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TRANSACTIONS
ELEVENTH ANNUAL MEETING

OF THE

AMERICAN LARYNGOLOGICAL ASSOCLATION

HELD IN THE CITY OF WASHINGTON,’ D. C.
May 30 anp 31, ann June 1

1889

NEW YORK
DY APPLETON AND COMPANY
1890

OPELGERS
(ELECTED SEPTEMBER 20, 1888)

PRESIDENT
ETHELBERT CARROLL MORGAN, M. D., Wasurneron, D. C.

Ist VICE-PRESIDENT
WILLIAM C. GLASGOW, M.D., Sz. Louis

2d VICE-PRESIDENT
CHARLES E. SAJOUS, M. D., PumapeLpnia

SECRETARY AND TREASURER
D. BRYSON DELAVAN, M.D., New York

LTIBRARIAN
THOMAS R. FRENCH, M. D., Brookiyn

COUNCIL

J. SOLIS-COUWEN, M. D., Pamapetpeura
FRANKLIN H. HOOPER, M. D., Boston
GEORGE M. LEFFERTS, M.D., New Yorx
FREDERICK I. KNIGHT, M. D., Boston-

TABLE OF CONTENTS,

PAGE
President’s Address. f : : ; : , ‘ 1
Papers :

I. Report of the Removal of a Supernumerary Tonsil. c sien
and Drawings. Dr. MorGan ; 4

Il. The Relation between Facial Erysipelas an Mevilicing on ‘the one
Hand, and Intranasal Pressure on the other. Dr. Masor : 9

III. Acute Multiple Adenitis (Septic?); (idema of the Larynx, with
Spontaneous Cure. Dr. LanGmarp : 14

IV. An (dematous Form of Disease, or Septic (Edema of the Wee
Air-passages. Dr. Grascow - 18

V. Some Discursive Remarks based upon havi oneaired Tntiinate
Relations between Chronic Diseases of the Upper Air-tract and

Neurasthenia. Dr. Dary. : : : : se SL
VI. A Case of Sarcoma of the Thyreoid Gland. Dr. J. Souts-Conen . 37
VII. Some Points in the Pathology and Treatment of Disease of the

Nasal Pharynx. Dr. Mackenzie . : 42

VIII. Some Personal Observations upon the Acute and Granade ene:
ments of the Adenoid Tissue at the Vault of the Pharynx, and

the Means used for their Relief. Dr. DeLavan . 44
[X. Three Rare Cases illustrated. Multiple Papillomata of the velit,
Immense Fibroid Tumor of the Tonsil, and Fibroid Tumor of the

Nasal Septum. Dr. Lerrerts . : : : a ae
X. Warty Growths in the Naris. Dr. Incats . , one G4
XI. Dysphonia Spastica. Dr. F. I. Kyicur : 67
XII. Some of the Manifestations of Syphilis of the Tippee Bierce gee!
I Dr. De Bios. ; 70
XIII. Note on the Galvano- Henan in the iestnbart of Byperteaphiea
Tonsils. Dr. C. H. Knicur : 78
XIV. The Treatment of Diseased Tonsils when nana with yack.
trophy. Dr. Ror. : ee CY

XV. Some Unusual Manifestations of Tubercnlosis of the Datvar Dr.
RIcE : : : MS ; : edo

iv TABLE OF CONTENTS.
PAGE
XVI. Report of Two Cases of Buccal Tuberculosis. Dr. Bean . ods
XVII. Note on the Occasional Topical Use of Solutions of Silver Nitrate
in the Treatment of Chronic Laryngitis. Dr. S. Sonts-Conzn . 116
XVIII. Local Treatment of Diphtheria. Dr. Murnatn. se ue
XIX. Some Manifestations of Lithemia in the Upper Apa Dr.
HINKEL . : - . 124
XX. Hemorrhage from the Lary. eae : , Lei

XXI. Report of the Evulsion of a ie es Tumor which earned
Twenty-two Years after Removal by Laryngotomy. With Photo-
graphs. Dr. Lincotn . : : f : =) W837)

Presentation of Instruments :
A New Qsophageal Bougie, an Improved Powder-blower, and a Nasal

Bow-saw. Dr. Ror. x E : ; ; 2 AT
A Pharyngeal Douche. Dr. Jonnston . : : : . 144
A Modification of Voltolini’s Palate Retractor. Dr. Morgan. ab

Business Meetings.

Roll Call : : : : : : : : . 145
Ist day : : : , : : ‘ . 145
2d“ : ; : é : afer ee , . 146

3d“ ‘ : i : : : 3 . 149

TRANSACTIONS
OF THE
ELEVENTH ANNUAL MEETING
OF THE
AMERICAN LARYNGOLOGICAL ASSOCIATION,

HELD IN THE CITY OF WASHINGTON, D. C., MAY 30 AND 31, AND
JUNE 1, 1889.

ADDRESS OF THE PRESIDENT.
By ETHELBERT CARROLL MORGAN, A. B., M.D.

Fellows of the American Laryngological Association :

Tue eleventh annual session of this organization is inaugurated,
and I experience profound pleasure, as your president and as a citi-
zen of Washington, in bidding you cordial welcome to the national
capital, to our hearts, and to our homes. Few among you can appre-
ciate my joy to-day at being spared to greet this association in my
native city, and, more than all, to have the honor on this occasion of
acting as your presiding officer.

You find our historic city decked in the robes of spring; on all
sides the industry, learning, and generous wealth of a great nation
are reflected. You are surrounded by the beauties of nature and art,
and are in the home of the scientific libraries, laboratories, and mu-
seums, fostered and encouraged by a liberal Government. Every
American and every physician should alike share in the desire for
the substantial improvement and adornment of the Mecca of this
great and populous country.

Wisely you decided to follow in the wake of the numerous scien-
tific bodies, among them the National Academy of Sciences, that
make pilgrimages to our city and exert a healthy influence toward
popularizing their special fields of scientific investigation.

1

2 Transactions of the American Laryngological Association.

The history of laryngology, her struggles and her conquests, in
the capital of your country is brief, and embraces a period of scarce
fifteen years; hence your meetings here will create a happy influ-
ence.

When you visited our city last September you constituted an im-
portant and honored branch of a congress which did much to spread
the fame of American medicine and advance the cause of scientific
research, Your work in that congress is attested by the volume of
our ‘* Transactions ”
creditable alike to the American Laryngological Association and to

now in press, and forms an enduring monument,

the Congress of American Physicians and Surgeons.

The noble work in which this association has been absorbed dur-
ing its eleven years of existence has resulted in placing laryngology
upon a substantial basis, and of demonstrating its truths and benefits
alike to the profession and to suffering humanity.

The outlook for laryngology was never brighter, new conquests
lie within our grasp, the field is unlimited, no pessimist can flourish
in our ranks, the honor of fellowship in this gssociation was never
more coveted, our influence upon medical thought in the Old World
was never greater, and the wisdom of the coterie of laryngologists
who organized the American Laryngological Association at Buffalo
in June, 1878, is apparent.

The harmonious and business spirit which has always character-
ized our meetings is traceable to the unselfish and untiring zeal of
our secretary, Dr. Delavan, whose sole thought is the welfare of the
association and the best interests of its members as individuals.

Reviewing the history of the association, I find that a kind Provi-
dence has left our band of co-workers intact, and there are, happily,
no deaths to chronicle.

A valuable and superbly illustrated volume, containing the trans-
actions of our tenth meeting, will be printed in eight months after
the reading of the papers, but has entailed much labor upon our
faithful and ever-willing secretary. The expense attending the
printing of these transactions was increased cwing to the fact that
the “ New York Medical Journal” could not accept the contract on
account of the lateness of our meeting. This volume has a table of
contents of all papers read to the association since its organization,
and this alone would justify the additional expense. We expect to
derive a revenue from the sale of these volumes, and to be able to
consummate an advantageous contract for their future publication.

An important amendment to our Constitution, increasing the

Address of the President. 3

limit of active fellowship, comes up at this meeting. I hope the
discussion thereon will be general and marked by the candor and
spirit of friendship which characterize all our debates and = to
results favoring the best interests of the association.

The limit of our membership is fifty, and will be reached when
the two members-elect of this session are installed. There is a
probability of two vacancies in the near future, and for them numer-
ous gentlemen engaged in our common specialty are available.

This matter has been referred to in preceding presidential ad-
dresses, has been fully discussed at several of our sessions, but action
invariably postponed. I think the question should be definitely de-
cided at this meeting.

Our library, under the assiduous care of Dr. French, has assumed
very creditable dimensions, containing nearly a thousand separate
titles, but I regret to learn of a lack of interest in making contribu-
tions to its shelves among our members. The librarian thinks our
collection would be more accessible and popular if in charge of the
Surgeon-General’s Office, and he recommends its deposit in that
library.

Dr. Billings informs me that he will, as far as possible, keep the
collection intact and permit the free use of the books by our mem-
bers if they are placed in his custody.

I venture some opinions regarding the entertainments in connec-
tion with our annual gathering, at the risk of being ruled out of
order. The time has arrived when rules relative to their number,
their character, and the time of their occurrence should be adopted.

The expenses attending the annual dinner, one of the pleasantest
features of our meetings, should be charged to all members attending
the sessions, whether they participate in the dinner or not. Thus
much annoyance would be avoided, and in the event of a small
surplus it could be utilized for a few invited guests at each dinner,
or turned into our treasury. We should never dispense with this
dinner, as was the case last September, in deference to the interests
of the congress in which we were participating.

A committee having full power to provide proper entertainment
(private and official) should be appointed for each meeting, and
should be known as the “ Committee of Entertainment.” |

And now, gentlemen, I can not refrain from reiterating the as-
surance of my heartfelt appreciation of the good-will and friendship
which must have influenced you in selecting me as the president of
this distinguished body.

4 Transactions of the American Laryngological Association.

Amid the many attractions of this scientific and educational cen-
ter, we should gain renewed impetus for our important and humani-
tarian work. I therefore wish you a pleasant sojourn in Washing-
ton, a profitable scientific session, and an early repetition of this
meeting.

Paper.

REPORT OF THE REMOVAL OF A SUPERNUMERARY TONSIL.
(Specimen and Drawings.)
By ETHELBERT CARROLL MORGAN, A.B., M. D.

R. D. BRYSON DELAVAN * has said: “ Of all the internal

organs of the body, none are more easy of observation than
the tonsils. And yet, with an almost complete knowledge of their
appearance, relations, and anatomical construction, there are few
parts whose physiology and pathology are so unsatisfactorily ex-
plained.” Hence no apology is needed for recording the following
rare case :

History.—Mr. C. N. B., aged twenty-six, a vigorous and otherwise
healthy man, by profession a stenographer, consulted me September 7,
1886, for what he feared was a malignant tumor of the pharynx.

He stated that a growth, which he could see as well as feel with the
finger, near the palate, was causing him pain and discomfort. This
growth he first discovered four years previous. Occasionally it had given
him considerable pain, especially after smoking or when he became
bilious.

During the last two months, however, the tumor had greatly increased
in size, and the pains had become of a shooting character, extending to
the ears, larynx, and top of the bead, forcing him to seek medical aid.

He also informed me that his mother died of cancer of the breust, and
that, at the age of sixteen, he had contracted syphilis, which, beyond
mild secondary cutaneous manifestations, had never troubled him in any
manner since.

My examination revealed a pendent tumor between the right palatine
folds near the uvula, and protruding beyond their borders perhaps half
aninch. The tumor was the size of a small almond, having its broad end
to the velum and its point downward, but the outline was somewhat
irregular. Its color, as well as that of the velum and pillars, was a dusky
red. Slight engorgement of the cervical glands appeared to exist.

The patient was agitated by the persistency of the pain, was losing
weight and strength, and was anxious to have relief, if an early operation

* “ Archives of Larvngology,” New York, i, 4, 337.
. D oJ) » cy } ’

Report of the Removal of a Supernumerary Tonsil, 5)

gave any promise, for he was convinced in his own mind of the malig-
nancy of the growth.

I watched the case, administering Donovan’s solution internally, and
used topical measures, but, there being no amelioration, I decided to re-
move the tumor.

Accordingly, on September 14, 1886, in the presence of Dr. James E.
Morgan, Dr. J. C. McConnell, and others, the patient properly arranged,
I seized the growth here exhibited with a volsella, readily lifting it
from its bed, and was surprised to find the breadth and depth of its at-
tachment.

With a bistoury I cut deeply into the tissues adjacent to the tumor,
which occasioned slight pain and moderate hemorrhage, and lastly, with
the cautery blade at a bright red, | burned the wound made in operating.
A sedative spray, rest, and bland food were ordered, and in ten days the
wound had cicatrized so that I simply watched the patient thereafter, dis-
charging him, cured, on November 16, 1886.

On March 26, 1887, in writing me a history of his case, he says:
“T have gained in strength, flesh, and good health since the opera-
tion, but occasionally, after smoking, have a pricking feeling in the
throat.”

I have examined Mr. B. recently (May 20, 1889), and find him,
nearly three years after the operation, with no recurrence, and with
no throat trouble except what he traces to the inordinate use of
tobacco at times. His normal tonsils have always been ill-defined,
and only became plainly visible when acutely inflamed.

The tumor was submitted to microscopic analysis by Dr. Gray, of
the Army Medical Museum, who stated that its structure was identi-
eal with that of a faucial tonsil which had undergone hypertrophic
changes. Dr. Gray made these excellent photo-micrographs and fur-
nished the following written statement :

War DepartMENT, SURGEON-GENERAL’S OFFICE,
Unirep Srares Army Mepicat Museum anp Liprary,
Trento Srreet, Wasnineton, D. C., September 16, 1886.
Dr. E. Carrott Morean:

My pear Dooror: The specimen sent for microscopic examination
proves to be, as you suspected, a supernumerary tonsil. It somewhat re-
sembles an ordinary hypertrophied tonsil, but differs from it and the
normal gland by having the submucous connective tissue immensely
thickened and degenerated into a dense fibrous connective tissue. The
gland also differs from the normal by being divided up into small lobes,
the septa being formed by bands of connective tissue coming from the
submucous connective tissue, and by folds of the mucons membrane.
There are no mucus-secreting glands inside the folds of the mucous mem-

6 Transactions of the American Laryngological Association,

brane as in the normal gland. The specimen resembles the normal in
possessing numerous lymph follicles and by being formed largely of a dif-
fuse adenoid tissue. Yours very truly,
W. M. Gray, M. D.,
Microscopist to Army Medical Museum.

The location and the microscopic characters of this tumor, as
well as the history of the patient, prior and subsequent to the opera-
tion, prove that I had an hypertrophied accessory or supernumerary
tonsil to deal with, an interesting and exceedingly rare abnormity.

Some of the so-called ductless glands show a tendency to divide
or form supplemental masses (Allen). They include the spleen,
thyreoid body, thymus body, suprarenal bodies, intercaretic bodies,
and coccygeal body.

Accessory, supplemental, or supernumerary spleens, called also”
spleniculi or lieniculi, are frequently found in the gastrosplenic
omentum, near the lower part of the spleen. They are commonly
spheroidal in shape and vary in size from a pea to a walnut. Maulti-
plicity of the other organs named is much less frequent than the
spleen.

The pituitary body in part, the thyreoid, thymus, intercarotic, and
coccygeal bodies are developed from the embryonic hypoblast in as-
sociation with the primitive alimentary tract (Allen). They present
some features in common with the lymphatic system, but still form a
distinct group.

The spleen, tonsil, solitary and agminated bodies of the small in-
testine, and other adenoid structures of the alimentary canal, are close-
ly related to the lymphatic system. Lymphatic glands are variable in
number, in size, and mode of aggregation. It may be expected,
therefore, that the above-mentioned related organs will likewise vary.

Follicular lymphoid glands, commonly more or less conspicuous,
are found on the posterior third of the tongue, where their orifices
are distinctly visible, and they give to the surface an uneven appear-
ance. The tonsils are compound glands of the same character. Fol-
licular lymphoid glands are numerous in the pharynx, and give the
surface of the pharynx a more or Jess mammillated aspect. <A patch
of these bodies extends between the mouths of the two Eustachian
tubes across the back of the pharynx, and is called the ‘ pharyngeal
tonsil.” Hunter is said to have first called attention to them.
Lacauchie, in 1853, had described them, and Luschka, in 1862, gave
them their name.

Kélliker, in 1854, confirmed the existence of the pharyngeal

parating the gland into

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Fie. 2.—Showing ly

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Report of the Removal of a Supernumerary Tonsil. if

tonsil; he also hinted that what appeared to be similar follicles were
to be found in other parts of the pharynx. In the 1867 edition of
his ‘“‘ Gewebelehre ” he definitely stated that these are lvmphoid fol-
licles in the following language: “ Follicular glands, simple as well
as compound, analogous to the tonsils, are met with in the vault of
the pharynx, where the mucous membrane is closely attached to the
base of the skull. Here a glandular mass stretching from one Eusta-
chian opening to the other, and from one to nine millimetres thick,
may constantly be met with; it is, upon the whole, smaller, but other-
wise its structure resembles, in all essential respects, that of the tonsils
(p. 132). Besides this mass—which I will call the follicular glands of
the pharynx, and which also Lacauchie appears to have seen (‘ Traité
d’hydrotomie,’ 1853, Table ii, Fig. 10), whose largest sacculations
are situated in the middle of the roof of the pharynx and in the re-
cesses behind the Eustachian apertures, and which in aged persons
frequently present enlarged cavities filled with puriform masses,
while in children and in the new-born they are mostly hyperemic,
like the tonsils—there occur round the apertures of the tubes and upon
them, toward the choanz, on the posterior surface of the velum
palati, and on the lateral wall of the pkarynx, as far as the level of
the epiglottis and the laryngeal orifice, more or less numerous smaller
or larger follicles, which have the same structure as the simple fol-
licles of the root of the tongue.”

There would seem to be nothing in the way of these several lym-
phoid structures undergoing hypertrophy as such structures do in
other situations. Probably they often do so. In the region of the
pharynx such an hypertrophy would have the appearance of the faucial
tonsils, and suggest the name supernumerary. Such additional ton-
sils, however, excepting the inter-Eustachian, are scarcely at all men-
tioned by writers. A fair amount of research has discovered only
the following by Jurasz,in the “ Monatsschrift fiir Ohrevheilkunde,”
etc., Berlin, 1885, p. 361 et seg. His paper is entitled ‘ Casuistische
Beitrige zur Lehre von den Anomalien der Gaumentonsillen.”

Casr I.—A man, aged eighteen, spoke in a high-pitched voice through
his nose, and had done so from early childhood. He made no other com-
plaint. The nasa! cavities were, however, free. The space between the
right palatine arches was quite large, but the tonsil was only rndiment-
ary ; the left was better developed.. While examining the parts, the doc-
tor was surprised at the sudden appearance from the throat of a large
tumor which rapidly filled the entire faucial space. The tumor was whit-
ish gray, soft, lobulated, and the size of a hen’s egg. Pedicle small and

8 Transactions of the American Laryngological Association.

short. It was removed by Czerny, and was found to spring from the
lower anterior portion of the right posterior pillar. Microscopical ex-
amination showed the structure of a hypertrophied tonsil, with some
hyaline degeneration of the reticular tissue.

Oase If.—His second case, which he-calls “ tonsilla accessoria,” was
in a woman aged thirty. She had an irritating cough; but the thoracic
viscera were found to be normal, except a marked smallness of the tonsils.
On rhinoscopic examination of the naso-pharynx, he found a red, uneven
tumor, size of a hazel-nut, with broad base attached below the right tubal
prominence. The mouths of the tubes were of the normal yellow color,
the pharyngeal tonsil not enlarged; the choanz were free. Externally
the tumor looked like a papilloma; microscopic examination showed it
to be of the same structure as the faucial tonsil.

Conciusions.—1. The lymphoid follicles of the soft palate and
pharynx are liable to be aggregated, resembling in arrangement the
faucial tonsils. 2. The condition is exceedingly rare, since, except-
ing the so-called “ pharyngeal tonsil,” I have found but one case re-
ported. 3. These lymphoid follicles are also liable to hypertrophy.
4. Such hypertrophies probably occur oftener than is generally sup-
posed. 5. The indications for operative interference in this condi-
tion are identical with those for the faucial tonsil.

Discussion.

Dr. J. N. Macxenzir, of Baltimore: In connection with the case re-
ported by Dr. Morgan, I would briefly refer to a case which I reported
some time ago, an account of which has not yet been published. It was
a case of tumor of the pyriform sinus, which was removed with the wire
snare. Upon microscopical examination, it was found to be composed of
the lymphoid tissue so graphically described by Waldeyer and his pupils.
I have on several occasions removed growths from the tonsils, and once
from the anterior faucial pillar, but I am sorry to say they were not
examined microscopically. They would doubtless have shown a similar
structure to that found in the pyriform sinus.

Dr. D. Bryson Detavan, of New York: This subject has been so
thoroughly and carefully worked out by Dr. Morgan that it has given me
considerable interest to try to recall a similar instance. While I remem-
ber to have seen it stated that supernumerary tonsils may occur, yet,
after a careful search through the literature, I was able to find but the two
cases referred to by Dr. Morgan. I have seen several cases of tumor of
the tonsil, which were distinctly pedunculated and easily removed, but
which proved to be largely of a fibrous structure. It seems pos-ible that
these tibrons tumors, which are not uncommon, may be degenerated
supernumerary tonsils. In the case reported there had been considerable
growth, the tumor increasing markedly in size during three or four years.

Facial EHrysipelas and Intranasal Pressure. 9

It may be that these fibroid tumors begin as supernumerary tonsils, and
later, becoming rich in fibrous structure through the irritation to which
they are exposed, assume the character of the former growth.

Paper.

THE RELATION BETWEEN FACIAL ERYSIPELAS AND ERYTHEMA
ON THE ONE HAND, AND INTRANASAL PRESSURE ON THE
OTHER.

By GEORGE W. MAJOR, M. D.

ite is my firm conviction that facial erysipelas is sometimes pro-
duced by nasal causes acting independently of external infection.
This decision has been arrived at as the result of careful observations
extending over a number of years. I believe that a definite relation
exists between many cases of erythema and erysipelas occurring on
the nose, or in its neighborhood, and inflammatory conditions within
the nasal chambers, more particularly when they are productive of
pressure,

If such is the case, then it becomes our duty to distinguish ery-
sipelas and erythema of an intranasal origin from the same diseases
dependent upon other causes. The importance of accurately estab-
lishing the origin of these attacks can not be overestimated when
we consider that success will often depend upon its recognition.
The majority of subjects of facial erysipelas doubtless convalesce
under local and constitutional measures even though the exciting
cause is unknown and therefore is allowed to persist. The duration
of the illness will be greater and the liability to extension and com-
plications will be manifestly increased, not to mention the tendency
to recurrence. If, therefore, a removable cause can be demonstrated
as productive of facial erythema and erysipelas, we shall find our-
selves in a better position to arrest the course of the disease when
present, and in the future to prevent it altogether. This is my
apology for briefly placing on record the four following cases, with
a few remarks thereon: { .

Case I.—In March, 1884, M. C., a young lady, aged twelve years, was
referred to me by Dr. Arthur A. Browne, of Montreal, for the treatment
of a troublesome nasal catarrh. On examination of the nose, I found a
general hypertrophic condition present. The right middle turbinated
body was very wuceh enlarged, turgid, and abnormally sensitive to the
touch. It was in contact with and pressing upon the nasal septum. On
the cheek bone of the same side there was a dark, dull red and elevated

10 = Transactions of the American Laryngological Association,

patch of erythema of the area of a balf-dollar. On inquiring into the
history, I learned that this eruption had lasted for five months, that it
had first made its appearance during a severe cold in the head, and that
a nose bleed seemed to diminish its prominence; a variety of local and
constitutional remedies had been adupted without success. Tbe proba-
bility of pressure being the cause at once suggested itself to my mind.
Scarification and puoctures of the middle turbinated tissue relieved the
sensitiveness of the parts locally and diminished the redness of the facial
patch. Soothing local collunaria also gave further relief. Subsequently
aseries of galvano-cautery applications permanently removed the press-
ure, and with it the erythematous blush gradually vanished. No local
treatment was adopted for the eruption, nor were any constitutional
means employed. There has not been at any time since a recurrence of
the disease.

Case II.—In February, 1885, I saw, in consultation with the late Dr.
R. Palmer Howard, a case of facial erysipelas in a child of four years.
The disease had commenced on the bridge of the nose and had extended
to the cheeks. The condition had lasted for five days and showed no in-
clination to yield to the usual local and constitutional remedies. The
child’s stomach had become irritable and refused to retain anything what-
ever. On examining the nasal chambers, I found both nostrils obstructed
with swelling, the result of an acute cold, and suggested the abandonment
of all local and constitutional medication and the substitution therefor of
warm alkaline nasal injections. In the course of twelve hours the swell-
ing in the nasal chambers showed considerable reduction, and pari passu
the erysipelatous blush. In twenty-four hours all trace of the di-~ease
had disappeared.

Dr. Howard knew of my views relating to intranasal pressure, and
willingly acceded to the change in treatment.

Case II].—In the winter of 1884 I saw, in consultation with Dr. :
Browne, W. C., aged twelve years, suffering from erysipelas of the nose
and cheeks. This child lad frequently suffered from erysipelas having
its origin always in the same region, though generally spreading to other
parts of the body. Some of these attacks had been of most serious and
alarming character. I had previously seen him in consultation when suf-
fering from this disease, and had suggested to the medical attendant the
likelihood of a nasal origin.

I ordered nasal injections alone, and had the satisfaction of seeing the
disease disappear in the course of thirty-six hours. When convalescent
I destroyed the hypertrophied turbinated tissue, and have been informed
that no recurrence has taken place.

Case IV.—In February of this year A. J., female, aged thirty-six
years, was referred to my clinic at the Montreal General Hospital for an .
erythematous patch occupying the left cheek bone. She stated that it
had already lasted four months and that it had so far resisted all treat-
ment. A nasal examination revealed a swelling of the left middle turbi-

Discussion on Paper of Dr. Major. . 11

nated body exerting pressure on the septum. After deeply punctnring
the swelled tissue and allowing of a free flow of blood, a nasal cleansing
solution was ordered. In a week the patient reported herself free from
the disease.

I have notes of two more similar cases occurring under my own
observation, and of four kindly furnished by colleagues, but abstain
from making any use of them beyond their mere mention.

During an extended experience of nasal operative work common
to all in our specialty, I have but once met with facial erysipelas
succeeding a surgical operation in the nasal chambers. It was in a
ease of nasal polypi, and any interference invariably produced ery-
sipelas. The man, however, came of a family in which erysipelas was
a usual complaint. In the cases above referred to the erysipelas
always commenced on the bridge of the nose, and was greater on
the side of greater pressure. There was no condition present in the
nasal chambers that I could recognize as of an erysipelatous nature
in any of them. Medical literature, in so far as I have been able to
ascertain, is barren of any reference to the matter to which I have
thus briefly referred.

Discussion.

Dr. J. O. Ror, of Rochester: I have seen a number of cases of erythem-
atous rash about the face which was due to the cause described by Dr.
Major. This was well pronounced in a case recently seen—that of a girl
twenty-three years of age. She bad an erythematous rash upon the face,
very red, and studded with blebs and blotches, giving a very conspicuous
appearance. She had been treated with constitutional remedies by two
or three distinguished men, without benefit. They afterward referred her
to me, and I found in both nostrils that the middle turbinated bodies pro-
jected firmly against the septum. I removed the projecting portions,
rendering the passages free, and there was an immediate subsidence of the
erythematous trouble, and it has now entirely disappeared. I can not
agree with Dr. Major that erysipelas is due per se to intranasal pressure.
Erysipelas is caused by a distinct germ, and is an infectious disease.
Those who have intranasal difficulty with erosions are more liable to
become infected by these disease germs. As we know, erysipelas may
come from the infection of a scratch, but the latter is quite different
from the erythematous rash which may be excited by simple local irri-
tation.

Dr. Mackenzie: I can not agree with Dr. Major in regard to the
silence of medical literature upon this subject. I think that it has been
pretty fully discussed in the last five or six years. I know that some
centuries ago, in the time of Willis and Sylvius, this erythema of the nose
and face was discussed in separate chapters, and was attributed to intra-

12. Transactions of the American Laryngological Association.

nasal changes. I have myself discussed the subject pretty thoroughly in
Wood’s ** Reference Hand-book,”’ published in 1887. Tbe Germans have
reported cases of so-called erysipelas and erythema of the external nose
and cheeks as exceedingly common. I have seen erythema very often,
but I have not seen a case of true erysipelas. The so-called cases of
facial erysipelas from intranasal changes seem to me to be rather an
accentuation of the act of blushing. It is a sort of chronic blush. It can
hardly be called true facial erysipelas.

Dr. Daty: I am not a believer in the theory of intranasal pressure.
I believe that the conception of the theory is not good, and consequently
the superstructure is on a bad foundation. The evils, whatever they may
be, that we recognize as coming from so-called intranasal pressure, are
evils that in reality arise from intranasal turgescence. There is no ques-
tion in my mind that the condition which my friend Dr. Mackenzie speaks
of as an accentuated blush, a prolonged blush of the parts—a very pretty
idea—is, when divested of all superfluous mystery, largely due to hyper-
nutrition from a turgescent and permanently dilated and enlarged blood-
supply.

During the past year or year and a half I have had under my profes-
sional care two cases. One of these was a very well marked case of ery-
thema of the skin of the nose and extending out upon the cheek. I was,
however, not consulted by the patient on account of the skin disease, but
for a condition which he spoke of as intranasal catarrh. I resorted to
prompt surgical measures, removing the turgid condition of the intranasal
structures—in a word, cutting off the blood-supply by destroying the
blood-vessels ; and, as a result, the condition of which he complained as
catarrhal was removed, and subsequently also the erythema disappeared.
I met the man, who was from a neighboring town, a few weeks ago, and
did not recognize him. The turgid and red condition of the nose had
disappeared, and he presented quite a respectable appearance and was
altogether much pleased with himself.

The second case was of a somewhat similar character in a young
lady. She had erythema of the external surface of the entire nose, with
a horseshoe-shaped patch around it of the same kind extending down to
the outer angle of the mouth on each side. She had been told that it was
due to menstrual disorder. I lost sight of that opinion after finding that
there was sufficient intranasal deformity to warrant interference for steno-
sis. After relieving surgically almost complete stenosis of one naris and
partial stenosis of the other, the erythema disappeared. In this case, by
the way, there was copious hemorrhage, almost causing death, after one
of the operations with the saw. I had said to the patient that a little
bleeding would do no harm. She went to her home, two miles and a
half in the country, and there bled copiously, but assured her friends that.
the doctor had said that bleeding would not matter. She bled well into
the night, when my assistant was sent for, and found her almost in ar-
ticulo mortis. She, however, recovered, and is now perfectly healthy

Discussion on Paper of Dr. Major. 13

and a handsome girl, with good nasal respiration, with no defect of skin
or complexion.

I do not believe in chronic facial erysipelas, and think that the term
isa misnomer. I regard erysipelas as essentially an acute inflammatory
disease of a specific type, and depending oftener upon an acute constitu-
tional disorder than a local one, and as diverse from the condition of
chronic erythema as possible—in fact, I don’t believe such a thing as
chronic erysipelas exists at all.

Dr. F. I. Kmianr, of Boston: Without repeating what has been said,
and well said, upon this subject, there is one point which the gentlemen
seem to have overlooked. This isin regard to another condition which
may serve as a cause of erythema of the nose and face. It is one which
I always search for and frequently find—namely, necrosis. When a
patient presents bimself to me with a localized strong blush on the nose
or cheek, I look for necrosis, just as in a case of unilateral profuse puru-
lent discharge I look for a foreign body or necrosis. The worst cases
that I have seen have been where there was decided necrosis. Here the
erythema has been removed by giving free vent to the purulent discharge
and keeping the parts clean.

Dr. Detavan: In four cases of this affection that I have seen the
erysipelas has been very severe. The first case was a girl, seventeen
years of age, who had recurrent attacks of erysipelatons swelling over
the ale of the nose and extending over the cheeks. These attacks re-
curred every two or three weeks. I thought that some necrotic process
might be the cause of this condition, but I failed to find it. I found, how-
ever, marked turgescence of the nasal mucous membrane. The condi-
tion was treated topically, and in time, with the subsidence of the catar-
rhal trouble, the erysipelatous attacks disappeared and did not recur.

Another case was that of a girl, fifteen years of age, who suffered
from adenoid hypertrophy at the vault of the pharynx. She had had re-
current attacks of erysipelas. That this was true erysipelas was proved
by the fact that the inflammation was very severe, that the nose swelled
to a large size and remained thickened for a number of weeks, and that,
with the subsidence of the attacks, there appeared a distinct herpetic
eruption, as often occurs in erysipelas. In this case no necrosis was pres-
ent. There was, bowever, extensive engorgement of the nasal mucous
membrane, with some pressure in the neighborhood of the middle turbi-
nated body on both sides. The patient had improved under treatment.
About two weeks after her last attack, a younger sister, sleeping in the
same room, suffered from the same condition. In the latter case there
was also some turgescence of the intranasal mucous membrane.

Dr. Harrison Aten, of Philadelphia: I think if Dr. Seiler were
present he would tell us of the connection between nasal disease and
acne. It has been my experience to see in two cases attacks of furuncles
follow treatment of the nose. In athird case these furuncles occurred
without surgical-treatment of the nasal cavities. In one of the cases there

14. Transactions of the American Laryngological Association.

was distinct flushing of the face and nose. I looked upon this as a mild
form of cellalitis. I see no difference between a diffuse form of cellulitis
of the face arising from intranasal causes and that which follows abscess
of a tooth. Under the latter circumstances we frequently see cellulitis
of the entire face. I think that Dr. Major meant erysipelas and not
cellulitis, so that these remarks refer more to what was said by previous
speakers than to the paper itself.

There seem to be several different conditions—first, a distinct ery-
sipelas; second, diffuse cellulitis in various forms; and, third, a chronic
determination of blood to the face dependent upon chronic irritation.

Dr. S. W. Lanemarp, of Boston: I recently saw a case of erysipelas
in Dr. White’s clinic in Boston, and he remarked that in such cases we
should look for the cause in the nose. The dermatologists have therefore
not lost sight of th’s faer.

Dr. Masor: In my paper I have avoided theory and confined myself
simply to facts. My opinion is based upon clinical observation that led
me to look for these cases. I have looked for them ard | have found
them. These have been cases of erythema and erysipelas under medical
treatment by men high in the profession, but without benefit—cases that
have been under the care of dermatologists for montlis without improve-
ment, and they have been cured by simple removal of the pressure. That
is about as straight evidence as to cause and effect that any one need want.
I do not think that turgescence will produce erysipelas or erythema unless
it causes pressure. In regard to necrosis, this is commun enough in sy phi-
litie cases. The erythematous condition may continue for months. I
have not mixed up erysipelas and cellulitis. One of my patients had
fourteen attacks of erysipelas. All commenced in the nose and extended
over the body. In regard to the literature, I would say that I consulted
a number of books, but saw no reference to this matter. I am sorry that
[ overlooked Dr. Mackenzie’s observations in Wood’s “* Hand-book.”

Paper.

ACUTE MULTIPLE ADENITIS (SEPTIC?); (DEMA OF THE LARYNX,
WITH SPONTANEOUS CURE.

By S. W. LANGMAID, M. D.

N Tuesday, April 30, 1889, I was summoned by telegraph to visit

Mrs. R. at a city sixty miles from Boston. The case was supposed

to be one of amygdalitis. I arrived at the hotel at which Mrs. R. was

temporarily staying, and when she had been ill for eight days, at halt-
past five in the afternoon.

The patient, a Jady about forty years old, was in bed, propped up

by pillows, very restless, with anxious expression, breathing with difli-

Acute Multiple Adenitis. 15

culty, with dry, croupy inspiration. There was no lividity of the face,
or other indication of impending suffocation; but I was informed that
during the preceding twenty-four hours there had been at times danger
of strangulation. The submaxillary glands were much enlarged, as were
those lower down in the vicinity of the Jarynx. The whole region of the
neck was swollen, and the tissues in front of the larynx and trachea were
thickened. The pulse was feeble, but not rapid. The temperature was
99° F. The voice was fairly loud and clear.

Mrs. R. was able to get out of bed and allow me to make a laryngo-
scopic examination by sunlight illumination. The mouth and pharynx
were normal. There was no enlargement of the tonsils, no membrane,
and nothing unusual in the naso-pharynx. The epiglottis was very erect,
normal in shape, and only slightly congested. A tumor, apparently as
large as a filbert, in which the arytenvids seemed to be incorporated,
occupied the posterior arytenoid space, and covered two thirds or more
of the glottis. The anterior third of both vocal cords could be plainly
seen approximated and scarcely moving during inspiration. Nothing
abnormal was discovered in the lungs. My diagnosis was edema of the
vestibule of the larynx, caused by the pressure of the enlarged cervical
glands; cause of adenitis unknown, but diphtheria suspected, of which no
trace now remained in the throat, mouth, or naso pharynx.

The attending physician was an irregular practitioner, and had not
looked in the throat during the first four days of Mrs. R.’s illness. An-
other physician had been called the day previous to my visit, who had
ordered poultices to the neck, after which the dyspnoea seemed to be
slightly relieved. No nourishment had been taken for days because of
inability to swallow, but the mouth and throat had been constantly washed
and gargled with milk and Apollinaris water. No other treatment seemed
to have been used, except hypodermic injections of morphine, which the
patient demanded, and which she had been accustomed to take occasion-
aliy for attacks of severe headache.

Mrs. R.’s condition seemed most critical. Dr. George W. Gay, of
Boston, was telegraphed for, and asked to bring tracheotomy instruments,
The patient was closely watched, the throat frequently gargled with milk
and water, which seemed to assist in expelling small quantities of viscid
mnucus, and nine or ten ounces of milk were swallowed. Stimulants were
refused by the patient.

I determined to wait as long as possible before attempting any opera-
tive procedure, but, should suffocation seem imminent, I hoped to be able
to reach and open the laryngeal tumor with a curved bistoury, and, if
necessary, afterward open the trachea.

Dr. Gay arrived four hours later, and, having examined the patient,
agreed that it was best to delay any operation, as there had been po
glottic spasm during the day, and the voice remained good. The poul-
tices were continued, and ten grains of quinine and a mixture of chlorate
of potassium and chloride of ammonium were given at Dr. Gay’s sugges-

16 Transactions of the American Larynyological Association.

tion. Up to midnight, when we left Mrs. R. with her attendants, no
change had occurred; but at four o’clock in the morning I was called,
with the report that something had broken in the throat. I found that
several handkerchiefs had been saturated with a thin mucoid discharge,
which was being incessantly hawked up, and which at first was faintly
tinged with blood. It was noticed that the dry, sonorous inspiration was
more moist in character and less noisy. The patient was informed that
through such a discharge great relief would probably be produced, and
was again left with her family. The discharge had been so copious that
Mrs. R. feared she ‘‘ would be drowned by it.”

Three hours later a laryngoscopic examination was made. It has
been said above that at the previous examinations a tumor was seen in
the region of the arytenoids and posterior arytenoid space, below which a
portion of the vocal bands was plainly visible. Now, nothing could be
seen except the erect epiglottis, almost doubled upon itself laterally, and
from the recess so made muco-purulent matter welling up.

The dyspnoea was greatly relieved, quiet inspirations being accom-
panied by moist bubbling sounds. The swollen neck seemed to be softer.

The patient was left in the charge of Dr. T. C. Morril, who had seen
her the previous day.

Upon my return late in the afternoon, I was disappointed to find the
respiration still somewhat noisy, and that there was no change in the
laryngoscopie appearances. The epiglottis was still bert laterally upon
itself, and purulent matter was still flowing. There had been constant
expectoration during the day and one attack of vomiting, during which
half an ounce of pus had been ejected. Milk had been taken in fairly
large quantities, and the patient’s strength had not diminished.

A restless night was passed, but with increasing freedom in inspiration.
In the morning the neck was less swollen and softer, and the epiglottis
had resumed its normal shape. Pus was seen welling up behind the
interarytenoid space. The arytenoids themselves had not regained their
normal contour, but were not edematous. The discharge of pus continued
in diminishing quantities for several days. On the seventh day from my
first visit Mrs. R. was removed to Boston. The neck had at this time
nearly resumed its natural size, but considerable induration of the tissues
in the vicinity of the larynx still remained. The interior of the pharynx
and larynx showed only slight alteration of color. On May 10th Mrs. R.
was able to be moved by special car to her home at Baltimore.

This case has seemed worthy of presentation to the society for
several reasons:

1. On account of the obscurity with regard to the origin of the
adenitis with consequent oedema.

2. The unusual sequel to such a condition—viz., the spontaneous
rupture of the edematous tumor and safe evacuation of its contents,

Acute Multiple Adenitis, 17

together, probably, with that of a suppurating gland or glands in the
neighborhood.

3. The opportunity which was afforded by laryngoscopy for
observing the exact condition during the dangerous stage of par-
tial glottic occlusion and fixation, as well as the reassuring appear-
ances after the evacuation of the tumor and glands,

When I first saw Mrs. R. I had no doubt that the adenitis was
septic from diphtheria. When told that no membrane had ever
been seen or expectorated (I supposed then that careful examinations
had been made of the mouth and fauces during the first days of the
attack), and the perfectly clean, pale condition of the mucous mem-
brane of the whole upper respiratory tract had been observed, under
excellent illumination, I was forced to abandon that hypothesis.
The fact that eight years previously a gland had suppurated and
discharged on the back of the neck did not help to clear up the
mystery of the present acute multiple adenitis. The only history
immediately antedating the severe seizure was that Mrs. R. had not
seemed quite well for two weeks, and on the day previous had been
“chilly ” and had a slight “ soreness of the throat.”

It has seemed, however, to Dr. Gay and myself, since then, that
there must have been a very limited diphtheria, all traces of which
had disappeared by the eighth day. The account which I obtained
from Mrs, R., to whom no mention of diphtheria had been made,
after her removal to Boston, lends support to such a view, for she
said that at the commencement of her illness she had a “sore throat,”
and she saw on one side of the back of the throat a red place on which
there was a white covering. The urine was free from albumin.

The spontaneous rupture of an edematous swelling in the region
of the larynx is probably rare. Intralaryngeal puncture sometimes,
but tracheotomy generally, is required. Intubation, if instruments
were at hand, would be in such a case as this the remedy par excel-
lence, it seems to me. The importance of laryngoscopic examination
in this case can hardly be overestimated, for if it is granted that the
rational signs were enough to guide the surgeon to the diagnosis
and conduct of the case, it will not be denied that the added informa-
tion with regard to the situation and nature of the obstruction made
the instant and succeeding treatment more exact, and added greatly
to the knowledge of the pathological conditions.

2

18 Transactions of the American Laryngological Association.

Paper.

AN (EDEMATOUS FROM OF DISEASE, OR SEPTIC (DEMA OF THE
UPPER AIR-PASSAGES.

By W. ©. GLASGOW, M.D.

URING the winter of 1886 I reported to the Medico-chirurgical
Society of St. Louis the existence of an unusual form of throat
disease which had been more or less prevalent for two years, and
which at that time prevailed to such an extent that it could not fail
to attract attention. I called it then rheumatic or edematous sore
throat, from the great similarity of certain of the symptoms to those
seen in the ordinary angina rheumatica. I also drew attention to
the fact that in certain of these cases patches of exudation were seen
in the throat, and I was inclined to consider that these conditions had
acommon cause. The exudative cases bore a certain similarity to
the diphtherias, but the surrounding condition of the throat was
utterly dissimilar from that seen in diphtheria. At that time, how-
ever, I had not given these cases a sufficient study, and waited to see
what further observations would develop. In 1887 Dr. Boisliniere,
my assistant in the clinic at the Post-graduate School of Medicine,
published in the “St. Louis Courier of Medicine” a short article
entitled “‘ Edematous Sore Throat,” in which he embodied my views
and treatment of the disease. During the winter of 1887 and 1888
these cases were very numerous, disappearing almost entirely during
the late spring and summer months, appearing again in the early
part of the past winter. About the 1st of January of this year they
again appeared, and they have continued during the spring, through
the present month. During March and April the cases were unusu-
ally prevalent, and the disease might well be called epidemic. I call
it epidemic rather than endemic, as I have seen many cases that have
originated in different parts of the country. I have also learned
from Dr. Seiler, of Philadelphia, that be has seen similar cases in
that portion of the country. During the prevalence of this disease
I have. noticed the disappearance of the ordinary forms of catarrhal
inflammation of the throat

a condition which is usually so preva-
lent during the spring months.

The appearance of the throat. in this cedematous form of disease
is characteristic, and will always define the disorder. In all cases
we find on inspection a pale, swollen, edematous condition of the

Septic Hdema of the Upper Air-Passages. 19

fauces. In some this is limited to certain parts, while in others the
entire mucous membrane of the fauces is involved in the process.
The cdema is a solid edema, and differs from the usual serous
cedema seen in catarrhal inflammations. To the touch the mucous
membrane feels firm and waxy, lacking the moist elastic sensation
of a normal mucous membrane. A peculiar glistening appearance is
very marked in many cases, and I have seen the palate, when the
light was thrown at an angle against it, appear as though set- with
minute brilliants. In the majority of cases the soft palate is the
site of the edema. In some it is so much swollen and thickened
that speech is impaired, suggesting the change caused by paresis of
the palate. A lesser degree of adema is more frequently seen. In
these cases the action of the palate is not much impaired, but on
phonation the uvula is seen to retract with ridges and folds in the
mucous membrane, suggesting the impression that the muscles are
unimpaired, while the mucous membrane is infiltrated with some
foreign substance. The palatine folds and the lower edge of the
palate appear at times translucent at the edges. The naso-pharyngeal
space and the nasal mucous membrane are also found in the same
condition. ‘The nasal mucous membrane presents most frequently a
swollen, very dry appearance. In two cases the naso-pharyngeal
space was almost obliterated through the great cedema of the mew-
brane. The epiglottis and the different parts of the larynx are also
affected. I have seen four cases where the epiglottis was converted
into a solid, swollen mass, and in very many cases the cedema of
the posterior surface of the larynx could be quite distinctly seen with
the mirror. In four cases the true cords were markedly cdematous.
They appeared as swollen, glistening bands with an almost translu-
cent appearance. In another case one, and in still another both false
cords were found swollen and enlarged. The two cases in which the
solid edema of the larynx was seen in life died suddenly with symp-
toms of spasm of the glottis or sudden laryngeal stenosis. In both
these cases the post-mortem examination showed a swollen, edema-
tous condition of the epiglottis and interior of the larynx, which did
not subside with deathy A peculiarity of this ceedema is the rapid
and great increase which seems to take place from slight causes.
In some cases it disappears almost as rapidly as it arises. In others,
however, it lasts for months, slowly subsiding, showing, however, in
its course acute exacerbations with an increase from time to time.
An enlargement or swollen condition of the veins is a marked
appearance in all cases. Most frequently this is the case with the

20 Transactions of the American Laryngological Association.

palatine veins, especially those at the root of the uvula and the
pharyngeal veins. Sometimes this venous enlargement is so great
as to cause purpura-like spots, and the mucous membrane appears
mottled, the dark spots contrasting with the pale surrounding sur-
face. In two cases I have seen these purpura spots in the trachea,
and both these cases showed recurrent hemorrhages. In one case
an enlarged vein was distinctly seen on the cord. A peculiar secre-
tion is characteristic of this disease. In some cézses it is scanty and
iu others it is very profuse. It is characterized by its viscid, gluey
nature. When it is taken on the finger and the finger pressed against
the thumb and again separated, a glue-like thread is formed, which is
so tenacious and elastic that the fingers can be widely separated with-
out breaking the thread. Ulceration is occasionally seen, and when
it occurs there seems to be a loss of tissue by absorption rather than
by destruction. In one case a large ulcer occupied the lateral and
naso-pharyngeal wall, extending toward the wall of the pharynx. In
three cases the soft palate presented a loss of substance. In one the
anterior pillar of the palate was perforated, forming a button-hole.
Ulceration of the epiglottis was seen in four cases. In one the loss
of substance originated at three different spots, and continued until
the greater part of the epiglottis had disappeared. In another the
ulceration extended through the mucous membrane, but did not in-
volve the cartilage. The former case died of tuberculosis, and in the
latter the ulceration healed and was followed in the course of three
weeks by a similar ulceration of the soft palate. In this case there
was no history of syphilis.

In certain cases we find, in addition to the cedematous condition,
patches of exudation in different parts of the throat. In some cases
this is limited to minute white or yellowish-white points, and in
others patches of varying extent are formed. These are seen most
frequently on the tonsils, both of which are usually involved. ‘These
patches on the tonsils usually commence as isolated points, and the
exudation in some cases coalesces, forming a complete covering of
the tonsil. In other cases we find the whitish points in the pharynx
and on the pillars of the palate. In one case there was a small patch
on the right tonsil and an elongated patch on the pillar of the palate,
the soft palate partially covered, and the uvula enveloped as a finger
in a glove. This patient recovered after a six weeks’ illness. In
another a patch existed on the hard palate, two distinct patches on
the epiglottis, with one on the posterior surface of the larynx. This
patient bad a syphilitic history. The patcbes disappeared in four

Septic Gdema of the Upper Air- Passages. 21

weeks. These patches have a yellowish-white appearance, are usu-
ally firmly attached to the membrane, and can not be removed ex-
cept by force, when a bleeding surface remains. If untouched, they
gradually fade away, the exudation growing thinner until they only
show a thin opaline patch resembling a mucous patch. Some of
these cases would be called diphtheritic, but the symptoms of the
disease and the appearance of the throat must preclude such a diag-
nosis. In all, in addition to the patch of exudation, we find the sur-
rounding tissue in a condition of cedema, and more or less of the
sticky, gluey secretion is present.

Tn six cases I have seen spots of mycosis; in three they were on
both tonsils and on the base of the tongue, with points on the pos-
terior pharyngeal wall. In three the two tonsils were alone involved.
Microscopic examination showed Leptothrix buccalis. Glandular en-
largement of the neck is frequent.

In most cases the glands are simply swollen, but in others they
become enormously enlarged. In some cases they are hard and tense,
and gradually soften and disappear as the patient recovers. In one
case, with massive cedema and ulceration of the lateral pharyngeal
wall, the submaxillary glands attained the size of a goose-egg. This
varied in aremarkable manner from time to time, both in size and
hardness, at times becoming so soft as to suggest suppuration, chang-
ing again to the hardness of a sarcomatous gland. In this case the
glands on both sides of the neck were involved. In two cases sup-
puration of the glands took place.

The symptoms of cedematous sore throat are both constitutional
and local. The constitutional symptoms are most prominent and are
often present when the local symptoms are wanting. The attack
commences suddenly in a condition of previous good health. There
is a feeling of intense languor and weakness, slight exertion produc-
ing an unusual fatigue; the mind is dull and a condition of apathy
prevails ; a condition of mental inertia is often present. During the
day there is great drowsiness, while insomnia is frequent in the same
individual. An unusual and excessive irritability is often noticed.
Pain is general throughout the body, the muscles and joints being
specially involved. A headache of varying intensity is present. It
is usually frontal but sometimes it is occipital. In many cases it is
simply a dull, heavy fecling of fullness in the head; in others it is
intensely violent, with throbbing pain. Pain in the back, especially
about the sacrum, is a characteristic symptom; from this point it
radiates toward the hips or into the pelvis. Occasionally the site

22 Transactions of the American Laryngological Association.

of pain is more in the lumbar region. Pains in the chest are fre-
quent. The pain is often intensified at night. In many cases we
find a soreness or tenderness about the muscles, with a hypereesthesia
of the skin, this soreness being limited to single groups of muscles
or a circumscribed spot, with a constant tendency toward a shifting
of the site. The joints have a feeling of stiffness, and in some cases
there is great swelling and tenderness of single joints, resembling
inflammatory rheumatism. There is this difference, however, that
the pain and the tenderness of the joint may only remain a few
hours, and then it will entirely subside, to again appear in another
joint. There is also the absence of the general constitutional symp-
toms of the rheumatic affection. Cramps, especially in the fingers,
legs, and toes, are often experienced. Some patients complain of a
tingling or numbness of the extremities. Black stools are very fre-
quently seen, and in a few cases bloody urine was passed. The
general appearance of the patient is suggestive of the disease. The
skin is of a dirty-white hue, suggestive of chronic malaria. The
superficial veins are engorged, and this is especially seen in the veins
of the forearm and in some cases in enlargement of the temporal
veins. The blood is of a dark Prussian blue, and this change often
attracts the attention of the patient. The fever varies greatly in
different cases. In the simple cedematous form of the disease the
temperature rarely rises above 101°. This may remain for twenty-
four to thirty-six hours. This is often preceded by a chilly sensation ;
in three cases a decided rigor was seen. In exudative cases the tem-
perature may rise to 103° F., or even more. A typical case com-
mences with a chill, a rise of temperature which may continue for
twenty-four to forty-eight hours, which then subsides, continuing at
about 100° to 101° during four to six days. I have noticed that
where the exudation is confined to the tonsils the fever continued
rarely more than twenty-four hours, but where it involved the pharynx
it continued from five to seven days. The pulse is always increased
in rapidity; it is full, soft, and compressible. Sweating is a very
prominent symptom, This occurs especially at night, and is accom-
panied by a chilly sensation resembling true night-sweats. The dis-
ease is certainly in a measure contagious. I have often seen different
members of a family develop it in succession. Sometimes one mem-
ber will show the simple edema and others will have the exudative
patches. In the children’s ward of the Mullenphy Hospital all the
children were affected, and all recovered.

The local symptoms vary in different cases and depend on the

Septic Gidema of the Upper Air-Passages. 23

part of the throat involved. In some they are very marked, in others
they are entirely wanting. When the nasal mucous membrane is
affected, a complaint is made of a fecling of fullness and dryness of
the nostrils. When the palate and palatine folds are involved there
is frequently pain on swallowing, and it is especially noticeable that
the pain is greater on swallowing saliva than on taking food. In
fact, the taking of food in some cases seems to produce a certain
amount of relief. In cases where there is great edema of the palate
the pain is often so intense as to almost preclude the taking of nour-
ishment. One patient told me that every attempt at deglutition pro-
duced a sensation as though a knife were drawn across the throat.
But this intense pain is only found in cases where the cedema is
great. In the large majority of cases the pain is slight and com-
plaint is made more of a feeling of dryness or a fullness of the
throat. It is noticeable that the pain is always increased toward
evening and during the night, diminishing, and in some cases almost
entirely disappearing, during the morning hours, to be again experi-
enced at the same hour of the afternoon the next day. In edema
of the posterior larynx there is a feeling of fullness with constant
desire to swallow, and a sensation as though a foreign body was
lodged at this point. Again, a sense of oppression is often experi-
enced in the upper portion of the chest, and there is a constant
tendency to sigh. In some cases I have seen an intermittent char-
acter given to the pain, it occurring with greater intensity on alter-
nate days. In cedema of the vocal cord there is always more or less
change of the voice. It seems to lose in strength and clearness. In
two cases, although the speaking voice was little impaired, the sing-
ing voice had entirely disappeared. With the subsidence of the
cedema the patients who are professional singers regain their voices
in the natural strength and purity. The characteristic ropy, gluey
secretion is sometimes so profuse that constant hawking and expec-
toration are necessary. This is also found even with scanty expec-
toration, the sensation being produced by the feeling of fullness.
Hemorrhages are quite frequent; usually they are small in quantity
and recur frequently. In three cases I have seen profuse hemor-
rhages in which the expectoration of blood continued through seve-
ral days. The blood is usually black, clotted, and may be mixed
with a viscid secretion, but often it is simply a pure dark blood.
When the larynx is affected, cough is a frequent symptom. It
may occur in an incessant hack. In other cases there are vio-
lent paroxysms. The cough at times bears a great resemblance to

24 Transactions of the American Laryngological Association.

the cough of whooping-cough, the inspiratory stridor being espe-
cially marked.

Without proper treatment the acute symptoms in the cedematous
form will continue from three to five days. A comparative state of
well-being then comes in which the symptoms are greatly mitigated.
This is followed by another attack. I have seen cases who have suf-
fered in this manner for four months in whom the acute exacerbations
occurred about every three weeks. In cases with exudation I have
seen the patches remain from one to six weeks.

Diagnosis.—The cedematous form of the disease can only be con-
founded with that due to a catarrhal inflammation. The pronounced
constitutional symptoms and the characteristic appearance of the
throat will differentiate the conditions.

In the exudative cases, where the exudation patches are promi-
nent on the tonsils, we should naturally think of simple follicular
amyedalitis. The general symptoms are in a measure similar and
the appearance of the tonsils is not unlike that of amygdalitis.
Close inspection, however, will show the minute white points in dif-
ferent parts of the fauces, and the condition of solid edema, which
is always present, is not found in simple amygdalitis. The tonsils
are never enlarged to the degree seen in amygdalitis, and, instead of
the red, hyperzemic condition, we find rather an unnatural pallor of
the membrane. The characteristic sticky secretion is also wanting.
When the exudation is extensive, especially when it is on the pharyn-
geal wall and the palate, the close similarity to mild diphtheria will
give us a good deal of anxiety. The presence of the solid cedema of
the fauces and the character of the secretion will help the diagnosis.
The behavior of the patch seems to me to give positive and definite
information toward a diagnosis. I have never seen paralysis follow
in these cases of exudative pharyngitis.

The treatment of the cedematous form of disease of the throat is
very simple. It consists in saturating the system with the benzoate
of sodium. I usually combine it with the liquor ammonii acetatis.
I have found it to act as a specific remedy in the disease. As a local
remedy I have found the bicarbonate of sodium in conjunction with
a little carbolic acid to act as a soothing, pleasant gargle. Under
this treatment the symptoms promptly disappear, and the patient
recovers. In some cases, when the joints are prominently involved,
the addition of the salicylate of sodium seems to be of service.
Although quinine moderates the symptoms, I have never found it
to produce permanent relief. After the subsidence of the acute

Discussion on Papers of Drs. Langmaid and Glasgow. 25

symptoms I have found the mistura ferri et ammonii acetatis, often
combined with arsenic, to be very useful in overcoming the anemia
which always remains after the acute attack has subsided.

From a study of these cases of cedematous disease of the throat,
I am convinced that we are considering a constitutional disorder
rather than a local disease, and that the condition of the throat is
simply one of the manifestations of a general condition. In a paper
I am preparing for publication I have endeavored to show an analo-
gous condition existing in the lungs to that seen in the throat. The
solid cedema found in the lungs resembles in many respects that seen
in the fauces, I maintain that this analogy is strictly legitimate,
from the fact that I have seen this condition of the fauces to exist
in connection with the pulmonary form of disease, and also from the
fact that there are frequent alternations of the two forms in the same
individual. Post-mortem examinations have proved that the patho-
logical changes in the body are such as are only found in septic
conditions, and cultures of the lung tissue show the presence of vari-
ous micro-organisms.

Hence I would consider the pathological changes in the throat
and lungs to be simply manifestations of a general septic condition,
dependent probably on some pathological change in the blood.

The appearance of the disease in certain portions of the year,
followed by its complete disappearance for many months, leads me
to think of an atmospheric influence in producing it. The recog-
nized fact that patients suffer more and are more prone to relapses in
cloudy or rainy weather and improve in the bright sunshine, seems
to strengthen this supposition. I have thought at times that it
might be a manifestation of influenza, a disease which, as is well
known, sweeps over the country in waves and then entirely disap-
pears. The symptoms of influenza, as portrayed by Graves and
others, bear a striking similarity to those seen in this septic edema.
Its long continuance during several years is, however, not in accord-
ance with the epidemics of influenza which have been described.

Discussion.

Dr. T. A. De Brots, of Boston: I have been much interested in Dr.
Langmaid’s paper, particularly with reference to the possibility of diph-
theria being coincident with the condition he describes. Last year I
was called in consultation to a case of supposed cedema of the larynx.
The epiglottis and the arytenoids were edematous, not so much at the
first examination as subsequently. I punctured the epiglottis and gota

26 Transactions of the American Laryngological Association.

slight discharge of blood, and in twenty-four hours the place of puncture
was filled by the exudation of diphtheritic membrane. The cedema then
progressed, and the arytenoids became so large and obstructed respiration
so much that they were punctured, and again extension of the membrane
occurred. There was no discharge of pus at all. Sometimes marked
cedema will precede a very slight exudation. As Dr. Langmaid has said
there might have been exudation which had passed away when be exam-
ined the throat; but I have never seen cedema follow exudation.

Dr. Daty: The condition which Dr. Glasgow has so wel] described
is somewhat new to me. The doctor spoke to me in regard to it a year
ago, and asked me if J had seen such conditions. At that time I had not;
but last autumn, when the bad weather began, there was in Pittsburgh
an endemic of the class of cases to which Dr. Glasgow has referred. A
number of them fell to my professional care, but by far the larger number
were treated by the general practitioners. I did not regard this swollen
condition of the fauces so much an cedema, as we understand that term,
as that it was a subacute inflammatory condition of the mucous mem-
brane, with attendant swelling. There was a sufficient number of these
cases that had superficial and very thin diphtheroid patches in various
parts of the fauces to warrant me in my opinion that they were cases of
a diphtheroid disease of the throat. I was confirmed in this opinion by
the subsequent occurrence of glandular enlargement, which came on in
nearly every case, and was located in the deeper regions at the sides of
the throat, sometimes in other parts of the body, and in one or two in-
stances in the axilla. In short, I regarded this endemic as a diphtheroid
disease, with exaggerated local symptoms scarcely warranted by the local
deposit of false membrane or fibrinous deposit; but, while there were
exaggerated glandular symptoms, there was a rather amenable condition
of the constitutional symptoms.

The calomel treatment, which I am so fond of employing in cases of
true diphtheria, and which has stood me in very valuable service—much
more so than any other plan of treatment that I have ever adopted—did
not give the results which I am in the habit of observing from it in true
diphtheria. These cases were usually manageable, but sometimes slowly
so, with a treatment something like this: Three or four times a day, three
to four grains of Dover's powder, with two or three grains of quinine upon
a full stomach, and then the use, both locally and internally, of a solation
of the chlorides—chlorate of potassium, Squibb’s preparation—with dilute
hydrochloric acid in syrup or, preferably, in glycerin. This was used as
a gargle in hot water, and a moderate dose taken every two or three
hours.

After the local disease subsided, the glandular enlargement was usu-
ally treated with an ointment of veratrine, or simple lanolin, and the use
of the iodides. Much handling of these giands was resented by increased
pain and swelling. I believe that this is a modified form of diphtheria,
with exaggerated local symptoms, but a more amenable condition of the

Discussion on Papers of Drs, Langmaid and Glasgow. 27

constitutional symptoms, and depending upon a modified form of the
germ or infection, It seems to me that it has sprung up in the Missis-
sippi and Ohio valleys, and has radiated from those regions.

Dr. J. ©. Murua, of St. Louis: I think that a great deal of credit
is due to Dr. Glasgow for being the first to recognize that there is a pe-
culiar type of inflammatory trouble of the upper air-passages sweeping
over the country. I can contirm, from experience in St. Louis, the
existence of this peculiar class of cases. The last acquaintance that I
saw before I left was a gentleman who came to the train to tell me that,
for the third time, he had tenderness in the throat. He came to me
two weeks ago with what he thought to be the symptoms of ordinary
quinsy. I found these white patches of exudation on one tonsil, and a
great deal of pain without edema. I regarded the case as one of ordi-
nary follicular amygdalitis, and treated it in the ordinary way. I gave
him aconite and a gargie of tincture of guaiacum. In forty-eight hours
he again presented himself with an abscess of one tonsil, but the usual
relief did not follow the evacuation of the pus. He again returned in
forty-eight hours, and then was present this peculiar type of edema, It
involved the uyula, the anterior and posterior pillars on the right side,
and extended down the pharyngeal wall on the right side. He then took
my advice and went to bed. The treatment which was then adopted
seemed to bave a marvelously rapid effect in relieving the trouble. It
was the old-fashioned antiphlogistic treatment. The inflammation seemed
to be of a rather active type, the temperature being from 100° to 108°.
The treatment consisted in the application of very hot poultices to the
side of the throat every half-hour, the administration of Norwood’s
tincture of veratrum viride, and antipyrine. Saline purgatives and scari-
fication were also employed. This treatment had a marvelons effect.
He recovered, but subsequently the throat again became sore, and exactly
the same thing occurred. The same treatment was pursued, and the
symptoms subsided in twenty-four hours. When I left St. Louis he had
been well for four days, but, as I have stated, he came to me to say that,
for the third time, symptoms of irritation of the throat had appeared.
Some time ago I saw another gentleman with the same sort of an attack,
which subsided, under the treatment mentioned, in forty-eight hours
without any recurrence. I have also observed the glandular implication
which is very unusual in ordinary sore throat. I saw one of Dr. Glas-
gow’s patients on Monday. He has been suffering since December 15th,
and it is only within the last month that the glandular enlargement has
begun to recede. His was one of the cases in which ulceration took
place. It is possible that the case described by Dr. Langmaid, and proba-
bly the case of Allen Thorndyke Rice, belonged to this class, having
involved the larynx and produced acute @dema. I have not seen any
of the cases in which there has been laryngeal involvement, although,
curiously enough, during the last winter I have seen two cases of acute
typical laryngeal cedema from erysipelas. With Dr. Daly, I think that

28 Transactions of the American Laryngological Association.

this affection originated in the Mississippi Valley, and has radiated to
other parts of the country.

I should like to say a word in regard to the pneumonia which has
occurred in connection with these cases. J was recently in the biological
laboratory of Dr. Bramer, of St. Louis, and he showed me the results of
some cultivation experiments from this form of pneumonia, side by side
with the cultures from the ordinary pnetmococcus. The growth was
entirely different, although the gross examination had shown interstitial
pneumonia in both instances.

Dr. S. Hartwett Cuapman, of New Haven: While expressing my
admiration for the exhaustive analysis and close observation of the
symptoms of this disease which is the subject of Dr. Glasgow's paper,
I can not but differ with him as to the character of the disease itself. It
is, 1 am sure, but another and not unusual development of diphtheria.
We are not obliged to seek in the Western States for these peculiar
phenomena, for they are quite as common developments of diphtheria
in the Eastern, and I feel confident that I am giving the experience of
laryngologists in the Middle and Southern States as well.

A case which occurred in my practice during the spring of this year
will illustrate the close connection between the ordinary forms of diph-
theria and this peculiar form of which we are indebted to Dr. Glasgow
for collecting the interesting symptoms. In the first week in March I
treated a lad of ten years, in a family consisting of parents and two
chilcren—this lad and a boy-baby of about eighteen months. This case
was one of mild typical diphtheria with well developed tonsillar and pha-
ryugeal membrane extending to the brim of the larynx, with moderate
glandular enlargement, considerable exhaustion, and moderate rise in
temperature. The case was treated with quinine, stimulants, and mer-
curials, and ran an ordinary course of about ten days, with no bad results
following. On the fourth or fifth day of this attack my attention was
called to the younger child, who was found to have a dense swelling of
moderate size directly under the chin, with rise in temperature and the
appearance of being very ill. The same treatment was adopted in this
case as in the other, with the addition of hot fomentations to the glandu-
lar enlargement. No membrane could be observed in the throat, and
indeed the mucous membrane seemed to be in a perfectly healthy state.
There was no hoarseness and no dyspneea,

Notwithstanding all preventive efforts, the glandular enlargement con-
tinued to increase, extended to other glands, and finally produced a uni-
forin infiltration of all the tissues of the neck. This occurred rapidly, so
that by the end of the fifth day the appearance of the little patient was
very peculiar. From the ears to the clavicles, and extending almost to
the shoulders, the swelling was one uniform smooth mass, into which the
face and chin seemed to have sunken. With the gradual increase of this
infiltration, dyspnoea appeared and became finally very alarming. The
process of deglutition ceased on the second day, and the patient was nour-

Discussion on Papers of Drs. Langmaid and Glasgow. 29

ished per rectum. It seemed likely that suppuration had taken place, so
that I made several deep incisions in the sublingual region. This opera-
tion was followed by rather copious hemorrhage, but no pus was found
and the symptoms were not at all relieved. An O'Dwyer tube No. 2 was
then inserted into the larynx, although with very great difficulty owing to
the infiltration. This was lett in situ four days, during which time the
infiltration so rapidly subsided that the conformation of chin and neck
again became evident. By the eleventh day the patient was again able
to swallow liquids. By the fifteenth day convalescence set in. During
the course of the disease there was no membrane to be observed, and the
mucous membrane of the pharynx and mouth retained its healthy appear-
ance. The peculiarity of the case was the development of enormous
infiltration into all the tissues of the neck, tourming a dense, bard, inelas-
tic swelling. During convalescence moderate suppuration of the sub-
lingual gland took place. As far as it is possible to judge, this seemed to
be a case of modified diphtheria of the general type of the disease so ably
described by Dr. Glasgow.

Dr. Cuartes E. Sasous, of Philadelphia: It has been my good for-
tune to see several of these cases, and the remark made by Dr. Chapman
that they are not limited to the West is exemplified by the fact that Dr.
Seiler described a number of them before the German Medical Society
of Philadelphia a few months ago. The first case that I saw of this affec-
tion was in a young man from New Jersey. He had been exposed to the
contact of no case of the kind in the neighborhood. I was struck with
the amount of pain and the severity of the general symptoins which ac-
companied the throat trouble. The appearance of the throat did not re-
semble the condition seen in diphtheria. Instead of the yellowish, leath-
ery membrane generally present in diphtheria, there were smal] white
patches, probably twenty or thirty in number, covering the pharynx and
tonsils. Around these patches was a narrow areola of redness which
gradually disappeared to again increase toward a neighboring patch. The
vault of the pharynx was slightly involved. There was slight oedema of
the soft palate. The temperature was raised throughout the entire course
of the attack (102°5°). The case appeared at first to be one of follicular
pharyngitis, but the general symptoms were such that I made up my mind
that it was an affection with which I was not acquainted. There was
redness of the fauces and slight tinnitus aurium. The patient complained
of incessant pain in the back and in both legs. After trying a number
of remedies, he was placed on benzoate of sodium, suggested by the
remarks of Dr. Seiler, which were reported to me by a member of the
German society who was present when the paper was read.

I saw another case in Wilmington to which I was called in consulta-
tion. This was in a child about two years and a half of age. The case
much resembled that reported by Dr. Chapman. The glands were greatly
enlarged—suiticiently so, in fact, to warrant the intention of the attend-
ing physician to freely open them, fluctuation being present. The knife

30 Transactions of the American Laryngological Association.

was not used, however, but the child was placed under minute doses of
the bichloride of mercury. The glandular swelling rapidly disappeared
and the child got well. The appearance of the throat and the general
symptoms were about those found in the case from New Jersey.

Dr. DeLavan remarked that this discussion was a timely one, coming
_as it did in connection with a recent celebrated case. He referred to a
patient in this condition whom he had seen suddenly die froin heart
failure. Other cases, apparently similar, had been occasionally reported.
He believed that they were analogous to those described by the older
French writers and by Sir Morell Mackenzie as ‘‘acute cedematous lar-
yngitis,” and more recently by Senator, under the name “ acute infectious
phlegmon of the pharynx.” The speaker thought that the possibility of
the disease being diphtheria had not been satisfactorily eliminated. In
view of the dangers attending it, he urged that the affection be more care-
fully studied and explained, and he thanked the reader of the paper for
the valuable light which he had thrown upon it.

Dr. Lanemarp: Dr. Glasgow’s cases seem to me quite different from
the one which I reported, in which the cedema was the result of pressure
and not necessarily a symptom of the disease which caused the adenitis.
I thought that the ease which I have related was of sufficient intcrest to
bring before the society, because it was almost diagrammatic. The neck
was swollen even from the jaw to the clavicle. The short history of
illness made me expect to find membrane or an ulcerated patch from
which inembrane had been discharged. I found a perfectly clean throat.
I can not conceive of an adenitis as extensive as this in a patient of the
age of this one, coming on as suddenly as it did and disappearing so sud-
denly, that was not septic. I believe that there was diphtheria in this
case, but, as the history of the fir-t eight days is not known, I can not
speak positively. There was no cedema of the pharynx or fauces when
I examined the patient. It also seemed to me that the spontaneous
evacuution of pus from some gland, as occurred in this case, must be very
upusual.

With regard to the cases spoken of by Dr. Glasgow, it has seemed to
me that, with the remains of a general practice clinging to me, if these
cases had occurred in Boston, I should have seen some of them. I do
not recall any such case, and, so far as I know, they have not been pre-
sented to the societies. For some years we have had conditions in Boston
which, with the constant presence of diphtheria in certain sections, would
render the occurrence of a general epidemic very probable. It has not
occurred, and it has seerned to me that, for some reason, the atmosphere
of our city is not suitable for the spread of diphtheria, This is possibly
the reason that we have not seen these bastard cases, such as Dr. Glasgow
has described.

Dr. Grascow: There is only one point to which I need refer, and that
is in regard to the connection between this form of disease and diphthe-
ria. No one could possibly consider the edematous form as diphtheritic,

Chronic Diseases of the Upper Air-Tract. dL

and the question could only occur when the exudation is present. In my
earlier observations I thought the exudative cases miglit be diphtheritic.
In one case, a young girl of seventeen, the whole palate and tonsil was
covered with exudation. 1 thought that it was a case of diphtheria, and
placarded the house as the law exacts. As I watched the case I became
convinced that it was not diphtheria. I called in one of our ablest pliysi-.
cians, and at first he said that it was diphtheria, but, after watching the
case for a few days, was convinced tliat it was something else.

The history of the exudation is not that of a diphtheritic patch. It
never comes away in a mass, but gradually fades away, growing thinner
and thinner day by day. It is not surrounded by the inflammatory zone
seen in diphtheria. That diphtheria may be ingrafted on such a condition
of the mucous membrane I am fully convinced, since | have met with it
in several cases. The cedematous condition of the mucous membrane
seems to furnish a fertile culture soil for the development of cocci.

Paper.

SOME DISCURSIVE REMARKS BASED UPON HAVING OBSERVED
INTIMATE RELATIONS BETWEEN CHRONIC DISEASES OF THE
UPPER AIR-TRACT AND NEURASTHENIA.

By WILLIAM H. DALY, M. D.

URING the past five years I have made some observations and
noted them with reference to certain symptoms or diseased
conditions referable to the intranasal structures or of the pharynx or
larynx which have either been the immediate precursors or the con-
comitants of neurasthenia. In other words, many of the patients
that have consulted me for a variety of symptoms referable to the
upper air-passages have at the same time given a history of concomi-
tant or early succeeding neurasthenia, and I think I may offer these
observations to the profession as being not only new to its literature,
but based upon a clinical experience sufficiently extensive to warrant
us in taking up a new line of thought as to some of the features ex-
pressed in naso-pharyngeal catarrh and functional and inflammatory
aphonia as they precede or coexist with neurasthenia in some one of
the latter’s many forms. It was the teaching of Murchison and others,
and quite generally accepted too by the profession, that many of the
conditions we know now as neurasthenia were conditions of suppressed
or undeveloped gout or lithemia; but if the thoughtful medical man
will carefully read Murchison, eminent and able reasoner and clinician
though he was, he will nevertheless be forced to conclude that the

32 Transactions of the American Laryngological Association.

data for pronouncing certain forms of nervousness, in men especially,
which are characterized by insomnia, indigestion, mental irritability,
etc., conditions of suppressed gout or lithemia are wholly insufficient
to satisfy those of us who like to believe we have found a rational
cause, or that we have been taught one that is to our minds reasonable
and borne out by future observations of our own upon patients. Un-
less this can be done, few of the thinking men in the profession can
long hold to any dogma, let it emanate from whatever source it may.

I am fonder of noting plain practical observations in pathology
and therapeutics than of indulging in abstruse theories as to what
causes these certain conditions noted. Why? Because it is much
easier for me to do this, and it suits best my practical bent of mind.
Yet how much commoner it is among medical men, as among lay-
men, that at once a cause is sought for an evil and little or no atten-
tion paid to the interpretation, meaning, or cure of certain manifesta-
tions! As I have said, I confess to being more wrapt in noting the
coexistence of symptoms, and, if possible, getting a remedy for their
alleviation and cure, than of diving into their mysterious workings
and explaining their manifestations by mere theories. The abler
heads may weave theories to their hearts’ content. But one page of
practical experience, with careful and intelligent observation honestly
reported, will redound more to our instruction than whole tomes of
dry and baseless theory or dogma, What I have to say will, I trust,
at least seem worthy of inspiring further observation in this direction.
In these days of hard going and pushing for place, fame, and fortune,
especially in cities, it is appalling indeed to see the early wreck of
the physical and mental constitutions of the cultivated and respecta-
ble men and women who are neurasthenic either through their own
folly or circumstances that are innocent enough of themselves if
guarded by common sense and -moderation. Now, it will seem
strange to you possibly to hear from me that I believe laryngology
and its congener, rhinology, have much with which to concern them-
selves in neurasthenia, as well as in the many reflexes that have been
so well studied by the able minds of J. N. Mackenzie, Hack, of Frei-
burg, Roe, of Rochester, and others. But you will not be alto-
gether surprised either. One of the old masters in medicine spoke
of the nose and throat as the gateways of life, and I believe he was
quite right. They are more than that; they are also the sentinels at
the gateways of life in more ways than one. It is from these regions
we are so often warned of the approach of discomfort, danger, and
disease.

Chronic Diseases of the Upper Air-T act. 33

I rieed not refer to the fact that all the disease germs enter the
system through these gateways. It is in one of these gateways that
the half-pleasing sense of titillation causing sneezing warns us that we
are catching cold; and, by the way, let me digress and ask, What is
“catching cold”? My observation has taught me that the causes of
so-called “catching cold” are as often intrinsic as extrinsic. That
is to say, a patient without any exposure whatever to draughts of air,
either suspected or real, may, by a certain state of the organs and
their secretions, be seized with a tickling in the pituitary membrane
and sneezing, followed by all the symptoms of “ catching cold,” and
subsequently have pneumonia or other form of pulmonary inflam-
mation with all its worst and most protracted consequences. Now,
resuming my subject, permit me to refer to a summary of twenty-
five cases of which I have the clinical records bearing specially upon
the question I have brought herein to your notice in the title of this
imperfect paper. These cases have a clinical history like the follow-
ing ones selected, with certain features altered, masked, or absent,
but the main ones to which I call your attention prominent and
leading—viz., the presence of acute or chronic disease of the upper
air-tract in some of its extent, and neurasthenia in one of its protean
forms.

Case I.—J. G., male, aged thirty, of bilious temperament, good pa-
rentage and habits of life, no acquired blood disorder, occupation active
and mentally exciting. Subjective symptoms, a sense of intranasal full-
ness under the bridge of the nose and alternating stenosis in one or the
other naris, especially at night when trying to sleep. Has a sense of
worry and anxiety constantly present, and his mind is very active when
repose is sought at night, precluding sleep, which, when obtained, is light
and fitful. Appetite good, and digestion thought to be good. Uses no
tobacco or stimulants. Social relations marital and excellent. No vices
or excesses. Local objective symptoms, a bony spur upon the left side of
the septum narium and a flaccid state of the mucous membrane on both
inferior turbinates. Still under treatment, with some improvement going
on, although the patient says he fails to discover the latter. This, how-
ever, will be discovered to him surely when the local intranasal condition
is cured, and a cure in this case is one of the most encouraging and cer-
tain of possibilities, with further time and care.

Case II.—Miss W. J., aged twenty-eight, nervo-phlegmatic tempera-
ment. A well-rounded, symmetrical, and apparently well-nourished fig-
ure. Complexion sallow. Nose flattened and tip deflected to the right.
Secretion of mucus from nares posteriorly copious and sometimes offen-
sive; tongue clean. Appetite and digestion always poor; bowels consti-
pated. Catamenia normal. Has lived for over a year on pancreatized

$3

34 Transactions of the American Laryngological Association.

milk chiefly. A sense of intranasal fullness even when she is certain the
canals are cleansed and freely pervious to air. Always weary and tired,
and especially at the latter part of the day she is utterly exhausted. Sleeps
badly, and always wakes with a bad taste in her mouth and a dry tongue.

Objective intranasal examination reveals a contorted condition of all
the internal parts throughout that looks as though the nose had been hit
with a hammer or caught in the door at some former time and badly
twisted in its extrication. All the ordinary anatomical relations are of a
cork-screw pattern and quite beyond a brief description. This patient is
improving, but nothing short of the highest and most skilled rhinoplastic
surgical art will ever make this nose a thing of beauty. The neurasthenic
state is improving under alterative, local, and general treatment.

In ten eases, with which I will not burden you in detail, there
was obstinate inflammatory aphonia attended with utter prostration,
nervousness, and insomnia; seven of these patients had nasal disor-
der of a chronic character; the remaining cases all had as leading
factors naso-pharyngo-laryngeal diseases in some form, with neuras-
thenia in some form also, Although one swallow does not make
a summer, a flock of them will cause us to look for a change of
weather; and will this little flock of cases not cause us to look out
for this too widely prevailing constitutional condition as one of the
unfortunate possibilities or concomitants of disease of the upper air-
tract? That they coexist there can be no question.

Discussion.

Dr. Joun O. Roz, of Rochester: This is a subject which can not fail
to interest us, because we all must have met with many such cases, and
it simply illustrates the general effect which local irritation may have upon
the system. The persistent nagging of a constant irritation will sooner
or later produce a depressed condition of the system, and, unless we re-
move the local cause, we can not hope to relieve the general condition.
It is useless to enlarge upon the subject, as most of us are familiar with it,
and it should not escape our attention in cases of general debility that we
must look for and remove causes of local irritation.

Dr. F. W. Hinxer, of Buffalo: I rise with some hesitation to express
my opinion, on account of my limited experience as compared with that
of the gentleman who read the paper. I can not concur in the opinion
that has been expressed. It seems to me that before we admit that a
general neurasthenic condition can be the result of any nasal lesion as
the sole cause, or as the main cause, a careful analysis of all the constitu-
tional conditions is required. I should be interested in hearing what the
general treatment was to which Dr. Daly alluded. I admit that any
local irritant would have its effect upon the neurasthenic condition, but

Discussion on Paper of Dr, Daly. 35

that pharyngeal or naso-pharyngeal lesions can be the main cause of
such a condition I am, from my own experience and general observation,
hardly able to admit.

Dr. Daty: [ hope that the gentleman will do me the justice to admit
the caution with which I approached this subject. The title of my paper
is ‘Some Discursive Remarks based upon having observed Intimate Rela-
tions between Chronic Disease of the Upper Air-tract and Neurasthenia.”
The problem I left largely for this body to solve, if it is within its power,
as to which is the causative condition.

Dr. Lanemarp: I did not understand Dr. Daly to say that the condi-
tion was due to disease of the nose, but that there was ap intimate relation
I did understand him to say. I should differ with Dr. Roe, and should
consider that much of the trouble in the nose was from the neurasthenia.
T am sure that is what Dr. Hinkel means. So often is this the case that
operative interference fails to relieve the patient because the neurasthenia
is not cured.

Dr. Mackenzie: I do not like to speak upon this subject, for I am
afraid that I should keep the society too long. In my paper, read at the
meeting in Philadelpbia, I made the statement that very frequently in
nasal troubles—as, for instance, in hay-fever—the local symptoms are due
in a certain class of cases to the neurasthenia, and, until the general con-
dition is relieved, the local treatment is without avail. It is a curious
historical fact that this peculiar dulness and incapacity for vigorous in-
tellectual work, dependent upon chronic affections of the nose, was recog-
nized by the ancients. A number of classical writers—for instance, Cicero
—mention this curious fact.

Dr. Sasous: I am inclined to support rather vigorously the remarks
made by Dr. Daly. It has been my fortune to observe a number of cases
in which I noted fluctuations in the nervous condition, and these corre-
sponded with fluctuations in the conditions within the nasal fossa. I have
now under treatment a gentleman who, some months ago, had an opera-
tion for deviated septum performed by a fellow-specialist. The operation
was done because all treatment directed to the general systemic condition
had been without benefit. After the nasal trouble had been corrected
the gentleman immediately began to improve, and the general neuras-
thenic condition, although it did not quite disappear, was materially
improved, and he was able to resume his duties, Iam sorry to say that
the secondary treatment of the case was not such as to maintain the con-
dition obtained immediately after the operation. The septum, as often
happens in these cases, returned to its original position, and at once there
was a marked return of the general symptoms. Having undergone a
second operation, with a carefully conducted secondary treatment, the
neuralgia and other symptoms not only disappeared as they had before,
but they did not return. In this case we were able to follow the fluctua-
tions as the case proceeded, and to note the marked benefit brought
about by treatment of the nose.

36 Transactions of the American Laryngological Association.

Dr. Daty: The imperfect manner in which I have been compelled
to present this subject does not do either myself or the subject justice.
I would say that the remarks of my friend, Dr. Roe, have a great deal in
them. I believe that he has epitomized a great deal that is valuable—
that is, that this local irritation, this local obstruction, which is a source
of continual nagging and local irritation year after year, is borne by the
patient because he does not know where to get relief, or is in the hands
of a practitioner who will not see these conditions or admit that others
can see them, and therefore temporizes with the case until some acute
disorder comes on, and with it an explosion, so to speak, of one of the
forms of neurasthenia.

While the presentation of the subject may seem crude and rather bold,
I assure you that it isa modest presentation. I have had sufficient ob-
servation, with flattering and lasting results in treatment, to warrant me
in re-uttering what I said to you with fourfold force if it were in my
power, that local treatment alone, leaving the neurasthenic condition out
of the question, is necessary, is advisable, is right, and that such local
treatment will be sufficient of itself to cure, and it will be surely followed
by relief from the disagreeable and troublesome neurasthenic symptoms.
I say followed, and I say it advisedly. These symptoms come on Jate in
the history of the case, and they take their departure late. In other
words, the physiological and anatomical condition of the intranasal struct-
ures can be made as near normal as possible, but still the neurasthenic
symptoms will linger. The patient will not be cognizant of any general
improvement, possibly of no local improvement at once, but tell the pa-
tient to wait. It will come in one or two months or perhaps a year, but
it will surely come, and come to stay.

In regard to the question of general treatment. I do resort to general
treatment, which is very simple and rational. In these cases of neuras-
thenia, while the predisposing cause may be, and I believe that it is, a
local condition, there is a condition of deficient nutrition co-existing, and
I direct mild remedies, but not frequently given, to act asa fillip to the
secretions. I give a mild hepatic stimulant once or twice a week at bed-
time, such as a quarter of a grain of calomel with fluid extract of senna,
with something to prevent griping. This is simply a stimulant to the
liver, and it gains these certain ends, not suddenly, but gradually. Other
than that, I do not rely much upon internal remedies. I do not believe in
the phosphates, which I regard as a once popular fad now moribund. I
depend largely, and would not hesitate to depend entirely, upon restora-
tion of the intranasal structures to what would be considered a normal
anatomical and physiological condition.

Sarcoma of the Thyreoid Gland. 37

Paper,
A CASE OF SARCOMA OF THE THYREOID GLAND.
By J. SOLIS-COHEN, M. D.

Pressure on the Right Sympathetic Nerve ; Unilateral Tonie Spasm of Laryngeal
Muscles ; Intermittent Clonic Spasm of Opposite Side ; Compression Stenosis ;
Tracheotomy ; Hemorrhage from the Gland Twenty Months later ; Pressure
upon the Left Sympathetic Nerve ; the Functions of the Compressed Pneumo-
gastrics aroused by Irritation of the Trachea ; Death from Disturbance in the
Functions of the Two Pneumogastrics.

Y. Z., of Wyoming Territory, a stock raiser, aged about forty-five
e years, applied to me July 18, 1887, at the instruction of his
physicians, with a swollen neck, dyspncea, right-sided ptosis and con-
tracted iris, abnormal warmth of the same side of the face, and with
frequent right-sided perspirations of both neck and face. His clinical
history was as follows: He was reared in a limestone district, and had
always led an active out-door life. His mother had had a goitre, which
he thinks was the cause of her death. A brother and sister have disease
of the throat, which he thinks is due to swellings in the neck.

Somewhere about 1871-’72 he began to notice that in running he got
out of breath much sooner than any of his companions, and that his neck
was getting thicker and thicker, so that within from five to six years it
increased fully two inches in circumference. His general health con-
tinued good. In 1874 he suffered pain for the first time. This pain was
a neuralgia of the right eye, which had been more or less continuous since,
and at times excruciating. In 1881 he had erysipelas of the right side of
the face, and about one month after recovery therefrom his right upper
eyelid drooped and the ptosis had been continuous. In 1885 he noted that
the right side of his face was hot, and this heat had been continuous since.
This heat had been attended by frequent perspirations of the right side of
the face and neck, sometimes several times a day.

The patient was a sturdy man of medium height, with an irregular,
dense, nodulated tumor of the thyreoid gland, larger on the right side,
with several enlarged cervical glands to the exterior of the tumor, and
with considerable collateral effusion into the surrounding connective tis-
sue. This effusion he stated was much less since he had left the high
altitude of Colorado. He had considerable continuous dyspncea, and had
had a few suffocative spasms. The outline of the lower portion of the
larynx and of the trachea could not be defined. He had contraction of
the right pupil, ptosis of the right upper eyelid, and redness and heat
of the right side of the face, with frequent perspiration of the same terri-
tory. The right vocal band was immobile in the median line (Fig. 1), and
the movements of the left band were feeble; but sufficient for respira-

38 Transactions of the American Laryngological Association.

tory and phonatory purposes. The diagnosis made was that of malignant

tumor of the thyreoid gland with stricture of the trachea by compression.

The ptosis, contraction of the pupil, heat of the

ees face, and perspiration I attributed to the re-

f \ sults of pressure upon the sympathetic nerve;

and the spastic contraction of the vocal band

in the middle line to the result of pressure

or irritation upon the recurrent laryngeal
nerve.

A tentative treatment with arsenic internal-
ly and with inunctions of diluted red iodide of

mercury ointment over the mass soon produced
MiG, 2a pane DNA improvement in breathing and marked diminu-
right vocal band in the 5
ee iaanlines tion in the bulk of the tumor, especially in the
nodules at its periphery.

On August 1st I noted for the first time clonic spasms of the left vocal
band, rendering the slit for breathing very narrow, but without producing
as much disturbance of breathing as I had noted in similar conditions. I
attributed this spasm to reflex irritation from traction on the right pneu-
mogastric by the contraction of the mass, rather than to any direct impli-
cation of the recurrent nerve of the lett side. The patient reported that
he had nearly choked the night before, apparently from something which
he had swallowed; but I attributed this to spasm. I deemed it most pru-
dent to send him at once to a hospital, where I performed a prophylactic
tracheotomy without anesthesia a few hours later.

On the right side of the middle line, the skin, the intermediate tissues,
the thyreoid gland, and the wall of the trachea were all one continuous
mass. The trachea was away over to the left side of the neck, and was
bent upon itself in its descent behind the sternum. The incision had te
be made directly through the enlarged isthmus of the gland. This struct-
ure was so calcified posteriorly as to necessitate the use of the curette to
scrape a way through to the trachea. After the trachea had becn opened
a terrific hemorrhage took place from a portion of the tumor which had
penetrated the left side of the trachea. This hemorrhage was so sudden
and so profuse that, had the patient been unconscious, he would in all
probability have perished through inability to obey instructions necessary
—to place his neck in a favorable position and to cough out the blood as
it flooded the air-passage. On account of the bend in the trachea, it was
found impossible to introduce the cannula with the aid of the ordinary
pilot conductors. Trousseau’s dilator and Golding-Bird’s dilator both
failed; but with the three-valved dilator of Laborde, fortunately at hand,
it was found practicable to keep the opening patent and to push the im-
peding swelling to one side, so as to admit of the introduction of the
tube. The patient professed to have experienced no pain whatever dur-
ing the operation, pain having probably been deadened by the attending
excitement. The condition of the parts was such as to justify the infer-

Sarcoma of the Thyreoid Glan 39

ence that the cervical vessels were involved in the growth, thus preclud-
ing attempts at extirpation of the mass in the future.

The neuralgia of the right eye ceased with the operation and did not
return, and the heat and perspiration of the face diminished considerably.
The ptosis and contraction of pupil remained uninfluenced.

Before the wound was dressed, the exposed portion of the diseased
gland was dusted with potassium-chlorate powder. This produced con-
siderable disintegration of a portion of the mass which discharged through
the external wound, and the size of the tumor diminished to such an
extent that, at the end of two weeks, the length of the tube had to be
lessened by nearly half an inch, and the tracheal opening had receded a
little toward the middle line of the neck.

I kept the patient under observation for about six weeks, during which
time be progressed very satisfactorily in every way, except that the clonic
spasm of the left vceal band soon became tonic, with permanent occlusion
of the glottis to a very narrow slit totally insufficient for respiration
(Fig. 2). It appeared in this instance, as I have noticed in similar ones,
that as soon as the artificial opening in the trachea insured access of air
to the lungs in sufficient quantity, the forced contractions
of the dilating muscles of the glottis, in the struggles for
breath, subsided, and the spasm became permanent and un-
opposed. I considered the condition to be spasm of the
laryngeal muscles, rather than paralysis of the posterior
crico-arytenoids, because of the tense condition of the edges
of the vocal bands and the backward position of the aryte- Fie. 2.
noid cartilages—physical conditions which require active
contraction of portions of the posterior crico-arytenoid muscles. The
voice was excellent as to modulation, but weak in intensity, reedy in
tone, and produced only with considerable expiratory effort.

About one month after the tracheotomy the patient complained of
regurgitation of undigested food about three hours after the mid-day and
evening meals. Whether this was due to pressure of the tumor upon the
esophagus, or to the presence of a diverticulum, remained undetermined,
as the condition soon subsided and did not recur.

The patient returned to his home with his tumor diminished to fully
one half of the bulk it had acquired previous to the operation. Tho
trachea had not receded from its position somewhat to the left of the
middle line. The contracture of the glottis had become permanent and
apparently complete, so that there was practically no room for respiration
through it.

Several months after his return to Wyoming Territory I received a
letter from his physician, under date of February 15, 1488, in reply to a
letter of inquiry, that ‘‘the patient was doing nicely, and coughed but
very little, the enlargements on the neck having reduced considerably in
size and being quite soft. The right pupil remained slightly contracted,
and he suffered from occasional attacks of facial neuralgia. He was in

40 Transactions of the American Laryngological Association.

good spirits. His weight was one hundred and forty-five pounds, a gain
of twelve pounds since he had left Philadelphia. His appetite was fair.
He underwent active exercise without much difficulty. He slept well,
and, in short, was doing nicely—much better than he had dared to an-
ticipate.”

About one year later, February 2, 1889, the patient returned to me to
learn whether anything could be done to disembarrass him of his tube,
the presence of which, interfering with his convenience, was the only
thing he complained of. He felt perfectly well and vigorous. His neural-
gias and other pains had almost ceased. The ptosis and contracture of
the iris were as formerly. The tumor had enlarged somewhat. The
larynx and trachea were fully an inch to the left of the middle line.
The glottis was oblique, from right to left, and prac-
tically air-tight, the vocal bands being in tense ap-
position (Fig. 8), and remaining quiescent on the
strongest efforts at inspiration.

The larynx showed no indication of structural dis-
ease. The voice was good and well modulated. While
no encouragement could be given as to any hope of
dispensing with the tube, I thought something might
be done constitutionally to reduce the bulk of the

Fia. 3. tumor, and therefore put the patient on a course of

Zittmann’s decoction of sarsaparilla, under the influ-

ence of which the tumor diminished considerably in size in about two

weeks, especially as regarded some enlarged lymphatic glands on the right
side and just above the clavicle.

Some bloody oozing from the top of the wound was now noted on
changing the cannula, but I could not determine its source. It did not °
occur every day, and did not seem to be due to any erosion of the tissues.
Despite my desire that the patient should remain with me, he insisted on
returning home to shear his sheep, shipping himself a quantity of Zitt-
mann’s decoction, and carrying the formula for its manufacture with him,
so that its use could be continued under the supervising sanction of his
own physician.

Some three weeks after his departure I received a telegram that he
was on his way to Philadelphia, his throat bleeding badly. Arrange-
ments were made for his instant admission to Jefferson Medical College
Hospital on his arrival. He arrived March 22d, looking well, but pale.
The wound was not bleeding. He told me that the oozing of blood at
changes of the cannula had gradually become more copious, and that,
after a serious hemorrhage, his physician had thoroughly cauterized the
track of the wound with nitrate of silver, and had started him off to
Philadelphia with strict injunctions not to remove the cannula under any
circumstances until he had reached me—a most judicious procedure and
advice, as the seqnel proved, all oozing having ceased for two days. I
allowed him to remain a day without disturbing the tube. On the next

Sarcoma of the Thyreoid Gland. 41

day, in the presence of the late Professor 8. W. Gross, whose co-operation
I had requested in anticipation of trouble, I removed the tube. Blood
poured out from the fistula as from a little pitcher. After a moment of
consultation, we cut down upon the parts without anesthesia, exposing
them freely, but we could find no bleeding vessels. The hemorrhage
was parenchymatous from the left side of the body of the gland, which
formed part of the fistula. We then cauterized the parts freely with the
thermo-cautery, which restrained the hemorrhage in great measure, but
not wholly. Then the cannula was replaced, after having been wrapped
in a tampon of gauze, into which a considerable quantity of Monsel’s salt
had been rubbed. This controlled the hemorrhage satisfactorily, and the
cannula was not removed until the fourth day. There was no further
hemorrhage. There was considerable dyspnoea after these procedures,
and the parts became somewhat swollen. I noted contraction of the left
pupil. This and the dyspncea indicated an additional pressure on the left
sympathetic and pressure upon the pneumogastrics. The dyspnoea would
come on suddenly, there would be an arrest of respiration, and then the
face would become pale and then livid, consciousness becoming benumbed
and occasionally abolished. Sometimes this condition would be preceded
by spasmodic, irregular, diaphragmatic respiration. Any irritation of the
mucous membrane of the trachea would relieve the dyspneea, redden the
face, and arouse the patient’s consciousness. The dying functions of the
nerves were aroused the most effectually by passing down a loop of wire
—in fact, the wire of the brush used for scrubbing the cannula. This
had been first used for the purpose of drawing out any clotted blood
which might have been occluding the trachea. Relief by its introduction
was so marked that the patient begged for its almost continuous presence
in the trachea. He could recognize the spot in the posterior wall at
which the loop of wire would be most effective, and would grasp the
physician’s hand to prevent its being moved therefrom. When it was
withdrawn from time to time, the phenomena of arrest in respiration
would supervene. Inhalations of oxygen gave but momentary relief
to the dyspnea. For three or four days there was little sleep, and
that fitful and irregular, respiration being maintained chiefly by the
presence of the foreign substance in the trachea, and the patient sank
from exhaustion on the evening of the fourth day. A promised autopsy
was prevented by the interference of relatives after they had arranged
to permit it.

The marked feature in this case was the rousing of the pneumogastrics
by titillation of the tracheal mucous membrane and the continuous pres-
ence of a foreign body—a.condition which I had never observed, and of
another record of which I have no knowledge.

42. Transactions of the American Laryngological Association

Paper.

SOME POINTS IN THE PATHOLOGY AND TREATMENT OF DISEASE
OF THE NASAL PHARYNX.

By JOHN N. MACKENZIE, M.D.

HAT the nasal pharynx is exquisitely sensitive to reflex pro-
ducing impressions is a fact which has been known for some
time, and the older medical literature contains isolated examples of
neurotic phenomena of various kinds emanating from pathological
conditions of this region. These reflex neuroses of the nasal phar-
ynx were, however, almost unknown except to special workers in
this field until the publication of a brochure by Dr. Tornwaldt, of
Dantzig,* in which prominent attention was drawn to the subject,
and which invested the so-called bursa pharyngea with a pathological
importance hitherto unrecognized and undescribed.

According to Tornwaldt, this bursa is a constant integral part of
the rhinoscopic picture, and can always be recognized, sometimes as
a furrow-shaped, sometimes as a blind ew/-de-sac, directly in the mid-
dle line in the center of a curve drawn from the upper edge of the
posterior nares to the atlas. This sac is the frequent seat of various
pathological processes—hyperemia, cystic formations, hypersecre-
tion, and simple and purulent inflammation; and these often lead
to reflex disturbances—such as asthma, cough, nasal polypi, various
ear troubles, neuralgia, inflammatory conditions of the naso-bronchial
tract, etc. He furthermore maintains the proposition that naso-
pharyngeal catarrh has its starting point, in very many cases, in a
localized pharyngeal bursitis, and that its cure is only possible after
destruction of the bursa itself. His treatment, accordingly, consists
in the obliteration of the bursa by means of nitrate of silver, follow-
ing insufflations of this agent (one to ten) with the application of
the fused solid directly to the sac. Tornwaldt’s hasty enthusiasm
carries him to the startling statement that, of 892 cases of naso-
pharyngeal disease examined by him, 202 were primary affections of
the pharyngeal bursa,

There are many objections which may be urged against the
theory of Tornwaldt. In the first place, the very constancy and
existence of the pharyngeal bursa is a subject of dispute among dis-
tinguished anatomists, and, according to my experience, the appear-

* “Ueber die Bedeutung der Bursa Pharyngea,” etc., Wiesbaden 1885.

Disease of the Nasal Pharynz. 43

ances described by Tornwaldt are by no means constant in the rhino-
scopic image.

In the second place, when we consider the changes which take
place in the pharyngeal vault during the different stages of inflam-
matory affections of the nasal pharynx—the frequent formation of
cysts of varying shape and contents, the formation of depressions,
furrows, and other conditions of the pharyngeal tonsil—it will be
readily understood how easily mistakes in diagnosis may occur, or
how difficult it often is to differentiate between well-recognized ap-
pearances in the pathological anatomy of post-nasal inflammation and
the theoretical primary bursitis of Tornwaldt. That such errors
have been indeed committed is evident from some of the literature
on the subject.

It is highly improbable, nor are there any just grounds for belief,
that an organ of such comparatively trifling anatomical and physio-
logical importance should be vested with the peculiar privileges as-
signed to it by the followers of Tornwaldt. Since I became aware
of Tornwaldt’s researches I have searched in vain for what might be
unequivocally termed a primary pharyngeal bursitis. When the
bursa has been involved, it has been so invariably in connection
with well-marked and far-advanced naso-pharyngeal disease. So
that, from the standpoint of my own clinical experience, I am unable
as yet to confirm the observations of Tornwaldt. Naso-pharyngeal
disease is the most common affection of this climate, and the innu-
endo of Carroll Morgan—that the postulate of Tornwaldt regarding
the great frequency of primary disease of the bursa, living, as he
does, in a city of small population, has not been confirmed by the
vast majority of specialists residing in large cities, and commanding
an immense amount of clinical material—may possibly carry with
it considerable force.*

While, then, Tornwaldt’s observations must, for the present, be
taken with a considerable amount of reservation, they have, at least,
directed prominent attention to a field of naso-pharyngeal pathology
of exceedingly great interest and importance. From them we may
learn the lesson that, in order to dissipate certain inveterate naso-
pharyngeal affections, we must not rely on astringents, alteratives,
et id omne genus, but we must destroy the source of the discharge.

My own observations concerning this class of naso- pharyngeal
neuroses may be briefly summed up in the following propositions :

* “Maryland Medical Journal,” March 19, 1887.

44 Transactions of the American Laryngological Association.

1. The nasal pharynx is, in quite a large proportion of individuals,
exceedingly sensitive to reflex-producing stimulation.

2. The areas chiefly involved are the posterior portions of the
turbinated erectile tissue and various points along the upper and
posterior portions of the naso-pharynx.

3. In consequence of this extreme sensitiveness, a local patho-
logical process, which in many persons would give rise to no reflex
neuro-vascular changes, may awaken a host of neurotic phenomena
referable not only to the region primarily involved, but also to other
and even remote organs of the body. These may include cough,
asthma, and various neuralgic affections, or the local structural lesion
may be the starting point of the various sympathetic affections of
the respiratory tract.

4, That this class of naso-pharyngeal neuroses are explicable on
the same general principles laid down in the article read before this
association, May 29, 1886 (vide “ Transactions,” page 154 et seq.),
and the pathology of the nasal and post-nasal affections is, therefore,
one and the same.

5. That the treatment should be carried out according to the
general directions laid down in the article just mentioned.

6. That when the morbid process originates in the pharyngeal
tonsil, attention should not be directed to the bursa alone, but an
endeavor should be made to extirpate the tonsil, as far as possible,
in its entirety.

7. That, while a favorable prognosis can not be safely predicted
by treatment of the bursa alone, extirpation of the pharyngeal tonsil
often offers the most favorable prospect in long-standing cases of
post-nasal inflammation.

Paper.

SOME PERSONAL OBSERVATIONS UPON THE ACUTE AND CHRONIC
ENLARGEMENTS OF THE ADENOID TISSUE AT THE VAULT OF
THE PHARYNX, AND THE MEANS USED FOR THEIR RELIEF.

By D. BRYSON DELAVAN, M.D.

a a subject of adenoid hypertrophy at the vault of the pharynx,
: although not a new topic, is one which has by no means been
exhausted. Many points connected with it have yet to be recog-
nized and explained. No apology, therefore, would seem necessary

Enlargements of Adenoid Tissue in the Pharynz. 45

for its study, if to it could be brought new facts, clearer light, or
fruitful discussion.

It is not the object of this paper to deal with matters long ago
investigated and already fully understood. It is hoped, however
that a few practical suggestions, gained through clinical study and
tested in the light of experience, may be added to the present stock
of information bearing upon the matter. With the history of the
subject and with the already recorded experience of others it will be
unnecessary, for the most part, for us to deal; nor can the usual cate-
gorical arrangement of matter be made, since the points to be pre-
sented are more or less disconnected, independent, and fragmentary.
Still, it has seemed desirable that they should be collected and thus
published together.

The material presented herewith may be classed under three
general headings—namely, as relating (1) to xtiology, (2) to pathol-
ogy, and (3) to treatment. As to the origin and development of
adenoids, the theory has generally been accepted that they usually
commence to grow during childhood, that they remain stationary
during youth, and, finally, that, if left to themselves, they will shrink
away and disappear with maturity. lence it has been taught that,
so far as they themselves are concerned, they might be allowed
to remain without interference on the part of the surgeon, the disas-
trous symptoms which are caused by them in the child being the
immediate reason for their removal.

While in a majority of instances the above assertions are beyond
question true, there are, on the other hand, many cases which seem
to prove them incomplete, and which in themselves would offer
abundant material for special consideration. Indeed, when carefully
studied, the exceptions will be found, we believe, to embrace several
large and important groups of cases—cases which occur by no
means uncommonly, and which are capable of giving rise to annoy-
ing and even serious symptoms.

Again, with regard to the pathology of the condition, much has
yet to be learned as to the varieties of deformity which it may show,
the relative importance of these varieties and of the symptoms grow-
ing out of them, and of the influence which it may exert upon sur-
rounding organs.

In the treatment of adenoids many improvements upon the
methods usually adopted are possible, several dangers are to be
avoided, and greater certainty and accuracy of result are to be at-
tained.

46 Transactions of the American Laryngological Association.

And, first, with regard to the origin of adenoids, one of the most
important statements quoted above is to the effect that hypertrophy
begins in early life.

While, without doubt, many cases originate during early child-
hood in some one or more of the causes already familiar to us, it now
and then happens that a patient will refer the first symptoms of the
difficulty to a period later than puberty. Of such cases it is my
belief that many are the immediate and direct sequele of an attack
of diphtheria or scarlatina, most commonly of the former. The
structure and pathology of Luschka’s tonsil are largely analogous
to those of the faucial tonsil. A general condition of enfeeble-
ment, repeated catarrhal attacks, and other well-known causes may
result in hypertrophy of the faucial tonsil at almost any age short
of middle life, and, to a certain extent at least, the same may be true
of the adenoid tissue at the vault of the pharynx. Not alone may
it happen, therefore, that the enlarged Luschka’s tonsil may not
atrophy as the child grows older, but, as has been stated above,
hypertrophy may even take place after the period of childhood has
been passed. Cases are not uncommon in which enlargement suffi-
cient to cause injurious results has persisted through middle life-
The writer lately operated, with marked relief, upon a gentleman
aged forty-four. In another patient, a well-known surgeon of over
fifty, he has observed a distinct enlargement, dating back to child-
hood and even now giving rise to troublesome catarrhal symptoms,
cough, and reflex irritation.

Among adults, however, he has seen a condition of moderate
hypertrophy, most frequently in women of thirty or under. The
patients of this class are usually somewhat stout in figure, and re-
semble each other in general type. They may or may not have con-
current disease of the faucial tonsil. They are subject to attacks of
catarrh of the upper air-passages. They are apt to suffer from various
impairments of digestion. Many of my own cases have been in
singers, whose voices have been directly injured in consequence of
the above irritation, vocalization being difficult, the notes husky or
at least impaired as to their brilliancy, and moderate efforts being
followed by fatigue. All of these symptoms are aggravated by the
slightest cold. Often the patient is able to locate with considerable
accuracy the seat of maximum irritation. Examination of the upper
pharynx shows a pharyngeal tonsil which very rarely extends below
the upper margin of the Eustachian prominence, but which is dis-
tinctly enlarged and congested, and bathed in mucus. The Eus-

Enlargements of Adenoid Tissue in the Pharynz. 47

tachian prominence, meanwhile, is pressed upon by it, in some in-
stances with injurious force, and while the thickening may be but
apparently slight, its effects, as above indicated, may be serious.
Among other results, impairment of hearing may be quite out of
proportion to the amount of hypertrophy present; but it is often,
however, wanting. Local topical treatment in these cases seems of
little or no avail, while operation is followed by distinct relief.

One of the most interesting phases of adenoid disease is that con-
dition in which a temporary enlargement of the tissue at the vault
of the pharynx takes place under special excitation, the enlargement
subsiding with the disappearance of the cause. As this condition
has not been heretofore described, so far as the writer is aware,
special attention is called to it. It is well illustrated by the follow-
ing case (I), which is exceedingly instructive as explaining a very
possible source of error and disagreement.

A young lady of eighteen, blonde, somewhat delicate, but on the
whole well developed and in the enjoyment of fair health, was treated by
Dr. Albert H. Buck, of New York, during one winter for deafness, with
good results. In the following summer she went abroad. While in
London she consulted Sir William Dalby, who, making a digital explo-
ration of the upper pharynx, stated that he found there a considerable
mass of adenoid growths which, in his opinion, should have been long
ago recognized and removed. Sojourning in Paris, the patient was placed
under the care of Dr. A. Gouguenheim, who made a careful rhinoscopic
examination and failed entirely to contirm the diagnosis of the London
physician. In the fall she returned to New York and again visited
her American physician. He, having heard the testimony from abroad,
re-examined the vault of the pharynx and found an abundant hyper-
trophy. He admitted his failure to find it at former examinations, said
that the criticisms of the gentleinan in London were merited, and sent
the patient to me for operation. In the course of a month from this time
she appeared. Careful rhinoscopic examination of a pharynx remarkably
easy of demonstration revealed absolutely nothing except a decided red-
ness and a very slight degree of thickening at the pharyngeal vault. With
this series of successive contradictions the parties concerned were natu-
rally very much discomfited.

It was not possible that any of the observers could have made an
error in a condition so plain and so easy of demonstration, and it
occurred to the writer that some cause based upon an acute attack
must have been present at the time when the enlargement was
noticed.

Further investigation developed the fact that the patient had

48 Transactions of the American Laryngological Association.

contracted a severe coryza both on the outward and the homeward
voyage, and that she was suffering from these colds when examined
in London, and afterward in New York. Examined before her de-
parture, again in Paris, and finally in New York after the subsidence
of the acute symptoms, no appreciable enlargement was present.
The hypertrophy, therefore, was due to these acute attacks; it ex-
isted during their course, and finally, when they subsided, it disap-
peared. This phase of adenoid disease, although uncommon, should
not be allowed to pass unrecognized. Certainly it is so little under-
stood as, in the present instance, to have misled three of the most
eminent specialists living. It appears to be analogous to the acute
enlargement of the tonsils commonly seen in patients in whom these
glands are irritable and liable to swell during attacks of cold. It is
a condition capable of causing much annoyance. Perhaps the best
descriptive title which could be applied to it is, “acute recurrent
enlargement of the adenoid tissue at the vault of the pharynx.”

While cases such as this, in which the subsidence of the hyper-
trophy is nearly complete, are unusual, the acute enlargement of
pharyngeal adenoids already to some extent hypertrophied is a mat-
ter of the commonest occurrence, and opportunities for studying it
are constantly afforded. The condition is important, both on ac-
count of the temporary inconvenience which it causes and also of the
tendency which it manifests to leave behind a permanent enlarge-
ment of greater or less degree.

Chronic hypertrophy, as generally met with, is of two tolerably
distinct varieties. In the first the adenoid element seems to pre-
dominate, while externally the surface of the enlargement is irregu-
lar, often simulating atrue papilloma. The consistency of this variety
is one of its chief characteristics, for it is soft to the touch, friable,
easily broken up, and showing a tendency, when torn away, to
separate in large, spongy masses. In the second variety the con-
ditions are essentially different. The hypertrophied mass partakes
more of the nature of a well-defined tumor, its base being tolerably
small, its surface smooth, its consistence firm, and its substance com-
posed more largely of fibrous tissue elements. Operation upon the
latter variety is far more difficult than it is upon the former, as its
dense structure offers greater resistance to the efforts of the surgeon,
which, when successful, result in the detachment of but small frag-
ments of firm tissue, in marked contrast to the large masses which
are easily torn away in the variety first mentioned.

The actual degree of hypertrophy present may be no criterion

Enlargements of Adenoid Tissue in the Pharyna. 49

of the amount of occlusion or of irritation which it may cause, for,
in some cases, a comparatively small growth will give rise to symp-
toms of considerable severity. Again, thickening of the tissue at the
vault of a degree hardly sufficient to attract attention may indicate
the existence of a condition such as described in Case I, and thus
become of great value as a diagnostic sign. Palpation in such cases
is not a sufficiently exact means for determining the truth, and re-
course must be had to the rhinoscope, aided, perhaps, by the probe,
to establish the diagnosis.

Although the general effects of obstructed nasal respiration are
sufficiently well understood, there is one series of results which merits
more careful attention than it has yet received—namely, the perma-
nent deformities of the bony framework of the nose and hard palate,
due primarily, as it appears, to atmospheric pressure and associated
with obstruction to nasal respiration. While with the angular upper
jaw and high-arched hard palate it is sometimes possible to find a
normal nasal septum, the contrary is the rule. Some of the most
aggravated conditions of septal deformity are met with in these
eases. The well-known experiment of occluding one nostril in a
growing rabbit has proved conclusively that marked asymmetry of
the nose may result, and there is every reason to believe that similar
causes acting in the young child may be followed by like deformities,
and that, too, at a very early period in the child’s history. That
marked deformity of the septum and of the other bony structures of
the nose may arise early in life from obstruction to nasal respiration
due to adenoid hypertrophy in the naso-pharynx is certain, so that
impeded nasal respiration from the presence of adenoids during the
period of constructive activity is a constant menace to the normal
development of the osseous structures of the nose, as well as of the
adjacent antra, and, therefore, of the face itself. Case II illustrates
some of the points mentioned above:

F. M. O., aged three years and a half, a mouth-breather, was found ou
examination to have a large adenoid which was confined to the left side
of the pharynx, the right side being comparatively free. The right nasal
cavity was abnormally wide and unobstructed; the left was absolutely
occluded, the septum being pressed tightly against the turbinated bodies.
The adenoid was removed under chloroform, and it was proposed sub-
sequently to restore the position of the septum by gradual pressure. Mean-
while, however, the child was encouraged to breathe as much as possible
through the left nostril. The effect of this, within a few months, was to
cause such decided improvement in the position of the septum that spe-
cial efforts at dilatation seemed unnecessary.

4

50 Transactions of the American Laryngological Association.

The location of the growth is a matter of considerable import-
ance, not alone with regard to the means used for its removal, but
also because of the influence exerted upon the auditory apparatus.
While it is not uncommon to find that a very considerable amount of
hypertrophy may be attended with little or no impairment of hearing,
the converse is generally true. Congestion, deafness, and tinnitus are
often present in cases where the amount of attendant hypertrophy is
remarkably slight.

In proof of this, the following typical case (IIT) will serve as an
illustration :

Miss S., aged twenty-four, at twenty-one had an attack of scarlet fever,
following which she suffered a progressive loss of hearing until the deaf-
ness became almost complete. Examination of the tympanum showed a
moderate degree of opacity. Examination of the upper pharynx revealed
a small amount of hypertrophy of all of the adenoid elements of the
locality; the tissue at the vault was not so markedly involved as that at
the lateral walls of the pharynx, posterior to and a little above the pos-
terior pillar. The enlarged tissue at the vault was removed by slow de-
grees at repeated sittings by means of the curette, the galvano-cautery,
and chromie acid, and was only accomplished after the exercise of much
trouble. <A fair degree of improvement in the hearing distance followed
this, but the best results were not attained until the whole of the offend-
ing tissue had been removed from the lateral walls of the pharynx. Sub-
sequent to this the tinnitus vanished and a rapid and gratifying return to
little less than the normal hearing distance was accomplished,

To this case might be added the records of many more, all more
or less striking. Thoroughness, therefore, is of considerable import-
ance in the removal of these growths, and we are forced to believe
that testimony to the contrary is unsafe; although it has been stated
by competent observers that “it is not necessary to be too energetic,
or to imagine that every particle of the growths must necessarily be
brought away, the principal object of the operation being to establish
free nasal respiration. If this be effected, a small amount of adenoid
tissue left behind may not do harm. The vitality of the remaining
tissue is probably destroyed, and it will atrophy. The growths do
not recur after removal.”

With these opinions, as applied to certain cases at least, experi-
ence has forced us to disagree, for, as we have just seen, the estab-
lishment of free nasal respiration is by no means the only end to be
attained, although we may freely admit that it is the principal and
most important one.

Enlargements of Adenoid Tissue in the Pharynz. 51

As is now well known, the idea that a partial removal of the
faucial tonsil will be followed by atrophy of the part left behind is,
generally speaking, incorrect. As a rule, only so much will ulti-
mately disappear as has been taken away by the surgeon. The same
appears to be the case with Luschka’s tonsil. In several cases which
the writer has had an opportunity to examine at intervals for several
years after operation, the tissue left by him at the time of the opera-
tion has remained, going through the same processes of congestion
under the influence of attacks of cold and of improvement under
favorable conditions which were observed in the original growth.
From the history of such cases as the one exemplified in Case III, in
which the injurious effects of even small hypertrophies are shown, it
seems worth while to insist that operations for the removal of adenoid
tissue of the upper pharynx should be thorough and complete. If,
as often happens, the thorough removal of the tissue is not easily
accomplished in one operation, there can be no impropriety in so
informing the parents and in operating again. At least, the patient
should be occasionally examined, and the case not abandoned until
the removal of all offending tissue has been radically effected. Fail-
ure in the above precaution may seriously invalidate the result of a
really good operation and reflect unmerited discredit upon the opera-
tor. It is impossible to overestimate the importance of this precau-
tion, to which fact attention is particularly called.

Not uncommonly the subjects of this disease are the children of
tuberculous parents. Indeed, the frequency with which it is found
associated with a tuberculous history is somewhat remarkable.
Hereditary syphilis, too, is responsible for many cases, some of the
worst which have come under the observation of the writer having
been in the children of syphilitic parents. This, of course, is no
more than would be expected, as the hypertrophy of the pharyngeal
adenoid tissue is but another expression of the general strumous con-
dition under which such patients labor.

In operating upon pharyngeal adenoids, the greatest difficulty
seems to be in the thorough removal of the tissue anterior to the
vault and just above the roof of the nasal cavities, and of that upon
the lateral walls in the region of the fossa of Rosenmiller. Particu-
lar attention should be paid, therefore, to these localities, and, if
necessary, any remaining tissue subsequently removed.

Jelenfiy and others have referred to the danger of fragments of
detached tissue falling into the larynx and thus causing asphyxia.
While this might happen in the course of au operation done with the

52. Transactions of the American Laryngological Association.

ring-knife or curette, with the forceps carefully used it would not be
likely to occur. It is far more probable that dangerous obstruction
of the larynx should arise from the impaction of blood-clots in the
glottis, an accident which has happened in the experience of the
writer, with startling although not with serious results.

In operating, great care shculd be taken not to wound the
healthy parts, as laceration of the mucous membrane is liable to be
followed by persistent bleeding, if not by more serious results. In
the use of the forceps, particularly with the patient in the recumbent
position, it is absolutely necessary that the uvula be held carefully
away from the grasp of the instrument. Failure to observe this pre-
caution may result in the seizure and injury of this important organ,
if not in its destruction.

An English writer advises that the patient be examined the day
after the operation and all ragged ends and fragments of mucous
membrane found hanging from the posterior wall of the pharynx
carefully trimmed away with a pair of scissors! Such a procedure
should never be necessary, since it does not seem that the condition
mentioned could arise excepting from great carelessness in operating.
Nevertheless, the writer has seen one case—that of a young woman
of twenty-two, a slender blonde, in whom the pharynx was remarka-
bly narrow antero-posteriorly and the mucous membrane delicate—
where the removal of a fragment of adenoid tissue from the vault
by means of a modified Loewenberg forceps was attended with the
loss of a strip of mucous membrane from the median part of the pos-
terior pharyngeal wall of about an eighth of an inch in width and
extending downward to a point below the uvula. At a subsequent
sitting the same accident threatened, and was only prevented by the
employment of unusual care. It is possible, therefore, that, while
with the exercise of ordinary skill stripping of the mucous mem-
brane from the posterior wall of the pharynx should not occur, in
exceptional cases it may be necessary to observe unusual precaution
in order to avoid it. The accident may be best prevented by fol-
lowing up the detached mass with the finger inserted into the upper
pharynx, and, while pulling forward with the forceps, tearing away
from below with the finger-nail any adherent fragments of tissue.

The question of hemorrhage after these operations is important.
Occurring violently during the operation, it will be an effectual im-
pediment to the progress of the work, but can always, of course, be
recognized. The appearance or continuance of bleeding after the
operation has been completed, and, possibly, after the departure of

Enlargements of Adenoid Tissue in the Pharyna. 53

the physician, is a far more serious matter, and one which might
easily lead to disastrous results. Fortunately, cases in which either
of these things has happened are unusual, and, if recognized, the
bleeding should be tolerably easy to control.

Thus far only five instances have come to the notice of the writer.
In one child, a victim of heematophilia, fatal hemorrhage was caused
by the simple exploration of the pharynx with the finger—certainly
a most unusual accident. In another case a small forceps was intro-
duced into the pharynx for purposes of diagnosis, and one small mass
of tissue removed. Bleeding continued for two days. Dr. R. J.
Hall informs me that he was called upon to control a severe hamor-
rhage from the vault of the pharynx of a mulatto of nineteen, follow-
ing an operation upon that part, and succeeded in doing so by means
of an astringent tampon,

My friend Dr. George A. Richards operated upon a young boy in
whom profuse bleeding occurred during the operation and continued
after it until syncope supervened. The child was exsanguinated, and
remained in an anemic condition for some time. In one of my own
cases, a delicate boy of four, bleeding was profuse, and the effects of
the operation were felt for two months.

There can be no question that the forcible removal of adenoids is
a painful operation. From all patients, old as well as young, comes
the same testimony. Time and again the writer bas operated upon
adolescents and upon adults at repeated sittings. Time and again
he has had the testimony of intelligent subjects to the effect that the
act of operating was exceedingly painful. Time ard again he has
seen the same patient suffer for a number of hours after each sitting
with neuralgia, headache, and sometimes with pain in the ears. He
has found it not uncommon fora patient to run down under the
shock of repeated operations to such an extent that the nervous sys-
tem was severely impressed.

By reason of these considerations he has been forced to believe
that, in a large number of the more severe cases operated upon,
anesthesia is a most valuable adjunct. Not that the risks of anes-
thesia should be incurred needlessly in a patient of good nervous
force and in whom the amount to be removed is small, but that, on
the other band, the great majority of patients suffering from the
complaint under discussion are abnormally weak, timid, and nervous.
They are difficult to operate upon, the work is apt to be imperfectly
accomplished, and the results are by no means so satisfactory as
when full opportunity is given to explore the pharynx at leisure, and

54 Transactions of the American Laryngological Association.

to remove at once every vestige of adventitious growth that can be
reached.

What particular anesthetic should be used must be determined
by each individual operator. Of late the writer has had chloroform
administered, and, with an experience of about sixty cases, he is able
to speak favorably of it. Its special advantages over ether in this
operation, aside from its quickness, lack of irritating qualities, and
less nauseating effects, are its ease of administration during the
operation, and the fact that it does not cause the same abundant
secretion of viscid mucus from the faucial region which is excited
by ether, and which in many cases becomes a cause of much embar-
rassment during operation.

The writer has seen one case in which the removal of an adenoid
from a strumous boy of fifteen was followed by a mild double otitis,
which subsided after a few days. He bas known the same accident
to follow the work of other operators. Its possibility, therefore,
should not be lost sight of.

It is highly important, when once the necessity for operating is
recognized, that the operation be performed without unnecessary
delay. The choice of time for operating, however, is a matter of
some importance, as the operation may be followed by more or less
general depression and the patient be exposed, therefore, to greater
risk from the diseases most dangerous to children. The late spring
and early summer offer the greatest immunity from danger, while the
late autumn and winter are the most unfavorable periods. Any
possibility of infection from diphtheria should be most rigorously
avoided.

In a case operated upon by the writer in a large apartment house,
in which a marked rise of temperature persisted for several days after
the operation, with other ill-defined but threatening symptoms, it was
finally discovered that an epidemic of diphtheria was present in the
house.

The immediate effect upon the voice of an operation may be
disappointing, the faulty pronunciation being retained. This is
sometimes due, not to imperfect removal of the pharyngeal ob-
struction, but to a condition of paresis of the velum which has been
caused by the presence of the adenoid, and which may persist for
some time after its removal.

Finally, as to the general conduct of these cases it must be in-
sisted that they are surgical, and therefore that they should be

Discussion on Papers of Drs. Mackenzie and Delavan. dd

treated upon correct surgical principles by men well versed in these
principles, both in theory and in practice.

I consider it most important that, after a radical operation for the
removal of adenoids, the patient should remain in bed until the shock
of the operation is evidently past; that he be placed upon a course
of tonics, particularly iron and quinine, until any loss of blood shall
have been made good and any depressing result of the operation done
away with; and, finally, that it be not taken for granted that every
possible benefit has been gained with the completion of the opera-
tion. Patients should be examined after recovery from the opera-
tion, and not only should the imperfect removal of tissue be reme-
died, either by surgical or topical means, but the attendant catarrhal
symptoms which may remain should be treated, and the general
condition of the patient investigated and, if necessary, improved.
In this way the best ends may be secured, and what has been a good
operation be made to yield finally the most brilliant results.

The all-important question, What degree of hypertrophy consti-
tutes a pathological condition? is one which must arise in the ex-
perience of every careful observer, and which has never yet been
satisfactorily answered, particularly when it is remembered that sim-
ply the removal of obstruction is by no means the only end to be
attained. Certainly, an enlargement sufficient to give rise to trouble-
some symptoms, whether these symptoms be mechanical or not,
should be regarded as important, and, if not remediable by topical
means, should call for the employment of those of a more radical
nature.

Discussion.

Dr. F. H. Hooper, of Boston: I have been much interested in both of
these papers and agree, in the main, with what has been said. I think
Dr. Delavan’s explanation of the case seen by Sir William Dalby and
others correct. The extreme vascularity and erectile nature of this ade-
noid tissue were impressed upon me by one of my own cases. A young
lady, twenty years of age, came to me with an attack of acute coryza,
and I found what I considered a good-sized adenoid growth at the vault.
After the acute attack subsided the growth had almost entirely disap-
peared. .

I think the post-nasal probe an indispensable instrument for a proper
examination of the naso-pharyngeal cavity in adults. The parts often
look smooth when examined with the mirror, and I have been surprised
in these cases, when examined with the probe with the aid of the mirror,
to find what a large amount of hypertrophied tissue might be present.
In many cases we might be deceived regarding the condition of this cavity

56 Transactions of the American Laryngological Association.

if we relied upon the eye, while an examination with the probe or the
finger would set us right. When adenoid tissue is present it ought to be
removed as thoroughly as possible. The two chief indications for its
removal are obstructed respiration and defective hearing. When a child’s
nasal breathing is obstructed by these growths they should be removed
immediately, no matter what the season of the year might be. With
regard to the question of hemorrhage, I have never seen alarming bleed-
ing except in one case. This was in a very sickly boy, ten years of age,
with typical heematophilia, on whom I declined to operate in the usual
manner. In this case fatal hemorrhage followed gentle scraping of the
adenoid mass with the tinger nail. The amount of secretion during the
operation depends, I think, upon some idiosyncrasy of the patient rather
than upon the nature of the anesthetic, whether chloroform or ether.

Dr. S. W. Lanemaip, of Boston: There is one thing that bas not been
mentioned in regard to anesthetics. As Dr. Hooper has said, we do not
give chloroform. We give ether, with the greatest confidence as a stimu-
lant, to patients with a failing pulse. If the pulse is feeble, it increases
in volume and strength during the administration of ether. Yet, confident
as we are in the use of ether, ] had an experience a few weeks ago which
is not uninstructive. I was asked to operate at the Children’s Hospital.
I had not seen the child until it was brought to the table. It was ascrofu-
lous, rather weak child, and I was told that it bad hip disease. I pro-
ceeded in the ordinary way and removed the adenoma. All at once
there was heart failure, requiring the rectal injection of ammonia and
brandy, and also the subcutaneous injection of the same drugs.

Dr. Harrison ALLEN, of Philadelphia: I wish to confirm the state-
ments of Dr. Delavan. I had intended to prepare a paper upon the sub-
ject which he has so admirably treated. This is now unnecessary. It
may interest the fellows to know that the cases that I have had confirm
in every particular the conclusions which he has presented. There isa
state of pharyngeal distress and ear distress in adults due to something
at the vault of the pharynx. Whether it is a recession, or a juvenile
condition, or pharyngeal palsy, or some other factor, the truth remains
that there is something which the eye will not detect, but which the
probe will detect, and, above all things, the finger will detect. The finger
can not be used without the employment of an anesthetic. I think that
this is an important thing to be considered. I always insist that an an-
cesthetic should be given if the condition of the heart admits. This con-
dition is not one that can be treated by nagging processes. Under
anesthesia you can clear out the pharynx and you have the aid of the
sense of touch. I have noticed that this material may remain at the
anterior part of the vault over the sphenoid bone. I bave not been able
to dissociate it from some trouble connected with the union of that suture.
There is often a recession which is not detected by the mirror.

In respect to ear complications, we read in books devoted to the ear of
obstruction of the Eustachian tubes. I have never found mucus in the

Discussion on Papers of Drs. Mackenzie and Delavan. 57

tubes where aural trouble was complained of, and you may often see a
quantity of mucus, pus, or something else occupying the tube and no ear
distress. Is it not possible that the ear distress is due to a state of vascu-
larity and congestion determined by pressure outside of the tube by the
adenoid? At any rate, a very small amount of this tissue will cause these
symptoms, and often nothing but the finger-tip will reveal its presence.
Doubtless this may exist without symptoms, but where reflex symptoms
are complained of and the patient comes for diagnosis and treatment, we
shonld make a thorough exploration under an anesthetic, and if anything
is found, take it away. I have ofteu etherized patients and found noth-
ing, but I have never regretted it. There is often no way of determining
the presence or absence of this condition without anesthesia. I always
use ether. I was educated never to use chloroform, and I am timid about
it. Whether or not this is simply the result of early impressions I am
unable to say; I am not able to analyze it. I have used ether without
accident.

Dr. J. C. Mutmatt, of St. Louis: I have for several years laid it down
as an axiom for practical guidance that the pathology of the pharyngeal
tonsil was exactly the same as that of the faucial tonsil. Some two years
ago a physician of St. Louis came to me with an acute attack, with a tem-
perature of 103° and a great deal of distress and pain about the ears. On
examination, I told him he had a follicular inflammation of the pharyn-
geal tonsil, and he was very much surprised. There was a great deal of
swelling of the parts with some exudation from the follicles. That we
may have acute exacerbations of the hypertrophy of this part there is no
doubt.

I wish to call attention to an instrument which has been very satis-
factory in my hands and which was invented by Dr. Gradle, of Chicago.
The only objection that I have to it is that the blades open laterally. In
one case, in attempting to use this instrument, I caught a portion of the
soft palate and tore it. Another objection to the instrument is that it is
difficult to grasp that portion of the adenoid that lies close to the septum,
and that you are liable to grasp the septum. I have had a forceps con-
structed with the blades opening antero-posteriorly, and with this instru-
ment I have always been able to remove all the tissue in that region. I
have operated a great many times, and only in two or three instances did
I require an anesthetic. Since the introduction of cocaine I bave found
that the disagreeable part of the operation, which is the scraping of the
instrnment against the healthy pharyngeal wall and palate, can be avoided.
I have applied cocaine thoroughly to these parts, and have succeeded with-
out general anesthesia. I have never seen any shock in these children.
Only on one occasion, where, by the way, this adenoma had escaped de-
tection for ten years, was there any difficulty in inducing the child to re-
turn. I have never seen any hemorrhage. I should like to repeat the
fact, not generally known to the profession, that the pharyngeal tonsil is
liable to the acute diseases that affect the faucial tonsil.

58 Transactions of the American Laryngological Association.

Dr. F. I. Kyteut, of Boston: I should like to give, as I have no doubt
that it will be of interest, the experience of one of our surgeons in pre-
rhinoscopie days. This surgeon had had a great deal of experience in the
removal of naso-pharyngeal tumors. One day he told me that he had a
case of naso-pharyngeal tumor, and that he would like me to look at it
with my mirror. Hehad done a preliminary tracheotowy, and intended
to slit the palate and remove the tumor. I examined the patient and told
him that I did not see anything except a little hypertrophied gland tis-
sue. He replied that he had felt a tumor with his finger. He again intro-
duced his finger, and was surprised to find but a small remnant of the
former growth. It was one of those cases of acute exacerbation of the
adenoid hypertrophy which would have puzzled any one not familiar
with the peculiarities of this disease.

In regard to chloroform, we have always been instructed that, while
chloroform may be given with perfect safety in the recumbent posture—
as, for instance, in midwifery—we have always been told not to give it
in the sitting posture. I would ask Dr. Delavan whether he operates with
the patient in the sitting or in the recumbent posture.

Dr. Detavan: I always place the patient upon his back. Ido not
consider it safe to use chloroform in the sitting posture.

Dr. W. E. CasseLBerry, of Chicago: There is one point concerning the
technique of the operation for naso-pharyngeal adenoma which I have not
seen mentioned. I am impressed with the importance of thoroughly
eradicating these growths. This was especially shown in two cases re-
cently in which the operation was performed for the relief of reflex symp-
toms. In one case spasm of the glottis, and in the other spasmodic
asthma, was associated with adenoid enlargement. In both cases mate-
rial relief followed the operation. The patient with spasmodic asthma,
from having the attacks every week or every few days, remained free on
one occasion as long as six months. The spasm of the glottis, attacks
of which had recurred several times daily, now came only two or three
times a month. In neither case was the operation sufficiently thorough
to eradicate all the growths, as prominences here and there could subse-
quently be seen with the rhinoscope, and sufficed, doubtless, to occasion
the remnant of symptoms.

With a view to greater thoroughness, I thought it might be possible
to see what was being done during the progress of the operation. In
order to do this I tied the velum forward with an elastic band passed
through both nostrils and out through the mouth. I used the Vienna
chloroform mixture, for two reasons—first, because I thought that it
might occasion less secretion, and, second, because I desired to have my
gas lamp in immediate proximity. I operated with the patient in the
sitting posture, and ether no doubt would be safer, and, with the substi-
tution of the electric light for the gas flame, would be unobjectionable.
The operation, so far as seeing was concerned, was not an entire success.
In one case I could sponge out the blood and occasionally get a view; in

Discussion on Papers of Drs. Mackenzie and Delavan, 59

the other case I was unable to do even this. I, however, found that tying
the velum forward facilitated the operation. It was no longer necessary
to hook the velum forward with the finger, which delays the operation.
It might be urged in this connection that tying the velum forward would
prevent the ready swallowing of the blood, and thus favor its entrance
into the air-passages. To obviate this, as soon as a piece was taken out
I had the patient’s head and body inclined forward, It is important to
do this at all times when there is anything like free hemorrhage, and
when operating with the patient in the sitting posture. The tying of the
velum forward and the inclining of the patient forward are two points in
the technique of the operation which have given me great satisfaction.

Dr. J. N. Macxenzis, of Baltimore: In operating I do not adopt the
plan referred to by Dr. Delavan and Dr. Hooper. Unless the patient is
young, or unruly, or comes from a distance, I generally operate at different
sittings, removing a portion every day, or every other day, for about a
week or ten days. In this way I get rid of the growth with no hemor-
rhage to speak of, with very little pain, and without the use of anes-
thetics. If the patient seems to feel pain, I use cocaine or some other local
anzesthetic.

In regard to the point made by Dr. Hooper with reference to passing
a probe over a smooth and apparently healthy surface, I have had this
experience. Some time ago I treated a case of ubstinate post-nasal
eatarrh in which there was apparently no hypertrophy of the pharyngeal
tonsil as seen by the mirror. An immense quantity of muco-purulent dis-
charge poured out of the pharynx every day, and I became completely
dissatisfied with my work. It suddenly occurred to me to make a deep
incision in the pharynx, and, with the acquiescence of the patient, I made
an incision with a curved knife into the smooth and apparently healthy
tissue. This was followed by the discharge of a large amount of a colloid
sort of matter, and with great relief to the patient after a few days. He
is still under observation. I am trying to remove as much as possible of
the pharyngeal tonsil. Since the incision the amount of discharge has
lessened very notably.

I have seen only one case in which hemorrhage was very severe. It
was the case of a young colored girl sent to me from one of the lower
counties of Virginia. The growth was apparently of an adenomatous
character. The soft palate was pushed forward almost to the teeth, the
whole mouth was filled with this enormously stretched palate, and nothing
could be seen beyond the mass of flesh and tumefaction. There was a
little slit on the side through which she could take liquid nourishment.
The child was badly nourished, and also had a large adenoid tumor of the
neck. When I put my finger into the naso-pharynx, it caused a most
alarming hemorrhage. When I examined the nose, a tremendous flow
of blood took place from both nostrils. She had also strabismus, and
both eyes were exophthalmic. I hesitated about performing any opera-
tion. I took her to the Baltimore Academy of Medicine, and several sur-

60 Transactions of the American Laryngological Association.

geons examined her. One of them put his finger into her mouth, and the
bleeding was so great that we thought she was going to die. None of
them would undertake the case, and neither would I. Afterward she left
the hospital by climbing a tree and jumping the fence and escaping.

As arule, the hemorrhage in operating is very slight. It may pour
out of the nostril, but it always stops of itself. I think that hemorrhage
on digital examination may be considered almost a diagnostic sign.

I have never met with any accident. The only thing that I recall was
in the case of a little girl who was thoronghly anesthetized and the opera-
tion done at a single sitting. A bichloride solution was left with which
to syringe out the naso-pharynx. The next day there was arise of tem-
perature to 103° or 104°, with some pysemic symptoms. These all passed
away after washing out the retro-nasal space.

I consider these cases of adenoid growths as among the most brilliant
that we meet with in nasal surgery. There is only one other point to
refer to, and that is the nature of these growths. They have been spoken
of as adenoid. The growths that I have seen in Baltimore have been of
a papillomatous character. I have examined a number of them under the
microscope, and their structure does not differ from that of papillomatous
growths in other localities. There is, however, a variety which is ade-
noid; and I believe that is the form which Dr. Hooper sees in Boston,
and which Meyer saw most frequently in Copenhagen. We should dis-
tinguish between these different varieties. The adenoid growths are more
difficult to remove, and occasion more pain than the soft papillomatous
growths.

Dr. Detavan: I have nothing to say in addition, except to reiterate
the fact, which I appreciate the more the oftener I operate, that the
operation is painful and that in many cases cocaine does not meet the re-
quirements. Indeed, it seems impossible that it should in a growth of
considerable size, for the cocaine can only be applied to a small portion
of the surface, and that the most remote from the pedicle. The operation
is painful, and in the majority of cases an anesthetic will give great help
not only to the operator but to the patient.

Paper.

THREE RARE CASES ILLUSTRATED: MULTIPLE PAPILLOMATA OF
THE VELUM, IMMENSE FIBROID TUMOR OF THE TONSIL, AND
FIBROID TUMOR OF THE NASAL SEPTUM.

By GEORGE M. LEFFERTS, M.D.

HE cases illustrated herewith are of a rarity that justifies me in
presenting them.
The physical appearances of the tumors are well shown in the
drawings, and require, therefore, no detailed description.

Three Rare Cases. 61

The differential diagnosis in cases so well marked and distinctive
as these presents no difficulty. Macroscopical signs alone will suffice
for the recognition of their true nature.

Although papillomata are the commonest varicty of true neo-
plasm of the fauces, a growth the size of that shown in the present
instance must be very unusual. It occurred in

Oasx I.—A girl, aged sixteen, who only accidentally noticed its pres-
ence in her throat when it had attained fully one third the dimensions
here shown. Thereafter it grew rapidly, and in eight months’ time resem-
bled the drawing. Little or no inconvenience was caused, dysphagia
never being present, and but slight interference with the timbre of tbe
voice.

Fig. 1.—Papillomata of the yelum.

After anesthesia of the parts by cocaine, the multiple tumors that
made up the mass were removed by scissors curved on the flat. The uvula
was not involved and was left intact.

62 Transactions of the American Laryngological Association.

A superficial stellar cicatrix now shows the former site of the sessile
portions of the growth.

There has been no sign of any recurrence.

Case IJ.—A man, aged fifty-five, who for many years had been aware
of the existence of a slowly growing tumor in his throat, but increase in
size being gradual, and ro pain, interference with deglutition, nor embar-
rassment in respiration having until lately been experienced, no operative
procedures had been allowed.

Fic. 2.—Fibroid tumor of the tonsil.

Now, at the date of examination, dyspnea at night when in a recum-
bent position and difficulty in the deglutition of both fluids and solids, the
growth descending during the act and blocking the path to the wsopha-
geal mouth, demand surgical interference for their relief.

From the region of the right tonsil, the latter being involved in the
growth, springs the large, dense tumor, covered by a thin, non-vascular
mucous membrane, that is shown in thedrawing. It possesses a more or
less distinctly defined narrowing at its point of attachment, which renders
it an easy matter to encircle it at this part with the wire of the écraseur.

Three Rare Cases. 63

This was done by Dr. O. E. Beebe and the tumor thoroughly and neatly
removed. No hemorrhage.

Oase III.—Man, aged thirty-six. I am acquainted with no instance
in practice or literature of a fibroid tumor springing from the nasal sep-
tum save the one here shown. ‘The little tumor was hard and dense, its

fe

Fie. 3.—Fibroid tumor of the nasal septum.

covering a thin vascular mucous membrane, and it was distinctly peduncu-
lated by a delicate pedicle, the latter attached to the nasal septum just
above the muco-cutaneous junction, in the right nostril. The sole symp-
tom caused by its presence was occlusion of the right nasal passage, the
discomfort of which had caused the patient to seek advice. He was un-
able to state how long tbe growth had existed.

The pedicle was cut through with scissors and the tumor removed.

64 Transactions of the American Laryngological Association.

Paper.
WARTY GROWTHS IN THE NARIS.

By E, FLETCHER INGALS, M. D.

PECULIAR ease of this rare affection has for some time been
under my treatment, which I believe will be of interest to
this association.

Mr. X., a gentleman forty-six years of age, came under my care three
years ago, complaining of hawking and spitting, and hoarseness upon
using his voice for a short time. These symptoms were found due to a
recurrent pharyngo-laryngitis induced by thickening and deflection of
the septum narium and swelling of the inferior turbinated bodies. He
objected to operative procedures; therefore the treatment was limited to
means for reducing the swollen condition of the turbinated bodies and
relieving the congestion of the larynx. Ina short time these measures
were so far successful that he was relieved and had no more trouble for
several months, but the following spring the difficulty returned, and was
associated with a subacute tracheitis. I saw him occasionally for a few
weeks, and subsequently he remained well, until be finally returned in
March, 1888, complaining of similar trouble. At this time, in addition to
the appearances formerly noted, I found a small, grayish, sessile, warty
excrescence on the mucous membrate of the left naris, about a centi-
metre and a half within the nostril. To this I applied chromic acid,
which completely removed it, and there had been no return at the end of
five weeks, when he started for New Mexico. Upon his return, about
three weeks later, I found the left nostri] about one half occluded by a
soft papillary growth, which sprang from the mucous membrane of the
septum within about a centimetre and a half of the nostril. This was
about seven millimetres in diameter by seventeen millimetres in length,
and had a base fully as large as the diameter of the growth. I removed
this with a snare and cauterized the base with chromic acid. A week
later two or three small growths, grayish in color and hard to the touch
(indeed, in all respects, excepting color, exactly resembling warts on the
skin) were found—one on the floor of the naris, just within the line of
union of skin and mucous membrane, and others on the anterior end of
the inferior turbinated body. These were cauterized thoroughly with
nitric acid. A month later two more warts were destroyed in the same
way, and three weeks later two others had appeared on the septum,
about fifteen millimetres from the nostril. These were also touched with
nitric acid. A week later, finding that the warts on the septum and tur-
binated body continued to grow, I thoroughly cauterized them with the
galvano-cautery. A month later other small warts had appeared in the

Warty Growths in the Naris. 65

same locality. These were cauterized with nitric acid, and when they
reappeared were touched with a ninety-five-per-cent. solution of carbolie
acid. Afterward, from time to time, chromic acid and nitric acid or acid
nitrate of inercury were used to destroy the warts. Some were eradi-
cated, others grew again, and still others were developed from the sur-
rounding mucous membrane. In December, 1888, and the early part of
January, 1889, I curetted out all of the warts to a depth of about three
millimetres below the surface of the membrane with the galvano-cautery,
but by the 19th of January another small wart had developed near by,
and similar growths have continued to spring up at intervals ever since,
so that altogether I must have destroyed twenty-five or thirty. Some
places where the warts have been removed now appear perfectly healthy,
and others show healthy cicatrices. I have not used the galvano-cautery
often latterly because I did not wish to destroy so much tissue; besides,
the results from it were not much better than from other caustics,

On the 20th of April the patient returned after an absence of two
weeks, and I found, besides two or three minute warts on the septuin and
one of considerable size at the lower part of the nostril, a comparatively
large mass of warty tissue at the anterior extremity of the inferior tur-
binated body which grew from a broad base about eight by sixteen milli-
metres in size, and was about six millimetres in thickness at its largest
part. This was of a pink color, had a slightly raspberry-like surface, and
the little nodules, which were somewhat lighter in color than the tissue °
between them, presented a few small red spots similar to those seen on
ordinary warts. The smaller warts were touched with acid nitrate of
mereury; the large mass I removed with the galvano-cautery, scooping
out the soft tissue nearly down to the bone.

Professor Walter S. Haines has examined this and reports as follows:
“The small tumor which you recently sent me has been carefully exam-
ined under the microscope conjointly by Dr. A. J. Ochsner and me, and
we find it to be a papilloma similar in structure to a common wart. It
consists of a central portion of connective tissue, sending off numerous
delicate branches or papilla, which are covered with a somewhat pro-
lific layer of epithelium. The latter, however, although abundant, is en-
tirely superficial, not extending down into the connective tissue itself.
We find no nests of cells, nor any other important histological elements
excepting those mentioned above.”

For several months preceding the middle of April, 1889, the warts
have developed less rapidly and have had almost exactly the density
and appearance of cutaneous warts, excepting that they were some-
what lighter in color on account of the moisture of the parts. The
patient has never had pain in the growths, has no cachexia, is appar-
ently in perfect health, and wounds of the parts heal kindly ; there-
fore I do not think these growths of a malignant or lupoid character.

5

66 Transactions of the American Laryngological Association.

Ile has several healthy children, is a gentleman with a clean history,
and has no sign or scar indicative of specific disease ; indeed, there
seems every reason for believing that there is no such taint. At only
one time have the growths resembled condylomata, but for a period
of about fifteen months they have sprouted up and grown rapidly to
a moderate size like cutaneous warts which they so closely resemble ;
therefore I believe them essentially the same as the verruce so
frequently seen upon the hands of children.

I have never observed this affection in other patients, and, though
authors speak of papillary growths and condylomata in the naris, I
have been unable to find a description of any case closely resembling
this. I have had the library of the Surgeon-General’s office carefully
searched and can find records of only two cases at all similar to it,
but in each of them there was only one growth which upon removal
did not recur. The cases referred to are as follows:

First, ‘‘Condylomatous Polyps of Nasal Fossa,” ete., by Dr. A.
Testelin, “Jour. de méd., chir. et pharm.,” Bruxelles, 1859, xxviii,
p. 147. The growth was described as tongue-shaped, slightly thick-
ened at its edges, like a cock’s comb, about six centimetres in length
and about six millimetres in thickness; soft to the touch; nowhere
vesicular in appearance, and with no evidence of serous infiltration.
Its color grayish-yellow, dotted with minute red spots. It was ap-
parently attached, by a portion about twelve millimetres in length,
to the border of one of the turbinated bodies. This growth seems
to have been very similar to the largest growth, which was removed
in the early part of the treatment, in my case.

Case second, “ Papilloma of Septum,” by H. T. Butlin, “St.
Barth. Hosp. Rep.,” 1885, xxi, p. 150. The author found a “ warty
growth” depending from the upper part of the front of the naris,
nearly blocking the passage. He removed it with the galvano-
cautery and it did not return. He says: “So far as the diagnosis
is concerned it is easy, for the warty character of the tumor is dis-
tinctly visible as it lies in the interior of the nostril. It may, of
course, be mistaken for a warty epithelioma, a disease even more
rare.”

I saw a warty growth similar to these in the person of an elderly
lady about three years ago. It was about a centimetre in diameter,
grew by a comparatively small pedicle from the mucous membrane
of the anterior portion of the septum, and had the same genera
characteristics as that described by Testelin. J removed it with
steel-wire snare, and there has been no recurrence.

Dysphonia Spastica. 67

These cases seem to be of the nature of the large single warts or
moles not infrequently met with on the back and sides. In the case
of Mr. X. the growth resembled as closely as possible the apparently
contagious ordinary wart known as verruca vulgaris. There were
two or three very small warts when the condition was first noticed,
but others have grown near these and upon the opposite surface, ap-
parently spreading from the original warts. Many times the growths
have seemed to be eradicated, but the warts have appeared again in
the same or other places until altogether there must have been
twenty-five or thirty, varying in size from three to eight millimetres
in diameter.

If any of the members of this association have seen similar cases,
I shall feel under great obligations if they will tell me how to cure
this so that the growths will not return. It now appears that my
present line of treatment may succeed with the efficient aid of time,
but I should like to escape obligations to this ancient remedy.

Paper.
DYSPHONIA SPASTICA.

By FREDERICK I. KNIGHT, M. D.

WOULD like briefly to introduce this important subject, in the

hope that, as so little has been published on it, | may perhaps be
the means of drawing out some unpublished observations by mem-
bers of this association, before whom the subject has not been pre-
sented in many years.

All of our members are probably familiar with the disturbance of
the voice-production which has been variously named aphonia spas-
tica, aphthongia laryngea spastica (Gottstein), stammering of the
vocal cords, spasm of the tensors, speaker’s cramp, ete.

In this phenomenon there is evidently a spasmodic action of the
muscles of phonation or respiration, or both, which gives rise in the
majority of cases to a high-pitched, jerky, and feeble voice. There
is sometimes a long intermission in the vocal sound, so that the term
aphonia spastica might be appropriate, but in the cases which I have
seen the term dysphonia spastica seems more suitable.

The fellows of the association who were present at the meeting
in Boston in 1882 will remember a patient with this affection well
marked, whom I presented to them. Since that time I have seen

68 Transactions of the American Laryngological Association.

only four cases, which leads me to agree with Sir Morell Mackenzie,
who considers the affection a very rare one, rather than with Mr.
Lennox Browne, who considers it ‘so far from being rare, in its
We do some-
times see a condition of somewhat similar nature in cases of acute
laryngitis, and perhaps such a condition might be easily overlooked
when a patient was suffering from acute inflammation of the larynx,

milder forms one of almost every-day occurrence.”

and every effort was being made to prevent him from using his voice,
but I am sure that as a chronic condition the phenomenon can not be
overlooked, and consequently, in my experience, I believe that it is
rare.

Three of my cases occurred in men, and one in a young woman
of twenty years. One of the men was a physician, one was in mer-
cantile business, and one was superintendent of a factory, where he
was obliged to talk to men in the midst of much noise. His mother,
moreover, was deaf.

The woman, whom I have recently seen, is a teacher, and the
trouble developed while she was forcing herself to talk with a hoarse
cold. This is the lightest case I have ever seen, and one in which it
might appear that the prognosis was better than usual, though the
condition has already existed a year. There is no obstruction in the
nasal passages, but, on the contrary, a tendency to an atrophic con-
dition, and a slightly offensive secretion. Under the use of cleans-
ing solutions for the nose, strychnine internally, and cold douches,
the spastic symptoms have improved, but they return, especially on
conversation with strangers. Massage of the larynx or compressing
the wings of the thyreoid improves the voice temporarily. There is
nothing especially morbid on laryngoscopic examination, and I was
not able in any of the cases to obtain a view of the spastic phenome-
non. It seemed as if the simplicity of the required vocal effort pre-
vented nervous excitement.

In the absence of post-mortem examinations it is impossible to
say what the lesion is in these cases.

It seems natural in some, with Schech, to call the affection a co-
ordinated neurosis of occupation, like writer’s cramp, etc. Cases like
that of Heymann * suggest a central lesion, while such cases as E.
Hoffman's ¢ and Hering’s { suggest a probable reflex origin.

The lesion and mechanism are probally not always the same.

* “Internationales Centralblatt fiir Laryngologie, ete.,” vol. iii, p. 260.
+ ‘“ Monatsschrift fiir Ohrenheilkunde, ete.,” 1885, p. 428.
+ “Internationales Centralblatt,” vol. ii, p. 571.

a

¥

Discussion on Paper of Dr. F. I. Knight. 69

My own experience in these cases would lead me to regard the
prognosis as very unfavorable, but of course would be favorable in
reflex cases dependent on a cause capable of removal, as in Loff-
man’s patient, who was cured by the removal of the hypertrophied
anterior ends of the middle turbinates.

I have nothing to add to the long list of therapeutic measures
laid down by Schech and others—viz., absolute rest of the voice,
galvanism of the throat and brain, vocal exercises, tonics, and cold
douches on the head and neck, which latter remedy cured one of
Schech’s cases after all other treatment had failed.*

I would like by this communication to draw out from the fellows
of this association a report of every case of chronic aphonia or
dysphonia spastica which has been cured or modified by treatment.

Diseussion.

Dr. G. W. Masor, of Montreal: I have had one case of aphonia spas-
tica and two of dysphonia spastica. The case of apbonia occurred in a
boy of fourteen years of age with a well-marked history of hereditary
syphilis. The two cases of dysphonia spastica were met with in adult
young men, and in both Hutchinson’s teeth were observed. In the case
of aphonia the vocal cords closed spasmodically on phonation, and alto-
gether acted much in the same manner as in defecation. I noticed in this
case also a spasmodic action of the diaphragm synchronous with the clos-
ure of the cords. Under treatment no satisfactory improvement occurred.
The thought has more than once suggested itself to me that there may be
some relation between syphilis and spastic aphonia.

Dr. S. W. Lanemaip, of Boston: I reported one case fifteen or sixteen
years ago, and in that case everything I tried was unsuccessful. The
patient always prescribed for himself a little whisky when he had to use
the voice, and that answered for the time being. The condition seems to
be about the same as at that time.

Dr. D. Bryson Detavan, of New York: In one of the cases referred
to by Dr. Knight the same phenomena were observable as in the case men-
tioned by the last speaker. The patient, after fortifying himself with a
stimulant, would talk tolerably well. I had him under treatment for two
months, and he seemed to improve under local applications to the laryux
and vocal training, especially directed to the management of the breathing,
and it seemed that if the training could have been continued long enough
the trouble might have been done away with.

Dr. F. I. Kyteut: I really believe that more cases have been seen
than have been reported. I should like to have had some opinion upon
the idea of Lennox Browne that these cases are not infrequent.

* “ Monatsschrift fiir Ohrenheilkunde,” 1885, p. 1..

70 Transactions of the American Laryngological Association.

Dr. C. E. Bean, of St. Paul: About two years ago a case was referred
to me by a physician in St. Paul. The patient was a man, twenty-five
years of age, with a syphilitic history, suffering with aphonia spastica.
I had him under observation two months, using galvanism, faradism,.
strychnine, ete., without the slightest benefit. He is now in about the
same condition as at that time.

Paper.

SOME OF THE MANIFESTATIONS OF SYPHILIS OF THE UPPER
_ AIR-PASSAGES.

By THOMAS AMORY DE BLOIS, M. D.

N bringing before you this well-worn subject, it is merely to
chronicle a few of the different forms of cases as seen by the
laryngologist in his daily practice, perhaps showing what we may
do and what we had better leave undone, with a view of preventing
some of the horrible deformities which are so often the sequel of
syphilis in its nasal and buccal lesions.
It would be most natural to divide the subject into three local
varieties—according to whether it occurs in the nasal passages, the
pbarynx, or the larynx; and these in turn according to its attack-

ing the soft or the deeper or hard structures—call it secondary or
tertiary if you will,

The “plaque muqueuse” of the nose is rare compared to the
occurrence of “patches” in other localities. I have never known
it to resist the ordinary astringent treatment. But when the carti-
laginous septum of the nose is attacked it is a very different matter;
perforation inevitably follows, and it is with great difficulty that the
necrosis is arrested, the process creeping along beneath the mucous
surface, and it is generally not checked until it reaches the surround-
ing bony structures. The falling in of the end of the nose does not
necessarily follow; I have seen many cases where the nose was to
outward appearance intact, but was within a ruin.

The turbinates and vomer frequently die and remain entombed,
the nares being too small to allow of their removal whole.

Two years ago, at the Boston City Hospital, I had a case of this
kind, the sequestrum being too tough to be cut with the forceps, and
it was without sufficient support to allow of being drilled through
with the dental engine. It was found necessary to split up the nose,
and I then removed the vomer and one turbinate with the forceps.

Syphilis of the Upper Air-passages. 71

Long drills will frequently be found convenient for detaching and
removing these fragments. Perforations into the antrum are most
disastrous in their results, because it is so difficult to properly treat
and cleanse these localities and remove what necrosed tissue may
exist.

J. W., a fireman by occupation, contracted syphilis six years previous
to my seeing him. He had a large perforation into the right autrum.
Necrosis was still progressing rapidly ; the fcetor was fearful. I removed
pieces of dead bone many times, and -curetted whenever and wherever
possible. He was obliged to leave the fire department on account of the
disagreeable odor, and he disappeared unrelieved.

When the destruction of bone extends from the anterior nares
down around the incisor teeth, these should be removed, and the
necrosed alveolar plates drilled out with the dental burr. It will be
found that this operation is an exceedingly bloody one. Llodoform
and tannin blown with a great deal of force up into the empty tooth
cavities is a good antiseptic dressing.

A. F., an Italian, a Boston Dispensary patient, had syphilis of un-
known duration even to himself. One central incisor tooth had come
away and one was removed; the drill passed easily up into the nares,
through the alveolar processes, which were easily removed, shortening
the dental arch considerably. He improved somewhat under large doses
of iodide of potassium, the bichloride pill, and cod-liver oil.

The loss of the anterior nasal-spine of the superior maxillaries is
followed by the frog-like deformity which disfigures so much. If
any treatment short of excision of the bone is possible, it certainly
should be diligently followed, for the aspect of the face is more
repulsive than when the cartilaginous septum is entirely gone.

In the mouth and pharynx we find our most usual field of syphi-
litic affections, and, although the destruction of the soft parts ad-
vances with lightning-like rapidity, yet it seems as if Nature were
here more lavish in her restoring processes.

The perforating ulcer of the velum is the ordinary form which
the lesion takes, and, as the part is in such constant motion, the
healing is rendered doubly difficult.

It is useless to employ any form of local treatment before the
patient is fully under the influence of medicines, and, although mer-
cury is necessary, yet the greatest reliance must be placed on the
potassic iodide. Its quick effect upon the symptoms of syphilis is
certainly the greatest help we have at our command. In most cases

72 Transactions of the American Laryngological Association.

the destructive process may be retarded or checked in twenty-four
hours, but sometimes a much longer period is required.

The sketch (A) is from the case of Mr. C., a theatrical manager, who
was sent to me, having been under treatment with stillingia for some
weeks, during which time the largest single perforation I ever saw had
progressed to the size shown in the diagram. After he had been on the
iodide for about forty-eight hours I freshened the edges of the ulcer and
bronght them together with silk sutures; at the end of another day these
had completely sloughed out. I attributed my want of success to having
been too hasty in my procedures. I then increased the iodide and used
the stick nitrate of silver as a caustic and stimulant; under this treatment
the perforation closed gradually. I never allowed the edges to harden,
and finally, although the opening never closed entirely, it was reduced to
such a size that a probe could with difficulty be passed through it, and
speech and deglutition were normal.

In a few other cases, where the perforation was not so large, en-
tire closure was effected without suturing.

Mrs. K., a married lady, who bad contracted syphilis and concealed
it from her husband, and whose palate I was very anxious to save, I had
the same experience with. As the transverse perforation was very large,
I was afraid one of the two isthmuses would slough, so I sutured very
soon after seeing the case. But the sutures sloughed out, and one isthmus
also, so that the semi-detached portion hung down on one side, and
finally, after causing a great deal of trouble in swallowing, was to a great
extent absorbed, and remained as a kind of excrescence at the side of the
tonsil. excision having been declined.

Mrs. R. (sketches B and B’) showed another example of a perforation
which did not heal until the isthmus had been cut through, treatment not
having been commenced svon enough. The deep ulcer behind the right
pillar was prevented from forming cicatricial adhesions by frequently
being stretched open with a probang.

Mrs. T. (sketches OC and ©’), also a married lady. In this case there
was a perforation of the soft palate, with one through the anterior pillar,
and a third through the mucous membrane and involving the bony palate.
In this case the perforations were treated with nitrate of silver, and the
denuded and necrosed palate was cnretted with a sharp scoop; the open-
ings healed rapidly, except the one near the tonsil, which, although it
healed, never closed.

Of three other cases involving the hard palate, in two the opening
healed, in one after curetting and in one after being burred out with
the dental burr. In one case, after being burred out under ether and
once with cocaine, it did not heal, and finally, after a good deal of

‘ ’ x om,
s

2,

i, i ’ Laey
Ard i bee tir, a, kage it) add

Syphilis of the Upper Air-passages. 73

necrosis had taken place, the palate plate was removed with forceps
at the Boston Dispensary by my colleague, Dr. J. W. Farlow.

Miss N. H., an actress, came to my office complaining that a furuncle
had ruptured in her mouth. On examination, I found that there were
two syphilitic ulcers involving and exposing the bones of the hard palate.
The lower surface was cut out with the burr and the edges were stimu-
lated with caustic, and they healed quickly under iodide of potassium and
the corrosive chloride of mercury.

Mrs..O. D. B. (sketch D) had bad loss of substance of the soft palate,
which had adhered to the pharyngeal wall, quite high up. This closed
the posterior nares and occasioned great discomfort. ‘In syringing
through the nose I found that there was, as is usual in these cases, a
very small opening into the mouth. This I carefully stretched until the
nozzle of a syringe could be passed through. I refrained from detaching
the velum from its new adhesions, for, whereas phonation was almost nor-
mal (as is invariably the case where the attachment is high) and degluti-
tion all that could be wished, yet I knew that, if the palate were even
successfully detached, neither function would continue, without the use
of an obturator plate, on account of the great shortening of the velum.

Passing on to the larynx, we find that the worst results in this
locality are from the cicatricial adhesions which so frequently take
place.

Mr. G. F. had had a certain loss of substance on the tip of the epiglettis,
and also bands of cicatricial tissue binding it down on the left side as far
as the arytenvid, which was thus greatly crippled in its action. When I
first saw him, ten years after the first infection, he was almost voiceless.
Very little effect, except to increase the inflammation, was derived from
such operative measures as dilating and stretching the parts. ‘ Medication,
and the consequent absorption which touk place, was of great benéfit,
and his voice is now quite audible, the motion having been greatly in-
creased and vicarious action from the other side set up.

I might, in conclusion, draw attention to my poor results in any
attempt at operative procedures during the activity of the ulcerative
lesions of syphilis, for at that time the vitality of the parts seems to
be much more feeble. But when, through the action of medicine,
the ulceration is apparently arrested, it is the proper time to endeavor
to correct or prevent deformities.

In removing necrosed portions of the hard palate with the drill,
burr, or trephine, it seems advisable not to perforate the bone, for
not only would a fistulous opening be very apt to follow, but, should
this not be the case, there would be much more scar contraction than
if the outline of the bony parts was left.

74 Transactions of the American Laryngological Association.

Discussion.

Dr. F. H. Bosworru, of New York: I am sorry that the speaker
did not touch more upon bone lesions, which I consider the more im-
portant feature of the tertiary syphilitic manifestations in this portion of
the air-tract. There is still one question undecided, and that an exceed-
ingly important one, and that is, How far is the bone involved in these
deep ulcerations of syphilis? Of course the ulcerative process means
ultimately a necrosis of the bones to a great degree covered by the origi-
nal gumma, and the question is not only how far is the bone involved, but
also what is the ultimate tendency? My own view is that the syphilitic
manifestation in the deep layers of the periosteum of the hard palate
expends its virulence in the primary deposit of the gammatons material,
and that the morbid process now becomes mainly a local one, which
consists in the development of an endarteritis, as has been shown so
clearly by Schister and Sanger, under the action of which localized ne-
crosis or ulceration of the soft parts ensues, purely as the result of a shut-
ting off of the normal blood-supply. As a final result, the nutrition of
the bone is interfered with and bony necrosis takes place. The primary
deposit of gummatous material limits the extent of the necrosis, so that
the idea of the extension of the ulceration is not correct.

Taking this view, I think that the ulceration is not the important
thing; it is the bone. Deal with the bone and the ulceration will take
care of itself. After the primary breaking down of the gummatous
material, the maintenance of the ulceration is dependent upon the ne-
crosis of the bone, so that removal of the diseased bone is an important
part of the treatment.

The point which I desire to make here is that the original gummy
deposit occurs as the result of the constitutional disease; the ulceration
is a local process, the necessary result of the pathological features of the
gummatous material causing an endarteritis; furthermore, the ulceration
is limited by the original gummy deposits, and no new gummy matter is
deposited later, except as a new explosion of the disease, as it were; a
gummy deposit occurs suddenly, and is not progressive. Bony recrosis
results from the gumma, and, a bony sequestrum being formed, this be-
comes the prominent feature of the local disease in that it keeps up the
ulceration by its mere presence, as of a foreign body.

I indorse Dr. De Blois as regards the treatment in the administration
of potassic iodide and not the use of mercury until the lesion has disap-
peared. After the syphilitic lesion has disappeared, then mercury should
be given for the removal of the syphilitic virus. As regards operative
treatment, it had better be let alone until the syphilitic virus is thoroughly
under control.

Dr. ©. C. Rice, of New York: In regard to operation in cases of
adhesion of the soft palate to the posterior wall of the pharynx, one
point must not be forgotten—viz., that in some of these cases there is

Discussion on Paper of Dr, De Blois. ‘i

Or

extensive cicatrization and contraction in the post-nasal pharynx above
the line of adhesion; consequently, after the lower adhesions have been
separated, we do not get the good results, so far as nasal respiration is
concerned, that we should expect. The reason of this failure is that the
cicatrization in the post-nasal pharynx still remains. This part of the
operation should be attended to, and is as important as the freeing of the
lower adhesions. It has been said that we should not operate until the
“force of the specific disease has spent itself,” but it is difficult to deter-
mine when this point has been reached. I have had a case within a
year where there was complete adhesion and in which there had been
no manifestation of a syphilitic process for many years. The patient had
taken medicines, and was apparently cured. I separated the adhesions
with the galvano-cautery, but the ulceration produced by the operation
refused to heal kindly, and extended somewhat, in spite of all that I
could do in the way of constitutional and local treatment. I have found
that there was less tendency to readhesion where the galvano-cautery
was used with alow grade of heat than when cutting instruments were
employed. I have lately heard of an operation which bas been tried in
New York for the relief of these adhesions. An ingenious physician has
made a perforation through the line of adhesion with the galvano-cautery,
and a ring has been passed through this and worn until cicatrization
has taken place, and then be has freed the adhesions in the circle of the
ring. This, it is maintained, will prevent readhesion.

Dr. J. N. Macxenzin, of Baltimore: Dr. De Blois has referred to the
dangerous symptoms from the extension of the ulceration into the acces-
sory sinuses, principally the antrum. I would like to caution the mem-
bers of the association, if they have not had a similar experience, against
the too vigorous removal of diseased bone from the nasal passages. You
frequently pull out more than you want, and from dangerous regions. I
have not had this occur in my own practice, but I have seen it in that of
others. I have seen a portion of bone drawn out, and some of the brain
membranes with it.

I had avery sad case on my hands a few years ago—that of a lady
who had acquired or inherited syphilis. -I removed nearly everything in
the nose—the turbinated bones and the sides of the antrum of Highmore,
and finally the perpendicular plate of the ethmoid became so loose that
I removed it. The plate of the ethmoid which had been removed had
attached to its upper surface a portion of membrane, but I am in doubt
as to its nature. I placed her on the use of iodide of potassium and stimu-
lating and nutritive treatment, and she remained well for two years.
She was then taken with a violent headache and a profuse fcetid dis-
charge from the nose. This headache passed off in a few days, and she
did not consult me until two weeks after the headache had first appeared.
I found that the process had broken out again and had invaded both antra.
Offensive pus was discharged through the mouth and throat and every
possible way of escape. I began vigorous antisyphilitic treatment, and

76 Transactions of the American Laryngological Association.

did everything that I knew of to relieve her, but she finally went into a
state of coma, and had general convulsions. Symptoms of meningitis set
in, from which she died. I am of the opinion, from my examination and
digital exploration of the case, that the process extended to the brain,
not through the nasal passages, but that ulceration had penetrated through
some other avenue. A post-mortem examination was not allowed, so
that I can not prove this point.

I fail to comprehend the point made by Dr. Bosworth. Do you leave
the ulceration alone and just pay attention to the bone?

Dr. Boswortn: The original deposit of gummatous material limits
the extent of the ulceration. The ulceration does not extend beyond.
I do not believe that it invades the antrum unless there has been a primary
deposit in the antrum. Of course, the ulcer is to be treated, but it can
not be cured until the prominent perpetuating cause has been removed—
viz., the necrosed bone.

Dr. Mackenzie: What are the clinical facts to support this view ?

Dr. Bosworru: Syphilis shows a tendency not to transgress anatomi-
cal boundaries. It extends only so tar as the original deposit of gum-
matous material. The syphilitic uleeration does not extend from one
place to another. Furthermore, I believe that clinically the extent of
the swelling, tumefaction, and redness indicates the extent of the gum-
matous deposit.

Dr. Mackenzie: I am not prepared to accept or deny this view,
which, if it can be proved, marks a decided advance. It would almost
revolutionize our treatment. __

Dr. W. H. Daty, of Pittsburgh: Iam somewhat surprised at the state-
ment of my friend, Dr. Rice, that he, a man of acknowledged ability, had
used the galvano-cautery knife in freeing the adhesions of syphilis. I am
very glad that he has brought this up as a warning to others. I should
consider it a very bad method of practice to use the galvano-cautery on
any adhesions of such low vitality as syphilitic tissues. There is also a
great tendency to the readhesion of cauterized tissues. I believe that the

‘galvano-cautery is a very much abused instrument, but abused by its
friends. I believe that it is often used by skillful practitioners from an
unfounded fear of hemorrhage in the use of the -knife. I feel satisfied
that we can always obtain better results in the fauces, in the nose, in the
larynx, and, in fact, in any operation anywhere, if we do it with a sharp
cutting instrament and allow as free hemorrhage as is consistent with
good judgment and safety. In other words, the freer the hemorrhage
within certain limits, the more certain are we to have immunity from
septicemia and the more certain to bave rapid union with satisfactory
results. While I think that the galvano-cautery knife is a useful instru-
ment, I think that it is a very much abused instrument. I am glad that
my eminent and able friend, Dr. Rice, has made this honest confession.
It may be a warning to others less experienced than himself.

Dr. H. L. Swain, of New Haven: I should like to hear if there is

Discussion on Paper of Dr. De Blois. rus

any way of proving the statement that ulceration takes place only in the
portion where there has previously been a gummatons deposit. It would
seem that we have a contradiction of this view in the secondary ulcera-
tions which occur in the course of treatment where everything is appar-
ently healthy and there is no evidence of gummatous depesit. These new
ulcerations come in different places from those in which ulceration first
occurred.

Dr. J. C. Murumatt, of St. Louis: I can scarcely let the statement of
Dr. Bosworth pass without question. How does he explain the cases of
tertiary syphilis in which almost every portion of the bony framework of
the nose is involved? Does he say that there are gummatous deposits
involving the nasal cavities en masse? Every one of us lias seen cases of
tertiary syphilis where hardly any portion of the boundary of the nose
was uninvolved. I therefore take issue with his assertions, first, that
gummatous deposit must take place before ulceration; «nd, second, that
the limits of the ulceration will not extend beyond the first deposit of
gummatous material.

Dr. F. H. Boswortn: The investigations of various observers have
shown the cause of the ulcerations of syphilis. It has been shown to be
due to the gummatous deposit. That is the only explanation that we
have of the ulceration. The explosion of svpbilis consists in the deposit
of gummatous material under the mucous membrane, and the explosion
exhausts itself in that deposit, but the local process goes on. There is no
subsequent deposit until there is another explosion. The thing exbausts
itself for the time being. Syphilis involving the whole nasal cavity is not
due to extension. I have looked for it, but I have not found it. Uleera-
tion occurs only where the original deposit took place. Subsequent
deposits may involve other portions of the nose. I think there is no-clin-
ical evidence showing the extension of a syphilitic alceration of the vari-
ety under discussion. - +

Dr. A. T. DE Buors: The discussion bas taken so. wide a field that it is
difficult to touch upon the points that have been brought up. I would
only say in regard to the assertion of Dr.-Bosworth that we should re-
move the bony structures and let the ulceration take care of itself, that
it is very difficult to say how far'the ulcerative process in the bone has
extended. I have seen these ulcerations heal after a very slight scraping,
while in other cases the whole bone has had to be removed. When ulcera-
-tion occurs in the soft parts, we can not ltt it absolutely alone. It will
heal, but it will heal open, and you will have all of the distressing results
which follow that condition. .

78 Transactions of the American Laryngological Association.

Paper.

NOTE ON THE GALVANO-CAUTERY IN THE TREATMENT OF
HYPERTROPHIED TONSILS.

By CHARLES H. KNIGHT, M.D.

N a paper on this subject, read at a meeting of this association
two years ago, the following opinion was expressed: ‘“ Galvano-
cautery should be reserved for a comparatively small proportion of
cases, including those in which the hemorrhagic diathesis is present
or suspected, those in which vascular anomalies may be recognized,
those in which anatomical conditions prevent a sufficiently complete
excision of the organ, and those in which the use of a knife is posi-
tively declined.” With regard to adults it was recommended that
“a patient above the age of twenty years be allowed his option after
a fair presentation of the risks and advantages of the two methods”
——namely, cauterizing and cutting. During the last two years my
experience in eighteen selected cases in hospital and private practice
has, on the whole, confirmed my original conclusions. As to cauter-
izing tonsils in young children, it may be said that it is next to im-
possible to persuade children under ten years of age to submit to
galvano-puncture often enough and to a degree sufficient to accom-
plish much, and the use of the cautery-loop is in them out of the
question, except under general anzsthesia.

The experience of Saint-Germain,* who is a rather extravagant
advocate of ignipuncture, has been decidedly different from my own.
The ages of his patients, as recorded in twenty observations, range
from two to fifteen years, but it is noticeable that in his younger
cases a single cauterization sufficed. The inference is natural that
he is satisfied with less complete results, especially since he remarks
that tonsillotomy should be practiced only when the tonsils meet in
the median line. It seems to be accepted in this country that tonsils
which do not reach this degree of enlargement may be sources of
irritation and should be removed. Paul Balme,+ who follows the
teaching of Ruault, advises the amygdalotome for children of from
two to five or six years. After the latter age he finds electro-
puncture practicable. He is in the habit of transfixing the tonsil

* “Rey, des mal. de l’enfance,” 1884, ii, 520; see, also, “Trans. of the
Ninth Internat. Med. Congress,” vol. iii, p. 457.
+ “De Phypertrophie des amygdales,” Paris, 1888.

Galvano-cautery in Hypertrophied Tonsils. 79

at four or five places with an electrode brought to a white heat,
the cauterizations being repeated three to six times, at intervals of
ten or twelve days. To one who has witnessed the terror of a child
who has once felt the heat of the cautery point when it is proposed
to repeat the experiment, this statement seems almost incredible. In
my opinion the guillotine is far preferable in children, and in those
of highly nervous temperament it should be used under nitrous-oxide
gas or ether, the anzesthesia with the latter not being profound. For
these cases nitrous oxide is the ideal anesthetic. Its effect is rapid,
recovery is prompt, and the period of unconsciousness is ample.
Thus, much of the shock attending an excision of the tonsils may be
avoided, the bleeding is not appreciably more, and the operation may
be done with equal thoroughness. In older children and in adults
the galvano-caustic point and knife, and more particularly the cautery-
loop, are of service in the treatment of hypertrophied tonsils. My
attention has been especially directed to the effect of cocaine, and to
a comparison of the degree of pain experienced by the same indi-
vidual under different methods of operating on either tonsil. It is
very difficult to estimate pain. One patient will declare that excision
of a tonsil does not burt at all, while another will make the most
vehement demonstrations. But at least an approximate idea of the
pain may be formed by adopting a different operation for the second
tonsil.

This procedure was resorted to in five of my cases. In every
case cocaine in ten-per-cent. solution was applied on a pledget of
cotton or sprayed into the fauces. In one the cold-wire snare was
used on one side and the galvano-cautery loop on the other. In this
case the pain of the cold-wire operation was so intense that, when
nine days later the removal of the second tonsil with the cautery
loop was undertaken, the patient, a young woman of seventeen, was
so nervous and restless that great difficulty was found in applying the
loop. Consequently, the cold-wire operation proved to be the more
radical. There is no question, however, that in this case the hot wire
was less painful, more rapid, and was followed by less inflammatory
reaction than the cold snare. After the latter the pain persisted,
and for several days the formation of a phlegmon was threatened.

The histories of the four remaining cases, in which the cautery
loop and the amygdalotome were used, are very similar, That of
my most recent case will answer for all,

The patient was a colored girl, twenty-four years old. The right ton-
‘sil was removed completely two weeks ago with the cautery loop. Five

80 Transactions of the American Laryngological Association.

days later, reaction having subsided, the left tonsil was excised with the
tonsillotome. The contrast in the behavior of the patient on these two
occasions and in the subsequent appearance and action of the wounds
was not remarkable. The base of the first tonsil was cut through by the
hot wire in Jess than a minute, the patient offering but very little objec-
tion, and not a drop of blood being lost. The soreness and pain in swal-
lowing began to subside at the end of thirty-six hours, the patient mean-
while using a carbolized gargle at short intervals. On the third day there
remained a little edema of the uvula, and there was considerable inflam-
matory swelling of the pillars of the fauces. Except for the slovgh,
which was beginning to separate and which involved to a slight extent
the posterior pillar, the parts presented precisely the appearance expected
after an excision of the tonsil. The left tonsil, considerably smaller than
the right, was removed with Mackenzie’s amygdalotome on the fifth day
Hemorrhage at the time was much less than usual. The patient asserted
that the pain was much more than with the preceding operation. In this
case there was no subsequent bleeding, the soreness was of rather shorter
duration, and the wound healed more quickly, which may be attributed
to the relatively smaller dimensions of the second tonsil.

As a general rule, it is impossible to distinguish any marked
difference in the sensitiveness of the stump or in the rapidity of the
healing process.

These tests have satisfied me that the pain caused by the cautery-
loop operation is not so much greater as to constitute a valid objec-
tion. Electro-puncture is in the aggregate more painful because of
the frequent repetitions required, and is adapted only to cases in
which for any reason the snare can not be used. By the use of co-
caine it seems to me that but little, if anything, is gained beyond
securing more complete rest for the parts and so facilitating the ad-
justment of the wire loop. In some cases even this effect of cocaine
is defeated by the nausea which the drug is apt to produce.

In the technique of the galvano-cautery operation there is but
little new. For the purpose of tucking the loop around and behind
the tonsil, and holding it in position until the wire can be tightenod,
a little two-pronged instrument made of copper, so that it may be
bent at any desired angle, and held firmly in a handle, will be found
very convenient. It isa good plan, the moment the loop is seen to
encircle aud be in contact with the tonsil, to turn on the current for
an instant. The wire adheres and may be tightened at leisure with-
out danger of slipping or being thrown off by the act of gagging.
In spite of the utmost care, the pillars of the fauces are in some cases
more or less damaged, but the injury is generally superficial. In
many cases, owing to the shape of the tonsil, the adhesion of a pillar,

Galvano-cautery in Hypertrophied Tonsils. 81

or the intolerance of the patient, it is very difficult to include more
than half of the tonsil. These difficulties may be in part overcome
by preliminary training of the patient and by thoroughly releasing an
adherent pillar.

Additions to the literature of this subject have been rather numer-
ous. The galvano-caustic method has been approved by Dr. F. H.
Potter,* of Buffalo, in a paper read before the New York State Medi-
cal Association, and in a short communication from Dr. Jonathan
Wright,t of Brooklyn. Dr, E. G. Kegley { reports a case of extreme
tonsillar hypertrophy in a man forty-three years old, in whom spas-
modic attacks resembling hay fever, with the additional symptom
of profuse salivation, were entirely relieved upon removal of the
tonsils with the galvano-cautery loop. Noquet* reports a case of
chronic abscess in the stump of an excised tonsil cured by use of the
galvano-caustic point. This author, as well as Heryng and Charazac,
expresses a preference for the galvano-cautery in removing enlarged
tonsils. On the other hand, Moure prefers the amygdalotome, and
he professes to have seen in children the development of retropha-
ryngeal and circumtonsillar abscess after the use of the galvano-
cautery. Three cases similar to that of Noquet have been observed
by Garel,|| who strongly recommends the cautery in hypertrophied
tonsils, especially in cases showing a tendency to suppurative inflam-
mation. Kafemann* recommends the galvano-cautery, while G.
Dodart () maintains that amygdalotomy should be employed but
rarely, on account of the numerous accidents possible, and that
ignipuncture is the operation of choice. Barette { describes the
methods of operating, and expresses a decided preference for the
thermo-cautery or the galvano-cautery as compared with the bis-
toury and the amygdalotome. Ina paper by Ouspenski,} on ‘‘ The
Treatment of Enlarged Tonsils in Children,” based ‘on fifty-two
observations, the method by galvano-puncture is highly praised;

* “Med. News,” Philadelphia, March 10, 1888.

+ ‘“‘ Med. News,” Philadelphia, March 24, 1888.

t “N. Y. Med. Jour.,” Sept. 22, 1888.

# “ Arch. de laryngol., de rhinol.,”’ etc., June 15, 1888.

|| ‘‘ Ann. des mal. du larynx,” ete., January, 1889. See also Ricordeau, ‘ Thése
de Paris,” 1886; Gache, ‘“Thése de Paris,” 1888; and Chauveau, “Thése de
Paris,” 1888.

4“ Deutsche Med.-Ztg.,” No. 23, 1889.

) ‘“ Thése de Bordeaux,” 1888.

} ‘“ Rev. gén. de clin. et de thérap.,”’ Oct. 22, 1888.

} “‘ Ann. des mal de Voreille, du larynx,” ete., July, 1888.

6

82. Transactions of the American Laryngological Association.

and Valat,* after noticing the fact that hemorrhage following ex-
cision of the tonsils, rare in children, is by no means infrequent in
adults, advises the use of the thermo-cautery.

Wilhelm Roth,t of Fluntern, advises the employment, under
cocaine in ten- to twenty-per-cent. solution, of the finest point of the
thermo-cautery inserted at three or four places in the tonsil, the
operation being repeated four or five times at intervals of two or
three days. He finds this sufficient to reduce the tonsils to their
normal size, with scarcely any pain and without the risk of trouble-
some hemorrhage, which, contrary to my own experience, he says
is not uncommon, especially in young children.

In commenting on the views of Saint-Germain, Delavan { ex-
presses his disagreement for three reasons: 1. The process is far
more difficult and painful than amygdalotomy. 2. There is not an
authentic fatal case of hemorrhage after tonsillotomy on record. 3.
While he has seen and performed hundreds of amygdalotomies with-
out having known diphtheria to occur in the wound in a single in-
stance, he has known four cases in which the disease immediately
followed the use of the galvano-cautery. The first objection should
be modified to read “somewhat more difficult and painful.” It is
true that the galvano-cautery operations, at least those with the loop,
require more time and trouble, possibly more manipulative skill, and
somewhat elaborate apparatus. The second point may be admitted,
and yet it is not much comfort to a patient who has lost a pint or
so of blood, who is just on the verge of syncope, and who is already
frightened almost to death, to be told that no one has ever yet bled
to death after amygdalotomy, and he probably will not. All the
statistics in the world will not reassure him. With-regard to diph-
theritic infection, it seems to me unreasonable to suppose that the
germs of disease are any more likely to invade the system through
a wound covered by an eschar than’ through an open wound left by
amygdalotomy. The period of incubation in diphtheria varies from
two days to a fortnight,* fresh wounds being earliest affected, and
constitutional symptoms often preceding the appearance of. the local
lesion. It seems perfectly fair to assume that in these cases of im-
mediate diphtheritic development, such as Delavan refers to and as
cited by Saint-Germain, || the patient was already under the influence

* “Gaz. des hop,” No. 132, 1888. |
+ ‘‘ Lancet,” London, Feb. 16, 1889.
¢ “ Annual of the Univ. Med. Sci.,” 1889, vol. iv, p. 18, E.

#* Jacobi, ‘Treatise on Diphtheria,” p. 67.
|| ““ Rev. des mal. de l’enfance,” 1884, ii, 520.

Galvano-cautery in Hypertrophied Tonsils. 83

of the disease at the time of the operation. Such an accident has
not occurred with either operation in my experience, and, indeed,
it seems to me quite as apt to occur in the condition of the tonsils
for which their removal is demanded as it is after any operation
whatever. An enlarged tonsil, its crypts deepened and distended
by inspissated and decomposing secretion, would seem to offer most
excellent soil for the lodgment of disease germs.

One of the strongest arguments in favor of the galvano-caustic
method is the fact that it insures against hemorrhage, but a case
recently reported by Werner * would seem to show that our conten-
tion in this particular must not be too positive. His patient began
to bleed five days after treatment with the galvano-cautery, and is
said to have been saved by compression of the carotid for ten days.
Not having access to the original, I can not give further details, In
the case of Capart, mentioned in my former paper, hemorrhage was
undoubtedly provoked by immoderate use of the voice. I suspect
that to this cause, and perhaps indiscretion in diet, may be added as
possible factors deficiency of heat and excessive traction on the loop
during the operation. It is easy to conceive that in such case the
resulting eschar might fail to give sufficient protection to the stump of
the tonsil. Violent exercise, loud talking or singing, or an irritating
particle of food might easily be the exciting cause of hemorrhage.
We can not too closely observe precautions in these particulars, espe-
cially when we have reason to mistrust the caustic effect of the wire.

My zeal in advocating this method of treating hypertrophied ton-
sils is tempered by two facts, which I at least feel obliged to admit.
First, burning, if not mére painful, is at any rate more disagreeable
to most people ‘than cutting; second, the prevalent dread of hmor-
rhage after excision of the tonsils is not warranted by clinical experi-
ence. I am more firmly convinced that the danger of hemorrhage
after the use of Mackenzie’s amygdalotome, whith is by far the most
convenient, most efficient, and safest cutting instrument, has been
unduly magnifie@& - This is especially true of children, and in adults
it seems to be the rule that bleeding ceases on the occurrence of syn-
cope, if not before, and seldom recurs to an alarming extent. - This
statement has been verified by three cases which have come to my
notice within the last eighteen months, by the case reported by
Fuller,t in which the common carotid was tied without effect, and

* “ Wiirtemberg. med. Corr.-Blatt,” No. 31, 1888, in “Jour. of the Resp.
Organs,” January, 1889.
+ “Am. Jour, of the Med. Sci.,” Apr., 1888.

84 Transactions of the American Laryngological Association.

by numerous other instances. Excluding hzmatophilia, which is
under any circumstances an alarming condition, we are not likely to
meet with bleeding after amygdalotomy which need cause any anx-
iety. Perhaps Mackenzie’s estimation of tanno-gallic acid as a he-
mostatic is exaggerated. Should it fail, however, without wasting
time with other styptics, so justly condemned by Levis, we may con-
fidently resort to the use of the tenaculum as suggested by that
writer,* or the loop of the cold-wire snare may be applied, possibly
with the aid of a transfixion needle. Cases in which ligation of the
external carotid artery will need to be considered should become ex-
ceptional. The researches of Zuckerkandl ft have proved that the
course and relations of the internal carotid artery must protect it
from injury at least in guillotine operations. No one should be
deterred from securing the relief afforded by amygdalotomy by fear
of bleeding to death. Delavan asserts that there is not on record a
single case of fatal hemorrhage after the use of the guillotine for
simple hypertrophy. The detrimental effects of enlarged tonsils
are too obvious to be ignored. The benefit following their removal
is with many of us a matter of almost daily observation. The risk of
the operation itself need excite no apprehension,

At the same time the limited class of cases included in my enu-
meration must in some way be provided for, and for these the gal-
vano-caustic method seems to combine the most desirable with the
fewest objectionable features. The removal of a tonsil in this way
requires a little more time, but in the majority of my cases the pain
has not been excessive, the extirpation has been thorough, and the
final result in every respect satisfactory.

Discussion.

Dr. T. A. DEBuots, of Boston: I think that the principal objection to
the removal of the tonsil, or rather snipping it off, is the production of a
scar in the mouth. I have not cut a tonsil for a great while. I used to
cut every one that I could. I have used the cautery point in two cases
of enlarged tonsil, with excellent results. I have not heard Dr. Knight
refer to the use of the electrolytic needle, which I have employed with
satisfactory results. The pain under cocaine is very slight. A very small
amount of electricity will produce chemical changes in the flaids of the
part. Half a dozen punctures each day will in a short time, in the ma-
jority of cases, produce a great diminution in size. I use this only in

* “ Med. News,” Philadelphia, Dec. 8, 1888.
+ “Med. Jahrb.,” Wien, 1887, p. 309.

Discussion on Paper of Dr. C. H. Knight. 85

adults. I do not employ it in children, for in them the tonsils are very
apt to lessen in size.

I agree with Dr. Knight in regard to the pain and distaste of the
cautery point. The smell is very objectionable, particularly in the clinic
room, where the smell will last half the morning. These patients do not
come back if they can help it. I think even then it is preferable to the
use of the guillotine.

Dr. Cuartes E. Sasous, of Philadelphia: I have frequently used the
galvano-point. I think that in his first paper Dr. Knight stated that
eight or ten applications were sufficient to bring down certain tonsils.
Such has not been my experience. It has generally taken eighteen or
twenty sittings to reduce tonsils of any size. So far as the odor and
pain are concerned, I think that after the first or second visit we have
very little trouble with the patient on that score. I can lend my voice to
that of Dr. Knight in support of the galvano-cautery point in the treat-
ment of enlarged tonsil, especially where the density is not great. In
these cases cicatricial contraction assists in reducing their size. I burn
as deep as the knife will go—about a third of an inch.

Dr. W. H. Daty, of Pittsburgh: I must say that [ have very littie
patience with methods of treatment of enlarged tonsils which would sub-
ject the patient to half a dozen sittings with a plaything like the instru-
ment that my friend Dr. BeBlois speaks of.

I believe that in the normal throat there is no tonsil that you can dis-
cover beyond the line of the half arches, and that should be the rule to
guide us in abscission—and I mean abscission and not burning with the
galvano-cautery knife. We should have one object in view, and that is
to restore the abnormal throat to a condition as near anatomically perfect
as possible. First use the amygdalotome if you wish to, but this will not
do the work completely. Then with a probe-pointed curved bistoury and
toothed forceps trim off the remaining portion of the tonsil until the half
arches fall where nature intended them to fall—to their proper places.
You will then have improved phonation and improved general health,
and, if the patient has a predisposition to pulmonary disease, he will not
be handicapped by a condition of affairs which should not exist in health
at least.

Dr. DeBuors: I do not think that the electrolytic needle should be
spoken of as a toy, for it does its work. I have seen tonsils atrophy under
its use. There is no reason because we do surgery that everything should
be cut off, and nothing treated so as to atrophy, if that is possible.

Dr. F. H. Boswortu, of New York: I believe that the simplest opera-
tion in surgery in the hands of a competent laryngologist is cutting out
of the tonsils. I can conceive no possible justification in submitting a
patient to eighteen or twenty operations when the whole thing can be
done in a moment. The enlarged tonsil requires to be taken out just
as much as a fibroid tumor of the uterus, and it should be taken out en-
tire, not in pieces. I do not suppose that any man would say that a

86 Transactions of the American Laryngological Association.

fibroid tumor of the uterus should be partially removed. In the same
way there is no justification for removing a part of the tonsil. No one
would think of removing a fibroid tumor in eighteen or twenty sittings.
There is no case on record of death from hemorrhage after the opera-
tion of cutting out the tonsils, and this is the only danger attendant upon
the operation.

Dr. C. C. Ricz, of New York: There are a few cases of enlarged ton-
sils in which the use of the galvano-cautery is the best operation that can
be employed. I have in mind a case operated on within the last few
weeks—that of a gentleman about forty-five years of age, who has had
attacks of suppurative amygdalitis repeatedly ; the tonsil was very large,
very firm, and filled with blood. One tonsil had been excised by a physi-
cian in New York and the man nearly bled to death. He bled, in fact,
until syncope took place. I saw him some weeks later, when he was
suffering with a fresh attack of amygdalitis. The tonsil which had been
removed was excised with the guillotine and the pillars were not injured.
I preferred, with such a history, to use the galvano-cautery for the re-
maining tonsil. I would say to those who think that little can be accom-
plished with the galvano-cautery, that the whole of a large tonsil in an
intelligent adult can be removed at a single sitting. The tonsil was
treated with cocaine, and the edge of the galvano-cautery point was in-
serted into the tonsil at the level of the pillars and the tonsil cut through.
The whole of the tonsil down to the pillars was removed at one sitting.
There are a few such cases in adults, where there has been a history of
hemorrhage and where frequent attacks of inflammation have left the
tonsil immensely congested, where the galvano-cautery used in this man-
ner is efficient. In excising large congested tonsils in adults I have sev-
eral times proceeded in the following manner: I have employed a dull
amygdalotome, and have pushed the blade down very slowly. Cocaine
is used so that the patient can easily tolerate the instrument in the mouth
for some time. There is little pain. In this way the blood-vessels are
compressed before they are cut.

Dr. C. H. Kyieut, of New York: One object of my paper is to call
attention particularly to the loop operation, which in my opinion is supe-
rior to ignipuncture. It can be done at one sitting. The portion of tonsil
removed does not indicate the extent of the operation. A good deal of
the tissue that remains will slough, and contraction takes place. The
thoroughness of the cautery-loop operation has been equal to that with
cutting instruments. I would not for a moment be suspected of opposing
amygdalotomy. Yet we sometimes meet with cases which can not be cut,
and it is to these exceptional cases that the galvano-caatery is adapted.

The Treatment of Diseased Tonsils, 87

Paper.

THE TREATMENT OF DISEASED TONSILS WHEN UNATTENDED
WITH HYPERTROPHY.

By JOHN O. ROE, M.D.

T is my purpose in this short paper to call attention to some
chronic diseased conditions of the tonsils not characterized by
hypertrophy. Such diseased conditions have frequently proved, in
my experience, to be of marked clinical importance and to demand
appropriate and thorough treatment.

The group of glands between the pillars of the fauces which
constitute the faucial tonsils is, as has been stated by Dr. Bosworth,*
so small in size when in their normal condition as to be scarcely per-
ceptible on ordinary inspection. The condition of moderate promi-
nence of the tonsil that is commonly seen is not a normal condition,
although the tonsils may not be so much diseased as to give rise to
any particular disturbance. It is a fact, however, that the tonsils
may be and very often are so extensively diseased as to give rise to
well-pronounced and often serious local and general disturbances,
while at the same time they retain or may be reduced to about the
same size as in health, and it is to this condition that the writer
wishes to direct particular attention.

This condition of the tonsils has not only not received the atten-
tion it demands, but is not even mentioned by the majority of writers
on tonsillary diseases, although it has not remained entirely unrecog-
nized,

In conjunction with “ Chronic Follicular Tonsillitis,” Dr. Cohen ¢
recognizes the fact that the tonsils may be quite extensively dis-
eased without being in a condition of hypertrophy, and Dr. Harrison
Allen { has reported five cases of tonsillary disease producing well-
marked and persistent symptoms in which the tonsils were small and
so hidden behind projecting faucial pillars as to remain unnoticed.

* “The Function of the Tonsils, with some Practical Suggestions in Regard
to their Diseases,” Congrés périodique international des sciences médicales, Copen-
hague, “ Compte-Rendu,” vol. iv, p. 54.

+ “Diseases of the Throat and Nasal Passages,” 2d edition, p. 222.

¢ “The Tonsils and Follicular Irritation,” ‘“‘ Medical News,” Philadelphia, vol.
xli, p. 31.

88 Transactions of the American Laryngological Association.

A similar condition has been alluded to by Mr. Lennox Browne *
in his brief description of ‘Chronic Lacunar Tonsillitis,” and a case
is reported by him similar to those reported by Dr. Allen. Dr.
Maxwell,t of Jacksonville, Fla., has practically recognized certain
conditions of the tonsils that form the subject of this paper, but the
title of his paper, “ Ablation of Tonsils when Smaller than Natu-
ral,” is misleading, for the reason that it presupposes or implies that
tonsils are normally prominent and well-pronounced bodies.

Wagner, in describing chronic catarrh of the lacune in con-
junction with atrophy of the tonsils, says: “ The cyst-like dilatations
of the lacunz (like comedones) have a clinical importance from the
fact that their contents act irritatingly on the contiguous parts, either
mechanically or chemically. In this way are produced, and usually
repeatedly, the various kinds of tonsillitis, and especially intratonsil-
lar and peritonsillar abscess.”

It is interesting to note that for these conditions, which are capa-
ble of producing so much mischief, Wagner recommends no treat-
ment whatever, for the reason, he says, that they are seldom detected
during life. Itis a traditional and a very generally accepted idea
that only hypertrophied tonsils require treatment, but the fallacy
of this idea will be apparent by a careful consideration of these ob-
scure abnormal conditions of the tonsils, which so often escape
observation.

The primary and most common form of disease of the tonsils is
hypertrophy. In children it is rare that we find any other than the
hypertrophied form of tonsillary disease; but in adults other dis-
eased conditions of the tonsils are of frequent occurrence. It is
a recognized fact that hypertrophied tonsils in children become
smaller when adolescence is reached; and it is also the common
belief that the subsidence of these tonsils indicates a return, not
only to their normal size, but to a normal condition. But a careful
examination will readily show this belief to be a fallacy; and it is
not infrequently the case that these small tonsils will give quite as
much annoyance to the patient as he experienced from the tonsils
in their enlarged condition. It is almost invariably the case that
these small but diseased tonsils in adults follow as a sequel the
hypertrophic tonsils of children, and exemplify the importance of

* “The Throat and its Diseases,” London, 1887, 2d edition, p. 885.

+ ‘The Medical and Surgical Reporter,” Philadelphia, 1889, vol. lx, p. 196.

t Von Ziemssen’s “ Cyclopedia of the Practice of Medicine,’ American edition,
vol. vi, p. 971.

The Treatment of Diseased Tonsils. 89

removing from the throats of children all tonsils attended by any
considerable degree of hypertrophy. All chronic diseased tonsils in
adults almost invariably follow a condition of hypertrophy in cbild-
hood or youth; but in exceptional cases hypertrophy may not pre-
cede the diseased conditions under consideration,

The two forms of chronic diseased tonsils which remain after the
subsidence of hypertrophy, or which may exist independent of hy-
pertrophy, are—

1. A chronic disease of the crypts and lacunz of the tonsil.

2. A fibroid degeneration of the stroma of the tonsil or a cica-
tricial formation at the base of the tonsil.

The first condition is the result of chronic follicular inflammation
of the tonsil, and is almost invariably associated with chronic follicu-
lar pharyngitis. The most common form of this is attended by the
destructive degeneration of hypertrophied tonsils in children, and is
distinctly a diseased condition of the follicles of the tonsils, This
slow but progressive destruction of the follicles of the tonsils is the
exciting cause of the frequent attacks of suppurative inflammation,
which often attends this condition, and which is easily induced by
slight exposures or deranged conditions of the system. These de-
generate tonsils often have the appearance of being hypertrophied
when the crypts and lacunz are filled with the débris of the degene-
ration, which frequently has a very offensive odor and causes the
person to have a very bad-smelling breath.

It is not uncommon to find the surface of diseased tonsils studded
with white spots which mark the openings of the lacune. These
white spots are caused by the material discharged from the crypts
and lacune of the tonsils and is the chronic inflammatory exudate
resulting from the disease of the tonsil. On squeezing this out, it
will be found to be of a soft, cheesy consistence, to resemble very
much the contents of comedones, and to have an offensive odor, which
may be more fully brought out by crushing it. It is usually the case
that much deposit of this material is associated with more or less
hypertrophy of the stroma of the tonsil, for when the stroma and
follicles have undergone further degeneration, this substance is
poured out in a fluid form.

The second condition is also the result of the follicular disease,
except that, simultaneously with the degeneration of the lymph fol-
licles, there is a deposit of fibrous material in the stroma. The cica-
tricial formation at the base of the tonsils is the result of the fre-

90 Transactions of the American Laryngologtcal Association,

quent attacks of suppuration around the base of the tonsils which is
induced by the follicular disease.

The reason for these conditions being so frequently overlooked is
that they usually give rise to little or no discomfort to the patient
which he refers to the tonsils themselves; because the disturbances
to which they do give rise are usually located in other parts, and are
of areflex character. Another reason for their being so readily over-
looked is that, on examining the throat, the diseased condition of
the tonsil generally looked for is hypertrophy. This being absent,
the real disease of the tonsil remains unsuspected.

The chronic disease of the interior of the tonsil, even when it
is attended with considerable discharge, is frequently undetected for
the reason that the discharge is so readily cleared away by swallow-
ing or drinking. In other cases the tonsil may be partially or com-
pletely hidden behind large and projecting faucial pillars. In the
latter case the free exit of the tonsillar discharge may be prevented
by the overlapping pillars, thereby causing a distension and dilata-
tion of the crypts and a bulging of the pillars over the tonsils.

In these cases the anterior pillars should be drawn forward with
a blunt hook. For this purpose an aneurysm needle or a plain
palate retractor is very conveniently adopted. The act of gagging
also assists materially in the examination by throwing the tonsils
inward and forward, thus exposing them completely to view.

In all cases of obscure disease of the throat the tonsils should be
carefully examined. The enlarged crypts and lacune may be ex-
plored with a probe for enlarged pouches which are so often filled
with muco-purulent discharge; and this discharge can be readily
demonstrated by simply squeezing it out with the finger. The forma-
tion in the tonsil and around its base of cicatricial tissue, which is
very often the exciting cause of throat irritation, can also be readily
detected with the probe and finger, and can usually be suspected by
simply a careful inspection.

The local irritation produced by the diseased condition above
described is manifested in a variety of disturbances about the throat
and head. The association of this diseased condition with follicular
inflammation of the pharynx renders a removal of the abnormal
condition of the tonsils a necessity, before the latter can be cured.
Also, disease of the faucial tonsils is frequently the exciting cause of
diseased conditions of the other so-called tonsils—the lingual and
the pharyngeal tonsils.

It is also frequently manifested in irritation of the larynx and

The Treatment of Diseased Tonsils. 91

hoarseness; and it is not infrequent that cicatricial formations in and
about the tonsils will produce neuralgia of the face, neck, and more
or less frequent or persistent neuralgic affections of the ear.

The necessity of treatment of these diseases is therefore evident,
not only from the existence of the disease itself, but from the lia-
bility of its becoming aggravated by the slightest causes, and also
from the accompanying disturbances which it almost invariably pro-
duces. The method of treatment in these cases is always local, ex-
cept in those conditions of the tonsil that depend upon specific
disease, or those conditions of chronic inflammation of the circum-
cellular tissue of the tonsil that accompany rheumatic conditions,

Local applications of medicinal substances in these conditions of
the tonsils are practically useless. The application of caustics, such
as the Vienna or London paste, may be used in the first form of the
disease described, in which the tonsil itself is soft and flabby. In
the case of the fibrous or cicatricial formations, the efficacy of the
paste is not so great, as the tissue is not readily destroyed by it.
The galvanic cautery, which is sometimes employed for the removal
of hypertrophied tonsils, may also be employed in these cases. It
is, however, far more efficacious in the treatment of disease of the
lacunze and crypts, for the reason that the application of the galvanic
cautery tends further to increase the formation of cicatricial tissue.

The treatment par excellence in all cases is that of ablation with
the knife. In the case of diseased crypts, they may be laid open
with a bistoury, and the interior of the crypt thoroughly cauterized
with chromic acid or a solid stick of nitrate of silver, or the silver
fused on a platinum probe, as proposed by Dr. Cohen. The best
plan, however, in these cases is, according to my experience, that of
excision. In such case, however, the amygdalotome can pot be em-
ployed. The method of removing these tonsils is simply to grasp
the tonsil with a double tenaculum, draw it forward from its bed,
and remove a portion at a time. It is rarely advisable to attempt
to remove the whole mass at one cut, for these tonsils are so often
attached to the pillars of the fauces that wounding the pillars is
liable to take place if care is not exercised. The plan which I adopt
in these cases is, first, to anesthetize the parts as thoroughly as
possible with cocaine. This has a double advantage, in that it not
only renders the operation less painful, but decreases the liability
to hemorrhage. Then with a double tenaculum and a curved blunt-
pointed tonsil-knife to remove small portions of the tonsil until all
the diseased mass is thoroughly extirpated, usually leaving a deep

92 Transactions of the American Laryngological Association.

excavation between the pillars of the fauces. In the case of a cica-
tricial formation, it should be removed as thoroughly as practicable.
In some cases of chronic disease of the crypts of the tonsils it is ad-
visable to remove the outer portion of the tonsil completely, thus ex-
posing the interior of the crypt, which can be cauterized thoroughly.

In all cases, however, the complete extirpation of the gland when
possible is far preferable to any other form of treatment, as nothing
but a surface of healthy tissue is left, which heals quickly and per-
manently. In no instance has the writer observed any troublesome
hemorrhage in these operations. This is doubtless due to the fact
that in these cases the nutrient vessels going to the tonsils are small
or are not so distended as they are when the tonsils are in a con-
dition of hypertrophy.

A large number of cases illustrating the foregoing observations
could be cited, but, as the recital of cases is tedious, I will simply
state that in every instance excision of these small but diseased
tonsils has resulted in a complete cure of the tonsillary disease, and
entire relief from all the attendant symptoms of local disturbance
and reflected irritation.

Discussion.

Dr. H. L. Swarn, of New Haven: I have had an interesting case in
which the recurrence of swelling of the lingual tonsil was due to the
presence of these hard or caseous masses in the faucial tonsil. I only
succeeded in subduing these attacks by treating first these crypts in the
faucial tonsil. Tbe treatment which proved successful, and easily so, was
the laying open of the crypt with the galvano-cautery knife and thoroughly
cauterizing the interior, more by ignipuncture than by any attempt to
burn out the whole cavity. The case has been watched for several
months and the result remains good.

Dr. J. Sorts-Conen, of Philadelphia: These conditions of the tonsil
have given me a great deal of trouble for years. I find that many cases
of spasmodic cough are due to nothing else than the presence of these
masses in the crypts and lacune of the tonsil, sometimes even without
any evidence of their presence on the surface. I find these not only in
he enlarged tonsil, but also in the apparently contracted tonsil. It is
sometimes necessary to produce some gagging so that the posterior sur-
face of the tonsil will present itself before you detect the mass. In
obscure cases of spasmodic cough I have for a long time carefully
examined the tonsil as a possible source of reflex irritation.

Where the tonsils are enlarged I believe the best treatment to be
excision. In those cases where the tonsil is atrophied or apparently
atropbied—for even here the tonsil may be as large as a large almond—

Discussion on Paper of Dr. Roe. 93

I press the matter out with a blunt scoop, and then use a simple astring-
ent consisting of one grain of creasote, one grain of iodine, and five grains
of iodide of potassium to the ounce of glycerin. By getting this well
down into the lacune, you can sometimes cure these cases. Where this
does not answer, I have taken a pair of curved serrated scissors, such as
were long ago recommended for other purposes by Dr. Benjamin Ward
Richardson, to cut the crypts open. One blade is put into the orifice
and the part is cut through, and then with a dull scoop the crypts are
scraped as thoroughly as possible. Sometimes this leaves ragged edges,
but these can readily be snipped off.

I believe that this disease is not so well appreciated by the profession
as it should be. I have seen many cases of prolonged cough, extending
over a period of five or ten years and longer, completely and permanently
relieved by treatment of this condition.

Dr. Detavan: My experience is entirely in harmony with the state-
ments of Dr. Lennox Browne upon this subject, and I agree with the
reader of the paper. The pathological tonsil is, I think, by no means
limited to the one in which hypertrophy alone is present. There are
many other conditions of the tonsil which give rise to difficulties both
direct and reflex, and which can only be relieved by attention to the
tonsil.

Dr. Daty: There is another condition which was not brought out in
the paper, and which I have more than once observed in cases where the
lacune had become filled with cheesy matter, and that is that the patient
would become really ill, suffering with headache, loss of appetite, lassi-
tude, and other evidences of disordered secretion; and, before I adopted
the method of abscising the tonsil and obliterating the lacune, I made
sufficient observations to satisfy myself that these accumulations were
the cause of the general symptoms by an auto-infection.

There is another point: these accumulations render the breath ex-
ceedingly offensive, and to some persons this is especially disagreeable.
I am much obliged to Dr. Roe for giving us this excellent puper and
dealing with this subject in such a common-sense way. I believe that the
treatment should be radical] and curative, not tentative.

Dr. F. I. Kntent: It seems to be a question whether or not in such
cases the underlying condition is not some constitutional fault, or possi-
bly some digestive disturbance. In some typical cases I have seen the
follicular exudation not only upon the tonsil, but also upon the tongue,
the lingual tonsil, the soft palate, and the back of the pharynx. It seems
as though they frequently came in connection with some constitutional
disturbances, and we shall not succeed in relieving the patient entirely
from this exudation until we modify the constitutional or digestive con-
dition.

I had one notable case, such as Dr. Cohen describes, where the patient
for years had an irritative cough, and discomfort always referred to one
side of the throat. The cause of the trouble had escaped detection by

94 Transactions of the American Laryngological Association.

several observers, and I did not discover it for several visits. On making
her gag and throw out the tonsil, I found the point of one of these exu-
dations. I then passed a probe in as far as possible and scooped out a
cretaceous mass as large as a pea or larger. The symptoms were at once
relieved.

As far as local treatment is concerned, I would say that I have had
satisfaction with the cantery point, or with any destructive agent which
I have had the patience to introduce into each one of these follicles after
it was emptied.

Dr. 8. Jounston, of Baltimore: As bearing upon this condition of the
tonsil, I would state that in three cases which have come under my obser-
vation the exudation from the follicles, instead of being a soft, cheesy
material, resembled little spicules of bone or small crystals of alum. These
adhered with great tenacity to the tonsils, to which, however, they were
not confined, but were also found on the fauces and the post-pharyngeal
wal]. They can sometimes be drawn out with great difficulty, and are
exceedingly painful to the patient, who often complains of a foreign body
in the throat. Two of my cases were in children and the third was a
physician from a neighboring county. I tried a great variety of reme-
dies, but the best results were obtained from chromic acid in ten-per-
cent. solution. After one application, the parts being previously sprayed
with an antiseptic solution of phosphate of sodium and carbolic acid,
these crystals could be drawn out with the forceps. The specimens were
not examined microscopically. If any of the gentlemen have had similar
cases I should be glad to hear of them.

Dr. Rice: I have recently seen a most remarkable case of retained
tonsillar secretion—remarkable on account of the large amount of cheesy
material present; not only does it fill the lacune of the faucial tonsils,
but the lymphatic tissue at the back of the tongue is whitened with the
deposit. In this case the tonsils are normal; there are no adhesions to
the pillars. I have listened with interest to the remarks of Dr. Daly,
and I had hoped that some information would have been gained as to
the constitutional conditions causing or associated with this retention of
tonsillar secretion. I have tried to discover any constitutional peculiari-
ties in my case. The patient has had diphtheria two or three times, and
everything in the way of an explanation seems to point toward local
causation.

I can bear witness to Dr. Daly’s belief that this retention affects the
general health. It also causes an offensive breath. While the general
condition of my patient is quite good, she suffers with headaches, symp-
toms of indigestion, and is frequently tired and miserable. The tongue
is very much coated. This tonsillar cheesy material has been found by a
German investigator to contain putrefactive bacilli.

I am treating my case with the galvano-cautery puncture.

Dr. Daty: I fear that I did not make myself clearly understood. I
desire to emphasize the point that the retention of this fcetid filthy ma-

Tuberculosis of the Laryne. 95

terial in the tousillar lacune is the cause of the general illness of the
patient.

Dr. Ror: I am glad to know that the observations of so many of the
fellows present have been in accord with those which I have made on
these particular diseased conditions of the tonsils. There is one point
regarding the etiology of the first condition of the tonsils described in
my paper that has been, I believe, entirely overlooked. It is that this
lacunar catarrh and disease of the crypts are the result of hypertrophy
of the tonsil, and that the closing up of the lacune often results from the
attempts that are made to reduce the size of the tonsil during childhood
by repeated applications of astringents, which have no other effect than
to close the external orifice of the lacune and to cause a retention of the
secretion which distends the crypts of the tonsils, and the secretion, be-
coming decomposed, adds to the abundance of the discharge. The ton-
sils, accordingly, become diseased throughout, and are in appearance,
when cut through, much like a honeycomb. I have found the application
of remedies thrust into the openings of such tonsils to be of no value,
because so few of the crypts can be reached. The only radical treatment
is the removal of the diseased portion. This is also the case with the
fibrous form, which results from atrophy of the stroma and the deposit
of fibrous tissue. In both of these cases the function of the tonsil is prac-
tically abolished, and the only way to remove the difficulty is to remove
the diseased mass.

Paper.

SOME UNUSUAL MANIFESTATIONS OF TUBERCULOSIS OF THE
LARYNX.

By CLARENCE C. RICE, M.D.

HE object of this short paper is simply to cite several cases of
laryngeal tuberculosis which have come under my observation
during the past year. None of the pathological conditions to be
described are entirely unique. In quickly reviewing the vast amount
of literature which has been written on laryngeal consumption during
the past two years, I have found laryngeal lesions somewhat similar
to those observed in my cases described by writers. And these writ-
ers are, with few exceptions, members of this association. In fact,
it would be difficult to find any subject pertinent to laryngology
which can not be found thoroughly treated in the “ Transactions ”
of this society.
It is not altogether an Hibernianism to say that unusual mani-
festations of laryngeal tuberculosis are rare, because tuberculosis of

96 Transactions of the American Laryngological Association.

the larynx manifests itself with but little variety in pathological con-
ditions. We know where to look for its first appearance; we can
predict the mode of its extension; and the stages of its destructive
process follow one another with remarkable regularity. It is well to
tabulate cases of any disease which present lesions at all unusual,
because these are the cases which are somewhat difficult of diagnosis.
It would be worse than a waste of time to cite the different opinions
and the reasons on account of which they are held at the present
time. As to the etiology and pathology of laryngeal phthisis, we
believe that in five years from now there will remain but very few
of the minority who to-day think that the name of tuberculous
laryngitis does not describe the pathological condition in, we were
going to say, all cases of laryngeal disease associated with pulmonary
phthisis. The question as to the existence of primary tuberculosis
has been fully discussed by this association. And we know, too, the
opinion of nearly every leading laryngologist as to the curability of
laryngeal consumption. In addition to the very truthful description
of this disease in Cohen’s text-book, published nine years ago, but
which requires but little revision to-day, we find in the first volume
of the “Transactions” of this association a paper on “‘ Bucco-pharyn-
geal Tuberculosis,” by Bosworth; in the second volume, “ Primary
Tuberculosis of the Larynx,” by Cohen, and “The Therapeutic Value
of Rest in Phthisical Laryngitis,” by Robinson; while such papers
as “Tubercular Ulceration of the Tongue,” by Bosworth, “The
Progress of Laryngeal Phthisis,” by Porter, and “The Laryngeal
Affections of Pulmonary Phthisis,’ by Robinson, are published in
the third. In the fifth (1883), “Treatment of Laryngeal Phthisis,”
by Ingals, and “The Healing of Ulcers in Laryngeal Phthisis,” by
Jarvis. De Blois cites ‘Cases of Buccal Tuberculosis” in the sixth
report. Robinson contributes a paper on “ Alimentation in Laryn-
geal Phthisis” in the seventh. In the eighth we find a paper by
Delavan on “ Buccal and Lingual Tuberculosis.” At last year’s meet-
ing we heard two papers pertinent to the subject—viz., ‘““ A Specimen
of Stricture of the Larynx with Extensive Cicatrization from a Case of
Ulcerative Tuberculosis,” by Cohen, and “ Residence at Certain High
Altitudes as a Means of Cure for Laryngeal Phthisis,” by Wagner.

In addition to these, valuable monographs have been published
outside the “Transactions” by members of this association. This
much and more has this association accomplished in the way of in-
vestigating laryngeal tuberculosis. And nothing new can be stated
at this meeting.

Tuberculosis of the Laryna. 97

There is one clinical point relative to laryngeal tuberculosis which
I think has received too little attention, and that is the frequency of
the active co-existence of tuberculous and syphilitic laryngitis. This
is, of course, especially true in hospital and dispensary practice.
Many cases of larynx disease which it is difficult by their lesions
to classify are combinations of tubercular and syphilitic disease. It
is a mistake to try to relegate such cases solely to either one of
these diseases. The prognosis will depend upon which one of these
two diseases is the more active. Students who expect to find the
laryngoscopic illustrations of text-books easily corroborated by the
laryngeal mirror should be taught the coexistence of tubercular and
syphilitic laryngitis, and should consequently expect to find the
characteristic laryngoscopic appearances of either of these diseases
marked by a case in point:

Mr. F. Y., aged thirty-five, superintendent of a manufactory, came to
me in 1886. He had suffered with throat symptoms for six months.
Soreness over larynx and pain in swallowing had been excessive for a few
weeks at a time, and had then become much less troublesome. One par-
ent had died of pulmonary phthisis. The history pointing to syphilis
was obscure, though he had had venereal disease other than gonorrhea.
He had lost twenty pounds in weight, and had a slight cough. His tem-
perature was about 100° F. Slight dullness over one apex and change in
quality of respiration. The appearance of the larynx at his first visit is
shown in Fig. 1. I was struck with the extensive destruction of the

Fie. 1.

epiglottis as compared with the intralaryngeal degeneration. The aryte-

noids presented the typical semi-cedematous swelling, and there was

slight ulceration on both sides of the larynx, but the larynx as a whole

presented a mnch healthier appearance than would have been expected

if the destruction of the epiglottis had been occasioned by tubercular infil-

tration and ulceration. The man, though a little emaciated, seemed to
7

98 Transactions of the American Laryngological Association.

me to have sufficient vitality to recover. None of the tubercular bacilli
were found. He was put on increasing doses of the saturated solution
of potas. iodid.; the ulcerated surface of the epiglottis was treated with
iodoform in ethereal solution every day. The ulceration of the epiglottis
was controlled as if by magic, and complete cicatrization took place.
The ulceration in the laryngeal cavity also healed, but the arytenoid
remained enlarged. His general health improved. The loss of the epi-
glottis gave him little discomfort. He regained his weight. He remained
in good condition for almost a year, when he caught another cold. His
cough increased, and in two months his larynx was the seat of a typical
ulcerative tuberculous process. These ulcerations were confined to the
cavity of the larynx. He lived about six months. There was also rapid
degeneration of the lung tissue.

Here undoubtedly was a case where syphilis and tuberculosis
were blended. The epiglottis was destroyed by syphilitic ulceration,
but the interior of the larynx was tuberculous. The epiglottis was
healed by appropriate treatment, but the club-shaped arytenoids
remained.

Had the entire process been tuberculous it would have been
impossible to control the extensive ulceration of the epiglottis.
Deep contractile scar tissue, so characteristic of syphilitic ulcerations,
covered the epiglottis. I think this combination of tuberculosis and
syphilis is far more common in the larynx than is supposed. Some
of the cases of cure which have been credited to the tuberculous
process should, I believe, be placed under the head of syphilis. The
results of treatment will in some of these cases of ulcerative laryngitis
be the only way of determining the quality of the inflammatory
process. A second case, quite similar to the above, I have seen this
winter; the same great destruction of the epiglottis was present, but
the tubercular indications of the larynx were more marked than in
Case I. The effect of appropriate treatment on the syphilitic por-
tion of the lesion is wonderful in these cases, and for a time the
physician is almost deceived into the belief that he can heal the
larynx, but the tuberculous process soon asserts itself and the end
is only shortly delayed.

A second pathological condition which frequently complicates to
a small extent the usual laryngoscopic appearances of a tubercular
larynx was present in a remarkable degree in a case which I saw one
year ago. The pathological condition referred to is the proliferation
of the so-called granulation tissue from the bases and edges of the
ulcerations of phthisical laryngitis. This condition is fully described

Tuberculosis of the Larynx. . 99

by Dr. John N. Mackenzie,* and is called by him one of granular
hyperplasia. I believe that he is correct in the impression that this
growth from an ulcerated surface “ may be regarded as representative
of a connection process—as a natural step toward cicatrization.” I
would go a step further and say that the degree of vitality remaining
in the laryngeal structure may be measured by the’ amount of this
granular tissue which nature is able to construct. The most rapidly
destructive cases of laryngeal tuberculosis, and consequently those in
which the vitality of the tissues has been more markedly impaired
by tubercular infiltration, do not—so far as my experience goes—
show much tendency toward the formation of connective tissue.
The surfaces melt away without any attempt at repair. The rapidity
of the pulmonary and laryngeal process may also be measured some-
what by the presence or absence of this tissue. 1 cite the following
case only because the larynx contained so much of this granular
tissue :

W. M., a Hebrew, about forty years old, merchant. Previous or
family history of little significance. Though of moderate means, he had
denied himself proper food and care, and was in impaired general condi-
tion when he contracted the cold some eight months before he came to
me. His laryngeal symptoms had come on very slowly—only slight pain
and tenderness over larynx. Increasing hoarseness and dyspncwa were
his most troublesome symptoms. When I first saw him he did not pre-
sent the general appearance of a phthisical patient, but the look of a per-
son who had had too little nourishing food, together with the anxious
facial expression of one suffering from dyspncea; a moderate amount of
cough was present. Slight rise of temperature. Fig. 2 represents the
laryngoscopic appearances of the larynx; they were as follows: Epiglot-
tis slightly reddened and thickened, but not ulcerated. Arytenoids mod-
erately enlarged but not typical. The interarytenoid commissure was
filled with a papillomatous outgrowth seen frequently in both tuberculous
and syphilitic laryngitis. The dyspnoea was found to be partially due to
the lack of abductive power of the vocal bands, but more to the blocking
of the Jaryngeal cavity with both granular tissue and tissue which was
papillomatous in appearance. There was little ulcerated surface to be
seen, although tbe sides of the larynx presented the dull-green appear-
ance common to tuberculous ulceration. From the sides of the larynx
above the ventricular bands, from the ventricles themselves, and from the
vocal bands proper, there could be seen, not only the small, grayish-red,
slightly elevated tissue common to ulcerative laryngitis, but tissue much
more prolific in appearance like that springing from the interarytenoid
depression. This latter tissue did not, I believe, grow from an ulcerated

* Mackenzie, J. N., ‘‘ Archives of Medicine,” vol. viii, p. 108.

100 Transactions of the American Laryngological Association.

surface, but was covered by epithelial elements. The case was demon-
strated to a class of students, and I intended to remove portions of the
obstructing tissue with forceps, both to relieve the dyspnoea and for ex-
amination microscopically. The case fell into other hands at the college
two days later, and as a strong solution of nitrate of silver was applied to

Den a

the laryngeal cavity, the appearances as described above were never again
seen. When I next saw the case some months later, it was found that
the degeneration of lungs and larynx had progressed rapidly, and the
larynx presented the usual appearance of a tuberculous process. I saw
him a few times and he then disappeared, and I dare say he died within
a short time.

In this larynx there were, I believe, two conditions present—(1) a
granular hyperplasia, ingrafted upon an ulcerated surface, and (2) a
proliferation of those papillary excrescences which are eminently
characteristic of the tuberculous process when they are found upon
the interarytenoid fold, and which spring oftentimes from the pos-
terior wall of the larynx and trachea. The presence of tissue in-
grafted upon ulcerated laryngitis oftentimes renders the diagnosis
somewhat difficult, and the appearance may very much resemble a
true growth of the larynx, either benignant or malignant. It will be
necessary to weigh all the evidence before deciding upon the nature
of the disease.

3. Another pathological condition, and to me an unusual one,
was seen in a tuberculous patient who is at present under my care.
The condition is pictured in Fig. 3. It represents the larynx as it
was first seen by me a month ago, I need only say a word as to his
history. A tailor, aged thirty-five, good family history, emaciated,
cough, considerable dyspnoea. Evidences of pulmonary degenera-
tion on both sides. The vocal bands were adherent along their an-
terior half. There was but slight respiratory movement of the vocal
bands, This loss of motion was not due to the adhesion, but proba-
bly existed before the adhesion, and was one of the factors which
rendered this adhesive inflammation possible. ~The loss of motion

Tuberculosis of the Laryne. 101

was due to the enlarged arytenoids, and also to the proliferation of
granular tissue, which the figure does not represent, but which existed
both above and below the vocal bands. This sprung from the sides
of the larynx, and, jutting into the caliber of the glottis, furnished
lateral support for the formation of the web of tissue which held
together the vocal bands anteriorly. All the conditions were in this
case favorable to adhesive inflammation. How long this adhesion
had existed I do not know. I found that the tissue was not strong,
and could be broken through with an ordinary blunt laryngeal ap-
plicator. I have broken it through several times, but the gap soon
refills because the vocal bands remain immovable and near together.
I have seen and operated upon two cases of syphilitic membranous
adhesion of the vocal bands anteriorly. In both the web of tissue
was so tough that it could hardly be cut or burned. Cohen * de-
scribes and illustrates a somewhat similar case. Speaking of granu-
lations of the larynx, he says that “ when occupying both vocal bands,
the attrition of the ulcerated surfaces may excite adhesive inflamma-
tion, culminating in the formation of an organized web between them.”
In the particular case cited, he shows the manner of development of
that solid web, commencing first from a number of fine membranous
bands. And Ingals + speaks of the possibility of adhesive inflamma-
tion between the cords resulting from tuberculous ulceration.

This condition must be rare, since phthisical ulcerations show
such slight disposition to heal and cicatrize. The very fact that cica-
trization is present is a strong argument in favor of a syphilitic
process.

Von Ziemssen,{ however, treated two cases where the cicatrix
-could be demonstrated post mortem, but he adds that “it is true
that new ulcers generally develop afterward.”

Adhesive inflammation in a tuberculous process will rarely if ever
be found, unless all the favorable conditions mentioned in my case
are present; and even then the bridging across from one vocal band
to the other is accomplished more by a filling in of granulation tissue
from the sides both above and below the vocal bands, rather than by
the formation of a membranous web.

In my case it may become necessary to employ a tracheotomy
tube. An O’Dwyer’s tube, coated with a gelatinized astringent

* Cohen, “ Diseases of the Throat,” etc., p. 505.
+ Ingals, ‘‘ Diseases of the Throat,” p. 355.
t+ Von Ziemssen, vol. vii, p. 842

102 Transactions of the American Laryngological Association.

remedy, might serve the double purpose of dilating the glottis and
healing the ulcerations.

I will speak of but one more pathological condition, which I have
lately seen in a tuberculous larynx. This condition can hardly be
said to be unusual, as it is frequently associated with the ordinary
lesions of tuberculosis; but the case to be mentioned is worthy of
remark, because this lesion was the only manifestation of disease of
the larynx, and because there was some doubt as to the diagnosis.

I saw the case three times in consultation with Dr. H. M. King,
who kindly allowed me to manipulate the larynx fully. 1 obtained
the following history :

P. L., Russian Hebrew, aged twenty-nine. In 1886 he swallowed a
fish-bone, which fact added to the doubt of diagnosis. In June, 1888,
pain in swallowing commenced, followed by boarseness, increasing dysp-
neea, and cough. When I saw him he was but little emaciated or
anemic. His breathing was noisy, and his chief complaint was difficulty
in swallowing. I found the condition of the larynx present represented
in Fig. 4. I may add that the swelling involving the left arytenoid was
less regularly rounded, somewhat larger, and extended outward more than
is pictured by the drawing. The color of the arytenoid indicated that an

Fie. 4.

active inflammatory condition was going on. I at first thought that it
might be an abscess due to the swallowing of the fish-bone. The swelling
could be indented deeply by the pressure of a probe. It was somewhat
painful to the touch. I punctured the swelling with a laryngeal lancet
several times to ascertain if there was pus, but found none. I also scari-
fied it with the object of diminishing the inflammation. All this pro-
duced no benefit, but rather increased the pain in swallowing. The size
of the swelling remained the same. I had now arrived at the opinion
that I was dealing with a tuberculous perichondritis, as syphilis could be
excluded, and because there were slight evidences of commencing pulmo-
nary degeneration. As Dr. King left town at this time, the patient
visited the various dispensaries, and finally went to the Mount Sinai Hos-
pital, where he was attended by Dr. A. G. Gerster, of New York, who
performed a laryngo-pharyngotomy for the removal of the growth. Dr.

Tuberculosis of the Larynx. 103

Gerster has written an instructive account of the case and the operation,
which was read before the February meeting of the Laryngological Sec-
tion of the New York Academy of Medicine, and published in the April
6th number of the ‘*New York Medical Record.” I need not describe
the steps of the operation. Dr. Gerster says he decided to operate because
of the steady growth of the swelling. Tracheotomy above the isthmus
was performed on October 19, 1888, and the tampon cannula employed.
The growth, involving the left arytenoid and a portion of the posterior
extremity of the left vocal band, was freely excised. The tracheal can-
nula was removed on October 22d, and the external wound sutured.
Union of the soft parts was readily obtained, but not of the thyreoid
and cricoid cartilages, and a fistulous opening remained. A plastic opera-
tion for its closure was performed on January 4, 1889, with good success,
I believe.

The foregoing is obtained from Dr. Gerster’s account. I saw the
patient next when he was presented at the academy. He was very
much emaciated, and gave every appearance of a person in the last
stages of consumption. He died shortly after. I believe there was
ulcerative degeneration of the larynx during the last few montlis.
Whether Dr. Gerster supposed the swelling was tubercular in charac-
ter before the operation I do not know. The microscopical exami-
nation of the growth was done by Dr. Cunningham, of the Mount
Sinai Hospital, and was as follows:

Several sections were made, and they all exhibited a lymphoid
structure with giant cells; tubercle bacilli were present in abundance.
Dr. Gerster lays special stress on the fact that this was a localized
solitary tumor, the sole manifestation of tubercular disease of the
larynx. He does not maintain that the tubercular deposit was pri-
mary in the larynx. Dr. King, who saw and examined the patient
often, could never satisfy himself that there was any pulmonary dis-
ease until after the operation, and believes that the laryngeal process
was primary. I myself believe that deposition of tuberculous ma-
terial had already taken place in the lungs.

I can not but believe that this was a case of pericbondritis of the
erico-arytenoid joint, the exciting cause of which was the deposition
of tubercle. It seems to me that it is not to be classified with those
rare cases of “solitary tubercular tumors” of which Dr. John N.
Mackenzie * mentions two cases, the growth being solitary and in the
trachea in one and marked by a formation of submucous nodular
growths in the laryngeal cavity in the other. Hennig,t of Kénigs-

* Mackenzie, Dr. J. N., “ Archives of Medicine,” vol. viii, p. 109.
+ Hennig, ‘ Berliner klinische Wochenschrift,” 1888, No. 28.

104 Transactions of the American Laryngological Association.

berg, says that aside from one case of solitary tubercular tumor
which he reports, only six additional cases could be found in medical
literature. In Hennig’s case three tumors, which were afterward
found to be tubercular, were removed by the thermo-cautery after
laryngotomy. Patient died of pulmonary tuberculosis, as demon-
strated by post-mortem examination thirty-seven days after the
operation.

The interest in this case lies in the obscure manner in which
the tubercular infection was received and its strictly localized depo-
sition. I can not believe that extirpation of such growths by exter-
nal laryngeal operation will add to the patient’s comfort or prolong
his life. The shock and the exhausting effects of the operation, the
annoyance of the tracheal cannula, all hasten the pulmonary degen-
eration, Skillful endolaryngeal treatment, both medical and surgical,
will furnish the most benefit to the patient. Illustrative of what can
be accomplished by such treatment, I must before closing cite one
case more which the association will, I believe, consider of interest.
Figure 4 almost exactly represents the case also, except that the
tumor involving the left arytenoid was much larger. It occluded
nearly the entire glottis, and the dyspneea, when the man first called
at the office, was so dangerous that I forbade his going home and
sent him to the hospital. The air could be seen to suck through
the larynx at each inspiration. It was agreed, on consultation, to
wait until evening, and then do tracheotomy if the dyspnea con-
tinued as urgent. Moist inhalations acted badly and were discon-
tinued ; hot compresses on the outside of the neck gave more benefit
than cold. The great relief, however, was obtained by the use of a
two-per-cent. solution of cocaine. This was tried with some mis-
giving, as we feared an increase in the swelling when reaction took
place, but there was no reaction, and nearly all the reduction in the
size of the swelling obtained by the cocaine was permanent. I
learned this clinical point in this case, that it is far safer to employ
cocaine in a greatly obstructed larynx, when the swelling is partly
cedematous, as it was in this case, than when the swelling is entirely
made up of actively congested tissue. Jn the one the water is driven
out not to return, but the expulsion of the blood from the inflamed
region can hardly be more than temporary, and the last condition is
likely to be worse than the first. The swollen arytenoid was reduced
to one third of its size in a week. It was then punctured with the
galvano-cautery, and by this means was still further reduced in size.
It is at present considerably larger than its fellow, but it is not

Tuberculosis of the Larynz. 105

troublesome to the patient. What the character of this swelling is
I do not know. I excised a portion of it with a snap guillotine for
microscopical examination, but the sections showed only normal
elements. I can find no evidence of syphilis. The patient is a
very large, stout, flabby man weighing more than two hundred and
fifty pounds, thirty-two years old, complexion a dirty green; no evi-
dence of pulmonary disease can be found, Patient has been a man
about town and has drank and smoked to excess. I do not at all
advise extirpation of the growth by external incision, neither do I
think removal by cutting forceps would be productive of good re-
sults. This case, which may be somewhat irrelevant to the subject
of this paper, is cited because it so closely resembles the previous
case, which was found to be tubercular. The great size of the swell-
ing, the urgency of the dyspnea, and the beneficial effects of the co-
caine, are its interesting features.

“The unusual manifestations of tuberculosis of the larynx” men-
tioned in this paper are as follows:

1. In those cases where tuberculosis and syphilis coexist, the
lesions of one process mask those of the other. The syphilitic ul-
cerations, even when combined with a tubercular process, are fre-
quently controlled by appropriate treatment, while the phthisical
ulcers defy all efforts to heal them.

2. The typical appearances of a tuberculous larynx are some-
times greatly hidden by the proliferation of two varieties of tissue—
the one being ordinary granulation tissue springing from an ulcerated
surface, and the second a papillomatous growth made up of normal
elements, very much resembling the ordinary papilloma of the larynx
—and existing, perhaps, as a mere coincidence, but probably occa-
sioned by the chronic inflammatory condition of the larynx.

3. Adhesive inflammation at the anterior ends of the vocal bands
may occasionally take place in a tuberculous larynx, but only when
such favorable conditions are present as immovable cords and a
general proliferation of tissue.

4. The deposition of tubercle may be localized in one arytenoid,
giving none of the typical signs, the larynx as a whole remaining
perfectly normal in appearance.

Discussion.

Dr. W. H. Daty, of Pittsburgh: There are two points with reference
to tuberculous disease of the larynx which I believe are worth noting. I
have demonstrated to my own satisfaction in several cases—three or four

106 Transactions of the American Laryngological Association.

—that tuberculous ulceration of the larynx can be cured. In these cases
I could discover no syphilitic complication either inherited or acquired.
I have arrived at this belief contrary to the teachings that I had re-
ceived from men in whom I had confidence as teachers and authors. In
so far as the treatment was concerned, it was the most approved consti-
tutional treatment, but I do not believe that the constitutional treatment
had as much influence as the persistent careful local treatment. If I were
to be denied one or the other in the treatment of tuberculous ulceration
of the larynx, I should certainly elect to be deprived of the constitutional
treatment. The local treatment resolved itself into a question of cleanli-
ness and antisepsis, and to this end one can use what he pleases. In the
cases referred to, recovery took place under the persistent nse of alkaline
sprays and inhalations followed by the free use of iodoform—not iodoform
modified by any medicament to correct the odor, but iodoform pure and
simple.

There is another point. It may seem like rank heresy, but I believe
that tuberculous ulceration of the larynx occurs as a local disease—that is
to say, it may occur in patients with no evidence of tubercular deposit
elsewhere. There are in Pittsburgh two such cases; one of them I saw
a day or two ago. The patient is a clerk in a jeweler’s store, an occupa-
tion anything but favorable to the maintenance of a cure. For over a
year that young man has been working hard at long hours. The voice is
somewhat affected by the diseased action and changes in laryngeal struct-
ure which took place before he came under my care, and a part of the
epiglottis is gone. After he was placed under treatment there was little
further destruction. He is now ten or twelve pounds heavier than before
his illness and twenty or twenty-five pounds heavier than when he came
under my care. I regard the case as a cure. The diagnosis was con-
firmed by the microscopical examination made by a competent young
gentleman after the method of Koch. There was no evidence of lung
disease. Being a strong believer in the theory that tuberculous, strumons,
and scrofulous diseases are the offspring of syphilis, I investigated this
-poiut very closely in this case to place it where it belonged.

Dr. J. C. Murmatt, of St. Louis: I am glad to congratulate Dr. Daly
on having cured laryngeal phthisis. I, however, think that his position
is a hard one to maintain, for this reason: It is easy enough to get micro-
scopical proof of phtbisis in the presence of the bacillus without phthisis
existing, for in the secretions of the mouth and throat of even healthy
individuals this bacillus is sometimes found. Again, I do not doubt that
there is such a thing as catarrhal ulceration of the larynx. If we take
these two facts into consideration with the fact that catarrhal ulceration
can be cured, we can understand how one might readily fall into error.

That laryngeal phthisisis ever primary is also difficult to prove. That
it is sometimes the first sign of the condition there can be no doubt. We
also know very well that tubercular disease may exist in the lungs and
not be accessible to physical examination. Post-mortem examinations

Discussion on Paper of Dr, Rice. 107

have proved this. Post-mortem examinations have also proved that in
every case of laryngeal phthisis there is pulmonary plthisis. It is said
by experts in lung disease that unless the lung is diseased in a portion of
the size of a silver dollar, its presence is readily overlooked. It is there-
fore easy to be deceived.

That laryngeal phthisical ulceration can be healed I have no doubt,
but that it can’ be cured I do doubt. After our attention was called to
the value of lactic acid I at once made use of it in tubercular ulceration
of the larynx, and I have seen the ulceration heal on one side and appear
on the other side. I went one step further than the one who recom-
mended this agent, Krause, and applied the pure lactic acid after spraying
with cocaine. Clinically I know that laryngeal ulcerations of a plithisical
character will heal under the influence of pure lactic acid. I have seen
them heal in the pharynx in a dying patient. I, however, can not say
that I have ever seen life prolonged to any appreciable extent.

I was once a firm believer in the theory that ulceration never occurred
in chronic catarrhal disease. I have had two physicians under my care.
One bad a terrible cough for two years, his health had run down, and he
had quite a large ulceration in the larynx, which rapidly healed in the
course of a month under lactic acid. The cough lessened and he improved
in weight and constitutional condition and was entirely cured. This was
not a tubercular ulceration.

Dr. F. I. Kntenr: How do you know that it was not tubercular?

Dr. W. H. Daty: What are the characteristics of catarrbal ulcera-
tion?

Dr. J.C. Mutmati: Catarrhal ulcers occur usually in some part of the
larynx where there is a great deal of friction and come on after a distinct
history of severe laryngitis. The ulcer has clean-cut edges and not the
creeping edges of the tubercular ulcer; is single and unaccompanied by
other familiar signs of laryngeal tuberculosis.

Dr. F. I. Knteut: The first point raised by Dr. Rice is certainly inter-
esting. I have had a great deal of trouble in the diagnosis of these cases.
It is hard enough to make an accurate diagnosis where we have only one
disease to deal with. In some cases where I have been almost sure
enough of my diagnosis of tuberculous disease of the larynx to let the
patient go without constitutional treatment, 1 have been happily disap-
pointed in seeing the ulceration disappear under specific treatment.
These mixed cases are certainly annoying, and the only thing that we can
do in endeavoring to make a prognosis is to find out if we can which
disease predominates, for, although there may be evidences of tubercu-
lar disease elsewhere, the effect of specific treatment may be very satis-
factory if that element has entered into the case.

In regard to the possibility of tabercular ulceration being cured, I
have not the slightest doubt that such ulceration in the larynx has got
well just as in other parts. That it will-heal under mild treatment I
have proved by the effect of alkaline applications and iodoform. I have

108 Transactions of the American Laryngological Association.

no question that lactic acid will heal tubercular ulcerations more quickly
and certainly than anything yet proposed, but after we have them healed
they do not stay healed, unless we happen upon the time when the pa-
tient is ready to recover and the ulcer of the larynx is the last point to
be cured. If the pulmonary disease is in a quiescent condition and the
digestion is good, and there is this one lesion in the throat which is the
particular thorn, I believe that in some cases, if we heal that, we get
what is practically a cure. If the disease in the lung is active and the
patient is miserable in other ways, the cure of the ulcer in the throat is
not, going to do much good.

I have seen what I suppose Dr. Mulhall calls catarrhal ulcerations.
They are catarrhal. I should call them abrasions occurring in acute in-
flammatory conditions; but where there is loss of substance, as in the
case referred to by Dr. Daly, I should, in considering the diagnosis, rule
catarrhal ulceration out of consideration.

In regard to the occurrence of tubercular ulceration as a primary
affection in the larynx, I see no reason why we should doubt that it may
occur there as well as anywhere else. I think, however, that all who are
familiar witb this class of cases and are tolerably competent in physical
diagnosis will agree that in the vast majority of cases careful examina-
tion will prove that there is disease in the lung, and in other cases, where
we do not get positive physical evidence, we find rational symptoms
which would lead us to infer that there is pulmonary disease. I have
had many cases brought to me as illustrations of primary tubercular dis-
ease of the larynx, but, on careful examination, I have found good evi-
dences of disease at the apices of the lungs. In other cases I have failed
to get physical signs, perhaps because they did not exist. Sometimes a
condition of glottic rigidity prevents us from getting tbe signs that may
be present.

The earliest signs of tuberculosis of the lungs are by no means changes
in resonance on percussion and in the respiratory murmur which many
seek for, but they are localized rales which are only obtained upon cough-
ing, and a cough properly made.- In my experience this is an early sign.
Many physicians examine a patient without asking him to cough. I once
saw a distinguished professor of Vienna make this mistake. He examined
a patient in my presence and said there was no phthisis. I asked him to
try the cough, and he found an abundance of localized high-pitched rales,
and corrected his diagnosis. Most patients when asked to cough take a
deep inspiration, cough, and at once breathe. The deep breath which
they take before may spoil the rale, or, if they breathe too soon after the
cough, the rale may not be heard. The patient should cough from a rest
and not breathe immediately before or immediately after he coughs. In
that way in many cases we get an explosion of rales, which we should
not otherwise hear. I have seen very few cases in which it seemed to me
that the tubercular disease was primary in the larynx. If we get a case
where the disease is primary and localized, and cure the ulceration, I do

Discussion on Paper of Dr. Rice. 109

not see why it should not remain cured, unless there is subsequent infec-
tion.

The other points in the paper are interesting. I have seen anterior
adhesions occur from other causes, but not from tubercular ulceration. I
had recently a notable case—one of cut throat.

T have not seen an isolated tubercular tumor such as Dr. Rice de-
scribes.

Dr. W. E. OCassetperry, of Chicago: I wish to support the position
of Dr. Mulball with reference to catarrhal ulceration. A year or so ago
I saw a physician of Chicago who had suffered from recurrent attacks of
laryngitis, suspected to point toward tuberculosis, for which reason he
had spent three winters in the South, much to the detriment of his uffairs.
At this time he had an elongated uvula, occasioning a good deal of cough,
and the larynx and naso-pharynx were in a catarrhal state. I first excised
the uvula. There were no ulcers at this time. A few weeks later he
appeared with a small but pronounced superficial ulcer on the epiglottis,
not much more than an abrasion, but still with distinct loss of substance,
and a smaller ulcerated spot on the false vocal cord. I told him that
these were catarrhal ulcers, and did nothing for them beyond keeping the
parts clean, and in a week or ten days they disappeared. He has since
been perfectly well.

I am glad that Dr. Rice called attention to the rather common coex-
istence of tuberculosis and syphilis. It has been my conviction that the
existence of either one of these diseases predisposed to the other; that
one of the dyscrasie having attacked the larynx, a favorite site for the
manifestations of either, predisposed that organ more than ever to the
_ invasion of the other disease.

Dr. J. N. Maoxenzim, of Baltimore: I fully indorse the statements of
Dr. Knight concerning the presence of localized rales as indicative of
incipient tuberculosis, and I have found that where they can not be heard
over the apices they can often be heard behind the scapula. By this
means I have often been able to make a very early diagnosis of tuber-
culosis.

The question of the existence of primary tuberculosis of the larynx
has been raised. This is a question which can only be determined by the
scalpel. Dr. Orth, professor of pathological anatomy in the University
of Berlin, in a work published some years ago, describes such a case.
All the organs of the body were examined, but the larynx was the only
one in which tubercles were found. I think the patient died of the tuber-
culosis. Primary tuberculosis of the larynx has been demonstrated in the
same way by other observers.

Dr. Malhall has already stated what I was about to say, that while
undoubtedly tubercular ulceration of the larynx wil] heal, yet the healing
of the tubercular ulcer in the larynx by no means indicates the cure of
the disease. The same thing may be said of tubercular ulcers of this

110 Transactions of the American Laryngological Association,

region as was said of syphilis by Vidius, ‘* They make many truces, but
never peace.”

As regards isolated tubercular tumors, which were first brought to the
notice of the profession by myself, I should like to refer to one of the
cases in which death occurred from carcinoma of the stomach and liver.
At the post-mortem examination tubercular cavities were found in the
lang. In the trachea there was a small tumor, which I described, and
which I took to be an isolated carcinomatous nodule in the trachea, of
which only a few cases had been reported. I removed the nodule care-
fully and submitted it to microscopical examination, and was astonished
to find that it was of a tubercular nature. It presented distinct miliary
tubercles in all stages of degeneration, set in a dense network of fibrous
connective tissue. In this case a nodule, resembling in structure the
tracheal growth, was found in the pericardium. The patient died, not
of tuberculosis but of the carcinoma. The tuberculous process in the
lung was, however, well marked.

I have several times seen the coexistence of syphilis and tuberculosis
of the larynx, and the diagnosis is one of great difficulty. In all such
cases we have to resort to the test of treatment.

With reference to catarrhal ulceration of the larynx, while I should
not like to absolntely deny the existence of such a condition, I have never
seen it. By ulcer I do not mean the erosion or abrasion of the larynx
which results from coughing or the application of an instrument, but I
mean a well-marked, distinctly excavated ulcer—a true ulcer. In my
experience such an ulcer is indicative of some constitutional trouble,
whether it be syphilis, tubercle, or what n6ét; it is generally indicative of
a dyscrasia.

In regard to the treatment of laryngeal tubercular ulcers by harsh
methods—such as the application of lactic acid, which is, perhaps, less
harsh than some others, the application of the galvano-cautery, and the
treatment of Schmidt, of Frankfort-on-the-Main, by incision of the infil- —
trated tissues—I am glad to say that the common-sense, conservative ele-
ment of American laryngology is decidedly opposed to such measures,
which I believe do more harm than good. I have never had a patient in
private practice who would have allowed me to resort to such measures,
even hud I desired to do so.

There is a form of ulceration which occurs in the later periods of
tubercular disease which is found principally in the lower part of the
trachea and near its bifurcation and in the bronchi, but which may be
found higher up in the larynx and in the pyriform sinus. In 1881 I pub-
lished a paper in Berlin in which I dealt in an elaborate way with this
question. These ulcers resemble the so-called aphthous ulceration of the
old Rokitansky school, and the so-called diphtheritic ulcer. The tissue
becomes invaded with a rapid cell proliferation, necrosis occurs, a slough
follows, and ulceration is the result, but it presents none of the character-
istics of the true tubercular ulcer. J mean by a true tubercular ulcer one

a

Discussion on Paper of Dr. Rice. 111

that is formed by the breaking down of myriads of miliary tubercles.
These ulcers may or may not contain bacilli. Orth speaks doubtfully
upon the snbject, but seems to regard them as tubercular. Dr. Osler has
found the same ulceration in the rectum, and has been at work upon the
subject, but I do not know what conclusions he has reached. It is, how-
ever, readily conceivable that these ulcers may easily heal. I have no
doubt that many of the so-called healed tubercular ulcers are nothing
more than healed aphthons erosions which have been produced by the
corrosive action of the sputa in the later stages of the disease.

Dr. Witttam C. Grascow, of St. Louis: A good many years ago I
stated my belief that tubercular ulceration of the larynx was never bealed.
My experience since then confirins me in that belief. I have heard a
great deal and read a great deal about tubercular ulcerations being
healed. There is a common belief that any ulceration in the Jarynx, not
syphilitic or lupoid, is tubercular. I have seen many ulcers of the larynx
heal. I have seen them heal in cases of pronounced phthisis where the
physical signs demonstrated phthisis, and I have seen them heal where
there were few or no physical signs of this disease. I do not consider
these ulcers tubercular, They heal under the simple treatment of which
Dr. Daly speaks and which I have used for fifteen years—that is, iodo-
form and morphine by insufflation. I recall one case in which a man in
the Jast stages of phthisis, with large cavities in the lungs, hectic, ete.,
was unable to swallow on account of a large ulcer on the posterior
portion of the larynx. Under the use of iodoform he was able to swal-
low, but died in a short time. I did not consider this a case of tubercular
ulceration. I have used lactic acid, but have not found it ss useful as
others claim. I think that iodoform has given me better results.

One remedy that I have used with great success in the Jast two years
is peroxide of hydrogen. I have seen these ulcers heal almost miracu-
lously under a simple spray of peroxide of hydrogen. A case came to me
last spring with two thirds of the epiglottis destroyed. The lungs were
examined with negative result; no bacilli were found. Under the use
of peroxide of hydrogen the ulceration or seeming ulceration, for I do
not think that it was true ulceration, entirely disappeared, and the patient
was able to swallow. The destructive process took a fresh start on the
ventricular bands—first on one side and then on the other—and this con-
tinued until death. Repeated examination of the lungs and of the sputa
developed nothing until September, when bacilli began to appear. This
man died of marasmus, and at the time of his death the rales of which
Dr. Knight spoke were appreciable at the apex of one lung. His death
occurred within a month of their development.

I do not believe in primary tubercular disease in the larynx. In all
the cases that I have seen there has been more or less disease of the lung.
In addition to true tubercular ulcers, I have seen catarrhal ulcers and
others which I have not been able to define; but I do not consider them
tubercular. Some of these ulcers occur in the condition of septic edema

112 Transactions of the American Laryngological Association.

described in my paper. In true miliary tuberculosis of the larynx I have
always found some evidence of disease in the lungs, and these cases have
never recovered.

Dr. W. H. Daty: What is the value of the tubercle bacillus as a means
of diagnosis? Dr. Glasgow states that it was present in one of the cases
to which he has referred.

Dr. Grascow: Its presence demonstrates tuberculosis. Its absence
does not demonstrate anything.

Dr. GC. C. Rice: The different points in the discussion have been thor-
oughly covered. I have been particularly impressed with one thing, and
that is the radical change in the opinion expressed to-day as compared
with that expressed by this association four or five years ago. If the
gentlemen will take the pains to compare this discussion with that on the
same subject four years ago, they will find that there has been a radical
change in the opinion of this association in regard to the curability of
tubercular ulceration. I refer to the discussion on Dr. Cohen’s paper.
The opinion expressed at that time was to the effect that these ulcera-
tions were rarely if ever cured. The prognosis, so far as the laryngeal
manifestations were concerned, was exceedingly bad. I have been sur-
prised during this discussion to hear of the number of cases of laryngeal
ulceration that have been cured. I am ata loss to understand the char-
acter of the large number of ulcerative cases referred to by Dr. Glasgow
which he believes to be neither syphilitic nor tubercular. Ulcerations
which belong to neither of these affections are exceedingly rare in my
opinion. The catarrbal ulceration spoken of is a very uncommon mani-
festation. I do not refer to slight erosions. I do not believe that a
catarrhal ulcer can occur unless, in addition to the acute inflammatory
condition, there is a direct traumatic cause, such as friction and an ex-
plosive cough. We often see erosions. They occur on the tip of the
epiglottis where it comes in contact with the tungue. They occur on the
vocal bands where they rub against each other. I do not believe that
catarrhal ulcers are seen on the sides of the larynx. If ulcerations of
any size are found in that location, I should look upon them with sus-
picion. We know that primary tuberculosis of the larynx is very rare.
In the treatment of laryngeal tuberculosis I think that more reliance is to
be placed on milder drugs than upon the use of acids and surgical meas-
ures, ete. Cleanliness and the use of cocaine to allay irritability of the
larynx is important. This, with iodoform, seems to me to furnish the
best means of benefiting these patients.

Report of Two Cases of Buccal Tuberculosis. 113

Paper.
REPORT OF TWO CASES OF BUCCAL TUBERCULOSIS.
By O. E. BEAN, M.D.

AM aware that during the past two years a great deal has been

written on this subject and quite a number of cases reported,
but I wish to add these recorded cases, for only by additional notes
and evidence can data satisfactory and conclusive be obtained.

One of these cases is of especial interest, not only from the ex-
tent of the ulceration, but from the fact that it was developed in a
female, this being, so far as I can learn, only the third case of the
kind on record.

Case I.—Henry B., farmer, aged thirty-two, was seen in May, 1887,
and gave the following history:

Up to four years before this time he was entirely healthy, with the
exception of a slight cough. After working hard all of one afternoon,
drawing water from a well with a bucket, he expectorated a slight amount
of blood. This had continued at intervals ever since, though at no time
was there any severe hemorrhage. Up to a year ago he had not lost
any flesh. In the fall of 1886, whenever he smoked or chewed tobacco,
his tongue would sting and burn and get very red. This troubled him to
such a degree that he was forced to give up the use of tobacco alto-
gether.

Four months ago (January, 1887) a sore appeared on the right side
of the end of the tongue, commencing like a crack. Two months ago
(March, 1887) it began to grow larger, and has gradually grown ever
since. At this time the tongue began to swell, and is now (May, 1887)
about twice its normal size, while an ulceration extends on the right side
from the tip back as far as the middle, three sixteenths of an inch deep,
with shelving edges. On the 4th of July, 1886, he caught a severe cold,
and, following that, his voice was a trifle hoarse. In the middle of
March, 1887, bis throat began to get sore, and his voice grew gradually
worse until, about ten days after, his voice had entirely disappeared.

Two years ago his weight was one hundred and fifty-five pounds; one
year ago, one hundred and forty-five pounds; now only one hundred
pounds. Unable to swallow any solid food, and only a small quantity of
liquids.

Examination of the Larynx showed thickening and ulceration of the
right free edge of the epiglottis and ulceration of both vocal bands their
entire length.

Examination of the Chest.—Dullness on percussion over entire right
lung, with moist rales. Bronchial breathing and dullness in apex of left
lung.

8

114 Transactions of the American Laryngological Association.

Family history: Both parents living, and over seventy years of age.
Father’s sister died of phthisis. His three brothers and two sisters are
healthy.

Temperature, 101:2° F.; pulse, 124; respirations, 34.

As the patient resided at a distance and it was plainly evident that
he had only a few days to live, I sent him home and advised morphine
hypodermically and cocaine locally to ease his intense suffering.

Case IJ.—Mrs. S. was seen in August, 1887. Her history was as
follows:

Family history: Mother died of consumption, aged forty-five, and a
maternal aunt with the same disease, age unknown.

Patient’s history: Up to three years before the time I saw her her
health had been comparatively good. At that time, following a cold,
she had protracted cough, with slight frothy expectoration. This con-
tinued for six months, when cough and expectoration almost entirely
ceased, the cough being only in the morning and at night. About one
year after the first symptoms she had, without any premonitory symp-
toms, a severe hemorrhage; slight hemorrhages followed, at intervals
of from three to six months, up to the time I saw her. During the last
two years the expectoration had been thick, firm, and yellowish-green
in color.

Some time in the spring of 1887 (the patient thought in February
or March) her tongue began to feel sore and stiff, with occasional severe
pains, but mostly a dull aching.

About June there appeared, near the tip of the tongue on the right
side, a small ulceration, which grew rapidly until, in August when I saw
her, it had extended along the right side of the tongue, involving the
lower portion of the tonsil and back wal] of the pharynx on the cor-
responding side. The tongue was thickened, and the act of deglutition
was accompanied by excruciating pain. The voice was thick and muffled,
and it was only by an effort that any words could be articulated.

The ulceration was irregular in shape, with for the most part clean-cut
edges. The floor of the ulceration was bathed in pus.

Examination of the larynx showed only a superficial inflammation.

Examination of the lungs showed extensive destruction of the right
lung and consolidation of the upper lobe of the left lung. Temperature,
100°; pulse, 110; respirations, 28.

The following line of treatment was advised to the consulting physi-
cian:

Internally, cod-liver oil.

Locally, applications of oleate of cocaine (5 per cent.) made to the
entire ulceration, and afterward lactic acid to be carefully applied.

This patient lived two months, but at no time was there apy im-
provement in the appearance of the ulceration or relief from the
pain.

Discussion on Paper of Dr. Bean. 115

Tuberculosis of the tongue is to be especially distinguished from
carcinoma and syphilis. When it is secondary it is not a difficult
question ; but the development of it primarily has been so frequently
demonstrated, although it is in a large proportion of cases secondary,
as to render its existence no longer a question.

It is distinguished from carcinoma by the absence of the glandular
enlargement and the sharp lancinating pains characteristic of the lat-
ter disease.

From syphilis, outside of a positive specific history, the internal
administration of antisyphilitic remedies alone can settle the diag-
nosis.

Treatment.—In neither of the two cases reported was there any
opportunity for personal attention to treatment; indeed, both cases
were so far advanced that no amount of treatment could have been
of any permanent benefit.

The three plans of treatment most advocated are curetting, with
subsequent applications of the cautery, excision of the tongue, and
lactic acid.

In a paper on this subject read before this association in 1886,
Dr, Delavan reports a case cured by excision.

Lactic acid has been very much vaunted, and one or two cases are
reported as having been cured by means of this remedy, well rubbed
into the ulceration; but the numerous failures to even afford tempo-
rary relief seem to demonstrate the fact that it is no more to be de-
pended upon when the disease is situated in the tongue than when
it has been developed in the larynx; and the result of treatment in
that location has been disappointing.

Thorough and deep curetting, with careful and repeated applica-
tions of the Paquelin or galvano-cautery, offers the most efficient
plan of treatment yet suggested for the primary manifestation.

When it is secondary to lung complications we are as powerless
to arrest its progress as we have ever been.

Discussion.

Dr. D. Bryson Detavan, of New York: As Dr. Bean referred to a
case which I reported, it may interest the fellows to know that the patient
is still living. I heard from him three months ago, and there has been
no recurrence of the tubercular disease. I reported my experience in the
paper referred to. In regard to lactic acid I can only substantiate the
statements made by Dr. Knight—that it does have a marked influence in
certain of the milder ulcerations, which are neither deep nor extensive.

116 Transactions of the American Laryngological Association.

It heals them for atime. In the more severe ulcers, while it improves,
cleanses, and enlivens them for a time, it is not curative. In a case
recently seen there was what appeared to be a large tubercular ulcer at
the tip of the tongue of the size of a ten-cent piece. The unusual feature
of this case was that pain was entirely absent. Syphilis was carefully
looked for, but there was no evidence of its presence, while there was
extensive pulmonary disease. Microscopic examination proved that the
ulcer was not tuberculous, but epitheliomatous, thus illustrating the dif-
ficulty of making a positive diagnosis in ulcerative lesions of the tongue.

Dr. CO. E. Bean: There is nothing more to be said. The subject has
been thoroughly gone into in the previous discussion, The treatment,
aside from the use of the curette, is in no wise different from the treat-
ment of tuberculosis of the larynx.

Paper.

NOTE ON THE OCCASIONAL TOPICAL USE OF SOLUTIONS OF SILVER
NITRATE IN THE TREATMENT OF CHRONIC LARYNGITIS.

By SOLOMON SOLIS-COHEN, M. D.

f Fra are many subjects of greater scientific interest than the
treatment of chronic laryngitis, yet very few of more practical
importance to a large number of our patients.

The general questions of therapeutics, systemic and topical, of
this affection have been so ably and thoroughly discussed in text-
books and special articles by so many distinguished members of this
body, that further elaboration now would be superfluous; and [
simply desire to briefly communicate the results of personal experi-
ence during the last three or four years with a single agent, for the
purpose of eliciting an expression of opinion from the competent
observers present as to the real value of that agent—once over-used,
now over-neglected. 7

There is no necessity to report cases in detail. They have not
been due to nasal disease or obstruction, nor have they been those
in which all topical treatment is unnecessary. Where indigestion,
constitutional disease, or diathesis have been present, these have, of
course, received due attention—hygienic, dietetic, and medicinal.
It is thus simply of topical applications for the relief of local condi-
tions that I speak. We have all encountered cases of chronic
laryngitis, especially in singers, clergymen, lawyers, traveling sales-
men, public speakers, etc., in which, after all discoverable sources of

Local Treatment of Diphtheria. 117

irritation, local or general, have been removed, and approved topical
treatment suited to the individual case has been faithfully employed
for a longer or shorter time, improvement would take place up to a
certain point and there stop. Perhaps all visible evidence of disease,
except an irregular pinkish striping of the vocal bands, would have
disappeared; or perhaps there would be a uniform faint coloration,
or may be only a loss of luster; but something there would be that
persisted and that prevented the patient from resuming with comfort
full use of the voice in singing or speaking, or perhaps even in ordi-
nary conversation for social or business purposes.

It is in such conditions as this, the last obstinate remnants of the
disease, that I have derived considerable satisfaction from the topical
use by sponge, cotton-wad, or brush of weak solutions of silver ni-
trate, about ten grains to the ounce, applications being made every
day for two or three days until some congestive reaction was pro-
duced ; after that at longer intervals. In the course of treatment,
too, in some cases, before reaching the last stage above described, I
have found recovery apparently hastened by occasionally substituting
stronger solutions of silver nitrate, forty to sixty grains to the ounce,
for the iodized glycerin, tannin, tar, or other routine application. A
visible increase in congestion immediately follows the use of the sil-
ver solution ; but this passes off quickly, and at the next visit great
improvement is usually manifested. These applications are made
once in about two or three weeks, according to circumstances. By
thus using solutions of silver nitrate, not as a routine measure, but
occasionally in the course of other treatment, as a topical stimulant
—the strength of the solution being in inverse ratio to the progress
of the case toward recovery—I believe that in very many of the
cases in which topical treatment is indicated recovery may be hast-
ened ; and in particular that the troublesome final stage may be man-
aged with greater ease than by the use of any other agent with which
I am acquainted,

Paper.
LOCAL TREATMENT OF DIPHTHERIA.

By J. O. MULHALL, M.D.

HERE is hardly a familiar disease concerning which the evi-
dence of witnesses is more conflicting than in diphtheria, no
matter from what standpoint it may be viewed.

118 Transactions of the American Laryngological Association.

Statistics based on mistakes in diagnosis, on the varying nature
of epidemics, on faulty reports as to anatomical regions invaded, and
on our general ignorance as to its method of diffusion, its etiology
and pathology, no doubt account for this confusion.

A vast number of agents have been employed in the local treat-
ment of the disease with the usual conflicting testimony as to value.

It is, however, chiefly concerning the method used in their appli-
cation that I desire to draw attention to a plan which for four years
has yielded me gratifying results. When I originated this plan I
took for granted several propositions commonly accepted by ob-
servers :

First, that the disease is a germ disease.

Second, that in the vast majority of cases the specific microbe
selected the tonsils as their initial culture soil.

Third, that, unless checked by germicides, their colonization usu-
ally resulted in local putrefactive changes with general secondary
septicemia,

Fourth, that implication of the laryngeal or nasal chambers
largely increased the mortality.

Fifth, that the disease is acutely adynamic.

It occurred to me, therefore, that, as was already largely prac-
ticed, the local treatment should be chiefly antiseptic, and that, as
the disease spread rapidly and the salutary effect of antiseptic solu-
tions in the upper air-passages, from anatomical reasons, could be of
but short duration, this antisepsis should be, if possible, continuous.
It will be readily admitted that it is of the utmost importance to
maintain the patient’s strength, and that, therefore, an element in
ideal local treatment is, other things being equal, the employment
of agent and method which least harass the child and which permit
the recumbent attitude throughout. It suggested itself that a method
which washed out from the throat the perverted secretions was prefer-
able to that which invited a subject too young to expectorate to swal-
low them, and which permitted the larynx to be bathed in them, as
must occur in the use of a spray. The instrument with which these
requirements can best be met is one which is found in nearly every
domicile—namely, the common household syringe. It is a fact not
generally known that if the end of such an instrument is introduced
into the pharynx or into the back part of the mouth of a young child,
the throat can be boldly flushed out without causing gagging, vomit-
ing, coughing, or strangulation. Reflexly, the tongue immediately
retracts and pushes the epiglottis down, making a water-tight glottis,

Local Treatment of Diphtheria. 119

and the child involuntarily ceases to breathe while the pharyngeal
irrigation goes on. The first treatment, like any other first local
treatment, in a young child is met with repulses, but even very
young children soon learn to appreciate the agreeable effect of clear-
ing the throat of foul and adhesive secretions, and soon quietly sub-
mit. With badly trained children, some of whom even repulse the
nurse when she smears the nostrils and lips with a soothing oint-
ment, I commonly use the rectal tip, or, better, a pewter tip which
can be curved so as to be insinuated behind the last molars; but
ordinarily I use no tip, simply the rubber hose, which is soft and has
the further advantage of providing a larger stream. The physician
himself carries out the first treatment as a demonstration to the nurse.

The child lies in a crib, one side of which is open; a rubber
cloth conducts fluids into a vessel. The child’s head is brought to
the edge, the face turned toward the vessel, and the flushing is
rapidly accomplished. The exertion, even of sitting up, is usually
avoided. I direct the washing to be done every hour in the waking
state, and to never permit the child to sleep three hours without it.
I have used various antiseptics. I prefer a mixture of carbolic acid
and compound solution of iodine properly diluted with warm water,
which frequently, in addition, is saturated with boric acid. An ordi-
nary water tumbler of fluid is consumed at each irrigation,

This plan is so far imperfect, since it does not provide for dis-
infection of the post-nasal region, and there are few cases of diph-
theria which do not more or less implicate this region, rich in lym-
phatics and probably, next to the tonsils, most frequently the line of
poison march to the system at large.

I have been amazed in consulting practice to observe the fre-
quency with which the nose had been neglected until serious nasal
signs—such as hemorrhage, fcetor, or total obstruction—had com-
pelled some kind of attention, very often too late, for this triad of
symptoms is most commonly the harbinger of death.

If we consider that the general practitioner is usually unacquainted
with rhinoscopy, that even the expert has often failed in illuminating
and seeing the nasal cavities of a young child, that the nose which
the evening before seemed uninvaded is found in the morning to be
seriously affected, it can hardly be gainsaid that prophylactic treat-
ment of the nasal cavities in pharyngeal diphtheria is a wise thera-
peutic measure. Antisepsis of the nasal cavities can do no harm,
while it may prevent or render mild invasion from the throat. More-
over, since for many reasons we can not in these cases treat the

120 Transactions of the American Laryngological Association.

pharyngeal vault from the mouth, the anterior nasal cavities form
ready avenues of approach for the disinfection of this region, and
this is an integral part of my plan of continuous antisepsis. Let me
repeat that, apart from this being a channel for the antiseptic treat-
ment of the throat, I desire to strongly recommend to the profession
that in every case of diphtheria, whether the nose be affected or
not, the nasal cavities be kept sterile from the first. The method
of accomplishing this varies. When it is clear that neither the post-
nasal nor nasal chambers are attacked, the frequent insufflation of a
non-irritating antiseptic powder may be sufficient. When uncer-
tainty exists, or it is apparent that invasion has taken place, the
nurse is instructed to wash out the nasal cavities with the same anti-
septic solution as that employed in the throat, except that it should
be far weaker, so as to irritate the nose as little as possible, and
should seldom exceed in amount more than two teaspoonfuls for
each nostril. The child, if possible, clears the nose and the anti-
septic powder is at once forcibly insufflated. This, as the child lies
on its back, gradually trickles into the pharynx and assists in the
plan of continuous antisepsis. I commonly use finely powdered
sulphur, or iodoform, or salicylic acid highly diluted with a trifle of
cocaine, to prevent irritation.

This cleansing of the nose should not be done with the household
syringe, for it throws a stream too small in diameter, and one far
too forcible in careless or unskillful hands; nor does it permit of
the regulation of the amount of fluid to be injected. The point of
the ordinary glass syringe introduced into the nostrils of an impa-
tient child is apt to produce an undesirable wound of the septum.
Moreover, the caliber of the nozzle is far too small, permitting a
slender, swift, painful, and inefficient stream.

The syringe which I show you is made for me by Mr. J. M. Good,
a druggist of St. Louis, and fulfills, I believe, the ideal requirements
of a syringe for anterior nasal medication in young children. Its
capacity is about two drachms. It terminates in a bulbous enlarge-
ment which prevents a forcible stream, forms a shoulder to rest
against the margins of the nostrils, and, since it terminates abruptly
in the nozzle, can not enter the nose and abrade the mucous mem-
brane. The diameter of the outlet is one fourth of an inch, thus
permitting a large yet gentle stream. Before I invented this syringe
I was in the habit of filing through a small glass syringe at its neck,
where the diameter was large, thus avoiding the objections of the tip.
The nozzle thus altered should be held in an alcohol flame to smooth

Local Treatment of Diphtheria, 121

away irregularities. The frequency with which the nasal cavities
should be irrigated is a matter of individual judgment. Gently and
quickly done with agents that are not painful, children readily sub-
mit to it—an important matter, for, whatever the plan of local treat-
ment be on the adynamie diseases of childhood, that plan is best
which, other things being equal, meets with least resistance. The
rapid dissolution of the membrane is undoubtedly an element of
successful local treatment, and I frequently make use of solvent reme-
dies immediately succeeding the cleansing of the diseased surface.
I have best succeeded with papoid.

There is but one method of local medicinal treatment which can
be efficiently pursued in the laryngeal diphtheria of children—that
by vapors. At appropriate stages, the inhalation of the fumes of
slaking lime deserves always to be remembered.

I beg leave to call your attention to a modification of the plan
of Delthil, which I have hitherto employed in seven cases, with a
final result of four recoveries and three deaths.

A small apartment in the house is selected, the carpet and other
belongings removed; the room is thoroughly fumigated with sul-
phur, and a sheet saturated with a disinfectant spread across the
doorway.

A gas-stove is introduced which will support two vessels. Into
each is poured a half-gallon of water. Into each of these a half-pint
of pine tar is stirred, and a tablespoonful of oil of turpentine. As
steam is generated, water is occasionally added, so that the half-
gallon mark is maintained. The amount of tar will be sufficient for
the entire treatment, but to each vessel there is added every hour a
tablespoonful of the oil of turpentine. I have not as yet observed
strangury or the characteristic odor of the drug in the urine.

The air from outside should be admitted several times daily.
The heat from the gas precludes this method in warm weather.

In three of my cases, with one death and two recoveries, I have
been able to demonstrate membrane with the laryngoscope. The
four children safely passed the laryngeal crisis with but little cough
and no glottic spasm. Ina boy aged four, seen with Dr. Holland
and Dr. Frazer, of St. Louis, who died on the seventeenth day from
exhaustion, not the slightest dyspnaea was at any time observable,
though total aphonia existed, and I was able to demonstrate to these
gentlemen the presence of membrane in the larynx. The steam is
generated day and night, and in one of my cases was continually
done for six days.

122 Transactions of the American Laryngological Association.

In diseases in other parts of the body whose natural termination
is in putrescence the surgeon, in anticipation of this event or on its
actual arrival, thinks first of antiseptic measures. It is therefore
probable that analogous measures are the best that can be employed
in diphtheria. I have endeavored to describe a reasonable method
of their execution.

Discussion.

Dr. Wri1am O. Grascow, of St. Louis: I am one of those who be-
lieve that diphtheria is a blood disease rather than a local affection, and
the only objects of local treatment that I see are cleanliness, disinfection,
and the loosening of the membrane. There is one remedy which I have
found valuable in loosening the membrane. It is the peroxide of hydrogen
used as aspray. Last winter I was called in consultation to see a young
girl where the membrane had invaded the larynx. The symptoms were
so urgent that I advised the gentleman in charge to stay all night, and
stated that I thought tracheotomy would be needed. As a preliminary,
I recommended the use of the peroxide of. hydrogen by the atomizer.
After a few applications a large piece of membrane was thrown out.
The next day the larynx was much clearer, although there were still por-
tions left. That was the only local treatment employed in this case.
Every hour a gush of the peroxide was thrown into the larynx. It
produced a veil of foam, as it always does, and it seemed to lift up the
membrane by the formation of gas. This patient entirely recovered. I
look upon the local treatment simply as an adjuvant. I think that the
constitutional treatment is the main thing. The constitutional treatment
that I have found most successful is that by bichloride of mercury and
benzoate of sodium. This is combined with very simple local treatment.
There are cases of diphtheria where more local treatment is necessary.
In these cases the method which Dr. Mulhall has described would be of
value.

Dr. D. Bryson Detavan, of New York: I think that not only the
general practitioner but also a great many specialists can not receive too
much warning as to the importance of the early detection of the extension
of diphtheria to the nasal passages. I have seen case after case in the
hands of well-known specialists where any chance that the patient may
have had was lost by the neglect of reasonable precautions.

During the past ten years I have used the bichloride and the cyanide
of mercury in the treatment of diphtheria, with increasing confidence in
the value of these drugs. Asis now well established, the biehloride of
mercury is the most active destroyer of the streptococcus known.

Dr. W. H. Daty, of Pittsburgh: I do not know that I should transgress
the bounds of this discussion if I were to allude to the treatment that I
brought to the notice of this association in Philadelphia in 1887.* I think

* “The Simplest and Most Efficient Treatment of Diphtheria,” ‘‘ Transactions
of the Amer. Laryng. Assoc.,” 1887, read at the Philadelphia meeting.

Discussion on Paper of Dr. Mulhall. 123

that it is probably as active and efficient as a local remedy as it is active
and efficient as a constitutional remedy. Of its constitutional action I
shall not speak. I refer to large and oft-repeated doses of calomel, un-
triturated, unmixed with sugar. I have in my possession large numbers
of personal letters, from general practitioners from distant and near parts
of this country and abroad, thanking me for having given to the pro-
fession my experience in the use of calomel in the treatment of diph-
theria, and I take the liberty of again bringing it to your notice in con-
nection with this paper more especially with reference to its local effect.
I believe that a large part of the valuable therapeutic effect of calomel
administered as I recommend it—that is, two, three, four, or five grains
every two hours to a child one and a half or two years old—is due to the
local action of the drug upon the diphtheria poison in the fauces. I feel
sure that the gentlemen who try that treatment will not be disappointed.
I presume that it is your experience, as it is my own, that many cases of
diphtheria that come under our observation are in an advanced stage and
are in the hands of the general practitioner, and we do not have that fall
control of the case that we should if it were in our own hands; but if
you will investigate this treatment and try it, I promise you that you will
not be disappointed. The treatment is very simple and easy—simply
floating the calomel on a teaspoonful of ice-water and opening the child’s
mouth and putting it in. If it is swallowed, well and good; if a portion
remains in the mouth and fauces, well and good. I hope that you will
pardon me for again bringing this to your notice. This is a valuable and
tried therapeutic measure and not a new one.

Dr. Harrison Atten, of Philadelphia: I have found trypsin useful in
removing the membrane. It is purely a local agent. I apply it directly
to the membrane, and it is best used where you can see the membrane,
but I have not hesitated to carry it by curved probes to the lower part
of the pharynx and to the larynx. It is of a pasty nature when mixed
with mucus and readily adheres. A piece of absorbent cotton is put on
an ordinary holder, slightly moistened, and dipped in the trypsin, lying
on a watch glass. A large portion adheres, and this is then carried to
the affected surface. The ordinary act of deglutition will not dislodge it.

A lady, the wife of a physician, was under my care last winter. She
appeared to have had an ordinary tonsillitis. I plunged a lancet into the
mass but found no pus. At my next visit I found the whole tonsil covered
with diphtheritic membrane. The lady was extremely ill. In this case I
had the happiest effect from trypsin, and I believe that it saved her life.
The membrane did not extend beyond the point first affected.

Dr. 8. Jounston, of Baltimore: In the discussion on Dr. Daly’s paper
I called attention to trypsin and stated how valuable it had been in the
cases in which I had used it. I then predicted that it would be used
universally as a local measure in this disease. Since then, in several in-
stances, I have found it a most useful solvent of diphtheritic membrane.
I am glad to hear Dr. Allen’s remarks.

124 Transactions of the American Laryngological Association.

Dr. J. C. Mutuatt: I am sorry that the main object of my paper has
been overlooked, and that was the method of carrying out the application,
not of using any particular remedy. I may therefore presume that my
method is peculiar to myself.

I purposely omitted to touch upon the constitutional treatment of the
disease. I surmise that the effect obtained by Dr. Daly from calomel is
a constitutional effect. Looking into the throat when the membrane is
beginning to separate, we find a good deal of catarrhal secretion, and I
do not see how the application of any powder can affect the tissues
underneath without first the complete removal of the secretions.

Peroxide of hydrogen is certainly a valuable local agent. I have used
it as well as trypsin and other solvents extensively, but I think that I get
more rapid solvent effects from papoid.

I am sorry that more was not said about getting rid of the poison in
the throat. This was the prime object of the paper.

Paper.

SOME MANIFESTATIONS OF LITH#MIA IN THE UPPER AIR-
PASSAGES.

By F. WHITEHILL HINKEL, A.M., M.D.

HE influence of litheemia and allied conditions upon the mucous
membrane of the upper air-passages appears in a general way
to be recognized by the profession, but an examination of the
“Index Catalogue of the Surgeon-General’s Library” fails to show
any indication of this recognition by title or reference. Harrison
Allen,* in the past year, has reported five cases of gouty sore throat,
with a description of the general characteristics of such cases. His
brief résumé of the literature extant upon the subject shows that it
has received slight consideration in laryngology. That the existence
of an influence so obvious in its effects upon the upper air-passages
in a limited class of cases should have escaped more general descrip-
tion in laryngological text-books and in current literature is appar-
ently due to the great advance made in recent years in improved
methods of topical application and to the increased interest in nasal
surgical pathology and appreciation of its influence upon laryngeal
disease, which have led to a perhaps too strictly local and surgical
view of some diseased conditions of this region.
In addition to the sore throat found in distinctly gouty subjects
described by Allen,+ there is a less well defined form of inflamma-

* “ Medical News,” June 16, 1888. + Loe. cit.

Lithemia in the Upper Air-passages. 125

tion—of which his second case appears to be an example—that
presents certain appearances and symptoms which, while not at all
pathognomonic, yet, taken with the history and general symptoms,
and, above all, with the results of therapeusis, are clearly indicative
of their dependence upon a lithemic or allied condition. These local
manifestations of lithemia are of necessity not clearly definable, for
the general condition upon which they supervene is one of whose
underlying pathological conditions we know but little. The term
lithemia, tentative in character, is based solely on clinical manifesta-
tions, and is applied with considerable latitude of meaning. Some
even speak of an acute so-called “bilious attack” as an attack of
lithemia. The term is here used to express the now well-recog-
nized conditions to which Murchison* applied the name, not to
conditions brought about in an individual with fairly normal digestive
and assimilative functions by temporary excess, or even by constant
irregularities of diet of a gross character, but to that condition of
suboxidation and overcharging of the blood and excretions with
excretory matter in a state of faulty elaboration due to inherent and
hereditary abnormity of function, or to prolonged exposure to de-
pressing environment.

As S. Solis-Cohen well says, in a recent article on the “ Thera-
peutics of the Gouty Diathesis:+ “It is not a disease—not a sudden
or gradual departure from the usually normal action of the organism
—that we are dealing with, but it is, if I may be permitted the ex-
pression, an abnormal normality—that is to say, an inherent departure
of the individual organism from the typical action of like organisms.”

Individuals of this diathesis are prone to digestive disturbance
from the most ordinary articles of diet, particularly the starches and
sugars and acid fruits. Simple and regular habits of diet are not
sufficient to prevent recurring exacerbations of the characteristic
symptoms, if unusual mental or nervous strain is undergone in a
sedentary pursuit. There is a tendency to form uric acid in excess,
from which the condition is named, and to a waste of phosphates
—conditions most easily detected in the urine—along with digestive,
mental, and nervous phenomena of depression familiar to all. While
this condition is found in those of gouty antecedents or of distinctly
gouty tendencies, so that the term lithemia or the gouty diathesis
may be used interchangeably to describe it in some cases, yet its sub-
jects may never have true gout, or even distinct irregular manifesta-

* “ Clinical Lectures on Diseases of the Liver.’
+ ‘“‘ Medical News,” May 18, 1889.

126 Transactions of the American Laryngological Association.

tions of it. Indeed, under the environment of most Americans, the
development of local attacks of gout is rare, while the nervous and
digestive arrangements under consideration are not unusual. From
this it appears that a distinction must be drawn, as pointed out by
Allen,* between cases of gouty sore throat—where the throat lesions
accompany or follow distinctly local manifestations of gout in other
parts of the body—and cases where, with no distinct personal or
family history of gout, there are throat symptoms referable to a gen-
eral lithzemic or allied condition, and relieved by treatment directed
against such condition.

I have qualified the definition of these cases as lithemic because
the term is of necessity somewhat vague and elastic in its application
to conditions that vary from typical and unmistakable clinical mani-
festations to almost normal health. It includes many cases of “ mus-
cular rheumatism ” so called, and the tendency to affections of fibrous
structures seen in sufferers from torticollis, lumbago, etc., is more
allied to lithiasis than to the acute affection from which it borrows
its name. The same may be said of certain forms of chronic rheu-
matic sore throat described by Ingals.t Some of his cases appear to
me as expressions of a lithic rather than a true rheumatic state.

The manifestations of lithemia in the upper air-passages do not
fall uniformly under any one type, nor are they sharply distinguished
as being of lithemic origin by the local conditions they present, but
there are certain appearances or symptoms that are more or less con-
stantly connected with lithiasis, and at least suggest the presence of
that element and the need of general therapeusis on that line, what-
ever local measures may be indicated.

An appearance occasionally seen in cases of irritable throat asso-
ciated with lithemia is a patchy congestion of the laryngeal face of
the epiglottis extending along the aryepiglottic folds and over the
posterior aspect of the ventricular bands. This is associated with a
harsh, dry, explosive cough, and sense of extreme irritation about the
larynx. My friend, Dr. Roswell Park, has informed me that he has
seen with the cystoscope the same patchy congestion of the mucous
membrane of the bladder in a case of inflammation of that organ in
a markedly litheemic subject. A case illustrating this form of laryn-
gitis, associated with litheemia, is the following: Male, aged about
thirty-eight years, of sedentary habits. Is subject to attacks of con-
stant irritable and explosive cough, with some impairment of strength
of voice. The attack at time of first consultation had lasted about

* Toc. cit. + “ Am. Jour. of the Med. Sci.,” January, 1888.

Lithemia in the Upper Air-passages. 127

one week, Laryngoscopic examination showed irregular patches of
deep congestion on the margins of the epiglottis and on its laryngeal
surface. The upper larynx generally showed more congestion than
in the plane of the glottis. Warm aromatic inhalations and subse-
quently mild astringent sprays failed to give material relief. A solu-
tion of sulphate of zine or of nitrate of silver, of a strength usually
non-irritant, caused much discomfort and aggravated the symptoms.
A urinary examination showed high acidity, with uric acid and ox-
alate of lime in excess. He informed me that he was accustomed to
take alkalies at intervals, by medical advice. The administration of
alkalies and antifermentatives, with regulation of the diet and the
inhalation of dilute lime-water, gave prompt relief. The extreme
sensitiveness of the mucous membrane to astringent or stimulant
applications here noted is common to these cases, as mentioned by
Allen concerning gouty sore throat. I regard it as a point of diag-
nostic significance, suggesting a careful examination as to the pres-
ence of a lithic diathesis.

A similar form of patchy inflammation of the pharynx is seen in
some cases, the congestion extending in streaks usually along the
postero-lateral walls. It is accompanied by an ill-defined sensation
of “sore throat,” with perhaps some laryngeal irritation. A sense
of uneasiness or even positive pain on swallowing is at times referred
to one or other side of the larynx externally, often opposite the supe-
rior cornu of the thyreoid, as noted by Ingals.* This referred sen-
sation occurs more often, in my experience, from inflammation of the
pharynx or peritonsillar region than from inflammation of the laryn-
geal mucous membrane. A case in point is the following :

Mrs. G., aged about thirty-five years, subject to sore throats, referred
especially to the sides of the throat, with occasional darting pains into
one or other ear. There is some dry and painful cough; no marked pha-
ryngeal secretion. The lateral walls of the pharynx present deep con-
gestion extending above the free margin of the soft palate and below the
plane of the superior margin of the epiglottis. The median posterior wall
of the pharynx is but slightly congested. Her attacks are preceded and
accompanied by muscular lameness, especially in the muscles of the neck
and upper back. Gentle pressure upon the regions of lateral congestion
causes them to swell slightly and produces pain darting into the ear and
lower pharynx. There is a history of an attack of acute rheumatism in
one member of her family. The urine is scanty and high-colored. She
is subject to headache, indisposed to exercise, feels often heavy and dull,
and lives upon rich diet. Stimulating applications cause distress and

* Loe. cit.

128 Transactions of the American Laryngological Association.

aggravate the symptoms. She has improved much by regulation of diet,
exercise, and the administration of alkalies and antifermentatives. She
has frequent relapses owing to her unwillingness to regulate her habits as
directed. These exacerbations are improved by general antilithic medi-
cation more than by any local treatment applied.

I have noted a few cases in individuals of lithemic tendencies in
which their lithic storms were accompanied by a marked naso-
pharyngeal catarrh, not present in any appreciable degree during
the intervals. This symptom is noticed for several days before the
digestive and other derangements make themselves manifest. In.
one case it is so marked that the appearance of the pharyngeal catarrh
is regarded as a signal for appropriate general medication and hy-
giene, with the effect of checking both the catarrh and the general
attack. In these cases the use of the various solutions of iodine is
extremely irritant, and all stimulant applications are ill received.

I have observed a condition of obstinate relaxation of the venous
plexus of the turbinated bodies in some individuals coincident with
general indisposition of a lithemic character and apparently depend-
ent upon it. Caustic applications are badly borne and fail to accom-
plish their desired effect on account of too great inflammatory reac-
tion. The use of soothing local applications and diluents and alkalies
internally, with general hygiene, gives improvement in some cases.
In others, the time of year marked by damp, cold winds, invariably
finds them from time to time attacked by symptoms of inflammation
and occlusion of the nasal chambers, not necessarily severe, but suf-
ficient to annoy. This resistance to appropriate local measures I
have been led to attribute in some cases to intractable lithemic tend-
encies.

In conclusion, I desire to repeat what has been stated above—
that the manifestations of litheemia here described are not regarded
as typical; but they have so often been found associated with more
or less pronounced lithemie or allied conditions, and so responsive
to therapeusis adapted to this state, that their presence should at
least lead to a careful examination of the personal and family his-
tory and general condition to discover what influence lithiasis may
have in the case under consideration.

Discussion.

Dr. Wir11aM O. Graseow, of St. Louis: I have listened with pleasure
to this paper, and I think that such papers are what we particularly need
in directing attention to the constitutional origin of local troubles. There

Discussion on Paper of Dr. Hinkel, 129

is no doubt that a great deal of local trouble is due to constitutional
changes. I have seen the cases referred to, but I have not looked upon
them as lithemic. I have not been able fully to explain them. I have
understood them so far as not to use local treatment. The success that
has attended remedies directed to the constitutional condition and to the
stomach and digestive organs has been sufficient. These cases I have
called gastric, from the occasional eructations of gas and fullness after
meals; but in some of them there have been slight evidences of dyspep-
sia. An abnormal fermentation may be the provoking cause. In all of
them I have found the use of bichloride of mercury in minute doses with
bismuth and bicarbonate of sodium efficient. An old lady, who had snuf-
fered for two weeks with a trouble of this kind, recovered in a few days
under this simple treatment. I have seen many such cases. Perhaps
they are lithemic, but I have looked upon them as due to a disorder of
the stomach or viscera. The paper is valuable in drawing attention to
the possible constitutional nature of these local disorders.

Dr. Harrison ALen, of Philadelphia: This is certainly a most ex-
cellent paper. There is need of defining this notion of lithemia more
accurately. In the paper referred to as written by myself, I attempted
to separate the signs by which lithemic sore throat could be separated
from the gouty. There is one phase of the subject which has not been
alluded to; that is, that in adolescents you get a type of throat which is
very puzzling. Young, vigorous people, especially young men, will have
a litheemic sore throat which is very puzzling. These cases resist local
treatment. Reverting to the discussion of yesterday on Dr. Roe’s paper,
suppose such a condition existed and you used the bistoury or cautery,
you would at once excite a traumatic pharyngitis. The throat is of the
color of a boiled lobster. I find this condition generally in those living in
luxurious homes; I believe that they are over-fed and under-exercised.
In Philadelphia we have a great deal of luxury, and there is a large class
that eat too much. This is a matter of common comment among school-
teachers. The testimony of teachers is that many of these young persons
do not get along in their studies as well as they should on account of —
foolish luxury in their homes. If this is the case, we can understand that
in its crude form this added material is useless if not injurious. It seems
to me that the use of too much sugar, starch, and rich wine would pro-
duce the condition of which Dr. Hinkel speaks. We, however, can not
prove this position, for it is impossible to control the habits of these
patients.

Dr. D. Bryson Detavan, of New York: These cases are commonly
met with among the over-indulged children of wealthy and injudicious
parents. The average child will not select the most wholesome varieties
of food if allowed to choose for himself, so that sweets must be inter-
dicted. Unless we can control the diet, the management of these patients
is difficult. It is valuable to have attention called to it, so that a senti-

a

130 Transactions of the American Laryngological Association.

ment may be excited against this over-indulgence which we find among
the richer classes. Among people of nore moderate means such troubles
are not socommon. Until these cases can be put upon a proper regimen,
which it is easy to suggest but difficult to carry out, I do not think that
medicine or local treatment will be of much avail.

Dr. F. I. Kytent, of Boston: This class of cases is familiar to most
of us now. -It is only recently that the peculiar irritability under the
topical measures struck me very forcibly. Within the past year I have
noted it particularly in a number of cases. The gentlemen may remem-
ber that a number of years ago there appeared an article in the “ Popular
Science Monthly ” by, I think, a layman, in which catarrh was attrib-
uted to the disproportion between the amount of food ingested and the
amount of exercise taken. Although the views were exaggerated, there
was a good deal of truth in the article. I can say that where I have been
able to make patients carry out the proper treatment I have usually been
rewarded by very good results. The treatment has consisted in cutting
down the diet at once, the cutting off of the excess of sugars and starch,
the almost complete elimination of pastry and potatoes, and, in addition,
the free use of alkaline drinks. In cases where the urine has shown a
good deal of oxalate of lime, particularly where there is irritative cough,
I have several times seen extraordinary results from the administration of
hydrochloric acid. I have in several cases seen a cough which had per-
sisted for several months cease in a few days under this treatment. The
exercise is a part of the treatment which it is hard to induce the patient
to carry out; unless you lay down some definite means, unless you insist
upon a man buying a horse or a young man going to the gymnasium, it
will not be done. In most large cities there are men who will take charge
of such discipline. We have now a Swedish gentleman of good education
who is doing a great service for some of our patients in this way.

Dr. W. H. Daty, of Pittsburgh: This question has been brought to
our notice before by Dr. Allen and, I believe, by Dr. Ingalls, and to-day,
in a very instructive manner, by Dr. Hinkel. It makes one rather proud
of being a laryngologist to see these practical and substantial lines of
thought branching out in various directions. It certainly promises well
for the future of medicine, and especially for laryngology. I confess that
my attention was first called to it by Dr. Allen’s paper, and I have since
read his paper once or twice, and I must further confess that I am very
much at sea as to any definite belief as to the pathology of these cases,
whether they are primarily a digestive disorder, or a liver disorder, or
whatever else it may be.

In this connection I wish to say a word with reference to Murchison,
and there never lived a higher authority on questions connected with dis-
ease of the liver and some forms of lithemia and gout; but a man who
wrote so much and taught so much could not avoid making some errors.
Of these I do not intend to speak. It is not safe to follow Murchison
through all the mazes of his theories. I say this with all due respect, for

Hemorrhage from the Larync. 131

I enjoyed a personal acquaintance with Murchison during his life, and feel
proud to have known him.

As we are, in a practical way, more interested in dealing with these
patients in a curative way than any other, it may be well for me to refer
to a simple method which I have resorted to with probably more satisfac-
tion than any other. In my experience with salicylate of sodium I have
never been able to get patients outside of hospitals to take it longer than
twenty-four hours at a time within the past year in such cases as have
been referred to by Dr. Allen and Dr. Hinkel. I have ordered equal
parts of salicylic acid and bicarbonate of sodium to be mixed, and of this
the patient takes from a half to a whole teaspoonful, in a small, strong
lemonade, half an hour before each meal. Patients will take the drug in
that way longer than in any other. I do not continue it more than four
or five days at the furthest. Good results are obtained in a fair propor-
tion of cases very quickly.

Dr. F. W. Hryxet: I am glad to receive the corroboration of the gen-
tlemen present. I knew that they had all seen this condition in some
form. I wanted particularly to point out the fact that there are some
cases in which the digestive disturbance is not due to great excesses on the
part of the patient, and also that there are a few symptoms—such as a
patchy appearance of the mucous membrane—which I have seen asso-
ciated with the general condition frequently enough to think that it is a
local sign of some significance, and might lead one to suspect lithemic
complications where the appearance of the patient might not suggest it.
As Dr. Glasgow has said, there is frequently gastric derangement. Fre-
quently there is a chronic gastric catarrb, which must be relieved by the
physician before the laryngologist can hope to relieve the condition in the
upper air-passage. Whether this gastric condition is not due to the under-
lying constitutional condition is a question.

When we give bicarbonate of sodium and salicylate of sodium, we are
really making use of remedies which will check the fermentative action
which goes on in the intestinal tract, and prevent that acidity which I am
perfectly sure frequently stands in a causative relation to the nerve storms
which sweep over such individuals. In this way the local conditions are
relieved by removing the source of irritation from the intestinal tract.

Paper.
HAMORRHAGE FROM THE LARYNX.
By WILLIAM PORTER, M. D.

ANY objections have been urged against the use of the term

laryngitis hemorrhagica, and it is. probably well to begin

with a few definite statements which I believe are supported by
facts.

132 Transactions of the American Laryngological Association,

Hemorrhage from the larynx is seldom if ever unaccompanied by
other symptoms or evidence of laryngeal disease, though sometimes
these may have been previously unnoticed. It is rare, yet frequent
enough to have been accurately observed and described. In most
cases it is slight and, unless as a symptom of serious discase, is unim-
portant, yet in a few instances it has been profuse and alarming.
Granting its frequency and the fact that it is generally in itself of
little importance, it is still an interesting study, as an indication of
pathological conditions and also because it is often erroneously
credited to pulmonary lesions.

In examining the recent literature upon this subject, I can not
but feel that careful observation will give it a more important place
in the catalogue of symptoms of laryngeal disease. That it is not
so is doubtless due to the fact that it has generally been found to
be, when severe, but a symptom of some grave and definite morbid
process, as of malignant, tubercular, or syphilitic character, and,
when slight, to be of little importance.

Reasoning in the abstract, we might probably conclude that the
larynx would be a favorite site for such local lesions as would result
in hemorrhage. The parts have free vascular supply, as has the
pharynx or naso-pharynx, where hemorrhages are not infrequent.
The functions of the larynx require almost constant movement, and
this is favorable to rupture of blood-vessels already weakened by
disease. Such would be a reasonable hypothesis aside from recorded
facts.

Against this supposition is the almost unanimous verdict of the
members of the Section in Laryngology and Rhinology of the
British Medical Association of last year. The president, in sum-
ming up the discussion, pointed out that there was an evident opinion
among those present that hemorrhages from the previously healthy
larynx and pharynx were extremely rare—far rarer than was supposed
by the profession at Jarge—and that in any case of hemorrhage into
the upper air-passages of obscure origin it was probable that the
heemorrhage was due to pulmonary tuberculosis, even in the absence
of physical signs of that condition.

I would not thoughtlessly dispute the conclusions of such high
authority, and yet I must confess a doubt as to its entire accuracy.
There might of course be on the part of some a disposition to hide
behind technicalities. For instance, no one would oppose the state-
ment: hemorrhages from a previously healthy larynx are infrequent,
for without previous lesion, small though it be, there could not well

Hemorrhage from the Larynz. 133

be hemorrhage, which is a symptom of lesion. The thought in-
tended to be conveyed, however, is plain enough, and while I grant
that well-marked laryngeal hemorrhage is rare, yet, as I have already
intimated, I believe enough cases have been observed to make it
worthy of study.

It seems to have been the experience of many observers that
most of the cases of so-called laryngeal hemorrhage are of pul-
monary origin, or that pulmonary disease becomes evident sooner
or later. It is generally true that bleeding through the mouth
denotes pulmonary disease and is suggestive of grave conditions,
but it is in some cases of this kind that the laryngologist is able
to say that the hemorrhage is not from the lungs, that it is purely
local, and does not indicate a progressive course and fatal termina-
tion.

In twenty-two cases reported by six observers, most of whom
are members of this association, phthisis followed in but three.
The general tenor of replies to Gleitsmann’s circular letter of inter-
rogation upon this subject was ‘that hemorrhage from the larynx
ean be regarded as a precursor of phthisis in exceptional cases only.
The data furnished further tend to sustain the assertion made in this
paper that many, if not the majority, of cases are not published,
and that they are by no means so rare an occurrence as generally
supposed.” Regarding the first statement, I can say that three of
the four cases of which I have notes have given no evidence of pul-
monary disease, and am not sure but that in the fourth (No. 3 in the
series) the pulmonary involvement has been the result of the hemor-
rhage, as will be mentioned hereafter.

In this paper I will not attempt to present a full bibliography
upon the subject, as this has been given by Dr. Gleitsmann in the
“American Journal of the Medical Sciences” for April, 1885, with
an additional series of cases compiled by the same author in the
“‘ Medical Record” for October 29, 1887.

Permit me, however, before mentioning several cases in my own
practice, to recall a few well-marked ones which have been recorded
by others.

Ten years ago Dr. J. H. Hartman, at the first annual meeting of
this association, reported a case of laryngeal hemorrhage from the
rupture of a large capillary vessel upon the surface and about the
middle of the left ventricular band. The patient had been singing,
the hemorrhage came on suddenly, several. ounces of blood were ex-
pectorated, the next morning a recurrence, and two or three ounces

134 Transactions of the American Laryngological Association.

of blood were again lost. The application of a strong solution of
ferric alum was sufficient to stop the bleeding.

An interesting case was reported by Fraenkel in 1874 in which
the patient, a woman in the fourth month of pregnancy, had repeated
and severe hemorrhage continuing at intervals for four weeks. As
soon as the blood crusts which had formed on the laryngeal mucous
membrane were removed, parenchymatous bleeding from the cords
and posterior wall could be distinctly seen.

During the past ten years a score of writers have contributed the
history of cases to the literature on this subject, and of these I will
mention but one which seems to me to be in every way typical. In
the Section in Laryngology of the Ninth International Congress,
Dr. Stockton, of Chicago, presented the history of a young lady, an
opera singer, who suddenly lost her voice while practicing, ard in a
few minutes coughed up some bright frothy blood. The larynx was
found coated with blood, and when it was removed, a small pulsa-
ting vessel was seen, and from it came the hemorrhage, which was
controlled by the galvano-cautery.

In my own experience I have records of but four cases of heemor-
rhage from the larynx, not associated at the beginning with serious
local disease or pulmonary tuberculosis. Elsewhere I have reported
cases of pharyngeal hemorrhage which were ascribed to pulmonary
sources; but of necessity these are excluded here, though of the same
general class as those under consideration and giving rise oftentimes
to the same errors in diagnosis.

OasE I.—Miss K., aged eighteen, with good family history, had repeated
hemorrhages with some hoarseness, and at times soreness in the glottic
region. After failing the first time to find any chest complication and
nothing to indicate laryngeal bleeding except a chronic laryngitis, I saw
her a second time while she was expectorating blood. The site of the
heemorrhage was seen to be a small perforating ulcer of the right ventricu-
lar band. The bleeding was, after several recurrences, finally controlled,
and the laryngitis has under treatment been relieved. It is two years
since I first saw Miss K., and there bas been no return of the bleeding
and no evidence of pulmonary disease. This case is also reported in the
proceedings of the last Medical Congress, vol. iv, p. 45.

Case II.—In January of the present year I saw Mr. G., a Government
inspector, whose duties frequently required him to be in the holds of boats
which are often damp and foul. He was forty-two years old, robust, and
witb a good family record. He said that for a year he had had recurrent
hemorrhages which he feared were from the lungs. He was slightly
hoarse and was expectorating blood when I saw him. I found nothing to

Hemorrhage from the Larync. 135

indicate lung disease, but in the larynx discovered the bleeding to come
from the posterior part of the right vocal cord, which was red and swollen.
I believe that all the hemorrhage came from this part of the larynx, be-
cause it was entirely controlled by the direct application of iron, and the
local inflammation has improved under the usual treatment.

Oase III.—Miss L., a pale, delicate-looking little lady of about thirty-
five years of age, consulted me three months ago on account of almost
constant cough and repeated though slight hemorrhages existing for six
weeks. There was no expectoration other than the blood and a little
mucus, half a degree of fever, pulse slightly quickened, but no loss of
flesh, and fair appetite. The family history was free from any trace of
so-called hereditary disease. A careful examination of the chest gave
negative results. The larynx was red and the mucous membrane over the
left arytenoid cartilage, and indeed the whole left side of the larynx, in-
cluding to some extent the vocal cord, appeared swollen. There was at
this time some hoarseness, but no bleeding. Although the circumstantial
evidence was in favor of laryngeal hemorrhage, it was not until her third
visit that I could affirm it. While waiting in my office the bleeding re-
turned. At once making an examination, I found that the hemorrhage
came from the suspected region of the larynx, especially from near the
posterior attachment of the left cord. After this the bleeding returned
a number of times, but has not appeared during the last two months.

A fortnight since, or nearly four months trom the first hemorrhage,
I found evidence of pulmonary consumption, not at the apex, where
phthisis as a rule begins, but in the right lung at the third intercostal
space anteriorly. There was and is now slight dullness, diminished ve-
sicular murmur, and prolonged expiration.

It has been shown by Dr. Alexander Hodgkinson (“ British Medi-
cal Journal,” September 15, 1888) that blood may pass from the phar-
ynx into the larynx and down the trachea with the utmost facility.
After an operation upon the pharynx he found the blood trickling
over the interarytenoid fold, and apparently giving rise to no laryn-
geal irritation.

In discussing this subject before the Section in Laryngology and
Rhinology of the British Medical Association, 1888, Dr. David New-
man, of Glasgow, raised the interesting question as to whether or not
hemorrhages from the upper air-passages might act as a predisposing
cause to tubercular disease. He reported a case which is so suggest-
ive, taken in connection with Miss L.’s history, that I quote it. There
was a “papilloma attached to the posterior pharyngeal wall from
which repeated and sometimes copious hemorrhage took place. The
blood escaped by the nose and mouth, but on several occasions it
flowed into the trachea and was subsequently coughed up. For six

136 Transactions of the American Laryngological Association.

months these hemorrhages were observed to occur at irregular in-
tervals, and no symptoms developed nor could physical signs be dis-
covered to support a suspicion of pulmonary disease, the patient be-
ing in perfect health with the exception of the growth in the pharynx.
At the beginning of last year, however, the condition of the upper
lobe became suspicious, and within three months marked signs of
consolidation developed.”

In the case of Miss L., it is true that the general condition pointed
to something more than a recurrent hemorrhage that was never very
severe, but, sustained by Dr. Newman’s experience, I can not but be-
lieve that this is one of those instances of “ phthisis ab hemoptoe,”
for it is a pathological fact that tubercular disease may follow a pul-
monary hemorrhage. ‘The inhaled blood is simply dead organic
matter, offering no resistance to the action of specific micro-organ-
isms, and, when it becomes infected, induces changes in the sur-
rounding tissues which result in consolidation and terminate in tuber-
cular phthisis.” It may be that in this case the laryngeal hemor-
rhage was but one of several factors in the development of the pul-
monary condition, yet the bleeding was distinctly laryngeal and the
pulmonary symptoms were not evident until some months after the
hemorrhage began.

Case IV.—Mrs. R. was brought to me by her husband, himself a
physician, on account of two slight hemorrhages ten days apart. She |
was expectorating blood in small quantities when I saw her, Here there
could be no doubt as to the nature or location of the lesions for the veins
at the base of the tongue were distinctly varicose and one, and perhaps
more, ruptured.

This case can scarcely be cited as one of laryngeal hemorrhage,
but I mention it for the sake of completeness. Mr. Lennox Browne
believes these conditions to be associated with varix in other parts of
the body, and often manifested to such an extent as to constitute a
“truly hemorrhoidal state of affairs.” In confirmation I can add
that there is a varicose condition of the veins of the left lower ex-
tremity in the case just reported.

Fortunately, I have not seen a case of marked submucous infiltra-
tion of blood in the larynx as described by Ingals, Schnitzler, Lewin,
and others.

The subject is so interesting that any attempt at completeness or
to include the study of laryngeal hemorrhage from well-defined
general disease, or those of traumatic origin, would extend this
paper far beyond its limit.

The Evulsion of a Laryngeal Tumor. 137

I beg to offer the following conclusions :

1. Laryngeal hemorrhage may occur from simple local condi-
tions.

2. Unless associated with other and more positive symptoms, it
is not indicative of pulmonary lesion.

3. It is possible, through the passing of blood from the larynx
into the lungs, that pulmonary disease may be incited.

4. Care should be taken to distinguish between pulmonary and
laryngeal hemorrhages, not only for the sake of more exact treat-
ment, but especially because of the more favorable prognosis that
may be given in many cases of the latter condition.

Paper.

REPORT OF THE EVULSION OF A LARYNGEAL TUMOR WHICH
RETURNED TWENTY-TWO YEARS AFTER REMOVAL BY LARYN-
GOTOMY. WITH AN ILLUSTRATION OF THE ORIGINAL TUMOR
AND PHOTOGRAPHS OF THE NEW GROWTH AND OF THE
LARYNX AFTER ITS REMOVAL.

By RUFUS P. LINCOLN, M. D.

HE reappearance of a growth in the larynx on the site of one

removed twenty-two years previously is a phenomenon of sufti-

cient interest to workers in our specialty to warrant the appearance
in our records of the following brief notes:

An additional interest is assured by my good fortune in being
enabled to exhibit a lithograph of the original tumor in situ (Fig.
1), together with a photograph of the larynx showing the new
growth as it appeared when I first saw it last March (Fig. 2); and
also a second photograph exhibiting a picture of the larynx imme-
diately after the removal of the tumor (Fig. 3).

I am fortunate in being able to refer to a very full report of the
early history and treatment of the original growth made by our late
fellow, Dr. Louis Elsberg, embodied in his prize essay, to which the
American Medical Association awarded the gold medal for 1865.

A colored lithograph made by a portrait artist, who bestowed
great care and effort at accuracy in his work, accompanies this report.
It is to the kind and skillful labor of our fellow, Dr. French, that I
am indebted for the photographs that are submitted herewith. An
examination of the lithograph and photographs illustrates the ac-

138 Transactions of the American Laryngological Association.

curacy of the camera over the ability of an artist to delineate cor-
rectly, no matter how conscientious the latter. These pictures I
now submit to your inspection.

Fie. 1.

The history of the first growth and the account of his efforts at
removal per vias naturales, together with its microscopical appear-

Fic. 2.—March 12, 1889. The larynx Fig. 3.—May 28, 1889. The same
with the tumor in sifu. after removal of the tumor. The
distorted appearance of the in-
terior of the larynx resulting
(After photographs taken from the laryngotomy is cor-

by Dr. Thomas R. French.) rectly represented.

ance, I abstract from Dr. Elsberg’s essay without further acknowl-
edgment.

The patient, a lady, in June, 1862, when twenty-three years of age,
first experienced persistent hoarseness, which was followed by complete
loss of voice the following August. Cough and dyspneea soon succeeded

The Hvulsion of a Laryngeal Tumor. 139

aphonia, but it was not till January, 1864, when Dr. Elsberg first saw
her, that a correct diagnosis was made. He says: On introducing the
laryngeal mirror I immediately saw a tumor hanging down on the left
side, covering the posterior attachment of the vocal cords. The epi-
glottis was in a state of unconquerable pendence, and the fauces so irrita-
ble that the laryngoscopic examination could not long be endured.

Four months were consumed in educating the parts by almost daily
manipulation to secure tolerance of instruments, during which period the
seat of the tumor was defined. It was of large size, passing to a con-
siderable depth below the vocal cords and hanging with its lower por-
tions, either free or attached, into the trachea. It was attached in front
along a line across the whole of the epiglottis, half an inch below its
crest, and laterally it seemed to issue from the ventricles of Morgagni.
Not alone along its peripheral line, but also centrically in every portion,
except the most depending, the tumor was attached to parts below. Its
consistence was semi-soft, and it had the appearance of cauliflower ex-
crescence or irregular strawberry formation.

With reference to the colored lithograph which is herewith sub-
mitted, Dr. Elsberg says: It was the studied result of the efforts of
two portrait artists, who made many examinations of the tumors,
and were it not for its immobility it would perfectly give to the be-
holder the image as to form which the living larynx of this young
lady presented to the examiner with the laryngoscope.

Extending over a period of two weeks, by means of scissors, cutting
forceps, and polypus forceps, there was removed in bulk as much as a
small, ordinary egg. He finally cauterized the remnant with acid nitrate
of mercury. Asa result of this treatment, the patient’s respiration was
deemed unimpeded; her whisper, more distinct, more audible, gave less
trouble and required less effort.

The microscopical appearance of the tumor is of special interest. On
section, it had a more or less fibrous look, with an indefinite cell struct-
ure. It was composed of areolar, fibrous or connective tissue, Laving
interspersed throughout its substance numerous fusiform bodies. Ap-
proaching the surface of the tumor, the fusiform cells resembled the so-
called fibro-plastic cells of Hebert. These cells seemed gradually to
change their shape and become more and more globular until they resem-
bled epithelium.

Its starting point being in the connective tissue, the tumor un-
questionably has a right to the title connective-tissue tumor, or
“fibroma,” but every pathologist examining its superficial portions
would as unquestionably call it a true and typical “ epithelioma” ;
and as to seriousness of prognosis it approximates the latter, or at all
events a “sarcoma,”

140 Transactions of the American Laryngological Association.

Unfortunately, the hope of a satisfactory result from this treatment
by evulsion was not realized. The voice was not restored and the growth
reproduced itself until further interference was imperative to save the
patient’s life. Therefore, laryngotomy without tracheotomy was per-
formed by Dr. Elsberg in the month of November, 1867, and the interior
of the larynx freed from every vestige of the growth. A good recovery
was made, and, according to the patient’s statement, the voice became
fairly good in about three months.

Nothing to suggest any return of the trouble occurred till the
summer of 1888. This led the patient to seek a laryngoscopic ex-
amination, when another growth was discovered last October.

I first saw the patient two months ago, and found a tumor of about
the size of a large kernel of corn growing from the posterior third of the
right vocal cord.

The tumor yielded readily to the pressure of a probe, was of a light-
pink color, and resembled in appearance an ordinary papilloma. An idea
of its shape and situation is best illustrated by the photograph of the
larynx and its contents made by Dr. French, March 12, 1889.

On May 24th, the condition seeming opportune, I made ny first effort
to remove the tumor, and succeeded at one sitting in evulsing the whole
of the growth with a Ouzco’s laryngeal forceps. By free use of a solu-
tion of cocaine the operation was much facilitated. The bleeding was
insignificant. There was some immediate improvement in the voice.

I propose in a few days to apply the galvano-cautery to the seat
of the tumor.

Dr. F. Ferguson, pathologist to the New York Hospital, has sent
me the following report, the result of his examination of a specimen
of the tumor:

The fragments which you sent me are a papilloma without anything
unusual in its structure. The epithelium follows the normal type of
mucous membrane epithelium, and in its complete removal I believe
this kind of tumor to be the least likely of all the epithelial varieties to
return.

Presentation of Instruments. 141

Presentation of Instruments.

A NEW @SOPHAGEAL BOUGIE.—AN IMPROVED POWDER-BLOWER.
—A NASAL BOW-SAW.

By JOHN O. ROE, M.D.

“Ar the meeting of this association last year I reported a case of internal
esophagotomy, and also described a new cwsophageal bougie. I should now like
to present, not only an improved form of the bougie then described, but also cer-
tain other instruments I have devised and have found exceedingly useful.

“4 New Csophageal Bougie.—The bougie which I described last year was
made by attaching the tip of a conical gum-elastic bougie about three inches in
length to the end of a hard-rubber bougie by means of a plug and screw. Since
that time I have made this improved cesophageal bougie, which I now show you
(Fig. 1). This is made all in one piece by simply governing the vulcanizing process
so that one end of the bougie is vulcanized as hard rubber while the other is vul-
canized as soft rubber.

——_— >
= &, TIEMANN & CO;

“Tt is well known that caoutchouc when mixed with 25 per cent. of sulphur
and vulcanized at about 250° F. becomes soft rubber, whereas if the caoutchouc
is mixed with 50 per cent. of sulphur and vulcanized at about 300° F. it becomes
hard rubber. By carefully considering these principles in the manufacture, the
bougie is made with one end of hard rubber and the other end of soft rubber, as
is represented by ¢ and d, Fig. 1.

“These bougies are made in a series of six or more of different sizes. I have
each one of mine attached firmly to a whalebone stem, although the bougie can
be so made that one stem can answer for the set by attaching it to them with a
screw. The advantage of this form of bougie over both the long gum-elastic
bougie and the bulbous hard-rubber bougie is that it combines the advantages of
both and overcomes the objectionable features that both possess. The flexible
soft-rubber tip facilitates the passage of the bougie through the throat and readily
directs it into the stricture, and is thereby more easily introduced than is the hard-
rubber bulbous bougie; and the slender, flexible whalebone stem causes much less
irritation of the throat and gagging, and does not fill up the throat as does the
long gum-elastic bougie.

“The advantage of combining the hard and soft rubber instead of making the
instrument entirely of soft rubber is that the hard-rubber portion is unyielding
and far better for the purpose of dilating oesophageal strictures than it would be
if the instrument were made entirely of soft rubber.

“An Improved Powder-blower.—The next instrument is an improved powder-
blower. Nearly every powder-blower has its objectionable features. Some have
to be recharged each time they are used. Some are used with a bottle as a reservoir

142 Transactions of the American Laryngological Association.

for the powder, and are necessarily bulky and clumsy and easily broken, or the pow-
der is liable to spill out in handling or to find its way back into the rubber bulb that
is used for blowing. I think you will agree with me that nearly all these objection-
able features are overcome in this powder-blower, which I now show you (Fig. 2).

Fig. 2.

The stem of the instrument passes through the bottom of the reservoir. A hole
is made in the bottom of the reservoir to correspond with a hole that is made in
one side of the stem of the instrument. It will therefore be seen that if the hole
in the side of the stem, 4, is turned upward so as to be directly under the hole
in the bottom of the reservoir, a, the powder will fall into the stem or barrel of
the instrument; and by giving it a half turn the powder in the reservoir is com-
pletely cut off. The position of the hole in the stem is indicated by an ivory
guide, 7, placed on the stem. When the stem is charged, only the powder that
has fallen into it can be blown out. The stem is secured in the reservoir by the
binding nut, g, which can be removed and the stem taken out for cleansing. The
instrument can be used for throwing the powder not only straight, but also in any
direction that is desired, by attaching, in the latter case, the curved tip, c, to the
point of the stem. A flexible rubber tube can be attached to the stem at e, by
which the powder can be blown out by the operator’s breath, or by the rubber
bulb, d, as shown in the cut. The different parts of the instrument are so nicely
adjusted as entirely to prevent the escape of any powder from the reservoir, and
it is thus admirable for the use of iodoform.

“The only objectionable feature is that this instrument is not so well adapted
to the use of a variety of powders as an instrument made without the reservoir ;
but the surgeon can readily provide himself with several of the powder-blowers,
as their cost is not great, and keep them filled with the powders which he most
frequently uses. The facility with which this instrument is used and the saving
of time otherwise required for charging the plain powder-blower can at once be
appreciated by those who do a large amount of office work.*

“A Nasal Bow-saw.—I have one other instrument to show you which I have
recently devised, and that is a new form of nasal hand-saw. At the meeting of
this society last year I showed you my latest improved electric nasal saw, but as

* Since I described and exhibited this instrument before the Laryngological
Association on May 28th last, the idea has been appropriated by a certain instru-
ment-maker, who has published a similar cut of the instrument without giving any
credit to the originator of the idea.

Presentation of Instruments. 143

ap instrument of this kind is not always at hand, the most simple and most nearly
perfect hand-saw is therefore a desideratum.

“This form of saw, as you see (Fig. 3), consists of a blade of a jeweler’s saw
held by a bow similar to a bow-saw, but made very light and delicate.

Fig. 3.

“The saw devised by Dr. Bosworth is a very ex-
cellent instrument. The only disadvantage the op-
erator finds in using that saw is the flexibility of the blade,
so that in attempting to saw off a very hard and rounding
exostosis it is often with difficulty that the blade can be started
in exactly the spot the operator desires; and even in making a
slight lateral pressure to hold the blade up to the point desired,
the saw is very apt to make a curved cut. With this little bow-saw these
objections are entirely done away with. A very much thinner and finer blade can
be used in these saws than in the case where the blade must be sufficiently thick
to carry itself. By using the same thin and highly tempered blades that jewelers
use for sawing metal, an exostosis of any degree of hardness can be very easily
and quickly cut through. These saws I have had made for me in various sizes
and shapes. The only disadvantage attached to the saw is that the blade can only
be made to cut as deep as the distance of the saw from the back. This objection
is obviated by having a saw with the blade placed at right angles to the bow, and
with the bow sufficiently high to allow it to pass over the obstruction. In other
cases where the bow may interfere with the completion of the operation, the first
incision may be made with this saw at exactly the spot desired and the operation
completed with the Bosworth saw. The latter saw will then have the perfectly
straight groove to run in which has been made with the bow-saw. One of the
special advantages of this little bow-saw with the blade set at right angles is in
sawing out exostoses in the floor of the nostrils. The very narrow blade will per-
mit the sawing to be done on the exact curve of the floor of the nostril. The saw
is also admirably adapted to remove small angular projections and irregularities of
the septum. The very fine teeth of this little saw also give it an advantage over
saws with coarser teeth, in that they leave a very smooth surface over which the
soft parts more quickly spread, and the wound more readily heals.

“Some of these saws I have had made with the handle straight, on the line
with the blade of the saw, while in others I have had the handle placed at about
the same angle as in the Bosworth saw (see a, 5, and c, Fig. 3). In many instances

144 Transactions of the American Laryngological Association.

the little straight handle is much more conveniently used than the bent handle,
especially when in sawing it is desired to deviate from a straight line.

“The saw with the plane of the blade placed at right angles to the back is
represented by a, Fig. 8. The blade of this saw is made with teeth on both edges,
so as to saw in either direction. In order to prevent the blade from cutting under,
when sawing close to the septum, the blade should be placed entirely on the side
of the bow, as shown by 4, Fig. 3. The blade can be put on either side of the bow
for sawing upon either side of the septum.

‘“‘ All these instruments have been made for me in the most admirable manner
by Messrs. Tiemann & Co., 107 Park Row, New York.

A PHARYNGEAL DOUCHE.

By SAMUEL JOHNSTON, M.D.

Tus simple apparatus consists of an ordinary soda-water siphon charged in the
usual way, with a soft-rubber tube twelve inches long attached to the nozzle.

The method of using it is as follows:

A bib of water-proof cloth or oiled silk large enough to protect the clothing is
first fastened around the neck of the patient, the free end of the bib resting in a
basin to receive the return current. The tube is then inserted into the mouth to

a convenient distance, and the pressure turned on by the attendant; the contents
of the bottle will then flow with foree into the mouth and out again, varying, of
course, with the amount of pressure exerted on the stop-cock.

The quantity of tenacious mucous expelled by this means in some cases is

Business Meetings. 145

enormous, and the relief afforded can only be appreciated by those who have had
experience with this process of cleansing the oral cavity.

We have all, doubtless, used the syringe with a flexible rubber tube attached
to the tip for washing out the mouth and nasal passages in cases of acute amyg-
dalitis, diphtheria, scarlatina, etc., but I believe we have in this simple apparatus
an agent which will give greater ease to those suffering with the class of affections
before mentioned than any other local treatment yet employed.

Thus far I have only used soda water; the contents of the siphon can, how-
ever, be carbolized or otherwise medicated to suit special cases, A lady, recently
under my care with quinsy, for several days used six to eight siphons daily in this
way, greatly to her comfort and relief, and it is to her that I am indebted for the
suggestion of this novel application of the soda-water siphon.

A MODIFICATION OF VOLTOLINIS PALATE RETRACTOR.
By ETHELBERT CARROLL MORGAN, M. D.

THis instrument is intended to draw the velum forcibly forward while operat-
ing on the bursa pharyngea. The handle is so bent as to allow the hand of the

TRUAX & Co.

Fie. 5.

assistant, who retracts the velum, to be entirely out of the line of vision of the
operator. Truax & Co., of Chicago, make the instrument.

BUSINESS MEETINGS.

Tre Eleventh Annual Congress of the American Laryngological Asso -
ciation was formally opened, at ten o’clock on the morning of Thursday,
May 30, 1889, by the President, Dr. E. Carroll Morgan, who occupied
the chair.

The Secretary proceeded to call the roll, the following Fellows being
present during the meeting:

E. Carrott MorGcan, Washington, President.

W. C. Guasgow, St. Louis, First Vice-President.

Cartes E. Sasous, Philadelphia, Second Vice-President.
D. Bryson Detavan, New York, Secretary and Treasurer.
J. Soris-Conen, Philadelphia, Member of Council.
Frankiin H. Hooper, Boston, Member of Council.
Frepertck I. Knieut, Boston, Member of Council,

10

146 Transactions of the American Laryngological Association.

Harrison Aten, Philadelphia.
Cuartes E. Bean, St. Paul.
Francke H. Bosworrs, New York.
S. H. Cuapman, New Haven.
Wittiam H. Daty, Pittsburgh.
T. Amory Der B tots, Boston.

J. H. HarrMan, Baltimore.

F. Wauitenitt HINnKEL, Buffalo.
SAMUEL JOHNSTON, Baltimore.
Cuartes H. Knicut, New York.
SamuEL W. Lanemaip, Boston.
Joun N. Mackenzin, Baltimore.
GrorGeE W. Masor, Montreal.

H. Crinton McSuerry, Baltimore.
J. C. Murwatt, St. Louis.
CLaRENCcE C. Rice, New York.
Joun O. Rog, Rochester.

Among the guests of the Association present during its proceedings
were Surgeon John S. Billings, U.S. Army, and Drs. T. Morris Murray,
N.S. Lincoln, Frank Hyatt, Charles E. Hagner, W. M. Gray, J. M. Toner,
Samuel C. Busey, G. L. Magruder, Robert Edes, J. H. Bryan, J. Dadley
Morgan, J. W. Lovejoy, and J. W. Bayne, of Washington, and George A.
Richards, of New York.

The President, Dr. E. Carrott Morean, then delivered his address,
which was followed by the reading of papers.

At the close of the morning programme the Association went into
executive session.

The following-named gentlemen, on recommendation of the Council,
were unanimously elected active Fellows of the Association: W. E. Cas-
selberry, Chicago, who presented a paper on ‘‘A New and Improved
Method of Feeding in Intubation of the Larynx,” and H. L. Swain, New
Haven, whose paper was entitled ‘‘ Gargles and Gargling.”

The President appointed the following committees :

Nominating Committee—Dr. F. I. Knight, Dr. Roe, and Dr. Major.

Auditing Committee.—Dr. Hartman, Dr. De Blois, and Dr. O. H.
Knight.

The Association then adjourned to the afternoon session, which was de-
voted to the reading of papers.

On the morning of the second day the meeting was called to order by
the President, Dr. Morgan, at 10.20 o’clock. The minutes of the last
regular meeting, together with those of the Council for 1888-’89, were
read and approved.

Secretary's Report.—The Secretary reported that satisfactory progress
was being made in the publication of the Tenth Annual Volume of
Transactions. He called attention to the rapid increase in the sale of the
Transactions, and urged greater enterprise on the part of the members

Business Meetings. ’ 147

of the Association in distributing and advertising them. He stated that
D. Appleton & Co. had offered to publish the eleventh volume on terms
similar to those which they had made in previous years. . During the year,
by unanimous vote of the Council, the name of Dr. W. F. Duncan had
been dropped from the list of active Fellows of the Association,

Treasurer's Report.—The report of the Treasurer was then read and
approved, as follows: ,

THe AmertoaAN LARYNGOLOGIOAL Association, May 30, 1889.
In Account with D. Bryson Delavan, Treasurer.

By balance, 1888 . : : , : $114 34
Annual dues, 1889—46 by $15 , , 690 00 |

Sale of “Transactions” . ‘ Aros 60 62

= $864 96

To stenographer ©. . 2.) %°~.. - $100,00 .
Printing . F ; 2 . : ; 45 50
Rent of hall. j ‘ eet: ; 20 00
Printing . ; ae aoe F : ; 11 75
Electrotypes . : , : , : 7 63

= $184 88

Balance on hand . : : i : : $680 08

Audited and found correct.
J. H. Hartman,
Cuartes H. Knieur,
Tuomas Amory De Brots.

The Librarian’s Report was then read by the Secretary :

The Librarian regrets to be obliged to report that a marked decline in
interest in the library of the Association has been shown during the past
year. No better proof is needed than the statement that only one book
and seventeen pamphlets have been contributed since the last report was
presented. Of these, the book and four of the pamphlets were American
publications.

The library was transferred to the present incumbent in December,
1883. It then contained 12 bound volumes and 133 pamphlets. It now
contains 58 bound and unbound books and 899 pamphlets—an increase
in six years of 46 books and 766 pamphlets. Most of these were
contributed between 1883 and 1886, during which time a lively interest
was shown in this department. In 1887 the interest began to decline,
and, though circular-letters were sent to every laryngologist known to
your Librarian in this country and in Europe and attention called to the
fact in the annual reports, the decline continued. The failure to main-
tain interest in the library may in part be explained by the fact that
circular-letters were not sent out often enough to keep possible contriba-
tors in mind of the existence of the library. Your Librarian, however,

148 Transactions of the American Laryngological Association.

did not think it proper to issue a begging letter oftener than once in
two or three years. The increase in the library depended entirely upon
voluntary contributions, and an occasional reminder of the fact that the
library was in existence and donations to it would be welcomed seemed
to him to be the extent of his privilege within the bounds of propriety.
Had he been in a more independent position as Librarian he would occa-
sionally have been able to make proposals which would, no doubt, have
resulted in a material increase in the number and value of books and
reprints. The library has now almost ceased to attract contributions, and
is not of sufficient size to be of much value.

It is possible that new life might be infused into the department by
placing it in the hands of one who would beg more actively and perhaps
send a postal to every writer as soon as his article is published.

Your Librarian is of the opinion that without funds the library cafr
never be made a suecess, and, unless a fund is established, it would be
wisest to present the whole collection to some such repository as the
Library-of the Surgeon-General’s Office, where it would be of much greater
value than it can ever be under existing conditions.

It is probable that the library contains but few writings which can not
be found in the large medical libraries in this country.

The library has ceased to reflect credit upon the Association ; therefore
your Librarian is unwilling to accept a renomination should it be offered
him.

In taking leave of the office he desires to express his sincere thanks to
the. Fellows of the Association for the many courtesies which they have
extended to him, and for the confidence which they have shown by re-
peatedly honoring him with re-election.

Respectfully submitted,
Tuomas R. Frenou, Librarian.

Dr. BoswortH moved that the suggestions of Dr. French be adopted,
and that the library be transferred to the Surgeon-General’s Office on
terms to be agreed upon by the Council and Dr. Billings.

Dr. Harrman asked if such action would not necessitate an amendment
to the constitution relative to the office of Librarian.

The Presipent announced that he had the assurance of Dr, Billings
that the library should be kept ‘intact as far as possible, that it should
retain its present title, and that it should be at the disposal of the mem-
bers of the Association under rules ordinarily governing the management
of such collections.

Dr. Bosworth moved that the matter be referred to the Council with
power. Seconded’by Dr. Jounsron and carried.

Dr. Rioe moved that $25 be appropriated for the use of the Librarian
the ensuing year. This motion was withdrawn on the understanding
that the Council should make an appropriation for this purpose at their
discretion.

Business Meetings. 149

On motion of Dr. Bosworts, it was voted that Dr. French be requested
to withdraw his resignation as Librarian.
The Nominating Committee reported as follows:
For President.—Dr. J. N. Maoxenete, Baltimore.
For First Vice-President.—Dr. Epaar Hotpen, Newark.
For Second Vice-President.—Dr. C. E. Bran; St. Paul.
For Secretary and Treasurer.—Dr. O. H. Kyteur, New York.
For Librarian.—Dr.,T. R. Frenocu, Brooklyn.
For Member of Council.—Dr. D. Bryson Detavan, New York.
For Representative to Congress of American Physicians and Surgeons.
—Dr. Harrison Aten, Philadelphia.
Place of meeting, Baltimore; time to be determined by Council.
F. I. Kyient,
[Signed. | J. O. Ros,
G. W. Masor, .
Committee on Nominations.

The Auditing Committee reported that they had found the Treasurer’s
accounts correct. ek

The amendment to the constitution, proposed by Dr. J. Solis-Cohen,
striking out Section 2, Article III, referring to limit of membership, then
came up for consideration. After much discussion, a vote was taken, and
the amendment was defeated.

The executive session was then dissolved.

At a business meeting held at the close of the proceedings on the
third day, Dr. Daty gave notice of an amendment to Section 3, Article V,
of the constitution, which he proposed to offer, as follows: ‘‘The nomi-
nation and election of officers shall take place by ballot on the last day of
the meeting.”

A letter was read from Dr. W. H. Carmalt, Secretary, regarding the
cost of publishing the Transactions of the Congress of American Physi-
cians and Surgeons.

The Association then proceeded to the election of officers for the en-
suing year, and, on motion of Dr. Daty, the Secretary was instructed to
cast a ballot for the candidates proposed by the Nominating Committee.

The retiring President, Dr. E. Carrort Morean, then introduced the
President-elect. ‘In retiring from the presidency of the American Laryn-
gological Association—a trust which I have endeavored to fill to the extent
of my ability—I embrace the opportunity to thank you for the assistance
which one and all bave freely extended me in expediting the business of
this session.

“ We have accomplished much work, the scientific discussions have been
long and interesting, and our business meeting, I must admit, somewhat
complicated. Nevertheless, the questions presented were considered in a
candid manner, and the results are more than satisfactory.

“Tt now becomes my pleasant duty to welcome your President-elect,

.

150 Transactions of the American Laryngological Association.
Dr. John N. Mackenzie, and te congratulate him and you opens the well-
merited honor which has fallen to his lot.

“T would appoint Drs. Daly and Delayan a committee to escort the
President-elect to the chair.”

On taking the chair, Dr. Mackenzie spoke as follows:

GENTLEMEN: The distinguished honor which this Association has seen
fit to confer upon me is now more than ever gratefully appreciated since
the kind words of Dr. Morgan, the retiring President. As I take the
place which he so faithfully, so gracefully occupied, I can say, without
the slightest shadow of affectation, that I do so with genuine embarrass-
ment. By his unflinching courage, by his ability, and by his unswerving
love for the interests of this Association, he has battled against odds
before which most, if not all of us, would have fallen. I repeat it that |
the place of such a man is hard to fill. Long may he live to be with us,
to show us by his example what courageous manhood can accomplish.

To you, one and all, fellow-mmembers, I shall offer no set address. I
shall try to do the best I can and to do my duty, and I hope you will be
satisfied with whatI do. Ibelieve that, with perhaps one or two exceptions,
I am the youngest member of this Association, and I can not but believe
that in selecting me for your President you were guided by motives other
than a mere desire to visit the city of Baltimore and participate in its hos-
pitality, and for this kind evidence of friendly esteem thank you from
the bottom of my heart.

I now declare the Eleventh Annual Congress of the American toys
gological Association adjourned,

RF American Laryngological

a Association

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