1 y. Class Book. 4b Copyright N^__J_10C_ COPYRIGHT DEPOSIT A TEXT-BOOK DISEASES OF THE NOSE AND THROAT D. Braden Kyle, M. D. Clinical Professor of Laryngology and Rhinology, Jefferson Medical College ; Consulting Laryngologist, Rhinologist and Otologist, St. Agnes' Hospital; Bacteriologist to the Philadelphia Orthopedic Hospital and Infirmary for Nervous Dis- eases ; Fellow of the American Laryngological Association, etc. WITH 175 ILLUSTRATIONS, 23 OF THEM IN COLORS SECOND EDITION PHILADKLl'IIIA W. B. SAUNDERS & COMPANY 1900 84243 Library of Congroas IWU CtMMCS ReCCIVED DEC 5 1900 .\<; SECOND copy IMMralto ', F^C::' . 0R0£« DIVISION APR.6J99IO, ,r^9 Xcl. ^X- \C|00 Copyright, 1900, By W B. SAUNDERS et COMPANY. THIS BOOK RESPECTFULLY DEDICATED TO MY TEACHER AND FRIEND Dr. W. W. Keen. PREFACE TO THE SECOND EDITION. The early exhaustion of the first edition of this work, which appeared in September, 1899, is gratifying to the author, and affords him a welcome opportunity to acknowledge the deep obligations under which he is placed because of the cordial reception and generous criticism of the book by the medical profession and press. The second edition naturally cannot differ greatly in text from the first, as very little revision would be necessary in so short a time. However, some changes of expression and the correction of a few typogra])hical errors were deemed necessary, and it is hoped that this (.'ditiou will be found to merit as favorable a reception as that accorded the previous one. D. BRADEN KYLE. 1517 Walnut Street, Philadelphia. October, 19U0. PREFACE. It has been my aim to present to the reader the subject of Diseases of the Nose and Throat in as concise a manner as is com- patible with clearness. While the arrangement differs somewhat from many of the other text-books on this subject, it has been my aim to classify the diseases according to the pathological alterations caused by them. While some of the chapters necessarily show repetition, it is because of my desire to make each chapter com- plete in itself, so that the reader on turning to a certain subject may find under that heading the matter desired. While there are many things in the book that may seera superfluous to the specialist, yet, since the work has been pre- pared for the student and the general practitioner as well, there is a necessity for this fulness and apparent repetition. The lithographs and original illustrations are made from speci- mens prepared by the author in his own laboratory, and the draw- ings are from cases under his immediate observation. Some of the illustrations under anatomy are composite, being made from several other illustrations together with the original specimen. The cuts of instruments in many cases illustrate only one of many that might be used, but in the majority of instances the instruments are those used by the author, and the ones that have proved satisfactory in his hands. In treatment I have endeavored to be specific for definite con- ditions. While the doses given may seem positive and even dogmatic, it is understood that the dose of the drug must be indi- cated by the symptom to be relieved. Considerable space has been devoted to certain diseases which are somewhat rare, in the belief that when information is wanted on such subjects, it should be full and complete. I have purposely omitted reports of individual cases, and, in- stead, have grouped symptoms and generalized cases. 8 PREFACE. In looking np the literature, all the standard works have been consulted, such as Bosworth, Ingals, Mackenzie, Browne, Seiler, ]5urnett, Sajous, Solly, Bishop, Bell, McBride, Scheppegrell, Cryer, Bryan, and Hall ; also monographs by John X. Mackenzie, Roe, Myles, Thorner, Jonathan Wright, Casselberry, Delevan, Richardson, and others. The pathology conforms to the views advanced by Hamilton, Ziegler, Coplin, and Stengel, The following instrument-makers have kindly furnished elec- trotypes of various instruments : Messrs. Charles Lentz & Sons, Yarnall Surgical Company, Jacob Ostertag, and Williams, Browne & Earle, of Philadelphia ; George Tiemann & Company and E, B. Meyrowitz, of New York ; and Truax, Greene & Co., of Chicago. I am indebted to numerous writers for their many courtesies in furnishing reprints and copies of their various journal articles on special subjects. I am particularly indebted to Professor Keen for giving, in a special chapter, his own method of surgical operations on the larynx. I desire to thank Dr. W. H. King for his constant help in reference work and in reading the page proof, as well as for his valuable aid in making the index ; also Dr. J. Hervey Buchanan for his help in reference work. Acknowledgments are due to Mr. T. F. Dagney, the man- aging editor of the publishing house of W. B. Saunders, for his able assistance. D. BRADEN KYLE. 1517 Walnut Street, Philadelphia CONTENTS. CHAPTEK I. PAGE Anatomy and Physiology of the Nasal Cavities 17 Anatomy of the Anterior Nasal Cavities, 17. — Postnasal Cavity, or Nasopharynx, 25. — Physiology of the Nasal Cavities, 27. CHAPTER II. Illumination and Examination 30 Illumination, 30. — Light, 30. — Mirrors, 31. — Examination, 33. — Posi- tion of the Patient, 34. — Rhinoscopy, 34. — Anterior, 35. — Posterior, 37. — Instruments Needed for Office Work, 43. — Atomizers, 43. — Insuf- flator, Inlialers, 46, 47. — Applicator, 46. CHAPTER III. General Consideration and Pathological Alteration of Mucous Membranes 50 General Remarks, 50. — Inflammation, 52. — Clinical and Microscopi- cal Phenomena, 54. — First, Second, and Third Stages, 54. — Varieties of Inflammation, 55. — (1) Catarrhal, 55. — (2) Membranous, 58. — (a) Croupous or Pseudomembranous, 58. — (6) Fibrinoplastic, 58. — (c) Diph- theritic, 58. — (3) Hemorrhagic, 59. — (4) Gangrenous, 59. — (5) Suppu- rative, 59.— (6) Chronic Infectious, 60.— (a) Syphilis, 60.— (6) Tuber- culosis, 60. — (c) Actinomycosis, 61. — {d) Glanders, 61. — (e) Leprosy, 61. — (/) Rhinoscleroma, 61. Nasal Bacteria and their Relation to Diseases, 62. CHAPTER IV. Diseases of the Anterior Nasal Cavities . 65 Acute Inflammatory Di.seases, 65. — Rhinitis, Acute, 65. — 1. Simple Acute Rhinitis, 65. — (i. In the Young, 73. — b. Simple Acute Rhinitis in Certain of the Constitutional Diseases, 75. — Measles, 75. — Pertussis, 76. — Scarlet Fever, 76. — Variola, 76. — Typhoid Fever, 76. — Rhenma- tism, Acute Articular, 76. — Diabetes Mellitus, 76. — Epidemic Influenza, 9 10 CONTENTS. PAGE 76. — Diphtheria, 76. — Erysi{)elas, 77. — Scorbutic Rhinitis, 77. — Anemic Rhinitis, 77. — .Scrol'uloiis Khinitis, 78. — Caseous Rhinitis, 79. — (2) Membranous Rhinitis, 80. — (a) Croupous or P.seudomembranous, 80. — (6) Fibrinoplastic, 83. — (c) Diphtheritic, 85. — (3) Occupation Rhinitis (Traumatic), 85.— (4) Hyperesthetic Rhinitis (Hay Fever), 87. — (5) Ulcerative Rhinitis, 87. — (6) Edematous Rhinitis (Acute Edema), 87. — (7) Plilegmonous Rhinitis, 88. CHAPTER V. Diseases of the Anterior Nasal Cavities 89 Chronic Inflammatory Diseases, 89. — Rhinitis, Chronic, 89. — (a) Sim- ple Chronic Rhinitis, 89. — (6) Intumescent Rhinitis, 94. — (c) Hyper- plastic Rhinitis, 95. — Ozena, 102. — (t/) Atrophic Rhinitis, 104. — (e) Purulent Rhinitis, 118. — (/) Nasal Hydrorrhea, 120. — (>; ;//.///., michih' mcaliis ; i.l.. iiil'ci-ior turliinate; i.m., inferior meatus ;,/'., Ilimr of uose ; ///..-;., nuixiUary siuus, showin.LC septa ol bonr dividing the sinus. Note the iiiiu eoN'eriug tjf tlie roots (jf tl'ie leetli, sliowiiig that tlie skull was taken from a white i)er.son. upper portion, extending from the nostrils to the u])per boundary of the oropharynx ; a niiddh- portion, comprising tlic oro])harynx 2 17 18 DISEASES OF THE NOSE AND THROAT. and tlie laryngopharvnx, which it sliarcs in common Avith the alimentary tract ; and a h)wcr portion, extending from the glottis to the uhijnate air-eel l^^ of the lung, and comprising the larynx, trachea, and l)ronchial tubes, with their successive subdivisions and terminal expansion. The upper portion of this tract proper is anatomically divided into two regions — a posterior, or postnasal space, and an anterior space, Avhich is subdivided by a vertical septum into the two anterior nasal cavities. Each anterior cavity, extending from the anterior nares or nostrils in front to the posterior nares within, has a floor which is almost horizontal ; a roof, horizontal in its middle third, but inclining downward anteriorly and posteriorly ; an internal vertical wall, formed by the nasal septum ; and an outer wall, which slants downward and outward ; so that the cavities may be briefly described as irregular four-sided passages of an approximatelv pyramidal form. The bonv framework of each is as follows (Fig. 2) : The roof is formetl in front by the nasal bone and the nasal process of the frontal, the middle portion by the cribriform plate Fig. 3.— Cartilage and hones of the septum of tlie nose: a, lower lateral cartilage; b, cartilage of septum ; r, perpendieular plate of etlimoid ; d, vomer : c, superior maxillary ; /, palatal; g, nasal ; /(, frontal ; i, horizontal i)late of ethmoid ; k; rostrum of sphenoid. of the ethmoid, and the posterior portion by the under surface of the body of the sphenoid and the sphenoidal turbinated bones. The floor is formed in its anterior three-fourths by the palate process of the superior maxillary, and in its jiosterior fourth by the palate process of the palate-bone. The outer wall is formed anteriorly by the nasal process of the superior maxillary and ANAT03fY AND PHYSIOLOGY OF THE NASAL CAVITIES ll lacrimal bones ; in its middle portion by the ethmoid and the inner surface of the superior maxillary and inferior turbinated bones ; and posteriorly by the vertical j)late of the palate and the internal pterygoid plate of the sphenoid bone. The inner wall is the septum narium, and is composed of both bone and cartilage. It is formed by the crest of the nasal bones and the nasal spine of the frontal, by the perpendicular plate of the ethmoid and the vomer, which receive in the notch between them the triangular cartilage of the nose, posteriorly by tlie rostrum of the sphenoid, and below by the nasal crest of the superior maxillary and palate-bones. ^N^ormally the septum is vertical, but after the seventh year it is frequently deflected, usually to the left, constituting the condition known as devia- tion of the septum. It varies in thickness from Y^Q of an inch at its anterior margin to ^ at its posterior. The remaining portion of the nasal cavity is known as the vestibule, and comprises that part embraced between tlie an- terior orifice and the termination of the os- seous boundary. The framework of each ves- tibule consists of an upper and a lower lateral cartilage, two or three smaller cartilaginous plates (Fig. 4), and the median triangular cartilage of the nose already mentioned. From the outer wall of each fossa there extend inward toward the septum, but not touching it, three, and sometimes four, shelf- like processes of bone, which from their scroll- like form are named the turbinated bones. Each is formed of a thin plate of bone, somewhat triangular in form, and so curled as to present a convexity upward, inward, and somewhat forward ; their lines of attachment being nearly horizontal and equidistant. The superior turbinate is the smallest and least rolled (Fig. 1). It arises from the lateral mass of the ethmoid, and hangs nearly perpendicularly in the nasal cavity. Its anterior margin coalesces with tlie middle turbinate, while the posterior is unattached, and in about one-tliird of all cases (Zuckerkandl) is split horizon- tally, thus forming a fourtli turbinate l)one, or the "concha Santo- riniana." Beneath the superior is the middle turbinate (Fig. 1), larger tlian the former, broader, more rolled at its center, and projecting liorizontally instead of vertically. At its anterior free margin is the "agger nasi," a small elevation directed downward, and opjio- site a corresponding slight elevation on the septum. These are important as marking the line between the olfactory area above Fig. 4.— Lateral carti- lages of nose : a, upper lateral cartilage; b, lower lateral cartilage; c, cell- tissue ; d, sesamoid bones. 20 DISEASES OF THE NOSE AND THROAT. and the rospiratory region below. This bone also springs from the lateral mass of the ethmoid. The inferior turbinate is the lowest of the three (Figs. 1 and 2) as it is also the longest and largest. It is mon; highly developed and compact than the others, and, unlike them, is a separate bone. At Fk;. 5.— Splion.ii.), or antra of Highmore, are two large pyramidal cavities situated one in the body of each superior maxillary bone. The roof of each antrum is formed by the floor of tlie orbit, its floor by the alveolar process, its external wall by the facial surface, and its posterior wall by the zygomatic surface of the superior maxillary. It opens into the middle meatus (Fig. 2), near the posterior part of the hiatus semilunaris, by a circular opening, the ostium viaxillare, behind which is occasionallv a second opening, the ostium maxillare accessorius. These cavities vary much in size, both in races and in individuals. They are frequently crossed by thin laminjie of bone. In the pos- terior wall are the canals transmitting the posterior dental vessels and nerves to the teeth, and on the floor may often be found con- ical projections caused by the roots of the first and second molar teetli. In the anterior region of the inferior meatus is the orifice of the lacrimal or nasal duct, leading from the lacrimal sac to the nose (Fig. 114). The mucous membrane lining the accessory sinuses differs slightly from the nasal mucous membrane. The epithelial lining consists in a single layer of pavement epithelial cells. The base- ment membrane and submucosa are much thinner than the exposed mucous surfaces, and the gland element largely limited to the ori- fice communicating with the nasal tract, the glands of the sinus mucous membrane being few in number. The bony walls of the nasal cavities and the accessory sinuses are completelv lined by mucous membrane, which in front is con- tinuous with the skin, and at the jwsterior nares with the mucous membrane lining the pharynx. This membrane, which is vari- ously known as the pituitary or " phlegni-producing," the Schnei- deriau, or the nasal mucosa, is intimately applied to the bony structure, varies in thickness and character in different areas, and modifies greatly the size of the nasal fossse and their accessory shnises and orifices, as seen in the skull. It is thickest over the turbinated bones, somewhat thinner over the septum, and very thin over the floor, the under surfaces of the turbinated bones, and in the accessory cavities. The color of the nasal mucosa also varies. In the upper or olfac- tory region, including the roof, superior turbinated bone, superior ANATOMY AND PHYSIOLOGY OF THE NASAL CAVITIES. 23 meatus, upper third of the surface of the middle turbinated bone, and the corresponding portion of the septum, the membrane is a yellowish pink ; below this, in the respiratory region, it is a light pink ; and at the posterior ends of the turbinates the tint becomes whitish. In the accessory cavities the color is a pale pink. It must, however, be borne in mind that in the entire surface the color depends upon the vascular condition, deepening in plethora, and in anemia becoming paler. So pale may it become in the latter condition as, even where the membrane is thin, to show a yellowish tint from the color of the underlying structures. ■'..:^ M' ■J c^^ '-'Mm. ^s.. ^m. ■^ij^^-j'ii^ Fig. 7.— Section of normal mucous membrane : c.c, ( brane; c.t., connective tissiie (suhnnu'osa) ; s.()., superliri a., artery cut transversely; '/., duct; o.d., orifice ol ilu X, open spaces from whicli gland structure has falleii in right of the figure is seen a hirge vein (cavernous sinusj illiclial fells;?) liiiseiiient mem- /,, iniieipanms glands; \' cut iMiPjitudinally ; (111 o|- sieiiou. To the specimen.) (Author' In structure the membrane shows three distinct comj^onent parts. The upper layer is of epi- and hy]i()blasti(! origin, and is composed of varied epithelial elements which rest u])on tlie second layer of basement membrane. This layer is in turn supported by tlie third or submucous layer, varying in thickness, composed of white 24 DISEASES OF THE NOSE AND THROAT. fibrous and elastic elements, and containing the vascular, lymphatic, ner\'e, and glandular structures. The lining membrane of the vesti- bule is cutaneous in character, and the epithelium is the flat pave- ment or squamous variety. In the deeper part, however, it con- tains both cutaneous and mucous elements, and at the junction of the vestibule and the nasal fossa proper it shades into true mucous membrane. In the olfactory region the mucous membrane is thin, comparatively non-vascular, closely adherent to the periosteum, and its epithelial investment is formed of columnar cells which for the most })art present a sharp outline on their free surface and are not ciliated. Lying among them are the olfactorial cells of Schultze, su])posed by most ol)servers to be in direct communi- cation with the non-medullated filaments of the olfactory nerve. Beneath this epithelial covering, and opening on its surface, are numerous branched tubular glands — the glands of Bow- man. In the respiratory region the epithelium is of the stratified columnar variety — ciliated ; and interspersed numerously among the other cells are the so-called goblet- or chalice-cells. Glands. — The glandular structures are both mucous and serous in character, are of the racemose type, and open by small funnel- like (Fig. 7) orifices on the free surface of the membrane. These glands are most numerous at the middle and back parts of the cavities, and largest at the lower and posterior part of the septum. A most important feature is the large size of the venous net- works in the submucosa, wdiich form large cavernous sinuses capable of sudden distention, giving to the tissue an erectile char- acter ; this is most marked on the surfaces of the middle and in- ferior turbinates and lower part of the septum, and from their resemblance to the cavernous structures of the penis, Bigelow has introduced the term turbinated corpora cavernosa. The term turbinated bodies comprises both the mucous membrane and the bone invested, while the venous plexuses themselves have been termed " Schwellenkorper " (swollen bodies) by Zuckerkandl. The mucous meml)rane of the accessory sinuses is very thin, and its epithelium a])j)roaehes the squamous variety in character. Blood-supply. — The arterial supply of each nasal cavity is derived from the sphenopalatine branch of the internal maxillary, a minute twig from tiie small meningeal branch of tlie same, the anterior and posterior ethmoidal l)ranches of the o])hthalmic, the artery of the se])tum from tlie superior coronary, and the alveolar branch of the internal maxillary which is distributed to the lining membrane of the antrum. The sphenopalatine artery enters the fossa by a foramen of the same name just back of the superior meatus, where it divides into two branches, an internal, the naso- palatine or superior artery of the septum, wOiich jiasscs downward and forward along the septum supplying the membrane, and an external branch, which subdivides into smaller branches supply- r Fig. 8.— The upper figure represents the sphenopalatine ganglion and i lower figure, the nerves of the nasal septum, right side. inches ; the ANATOMY AND PHYSIOLOGY OF THE NASAL CAVITIES. 25 ing the lateral mucous membrane, the antrum, sphenoidal and ethmoidal sinuses. The anterior and posterior ethmoidal arteries enter their respective sets of ethmoidal cells, and after supplying them enter the cranium and give off numerous small nasal branches which, passing through the cribriform plate of the ethmoid, extend a short distance down the walls of the fossa. The anterior branches also supply the frontal sinuses. The anterior portion of the septum is supplied by the artery of the septum, which is a branch of the superior coronary of the facial, ancl enters the nose at the junction of the nostril and the lip. The abundant vascular system with its free anastomoses explains the considerable hemorrhage often attendant upon operations in the nasal spaces. Nerves. — The nasal nerves (Fig. 8) are of special and general sensation. The olfactory nerves, or those of the special sense of smell, arise from the under surface of the olfactory bulb, pass through the foramina in the cribriform plate, and are roughly divisible into three sets : an inner set, spread out over the upper third of the septum ; an outer set, which is distributed over the superior turbinate, the upper part of the middle turbinate, and the surface of the ethmoid anterior to them ; and a middle set, supply- ing the roof between the distribution of the others. Branches of the sphenopalatine ganglion of the sympathetic nerve enter the nasal spaces and are distributed to the upper, mid- dle, and posterior parts of the septum, to the lower edges of the superior, and the surfaces of the middle and inferior turbinates. General sensation is supplied to the upper and anterior part of the septum, the nasal floor, outer walls, and the anterior surface of the inferior turbinate by the nasal branch of the fifth pair, while filaments from the anterior dental branch of the superior maxillary nerve are distributed to the inferior meatus and inferior turbinate. The Vidian nerve supplies the upper and back part of the septum and superior turbinate. Postnasal Cavity, or Nasopharynx. — The postnasal space or nasopharynx (Fig. 1) includes that portion of the upper respiratory tract comprised between the plane of the posterior nares and a hori- zontal plane extended backward at the level of the free margin of the soft palate. It is continuous in front with the nasal fossae through their respective openings, below with the oropharynx, and laterally, by means of the Eustachian tubes, with the tympanic cavities of the ears. The roof of this space, continuous in front with the upper limits of the nasal fossae, slopes gradually to the posterior and lateral walls, forming a dome-shaped structure, known as the vault or dome of the pharynx. These walls, beneath tlie invest- ment of mucous membrane, are formed by a rather dense fibro- muscular tissue, which in the posterior region is freely movable upon the mass of retropharyngeal cellular tissue separating it irom the prevertebral muscles of the cervical spine. Laterally 26 DISEASES OF THE NOSE AND THROAT. at the anterior and lower portion of the space, opposite the pos- terior terminations of the inferior turbinates, and about f of an inch from them, are the eminences marking the orifices of the Eustachian tubes. Anteriorly the boundary is formed by the posterior nares or choanre, the posterior edge of the septum, and the soft palate. Between the free border of the soft palate and the i)osterior pharyngeal wall is a space called the " isthmus," which is closed during deglutition by the elevation of the velum palati or soft palate. Above the vault of the pharynx are the body of the sphenoid and the basilar ])roccss of the occipital bone, wnth the so-called ])asilar fibrocartilage. Posteriorly is the first cervical vertebra, and laterally are the internal pterygoid plates of the sphenoid and the petrous portion of the temporal bones. Anteriorly are the posterior bony margins of the anterior nasal cavities. The mucous membrane of this space is continuous with that of the nasal cavi- ties and of the oropharynx, as well as with the membrane lining the Eustachian tubes and their connected aural cavities. In its essential elements the mucous membrane presents but little varia- tion from the lining of the nasal cavity proper ; the epithelium being columnar and ciliated, with here and there goblet-cells, the three component strata of the membrane being well marked. It does differ from the nasal mucosa, however, in the absence of the large venous sinuses of the submucosa and in the presence of a greater number of glandular structures of both the follicular and racemose type. In the posterior part of the pharyngeal vault is situated a structure known as the third or pharyngeal tonsil, or tonsil of Luschka. This differs little in structure from the faucial tonsils, and is composed of a mass of adenoid tissue thickly placed, in which are numerous follicular glands. This tonsil extends from the median line on each side to a well-marked depression termed the fossa of Rosenmiiller, or recessus pharyngeus, which separates it from the Eustachian orifice (Fig. 1). This fossa is an impor- tant landmark in locating the tubal o]iening. The surfiice of the tonsil is somewhat elevated, marked by depressions termed lacuna or crypts, and studded with minute projectiims marking the gland- ular orifices. In the majority of cases there is a slit-like orifice in its lower ]>art leading to a small sac beneath, termed bv Luschka the ])h(iri/}if/cal hurs((. The agglomerate glands are most numer- ous behind the proie(!tions which contain tiie Eustachian orifices, and are closely grouped together on the upper surface of the soft palate. The color of the membrane in the vault is a deeper pink than that observed in the nasal cavities ; it is lighter, however, around the Eustachian eminences, and shades to a yellowish tint immediately surn)unding the orifices. The arterial supply of the nasopharynx is derived from the ANATOMY AND PHYSIOLOGY OF THE NASAL CAVITIES 27 external carotid — branches of the ascending pharyngeal supplying the greater part of the region ; while the anterior portion receives the terminal branches of the descending palatine and spheno- palatine from the internal maxillary. The facial artery, through its ascending palatine branch, supplies the soft palate and the palatine glands. The venous return is through subdivisions of the internal jugular vein. The nerve-supply is derived largely from branches of the second division of the fifth nerve. The nasopharynx also receives branches from the glossopharyngeal nerve, the spinal accessory nerve, and the superior cervical ganglion of the sympathetic nerve through the pharyngeal plexus. Physiology of the Nasal Cavities. — The function of the nasal cavities is regarded by most physiologists as essentially three- fold, and is usually considered in relation to respiration, olfaction, and phonation. In addition, these cavities perform a very im- portant secondary part in the modification of certain functions of more or less intimately related organs. In considering the respira- tory function, it will be found that the external air, rarely fitted for entrance into the delicate structures of the lower part of the respira- tory tract, is modified by the upper passages in three important particulars — temperature, moisture, and purification from sus- pended foreign matter. Whether the temperature externally be above or below that of the body, after having passed through the nasal cavities, the inspired air will be found to be at almost blood heat on reaching the larynx. This alteration is brought about not only by the temperature of the area traversed, but also by the admixture of the air with glandular secretion, and by the moist vapor exhaled by the lungs, deposited upon the mucous membrane and kept at body heat by the underlying vascular supply. The air, moreover, is in inspiration to a greater or less extent filtered. This is brought about in two ways : the larger particles are arrested by the vibrissse or short, moderately stiff hairs which project from the anterior portion of the vestibule, as it were, " sieving " the air. The smaller particles brought in contact by the air-current, or precipitated by the moisture and lodging on the membrane, become entangled in the tenacious mucus, and with it are gradually propelled toward the nostrils by the constant vibrations of the ciliated epithelium. The air thus tempered, moistened, and freed largely from mechanical irritation, is prepared to pass over the delicate l)rouchial surfaces without injury to them. The distribution of the olfactory filaments has already been described (Fig. alate will remain relaxed. The mirror should be held in the right hand, exactly as in the Spencerian method of holding the ])cn, so that the position may be controlled by rotating the handle by means of the thumb — the mirror being held by the index and second fingers, the thumb being merely a stay and rotator. It is then introduced, keeping the rod fully in the angle of the mouth on the left side, and passed backward somewhat edgewise until it passes through the space between the uvula and the faucial pillar on the right side, the nasal fhamber. being careful not to touch the parts. A\'hen fully within the ])haryngeal space behind the ])alate, the handle is rotated slightlv from right to left, bringing the reflecting surface around so as to face the operator; it can then by simple rotation be made to assume any j)osition desired. All backward and forward move- ment of the wrist should be avoided, as that would be almost cer- tain to bring the mirror in contact Avith some ])art of the sensitive structures and cause retching. By manij)ulating the mirror-rod M'ith the thumb and fingers, oidy lateral motion is obtained and this un])leasant result is averted. In making an examination of the nose, either anterior or j)os- terior, if the instruments cause the least inconvenience to the patient, they should be withdrawn at once, and after waiting a moment or two, the examination re-attem])ted. I find that in a number of eases this posterior examination can be made without ILLUMINATION AND EXAMINATION. 39 the aid of a tongue-depressor, which to many patients is an objec- tionable instrument. By inserting the mirror along the median line of the tongue, in many cases that member will with only the slightest pressure — and in some cases with no pressure at all — assume a position low enough to permit the rhinoscopic examina- tion. The examination should be made quickly and the mirror kept in position only a few seconds, repeating as often as neces- sary. In case a tongue-depressor is used, the one shown in Fig. 21 will be found quite as convenient as any, and can be so constructed that separate blades may be used for each individual, thereby assuring absolute cleanliness and freedom from possibility of in- fection. The fewer and simpler the instruments, and the shorter the time they are left in position, the better. In applying the tongue-depressor, the tip of the tongue should be placed against the lower teeth ; the depressor, after being slightly warmed, is passed in with a gliding motion and not too far back, only slightly beyond the arch of the tongue. This caution is necessary for the reason that, if passed too far back and the tongue depressed, the end of the instrument will touch the sensitive parts at the base of the tongue or on the pharyngeal wall and excite a prompt reflex, which will interfere with the free movement of the mirror. The tongue should be pressed doMaiward and forward by a rotary movement of the depressor, the back of the instrument being made to revolve in the arc of a circle, the center of which is the teeth of the lower jaw. If this movement be made slowly, but with firm pressure, it will expose the whole of the lower pharynx, and at the same time Mall prevent the uvula from re- maining pendulous. The depressor should be held between the thumb and index finger, the thumb pressing against the angle, while the second finger passes under the chin of the patient. In this man- ner it can be firmly held in position and the movement of the patient's head, to a great extent, be controlled. It is a good rule to always use the depressor with the left hand, leaving the right hand free to manipulate the mirror. The size of the mirror used will depend entirely upon the space existing between the base of the tongue and the border of the soft palate, and that between the soft palate and the ])osterior nasopharyngeal wall. The largest mirror possible should be used, to obtain both better illumination and a larger image. At times, even \vhen great care and patience have l)een used in these manipulations, the jxitient is unable to control the movements of the palate, and the physician is forced to secure their obedience by medical or mechanical means. Among the last resorts to be employed for this purpose, recourse may be had to the application to the fauces of a 3 to 15 per cent, solution of cocain. This to many is quite unpleasant, producing a sensa- 40 DISEASES OF THE NOSE AND THROAT. tion of choking or suflPocation, but, as a rule, the inconvenience is only temporary. By the use of the small tongue-depressor (Fig. Fig. 21.— Tongue-depressor. 21), the uvula may be elevated, aiding materially in obtaining a view of the postnasal structures. As to the many palate-hooks and retractors that have been Fig. 22.— Case of adjustable blades for tongue-depressor (Fig. 21). employed, while theoretically good, they are of little practical value. So for examination by reflected light only has been considered. Some specialists question the practicability of introducing into ILLUMINATION AND EXAMINATION 41 the nasal cavities a better light than can be furnished by means of reflectors. A very good method, however, of examining both the anterior and posterior nasal cavities is by the introduction of a small incandescent electric bulb (Fig. 23) into the postnasal space. This lamp is placed on flexible wires, so that it may be bent to any angle desired, and it can be introduced within the postnasal space by following the rules given for the introduction of the rhinoscope. The lamp is quickly inserted back of the uvula, and the patient immediately closes his teeth upon its stem, holding the instrument firmly in position. I have had no trouble, even with very sensi- tive throats, in inserting and retaining this instrument when strictly adhering to this method. The lamp is enclosed in a small platinum cap with an aperture for the transmission of the rays, which also acts as a reflector and protects the parts from the heat generated by the current. By turning the current on and ofl^, the lamp can be retained in the postnasal space for several minutes without any annoyance from heat. The cap is so arranged that its aperture can be turned in any direction desired, and, with the aid of the nasal speculum, an excellent view of the anterior and largely of the posterior nares can be obtained. By closing the mouth and nostrils of the patient, the condition of the accessory cavities can in a great measure be determined. If no fluid or tumor be present in the accessory cavities, the Fig. 23.— Author's postnasal lamp. transmission of light is uninterrupted ; their presence will be shown by a dark outline ; however, the irregularity in the size of the antrum must be taken into consideration. Sufficient current can be obtained from any of the many storage batteries or from the street current. The use of the Eontgcn ray will play an im- portant part in the future of laryngology and rhinology. By its use the condition of the bony structures of the throat, nose, and ear may be determined, as well as the accurate location of the position of foreign bodies. Having considered in regular order the apparatus necessary to make a comj)lete examination and the methods to ha employed in using them, a description of the normal appearance of the parts is next in order, their abnormal appearances being given under the special diseases in which they are characteristic. Anterior. — By placing the head in the positions described 42 DISEASES OF THE NOSE AND THROAT. on page 37, tlirough each nasal opening will be seen the anterior portion of the middle and snperior tnrhinated bones on the outer side, and the anterior portion of the wall of the septum on the inner. By tilting the head slightly backward and inclining the chin slightly to the right or left, as either side is examined, the view will be more extensive. This procedure will fully expose the middle turbinated bone, the nasal roof, and superior turbinated bone. If the head be lowered, a perfect view can be obtained of the floor of the nasal cavity and, in the majority of cases, the anterior portion of the inferior turl)inate and the inferior meatus, while the middle turbinated bone will almost disa])pear from view. In their normal condition tiiese parts are a (/rdt/ish-puik with the exceptions of the anterior portion of the middle turbinated, which is dark pink, the superior turbinated bone, which is pink tinged with yellow, and the roof of the nose, which is also yellow- ish-pink, but of a lighter shade. The membranous covering of the septum is a bright pink, showing somewhat darker along the floor of the nose and with a yellowish shade if seen by transmitted light. Posterior. — In posterior examination the oval-shaped open- ings of the posterior nares, or choanse, are brought into view. The student must not forget, however, that the image shown in the rhinoscope is a reversal of the true position. Fig. 14 shows fairly well the position of the parts, but it must be remembered that the region is seen only in detail, and not as a whole. Above the upper surface of the soft palate and slightly back of it is seen the septum, broad above and tapering to a thin edge as it reaches the floor ; and on each side of it, though somewhat shaded, the nasal passages appear. Apparently resting on the floor of the nose is seen the inferior turbinated body, which appears as a somewhat elongated mass of a pinkish-gray color, and just above it is visible a considerable portion of the middle meatus. Projecting above this will be noticed the middle turbinated body, which appears as a somewhat elongated and slightly fusiform projection, the edges of which are yellowish-red, deepening in color toward the base. The superior meatus, which shows as a dark line above the posterior portion of the middle turbinate in the posterior nares, separates the middle from the superior turbinated body ; this latter shows dimlv as a light reddish band which, owing to its position, is dimly lighted; the postnasal lamp, however, clearly defines it. It shows the same yellowish-red color as tiie middle turbinate, and its edge slants slightly upward and forward, and a])pears as though sus- pended from the roof. As a rule, a good view cannot be obtained of the inferior meatus and floor of the nares by posterior rhinoscopy, but illumi- ILLUMINATION AND EXAMINATION. 43 nation and anterior rhinoscopy outline the parts fairly well. If the mirror be now turned somewhat to one side, there will be seen the eminence surrounding the Eustachian tube, which is separated from the posterior wall of the vault of the pharynx by the fossa of Rosenmiiller, the orifice of the tube showing as a grayish funnel- shaped depression. By elevating the handle of the rhinoscope, causing the mirror to incline nearer the horizontal, there is brought into view the half- dome-like cavity of the vault of the pharynx, which presents a rather irregular outline, its glandular tissue (pharyngeal tonsil) rendering its surface irregular and furrowed. This irregularity depends largely on the age of the patient. Usually in adult life the pharyngeal tonsil has atrophied, the irregularities then depend- ing on the amount of atrophy. In some cases very little atrophy has taken place, while in others no evidence of the tonsil can be seen. In children the pharyngeal tonsil is always present, some- times rudimentary, and again enormously enlarged. This enlarge- ment may be mere swelling or actual tissue-proliferation. The color of the tissue seen by this view varies with the age of the patient, often in the young showing a deep-red color, while in the adult more of a pinkish-gray. The parts appear much smoother as the view passes down, until there is seen the smooth, shining, dark-red surface of the lower pharynx. With children it is often difficult to obtain a good view of the postnasal tissue, but an ap- proximate idea may be formed by introducing the index finger back of the soft palate and quickly sweeping it over the tissues. It must also be borne in mind, in examining the mucous mem- brane of the upper air-passages, that the long exposure of such a delicate membrane to the reflected rays of light, and the changes produced by the action of underlying muscles, alter the color of the membrane in a very short time. The first vieM' obtained gives the true color, and therefore the examination should not be pro- longed. This is especially true of the pharyngeal and the laryn- geal membrane. Instnitnents Needed for Office Work. — A brief descrip- tion of the iustrumonts necessary in treatment of the anterior and posterior nasal cavities may not be amiss here, leaving those required in special treatment to be described under the special conditions demanding the™. In local treatment of the nnicous membrane of the up])er air- passages, the essential element is (cleanliness, and for this purpose various forms of cotton a])]ilicators, douches, atomizers, etc., have been devised. To reach tiie diseased area M-ith medicating fluids depends on our a])ility to cleanse the membrane thoroughly, and this can best be accomplislicd by reducing the cleansing fluid to a state of minute atomization or by the employment of the douche. Atomizer. — Many atomizers have been placed on the market 44 DISEASES OF THE NOSE AND THROAT. — somo elaborate, complicated, and expensive ; others plain and simple in construction, hut all involving the same general prin- ciple. The atomizer giving the most satisfaction is the one simplest in construction. I believe that with the ordinary single-bulb hand-atomizer, one's work can be quite as well performed as with more complicated apparatus, the pressure being easily controlled to suit the sensitiveness of the mucous meml)rane in each partic- ular case. Tiie majority of the compressed-air apparatuses create entirely too strong a spray for such a delicate membrane as that which lines the up])er air-passages; in fact, a case of rhinitis can easily be aggravated by using too strong a spray, and when such apparatus is used, this danger must be carefully guarded against by ])ressure regulators. Xn ordinary straight-tube atomizer, constructed on the same principle as that of the Richardson atomizer and Sass's spray tubes, is quite satisfectory. The straight-tube atomizer is made with screw top, metal cap and tube, and the diameter of the tube should be not more than \ inch, at least 5 inches in length and slanted slightly upward. The bottle is graduated, thereby ena- bling the patient to obtain a definite amount of the solution used. By careful manipulation of this atomizer, the spray can be so directed as to reach any portion of the anterior region, and by inserting the tube carefully along the floor of the nostril, the Fig. 24.— LlewuHyi )f Bergsou's atom spray can be thrown into the nasopharynx. In cases in which there exists malformation or hypertrophy of the nasal structures, this is difficult and in a few cases impossible ; yet if the tube be carefully inserted, using no force, but rather directing in the line of least resistance, it will pass into the posterior nares. This pro- ILLUMINATION AND EXAMINATION. 45 cedure renders it possible to cleanse the nasopharynx thoroughly. The spray will insure more thorough cleansing than the douche, as the cleansing solution by this procedure can be brought in con- tact with the entire mucous-membrane surface ; while in the douche the direction of the current is influenced by the structures of the nasal cavity, and cleanses only that portion in direct line of the current. Sass's tubes can be used anteriorly or posteriorly. These are made of glass or hard rubber. Of the many atomizers I have tested, I consider that made after the suggestion of Bergson and modified by Llewellyn the best (Fig. 24), and use it in my private and hospital practice. A much simpler method of cleansing the nasal cavities, both anterior and posterior, is by means of the Kirkpatrick or Ber- FiG. 25.— The Kirkpatrick nasal douche. mingham nasal douche. The accompanying cuts are sufficient description. In the use of the nasal douche care should be taken that the solution is not drawn into the Eustachian tube, and the fluid Fig. 26.— The Bu should be allowed to flow through the nasal cavities rather than forcibly drawn through, thereby lessening that danger. The repeated and loiif/-cn7itinued use of any solution, even by means of the douche or atomizer, should be carefidly c/uarded against, as the nasal mucous membrane requires the same rational treatment as is 46 DISEASES OF THE NOSE AND THROAT. necessary in the treatment of any other disease. As the disease process goes on to recovery, the sokition should be modified in strength or discontinued ; otherwise the mere use of the sohuion may keep up inflammatory action. If the postnasal space cannot be thoroughly cleansed by the methods described above, excellent results can be obtained by Fig. 27.— Straight siiiuoth applicaiur. usiug the postnasal syringe, which is a common barrel syringe, fitted with a curved tube perforated at the end, which sends jets in everv direction. This can be used either for the nose or pharynx. After the atomizer and douche another instrument is necessary, despite many well-known authors to the contrary. This is the long, narrow applicator or probe (Fig. 27 j. The one which I "ia4|4r- Fio. 2b.— hajous b iiiiUlUator. prefer is of copper, especially hardened, but sufficiently pliable to be bent to any angle or curve desired, and should be made to fit the universal handle. After cleansing the parts by means of the douche, atomizer, or probe and cotton, the surface should be care- fully dried by means of cotton wrapped sufficiently tight upon the end of the applicator, to allow of thorough mopping. This will remove auy crusts of dried secretion, or at least loosen them so that they caii be reuioved with slight effi)rt on the jiart of the patient. ILLUMINATION AND EXAMINATION. 47 The insufflator which I consider best for all practical purposes is shown in Fig. 28. Fig. 30.— Large inhaler, with compressed-air and hot-air attachments. The nebulizer and the inhaler are indispensable articles, the advantage being that vapor will penetrate where fluids will not Fig. 31.— Hot-air apparatus. The space above the lamp is the hot-air chamber, through which the medicated air passes. The holder on top is for bottles, in which may be placed solutions that are to be heated. roach. In the nebulizer the remedial agent should be sus})ended in some bland oil which will adhere to the membrane, causing it 48 DISEASES OF THE NOSE AND THROAT. to remain in contact for some time, as well as aflfbrcling protection to the sensitive area. The best appliance for the application of such solutions is the Globe inhaler or some modification of this instrument. A useful attachment to the nebulizer shown in Fig. ,30 is the hot-air aj)})aratus (Fig. 31), which is employed in the treatment of lesions of the accessory sinuses and of the middle ear. It per- inits the use of plain hot air, or hot vapor, or medicated vapor. In the acute lesions of the accessory sinuses, especially of the sphenoidal and ethmoidal, the hot yapor considerably allays the swelling and irritation by relieving somewhat the blood-pressure, although in the majority of cases the relief is more temporary than permanent. In the treatment of acute inflammatory condi- tions of the middle ear, however, it is highly beneficial. An inhaler affording a convenient and simple method of appli- cation is Coulter's, whicii consists of a small spirit lamp, over which is fitted on the same stand a water reseryoir, to the top of which is connected a bulbous tube. This tube is jointed at the bulb, and within the ex- pansion is placed a sponge on which the solution to be inhaled is poured (Fig. 32). When the lamp is lighted, the steam from the heated water passes through Fig. 32.— Coulter's inhaler. Vutlior's sterilizer. the sponge and l)ecomes impregnated with the medicament, any excess from condensation or oversaturation being collected by a little cotton placed in the wide mouth-piece ^yith which the tube is ILLUMINATION AND EXAMINATION 49 provided. In its use the patient places the month-piece directly in front of the face and inhales the fumes. A simple inhaler can be improvised with a pitcher of hot water in which the medicinal agent is placed. A towel is then folded and formed into a cone, or an ordinary tin funnel of sufficient size may be employed, and placed with the large end over this reser- voir, concentrating the vapor, and the patient directly inhales the fumes. An essential feature in office work is the thorough cleanliness of the instruments used. This can be accomplished by steam sterilization and by the use of antiseptics. The small steam ster- ilizer, as shown in Fig. 33, which can be placed on a table and heated by means of a Bunsen burner, permits of rapid steriliza- tion. At the same time the separate compartments admit of hav- ing always on hand boiling water. Besides the cleansing of the instruments by heat, they should be dipped in absolute alcohol and aqueous extract of hamamelis, equal parts — a combination that removes any objectionable metallic taste. Instruments used in routine examination should be thoroughly disinfected after each usage. It would be w^ell to have of the instruments most com- monly used — that is, the tongue-depressor and nasal speculum — a number of duplicates, thus enabling the practitioner to use for each individual a separate instrument. CHAPTER III. GENERAL CONSIDERATION AND PATHOLOGICAL ALTERATION OF MUCOUS MEMBRANES. The term " catarrh " as o:enerally used implies much ; liter- ally it means '' to flow downward." It is popularly used in desig- nating all varieties of mucous-membrane inflammation of the nares, whether acute or chronic, hypertrophic or atrophic. Ap- plied to any of these conditions the term is a misnomer, as the catarrh is merely a symptom. I therefore shall not use the word " catarrh," but, in its stead, a term which will describe the exist- ing pathological condition. It is jiroper, however, to speak of a catarrhal iuHammation, meaning that special condition in which secretion and elaboration of mucus are increased. In many constitutional diseases there is an incr(>ased exudate from the mucous membrane. This is brought about by inter- ference with the circulation, by vasomotor phenomena, and by alteration in the blood. It is also due to changes in internal organs whereby elimination is interfered with — as, for example, in dis- eases of the kidneys, when the skin and mucous membrane vicari- ously aid as eliminators. Congestion, acute or cyanotic, of internal viscera causes markcnl alteration in the mucous membrane, even of the larynx and pharynx. Intestinal irritation and chronic constipation may cause the pharyngeal and laryngeal mucous membranes to become thickened and congested, and even the veins to ])resent a varicose condition. Diseases of the liver, kidneys, intestines, lungs, pleurse, heart — in fact, ahiiost any serious inflammatory lesion — will be manifested in the mucous membrane of the u]^per air-passages by some altera- tion in its fimction due to circulatory changes, which, if continued, may ])roduce structural alterations. These systemic conditions illustrate the importance of urinary exaiiiinntion on the ])art of the specialist as well as the general practitioner. Primary lesions of the accessory sinuses may give rise to true or api)arent nasal lesions. The nasal discharge coming direct from the sinuses will produce secondary irritation of the nasal mucous membrane. It is a well-known IJiet that in anemia there is edema, leakage of scrum from the kidneys, and in some instances intestinal changes, as watery diarrhea. In these cases the respiratory mem- brane will also show a thin, slightly albuminous, watery exudate, This is especially true in children, and is due in a large number 60 GENERAL CONSIDERATION OF MUCOUS MEMBRANES 51 of cases to the intestinal irritation set up by such parasites as the Ascaris hirabricoides. Such cases shoukl not be confused with strumous rhinitis. The shape of the nostril has much to do with the so-called catarrhal diathesis. Not infrequently patients wall say they have inherited catarrh, when, in fact, they have inherited the family nose — the narrow, slit-like nasal cavity, so straitened that the least congestion of the mucous membrane closes the nose by nar- rowing the lumen of the nares and lessening the size of the nasal cavities ; for, backed up as the mucous membrane is in this locality by bone or cartilage, it can distend in but one direction — that is, toward the lumen of the air-passage and aw-ay from its resistant background. The free passage of air and perfect drainage are interfered with, causing an accumulation of secretion, which by its presence irritates the mucous membrane and produces some form of rhinitis. The idea is quite prevalent, especially among the laity, that catarrh, as they state it, " runs into consumption." There is no doubt that long-continued catarrhal inflammation tends to weaken the tissue-resistance, and that a postnasal rhinitis wdth accumula- tion of secretion at night will cause pharyngitis and laryngitis. The idea is quite prevalent, especially among the laity, that catarrh, as they state it, " runs into consumption." There is no doubt that long-continued catarrhal inflammation tends to weaken the tissue-resistance, and that a postnasal rhinitis with accumula- tion of secretion at night will cause pharyngitis, laryngitis, trache- itis, and bronchitis. The patient unconsciously swallows, at such time, some of the secretion, and this, collecting in the esophagus and stomach, will soon generate a catarrhal condition in these parts. The physiological resistance being lessened in this way, and the patient being possibly of a tubercular tendency through ex])()sure to tuberculosis, he may develop the disease ; but disease, like tissue, never changes type ; it can only predispose. Too much importance cannot be attached to nasal breathing. Many cases of disease of the nose and throat necessitating mouth- l)reathing, if continued for any length of time, produce a marked efix^ct on tlie general health. This is especially true in children, and should be corrected early. If interference is not prompt and effectual, the obstructed nasal breathing, with the continuance of the forced snuffling inspiration so often seen in these cases, may cause a drawing down of the facial muscles, not only changing the child's expression, but often, by the continued pressure, altering the {'ontour of the u]>pcr arch by drawing in the U])per jaw. The hard ])al:ite, iustead of forming the perfect dome, is moulded into a high irregular arch. When the floor of the nose or siiiicrior maxillary bone is thin from deticient breathing in early cliildhood or fr<')ni other <'ause, the terminal nervc-iilaincnts going to the root of the tooth course 52 DISEASES OF THE XOSE AM) THROAT. sujKTlicially alonu' tho floor of the nose, and in cases of deflected se])tuni, wJierc the deflection is close to tiie floor of the nose, Avith redundant tissue, an inflaninuitory process is set up which injures the nerve-roots and may cause devitalized teeth, or may ulcerate and produce a sinus dischari2:iui; around the tooth, simulating pyorrhrea alveolaris, I have observed a munber of such cases. The shai)e of the bony framework of the nose, especially the floor and the turbinated bones, will determine larj^ely the drainage of the normal secretion, whether it go forward or baclvAvard, and will also determine the liability to accumulation of dust. This may explain in many cases the catarrhal tendencies. Frontal headaches and facial neuralgia in many cases may be entirely dependent upon nasal or accessory sinus-lesion. The relation of the nasal regions to aliections of the eye will be men- tioned under a separate chapter. The changes produced in the blood are well shown in a series of blood-counts which I made in cases in which there was nasal obstruction, the coimts being made before and after the removal of the growths. In every case before removal the red blood- corpuscles (the oxygen-carriers) were reduced to .■>,000,000, in some instances as low as 1,500,000, with the hemoglobin reduced to 50 or 60 per cent, of normal, and in many cases with slight increase of the w^hite corpuscles. After removal of the obstruction both hemoglobin and corpuscles gradually increased to the normal. Occupation also causes mouth-breathing, as is seen in engineers, car-drivers, trainmen, motormen, and bicycle-riders. The tendency is to keep the mouth slightly open, and in many patients of these classes marked alteration in the mucous membrane of the pharynx and larynx will be found, due to irritation caused by the direct inhalation of dust. INFLAMMATION. As the diseases of the mucous membranes are nearly all in- flannnatory, before taking up the diflerent varieties it is necessary to consider the structmv of the membrane as \vell as its general and sj)ecial inflammatory lesions. Mucous membrane consists essentially of three layers or parts : (1) Upon the surface, ej)ithelial cells; (2) abasement membrane upon which the epithelial cells rest; (3) the submucous connective tissue, in which ramify the blood-vessels, lymphatics, and nerves essential to the life of the layers above (Fig. 7). The epithelial layer varies in two particulars — chiefly the character of the epithelium, and the number of its layers. As a lining membrane of open cavities, it is essential that it should be soft, moist, and pliable. This is especially true of the nasal cavities, where the surface is exposed to the drying action of the air. Tlu^ anatomical arrangement and physiological function of the mucous membrane fortunately counteract this tendency. GENERAL CONSIDERATION OF MUCOUS MEMBRANES. 53 The anatomy of the mucous membrane is the same wherever found, with slight variation as to function and layer of epithelial cells. Where the function of the epithelium is protective in char- acter, it is found in several layers ; where secretion is essential, there is usually but one layer. Where protective or propulsive force is needed, the epithelial cells are supplied with cilia, as in the bronchi and in the anterior nares. Epithelial cells possess the faculty of manufac^turing from supplied nutrition new chemical compounds, as is seen in the secre- tion of the salivary glands, the gastric follicles, and the pancreas. Every mucous-membrane surface is, then, as it were, a labora- tory by which is elaborated material, of which the most constant is mucus. When altered by disease its physiological product is changed and does not serve its proper function, or it prevents the excretion of an agent for which the organism has no further use. The degree of this perversion of cell-activity largely controls the classification of mucous-membrane diseases. As cellular function is controlled by nutrition, and as the epithelial layer is dependent upon the subepithelial layer for its nutrition, any alteration in these substructures, local or constitutional, must necessarily aifect the functional activity of the epithelial cells. The basement membrane consists essentially of two layers, one of which is always present, though both may not be demonstrable. The outer or genetic layer is composed of that part of the epithelium which reproduces the cells above ; this layer is absent in a few instances, in which, when the surface is deprived of epithelium, it re-forms from the margins. The connective-tissue layer of the basement membrane is con- stant. This layer is composed of fibrous tissue, and may have a scant supply of unstriped muscle-cells. The basement membrane varies in thickness. In the mouth and nose it is easily demonstrated, while in the alveoli of the lung it is almost invisible. Where changes in the size and surface of the organ occur, the basement membrane appears in irregular ridges. The nerve-fibers do not penetrate the membrane, the basement membrane being just beyond them, while the lymphatics open by stomata immediately beneath or into the genetic epithelial layer. The submucosa (the submucous connective layer), being the vascular layer, is the most important, and varies with location. In the anterior nasal fossae it is erectile, and where the tissue is subject to rapid alterations in surface, as in the stomach, it is espec- ially abundant. The function of the mucous membrane is to secrete mucus, to offer an absf)rbent surface, and to afford a smooth, moist, plial)le, and protective lining to the ()])en cavities — that is, those communicating with the exterior of the body. The follicular and mucous glands 54 DISEASES OF THE NOSE AXD THROAT. secrete mucus, while at the same time the epithelial cells elaborate it. The rapidity witii which fluids are absorbed is a physiological characteristic of mucous membranes. This action depends, with few exceptions, larirely on the number of layers of epithelial cells. Inflammation of the Mucous Membrane. — Before giving the special inlhunuiations of the mucous incinl)rane, for the con- venience of the student inllaunuatiou in general should be con- sidered. " luHannnation is the aggregate of those changes which take place in any tissue as the result of an injurious action to which it has been exposed, providing the injury is not sufficient to devital- ize the part." Injury does not necessarily mean trauma, but may be direct or indirect irritation (toxins) — mechanical, chemical, or thermal, local or constitutional. In all acute inflammatory lesions certain changes or i)henoniena take place. These changes may be considered from two standpoints — the macroscopical or clinical, and the micro- scopical. The e/i ideal phe)ioinena are subjective and objective, and com- pose the five clinical symptoms — pain, swelling, heat, discoloration, and disordered function. The microscopical phenomena are demonstrable only under magnification, and may be briefly stated as follows : Dilatation of the blood-vessels, with increased flo\v and accumulation of blood in the parts, followed by a retardation of the current, due to lessened lumen caused by the adherence of the white corpuscles to the wall of the vessels, together with paresis and jiaralysis of the vessel. This condition, increasing, causes oscillation of the now sluggish current, followed by complete stasis. Previous to the stasis some of the liquid portion of the blood exudes into the perivascular tissue ; after stasis this exudation is more marked, and with it there is a migration of the white cor- puscles by their ameboid movement ; this migration, when com- pleted, is known as diapedexis. If the inflammation is severe and sudden, there is also migrati(m of the red corpuscles. This process is^ followed either by absorption of the exudate or by proliferation of the fixed connective-tissue cells and the migrated corpuscles. In the latter case, if nutrition is good, capillary budding takes place, and by the process of canalization the tissue is vascularized; but if nutrition fiiils and the tissue is not infected, simple lique- faction-necrosis and absorption may occur ; if, however, the area be infected, suppuration will take place. All inflammatory conditions are divided into three stages : Fird triage. — The change is in the blood, in its current, and in the blood-vessel walls — the intravascular stage, clinically the dry stage. Second Siaye {Extramscidar ^tayc). — Exudate of liquor sau- GENERAL CONSIDERATION OF MUCOUS MEMBRANES. 55 guinis and migration of white cells ; clinically the wet stage, but more properly the exudative stage, as the exudate may be plastic (dry). Third Stage. — The terminative stage, depending on the condi- tion of nutrition and infection. These three stages are the constant phenomena of inflammation. By special inflammation is meant the phenomena that occur in various tissues, organs, or parts, or of a special disease or group of diseases. CLINICAL, PHENOMENA. MICROSCOPICAL PHENOMENA. (1) Heat. f (1) Contraction (?). (2) Dilatation. I (3) Acceleration. (2) Swelling. First Stage -| (4) Accumulation. (5) Retardation. (3) Pain. (6) Oscillation. L (7) Occlusion. (4) Discoloration. Second Stage \ gj Exudation (of liquor sanguinis). ^ ' (. (9) Migration (ol corpuscles). ici\ T\- J ^ c r (10) Termination — (a) by resolution ; (5) Disordered func- ^j^^^^ g^^^^ ^^^ ^^ new-formltion ; (c) by [ suppuration. tion. The second stage, as a rule, determines the variety of inflam- mation. The varieties of inflammation of mucous membranes that pathologically constitute special forms of inflammation, are : 1. Catarrhal. 2. Membranous — (a) croupous or pseudomembran- ous, (6) fibrinoplastic, and (c) diphtheritic. 3. Hemorrhagic. 4. Gangrenous. 5. Suppurative. 6. Chronic infectious. From these originate nearly all the varieties of rhinitis. In addition, there are the constitutional diseases, infectious fevers, etc., which cause many lesions of the mucous membranes, Avhich properly come under one of the varieties above, differing slightly in cause and treatment. (1) Catarrhal Inflammation. — From a clinical standpoint catarrhal inflannnations arc divided into the acute and the chronic. Pathologically the conditions found are the resultants of processes usually acute to a greater or less degree, which merge into the chronic by a continuation of one of the stages of the acute variety or by repeated acute attacks. (a) Acute catarrhal inflammation of tlic upper respiratory tract may be due to a great variety of causes ; all of these causes, how- ever, produce the condition in one of two way.s — by direct external irritation of the membrane, or by exerting their influence from the circulatory side of this structure. Of the factors that bear an etiological relation to tliis condition, infection is i\\v most common. Catarrhal inflammation of the mu(!Ous nuMnbriUic, especially of the upper air-passages, is eitlier the ('onconiitant or tiic sequel of such 56 DISEASES OF THE NOSE AND THROAT. acute infoctioiis diseases as measles, scarlet fever, typhus fever, diphtheria, and typhoid fever, while a similar condition will be found in the early stages of such chronic diseases as tubercu- losis and sypiiilis. After infection a large variety of causes may be grouped under the head of irritants, comprising exposure to cold, foreign bodies, heat in the form of either hot air or steam, irritating gases (such as chlorin, broiuin, ammonia, sulphurous acid), poisonous escha- rotics (as the mineral acids, arsenic, etc., in sufficient dilution not to destroy the surface with which they come in contact), ptomains, etc. Rapid thermal and barometric changes, excessive humidity, and sudden changes in atmospheric pressure (caisson disease) are by no means uncommon causes, the inflammation being brought about by the alteration in the circulation and secretion, which is followed by a lessened normal resistance to the disturbing agent. This is practically true of all causes acting from without. Catarrhal inflaiumatiou may also be caused by a pure mycosis, as occurs in thrush. Pathological alterations in the lungs, kidney, and liver may be predisposing factors or even actual causes of the condi- tion. The same is true of rheumatism, gout, and allied conditions, as well as of intestinal irritation with obstruction to the circula- tion. Age is an important factor, the resistance of the membrane being at its maximum in adult life, while in the young and the aged it is most feeble. The above may not embrace all the causes of catarrhal inflam- mation of the respiratory tract, yet the majority not mentioned are subdivisions or closely allied to those given. It is imj)ortant to remember in this connection that all mucous- membrane inflammations, of whatever type, have a catarrhal stage, just as cutaneous inflammations are associated with des- quamation. In the flrst stage of the inflannuation the surface is dry, and, owing to obstruction of the nniciparous glands brought about by the engorged vessels of the sul)uuicosa, is usually covered by a thin layer of tenacious nuicus. Tiiis condition is soon followed by edema, due to the presence of the exudate in the submucosa. The tissue then becomes swollen, and when this occurs in the upper air-passages breathing is necessarily interfered with, the swollen membrane lessening the lumen and restricting the free passage of air. The color is an intense, almost dusky, red. The infiltration of the submucosa with serum and leukocytes follows close upon the engorgement of its vessels. The epithe- lium, being in this way deprived of its nutrition, becomes cloudy and swollen, and begins to desquamate. The voice becomes husky, at times even being lost, because of the lack of secretion brought about by this congestion of the submucous vessels. Nasal breath- ing is interfered with by the engorged erectile tissue, and a pecul- GENERAL CONSIDERATION OF 3IUC0US MEMBRANES, bl iar '' nasal twang " is given to the voice, o^ving to the lack of the customary resonating space. This first stage usually gives way in a short time to an abun- dant secretion. Desquamation of the epithelial cells rapidly takes place, and the surface is covered with an exudate consisting of degenerated cells, including epithelial nuclei, leukocytes, and serum, the amount of fibrin and albumin present depending on the cause and severity of the inflammation as well as upon the condition of the blood. By the pouring out of the exudate and by the action of the lymphatics the infiltration in the submucosa is usually greatly lessened, and if the cause underlying the con- dition be removed, the circulation in the affected area will soon return to normal. The epithelial layer is re-formed from the genetic layer. As the basement membrane is rarely aifected by inflammation of the acute catarrhal type, ulceration is not often seen. Should it occur, however, it will generally be found to be due to arterial thrombosis causing localized superficial death by coagulation- and liquefaction-necrosis. (6) Chronic Catarrhal Inflammation. — A series of acute in- volvements of the mucous membrane, due to the causes given above, often precede inflammation of this type. More frequently, however, these acute attacks will be found as local manifestations of a persistent systemic affection such as syphilis, the slowed cir- culation of chronic heart disease, the blood-changes and vascular changes of Bright's disease, gout, rheumatism, and malaria. Con- tinued local irritation, as by a tumor, will effect a similar result. Permanent alteration in the tissue will result from the infiltration of the submucosa by the leukocytes and serum. This embryonic tissue is produced by the proliferation of the migrated leukocytes and the fixed connective-tissue cells, which, if nutrition be ade- quate, goes on to organization and the formation of a fibrous structure which alters the nutrition of the submucosa by contrac- tion and impairs the functional activity of the mucous glands. The membrane is thickened and edematous in the early stage of the condition, because of the abundant exudate in the submucosa. By organization of tins inflammatory exudate, together with a proliferation of the fixed connective-tissue cells, the so-called hy- pertrophic condition is l^rouglit about. Extension of the process by the contraction of the newly-formed submucous tissue, thereby lessening the blood-supply to the surface and altering tlie normal function of the meml)rane, with consequent shrinking and enlarge- ment of the lumen of tlie air-passage, merges it gradually from one of apparent hy])ertro])hy to one of atrophy, a condition which has also been called ''dry catarrh," because of the diminution in the secretion, due to the contraction above mentioned. Irrespec- tive of the original cause of the inflammation, should the secretions 58 DISEASES OF THE NOSE AXD THROAT. (usually dry and ditlicult of reineval) be infected by the bacteria of decomposition, titid and ])oisonous products will result, as uuiy be seen in ozena and in clironic iuHaniniations of the ear. (2) Membranous Inflammations. — In regard to the mem- branous iuHamniations there is mucli diversity of opinion. From a pathological standpoint they may be divided into : (rt) Croupous or pscudomeiiibrcuious inflammation, which is the lowest grade of membranous exudate, and is not due to any specific bacteria. The exudate, a highly coagulable albuminoid material, forms on the surface of the mu{H)us membrane, and does not ulcerate nor organize. This condition may be ])roduced by irri- tants (as chlorin and ammonia) or by escharotics Mhitdi do not de- stroy the basement membrane ; it may also occur in infectious fevers, pyemia, and allied conditions. It is not necessarily limited to the upper air-passages, but may occur in tiie intestines or in the bronciiial tubes — in fact, on any mucous membrane. The bacteria wiiich an^ possibly etiological factors are the stre])tococcus (identi- cal witii that found in suppuration and erysipelas) and Von Hoff- mann's bacillus. (6) Fihrinoplastic inflammafiou, in ^vhich there is thrown out upon the surface a plastic material capable of organization, non- bacteric in causation, and in which the membrane tends to organize either in layers or in mass, and is usually limited to the nares. (c) Diphtheritie Inflammation. — This variety, like all the mem- branous varieties, begins as a catarrhal inflammation. The exudate is of a low grade and is due to a specific germ, the Klebs-Loffler bacillus, or Bacillus diphtherije. The diphtheritic poison ])roduced by the germ induces, first, a death of the superficial epithelium and the leukocytes with which it comes in contact, followed by a change in the deeper cells of the mucosa. Tiie second change is a eoftf/ulation-necrosis or hvaline transformation of the affected cells, the filse membrane being an aggr(>gation of dead cellular elements, nearly all of Avhich have been transformed into hyaline material. That the foci of necrobiosis start from the epithelial surface and proceed inward is a distinguishing characteristic of diphtheria. The membrane forms on the surface as in any membranous condition, but on its removal a bleeding surface is exposed. This condition is due to destruction of tissue, or ulceration, and on further examination it will be found that this ulceration extends through the basement membrane, or that, the nutrition which necessarily comes from the submucosa being cut off, the area beyond, which is dependent upon it for nutrition, undergoes infective coagulation-necrosis with sloughing. In this variety of inflammation, should healing occur, flbrous-tissue formation and contraction will follow, with only partial, if any, re-formation of the e])ithelial coating. GENERAL CONSIDERATION OF MUCOUS MEMBRANES. 59 (3) Hemorrhag-ic Inflammation. — Inflammation of this variety does not often afPect mucous membranes, but when seen is usually found accompanying processes virulently infectious, such as pyemia, septicemia, diphtheria, and anthrax ; it may, however, follow the application of a counterirritant, such as carbolic acid. It consists in a rapid inflammation of the mucous surface, with hemorrhage into the interstitial structure. The capillaries supplying the area are blocked up, and the blood may even be poured out on the sur- face of the membrane. Should the area involved be small, it is likely that gangreue will result. The essential point of difl'erence between this condition and simple purpuric interstitial hemorrhage is that the latter is absorbed without destruction of the mucous membrane, while in hemorrhagic inflammation destruction of tissue invariably takes place, with a resulting scar. (4) Gangrenous Inflammation. — Inflammation of this type is usually found in debilitated children, following one of the acute infectious diseases, most commonly measles. It may be due also to burns, scalds, or trauma of the mucous surface. An embolus cutting off the blood-supply to a limited area may give rise to the condition. The careless administration of such drugs as mercury, antimony, and arsenic may bear a causal relation. The inflammation may be the result of a hemorrhagic process, as before mentioned. The condition is common in diphtheria. Its mechanism is the same, irrespective of causation — /. e., the circulation supplying a certain area is cut off, and coagulation- necrosis and gangrene result. Breaking down of the tissue follows, due to infection, be it primary, secondary, or multiple. Because of the fact that the submucosa is involved to a greater or less degree in all cases, the lymphatics are widely opened and absorb the toxic products of the microbic infection, which eventually gives rise to a condition of general septic intoxication. Hemor- rhage may result from the breaking down and infection of the obliterating thrombi blocking up the vessels. Bacteria (most often the streptococcus), entering the opened lymphatic pathways, may cause enlargement and even abscess-formation in the neighboring lymph-glands ; or, should they effect an entrance into the blood- vessels, septicemia may result. Gangrenous inflammation is not often seen in the nose, but is common on the tonsil and in the mouth and jiharynx. (5) Suppurative and Pustular Inflammation. — This variety of inflammation may occur in the (ujurse of septicemia, pyemia, chicken-pox, small-pox, or erysipelas of the nuicous meml)rano, but is rarely seen in other infectious diseases. The formation of pus in the submucosa may be due to mixed infection in diph- theria. The submucosa may become infected by abrasion or de- struction of the protective epithelium, due to the fact that the over- lying structure offt;rs more resistance than the glandular basement 60 DISEASES OF THE NOSE AND THROAT. membrane. The ])()uriiio: out of the infected contents of these glands into the snbinucosu results in distention and pus-formation. Suppurative tonsillitis and similar affections are caused in this way. Pus, being a ])r()duct of connective tissue, develops in the submucosa, and secures egress by rupture of the basement mem- brane, through gangrene or ulcerative processes ; or the infected material may be disseminated by means of the lymphatics, as occurs in gangrenous iuHanunation. It is to be noted that sup- purative processes are, as a rule, found in those areas of the mem- brane most liable to injury or where numerous sulci afford easy lodgement for the infected material. (6) Specific Inflammatory Processes. — Si/}ionj/ms. — Chronic infectious intiammations ; Specific granulomata ; Chronic specific inflammatory ])rocesses ; Infectious granulomata. Of tlie specific inflammatory processes there are six varieties : CI) Syphilis; (2) tuberculosis; (3) actinomycosis ; (4) glanders ; (5) leprosy; (6) rhinoscleroma. (1) fSijphiUs. — The mucous membrane is commonly the seat of the primary lesion of syphilis. At its site the submucosa becomes infiltrated with small, round, epithelioid, and giant cells. By obliterative changes in the arteries the blood-supply to the surface is cut off, and ulceration ensues. These necrotic areas occur on the tongue, gums, cheeks, tonsils, palate, and pharynx. The ter- tiary lesion (gummata) of the mucous membrane occurs in the sub- mucosa, develops in the same manner as any other infectious granuloma, and passes through the same ulcerative process. When healing occurs, owing to the amount of fibrous tissue developed, marked contraction takes place, giving rise to strictures, usually presenting a characteristic stellate scar. (2) Tuberculosis. — As a rule, tubercular conditions of the ujiper air-passages are secondary to pulmonary lesions, yet primary tuberculosis of tlie upper respiratory tract is not a rare condition. Tiie cause of tuberculosis, the tu.hr rc/e bdci/las, gains ingress to some portion of the mucous-membrane tract, and miliary tubercles develop around the vessels in the submucosa. ^\"ith the destruc- tion of tissue and the enlargement of the tubercle, which is a homogeneous, non-vascular mass, tlie basement membrane and epithelium are deprived of their nutrition by the obliterative vas- cular changes induced, causing necrosis with ulceration. The basement membrane and the epithelial cells break down and an ulcer is fi)rmed. Througli this opening the tubercular caseous material is discharged. Since the tul)ercular infiltration follows the blood-vessels, it is a natural seciuence that the long axis of the ulcer is, as a rule, transverse to the h)ng axis of tlie membranous tulx", owing to the circumferential distril)ution of the vessels. Sur- rounding the area of ulceration new fibrous tissue may develop, whicii when contracting causes stenosis. GENERAL CONSIDERATION OF MUCOUS MEMBRANES. 61 (3) Actinomycosis. — This affection is common in the mouth, and is clue to the ray fungus, or actinomyces. Abrasion of the mucous surface affords a nidus of infection which is usually introduced into the system by food containing the bacteria. The granulation- tumor which develops is similar in structure to the tubercle ; the surrounding zone of proliferating tissue usually resembles sar- coma. Sooner or later mixed infection occurs and suppuration follows. The finding of the ray fungus in the tissue or discharge determines the diagnosis. (4) Glanders. — This disease, which is caused by the Bacillus mallei, usually manifests itself in the nose in the form of ulcers resulting from the breaking clown of the nodules whicli have formed in the submucosa in the same manner as in the preceding forms of inflammation. In the acute form gangrenous and septic conditions may occur. In the chronic form the ulcers resemble those due to protracted catarrhal conditions, tubercular or syphilitic disease, but are differentiated by the finding of the bacillus in the dis- charge. In the mucous-membrane surface from the overgrowth of the surrounding connective tissue and the extensive involvement of the submucosa, the resulting growth will clinically closely resemble sarcoma, as was shown in a case under the care of Dr. Emma Musson, of Philadelphia, in which the diagnosis was only estab- lished by microscopical examination and bacteriological investiga- tion, by which means the bacillus of glanders was clearly demon- strated. (5) Leprosy. — This variety of chronic infectious inflammation is rare in the upper air-passages, but occasionally may attack the nose and larynx, and is usually of the tubercular variety. The leprous nodule is formed like that of tuberculosis ; though ulceration does not always take place, pyogenic infection and breaking down may occur. The disease is due to the Bacillus leprce. (6) Rhinosclerom.a. — This rare variety of inflammation mani- fests itself in a thickening and tumefaction of the nasal mucous membrane ; also the larynx may be tlie site of the lesion. Micro- scopically, the tissue appears to be allied to the round-celled sar- coma, though there are present certain small, highly-refracting hyaline bodies which form a characteristic element of the growth. The newly-formed cells do not present the finely-granular indis- tinct nucleated appearance met Avith in lupus and leprosy. The tumefied areas are at first red or pink and very tender, but later the tissue becomes white. The disease is- believed to be due to the Bacillus rhinoscleromatii<, but the belief is by no means general. It is most common in Austria, Russia, and Central America, and is rarelv seen in this country. It is essentially a chronic condition. 62 DISEASES OF THE NOSE AND THROAT. NASAL BACTERIA AND THEIR RELATION TO DISEASE. Within the jiast few years there has been consideral)le investi- gation as to the import of bacteria present within the nasal chambers, and the relation of such bacteria as causal factors in disease-processes. Opinions differ as to the presence of pathogenic bacteria in the normal nasal secretions and in normal membranes. This raises the question as to Avhat constitutes a normal nasal mucous membrane. While the membrane may be normal as to its function, yet the construction of the nasal cayity may be such as to permit of the accumulation of normal secretion within that cayity. This accumulated normal secretion forms a suitable nidus for the lodgement of dust and other irritating materials, which would soon cause local alteration, besides peryerting secretion and being nutrient media for the deyelopment of bacteria, which are constantly being inhaled and find lodgement in the localized irri- tated areas. Inoculations from a nasal cavity in which, as regards structure, anatomical relations, and physiological functions, the tissue is what is called normal, in the majority of cases will show bacteria present ; however, unless the normal secretion has been retained and has undergone some chemical change, it does not form a suitable nidus or medium for the development of bacteria. Another important question whicii arises is the pathogenesis of the ])acteria present. Although of the variety known as patho- genic, they may l)e non-virulent, and if the mucous membrane is not subjected to some irritation giving rise to lessened })hysiological resistance of the epithelial cells, these bacteria do not find a nidus for proliferation and are practically harmless. From my own in- vestigations, which include over 200 inoculations, I have been unable to draAV any definite conclusions ; however, the surround- ings of the individuals have mucli to do M'ith the presence or absence of bacteria, as well as the variety, found within the nasal chambers. For example, inoculations from nasal cavities which presented normal appearances, made under different sur- roundings, gave entirely different results. Repeated inoculations were made from the same individual, from the nasal mucous mem- brane, on rising in the morning, after staying in an office or room for several hours, after having been exposed to the street dust, and aft(n' having attended places of amusement. The results ^vere as varied as though the experiments had been carried on in diffcnvnt individuals. Again, inoculations made from individuals having various forms of catarrhal inflammations of the nasal mucous membrane gave the same varied result ; however, in many in- stances I believe that the bacteria bore an important relation to the inflammatory conditions present, but that their etiological Halation was secondary and not causal, and that before the bacteria found access to the mucous membrane there was some alteration in GENERAL CONSIDERATION OF MUCOUS MEMBRANES. 63 the epithelial surface, brought about either by external or internal irritants, which lowered the physiological resistance of the indi- vidual epithelial cells. Besides pathogenic bacteria, there are associated varieties of the blastomycetes, which, while not possess- ing any pathogenic properties, are capable of producing irritation and admit of absorption of saprophytic products. If the nostril is thoroughly cleansed under the strictest antiseptic precautions, and a pledget of sterilized antiseptic cotton placed within the nose, which in turn is protected by antiseptic measures, in the majority of cases the secreted mucus will be free from bacteria ; but from my own experience it is almost impossible to render the mucous surface thoroughly aseptic. As to the antiseptic properties of the nasal mucus, I am willing to grant that in certain individuals the secretion possesses such properties, depending upon the chemical reaction of the secretions — which differs in individuals — and it is largely controlled by the general healtli of the individual and by constitutional diathesis. In persons with irritated mucous mem- branes and w^th excoriations about the nasal orifice, in which, from urinary examination and from testing the nasal secretions, it was found to be decidedly acid, the bacteria present were non- virulent, and where growths w^ere obtained on blood-serum they were feeble and slow of development. This can be explained by the fact that with few exceptions pathogenic bacteria require alka- line media. In diseases of the nasal cavities in which there is accumulation of secretion, as is the case in the various forms of atrophic rhinitis, the bacteriological examinations present such a variety of bacteria that no special one can be assigned as an etiological factor. Besides, there are always present the bacteria of decomposition — the saprophytic bacteria ; however, in such conditions it must l)e remembered that the products of these germs are constantly being absorbed from the mucous -membrane sur- faces, and in many cases may account for some of the ill effects on the general health of the individual, nearly always present in the advanced stage of disease. While the bacteria present may liave largely lost tlieir virulent properties, yet with suitable chem- ical constituents and reaction of the secretion, proliferation of the germ is favored and its normal virulence regained. Accumulated secretion in the nasopharynx and pharynx during sleep is fre- quently unconsciously swallowed l)y the patient. This infected material may ])ring about gastric disturbances, as is shown by the frequent association of gastric lesions with those of the upper respiratory tract ; however, this docs not explain many of the associated conditions, but often, wlien such a])]iarcnt relation exists, the local lesions were induced by and clependent ujion some constitutional condition wliich ])r()ught about tlic ](iA\cr('d resistance on the ]>art of the local ejiitlielial structures. The bacteria found ]>r('sciit on tlic nasal iiuicoiis membranes 64 DISEASES OF THE NOSE AND THROAT. and ill tlie secretion includes many of the patliogenic cocci and 1)acilli, besides many unelassitied non-pathogenic germs. The bac- teria most commonly found are the staphylococci or micrococci, especially the Staphylococcus pyogenes aureus, citreus, and albus, the Micrococcus pneumoniie (Friinkel), Bacillus tuberculosis, Fried- liinder's pncumococcus, Kl('hs-L(")lfler bacillus, Von Hoifmau's bacillus (bacillus of pseudodiphtheria). Bacillus foetidus, Loew- enberg's ozena diplococcus, and various forms of sarcina. Quite fre(piently the streptococcus is present, although in the ma- jority of instances it was associated with an acute inflammatory process. With this exception, frequently the isolated bacteria were not associated with any special inflammatory condition. Tiie bacillus of diphtheria was found on the apparently healthy mucous membrane, after the individual had been ex})osed by pass- ing through the diphtheritic wards in the hospital, although there was no associated inflammatory process. Frequently the bacillus of tuberculosis was found present after the individual had been exposed to dusty air of the street, the inoculations being made from the nasal mucous membrane after one-half hour's exposure to the dust. While I do not mean to belittle the importance of bacteriological investigation, nor the important relation of bacteria to disease, yet I do believe that, in a great many cases of lesions of the mucous membrane of the upper respiratory tract, the part played by the bacteria is purely secondary. If anatomical struct- ure of the nasal cavities is such as to permit of accumulations of secretions and dust, or the physiological resistance of the mem- brane is lowered by constitutional diatheses or organic lesions, the altered and accmnulated secretion forms a suitable nidus for bac- terial proliferation. CHAPTER IV. DISEASES OF THE ANTERIOR NASAL CAVITIES. Acute I^fPLAMMATOEY Diseases. Acute Ehinitis. a. Simple Acute Ehinitis. 0. In the Young. /3. Acute Ehinitis in Constitutional Diseases. 1. Measles. 2. Pertussis, or Whooping-cough. 3. Scarlet Fever. 4. Small-pox. 5. Typhoid Fever. 6. Eheumatism. 7. Diabetes Mellitus. 8. Epidemic Influenza. 9. Diphtheria. 10. Erysipelas. 11. Scorbutic Ehinitis. 12. Anemic Ehinitis. 13. Scrofulous Ehinitis (Strumous). 14. Caseous Ehinitis. b. Membranous Ehinitis. 1. Croupous or Pseudomembranous. 2. Fibrinoplastic. 3. Diphtheritic. (See Diphtheria.) e. Occupation Ehinitis (Traumatic). d. Hyperesthetic Ehinitis (Hay Fever). (See Neurosis.) e. Ulcerative Ehinitis. /. Edematous Ehinitis (Acute Edema). g. Phlegmonous Ehinitis. SIMPLE ACUTE RHINITIS. Definition. — An acute inflammation of the nasal mucous memljranc, extending occasionally to neighboring cavities, as the pharynx, the larynx, and the lower air-passages, and also in a milder degree to the accessory cavities. This tendency to exten- sion is usually shown only after repeated attacks. It is character- ized in the early stage by tumefaction and dryness of the tissues, followed by a copious discharge due to an hypersecretion and elaboration of mucus with cell-desquamation, and with more or less nas;d ol)struction. It may be limited to oue nostriL Synonyms. — Acute coryza ; Acute idiopathic rliinitis ; Acute nasal blenu(;rrhea ; Acute nasal catarrh ; Acute rhinorrhea ; Ca- tarrhal rhinitis; Cold, or Cold in the head; Common sporadic catarrh ; Rhinitis catarrhalis ; Simple acute rhinitis ; Simple catarrh ; Snuffles. 66 DISEASES OF THE NOSE AND THROAT. Ktiology. — Predisposing Causes. — Chief among the predis- posing cau.ses of acute rhinitis are the various manifestations of a lowered bodily resistance to the exciting causes, such as more or less extended confinement in unevenly or overheated rooms, lowered nervous tone, the so-called nervous temperament, prolonged mental strain, an enfeebled circuhition, feeble activity of the sudoriparous glands, the absence of the natural protection of the head, as seen in baldness, and extreme physical fatigue. Certain malformations of the nasal jiassages, as deviation of the septum, or stenosis by misdirecting the air-current, thus causing it to act as an irritant, or a membrane below par as the result of repeated acute attacks or of a chronic condition, may also be mentioned as predisposing factors. In some cases heredity seems to play a marked part. This is due to the inherited condition, or function of the nasal cavities, which predisposes to the disease. Some chronic condi- tions, as hay fever, asthma, rheumatism, tuberculosis, and sy])hilis are predisposing agents. Clothing either not suited to sudden changes of temperature, deficient in amount, or lacking over sensi- tive areas will produce a similar result. Some persons exhibit a tendency to acute rhinitis, which can be classed only under idio- syncrasy. Thermic and climatic conditions liave an important influence. Individuals living in low-lying districts and exposed to all extremes of heat, cold, and moisture, are more susceptible to acute rhinitis than those residing in higher and dryer altitudes. Sexual excesses exert a marked predisposing influence. The aged enjoy a comparative immunity from the afl'ection. Exciting- Causes. — The chilling of tlie body, whether from exposure to draughts, wet feet, sitting in damp clothing, or sudden exposure to cold after leaving an overheated room, or from cold to overheated rooms, violent exercise, or the like are the most prominent of the causative agencies. Prolonged exposure to un- due heat, artificial or solar, is also given by some writers as a cause. Acute rhinitis occurs also as a concomitant condition in the onset of certain of the infectious diseases, notably measles, in- fluenza, and tertiary syphilis. The afl^ection may occur in certain forms of gastric and intestinal irritation, or follow the sudden cessation of the discharge in a case of otitis, gonorrliea, or oph- thalmia. It may be due to the extension of an inflannnation from the pharynx, larynx, conjunctiva, or the accessory cavities, an ex- acerbation of the chronic form of inflammation, or occur in connection with eczema or impetigo. Acute rhinitis occurs occa- sionally in epidemics, due probably to existing climatic conditions rather than to any specific; germ. Hajek, however, has described a large diplococcus, the " Diplococcus coryzse," present at tlie on- set of the attack, but its causative influence is as yet un])roven. Others suppose an organism to exist, which has an incubation- period of about two days. Whether the disease itself is conta- DISEASES OF THE ANTERIOR NASAL CAVITIES. 67 gious or not is as yet an open question, some claiming that it is, others that it is not, the latter citing the numerous failures to pro- duce the disease by inoculation with the discharge from a patient. There is much confusion, not as to what constitutes a simple rhi- nitis, but as to where the process ends. Some authors limit the process to what is strictly an acute coryza, but whether simple or associated, primary or secondary, it is the same ; its termination depending on its course, its association, its repetition. A very large proportion of cases occur in those whose occupa- tions expose them in a greater or less degree to the inhalation of irritants, mechanical or chemical. Such a list would include workers in irritant drugs, artisans employing chlorin, ammonia, etc., stone- cutters, cement- and bronze-workers, weavers, millers, threshers, and grinders of spices. Inflammation produced by such irritants is more properly classed under occupation or traumatic rhinitis. For- eign bodies introduced into the nose will also escite an acute rhinitis in a short time, as will also the presence of certain tumors of rapid gro^vth. The abnormal direction of the air-current striking against the membrane in an unnatural way, whether it be due to some structural alteration from trauma, morbid growths, or congenital defect, is also an exciting cause. Certain drugs, if given inter- nally in large doses, have an irritant effect upon the nasal mucosa, notably the prolonged administration of the iodids, and in some individuals the tincture of cinchona. Dry air from heaters or gas from the range or the stove may act as an exciting cause. The physiological resistance on the part of the individual largely con- trols the susceptibility either to predisposing or exciting causes. Pathology. — The pathology of acute rhinitis is essentially that of a simple catarrhal inflammation, a description of which has already been given in the chapter upon General Considerations. The membrane is swollen, dark red in color, the vessels injected, and during the early stage the surface is dry or glazed with a thin film of tenacious mucus. Following this there is an ^udate of the blood-fluid into the submucous connective tissue, with mi- gration of the white cells, and escape to a greater or less degree of the red corpuscles. Simultaneously there is a discharge of serum upon the surface which is clear, limpid, laden with salines, and irritant to the surfaces with which it comes in contact. The epithelium, deprived to a large extent of its nutriment, becomes cloudy, swollen, dies, and is washed off". The leukocytes pass out, and the serimi, at first clear and limpid, through admixture with these corpuscular elements and mucus, becomes abundant, cloudy, and thick, and is described as mucous or mucojiurulent according to the amount of cellular constituents present. Occasionally, if the inflammation he very severe, there may be small ccchymoscs seen, or minute abrasions or erosions may occur. If the attack be un- complicated and end in recovery, the vessels gradually regain their 6S DISEASES OF THE NOSE AND THROAT. tonicity, the extravasated elements are absorbed, the discharge upon the surface lessens and thickens, and finally ceases, the denuded epithelium is replaced by new cells arising from the genetic layer of tlie basement membrane, and the membrane then returns to the jn-oper performance of its normal function. Symptoms. — The attack is usually preceded by a general feeling of lassitude and discomfort, and if severe, with aching pain in the limbs and back. There may or may not be an initial chill. Generally there is more or less sneezing. Soon there fol- lows an oppressive sense of stuffiness in the nose, with obstruction to breathing and a dull, throbbing frontal headache over the site of the sinuses. The senses of smell and taste are impaired, and often that of hearing as well, due to involvement of tiie Eustachian orifice. The voice acquires an unaccustomed nasal twang. On inspection the nasal membrane is found swollen, dry, or glazed, and the nasal passages almost or quite occluded. The malaise increases, the skin is dry and becomes hot ; thirst, anorexia, and a furred tongue may be pres(nit. The nasal discharge, at first absent or scanty, becomes abundant, clear, and irritating from its excess of salines. Tiiere is more or less sneezing, the patient is obliged to use his handkerchief freely, and this with the irritant discharge gives rise to excoriation of the nasal alse and the upper lip. The alse of the nose are swollen, the eyelids are turgid, and there is ex- cessive lacrimation, with perhaps some photophobia. The dis- charge on declining may show a tendency to gravitate, the patient finding the lower nasal chamber filled with it on arising, while the upper chamber is clear. There is interference with proper masti- cation and deglutition, and the food, mixed with an undue amount of air from the necessitated mouth-breatiiing function, causes an uncomfortable sense of fulness after eating, which is soon relieved by eructation. The nasal discharge becomes thicker and more opaque as the second stage progresses, and the corpuscular elements -increase in number. In severe cases constipation de- velops, and the urine becomes high-colored. There may be a moderate fever. Toward the close there may be an intercurrent attack of labial herpes. During the second stage inspection shows a swollen membrane, intensely red, injected, and covered by the characteristic mucous or mucopurulent material. The second stage shades imperceptibly into the last, and if the termination be in recovciry the symptoms al)ate. The discharge becomes thicker and scantier, and may even crust or become iid'ected by saprophytes ; the swelling subsides, the constitutional manii'cstations lessen and disaj^pear, the special senses return to their normal state, and by a week or ten davs the attack is usually over. It must be borne in mind, however, that this description applies to the typical so-called "idiopathic" fi)rm, the " cold in the head " of popular nomenclature. Acute rhinitis DISEASES OF THE ANTERIOR NASAL CAVITIES 69 due to irritants, etc., as a rule, runs a shorter course, lacks the con- stitutional symptoms, and ceases usually after the withdrawal of the cause and the establishment of a free discharge. In speaking of the establishment of drainage, I am reminded that this flow from the anterior nares or from the posterior nares, or both, is dependent on the direction in which the turbinate bone or floor of the nose directs the flow from above — i. e., from sinuses or mucous membranes. In some cases considerable postnasal drip- ping or discharge is due to the backward tilting of the turbinates, directiug the mucus flowing from above backward instead of for- ward. Diagnosis. — Usually no difficulty attends the recognition of acute rhinitis, its symptoms being so constant and, as a whole, pathognomonic. The greatest care must be taken, however, in diagnosticating to search for symptoms of other severer maladies in the symptomatology of which acute rhinitis occupies a promi- nent place. Prognosis. — As a rule, the prognosis is favorable ; less so perhaps in the aged. Various complications may arise, or the condition itself may become a chronic one through repeated attacks due to continuation of the irritant, which may be acting from without or manifested from within the body. Complications. — The complications of acute rhinitis, as a rule, are not serious, and are so constant in well-marked idiopathic cases as to be classed under symptoms. Extension of the inflam- matory process to the accessory cavities, which may become acutely suppurative, temporary occlusion of the nasal and aural ducts with consequent epiphora and perverted audition, acute conjunctivitis, pharyngitis, laryngitis, otitis, which may become suppurative, and labial herpes which may be the starting-point of a facial erysipelas, are mentioned as possible complications, only that they may be anticipated and avoided by proper prophylactic treatment. Treatment. — The treatment of acute rhinitis depends on the severity of the attack, the condition of the individual, as well as upon how far the inflammatory process involving the nasal mucosa has progressed. Unfortunately the patient rarely presents himself for treatment in the first stage of the affection. However, if the opportunity is afforded, much can be done to a])ort an attack. The blood-vessels in the submucosa in the first stage of the process are engorged. By the presence of this engorgement the ducts of the secreted glands arc occluded, giving rise to dryness of the surface, the swelling being due largely as yet to the engorged vessels. The depletion of these vessels may be brought about in one of two ways, either by hastening exudation or by the use of remedial agents which, by their action on the ncrvc-fila- ments controlling the peripheral vessels, will cause contraction and thereby depletion. 70 DISEASES OF THE NOSE AND THROAT. If tlu! former plan be followed, there should be placed in one or both nostrils, depending on the involvement, a tablet c(m- taining 1 grain of sodium ciilorid. This shoidd be allowed to remain in position until completely dissolved. Its dissolution will be followed by a copious How of mucus and serous exudate, leaving the membrane pale and relaxed. This should be followed by tlie ap{)lication of an agent that will protect the membrane. For this i^urpose there is nothing better than a balsam preparation or an oily solution. If a slight astringent action is also desired, there should be applied to the membrane, by means of cotton and prol)e, a solution of equal parts of the compound tincture of ben- zoin and 50 per cent, boroglycerid. If protection merely is wanted, there should be dropped into the nostril a few drops of the fol- lowing solution every two hours, continuation depending on the relief aiforded : I^. Olei cassise, Olei santali, da gtt. vj (.36) ; Alboleni (liquid), flgj (30). If depletion by contraction is desired, there is nothing better for the purpose, notwithstanding the objection to the reactionary relaxation, than a weak solution of cocain ; 4 per cent., as a rule, will suffice. Personally, I insist on making the application of this drug myself, thereby lessening the danger of creating the cocain-habit by placing in the hands of the patient one of the most dangerous drugs. If good results are to be obtained from the cocain, it must be used at least every three hours for not more than four applications. Tiio frequency of treatment necessarily lessens the practicability of the procedure, as it would only be singers or public speakers, who depend on their voice for their livelihood, that would resort to the physician for such prompt relief. Heat applied in the form of a partially-filled hot-water bag, or the frequent application of a towel wrung out in hot water, or hot air applied by means of the apparatus as shown in Fig. 31, will relieve the disagreeable frontal headache due to the engorgement of the frontal sinus secondary to the nasal congestion. A simple and often eifective procedure for the relief of this engorgement is to lean over the bath-tub or basin and dash into the face and nos- trils water as hot as can be comfortably borne. Internally the administration of a purgative is advantageous. This should be given although there is no tendency to constipa- tion, the object being depletion through the intestinal tract. Besides the depletion, the intestinal tract will, in this way, be rid of any irritants or sources of auto-intoxication which in them- selves might be causes predisposing to the attacks of coryza. If DISEASES OF THE ANTERIOR NASAL CAVITIES. 71 the patient can remain indoors during the day, or if he is seen in the evening, the administration of a 10-grain Dover's powder will, by its diaphoretic action, materially aid in the relief of the nasal congestion. This should not be given unless the patient will remain indoors at home. If the attack is ushered in by the more marked constitutional symptoms, there should be administered every three hours, until four doses have been taken, 5 grains of bromid of quinin. This should be followed by a warm drink, preferably a hot lemonade. Equally as good results can be ob- tained in this way as by a Turkish bath or by the hot-air bath, and there is less danger of evil after-effects. The patient should not be confined to his bed or even to his room, unless from the severity of the attack involvement of the accessory sinuses or the middle ear is threatened. Frequently it is impossible for the patient to be confined to his house, and usually his symptoms are not sufficiently alarming to justify such a course. In such cases admirable results can be obtained by the use of the following : I^. Pulveris camphorse, gr. | (.03) ; Extracti belladonnee, gr. ^ (.007) ; Quininse bromidi, gr. j (.06). M. et fiat capsula No. i. This should be given every hour for three or four doses, or until the patient notices the physiological dryness in the throat, when the administration should be stopped for some three or four hours. The patient should also be instructed to drink plenty of water with the taking of each pill or tablet. In cases of cold due to exposure alone and with its manifestations limited to the nose, the fol- lowing, if used early and in proper dose, usually aborts the pro- cess. There should be given every hour 5 grains of the modified official compound morphin powder (Tully's) in Avhich there has been substituted for the morphin ^ grain of codein. This does not have the disagreeable nauseating effect of the morphin. This preparation should be given in 5-grain capsules every hour for three or four doses, the last dose taken at bedtime with a hot lemonade. In the second stage, or the stage of profuse exudation, very lit- tle can be done for the immediate relief from the secretion, as the process is going on to a resolution in tlie natural course of an inflammation. However, something can be done to prevent block- ing up of tlie nostril by tlie profuse secretion. Tliere should be used through the Berminghani douclie an alkaline solution consist- ing of 10 grains of biborate aiid bicarbonate of soda to the ounce of water, or, what is still more soothing to the membrane, tepid milk to which has been added 8 grains of sodium chlorid to 72 DISEASES OF THE NOSE AND THROAT. the ounce. Tliis should be followed by inhalations of l)enzoin with oil of tar, placing a tablespoonful of the compound tincture of benzoin with a fourth of a teaspoonful of the oil of tar in a vaporizer, as shown in Fig. 32, or an ordinary cup, or any wide- mouthed vessel ; there is then poured in the vessel a half-pint of water, which should be almost at the boiling-point. The cup is held so that the patient may inhale the fumes rising from it. Should the secretion be very profuse and thin with a prolongation of the second stage, astringents may be employed. For this pur- pose a 2 per cent, formalin solution will give admirable results, despite the pain arising from the application. Equally as good is the 2 per cent, solution of clilorid of zinc. If astringents are resorted to, there should be applied to the membrane, beginning at least four hours after the application of the astringent, the follow- ing : I^. Olei eucalypti, gtt. ij (.12) ; Olei cassia, gtt. iv (.249) ; Alboleni, flsj (30.00). The patient should be instructed to apply by means of an ordi- nary medicine-dropper a few drops of this solution into the nos- tril every few hours. As to the repetition of the astringents, the effect of a given application must determine. A good cleansing solution as well as astringent is : J^. Extracti hamamelidis (aqueous), 5J (30.) ; Extracti hydrastis (aqueous, colorless), siv (15.); Aquse destillatie, q. s. ad gij (60.). — M. Sig. — A few drops in each nostril two or three times daily. Internally during this stage, especially in cases in w^hich the constitutional sym])toms continue, good results can be obtained from the following : Iji. Ammonii chloridi, 51] (7.5) ; Tinctune oi)ii deodorati, gtt. xl ad Ix (2.4-3.6) ; Sacchari, .^iv (15.) ; Aquffi camphors, q. s. ad flsiij (90.). — INI. A teaspoonful should be administered every two hours for four doses, and repeated once every three hours as long as the symp- toms demand it. If, after the relief of tiie profuse exudate, there should be a tendency to bogginess of the membrane, 20 per cent. chromi(;-a('i(l solution should be applied to the swollen membrane. ]>elbre applying the chromic acid the tissue should be thoroughly wijied dry l)y means of a cotton-covered probe, and this followed by a 4 per cent, solution of cocain. After allo^^ing the cocain to DISEASES OF THE ANTERIOR NASAL CAVITIES. 73 evaporate thoroughly, the membrane is again dried and the chromic acid applied. The object of drying the surface is that the acid may not be diffused over the surface. In applying the acid a very small piece of cotton should be tightly wrapped on a thin, fine-pointed probe. This should be dipped in the acid, the excess removed by drying with another piece of cotton, and instead of mopping the surface with it, the probe should be drawn in straight, parallel lines over the turbinates. If there be threatened involvement of the accessory sinuses, the quickest method of arresting the speading is by relieving the nasal engorgement. This can be done by puncturing the nasal mem- brane by means of a sharp-pointed bistoury, which will relieve the local congestion. Anodynes should be pushed and thorough pur- gation insisted on. Heat should be applied externally and the nostril sprayed with water as hot as can be borne. Should the Eustachian tube become involved in the catarrhal process, the secretions collected within the tube should be drawn off by means of the Eustachian catheter and suction-apparatus, care being taken to use no inflation. Should examination of the urine, in an indi- vidual subjected to repeated attacks of acute rhinitis, show uric- acid tendency, the treatment should be directed toward the relief of the diathesis. Of the many alkalies used for this, one of the best is citrate of lithium in 5- to 20-grain doses. Acute Rhinitis in the Young. This condition differs but little from that observed in adults, save in such modifications as may arise from the relatively smaller nasal spaces and orifices of the connected structures. The causa- tive influences with certain limitations and the pathological char- acteristics are identical. The symptoms are practically the same — sneezing, evidences of discomfort, swelling of the nasal mem- brane, noisy mouth-breathing (especially during sleep), an abun- dant discharge from the nostrils, with some lacrimation or photo- phobia. In the very young an important symptom is the lessened ability of the infant to nurse, it being unable to grasp the nipple properly or exert sufficient suction. The attack, as a rule, runs a course of from one to two weeks, and the diagnosis of the con- dition is not difficult ; a differential diagnosis must, however, be carefully made between a simple acute rhinitis and that associated with congenital syphilis. The foHowing table presents the chief points of impoi-taucc in the early condition : 74 DISEASES OF THE NOSE AND THROAT. Differential Diagnosis.— Specific Rhinitis. Parental history specific. Child small, imperfectly developed, shrivelled and senile in appearance. Skin unhealthy, and sallow in hue ; varied rashes present. Specific lesions present, including condylomata, mucous patches, copper- colored blotches, onychia, osseous en- largements, alopecia, or a peculiar lus- terless, brittle hair, ulcerated lips, rhag- ades, and, rarely, subcutaneous hemor- rhages. Enlarged liver and spleen. Child rarely smiles, has a plaintive, feeble voice, and a peculiar character- istic cry. Fretful and wakeful at night. Nutrition greatly impaired during local manifestations. Painless enlargement of glands, es- pecially cervical, cervicomaxillary, in- guinal and axillary. Runs a fixed course. Pyrexia absent. Tendency to ulceration of membrane and cartilage, with flattening of nose. Discharge purulent, with shreds of necrotic tissue, frequently blood- streaked and offensive. Formation of nasal crusts. Fissures and ulcers in ahe nasi. Simple Acute Rhinitis. Parental history non-specific. Child normal. Skin normal ; no characteristic rash. Absent. Normal. Child normal in these particulars. May fret occasionally, but, as a rule, sleeps fairly well. Nutrition unimpaired. Maxillary glands may enlarge ; not usually. Painful. Not definite ; irregular. Moderate fever at onset. No ulceration nor flattening, and rapidly terminates. Discharge never absolutely purulent, rarely blood-streaked, and is inoflfen- sive. No such formation.s. Not seen. Simple acute rhinitis in children must not be confused with the purulent variety contracted by exposure to infection in the birth- canal of the mother. Prognosis. — The prognosis of acute rhinitis in infants is favorable if }>rompt treatment is instituted, but the condition is likely to become purulent and fetid if neglected, and if permanent alteration of the nasal mucous membrane occur. In the very young, acute rhinitis without some mechanical cause is a rare condition. In my own experience, in the majority of cases occurring in infants from a few weeks to six months of age, the acute rhinitis could usually be traced to some carelessness in bathing. For example, when the new-born child is first bathed, the nurse may carelessly allow the soa]) and water to come in con- tact with the nasal mucous meml)rane. This membrane, sensitive in adult life, is extremely so in the new-born. The irritation set up will produce in the infant symjitoms identical with acute rhi- nitis. Indeed, the condition may be aggravated to one of almost purulent rhinitis owing to the fact that the patient is not able to DISEASES OF THE ANTERIOR NASAL CAVITIES. 75 keej) the nostril clear. The mother and nurse should be instructed to avoid this danger. Also, attacks of acute rhinitis in children may be excited by irritating vapors or gases. As the little one is not capable of expression or locomotion, but is strictly passive, it may be placed in the direct line of dry air from the heaters, or noxious gases from the stove or the range, which may be the ex- citing causes of acute attacks. When an acute catarrhal condi- tion is once established in the infant, it should be given prompt attention. As the little one is not capable of keeping the nostril clear, the collected secretion will act as an irritant, saprophytic bacteria may gain ingress, the condition from being a simple one may become one of alarming gravity, and permanent changes may take place in the nasal mucous membrane. Treatment. — The treatment is necessarily purely local. The nostril should be cleansed with tepid milk, to which has been added 3 grains of sodium chlorid to the ounce. This should be followed by a tepid boric-acid solution of the same strength, and the nostrils cleared as thoroughly as possible. This cleansing process can be done by saturating cotton with the solution, then allowing it to drip into the nostril, working the end of the loose cotton into the nose as far as possible, thus preventing irritation of the sensitive membrane. The nose may then be taken between the thumb and index finger, and by drawing down — pressure and slight suction being thus obtained — and repeating the process sev- eral times, the nostrils can be thoroughly cleansed. There then should be dropped into the nostril 2 or 3 drops of liquid albolene or cosmoline. The treatment in such conditions should really be a preventive one, as a majority of cases in infants, outside of those associated with the diseases of childhood, are largely mechanical in origin. The complications are rare, but may be the same as in adults. Simple Acute Rhinitis in Certain op the Constitu- tional Diseases. Simple acute rhinitis occurs with varying symptomatic im- portance in several of the severer diseases. This is notably true in tlie following : Measles. — ^An acute coryza is one of the most marked symp- toms of the invasive stage of measles. There are marked con- junctival injection, excessive lacrimation, and photophobia, and with these are associated cough, a temperature rapidly rising to 102° or 103° F., and a characteristic drowsiness. There may be head- ache, nausea, and vomiting. The eruption of the rash about the fourth day clears the diagnosis. Ulceration of tlie septum is said to follow severe coryza in some cases. 76 DISEASES OF THE NOSE AND THROAT. Pertussis ( W/i»ojjiiir/-ro)if/h). — Whooping-cough begins as a catarrhal iuflannnatioii of all the exposed mucous surfaces, and the patient has the symptoms of having taken a severe cold. Indeed, the conjunctivitis, photophobia, and pronounced nasal coryza, with its developing cough, may be so severe as to imitate strongly the onset of measles. Scarlet Fever. — The prominent catarrhal symptoms of the pharynx in scarlet fever are, except in the mildest cases, accom- panied by an acute catarrhal inflammation of the pituitary mem- brane, with a thin, acrid, watery, or corpuscular discharge. Variola {>Sia((U-pox).—The invasive stage of small-pox ex- hibits a marked involvement of the nasal mucosa with decided coryza and an associated conjunctivitis with epiphora and photo- phobia. The severe constitutional symptoms, initial rashes, and historv of exposure should place the physician upon his guard. Typhoid Fever {Eatcrie Fever). — Congestion of the nasal mucosa is not uncommon during the progress of typhoid fever. This may be preceded by epistaxis. Coryza is a rare sequel unless associated with necrosis of the cartilage. Rheumatism, Acute Articular. — Acute rhinitis not infre- quently accompanies the comnuMicement of the attack of articular rheumatism, due to the irritating action of the excessive uric-acid condition, the mucous membrane aiding in elimination. Diabetes Mellitus. — I have seen two cases of diabetes mellitus in wliic-h the acute coryza present was apparently due to no influence beyond that of the constitutional condition. Each attack of rhinitis was apparently controlled by the presence and amount of sugar in the urine, the attack of coryza diminishing as the amount of sugar lessened and returning with its increase. Epidemic Influenza {La Grippe). — In the thoracic form of influ(Miza a ty])ical coryza is a prominent symptom, as a rule accomjiauicd l)y painful and paroxysmal cough, but the constitu- tional symptoms accompanying it follow so rapidly as to allow of no mistake as to diagnosis. Diphtheria. — An acute simple rhinitis occurs very commonly in diplitheria. Usually it heralds the extension to the nasal cham- bers of a precedent diphtlieritic process of the pharynx and naso- pharynx, and the symptoms of a nasal diphtheria soon supervene. In cases, however, in which the diphtheritic infection occurs primarily on the nasal membrane and the inflammatory swelling obscures inspection, the catarrhal symptoms may lead to the diag- nosis of a severe coryza, the real nature of the case being unsus- pected. In certain cases a catarrhal process may be substituted for tlie formation of a membrane. In cases of severe coryza the glands at the angle of the jaw should be examined for enlarge- ment, and the intensity and character of tlic constitutional symp- toms be taken into account. When no membrane is formed in DISEASES OF THE ANTERIOR NASAL CAVITIES. 77 the nose after the disease is well advanced, the nasal inflamma- tion will continue, caused by the absorption and presence of toxins in the blood. KlTSip^l^S. — An acute rhinitis is sometimes seen accompa- nying a primary infection of the nasal cavities by erysipelas. The inflammation is very severe, the membrane extremely swollen, and there is a marked tendency to extension of the process to the nasal duct and the cutaneous surfaces. Scorbutic Rhinitis. — An inflammatory condition of the nasal mucous membrane with excoriation about the nasal orifice is not infrequently seen in infantile scurvy. Anemic Rhinitis. — Anemic rhinitis is a non-inflanmiatory condition of the nasal mucous membrane, characterized by en- gorgement of the vessels of the submucosa with the discharge of a clear exudate, and is unattended by any of the symptoms of acute rhinitis. It may occur at any age. While this condition is non-inflammatory, it properly comes under constitu- tional lesions with local manifestation. Etiolog-y. — The nasal mucous membrane in anemic individuals presents much the same condition as the mucous membranes of the other functionating organs. There is no local irritation, but with the generally bad nutrition and muscular relaxation the blood- vessel walls of the submucosa relax and allow leakage ; not alone from the arterioles, but from the lack of vessel-tone the circula- tion is slowed, and there is a certain amount of venous stasis followed by effusion. This is true of the kidney and intestinal mucous membrane in anemic individuals, and it would seem that a variety of mucous-membrane inflammation known as anemic were justifiable. These cases are not to be associated with the strumous variety. Pathology. — The surface of the membrane is watery, pale, and at the junction of the skin and mucous membrane the tissue is draAvn or puckered in appearance. The cells undergo a watery infiltration and hydropic degeneration. The vessels not being backed up by muscular tissue readily fill with blood, but the tissue being relaxed and weakened by poor nutrition, there is a marked tendency to stasis, both venous and arterial. This, then, is fi)ll()wed by exudate or leakage into the tissue ; the epithelial cells, from pocu' nutrition and absorption of the exudate, undergo destruction l)y hydropic degeneration. Symptoms. — The individual presents the characteristic con- stitutional syni]>toms of anemia. The nasal membrane is coated with a thin exudate which at times is sliglitly irritating. There is little, if any, tendency of the discharge to dry on the surface and form crusts. There is slight blocking of the nasal breathing; no odor. The discliarge is continuous, and tlie greatest incon- 78 DISEASES OF THE NOSE AND THROAT. venience to the patient is the constant use of the handkerchief. This anemic condition may be also present in the pharyngeal and nasopharyngeal mucosa, but not to such a marked degree. Treatment. — Local treatment other than a cleansing solution is of little avail. The general condition must be improved. In- ternal administration of iron, in the form of the peptomanganate, is advisable. The diet should be regulated. Strict attention should be paid to the bowels, correcting any tendency to constipation. Outdoor exercise is indicated. With improvement in the general health, the nasal symptoms will disappear. To accomplish this the active cause of the anemia must be sought for and the appro- priate remedial agent administered. For example, if the patient be a young girl suffering from anemia from menstrual disturb- ance, the treatment would be vastly different from that indicated if the anemia were due to rheumatism, kidney-lesion, or chronic malaria. The treatment must be directed toward the special causal factor. Scrofulous Rhinitis. — Synonyms. — Tuberculous rhinitis ; Strumous rhinitis ; Scrofulous ozena. Scrofulous or strumous rhinitis is not a local condition, but is a local manifestation of a constitutional diathesis, and occurs in poorly-nourished children, especially of the peculiar lymphatic temperament having the inherited tendency which predisposes them to tuberculosis. Indeed, it is nothing more than one of the manifestations of the initial stage of tuberculosis, which under favorable conditions with proper hygienic and constitutional treat- ment may be relieved, or may progress to an actual tubercular infection, bearing the same relation to tuberculosis as Paget's dis- ease of the nipple does to carcinoma. Scrofulous rhinitis is usually associated with enlargement of the cervical, submaxil- lary, and sublingual glands. There is a characteristic anemia, with the pinched face giving an expression almost as of one suf- fering pain. The orifices of the nostril are usually excoriated, and there is tendency to crust-formation with accumulation of secretion high up in the nostril. There may or may not be odor. To the sense of touch, the nose, especially the cartilaginous portion about the orifices, has a leathery feeling. The microscopic examination of the secretion shows no specific micro-organisms. Usually staphylococci and saprophytic bacteria are found. When, how- ever, if associated with these organisms the streptococcus is found, the condition is more acute, is attended with more con- stitutional symptoms, and demands prompt and energetic treat- ment. Treatment. — The treatment of tuberculous rhinitis should be largely constitutional, the local treatment being purely palliative and cleansing. For this purpose there should be used, by means of an atomizer or Bermingham douche, the following : DISEASES OF THE ANTERIOR NASAL CAVITIES 79 'B^. Sodii biboratis, Sodii bicarbonatis, Sodii chloratis, da gr. viij (.48) ; Aquge (tepid.), fl|j (30.). This solution should be used two or three times daily for effect, the object being to keep the membrane thoroughly clean. Should the secretion be very tenacious, the use of this douche should be followed by !^. Aquse cinnamomi, Hydrogeni peroxidi, Extract! hamamelidis (aqueous), da flsj (30.). in the same manner as above. After thorough cleansing there should be applied to the irritated membrane an oily solution composed of: ^,. Camphorse, gr. j (.06) ; Menthol, gr. iij (.18); Acidi carbolici, gtt. ij (.12); Alboleni (liquid) flij (30.). Constitutional treatment should consist in outdoor exercise. A diet containing plenty of fats, beef, and nitrogenous foods should be prescribed, and tonics administered. As to the form of tonics to be employed, it remains for the physician to choose that one best adapted to the various cases. The best results will be obtained, however, in the majority of cases by the administration of the lactate or peptomanganate of iron ; an equally good tonic alternative is the double sulphid of arsenic in doses varying from Ti to i gi'ain, according to the age of the patient. Caseous Rhinitis. — Synonyms. — Coryza caseosa ; Choles- teatomatous rhinitis ; Rhinitis caseosa. This rare disease seems to be more the result of some asso- ciated condition than a process actually involving the nasal mucosa. In the few cases reported, each shows different etiological fac- tors. There is an accumulation in the nasal fossa of a cheesy, gelatinous material, often to the extent of actual displacement of structures and facial deformity. There is associated with it an extremely fetid odor, fouler, if possible, than tliat occurring in ozena. No special micro-organisms arc found except those of decomposition. Microscopically, the material shows fatty cells, granular leukocytes, stearin, and cholesterin crystals. Tlie con- dition occurs in individuals with tubercular tendency, or in those who possibly have been infected with syphilis. In one case reported, the cause was believed to have been a myxomatous 80 DISEASES OF THE NOSE AND THROAT. growth which had undergone degeneration. Caseous rhinitis was first described by Duphiy and Follin in 1874. Treatment. — The treatment consists in removal of the septic material by curetment and the use of a solvent, such as bicarbon- ate and bi borate of soda, 10 to 15 gr. to the ounce, followed by an antiseptic irrigation, as hydrogen peroxid and cinnamon water in equal parts. MEMBRANOUS RHINITIS. Under this heading is included (1) croupous or pseudomem- branous rhinitis; (2) fibrinoplastic rhinitis; (3) diphtheritic rhi- nitis — the form due to the action of the Klebs-Litlller bacillus. Croupous or Pseudomembranous Rhixitis. Synonyms. — Membranous rhinitis ; Primary pseudomem- branous rliinitis. Definition. — Croupous rhinitis is an acute inflammation of the nasal mucous membrane, occurring in both children and adults, though running a longer course and with severer symptoms in the former. It is characterized by the deposit of an albuminous exu- date, forming a false membrane, which lies upon the epithelial coating and does not involve the deeper structures. This exudate does not tend to organize. Ktiology. — Croupous rhinitis is due, at least in a majority of cases, to local irritation produced by the action of micro-organisms on the surface of the mucous membrane, associated with lessened cell-resistance ; or it is due to some constitutional condition in which the individual cell-resistance is less than normal. It is not produced in each case by the same specific bacteritic cause, but there may be a number of micro-organisms associated as causal agents. The Streptococcus pyogenes is often, unquestionably, the chief ex- citing factor. This may or may not be associated with the vari- ous forms of the staphylococci and the attenuated form of the diphtheria bacillus known as Von Hoffman's bacillus. Cases have been observed following nasal operations involving the use of the galvanocautery, section of the mucous membrane, or the insufflation of impure water after operations. In one case observed by the author the application of the cautery had been followed by the formation of a croupous membrane, and tiie process, extending up through the nasal duct, had involved the anterior conjunctival and ])alp('bral surfaces with a similar structure having no tendency to orgauizjition. It has been reported as following measles and ton- sillitis, as occurring witli a history of hereditary syphilis, and, in one case, as subsequent to a toxemia originating in a razor-cut. The disease is more prevalent in America than in Eurojw, and its predisposing causes are largely the same as those of diphtheria, DISEASES OF THE ANTERIOR NASAL CAVITIES. 81 bad hygiene and defective sanitation being causal agents in low- ering the individual resistance. Pathology. — The pathology of croupous rhinitis is at first essentially that of an acute catarrhal rhinitis. The nasal mu- cosa is swollen, turgid, and congested ; there follows an abun- dant escape of serum and cellular elements upon the surface, and the discharge becomes somewhat purulent, rarely fetid, and causes excoriation of the upper lip. In a fully-developed case there will be found the croupous membrane, varying in extent from a small patch to involvement of the nasal passage ; in adults thin, gelat- inous, but tenacious and of a somewhat pearly tinge. In chil- dren the exudate may be thicker and even somewhat friable in texture. This membrane, placed upon the surface of the mucosa, does not involve its deeper structures, and never goes on to com- plete organization. Microscopically, the membrane presents the characteristic ap- pearances of a croupous exudate — a network of fibrin-threads entangling leukocytes, some few red blood-cells, desquamated epithelium in various stages of disintegration, and various bacteria. The usual site of the process is the surface of the lower and middle turbinates and the anterior part of the septum ; it may occupy the entire area of the nasal mucosa. It has a marked tendency to recurrence upon removal. Symptoms. — The attack begins — as does the ordinary sim- ple acute rhinitis — with chilliness, or even a decided chill, malaise, headache, pain in the back and limbs, fever to 101° or 103° F., and anorexia. Swelling of the nasal membrane succeeds, occlu- sion of the passage follows, with mouth-breathing and, perhaps, sneezing. The dry stage of the inflammation is very brief, and there soon folh)ws an abundant discharge, at first clear, but soon becoming thicker, more opaque, but rarely fetid. The fever drops to 101°, or 100° F., the sense of malaise remaining marked. There are frontal headache, partial or complete loss of smell, and neuralgia of the nasal nerve may become an annoying feature. With the thickening of the nasal discharge there begin to be formed shreds or small pieces of the false membrane, and this usually constitutes the first distinctive feature of the symptoms. On inspection the membrane will be seen, unless the occlusion of the nasal cliamber by the engorgement of the turbinal mucosa be so complete as to prevent a view. The condition lasts, as a rule, in adults from eight to fourteen days, and in children from ten days to five weeks. Diagnosis. — Tlie diaguosis of this membranous inflammation from sini])I(! acute rhinitis is based upon the presence of the shredded bits of membrane in the nasal discharge, and on the presence of the membrane as revealed by inspection. The differ- 82 DISEASES OF THE NOSE AND THROAT. eutial diagnosis from nasal diphtheria, however, must be carefully- made, and the following table will be found of use : Diflferential Diagnosis. — CROUPOUS RHINITIS. Constitutional symptoms present, but not severe. Sporadic. Primary, and usually the membrane is confined to nasal space. No albuminuria. No lymphatic involvement. Color of membrane brighter and pearly in tint. Membrane superficial. Membrane is readily detached. Seldom leaves a bleeding surface on removal, except perhaps a slight capil- lary oozing. No ulcer nor scar follows removal. Discharge slightly, or not at all, fetid. May become chronic. May occur at any age. No paralysis. NASAL DIPHTHERIA. Constitutional symptoms marl^ed and usually severe. Epidemic ; sporadic cases may occur. Usually secondary, either from auto- infection or extension, with fiilse mem- brane on fauces, pharynx, or soft palate, eitlier accompanying or preceding. Albuminuria. Cervical glands enlarged. Color grayish or dirty white ; shaggy. Involves deeper layer of mucous membrane. Closely adherent. Always bleeds. May ulcerate and leave subsequent scar. Discliarge fetid. May become chronic. Most common in the young. May be paralysis of soft palate. Prognosis. — The prognosis for the attack is extremely favor- able, especially under proper treatment. The predisposing in- fluence of one attack upon subsequent attacks must,, however, be carefully l)orne in mind. Treatment. — Local Treatment. — For the purpose of re- moving the meml)rane there should be used a warm alkaline douche consisting of biborate of soda and bicarbonate of soda, of each 8 grains to the ounce of water. This will clear away the loose material, and should then be followed by hydrogen peroxid (15 volume) diluted with an equal amount of cinnamon water, applied either by means of spray, douche, or cotton pledget. This application will coagulate the albuminous material left after the first cleansing. The alkaline solution should now be repeated, and any particles of the caseous material still adherent should be removed by means of cotton loosely wTapped on a probe, care being taken not to injure the exjjosed and inflamed membrane. The surface should then be carefully dried, and there should be applied to the site of the membrane, by means of a cotton carrier, Loffler's solution, which is : I^. Toluol, 36 parts Alcoholis absoluti, 60 " Liquoris ferri sesquichloridi, 4 " DISEASES OF THE ANTERIOR NASAL CAVITIES. 83 This application should not be made more than three times daily, although the cleansing solution may be used as often as once every two hours. For the relief of the irritation and the feeling of raw- ness left after the removal of the membrane, if the Loffler's solu- tion is not used, the following oily preparation may be employed : I^. Olei eucalypti, gtt. ij (.12) ; Acidi carbolici, gr. j (.06) ; Olei cassige, gtt. iv (.24) ; Alboleni (liquid), flgj (30.).— M. Internal Treatment. — As the progress of the disease is largely controlled by the general condition of the patient, the constitutional treatment should be directed toward the improvement of the general cell-resistance. First, there should be thorough cleansing of the intestinal tract. For this purpose, and also for its general alter- ative effect, there should be administered calomel in y^^'gi'^i^ doses, with 1 grain of bicarbonate of soda every hour for ten doses. This should be followed in three hours by citrate of mag- nesia. This course of medication should be repeated on the second day, as the repetition materially shortens the attack and lessens its severity. As a tonic, there should be administered iron, quinin, and strychnin. More rapid results can be obtained by the use of the tincture of the chlorid of iron, which can be given alone in from 10- to 20-drop doses. There should be administered also bromid of quinin in from 2 to 5 grains, with extract of nux vomica -|- grain every four hours, in either pill or capsule, the dosage controlled by the age of the patient. If the fever be of such severity as to demand special attention, the usual antipyretic measures should be employed. FiBRiNOPLASTic Rhinitis. Fibrin oplastic exudates are much the same as those occurring in the croupous variety mentioned before, except that they are more highly fibrinous and are of a higher grade, tending to organi- zation. No special bacteria seem to be associated with them, nor is the individual's general health necessarily impaired. Bad hygienic condition and bad sanitation seem to predispose to the affection. It is most common in the young. Tlie fibrinoplastic variety of rhinitis l)egins as any other inflam- mation that is catarrlial, followed rapidly by a highly-fibrinous, coagulable, albuminoid exudate, which forms on the surface. Capillary budding may take place in localized areas, and vascular- ization folloM'. In two cases seen at the St. Agnes Hospital, an examination of the nose sliowed the false membrane extending from the nasal mucocutaneous surface to the nasopharyngeal mem- 84 DISEASES OF THE NOSE AND THROAT. brano, also involving the ])harvnx and tonsils. This membrane was distinctly laminated, ajjpearing the same in both nostrils and completely obstructing nasal breathing. On attempting removal, it was found to be firmly adherent to underlying structures, and, Avhen forcibly detached, there followed considerable hemorrhage, largely capillary oozing. The bleeding occurred on the surface of the mncous membrane, and there was no ulceration (Fig. 34). The membrane was so firmly adherent that it had to be removed with forceps, and could be detached only in small pieces. Serum-tube inoculations from the infected area showed no virulent germs present, except staphylococci. The membrane formed in the anterior nares showed much furtlier organization than that found in the posterior part of the anterior nares. The membrane was sufficiently organized to permit of hardening and section-staining, which showed organized and unorganized material, fibrin entan- gling in its meshes leukocytes and epithelial cells. The fibrin was distinctly laminated, and the layers next to the mucous membrane showed greater organization than the central layer, with partial vascularization. While the organization was irregular and not complete, yet it demonstrated that, in order to even partially organize, capillary budding must have taken place. This variety of membranous inflammation occurs sporadically, and shows no infectious or contagious properties. It bears the same relation to the croupous variety that an aplastic exudate does to a plastic, the difference being simply one of degree. This variety of inflammation occurs in the chronic form. The symptoms and pathology differ very little, if any, from the acute variety. It is simply a continued fibrinous inflammation. Treatment. — Cleansing solutions alone will have little effect on the membrane, its removal being effected by the use of for- ceps. It will be found that the surface will bleed in irregular areas ; such surfaces should be touched with a 15 per cent, chromic- acid solution, after the nostrils have been cleansed with hydrogen peroxid (15 volume) and the simple alkaline wash. The surface should be carefully watched, and any tendency to re-formation of the membrane should be arrested by the application of the chromic- acid solution. General Remarks. — Before passing to the next variety of membranous rhinitis, it may, perhaps, be best to remind the stu- dent that in certain cases, instead of a succeeding acute catarrhal inflammation, an intensification of the acute cause leads to an exudate of an altered character, more fibrinous, with subsequent formation of a superficial fibrinous membrane. This is seen in the membrane-fi)rmation following iniialations of chlorin, ammonia, etc., and in that sometimes following cauterization. The grade of this exudate is slightly higher than the croupous, yet not so high as the fibrinoplastic variety mentioned above. It is more like a Fig. 34.— Laminated fibrinoplastic exudate, partially organized. The picture shows an oblique section of a blood-vessel with illy-formed wall. DISEASES OF THE ANTERIOR NASAL CAVITIES 85 coagulation-necrosis, differing from the diphtheritic in that it is not due to any special micro-organism nor accompanied by any characteristic constitutional symptoms. The local treatment is largely the same as has been given. Diphtheritic Ehhstitis. Definition. — An acute inflammation of the nasal mucous membrane due to a specific germ, the Klebs-Loffler bacillus. It is characterized by severe constitutional symptoms from the ab- sorption of poisonous products engendered by the germ at the site of invasion, and by the formation locally of a characteristic false membrane. The disease is highly contagious, and one attack confers no immunity from subsequent infection. Synonym. — Nasal diphtheria. For discussion of the etiology, pathology, symptoms, prognosis, treatment, complications, and sequelse the reader is referred to the article on Diphtheria. The differentiation between diphtheritic rhinitis and croupous rhinitis may be found under the latter article (page 82). OCCUPATION=RHINITIS. Definition. — An acute inflammation of the nasal mucous membrane, differing from simple rhinitis only as to cause. Synonym. — Traumatic rhinitis. Etiology. — This variety may be caused by irritating vapors, as those of chlorin, ammonia, iodin, bromin, or by irritating sub- stances suspended in the atmosphere, as observed in the case of millers, coal-miners, wood-carvers, brush- and hat-makers, weavers, and all ])ersons engaged in kindred employments, and is in reality a condition analogous to pneumonokoniosis. Irritants, such as steam or smoke, should also be classed as causes, although the nasal mucous membrane has much more resisting power, and does not suffer in the same degree as the pharynx from exposure to these agents. Direct injury and the presence of foreign bodies are important etiological factors. The condition brought about by the irritation of the pollen of plants will be considered under hay fever. The fumes from such drugs as bichromate of potassium, mercury, arsenious acid, and osmic acid arc also classed as causes, and are exemplified in ])ersons whose occupation necessitates their continued exposure to them. This should be carefully considered in complicated cases, and the occupation of the individual may lead to valuable aid in diagnosis au'l treatment. Pathology. — Tlie pathological alterations in this variety of rhinitis do not differ from those found in the simple acute form, except when due to the irritating fumes of bichromate of potassium, 86 DISEASES OF THE NOSE AND THROAT. mercury, and arsiMiious acid, the iioisonons effect beino; purely local, and not tlie result of constitutional absorption, as is found in elii-onie pliosphorus-poisoning. Following the phenomena of acute intiamniation there are local areas of degeneration which ex- tend to, and involve, the subinueosa and form ulcers, which, at first small and round, subsequently enlarge and become oval. This usually occurs on the cartilaginous septum, and may lead to per- foration. Symptoms. — The symptoms of traumatic rhinitis are a sneezma: &' tiekliug sensatiijn in the nose, followed by paroxysmal ^ associated with, or followed by, an abundant discharge, which at first is watery in character, but later, as the secretions accumulate on the membrane, the bacteria of decomposition (saprophytic) cause the discharge to become greenish in tinge and much more tenacious. These symptoms occur regardless of which substance is the cause. The symptoms being largely the result of local irri- tation, when superficial necrosis begins, the secretion forms in crusts ; and later, as ulceration takes place, hemorrhage occurs. There is rarely, if ever, an odor. The ulceration is usually on the upper and posterior part of the septum or turljinated bodies — more commonly on the septum — and may extend even to the discharge of portions of any of these structures. The lower and anterior portion of the cartilage remains intact, and there is never any falling-in of the n()S(\ Prognosis. — With the removal of the cause the prognosis is usually good. Persons recovering from traumatic rhinitis are afterward less liable to catarrhal inflammations of the nasal mucosa. Treatment. — Remove the cause. In individuals whose occu- pation necessitates exposure to the irritating substances, the nasal membrane should be protected by moistened cotton or woollen plugs. When ulceration takes place, the same treatment as in simple ulcer should l)e employed — cleansing, drying, and the appli- cation of liquid astringents, as 3 per cent, chlorid of zinc or 5 per cent, alumnol. Before ulceration, alkaline cleansing solutions should be used, such as — ]^. Acidi carbolici, Sodii biboratis, da 10 per cent. ; (llycerini, 30 per cent. ; AqufB destillatse, 50 per cent. This should be followed by — I^. Olei cassite, Olei santali, aagtt. v(.3); Alboleni (liquid), flgj (30.). DISEASES OF THE ANTERIOR NASAL CAVITIES. 87 or compound tincture of benzoin with equal parts of boroglycerid, 50 per cent., for its sedative action. HYPERESTHETIC RHINITIS. Hyperesthetic rhinitis should be considered under nasal neu- roses. A¥hile the inflammatory condition present with its asso- ciated phenomena is, in a measure, a local condition, nevertheless, it is controlled by, and dependent upon, some peculiar susceptibil- ity on the part of the individual to irritating agents from without or manufactured within the body. Without this susceptibility on the part of the individual, this variety of rhinitis would not be separate and distinct, but could be classed either under simple acute rhinitis or occupation-rliinitis. For the complete article on this subject, reference should there- fore be made to the chapter on Neuroses. ULCERATIVE RHINITIS. Under this head, or that of its Latin equivalent, rhinitis ulcerosa, some writers describe various forms of ulcerative proc- esses of the nasal mucosa. There is, however, no inflammatory condition of the membrane in which ulceration is in such pre- dominance or of such constant type as to Avarrant the use of the term in a distinctive sense. Ulceration is, however, of far too common occurrence, existing as it does with greater or less fre- quency in every morbid nasal process, to receive but a passing notice in the descriptions of the various diseases. The author has therefore devoted a special chapter to the consideration of Ulcers, with reference especially to their pathology, special characteristics, and local treatment, to which the reader is referred. EDEMATOUS RHINITIS (ACUTE). Acute edematous rhinitis is a separate and distinct condition from rhinitis edematosa or cyanotic rhinitis. The acute condition is identical, as regards pathological altera- tion, with the edema occurring in any other structure — more likely to occur here than elsewhere, however, because of the fact tiiat tlie mucous membrane is not supported by muscular structure. The condition is brought about by sudden changes in the vas- cular tissue, from which, due to its ovcrdistention, there is a watery infiltration of the connective-tissue spaces of the sub- mucosa, of the (ronnective-tissue cells, and possibly of some of the epithelial cells of the surface, ft differs from the infiltration that occurs in simple acute rhinitis, or any simple inflaniniatory ]>rocess, only in this respect, that it has for its cause some irrita- tion to the mucous membrane, cither direct or transmitted, whi(;h 88 DISEASES OF THE NOSE AND THROAT. brings about a sudden and rapid distention of the vessels, with leakage of liquor sanguinis, the inflammatory phenomena not pre- ceding, but rather following the leakage, similar to an injury in any lax structure, such as an ordinary black eye, in which the swelling or edema takes place suddenly and the phenomena of inflammation orderly follow. The condition would be seen, then, after inhalations of steam, highly irritating fumes, and following injuries not only to the membrane itself but also to the bony framework and connective tissue of the nose. Treatment. — The affected area should be punctured, if the severity of the nasal obstruction justify this procedure, as the majority of these acute edematous conditions will subside of themselves in twenty-four to forty-eight hours. However, if it is necessary to puncture the tissue, 6 ])er cent, sulphocarbolate of zinc or 3 per cent, chlorid-of-zinc solution should be applied as frequently as d(Muanded by the existing condition. Should there be much irritation, drop into the nostril a few drops of plain benzoinol. PHLEGMONOUS RHINITIS. Phlegmonous rhinitis is nothing more tlian acute abscess of the septum, or an abscess involving merely the submucosa of the mucous membrane. It differs very little from the ordinary nasal furuncle except in position and severity. The condition is not difficult of diagnosis, as it shows a distinct localized swelling on one or both sides of the septum, and has the ap]>earance of, and is accomj)anied by, the same clinical phenomena as acute-abscess for- mation elsewhere. If seen early, local application for the pre- vention of suppuration should be used. Paint the part with iodin, followed by applications of cold in the form of ice or cloths wrung out of ice water. If, however, it has gone to sup- puration, free incision should be made and heat applied. The condition may be associated with empyema of the antrum of Hio-hmore or with alveolar abscess due to diseased teeth. CHAPTER V. DISEASES OF THE ANTERIOR NASAL CAVITIES. Chronic Inflammatory Diseases. Chronic Eliinitis. a. Simple Chronic Rhinitis. b. Inturaescent Ehinitis. c. Hyperplastic Rhinitis. d. Ozena as a symptom. e. Atrophic Rhinitis. /. Purulent Rhinitis. g. Nasal Hydrorrhea. h. Edematous Rhinitis (Cyanotic). i. Specilic Inflammations (Granulomata). 1. Syphilis. a. Congenital. b. Acquired. 2. Tuberculosis. 3. Glanders. 4. Leprosy. 5. Actinomycosis. 6. Rhinoscleroma. SIMPLE CHRONIC RHINITIS. Definition. — Simple chronic rhinitis is a chronic inflamma- tion of the nasal mucous membrane, occurring as the result of prolonged irritation or of successive attacks of the acute form. It is characterized by a relaxed and boggy condition of the mem- brane, alteration in tiie amount and character of the secretion, and an increased susceptibility to acute exacerbations. It is interme- diate between simple acute and beginning atrophic rhinitis. Synonyms. — Catarrhus longus; Chronic blennorrhea ; Chronic coryza ; Chronic nasal catarrh; Chronic rhinitis; Chronic rhinor- rhea ; Flcxiis nasalis ; Rhinitis chronica ; Rhinitis simplex; Sim- ple chronic nasal catarrh. Htiology. — Sim])le chronic rhinitis is due either to r('])eated attacks of tlie acute form or to a continuation of a severe attack. The predisposing causes of this condition are identical witli those of sim])]c acute rliinitis — already given — and its exciting causes, either repeated or j)rolonged exj)osure to tlie exciting causes of the acute ty])e. It is ])eculiarly liable to follow the simple form occurring in the ini'ectious diseases, or the acute rhinitis of tlie new-born. The disease is most common between the ages of ten and thirty-five. 90 DISEASES OF THE NOSE AND THROAT. Pathology. — The meinhnuic and erectile tissue are relaxed, Habbv, readily di.-^tended hv hluod, and present all the characteris- tics of an atonic state of tlie vascular system. Tiirouo^h repeated or prolonged inflaniniatorv distention the vessel-walls partially lose their normal contraetibility (Figs. 35, 36). The venous plexuses of the turbinate bodies l)ecome enlarged through overdistention. There is a heightened permeability of the vessel-walls as the process advances, and an increased escape of the blood-elements, notably the white corpuscles, which penetrate the tissue, pro- liferate, and, together with the proliferation of the fixed connec- tive cells, give rise to new tissue of inflammatory origin. As the simple clironic inflammatory condition advances, and after the organization of the newly-formed tissue, but before contraction, there occurs the intermediate stage, which goes on to contraction and passes into the atrophic variety, as described on page 109. At this stage the symptoms are almost identical with hyperplastic rhinitis, and are identical with the early stage of the atrophic just as contraction begins. It is this intermediate stage that is so often called hypertropliic. There is a varying amount of surface- exudate, and migrated cells, with degenerated epithelium ; and the prolonged pressure due to the vascular distention and increase in connective tissue leads to a certain amount of glandular atrophy. Symptoms. — Usually the first symptoms to annoy the })atient are the presence of an increased nasal and, sometimes, postnasal discharge, aggravated upon trivial exposure, and with a constant, ill-defined sense of nasal discomfort. Early in the establishment of the disease the secretion is tliin and watery ; later, as a rule, it becomes thicker and more tenacious, mucopurulent, or even purulent. In some cases there form upon the surface dry green- ish crusts, or thin stringy bridges crossing the nasal spaces. These crusts may l^ecome infected with saprophytic bacteria and give rise to an annoying odor ; or in their removal tlie patient, through constant irritation by picking, may cause serious ulceration of the vestibule and septum, which may go on to perforation. Occasion- ally, if it should occur in the debilitated, the discharge may take the form of a profuse, non-irritating flow of clear, watery fluid. There is partial — or occasionally complete — intermittent stoppage of the nose, with a corresponding degree of mouth-breath- ing, and sometimes a tendency of gravitation is shown by the occlusion of the lower space on lying down. INIore or less stuffi- ness of the nose is present, a dull heavy pain over the nasal bridge, dull frontal headache, and in severe cases a mental hebetude and an indisposition for work. Various neuroses may occur — itching or tickling in the nose; sneezing; vomiting; spasmodic cough, usually dry and barking; or asthma. The voice is nasal in tone. The sense of smell, at first unimpaired, may later become obtunded. Constitutional debility may develop, due probably to digestive Fig. 35.— Section from tissue in simple chronic rhinitis, showing organization of inflammatory tissue. Contraction has not yet taken place, although some areas are becoming slightly fibrous. It will be noted that the epithelial layer is somewhat thinned- The basement membrane is not demonstrable. The organized tissue shows longitudinal and transverse sections of the newly-formed blood-vessels (author's specimen). Fig. 36.— Section of tissue in intumescent rhinitis. The connective tissue (submucosa) shows round-cell infiltration. The connective-tissue fibers are separated and swollen, owing to the watery infiltration. The epithelial cells show somewhat the same swollen condition (author's specimen). ■;< «»' «•►'# ^' f DISEASES OF THE ANTERIOR NASAL CA VITIES 91 derangement from swallowed secretion or improper mastication. There is a marked tendency to attacks of acute rhinitis on the least exposure ; this is especially true in damp weather. Extended cases may develop a redness and congestion of the tip of the nose, often transitory and not unlike the beauteous " rum blossom," and there may be a swelling of the cutaneous surfaces of the tip and alse, with a concomitant acne. On inspection the mucous mem- brane will be found diflPusely, but slightly, swollen, especially on the septum and the middle and inferior turbinates, red, soft, and cushion-like, and showing here and there areas covered by secre- tion. The membrane is irritable, especially on the septum and inferior turbinates, and pits slightly on pressure, the dent slowly disappearing. There are certain areas of marked hyperesthesia, and the application of cocain causes a slow^ subsidence of the conges- tion, leaving a wrinkled appearance of the mucous membrane. In the case of the debilitated and aged, the membrane may be pale and covered with a watery secretion. The symptoms, as a whole, are less severe than in the acute. The appearance of the mem- brane and many of the symptoms of simple chronic rhinitis after the proliferation of the connective-tissue elements has taken place and before contraction, are almost identical with those of hyperplastic rhinitis and the first variety of atrophic rhinitis, and do not necessitate repetition. Diagnosis. — Usually not difficult, and is based upon the history of the case, inspection, and palpation. Prognosis. — If untreated, the disease remains stationary or becomes hyperplastic or atrophic. Removal of the cause and proper treatment, however, offer a fair chance of recovery. The condition may recur as a new process. It occasionally is the starting point of polyp development, and frequently antecedes a severe catarrh of the Eustachian tube. Complications. — During the course of the disease the sense of smell may be slightly or greatly impaired, and the correlated function of taste correspondingly affected. Aural complications not infrequently occur through implication of the Eustachian tube in the inflammatory process. The accessory cavities may be in- volved. Symptoms of gastric derangement are not uncommon. Treatment. — There enter into the treatment of simple chronic rhinitis two elements — first, the discovery and elimination of the underlying cause ; and second, the relief of tlie alterations produced in the nasal mucosa. By this latter statement is meant that in a simple chronic rhinitis depending, for example, upon a uric-acid diathesis, or a renal or hepatic lesion affecting the nasal circulation by irritation and vascular pressure, there would be produced altera- tions in the submucosa and the epithelial layer of the mucous meml>rane. This alteration would persist despite the removal of the cause. Treatment then must be constitutional and local, and 92 DISEASES OF THE NOSE AND THROAT. the result is necessaril}- controlled by the extent and ])ernianence of the alteration. ]\Iany cases of simple chronic rhinitis, in which the turbi- nated bone, usually the middle, is of the hanging variety (Fig. 46), hanging down into the nasal cavity, the mucous membrane being Fig. 37.— Morbid anatomy of cystic turbinates. subjected to irritation from all points, thicken as a result of slow inflammatory change. This, together with the large and spongy turbinate, may necessitate radical treatment. As a rule, enlarge- ment is limited to the membrane covering the turbinate bone. If the bone is enlarged, it is usually due to a cystic condition as seen in Figs. 37 and 38, and not to any overgrowth of bony structure. However, before the removal of the portion of the turbinate is attempted, gradual pressure should be used. This can be accom- plished by means of a malleable silver tube (Fig. 86), which can be fitted to the nostril, and pressure increased as desired. In the beginning the tube should be worn only a short time, from one to two hours, the time being gradually prolonged. Another admirable method of reducing the tissue, without leaving a surface- scar, is to scrape the turbinate bone by means of a sharp-pointed probe. After cocainizing the tissue, make a simple puncture, passing the probe directly through the membrane down to the periosteum, and, by gently scraping the tissue, sufiicient inflam- matory process is set up to produce rapid inflammatory change. The contracting tissue will rapidly reduce the swelling. Personally, I am opposed to indiscriminate removal of the turbinate or por- tions of that body, and in all cases its removal should not be attempted save as a last resort, and only when interference with nasal breathing is sufficient to demand such radical measures. When the obstruction is sufficient to justify removal of a por- tion of the bone, the nuicous membrane should be dissected up from the turbinate and the edge of the bone removed. For the incision and the dis.section of the membrane, the instruments seen in Figs. 39 and 40 are admirable. For the rwmoval of the bone, Milbury's bone-forceps, which are a modification of Gleitsmann's, are the'best (Fig. 41). Fig. 38.— Section of cystic turbinate. The section shows a complete cyst with the dense wall of tissue surrounding it. The cancellated bone-structure shows outside the dense wall of the cyst. The mucous membrane shows on either border of tlie section. There is some slight round-cell infiltration within the connective-tissue element of the cyst wall. DISEASES OF THE ANTERIOR NASAL CAVITIES. 93 Constitutional Treatment. — The constitutional treatment should be directed toward the eliminating of any lesion which, directly or indirectly, alfects secretion or circulation. An enu- meration of all the possible constitutional lesions that by their influence would bring about a chronic rhinitis is of course impos- sible ; but an instance is given, with its appropriate treatment, to Fig. 40.— Modified Asch's knife. illustrate the point under consideration. For example, if from the clinical history of a case it is ascertained that the intestinal tract is at fault, due to deficient hepatic and glandular secretion, with the accompanying train of digestive and assimilative disturbances, there should be administered first a mild purgative, followed by decided doses of the granular eifervescing phosphate of soda. This Fig. 41.— Milbury's conchotome. should be given in one to two tablespoonful doses night and morn- ing, and continued until the looseness of the bowels calls for a diminishing of the dose. I know of no better drug, if persistently used, for the increase of glandular secretion. At the same time, tonics should be given, the dosage being controlled by the patient's general condition. In addition, there should he. administered, however, a drug that will increase vascular tone. For this pur- pose there is nothing better than sulphate or nitrate of strychnin in doses of ^i^-grain three times daily. Any peculiar susceptibility on the part of the ])atient to cold on ex]K)sure should be guarded against by proj^er clothing. Also, should the exciting factor be a hical one, such as ex])osure to dust or irritating material of any kind, promi)t removal from such ex- posure should be insisted upon. Local Treatment.— The local trcatiiicnt should consist in the 94 DISEASES OF THE NOSE AND THROAT. thoroii^li cleansing of the menil)rane by the use of an alkaline solution, such as — ^i. Sodii biboratis, Sodii bicarbonatis, Sodii cliloratis, Potassii l)icarbonatis, da gr. xv (.9) ; Aqua- (tepid.), H^ij (()Uj ; night and morning tlirough tlic atomizer or JJermingham nasal douche. This treatment may be carried out by the patient, and the physician sliould apj)ly every other day to the atiected area, after cleansing with tiie above solution and carefully drying the membrane, stimulating sohitions to meet the requirements in the case. The aqueous solution of ichthyol, 20 per cent, to 40 per cent., applied by means of a cotton-covered probe ; the compound tincture of benzoin and boroglycerid, 50 per cent. ; glycerite of tannic acid, 75 per cent. ; alcohol and distilled water, 25 per cent., applied in the same manner, are equally beneficial in properly selected cases. In plethoric individuals stronger astringents are indicated, and recourse should be had to nitrate of silver, 4 per cent, to 8 per cent. ; sulphocarbolate of zinc, 2 per cent, to 5 per cent. ; chlorid of zinc, 3 per cent, to 5 per cent. These solutions should be applied every third day until the tissue is sufficiently retracted. In cases in which the nasal structure has undergone such permanent altera- tion as not to be affected by the astringents mentioned, instead of using escharotics or the actual cautery, better results can be ob- tained by the incising of the turbinal membrane, making one or two cuts parallel to the long axis of the turl)inal bones, thus per- mitting free depletion. The cut sliould be made with a sharp knife, extending through the entire mucous membrane down to the bony structure, and the resulting organized inflammatory tissue will be largely limited to the submucosa, preventing the surface- sear which follows the use of the actual cautery or escharotics. In this way the tendency to crust-formation is also lessened. Electrolysis will accomplisli much in many of these cases. The same can be said of kataphoresis ; yet it is onl}^ in cases due to purely local lesions tliat this method of treatment is of avail. INTUMESCENT RHINITIS. Intumescent rhinitis is not a separate form of disease, but merely a diffiMx-nt ]ihase of chronic rhinitis, in which in one or both nasal cavities there is an extremely sudden swelling, with a permanent boggy condition of the mucous membrane. The struct- ural alteration is apparently very slight, as at times the membrane assumes almost a normal condition. There is during the exacer- DISEASES OF THE ANTERIOR NASAL CAVITIES. 95 bation an excessive flow of mucus, at times clear and watery, at others more tenacious and mucopurulent. The exacerbation may be preceded or accompanied by intense itching due to the irrita- tion produced by the vascular change. The cutaneous structures of the nose often show engorgement of the vessels, and the skin is reddened and rather sensitive. Symptoms. — The symptom peculiarly characteristic of this affection is the sudden swelling and turgidity of the turbinal and septal mucous membrane. The swelling is due to the exudate ; while in cyanotic rhinitis it is due to engorged vessels. This may occur in both nostrils, or may involve them alternately for a varying length of time. After lying down, the lower- most side of the nose may be found to be occluded, a con- dition which may persist throughout the day or disappear spon- taneously within a few hours. There seems to be a peculiar liability on the part of the individual affected with this disease to take cold, especially during the fall and winter, on the slightest exposure. On arising in the morning the voice is often hoarse, necessitating a disagreeable hawking to remove the tenacious mucus, which often clings so tightly to the soft palate that vomit- ing may be induced before the offending material is expelled. During the day a hacking cough may be noticed and an irritating hoarseness on attempting to sing, requiring effort to clear the voice, which readily tires after short exertion. There may be dull frontal headache and a tired feeling in the eyes. Dryness and tickling in the throat are often met with. Offensive breath, coated tongue, gaseous eructations, and digestive disturbances may be found. Treatment. — The treatment of this variety of rhinitis is prac- tically the same as for simple chronic rhinitis, but the prognosis is more favorable. For the intense itching, which is often a great source of annoyance to the patient, relief can be afforded by intro- ducing into the nostril a pinch of ordinary table salt and allowing it to dissolve on the tissue. The external redness may be relieved by the application at night and in the morning of water as A\arm as can be comfortably borne by the patient. This should be kept up for ten to fifteen minutes, and the skin patted thoroughly (h-y with a soft towel. After the removal of the cause, the mncoiis incmbnmc r;iii be supported by the same pressure-method :is i-ccdiniiiciHlcd iindcr Simple Chronic Rhinitis. The size and length ol' the tubes is determined by individual cases. HYPERPLASTIC RHINITIS. Definition. — A chronic lesion of the n:is:d niiieou^ nieiiihr:iiie characterized by permanent loe;dI/ed inere:i--e in the n:i-:d nineo-a, causing more or less obstruction within the u:\>-a\ cavity. 96 DISEASES OF THE NOSE AND THROAT. Synonyms. — Obstructive rhinitis ; Hypertrophic nasal ca- tarrli ; Hyj^ertrophic ozena ; Hypertrophy of the turbinated bones ; Clironic hypertrophic rhinitis ; Hypertrophic rhinitis. Ktiology. — Tliere is considerable diflerence of opinion in regard to the etiology and pathology of the so-called hypertrophic rhinitis. Clinically, it is often difficult to diiferentiate between simple chronic rhinitis, inturaescent rhinitis, and the so-called hy})ertrophic form (Fig. 43). In certain stages the symptoms of each are practically the same, but there is no doubt that the termi- nation of the forms mentioned is different and distinct. In the true hyperplastic variety the main alteration in structure is an increase of the connective-tissue elements of the submucosa. The causes which may produce this increase in the connective tissue element do not seem to diffiL'r much from the causes producing the other varieties of inflammation, but in this case the increase is more of the order of a hyperplasia. When the connective-tissue element is increased, due to an in- flammatory process, as a rule it is followed by a contraction. In this variety, however, the overgrowth of tissue is almost identical with that in a benign tumor, and is not followed by contraction. The term hypertrophic or, as I prefer to call it, hyperplastic, should be limited to those cases in which the increase of tissue is not followed by contraction. It is, indeed, analogous to the so- called hypertrophic variety of cirrhosis occurring in the liver. I grant that no satisfactory explanation can be given wdiy in certain cases it should assume this form, and not in others, yet the same may be said of any other hyperplasia. There is no doubt but that the hyperplasia or overdevelopment of the connective-tissue ele- ment must be brought about by increased blood-supply, as in an inflammatory process, "or in a modified inflammatory process in whi(^h the regular microscopical phenomena do not take place. This is possible, for example, where the irritation is sufficient to keep up hyperemia of the part, the process not going on to con- gestion ; the increased nutrition will cause cell-proliferation of the then existing connective-tissue element. This process would necessarily be slow. The increase in the parts would be identical with a numerical hypertrophy. This increase in tissue may also involve the gland-element present, and histologically is identical with the normtd structure, but falls short in its physiology — that is, the new gland-tissue present does not functionate. The tissue is fully organized, but fails in function. This variety, the true hyperplastic form, is not as common as is generally supposed. The interferenc(Mvith the glandular elements of the mucous membrane, instead of being brought about by pressure from contraction, is due to pressure from excessive amount of the connective-tissue element. The condition may be caused by repeated or contitiued attacks of the simple chronic variety, which in turn may be due DISEASES OF THE ANTERIOR NASAL CAVITIES. 97 to some irregularity within the nares, either the shape of the nostril, malformations, deformities, or deflections of the septum, bony growth, irritating snuffs or dusts, etc. Climate does not play an important part other than that in localities where there are sudden changes of temperature and humidity, in individuals having any of the above nasal irregularities the tendency to nasal affections is more marked. Pathology. — A consideration of the etiology of this subject has necessarily involved some of the pathological alterations. The morbid histology confirms the statements made above in regard to the overgrowth of the coimective-tissue element, as well as the in- crease in the glandular structure, and the physiology shows the fail- ure of function in this new gland-structure. The submucosa shows a greater amount of fibrous formation (Fig. 42), the veins and arteries are surrounded by thicker connective-tissue support, and the venous plexuses are separated by thickened fibrous walls, lessening their liability to collapse. In the outer part of the submucosa there is an increase in the glandular elements, which, later, gives way to a fibrous formation. There is a marked increase in the number of capillaries in the tissue. The basement membrane shows little or no alteration. The epithelial investment is mark- edly thickened, and shoAvs the hyperplasia consequent upon pro- longed irritation with sufficient nutriment. The cell-layers are greatly increased in number. The outermost layer may or may not be ciliated, the underlying layers vary in their cellular size, and the lower layer is of quite large, columnar epithelium. This upper stratum of the mucous membrane is everywhere thrown into folds and furrows, thus greatly enlarging the free surface. In- spection shows a lobulated, uneven membrane, which does not pit, but indents, on pressure, most marked in the membrane covering the middle turbinate, the anterior portion of the superior, and the posterior portion of the inferior turbinate. Symptoms. — The symptoms of hyperplastic rhinitis are not in themselves characteristic. By this is meant that the sanie symptoms may be met with in certain stages of simple chronic rhinitis, intumescent rhinitis, and the form due to cyanotic con- gestion, as well as the condition presented in plethoric individuals. It must be remembered that the symptoms described are those produced by an excess of tissue, and not strictly by an iiillanima- tory process. The condition may involve both nostrils or may be limited to one, may involve either the front or the l)ack ol' ilir tnrbinal mucous membrane or its entire surface, and is a markedly slow- process. The color of the membrane cannot be :icciii-:itcly de- scribed, as it varies with the stage or degree of the proeess. There is an irregular diseharge, sometimes profuse, at other times scanty ; the secretion is altered in character. The disease in its true form 98 DISEASES OF THE NOSE AND THROAT. usually occurs iu individuals otherwise healthy. It must also be remembered that iuflannnatory processes nuiy secondarily involve this iivperplastic tissue, a fact which would naturally complicate the symptoms. There may or may not i)e associated actual in- crease in the turbinated bone. The condition is frequently asso- ciated with dcHection, exostosis, or enchondrosis of the septum. The thickened nuicous meml)rane at times resembles a fibrous polyp — indeed, may be easily mistaken for such a condition. There is marked interference with nasal respiration ; the membrane tends to sudden eufj^orgement on the slightest irritation; any posi- tion whicii favors gravitation increases the distention. As the hyperplasia is limited to certain areas only, there is still remaining a certain amount of nasal mucosa, wdiich, aside from the local irritation, is not involved in the process. This tissue, however, is the site of engorgement, and the nasal obstruction with the retained secretion necessarily produces irritation and simple inflammatory phenomena, w^ith the usual chain of symptoms. The permanent nasal obstruction, often worse at night tiian in the day, leads to habitual mouth-breathing, and the patient frequently acquires a gawky, staring appearance, due to his wide-open mouth. The secretion is thick, tenacious, and difficult of removal, even though it is scanty. The membrane, from involvement of peripheral- nerve filaments, loses its sensibility largely, and the sense of smell may be markedly impaired or destroyed. The hyperplastic tissue at different stages presents varying appearances in different sites, and, in describing it, it will perhaps be more convenient to refer to the anterior, middle, and posterior hyperplasias, according to their localities. In the anterior regions the color of the tissue may be nearly normal, or red, varying with the severity of the process. The anterior end of the inferior turbinate is swollen, and presents a surface which may be smooth, or lobulated, or in som(! cases somewdiat foliated. It may even be so swollen as to touch the septum. The same is true of the middle turbinate, the hyperplasia being mostly on its anterior border, or fore part of the inferior border, and red, smooth, nodular, or glandular, as the case may be. The membrane of the septum, as a whole, is un- evenly swollen, w'ith irregular areas of marked elevation, usually most frequent in the low^er part. In the posterior enlargements the inferior turbinate plays usually the largest part, and posterior rhinoscopy reveals a rounded whitish tumor, irregularly crossed and fissured, or even lobulated. The same structure may be seen in the middle turbinate, but usually smaller and more spindle- shaped. These overgrowths may partially or completely fill the choanae, or may even project so as to obstruct the orifice of the Eustachian tube. Instead of this pale structure there may be seen another, usually regarded as an earlier stage of its develop- ment, and termed the rasplx^rry or nnilberry form. This is dark Fig. 42.— Section of tissue in hyperplastic rhinitis. The section shows overgrowth of connective tissue, which is normal in character and shows no tendency to contract. The alteration in the gland-structure is due to pressure from the excessive amount of connec- tive tissue. DISEASES OF THE ANTERIOR NASAL CAVITIES 99 red or purplish in hue, and has a tendency to bleed on slight irritation. Both of these structures may occur on the posterior portion of the septum. In the middle region the hyperplasia is found on the same structures as in the anterior and posterior, the middle and inferior turbinated surfaces being red, smooth, or granular and rough. Often pedunculated processes may de- pend from them, and formations like papillomata may occur. The septum may show a longitudinal groove, or grooves, from the pressure of the impinging turbinates, and in the anterior regions myxomatous formation not infrequently occurs. The superior turbinates and roofs of the fossae, as a rule, are slightly or not at all involved in the overgrowth — an important fact to recall in the diagnosis of polypi. When, however, they do become implicated in the process, various eye-lesions seem to be peculiarly asso- ciated. Both nasal fossae are usually symmetrically involved, or only one may be affected. Or one nasal chamber or area may show the hyperplastic development, while the other is normal, or in the acute, or simple chronic, or, perhaps, atrophic stage. The timbre of the voice is altered owing to the interference with nasal resonance. If the middle turbinate is involved, there will be occlusion of the lacrimal canal, which on the slightest ex- posure will produce conjunctival irritation with watery overflow. If the posterior portion of the middle and inferior turbinates is involved, there will be impairment of hearing, owing to the occlu- sion of the Eustachian orifice. There will be dull, intermittent, frontal headache. The overstimulation of the glandular element will give hypersecretion of not only the anterior but also the pos- terior nasal membrane. There may be accumulation of secretion in the nasal cavity, owing to the irregular surface and the altered character of the secretion. This, becoming infected with sapro- phytic bacteria, may become offensive. This irritating secretion passing into the nasopharynx may produce cough. The appearance of the true hyperplastic tissue is usually red or purplish, and, when it presents the whitish or grayish appearance, it is undergoing mucoid degeneration. There is often a sense of fulness and press- ure over the bridge of the nose, associated with some face-ache. There may be associated M'ith the condition nasal polyps. Diagnosis. — The diagnosis of hyperplastic rhinitis is impor- tant for this reason, that, in the simple chronic, the intumescent, the cyanotic variety, and the engorgement of mucous membrane found in plethoric* individuals, while ])resenting vcrv iiuicli tlic same condition and appearance on insju'ction, the Ircntniciit is radically different, as tlic object should be to save llir mucous membrane and produce as little scar as possible; lor in the true hyperplastic rhinitis there can be no ndini to the normal function of the mucous memi)rane, while in lli<' other varieties mentioned, by the proper treatment such results e:in l>e (»i)t;iine(l. In the L.ofC. 100 DTSEASES OF THE ^OSE AND THROAT. liypcrplastic fonii, the main ol/jcct is to restore pro[)er nasal breath- ing by the removal of the thickened tissue, thereby allowing the normal elements yet remaining and not involved to functionate ])ro])erly. (^n the application of coeain tliere is marked reduction in all the varieties except the hyperplastic, and in that the con- traction is only slight, simply relieving the surface engorgement. Another diagnostic proc(Klure is based on the relative promptness of resumption of sha])e by the turbinal tissue. If, "without cocain- ization, a prol)e is ]>ressed with sufTieient force on the affected area, it will, if the condition is found to be one of true hyperplasia, leave its im])ression for some time, the indentation slowly filling in ; if the condition be one of simple ciironic or intumescent rhinitis, as soon as the pressure is removed, the tissue rebounds to its original shape (Fig. 43). r j ^"^s^ ''^^^--^^- .,^ ^^2; 1->7>,c^ -^ ^ Fig. 43.— Left nostril shows hyper7)lasti(' tissue, yielding "iily sli,i,'htly to probe-pal- pation. Right side shows the pitting noted both in simple elironic and intumescent rhinitis on probe-palpation. Prognosis. — With surgical interference the prognosis is good, as reganls the relief of the patient. While it cannot be hoped to restore; the entire mucous surface to normal, yet, by the removal of the excessive growtii involving certain areas, and by the estab- lishing of nasal breathing, there may be sufticient of the normal mucous membrane lel't to keep up in a great measure the proper nasal functions. Complications. — A nasopharyngitis, or ])haryngitis — or both — tracheitis, or l)ronchitis are almost sure to accom])any the nasal condition. Reflex attacks of epile]),sy, asthma, chorea, spasms of glottis, various eye-complications, such as optic neuritis and forms of headache, mental hebetude, difterent manifestations of aprosexia, DISEASES OF THE ANTERIOR NASAL CAVITIES. 101 and, perhaps, amnesia may occur. The lowered tone or loss of the olfactory or aural functions has been referred to as quite sympto- matic, and middle-ear catarrh is not uncommon. Occlusion of the nasal duct may produce a conjunctivitis or epiphora. Obstruction of the sinus outlets may cause mucocele, or, if infection be present, suppurative processes. Deafness from Eustachian involvement and, frequently, an associated nasopharyngitis are present, with a relaxed velum palati and uvula. Digestive disturbances are extremely common, and are exhibited both as local and constitu- tional effects. Locally, various forms of tumors, especially polyps, and, in the nasopharynx, adenoid growths, may develop. Treatment. — Locally, cleansing solutions should be applied, not so much for their curative effect, as to rid the nostril of any retained secretion and keep the part as thoroughly cleansed as pos- sible. The curative treatment consists in the removal of the excess of tissue. This can be done by means of acid or the actual cautery. Personally, I prefer excision with the knife shown in Fig. 39. A wedge-shaped incision may be made, and the excess of tissue removed either by the saw-scissors or the snare- loop, and the resulting scar will be thereby lessened in extent. Should there be thickening of the turbinate bone or any ten- dency to shelving or hanging of the bone after the removal of the tissue, the mucous membrane should be dissected away from the bony surface, and the edge of the bone removed l)y means of the alligator-biting forceps (Fig. 44) or the nasal saw (Fig. 45). Fig. 44.— Alligator-jaw forceps. Fig. 4.').— Author's iiasa For the removal d" ivr.H-(.(hirc has been U select tlie most dependent part of the <.\ci-l;i-<'\\ t li <>r tliat \k\v\ ni..s 102 DISEASES OF THE NOSE AND THROAT. prominent in causing obstruction or irritation. The site being cliosen, I make a V-siiaped incision with the knife shown in Fig. 39, cutting away from the septum and causing tiie two areas of the Vto intersect at a fixed point on the turbinal bone, including by its removal as much tissue as will free the nostril and relieve irri- tation. AVhen the incisions are made, if the excised portion cannot be removed, cut it free with the saw-scissors. The V-shaped gap in the turbinal tissue will now close on itself, and the union will leave on the surface a linear scar only, parallel to the long axis of the bone. After the operation the nostril should be kept carefully cleansed by the use of — Iji. Sodii bil)oratis, Sodii bicarbonatis, Sodii chloratis, da z] (3.6) ; Aqujfi, fi;^iv(120.) every three hours, in a Kirkpatrick or Bermingham nasal douche. If the oifending tissue is corrugated or sessile, I prefer to remove it en masse with the cold snare. Fitting the loop closely about the tissue to be removed, tighten it by two or three turns, then wait a few moments ; again twist the wire still tighter, wait a short time, and repeat the procedure until the snare has com- pletely severed the mass. By proceeding in tliis way the danger of hemorrhage is minimized. The stump should be cauterized with the galvanocautery, or chromic acid fused on the point of a probe. After the operation, cleanse the cavity daily with the solu- tion given above. Tissue may also be removed by the electro- cautery snare more rapidly tlian with tlie cold-wire snare. The reactionary contraction to linear cauterization of the offending tur- binate will often widen the cavity sufficient for ordinary breathing purposes, and thus give relief. Electrolysis, using the bipolar method and preferably a double electrolytic needle, has given very favorable results. A current of from 5 to 10 milliamperes, gradually admitted and as gradually diminished, will in from two to live minutes effect the desired re- sult. The points in favor of this method of treatment as against other metiiods have been well summarized by Scheppegrell, and are that it is a conservcr of tissue ; that it is, at least, not more painful than any other ; there is little reaction, and, finally, that, being submucous, there is no danger of synechia. OZENA. It has seemed advisable to the author, in view of the ofttimes perplexing employment of tliis term by medical writers, to give a little space to a consideration of its proper limitation. The DISEASES OF THE ANTERIOR NASAL CAVITIES 103 term itself, as derived from the Greek oCaeva, signifies properly a stench, and has had its place in medical nomenclature from far remote times. The early Greek and Koman writers, however, did not restrict the term to a fetid odor merely, but used it as includ- ing both the odor and an associated ulcer. Later in the history of medicine it was used as a synonym of a nasal ulcer, whether fetid or not, and this application seems to have been accepted gen- erally for a long period. In the twelfth century, however, one writer departed from this and described the condition as due to a decomposition of secretions, not mentioning ulceration in the same connection, and in the seventeenth century again this same opinion was expressed. It is little wonder, then, that a word with such a history should in the present time stand ready to represent indif- ferently, at the will of the writer, either a disease or a symptom. But ozena is not in any sense a true disease in itself; its peculiar place is that of a symptom, and in no other light can it properly be regarded. It bears to certain diseases of the respiratory tract precisely the same relation that the rash does to the eruptive fevers, and, like the rash, it varies in character and intensity in accord- ance with the graver disease with which it is associated. It is just as proper intrinsically to speak of a rash as a disease always attended with measles, for example, as it is to speak of ozena as a disease, when the presence of a graver malady is only too evident. Thus the terrible sickening odor of atrophic rhi- nitis may be so intense as to constitute practically the sufferer's main trouble, and yet we scarcely think that it would be strictly right to speak of ozena with an attendant atrophy of the nasal mem- brane. The same is true of the ozena present in syphilis, in sup- purative processes of the accessory sinuses, in glanders, in coryza caseosa, in certain neoplasms — malignant or benign — in congenital malformation of the nasal spaces, and in some cases of an occlud- ing foreign body, in all of which conditions it plays the simple, more or less important role of a symptom. Ozena displays, in the different conditions in which it occurs, a considerable variation in its manifestations. It may be extreme, almost overpowering, or it may constitute but a slight annoyance frf)m continued presence. It may be perceptible to the patient and not to those near him, or vice imsd ; maybe unilateral or bilateral, constant or intermittent, and may disappear by applica- tion of disinfectants, or show no reaction to their presentee. As to the causation, there is little that can said with certainty. Upon this phase of the subject, speculation and theory have been given full rein. The growth and development of l)act('riology, which has given the solution to so many formerly obscure etiolo- gies, would seem to have given no more than a due in this case. Nay, it even leads into confusion, if we acccj^t a bacterial causa- tion, as to whether it is the result of a saprophytic decomposition 104 DISEASES OF THE NOSE AND THROAT. of secretions, or, in some particular cases, whether the odor be not the peculiar product of some specific germ — alone, it may be, or in combination with the former. Certainly no better life-condi- tions could be found for germ-growth than the warm, moist secre- tions of the nasal cavities. A second theory has been advanced — namely, that it is due to a product of fermentative changes in the secretion. Another theory, based upon pathological retrogressions in tissue, claims that the odor is a combination of various fatty acids, set free in the decomposition of fat resultant from a fatty cellular degeneration. A fourth theory expresses the hypothesis that the odor in each case is sul generis, an entity which belongs to each underlying condition as its peculiar attribute. Personally, I believe that the action of the saprophytic bacteria seems to offer the most rational single view, and finds corroboration both clini- cally and theoretically. Moreover, if we go a step further and study the putrefactive processes taking place in certain other in- fected conditions, as, for example, pulmonary abscess, or gangrene, we find exhibited on a larger scale the same conditions and the same results which obtain in the diseases already mentioned as attended with ozena. Especially is the characteristic odor which accompanies the latter conditions similar to that of ozena. But yet with this proof, in the present condition of uncertainty, we must not accept it as the sole explanation. It is possible, or, per- haps better, it is probable, that ozena may in a given case be due not to one cause, but to a combination. For example, the ozena in atrophic rhinitis may be attendant upon putrescent secretion, and the fetid odor of nasal syphilis may be the expression of a factor as yet unknown, possibly acting alone, or in combination with decomposition. I have seen a number of cases of apparent ozena in which the cause was entirely dental ; the incisors, one or both, being diseased, had, by extension of the degenerative proc- ess by contiguity of structure, involved the floor of the nose, and the odor emanated from the necrotic tissue, and the nasal odor was due entirely to tliis process. Again, in several instances where, from decomposition at the root of a tooth extending into the antrum of Highmore, gases from such tissue-decomposition accumulated and esea])ed through the nostril, the odor was that as noted in atroj^hic rhinitis. But however originating, the essential fact must not be overlooked tiiat ozena is in no true sense a disease, but is solely a symptom. ATROPHIC RHINITIS. Synonyms. — Atrophic catarrh ; Atrophic nasal catarrh ; Chronic atrophic rhinitis; Chronic fetid rhinitis; Cirrhotic rhi- nitis ; Dry catarrh ; Dry nasal catarrh ; Dysodia ; Fetid atrophic rhinitis ; Fetid catarrh ; Fetid coryza ; Fetid rhinitis ; Idiopathic Fig. 46.— Hanging turbinate as seen In various forms of rhinitis. It acts as a mechan- ical obstruction in causing congestion above and below, and thus doubly obstructs the nasal cavity. -^ -, :.. ./■^Vuraoirelta WGiKiiiytor Fig. 17. he left nostril shows the morbid anatomy of atrophic rliiiiitis ; th shows the appearance of simple chronic rhinitis before cuntiacti DISEASES OF THE ANTERIOR NASAL CAVITIES. 105 or constitutional ozena ; Ozena ; Rhinitis atrophica ; Rhinitis atroph- ica simplex ; Rhinitis foetida atrophica ; Rhinitis sicca ; Sclerotic rhinitis ; Simple ozena ; Atrophic endorhinitis. Classification. — Atrophic rhinitis is in reality not a separate process nor an inflammatory condition, but the result of pre-exist- ing conditions, and as to cause may be divided as follows : First, an atrophy of the nasal mucous membrane which is brought about by a pre-existing inflammatory process followed by contraction (Fig. 47), which necessarily lessens the blood-supply to the part^a fact which in itself will tend to cause atrophy, and also, by pressure, to lessen the function of the glandular ele- ments present. Second, an atrophic process which is truly a pressure-atrophy brought about by overdistention of the blood-vessels of the sub- mucosa, not due to any local obstruction, but interference in the systemic circulation, by which the blood is dammed back on the mucous surface, and by the pressure thereby produced there is caused atrophy of the connective-tissue and glandular elements (Fig. 49). It is pathologically a cyanotic congestion and a press- ure-atrophy, and is identical with the condition seen in red atro- phy of the liver. Third, an atrophic rhinitis which is a simple atrophy or a trophic process. It will be seen that the above arrangement differs from the classification given in most works on diseases of the nose and throat, yet it is based on clinical observations and the knowledge of the pathological alterations of the structure, and while the result of the atrophic process when completed is practically the same regardless of cause, yet the pathology and treatment of such alterations would necessarily be different. For convenience, atrophic rhinitis may be divided as follows : (1) Primary, or a direct lesion of the part, such as a simple atrophy or a trophic process. (2) Secondary, or atrophy as a result of {a) pre-existing heal lesion in which, as a result of this lesion, there is atrophy of the membrane, and (6) atrophy which is secondary to a lesion some- where else, or, in other words, a condition which is forced upon tlie meinl)r;uK' — a pressure-atrophy. General Remarks. — It must be remembered that atrophy and degeneration are separate processes ; also, that in simple atro- phy of a part there is diminution in nutrition, with lessened func- tion, though not necessarily lessened size, for the size may be in- (Tcased owing to fluid distention, as is shown in red atro])liy of the liver, nevertlu'k'ss the structural element is lessened. In sim})le atrophy there is a reduction in tlu; size of the cellular elements, and })ossil)ly a numerical reduction, but there is still present the individual cell, which by improved nutrition and improved func- 106 DISEASES OF THE NOSE AND THROAT. tion may be restored to its proper condition ; while in degeneration there is an entire loss of function, the then existing cell is con- verted into another material, and there is no possible return to the normal. I believe then, in atrophic rhinitis so-called, that in certain stages the tissue is simply atrophied, and, if the cause can be removed and nutrition established, it might be brought back to the normal. Unfortunately the cause can rarely be removed, and the condition goes on to a degenerative process, which explains the fact that it is rarely cured. To use the term "atrophy with degeneration " is incorrect ; it should be " atrophy followed by degeneration," as the processes are separate and distinct. True, degeneration may be, and frequently is, secondary to the process of atrophy, but it is possible to have a degeneration not preceded by the process of atrophy. There seems to be an idea prevalent that the connective-tissue element is the first to suifer, but this I do not believe to be true. While it may be the first involved, it is a well-known anatomical and physiological fact that the con- nective-tissue element is the essential and independent structure ; also, that connective tissue can exist without epithelial cells, but that epUhelial cells are dependent structures, and cannot exist without connective-tissue basement-membrane support. Now, if any alteration takes place in the submucosa, which is the essential structure — that structure wiiich commands and controls nutrition — and is, of course, the first altered, the tissue farthest from nutri- tion would be the first to suffer*— that is, the epithelial cells. I grant that the change is largely one of degeneration, which is sec- ondary to the atrophy, and the term cirrhosis (meaning a fatty degeneration or fatty change) and the term sclerosis (meaning a hardening) are both correct, but the cirrhosis or fatty change fol- lows the sclerosis. Now, in the consideration of the atrophic proc- esses, we must distinctly remember that the condition is con- stantly changing — that, in reality, it is a termination of other con- ditions, a resulting state with definite structural changes ; and as to whether it be called atrophy or whether it be called degeneration depends entirely on tlie stage of the pathological alteration ; that is, if this alteration can be arrested while it is still an atrophic process, a fiiir amount of function may be re- stored ; l)nt if it has gone on to a lower retrograde change, that of degeneration, then the cell-function can never be restored. Too much stress has been laid on the various forms of atrophy, which has only added to the confusion of classification and the multiplicity of terms. It makes no diflPerence, in the actual proc- ess in the tissue, whether an atrophy be primary or secondary ; the atrophic change is the same. The causes may be different, and in some cases, as in a pressure-atrophy from inflammatory contrac- tion, the process cannot be arrested while it still exists as an atrophy ; and, although the process is the same, in an atrophy DISEASES OF THE ANTERIOR NASAL CAVITIES 107 from lessened nutrition, if nutrition be supplied, the tissue may again return to the normal, but the atrophic condition as it existed is identical with any other atrophy. The variety of rhinitis often described as atrophic is usually that which follows the simple chronic variety (Fig. 47), and not the hyperplastic variety. The process does not begin as one of atrophy, for, when it reaches the point of atrophy, it is really not an inflammatory process at all, but simply a result ; and the changes which take place in the structure — the cirrhosis, the desquamation, the involvement of gland-structure, with atrophy and degeneration — are due to the facts that the nutrition is cut off by the sclerotic or fibroid change, and that the atrophy has gone on to a further retrograde change, that of degeneration. The fact that — in the varieties of atrophic rhinitis with much shrinking of tissue with the wide-open nostril, the irregular cavity showing almost as if the bony walls were exposed — there is very little bleeding if irritation is produced, confirms the theory of fibrous-tissue formation with contraction, as the fibroid contraction would lessen the blood-supply and thereby lessen vascularity and tendency to bleed. I have seen ulcers in several cases of this ad- vanced variety which were brought about by degenerative proc- esses, and from which there was practically no bleeding unless considerable irritation was produced. Much has been said in regard, to the atrophy of the turbinal bones in atrophic rhinitis. Some of the cases of apparent bone- atrophy may be explained by the fact that the turbinated bones may have been rudimentary, or were of arrested development. In comparing the shrunken and apparently atrophied bones seen in cases of atrophic rhinitis with the appearance presented by the cadaver in the anatomical rooms, I find there is very little differ- ence, and the apparent diminution is largely confined to the mucous membrane covering these bones. Absorption of bone may take place, but in order to have absorption of a bony structure there would necessarily have to be marked alteration in surrounding structure, which alteration would be degenerative. In some cases there is unquestionably bone-involvement ; but, when such a process takes place, if a careful clinical history be obtained, it will be found that there are present tuberculous or sypliilitic conditions. I insist on the sejiaration of the terms atrophy and degeneration, because the simple atrojihy without degeneration may be restored to the normal ; but, wlien degeneration takes place, the process is separate and di.stinct, and the tissue which has actually degenerated cannot return to the normal. The reason tliat atrophic rhinitis is so difficult of cure is that the process of atrophy has in many cases progressed to one of degeneration, and there is no restoration pos- sible. In cases in which ozena is the prominent symptom, in which there 108 DISEASES OF THE NOSE AND THROAT. is practically little or no alteration in the nasal mucous membrane, and yet a frig'htful and persistent odor is present, the source of the same is, in the majority of" tlie cases, from one or more of the acces- sory sinuses. The odor and the atrophic inflammatory change which occurs in the nasal mucous membrane may be due to the fact that, in tiie bony formation of the floor of the nose, the bony wall assumes a concavity (Fig. 48), in which there is a natural tendency to the Fig. 48.— Concave nasal floor (after Cryer). The flat palatal arch causes the nasal floor to be concave in.stead of flat, as it otherwise would be. Here secretions collect and crusts form, cau.sing ulceration ; or else the secretion runs posteriorly instead of draining for- ward, and thus sets up a nasopharyngitis. accumulation of secretion. Tliese inflammatory secretions by the continuous irritation will produce inflammatory tissue-alteration. Indeed, this explains some cases in which there have been ulcera- tion and perforation of the hard palate. In all such cases it will be found that the bony wall was very thin at that point, owing to the concave formation. Atrophy Due to a Pre-existing Local Lesion. Ktiology. — As this variety follows inflammatory processes, either siin|)l(' or infective, the causes would necessarily be those which would produce simple inflamniatory proces.ses of the mucous membrane, such as are given under traumatic rhinitis, simple chronic rhinitis, and the membranous varieties. Malformations, nasal deflections, septal spurs, ill-formed nasal orifice, imperfectly developed turbinates, all act as ])redisposing factors. The heredi- tary tendency supposed to exist in some families can be exjiiained by the inherited family nose, which, owing to its shape, predisposes DISEASES OF THE ANTERIOR NASAL CAVITIES. 109 to nasal inflammation. There should be classed here those varie- ties which are due to, or associated with, infectious inflammatory processes, in which there is not only involvement of the sub- mucosa, but also permanent alteration of the epithelial layer. Other exciting causes are the infectious diseases, such as measles, diphtheria, scarlet fever, and, occasionally, typhoid fever. The condition is also subsequent to chronic catarrh of the frontal, ethmoidal, or sphenoidal sinuses, especially the last, or to an involvement of the antrum of Highmore, either by infection from the nose, or in most cases associated with carious teeth. The variety of atrophic rhinitis following simple chronic purulent rhinitis, which undoubtedly produces atrophic processes, should be classed here. The age of the individual at which this condition may occur is usually under thirty, although it may be found in the very young or in adult life. In my own experience I find little difference as to sex. The simple dry rhinitis of the aged I do not believe should be classed as an atrophic process, other than that with advanced age we find a lessened physiological function of the entire body, and that the atrophic process occurring in the nose, with the altered secretions, is nothing more than the physiological alteration of old age. I have : in the nasal cavities, need but brief mention. The site may be any portion of the mucous area accessible to the infected finger or instrument, and in the majority of the reported cases has been the alse or septum. The chancre itself is painless ; but pain from its presence and continued pressure, usually of a neuralgic character, is not uncommon. The local symptoms do not differ from those of a simple, non-specific ulcerating papule at the same site. There is more or less occlusion of the nasal space, with proportionately affected respiration, phonation, and olfaction. Slight fever may attend its presence, and various reflex disorders may coexist. The papule is hard and firm to the probe, sharply circumscribed, and rapidly ulcerates. Its size may vary, and, when occurring on the anterior part of the septum, may com- pletely fill the vestibule and push aside the opposite ala. In- spection is often impossible because of the swelling. A very important symptom often present and occurring with the appear- ance of the chancre is the enlargement of the allied submaxillary lymphatic glands, forming the so-called indolent bubo. These enlargements are characterized by their distinctness, free move- ment, induration, slow growth, and comparatively small size. Furthermore, they are painless, do not usually suppurate, and are covered by normal integument. Local medication has no effect upon them, but specific treatment causes a prompt reaction. Secondary. — The secondary symptoms of nasal syphilis occur in a certain number of cases, and are but part of the constitutional exhibition of the specific virus, usually appearing within six months after the chancre, whether that occurs in the nasal mem- brane or elsewhere. The patient in a well-marked case at the onset of this stage generally believes he has taken a moderately severe cold. There is often a fever lasting until the eruption appears, with restlessness, sleeplessness, and peculiar shifting bodily pains. Anorexia is usually present. Whether it is generally true or not, the clinical observations seem to confirm the fact that in primary syphilitic infection in the throat, nose, or mouth, during the eruptive stage the ear- lier eruption is likely to a]>pear on the palm of the hand ; while, in the general treatise on Sy])hilis, palmar eruption is generally cited as of infrequent early occurrence. Soon the symptoms of a croryza appear, varying proportionately with the severity of the disease ; sneezing, lacrimation, photopho- bia, dull headache, ditfieult respiration and ]ierverted olfaction, gustation, and phonation may be met with. The nasal discharge is abundant, and at first is watery and thin. The membrane on inspection is red, swollen, and congested, and may be edematous — features most marked on the middle turbinate. The coryza increases in severity, the discharge becomes thicker, gradually DISEASES OF THE ANTERIOR NASAL CAVITIES 129 acquires a somewhat fetid odor, and finally becomes almost or (juite purulent, showing, perhaps, admixture with a slight amount of blood. The surface of the pituitary membrane, at first covered by thin secretion, shows here and there areas tending to extend and coalesce, which are covered by a greenish-yellow secretion. Later, mucous patches may be observed just within the vestibule^ or at cutaneous margins on the alse or the septum, or in the poste- rior nares, showing as slightly elevated areas, purplish-red or ashy in hue, ulcerated, surrounded by an inflammatory area, and usually covered by a yellowish secretion. The coryza is apt to be pro- tracted, and usually resists any treatment save that directed against the specific disease. An important fact in the symptomatology is the coexistence of the ^-arious skin-eruptions and rashes. Tertiary. — The tertiary symptoms — if the disease, either through neglect or improper treatment, has reached this final stage — develop after a varying period, usually from five to twelve years, of complete absence of any manifestations, save, perhaps, the so- called " reminders." The mucous membrane gradually swells from cellular infiltrate and proliferation, either diffusely and involving areas of varying size, or in local nodules or gummata, situated usually in the respiratory region. The color is reddish or purplish- red, but later pales. The swellings, hard and firm at first, pit little under the probe, but later become softer. Pain may be present of a neuralgic character, due, not intrinsically to the growth, but to its continued presence and the protracted irritation of adjacent tissue. The usual symptoms of nasal obstruction develop. The further duration of the disease varies. In some cases results ensue not dissimilar to those of atrophic rhinitis. The bony and cartilaginous structures necrose and undergo absorp- tion without breach of surface-continuity or secondary infection, and scar-tissue takes their place, subsequently contracting and in- creasing tlie nasal space. The secretion is diminished and inspis- sates, forming crusts, and there is a marked odor. The sense of smell is lost, and the wide-open cavities permit the free inhala- tion of unmodified air. In the majority of cases, how^ever, ulcera- tion follows. The inflammatory masses break down, soften, and suppurate. The discharge increases, becomes abundant, often of a dark color, and is of a horrible and persistent odor, which disin- fectants fail to influence. Inspissation and crust-formation cause the membrane and ulcerated areas to be covered by dark -yellow- ish or yellowish-green scabs. Ulceration slowly spreads, forming large suppurative foci, ^^•ith more or less overlying crust of dried secretion and necrotic shreds. Necrosis of the bone occurs, or has already occurred, and the discharge contains small, dark- greenish, " worm-eaten," and ill-smelling sequestra. If the probe be used upon these areas, distinct grating \v\\] be elicited, and fragments of diseased bone can be readily brought away. The 130 DISEASES OF THE NOSE AND THROAT. process contimu's and, from the persistent loss of bony substance, grave structural changes are induced. The cartilage of the sep- tum melts down, and the tip of the nose falls in ; the vomer necroses, and the bridge flattens. The turbinates partly or wholly disappear. Perforation of the septum, or its complete destruc- tion, and perforation of the hard ])alate are by no means unlikely to follow. The process may involve the entire nose, and leave as nasal orifices two large gaps in th(> face, surrounded by cicatricial tissue. Perf )ration into the cranial cavity may occur. It is need- less to mention tlu; changes that would obviously take place in the special senses, directly or indirectly connected with the nose, during such extensive tissue-involvement. The process may be unilateral or bilateral, and it may be in different stages in different sites at the same time, and, under appropriate treat- ment, healing of the ulcerated areas and the formation of stellate cicatrices result. Following healing of the ulcerated or absorp- tion of the non-ulcerated gummata, the scar-tissue of the cicatrix, in connection with the filjrous tissue formed adjacent to the gum- mata — a feature conimon to the specific inflammatory processes — constitute the areas of fibrous structure. As c(^ntraction takes place, however, the obliteration of the blood-supply may lead to degenerative changes in this tissue, forming the so-called areas of fibroid degeneration mentioned by various writers. Diagnosis. — Primary. — The primary sore in the nasal spaces by its very rarity renders the diagnosis often obscure. Usually an absolutely certain diagnosis can be made only upon the ap)>earance of the secondary lesions. The history of the case may throw some light upon it. Secondary. — The secondary manifestations in the nasal spaces may be so slight as to be overlooked. The diagnosis is based u])on the history, symptoms, the constitutional manifestations, and the reaction to specific treatment. Tertiary. — The tertiary lesions of the nose present a picture that can scarcely be mistaken for anything else. The necrotic lesions, the intractable stench, the history of the case, and the prompt response to the iodids should make the diagnosis com- ])aratively easy. Prognosis. — Under proper treatment instituted during the secondary stage, th<» chances of recovery are extremely good. During the tertiary stage, if the necrosis is not excessive and vigor is fairly unimpaired, early treatment offers good chances for recovery. The j^rognosis becomes graver, however, in proportion to the severity and extent of the lesions and the length of time that they have been untreated. After recovery, the cicatricial tissue formed juay cause impairment of various associated func- tions. DISEASES OF THE ANTERIOR NASAL CAVITIES. 131 Complications. — Necrosis into the cranial cavity may occur, or partial destruction of the sphenoid, ethmoid, occipital, and supe- rior maxillary bones. Treatment. — Primary. — The treatment of nasal chancre should consist in thorough cleansing by the use of a warm alka- line solution described on page 115, followed by mopping the lesion with — !^. Extracti hydrastis (aqueous, colorless), 3ij (7.5) ; Hydrogeni peroxidi, Aquse cinnamomi, da flgj (30.). The ulcer is never to be cauterized or excised. The enlarged glands should be smeared with equal parts of ichthyol and lanolin, or painted with iodin. No mercury is to be given in this stage of the disease, for the reason that, by the suppression of the sec- ondary eruption, proper diagnosis is interfered with, and from the uninfluenced secondary lesion a more definite prognosis can be given. Secondary. — For the coryza of secondary syphilis local medi- cation is of little or no avail. The mucous patch should be thoroughly cleansed with equal parts of hydrogen peroxid (15 volume) and cinnamon water, and touched daily with the solid stick of nitrate of silver or with nitric acid applied on sharp- ened bits of wood. The constitutional treatment should now be instituted and kept up uninterruptedly for two years, in the form of the protiodid in doses of ^ grain, as the green iodid in |-grain doses, or as the bichlorid in Jg-grain doses. Mercury is to be administered three times a day. On the second day the morning dose is to be doubled, on the third day the noonday dose is to be doubled, and so on, increasing the dose of each entire day by the size of the original dose until there is slight diarrhea, griping, a metallic taste in the mouth, or soreness on snapping the teeth together, when the day's dosage should be reduced by the same increment as it was increased, until these symptoms cease. This is the point of tolerance for each individual and is the maximum dose. Tertiary. — Local. — The tertiary ulceration of the nasal cavities is to be cleansed by the application of hydrogen peroxid (15 vol- ume) by means of the atomizer or cotton-covered probe. After thorough cleansing, the involved areas should be touched with the solid stick of nitrate of silver, and, if they tend to proliferate, they should be excised or burned with the actual cautery. If the deeper structures be involved, tliey should be carefully curetted and pieces of loose bone removed. The; disagreeable odor arising from the destructive nasal processes can be controlled by doucMng with— 132 DISEASES OF THE NOSE AND THROAT. I^. Potassii pennauii^aiiati!?, gr. ij (.12) ; Acidi l)onci, gr. v (.3); , Aqiu« (ti'pi(l), rt5j (30.) ; every three or four hours. Con-sfifiifioiia/. — The eoiistitutioual treatment of the so-called " late secondary " or teitiary .stage of syphilis should consist niainlv in the administration of the iodid of j)otassium or sodium and mercury. The; best method of ol)taining results, gratifying alike to physician and patient in the administration of these drugs, is to prescribe tlie iodid of sodium in a saturated solution, com- mencnng with 20 grains three times daily in a half-glass of milk at least a half-hour after meals. Give the mercury in the form of the bichlorid in compound syrup of sarsaparilla, commencing with -^\r- to ^-gr. doses at the same time as the iodid. By giv- ing these drugs in this manner, the dose of the iodid may be increased or decreased at will, without affecting the size of the dose of mercury, or adding more sarsa])arina to disorder the diges- tion. The iodid may be increased by large amounts, 20 grains at a dose, or by smaller amounts, 5 grains, as the case requires, lodism may be guarded against by administering 5 to 10 grains of sodium l)romid with each dose of the iodid, as recommended by Bosworth, or by discontinuing the use of the drug on the appearance of the " iodic " rash or coryza. In individuals who cannot take iodids on account of the rash produced, if one hour before administration of the iodids there is given ^ grain of the extract of belladonna, tiiis disagreeable effect can be avoided. The use of alcohol (as a beverage) and tobacco is to be inter- dicted ; outdoor life is to be insisted upon. A stimulating diet should be prescribed. Any falling off in weight calls for the addition of tonics. One of the best formulae for administration in conjunction with the specific treatment given above is — 1^. Pulveris kola^, gr. iij (.18); Ferri lactatis, gr. j (.06) ; Strychninje nitratis, gr. ^L. (.002). — M. given in pill or ca]>sul{> three times a day. Nasal deformity is to be guarded against by careful pro]>hylaetic treatment. If the case is seen after the bridge of the nose has sunken in, an artificial bridge may be inserted, or modified JNIayer's tubes, of a slia|)(' ada]ited to each cas(\ may be worn, obtaining the desired form by taking an impression with dental wax. When the cartilaginous suj)port of the end of the nose has been destroyed so as to let the tij) fall upon the upper lip, Bishoj) has restored the natural shape DISEASES OF THE ANTERIOR NASAL CAVITIES. 133 by using his nasal supporter of vulcanized rubber (Fig. 53.) with admirable results. Fig. 53.— Bishop's appliance for elevating sunken bridge of nose. Hereditaey Syphilis. Definition. — By hereditary syphilis is meant that form of syphilis in Aviiieh the infection takes place before birth. In the early form it appears usually prior to the third month, and its manifestations may be considered as being of the secondary type. The late form appears at or before puberty, and is generally of the tertiary type. Synonyms. — Congenital syphilis of the nose ; Inherited syph- ilis of the nose. Special Synonyms. — Early, Snuffles ; Late, Syphilis tarda. Etiology. — This may be briefly summed up in the terse state- ment, "parental transmission." The poison may be transmitted through the father, in which case the term sperm-inheritance is employed, or it may be conveyed by the mother, the so-called germ-inheritance, and in not a few cases both parents have been syphilitic. The student must not forget, however, that syphilis arising from inoculation during the passage of the child through the birth-canal is the acquired, not the hereditary, form. Pathology. — Early. — The pathology of this stage is the same as that already described in the pathology of the secondary acquired form, with the exception that the inflammation is rela- tively more intense, and in the smaller nasal spaces of the young child is productive of more marked phenomena. Necrosis and absorption of bone and cartilage may occur as tlie result of a deeper extension of the inflammatory process. It is probable that the flattened nasal bridge characteristic of this period is a mal- development consequent upon the reaction of the young tissue to the inflammatory process. Late. — The pathology is identical with that o\' the tertiary lesions of the acquired form. Gummatous formation, ulceration, necrosis, and di.scharge or a])sorption of the tissues occur in pre- cisely tlic same niannci-. Symptoms. — Early. — In the scicond or third week afterbirth, sometimes earlier, but rarely later than the third month, the child gives evidence of a severe ihinitis. The nuieous membrane of the 134 DISEASES OF THE NOSE AND THROAT. nose is red and swollen. There is an al)undant discharge of a clear watery character, which is very irritant and excoriates the surface with which it comes in prolonged contact. Later, it becomes muco- purident, thickens, and tends to the formation of crusts. If the disease follows a severe course to ulceration and necrosis, the dis- charge becomes purulent, admixed Avith blood, contains shreds of necrosed tissue, and possesses a characteristic fetid odor. Fissures at the angles of the alse and upon the nasal margins develop. Noisy breathing from the nasal obstruction is a pronounced symp- tom, giving origin to the popular designatiou of " snuffles," and the mouth is used more or less as a respiratory adjunct. Suffo- cative spasms during sleep are not uncommon, and the child can- not nurse properly. Mucous jnitches are liable to occur at the angles of the nostrils and in the mend^rane of the nose, and in some cases necrosis of the nasal framework develops. A pecul- iar pathognomonic ilattening of the nasal bridge occurs, which is prol)ably a maldevelopment from inflammatory interference with the proper growth of tissue. The constitutional involvement is severe. The child is at birth ill-nourished and weazened, or rapidly becomes so. The impaired nursing ability rapidly de- creases its nutrition, and the inhalation of noxious gases and unconscious swallowing of fetid secretion still further impoverish its vitality. The characteristic skin-lesions are present — a sallow, muddy, unhealthy line, and tlie varied eruptions. Mucous patches are common, especially at the various mucocutaneous junctions, and the hair and nails are affected. The child is restless, yawns frequently, sleeps badly, and its voice acquires a characteristic shrill pitch. A terse pathetic and comprehensive picture of a child with inherited syphilis is ]xiinted in the following sentence : "A little, dried-up old man witli a cold." Late. — The late manifestations of hereditary sy]ihilis appear between the third montii and puberty, and do not differ from the symptoms which we have already described as characteristic of the tertiary acquired form. There is the same inflammatory infil- trate into the nasal nmcosa, which causes a diffuse swelling or takes the form of small gummatous nodules. These undergo pre- cisely tlie same processes of softening and absorption or ulceration and necrosis. The nasal discharge becomes purulent, blood- streaked, thick, dark, and extremely offensive. It becomes mixed with shreds of necrosed tissue and sequestra of diseased bone. Crusts form, which are dark and ill-smelling. Extensive osseous and cartilaginous destruction follows with perforation of the sep- tum or hard palate, and more or less facial deformity from destruction of the bonv support. The patient's general health is impaired, and the eoustitutioual exhibitions of the disease in their various other local manifestations are present. Diagnosis. — Early. — The early form is usually pathognomonic DISEASES OF THE ANTERIOR NASAL CAVITIES. 135 in its symptoms, and can scarcely be mistaken for any other affec- tion. Tlie parental history, obstinate eoryza, general facies, and reaction to specific treatment form the chief points. Late. — The diagnosis is usually not difficult. The progressive nasal-tissue destruction, the characteristic and horribly offensive odor, the response to alterative treatment, the general manifesta- tions, and the history of the case should make it clear. Lupus may confuse, but this is slower in growth, is associated with the tubercular diathesis, attacks cartilage only, does not invade the hard palate, and has not so pronounced an odor. Specific treat- ment gives a decided diagnostic test. Prognosis. — Early. — The prognosis of the disease at this stage depends upon its general severity and the strength and nutrition of the child. Proper specific treatment, in the milder cases, and good management of the nutrition offer a very fair prognosis. Severe cases, on the other hand, ill-nourished and with gastro- intestinal disorder, offer but little chance of recovery. Statistics would seem to indicate a relation betw^een the transmission of the disease and the mortality. If transmitted from the father, the death-rate slightly oversteps 25 per cent. ; from the mother, about 60 per cent. ; and if both parents are syphilitic, it rises to nearly 70 per cent. Late. — The prognosis of this form of syphilis depends upon the strength of the patient, upon the extent and the severity of the necrotic changes, and upon the early treatment of the disease. In the early stages, before extensive loss of tissue and general weakening of the patient, the prognosis under treatment is good. Later, however, the extension of the unmodified process renders the prognosis proportionately grave. Treatment. — Local. — The treatment of hereditary syphilis should consist locally in thorough cleansing of the nasal cavities. This can be effected as described under the treatment of acute rhi- nitis in children, using as the astringent and deodorant solution either — I^. Acidi borici, gr. v (.3) ; Potassii permanganatis, gr. j (.06) ; Aquffi, flfj (30.) ; or, I^. Acidi carbolicl, gr. j (.06) ; Sodii bicarbonatis, gr. vj (.36) ; Acidi borici, gr. v (.3) ; Aquffi, fl.SJ (30.). Morell ]\Iaekcn/ie's method of obtaining a similar result is : " The child should be placed in the nurse's lap and the nasopharynx plugged by means of the temporary sponge tampon. The little 136 DISEASES OF THE NOSE AND THROAT. patient's head should then be slightly raised and the nose washed out with a fine syringe, or, if it be preferred, a spray or nasal douche can be used, care being taken in the latter case that too much force is not employed," For cleansing purposes, warm milk, to which is added ."> to 5 grams of sodium chlorid, may be employed. Constitutional. — Tlie constitutional treatment of this form of syphilis should consist, first, in the administration of mercury in the form best suited to the case. There should be rubbed in the sole of each foot or the palm of each hand 5 grains of the mer- curial ointment every morning and nigiit, as advised by J. Chal- mers Da Costa ; or the ointment, in the strength of 1 dram to the ounce, may be spread on the belly-band, renewing the application daily. Mackenzie ]n-efers mercury with chalk in doses of 1 to 2 grains twice daily. If diarrhea is set up, 1 grain Dover's powder or an additional grain of chalk should be combined with each dose of the gray powder. "Any of these remedies are to be used until the symptoms disappear, but mercury must not be forced or continued too loug after the symptoms arc gouc (Da Costa)." On the appearance of tertiary sym])toms give from l to 1 grain or more of iodid of potassium several times a day in milk. White recommends the continuation of the mixed treatment inter- mittently until puberty. As adjuvant tissue-builders give cod- liver oil, the syrup of the iodid of iron, or the double sulphid of arsenic, the last named in -^^- to ^^^-grain doses, according to the age and size of the child. An admirable medicament for con- structive metamorphosis is lactophospliate of lime in 1-dram doses everv four hours. NASAL TUBERCULOSIS. Definition. — An extremely rare, chronic infectious inflamma- tory disease of the nose, due to a sj^ecific organism. The disease is marked by the formation of the ciiaracteristic tul)crcular ulcers on the nasal mucosa, or by the growth of tubercles forming tumors of varying size, which subsequently break down and ulcerate. These manifestations may coexist. There is an increased nasal discharge, which is uiarkedly fetid. The disease runs a slow, pro- tracted course, modified little, if at all, by treatment. Synonyms. — Nasal phthisis; I'hthisis nasalis; Tuberculosis nasal is. Ktiology. — Nasal tuberculosis is extremely rare, compara- tively few cases being recorded in medical literature. Predisposing- Causes. — The majority of cases occur in those possessing tlie tubercular diathesis. As a rule, also, the disease is a secondary infection from tubercular lesions elsewhere. All con- ditions of the nasal mucosa in which abrasions occur, as well as DISEASES OF THE ANTERIOR NASAL CAVITIES 137 lowered bodily resistance, play important predisposing parts. Con- genital or acqnired malformation of the nasal space, favoring lodgement of the inspired germ, mnst not be overlooked. Age, sex, etc., have no bearing as to its occurrence. The disease is, however, contagious, and occupations necessitating contact with those suffering from it, especially in rooms inhabited by them, filled with germ-laden dust, predispose to no slight extent. Exciting- Causes. — The specific organism is known as the Bacillus inberculosis, or, as it is sometimes called, the bacillus of Koch. This is a straight or slightly curved rod, often beaded, with rounded ends, non-motile, and reproducing probably only by fission, though spore-formation has been claimed to take place. A peculiarity of the germ is its behavior to stains, staining slowly wdth alkaline fluids, and not decolorizing with dilute acid solutions. This property is explained by the shrinkage of the germ in the thin investing capsule by the action of the acid. Primary infec- tion of the nose is extremely rare, and requires the lodgement of the inspired germ upon an abraded surface for its inception. That it does not occur oftener is possibly due to the fact that, in the greater number of instances, the germ when so deposited is washed off by the nasal secretion. Secondary infection may take place through the blood- or lymph-channels, by continuity or by con- tiguity of structure. Usually it follows infection occurring in the lower part of the respiratory tract, the germ being deposited on abraded areas in the nose, in small portions of expectorated mate- rial, during a violent fit of coughing. Pathology. — Macroscopically the morbid process may take the form of a diffuse swelling from general tubei'cular inflamma- tory infiltration, or the more characteristic form of development ; in either, miliary nodules may be seen, which may later coalesce into a single growth, or the formation of single tubercles. In either form, the process sooner or later by its growth destroys its nutriment, liquefaction-necrosis follows with ulceration, and mixed infection occurring, a typical tubercular ulcer results. The ulcers spread slowly, ancl frequently in their floors and margins small miliary tubercles may be seen, which undergo the same softening and breaking down, and add to the ulcerated area. Usually there is more or less evidence of a surrounding inflammatory action. Microscopically there is found a great number of small round lymphoid cells, numerous epithelioid cells, and some giant cells. Tlie tubercle bacilli may be present in small numbers. The cells tend to collect in masses, which througii their proliferation in- crease in size and exercise considerable pressure. As a result, there is mechanical interference with the blood-supply, and finally it is obliterated, and the mass undergoes liquefaction-necrosis and subsequent ulceration. The microsco])e also shows considerable involvement of the glandular structures by the pressure of the 138 DISEASES OF THE NOSE AND THROAT. infiltrate. Some of the glands are distorted, others obliterated, still others show desquamation of their secretory epithelium. The infiltrate thus collectino; also ac^ts as a foreign body, and the sur- rounding tissue shows inflammatory phenomena. The tubercular tumor varies from small nodules the size of a pin-head, to those as large as a pea. They grow slowly and present appearances which vary according to the stage of development or retrogression. Usually the growth is single, but it may be formed by the coa- lescence of several miliary nodules. At first firm to the touch and attended In- considerable hyperemia, they later become softer and paler as degenerative changes ensue and the blood- supply lessens. They have usually a broad base, and a sur- rounding zone of inflammation is present. The morbid his- tology is the same as that of tubercle anywhere, with perhaps slight modification from the vascularity of the nasal site. There is the same growing mass of small round cells, of epithelioid and giant cells, and lying between or sometimes within the cells are bacilli more or less numerous. Later the vascular supply is ob- literated, the mass undergoes liquefaction-necrosis, beginning at its center and extending to its periphery, partial absorption of the fluid may occur and caseation result. Usually the overlying tissue breaks down, and discharge of the cheesy contents, together with pyogenic infection, produces the typical tubercular ulcer. In some cases, both in this and the preceding form of tubercular lesion, attempts at healing may occur, and proliferation and organization of inflammatory tissue into a fibrous cicatrix may result. Such formation, however, is extremely apt to undergo fur- ther tubercular breaking down at a later stage. There is gener- ally more or less of a fibrous thickening in the tissue surrounding the tubercle, due to simple inflammatorv organization. Symptoms. — The disease being usually secondary to other tubercular lesions, the constitutional condition may be impaired proportionately to the extent and severity of the primary disease. This necessarily gives a wide range of symptoms, from the slight evidences of hereditary tendency, intensifying with the progress of the morbid process, to the distressing picture of emaciation, hectic flushes, racking cough, and profound exhaustion of the later stages. Locally the onset is insidious. In the ulcerative form, the process begins usually as a small ulcer on the ant(>rior portion of the sep- tum, which slowly spreads over the septal surface to the floor of the fossa, but rarely to the turbinated surfaces. It may extend beyond the mucocutaneous juncture and attack the up]>er lip. In shape, the ulcerating area is round or ovoid, its edges are irregular and uneven, and may be slightly raised or on the same level with the adjacent surface. It may bediflicult to tell on inspection the exact limit of the process, so gradually may it shade into adjacent tissue. The floor is rough, covered by grayish or yellowish broken- DISEASES OF THE ANTERIOR NASAL CAVITIES 139 down tissue, and small caseating tubercles may be present both here and in the margins. The ulcer may perforate the septum. The nasal secretion is increased, and is mucoid or mucopurulent in character, and more or less offensive. It may in some instances tend to crust, and a slight hemorrhage follow removal of the in- spissated layer. A peculiar feature of the disease is its remarkable freedom from pain. There is little or no tendency to heal, and should healing take place, the morbid process sooner or later recurs. The form characterized by tubercular neoplasms, as a rule, has a different nasal site, occurring almost wholly on the turbinated bodies. The tumors vary in size and give rise to more or less marked obstructive symptoms. Their shape is usually irregularly rounded ; they may be smooth, granular, or nodular, have a broad base, and the overlying tissue in varying stages of hyperemia ranges in color from a gray or pale pink to dark red, or, later becomes yellowish or whitish. A peculiar pallor of the mucous membrane has been noted in some cases. They may bleed on slight irritation — in fact, scanty hemorrhages do, not infre- quently, occur. At first they are hard and firm to the touch, but later they become soft in the center with a hard periphery, and finally complete softening, rupture, and discharge occur, and a tubercular ulcer identical with that first described is formed. The nasal secretion is moderately increased and, after ulceration, assumes the characteristics already given. Pain is absent, and practically the only annoyance is the nasal obstruction, which may amount in some cases to complete occlusion. They exhibit the same tendency to resist reparative processes. If the tumor be removed, its site heals with extreme slowness and the growth tends to recur. In one or two reported cases the condition has taken the form of luxuriant granulations completely filling the nasal space. Both forms may occur at the same time, and the disease may be unilateral or involve both spaces. Diagnosis. — The ultimate test is the identification of the specific bacillus in the discharge or in the growth, and in some cases may be the only sure diagnostic point. Tubercular symp- toms elsewhere, as in the mouth, the tongue, the pharynx, the larynx, or the lungs, form highly important diagnostic aids, as does also a history of hereditary taint. Syphilitic lesions may be eliminated by the history, general symptoms, and by their behavior to antisyphilitic measures in cases otherwise doubtful. It must not be forgotten that the two conditions may coexist. Malignant growths run a moi-e ra])id course ; most of them are painful, and they are more or less influenced by age. Prognosis. — The outlook as to cure is extromolv unfavorable. It is consiaercd, liowcver, to be in itself the h'ast latal oC all the tubercular manifestations, and may run a slow chronic course extending over many years. With serious involvement in other 140 DISEASES OF THE NOSE AND THRO AT. rt'tjions of the rern. It sometimes happens tiiat 142 DISEASES OF THE XOSE AND THROAT. the disease, instead of followino; the ulcerative course described, reaches its nuduhir development, undergoes degenerative changes, and is finally absorbed instead of being discharged, leaving behind it a cicatrix of librons tissue which subsequently leads to atrophic change. Symptoms. — The disease may be confined to one cavity or it may attack l)()th. 'Die most marked symptom is the occlusion of the nasal space or spaces by tlic nodular growth. In many of the cases inspection of the deeper parts of the nose may be impossible and the middle turbinates may be completely obscured. There is but little discharge, which, at first clear, becomes thicker as ulcera- tion proceeds, and may become somewhat fetid, if retained long enough in the cavity for putrefaction to take place. The lesion has a marked tendency to crust, forming small scales or scabs, grayish or dark in color, which are more or less tenacious, and may cause a slight oozing of blood on detachment. On inspection, if this is possible, the small characteristic nodules, less regular in outline, perhaps, than in cutaneous lupus, may be seen, located usually on the se])tnm. They are hard at first to the probe, but as they soften, the instrument can be easily pushed into their sub- stance and even through the cartilage, causing slight hemorrhage. The growths are painful, as a rule, to the touch, though their presence and growth give rise to little pain. If they go on to ulceration, the characteristic appearances already described are present, and the serpiginous method of spreading is to be observed. The advance is usually of slow progress, and the occurrence of septal perforation has been mentioned. The external appearance of the nose is altered, becoming pale and rigid, and having a pinched and shrunken look as cicatrization advances. Or if the same process occurs simultaneously in the skin of the nose, the latter organ may present extensive ulcerations and erosions, lead- ing to large areas of tissue-loss, horrible deformity from the result- ant cicatrices, or even to stenosis. Itching may be present. The form of the disease with ulceration is known usually as lupus ex- edens, while that in which ulceration does not take place is termed non-exedens. The latter form is identical with the former in de- velopment and symptoms up to the stage of completion of nodular formations. Instead of this going on to ulceration, however, ab- sorption of the softened material takes place, and inspection shows tlu^ fi)rmation of bluish-white cicatrices at the site of the process, which subsequently contract and cause atrophy of tlie affected area. The pnxicss does not spread as does lupus exedens. Con- stituticmal impairment in either case is not marked. Diagnosis. — The diagnosis is usually easy. The history of the patient, the coexistence usually of the cutaneous form, the slow course, nodular growth, and serpiginous spread in the exedens, or the cicatrization in the non-exedens, make the diagnosis evident. DISEASES OF THE ANTERIOR NASAL CAVITIES 143 Syphilis is differ en tiated by its history, by its intermittent periods, by the presence of bone-involvement, and by response to specific treatment. Malignant neoplasms are usnally more rapid in growth, are painful, and occur, as a rule, later in life. Fibroma is firmer and not easily torn. Mucous polyps are smooth, soft, and trans- lucent, and usually pedunculated. The nodules of nasal tuber- culosis are not irritable to the touch, and the ulceration does not spread in the same manner nor exhibit, save rarely, reparative tendencies. Prognosis. — The prognosis is grave as to cure of the disease or prevention of deformity ; not, however, as regards life. The disease runs a slow chronic course, which is more amejiable to treatment than lupus of the skin, and may in a few cases be checked. A few cases of spontaneous recovery are on record. Complications. — Erysipelas has been reported as occurring during the course of the disease. Any of the infectious conditions are liable to be contracted through the ulcerated surface. Treatment. — Local. — The lesions of lupus of the nasal cavity should be thoroughly and carefully extirpated. This can be done after cocainization (1) by removing the crusts to see the full extent of the invading process, (2) by using the curet to remove all the visibly afPected tissue and a little of the healthy tissue beyond, (3) by the application of 60 per cent, lactic acid to the denuded area. The more thoroughly tliis is done the less liable is there to be recurrence of the growth. The field of operation should be kept scrupulously clean by flushing it daily with an alkaline antiseptic solution such as : I^. Sodii biboratis, Sodii bicarbonatis, Sodii chloratis, da gr. xv (.9) ; Acidi carbolici, gr. iv (.24) ; Aqua?, flSj (30.) ; followed by thoroughly covering the site of the lesion with — I^. Pyoktanin, gr. xx-lx (1.2-3.6) ; Zinci stearatis, .^j (30.). Constitutional. — Cod-liver oil during the cold weather, the hy])Oj)]iosphites in summer, besides iron and strychnin are to be administered. Equable climate with an outdoor life and a gen- erous dietary are to be prescribed. GLANDERS. Definition. — A highly contagious disease of horses, rarely transmitted to man, but, mIuii so existing, is characterized by 144 DISEASES OF THE NOSE AND THROAT. severe eonstitutional syin])tonis, and bv formation, in the sub- mucosa of tlie infected nmcons membranes, of granulation-tumors which run a rapid course to uh'eration, and are aecoiujianied by an oifeiisive discharge. Tiie nasal mucosa is usually ])rimarily in- volved. The disease is rapid in progress, extremely fatal, and occurs in both (icnfc and chronic manifestations. This detinition considers only the relation of the disease of the respiratory tract, the consideration of its other lesions being scarcely within the sco]>e of the present M'ork. Synonyms. — Ecpiinia; ^Nlaliasmus ; Malleus; Malleus hu- midus. etiology. — The specific cause of glanders was discovered by Ijr)iilt'r in l.Sroducts of the germ ; there is a proliferation of leu- kocytes forming lymphoid cells, and of connective-tissue cells forming (>])ithelioid cells, and gradually an increasing mass of these and the bacilli is formed. As growth goes on, there is interference with nutrition, and, because of this, with perhaps additional action of the bacilli, beginning at the (;enter — that being the point farthest from nutrition — the mass undergoes li(juefacti(m-necrosis ; there is a thinning followed rapidly by rupture of the intervening DISEASES OF THE ANTERIOR NASAL CAVITIES 145 tissue, and a discliurge of the puriiloid material upon the surface of the membrane. As a result of this process, there are formed numbers of what are practically small abscesses or ulcers, varying with the extent of the lesion. If a section be made of the tumor and it be examined microscopically, it will be found to consist almost wholly of epithelioid and lymphoid cells, with numerous bacilli scattered between them, and a considerable amount of fibrous structure. In the acute form also there will be evidence of acute inflammation in the number of multinuclear leukocytes infiltrated into the adjoining tissue. In the chronic cases the necrotic process frequently involves the deeper structures, and complete disintegration of parts of the bony structure have been reported. Gangrene of the softer tissues may occur. Symptoms. — The chronic form in man is not so frequent, nor is it so rapid, as the acute form, but, since the acute usually forms the terminative stage if present, we shall reverse the usual order and consider the chronic first. In both cases the constitutional symptoms are so essential that a brief description of the disease as a whole is necessary. In the chronic form the membrane becomes swollen, may be painful, though it frequently is not, and is covered with dirty crusty scabs. There is more or less of a peculiar, vis- cid, mucopurulent discharge of marked fetor, which, as ulceration progresses, becomes more serous. Cutaneous involvement with either the development, maturation, and discharge of subcutaneous nodules, or with the more superficial formation of bullge, is seen. There are extensive lymphadenitis and lymphangitis, and the wide distribution of the suppurative process causes irregular fever. Destruction of the deeper structures occurs, as well as necrosis of bone and cartilage, with discharge of necrosed material and gan- grene of the superjacent or adjacent surfaces. If the acute form does not terminate the disease rapidly, the patient goes on t(^ emaciation, profuse sweating appears, colliquative diarrhea with accompanying exhaustion and death eventuates from collapse. In the acute form, the disease is ushered in rapidly with all the symp- toms of an acute infection ; lassitude, rigors, pain of a rheumatic character in the trunk, back, limbs, and tlio joints, in addition to headache, dyspnea, irritation of the stonuich with nausea and vomit- ing, and diarrhea follow. The site of infection becomes liot, red, and swollen, lym])hangitis follows, and adjacent parts swell and redden. Small nodules appear in the submucosa, at first translucent, later darkening, and then turning a yellowish hue, and finally rnpturing. There is a discharge of a thick, deep-yellow, often blood-streaked, offensive, semi-fluid material, ])ossibly more from one nostril than the other. Ulceration follows, Avhicli shows but little tendency to heal. The cutaneous structures become similarly involved, the nodules form, go through the stages of ])iipule and ])ustule, and })rac- tically become abscesses. The lymphatics, especially of the neck, 10 146 DISEASES OF THE NOSE AND THROAT. swell and become enlarged. The systemic impression is profound, tlie temperature and ])ulse are higli, the tongue is dry and coated with a whitish fur. The disease progresses rapidly into a typhoid state ; there are wasting, weakness, and exhaustion from profuse sweats, nausea and vomiting and frequent diarrliea, and death soon supervenes. Diagnosis. — The ultimate diagnostic test is the identification of the germ, either by staining or the more satisfactory test of in- oculation in susceptible animals, lieaction to raallein offers a pre- sumptive proof. The physician, as a rule, because of the rarity of the affection, is apt in a given case to think of glanders last of all the possible conditions, or overlook it altogether. A history of in- oculation or exposure must be sought for diligently, full character- istic symptoms, if possible, elucidated, and the practitioner should base his diagnosis from a broad comprehensive view, rather than the careful investigation of any set of manifestations. Venereal disease of the respiratory tract may be separated by the lesser constitutional exhibition and the reaction to potassium iodid. It may simulate typhoid, but lacks the rose spots. Pyemia is, perhaps, the most likely condition for which it may be mistaken, and may, as it rightfully should, force a bacterial examination. In certain stages it is difficult to differentiate from malignant growths. Prognosis. — The outlook in either the acute or chronic form is extremely grave. Several cases of the acute have been reported as recovering, and these usually have had little accompanying eruption. Death, however, usually occurs after a variable length of time — a few hours to several days. The chronic form with skin-manifestations is usually fatal. Broardel's dicitum — " so long as the nose is not affected, there is still room for hope " — is to be considered in making the prognosis. A few cases run a course of repeated series of abscesses and recover. The large proportion of cases die in from six to eight months. Complications. — A subacute jmenmonia is reported as hav- ing occurred in conjunction with the disease. Treatment. — The treatment of the nasal manifestations of glanders shouUl consist in the opening and curetting of abscesses, in the curetting and cauterizing of the ulcers, and the thorough removal of any suspicious growths. For the offensive discharge Elliotson recommends the use of a douche three times a day con- sisting of 2 grains of creosote to the pint of water. Carbolic acid (1 : ()()) may be applied on lint as a dressing for ulcerated areas (Ma(tkenzie). In the light of the highly contagious nature of the disease, prophylactic measures should be insisted upon, and the most rigorous antisepsis preserved. Constitutional. — Iron, quinin, whiskey, and strychnin are to be employed in heroic dosage. Da Costa states that iodid of DISEASES OF THE ANTERIOR NASAL CAVITIES. 147 potassium has cured cases. When a positive bacteriological diag- nosis has been made, while the curative effect of mallein is still doubtful, it should be employed. LEPROSY. Definition. — Leprosy of the respiratory tract is a rare disease in this country, and occurs almost or quite exclusively as nasal, pharyngeal, or laryngeal complications of the general condition. The anesthetio variety is characterized by local anesthetic areas from neuritis of the connected nerve-supply and by subsequent trophoneurotic changes. The tubercular variety is distinguished by the formation in the submucosa of local masses of granulation- tissue, which undergo liquefaction-necrosis and ulceration, the ulcers exhibiting a varying tendency to heal by cicatrization. It is due to a specific germ. We are considering the disease only in its relation to the respiratory tract. Synonyms. — Elephantiasis Grsecorum ; Lepra. ^^tiology. — It is now generally considered that leprosy is due to a specific germ, designated the Bacillus leprae. This germ re- sembles the bacillus of tuberculosis morphologically and in its behavior to certain differentiating stains. It is non-motile, possesses no flagella, and reproduces apparently both by spore -formation and fission. The disease is most common in the Sandwich Islands, China, and India, and the majority of cases occur between the ages of fifteen and thirty years. Leprosy is feebly contagious, but the exact modes of inoculation are not clearly understood. It has apparently been contracted through sexual intercourse, by in- oculation during vaccination, and seems, in short, to be as varied in the manner of transmission as is syphilis. Hereditary trans- mission is a common feature in the history. Pathology. — Two forms of the disease are recognized, the anedhetic and the tubercular, and both exist synchronously in the same patient. In the anesthetic variety the lesions show changes in the nerves su])plying the affected areas on the body, which, if examined microscopically, are seen to consist of a cellular infil- trate between the fibers of the nerve, with a subsequent organiza- tion and contraction of cicatricial tissue — in short, a chronic in- terstitial neuritis. Following loss of the nerve-influence atrophic changes occur, ulceration of anesthetic areas, wasting of muscle and glands, with necrosis and discharge of bone. The lesion of the tubercular form is characteristic, and is the distinctive feature placing the disease among the infcc^tious granulomata. At the sites of germ-invasion, the bacilli generate an inflammation which is followed by infiltration and prolifi^ration of all the cellular ele- ments and the fi)rmati()n of a granulation-tumor. If the morbid histology of this growth l)e studied, it will be found to be much 148 DISEASES OF THE XOSE AND THROAT. like the ijrowth.s of tlio otliers in thi.s class. There is a large nmnber of small round epithelioid and lymphoid cells, and not a few giant cells. Certain of the giant cells show a remark- able tendency to the formation of va(uioles at the expense of their j)rotoplasm, practically becoming sacs filled with the bacilli. The germ is also seen in great numbers in the lymph-spaces, by which channels, excepting in a few cases, it is believed to spread. The til)rous tissue is increased in amount and is largely inflammatory in character. If the section be made at a later stage, there will be evidences of a central li(juefaction-necrosis in progress, with encroachment toward the surface, and, if the section l)e made after rupture and escape of the licpiefied tissue, the his- tological picture of a sin)purative ulcer is presented. In both varieties the pathological alterations differ only from the cutaneous lesions as to site ; the processes are identical. Symptoms. — In most cases, with perhaps very few exceptions, the condition is secondary to the cutaneous and systemic invasion of tile disease, and its appearance in the respiratory tract is there- fore anticipated. The anesthetic form is said not to make its appearance until the disease is at least of live years' standing. There are areas of the membrane with complete anesthesia, both in the nasal spaces and the ])harynx ; the soft palate is insensitive, and motor ])aralysis of the larynx may occur. Ulceration follows, and later there is an absorption of the nasal bones. In the tuber- cular form, the nodules follow precisely the same developmental course as in the skin. During the first or erythematous stage, the mucous membrane reddens, becomes hyperemic, and slight epis- tiixis may occur at intervals. Later, the membrane pales and becomes thickened, especially in the lower ])harynx. It appears as though covered with a thin transparent coating, and its sensi- bility both to smell and general impressions is notably decreased. The swelling may cause interference with respiration, and, if occurring at the same time in the pharynx and larynx, there are early fatigue, and dryness of the throat in speaking, and the voice becomes ])rogressively nasal, then shrill, and finally ends in aj)honia. Following this, the second stage; comprises the develop- ment in these inflamed areas of munerous small nodular masses, which may remain discrete or coalesce. Their [)resence causes a pressure-atro])hy oi the glandular elements in the overlying struct- ure, and its surface becomes smooth, tense, and glistening. The evidences of varying respiratory stenosis contimie. This stage may show great variation in duration, running a course of a few weeks to several months, and in some cases may be the termina- tive period. In most cases, how(>ver, it is followed by a third and flnal stage, 'i'he nodule softens, o]>ens, discharges, and a small ulcer forms. Pyogenic infection is su})eradded, the discharge be- comes thicker, yellowish or brownish, has a tendency to crust, and DISEASES OF THE ANTERIOR NASAL CAVITIES. 149 is usually offensive. The ulceration increases in extent and depth, and changes not unlike those of tertiary syphilis are produced in the facial appearance of the patient. The turbinates atrophy and finally disintegrate ; the septum is perforated by the ulceration, and not infrequently also the hard palate ; the cartilaginous and bony framework of the nose is weakened, and the nose flattens and col- lapses. The soft palate may be quite destroyed. Bands of cica- tricial tissue may form, and by their contraction markedly distort the weakening structures in which they occur. Diagnosis. — The diagnosis is generally easy, because of the usually antecedent condition displayed on the bodily surface. Ter- tiary syphilis may be differentiated by its history and its reaction to specific medication. Prognosis. — The prognosis for the nasal involvement is essentially that of the general disease, and this is almost always ended sooner or later by death from exhaustion. The respiratory involvement increases the gravity of the prognosis by its added liability to sudden suffocation from edema or a lower stenosis. The anesthetic variety runs a course of from fifteen to twenty years and the tuberxular of from eight to ten years. Occasionally spontaneous recoveries have taken place, and recorded cures are not infrequent. Treatment. — ISTo treatment has been found that will cure leprosy. The internal administration of chaulmugra oil, 5 to 60 drops daily, according to Ingals, has apparently benefited some cases. Inunction of an ointment prepared from the same oil, with 5 or 6 parts of lard, should be used at the same time. NASAL ACTINOMYCOSIS. There seems to be no authentically reported case of this mem- ber of the infectious granulomata occurring in the nasal spaces. There is evidently no reason why infection should not, under favorable circumstances, take place, since inoculation with the specific organism is as surely followed by development of the dis- ease as it is in the case of the other members of the group. That it has not occurred more frequently is, perhaps, due to its com- parative rarity in the human race and to the fact that it occurs usually in the mouth, pliarynx, alimentary or respiratory tract below that level, as a result of metastasis or of the ingestion of infected food. It is by no means improbable, however, that cases liave occurred in which the diagnosis of tuberculosis, or more likely of malignant growth su(;h as sarcoma, has erroneously been made, and certainly the clinical history and physical appearances of the disease have much to ext(!nnate such an error. We shall (consider the features of the disease under its pharyngeal appear- ance, and refer the reader to that article, on page 471. 150 DISEASES OF THE NOSE AND THROAT. RHINOSCLEROMA. Definition. — Rhinoscleroma is an extremely rare disease of the nose and, by extension, of the npper respiratory tract. It is characterized by the formation in the submncosa of the mncous membrane or the deeper hiyer of the cutaneous structure of firm, liard, nodular tissue, which shows marked tendency to lateral extension. The disease is paiidess, is unaccompanied by discharge, and rarely, if ever, progresses to idceration. There is no con- stitutional involvement, and tlie local condition is remarkable for the extreme slowness of its course. It is believed to be due to a specific organism. ^Etiology. — Tiie weight of jiresent evidence regards the dis- ease as due to a sjx'cific germ — a short rod with rounded ends and usually ea])sulat('d, known as the bacillus of rhinoscleroma. As to the manner of inoculation, there is nothing definitely known. There are apparently no predisposing influences ; sex, constitutional diseases, personal habits and occupations seeming to bear no rela- tion to its occurrence. The cases reported show ages ranging from fourteen to forty-five years, and the greatest number as having occurred in Southeastern Europe. Pathology. — The lesion of rhinoscleroma consists patholog- ically in a ri)und-celled infiltrate into the corium and papillae if occurring in the skin, or into the submucosa if occurring in mucous membranes. Histologically, the structure is composed of con- sideral)le fibrous tissue and an abundance of small round cells. A peculiarity of the lesion is the presence of certain large spherical hyaline cells with a protojdasmic reticulum containing one or more nuclei, smaller translucent liyaline particles, and the bacilli already mentioned ; or the smaller hyaline granules and the bacilli may be found in the interstitial lymph-channels in the fibrous structure. As i\\o. infiltrate inc^reases, there intervenes more or less pressure- atrophy of the glandidar elements. The round cells also undergo a change, becoming s])indle-shaped, and finally forming fibrous tis- sue. It is of important pathological note that at no time during the history of the case will sections show any evidences of fatty or granular degeneraticm or evidences of breaking down. In one re- ported case cartilage-formation was in progress, and in another not only was cartilage present, but apparently ossifieaticm had begun. Symptoms. — The absence of (ronstitutional symptoms and the slow development and spread of the local i)rocess are charac- teristic of the disease. It begins usually at the margin of the nostrils and contiguous part of the U]>per lip by the develo]>ment of small nodules, which may b(> confluent or discrete. These firm, sliar])ly defined, slightly elevated patches, which feel hard and smooth to the touch, are traversed by dilated l)lood -vessels, are hairless, and may or may not be somewhat shiny. The overlying DISEASES OF THE ANTERIOR NASAL CAVITIES 151 tissue is natural in color or perhaps slightly darkened in hue. There is no discharge, no ulceration, and no pain, except a slight tenderness on pressure. The process tends more readily to follow the mucous membrane in its advance than the cutaneous surface, and spreads by extension of the infiltration laterally, or by coalescence of discrete nodules. In some cases it may take the form of a general diffuse infiltration without the forma- tion of nodules. The swelling gradually spreads through the nasal membrane, and may extend to the pharynx and to the larynx and trachea, giving rise to symptoms of obstructed respiration and phonation. The process may involve the skin of the lips, brow, and part of the alse ; cracks and fissures may occur at the junction of the latter with the facial integument. It may involve the septum, gums, and alveoli, and, in rare cases, the tongue, eyes, and ears may become implicated. The surfaces adjacent to the swelling show no edema nor evidences of inflammation ; the swelling itself presents clinically no evidences of inflammatory or degenerative change, and is in the majority of cases symmetrical in distribution. The nose, as a result of the disease, becomes thick- ened, acquires an unnatural stiffness, and causes nasal obstruction. Diagnosis. — The rarity of the disease in this country is a potent factor in obscuring diagnosis. Constant nasal localization, hardness of affected parts, with sharp outlines and absence of adjacent inflammatory phenomena, slow development and absence of pain, lack of constitutional symptoms or any evidence of retro- gressive change in the growth, stubborn resistance to treatment, and, lastly, demonstration of the germ form the correlated group of diagnostic points. Syphilis may be differentiated by the history, con- stitutional exhibitions, and reaction to antisyphilitic measures. Epi- thelioma may be separated by its bleeding, softness, ulceration, and more rapid spread. Keloid in many cases may differ symptomati- cally only in the absence of the associated germ of rhinoscleroma. Prognosis. — The disease seems intrinsically to have no effect upon the prolongation of life, but may become a very serious men- ace mechanically by occlusion of the larynx and trachea. The prognosis as to cure is most unfavorable ; no drugs modify the dis- ease, and complete extirpation of the diseased areas is in almost every case followed by a return of the growth. Complications. — The extension of the process to the pharynx and the involvement of the uvula with its subsequent atrophy, occa- sional attacks of aphonia and laryngeal spasm, and the increase of the growth to suffocation are the commonest of the complications. Treatment. — The treatment of rhinoscleroma is purely pallia- tive. Surgical interference is limited to the removal of sufficient tissue to relieve nasal obstruction. Internal medication, outside of the improvement of the patient's general condition, should con- sist in the administration of mercury and the iodids. CHAPTER VI. FURUNCULOSIS. Synonym. — Phlegmonous rhinitis. Definition. — The term furnnculosis is applied to abscess- formation involving any part of the nose, while the term phleg- monous rhinitis is limited to abscesses involving the nasal mucous membrane, and is a rare condition. Ktiologfy. — The condition usually follows an injury, and occurs most frequently on the septum and near the nasal orifice. The furuncle may be single or multiple. The inflammation may have its origin in a hair-follicle. In many individuals the attacks of boils frequently recur, and the cartilage is always involved. It most commonly affects the young or middle-aged, and is associated with blood-dyscrasia. Persons who are the subjects of chronic constipation are frequently attacked. It is often associated with infectious fevers. Pathology. — The pathology is the same as in any abscess- formation. Symptoms. — The symptoms consist in the characteristic phenomena, both clinical and microscopical, of any inflammatory process, with the swelling, throbbing, and tension characteristic of inflanunation in unyielding structures. Treatment. — If j>us has formed, the abscess should be freely opened and thoroughly cleansed with an antiseptic solution. Com- presses may l)e apjilied early, either hot or cold. For relief of the pain a solution of chloral hydrate, 1 dram to 1 ounce each of glycerin and water, may be used locally. If seen early, before pus has begun to form, applications of 50 per cent, ichthyol solution may arrest its development. In opening the abscess the puncture should be made within the nostril, so as to avoid any external scar. Frequently the pus forms within the septum, separating the carti- lage. Care should be taken in attempting to puncture, as the cartilage is firm, njquiring a sharp bistoury and deep incision. 152 CHAPTER VII. INFLAMMATORY DISEASES OF THE ANTERIOR NASAL CAVITIES. Ulcers, non-infected. a. Simple. 1. Catarrhal. 2. Herpetic. 3. Eczematous. 4. Due to foreign bodies. 5. IS^europaralytic. 6. Scorbutic. 7. Diabetic. 8. Varicose. 6. Compound — Malignant. Ulcers, infected. 1. Tubercular (lupoid). 2. Syphilitic. 3. Leprous. 4. Glanders. 5. Diphtheritic. 6. In measles. 7. In rheumatism. 8. In scarlet fever. 9. In small-pox. 10. In typhoid fever. 11. In typhus fever. ULCERS. It has seemed best to consider thus collectively the various forms of ulceration occurring in the mucous membrane of the nose. An ulcer of the mucous membrane is a superficial necrosis which must extend through the basement membrane, and may or may not involve the submucosa. In diseases in which there is ulceration or fetid discharge, the parts should always be carefully inspected before the removal of the secretion, as tlie character will aid materially in the diagnosis. Tlie numerous causes of necrosis will be mentioned under the different forms of ulceration in which they occur. 153 154 DISEASES OF THE XOSE AND THROAT. XON-INFECTED UlCERS. (a) SIMPLE ULCERS, Catarrhal Ulcers. — Occasionally, in nasal conditions in which abiuulant (lisciuiroe is a })rominent symptom, simple ulcer- ated areas are seen near the nasal oritices on ])oints of prominence, such as exostoses of the septum, or points of contact of enlarged turbinates with the septum, or any location where secretions may lodge. These denuded areas are painful and sensitive and give rise to considerable annoyance to the patient. They should be cleansed ^ith hydrogen peroxid and cinnamon water and covered with a jirotective stimulant, such as the com- pound tincture of benzoin and boroglycerid (50 per cent.) in equal parts. The removal of the cause of irritation, together with the above procedure, will generally prove curative. Stimulation may be applied by using chromic acid (10 per cent.) on a cotton-covered ]>robe. Equally good results may be obtained, especially if the ulcer is sluggish, by the local ap])lication of a 3 per cent, formalin solution. Herpetic Ulcers. — The mucous membrane of the nostrils may be attacked by herpes. The disease appears as groups of vesicles, each about the size of a millet seed or a split pea, and is accompanied by local rise of temperature, thirst, rapid pulse, and local irritation. In a few days the vesicles dry up into thin scabs, which are sometimes confluent, and not generally surrounded by an inflammatory zone. Treatment of the condition should consist in giving calomel, grain ^, bicarbonate of soda, grain 1, every hour until six doses are taken, followed in six hours by a Seidlitz powder. The crusts should be softened and removed with hydrogen peroxid and cinna- mon water in equal ])arts, and a 3 per cent, chlorid-of-zinc solu- tion mopped over the sin-face. Bc^ematous Ulcers. — The eczematous ft)rm of nasal ulcer is seen most frequently in young children who have the eczema- tons eruption on the uj)per lip and cheeks. It is also observed following the exanthemata, especially measles. Occasionally the lesion may be found in older persons having the eczematous diathesis. In children, overindulgence in impro]>er food, especially sweets, or irritation in the lower bowel due to the presence of ascarides are generally the chief sources of distm'bance. There is not, as a rule, pronounced odor from the discharge, which may or may not be copious. Crusts tough and dislodged with difficulty form at various ]>oints. The constant picking at the nose, due to the itching, is a continual source of irritation, and tends to prolong the atlection. INFLAMMA TOR Y DISEASES OF ANTERIOR NASAL CA VITIES. 1 55 In adults there is, as a rule, excessive deposit of urates iu the urine, a disinclination to take healthful exercise, with drowsiness after eating, and an habitually torpid condition of mind and body. Treatment. — The nostrils should be kept clean with the warm solution mentioned on page 115. Santonin in proper dosage should be given to children. Calomel and bicarbonate of soda in divided doses should precede and follow the administration of the san- tonin. This should be followed by granular effervescing phos- phate of soda in tablespoonful doses night and morning to stimu- late normal gland-secretion. Remove the crusts by softening with equal parts of hydrogen peroxid and cinnamon water, touch the denuded surface with nitrate of silver, 2 grains to the ounce of water, and cover the entire area involved with benzoated zinc-oxid ointment ; the benzoin should be double the amount given in the official preparation. In adults, correct any digestive disturbances present. Restrict the diet to plain meats and vegetables, and give tonics of iron, quinin, and strychnin, with lithiated waters. Ulcers Due to Foreign Bodies. — A foreign body, by its presence in the nostrils, may cause sufficient irritation to give rise to the formation of an ulcer which is of the simple catarrhal type, and, after the removal of the cause, should this not effect a cure, should be treated along the same lines. Neuroparalytic Ulcers. — Areas of ulceration in the nose have occurred, due to paresis or paralysis of the fifth pair of nerves. The mucosa is excoriated in patches of varying size, dry, sluggish, showing no tendency to heal. Hemorrhage from the affected side of the nose, and also loss of smell, have been reported as attendant symptoms. The treatment should consist in an attempt to re-establish proper trophic nerve-control by the use of electricity and strychnin nitrate, grain -^ to ^V? thrice daily. The ulcerated areas should be cleansed, stimulated, and protected. For this purpose, bovin- ine mopped on the surface acts, as it does in other trophic ulcera- tions, admirably. Scorbutic Ulcers. — kScorbutic ulcers are extremely rare, ex- cept M'hcn due to some accidental irritation in the course of scurvy, or when part of a general facial involvement by scorbutic ulcera- tion. There is an intolerable odor due to the fetid discharge. The edges of the ulcer are hard, thick, and shiny, and the surface, covered with clots due to the state of the blood, is fungoid and bleeding. The tendency to rapid enlargement of the lesion is marked. The treatment should consist in the administration of the juice of a lemon three times daily, a diet largely vegetable, and tonics. The ulcer should be ke]it clean, ]ireferably by an acid wash consisting of dilute hydrochloric acid, 10 drops to the table- spoonful of water ; the fungoid masses ought to be cleared away 156 DISEASES OF THE NOSE AND THROAT. with the scissors and forceps, and chromic acid (10 to 20 per cent.) applied to stiniidate healintr. Diabetic Ulcers. — Due to the general blood-dyscrasia in diabetes mellitus, there is often seen a low-grade inflammation of the upper respiratory tract. At various points of the mucous membrane there occur spots of ulceration, usually near the nasal orifice, and in most cases due to the patient picking and rubbing the nose to relieve the intolerable itching present in diabetic cases. These seem to bear in their extension and growth a direct ratio to the amount of sugar in the urine. The appearance of these ulcers is not especially characteristic, yet in connection with glycosuria and the low-grade rhinitis mentioned, the lesion should not be regarded as independent, and further cause for its existence sought, but the ulcer should be treated as a local manifestation of a sys- temic infection. Varicose Ulcers. — The engoi-gement of the venous plexuses, especially in the turbinal region of the nose, may be so great as to cause distention to the point of rupture and ulceration. It may also be found on the posterior border of the soft palate. Varicose ulcers are often associated with cyanotic conditions of the mucous membranes, and are in reality only local lesions due to systemic conditions. These ulcers are sluggish, slow to form, and slow to heal. They bleed easily and freely. In appearance, they are blu- ish-red, indolent, irregular in outline, shallow, and covered with a sanious, crusty discharge. Locally, the treatment should consist, after cleansing, in the application of stimulating astringents, such as 3 to 5 per cent, formalin solution or glycerite of tannin. Systemic treatment should be directed toward the relief of the underlying cause. (h) COMPOrXD, ifAUGXAXT T'LCERS. Any malignant growth occurring in the nose may be the site of a superimposed ulcerative process due to degeneration or press- ure. As the appearance of these ulcerated areas in the nose does not differ essentially from that seen in oth(>r localities, the reader is referred for a complete description of the process to the chapter on Tumors. Infected Ulcers. Tubercular Ulcers (I/Upoid). — Tuberculosis of the nasal fossa is rare. The septum is the favorite site of the ulcerative process, but it may be found involving one of the turbinated bones. The simple tubercular ulcer has a whitish-gray surface. It is shallow, with irregular outline, and it is sometimes difficult to determine accurat(»ly where the disintegrating tubercular infec- tion ends and the healthy membrane begins. In the earlier stages, INFLAMMA TOR Y DISEASES OF ANTERIOR NASAL OA VITIES. 1 57 the miliary tubercles that have not broken down may be seen in the outlying parts of the ulcer. There is a tendency to bleeding, and the whitish-gray surface may be coated with crusts of dis- colored mucus. The treatment consists in the radical removal of the ulcer with the knife or cautery. The site should be treated with 50 per cent, lactic acid and dusted with pyoktanin, or 40 grains to the ounce of stearate of zinc, or aristol by means of Gleitsmann's powder-blower. Antitubercular treatment, addressed to the general systemic involvement, should be instituted. Syphilitic Ulcers. — The intranasal ulcerations of syphilitic origin include the chancre, the mucous patch, the superficial ulcer, and the deep ulcer with necrosis. Nasal chancre is exceedingly rare. It may be granular in appearance, or hard and cartilaginous with an ulcerating surface. The symptoms arising from the lesion are epistaxis, stenosis, and deformity if it be situated on the alae. No subjective symptoms are likely to be traceable to the mucous patch in the nose. It differs in no way from similar lesion occur- ring in the mouth, and needs no further description. The superficial ulcer, like the chancre, is not often met with in the nose. It occurs most frequently on the septum, but may be seen on the floor of the nose or on the surface of the turbinated bodies. The borders of the ulcer are fairly well defined, and the mucous membrane surrounding it is perfectly normal in appear- ance. The edges are neither sharply cut nor depressed, and there is no areola of redness. The surface of the ulcer is slightly depressed in the center and is covered Avitli a coating of thick, stringy, yellowish-gray mucopus. On removal of this puroid material a grayish-pink color of the cleansed surface is seen. The lesion is feebly sensitive to the touch and bleeds easily. It has no marked tendency to extend, because its destructive activity is feeble. The deep ulcer of syphilis with hony necrosis arises directly from the gummy deposit, and occurs usually from ten to fifteen years after the primary lesion. The most frequent site of the process is on the sejitum, but if occurring on the turbinated bones, it is less amenable to treatment, pursues a more chronic course, and results in destruction of a greater amount of tissue rather by extending down into the underlying structure than by lateral spreading. As a rule, these ulcers do not extend beyond the posterior nares. The treatment of syphilis has been described, and needs no r('])etition. lyCprous Ulcers. — The mncons membrane of the nose is often involved in leprosy by extension from the ahe nasi. When the leprous nodules ulcerate, the stench of the sanious 158 DISEASES OF THE NOSE AND THROAT. watery discliarge is intolerable. The cartilaginous septum may be perforated and, with the alee nasi, maybe destroyed by extreme ulceration. Inspection of" the nose may show a diffuse thicken- ing rather than a tui)ercular aj)j)earance of the turbinated bodies, followed by ulceration and fetid discharge. Epistaxis may be the first symptom noted by the patient. The diag-nosis and treatment of the condition have been mentioned under Xasal Leprosy. Ulceration in Glanders. — A few days after the general symp- toms of glanders — which are chills, rheumatic pains in the limbs, fever and headache — there flows from the nostrils a glairy, thick, fetid discharge of a deep-yellow color streaked with blood, which may be greater from one nostril than the other. This discharge is due to the ulceration and breaking down of the lesions on the mucous membrane of the nose. The characteristic nodules of glanders in the nose are at first quite small, occurring singly or in groups. They rapidly increase in size. At first colorless, they become red, then gradually yellowish, and resemble pustules. A marked tendency to ulceration is present in these pustular lesions, and the resultant formation shows a foul sore with irregular edges, having little tendency to heal. The adjacent sinuses may be involved in the ulcerative process. The ulcers of glanders are not of themselves jxithognomonic, but the diagnosis is aided by the rapid swelling of the adjacent structure, the extension of inflammation by the lym- phatics, and the rapid formation of swellings and phylazacious pustules around the original pustule. The treatment has been given under Nasal Glanders. Diphtheritic Ulcers. — Diphtheritic involvement of the nasal chambers may be either ])rimary, or secondary by extension. The common characteristics of all the lesions are the formation of the ])C(!uliar grayish membrane and an acrid, irritating, brown ichorous discharge. The diphtheritic ulceration does not differ from that occurring elsewhen* in the body, except that in the primary form there is not that marked tendency to spread noticed if the membrane occurs elsewhere. Croupous or Fibrinous Ulceration — Chronic. — In certain cases, where there is a low-grade nutrition, there may be a chronic membranous condition involving the nasal mucosa. It has been described under Chronic Nasal Diphtheria, the diagnosis being based on the fact that the Klebs-LofHer bacilli have been found present. While this may be true, I do not believe that they are in any sense an etiologic factor, as I have frequently demonstrated their presence in the secretions collected in the nostril in atrophic rhinitis. There may be local ulceration in this ccmdition which is due to the combined local infection and the low-grade systemic nutrition. The treatment is the same as given under Fibrino- plastic iihinitis. INFLAMMATORY DISEASES OF ANTERIOR NASAL CA VITIES. 1 59 Ulcers in Measles, Rheumatism, Scarlet Fever, Small-pox, Typhoid Fever, and Typhus Fever. — Ulcer- ation of the nasal mucosa, with implication of the bones and carti- lage to a greater or less extent, may occur in measles, rheumatism, scarlet fever, small-pox, typhoid fever, and typhus fever. Per- foration of the septum may result, and, in small-pox, obliteration of the nostrils has been reported as resulting from the union of the opposite raw surfaces of the outer and inner nasal walls when the crusts have come away. The ulcers are not in themselves peculiar or characteristic, and are mentioned that they may be guarded against by proper prophylactic treatment when such pro- dromata as nasal swelling, pain, and tenderness with discharge are noticed in any of the above-mentioned diseases. In scarlet fever the ulceration is generally due to a hemorrhagic inflammation, and amounts practically to the breaking down of the area of infarction. It may be infected either primarily or secondarily. In typhoid fever the ulceration is of more import, and is usually of greater severity. It is secondary to the disease, or rather a sequel, and is usually associated with inflammation of the carti- lage — a chondritis or perichondritis, followed by necrosis and ulcer- ation of the surface. The turbinal bones may be involved. The ulceration is always deep, involving the bony or cartilaginous framework, and occasionally followed by considerable loss of tis- sue and, possibly, caving deformity. CHAPTER YIII. NEUROSES. Neuroses of Olfaction. Parosmia. Hyperosmia. Anosmia. Reflex Nasal Neuroses. Respiratory Neuroses. Sneezing. Hydrorrhea. Hyperestiietic Rhinitis (Hay fever). Cougli. Pharynx and mouth. Larynx. Asthma. Reflexes Outside of the Respiratory Tract. Ear. Eye. Migraine, Congestive Headache, Neuralgia. Chorea, Epilepsy, Vertigo, and Aprosexia. iStomacli. Heart. Sexual Organs. Under the heading of Nasal Neuroses are to be included (1) Neuroses of olfaction, having to do with alteration in the sense of .■^nu'U ; (2) The phenomena originating directly or indirectly in intranasal excitability, styled reflex. NEUROSES OF OLFACTION. The scn.se of smell, if normal, implies healthy olfactory bulbs, normal nuicous membrane covering the superior turbinate, the upper half of the middle turbinate, and the upper three-fourths of th(> posterior part of the se]>tum, and free ingress for the air laden with the odorous particles which excite the nerve-filaments. Alteration in any one of these factors may cause perversion or loss of olfaction. The uein-oscs of olfaction arc i*arosniia, Hyperosmia, and Anosmia. Parosmia. — liy j)arosinia is meant a perversion of the sense of smell — a perception of imaginary odors su})crimpo. treatment may be instituted much enrlier and occasionally interrupted. The best remedial agents for this condition I believe to be iron or arsenic. Of the ju'eparations of iron, the best results will be obtained by the administration of NEUROSES. 173 the original Blaud's pill, one pill to be taken three times a day one hour after meals. Two or three weeks before the attack may be substituted a pill containing ^-^ grain of the double sulphid of arsenic. During the attack the same treatment should be con- tinued, and the means as given under the variety above for the relief of the nasal congestion be resorted to. The administration and dose of drugs are of necessity controlled by the general condi- tion presented by the individual. Irregularities of the Nasal Cavities and Hyper sensitiveness. — Necessarily, the treatment in such cases would consist in the cor- rection of the existing irregularity, whether in the form of deflec- tions of the septum, nasal polypi, inflammatory or non-inflamma- tory thickening of the mucous membrane, or any condition ^Ahich tends to produce a chronic congestion. Treatment for such con- ditions should be instituted any time between attacks. In the cases where there are markedly sensitive areas, they may be destroyed by means of the cautery, actual or potential, before or during the attack. The local treatment given in the other conditions for the immediate relief of the paroxysm is equally applicable in this form. The turgescence of the mucous membrane, with its consequent ex- cessive secretion, may be relieved by linear cauterization or scari- fication, care being taken not to destroy to any extent the nasal mucous membrane, and thereby avoid any after-effects through the formation of scar-tissue. For the relief of the continued irrita- tion of the nasal secretion in cases in which the treatment given above fails, the administration of a pill containing 2 grains of bromid of quinin, -^^-^ grain of atropin, and ^ grain of codein, three times a day is highly beneficial, but should not be long continued. The inhalation of the fumes of burning stramonium leaves — in fact, any of the common inhalations, afford only tem- porary relief. When the predisjjosing factors exist in combination, the treatment must be combined to suit individual cases, and, necessarily, no definite plan can be formulated. In all cases, gen- eral hygienic measures, such as the regulation of food, clothing, and habits of life, should be rigidly enforced. In all cases, the treatment should be directed to the localization and controlling of the predisposing factors, remembering that the nasal symptoms and the existing hyperesthetic condition are only local manifesta- tions. Occasionally in severe cases there is thrown out on the nasal mucous membrane a highly fibrinous exudate. In such cases the exudate should be thoroughly removed, and the tissue coated over with a 20 per cent, chromic-acid or 3 per cent, chlorid- of-zinc solution. After the acute attack, should there be any existing catarrhal condition, the treatment given under Acute Coryza should be employed. Cough. — Nasal cough can be caused by simple coryza, simple chronic and hyperplastic rhinitis, spurs and deflections of the septum, 174 DISEASES OF THE NOSE A XI) THROAT. polyps, engorgement of the cavernous tissue over the vomer, adenoid growths in the vault of the pharynx, enlargement of the middle turbinate, or sim])le vasomotor changes in the nose. The mechan- ism of its causation is supposedly due to the irritation of the so-(!allcd cough-area of Mackenzie by any of the means men- tioned above. A cough that has proved intractable to ordinary means of treatment should suggest intranasal inspection as a rou- tine ]>rocedure in the management of the case. Should patholog- ical alteration, malformation, or irritability of the intranasal spaces be found, they should be eliminated as possible factors in causa- tion of the (!ough by ajipropriate treatment. Cocain ap])lied within the nose may lessen the severity of the cough, in which case the nasal origin of the reflex is assured. A failure of the cocain, however, to cause anesthesia in the excitable region does not elim- inate the nose from the role of exciting cause, but further search for abnormality or disease should be instituted and remedied, if found l)ef()rc al)andoniug the field. Pharynx and Mouth. — Due to intranasal disease, there have been rej)orted as occurring reflexly in the pharynx and mouth, hyperesthesia, paresthesia or imaginary foreign body, neuralgia, paresis of the palate, dysphagia (paretic and oesophagismus), hic- cough, and salivation. lyarynx. — Of the neuroses affecting the larynx, a])honia is to be mentioned. Cases of aphonia, independent of actual laryngeal disease, have been reported cured by medication of the nose. Whether the cure be due to the revulsive action of the methods employed or to the actual elimination of a nasal etiologic factor might be questioned from either standpoint. That ])athological conditions of the nose or nasopharynx may produce glottic spasm or spasmodic croup, clinical data clearly substantiate. Adenoids of the nasopharynx have been found in a large number of cases of laryngeal spasm or spasmodic crou]>, and Lennox Browne seems to think that their removal will effect a cure. J. A. White reports a case of croup in which the irritation of operative interference, due to removal of adenoids, was suffi- cient to cause a severe laryngeal spasm a day later, controlled, however, by the a])]>lication"*of cocain, showing that neither ade- noids nor other obstructive l(>sion was the cause of the spasm, which, from the ju'ompt I'csult obtained by the cocain, seems to have been ch^arly due to reflex irritation from the nasopharynx. Asthma. — (Jranting thnt asthma be due to vasomotor ]>aresis and bronchial spasui, and admitting the alteration of the nerve- centers with ])re(lisposition to nervous disturbance in the bronchial region, it is fair to assume that nasal as well as other forms of perij)heral irritation may reflexly ])roduce the asthmatic paroxvsm. The irritation within the nose may be brought about by inflamma- tory j)ressure on the terminal-nerve filaments in the mucosa, or NEUBOSES. 175 may be due to turgeseence of the erectile tissues caused by trans- mitted vasomotor alterations from distant parts of the economy — e. g., the eye, stomach, liver, intestines, etc., or from a diseased ganglion itself, or from any pathological lesion in the intranasal spaces. In a search for the underlying cause of the bronchial spasm, eliminate cardiac trouble, renal disease, malarial influence, gastric and intestinal disturbances, irritation of the cervical sym- pathetic by enlarged glands and growths, chronic bronchitis, skin- lesions, sexual irritation, rheumatism, gout, and psychical causes, then examine the nose. There is nothing peculiarly pathognomonic in the symptoms or physical signs of nasal asthma, the paroxysms being identical with those due to other lesions, except that imme- diately preceding and after the attack, the rales heard on aus- cultation are dry ; while in the form due to bronchitis they are moist. Treatment. — The treatment should be directed toward — first, removing the peripheral irritation ; second, improving the nerve- centers ; and third, controlling the paroxysm. Correct any deform- ity. Treat any existing inflammation on lines laid down else- where. Cocain in 4 per cent, solution, warmed and sprayed into the nostrils or mopped over the surface, will obtund the terminal- nerve excitability. Care must be exercised in the use of this drug for fear of the resultant dilatation of the vessels. The irritable areas should be pencilled in parallel lines with a 10 per cent, solu- tion of chromic acid applied on a probe tightly wrapped with cotton, the excess of the acid being carefully removed by another piece of cotton. For the paroxysm itself, hypodermic injection of: I^. Strychninse sulphatis, gr. 20 Atropinse sulphatis, gr, ^^ (.0009) ; Morphinse sulphatis, gr. i (.024).— M. is exceedingly beneficial. Or equally beneficial is : ' i;^. Morphine sulphatis, . gr. f-i (.012-.024) ; Strychninte sulphatis, gr. -^^-^ (.0036-.0024) ; Hyoscinse hydrobromatis, gr. -^^ (.00012). — M. given every third or fourth hour. Inhalations of stramonium leaves and saltpeter in equal parts, burned on a plate, maybe employed. Quebracho ]>ushcd to nausea and then decreased in dose may be used to advantage in some cases. Tonics and change of location may prove beneficial. 176 DISEASES OF THE NOSE AND THROAT. Reflexes Outside of the Respiratory Tract. Kar. — There are at times reflex phenomena in the ear, withont discoverable loeal eause, that iiave been referred to intranasal irri- tation. Persistent and eontinued eough may be caused by reflex irritation from impacted cerumen. I have seen several cases in which a cough that persisted for months was entirely relieved by the removal of the cerumen. Earache, tinnitus aurium, audi- ble contraction of the tensor tympani, a condition similar to hay fever, described by Mackenzie, coming on periodically, in which there was intolerable itching, swelling, and secretion of the exter- nal meatus, have been descril)ed as being reflexly due to nasal dis- turbances. They may be due to vasomotor alterations through the medium of the otic ganglion. Hye. — Intimately connected and closely associated as are the nose and eye, if reflex action were found anywhere, it would be natural to expect it here. Notice of extension of morbid proc- esses from the nose to the eye, or conversely, will be taken in the proper place ; and only those conditions mentioned here Avliich can be accounted for in no other way than by reflex action. Lacrimation may occur by irritation of the nasal tissue in making intranasal application or by the irritation set up by morbid proc- esses. Scintillating scotomata due to turgescence of the inferior turbinate have been reported by Hack. Conjunctival irritability with peri-ophthalmic congestion, blepharospasm and twitching of the eyelids have been mentioned as of reflex nasal origin. Edema of the lids has been cured by shrinking erectile tissue in the nose. A list of reflex ocular disturbances is given in order that, failing medication directly to the eye, thought might be taken of the possibility of the nose bearing a causal relation to the eye-condi- tion, and, having found the source, with proper treatment a cure might be affected. Asthenopia, intolerance of light, retinal hyperesthesia, muscle volitantes, pain in the eyeballs, contraction of visual fields, red- ness of eyelids, phlyctenular ophthalmia, trophic changes of the cornea, and glaucoma are some of these aflections. It is to be remembered, too, that operative procedure within the nose has ))ro(luced similar troubles. F. R. Packard has reported a case of amaurosis following turbinotomy. Migraine, Congestive Headache, Neuralgia (Supra- orbital, Tic Douloureux). — Migraine or sic-k headache and the so-called congestive headaches have been cured in a large number of cases by intranasal treatment, and neuralgia of the various branches of the trigeminus has been benefited in the same way. Hack has gone so far as to speak of headache as turbinated engorgement. Attention has likewise been called to the irritabil- ity of the nasal nnicosa occurring with the headaches of puberty. NEUROSES. 177 Neuralgia may be due reflexly to adenoids, turbinal lesions, espe- cially of the middle and posterior parts of the inferior turbinate, spurs from the septum, and intranasal synechise. Chorea, epilepsy, Vertigo, and Aprosexia. — Chorea has been reported as having been cured when such nasal condi- tions as rhinopharyngitis, deflections of the septum, tonsillar hypertrophy, or adenoids were remedied or relieved. The con- nection between the choreiform convulsions and the irritation pro- duced by these intranasal conditions would appear proven when removal of the nasal disease causes cessation of the convulsion. However, this does not prove the connection, and the benefit derived by the remoNul of the nasal growth may be explained by the improvement in general health due to improved respiration and digestion. The removal of the nasal polyps, exostoses, hyperplasise, angio- mata, etc., have been reported as coincident with the cessation of epileptic seizures. Vertigo has been relieved by the treatment of nasal disease, leaving the question open, however, as to whether the vertigo was purely reflex in origin or " aural " in type, due to pathologic alter- ations in the Eustachian tube, middle ear, etc., brought about by extension of the nasal condition, Aprosexia (inability to fix the attention, loss of memory) is another nasal reflex supposed to be dependent on the connection between the nose and the brain. Stomach. — Gastralgia, indigestion, flatulency, vomiting, etc., have been recorded as being produced reflexly by intranasal change. Before, ho\s^ever, such symptoms as these are definitely classed as reflexly nasal in origin, it would be advisable, with the thought in mind that the mucosa of the stomach and nose are continuous, to investigate these phenomena on this basis — that nausea, indiges- tion, etc., may be caused by the swallowing of nasal secretions, or even of air, when the nose is occluded. Heart. — Nasal irritation giving rise to cardiac disturbances has been referred to by a number of writers ; and instances of ex()j)htlialmic goiter benefited or cured by intranasal treatment have l)een reported by observers whose ability cannot be gain- said. Ervtheina, urticaria, and acne of the nose and face have been attributed by various authors to intranasal disturbances. That removal of an enlarged middle turbinate has partly, if not wholly, relieved a most annoying and disfiguring redness of the tip of the nose has been observed in a numl)er of well-authenticated cases. Sexual Organs. — The s})ecial causes of such reflex nasal plicnoiiicii:! as sneezing, dyspnea, cpistaxis, when emanating from the sexual orgiins, are continued abuse of their physiological function, the disturl^anccs attending the advent of puberty, preg- 12 178 DISEASES OF THE NOSE AND THROAT. nancy, menopause, chronic affections of the uterus and ovaries, and all the abnormalities of menstruation. Treatment. — The treatment of nasal reflex neuroses should be first local, and, secondarily, attention should be devoted to restoring the mistable nerves and nerve-centers to their proper equilibrium ])V way of general systemic inedication. Local. — Polyps, adenoids, or other growths should be removed by the cold-wire snare or scissors. Deflections of the septum should be straightened, and cartilaginous and osseous projections are to be sawed off". P^nlargement of the middle turbinate and a puffiness of the vomer, if accompanied by irritability, should be treated by the obtunding of the su|)erficiai nerve-endings ^^■\th the galvanocauterv lightly apj)lied, with chromic, nitric, or trichlor- acetic acid, careftdly regulating the amount of tissue and depth to which these agents penetrate. Especial care should be exercised in all of these operations, lest they aggravate rather than benefit the existing condition. It is to be expected that for a short time the equilibrium of the already-disturbed nervous control should be still further unbalanced, but only for a time, however, to be followed at an interval regulated by the severity of each individual case by the desired amelioration or cure. General. — Each case should be carefully studied on its own merits, and the physician should not despair if the desired result is not rapidly obtained. As a general tonic, the following, given in pill or capsule three times a day after meals, will be found advantageous : ^i. Strychnine nitratis, gr. ^Q-gr. yV (.0015-.003) ; Acidi arseniosi, gr. g^gr. J^ (.001-.0015) ; Ferri redacti, gr. i-gr. i (.015-.03); Quinime hydrobromatis, gr. j-gr. iij (.06-18); Pepsini saccharati, gr. iij (.18). Or the following pill, which is a modified form of that recom- mended by John N. Mackenzie, to be taken before meals : R. Zinci phosphidi, gr. -^ (.004) ; Quinimie bromidi, gr. ij (.12) ; Extract! nucis vomica, gr. ^ (.015). If there is tendency to constipation, there should be added i to ^ grain of the ])owdered extract of cascara sagrada. Shower baths, cold or tepid, or local s])onging with cold water and alcohol should be ordered. Nutritious diet and an outdoor life are to be insisted upon as far as practicable. CHAPTER IX. NON=INFLAMMATORY DISEASES OF THE ANTERIOR NASAL CAVITIES. EPISTAXIS. Varieties as to cause : (1) Trauma ; (2) Local nasal lesions ; (3) Constitutional conditions ; (4) A^icarious. Definition. — Hemorrhage from the mucous membrane of the nose. Synonyms. — Bleeding from the nose ; Hemorrhagia narium ; Nose-bleed ; Rhinorrhagia. l^tiology. — Epistaxis has been said " to take place as a symp- tom, as a disease, and as a physiological process." In general, it occurs more frequently in males — owing probably to their more exposed life — than in females, and is most frequent between the second year of life and puberty. No age can be said, however, to be exempt from its occurrence. The conditions in which it is present are many and widely varied. We may simplify a consid- eration of these in their etiological relationship by classifying them into four divisions. Thus we may consider epistaxis as caused by trauma, as attending local nasal lesions, as present in constitu- tional conditions, and as the vicarious performance of a suspended process elsewhere. 1. Traumata. — Perhaps the most frequent of these are blows upon the external nose, received during a fist-fight, from colliding with beams or with an open door, from falls, recoil of a gun, and a host of similar exhibitions of mechanical violence. Abrasions or cuts of the mucous membrane, whether accidental, as by punct- ure with a fork, pencil, or other sharp-pointed instrument entering through the nares or penetrating through the integument, or instru- mental, either at the site of operative procedures or from care- less handling in examinations and topical applications, are frequent causes. The introduction of foreign bodies into the nose, as fre- quently done by children in play, is often attended by hemorrhage more or less severe. The same is true of the wounds produced by picking the nose in various nasal irritations, or in the removal of crusts — a practice not limited to tliosc of younger years. Cer- tain occupations have a greater or less ])rc(lisposing influence, as thev involve the inlialation of nicchanical irritants. These include 180 DISEASES OF THE NOSE AXD THROAT. stc't'l-grindinu', st<>iic-(!rcssiiiu\ and the like. The same is true of occupations involviiiii; the inhalation of acrid funics, such as stron*^ ammonia, and various chemical and medicinal sul)stances. Rarely, e|)istaxis may follow the violent rupture of hematomata. '1. Local Causative Agents. — The various local liyperomic conditions by their very nature markedly predispose to epistaxis. The hyperemia associated with the t>ar]y stages of acute rhinitis, that due to the stroniily overacting heart of the athlete or liard- working lal)orer, and that occurring in the general tilling out of th(! l)0(lily structure during pubescence, may be cited as examples, and the ejnstaxis may in a certain sense be regarded as a natural relief measure. Some trace a causative influence in a nasal hyper- emia from natural or unnatural use of the sexual apparatus. Ulcerative processes, however widely varied as to origin, are notablv active in producing a bloody discharge. Especially is this true of the ulceration attending the more rapid malignant growths. Foreign bodies not infrequently cause a hemorrhage from the liyperemia following their continued presence as irritants, from actual abrasions, or from superficial necrosis of the contigu- ous membrane, with exposure and erosion of the smaller blood- vessels. In some cases these bodies may be animate, as maggots and various forms of worms, and more or less wounding of the membrane by their movement and the harder portions of their external structure may be the (^ause. Certain of the neojilastic growths of the nose, such as the angiomata, sarcomata, and car- cinomata, are also attended with varying hemorrhage. Polypoid growths frequently are ax^companied by a blood-streaked discharge, and the same condition frequently attends adenoid vegetations. Hay fever is often marked by a discharge tinged with blood. Malformations — especially of the septum — such as spurs, exos- toses, and deviations, j)redispose in no slight degree, lK)th by the alteration in air-currents and by the thinning of the nuMnbrane at the variously sharj)ened angles, with subsequently lessened pro- tective backing for the delicate vessels. It is apt to occur with little provocation in simple chronic and atrophic conditions of the nasal mucosa, o. Constitutional Conditions Favoring- Epistaxis. — The list of these is a long one, and nasal hemorrhage occurs with trifling or grave import. Of these, we may fittingly first mention the hemorrhagic diathesis, hemophilia or bleeder's disease, which not infrecpiently first exhibits its ])resence l)y the copious and intract- able nasal hemorrhage that may appear on trifling provocation. It occurs during the onset of ty])hoid fever, and at various times (biriuii the eruptive fevers. Pneumonia, dijihtheria, relapsing fever, gout, ephemeral fever, iuHuenza, scurvy, ])ur))ura, the vari- ous anemias, bronchitis, enq)hvsema, and the specific inflamma- tions, especially syphilis, tuberculosis, and leprosy, may all be NON-INFLAMMATORY DISEASES, ETC. 181 marked by its occurrence. Congestive conditions of the membrane due to cardiac lesions, such as insufficiency of the right side of the heart, are apt to find relief in escape of blood from the nose. The same is true of the cyanotic conditions from portal obstruction, as in acute yellow atrophy of the liver, the varying cirrhoses of that organ, or pressure from neighboring tumors or enlarged organs. Similar conditions may attend Bright's disease. Nor must con- gestions caused by more local processes be overlooked, as that ibllowing pressure upon the return channels of the neck by tumors, notably a bronchocele, or by too tight constriction from ill-fitting neckwear. The general hyperemia seen in plethora may find oft- times a partial relief in a nasal hemorrhage, and we have already mentioned the hyperemia of the overacting heart. Alcoholism is peculiarly liable to develop attacks of nose-bleed, and the athe- roma of old age, through structural change in the vascular system, decidedly predisposes. Apoplexy may in some cases be heralded by a slight epistaxis, and it may occur as a natural relief during the attack. Similarly, congestions of the cerebral vessels during prolonged or severe mental effort may be partially relieved by a flow of blood from the nose. Atmospheric conditions play a very decided part in certain cases, from the disturbance between intra- and extravascular pressures which they cause. This explains the copious nose-bleeding so often seen in a rapid ascent to higher altitudes and lessened atmospheric pressures, examples of which exist in those climbing high mountain-peaks, in those making balloon-ascents, and in the workers in caissons or deep mines. Lastly, we may mention certain drugs whose ingestion in full amounts or in toxic doses may be attended with epistaxis. Such a list would include phosphorus, chloralimid, and the various compounds of the salicyl group. 4. Vicarious Epistaxis. — The site of vicarious menstruation is in a large proportion of cases the nasal mucosa, and sudden cessation of a iiow gf blood from hemorrhoids is apt to be replaced by epistaxis. As will be seen, epistaxis occurs in many conditions, and its significance is usually evident. In many of the cases, the severity of the attendant process accounts for the physical conditions neces- sary to permit the escape of blood. In others, an active and energetic immediate cause is necessary, and this is usually fur- nished by a severe sneeze, cough, or violent blowing of the nose. Pathology. — The anatomical features are of importance in this coiiucction. The blood-vessels of the pituitary membrane, it will be remembered, are lacking in muscular backing, and arc more or less intimately related to the bony or cartilaginous forma- tions underneath. Tiiis condition furnishes a firm counterresist- ance which docs not permit the vess(^l to avoid or mitigate force from without by sinking into the softer bed that muscular 182 DISEASES OF THE NOSE AND THROAT. tissue Avould fiirnisli, nor in particular, the so-caUed site of })redilection, at the anterior inferior part of the se]>tum, which has been so named from the relative frecpiency of occurrence there. Macroscopically, the membrane may be swollen and red, it may show varicosities or erosions, or there may be a clean, sharp cut. It may be the margins of a septal perforation that supply the points of escape, or the ragged edges of a ruptured cyst. On inspection the hem- orrhage may be seen in the form of an arterial spurt, a slower welling-out of blood, or a slow, steady capillary oozing. Micro- scopically, the lesion is either an overdistention of the blood- vessels, with paresis, leakage of blood into the submucous tissue, and subsequent escape upon the surface, or a rupture or wound of the vessel-walls, with exit upon the surface. The hemorrhage tends usually to stop spontaneously, and this generally is brought about ])y the formation of parietal thrombi. Dislodgement of tiiese is a common cause of secondary hemorrhage. Following a profuse; escape of l)lood, the membrane not uncommonly is pale and anemic, returning soon, however, to its normal state. Not all the cases of epistaxis must be regarded as of patiiological import, as the process is in some instances evidently natural and physio- logical, and is nature's method of blood-letting. Tiiis is true of plethora, and the various renal, hepatic, and cardiac congestions. Symptoms. — The dominant symptom is, of course, loss of blood through the nose. If the lesion be in the anterior part of the nose, it escapes through the anterior nares ; if in the posterior regions or if the patient be recumbent, it has exit through the choante into the pharynx, and, from swallowing or entrance into the bronchial and pulmonary tracts, the subsequent ejection may simulate hematemesis or hemoptysis. The amount of blood lost varies greatly. It may be a jiersistent and profuse flow, or it may be a slight escape, barely tinging the nasal secretion. Tlie attacks may be irregular and isolated, they may occur with })eriods of varying quiescence or as daily outbreaks, and the flow may last from a few minutes to several hours. Usually the blood shows a ready ten- dency to coagulate, but such, however, is not the case in hemo- philia. Premonitory symptoms may precede the attack, such as congestive headache, fulness, roaring in the ears, vertigo, and dis- turbances of vision. In many cases, the first intimation of the hemorrhage is a bubbling of insj^ired air through the fluid blood in tile nasal space or spaces, or the discoloration of th(» handkerchief used to relieve a sup]>osedly ]>r()fuse discharge of secretion. The symptoms following the epistaxis vary greatly, and are severe pro- portionately to the amount of blood lost. There may be, and fre- NGN-INFLAMMATORY DISEASES, ETC. 183 quently is, a sense of absolute relief. The head feels clear and the brain is active, respiration is easier, and the heart free and less laboring in its action. The congestive symptoms, if present before, are now abated. On the other hand, headache may follow, or a moderate epistaxis in a healthy person may cause little or no after-effect. If profuse, however, all the symptoms of exsanguin- ation and syncope may rapidly supervene. The bleeding may take place from one side, or it may occur from both. Traumata usually cause one-sided hemorrhage, and the majority of the local affections do the same. The constitutional causes and the vica- rious manifestations are, however, almost always from both nares. Inspection, as a rule, either by anterior or posterior rhinoscopy, will reveal the site of the process, and stress is laid by some authors upon a brownish stain observed between periodical attacks as indicating the site of escape. Diagnosis. — The diagnosis of epistaxis is usually not diffi- cult, but may frequently require anterior or posterior rhinoscopy for a sure recognition of the trouble. Hemorrhages from local lesions are generally unilateral, while those from the stomach, pharynx, tongue, lungs, and fractures at the base of the skull, if passing through the nose, are generally bilateral if the spaces are both clear. Moreover, in the latter class of cases there is usually a history of greater or less diagnostic import. Hemorrhage from the posterior and inferior part of the septum may be misleading. Bleeding from one or more of the accessory sinuses may be extremely difficult to differentiate. Inspection, however, showing exit of blood at or near the sinus-outlets, should be suspiciously regarded, but little dependence can be placed upon the character of the blood in given cases. Prognosis. — The prognosis in the majority of cases is good, and in itself the nasal hemorrhage is rarely fatal. In nasal dis- ease, excepting when due to malignant growths, the outlook is favorable. In the systemic conditions, the prognosis depends upon the amenability of the disease to treatment. Diathetic conditions, especially hemophilia, present largely a bad forecast, and the same is true of chronic heart disease. In plethora the outlook is good ; the blood lost in an attack is usually soon re-formed. Complications. — Syncope occurs in some cases, not alone as a result of blood-loss, but as the expression of the nervous shock which sensitive people sometimes experience at the sight of blood. Treatment. — The constitutional derangements with which epistaxis is associated, it is needless to say, must receive their proper treatment, and usually witli their subsidence the cessation of the attacks of epistaxis occurs. I*\)reign bodies, both animate and inanimate, must be removed, in many cases no treatment is necessary, the hemorrhage subsiding sjiontaneously. Other cases recjuire local measures of greater or less severity. Moderately 184 DISEASES OF THE XOSE AND THROAT. severe attacks may cease with simple digital ])ressure on the uasal alaj, or on the application of ice to the nose, to the forehead, or to the nape of the neek, or by insufflation of iced water or hot Avater. Insufflation of finely powdered alum, or tannic acid, or 8 to 10 per cent, solutions of the same drug may be used. Solutions of zinc sulphate, acetate of lead, or sulphate of copper, in the propor- tions of 30 grains to the ounce of water, may be applied by syringe or on pledgets. Cocain in weak solutions has been recommended, but is open to the danger of absorption causing toxic effect from the open surface, and to the subsetpient reactionary hyperemia it causes. Ulcerated sjMjts may be touched carefully by a 15 per cent, solution of chromic acid, avoiding the adjacent tissue in the application. The actual cautery is recommended by some. Digital compression of the facial artery is sometimes useful, and a recum- bent posture, with arms extended over the head, favors cessation of the flow. At the same time, the internal administration of certain drugs may be employed, such as tincture of ergot, in 10- minim doses every two or three hours, or the oil of erigeron ; 5- to 10-drop doses of dilute sulphuric or nitric acid every hour for three doses may be tried, or tincture of opium, in 5- to 8-rainim doses every three hours to an adult, avoiding its use in children. These methods failing, resource must be had to- various methods of local pressure, with or without the use of styptic solutions. Thus the spaces may be filled with plugs of wool, lint, or absorbent cotton, which should be aseptic, and may be plain or medicated. An 8 per cent, solution of antipyrin is admirable, as are the solu- tions already mentioned. The plugs may be prepared by soaking and then drying, and thus prepared may be kept on hand until needed ; when they are to l)e used, simply wet them with plain water, or they may be freshly prepared. Fresh solutions of a 15 volume strength of percxxid of hydrogen, dilute solutions of hamam- elis, or 1 : 1 000 solution of trichloracetic acid are excellent. It is advisable to attach a fine but strong cord to each pledget to facilitate removal. These are inserted through the anterior nares, 'and jmcked one by one carefully to insure equable pressure. Vari- ous forms of rubber bags have been introduced, which, inserted empty, may afterward be inflated, and have more or less prac- tical value ; or as a last resort, the posterior and anterior nares may both be plugged, using a Belloccj cannula or a soft gum catheter. In one case of the author's, a Jiolyp snare gave good results. The instrument is passed through the passage and out into the pharynx, where it is seized and drawn forward enough to fjisten the attached strings to a dossil of size sufficient to half-fill the space. The instrument is then withdrawn, bringing with it the strings, and by traction on these the dossil is brought firmly up to and within the choante, completely occluding them. The strings are left in the space, the anterior nares are plugged, and NON-INFLAMMATORY DISEASES, ETC. 185 the strings are fastened by tying in the anterior plug or by tying around the head. This gives a sjmce between the two plugs, which tills with blood, the pressure gradually equalizes, and clotting and occlusion of the points of exit take place. In packing the nasal spaces, care must be taken not to pack so tightly as to cause any danger of devitalization of the membrane from inhibition of the blood-supply. Nor in any case should the plug be left in longer than is necessary to insure formation of a iirm clot, as in more than one reported case grave pyemic symptoms have followed sup- puration behind a pledget too tightly packed to allow exit of the pus, and kept in place long enough to allow it to form. Forty- eight hours should be the extreme limit for their retention. After their removal the nose should be carefully cleansed by mild solu- tions to detach and bring away the blood-clots, and the patient carefully watched for some time, and enjoined to avoid violent exercise for several days to prevent recurrence of the trouble. Epistaxis Occurring in Bleeders (Hemophiliacs). — While packing the nostril may fail to arrest the hemorrhage, yet suffi- cient cotton should be put in the nose to prevent nasal breathing, as in cases in which the oozing is very slight the suction produced by breathing is suflicient to keep up the bleeding. Blocking of the nostril will prevent this suction. In many cases where the arterial pressure is low, large doses of nitrate of strychnin are highly beneficial. CHAPTER X. FOREIGN BODIES IN THE ANTERIOR NASAL CAVITIES. 1. liiaiiiinatc. «. Kliinolillis. h. Miscellaneous. 2. Animate. a. Parasites. INANIMATE. Rhinoliths. Definition. — A foreign body formed within the nasal space by the deposition of mineral salts ; in most, if not all, cases there is a niu'lciis of some character as a basis for deposition. Synonyms. — Nasal calculi ; Nasal concretions. ;^tiology. — The causation of rhinolith-formation is usually referred to two underlying conditions : First, alteration in the quality of the nasal secretion ; second, the existence of conditions favoring its retention. The gouty diathesis has been advanced as an etiological factor and has received several supporters. Rlii- noliths usually are found in adults, and more females than males seem to be affected. Pathology. — The pathology of rhinolithic formation, other than that it represents an excess of suspended mineral matter in tlie nasal secretion, is unknown. The pathology of the morbid process it finally causes, if not removed, is identical with that of any other foreign body in the same location, and need not receive repetition here. Site. — Any portion of the nasal space may be the site of their formation, although usually found in the lower meatus. Characteristics. — Ivhiuoliths are usually single, though cases of doui)Ic occurrence are re])orted, not, however, involving more than one nostril, and usually linked. In weight and size they present wide differences, from small bits of a grain or .so to the enormous mass reported as weighing 720 grains. In shape they are widely variant, the ]>()rtion of the nasal sptice in which they originate being regarded usually as exercising a determinant influ- ence in that respc(;t. '^Fhe surface is comparatively rough or cor- rugated, or may be rather smooth. Tlie color varies from a dirty- FOREIGN BODIES IN THE ANTERIOR NASAL CAVITIES. 187 white to a gray, brown, black, or greenish tinge. In consistence they may be soft and crumbling, or grow through different degrees of hardness to a formation firm and hard in texture. The outside may be firm and dense and the inside soft and crumbling. Chem- ically, they are largely salts of calcium and magnesium, principally the carbonates and the phospliates, with traces of the chlorid and carbonate of sodium. Some organic matter is usually intermixed in the substance. Usually, they exhibit the typical structure of a calculus, being formed of concentric lamellae of earthy matter dis- posed about a nucleus. The latter may be of almost any character. In some cases, the rhinolith has been found without a nucleus, but with a hollow, soft, or gelatinous center ; in others, there is seen neither nucleus nor peculiar center, the nucleus apparently being a flake of encrusting mineral deposit, or so small as to be practically invisible. From this circumstance has arisen a discussion as to whether rhinoliths may or may not be of two varieties — one in which there is no nucleus for deposition of the mineral salts, and another variety in which the nucleus is present and becomes gradually encased in the succeeding earthy coverings. Whichever view is correct, it certainly is a fact that the formations with a demonstrable nucleus are of far greater number. Symptoms. — Rhinoliths during their formation give rise usu- ally to no symptoms, except it may be those of increasing nasal obstruction. They are, however, foreign bodies, and, as they increase in size, the symptoms of a foreign body impacted in the nasal space gradually develop. Having already considered these elsewhere, we need not repeat them here. Diagnosis. — The diagnosis is made by inspection after cleans- ing the space with an alkaline wash, by exploration with a probe, and by the history. A calculus may not unlikely be mistaken for a polypus ; the touch of the latter is, however, different. The rough presenting part may look and feel to the probe like necrosed bone, but has not the stench of the latter, and the history is different. Prognosis. — The prognosis is practically that for any foreign body in the same location. Treatment. — The rhinolith, as well as other foreign bodies, can often be easily syringed out ; but when encysted, after freeing the foreign body it (;an be removed by instrumental means, the instrument employed being the one best adapted to the individual case. The instruments shown in Figs. 55 and 56 are suitable for such cases. The rhinolith may be cnislied and tlien removed by syringing. The nostril should {)e carefully cleansed twice daily by an anti- septic alkaline wash until all syinptonis of irritation disap]iear. 188 DISEASES OF THE NOSE AND THROAT. IMrSCKLLAXEOU.S. The list of reported iiiaiiiinate foreion objects wliieli liave been found within the narrow eontines of the nasal spaees is amazing, both as to its length and the wide variety of articles which it com- prises. It is useless here to attempt even a brief mention of such objects, save to remark that size is practically their only limi- tation. We are considering, of course, only the cases in which such objects after entrance to the nasal spaces become lodged, and, finally, after successfully resisting attempts of the patient at their reuioval, are brought, it may be after the lapse of years from their insertiou, to the ])hysician's attention. Etiology. — Foreign bodies of this class may enter the nasal spaces in thnH' iuiportant ways. They may be inserted directly into the nose by the patient. This is more frequent in children, in those of unsound mind, and in that strange class of morbid entities — malingerers. ScH'ondly, they may enter the na.sal spaces through the choansi?. This occurs usually in vomiting or choking, in which swallowed substances are forcibly ejected and pass behind the soft palate. Paralysis of this organ markedly predisposes to this method of entrance, even in deglutition. A very few cases of instrumental introduction are recorded. Thirdly, though this is rarely the case, they may find entrance through peuetration of the nasal walls or floor of the nasal hood. We uiay also mention, as a foreign body of local jiroduction, the so-called rhinoliths or )tas(i/ cdlcnH, which will be considered elsewhere. Pathology. — The pathology varies greatly with the nature of the object. The object may be small, so situated and of such a character as to evoke practically no manifestations from the membrane, save a somewhat greater irrital)ility to external influ- ences or an increase in the normal secretion of the adjacent glands. On the other hand, with varying degrees intervening, the opposite extreme may occur. The object at once, or perhaps after years of quiescence, causes an acute inflammation by its irritation. The membrane becomes swollen and turgid, and its vessels become dilated. The submucosa Ix-comes infiltrated with fluid and cellu- lar elements, and the glauds adjaceut to the object are spurred to greater secretion. The swelling continuiug, the ])ressure gradu- ally increases, helped, it may be, by swelling of the object itself, if it be of such a ciiaracter, aud acts as a cut-otf to the supply of nutriment. As a result, the epithelium depeudeut upon this undergoes necrotic changes, desquamates, and ex])oses the under- lying bogtry tissue. Pyogenic infection occurs, attempts at cell- proliferation and organization are counterbalanced by the liquefy- ing action of the pyogenic organisms, and superficial necrosis takes place, forming irregular ulcerated areas. If, now, from adjacent vessels not so directly influenced by the pressure, sufficient nutri- FOREIGN BODIES IN THE ANTERIOR NASAL CAVITIES. 189 ment is obtained by budding, granulation-tissue may be formed, embedding, as it were, the object in a nest of granulations. If the pressure continues, the necrosis and infection may extend deeper, even to perforation of tlie septum, the nasal floor, or the lateral wall, and discharge of the irritating medium follow. This, however, is rarely the case, and the foreign body, before advan- cing beyond the formation of ulcers, usually causes such annoyance or even pain as to compel the sufferer to seek a physician for its removal. Coincident with the inflammatory process, the increased secretion, dammed back by the nasal obstruction, becomes infected both by putrefactive organisms which give rise to an evil smell, and by principles it contains irritant to the membrane, thus increasing, or helping to maintain the inflammation. Slight epis- taxis may follow rupture of vascular twigs. After removal of the object, and under appropriate medication and protection, the mem- brane gradually returns to a condition more or less normal, depend- ing in each particular case upon the extent of the tissue-loss or -change. Symptoms. — These, as will readily be seen, must vary in accordance with the character of the foreign element. A small smooth object may cause no inconvenience at the time of intro- duction, and be practically forgotten so far as its presence is a source of annoyance. Quite large bodies have lain in the nasal spaces for years, giving no annoyance by their presence, and then suddenly causing severe inflammatory phenomena. On the other hand, the inflammation may begin immediately after the object is inserted. In either case, the symptoms are those of irritation and obstruction. The essential features of a fairly severe case arc, })riefly, as follows : The membrane of the aflected side becomes swollen and pain- ful ; the discharge increases, at first glairy, later mucoid ; finally, purulent, and often offensive. Not infrequently it is streaked M'ith blood, and, excepting in severe cases with septal perforation, uni- lateral, and may or may not excoriate the nostril and lip. Obstruc- tion of the aflected side is marked and annoying, aff'ecting the respiration and giving the voice a nasal twang. The ala may participate in the inflammation and become red and swollen. Pain of a neuralgic character in the nose, cheek, and head may be present, and various sympathetic disturbances of the eye and ear, such as increased secretion, tinnitus, and otalgia. Attacks of sneezing may occur, vertigo, possibly nausea and vomiting, and in one very severe (sase reported there was a unilateral facial hypcr- idrosis of the sanu^ side. On inspection, for wliich cleansing by an alkaline wash may be necessary, the mcmln'ane will be found swollen and congested, possibly hiding the ol)ject. '^Pliis, howevei", )nay be visible, and in cases of long standing may be seen sur- rounded by granulation-tissue, giving an appearance not unlike 190 DISEASES OF THE NOSE AND THROAT. that of cancer or other malignant process. A curious case is recorded in which a bean in the nasal space underwent germina- tion, the true nature of the trouble not being discovered until an attempt was made to remove the sprouts, which had been mis- taken for polypi. The site of the body may vary, and it may take almost any portion of the nasal space for its lodgement. Anteriorly, however, impaction usually takes place in the inferior turbinate and the septum. Diagnosis. — Usually this is not difficult. The history, uni- lateral discharge and its character, inspection, and the use of the ])r()be form the essential elements. Prognosis. — The outlook is good. Recovery rapidly takes place, as a rule, after the removal of the foreign element. If untreated, however, the case runs a slow chronic course, the dis- charge never wholly ceasing, and the duration being marked by exacerbations such as we have described. Treatment. — For the removal of the foreign body, the forceps shown in Figs. 55 and 56 are of the best ; however, the size, shape, and location of the foreign body will often necessitate the use of a special instrument adapted to the case. The after-treat- ment should be palliative. After cleansing the nostril wdth a warm boric-acid solution, 10 grains to the ounce, there should be applied twice daily to the irritated surface the following : I^. Cann)horie, gr. j (0.6) ; Thymol, gr. j (0.6) ; Menthol, gr. ij(.12); Cosmolin (liquid), flsj (30.). ANIMATE. It not infrequently happens that the nasal passages are invaded by various lower forms of life. Such reported cases include vari- ous insects, intestinal worms, leeches, and the like. These, as a rule, quickly give evidence of their presence by the itching, increased discharge and pain, which they cause through their presence and movements. As a rule, they are quickly recognized and as readily removed, living or dead, unless they unfortunately have penetrated the connected sinuses. To enter into a detailed account of these is scarcely necessary. There is, however, a phase of this condition, fortunately rare in northern latitudes, but which is of sufficiently common occurrence in tropical climates to demand attention. This is the condition })roduced by the development within the nasal structures of the larvie of certain flies, and which is termed myasis nariuni, or, in vulgar Fuglish phrase, " maggots in the nose." !^tiology. — The direct cause of this condition is the deposi- A Manual of MODERN SURGERY. By J. Chalmers Da Costa, M«D., Pto- fessor of Practice of S«rg:efy and Clini- cal Surgfery, Jef fer- DA COSTA'S SURGERY son Medical College, Philadelphia; Surg-eon to the Philadelphia Hospital, etc Handsome octavo, 911 pages, co- piously illustrated. Cloth, $4.00 net; Half Morocco, $5.00 net. ^ ^ ^ NEW AND ENLARGED EDITION The remarkable success attending Da Costa's Manual of Surgery, and the general favor with which it has been received, have led the author in this revision to produce a complete treatise on modern surgery along the same lines that made the former edition so successful. The Reviews of the First Edition. " We know of no small work on surgery in the English language which so well fills the require- ments of the modern student." — Medico-Chirur- gical Journal, Bristol, England. " Essentially practical in its scope, judicious in its advice, and likely to prove of value to the student." — New York Medical Journal. book has been entirely rewritten and very much enlarged. 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Collected and ar- ranged, with critical editorial comments, by 28 eminent American Specialists and Teachers. <^ Sent post-paid on receipt of price. W. B. SAUNDERS & CO., Publishers, 925 Walnut St., Philadelphia. An American Text -Book of DISEASES OF THE EYE, EAR, NOSE, AND THROAT. Contributions from 60 prominent Ameri- can Specialists. Edited by G. K de Schweinitz, A.M., M.D., Professor of Ophthalmology, Jefferson Medical GolIeg:e, Philadelphia; and B. Alex. Randall, A.M., M.D., Clinical Profes- sor of Diseases of the Ear, University of Pennsylvania. Imperial octavo. J25J pages, 766 illustrations, 59 in colors. Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. J- J- J- J- RECENTLY ISSUED. AMERICAN TEXT-BOOK OF DISEASES OF THE EYE, EAR, NOSE, AND THROAT The present work makes a special claim to favor based on an encyclopedic, aotlioritative, and practical treatment of the subjects. Each section of the book has been entrusted to an author es- pecially identified with the subject, who there- fore presents his case in the manner of an expert. Particular emphasis is laid on the most approved methods of treatment, so that the book shall be one to which the student and practitioner can refer for information in practical work. J^ ^ J^ Sent post-paid on receipt of price. W. B. SAUNDERS & CO.. Publishers, 925 Walnut St., Philadelphia. FOREIGN BODIES IN THE ANTERIOR NASAL CAVITIES. 191 tion of the ova within the nasal space, or spaces, and the hatching of the larvae under the favoring conditions present. Several varieties of flies have been proven responsible, and it seems more than probable that the eggs are deposited directly by the female, either within or at the margin of the anterior nares. Some observ- ers, however, have claimed that the eggs are taken into the nose during the act of smelling various substances which have harbored them. The condition is rare in temperate or cooler climates, though isolated cases have occurred, but is more prevalent, even quite common, in the tropical countries, especially South America and India. The favoring local conditions seem to be those attended with a fetid secretion, explainable by the instinct of the Fig. 55.— Forceps for foreign bodies. Fig. 56.— Forceps for foreign bodies in the nose. insect to deposit its eggs in putrid surroundings. It is even claimed by some that a healthy membrane is never affected in this manner. Patent conditions of the nostrils and the passages, as in atropliic changes, are also to be considered as favorable. The term '' peenash," as used in India to designate the disease, seems to ])e a" rather vague term, comparable possibly to the loose manner in wliich ozena is used in English. Pathology. — The ])resence of the larvae, of course, excites a catarrhal iuHammation. This, however, is but a brief prelude to the ravages caused by tlieir voracious activity. The mem- brane is attacked, as it were, " tooth and nail," and rapidly ])ulpified. If the larvte are not removed, the structures immedi- ately investing the bono and cartilage are (juickly destroyed, and caries of the bone immediately follows. Sup[)uration is inevitable. 192 DISEASES OF THE XOSE AM) THROAT. and takes place not alone at the site of larval activity, but spreads widely as the germs gain ready entrance to the connective-tissue spaces. The larva3 not infrequently burrow out through the nasal walls, and, forming sw(!llings not unlike abscesses in character, finally eat through tiie integument and escape. They may burrow through into the bony sinuses, or even into the cranial cavity. The ethmoid, sphenoid, palate, and even the superior maxillary bones may be totally (k'stroyed, and inflammation of the meninges is almf)st sure to foHow in fatal cases. Symptoms. — The symptoms are severe and rapid in course. The entrance of tiie fly may or may not have been noticed. The; incubation-period of the ova being, however, short, \vithin a day or so after their deposition there is a sense of uneasiness in the nose, a slightly increased discharge, and a slight tickling. This last sym})tom rapidly increases, and attacks of violent sneezing succeed, and, shortly, as the larvse develop and increase in num- bers, the tickling develops into formication, which, by its per- sistency, is almost unbearable to the patient. Pain is present, severe and persistent, over the frontal, occi})ital, or vertical regions, and severe throbbing headac^hes, all so constant and severe as to (!ause insomnia of a dangerous ty})e in itself. The nasal discharge is early increased, and gradually becomes thicker and ])urulent, containing the pul})ified tissue, and })0ssibly also, in varying num- bers, the maggots themselves. Epistaxis is frecpient, from a small tinge to a dangerous burst of blood. Edema of the face and eye- lids, possibly also of the palate, is likely to follow, and small tumors not unlike abscesses in character are apt to form, each tending to open on the surface and discharge its contained lar\a with the mass of j)utrid material in which it is embedded. Unless relief is obtained, the loss of tissue is rapid and extensive. The raucous niembrane is pul])iHed and discharged; the bones and the cartilage, owing to loss of nutriment from the supply furnished by vessels from the already-destroyed softer structures, perhaps also directly attacked by the larvie, are necrosed, and come away in the foul discharge. The bony and cartilaginous framework of the nose, in whoh^ or part, may be destroyed, with not infrequently fatal or terribly disfiguring results ensuing. It is scarcely neces- sary to speak of the profound systemic involvement that rapidly develops. All the; evidences of a septic intoxication of no mild degree quickly come on — iiigh and irregular fever, chills and sweats, gastric disturbances, in short, a tyjiical case of pus-intoxi- cation. As the disease progresses, the symptoms of greater local action become more marked — vertigo, sudden s])ells of temporary blindness, agoui/iug headache, and maniacal delirium, rndced, suicide is not unlikely to l)e attempted to escape the frightful agony. Finally, from the septic intoxication or an acute menin- gitis, the death of the patient takes place in convulsions and coma. FOREIGN BODIES IN THE ANTERIOR NASAL CAVITIES. 193 Diagnosis. — The absolute diagnosis is, of course, made by the discovery of the maggots either in the discharge or in the nose itself. There may or may not be sufficient history to be of assistance. The rapid course, severity of symptoms, and char- acteristic pulpification of the tissue are all points of essential interest. Prognosis. — The prognosis depends entirely npon the extent of tissue-loss and the accessibility of the maggots for the applica- tion of local anthelmintics. Cases earl}^ recognized, of easy access, and properly treated, offer a good outlook. On the other hand, cases recognized late, with extensive and increasing tissue-loss and suppuration, sinuses filled with the larvae and not accessible to treatment, offer an extremely grave prognosis. The possibility of suicide must be borne in mind. Treatment. — The use of chloroform-injections seems to have met universal approval, and to have superseded solutions of tur- pentine, tobacco, and various astringents and anthelmintics. This drug may be used pure or mixed with equal bulk of water, before separation takes place between the two, or even by inhalation. The injection is, however, painful, and a general anesthetic, pref- erably chloroform itself, had better be used before the injection is made. The procedure quickly kills the larvae, after which they should be removed, and the cavities cleansed by hydrogen-peroxid injection ; if ulceration is present, the area should be touched with 3 per cent, chlorid-of-zinc solution for its stimulating effect ; if much irritation is present, it may be relieved by application night and morning of an ointment : I^. Acetanilid, gr. v (.3) ; Salol, gr. iv (.24) ; Menthol, gr. v (.3) ; Unguenti petrolati, Unguenti zinci oxidi, ad 3iv(15.). — M. If, however, the maggots are present in the various sinuses, opera- tive procedures in order to reach and dislodge them must almost invariably be undertaken. CHAPTER XI. NEOPLASMS OF THE RESPIRATORY TRACT. (Classification. Non-malignant : Orif^in. — Blastodermic layer — hypoblastic and epiblastic layers. Kpithelial-tissne type — adult variety (typical, benign). 1. Papilloma. 2. Adenoma. Origin. — Blastodermic layer — mesoblastic layer. Connective-tissue type — adult variety (typical, benign). 1. Angioma. 2. Chondroma (Enchondroma). 3. Exostoses. 4. Fibroma. o. Lipoma. (3. Osteoma. a. Eburnated. h. Cancellated. 7_ Myxoma (Poly])). ((. Myxofibroma. b. Mucocele. c. Cystic. Malignant : Origin.— -Blastoderm lie layer— hypoblastic and epiblastic layers. Elpithelial-tissue type— embryonic variety (atypical, malignant). 1. Carcinoma a. Epithelioma. 1. Squamous-celled. 2. Cylindrical-celled. 3. Tubulated. b. Glandular. 1. Scirrhous. 2. Encepbaloid. Origin. - -Blastodermic laver — mesoblastic layer. Connective-tissue ty] pe— embryonic variety (atypical. , malignant). 1. Sarcoma. a. Ronnd-cclkMl, small and large. h. Spiii(llc-cclU-(l, small and large. c. Mixo(l-ec41c(l. d. Giant or myeloid. e. Alveolar. Mixed tumors. 1. Adenocarc inoma. 2. Myxocarcinoma. 3! Myxosarcoma. 4. Myxotibroma. 5. Teratoma. Cysts. 1. Simple or Retention-cysts. 2. Cystoma. 3. Dermoid cvsts. NEOPLASMS OF THE RESPIRATORY TRACT. 195 It is our purpose to treat the subject of New Growths in a separate chapter, and to include all neoplasms, both benign and malignant, occurring within that portion of the respiratory tract that is within the scope of this work. The classification given above is constructed upon a histologic basis, and is practically that given by the late Professor Gross, as well as that used by J. Bland Sutton in his work on Tumors. Much has been written in regard to the transition of benign growths into malignant in the nares, nasopharynx, and larynx. The simple typical pajnlloma is fre- quently found. This in itself is a non-malignant tumor. It is a well-established clinical fact that slow chronic irritation of such a tumor tends to produce carcinoma, and that trauma may produce sarcoma. There is no histologic reason wdiy this cannot occur. In the locations mentioned, nares or larynx, the irritation is likely to be chronic. By this attrition from the epithelial elements pres- ent, carcinoma may develop, or from trauma, the central portion, composed of connective-tissue elements, sarcoma may originate, there being no change of tissue-type, as the papilloma contains both epithelial and connective tissue. I grant that it is difficult to say whether the tumor was originally a simple papilloma, as a microscopic examination after malignancy develops would not settle the point. In the case reported by Ward of Pittsburg, the tumor when first seen was a simple papilloma, as was shown by the microscope, and yet there later developed at the site of the papilloma a carcinoma, Avhich was also proven by microscopic examination. Frequently, in growths from the upper air-tract, a small portion is snipped off for examination. This is often a source of mistaken diagnosis. Even in malignant growths, the surface-epithelium may be intact, and the section show nothing malignant ; or marked inflammatory changes may be mistaken for malignant connective-tissue growth, as simple inflammatory cells are embryonic connective tissue. Or, again, the surface may be ulcerated, and the tissue removed include the ill-formed embryonic tissue beneath the ulcer, which cannot be distinguished from sar- coma, neither one having fully-formed vessel-walls. I have exam- ined a number of sections in wdiich these errors could easily have oc(;urred. Carcinoma of the upper air-passages is by no means a common occurrence. It may develop primarily, and s])read by the lym- phatics to adjacent structures, or may originate in adjoining struct- ures and s])read to the mucous-membrane surface ; besides, carci- noma usually attacks the more superficial structures. Sarcoma usually originates in the deeper structures and involves the mucous membrane secondarily. Both may tend to ulceration and second- ary changes. We may find in tlie structures of the respiratory tract any growth met with in the other structures of the body. 19G DISEASES OF THE NOSE AND THROAT. PAPILLOMA. Nares. — WIkmi a papilloma is located at the juncture of the skin and mucous membrane, it is usually of the hard variety, and reseinl>les microscopically the skin-wart, consisting of an epithe- lial covering, with central vascular loop and lymphatic supply supported by connective-tissue elements. It is commonlv single, although it may be found multiple ; usually lobulated, being sub- ject to constant irritation from its location, it is likely to be the site of malignant change — a fact equally true of such a growth elsewhere. Papilloma usually occurs in one orifice only. Treatment. — Unless exposed to irritation from location, the tumor being benign, surgical interference is not necessary ; but if subjected to irritation, it should l)e removed at once. If its pres- ence causes obstruction with subsequent catarrhal conditions, or it is associated with reflex irritation, it then becomes surgical and should be excised. This should be done by means of a sharp knife, lacerating the adjacent structure as little as possible. Nasal Cavity. — Papillomata within the nasal cavity occur, according to some writers, quite frecjuently. Hopmann maintains that they are often confused with })olypi. In a polypus with con- siderable fibrous tissue (fibromyxoma), in which from any irrita- tion inflammatory processes take place, the organized inflammatory tissue from contraction would cause the tumor to simulate a papil- loma. Personally, I consider it a rare tumor of the nasal cavity. The common sites for the growth are the inferior turbinate, the lower and anterior portion of the septum, and the lining of the vestibule. It is most commonly of the hard variety, as is usually the case where there is squamous-celled epithelium, nor does it differ materially in microscopic appearance from the skin-wart, except that the epithelial covering is very thin. It is highly vas- cular and tends to ulceration ; it is usually single and small in size. Symptoms. — There is a sense of irritation within the nostrils; often, profuse discharge due to the irritation ; at times there is slight pain. Although the tumor is usually small, it may attain a size sufficient to cause nasal obstruction. Slight bleeding may occur. Through reflex ])henomena asthmatic cough may exist. If much bleeding and ulceration occur, a possibility of malignant change should be taken into consideration. Treatment. — Treatment should consist in complete removal by means of cutting-forceps or the knife. Acids should not be applied. In one ease reported (Dunn) s])ontaneous separation occurred. Nasopharynx. — Papillomata of the naso})harynx are ex- tremely rare, only a few cases having been re])orted. These were of rather a mixed variety, resembling more closely villous papil- lomata, and were situated on the posterior inferior border of the inferior turbinate. NEOPLASMS OF THE RESPIRATORY TRACT. 197 Symptoms. — From the irritation produced by the presence of the tumor, which is practically that of a foreign body, there exists a nasopharyngitis. The growth, depending on size and location, may obstruct nasal breathing, and also occlude the orifice of the Eustachian tube. Constant hacking, with a sense of the presence of some body in the nasopharynx, is present. In the cases reported, on pressure slight bleeding occurred. The growth was rajaid and associated with nasal polypi. Treatment. — The tumor should be excised through the nostril or by the buccal route ; the latter is preferable in large growths. Pharynx. — Any portion of the pharynx may be the site of papilloraata — the common location being the free margins of the pillars, the uvula, or the tonsil. They may be multiple or single, and are usually of the hard variety ; they are often associated with, or rather follow, some inflammatory process. Symptoms. — The symptoms are obvious. Faniham's forceps, showing different forms of blades. Treatment.— Excise by means of cutting-forceps (Fig. 57), tiikiiig cnrc to produce as little trauma as possible. I^arynx. — In the hiryux the ])apill()inata are the most com- mon of ;ill Ixnigii growths. The condition has l)een the subject of consid(Tal)lc discussion. I see no reason, as stated on page 195, 198 DISEASES OF THE NOSE AND THROAT. wliy .such a o-rowth may not exist, and also why, owing to irri- tation either from its location or from "tinkering" by the laryn- gologist's application of irritants (acids, etc.), this benign growtli may not become the site of a malignant tumor (carcinoma), or in the young become the site of sarcoma. When located (m the vocal cords, on removal and microscopic examination, the tumor is often found to have a predominance of connective (fibrous) tissue, raising the question as to its being a true papilloma, as well as lessening the tendency to the development of carcinoma (Fig. 81). The tumor being a fibrous papilloma this is j)robable, as there is no change of tissue-type, and the blending of the two types occurs in other varieties — c. g., fil)ro-adenoma. The different varieties of papilloma reported really depend upon the amount of fibrous tissue found and the extent of involvement of the subepithelial elements. The diffuse form — j)achi/liarynx is that known as the pharyngeal tonsil, which is a conglomerate gland and does not belong strictly to the adenomata, so that pure NEOPLASMS OF THE RESPIRATORY TRACT. 201 adenoma of the nasopharynx does not commonly occur, although its occurrence has been noted. Fauces. — Owing to the histological structure of the soft palate, especially of the posterolateral surface, and owing to the great number of muciparous glands in this lax structure, and also to the fact that it is the common site of an inflammatory process, cystic adenoma may occur in this location. The simple adenoma, however, is rare, the growth usually being in reality an adeno- fibroma (Fig. 61). Its etiology is identical with that of any benign growth which Fig. 61.— Adenofibroma. a. Transverse aud partially oblique sections of acini ; b, fibrous connective t ' is adult in type, and falls short only in function. In adult life it is most common, occurring as late as the fiftieth to sixtieth year. Statistics show that it is more common in females than in males. Symptoms. — Like all benign growths its development is slow, and the symptoms produced are simply due to obstruction — in fact, are identical witli the symptoms of adenoid vegetations in early life. The nasopharyngeal symptoms due to adenomata occurring in this location in adult life would not consist in the same amount of nasal irritation and interference with nasal respira- tion and development as would be shown if occurring in childhood. There arc a sense of fulness in the throat, some interference with deglutition — or rather a continual desire to swallow an imaginary body — occasionally pain, but only when the terminal nerve-fila- ments are involved; and, as a l)enign tumor does not contract, it would ne(!essitate an accom]>anying inflammatory process. From pressure there may be erosion and hemorrhage, Mhich is only slight, as the tumor is not vascular. Patholog-y. — An adenoma is a simple hyperplasia of gland- structure, having its type in the acinous or tubular gland-struet- 202 DISEASES OF THE NOSE AND THROAT. lire. It may become cystic from obstruction of the duct and undergo mucoid degeneration. It is usually sessile in shape. Diagnosis. — Fibroma. Adenoma. Develops rajjidly. Develops slowly. More painful. Less painful. Interference to greater extent with No great amount of interference with function. function. Rare. Common. Earlier decades. Twenty-five to sixty years. Treatment. — If the tumor is of sufficient size to interfere with the normal function of the part, surgical interference should be instituted. As the lesion is not a malignant one, and the removal of the entire growth might necessitate interference with the ana- tomical structure of the .soft palate, only a portion of the tumor should be removed. If the growth is single and encapsulated, it should be carefidly dissected out and removed en masse. If multiple, the same rule should be applied to each individual tumor. I/arynx. — Fn^n the histological structure of the larynx, there is not mucli likelihood of a pure simple adenoma developing there. Consideration of adenoma of the larynx as a purely benign growth necessarily involves the question of malignancy, because it is a well-known fact that tumors of the adult epithelial type — namely, adenoma and papilloma — when located where they will be sub- jected to constant irritation, may become the sites of malignant growth. This question is one which has been discussed by the pathologist, the laryngologist, and the surgeon. Regardless of theories and dogmatic statements, either by the clinician, the laryngologist, or the pathologist, the fact remains that quiescent tumors of the larynx may suddenly develop into rapid and unex- pected malignancy. Wlu>ther it was merely a latent carcinoma, or whether it was a benign tumor, which from irritation became the .site of malignant growth, it matters little, but the clinical fact remains that, regardless of the name applied to the neoplasm, when it occurs within the vestibule of the larynx, its removal as early as possible should be insisted upon. ANGIOMA. Nasal Passage. — Angioma of the nasal passage is of rare occurrence, but, when found, is seen more frequently on the septum than on the turbinal wall. Like the other benign tumors, there is no assignable etiological factor for its existence ; but like all vascu- lar tumors, it seems to consist rather of a distention of the already existing vessels than a new growth of vessels. This distention. Fig. 62.— Angioma of septum. NEOPLASMS OF THE RESPIRATORY TRACT 203 however, differs from that due to congestion or that caused by the circulation itself, for it is brought about by an alteration in the vessel-wall which may be the result of some deficient nutritive proc- ess. Whether or not it be of import from an etiological standpoint, it is clinically true that these vascular tumors are more likely to occur in individuals of a lymphatic temperament. It is impossible to say whether this is due to any peculiar formation of the vessel- wall in these individuals, or whether it is the effect of the low- grade nutrition secondarily affecting the wall ; yet the clinical fact remains. Symptoras. — Because the tumor acts as a foreign body, the main symptom, is that of obstruction, to a degree depending entirely on the location of the growth and its size. There is little, if any, pain. If the obstruction is marked, there will be considerable mucopurulent discharge. Bleeding may occur, and, while in most cases it is only slight, yet in angioma, especially of the septum (Fig. 62), hemorrhage may be considerable. This is especially true if it is located well down toward the nasal orifice. The continued slight loss of blood may eventually produce altera- tion in the patient's general health. Angiomata rarely reach such dimensions as to cause any nasal deformity. The common varie- ties of these growths occurring in the nasal passages are the sim- ple and cavernous. Simple angioma is usually small and rather smooth on the surface, and may or may not be congenital. On microscopic examination the sections will show the vessels thin- walled, held together by fibrous or cellulo-adipose tissue. As a rule, there is a communicating vessel, larger than those found in the tumor-mass, which connects it with an adjacent artery or vein. In the cavernous variety the vessels are much larger, and the tumor is more irregular on the surface. On section the vessels show as irregular sinuses separated by thin fibrous walls. Either variety is more frequently found in early life ; but rarely, if ever, in old age. When involving the nasal mucosa, if its origin be in the subraucosa, it may be apparently encapsulated. This capsule is formed by the tissue which is crowded up ahead of the tumor by the distention. In such cases the growth will be covered with a thin layer of epithelium, and there may be infiltration of small round cells, leukocytes, and proliferation of the fixed connective- tissue cells. Diag-nosis. — The tumor can be reduced largely by pressure. As a rule, it pulsates, especinlly when in communication with an artery. Pulsation is slight if the communication be with a vein. Angiomata bleed easily, and great care should be exercised in examination to prevent hemorrhage. The color necessarily varies, depending on the size of the tumor, its association with vein or artery, or with both. If the growth is connected with an artery alone, it is usually light redj and distinctly pulsates. If the com- 2(J4 DISEASES OF THE NOSE AM) THROAT. immicatioii be with a vein, the tiiiiior will l)c darker in color, l)lu- i.sh-red, and tin; pnlsation will \)c slioht or absent. If, however, the coiuniunication be with both vein and artery — which I believe to be the case in most growths of this character — the tnmor will be dark red. The color of the surface will also be controlled largely by whether the tumor is superficial or more deeply seated. Pi-og-nosis. — The ]>rognosis necessarily depends on the surgical interference, which, if conducted properly, should entirely relieve the patient. Angiomata do not tend to recur. Treatment. — The best plan for removal is to exert pressure slowly on the pedicle of the tumor. This can best be done by the use of the cold-wire snare, employing heavy wirQ and gradually constricting until the pedicle is entirely cut through. This slow process is by far the best method, as rapid removal is always attended by serious hemorrhage. Angioma of the septum occa- sionally appears as a sessile growth. In such formation it will be difficult to retain the snare-wire at the base of the tumor. This difficulty can be overcome by placing the loop in position and, before tightening the snare, transfixing the tumor with a needle, so as to hold the wire in position ; then use the slow method of strangulation. The growth can be removed by silk ligature, passing a number of sutures through the tumor and ligating. The remain- ing stump should be cauterized carefully with 20 per cent, chromic Fig. 63.— Delavan's electrolysis needles, unipolar and bipolar. trichloracetic acid, 1 : 2000, or the galvanocautery. Bipolar elec- trolysis (Fig. (Jo) may prove effective in selected cases. Fauces. — Angioma of the fauces rarely appears in the simple form, but is usually a mixed vari(»ty of tumor. The etiology and pathology of angioma in this locality do not differ from those given for the nares. The common site is the lateral walls of the pharynx. Owing to the vascularity of the ])arts, the vessels of the tumor occurring in this location are likely to be larger, and the tendency to hemorrhage more marked. The only symjjtoms of importance are the feeling of obstruction in the throat — as of an imaginary foreign body — pain on swallowing, and a tendency to hemorrhage. In the removal of an angioma in this location, the galvano- cautery should be used instead of the cold-wire snare, and while NEOPLASMS OF THE RESPIRATORY TRACT. 205 by its use the hemorrhage can better be controlled, yet it must be borne in mind that to the wound there is added trauma— a burn. Great care should be exercised in the removal of an angioma, owing to the tendency to hemorrhage. Pharynx-' and Uvula. — The bundle of veins at the back of the pharynx, known as " Cruveilhier's submucous venous plexus," has been reported as becoming engorged and varicosed to the extent of causing a disagreeable fulness in the throat and an irri- tating cough. It has been our good fortune while preparing this book to see — but once, however, and that but for a short time — an exceedingly interesting case of angioma of the uvula occurring in the service of Dr. Alexander MacCoy, at the Pennsylvania Hospital. The patient, a colored woman, complained of a lump in her throat. On inspec- tion the uvula was found to have been enormously enlarged into a tumor, covered with distended and black veins, extending down into the pharynx. This could be pulled up out of the pharynx with a probe and laid on the tongue. Tonsil. — Angioma varicosa has been reported as occurring in a limited number of cases on the tonsil. The tumor is composed largely of capillary blood-vessels with a thin, but firm, connective- tissue stroma. Slow and careful removal with the cold-wire snare should be the treatment. I^arynx. — Angioma in the larynx is exceedingly rare, but cases have been reported involving the ventricular bands, the epiglottis, the hyoid fossa, and the lingual sinus. When occur- ring in the location mentioned above, the tumor is usually small, of a bright-red color, racemose in appearance, and usually uni- lateral. Treatment. — The only treatment to be instituted is complete removal. This wdll have to be done, if the tumor is small, by the Fig. 64.— Gibb's laryngeal ucraseur. use of the cold-wire snare (Fig. 64). Owing to the location, the slow process will be very difficult. If the tumor is of large size and very vascular, it may necessitate a thyrotomy wdth, possibly, a ju'climinary tracheotomy. 206 DISEASES OF THE NOSE AND THROAT. CHONDROMA (ENCHONDROMA). Nasal Passage. — Wliile some authorities consider chon- droma, cDclioiKlroiun, and eeciiondroses as synonyms, from a patho- logical standpoint the last-named should be classed under inflam- matory thickenings occurring in the septum. As a chondroma is purely a benign tumor of the adult connective-tissue type, it should not be confused with inflammatory processes of any character or in any situation. Pure chondroma of the nasal cavities is rare, but, when found, is usually located at the junction of the cartilaginous* septum with one of the alar cartilages — i c, at the posterior inferior angle of the cartilaginous septum. The tumor is usually small, round, and nodular, is clinically somewhat like fibroma, and micro- scopically contains cai'tilage-cells. It usually occurs early in life, and, like all the benign tumors, has no assignable cause for its existence. It is usually found in one nostril only. Microscopic examination will show hyaline cartilage-cells, poorly formed in places, with areas of cystic degeneration. At various points there may be slight tendency to ossification, which is, in reality, only a deposition of lime salts instead of an attempt at organization of osteoblasts. The base of the tumor will show some fibrous tissue containing capillary-loops. Symptoms. — ^Tiic amount of nasal obstruction Avill depend entirely on the size of the tumor. It is usually sufliciently large, however, to cause partial stenosis, Avhich in turn produces an accumulation of secretion that may become mucopurulent and offensive. The tumor may reach sufficient size to cause external nasal deformity. As a rule, there is no pain except from pressure due to size or location. Owing to the non-vascularity of the tumor, there is no tendency to hemorrhage. Chondroma is of exceedingly slow growtli. Diagnosis. — The tumor is very dense and immobile ; its color is yellowish-wliite or ])ink ; it may be irregular and nodulated — hard, yet slightly springy to the touch. Perforation with a sharp- pointed needle will differentiate the growth from osteoma. Fibroma is usually pediuiculated, yields more to pressure, and usually does not spring from the septum. Prognosis. — The prognosis is good, as regards after-effects, if the tumor has been removed Ijcfore any nasal deformity has taken ])lace. Treatment. — (\^mplete removal can be accomplished by the cold-wire snare, or the author's saw as seen in Fig. 45, or there is no objection to tiie use of the knife, as there is no tendency to gn^it lieniorrhage. Nasopharynx. — Only two cases have been reported of chon- droma occurring in the nasopharynx, and both were in young adults. NEOPLASMS OF THE RESPIRATORY TRACT. 207 I^arynx. — Chondromata of the larynx usually involve the cricoid cartilage, but the thyroid, epiglottic, and arytenoid carti- lages are more rarely the site of the growth. Usually they extend inward, .and are sessile and immovable. They may attain considerable size, causing dyspnceic symptoms. The irregular sur- face of the tumor is, as a rule, covered with a slightly hyper- emic membrane, and the bleeding which occurs is from this structure. The body of the tumor is composed of hyaline carti- lage, except when it arises from the epiglottic cartilage, when it contains more fibrous structure. Some calcification may take place. This, however, occurs in localized areas. Diagnosis. — Chondroma is hard, dense, somewhat lobulated, and exceedingly slow in development. The most common site is the cricoid cartilage. The following table gives the points of dif- ference in the conditions with which chondroma may be confused : Perichondritis. Carcinoma. Chondroma. Usually some assign- None. None. able cause. Any age. Late in life. Usually early in life. Sudden onset. Slow. Slow. Acute local inflamma- Inflammatory symp- No inflammatory con- tion. toms late. ditions, except produced by obstruction. Early tendency to Late, if any. Late, if any. edema. May involve any of the Earelv below the glot- Common site cricoid cartilages. tis. cartilage. Localized. Tends to spread with Localized ; no tendency glandular involvement. to spread. The prognosis is good if the tumor is removed early. Treatment. — Chondromata can, if small, be removed by cauterization or the biting-forceps. If of greater bulk, a thyrot- omy may be necessary to remove the growth successfully. EXOSTOSES. The term exostosis, according to Ziegler, may be applied to either bony or cartilaginous growths. One variety, which springs from cartilage or bone, and which may be partly cartilaginous or entirely bony in structure, is known as a connective-tissue exos- tosis. The other variety, which springs from cartilage alone, is known as a cartilaginous exostosis or ecchondrosis. These growths occur in the nostril, either from the septum or turbinated bones, and are commonly referred to as spurs, crests, ridges, excrescences, or redimdancics. Tlie ])()ny or connective-tissue exostosis may be situated ante- riorly on the cartilage of the septum, or posteriorly on the vomer ; or they may spring from the floor of the nostril, or from 208 DISEASES OF THE NOSE AND THROAT. any of the turbinates, but more commonly the middle. When growing from the turbinate bones, the growth is more in tlie shape of a spur, and may extend entirely across the nasal orifice. Its only pathological significance is the mechanical obstruction to the nasal respiration. An exostosis may spring directly from the bone or from the periosteum, and is always covered with a layer of mucous membrane. The growth in tlie turbinal area is slightly sessile, but not so markedly so as tliose occurring on the vomer or cartilaginous septum. These growtlis, either cartilaginous or bony, may be congenital. They may be the result of malforma- tions or traumatic deformities. Whether inflammatory processes haV'C anything to do with their origin is questionable. I am inclined to think that the existing catarrhal condition, which is always present, is rather tlie result of the growth, than that the growtli is the result of an inflammatory process. The cartilag- inous spur on tlie septum usually appears as a short ridge close to the floor of the nose, at the junction of the cartilage with the bone ; at least it is most frequently situated in the lower third of the septum. At first it may be entirely cartilaginous, but later may become decidedly bony, and in some cases be as firm and dense as the eburnated variety of bone, rendering it almost impossible to use the ordinary nasal saw in its removal. In some cases I question whether this is actually bony formation, or whether it is not more of a calcareous infiltration. If it involves the posterior part of the cartilaginous septum or extends over to the vomer or bony septum, the growth resembles a ridge or fold, the anterior portion being partially cartilaginous, while the posterior part is more bony, but in either case is covered by mucous membrane. Quite frequently this ridge or projection has on the opposite side of the septum a corresponding depression. This fact must not be overlooked before the removal of the spur, else the septum may be permanently weakened or even perforated. Treatment. — First, unless the ridge or spur is so located as to form mechanical ol)struction to nasal respiration, or by its pres- ence cause accumulation of secretion, thereby being a source of irritation, its removal is not necessary, as the resulting scar will be of more injury to the individual than the spur or ridge. If there be associated any peculiar reflex ])henomena without any assign- able cause, the physician is justified in the removal of the ridge as a tentative curative measure. When the spur is to be removed, the mucous membrane should be carefully dissected up from the lower margin of the growth, as shown in Fig. 91, after the tissue has been benumbed by the application of a local anesthetic, ])refer- ably a 6 per cent, solution of cocain. The projecting s])ur may then be removed l)y means of saw, biting-forceps, or the alligator- jaw forceps shown in Figs. 44 and 57. Personally, I prefer to use the saw shown in Fig. 45, which is easily handled ; the cut- NEOPLASMS OF THE RESPIRATORY TRACT. 209 ting surface can easily be controlled, and Avith this instrument the growth can be removed without injury to adjacent structure. Besides being able to control the cutting surface of this saw, it has a double cutting edge, which does not tend to jump — one of the objections to the long nasal saw. The gouge shown in Fig. 71 can be used advantageously in some cases. After the removal of the cartilaginous or bony portion, the flap, which has been dissected up, should drop over the denuded surface. Unless there is severe hemorrhage, the nostril should not be packed, but should be left freely open, and should be douched from four to six times in twenty-four hours with an antiseptic solution. After the flrst twenty-four hours the cleansing solution should not be used more than twice daily, as the irritation will retard healing. For this purpose there should be used hydrogen peroxid 1 part, and cinnamon water 2 parts. If the flap should become infected and slough, and an ulcer form, it should be touched with a 3 per cent, solution of formalin ; or, if this prove very painful, a 1 per cent, formaldehyd solution in 4 per cent, cocain should be used. The surface should then be dusted over with 5 per cent, pyoktanin in stearate of zinc. The majority of cases, owing to the vascularity of the part and the recuperative powers of the mucous membrane, heal promptly, usually in a few days, rarely longer than two weeks. Occasionally, owing to local infection or to blood dys- crasia or latent constitutional condition, it may be almost impossi- ble to promote healing. While this does not often occur, it is well, as in all operations, to acquaint your patient with the fact before operating. FIBROMA. Nasal Passage. — Fibroma involving the nasal cavity may exist as a simple tumor, but, as a rule, it is either in a mixed form or has undergone some degenerative process. As the growth is a connective-tissue tumor, it must necessarily spring from the adult connective-tissue element — that is, tlie submucosa. This tumor demands a high grade of nutrition, and usually springs from a highly vascular area. Its morbid histology is very much the same as simple fibroma in other locations (Fig. 65). The micro- scopic appearance, especially if the tumor be the site of some infianunatory process, may be confused with small spindle-cell sanroma. Fil)romata usually occur early in life — from the fifteenth to the thirtieth year — and are most common in males. When degenci'ative pro(K*sses liave taken place in the tumor, and if the tiunor is sul)iected to much irritation, it may be the site of malig- nant growth. l'^il)roni;ita rarely ever spring from the septum. "^Phc cotumoii site is the j)osterior and inferior margin of the middh' turhiuatc, w hich wouhl necessitate the involvem(>nt of the 210 DISEASES OF THE NOSE AND THROAT. postnasal space. Wlicn located in tlie anterior nares, they usually sprinir from the lower margin of the middle turbinate, or they may be found growing from the anterior portion of the superior turbinate. I saw one case in which the fibroma, which was pedunculated, had its origin in the floor of the nose. The shape of the tumor is controlled somewhat by its location. AVhen occur- ring in the nasopharynx, it is apt to be pear-shaped, although pedunculated. If found in the anterior nares, they are usually not so large and markedly elongated. Early in the development of fibroma there is practically no pain, and it is only when the tumor reaches a large size that there is associated pain, which is I' '4 I Fig. 6.1.— -iiiipli I I caused by pressure on adjacent structure rather than occurring in the tumor proper. There is often considerable epistaxis, which may be not only from the tumor, but also from the adjacent raucous membrane, which has become ulcerated by pressure. The nasal obstruction will necessarily depend on the size of the tumor, which is frequently of sufficient size to obstruct the nasal cavity entirely, and even produce external nasal deformity. There is often associated partial loss of smell, which may be due to direct ])ressure of the tumor, or may be brought about by inflammatory processes due to its presence. There will be lack of nasal reso- nance, giving a peculiar na.^al twang to the voice. The pathology of nasal fibroma is ])racti('ally the same as for the growth else- where, except that it is often liighly vascular and the blood-vessel walls are markedlv thinned. The fibrous network, instead of consisting of bundles of fibers, will show more spindle- or stellate cells, rendering it difficult to difltM-entiate from the small spindle- cell sanroma. Fibroma may be associated with a myxoma, or it may be a simple fibroma which has undergone myxomatous degeneration. NEOPLASMS OF THE RESPIRATORY TRACT. 211 Diagnosis. — As a rule, the application of cocain to any of the benign or malignant growths is an uncertain aid to diagnosis, as hyperplasia is only slightly aifected by this drug. The sense of touch is one of the best diagnostic features. There is a certain amount of springiness and firmness in fibroma, which can be detected by the probe or finger. If the tumor is rather large and extends into the nasopharynx or projects from the nasal orifice, the dependent portion will be rough and feel very much as if the finger were passed over a hard papilloma, or it may resemble dis- tinct papillae, or possibly may be more like shrunken leather. The tumor usually appears singly, but may be multiple. It may be lobulated and nodular. The so-called frog-face, which is possibly more marked in fibroma than in any other form of nasal obstruc- tion, is not pathognomonic, because any obstruction in the nose which causes pressure will obstruct venous return. This in turn will give a swollen appearance to the external portion of the nose and cheeks, and obliterate the labionasal fold, which individualizes facial expression. Prognosis.— The prognosis necessarily depends on the prompt removal of the growth. If this is done before any serious patho- logical alteration in structure has taken place, the outlook is good. Treatment. — Prompt removal by means of the cold- wire snare is possibly the best plan of treatment, although, if the tumor is pedunculated, the pedicle may be firmly grasped by the hemostatic forceps and thoroughly compressed ; the tumor may then be removed by the alligator-jaw forceps (Fig. 44) or the ordinary ^^g^ Fig. 66.— Potter's serrated scissors. saw-scissors (Fig. QQ). The compression, which practically amounts to torsion, would jirevent any marked hemorrhage. Should hemorrhage occur, it can be controlled by douching or spraying the nostril with cold water or by the ice pack. Should the procedure fiiil to control the flow of blood, the nostril at the point of oozing or bleeding may be packed with antiseptic gauze saturated with hydrogen peroxid, which serves a double purpose, acting as an antiseptic as well as coagulating the albumin in the the blood, thereby increasing the tendency to clot-formation. Nasopharynx. — Sinii)le fii)roma may spring from, and be 212 DISEASES OF THE NOSE AND THROAT. l()(!ated purely in, the imsopharvngeal space. Its conamon site of oriii^in is from the basilar process of the occipital bone, a location from Avhich it slowly, but surely, spreads. There seems to be no la^\• controllino; the rate or direction of its growth. It may extend upward, producing displacement of bony structure to such an extent as to demand prompt and thorough surgical interference. On extending downward it may till the naso])haryngeal space, and even involve the pharynx. The symptoms will be controlled by the extent of the growth and the line of involvement. If the tendency is downward, there will be early impairment of the voice-resonance, the sensation as of the presence of a body in the pharynx — causing continuous swallowing — sensitiveness of the surrounding ])arts, and slight tendency to hemorrhage, and the individual will have a gaping a])pearan('e, owing to the necessitated mouth-breathing. If the growth extend upward, the symptoms will be the same as de- scribed for growths occurring in the posterior part of the anterior nares, although there may be more persistent headache and a greater feeling of pressure over the bridge of the nose. When the tumor extends downward, there will be interference with the normal faucial movements ; owing to the obstruction and some partial paralysis from pressure, there w^ill be loss of motion of the soft ])alate and uvula. The morbid histology of the tumor in this location differs from that found in the nasal cavity only in the fact that there are more bundles of fibers and fcAver individual stellate cells. This is possibly due to the fact that in the naso- pharynx and fauces there is more connective tissue present. The diagnosis is practically that given for nasal fibroma. Prognosis. — Fibroma of the nasopharynx is of more serious im])ort than when situated in the anterior nasal chambers, and the prognosis depends on the early and thorough removal of the growth. In early life, owing to the changes in the pedicle, the tumor may have undergone retr(\grade change, ^vhich might be followed by spontaneous cure. Treatment. — Beneficial results have been claimed by many from the injection of certain drugs, such as saturated solution of chlorid of zinc or a few drops of dilute acetic or hydrochloric acid. In my own hands I have not obtained good results from this method. Electrolysis has produced favorable results, using a strong current under general anesthesia. I think a more prom- ising mode of treatment is the introduction of drugs by means of the electric current, known as cataphoresis, although in my own ex])erience I have not had sufficient permanent clinical results to warrant absolute statements. The safest plan for com- plete and satisfactorv cure is to remove the entire mass l)y nu'ans of the cold-wire snare. Tonsil. — .\ few cas(>s have been reported of fibroma of the NE0PLAS31S OF THE RESPIRATORY TRACT. 213 faucial tonsil. As fibroma develops from connective tissue, it must have its origin in the trabeculse of the tonsil. Tumors in this loca- tion are usually of the fibroplastic variety. They are of very slow growth, and the symptoms produced by them are largely mechan- ical, being practically the same as caused by an enlarged or hyper- trophied tonsil. If the tumor should be pedunculated or attain con- siderable size, it may interfere with respiration, owing to its press- ure on the larynx, or owing to interference with the movements of the epiglottis, when dyspnea of an alarming nature might be produced. The question of diagnosis may be determined before operation by the removal of a small portion of the tumor, as the extent of the surgical interference will be determined by its benign or malignant character. The growth can be removed by means of the cold-wire ecraseur, either en masse or piece- meal. If the tumor is not highly vascular, it may be removed by the ordinary tonsillotome. Should tonsillar adhesions exist, they should be broken up before the attemj^t at removal. I/arynx. — Whether irritation has anything to do with benign growths as an etiologic factor, there is much diversity of opinion. Personally, I believe it may be an exciting factor, yet I do not believe that the tumor of itself is of inflammatory origin. The high vascularity and the constant exposure of this portion of the respiratory tract — the larynx — seem to make it a favorite site for benign growths. The constant irritation, I believe, has more to do with malignant neoplasms than with benign. Fibroma of the larynx usually originates in the vocal cord, no special selection as to right or left being noticed. As a rule, the tumor is not of large size, not for any histologic or pathologic reason, but from the fact that its location directs attention to its presence very early in its growth, and its prompt removal thus early prevents further increase in size. Although general consti- tutional conditions or local inflammatory changes may tend to tlie development of fibroma, the fact remains that they are often dis- covered in a larynx which has been previously perfectly normal and hcaltliy. Besides, fibroma in other locations is by no means necessarily associated with inflammatory process, and there is no reason why it should not l)e controlled by the same laws when occurring in the larynx. Symptoms. — One of the first symptoms manifested, especially if occurring above the glottis, is the interference with phonation. riii< may be inspiratory or expiratory, but it gradually liecomes |icnnanent. The tumor acts as a foreign body, and there is fre- (jnciitly associated s])asmodic contraction of the laryngeal muscles. Tlu'rc is usually considerable cough bi'onght about by the constant irritation of the movable foreign body. There maybe sliglit pain, bnt, as a rule, tliis sym])tom is absent. Should ulceration occur, there will be hcniorrlKiuc, but, as the fibroma is one of the well- 214 DISEASES OF THE NOSE AND THROAT. nourished tumors, ulceration is not likely to take place unless pro- duced by friction. Next to the papilloma, the fibroma is the tumor most frequently found in the larynx. It is generally seen in the young or in early adult life, and is very rarely seen in the adult or aged. The mucous membrane covering the tumor — and in this location it usually has a mucous-membrane covering — is highly vascular. Fortunately, the tumor is, as a rule, single, although it Fig. 67.— Sehroetter's improved laryngeal tube-forceps. may be loljulated. Just as unfortunately, it is usually sessile, the pedunculated variety being easily removed. Diagnosis. — By its smooth and vascular surface it may be differentiated from papilloma occurring in this location. At the same time, if the papilloma be smootli or of the fibrous variety, only the microscope can substantiate the diagnosis. Prognosis. — The prognosis is good as to the complete removal Fig. 68.— Laryngeal forcejjs, Mackenzie's lateral cutting-edge. of the tumor, yet its size, its location, and the manner of removal will determine whether there will be any alteration in the voice. Treatment. — On account of the great interference with respira- tion, endolaryngeal operation is usually impossil)le. Tracheotomy should be first performed under eucain anesthesia. The trachea should then be opened above the tube, and gauze packed about the tube to prevent the entrance of blood. The tumor can then be removed by means of the biting-forceps (Figs. 67 and 68) and the curet. Such a case is reported by John W. Farlow of Boston. NEOPLASMS OF THE BESPIRATOBY TRACT. 215 LIPOMA. NareS. — Lipomata involving the anterior nasal cavity consti- tnte an exceedingly rare condition, while their occurrence on the external surface of the nose is by no means uncommon. They are usually situated on the alar portion, and are pendulous masses, usually containing considerable fibrous tissue. They really con- stitute localized elephantiasis. Nasopharynx. — One case has been reported by Bach in which lipoma occurred in the right fossa of Rosenmiiller. There is no histologic reason why lipoma should not occur in any struct- ure containing connective-tissue elements. It must be remembered, however, that fatty degeneration may occur in any benign growth, which might be the source of error in diagnosticating a given tumor, not strictly a lipoma, but ^ome other benign growth, which has undergone fatty degeneration. Pharynx. — Lipoma of the pharynx is of rare occurrence, only one case having been reported, in which the timior had its origin in the left side of the epiglottis and lateral pharyngeal wall. The symptoms produced were mechanical, and were those of a movable foreign body in the pharynx. In the case reported the patient was over eighty years of age. I/arynx. — Only 10 cases of lipoma of the larynx have been reported. Of these 5 were removed during life. Two of the cases Mathieu's throat-forceps. were reported by McBride, 1 by Hohlbreck, 1 by Schroetter, and 1 by Bruns, showing the tumor to be exceedingly rare. In the cases reported, the tumor was situated in the ary epiglottic folds, the sinus pyriformis, the ventrich^ of the larynx, or else- 70.— Coheu's laryngeal where within the laryngeal cavity. The tumor in this locality does not differ in its histology from the ordinary lipoma. It may be single or multipk', and is usually not of large size. It may be 216 DISEASES OF THE NOSE AND THROAT. sessile or pecliuiciilatwl, and is usually covered with a mucous membrane consisting of thickened epithelial layers. There is a tendency for lipoma to recur, which would suggest a possible malignant tendency of the growth. The tumor, which is soft, may be removed by means of the biting-forceps (Fig. 69) or cm-et (Fig. 70). There is a very sliglit tendency to hemorrhage. OSTEOMA. Nares. — Osteonuita of the nasal jiassages may be growths pri- marily from the bony or cartilaginous walls of the nose, or may have their origin in some of the accessory sinuses, and project thence into the nasal cavity. The tumor usually originates high up in the nasal passage ; its shape is largely determined by press- ure from surrounding structures, which is usually considerable — indeed, often of such an extent as to produce marked deformity. Like osteoma in any location, they are of two varieties, eburnated and cancellous. The tumor may have its origin from the juncture of bones or the union of bone \vith cartilage. The proliferation of the osteoblast usually begins in the periosteum. The actual cause of the bony growth is not known. Patholog-y. — While the tumor is divided into the eburnated and cancellous, both varieties of bone are usually present, one or the other predominating. .\.s an osteoma may spring from either cartilage or bono, it is possible that it may have its origin in latent cartilage- or bone-cells. Some are inclined to the theory that minute centers of calcification have to do ^vitIl the origin of the tumor, but this is not in accord with modern pathology, as calcification is a process of infiltration of lime salts and of their deposit watliin tissue. By their presence and from the cause which would lead to their presence, nutrition would naturally be inter- fered with. This would not tend toward new growth, but rather toward degenerative processes. The accessory cavity from which osteomata usually spring is the ethmoid sinus. Osteoma, like all the benign connective-tissue growths, while following its type as to structure, falls short in its physiology. In this tumor, the Haver- sian systems are imperfectly developed. They are irregular in sha])c and sometimes lobulated, but the location of the tumor and the bony resistance offered to its growth largely control its contour. It is usually single. Symptoms. — The early symptoms of osteoma may be those of a sinus-lesion, the nasal symptoms being due to irritation reflected from the site of origin. The pain, wliich will be present early and continue until th(! nerves from pressure cease to transmit sensation, is usually severe. As the tumor is generally situated in the upper portion of the nasal chamber, its presence will rapidly cause a deformity. Owing to the pressure, there will be some NEOPLASMS OF THE RESPIRATORY TRACT. 217 engorgement and congestion externally opposite the greatest point of pressure. The growth may extend upward through the ethmoid cells, invade the orbit, and press on the eyeball. The obstruction to nasal respiration will depend entirely on the size and location of the tumor. As a rule, there is considerable discharge from the nostril, which at times is very offensive ; but this will also depend on the location of the tumor, as to whether by its presence it causes accumulation of secretion. Diagnosis. — The presence of the tumor is easily recognizable, and its bony character can be determined by probe-palpation. As the simple osteoma is usually of slow development, should there be any tendency to rapid growth, the question of a sarcomatous element must be considered. This can be established by the removal of a small portion for microscopic examination. Even this procedure may be a source of error in this variety of tumor, for, if the osteoma is undergoing any sarcomatous change, it will be at the base of the tumor and not at the apex, where the portion for examination would likely be removed. Rhinoliths have no mucous-membrane covering, but may become encysted. Prognosis. — The prognosis is fairly favorable in the majority of cases, owing to the fact that attention is directed to the tumor early in its growth on account of the tendency to deformity as well as the existing pain from pressure. Should the tumor not be removed until serious facial deformity has been produced or until adjacent cavities have been invaded, the prognosis is not so good. Treatment. — If removal is attempted early, it may be done through the nares by means of bone-cutting forceps (Fig. 57), saw Fig. 71.— Schwarze's gouge. (Fig. 45), or gouge (Fig. 71). Yet in the majority of cases, as the tumor originates in the accessory cavities, it will necessitate an external operation for its complete removal. Remnrkf;. — The nasopharynx, pharynx, and larynx seem to he immune to this form of tumor-invasion, as no eases have been reported occurring in these locations. MYXOMA (NASAL POLYPUS). Myxoma is one of the lowest grade of adult connective-tis- sue tumors, having its type in Wharton's jelly and the vitreous humor of the eye. When occurring in tlie U]>])er respiratory tract, especially in tlic nasal passages, some confusion in the nomen- clature as well as the literature on the subject has been brought about by the fact that mucoid and myxomatous degeneration of l)re-existing structure has been confused with an actual neoplasm. 218 DISEASES OF THE NOSE AND THROAT. There is no (|Ue8tion tliat myxomatous degeneration does take place in the nuieous membrane lining the dependent portion of the turbinate bone, especially the middle. That from passive congestion and sui)se(|uent watery infiltration into the connective- tissue spaces, followed by absorption into the actual connective- tissue cells, there is brought about a hydropic degeneration in some cells and myxomatous or gelatinous change in others, giving rise to a polypoid-like growth, is also admitted. The same condition may also l>e brought about by a simple chronic form of inHanmiation. Ktiology. — The myxomata, simple or mixed, are the most common of all nasal tumors. Many theories have been advanced as to their etiology, but personally I believe it to be the same as for any other benign connective-tissue tumor; there is no definite cause known, at least there seems to be no one specific cause. Some maintain that myxoma is due to an inflammatory process, but from my own experience I believe the inflammati(jii and catarrhal con- dition, in a majority of cases, is secondary to the tumor. With the formation of nasal myxoma there is frequently an associated infectious process or lesion of the accessory sinuses. The growths may be associated with necrosis of the ethmoid cells, or may originate in any of the accessory sinuses, and project thence into the nasal cavity. The theory that the tumor is caused by gravity and respiratory suction is a faulty one, as the current of respiratory air exerts as much pressure on the membrane as it does suction, and the result would be nil. Gravity may exert some influence as an etiological factor in producing the pedicle, but is not a factor in the formation of the tumor. That the mucous membrane surrounding the tumor is more or less inflamed and edematous is explained by the fact that the tumor is a foreign body, and necessarily causes a certain amount of accumulation of secretion, w^ith secondary inflamma- tion. Age and sex do not exert any particular influence, although myxoma is more common l)etween the ages of fifteen and thirty. The tumor may be single, but is more commonly found multiple. It is more frequently pedunculated than sessile. The sessile variety is more difficult of removal, and more likely to recur and become the site of a sarcomatous growth. The myxomata may be found in one or both nasal cavities. If the cavities are of unequal size owing to deflected septuui, the tumor will usually be located in the larger nostril ; and should the constriction and narrowing in the smaller nostril be anterior, the grow'ths will be situated poste- riorly behind the obstruction. The pure myxomata are markedly influenced l)v barometric; change, the size of the tumor being greatly increased in damp weather, with the same marked diminution in dry weather. Cold and heat have little or no effect in altering the size of the tumor. The general systemic condition seems to have little influence as a causative factor, yet at the same time the NEOPLASMS OF THE RESPIRATORY TRACT. 219 individual usually manifests some systemic derangement. In rare cases the "individual seems to be in perfect health. It must be remembered, however, that the apparent ill-health associated with the nasal polyp may be entirely due to the interference with nasal respiration, and is in no seuse a causative factor. While myxoma may spring from any part of the nasal cavity, its common site is the middle turbinate bone. The size and shape of the tumor, whether it be pedunculated or sessile, single or multiple, depend largely on its location. The growth may be so large as to project from the nasal orifice. In such cases, the pedicle is usually long and thread-like. I have seen 3 cases in which the polyp was single and sprang from the floor of the nose, with a long thread- like pedicle, which allowed free movement to and fro in the nos- tril. When the turbinated bone is large and shelf-like, the tumor often springs from its under surface — a fact to be remembered when removal of the tumor is attempted. The color of a myxoma is grayish and translucent, and on probe-palpation the growth is springy, giving a sensation of fluid-resistance. The surface is usually smooth and shows distended and clearly outlined blood- vessels. At times the tumors may be irregular, and wave-like Fig. 72— Angiofibromyxoma, slii;htly fibrous (blood-polyp). projections may be seen, as in the papillary edematous p)olypi, \vhich are nothing more than an elongation of the row of epithe- lial cells on the surface, instead of an increase in the number of layers. The growth may spring from any portion of the nasal cavity, from the septal or turbinal side, the floor or the roof, the anterior or the posterior extremities. The size varies from that of a pin-liead to projiortions sufficiently large to include the entire nares or nasopharynx. When originating in the floor of the nose or septum, niy.xoinata are usually single. A\'lien on the middle turbinate or above that structure, either anteriorly or posteriorly. 220 DISEASES OF THE NOSE AND THROAT. they are most coniiiionly multiple. AVhere the growth occurs on the sei)tum, it is usually of the mixed variety, angiofibromyxoma (l)lee(ling polv]) ; Fig. 72). Pathology. — Myxoma may he nothing more than a thin sac of eonneetive tissue witli its epitiielial covering (Fig. 73), contain- ing fluid highly mucoid in character, with peculiar spindle-shaped Pig. 73.— Section of polyp (myxoma) a, epithelial surface shown intact; b, basement membrane; c, polyp-structure. The portion diitctlj uiuierneath the mucous membrane shows more fibrous structure than the body of the polyp, it being simply a network of bipolar cells with line trabeculte of tissue. "The polyp was preserved intact, hardened in formalin, and embedded in paraffin, so that the sections were obtained with practically no change in the contour and structure of the tumor. cells and fine trabecuhe of connective tissue. However, there is in most cases a considerable amount of fibrous connective-tissue stroma present ; indeed, there are few pure myxomata, the major- ity being, in reality, mixed tumors — myxofibromata. This, how- ever, should not prevent their being called myxomata, because for the same reason the adenomata could be excluded, as these tumors always contain fibrous tissue, and are, in reality, adenofibromata. The blood-vessels are clearly outlined in the mucous membrane lining the tumor, although the blood-supply seems to course around the surface of the growth, and rarely ever penetrates the tumor- mass. The same condition holds good for the nerve-filaments, although in some cases these do not seem to be present, as the tumor may be removed without th(^ use of any local anesthetic, and the patient experience im pain whatever. In other cases the presence of nerve-filaments is clearly dcMnonstrated by the excessive pain when the growth is torn free. Symptoms. — The symptoms vary with the size, number, and location of the tumors. The voice lacks nasal resonance, having the i)eculiar nasal twang characteristic of nasal obstruction. There is usually considerable discharge, which may or may not be offensive in character, depending entirely on associated conditions. NEOPLASMS OF THE RESPIRATORY TRACT 221 For example, with ethmoid necrosis the ozena Avill be quite marked. There will be associated considerable irritation of the pharynx and larynx, owing to the fact that the patient will be, of necessity, a mouth -breather. There will also be complaint of dryness of the mouth. The obstruction in the nostril is juarkedly increased in damp weather. If the tumor is high up in the nasal tract, it may obstruct the lacrimal duct and give rise to eye-symptoms. The tumor, either multiple or single, may assume sufficient size to cause marked facial deformity. By its presence the tumor may obstruct the opening into the antrum of Highmore and produce antral complications. Nasal myxoma may give rise to peculiar reflex neuroses, asthma, laryngeal cough, etc. This is especially true of the small single tumor situated high up in the nasal tract. I have seen several cases in which there Avas a marked asthmatic condition, with persistent " non-relievable " cough, which was almost instantly relieved by the removal of small nasal polypi. Owing to the pressure produced by the tumor over the olfactory fissure, there is nearly always impairment of the sense of smell. It must be remembered that a nasal myxoma is, in reality, a foreign body, and that the symptomatology there- fore varies in individual cases, according to the location and size of the growth. Diagnosis. — This can easily be determined by inspection and probe-palpation. The posterior part of the anterior cavity should be carefully inspected, especially in the upper third, as the tumor may be small and easily overlooked. There is frequently found on the inferior border of the superior turbinate, especially if it be one of the long, jjrojecting variety, the so-called polypoid hypertro- FiG. 74.— Shjous' nasal snare. />////, wliicli is iiotliiiig more than :i iiif/roiiKifcns or iiiiicold (Jegener- (tfioii occni-riiiu; in association with, or f(>lh)\\in ^ 1^— ^ -^ Fig. 75.— Jarvis's nasal snare. the Sajous. The nostril should be carefully cleansed after the operation, three or four times daily, with the aqueous solution of hamamelis and cinnamon water in equal parts. It is not neces- sary in all cases to use any stronger solution on the cut surface. However, should the bleeding be severe, it may be controlled by the application of an 8 to 10 per cent, solution of alumnol. After removal of the tumor, should any partially detached portions of tissue remain, they should be removed by the scissors shown in Fig. 6() or 76. Much has been written in regard to the recur- rence of these tumors. In my own e.\])erience I have never seen one of these timiors recur from the site of removal. There is a marked tendency, however, to the formation of a new growth, which I believe in many cases to have previously existed, simply held in abeyance by pressure. In some cases this, however, is not true, and tiiere may f)e no further formation of tumors for months or even years. AVliere this tendency of re-formation exists, nothing more than theoretical explanations can be offered, as the origin NEOPLASMS OF THE RESPIRATORY TRACT. 223 of the tumor is controlled by the same unknown law which governs all benign growths. If the middle turbinated bone be large and shelving and its mucous-membrane covering thickened and boggy, the mucous membrane should be dissected up and the shelving portion of the bone removed. Should any irregularity in the nasal passage exist, it should be corrected, if possible. By these means, possibly, a new supply of growths may be obviated. As to the use of caustics on the affected area, for the base or stump of the original tumor cannot be accurately located, I but mention them to advise against their use. The procedure is irra- tional because the exact spot to be cauterized cannot be located, and a certain amount of healthy mucous membrane is subjected to treatment not only unnecessary, but which might supply sufficient amount of trauma or irritation to stimulate return of the growth or malignant change. Fibrous Nasal Polyp, or Myxofibroma, Fibrous polyp, or myxofibroma, is in reality a myxoma contain- ing a fibrous connective-tissue framework. Ktiology. — The etiology of this gro^vth does not differ from that of the pure myxoma. It most commonly occurs between the . ages of twenty and thirty, and is exceedingly rare in children and in the aged. The earliest age at which I have seen it occur was in a boy of ten years. The right nostril contained two small polypi springing from the middle third of the middle turbinated bone. The fibrous myxoma is more commonly sessile than pedun- 'V "".— MvxfisarrTima. '(, Sarcomntous tissue; h, blood-vessel; r, mvxomatous stniot- nrr, showin- small niiiinl sarcoma cells infiltratins the tissue. itc'nx, though usually in its uj)per portion. In apjiear- ancc they are somewhat translucent, of a pinkish-gray color, with clearly outlined blood-vessels on the surface. Myxomata fre- quently occur in middle life, and whether it be of any etiologic signiticance, it is more or less true they are most often found in persons who throw an unusual amount of strain on the voice by frequent use. This is a separate and distinct condition from what is known as " singers' nodes." There is little tendency to recur- rence after removal. When excessively fibrous they reseml)le papilloma ta very closely, and can be differentiated only by means •of the microscope. Pathology. — The microscopic appearance of myxoma is prac- tically the same as given under Fibromyxoma of the Nares, except that when occurring in the larynx there is more of a fibrous capsule. Symptoms. — The symptoms are practically those of a mov- able foreign body. There may be alteration in the tone and char- acter of the voice, without complete loss. If the tumor is located below the vocal cords and movable, there will be spasmodic inter- ruption in phonation, owing to the fact that, in exhaling, the tumor may be forced up into the vocal bands. Depending on the size of the growth, the breathing may become difficult, even to the point of threatened dyspnea. Tliis symptom may become suffi- ciently alarming to warrant surgical interference by the perform- ance of tracheotomy. There is rarely any pain or hemorrhage, the main symptoms being those of obstruction and alteration in voice. DiagTiosis. — Owing to the extreme sensibility of the parts, due to local irritation produced by the tumor, it may be difficult to obtain a tiiorough laryngoscopic view of the larynx, even after the use of cocain as a local anesthetic. From its appearance and attachment the diagnosis of benign tumor may be made, but its histologic nature must be determined by post-operative microscopic examination. Prognosis. — The prognosis depends on the size and location of the growth ; but, if recognized early, Avith prompt removal, in many cases complete return of the voice may be obtained, or at least the distressing symptoms relieved. Treatment. — The removal of laryngeal tumors is a delicate and difficult ])rocedur(', and should be attempted only by a skilful manipulator. Indeed, more ]>ermanent alteration may be caused by the careless use of cutting instruments than was actually caused by the growth. If the intralaryngeal operation can be done, NEOPLASMS OF THE RESPIRATORY TRACT. 227 there should be used a local anesthetic, preferably cocain, and with the aid of the larj-ngeal mirror and the cutting laryngeal Fig. 78.— Mackenzie's lateral forceps, serrated edge. forceps (Figs. 78 and 79) the tumor may be removed. Under no consideration should the forceps be closed unless the cutting- FiG. 79.— Mackenzie's laryngeal polypus-forceps. blade and its relation to the growth be clearly outlined in the laryngeal mirror. EMBRYONIC EPITHELIAL TUMORS. CARCINOMA. Nasal Passage. — Carcinoma of the nasal passage usually ooctn-s as the variety called squamous-celled epithelioma. It is rare, but when found is usually primary and invades the adjacent structure. It may have its origin at the mucocutaneous junctures, and involve not only the mucous-membrane structures, but extend e.Ntcrnally. The growth usually l)egins as a small nodular infil- trated area, which extends rather ra])id]v and tends to ulcerate caHy. Etiology. — The cause of tumors is largely a matter of theory. The ( ohnhcim inclusion-theory — the one generally accepted — sup- poses that there is an excess of embryonic cells neces.sary to the 228 DISEASES OF THE NOSE AND THE OAT. coiistnictiou of fetal tissue, and that these masses of latent embry- onic cells may be later in life stimulated to active proliferation. Carcinoma in all its varieties belongs to the epithelial type of tissue, and is embryonic. The so-called heredity is merely an inherited tendency, and can only predispose. It is a well-known clinical fict that constant irritation is an exciting factor in carci- noma, "while trauma predisposes to sarcoma. This, at least partially, explains the tendency of benign growths to form the site of malig- nant growths when they are so located as to be subjected to con- stant irritation or trauma. This is not a change of type of tissue, but simply the formation of a suitable site for development. It is also a well-established clinical fact that physiological activity favors the development of sarcoma, while physical decline favors the development of carcinoma. As tissue never changes type, carcinoma must therefore have its origin in the epithelial or papil- lary surface, while sarcoma springs from the deeper or connective- tissue elements. Carcinoma of the nares usually begins in the anterior portion of the nose, which may be explained by the fact that these structures are the most exposed to irritation, although it is often difficult to give the exact location or origin of the tumor. Pathology. — The morbid anatomy or microscopic appearance Avill depend somewhat on the stage or development of the tumor. Occasionally, considerable normal tissue will be found present. This is due to the fact that carcinoma spreads by the lymphatics, thereby spreading irregularly. The real cause of the growth is the proliferation of the embryonic epithelial cells which have invaded the normal structure, and the connective-tissue frame- work of the tumor is nothing more than the altered pre-existing tissue of the parts. The nests of epithelial cells vary in size as well as in the shape of the cell ; indeed, it would be impossible to differentiate an individual cell from an ordinary connective-tissue cell, as the rapidity of growth and the amount of pressure on the cell or the resistance offered to growth will determine its shape and size. The nests of cells are surrounded by connective tissue, Avhich in the early stage of development of the tumor resembles closely the normal connective tissue of the part ; but, as the tumor develops, the connective-tissue stroma will become more fibrous and tiie tumor more firm, more closely resembling the variety known as scirrhous carcinoma. The blood-vessels will be always found in the connective-tissue stroma. Their walls are usually thickened, due rather to the change in the perivascular connective tissue than in the actual vessel-wall. Symptoms. — One of the earliest symptoms of carcinoma of the nose is the peculiarity of the pain, which, although irregularly so, is at times lancinating. While the pain is characteristic, it is not NEOPLASMS OF THE RESPIRATORY TRACT. 229 SO severe or continuous as in carcinoma elsewhere. There is a mucopurulent discharge, which is almost characteristic in color and odor. There is usually some bleeding, although not so exten- sive as in sarcoma. Early in the disease there is not much inter- ference with nasal respiration, although later the obstruction may be marked. Occasionally the growth spreads to the ethmoid and sphenoid cells. When such is the case there is impairment of vision ; the growth may extend and enlarge sufficiently to cause protrusion of the eyeball. In primary carcinoma of the nose there is only slight lymphatic enlargement. When secondary, or associated with general carcinomatosis, there may be general gland- ular involvement. The ulceration is peculiarly deep and ragged, discharging a thin grayish-brown offensive material. With the progress of the growth there is increased cachexia. Diag-nosis. — By inspection and from the clinical history alone, it may be difficult to establish the diagnosis of carcinoma, and it may be necessary to resort to the microscope for confirmation before extensive operative interference. Care should be exercised in the obtaining of this specimen, for two reasons : 1. That there should be as little laceration and irritation of the parts as possi- ble. 2. That the portion removed should not involve directly the ulcerated area, which will contain inflammatory embryonic con- nective tissue. As has been pointed out by J. Bland Sutton, this cannot be differentiated from sarcoma or from a simple inflam- matory process with ulceration. If, hoAvever, the specimen is taken early, before ulceration has occurred, this source of error may be obviated. Sufficient tissue should be removed to permit of a thorough and careful examination. The import of this exam- ination is too great to permit of any error of diagnosis, as the thoroughness of the surgical procedure is entirely controlled by A\!iethcr it reveals malignancy or the opposite. In carcinoma the secretion docs not adhere to the surface of the growth, while in tubercular lesion it is tenacious, stringy, and adheres. Prognosis. — The prognosis is grave. In some cases the extent of the lesion may be such as to render it inoperable, and, unless thorough eradication can be accomplished, it is better to leave the tumor alone, as clinical experience shows that partial or incom- ]>lete removal tends to increase the growth and the dissemination of the tumor rather than to lessen it. Treatment. — The clinical data seem to show that operative procedures shorten rather than prolong life in advanced cases. If, iiowever, the character of the growth is recognized early, prompt and thorough operative interference should be instituted. If the glandular involvement is marked, or if extensive and considerable ulceration has occurred, thorough cleansing with sedatives and palliative measures should be adopted. This should consist in the relief of the pain and the improvement, as far as possible, of tlie 230 DISEASES OF THE NOSE AND THROAT. general condition of the j)citient. Locally, orthoform is a good sedative. Aristol, 20 grains to the onnce of stoarate of zinc, shonld be dnsted on the ulcerated area. The progress may be arrested by the use of acid applications, either the dilute nitric or hydrochloric, applied every other day. Lactic acid, I find, gives no better results. I have obtained quite beneficial results as to arresting the ])i-()cess elsewhere by a 5 per cent, formalin solution. Nasopharynx. — Primary carcinoma of the nasopharynx is a rare condition. When it does occur, most likely there is involve- ment of the soft palate, with extension into the pharyngeal struct- ures ; or the ]irimary growth may be in the anterior nares, and extend In' the lymphatics into the posterior nares. Symptoms. — The tumor is of rather slow development, giving rise to gradual interference with nasal respiration. At first, the pain is slight, gradually becoming more marked and reflected to a greater degree. There will be increased secretion, which, Avhen ulceration occurs. Mill become mucopurulent and blood-stained. The gland-structure of the nasopharynx, the pharynx, and the cervical glands will become secondarily involved. Diagnosis. — Accurate diagnosis from this standpoint of a cura- tive treatment can be made only by a microscopic examination of a portion of the growth. Prognosis. — Carcinoma of the nasopharynx is usually fatal in from one to three years. Treatment. — The treatment consists largely in the attempted amelioration of the distressing symptoms. Radical operation will be determined by the patient's condition, the character of the growth, and the structures involved. Soft Palate. — Carcinoma of the soft palate usually appears in the form of epithelioma, either cylindrical, squamous-celled, or tubulated. When occurring in this location, they usually do not appear before middle life, or, more often, late in life. The ques- tion of the effect of sex is markedly illustrated in carcinoma of the soft palate, as from reported cases it is unquestionably more common in males than in females. This naturally brings up the question of chronic irritation, such as would be produced by overindulgence in smoking or by the continuous chewing of tobacco. This I do not l)elieve to be an exciting factor always, as I have seen several cases in which the individual did not use and never had used tobacco. (Carcinoma of the uvula or soft ])alate has its origin in the muciparous glands found in this tissue. Hence the most common variety is that known as the tubulated epithelioma. In other parts of the body, the tulndatcnl variety of epithelioma occurs earlier in life than the other varieties. This does not seem to be true of the soft palate. Carcinoma of the soft palate is usually primary, and in many cases limited to the soft palate, although NEOPLASMS OB' THE RESPIRATORY TRACT. 231 occasionally, late in the disease, it does extend to the adjacent structures — usually the pillars, both anterior and posterior. Another peculiarity of carcinoma in this location is that on its removal there is an early recurrence. The tendency to spread is soinewhat controlled by the location, or rather the origin of the tumor. If it has its origin in the tonsillar gland-structure, there is a marked tendency to spread by the lymphatics. If, however, it has its origin in the muciparous glands, the tendency to spread is much less. This is due to the fact that the tumor, having its origin in the epithelial lining of the gland or of its duct, the growth will at first be confined within the lumen of the tubule. By the distention thus caused by the cell-proliferation, the lym- phatic system is largely interfered with by pressure, and by the time the embryonic epithelial cell invades the surrounding struct- ure owing to this pressure, the tendency to spread by the lym- phatics is at its minimum. Whether the tumor begins purely as a malignant growth, or whether it be a papilloma which has been the site of a malignant change, does not alter the prognosis or treatment. There is a condition, which is frequently observed on the anterior border of the soft palate, which is known as leuko- plakia buccalis, in Avhich there are minute areas varying in size from a pin-head in diameter to as large as a ten-cent piece. The white areas seem to be brought about by fatty degeneration in the surface-epithelium, which seems to be largely due to local inter- ference with blood-supply. While the condition itself is not car- cinomatous, yet it seems to bear the same relation to carcinoma as Paget's disease of the nipple does to carcinoma of the breast. Although this condition is rarely found on the soft palate, and spots resembling it very much may appear there, associated with diseases of the stomach, yet if the condition persists and there is desquamation, it should always be looked on as suspicious. Symptoms. — The early symptom of carcinoma involving the soft palate is a loss of free movement of the palate. As the tumor advances in size, this becomes more marked and increases the faulty action of the soft palate, permitting the food to regurgitate in the nasopharynx. There is faulty phonation, which is at first largely due to the impaired nasal resonance, but later may be increased by the congestion brought about by interference in the venous circu- lation. The mucous membrane covering the adjacent structures may be slightlv inHamccl, with slight edema of surrounding struct- ures. Should the tumor invade the adjacent tissue and reach a size large enough to ])r<)duce mechanical laryngeal obstruction, the dyspnea produced may be so serious as to necessitate tracheotomy. Th(! ])ain is irregular and usually not severe, unless it is late in the growth and tliere is marked involveuient of adjacent structures. This is possibly due to tlic \ iddiiiL: cIimi'mcI* r of tiiese tissues, there being very little bony resistance. In piimai-y canjinonia involving 232 DISEASES OF THE NOSE AND THROAT. the soft palate, there is no marked tendency to ulcerate. This is possibly due to the (hjuble vascularity of the part and to the fact tiiat carcinoma is usually of the variety known as tubulated epi- thelioma, which is not so liable to ulceration. Should recurrence of the tumor take place, there are usually ulceration and hemorrhage, the recurrent variety, as a rule, being more of the s<'irrhous variety than any of the other forms of epithelioma. With recurrence there is usually marked enlarge- ment of the cervical glands. However, in primary carcinoma such involvement does occur, though not always. The patient gradually assumes the cancerous cachexia. Diagnosis. — The differentiation between carcinoma, papilloma, and adenolibroma can be reliably accomplished only by means of the microscope. Prog-nosis. — In the majority of cases the prognosis is fatal, although operation may prolong life, as recurrence may not take place in from a few months to a year. Treatment. — The result of operative treatment, other than for palliative purposes, seems to be negative. Pharynx. — Carcinoma of the pharynx is rarely ever limited strictly to that structure ; in most cases the adjacent tissues, either the tonsil, the soft palate, or the nasopharyngeal structure, are associated in the involvement. Frequently, carcinoma of the pharynx is associated with that of the esophagus. It usually begins on the posterior walls and follows the course of the lym])hatics, and extends around the lateral and anterior walls. Carcinoma occurring in this location is usually of tlie squa- mous-celled epithelial variety, but the scirrhous variety has been observed. Symptoms. — Early in the growth of the tumor there is little ])aiii, l)ut with ulceration, which comes on rapidly in carcinoma in this lo(;ation, pain will become one of the chief symptoms. This pain is increased on swallowing, especially when taking food, and is of a lancinating, radiating character. Phonation is imper- fect. Expectoration is profuse and, after ulceration, becomes white, fetid, and offensive. If the carcinoma be of the epithelial variety, the growth is soft and spongy in character ; or if of the scirrhous variety, it begins as a hard, irregularly outlined mass. In either form, early in the growth the mucous-membrane surface is fairly normal in appearance ; but with ulceration this is entirely lost. The cervical glands are involved, and in the scirrhous variety this involvement takes place early. If the growth occurs low down in the pharynx and is limited to the posterior surface, it is more often of the fungoid character. It is very irregular in outline, and the surrounding structures are swollen almost to the point of being edematous. In low involvement of the pharynx there is not such marked implication of the cervical glands. NE0PLAS3IS OF THE RESPIRATORY TRACT. 233 Diagnosis. — CARCINOMA. May be limited to pharynx, but likely to in- vade adjacent structure. Sessile. Irregularly firm. Ulceration. Ulcer does not tend to heal. Not aflPected by reme- dial agents. Pain severe. FIBROMA. Limited to pharynx ; no involvement of ad- jacent structure. Pedunculated. Dense and firm. No ulceration. Not affected by reme- dial agents. No pain. SYPHILIS. May be manifestations elsewhere; ulceration may be single or multiple. Indurated. Fairly firm, with sur- rounding areas of inflam- mation. Ulceration. Tends to Leal. Responds to thera- peutic test. Pain on irritation. Prognosis. — Unfortunately grave and fatal. Treatment. — The treatment is largely palliative, as no radical operation can be successfully performed. If the tumor attains sufficient size to interfere with deglutition, a portion may be removed to lessen such interference, but such operative pro- cedure tends to irritate the growth rather than relieve. Tonsil. — Carcinoma of the tonsil is rather a rare lesion. When it does occur, it is generally in the form of the squamous- or cylindrical-cell epithelioma. It is rarely ever a primary growth, usually extending to the tonsil from the tongue or the pillars of the fauces. In epithelioma of the tonsil ulcerations occur, and the cervical glands are involved early. Carcinoma in this loca- tion rarely occurs under forty, but some cases have been re- ported as early as thirty. The tumor is not usually of large size, but tends to involve the adjacent structures rapidly — if primary, of the tonsil, although in the majority of cases the adjacent struct- ures are the first involved. The ulceration which occurs in this variety of carcinoma is accompanied by a characteristic odor that cannot be described, but is recognizable even by the laity. The patient shows the cachexia peculiar to wasting diseases and mal- nutrition. There is excessive secretion, which, as ulceration advances, becomes almost purulent and is highly irritating. The pain is marked, and increased by deglutition. Should the tumor invade deeper structures and involve tlie greater vessels, severe and even fatal hemorrhage may result. With the ])rogress of the tumor the cachexia increases, with a tendency to edema of the glottis. There is marked alteration in the voice. The treatment is the same as given under Sarcoma, and docs not necessitate repetition. I/arynx. — Tliere is a vast difference of o])inion in regard to malignant growths of the larynx, especially in the form of car- cinoma, (^entering on the question of the growth being always primarily malignant. It is a matter that is always open for di.s- cussion, and in many cases can never be settled from a microscopic 234 DISEASES OE THE XOSE AXD THROAT. .standpoint. For example, a carcinoma in any of its varieties may orij^inate in the larynx, showin*,^ a nodnlar papillary snrface, and the clinical diagnosis of papilloma may be made. xVs the tnmor progresses and shows its tnie natnre, it may be clinically stated that it was a pa])illoma which had undergone carcinomatous change. On the other hand, the growth may have been primarily a benign tnmor — papilloma — which, either from the irritation due to attempted removal or from mechanical irritation due to its loca- tion, may be the site of a malignant growth. I do not mean by this that it " turns into a carcinoma," because tissue never changes type, but that, as it is a low grade of adult tissue, it would be a suitable nidus for the development of carcinoma. Personally, I believe that either condition may occur, and the great diversity of opinion is largelv due to the fact that rarely, if ever, is a micro- scopic examination made early in the growth ; and without such examination the cpiestion of secondary change cannot be deter- mined. This was especially true in the famous case of the Emperor Frederick of Germany. That a papilloma may be the site of a carcinomatous growth is illustrated in the case that was reported by Dr. IM. R. \Vard of Pittsburg, in which the primary papilloma was removed, sections made, and microscopic diagnosis Fig. 80.— Section of carcinomatous tissue from laryux : - ures will be involved, and through the communicating lymphatics the glands of the neck will be enlarged, and are usually involved early in the disease. Symptoms. — The syni])toms are necessarily somewhat those of a benign tumor, especially in the early stage of the carcinomatous growth. The early impairment of the voice will depend entirely on the location of the tumor. If the vocal cords and ventricular bands are the primary site of the growth, loss of voice will be one of the earliest symptoms. The alteration in the voice is rather characteristic, consisting in a change in the force rather than alteration in tone and register. .Vs the tumor progresses, there may be marked dyspnea. If the growth is intrinsic, there may be some dysphagia, which will account for the excessive flow and accumulation of secretion in the mouth. There may or may not be glandular involvement. In the extrinsic variety, glandular involvement occurs early. In the intrinsic variety, if at all, it will be late. Ulceration usually takes place in from three to six months, which is rather early when compared with carcinoma in other locations. With the ulceration hemorrhage begins, which NEOPLASMS OF THE RESPIRATORY TRACT. 237 increases with the destructive process. The ulceration is not usually deep, but in some cases there may be involvement of the deeper structures, causing interstitial necrosis. In such cases the ulcer will be deep and irregular. This, however, does not occur except in the encephaloid variety, Avhich is rare in the larynx. Before ulceration occurs, the secretion is excessive, but of a healthy character, caused rather by the presence of the growth than by its effect on circulation. However, after ulceration takes place, the secretion becomes more mucopurulent and tenacious. It may be slightly blood-streaked, grayish or greenish-brown in color, and contains pus-cells and necrotic tissue. The breath is almost char- acteristic, having a peculiarly offensive musty odor. Hemorrhage is usually not severe, although late in the growth, with marked ulceration, it may be of an alarming character. The pain begins early and is usually a constant symptom. When the growth is situated within the larynx, pain is not such an early symptom, nor is it so marked. HoM'cver, if the growth is extrinsic, the pain is lancinating and radiating in character. In the intrinsic variety the cancerous cachexia is slight ; it is more marked in the extrinsic. Diagnosis. — The diagnosis of intralaryngeal growths is by no means easy. In the healthy larynx in some individuals it is very difficult to make a complete and satisfactory examination, while in a diseased larynx it is even more difficult, often requiring the greatest skill in manipulation to obtain even a partial view. How- ever, the location of the tumor, the ulcer, and the gland-involve- ment aid materially in the diagnosis. In some cases a small por- tion of the growth can be removed for microscopic examination. If this is done, care should be taken that the piece of tissue removed does not inckide the ulcerative process, for in such tissue but little can be determined from microscopic examination as to its malignancy. It must also be noted that jDrolifev-ating epithe- lial cells on epithelial S'arface do not mean cancerous growth, but the proliferating epithelium must actually have invaded the con- nective-tissue structure and shoiv jjroliferation there. As a rule, the secretion does not adhere to the tumor, the surface being practi- cally free from secretion, while in tubercular lesion it is tenacious, stringy, and adheres. Prog-nosis. — The prognosis is bad. In a large percentage of the cases in which 0])eration has been done, and in over 10 per cent, of cases in wliich the primary operation alforded relief, recurrence has taken place. Treatment. — Early and radical operative ]'>roce(lurc is the only curative measure that can be attempted, and, as statistics show, this is not at all a certainty. The distressing symptoms caused by the growth may be relieved by anodynes, and the jiarts should be thorouglily cleans;'d by disinfectant solutions. For kee])ing the parts thorouglily clean nothing is better than ^- percent, pyoktanin 238 DISEASES OF THE NOSE AND THROAT. solution, the only disagreeable feature being that it stains blue all tissues with which it conies in contact. A 2 per cent, solution of permanganate of potasii will largely lessen the disagreeable odor. If hydrogen peroxid should be used, the parts must first be cleansed with an alkaline solution, as the hydrogen peroxid will cause coagulation of the material, making it very difficult of removal, especially when associated with the impaired muscular action due to the growth. Palliative results can be obtained by dusting the parts with cocainized iodol (containing 1 per cent. cocain). Equally good results may be obtained by dusting the ulcerated surface with morphin powder, altliough personally I prefer to use th(! drugs in solution, as the powders are more likely to produce irritation and cough. If the pain is very severe the affected area may be sprayed with a 5 to 10 ])er cent, solution of cocain, but this has to be repeated frequently. The hypodermic injection into the mass of the tumor of 1 : 1000 formaldehyd solution, the strength gradually increased to 1 : 500, has at least been bene- ficial in some cases, although the best results seem to be obtained by the rather deep injection of minute quantities around the border of the tumor. The dyspnea may become so marked as to require palliative tracheotomy. Of the radical methods, endolaryngeal operations are least successful. Caustics and escharotics are to be carefully avoided, as they only irritate and do not have any cura- tive properties. The best surgical operation can be chosen from thyrotomy, resection, or complete extirpation (see Laryngectomy, page 611), according to the case. Thyrotomy gives a lower per- centage of successful terminations than either resection, complete extirpation, or Keen's method of partial or complete laryngectomy. In inoperable cases, any palliative measure that will give comfort to the patient is justifiable. EMBRYONIC CONNECTIVE=TISSUE TUMORS. SARCOMA. Nasal Passage. — Primary sarcoma of the nose is not of fre- quent occurrence ; but, as a rule, it has its origin in the adjacent structures, and spreads thence into the nasal cavity. Like carci- noma, it raises the question of transition of benign growths into malignant, and the same rule as given under Carcinoma is appli- cable to sarcoma. Myxoma, which is the lowest grade of benign connective-tissue tumor, from trauma may be the site of sarcom- atous change. This fact does not at all show transition, as sar- coma may develop from a simple inflammatory tissue. Nasal sar- comata are of rather slow development, and may occur at any age and under any condition, although they are more common before forty. NEOPLASMS OF THE RESPIRATORY TRACT 239 Patholog-y. — The tumor has its origin in the deep connective tissue, and spreads to the mucous surface. If the tumor is of rapid growth, it is usually of the small round-celled variety (Fig. 83). However, in this location sarcoma is usually of the large- cell variety and of slow^ growth. The mucous membrane covering nl^^ft^-. %. Fig. 83.— Small round-celled sarcoma, a, Sarcomatous cells held together by intercel- lular material ; 6, blood-vessels. The absence of organized connective-tissue is to be noted, showing the structure to be an entirely new growth, and not an infiltration. the tumor is normal, the tumor usually coming from below. As the growth progresses, the mucous membrane will become thin- ner and the epithelial cells flattened. The tumor contains very little, if any, fibrous tissue, the cells being held together by a fibrinoplastic intercellular substance. Sarcoma is nodulated and fungoid in appearance, usually soft, almost semi-fluctuating, the location and resistance offered to the growth determining its density. Symptoms. — The first symptoms of sarcoma of the nose are those of obstruction. Ulceration, which comes on late together with the vascularity of growth, will result in profuse hemorrhage. Before ulceration there is a discharge of a catarrhal nature, resem- bling that found in any obstruction to nasal breathing. After ulcer- ation the discharge becomes more mucopurulent, blood-stained, and is decidedly offensive in character. Deformity will depend entirely on tlie location of the tumor. The same can be said of the pain. If the tumor involves only the soft structure, the pain is, as a rule, slight ; but if tissues backed up by bony structure are involved, it will be severe. This is especially true when the tumor originates in, or secondarily involves, the accessory sinuses. Diagnosis. — Accurate diagnosis can be made only by the removal of a small portion and by a careful microscopic examina- tion. The tumor is soft and pseudofluctuating, highly vascular, and may affect any of the nasal structures, frequently involving 240 DISEASES OF THE NOSE AND THROAT. the septum. While the microscopic examination is of the greatest import, vet the (finical liistory must be taken into consideration in estal)"lishing a positive diagnosis. ,. . . ^i Prognosis.— As sarcoma is one of the mohgnant tumors, the prognosis is alwavs grave ; although if the nature of the growth is recognized earl'y, and the tumor is promptly removed, the prog- nosis i? better when occurring in this location than in any other portion of the bodv. The early recognition of the tumor, its location and rapiditv of growth, and the age of the individual must be taken into consideration in giving a prognosis. _ Treatment.— Earlv, complete, and thorough eradication is the best plan of treatment'! This can be accomplished by the curet or tlie cnilvanocauterv. If removal is attempted at all, it must be thorough and complete, leaving absolutely none ot the tumor- structure, otherwise the operation will only aggravate the growth. As sarcoma is highlv vascular, there is danger of excessive hem- orrhage, which can be controlled by plngging the nostril with iodoform gauze. If the extent of the lesion is such as to involve adjacent structures, external operation will be^necessary. ■ Nasopharynx.— Etiology.— Sarcoma of the nasopharynx is not of common occurrence. It is found more frequently in males than in females, more often between the ages of forty and fifty than at any other time in life, although it may occur early m life, one case reported occurring at two years of age. The tumor has its oricrin in the submucosa of the mucous membrane lining the bas- ila? process of the occipital bone. The growth, which usually extends downward, is lobulated and irregular, and, as it is usu- ally of tlie small round-celled variety, extends rapidly and soon involves the pharvnx. As a rule, the bony structures are not implicated, although in some cases such involvement does occur. The tumor is soft and fungoid in character and rapidly invades the lower pharynx, although it may extend upward and involve the sphenoid or sphenomaxillary sinuses. Symptoms.— The early symptoms are those most commonly found due to nasal obstruction. The discharge rapidly becomes offensive and bloody. Ulceration and hemorrhage occur early. The o-eneral health is affected, due to interference with nasal respi- ration, as well as to the fact that deglutition is difficult. There is early impairment of hearing, owing to the involvement of the Eustachian oritices. The pain is not usually severe until the tumor has attained a size sufficiently large to cause pressure on adiax^ent structures. It is reflected and radiating _ ■ Diagnosis.— The diagnosis, which is rather difficult in some cases can be based on the rapidity of the growth, its lobulated appearance, its soft (almost pultaceons) feeling, and its high vas- cularity. The removal of a small portion for microscopic exam- ination" will materially aid in the diagnosis. NEOPLASMS OF THE RESPIRATORY TRACT. 241 Course and Prog-nosis. — In early life sarcoma runs a rapid course, as it is usually of the small round-cell variety. If it be of the large-cell variety, it will invade adjacent structure slowly, and the forecast as to prolongation of life is more favorable. The prognosis, however, as to thorough eradication is markedly unfa- vorable. Treatment. — Statistics show that the radical operation gives a high mortality. Besides, should relief be given at the time, there is a marked tendency to recurrence. The treatment is, of necessity then, largely palliative. The patient's general health should be sustained by means of tonics. Arsenic, in the form of the arse- nous acid, pushed to its full physiological effect, seems to exert a favorable influence, but is not curative. Hemorrhage from ulcera- tion may be quite marked and necessitate the use of the galvano- cautery or styptics. Fauces, Pillars, and Soft Palate. — Sarcoma involving these structures is usually of tlie mixed-celled variety, and is con- sequently irregular in its growth. It is slow of development and tends to localize. If the neigliboring tissue is involved, it is late and the involvement is s1om% Owing to the double blood-supply and the lack of pressure, ulceration in these structures is not con- stant. The deeper structures are rarely, if ever, involved, and there is no external manifestation of the growth. Symptoms. — The symptoms are practically those of sarcoma of the nasopharynx, except that the pain is not so marked. There are very little ulceration and hemorrhage. Edema of the sur- rounding parts is often seen. Diagnosis. — The diagnosis can be established by microscopic examinatiiMi associated with the clinical phenomena. In fact, this should be done in every growtli, either malignant or benign. Prognosis. — The prognosis is fairly good. Statistics show recovery in :>0 to oO per cent, of the cases. However, there is a tendency to recurrence, either in the original site of the growth or in the adjacent structures. Treatment. — The treatment should consist in thorough and complete eradication l)y means of curet, knife, or cautery, although this is rarely pcjssible. Hemorrhage is likely to be severe, and may necessitate ligation of some of the larger vessels. Pharynx. — Sarcoma of any variety occurring primarily in tlie pharynx is rare, but, when found, is seen in middle life, usually from thirty-five to fifty. Pathology. — The pathology of sarcoma in this lot^ation does not differ from that o<;curring elsewhere, except that it may assume the variety known as lymphosarcoma. This docs not imply that sarcoma spreads by the lymjihatics, as pathologists have tnutrht us that sarcoma s])reads by the blood-vessels, and carcinoma l)v tlic Ivmpliatics. However, in this location, owing to If. 242 DISEASES OF THE NOSE AND THROAT. the peculiar vaseiiltir supply, the lyiuph-spaces are simply invaded by the sarcomatous cells ; or, in other words, a lymphosarcoma is nothino; more than lymphatic structure, invaded by the sarcom- atous cells in the sanu' manner as any other connective tissue, as was pointed out by Ziegler. Symptoms. — The symptoms are those of mechanical obstruc- tion, together with the constant sensation of a foreign body in the pharynx. There is interference with deglutition, and, if the tumor reaches a considerable size, there will be some dyspnea, especially on lying down. Before ulceration occurs, there is hyper- secretion ; after ulcenvtion begins, the secretion becomes more tenacious, blood-stained, and of a disagreeable odor. The pain is not marked, exce])t on irritation by pressure or by the involve- ment of adjacent structure. Hemorrhage may be marked, but, as a rule, is only slight. There is considerable interference with nasal respiration, and considerable alteration of voice. Edema and congestion of surrounding parts will occur. The cachexia which is present is due possibly rather to the inability of the patient to take food than to the presence of the growth. Diagnosis. — The diagnosis can best be determined by micro- scopic examination of a small portion of the growth. When ulcer- ation is present, the same precautions should be taken here as in any other ulcerating tissue — that is, it should be borne in mind that partially formed embryonic tissue at the base of an ulcer cannot be difterentiated from sarcoma. Prognosis. — The prognosis depends somewhat on the variety ; but it is only a question of time when any form of the growth will result fatally. Treatment. — As sarcoma is sometimes surrounded by a pseudo- capsule, it may be possible in some cases to enucleate the tumor entirely; but in the majority of cases the growth ^vill have pene- trated this false capsule and invaded surrounding structure, and the enucleation, which at the time seemed to be complete, will be followed only by rapid recurrence. Palliative tracheotomy may have to be done if there is much dysjmea. If thorough eradica- tion cannot be accomplished through the mouth, a subhyoid pha- ryngotomy may be the last resort. If the lymphatic structure is extensively involved and the tumor so situated as not to permit of removal, eradication of the main growth will serve only to irritate. The ulceration, which is very disagreeal)le in this location, should be frequently cleansed with hydrogen peroxid and cinnamon water, in equal jiarts. The pain and irritation produced by the raw sur- face can be considerably relieved by allowing the patient to chew pineapple, which has been cut up into small strips, or by using the pre])are(l juice of the pineapple as a gargle or mouth-wash. Tonsil. — Primary sarcoma of tiie tousil is the most common of the malignant growths occurring in the tonsil. It is usually of NEOPLASMS OF THE RESPIRATORY TRACT. 243 the lymphosarcomatous variety. It forms a distinctly prominent tumor, which projects into the fauces, interfering with nasal respi- ration, owing to obstruction of the nasopharynx ; also, from its large size, causing difficult deglutition and interference with pho- nation. It is also, as a rule, highly vascular, tends to ulcerate, and is liable to severe and even fatal hemorrhage. Sarcoma of the tonsil tends to invade the deep structures. It may be of any variety as to cell-formation. In the cases of rapid growth, it is usually the small round cell which is the most malignant variety, the size of the cell not determining the malignancy, but the malig- nancy the size of the cell. Lymphosarcoma is nothing more than a mixed-celled sarcoma. Symptoms. — The symptoms produced by sarcoma of the tonsil are not peculiar to this growth, but similar symptoms may be found in other conditions. There is usually increased secretion, along with a peculiar fetid odor, especially after ulceration, which is almost characteristic and easily recognized by those frequently coming in contact with ulceration in these malignant growths. Often there is pain, which is of a peculiar character, increased on swallowing, and which is reflected to surrounding tissues — to the ear, to the angle of the jaw, and even to the tongue and teeth. Fortunately, the pain begins rather early in the tumor and soon directs atten- tion to the growth. AVith increase in size of the tumor, all the symptoms will be augmented. The difficulty in breathing and the impairment of the voice will become more marked as the size of the tumor increases. If the sarcoma should be of the large- celled variety or lymphosarcoma, the growth is not so rapid and the symptoms are less pronounced. Sarcoma of the tonsil is usually nodular and rather firm, but not hard, the consistency being often fluid or semi-fluid. The tumor contains very little fibrous tissue except as the lymphosarcoma, which will show fine trabeculse of connective tissue. The blood-vessels have ill-formed walls, and in the small round-cell variety they are mere sluice-ways, the walls being composed of the cells of the tumor, the vessels passing directly through the nests of cells. The tumor usually involves only one tonsil. Diagnosis. — Sarcoma ok the Tonsil. Carcinoma of the Tonsil. At almost any age ; usually over Does not occur early in life ; usually fifteen. over forty. (Cases have been reported at thirty years of age. ) Often primary. Rarely ever primary. Plighly vascular ; ulcerates early. Ulcerates late; very little henior- rliage. Cervical i^liuids not involved except Cervical glands involved early, late. May be encapsulated. Not encap.sulatcd. Difierence not noted. More common in males tiian females. 244 DrSIUSES OF THE NOSE AND THROAT. Prog-nosis. — Tlie progiio.^is for .sareoiiuita of the tonsil is bad, as thev are ajit to reeur. Treatment. — Prompt suroical interference should be instituted; and, if the inalit>:naney of tiie growth be early recognized, its com- plete eradication may be effected through the mouth, or from the outside by an incision in tlie neck. Removal throtu/h tlic Mouth. — This may lie accomplished by means of the thermocautery or the galvanocautery. In the early stage the tumor is usually encapsulated, and may be dissected out by means of a scalpel and dry dissector. The entire mass may in some cases be removed by the ordinary tonsillotome. Rtiiiovdl by Incision f/woKfjIi the Xcck. — This consists in an incision extending from along the anterior l)order of the sterno- mastoid muscle, beginning on a line with the base of the ear, and extending to below the level of the tumor. This will necessitate an incision of from 2^ to 4 inches in length. A second incision extends along the lower portion of the inferior maxilla and joins the first incision. The tissues can be carefully dissected down until the tumor is reached and removed. Czerny's method consists in an external incision which extends from the angle of the mouth to the anterior border of the masseter muscle, and thence downward to the level of the hyoid bone. Tliis operation necessitates a preliminary tracheotomy. I/arynx. — Some confusion in the classification of malignant growtlis of the larynx is due to the fact that the word malignant has been used to designate both sarcoma and carcinoma in their different varieties — indeed, the words sarcoma and carcinoma have been used as almost synonymous ; but the fact that sarcoma is an embryonic connective-tissue growth and carcinoma is an embryonic ejyifhelial-tissue growth has enabled a differentiation to be made between the two mtdignant growths, and has cleared up the confusion. Sarcoma of the larynx may occur at any age, though not usu- ally in the very young. The earliest authenticated case reported was at the age of nineteen. There seems to be no definite eti- ological factor prcdisj^osing or exciting. The histology of the tumor is the same as ^vhen found elsewhere, and the growth is con- trolled by the same law that ap])lies to all varieties of sarcoma — the larger the cell the slower the growth ; the smaller the cell the more rapid the growth. The tumor has its origin in the dee})cr struct- ures, and, while the growth may be nodular, it ]M'esents a smooth surface. Although finally involving any ])ortion of the larynx, it is usually located ]3rimarily in the vocal cords, and implicates the ventricle and ventricular bands, and, occasionally, the e]>iglottis. It is usually confined to the structures of the larynx, although this failure to extend is ti-iic of sarcoma in any location that is backed up by bony or cartilaginous \valls. The growth may NEOPLASMS OF THE RESPIRATORY TRACT. 245 involve the entire larynx, or it may be unilateral, anterior or posterior. Symptoms. — There is early impairment of the voice in addi- tion to interference with respiration, which rapidly grows worse with the growth of the tumor. There is an irritating, spasmodic, hacking cough. Before ulceration there is very little change in the secretion. The apparent increase is due to the accumulation of the normal secretion in the mouth, owing to the fact that swal- lowing causes pain. After ulceration begins, the cough increases, the secretion becomes of a more mucopurulent character, is more tenacious, and oifensive in character. Ulceration occurs early, and there is usually considerable hemorrhage, which, however, is more continuous than it is profuse, and is usually not alarming. Sar- coma of the larynx does not, as a rule, attain considerable size, owing to the fact that its interference with respiration causes early recognition. When the tumor is of the small round-cell variety, its growth is very rapid. In sarcoma of the larynx the adjacent structure is rarely, if ever, involved ; but, if occurring in the adjacent structure, the larynx may be involved secondarily. The cachexia which is present in some cases is not due to the tumor so much as it is to the interference with respiration and deglutition. The pain is irregular and intermittent, and, while at times it may be severe, is usually rather a feeling of discomfort than actual pain. Diagnosis. — A positive diagnosis of sarcoma of the larynx is difficult to make. However, much can be done toward a def- inite diagnosis by reinforcing the clinical history by a microscopic examination of a portion of the growth. The obtaining of a specimen from a tumor of this kind is by no means an easy task, and the irritation produced makes it questionable whether the procedure is warranted ; besides, the nature of the growth, whether malignant or benign, sarcoma or carcinoma, demands surgical interference. The prognosis is fatal. Treatment. — Any surgical interference, except complete resec- tion or extirpation of the larynx, serves only as a palliative meas- ure. The form of operation will depend entirely on the size of the growth and the extent of involvement. In most cases, pre- liminary tracheotomy is necessitated. MIXED TUMORS. Adenocarcinoma. — The tumor described under this heading is, in reality, nothing more than a tubuUited epithelioma — whicli is a carcinoma having its origin in ghuid-structin-es — where the ])roliferated epithelial cells iVoin the lining acini or tubuh's invade the surrounding tissues. 246 DISEASES OF THE NOSE AND THROAT. Myxocarcinotna. — 'VUv so-calkd myxocarcinoma is, from a pathological staii«li)()int, really not a ft('j)arate variety of carcinoma. It is a mucoid or myxomatous (lc<>:cncration occurring in any variety of carcinoma. Myxocarcinoma bears the same relation to carcinoma that the term melanotic does to sarcoma, merely expressing the variety of change. Teratoma. — This is a mixed tumor containing hypoblastic, epihlastic. and mesoblastic structure. It is really a congenital tumor. Under this variety we have the dermoid growth, which is more properly considered under Cysts. CYSTS. There seems to be considerable confusion in the classification of cysts, largely due to the different views as to the etiology and pathology of the various forms. Again, the distinction does not seem to l)e made universally between cystic degeneration and a true cyst. By a simple or rdcntlon-cyst is meant that by some inflamma- tory process, either within the duct of the gland or in the surround- ing structure causing pressure on the duct, its lumen is gradually obstructed. This gradual obstruction, interfering with the outflow of secretion, slowly produces a saccular dilatation within the duct. With complete occlusion and by continued secretion the cyst increases in size. Owing to distention and pressure, the epithelial cells lining the obstructed duct will atrophy and be followed by degeneration and desquamation. By its own weight it drags down the loose structure and gradually becomes more pedunculated. This pressure and distention cause thinning of the wall of the cyst. Retention-cyst usually occurs after twenty years of age, more commonly in middle life or in the aged. Ct/stoma has been used by many writers as a genei'al term applied to any variety of cyst, but such pathologists as Hamilton, Ziegler, Cornil, and Ranvier use the term as a])])lying to congen- ital cyst-formation, or to a cystic dilatation not necessarily con- genital occurring within the lymphatics. Dermoid n/sfs develop either from inclusion of a portion of the epiblastic layer within the mesoblast, or from the distention of the cavity of some persistent fetal structure which in the normal proc- ess of development should have been obliterated. The cyst-wall contains hair-follicles and sebaceous glands, while the contents of the (!yst are formed by the secretions from the sebaceous glands within the wall. Although they may occur in almost any part of the body, the (;ommon site is at a point in the embryo where fissures exist, permitting of possible inclusion of a portion of the epiblastic layer dema (Submucous Infiltration). 6. Abscess. (t. Acute. b. Chronic. 7. Depression of Nasal Cartilage. 8. Tumors. o. P^xostoses, Ecchondroses, Spurs, etc. (See Tumors, page 207.) b. Blood-cyst or Hematoma. SEPTUM. The septum of the nose is composed of cartikige and bone. The posterior bony part is formed by the vomer. The anterior or cartilaginous portion, known as the cartihige of the septum, is some- what quadrilateral in form, thicker at its margin than in the cen- ter, and completes the separation between the nasal fossae in front. Its anterior margin, thickest above, is connected from above down- ward with the nasal bones, with the front part of the two upper lateral cartilages, and \vith the inner portion of the two lower lateral cartilages. Its posterior margin is connected ^vith the per- pendicular lamella of the ethmoid ; its inferior margin with the vomer and the palate jiroeesses of tiie superior maxillarv bones (Fig. 3). The cartilages and bones are united by tough fibrous mem- branes — the perichondrium. The mucous membrane lining the interior of the nose is continuous with the skin externally. The cartilaginous framework consists of five pieces — the two upper and two louver lateral cartilages, and the cartilage of the septum (Figs. 3, 4). The upper lateral cartilages are situated below the free margin of the nasal bones ; each is flattened and triangidar in shape. Its anterior margin is thicker than the posterior, and is connected with 24S DISEASES OF THE ANTERIOR NASAL CAVITIES 249 the fibrocartilage of the septum. Its posterior margin is attached to the nasal process of the superior maxillary and nasal bones. Its inferior margin is connected by fibrous tissue with the lower lateral cartilage ; one surface is turned outward^ the other inward toward the nasal cavity. The lower lateral cartilages are two thin flexible plates, situated immediately below the preceding, and bent upon themselves in such a manner as to form the inner and outer walls of each orifice of the nostril. The portion which forms the inner wall, thicker than the rest, is loosely connected with the corresponding part of the opposite cartilage, and forms a small part of the columna. Its outer extremity, free, rounded and projecting, forms, with the thickened integumeut and subjacent tissue, the lobe of the nose. The part that forms the outer wall is curved to correspond with the ala of the nose ; it is oval and flattened, narrow behind, where it is connected with the nasal process of the superior maxilla by a tough fibrous membrane, in which are found three or four small cartilaginous plates (Fig. 4) (sesamoid cartilages) — cartilagines minores. Above, it is connected to the upper lateral cartilage and to the front part of the cartilage of the septum ; below, it is sepa- rated from the margin of the nostril by dense cellular tissue ; and in front it forms, with its fellow, the prominence of the tip of the nose. The arteries of the nose are the lateralis nasi from the facial and the nasal artery of the septum from the superior coronary, which supplies the alse and septum, the sides and dorsum being nourished by the nasal branch of the ophthalmic and infra-orbital. The veins of the nose terminate in the facial and ophthalmic. The nerve-supply is derived from the facial, infra-orbital, infratrochlear, and a filament from the nasal branch of the ophthalmic. The conditions causing nasal obstruction have been admirably arranged by Walsham, and the following table is as arranged by him, wdth some slight modifications and additions. Tabular View of Conditions Causing Nasal Obstruction, a. intranasal. I. Local. — a. /Septal. — 1. Spur and erection of tubercle. 2. Deviation and deflection, or split septum (Fig. sii( , concave; f>, nil flection with overh to risrht nostril ; no ; 4, redundant tissue ..AT curvature; 7, split on opposite side ; 9 and the letter S or scroll-shaped variety, as shown in Fig. 85, 2. It may be limited to the cartilaginous portion or may involve both cartilage and bone, rarely ever involving the bony septum alone. Fig. 85 shows some of the various deflections with and without redundancy. DISEASES OF THE ANTERIOR NASAL CAVITIES. 253 1. Deviation or Deflection from Disease. — Deflection of the septum may be brought about by disease occurring directly in the structure, or as a secondary condition depending entirely upon some constitutional lesion. Inflammatory processes involv- ing the mucous membranes lining the cartilage may so weaken it as to permit of slight deflection. This is especially true in puru- lent rhinitis in children, also in the strumous and the rachitic diatheses. Atrophic rhinitis has been granted by some authors as a possible cause of deflection. It is possible that in the early stage of the inflammatory process the cartilage, owing to its inflamed condition, and possibly to its irregular, uneven development from muscular action of the external nasal muscle, may be slightly deflected. However, I think, as a rule, the deflection existed before the atrophic rhinitis, and was rather an exciting factor than a result of that process. Deviations may also follow, in childhood, upon diseases of the teeth^ especially during first dentition ; and, if early recognized, many cases might be prevented. Superficial ulceration in syphilis, tuberculosis, and lupus, without actual per- foration, may cause deflection and deformity. Simple ulceration, as well as ulceration following diphtheria and typhoid fever, are also exciting factors in deflection. Perichondritis, w'hether asso- ciated with any specific inflammation or not, may result in deflec- tion. Enlarged turbinated bones, by pressure on the septum, w^ith the resulting inflammatory changes, will produce deflection ; the same can be said of tumors. In uric-acid diathesis there is pro- nounced irritation of the mucous membrane, which may result in perichondritis and tend toward deflection. Deviation due to sim- ple abscess of the septum presents a very small scar on the surface, while that due to a specific process will present considerable scar- tissue. Perichondritis, regardless of the cause, may result in the destruction of a portion of the cartilage, leaving the soft parts intact ; yet sufficient of the cartilage is destroyed to give marked deviation and deformity. 2. Traumatic Deflection.— Deviation of the septum from injury occurs most frequently in childhood, although it may not be recognized until adult life. Children are subjected more often to injury of the nose, and at the time little attention maybe given to the injury, which may later result in a serious deflection. Owing to the flexibility of the cartilaginous septum, blows of sufficient force to cause deflection of this structure must necessarily involve the bony septum. Great difficulty may be experienced in determining the cause of tlie deflection ; yet frequently, when the patient is con- scious of the obstruction or irregularity of his nostril, he will state that it followcfl a s(!verc blow on the nose. Such an injury may occur in a child that is not of sufficient age to re(Migniz(' the impor- tance of nasal l)reathing. Through fear of treatment it may say nothingularlv formed teeth, with ]ierfect facial con- tour, while those with im])erfe('t nasal respiration show exactly the opposite. T assert, then, that what is often teruied malformation or congenital deformity is, in reality, develo])niental deformity, 256 DISEASES OF THE NOSE AND THROAT. brought about by imperfect nasal respiration, or iuiperfect and irregular developuieut due to systemic malnutrition or dyscrasia. The worst feature of these developmental deformities is, that unless perfect nasal respiration is estal)lished ear/i/ in life — /. v., before the fifth or sixth year, or not later than the seventh — the bony and cartilaginous framework l)ecomes so firm that little can be done toward increasing the nasal space for breathing, and the individual will of uecessity be a mouth-breather for life. Treatment. — To give a plan of treatment that would be applicable to all cases of deviation and deflection would be impos- sible. Many methods have been advanced, and there are many modifications of the various methods presented, which are in real- ity only some modification of .Vdams's original operation. Yet each individual case, with its own ])eculiarities and variations, demands its own special modification of treatment. AVhile, then, it is im])ossible to enumerate the special forms of treatment, yet certain general rules may be followed. There is a variety of deflection involving only the cartilagi- nous portion, which is very thin and flexible. By inserting the finger into the nostril the septum may be straightened back to the perpendicular. In such cases, it is not necessary to lacerate the tissue by holding it in position with pins or by cutting to weaken it, so that it may be held more readily in position. The })lan which I have found very successful — merely a modification of the pressure- method suggested by (^uehnalz — is tlie use of a flexible or, rather, malleable tube, which is shaped first to fit the deflectiful not to cut through the mucous membrane on the opposite side. This incision in the cartilage may be made by means of DISEASES OF THE ANTERIOR NASAL CAVITIES. 261 the saw shown in Fig. 45, or the knife shown in Fig. 39. After the V-shaped incisions are made, the detached portions of cartilage should be carefnlly dissected off by the dissector shown in Fig. 40, which is a modification of Asch's instrument, although in many cases the detached piece of cartilage can be readily dissected by the use of the finger-nail. The after-treatment should consist in freeing the nostril of any retained secretion, but better results are obtained if the parts are not irritated by repeated douching. Sterile water with 5 to 10 grains of boric acid will render the surface sufficiently clean. Much of the success in straightening the septum by the use of malleable metal tubes depends upon careful attention on the part of the operator. The patient should be seen frequently and the caliber of the tube altered, so as to prevent too long- continued pressure in one place, thereby lessening the danger of ulceration ; for if ulceration occurs from pressure, it will necessitate the removal of the tubes for a time sufficient to allow healing of the ulceration, and possibly cause failure to straighten the septum. The variety of deflection shown in Fig. 85, 8 is fre- quently associated with lesions of the central incisors. This is especially true when the alveolar process of the upper jaw is thin and the tip of the root of the tooth is in close contact with the floor of the nose. The irritation produced by the accumulated secretion beneath the projection on the septum causes ])eri- cementitis, and the method of correction of such deformity of the septum is shown in Fig. 85, 9, 10. Each deflection will require some modification from a given method, and no one operation will answer in all cases. This is shown by the many methods proposed. The conditions presenting, however, will necessitate a combination of methods rather than the following of any one. Of the methods introduced at various times, Ave have Blandin's, in which a punch was used and the septum perforated in front of the deviation ; Roberts's, in which the puncli was also used, but the septum perforated at the point of greatest deflection, and held in position with pins ; Adams's and Roe's methods of crushing with forceps ; Bolton's method of serial incisions of the septum ; the well-known method of Asch, with the triangular flaps supported bylNIayer's tubes; Steele's modifica- tion of Bolton's method, in which the stellate incision is made by forceps devised by Steele for that purpose ; Sajous' punch, which is a modification of Steele's, producing a series of incisions, either linear, curved, or stellate ; and Hope's method, which is only a modification of Steele's or Sajous'. In Ingals's method the incision is made w^ith a knife from the top to the l)ottom of the septum, dissecting up a flap of mucous membrane and resecting elliptical-sluiped ])ieces of cartilage suffi- cient to allow replac(!ment, care being taken not to injure the 262 DISEASES OF THE NOSE AND THROAT. membrane covering tlie otlier side of the septnm. The flap is then tnrned down and stitelied. In Watson's Hap-opcration, instead of destroying the resiliency of the septum, the flap is used to hold it in position. Watson makes a bevel-edge incision through the septum, along the crest of the deviation, the highest edge of the bevel on the side of the dilated nostril. The flap is pushed over this edge, Avhich acts as a stay to hold it in place. Gleason's method, which also preserves the resiliency of the septum and uses the flap to hold it in position, consists in a U- shaped bevel incision at the base of the septum, so as to surround, excepting above, the whole deflected area. He then denudes the convex edge of the flap and concave edge of the base of the septum, and forces the flap through the incision. It is held in place by its elasticity. This operation and the one given on page 260 I consider the best in cases of redundancy. The technic of Gleason's operation is as follows : After cocainizing the tissue, the septum on the ol)structed side is sawn transversely close to, and parallel with, the floor of the nose, until the teeth of the saw have penetrated somewhat deeply into the cartilage or bone. The direction of the sawing is then somewhat rapidly changed, until it becomes nearly vertical. Care- fully retaining the saw in a position parallel to the intermaxillary suture, the sawing is continued until a U-shaped incision has been made through the septum, surrounding, except above, the whole deflected area of the septum. This cut is larger on the convex side of the septum ; the smaller size of the U-shaped cut is on the concave side of the septum. As the result of the sawing, there is pro- duced a buttonhole with bevelled edges through the septum, covered hy a tongue-shajied fla]>. This tongue-shaped flap is thrust through the buttonhole in the sep- tum with the tip of the operator's forefinger, and the parts assume the ,,^ ])osition shown in Fig. 92. The .r tin success of the operation depends afu'r'un''i..ii'!jn(''sii,-i|'M',i'iia|.''iias hem largely upou the carc that is exer- Sum'''''""' ''"■''""""'"'" '"''"" cised'in thrusting the flap com- pletely through the septum. The finger-tip of the op(^rator, (tarrying the lower edge of the flap before it, is thrust through the septum until its further progress is prevented by the outer wall of the formerly unobstructed nostril. The finger- tip is then slightly withdrawn, and is made to feel along the posterior edge of the flap, to assure the operator that the posterior edge of the DISEASES OF THE ANTERIOR NASAL CAVITIES. 263 flap has completely cleared the posterior edge of the buttonhole as far up as the saw-cut has extended. The same maneuver is exe- cuted along the anterior edge of the flap. If the flap consists largely of bone at its upper portion, the bone will be fractured across the neck or upper portion of the flap, and will give way with an audible snap. Under such circumstances the resiliency of the flap is destroyed, and there is no tendency for it to pass back again through the buttonhole, assume its former position in the formerly obstructed naris, and reproduce the original condition. If, however, the neck of the flap is not fractured during the manipulations for clearing the anterior and posterior edges of the flap from the buttonhole, an effort should be made to fracture the neck of the flap by pressing the finger-tip firmly against it from below upward, the neck of the flap being by this means bent nearly to a right angle. Nevertheless, if the neck of the flap con- sist entirely of cartilage, as is sometimes the case in young sub- jects, where the deflection involves only the most anterior part of the septum, the cartilage will not be fractured, nor will its resili- ency be greatly lessened. Only under such circumstances is sup- port needed during the healing process. As a means of support after the operation, the nasal tube described in Fig. 86, or the Harrison Allen nasal tube, may be used. This tube is intended for support only, and should exert no pressure whatever. When a tube is required, it is best to allow it to remain in position for the first forty-eight hours after the operation, spraying an alkaline solution through it, in order to keep it free from mucus. After the first forty-eight hours the tube should be removed, in order to cleanse it, as well as the nos- tril, daily, and the condition of the septum should be inspected. At the end of a week or ten days the patient can ordinarily remove the tube from his nose and replace it. It will, however, probably be safest for him to wear the tube constantly for a week or ten days, except when it is being cleansed, and for half an hour each day for about a month longer, at the end of which time any danger of the septum returning even partly into its old position will have entirely disapi)eared. 2. Synechia. — A synechia is usually a bony, cartilaginous, or fibrous l)and extending from the septum to the lateral nasal wall. Although this is the common site of the synechia, yet a similar union may exist between the turbinals, and is as true a synechia as if attached to the septum. Synechia may be divided into congenital and acquired. Congenital. — It is difficult to establish the etiological fact underlying a congenital synechia, but when observed in the very young we are warranted in (classifying it as congenital, especially if it be cartilaginous or bony in character. The common site of 264 DISEASES OF THE NOSE AND THROAT. adhesion is between the middle turbinate (Fig. 93) and the septum, although it may occur in any location. Acquired. — In the ac(iuircd variety, the condition requisite to the formation of synechia is desquamation or ulceration involving both septal and turbinal walls. While usually the ulcerative sur- FiG. 93.— Vertical section, looking backward, showing redundancy of the septum on the right side, with false union (synechia) between it and the adjoining turbinate. Punct- ure of the right antrum through the alveolar route would fail, and entrance would be made into the enlarged nasal cavity (after Cryer). faces come in direct contact, permitting of adhesion, yet it is possible to have a fibrous adhesion due to the building up of the plastic material from the ulcerated surfaces, until separated portions are brought together. As this band is of inHammatory origin in its early organization, the two surfaces will be very close together ; but as contraction occurs, and such contraction always does take place in inflammatory organized tissue, the septal and turbinal walls are still further separated, and the junction becomes more band-like. The ulceration necessary to form a synechia may be brought about in a number of ways — irritation from foreign bodies, in simple chronic and hyperplastic rhinitis, in which from pressure ulcerative processes occur, or from surgical interference for the removal of nasal obstruction, or following the a]iplication of the thermocantery or escharotics. Owing to the obstruction to nasal breathing in either the congenital or ac<|uired synechia, there may be brought about inflammatory processes in the nasal mucous membrane of the obstructed nostril, which, in turn, from the interference with DISEASES OF THE ANTERIOR NASAL CAVITIES. 265 respiration and the accumulation of secretion, may involve the nasopharynx and pharynx. Treatment. — As this condition always interferes with nasal respiration, its prompt removal is necessitated. This should be accomplished with as little injury as possible to the healthy struct- ure surrounding the attachments. If the synechia be of bony formation, its removal can be accomplished by means of the nasal saw seen in Fig. 45. Care should be taken to remove a little tissue below the surface of the points of attachment of the synechia, thus farther separating the inflamed surfaces and preventing sub- sequent union due to inflammatory reaction. The nostril should be loosely packed with absorbent cotton, saturated with hydrogen peroxid, repeatedly changed. Thorough cleansing with a saturated solution of boric acid should be insisted upon. Should any exuberant granulations occur at the point of removal, these should be touched with 20 per cent, chromic-acid solution ; or, if they are only slight, a 3 per cent, chlorid-of-zinc or 5 per cent, formalin solution will suffice. The patient should be seen until complete healing has occurred, otherwise the synechia will re-form. 3. COLLAPSE OF NASAL AL/E. Collapse of the nasal alse or narrowing of the nostril may be brought about by faulty formation of the lateral cartilages, or may be due to the fact that in early childhood there was inter- ference with nasal respiration as well as inability of the child to breathe through the nose, aud the orifice remained undilated from lack of use. Also, from non-use the dilators of the nasal alse lose their tone and the nostrils collapse. Again, from the contour of a long, pointed nose with a long, narrow, slit-like nasal orifice, there may be a tucking-in and narrowing of the nasal orifice, due to the action of the constrictor muscles. This collapse or narroM^- ing of the nasal orifice brings about, through forced mouth-breath- ing, a variety of diseases of the pharynx and larynx. While there may be subsequent nasal inflanmiatory conditions, yet from the forced mouth-breatliing, through inability to breathe through the nose, the symptoms will draw attention to the pharynx and larynx rather than to the nose. For the relief of this collapse or narrowing I have had satis- factory results from the use of a short, perforated silver tube, made for each individual case. The tube can be fitted withiu the nostril, and sliouhl uot reach up as far as the bony septmu. The patient is instructed to wear the tube irom twelve to fifteen hours out of the twentv-fi>ur, or at night only. If tliis be ]iersisted in for sev(!ral months, much will l)e done toward relieving the col- lapse. From time to time the diameter of the tube can be increased to exert slight pressure. After a few weeks the patient 266 DISEASES OF THE NOSE AND THROAT. becomes accustomed to wearing the tube, and in several instances I found that it had been worn, contrary to instructions, during the entire twentv-four hours, only removing it long enough for cleans- ing. As a rule, the patient complains more of the obstruction at night than during the day. This is possibly due to the venous and lymphatic stasis while in a recumbent position. In such cases it is better to have the tube worn at night only. This same method will, if persisted in, often relieve the obstruction caused by the tucking-in of the oritice, due to the contraction of the constrictor muscles. 4. ULCERATION AND PERFORATION (CARIES AND NECROSIS). Ulceration. — Ulceration and perforation of the septum are closely allied processes. True, there may be ulceration that does not go on to perforation, and perforation may exist without pre- existing ulceration ; but, excluding congenital defects or trauma, perforations are preceded by ulceration. As an exciting factor in ulceration, irritation may come from without in the form of dust, as in occupation-rhinitis, or in any mechanical irritation. Again, ulceration may be due to vascular changes brought about by irri- tating material floating in the blood, as occurs in the uric-acid diathesis. Besides these irritants, systemic conditions which tend to passive congestion may, by the alteration in circulation, pro- duce a similar condition. Ulceration is not only due to the inter- ference with blood-supply, but, owing to the vascular change and passive congestion, there is a certain amount of itching and irri- tation within the nose, which gives rise to constant desire to pick at the septum. Deflections of the septum, especially the acute angular deflections, are liable to ulceration in their concave por- tion. This is due to the fact that the l)lood-supply is poorer at that point, owing to pressure, and also that at that, the dependent portion, there is marked irritation, owing to the accumulation of foreign material. In any interference with intestinal circulation, the nasal mucosa has a marked tendency to engorgement, with subsequent irritation and inclination to pick the nostril. This is especially marked in children, and is exemplified in children in whom the irritation is due to intestinal worms. The constant picking of the nose, with the subsequent abrasion followed by infection from the finger-nails, will lead to ulceration. One patient seen at my clinic at the Jefferson Medical College Hospital, a boy seven years of age, had ulceration of the septum, which had gone on to perforation, in which there was a distinct history of intestinal worms and constant picking of the nose. While it may be difficult to explain some of the reflex causes of nasal irritation with ulceration, yet the fact remains unques- tioned. Moreover, ulceration may be brought about by foreign DISEASES OF THE ANTERIOR NASAL CA VITIES. 267 bodies or by pressure from intranasal growths, and may also be associated with chronic inflammatory processes involving the nasal mucosa. Again, nasal ulceration may be brought about by lesions of the cartilage, or a perichondritis which may be the result of some acute infectious fever or specific inflammatory process. In such cases the ulceration is a secondary process. The necrosis begins in the deep structures and ulcerates to the surface, although the common variety of ulcer of the septum begins by an abrasion of the mucous surface, followed by infection and gradual invasion of deeper structure, extending from without inward. In any cachexia or condition in which systemic nutrition is poor, there is a marked tendency to ulceration of the mucous membrane. Owing to the poor blood-supply of cartilage, this ulceration is quite likely to occur in the mucous membrane lining the septum. In the atrophic form of rhinitis, in which there is accumulated secretion within the nostrils, the irritation produced by it often leads to picking of the nose; and by undue violence in this way ulcera- tion may be produced, although it is rare. Syphilitic ulceration is usually associated with syphilitic necrosis of the bone. Expos- ure to excessive heat or cold, causing sudden and rapid changes in circulation, may produce ulceration. The same is true of irri- tating fumes or vapors. Ulceration may follow the application of the actual cautery or the use of escharotics. Certain forms of ulceration, after irritation has been produced, are unquestionably influenced by bacteria. In the majority of cases, the bacterial infection and the part it plays in the progress of the ulceration are secondary. One patient coming under my observation, who has a simple chronic ulcer of the septum, says that if he is exposed to ery- sipelas, he always develops an attack of facial erysipelas. The so-called trophoneurotic ulcer is usually associated with systemic conditions or localized hemorrhagic areas. Ulceration is likely to occur in any age of life. In the very young and very old, how- ever, it is not so common. When occurring in the very young or in infants, it is always suggestive of congenital syphilis. Site. — The ulceration usually occurs in the mucous membrane overlying the cartilaginous septum, although from specific or infec- tious processes, that lining the bony septum will also be involved. As a rule, the ulcerative process is located in the upper two-thirds of the se])tum, although its position will depend upon the cause — whether it be due to external irritation or to circulatory interfer- ence. The conunon site for a simple, non-infectious ulcer, seen in individuals w ho i'n'(|ucntly blow or pick the nose, is just within the nostril ; it, iu rcaliiy, begins as a traumatic ulcer. Its size varies from a mere pin-head to the involvement of almost the entire mucous-nK'inl)iaiic siirliice. The ul(;er usually iinadcs one nostril only, and when occiiri'iiig in both nostrils is not symmetrical as to location. The dischar: ulcer has been described by Hajek, which seems to be identical with "perforating ulcer" occurring in any other structure. This particular ulcer is not associated with any specific inflammatory process. Often the patient is not aware of a perforation until it is dis- covered by the physician. Perforation may be associated with other nasal conditions, either as a complication or as an allied proc- ess. The shape and size of the opening in the septum de])end largely on its cause and location. When involving the cartilagi- nous portion of the septum, the perforation is usually round or oval. If, however, the bony portion is involved, it is usually very irreg- ular in shape ; altliough perforation of the bony portion, except- ing extensive syphilitic necrosis, is indeed rare, the cartilaginous part alone being usually involved. The perforation is usually single, although rare cases are reported in which there were sev- eral small holes through the septum. The lesion may occur in any portion of the cartilaginous septum. Fig. 94 shows a per- Fic. 91.— riceratiou and i)erfi)nitioii of tht; c-artilagiuous septum. foration on tlic center of the triangular cartilage. My own obser- vations show that the perforation most often occurs in individuals with the narrow, slit-like nasal cavity. Congenital defect of the septum is usually recognizable by the absence of any evidences of inflammation and by the fact that BISEASES OF THE ANTERIOR NASAL CAVITIES. 271 malformation and irregularity in the other facial bones are usually associated. Abscess of the septum, if allowed to rupture spon- taneously, is liable to lead to necrosis of the cartilage, with per- foration. The perforation due to the specific inflammations usually begins at the junction of the bone and cartilage, and shows a ten- dency to spread and invade continuous and contiguous structures. The simple ulcerations are usually limited to the cartilaginous structure, and are definitely outlined. Perforation may occur as the result of malignant growth, especially carcinoma. The vari- ous forms of rhinitis are believed to be causative factors in per- foration ; but I think that in the majority of cases the variety of rhinitis with which the perforation is associated is one which is brought about by irritants introduced from without, and the same irritant which produced the rhinitis is the exciting factor of the ulceration and perforation. The causes of nasal perforation may be grouped under the following general headings : 1. Perforation due to faulty development. 2. Perforation due to localized inflammatory processes. 3. Perforation due to injury. 4. Perforation as a local manifestation of a systemic condition seen in the specific inflammations, the infectious fevers, and rheu- matism. Sex. — Statistics on the subject show that sex has very little to do with the condition. Occupation, nasal deformity, and systemic conditions are the important factors. Ag-e. — Perforation in the very young is of rare occurrence, the youngest case coming under my own observation — referred to under Nasal Ulceration — was seven years of age. The most common age is between twenty and forty, although perforation may occur at almost any age. As a rule, the ulceration which leads to perfo- ration begins on one side. This is true if it begins as an ulceration of the mucous membrane, finally involving the cartilage, which is always unilateral, as it is not likely that a point of ulceration directly opposite, on the other side of the septum, would occur at the same time. When breaking down occurs on both sides, it is that variety of perforation which is due to the primary involve- ment of tlie cartilage (necrosis) brought about by systemic infection, as in the specific inflammatory diseases or the infectious fevers. Patholog-y. — The pathological alterations which will cause perforation of the septum through necrosis do not differ from necrosis of tissue elsewhere. It may result from ulceration that spreads by continuity and contiguity of structure, necessarily pro- duced l)y the localized, limited blood-supply. The necrosis follow- ing this cutting off of blood-supply may or may not be due to infection. Although there is no one cause of nasal perforation, and although various causes may effect perforation with different degrees of rapidity, whether infected or non-infected, the ulcera- 272 DISEASES OF THE NOSE AND THROAT. tive process, with liquefaction-necrosis and sloughing, is practically the same. Symptoms. — There are no special symptoms peculiar to per- foration, and it is often accidentally discovered during routine nasal examination. If, however, there is beginning deformity, this may call attention to the perforation. Once the perforation has occurred, very little can be done toward closing the opening, and treatment should be directed toward the prevention of further destruction of tissue by ulceration. Treatment. — In individuals subjected to irritants from with- out, in which ulceration is still associated with the perforation, the first efforts for their relief should be directed toward removal from such exposure. If, however, necessity compels their exposure, much can be done toward preventing further ulceration and also toward adding to their comfort, by prot(;cting the nostril with a small piece of sponge and by the repeated cleansing of the nose with a warm alkaline solution. There is nothing better for this purpose than tepid milk, to which has been added 2 or 3 grains of common salt to the ounce. Where the ulceration still continues at various points in the margin of the perforation, the area should be carefully cleansed and tlie perforation filled with a pledget of cotton saturated with carbolizecl vaselin, to which is added benzoic acid, 2 to 5 grains to the ounce. If there is much bleeding, astringents are indicated. Should they be necessary, cocain should be first applied, and the margins touched with the acid nitrate of mercury. When this drug is used, it should be followed by an ointment of carbolized vaselin to which has been added 3 to 5 grains of the yellow oxid of mercury to the ounce. In perfora- tion due to syphilitic origin, resort to the constitutional treatment is imperative. As a rule, the perforation occurs in the tertiary stage, and the iodid of potassium alone is indicated. This should be pushed to its full physiological effect, regardless of dosage. Perforation due to tubercular infection does not tend to heal, and gradually invades continuous structures. Treatment should be directed toward the thorough cleansing of the parts. If the proc- ess be purely a local one, or lupoid in character, thorough cauter- ization may eradicate the infected tissue. As a rule, however, it is associated with a systemic process, and radical measures serve only to open u]) the lymphatics for further diffusion of the infec- tion. Pyoktanin seems to exert as fiivoral)le an influence over this variety of ulceration as any drug. It may be applied in a 10 to 20 ])er cent, solution, or in powdered form, 10 to 20 grains of pyoktanin to the ounce of stearate of zinc. Equally good results may be obtained by the dusting on of pure aristol, or aristol and stearate of zinc in equal parts. The surface should be carefully mopped and dried before the jjowder is applied. In the non-infected varieties of perforation I have obtained DISEASES OF THE ANTERIOR NASAL CAVITIES. 273 good results from the application of liquid papoid, also the glyc- erinated extract of suprarenal capsule. These solutions should be applied daily, and, if beneficial, will usually stop the contin- uance of ulceration in from 4 to 6 applications. 5. EDEMA (SUBMUCOUS INFILTRATION). Edema in any portion of the mucous membrane of the septum may occur at any age. It may be due to external irritants sud- denly applied — for example, inhalations of irritating fumes, such as iodin, bromin, etc., or of hot vapors ; it may follow injuries not sufficient to fracture the cartilage or bone, and is also associated with perichondritis, there being marked edema over the area of inflammation. This is especially true in the specific inflammatory processes, or when the cartilage is involved after typhoid fever or other infectious fevers. The edema may be limited to one side of the septum, or both sides may be involved, more frequently the latter. Edema may also follow injuries involving the bony framework or operations on the septum. It may be associated with diseases of the teeth, or the inflammatory process may spread upward by contiguity of structure from the floor of the nose. It frequently follows the application of the galvanic cautery or escharotics. The edema will often disappear by absorption and require no treatment whatever. But if severe and obstructive, it may be relieved by puncture or scarification, or by the application of 40 per cent, ichthyol in lanolin, or the application of 3 per cent. chlorid of zinc, or sulphocarbolate of zinc, 10 grains to the ounce. The best method of treatment is puncture or scarification, which should be followed by the application of a 3 per cent, formalin solution, or, if this is painful, by the application of ylg- of 1 per cent, formaldehyd solution, to each ounce of which is added 24 grains of cocain. 6. ABSCESS. Acute Abscess. ^Etiology. — Acute abscess of the septum may be the result of trauma, either direct or following efl'usion of blood into the tissue as the result of a blow. It may follow the infectious fevers, such as measles, scarlet fever, or typhoid fever. When due to injury, there is usually some external manifestation which gives a clue to its cause. There may be injury of the bony structure as well as of the cartilaginous portion. Abscess of the septum may also form in erysipelas, or may be associated with uric-acid, gouty, or rheumatic diathesis, which possibly explains some of the cases of acute abscess-formation from tlie so-called acute idiopathic perichondritis. Acute abscess of the septum may 274 DISEASES OF THE NOSE AND THROAT. follow sudden acute inflammations of the nasal mucous membrane, as in acute coryza. It may be associated with purulent rhinitis in children, may occur in the scrofulous or rachitic diathesis, or may also be due to disease of the teeth, in which the infection reaches the septum by contiguity of structure. This is especially true of individuals with ill-formed superior maxillary bones, giv- ing a Hat and narrow arch. Pathology. — The pathology of abscess of the septum is iden- tical with the pathology of abscess-formation in any other struct- ure. The cartilage is usually separated and the cavity formed between the two layers. There is a tendency to bulging or to spreading to the tip of the nose, which is the line of least resistance. There are present all the phenomena of acute inflammation going on to rapid termination, which in abscess-formation results as liquefaction-necrosis due to infection by the pus micro-organisms. Symptoms. — If due to trauma, there will be evidence of external injury, supported by the history. The mucous membrane on both sides of the septum will be intensely swollen and edema- tous, even to the extent of occluding both nostrils, but, as a rule, more marked on one side. The nose is swollen externally, red and inflamed. There is intense headache in the nasofrontal region ; the eyes are injected and the lids puflFy. The pain in the nose is intense and of a throbbing, lancinating character, difficult to con- trol even with anodynes. There is general malaise, and often an associated rise of temperature. Usually, in from twenty-four to forty-eight hours, the swelling shows distinct pointing ; the dis- coloration becomes more marked and the pain less severe. The entire fiice may be swollen or the upper lip alone involved. The nose is excessively sensitive to the touch. As the abscess-forma- tion progresses, there will be noticed fluctuation on pressure, the cartilage distinctly yielding at its dependent portion. Diagnosis. — The diagnosis of acute abscess of the septum is, as a rule, clear ; the only condition permitting of confusion would be acute edema of the septum. This condition resembles acute abscess from a standpoint of swelling alone, with all the other symptoms less marked. Prognosis. — The prognosis of acute abscess of the septum is good, although in some cases, when the abscess is allowed to progress until spontaneous rupture occurs, there may be result- ing deformity or perforation ; but if the condition is recognized early nnd free incision made, the prognosis is good. Treatment. — The treatment consists in early and free inci- sion of the cartilage from one side only. This incision should be made through the cartilage low down on tlie septum, so as to insure free drainage from the dejiendent portion of the abscess. There is a tendency of the cartilage to close after the incision, thereby interfering with drainage. This may be obviated by DISEASES OF THE ANTERIOR NASAL CAVITIES. 'lib placing in the opening a small piece of gauze, or, if the cut be made obliquely to the perpendicular septum, this tendency to close can be markedly lessened. After the opening of the abscess, the cavity should be carefully washed out, first with an antiseptic alkaline solution, such as boric acid, or carbolic acid and water, followed by hydrogen peroxid and cinnamon water in equal parts. The cavity should then be flushed out with a 1 : 500 aqueous pyoktanin solution, the only objection to this being that it stains the tissues with which it comes in contact externally. This stain, however, can easily be removed by the use of dilute acid alcohol. I insist on early and free incision, since by this means any bad results, such as necrosis, ulceration, and deformity, can be obviated. Internal medication should consist in free purgation. If there is any existing rheumatic or gouty diathesis, the recurrence of abscess-formation may be lessened by the constitutional treatment of such condition. Chronic Abscess. Chronic abscess of the septum is a rare condition. As a rule, it is the result of involvement of the cartilages after typhoid fever or other specific fevers, although it may be due to syphilitic or tuber- culous necrosis, yet the latter conditions are more often associated with perforation. Chronic abscess usually involves the anterior portion of the cartilaginous septum. It is of slow progress, and the clinical phenomena are not marked. On examination, a fluct- uating tumor will be found involving the septum ^ and slightly obstructing both nasal cavities. If it be of syphilitic or tuber- cular origin, the history of the case wall greatly aid in the diag- nosis. In ulceration of the septum following typhoid fever, there may be no associated nasal conditions. 'Treatment. — The treatment should consist in free incision of the cartilage on one side only, thorough and complete curetment of the pyogenic or limiting membrane, and thorough flushing with an antiseptic solution. The cavity should be packed with iodo- form gauze. Following chronic abscess there is a marked ten- dency to perforation of the septum. The individual's general health should be improved by the administration of systemic tonics. 7. DEPRESSION OF NASAL CARTILAGE. Depression of the cartilage gives rise to innum('ra])lc varieties of external deformity. The cause of the depression may be ti-au- matism or abscess of the se]>tum, M'hich gives rise to the deforni- itv known as pug nose. The condition may be associated witli ulceration and ^perforation of the septum, as is seen in syphilis or 276 DISEASES OF THE NOSE AND THROAT. tuberculosis, and in scrofulous, strumous, or rachitic diatheses. Accordingly, depression of the cartilage may occur Avithout loss of structure, or it may be due to partial destruction or entire per- foration. Where perforation has taken place, the depression is usually flat, and the soft structures seem to spread out on the face. The lateral diameter of the nasal orifice is increased, while the pi-rpeudicular dimension is markedly diminished. Depression from injury or septal abscess gives the peculiar sunken appearance on the top of the nose, ^vith the odd up-tilted tip. For the cor- rection of these various deformities it is impossible to outline a treatment that would apply to every case. Much can be done, however, toward correcting the disfiguring deformity by elevating and supporting the structure with the aid of bone, ivory, or metal plates. For the correction of the deformity due to abscess of the septum, an ingenious and common-sense method has been suggested by Roe. This consists in strengthening the septum by tissue brought in from the sides. As is pointed out by him, there is usually marked thickening of the dorsum. This thickened tissue is incised through to the under side of the skin on both sides, a short distance from the septum, at a point where it thins into the ala of the nose. The skin is then raised from the dorsum, and the flaps turned upward and held in place by perforated ivory splints, these being retained in position by means of sutures passed directly through the flaps and tied so as to hold them in place, care being taken not to exert sufficient pressure to produce strangulation of the parts. In order to elevate the arch of the nose and increase the solidity of the septum, each side of the lower portion of the septum and floor of the nose is scarified and the anterior portion of the septum divided, leaving the front portion of the skin intact. Thick flaps of tissue are then cut from the floor of the nostril opposite the portion of the septum which is to be rendered more rigid. These are held in position as given above, and also connected to the cut portion of the septum by fine sutures. This method, as well as any other, will have to be modi- fied to suit individual cases. 8. TUMORS. The bony growths involving the septum, including osteoma, chondroma, exostoses, ecchondroses, spurs, etc., have been fully considered under Tumors. Hematoma of the Septum (Blood-cyst). Hematoma or blood-tumor of the septum is not, in reality, a new growth, but is a sudden effusion of blood into the submucosa, as the result of contusion. It may occur on one or both sides of DISEASES OF THE ANTERIOR NASAL CAVITIES. 277 the bone or cartilage. This extravasation of blood may be asso- ciated with fracture of the bone or cartilage. There are always a history of injury of sudden onset and the secondary inflamma- tory phenomena. The extravasation may become encysted or, owing to the secondary inflammatory phenomena, may break down and suppurate. Small hematoma may occur from rhexis, as is seen in tlie eruptive fevers, or associated with uric-acid or rheu- matic diathesis, or even occasionally after violent exercise. These undergo absorption and require no special treatment. However, in extensive extravasation it is usually necessary to puncture the tumor under antiseptic precautions. The nostril should then be packed with antiseptic gauze thoroughly impregnated with boric acid. The packing should be so placed as to exert pressure at the site of the hematoma, and should be changed at least every twenty-four hours. Care should be exercised in the packing of the nostrils, so that pressure sufficient to cause ulceration is not exerted. CHAPTER XIII. DISEASES OF THE ANTERIOR NASAL CAVITIES. DISEASES OF THE ACCESSORY SINUSES. of the Maxillary Sinus. d. Specific Inflammations. a. Catarrhal Inflammations. e. Acute Infectious Diseases. 1. Acute. 2. Chronic. /. Emphysema. h. Ozena. g. Foreign Bodies, c. Empyema. h. Mucocele. 1. Acute Purulent Inflammation. i. Tumors. 2. Chronic Purulent Inflammation. j. Phlegmonous Inflammation. 3. Confined Suppuration. But little is absolutely known as to the physiological function of the accessory sinuses, and to this fact, perhaps, is in part clue the too frequent errors in diagnosis which their pathological processes in- volve. Cryer, Holmes, and others have done much to^vard clearing up the relation and topography of the cavities. The late development of the sinuses is possibly a second factor ; \vhile yet a third ele- ment may be found in the tendency of the practitioner to assign to a coexistent nasal lesion all the symptoms observed in a given case, though their main body, perhaps even their exciting cause, may be traced to the manifestations of a diseased sinus. It is undoubtedly the case that many of the nasal lesions which the specialist is called upon to treat, and which refuse to yield to treat- ment, however proper and correct its rationale, will upon careful search be found to be inflamed and aggravated by some active pathological process in the accessory sinuses. So that here, as in all branches of medicine, the necessity of a thorough painstaking search to elicit genetic factors is a prime essential to successful treatment. Unfortunately, as yet the aflFections of the sinuses have not received the very careful and systematic study to which they are entitled, and, while there are certain processes about which mucli is known, there are also a great many conditions about which we have little definite knowledge. The Antrum of Highmore (Maxillary Sinus or Sinus Maxillaris). — These structures, two in numl)cr, one in each superior maxillary bone (Fig. 2), are the largest of the connected nasal structures. Anatomically, a brief study of each cavity, to the article on which the reader is referred, shows many peculiarities 278 DISEASES OF THE ANTERIOR NASAL CAVITIES. 279 favorable to the origin of morbid processes. Fig. 95 shows a normal antrum and its anatomical relations. First of all may be noted the comparatively large size of the antrum, with its one opening so situated as to make the chamber practically a dependent cavity Fig. 95.— Anterior wall of antrum removed (after Cryer) : a.e.c, anterior ethmoidal cells; ^.s., hiatus semilunaris; w.p., uncinate process; m.,s., maxillary sinus; K., inferior turbinate; Im., inferior meatus; o.m.s., opening into maxillary sinus; i.w., infra-orbital nerve; to., muscles of face; h.p., hard palate; a.p., alveolar process; i.s., infra-orbital sinus. suited for fluid-retention. The small size of the opening, with its ready occlusion by even slight turgescence of the investing membrane or encroaching growths, its situation so as to be bathed by the constant dripping from the ethmoidal- or frontal-sinus discharge, as well as to admit it to the antral cavity indirectly, or by direct communication, as shown in Fig. 99, and the continuity of nasal and antral membranes which it permits, are all features of importance. The floor of the antrum shows either conical projections marking the fangs of a varying number of the upper teeth, or is directly penetrated by them (Fig. 6) ; while the posterior dental vessels and nerves traverse the spaces to their respective distributions. This close relationship of teeth and antrum, especially if the extraction of a tooth has given fairly free buccal communication to the antral cavity, is a very important factor in the etiology of many morbid conditions. Too much importance cannot be attached to the teeth as a causal factor in antral lesions. A majority of cases, I believe, are due to disease of the teeth, and the rhinologist should ])()ssess a thorough knowl- edge of these structures and their relation to the antrum, or else call in con.^ultation the dentist. As has ])een ])()inte(l out by Cryer, occa- sional branches of the superior dental nerve cross along the floor 280 DISEASES OF THE NOSE AND THROAT. of the antrum, being protected only by the thin layer of mucous membrane lining that cavity. In sucli cases the slightest inflam- matory process or accumulation of fluid will be followed by pain out of proportion to the other symptoms. The opening of the antrum varies in individuals as to location, also in number, as shown in Fig. 96. In a number of cases the Fig. 96.— Outer wall of the antrum removed, showing two openings into the cavity: o, openings into antrum (after Cryer). opening is much higher than normal, in reality being above the level of the floor of the orbit. In such cases there is marked tendency to accumulation of fluid should any inflammatory process take place. In diseases of the antrum the discharge will vary according to the position of the patient. This is true whether one or both sides be affected. CATARRHAL INFLAMMATIONS. Acute Catarrhal Inflammation. — This may arise with the existence of an acute rhinitis of whatever type, and is thus an extension of inflammatory process from the nose to the antrum, and the etiological factors of the first become of potential import in the secondary involvement. Temporary closure of the ostium maxillare, or antral opening, is a probable cause in some instances, and spread of inflammatory phenomena, by contiguity of tissue from inflammatory conditions in the alveolar or adjacent struct- ures, is not unlikelv to take place. Some cases may be traced to the entrance of the discharge from the frontal or ethmoidal sinuses through the antral opening, or to abnormal communi- cation, as shown in Fig. 99, or to tlie entrance of foreign mate- rial, as in powder insufflations or in the use of the nasal douche. It may follow the reception of traumatism, accompany the nasal DISEASES OF THE ANTERIOR NASAL CAVITIES. 281 symptoms of the acute infectious diseases, or be a part of a general manifestation of some more distant lesion, as of the heart or kid- neys. Some cases are traceable to the presence of animate and inanimate foreign bodies, in which latter category may be included as foreign elements certain tumors, teeth, and the like. It may be associated with systemic poisoning from drugs or metals, such as arsenic, lead, and mercury. The tendency is for a spontaneous recovery upon the removal of the existing cause, though it may be the initial stage of a chronic condition, an exacerbation of the latter, or quite possibly go on to suppuration. Both sinuses or only one may be implicated. The symptoms peculiar to the con- dition are not marked, and consist of deep-seated pain in the upper jaw of the affected side, with pain in the teeth supplied by the nerves traversing the inflamed antral space. Tenderness on pressing the upper teeth may possibly be elicited, and some intra- orbital pain be felt. Inspection is of practically no diagnostic value, the slight secretion from the antrum mingling undiffer- entiated with that of the affected nasal mucosa. There is usually some edema of the nasal mucosa on the antral side. The diagnosis can be easily made in a typical case. The prognosis, as a rule, is good. Treatment. — As the inflammatory process involving the mucous-membrane lining of the antrum does not differ from mucous-membrane inflammation elsewhere, the treatment would apparently be the same ; but, unfortunately, it is practically a closed cavity, and the small opening into the nose may be occluded by the inflammatory process, either within the antrum or within the nose. If there be no infection and merely an acute inflam- mation, efforts should be made to establish drainage through the antral orifice. As there is usually associated an inflammatory condition of the nasal mucous membrane, this should be treated as in acute rhinitis. However, I believe there should be applied about the hiatus an 8 to 10 per cent, solution of cocain, in order to contract the tissues and establish drainage. In the early stage of the inflammation, good results may be obtained by the application of cold, in the form of ice-bags or cold-water pack, over the nose and antrum. If the inflammation progresses rapidly and there is marked nasal swelling, good results will be obtained by the application within tlie nostril of 40 per cent, iclithyol in lanolin. By this treatment I have been able to abort a number of cases. There should bo administered a cathartic fol- lowed l)y a saline, and, if the. catarrlial inllaniination is associated with or the result of a cold, the an not be made without an exploratory operation. BISEASES OF THE ANTERIOR NASAL CAVITIES. 301 Treatment. — The removal of cysts from the antral cavity may necessitate the cutting away of the outer wall of the cavity, in order to permit free curetment, although puncture and drainage should first be tried. PHLEGMONOUS INFLAMMATION. Phlegmonous inflammation of the antrum is usually associated with a similar condition involving the upper respiratory tract. The symptoms are those of an acute catarrhal inflammation highly exaggerated. It is rapidly fatal. Fortunately, it is an exceedingly rare condition. DISEASES OF THE ETHMOIDAL CELLS. a. Catarrhal Inflammation. 1. Acute. 2. Chronic. h. Suppurating Ethmoiditis. 1. Acute. 2. Chronic. c. Mucocele and Non-infected Fluid-retention. d. Specific Inflammations. e. Tumors. Anatomically, there are certain points in the situation and con- struction of these cavities that are of importance both in a consid- eration of their morbid processc It is more tlian probable that •Mu\ in tlic fonnalion of ain-prodnction, notably unequal air- pressure through tumefaction of the membrane related to the frontal canal or, again, the pressure of the swollen and actively secreting membrane of the sinus itself. There is marked tender- ness of the supraciliary regions, especially over the course of the supra-orbital nerves. Reflex eye-symptoms are prominent, such as conjunctival or palpebral congestions, photo])hobia, and exces- sive lacrimation, and there may be some peri-ocular edema. Nau- sea and vomiting are not uncommon. Nasal inspection offers nothing of value excejit the signs of the existent nasal lesions. The diagnosis is usually not difficult, and is based upon the princi])al localizing synijitoms given, with the existence of an inflammatory condition of the nose. The prognosis is good, as the DISEASES OF THE ANTERIOR NASAL CAVITIES. 315 disease usually subsides with the cessatiou of the nasal trouble. It may cease suddenly, usually after the discharge of a considerable amount of thin nuicus from the nostril. It may, however, go on to the chronic type of inflammation, or become suppurative — con- ditions dependent upon the continued presence of the exciting cause and the addition of infection. Treatment. — The treatment consists first in looking carefully into the condition of the nasal cavity, correcting any obstruction or lesion that would lead to inflammatory processes. Cocain in 4 per cent, solution sprayed into the nose, or applications of similar strength on a cotton-covered probe, will often relieve the congestion. The effect of this will be heightened and prolonged by the addition of aqueous extract of suprarenal gland. Heat should be applied in the form of hot-water douches as well as externally. The inter- nal nasal application of the hot-water douche should be continued from five to ten minutes every two or three hours. Instead of hot water, a very soothing effect can be obtained by the use of hot milk at a temperature which can be comfortably borne by the patient; to each ounce of this solution should be added 3 grains of sodium chlorid. Internally, there should be administered a brisk mercurial cathartic, followed by a saline. If the pain is excessive and demands special treatment, the internal administration of a pill containing — Extracti belladonnse, gr. i(.007); Camphorie, gr. 1 (.03) ; Quininte bromidi, gr.|(.03); every hour for three doses will usually give relief. Any idiosyn- crasy to the action of the belladonna should be carefully noted. Equally good results can be obtained by a pill containing ^ grain of camphor to ^ to |- grain of codein administered every two hours for from two to four doses. A warm bath, followed by a hot lemonade and a 5-grain Dover's powder early in the attack, will often entirely arrest or at least shorten the attack. CHRONIC CATARRHAL INFLAMMATION. This arises as a continuation of an acute inflammation or as the result of repeated acute attacks, and its existence depends upon the recurrence or continued presence of the irritative cause, prominent among which stand intermittent or protracted nasal obstru(!tions to tli;- frontal canal, as from a turgescencc of the nasal membrane near the exit of the canal, obstruction l)y ]iolyi)i or other growths which lead to the retention of an unnatural and irritating amount of secretion from th(! sinus itself. Sim- ilarly, the presence of certain tumors within the cavity of the 316 DISEASES OF THE NOSE AND THROAT. sinuses, foiXMii;;n bodies, however introduced, or the retention of strong solutions from a nasal donchc may provoke it. This form not uncommonly leads to a retention of seronnicous material within tile cavities, or to a mucoid degeneration of the investing mem- hrane, with the formation of mucous cysts, or myxomatous growth, tilling the cliamber and constituting a condition known as muco- cele, the symptoms of both conditions being identical. Pathologi- cally, the membrane shows an irregular thickening and roughen- ing, and may be granular, as in any chronic catarrhal disorder, or, in the later stage, show evidences of myxomatous proliferation. The attendant symptoms are in a great measure^ identical with those noted in a simple catarrhal attack. There is, however, this difference, that the pain is more constant, with frequent and severe exacerbations. The dulness and weight may become very marked, with the retention and accumulation of secretion in the cavities, and be greatly relieved by its discharge, and this may occur at fairly definite intervals. All the pain-symptoms are aggravated by inclining the head forward, by coughing, or l)y blowing the nose. The eye-symptoms are present, but usually are of less degree than in the acute form. Tenderness over the cavities and over the sites mentioned in the acute variety is to be noted in the chronic form as well, and should considerable accumulation of fluid take place, this becomes marked, and a slight but notice- able bulging may be noted near the inner angle of the orbit of the affected side. A prominent symptom is the occurrence at irregular intervals of a discharge into the nostril of a varying amount of clear mucoserous fluid, attended by markerl relief of the pain and tenderness in the frontal region. The diagnosis is usually not difficult, and is made on the frontal symptoms, the cooxistence of a nasal lesion as revealed by rhinoscopy, and upon the irregular discharge into the nostril of the contents of the cavity, with attendant relief of the frontal distress. The prognosis is good, as a rule. Suppuration may super- vene, and tlie distention which may follow a catarrhal secretion without vent, or suppuration occurring under the same circum- stances, must modify the ])rognosis, in view of possible cerebral sequelae or fistulous formation. Treatment. — Chronic inflammatory processes involving the frontal sinus are most frequently associated with the same condi- tion involving the nasal mucosa. The first plan of treatment, then, should be directed toward the existing associated lesion, as given in the special chapters for such lesions. Any astringent and antiseptic cleansing solutions employed should never be cold, but at a temp(>rature that can be comfortably borne by the ]iatient. The ap})lication of ichthyol is highly beneficial. A pledget of cotton should be saturated with a 15 to 40 per cent, solution, the DISEASES OF THE ANTERIOR NASAL CAVITIES. 317 strength being controlled by each individual case. The pledget should be placed high up in the nasal tract and allowed to remain from one-half to two hours. This sliould be repeated every day until amelioration of the inflammatory phenomena occurs. Equally good results can be obtained by the application in the same mari- ner of carbolized vaselin, to which has been added 6 grains of alum or 4 grains of tannic acid to the ounce. There is, however, a marked tendency for the chronic inflammatory process to become infected. The treatment then will necessarily be the same as that given under Emp}'ema or Suppurative Conditions of the Frontal Sinus. EMPYEMA OF THE FRONTAL SINUS. Acute Purulent Inflammation. This may occur at any time during the existence of the acute or chronic catarrhal inflammation, or may be an original inflam- mation of the frontal sinus. Suppuration is not common in these cavities, probably because of the free drainage they usually have. Infection may take place in one sinus or in both ; it may occiu- from within or, more rarely, from without the nasal cavities ; and it is reasonable to suppose a sufficient degree of obstruction present from inflammatory phenomena to favor the lodgement and prolif- eration of the pyogenic organisms. The nasal douche may be the carrier ; it may be forced up in inflation of the middle ear ; it may be rarely carried up by insects or, more rarely still, be a metastatic process. Diphtheria or erysipelas may precede its development. Compound fractures and traumatisms, external and internal, may be the means of admitting it, and it may follow' bone-necrosis. In many cases it is impossible to determine the mode of infection. The predisposing elements that were noted in the etiology of the catarrhal malady are equally of force here, especially the diathetic strain of tuberculosis. The symptoms are in general those of catarrhal inflamma- tion exhibited in greater intensity. The pain is sharper, Avith more of a tendency to a beating and throbbing character, and it may even be mistaken for neuralgia. There is also an intermittent or continuous discharge of a bright-yellow, sometimes offensive pus from the nostril of the affected side. This needs to be differ- entiated froni that coming from tlie antrum, and not infrequently it is mingled with pus from the latter source in a common dis- charge. The localizing symptoms, of course, must be taken into account, as well as the fact that inversion of the head favors the antral (ivacuation and retards that from the frontal sinuses. It may be difficult in some cases to diff'crentiate the discharge from the purulent exhibition of ethmoidal disease ; so that the diagnosis is sometimes attended with difficulty, csiH'cially at the first exam- 318 DISEASES OF THE NOSE AND THROAT. inatioii of the case, and it may be masked a long while by the symptoms of a suppuration from the other accessory sinuses. The local symptoms, the observance of pus beneath the middle turbinal, which,' unlike that from the antrum, does not recur with the head in tiie inverted position, are the main diagnostic points. Trans- illumination is of possible value both in the direct and differential diagnosis. The lamp as shown in Fig. KJi), or protected by a rubber tube, is placed in the angle between the nose and the eyebi'ows and directed upward. The emptying of the cavity by drainage ren- ders this means of diagnosis of little avail, except in confined cases. Transillumination through the mouth is of doubtful value for the same reason, with the added objection that anatomical con- FiG. 109.— Ek'Ctric illurainatur for frontal sinus. ditions of the frontal sinus, or the nasal chamber, or ethmoidal cells will vitiate the findings. The prognosis is uncertain. Many cases run a course even of several weeks, and then cease spontaneously. Others termi- nate in a stubborn and intractable chronic suppuration, while still others early in their course, or it may be after a chronic condition has developed, through loss of drainage by some occlusion of exit, lead to an accumulation of pus within the sinuses, that may be very disastrous in its result. Tiiere is little danger to life except in the latter condition, which, if not relieved, is of grave import in its cerebral relation. Chroxic Suppurative Inflammation (Chronic Purulent Inflammation). This occurs either as a sequence of an acute suppuration or as the result of repeated attacks. The persistence of the infec- tion is dependent upon the continuance of an exciting cause and the maintenance of sufficient obstruction in the sinus-out- lets to prevent free drainage. Thus, the inflammation may be kept up by the presence of a tumor within tlie sinus, the irrita- tion of a foreign body, carious bone, insects or worms, or of smaller objects washed in by a douche or introduced by trauma- DISEASES OF THE ANTERIOR NASAL CAVITIES. 319 tism. The retention of the purulent fluid is in itself a very active means of prolonging its production. Thus it is that some cases of suppuration occur, particularly if the result of traumatism, which progress slowly, give rise to no severe or marked symptoms, and indeed are very ill-defined before accumulation of pus begins to show itself in the systemic and local manifestations of an abscess. Necrotic conditions involving the neighborhood of the sinuses, whether local or systemic, as of tertiary syphilis, are attended by it. The occlusion of the outlets may be caused by the swelling of a hyperplastic rhinitis or by the existence of nasal polypi, and is a considerable factor in the maintenance of the process. Not rarely it may be so complete as to preclude pus- exit at all, and lead to its dangerous retention within the frontal chambers. The pathological picture is that of a thickened and rough, shaggy, pyogenic membrane covered with yellow and possibly fetid pus. The symptoms are but modifications of those observed in the catarrhal involvement. The pain may become of a dull, constant, aching character, with severe exacerbations either in damp weather, on access of nasal inflammations, or on taking cold, or it may be sharp and neuralgic. There may be a periodic tendency noted, marked by the gradual increase of all the symptoms, until almost unbearable, and then attended by a gradual relief, as the evacuation of the retained pus occurs. Reflex disturbances of the eye are commonly noted, and are proportionate in severity to the other symptoms observed. The patient's general mental con- dition is apt to become impaired, and he becomes apathetic, for- getful, and unable to attend to business, and generally depressed in a degree commensurate with the duration and severity of the process. Tliere may in some cases be observed the same aversion to society that has been already mentioned in connection with condi- tions attended by more or less offensive odor. The discharge from the sinus afl^ected may be constant or, as more frequently occurs, periodic. In amount it may be slight or profuse, of a decided yellow tint. It may be possible to observe its collection under the middle turbinated bone of the affected side, though the possibility of admixture from other sources should not be forgotten. Polypi, edema, and the like should be noted in this region in their causa- tive relationship. The diagnosis is usually not of difficulty, although, as in the acute form, it may require a more or less extended observation before it is determined. It may be necessary to make it by the exclusion of other manifestations, though this is rarely tlie case. Transillumination may give confirmatory diiiunostic data. The prognosis is'uot favorable for a spoulaiieoiis cure, and in any case depends upon the al)iliiv of the physician or >nrgeon to 320 DISEASES OF THE NOSE AND THROAT. ascertain and remove the exciting causes. Should a confinement of the pus occur, the cerebral involvement possible without relief must be taken into account. ("OMINKD SUPPFKATION. This is tiic gravest of the suj)purative conditions of the iVontal sinus. It may arise during cin-onic or acute suppuration, or be the result of an infection of a retained mucoserous secretion. It may appear a long while after the access of the pyogenic organ- isms and be the sudden development of a dormant and unsuspected inflamination. The sources of irritation and the causes of occlu- sion of the frontal canal have already received sufficient mention without fui'thcr repetition here. The symptoms of the condition are such as would accompany the formation of an abscess in any closed cavitv. Tiicre are usually the symptoms of the precedent condition, wliich, instead of retaining their intermittent charac^ter, gradually or it may be sud- denly become constant and of greater severity. l*ain beconies constant, throbbing and boring in character, and h^'alized in the frontal region. Headache is persistent and severe. The patient cannot sleep, and is in the severe torture of abscess-pain dav and night. The eyes are watery and suffused. The tissues overlvino- the affected sinuses are red(h'ned, swollen, and edematous. Pressure Fk;. 111).— Horizontal section through the fidiilal siiiusts/showiiiK uiulateral occlu- sion with consequent accumulation of secretion anil perforation into the cranial cavity. Tlu! diH'erence in size of the two sinuses is to be noted (after Cryer). becomes extremely [)ainful. The systemic exhibition of pus- intoxication begins, and chilliness, sweats, and the suppurative fever are to be observed. With the progress of the case the reten- tion of pus leads to the (h'velo])ment of pressure-effects. There is marked bujoiuo- over the affected area, more noticeable at tiie DISEASES OF THE ANTERIOR NASAL CAVITIES. 321 inner angle of the orbit. The eyeball is displaced, and diplopia results ; or, if the optic nerve be encroached upon in the swelling, amaurosis is possible. The sense of smell may be markedly diminished. Cerebral symptoms not unlikely may supervene. With the continued and increasing pressure within the sinus, thin- ning of its walls occurs, and a distinct sense of fluctuation or of crackling may be elicited; and, finally, unless relief is given by the surgeon, following the path of least resistance there is a rupture of the thinned and overdistended tissue, and the abscess forms its own outlet. This may take place in any direction — outward through the inner angle of the orbit (Figs. 110, 111), backward into tlie orbit, upward into the space between the dura mater and the inner table of the skull, inward into the nasal cavity, or in rare cases outward through the external tables of the frontal bone. ^M P mm "-*- ^ Bi 5 M I^BHki^'''''' j^^^i ^H^HH^^^^ i^ ^H^Vsdi ^ ^^^1 "^M ^■' ' ■ 1 lEk^ 5K2 •oj^:, Fig. 111.— Showing the destruction to the inner wall of the orbit by the abscess originating in the frontal sinus. From the same skull as Fig. 110 (after Cryer). This last route of rupture occurred in a case of my own. The condition followed la grippe in January, 1898, and had persisted till June of the same year, w^hen I first saw the patient. Pass- ing a probe over the tumor in the frontal area caused rupture, so thin had become even the covering of skin. Concluding that cerebral complications had ceased to be a probability, as the pus had followed the line of least resistance, I explored the cavity with a probe, which finally emerged from the normal nasal outlet. The cavity was thoroughly cleansed with an antiseptic solution, packed with gauze, gradually lessened in amount as healing progressed, and the j)atient made an uninterrupted re(;()very, only the smallest scar and indentation, about one-half inch al)()ve the supra-orbital ridge, showing the point of ruj)tur('. The relief after ruj)tur(' is in(l('S('rii);il)iy jn'oinpt, iind with tlie free escape of the |)iiriilciit material the syiiij)toni.'^, urgent belbre, rapidly abate 322 DISEASES OF THE NOSE AND THROAT. The diagnosis is not difficult after the establishment of the local swelliin;- and the systemic symi)toms. Retention of uninfected material lacks the acute, purulent, intlammatory symptoms to be observed externally. Certain tumors may grow to such extent as to cause the pressure-symptoms, and even, if attended by sup- puration, simulate tlie presence of ])ent-up pu.s; thinning of the walls may even occur, but the growth is slower and the })ain less intense. Abscess of the lacrimal sac may confound a diagnosis, but the interference with the lacrimal secretion is too marked a feature in most cases. Transillumination is of confirmatory value.. The prognosis should be very guarded. The swelling may last a long while before it is followed by rupture, or it may break early. It may open anywhere and become the starting point of a fatal meningitis. Panophthalmitis may result and require removal of the affected eye. Spontaneous rupture may lead to the forma- tion (if an obstinate fistulous tract. Treatment. — The local treatment should be the same as given under Catarrlial Infiammation. Surgical procedure offers a good chance of recovery. The best plan of surgical interference is Bryan's operation, a modification of the Ogston-Luc method, which consists in the incision being made not in the median line, but along tlie under margin of the supra-orbital ridge. When properly treated, the Luc method leaves a very small, but not disfiguring, scar. By the latter or modified procedure, what slight scar is formed falls just under the l)row, and is further concealed by the hair of the brow. After removing all obstructive tissue within the nose, such as polypi, exostoses, or permanent enlargement of the turbinates, the ethmoidal cells are examined to ascertain wiiether they are in a state of caries. If so, they are freely curetted. The eyebrow is shaved, and the skin of the forehead is prepared as for any surgical operation. The integument is pulled up on the forehead, so that the incision, which should commence just A\'ithin the supra-orbital notch and be made down to the bone, falls just under the supra-orbital ridge. The cut is carried to the inner angle, and the flap thus formed, composed of the skin and periosteum, is elevated. If there is not sufficient room for the application of the trephine, the flap should be increased by carrying the incision across the root of the nose to the corresponding inner angle. After the elevation of the flap, a small crown trephine aliout 1 cm. in diameter is placed about two lines outside of the median line and about the same dis- tance above the supra-orbital ridge. After the removal of the button of bone, all carious and granulation-tissue is removed, the frontonasal duct enlarged, and a self-retaining drainage-tube introduced. After thoroughly irrigating the parts with an anti- septic solution and touching the lining membrane of the sinus with a 20 per cent, solution of chlorid of zinc, the wound is then DISEASES OF THE ANTERIOR NASAL CAVITIES. 323 closed with an interrupted or a subcutaneous suture. If there should be any caries of the fronto-ethmoidal cells and ethmoidal cells proper, this diseased tissue must be removed by means of the curet, operating from within the sinus, and using the little finger within the nose as a guide. Next, a large communication is made between the sinus and the nasal cavity. The drainage-tube in this instance is done away with, and the cavity packed with iodoform gauze brought down into the nose. The wound is then closed as above described. After the removal of the gauze, the cavity is irrigated through a curved cannula with mild antiseptic lotions, until healing takes place. MUCOCELE OF THE FRONTAL SINUS. This condition arises as the result of a prolonged catarrhal inflammation within the sinus, Avhereby there is either a formation of myxomatous masses, a mucoid degeneration of the investing membrane, or proliferation of mucous cysts. Through the growth of these elements, there is developed a mass retained by a thin membrane, and consisting largely or entirely of the elements con- stituting normal mucus. The symptoms comprise exactly the same phenomena as are seen from the accumulation of free mucoserous fluid within the sinuses. They may be very obscure in the earlier stages, amounting perhaps to a slight annoyance over the nasal bridge or to a sense of weight or fulness. Usually, the syiuptoms of a chronic catarrhal inflammation have been Mell marked for some time, and gradually give way to the symptoms of internal pressure, without, however, the marked external phenomena, and lacking systemic purulent intoxication. With this exception and the less severity of pain, the symptoms are like those observed in the exhibition of confined pus. Thinning of the sinus-wall may take place and, possibly, escape of the sinus-contents. Degenerative changes may occur, and the whole mass become a homogeneous fluid, which may still further undergo infection, be converted into pus, and be the basis of a frontal empyema. Or, reaching the limits of the normal sinus, degenerative process may occur and the mass become softened, fluid escaping into the nostril through the frontal canal. The diagnosis is not easily made, and indeed may be impos- sible in some cases. The pressure-symjotoms, with lack of pus- intoxication, together with the history of the case, furnish sus- ]>icious data. It is almost impossible to separate the condition from that of any tumor having its site in this location. Tiie prognosis is good as regards life. Empyema may result. The cerebral ;ind ocuhir dangers are not so grave as in the filling of the cavity with confined pus, but are still present to a limited extent. 324 DISEASES OF THE ^'^OSE AND THROAT. Treatment. — Occasionally, spontaneous rupture and discharge may oi-cur. Jlowever, as a rule, surgical interference is necessary. In a majority of the cases this can be accomplished by perforation, Avith the instrument shown in Fig. 112, into the frontal sinus, through the frontonasal duct from the nose. Absence of the Fig. 112.— Palmer' frontal sinus must be borne in mind when attempting paracentesis. This operation, if successful, will permit of the exit of the retained material, and, should it fail to be curative, M'ill at least be of value from a diagnostic standpoint, besides establishing free drainage into the nose. The opening should be followed by curetment. If this method should fail to effect a permanent cure, recourse will have to be made to the external operation as given under Empyema. FOREIGN BODIES. These may be either inanimate or animate. The former com- prise such bodies as sj)ent bullets or shot, or pieces of metal, and the like, the existence of which within the cavity is usually known because of the traumatic history of the case. They may give rise to no symptoms, but remain hrmly placed in the frontal cavity. On the other hand, they may constitute the exciting cause of a chronic catarrhal or suppurative inflammation of the sinus, which will refuse to yield to any treatment short of their removal. Fortunately, such cases are rare. Of the animate foreign bodies, there are a number of recorded cases of invasion into the frontal sinuses. These consist of a variety of worms or larva? and, particularly, maggots. The symp- toms produced are necessarily those of excruciating pain in the frontal sites, suppuration and fetid discharge, with ulceration and necrosis of the structures attacked by the insects. The diagnosis is made by the presence of numbers of worms in the nasal dis- charge and by the lo(!alizing symptoms. These cases are more often observed in tro]iical and warm climates than in the temper- ate zones. The prognosis must be guarded. Treatment. — Tlie treatment is the same as in Suppurative Inflammation. However, when animate foreign bodies are present, relief may be obtained without resort to operative procedure by the application of an ethereal solution or chloroform, followed by DISEASES OF THE ANTERIOR NASAL CAVITIES. 325 flushing with an antiseptic solution, either a weak sohition of car- bolic acid or bichlorid of mercury, 1 : 2000 or 1 : 3000. INFECTIOUS CONDITIONS OF THE FRONTAL SINUS. The frontal sinuses are liable to the invasion of erysipelas, diphtheria, syphilis, tuberculosis, la grippe, etc., but such involve- ment is preceded by nasal manifestations of the same process, and is of rare primary occurrence. TUMORS. Various forms of benign and malignant growths may occur ; they may be primary, or are associated with similar tumors in adjacent cavities or structures. The most common are the fibroma, myxoma, and osteoma, given in the order of their frequency of occurrence. The fibroma is usually single, of small size, and of slow growth, although it may extend into the nose or, if not interfered with by operative procedure, extend backward and upward into the cranial cavity. The myxomata may be either single or multiple — most fre- quently the latter — and are of rather rapid growth. They are usually associated with myxomata of the nasal cavity. The osteomata are rather rare, and may primarily originate in the sinus or in adjacent bony structure, involving the sinus. They tend to involve adjacent structures and to penetrate the cranium. This tumor is of very slow growth and, if allowed to attain any considerable size, produces marked facial deformity. The malignant growths of the frontal sinus are usually secondary, being associated with malignant growths in adjacent structures. They are necessarily fatal. Cystic tumors of the frontal sinus may occur at any age or may be congenital. They consist in the reten- tion variety (mucocele), or are steatomatous in character. Tumors of the frontal sinus, either benign or malignant, are of grave im- port, and the prognosis is unfavorable. Cysts and the benign tumors may be removed by external incision, and, if recognized early, outside of some facial deformity, curative results may be obtained. For the malignant growths operative procedure is of little or no avail. CHAPTER Xiy. RELATED PATHOLOGICAL CONDITIONS OF THE NOSE AND EYE. Following the diseases of the accessory sinuses and their relation to diseases of the nose is the consideration of the lesions of the lacrimal duct and the mucous membrane of the orl^ital cavity. Fig. 113.— Vertical section (after Cryer), showing a thread through the ostium inaxil- lare : m.s., maxillary sinus ; m.b., malar bone ; z.o.c, infra-orbital canal ; iv.n.s., wall of nose and sinus; a.p., alveolar process; i.»i., inferior meatus; if, inferior turbinate; ?i.d., nasal duct; vi.m., middle meatus; m.t., middle turbinate; s.m., superior meatus; f.s., frontal sinus. AVhile this cannot be considered an accessory cavity, yet the com- munication established between the eye and nose by the lacrimal duct' is more direct and more open to infection and more liable to extension of inflammation than any of the accessory cavities. Any inflammatory process spreads by continuity or contijruity of structure, or through the blood-vessels or lymphatics.^ Inflam- matory processes in the nose, either infectious or non-infectious, may extend up through the lacrimal duct by continuity of struct- ure, as the mucous membrane lining this duct is a continuation 326 RELA TED PA THOLOGICA L CONDITIONS OF NOSE A ND EYE. 327 from below of the nasal mucosa, and from above is a continuation of the mucous membrane lining the orbital cavity. The location of the lacrimal duct and its environment are well shown in Figs. 113, 114. Inflammation, then, may spread from eye-lesions Fig. 114. Fig. 115. Fig. 114.— Perpendicular transverse section just within the infra-orbital ridge, anterior ■wall of the maxillary sinus removed (after Cryer). Note septa traversing the sinus ; twine in infra-orbital canal : n.c, nasal cavity; n.s., nasal septum; t.t, inferior turbinate; i.m., inferior meatus; h.ji., hard palate; a.p., alveolar process; m.s., maxillary sinus; m.b., malar bone ; n.d., nasal duct; f.s., frontal sinus. Fig. 115.— Section from posterior wall of antrum and orbit (after Cryer) : thinned bones indicate old age : m.s., maxillary sinus; Ti.p., hard palate; i.m., inferior meatus; Lt., in- ferior turbinate ; U.S., nasal septum; to. «., middle turbinate; m.m., middle meatus; p.e.c, posterior ethmoidal cells ; u., orbit. through the lacrimal duct to the nose, the influence of continuity of structure being aided by gravity. Obstructive lesions of the nose, by occluding the nasal duct, may lead to accumulation of material wnthin that tract, with overflow through the eye. This accumulation may lead to irritation and infection, causing primary inflammation of the duct. While this is not a direct extension of inflammation from the nasal mucosa, yet the essential exciting etiological factor is to be found in the nasal cavity. The associ- ated diseases may be classified generally into : 1. Lesions of the lacriniid duct and eye, brought about by nasal obstructions in the form of deflected septum, congenital or trau- matic, involving either the cartilaginous or bony portion, spurs or exostoses, tumors, enlarged turl)iiiates, the various forms of simple chronic rhinitis, and foreign bodi(>s. Simple chronic rhinitis, by the thickening of the membrane, but not necessarily the bone, offers the same obstruction as a new growth. 0])erative interfcr- 328 DISEASES OF THE NOSE AND THROAT. ence in the nose may lead to lesions of the duct by trauma. Sep- tal operations in which there is introduced into the nose any form of tube for the supj)ort of the septum, by pressure may lead to obstructive lesions of tlic duct. 2. Conditions in which there is no nasal obstruction, but in which there is an infectious intianimation of the nasal mucous membrane. The inflammatory })roccs8 then, spreadinui; by continuity of struct- ure, will extend to the mucous membrane of the eye. 3. Inflammatory processes involving the mucous membrane of the eye, in which there is no lesion of the duct or nasal cavity, may extend from the eye to the nose. This is especially true if the process be infectious, although such extension will also occur in the non-infected varieties of inflammation. In membranous inflammations of the nose the process may extend through the lacrimal duct to the eye. I have observed several cases of hay fever in which there was formation of an actual membrane in the nose, which had extended to the eye. On removing the membrane from the conjunctiva, there was also removed an almost perfect cast from the lacrimal duct. While there is little danger of bacteritic infection in the healthy mucous membrane lining the lacrimal duct, yet from any simple inflamma- tory process or any condition in which there is lessened physiolog- ical resistance, the harmless, non-virulent bacteria find a suitable nidus for their proliferation, and the simple inflammatory process is converted into an infectious one. Even in infectious nasal con- ditions without an associated lesion of the lacrimal duct, the repeated efforts on the part of the patient to clear the nostril may be the means of forcing up into the duct infectious material, with subsequent inflammation. There is no question but that in many cases of simple rhinitis, either acute or chronic, the irritation caused by the continuous or too frequent use of the nasal douche may produce inflammatory processes in the accessory sinuses and continuous mucous-membrane structures. The important relation existing between the nose and eye should be carefully studied in the treatment of persistent inflammatory lesions existing in either the nose or orbital nuicous membrane, as lesions of the eye, which do not seem to yield to any plan of treatment, may be found to have in the nose the causative fiictor, the correction of which will clear up the eye-symptoms. On the other hand, a continuous inflammatory lesion of the nose, in which there is an infectious process going on in the mucous membrane of the orbit, may have in that its etiological exciting factor. In the anemic and stru- mous forms of rhinitis occurring in children, with offensive, slimy discharge from the nostril, with watery eyes, edematous and swol- len lids, with the teudency to excoriation of the skin surround- ing cither the nasal or ocular openiug of the duct, the condition may be an associated one — the result of a constitutional diathesis. CHAPTER XV. DISEASES OF THE NASOPHARYNX. a. Acute and Chronic Inflammatory Diseases. 1. Acute Nasopharyngitis. 2. Simple Chronic Nasopharyngitis. 3. Atrophic Nasopharyngitis. 4. Hyperplastic Nasopharyngitis. 5. Specific Inflammations. (1.) Syphilis. (2.) Tuberculosis. a. Lupus. (3.) Glanders. (4.) Actinomycosis. h. Neuroses. ACUTE NASOPHARYNGITIS. Definition. — An acute catarrhal inflammation of the mucous membrane of the nasopharynx, occurring either as the accompani- ment of an acute rhinitis or pharyngitis, or of both, as the acute exacerbation of a chronic catarrhal inflammation, or more rarely as a primarily localized inflammation. It is characterized by a protracted dry stage, followed by the abundant formation of a thick, tenacious, mucoid or mucopurulent discharge and a gradual subsidence of the symptoms. The attack runs a course of about two weeks, and repeated attacks tend to establish the chronic con- dition, if it be not already present. Synonyms. — Acute catarrh of the nasopharynx ; Acute post- nasal catarrh ; Acute retronasal catarrh ; Acute rhinopharyngitis. Htiolog"y. — Predisposing- Causes. — Chief of these may be classed the irregularities of climate, particularly those occurring in the spring and fall months. These become proportionately more active as the patient's bodily tone is below its normal. In many cases there is apparently an oversensitive state of the mem- brane of the nasopharynx, not improbably a local exhibition of a neurotic condition, which seems not infrequently to predispose. This element is more marked in the female sex. Adults seem to be more frequently affected than those of younger years, and the scrofulous diathesis strongly ]n'edisposes. A goodly proportion of cases are tlic acute exacerbations of a chronic condition. Exciting- Causes. — The condition may accompany an acute rhinitis or pharyngitis, or l)oth, either as an extension of the inflam- matory process l)y continuity of tissue, or arising as the result of the same causes, acting locally, -which produce these conditions. 329 330 DISEASES OF THE NOSE AND THROAT. Such causes include the inhahition of dust, and tlie various chem- ical or mechanical irritants. Exposure to extremes of temperature, sudden chillinj]:, and the like may produce it; in short, the whole chain of causes which may be productive of acute rhinitis may exercise the same causative influence here. Certain of the infec- tious fevers, such as scarlet fever, measles, and diphtheria, may be comj^lieated rr followed by an acute postnasal catarrh. Pathology. — The pathology of the condition does not differ from that of an acute catarrhal inflammation of any mucous mem- brane. Tliere are the same vascular phenomena of engorgement, somewhat prolonged and followed by the escape of fluid and cells into the submucous tissue, and an increased surface-discharge, both from this source and from the extra activity of the glandular structures, due to increased irritation. Not infrequently a few of the glands may be occluded at their orifices and become filled by cellular debris undergoing cheesy degenerative changes — a condi- tion characteristic of follicular pharyngitis. Finally, the stage of resolution superv^enes, the vascular tonus is regained, the exudate is absorbed, and the membrane returns to the condition existing before the attack. Instead of resolution, evidences of a chronic course may appear in the attempted organization of the cellular elements into tissue more or less new, and the slow, impaired return to normal which the vessels display. Symptoms. — As may readily be imagined, these are of vary- ing degree of severity. If the nasopharyngitis is coincident with an acute rhinitis or pharyngitis, the symptoms of these affections may effectually mask the symptoms of the former. A typical well- marked case of acute nasopharyngitis occurring alone, however, usually presents the following symptoms : The onset is sudden, and, as a rule, is attended with mild febrile symptoms — malaise, gastro- intestinal derangement, a furred tongue, and a temperature rarely exceeding 100° or 101° F. There is an almost painful dryness in the postnasal space, and a sense of tightness that becomes more marked on swallowing. Pain usually accompanies, of a neuralgic character and referred to the vertex, the upper pharynx, the roof of the mouth, and the angles of the jaws. Tiiis usually persists throughout the attack. Sligiit hemorrhages may take place. The dryness continues for from one to two days, and then gradually the secretion begins to appear, at first thick and tenacious, but comparatively clear, later becoming whitish and starchy, and finally quite purulent. This clings closely to the membrane, and causes continued " hawking " and spitting to remove it. Some- times it is forced out through the nostrils, as a rule, hoAvever, through the mouth ; and not a little is involuntarily swallowed and increases the gastric trouble, which has possibly been already aggravated by the establishment of the secretion. The discharge may irritate the nasal spaces and excite an acute rhinitis. In DISEASES OF THE NASOPHARYNX. 331 severe cases catarrhal ulcers may form. Impairment of hearing and alteration of the vocal tone are apt to occur, the hoarseness being cine to interference in circulation. Cough is rarely, if ever, present. After lasting about ten days to two weeks the symptoms gradually abate, the pain lessens, the discharge decreases in amount and returns to normal, the congestion of the membrane disappears, and the attack subsides. There is rarely any tendency to involve the tracheal and bronchial membranes, though the lower pharynx may become implicated. Inspection shows during the early stage a reddened, swollen condition of the membrane, the surface of which is dry and glazed and displays many tortuous and congested ves- sels. Later, masses of the secretion may be seen clinging to the walls or hanging from them, and filling the crypts and recesses of the tonsil of Luschka and the fossa of Rosenmiiller. Diagnosis. — The diagnosis is made by the history and by inspection of the nasopharynx. Acute follicular inflammation is excluded, after cleansing, by the absence of the elevations marking the inflamed glands. Moreover, it is accompanied by a higher fever at the onset. Prognosis. — Acute nasopharyngitis is not dangerous to life. It usually runs a course of about ten to fourteen clays, and, if not already the acute exacerbation of chronic nasopharyngitis, should be regarded as its starting point. Early treatment may abort the attack or lessen its duration. Treatment. — The treatment of acute nasopharyngitis is necessarily controlled by associated and allied conditions. When directly associated with an acute rhinitis, the treatment employed is the same as given for that condition ; however, at times the inflammatory process is limited to the nasopharyngeal structures. The cause of this inflammatory condition may be either local or systemic. Careful attention should be given to the intestinal tract and any irregularities relieved. Local applications by means of Fi(.i. ]]G.— Frocniaii's syringe with catheter. a douche should always 1)C used as worm as can be comfortably borne by the patient. If there is a tendency tf) the accumulation of the secretion in the naso])harynx, n^lief can be obtained l)y wasliing out l)y means of the postnasal syringe (l^^ig. 116), using a warm alkaline solution, such as 8 grains of biborate or bicarbonate of 332 DISEASES OF THE NOSE AND THROAT. sodium to tlie ounce of tepid water, or an equally ^ood cleansing solution is warm milk to which is added 3 to 6 grains of sodium chlorid. In the early stage, before secretion takes place, in wliich there are marked burning and itching in the naso- l^harynx, due to the hyperemia and congestion, relief may be obtained by the inhalation of medicated vapors ; but better is the internal administration of a granular effervescent pilocarpin tablet containing -pl^^ grain. This should be administered every hour nntil the secretions are established. The tablets should be placed in the mouth and allowed to dissolve gradually. If there is a tendency to a continuation of the hypersecretion and a prolongation of the process after thoroughly washing out the nasopharynx, which should be done with the alkaline solution on a cotton pledget, use boroglycerid, 50 per cent., with an equal amount of compound tincture of benzoin. If, however, a more astringent effect is desired, there should be used a balsam solution, such as — i;^. Olei eucalypti, gtt. ij (.12); Olei cassise, gtt. ij (.12); Extracti pini canadensis, gtt. x (.6) ; Tincturse benzoini, q.s. ad fl. 5J (30.). If the tissue is very sensitive and markedly irritated, 3 per cent, cocain should be added to this solution. Quite often there is associated with acute nasopharyngitis a sudden blocking up of the Eustachian orifice and continual irritation of the orifice of the Eu- stachian tube. This may lead to grave complications in the ear, and many an attack of acute otitis media can be averted by cathe- terization of the Eustachian tube and drawing off the accumu- lated secretion. When an acute inflammatory condition of the nasopharynx is associated with a like condition in the anterior nasal cavity, the treatment is the same as that given under Acute Rhinitis. If the secretion is not mucopurulent, but rather thin and watery, with relaxation of th(! mucous membrane, good results can be obtained by the internal administration of — , If Extracti belladonna, gr. i (.008) ; C'amphorjie, gr. ^ (.03) ; Quininte bromidi, gr. ^ (.03). This should l)e given every two hours from one to three days, and tlie physiological effect of the bclhidonna on the ])haryngeal mucous membrane should be carefully noted, as this drug seems to have a peculiar action on the blood-vessels of the pharynx and nasopharynx. Systemic conditions liable to interfere with venous circuhition should be corrected. It is well in this variety of nasopharyngitis, as well as in most conditions of the DISEASES OF THE NASOPHARYNX. 333 upper respiratory tract, to administer a mild purgative, followed by a saliue. Quite often acute inflammatory conditions of the nasopharynx are associated with acute infectious processes. This part of the upper respiratory tract is often involved during an attack of la grippe, and frequently after the attack is over there is left remaining localized inflammatory areas. In this condition, as well as in infectious processes in which the con- trolling inflammation is a resulting condition or is secondary, there is always demanded the administration of tonics, agents to increase vascular tone and cellular activity. There is none better than a capsule containing — Ki. Pulveris kolse, gr. ij (.12) ; Ferri lactatis, gr. \ (.016) ; Strychninse nitratis, gr. Jg- to ^V (.0016-003). This should be administered after each meal. SIMPLE CHRONIC NASOPHARYNGITIS. Definition. — A simple chronic catarrhal inflammation of the nasopharynx. It is characterized by the constant secretion of a thick tenacious mucus, which may become purulent, or, in long- standing cases form crusts. The secretion adheres tenaciously to the nasopharyngeal walls, its excess gravitating slowly to the lower pharynx ; it is somewhat abundant, and causes constantly repeated efforts of the patient to remove it by " hawking." The course of the aflFection is marked by a tendency to acute attacks upon slight provocation, and there may or may not be an associated rhinitis or pharyngitis. Synonyms. — American catarrh ; Chronic catarrh of the naso- pharynx ; Chronic postnasal catarrh ; Chronic retronasal catarrh ; Chronic rhinopharyngitis ; Catarrh of the pharyngeal bursa ; Chronic adenoiditis. Ktiologfy. — Simple chronic nasopharyngitis is undoubtedly produced or favored by many causes. In a large proportion of cases it is the result of repeated attacks of the acute form, and the causative conditions of this, Avhich are not dissimilar to those of rhinitis and ]iharyngitis, play, therefore, an important part. It may, however, from the prolongation of an acute attack under the continued influence of its exciting cause, become chronic in a short period, and the subsequent acute attacks be but exacerba- tions of the chronic condition. Not infrequently it accompanies a chronic pharyngitis or rhinitis, and may be an extension of either or both to the postnasal space. Predisposing- Causes. — The condition is more common in the young than in those of adult years. Heredity is claimed to have 334 JJIS EASES OF THE NOSE AND THROAT. an influence in its occurrence, but tliis is true only in so far as there is an inherited peculiarity of nasal structure, or a predis- posing diathesis in tlie family history. The lymphatic and neurotic temperaments are regarded as predisposing, and the same is true of the scrofulous, anemic, gouty, and rheumatic diatheses and weakened personal resistance. Gastric and intestinal troubles, especially the prevalent " American " dyspepsia, are in some cases undoubtedly more than predisposing factors. A torpid liver, pos- sibly through sluggish performance of its function in toxic elimina- tion, at least favors, if not directly causes, the inflammation through the increased work it forces on the membrane in its vicarious efforts at elimination. The infectious diseases, such as measles, scarlet fever, etc., are often followed by the chronic con- dition engendered in its acute form during their course. Public speakers, singers, and those wlio suddenly are called upon for pro- longed and severe vocal effort, without an accompanying knowl- edge of proper vocal management, are apt to develop it as the residt of repeated or prolouged irritation. Certain local conditions of the nasopharynx, nasal cavities, or the lower pharynx are prone to be attended by a chronic nasopharyngitis. Such a list would include especially the obstructive conditions of the anterior cavities and those attended with an irritating ])osterior discharge. The same is true of widely opened anterior passages, permitting a too free impact of unmodified or contaminated air upon the wallsof the nasopharynx. Certain abnormalities within the nasopharynx are often attended by chronic inflammation. Particularly is this true of affections of the pharyngeal tonsil, the chronic condition often persisting after the atrophy of this structure. The pharyngeal bursa has been claimed to have an especially determinant action in the etiology of this lesion. The presence of inflammatory conditions, of whatever type, in the adjacent territory, whether in the nasal mucosa or in the oropharynx, are extremely liable, by continuity of structure, to involve the nasopharynx in a chronic catarrhal inflammation. Exciting- Causes. — Many of the predisposing elements already mentioned may be in themselves of sufficient intensity to act as active causes, and, indeed, it is difficult to say in many cases whether certain causes are active or merely predisposing. In general, it may be stated that the exciting causes are of the same type as those producing rhinitis and pharyngitis. Prominent among them stands the influence of climatic c(mditions — a damp, variable climate exerting in certain cases almost a specific influence. Abrupt changes, chilling of the body, im])roper clothing, the local action of irritants from prolonged inhalation of smoke, fumes, or dust, by posterior dis(!harges from the choanie, or in misapplied or erroneous pharyngeal medication by the jiatient or practitioner, are of ])ositive causative effect. Finally, in this connection must be taken into account the situation of the nasopharynx, the ready DISEASES OF THE NASOPHARYNX. 335 lodgement it affords for irritant media, and the difficulty with which the patient can by his own efforts cleanse the region, either by expiratory efforts or gargles. Pathology. — The general character of the morbid process does not-differ essentially from that observed in any simple chronic inflam- mation, or in the beginning atrophic and the hyperplastic rhinitis. In its macroscopical appearance it is, as a whole, paler than normal, more or less boggy and edematous, and scattered somewhat pro- fusely over it are red punctations marking the inflammatory process at the glandular sites. The student should bear in mind that the reddened hyperemic condition seen immediately following a cleansing application is not the true appearance of the abnormal condition. Symptoms. — The establishment of the condition is generally marked by a feeling of uneasiness, hard to describe, in the upper part of the pharynx. The patient usually complains of an unnatural dryness, with a sensation as of a foreign body lodged within the postnasal space. He " hems " and " hawks," and may even retch and vomit in his efforts at dislodgement — possibly expectorating, as a temporary relief, a certain amount of tenacious secretion of a character varying with the progress of the disease. This feeling, with the accompanying efforts at dislodgement, is usually worse in the morning, and the expectoration is then proportionately greater in amount. In mild cases the relief obtained through these efforts may be more than of merely temporary duration, and the patient is compelled to repeat it but a few times daily. In severe cases the secretion may be so great as to necessitate almost continually a clearing of the throat to obtain relief from the annoy- ing " dropping," as the patient usually expresses it, which may become still more aggravating from spasmodic cough caused by the irritation of the lower pharynx. The character of this discharge varies with the chronicity of the case. Early in its establishment it is thick, tenacious, clear and whitish or gelatinous in character. Later it becomes mucopurulent or purulent, and varies in color from a light yellow to a dirty shade of green. Still later it may show a decided tendency to the formation of scabs and crusts, or take the form of thick, semi-solid lumps. Saprophytic infection may take place, with the development- of a disagreeable odor, pos- sibly intensified by the fetid breath of a disordered stomach. Not infrequently the expectoration is slightly blood-streaked. The connected aural structures rarely escape implication. The hearing is impaired, and tinnitus aurium is often associated — both possibly dependent upon improper balance of the intratympanic pressure. The voice is weakened and becomes muffled and thick, clearing after expectoration. Varying Avith the severity of the case, and with individual cases, certain other symptoms occur. Thus, dull frontal or occipital headache, pain in the nape of the neck, a dull, 336 DISEASES OF THE NOSE AND THROAT. lieavy, tired feeling in the head, Avith annoying incapacity for work, either manual or mental, and possil)ly transient loss of memory may occur. Digestive disorders, exhibiting their presence in a fetid breath, coated tongue, fever, constipation, and a general atonic state of the bodily structures, are of frequent occurrence. To the symptoms referable to the nasopharynx may be added those of an aceonijwnying chronic rhinitis, pharyngitis, or laryn- gitis, with a ])r()p(>rtionate intensification of the symptoms of the disease ])r()por. The duration of the process is marked by frequent exacerbations, in no wise different from acute attacks. Inspection of the postnasal space before cleansing shows the contour of the cavity to be swollen, the orifices of the Eustachian tubes occluded, and the surface covered with the characteristic secretion, either in a roughly uniform coat or in dis- crete masses closely attached or slowly descending the pharyngeal wall. Especially is this marked over the pharyngeal tonsil, and ofttimes the pharyngeal bursa may be located by the somewhat triangular mass of secretion pointing to it. In long protracted cases swelling and relaxation of the soft palate and uvula may also be noted as concomitant occurrences, while evidences of an accom- panying pharyngitis or rhinitis may be observed. Diagnosis. — The diagnosis of simple chronic nasopharyngitis is usually not difficult. The story of the patient, his efforts at expectoration, the chronicity and personal history of the case furnish ground for a diagnosis, which the rhinoseopic examination of the ]iostnasal space readily confirms, or as readily disproves. Prognosis. — The disease is not dangerous to life, and may disa]ipear as middle age is reached ; on the other hand, it may lead to atrophic changes in the nasopharynx. The outlook as regards extension to or involvement of the connected structures, especially the ear, does not admit a positive prognosis either one way or the other. Complications. — A simple chronic inflammatory process may predisj)()se the tissues and render the individual more suscep- tible, especially in early life, to the infectious diseases, particularly the eruptive fevers. There is frequently associated gastric dis- turbance, due to the individual unconsciously swallowing the accumulated secretion, especially during sleep and on eating. Besides, the accumulated material, by its irritation not only of the nasopharynx, but the structure's below, predisposes the ])haryngeal and laryngeal structure to inflammatory processes, and not only laryngeal, but again, in turn, bronchial irritation and catarrhal affections of the air-vesicles. By the swollen and thickened mucous membrane the Eustachian orifice may be closed, and serious lesions of the ear result. Treatment. — The application of non-irritating solutions is essential. At the same time, the lony-continued and repeated use DISEASES OF THE NASOPHARYNX. 337 of such solutions may only aggravate the condition and bring on acute attacks. If the structure is markedly thickened and obstruc- tive in character, surgical measures should be promptly adopted. Local applications of astringents in the form of sprays or by means of the curved applicator and cotton pledget are highly beneficial. A slightly astringent antiseptic solution which will give good results is 1 drop of carbolic acid, 5 grains of biborate of soda, 12 drops of glycerin to 1 ounce of water. The application by means of the cotton carrier of a 1 : 2000 trichloracetic-acid solu- tion, or a 2 to 5 per cent, solution of chlorid of zinc, or 8 grains to the ounce of sulphocarbolate of zinc, or a 1 to 3 per cent, formalin solution is equally beneficial in selected cases. The selection of the astringent, as well as its strength, is determined by the severity and gravity of the case. In making the application to the postnasal space care should be taken to have the probe so curved that the posterior part of the soft palate can be thoroughly mopped, as this is the common site for the lodgement of secretion. Unless this precaution is taken, the solution will reach only the postpharyngeal wall. ATROPHIC NASOPHARYNGITIS. The atrophic lesion occurring in the nasopharynx is usually associated with the same condition in the anterior nasal cavities, although it is possible for it to occur as a separate lesion. It is well known that the inflammatory conditions of the mucous membranes do not always extend by continuity of structure, but that the process occurring in the various mucous-merabrane structures is brought about by the same etiological factor. The atrophic process occurring in the posterior nasopharynx is identical with that in the interior nares ; however, the formation of the nasopharyngeal space may have something to do with the aggravation of the condition. Frequently the individual has a very narrow nasopharyngeal space, and the posterior wall, not continuing down into the pharynx, has a slight curvature just at the point where the soft palate closes back against the nasopharyngeal wall. In such cases the attach- ment of the faucial arcli to the lateral pharyngeal wall with the anterior nasopharynx will make a pocket on each side. While in the atrophic rhinitis there is a tendency to collection of secre- tion, owing to their altered character and tcnaciousness, yet M'ith tliis pocket-formation there is an increased tendency to accumula- tion just at that ])oint. It is in such cases that the patient com- plains of the sensation of a foreign body in the pliarynx, and where there is a constant hawking, with repeated efforts to clear the throat. The same condition, as far as accumuhition of secretion and altered mucous membrane go, may also exist in the pharynx. 22 338 DISEASES OF THE NOSE AND THROAT. The accumulation within the nasopliarynx will not only take place on the postpharyngeal wall and in the pockets formed by the soft pillars in the lateral walls, but also on the posterior portion of the anterior postnasal wall. In freeing the postnasal space from these pent-up secretions this is often overlooked, and the tenacious material is left clinging to the posterior wall of the soft palate. The most serious complication of the atrophic form of naso- pharyngitis is the involvement of the Eustachian tube. Owing to the accumulation of the altered secretion, there is a suitable nidus formed for the invasion of infectious bacteria. Not only may the infectious process extend up in the Eustachian tube, but the venti- lation of the middle ear and the tympanum is markedly interfered with by the accumulation of this material about the orifice. The atrophic form occurring within the nasopharynx as a separate condition does not exist. While it may exist as such in the pharynx, yet its pure limitation to the nasopharynx has not been described. In some forms of the simple chronic rhinitis there is a marked tendency for the secretion to lodge in the nasopharynx, wdth crust- formation, but the atrophic process has not taken place in the mucous membrane lining that structure. The pathology of the changes which occur in the various forms of the atrophic process involving the mucous membranes has been thoroughly considered under the heading of Atrophic Rhinitis. The diagnosis can be easily made by the associated conditions. The prognosis is gov- erned by the same rules given under Atrophic Rhinitis occurring in the Anterior Nasal Chambers. Treatment. — In treating this condition, the same general local and systemic treatment should be emj^loyed as given in the chapter on Atrophic Rhinitis. However, much difficulty may be met with in endeavoring to free the anterior wall of the nasopharynx of the secretion. This can be done by the postnasal syringe (Fig. 116), in which a tepid alkaline antiseptic solution should be used freely. This should be followed by hydrogen peroxid (15 volume). Even with the free use of these solutions, some of the material may still cling to the nasopharyngeal structure. If, then, the curved appli- cator is used, on which a pledget of cotton is carefully wrapped, the surface may be freely mopped and many of these tenacious crusts loosened. In the very early stage, where the membrane presents a shiny, glistening appiMirauce, looking as if it is coated over with a thin layer of varnish, the prognosis is much more favorable, because at this stage there is only incipient change in the muciparous glands, with no marked alteration in the nasal mucosa. There should be administered at this stage tonic alteratives, one of the best being the compound wine of iodin (Llewellyn's) : DISEASES OF THE NASOPHARYNX. 339 ^i. Phosphori, gr. ^^ (0.0006) ; lodini, gr. i-i (0.008-0.01) ; Bromini, gr. i-i- (0.008-0.01) ; Vini Xerici, 3J (4.0).— M. all the ingredients of which are eliminated by the mucous mem- brane. At the same time, attention should be given to the correc- tion of any perverted gland-secretion by the administration of drugs having this constitutional effect. As the disease advances and the accumulations become more marked, forming slugs which are distinctly offensive, the possibility of cure becomes more remote. There is a variety of atrophic conditions of the nasopharynx, which I believe to be due largely to lesions of the stomach or various gastric disturbances. Much can be doue for the relief of this form of nasopharyngitis by the early recognition of the causa- tive factor ; yet in many cases, before any atro])hic j^rocess or dis- eased process of the nasopharynx is brought about, the remote lesion causing such condition has progressed to a chronic form, rendering cure less likely. The peculiar dry, cracking sensation experienced by the patient is most disagreeable. The accumulated secretion, by its irritation and by the violent efforts on the part of the individual to effect its dislodgement, frequently causes gagging and, indeed, vomiting. For this disagreeable dryness affecting the nasopharynx and pharynx, sprays of the essential oils will give the best results. The oil of cassia and the oil of sandal-wood, of each 6 drops to the ounce of liquid albolene or benzoinol, used either as a spray or dropped into the nostril by means of an ordinary medicine- dropper and allowed to filter through into the posterior naso- pharynx, is one of the best remedial agents. This should be repeated every two to four hours, or as often as the symptoms demand. Equally beneficial results may be obtained by mopping or spraying the surface with petroleum. Besides the relief given by overcoming the dryness, the essential oils are also beneficial in stimulating the mucijiarous glands or follicles. If ^ drop or 1 drop of the essential oil of mustard be added to the above solution, this stimulation will be markedly increased. HYPERPLASTIC NASOPHARYNGITIS. The etiology of hyperplastic nasopliaryngitis is the same as that occurring in the anterior chambers, and the variety is limited to such conditions, in whicli there is an overgrowth of the con- nective tissue of the submucosa, which is not followed by con- traction and is identical with the same ])rocess occurring in other structures, as in the so-called hypertro])hic variety of cirrhosis of the liver. The tissue usually involved in the nasopharynx is the 340 DISEASES OF THE NOSE AND THROAT. posterior and inferior ends of the turbinated bodies, especially the middle and inferior. This may be associated with the same lesion of the anterior nasal cavity, or it may be a separate and distinct process. As far as macroscopical appearance of the tissue goes, there is very little difference observed on rhinoscopic examination between the hyperplastic and the simple chronic rhinitis. However, the hyperplastic variety, while it may be lobulated, usually has a smooth surface, and the superficial growth usually resembles that of a benign tumor, and in appearance is almost identical with that of the adjacent structure. The masses may be so large, especially when the middle and inferior turbinates are involved, as to occlude the Eustachian orifice. However, in the hyperplastic variety, lesions of the Eustachian tube are not as frequent as in the atropine. The symptoms are those of post- nasal obstruction, and have been given in the previous chapters, so they do not need repetition here. . As to treatment, tiiere is only one thing to do — remove the excess of tissue. As it is a pure overgrowth or hyperplasia, it 'is not infiueuced by local applications or internal medication any more than a benigu tumor would be by such treatment. Operative interference may be made either through the anterior nasal cham- bers or through the mouth, and can be accomplished either with the curved postnasal snare (Fig. 74) or the biting-forceps (Fig. Fig. 117.— Cohen's postnasal biting- forceps. 117). The after-treatment usually consists merely in thorough cleansing of the parts with antiseptic, alkaline solutions. Should hemorrhage occur, the surface should be mopped with a 6 to 10 per cent, alumnol solution ; if the hemorrhage is severe, plugging of the nasopharynx may be necessary. SPECIFIC INFLAMMATIONS. The specific inflammations are included with those of the uvula, tonsils, and pharynx. BISEASES OF THE NASOPHABYNX. 341 NEUROSES OF THE NASOPHARYNX. The various reflex troubles associated with or dependent upon alterations in the structure of the nasopharynx have not been so carefully studied as those of other portions of the upper respiratory tract. There are, however, quite a number directly traceable to lesions of the nasopharynx. The most common which have been noted are attacks of laryngismus stridulus, general convulsive seizures, and stammering. Certain forms of gastro-intestinal trouble, like vomiting and eructation, may be reflex, but are more likely to be due to the irritation produced by the swallowing of the secretion from the nasopharynx. The aural reflexes are more a complication or result due to the inflammatory process extending to the middle ear through the Eustachian tube. The peculiar nervous temperament of the individual, which predisposes to reflex neuroses, must be taken into consideration. CHAPTER Xyi. DISEASES OF THE UVULA AND SOFT PALATE. Malformations. Eitid and Rudimentary. Elongation. Inflammatory Diseases. Acute I'vulitis. Chronic Uvulitis. Ulceration. Non-inflammatory Adhesions. Neuroses. Hyperesthesia. Anesthesia. Paresthesia. Neuralgia. Spasmodic Contraction. Paralysis. Acute Bulbar Paralysis. Chronic Bulbar Paralysis. Apoplectiform Bulbar Paralysis. Herpes of the Fauces. BIFID AND RUDIMENTARY MALFORMATIONS. The most common anomaly of the nvular continuation of the soft palate is bifurcation more or less completely accomplished, Fig. 118.— Showing congenital nl)! orilicu slu. I' of thu hard and soft pahitcs ; the Eustachian >hiinly on the right side. though con in the alveolar process, or, if placed in the arch, they will be crowded and irregular. If the irruption occurs high up, it will add to the protrusion of the upper lip, increasing the facial deformity so o5G DISEASES OF THE NOSE AND THROAT. characteristic of adenoid obstructions. " Inliorited tendency" to adenoids is often, in reality, tiie inherited family nose, children with the narrow, slit-like orifice being more prone to thickening of the adenoid striictnre than those having a wide-open nostril. As a rule, this postnasal obstruction due to adenoids interferes with both nostrils, yet occasionally it is one-sided. I have seen several such cases, and unless the obstruction be removed early in life, irregular, one-sided development and uneven facial contour is observed. The condition then may precede and be the cause of anterior nasal stenosis, or the latter condition may be a factor in the enlargement of the adenoids. The term adenoid vegetations includes enlargement not only of the pharyngeal tonsil, but also of the closed follicles situated in the mucous membrane of the posterior surface of the vault and the posterolateral walls of the nasopharynx. Htiolog"y. — Attention is directed to the glandular enlargement most frequently between the ages of three and ten years, although it may begin before the third year, or may even exist at birth. From the tenth to the fifteenth year the structure undergoes physiological atrophy. This may occur even if the tissue is not enlarged, as well as when it is the subject of pathological changes. Sex is not associated as an etiological factor. The fact that enlargement may occur in several children in the same family involves the question of heredity only as to the inherited family nose or lymphatic temperament. In constitutional dyscrasia, as in the syphilitic or tubercular condition, there is a tenden(;y to general glandular involvement, which is increased by the fact that from the lessened physiological resistance and dimin- ished vascular tone there is a tendency to sluggish circulation in lax structure, especially the mucous membrane. This will tend to engorgement and watery infiltration, more marked where the lymph-channels are numerous. Any condition bringing about anemia will produce this phenomenon. Climate is an important exciting factor, the enlargement being more common in damp climates or in locations in which there are sudden changes of temperature. This is especially true in the lymphatic type of individuals, as they are more affected by sudden therraometric alteration. The disease seems to be more prev- alent among children in the city than in the country, which may possibly be explained by the fact that children living in rural districts are healthier and are not constantly breathing a dust-laden atmosphere, a source of continuous irritation. Irritating vapors, too, may be an exciting factor in bringing about engorgement or inflammatory changes in the anterior and posterior nasal chambers. The relation and association of adenoid vegetations with the various forms of rhinitis is (juite marked. This is especially true in purulent rhinitis and the infectious inflammations, though it DISEASES OF THE TONSILS. 357 must be granted that " adenoids " may exist prior to the inflam- matory condition of the nasal mucosa, and that owing to this obstruction to nasal breathing and the tendency created by them to the accumulation of secretion Avithin the nasal chambers, a lowering of physiological resistance is established, and the likeli- hood to infection is increased. On the other hand, it may be argued that in a pre-existing infection of the anterior nasal cavity there is a discharge of the irritating material into the nasopharynx, which will excite inflammatory processes in the gland-structure. As an exciting factor, irritating materials coming from the circulatory system, as in the uric-acid diathesis, may bring about enlargement of the postnasal gland-structure. This, however, is always associated with inflammatory conditions of the adjacent mucosa, as Avell as of the other mucous-membrane tracts. Enlarge- ment of the pharyngeal tonsil and associated gland-structure of the nasopharynx does not necessarily mean hypertrophy or hyperplasia. The gland-structure may be enlarged by a natural increase in structure, due to increased blood-supply, and is in reality hyper- plastic. This structure will be rather firm, although not dis- tinctly fibrous. Again, there may be enlargement of the pharyn- geal tonsil as the residt of inflammatory processes. The organi- zation of this inflammatory material will give rise to a firmer and more fibrous mass in the nasopharynx. On the other hand, the tonsil may be increased in size as a result of interference with systemic circulation, bringing about reflex phenomena in structures remote from the site of the lesion. For example, it is a Avell- known fact that cyanotic conditions occurring in the liver, kidney, or lung will produce cyanosis in the mucous-membrane tract; that intestinal irritation with chronic constipation will produce engorge- ment of the upper respiratory tract, especially the nasal mucous membrane. In children, then, with intestinal irregularities, such as obstruction, constipation, or irritation produced by intestinal Avorms, there will result turgescence and cyanotic congestion, with watery infiltration of the nasal and postnasal structure. The pharyngeal tonsil in childhood is a normal structure, and its enlargement as described above is frequently mistaken for an increase in cellular element, when in reality it is only the normal structure enlarged by fluid-distention, either intra- or extravascu- lar. I have seen many cases of postnasal obstruction in children, which on exainiiiiitiou would seem to indicate immediate surgical interference, in which coiii])l('tp relief Avas obtained l)y tlio correc- tion of the intestinal irregularities, the most common of which I believe to be due to intestinal avoi'ius. Enlargement of the ])haryn- geal tonsil may be associated with eleft plate and also enlarge- ment of the fiuieial and lingual tonsils. Sneli conditions are allied processes ratliei' than etiological fiictors. Pathology. — The microscopical examination of the normal 358 DISEASES OF THE NOSE AND THROAT. pharvni^eal tonsil shows that it does not differ from other gland- structure of the same type ; that it is made up of fine trabeeuliB of wavy connective tissue which hold in position nests of lym- phatic cells. The surface of the gland is covered with mucous membrane in which tlie basement membrane is ill-formed and not always demctiistrabie. The layer of epithelium is usually single, the cells being of ihe columnar variety and irregularly ciliated. However, in the enlarged or inflammatory tonsil this epithelial structure varies, when there may be several layers of epithelial cells of the pavement variety, and the basement membrane will be more distinct, Pathologicallv, we reall\' have to deal with four different vari- ties of enlargement of the j)haryngeal tonsil. There is the farasites. The structure is smooth and tens(% although easily eomj)ressible. In the hdrd rarlcfi/, or liy})erplastic, there is an increase in the lymphoid structure, with a decided overgrowth in the connective- tissue element. The mucous-membrane lining is well formed, and there are usually several layers of epithelial cells. The surface is more lobulated, although smooth to the touch. Anotlier hard variety (Fig. 123) is that M^iich follows inflam- matory lesions of the lymphoid structure, in which there is inflam- matory organization in the connective-tissue element, followed by slight contraction. This (iondition is usually secondary to inflam- matory lesions of the nose and nas()])harynx, or may be brought about by thci-mocautery. In the inflammatcny stage the obstruc- tion will be more marked, due to the edema and inflammatory congestion. The macroscopical a])]H'arance of these conditions is a varying one, depending entirely on the stage of the lesion. Owing to the small nasopharynx in children, it is im])ossible to obtain a good view by posterior rhinoscopy. A better idea of the structure can Fig. 122.— Section of soft adenoid growth from a child (author's specimen). Fig. 123.— Section showing tne iiTirous .■iircmiid rrum an adult (aiithnr's specimen). DISEASES OF THE TONSILS 359 be obtained by digital examination. This can be done by carefully sterilizing the index finger of the left hand ; then having the child open its month, the index finger of the right hand is placed beneath the jaw, while with the thumb of the same hand the cheek is pressed in between the teeth. This makes a good mouth-gag and prevents the operator's finger being bitten. Frequently the gland-structure just behind and parallel to the posterior lateral pillars is enlarged, usually secondary to enlarge- ment of the pharyngeal tonsil, and will, as a rule, disappear after the relief of the enlarged tonsil. Much of the so-called recur- rence of gland-structure after removal is due to a continuation of the enlargement of the structure left instead of recurrence from the original site of removal. As a rule, the physiological pharyn- geal tonsil atrophies before the fifteenth or sixteenth year of age. If, however, it has been the site of hyperplastic or inflammatory change, it may persist into adult life or even old age, and be the source of constant irritation ; it is always associated with anterior and posterior rhinitis, a condition which was observed in a man twenty-seven years of age. Symptoms. — The clinical symptoms of adenoid vegetations are very much the same as those found in any nasal or postnasal obstruction, excejDt that they are more pronounced and more likely to produce permanent alteration in adjacent structures. The most characteristic is the peculiar facial expression, or rather the pecul- iar expressionless face, which is caused by the loss of the labio- nasal fold ; the protruding upper lip with the receding chin ; the broadening of the bridge of the nose, which is partially due to the swelling of the superficial structure brought about by interference with the venous circulation. The mouth is usually open, or, if the lips are closed, the lower jaw hangs, giving to the child a pecul- iarly stupid look. The mental hebetude and aproscxia, or inability of the patient to concentrate attention, arc the result of a number of conditions rather tlian of any one special cause. As the condi- tion is usually associated -with deafness, some of the dulness is explained by inattention brought about by inability to hear general conversation, making the child indifferent and listless. The child complains of being tired, and is often irritable, peevish, and bad- tempered ; while the mouth-breathing causes restless nights, with subsequent impairment of general heaUh, which in itself will cause impaired activity. Cohen and Allen have called attention to the fact that possibly tlie dull mental condition is due in some cases to alteration in the circulatory relation Ijctwccu the brain and naso- pharynx, either lym])liatic or vascular. TUv deleterious effects of mouth-breathing cannot be overestimated. When the postnasal obstru(;tion is only slight and when tlie nasal breathing during the day isonlv slightly obstructed, it may heeonie niorc" marked at night; in fact, the child may be a iii(//if mouth-breather, and the only 360 DISEASES OF THE NOSE AND THROAT. syraptoni (Mnnj)];iiii((l of (liiriiiu:: tlie day will bo irritation in the pharynx and larynx, tiie real canse of which may be overlooked. This postnasal obstrnction interferes with the free passage of air through the nose, and permits of aecumnlation of secretion -and the lodgement of dust within the nasal cavity, thereby causing irritation and setting up an inflammatory condition of the anterior nares, which in turn aggravates the postnasal tissue. A suitable nidus for the proliferation of bacteria is thus established, and may lead to the invasion of the accessory sinuses. This irritation also lessens the resisting power of the membrane by destroying the cilia of the epi- thelium. It is also to be borne in mind that this direct mouth- breathing will produce irritation of the pharyngeal and laryngeal structure, as the inspired air is not properly moistened or freed from dust, nor is the temperature altered before reaching the bronchial or lung-structure. As a complication, then, there will usually be spasmodic cough, with a constant tendency to take cold ; the child may be subject to attacks of laryngismus stridulus, and croup, and frequently asthma. There may be associated deformities of development, owing to imperfect breathing, such as narrowing of the chest, the peculiar chicken-breast, limiting the freedom of lung-action, thereby lessening the physiological function of that structure and predisposing the child to grave lesions of the lung. The profound anemia associated with this condition in grave cases is demonstrated by blood-examination, which shows marked interference with proper oxidation, with deleterious effect on the red corpuscles. The child may be round shouldered, ill-developed, and suifer fnnii night-sweats, which are the result of labored breathing, increased on closing the mouth. It is restless, snores, and is troubled with night-terrors. When the adenoids are large they prevent ]>roper closure of the soft palate, which allows regurgitation of food during deglutition. One of the early symptoms is the marked alteration in the character and tone of the voice, imjiarting to it a peculiar nasal twang, due to interference with nasal resonance. The enunciation and pronunciation, especially of consonants, is faulty, which may lead to stuttering and stammering. By the lowered tone and the lessened physiological resistance of the nasal and pharyngeal mucous membrane, as well as the weakened vitality, susceptibility to infectious diseases is increased. Earache and deafness are among the prominent symptoms. These may be due to the enlargement of the adenoid structure impinging on the Eustachian orifice, or there may be gland-tissue lying within the. tubal opening — the so-called tubal fovsi/. This obstruction to the Eustachian tube interferes with the ventilation of the tym- panum and leads to Eustachian catarrh, catarrhal conditions of the middle ear, and, if infection occurs, may lead to chronic suppurative conditions, with involvement of the tympaiumi and DISEASES OF THE TONSILS. 361 possibly bony necrosis. In at least 90 per cent, of cases of ade- noid vegetation there is involvement of the Eustachian tube with deafness in a varying degree. There is no doubt, in some cases in which the deafness is only slight, followed by atrophy of the gland-structure, that the deaf- ness will entirely pass away ; but, as a rule, by the time atrophy takes place, permanent pathological alterations have been produced within the Eustachian tube and middle ear. Epistaxis, usually at night, may occur ; but, as a rule, the bleeding is very slight and is shown only by the blood-stained secretions. When the vegetations are low down in the nasopharynx, wath enlargement of the gland-structure behind the posterior pillars, the child will often complain of choking, when swallowing fluids. Enlargement of the faucial tonsil, relaxation of the soft palate, and elongation of the uvula are frequent concomitants of adenoid growth. The glands at the angle of the jaw are almost always enlarged. From the inability of the child to breathe through the nose there may be collapse of the nasal alse, with atrophy of the nasal muscles, and owing to mouth-breathing the patient Avill suffer from dry mouth — xerostoma. There may also be a partial or complete loss of the sense of taste. The difficulty of breath- ing is increased while eating, owing to the fact that the child is compelled to use the alimentary tract as a substitute for the re- spiratory tract. This will cause the swallowing of air with the food, and there will be eructation of gas after meals. Owing to the accumulated mucus in the nasopharynx and pharynx, together with the thickened gland-structure, the irritation produced will give rise to the constant desire to swallow. There is frontal head- ache, the eyes are dull, and the conjunctiva is frequently inflamed ; the sense of smell may be slightly affected, due to the congestion causing pressure on the terminal nerve-filaments. The symptoms given above will not all exist in any one given case, but will vary in intensity and in gravity, and depend in great measure on the location and size of the enlarged gland-elements. The shape of the nasopharynx also has much to do Avith the symptoms produced by glandular enlargement, as in some cases the cavity may be large enough to permit of marked distention without producing much obstruction to respiration. Indeed, considerable adenoid structure may exist in the central portion of the nasopharynx and produce no symptoms \\hatever. As tlic coiiditiitn is often associated witli various forms of rhi- nitis, there will also exist at the same time the symptoms iieeuliar to such form of inflammation. Diagnosis. — In early cliildhood one of the best points of diagnosis between adenoid vegetations and other obstrnrti\-e lesions is the irregularity in the teeth, together with the peculiar facial 362 DISEASES OF THE NOSE AND THROAT. oxprossioii, tlie characteristic altomtion in the voice, and the asso- (•iatcd lesions of the ear, pharynx, and larynx. Tumors of the nasopharynx rarely occur as early in life as adenoid vegetations. Rhinoscopic and digital examination will reveal the character and location of the structure. Prognosis. — If the condition is recognized early and prompt removal is accomplished, the prognosis is good. If, however, the gland-structure is allowed to remain until the bony framework is fixed, perfect nasal breathing may never be established. The effect on hearing depends upon the amount and continuance of the obstruction. Treatment. — Any impediment to the entrance of air through the upper or lower air-passages, especially in infancy and child- hood, gives rise to symptoms which call for (piick recognition and demands early and prompt relief. In this one instance radicalism is less dangerous tiian inactiviiy. The successful treatment of enlarged gland-structure in the nasopharynx depends largely on its early recognition and prompt removal. This does not always demand operative interference, but in the majority of cases opera- tive measures to some extent will be necessary. The general con- dition of the patient should be looked into, and any existing constitutional diathesis corrected. In the cases in which the enlargement is largely edematous and due to intestinal irritation, treatment directed to the intestinal tract will usually give prompt relief to the nasal obstruction. This is of necessity controlled by the existing symptoms in individual cases. The soft variety of adenoids will not demand the same ener- getic surgical interference which will be necessary in the hard variety. In the very young, in whom the gland-structure is quite soft, all that will be necessary is to insert the index finger in the nasopharynx and lacerate the gland-structure by scraping with the finger-nail ; this will not require an anesthetic, cither local or general. Slight inflammatory action will follow, and absorption will take jilacc. There is very little bleeding, with practically no pain. This operation should be done under measures as strictly antiseptic as possible. The nasopharynx should be carefully cleansed with a warm alkaline solution consisting of 8 grains of biborate and bicarbonate of soda to the ounce of water, followed by hydrogen ])or()xid and aqueous extract of hamamelis, in equal parts. The index finger should be carefully sterilized, particular attention being given to the finger-nail. One case obs(>rved in my clinic at the Jefferson Medical Col- lege Hospital, a child seven weeks old, with adenoids which evidentlv from the symptoms had existed since l)irth, revealed the gland-structure occluding the nasopharynx, the child being unable to feed without stopping at every act of swallowing to breathe through th(» mouth. The gland-structure was very soft, and easily DISEASES OF THE TONSILS. 363 crushed and removed Avith the finger. JSTo anesthetic was given. In two days after the operation, the child was breathing freely through the nose and able to feed naturally. The after-treatment should consist in the thorough cleansing of the nasopharynx, by means of a postnasal syringe, with a boric- acid solution, 8 grains to the ounce. This should be continued as long as the secretions are blood-stained. If there is much irrita- tion, after the cleansing there should be applied every other day to the surface, by means of a curved applicator, a solution of the tincture of benzoin and 50 per cent, boroglycerid. However, often no after-treatment is necessary. Equally good for local application is the benzoate-of-soda solution, 10 grains to the ounce, or 3 per cent, chlorid of zinc. From its good effects elsewdiere, I would suggest the application of glycerinated extract of suprarenal capsule. If the tissue is very sensitive, good results can be obtained by the local applica- tion of a -^-Q of 1 per cent, formaldehyd in 4 per cent, cocain. Good astringent effects may be obtained by applying a solution containing 8 grains of alum and 4 grains of tannic acid to the ounce of M'ater. The existing conditions may be such as to demand immediate radical surgical interference — as the procedure given above applies only to the very soft variety. In the removal of the pharyngeal tonsil it must be remembered that it is not a new growth in the nature of a neoplasm, but simply an enlargement of a physiological structure, and that the ablation of such gland-structure is demanded only when it is interfering with nasal respiration, when its presence is deleterious to the child's health, or when it produces lesions of associated structures. Operative interference raises the question of anesthesia. In children it is better to give a general anesthetic than to use a local one. The selection of the anesthetic is determined by the condi- tion of the individual and the extent of the surgical interference. There is less shock, too, from the operation when anesthesia is employed ; besides, the case can be observed longer after ojiera- tion — especially clinic cases — and often complications after opera- tion can be averted. Where profound narcosis is not necessary, the nitrous oxid and oxygen gas, after the method of Casselberry, is quite sufficient. Where the operation is likely to occupy more time, and where it may be necessary to remove a portion of the faucUil tonsil, ether should be employed. Personally I prefer chloroform with oxygen, and when achiiiuistered by a competent anesthetizer, I think it is as safe an anesthetic as can be employed ; besides, it is rapid in its effect, and the after-effects are not so bad, as in the case of ether. Neither nitrous oxid nor chloro- form produces so much turgescence of the mucous membrane as ether. When the patient is completely under the influence of the 364 DISEASES OF THE NOSE AND THROAT. anesthetic, he should be placed on the table in such a position as to allow the head to drop over the edge of the table, or, if an oper- ating table is used, he should be placed in a modified Trendelen- burg position. By inserting the mouth-gag, drawing the tongue forward, and elevating the uvula a part of the nasopharynx will be exposed, giving a fair view of the field of operation. A modified Gottstein curet (Fig. 124) should be used. The blade is not so large Fig. 124.— Gottstein's adenoid curet. as the original instrument ; the curved portion is a little longer and the curve more pronounced. In some cases the adenoid structure is small in amount, but located high up in the vault of the naso- pharynx, thereby causing marked obstruction. In such cases the curet shown in Fig. 125 should be used. It can be passed through Fig. 125.— Author's adenoid curet to be used through the nose. the nose, and the finger passed into the nasopharynx will guide the instrument. If the field of operation cannot be even partially exposed, the Gottstein curet should be guided with the index finger, care being taken not to lacerate the structures around the Eustachian orifice. The after-treatment should consist in frequent cleansing of the nasopharynx with a warm alkaline solution, applied by means of the nasal douche or postnasal syringe. It is well to kee]5 the patient quiet for two or three days. If there is enlargement of the fiiucial tonsil to such an extent as to demand removal, this should be done before the removal of the adenoids. There is very little danger from hemorrhage in either case, unless from an anomalous vessel. If marked bleed- ing should occur from the nasopharynx, it can usually be controlled by compressing into the nasopharynx a large pledget of cotton and exerting pressure for a few minutes. Secondary hemorrhage rarely ever occurs, but should it take ])lace and be of an alarming character, the postnasal space should be packed with gauze. Heal- ing usually takes place rapidly, the only cases in Avhich it is delayed being those of strumous or tubercular tendency, which are more likely to become infected and lead to ulcerative proc- DISEASES OF THE TONSILS. 365 FAUCIAL TONSIL. Inflammatoiy Diseases. a. Acute: 1. Acute Superficial Tonsillitis. 2. Cryptic Tonsillitis. 3. Klieumatic or Gouty Tonsillitis. 4. Herpetic Tonsillitis. 5. Tonsillar and Peritonsillar Abscess. 6. Membranous Inflammation of the Tonsil. 6. Chronic : 1. Enlargement or Hypertrophy of the Tonsil. 2. Caseous Tonsillitis. 3. Chronic Abscess of the Tonsil. 4. Atrophy of the Tonsil. 5. Mycosis of the Tonsil. c. Foreign Bodies in the Tonsils. The faucial tonsil is, in reality, a large lymphatic gland. From its intimate vascular and lymphatic connection with tissue and its exposed position it is an important structure from a pathological standpoint, as it is the site not only of local pathological changes, but also of pathological alterations which may be local manifesta- tions of a constitutional condition. Again, the tonsillar structure, when subjected to superficial ulceration, may form a channel for systemic infection. The local primary infection may be associated Avith involvement of other pharyngeal and laryngeal structures, as is observed in the eruptive fevers, diphtheria, scarlet fever, small-pox, and measles. Irritating materials in the blood may also be an exciting factor. This is especially true in the rheumatic and gouty diatheses, or in any form of intestinal obstruction in which there is absorption of toxic material into the systemic circulation. In all forms of anemia there is a tendency to pathological alteration in the lymphoid structure of the tonsil. The inflammatory process may be limited to merely the mucous membrane covering the tonsil and extending over adjacent structures. This is known as acute superficial or catarrhal tonsillitis. In reality, many of the different varieties of inflammation of the tonsil differ only in degree and cause, the severity of tlie attack determining the pathological alteration. When the inflammation involves the crypts or lacunae, it is known as cryptic (lacunar) tonsillitis. If the whole gland-structure of the tonsil is involved, it is known as parcnchy- matoufi tonsillitis. Occasionally the lacunar variety may go on to ulceration, and is known then as ulcerative lacunar tonsillitis. However, in any form of inflammation involving the tonsil, ulcer- ation may occur. This is true whether it be due to a gouty or a uric-acid diathesis, whether it be ns.^^ociated with an infectious proc- ess or due to inflammation extending from adjacent structure. 366 DISEASES OF THE NOSE AND THROAT. ACUTE SUPERFICIAL TONSILLITIS. Definition. — An acute inflamnuitorv process involving the mucous nicuibrane covering the tonsil, which may also involve the crypts and deeper structure, and either spread through or be caused by inflammation of adjacent structures. Synonyms. — Acute catarrhal tonsillitis ; Tonsillitis ; Acute catarrhal angina. Ktiology. — Acute inflammation involving the mucous-mem- brane lining of the tonsil is most common in children and young adults. This may be explained by the fac^t that the lymphoid structure is at its full development at this age, and with increased years undergoes atrophy, with a lessened likelihood of inflamma- tion. Many cases of the acute angina are due to exposure to cold or sudden thermic changes. They also may be brought about by injury, either direct to the tonsil or of adjacent structure. Direct irritation may be mechanical, or may be the result of irritating fumes, vapors, scalds, or inhalation of steam. Irregularities in the respiratory tract causing mouth-breatliing may also predispose. Systemic involvement, with lowered vascular tone, is also an important predisposing factor. Gastro-intestinal involvement through venous stasis may predis])ose to acute tonsillitis. The simple variety may predispose to a more serious aflPection, as the secretion and inflammatory exudate which collects in the crypts will form a suitable nidus for bacteritic infection. Secondarily the deeper structure may be involved, and superficial tonsillitis become a parenchymatous one. Pathology. — The pathology is that of a catarrhal inflamma- tion of any mucous-membrane surface. The inflammatory process may undergo resolution and return to the normal, or the secondary infection may entirely alter the variety of inflammation and be followed by superficial necrosis (ulceration). Symptoms. — The symptoms vary much in severity. There is usually a feeling of malaise, slight headache, stifliiess in the muscles of the neck, a slight chill followed by fever. At first there is slight pain on swallowing, with the sensation of a swell- ing ; and, as the case progresses, the pain may be continuous, although aggravated by deglutition. As the case grows worse, movements of the head and neck become painful, and there may be actual torticollis. The surface of the tonsil is deep red in color, and slightly edematous-lookiug ; the surrounding structures, espe- cially the palate and uvula, are similarly involved. As the inflam- matory exudate increases, the crypts will become filled with serum and fibrin resembling patches of membrane. There may be reflected pain in the ear, and by the vascular alteration there may be tin- nitus on the aflPe(!ted side. Owing to the alteration in the vas- cular supply about the epiglottis and vestibule of the larynx, there DISEASES OF THE TONSILS 367 will be marked alteration in the voice. The voice may also be altered owing to interference with nasal resonance from the involve- ment of the uvula and soft palate. In children the symptoms may be much more aggravated and the onset more sudden. There is a marked tendency to recurrence, and the repeated attacks will cause marked permanent enlargement of the tonsil. In this super- ficial variety there is rarely any glandular involvement. Diagnosis. — In this variety both tonsils are frequently involved. The rapid course of the disease, the associated clinical phenomena, and the absence of the adherent membrane, either on the tonsil or adjacent structure, will aid materially in the diagnosis. Progtiosis. — The prognosis is good as regards recovery from the immediate attack, but there is great likelihood of recurrence. Complications. — Occasionally, after the acute phenomena have passed away, there may be relaxation of the vocal bands, caused by congestion about their base. This loss of voice may come on when all soreness in the tonsil has disappeared. Occasionally there may be catarrhal or purulent otitis media. There may be elongation of the uvula, due to relaxation of the soft palate. Treatment. — If the patient is seen early in the attack, much can be done toward shortening the attack and lessening its sever- ity. There should be administered at once a purgative — calomel, grain ^, and sodium bicarbonate, grain 1 — every hour for six doses, followed by a saline such as a Seidlitz powder, and the tonsils should be carefully touched with pure guaiacol. This should be not only on the outer surface, but the crypts should be mopped as well. The application should be made by means of cotton tightly wrap- ped on a probe, being careful to remove the excess of guaiacol before applying to the membrane, so as to prevent the solution running over the surrounding structures. This procedure should be repeated not oftener than every third hour for three applica- tions. Usually three applications suffice to abort the attack. If not effectual after the tliird application, the use of the guaiacol should be discontinued. At the same time there should be given internally from 15- to 20-drop doses of ammoniated tincture of guaiac in wine or milk — each dose at an interval of two houi's. Instead of the internal administration of the guaiac there may be used 15 to 30 drops of tincture of chlorid of iron every three hours, or a capsule containing bromid of quinine 2 grains, extract of belladonna |- grain, and salol 3 grains, one capsule every three hours. If, from the character of the onset and symptoms, a severe attack is anticipated, the patient should be put to bed and a 5- to 10- grain Dover's or 5-grain Tully's ])o\vder a breath foul. Thirst is constant. The marked clinical phenomenon which accompanies all inflammatory processes — that of perverted secretion — is quite marked in this variety of tonsillitis. There is obstinate constipation ; the urine is scanty in amount, high-colored, contains an excess of urea and urates, and often a marked amount of indican, with usually a harvngcal structure, with threatened edeuia of the glottis. As the structure goes on to suppuration, all of these symptoms will increase, swelling of the external tissues becomes more markcid, deglutition more difficult, due to the inability of the patient DISEASES OF THE TONSILS. 377 to open his mouth. In some cases this condition closely resembles lockjaw. On account of the swelling and extreme pain on motion, the patient is unable to open his mouth. There is marked tender- ness externally at the angle of the jaw, with excruciating pain on pressure. At the onset there may be pronounced rigor followed by repeated chills, the breath is excessively foul, the tongue coated with a brownish, furry material. As a rule, the amount of pus- formation does not correspond with the severe and excessive clini- cal phenomena. Spontaneous rupture may occur at the most dependent portion, or in grave and especially infected cases there may be a necrosis and partial sloughing of the tonsil ; but, as a rule, the symptoms will demand surgical interference before such extensive necrosis can take place. Occasionally the suppurative process may be followed by ulceration ; but, as a rule, upon the relief of the pent-up pus the tissue goes on to rapid healing. In the tonsillar abscess the symptoms are almost identical with the peritonsillar, although not so severe. The external swelling and glandular involvement, as a rule, are only slight. The sup- puration may not be localized, but there may be minute abscesses formed here and there through the tonsils. These may be deep in the structure and require puncture, or they may open sponta- neously. The fluctuation described by some writers is difficult to elicit on account of the extreme swelling and edema of the parts rendering all the structures tense, and, even if free access could be had to the tonsillar structure to admit of palpation, the pain would be so great as to preclude tliat means of diagnosis. The severity of the symptoms will depend largely on the systemic condition of the individual and whether there is any associated dis- ease. When occurring as a complication in measles, scarlet fever, t3'^phoid fever, or influenza, it is apt to run a slower course and is usually of graver import. This is determined, however, by the generally bad nutrition of the individual. Fortunately, tonsillar and peritonsillar abscesses are generally unilateral, although both sides may be involved. Complications. — Serious complications may arise by the spreading of the abscess, through gravity and the line of least resistance, into the deeper cervical structures, thus causing pointing externally ; or from the surrounding inflammatory condition, with watery exudate into the intercellular spaces, there may be threat- ened edema of the glottis. By the pressure and swelling extend- ing up into the nasopharynx, the Eustachian orifice may be occluded, with subsequent middle-ear inflammation, or even su])- puration. If the abscess is dce])-seated and there is extensive necrosis, there is a possibility of the involvement of the internal carotid artery, or even thrombosis of tlie jugular veins. However, these are exceptional complications. Tiiere may be thickening of the tonsillar structure as a result of the inflammatory process, with 378 DISEASES OF THE NOSE AND THROAT. after-contraction, leaving the tonsil lobulated and irregular. Nearly always there is adhesion between the tonsil and the anterior and posterior ])alatine arches (Fig. 129). Diagnosis. — The diagnosis is based on the clinical phe- nomena — the external and internal swelling, difficult deglutition, pain in the ear, threatened edema of the glottis, inability to open the mouth — together with the previous history. The hypodermic syringe or aspirator is a usefid instrument for diagnosis. Even where there is not marked external swelling, in all cases in which the patient is not able to open the moutli, peritonsillar abscess should be suspected, as there are several hospital cases on record in which the individual died of suffocation before a spontaneous o]iening of the abscess occurred, the condition somewhat resem- bling lockjaw, thereby misleading the diagnostician. Prognosis. — As far as recovery is concerned, the prognosis is good. This, however, is determined by the early recognition of the abscess and the prompt surgical interference. Treatment. — Usually mu'-h relief can be afforded the patient before actual suppuration has occurred. A brisk purgative should be administered. There should l)e given internally 15- to 20-drop doses of tincture of chlorid of iron, either alone or in combination with glycerin, 10 to 30 drops. This should be administered every two hours for six or eight doses. A 10-grain Dover's powder given at bedtime affiirds great relief. Scarification of the tissue or deep puncture will relieve the tension, and in some cases may prevent suppuration. The tonsil should be opened with a sharp-pointed knife or curved bistoury, incision being made at the dependent portion or where, from inspection, the abscess shows pointing. The edge of the knife — ex(;ept the actual cutting surface to be used — slu^uld be carefully wrapped with cotton or adhesive plaster, so as to avoid wounding adjacent structures. The knife shown in Fig. 40 is well adapted for this purpose. Incision should always be made from the tonsil toward the pharynx, so as to be direct(Ml away from the blood-vessels lying external and anterior to the tonsil, thereby lessening the danger of wounding these structures. MEMBRANOUS INFLAMMATION OF THE TONSIL. Synonyms. — Membranous tonsillitis ; Fibrinous tonsillitis. There are a number of conditions of infection of the tonsil in which there is formed on the surface or within the crypts a mem- brane closely resembling that found in diphtheria. Frequently the caseous material forming within the crypts of the tonsil and extend- ing to the orifice will appear as a localized membranous inflam- mation. Again, in conditions assoitiated with streptococcal infection, mem})rane is quite often formed on the j)illars, on the tonsil, and even on the pharyngeal wall. In gastric disorders and intestinal DISEASES OF THE TONSILS 379 lesions the whole pharyngeal and faucial membrane may become reddened and inflamed, and frequently there are associated slight membranous patches. Membrane may form on the tonsil after the cautery or application of escharotics. The pathology of the condition is almost identical with that found when the infection is due to the Klebs-Loffler bacillus. There is a local coagulation-necrosis of the super- ficial epithelium, with surrounding areas of inflammation. Occa- sionally, from the absorption of the toxins manufactured by the staphylococci, streptococci, and pneumococci, which are nearly always present, there are marked systemic manifestations. Bacteriological examination of the mucous membrane of the throat shows clearly that even in health there are present numerous bacteria which under pathological conditions would be called etiological factors in the disease ; at the same time, with the mucous membrane normal these bacteria are non-virulent, and it is only when the physiological resistance of the membrane is les- sened by some inflammatory condition that the non-virulent bac- teria become virulent and pathogenic, and frequently, by micro- scopical examination, to the bacteria present are credited certain pathogenic properties, w^hen in reality they are merely associated germs. The organisms present are in reality of secondary impor- tance. They are not so much etiological factors as is the inter- vention of some exciting cause, such as exposure, surgical operation on the tonsil, lesions of adjacent structures, or the lowered general vitality of the individual — the resultant localized inflammatory process forming a suitable nidus for the proliferation of the bacteria. The condition may progress, and, the deeper structures becoming involved, there will be produced localized ulcers, multiple or sin- gle, giving rise to the so-called ulcerative tonsillitis. This is more marked when the crypts are extensively involved. The ulcerative variety is not a distinct and separate variety, but the ulcers may be due to a number of causes, may occur in the ordinary simple, superficial inflammation, or may be associated with the parenchym- atous or lacunar variety. The symptoms are rarely very alarming, although from infec- tion through the lymphatics there may be enlargement of the glands of the neck, constant pain in the tonsil, increased by deglutition, offensive breath, partial loss of voice, due to the extension of the inflammation to the base of the tongue and the preglottic structures. Infection may lead to pharyngeal inflammation and possibly abscess- formation ; however, if treatment is instituted early, the com])lica- tions are few. Treatment. — The treatment should consist in the thorough cleansing of the tmisil l)y antiseptic; solutions, preferably by mop- ping the infected areas with a 15 volume hydrogen-peroxid solution, followed by a 1 : 500 pyoktanin solution, or, instead, the localized 380 DISEASES OF THE NOSE AND THROAT. areas should be toiiehed with a 3 to 5 per cent, solution of chlorid of zinc, or Loffler's solution. The intestinal tract should be thor- oughly cleansed' with purgatives and salines, and the patient's general healtii should be improved by the administration of tonics. ENLARGEMENT OR HYPERTROPHY OF THE TONSIL. Synonyms. — Hyperplastic tonsillitis ; Hypertrophic tonsillitis. Of the enlarged or hyperplastic tonsil there are two varieties — one in which the structure is very soft (Fig. 127), and in which the increase in actual structure is largely of the glandular type, with very little alteration of the connective-tissue element ; while in the other variety there may be considerable increase in the actual gland-element, yet the most marked increase is in the con- nective-tissue stroma (Fig. 128), giving rise to the firm, hard, lobulated tonsil. It must be remembered that an enlarged tonsil does not necessarily mean an actual increase of tissue-elements in the sense of hypertrophy, or hyperplasia, or inflammatory thicken- ing, for the enlargement may be due to vascular changes, venous stasis, or watery iuHltration into the tonsillar structure. It must also be borne in mind that in children the tonsils are normally large and that, because the gland-structure extends beyond the pillars of the fauces, the enlargement is not necessarily pathological. The term hypertrophy is commonly applied to any enlargement of the faucial tonsil, when, in reality, many of the enlargements are not true hypertrophies, but purely inflammatory or hyperplastic. Htiology. — The causes of the various enlargements of the tonsil cauuot be classified under any one special head, as the increase in size may be due to a number of factors. The condi- tion is more common, however, in children of inherited strumous diathesis, or in individuals of acquired constitutional dyscrasia. Inherited diatheses are often illustrated by the fact that several members of the same family have enlargement of the tonsil. A chronic inflammatory process, as a result of gouty or uric-acid con- ditions, is one of the common causes. The condition is practically one of childhood and early adult life, being most common at the age of puberty. Sex does not seem to exert any predisposing cause. Associated lesions of the throat are important etiological factors. Climate may predispose to local inflammation not only of the tonsil but of adjacent structure. The specific inflammatory processes act as predisposing causes through the lowered vitality produced by them. Because the tonsil possesses numerous crypts it is subjected to a greater amount of irritation and is more liable to chronic inflam- matory changes. The acute infectious diseases of childhood are fre(piently followed by chronic tonsillar lesion and permanent enlargement. Enlargement of the tonsil may also be due to inter- ference with venous circulation. Especially is this true in cardiac, Fig. 127.— Section of soft faucial tonsil (author's specimen). Fii;. 128.— Section showin.i,' the hard fibrous tonsil after chronic inflammation, caustics, or DISEASES OF THE TONSILS. 381 pulmonary, hepatic, renal, or intestinal lesions where there is per- version of the venous return or damming back of the returning circulation. This always produces cyanosis of mucous structures. When such conditions exist, there is an enlargement of the tonsil of the soft, boggy variety, which is largely due to watery infiltration or leaking of the serum from the blood-vessels into the surrounding structures, wdth a slow, chronic, inflammatory change. Repeated attacks of tonsillar or peritonsillar abscess are causative factors, the enlargement, however, being an inflammatory increase in the connective tissue. Pathology. — In hypertrophy of the faucial tonsil there is an increase in the glandular as well as the connective-tissue ele- ments. In the soft variety (Fig. 127) the glandular structure pre- dominates, and the clusters of glands are held together by a fine trabecula of connective tissue. The tissue, both glandular and connective, does not differ from the normal tonsillar structure. However, in some cases in which the chronic inflammatory proc- ess is more pronounced, the connective-tissue framework will be largely increased (Fig. 128) and dense in character, as is shown by the marked resistance on attempting removal with the tonsillo- tome. This marked fibrous character of the connective tissue can be explained by the organization of inflammatory material. The same fibrous-tissue formation will follow the cautery. If it were truly hyperplastic, although the connective-tissue element might be in excess, it would show no tendency to contract. In the varie- ties, then, in which the connective-tissue element is distinctly fibrous, the tonsil is markedly lobulated, the crypts are deeper and more irregular in shape, and by involvement in the fibrous contraction their openings may be decidedly narrowed. In this variety there would be an increased tendency to the accumulation of material within these crypts, which in turn will act as an irri- tant, bringing about further inflammatory reaction and tending to aggravate the condition. In the variety of enlargement in which the connective-tissue element is more hyperplastic in type and in which the contraction is less marked, the crypts are less saccular and not so prone to the retention of caseous material. In the enlarged tonsil, in which the increase in the structural elements is due to chronic irritation such as would be produced in a gouty or uric-acid diathesis, the tonsillar thickening is more regular and diffused throughout the entire gland-structure. When due to repeated inflammatory attacks, it is more irregularly fibrous, and hence, when contracting, produces a more irregular, lobu- lated tonsil. Th(! soft, boggy variety is largely influenced by climatic conditions, as well as by the general vascular condi- tion of the individual. The soft \'ariety and the true hyper- ])lastic variety usually atrojihy in adult life; but occasionally this docs not take place, and the individual is left Avith a per- 382 DISEASES OF THE NOSE AND THROAT. raanently enlarged tonsil. In an enlarged tonsil due to inflamma- tory thickening tiiis physiological atrophy is less likely to occur, although the tonsil is often diminished in size by the contraction of the organized inflammatory tissue — a pressure-atrophy. This last variety is also more likely to be associated with inflammatory processes in adjacent structures, with the consequent org:anization of adhesions between the tonsil and faucial pillars (Fig. 129). The symptoms produced by such adhesions are often productive Fi<;. 129.— Enlarged glands in the soft palate : also enlarged veins on the pharyngeal wall, with adherent tonsil. of symptoms as grave as those of the enlarged tonsil. The tonsil of this character is likely to remain as a hard fibrous mass and Avitli the resulting contraction of the inflammatory tissue be a con- stant source of irritation, producing symptoms similar to chronic pharyngitis. Besides, from the fibrous contraction there is glan- dular enlargement in the soft palate and pillars of the fauces, as seen in Fig. 129. Symptoms. — The tonsils may be so large as to fill the throat almost entirely. Cases have been reported in which they have touched, and from ulceration have become adherent one to the other. There is marked interference with nasal res])i ration, and on account of the enlargement of the tonsils there will be imperfect mobility of the uvula ; on swallowing food and fluids, regurgita- tion into the nasopharynx will take place. Frequently, from press- ure, the p]ustachian orifice may be involved, either directly or by extension of the inflammatory })rocess. On account of interfer- ence with the nasal respiration, the child is apt to become a mouth- DISEASES OF THE TONSILS. 383 breather, with subsequent pharyngeal and laryngeal irritation. The facial expression is very similar to that of adenoid vegeta- tions, although not so pronounced. The child is restless at night, and is frequently disturbed by a rasping, hacking cough, brought about largely by mouth-breathing. Quite frequently, enlargement of the tonsil is associated with adenoid vegetations, and, when such is the case, the symptoms as described in that chapter will be even more aggravated. The systemic effect of interference with nasal respiration will be marked ; the child will be anemic, languid, and mentally and physically below par. Not only is nasal reso- nance altered, but there is also marked interference with articula- tion, on account of the enlargement of the tonsil not only imped- ing the tone, but impinging upon the muscles of phonation, as well as those at the base of the tongue: Because of the probabil- ity of involvement of the Eustachian tube from the faucial tonsil, or from the associated enlargement of the pharyngeal tonsil, there is likely to be serious middle-ear lesion. Deglutition is markedly interfered with, especially in children. Although some question the fact that the faucial tonsil ever interferes directly with the orifice of the Eustachian tube, in some cases this undoubtedly does take place. If the Eustachian orifice were always in what is termed its normal location, this possibly would not often occur ; but it must be remembered that the position of the Eustachian orifice varies, and that in some cases it is quite low down and directly back of the posterior faucial pillar, where it would be subjected to pressure from an enlarged tonsil. With the enlarged tonsil, adhesions to the palatine folds are nearly always present. As these adhesions are of inflammatory origin and are always fol- lowed by contraction, the extent and location of the adhesion will have much to do with the macroscopical appearance of the tonsil. An enlarged tonsil may be more a source of discomfort than an actual disease. There is a constant sensation similar to that pro- duced by a foreign body in the throat, often combined with gastric phenomena, and the patient is easily nauseated. A number of reflex neuroses may be produced, especially bronchial and asthmatic cough. As a rule, ail the symptoms are aggravated when the patient is in a recumbent position. The condition is rarely, if ever, congenital. Much has been said in regard to the tonsils as a source of infection and contagion. It is unquestionably true that the irregular nodular surface of the tonsil, with its numerous crypts, forms a suitable nidus for develo])ment of bacteria, and in the infectious processes involving the upper respiratory tract, ton- sillar involvement becomes a serious complication. The open lymj^liatic networlv gives free access to the absorption not only of pathogenic bacteria, but also of the toxins produced by them. Diagnosis. — Tli<' diagnosis of enlarged tonsil is not diffi- cult. Tlic mere visual cxaiiiinatiou is ii.-iially siilficiciit. Dimtal 384 DISEASES OF THE NOSE AND THROAT. examination avIU at once detennine tiie cliaracter of the enlarge- ment. Prognosis. — Many eases of enlarged tonsil eontinue untreated throiigh life ; some undergo physiologieal atrophy and leave behind practically no pathological alteration in the structure ; although, as a rule, if occurring early in life and allowed to pro- gress without surgical or medical interference, there is usually associated maldevelopment, in addition to permanent pathological alteration in the adjacent structures. The })rognosis, from the standpoint of treatment, is good, either through medical or sur- gical interference. Occasionally, through anomalous blood-vessels, the ablation of the tonsil may lead to serious complication, giving rise to alarming and, indeed, fatal hemorrhage. Treatment. — From the standpoint of treatment of enlarged tonsil there are really two conditions to be considered. There is the tonsil enlarged, firm, and dense, in wliich there is marked increase of the connective-tissue eleinent, and the soft, boggy, spongy tonsil, containing very little connecti\e tissue. It must be remembered, in the treatment of either condition, that the age of the patient, the amount of inconvenience or irritation produced by the enlargement, and the underlying systemic condition must be considered. In children and young adults the tonsils are usually large, and, unless they give rise to irritating symptoms or inter- ference with deglutition and phonation, require no treatment. This is equally true in advanced adult life. When the condition is such as to demand treatment, local applications are of little use in the fibroid variety. The contour of the tonsil will determine the treatment somewhat. If the surface of the organ be regular, the removal of a small jjortion (fonsillotomi/) by means of the tonsil- lotome (Fig. 130) will, by reason of the contraction of the scar- tissue which necessarily follows, materially reduce its size, the object of this procedure being merely to relieve the symptoms without the removal of the entire tonsil, as its presence is physi- ological. If the surface is irregular, nodular, and pedunculated, the various projections may be removed by means of the tonsil- scissors (Fig. 131). The after-treatment in either case consists in keeping the parts thoroughly cleansed by means of astringents and antiseptic gargles, such as biborate or biearl)onate of soda, 10 grains DISEASES OF THE TONSILS. 385 to the ounce of water, to which is added 1 to 5 drops of carbolic acid. This can be accomplished only to a limited degree, as it is impossible to render the tissues in this position thoroughly anti- septic. In the soft, spongy variety the parts should be thoroughly cleansed and dried, and the tonsillar tissue as well as the tonsillar crypts carefully mopped with dilute hydrochloric acid applied on Fig. 131. — King's tonsil-scissors with serrated cutting edg a cottou-covered probe, after carefully removing the excess of the acid. This treatment continued every other clay, together with attention to the underlying general systemic conditions, will generally afford relief. In children particular attention should be paid to the intestinal tract, as any irregularities there tending toward constipation undoubtedly influence this gland-structure. Attention should also be paid to any systemic condition liable to cause cyanotic congestion. The application of the dilute hydro- chloric acid must be continued for from ten days to six weeks. Even after sufficient reduction of the enlargement to relieve the irritating symptoms, there is a tendency to recurrence of the con- dition. If, then, the application of the dilute hydrochloric acid only gives temporary relief, linear cauterization may be resorted to. Tlie line of cautery should be made in the long axis of the tonsil, thereby lessening the liability of involvement of the faucial pillars ; or the puncture method at the base of the tonsil will give equally good results. The subsequent contraction permanently diminishes the tonsil. If the tonsil is enormously enlarged, boggy, and with large crypts in which there is a tendency to accumulation, associated with the condition known as caseous tonsillitis, the tonsil should be removed (tonsillectomy) by means of the tonsillotome, as shown in Fig. 130, or by the cautery tonsil-snare, shown in Fig. 132. As a Fig. 132.— Knight's electric tonsil-snare. rule, the bleeding after such removal is only slight ; but occa- sionally from anomalous vessels, or from cutting too deeply in the structures, severe hemorrhage may take pUicc. In such cases the tonsillar tissue should be grasped by means of hemostatic forceps, and traction made to draw the stump directly away from the 25 386 DISEASES OF THE NOSE AND THROAT. pharyngeal wall, so as to permit of a ligature being thrown around the entire pedicle. This should be drawn sufficiently tight to pro- duce strangulation, and left on long enough to permit of clotting. Should this procedure fail, the instrument shown in Fig. 133 should be used. Fig. 133.— Butt's tonsillar hemostat. In considering the subject of hemorrhage after the removal of the tonsil, the age of the patient is an important matter. Nearly all cases of alarming hemorrhage have been in adults, and most of the cases of severe hemorrhage have occurred after rapid removal of the tonsil by the bistoury or sharp tonsillotome. While a dull tonsillotorae may leave a roughened surface and appear to be a more crude procedure, yet it is by far the safer method, as it allows compression and torsion of the vessels and lessens the danger of hemorrhage. The removal of the tonsil with the thermocautery snare also lessens the danger of profuse bleeding. The objection, however, to this method is that besides the cut there is added a burn. The sources of danger from hemorrhage after the excision of the tonsil are — 1, an anomalous ascending pharyngeal artery ; 2, an anomalous tonsillar artery ; 3, a large artery in the anterior pillar ; 4, an enlarged venous plexus at the lower border of the tonsil — really, dilated veins from stasis ; 5, large patulous tonsillar arteries. It is to be remembered that, as a rule, there is considerable hemorrhage at the time of operation. One of the best styptics to be applied to the tonsil is a 10 per cent, alumnol solution. Ice-water spray is equally good. Another useful astringent is 6 grains of tannic acid and 8 grains of alum to the ounce of water. If the bleeding is due to a patidous artery which can be located and grasped, it should be twisted or ligated. Internally, for the relief of continued oozing, 1-grain doses of ergotin, given every two hours for three or four doses, will be of service. Occasionally, alarming secondary hemorrhage may occur. Another source of danger is the condition known as hemophilia, found in persons ordinarily known as " bleeders " ; it is often difficult to obtain this knowledge, however, before operation. DISEASES OF THE TONSILS. 387 While alarming hemorrhage is of rare occurrence, yet in the removal of the tonsil its possibility must always be remembered. Frequently, in cases of enlarged tonsils from inflammatory in- volvement, there are adhesions involving the tonsillar and peri- J— ^ Fig. 134.— Kirkpatrick's knife, double cutting edge, for dissecting loose adherent tonsils. tonsillar tissue, and the contraction which follows such adhesions produces sensations of constriction and discomfort in swallowing, -Set of tonsil instruments (Makuen's), consisting of two knives (right one probe, and one curet. left), with alteration in the voice. In such cases relief can be obtained by breaking up the adhesions and thoroughly freeing the tonsil by means of the instruments shown in Figs. 134 and 135, without necessitating the removal of the tonsillar tissue. CASEOUS TONSILLITIS. This variety of inflammation of the tonsil is really mechanical in its origin. Either from pre-existing inflammatory process or from the enlarged tonsil with its deep crypts (Fig. 126), which have been altered by catarrhal inflammatory processes, pockets of varying size form here and there over the tonsil. The location of these pockets, as a rule, is in the lower portion of the tonsil. However, frequently from adhesions after tonsillar and peritonsil- lar inflammations a pocket may be formed high up, and can be demonstrated only by drawing the tonsil out, or is sometimes shown by the patient when gagging is produced by the use of the tongue-depressor. In these pockets, secretions and particles of food accumulate, which in tliemselves act as foreign bodies, and by the presence of bacteria of fermentation, as well as pathogenic 388 DISEASES OF THE NOSE AND THROAT. micro-organisms, an irritation is set up, which will produce inflam- matory processes in the surrounding structures. The usual history of these cases is one of repeated attacks of sore throat, a pricking sensation in the tonsil, with occasional discharge of minute masses of foul-smelling caseous material. These little masses are usually referred to by the patient as " peas." Quite often the patient is able to relieve the tonsil of the accumulated secretion by pressure externally, at the same time passing the finger quickly over the tonsil pressing forward ; but frequently tlie masses become retained through the occlusion of the orifices by acute inflammation. The symptoms in the aggravated cases closely resemble those of ton- sillar or peritonsillar abscess, although more prolonged and less severe. Occasionally the mass may become healed in, and not infre- quently there Avill be seen in the tonsil a peculiar grayish-white nodule of which the patient is not aware. On puncturing there will flow out a semi-fluid material which is most offensive. This is nothing more than a healed-in crypt. Occasionally there may be deposited in these pockets, along with the caseous material, an excess of lime salts, which in turn form a calculus known as a tonsillolith or amygdaloUth. Quite frequently, from adhesion at the base of the tonsil with the anterior pillar, there is formed behind it one of these pockets which is not included in the tonsil — really jK'ri tonsillar. Treatment. — The treatment consists in the free opening of the crypts or pockets by means of the knife shown in Fig. 136. V.^WT-Z.B^'SD't^'S Fig. 136.— Hook blade for opening crypts in tonsil. The pockets should be slit from top to bottom, and should be care- fully mopped out with carbolic-acid solution or thoroughly curetted, so that in the healing process their entire obliteration will occur. In spite of careful watching, minute pockets may be formed after healing has occurred and connective-tissue contraction has taken place. Should this happen, the pocket-formation should be treated in the same manner as before. CHRONIC ABSCESS OF THE TONSIL. A few cases of chronic abscess of the tonsil have been described. From the clinical history as given and from two cases coming under my own observation, I believe the condition to be due to a caseous crypt rather than a pyogenic process. However, it is possible in tubercular processes to have the so-called encysted abscess. DISEASES OF THE TONSILS. 389 The treatment should consist in incision, thorough curetment of the limiting membrane, with cauterization of the entire surface. ATROPHY OF THE TONSIL. As a rule, atrophy occurs as a physiological process from the twelfth to the eighteenth year. Should it occur as a pathological process, it is of little clinical significance. After repeated attacks of tonsillar and peritonsillar inflammation, with marked adhesion to the faucial pillars by the contraction which follows the organ- ized inflammatory tissue, there may be a limitation of the blood- supply, causing a simple pressure-atrophy of the tonsillar structure. A similar condition may be brought about by linear cauterization or actual scarification of the tonsil. MYCOSIS OF THE FAUCIAL TONSIL. This mycotic affection of the tonsil is often due to the Leptothrix buccalis, which attacks the outer layer of the epithelium and gives rise to yellowish or yellowish-white patches, sometimes within the crypts of the tonsil, but more frequently about their orifice. The condition is really a coagulation- or liquefaction-necrosis of the superficial epithelial layer. It may extend to the pillars of the fauces, or even to the pharyngeal surface, and is often associated with a similar condition at the base of the tongue (the lingual tonsil). As etiological factors there are frequently associated lesions of the intestinal tract, especially of the stomach. Lesions of the mouth, especially carious teeth, may be associated, although the decay of the teeth may really have been the cause of the gas- tric disorder. The condition gives very little inconvenience to the patient ; indeed, it is usually discovered by accident. Occa- sionally it may cause a pricking sensation very much the same as in caseous tonsillitis. Microscopical examination will determine the diagnosis. Prognosis. — The affection itself is not serious, but the mycotic areas soon re-form after their removal. It seems to resist any but continuous treatment. Treatment. — All diseased teeth should be carefully treated and any intestinal or gastric disorders corrected. The localized areas should be cleansed with hydrogen peroxid (15 volume), carefully dried, and each individual area touched with tincture of iodin, which should be repeated every day until cure is effected. Resort to the actual cautery may be necessitated in some cases. FOREIGN BODIES IN THE TONSIL. Tlic location and structure of the tonsil, as well as its frequent enlargement, render it especially liable to lodgement of foreign 390 DISEASES OF THE NOSE AND THROAT. bodies, such as spicules of bone, pins, fish-bones — in fact, any pointed foreign material. The symptoms produced are identical with those of a foreign body of the pharynx or the base of the tongue. On inspecting the tonsil for foreign bodies, care should be taken to produce very little muscular contraction or spasm, and efforts should be made, as far as possible, to keep the parts relaxed, as the foreign body may be so located that by muscular contrac- tion it may be thrown behind the faucial fold, thus hiding it from view, whereas if the parts are relaxed it will project into the pharynx and be readily seen. LINGUAL TONSIL. 1. Acute Inflcammation (Preglottic Tonsillitis). 2. Acute Phlegmonous Intlammation (Abscess of). 3. Hyperplasia. 4. Mycosis. 5. Varices. a. Regular Dilatation. 6. Saccular Dilatation, c. Idiopathic Hemorrhage. Synonym. — Buccal tonsil. On the base of the tongue (Fig. 1), behind the circumvallate papillffi and above the attachment of the epiglottis, are a series of rounded elevations composed of adenoid tissue — the lingual ton- sil. In the center of each elevation is a small orifice leading into a central cavity or crypt which is lined with stratified pavement epithelium, and is surrounded by a layer of adenoid tissue which is supported by the normal connective-tissue elements of the part. At the bottom of each crypt is the orifice of the duct of a mucous gland. The importance of this structure, from a physiological and pathological standpoint, is frequently overlooked. Situated as it is at the base of tlie tongue, it has an intimate vascular and lym- phatic relation with that organ, the upper portion of the larynx, the pillars of the fauces, and the lateral pharyngeal walls. It consists in a number — usually from ten to twenty — of glandular masses of the modified racemose variety. Its location renders it liable to irritation from food and drink, and it tends, like other gland-structure, to direct or indirect alteration, dependent upon systemic or associated local lesions. ACUTE INFLAMMATION. Synonym. — Preglottic tonsillitis. Ktiology. — The usual pathological alteration occurring in this gland-structure is an acute or chronic inflammatory process — a secondary result of some constitutional diathesis. It may accompany and follow the infectious fevers ; or it may be involved I DISEASES OF THE TONSILS. 391 in the specific inflammatory processes, especially tuberculosis and syphilis. Frequently the inflammatory condition persists after an attack of influenza, especially that variety attacking the upper respiratory tract. Stomachic conditions, especially acid indiges- tion associated with eructation of gases, intestinal lesions such as constipation, with interference of venous circulation and the reab- sorption of irritating materials into the blood, are also important etiological factors. The uric-acid diathesis, in which the entire mucous-membrane surfaces are also subjected to irritation, is an important factor. Habitual users of tobacco, either smokers or chewers, are frequently sufferers from inflammation of this gland- structure. Enlarged lingual tonsil or any inflammatory condition of the lingual tonsil, owing to the accumulated secretion and the con- stant irritation present, may be the cause of persistent and hacking cough. This is especially true in children. Owing to its location, the tonsil is a frequent site for the lodgement of foreign bodies. Pathology. — The pathological alteration occurring in the lingual tonsil does not differ from the simple acute or chronic catarrhal inflammation described in the chapter on General Con- siderations. The gland-structure is swollen and edematous, and stands up as large prominences which can be seen macroscopically, either directly or by the aid of the laryngoscope. The involve- ment of the lingual tonsil frequently follows inflammatory condi- tions of the adjacent and surrounding structures. Symptoms. — There is excessive secretion and constant ten- dency to clear the throat, and, while such effort frees the membrane from secretion, there remains the sensation as of the presence of some foreign material in the pharynx. On swalloM'ing there is the feeling, as often expressed by patients, as if they " swallowed over something." In the use of the voice the patient soon com- plains of throat-ache, with a certain amount of hoarseness, which is due to the hypersecretion and the associated inflammatory con- dition about the larynx, sometimes involving the vestibule. These symptoms are aggravated by eating. There may be slight cough besides. The sense of taste, usually onh^ impaired, in some chronic cases may be entirely lost. There may be slight enlargement of the sublingual glands as well as those at the angle of the jaw. Where there is a general catarrhal condition involving the entire nasopharyngeal structure, with relaxed elongated uvula, it is well to remember tluit while the parts are relaxed this elongated uvula may come in contact with the epiglottis or lingual tonsil and be the cause of constant tickling and hacking cough. Diagnosis. — The diagnosis can be easily made by the aid of tlie laryngoscopic mirror, wliich will sliow the prominent elevations at the l)a,sc of the tongue, M'ith the accumulated secretion. Prognosis. — Under proper treatment the prognosis is good. 392 DISEASES OF THE NOSE AND THROAT. Rarely ever does the conditi(>n progress to such permanent patho- logical alterations as to render the gland-structure not amenable to treatiiR'Dt. Treatment. — The treatment should be directed toward the correction of the underlying causative factor, whether it is a purely local lesion or whether it is a local lesion dependent upon some constitutional or remote condition. Irregularities in the intestinal tract should be corrected and constitutional dyscrasise relieved by alterative and tonic treatment. Inflammation of the lingual tonsil is frequently confused with pharyngitis or lesions of the faucial tonsil, and often the whole treatment is directed toward these structures, with entire neglect of the area really diseased. For the local treatment, astringents are the most efficacious. They should be preceded, however, by gentle purgation. An admirable astringent gargle is alum 8 grains and tannic acid 4 grains to the ounce. This should be used, preferably after each meal, as a gargle, diluted with an equal amount of water. As a local appli- cation by means of the curved applicator and a pledget of cotton, there should be used such astringents as sulphocarbolate of zinc, 6 to 10 grains to the ounce, or a 2 to 5 per cent, chlorid-of-zinc solution, which should be applied every day until the symptoms are relieved, which will usually occur after the fourth or fifth application. Equally good results may be obtained by the appli- cation of compound tincture of benzoin with 50 per cent, boroglyc- erid, or by the application twice daily of tincture of iodin direct to the lingual tonsil. ACUTE PHLEGMONOUS INFLAMMATION. Acute phlegmonous inflammation may occur as a primary affisc- tion, either in association with phlegmonous inflammation of adjacent structures or as the result of mechanical injury. The inflammation may involve a portion of the glandular masses ; but, as a rule, it involves the entire mass. Symptoms. — Besides the general febrile symptoms there is ])aiu in the throat, especially localized in the region of the hyoid bone, on one or both sides. Deglutition is extremely difficult and painful, the attempt causing shooting pains in the ear. An effiart to protrude the tongue usually increases the pain, although no difficulty is experienced in opening tlu; mouth. There is usually a marked increase in the flow of the saliva. In severe cases there may be tlireatcned edema of the glottis. The diagnosis can easily be made by the use of the laryngo- sco]X' nnd by digital examination. Treatment. — As the abscess forms rapidly, it is likely to rupture spontaneously ; but if recognized early, it should be immediately incised. DISEASES OF THE TONSILS. 393 HYPERPLASIA OF THE LINGUAL TONSIL. Hyperplasia of this gland-structure rarely ever occurs. It may accompany chronic inflammatory processes of the pharynx. The sytnptoms are very much the same as in acute inflamma- tion with absence of pain, while the sensation of a foreign body in the throat is reflected to the center or either side of the hyoid bone. The symptoms disappear during eating or drinking, but are increased by the use of the voice. The diagnosis can be easily made by the use of the laryn- goscope or by digital examination. Treatment. — For the reduction of this thickened tissue the best and the most effectual means is the galvanocautery, which, however, should be carefully used, and the cauterization should not be deep. Considerable reduction of the thickened tissue may be brought about by the direct application of dilute hydrochloric acid to the projecting masses, applied by means of cotton and probe. The cotton should be wrapped tightly on the end of a fine-pointed probe, and after saturating it with the acid, any excess should be removed by applying a bit of absorbent cotton to the saturated pledget ; this will prevent the acid spreading over healthy tissue. The application should be repeated not oftener than every fourth day. Twenty per cent, chromic acid or 3 per cent, chlorid of zinc applied in the same way is equally beneficial. MYCOSIS OF THE LINGUAL TONSIL. This is an inflammatory condition brought about by the local infection with the Leptothrix buccalis. Under the tonsil small yellowish projections appear, resembling mold. As a rule, slight, if any, ulceration occurs, it being more of a superficial desquamation of the outer layer of the epithelium. Treatment. — The condition should be treated by antiseptic month-washes and careful attention to the intestinal tract ; the local areas should be touched with a 6 per cent, solution of chlorid of zinc, or, what is still better, pure iodin. A 2 per cent, forma- lin solution in some cases is just as efficacious, although at times the condition is very obstinate, and resort to the actual galvano- cautery may be necessary. VARICES. The veins at the base of the tongue may be uniformly dilated and show as bluish tortuous cords. Occasionally they are mark- edly irregular, showing saccular dilatation which apjwars above the surface, and which nuiy rupture and cause severe hemorrhage. This vasomotor neurosis in females often accompanies menstrual disorders. It is especially likely to occur during pregnancy or 394 DISEASES OF THE NOSE AND THROAT. the meno])ause. It may also be the result of alcoholism. These enlarged veins may produce peculiar subjective sensations, the most common of which is a peculiar sensation such as Avould follow a moving body in the throat. Treatment. — The condition is usually dependent upon some iiitcrierenec with venous circulation, and is often seen along with intestinal lesions, or lesions of the heart, kidney, or liver. Treat- ment should first be directed toward the relief of these underlying causes. Should this fail to give relief, the dilated vessels should be j)unctured here and there by the galvanocautery. The rupture of these saccular dilated veins will account for the so-called idio- pathic hemorrhage occurring at the base of the tongue. The act of spitting blood is most alarming to the patient, and when such has occurred, in endeavoring to locate the site of hemorrhage, the dilated vessels at the base of the tongue should never be over- looked. As a point in differential diagnosis, in cases of hemorrhage from the dilated vessels at the base of the tongue there will be absolute absence of rales — in fact, no lung-symptoms. LARYNGEAL TONSIL. Situated w^ithin the ventricle of the larynx, involving the mucosa, embedded Avithin the meshwork of the fibrous connective tissue, are small areas of adenoid tissue, which are, in reality, aggregated lymph-follicles. Physiologically the structure cannot be demonstrated except by microscopical study. However, in inflam- matory conditions of the larynx, especially about the cords in the vestibule, these follicles become engorged, swollen, and edematous, and show as minute elevations. As such a condition is always associated with lesions of the larynx, it is sufficient merely to mention its presence. CHAPTER Xyill. DISEASES OF THE PHARYNX. Malformations and Deformities ; Stenosis. 1. Dilatation (Pharyngocele). Diverticulum. Acute Inflammatory Diseases. 1. Simple Acute Pharyngitis. 2. Infective Pharyngitis. 3. Membranous Pharyngitis. a. Croupous ; Simple Membranous. b. Diphtheritic. 4. Gangrenous Pharyngitis. 5. Traumatic Pharyngitis. 6. Hemorrhagic Pharyngitis. 7. The Pharynx in the Exanthemata and other Febrile Affections. a. Scarlet Fever. 6. Small-pox. c. Measles. d. Erysipelas. e. Intermittent Fever. /. Gout. g. Typhus Fever. h. Typhoid Fever. i. Influenza. j. Varioloid. k. Chicken pox. 8. Ludwig's Angina. Chronic Inflammatory 1. Simple Chronic Pharyngitis. 2. Subacute Pharyngitis. 3. Follicular Pharyngitis. 4. Hyperplastic Change in the Pharyngeal Structure. 5. Atrophic Pharyngitis. 6. Kheumatic Pharyngitis. a. Acute. b. Chronic. 7. Infectious Granulomata of the Pharynx and Nasopharynx. a. Tuberculosis. ]. Lupus. h. Syphilis. c. Glanders. d. Actinomycosis. Abscess, Ketropliaryngeal. Urticaria. Herpes. Pharyngomycosis. 395 396 DISEASES OF THE NOSE AND THROAT. Non-inflammatory Diseases. 1. Pulsating Arteries. 2. Anemia of the Pharynx. 3. Neuroses of the Pharynx. a. Anesthesia. b. Hyperesthesia. c. Paresthesia. d. Neuralgia. e. Neuroses of Motion. 1. Spasm. /. Paralysis. Foreign Bodies in the Pharvnx. MALFORMATIONS AND DEFORMITIES OF THE PHARYNX. Of the raalforniations met with in tlie pharynx, one of the most important is stenosis, which may occur early, congenitally, or may be found as secondary to inflammation or injury within the cavity or the tissues of adjacent structure. A few cases of congenital atresia, either complete or partial, have been reported. Complete closure of the pharynx from birth is usually associated with pouches, and will be treated under that heading. Secondary stenosis of the pharynx may be due to cicatricial contraction, the result of specific inflammatory processes or of traumatism. Of the former class, the lesions consequent upon syphilis are the most common. Adhesion of the pharyngeal structure to adjacent tissue, or contraction due to specific lesion in the pharynx itself, is by no means an uncommon occurrence. It may be found high up in the pharyngeal cavity or in the laryngo- pharynx, and presents the peculiar stellate appearance cha'racteris- tic of the syphilitic scar — the symptoms, of course, differing accord- ing to the location. The treatment is most unsatisfactory, and the amount of success will largely depend on the length of time that the stricture has existed, and the perseverance of both patient and surgeon. Antisyphilitic treatment should, of course, be insti- tuted at once ; the stenotic stricture should be split and dilated persistently by graduated bougies. The best method of incising the constricting tissue is with the galvanocaustic knife. Tul)ercular contractions are rare — practically unknown — as tubercular ulceration docs not tend to heal, and the majority are due to that modified form, perhaps, of tuberculosis known as lupus. Of the infective diseases which are most likely to be fol- lowed by septic inflammation, adhesion, and contraction, may be mentioned scarlet fever, diphtheria, small-pox, and erysipelas. Traumatic stenosis may occur at any age, and is usually the result of a scalding burn, or of the accidental or intentional swal- lowing of caustic liquids. As a ride, this form of trauma is rapidly fatal, because of the extent of the lesion and because the resultant DISEASES OF THE PHARYNX. 397 inflammation is usually associated with edema of the glottis. While the treatment varies with each individual case, emollients should be used in all cases of burns, such as menthol 20 per cent. in either carbolized vaselin or plain liquid albolene. Spasmodic contraction of the pharynx is due in great part to the same cause that produces pouches — i. e., the bolting or hurried swallowing of food, or food improperly masticated. Extrinsic Stenosis. — Of the causes outside of the pharynx which are likely to produce narrowing of the structure, the chief is disease of the vertebral column. Early deformity, such as for- ward curvature of the spine, or the rotary twisting of one of the vertebrae upon its axis, will produce a lessening, either in part or whole, of the pharyngeal cavity. Retropharyngeal abscess, independent of caries of the vertebrae, is another condition which may affect the size of the pharynx by encroaching upon its cavity. Enlargement of the apices of the lateral lobes of the thyroid gland may also, by pressure, result in inflammation, and cause choking sensations and other signs of respiratory disturbance. In Hodgkin's disease, if the cervical glands are involved, it may also tend to cause contraction in the size of the pharynx, and the same may occur in carcinomatosis. Diverticula, or dilatations of the pharynx, are seen either as a result of defective development during the fetal state, or have been brought about by imperfect growth or mechanical distention. Congenital pouches are almost always associated with complete atresia of the pharynx or absence of the esophagus. The etiology of the condition is not well understood, but perhaps the congenital displacement of the right subclavian artery may have something to do with it. Pouches, or dilatations of the pharynx (pharyngocele), generally occur in the aged, although it is likely that they are often overlooked or their importance belittled for years. The customary cause of the condition is the ingestion of food improp- erly masticated because of unsound or defective teeth, or the swal- lowing or bolting of masses of food that cannot be handled by the constrictor muscles of the pharynx. The first symptom of the condition will usually be an inability to swallow, or pain on deglutition. Boluses of undigested food may l^e spontaneously ejected, without retching or vomiting, at varying intervals after eating. The pouch may^be of such a size that the food collected within it may cause considerable distention, visible on the outside of the neck ; and the patient may be able, by pressure from with- out, to cause tlic food to enter tlie pharynx and subsequently the esophagus. The treatment of tlie ctmdition depends largely upon the position and size of the pouch. Should the cavity of the diverticulum be sufficient to cause a tumor visible externally, a pad properly fitted to tlie neck may obviate tlic disturbance and 398 DISEASES OF THE NOSE AND THROAT. enable the patient to swallow without great difficulty. This plan failing, resort might be had to the galvanocautcry, and the edges of the pharynx cauterized and brought together in an attempt to cause coalescence and contraction, or even the mouth of the cavity might be denuded of the mucous membrane and held together by stitches — a procedure difficult of performance and fraught with uncertain results. SIMPLE ACUTE PHARYNGITIS. Synonym. — .Vcute catarrhal pharyngitis. Definition. — An acute catarrhal inflammation of the pharyn- geal mucous membrane in M'hicli are hyperemia and congestion -with slight submucous infiltration, as well as hypersecretion and hyperelaboration of mucus. Ktiology. — Acute pharyngitis may be brought about purely by cold or exposure or may spring from inflanunatory processes of the adjacent or contiguous structure — at least, catarrhal condi- tions in the nasopharynx and anterior nares are predisposing fac- tors. The same may be said of the gastric or intestinal disorders. While they may not be direct factors, they are predisposing, inasmuch as the lowered vitality and local congestion due to venous stasis render the pharyngeal structure more susceptible. Epidemic influenza (la grippe) is a frequent cause. Constitutional diatheses are also important factors. Bad hygienic conditions, improper ventilation, insufficient clothing, through their vitiating effect on general health, are also causal factors. Persons whose occupations are of a sedentary character are especially liable to attacks of acute pharyngitis. Inflammatory conditions of the lingual tonsil frequently give rise to symptoms simulating pharyn- gitis. Alcoholic intemperance, the use of tobacco, and the over- indulgence in any stimulant, through their constitutional effects, also predispose. Age is not such an important factor, although it is especially common in the young and middle-aged. In children it is noticed as quite often due to intestinal irritation. The fact of taking cold can usually be explained by some of the aiiove-mentioned predisposing elements. Those whose occupations expose them to irritating fumes, dust, hot air, or the discomforts of overcrowded rooms, or who are exposed to draughts or sudden changes of temperature, are especially liable to attacks of acute inflammation of the pharyngeal structures. Occasionally an acute pharyngitis may be the result of an acute process in adjacent structures, such as the tonsil or nasopharynx. Pathology. — The pathological alteration in the mucous mem- brane of the pharynx in acute catarrhal pharyngitis is the same as in acute catarrhal inflammation in any mucous membrane. It con- sists in hypersecretion and hyperelaboration of mucus with hyper- emia and congestion of the blood-vessels in the submucosa with sub- DISEASES OF THE PHARYNX. 399 sequent pressure on the mucous glands situated in the membrane. Inflammatory exudate is poured out largely on the surface, which, mixed with the mucus and desquamated epithelial cells, gives it its peculiar whitish or grayish color. The amount of fibrin present will largely determine the tenacity of the secretion. The character of the secretion and the inflammatory exudation is also largely con- trolled by the general condition of the individual. Not only when there is any constitutional diathesis or generally bad nutrition is the character of the normal secretion altered, but when influenced by inflammatory processes the variation is more marked, as the chemical constituents of the blood in a great measure determine the character of the exudate. If the exciting cause of acute pharyngitis produces sudden congestion, rupture of the minute blood-vessels is liable to occur, and the secretion and exudation may be blood-stained. When the inflammatory process is very slight, the exudate will be more fluid in consistence, with very little tendency to accumulation. As a rule, the severer the inflam- matory condition, the more fibrinous and albuminous will be the exudate. This is due to the fact that the hyperemic and con- gested vessels of the submucosa block up the muciparous glands and prevent the elaboration of mucus. In the second stage, how- ever, wdth the pouring out of the liquor sanguinis the vascular pressure is relieved, and the surface is covered M'ith the pent-up secretion and the inflammatory exudate. Occasionally this exu- date may be so highly fibrinous as practically to form a membrane which is neither infectious nor diphtheritic in character — in real- ity, a non-infectious membranous inflammation. A certain amount of inflammatory exudate within the sub- mucous connective tissue will give rise to slight edema. This edematous condition may extend to the surrounding structure, especially the uvula and soft palate. If the variety of inflamma- tion is purely catarrhal, and is not an acute exacerbation of a chronic condition, after the subsidence of the inflammatory phe- nomena the tissue will return to the normal. Symptoms. — The onset is usually sudden, the severity of the symptoms depending entirely on the suddenness of the attack. The color of the membrane varies from a bright pink to a livid red, and the surface may show distinctly outlined injected vessels, the congestion as well as the color gradually fading off into sur- rounding structure. The uvula, soft palate, and pillars of the fauces may be slightly translucent from edema. In the early stage the surface of the membrane will be shiny and smooth ; gradually, as it progresses into the second stage, it will become more rough- ened and granuhited. In the first stage the throat is dry, witli small patches of dried mucus here and there. In the second stage the secretion and exudate are profuse, and at first of a w^atery consistency, gradually becoming more tenacious and nnicopurulent, 400 DISEASES OF THE ^'OSE AND THROAT. and, if higlily fibrinous, Avill tend to coagulate on the surface. The sufferer's constant effort to clear the throat of mucus is in itself a source of irritation. The pain is usually severe, although not unbearable, is decidedly irritating, and is increased by functional action of the pharyngeal muscles. There is a sensation of fulness or constriction of the throat, almost that of the presence of a foreign body, causing a constant desire to swallow. The pain may be reflected to the ear, or the acute pharyn- gitis may exist along with acute catarrhal inflammation of the nasopharynx, which in itself would cause pain in the ear. Owing to extension of the inflammatory process by continuity of struct- ure, there may be associated inflammation of the larynx. In fact, any of the adjacent or continuous structures may be involved. The impairment of hearing will depend entirely on the involve- ment of the nasopharyngeal structure. The pain is always in- creased by the act of swallowing, rendering it almost impossible for the patient to partake of solid nourishment. The sense of taste may be partially impaired, which is especially true if the Ungual tona'd is involved. On account of the accumulated secre- tion and the irritation to the peripheral nerve-filaments, there is a constant tendency to ha^vk or cough. If associated with consid- erable laryngeal or bronchial irritation, the cough will be more severe and spasmodic in character. Occasionally the expectorated mucus will be blood-stained. Unless occurring along with laryn- geal or nasal involvement, respiration is not interfered with. The voice is thick and husky and altered in pitch and tone, and, if at the same time there is laryngeal inflammation, it may be com- pletely lost. The constitutional or clinical })henomena are present in a degree proportionate to the severity of the local lesion. There is usually a slight rise of temperature with digestive disturbances, besides perverted secretion evinced by the constipation and the scanty, high-colored urine. The tongue is coated and the breath foul. Quite frequently the inflammation of the pharynx is only an associated condition or a local manifestation, as observed in epidemic influenza. In such cases the systemic phenomena will be more marked, although in the simple acute variety there may be pains in tiie muscles of the neck and joints in addition to an unbearable headache. Diagnosis. — Acute catarrhal pharyngitis cannot always be differentiated solely by the local condition from that accompany- ing the eruptive fevers, or a rheumatic or gouty diathesis, or that occurring in epidemic influenza or la grippe. The constitutional phenomena must also be taken into consideration. In children this is especially true, and the diagnosis should be guarded. Prognosis. — The prognosis is good, as the acute attack usually lasts from four to ten days, and when uncomplicated is not dansrerous. DISEASES OF THE PHARYNX. 401 Treatment. — In the early dry stage, cold applied externally in the form of ice-water cloths or ice-pack is highly beneficial. Where there is no cardiac lesion^ tincture of gelsemium may be administered in 1- to 5-drop doses every three hours. This will aid materially in lowering the vascular tone and will lessen the tendency to congestion. However, it must be remembered that the drug is a powerful motor depressant, and its physiological action should be carefully noted. For the relief of the dryness of the throat in the early stage, after the ice-packs have been discontinued, the throat should be gargled with hot water, or great relief can be obtained by the use of aqueous, extract of hamamelis, cinnamon water, and peppermint water, in equal parts, as a gargle every hour. As the lesion may be due purely to a local irritation, or may be a local manifestation of some constitutional condition, or may accompany or result from the latter, the symptoms produced, regardless of cause, are very much the same, and plans of rational treatment are naturally based on the etiological factors, either primary or secondary. First, then, treatment for the immediate relief of the distressing symptoms ; and, second, the appropriate treatment for such conditions, consti- tutional or local, which may give rise to attacks of acute pharyn- gitis. Should the attack be due to gastric or intestinal irritation, or to a gouty or rheumatic diathesis, the general treatment should be directed to the relief of the underlying cause. If the lesion is associated with, or a continuation of, an acute inflammatory process of the postnasal cavity, the treatment should be directed more to the nasopharynx than to the pharynx proper. The administration of certain drugs, such as iodin, bromin, and phos- phorus preparations that are eliminated by the mucous membrane, may be the cause of the inflammatory process. Their prompt withdrawal is usually the only treatment necessary. AVhen the inflammation is limited to the pharynx — and by the pharynx is understood that ])ortion of the wall that is visible on oral inspection — the remedial agents should and can be applied directly to the part. This can be done in a number of ways — by means of gargles, sprays, the direct appliention by moans of cotton and applicator, or in the form of lozenges. If the patient is seen in the early or first stage of the inflammatory process, the treatment indicated is vastly different from that demanded when it lias I'cached the second or cxudafixc stage. It nuist 1)0 rotiiotnhcrcd tliat in the flrst stage tlio pathological altera- tion is not a structural one, but is entirely limited to the vessels; that the mucous niembrane has its normal lubricating secretion, Avhich is furnished by the mucous glands located in the submucosa ; that in the first stage, or stage of engorgement, the ])ressur(i exerted by the now overdistended arterioles and ca])illaries cuts ofl' this normal seeretion by the temporary occlusion of the excre- 20 402 JJISEASES OF THE NOSE AND THROAT. tory ducts, niul therefore the surface will l)e dry and irritated. The object of treatment in this stage should be de})letion and the r:i])id relief of the vascuhir engorgement. The local or constitu- tional ai){)lication of such agents as cause relaxaticm of tissue will bring about tle})letion, if not more rapidly, at least more in accord- ance with nature's ])rocess, than by the a})plication of astrin- gents or remedies which (-ontract the tissue. While it is possible to relieve the engorgement and cause contraction of the vessels, and even re-establish circulation and secretion in local spots of inflam- mation, yet the irritation produced by the application of such reniedial agents to the delicate mucous-membrane surface may augment the very condition you are aiming to relieve. Instead, then, of the application of such solutions as iodin, nitrate of sil- ver, etc., there should l)e administered internally and locally such drugs as pilocarpin, apomorphin, ipecac, tartrate of antimony, and other drugs of the same nature. These should be administered in small and frequent doses. An effervescing tablet containing y^^- of a grain of ])ilocarpin, allowed to dissolve slowly in the mouth and repeated every hour for three or four doses, will usually give relief. The administration of drugs which act on the vasomotor sys- tem, causing contraction of the vessel-wall, may give the desired result, and is jn-efcrable to the local application of any irritating agent. If the inflammatory process be localized, astringents may be used with good results ; but if the process involves the entire pharyngeal surface, they should not be used. If the throat is irritable, or there is present the raw feeling of which the patient so frequently complains, local sedatives should be used. The parts should be sprayed with a l)land oil containing 3 drops each of oil of sandal-wood and oil of sassafras to the ounce, the oil of sandal- wood being decidedly sedative to the mucous membrane and the bland oil serving the double purpose of a lubricant and a protector. To some patients the oily preparations are decidedly disagreeable ; in such cases the surface may be sprayed with a weak hydrochloric- acid solution, not stronger than 5 to 10 dro})s of the dilute acid to the ounce of water, the object being more to relieve the irritation than to cause contraction of the vessels. When menthol is used for the relief of this condition, it should not exceed 2 grains to the ounce. If used in combination with camphor, much better results are obtained. The following usually gives relief: I^. Camphors, gr. ij (0.12) ; Menthol (crystal), gr. i] (0.12) ; Olei santali,' gtt. 'iv (0.24) ; Alboleni (li(iuid), flaj (30.0).— M. It is rarely necessary to administer drugs internally for the relief of this irritation. Should the severity of the symptoms DISEASES OF THE PHARYNX. 403 demand internal medication, we have in codein in small doses the best remedial agent. When the pharyngitis is not dependent upon purely local conditions, but is caused by gastro-intestinal or hepatic disturbances, immediate attention should be given to the gastro-intestinal tract. A purgative should be given, followed by a saline ; such as the administration of 1 to 3 grains of calomel to 1 grain of compound colocynth powder, followed by a saline that will stimulate glandular secretion. This can be accomplished by the administration of the granular eifervescing phosphate of sodium, 2 to 4 drams, which may be repeated three times daily. The succinate of soda in 5- to 20-grain doses is equally effica- cious. In the second or exudative stage, where the vessels and glands have relieved themselves of engorgement, very little medication is required. If the secretions are profuse and tenacious, the mem- brane should be cleansed with a simple alkaline wash. If the inflammation is localized, due to any of the above causes, and does not involve the entire pharyngeal surface, astringents may be used. Such solutions as alum, 4 to 8 grains, with 4 to 8 grains of tannic acid to the ounce; or chlorate of potassium, 10 to 15 grains to the ounce, should be applied by means of sprays, or, better, by means of cotton and an applicator. When the inflam- mation is localized to the margins of the pharyngeal wall, which is often the case if dependent upon gastro-intestinal irritation, relief can be obtained by the use of a mild astringent, such as the compound tincture of benzoin, with equal parts of a 50 per cent, boroglycerid. Should the second stage not pass rapidly on to resolution, the hypersecretion and elaboration of mucus can be controlled by the administration of minute doses of belladonna in the form of atropin, or aconite in the form of aconitin — of either, the -f^-Q to g-^Q- of a grain — not repeated oftener than every three or four hours, and only to the point of beginning physiological effects. These drugs apparently have a specific action on the faucial circulation. INFECTIVE PHARYNGITIS. Synonyms. — Ulcerative sore throat ; Hospital sore throat ; Phlcgnionoiis pharyngitis ; Su})purative ])haryngitis. Definition. — Superficial ulceration of the nnicous memlu-ane of the pharynx, due to infection. Btiology. — There is often seen in individuals exposed to the iuflucuce ol" septic poisons an attack of acute infectious inflamma- tion of the pharyugcal mucous membrane. Some ])eople are more susceptible than others. The condition is quite frequently seen in physicians during ('ijidemics of diphtheria or scarlet fever, and sometimes occurs in surgeons mIicu exposed to septic poi.sons. 4U4 DISEASES OF THE NOSE AND THROAT. Tliere is usually some lessening of" ])liysiologioal resistance on the part of the mucous membrane lining- the pharynx, brought about either by constitutional diathesis or pre-existing local inflamma- tory process, rendering the individual more susceptible. Nurses and hos])ital attendants are frequently attacked. A somewhat similar condition lias also been observed in students who are working in the dissecting room. The usual bacteritic infection is the streptococcic, although associated with it are always stapliylo- cocci. Occasionally the psendo/jaci/las of (lip/itheria is also pres- ent. l)ut not as a dircctt etiological factor. Pathology.— ^W'iiile ulceration of the pharyngeal nuicous membrane may occur in almost any of the inflammatory jjrocesses, yet it is most likely to take place when such processes arc of au infectious nature. In this ulcerative variety the epithelial cells on the surface are attacked by the pathogenic bacteria and undergo liquefaction-necrosis, with invasion of the bacteria into the deeper structure, where, from the local cutting off of the blood-supply, owing to the inflammatory processes, together with the rapid liquefac- tion-necrosis brought about by the infection, there soon form minute ulcers extending through the basement membrane. However, in many cases the process is not distinctly ulcerative, but one of desquamation, the localized spots of liquefaction-necrosis not involving the basement membrane. Occasionally the infection may localize beneath the mucous membrane and produce abscess- formation, or the superficial structures by the local infection may secrete or manufacture pus and produce a granular appearance, which resembles, and in reality is, a pyogenic membrane, thus giving rise to the suppurative variety. When small abscess-for- mation occurs in the submucosa, it is likely to become diff'used and give rise to the diff'used suppurative pharyngitis — periptharyn- f/eal phler/moii. From all the varieties of infection excepting diphtheria the process diflers only in degree. Symptoms. — The earliest symptom will be extreme sensi- tiveness of the tliroat, especially on swallowing. Gradually the throat feels dry, swollen, and rigid. Reflected pain will be felt in the ear and the muscles of the neck, frequently extending down to the muscles of the pharynx. There is a slight rise of tempera- ture, and the patient feels restless and depressed. Secretions are deficient, the tongue is heavily coated and furred, and the breath very ofllMisive. There is generally consideral)le frontal headache and mental hebetude. The ulcers are usually located on the lateral pharyngeal walls, and quite frequently on the tonsil and soft palate. One special site of location is just behind the pillars of the fauces, which can be seen only \\iien the pharyngeal struct- ure is in a relaxed position. The ulcer is usually very small in size, and is coated with shaggy membrane Avhich is formed by liquefaction- and coagulation-necrosis. This, however, varies DISEASES OF THE PHARYNX. 405 in appearance, as often the material is sloughed away and leaves a perfectly clear ulcer. Diagnosis. — From the accompanying history, together with the rapid development and associated bacteriological examination, the diagnosis can easily be made. Prognosis. — Prognosis is, as a rule, favorable, although septi- cemia may result. Treatment. — The patient should be placed in hygienic sur- roundings as good as possible. The bowels should be freely purged and minute doses of calomel and bicarbonate of soda continued. Internal administration of tincture of chlorid of iron in from 10- to 30-drop doses every two hours will be of great service in com- bating any tendency to septicemia. The throat should be fre- quently cleansed, first with an alkaline gargle used as warm as can be comfortably borne by the patient. The ulcerated areas should be touched Avith a 3 per cent, chlorid-of-zinc solution, or dilute nitric acid, 20 drops to the ounce of water. Considerable relief to the sufferer may be afforded by the use of Mackenzie's carbolic- acid throat-tablets (B. P.), allowing the patient to dissolve a tablet slowly in the mouth every one or two hours. If the ulcers are very painful, relief can be afforded by the local application of an oily solution such as benzoinol, to which has been added 4 grains of menthol, 4 drops of sandal-wood oil, and 2 drops of oil of eucalyptus to each ounce. This can be applied every few hours. Orthoform is equally good for the relief of the pain. Heated vapors afford temporary relief. Cold should only be used very early in the process, and may do much to arrest its progress. The patient should be instructed to wrap an ice-water cloth around the neck, enveloping that in a dry towel, and also allowing small particles of ice to be dissolved in the mouth. However, if the condition has gone on to necrosis, or advanced in the inflam- matory stage, hot applications are indicated rather than cold. After the relief of the acute symptoms the patient's general con- dition should be improved by the administration of tonics. MEMBRANOUS PHARYNGITIS. Varieties. — '■'. Croupous ; simple membranous ; b. Diphtheria. Croupous. Often the practitioner will observe an inflammation of the pharynx that is in no wise diphtheritic, and while there is no question but that the condition is an infectious one, yet the infec- tion is not due to any specific bacteria or special germ, though the Streptococcus pyogenes is present to such an extent as to give rise to the term streptococcal infection. It is the same condition described by some writers as erysipelas of the throat. The clinical phenomena are almost identical with diphtheria, although of not 4U() DISEASES OF THE NOSE AND THROAT. 8iR'li a ijrave character and of iiiucli shorter duration. The affec- tion is frequently seen in laboratory workers and persons exposed to infectious processes. Althongli somewhat resembling the ulcer- ative variety, in the pure membranous sore throat there is neither ulceration nor involvement of the basement membrane. The condition is, in reality, an acute infectious process in which there forms on the mucous-membrane surface a highly coagulable albu- minoid material which constitutes a false membrane and occurs along with desquamation of the superficial epithelium. On strip- ping off the membrane no ulcer is found, and, if any bleeding does occur, it is from capillary oozing. The question of infection and contagion is one which has been discussed by the profession from every standpoint ; and while the general consensus of opinion, con- firmed by clinical observation, proves that many of these cases are not infectious or contagious, at the same time the early clinical phenomena are so nearly identical M'ith those of diphtheria that until the diagnosis is clearly established the precaution of isolation should be taken. Diagnosis. — The diagnosis is established by bacteriological examination and associated clinical phenomena. Treatment. — The treatment should consist in thoroughly cleansing and removing the membrane by first using an alkaline solution, followed by a solution of hydrogen peroxid(15 volume), aqueous extract of hamamelis, and cinnamon water, in equal parts. After the thorough cleansing and drying of the membrane, there should be carefully applied, by means of cotton tightly Avrapped on the applicator, great care being taken to remove any excess of the fluid, Loffler's solution : :^. Toluol, 36 parts; Alcoholis absoluti, 60 " Liquoris ferri sesquichloridi, 4 " While this is especially adapted to the treatment of diphtheria, yet in any infectious process its highly disinfecting properties are decidedly advantageous. Attention to general health and thorough cleansing of the intestinal tract are of importance. After the use of Loffler's solution the throat should be jiainted with compound tincture of benzoin and 50 per cent, boroglycerid, in equal parts ; or, if the [)ain is severe, there may be used instead — I^. Camphorse, gr. j (.06) ; Menthol, gr. iv (.24) ; Alboleni (liquid), fl.5 (30.). To relieve the congestion and stimulate circulation a spray or gargle of hot water is highly beneficial. When the congestion is DISEASES OF THE PHARYNX. 407 quite marked and the membrane tends to re-form, repetition of the application of Loffler's solution will be found necessary. As soon as the membrane ceases to form, the use of this solution should be discontinued. Equally good results may be obtained by the local application of pure guaiacol, observing the same pre- cautions as in the use of Loffler's solution. Diphtheria. Definition. — Diphtheria is an infectious disease, primarily locally manifested by a fibrinous exudate, followed by general systemic toxic involvement. The specific cause of the disease is the Klebs-Loffler bacillus, and the systemic symptoms and sequels are due to the toxins generated by this bacterium and its associ- ates. Synonyms. — Putrid sore throat ; Diphtheritis ; Angina diph- theritica ; Angina membranosa. History. — From D'Hanvantare — an Indian physician, a con- temporary of Pythagoras — there has been described an affection of the throat which may be interpreted as diphtheria. It would be impossible to give in detail the views of the various authors on the subject without devoting too much space to it, and for further information on the history of diphtheria the student is referred to the writings of Samuel Bard (1770) ; Bretonneau (1823-1855) ; Deslandes (1827); Fuchs (1828); Headlam Greenhow (1860); Jacobi (1877); Kauchfuss (1878); Morell Mackenzie (1879); Ruault (1892), and Lennox Browne (1895). Ktiology. — For the production of diphtheria two factors are necessary : 1, The introduction of the specific germ, and 2, a suit- able soil for its growth. The human organism may be rendered susceptible to the inva- sion of the Bacillus diphtlierise by variations from the normal in the oral cavity, or its continuation due to purel}- local causes or due to a systemic involvement evidencing itself locally in altera- tion of the upper respiratory tract. Again, an economy below par, from whatever cause, is more prone to the disease, i-('teri.'< jxirihun, than a perfectly healthy organism. The factors predisposing and preparing a nidus of iufection we shall divide, then, into heal and co)ixiiiufionnJ. Local Causes Predisposing- to Infection. — Enlargement of tlic faucial tonsil, overgrowth u[' Luschka's tonsil, carious and badly ke])t teetli, naso])haryug('al catan-Ii, aud any dis- eased condition of the mucous m('Uil)i'niic oi" the month render an individual, especially in childliood, liable to inl'eetion. Tonsil- lar enlargement, causing month-breatliing with its attendant low(>r- ing of vitality and resisting ])owei-, tends to decrease about ])nbertv, wiiieh might account for the Caet tli:it the niaxinnnn death-rate as 408 DISEASES OF THE NOSE AX I) THROAT. well as the largest percentage of cases seem to he concurrent with that epoch. Another classification of the so-called predisposing causes is, lirst, into the factors increasing the virulence of the specitic germ, and, secondly, into the circumstances which increase individual susceptil)ility. Any of the exanthemata — scarlet fever, measles, chicken-pox, etc. — or, in fact, any disease lowering bodily resistance or affect- ing the throat, acts as a predisposing cause by preparing an easy mode of entrance for the germ or favoring its development. Improper drainage, poor sewage, and unsanitary surroundings act as ])redisposing factors by causing an ordinary sore throat, which affords an inviting and fertile soil for the growth and prop- agation of the infecting agent. During an epidemic all classes are attacked alike, irrespective of social position. Children are the victims in far greater proportion than adults, the inajority of cases occurring between the third and the fifteenth year. The infective principle is disseminated by the saliva, in the secretions from the patient, and by contact with the patient. It is highly tenacious and may persist indefinitely. Sporadic cases or infection that cannot be accounted for by actual contact with the disease may be due to the entrance of the germ from books, articles of clothing, etc., which harbor it in dried form until it revives and infects under favoring circumstances. Diphtheria is more prevalent in the cold, damp Aveather, irre- spective of the time of year — due, probably, to the greater number of ordinary throat-affections occurring at that time. Specific Cause of Diphtheria. — In 1875, at a congress held at Wiesbaden, Klebs of Zurich announced the detection of the causo of diphtheria. It Avas not until 1883, however, that the discovery was given prominence. Loflfler in 1884 isolated the germ, produced the disease in animals with the pure cultures, re-isolated the germ, but failed to jiroduce paralysis. It remained for Roux and Yersin to succeed in 1888 in producing the disease as well as the paralysis, Avhich furnished conclusive ])roof of the pathogenesis of the bacillus of diphtheria. If a platinum needle or a cotton swab be passed over the suspected membrane and cover-slips prepared, microscopical examination will show, if the exudate be diphtheritic, a great variety of organisms ; but chief among them will be noticed slightly curved bacilli of irregular size and outline ; there will be noticed a clubbing at one or both ends, at times segmented, spindle in shape, or as curved wedges. Irregidarity in outline is a marked characteristic of the BaeiUus (Jiphiherkv. If Loffler's alkaline methylene-blue stain be used, many of these irregular rods will show clearly defined points in their protoplasm stained deeply, almost black. It is not the morphology alone, however, that establishes the identity of these DISEASES OF THE PHARYNX. 409 bacteria, but their cultural peculiarities as well as their pathogenic activity when introduced into the tissue of a susceptible animal liave to be taken into consideration. Associated with the Bacillus diphtherise, and accredited with causing much of the confusion that exists between the clinical and the bacteriological diagnosis of diphtheria, there are found a number of other bacteria — e. g., streptococci, diplococci, staphylococci, "Brisou" coccus, and others. Much has been said and written for and against the identity of the germ of Von Hoffmann (the non-virulent bacillus) witli that discovered by Loffler. Morphologically they are identical, differ- ing only in their pathogenic properties. We have concluded that the germs are the same, the diiference in clinical symptoms and sequels depending on the amount and character of inoculation, together with the individual's power of resistance, modified by his environment. The difference in severity of epidemics is a well-known fact that can be explained as above. To the direct action of the bacilli of diphtheria is the membrane due ; their systemic effects are produced by their soluble products. The paralysis, the albuminuria, and other systemic evidences are due to the toxins of the specific germs ; while to the products of its associates — the streptococci and other pus-organisms — the phleg- mon, suppuration, and aspirative manifestations can be ascribed. The accompanying illustrations will give a good idea of the variation in appearance of the Bacillus diphtherise (Fig. 137) after the use of serum-therapy, their appearance in a case treated with- out the use of the antitoxin (Fig. 138), and the change in appear- ance they undergo while developing on culture-media (Fig. 139). m 'ma Fig. 137. Fig. 138. Fig. 139. Fig. 137.— Tube inoculated forty hours after serum-injection. Fig. 138.— Tube inoculated forty hours after admission. The diphtheria bacilli are smaller and more regular in form than the preceding. Fig. 139.— Tube inoculated from growth forty-eight hours old. Irregular staves, stain- ing, for the most part, very unevenly. The bacilli seem to tend to the formation of short chains. Few ovoidal bodies are present. Pathology. — l^itliologists and clinicians differs as to the pathological alterations in dij)htheria ; this is largely due to the irregularities in the etiological factors. Irrespective of cause, we have to deal with two distinct varieties of this menibrano-iiiflam- mation. That when the disease is due to a sjieeific infecting agent, as the bacillus of diphtheria, the membrane forms on tlut surface, as in any membranous condition ; but on its removal there will be 410 DISEASES OF THE NOSE AND THROAT. bleeding, which is clue to destruction of tissue or ulceration, and on microscopical examination this ulceration will be found to extend tiirough the basement membrane, or that the nutrition which necessarily comes from the submucosa must be cut off"; the area beyond, being dependent on these vessels for nutrition, imdergoes infective coagulative necrosis with sloughing. In some cases of diphtheria where the visible membrane is slight, the constitutional symptoms are marked and paralyses are produced, and there may be, low down in the air-passage, this ulceration. We do have a variety of membranous or fibrinous inflammation occurring on mucous membrane, in which there are no specific micro-organisms and in which there is no ulceration ; the mem- brane can be easily stripjjed oif and does not bleed ; or if it is adherent and does bleed, it is due to the plastic material partially organizing on the surface. When stripped oif, if it does bleed, it is due to the capillary budding having taken place in the attempt at organization. Symptoms. — The period of incubation of diphtheria, if experimentally produced, varies from twelve hours to three days. Ordinarily the period between the exposure to the contagion and the appearance of false meml)rane is generally from two to four days, occasionally reaching seven days. The onset of the disease is usually sudden in infants and very young children. The reverse holds good with older children and with adults. Rarely is the disease ushered in with a chill. As a rule, there is a general feeling of depression, followed by headache, nausea, pain in the back and limbs, accomi)anying the throat-symptoms. Vomiting occurs at times. The bowels may be constipated or loose. Stiffness of the neck is complained of and pain at the angle of the jaw, not so markedly increased on attempting to open the mouth as in tonsillitis. The voice may lose its normal tone and become hoarse even before laryngeal involvement. There is nothing characteristic to be noted about the tongue, except that it is not so deeply furred and befouled as in tonsillitis. In the ordi- nary case of diphtheria the breath is not markedly affected, but in the severer instances of the disease it may become exceedingly offensive and characteristic. The child becomes listless, peevish, and does not play as is its wont. During the attack in children there will often be noticed a particularly characteristic pallor and waxiness of the complexion, with a pinching of the nostrils. An evanescent erythematous eruption occasionally is noticed on the trunk, which may confuse the diagnosis. The temperature in diphtheria uncomplicated l)y nephritis, otitis, adenitis, bronchopneumonia, paralysis, or cardiac involve- ment is disproportionate to the other systemic manifestations of the disease and rarely exceeds 101°-103° F. A rise of tempera- ture to a point beyond that usually registered suggests extension DISEASES OF THE PHARYNX. 411 of the membrane or complications, and should be a signal for increased watchfulness on the part of the attendant. The pulse of diphtheria is usually rapid in the extreme, and a sudden and decided slowing in the rate is to be looked upon as an omen portending ill, because the pulse-rate shows the extent to which the diphtheritic poison has in^'olved the cardiac centers, the vagus, or the heart-muscle itself. The whole chain of cervical glands, usually attacked early by the infection, becomes tender and easily felt. It is to be borne in mind that children or even adults may have had enlarged cervical glands before the attack of diphtheria, and this possibility should be eliminated before attaching too much weight to this symptom. In severe and complicated cases the parotid and submaxillary glands may be implicated, and may go on to the formation of abscess. Strict attention should be paid to the amount and character of the urine voided. As a rule, albuminuria, which occurs in about 33 per cent, of cases, is noticed early in the attack, due to the toxic action on the kidneys. There is an excess of urea, and epi- thelial casts and cells are found in some cases. Hematuria is comparatively rare. Inspection of the mouth early in the disease sliows, as a rule, the tonsils and fauces red, swollen, and thickened. Soon patches of exudation are noticed extending rapidly, growing thicker, and becoming tough and tenacious. Situation. — The membrane of diphtheria may be situated on any part of the mucous tracts of the body or at mucocutaneous junctures. A special predilection for the tonsils is displayed by the germ, however, as a site of the necrotic process, Avhich may extend thence in any direction. This is due to the situation of these structures and to their affording in their crypts an undis- turbed and favorable point for lodgement and development of the special bacteria. V irchow has aptly termed them "^ open wounds." The pillars of the fauces and the uvula seem to be favorite routes of extension from the tonsils. The larynx may be prima- rily involved, or secondarily by extension from above. The nose is rarely the seat of the membrane other than by secondary involve- ment. Into the nasopharynx and through the Eustachian tubes, involving the hard or soft palate, covering the gingival or buccal mucous membrane, extending down into the esophagus or trachea, through the tear-duct to the conjunctiva and into the antra, — there is no part of the oral cavity oi" its continuation exempt from pre- emption primarily or by extension by the membrane. Considencjf. — The consistency of the membrane varies in diflPer- ent stages of the disease. Eiirly in the course of the disease it is tough, firm, and difficult of detachment, and leaves an abraded bleeding surface behind it. Later it is soft, shreddy, and more 412 DISEASES OF THE NOSE AND THROAT. easily detached. The membrane sometimes appears as though " plastered " ou the surface. The center is often thinner than the edges, which wrinkle before they separate. Color. — In a typical case of diphtheria the deposit is at first bluish- white, becoming more white and opaque or a pale lemon tint, merging into a yellowish or greenisii-gray, and may finally become brown, and sometimes almost black, due to extravasation of blood. Karely in hicniuir diphtheria is the exudation seen as discrete yellow spots, finally coalescing. Nasal Diphtheria. — Acute. — When the nose is aifected either primarily or bv extension, a serous or serosanguineous discharge is an early symptom. This discharge is very irritating to the skin of the nasal orifice and up])er lip, producing redness and excoria- tion, and, at times, formation of the false membrane may occur. Epistaxis often takes place, and a peculiarly disagreeable and characteristic odor, due to the pent-up secretions, is noticed. It has been observed that in cases in which the membrane was pri- marily situated within the nose, there was not the same tendency to spread into the nasopharynx as from other situations. (Jhro)iie. — On record are well-authenticated cases of the for- mation of a false membrane in the nose, due to the Bacillus diphtheriiie, but unattended by toxemia. A feeling of fulness in the head and a disinclination to mental effort were the chief sub- jective symptoms. Occlusion of the nostrils by a grayish-white, tenacious membrane lining the nasal chambers Avas revealed on inspection. Kemoval of this pellicle left a bleeding and abraded surface, soon covered by the re-formation of the membranous investment. The condition persisted for months despite treat- ment. It is our belief that in this case and others like it the mem- brane is not due to the influence of the bacillus, but can be classed under the fibrinoplastic form, and that the Klebs-Loffler bacilli are coincident rather than causal. This is illustrated in the cases mentioned on page 83. Diagnosis. — The early differentiation between diphtheria in a mild form and acute tonsillitis by the clinical symptoms is a difficult matter in many cases. There are forms, too, of mem- branous inflammation affecting the throat due to other organisms, especially the streptococcus, that confuse the diagnostician. Bac- teriological investigation, of course, will determine the presence or absence of the Bacillus diphtheriie ; but the finding of the Klebs- Ijoffler bacillus in the laboratory, and the consequent dictum by the bacteriologist that the case in question is " undoubtedly one of true diphtheria," often does not satisfy the clinician, who has seen the case apparently recovered from any symptoms whatever before the bacteriological diagnosis has been finished.. As "one swallow does not make summer," so the findino; of a few Klebs-Lofller I DISEASES OF THE PHARYNX. 413 bacilli does not prove that a given case is a disease consisting of a complexus of symptoms clinically recognized as diphtheria. It has been proved that the Klebs-Lofiier bacilli exist in the throat without causing any appreciable reaction. I found them in my own throat, without experiencing any discomfort whatsoever, while making some researches in the antitoxin treatment at the Municipal Hospital, Philadelphia, early in 1895. There is no attempt in these statements to cast discredit on the bacteriologist's findings, but merely to bring out the fact that another factor enters into the establishment of clinical diphtheria beyond the mere presence of the specific bacillus. This may be either the susceptibility of the patient or the virulence of the inoculation. On these factors, together with the finding of the germ, depends the actual portrayal of a case of true diphtheria. Animal inoculation is the only method of determining germ-viru- lence, and often the case has Morked out its own diagnosis before this can be established. The finding of the Bacillus diphtherise in any case, however, should put the physician on his guard, and the case should be isolated until further bacteriological investigation be made ; because a case at first apparently controverting the labo- ratory diagnosis may later, either from re-inoculation or lowered resistance, develop true diphtheria, or may impart to others the contagion, which may find a suitable non-resisting economy and develop with the greatest virulence. In establishing a diagnosis of diphtheria, the procedure should be somewhat as follows : Remembering that diphtheria is far more apt to occur amoug children than adults with the same exposure to contagion, let that have its weight. Next, obtain carefully the number of members in the household and their " throat " history. Ascertain accurately whether the patient or any of the family have been exposed to diphtherial infection, directly or indirectly, or to any other disease in which sore throat is a symptom. Look into the sanitation and hygiene of each case. Accurately determine the date of the initial symptoms, so as to establish, if possible, the period of incubation. Make a careful physical examination of the patient, taking the temperature in the axilla, or in the rectum if a child, not forgetting to examine the glands — cervical, submaxillary, and parotid. Then examine the throat by the following method : Stand on tiie left side, facing in the same direction as the patient, who, if a child, is held on the nurse's lap ; or if an adult, he may be seated in a chair, sitting up in bed, or recumbent. Place the right hand firmly on the crown, so as to control by wrist- motion botli the lateral and vertical movement of the head. Insert the tongue-depressor with the left hand, and bend your body forward, turning the face at tlic same time toward the patient's, and somewhat above the j^lanc of his moutii. On the slightest tendency to cough, either lotiitc the patient's head by twisting the 414 DISEASES OF THE NOSE AND THROAT. hand on the crown of his head, or remove your own face up\\ard from the line of ])rojection, at the same time depressing his face, liefore using the tongue-depressor, have the patient open his moutli, and note the presence or absence of pain at the angle of the jaw. Pain and dysphagia point early in tiie disease toward ton- sillitis rather than diphtheria. While the patient is holding the mouth open, look carefully as to the condition of the gums, teeth, and entire buccal mucous membrane, not forgetting the roof of the mouth. Examine the half-arches, the uvula, and as much of the tonsils and pharyngeal wall as can be seen. Now introduce the tongue-depressor, and look carefully over the entire extent of the tonsils by forcing them out into view, if not enlarged already, bv external manipulation or pressure on the root of the tongue with the tongue-depressor. Be especially careful to examine the nasopharynx in all cases, ^vith the mirror if necessary, for the membrane may be detected in this locality before it is observed elsewhere. Look, too, at the collection of glands at the base of the tongue, known as the lingual tonsil. If a membrane be seen on the tonsil or elsewhere, try to dislodge it gently with a probe. If it tears away with difficulty, leaving a bleeding surface, the supposition is that it is l)acteriological in origin. Use the laryngoscope and the rhinoscope wherever practicable or pos- sible in laryngeal or nasal cases. Before making any medicinal application to the affected area, take a culture for bacteriological examination. If, when the examination is complete, the diagnosis is still in doubt, and there is the slightest leaning in your mind toward infection by the diphtheritic agent, treat the case exactly as if it loere diphtheria by giving a guardedly grave diagnosis pro- visional on the bacteriological finding. Isolate the patient, and, if the diagnosis of diphtheria be substantiated clinically or bacterio- logically, use prophylactic measures in all of the exposed cases. Prognosis. — From the initial symptoms to the height of the disease usually three or four days elapse. By this time in a mod- erate faucial case the membrane has ceased to extend ; the tem- perature ranges from 100°-103° F., and the patient is not greatly distressed, either l)y the throat-involvement or the systemic infec- tion. The membrane now ceases to re-form and separates, leav- ing a surface tending to heal, and by the eighth to the twelfth day the throat has cleared up and convalescence is established. Deviation from this course means extension of the membrane or complications. The membrane in the above ty})ical case has begun on the ton- sils, gradually covered them, and by the third or fourth day has climbed up the half-arches, invested the uvula and, perhaps, the posterior pharyngeal wall. Growth beyond this arbitrary limit means extension and further systemic intoxication. Prognosis in cases even of this character should be miarded, for there is no DISEASES OF THE PHARYNX. 415 foretelling to what extent the membrane may grow, or what com- plication may at any moment render an otherwise favorable out- look exceedingly grave. It is to be borne in mind also that the systemic poisoning and symptoms may be disproportionate to the visible membrane ; that the slightly affected fauces, with severe, perhaps rapidly augmenting, prostration or unaccountable compli- cation, may be but part of the diphtheritic membranous infection, the rest of which is situated out of sight farther down the aliment- ary or respiratory tract. Extension to the nose should be regarded as adding materially to the gravity of the prognosis because of the obstruction to breathing as well as the greater absorption of toxins through the rich supply of lymphatics in that structure. Should the membrane involve the larynx, the outlook is also ren- dered less favorable because of the obstruction to respiration. Rarely the membrane extends into the stomach by way of the esophagus and may even reach the intestines, when the lesion will be found in Peyer's patches — the intestincd tonsils. Such involve- ment, with its train of digestive disturbances, is naturally of the gravest import. Temperature. — Tlie temperature of diphtheria is prognostic to the extent that any sudden decided change beyond the usual limits means, if it suddenly falls, collapse ; while a corresponding rise indicates pus-formation or increase of septic absorption. Pulse. — A rapid pulse, not varying much in rate or rhythm for days, is not of unfavorable significance. Progressive accel- eration, however, with irregularity and loss of force, renders the outlook proportionately grave. Heart. — Cardiac involvement in diphtheria occurs in a number of cases, and should be regarded as of particularly grave portent. Death due to implication of the heart may be brought about, according to Lennox Browne, by (1) direct effect of the toxic poi- son on the heart ; (2) clots in the ventricles or great vessels of the heart ; (3) cardiopulmonary paralysis ; (4) vomiting and other causes acting through the vagus; (5) ulcerative endocarditis, myo- carditis, and fatty degeneration of the cardiac muscle, which may cause death months after cessation of active symptoms. Lungs. — Extension of the membrane to the lungs, the entrance of particles of food, shreds of sloughing membrane, or of pus into tlie esophagus, and obstruction of the nares may cause, during the course of diplitheria, symptoms in the lungs which are at once alarming and extremely dangerous to life. ]^ronclio])neumonia, septic jincMunonia, ])u]monary congestion, \()hnv ]Mi('uni()iiia, and colla])se of the huigs may 1)C caused in this way, and their occui-- rencc renders the case so much the more to be (les|>:iii'e(l of. Kidney. — Albuminuria, as before stated, ocem-s in about one- third of tiie cases, and of itself is not of gi'ent prognostic impor- tance unless persistent. Re(hietion in the nniount or snp])ression 416 DISEASES OF THE NOSE AND THROAT. of urine, eiif^ts, epithelial cells, or hematuria are of far more grave import. Uremia may arise in the severer cases of kidney-involve- ment. It has been noted that in the uremic poisoning of diph- theria the intelligence has remained clear, up to the verv end of life. Neuroses. — The neuroses arising in diphtheria are due to "acute segmentary neuritis," causing fatty degeneration of the nuiscles supplied by the diseased nerve, to toxic poisoning of the nerve-centers, or to the local ulceration Avhich consumes the periph- eral nerve-filaments in its invasion of the tissue. The gravity of the neuroses from a prognostic standpoint depends on the stage of the disease when they occur and upon the role played by the affected muscle. The neuroses may occur (1) in the acute stage ; (2) during con- valescence ; (3) later than four weeks from the commencement of tiie disease. During the acute stage the cardiac or res})iratory nerves may l)e involved in the toxic process, which may cause cardiac or pul- monary collapse or paralysis of the diaphragm. During convalescence the first muscles to be involved are the jialatal, causing a nasal tone in the voice. Anesthesia of the pal- ate is associated at times. Morell Mackenzie has pointed out that infants may die in advanced palatal paralysis, due to their inabil- ity to suckle. Passage of fluids into the glottis and nasal regurgitation may follow paralysis of the muscles surrounding the laryngeal vesti- bule. The constrictors of the pharynx and the iuvoluntary mus- cular fibers of the esophagus are rarely affected. Ocular paralysis affecting accommodation, and more rarely through the sixth nerve causing strabismus, has been observed. Ptosis also has been noted. Slight facial paralysis has been noted, and the trunk and limbs may be involved by both motor- and sensory-nerve manifestations, the sensory symptoms, such as hyperesthesia, formication, and neuralgia, occurring rather later in the disease than the motor. The bladder may be paralyzed, as may be the lower ])owel and the rectum. Hughling Jackson calls attention to the fact that loss of reflex is an early prognostic symptom of nerve-impairment in diphtheria, and strict watch should be kept on the reflexes by way of antici- pating, if j)ossible, the consequent nerve- involvement. Bacteriolog-ical. — Should the bacteriological examination show the presenc(> of the Klebs-L()ffler bacillus alone, the prognosis is more favorable than if it were associated Avith other organisms. The formation of membrane and the paralyzing efl'ect on nerves and nerve-centers are to be considered as being especially due to the action of the specific bacilli. The presence of strejitococci in DISEASES OF THE PHARYNX. 417 addition to the Bacillus diphtherise augurs ill for the patient, because to their efforts are due the complications of the more malignant character, and rapid and phlegmonous glandular in- volvement, bronchopneumonia, nephritis, and other septic phe- nomena are to be expected. Staphylococci are found associated with the specific cause of diphtheria, and, while not especially vindicative of themselves, from association with more virulent organisms they comj)licate and render the prognosis more grave. Date and Mode of Death. — Sudden death in diphtheria may be due to suffocation from the membrane, spasm of the glot- tis, or toxemia during the first week. Paralysis of the respiratory or cardiac functions may cause death early or late. Formation of a clot in the heart or great vessels may cause death suddenly and unexpectedly. Death from kidney-complications may not occur for weeks. Treatment. — The treatment of diphtheria should be along the following lines, modified to suit the needs of the individual case : General Directions. — Isolate the patient in a well-lighted, well-ventilated, upper room, allowing 2000 cubic feet of air for an individual. Maintain the temperature of the room at as near 65° F. as possible. Have all furniture, curtains, etc. removed before the case is admitted, except a plain cot-bed, rug on the floor, table, plain chairs, and receptacle for clothes. Impregnate the room, especially if the case be one of laryngeal involvement, with steam containing eucalyptol, carbolic acid, or lime water. Keep the patient quiet in bed. Use the bed-pan for evacuations. Do not let him rise to eat. Feed with feeding-cups or spoon, in this way avoiding the danger of sudden cardiac or respiratory tail- ure due to exertion. Diet. — For the first few days give small quantities of concen- trated liquid food at frequent intervals, day and night. Beef-tea, milk, the yolk of raw eggs, broths given every two or three hours in amounts suited to the age and size, are satisfactory. Oranges and lemon drinks are grateful and not injurious. Ice may be given as frozen milk or frozen beef-tea. Give no sweets or articles contain- ing sugar. As soon as the membrane has cleared, fish, fresh vege- tables, and rice pudding may be added, and a full, nourishing diet should be resumed as soon as possible. Local Remedies. — As soon as the case is seen, apply I^offler's solution with a cotton swab. Repeat every two liours, carefully covering tlie meml)rane and surrounding tissue with the solution. The throat should be sprayed every hour with equal ])arts of liydrogen peroxid, aqueous extract of liamamelis, and cinnamon water. In nasal diphtheria the nose should be ke]>t chnir by removing the occluding m(!mbrane and n))])lying I-(r)ffler's soluti(m, and by the use of the cinnamon-water and hydrogen-peroxid spray. 27 418 DISEASES OF THE NOSE AND THROAT. Care should be taken to apply the agents to the postnasal area and the pharyngeal vault before the membrane has extended so far. Loffler's solution is highly germicidal ; it will destroy pure cul- tures of the Klebs-Lcifller bacilli, as well as those of the organ- isms usually found associated with that germ, especially the strep- tococcus, when exposed to the solution for only a few seconds. His solution consists of: I^. Alcohol is absoluti, 60 parts. Toluol, 36 " Liquoris ferri sesquichloridi, 4 " The membrane is readily dissolved by it. Lr)ffler himself obtained equally good results by substituting creolin for the iron in the above solution. Menthol is added, 20 grains to the ounce, to relieve pain. Chloral 20 grains, and glycerin 2 drams to the ounce of water may be used in the same way for the same purpose. The use of ice-bags, or, preferably, Leiter's coil, applied externally to the neck, is grateful to the patient and will tend toward reduc- tion of inflammation. Constitutional. — Begin the treatment of diphtheria by pre- scribing calomel in divided doses, ^^ to ^ of a grain with 1 to 2 grains of bicarbonate of soda every hour until the bowels are freely moved. Often the milder cases require little else. Tincture of chlorid of iron may be given in 4- or 5-drop doses hourly to a child of three years of age, and is an old but reliable mode of aiding the organisms to combat the disease. Antitoxic Serum. — The use of the antitoxin as a curative and immunizing agent in the treatment of diphtheria has passed beyond the period of experimentation, and the success obtained by this mode of treatment in intelligent hands is remarkable. Immunity. — It is a well-known fjict that age, condition, and previous attacks render individuals immune to certain diseases, and that measles, scarlet fever, and diphtheria are diseases of childhood, rarely of adult and middle age, and in old age the indi- vidual is, with the rarest exception, immune. Again, it is a fact that of several children exposed alike to infectious diseases all may take the disease sav^e one, who will resist the attack. This can be extended beyond individuals to exclude the fact that certain tissues of high grade resist infection and are practically immune ; for example, muscular tissue is rarely infected by tuberculosis. There must, then, be something within the cellular elements, either of the tissue or fluids, which enables the individual to resist infec- tion. The resistance secured by previous attack indicates that immunity can be acquired, and resistance to the disease without previous attack means that the individual is caj^able of manufac- turing a certain amount of immunizing material which increases DISEASES OF THE PHARYNX. 419 his physiological resistance to disease. I believe this power lies largely in the leukocyte or the nuclein product. This degree of immunity varies in diiFerent individuals. If this assumption as to immunity be true, the individual does not manufacture an antitoxin, but he does increase the capability of cellular elements to throw ofp or resist the invasion of the poison. On this theory is serum-therapy based, and upon its efficient aid to the defensive leukocyte does its success depend. Serum. — The serum I have most frequently employed is Behring's, although Mulford's, Parke Davis's, and Aronson's are probably just as good. Preference should be given to the prep- arations of high antitoxic unit-strength per cubic centimeter, and only standardized articles employed. Syringe. — A variety of syringes are manufactured especially for the injection of the serum, easy of manipulation and steriliza- tion (Figs. 140, 141). It is not at all necessary to have one of the Fig. 141. — Roux's antitoxin syringe. special syringes ; any ordinary hypodermic syringe with a large needle can be used, or even a new asjiirating needle may be sub- stituted, with ])reeautions as to sterilization, wliicli can be effected by l)oiling water and 5 per cent. tri(a-es()l. Injection. — The injections are made by j)in('liing a fold of the skin in the intrascapular region or lateral abdominal Avail and allowing the serum to enter slowly. After the desired amoimt has been introduc^ed, the s])ot is covered with a])sorbeut cotton, 420 DISEASES OF THE NOSE AXD THROAT. Avhich forms a sort of collodion with the serum that flows back through the orifice, and thus completely closes it. A slight edema occurs during the injection, but disappears within fifteen minutes or half an hour. Xo serious objection can be raised against the injections, the only untoward circumstance being an occasional slight urticaria of no moment. Complications I believe to be due to faulty technic, imperfect sterilization, or a poor serum. Should the point of injection become sore, apply heat, either as hot-water bag or moist, warmed antiseptic dressing. Dose of Serum. — In the serum we have a remedial agent that may be used preventively or therapeutically. The dose is given in antitoxic units throughout. When a case of diphtheria occurs, all who have been exposed should be protected by injecting 500 units ; or if infection and incubation be suspected, the curative dose of 1000 units should be employed at once. These instructions may seem radical ; but experience has proved their value, and their neglect may sooner or later cause regret. There is no danger in these doses, as clin- ical experience in skilful hands has proved that a person cannot be too immune. For a child of two to five years with suspicious throat-symp- toms or having a moderately severe tonsillar involvement sup- posedly diphtheria, the dose should be 1000 to 1500 units. In well-marked faucial, nasal, or laryngeal cases, the initial dose should be 2000 units. The later the case is seen, the larger should be the dose. The physician should administer this remedy with promptness and courage for effect, irrespective of dosage ; but the following directions from J. Madison Taylor are so complete that they may serve as a guide in the general management of the quantity to be used : " If at the end of six hours the case is in the same condi- tion, repeat the dose of 2000 ; if it is worse, use a dose of 3000 ; if much better, wait until twelve hours have passed, then if the same condition, repeat 2000, or if ever so little worse, 3000 or 4000 units at a dose. Then wait six or twelve hours, and repeat again if the same condition maintain — at six hours, 3000, if worse, 4000 ; if better, wait until twelve hours elapse, and give 3000 or 4000 units, making the third dose in a favorable case, or the fifth dose in an increasingly ill case. These three doses, or at most five, will usually be sufficient. "When the symptoms grow steadily worse, the dose maybe repeated every six hours, increasing by 1000 at each injection, thus — 2000 units in six hours ; 3000 in six hours more (total, twelve hours) ; 4000 in six hours more (total, eighteen hours) ; 5000 in six hours more (total, twenty-four hours) ; 6000 units at this last dose — continuing thus to increase if necessary. "There is a sign which is regarded as pathognomonic of improve- DISEASES OF THE PHARYNX. 421 ment, which is described as a blood-red line surrounding the diph- theritic patch in the throat, noticed also in all healing infected inflammations, showing a demarcation between the diseased and healthy areas. The effect of the serum is to lower the tempera- ture ; hence, if after the first dose this still keeps high, the dose may be repeated in six hours, or all the more promptly and increasingly." Too much importance cannot be given to the early treatment of the disease. After the absorption of the alkaloidal products (toxins) which are generated at the point of infection, the func- tional activity of the cells is impaired ; the degree of impairment depends upon the resistance manifested by the patient and on the amount of toxin generated, as well as the length of time the cellular elements are subjected to the destructive influence of the toxins. If this has reached a stage of pathological alteration of tissue, we cannot hope to have in antitoxic serum a remedial agent ; it, no doubt, would arrest the progress of the disease and possibly enable the tissue to resist further infection. As to its effect on the germ, " It is a well-known fact that environments alter the characteristic features of all germs. That in the descrip- tion of the germ, temperature, light, culture-medium, and absence or presence of other bacteria must be taken into consideration ; also the laboratory germs, which depend on artificial nutrition, differ some- what from those found in the body (see Fig. 139). This is especially true of the bacillus of diphtheria, which is demonstrated by the difference in the descriptions given by various authors. The alteration of the Klebs-I^Sflfler bacillus, as due to the age and con- dition under which the germ was found and grown, has been the subject of careful study. Now, as to the effect of the blood- serum on the germ, it is not claimed that the antitoxin has any direct action ; but by counteracting the poison in the system pro- duced by the product of the germ, the resistance on the part of the patient manifested at the nidus of infection indirectly affects the germ's nutrition, thereby altering its character." Statistics show that when the treatment is begun on the first or second day of the disease, the mortality is reduced to almost 1 per cent., but that it gradually increases when treatment is delayed, and by the fifth or sixth day the mortality is almost as high as when no serum is used. This points, then, to the immediate in- jection of the serum before serious tissue-alteration and profound toxemia have occurred. Even if this is an antitoxic agent, it must be remembered that its action is largely constitutional, and that local treatment and even stinndating coiistitutidual treatment sliould also be employed. The infected mucous-membrane surfaces should be frequently and thoroughly cleansed and the patient stimulated. 422 DISEASES OF THE NOSE AND THROAT. Stimulants should be given, in the form of brandy or whiskey, when the strength begins to fail. Nitrate of strychnin, aromatic spirits of ammonia, or digitalis is to be used if cardiac or respira- tory failure threatens, the dose to be suflfieient to meet the require- ments of the case. Complications and Sequels. — Aural Diphtheria. — The involvement of the middle ear is not usually heralded by pain, and the first symptom may be the suppurative discharge from the meatus. Should this complication arise, syringe the ear with 1 part boric acid and 25 parts water at 100° F., three or four times a day. Ocular Diphtheria. — Sliould the di])htiieritic jjrocess involve the conjunctivae, which rarely haj)pens, iiowever, Hermann Cohn of Breslau highly recommends hourly pencilling with 5 per cent, solution of benzoate of sodium. The use of bichlorid of mercury, 1 : 5000, as an irrigation will eifect a similar result. Laryngotracheal Diphtheria. — The use of steam surcharged witli eucalyptol carbolic acid has been spoken of, and may be used under the so-called "bronchitis tent" — e.g., a sheet thrown over four broomsticks, one at each corner of the bed. A kettle contain- ing boiling water is arranged so that the impregnated steam shall pass under the sheet and keep the atmosphere moist and bland. An emetic given early may aid in the expulsion of loose pieces of membrane. The best emetic for a small child (one to five years) is wine of ipecac in teaspoonful doses every fifteen minutes until vomiting is produced. Leiter's coils, with cold water ]mssing through them, applied externally to the neck are useful in affording some comfort to the distressed child. Tile throat should l)e frequently exauiincnl with the laryngeal mirror whenever })ossible, and the extent of the membrane observed and watched. In this way a small patch of membrane wliicii might be the whole cause of trouble can be removed with forceps, avoiding the necessity of intubation or tracheotomy. Should progressive asphyxia threaten, as shown by suppression of voice, increasing dyspnea, stridor, cyanosis, and especially retrocession of the chest-walls, perform tracheotomy or do an intubation. The various factors compelling or indicating a choice between these two ojierations, as well as their description, will be found described on pages 592-601. Paralysis. — Strychnin should be pushed. Electricity may be used as soon as the acute stages have passed, either as the galvanic or faradic currcut. Prophylaxis, Hygiene, and Disinfection. — As soon as suspicion j^oiuts strongly to a case l)eing one of diphtlieria, it should be isolated. A room in the ui)per story of the house should be selected, from which all that is not absolutely necessary to the com- DISEASES OF THE PHARYNX. 423 fort of the patient has been removed. Communication with the rest of the members of the household should be absolutely cut off. As soon as an absolute diagnosis is made, it should be reported as such to the relatives and to the authorities of the city or town. The practice in some localities of placarding the house as soon as diphtheria bacilli are found by the Board of Health bacteriologists, without consultation with the attendant physician or investigation into the clinical symptomatology of the case, seems a little too rigid enforcement of red-tape ; yet it is probably considered as the safest procedure to err on the safe side by protecting the community's welfare without thought of the individual. The room should be kept as well supplied with fresh air as pos- sible. A sheet moistened with a solution of bichlorid of mercury, 1 : 5000, should be hung outside of the door. In cases of laryngeal or tracheal involvement eucalyptol may be added, in the proportion of |- ounce to a pint of water, and kept simmering over the flame. All excretion should be carefully disinfected by the addition of bichlorid-of-mercury solution, 1 : 500. Every article employed in the sick-room should be carefully disinfected with a similar solu- tion, 1 : 2000, before it can be taken out for purpose of cleansing or for any other reason. This applies to the plates, cups, spoons, and all eating utensils, bed-linen, articles of clothing — in fact, any- thing removed from the room after the entrance of the affected patient. Old linen rags should be used instead of a pocket- handkerchief, and should be burned as soon as no longer of use, as should all dressings, etc., employed in the treatment of the case. An old night-shirt might be kept in the sick chamber for the use of the attendant physician, which could be slipped over his ordinary clothes before examination of the patient and discarded as soon as the treatment has been finished, lessening in this way the only means of carrying the infection, if isolation has otherwise been carefully carried out. Lennox Browne speaks in this connection of the personal hy- giene of a sanitary engineer who always "blew his nose, gathered his saliva, and expectorated after he had inhaled any unpleasant effluvium ;" and the procedure might be carried out to advantage by the attendant or physician. All instruments employed in examination or treatment should be boiled for ten or twenty minutes or disinfected by the use of carbolic acid, 1 : 20. Care should be taken, while examining or treating the patient, that none of tlie nunubrane or oral contents is expectorated or coughed up on the ])liysician's clothing or face. If this should occnr, promptly remove tlie expectorated matter with a (•l(»th dipped in an antiseptic solution and thoroughly wash the alfcctcd parts. Should the case terminate fatally, all who have not previously 424 DISEASES OF THE NOSE AND THROAT. been in the sick-room sliould be forbidden entrance, especially children. The patient's tliroat, if recovery takes place, should be treated with antiseptic gargles or sprays, such as — 'Sf. Extracti hamamelidis, Aquse cinnamomi, Hydrogeni peroxidi, cid every four to six hours, and a bacteriological examination should be made each week until no bacilli are found. If the findings are negative three weeks after convalescence, it may be considered reasonably safe to permit the quarantine to be raised. Disinfection of Sick-room. — If the rules laid down before as to the removal of all unnecessary furnishings, bric-a-brac, carpets, curtains, and hangings have been carried out, the disinfection of a sick-chamber will not be especially difficult or expensive. Of the various methods of disinfection, that of the l)urning of sulphur lias Fig. 142.— Leiitz's fonnaldchyd apparatus. been the most generally used. One pound of sulphur should be em- ployed for every 1000 cubic feet of air-space to be disinfected. The room should be hermetically closed by pasting strips of paper about the windows and doors, the sulphur should be placed in a receptacle DISEASES OF THE PHARYNX. 425 which should rest in a pan of steaming water ; other pans contain- ing water placed about the room will render this procedure more eifective. After the room has been closed eight to twelve hours^ it should be freely opened and allowed to air for twenty-four hours more. After this the wall-paper should be removed, the floors and woodwork scrubbed with soap and water and further cleansed with corrosive-sublimate solution, 1 : 1000, before it can reasonably be said to be safe for future occupation. Better than the employ- ment of sulphur for disinfection, because it is more efficient and is less injurious to goods disinfected, is the use of formaldehyd or for- malin in the apparatus shown in Fig. 142. GANGRENOUS PHARYNGITIS. Synonym. — Putrid sore throat. Gangrenous pharyngitis is purely a secondary condition, and is fortunately very rare. The process is always preceded by catarrhal inflammation of the mucous membrane, which, however, is depend- ent upon some infection, as the condition when it does occur is usually associated with the infectious fevers, such as scarlet fever, diphtheria, and typhoid fever, or it may follow trauma or opera- tive procedures. It is due to a local infection, or rather a localiza- tion of an infectious process within the submucosa, which may be the result of infectious bacteria of the pathogenic variety floating in the circulation. There may lodge in the submucosa an infected embolus, which in turn gives rise to abscess-formation. The base- ment membrane is dependent upon the submucosa for its nutrition, which being cut off by the infectious process, rapid necrosis takes place. The inflammatory products accumulate on the surface, and form over the area where necrosis is taking place a fibrinous mate- rial, which, when removed, carries with it a slough. It is really a localized superficial necrosis, and, as it involves the basement membrane, gives rise to a true ulcer of the pharynx. This gan- grenous variety may also occur, due to local infection of })acteria, causing liquefaction-necrosis of the epithelial surface, and through the lymph-channels involving the deeper structures ; it really produces phlegmonous inflammation of such severity as to cause local death from bacterial processes, with resulting slough. The throat-manifestations come on suddenly and pursue a rapid course on account of the infectious nature of the process. There is usu- ally a rapid rise of tcmpc^raturo^, owing to the absorption or presence within the system of toxins. When the condition goes on to actual necrosis, the temperature may suddenly drop to subnormal. The pain is usually severe and of a lancinating character. The cer- vical and subinaxillary glands are nearly always involved. As the necrotic process advances, the breath is frightfully fetid — that characteristic odor from gangrenous tissue which cannot be 426 DTSEASES OF THE NOSE AND THROAT. described, but once detected will always afterward be recognized. Present always is marked prostration with mental depression, similar to that occurring in any septicemic process. The absorp- tion takes place not only from the local })oint of inflammation, Vmt also from the gastric and intestinal tract, owing to the swallowing of the ])utri(l masses. Prognosis. — Tlie prognosis is bad, the j)atient usually dying from svnc()])('. Treatment. — The treatment should l)c directed toward the undcrlving svstcmic infection. The secretory function should be stimulated, and remedial agents which aid in elimination should be administered. Stimulating medication should be instituted at the very onset. Ijocally, the surface should be repeatedly and thoroughly cleansed by disinfecting antiseptic solutions, such as 2 to 5 drops of carbolic acid to the ounce. For relief from the dis- agreeable odor, a spray of permanganate of potash followed by hydrogen peroxid (15 volume) should be employed. TRAUMATIC PHARYNGITIS. Synonym. — Occupation-pharyngitis. Definition. — An acute inflammation of the pharynx, caused by wounds, foreign bodies, inhalation of various forms of dust, vai)ors, or caustic substances. Htiology. — This variety of pharyngitis is most commonly seen in children, since they are more liable than grown persons to drink accidentally corrosive liquids or l)oiling solutions. It may also be caused at any age by foreign bodies or the inhalation of hot air or steam. It may also occur in individuals who are constantly exposed to some variety of dust, as in sweepers, weavers, miners, etc. Chemists who are exposed to the fumes and vapors ])roduced by chemical reaction during experimentation are also liable to the disease. The emVjedding of sharp foreign bodies, such as fish- bones, spicules of shell, splinters of bone or wood, pins, etc., in the tissue are also common causes. One case coming under my obser- vation was caused by the inhalation of fine particles of glass from the brush used in burnishing the gold on hand-painted china. The minute partick^s of glass, being inhaled not only through the mouth but also through the nose, produced a marked irritation in all the upper respiratory tracts. When the inflammation is due to foreign bodies, it has its origin at the point of irritation and spreads to the surrounding tissues. If the wound caused by the foreign body involves the submucous connective tissue, it is quite likely to give rise to suppuration and abscess-formation. In the varieties of inflammation caused by vapors, fluids, or fine particles of dust, the whole pharyngeal structure is more regularly involved, there being no localized nidus of inflammation ; besides, the con- DISEASES OF THE PHARYNX. 427 tinuoiis mucous-membrane structures are also implicated. In the varieties brought about by escharotics, scalds, or burns, there is great danger of immediate edema of the glottis, as the irritation would not be limited to the pharyngeal structure alone, and even if it were, that tissue would rapidly become edematous. Regard- less of cause, this variety of pharyngitis runs a rapid course and is accompanied by exaggerated inflammatory phenomena. Treatment. — When a foreign body is the exciting cause, if it can possibly be located it should be promptly removed. Fre- quently, though, when a patient presents himself for treatment, the body has been discharged, and there is left the infected wound with the subsequent inflammatory area. Where there is threat- ened edema, frequent multiple punctures should be made under antiseptic precautions. Locally, to relieve the pain in scalds, burns, etc., there is nothing better than smearing the parts freely with carbolized vaselin to which has been added 4 grains of menthol to the ounce. Its protective qualities may be increased by rubbing into each ounce thoroughly an ounce of compound tincture of benzoin with equal parts of 50 per cent, boroglycerid. Cold ex- ternally may aid in combating the inflammatory process. The edema may be so rapid as to necessitate resort to intubation or tracheotomy. However, if the inspired irritant has caused involve- ment of the larynx and trachea, the edema may extend below a point which would be relieved by such procedure. The internal administration of opium or morphin is always beneficial ; and, as a local sedative, insufflation of morphin, ^ to |^ grain in precipi- tated chalk or stearate of zinc two or three times daily, affords great relief. This should not be repeated oftener than every four hours. Of the numerous escharotics which might be the exciting cause of traumatic pharyngitis, it is impossible to give the various antidotes that would neutralize their caustic effects. At the same time the action of such irritants is so rapid that little benefit would be derived from the internal administration of antidotes. The treat- ment always indicated is to relieve the pain by anodynes and the local application of emollients. After the subsidence of the acute symptoms the main treatment is the thorough cleansing by bland alkaline antiseptic washes, such as boric acid 8 grains; carbolic acid 3 droi)s to tiie ounce of water. HEMORRHAGIC PHARYNGITIS. Definition. — By this variety of inflammatory process of the ])liarviigcal structure is meant inflammation that is l)rought about by minute areas of hemorrhagic infarction caused by i-h<>xis. Although this condition may orruy in association w ith ;in acute inflammatorv process, in the true hemorrhagic variety this inflam- mation is always secondary to hemorrhage. It frequently occurs 428 DISEASES OF THE NOSE AND THROAT. after an attack of illness, especially of the eruptive fevers, in which there is altered vascular tone with relaxed vessel-walls and lax ])erivascular tissue. The hemorrhagic areas are very small, and show as small, dull-red, slightly edematous spots. If seen early they will exhibit very little, if any, inflammatory reaction ; but after twenty-four to forty-eight hours they will show considerable evidences of inflammation. These areas may be located anywhere in the ])harvugeal surface ; but they are usually on either side of the median line. They may be single, although generally multiple. Where the hemorrhage is very slight, it will resemble more the j)etechia of eruptive fevers. Frequently in the specific inflamma- tory processes, especially syphilis and tubercidosis, where altera- tion in blood-vessel walls is a common symptom, these hemor- rhagic areas will be observed not only on the pharyngeal, but also on the mucous-membrane surface of the soft palate and uvula. The symptoms are similar to those of acute pharyn- gitis, but are likely to be of longer duration. Occasionally, there may be expectorated slightly blood-stained mucus. The pain is more localized than in ordinary acute pharyngitis, and usually not severe. Occasionally, necrotic changes may take place in the area of infarction, owing to the cutting off of the blood- supply ; and the minute portion sloughing off gives rise to ulcera- tion, which is described as hoiiorrliucjic ulceration of the phari/nx. Treatment. — The treatment should be directed toward the correction of any constitutional diathesis as well as the relief of any tendency to constipation. Locally, the throat should be repeatedly gargled with hot water, which will materially aid in re-establishing circulation. Of the local applications, those afford- ing the most relief are the astringents, in the form of a 3 to 6 per cent, alumnol solution or 5 to 10 grains of sulphocar- bolate of zinc to the ounce of water. However, the local appli- cations will only relieve the accompanying inflammation, and the treatment given under Acute Pharyngitis is also applicable here. THE PHARYNX IN THE EXANTHEMATA AND OTHER FEBRILE AFFECTIONS. Scarlet Fever. — Although there seems to be some difference of opinion as to the occurrence of involvement of the pharynx in every case of scarlet fever, it would appear that the statement — the disease in the throat is the most regular in its appearance of all the symptoms of scarlatina — is a safe one. Commencing with a certain amount of redness as early as the occurrence of the fever, the throat-lesion may be of varying degree of severity. According to Osier, they may be classified in three groups — first, slight redness, with swelling of the follicles of the tonsils ; DISEASES OF THE PHARYNX. 429 second, a more intense grade of swelling and induration of the parts, with follicular tonsillitis ; third, membranous angina, with intense inflammation of all the pharyngeal structure and swelling of the glands below the jaw, and in very severe cases a thick, brawny induration of all the tissues of the neck. The condition of the pharyngeal mucosa is almost pathognomonic of scarlatina, and consists of a " deep bluish-red injection of the mucous mem- brane and tonsils in the neighborhood of the highly swollen papillae of the posterior portion of the region of the cricoid carti- lage and that portion of the pharynx which includes these different parts." Even in comparatively mild cases the inflammatory proc- ess may extend over the pharynx and involve the Eustachian tube and the lining membrane of the ear, most likely complicated with pre-existing enlargement of the pharyngeal tonsil, which is a suitable nidus for infection. Ulceration of any other part of the throat than the tonsils usually does not occur before the fifth day, except in the severest cases, although the excess of the secretion of the parts spread over the surface is very liable to be mistaken for sloughing. Membranous inflammation of the pharynx, if occurring early in the disease, or even later than the fifth or sixth day, may be due to the action of the Klebs-Loffler bacillus, which would be purely diphtheritic in type, or to the influence of streptococci or various forms of micrococci. In streptococcic infection the invasion is more apt to involve deeper structures and to cause sloughing and even gangrene. Inflammation of the lymphatic glands is almost always induced in such conditions. With the discharge of the sloughs there is an offensive odor ; the sloughs may lay bare the cartilage and bone. In malignant scarlatina the throat-affections are proportionate to the systemic involvement. Treatment. — In all cases of scarlet fever in which the throat- lesions are severe, external applications to the neck are indicated, and in the early stages should consist either in the Leiter coil, the rubber bag filled with cracked ice, or the application of cloths wrung out in cold water. Later, the application of heat, either dry or moist, is equally efficacious. Detergent and antiseptic spray-applications are indicated locally. Hydrogen peroxid of full strength, or mixed with cinnamon water, pepper-mint water, and extract of hamamelis, in equal })arts, may be used as a spray ; or the following used in the same manner: ^. Sodii biciirbonatis, Sodii biboratis, da gr. x (.6) ; Acidi carbolici, Vdv (.3) ; Aquse cinnamomi, Aqure mentlue piperitte, nd fl5ss (l-'j.)- 430 DISEASES OF THE NOSE AND THROAT. Small-pox. — The throat-trouble iu small-pox often com- mences during- the stage of infection, or even during incubation, and in some cases consists of a dusky injection of the mucous membrane of the pharynx, and in others amounts to a catarrhal inflammation, with redness and swelling of the adjacent parts, which in rare instances extends to the lymphatics. In the hemorrhagic small-pox the throat may be involved in ecchymoses and mem- branous exudation before the eruption appears upon the body. As a rule, however, the eruption proper does not appear in the throat imtil after its development upon the skin, and is modified by the tact that the structures of the mucosa differ from the ordinary epidermis. Pseudomembraue may develop in some cases, causing great pain, discomfort, and difficulty in deglutition. Among the complications and sequels of small-pox are infectious inflammation of the parotid and other glands, purulent otitis media, and abscess of the larynx. On account of the excessive soreness and pain in the pharynx, especially in the complicated variety of the disease, applications of cocain and menthol may be indicated. A gargle of chloral hydrate 5 to 10 grains, glycerin ^ dram to the ounce of water, is equally soothing. External applications of cold or heat, which- ever is more gratefully borne, may be of service. Disinfectant gargles, sprays, or applications are to be used, however, as in any other acute inflammation of the pharynx. Measles. — Although there seems to be some discussion in regard to the importance of the prodromal rash occurring in measles, yet there is no doubt but that the involvement of the faucial and pharyngeal mucous membrane does occur in a manner thoroughly characteristic of the disease. There may be merely a diffused redness upon the mucous membrane or on the palate uvula, and sometimes on the pharynx a blotchy or punctate rash, which either occurs conjointly with or may antedate by a few hours or days the appearance of the cutaneous eruption. The catarrhal inflammation which always involves the upper respiratory tract in measles spends most of its force on the larynx and bronchial mucosa. Extension of the inflammation over the pharynx and aural cavities is one of the complications which is to be men- tioned only to be avoided, if possible, by proper prophylactic measures. Coating the membranes with carbolized vaselin to which has been added one dram of compound tincture of benzoin is highly efficacious. Apart from this treatment, the ordinary alkaline detergent and antiseptic sprays will answer for all the symp- toms arising from the involvement of the pharynx. l^rysipelas. — Erysipelas of the pharynx occurs primarily or may be found as a secondary complication of the cutaneous mani- festation of the disease. The ordinary redness with diffuse inflam- DISEASES OF THE PHARYNX. 431 mation, in which the tissues are swollen, livid, and shining, the formation of vesicles, varying from the size of a pin-head to J inch in diameter, which terminate in gangrene, embraces probably the full extent of the involvement of erysipelas. The constitutional manifestations are most marked. Epidemic ei'ysipelatous fever, commonly known as "Black tongue," may involve the pharynx and even extend to the larynx. When the pharynx is involved by extension from without, the process may enter by the mouth, the nose, or the ear by continuity of tissue, or there may be a metastatic interchange between the cuticle and the internal position of the disease. Erysipelas of the pharynx begins with difficulty in swallowing, or with a sharp pain in the throat, ushered in by a high fever, which may last for a few days before the efflorescence makes its appearance. When this occurs, the fever may or may not decline, again to ascend on further development of the erup- tion. The membrane, swollen and glistening, appears as though varnished, and here and there may be found vesicles filled with serum, blood, or pus. Gangrenous areas may develop. Exten- sion to the accessory sinuses, the tonsils, and the middle ear may occur in almost all cases where there is glandular involvement. Abscess may result, and in severe cases meningitis may follow. Involvement of the pharynx alone, without extension, is com- paratively rare. Erysipelas may occur in this locality as a com- plication of small-pox, typhus or typhoid fever, and other febrile diseases. The prog-nosis should be guarded in all cases, because of the possibility of fatal termination by extension and involvement of the larynx or other contiguous or continuous structures. Treatment. — Constitutional. Tincture of chlorid of iron should be given in large doses, J dram to a dram every two or three hours, well diluted in water. Alcohol in some of its forms, strychnin, or other supportants should be administered freely. Locally, there have been a number of remedies offered, and from their very great profusion there can be no other inference than that no one is especially efficacious. Ice, externally and internally, soothes the membranes and perhaps acts beneficially. Ichthyol, 40 per cent., painted over the affected area, is highly beneficial. Hydrogen peroxid exerts some germicidal influence, and sliould be a]^]>liod by means of a cotton swab. Intermittent Fever. — Intermittent fever, evidencing an irritation or iiltcratioii in tiie blood, due to the infection of the parasite of malaria, may be manifested in the upper respiratory tracts, and tlic inflammation may involve tlie mucous membrane from the nose to the smallest division of the lung. These evidences of involvement may appear as attacks of coryza, or in certain cases paralyses of tlie organs of deglutition have Ix'cn olisorved. Burning pain in the pharynx has also hccn noti'd as a sym])t(nn. 432 DISEASES OF THE NOSE AND THROAT. Pliarvni^itis or tonsillar enlargement may be observed as a loeal manifestation ot" the systemic involvement. Treatment consists in c(^mbating the malarial infection. Gout. — Inilammatory conditions of the pharynx or larynx, as local manifestations of the general systemic involvement, nndoubt- edly do occur. As with tlie supervention of the acute podagral attack the throat-aifections have disapj)eared, the irritant cause of the general affection j)rol)ably evidencx's itself in this inflammation of th(> mucous-membrane structures in the pharynx and larynx. Typhus Fever. — In this disease the mucous membrane of the pharynx usually becomes involved, as does the mucosa of the mouth, and appears dusky red, injected, with enlargement of the mucous follicles, Avhich contain puroid material, or even collections of puriform matter may be found in the areolar tissue behind the pharynx. The membrane may be covered with a viscid mucus or with flakes of pseudomembranous exudation. Difficulty in swal- lowing may occur. Suppuration or ulceration is rarely seen, unless streptococcal infection occurs. The treatment should be that appropriate to the general dis- ease, with the addition of cleansing and antiseptic sprays and gargles. Typhoid Fever. — In a considerable number of cases both the pliarvux and larynx are involved in typhoid fever, though affections of the latter are more serious than those of the former. Catarrhal, follicular, ulcerated, croupous, or diphtheritic and aph- thous inflammations of the pharynx are met with. Difficulty in swallowing, due to the dryness of the throat, is very often com- plained of at the beginning of the disease. Later on, it may be a purely nervous affection. Especially is this true in children. There is usually a certain amount of injection of the pharyngeal mucous membrane, but actual sore throat is comparatively rare. It has been stated that the follicles of the pharynx and tonsils, faucial or lingual, may be involved coincidently with the intes- tinal glandular implication. In fact, there may be rare cases in which the amount of infection is so great that the name tonsiUo- ti/phoid or i^luu-iitu/otiiphoid has been ap})lied. Since the involve- ment of the typhoid process is more to be feared in the direction of necrosis of some of the bones and cartilage, or abscess-forma- tion, the lesions of gravity are rather to be expected in the larynx than in the pharynx, and such is the actual state of affairs in the majority of cases. The frequency of such complications and sequels has been shown by Keen in his work on " The Surgical Conipli- cations and Se(piels of Typhoid Fever." Influenza. — With the majority of cases of epidemic influenza ("la grip[)e"), particularly of the pneumonic variety, an inflam- mation of the pharynx will be associated. Though characterized by no especial peculiarity as to type, the affection is usually found DISEASES OF THE PHARYNX. 433 as an acute catarrhal process, involving the pharyngeal mucosa only as part of the more general implication of the upper respira- tory tract, with decided tendency to become chronic. The char- acter of the inflammation is influenced to a great extent by the organisms associated with the bacillus of PfeifFer in the produc- tion of the condition. Ulcerative termination of the process, while uncommon, has been observed, as has croupous deposit on the tonsils and posterior pharyngeal wall. Varioloid. — The pharyngeal involvement of varioloid is usually slight, the eruption being, as a rule, scantily developed, though occasionally it may give rise to considerable inflammation, with dysphagia and hoarseness. Chicken-pox. — If the cutaneous eruption of chicken-pox be at all abundant, involvement of the pharynx may be looked for ; though more numerous on the soft and hard palate. Usually appearing as flaccid vesicles surrounded by an area of hyperemia, the epithelial cells covering the vesicle soon desquamate and leave excoriations. The throat is usually sore and painful, and there may be some involvement of the glands of the neck. Treatment other than that addressed to the disease in general is not necessary, except the ordering of a gargle that will soothe the parts and promote healing. The following may be employed to advantage : ^. Tincture cinchonse compositse, fliss (15.) ; Menthol, gr. xv (.9) ; Glycerini, q.s. ad flsj (30.). Sig. — One teaspoonful every three hours in one ounce of milk as a gargle. LUDWIQ'S ANGINA. Synonyms. — Angina Ludovici ; Cellulitis of the neck. This affection is in reality an acute cellulitis of the neck, and is usually secondary to the specific fevers, especially diphtheria and scarlet fever. Though at times clue to trauma, this affection is in all probability bacterial in origin. Symptoms of intense streptococcic infection in the throat, especially of the pharyngeal portion, are soon followed by glandular, parotid, or submaxillary infection, which rapidly goes on to suppuration. Unless met promptly by energetic surgical procedure, general systemic involve- ment is sure to follow. SIMPLE CHRONIC PHARYNGITIS. Synonyms. — Clergyman's sore throat ; Voice-users' throat ; Exudative pharyngitis. 28 434 DISEASES OF THE NOSE AND THROAT. Definition. — A chronic catarrhal inflaiiiniation involving the niiicous menihrane of the pharynx, in which there are permanent alterations either within the gland-structure or in the submucous connective tissue. Ktiology. — This condition may be the result of a continued acute or subacute pharyngitis. It is a well-known fact that from the continued use of the voice, as in public speaking, there is a reac- tionary muscular contraction of the larynx and pharynx, with forced local anemia of the part, and that after the pressure from muscular contraction is taken off there is stasis and dilatation of the vessels. This often repeated will bring about changes in the perivascular tissue almost identical with those of chronic inflam- mation. The pathological condition produced is very much the same as that due to a cyanotic congestion. Although there is an excess of blood to the part, it is not nutritive, and the peri- vascular tissue is subjected to pressure, thereby lessening its nutri- tion as well as the l)lood-supply itself. While the causes of the pathological alteration in the structures and the symptoms pro- duced may differ, yet the actual change is the same. Simple chronic pharyngitis may be brought about by continuation of acute processes, or may be due to constitutional conditions in which there is alteration in the blood-supply, produced by venous stasis or eijanotie congestion, owing to interference in circulation in the various organs, as the liver, kidney, lungs, or to cardiac lesions. Peculiar nervous phenomena, peripheral in origin, also exercise considerable influence on the causation of the condition. This may either consist in a primary lesion or may be due to an involve- ment of the peripheral nerves in other pathological processes. Irregularities in the digestive tract also exert considerable influ- ence. The continued use of any stimulant, such as alcohol or tobacco, or the excessive use of narcotics, will eventually produce the same condition. Frequently the so-called " rum cough " is brought about by circulatory changes from the stimulation of the alcohol. Sexual excesses also exert a marked influence. The chronic irritation produced by smoking is in reality not only a local one, but a local manifestation of a constitutional condition brought about by the al)Sf)rption of the various alkaloids of tol)acco — namely, nicotin and pyridin. Tlie various forms of pneumono- koniosis are also exciting factors, although tliey properly belong under Traumatic Pharyngitis or Occupation Pharyngitis. At the same time the irritation is productive of a chronic inflammatory process. Certain constitutional diatheses, such as a gouty, or uric- acid, or blood dyscrasia due to the absorption of toxins from the intestinal tract, or any lesion that interferes with the excretory or secretory organs, are also important etiological factors, either primary or secondary. Constitutional conditions, such as tuber- culosis and syphilis, in which there is alteration in the blood- DISEASES OF THE PHARYNX. 435 vessel wall, may also show manifestations in the lax mucous- membrane structures. Irregularities in the formation of the pharynx, especially the condition known as slanting pharynx, is an important causal factor. Another cause of chronic pharyngitis, as observed in singers and in speakers, is unquestionably the improper use of the muscles of phonation and articulation, owing to improper breathing, in which the faucial and laryngeal muscles are overtaxed, or increased work is thrown upon the structures by the increased vascular supply. There will be produced in this manner certain alterations in the connective-tissue elements, which will produce symptoms identical with chronic pharyngitis, although they cannot be properly classed as inflammatory changes. The various forms of rhinitis occurring in the mucous membrane of the anterior or posterior nares are also important factors. While the inflammatory process may not actually spread by contiguity of structure, yet by the discharge of the irritating material over the pharyngeal wall from the nasopharynx, the irritation will event- ually produce a chronic inflammatory change in the pharyngeal structure. This may be due not so much to the immediate action of the irritating material on the mucous membrane, as to the con- stant elFort of the individual to clear the throat of irritating material. Together with the long-continued use of the voice and the muscles of phonation, there must also be considered the forced use, as is observed in outdoor speakers, where the individual, of necessity, in his efforts to be heard by his listeners, exerts tre- mendous effort in speaking. Combined with this effort is the atmospheric condition, which is an aid to the irritation that very rapidly produces marked inflammatory changes in the pharyngeal structures. This is a condition in which there may have been originally very little inflammatory process present, but by the re- peated engorgement of the vascular system there has been brought about an overnutrition, and in the relaxation that always follows the continued use of the voice there has taken place a leakage from the blood-vessels into the perivascular tissues, and the inflam- matory condition there produced is secondary to the congestion. Combined again with the excessive v^se of the voice, individuals speaking in public buildings where vast crowds are assembled have also to contend with the irritating effects of the dust. This alone is sufficient to produce irritation and inflammatory changes in the upper respiratory tract. The condition is also found in persons in whom there is obstructed nasal respiration, either anterior or posterior, due to malformations, se])tal deflections, or neoplasms. This is dne to the fact that on account of the interference with nasal respiration mouth-])rea thing becomes necessary, and the inhalation of air that has not Ijeen cleared of dust, or moistened, or reduced to the proper 436 DISEASES OF THE NOSE AND THROAT. temperature acts as a direct irritant to tlie pharyngeal mucous- membrane surface. This Avill often expkiin cases of repeated attacks of acute pharyngitis where possibly the individual has been so placed in the sleeping apartments that he inhaled directly the Mann, dry, and dusty air from the register. Also adding to the irritation are tlie coal-gases generated from the base-1)urner. Pathology. — The pathological alteration occurring in the pharyngeal membrane in chronic pharyngitis varies, and many of the chronic forms of pharyngeal lesion are entirely dependent upon the stage of progress of the inflammatory process. Take, for example, a simple chronic pluiryngitis, in which there is a slow inflanimatory change in the submucous connective tissue. Grant that the irritating cause is sufficient only to bring about a low grade of inflammation, in which there is a slight exudate from the blood-vessels, with few migratory leukocytes, with their gradual proliferation in the connective-tissue spaces. This, together with slow proliferation of the fixed connective-tissue cells, will bring about a permanent thickening of the pharyngeal mucosa. At this stage, by the increase in the connective-tissue element, there will also be produced a certain amount of irritation within the gland- ular elements, with hypersecretion, by the irritating material that brouglit about this increase. As this inflammatory material organ- izes, by its actual bulky presence it will press upon the glandular elements in the submucosa. Now, as inflammatory organized con- nective-tissue elements are sure to undergo contraction, it brings about an entirely different condition, as at this time tlie inflammatory stage is past and the condition is not now one of inflammation ; but as the tissue is suffering rather from the effects of an inflammatory organized tissue and from the contraction of the submucosa and the involvement of the glandular element, there will be brought about a condition which is one of atrophy due to pressure. Such con- dition will be described under Atrophic Pharyngitis. While this pathological finding will vary according to the different causes found associated, and Avhile its progress may be more rapid in one instance than another, yet the actual pathological alteration is practically the same in all cases of chronic pharyngitis. There is, however, a condition in which there is an actual increase in the connective-tissue element, which partakes more of the nature of a hyperplasia. It is not truly hypertrophy, because there is no increase in the actual function of the membrane, rather a decrease ; yet in certain conditions, in which the general nutrition is good and in which there is present no constitutional diathesis or dyscrasia, the overgrowth of the tissue is a simjfle hyperplasia. In such conditions an atrophic process will not follow, and the only marked pathological alteration will be in the glandular elements that are subjected to pressure from the increase in the connective tissue. DISEASES OF THE PHARYNX. 437 not however, from contraction. In all hyperplasia the nutrition is good. The very fact that the hyperplasia occurs, of necessity proves this. With this good nutrition, then, there will be kept up a fair amount of glandular secretion, and the condition will not progress to one in which the mucous membrane becomes dry and permits of accumulation of altered secretion on its surface. Symptoms. — The mucous membrane is either hyperemic or congested, but never uniformly so. There is a marked variation in color. The whole border of the pharyngeal structure is of a brighter color, while the actual pharyngeal structures tend more to the color produced by congestion. The palatine folds and the inferior and anterior margin of the soft palate is of a lighter red color, resembling more the blush of an acute inflammation. The pharyngeal surface may show congested capillaries and congested venules (Fig. 143). The surface is irregular and slightly nodular, not projecting so markedly as in the true follicular variety. A varicose condition of the vessels may also be observed at the base of the tongue — extending partially into the pillars of the fauces. This, however, is more marked in the varieties of chronic phar- yngitis in which the organized inflammatory connective tissue has gone on to actual contraction. The depressions in the pharyngeal structure will be filled with tenacious mucus, and at first appear- ance will resemble membranous inflammation very closely. When the condition is brought about in any of the forms of pneumono- koniosis the secretion is always colored, the color corresponding to the material which is responsible for the inflammatory process. The secretions are markedly altered in character, owing to the pathological changes which have taken place in the secreting gland-structure. As the case progresses, the secretions become more tenacious, with a tendency to become encrusted, resembling very much the condition in the nasal cavities in the beginning of atro- phic processes. The voice is usually aff'ected, there being consid- erable hoarseness, and the patient seems to lose somewhat the con- trol of the muscles of phonation, causing a peculiar jerky voice. This condition, however, is not due to laryngeal alteration as much as it is to the alteration in the pharyngeal muscles, which causes, on attempt at jilionatiou, a spasm of the pharynx. Besides, there may be some sliglit iiTitation of the superior laiyiiiioal nerve, from the inflammatory condition, which extends l)y (•oiiiinuity of struct- ure to the tissue surrounding the vocal cords.. There is a pecul- iar weakness of the voice, and the individual soon complains of "throat-tire," with a decided aching in the nuiscles of the throat. This aching sensation is relieved by the patient grasping the throat and sii])|)orliiig the muscles by slight pressure. In attempting to use the voice in singing, there is marked limitation of tlie register, with uncertainty of tone and inability to control ihc pitch of the voice, although the singer may be conscious that his \-oico is out 438 DISEASES OF THE NOSE AXD THROAT. of tiiue. The nasal respiration may not be markedly interfered with, nnless there be complicated with the process enlargement of the gland-structure in the vault of the pharynx or in the faucial pillars, or associated obstructive lesions; breathing is, however, often shallow and insufficient. The cough is irritable and rasping, and a constant desire on the part of the individual to clear the throat of mucus keeps up a continual hacking, Avhich in itself is a source of unceasing irritation and productive of the exact condi- tion for which the ])hysician is attempting to afford relief Some- times the secretion may be slightly blood-streaked, which, although alarming to the patient, is rarely of any import, as associated Avith the pharyngeal inHammatory process there is usually the same condition present at the base of the tongue, in the periglottic structures, and from the constant effort to free the throat from secretion there may be rupture of dilated veins or overdistended capillaries or arterioles. There is a constant desire to swallow, which is brought about by the associated enlargement of the lin- gual tonsil and by the accumulated secretion in the pharyngeal structure just above the point that is cleared by the act of swal- lowing. The patient will complain of the sensation of a foreign body in the tiiroat and afford some grounds for suspecting the con- dition described as "globus hystericus," as it will give rise to symptoms resembling very much this hysterical phenomenon. The pain on swallowing will vary with the extent of the inflam- mation and the degree of patiiological alteration. As a rule, there is only slight pain on swallowing, except when taking warm fluids or food highly seasoned with pungent condiments. The sense of taste will be slightly affected if the process is lim- ited largely to the pharyngeal structures. However, if the nasal cavities and anterior pharynx are involved, there will be marked interference not only with taste, but also with the sense of smell. The same rule as to involvement can be applied to the Eustachian tubes and to the effect on hearing. After meals the secretions are always increased, and the patient is subjected to a paroxysmal fit of coughing and hacking, in which frothy and slightly colored mucus is expectorated. Inhalations of dust or sudden changes of tem- perature, as going from a warm room into a cold one, will also pro- duce paroxysmal cough. There is nearly always associated digestive disturbance. This may be, however, primary to the })haryngeal inflammation and associated directly as an etiological factor ; or it may be secondary, caused by irritation from the unconsciously swallowed secretion. There is frequently an accompanying laryngitis, which may be produced by an extension of the inflam- mation by continuity of structure ; but in the majority of cases it is due to the same etiological factor producing the inflammation in the pharyngeal structures. Diagnosis. — Simple chronic pharyngitis as a condition is not DISEASES OF THE PHARYNX. 439 difficult of diagnosis. However, as the prognosis and treatment of the condition depend entirely upon the causal factor, this can be attained only by careful clinical observations. Prognosis. — The prognosis depends entirely upon the correct recognition of tlie causal factor, as on this depends the success or failure of treatment. Treatment. — Careful attention should be given to the indi- vidual's general condition and to the correction, as far as possible, of any underlying constitutional diathesis or organic lesion. There should be free stimulation of the glandular secretions of the ali- mentary and the urinary tract. For this purpose nothing is better than granular effervescing phosphate of sodium in from 1 -dram to |-ounce doses, given in the morning or before each meal. Equally good is succinate of soda in 10- to 20-grain doses. For its tonic alterative effect, compound wine of iodin (Llewellyn's) — each dram of which contains ^ grain of iodin, ^ grain of bromin, and j^-^ grain of phosphorus — should be administered three times daily after meals. It sliould be taken in a fourth of a glass of water. Locally, the membranes should be frequently and thoroughly cleansed by the use of sprays or gargles. For this purpose a gargle of plain hot water, at a temperature that can be comfortably borne, will generally give relief, besides being a local stimulant to the blood-supply. However, the secretion may be so tenacious as to require some dissolving solution. To accomplish this a spray or gargle of a strong salt solution or an alkaline wash of bicar- bonate of soda or bicarbonate of potash, 15 grains to the ounce of water, will usually suffice. However, in cases in which there is marked irritation a cleansing and sedative effect will be produced by the use of hot milk, to which has been added 10 grains of sodium chlorid to the ounce. If such irritation remains after the cleansing of the surface, a gargle of dilute hydrochloric acid, 10 to 20 drops to the ounce of water, or a teaspoonful of camphorated tinct- ure of opium to an ounce of Avater, will afford relief. However, where there is marked engorgement of the blood-vessels, with per- manent thickening in the submucosa, as a result of inflammatory changes, gargles or sprays of any kind afford only temporary relief. If there is any irregularity in the u])])er respiratory tract in the form of nasal obstruction, which is acting as an exciting factor, such obstruction must l)e promptly removed. W the condition exists along with formation of the bony structure supjwrting (he ])haryngeal membrane, as in the .shmfinff pharynx, or in the pecul- iar curved pharynx, permanent cure Avill rarely ever be accom- plished. In those cases in which the condition is brought about by misuse or overuse of the voice and tlie muscles of ])honation, absolute rest must be insisted upon. Many cases of pharyngitis and laryngitis of tliis varict\- cninidt merely be temponirily re- lieved, but even permanently ciii-ed l>y iii-t I'lietion in the proper 440 DISEASES OF THE NOSE AXI) THROAT. methods of respiration and elocution. "Where the condition is due to the effects of stimulants, as alcohol and tobacco, the use of such should be interdicted. Existing diatheses, as the rheumatic or gouty, which frequently are exciting factors, must receive prompt and energetic treatment. A change of climate is often beneficial, regardless of the exciting cause. SUBACUTE PHARYNGITIS. A subacute inflammatory condition of the pharyngeal mucous membrane is not a special disease. It is, in reality, the late stage of an acute pharyngitis in which there has been neglect of treat- ment, or in which the condition has failed to respond to treatment. The symptoms and pathology are identical with the late stage of the acute condition or the early stage of the chronic. It is the inteniiediate process, when the permanent structural alterations are just beginning to take place and reach that point in which there is less likelihood of its return to the normal. The remedial agents as described under Simple Chronic Pharyngitis should be employed, as indicated by the symptoms present. FOLLICULAR PHARYNGITIS. Synonyms. — Clergyman's sore throat ; Dysphonia clericorum ; Folliculous pharyngitis; Granular pharyngitis. Definition. — A chronic inflammatory condition of the phar- yngeal mucosa, especially involving glandular structure. It is characterized by an altered secretion and by irritation of the pharynx, accompanied frequently by a sharp, hacking cough. Alteration of the voice is a constant symptom, varying under different circumstances from a slight hoarseness to complete aphonia. The membrane presents a characteristic appearance, wdth more or less general congestion and a surface studded with small reddish or yellowisii elevations, either discrete or coalesced, and caused by the inflamed and distended glands. If these have discharged their contents, small patches of a thick whitish or yel- lowish material may l)e seen closely adherent to the elevations. Htiology. — Predisposing- Causes. — In this connection must again he cited the general conditions already mentioned as favoring chronic inflammatory processes in the mucous membrane of the respiratory tract. The young and middle-aged are more liable to its occurrence than those of elderly life, and males, possibly because of more exposed life, are more often afl'ected than females. Here again the scrofulous, rheumatic, gouty, and anemic diatheses, as well as a generally lowered tone of the bodily organ, are of im- portance as predisposing conditions. The same is true of the con- dition of the raucous membrane following the infectious diseases, DISEASES OF THE PHARYNX. 441 such as measles, scarlet fever, and the like. The neurotic tem- perament, whether inherited or acquired through excessive nervous strain, as from overwork, mental or physical, improper stimulating diet, the demands of social duties, and a host of other causes, are favorable to the establishment of the condition. Nor must the influence of the various gastric and hepatic disorders, as well as conditions tending to cause a venous congestion of the sub- mucosa, be overlooked. Certain local conditions are extremely likely to be attended with this pharyngeal involvement. These include chronic rhinitis, nasopharyngitis, the various obstructive lesions of the nasal cavities, and conditions of the anterior and posterior cavities attended by irritant discharges which more or less constantly are brought into contact with the lower membrane. In fact, frequently the symptoms assigned to follicular pharyngitis may be almost entirely due to irritation in the nasopharynx. The fact that many of the cases occur with such inflammatory processes accounts for many of the distressing throat-symptoms which are referred from the nasopharynx and not entirely due to the enlarged follicle to which these symptoms are often attributed. Climatic conditions are of importance, as is the constant inhalation of vari- ous substances of irritating action. In the latter connection the habitual use of tobacco has been the subject of much discussion ; to say the least, ho^vever, it cannot be regarded as a prophylactic against the occurrence of the condition, nor as a palliative of it when once established. The influence of occupation is a most important one, those who are compelled by their vocation to use their vocal apparatus under many and varied unfavorable condi- tions being especially liable to the acquirement of the malady. Thus, it is peculiarly a disease of clergymen, who in addition to their Sunday services are taxed by other public demands ; of law- yers with practices necessitating long and fatiguing pleas in dusty and ill-ventilated court-rooms ; of campaign speakers ; actors ; singers, and of those in the host of minor callings, such as hucksters and auctioneers. The condition is but another phase of simple chronic pharyngitis. Repeated attacks of acute pharyngitis are liable to create the condition, either from frequent repetition or prolongation of a severe attack. Exciting- Causes. — The overuse of the voice — the " straining of tlic voice," as it is popularly termed — is among the most impor- tant of these. This may be active in several ways. Prolonged and repeated use of the voice, rejjeated eflbrts to attain and main- tain either extreme of the singing register, as in opera singers, and tiie taxing of the vocal apparatus in loud, high-keyed speaking are the usual examples. In many cases inijiroper vocalization during such efforts is an additional source of irritation, ibr the lips, teeth, tongue, etc., are not made to perform their functions fully, which to a certain extent causes increased effort on the part i»l" the i)iiai'yn- 442 DISEASES OF THE NOSE AND THROAT. geal structure. It may be that the use of the voice in itself is not sufficient to have a determinant effect, but coupled with an exist- ing irritation, as in acute catarrh, a dusty or smoky atmosphere, or other unfavorable condition, it is sufficient to establish it. Exposure to a variable climate and the various other agencies which, sepa- rately or combined, act in the causation of colds are prolific of the condition. The habitual taking of hot, pungent foods, solid and liquid, as well as the inhalation of irritants, especially those over- stimulating to the glandular structures, are undoubtedly active causes in many cases. In some cases there apparently exists a liability to its occurrence, in which no definite causative factor can 1)0 ascertained. Pathology. — The pathology of this condition does not differ, as regards the membrane in general, from that of any simple chronic catarrhal condition. There is the same submucous infil- tration of fluid with proliferation or retrogression of cells. The vascular tone is below normal, and the vessel-walls are relaxed and usually, especially the veins, distended. The surface-epithe- lium is swollen and desquamating, and the surface is more or less covered by a thick secretion intimately admixed with cellular elements and debris. In certain areas the inflammatory prolifera- tion may have organized in fibrous tissue, forming a so-called hypertrophic change. Or possibly, if the condition is of sufficient chronicity, these may have contracted into areas of atrophic char- acter. The peculiarity, however, of the condition, both clinically and pathologically, consists in the glandular phenomena. The primary function of the glands is, of course, the secretion of mucus, and normally the law of supply and demand is as operative here as elsewhere. Increased demand in the shape of suitable stimuli from without or within is followed by increased secretion. If, however, this stimulation be sufficiently repeated or prolonged, in short, of exactly such a character as we have already considered in this connection, the functional activity of the glands is exhausted, and thev, with their immediately adjacent tissue, become inflamed and practically form encysted foreign bodies. This explains the excessive action of the voice in producing the affection, since it calls for increased secretion to sujiply sufficient lul)rication, thus overtaxing the glands and resulting in their inflammation. The same is true of the other causes mentioned. Macroscopically, the affected structures present themselves as small elevations, from one to several pin-heads in size, reddish or lighter in hue (Fig. 143). They may be scattered or coalesce (Fig. 144), be few or many. This swelling is due partly to the inflammation in the periglandular tissue and partly to the increasing distention of the gland-cavity through the occlusion of its orifice. If, however, the follicle be seen at a later stage, it may possibly have ruptured, and its apex or the apices of the associated follicles, which may also have dis- IT Fig. 143.— Follicular pharyngitis with adhesion of pillars to faucial tonsil. ^^^ A ^/yrgareltaV/cuiKiptjt r. I'iG. 114.— Large follicle on pharyngeal wall. Pilatoi! vessels with enlarRed and adherent tonsils. DISEASES OF THE PHARYNX. 443 charged their contents, are covered by a thick, pasty, cheesy and foul, light-colored mass. This is the so-called exudative form, as contrasted with the other or simple chronic variety. Microscopi- cally, there are in the tissue adjacent to the glands the usual inflammatory phenomena. The orifices of the glands are seen to be occluded, either by inflammatory swelling, by impacted cell- masses, or by inspissated secretion. The caliber of the glands or their efferent ducts are enlarged. The lining epithelium is sw^ollen, and the constituent cells are in various stages of fatty degener- ation. There is an abundant desquamation, and the gland-cavities are filled with detached cells, whole or disintegrating, by granular debris, and by fat-globules from the broken-down cells. There is more or less fluid present, the absorption of which leads later to the caseation of the intraglandular masses. This condition may persist, the whole forming practically a foreign body embedded in the membrane and adding to the irritation. Or the gland-contents may find exit either through a minute opening of the obstructed outlet or by rupture, and the cheesy mass may slowly exude and cover the surface with a foul, ill-smelling coat. In some cases calcareous deposition has taken place in the mass, and concretions of varied shape have been the resultant effect. The condition is frequently associated with adhesion of the faucial pillars to the tonsil, as seen in Fig. 129. Symptoms. — The establishment of the condition proper is generally preceded by either repeated or prolonged acute inflam- mation of the pharynx or a chronic condition of the same charac- ter. The direct onset is usually not rapid. In its incipiency the glandular structures may respond to the stimulus present and cause a profuse outpouring of secretion, the patient being unable to use his voice properly because of the constant filling of the mouth with fluid. This is, however, soon abated, and the true nature of the trouble appears. The overtaxed glands inflame, and the secretion proportionately lessens and deteriorates. The patient notices a dry, uneasy feeling in the throat, especially after use of the voice. This may last but a short time, only to return again more severely upon a second irritation. The attacks grow longer in duration and severer in character with each succeeding expos- ure. The feeling of throat-uneasiness gradually intensifying, perhaps after a few weeks, even months, and not unfrequently a year or so, runs into a persistent feeling of weariness as the per- manency of the condition becomes assured. The voice, on the slightest use beyond a limit peculiar to each case, becomes hoarse and muffled, its quality is altered, and it may fall to a mere harsh M-hisper or even complete aphonia. Following its use, especially if at all prolonged, the uneasy feeling intensifies, the throat is " tired," and may even become acutely painful. Speech may become slow and hesitating from the pain and soreness produced 444 DISEASES OF THE NOSE AND THROAT. by the use of the voice. In cases of long standing, pain is apt to develop as a more or less constant symptom, usually of a burning, pricking, or stinging character, not unlike and frequently described by the patient as resembling a fish-bone or other sharp foreign body lodged within the pharyngeal limits. It may be of a dull, aching character, and the irritation in the pharynx may be intensi- fied by deglutition, causing a feeling of rawness or soreness on swallowing. The secretion resembles that of a simple chronic pharyngitis, and its quantity is iniluenced to no small extent by the number of the glands involved. Early in the course of the malady it becomes thick and glairy, but is usually clear ; later it becomes more or less mucopurulent, and finally may even tend to crust-formation. It is scanty in quantity, and causes a constant effort on the part of the patient to remove it. The effort to clear the throat may for a brief moment give some relief, and any hoarseness of voice may temporarily disappear. Soon, however, the condition redevelops, or in not a few cases no relief at all is obtained, and the expectoration, if any, is scanty and may possibly be blood-streaked. Cough is a troublesome symptom, usually sharp, barking, or metallic, either practically constant or occurring in paroxysms, and a severe attack is more than apt to produce soreness and aching in the throat and region of the soft palate. It is due undoubtedly to several causes, such as irritant secretion, the general irritability of the pharyngeal mucosa, and the " tickling " produced by a relaxed uvula. In some few instances the cough has apparently been replaced by asthma of a mild or rather severe type. In long-standing cases the infiammatory process may extend to the nasal, lower pharyngeal, and laryngeal regions, and excite acute or chronic manifestations there, with varied associated de- rangements, such as impairment of hearing, smell, and taste. Constitutionally, there is a great variance in different cases. There may be little or no impairment of the general health, though some lowering of the bodily vigor, possibly even of grave import, is apt to be present. The predisposing diathesis may be noticed in greater or less marked degree. Gastric and intestinal derange- ments are of very common occurrence, acting in some cases possi- bly as a cause, in others as an effect, and explanatory, no doubt, of many of the skin-eruptions that have been noted from time to time as accompanying the pharyngeal condition. Mental dulness is not impossibly an occasional development. Inspection shows a char- acteristic condition of the pharyngeal membrane. The surface displays a number of elevations varying in size, reddish or reddish-yellow in hue, which stand out from the surface (Fig, 14.3). These may be scattered, grouped in small collections, or form large elevated areas. Not uncommonly there is associated a band-like thickening behind the posterior half-arches, forming the so-called i^haryngitis hypertrophica lateralis. If the jirocess is DISEASES OF THE PHARYNX. 445 further advanced, the small irregular patches of cheesy material may be seen adherent to the apices, more abundant possibly in the anterior region than on the posterior wall. Between and surround- ing the follicular groups maybe seen the dilated vessels (Fig. 143) forming a rather complex network. The membrane is partially or more generally congested. In long-standing cases the whole membrane may be relaxed, the uvula and soft palate be flabby and toneless, and the base of the tongue involved. In some cases there may be quite an extensive involvement of the follicles with- out the production of any marked symptoms. Diagnosis. — This is usually not of great difficulty. The characteristic symptom is, of course, the presence of the enlarged follicles, as revealed by inspection. The history of the case, the voice-phenomena, the peculiar throat-symptoms, and the occupa- tion of the patient are to be taken into account. Prog'tiosis. — The disease is not dangerous to life, and can usually be relieved by systemic and long-continued treatment. It has, however, an important bearing on the development of laryn- geal and nasopharyngeal troubles. Treatment. — The treatment should be, first, careful attention to the general health of the patient ; and second, local treatment of the follicles and engorged vessels. The constitutional treatment must depend entirely on the clinical indications presented by the patient, and must be determined by the practitioner. In the early or acute stage, where permanent structure-change has not taken place, I have obtained excellent results from the adminis- tration of drugs which are eliminated by the mucous membrane. The following should be administered three times daily : ^. Phosphori, gr. ylo (0.0006) ; lodini, gr. i-i (0.008-0.01) ; Bromini, gr. f-L (0.008-0.01) ; Vini Xerici, flsj (4.0).— M. The distressing cough and constant irritation can be relieved by the administration of codein, in doses of yV to 1 of a grain, three or four times daily, or a dram of camphorated tincture of opium to an ounce of water as a gargle. As to the treatment of the actual follicle, each follicle may be touched with a 20 per cent, chromic-acid solution or the dilute hydrochloric acid. This can be done without contact to the surrounding structure, if a fine- pointed applicator is used, on the ])oint of which is tightly wrapped a small jiortion of absorbent cotton ; the cotton is saturated with tiie solution, tlu; excess dried off" with another piece of cotton, and then applied directly to the follicle, using very little pressure. Equally beneficial results may be obtained by the mopping of the entire surface with — 446 DISEASES OF THE NOSE AND THROAT. 3^. Olei plni sylvestris, Olci eiicalvpti, mi gtt. v (.3) ; Menthol (crystals), gr. iv (.24) ; Tincturae benzoini, flsj (30.). This should be applied every other day for its stimulating effect and tendency to promote resolution by absorption. In more obstinate cases, the simple puncturing of the follicle by means of a sharp-pointed applicator or probe is sufficient. The probe should be bluntly needle-pointed and with no cutting surface. Relief of the engorged vessels may be obtained in the same way, or the patient should be instructed to gargle the throat frequently with water as hot as can be comfortably borne. This is especially bene- ficial in the variety where several follicles coalesce and form blebs (Fig. 144). This, through its local stimulation to circulation, does much toward re-establishing the normal function of the gland by relieving congestion. In many cases the above procedure will give permanent relief. Should the condition be chronic, with fixed tissue-alteration, the application of the galvanocautery is Avarranted. The needle should be fine-pointed and heated to a white heat, and should be applied directly to the follicle, care being taken not to penetrate too deeply into the tissue and not to involve the healthy surrounding structure. I have seen cases in which a great number of follicles had been removed by the galvanocau- tery several years previously, in which the condition of the pharynx, brought about by tiie extensive and possibly careless cauterization, was much worse than that originally produced by the follicular pharyngitis. When follicular pharyngitis occurs along with naso- pharyngeal catarrh, treatment for the associated condition should be instituted. While the excessive use of tobacco and alcohol may not be direct causal factors, yet they may aggravate the condition, and their use should be prohibited. HYPERPLASTIC CHANGE IN THE PHARYNGEAL STRUCTURE. Occasionally there is scon in the lateral walls of the pharynx a thickened condition involving the mucous membrane and under- lying structures. There seems to be no tendency to contraction, and the pathological alteration is apparently an overgrowth of the connective-tissue elements similar to that of a benign tumor — in reality, a hyperplasia. It rarely ever involves the actual pharyn- geal structure, and, owing to the fact that it is usually lateral, has been described in various works as Pharyngitis hypertro})hica lateralis. It seems to be associated with chronic inflammatory processes in adjacent structure. As the condition is usually found occurring Avith chronic nasopharyngeal inflammation, especially DISEASES OF THE PHARYNX. 447 that involving the portion back of the soft pillars, it seems to be rather an extension of the chronic inflammatory process by con- tinuity ; or while not, in reality, an inflammatory process, the increase of the connective-tissue element may be exjplained by the increased nutrition brought about through the inflammatory process situated above, as the hyperplastic structure is in the direct line of the vascular supply as well as in direct line of continuity of structure. ATROPHIC PHARYNGITIS. Synonyms. — Dry pharyngitis ; Pharyngitis sicca. Atrophic pharyngitis is in reality not an inflammatory process, but the resulting permanent pathological alteration in the mucous membranes of the pharynx. Btiology. — Although the causes of atrophic pharyngitis may be different, the histological and physiological changes of the mucous membrane of the pharynx are practically the same, regard- less of cause. Any condition that will bring about a chronic inflammatory process, such as local irritation, as observed in indi- viduals whose occupation subjects them to constant exposure to the inhalation of dust, irritating fumes or vapors, or involvement of the pharynx by a continuation of inflammatory processes from adjacent structure produces a permanent thickening of the sub- mucosa with organization and contraction. By the contraction of the inflammatory organized tissue the muciparous glands of the mucous membrane are involved and their functional activity altered, or the gland may be even entirely obliterated. This gives rise to perverted secretion on the surface, with a tendency to accumulation of material which in itself is a constant source of irritation. Such would be the variety of atrophic pharyngitis that would follow any chronic inflammatory process. Again, in any constitutional condition in which there is inter- ference with the systemic circulation and damming back of the blood in any part from venous stasis of the dilated blood-vessels, through pressure and poor nutrition there may be brought about an atrophic process. Although the appearance of the membrane is somewhat different, yet it is as truly atrophic, as regards function and loss of actual cellular structure, as the first variety. Or a simple atrophy may result from tro]>hic lesions. The etiology may be obscure, nevertheless the simple atrophic process takes placie in tlic mucous membrane and brings about, as far as function is concerned, an alteration similar to that due to contract tion of inflammatory tissue. There; is a variety, however, of dry pharyngitis which is not atrophic, that is duo to some constitutional disease in which there is an alteration in the general nutrition, and the ghmdular secretion 448 DISEASES OF THE NOSE AND THROAT. is modified as to its cliemical constituents. When such a condition arises, the normal secretion poured out on the pharyngeal surfa(;e tends to adhere, and the surface becomes glazed and looks as if it Iiad been coated with a thin layer of varnish or shellac. In such cases there is very little actual alteration in the mucous-mem- brane structure, and the condition is one of perverted secretion rather than pathological alteration in the structure. This has been observed in diabetes mellitus and in various forms of gastric and intestinal disorders. Atrophic rhinitis is given by many as a causal factor of atrophic pharyngitis. I am inclined to believe that the condition wliich would cause an atrophic rhinitis would also be responsible for the atrophic pharyngitis, although in some rare cases the inflammatory process travelling by continuity of structure, aided by gravity, may extend from the nasal and naso- pharyngeal cavities to the pharynx and even to the larynx. In the majority of cases, however, instead of spreading by continuity, it is an association of cause that produces both conditions. Nasal obstruction, however, is an important factor in certain forms of dry pharyngitis, ^yhen the nasal obstruction is sufficient to cause mouth-breathing, tlie pliaryngeal mucous membrane is irritated by the inhalation of air which is neither moistened, freed from dust, nor subjected to the proper thermal changes — in other words, which has not been subjected to the physiological action as affi^rded by the nasal mucosa. This in itself may produce dry pharyngitis, and in turn a simple chronic pharyngitis, and then by inflammatory or- ganization and fibrous contraction there is produced a true atrophic condition. As a rule, then, excluding the simple atrophy of ner- vous origin, the varieties of dry and atrophic pharyngitis are sec- ondary and a result of local or constitutional causes. Pathology. — In the simple dry variety, in which the surface of the pharynx is coated with a thin, glairy mucus, wliich har- dens and dries on the surface, the pathological alteration while in that stage is largely one limited to secretion, in which the chemical constituents of the normal secretion are markedly altered, due to some constitutional dyscrasia. This secretion in itself, by local irritation, may bring about chronic inflammation in which there is leukocyte migration and fixed connective-tissue cell-prolif- eration in the submucosa, and with the supplied nutrition capillary budding will take place, the origin of inflammatory tissue. This, by excess of tissue, will produce some pressure ; but by complete organization there is contraction of the inflammatory tissue, which is now practically scar-tissue, and the inflammatory process no longer existing, there is brought about an atrophic process, which is one of pressure. This contracting tissue eifects the partial obliteration of the blood-supply, and also produces pressure upon the secreting glands, with interference in tlieir secretion and their final obliteration. The pathological alterations brought about by DISEASES OF THE PHARYNX. 449 vascular changes, as noted in circulatory interference, are seen in lesions of the heart, lung, liver, kidney, or intestine, in which there is damming back of the venous circulation. From this cyanotic condition of the mucous membrane there is interference with nutrition as well as pressure on the perivascular tissue from the overdistended vessels. This will also include the gland-struct- ure of the part. If this condition is kept up sufficiently long, although slight inflammatory changes may take place early, it must eventually result as a pressure atrophy ; and, unless the cause is removed before this permanent alteration has taken place in the tissue, the change will be a permanent one. Bacteriolog- ical examination shows that there is no special organism which plays an important part as an etiological factor. From my own investigations I believe that the majority of bacteria present are secondary, and the fact that various pathogenic germs were found present, such as the Staphylococcus and Streptococcus pyogenes and the Klebs-Loffler bacillus, does not prove that they were in. any way associated as causal factors, and in many cases animal experimentation shows these bacteria to be non-virulent. There is also present a large number of saprophytic bacteria, which are in tliemselves non-pathogenic. Symptoms. — The prominent symptom of atrophic pharyn- gitis is a burning, itching sensation in the throat, with intolerable dryness. Swallowing is difficult, it being almost impossible to swallow solid food unless the pharyngeal surface is first moistened. There is a certain amount of rigidity and stiffness about the throat. Occasionally the dried mucus on the surface will be so firm that on friction with the probe or the tip of the tongue-depressor a dis- tinct grating can be heard. The character of the secretion will depend entirely upon the variety of change and the stage. In the simple dry pliaryngitis, in which the alteration in the structure below is very slight, tlie membrane is thin, almost transparent, at least translucent, and the surface smooth. However, as the change in the glandular and submucous structure advances, the secretion ^vill become thicker, more wrinkled, and accumulated in masses, and will be colored brown or green. There is a hacking, rasping cough, not relieved l)y exjiectoration, with the sensation of a for- eign body in tlic tliroat. There is usually associated with the piiaryngeal aitei'ation a similar condition in the nasopharynx and nasal cavities, so that the aeeunudated secretion usually extends u]) into the naso|)lKivyn.\-, with iVecpient sinudtaneous involvement of the Eustachian tube. In the dry variety, or in the early stage of the atrophic process, on removal of the tenacious secretion the underlying nuieous-menilirane sin-faee will be reddened and ex- tremely sensitl\-e. IIowcN-ei-, as tile process advances and the secretions become more tenacious und tend to accunudate in crusts, on renio\al the surface will present irregularly eoloi-ed areas, some 450 DISEASES OF THE NOSE AND THROAT. spots bein^ markedly inflamed, while others are pale and colorless. The membrane will seem thinner than normal. This is true except in the variety in which the atroj)liic change is due to the venous stasis and the pressure-atro})hy. The surface will then be more nodular, vessels will be seen coursing over the surface, and the secretions will not accumulate in crusts or masses, at least not early in the pro(!ess ; but when the atrophic process is far advanced, such crustation may take place. The breath is usually heavy and the odor fetid, as the condition usually exists along -ivith an atrojihic rhinitis. Diagnosis. — The diagnosis is easily made, simple inspection being sufficient. However, the prognosis and treatment depend entirely on the underlying cause, which may not be so easily ascer- tained. Dryness of the throat may be a sym})tom in certain infec- tious fevers, but the associated phenomena will make the diagnosis easy. Prognosis. — In the simple dry variety the prognosis is good. In the early stage of the atrophic variety from contraction prog- nosis is also good ; but when the atro})hic process has advanced, with permanent alteration in the structure, the outlook is not so favorable. The same can be said of the variety due to cyanotic congestion, unless the cause of the cyanosis can be removed before permanent alteration in the tissues occurs. Treatment. — As the condition is, in reality, not an inflannna- tory process, but a pathological alteration produced in the mucous membrane secondary to such processes, and necessarily involves a number of causative elements, this contraction involves the sub- mucosa and the muciparous glands as well as the epithelial layer. Upon the amount of fibrous tissue and the alteration produced in the structure involved in the contraction, as well as the extent of the area involved, will depend the prognosis as to palliation or cure ; for, if the process is well advanced, no amount of hx'al or constitutional treatment will alter the already formed fibrous tissue or arrest its contraction. The process may be limited to the pharynx, or it mav be sub- secjuent to the same condition pre-existing in the anterior nasal cavity and nasopharynx ; when such is the case, the morbid proc- ess involving the true pliaryngeal surface is somewhat different, and is more amenable to treatment than when secondary to local- ized infiammatory conditions of the pharynx. This is true for the following reasons : The condition is brought about by mechan- ical irritation, instead of spreading by continuity of tissue from the nasal mucous membrane. \\'ith atrophy of the mucous mem- branes of the nasal cavities there is marked enlargement of the space for the transmission of air. This allows an increased vol- nme of air to pass through the nasal cavities. Owing to the altered condition of the membrane, even the normal amount of DISEASES OF THE PHARYNX. 451 air would not be physiologically altered in temperature and moisture, much less the increased volume. This in itself would act as an irritation to the pharyngeal wall. The ciliated epi- thelium has also lost its function, owing to the atrophic process of the nasal mucous membrane ; therefore the particles of dust carried in by the air, instead of lodging and being expelled, pass directly into the nasopharynx and pharynx. The fact that such cases are more amenable to treatment does not depend so much upon the structural alteration of the tissue as it does upon the fact that the pre-existing condition in the anterior nares and nasopharynx directs attention to the pharynx proper, and treat- ment can be instituted early. The varieties of dry pharyngitis due to other causes present the same appearance clinically, but differ very much in their structural alteration. For instance, in dry pharyngitis due to cer- tain fumes or vapors the change is limited, at least for some considerable time, to the epithelial layer, and the discontinuance of exposure to such fumes will usually promote a rapid recovery. The variety seen in diabetes mellitus also presents very little structural change, and requires no separate treatment other than that directed toward the relief of the special disease. A mild variety of dry pharyngitis may be induced by nasal obstruction causing mouth-breathing. The treatment is obvious ; remove the nasal obstruction. If this should be done early, before any structural change has taken place in the pharyngeal tissue, the irritated mem- brane will rapidly return to normal ; but should the obstruction be of long standing, the condition of the pharyngeal tissue will be that induced by any chronic inflammatory jDrocess. It has been my own experience that solutions used by the patient rarely cleanse the membrane. While the patient should be given a solution for this purpose, to use two or three times daily, to ensure perfect cleansing he should be seen by the attend- ing physician at least every other day, or better daily, and the dried secretion be thoroughly removed, preferably by swabbing the entire surface with hydrogen peroxid and cinnamon Mater, in equal parts, follo\\ed ])y an alkaline wash, such as — I^. Sodii l)iearbonatis, 8odii biboratis, Sodii chloratis, Potassii bicarbonatis, da gr. xv (1.0); Aquje, fl.si.j (GO.O).— M. This solution should be as liot as can be borne by tlie patient. The mcml)rane should be thorougldy dried l)y pledgets of absorb- ent cotton carefully mopped over the surfhcc, and a mihl, slinuila- ting soluti(m applied. For the locnl stimulation, \ to 1 drop (»!' 452 DISEASES OF THE NOSE AND THROAT. oil (if mustard, or '2 drops of oil of cassia to an ounce of alholene or li(|uid vascliu, a])})lic(l every other day directly to the diseased surface, is the best aiicnt. Equally good results can be obtained bv using, after ckansing and drying the nienibraue, pledgets of cotton saturated with an ointment of ichthyol and lanolin, equal parts, the pledgets being placed far back in the nostril, so that the solution will come in contact with the nasopharyngeal surface, and should be allowed to remain from fifteen to thirty minutes, or until there is marked stimulation of the membrane. The application of crude ])etroleum in the same manner, as well as the thorough mopping of the entire pharyngeal surface, is highly beneficial. The object of such ap])lications is to produce merely a hv])er- emia of the vessels, and care must be taken not to set up too violent irritation, or the resulting inflammatory condition will entirely offset the benefits of stimulation. Even after the most thorough cleansing of the membrane there is a tendency to the rapid accumulation of the altered scH'retion, and for the relief of the distressing svmptoms caused by this accumulation there should be prescribed for the patient an oily preparation, which not only lubricates the parts, but also softens the secretion. The following formula will produce the desired eflect : 1^. Olei gaultherise, gtt. j (.06) ; Menthol, gr. v-x (0.;3-0.65) ; Alboleni, vel Vaselini (liquid), fl.sj (:]().()).— :\I. In the cases in which the change in the pharyngeal structure is an inflammatory one, there is no local application which will afford more relief for the distressing symptoms, besides being markedly useful in stimulating any remaining structure in which partial func- tion is still jircscrved, than refined or, better, crude ])etroleum. The jnitient can be instru(;ted in the method of applying the oil, which should be done twice dailv. In a number of apparently almost hopeless cases, in which this treatment was continued for a period extending over from six to ten months, almost permanent relief Avas obtained. After thoroughly removing the accumulated and dried secretion, benefit may Ix' derived from mere massage of the mucous membrane. This can be accomplished by rubbing the surface Avith cotton or sponge. In some few cases of the simple atrophic variety the mild faradic current has been beneficial. The appli- cation of drugs by cataphoresis I have not found so satisfactory in the ])haryngeal structure as in the nasal and laryngeal tissues. While the fibrous tissue cannot be altered or caused to return to the normal and a jiermanent cure effected, yet to the patient the relief of his distressing symptoms is the object sought. DISEASES OF THE PHARYNX. 453 The special constitutional treatment should consist in the ad- ministration of drugs whi(;h directly affect glandular secretion and are at least partially eliminated by the mucous membranes. In the general treatment, it is well to give some drug that will ensure the regular and free movements of the bowels, not so much by its purgative action as by its stimulation of glandular secretion. For this purpose the phosphate of soda should be given in from 2- to 4-dram doses, in the form of the granular effervescing pow- der, twice or thrice daily, the frequency and size of the dose depending upon the therapeutic effect and the clinical indications. Sulphur waters are helpful adjuvants. The iodids, in the form of iodid of potassium and sodium, or benzoate of sodium, from their therapeutic action on glandular secretion, are unquestionably indi- cated and beneficial, but the long-continued use of these drugs produces gastric irritation. The arsenical preparations, however, are equally efficacious as remedial agents, and, owing to their lessened tendency to produce gastric irritation, are preferable. The best results will be obtained by the administration of from gr. ^^ to gr. ylg- of the double sul- phid of arsenic, given in pill form three times daily after meals. ACUTE RHEUMATIC PHARYNGITIS. Synonyms. — Rheumatic sore throat ; Rheumatic angina ; Gouty sore throat. Definition. — An acute inflammatory process caused by the presence of an irritant in the blood, consisting of some form of the acid urates, which excites inflammatory processes in superficial structures, especially those concerned in secretion and elimination, the great vascularity of the pharynx rendering it particularly liahle. Ktiologfy.— The uric-acid diathesis manifests itself in a num- ber of forms. In any variety where there is an excess of uric acid in the system, there is produced in the secreting or glandular structures a certain amount of irritation. This is due to the fiict that when an excess of elimination is demanded by tlie excretory organ, and the necessity of elimination is beyond the poM'er of function of that organ, as of the kidney, certain other nnicous- membrane structures aid as eliminators. It is well known that uric acid in its various forms excites inflammatory reactions in the nuicous meml)rane of the kidney, where it is in reality a local irritant. The sauie is true in the other niucoiis-mcinbranc tracts. In that variety of nric-ncid dinthcsis known as lithcinia, in which there may not be an excess ol" uric aeiatient should be instructed to drink large quantities of water. This should be insisted upon, and the patient instructed to drink as much water at one time as possible. This will give better results than if a little is taken often. Vichy water is pref- erable. The action of the kidneys should be stimulated. There vsliould be administered from 2 drams to ^ ounce of Basham's mixt- ure every two to three hours during the acute attack, and three times during the day, while treatment for the correction of the diathesis is continued. Equally beneficial results may be ol)tained bv the administra- tion of 3- to 5-grain doses, three or four times daily, of salophen. CHRONIC RHEUMATIC PHARYNGITIS. Synonym. — Gouty sore tiiroat. Definition. — This is a chronic inflammatory process in which there is permanent alteration in the ])haryngeal mucous membrane brought about by the continued irritation, as manifested in the uric-acid diathesis. DISEASES OF THE PHARYNX. 457 !^tiologfy. — The etiology is the same as for the acute process ; in fact, the condition is simply a eontinnation and the result of repeated attacks of acute inflammation, and the changes in the tissue are very much the same as those in simple acute pharyn- gitis. Pathology.^ — Besides the subacute inflammatory symptoms, there is a permanent thickening in the connective-tissue elements of the subraucosa, which is due to the organization of the products of the inflammatory process. This process is slow, owing to the fact that the continued irritation is only sufficient to keep up a mild form of hyperemia and congestion, augmented and aggra- vated by sudden acute exacerbations. Symptoms. — The symptoms of the acute exacerbations are those of rheumatic sore throat ; however, there is always present a constant sensitiveness of the throat, with a continual hacking and clearing of the throat on account of the accumulated secre- tion or the irritation produced by the chronic inflammatory proc- ess. The patient is easily affected by exposure to cold and damp- ness, or to ill-ventilated or overheated rooms or sudden changes of temperature. On account of the constant irritation and the continued inflammatory process, there is nearly always associated some laryngeal involvement. This is due to the same cause as the pharyngeal inflammation, and in the chronic variety there is almost always some alteration in the voice. While the hoarse- ness may be only slight, the voice is altered in character and tone. Diagnosis. — Tlie condition is not likely to be confused with the specific inflammations or with malignant growth, as in rheu- matic sore throat there is rarely, if ever, any tendency to ulcera- tion, while in the specific inflammatory processes this is always the case, and in the malignant growths, before ulceration occurs, examination would locate the tumor. The diagnosis, then, can be made from the urinary examination, coupled with the history of repeated attacks of sore throat. Prog"nosis. — The ]irognosis, as regards the relief of the gouty or rheumatic diathesis, is fairly good ; however, if permanent structural alterations have been produced in the ])haryngeal nuicous membrane, internal medication or local applications cannot restore such structure to its normal condition, although by the relief of the exciting cause the condition may be markedly benefited, and the individual, as far :is his ])('rsoiial comfort is cf)nccrncd, maybe entirely rclicx'ccl. Treatment. — 'i'hc same general rules of treatment as given under the acute variety should be instituted, es])ecially the Turk- ish baths and the (h-inking of large (luantities of water; however, the course must be ])rol()ng(!d and given in sutliciciit doses to pro- duce the physiological eflect of the drugs, wliich nuist necessarily 458 DISEASES OF THE NOSE AND THROAT. vary Avitli the different iiulividuals. The benefieial effects of large draughts of water in tlie chronic variety cannot be overestimated, tlie physioh)gical effect of such being that it flushes the kidneys and promotes elimination. If the alkalies are to be administered, possibly ihe most benelicial is citrate of lithium, either plain or in granular, effervescing form, given in 3- to 6-grain doses every two hours, or given in 5-grain doses from once to three times a day. li' frequently repeated the doses should be small. This is a better plan than to give a large dose once daily. Succinate of soda in 5- to 10- grain doses, given in half a glass of water three times daily, is highly serviceable. Careful attention should be paid to the cloth- ing worn. While it is impossible to give detinite and fixed rules to suit every case, the patient should be warmly clad. Experi- ence will usually have taught him what clothing is most suitable to his temperament. INFECTIOUS QRANULOMATA OF THE PHARYNX, NASOPHARYNX, AND TONSILS. TUBERCULOSIS. Synonyms. — Tuberculosis of the pharynx ; Consumption of the pharynx. This is in the majority of cases a process secondary to pulmo- nary tuberculosis, and either concomitant with or following a laryn- geal involvement. It is rarely a primary process, and may be part of a general tuberculosis. The etiological and pathological characteristics have already received sufficient notice without repetition here. Tuberculosis of the pharynx is a comparatively rare condition. Symptoms. — The early symptoms of the disease are those of an acute or subacute pharyngitis, and their true import, as a rule, is not recognized unless strong suspicion be aroused by the pres- ence of an active pulmonary lesion. These symptoms intensify, and the membrane becomes the site of local swellings caused by the peculiar inflammatory infiltrate, which may involve the velum palati, the uvula, the pillars of the fauces, the area of the pharyn- geal tonsil, or, in short, any portion of the pharyngeal mucosa. The tonsils are in somewhat rare instances implicated, either pri- marily or, more commonly, secondarily, and, as a rule, the ten- dency is for the disease in the pharynx to spread with greater rapidity downward than u])^s'ard. Various symptoms are directly traceable to this infiltration and thickening of the membrane. Thus a stiffened velum i)alati may prevent proj)er obstruction to the posterior choanw, and allow the entrance of liquids or solid bits of food into the nasal chambers during deglutition. The same condition favors the acc;umulation and inspissation of mucus or DISEASES OF THE PHARYNX. 459 mucopurulent discharge, especially after ulceration, which it may require considerable effort to dislodge. Thickening of the uvula may be sufficient to produce a short, hacking, irritative cough, repeated painfully often, and the two combined may effect con- siderable change in the voice. With the swelling begins the for- mation of numbers of miliary tubercles as minute yellowish spots beneath the surface of the membrane. These last a variable length of time, soften, rupture, and form minute ulcers, which are small, perhaps hardly noticeable, have a well-defined but irregularly rounded outline, are shallow, the floor covered by a grayish secre- tion, without marked inflammatory areola, and they are attended by a general pallor of the membrane. Spread of the ulcerative process is rapid. Each focus enlarges in breadth and depth, and neighboring areas unite to form more extensive spread of the necrotic process. The pharyngeal membrane may show ulcerative foci separated by intervening bits of unaffected tissue and present- ing the so-called " moth-eaten " appearance. It may be possible to observe miliary tubercles in the bases of the ulcers, possibly even granulations in masses along the edge, and bleeding may ibllow irritation by a probe or foreign body. The secretion increases, becomes more slimy and tenacious, and may interfere with respiration or give it a peculiar wheeze. The spread is rapid and extensive, and may even lead to complete destruction of the palatal structures, with the attendant opening of the nasal cham- bers to the entrance of material from the pharynx. Not infre- quently the ulcerative process is intensified by the existence of the same process in the larynx, or even in the mouth. Partial cicatri- zation may occur in some cases, but it is a rare sequence. Pain is a constant symptom, variable in degree, and its location is dependent upon the site of the morbid process. The dry, parched, burning ache of the earlier stages grows into the sharp, lancinating pain of the late periods, ^vhich may radiate to the ear, or even cause otalgia, especially if the lateral wall of the pharynx or the pillars of the fauces be the seat of active processes. Pain is inten- sified on motion, and tenderness of the aflected area is extreme. Deglutition becomes progressively more and more painful and difficult, and food is often not taken because of the agony in swal- lowing. The voice is thick and muffled, and the patient has difficulty in clearing the throat, both because of tlie ensuing pain and because of the tenacious secretion wliieli is fairly abundant, but is not noticed in tlie greater expectoration from tlio hnigs. Cough is usually referable ratlier to the puhnonary lesion than to the pharynx, though a dry, ha(;king, irritative cough attends the latter manifestation. TJiere is marked fctur of the bi'cath. The other symptoms to be noted are those traccai)le to the lesion of the lungs, which either accompany or shortly follow the i)rocess in the upper respiratory region. These include, of course, emaciation, 460 DISEASES OF THE NOSE AND THROAT. fever, sweats, and the whole train of well-known symptoms of pulmonary tubereulosis. The diagnosis is usually not diffieult, but it may be some- what obscure l)etbre the uleerative action begins. Scrapings from the ulcer should give strong presumptive evidence on a bacte- riological examination. The history of the case, the tubercular lesions elsewhere, and the local symptoms given should be sufficient for ret'ognition. The very |)ossible existence of a mixed infection, especially with syphilis, is to be carefully borne in mind. The prognosis is very grave. Some few cases of local infec- tion have recovered after removal or destruction of the diseased area. In all rarer instances cicatrization has occurred and an apparent cure resulted. Death is rarely delayed more than six months. Treatment. — Primary tuberculosis of the pharynx alone rarely ever occurs. It is usually subsequent to pulmonary or laryngeal tuberculosis. As to the treatment of the condition, the nK^thod is the same whether -it be primary or secondary. The prognosis, however, is more favorable in the primary uncomplicated cases than in those associated with pulmonary or laryngeal lesions. The local treatment in any case is directed toward the alleviation of the intense pain and discomfort caused by the ulceration, as, with the exception of possiijly an absolutely primary local lesion, a cure can hardly be hoped for. Owing to the tiict that the patient's general vitality is much lowered, together M'ith the presence of the specific infective agent, the healing of the ulcer is a slow and almost hopeless process. For the relief of the i)ain, which is aggravated by swallowing, th(? local application of a 5 to 10 per cent, solution of cocain will suffice. This, however, is only palliative, and from the chronic condition of the ulcer will necessi- tate the long-continued use of the drug, with the necessarily bad effi^cts, not only locally, but also on the general system. I have ol)tain(Ml equally good results, not only for the relief of the local irritation, but also from its cleansing as well as its slightly antise])tic action, by the use of dilute nitric acid in an equal ((uantity of water, applied directly to the ulcerated areas either by means of an applicator or in the spray form. A simjile therapeutic Mayor's iiliaryiiiieal curet. agent which gives much relief is the juice of the pineap])ie used as a spray or gargle ; it is cleansing and acts as a slight astringent, also relieving the irritation and pain. DISEASES OF THE PHARYNX. 461 The treatment by ciiretment (Fig. 145), while it may be a beneficial method, is questionable as a curative measure, for the healthy underlying structure is protected by the limiting membrane peculiar to the specific inflammatory processes, and this prevents spreading other than by continuity of tissue. Now, unless the curetment be thoroughly done and all of the infected area removed, the lymphatic system may be opened and further spreading take place. The most satisfactory plan of treatment is the thorough cleansing of the ulcer with an antiseptic alkaline solution, such as — ]^. Sodii biboratis, Sodii bicarbonatis, da gr. x (0.65) ; Acidi carbolici, gtt. ij (0.12) ; Aquffi, q.s. ad flsj (30.0).— M. The surface should then be dried and an acid applied. The repeated use of Mackenzie's carbolic-acid throat-tablets affords considerable relief when the membrane is dry. Of the various acids used I have obtained the best results from the use of the dilute nitric or hydrochloric acid. This should be repeated two or three times a day. The application of powders, such as iodo- form, aristol, etc., is of doubtful value, besides being decidedly disagreeable to the patient. In the early or catarrhal stage the membrane should be cleaused and dried and a mild astringent applied, such as tannin, 8 to 10 grains to the ounce ; at the same time there should be administered internally carbonate of guaiacol in 1- to 5-grain doses three times daily. The spraying of the sur- face with glycerated extract of suprarenal capsule is useful in these cases. Injection of 98 ])er cent, alcohol in the cases in which the lesion is primary to the pharyngeal structure will be productive of good results ; however, if it is complicated with pulmonary tuber- culosis, owing to the lowered vitality of the individual, local appli- cations or injections will be of little avail. The placing of the patient under the proper climatic conditions is of the greatest importance, and, when the diagnosis is established early, the patient should be at once sent to a suitable climate, and such constitutional remedies as cod-liver oil, hypophosphites, or the lactophosphate of lime should be administered. IjI'its. The exact nature of this aff(>ction has for a loug time eugagcd the attention of medical men, and numerous opinions as to the process have been advanced. It is, however, establislied almost beyond question clinically, by study of the miuutc anatomy and pathological processes and by the presence iu small numbers of the bacillus of Koch within the lupus structures, that the disease is a 462 DISEASES OF THE NOSE AND THROAT. local tubercular manifestation. The strumous diathesis is favorable to its origin, but its occurrence does not depend upon the existence of tuberculosis of special organs or a general tubercular involve- ment. In the jiharynx it may l^e primary, but, as a rule, is secondary to a previous nasal or buccal process, which in turn may follow extension from the dermal structures of the nose or face. It may involve any part of the ])haryngeal mucosa, the pillars of the fauces, or the tonsils. It is of slow progress and causes exten- sive loss of tissue. Males seem less disposed to its occurrence than females ; it is more common in early life, and in many instances it is preceded by repeated attacks of pharyngitis. Pathologically, there is to be observed a cellular infiltrate into the deeper layers of the mucous membrane and the structures beneath. This infiltrate is not a diffuse process, but is seen in masses lying between trabeculse of connective tissue and glandular structure and placed in close relationship with a blood-vessel. Microscopically, these masses show the characteristics of granula- tion-tissue, with numerous pale, well-formed giant-cells among the cellular elements, and in scanty numbers the bacilli of tubercu- losis. The subsequent appearances are those of ulceration and extensive and rapid cicatrization, or more rarely of absorption of the inflammatory tissue. The process may be noted in any part of the pharynx, the pillars of the fauces or the tonsils, and is much slower in its progress than the other specific inflammatory conditions. The symptoms of the disease are subjectively not severe, and quite frecpiently the process has been of considerable standing before the patient has deemed it of sufficient severity to consult a physician. Pain is practically absent, and the proper performance of the pharyngeal functions is not altered to any extent unless the epiglottis is severely involved, or the region surrounding the Eustachian orifices becomes swollen or adherent to neighboring structures iu such a way as to occlude the o]>enings. Early in the history of the case the membrane of the affected areas becomes livid, smooth, and dry, and may even be granular. Small ligliter- colored points may be observed, which mark the site of the typ- ical lupus swellings. Soon these apjiear as small miliary nodules, from the size of a pin-head to half a pea, plentifully scattered over the affected area and giving it a mamraillatcd appearance. In color they do not differ from the membrane itself, are smooth, and to the touch are soft, easily penetrated, and without pain. In certain cases this may be the extent of the process, and absorption of the inflammatory infiltrate may lead to extensive loss of tissue without external ulcerative ]ihenomena. More usually, however, ulceration ensues. Each nodule softens, breaks down, and forms a necrotic focus slightly elevated above the adjacent tissue, with thickened and inflamed borders, and covered with a tenacious. DISEASES OF THE PHARYNX. 4(i3 glairy, grayish secretion of fairly considerable amount. These points of loss of tissue may slowly run together and produce by confluence larger areas of ulceration, or they may remain discrete and slowly increase in size. The adjacent membrane shows the nodular formation preceding its involvement in the necrotic proc- ess. Ulceration becomes extensive and is responsible for consid- erable tissue-loss. It is not, however, so deep as that observed in syphilitic necrosis of the tertiary type. Following ulceration, the characteristic tendency of the disease for cicatrization is appa- rent. This follows closely the ulcerative process, and both may not infrequently be seen coincidently. The fibrous cicatrices so formed are strong and firm, and by their subsequent coutraction lead to extensive alteration in the contour of the entire pharynx. Thus ulceration in the lateral regions may cause destruction of the tissue in the neighborhood of the Eustachian outlet. Not un- commonly, ulcerative surfiices coming in contact especially with the posterior pillars and the lateral walls may lead to a firm union and formation of practically a single membrane, Avith ulceration marked upon its surfaces. Such condition may cause occlusion of the Eustachian tube and precede deafness, or catarrhal and sup- purative disorders of the middle ear. The velum palati may undergo swelling, subsequent ulceration, and contraction, interfer- ing with deglutition. The posterior nares may become closed and give the voice a nasal twang. The tonsils may become inflamed and granular, and be indistinguishable from the pos- terior pillars. Soft, reddened ulcerations appear, which show a slight tendency to spread, and, finally, cicatrization with its shrink- age reduces the organ to a mere whitish mass of fibrous tissue, not diifering from similar tissue in the other affected regions. The uvula may shrink to a mere rudiment. The epiglottis rarely escapes, and may be completely destroyed, or may dwindle to a mere fragment. The pharyngeal membrane is shrunken, traversed by web-like bands of cicatricial tissue, which may not infrequently form pockets retentive of considerable secretion and demanding a releasing incision. The course of the disease is not usually marked by any special impairment of the general health. The diagnosis is not difficult in the majority of cases, and yet the process is extremely apt to be wrongly considered as syph- ilitic. The history of the case, the slow ])rocess, more shallo-w ulceration, and more rapid cicatrization of lupus, together witli failure of res])onse to antisyj)hilitic treatment, should clear up any existing doubt. The prognosis is not favorable for cure of the disease. A few cases of early recognition have been reported cured through prompt and extensive tissue-ablation. More commonly it defies treatment. Many cases die from tu])ercular conditions of the lungs, and others from complications due to local impairment. 464 DISEASES OF THE NOSE AND THROAT. Treatment. — Tivatnient slioukl consist in the thorongh removal of all the diseased tissue. This can be accomplished by curettino; or by the galvanocautery. Chemical caustics, while of remedial value, are more difficult to control. The small nodular masses, before breaking down occnrs, should be cauterized with 3 to 5 per cent, nitrate of silver. The ulcerated areas should be repeatedly cleansed with acid gargles, which are in themselves slightly astringent and decidedly germicidal. The best is dilute hydrochloric acid, 10 to 20 drops to the ounce. After the thor- ough cleansing of the surface, where there is tendency to marked ulceration, good results can be obtained by the insufflation of 5 per cent. i)yoktauin in stearate of ziuc. The patient should always be instructed to iill the lungs to their utmost capacity before the insufflation, so that the first respiratory eifort will be expiratory. When the diseased area extends over the entire pharyngeal surface, involving adjacent structures, the laryngeal complications, not only from the spreading of the disease, but also from the threat- ened edema, may necessitate tracheotomy. SYPHILIS. Both the acquired and congenital forms of syphilis are to be noted in these regions. The acquired form may be contracted at any age, but it is more frequently noted after puberty. The hereditary form is seen in both secondary and tertiary manifesta- tions ; the former being the early variety, seen usually during the first month or so of the patient's existence; while the latter are rarely seen before the fifteenth year, and constitute the type known as late congenital syphilis. The syphilitic condition of the throat constitutes a not insignificant portion of the general specific display. The three periods are well marked, and are attended by distinct and charaeteristic symptoms. The Primary Form. — Next to the genitalia, the tonsillar and pharyngeal sites are, perhaps, the most frequent seats of the pri- mary lesion. Infection takes ])laee through the medium of infected utensils, surgical instruments, finger-nails, and kissing. Cases have been reported of infection from a syphilitic nurse, while dis- gusting sexual ])erversions are resj^onsible for a considerable per- centage. Females seem to be more affected by the primary sore in this site than males. The tonsils are more frequently the seat of chancre than the remaining structures, probably because of their follicular openings being fiivorable to retention of the infecting principle and because of their close proximity to the mouth. One tonsil is usually atf'ected, but cases in which the lesion has been bilateral have been reported. A large proportion of cases undoubt- edly escape notice, or are incorrectly diagnosticated through refer- BECK ON FRACTURES FRACTURES. By Carl Beck, M.D., Surgeon to St. Mark^s Hospital and to the German Poli- klinik. With an Appendix on the Practical Use of the Rontgen Rays. Handsome octavo volume of 335 pages, with J 78 illus- trations, mostly original. Cloth, $3.50 net. JUST ISSUED. In this book the author devotes particular atten- tion to the value of Rontgen rays in the diagno- sis of different varieties of fractures. Publica- tions on this subject hitherto have not claimed to be more than tentative sketches. This book represents an effort to embody in a systematic treatise the important essentials of this subject, based on the extensive experience of the author in X-ray ■work. All the common and some of the rarer types of fracture are represented skia- graphically, and the skiagrams and most of the drawings represented are originals. Necessarily, the differentiation of the more frequent luxations which closely resemble fractures have received considerable attention. This comparatively new field Dr. Beck has made practically his own, and the large number of skiagraphs contained in the book have been pronounced by competent critics the finest specimens of such work in existence. For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS & CO., Publishers, 925 Walnut St., Philadelphia. SAUNDERS' FIFTY THOUSAND COPIES MEDICAL HAND-ATLASES. Two years ago Mr. Saunders contracted with the original publisher for 100,000 copies of the twenty-six volumes that are to form the series fcnow^n as Saunders' Medical Hand-Atlases. Of these tw^enty-six vol- umes only eight have appeared, and yet 50,000 copies have already been imported. ^ ,^ S The volumes in this series are selling with re- markable rapidity, and there is every indication that 100,000 copies will be sold of these eight volumes alone. Basing the sales of future numbers on those already issued, the prospects are that the original contract will be exceeded three times over, and that the sales of the com- plete series will reach at least 300,000 copies. On account of the marked favor with which these books have been received by the medical profession, and the enormous sale that they seem destined to reach, the publisher has been en- abled to prepare and furnish special additional colored plates, making the series even hand- somer and more complete than was originally intended. t^t^^ir*e^«^<^tp*tr* DISEASES OF THE PHARYNX. 465 ence of their symptoms to a catarrhal condition. The symptoms vary, bnt, as a rule, are not severe, nor of extended dnration. There are the manifestations of a more or less severe inflammatory reaction in the adjacent membrane, while it may be possible to observe the chancre as an indolent inflammatory nodule, isolated, rapidly becoming deprived of its in\'esting epithelium, and appear- ing as a reddish-gray denuded area, witb irregular margins and covered by a thin, glairy secretion. The base is firm and indurated, and the adjacent membrane inflamed. This persists a short while, and then disappears spontaneously, its site being marked by a small yellowish cicatrix. If the pharyngeal walls be already the seat of an active morbid process, it may be impossible to locate or perhaps diagnosticate absolutely the entrance site of the specific poison. The lesion may occur in any abraded point of the pharyn- geal membrane. Chancre of the tonsils is, however, the most frequent form, and even this may be very much obscured by the inflammatory phenomena. It may, however, be possible to observe the typical sore upon the surface of the organ and to palpate its hard base with a probe. Or the tonsil may mark the entrance of a specific virus by a mild form of tonsillar inflammation, or may take the form of a somewhat extensive nlceration of considerable deptli and severity. Some few cases show a tendency to cover the chancre with a pseudomembranous investure, the removal of which is easy, and discovers at once the typical sore beneath. The entire organ is markedly inflamed, indurated, and enlarged. The primary sore is not of long duration and subsides spontaneously, leaving an indurated inflammatory mass or scar, with subsequent contraction. With its disappearance cessation of the local inflam- matory phenomena occurs. Pain during the presence of the chancre is a variable quantity, but there are always more or less dysphagia, local tenderness, and the subjective annoyances of a sore throat. If the lesion be placed upon the posterior pillars, pain referred to the ear may be noted, and aural symptoms may develop through occlusion of the Eustachian outlets. A jiro- nounced and typical condition of the lymphatics attends the presence of the chancre, which consists in an indolent, slow^ swell- ing of the glands along the angle of the jaw and sternocleidomas- toid muscles of the affected side, or both sides if both tonsils are affected, or if the chancre is located on the median line of the pharynx. The skin overlying the glands is not discolored ; the glands tliemselves are felt as firm, freely movable bodies, well outlined, and there is no tcndcMicy to suppuration, though the swellings may become quite noticeable. The Secondary I/esions. — These may Ix'long i<. cidicr tlie congenital I'oi-ni or the ae(|uire(l. If congenital, llie\- ai-e seen usually within the first month or so of the patient's birth. If acquired, they appear with the other systemic secondary symptoms^ 466 DISEASES OF THE NOSE AND THROAT. usually some six to eight weeks after the primary infection has occurred. The chief manifestations are the erythema, the mucous patch and, in some cases, the superficial ulcer. The erythema is, us a rule, the earliest in appearance, and may cover the entire visible pharyngeal wall, distributed symmetrically or occurring in an isolated area. No portion of the pharyngeal and tonsillar sur- faces is exempt from its possible occurrence ; but, as a rule, it is rarely noted above the level of the hard palate. It may present the appearance of a diffuse, dusky, dirty reddening, or more com- monly occur in collections of small, well-defined, dusky-red areas that are separated by small intervening spaces of comparatively normal tissue, and give the throat an almost pathognomonic mot- tled appearance. With the erythema there are possibly some slight local symptoms, such as cough, a dry or tickling sensation, and dull pain. There may be a slight elevation of temperature ; in short, the usual symptoms of a mild catarrhal pharyngitis may all be noted. The erythema usually remains as long as the cuta- neous eruptions are present, and, like the latter, is readily scattered by the exhibition of antisyphilitic treatment. Following the appearance of the erythema at a varying period, mucous patches may be observed on the membrane. These may occupy any posi- tion on the pharyngeal, tonsillar, or faucial surfices, though in the latter sites they are more commonly observed on the anterior aspect than on the posterior. They begin as dark, dusky-red, rounded elevations, well defined upon the membrane, which undergo soften- ing and superficial necrosis and form rounded patches with well- defined borders, projecting slightly above the surface of the adjacent membrane, covered by a grayish and very virulent secretion, and surrounded by an inflamed areola. As a rule, they are not deep, do not spread, and end in cicatrization and contraction of the resultant fibi'ous scar. They may be attended by some fetor of the breath, but aside from local tenderness give rise to little or no subjective annoyance. Some cases show a tendency to a super- ficial erosion of the membrane, preceded by a whitening or cloudiness of the upper layers. This, however, does not go on to any serious extent, and needs only a brief mention. One peculiar feature of the secondary period is that of the tendency which its manifestations have to re-appear under certain circumstances, such as the cessation of specific medication. The Tertiary I/esion. — Tertiary manifestations may occur as early as seven years, or not be observed until twenty or more years after the primary infection has occurred. In the hereditary form it is rarely seen before the fifteenth year. The characteristic lesion is the gumma, to the development, ulceration, and subse- quent cicatrization of which are due the major portion of the pro- found structural changes that occur. In certain rare cases tertiary syphilis may show itself as a widespread, malignant, gangrenous DISEASES OF THE PHARYNX. 467 ulceration of the entire pharynx, and prove rapidly fatal. The characteristics of gumma-formation have been too thoroughly described elsewhere to need repetition here. Any portion of the area under consideration may be the seat of their formation, and this in turn may be either in discrete, well-defined tumors, or take, less commonly, the form of a diffuse, inflammatory, gummatous infiltrate. The tumors formed are smooth, well defined, and, before degenerative changes occur, show no noticeable discolora- tion of the overlying membrane. They persist a variable length of time, and then inevitable ulceration, both of the gummata and of the diifuse form, takes place. The ulceration is deep and extensive, no tissue is exempt from its ravages, and the destruc- tive results of its progress baffle any attempt at adequate descrip- tion. The j)haryngeal mucosa may be irregularly eaten away, the tonsils be wholly or in part destroyed, the pillars of the fauces eroded, and the velum and soft palate be sloughed off or perforated. Occasional cases of ulceration into the deep vessels of the neck, with a subsequent fatal hemorrhage, have been recorded. The bony structures at the rear of the pharynx or the vault rarely escape. Necrosis of the vertebral laminae and of the bodies of the vertebrae, even to exposure of the spinal marrow, has been recorded. The base of the skull may be exposed, and access to the brain fol- low necrosis and discharge of the dead basal bone. The odor from such extensive ulceration is pronounced and sickening. There is no inconsiderable amount of necrotic tissue discharged — foul, dirty, purulent material, with bits of worm-eaten bone mingled with it. Occasionally, sequestra are formed, and palpation by the probe gives the pronounced grating sensation of carious bone. Follow- ing the destructive process in certain cases, even M'ithout the use of antisyphilitic treatment, healing takes place by the formation of thick fibrous and contracting cicatrices. Following this forma- tion the greatest alterations in the structure are to be observed. The whole pharynx is irregularly draAvn and deformed, the naso- pharynx may be obliterated, and the velum and soft palate be destroyed. Adhesions between neighboring ulcerated areas have been reported, with pocket-formation, or even partial or complete occlusion of the pharyngeal spaces. With such extensive altera- tion in structure there is, of course, profound alteration and even loss of the major part of the pharyngeal function. Yet, in the majority of cases, the j>rocess is not attended by anything like a proportionate amount of suffering and pain. Some ]iati('nts suffer less a(;tual ]iain than others evince from a simple catarrhal ])haryn- gitis, and complain of nothing save the aunoyauce of imperfect deglutition and ])honation. Others may ex])ericnce constant dull, heavy pain in the tliroat, with agoin'ziug exacerl)ations upon attempting to employ the ])h;n'yn\ in tlic performance of its normal functions. 4G8 DISEASES OF THE XOSE AND THROAT. The diagnosis of sypliilis of the j)liaryux and tonsils is not difficult in tlie secondarv or tertiary forms. The lesions themselves are so pathognomonic, the extrai)liaryngeal symptoms so constantly developed, and a clear specific history so often obtainable as to make error j)ractically inexcusable. Furthermore, the usually (juic^k response to antisyphilitic; remedies furnishes indisputable eonhrmatory evidence. The primary lesion may be very obscure and incorrectly diacjnosticated, or if suspicion as to its character be aroused, it may not be confirmed until the secondary symptoms appear. The indolent y^landular swellings of the neck and angle of the jaw are to be regarded as of extreme diagnostic value, and their true nature may be sometimes determined by a clear history of suspected infection. The prognosis is largely that of the general condition. Few conditions are more virulent, and none is more certain to yield to proper medication. The tertiary form is the gravest, and may prove fatal through meningeal extension or necrosis into the vital structures of the neck. Grave structural changes are sure to ensue before the influence of medication is observed, and these become of greater extent and severity the longer that specific treatment is delayed. The treatment of syphilis is fully given on pages 131, 560. GLANDERS. Synonyms. — Equinia ; Malleus humidus. Ktiology. — The specific cause of the disease is a bacillus known as the Bacillus mallei. Morphologically, it is shorter and thicker than the bacillus of tuberculosis, and is found abundantly in the purulent discharge from the affected sites. Primarily, glanders is a disease of the higher animals, especially of horses, which is readily communicable from them to man, and may also be contracted by one human being from another. The transmis- sion of the infection may occur in several ways. Thus, the infected nasal secretion may be thrown in fine spray from the nostrils of an infected animal by its sneezing or coughing, and thus reach the site of inoculation. It may be conveyed by the careless use of vessels used in watering them, the use of utensils or fingers that are infected by the virulent discharge, or by the indiscriminate use of clothes that have been used aroimd the diseased animals. In the human race the disease is perhaps observed more often within the nasal limits than in the tonsillar or ])haryngeal areas, and in these sites is not infrequently an extension from the nose- confines. The involvement of the mucous membrane may be either primary or a feature in the pyemic extension of glanders or farcy of tlie subcutaneous structures of the body. Infection undoubtedly requires an abrasion or some solution of continuity DISEASIJS OF THE PHARYNX. 469 permittiug free entrance of the germ to the tissues beneath the sur- face, though the question of possible infection through an un- broken surface is raised by some observers. As may be readily inferred, males and those employed around animals are from the nature of their work more liable to its contraction than others. The incubation-period is usually from three to five days, though so long an interval as three weeks may elapse before known exposure to infection is followed by establishment of the morbid process. Pathology. — Histologically, the phenomena of a low-grade inflammation are to be observed, resulting in the formation of masses of granulation-tissue, among the cellular components of which are to be observed the peculiar bacilli in large numbers. This soon gives way to the picture of a rapidly spreading suppura- tion, with extensive adjacent inflammatory phenomena. Infection spreads rapidly, following the line of the lymphatics, the glands in their course becoming swollen with inflammatory products and rapidly breaking do^^■n, and the general evidences of pyemia appearing. Necrosis of the bones and cartilages related to the suppurative process is not unknown, and the abscesses of the sub- cutaneous regions, as a rule, tend to burro av deeply. The chronic form difi^ers only in that the local phenomena do not develop so rapidly, pus is less apt to be present, and the pyemic spread is not so severe or rapid as in the acute form. Symptoms. — Two distinct types of the affection are noted, based upon the rapidity with which the disease progresses, and termed respectively the acute and chronic forms. The acute form may be an extension of the process already established within the nasal limits, and, as such, its peculiar symptoms form a grave fac- tor in the original prognosis, or it may be of primary location w^ithin the pharyngeal areas. Inoculation by the virus is followed shortly by a vague, ill-defined, but persistent sense of general dis- comfort. In a few days pain becomes localized in the infected neighborhood, and the site of inoculation shows a small, reddened, and somewhat tender nodular swelling. The nodules increase in number, and vary in size from a millet-seed to a small cherry. Degenerative cliangcs ensue, the swellings soften and break down and form ill-conditioned idcers, with thin, undermined edges and with a moderately deep floor covered by a yellowish, purulent discharge of a fairly thick consistency. The surrounding tissue is swollen and iunitrated, tlic ulcerative process spreads rapidly, and the a, rricutliyi..i.l li-ainmt ; 6, arytenoid cartilage ; 7, prominent external angle of the liasf intn wliicli (■niu-arytinnid muscles are inserted; 8, epiglottic cartilage; 9, thyro-epiglnttic ligament ; m, i.iistcrinr membrane of the trachea. Equally good results can be obtained by having the patient close his eyes during the entire procedure. If, however, he begins to gag, the examination should be stopped at once, the patient to relax the muscles and relieve spasm, or allowed to take a drink of water. In the manijMilation of the mirror the utmost care should be taken not to touch the ]iharyngeal wall, or, in fact, any sensitive structure; l)ut if the construction of the pharynx is such that the larynx cannot be seen without ]>lacing the mirror directly against the soft palate and uvula, the pressure by the mir- ror should be made at once, and, although not roughly, with firm- ness. Tins procedure will produce less gagging and spasm than if DISEASES OF THE LARYNX. 489 it is gently touched against the soft palate or pharyngeal wall. In many cases where examination of the larynx in the sitting posture is quite difficult, if the patient is asked to stand up, incline the body slightly forward, and draw the tongue out firmly, and the mirror is inserted directly against the soft palate by the examiner, who remains seated, a perfect view of the larynx may be obtained. If the examination is a prolonged one, it is better to allow the patient to rest repeatedly, as the continued forced aiid unnatural *•? .J Fig. 149.— Showing position of the tongiie-controller and laryngoscope in examination of the vocal cords and larynx. Cords and arytenoids are shown in the mirror. I^osition of the muscles rapidly becomes uncomfortable to the patient, and much better results will be obtained than by prolonged and enforced examination. Jt is much better to examine the hu-ynx without the use of cocain to allay irritability, as the normal condition of the tissue can be better a])preciated than when it is influenced by a local anesthetic. One of tiie great difficulties in 490 DISEASES OF THE NOSE AND THROAT. laryngeal examination is met with in a buccal cavity that is elon- gated and narrow, with a thick and muscular tongue. Occasion- ally, and esjK'cially is this true in children, an enlarged tonsil forms a marked obstruction to laryngeal examination. As a rule, where the tongue is thick and muscular, the use of the tongue- depressor, as described on page 40, will answer much better than attempts to drag the tongue forward. Fig. 149 shows the mirror and tongue-depressor in ])osition. If the tongue-depressor is used without any force, gradually allowing the muscles to relax, a good view of tiie larynx can be obtained. During the examination, should the patient show an inclination to gag, if he is asked to take quick, short, almost panting respirations, a good view of the cords may be obtained, and any irregularities in structure or motion can be easily detected. The rapid forced respirati(^u brings the cords into rapid play ; besides, gagging will be avoided. Yet in many cases a good view of the larynx may be obtained if the patient is asked to breathe quietly, allowing all the parts to be relaxed. The position and relation of the cords can also be demon- strated by directing the patient to say " ah " or " eh." The size of tlie mirror to be used will be determined by the anatomical relations of the part. The same may be said of the angle tiiat the mirror is to be placed to the handle, which will vary for different individuals. The proper angle can be obtained by bending the mirror rod. In making an examination with the mirror, the fact must not be overlooked that the position of the parts is reversed, as this is highly important when laryngeal applications are to be made. While some authorities insist that the mirror should rest on the posterior wall of the pharynx, having first pushed up the soft palate and uvula, so that the instrument will come in contact with the less sensitive structure of the nasopharynx, the method is not applicable in all cases ; in fact, in a very small proportion of the (iases will it be found successful. In a large number of persons the examination can be made without touching the pharyngeal wall ; besides, the difference in degree of sensitiveness of the struct- ures of the pharynx and nasopharynx is very slight, even when the tissue is in a normal condition, and, as a rule, when laryngeal exam- ination is necessary, it is always attended by some pharyngeal and nasopharyngeal lesion, so that while the sensitiveness of the parts might vary somewhat, yet that variance w^ould not be sufficient to be of any considerable im]>ortancc from the standpoint of examina- tion. In using the larvngeal mirror the epiglottis will be the first tissue observed, standing out prominently, its edges and surface showing differently in different individuals. In some it assumes a decidedly double concave apjjearance, with crescentic edge ; in others more nearly on a plane ; and again, rather V-shaped (Figs. 150-152). The color varies in different stages of the examina- Fig. 150.— Laryngoscopic image during respiration. Fig. 151.— Laryngoscopic image during plionation. ^■^,artjuf2tru.V/J"ih: riu1 Fig. 152— Laryngoscopic appearance of chronic infianiniation. The cords lack luster; the pericordal tissue is inflamed; the epiglottis is notched, the result of ulccrutidu. DISEASES OF THE LARYNX. 491 tion. The lirst glimpse will give most accurately the correct color, as muscular contraction, interfering with circulation, rapidly alters the surface appearance. There will be observed three folds of mucous membrane, which stretch from the lingual surface of the epiglottis to the base of the tongue. In some instances they resemble folds, while in others they are distinctly cord-like. These three bands form the glosso-epiglotUc ligaments, and the two depressions formed between the three ligaments are known as the glosso-epiglottic or lingual fossa\ The aryepiglottic folds, which really form the lateral walls of the larynx, are seen passing backward and downward from either side of the epiglottis to the arytenoid cartilages. These two arytenoids show as grayish-white, bulb-like prominences, the position of which varies during respira- tion and phonation. On either side of these folds will be seen the pyriform sinuses. At the posterior portion of the folds, close to and directly in front of the arytenoid cartilages, are two small prominences, one on either side, branches of the arytenoid carti- lage, and known as the "staff of Wrisberg." Each arytenoid car- tilage is strengthened and enlarged by the cartilages of Santorini. This, however, cannot be recognized with the laryngeal mirror, and can be demonstrated on the cadaver only by dissection. The arytenoid commissure passing between the two arytenoid cartilages forms the posterior wall of the larynx. Immediately behind the commissure will be observed the closed fissure which marks the orifice of the gullet. Thus we have the epiglottis in front, the aryepiglottic folds on either side, the arytenoid cartilages and commissure posteriorly. Directly below the aryepiglottic folds, on either side, will be distinctly seen the two ventricular bands or folds, as they are nothing more than folds of mucous membrane, extending from the angle of the thyroid cartilage in front to the base of the arytenoid cartilage behind. These folds of mucous membrane are somewhat thickened at the margin and are of a deeper color than the other laryngeal structures. They lie parallel Avith the vocal cords, which are directly beneath them, and change position with the movement of the arytenoid cartilages. The true vocal cords, which lie directly beneath the ventricular bands, show as tense bands of inelastic fibrous tissue, or rather tissue which is controlled by attached muscular tissue. The color of the vocal cords depends entirely upon the position assumed (Figs. 150, 151), as the greater the tension the paler and whiter the cord; besides, the necessity of laryngeal examination is usually one of some diseased condition, and the cord will be infiuenced by the pathological alterations in the adjacent structure as well as by constitutional lesions. It may show a thickened, uneven sur- face, with dense injection and dull-red color ; however, normally it appears as a clear white band, becoming slightly more pinkish in color when relaxed. The width of the band is increased in 492 DISEASES OF THE NOSE AND THROAT. attempted phonation. The entrance to the ventricle of the larynx, which is scarcely recognizable, lies l)etween the ventricular bands and the true cords. It appears rather as a shaded line or depres- sion. Autoscopy. — As supplementing the laryngoscopic mirror in the examination of the larynx and trachea, we have the autoscope, with the added claims of direct inspection and view of the poste- rior walls of these important structures. Kirstein of Berlin is the inventor and perfector of this instrument, Avhich consists of three parts — the spatula, the sliding hood, and the handle. The spatula is a slightly concave metal plate, 14 cm. in length, which is in the main straight ; but it is slightly curved downward toward its laryngeal end, where it has a somewhat thickened lip and rounded edges to prevent injury to the parts with which it comes in contact. The sliding hood serves the purpose of keeping the teeth, the lips, and in man the moustache, away from the spatula, leaving sufficient space between the two plates for inspec- tion and for the introduction of any instrument. The handle is the electroscope of Casper, which by means of its small electric light illuminates the entire length of the spatula and the parts beyond. The two main conditions upon which the autoscope depends in laryngeal inspection are — first, that firm pressure npon the root of the tongue and the median glosso-epiglottic ligament will elevate the epiglottis, thus giving the desired view ; and, second, that by proper position the laryngotracheal tube may be made to form a straight instead of an angular line with the axis of the buccal cavity. The technic of the examination is as follows : The physician stands before the patient, who is seated in a chair, with the neck inclining slightly forward. The autoscope is introduced in exactly the same manner as in applying an ordinary tongue-depressor. A view of the buccal cavity and oropharynx is thus obtained. By pushing the spatula farther backward, elevating the handle, and pressing firmly downward and backward on the base of the tongue, being careful not to use the upper teeth as a fulcrum, the lower part of the pharynx, the larynx, and (if the patient's posi- tion be correct) the trachea may be seen. The actual tissues appear in autoscopy, not their image- with a remarkable distinct- ness of anatomical detail. Above all, the posterior wall of the larynx, the interarytenoid fold, which can be examined only with great difficulty by the aid of the mirror, can be inspected almost in a surflice view, and the possibility of insjiecting the whole of the trachea and the beginning of the bronchi should alone be sufficient to ensure for autoscopy recognition among diagnostic resources. Inspection of the Posterior Wail of the I^arynx. — Various devices have been employed from time to time in order DISEASES OF THE LARYNX. 493 to expose the posterior wall of the hirynx to inspection, the fore- shortening of its image in the ordinary method of laryngoscopy often preventing dne appreciation of existing lesions. The latest device is by Dr. Mermod of Iverdon. This con- . sists in the use of a second mirror, which is placed within the cavity of the larynx, and ^vhich he appropriately calls a laryngen- doscope. Its reflecting surface is directed toward the reflecting surface of the ordinary mirror. A small, heart-shaped mirror, movable upon its shank and controlled by a screw, is attached to the extremity of a laryngeal handle of the ordinary curve. The illumination must be good in these cases, because the image has to be reflected from one mirror upon the other. MALFORMATIONS AND DEFORMITIES. The conformation of the larynx may deviate from normal either before birth or afterward by acquired disease. The congenital variations may be divided into stenosis, dilatation, and hyper- trophies. As to the actual cause of the variation in utero of the laryngeal structures from the normal, oar knowledge is limited, yet it must be confessed that parental disease or taint may bear at least a predisposing relation. Absence of the larynx is usually noted in monstrosities, where there is deficiency in development or overdevelopment in other organs. Malformations of the larynx may also consist in an extremely small organ. In individuals the formation of the larynx varies. Congenital Stenosis. — Arrested development of the larynx is often found along with imperfection of the genital tract, and, as the continuation of the respiratory apparatus is formed from the same source as the larynx, it is rare to find that organ maldevel- oped without some coexistent want of development in the lungs, trachea, or bronchi. Webs or bands stretching across the glottis are the most frequent forms of stenotic closure. These are found generally in the anterior commissure. The interarytenoid region is usually a seat of a different jDhenomenon — a cleft which may extend from the palate and epiglottis above and penetrate through the cricoid cartilage. This Aveb usually binds together the vocal cords, sometimes the ventricular bands. Its color closely resem- bles that of the cords themselves. It is usually thin and easily torn, but may be elastic. There may be a family history of similar growths. An incomplete separation of the vocal cords anteriorly is occasionally seen and may not interfere Avith the voice. The congenital stenosis may exist for many years M'ithout attracting notice, until some intercurrent malady directs attention to tlie larynx. A papillomatous web uniting the vocal cords, causing aphonia, was rejjortcd by ]\rorcll iNfackenzie. Treatment. — Any obstnictioii to breathing, such as enlarge- 494 DISEASES OF THE NOSE AND THROAT. ment of the faiu-ial tonsils, adenoids, nasal polypi, or abnormal- ities of the septum, should be corrected. As to the treatment of the actual condition itself, the introduction of O'Dw yer's tube may be sufficient. Should this means fail, the web should be cut by some such cutting dilator as seen in Fig. 153. The tube should Fig. 153.— Whistler's cutting dilator. be worn for several days after the operation, or should be passed at intervals. The fact that tracheotomy may be obligatory at any time should warn the surgeon to be ever prepared to perform the operation. The imminent danger to life from the closure of the glottis should cause any one who favors non-operative interference to weigh carefully the reasons for and against operation before a non-interference has been decided upon. Dilatations or Pouches. — I^aryngocele or pouching of the lining of the larynx, due to abnormal communications from with- out — extremely rare in man, although common in lower animals — may be due to congenital malformation and failure of union in portions of the thyroid cartilage. It may also form after necrotic processes, Avhere portions of the cartilage have sloughed. Hypertrophies. — Elevations of normal tissues are occasion- ally observed in the anterior commissure or growing from the true vocal cords. These may be congenital or acquired. They are, in reality, hyperplasias. The cause of these growths is not definitely known. Mouth-breathing due to adenoids may lead to hypei'emia, with increased nutrition. The irritation of the larynx may be responsible for the actual origin of the growths. Syphilis or tuberculosis may also have causal relation to them. The symp- toms consist in imperfect phonation, which may be coupled with a metallic cough that is persistent, or there may be associated actual attacks of sjiasm of the glottis. Treatment. — Treatment of these cases should consist in the removal of all obstructions to free breathing in the upper air- passages. The application of astringents or escharotics is to be condemned, and the former should only be resorted to in the event of complications preventing surgical interference. Spontaneous DISEASES OF THE LARYNX. 495 cure of these outgrowths may result after all source of irritation be removed, though this is exceptionally rare. The performance of a preliminary tracheotomy to afford physiological rest to the irritated structures might be justifiable in aggravated cases. Endolaryngeal ablation should be done with the greatest care, with guarded instruments, and under the strictest antiseptic directions. Acquired Stenosis. — Persistent narrowing of the laryngeal aperture may be due either to trauma or to constitutional causes. a. Cicatricial contraction or redundant granulation may pro- duce stenosis. The active cause of such condition may be injury by foreign bodies, attempts at suicide by cutting the throat, the accidental or intentional swallowing of hot or caustic liquids, or inhalation of steam. The outlook is always grave, not only for the preservation of the vocal function, but also from the fact that the cicatricial contraction or edema may actually endanger the patient's life. The treatment should be adapted to each special case. Tracheotomy should always be performed if the stenosis is such as to threaten life. When the contraction of the cicatri- cial tissue is not active and the stenosis is not very great, the cutting dilator shown in Fig. 153, followed by the introduction of O'Dwyer's tube for a few* hours daily, may effect a cure. For a more extensive membranous involvement Schr5tter's method by the knife or electric cautery may be adopted, with subsequent dilatation by means of bougies. Should either thyrotomy or tracheotomy be imperative, absolute rest of the voice ought to be insisted upon until the wound is healed. 6. Stenosis due to syphilis in the larynx may assume a variety of aspect, and form here as elsewhere. The narrowing may be due to chronic edema at any period of syphilitic lesion. In children, sudden acute severe dyspnea should always sug- gest the possibility of syphilitic edema and the application of the proper remedial agents. The commonest form of stenosis due to syphilis is that of a cicatricial web or band of varying thickness. These web-like bands may be found connecting the vocal cords and ventricular bands, or may unite one part of the larynx to another in its cicatricial involvement. The symptoms consist in a permanent hoarseness of the voice or restriction in its register. There may be some interfer- ence with l)r("atliing, dependent in amount upon the degree of stenosis. Interniittent attacks of dyspnea continuing for many years are always pathouiioinoiiic of sypliilitic h'sion of the larynx (Lennox Browne). TJic coiigli is s])asni()dic, tlic cxiK'ctoration scanty. Pain and (lifficiilly in swallowing are usually marked, although they may be absent. The bizarre formation of the hiryn- geal enmeshnient will aid in the diagnosis. Treatment. — Treatment should ccmsist in a pronii)t meeting 496 DrSKiSES OF THE NOSE AND THROAT. of alarming or aggravatino^ syniptonis. Tracheotomy raay be required Avhen edema oe(;urs, and should always he done as low- down as possii)le. The tube should under no consideration be allowed to be removed, lest subsecjuent edema should prevent re- insertion. Intubation alone is not generally successful. Dilatation of the structures by means of the instrument shown in Fig. 154, Fig. 154.— Mackenzie's laryngeal dilator. after cutting, is extremely slow and uncertain. The wearing of O'Dwyer's tulies after this operation, or the passage of bougies, is tlie most rapid and satisfactory method. Tuberculous stenosis is rarely ever cicatricial, as it does not tend to lieal. The only danger is from tiie edema. The heal- ing in lu})us, however, will form stenosis and cicatricial bands, the scar-tissue being very firm and unyielding. I/Upus. — The narrowing of the laryngeal aperture, due to cica- trization of an old lupus-involvement, is characterized by a gen- eral matting together of the parts, which may be to the extent of the formation of a pin-hole aperture. The tissues are gener- ally anemic, cx("cpt where small rosy nodules give evidence of acute inflammation. The symptoms are out of proportion to the actual aj)i)carancc ; difiRculty in swallowing and breathing are usually absent, and there is not often great modification of the voice. Tlie situation of the lupous web is generally supraglottic, while in sypiiilis or tuberculosis the structures l)clow and at the level of this aperture are generally attacked. Lu])us of the face that is qucstionnl)ly diagnosticated may be confirmed by laryngeal examination. The prog-nosis is generally not so grave as for the other con- ditions mentioned, as the deposit may undergo a spontaneous but gradual atrophy, which may be complicated by a later change of condition to actual true tuberculosis. The severity of the narrowing should determine the treatment. The dense, clastic character of the scar-tissue renders intubation of littU' permanent value, and simple dilatation is ineffectual unless coupled with cutting or slitting of the web. Operation within the larynx in the nature of cutting or incising DISEASES OF THE LARYNX. 497 the tissue should not be undertaken until all signs of inflamma- tion have disappeared, and in no case unless there is an absolute demand for operative interference. Narrowing of the larynx by leprosy occurs late in the disease, and need only be considered to suggest the necessity of tracheot- omy to prevent asphyxia. INFLAMMATORY DISEASES OF THE LARYNX. ACUTE CATARRHAL LARYNGITIS. Synonyms. — Acute catarrh of the larynx ; Laryngorrhea ; Spurious croup. Definition. — An acute catarrhal inflammation of the mucous membrane of the larynx, giving rise to slight dyspnea and hoarse- ness, which is seldom dangerous to life, although more severe when occurring in children. The inflammation may be either superficial, identical with parenchymatous involvement in other organs, or interstitial, involving deeper structure, with a greater likelihood to become chronic and leave permanent alteration. Ktiology. — The causes of acute catarrhal inflammation of the larynx are such as favor similar affections of nmcous membranes generally, though it is to be noted that of the entire respiratory tract, lesions of the larynx are less common than of any other portion. Individuals, especially children who are kept indoors a greater portion of the time, are especially liable to the disease. Those in whom the general health is poor on account of some constitutional diathesis are usually sensitive, owing to the lowered resistance of the membrane. Irregularities of the gastro-intestinal tract emphasize the susceptibility. This is more marked in children. Cold and exposure, particularly by allowing the feet to remain wet or cold or by wearing damp clothing, predispose to the condi- tion, unless the body is kept active. Obstructive lesions of the nose by which mouth-breathing is demanded are directly or indi- rectly exciting factors, just as the direct inhalation of improperly moistened air or particles of dust sets up irritation and renders one susceptible. CWtinued and excessive use of the voice and strain- ing of the parts by violent coughing are not uncommon causes. The overuse of hot or alcoholic drinks and the constant or pro- longed use of tobacco, either by chewing or smoking, by reason of their local and systemic stimulating efl'ect, arc also exciting factors. Moreover, improperly ventilated rooms predispose. Irritating fumes from stoves or from the register, by being inhaled or from the patient sleeping in the direct line of the current of heat, will frequently bring on an acute attack of laryngitis. Irritating vapors from gas-tanks or a leaking gas-jet are equally exciting. Dusty air, chemical vapors, as mentioned in tiie occupation variety 32 498 DISEASES OF THE NOSE AND THROAT. of laryngitis, are important factors. The inflammatory condition frequently extends to the trachea and bronchial tubes. Continued outdoor habits rarely ever predispose to the disease, as private and hospital records show that the majority of cases occur in indi- viduals of indoor or sedentary habits. Previous attacks are main- tained by some as predisposing to others ; but, if the case is care- fully investigated, it will be found that this tendency to recur- rence is due rather to the individual being exposed to a con- dition similar to, or his systemic condition being the same as, that which brought on the previous attack. Age and sex are not important etiological factors, the environments of the individual, his habits of life, and his general condition playing by far the most im])ortant part. The laryngeal catarrh may be merely an accom- paniment of the eruptive fevers, influenza, or hay-fever, or may occur along with an asthmatic tendency. Foreign bodies lodged about the larynx may also bring about laryngeal inflammation. The same is true of external pressure from any cause. Frequently attacks of acute laryngitis may be set up by the application of remedial agents to the pharynx. Several such cases have come under my notice, in which the powders or fluids applied directly to the pharynx were inspired by the patient, bringing about a severe and acute attack of laryngitis. Patholog"y. — The pathology of acute catarrhal inflammation of the larynx is identical with that occurring in any portion of the mucous membrane in the upper respiratory tract, with the excep- tion that in the larynx the glandular element is quite deficient and the excessive catarrhal exudate is rather the product of inflam- mation, while in the other mucous-membrane tracts the excessive exudate is the result of hypersecretion plus the inflammatory exu- date. There is a vascular engorgement which, owing to the struct- ure of the larynx, would be bound to lessen its lumen and produce slight impairment of breathing, and in the first stage of the inflam- matory process the membrane would be dry, producing a sensation of raspiness and discomfort. This is followed by hypersecretion and exudation by reason of leakage from the engorged vessels and the overflow of mucus from the pent-up gland-secretion. Owing to the desquamation of the epithelial cells and leukocytes the exu- date becomes more tenacious and white in color. Unless the irritation be kept up, with the relief of the engorgement and the restoration of the circulation to normal the symptoms rapidly dis- appear, and there is left no structural alteration. However, in many cases the exciting or predisposing cause is continued, and the condition passes into a chronic inflammation, with permanent structiu-nl alteration. Symptoms. — Frequently the first sym];>tom noticed will be a disposition to cough, owing to slight dryness of the throat, and a sudden alteration in the voice, which will be rapidly followed by DISEASES OF THE LARYNX. 499 considerable soreness or a sensation of roughness and thickening in the throat, with a feeling of constriction. To the sense of touch there is practically no pain, but attempts to use the voice cause aggravation of all the symptoms above mentioned. Often the voice may remain hoarse throughout the entire attack, but fre- quently there is sudden loss of voice, in which the patient is unable to speak above a whisper. The cough is usually shrill and metallic, and in the early stages is dry and rasping. Impeded respiration is more marked in children, although, unless attended by consider- able edema, as seen in the traumatic variety, the interference is not marked. As the case progresses into the second stage, the secretion will considerably relieve the dryness and cough, which will become less rasping and irritating. There may be a slight rise of tem- perature, especially in children. In either the second or third stage of the disease in young subjects, suffocative attacks may occur during sleep. This is most likely due to accumulated or dried secretions within the larynx. Examination of the laryngeal mucous membranes shows a distinct hyperemia of the entire sur- face. The injected vessels may be distinctly outlined. Occasion- ally, minute ruptures may occur, allowing leakage into the sub- mucosa. This hemorrhagic condition may occur as the result of violent respiratory efforts, as in coughing or vomiting, and has given rise to the variety known as hemorrhagiG laryngitis. The mucous membrane will appear swollen and tense, and occasionally the injection of the ventricular bands will cause them to overlap the true cords slightly, and thus interfere with phonation. The epiglottis may be slightly engorged, but, as a rule, there is no tendency to edema. Occasionally, small areas may be covered with tenacious secretion, causing slight desquamation of epi- thelial cells underneath, and on inspection somewhat resembles areas of ulceration. The interference with phonation may be the result of involvement of the base of the vocal cords, but is oftener due to involvement of the surrounding structures, such as the ventricular bands, the epiglottis, rim of the glottis, or the mem- brane covering the arytenoids. The interference with innervation in the inflammatory stage is a secondary matter ; the irregular and incomplete tension of the cord is brought about rather by the congestion of the vessels and the inflammatory exudate into the subniufosa. Diagnosis. — The ol)j('ctive and subjective symptoms are quite clear. However, in children and young adults the possibility of their being symptoms of a more serious lesion, such as diphtheria or the eruptive jfcvers, sliould always be taken into consideration. Prognosis. — The prognosis is favorable. Many cases will recover in a few days witii very little if any treatment, although in some instances in which the exciting factor persists the condi- tion passes into one of clirouic inflaniniation. 500 DISEASES OF THE NOSE AND THROAT. Treatment. — An acute iiiHiunmatory process involving the mucous membrane of the hirynx is not always a serious condition, yet, from its location and the tendency to edema, with subsequent interference to respiration, it always demands prompt and energetic treatment. By the use of the laryngoscope the area of inflamma- tion can l)e outlined and its severity determined. If seen early and the process is limited, with no threatened edema, such reme- dial agents should be used as will relax peripheral vessels, thereby diminishing local |)ressure. For this purpose, as well as to lessen the dry, irritating cough, there should be administered internally every hour, for three or four doses, an effervescing pilocarpin tablet containing jho grain of the drug. Hot mustard foot-baths should be given, followed by hot drinks, such as hot lemonade, to promote diaphoresis. The temperature of the room, maintained at from 60° to 70° F., should be rendered soothing to the inflamed membrane by surcharging the air with steam. Attention should be given to the condition of the intestinal tract, and, although there is no existing constipation, a gentle purgative is beneficial from its general derivative action. No irritating food of any kind should be allowed during the course of the disease. This plan of treatment in a majority of cases will relieve the congestion and rapidly promote resolution. If the tissue surrounding the cords be involved in the inflammatory process, inhalation of compound tincture of benzoin, a teaspoonful to a half-pint of boiling water, is useful. If there is marked irritation, there may be added to the benzoin a teaspoonful of paregoric. Equally good is the local application, by means of spray or nebulizer, of some bland oil, such as liquid vaselin or albolene 1 ounce, to which is added from 4 to 6 drops of oil of sandal-wood and 1 to 3 drops of oil of tar. If the inflammatory pi'ocess be in the early stage, and the patient's occupation demands the constant use of the voice, relief can be given in a few hours by the administration of 5 to 10 drops of dilute nitric acid in water, repeated at first every half-hour, then every hour, for two or three doses, or a tablet of — I^. Acidi nitrici diluti, TTtiij (.18) ; Tincture opii deodorati, TTiiij (.18) ; Cocain phenate, gr. jL (.006) ; given every hour for three or four doses, will often give prompt relief, from its action on the arterioles and relief of the conges- tion, thereby depleting the part. If this treatment is used in the evening, the morning will usually show a return of the con- dition, unless the irritation be very much localized, when there is more hope of a permanent recovery. The use of external applications affords some relief. In the DISEASES OF THE LARYNX. 501 early inflaramatoiy process the external application of cold by means of the ordinary ice- or cold-water bag may prove beneficial. This should be used only early in the case, and should not be applied longer than a few minutes at a time, repeated application for a short period affording more relief than the continued appli- cation. The insufflation of powders is highly objectionable, as the irritation produced by such agents increases the condition that is sought to be relieved. It must be remembered that diseases of the larynx are not cured by gargles ; that the cases in which the vari- ous solutions used as gargles seem to be beneficial are those in which there is associated pharyngeal involvement or inflammation of the lingual tonsil. In the stage of exudation, when there is profuse secretion, before applying the oily solution as recom- mended above, the parts may be sprayed by a simple cleansing alkaline wash, such as biborate or bicarjaonate of sodium, 10 to 15 grains to the ounce of tejaid water. Very little of such applica- tion will come in contact with the laryngeal tissue, but it serves to clean away the mucus surrounding the epiglottis and low down in the pharynx. When there is existing edema involving the glottis and laryn- geal structure, prompt surgical interference is necessary. The edematous tissue must be punctured. Puncturing is better than scarifving, as there is less danger of causing any serious hemor- rhage, and there is less laceration of tissue. It must be remem- bered that in edema the engorgement is not a vascular one, but a w^atery infiltration of the perivascular structure, and that such exudation somewhat relieves the engorged vessels. Puncturing, then, will relieve this watery infiltration, while scarifying will accomplish the same end, but with the added evil of more exten- sive laceration, with hemorrhage. This procedure may be followed by the application of mild astringents, such as liquor ferri persul- phatis, 5 to 10 drops to the ounce, argenti nitras, 2 to 5 grains to the ounce. If the edema be rapid and well advanced and the danger of sufTocation imminent, immediate intubation or tracheotomy is indicated. If there is a tendency, after the subsidence of the acute attack, to huskiness or even complete loss of the voice, lasting for several days or weeks, there should be administered internally 5-grain doses of benzoate of sodium, or dram doses of comjiound elixir of terpin hydrate (Llewellyn's). At the same time tliere should be used locally mild astringents, such as tannin or alum, 5 to 10 grains to the ounce of water, in spray. General medication is not usually indicated in acute laryngitis, although there may be attendant conditions demanding special attention. For the distressing cough there may be administered an anodyne, as codein sulphate in doses of gr. J^ to 1, repeated 502 DISEASES OF THE NOSE AND THROAT. only to the point of relief of tlu; synn)toni. It must be remem- bered that many cases of api)arent hiryngeal cough are due to mechanical irritants, and that if the coughing is continued a suffi- cient length of time and is paroxysmal in character, the act itself mav bring about laryngeal congestion and simulate true disease of the larynx ; in such conditions sedatives are indicated. In indi- viduals of a rheumatic or gouty tendency an alkali should be given. The importance of resting the voice during any laryngeal involve- ment cannot be overestimated ; and if the vocal bands are mark- edly involved in the inflammatory process, causing complete loss of voice, absolute rest should be insisted upon. ACUTE LARYNGITIS IN CONSTITUTIONAL DISEASES. Erysipelas. — The larynx may be involved primarily by ery- sipelas, or the disease may extend from its cutaneous structure to implication of that organ. Many of the so-called idiopathic cases of facial erysipelas may be explained by a pre-existing faucial involvement. The inten- sity of the erysipelatous involvement may range from a simple diffused redness with edema, through a phlyctenular type, in which vesicles or blebs are found resembling herpes, which, when rupt- ured, discharge serum or pus, and have a yellowish-white, easily detachable base, to gangrenous changes of the structures. The disease is generally epidemic or endemic ; it may begin with a chill, followed by fever, vomiting, delirium, and prostration, with local throat-symptoms of pain, dyspnea, or odynophagia. The lar- ynx early in the affection resembles an acute attack of simple lar- yngitis, but the tendency of the affection to extend, the occurrence of other cases, the constitutional involvement, lymphatic enlarge- ment, together with the bacteriological finding, early distinguish it from the simpler form. The prog-nosis should be grave and guarded, as the great majority of cases ])rove fatal. The treatment sliould be that applied to erysijx'las in general, plus the relieving of symjitoms caused by its special involvement. Tincture of chlorid of iron, quinin and whiskey or brandy should be given frequently in large doses. Some authors have strongly recommended the local application of nitrate of silver, 60 grains to the ounce, at the junction of the diseased with the healthy membrane. Antiseptic mouth-washes and gargles should be employed. Cocain or menthol, 10 per cent, in albolene, sprayed over the tissue affected, will relieve the pain. Counterirritants externally are of doubtful value. Measles. — One of the constant and characteristic symptoms of measles is a catarrhal inflannnation of the entire upper respiratory tract, either preceded or accompanied by the characteristic spot- DISEASES OF THE LARYNX. 503 ting of the disease. This catarrhal condition may exist through- out the attacli, and leave the membrane in a condition favorable to subsequent involvement. In the great majority of cases the laryn- geal implication rarely exceeds a catarrhal type, though occasionally mechanical ulceration from coughing, or even gangrene, may be met with. The inflammatory condition may assume a pseudo- membranous form. In severe cases of the laryngitis of measles the symptoms consist of a dry, hard, painfully frequent cough, a loud, whistling respiration, and, rarely, suffocative spasmodic attacks, followed by the expectoration of dry, inspissated mucus. The larynx, on inspection, is of a deep-red color, the vocal cords yellowish-red and slightly injected. The prog-nosis for measles is not rendered more grave by the ordinary catarrhal involvement, except by the danger of sudden edema ; but in the other varieties, such as the membranous or ulcerative, the outlook is exceedingly serious as regards recovery. The treatment should consist in the rigorous use of antiseptic and detergent sprays or gargles, as prophylactic measures, before there is any actual involvement of the larynx. Boric acid, 10 grains to the ounce, or aqueous extract of hamamelis, hydrogen peroxid, and cinnamon water, in equal parts, may be used for this purpose. If there is much pain, a gargle of — B^. Chloral hydrate, gr. x (.6) ; Glvcerini,' 3ss (3.9) ; Aqufe, flsj (30.) ; should be employed as often as necessary. The ulcerative and gangrenous lesions may receive similar treatment, plus the ap- plication of the compound tincture of benzoin and 50 per cent, boroglycerid equal parts to the former and 10 per cent, aluminol to the latter. Scarlet Fever. — The laryngeal involvement of scarlet fever is usually mild, consisting in a hyperemia or slight catarrhal inflammation. This is proved by the fact that hoarseness and cough are not usually met with in scarlatina. In severe and grave cases, however, the laryngeal involvement may be the main source of danger. There may be in instances of this kind a severe catarrlial laryngitis with edema ; ulceration may occur, pseud()ni('nd)rane may form, or even gangrene result. Small-pox. — In small-jiox the larynx is frequently involved. There may be only a catarrhal involvement, as evidenced by hoarse- ness, or edema of the aryepiglottic folds may occur, as may ulcera- tion of a degree even to perforation ; cord ]>aralysis, spasm, and even mechanical obstruction due to rcdmidant tissue may occur. In the confluent or hemorrhagic forms of variola the laryngeal legions are proportionately graver, and asphyxia may result from the swelling, 504 DISEASES OF THE NOSE AND THROAT. collection of viscid phlegm, and spasm of the glottis. Permanent alteration or loss of voice may result from the ulcerative laryngeal involvenuMit. Pseudomembranes may form in the larynx during the course^ of the disease, or true diphtheria may complicate it. Typhoid Fever. — During the course of typhoid fever the larynx in a certain percentage of cases may be involved by a simple catarrhal inflammatory process, or, by extension from the pharynx, may be implicated in any of the processes mentioned as occurring in that locality. Ulceration of the larynx occurs in a few cases, and may consist in a simple catarrhal ulceration — ulcer- ative lesions closely akin to those found in the intestine, or of a diphtheritic character. These lesions do not usually develop until late in the disease, and may even destroy the cartilages in their necrotic involvement. They are considered under Chondritis and Perichondritis. This process may give rise to alarming edema. Typhus Fever. — Laryngitis is at times met with in typhus fever, and is usually a dangerous complication. The swollen mem- brane assumes a Ijright- or dusky-red, hue covered with sticky mucus or pus. Occasionally, ulceration of a peculiarly destructive type is observed, often baring the cartilages and leaving a blackish- gray denuded surface. Influenza. — In a considerable proportion of cases of influ- enza the larynx is involved in an acute inflammatory process, evidenced by aphonia of an intermittent character. The mucous membrane is swollen, shiny, and reddened ; later, M'hite or grayish spots may appear, resembling superficial necrosis. Edema, local- ized or general, may supervene at any time, requiring prompt and energetic interference. Spasm or j^aralysis may result, or an in- flamed condition left that may persist indefinitely, resulting in a chronic inflammati( >n. Miasmatic Epiglottitis. — Under this heading Jacob D. Arnold in Bufiicft'-s f'^i/sfon mentions an acute inflammatory condi- tion particularly involving the epiglottis. There is marked edema of that structure, causing dyspnea and odynophagia, and in one case reported by him the obstruction to breathing became so great that tracheotomy was performed. He believed the condition " due to some animal, vegetable, or chemical })oison in the exhalations of the salt marshes." Malarial poisoning may evidence itself locally in the larynx by producing symptoms resembling croup. Fever occurring at regu- lar intervals, as well as hoarseness, difficult breathing, and injec- tion of the structure, are the main symptoms. The enlarged epiglottis should be punctured or scarified, with the patient's head held fi)rward to prevent entrance of the contents into the larynx. Ice-water sprays and astringents will hasten reso- lution. If malaria be the suspected cause, quinin in the form of the bromid should be administered. DISEASES OF THE LARYNX. 505 Rheumatism. — Acute involvement of the larynx by rheuma- tism has been observed in a number of cases. It may consist in a rheumatic arthritis, evidenced by pain on attempted phonation and by hyperemia of varying amount ; the cords may be immobile, swollen, and deeply colored, while the articulation affected is swollen and tender. The gums and teeth should be examined for evidence of uric-acid diathesis. Sedative applications internally and counterirritation by a blister externally, in conjunction with the administration of the salicylates and tonics, may be efficient aids in relieving the con- dition. ACUTE LARYNGITIS IN CHILDREN. Synonyms. — Spasmodic croup ; False croup. The acute catarrhal inflammation involving the mucous mem- brane of the larynx in children does not differ in its etiology and pathology from the same condition occurring in adults ; but the fact that the caliber of the larynx is much smaller in children, the mucous-membrane structure more relaxed, Avith a tendency to rapid engorgement, makes the condition more serious, and alters the symptoms and course of the disease. The inflammation may involve the membrane above the glottis, and is known as acute supraglottic laryngitis; or it may be limited to the membrane below the glottis, and is called subglottic laryngitis ; or both struct- ures may be involved under the general term of acute laryngitis, in which there would be combined the symptoms of both supra- and sub-glottic inflammation. In children the condition is most likely to occur between the ages of two and five years, although it may occur as early as the first or as late as the fifteenth year. The condition may be brought about by any mild catarrhal inflam- mation of the upper air-passages, or as a result of inflammation of the pharyngeal, faucial, or lingual tonsil. I think in children quite frequently the predisposing cause will be found in involvement of the lingual tonsil, due to its close proximity to the larynx and epiglottis and its direct lymphatic and l)]ood-supply. The usual exciting cause is exposure to cold, possibly increased by some sys- temic irregularities, such as gastric or gastro-intestinal lesion. There may be associated some systemic disturbance, such as fever, with loss of ap])etite, or there may be entire absence of stomachic symptoms, the inflammation being purely local and involving the supraglottic structure. There will be hoarseness of voice, and in some cases complete aphonia. There is usually a sensation of irritation in the throat, although seldom sufficient to cause pro- nounced coughing. If tlie inflammation is limited to the supra- glottic region, there will be very little dyspnea, with little or no tendency to spasm of the glottis. It is a much milder form than 506 DISEASES OF THE NOSE AND THROAT. the subglottic variety, in which there is more likely to be spasm of tiie glottis. Any acute inflammatory condition involving the laryngeal membrane in children should always be looked upon with suspicion, and the diagnosis determined as rapidly as possible. In children it is difficult to make a complete laryngoscopical examination, although with care and patience in the majority of cases a good view of the larynx can be obtained. I do not agree with some writers that forcible examination should be made and the child's tongue held until it struggles or gags, as I think the irritation produced is of decided harm to the child ; but, on the contrary, there should be as little irritation and muscular spasm as possil)le. In itself the supraglottic variety is not dangerous, but the inflammatory process tends to become subglottic. This is especially true if associated with inflammatory processes in adjacent structures, such as the tonsils, either pharyngeal, faucial or lingual. It must be rememl)ered that this variety of acute laryngitis is also an early symptom of much graver lesions — those in scarlet fever and diphtheria. The mucous membrane, not only of the laryngeal structure but of the entire respiratory tract, may present a condi- tion of catarrhal inflammation. Treatment. — The treatment of acute laryngitis in children should be begun by the administration of divided doses of calomel and bicarbonate of soda, followed by a saline. The air of the room in which the patient is confined should be kept moist and soothing by generating steam in a kettle or other appliance. Applications direct to the larynx are not only difficult but exceedingly danger- ous, and should not be resorted to. Inflammatory involvement of adjacent structures, such as the pharynx, nasopharynx, or ton- sils, should receive prompt and energetic attention, if the laryn- geal implication is to be bettered. Externally, camphorated oil should be energetically rubbed into the tissues about the larynx and overlying the trachea and bronchi. Early in the attack benefit may result from wrapping about the throat a towel, the end of which, next the skin, should be dipped in ice water from time to time. Coal oil diluted may be applied on flannel to the neck as a coun- terirritant, and allowed to remain in position over night. For the profuse secretion compoimd tincture of camphor combined with squills, given in dram doses, answers adniiral)ly. Dover's powder in small doses serves, as* does paregoric, to allay the irritating cough. Internally, good results can be obtained by giving repeat- edly hot milk seasoned with salt as strongly as can be taken. Should the symptoms demand an emetic, the administration of a teaspoonful of sodium chlorid, followed by warm water, will act promptly. In the way of prophylaxis nuich can be done with those chil- dren predisposed, by inherited tubercular or other tendency, to frequent laryngeal and pulmonary attacks. Cold sponge-baths DISEASES OF THE LARYNX. 507 combined with brisk friction, flannels of proper weight worn thronghoiit the year, a suitable chest-protector, outdoor life, prop- erly ventilated rooms (especially the bed-chamber), an annual excursion to the sea or mountains for salt or pure air, are to be insisted upon whenever practicable or possible. LARYNGISMUS STRIDULUS. Synonyms. — Spasm of the glottis ; Spasmus glottidis ; Spasm of the larynx ; Laryngeal spasm ; Spasmodic laryngitis ; Spasm of the abductors of the vocal cords ; Spasmodic croup ; Cerebral croup ; False croup ; Child-crowing ; Thymic asthma ; Miller's asthma ; Asthma rachiticum. Laryngismus stridulus denotes spasm of the larynx accompanied by stridor, and while in itself it is not a separate disease, yet it is an alarming symptom, which may be associated with any afTection of the larynx or trachea, due either to direct lesion or indirectly from reflex causes of irritation. It is most common in children. It may be a symptom in inflammatory or uninflammatory diseases of the larynx. For example, spasm of the larynx with stridor is observed in croup (either true or false), whooping cough, gastric or intestinal disturbances — such as intestinal catarrh, constipation, or intestinal worms — and during dentition ; it may occur along with other convulsive symptoms ; it may be present in rachitic children or children of the neurotic temperament ; it may be brought about by direct irritation of the fauces by foreign material, or new growths, or by the application of drugs ; it may be reflex from irritation in the nasopharynx ; it may also be reflexly associated with uterine lesions or sexual excesses. Again, it may be due to uric-acid diathesis, as observed by Cohen in a case in which laryn- gismus stridulus was cured by relieving the uric-acid tendency. Moreover, the. spasm may be caused by an elongated uvula drop- ping into and irritating the laryngeal structure. It may also occur in laryngeal crises of tabes, and would be associated with absent knee-jerk and ataxia. Caries of the vertebrae may also, from pressure, bring about spasm of the larynx. The same is true from pressure of enlarged thymus gland (thymic aMhma), acute or chronic abscess, as well as from enlarged bronchial gland. This may be either direct or from pressure on some part of the pneumo- gastric or spinal accessory nerve. There may be also associated some paralysis of the posterior crico-arytenoid muscle, either bilateral or unilateral. Lesions of the tongue, especially enlarge- ment of the lingual tonsil, are important direct or reflex etiological factors. The spasm may also be a symptom Avhere cerebral irritation exists. The condition should be looked upon and treated as an associated lesion, or rather a local manifestation dependent u])on some local, constitutional, or remote disease, which is reflected 508 DISEASES OF THE NOSE AND THROAT. from the muscles of tlie larynx, and is in reality a neurosis. It is a symptom and not a disease. The conditions in which laryngismus stridulus is best illus- trated are spasm of the larynx in children, spasm of the larynx in adults, and sjiasmodic laryngitis. Treatment. — C|uite fretjueutly the spasm will relax before death occurs, owing to the anesthetic eifect produced by the retained carbonic-acid gas, due to interference with respiration ; however, this cannot always be depended u]wn, and the condition is so alarming as to call for immediate relief, and may demand the perforjuance of tracheotomy at once. Direct inspection of the pharynx and larynx should be made without delay to determine the presence of foreign bodies or any source of irritation. Between the attacks careful search should be instituted for the direct or reflex cause, as the relief of the condition in the majority of cases will be determined by the controlling of the associated or reflex lesions. For the relief of the paroxysm the dashing of cold water on the face or neck, or the application of hot water to the nape of the neck, will often give prompt relief. Traction on the tongue by firmly grasping the tongue between the thumb and index finger and making traction at intervals of eighteen times per minute, by reason of its reflex action through the phrenic nerve on the respir- atory centers, is one of the simplest and best methods to relieve the patient of the spasm. Should the jaws be set, almost the same reflex action can be produced by placing the fingers under the angle of the jaw and making traction by deep-seated pressure. Spasji of the Laryxx in Children. Synonym. — Spasm of the glottis in children. Ktiology. — Given a rachitic child fed on improper food, with unhygienic environment, insufficiently clad, let some intercurrent provocation, such as a prolonged fit of crying, exposure to cold, fright, irritation of the gums in dentition, intestinal worms, for- eign bodies in the esophagus, acute indigestion, whooping cough, or the entrance of a drop of milk into the larynx be interposed, and you have all the conditions favorable for an attack of spasm of the larynx. Enlarged bronchial or tracheal glands, by })ressure on the ]aryug(>al nerves, may also give rise to the condition. Pathology. — Impairment of nutrition at the nerve-centers controlling the larynx renders them unstable, and impulses, either originating there, or referred from a larynx locally disturbed, or coming from other portions of the body, are reflected to the larynx, causing spasmodic closure of the glottis by stimulating the action of the tensors and adductors of the vocal cords. Symptoms. — The child, usually less than two years of age, is suddenly seized, either waking from sleep or while awake, DISEASES OF THE LARYNX. 509 with an attack of dyspnea, drawing the air in with the greatest difficulty and forcing it out after equally great effort ; or, starting up in bed from a sound sleep, with an expression of terror in its face, respiration may be for ten to twenty seconds absolutely impossible ; the child becomes cyanotic, the neck becomes turgid, the eyes converge, spasmodic contractions of the hands or feet may occur, or there may be a general convulsive seizure even to opis- thotonos, which may terminate fatally, rarely, in the first attack ; or, the spasm of the larynx relaxing, the symptoms abate, and with a loud inspiration the child lies completely exhausted. A series of these seizures may take place, separated by minutes, hours, or days, and even weeks may elapse before a recurrence. The nutri- tion of the child, originally bad, is rendered worse by the loss of sleep and the drain on the nervous system. Diagnosis. — A neoplasm may cause dyspnea that is pro- gressive, in contradistinction to the suddenness of its onset in this aifection ; hoarseness or loss of voice is usually noticed in intralaryngeal growths. Fever and symptoms pointing toward laryngeal involvement between the attacks indicate laryngitis, edema, or general infectious disease. Bilateral abductor paralysis is rare in infancy, is more chronic in character, and the attacks of dyspnea, though longer, are not so severe. Prognosis. — The extent of impairment of the general health and the severity and frequency of recurrence control the outlook, which is at best exceedingly grave. Treatment. — The treatment of a case of spasm of the larynx comprises the controlling of the spasm and attempts to prevent its recurrence. During the actual attack the clothing of the child should be loosened, and the windows of the room opened to allow the en- trance of fresh air. Place the child in a semi-recumbent position, with the feet in a mustard foot-bath at 95° F. Apply mustard plasters to the back of the neck. Dash cold water in the face or apply cold compresses to the head. A ^V grain of morphin, with Z^Q grain of atropin subcutaneously, Bosworth considers safe. Ammonia, chloroform, or nitrate of amyl by inhalation might be attempted, though the interference with respiration would seem to render these agents useless. Tickling the back of the throat with a feather may cause vomiting and relieve the spasm. Traction on the tongue may be resorted to, as described under Laryngismus Stridulus. Oxygen under pressure is beneficial. Should the spasm threaten life, intubation, the introduction of a soft catheter into the larynx, or tracheotomy sliould be done at once. Duriug the intervals between the attack the direct and indirect causes should be; diligently sought for and corrected. The general condition should be built up by the administration of cod-liver oil, hypophosphitcs, or syrup of iodid of iron. The food should 510 DISEASES OF THE XOSE AND THROAT. he uiitritioiis and non-irritating ; the clotliing should be warm and ])rotective. The child shoultl he })laeed in healthy surroundings and out of doors as much as possible. Lance the gums if the teeth be at fault. If the child nurses with difficulty from the breast, feed with a spoon. To prevent recurrences by quieting the nerve-centers and conduits, use chloral, bromid of soda, anti- pvrin, physostigmiu, or valerian. Si'ASM OF THE Larynx in Adults. Synonym. — Spasm of the glottis in adults. Ktiology. — An abnormal excitability of the nervous system j^redisposes to attacks of spasm of the larynx in the adult. The direct course of the condition is generally reflex in nature, orig- inating, as a rule, from some diseased condition in the respiratory tract, though stimulus may come from other sources. Again, it may be but one of the symptoms of a systemic disease. The so- called laryngeal crisis occurring in locomotor ataxia may be cited as illustrative of the last variety of causes, as may diphtheria, hydrophobia, and tetanus. Such conditions as atrophic or hyper- plastic rhinitis, nasal polyps, adenoids, deflected septum, and obstructive lesion of the upper air-tract may reflexly produce the condition ; the same is true of lesions of the ear. Syphilis, tuber- cidosis, traumatism, ulcers, tumors, and rough instrumentation or examination, or foreign bodies in the larynx or adjacent struct- ures may reflexly cause the spasmodic laryngeal closure. Central nerve-lesion or pressure on the efferent nerve by a bronchocele, aneurysm, enlarged glands, tumors, or any enlargement may also produce a similar result. The spasm may also be due to or asso- ciated with tubercular laryngitis. The condition is often noted in hysterical individuals. One case I observed in my own practice, in which such spasm of a most alarming nature occurred. Symptoms. — The attack of dyspnea, varying in degree and frequency according to the cause, usually lasting but for a few seconds, comes on generally at night. There is a struggle for breath, a few crowing, noisy respirations with cyanosis. The attack gradually subsides, the spasm lasting from five to twenty seconds. There are lacking the periodicity and regularity in the recurrence of seizures seen in glottic spasm in children. Attacks during the day are more apt to be due to central nerve-lesion, pressure on the nerve-trunk, or systemic affection, such as loco- motor ataxia, in which case there is likely to be a precedent cough. Diagnosis. — The main difficulty in the diagnosis of the con- dition is the accurate establishment of the underlying cause. Care- fully examine the upper air-passages for abnormality of disease, liook for the other symptoms of the general involvement, if tabes DISEASES OF THE LARYNX. 511 or other systemic disease be the cause. The laryngeal image, by revealing the impaired movement of the muscles supplied, will aid in establishing a pressure-lesion on one of the nerves. In bilateral abductor paralysis the laiyngeal image will show an absence of abducting motion making clear the diagnosis. Prognosis. — Except in those cases due to systemic involve- ment the outlook for relief of the condition is usually good, fatal termination of a spasm being fortunately a rare occurrence. Treatment. — Removal of spurs from the septum, correction of deflection, ablation of polyps or adenoids, treatment of the atro- phic or hyperplastic conditions, in fact, the correction or removal of any diseased condition of the upper respiratory tract, is essen- tial to cure. Frequently the spasm can be controlled by the application of bland oils to the nasopharynx. To alleviate the attack or obtund the nervous instability and hypersensitiveness, bromid of potassium or sodium should be given in 10- to 15-grain doses three or four times a day, increasing the daily doses by 5 grains until a result is obtained. The personal hygiene of the patient should be looked to, and a nutritious diet and outdoor exercise insisted upon. Should the condition be due to nerve- pressure, the excitable and irritable laryngeal mucosa, as in all other conditions, should be soothed by spraying a 2 per cent, cocain or menthol solution, or by the inhalation of such antispas- modics or sedatives as infusion of poppies, or tincture of benzoin with paregoric. Spasmodic Laryngitis. Synonyms. — Stridulous laryngitis ; Stridulous angina ; Laryn- gitis stridulosa ; Spasmodic croup ; Mucous croup ; Spurious croup ; False croup ; Catarrhal croup ; Catarrhal laryngitis ; Spasm of the larynx ; Pseudocroup. Spasmodic laryngitis is a condition in which there is always present an inflammation of the laryngeal and tracheal mucous membrane, associated with spasmodic contraction of the muscles of the larynx, which gives rise to peculiar cough, difficult respira- tion, stridor, and even paroxysms of dyspnea. The inflannnatory process may be very slight, yet the spasm be quite marked. It may be supraglottic or subglottic, the supraglottic variety being usually associated with spasm, while the subglottic variety is true or membranous croup, although in many cases an involvement of both su])ra- and sub-glottic stru(;tures occurs. There is a condi- tion of spasm of the glottis, or true laryngismus stridulus, which is purely a neurotic condition and not connected M'ith any inflam- matory process; it is sj)asmodic, begins suddenly, and abates rap- idly. It is identical with the tonic convulsion of external muscles, being limited in this case to the internal muscles of respiration. 512 DISEASES OF THE NOSE AND THROAT. Htiology. — Of the predisposing causes of simsmodie laryngitis or fal.-^c croup, inherited tendency plays an important part, chil- dren of lymphatic temperament being especially liable. Children witii short, stout, chubby necks are also predisposed. Intestinal irregularities and gastric disorders in children are also predispos- ing factors. The exciting factor in most cases is exposure to cold. The condition is not uncommon in the commencement of various childhood diseases, especially in measles. In child- hood the narrowness of the rima glottidis, coupled with the sus- ceptibility of the nervous system, forms an additional predis- posing factor. Pathology. — As to the pathological alteration little is known. In the few cases in Avhich post-mortem reports have been given, little or no alteration in the laryngeal structure was noted, outside of some tumefaction of the tissue, which in a number of cases was more than likely due to the use of remedial agents rather than the result of the disease-process. It would seem that the etiological factor was remote from the site of the disease, and that the spasm of the laryngeal muscles was due to direct or indirect nerve-irrita- tion rather than a local inflammatory process, and the condition should properly be classed under Neuroses, There is, however, nearly always some local inflammatory process, and it is difficult to determine whether this be the cause of the laryngeal spasm or merely an allied condition. Symptoms. — The disease is strictly one of childhood, and occurs in children from a few months to ten or twelve years of age. The spasmodic seizures are usually preceded by slight cough and the characteristic symptoms of a mild coryza. However, in some cases the onset is abrupt, and the premonitory symptoms are absent. One of the peculiarities of the condition is that it occurs at night — usually after the flrst sleep — between ten and twelve o'clock. The child may go to sleep quietly and naturally, and in a few hours awake with a loud, rasping, wheezing, asthmatic cough, struggles and gasps for breath, and the breathing has a peculiar whistling sound on inspiration. The face is flushed and anxious, with a marked expression of terror, and the child will cling to the attendant as though frightened. The pulse is hard and full, owing to the increase of vascular tension by improper respiratory func- tion. The attack may last from a half-hour to two or three hours. Usually, with proper treatment, in a half-hour the symptoms have abated, and the child drops off' into a sleej) indicative of fatigue. Occasionally the attack may be repeated the same night, or during subsequent nights. The inflammatory action is more marked after the abat(>ment of the attack than before ; however, this can be explained by the irritation produced by the violent coughing and labored breathing. Frequently for two or three days the child has a hoarse, croupy cough, with profuse catarrhal secretion ; and, BISEASES OF THE LARYNX. 513 where the cold and exposure have been pronounced, the attack may be followed by catarrhal pneumonia. Diagnosis. — The condition may be — in fact, quite frequently is — mistaken for pseudomembranous croup. However, the true membranous variety begins insidiously, with slight cough, which gradually increases in intensity. The cough becomes more harsh and the respiration more difficult by degrees, and continues by day as well as by night ; while the spasmodic laryngitis or false croup commences abruptly, may be preceded by slight cough and nasal catarrh, yet the onset, in which respiration is interfered with, is sudden, and rapidly reaches its maxinumi intensity. It always occurs at night. In true croup the cough is harsh and rough from the presence of the membrane, portions of which may be coughed up ; in spasmodic laryngitis the cough is loud, M'heezy, and dry, and the alteration in the voice is due onh^ to the interference with respiration ; in the membranous variety the voice is altered, due to the presence of foreign material. In true croup the alteration in voice is gradual, while in spasmodic laryngitis it is sudden. Besides, in the membranous variety careful inspection will usually show on the faucial surface evidence of false membrane ; while in the spasmodic variety tlie membrane is not present, with usually very little, if any, inflammation in the faucial structure. iProgHOSiS. — Under proper treatment the prognosis is favor- able, although tlie fact must not be overlooked that death may occur. The symptoms of unfavorable termination are the con- tinued marked dyspnea, which does not respond to proper remedial agents ; stridulous breathing, both inspiratory and expiratory ; the lividity of tlie face and the fingers, due to cyanotic congestion, on account of the lack of oxidation and non-aeration of the blood ; cold, pallid surface and irregular pulse, Avith tendency to con- vulsions. Treatment. — The treatment should be directed, first, to relieving the spasmodic action of the laryngeal nuiscles, and, secondlv, to allaying any laryngeal inflammation. For the first there is nothing better than tlie warm bath, which should be at a tem])eratur(' as warm as can be conifortably borne. The little patient should he left in the bath at least ten or fifteen miuutes, and placed so as to l)c couiplotely immersed, with the exception of the head, allowing the watei- to extend up to the chin. Sufficient ground mustard may l)e added to the hntli to |»rouiote surface stinuilation. With the warm bntli should he coiiiMued the use of emetics. For very young children the syiii]) ol" ipecacuanha in doses of 20 to 60 drops, repeated every twenty to thirty minutes until vomiting occurs, is one of the best emetic^s. For children over three years of age tliere may be combined with the syrup of ipecacuanha an ('(|nal amount of syrup of Sfjuill. Warm salt water will also ])r()(luce tlic same effect, or if immediate vomiting is 514 DISEASES OF THE NOSE AND THROAT. neeessarv, irritation of the fauces by the tip of the finger, or run- ning the finger down the throat, may produce a sufiicient reflex to incUice vomiting. The object of the warm bath and the emetic is to promote rehixation and stinudate secretion. A few whiffs of ether or chloroform will produce rehixation in the cases in which there is associated very little inflammatory ])rocess. To prevent the recurrence of the attack, careful attention sliould be given to the study of the condition of the bowels, and if tlie movements are not free and brisk a purgative should l)e administered, followed by a saline cathartic. Of the purgatives tliere is none better than calomel, in doses graduated to the age of the child, followed by a decided dose of Rochelle or Epsom salts. If an emetic has been administered, it will be necessary to wait some little time before the administration of any other medicine, on account of the nausea ])r()duced by tlie emetic. In the si)asmodiG variety of laryngitis inhalations are of some slight benefit ; but, owing to the interference with respiration, scarcely enough of the medicated vapor reaches the area to produce any marked benefit. The application of mustard plasters to the neck and sternum, or, in the very young, the hot spice poultice to the chest, is highly beneficial. Inhalations of slacked lime do very little good, but tend to moisten the atmo- sphere of the room. If there is much laryngitis following the attack, stimulating expectorants, such as ammonium carbonate, should be administered after careful attention has been given to the intestinal tract. In the majority of cases subject to such attacks the child is of a nervous temperament, and general treatment should be directed toward the improvement of the general system. There should be administered chalybeate and vegetable tonics, and plenty of outdoor exercise is indicated. The victim of such attacks should never be kept in a room in which the air is likely to become dry, nor placed Avhere there will be a direct current of air from a heater or gas from a stove. After an attack beneficial results can be obtained for the prevention of a recurrence on the following night by coating the neck over the region of the irritation with crude petroleum, late in the afternoon or early in the evening. A flannel cloth, saturated with the crude oil and left in contact with the tissue for two or three hours, will do nuich toward stinudating secretion and circulation. ACUTE EPIGLOTTITIS. This term has been a])plied tocontlitions in which acute inflam- mation is largely limited to the epiglottis. It is not, in reality, a se])arate (condition, as there is always an associated laryngitis, with pharyngitis or inflammation of the lingual or faucial tonsil. In many cases it is entirely due to involvement of the lingual tonsil. There is frequently, however, an involvement of the ])harynx and epiglot- tis, with only slight, if any, laryngeal implication. In such cases DISEASES OF THE LARYNX. 515 there are no symptoms referable to the larynx^ though attempt at swallowing may cause some laryngeal spasm. The patient com- plains of the sensation of a foreign body in the throat, an inclina- tion to gag or vomit, slight difficulty in swallow- ing, with very little, if any, pain. There is marked tendency to edema. There is an excessive secre- tion of mucus, which is more marked after meals or when the tissue has been irritated. As a rule, there is no tenderness on pressure, although at' times there may be slight tenderness over the hyoid bone. There are no constitutional symp- toms unless the condition is associated with graver lesions elsewhere. The treatment is practically the same as for acute laryngitis. Sliould there be any tendency to edema, it may be necessary to puncture or scarify the tissue, as directed under Edematous Laryngitis. The instrument shown in Fig. 155 is useful for puncturing the edematous tissue. TRAUMATIC LARYNGITIS. This variety of inflammation differs very little from acute laryngitis, except as to cause and sever- ity, the severity depending entirely upon the nature of the injury. It is a violent inflammatory process of the mucous membrane, not only of the larynx, but usually of adjacent structures and of the con- tinuous mucous membranes. AVhen due to foreign bodies or direct wounds the inflammation may be limited to the laryngeal structure. From inha- lation of vapors, from scalds or burns, or from corrosive poisons, the inflammatory process not only involves the larynx, but also the structures above — the fauces, tongue, and especially the ton- sils. The last-named variety is most likely to oc- cur in quite young children. From scalds, burns, or corrosive poisons the inflammation is generally very violent in character, and nearly always fol- lowed by gangrene. Usually there is marked edema at the same time ; in fact, the condition is almost the same as edematous laryngitis, tliough differing in degree. The inflammation set u]i by a foreign body generally sul)si(l('s on the removal of the offending substance; however, tlic wdimd m.iy he sufficient to cause alarming edema and wide diffusion of the inllanimatory process, and even after the removal of the foreign body, o^ying to the rcs]iira- tory interference, tracheotomy may be imperative. The edematous :'"IG. 155. — Urun's epiglottis pincet. 516 DISEASES OF THE yoSE AND THROAT. condition piv^scnt should he treated in the same way as edematous hiryngitis ; while in the eases in which the process is brought about by corrosive poisons, scalds, or burns, emollient applications are most suitable, such as sweet oil with menthol, gr. iv to the ounce, or camphorated oil and vaselin in equal })arts, with boric acid, gr. v, and menthol, gr. iv, to the ounce. For the relief of the edema, puncture or scarification is the most rational uiethod of treatment. The interference with res- piration shouhr be carefully watched, and if there is alarming dyspnea, with danger of immediate suifocation, prompt tracheot- omy should be performed. Non-depressant emetics may be of some value ; but, as a rule, the process is very rapid, and much of the edema and swelling occurs almost instantly (from the above-mentioned causes) ; for in reality the edema and leakage from the blood-vessels at the start do not constitute an inflamma- tory process, but are more in the nature of a blister, and may be followed bv inflammation. SUPPURATIVE LARYNGITIS. Synonyms. — Phlegmonous laryngitis ; Purulent laryngitis ; Suppuration of the larynx. Suppurative processes involving the larynx should reallv not be called suppurative laryngitis, for the inflammatory process involving the laryngeal mucous membrane is secondary to some infectious condition in the submucosa or the cartilaginous or bony framework of the larynx. The majority of the cases originate in a chondritis or [)eri('hondritis, most commonly due to syphilitic lesion or following ty|)lioi(l fever. In many eases the latter cause is overlooked, as is shown by Keen in his work on Surgical Compli- cations of Tifj}/ioid Fei'er. The threatening complication of any suppurative process involving the larynx is edema, due to the infiltration from the surrounding inflammatory area, so that the symptoms produced by laryngeal suppuration are almost identical with acute edema. Th(^ u})per part of the larynx is most fre- quently involved, although the suppurative ])rocess, originally supraglottic, may by extension of the inflammatory process rapidly invoh'c the cords and become subglottic. Patholog'y. — The pathology is that of abscess-formation, and does not ditfci- from that occurring elsewhere. When the lesion is due to an iuHammation of the cartilage, where necrosis of that structure takes place, there is lik<>ly to be breaking down of the tissue, with discharge of necrotic cartilage or bone. The condition may be a localization of some septic infection. Symptoms. — There is a localized spot of tenderness exter- nally, and tliere may be some external swelling. The pain is con- tinuous, althougii not excessive, but is increased on pressure. DISEASES OF THE LARYNX. 517 Deglutition is difficult, with irregular impairment of the voice and respiration. The interference in respiration and oxidation of the blood is manifested by the red face and tendency to cyanosis, which comes and goes with the increase in, or relief from, the swelling. There is a constant tendency to clear the throat. The patient will have acute attacks of choking, which will be relieved after a violent fit of coughing. The inflammation about the aryteno-epiglottic folds and about the cords and epiglottis below is so great as to render it impossible to inspect the larynx. Diagnosis. — The localized point of tenderness externally, the history of the case, the systemic symptoms, the rather slow prog- ress of the affection, will aid in differentiating the condition from diphtheria and membranous or spasmodic croup. Prognosis. — The prognosis is generally bad, the patient dying from suffocation or general systemic infection. Treatment. — Early in the lesion cold should be applied externally, and the patient allowed to keep small pieces of ice in the mouth. The air in the room should be kept moist, and the patient's general condition supported by stimulants. The edema- tous structure sliould be scarified, and as soon as the threatened area of suppuration can be localized, it should be frequently scari- fied. If there is evidence of chondritis or perichondritis, an in- cision should he made over the localized spot of tenderness. However, before resorting to such surgical procedure, trache- otomy should be performed. As a rule, intubation is of no avail, as the edema and inflammatory swelling extend below the point reached by the tube. RHEUMATIC LARYNGITIS. Synonyms. — Laryngeal rheumatism ; Gouty sore throat ; Gouty throat. Acute laryngitis that is due to a rheumatic or gouty diathesis differs only from the simple acute laryngitis in that the cause is an irritating material within the circulation, locally manifested by disturbaiK-e iu the kiryngeal mucous membrane. There is more pain than in the simple variety, with greater tendency to throat- ache. There may be no other signs of rheumatism ; indeed, the urinary examination may show (leficicnt elimination instead of excess ; this, however, is more highly important than should an excess be found, as it shows a retention of the products of urea within the circulation. The ]iain may be increased on deglutitio-n and external pressure. Occasionally in the severe types there may be slight laryngeal hemorrhage, owing to the rupture of the con- gested vessels; as a rule, however, there is an associated inflam- mation of the larynx and tonsils, althougli it may be limited to the laryngeal structure. There is usually marked alteration ol'thc voice, 518 DISEASES OF THE NOSE AND THROAT. witli lioarseness, and even aphonia. One of the main symptoms, outside of the local laryngeal manifestations, is the lassitude, even hebetude, of which the patient complains. Additional symptoms are the inability to think and work, with draggy feeling and slight, aching pains in the muscles of the neck. The patient frequently complains on swallowing of a peculiar '' creaky" sensation in the throat, and at times there is almost a distinct click. There is a constant tendency to clear the throat, although no pronounced cough. In the true gouty conditions there may be a deposit about the crico-arytenoid joints ; but, as a rule, in this variety there are systemic manifestations of the conditions, yet the throat-manifesta- tions are always pronounced and the symptoms intensified. Treatment. — The treatment is practically the same as that indicated in gout or rheumatic conditions ^vhen occurring in other portions of the upper respiratory tract, and should consist in the internal medication, as local treatment is only palliative, and is practically the same as given under Rheumatic Pharyngitis. EDEMATOUS LARYNGITIS. Synonyms. — Purulent suppurative laryngitis ; Phlegmonous laryngitis; Edema glottidis; Acute cellulitis of the larynx; Edema of the glottis. This is a condition of the laryngeal mucous membrane in which there is watery infiltration into the submueosa, owing to leakage from vessels, either from sudden hy])eremia or from the hyperemia and congestion of inflammations, or in cyanotic conditions [angio- neurotic). Although there are a number of varieties of edema given by the various writers, they are all really based on the exciting cause, and the edematous process is practically one and the same. If the process is infectiinis, it may run a more rapid course, yet there is not sufficient difference to warrant the confusion caused by a description of the varieties based on cause. Ktiology. — The condition may be brought about first by injuries in which there are fractures producing sudden inflamma- tory proc^esses, or by inhalations of steam, irritating vapors, or escharotics. It may also be caused by the accidental swallowing of irritating fluids, or even by the careless application of medicinal agents. This occurred in a case brought to my notice, in which tlie edema was alarming, and was brought about by the patient making a sudden inspiratory effort after the application of a solid stick of nitrate of silver to an ulcer of the tonsil, by which the secretion was drawn into the larynx. Again, the edema may be due to inflammatory conditions in adjacent structures, such as abscess in the tonsil or peritonsillar tissues ; enlarged and sup- purating lymphatic glands of the neck, causing pressure ; wounds DISEASES OF THE LARYNX. 519 or foreign bodies at the base of the tongue, involving the lingual tonsil ; tumors involving adjacent structures, by their pressure and interference with venous return. Foreign bodies in the esophagus, located directly behind the laryngeal or tracheal struct- ure, may also cause the condition, as may chondritis or perichon- dritis. This affection is frequently associated with specific inflam- matory processes, or, as is shown by Keen in his work on Surgical Complications of Typhoid Fever, is often the result of that disease. Under tlie classification of primary and secondary edema can be included all the causes. The edema, however, in the majority of cases is secondary. Quite frequently the edema is brought about, although more of a chronic variety, by cardiac lesions, in which there is lessened vascular tone, with a tendency to cyanotic condi- tions of the lax structures, in which the blood is dammed back on the venous circulation. There will be produced in the mucous membrane of the upper respiratory tract a condition analogous to that occurring in the kidney and liver, known as cyanotic con- gestion. Owing to the lax structure, there is a tendency to watery infiltration, and the so-called chronic edema results. Again, in fibroid changes in such structures as the liver, kidney, and lung, in which there is interference with the systemic circulation, the blood is dammed back on the venous system, and a cyanotic condition is produced in the membrane, identical with that of the cardiac lesion. In the specific inflammations due to local ulceration, with subsequent fibroid-tissue formation and contraction, there may be involvement of the venous structures to such an extent as to produce local edema. Major surgical operations about the throat and lower jaw, in which considerable scar-tissue formation has taken place through the fibroid contraction, may produce the same condition. Infectious processes of the surface, such as occur in diphtheria, scarlet fever, and streptococcal infection, all of which are likely to be quite virulent, may rapidly bring on an acute edema. This may be due to the direct infection or to spreading of the inflammatory process by continuity or contiguity of struct- ure. The acute edema is usually attended by acute inflammation, while the chronic edema may have no local inflammatory ])rocess as an exciting factor. As a rule, it is dependent upon some struct- ural alteration which involves venous circulation, either in direct relation with the part or from organic lesions. Pathology. — The higli vascularity of the larynx, together with the i'act that the bloromj)tly relieved, give rise to hydropic degeneration — especially true in the chronic i'onn, although it is rare in the 520 DISEASES OF THE NOSE AND THROAT. acute form, as in acute edema the case terminates before such (Icgenerative change can take phice. Besides, the waterv infiltra- tion exerts a certain amount of pressure, and thereby lessens cel- lular nutrition, which in chronic edema would tend to further degenerative changes. That in the acute varieties there is very little structural alteration is shown bv the fact that when the case goes on to actual recovery there is practically no structural altera- tion, the tissue returning to its normal function. The edema may be more marked in the ventricular bands, the epiglottis, or the arvepiglottic folds. The surrounding laryngeal structure may also be involved, and it may even extend to the muscles of the neck. In some cases the edematous condition exists not only in the larynx but in the trachea. This is especially true when the excit- ing cause is the inhalation of irritating materials, such as flame, steam, escharotics, or foreign bodies. In chronic edema, Avhile the alteration is not so marked, it may involve the same structures. Post-mortem examination will show very little edematous infiltra- tion, but the relaxed structure can be seen ; this condition, as far as is demonstrated after death, is practically the same as in hyper- emia or congestion — simply showing the result, and not the actual process itself. Symptoms. — In acute edema tlie onset is sudden, and if con- current witli inflammation of adjacent structures, there may be chilly sensations or an actual chill. There is rapid and early im- pairment of the voice in addition to stridulous breathing. Dysp- nea is one of the early symptoms. The interference in breathing, both inspiratory and expiratory, becomes rapidly more marked, and tiie face becomes flushed ; in fact, the whole systemic circula- tion shows the interference with the respiratory function, combined Avith the lessened oxidation of the blood and the elimination of poisonous gases. The patient is restless and apprehensive. The .symptoms rapidly increasing, some few cases demand prompt sur- gical interference, or they will terminate in death. Fortunately, in almost all instances the attack is not so severe nor the symp- toms so marked. There is considerable pain on swallowing, and a sensation in the throat as of a foreign body. There is a wheezy, labored cough, with unsuccessful efl'ort to clear the throat, the expectoration being very slight. The patient is more comfort- able in the u|)right ])Osition, with the body leaning slightly for- ward, InsiK'ction will show the epiglottis enormously swollen — in fact, so much so, in many cases, as to obstruct the laryngeal view — and frequently the edematous condition will have so altered the anatomical relations as to render laryngeal examination of little value. Rapid digital examination, together with the unmis- takable symptoms of laryngeal obstruction, is sufficient to deter- mine the diagnosis. While the edematous condition may be sub- glottic, as a rule it involves not only the entire intralaryngeal DISEASES OF THE LARYNX. 521 structure, but also the surrounding tissues. In the chronic variety the symptoms are not so alarming ; the onset is slower, the altera- tion in the voice is more gradual, and the interference with respira- tion less marked and irregular. The condition may last for weeks without serious complication, and through the collateral circula- tion the tendency to cyanotic congestion may be relieved. If it is due to cicatricial contraction or local involvement, such as is observed in tumors, such alarming symptoms may be produced as to necessitate tracheotomy. The diagnosis in acute edema can be easily made by inspection and by subjective symptoms. In chronic edema, by the history of the case, with a careful laryngeal examination, the diagnosis can be established. Prognosis. — In the acute variety the prognosis is favorable if prompt treatment is instituted. However, the symptoms may be so alarming as to make tracheotomy imperative. Where the involvement of the structure is extensive and is below the point that can be relieved by tracheotomy, the prognosis is bad. Treatment. — The treatment should first be directed toward relief of the edema, whether it be due to an acute phlegmonous inflammation, passive congestion, irritation from foreign bodies, or irritating vapors, and then the curative or the prophylactic treat- ment should be addressed to the underlying cause. Besides the irritation caused by disease-processes in the struct- ures immediately adjacent, it must be remembered that edema of the larynx may be caused by cardiac and pulmonary conditions producing cyanosis of the mucous membrane ; furthermore, renal and hepatic lesions, especially the fibrous changes, through their action on the heart, may bring about the same condition. In all such cases the constitutional treatment should be directed toward the oifending structure, to prevent, if possible, a recurrent attack. For immediate relief of the edema, puncturing or scarifying should be done at once; the patient should be given a saline cathartic and kept in a warm room, in an atmosphere thoroughly surcharged with moisture, and a diaphoretic administered. The punctures and scarifying should be done according to the rules mentioned under Acute I^aryngitis with subsequent edema. The application of astringents after ]>uncturing is rarely necessary if the above method has been carried out. However, sliould it be necessary to apply astringents, 10 grains to tlic ounce of nitrate of silver, or a 10 per cent, alumnol solution, should be used. As a rule, if the puncturing be followed by the a])])li<':ition of a 20 to 30 per cent, aqueous sohition of ichtliyol, tlie tendency to recur- rence is markedly diniinislied, as the ichtliyol promotes rapid reso- lution. In all cases of edema concurrent with i-eiial, cardiac, or hepatic disorders, free daily movements of the bowels must be secured until the condition is relieved. The a})plication of cold, 522 DISEASES OF THE NOSE AND THROAT. in the form of the ice-bag or Leiter's colls, or the application of leeches may be of service in arresting further edema, as the li^'wX produced by sucii procedure is largely limited to the blood-vessel itself, while the condition to be relieved is entirely a perivascular one, and consists of a watery infiltration of the structures involved. Such procedure, then, would be of service only by toning up the vessel-walls, and in this way preventing further leakage, but would not affect tlie serum already poured into the perivascular tissue. In cases of sudden edema which commonly are attended by acute suppurative processes, it may be so sudden and rapid that the patient is in danger of sutibcation. In these instances intuba- tion or tracheotomy should be performed at once. Tracheotomy is preferable to laryngotomy only because the opening in the air- passages is at a point away from the inflammatory process. In edema of the larynx associated with syphilitic lesions, it must be remembered that the administration of potassium iodid, while not actually producing the condition, tends to complicate and aggra- vate it, and should be discontinued. Edema may occur along with either perichondritis or chon- dritis as a causative factor, and when the diagnosis is assured, the treatment should consist, early in the condition, in the applica- tion of the aqueous solution of ichthyol internally, and exter- nally an ointment of ichthyol and lanolin, in equal parts. Should the edema be threatening and require immediate relief, it will be necessary to resort to scarification and puncture. Involvement of the cartilage or pericartilaginous structures is seldom concurrent with simple acute inflammatory processes, but commonly with infectious diseases, especially typhoid fever. CHRONIC EDEMA OF THE LARYNX. This condition is generally due either to some local manifes- tation of a systemic condition, such as syphilis, tuberculosis, or malignant growths, or is brought about by systemic alterations. It may be the sequel of acute edema. The pathological alteration in the structure is one of hydropic degeneration and pressure- atrophy. The prognosis is bad as to cure, and the treatment con- sists in scarification, if due to tuberculosis, or syphilis, or systemic conditions such as cyanotic lesions ; if due to malignant growths, tracheotomy is usually imperative. MEMBRANOUS LARYNGITIS. Synonyms. — True croup ; Membranous crouj) ; Diphtheritic croup; Idiopathic membranous croup ; Pseudomembranous croup; Fibrinous croup ; Pseudomembranous laryngitis ; Fibrinous laryn- DISEASES OF THE LARYNX. 523 gitis ; Croupous larvugitis ; Laryngeal diphtheria ; Laryngotra- cheitis ; Cynanchea trachealis. Varieties of membranous laryngitis correspond with mem- branous varieties of inflammation of the mucous membrane as given under Pharynx and jSTose, — namely, croupous, fibrinoplastic, and diphtheritic. The following description pertains more to the croupous and fibrinoplastic, the diphtheritic being fully con- sidered under Diphtheria. This affection consists in a membranous inflammation involv- ing the laryngeal mucous membrane, especially the subglottic por- tion, in which there is poured out on the surface a croupous or membranous exudate, which is highly fibrinous, coagulable, and albuminoid. That bacteriological research in many of these cases shows the presence of the Klebs-Lofifler bacillus, either in its virulent or modified form, does not alter the clinical fact that frequently such inflammation does occur in which there are no signs of contagion or infection. Htiology. — Membranous inflammatory processes of the mucous membrane are dependent upon two conditions — first, the systemic state of the individual, especially as regards the chemical con- stituents of the blood ; and, second, an agent irritating the mucous membrane. Membranous inflammation may be brought about by corrosive chemicals, follow scalds or burns, thermocautery, wounds, and inhalation of irritating vapors, and may also be caused by the action of certain pathogenic bacteria, such as the Bacillus diph- therise and the Streptococcus pyogenes. In membranous croup the Klebs-L5ffler bacillus, in its true virulent form, is not a fac- tor from an etiological standpoint. The membranous variety of inflammation may occur at any season of the year. It is especially common in children from the first to the sixth year. It may, however, occur later in life, although rarely. On account of the greater exposure, the disease is more common in boys than in girls. It frequently occurs in children as a complication of the eruptive fevers, especially scarlet fever and measles, or may be secondary to a membranous inflammation of the tonsil or pharynx ; the majority of cases of membranous inflammation of the larynx, however, are truly diphtheritic. The fact that the bacillus of diphtheria is found ])resent in cases which show no contagious or infectious tendency rcifders the diagnosis between that and the so-called true diphtheria impossible, other than by simjily watching the case. There has been, and still is, a great variance of ojiinion as to the contagiousness and non-contagiousness of the membranous variety of inflammation. Unf|uesti()nal)ly, there are cases of true mem- branous laryngitis of" llic (Iliriuoiis variety which are in no sense contagious or infectious. There is in iiiaiiy eases very little local clinical difference l)etw('en this eonditiou and true di|)htheria. Even the symptoms, course, and terniiuatioii may be very much 524 DISEASES OF THE NOSE AND THROAT. the same pathologically ; however, in the true, simple, non-diph- theritic membranous variety the false membrane is on the sur- face of the mucous membrane, and when stripped off shows no evidence of necrotic change or ulceration ; while in the diphtheritic form there is ulccnition which perforates the basement membrane. In the true diphtheritic variety, however, the membranous exudate and acute inHammatory process are largely limited to the laryngeal structure. The given case of membranous inflammation may be ])urely laryngeal, which brings us back to the original question of diagnosis. \\^hile the local manifestations are practically the same, in true diphtheria the systemic infection is more marked and the clinical ])iienomena are much more pronounced. It is a safe plan in the beginning to treat every case of membranous inflammation as though it were both contagious and infectious, as it is much better to err on the safe side and isolate a case which is not con- tagious, and which in a few days, or, as often occurs, in from twenty-foiu' to forty-eight hours, will be perfectly well, than to fail to isolate a case of true diphtiieria. The prophylactic treatment and the treatment of the early stage will be practically the same. In true diphtheria the patient will not recover in twenty-four hours, with entire disa])pearance of the symptoms, nor even in three or four days. While it is always best to be on the safe side, prejudice should not carry us so far as to cause us to for- get the rights of our patients and the inconvenience to which they may be subjected by the strictness of quarantine. It may also happen that we have placed ourselves in the annoying position of finding our little patient perfectly Avell in two or three days, and yet the house will be quarantined for some two or three Aveeks by the city authorities if the diagnosis of true diphtheria has been too hastily reported. The majority of cases of so-called membranous laryngitis may be really laryngeal diphtheria ; yet there is such a thing as membranous laryngitis which is not di})htheria. Patholog'y. — The pathological alterations in the structure are those of an acute inflanniiatory process. Poured out on the surface, however, either uniformly or in patches, is the croupous or mem- branous exudate, which consists of fibrin, entangled in the meshes of which are leukocytes, blood-corpuscles, and desquamated epi- thelial cells. The false membrane may appear in any portion of the larynx ; it may be above the cords, involving the ventricular l)ands or the epiglottis, or may be below the vocal cords, really laryngotracheal. When stripped off the mucous membrane, it will leave a raw, reddened surface ; slight bleeding may occur, but not from ulceration — due merely to capillary hemorrhage. The severity and character of the inflammation, however, have largely to do with the extent of involvement of the deeper structure. The virulence of the bacterial agent in one person and the non- virulence in another can be explained by the varying physiological resistance DISEASES OF THE LARYNX. 525 of individuals, which also explains why a case of diphtheria may develop from an apparently harmless or mild sore throat, or the reverse condition. Syinptoms. — The symptoms of this dangerous disease are peculiar brazen cough, slight, stridulous breathing (both inspiratory and expiratory, as noticed in false croup), gradual alteration in voice, and peculiar hoarseness, with probably slight dyspnea. The fever comes on gradually. The attack of membranous laryngitis is usually preceded by slight cough or a catarrhal inflammation, with slight fever and very little alteration in voice. This may last from one to three or four days, with the disappearance of all symptoms, A slight membrane forms, with practically no con- stitutional symptoms, or the patient rapidly grows worse, and the symptoms become more pronounced. The cough assumes the peculiar harsh, ringing character, coupled with rapid change in the voice and difficult respiration. Later, there is high fever with marked systemic depression. The difficulty in respiration and the fever, however, will show marked exacerbations and remissions. There is excessive thirst, and the eliminative functions are per- verted ; the skin is dry and the bowels are constipated. This condition may last for several days. The child will be restless, the head thrown back, the respirations labored ; and the peculiar croupal sound never entirely disappears, although the patient at times is apparently much better. Frequently, portions of the membrane may be coughed up or vomited. There is very little difficulty in swallowing. The cough may cease altogether. Instead of dyspnea that is paroxysmal, it becomes continuous ; the skin is livid and loses its ordinary sensitiveness ; the extremities become cold, and unless relief is afforded at once, death is almost certain. Quite frequently, when the case continues for three or four days, it is aggravated and the prognosis made more grave by compli- cating attacks of bronchitis or pneumonia. In fact, in all cases of inflammatory processes of the upper respiratory tract in children, careful attention should be paid to the lungs. The use of the stethoscope may aid in locating the site of the membrane in the larynx, although its accuracy is by no means certain. The laryn- goscopical examination is difficult to carry out, but will show the presence of the membrane, the immoljility of the vocal cords, and the a]-)pni\'nt binding together of the arytenoid cartilages and the interarvtenoid space by the false membrane. Diagnosis. — Tlie conditicm is likely to be mistaken for false croup or sjxismodic laryngitis, acute laryngitis, edema of the larynx, diphtheria, retroj^liaryngeal or retrolaryngeal abscess, tonsillitis, capillary bronchitis, whooping cough, or foreign bo(li(>s in the throat or larynx. Edema of the Larynx {(Uoitix). — The dyspnea is of the same degree as in crouj), although more paroxysmal. The cough is 526 DISEASES OF THE NOSE AND THROAT. more smothered and not so harsli, nor is respiration noisy. The symptoms do not disappear during- the paroxysms of coughing ; in that respect it resembles croup. Slight, if any, stridulous breathing occurs ; there is more marked inspiration, with profuse expectoration. There is very little fever. The condition is more common in adults, and the edema is usually associated with other conditions. Laryngeal examination is not so difficult. Diphtheria. — The expectoration is about the same as in croup. The pharynx and fauces may be involved in the membranous formation. The cough is slight and paroxysmal. Difficulty in breathing varies ; sometimes the interference is marked, causing dyspnea. The voice is not so markedly altered as in croup, and is more nasal in character. There is always the accompanying pecul- iar characteristic odor, which, once noted, is not soon forgotten. Retropharyng-eal Abscess. — There is stridulous respiration, both inspiratory and expiratory, and the voice is altered. The expec- toration is slight and not membranous, but the cough is of a hacking variety. There is marked difficulty in swallowing, with external tenderness on pressure, and localization of the external swelling occurs. The dyspnea is marked, and may even be paroxysmal ; it is aggravated by swallowing, which is not the case in croup. The dyspnea is increased by pressure on the larynx, and is aggravated when assuming the horizontal position. This is not true in croup, although in membranous inflammation change of position will bring about paroxysms of dyspnea, on account of the shifting of the membrane. The alteration of voice in croup is one of tone, while in abscess-formation the patient is able to make sounds, but cannot articulate, and it is almost impossible to understand what is being said. There is tendency to edema, and it is difficult for the patient to open the mouth wide. Tonsillitis. — The breathing is not impaired, and examination will determine the nature of the disease. Capillary Bronchitis. — The dyspnea is marked but unremit- ting, and is associated with rales all over the lung. The cough is lof)se and the expectoration profuse. The voice is only slightly altered, if changed at all. Whooping- Cough. — There are paroxysms of coughing and dyspnea, followed by the distinctive whoop. There is practically no fever, and the voice is not husky unless irritation has been pro- duced by the violent coughing. Between attacks the child is per- fectly well. The deep cervical glands are enlarged. Foreign Body. — The presence of foreign bodies will give rise to stridulous breathing and violent spasmodic cough. There is no fever unless it is after inflammatory action takes place. The his- tory of the case will aid greatly. All symptoms will be altered as the foreign body changes its position. The stridulous breathing is more marked on expiration, as was pointed out by Gross. DISEASES OF THE LARYNX. 527 Progfnosis. — The prognosis in severe cases is very grave. The condition lasts from four to six days. Under all forms of treatment the mortality ranges from 60 to 80 per cent. Exten- sion of the process down into the trachea or bronchial tubes renders the prognosis more unfavorable. Treatment. — The nasal passages and the pharynx should be thoroughly cleansed Avith a spray of — I^. Hydrogenii peroxidi, Extracti hamamelidis fluidi, Aquae cinnamomi^ da fl.^j (30.). Besides the above given spray, the frequently repeated use of lime water is highly beneficial. The atmosphere of the room in the beginning of the disease should be charged with steam. The best way to accomplish this is to form a tent of any suitable material over the bed, leaving a large opening at the side, near the head, for ventilation, the steam being introduced by means of a tin pipe extending from the generator, which can be an ordinary kettle filled with water, to which may be added oil of eucalyptus, oil of tar, oil of white pine, from 15 to 30 drops each to the half-gallon of water. In the early stages cold externally to the throat, or the application of (U'ude petroleum, is highly beneficial. Several cases in which no other treatment was employed, the petroleum being used both internally and externally, were followed by highly beneficial results. This remedy is almost a household one in the oil regions. Emetics are indispensable, for they materially aid in the expulsion of the false membrane, and should be repeated if symptoms indicate. They may afford permanent aid and hasten the recovery. Of the many emetics employed, one of the safest and best is a teaspoonful of salt in lukewarm water. The internal medication — in fact, the whole treatment — is very much the same as that of diphtheria. Minute doses of calomel, given every one or two hours, and continued for even two or three days, are very useful. Should the bowels move too freely, they may be controlled by opiates, the dose and its continuation being controlled entirely by the symptoms indicating relief of the laryn- geal obstruction. To sustain the. patient stimulants should be administered, preferal)ly whiskey or brandy, and the child should be sponged frequently with whiskey and water or alcohol and water in equal ])arts. The general system should also be sup- ported by the ;i(hiiiiiistration of iron preparations, the best of which is tincture of llic clilorid, the dose graduated by the age of the child. A child from one to llircc years of age should be given from 3 to 10 (h'oj)s, well dihilcd in walci', v\oYy one to two hours. The small dose fre<(ueiitly rcjx'iitcd is hcltci-, on nccouut of large doses causing gastric disturbamc in cliildi-cn. 528 DISEASES OF THE NOSE ASD THROAT. Surgical Treatment. — Altlu)iii>;li the best possible treatment nmv l)e institiitetl early in the disease, it may fail to relieve the dyspnea whieh euntimies and threatens immediate snffoeation of the patient. If there is a gradnal increase of the stasis, as well as constant dyspnea, in spite of the continued and jndiciotis use of remedial au'cnts, and if the restlessness of the child increases, while there is an expression of suff'erinji; in his features, with lividity of the surface, prompt surgical interference must be instituted, and should consist in either intubation or tracheotouiy, the former offei'ing the iiigher percentage of cures. The two i)rocednres are considered under other and separate headings. HEMORRHAGIC LARYNGITIS. Synonym. — Hemorrhagic inflammation of the larynx. Laryngeal hemorrhage and hemorrhagic laryngitis represent entirely different conditions. Hemorrhage from the larynx may occur in syphilitic or tuberculous ulceration, in malignant disease, from wounds, from the presence of foreign bodies; or it may take place as the result of a sudden acute inflammatory process, or of lesion of the blood-vessel wall, or of sudden distention of the blood-vessel by an increased circulation. In the inflanmiatorv condition the hemorrhage is secondary to the inflammation. In the syphilitic or tuberculous ulceration, or in malignant disease, while it may be associated with the inflammatory process, yet the hemorrhage is a secondary condition, the result of necrosis. True hemorrhagic laryngitis is rare — /. (\, the condition in which there are areas of hemorrhagic infarction, due to rhexis of the vessel, and in which the inflammatory process is secondary to the hemor- rhage. There is a condition, however, described under Cyanotic Laryngitis, closely allied to chronic edema, in which from some constitutional or organic lesion, such as interstitial hej)atitis, val- vular disetise of the heart, fibroid lung, various forms of anemia, or contracting kidney, or any condition which interferes with the systemic circidation, the blood may be dammed back on the nnicous membrane, and by pressure and overdistention the vessel-wall may be thiimed and ruptured. This, however, is not a hemorrhagic laryngitis, but a laryngeal hemorrhage. Frequently, from violent use of the voice or of the' nniscles of the neck, as in violent cough- ing and vomiting, or even from violent exercise, the local hyper- emia may produce capillary hemorrhage with blood-stained secre- tion. This is especially true in plethoric individuals. Pathology. — Where the hemorrhage occurs into the tissue, due to the rupture of a vessel, there is a small area of hemorrhagic infarction. If this is in the submucosa and has snfficient collateral circulation, the extravasated blood will be absorbed and leave no permanent alteration. However, if it is sufficient to cut oif the DISEASES OF THE LARYNX. 529 blood-snpply partially and cause local necrcsis without infection, the inflammatory area surrounding the area of infarction having good nutrition, the space will be filled with connective-tissue cells or granulation-tissue, and through the processes of proliferation and vascularization forming ne^v tissue, give rise to slight scar-forma- tion. The same condition is found in the lung and in the kidney. The epithelial cells covering the area of infarction will desquamate. If the basement membrane is also intact, with re-establishment of circulation there will be re-formation of the epithelial layer. If, however, the area undergoing necrosis be of any considerable extent, at least sufficient to prevent the filling in of the epithelium from the sides, a scar will be the result. Symptoms. — The laryngeal irritation is only slight. There is a sensation of irritation in the throat, with a slight tendency to cough. The alteration in the voice, if the area of hemorrhage involve the vocal cords, will be marked. If the vocal cords or ventricular bands are not involved, there may be no alteration in the voice. The extent of the extravasation will determine the interference with breathing. If the hemorrhage is sufficient to obstruct breathing, it should be classed under hematoma and not considered as a simple hemorrhagic infarction, although the process differs only in degree. If the hemorrhage be on the surface, the saliva will be blood-tinged. If it is within the submucosa, con- stituting a true hemorrhagic infarction, there may be no evidence of blood in the secretion. Diagnosis. — In the differential diagnosis, inspection will de- termine as to whether the hemorrhage occurred within the naso- pharynx, the pharynx, or the tonsil, either pharyngeal, faucial, or lingual. When the hemorrhage occurs below the vocal bands, either within the larynx, trachea, or lung, the blood will be mixed with mucus ; however, when it is from the larynx, no evidence of rales in the lungs will be detected, and while the mucus may be blood-stained, it is not thoroughly mixed. Quite frequently the laryngoscope will determine the localized spot from which the hemorrhage has taken place. Prognosis. — The hemorrhage from the larynx is not alarming, and is rarely ever fatal ; in fact, laryngeal hemorrhage is rarely ever attended by pulmonary hemorrhage, unless associated with advanced puhiionary tuberculosis ; then the history and condition of the individual will determine the diagnosis and prognosis. Treatment will dejx'ud entirely u])on the cause. If the ex- travasation is sufficient to cause a hematoma, it should be incised and the clot excavated. The small hemorrhagic areas will undergo absorption or reorganization. If the hemorrhage is from the sur- face and is in quantity sufficient to cause alarm, cold ai)i)Hcations should be made to the; l)ack of the neck. There should be administered intei'nallv a grain of ergotiii t'veiy hour ibr 530 DISEASES OF THE NOSE AND THROAT. two or three doses, or until the physiological effect is produced. To allay the tendency to cout>h and to clearing the throat, y^^ to '\ grain of codein should be administered every three hours. When the cause of hemorrhage is determined, whether it be local or constitutional, the patient should be instructed in the amount of exercise compatible with his condition. The intralaryngeal appli- cation of astringents is of questionable benefit, as the spasm and irritation produced by the introduction of the applicator into the larynx are likely to cause local congestion and aggravate the very condition it is aimed to relieve. If the solution can be applied by means of a laryngeal atomizer, beneficial results may be obtained ; but, as a rule, very little of the solution goes into the larynx when applied in this manner. Of the astringents, alum, grs. v-x, and tannic acid, grs. iij-vj to the ounce, will give the best results. Careful attention must be given to the systemic condition, and any vascular, organic, or intestinal irregularities corrected. CHONDRITIS AND PERICHONDRITIS. Chondritis of the larynx, or inflammation of any of the car- tilages of the larynx, is so closely allied, both from an etiological and symptomatical standpoint, to perichondritis that each will be considered under the same heading. Ktiology. — Traumatism, such as blows (direct or indirect), gunshot wounds, stab wounds, choking or grasping of the throat, often produces an inflammation of the cartilage or its perichon- drium. Either by infected emboli or through the raucous mem- brane, septic or specific micro-organisms gain access to the peri- chondrium and produce perichondritis. Foreign bodies, too, finding lodgement in the esophagus and causing wounds, may produce a perichondritis or chondritis in the larynx by perforating or irritating the posterior portion of that structure. Rheumatism or gout may play the role of etiological factor, and produce a peri- chondritis which, while occurring at any age, is most often seen in adult or middle life, and is but one of the group of symptoms which go to make up the disease. Any of the specific inflammations, especially syphilis, tubercu- losis, actinomycosis, and glanders, may bear causal relations to the condition. By direct involvement or by pyemic metastasis peri- chondritis or chondritis may occur in small-pox, diphtheria, and ty[)hoid fever. To the last cause such a large proportion of cases is attributable that much of value has been Avritten concerning it. Tumors, either malignant or benign, within the larynx or situ- ated immediately surrounding it, may produce this condition. A number of observers have assigned as a cause of perichondritis pressure of the plates of the cricoid against the vertebra in aged people, or in those whom illness and weakness compel to lie con- DISEASES OF THE LARYNX. 531 stantly in bed. The generally bad nutrition, combined with the local pressure and irritation from the bolus of food as it passes into the esophagus, produces, so to speak, a laryngeal bed-sore. Exposure to damp or cold, sudden chilling of the body, oyeruse of an inflamed larynx in talking or singing, may cause a painful inflammatory inyolvement of any or all of the cartilages of the larynx or their perichondrium. Pathology. — Syphilis. — The pathological alterations occur- ring in syphilitic chondritis or perichondritis in the larynx do not differ from those seen in other cartilages. The mucous patch sometimes occurs in the larynx, coming on in the same manner as similar lesions in the mouth. Deep ulceration is an evidence of tertiary inyolvement, and is usually seen from three to five years after the primary infection, although it may occur much later in life. In syphilitic gumma of the larynx there is first noticed beneath an unbroken mucous membrane a grayish-yellow nodular projection, which gradually undergoes ulcerative changes, modified, as are all superficial inflammations, by the condition of the sur- rounding structure. Infiltration into the submucosa may now come on, or may have preceded this stage and produced a sudden and alarming edema. Hemorrhage too occurs, which may emanate from any spot in the larynx that has been the seat of ulceration, from the epiglottis to low down in the trachea. When these ulcerative areas begin to heal of themselves or under appropriate treatment, there is left a peculiar stellate cicatrix, which on con- tracting causes stenosis and brings about an alteration in the voice, not only from the mere amount of structure inx'olved, but also by displacement of the cartilaginous structure. Adhesion of the vocal cords or ventricular bands may occur. Tuberculosis. — Involvement of the larynx by tuberculosis may develop primarily by localization of the nodule, or may ex- tend by way of the soft tissues from some surrounding infected area. There is usually a great deal of edema in tubercular peri- chondritis, which impedes the motion of the larynx and causes marked alteration in the voice. In the early stage there is but little ulceration ; but as the disease increases in intensity, the edema grows less, and an ulceration of a shaggy gray color begins to slough its way around the larynx, generally connncncing from behind and working toward the front. Even after the ulceration occurs, there usually remains a certain amouut of edema that is apt to be permanent. The secretions are tenacious and adherent. Later still, necrotic or gangrenous clianges may involve the carti- lage by their interference with the circulation. Fungous growths, the so-called tuberculous granulomata or papillonintn, may be seen springing from the edge of the ulcerated area. Typhoid Fever. — ('ommcncing with hypcrcinia ami congestion, there rapidly follows an inflammatory edema, with exudation into 532 DISEASES OF THE NOSE AND THROAT. the .surrouiKliug; or adjacent soft structure, wJiich, on account of the location and the limit set by the cartilaginous wall of the larynx, must extend inward, and rapidly lessens the lumen of the larynx. This edematous stage and the stage of ulceration which has gone on to necrotic involvement of the cartilages differ only in degree, but not in kind. The cartilages of the larynx are at best poorly supplied with blood, rendering them at all times susceptible to necrotic change. When during the course of typhoid fever the nutrition is lowered throughout the body, circulation in this locality suffers to a greater extent, as it is de})endent on surrounding tissue for its blood-supply, and rapidly undergoes necrosis, which may slough out in small portions or be discharged en masse. This breaking down of tissue, as in abscess-formation, may penetrate toward the point of least resistance, rupture, and virtually form an ulcer. In the majority of instances of perichondritis or chondritis due to typhoid fever I believe that the infection and inflammatory process are similar to those seen in abscess-formation, ^vhich, making for the point of least resistance, open in ulceration on the mucous surface. The typhoid bacillus is usually found jiresent in the necrotic mass. The ulceration is commonly situated posteriorly, and the cartilaginous involvement is on the side and tow^ard the back part of the larynx. By reason of the character of the blood- vessel topography, thrombosis is most likely to take place in this posterolateral area, with the added weight of the decubital posi- tion, as has been explained before. If only a part of the cartilage has been destroyed, and the perichondrium remains, there may be a reproduction of the cartilage, which has practically taken place in a case now under my observation. In any event, it is likely that the abscess will be followed by a fistula, and it is always to be remem- bered that suppuration icithoid necrosis of the cartilage — which is nothing more than abscess-formation — may occur, though it is an exceedingly rare condition. Traumatism ; Rheumatism. — In chondritis and perichondritis due to these causes, the exudation and swelling may go on to absorption and resolution. A similar result may be noticed in typhoid fever, though in this disease, as in syphilis and tuber- culosis, there is nearly always sup])uration, with necrosis of the affected cartilage. This is especially true of the cricoid and the arytenoid involvement. In this latter group a purulent exudate may exist for montiis or years until all the necrosed tissue has been exfoliated. However, prompt treatment and thorough removal of all diseased structure are usually demanded by the severity of the symptoms long before nature has removed it. In all of the varieties the process ordinarily begins about the cartilage as a perichondritis, the cartilaginous involvement being secondary. Order of Involvement of Cartilag-e. — The cricoid cartilage is usually involved to greater extent and ofteuer than any of the DISEASES OF THE LARYNX. 533 others. Its inner surface is, as a rule, implicated by marked tumefaction. The arytenoid cartilage is next in order, usually unilateral, and, like the cricoid, implicates both the air- and the food-tracts. Necrosis will generally occur much earlier in the arytenoid than in the cricoid. Either surface of the thyroid carti- lage may be involved, the outer or inner, one or both wings, but commonly it is unilateral with an internal involvement. As the thyroid cartilage has a better blood-supply than either the cricoid or arytenoid, extensive necrosis is not so likely to occur when it is a part of a general involvement. The epiglottis is seldom involved primarily, but may be, by extension from the adjacent cartilaginous structure. The tracheal rings, too, may become involved. After any implication that has gone on to necrosis, the tissue may organ- ize from the surrounding healthy structure, and give rise to a caving in of the necrotic area, with subsequent scar-tissue. Symptoms. — The symptoms of chondritis and perichondritis are almost identical, and the diagnosis between the two is of little import, as in either case treatment is practically the same, both demanding constant attention and being controlled to a great extent by the symptoms as they arise. Syphilis and Tuberculosis. — The symj)toms occurring in peri- chondritis or chondritis due to either of these causes are to a great extent the same. They resemble those seen in chronic laryngitis, except that there is more pain in the tubercular variety, which increases as the ulceration goes on. The previous history of the case is to be carefully determined in order to differentiate the actual underlying cause. In both syphilitic and tuberculous cases there is usually a slight rise of temperature. The edema in the tuberculous instances may be so alarming as to produce symptoms in the respiratory tract of such moment as to necessitate immedi- ate tracheotomy. Deglutition too is very painful, due to the fact that the posterior part of the larynx is usually involved. Later on there may be partial or complete aphonia due to the loss of the cartilaginous framework. Spontaneous rupture, if it occurs, takes place into the larynx or, possibly, into the pharynx. If the epi- glottis is involved — an exceedingly rare complication — it only adds to the gravity of the case by the extent of involvement. In syphilis there is sometimes a peculiar odor from the secretions, suggestive of their specific origin. There is marked pain in both varieties, increased on swallowing. Typhoid Fever. — When cliondritis or perichondritis occurs as a complication of typhoid fever, attention may not be directed to the larynx on account of the apathy of the patient, so tliat it may be several days l)efore it is recognized. Hoarseness is quite a com- mon complication of typhoid fever, with sliglit dys]>hagia. These may persist well along in convalescence, and suddenly, from a slight cold or exjjosure, swallowing becomes more painful, and the 534 DISEASES OF THE NOSE AND THROAT. hoarseness increases. The onset from now on is very apt to be rapid, and in a few hours marked difficulty in breathing and suffocative attacks may supervene. Laryngeal stenosis sets in, with stridor, inspiratory depressions of the neck and chest-walls, and rapid respiration that is labored and exhausting. The auxili- ary muscles of respiration are called into use ; owing to the lim- ited lung-expansion occasioned by the quick, short respiration, mucus accumulates and the respirations become noisy. Dyspnea becomes marked, and nourishment can be taken only with diffi- culty. The expectoration is not greatly increased. Attacks of suffocation come closer together, and are more terrible. The face becomes livid, and there is the unrest of despair. Trache- otomy may now have to be done to prevent suffocation. The symptoms may subside before reaching such a point, although with each recurring attack they become more alarming. Occasionally, discharge of pus and necrosed cartilage, from the breaking down of the affected area, may give relief to the patient. There is like- lihood, however, of recurrence, or even of a permanent fistula. One case was seen in my office in which there had been necrosis of the first tracheal ring on the right as a sequel to typhoid fever; the swelling was pronoimced, both externally and internally. The tissue had broken down, and there was discharged a portion of the cartilage. After the discharge of the necrosed cartilage the patient made an uninterrupted recovery. The temperature is not usually as high as in acute abscess, although there is considerable fever. The condition drags along for days and weeks. Cases of suffocation, as shown by Keen, are those in which the marked dyspnea and suffocating attacks occurred early or from the acute infiammatory swelling. If the perichondritis be due either to the Bacillus typhosus or to pus-organisms, there will inevitably result necrotic changes, with complete or partial destruction of the car- tilage. The symptoms are most intense and severe, and the danger of suff(wation from edema is most marked in the earlier stage, when it is limited to the perichondrium, and the obstruction is due to the edematous swelling. The acute stage is soon com- pleted. The symptoms are less marked in the chronic stage, being modifications for the better of the symptoms of the primary or acute condition. There is, however, as a rule, a typhoid state or condition of weakness not the result of the chondritis, but of the fever. Emphysema of the tissues of the neck may occur, dne to a perforating ulcer in the posterior wall of the larynx. The suppuration may extend down into the mediastina. Both of these complications are rare, but of exceedingly serious import, and it is to be noted that all of these laryngeal implications' arc more common in adults than in children, and may involve any or all of the cartilages of the larynx. Necrosis of the cartilage is common and extremely dangerous, the mortality running as high as 95 per DISEASES OF THE LARYNX. 535 cent, of the cases involved. Keen has shown in his Toner Lectures and in his Surgical Complications and Sequels of Typhoid Fever that the fatal cases usually have edema of the lung. Laryngo- scopical examination will reveal that in the majority of cases the broad posterior plate of the cricoid cartilage is affected. Be the perichondritis wdiere it may, its site will show as an irregularly nodular and unilateral inflammatory swelling distinctly outlined. Sometimes ulcers may be seen on the posterior laryngeal wall or on the vocal cords. The area involved, covered with a mucous membrane red, boggy, and edematous, may bulge out and encroach upon the subglottic space or press on the vocal cords, or may be located posteriorly. The vocal cords, epiglottis — in fact, all the surrounding tissue — may be markedly swollen and congested. If the perichondrium of the thyroid cartilage be inflamed on its inner surface, it will present a smooth, red swelling around and involving the ventricular bands. If the entire perichondrium be involved, the swelling will be external also, and there will be a localized point of tenderness. Muscle-paralysis may result from this inflammatory process, more commonly seen in men than in women. A rapid rise of temperature may, in the course of an otherwise uneventful convalescence from typhoid fever, be accom- panied by pain in the larynx, besides dysphagia, if the involve- ment be posterior, not so marked if it be anterior. In addition to these symptoms, dyspnea that is inspiratory and aphonia that may vary from complete to any degree of partial loss of voice, with a tendency to choking attacks or suffocation later on, point toward the diagnosis of perichondritis or chondritis following typhoid fever. Rheumatism, Traumatism, Exposure to Cold, etc. — The earlier symptoms of perichondritis or chrondritis due to any of these causes are not very characteristic, but there is usually some hoarseness, with pain localized to an individual point or area, especially developed by movement or pressure externally. Again, efforts at swallowing or talking will cause a varying amount of discomfort or pain in the larynx. The voice may later become hoarse, and a cough may develop. Dysphagia and, later, dyspnea, with perhaps stridor or suffocative attacks that are paroxysmal, will develop, and finally stenosis may occur. When the abscess is evacniated, citlier artificially or unaided, pus and the product of the inflammatory degeneration are expectorated and the symptoms ameliorated. Cricoid Cartilage. — If the cricoid cartilage be the seat of involvement, the posterior surface is most likely to be inlected, owing to its exposure to friction. Jlere the inflammatory process usually proceeds from the u))per articuhir surface toward the ary- tenoid cartilage, so that, if the couditiou he liir advanced, the arytenoids are usually involved, the swelling in\(>l\ing an area 536 DISEASES OF THE NOSE AND THROAT. similar to perichondritis of the arytenoid cartilage. It is most typical when seen beneath the true vocal cord, where it shows as folds or convolutions. Dyspnea that is both expiratory and inspiratory occurs, with marked dysphagia and loss of voice in all cases, either permanent or temporary, which may be due to direct involvement of the cords, to watery infiltration, or to involvement of the cartilage or muscle. Cough of varying character is nearly always present. Arytenoid Cartilag-e. — Perichondritis of this locality is very common ; the swelling is seen over the cuneiform cartilage, with an abnormality of movement and a delay in the action of the vocal cords. The swelling internally resembles closely a cold abscess, and may extend beyond the true vocal cords. If the crico-aryte- noid joint is involved, ankylosis or necrosis may result, with a change in the voice that amounts to permanent alteration, or loss in the severer cases. Thyroid Cartilag-e. — If the involvement be external, the swelling of the alae can be felt and seen. Both within and with- out the larynx, pain is localized. There may be an inward bulging between the vocal cords in the anterior angle. The voice is markedly altered, respiration and deglutition are interfered with, and such symptoms as edema, dyspnea, and dysphagia vary pro- portionally with the extent of involvement. If the entire thyroid cartilage be involved, the termination is usually fatal. Perichondritis of the smaller cartilages cannot be recognized clinically. It is to be noted that ossification of the cartilages of the larynx occurs, as a rule, as old age approaches. This is not a pathological process. The only significance is that inflammation in these localities is less likely to occur than before. Fibrous degeneration in the cartilage is an extremely rare condition, and ^vhile possil)le, no well-authenticated cases have been reported. Diagnosis. — Syphilitic Perichondritis. — In making the diagnosis in syphilitic perichondritis, the previous history of the case is to be carefully searched for any specific manifestation, going back a decade of years, if necessary, in the search. Syphilitic manifestations elsewhere in the body are to be carefully looked for. The lungs are to be diligently examined, and absence of lung- involvement points rather toward the diagnosis of syphilis than tuberculosis, as a tubercular condition of the larynx is rarely ever primary. There is more likely to be external swelling in syphilis than in tuberculosis. There is a tendency to heal in syphilitic in- volvement that is not seen in tuberculosis and carcinomata. The ulceration of tuberculosis is more extensive and has a rather worm- eaten a]ipearance, which is not the case in syphilis. Secretions are fairly profuse in syphilis, and there is a marked odor. Tuberculosis. — Early in tubercidar involvement the mucous DISEASES OF THE LARYNX. 537 membrane is pale, and peculiar, circumscribed, nodular areas of tumefaction are noticed, especially about the supra-arytenoid ex- tremity of the aryepiglottic fold. These points of involvement are frequently most marked posteriorly. They may or may not be found on the same side as the affected lung. The history of the individual case, of his correlatives, and of his progenitors is to be carefully obtained, with a view to establishing an inherited pre- disposition toward tubercular infection. The sputum should be examined for the presence of the tubercle bacilli. The edema of tuberculous perichondritis is more apt to be chronic than that occurring in syphilis. When ulceration occurs, it is of an irregu- lar shaggy appearance, covered with greenish tenacious pus, sur- rounded with papillomatous proliferation. This ulceration usually extends from below upward, while the ulceration of syphilis extends from above downward. Typhoid Fever. — The diagnosis of the perichondritis or chon- dritis following typhoid fever involves, as a rule, no difficulty as to causation, and the symptoms of the condition, already given, will render it plain. Rheumatism, Traumatism, Exposure to Cold, etc. — In peri- chondritis or chondritis due to rheumatism or gout it is rare to find an entire absence of manifestations in other parts of the body. The urinary examination will do much toward establishing a diag- nosis in doubtful cases. The history of the case, showing that some time previous the external tissues of the throat have been roughly handled or injured, or harm has been done internally to the structure, will make clear the cause of the condition under the head of Traumatism. The laryngeal pictures of all of the conditions due to this group of causes is so similar that the history of the case alone will decide to wliieli subdivision it properly belongs. Prognosis. — Tuberculosis. — The outlook for tubercular peri- chondritis is bad, although the disease may persist for a number of years. If the larynx is seriously involved, cure is not possible. All cases of pulmonary tuberculosis are not complicated with laryn- geal tuberculosis, though, when associated, the throat-condition may appai'cntly come and go. Tiie outlook for syphilitic perichondritis, while not favorable, is Ix'tter than for the tubercular variety, and de]K'nds largely on the length of tiuie that the conpro]>riate medi- cation is administered. Following typhoid fever, the outlook for ])(Tichonfreshing to the affected parts and to the economy at large should be gained by regular hours for sleep in a properly ventilated and quiet bed-chamber. The digestive tract should be most carefully watched over, as upon the proper dis- charge of this function hangs any hope for ultimate success in medicinal treatment. Cod-liver oil in the winter, with the hypo- phosphites or lactophosphate of lime in the summer, malt prepara- tions, quiuin and iron, should be given freely. The internal administration of the carbonate of guaiacol, in 3-grain doses every three hours, is one of the best internal medicaments. If the con- dition is far advanced, treatment will be of no avail. Syphilis. — The treatment of syphilitic perichondritis or chondritis follows along the .same line as fully laid down on pages 131 and 560. The iodids should be pushed to the point of full tolerance, and if not well sustained, or causing an excessive flow of secretion, mercury should be substituted, and administered to the point of physiological tolerance. Failing with either of the.se drugs alone, they should be administered conjointly, rein- forced by the giving of such tonics as iron, ar.senic, quinin, and strychnin. The possibility of sudden closure of the glottis due either to spasm or to edematous enlargement should always be borne in mind, and tracheotomy well below the seat of infection, or intubation if the involvement be high up, should be resorted to promj)tly. Typhoid Fever. — Scarification, in addition to puncture, inter- nal and external, may be resorted to early in this affection. In simple edema, intubation may be successfully performed ; but it offers little hope if the perichondritis has gone on to suppuration, with necrosis of the cartilage. The moment perichondritis is recognized and suffocative attacks occur, tracheotomy should be performed early, before the patient becomes exhausted. The dis- eased area can l)e better explored and medication more intelligently administered after the tracheotomy. Strictures caused by scar- tis.sue after necrosis may necessitate the wearing of a tube. Dilata- tion with bougie and wearing of special cannula are wearisome, and give only questionable results. External application of ich- thyol and lanolin, in equal parts, is highly beneficial in reducing the swelling by absorption. DISEASES OF THE LARYNX. 539 Traumatism, Rheumatism, Exposure to Cold, Etc. — In the early stages of perichondritis due to any of these conditions, ice externally, the cold pack, and ice to hold in the mouth until it is melted, should be given. Failing in this way to promote resolu- tion, incision should be made into the involved area, from within or without, to afford proper drainage. Absorbents externally should be applied. Any underlying systemic pathological condi- tion, as in rheumatism, should be combated by the proper internal medication. SIMPLE CHRONIC LARYNGITIS. Synonym. — Chronic catarrh of the larynx. Definition. — A chronic inflammatory process involving the superficial or deep structures of the larynx, causing structural alteration. The variety usually described as subacute is the begin- ning of the chronic inflammatory process, and only differs in that the structural alteration is not so marked if the lesion is arrested in that stage. It is characterized by hoarseness or loss of voice, and may lead to ulceration. etiology. — Simple chronic laryngitis may be associated with or a result of repeated attacks of catarrhal inflammation of the mucous membrane, either of the larynx or of the continuous struct- ures above. When associated with inflammatory lesions of the upper respiratory tract, the existing inflammation in the larynx may be due to the s])reading of the inflammatory process by con- tinuity of structure ; but it is most likely to be due to the fact that the cause which produces the lesion above is responsible for the laryngeal inflammation. In catarrhal inflammations where the secretions accumulate about the larynx and in the esophagus, and by their irritating action may set up inflammatory processes, the condition is further aggravated by the constant effort on the part of the patient to clear his throat. Inflammatory conditions of the esophagus, spreading by contiguity of structure, may be the cause of the chronic laryngitis. Quite frequently, laryngitis exists as the result of e])idemic influenza, ordinarily known as la grippe, where, during the attack, the laryngeal mucous membrane becomes infiltrated with intlanimatory material which seems to differ from tlio ordinary inflammatory exudate, and has a marked tendency to remain jH-rinanent. Constant and continued exposure to air satu- rated with irritating gases or fumes will, by their irritating action, keep up a catarrhal condition and cause chronic inflammation. Systemic conditions with altered circulation are also predis])osing causes. In individuals in whom nasal obstruction exists, the forced mouth-brcatliing and direct inhalation of dust or of air not pro])erly moistened, as well as the constant irritation, will produce a continued inflammation of the larvnx, bringing about chronic; lesion 540 DISEASES OF THE NOSE AND THROAT. ^vith permanent alteration in structure. Excessive and incorrect use of the voice is also an exciting factor. This is especially noted in orators, open-air singers or speakers, and revivalists — who are most susceptil)le to this form of laryngitis. A number of patho- logical alterations may he produced in the larynx from continued or extreme use of the voice. Following the forced anemia of the laryngeal structures, owing to the muscular action during speak- ing, there is, when the parts are at rest, a reactionary engorgement. This repeated often day and night will bring about permanent dilatation of the vessels, with paresis or partial paralysis of the vasomotor nerves ; or from the violent efforts in speaking and the weakening effect of the rapid vascular changes on the l)]ood-ves- sels, there may take place minute hemorrhages in the submucosa, bringing about really a hemorrhagic laryngitis and, quite fre- quently, permanent structural alteration. In a number of cases this will explain the loss of voice where the hemorrhagic area, from its involvement of peripheral terminal-nerve filaments, with the alteration in structure from organization, interferes with the action of the cords and causes incomplete phonation. Intestinal lesions, especially chronic constipation, through their effects on cir- culation, are also important factors. The irritation and overstimulation, as seen in tobacco-users and alcoholics, are also important etiological factors. The same is true of irregularities in the pharynx, such as an elongated uvula or enlarged faucial or lingual tonsils. I think this is especially true of the lingual and fiiucial tonsils. Atmospheric conditions in themselves are not important factors, but when there are asso- ciated lesions, atmospheric changes are important as causal factors. The occupation of the individual must also be taken into con- sideration, although that strictly comes under inflammations brought about by mechanical irritants. The alteration in the voice from maldevelopment of the larynx, or irregularities in the formation or development of the organs of phonation, must not be confused with chronic laryngitis. The correction of such irregularities really comes under a separate specialty — that of defects of speech. It might he well to add a few words re- garding the effect of impairment of speech on the mental development of cliildren. Many children are allowed to grow up neglected, being impressed with the fact that they are dull and not of the same mental caliber as their playmates, simply because they cannot talk as ^vell as other children, and many of them are allowed to go through life with a blunted mental capacity, whereas if the defect of s])eech had been corrected early in life, such mental deficiency would have been averted. Pathology. — The pathological alteration varies largely as to cause. Where irritation is continued, and the slow inflammatory process permits of proliferation of the inflammatory exudate and DISEASES OF THE LARYNX. 541 fixed connective-tissue cells, giving permanent increase in the con- nective-tissue elements of the submucosa ; or the thickening of tissue may also be due to engorged blood-vessels causing perma- nent dilatation and secondary change from pressure in the perivas- cular tissue ; in either case the epithelial layer of the mucous membrane, which is dependent upon the submucosa for its nutri- tion, will be affected. This inflammatory process may be limited to the laryngeal mucous membrane or may involve the deeper muscular structure. In cases in which the deeper structure is involved, the symptoms are more marked, and the tendency to permanent pathological alteration is increased. Where involve- ment of the cartilage and muscles — in fact, any of the deeper struct- ures — takes place, the alteration in the voice is more pronounced. Permanent thickening of the mucous membrane involving the ventricular bands will also alter the true cords, if not by inflam- matory process, certainly by the altered circulation and involve- ment of the intrinsic muscles. There is in some cases a slight increase in the lymphoid structure of the larynx. Where the con- nective tissue is markedly increased from the inflammatory change, permanent alteration in the tone and character of the voice will take place. This may be due to contraction of the organized inflammatory tissue, with its direct effect on the muscles and car- tilages involved in phonation, preventing the perfect approxima- tion of the cords. In cases where contraction does not occur, the thickening in the connective-tissue element, involving as it does the base of the cords, renders that structure more highly vascular, showing the tortuous vessels on the surface and causing perma- nent alteration in the character of the voice. Symptoms. — The symptoms of chronic laryngitis are marked, objectively and subjectively, on attempted use of the voice. The voice is irregular and jerky, and the individual complains of throat-ache and muscle-tire. When the voice is at rest, there is very little to call the patient's attention to his laryngeal condition. There may be a slight sensation of dryness or irritation. In the mornings and after meals the secretions are profuse, exciting sufficient irritation to cause constant hawking or cough. On attempting to use the voice a tickling sensation is created in the larynx, which interferes with phonation through the necessary coughing. Quite often the individual may be able to pronounce a few words — in fact, sentences — when the voice will suddenly disappear, only to return as suddenly. Fre- quently the patient complains of a peculiar raspy feeling, and, as he will often express it, as if something was tearing loose in his throat. The effect on the voice, however, differs in indi- viduals. Frequently it is very husky at first, but after using for a few minutes the tone clears U|). This is due to the fact that the muscular action brings about forced anemia of the 542 DISEASES OF THE ^^OSE AND THROAT. parts, fillowinti: five action of the cords. The condition, however, is only temporary, and when the parts are relaxed, reactionary congcf^tion ra])idly takes place, with complete loss of voice. If the laryngeal inflammation is uncomplicated, the secretions are usually not so copious, though very tenacious, and the color varies from a frothy-^vhite to a yellowish-gray or even yellowish ])us-like secretion. Occasionally the secretion is slightly blood- stained, either due to capillary hemorrhage following excessive use of the voice, or possibly to capillary hemorrhage from the vio- lent ])aroxysmal coughing. Inspection of the membrane shows a peculiar reddish, boggy, or edematous appearance. Blood-vessels mav be distinctly outlined on the epiglottis or even within the larynx. The tissue at the base of the cords and within the ven- tricular bands will be injected and swollen (Fig, 152). Most frequently the inflammation is situated in these structures, and the vocal cords are involved secondarily. Normally the vocal bands receive their blood-supply by osmosis, and it is only during hyperemia or congestion that vascularization of the cords shows distinctly. The inflammatory process may be limited to one side, or may involve both cords or the entire larynx. As a rule, the posterior part shows the most inflammatory proc- ess. The appearance, as observed by inspection, of course varies in individuals, and is also controlled by the severity of the case and the stage of the inflammatory process. Alteration in the vocal cord is influenced more by the inflammation of the sur- rounding tissue than by the actual cord-structure. This tissue may be permanently thickened, and while affecting the cords also affects the supporting structures, which interferes with the mech- anism of vocalization and phonation. Thickening of the inter- arytenoid folds may also take place, and interfere with the approx- imation of the arytenoid cartilages, causing irregular action of the cords, and thereby affecting the voice. Any irregularity, either in the cord or surrounding structure, which prevents approximation, necessarily causes irregular action, throwing more stress upon one than the other, and producing permanent alteration. Superficial ulceration may take place, or, more likely, localized spots of desquamation may appear. This is most com- monly noted between the arytenoid cartilages. The ulceration, however, may involve deeper structures, followed by organized granulation-tissue or trachoma. It is a noticeable fact that in singers or speakers reactionary congestion does not always pro- duce hoarseness. Diagnosis. — Simple chronic laryngitis may be confounded Avith edema, paralysis, malignant growths, tuberculosis, and syphilis. Edema, — The swelling is more marked and comes on rapidly. There is very little difference in the color, although the tissue is DISEASES OF THE LARYNX. 643 more water-soaked. It runs a rapid course, and is accompanied by dyspnea. Paralysis. — There is very little, if any, swelling. There is present the peculiar characteristic odor from retained secretion. The hoarseness is always the same. Absence of motility of the larynx is a feature. Chronic Laryngitis. — The hoarseness varies, and is worse in the morning and after meals. The voice constantly changes in character, being irregular and jerky. There is absence of motility of the larynx, although it is not so marked as in paralysis. The forced use of the voice may clear it for a time, but afterward the symptoms all return, usually each time with increased severity — not true in paralysis, edema, syphilis, or tuberculosis. The history in any case is an important factor. Tubercular Laryngitis. — The general condition and history of the patient are of great importance. The existence of associated tubercular lesions, especially of the lung, should be carefully sought for, and examination of the sputum will go far toward establishing a diagnosis. The temperature of tubercular laryn- gitis is apt to follow the general type of phthisis. There is also an irregularity in pulse, with night-sweats and a constant pain in the throat, increased on swallowing. This last fact is not true in chronic laryngitis. In tubercular laryngitis the mucous meinbrane is pale, ragged and shaggy in appearance, especially if ulceration has set in. In the pre-ulcerative stage there exists a catarrhal con- dition in which there is practically no discoloration, but rather a nodular appearance ; but if the membrane be reddened, it is unevenly so. Tubercular conditions usually involve the deeper structures, and ulcerate ; they are usually located posteriorly, and extend thence around the larynx, following the line of the circulation and lymphatics — a fact not observed in simple laryngitis. The swell- ing is most marked in tuberculous conditions beyond the area of infection. Ulceration and erosion are not common in simple lar- yngitis, while in the tubercular variety it is almost characteristic. There is little tendency to heal in tubercular lesions, and hence no scar-i"orniation. Syphilitic Laryngitis. — As in the other conditions, tlie history is of great importance. The "therapeutic test" will often render the diagnosis clear in the early stages of the condition. Healing occurs with scar-foruiation of a peculiar stellate apj^earancc, and is usually high up in the larynx. The cdcana is not localized in syphilitic laryngitis, but is more general in eliarnclcr and causes dyspnea. In the tertiary stage tliere may bo tendency to localiza- tion, due to syphilitic chondritis or jieriehondritis. Malignant Disease. — The age and history are important. The glandular involvement takes place late in laryngeal carcinoma. There is very little edema until the ease has progressed beyond 544 DISEASES OF THE NOSE AND THROAT. the staii'c in which diagno.sis would be difficult. There is early alteration in the voice. There is always associated some catarrhal condition. Gradually, as the growth increases, the swelling and edema begin and ulceration takes place ; the odor is characteristic, and resembles that noted in paralysis. With the ulceration, hemor- rhage of an alarming nature takes place. The pain is pronounced, reflected, and sharj). Prognosis. — If seen early and before much structural alteration, with j)r(iper treatment many cases can be cured ; but if the structural alteration has taken place, permanent restoration of the voice can- not be accomplished. While the inflammatory symptoms may be entirely relieved, the voice cannot be restored to its proper quality. Treatment. — In all catarrhal conditions of the nose, naso- pharynx, and pharynx, with the constant accumulation and the irritation produced by such accumulation, there must necessarily be produced continued irritation of the laryngeal structure. Repeated and thorough cleansing of such affected parts should be strictly enforced. For its cleansing and detergent effect, bicarbonate of potassium and bicarbonate of sodium, of each 10 to 15 grains to the ounce of warm water, three or four times daily, as a douche or by means of a spray, should be used. For the treatment of the catarrhal condition after cleansing, there should be applied directly to the structures a mild astringent. For this purpose a solution of sulphate of copper or nitrate of sil- ver, 5 to 10 grains to the ounce, or, better, 3 per cent, chlorid of zinc may be employed, and intralaryngeal applications made. When applied by means of cotton or sponge, care should be taken that no excess of the solution be used, as the pressure employed in the application may cause the solution to run over healthy structures and down into the trachea. An instrument suitable for intra- laryngeal applications is shown in Fig. 156. Equally good results Fiij. l:>'i.— Cohen's laryngeal cotton forceps, three curves. will be obtained by the application, by means of a spray, of a 3 per cent, solution of alumnol ; although a comparatively new^ drug, I have found it highly beneficial in such conditions. The employ- ment of astringents is often overdone, and applications should not be made oftener than every other day. Besides the correction of any nasal irregularities, attention must be given to the individual's personal habits as regards the use of DISEASES OF THE LARYNX. 545 tobacco and alcohol. As climate and occnpation may have to do with the case as etiological factors, temporary or possibly perma- nent change from such exposure should be insisted upon. It must be remembered that the condition may be dependent upon or aggravated by gastro-intestinal, hepatic, and even renal lesions. In such cases treatment should be directed toward the offending organ. If the general health is at fault, constitutional treatment should be instituted. Of the therapeutic agents administered for the direct effect on the mucous membrane, if the secretions are profuse, yet tenacious, benzoate of sodium, three or four times daily in 5-grain doses, is highly beneficial. An admirable drug for this stage is hydrastin in 1- to 5-grain or the fiuid extract in 5- to 30- drop doses, three or four times daily, or the compotmd misturse hydrastis (Llewellyn's) in teaspoonful doses in plenty of water after meals. If tlie secretions arc scanty and there is a tendency to dryness of the membrane, iodin gr. ^, phosphorus gr. j^-^, bromin gr. ^, in sherry wine (compound wine of iodin), with plenty of water three times daily is useful. FOLLICULAR LARYNGITIS. Synonyms. — Granular laryngitis ; Glandular laryngitis ; some- times called Clergymen's sore throat, but when so called it is associated with follicular pharyngitis. Definition. — An inflammatory process beginning usually in and invohing primarily the entire mucous membrane, becoming localized in the small racemose gland-structure. However, the condition may be associated with follicular pharyngitis. From the inflammatory swelling there is retained secretion, giving rise to the minute elevations on the laryngeal surface. These retained secre^ tions may escape by ulceration. ^^tiology. — Follicular laryngitis is rather a rare condition, The small mucous follicles, which are few in number, are largely located on the lateral and posterior surfaces of the laryngeal struct- ure. The involvement of these minute follicles is quite frequently associated with constitutional conditions or ibllowing fevers or wasting diseases in which there is perverted glandular secretion. It is also o])serv('d in s])eakers or individuals whose occupation necessitates the continued use of the voice, where the nnicous niembranc is liiiMc to vascular engorgement, interfering tenipo- rarilv with the ulamlnhir sccrcti nc arly always associ; itcd with the same condition in the | ihar; *ii\. Pathology.— Til < | )alh( .lonica 1 allci'ation> arc p ractically the 546 DISEASES OF THE NOSE ANT) THROAT. same as in follicular pharyngitis, although in the pharynx the inyolyement is limited more to the actual gland-structure. There may he considerable alteration in the connectiye tissue of the sub- nnicctsa, but, as a rule, it is slight, if at all. Diagnosis. — The diagnosis can usually be made by aid of the laryngoscopic mirror. Prognosis. — The prognosis is good as to life, but a perma- nent cure may not be etfected, unless the cause is remo\ed before structural alteration of the tissue has taken place. Symptoms. — The symptoms are usually referable to the larynx. There is a peculiar sensation of tickling in the throat, causing a frequent desire to clear it, the effort giying only tempo- rary relief. When attended with cough it is of a yoluntary ■character, unless complicated with inflammation of the bronchial tubes or trachea ; then it is more spasmodic and inyoluntary. Expectoration is usually scanty, appearing more like pellets of mucus. Frequently the cough is dry and there is little or no expectoration. Profuse expectoration would indicate associated inflammatory conditions. The alteration in the voice is not characteristic, but varies greatly in difl^erent jjersons ; there is slight hoarseness, which is due largely to the presence of tenacious mucus. Besides the accumulation of mucus about the vocal bands, the tone or character of the voice will be altered by the slight hyperemia or congestion occurring in the submucosa of the mucous membrane. In imcomplicated cases the symptoms are practically the same as in simple chronic laryngitis. Treatment. — In the treatment of follicular laryngitis it is of the utmost importance to ascertain, if possible, the underlying cause — whether it is due to occupation or is dependent upon some systemic condition. The internal medication should be directed toward the relief of any congestion, the re-establishment of circulation, and the use of such remedial agents as will stimu- late glandular secretion. Careful attention to the intestinal secre- tion, the use of salines, and the continued use of alkaline waters are highly beneficial. The internal administration of y^ grain of phosphorus, |- grain each of iodin and bromin in sherry wine, given three times daily in water, after meals, is an excellent tonic to glandular secretion. Small doses of the syrup of iodid of iron are equally beneficial. Local applications are of little, if any, value. However, the external ap])lication of cold-water cloths, followed by thorough drying of the skin by rubbing, may tend to promote the circulation and stimulate secretion. DISEASES OF THE LARYNX. 547 DRY LARYNGITIS. Synonyms. — Laryngitis sicca ; Atrophic laryngitis ; Ozsena laryngis. Definition. — This is a condition of tlie larynx in which the secretion and exudation from the mucous membrane tend to lodge upon the surface and form crusts. Ktiology. — Atrophic or dry laryngitis usually occurs along with a similar condition of the pharynx and possibly of the naso- pharynx and anterior nares ; in other words, a condition, either local or systemic, which would bring about a similar condition in the structure above, is responsible for the laryngeal lesion. How- ever, the lesion in the larynx does not occur so often as in the structures above. This may be explained by the fact that the blood-supply is different and that the larynx is better protected from irritating foreign material. The fact that the process involves the anterior nares, nasopharynx, pharynx, and larynx, one after the other, by no means proves that it spreads by continuity of tis- sue. In the majority of cases in which the spreading follows in the order given above, it can be explained from a circulatory or nutritive standpoint, or from a standpoint of external irritation, in \vhich the change in the mucous-membrane structure nearest the orifice permits the irritating material to be carried farther and farther back into the respiratory tract. Besides, the local change in circulation, brought about by the pathological alteration in the submucosa, would in a measure necessitate spreading of the process by continuity and contiguity of structure. Whatever is the cause, be it due to systemic lesion, in wliicli there is interference with venous circulation, causing cyanotic congestion, or to an inflam- matory process arising from some local irritation, there is not only an alteration in the submucosa but an interference with glandular function, thereby producing perverted secretion, and this altered secretion varies with the degree of change in the mucous-membrane structure. Inhaling of overheated air or air charged with gases is an important etiological factor. Pathology. — The secretion which accumulates on the surface of the mucous membrane is made up of inspissated mucus, in which are retained leukocytes and des(|uaniated e])ith('lium. This exudate is altered in character, being deficient in serum and con- taining an excess of fibrin. The secretion may become infected with bacteria, especially the Bacillus fo'tidus, and give rise to offensive breath— tlic s(."-r;illc(l /ari/n!,n/rfi<-hrl<, r()perly one of dry laryn- gitis, due to perverted secretion ami interference with vascnlar snp})ly, the strnctnral alteration being less marked than in the varieties described under Nose and Pharynx. Symptoms. — The symptoms are markedly influenced by cli- matic change, temperature, and moisture. Again, the symptoms ])resent during the day differ very much from those at night. During the sleeping hours, while the patient is in the recumbent position, there is a greater tendency for accumulation of mucus and crust-formation, and the patient is likely to be weakened by distressing cough caused by the laryngeal irritation. There may be some difficulty in breathing, with considerable alteration in the voice. Th'c irritiition produced by the accumulated material with- in the larynx brings about violent coughing, in which the indi- vidual is able to free the structure of the accumulated masses, obtaining partial relief. In the variety in which there is little tendency to crust-formation, where the secretions are deficient and the membrane is dry and glazed, this difference in symptoms does not occur. The cough, however, is aggravatingly continuous, with a sudden altered tone and with practically no interference in respiration. The accumulated material when expelled closely resembles that seen in atrophic pharyngitis or rhinitis. AVhen the cough is of a violent nature, the expectorated material may be slightly blood-stained, owing to capillary hemorrhage. The appear- ance of this blood-stained secretion is often alarming to the patient. Diagnosis. — The subjective symptoms, in addition to the laryngeal examination, will render diagnosis easy. The thin, accu- mulated crusts beneath the vocal bands or adherent to the ventric- ular bands or arytenoid structure might be mistaken for ulcera- tion. Although the entire laryngeal structure may be involved, it is usually sul)glottic, with concurrent glandular atrophy. Prognosis. — The prognosis is not uniformly good, but will depend entirely upon the amount of alteration of the mucous mem- brane and the amount of glandular atrophy M'hich has taken place, or upon the permanent alteration of secretion dependent upon con- stitutional diatheses. The condition is always a chronic one, and from a curative standpoint the prognosis should be very guarded. Treatment. — The treatment should be directed toward the correction of any constitutional diathesis, with internal medication specially directed toward increasing glandular secretion. This can best be accomplished by the internal administration of phosphorus y^Q- grain, iodin ^ grain, bromin l grain in sherry wine, three times a day after meals. Ecpially good results may be obtained by the administration every three or four hours of 3- to 5-grain doses of terpin hydrate. If there is any con- joined bronchial irritation, 2- to 5-grain doses of carbonate of truaiacol should be administered. For its action on grlandular DISEASES OF THE LARYNX. 549 secretion there should be administered, night and morning, table- spoonful doses of the granular effervescing phosphate of soda. Abnormalities in the nasal cavity and nasopharynx should be cor- rected. For the relief of the irritation caused by the accumulated dried material within the laryngeal structures, direct medication is essential. There should be applied directly to the surface, by means of inhalations, sprays, or applicator, dissolving emollient solutions. As an aid to dissolve the secretions, inhaling the steam from boiling water to which has been added 1 to 3 grains of carbolic acid to the pint, is admirable. Five grains of sulpho- carbolate of zinc to the pint of water is equally beneficial. Where the irritation is marked, great relief can be obtained by inhaling the fumes of compound tincture of benzoin, 1 dram, and chloroform, 10 drops, on which is poured a pint of boiling water. The application of stimulating solutions directly to the larynx, after the removal of the inspissated material, is in many cases necessary. The irritation of the membrane by the intro- duction of the applicator will be productive of no harmful results ; in this condition a slight irritation is really beneficial. After the removal of the inspissated mucus the parts should be lubricated with a bland oily solution, such as liquid albolene or benzoinol, to which has been added 6 drops of the oil of sandal-wood to the ounce. This solution, applied at intervals of three or four hours, will relieve the patient of the distressing symptoms produced by the drying of the secretion. For its stimulating action there should be applied, with the aid of the laryngeal mirror, directly to the laryngeal structure, a 1 to 3 per cent, solution of chloi'id of zinc. This should be done quickly after the patient has taken a full inspiration. Highly satisfactory results can be obtained by the local application externally of petroleum. This should be rubbed in, and a saturated flannel cloth should be wrapped around the neck during the night. The benefit derived from such appli- cations will offset the disagreeable odor of the drug. CYANOTIC LARYNGITIS. Synonyms. — Symptomatic laryngitis; Chronic edema ; Angio- neurotic ('(Iciua. This condition has been fully described under Nasopharynx and Anterior Nares. The lesion of the laryngeal mucous mem- brane differs very little from that in the above-mentioned situa- tions, the structural alterations depending upon the condition whicli pnxhices the cyanoti(^ congestion ; however, tumors of the neck, by pressure, may ])roduce the condition in llic larynx.^ The same is" true of aneurysm of the aorta, which, by its interference with the circulation, will pi-n.JiK'c cyanosis or chronic congestion of the laryngeal iik iiil)i;iiic. 550 DISEASES OF THE NOSE AND THROAT. The syinptoins are the same as those of chronic pharyngitis. This condition is practically the same as that described by Morell Mackenzie under the term phlebeetasis laryngea, which is nothing more than a varicose condition of" the veins of the epiglottis, ven- tricular bands, and arytenoids. The prognosis will depend entirely on the causal factor, and whether it be one amenable to treatment ; or if the continued press- ure and malnutrition brought al)out by the cyanotic congestion have lasted long enough to produce atrophic processes in the mucous- membrane structure, even with the removal of the exciting cause there will be left permanent alterations in the laryngeal membrane. Treatment. — Local treatment is practically of no avail, and the systemic medication should be directed toward the relief of the nnderlying cause. HYPERPLASTIC LARYNGITIS. Synonyms. — Hypertrophic laryngitis ; Hypertrophy of the laryngeal tissue. Hyperplastic laryngitis is a rare condition in which, from slight irritation, there may be brought about a proliferation of the fixed connective-tissue cells, which is not of inflammatory origin, or which, if so, never goes on to the stage of complete organization and contraction. There is permanent thickening of the tissue, giving rise to some symptoms of obstruction and interference with mobility of the larynx. The tissue-change is identical with that in other structures, especially the so-called hypertrophy of the liver, in which there is overgrowth, but no tendency to contrac- tion. The cause is indefinite. No treatment is productive of beneficial results unless there is removal of the tissue, which is not advisable, as it leaves scar- formation. ANEMIA OF THE LARYNX. Anemia of the larynx is merely a local manifestation of a con- stitutional diathesis. There is not only deficient blood-supply, but deficient vascular tone. Besides the relaxed vessel, the entire tissue will be loose and boggy. There is a tendency to venous stasis and leakage from the relaxed vessels, giving rise to slight bogginess of the tissues. It may be sufficient to cause alteration in the voice, especially in tone and force ; besides, the edema may be sufficient to interfere with vocalization. Structural alteration in the tissue is very slight unless concurrent with some other lesion. The diagnosis, prognosis, and treatment will depend entirely upon the cause of the anemia. Local treatment is not productive of permanent results, afford- DISEASES OF THE LARYNX. 551 ing only temporary relief. The treatment should be directed toward the underlying cause. HYPEREMIA OF THE LARYNX. Hyperemia not connected with any inflammatory lesion occurs in individuals Avho are subjected to conditions which produce sufficient irritation to cause localized increase in the blood- supply, and yet not sufficient to bring about actual inflammatory phenomena. The same may be said of plethoric individuals or of persons who are continuously using the voice, or -whose occupa- tion subjects them to the slight but continual irritation from dust or irritating fumes. Persons who habitually use tobacco or alcohol also exhibit a somewhat similar condition. Pathology. — The hyperemia may be irregularly distributed in the laryngeal structure, both supra- and sub-glottic. There is practically no structural change, except that from the hypernutri- tion there may be overproduction of the connective or epithelial elements. In the plethoric condition, where, from overstimula- tion of the already hyperemic vessels, slight hemorrhage may occur, as referred to in Hemorrhage of the Larynx, the voice is usually altered in character, being somewhat irregular and imper- fect in tone. There is a constant tendency to clear the throat, and there may be some hypersecretion. No pain is felt unless asso- ciated with some other condition. Treatment. — The treatment should be directed toward the relief of any condition which causes the local hyperemia. A change of occupation, together with the removal of any stimulant, should be insisted upon, if such is known to be the exciting cause. The treatment is not local, but should be directed toward the systemic condition. PEMPHIGUS OF THE LARYNX. This is a rare, peculiar, inflammatory condition in Avhich there is an eruption of vesicles resembling very mucli those seen on the skin in cases of herpes. The vesicle may form anywhere in the laryngeal structure, but is usually found on the ventricular bands and arytenoid surfaces, altliough they may be below the vocal bands. The formation of the vesicle is usiiered in by slight sys- temic symptoms, such as rigor wwd slight rise in temperature. There is soreness of the throat, willi -liL^lit alteration in the voice, and sharp, cutting pains, especially on swaUowing, whik^ inspec- tion will show ;i siiiiihir condilion on tlic pharyngeal structures — in fact, on any of the raiii'ial iinicoii--iiicml)rau(' surfaces. There may be slight eck'nia siin-onndiiiLi the \(sich". The condition com- monly exists along with ua-tid-iiitoliiial h'sions, oi- CoMows hmg- 552 DISEASES OF THE NOSE AND THROAT. ])rotr;u'ted illness or su|)j)urative processes. The vesicle nsnally ruj)tiires in a few hours, and leaves a minute su[)erficial ulcer. Treatment. — The treatment should consist in the correction of anv intestinal irregularities, followed by drugs to stimulate the normal secretion, sucli as the granular effervescing phosphate of sodium or succinate of sodium. Antiseptic, cleansing mouth- washes should l)e used, such as boric acid, 10 grains to the ounce, or combined with -'> to 5 drops of carbolic acid. SINGERS' NODULES. Synonyms. — Chorditis tuberosa ; Trachoma of the vocal cords ; Pachydermia laryngis ; Trachoma ; Trachoma of the larynx. Definition. — A new growth, the result of inflammatory action, situated within the vocal cord, involving its margin, and usually located near the junction of the anterior and middle thirds. It consists of a small ovoid nodule situated on the edge of one or both vocal cords, and may be opposite or located at different ])oints. It may be single or multiple, and may develop on both cords simultaneously, or merely on one, followed later by the same condition on the other cord. Ktiology. — This nodtdar affection of the cord is not only an inflammatory process, but the result of inflammatory organization, and the interference with phonation continues after the subsidence of the inflammatory action. The most common cause of the con- dition is generally believed to be improper methods of producing tone, as well as too frequent and forcil)le use of certain tones, in ■which the same intrinsic and extrinsic muscles are brought into play and the vocal cords kept practically in the same position. This is especially true in certain registers, more commonly in the medium or upper medium register. While the condition is most likely to occur in singers or persons who constantly use the voice, yet causal factors are by no means thus limited. It is not neces- sarily due to improper or extreme use of the cords, but may be the result of using the voice when the surrounding tissue of the cords is congested from direct or associated laryngeal inflammation, or from the forcible or sudden use of the voice when the parts are hyperemic from violent exercise. While some cases may be caused by chronic laryngitis or attended by it, yet in the majority of cases the inflammatoi'y action involving the laryngeal structure seems to be secondary to the nodule. I have observed a number of cases of involvement of the larynx and cords during and following an attack of la grippe, in Avhich I believe the nodular formation (Fig. 1 57) was due to localized hemorrhagic areas, with localized spots of inflammation and organization. In many cases not of inflammatory origin, but where sudden or improper stress had been tlirown upon DISEASES OF THE LARYNX. 553 the vocal cords, I believe this hemorrhagic condition explains the process. The fact that a nodule may appear suddenly, regardless of cause, bears out the hemorrhagic theory. People of a tubercular family history or tul)ercular tendency seem to be predisposed. However, any condition in which the vascular tone was not up to par would be an equally predisposing factor. Pathology. — The pathological alteration within the tissue seems to be, as has been shown by Kanthack, largely that result- ing from inflammatory change. The different appearances observed by microscopical examination are only the different stages of the inflammatory condition, with its subsequent fibroid changes. That the nodule is of inflammatory origin is proved by the fact that there is no tendency to increase in size. Tumors and hyperplasias show this tendency. Friinkel and others believe the nodules to be of glandular origin. This, however, I do not consider correct, on account of the absence of gland-element in the cord-structure, and when the glandular element is found _ present, it is more indicative of a benign tumor. The epithelial layer will be j>-- thickened, and even papillary prolonga- ,.^. •~>8k^.\,i«?. i tions be formed, very much resembling ^-^V.' '"+^^!i^^.. papilloma. The whole cord may be in- "^* ^ '%'^5 volved with minute granulations, the thickening being more tcithin the cord than on the surface. However, owing to the nodules the edge of the cord is uneven, and the nodular thickening pre- '^ vents perfect apijroximation (Fig. 157). fig. i57.-showing nodular in- rrii •!•,• 1 1 J.1 filtration of the vocal cords fol- This condition may be due to hemor- lowing "grippe." rhage. In certain inflammatory lesions, especially la grippe, there seems to be poured out into the tissue a material which remains quite similar to an amyloid infiltration. Tliis tends to render the structure irregular and nodular. Such a condition is shown in Fig. 157. Where the nodule is on the surface, its structure and inter- ference with approximation of the cords are very much the same as the condition in the heart-valve where papillary organization occurs as a result of endocarditis. Symptoms. — The symj)toms, wliic^h are largely those of alteration in voice, vary in accordance with the stage and degree of iinolvement of the cords. Tiie alteration in tone will vary fi'diii sliglit hoarseness to complete loss of voice. The pitch is altered and the tone irregular and uncertain. The jjatienl is appre- hensive and nervous, which adds to the irregularity and uncertainty of tlu! voice. Where there is c(jni])lete loss of the voice, there is usually associated some paresis of the tensor muscles, as well as catarrhal laryngitis; this, however, may be the result of inflam- 554 DISPJASES OF THE NOSE AND THROAT. matorv action produced .by thickening of the nodule uj)on the oppo- site c(n-d. The alteration in th(> ^•()ice will become more marked as tiie notlule l)ecomes more fibrous and involves in its contraction surrounding- structure. By the aid of the laryngoscope the nodule can be seen reddish in the early stage and, later, whitish or gray- ish-white in appearance, varying in size — sometimes no larger than a millet seed. Where the nodule is single, there may be a cor- res)>onding depression on the opposite cord. Where multiple and unilateral, the cord will present a peculiar zigzag appearance. Diagnosis. — The history of tlie case, the location of the nodule, and tiie accompanying symptoms render the diagnosis easy. However, the possibility of incipient malignant growth should always be remembered. Prognosis. — If single, and tiie condition is not too far advanced in fibrous-tissue contraction, the prognosis is fairly favorable. However, if of long duration, with the formation of fibrous tissue, the prognosis as to recovery of voice is bad. As far as the general health is concerned, the prognosis, of course, will be good. Treatment. — It has been shown that much can be done for the relief of tiiis condition by the proper exercise of the intrin- FiG. 158.— Mackenzie's throat forceps opening laterally, with serrated jaws. sic and extrinsic muscles of the larynx, more especially the in- trinsic. The surgical treatment varies with the size and location Fio. 159,— Mackenzie'.s laryngeal anteroposterior forceps. of the nodule, as well as whether it is multiple or single, sessile or pedunculated. If the tumor is pedunculated, which is rarely DISEASES OF THE LARYNX. 555 ever the case, its removal can easily be accomplished by means of the laryngeal cutting forceps shown in Figs. 158, 159. If the nodule is distinctly sessile, the advisability of surgical interference is questionable, owing to the danger of further and permanent injury to the vocal cords. Local applications are advised by such authorities as Mackenzie, Bosworth, Schrdtter, McBride, and others. For such local applications the solutions giving the best results are the 3 per cent, solution of chlorid of zinc, or perchlorid of iron of the strength of 1 dram to the fluidounce. Early in the nodular formation, good results may be obtained by crushing or squeezing the nodule by means of dull forceps. CHRONIC INFLAMMATIONS OF THE LARYNX. SYPHILIS OF THE LARYNX. Synonyms. — Specific laryngitis ; Laryngitis specifica. Definition. — A specific inflammatory condition of the larynx occurring as part of the systemic exhibition of syphilitic infection. It presents secondary and tertiary lesions analogous to the second- ary and tertiary lesions observed elsewhere, the primary lesion in this location being practically unknown. In the secondary stages the laryngeal involvement is characterized by erythema, superficial ulceration, mucous patches, and small condylomata. The tertiary stage is distinguished by formation of gummata, deep and destruc- tive ulceration, and subsequent cicatrization. It may be hereditary or acquired, and may occur at any age, though some periods are more prolific than others. Btiology. — Primary laryngeal infection is a condition prac- tically unknown, though the possibility of its occurrence is, of course, to be considered. Laryngeal syphilis is usually part of the manifold exhibitions which the disease offers in the human economy. Both secondary and tertiary lesions occur in individ- uals who have acquired the disease through personal inoculation ; but the laryngitis of hereditary syphilis is almost exclusively of the tertiary type. Of the two types the tertiary more often occurs, and it may appear a great many years after the existence of the primary lesion. Males are more frequently affected tlian femah's, and there are more cases reported in the winter months than in tlie suninicr. No age is exempt from its occurrence. Pathology. — The inflammatory plienoniena liave l)een already described at lengtli on pages 125 to 128. To this article the reader is referred to avoid inincccssai-y repe- tition, as histologically tiie structures and processes in the larynx, .save as they differ from the contour of the region, are not difTernltaceous mass, which may be somewliat l.lo(,(|-iiii-c(|. The floor of the |)a1<-h may he llic seat of rapid and prr-islcnl i: ram da lions, which tend to i-c|)ro- 558 DISEASES OF THE NOSE AND THROAT. duction, if removed. The patches themselves may be paiiifid to the touch of tlie probe, and are usually resistant to treatment. They may be sint^le or occur in multiple groups, and healing is commonly followed by a well-marked cicatrix. The virulent and dangerous character of the secretion of a mucous patch is to be borne in mind. Recurrence of the lesion is not unlikely. Condylomata. — These occur in some cases as small, yellowish pimples, having an elevated base. They rarely cause annoyance, and usually disaj)pear spontaneously. The Tertiary Manifestations. — The tertiary type is that of hereditary syphilis. If not so occurring, however, it usually begins some five or six years or later after the primary sore. The Gumma. — This occurs usually in the epiglottis, upon the arytenoids, or in the interarytenoid commissure, though it may take place in any part of the larynx. The process may be limited to a single lesion or it may be multiple. Gummata first appear in the deeper layers of the meml)rane, and present the appearance of small, smoothly rounded protuberances, not differing in hue from tli(i adjacent membrane, and increasing slowly in size. At their full size they vary from that of a pin-head to a small marble, and their existence is commonly not preceded by inflammatory symptoms, but is sudden in origin. After they attain their full size, softening of the mass takes place, a yellow spot appears in the center, rupt- ure of the overlying tissue and discharge of the softened material occur, with formation of a deep and destructive ulcer. The process is generally rapid, but cases in which breaking down of the gumma is long delayed, or even sometimes totally absent, may be occa- sionally observed. The presence of gummata is attended by symp- toms proportionate to their size and location. Pain, if present, is generally the dull, deep-seated aching of nerve-pressure. Local tenderness may be elicited. There may be some discomfort in deglutition, and phonation may be impaired. Cough is not usual, but respiration may be embarrassed seriously by the swelling of the gummata, which occlude the air-passage, or by the inflam- luatorv edema. Paralytic conditions may not uncommonly be observed, usually unilateral, and attended by a peculiar stridor of the voice in phonation. The Tertiary Ulceration. — As already mentioned, this occurs as a sequel of gummatous degeneration, and is one of the most severe and destructive of the syphilitic lesions. Following the rupture of the gummatous mass, there is left at its site a deep, foul, and rapidly spreading ulcer. This, of course, occupies the region of the original gumma, is more frequently seen on the free margins of the epiglottis, and is not rarely symmetrical. The ulcers are deeply placed, the edges ragged, shreddy, and sharply defined ; the ])it of the ulcer is filled with a foul-smelling, nasty, greenish or yel- lowish mass of purulent, tenacious, necrotic tissue, and the adjacent DISEASES OF THE LARYNX. 559 membrane shows a deeply inflamed, elevated zone immediately sur- rounding it. The spread is rapid, both in extent and depth, and coalescence of adjacent ulcerative processes is observed. Later, the perichondrium is attacked, and ulceration and necrosis of the laryngeal cartilages occur, with a permanent loss of more or less of these structural elements. No position of the larynx is exempt from the process or its spread, and the ensuing condition is both pitiable and dangerous in the extreme. The epiglottis is often totally destroyed ; the arytenoids also and the cricoid cartilage may undergo necrosis, with sloughing or the formation of retained sequestra. The involvement of the thyroid is, as a rule, confined to the very latest stages of the disease. During the progress of tertiary ulceration the condition of the patient is pitiable in the extreme. Pain may be severe and constant, dull and deep-seated. Deglutition is attended possibly with severe pain. Dyspnea may be urgent and alarming. Dysphonia or even aphonia is frequently observed, or, at the least, a marked alteration in the voice. The expectoration is of a mucopurulent character, mixed with dark, ill-smelling bits of necrosed tissue, and is sometimes blood-stained. Hemorrhage is, however, rare. Bits of the eroded framework of the larynx may be expectorated or swallowed, and one case of fatal asphyxia is recorded from impaction of a loosened and necrotic arytenoid in a stenotic windpipe. In the later stages, not only dysphagia may be present, but the attempt to take food may be embarrassed by the passing of solid bits, or even of fluids through the exposed glottis, followed by paroxysmal choking and strangling. Tenderness and pain, especially after the involvement of. the perichondrium, may be very severe. There may be marked external swelling. Not rarely among the ulcerative phenomena is a tendency to recurrent exhi- bitions or outbreaks following quiescent intervals. Cicatrization. — Following the ulcerative i)ro('ess of the tertiary stage, nature attempts a rapid cicatrization of the necrotic areas, and, as usual, this is attended by contraction and tlie formation of dangerous stenoses. These cause in the larynx marked alterations in the contour of the structure, and lead to permanent change in tlie performance of its function. The subjective symptoms of the ulcerative stage are all intensified, and there arises the danger of asphyxia from the ])rogressive narrowing of the air-])assage. Such a stricture is tiioi-c coininoii Mf'tcr siicccssix'c attacks of ulccnilion than after a single occiinvncc. 'I'lic \-oicc is pcnnniiciit ly iiii- |);iirc llic ;il -1 pat lio-iionioiiic cliai'actn'istics in a luarkc.l dc-i-cc, and all nf il,,. ^-mi-toni^ may he a--Tava1c.l by the snhacntc or clir..ni<' calarrlial inllaniniat ion of 1 he nienihraiic not showing othei- .-peeilic a|>|>earanc<'s. Diagnosis.' 'I"he dii-ed .lia-no.^i^ i,-^ h. he ha>ei.lerati 5f)() DISEASES OF THE NOSE AND THROAT. of the general symptoms and condition of the patient ; (3) tlio I'csult of antisyphilitic therapeusis, and (4) the local symptoms. With such means of identification a direct diagnosis should he made without difficulty. In making a differential diagnosis the possible existence of a double lesion, especially Avitii tubercular laryngitis or carcinoma (see table, page 567), is to be kept in mind. Tubercular laryngitis has a pale membrane and more siiallow ulceration, without inflammatory areola ; more pain and less healing tendency are exhibited, and its pulmonary lesion is a valuable diagnostic medium, unless mixed infection exists. The therapeutic test is of great value. Carcinoma before ulceration is a distinct, well-defined, and not distorting tumor, and its pain is, after ulceration, sharp and lancinating. Lupus does not ulcerate so freely, if at all, and cicatrization is by no means marked. Here the clinical history is valuable. Prognosis. — As a rule, the outlook is favorable to life, though the process may cover some time. The disease can usually be halted by proper antisyphilitic treatment, though irretrievable loss of tissue in the later stages leads to serious impairment of function. The secondary phases offer better opportunities for suc- cessful medical ]>rocedure ; while in the later tertiary stages sur- gical measures mav need to be invoked. The danger to life is largely that of suffocation from inflammatory edema or stenosis. Treatment. — In the superficial ulcer the parts should be thoroughly cleansed, following the same method as given under Tuberculous Lesion of the Larynx, and then touched with 20 to 40 grains of nitrate of silver to the ounce of water. Good results may be obtained, when the ulcer is accompanied by an acute infiaminatory process involving the surrounding tissue, by insuffla- tion, after thorough cleansing, of pyoktanin (1 to 2 drams to the ounce of stearate of zinc). The objection to the use of powders is the danger of drawing the powder farther into the respiratory tract and ]iroducing irritation. This can be obviated by the ])atient taking a deep inspiration and holding the breath din'ing the insufflation. Bv so doing, the first respiratory act after the application will be one of expiration. For relief of the pain, insufflations of orthoform are highly beneficial. In the deep ulceration due to gummatous degeneration the same course of local procedure as is followed in the secondary lesions should be observed. In the secondary and tertiary stages, while the local treatment is of importance, yet the internal medi- cation is the prime factor, and the system must be brought as soon as possible completely under antisyphilitic influence. The systemic plan of treatment of syphilis in the secondary and tertiaiy stages as given below is practically the same as given in text-books of surgery and medicine, and is really the method fol- lowed by Gross, Keen, and White, as given by J, Chalmers DaCosta. DISEASES OF THE LARYNX. 561 Secondary Stage. — In the secondary stage the aim is to cure the disease. That it can be cured is known from the fact that reinfection occurs in some persons. The old axiom, " Syphilis once, syphilis ever," is not true. Mercury must be used, the form being a matter of choice. Fournier first advocated intermittent treatment. In this plan give gr. |^ of protiodid of mercury daily for six months, then stop a month ; then give mercury for three months, then stop two months. During the first year the patient is under treatment nine months, and during the second year eight months. Some prefer the intermittent and others the continuous plan. White greatly prefers the continuous plan. The rule in most cases is to give mercury for two years. Find the patient's dose of tolerance, and keep him on this amount. Gross's rule for continuous treatment was to order pills of the green iodid of mer- cury, each pill containing gr. |-. The patient was ordered one pill after each meal to begin with ; the next day he took two pills after breakfast; the following day, two after dinner, and so on, adding one pill every day. This advance was continued until there was slight diarrhea, griping, a metallic taste, or tenderness on snapping the teeth together, whereupon one pill was taken off each clay until the unfavorable symptoms disappeared. This experimentation gives a dose on which the patient can be kept with entire safety for a long time ; but if it is found that colic or diarrhea is apt to recur, there must be added to each pill gr. -^^ of opium. The patient is given mercury in this way for two years. Every time new symptoms appear the dose is raised, and as soon as they disappear, it is lowered to the standard. If the protiodid is not tolerated, give the bichlorid : I^. Hydrargyri chloridi corrosivi, gr. iss (0.1) ; Syrupi sarsaparillse compositi, flsiv (120.). — M. Sig. — One teaspoonful in water after meals. Tertiary Stage. — If at any time during the case tertiary symptoms apjiear, the patient should be put on mixed treatment. In any case, after two years of mercury, add iodid of potassium to the treatment. AVhite's rule is to use this mixed treatment for at least six months (if any symptoms appear), the six months' course dating from their disaj^jx'arance. This emphasizes the fact that the iodids alone will not cure tertiary syphilis. In obstinate ter- tiarics or in nervous sy])hilis the iodids should be run up to an enormous amount (from 30 to 250 grains ])er day). An easy way to give iodid is to order a saturated solution, each dro]) of which equals 1 grain of the drug. Each dose of tlie iodid is given one hour after meals, and in at least half a glass of water. If the iodid disagrees, it may be given in water containing 1 dram of aromatic spirits of ammonia, or in milk. Iodid of sodium may be tolerated better than the potassium salt, or the iodids of sodium, potassium, 562 DISEASES OF THE NOSE AND THROAT. and ammonium may be combined. In giving the iodids begin with a small dose. During a course of iodid always give tonics and insist on plenty of fresh air. Arsenic tends to prevent skin- eruptions. The iodids, when they disagree, produce iodism — a condition which is first made manifest by running of the nose and the eyes. In some subjects there is an outbreak of acne, vesicular eruptions, or even bull?e or hemorrhages. Iodism calls for a reduc- tion in dosage, and if severe or persistent, for the abandonment of the drug. After the patient has been for six months under mixed treatment without a symptom, stop all treatment and await devel- opments. If during one year no symptoms recur, the patient is probably cured ; if symptoms do recur, there must be six months more of treatment and anotlier year of watching. The injection of graij oil, beginning with 1 drop and gradually pushing up the solution until 6 or 8 drops has been reached, followed by interruption with mixed or iodid-of-potassium treat- ment for ten days to two weeks, is admirable in the tertiary stage. This is highly recommended by J. Solis Cohen. This plan of treatment is highly beneficial in the tertiary stage, especially if the cartilage is involved — a chondritis or pericliondritis ; however, in cases in which there is marked inflammatory edema, when iodid of potassium is administered care must be exercised, as the dose is increased, that the original edema is not aggravated by iodism. Much has been written in regard to the treatment of syphilitic stenosis due to fibrous-tissue formation after ulceration. This should not occur if, upon early recognition of the lesion, proper, prompt, and energetic antisyphilitic treatment has been instituted ; and it is only in neglected or exceptional cases that such lesions exist. Once fibrous-tissue formation has taken place, no amount of internal medication will be of benefit. The resulting cicatricial tissue presents the well-known stellate scar, with the peculiar contraction and alteration of the contour of the part. The division of the stellate bands may relieve somewhat the condition ; but the incision that divides the bands brings about another inflammation, with its subsequent contraction. Various dilators and cutting in- struments as seen on pages 494, 496 (Figs. 153, 154) can be used. These produce beneficial results, but it must be remembered that we are dealing with an inflammatory fibrous tissue, and while dilata- tion may retard and somewhat arrest the contraction, it cannot entirely remove the stenosis. The contraction may go on to such an extent as to necessitate, in order to prolong the patient's life, the performance of tracheotomy. DISEASES OF THE LARYNX. 563 TUBERCULOSIS OF THE LARYNX. Synonyms. — Consumption of the larynx ; Consumption of the throat ; Laryngeal phthisis ; Tubercular laryngitis. Definition. — A specific inflammatory disease of the larynx due to the Bacillus tuberculosis. The aifection occurs coexistently with a similar process in the lungs, and usually follows it, though rarely it may precede. It is characterized by swelling of the laryngeal mucosa and development of miliary tubercles, which subsequently break down and form minute, spreading ulcers, that coalesce and lead to extensive ulceration, with alteration of the laryngeal struct- ure. Accompanying the disease is a widely variant train of symp- toms, such as voice-impairment, dysphagia, and the like, due not only to the local lesion, but also to the pulmonary involvement. The affection runs a more or less rapid course, and is usually of grave prognosis. Btiology. — The essential factor is the lodgement and pro- liferation of the Bacillus tuberculosis, or Bacillus of Koch, in the laryngeal structure. A¥hether this may be a 'primary condition arising from infection drawn from without the body, or whether it is always a secondary manifestation from a pre-existing pulmonary consumption, has long been a theme for discussion. With Cohen and others the author believes, however, that primary infection of the larynx may occur. This view is fully sustained both by theoretical considerations and by post-mortem examinations. Such cases are sooner or later invariably followed by the establishment of tuberculosis in the pulmonary organs. In the vast majority of instances, however, it follows rather than precedes the process in the lungs. As strong predisposing elements must be regarded the tubercular diathesis, a lowered bodily resistance from whatever cause, or existent local impairment due to prolonged catarrhal inflammations or the like. Any lesion productive of epithelial desquamation and permitting free access to the deeper layers of the mucosa must be regarded as favorable to its establishment. The greater number of cases occur between the ages of twenty and thirty-five; and males, probably from their more exposed life, are nifd'o fro(|iH'ntIy affected than females. Pathology. — The essential features of the nun-bid ])n)c('ss do not present in this location any variance in minute anatomy from those exhibited elsewhere. Presented microscopically is the same picture of invasion, cell -pi roliferation , formation oC mil iary tul ber- cles, blockin iir off O f nutr ition and subs('<|iient s» )ften ing of the tubercles, ^vi th disHi arn-c (. r th.' softc lied masses niK 1 th. :■ formation of small, spreading ii il. •."]•.-. The |KTi cliiMMb-iiiiii, if th.. 1 t.ati. 'nt 1 sur- vive so h)ng. may be invM.I .•(1 by the tiibri-ciilar 1 iroi i-ess, and 1 ne^ cro- sis or caries of the cartil: ILI'IIIOI 1. ..]( ■iiiciits t;ik( ■S ] l.hl... b':n vlv, however, in this or ■gan d (K'S 11 atiir( • exhibit a te ii.h'ney tow ard 564 DISEASES OF THE NOSE AND THROAT. siiontaneous cure, though stenotic conditions do sometimes arise through partial attempts at cicatrization. Symptoms. — The symptoms of the affliction vary greatly according to the case, because of the somewhat wide range of sites for the location of the morbid process and its spread, and the rajiidity of its progress. The disease may extend up the larynx from a point near or within the trachea, or its first manifestations may be upon the vocal cords themselves. Usually, the posterior region of the larynx is the seat of invasion — a fact readily accounted for by the bathing it receives in expectoration of infected debris from the lungs, and the favoring reception and lodgement of infected material which it otfers in the prone position. The onset is gen- erally insidious, and the course of varied duration. In some cases the course is so rapid as to merit a terminology similar to the pulmonari/ jphthisis floridd. In other cases the course is more chronic, and between the two extremes lies a wide range of differ- ence in duration of the process. Generally, the patient seeks relief for a dry and burning sensation in the throat, attended with a progressive hoarseness and weakening of the voice. This annoy- ance may have been present for some time, since the existence of an acute, subacute, or chronic laryngitis not infrequently precedes the establishment of the tubercular lesion. The sensation as of foreign bodies in the throat, which irritate and scratch, is very commonly complained of. Actual pain in the earlier stages is rare, though it may occur. As the process goes on to ulceration, however, pain as a subjective symptom may become very urgent, both from pressure upon, or oftener, from erosive exposure of, terminal nerve-filaments, and its referred location depends upon the nervous distribution attacked. Tenderness and pain on press- ure or even touch of the throat may, ho^wever, be very severe. The character of the voice changes, and assumes a nature de])end- ent upon the causative lesion. Thus the proper approximation of the vocal cords may be interfered with through hindrance in the working of their mechanism, and the voice show the effect of lessened vibration and escape of air not productive of sound. Otherwise, ulceration of the cords themselves may take place and be responsible for hoarseness and unevenness of tone. Usually, the voice becomes hoarse and lower in ])itch, and may go on even to complete aphonia. The exercise of talking may become so painful and difficult as to keep the patient from making the effort. Cough is commonly present, and may be attended with little or no annoyance ; or, in the later stages especially, be the source of the most excruciating agony during paroxysmal seizures. Deglu- tition becomes gradually more painful in tlie majority of cases, and is attended by attacks of choking and strangling, which render the taking of food difficult and play no small part in causing the gen- eral emaciation that is frequently observed. In the late stages the DISEASES OF THE LARYNX. 565 regurgitation of food and the drawing of bits of food or of fluid into the larynx during inspiration are not uncommon. Secretion from the larynx itself is slight but tenacious, and if an excessive amount be present, it must be traced to the lungs. Portions of eroded cartilage may, however, be expelled in the later stages. Dyspnea is a feature that may be present early or late, and may require tracheotomy for its relief; and in a small proportion of cases a stenotic condition from partial cicatrization of the ulcera- tive process may render the same procedure imperative. In addi- tion to these symptoms of local reference, the systemic effects of the pulmonary lesions are to be noted. This is not the place to describe the physical signs of the chest, and mention only need be made of the night-sweats, suppurative fever, hectic flush, and general pallor and emaciation that are pathognomonic. Hemoptysis is of pulmonary origin, and is rarely ever even slightly increased by any blood from the larynx. So, also, the expectoration of muco- purulent material is from the lungs and not from the larynx. Inspection by the laryngoscope reveals a picture as varied in individual cases as are the attendant symptoms. This is due both to the variation in location possible in the process and to the some- what different appearance in the phenomena of the acute and chronic forms. Thus, in the rapid variety there is more of a hyperemic appearance of the affected membrane ; while in the more chronic form there is a marked anemic condition of the membrane wdiich is almost pathognomonic. The diseased areas, as already stated, may be observed as an extension of a process located lower down in the respiratory tract and gradually working upward ; or the morbid manifestations may appear first on the epiglottis, and from thence extend downward. They may be on the vocal cords, unilateral or bilateral, and not infrequently an apparent coex- istence of unilateral laryngeal tuberculosis has been noted, with pulmonary involvement of the same side. Usually, however, the posterior region of the organ is that in which the process is to be seen most clearly and is most plainly in evidence, for the reasons already advanced. Excluding the symptoms of an existent catarrhal inflammation, there is seen in the infected region at first but little to indicate trouble. Later examination shows localized swellings of the meml)rane, which only in the acute form reveal noticeable hyperemia, and in the chronic form are decidedly anemic. These areas of swelling increase in size and spread. Sometimes they become so large as to cause dyspnea, especially if tiiey occur in the tissues near the laryngeal inlet. Tiie c])igl()ttis is a favorite site for tubercular infiltration, and this organ may assume a sini])le gloliidar, puifcd form, a thickened crescentic shape, or simulate the Turkisii turban — the so-called ''turban" ej)iglottis. Swelling of the aryteuoid regions is common, and a jx-culiar rdiindcd turgcs- cenco of tile arytenoid prominences has origiuated the desig- 6GG DISEASES OF THE NOSE AND THROAT. nation of the " club-shapod " arytenoids. Within the mem- brane, which becomes progressively paler and anemic, are soon to be observed the presence of countless numbers of bodies like small, yellowish seeds, plainly visible beneath the investing covering. These increase in number and degenerative changes occur ; they soften and discharge their contents, and numerous small ulcers mark their sites. With the formation of these small, necrotic areas the beginning of the final stage of the process is ushered in. They spread, coalesce, and form larger areas, and these in turn unite in the necrotic extension. The total facies of the larynx changes, and may present a picture, at different stages, of discrete, small, but spreading ulcers, with well-defined margins without marked adjacent phenomena, shallow, with a dirty, ragged, grayish floor, and covered with a grayish, ropy secretion ; or the image may be that of a larger involvement of the larynx in a rough, ulcerated, irregular, and altered contour of its lining sur- face. In the later stages it Jnay, in exceptional cases, be even pos- sible to observe exposed cartilage, and in more frequent instances the stump of an ulcerated epiglottis. The vocal bands, as a rule, are not markedly affected until the process has been present some time ; but gradually they lose their luster, become dingy, and vilceration occurring, all sorts of dentations and roughenings may be found on their margins. On the other hand, involvement of the cords may be among the earliest of the manifestations, and between the two extremes is a large range of varying degrees. Occasionally, on the edges of the cords may be seen small vegeta- tive projections; and rarely, between two ulcerated areas, an adhe- sive union may take place. Throughout the whole process it may at times be possible to observe attempts of nature toward a repar- ative process. Finally, the author wishes again to emphasize the fact that few conditions present so varied, and yet, on the whole, pathognomonic manifestations, which baffle all attempts at a thorough description, as does tuberculosis of the larynx. In addition to this diverse exhibition of tubercular signs and symp- toms, must be borne in mind the possible coexistence of a mixed infection. Diagnosis. — This is not usually of much difficulty, especially if, as is commonly the case, demonstrable pulmonary lesions are present. Time is an important factor in doubtful cases of laryn- geal location, especially in the various forms of laryngitis occurring coincidently Avith pulmonary phthisis. The presence of tubercle in the sputa is evidence only of tubercular lesion in the respiratory tract, and must not be held of localizing importance unless marked laryngeal symptoms accompany ; besides, in laryngeal tuberculosis the sputum rarely ever shows the bacilli as they are located in the tissue. Syphilis may be differentiated by its history, by the char- acter of the yellowish discharge on its ulcers, their irregular contour DISEASES OF THE LARYNX. 567 and edges, lack of previous tubercle-formation, and the reddened areola which surrounds them. Constitutional symptoms should be taken into account and the therapeutic test applied. The latter will also be employed in determining the existence of a dual infec- tion. The nodular swellings of lupus may confuse ; but these have no secretion and do not present the same ulcerative and painful character, cough, expectoration, or constitutional symptoms. Ma- lignant disease is attended by more livid hyperemia in the early stages, and greater necrosis and more profuse secretion in the later periods of Avell-established ulceration, Avhile the pain is of a sharp, lancinating character. The following table by Joseph S. Gibb shows the main points of differential diagnosis : Tuberculosis. Pain usually slight, j Pain constant, lanci- 1 nating. Attacks any portion i Attacks any portion of larynx and ul- of larynx, and ul- cerates rapidly. 1 cerates more slow- I ly than syphilis. Is rarely seen in the stage of induration, the first evidence being a clear-cut, deep ulcer. Some induration around the ulcer, but usually very little edema. Ulcerextends deeply, often involving car- tilage. Surface of ulcer cov- ered by mucopuru- lent secretion and necrosed tissue. Mucous membrane hyperemic and in- jected. Laryngeal stenosis not common until cicatrization oc- curs. tjieneral health un- impaired. Frequentlyevidences i of sypliiritic disease in other tissues. Rapidly improves under the iodids. The first appearance is that of a new growth occupying the laryngeal cav- ity; no clear-cut nicer. The growth fills or encroaches on the laryngeal cavity. Growth extends in all directions, in- volving all tissues in its course. Surface of growth covered by dis- charge. Mucous membrane hyperemic. Laryngeal stenosis quite common. Early in disease no impairment of gen- eral health : later a marked cachexia. In primary laryncreal loilid.s have no iuUu- ence on the course of the disease. Pain severe on deg- lutition. The favorite site is in the interaryte- noid space or the base of arytenoid cartilages ; ulcer- ates slowly. Usually the first ap- pearance is small spots of indura- tion, which is rap- idly followed by great edema. Great edema of ary- tenoids. Ulcer extends later- ally, but not deep- ly- Surface of ulcer cov- ered by thick mu- copurulent secre- tion and aggluti- nated mucus. Mucous membrane pale. Laryngeal stenosis rarely occurs. Health impaired previous to laryn- geal involvement. Previous and coinci- dent pulmonary trouble common. Iodids have no in- fluence. No pain. Attacks any portion; ulcerates very slow- ly- Nodular masses. Very slow in prog- ress ; ulcer rarely observed. Little or no discharge. Mucous membrane injected. light stenosis. Very slight impair- ment of general liealth. Frequently cutaneous manifestations. Iodids have no influ- ence. Prognosis. — As a rule, most unfavorable. A few cases are on record of undoubted laryngeal tuberculosis in which very early recognition of the character of tlie disease was made, and removal or destruction of the affected areas has been followed by no furtlier 568 DISEASES OF THE SOSE AND THROAT. manifestations. As a rule, the prognosis can be given only on the basis of the weeks or months of life yet before the patient. Treatment. — Tuberculosis of the larynx usually occurs sec- ondarily to pulmonary tuberculosis, although primary involvement may occur. The treatment in eitlier case is the same, although the prognosis in the primary condition is more favorable than when dependent upon pulmonary lesion. Much can be done by systematic local treatment to retard the progress of the disease, and possibly in some cases a cure may be effected. As a rule, the condition when presented for treatment has advanced to ulceration. Repeated and thorough cleansing of the part should be instituted at once. This can best be accomplished by spraying the parts with hydrogen pcroxid (15 volume), folloAved by an alkaline anti- septic solution, such as biborate and bicarbonate of sodium, of each 10 grains to the ounce of aqueous extract of hamamelis and dis- tilled water, in equal parts. For this purpose the syringe shown in Fig. 160 is useful. After cleansing and drying, the ulcerated Fig. ICiU.— Dennis's antiseptic syringe with laryngeal and antral attachment. surface should be carefully touched with dilute nitric or hydro- chloric acid. The frequency of such applications must be left to the judgment of the physician, based on his knowledge of the Fig. 161.— MacCoy's flexible acid-applicator. case ; but, as a rule, once daily is sufficient. Lactic acid is highly recommended, but I do not find it any better than the dilute hydrochloric acid. For intralaryngeal applications of acid solu- DISEASES OF THE LARYNX. 569 tious the iustrument shown in Fig. 161 answers admirably. I have used the extract of suprarenal capsule in a few cases w^ith beneficial results. If the ulcer is deep, curetment under cocain- or eucain-anesthesia should be done. The curetment should be thorough, as it must be remembered that the tubercular area is surrounded by a limiting membrane, and unless the infected tissue be thoroughly removed, the breaking up of the protecting mem- brane may be the means of rapid dissemination of the tuberculous infection through the lymphatics or blood-channels. After thor- ough curetment the patient should be sent to a suitable climate. Solly of Colorado Springs, who has a large experience in the dis- ease, highly advocates this plan. It is unquestionably the plan in primary tuberculosis of the larynx, which is a rare condition. It is also in these primary cases that the performance of laryngec- tomy produces cure. Ernest Crapon recommends laryngofissure as beneficial in some cases. In cases in which the ulceration is not far advanced or the process is somewhat limited, after the cleansing and drying of the surface there should be applied directly to the ulcerated area, either by means of spray or applicator : ^. Creasoti, 5J (4.0) ; Olei picis liquidse, gtt. xx (1.3) ; Alboleni (liquid), flgss (15.0).— M. Castor oil may be substituted for the albolene on account of its viscid and tenacious properties, but I find it productive of no better results. The most distressing symptom experienced by the patient is the constant pain, which is especially aggravated by swallowing. A number of agents are recommended for the relief of this con- dition, no single remedy being efficacious in all cases. The sim- plest and the one from which I have obtained the best results is the juice of the ordinary pineapple, ap])lied by means of spray or applicator, although in some cases I find it is irritating. Tins can be frequently repeated without any ill eifects. Cocain, in a 6 to 10 per cent, solution as a spray, will give relief, but it is not lasting and requires frequent repetition. Inhalation of benzoin or insuttlation of orthoform gives partial relief For the irritating cough : I^. Extracti hydrastis canadensis fluidi, Extract! ergota fluidi, ri,i fl.^ j (30.0).— M. 15 to 40 drops of the solution after meals and at bedtime, given in plenty of water, may ])e used. For relief of the burning sensa- tion in the throat and the congli due to local irritation, the I'ollow- ing gargles or sprays should i)e used : 570 DISEASES OF THE XOSE AXB THROAT. I^. Extract! hydrastis (colorless), Hydrogenii peroxidi, Aquae cinnamomi, equal parts. ■with 2 ])er cent, cocain solution added. Should there be dryness of the parts, a solution of: i;.. Menthol, gr. iv (0.25) ; Olei santali, gtt. iv (0.25) ; Alboleni (vel benzoinol), flsj (30.0).— M. Avill lubricate the surface and relieve the irritation. Cracked ice acts favorably and gives some temporary relief. Liquid diet should be instituted and no irritating condiments used. In the advanced stage of the disease, in which the treatment is purely palliative, narcotics may have to be administered to relieve the intense suffering. The application of electricity has been recommended, and is worthy of trial. The application of remedial agents, using elec- ©(!)iration that is almost normal may set in, with, however, a history of recurrence of these attacks, de])endent either on the change in position of the jmtient or the ciiaractcr and location of the foreign body. If the body be angu- lar, sliarji, or ])ointcted ejection ])y tiic patient or re \:il liy tlic pliysiciaii. A si)asinodi(;, hoarse cough, with loss of voice, may be noticed. In some in- stances tile cough may be croupy in character, closely resembling 574 DISEASES OF THE NOSE AND THROAT. that of whooping cough. The more remote effects of the presence of a foreign body upon the npper respiratory tract may be reac- tionary inflammation and ulceration. According to its location, " laryngitis with edema, inflammation or ulceration of the trachea or bronchi, emphysema, pneumonia, pleurisy, abscess of the lungs, abscess of the larynx followed by necrosis of the cartilages either of the larynx or trachea, may result." Diagnosis. — Usually, the diagnosis of the presence of a for- eign body in the larynx or its continuation is not attended with difficulty, as the history of the case and inspection, if it be pos- sible, or palpation, are sufficient to establish a diagnosis. Foreign bodies in the esophagus may give rise to symptoms much the same as if the body was in the larynx. As a rule, when the foreign body is in the esophagus all the symptoms are aggravated, and the tendency to dyspnea increased when the recumbent position is assumed. Difficulty of diagnosis, however, may arise if the body be inspired during sleep, during an epi- leptic seizure, or at the moment of receiving an injury or blow, Avhen the effects may be attributed solely to the accident or attack and the presence of the body overlooked. In locating a body that has passed into the bronchi, the anatomical structure of this locality should be borne in mind ; and it should be remem- bered that more often the substance will find lodgement in the right bronchus or its bifurcation than in the left, because the right bronchus is located higher up than the left. Auscultation may reveal peculiar harsh or sonorous rales at the location of the substance. Cohen notes that obstruction of the left bronchus causes an absence of respiratory murmur over the entire lung ; while occlusion of the right bronchus usually produces absence of the respiratory murmur over the lower lobe alone of that side, the division of the latter bronchus being nearer the bifurcation. The body may be located by the use of the tongue-depressor alone, if it be situated high up in the larynx or in the laryngopharynx. Failing in this, the laryngoscopical mirror may be employed, although an examination of such a character is exceedingly diffi- cult at any time, either during the acute attack, because of the danger of increasing the dyspnea, or during the interval, because of the hypersensitiveness usually existing. The palpating finger may locate a body in the larynx when the examination with the mir- ror is impossible. Tlie differential diagnosis between ])ulmonary phthisis and foreign body of long standing in one of the bronchi is a matter of exceeding difficulty. The one-sided bronchitis, which recurs, the mucopurulent expectoration tinged, perhaps, with blood, and the inability to discover the tubercle bacillus in the sputum may be of aid. Prognosis. — The outlook in all cases of foreign body in the larynx, irrespective of position or regardless of removal, should DISEASES OF THE LARYNX. 575 be exceedingly grave. Expulsion of the body by the effects of nature may occur at once or at any time subsequent, as cases where it has remained in position from one day to sixty years have been reported in which unaided expulsion of the body has occurred. Effort should be made, however, to extract the body at the earliest possible opportunity, as there is no doubt but that, even if opera- tive interference is at length imperative, the danger to life is not proportionately increased. Treatment. — After the acuteness of the spasm of choking has subsided, effort should be made, by the methods given, to ascertain the position and character of the offending body. If, however, the dyspnea does not abate and seems to threaten life, operative interference should be instituted at once. The admin- istration of sternutatories and emetics should be avoided. No attempt should be made in the great inajority of cases at volun- tary efforts at expulsion by the patient, especially if the body is irregularly shaped, sharp, or angular, as there would be danger of further embedding it in the structure. The patient should be inverted or placed on his back on a table, with the shoulders drawn to the edge, so that the head hangs over it ; in this way the danger of the body falling still further into the larynx during the attempt at removal is obviated, breathing is rendered freer, and examination is much easier. If the exact position of the body can be located either with the mirror or palpating finger, it may be grasped by the curved laryngeal forceps and its removal effected. Inversion alone sometimes succeeds in freeing the body, especially if it be round or smooth. Should all of these methods fail, recourse should be had to tracheotomy, the position of the operation depending on the location of tlie body. Not infrequently after tracheotomy the body, if located below, maybe expelled through the artificial opening, or may be forced up so that it can be grasped and removed. Should this not occur, the patient's body should be shaken or the inverted position assumed, with the hope of bring- ing the offending substance within reach of instrumentation. If it be impossible at the time of operation to locate the body, the edges of the trachea may be stitched to the integument and the wound left 0])en for further search. The introduction of a small mirror may assist in locating the body. Blowing strongly into the trachea may assist in expulsion by the reactionary expiration, or the artificial production of cough by a feather may be also of use in dislodgement. 576 DISEASES OF THE NOSE AND THROAT. PROLAPSE OF THE LARYNGEAL VENTRICLES (EVERSION OF THE VENTRICLES OF THE LARYNX). The freeing of the mucous lining of the ventricles of the larynx from its attachment, followed by a pouching or eversion of this tissue, encroaching upon the cavity of the larynx, is an unusual occurrence, and rarely diagnosticated during life. Persons in whom this condition has been observed have been afflicted with either tuberculosis or syphilis, a fact which may or may not bear a causal relation to the affection. During a violent fit of coughing the relaxed mucous membrane may be torn from its attachment and bulges out into the lumen of the larynx. The symptoms caused by the existence of these rounded, soft, smooth tumors, pale pink, somewhat injected, lying on the cord, apparently arising from the ventricular fissure, may be so slight as not to be noticed, or may consist in dyspnea varying in intensity with the size of the mass. From malignant growth, the absence of ulceration, con- sidering the length of time the symptoms have existed, with lack of glandular involvement, easily differentiates the affection. The density of a fibroid, its irregular nodulation, coupled with the fact that it never springs from the ventricles, are the main points to be considered in differentiating it from a prolapse of the ventricle. The hernia-like protrusion cannot be replaced with any likeli- liood of its remaining in position. Astringent applications of chromic acid may have some effect in reducing the size of the ever- sion. Ablation of the prolapsed tissue with the snare or cutting forceps (Figs. 60, 64), either through the natural passages or fol- lowing thyrotomy, has been successfully effected. CHAPTER XX. NEUROSES OF THE LARYNX. Nervous Cough. Neuralgia. Mogiplionia. Hysterical Aphonia. Anesthesia. Chorea of the Larynx. Paresthesia. Dysphonia Spastica. Hyperesthesia. Laryngeal Vertigo. Paralysis of the Vocal Cords. a. Paralysis of the Superior Laryngeal Nerves. h. Recurrent Laryngeal Paralysis. c. Bilateral Abductor Paralysis. d. Unilateral Paralysis of Abductors. Paralysis of Individual Muscles. a. Paralysis of Central Adductors (Arytenoids). 6. Paralysis of Internal Tensors (Thyro-arytenoids). c. Bilateral Paralysis of Adductors (Lateral Crico-arytenoids). d. Unilateral Adductor Paralysis (Lateral Crico-arytenoid). NERVOUS COUGH. A SPASMODIC, croiipy, even musical laryngeal cough occurring in persons of a neurotic type, for which no other cause can be assigned, is to be considered of nervous origin. Continuing through the day in distressing spasms or almost continuous, barking in character, increased by excitement, when there may be some facial twitching, the cough may become a source of annoyance not only to the patient himself, but also to those around him. During sleep there is usually a remittance of the affection, only to return, on waking, with renewed vigor. It is usually seen in hysterical females or neurotic males. In the search for possible cause of the condition the chest should be carefully examined, the nose and nasopharynx should be inspected for abnormality or possible cause of reflex irritation, or especially hypersensitive areas wdiose stimu- lation gives rise to the condition. The pharynx and fauces should be carefully reviewed for the cough spots (jf Stoerk or enlarged tonsils. The ears should be inspected for imjiaction of cerumen or a foreign body which might reflexly produce the cough. Failing by these means to detect the origin of the symptt)ni, attention should be given to the digestive and generative tracts. If the search for an assignable cause has been unavailing, treat the case as one of purely nervous origin. Cive ncrvc-^-dali vrs, such as bromid of soda, lOgniiustlmv limes n (l;iy,:in.l npply locnlly every other day 578 DISEASES OF THE NOSE AND THROAT. menthol or cocain in benzoinol or liquid albolene, 10 grains to the ounce. The aifection will be usually found difficult to relieve suc- cessfully, and tonics, such as iron, quinin, and arsenic, or a pill containing 1 grain each of valerianate of iron and zinc, with cold douching, change of air and scene, and outdoor exercise, may have to be added before appreciable results can be hoped for. MOQIPHONIA. Owing to a lack of tension of the vocal cords, singers or speak- ers may notice that singing or forced or accentuated speaking may become at first difficult and finally impossible. The cords era- ployed in ordinary conversation, without the added burden of increased effort, as in singing or loud declamation, respond nor- mally. The condition is known as mogiphonia, and is analogous to other occupation-neuroses, such as writer's cramp, etc. The affec- tion may simulate either the tremulous or paralytic variety of this disease, the latter form, according to Friinkel, being the more important. Massage and friction give best results in the treat- ment. ANESTHESIA. Ktiologfy. — Loss of sensation of the larynx may be artificially produced by the use of a general or local anesthetic. In hysteria, during epileptic seizures, in the later stages of cholera, in paral- ysis of the insane, and in bulbar paralysis anesthesia of the larynx may occur. If occurring after diphtheria both sides of the larynx are insensitive, and are usually bereft of motion as well. As a rule, motor paresis of the larynx and palate have an associated loss of sensation. Such intracranial lesions as softening, hemorrhage, tumors, cysts, and gummata usually produce unilateral anesthesia, if affecting one side of the medulla. Locomotor ataxia, progressive muscular atrophy, and railway spine may also produce an absence of sensation in the larynx as one of the symptoms of their involve- ment. Erysipelatous or variolous affections of the larynx may leave the condition as a sequel. Loss of function of the superior laryngeal nerve or certain fibers of the pneumogastric by any of the causes mentioned above explains the mechanism of the condition. Symptoms. — The tendency for food or drink to enter the trachea and set up spasms of choking or coughing is the most prominent symptom of the affection. A septic pneumonia from the lodgement of foreign matter in the lung should always be feared. Inspection with the laryngeal mirror may show an erect epiglottis due to the paresis of the thyro- and ary-epiglottic mus- cles. Morell Mackenzie has spoken of a waviness in the outline of the glottis due to the same cause. The diagnosis can be substantiated by the failure of response NEUROSES OF THE LARYNX. 579 when touched with the probe, neither sensation of any kind, nor cough, nor reflex closure of the glottis occurring after such a procedure. Prognosis. — The prognosis for this condition depends on the cause. Diphtheria's relation to the condition generally gives a better outlook for cure than any of the others, despite the most energetic treatment. Treatment. — Food should be given through the stomach- tube to prevent its entrance into the respiratory tract. Care should be taken to pass the tube well back in the pharynx, so as to be sure to enter the esophagus, as the anesthetic condition of the larynx gives no sign of its accidental insertion into that structure. Strychnin hypodermically, or by the mouth in large doses to its physiological limit, with electricity three to six times a week to the point of producing sensation but not pain, and massage are the mainstays of a treatment that is at best tentative in the majority of cases. PARESTHESIA. Under the .heading of paresthesia of the larynx are grouped those perversions of sensation referred to that structure, compris- ing prickling, heat, tickling, the feeling as of a foreign body, and constriction. If the sensation be one suggestive of the presence of a foreign body, it can be explained by one of three solutions : Either that a foreign substance before removal had given rise to change in the structure about the peripheral nerve-filaments of such a character as to leave a continuation of impulses simulating those transmitted during its actual presence. Again, pathological changes in the throat, such as enlargement of the faucial tonsil, cheesy concretions in the crypts of the tonsil, elongated uvula, follicular pharyngitis, enlarged veins at the base of the tongue, enlargement of the lingual, pharyngeal, or laryngeal tonsil, neo- ])lasms, or foreign body, may give rise to the same set of impulses. Or, lastly, some affection more or less remote may reflexly act in the same maimer. It is presupposed that careful search for a foreign body in the larynx or its adnexa has eliminated such a possibility. In anemia, hypochondriasis, hysteria, and phthisis careful search of the throat and lungs should be made for abnor- mality or actual disease l)efore a purely nervous origin is attributed to the condition. Ks])t'cially if the laryngeal nuicosa be anemic shouhl the hnigs be carefully examined for the possibility of an inci])ient ])hthisical involvement. The patient may become so I'earlul oi" cancerous or other malignant involvement, l)eeau,-e of the ])ain, especially if increased on l^reathing or swallowing, that the refraining from these func- tions or partial control of them to obviate the ]iain may endanger his life. In such cases strong moral suasion shctuld be brought to 580 DISEASES OF THE NOSE AND THROAT. bear as part of the treatment, and hypnotism may be employed in some cases to advantage. AVhen actnal pathological change exists elsewhere, it shonld be remedied. The general health should be built up by tonics, outdoor exercise, and diet. Bromid of soda may be given internally or as an inhalation. Menthol, 10 grains to the ounce of albolene, may be applied locally with advantage. HYPERESTHESIA. The sensitiveness of the laryngeal mucosa varies largely in different individuals in apparently good health, and in those of nervous temperament this reflex sensibility may be so great as to be termed hyperesthetic. Acute and chronic laryngitis renders the larynx acutely non-tolerant of foreign interference. Ulcera- tion, excoriation, small tumors, especially carcinoma, fissures at the base of the tongue or on the pharyngeal walls, tonsils, or pala- tine folds, incipient phthisis, bibulous pharyngitis, hysteria, the gouty or rheumatic diathesis, may all contribute in a greater or less degree to hypersensitiveness of the larynx. Cough that is peculiarly irritating, gagging, spasm, and even convulsive seizures may be produced by the slightest irritation, either by examination, the inhalation of cold air, dust, or smoke, or by contact of certain substances in deglutition. The treatment should consist in the careful search for, and removal of, the cause of the condition. Abnormalities in surround- ing structure should be corrected. Ulcerations, excoriations, and fissures should be carefully cleansed, and touched with a solution of nitrate of silver, 40 grains to the ounce, or even the solid stick, milder solutions being employed if stimulation is desired. The gouty or rheumatic involvement should be combated by the administration of colchicum, the iodids, or salicylates. If of nervous origin sedatives, such as bromid of soda, chloral, the triple bromids, and tonics, may be given. The application of sedatives locally should consist in the careful employment of cocain or menthol in spray form, in the strength of 5 to 10 grains to the ounce of benzoinol. Ice-water spray may be employed to advantage in some cases in obtunding the hyperesthesia of the tissues. The eliminative functions should be looked to and cor- rected regardless of the etiological factor. Change of air, sea- bathing, and outdoor exercise should be insisted upon when practicable. NEURALGIA. Pain in the larynx, that can undoubtedly be said to be purely nervous in origin, is rarely met with. Usually lesion, either in the larynx itself or in some adjacent structure, will be found resjionsible for the condition. Phthisis, rheumatism, gout, anemia. NEUBOSES OF THE LARYNX. 581 and malignant disease may give rise to pain in the larynx, and should be eliminated as causative factors before an absolute diag- nosis is made. The majority of the causes that have been enu- merated as bearing etiological relation to liyperesthesia of the larynx may, by intensification, produce actual pain in that organ. The treatment should be addressed to the elimination or cure of the underlying cause. For purely neuralgic pain phenacetin, acetanilid, or any of the coal-tar analgesics, cannabis indica, acon- itin — gr. y^ — until physiological effect is produced, or in some cases morphin may be administered. Menthol or cocain locally, hot water externally, or a small mustard plaster applied in the same manner may be effective in relieving the pain. HYSTERICAL APHONIA. A sudden complete loss of voice usually occurring in unmar- ried hysterical females between puberty and the menopause, with- out a discoverable pathological lesion for its causation, is classed under the heading Hysterical or Functional Aphonia. It seems to consist in a temporary loss of control of the adduc- tor nervous mechanism by the cerebral centers. Shocks, frights, anger, intensification, for any reason, of any of the emotional atti- tudes in a neurotic individual often immediately precede the con- dition ; or the patient may retire in full possession of the voice and awake to find any attempt at vocalization impossible. The voice may be entirely lost; in others a whispering note may be the only attainable result of attempt at phonation. This condition may persist for a time, and full return of the vocal powers occur as suddenly and mysteriously as their disappearance, only to be lost again at periods varying with each individual case. The diagnosis of the affection rests on the general nervous aspect of the case and the laryngeal image, which reveals an apparently healthy condition of the laryngeal mucosa, an absence of intrinsic growth, and perfect ordering of the nervous laryngeal mechanism, except that on attempted phonation both vocal cords are seen to begin to approach the median line, but fail at a point short of approximation controlled by the degree of involvement. Having for a moment been approximated, the controlling power being lost they immediately resume the partially approximated ]iosition. Cough, too, present in hysterical aphonia is coni])letely lost in true adductor paralysis. As in hysterical manifestations elsewhere, the laryngeal findings never form an accurate replica of any genuine paralysis. The administration of a general anes- thetic to the stage of excitation will, by tem])orarily restoring the voice, (Icliuitely determine a given case to be of hysterical origin. The treatment of the case sIioul o tn •SISAIVHVJ SISAIVHVJ "IVaONAHVT IVaONAHVT Hoiaadiis iNaaano3H . 9 io NEUROSES OF THE LARYNX. 585 attack comes on there is a deep sucking in of the air, which, imprisoned by the glottic spasm, increases the pressure in the chest, lessens the heart-action, produces syncope, and eventually lowers the health and undermines nervous equipoise. The prognosis for this startling, and often alarming, affection is happily good under proper treatment, which should consist in promptly putting the individual under the full influence of the bromids and correcting any diseased condition found existing in the upper respiratory tract. Measures like those employed under Dysphonia Spastica are also to be used in this disease. .^^^^ Fig. 166.— 1, Bilateral paralysis of superior laryngeal nerve ; 2, cadaveric position of cords seen in bilateral paralysis of recurrent laryngeal nerve ; 3, unilateral paralysis of right abductor during deep inspiration ; 4, paralysis of the arytonoidens muscle ; 5, bilateral adductor paralysis; 6, bilateral paralysis of abductors (crico-arytenoidei pos- tici) : this is the image during deep Inspiratory effort. PARALYSIS OF THE VOCAL CORDS. Paralysis of the Superior I^aryngeal Nerves.— By the sn])crii)r liirviigcal nerves the nnicous iiiembrai)e oi' lln' larynx is supplied with sensation, and by the same means motion is imparted to the cricothyroid nuiscles and, in part, to the arytenoids. Paralysis, then, of this nerve would cause a loss of scnsatioii in the lining of the larynx and an interference with or loss of voice, as the nuiscles which render the cords tense are at fault. Either one or both sides of the laryn.x may l)e involved. The condition may be caused by diphtheria, overuse of an 586 DISEASES OF THE NOSE AND THROAT. inflamed larynx in singing or shouting, by exposing tlie neck and catching cokl, or by injury or section of the nerve. The paralysis is rarely complete, except when duo to the last group of causes. The main symptoms of the paretic involvement are a hoarse- ness of the voice, an inability to produce the iiigher notes, or a peculiar " sliding rise in the pitch of the voice during ordinary conversation, M'hich is beyond control of the patient." Diagnosis. — In a well-marked case of bilateral paralysis of the superior laryngeal nerve, the image in the mirror is at once curious and characteristic (Fig. 166, 1). The approximation of the vocal processes divides the glottic aperture into two unequal parts — " a wavy outline," as Sir Morell Mackenzie expressed it. The lack of tension of the cricothyroid muscle, togetlier with anesthe- sia of the larynx, makes good the diagnosis. In unilateral paral- ysis there is a relaxation of that part of the aflPected cord between the vocal process and the thyroid cartilage. Prognosis. — The outlook for recovery in the majority of cases is good, the duration of the condition depending on the cause. Post-diphtheritic involvement usually lasts from one to three months, while recovery of the voice may be delayed for a year if the loss was due to section of the nerve. Treatment. — Mild cases will usually recover in time if left to themselves, but judicious treatment, such as mild counterirrita- tion by iodin, or a mustard plaster, or wet compresses, will hasten the desired end. In the severer cases food may have to be given through the stomach tube, on accc^unt of the danger of its entrance into the trachea owing to the anesthetic larynx. Strychnin in full dosage, friction, massage, and the galvanic or faradic current should be employed to promote return of sensation and motion. The electrode shown in Fiir. 167 is one of the best for electric Mackenzie's improved laryngeal electrode for paralysis of the cords. applications. In all cases the voice should be given as much rest as possible. Any inflammatory condition of the upper air-tract should receive prompt attention along the lines laid down in the special chapters. Recurrent Laryngeal Paralysis. — The movements of all of the muscles of the })iiaryiix except the cricothyroid are con- trolled by the recurrent laryngeal nerve, so that by its paralysis THE CARE OF THE BABY. By J. P. Crozet Griffith, M.D., Clinical Professor of Diseases of Children, University of Pennsylvania ; Physi- cian to the Children's GRIFFITH ON THE BABY Hospital, Philadelphia, etc. Octavo. 404 pages. Illustrated. Cloth, $t.50. SECOND EDITION, REVISED. The author has endeavored to furnish a reliable guide for mothers anxious to inform themselves ■with regard to the best way of caring for their "The best book for the use of the young mother with which we are acquainted. There are very few general practitioners who could not read the work through with advantage." — Archives of Pediatrics. cliildren in sickness and in health. He has made Iiis statements plain and easily understood, in the hope that the volume may be of service "The whole book is characterized by rare good sense, and is evidently written by a master hand. It can be read with benefit not only by mothers but by medical students and by any practitioners who have not had large opportuni- ties for observing children." — A)nerican Journal of Obstetrics. not only to mot^.ers and nurses but also to med- ical students and to practitioners whose oppor- tunities for observing children have been limited. For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS & CO., Publishers, 925 Walnut St., Philadelphia. ?<'■: «3t.fjt\' NERVOUS AND MENTAL DIS- EASES. By Archibald Church, M.D., Professor of CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES Clinical Neu- rologry, Mental Diseases, and Medical Juris- prudence, Northwestern University ; and Frederick Peterson, M.D,, Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York. Handsome octavo, 843 pages, with over 300 illustrations. Cloth, $5.00 net; Half Morocco, $6.00 net. SECOND EDITION. This book is intended to furnish students and practitioners with a practical, working knowl- edge of nervous and mental diseases. Written by men of wide experience and authority, it will present the many recent additions to the subject. The book is not filled with an ex- tended dissertation on anatomy and pathology, but, treating these points in connection with special conditions, it lays particular stress on methods of examination, diagnosis, and treat- ment. In this respect the work is unusually complete and valuable, laying down the defi- nite courses of procedure which the authors have found the most generally satisfactory. For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS & CO., Publishers, 925 Walnut St., Philadelphia. NEUROSES OF THE LARYNX. 587 the motion of the affected side is entirely lost, the immuned crico- thyroid causing no appreciable motion. Etiology. — Pressure on the nerve during its course is the most frequently observed cause of paralysis. Particularly is this true of the left side, where, by its close anatomical relation to the arch of the aorta, its power of transmission is exceedingly likely to be interfered with, especially by aneurysmal dilatation of that vessel. Enlarged lymphatic glands, mediastinal growths, cancer of the esophagus, pleuritic adhesions in incipient phthisis (more likely on the right side than on the left, because the pleura extends up higher on the right), effusion into the pleural and pericardial sacs may also, by pressure on the nerve during its course, cause paralysis. Central lesion, either by hemorrhage, embolism, endocarditis, disseminated sclerosis, or the ascending sclerosis of locomotor ataxia, may produce a similar result. The toxemia of such diseases as diphtheria and typhoid fever causes paralysis by giving rise to a toxic neuritis. The effect of these diseases on the terminal filaments of the nerves, either by the inflammatory involvement or by the local effect of the toxins, is to be considered. Local inflammation in the larynx, as of a simple laryngitis, may also bear an etiological relation to the condition. Symptoms. — Weakening of the voice rather than hoarseness is noted if there be unilateral involvement. Complete aphonia is the rule if both recurrent nerves be affected, the patient being- able to speak only in a labored whisper. In paralysis of one nerve only the voice after a time gains strength by the healthy cord being brought over against its affected fellow by the muscles of the soimd side. Other symptoms, such as cough, dyspnea, etc., are accidental and not relevant. Diagnosis. — In bilateral paralysis of the recurrent nerve the laryngeal mirror shows (Fig. 166, 2) the cords lying relaxed midway between adduction and pronounced abduction — the cada- veric position. The affected cord in one-sided involvement assumes a similar position, while the healthy side swings past its normal position in its attempt to meet its fellow, the sound aryte- noid cartilage passing somewhat in front and beyond that of the affected side. In determining this obliqnity of the chink of the glottis witii accuracy, align tlie center of the arytenoid commissure with the center of the epiglottis, or if that be at an angle, with the center of the soft palate and nvuln, anluml)isin, di]-ihtheria, enteric fever, and other acute infectious diseases. The symptoms, usually very mild — consisting only in .-liort- 590 DISEASES OF THE NOSE AND THROAT. ness of breath on exertion, probably due to the disease underlying the paralysis — are not paroxysmal in character. The voice is not aifected. The laryngeal mirror during phonation shows no ab- normality ; but during inspiration the cord of the affected side lies motionless in the center-line, while the sound cord is drawn away normally (Fig. 166, 3). The prognosis depends on the cause, and the possibility that implication of both sides may occur before the disease or condition producing the paralysis has run its course should always render the prognosis proportionately guarded. The treatment should be addressed to the factor causing the paralysis along the lines laid down under Bilateral Paralysis of the Abductors. Tracheotomy is never indicated. PARALYSIS OF INDIVIDUAL MUSCLES. Under this heading will be considered all those paralytic lesions of the other laryngeal muscles that are due to myopathic causes. AVith but few exceptions they are rare, usually the resultants of local inflammation ; or when associated with systemic diseases like rheumatism, lead-poisoning, gout, etc., are produced by the super- imposition of overuse of the voice or exposure on the local laryn- geal exhibition of the general condition. Paralysis of the Central Adductors (Arytenoids). — The arytenoid muscles alone may be aifected by paralysis, or the crico- thyroids also may be involved, if there is paralysis of the superior laryngeal nerve. The causes of paralysis of the central adductors are chronic inflammatory conditions of the larynx, hysteria, incipi- ent phthisis, diphtheria, or prolonged and severe illness of any kind. Hoarseness and a voice that easily tires or becomes lost are the symptoms produced by the partial closure of the glottis. The laryngeal image is characteristic, and consists, on attempted pho- nation, of accurate approximation of the cords for their anterior two-thirds, while a triangular opening is left from this point with the vocal processes at the apex, due to the failure of the arytenoids to contract (Fig. 166, 4). Paralysis of the Internal Tensors (Thyro-arytenoids). — This is the commonest form of paralysis of the cords, because by their anatomical relation, lying just beneath the mucous membrane covering the under surface of the cords, the thyro-arytenoid mus- cles are most often implicated in inflammatory processes involving this region. It may be bilateral or confined to one side of the larynx. Overuse of an inflamed larynx in singing or speaking, fatigue or strain of the muscles, and hysteria or diphtheria are the commonest causes of the condition. The voice is altered by being weakened and limited in range, the higher notes being either entirely lost or reached after painful effort. In severe cases the voice is reduced to a labored whisper. NEUEOSES OF THE LARYNX. 591 The appearance of the cords during phonation renders the diagnosis easy, for instead of closely approximating, there is seen an elliptical opening extending the whole length of the glottis, produced by the cords bellying up before the current of air instead of being tightly tensed, as they normally would be by sound thyro- arytenoids. Bilateral Paralysis of Adductors (I^ateral Crico- Ary- tenoids). — Hysterical aphonia is usually treated under this head- ing, but that condition being rather a paresis than paralysis of the cords, is considered elsewhere under Hysterical Aphonia. Bos worth asserts that, while he has never seen an instance of this disease, a genuine myopathic paralysis involving the lateral crico-arytenoid muscles may be due to lead-poisoning, exposure to cold, to diph- theria, or to any of the exanthemata, and would give rise to com- plete loss of voice with phonatory waste. The laryngeal image (Fig. 166, 5) so closely resembles that of double recurrent nerve paralysis that differentiation is practically impossible. Unilateral Adductor Paralysis (I/ateral Crico- Aryte- noid). — This condition is not only extremely rare, but also pecul- iarly difficult to diagnosticate. Myopathic paralysis, due to the same causes as mentioned above, has occasioned the condition which is characterized by impairment or absence of phonation. During phonation the affected cord lies tightly drawn in complete abduction, Avhile its fellow tries by extra effort, passing over the central line, to effect approximation, the sound arytenoid cartilage passing in front of that of the affected side. Prognosis. — The prognosis for all the preceding conditions depends on the character of the underlying cause and the length of time it has been operative. If consequent upon one of the acute infectious diseases or exposure, the outlook for spontaneous or speedy recovery under proper treatment is good. The inability to procure absolute rest for the affected muscles makes the prog- ress proportionately graver, especially in involvement of the thyro- arytenoids. Treatment. — Removal of the cause should be the first reme- dial effort, licst that is as nearly complete as possible should be insisted upon by forbidding loud or prolonged use of the voice, limiting necessary conversation to an easily produced whisper. Faradism or, failing this, galvanism should be applied daily to the affected niusclcs for five to ten minutes. Use l)oth electrodes within the larynx, or ])l;i('e one on tlie outside of that organ, while the other is introduced tlirough the mouth. Strychnin ])n>lic(| to f The general health shoiild ment by the ordering ol' co outdoor exercise, and lilx and the other vegetal dc ;ii dl tolerance is an admi I'IM'ClX'C IJl'dpCl' li\l^|l'|||C rable adjuvant, uid tonic treat- d,~|)on-vs, lollowcd hv Ti i;d diet, togetiicr with < d mineral tonics. iction, massage, •oca wine, kola, CHAPTER XXI. INTUBATION OF THE LARYNX. Definition. — Intubation, or, as it is termed from tlie name of the physician to ^vllom we owe the perfected operation, O'Dwyer's operation, consists in the location within the larynx of a suitable respiratory tube for the relief of dyspnea due to certain forms of larynijeal obstruction. Indications. — The indications for this procedure may all be Fig. 168.— Sh(3wing intubation tube just entering the larynx, as well as the method of introduction. referred to a single condition — namely, an obstructive dyspnea threatening life and arising from an occluded condition of the 592 INTUBATION OF THE LARYNX. 593 larynx, other than a glottic spasm. The difference between the indications for tracheotomy and for intnbation is one largely of degree rather than kind. The operation naturally finds its great- est utility in the treatment of membranous occlusions, either local- ized within the larynx or extending into it from above. The dangers of edematous conditions caused by inhalation of irritant vapors, by the swallowing of irritant fluids, as the result of burns or scalds, or occurring in the exhibition of renal symptoms or other organic lesions, may ofttimes be averted by it without resort to tracheotomy. Certain slowly progressive stenotic condi- tions, as of specific cicatrization, may indicate it. If, however, the larynx be the seat of growths, benign or malignant, especially if, in the latter case, a laryngectomy is intended, or of morbid process requiring cessation of functional activity, the physiological rest of the organ had better be obtained by tracheotomy rather than by in- tubation. It is an operation suited to those of younger years, and, with equal indications for its performance, is to be preferred to tracheotomy when the latter must be performed through a short, fat, chubby neck. The operation is contra-indicated if the obstruc- tion is with reasonable certainty believed to be located or extend below the lower end of the intubation tube. Nor must efforts at placing it in position be continued if more than a very moderate degree of force be necessary to pass it into or through the glottic chink. The operation is also contra-indicated during a spasm of the glottis. If, however, these occur in paroxysms, with remissions of sufficient length to permit it, intubation is most emphatically indicated during an interval. It is not an operation suited for the removal of foreign bodies. Instruments. — For this operation a special set of instruments and tubes is required, O'Dwyer's is preferable (Fig. 169). These comprise an introducing instrument, an extracting instrument for withdrawal of the tube, and a set of tubes with their proper gauge. In addition, a stout, self-retaining mouth-gag, some strong and fine braided silk, strips of rubber or adhesive plaster, open finger-stalls or a silk handkerchief for protection to the operator's fingers, and some sort of protective mask for the mouth and nose should be at hand. Sufficient instruments for the performance of a rapid tra- cheotomy should be held in readiness for any sudden emergency. The tul)es are in sets and accompanied by a gauge denoting sizes for each age. In shape, the shaft of the tube may not inaj)pro[)ri- ately be likened to a spindle laterally compressed, with a medium symmetrical bulge and with the lower end cut square off and the edges rounded. The upper end is expanded into a flat collar, with bevelled ui)per surface to permit better relationship with the epi- glottis, and the edges are carefully rounded ; in short, the usual shape of the entire tube may b(! com])arcd to an inverted hoof and foreleg of a horse, from the knoe down. Special forms are made — 38 594 DISEASES OF THE NOSE AND THROAT. all, however, modifications of the primitive shape and too varied to permit of description here. The lumen of the tube is elliptical in section, and is filled by a blunt rod or obturator, jointed and provided with a screw top, the whole being ingeniously arranged to support the tube in introducing it, and yet to be quickly released and withdrawn by the introducing instrument. Through the collar of the tube there is a smooth perforation intended for the passage and retention of the braided silk, to act as a safeguard against sudden slipping of the tube downward. The introducing instru- ment consists of a curved staff, fitted at its distal end with a screw thread to attach the obtin^ator, and provided with a sliding appa- FiG. 1fi9.— O'Dwyer's intubation set. ratus, worked from the handle, for its release. The withdrawing instrument is simply a long, curved forceps, fitted with a pair of small, broad blades at its extremity, and worked from the handle. The blades are introduced closed within the tubal opening, opened, and by pressure against the inner surface of the tuber exert suf- ficient friction to permit tractit)n on the tube and its withdrawal. The gag should be of sufficient size to hold the mouth open to its widest extent, but otherwise needs no comment. An equally good tube, which is a modification of the O'Dwyer tube, has been intro- duced by Max Thorner (Fig. 170), and is described by him as follows : " In demonstrating a set of instruments which may be called INTUBATION OF THE LARYNX. 595 improved instruments, I wish to state that I do not think the word ' improved ' could possibly be applied to the method of intubation itself; for when Joseph O'Dwyer gave his great invention to the world he had for five long years worked at it at the New^ York Foundling Asylum with such assiduity that the method was then well-nigh perfected. Indeed, all possible objections and obstacles had received so much of his thought that little, if anything, has Fig. 170.— Thorner's improved O'Dwyer's set. to be added, that was of importance, to the original communica- tions of the inv(!ntor. However, those who have used the method a great deal have suggested from time to time that it might be possible to overcome some of the difficulties in the mani])ulation of the instruments used for intubation by making certain changes in them, whereby the method would ])C more facilitated. This would not in aiiy way diminish O'Dwyer's immortal merit nor influence the characteristics of his method. On the contrary, it was likely to advance its usefulness and appreciation of its value, 696 DISEASES OF THE NOSE AND THROAT. for no one wonld think it worth while to make eiforts at improving a thing of little or no value. " AH of those who have had some experience, or, I should rather say, a great deal of experience, with intubation, know that at times the manipulation of the instruments may become quite difficult. One of the troublesome features is that one needs two separate instruments for either introduction or extraction of the tube. In addition, the introducer is, as you all know, quite a complicated instrument, the terminal screw of which frequently does not hold the tube firmly in the right position. Another dis- advantage is that each of the six tubes requires an obturator of its own, and it not infrequently happens that the old obturators do not ahvays exactly fit new tubes of the same size. The old extractor is likewise a complicated instrument, and everybody knows that it is not always easy, even for expert intubators, to remove the tube with the aid of it. •' It has been attempted at a very early day to overcome some of these difficulties by some alteration in the iustrumentarium. One modification in the extracting apparatus, which is used a great deal, is that of Dillon Brown, which consists of a hook fastened to a thimble and a ring, attached to the upper end of the tube. By this means, w^ith the thimble placed on the right index finger, the tubes are extracted. However, there have been a great many attempts to combine the introducer and extractor into one instrument and to do away wdth obturators, the latter having often been the cause of great annoyance to the operator and of danger to the patient. A good many different instruments have been invented for this purpose, the description of which I w'ill omit. " The greatest advance was made in the instrument of Ferroud, which I show here, and which is rather complicated, as it consists of seven distinct parts which cannot be readily taken apart. On the principle of this instrument, an introducer and extractor com- bined has been constructed by a Chicago firm,^ which surpasses, in my opinion, all former attempts at simplifying these instruments. " The instrument which serves as introducer and extractor (Fig. 170, 1) has at its extremity two serrated beaks (a) about two inches long. They are opened by pressure with the thumb on the upper portion of the lever (6), and are automatically held open by a ratched arrangement, while pressure with the index finger upon the lower end (6) of this ratched bar relieves it and closes the beaks, liy firm pressure the beaks hold the tube immovably, so that it cannot slip off nor turn during an attempt at introduction or extraction. This whole instrument consists of only two parts — the handle with one Ijeak and the lever and ratched arrangement with the other beak (6 and «) — which two parts are readily taken ' Frank and Kratzmueller, 56 Dearborn Street, Chicasjo, 111. INTUBATION OF THE LARYNX. 597 apart by screwing the thumb-screw (c) toward the right. This screw has the further advantage of being so fastened to the instru- ment that it cannot be removed from the shank of it by unscrew- ing it in either direction, and therefore cannot be lost at a time when such a loss would frequently cause a very disastrous delay. '' The tubes also have been slightly modified. While the gen- eral configuration of the tube is an exact reproduction of the orig- inal O'Dwyer tube, the top of it has been slightly changed, in that the opening has received a funnel shape, slanting from the edges of the rim of the tube toward the center. This facilitates the introduction of the beaks greatly when the tube is in the larynx, inasmuch as it allows the beak to glide from any point of the rim almost automatically into the opening, and what this means can be appreciated by tliose who have had experience with the old extractor. Another change that the tubes have received is that the lower end has been cut off at an angle of about forty-five degrees, slanting from right to left. This facilitates the passage of the tube between the vocal cords and at the same time will prevent injury to the tissues, as the knob of the obturator, which in the original tubes closes their opening, is absent in these. The absence of the obturator and its knob has the additional advantage that air passes through the tube along the side of and between the beaks of the introducer during and immediately after intro- duction — a fact which contrasts with the absolute obstruction to breathing while the obturator of the old instrument is in the tube. Therefore, with this instrument the operator need not be in such a hurry to introduce the tube and to withdraw the obturator. " A raouth-gag is furnished with this set of instruments which differs from the one usually found in the set of O'Dwyer's instru- ments.^ It consists of a wedge-shaped mouth-piece, wliich is fast- ened to two steel rings by the aid of a curved bar (Fig. 170, 3). In using it the assistant puts two fingers of his left hand through the rings, places the wedge-shaped mouth-piece, which is well cov- ered with rubber tubing, between the left molars, and keeps the left hand firndy pressed against the cheek of the patient. In this manner he not only keeps the mouth opened, but also steadies the head of the patient at the same time. "It can be readily seen that the method of intubation has not been altered in any degree by the use of these instruments, which Avill appeal to many as sim})lifying the manipulation to a great extent. '' In concliisioii, it may be added that the old tul)es can be used with this new iiitrodiu-cr and cxlractor as Avoll as the new tubes." Position of the Patient and Operator. — In the jnrform- ance of tiiis oj)eration the majority of ojierators place the ])atient upright, the arms confined by a sheet wound around the body, and ^ This nioutli-u:;iy' lias Ijccn devised by Dr. llcniotin of Chicago. 598 DISEASES OF THE NOSE AND THROAT. an assistant seated in a chair holding him immovably in the grasp of his knees and arms. A second assistant steadies the head from behind and at the same time makes strong vertical extension of the neck. The gag is placed, the oi:)erator introduces the forefinger of his left hand, guarded by the finger-stall, back in the mouth in the median line to the epiglottis, hooks it up, and holds it steadily lifted by slight lateral pressure on its edge. The tube, mounted on the introducer, is then passed carefully back in the median line to the top of the left forefinger, taking care to avoid touching sen- sitive areas, and keeping the handle of the introducer well depressed toAvard the patient's chest. Its end having reached the finger-tip, the handle is elevated, the end of the tube carefully guided into the larynx (Fig. 168), the obturator released aud withdrawn with the introducer, the tube gently pushed into its place by the finger, and the loop of silk either fastened to a tooth or brought out between the teeth and fastened to the ear or around the nock. Of course, previous trial should be made to be sure that the instru- ment is in working order and the loop of silk properly placed. But while this position has been and is used successfully, the author has adopted in his ONvn practice a position which has given him great satisfaction in operating, and which he finds possessed of certain advantages and without some of the disadvantages that the other entails. The arms and body of the patient are secured by a sheet wound tightly around them, and he is placed on his back at the edge of a table in such a manner that the head is allowed to hang over the edge and make firm extension on the anterior structure of the neck. An assistant on one side of the patient, leaning over, holds him firmly by pressure of his shoulders, and prevents lateral motion by confining him between his out- stretched arms, at the same time using his hands to hold the patient's head steadily in place between them. The operator takes his seat opposite the upturned fiice of the patient, inserts the gag with the handles turned away from him, and opens the mouth to its fullest extent. Using for the purpose a soft handkerchief, the tongue is seized by another assistant and drawn forward. Passing the guarded left forefinger into the mouth, the ejilglottis is lifted and held by lateral pressure of the finger. The introducer is taken in the right hand, the ends of the silk loop being secured by the fingers, and then, observing the same relation between patient and instrument as in the upright position, with the extended and curved right arm the tube is entered in the median line and advanced to the left finger-tip. By thus extending and curving the arm the operator may readily keep the instrument in the median line, and as he elevates the handle of the introducer in passing the tube into the larynx, he both works from himself and at the same time brings the handle in easy position to make the manipulations necessary to remove the obturator. The end of the INTUBATION OF THE LARYNX. 599 tube having reached the tip of the left forefinger, it is gently guided into the larynx, the obturator withdrawn, the tube care- fully pushed to its place, the silk loop secured, and the gag removed. This method the author finds in his experience to be easier in actual performance than when introduction is attempted in the upright position. The hard table gives a steady resistance of more utility in restraining the violent struggles of a patient than does the mere clasp of an assistant's arms. The light in the operating field is better and the danger of the tube slipping beyond control into the trachea or esophagus is averted. Further, if intu- bation should be found not practicable, or if any sudden impera- tive necessity arise, the position of the patient is at once available for tracheotomy. When the tube is in place, unless very marked, or at least sufficient, relief for the safety of the patient does not take place, thorough investigation must be made to discover the cause. Complications, Dangers, and Accidents. — Like all other operations upon the respiratory tract, the actual performance is more difficult than a written description would indicate. Strug- gling and gagging are more or less violent, and in spite of the vise- like grasp of the assistants, some sudden movement is almost sure to disarrange the relations of the instruments. Sudden slipping of the gag may occur during some such movement and result in a wound of the operator's hand, even if protected against it, which may lead to disastrous results. The operator runs the risk of per- sonal infection in eye, nose, or mouth from bits of material expec- torated during violent coughing. The tube may be found a mis- fit and require a repetition of the process. Or the tube may be dropped in the esophagus, or possibly even passed through the vocal bands into the trachea — complications which the prone posi- tion averts. Glottic spasm may occur sufficiently severe to pre- vent entrance of the tube, and even so protracted and severe as to demand tracheotomy. Finally, the tube may push ahead of it a mass of membrane and occlude the trachea beyond any hope of relief except througli tracheotomy, or it may become packed with shredded membrane and necessitate removal and (deansing. Postoperative Care. — A case of intul)ation, from the inser- tion of the tube to its removal, requires careful watching. Sud- den blockiiiu', |);irticiilarly in membranous cases, may occur and demand iimiicdint*' removal and cleansing. Tlie nurse in charge ]nust tlierefbre Ix- carefully instructed as to the dimger symptoms to !)(■ observed which demand the abstnietioii oi' the tul)e, and shown how to \\ith(h-;iw it b\- menus of ihe silk loo|t h'ft in silii. Should ;iii\- he.-it:iiii'\- lie iiole(| in the tube le;i\iiii:- its position, inversion of the patient nniM he |.erlni'inr(l, nnd the chest :ind back smartly Jni-ivd to di.^lod-e it. The tiihe may he ejected .hir- ing some parox\'sm of coiiLihinL:', in which ca.-c, noi inlV<'(|nentIy, it 600 DISEASES OF THE NOSE AND THE OAT. will be found on close observ^ation to l)e no longer necessaiy and may be removed. Or if it become detached from its loop and ejected, it may very likely be swallowed, though one need have little fear of untoward effects on its intestinal journey. Feeding of the patient presents some difficulty. By some patients liquids may be readily taken after a few preliminary efforts have been made. By others semi-fluids can be readily ingested, while still others may only be able to take milk or other fluids from an ordi- nary nursing bottle while lying with the head l)elo\v the level of the body. In some cases efforts at feeding seem impossible, and the stomach-tube or rectal alimentation may be necessary. Thirst may be assuaged by the sucking of small j^ieces of ice or the use of small rectal injections of water. If, however, it becomes evi- dent that nutrition is failing under the use of the tube, tracheotomy is to be performed and the laryngeal tube removed. Nor must the wearing of an intubation tube be in any case considered as in any way precluding the continued use of the general and local measures which exert a beneficial influence on the process present, and these must be rigorously maintained. The position and free- dom of the patient are to be modified only as the general course of his disease may demand. The removal of the tube is sometimes a matter of more dif- ficulty than its insertion. It may be ejected by the patient during a coughing paroxysm, and in such a case it may not be necessary to reinsert it. Careful watch must be kept on the respiration, and at the evidences of recurrent dyspnea the tube must be replaced. In removal of the tube for any cause temporarily, or to test the need of its further presence, the introducing instrument must be in readiness for its immediate replacement. If the tube is to be removed by the extractor, the same directions as for its insertion are to be followed, the closed blades of the extractor being passed to the glottic opening under the guidance of the finger-tip, the blades inserted into the tubal opening, separated, and the tube carefully withdra^vn. Sequels. — Following the wearing of the tube there is usu- ally a paretic condition of the vocal cords which ultimately dis- appears. Rarely, cartilage-erosion takes place from the pressure of a tube. SCUDDER'S FRACTURES THE TREATMENT OF FRACT- URES. By Charles L. Scudder , M. D., Assistant in Clinical and Operative Sur- gery^ Harvard Med= ical School. Hand- some Octavo volume^ with nearly 600 beaittifitl original illustrations. Crushed buckram, $4.50 net. .^ J- JUST ISSUED. This book is intended to serve as a guide to the practitioner and student in the treatment of fract- ures of bones, being a practical statement of the generally recognized methods of dealing with fractures. The attention of the student is di- verted fromi theories to the actual conditions that exist in fractured bones, and he is encouraged to determine for Iiimself how to meet the conditions found in each individual case. Methods of treatment are described in minute detail, and the reader is not only told, but is shown, how to apply apparatus, for, as far as possible, all the details are illustrated. This elaborate and complete series of illustrations constitutes a feat- ure of the book. There are nearly 600 of them, all from new and original drawings and repro- duced in the highest style of art. ^ ^ ^ For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS & CO., Publishers, 925 Walnut St., Philadelphia. OGDEN ON THE URINE icine anc CLINICAL EXAMINATION OF THE URINE AND URINARY DIAGNOSIS. A Clinical Guide for the Use of Practitioners and Students of Med- Surgery. By J. Bergen Ogden^ M.D.^ Instructor in Chemistry, Harvard University Medical School; Assistant in Clinical Patholog^y, Boston City Hospital. Handsome octavo, 425 pages, with 54 illustrations, and a number of colored plates. Cloth, $3.00 net. JUST ISSUED. The design of this work is to present in as con- cise a manner as possible the chemistry of the urine and its relation to physiologic processes; the most approved ■working methods, both quali- tative and quantitative ; the diagnosis of diseases and disturbances of the kidneys and urinary passages. ^J^^^^,^^,^,^ In addition to chemic and microscopic methods, which have been described in detail, special attention has been paid to diagnosis, including our present knowledge of the character of the urine, the diagnosis and differentiation of dis- eases of the kidneys and urinary passages ; an enumeration of the prominent clinical symptoms of each disease ; and, finally, the peculiarities of the urine in certain general diseases of the body. For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS & CO., Publishers, 925 Walnut St., Philadelphia. CHAPTER XXII. TRACHEOTOMY. Indications and Contra-indications. Low Tracheotomy. Operative Procedure. Laryngotomy. Instruments. Complications and Dangers. High Tracheotomy. Postoperative Care. Definition. — By tracheotomy is meant the incision of the trachea and the establishment, by means of tubes or otherwise, of an artificial patulous opening of more or less permanency. The same procedures upon the larynx are termed laryngotomy, thyrotomy, thyroidotomy, etc., according to the site of the incision. Indications and Contra-indications. — Prominent among these is the dangerous occlusion of the larynx by the membranes of diphtheria or croup, especially if the dyspnea be so severe as to cause recession of the vsofter tissues of the chest in inspiratory efforts. In these cases, unless intubation is practicable and affords marked relief, tracheotomy should be performed. The operation is often indicated in cases of edema of the glottis and periglottic tissues, whether caused by ammonia or other irritating liquids or gases, scalds or burns, or by some more distant lesions. Certain trau- mata at the base of the tongue and the pharynx, as well as laryn- geal fractures, may demand it. Protracted spasmodic seizures of the larynx may cause dyspnea sufficiently severe to indicate it. Tubercular laryngitis, especially if attended by much adjacent tumefaction of tissues, and the progressive stenosis of syphilis or its ol)structive gummata may require it. The same is true of obstruction from certain laryngeal neoplasms, external pressure, and iuoperable malignant disease. Finally, the presence of foreign bodies in tlie air-passages, whicli defy efforts at removal through tiic pharynx, is the cause of a goodly share of the total number of tlie operatious performed. The operation, however, sliould be doiil)! fully considered iu those cases in which intubation of the hirvux oifers fair cliance for relief of the dyspnea. It may not be amiss here to caution the practitioner against error in attributiug dyspuea due to puluiouary or other organic lesions to laryngeal oi- ti:icli(':il obsli-iiclions wliich, in reality, are not preset) t. Operative Procedures. — Tli<' |>i<>|>lioul(l be placed upon the 601 602 DISEASES OF THE NOSE AND THROAT. back, with the head held in full extension and the structures on the anterior aspect of the neck thrown in outline as firm and tense as possible. To this end a narrow table is admirably suited, the shoulders of the patient being elevated slightly by a firm support, the neck resting on a bag of sand or salt placed at the edge of the table, and the head hanging over the edge and held firmly in the grasp of an assistant's hands or, better, in his forearms, leaving his hands free to use the retractors. The limbs are to be restrained by the use of cloth bandages or the hands of assistants, and all sudden motions of the patient are to be guarded against as far as possible. The best light attainable is to be thrown on the site of incision, and care must be taken that it is not so placed as to be darkened or impeded by the hand of the operator. General anes- thesia may or may not be employed, according to the circumstances of the case or the peculiar conditions demanding operation. If ether rather than chloroform is to be used, it is to be chosen only after consideration of its probable irritant and spasmodic effects upon the laryngeal structures. The hypodermic use of local anes- thetics, such as cocain, eucaiu, and the like, must be guardedly advised, in view of the vascularity of the region and its close prox- imity to the heart. Pain, however, after the skin is cut, is slight, and dermal anesthesia sufficient in extent and duration to incise the superficial tissues is readily obtained by the freezing spray. The site should, of course, be prepared, if possible, with the usual surgical precautions. Instruments. — The surgeon should have at hand, if possible, the following instruments : A narrow-bladed scalpel, a dry (Allis) dissector, grooved director, two small, flat-bladed retractors, two blunt hooks or aneurysm needles, a tenaculum, dissecting forceps, hemostats, a sharp bistoury or tenotome for opening the trachea, and one with a blunt point to enlarge the incision, if necessary, Keen's silver tracheotomy tube. Fig. 172.— Richard's tracheotoniy tube. several sizes of tracheotomy tubes with tapes, a tracheal dilator, tracheal forceps, and a curved needle threaded with stout ligature. Sponges, feathers, bent-wire retractors, flexible catheter, mouth- gag, and an alkaline solution for membrane if present are needed. A cautery might be of use in severe hemorrhage, and a basin of TRACHEOTOMY. 603 Fig. 173.— Cohen's trachea tube. cold water should be at hand for affusion upon the chest, if respi- ration is retarded after the operation. The variety of tracheotomy tubes that can be used is extensive, and their selection is largely a matter of personal choice. Figs. 171-173 can be adapted to most any case. The principle, however, which gives the most satisfaction is that of a curved tube fitted with an inner and removable second tube. The first or outer tube is made of various metals, preferably silver, for its bactericidal action, or rubber, and has a movable collar, which in turn fits a flange sufficiently broad to fit the neck comfortably, and pro- vided with appropriate means for its retention in situ. A size should be used as large as is compatible with freedom from irritation and strain upon the trachea. The operation may be per- formed at different levels of the neck, the isthmus of the thyroid gland furnishing a definite anatomical division between them. Thus, if the trachea be opened above the level of the middle of the thyroid isthmus, the procedure is termed high tracheotomy ; and if the incision be extended upward so far as to divide the cricoid cartilage, whether unintentionally, as sometimes happens, or with the full intention of the surgeon to do so, the operation is properly termed laryngotracheotomy. If, however, the trachea be opened by an incision extending downward from the mid-level of the isthmus, it is termed a low tracheotomy. Of these operations, the high tracheotomy is the more easily performed, because of the more favorable anatomical relations, and is the operation preferred by the surgeon for the majority of cases. Low tracheotomy is, however, more advisable in certain cases of foreign bodies and where it is desired to maintain a per- manent o])ening. High Tracheotomy. — The patient being in the position described, the surgeon takes his stand, either behind or at which- ever side best suits his convenience. The prominence of the thyroid cartilage is noted, and below it the cricoid. If possible, the course of the anterior jugulars should be determined ])rior to their possible encounter in the incision. Then steadying, if neces- sary, the structures of th(! tliroat Avith his free hand, witli liis unsupported, armed hand tlie first incision is made, extending from about the level of tlie cricoid to an inch and a half or two inches below and exactly in tlie median line. The skin being opened, any presenting veins should be pushed aside or tied off 604 DISEASES OF THE NOSE AND THROAT. and cut, the superficial fascia opened to the same extent upon the grooved director, and the deep fascia exposed. This is opened in the same manner and to the same extent, and the presenting veins, as before, are either pushed aside or tied off and cut. The inter- muscular interval between the sternohyoids and the sternothyroids is now located and carefully opened by a blunt dissector. This being done, the edges of the openhig made so far must be kept carefully apart by means of blnnt retractors reaching to the bottom of the wound. Too much care in placing and supporting these cannot be taken, both to avoid the very possible danger of mis- leading the surgeon's knife through a malplacement of the trachea and to minimize the amount of pressure upon it. The floor of the opening should now be formed by a layer of the deep cervical fascia, which in this region splits to enclose the thyroid isthmus, and more or less of the latter structure may be easily outlined or found bulging into the wound. The fascia is to be opened on a grooved director and the isthmus drawn downward by a blunt hook or small retractor. In case the isthmus fills too much of the wound to be so treated, a short transverse incision over the cricoid, not over one-half inch in length and through the fascia, may be made, and fascia and isthmus may be together stripped up and drawn downward. A quantity of loose connective tissue just overlying the trachea must be cleared carefully away and the cartilaginous rings plainly exposed. The trachea thus cleared, a tenaculum hook is fastened in the cricoid cartilage and held to steady the trachea. The knife is then to be so guarded by the forefinger as to prevent too deep a cut and posterior transfixion, and with its back to the sternum is to be inserted in the trachea above the isthmus in the middle line, while the two or three rings above it are to be opened by an upward cut. Care must be taken that, if a membrane be present in the trachea, it is opened also, lest it be forced downward by the knife. The opening made, there is usually more or less coughing, with ejaculation of bloody mucus and the like. This being cleared away, the edges of the woimd are to be grasped with dissecting forceps and held open, or a dilator inserted for the same purpose, the trachea cleared, as far as possible, of mucus and noxious material, the tracheotomy tube inserted, the tenaculum removed, and the tube tied in by tapes passed around the neck and tied on one side. Suture of the wound below the tube may be performed. Or if the so-called operation without tubes be intended, blunt-retractor hooks are inserted and attached to the appropriate elastic neck-band necessary to keep the opening patulous ; the edges of the cut are sutured to the skin, or an oval or diamond-shaped portion is removed, its long axis coin- cident with that of the trachea, according to which of these three methods the operator prefers. I/OW Tracheotomy. — Low tracheotomy requires practically TEA CHEO TOMY. 605 the same technic as the high operation. The skin-incision is made in the middle line, and extends from just below the cricoid car- tilage nearly to the manubrium. The fascial layers are lifted by the grooved director and opened carefully, veins and small arterial branches being pushed aside or tied oflP and cut. The intermus- cular space should be cleared and the thyroid isthmus be drawn upward by a blunt hook. Or it may be necessary, both in the high operation and the low, to pass a stout double ligature under the isthmus, tie, and cut between on the median line. In this lower site, also, the thyroidea ima artery must be kept in mind, the occasional height of the innominate artery to as far as the eighth or seventh tracheal ring, and the inverse ratio in the size of the thymus gland to the age of the patient. The remaining steps in the procedure do not differ from those already described under High Tracheotomy. I/aryngotomy. — This operation, owing to the superficial loca- tion of the cricothyroid membrane and the absence of vascular structures of importance, is the quickest and the least dangerous of the operative procedures ujDon the air-passages. The mem- branous interval between the thyroid and the cricoid is located, and a median vertical incision is made through the skin and fascia ; the sternohyoid and sternothyroid muscles are separated, and the cricothyroid membrane is opened by a transverse cut close to the cricoid border. The transverse incision is so placed as to avoid the small cricothyroid artery, and is to be made with a sharp knife, carefully guarded by the surgeon's forefinger, as in trache- otomy. A tube may be inserted, preferably shorter than that used for tracheotomy, or the wound may be kept open by retracting hooks, or allowed to heal by granulation, if its purpose be served. This measure is preeminently an immediate emergency operation, and one the few details of which should be thoroughly known by every practitioner. It should not be attempted on a patient under thirteen years, because of the small size of the cricothyroid space previous to that age. Operative Complications and Dangers. — The opening of the trachea wliile intrinsically not a f()niiidal)lo operation, may nevertheless be seriously complicated and filled with danger in its performance. Wliile undue haste is to be heartily condemned, yet so varied are the exigencies indicating the operation, that life may demand the hurried knife-thrust, witli no other preparation than a hasty pal))ation of landmarks. The incision necessary is in many cases dillictilt lo make from the almost uncontrollable tracheal movement in the violent ins])iratory efforts of the patient. Hem- orrhage is apt to be severe from the engorged veins so abundant in this region, though, happily, this complication lessens with the free establishment of respiration. Sudden and severe hemorrhage may follow a chance cut of the thyroid isthmus, and require rapid 606 DISEASES OF THE NOSE AND THROAT. use of the hemostatic forceps. The retractors may be wrongly placed or slip from position, causing a dangerous lateral dissection back even as far as the vertebral column, and attended by danger- ous pressure on the trachea or injury to the post-tracheal structures. In incising the trachea, if a membrane be present, the latter may be pushed ahead of the knife without being penetrated, thus either defeating the relief of the dyspnea, or aggravating it by packing the membrane in the lumen of the tube. Such an accident demands the prompt use of tracheal forceps (Fig. 174) and the Fig. 174.— Trousseau's tracheal dilator. scissors or knife. Again, an incautious use of the the knife may cause the posterior wall to be wounded, or even penetrated and opened into the esophagus. The trachea may be clogged by mucus or blood and mucus, or blood may have entered Avith the incision and demand a clearance. If so, the Trendelenburg position, or semi-inversion, is of prime importance, coupled with the prompt use of means to keep the opening patulous and expel the material. Aspiration of the wound by the mouth is inefficient, and in infec- tious cases highly dangerous. The insertion of a flexible catheter is of value, and it may be attached to an aspirating bulb or, better still, may have air blown strongly in it. It should be inserted so far as to form a channel to the lungs, if possible. Sudden cessation of respiration may occur both before and after the actual incision has been made. If incomplete, the tracheal opening must be made at once and cleared, and efforts at restora- tion of respiration be immediately performed. Hot and cold affusions to the chest, sharp slapping of the back or buttocks, and artificial respiration are indicated. Fortunately, the cessation is but momentary in the majority of cases, and the function readily restored. Postoperative Care, Dangers, and Complications. — Upon this, fully as much as the operation, depends the success of the object sought. If the operation has been successfully per- formed — as, for example, for the removal of a foreign body — and there exists no reason for a further use of the opening, the w'ound may be cleansed thoroughly Avith corrosive-sublimate solution, protected under a moist aseptic or antiseptic dressing, and allow^ed TRACHEOTOMY. 607 to heal by granulation. If, however, there is, any reason to antici- pate, from the irritation of the operative measures employed or the condition present, a sudden edema of the laryngeal or glottic structures, a tube must be inserted, or the wound kept patent by the use of retractors and tapes until this danger is past. Anti- inflammatory drugs should be administered, cough quieted by some sedative mixture, and the patient kept quiet in the recum- bent position. Healing is usually fairly rapid, but care must be taken that drainage is free. The care of a patient in whom the opening is to be maintained, either by tubes or Avithout, is more complex. The room must be at an even temperature of between 75° and 80° F., without draughts, and the air must be moistened. This may be done either by boiling water and allowing the steam to permeate the air or by slacking lime in a suitable vessel. If necessary, a tent of sheets or of blankets may be constructed over the bed to confine the vapor better. Feeding is usually not dif- ficult. Rectal alimentation may in some cases be necessary, and at times the stomach-tube. Attention must be paid to the kidneys and bowels, and above all the insurance of sufficient sleep and rest must be obtained. Nor must the usual systemic and local treat- ment of the existent condition be discontinued after the operation. If a tracheotomy tube be used, the patient must be carefully watched and prevented from pulling it out, especially while com- ing out of ether, and afterward if he be not old enough to under- stand its use. A light piece of gauze or fine muslin is to be damp- ened and kept before the tube, as a strainer for dust. The tube must be kept clear, and this will require a varying amount of attention, according to the condition present. In croup, etc., the tube should be cleared at very frequent intervals, the tube being cleansed with an alkaline fluid and a feather. This may need to be done every half hour, and not infrequently the inner tube must be withdrawn for sudden blocking by a piece of detached mem- brane. The cannula should also be cleansed by an alkaline solu- tion, and must not be left too long without its inner tube. A bet- ter plan is to have two of the latter and use them alternately. In membranous cases, also, blocking may occur by a piece or roll of the membrane which cannot be removed through the tube, and may necessitate the withdraA\'al of the whole apparatus and the use of the tracheal dilator and the tracheal forceps — instruments which should be always at hand. The nurse should also be warned of this possibility and instructed how to withdraw it, remove, if neces- sary, the- impacted membrane, and keep the opening patulous by retractors until the siu-geon arrives. The replacement of the tube before the wound has healed sufficiently to form a canal for it requires some skill ; Init after the wound has so healed, about the third day, it is a conqjarativcly simple matter. Every tM'o or three days the outer tube should be withdrawn, spots of discolora- 608 DISEASES OF THE NOSE AND THROAT. tion from possible sloughing areas noted, and the areas touched by silver nitrate, the wound cleansed, and the tube cleansed and replaced. The length of time the tube is to be left in situ varies with the nature of the case and the object of the surgeon. In membranous cases from eight to fifteen days are usually required, the time of removal being indicated by the progress of the condi- tion and the respiratory ability, as shown by stopping the end of the tube momentarily with the finger. After its removal the canal formed usually closes in and heals kindly by granulation, a few thicknesses of gauze being kept over the opening until it closes, when a firmer dressing may be apjjlied. In some cases, however, there is difficulty in removal of the tube permanently, especially in young subjects, because of structural changes in the vocal cords, paralytic conditions of the laryngeal mechanism, or stenosis of the trachea. Granulation-tissue in the larynx or trachea may also pre- vent it. In these cases the tube must be worn until proper local treatment has remedied the obstructive cause. In any case, after removal of the tube the surgeon must stand prepared to reinsert it, until a reasonable lapse of time shows its needlessness. The care of cases without tubes is practically the same, the opening being kept as clear as possible and protected by moist gauze lightly over it. Cicatrization proceeds somewhat slowly because of the preventive measures used to keep the opening patulous, and it may be necessary, from time to time, to press the edges apart or slightly nick them. Postoperative complications sometimes occur, the most impor- tant being undue sloughing of the wound from pressure, cellulitis, emphysema, and edema of the cervical tissues. Secondary hemor- rhage is not unknown, and has proved fatal in a few instances. Erysipelas may develop, as well as diphtheritic infection of the wound. Exuberant granulations may occur, and sometimes of such size as to be termed vegetations. Sloughing of the tracheal cartilages is not so likely to occur, but does occasionally take place. PRACTICAL POINTS IN NURS- ING. For Nurses in Private Practice. By Emily A. M. Stoney, Graduate of the Training: - School STONEVS NURSING for Nurses, Lawrence, Mass.; Late Superintendent of the Training;-SchooI for Nurses, Carney Hospital, South Boston, Mass. 456 pages, handsomely illustrated. Cloth, $J.75 net. J- ^ SECOND EDITION, REVISED. The autliof explains, in popular language, the entire range of private nursing as distinguished from hospital nursing, and the nurse is instructed how to meet the various emergencies that arise. A valuable feature of the -work will be found in the directions for improvising everything ordi- " There are few books intended for non-profes- sional readers which can be so cordially endorsed by a medical journal as can this one." — Thera- peutic Gazette. " A work that the physician can place in the hands of his private nurses with the assurance of benefit." — Ohio Medical Journal. narily needed in the sick-room. The Appendix contains much information of great value to the nurse, including Rules for Feeding the Sick; Recipes for Invalid Foods and Beverages ; Dose- list ; and a complete Glossary of Medical Terms and Nursing Treatment. ^ *?« ^ ,^ ^ ^ For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS & CO., Publishers, 925 Walnut St., Philadelphia. • THE PATHOLOGY AND TREAT- f AENT OF SEXUAL ITy^OTENCE. By Victor G» Vecki, M. D. From the second German edi- tion, revised and re- VECKI'S SEXUAL m'DPOTEJ^CE written. Handsome Demi-Octavo vol- ume of nearly 300 pagfes. Cloth, $2.00 net. RECENTLY ISSUED. Although no one denies that the sexual function is of the very greatest consequence to the indi- vidual as well as to society in general, yet the subject of impotence has but seldom been treated in this country in the truly scientific spirit that its pre-eminent importance deserves, and this volume will come to many as a revelation of the possibilities of therapeutics in tliis important field. The author ventures to assert that in " It is a well-wrilten. scientific work . . . can be recommended as a scholarly treatise on its subject, and it can be read with advantage by many practi- tioners."— yo«r-«a/ of the American Medical Asso- ciation. many cases it is a better deed to restore to an impotent man the power so precious to every iadividual, than to preserve a dangerously sick person from death, for in many cases death is preferable to impotence. This edition, although based on the German edition, has been entirely rewritten by the author in English. ^ ^ ^ For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS & CO., Publishers, 925 Walnut St., Philadelphia. CHAPTER XXIir. OPERATIONS ON THE LARYNX. By W. W. Keen, M. D., LL.D., Professor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical College!^ Philadelphia. Preparatory Treatment. Complete Laryngectomy. Dangers. Artificial Larynx. After-treatment. • Partial Laryngectomy. Thyrotomy. Before considering the individual operations, there are a few general remarks applying to all such operations, the statement of which will prevent needless repetition. Preparatory Treatment. — While in the larynx, as in the nose and mouth, perfect asepsis cannot be obtained, yet partial asepsis, which is very practicable, has given so much better results than before that it should never be neglected. Tlie teeth should be thoroughly cleansed with a tooth-brush and po^^'der, and then by listerine or other similar agreeable antiseptic. If there are any old stumps or diseased teeth, they should be removed and a few days allowed for the healing of the Avounds. Next, if possible, for at least forty-eight hours before the operation, each nostril and the mouth should be sprayed every two hours with a solution of boric acid, gr. v to the fluidounce of Avater. Dangers.— The dangers of operations on the larynx are — first, shock ; second, hemorrhage; and third, and quite as serious as either of tlie others, a subsequent aspiration pneumonia. The first two dangers are to be met, as in any other operation, by the ordinary surgical means of prophylaxis against shock and the immediate arrest of hemorrhage. If serious liemorrhage is to be feared, prejiarations should be made for instant transfusion of salt solution, or, instead of this, for hyjKxlermoclysis. The third danger arises from the entriuu^e of l)lood and infected wound- and mouth-fluids through the trachea into tlie buigs at the time of operation, or later from the entrnucc of the infected wound- fluids aided l)y hvj)ostati(' congestion. lO iixoid these dangers during the operation tlie trachea is blocked nj) cither by an ordi- nary cannula surrounded by gauze, or by (icrstcr's, Ti-cndclcn- })urg's, or Hahn's cannulii. The last three I li:i\-e ninned in llie order of desirability. The nietli(M| ndvdcated below is, linwever, better, and avoids ilie nse ul' any t:nn|M.n cannulas. .S9 609 610 DISEASES OF THE NOSE AND THROAT. As an additional safeguard, most of the text-books recommend a preliminary tracheotomy. As to the time Avhen this preliminary tracheotomy sliould be done, opinions vary. Perhaps the majority advise it ten days or more before the laryngeal operation, so that the patient shall be well past its dangers and become accustomed to the novel method of breathing. Others prefer to do the trache- otomy as the first step in the laryngeal operation, objecting to the earlier tracheotomy, as it causes adhesion of the parts to be oper- ated upon. For my own part, in almost all operations on the upper air-])assages, such as removal of the upper or lower jaw, cleft palate, hare-lip, epithelioma of the lip, removal of the tonsil, removal of adenoid growths or of tumors of the nasopharynx, removal of the tongue, and thyrotomy, I do not, as a rule, prac- tise tracheotomy. After a good many years of experience, I find that I avoid both the entrance of blood at the time of the opera- tion and of pus or Avound-fluids afterward into the lungs, by placing the patient during the operation in the Trendelenburg position, and after tiie operation keeping him in the same position for two or three days by elevating the foot of the bed on a chair. In all such cases I prefer, if possible, to get my patient out of bed at the end of two or three, or at most four, days, and so avoid inviting a pneumonia by the hypostatic congestion of the lungs. After-treatment. — As already indicated, the Trendelenburg posture is kept up for a few days, and the patient got out of bed as early as possible. I also resume tlie use of the boric-acid spray through the mouth and each nostril, so as to keep the parts as aseptic as possible. The only other after-treatment to be consid- ered is the administration of food. I postpone giving food by the stomach for two or three days, using nutritive enemata during that period. The patient is then fed through a rubber tube, passed either by the mouth or nose ; and when feeding is com])leted, a tablespoonful or two of sterile water is poured through the tube, so tliat the Avithdrawal of the tube will not infect the mouth. Moreover, I use, as a rule, during this artificial feeding sterilized rather than plain milk. When this food is administered, the foot of the bed should be lowered to the level for the moment. It must be remembered also that sometimes patients can swallow solids better than fluids. If this is the case, feeding by the tube is not to be employed. THYROTOMY. This operation consists in splitting the thyroid cartilage in the middle line. Object. — The object of thyrotomy is either the removal of a neoplasm in the larynx, or occasionally the removal of impacted foreign bodies. Of course, a thyrotomy will never be done even for these conditions, if they can be dealt with through the mouth. OPERATIONS ON THE LARYNX. 611 Preparatory Treatment. — This has already been indicated in the general remarks. Posture. — The Trendelenburg posture is used at the time of operation. In no case have I done a preliminary tracheotomy in thyrotomy. It is especially bad in the case of foreign bodies, where the wound can be closed immediately without the slightest trouble. If edema follows the operation and requires tracheotomy, it may be done at that time, but it will rarely be required. Incision. — This should be made precisely in the middle line, from the hyoid bone to the first ring of the tracliea. The soft parts should be divided directly down to the cartilages. Before dividing the thyroid cartilage it is well to open the thyrohyoid membrane, retract its edges, and ascertain whether it is possible to complete the operation without dividing the cartilage. Division of the Cartilage. — This can be done in younger patients with a pair of scissors, but after middle life the cartilage becomes ossified and requires either a fine saw or bone-forceps. The greatest care must be taken to see that the division is precisely in the middle line, so that the vocal cords shall not be injured. Removal of the Growth. — The edges of the wound are now forcibly drawn apart by retractors, and occasionally, but rarely, it will be necessary to divide the cricothyroid and the thyrohyoid membranes transversely at the upper and lower borders of the cartilage. The growth can now be removed by scissors, knife, or sharp spoon, and hemorrhage easily controlled. As a rule, it is not necessary to remove the cartilage, as Mr. Butlin has shown that the cartilage is only involved very late in such new growths. Possibly, further experience may show that it is not wise to retain the cartilage. At this stage of the operation there is apt to be a good deal of reflex irritation and cough, which can be allayed by the use of cocain. Closure of the Wound. — As a rule, it is not necessary to suture the cartilage itself The raucous membrane may be sutured with fine catgut, and then the soft parts down to, but not through, the cartilage are sutured with interru])ted silkworm-gut sutures. After-treatment. — The after-treatnu'ut above indicated should be cai'ricd out carefully. COMPLETE LARYNGECTOMY. A Ithoiiuli llic first coinplcte laryngccldiny \\;is (lone l)y W'atsdU of j^fliuhiirgh in 1H(!(;, tlic operatioii I'cally' dales (r(»ni its intro- duction !)v IJillrotli in lS7o. i'artial lai-\ nuvcloni\- was (irst doiu; by liillroih in 187.S. Object. — Practically, laryngccl.nnv. citlu r |KirlIal or (•(anplcte, is done only in cases of malignant uiowllis. 612 DISEASES OF THE NOSE AND THROAT. The preliminary treatment has been indicated above. The posture during the operation should be the Trendelen- burg, the siii-geon standing to the patient's right and his principal assistant on tlie opposite side. Preliminary tracheotomy is done by most surgeons as the first step of the operation, but more commonly, as a rule, ten days or more before the principal operation. This accustoms the patient to breatliing through the artificial opening ; it facilitates the anesthesia, which is done through the tracheotomy tube, and, in addition to this, the lungs are far less likely to suffer from pneu- monia. My own judgment is that a preliminary tracheotomy can be entirely avoided by the technic described below. Doubtless there will be some cases to which this would not be adapted, and a tracheotomy would have to be done. This is certainly true in cases in whicli, from the dyspnea, the patient's general condition would be greatly improved by a week or two of unimpeded respi- ration through a tracheotomy tube. In not a few cases, however, the tracheotomy might be only a temporary one, and done at the time of the operation. The Operation. — A median incision is made directly down to the cartihiges and the trachea, from the hyoid bone to the second ring of the trachea. If there is any doubt as to whether a com- plete or partial laryngectomy is required, a thyrotomy, as indicated above, should be done, and the parts examined. If, then, it seems certain that complete laryngectomy is to be done, the operation is proceeded with. The technic which I adopted in my last case, and which is, I think, preferable to any I have previously practised, is the only one I shall describe.^ It was as follows : 1. After the preliminary treatment just described had been car- ried out for three days, the patient was placed in the Trendelen- burg position and etherized througli the mouth. This position was maintained tliroughout the operation and for three days afterward. 2. An incision was made in the median line, from the hyoid bone to within an inch of the sternum. A transverse incision may be made at the upper end if necessary, but I did not find it needful. 3. The soft parts on each side of the larynx down to the second ring of the trachea were dissected loose from the larynx as far as the esophagus posteriorly. Below the second cartilage, the separa- tion was made only in front in order to do the traclieotomy. In this dissection the operator should adhere as closely as possible to the larynx and trachea, unless the extent of the disease forbids it. 4. A low tracheotomy was done. Disregarding all special cannulas, which are apt to injure the lining membrane of tlie trachea, the largest-sized ordinary cannula was inserted into the trachea, and secured in place by disinfected tapes around the neck. ' " The Technique of Laryngectomy," Annals of Surgery, July, 1899. OPERATIONS ON THE LARYNX. 613 The inner tube was removed from the cannula, and in its place was inserted a metal tube connected by rubber tubing with the chlo- roform apparatus, which was now substituted for the oral method. 5. The trachea was now divided just below the cricoid cartilage. The larynx Avas then drawn forward to put on the stretch the tis- sues between the larynx and the esophagus. The esophagus Avas next very carefully separated from the larynx, chiefly by the finger, until the level of the arytenoid cartilages was reached, when the soft parts were all divided transversely and the tracheal box was removed. The attachment of the esophagus and pharynx is very intimate at the level of the cricoid, and special care is needed here to prevent buttonholing it. If this occurs, the opening should be immediately closed by Lembert sutures. 6. In order to prevent infection of the wound from the mouth, the upper edge of the anterior wall of the pharynx was next sutured quite closely to the tissues immediately below the hyoid bone. 7. The stump of the trachea was sutured to the skin of the neck. 8. The moment this was finally finished, the cannula was re- moved from the tracheotomy wound, and this wound, which had existed only for fifteen or twenty minutes, was closed by catgut sutures. What little chloroform was required after this was admin- istered on some cotton held in a pair of forceps over the tracheal opening. 9. The entire wound, excepting the mouth of the trachea, was now closed. A wisp of gauze was inserted to drain the space left by the removal of the larynx itself. If the epiglottis has to be re- moved, it should be done at the end of the fifth step, before sutur- ing the pharynx to the hyoid bone. By this means, I was able in this case to secure primary union throughout the entire wound, all the stitches being out at the end of a week. Tlie patient himself was up and walking about even before that. In my next case I purpose :i further improvement — namely, !•• omit any tracheotomy whatever (fourth ste]i), and to administei- the anestiuitic througii the mouth until the end of th(> fifth step, w oughly separated on both sides, an( .— Sliowinc the ( iixl trii dnvs nftc lie d J ,K,rts |-e:., 265 a cause of atrophic pharyngitis, 448 occlusion, due to empyema of the sphenoidal sinus, 311 polypus. See Myjoma, 217 resonance, alteration of, 383 tonsil, 354 tuberculosis. .See Tuberculosis, 136 twang, 28 Nasolacrimal duct, position of, Fig. 5. Nasopharyngitis, acute, 329 pathology, 330 treatment, 331 if complicating la grippe, 333 of ear complications, 332 of tirst stage, 332 for hypersecretion, 332 postnasal syringe in, 331 of relaxed circulation, 332 atrophic, 337 etiology, 337 symptoms, 337 as of foreign body, 337 position in which secretions accumulate, 338 Eustachian involvement, 338 treatment, 338, 339 liyperplastic, 339 treatment, 340 simple chronic, 333 complications, 336 diagnosis, 336 etiology, 333 predisposing causes, 333 exciting causes, 334 pathology, 335 prognosis, 336 symptoms, 335 treatment, 336 Nasopharynx, adenoma of, 200 anatomy of, 25 blood-supply of, 26 boundaries of, 25 carcinoma of, 230 chondroma of, 206 closure of by adhesions, 348 color of membrane of, 26 conditions causing nasal obstruction, 250 diseases of, 329 classification of, 329 fibroma of, 212 glands of, 26 infectious granulomata of, 458 inflammation of, 329, 337, 339 lipoma of, 215 nnicocele of, 225 mucous membrane of, 26 nerves of, 27 Nasopharynx, neuroses of, 341 papilloma of, 196 sarcoma of, 240 shape of, modifying pharyngeal ton- sil, 361 specific inflammations of, 340 view of in mirror, 35 Nebulizer, 47 hot-air apparatus with, 48 Necrobiosis, 58 Neoplasms, 194 adenocarcinoma, 245 adenoma, 200 of anterior nares, 200 of fauces, 201 of larynx, 202 of nasopharynx, 200 angioma, 202 of fauces, 204 of larynx, 205 of nasal passages, 202 of pharynx and uvula, 205 of tonsil, 205 carcinoma of ethmoid cells, 308 of larynx, 233 of nasal passage, 227 of pharynx, 232 of soft palate and uvula, 230 of sphenoid cells, 313 of tonsil, 233 cause of epistaxis, 180 chondroma of larynx, 207 of nasal passages, 206 of nasopharynx, 206 classification of, 194 cysts, 246 cystoma, 247 dermoid, 247 of frontal sinus, 325 simple or retention (mucocele), 247 exostoses, 207 fibroma of ethmoid cells, 308 of the frontal sinus, 325 of larynx, 213 of nasal passages, 209 of nasopharvnx, 211 of tonsil, 212 lipoma of larynx, 215 of nares, 215 of nasopharynx, 215 of pharynx, 215 lymphosarcoma, 242. See Sarcoma. of maxillary sinus, 300 mucocele, 225 myxocarcinoma, 246 myxoma, 217 of ethmoid cells, 308 of frontal sinus, 325 of sphenoid cells, 313 of neck, causing laryngitis cyanotic, 549 osteoma of the frontal sinus, 325 INDEX. 633 Neoplasms, osteoma of nares, 21 6 of sphenoid cells, 313 polyp, fibrous, nasal, 223 See Myxofibroma. papilloma, 196 of larynx, 197 of nares, 196 of nasal cavity, 196 of nasopharynx, 196 of pharynx, 197 sarcoma, 238 of ethmoid cells, 308 of fauces, pillars, and soft palate, 241 of larynx, 244 of pharynx, 241 source of origin, 195 of sphenoid cells, 313 of tonsil, 242 teratoma, 246 Nerves of nasopharynx, 27 of nasal cavities, 25, Fig. 8. Neuralgia of the larynx, 580 of the pharynx, 481 supraorbital, 176 Neuroses, complications hyperplastic rhinitis, 100 due to myxoma, 221 due to atrophic rhinitis, 114 of larynx, 577 anesthesia, 578, 579 chorea, 582 classification of, 577 cough, 577 dysphonia spastica, 583 hyperesthesia, 580 hysterical aphonia, 581 lai'yngeal vertigo, 583 mogiphonia, 578 neuralgia, 580 paralvsis, 585 bilateral abductor, 588, 589 adductors (lateral crico-aryten- oids), 591 central adductors (arytenoids), 590, 591 internal tensors (thvro-aryte- noids) 590, 591 recurrent laryngeal nerves, 586, 588 superior laryngeal nerves, 585, 586 ti.ble of, 584 unilateral abductor, 589, 590 unilateral adductors (lateral crico- arytenoids), 591 paresthesia, 579, 580 Neuroses, nasal, 160 of olfaction, 160 anosmia, 161 hyperosiuia, 161 parosmia, 160 treatment, 162 Neuroses, nasal, of nasopharynx, 341 aural reflexes, 341 laryngismus stridulus, 341 stammering, 341 of pharynx, 480 in prognosis of diphtheria, 416 reflex due to enlargement of faucial tonsil, 383 Neuroses, reflex nasal, 162 hydrorrhea as, 120 non-respiratory, ear, 176 aprosexia, 177 chorea, 177 epilepsy, 177 eye, 176 headache, congestive, 176 migraine, 176 neuralgia, supraorbital, 176 of heart, 177 of sexual organs, 177 of stomach, 177 tic douloureux, 176 vertigo, 177 treatment, 178 respiratory, asthma, 174, 175 cough, nasal, 173 hydrorrhea, 163 of larynx, 174 aphonia, 174 spasm, 174 of pharynx and mouth, 174 rhinitis hyperestlietic, 163 diagnosis, 170 etiology, 163 exciting causes, 165 history of theories as to, 163 predisposing causes, 163 summation of causes, 167 pathology, 167 symptoms, 168 treatment, 171-173 in simple chronic rhinitis, 90 sneezing, 162 of soft palate, acute bull)ar paraly- sis, 352 apoplectiform liulbar paralvsis, 352 chronic bulbar paralysis, 352 herpes, 352 neuralgia, 351 paralysis, 351 spasmodic contraction, 351 Nose, appearance in nasal lupus, 142 flattening of bridge in hereditary nasal syphilis, 134 leathcrv feeling of in scrofulous rhin- itis, 7S redness of in atrophic rhinitis, 117 in iiitumescent rhinitis, 95 ill simple dironic rliinilis, 91 swollen in acute abscess of the septum, 274 634 INDEX. Nose bleed, 179 Nostril, slit-like in catarrhal diathesis, 51 Obstructiox of nasal cavities, blood changes in, 52 causes of, 249 cause of pharyngitis, simple chronic, 435 Obstructive rhinitis, synonym rhinitis hyperplastic, 96 Occlusion of the nose, in acute abscess of the septum, 274 nostril, in confined suppuration max- illary sinus, 289 Occupation, as a cause simple acute pliaryngitis, 398 as a cause of septal perforation, 269 a cause of epistaxis, 179 causing acute rhinitis, 67 causing mouth-breathing, 52 favoring follicular pharyngitis, 441 pharyngitis, 426 rhinitis, 85 Odor in atrophic rhinitis due to pre- existing local lesion. 111, 112 of breatli frightful in gangrenous pharyngitis, 425 of breath in atrophic pharyngitis, 450 of breath in tuberculosis of pharvnx, 459 in carcinoma of larynx, 237 character of in purulent rhinitis, 119 in chronic supjiurative inflammation of the frontal sinus, 319 due to foreign bodies in nose, 189 in emphysema of the antrum of High- more, 297 extremely fetid in caseous rhinitis, 79 raav or mav not be in scrofulous rhin- itis,'78 none in rhinitis anemic, 77 rarely any in occupation rhinitis, 86 in simple chronic rhinitis, 90 O'Dwyer's instruments for intubation, 593 intubation for laryngeal stenosis, 494 Ogston-Luc, operation for empyema frontal sinus, 322 Olfactory nerves, 25 Optic neuritis, due to empvema sphe- noid cells, 311 tumors of sphenoid cells, 313 Oropharvnx. See Pharynx, illustration "of Fig. 1. Osteoma of frontal sinus, 325 of maxillary sinus, 300 of nasal cavities, anterior, 216 treatment, 217 of sphenoid cells, 313 Ostia ethmoidalia, 21 Ostium maxillare, Fig. 2 Otitis, acute rhinitis may follow cessa- tion of discharge in, 66 a complication of acute rhinitis, 69 Ozena, 102 a symptom properly, 103 diseases occurring in, 103 due to a combination of causes, 104 of maxillary sinus, 284 meaning of term, 103 not a disease, but a symptom, 104 synonym atrophic rhinitis, 105 hypertrophic, 96 larviicjis, 547 syphilitic, 123 variation in manifestations of, 103 Pachydermia diflusa, 198 laryngis, 552 verrucosa, 198 Packard, F. R., mentions amaurosis, following turbinotomy, 176 Paget's disease of nipple, compared with scrofulous rhinitis, 78 Pain, character of, in tonsillar and peri- tonsillar abscess, 376 in lupus nasal, 142 in suppurating ethmoiditis, 303 due to foreign bodies in nose, 189, 192 in pharynx, 485 freedom from, in nasal tuberculosis, 139 in actinomvcosis of the pharvnx, 473 " in acute catarrhal inflammation of the frontal sinus, 314 in acute nasopharyngitis, 330 in acute rheumatic pharyngitis, 455 in carcinoma of larynx, 237 nasal passages, 228 soft palate, 231 in chronic catarrhal inflammation of the maxillary sinus, 283 in chronic edematous rhinitis, 123 in chronic suppurative inflammation of the frontal sinus, 319 in confined suppuration of the frontal sinus, 320 in confined suppuration of tlie max- illary sinus, 289 in cryptic tonsillitis, 369 in edematous laryngitis, 520 in empyema of the :mtrum, 285, 288 frontal sinus, 317 sphenoidal sinus, 310 in follicular pharyngitis, 444 in glanders of pharynx, 469 in gouty or rheumatic tonsillitis, 372 in infective pharyngitis, 404 in nasal hydrorrhea, 121 in osteoma of nares, 216 in retropharyngeal absce-ss, 474 in sarcoma of larynx, 245 nasal cavities, 237 INDEX. 635 Pain in simple acute pharyngitis, 400 in syphilis of larynx, 556 primary of pharynx, 465 tertiary of pharynx, 467 in tubei-culosis of larynx, 564 on swallowing in acute superficial tonsillitis, 366 Palate hooks, condemned, 40 Palmar eruption, in syphilis of respir- atory tract, 128 Palmer's frontal sinus drill, 324 Panophthalmitis, in suppurating ethino- iditis, 305 Papillary edematous polypi, 219 Papilloma, nares, 196 nasal cavity, 196 nasopharynx, 196 treatment, 197 larynx, 197 causes of malignant change, 198 diagnosis of, 199 symptoms of, 198 treatment of, 200 varieties of, 198 pharynx, 197 treatment, 197 section of papillomatous growth, 235 site of carcinomatous growth, 234 Paralysis, acute bulbar of soft palate, 351 apoplectiform bulbar of soft palate, 352 chronic bulbar of soft palate, 352 diagnosis between simple chronic lar- yngitis and, 543 of pharynx, 482 progressive bulbar, 482 soft palate, 351 uvula, 351 of vocal cords, 585. See also Neuroses larynx. Paresthesia, larynx, 579 in atrophic rhinitis due to pre-exist- ing local lesion, 114 of pharynx, 481 Parosmia, 160 Peach cold, 163 " Peenash," 191 Pemphigus, of larynx, 551 of pharynx, 476* Perforation of septum, 269 Pericliondritis, cause of septal deviation, 253 diflferential diagnosis, 207 of larynx, 530. vSee Chondritis. relief ol'fiU-nia in, 522 I'eriddic.'il liypcrcsthetic rliinitis^l63 Peripliaryngeal piik'gmon, 404 PrritoTisiilar phlegmon, 375 Pertussis, 76. See Wht)opiii(i-cov(ih. Petroleum, externally in dry laryngitis, 549 Petroleum in membranous larvngitis, 527 in atrophic nasopharyngitis, 339 in atrophic pharyngitis, 452 Pharyngeal bursa, 26 catarrh of, 333 nystagmus, synonym spasm of phar- ynx, 482 tonsil, 355 Pharyngitis, acute rheumatic, 453 pathology, 454 symptoms, 454, 455 treatment, 455 atrophic, 447 diagnosis, 450 etiology, 447 alteration of secretion, 447 atrophic rhinitis, 448 due to atrophic lesions, 447 due to venous stasis, 447 following inflammatory contrac- tion, 447 gastric disturbances, 448 in diabetes mellitos, 448 nasal obstruction, 448 pathology, 448 bacteriology of, 449 cyanotic congestion, 449 scar-tissue pressure, 448 prognosis, 450 symptoms, 449 character of secretion, 449 cough, 449 Eustachian involvement, 449 itching of throat, 449 odor of breath in, 450 synonyms, 447 treatment, 450, 452 chronic rheumatic, 456 treatment, 457 complicating acute rhinitis, 69 hyperplastic rhinitis, 100 exudative, 433 follicular, 440 etiology, 440 pre(lisposing causes, 440, 441 exciting causes, 441, 442 treatment, 445, 446 gangrenous, 425 t real men t, 426 granular, synonym pharyngitis folli- cular, 440 hemorrhagic, 427 etiology, 427 follows eru])(ivc fevers, 428 treatment, 428 herpetica, 47(i hvpertropiiica latcriilis, 111 inrcctivc", 403 treatment, 405 meml)i-anous, 405 croupous, 405 uao INDEX. Pharyngitis, treatment, Loffler's solution in, 406 occupation, 426 phlegmonous, 403 sicca, 447 simple acute, 398 treatment, 401 simple chronic, 433 etiology, 434 constitutional diathesis, 434 improper respiration, 436 pneuraonokoniosis, 434 "rum cough," 434 slanting pharynx, 435 pathology, 436 prognosis, 439 symptoms, 437 digestive disturbances, 438 " globus hystericus " suspected, 438 " throat tire," 437 treatment, 439 subacute, 440 suppurative, 403 traumatic, 426 treatment, 427 Pharyngocele, 397 I'haryngomycosis, diagnosis, 478 treatment, 479 Pharyngotyphoid, 432 Pharynx, abscess, retropharyngeal, 474 actinomycosis of, 471 anemia of, 479 treatment, 480 angioma of, 205 carcinoma of, 232 diphtheria of, 407 diseases of, classification of, 395 diverticula or dihitation, 397 congenital pouches, 397 due to "bolting" food, 397 pharyngocele, 397 treatment, 397 dome of, 25 ecthyma of, 476 erythema of, 476 in exanthemata and other febrile af- fections, 428 chicken-pox, 433 erysipelas, 430 gout, 432 influenza (la grippe), 432 type of, 433 ulceration, 433 intermittent fever, 431 measles, 430 scarlet fever, 428 small-pox, 430 typhoid fever, 432 pharyngotyphoid, 432 typhus fever, 432 varioloid, 433 Pharynx, foreign bodies in, 484 glanders of, 468 hemorrliagic ulceration of, 428 herpes of, 476 hyperplastic change in, 445 infectious granulomata of, 458 lipoma of, 215 I.udwig's angina, 433 lupus of, 461 malformations and deformities of, 396 neuroses of, 480 classification, 480 anesthesia, 480 treatment, 481 hyj)eresthesia, 481 parestliesia, 481 neuralgia, 481 trcatinent, 482 of motion, 482 spasm, 482 paralysis, 482 glossolabiolaryngeal, 482 treatment, 483 reflex nasal, 174 papilloma of, 197 pemphigus of, 476 ])haryngomyc()sis, 478 jjulsating arteries of, 479 sarcoma of, 241 slanting, 435 syi.hilis of, 464 tuberculosis of, 458 urticaria of, 476 Phillips' electric head-lamp, 32 Phlebectasis laryngea, 550 Phlegm producing membrane, 22 Phlegmonous inflammation, acute of lingual tonsil, 392 laryngitis, 516 pharyngitis, 403 rhinitis, 8.S, 152 tonsillitis, 375 Photophobia in acute rhinitis, 68, 73 due to empyema of the sphenoid cells, 311 ■ Phthisis nasalis, 136 Physiology, maxillary sinus, 278 of nasal cavities, 27 Pineapple lor rawness, in sarcoma of ])harynx, 242 juice, in tuberculosis of pharynx, 460 Pituitary membrane, 22 Plethora, a cause of epistaxis, 181 Pneumonia, epistaxis in, 180 Pneumonokoniosis, affecting pharynx, 434 analogous to occupation rhinitis, 85 Poison, morphin, etc., cause of anosmia, 161 Pollen catarrh, 163 Polyp, fibrous, nasal, 223. See Myxo- Jibroma. INDEX. 637 Polyp, scissors, 222 Polypi causing chronic catarrhal inflam- mation of the frontal sinus, 315 mucous, 225 Polypoid hypertrophies, not to be mis- taken for pure myxoma, 221 growths, a cause of epistaxis, 180 Polypus, nasal, 217. See Myxoma. Porcher, on location of lesion in pharyn- geal paralysis, 483 Posterior rhinoscopy, 37 Postnasal catarrhal, chronic, 333 cavity 125. See Nasopharynx. lamp, 41 syringe, 46 Potter's saw scissors, 211 Preglottic tonsillitis, 390 Processes, specific inflammatory, 60 Prolapse of ventricles of larynx, 576 Prophylaxis of diphtheria, 422 Pruritic rhinitis, 163 Pseudocroup, 511 Ptosis in empyema of sphenoid cells, 311 Pulse in diphtheria, 411 Purulent ethmoiditis, synonym suppur- ating ethmoiditis, 302 inflammation, acute, frontal sinus, 317 inflammation, acute, maxillary sinus, 285 inflammation, chronic, maxillary si- nus, 286 nasal catarrh, 118 rhinitis, 118 Pustular or suppurative inflammation, 59 Putrid sore throat, 407, 425 Pyemia, hemorrhagic inflammation in, 59 QUELMALZ, method of treating deflec- tion of the septum, 256 Quinsy, 375 Rachitis, spasm of larynx in, 508 Rag-weed fever, 163 Ray fungus, 61, 471 Reflex nasal neuroses, 162 Reflexes, nervous, 114 Reigenier, cri ch canard, 474 Respiratory tract, subdivisicms of, 17 Retronasal catarrh, chronic, 333 Retropharyngeal abscess, 474, 526 treatment, 475 Rheumatic angina, 453 sore throat, 453 tonsillitis, 371 Rheumatism, acute articular, 76 rhinitis in, 76 causing chondritis of larynx, 530 diagnosis of chondritis of larynx due to, 537 laryngitis, acute, in, 505 nasal ulcers in, 159 Rheumatism, pathological changes, 532 prognosis of chondritis of larynx due to, 537 symptoms of chondritis of the larynx due to, 535 treatment of chondritis of larvnx due to, 539 Rhinoliths, 186 Rhinitis, acute simple, 65 complications of, 69 pathology of, 67 symptoms of, 68 treatment of, 69-73 acute, in constitutional diseases, 76 in diabetes mellitus, 76 in diphtheria, 76 in erysipelas, 77 in la grippe, 76 in measles, 75 in rheumatism, acute articular 76 in scarlet fever, 76 in scurvy, 77 in small pox, 76 in typhoid fever, 76 in whooping cough, 76 in young, 73 differential diagnosis between specific rhinitis and, 73, 74 treatment, 75 anemic, 77 eye implication in, 328 treatment of, 78 Rhinitis, atrophic, 104 atrophy due to trophic lesion, 118 atrophy secondary to lesion else- where, 116 pathology, 116 treatment, 117 classification, 105 primarv, direct lesion of part, 105 ■ secondary, due to pre-existing local lesion, 105 due to lesion elsewhere, 105 due to pre-existing lesion, 108 diagnosis, 114 etiology, 108, 109 pathology, 110 symptoms, 11 1 treatment, 1 14, 115 general remarks on, 1 05 fibrous formation and contraction, 107 , 109 los micro-organism ozena in, 101, 1 caseous, /9 facial deformilv in. 79 first described "l.v Dnphiv mikI I'uI- lin, SO treatment of, SO usually result of associated condi- tion, 79 638 INDEX. Bhinitis, croupous, 80 treatment, 82, 83 cyanotic, 122. See Rhinitis edematous chronic. diphtheritic, 85. See also Diphtheria, nasal. edematous, acute, 87, 88 treatment, 88 chronic, 122 treatment, 123 fetid, 104 chronic, 104 fibrinoplastic, etiology, 83 pathology, 83 treatment, 84 hyperesthetic, 163. See Neuroses. a cause of epistaxis, 180 hyperplastic, 96 membranous inflammation, lacrimal duct in, 328 pathology of, 97 symptoms, 97, 98, 289 treatment, 101, 102 hypertrophic, 96 intumescent, 94 treatment, 95 obstructive, 96 occupation, 85 treatment, 86, 87 phlegmonous, 88. See Furnnculosis, nasal, 152 acute abscess of septum, 88 may be associated with empyema of antrum of Highmore, 88 may be associated with alveolar abscess, 88 symptoms of, 88 treatment of, 88 plethoric, 117 purulent, 118 abscess of septum in, 274 etiology, 118 in new-born, 118 pathology, 118 in chronic variety is strumous rhinitis, 119 pyogenic membrane in, 119 treatment, 119, 120 in new-born, 120 relation of adenoids to, 356 sclerotic, 105 scrofulous, 78 occurs in poorly nourished children, 78 treatment, 79 sicca, 105 simple chronic, 89 causes, predisposing and exciting same as for acute, 89 intermediate between acute and atrophic, 89 pathology, 90 Rhinitis, simple chronic, symptoms, 90 treatment, 91 specific, difl'erential diagnosis between acute rhinitis in young and, 74 strumous, 78 eye-complication in, 328 not to be confused with rhinitis purulent, 118 syphilitic, 123 ulcerative, 87 Rhinopharyngitis acute, 329 chronic, 333 Rhinorrhagia, 179 Rhinorrhea, 65, 120 Rhinoscleroma, 61, 150 treatment, 151 Rhinoscope, 32 Rhinoscopy, 34, 37 Richard's tracheotomy tube, 602 Roe's operation for depression of carti- lages, nasal, 276 septum oiDeration, 261 Rontgen rays, of use in laryngology, 41 Rose catarrh, 163 cold, 163 fever, 163 Roux's antitoxin syringe, 419 Sajous' modification of Steele's septum operation, 261 nasal snare, 221 Sarcinse, found in normal nose, 64 Sarcoma, confused with actinomycosis of the pharvnx, 473 of ethmoid cells. 308 of fauces and soft palate, 241 of larynx, 244 cause of confusion as to, 244 symptoms of, 244, 245 treatment, 245 of maxillary sinus, 300 of may resemble glanders, 61 of nasal cavities, anterior, 238 treatment, 240 of nasopharynx, 240 of pharynx, 241 of sphenoid cells, 313 of tonsil, 242 lymphosarcoma of, 243 treatment, 244 Scarlet fever, acute rhinitis in, 76 apt to cause empyema of the an- trum, 285 cause of acute nasopharyngitis, 330 an exciting cause of atrophic rhin- itis, 109 laryngitis, acute in, 503 membranous in, 523 nasal ulcers in, 159 of pharynx, 428 pharyngitis, follicular, following. 441 INDEX. 639 Scheppegrell, cupric electrolysis in treatment of tuberculosis of larynx, 570 Schneiderian membrane, 22 Schroetter's improved laryngeal tube forceps, 214 lipoma of larynx reported by, 215 method of incising stenotic tissue in larynx, 495 Schwarze's gouge, 217 Schwellkorper, 24 Sclerotic rhinitis, 105 iScorbutic rhinitis, 77 Scotoma due to empyema of sphenoid cells, 311 Scrofulous ozena, 78 rhinitis, 78 Scurvy, epistaxis in, 180 nasal ulcers in, 155 Secretion, accumulation of, in atrophic nasopharyngitis, 338 acute nasopharyngitis, 330 alteration of, in simple acute phai'yn- gitis, 399 anemia of pharynx, 480 carcinoma larynx, 237 character in atrophic pharyngitis, 448, 449 character in simple chronic pharyn- gitis, 437 hydrorrhea nasal, character and dura- tion of, 121 increased in hyperplastic rhinitis, 99 in tuberculosis of pharynx, 459 in acute catarrhal laryngitis, 499 in laryngitis, dry, 548 follicular, 546 simple chronic, 542 in pharyngitis, follicular, 444 infective, 404 simple acute, 399 profuse in rhinitis, atrophic, 117 perverted in cryptic tonsillitis, 370 promotion of in cryptic tonsillitis, 371 in rhinitis, atrophic due to pre-exist- ing local lesion, 110 in sarcoma of the piiarynx, 242 in syphilis of larynx, 556 treatment of, in acute nasopharyngitis, 332 in tuberculosis of larynx, 566 of tuberculosis, nasal, 1 39 Sense of smell, disoi-ders of, Ki" Septicemia, hemorrhagic inll,iMiiii;itii)ii in, 59 Septum, abscess of, acute (phlegmonous rhinitis), 88 clironic, 275 abnormalities associated in hy[ier- plastic rhinitis, 98 anatomy of, 19, 248 Septum, anterior part, usual site of croupous rhinitis, 81 areas involved in hyperplasia in I hyperplastic rhinitis, 96 blood-supply of, 24 i cartilages of, 24S cartilages and bones of. Fig. 3 classification of affections of, 248 color of mucous membrane of, 23 conditions of, causing obstruction, 249 deflection and deviation, treatment, 256 pressure by tubes, 256 Gleason's "flap method, 262 histQry and list of operations for," 261 Ingals' operation, 261 operation for deflection due to disease of central incisors, 261 for deflection Avitli redun- dancy, 257 care in use of tubes, 261 diagram of, 260 tubes employed, 261 V-shaped part removed, 261 for siuiple curvature without redundancy, 257 causes of failure of crushing operation, 259 forceps for crushing, 257 method of controlling line of fracture, 258 operation for triangle deflection, 25S posto{)erative treat- ment, 257 removal of large tur- binates, 259 Watson's operation, 262 cause of anosmia, 161 due to lesion of central incisors, 261 deformities, 252 congenital deflection, 255, 256 deviation or deflection from disease, 253 traumatic deflection, 25:; dislocation of columnar cartilage, 254 treatment of, 255 split septum, 254 (icyiatioii of, pnvlis|i(i.siiiir cnusc of acute rhinitis, M\ distention of cayernous sinus at l.)wer part, 24 edema (submucous iufiltratinn), 273 abscess (acute), 272 exostoses of, 207 640 INDEX. Septum grooved by pressure in livper- plastic rhinitis, 99 iiematoma of, 276 liy peresthetic area on, in hyperesthetic rhinitis, 167 knife, author's, 93 malformations, 251 malformations of, a cause of epistaxis, 180 myxoma of, 220 nerves of, 25, Fig. 8 j)erforation of, 2<)9 etiology of, 269 illustration of, 270 list of causes, 271 pathology, 271 treatment, 272 in nasal leprosy, 149 in nasal svphilis, acquired, tertiary, 130 " in occupation rhinitis, 86 ulceration of, 266 etiology, 266 in measles, 75 treatment, 268 Sexual disorders, cause of hyperosmia, 161 organs, affections of as reflex nasal neurosis, 177 Sinexon's nasal dilator, 258 Singer's nodules, 552 Sinus thrombosis in empyema sphe- noidal sinus, 311 Sinuses, accessory, blood-supply of, 24, 25 color of mucous membrane of, 23 ethmoid, actinomvcosis, 307 anatomy of, 21," 302 catarrhal inflanuiiation. 302 classiticatiou of diseases of, 301 mucocele, 307 mucous membrane, character in, 22 position of. Fig. 5 position of outlets, 302 suppurating ethmoiditis, 302 diagnosis, 305 symptoms, 303 evacuation of pus, 305 eye symptoms, 305 mental involvement, 305 position whence discharge emerges, 304 retention of discharge, 305 treatment, 30b syphilis, 307 tuberculosis, 307 tumors, :>0S frontal, anatomy of, 21, 314 catarrhal inflammation, acute, 313 treatment, 315 catarrhal inflammation, chronic, 315 Sinuses, accessory frontal, chronic catar- rhal inflammation of, treat- ment, 316 ichthyol pledgets, 316 diseases of, 313 empyema, 317 acute purulent intlauuiiation, 317 symptoms, 317, 318 chronic suppurative inflamma- tion, 318 diagnosis, 319 symptoms, 319 confined suppuration, 320 prognosis, 322 symptoms, 320 cause of rupture, 321 due to pressure. 321 treatment, 322 Bryan's operation, 322 foreign bodies, 324 treatment, 323 infectious conditions, 325 infundibulum the outlet of, 22 mucous membrane character in, 22 mucocele, 323 position of. Figs. 1, 5 tumors, 325 functions of, 29 headaclie due to lesion of, 52 infraorbital, anatomy of, 22 position of. Fig. 6 involvement in carcinoma of the nasal passages, 229 of by animate foreign bodies in nose, 192 likely to be involved in rliinitis atrophic due to pre-existing local lesion, 114 mav be involved in atrophic rhini- ' tis, 117 in simple chronic rhinitis, 91 maxillary, actinomycosis of, 296 acute infectious diseases of, 297 anatomy of, 22, 278 catarrh of, in hydrorrhea nasal, 120 catarrhal inflammation, acute,28() treatment of, 281 catarrhal inflammation, chronic, 282 treatment, 283 symptoms, 282 diseases of, 278 disparity in size, 291 emphysema, 297, 298 empyema of, 285 acute purulent inflammation, 285 symptoms, 285 chronic purulent inflammation, 286 INDEX. 641 Sinuses accessory, frontal, chronic puru- lent inflammation, diagnosis, 288 confined suppuration in, 288 etiolog}', 289 symptoms, 289 transillumination, 290 treatment, 294 foreign bodies, classification, 298 glanders of, 296 may be associated with phleg- monous rhinitis, 88 mucocele of, 299 opening into, 280 ozena, 284 associated with nasal, 284 due to gas from tooth root, 297 treatment, 284 phlegmonous inflammation, 301 physiology of, 278 position of. Fig. 6 septa in, Fig. 2, 327 syphilis of, 296 teeth in relation to, 279 topography of, 279 tuberculosis of, 296 tumors, 300 nerves of, 25 ozena in, 103 primary lesions of, affecting nose, 50 sphenoidal, acute infection, 313 anatomy of, 21 catarrhal inflammation, 309 diseases of, 308 empyema, 309 from Thornwaldt's disease, 311 treatment, 312 mucocele, 313 mucous membrane, character in, 22 position of. Figs. 1, 5 syphilis, 313 tuberculosis, 313 tumors, 313 treatment, when involved by exten- sion in acute rhinitis, 73 use of postnasal lamp in diagnosis, 41 Skin, involvement in glanders, nasal, 4") I lesion of in svphilis, nasal hereditarv, 134 Slanting jiharynx, 435 Small-pox, acute rhinitis in, 76 causing chondritis of larynx, 530 laryngitis, acute, in, 503 maxillary siinis, 297 nasal nU^ers in, 159 of i)harynx, 430 pustular inflammation in, 50 Smeli, altered by myxoma. 221 lost in tertiary nas;il syphilis, 129 Smell, partial or complete loss in croup- ous rhinitis, 81 sense of, affected in rhinitis, simple chronic, 90 disorders of, 160 involved in suppurating ethmoid- itis, 305 lost in rhinitis, atrophic, 117 Snare, Jarvis' nasal, 222 Sajous' nasal, 221 Sneezing, due to foreign bodies in nose, 189 in acute rhinitis, 68 in acute rhinitis in young, 73 in animate foreign bodies in nose, 192 in nasal hydrorrhea, 121 paroxysmal, in occupation rhinitis, 86 Snoring due to pharyngeal tonsil, 360 Snuffles, 65 Soft palate, adhesions, 348 carcinoma of, 230 congenital absence of, 342 diseases of, 342 leukoplakia buccalis of, 231 neuroses, 350 neuralgia, 351 spasmodic contraction, 351 paralysis, 351 acute bulbar, 351 apoplectiform bulbar, 352 chronic bulbar, 352 occlusion, 349 congenital, 349 operation for, 350 syphilitic, 349 perforation, 348 sarcoma of, 241 syphilis of 464. See Syphilis of pharynx, Solly, climatic treatment of tuberculosis of larynx, 5(59 Spasm of abductors of vocal cords, 507 of glottis, 121, 507 of larynx, 507, 508, 510, 511 of pliarynx, 482 Spasmodic croup, 505, 507 laryngitis, 507, 511 Specific catarrh, 123 granuiomata, 60, 123 inflammations, 123 inllaminatorv processes, 60 riiiniiis. 123 Specula, 35 Sphenoidal sinuses. See Sinuses, acces- sor i/, Sji/ii ii'ilihll. Sporadic calarrli. 65 Spurious crnup, 497 Stages of inflammation, 51 Stammering, a neurosis of ii:isuph;irvnx, 311 Stapiiylococci found in normal nose, 64 642 INDEX. Steele, modification Bolton's septum operation, 261 Stenosis of larynx, 493 acquired, 495 congenital, 493 of pharynx, 396 Sterilizer, '49 Stoerk, cough spots of, 577 Stomach, affections of, as neuroses, reflex nasal, 177 Strabismus due to empyema of sphenoid cells, 311 Streptococci causing croupous pharyngi- tis, 405 membranous inflammation tonsil, 379 factor in rhinitis, membranous, 80 Stridulous angina, 511 laryngitis, 51 1 Strumous diatliesis in enlargement of faucial tonsils, 380 rhinitis, 78 Subacute pharyngitis, 440 Submucosa. See Mucous membrane. Submucous infiltration of septum, 273 Summer catarrh, 163 Suprarenal capsule for tuberculosis of pharynx, 461 Suppurating ethmoiditis, 302 Suppurative inflammation, chronic, of the frontal sinus, 318 laryngitis, 516 pharyngitis, 403 or pustular inflammation, 59 Sutton, J. Bland, classification of tumors, 195 Synechia, acquired, 264 appearance, Fig. 93, 264 etiology, 264 symptoms, 264 treatment, 265 adhesion of soft palate, 348 Syphilis, cause of chondritis of larvnx, 530 empyema of the sphenoidal sinus, 309 of parosmia, 161 of septal perforation, 269 of suppurating ethmoiditis, 303 chronic abscess of septum in, 275 depression of nasal cartilages in, 275 diagnosis, chondritis larynx due to, 536 epistaxis in, 180 ethmoidal cells, 307 hereditary, croupous rhinitis may oc- cur in, 80 larynx, 555 diagnosis, 559 from carcinoma, 567 from lupus, 567 from tuberculosis, 567 Syphilis, larynx, prognosis, 560 symptoms, 556 treatment, 560, 561 maxillary sinus, 296 may be found in rhinitis, caseous, 79 nasal, acquired, definition, 124 complications, 131 diagnosis, primary, 130 etiology, 124 pathology, 125 tertiary period, 126 prognosis, 130 symptoms, primary, 126 secondary, 128 tertiary, 129 treatment, primary, 131 secondary, 131 tertiary, 131 deformity, Bishop's support for, '132 Mayer's tubes for, 132 hereditary, definition, 133 diagnosis, 134 early, 134 late, 135 etiology, 133 " parental transmission," 1 33 pathology, 133 prognosis, 135 symptoms, early, 134 late, 134 treatment, 135 ozena in, 104 ulcers in, 157 paralysis of pharynx due to, 482 pharynx, diagnosis, 468 primary form, 464 prognosis, 468 secondary lesions, 465 tertiary lesion, 466 cicatrization, 467 gangrenous ulceration, 467 gumma, 466 ulceration, 466 treatment, 468 predisposing cause of acute rhinitis, 66 prognosis of chondritis of larynx due to, 537 soft palate, 464. See Syphilis pharynx. specific inflammatory process, 60 of sphenoid cells, 313 stenosis of larynx in, 495 of pharynx in, 396 symptoms of chondritis larvnx due to, ^533 tertiary, concomitant with acute rhi- nitis, 06 tonsils, 464. See Syphilis pharynx. treatment of chondritis of the larynx due to, 538 ulceration of uvula in, 347 INDEX. 643 Systemic diseases, influence of, on mu- cous membrane, 50 necessity of urinary analysis in, 50 Taste affected in pharyngitis, simple chronic, 438 altered in pharyngitis, simple acute, 400 Taylor, J. Madison, on dose of antitoxic serum, 420 Teeth affected in empyema of antrum, 288 in antrum, 298 close relationship to maxillary sinus, 279 crowded, due to improper nasal breathing, 355 diseases of, causing abscess of the sep- tum 274 of, as cause of sepfeal deviation, 253 gas from decayed, causing emphysema of antrum, 297 injury to, by nasal inflammation, 51 irregularly placed in developmental deformity, 255 opening the sockets of, for empyema of antrum, 295 ozena due to antral extension of, 104 due to nasal extension of, 104 preserved if possible in treatment of empyema of antrum, 296 tenderness of, in acute catarrhal in- flammation, maxillary sinus, 281 in confined suppuration, maxillary sinus, 289 Teratoma, 246 Third tonsil, 26. See Tonsils, pharyngeal. Thorner, Max, instruments for intuba- tion, 594 Thornwaldt's disease, 311 " Throat tire," 437 Thymic asthma, 507 Tic douloureux, 176 Tinnitus aurium, 310 Tobacco, use of, as cause of hyperes- thesia of pharynx, 481 Tongue-depressor, 39 Tongue in diphtheria. 410 Tonsil, angioma of, 205 carcinoma of, 233 Tonsils, classification of, 354 faucial, abscess, chronic, 388 tonsillar or peritonsillar, 375, 377 etiology, 375 pathology, 376 symptoms, 376, 377 treatment, 378 medical, 378 surgical, 378 faucial, 354 Tonsils, faucial, atrophy, 389 cryptic tonsillitis, 368 diseases of, 365 enlargement or hypertrophy of, 380 diagnosis, 383 enlarged, not necessarily increase of tissue, 380 etiology, 380 pathology, 381 prognosis, 384 symptoms, 382, 383 treatment, 384, 385, 386 varieties, 380 foreign bodies in, 389 symptoms of, 390 illustration of position of. Fig. 1. membranous inflammation of, 378 mycosis, 389 tonsillolith, 388 fibroma of, 212 infectious granulomata of, 458 intestinal, 415 laryngeal, 394 affections of, 394 anatomy of, 354 lingual, acute inflammation, 390 treatment, 392 acute phlegmonous inflammation of, 392 anatomy of, 390 classification of diseases of, 390 hyperplasia of, 393 illustration of position of. Fig. 1. location of, 390 mycosis of, 393 synonym, 390 varices of, 393 treatment, 394 mycosis of, 479 nasal, 354 pharyngeal, 354 behind pillars, enlarged, 359 cnusi' of enlargement, 43 (li-iial .■xaniination of, 359 diaguusis, 361 etiology, 356, 357 pathology, 357, 358 edematous or cyanotic, 358 four varieties, 358 hard variety (hyperplastic), 358 hard variety (inflammatory), 358 microscopic appearance, 357 soft varietv, 358 prcscMil in diildron, 43 posiiicnor. -H) prognosis, .'!li2 symptoms, 359 treatment, 3C)'_' :'.<;i usually atrophied in adiiKs. 43 sarcoma of, 242 syphilis of, 464. See SijpJiilis, plKirijux. tlibal, 354 644 INDEX. Tonsils, tubal, enlarged, 360 illustration of position of, Fig. 1. Tonsillectomy, 385 Tonsillitis, acute superficial, 366, 368 caseous, 387 cryptic, 368 diagnosis, 370 etiology, 368 parenchymatous, 368 pathology, 368 prognosis, 370 symptoms, 369, 370 treatment, 370, 371 diagnosis between laryngitis mem- branous and, 526 due to adhesions, 387 fibrinous, 378 follicular, 368 gouty or rheumatic, 371, 373 herpetic, 374 treatment, 375 hyperplastic, 380 lacunar, 368 membranous, 378 parenchymatous, 368 phlegmonous, 375 preglottic, 390 suppurative, 60 ulcerative, 379 Tonsillolith, 388 Tonsillotomy, 384 Tonsillotyphoid, 432 _ _ Tracheitis, complication in hyperplastic rhinitis, 100 Tracheotomy, 601. See also Larynx, tracheotomy. Tracheotomy, 603, '604 in laryngitis, membranous, 528 may be necessary in lupus of pharynx, 464 preliminary in complete laryngec- tomy, 612 for stenosis of larynx, 494 Trachoma of vocal cords, 552 Transillumination. 290, 318 Trauma, a cause chondritis of larynx, 530 pathological changes, in chondritis of larynx, 532 Traumatic laryngitis, 515 pharyngitis, 426 rhinitis, 85 Traumatism, diagnosis of chondritis larynx due to, 537 prognosis chondritis larynx due to, 537 symptoms of chondritis larynx due to, 533 treatment chondritis larvnx due to, 539 Trendelenburg's cannula, 609 position, for tracheotomy, 606 Tubal tonsil, 354 Tuberculosis as a cause of septal perfora- tion, 269 as a cause of chondritis of the larynx, 530 as a cause of empyema sphenoidal sinus, 309 chronic abscess of sej)tum in, 275 depression nasal cartilages in, 276 epistaxis in, 180 of ethmoidal cells, 307 of larynx, 563 diagnosis, 566 pathology, 563 prognosis, 567 symptoms, 564 appearance of lesions, 565 "club-shaped" arytenoids, 566 cough, 564 course of, 564 deglutition painful, 564 dryness, 564 dyspnea, 565 pain, 564 secretion, 566 situation of lesion, 564 ulceration in, 566 voice, 564 treatment, 568, 570, 571, 595 of maxillary sinus, 296 of nasopharynx, 458 nasal, 136 diagnosis, 139 etiology, 136, 137 pathology, 137, 138 symptoms, 138, 139 treatment, 140 ulcers in, 156 pathological changes in chondritis of larynx, 531 of pharynx, 458 prognosis, 460 symptoms, 458, 459 treatment, 460, 461 predisposing cause of acute rhinitis, 66 rhinitis, 78 of sphenoid cells, 313 stenosis of larynx in, 496 stenosis of pharynx in, 396 of tonsils, 458 ulceration of uvula in, 347 Tubercular laryngitis, 563 Tumors, 194. See jSeoplasms. Turbinates, appearance in hyperplastic rhinitis, 97 areas involved in hyperplastic rhinitis, 98 character of, in atrophic rhinitis due to lesion elsewhere, 117 in chronic rhinitis, 92 conditions causing nasal obstruction, 250 INDEX. 645 Turbinates, cystic, Figs. 37, 38, p. 92 enlarged, cause of septal deviations, 253 formation of, causing backward drain- age, 69 fourth, illustration, Fig. 1 hanging, Fig. 46 treatment of, 92 in hydrorrhea, nasal, 121 hyperesthetic areas on, in rhinitis, hyperesthetic, 167 hypertrophy of, 96 inferior, 20, 24, 42 _ position of head in examining, 37 usual site in croupous rhinitis, 81 middle, 19, 42 color of mucous membrane of, 23 distention of cavernous sinus of, 24 position of head in examination of, 36 usual site of croupous rhinitis, 81 usual site of fibroma, 209 mucous membrane of, 22 myxoma springing from, 219 in rhinitis, chronic edematous, 122 intumescent, 95 simple chronic, 91 treatment, 92, 94 superior, 19 color of mucous membrane of, 23, 42 description of normal, view of, 42 ulceration of, in occupation rhinitis, 86 Typhoid fever, acute rhinitis in, 76 causing chondritis of larynx, 530 chronic abscess of septum following, 275 diagnosis of chondritis larynx due to, 537 epistaxis in, 180 laryngitis, acute, in, 504 nasal ulcers in, 159 pathological changes in chondritis of larynx, 531 of pharynx, 432 prognosis of chondritis of larynx due to, 537 synij)toms of chondritis of larynx due to, 533 treatment of chondritis of larynx due to, 538 Thyrotomy, 610 Ulceratiox. See also Ulcers. associated with depression of the nasal cartilages, 275 in carcinoma of the larynx, 237 a cause of epistaxis, 180 cause of septal deviation, 253 character of, in nasal syphilis, ac- quired, second stage, 126 Ulceration due to foreign body in larynx, 573 in hemorrhagic laryngitis, 528 in la grippe of pharynx, 433 in leprosy, nasal, 149 in lupus of pharynx, 462 in nasal septum, 269 of nasal tuberculosis, 137 in pharyngitis, hemorrhagic, 428 in pharyngitis, infective, 404 resembling varicose ulcers in atrophic rhinitis, 117 in rhinitis, occupation, 86 in rhinitis, simple chronic, 90 in sarcoma of larynx, 245 in sarcoma of the nasal cavities, 239 in scarlet fever of the pharynx, 428 in syphilis of the larynx, 557, 558 of pharynx, primary, 465 secondary, 466 tertiary, 467 in tuberculosis of the pharynx, 459 of uvula, 346 Ulcerative rhinitis, 87 sore throat, 403 tonsillitis, 379 Ulcers, nasal, classification, 153 compound, malignant, 156 diabetic, 156 due to foreign bodies, 155 eczematous, 154 etiology of, 154 treatment, 155 herpetic, 154 infected, 156, 157 croupous or fibrinous, 158 diphtheritic, 158 glanders, 158 in measles, 159 in rheumatisni, 159 in scarlet fever, 159 in small-pox, 159 in typhoid fever, 159 in typhus fever, 159 inspect before removing secretion, 153 leprous, 157, 158 neuroparalytic, 155 treatment, 155 bcvinine, locally, 155 electricity and strychnin, 155 scorbutic, 155 treatment of, 155, 156 simple catarrhal, 154 syi)hilitic, 157, 158 tuberculous, 156, 157 varicose, 156 treatment, 15(1 Uncinate process, Fig. 2 position of, Fig. 5 Uric-acid diathesis, abscess of septum in, 273 646 INDEX. Uric-acid diathesis cause of acute inflam- mation of the lingual tonsil, 391 in enlargement of the faucial ton- sils, 381 goutv or rheumatic tonsillitis in, 371 laryngismus stridulus in, 507 laryngitis follicular in, 545 in pharyngitis, acute rheumatic, 454' treatment of, in tonsillitis, cryp- tic, 371 Urticaria of pljarynx, 476 Uvula, adhesion of, 346 angioma of, 205 carcinoma of, 230 diseases of, 342 elongation of, 343, 345 emphysema of, 348 malformations of, 342, 343 paralysis of, 351 ulceration of, 346 due to trauma, 347 in diphtheria, 347 in postnasal catarrh, 347 in syphilis, 347 in tuberculosis, 347 mycotic, 347 uvulitis, acute, 345 symptoms, 346 chronic, etiology, 346 Uvulotoniy, 344 Varices, of lingual tonsil, 393 Varicose ulcers, nasal, 156 Variola, 76. See Small-pox. Varioloid, of pharynx, 433 Veins, of nasopharynx. 27 Vertebra, absc^s of, 475 diseases of, stenosis of pharynx in, 397 necrosis of, in tertiary syphilis, 467 Vertigo, neuroses reflex nasal, 177 Vestibule, 24. See Nasal cavities, vesti- bule. histology of mucous membrane of, 24 Vibrissse, 27 Vicarious epistaxis, 181 Von Hoffmann's non-virulent bacillus, 409 bacillus, associated cause, rhinitis membranous, 80 foimd in normal nose, 64 Voice, afi'ected in laryngitis, simple chronic, 541 affected in pharyngitis, simple chronic, 437 alteration of, in singers' nodules, 553 alteration of, in syphilis of the larynx, 556 ■ altered, due to pharyngeal tonsil, 360 altered in hyperplastic rhinitis, 99 altered in leprosy, 149 Voice altered in membranous laryngitis, 525 altered in tonsillitis, acute superficial, 366 character of, in acute rhinitis, 68 character of, in chorea of the larynx, 582 character of, in dysphonia spastica, 583 character of, in hysterical aphonia, 581 character of, in follicular laryngitis, 546 character of, in simple chronic laryn- gitis, 542 character, in papilloma of the larjnix, 198 character, in rheumatic or gouty ton- sillitis, 372 character, in simple chronic rhinitis, 90 excessive and incorrect use causing laryngitis, simple chronic, 540 harsh, in intumescent rhinitis, 95 in hyperemia larynx, 551 impairment in carcinoma larynx, 236 improper use of, causing pharyngitis follicular, 441 interfered with in fibroma of the lar- ynx, 213 in laryngitis, acute catarrhal, 499 in laryngitis, follicular, 545 in rhinitis atrophic, due to pre-existing local lesion, 114 in tuberculosis of the larynx, 564 nasal twang in atrophic rhinitis, 117 overuse of, causing follicular pharyn- gitis, 441 rest of, in laryngitis, acute catarrhal, 501 tire in follicular pharyngitis, 443 user's sore throat, 433 weakened in nasopharyngitis, simple chronic, 335 violent use of, causing hemorrhagic laryngitis, 528 Ward (M. E.), papilloma, case of, 195, 234 Watson' s operation for septal deviation, 262 Welsbach light, 30 Whistler's cutting dilator of larynx, 494 Whooping cough, acute rhinitis in, 76 diagnosis between laryngitis membra- nous and, 526 Xerostoma, due to pharyngeal tonsil, 361 Ziegler, definition exostosis, 207 _ Zwaardemaker, division of anosmia by, 161 A New Work. A Unique Work, THE AMERICAN ILLUSTRATED MEDICAL DICTIONARY For Students and Practitioners W. A. NEWMAN DORLAND, A.M„ M.D., Assistant Obstetrician to the Hospital of the University of Pennsylvania ; Editor of the American Pocket Medical Dictionary. Handsome large octavo, over 700 pages, bound in Full Limp Leather, and printed on Thin Paper of the finest quality, forming a handy volume. This is an entirely new and unique work, intended to meet the need of practitioners and students for a complete, up-to-date dictionary of moderate price. 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Professo7- of Gynecology and Obstetrics, Johns Hopkins Umverrity, Baltimoie, Md. Medical Publications of W. B. Saunders & Co. 21 POWELL'S DISEASES OF CHILDREN. Second Edition. Essentials of Diseases of Children. By William M. Powell, M.D., Attending Physician to the Mercer House for Invalid Women at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of Children in the Hospital of the University of Pennsylvania. Crown octavo, 222 pages. Cloth, ^i.oonet; interleaved for notes, $1.25 net. [See Saunders' Question- Compends, page 21.] "Contains the gist of all the best works in the department to which it relates."— American Practitioner and A'ews. PRINQLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS. Pictorial Atlas of Skin Diseases and Syphilitic Affections (American Edition). Translation from the French. Edited by J. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex Hospital, London. 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Although there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of them approach the " Blue Series of Question Compends ; ' ' and the claim is made for the following points of excellence : 1. Professional distinction and reputation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Quality of illustrations, paper, printing, and binding. Any of these Compends will be maikd on receipt of price (see next page for List). Saunders^ Question-Compend beries* Price, Cloth, $1.00 net per copy, except when otherwise ordered. "Where the work of preparing students' manuals is to end we cannot say, but the Saunders Series, in our opinion, bears off the palm at present." — New York Medical Record. 1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Fourth edition, revised and enlarged. 2. ESSENTIALS OF SURGERY. By Edward Martin, M. D. Seventh edition, revised, with an Appendix and a chapter on Appendicitis. 3. ESSENTIALS OF ANATOMY. By Chart.es B. Nancrede, M.D. Sixth edition, thoroughly revised and enlarged. 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. By Lawrence Wolff, M.D. Fifth edition, revised. 5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth edition, revised and enlarged. 6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E. Armand Semple, M.D. 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- SCRIPTION=WRITINQ. By Henry Morris, M.D. Fifth edition, revised. 8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D. Third edition, enlarged by some 300 Essential Formulas, selected from eminent authorities, by Wm. M. Powell, M.D. (Double number, ^1.50 net.) 10. ESSENTIALS OF GYNECOLOGY. By Edwin B. Cragin, M.D. Fourth edition, revised. n. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, M.D. Fourth edition, revised and enlarged. 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. By Edward Martin, M.D. Second ed., revised and enlarged. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. By C. E. Armand Semple, M.D. 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised. 15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, M.D. Second edition. 16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, M.D. Colored " Vogel Scale." (75 cents net.) 17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner, M.D. Second cflition, thoroughly revised. 18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. Second edition, revised and enlarged. 20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition, revised. 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C. Shaw, M.D. Third edition, revised. 22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D. Second edition, revised. 23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D., and I'LiAVAKD S. Lawkanck, M.D. 24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D. Second edition, revised and greatly enlarged. Pamphlet containing specimen pages, etc. sent free upon application. Saunders' New Series of Manuals for Students and Practitioners, ' I *HAT there exists a need for thoroughly reliable hand-books on the leading branches of Medicine and Surgery is a fact amply demonstrated by the favor with -which the SAUNDERS NE^ SERIES OF MANUALS have been received by medical students and practitioners and by the Medical Press. These manuals are not merely condensations from present literature, but are ably -written by -well-kno-wn authors and practitioners, most of them being teachers in representative American colleges. Each volume is concisely and authoritatively -written and exhaustive in detail, -without being encumbered -with the introduction of "cases," -which so largely expand the ordinary text-book. These manuals -will therefore form an admirable collection of advanced lectures, useful alike to the medical student and the practitioner: to the latter, too busy to search through page alter page of elaborate treatises for -what he wants to kno-w, they -will prove of inestimable value ; to the former they -will afford safe guides to the essential points of study. The SAUNDERS NEW SERIES OF MANUALS are conceded to be superior to any similar books no-w on the market. No other manuals afford so much infor- mation in such a concise and available form. A liberal expenditure has enabled the publisher to render the mechanical portion of the -work -worthy of the high literary standard attained by these books. Any of these Manuals -will be mailed on receipt of price (see next page for List)* Saunders^ New Series of Manuals. VOLUMES PUBLISHED. PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital ; Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Gloth, ^1.25 net. SURGERY, General and Operative.— By John Chalmers DaCosta, M. D., Pro- fessor of Practice of Surgery and Clinical Surgery, Jefferson Medical College, Philadel- phia; Surgeon to the Philadelphia Hospital, etc. Second edition, thoroughly revised and greatly enlarged. Octavo, 91 1 pages, profusely illustrated. Cloth, ^4.00 net; Half Morocco, $5.00 net. DOSE=BOOK AND MANUAL OF PRESCRIPTI0N=WRIT1NG. By E. Q. Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- delphia. Illustrated. Cloth, ^1.25 net. SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and to the New York German PoUklinik, etc. Illustrated. Cloth, ^1.25 net. MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti- tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila- delphia. Illustrated. Cloth. $1.50 net. SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D., Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College,, Chicago. Second edition, thoroughly revised and greatly enlarged. PRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of Practice in the Woman's Medical College of the New York Infirmary; Instructor in Physical Diagnosis in the ^ledical Department of Columbia College, etc. Illustrated. Cloth, $2.50 net. MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Department of the Ne-A? Yorn University, etc. Beautifully illustrated. Cloth, ^2.50 net. MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant Demonstrator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dis- pensary, Pennsylvania Hospital, etc. Profusely illustrated. Cloth, $2.50 net. DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to Middlesex Hospital and Surgeon to Chelsea Hospital, London; and Arthur E. Giles, M.D., B. Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London. Handsomely illustrated. Cloth, $2.50 net. VOLUMES IN PREPARATION. NERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous Diseases, Medico-Cliirurgical College, Philadelphia; Pathologist to the Orthopaedic Hospital and Infirmary for Nervous Diseases; Visiting Pliysician to the St. Joseph Hospital, etc. *** There will be published in the same series, at short intervals, carefully-prepared work* on various subjects by prominent specialists. Paxnphlet containing specimen pages, etc sent free upon application. 23 Medical Publications of W. B. Saunders & Co. SAUNDBY'S RENAL AND URINARY DISEASES. Lectures on Renal and Urinary Diseases. By Robert Saundby, M.D. Edin., Fellow of the Royal College of Physicians, London, and of the Royal Medico-Chirurgical Society ; Physician to the General Hospital ; Consulting Physician to the Eye Hospital and to the Hos- pital for Diseases of Women; Professor of Medicine in Mason College, Birmingham, etc. Octavo volume of 434 pages, with numerous illus- trations and 4 colored plates. Cloth, §2.50 net. " The volume makes a favorable impression at once. The style is clear and succinct. We cannot find any part of the subject in which the views expressed are not carefully thought out and fortified by evidence drawn from the most recent sources. The book may be cordially recommended.' ' — British Aledical Journal. 5AUNDER5' MEDICAL HAND=ATLA5ES. For full description of this series, with list of volumes and prices, see page 2. " Lehmann Medicinische Handatlanten belong to that class of books that are too good to be appropriated by any one nation." — yournal of Eye, Ear, and Throat Diseases. '• The appearance of these works marks a new era in illustrated English medical works." — The Canadian Practitioner. SAUNDERS' POCKET MEDICAL FORMULARY. Sixth Edition, Revised. By William M. Powell, M.D., Attending Physician to the Mercer House for Invalid Women at Atlantic City, N. J. Containing 1800 formulae selected from the best-known authorities. With an Appen- dix containing Posological Table, Formulae and Doses for Hypo- dermic Medication, Poisons and their Antidotes, Diameters of the Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- somely bound in flexible morocco, with side index, wallet, and flap. ^1.75 net. "This little book, that can be conveniently carried in the pocket, contains an immense amount of material. It is very useful, and, as the name of the author of each prescription is given, is unusually reliable." — Medical Reco7-d, New York. SAYRE'S PHARMACY. Second Edition, Revised. Essentials of the Practice of Pharmacy. By Lucius E. Sayre, M.D., Professor of Pharmacy and Materia Medica in the University of Kansas. Crown octavo, 200 pages. Cloth, Si-oo net; interleavec for notes, $1.25 net. [See Saunders'' Question- Co7iipemis, page 21. J " The topics are treated in a simple, practical manner, and the work forms a very useful student's manual." — Boston Aledical and Surgical Journal. SCUDDER'S FRACTURES. The Treatment of Fractures. By Chas. L. Scudder, M.D., As- sistant in Clinical and Operative Surgery, Harvard Medical School. Octavo, 433 pages, with nearly 600 original illustrations. Cloth, $4.50 net. Medical Publications of W. B. Saunders & Co. 27 SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. Essentials of Legal Medicine, Toxicology, and Hygiene. By C. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lond., Physician to the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 212 pages; 130 illustrations. Cloth, |i.oo net; inter- leaved for notes, $1.25 net. [See Saunders Question- Compends, page 21.] ' ' No general practitioner or student can afford to be without this valuable work. The subjects are dealt with by a masterly hand." — London Hospital Gazette. SEMPLE'S PATHOLOGY AND MORBID ANATOMY. Essentials of Pathology and Morbid Anatomy. By C. E. Armand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 1 74 pages; illustrated. Cloth, $1.00 net; interleaved for notes, ^1.25 n^t. [See Saunders^ Qitestion- Compends, page 21.] " Should take its place among the standard volumes on the bookshelf of both student and practitioner." — Lottdon Hospital Gazette. SENN'S GENITO=URINARY TUBERCULOSIS. Tuberculosis of the Genito=Urinary Organs, Male and Female. By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chicago. Handsome octavo volume of 320 pages, illustrated. Cloth, ^3.00 net. " An important book upon an important subject, and written by a man of mature judg- ment and wide experience. The author has given us an instructive book upon one of the most important subjects of the day." — Clinical Reporter. " A work which adds another to the many obligations the profession owes the talented author." — Chicago Medical Recorder. SENN'S SYLLABUS OF SURGERY. A Syllabus of Lectures on the Practice of Surgery, arranged in conformity with " An American Text=Book of Surgery." By Nicholas Seen, M. D., Ph.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chicago. Cloth, ^1.50 net. " This syllabus will be found of service by the teacher as well as the student, the work being superbly done. There is no praise too high for it. No surgeon should be withoiu it." — New York Medical Times. SENN'S TUMORS. Second Edition, Revised. Pathology and Surgical Treatment of Tumors- By N. Senn, M.D, Ph.D., LI..1)., Professor of Surgery and of Clinical Surgery, Rush Medical College ; Professor of Surger\-, Chicago Polyclinic ; Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St. Joseph's Hospital, Chicago. Second EdUioii, T]iorou^.:;hly Revised. Oc- tavo volume of 718 pages, with 478 illustrations, including 12 full-page plates in colors. Prices: Cloth, $5.00 net ; Half Morocco, $6.00 net. " The most exhaustive of any recent book in English on this subject. It is well illus- trated, and will doubtless remain as ihe principal monograph on the subject in our language for some years, 'ihe Ixiok is handsomely illustrated and ])rinted, and tlie author hao given .« notable and lasting contribution to surgery." — Journal of the .Unoican Medical Association. 28 Medical Publications of W. B. Saunders & Co. SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition, Revised. Essentials of Nervous Diseases and Insanity. By John C. Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous System, Long Island College Hospital Medical School ; Consulting Neurologist to St. Catherine's Hospital and to the Long Island College Hospital. Crown octavo, i86 pages; 48 original illustrations. Cloth, $1.00 net; interleaved for notes, Si. 25 net. [See Saunders' Question- Compends, page 21.] "Clearly and intelligently written." — Boston Medical and Surgical Journal. "There is a mass of valuable material crowded into this small compass." — A^/ierican Medico-Surgical Bulletin. STARR'S DIETS FOR INFANTS AND CHILDREN. Diets for Infants and Ciiildren in Health and in Disease. By Louis Starr, M.D., Editor of ''An American Text-Book of the Diseases of Children." 230 blanks (pocket-book size), perforated and neatly bound in flexible morocco. ^1.25 net. The first series of blanks are prepared for the first seven months of infant life ; each blank indicates the ingredients, but not the quantities, of the food, the latter directions being left for the physician. After the seventh month, modifications being less necessary, the diet lists are printed in full. Formulas for the preparation of diluents and foods are appended. STELWAGON'S DISEASES OF THE SKIN. Fourth Ed., Revised. Essentials of Diseases of the Skin. By Henry W. Stelwagon, M.D., Clinical Professor of Dermatology in the Jeff"erson Medical College, Philadelphia; Dermatologist to the Philadelphia Hospital; Physician to the Skin Department of the Howard Hospital, etc. Crown octavo, 276 pages; 88 illustrations. Cloth, ^i. 00 net; inter- leaved for notes, I1.25 net. [See Saunders' Question- Compends, page 21.] " The best student's manual on skin diseases we have yet seen." — Times and Register. STENGEL'S PATHOLOGY. Second Edition. A Text=Book of Pathology. By Alfred Stengel, M.D., Professor of Clinical Medicine in the University of Pennsylvania ; Physician to the Philadelphia Hospital ; Physician to the Children's Hospital, etc. Handsome octavo volume of 848 pages, with nearly 400 illustrations, many of them in colors. Cloth, $4.00 net; Half Morocco, ^5.00 net. STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second Edition, Revised. A Manual of Materia Medica and Therapeutics. By A. A. Stevens, A.M., M.D., Lecturer on Terminology and Instructor in Physical Diagnosis in the University of Pennsylvania ; Professor of Pathology in the Woman's Medical College of Pennsylvania. Post- octavo, 445 pages. Flexible leather, $2.00 net. «< The author has faithfully presented modern therapeutics in a comprehensive work, and, while intended particularly for the use of students, it will be found a reliable guide and sufficiently comprehensive for the physician in practice." — University Medical Magazine. Medical Publications of W. B. Saunders & Co. 29 5TEVENS' PRACTICE OF MEDICINE. Fifth Edition, Revised. A Manual of the Practice of Medicine. By A. A. Stevens, A. M., M. D., Lecturer on Terminology and Instructor in Physical Diagnosis in the University of Pennsylvania; Professor of Pathology in the Woman's Medical College of Pennsylvania. Specially intended for students preparing for graduation and hospital examinations. Post- octavo, 519 pages; illustrated. Flexible leather, ^2.00 net. "The frequency with which new editions of this manual are demanded bespeaks its popularity. It is an excellent condensation of the essentials of medical practice for the student, and maybe found also an excellent reminder for the busy physician." — Buffale Medical Jotirnal. STEWART'S PHYSIOLOGY. Third Edition, Revised. A Manual of Physiology, with Practical Exercises. For Students and Practitioners. By G. N. Stewart, M.A., M.D., D.Sc, lately Examiner in Physiology, University of Aberdeen, and of the New Museums, Cambridge University ; Professor of Physiology in the Western Reserve University, Cleveland, Ohio. Octavo volume of 848 pages ; 300 illustrations in the text, and 5 colored plates. Cloth, $3.75 net. " It will mate its way by sheer force of merit, and amply deserves to do so. It is one of the very best English text-books on the subject." — London La7icet. "Of the many text-books of physiology published, we do not know of one that so nearly comes up to the ideal as does Prof. Stewart's volume." — British Medical Journal. STEWART AND LAWRANCE'S MEDICAL ELECTRICITY. Essentials of Medical Electricity. By D. D. Stewart, M.D., Demonstrator of Diseases of the Nervous System and Chief of the Neurological Clinic in the Jefferson Medical College.; and E. S. Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon- strator of Diseases of the Nervous System in the Jefferson Medical College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, $1.00 net; interleaved for notes, ^1.25 net. [See Saunders' Question- Compejids, page 21.] " Throughout the whole brief space at their command the authors show a discriminating knowledge of their subject." — Medical News. STONEY'S NURSING. Second Edition, Revised. Practical Points in Nursing. For Nurses in Private Practice. By Emily A. M. Stoney, Graduate of the Training-School for Nurses, Lawrence, Mass.; late Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated with 73 engravings in the text, and 8 colored and half-tone plates. Cloth, $1.75 net. " There are few books intended for non-professional readers which can be so cordially endorsed by a medical journal as can this one." — Therapeutic Gazette. " This is a well -written, eminently practical volimie, which covers the entire range of private nursing as distinguished from hospital nursing, and instructs the nurse how best to meet the various emergencies which may arise, and how to prepare everything ordinarily needed in tlie illness of her patient." — American Journal of Obstetrics and Diseases of IVoinen and Children. " It is a work* that the physician can place in the hands of his private nurses with liif assi;ratice of benefit." — Ohio Medical Journal. 30 Medical Publications of W. B. Saunders & Co. STONEY'S MATERIA MEDICA FOR NURSES Materia Medica for Nurses. By Emily A. M. Stoney, Graduate of the Training-School for Nurses, Lawrence, Mass. ; late Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. Handsome octavo volume of 306 pages. Cloth, §1.50 net. The present book differs from other similar works in several features, all of which are 'ntended to render it more practical and generally useful. The general plan of the contents sollows the lines laid down in training-schools for nurses, but the book contains much use- ful matter not usually included in works of this character, such as Poison-emergencies, Ready Dose-list, Weights and Measures, etc., as well as a Glossary, defining all the terms used in Materia Medica, and describing all the latest drugs and remedies, which have been generally neglected by other books of the kind. SUTTON AND GILES' DISEASES OF WOMEN. Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, London ; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand- somely illustrated. Cloth, $2.50 net. "The text has been carefully prepared. Nothing essential has been omitted, and its teachings are those recommended by the leading authorities of the day." — Journal of the American Medical Association. THOMAS'S DIET LISTS. Second Edition, Revised. Diet Lists and Sick=Room Dietary. By Jerome B. Thomas, M.D., Visiting Physician to the Home for Friendless Women and Children and to the Newsboys' Home ; Assistant Visiting Physician to the Kings County Hospital. Cloth, $1.25 net. Send for sample sheet. THORNTON'S DOSE=BOOK AND PRESCRIPTION=WRITING, Dose=Book and Manual of Prescription=VVriting. By E. Q. Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net. "Full of practical suggestions; will take its place in the front rank of works of this sort." — Medical Record, New York. VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH. Diseases of the Stomach. By William W. Van Valzah, M.D., Professor of General Medicine and Diseases of the Digestive System and the Blood, New Vork Polyclinic; and J. Douglas Nisbet, M.D., Adjunct Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic. Octavo volume of 674 pages, illustrated. Cloth, $3.50 net. " Its chief claim lies in its clearness and general adaptability to the practical needs of the general practitioner or student. In these relations it is probably the best of the recent special works on diseases of the stomach." — Chicago Clinical Review. VECKI'S SEXUAL IMPOTENCE. The Pathology and Treatment of Sexual Impoter.ce. By Victor G. Vecki, M.D. From the second German edition, revised and en- larged. Demi-octavo, 291 pages. Cloth, S2.00 net. The subject of impotence has seldom been treated in this country in the truly scientific st-.rit that it deserves. Dr. Vecki's work has long been favorably known, and the German Dock has received the highest consideration. This edition is more than a mere translation, »or, although based on the German edition, it has been entirely rewritten in English. Medical Pnhlications of W. B. Saunders & COo 31 VIERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Revised. Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi- cine at the University of Heidelberg. Translated, with additions, from the fifth enlarged German edition, with the author's permission, by Francis H. Stuart, A. M., M. D. Handsome royal octavo volume of 603 pages; 194 fine wood-cuts in text, many of them in colors. Cloth, ^4.00 net; Sheep or Half Morocco, 1^5.00 net. " Rarely is a book published with which a reviewer can find so little fault as with the volume before us. Each particular item in the consideration of an organ or apparatus, which is necessary to determine a diagnosis of any disease of that organ, is mentioned ; nothing seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and nervous system are especially full and valuable. The reviewer would repeat that the book is one of the best — probably ike best — which has fallen into his hands." — Ufiiversity Medical Magazine. WATSON'S HANDBOOK FOR NURSES. A Handbool<: for Nurses. By J. K. Watson, M.D., Edin. Ameri- can Edition, under supervision of A. A. Stevens, A.M., M.D., Lecturer on Physical Diagnosis, University of Pennsylvania. i2mo, 413 pages, 73 illustrations. Cloth, $1.50 net. WARREN'S SURGICAL PATHOLOGY. Second Edition. Surgical Pathology and Therapeutics. By John Collins Warren, M.D., LL.D., Professor of Surgery, Harvard Medical School. Hand- some octavo, S32 pages ; 136 relief and lithographic illustrations, 33 in colors; with an Appendix on Scientific Aids to Surgical Diagnosis, and a series of articles on Regional Bacteriology. Cloth, $5.00 net; Half Morocco, $6.00 net. " A most striking and very excellent feature of this book is its illustrations. Without exception, from the point of accuracy and artistic merit, they are the best ever seen in a work of this kind. Many of those representing microscopic pictures are so perfect in their coloring and detail as almost to give the beholder the impression that he is looking down the barrel of a microscope at a well-mounted section." — Amials of Surgery. WOLFF ON EXAMINATION OF URINE. Essentials of Examination of Urine. By Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia^ etc. Colored (Vogel) urine scale and numerous illustrations. Crown octavo. Cloth, 75 cents net. [See Saunders' Question- Conipends, page 21.] " /\ very good work of its kind— very well suited to its purpose."— r/w« a;;^ Register. WOLFF'S MEDICAL CHEMISTRY. Fifth Edition, 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., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, etc. Crown octavo, 222 pages. Cloth, $1.00 net; inter- leaved for notes, gi.25 net. [See Saunders' Question- Compends, page 21.] •'The scope of this work is certainly equal to that of the best course of lectures on Medical Chemistry." — Fharmaceutic1 I90y