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^ ■ . _^ 













Dr. ALFRED BRUCK (Berlin). 

Edited and Translated »y 
F. W. FORBES ROSS, M.D. Edin., F.R.C.S. England. 





Assist ED by 

Illustrated by 217 Figures and Diagrama in the Text, 
many of which are in Colon, 



1123 Bhoadway. 

Copyright, 191(1, bt 


Kkw York 

All righu retfrivd 


; •• • • » . 



Tliis book is intended to meet the requirements of the men in 
general practice. li«lying on the long experience in my own 
si)ecial practice, I liave tried to take the standpoint of the prac- 
titioner. Discussion of the theoretically important questions 
cannot l)o entirely omitted from a treatise like this. Con- 
sequently the large amount of material at my command has been 
condensed, and references to other authors have been restricUil 
to such as could not be neglected. Much space has been given 
to the GknkhaTj Skction in eacli of the four parts of the book. 
Anatomical and physiological points must of necessity receive 
attention in a text-book, sls they are needed for a projx'r under- 
standhig of the patliological process, viz., accessory cavities or 
nervous lesions. Still, I have endeavored to confine myself 
to the essential points, so as not fn weary the reader. Full 
allowance has been ma<le to the methods of examination. These 
are well illustrated by diagrams, partially schematic. For a 
clearer understanding of the oi)erntive technique I have, wherever 
■practicable, shown tlie instruments in situ. In order to achieve 
clearness and systematic arrangement, the book has been (livideri 
into Font Parts. 

I trust that the book will be favourably received by my col- 
leagues among the .specialists, and prove a useful addition to the 
library of the General Practitioner. Hahent sva jntn HbelH. 

Thk Author. 



The Translators of this useful book for Praclicians and Stu- 
doiits, in tlic course of their htbours were inipresswi with the 
fact that the Orisiiial Author had missed nothing whicli was of 
real practical vahie, and at the .same time had been able to get 
so niucli into so small a compass. One of tin? most salient fea- 
tures of the work is tli(' prevailing absence of any mmece.ssary 
vcrl)iagr or "padding out" in order to j>roduce a lengthy and 
impasing work. Tliis ha,s been successfully achieved in the 
smallest possible spare comi>atible with n-al practical value. 
Tlic Translators have endeavored as much as jHtssible to closely 
follow the flerman text ; even at the risk of not producing 
"classical I'"ngHsh" at the exiK-nse of the exact "shade of mean- 
ing" or sense which the author originally endeavored to convey. 

F. W. Fokuks Ross, M.D., F.R.C.S. England. 
Fhikdhich Gans, M.D. 





General Section. f^a* 

Anatomy 1 

The Extemiil Nose 1 

The Internal Nose 2 

Accessorj' Nasal Cavities 6 

The Mucous Memljrane of the Nose 10 

Blood Vessels 11 

Lymph Vessels 12 

Nerves 12 

Physiology 13 

Methods of Examination 16 

The Examinatinn from in Front 16 

Probing (Kxamination by the Probe; Sounding) 21 

Anaesthesia and Artificial Anaemia (Anaemization) . . 21 

Deflation of the Nose 23 

Posterior Rhinoscopy (^Examination from Behind) 24 

Transillumination 30 

Routine of Examination 31 

Anamnesis "31 

Hereility — General Conditions of I^ife — Previous Dis- 
eases — Present Diseases — Subjective Symptoms — (a) 
Pain — (b) Psychic Disturbance — (<) Obstruction — (d) 

Sneezing — (c) Disturbances of the Sense of Smell, ... 31 

Status I*raesens 32 

External Nose — Inspection — I'alpation 32 

Nasal Cavity — {.4) Examination from in Front — (a) 
Tost of Air-permeability — 1. Stenosis-bruit 
—2. Mouth-breathing — 3. Alteration of voi(« 
- — 4. Disturbance of speech — (^) Ascer- 
taining of Nasal Foet4)r — (c) Anterior and 
Middle Uhinoscopy — Quantitative ('hanges — 
Qualitative Changes — (rf) Examination of 

the Sense of Smell 33 




(B) Examination from Behind — Posterior Rhi- 
noscopy — Palpation of the Naso-pharjiigeai 

Space 34 

(O Transillumination — I, The Maxillary Sinus — 

2. Frontal Sinus 35 

Other Organs 35 

1. Eye — 2. Ear— 5. Upper Aii^passages — 4. Teeth — 

5. Brain — 6. Stomach— 7. Reflex Disorders 36 

General Therapy 37 

General Measures 37 

Local Treatment 37 

(a) Cleaning the Nose — Blowing — Wiping Out the 
Nose — Gottstein's Tamponade — Douching — Pre- 
cautions to be taken in Douching the Nose 37 

(t) Treatment by Drugs — Brushing — Jlassage^In- 

stillations — Powders — "Snuffs"— Cauterization. . 40 

(c) Operative Treatment — 2. Local Anaesthesia 41 

2. Oeneral Anaesthesia — 3. Instruments 41 

Galvano-cauterization — Electrolysis 43 

Hygieue and Prophylaxis 44 

Spectal Section. 

I. Diseases of the Skin of the Nose 47 

Eczema Vestibuli {Eczema ad introitum nasi — Eczema 

of the Entrance of the Nose) 47 

Sycosis Vestibuli (Sycosis; Pus-Infection) 48 

Furunculosis \'estibuli (Furunculosis; Boils of the En- 
trance of the Nose) 49 

Comedones 50 

Seborrhoea 51 

Congelatio Nasi (Frost-bites) 51 

Disturbances of Circulation of the Skin (Copper Nose; 
Erythema; Angeioma; Acne Rosacea; Pendulous 

Nose) 52 

Erythema 52 

Telangiectasis (Naevus) 53 

Acne Rosacea ("Blotchy Face"; Angeiectasic Erythema). 53 

n. Malformations and Deformations 55 

Adhesions of the Nose 55 

Synechiae 55 

Atresiae 56 

Deformation of the Septum 57 

Operative Methoils: 

Method of Infraction 60 

Resection. . 61 

Injurj- to the Nose 61 

Abscess of the Septum 62 

Deviations, Dislocations and Fractures of the Septum. ... 62 



ni. Haemorrhage 62 

(.4) Bleeding into or under the Mucous Membmiie 63 

(B) Free Haemorrhage — Local Cnusos — General Cauises. . . 63 

IV. Rhinitis Acuta (Coryza; "Snuffles"; "Cold in the 
Head'*j 69 

V. Rhinitis Chronica 74 

1. Chronic Rhinitis (Rliinitis Chronica Simplex Hyper- 

trophica) 75 

2. Rbinitia Atrophica (Ozaena) 82 

IV. Special Forms of Rhinitis 89 

1. Ulcus Septi Perforans (Perfonitin}; Ulcer) 89 

2. Hay-fever (Bostock's Disease) 90 

Vn. Acute and Chronic Infectious Diseases 02 

1. Acute Exanthemata 92 

2. Influenza 93 

3. Gonorrhoea 93 

4. Rhinitis IJiplitlierica (Fibrinosa) 93 

5. Tuberculosis and Lupus 96 

6. Syphilis 99 

7. Rhinosclemma 105 

8. Malleus ((ilanrlcMs; Farcy) 107 

9. Leprosy (Lepra; Klephantiasis Uraecoruni) 108 

Vm. Forei^ Bodies and Parasites 109 

1. Foreipi Bodies 109 

2. Parasites 113 

Actinomycosis 1 14 

EK. Tumours 114 

1. Benign New-growllis 114 

(a) Mucous Polypi 114 

(6) Benign Tumours of Special Kind 1 19 

2. Malignant Tumours 119 

X Nervous Lesions 121 

1. Disortlers of the Sense of Smell 121 

(a) Hyposmia and Anosmia 121 

(b) Hyperosmia. (t) Parosmia 123 

2. Disorders of Sensibility 124 

(a) Anaesthesia — (6) Hyperaesthesia — Paraesthesia. . 124 

3. Nasal Reflex Neuroses 125 

Intranasal Reflex Neurosis 126 

Nervous Cold — Erythema of the Fxtemal Nose — In- 
fluence of the Sexual Sphere on tlic Nose 127 

Rpflex Neui-oses in other Organs 128 

Asthma, 128 — Spasmodic Cough, 129 — Cardiac Neu- 
roses, 12iV—Dysmeuorrhoea, 129— -Other Neuroses, 129. 

rrABLS or oontentb. 



L Inflammations 132 

{a) Oeiwml . 132 

ift) Special. 137 

1. Inflainnialion of the Antmin i»f Highniore 137 

(a) In Acute Inflamnmtioti of tlic Maxillory Sinus, 
141— (?') .SunL-vitU Miixilliirw ('hn)nir:t iClmmic 
ItiRiiininiition of iKe Mnxilhiiy Ciivity). l-i:i. 

2. liiflaumisuion of the Frontal Siiiiia (Siniwitia 
Fmiit;»lb) 146 

(fl) in Acixic Iiiflamiiialion — (b) Chronic Sinusitis. 150 

3. Infliunriiation of ElluiKiidal Cells (Cellulitis Eth- 
moidnllR; KthmpifHlis) 152 

4. Infliimmat'ion nf th« 8phenoi<)al Sinus (Sinuatis 
ypheuoidalia) ,.,..... 157 

n. New-growths 162 

Kciiipn Tumours. . . 162 

MaliKtiant T\iinours 163 

ni. Injuries 164 

IV. Foreign Bodies and Parasites 164 

V. Tuberculosis and Syphilis 165 

PART n. 

Gkn'eral SEcnos. 

I. Anatomy 169 

The Lips— The Tongue, l6!)~The MuspIps ni the Mouth, 
171— (ii) Miisclc-a iif tilt; Up-^— (^) Musrles of the FlcMir of 
the .Mouth and of the Tcmgue, 171— Glands, 172— Blood- 
vessels, ]7;3— Lymph-vesacls, 173 — Nerves, 174. 

II. Physiology 174 

in. Method and Course of Examination 176 

U) Mclh.xl of Exitiiiiniitimi. ITfi -Wf) Tlic Course of Ex- 
nniiniiliou. 177— Olsonlcrs i>f tiiieerli— DistinltMS of Res- 
pinitiim Sw:illowiiiK. 1 77— Anomiilit's of Uie Sprrptian— 
lTicrfa-«ed Set:rwlioii — Pnnilytit: Salivation— I) Jminulion 
of tlip Salivary Secretions, 177— Disorders of Sensihility 
midTii:<t*-. I7S. 

IV. Hygiene and Prophylaxis 179 




Special Sectiok. r»«« 

I. MalformationR and Defonnicies ISO 

Euol(}}r\' and Palhologj-— (o) In tho lips. ISO— (b) In the 
Palatc.'lSl— (0 In the Toague, ISl— (ri) In the Jiiw. 181. 

n. Inflanimations 183 

Acute Stomatitis fStonmfJtU Acuiji) 182 

]. Stomntitis Acvita Catarrhalis (Acute Catjirrh of the 

ilouih) 183 

'2. Phle^^uuitoUH Stoiimtilis lUi 

3. Stomatitw Exxuiialiva . 1S7 

(a) Herpes Lnbialia ei Uiiccalis {Stomatitis Herpclicn; 
Herpefl of the Lips or Ch^k). 187 — (6) Perapliigiis, 
1S7 — (t) Aphthae (Slomatilis aphthom seii fibriiiosu; 
Aphthous UtoiiULtiti»). 187 — (</) Foot atiJ Mouth Dis- 
ease {Kpidpiiiic- Aphthou-s StoniaUtis), 188. 

III. Stomatitis Chronica ISO 

1. Chnjiiic Catarrh of tlw Mouth IbD 

2. GI(K«iti.s Ohmnit^a Su{>erliciiiti» 190 

{a) Ijjucoplakiii oris (Psoriftst* ave Ichthyoda Oris; 
Leucoplaltia; Fliiccal Psoriasint. 190— (i) Nigrities lia- 
IjruiU! (Linjiiia lugrsi; lllack Ti>n(tiie; Hair\' Tim(pie), 
192 — (0 IJnpm (tenprnpluoa (l-Jcfoliatio Linguae 
Arcafci) ((Jeojtraphical Toiijjur; Annuliin Migrans), 
193- (rf) Mwller's (linssitis Sii|KTfioialis, 104. 

3. Glot£iItib Chronica Pureiicliymatosn 1115 

IV. Stomatitis Ulcerosa •'Chronic Ulceration of the Tongue') . 106 
(a) Idiopathic llU-er— (b) Sy lUptuinaLic Ulcer — i.c) Trau- 
matic Liver — liXi. 

(a) Stonwrii (ITli-enition of the Mouth) 106 

(i>) StoniatitiJi Ulccro-Membrauosa (Aiigitia of I*l«.ut-Viii- 

pent) ....^..., 168 

(r) Iteciriar'B Aphthae _ 109 

(d) Stomatitis Kcorimticri (Scurvy) (titiharlxtpk) 199 

(f) Stimuilitlt Mercurialis (f mm Merrnriiil Pniivntin^ 200 

(/) Stomatitiin I'kerosa Traumatifa (Traumatic L'loor of 

the Mouth) '.1)1 

V. Stomatitis Gangraenosa (Noma; Gangrene of the Mucous 

Membrane; Cancrum Oris) 202 

VI. Acute and Chronic Infections, . 203 

1. Ainu? Hxaiilhfiiiata 203 

Mca-sli'M — Sr.irlfl.tina — Fever, 2fj:i — V'ariolA — \'ancella, 'AH 

2. (iimnrrhncu . - ....... 204 

3. Diphtheria , ,204 

4. Tubeirulosis and Uipua . . 204 

5. Syphilis .207 

6. .Malleus — Anthrax— IjeiJrn 212 



Vn. Parasites of the Mouth (Mycoses) 212 

1. Thrush ^Jj 

2. Actinomycosis ^" 

3. Other Mycoses ■" '^^^ 

Vm. Tumours 215 

1. Tumours of the Lip ^J^ 

2. Tumours of the Gums 217 

3. Tumours of the Tongue 217 

(a) Cysts, 217— (6) Hypertrophy of the Lingual Tonsil, 218 

Malignant Tumours 219 

Cancer of the Tongue 219 

IX. Nervous Disorders 220 

1. Disorders of Taste 220 

(a) Ageusia and Hypogeusia, 220— (6) Hypergeusia, 
221— (c) Parageusia, 221. 

2. Lesions of Sensibility 222 

(a) Anaesthesia — (b) H>-peraestheaia — (c) Paraes- 
thesia, 222. 

3. Disorders of Motility 222 

(a) Paralysis, 222— (6) Spasms, 223. 

X. Diseases of the Salivary Glands 224 

L Inflammations 224 

(a) of the Parotid Gland, 224 — (b) of the Submaxillary 
and Sublingual Gland, 22&— (c) Pfeiffer's Glandular 
Fever, 226— (r/) Angina Ludovici, 227. 

IL Salivary Calculi 228 

m. Tumours 229 

PART in. 


General Section. 

I. Anatomy 233 

{a) Pars Nasalis, 233— (6) Pars Ordis Pharyn^s, 236— 
((') Pars Laryngea Pharyngis, 237 — Muscles of the Pharynx, 
238— Vessels, 239— Nerves, 240. 

n. Physiology 240 

m. Method of Examination 243 

(A) l*2xaniiu*ation of the Naso-Pharj'ngcal Space 243 

(fi) I'.xamination of the Oral Part 243 

(C) Examination of the Laryngeal Pai-t 244 




TV. Course of Ezamination 244 

Afittiimesii) 245 

(a) tieiieral Syniplonis. 246— (6) Diaorrlera of Sicn- 
isibility, 24G — (c) Oisonlpn* of Swiillowiiig, 246 — (J) 
Wrturbiinccs of Hespiration, 247. 

Status t'riirH<iivs 247 

(I) Plifiryiix -((J) Oriil i'art. 247— (fc) Nasal I'iirt. 
217- (c) Larj-ngeal Part, 24S— (2) Other (Irgaiifi, 24!). 

V. General Treatment 24ft 

1. (ieiMTiil Me.'i.siiro«, . ,, 249 

2. Local Treatment. , . . 2ri) 

(n) Applications and Funu'ntjitioiis, 2511— (fc) Treat- 
ment by Congestion, 251— (r) Trcotmont by Di-ups, ■ 
252- ((/) Klertrical Trpatmcnt. 2.^3— (f) Operative 
TrRntmont, 254. 

VI. Hygiene and Prophylaxis , . 2S4 

RpKrrAT, Suction. 

L Malformations and Deformities 25& 

1. Abiiornuililica of (Jmwth 255 

2. -Viliesioiis and Htrictunw , 257 

Appendix — Injuries to tlie Thront 25ft 

n. Acute Pharyngitis , 250 

1. Afuip Ciitariliiil Pliaryngitis 200 

(fl) l{etromi'»al Phiirj'ngitiB. 261 

tb) Acute I'han-nKitis; " Sore Throat" 281 

(c) Acut« TonsillitLs 262 

2. Ililp^inonoiu Ph»r,-ngiti8 2ti5 

(a) TonsiUjir Abst«s8 , . . , . 266 

((>» Heritonsilliir AImwcss 389 

((■) lietmiilnirynKpai AbHcetw * . . , , 288 

ill) En,'sipelH.s of tlie Iliarj-rix 26ft 

(e) Aciitti Infectious Plilcgmon of the Pharynx 29ft 

3. R\ndativc i^haryngitis .,, 272 

(o) Herpotifnriii Plntrvngitia ,. 272 

ih) Peniphipia ,* 273 

(c) Aphtliae 273 

(d) Other Exuthitive Proceaaea. 273 

in. Chronic Pharyngitis 274 

(a) ('liix)iiic l;ciT<iii:u^l Ciitiirrh 275 

(b) t'hronic I'harynftilis 276 

(r) PharjTigitis . '2ii 

{it) TonHiUar Pharyngitis 277 

IV. Adenoid Vegetations 283 

(\»nip)icali«iiLs; ifii During Operation — (6) After Operation 292 

V. Enlarged TonsiU 2<»3 

C«mplicalion.-s During and After Operation 295 



VI. Acute and Chronic Infections 297 

1. Acute Exanthemata 297 

Measles — Scarlatina, 297 — Smallpox, 298 — Chicken- 
pox, 299. 

2. Typhoid Fever 300 

3. Diphtheriii 300 

Complications an<i Sequelae 304 

4. Tuberculosis and Lupus 308 

5. Syphilis 311 

6. Scleroma 314 

7. Glanders 315 

8. Leprosy 316 

Vn. Mycoses 316 

1. Thrush 316 

2. LeptothrL\ 317 

3. Other Mycoses 318 

Vm. Foreign Bodies 318 

Appendix— Calculi 320 

IX. Tumours 321 

1. Benign Growths 321 

(a) Typical Naso-pharyngeal Polypi 323 

(b) Reti'opharyngeal Goitre 326 

2. Malignant Tumours 327 

(a) Sarcoma and Carcinoma 328 

(6) Lymphosiirconia 330 

X. Nervous Disorders 331 

!. Disorders of Sensibility 331 

(a) Anaesthesia; (1) Central Causes — (2) Peripheral 
Causes, 331— (M H\'perae8thesia. 332. 

2. Disorders of Motility 333 

(a) Paralysis 333 

(6) Cramps (Spaams) 336 

PAltT IV. 


Gkxerai, Skctiox. 

I. Anatomy 341 

Tlie Cartilaginou.-; Skeleton 341 

(/() Cricoid Cartilage. 341 — (l>) Thyroid Cartihigc, 342 
--|ri I':pit'Ii>ltis. 342— U') Arylenoid. 313 — (c) .Ses- 
amoid Ciirtilage, 343. 

Ligaments of the I,;iiTnx 344 

Mu.-'ck's of the Larj'iix 348 


Ner\-cs of llic Larjitx 353 

Vessels Iff tlio Liinnx ... 355 

Mucous Membrano of the Lar^Tix - . - 356 

Appeiiiilx 357 


-Pitch of Voice 3fiO 

Vigor — Tinibr 

ni. Method of Examination > 363 

(.1) l^xternal Kxaminnticm of tlie LBr>-nx .^ 363 

(B) Internal ExjitiiiaHtkjii of the l^ryrtx , 384 

1. T«-tiii^ of Function 3M 

2. Intf?ni:il Iiiaptt-lion of Laij-nx 364 

(a) Indirect Methml 364 

Techiiic of Ijjrynpiacopy 365 

Difficulties Dui-ing IvxarniiuiUtin :Jfl7 

Varialioiis of In<lircct Larjiigoscopy 373 

1. In-siwKrtiou of thf Posterior Laryngeal 

Wnll 37-1 

2. InBpection of the I^ateral llegjonw 376 

3. Irispoctioii of the Subglottic Region 377 

(6) Direct Laryiipi>s(;"py (Autoi*copy) 378 

Dirrct Tniclipiisropy and BninchoMccpy 379 

STiperior. Direct liponchoscopy 3S0 

Palpation of the liu>ide of larynx 3S2 

rV. Course of Examination 383 

Aimranesia. . . . . 383 

1. Ht-reJity — 2. Ucncral Conditions of Life — 3. Prc- 

viniis Diseaja>s. 3S3 

4. Present Di^Mi^cs :JS4 

5, Subjective Syniptoiiui 384 

Status PriMssena '. 385 

(.1) Extemnl KxaminntioD: (1) lnspeeUon--(2) P&l- 
patinn. 3Sf). — ili) Internal Examination: (I) Testing 
of Kimrtion. 385— (2) Internal Inspection, 388— (3) 
Palpation of tl>e Iiit*inor of the I-irynx. 3JH).— (O 
Other Organ*; (1) N'usi*; Mouth; Thixiat — (2) Lungs. 
300— (3) Central Nervous System— (1) Keflex l>i9- 
ordcre, 391." 

V. Treatment 301 

1. tli-iii'i-al Meaaurw 3ill 

2. ljacn\ TmUiHpnt 394 

(a> Konienhilions — ib) LiRht Trciitment — (r) Klec- 

trifity. 394 

3. Tiwlnmifnts 4l»0 

VI, Hygiene and Prophylaxis 402 

SpEci.u, Section. 
1. Malformations and Deformities 




1. Anomalies of Development 405 

2. Stenoses 408 

Tracheotomy 417 

Intultation and ■'Catlieterisation"of the Air-passages. 421 

(a) Intubation of the I-aiynx after O'Dwycr 422 

(fc) Catheteiisation of the Windpipe after Schroet- 

/*'■ 426 

n. Acute Laryngitis 431 

1. Acute ('atarrh of the Larj'nx 431 

Drj' Haemorrhagic I.arj-ngitis 434 

Subglottic Laiyngitis 435 

2. Phlegmonous Larj-ngitis , . 439 

Circumseril>eil Phlegmonous Inflammation 442 

DiiTuse Phlegmonous Inflammation 443 

3. Exudative Laryngitis 446 

m. Chronic Laryngitis 447 

(1) Choniitis tulx-iwa 449 

(2) Chonlitis nodosji 44!) 

(3) Chorditis hyportrophica superior 44fl 

(4) Chorditis hy|x>rtn)phica inferior 449 

Pachyflcrniia larj'ngis 452 

Singer's Nodes 452 

Prolajwus ventriculi Xlorgagnl 453 

Larj-ngitis subglottica chronica 453 

IV. Perichondritis 458 

(1) Pcrichomiritis Ar\'tenoida 460 

(2) Perichondritis Criroidea. . 460 

(3) Perichondritis Thyi-oidea 461 

V. Diseases of the Joints 464 

VI. Acute and Chronic Infectious Diseases 467 

1. Acute Kxanthemata 467 

Measles^Scarlet Fever — Smallpox 467 

2. Whooping-cough 468 

3. Influenza 469 

4. Diphtheria 469 

5. Typhoid Fever 475 

6. Tulierculosis. 477 

Appendix 498 

7. Kvphilis 501 

8. Scleroma 508 

!l. Glanders 510 

10. Leprosy 510 

Vn. Foreign Bodies and Parasites 511 

1. Foi-eigii Bodies 511 

(n) in tlie Larynx— (/)) in the Trachea and Hi-onciii. . . . 513 

2. Parasites^ ATiimal — ■ Vegetable 520 

Vm. Injuries r)2! 

(,4) I'jitemal Injuries 522 



1. Contusions 522 

2. Wounds 522 

3. Fractures 523 

4. Dislocations 524 

(B) Internal Injuries 524 

1. Cauterisation and Sealdinfi; 524 

2. Unintentional Operative Lesions 525 

3. Haemorrhage and Rupture 525 

IX. Tumours 525 

(.4) Benign Tumours 528 

1. Fibroma 526 

2. Papilloma 528 

3. Cysts 529 

4. Other benign Tumours 529 

Intralaryngeal Operations 534 

Extralarj'ngcal Operations 537 

(B) Malignant Tumours 538 

1. Sarcoma 538 

2, Carcinoma 540 

Tracheal Carcinoma 553 

X. ITervous Lesions 553 

(.1) Disorders of Sensibility 553 

(fl) Anaesthesia. 553 

(b) Hj-peraesthesia 554 

(c) Paraesthesia 555 

(B) Disordei-s of Motility 556 

I. Paralyses and Parescs 556 

(a) Central Paralysis of the Laiynx 558 

(h) Peripheral Paralysis of the Larj-nx 561 

II. Spasms 577 

(A) Laryngospasms 577 

(a) Spasm of Glottis in Children 577 

(b) Laryngospasm in Adults 581 

(f) Laryngeal Crisis in I>ocomotor Ataxy — 582 

(B) Nervous Laryngeal Coughing 583 

(C) Vertigo and Ictus Ijarj-ngis 585 

III. Disorders of Coordination 586 

(A) Phonetic Spasm of Glottis 586 

(B) Inspiratory Spasm of CJlottis 587 

(C) Other Lesions of Coordination 588 

XI. Affections of the Voice in Singers and Orators 589 

Appendix — Meningitis Cerebrospinalis Epidemica 599 

Index 603 


f. HMU 

1. The 0W0OU8 and ciirtila^nnii» skeleton of thr itcptum 

nasi (viewotl from rlio riglit side) tafter Toldt) 3 

2. The left lateral wall ni the na*al cavity, showing the 

turbinaU ami ii;Lt:tl lUfalus (after Tolat) , . 4 

;i. I^ft Iiitt*ml wall of ria*iil ciivity (after Toldt) S 

4. Fr^iitul view uf llif nasal cavit}' (lifttr Toldt) 7 

5. Fruntal spction through llie posterior part ot the nasal 

cavity and maxiUiir>' sinus ,., 9 

fl. Septum of the notic. 11 

7. Rpflector (after Frankrl) 17 

8. Electric hcftfllnrnp (after Kiratein) 18 

9. Nasal speciil iiin (after Kramer'llaiimann) 18 

10. Antmor rhiiiusctipy. First iHwitinn 19 

1 1. Ant^iriur ihiiioMCdpy. Hccond jHi^itiun 20 

12. Spectihiiii for middle rhiiiasmpy (after KUltan) 21 

13. Nasal forceps (after flarlmann) 21 

14. Politner's bag with oUve-shapei.! nozzle 23 

15. Nasal asj)irat<>r (aftt'r Srhnfcrunn) 23 

16. Tonpuc (iciirt-ssor (after Frankd) 25 

17. Po9t*'rlor rliinnsropy rrpresentcd from In front 26 

IS. I'oatorior rhiriOKCupy sehematieallj- reprosenled from the 

adc 27 

19. Palatine h»)ok. (o) after Ji^raijw; (b) aitvr Schmidt 27 

20. Digital examinalitm of the naso-pharynfjeal space: Intro- 

duction of tlie index-finger int* the patirntH tiiouth. , 28 

21. Di^tid e.xajuinalion of the iiaao-pliftrjiigi'al i^pace: Pal- 

pation of the space acheamtically represented from 

the .side 29 

22. PrjHt-rhinoseopip imoKC 30 

23. Lamps for transillumination (after Wamccke) 30 

'24. Now? spray 38 

25. Nose douching with Starke't tlouching uppuratus 39 

26. Insudliilor 40 

27. Prol )e for eauterizntion 41 

28. a, KuHnrr'n palvaiio-cautery. univetsal hmndlc; t>, flat 

Imnier; c, jHjiuUnl burner 43 

29. Double needle.-* for elertnilysia 44 

30. Dilatation of the vessels oi» the projecting sqjtum. 53 

3 1 . Deviation in the lower septum towards the right 58 

32. Cutting forceps (after Gnimivld-Strujfcken) SO 



na. rM> 

33. Naaal saw (Schott) 50 

34. Double chisel 60 

35. H ei/j/iaitn' a uharp euppeil fort'eiw SI 

lis, Poty tiun uf tlic titiiiiHin (uftcr //ocAr/wyy) 08 

!J7. P«»Iy|)i at the atiteriur end uf the niicl4le amcha 77 

38. Polypoid onti pftpUlarj' hypertrophy of the end of the 

eonchik In the po^Whinitic picture 79 

3,9. PulypUB snare (afu?r Kmuxc) 80 

40. Bfckmann^a xitiaol scifisora 80 

41. Hnrtmann'» ronchotnine 81 

42. Nft«a! nir-filtcr (!>ft«r Afohr) 92 

43. S>i)liilitic smkUe now 102 

44. Syphilitic sadiilt; nusi', seen by anlerinr rhiiioscnpy 102 

45. Removal of ii foreign body from the lower meatus Ill 

46. Holdinji; child during removal of .i foreign lH«ly from the 

nose 112 

47. Removing a. mk^tl jxilypus 117 

4^. Latiifi-'x choaniil hn»k 118 

49. .Viisal elevator: (jn) I''(Idbau»cK-Iioth; [b) Sehmidthuism.. 123 

50. Probing of the frontal antl niaxillarj' sinus and of the 

antorior elhnioiilal cells (aft<?r Iliijck) 139 

61. Catheter tulie fur waslunK out the uiaxillnry cavity {after 

IJartmanrt) 140 

52. Sjritipe for the cxploralorv puncture of the maxillary 

oavity (after M, Sdwiuk) HI 

fi3. Resection uf the anU'rior end of tlie middle turbmal 

(djaprammalJc) ,_.. 142 

54. Trociw for nmxUlary eiwity 143 

.W. Gimlet for dental alveolus 143 

66. Lour punch furccps for the maxillary cavity (after 

Hajfk-Cla>ts) 145 

57. Cbronie empyenia tif the left (rnnljd simi.'* 147 

55. Oatlieter for wiLshinfC'Hittlie.fnmtal winufi [aftfT A.'t7Jicj7)) . . 14!) 

59. Kxplt)rat*tty openinjf of tlie frontal sinus in the eyebrow . 149 

60. Granifald's rotatory nasal forceps 151 

61. Iltijek's iiistrumetita for opening and Mcrajjung out tJic 

ethmoidal labyrinth 158 

02. IVobatory examination of the sphenoidal sinus 159 

&.i. Revolving punch fonreps for reseclluij; anterior wall ()f 

Bplieiiuidal sintis 161 

64. Cavum oris (afU-r Totdt) 170 

65. MacrogUissi.i (afler llfKhctwgfi) 195 

66. Tuberculosis of the tongue {flochenegg) 205 

67. Plaques iiiuqueuscs 208 

68. Fungus of thrush or Oidium albicans, prepared in glyteriu 213 

69. Hypertrophy of the liujiual toaiil 218 

70. Phnrjnx virwnl from behind (after Toldt) 234 

71. The natui-iiliarj-ngeal splice (after Tol4t) (right lateral 

view) 2:i5 



I a. 







Hj'pophar>*ng03fopy (wter wn Eieken) 246 

Suction upparatUM for the IoilsiI 251 

Spongeliol<!pr fur the throat niul nsso-pkarynx 253 

Stricture of pliar>-ns {aitcr Schech) 257 

Lt'fl-i*i(l«l pLTitoTisiUar tilisceasiflC InriKitm 268 

l*har5*ng(*al nckstirH with the bliiclcs bent oathc flat (after 

Conlts) 282 

Tiiiistl squcoBe (after liaitmann) 283 

Tori.Ml-.-<i>li(t(T (aftw M. Schmi4l) 283 

,\rkliniii vrgctutidiis 287 

AdoRototne (after IWhniann), ir v&rious yiscs 290 

Disj^raninmtir rcprcacntation of aJenolmiiy 2^1 

ToiiKil In limit' (aft^T Aftifhieu-FahneuHtock) 2ft5 

Appliciition of the tonsillotoinc 296 

TubcrriilfisU nf soft. iJiil.itn. , ;..,, 309 

Lupu-* tif tho mix. pnlftle (Tddl) 310 

GiiniTiiatoiin ulceration of the ^oft pnlatc in the left tonsil 

ami tht' posterior pliarynKt'itl wall (Tftrck) SIS 

T>'pic(il nasivpharj-npeiil jii-lv-pus (.V/t>w/i>j) 324 

I'lreratitig (rarcinnniii of the left toufiil (TiireJ:) 329 

Tho larynx, viowod from beliiail, tiic muados being 

rcmovud 343 

The atlitus liirj-ngis. viewed from lichind 844 

LiKatiionts of llio larynx. The loft half of the larynx, 

viewed froui w.-ithin (Toldt) 345 

Frontal section i.f tin- larynx, i-ir-wwi from liohJnd {ToltU) 34fi 

Sofottttl acction of hirj-nx. left side ( Tddt) 34T 

Musrlcs nf InPi'ux from Iwhind (after Stork) 34ft 

Musclea of larynx. Intersil view (.S'((Vfr) 349 

The thyroiil and arytctwid cartilages arc cut horizontally. . 350 
M. crieo-th)Toi<leu». viewed from in front and k-ft side 

[TddD 362 

Scnct, of tho lan-nx {Tddl) SS4 

Fusible cast of the bronehinl tree, frontal view (after 

Sahli) 357 

Diajiriinuiiiiiic n-pn-scnlntioii of the centers of respiration 

and phoniitirin in Ihi? brain and medulla oblongata 

and fhrir Iracti [aUcr RHhi) 302 

Lary-ngeal nurror , 364 

Indin-ct liir\'nfp>aw)pv. Insertion of the mirror (frontal 

view) . . ' ' 36ft 

Lnryngoscopia indircrta. Examination by mirror (lateral 

view) 369 

Omeysf^liaped epiglottis 370' 

RetroflcxR* epigiottiB. , 370 

HoklfTof rh.>ciiij;lottij< (after ^(ricAfrO .^ 370 

Relations of the larynf^oscnpical imjige to actuality 371 

Vocal cords during pliunation 372 

The same during respiration 372 







Snme during deep inapiration 373 

I.srj'ngo8copic imaK*-' (*'rilarged) 374 

ArninguiiM'iil for tlip exam inat ion by Kiltian'» metliutt. . . 376 
Position of the mirror in Killinns nietliud of oxaminatinn 376 

l'o»UTi(»r iilmn-np-iil wall iiiul liifurcu.ti<in i.KiUiiin) 377 

Siiljglottip liirj'iigoricopy .177 

Spatula of Kiralein 378 

Autoscopy (after Kimtein) (diiigrainmatii') 379 

Iiitralarj-npc'iil tubifonu spatula (after Kiilian) 380 

Univtraal dcmonstralioii dt'ctroscopi; (afti-r Casjxir- 

KU!ia?i) 380 

Long sponKO-lmlder for locul anawthcsia 881 

Tube fur l)ronrhnscopy 382 

A' itlian's syringe for aspiraUou of the nuious of Xhn tracliett 

or bronclii 382 

T.jM>Tigeal probe 383 

l^iynpial electrode 394 

iSpotiKoholder for the larj-tut 398 

PmntioK the- larynx , 396 

Liir>- ngciil syriuK"; 397 

Laryiigc:iJ iiisiifilfttor 397 

.\ppiirnMis for tnhfiJation 398 

(laivnnrf-cauMtic burner for larynx ; . 401 

Double n«>dl(' for c|['ctn>lysU 401 

Fibroa-* hands in the trjichca (after Tiirc^) 410 

Annular stenosis of the trarhcA (a.f1rr Tuirk) 410 

Soabbiird-eliaped conipreasion of trachon {Hodienegg) ... . 411 

Bilateral routpresaion of trachea (irnagr) {Tiirck) 412 

t'dtiipa-ssiofi of tht' left aik swn an inia|^> iSchriiUcr) 412 

Tracheal compression by ,i ivtrostcrnol thj-rwl gnitre.. . 415 

Tracheal dilator .418 

Tnichual eiuiula {LOer) 418 

KdTtv/n lung tracheal cnmila 420 

Insl.runieii1,s fur iiitubatidn (after O'thrncr) 422 

Intubation (after (yihi-ijvr) (scliematie) 423 

E?rtractor for O'Dirncr's tulu; 424 

Tube for calliotorisalion <after ScJirotter) 427 

Tin ililMor (bolt) for obturation of the larynx ami intro- 

dutiT (.SrirwHcrl 429 

Canula fittwl wirh Schriitler's tin holt 430 

C'himiifiy-canula (after Dtipuis) (one half natural aiae) . . . 430 

T-shapci.1 canula 430 

Subglottic liin.'n};itia 43fl 

"Cung«stiv<;" utiema of arytenoid farlila^ea and arj'- 

epiglnttii: ftilds - . . : 442 

Larj'nB^tis phlojnnonosa circumscriptn.. Altftciss of epi- 
glottis (Tfirrk) 442 

llnguardwl laryngeal knives (after B. Frtinkel) .... . 445 

Guarded larj-ageai knife (after Tcbdd) 445 



15S o. Paciiydermiii liirynpin 452 

155 ti. Thickpning of the epithelium of the piui-like projection 

nf tliR ptjiiitmiir wull 4fi2 

136. Chordilw notiusA (sinf;c>r*8 nodes). . . 453 

157. Chorditia h>T>ortrophica superior. 453 

158. Doubk- curetcc culling wnienlly i&tier hatidgral-Krausc) 457 

159. Scoopfxl fon^i'ps (after Itoxmhrrtf) . . 45S 

160. ItiRKt-adrd iM-richiindritia arytonuidea (TtircJt) 401 

Ifil. I*?t-aidpd ijerirhoiKlritis rricoidea (Tflrcft) 401 

162. l-iryngcal diphthtTia {Turck) 472 

Ifl.1. Hroiul-lnisfd iidillrftliun of t!ic pastfiriur lar^TigeaJ wall. . . 48^1 

164. Conica-l infiliratirm nf piiMt^-rior wall 4S3 

165. Serrated inrUtration and papiUnrj' cxcrcaccncca of the pos- 

ierinr wM , . , 4S4 

I6B. Infiltratiiin nf t\w (!pigloiti»!, arycpiglottie folds, an<l pus- 

torior Willi (Turvk) OH 

167. Tuljerciilous ulcers on bfjth vnral coriLt and ptwterior wall 485 

168. The loft vot'iil cord appears divided into two paxXs by a 

notcli-sliaped uIclt (lip-ulcer) 485 

169. Tiimitur-likp ulcer iif the right vocal cord, covered with 

gnimUatiuiis 486 

170. The right vocal cord is irregularly infiltrated, giving the 

appcarauu; of a tumour, with ulceration 486 

171. Pressure Forci'ps (after Krutiae) 493 

172. Curettewitli rmrolvingendforthepostoriorlarynppnl wall. 494 

173. Revolving double curettes <aftcr Krauw^ffrrnnf) with 

guide tube and wire, fixed oa a Krause'a univewal 
handle 495 

174. furftt^Miient of the right ventricular fold 496 

173. Remnv:il of thp (■piK](itti.< 497 

1 76. Lupus of the larynx (C'Awri) 490 

177. Condylomata of epiplotti.^ iCbian) 502 

ITS. Gummatous inriUraticin i)f epiglottis (Tiirck) 5o:i 

179. Ciummatous infiltration of iiRht vocal cord {Vkutri) . . 503 

180. Ciumniatoitf ulcxirs on the vocal cord and arj-cpiglottic 

foUU (7"(Jk*) _ 504 

ISl. Tlic same case as in Fj;;. ISO after healing up iTHrck) 504 

182. Both voffll rtinl<f ajp notched or Mrrated by gummatou-t 

ulcers i.Scknii^cr) ', 505 

183. Scleroma laryngis. Subglottic laryngitis; subglottir pads 

{TiltrJ:) '. ."HIS 

IS'I. Subglottic knot of scleroma on the right vocal conl 508 

185. Itwtrunicntii for rcmoviil of foreign bodies (after KUlian). 519 

186. Fibroma of right vocal eord [Tarck] 527 

187. .Same a» in Fig. 186 liuring photiation (Tiiret) 527 

18S. Pedunculated fibroma of Iffi vocal cord, ariiiing from tlie 

upiMT surface 527 

189. Hanie lis in Fig. IS8 during phunation. ... 527 

100. Fapillomn of right vocal cord (OtrfrO S28 



no. PMw 

!91. MuUipiG papitlomalA in larynx jin<l on ppiKlottis (OerteO.. 528 
1 92. Kxcet*sivc dcvt-lopuutit of papiUnnia in a cWld {Oertd) . . . 52S 

IM. Cj'st nf r|)i)tlt.ttis l}fackrmie) .■)»» 

l(M. Cyst ari^iiiK from the right \Ttitriclr (Brum) 529 

196. Revtilvinj; scuopfd foicL-ps. atluiiUtblc tti Krotiw** Linivci>u,l 

hiitiilk' 635 

196. Sessile siirccimn of the left vcntriculw fold 539 

197. I'tthiDciilntrc) siircoma of the rijelii vocal cord (Tiirck) . .. 539 

198. Small tulterouK carcmoiiia of right votal cord {Jtirtui) . . . 543 

199. Carcinoma covering thi- tiitirL- k-ft vocul conl ftrtci showing 

uleeralion (Tiirck) ! 643 

3(X). Cnrdnomii of the left side of larynx, showinR ulMration at 
thr jMistcriar wall, gpreeiaing on to the epiglottis 
(Tiirck) 544 

201. Carcinoma of the left aide of larynx, cliowing ulwration, 

jjeriflitmdritis. and cM^lrma {Tiiixk) 544 

202. C'arcinoriiii of rifihl hiilf of larynx, spreading; to the 

pharjiix and t^mpue (Tiirck) 546 

303. Carcinoma nf lower pharynx CTunci')'--- 546 

204. Hj*stpTic!iI pdnU^-mg of the .id Juctors on pho^nation 560 

*i05. HjTtteripal paraly«.'i of a<Idiictors. \'icarioiis lulduction 

of veutrii:id:ir foldl^ (Ckiari) 560 

206. PanityTq.s of left m. thym-an'tenoideus intemus during 

phonatirn 566 

207. Bilateral pamlj-asof mm. thjio-arj-tcnoulri interiii during 

phunation 566 

205. rnrulysisitf ni. arytpnoiilcus traiiaversu* during phonatlon. 506 
aw. Piirulv-sis of tlKi m. iirytcnoideiis transversns and both ram. 

tttyro-arjlenoidei int^^rni during phfination 566 

210. Paralyaia of left L'rii'0-ar\'tenoideiis posticus during res- 

piration ilf.ahi) ■ 56S 

211. Paralysisof hiJih thferico-an,-tenoidei|KMtiei. Kespirntion !S(i9 

212. Ptirnlj'si.'iof liciTh the ('ric(i-an,t<>noidpi postici. PhonHtiuii .WO 

213. PjiroKttis of left rrcurrciit unw (*lurins n-spinitioii) 571 

214. ParalvKis of loft rerurrent nerve (during phoniitionf 571 

215. Paralyeis of left recurrent ncr\-e (during phonalion) 572 

21fl. liilalend paralysia of tlie recurrent nerve 9>'minetrically 

on hoth wdtw 572 

217. Point««)f St iniulatioa of the lurvrigeal muscles (after ificfrta- 

««i) ' 576 


PART r. 

Diseases of the Nose and Its 
Accessory Cavities. 

Diseases of the Nose and Its Accessory Cavities. 




The shape of the nose is ouilinwl hy a skrlotoii rornposcd 
of ossi^ovis ami irartilaplnnus Heriti'iits. 

To tlic fttriiicr bi'loiig llic nascil professes of the tntperior mnjr- 
■iVae, which asceiul like wiri^. and the so-rsll(Hl tutml honet 
pro])cr, wliifh iiru coiiiiectwl with the rtiisRl process of the frontal 
bone un<l thus form the root ami the bridge of the nose. 

To those l>oiiPs arc fimily attachttl a few hyalmo nii'tilagcs. 

The triantjiilur rarlihfic jMLsscf from Iho aiitw'ior iiiargin of the 
cartihuintui.t M-ptum Intoralty uii both sides. 

To thfr*c an- attachf^l tlie u-ing cartilages, which tiini round 
(he nostril like a Uorwdiop. Mesially, bi^tween tlie two wing 

rtilages, can !»(■ feU, iii a sliallow groove, tlie lower end of the 
'^arlilntfinotiii Hejiliim. 

Betwwii the trifingidar nnd wing-shaped cartilages a few 
scsanioid cartilHgoR art' iiitersixTsed otj either side. 

Tlic lower margin of the trinngiilar cartilage turns a little 
towards thi- iumx r-ido. forming a ridgo, called the plica vt-jstibuli 
(vestibular fold), which separates tie vcstibuluin t»a«i from the 
iiasil cAvity proi^r. 

This walliil-iii space is aomfitlmea called the inner nostril. 

I'p'Ui the tiirlijagcs lie the niuscli-.-* which ililaU; or constrict 
the nares — levat«)r and depressor alae nasi. 

The outer nose is very vasculai'. The arteries are (lerived 
1 1 


mostly from the facial artery. The veins are connected icith 
thoNC of the nasal mucous membrane and enter the facial vein. 

Tlie iiervts are branches of the Nercnlh (facial), which sui)plips 
the nuL'^clcs; the infraorbital l)ranch of the .second ilivi.sion of the 
fifth, which is tlie .sensory nen'e of the bridge and alae nasi; 
and also tlie nasal branch of the first (o[)hthalmic) division of the 
fifth, which is the -sensory ner\e of the point of the nose. 

The skin of the outer nose, esix-cially at the tip and the wing, 
contains numerous sebaceous glantls, which often .show retention 
of their seeretions, and then are known as comedones. The 
skin is rcfiected mwards to line the introitus of the nase up as 
far as the ])lica vestibuli and the (interior end of the lower turbi- 
md. ICspccially in elderly jwrsons, particularly men, .stiff Iiairs, 
known as riifrissae, are found in the introitus, which not in- 
frequently may give rise to furunculous inflammation. 


Nasal Cavity. — The nasal cavity is divided by a septum into 
two halves, which open through the two choanae into the naso- 

The dividing partition (septum nasi.) consists of two bony 
parts: the one is the vomer, which extends from liehind forwards 
from its broad base at the choanae to its iH)int in front; alwve 
and in front of it is the other, the perix-ndicular lamina of the 

Attached to the os-seous elements is the cartilaginous iMrtion 
of the .septum— the qtiwlram/ular cartilage — which forms the 
UKist anterior part of the scptmii and often i)resents deviations. 
GSvFig. I.) 

The anterior border of the (]uadrangular cartilage is always 
covered by skin. 

,\t a jtoiiit on the septum, corresjwuding to the anterior end 
of the nud<lle turbinal. is a part of the mueiius membrane 
which is often thickeiK-d by a conglomeration of sebaceous 
glands, called the (nhcrcidum .lepli. 

.\n organ on the septum of great biological interest, but in 
man only rudimentally develo|H'd, is that known as the organ 
of Jiicobsim, culled the "corpus vomero nasale" (or vomero- 


naMi] body), which is ritijatcii in front aiwl Ik'Iow iho tuiwrpiiliini 
and funiitt a liibulai- etructun! nintajtiitig nerve rilaiiiPiits. 

nil? septum U at right angles to the mmf of ihi- iio!*, at Uie 
tamitia crtbrom, which is the thiunefit part of the basts cranii. 

Behind the lamina crihraaa. and forming aii atigV with it, 
the roof of the iiosp is formed by the anterior wall of the sphe- 
noidal sinus. (Sep IjcIow.) 

IVuta galli 
Lcmin* cribroM irlsht bolt) 

*""'"" penMnilimiliun iimi vlluitoiilBliM 
ProMMU* (phmoiilall* wiilt carillMiliMl 

-8iniM (mnioJIi 

-Siiiant niw*>rtiiitulii 


0> iiwiile (ikxinim) 


■rjiti uli^ 


Pan butifiiilslM (H 



Biltvn palaiiua ii«ii><rorK> 


Crhia luuMlb 

rnioi^vtt |i«Ji' 

^ I'kliitMin 

Fig. 1. — Tbo ttewoufl and cartilaeinous MlcdcUm d( Ihc scp;um vaA (ricwrd 
fniin x\iv rijKtit aiitcf la/lcr 7«J<A). 

Of (Treat imjKirtaticP Li the anatomy of the laleral nasal wall. 

The uiid'Tlyiiig strticturx? of the lateral iia!>al wall itt tlie inner 
surface of the »<ii|H>nnr maxilla. 

The large opening in the su|)i'nor maxilla — biatiiK maxillari.'> — 
is iiaiToweti throtigli tin- ntJadunent of various hones in Hiirh a 
way that only a -Hriiall hole remains, tlw ontiiim mnsiUnre, through 
which the mavillflry eavicy — tlie aiilnun of Highniore — coin- 
muuicak'^ with the nasal cavity. 

4 DI9E.\8E8 OV THE N06E. 

Tlic narrowing of Uic liiatur* i« partly iluft to the palat*; Imnc. 
ChicHy IhrouKli lhcprot'Csan.sclhiiiui(kIisi)f the inferior turimial 
uniting Willi ttir^ proi'i'ssus iiiiciimui-s of lli(> ctlnnoHltil Im>ih-, 
which liescends from above and in front, (h)wiiwarils ami liark- 
WBwls. (Spo I"ig. 2.) 

KswntiaJ in rt-ftanl to the topof^rnpliy of ihc nawil cHviiy are 
tho three turbinals ; thf upjter am! w 'Mk of wliiHi bduiiK lo the 

Cnnatut noMli* moiUa 
Oon«hk mbmU* lujiwwr 

Qiiliuni ■!>))* noidkle 
' ItiaWiiw «pherii»rihimiiilmlM | 

Hypophyv* ^^ \ 


ucci;iil»llB --^1^ 




Elevation •)( 


Vduw i«tallnitti 

U«B(iu OMti Bisdlua 


/— Sioii* (ronlafic 




AtniiBi IDmtw 

Uiu*n iiMi 


lum nail 


~ major 


Kamnliu nf ito 

Cvixha nanlii 

t1pnl<i* luwt iabrior 

l>1g. 3. — ^Th« Mt Ut«fal wall of the nftsal e*vi^, showing the turbinals and 
tuaal meatiu (<r/W TMt). 

ethmoidal bone, the lower being a structure of itself. The 
stiperior lurbiiuit (concha superior) is so hidden that it cannot be 
seen by anterior rhino?e«py. lis anterior end is continuous 
with thn middle turiiinal, whieh lies immediately below. 

The midifU' (urbinal (concha media) liiu; a lengtli of 20 lum. 
or more and projeetj* free into the cavity of tlie nose by its 
anterior end. or operculum, 10 to 12 mm. 


The small space Lelweeu Ihe uiidcUe lurbiiiaJ ami the spptum 
is called the olfaclorj- chink friiiia olfacloria). The inferior 
iurliiiuil (concha inferior) is attached by its iiiaxillar>' |>rocea8 
to \he nasal surface of (he sut»erior maxilla, ami its lower free 
margin protrudes into the nasal cavity. Its siiie varies much. 
Thi- IfiiKtIi \* between 2.'j and 50 mm. 

Iletween the up[K'r and ini(!dle turbJnals is llic suptrioT meatus; 

lafilDillliiiiluni with thr iiiuiUUry (Mtltun BiilUelhiiioi(l>]|a 
OpcmiiicK iiitu llw plhiiiiiiil laliynnlti 



Siniu luh*- 

milt tt*.liu^ 


\ini\ \U 


'- — Blnui fronnUla 

-OfUiini (nialalc 
Cul Dd|R at 

biniu* liut« 

hilwie »- 

"'. \ HmIih 

— lUUi 





Ln-ai<» ■ 


\ CunphA 

■ l)i>pnMilirn 


MoiiM niui Infrrlw 

Fig. :t. — Left lateral wall of nasal ravil^'. Ttie icrealf-r purl of llip iiiMiUe and 
llw aiiterior end of llii- U|)|)cr turliiimlit are irniuved istfter Toldt). 

bftn-wn the middle and lower turbinaU ia the mi(UUe mrtifiw, 
aiwl between the lower turi>inftl anil the floor of the now is the 
inlerutr meatus tif the iios<*. 

Into the inferior meatus, almiit 10 tiini. behiml the anterior 
end of the inferior lurbinal and ininipdialj^ly Ix-low its altach- 
inent, is (he opening of the naso-lachrt/tnat rfucM {ductus nflNO- 
tachrymalid) (Kig. 3). 



In the middle iiioatus aix' several K|jttci'>, varying in Mxc, 
DUmbtT, and form, and cttVCl*etl wilh mucous the 
mosi iniiHtrtaiit of which is the hiaius setnUunaris, running 
ciiniUiicarly fruiu alMJVe and iti front dtnviiwards and back- 
wards; this cxpandfi dmvruvnids in a funn<-i-»litt[>otl manner. 
foniiitig the injnTuiihnititii. Into the infundilniliiin oiM-ns above, 
the frontal sinus by tlu' ostiutu fnnilah; and a little Im-Iow and 
Itehinti o|X'iif the anli'uin of llighmore by the ostUiiii niaxillarc; 
l)ctwocn ihow* two aif the several (iiH^niuRs of the aJitcriwr 
clliinoiilal cells. 

Tlie bulla etl\moif(aH.\ ft boss-like expansion of the ethmoidal 
bone, ovi.rhangi' tlu-hiatiu' H-niiluiiariH, vaiyin^r verj- rt>nsiderably 
in size. «i that the anatomical configuration of this region is vtiy 
mucli iiilluenPiHl by it. 

Ile-sides the fronio! and maTtUary cavities and the anterior 
elhmoidal celU, tlie ponterior elhininddl cells, and sjiheitoidid 
mvity arc in cnniniiuucation vith the na^l fossae. 

Accessory Nasal Cavities- — The «mM.« maj-HJoris (antrum 
llifilitin'ri) lias llie slia|)(- of a |)jTaiiiid, the basie of which cor- 
rfwpouds to tbf outer wall of the now, and the ajjex towards the 
molar bone. The siirfares nf the pyramid are formed by the 
floor of the orldt, the anU'ri<ir or facial, and the posterior or 
latonil wall of the suix-rior niaxilla. Tlie anterior wall Iwlow 
the infniorhiial foramen in more or less doprcswd. forming the 
canine fossa (i-'ig. 4). 

W'hcr*? the facial and nasal walls of the antrum join, a broad 
groove is formed, running from before liockwards, which lira 
in Moine cases considerably (ieejxr Ihan the floor of the nose, and 
Zuekerkandl describes such a deep excavation of the alveolar 
proceaw as the sinus alveohris. This depression represents 
the most usual expansion of the antrum. 

On the other hand, (he Hoor of the maxillary cavity mip^t 
be on a level wilh. or higher llian that of. ihe luisal cavity. 
In any caxe the antrum varies in size and shape very frec|uently, 
and there are eases where Imlh i-avitieK fiiffer in size. Generally, 
the thinner its walls, the larmier i.i the anlruni. 

The ninus alvcolari.< might be so exces.'sively devoloiXHl that 
the roots of the teeth project into the maxillary (»vity. 


TTie frrmtal jfinue f^t^ina't frontalis) has the fonn of a three- 
mtImJ pyraiiii'i, the apex of which is directed towards the fore- 
liea«J; the \j)n^ 'a fonrie<l by the junction of the squamous 
arwJ orl>it&l jjart'i of the frontal bone. 

It lies over the rrxit of the nose, in the lower part (rf the 
Kt'jijarnoun fxjrtion of the frontal bone, and extends variably 
in all direetioni*. The cavity in adults extentls from the middle 
line an much an :> cm. Sontetinie^ the lunien is markedly small, 
and *A'en entirely al.»sent. 

TTie frontal f-inu.« Is di\'i(le<l in the median line by a more or less 
thick, sonietinu* iir-rforatc*!, septum, into two halves. 

The [»artition, however, v-- not always in the middle line, so 
that the two halves are often quite asyniinptrical. 

Tlie cavity ofjens Ijelow by means of the naso-frontal duct 
f^ductas tia.Mo-fron talis;, Ix'hind the anterior end of the middle 
turbinal Ikjuc. 

Tlie iiioiitli of the duct, the ostium frontale properly so called, 
licrt in the hi^ita" .'^■milmiaris, above and in front of the ostium 

The eihrnrnthd cells fcelhilac ethnioidales) form a labjTinth 
of thin-watled intercommunicating cavities, varying in shape, 
«ize, and numlwr, which arc separated from the orbit by the 
lamina pajivraceji Cos planum). 

f)rie differentiates anterior and ()f),<trrior ethmoidal cells. 
Tlic nnU^iiir cells oi>en by several aiKTt uros fforaniina ethmoidalis) 
into -the hiatus M'liiiluriaris of the middle meatus, heliiiid the 
ostium froritale. The j}o.yterwr cells oijen into the superior 
meatus, or are in direct conuiuinication with the sphenoidal 
sinus. By this way one can reach Hie sphenoidal siiuis directly 
from the etlimoidal Iai)yrinth. Sometimes one or the other 
of the anterior cells i)uljres towards the frontal .simis and its 
duct or lies in front (»f the latter; which relation might be of 
imi»ortaiice when using the probe. 

Of siH'cial imix)rtan('e is the bulla ethmoidalis, already men- 
tioned on page 0. 

It is actually an ethmoidal cell which convcxodly protrudes 
into the middle meatus laterally from the lamina papyracea. 
It usually contains a cavity, some-times of ipiite large dimen.sions, 

tbchMtl palate 

Vatmn palsllnam 

Fic. B, — Frontal MX-rion through the pontcrinr pari of llio niu»l vavit^r and 
tokxauiy maiXM. The poxtcrior f«ctJon u viewiKl Iroin tii front. 0|)cning of 
ill* ■phenoitbl caviUcH tjafur TMl). 

the other aficessory cavilies; somfliiiips it might f« ahnomiaJly 
small, anothrr time «'xc<'.-«ivfly large, aiiil iti such a ciii*c it might 
r-xlriid iiil<i rifiglilKiuriiig Imhios. Sonictinif-s the siiium w alto- 
gi>1hi-r nVutaing. and only a .slight n>RpKt on tJie anteiior wall 
<>f th(> Kjilinioiilal Ixxly, tvliich is liiti'il hy ria.«tal iinirouti menihrane, 
is all that m othor coiKlitions rcpi'eM-ntK Ihc sphrtioiiial siniut. 


The sphenoidal sinus is divided into two or more unequal 
parts by septa, or there is only one cavity, owing to absence of any 

The anterior walls of the sphenoidal sinus, which looks to- 
wards tlie nasal cavity, and the ?</>/>«■ wall, which carries the 
oplic cliiaam and the Itypophyns cerebri, arc relatively thin. 

This explains the hability of the eye and the orbit to become 
involved in inflammatory prneesses of the sphenoidal cells. 
The lateral walls are usually very thin; thicker is the lower 
wall, which forms the roof of the liindcnnost \ia,rt of the nasal 
cavity and n!i.-:o- pharyngeal space. 

The anterior wall of the sinus mipht be [mrtially or totally 
absent, aiul in this case the ethmoidal cells arc continuous 
with it. 

J'^mbryologically the sphenoidal sinus must be considered as 
really the liiiidermost of the jMisterior ethmoidal cells. 

At the point where (he anterior wall of the sphenoidal cavity 
meets laterally with the jjosterior end of the ethmoidal Ijone, is 
found a depression of the nasal mucous membrane called the 
reiTx.'<us ■■'plinio-clhiiioiildli.'^: into this recess o[)ens the sphe- 
noidal sinus, by tlie osliiiin sphenoidale. 

If investigated from within the nasal cavity, the oivning is 
found as a mimite aperture innn{;diately lielow the roof of the 
nose, somewhat al«)ve the iwsterior end of the middle turbinal, 
and a little lateralh-. 

The Mucous Membrane of the Nose.— The nasal mucous 
membrane can be difTerentiated into three sharply distiiiRuishable 
sections, wliicli are also different in regard to their function. 

Tlie lirst seclioii. which lines the vestibuluni nasi, is merely 
the continuation of the external skin, reflected round the carti- 
lages into the iulroitus, and is covered for this reason by several 
layers of .squnmom epillielinm. (See Fig. (i, septum nasi.) 

The following section, covering the greatest ])ortion of the 
nasal and the accessory cavities, shows Ihc characters of the 
respirator},- nmcous membrane. It is lined with ciliated epi- 
thelium and characterized by its liglit red color. 

The third and smallest portion, carrj'ing in its substance 
the specific terminations of the olfactory ner\T, is more yellow 


or ydlowish-browTi; it« (■pilhRliuiii is thicker than that of the 
Wwpiratiiry portion, aiul Im coiii|xbcJ of otfactor if ceils, supporting 
txUx, Olid basal cells. 

It iH iiiten-ittuig to nute that just Uiis i>ortion of the nasal 
iniHTOus iiiembram^ which funiw the niorpholnj^icfll hasis of 
thf st'Dsory organ peeuliar to the nosr, i^ limited to so small 
a region. This can Iw taken as a proof of the little <lelec1*ble 
fact that the sense of smell in Homo sapiens ia on a retroKratle 
iiiov(^iiicnt, or nct-nm to di^goneralc entirely, in coiilradistinction 
to his ariinial athnitif-s. 

In tlio olfacUn-y retfiua (reg^o olfacloria) »unie tubular glands 

&MC)'> ntfa^o-riii 



Tfnfuiilicin Ka4 | 
Ftg. 0. — Scplum of ihe DOM. 

(j;huul!< of Bon-man, RJanthiiae olfactoriae), an<[ in the respira- 
tory region (n^gio rocpiratoria) acinous glancis, in enonnous 
i)umh<;rs, arc fomul. 

Biootl-renneh. — Tlii; nasal mucous membrane is very vascular. 
The arterial blood-supply is derived chiefly from the s])lirno- 
palatiiie artery fartpria spheno-palatina). which, ariwinii from 
the internal maxillary artery, ilself ^ives o(T the fwslerhr and 
bUeral na»it arlerien to Ihe lateral wall of the nanal cavity, and 
tlie posterior niujal artcricH to the »ei>tuin. The scplum receivee 
also liranches from the facial arterj'- 




Lastly, the oplithaliiiic artery from the iuterual carotid 
sends the 07Uerior and postericr ethmoitlai arteries to the mucous 

■Rie veine accompany the arteries and open into Uie jacial 
and Uie ojMhalmic veins; but comniimicatc also, through the 
inminn cribrosa, with the wins of the dttra maler and loj\f)Uudi- 
iiai sinus. 

The veins form & dense network in the mu«jus membrane, 
especially on the tvirbinal IwHlies, whtTe the tissue assumes 
a cavernous character, due lo a pecidiar formation of the vcina 
thcniBdves, and siniis-likc dilatations of their lumina; in that 
rcsppct Ihcy art^ spokirii of a.^ caixmom bmiictt. The caver- 
nous bodifs, lbcn.'fore, as can be wren, art' interjKM^-d into the 
venous system. 

The fibrous tu»ue, wherein the MiK)iig>' cavernous tismie is em- 
iH'ilded, is rich in elliptic and muKCuhir fil»cn<: which cxi>Iaiiw 
ihc rapid swelling, on and olT, of the iiiucouk membrane, a. prooexs 
which '\s governed by the irigwninal nerve, es|)ecially by the 
fillers coming from the .spheno-pjUatine or MecktVs ganglion. 
The cAVprnoiiK bodies are, acconhng to Zuckerkandl, (imird in 
greater bulk where the mucous membrane conies in contaei with 
a large quantity of air; that is, on the entire lower turbinal 
Imdy. on the lower nunrgiti of the middle turbinal, and on the 
posterior ends of the middle and fu)X':rior turbinals. 

Some authors ileserilx" aLs<i ra\"rnu)UH tissue as being found 
nn the septum and tulR-rculuin septi. Proliably this is only 
an exceis of gUmdiUar tLsftut^ in that position. 

The cavernous lioilies liave the function of waniiitig the in- 
ttpircd air. |)eHia[»t also of keeping the mucotts metnbratie humid. 

Lifmph-t'&titeh. — Tlie hinph-vessels of Ibe nawd mucous 
membrane forai an extremely dense network, which, aeeoniing 
to Axtt Key and Rctsius, eoninuinicate with the mhdtiral and 
subamchnouial space: but this is denied by Zuckerkandl. 

.VfTiYs.— The ner^-es of the nasal nuieons membrane are 
deri^Tii from the olfadorii and trigeminal. The first is limited 
excl^la^Tly lo the olfactory r^on; (he Utter supplies (he 
olfactoT}' chink (rima olfactoria) and the entire respiratory 



TTic olfaciirry buJb (bulbus nlfactoriiis) lying on the lamiiia 
cribrosa wiids very lino filaiiK-iilf tlinniKli thf; holes of the 
cribrous pluk*, wliidi nuiiily tiiid ili*.-*rcii(l aluiif; Ihc .■•ijituin ami 
inner surfaces of the supt-rior turhuial. luicl Icrminatc in short 
processes, called nmellinti-hnin, vnthni thi- olfiirioi-j- cells. 

The fifth nerv'e pntvides, from its first nnd wcond division, 
the sensory nerves for the nasal mucous tiipnibrnne. TIk' Henn- 
Umj fibers are derivTU, according to Aschenbrandt, from the 
spheiio-palatinc nerve of the seconJ di\Tsioii. 


The iKwi" i.i not only an or;;an of winell, but piayn an unportant 
rOle iu ree^piralion, ae an air eouduit. Both functions are in a 
cerlaln connection with one anotJicr. The perception of snicll 
depends on the ijoseibllity of eonveymg stimuli to the olfactory 
chink \i\ means of the air current. If breathing Ik^ »ili>ppe<l, 
no anell caii be perceived, however volatile the oilorous fdibstance 
may be. 

I'nder normal conditions the air current in respiration passes 
throusb the nose exclusively. Mouth-brealhing is any way 
palhological. The direction taken by the air current in in- 
spiralioii — as JiiirchmrK has recently shown on a bisected skull, 
artilieiiilly (tiled with soft parts, and eorrutjorated by !Uih\ — 
goes from the nostril upwaril^ through the middle ineattu; 
and small deflections and irrepularities jiromote the conveyance 
of odouroiw substflncf-j^ to the olfactory region. On its way 
throufih the now the air is warmed, moistened, and cleaned. 
AccordiiiK to Aschenbrandt and Kayser. the air is wanned up to 
30** (_'., from mtxterate outdoor temperature; and is eonipletely 
eaturated with moisture. Both warming and moistening of the 
Mr are done by the cavernous bodies of the mucous niendirane 
(see pape 12). The air is not completely cleaned liy the ii(»fse, 
but anyhow a (»reat deal of the dust and other impurities are 
precipitated upon the moist mucous membrane, whereas the 
remainders deposited on the posterior pharyngeal wall, oppasite 
the choanae. Alonp with the dvut, l)acteria also are retained; 
hence tJie normal mucus is poor in microbes. Whether the 


nasal mucus, as is contended, has a bactericidal action is doubt- 
ful, and is certainly not proved by the fact that the nose forms 
the door of entrance for so many pathogenic organisms. It 
is certain that the protection affordef.! by the nose is not absolute. 
According to Schoiitiboe, bacteria are much more nimierous in the 
vestibule than within the nasal cavity. 

Snielliiig is a very complicateil fimction, and varioas points 
must Ik' considered. We smell not only during inspiration, but 
also during expiration. The ailniission of odorous particles 
through the choanae is, according to Nri(/el, more important 
than smelling through the nostrils. Kxpiratoiy smelling is 
most jironounced during the aet of swallowing; thereby volatile 
])articles invade th(; nose from hehinil and excite sen.sations 
which are fre(]U('ntly mistaken for gustatory i«>rceptions. Ztvaar- 
(k'lrutker sjjeaks of a ''pustatorj' smelling" in this sense. 

Whether tlie trigeminal ner\T takes part In smelling is not 
yet ilecidcd; I)ut is ])r(il)al)le from the investigations by 
Mnycndie and Kraufe. This nen'c prol)ab]y has tlie task of 
bringing to [XTception shar]). irritating, or acrid gaseous particles. 

In total anosmia acrid substances, such a,s sal anuiioniac, 
vinegar, formaldehyde, etc., are still ]>prceive(l, jx^rhaps as smell; 
although the sensory fillers of tlie trigeminal nerve may eon- 
duct the stimuli. 

In order to excite the sensation of smell, odoroas substances 
must I)e gaseous or in such a ])hysleid state that they can mix 
themselves actively or jiassively with the current of air (G(i)ile). 
By prolonged excitation the H^n^' can be so infiueneed that it 
becomes fatigued, and only after several minutes does the 
olfactoiy nerve once more recover fvuictionally. The simulta- 
neous uifluence of several odours ]>roduces a mixed sensation of 
smell, or a single odour might abolish the others. In children 
the sense of smell is very acute, but in old age it is <luuinished, 
and decrea.'Ts more and more. 

Now a few words about the nose as a rcfcKxcitiiH! organ. 
The rellex irritability of the nasal nuicous membrane is very 
markeil. owing to the almndance of its senson,' nerves. From 
every (lart of tlie nasal nmcous niemlirane a rcHex can be excited ; 
and, according to Snii/liiiaiiii, most easily from the so-ealleil 


"irrilable zones." Those lie on theiiiil<*rioraml po,storioroinlNof 
the Hiiddlc aiui lower conchat? (turbiiialsj and Ihe forrcspoiidiiig 
gitps ou tJic septum. Best known is tlie imeezing reflex, which 
acts, 80 to sjKaik, a« the wateh-doK of the respiratory tract. 
If the spu9or>' (ilwrs of the nasal ner\'c. a branch of the ophthalmic 
division of the trigeminal, an- riliuiulttltil hy a foreign hody or 
niechauicnlly by chemicals or by [jathoUjgiral |irori\ss(x-( in th^ 
mucoiis mombrane, the stinmlus \n ceiitrijji-tally (■onclu<'t<'(i 
lo Iho m{>dulla, and thence eenlrirugally to the motor norvi^ 
of the soft |ndate and the expiratory ninwlef*, and thwi produces 
fl sudden explosive expiration which forces open tlie closure 
of the tliroiit and nasal cavity and drives (he air cxirn-nt fnrpibly 
tbrouch the nose solely. Kccent investijielions which .Vo./e! 
and other authors have made tend to show that the expiration 
patmv not throuj^h the no«w, but through the mouth. Siniul- 
tam*oiit4ly the HTn-tiutis of I hi- iniicdiis niciiibrane nrr slimulaLf^l, 
And the silirinkinK f^aiiseil tliereby prnduir.'* a .sulijcctivi- fi:^'ling 
of freeneas within thy na.sal cavity as tlie result of the sneeze 
ilwlf. and not solely on aceonni of the ejection of the secret*?*! 
nuK'-Uf*. Just as in sneeziiiff the motor nerves are broupht 
into action, so in tacJirynialina serrelory nerves, and in the 
swelling and slirinkinp i>f the ravern<ms tissue vasomotor nerves, 
are wincerried. Hie irritability of Tlu' na-^al mucoiw membrane 
is als4j the physii>l(){;tcal basis of a whole scries of pathological 
reflexes which will be discussed later m the chapter on Reflex 

Tlie nose plays an important r5le iw a voice- and Mpeeeh-pro- 
ducing organ, in so far as, togi-llicr with the nayo-pharyiip-al 
Bpooc, it forma the re.sonator for the soimda praUicptl by the 
larynx. The vibraiions nf ihe air-eolunm in tlie nose and 
naso-iiharyngt-al sfiae*? iiiiTca-se the somid ami accord the charae- 
teriatic timbre; henee obstruction of th* uaso-phaiyiifieal 
channel tends to nWvv the sound of the voice. 

The function of the acci's.'fory pavitie.*! is, aj^ the matter staiKls, 
not yet clear. According to one theory, they are snppooif-d 
to lake part in the act of smelling; and according to another 
thcor>*, they contribute to the wanning of the inspired air. 
The cxtraonlinary variability of tlio accessory cavities in man 



provtw that they are not very uiiportajit from a pliysiological 
point of view. 


Examination of the exlcrnni no»e cuii6i»ls of tnspectjon and 

Kxuniiriation of the nastd canty indudra the roUowuig: 
(1) Kxaininntiun from in front. (2) Kxaniination from iM^biml: 
€. g., fniiii tlu^ choanan, rfHiihincil with examination of the naet^ 
[iharyngi-al simetf. (3) TraiiMlhuniiuitioiiof tlievariousacccssory 
uaviltesof the no»>. 


ThiK ooiiiditts of testing the fuiicttoii ([>pnneal>ility and sense 
of wiiell), observing any sfierial o<iour (footer); inspection 
(rhinosooiMa aiiteriorj, an well a« probing; and eventually re- 
sorting 10 local anaemia and local anaesthesia; in order to 
reduce the volume ami pensitiveiicsp of the mucoiie membrane. 

The jicrnieabiiity of the nose with re*»|;ect to air i* levied by 
shutting off one naitril and then estimating the strength of the 
air current ej»caping through the other nostril by niemw of the 
handheld in front; or. by jJacing in front of the nostril a 
ecil<l mirror and olMaerviiig the condensation of the exhalation 
thereon {Ztntardemnker) . 

On the obetructed or narrowed side the condensation area 
is wnallrr. One must listen at the same time for a hiding noise 
which may be hearri in congenital narrowing of the nose, and to 
Ihe patient's voice with regard to quality of speech, which is often 
altered in these cases. 

The test of Ihesenseof smell— with regard to quftHty— is cairied 
out by rewjrtio various seen tsplacrd within each nix<tril!<e|iflratcly 
(carbolic acid, icwlofonn. perfmnes, etc.), and with regard to 
quontily — «► far a« the practitioner h concerned — Ls earned out 
by means of Zic^ardepiaker's olfactometer. 

Foetor froni the now of patients is perceived by the exaiuiner'a 
own Bern* of amell. dealing with each nostril separately. 

For anterior rhinofropy a good liglit is necessary, and this may 
be cither an oil lamp, incandescent, gas, or electric liglii. A con- 


cave mirror reflector, cenl rally perforated, serves the purpose of 
concentrating the liglil. It sliould liavc a foeal distance of 
about 15 to 20 cm. (0 to S inches) mul a diameter of to 1'2 cm. 
(4 to 5 incluw). The reflector Is fixed by means of a band or 
ring to the forehead. wf> that the central hole comes just opiiosife 
the ohst^rver's (tietter) eye. liotli physician and patient should 
lie seated, tlic latter in such a way that the light is on the same 
level as the ear and on the same side as the reflector. If one 


Fig. ".— iteflcclor (afler Franlctl). 

uses a reflector fitted with an electric lamp in the center, there 
is more eaw and freedom of acti<Hi. 

Bejtiden an incandt*scetil gas flame witliin a ]K)rcelain shade, 
an electric head-lamp which is fitteil with a small perforated 
reflector (after Kirxteiti) will he found uwful. 

By manipulation of the rcttcctor the liRhl is tlirown into the 
nostril; the head of the patient is tlien eliphtly lM>nt backward 
and the point of the nose tille<l upwards with the finger in order 
to inspect the entrance of the now. 




Fig. K.- Elwliifr head-lsmp {aftfr 

If need be, it can aUoIx- inspected by a laryiiReal iiiirrurliekl 

in front and manoeuvered as is necessary. This donr. the nnml 

speculum niay be introduwHl in 
onier to dilate the entrance. 
Various specula arft in use, 
the mast rtininion Itoing thow 
of fhtjJay, Kramer-} iirrtmann, 
Franket. Jvraaz. I prefer 
I\ramrr~Hartninnn's s-pcmhwn — 
for chiidn^ii, a correspondingly 
Bmaller size — the blatlcs of 
which arc easily o]x'iictl. With 
children and infants one has 
very often to omit the insertion 
of a speculum. 

The .s[)t-i'iiluin h M'ia*d wilh 
Ihe left baiitl, au tiiat ilu* han- 
dles are dirccttni downward^, anil the liael; of the hand i^ turnetl 

towanis tlie mouth uf ihe )Kitii-nt; tlieii the cloKcil intitnunent 

is inwrled, aUml 1 to I) cm. into the notce, 

the point of which i.s puslicd upwards; and 

the two blades are separated by ailwiuato 

prewiure nf the hand, so that the iwtient does 

not exporioacc discomfort. Sj^cial cari' fhuultl 

be taken at the insertion and opcjunj; of the 

sjKCulimi if the entrance of the nose he fie- 

Buretl or coverol witli scai», Tlie right hand 

of the exaniinei- is plawd on Ih*; fon-head or 

OCciiHituf the iffltient. The jwilient's head is 

then iiielined forwards so Mint one can ins|(i*<'t 

througli the KiKTulum the flimr of the nose, 

tliB low^r nieAtiis antl concha, and ab«n the 

lowest part of the septum. In (his posilion, 

which is calliH I the firM ftosition. the sfieruhun 

lici* nearly horizontally. In order to in.'^pcot 

llie foremost [lart of tlie septum the speculum 

18 turned outwards for ninety deprees. so that the 

are not o|)«ied from right to left, but upwanU and 



This mothod of inlroduction is also useful in pnticnts who suffer 
from iiosp-bletHiinK. bccHuse the blepding point is nt*arly always 
st'aled on the foreiiitwt point i>f llie j^pluin. ami could easily 
be injured by the pressure of the point of the inner blade. (Sec 
He. 10.) 

If the nostril is wide enough, one is able to see in the tlepths 
a small part of the pusterior pharyngeal wall, and on intonation 

Fig. 10. — Antwiop rhliiMcopy. rin.1 nosnion. Thr siwculum linn liorf. 

of t or u, the niovpinenla also of tho pad of the levator palati. 

(Soel'arl HI. p. Zib.) 

The head of the patient is then Teclin«l bnekwarda and llie 
upcciihun turned tipwanlf^; which niovcnirnl brings into view 
the iniildlf nii>atu« anil ruiu-ba iinil the vippt-r part of the ."vp- 
liHU, ami sniiietinii'S al-^ti the roof of the nose. This is called 
the Hovtut jKufitum. fSec Fig- I '■) 

P^. II. — Atilerior rhinaci'opy. S>>(iitiil p(Kiii«ii. The i-pri^uliiiu i» lurued 
upuanU and a Utile crbliquoly. 

For tlie beginner it is at first a Httte difficult to orientate, 
liecause tbe parts in the interior of the nose are all more or less 
foreshortens I. ami in ihe in.HJority of otsps fhow ili'viatitms 
from the normal, wliii'lnncn pn^vi-nt i ion. Thi- licst 
fTiiiiling points are i\ie. anterior ends of the lower and mtddb 
concha. IT the patient t uniH the hetui, we are Hometiineni enabled 





Fig. 12. — Spoi'- 
iiltim for miclJle 



well into Uit depths along ami Ix'twcen Uic lower concha 

mtd the septum. 

Straight and wide noiie.>< admit an uuiTti- 

pedeil iaspcclion, and, as the case may be, a 

view of the upper margin of the clioanfU'. the 

tubar |wid, and even Ihe ostium o!" tiie lulw. 
Probing (Examination by the Probe ; Sound- 
ing). — A prol)c of lloxihio metal, copixr, or 

silver is indispensable for examination of the 

interior of the nose. 'Hie licad of Ihf probe 

must be blunt and smooth, to as not to hurt 

or irritate the very seiuntive munous mm!- 

brane. The probe facilitates inspection of 

the nose, by pushing aside lengthy vibris*ae 

which may obstruct the entrance of the nose 

or bulging of the mucous membrane or mov- 
able swclUiig>s of the conchac — of coiu'?^, 

under (luiilancp of the eye. It often happens 

that on mere touch vi-ith the probe the cavernous tisstic of the 

oonchac shrinks no much that the int^^rior of (he nose can be »ecn 

to greater extent than before. Accu- 
nuilutiil wcretion.s ciui alwo \k' loosenii,! 
and may then be more eji.sily blown out. 
Uoufhing ill order to remove M*cr(^• 
tions .sliould be used only in cai^ex of 

Anaesthesia and Ajtificiai Anaemia 
(Anaemization). — In order to make In- 
spection ca-Hier it is adWsable to cause 
the mucous membrane to ahrink by 
jiiunting it with a sohiiion of ailrenalin 
1 : HHHI. It irt wifTirient to paint the 
muroiL-* menibmne sevend times with a 
swab on a holder, soaked with the solu- 
tion; or, if (he patient Ije nervous, lo 
insert a pad of eolton-wool soakerl with 
the .lolulion for one or two minutes; 

which can Iw done by means of the nusul forceps or elbowed 

forceps. (Sec Fig. 13.) 

Fig. Ill 'NiulbI lorcepK 
ia/Ur tlarimann). 



Provided that thn wln-imlin wjlution be frcsli, the niucoai 
iiii-iiibraiiL- will Ix- rtrmlorwl r(niip)rl^*ly anaemic by it. It looks 
([uhv white and shrunken. If we nuw desire to render the 
niiicoiw nienibnuie inwnsilive iiLso, we [mint apain wilh a hlllc 
of tt 10 to 20 per cent, eocaiiie solution by means of a swab. 
It is very couveiiicnt (o mix 4 i>.c. of a I : 1000 adn^nalin solution 
with 36 c.c. of a 10 poi" cent, aolution of coeainc for the purpose 
of |«unliiig the inut«)U.'! inrmliranc. 

Tlie previous or Himilraiicous npplieatJou of adrenalin reduces 
very much the danger of eocaine poi.soning. whieh was fomicriy 
observeil freciuenlly if cocaine wa.-* used sjlely. 

If one inj*erts a cotton-wool Hwab with coeaine tfolulion. one 
should take earc that the patient always inclines the head for- 
wani, m that none of the solution shall run down into the plmn,'nx. 
In children and patients BufTeririg from heart diwiiw it wliould 
be very eautioasly applied. SyinjHonis of puisonifig are pidlor, 
discomfort, jalpitation. sensation of cold, sweating; more 
flwious syinplonis arc: oppn-jtsion, nausea. vomitiuK. fainting. 
All tlie syniptoiiiH may »ft4T a lime dtapixar of them.sclveji. 
The treatment of the poisoning Ls merely symptomatiev— the 
recumbent position, fresh air, smelling salts, brandy, ami warm 
applications. .Amyl nitrite has sliown ltj«>lf useful. (R. .\mylii. 
nitrofi, Spir. aetheris nitrosi, aS .5.0. F. M. Several ilrops on 
a podcct-haodkcrehief for inhalation.) 

Siibsfitute.^ far mcnint ftre: Ueta-eucaine, eucaine kctatc, 
anaoslhcsin, yohunbin, stovahie, novocaine, and alypin. 1 
poesces real e.>cpericnce of only the last {aly]>ui), and use it 
ill 10 per cent, soluliot), which is oqttal to the more jxpisonous 
cocaine witliiHit niu-sing the mucous membrane t^j alirink — 
an effect whicli Is .soinetimcs (le.siral)lc in certain oixTalions. 
Tlie only d'u^advantJigc T have seen from the use of il is ao 
increa-^eil watery .seeretion. .\s for cocaine, so for adrenalin 
also, other .xuhstituii-.i arn- in iw, all «)f which contain the 
ax'tivo principle of the adrenal glands. 

I use for eertain purposes renofnrm, which is the pow()prc<| 
dry c.'ctract of the adrenal glatid. su»[K'ndpd in a solution of 
boric acid and milk-sugar. This mi.\e<i iKiraled renoform 
soiutioti lias the atlvanlogt; of infinite durability, iu opix>sition to 


adrenalin solution, whicli is easily dpcotnposed by air aud 

Tlic accessory cavities can Iw sounded only aft«r previous 
anacstliftization and aiiacniization; and siioulil be done without 
using any iarct: The probe s^hoiild 
In* hciit arconiiiifj to the purpose for 
wliicli il. is rwijuirfHl. Jn atrophic 
iliinitis KiHiiiiliiif; i.t caxy, whereas 
it is n'nilcn'd iHtHrnh, nr oven iii]- 
jiussihlf in eonditiuiw of swelling, 
especially in the r^inn of the mid- 
dle concha, in excrescences or pro- 
jections of the septum, l-'or the 
details of souiidijig the various ac- 
oesaory cavities see later in the re- 
spertivp rhaptfTH. 

DeSation of the Rose. — In certain 
tUtteases of (he accessory cavities 
wme authors have recommended 

4feflation of the nose. In order to aspirato the seeretions, Tlie 
simple*=t method is the so-called Tiegaiive politzerization cicscTibcd 
hy Seifcrt. (.See Kigs. 14 and 15.) 

Fig. il.~ Pohtter's hag with 
olivtMliupiil 11(11x1 1>. 

'/3n»l (Jr. 

FiR. I.V— Nasal aspirator {after Sektutnaa). 

TIic patient takiw a nnxlerate mouthful of water, the nozzle 
of Hie compressed Palilzcr's Iwi^ is insertiHl. alr-tighi, intx) one 



aoetril, anil the uusc itself compressed. While the patient 
smllon-s with the mouUi cluswi, the bag is allon-cil to expand. 
Sottdermann, Lcuuisr, wid Schuerson have CMiMtructed special 
nasal asjMralwa wUidi are intrtxiuail tightly into the DOstriL 
The patient is reqw^u-d to intonate a long-drawn i or k or a hij^- 
[utched o, whicli (tuuh-m ihc soft palate to press againi>t the 
posterior pliarjiigeal wall. and so to shut off the nasal cavity 
Iroui the [jliarj-nx. In my opinion, Sdineerscm's apiwraliis, 
which is only a modified SiegU's aural speculum, aduiil« the best 
view of the nasal cavity. The utility of this nietho<l is doubted 
by other authors, who point out that the rarefaction of the air 
in the noee has an a.<<|))rating efTect only if the accv»4:ir\' cavities 
were poaBcaaeil of fU-xiliU- walls and were in contiumui-'ation with 
tlie outer air by a second ofienhig. 

According to Vohnen, ddlatioii of the air in the no8c causes 
only hyperaeniia and increai^ed swi-tling, and producea therefore 
iust what is not wanted — olwtruction of the apejiiiign. Tliere- 
fore he feeoniniends air preesure; for instance, through air- 
douditng (Politjerizinp); whereby currents are pnxhicetl in the 
■ceesBor^' cavities which are naitahlc of carrying with them the 
wcrotions. Owing to the uncertainty of all these methods 
which have now l>ccn described. — Vohxti w-rtainly underrates 
Uie danger to the miildle car, — one should for the pn-senl (iiiic be 
satisfied with the usual diagnostic and lherap»-utic methoiU, and 
only in exceptional cases resort lo deflation or conipresson of air. 

POSTERIOR RHINOSCOPY lExAmiiuttoo from Behind). 

This oonasta of inspection and palfiation rer^pt^tively of the 
parte situated most jjosteriorly, v\z. — the njiyo-plmrj'ngtail s|)ace. 

For posterior riiinowopy il toiiguc-ilepn??«)r anil a i^tall 
plane mirror are rtxiimfd; llu- Utter lixci at an ohttLsciUigleoo a 
long han<lle. (Sec Fig. 16.) 

lijdit is n*fWt«l directly on to the soft palate, and whilst 
with ihi* left hand the tongue Ls carefully depn'sse<l, with the 
riglil liand the mirror, previously wanned, nnlhoul touching the 
mueotB membrane anywhere, is introduced to the left or right 
of the m-ula as far backwar*l-: as the jwstcrior pharyngeal wall, 
in such a tray tlml the uiuror tooka upi^'artU and forwarda. 



Mucous bubbles which niay interruiit the view may be destroyed 
by the mirror or be burst by the current of exhaled air. 

Rxaminatioii, liowever, succeeds only if the velum |-«ilatt 
deiK-mls flaccidly; for at tho mooient when it is lifted the view 
is blockii'd. It is therefore iwoossaxy to direct the patient to 
broatht' (Quietly and wlmvly, or that he holds the breath as 
long as |Ki«.sili!e, or thai he abruptly expiratcs through the nose; 
tJie tatter advice, howevpr, is more eaaily given tlian followed. 
Sometimes there remains nothing else but to hook forward 
the soft palato by means of a palatine hook. (See Kig. 19.) 
Unfortunately patients are often .so 
sensitive that even the depresfuon of 
the tongue or the mere touching of 
the palatine arch excites retching; 
hence, avoid iluring the intnuluctiort 
of the mirror any touching of the 
sensitive palatine arch or nuit of the 
tongue, and keep jdwayn close to the 
uvula, which is always insensitive. 
There is, however, the disadvantage 
that if one touches the uvula the 
mirror is smeared and ol)Bcureil by 
mucus. In sensitive patients local 
anaesthesia might be resorted lo; 
but one shoulil, if possible, perform 
posterior Hiinoseopy without such an 

The lieginner uill doubtless have 
many difiiciiitips to overcome; but one will nearly always suc- 
ceed by patience an<l practice, and, last but not least, by calm- 
ing the patient, he he adult or child. 

In young children and in caws where all love's labour is lost, 
one should not loa' much time, hut insert the thoroughly clpaiised 
index-finger lichiiid the vehim palati into the uaso-pharj'ngeal 
space, and palpate <|uickly the vomer, choaiiae. and ronf. 
(See Figs. IS and 21.) 

The patient being ficated on a chair, the left ami of (he ex- 
aminer is passed behinil the patient's heatl, which in (his manner 


1 6.— TaiigiteHlpprasor 
{after Frankel). 

Hg, '20. — DipitrJ rrfiminnfinn nf the Tiftto-plinrynBeftl npn'pc: Intrrtiliieiion of 
tha iridax-liiigi-r iiitu ili>e patient s mouLh. 

ase, seat, ajid consistency. In very obstinate chilUrcn a gag 
might bo used. 

Orii-ritiitioii in thp i>o.-it-rirni(»r«pir inmgp. tnviiiE to the 
stiiaUiu'ss of the mirror aiiil tu llic fcri-iil fun-sborU-iiiii}: or tlic 



iunipy moimd, whicli vcr}* often shoin-js, in its mid^, an opening 
called the pliaryiigeal bursa or tiir ra-cnewi pharynt/ctat meditm. 



-- y 

Fig. 22. — Post-rliiMMCopic imofco. 

If the mirror is then raiswt forwarils, the ixwterior i^urface of the 
veluiu and the uvula eaii lie iimpectej. (See I-'ig. 22.) 

Transillumination is oidy retjuired for the examination of the 

ivcesiory cjivities. ("See I'ip. 2:i.) 
In oriler to transilluniinate the 
niaxillary cavity, a specially con- 
structed incandescent -lamp is in- 
iR'rte<l into the patient's month in 
a (lark room. The examiner aska 
him to close the lips and the cui^ 
rent us then tiinied on. Then both 
cheeks apjiear alight with a red 
glow, and tlie pupils also appesu* 
rod, and the patient himself ex- 
lierieneen a sensation of tight. If 
the wall of the eavity is thiekenwl 
or if the cavity contains an abnor- 
mal secretion, the coTre«|x»ndiiig 
Fie, 23.— Iahijw (or iranv ."ide of the face remains dark, 

iSru^ViJ;yr,r,^^^^^^^ 1" '-''-r to .ran.illun.inat.. the 

ini<>|i; i'>) ii)ai{r.irvi»ie U.b; (ri frontal sinus, the lamp, fitted with 
inaia-rtilM>fr»l>«aUi, <<()*pntuln. , •, ■ , , ,- 

Uie magmfymg lens and cnrnHM ui 

its indra-mbltpr (theat]), open in front, is pressed againpt the 

inner aiijrfe of llie orbit. 




l-jcaiiiiimtion by limtgcn rays ia not ofton iPtiiiirptl, save for 
fort'igri iHxlifs hidden in Uic nose or ita accessory cavities or 
for & Uiiiiour. 



1. Heredity. 

2. Genernl roiidUmis o/ UJe, occupation, ag<;, etc 

3. Preinoux (Hseiifien, psfjccially of tlie nose. 

4. J'r Meat ill >tm)<e. Duration. Course. Etiology: chill, rolcl, 
traiic- ilisoa-sps (iulialatioii of dust, vapours, flc), bad hahitu, 
nmiiraincnU (iodine, bromine, arsenic, otc.) ; infectious disoases— 
for iTisUiu'c. iiilhwriza, acute exanthciiis. diiihtbcria, typhoid, 
piirumotiiii., sy|ihilir<, ami other tlJeeases; injuries 
and prcvioiLs lr«;atincnt. 

5. Suhjectire t^ymfttoins. — («) Pain. — In diseases of the nose, 
and Ktill tiioif iji iIidw uf Ihif arccwwiry cavilii's. lieadache of 
various characters i.s n very nitniium symptom; M>riKati<iii of 
fuhu'S.?, Uirobbiiii^, tftabbiiiR. entitinuoiw f>r pim>xyKiiml in attack. 
The pains arc localized l)y the patient in various placejj. Neu- 
ralgic pains ill the varioas areas supplied by the trigeminal 
iicrvR und ]}oriodical jiaroxysinK of ptiin, may indicate itirica.'^ 
of an acccAsi'iry cavity. 

(fc) Psi/chic /)i.'«^(r?«ifrr<'.f,— Depression of mind — liisHittLde, 
forgctfuhiCKs, and ?*iinibir .lyiiijjttans may be very pronounceti 
in obstruction of tlu- na-so-pbaryngeal spaci? and diseases of the 
accpsnory caviti*"s. 

(r) Otjxtructwn. — The sensation of nasal obstruction is often 
siiniilated by abnormal drym'ss of the nmeoiis niembrnne, 
On tlip other hand, narrowing of the nasal cavity through 
tlevialion ur piojer lions of the wpluin ; ^veiling of thft nuieoiis 
nienibranc; new-growlh.s. such tm polypi, adenoid vcgetatioiis, 
and abnormal secretions, caase obstniction. The obBtruction 
may juni)) from one nostril to the other, or shows itself if the 
)>aticiit. coTiiini; from outside, enters a warm room. Tliis is due 
to the cl)anf;e.s in the condilion of (.welliiii; of the cavernous 
tissue, wiiich 18 most marked in nprvous dis^•a-ics. The fwitient 


calls such a long-standing obstiuetion of the noec " etuffy-noee.'* 
This mostly means that t!ie obstruction is pcnaslcnt. 

id) Sneezitiij.—hi disposes ol the now, p«]K-cially in non-ous 
patients, snee/Jng as a roliex is very coiniiidii. 

(e) Ih'Murbanccs of the seme <if srrtcli art; present m various 
degrees. Sometimes the imtictit himwlf jjerceives an unpleasant 
odou^^-cacoania— which is usually a sign of disease of an 
ftccawory cavity. 


External Sose.— /».«;>«■/?««.— .Simp*: of the nofle; hroadening 
of the liridKP of the iiui*, for instance, through ncw-growtlis, 
jwlypi, inaligimnl tumours; "saddle nose" in defects of the 
osseous or eartilaginous structures due to hyphilis: devislion of 
the now, due to deviation of the wptum near the liitroitus, or 
new-growths on one side; swelling or ili.scolouralloii. for instance, 
thnmgh haemorrhage, hoils, dilatation of the hlnod-vensels, especi- 
ally in the skin of the upper hji, which in children very often 
18 inflamed, red, and swollen as the result of nasal catarrh; 
eczema of the hitroilus nasi. 

Palpation. — Consistency; tenderness, for instance, in boils, 
abscess, inflammation. 

Nasal Cavity .^f^) Examination from m Front. — It '\s as well 
U> begin nith the examination of the now with regard to its 
air-permcftbilily, Imtjiusc we can complete the examination 
more readily, then to investigate for foetor, and to finish witli 
rhinoscopy, having examintni the function of smell. 

(a) Test a{ A\r-}>ermmbiHty. — Nose-breathing is entirely 
obstnirted in atresia of the introitus or ehoariae (anterior ami 
|M>sterinr nares) ; il is niore nr less diniinislietl if there is stenosis 
only. Stenosis may occur at any [wrt of tlie nose from t3ie 
fntroitus to the naso- pharyngeal spaee (fonnafion of scabs at the 
introitus. insjjiratory drawing-in of the alao nasi, deviations 
and rxcre.'<cences of the septum, hypcrtro])hy of the conchae, 
e8]M*cially tJie lower turbinal. catarrh of the mucous membrane, 
scabs, tumours, foreign Imdies, adenoid veg<*taticins}. 

If we find the iHrnicability reduced, the followijjg symptoms 
can usually l>e noted: 



1. Stenosis-bruit, to be tested for on eadi side; it might 
be Tinilatpral or bilateral. 

2. Mouth-breathing. The moutb is kept opon, also iKiring 
sleep (siiorinp) ; the expression of iJie fiice is rhill fstiipi(i). 
In loDg-Htaiidirig mouth-breathing, cspt'cmlly in phil<irt'n, wi-tain 
changca can be noted in the oral and njiso-pharyngcal cavities: 
viz., shortening of the iipiKtr lip, dental cartes, high vaulle<l 
palate, hypertrophy of the totiflils, pharyngeal catarrh (see 
below). In infants etenosiri uf the noae prevents suckling and 
renders fcetUng diflicult. 

3. Allrrtilion of voire. The voice Jfounib thick and repre-ssed 
(rhinolalia clausa) ; this w foiinii iwually in cases where the 
posterior region of the nasal cavity or naso-phai-jTigeal space 
is obstructed (for instanc**. by adenoids). 

In eontmdiKtiiiction is rhimiliiUn njicrla, which is so produced 
that in ppcaking and sintjing too niufh air escapes through the 
nose, owing to incomplete yhutling-off of the nasal from the 
oral cavity, for instance, in paralysis of the aift palate. This 
coriditiiin is impularly teniied ''talking through the norte." 

4. [>{if(urha7ic£ «/ .tfjeech. Constaiit mouth-breathing alters 
the siK-ci'li liy rendering it iridislinet (staraniering),and la some- 
times the t'atis<' of stuttering. 

(h) Ascertnininij of Nnxnl Foetor. — Bad odours from the nose 
must lie (toiight for on each mde sei>arately. It is very con- 
Hpicuoiw in ozaena ("Ktink none"); in ulcers and retention 
of fiecrelion ilue to foreign bodios, calculi, or sup]iuration in 
acceiwory cavities. 

On examining, one muBt see that the mouth \9 kept shut in 
order to exclude mouth-foetor (foetor ex orej from concretions 
in the tonsils or carious teeth, etc. 

(c) A nterior and M iddle Ithitw.'icopy. — Inspection of the various 
parts of the internal nose, introitas septum, floor, conchae 
(turbinals), posterior pharjTigeal wall; especially imj^rtant 
are; clianges in the secretion, (|uanti[ative and qualitative. 

Quantitative changes: hypersecretion m acut« or chronic in- 
flammation of the nose or it.*; accessor)' cavities ; diminit^ed 
secretion, usually in chronic processes of atrophie character; 

periodic discharge of pus in su])puration of the acccssorj- cavities. 



Qtialitathe chatiges: the RfiTi-tion w walfry. and if copious. 
i» caileil hijdrorrluiea namlia, in vasoiiioior lesions of the nose; 
or it is glairy, mucous, or iiimTu-punilonI or purulent, and in- 
clined to exsiccation. A imnili'iil scrirtimi is found in various 
condilions; for jnstanci', in 7<iippiii7iliiiit of iIr- m-eessor}' eaxities; 
sratxs are formed chiefly in atrophia condiiions. Sometimes the 
secretions are bloody or lilood-slairiwl ; for instanee, in ulceration 
or in atrophic discflw:- of the mucous nipml>ranc. fibrinous 
secretion is found in diphihcriu, fibrinous! rhinitis, and after 
caustic application?. 

It must be further ascertained whrlhtT the discharge i« tirtp- 
later(il—fX8 it is mostly in rif the accessory cavities and 
in cases with forcjgri hodies — or biiaterat. 

Finally, the place froni which the pus is derived must lie noted, 
aldiough it does not ahmys lulniil nf nhsoliile diimTuisis. Pus 
in the hiatus semilunaris, in the anterior part of the cavity and 
floor of tlic noBC is derived from (he maxillary or the frontal 
sinus or anterior ethmoidal cells, tir from several of these CHvities. 
Pus in the olfactory chink (rima olfaotorin) and in the posterior 
jart of the nasal cavity (ir luuso-pharynp-at .s[>ace and on the 
Itonterior pharj-ngeal wall, comps usunlliy from the poatftrior 
ethmoidal cells or the sphenoidal «ihis. (Tor details see 
siwcinl section.) 

KxAinination is completed by: 

1. Prohins (soimdinp); mobility nntl consistency of the [larts 
coiieenied; lendernose of the niucyus membrane; jwlypi; ostia 
of aeeessory eavitifH. 

2. Anaesthetizing ami anaemizing (arlifirinl anaemia). 

(d) Ej-aminnlion of the Sat-te of Schc//.— This will be neceffsary 
only in a case where the palirnt himself complains of disorder 
of his aense of smell; anil where certain conditions are present 
which lend us to suspect such a. h-siim, «,s, For instance, cerebral 
di-<eaw. Each side of Ihe now itiust !«• ti\-*t^xl seimrately; and 
the si'iise of taste must also be niitrtl. 

(B) ETnminalion frnyn lirhind. — Poslerior rhinoscojnj, and if 
this i« im|»oKsiblp. or has lo bi" siipplenu'id^-d: 

Fiiljvilion of the Xdsn-pluirifii'ietitSjHiri-. — Thi-rc are to !«» noted : 
Adenoid vegetations; limiours; ulcers in the naao-pbar^Tigea! 



Tpacpyaif^ia of the chtjanac; collections of pa*; aUcrntiona 
of the jxistci'ior cxtreniilk's of the conchae, ftc. 

(C) TTansilhimination. — 1. The MaxiHanj Sinut (Anlrum 
of liiijhmore). — If one half of the face below the infraorbila! 
tiiargin remains dark, if thf pupil does not apprar red, and the 
subjective tsenMilioii of lifihl is luissing, a collection of pus in the 
refi[)Gclivo sinus is probable; but only if ihere ore aixo oUicr 
chartif(eri.*tic sifviploftis of NUjfjmrolwn of that cnfUy. The fact 
of remaining dark jier se proves nothing, Ix'cauK- it might be 
alw) produced by a^^ynnnetry of the walls of the antrum, by 
tmiiours, and hypertrophy of the cavity, by polyjji; and, la«t 
but not,, by l!UU|KHts in the cavity of the iiohc (.\f. Scliniidt) . 

Still li'ss rclinbic is bilati-rjil darkne.'w, whidi is to bM;c\pl»ined 
by the thickness of the facial bones; on tht? other hand, Irans- 
parpncy do«"5 not iHsprovc suppunitiim of the stnas, 

Tranwiluniination, llicrerore, of the maxillary sinus is a very 
good aid to diagnosis, biU dues ttot asmtre it. 

2. Frontal Sinuti. — TranHilluininatlon of the frontal sinus is 
still Ic-w valuable; it dops not even show ns tlie limits nor the 
nature of the contents of the hIiiuh. 

Other Organs. — 1. Eye. — Dineaws of the now and its ac<w»t- 
sorj' cavities are liable to impiicate the eye, either by direct 
contitiuity of the intlatnmation to the orbit, or by transmiiwion 
of germs by lymph and blootl-vessels or by mechanical intiucncea 
on one or other part of the orbit. 

One finds lachryinntion Cepiphora). ilue ti> obstruction of the 
ductus naso-lachrynialis; ranjimctivitls; im|minnent of vision; 
contraction of the visual (icid; asthenopia; and in severe cases 
abscess of the orbit with iritis, i-xophllifllnin*;. etc. 

2. t^'ir. — Disea-ses of the now an> ofleii the sonri^e of nffections 
of the ear, es[»cia]|y in children, liecau.'ie. owing lo the gi-eater 
width and shortness i>r the FOustachian tulH*, the germs are more 
easily transmitted to the cavum t>Tnpani than in iwlults. If 
the air-way through the nose is obstructed — for instance, by 
ftatarrh, swelling of the conchae. adenoids, etc., — occlusion of 
the tutje may result, which in the end leads to rarefaction of the 
air in the tjTnpanic cavity and corrrs[Ton(ling retraction of 
the tympanic memhrane. Consequently, on the rarefaction of the 


mr ill the oaviim, transudation laktw place into it, as we «* it in 
casts of hy<{roiw ex vacuo. In other cases suppviratioii occurs. 
Uoarinj; is imiiaired either temporarily or jxTiiiaiifiill)-. 

3. '7'/«TArr-pa«3n(/«M.— Inflamiiiatiousof tln^plmryiix, larj-nx, 
and trachea are often WH|uelae of disea.-««s of the mist- ami its 
accessory cavities. Tliis is due to the .sccreiiims tluwjiig down 
aiid irrilaiiiig these piuewgcs (descending catarrh). 

4. 7'ce(/i.— (Jbslructftl nasal respiralioii i)fli>ti catistv caries of 
the teeth, for it fosl^-rs the invasion of the mouth by Imcleria. 
ManciMi fount! that m mouUi-hreathprs tJie uppt^r incisors 
and lower molars are chiefly alToctod. 

5/ ifrai'n,— Meningitis and abscess of the braiii may occur 
"I mflajnniHtions of the acceiJsorv- cavities through inflammation 
cxteiidijig into the skull. It is not yet quite certain whether 
tlie infection of the contents of the ckull enmuefi as a result of 
pervasion through the bone, or by the bones themselves being 
first Ulfcct^d. .'Vccording to Wekhselboiim, cercbrosi^inal menin- 
gitis IS not infrequently to Ik- traced to rhinitis. 

6. Stomach. — Disea.'ies of the stomach are sometimes simulated 
by Uie frct|ueiit vomiting due to abnonnal irritability of the 
phar}aix. Unpleasant sensations and a bad taste in the mouth, 
And morning sickness, are often symptoms of suppuration in 
the accessorj' cavities (Ilajeli). 

7. Reflex Disordere. — The nose plays a ijrent part as an organ 
exciting roHexes in other organN, (Tspccially in ner\'ous [witicnt*. 
In pariicular, a«tkma may be excited. 

We have tried in the alwve to give a sclienie which may suit 
most cases. It is, of courw,*, not necessary to emphawze the 
fact that in not every case of nawal diHease id there need of such 
a thorough analysis with reganl to arriving at a diagnosis. 
It might be sufficient in many cases to aasun- oneself of a few 
facts; and external inspection with anterior rhinoscopy will 
accomplish all that is rerjuirod. In other cases it is sufiicient 
to ascertain the more important points. 






Treatment of na-«l« ran only Ix- consi(lere<t as appro- 
priate if one lakes inUj coiwitleratioii all the manifolil relation- 
ships between afTcetioas of tlic nose aiid those of the whole 
IxKly. A great iiuniber of nasal diseases ori^ate in general 
(jiwordfi-s, or are in eonneetion with diseaw^ of other organs 
or Krou{iK of organs. A atyloly s|weializeHl trcatiiiciit, therofore, 
is not f<>asiblp, neither in the noec nor in other portions of the 
air-passages. Our attention should always be directed to an 
e\'entual priniarj' cau.*e or to a general disc-ase, and our trcataient 
has to be directed accordingly. The nose does not rcquij-e any 
Bpecial treatment in many cases. We very often succewl by 
general measures (see below). 


(a) Cleaning the Nose. — Hlotring. — ^Tlie simplest way U> clean 
the nose h blowing it "ft ia pnysan." The patient shiitj? one 
nostril — eventually the physician has to do it — ami blows tlu'ough 
the other nostril into a receptacle or hantlkerchicf. This method, 
of course, is [wssjble only where the nasal cavity is not t-oo 
narrow and the .tccretiun not too dry. Small childrr-n cannot 
blow the nose; anil here one can ht^lp matter.'* by inserting die 
oliviv^haixil nozzle of the iniiia-rublxT liag used for Politzeri- 
zation into one nostril, and expel the air by repealed sliarp 
couipressiiins whilst the child breathes (juietly. The spcretiona 
are thereby <'xpfll(Hl thrmigh the other imslril or into tlie pharynx. 

WiptTui Out the None. — IE thn patient is not too spniurive and 
the Fecretiein.s are not 1*i« nia»*i\*p, one can uee a s-[)ongp-holder 
dre»<e(l with cotton-wool, or even forceps, in the same way. 
This method can Ix; mailc more ca^ by previous local anaes- 
thesia and anaemia. 

GotUUcin'.'i Ttimponade. — If the secretions are desiccated, a 
plug of cotton-wool is put into the now and left there for some 
time. If tJien the plug w removed, the scabs adhere to it, or 
they are ren(lere<l so loose that their removal becomes an 

<ar TBX yOBS. 

*mf aMttrr. T^ut metlKxl is raOnl "GcAafatn'x tampanadp," 
mA ri ■ct* rdb^^ bv jnJaring secntioB. Ii is well to moistot 
Gbr flaf! vitfc s tittle fluid panffin. 

bmid di tg.—'Dif mifBng op of fluid or iloocfaing the noi« «ith 
Ivfpe ■ yrin g M imdcr Etroiig pnsure ^ouM be avoided, in oftler 
lo prpTMil the fluid fram pavtY&tinj; into the ear or arMssory 
nvitini. A mwe-^ nj i ay i» more safe, but is also morp oomplicatcil. 
rSee Kifi. 21.) In my optmui. ilauciung with i^o-caltnl noee- 
dooftMWMcnw fur^f^tlr t^tisfactory in cams wiiMV wr dmrt: 
only to desn the nacal ra\ity and na^o-phafyniERil fjiacc. 
Thive Daar douches an* ptar-, funnel-, ur lH>IMiapcil Ela»> vcRvL«i 
nf loataljlr mzr. with a ghcHl. inlet and a longrr hulh-ti)i|Mil 

deliver)- ni_)22Jf. fSif Fip. 2'>.1 I 
ailtnit that in all caav llir :«Treti(inj( 
an> not remcn'ed, but iliey arv at' 
leajft nioistrnoi! and lotisenw!, and 
thereby their n'riiovai is iiiaile eai^'. 
In exceptional caws I allow the pa- 
tient to aae an irri^tor. wliich, how- 
i-viT, intL-t not be huUR hifrfi up. so 
tliat no jin-wiire can W exeicisetl; 
or instead of this, a ;<nia]l syringe 
tn."ty be iiscd. 

Precauiiotu to fte taken m dottdiing 
the fUMf; 1. l*se no cold fluids or 
Kln>nfr sohitioiui. hut te|H(l. indifTer- 
Mit flutcbi of 2r>'' to 30" C, and wi-ak wilulioiu< of eoiniuoii snit 
((olium ehloridc). bicarlKitiale of wxla, !M>nix, ur iKirie arid. Of 
horax, nw otie-hnlf tt.'aspounful to half a pint of water; and of 
borip setd, in Foltition I or 2 per cent. 

2. The twdiition tthoukl be run in throufi^ the naiTOwer nostril, 
Ht llial it ran rucajie throuph the wider noptril. 

3. Hie {mticiil idiould bend his heati a tittle forwanl ko that 
(he xoliilion flnwM across (he ehoanae into the oilier nostril, 

•i. No prcwture .-Jiould be exercised, and llic flow sliould Iw 
rvtm, in onbr that tlie wifi [lalale remains contracteil and the 
na«>-i>luirjiigeal K|»aw? ."iliut off from tlio mouth. 

o. Ouriufc douctiing the putient should not be rHowihI lo 

nil. 24.-Sim-pnj. 



(b) Treatment by Drugs. —Medicaments arc mtroduceJ into 
the nose citiirr a^ Hu'uLs, liy painling, brushing, instillation, and 
massage; oraspowdrrs, by uisufflalion; or as "anuffs" (sniffing); 
or as vapours, by liihalatiou. For the purpose of painting, a 
probe or spoiige-lioldcr may both be used, liressod with cotton- 
wool, and thf same also for iiiassage. To perfonn the latlor, the 
mucous iiienibr-anp is nibbed in sliort rapid moveinents which 
should only be executed trout the wrist, after previous coeaini- 
zalioii, however (vibration niassaj?e). The liaiid may be rejjlaeed 
by an electro-motor. For instillation, aa ordinary cye^iroppcr 
can be usM. "Snuffs" «an be sniffed up through each nostril 
separately. Powders nin be inHutllat ed by means 
of an insuHlator. (.St-c Fig. 26.) \'nlatile 
rnedicaiiierits may be poun-d uilo the hollow of 
the hand or onto blotting-pa[x'r or tlie pocket- 
handkerchief, and sniffed up; urt»y means of prtv 
pared plugs of cotton-wool placed in the iiailril; 
for instance, fonnaldehyile or mentliol plugs. 

For bruxhing 1 use solutions of silver nitrate 
I to 10 per cent- and iodine (li : io<ii jniri, 
0.2 to 0.6; [lotassii i(Kli<ii, 2.0 to 3.0; glyceriiu 
pur., 20.0; ol. menth. pip., gtt. ij.). 

For ma«sage of the nuicoiis membrane I use 
the above iodine solution, or a niild ointment 
such as vaseline, boric- vaseline, lanoline, and 

Instillaliotvt are needed only in the cases of small children, 

and ben* I use liquid paraffin, of which I put into each nostril 

one to three drojw whilst the head is bent somewhat backwanls, 

Poiaderx «re iii-iufflated only after operative iiiaiiipulations, and 

even then seliloni {set- below). 

"Snuffs" are supposeil tti excite irritation of the mueous 
mcnihrane or to eavisn shritiking of Ibe same. For irritation, 
I use borax or boric acid; for shrinking, I use irientliol or cocaine. 
Cauterisation.—FoT cauterization, silver nitrate and perchlo- 
ride of iron (both dnigp in weak solution), and also chromic acid 
and triciiloraeetic acid (both in strong solution), are used- To 
apply perchloride of iron and trichloracetic acid a small probe can 

ftg. 26.— Iiuuf- 


be used, the end of which is dresftwl with a small piece of cotton- 
wool aiid then itfihtly ilipiH-d into the caustic. (Sit V'tg. 27.) 
Caustic poiiitfl uf liipiM iiifiTiia.Uriji.riil chnimit: liind «rv (ixL-d tu a 
probe or causlic-lioliicr. The prol)i' is heatol over & Hanie till 
it is red; it is now liroviglii into rtuitju-t \vi1h Uu' caustic point. 
When it has again becoTiif anilcii, a siiuill iiimiitityof the medica- 
ment will have adheriHl to the pmU', fonnijig a white Iwad 
thereon. Chromic acid is not so eiwy to umnago. The probe 
or caust^phoro is moistened and sonic of the chromic acid 
orystaU arc caught thereon and thai ren- 
dered molten at some distance from the 
flame. When cooHiig down, the. chromic 
acid forms an amorphous mass on the 
probe, of a sealing-wax red colour. If the 
chromic acid be heated too much, black 
chromic oxide is fornieil, which is ineffec- 
tive. Chromic acid Is very hygroscopic, 
and must therefore be kept \vell protected 
from the air. Liquefied chromic acid, how- 
ever, is also a Rooii eaiistic, and can be 
used by means of smaU cotton-wool swabs. 

Ferdiloride of iron and chromic acid 
jsLftin the fkiii yellow. I-apis infcnialla 
and triehUpracctic aciii Icavr while sloughs. 
The caustic .lihinild always hv used in small 
quantity and be placed on Ihe exact spot 
which it. is n't|uiri'd to cauterize. Ijipis 
infenmlis and chmniic acid should not Ik- 
aJlowcul to form large beads because tliey 
bnyik off ver>' ca^iily. Before cauterizing, local anaei^thcsia is 
re^iuired, and afterwards the superfluous caustic nmst be 
swabbed off. 

(c) Operative Treatment. — 1. Local ^nfle«//i«.siVi.— Almost all 
intra-na.-*!!! nmnipulaliim:^ are. at the prcst-nt time, jiorfiirnictl 
under local anw,stlie.sia. For this purpose, cocaine, 10 to 30 
per cent, solution, or alypin solution, 10 i»r cent., are uscti, 
having previously anaemized by the application nf luh-enalin. 
The use of these drugs for the purpose of exaniinalion haw lieeii 

Fig. 27.— ProlH! for 



already doscribeil (page 21). Yor treatment, the aforcttaid de- 
MTipiion (on [tfigo 21) holds good. In some cases, especially in 
oi)eratioiis on the scptuni, Schleicfi's im^'lUovl of local anaeatlll•^ia 
might tx; ifsorted to. Al'tor having cocaitiizLtl the site of injeo- 
iiuli, Schlinch's weak soluliun is injirtril under the nmcoua nietn- 
bninr until it is well mi-sed likt; a hlcb. (Schleicfi 's weak solution : 
Cocain. niur., 0.01; nioriJi. inur, 0.0G2; «(>lii i-hlorid., 0.2; 
aq. dest steril., ad 100.0; sol. acid, earlwlic. (5 %], gtt, 
ij.) Baumfjnrten Is satisiied with only a physuolngicsil wvhiLion 
yf SKMliuin chloride, lu *vhicli \w adds cucaiiu' (wnlli chkirkl., 
0.6; eucaiiie, 0.2 ; aq. destill. sleril., 100.0), and uites a curved 
cannula (or injection. After operation firm tamponade will be 
required in order to prevent after-haeniorrhafie. 

2. General anaesthe-^ia Ifi not f>ften r<spiirml in inlra-nasal 
o^X'mtions, but it iniglit be tuneful in ol)Htinat<- children wtio arc 
nol. eat^ily ronlrnllii] ; fcir instjincc, in iirdrr to ri'timvi- a furcigii 
bixly from the nose. I use chliirojirrm hy ihi- uMia! method of 
flropping it on a mask. The aiiftcslht-sja .^iboiild only be light, 
so that the cmighxng reflej .t/iouW no( lie nhotished, in order to 
prevent aspiration of blootl or seeivtioiw. I'or sliort operations 
I use ethyl bromide (aether broniatU!* puriwimiis). A large 
quantity is poured on to a mask, which i.-* covKred with an iui- 
jyenneable material (for instance, " ^fosclig's Batliste"), ami it i.-* 
then prcsscil onto the face; 10 to 15 grainmos art^ suflicieut, 
ponu'tiinw more. I'nconsciouKnew occurs after on&-half to 
nnc and nnr-liHlf minutes and last;^ nbcul two to three minutes; 
hence <iuickness in operation i.-* ilcsirable. 

More recently ethyl rhloridi' has Ihvii recomniendrtl; the 
waniith of the palm suffices to i-x}nA ethyl ehlori<ic fn>in the 
capillary opening of the lube onto tliP nuisk covered Willi six 
or eight layers of gauze. 

3. tnxtrunietUs. — \'rtrious tiu^lruments are used for nasal 
operations. They anil tliwr uhis will Ite deserilM»d in the special 
section under theirrcspecl ivechapter?. Here, it \s only necessary 
to tay a few wonis on galvano-cauterization and electrolysis. 

Calr<tno<iiuterizotion.—The source ol electricity may \k a 
galvanic Iwlteri-, an aciMinudator, or the main -supply. For 
lite tn'attueni of tlie nasid cavity [wintetland flatlencxl buruens. 


aiid snares of platiruini or steel wire are used. (S<« Fig. 28.) 
As n handle 1 prefer Kulhur's iiniversal in.strunicni. Tlic 
bumtr aucl stiare should iial be made hot before they arir plttrcd 
on the exact s]x)t. In ortler to prevent Wpeding thi! burner sliould 
not 1m' hcatwl to more than a dtill rwl and sliouM Ise lift<v! from 
till' niiifroiis Hii>nibranr> whilsl Mill red. Wldlc heat does not net 
as a HlypLir. Toiichiiip the skin of llie veslihulc is a mistake 
and should lie avoinlwi. Galvano-cautorizfition is a very effi- 
cacious means of destroying tissue, and has tho advantape of 
acting only on a particular s[iC)t aiid aL-w as a good styptic. 
These advatitam's are so 
con5j)iruuii3 that any dis- 
comfort cxfji'iicnccil after- 
wariis by Mif palit-nl are 
hardly to be considered; 
and they are so fiwcinntitiR 
that gnlvaiio - caiilerizalion 
has ijcrhaps fallen iuto 
abu.'v. Nowa<layrt a cer- 
tain di^incliiintion f^an be 
oKiiTViil with n-f;ard iu 
Kalvano-caastic over-cnthu- 
sia-siii, which we can only 
approve, (ialvano-eauslic 
and other oiH'raLionx in the 
now* should he reduw^d to 
the utmost niininiiim which 
i\ill still prc!^erve the phvM- 
olo^cal protectivR jxiwern; providml Uiat they haw not aln-ady 
hern lost by previoiirf diseases. 

Electroltfsis is relatively seldom iitiliwHl, becauw; of \ts slow 
effect. If a platino-iridilun needle be inserted into the liasiicrt 
and the cnrrent turned on, then with a crackling noiw at the 
IKwilivc clet'titKle Tanode) oxygen is pven off, and at the nejia- 
tive electrode f cathode) hydropeii is evolvcii. Water is abstracted 
from t!io titwue* and deconiix)sed into its component elements 
by the jralvanic current. At the anode the tissue is coagulated, 
owin;; to the oxidation, and at the eatliode it is liquefied. Tliut^ 
the tissue is slowly deetroye<l ; and the destruction is projiortlonal 

Fig. 38, — a, Ktittner'g mlvuno-rau- 
Itry. univCTnii! Iwiidic: b. flai burner: 
ft |Htihl(!il tiiiniiT. 




to the stretiRth of ilit- current aiid to the duration of its action. 
For tin,'* jmqxiao single or double necdlw are iis(tl (unifiolar 
or bipolar rnflliads). (Sec lug. 29.) Double jim-ilkw iire more 
effectual. In the unipolar inethcHi the jmmtive bul ton electrode 
is itjually placcil on same part of the skin of llip body and the 
npKativf; el(r(!lrode is inscrletl into the partinilar site in the nose. 
In the bipolar metliod both needles aeL Ui^fther. The site eoii- 
penied is previously anaesthetizetl. The in- 
t^'riwity iif the eurrent has to be measured 
aecording to the sensitiveness of the patient, 
and the current slowly turned on and off. 
The ."ingle sitting should Ifliit from live to ten 
or twenty ininut*'^; hut vitv ofti^n a whole 
iiftries of piMings an" n^iuirt-d, which take 
place at intervals of a few days. 

Fi?. 29.— Dou- 
ble ne«JI«i for dec- 
truly ilia. 


In the wonderful itevelopnient of modem 
medieine we we that, not only medieal treat- 
ment, but liypenic and dietetic factors are 
more and more taken into consideration, 
and, hand in hiuid with them, more .stress 
i.s laid on prophyla,\i.s. This make.s it our 
duly to iK-exime acquainteil with all the 
faet^irs whlcli aj*si.vt the organ (the nose) in 
uialnlaining its funetional powers, and to 
pii'lcct it inim damage. Tlie piihlie llieni- 
selves require advice frnm the 8|)ecialiRt as tti hygiene and 
prophylnxiK, and our entire servi(-e.'i are wimetiine** wilely com- 
pleted therewith. Owing to the iii(imal«' relatinn between the 
nose and other orgiuiy, we have to direct our attention and care 
frequently, not to the nose alone, but to the whole body. The 
rtjx'eialift must always he a complete physician ; he should never 
regard jxiriem pro Mo (the organ for the organism). 

The most important question here concemetl is "hardening." 
The more "hardened" a man is. the less liable is hi« none to the 
danger of '"cold"; and likewise the upper air-passage.'*, which 
are so much exposed to even* iwssible injuriou-s iiilhience. 


How a "cold" occurs is not alwuys easy to ascertain. Some- 
time« it is hy a sudden general cooling down of the body, and in 
Other caspa the ''cold" hits only a certain part of the body: 
e. S-, the heail, the neck, the feet, etc. "Uardening" has to be 
adapted to tho individual. In infants and old persons ii is better 
to abstain; whilst in children from the second year Ujmards 
the adaptation to weather changes must be earrfully regulaloU, 
This can be done by the regular application of eoltl water, move- 
ments, and suitAble clothing. 

At the beginning of tin- "hanlening" proccKS tepid ivuler 
should be used, about 20* C, and gnuhially diminish the 
temjKralure daily by half a degree lintil one ha.H arrived at 
a lemi^ratureof 10°C The method, however, nnL-st Ijedirected 
aeeordliig to condilion.s and individiml needs. I have seen ver>' 
good effects from cold frictions, which possess not only good 
results, but also are verj* convenient and cheap. For this niethoil 
linen or Turkish towelling soaked in cold water and wTiuig 
out is necessary. A large sponge might also sufiiee. The 
friction is beet done in morning on rising. Sometimes frictions 
can Ih- ordered twice daily, in the mottling and evening. It 
niigtit be liniiti'd to thr cbest and Iiack, or to neck and linib.s, 
or the whole hoily. in sections, can bt^ rubbed down, ftaving 
conipti't4'd the rnld wet friction, a dry frictitin follow. All 
the hanlening hy liydrufwithir procedures, niore e-sin-eially in 
rhildren, must be ]>erfornied gratjually aiid directeil according 
to infllvidnaUly. 

Hydropathic hanlnniiig U greally a.'«isted by iMxIily exercise, 
such a.s g>iii nasties, rowing, swiuuiiing, tobogganing, etc., and 
by suitable clothing. Too wanu clothing is not desirable. It is 
not the place here to enter into consideration of tJic controversy 
of clothing faddisni, or to decide whether wool, cotl^m, or 
Other materials be ))rcferable. B. Frnnkel mul M. Srkmidt 
are not strong advocate-s of the woollen regimen of clothing, and 
tlie former speaks of wool ns a "new ettu«- of ejien-atiuii." 
Woollen material as underwear Is objectionable and shoukl 
be allowed only where the skin is readily prone to jjersplration. 
On the other hand, it is well to recommend that a nettetl vest of 
cotton or silk should hp woni beneath the shirt. In any case 
the neck should be left free. 


Systffiimtiff hardwiing is only poi5eible in monis of suiublc 
temperature. Tho .iiatxjsition lo "colcb^* axnl rntAtrhs of ihe 
upfK-r ajr-passagcs w greatUj iitcrauicd by overhmtal apartments. 
'Ihv. IcmiK-raturt. of Uviiig-rooms slibuld be Ifi* to I9« C. The 
iKil-nwm diould I* Ir.iiperalf. Uul here, as in iiiiiny other 
malters, habil is o„r master. There are fieople who sleep even 
(luniiK tho coldi^t winter in unht-ai*-.! rooirw with o^nm windows; 
111 MK-h ptuies care shouhl he taken that a draught docs not 
blow dirwtly unt« the Iml. 

The air should be frm of dust and siuoke and should possess & 
certain amoimt of humidity, so that the nose is not hindem! 
an iLh funriion of cleonlnK and nioiMteninc the inppireil air. 
t'h'armg of the nasal cavity hy bimving tlir nose should l»e done 
through each nostril s«-iwinii4'Iy. (So- imge 37.) IWket- 
handkerebiefs should Iw frifiucntly rhanged, in order to prevent 
as niueh as iKjtisjblc ihc tniiifiniission of tmcteria at least. 

The naisal cavity is nflcii [Milhilnl by the wide-spread, hut 
nevertheless unclean habit of '•sniifF-takinp." and by the custom 
of ejecting cigftn>tle and ciRar snmk« tbroiiKh the nostrila; 
it in not iinpn)l>able tliat tbc vpruv of smell w Injured. As 
is tobacTO, so al.**o is alcohol noxious; and in smokers and 
drinkers swellinR of tho mucous membrane can very often be 
found, which in turn impedes nose-hreatbing. 

'llic »;wellinK in tbc cavity of (be no^e is al.'fo apt to pvo rise 
to chronic conia^'slion and is liable to cau-'w "copper nose" 
("giop blostwims "), which is so characteristic of drinkers. TIiils 
we see that alcohol and tol>acco play a great part in the etiohi^y 
of na.-'al dixeases; hence it should be our enileavor to exclude 
both where nasal disease or the disposition to such is prescul. 

IVsfessions and trades with malign influences on the nose arc 
numerous. ^;)t(»c-iiuiiienitcsnol Ics.s than onelimidml and fifty 
of these, all of which load to acute catarrh of the nose and the 
upper air-passages. For these, general nilcs as to hygiene and 
prophylaxis arc not applicable. At the most, one can only 
advi»- the patient sd as U* rrrluci' the jwrnirious effects of bis 
particular occupation and to place him in the most favourable 
circunistanceH with reganl to hi.s respiratory organs, so far as hia 
occujmtion iwrmils. 



(Eczema ad introltum nasi. Eciema of tlie Entrance of tfie Nose) 

Kczema of the introitiw is wUier acute or chronic. In the 
nruip fonii il slinw.s variuu.'* tlcgrees nf n-ttut-ss and swelling, with 
frecjueiilly tlip fnniiiitiun of ve.sick's. wahs. aiifl lissures. In 
the fhronic form the skin is inliltratetl — frfqiient ly itnlurated — and 
shows cracks ami fis-surt'S (-ovpred with luimerous scabs, whicti 
might l)c so thick that tliceiitraTice of the nose may he lilockwi. 
Thcprocrssofti'ninvji'lcslheadiacoiitpRrtsof the upper li[). which 
then appears swollen andwcrtwl; and the tisaun's, though tUcy 
may he small, form a ready cntrojice for pathogenic gerras, viz., 
cry.-'iiM'lii.'*. Iniih, wtptii-*, syroHis, and fiyphili.". 

Etiology. — 'riir Cfiieiiia iti thr iiiajnrity of nXi-iCM may lie tnicrcl 
to the irrilatidii ciiurifii by tin- NCeriiions of tin- iio-sf itself; 
aw in nc'titc or rhmiiic rliitiitis. or from tin- arrcssciry* cavities, 
or iiiuiti-phiirj'iix. «'S|ic<"i;illy in cases of ach-noid vegetations. 
It is very oflwi fouinl in .■wTofiiloius children. 

Course. — Thi' course is often prntnirled. Tin- patient has 
fniiuenlly to utv the handkerchief for the piT^istenl irritation, 
llip painful t«nwon, and the fwH)uenily tMi]»cled hn^athing through 
tlie now. Tlic patient- picks llic nose, thus scratching and 
f»eparatins the scabs, causing yet again fresh irritation. Ilaonior- 
rhagci* readily occur, and if infection super\'cno?, it may Inail in 
ver>' ciminic cai*cs to ulceration and perforation of the na«al 
septum (ulcu--^ sepfi jM^Tforan--*). 

Diagnosis. — Thi; tliagnosis, as a lule, is ea.*<y. Confusion with 

*Thouah niinwToiw afTcvfiont of rlie skin of Ihe nam are often only m mrl 
nf ecneml atTmiimn i>f iIk- iikiri found rWA'here, and which U'liilt llir wliole 
inUviiiii'!" . y'- " "linrt iHiniwinu of ihcin iltww tiiil here i«'m wipcrflnmiii. (or 
tbc priK'tiiMl r«i.'><>n lltal palirnlH aiilTcriru: fmm thoer c^inpluints oflfii [i>ti- 
mll the rliinoIo^Hi; and MPcwid!;'. bcwiiiBe many of iho >l>Dv«>-Inr?n[ionl^l 
affiM^tioiisurcin niurc or Icowintimulerrlutiviitu Ihcdinotuievf iheiMMdinttrior. 



Course. — The courae is always protractetl, and is relanled by 
ri'la]>sc;s ami is Bomptimes eoiiiplicateil liy jminfiil funmculous 
iiiflamniation. In long-staDiling cases the hair is iihually lost 
aii<l thi^ skill hcconies acarred, due to atrophy of the follicles. 

Diagnosis. — The diaj^nosis at the iMcginntiig is easy. I{ach 
pa[)ule «ir piwtiilL- is then pirforatwl hy a hair, l^ater on, if iho 
hair in lost ami scabs ari> fonnctl and all lh(? [wirtH ai'e inliltraltHl, 
Uius maskiiif; tho pidiirc-, distinction should bf made from chronic 
ecjsema, linea. s)'phUiH, and hipiw. In uncomplicated sycosis, 
lliere is no sucli exudation as in cezcnia or tinea. In lupus and 
ayphilU, ulceration is the main feature. 

Treatment consists in gentle epilation of the hair (jy means of 
ciliary forpri)s, in removing tlu- scabs, as we iiavo shomi in the 
foregoing; and aflerwaids, anointing with white preeipilate, or 
sulphur ointtnenl, or iehthyol. Tlinmgli the epilatiun, many 
pa>*tules arc DjH-nt-d, !>iil llu- utiicrs must 1m' incisfd with ii small 
lancet. The use of llie handkerchief .slumld i>e avoided; ami 
cleanKing of the n««H» s]u)ulil be dune by liDowiug "h la jxij/gan,*' 
or, what is more refined, by mopping with cotton-wool. 


A lx)il 13 an iiiflamniation of the sebaccoas glands of the skin, 
ending in Hiippuration through infection from staphylococci, and, 
as a matter of fact, is nothing else than a targe acne pustule. It 
often occurs at the entrance of the no«e in i)er.*oiis of unclean 
habitj*, who pick their nose. Chronic ecjsenia and sycosl-s pn- 
dispnse to it. The onset is slow; the patient feels a sort of prick- 
ing and often an increasingly painful l«nfHon. Tlie skin at the 
point or wing of the nose swells, reddens, becomes infiltraU-d. and 
a .swelling may l>e frwpn-'ntly noticed inside the nose, which sliows 
on the top a yellowish apfxiarance from suppuration. A Iwil 
situated at the angle of the entrance oftwi eoiicealH itself and 
can only ha discovered if the patient's liea<l is lH*nt strongly 
(>aekwarde. It may be more easily detected by viewing the 
iiureitufl in a reflecting mirror held in front of it. 

Treatment at the heginning sijould be to relieve pain by 
covering the infiltrated [larts with vaseline or byroline. It is 



still Ijcltcr to lay wiiall pif<*» of cotlon-wool rwakwl with acctato 
of altiniiniiiiii lii IcasiMjou to \ I.) aver the odgc of tlii' noi^- like 
a horsi'sli(K'. Sometimus I fountl that the inliitnition did not 
patw on to suppuration, atid Uic iuflammation Mul»n<I(xl by this 
nielhoil. Tmially after a few ilayi* (he furiuicle breaks (iown, 
the nerrotic matter is discharfred, an<l it wion heals. An incision 
iH iiKwtly uniieeo.«ary. Tlie jralieut should ht* slrejiuouwly 
ailviiKH) to [irotect hliusclf from furunculoeis by clGaiilinesii and 
the avoiding of any hritation. 


Tlie skin of the nose is a favourite place for comedones, especially 
in young adults at the time of puberty. They are caused by 
n'tention and thickening uf the wcretions of the sebaceous 
glands in the blocked and often dilated gland ductj*. To the eye 
(hey appear as small black pointi*, embeddetl in the mouths of 
the follicles, and are often elevatei.1 above them. Tliey look like 
small yellowi^ u'oi*ni.s with a black hcafl, whence came tlio 
name of comedo. Tlie black heat! is due to dirt. Microscopically, 
homy and fattily degenerat«l cells are found, together with 
fat globules and fine hair-roots; and often a parasite, 0.3 to 
0.4 mitt, long, Uie acarus foUiculorum. Tlila acarus is a very 
hamdiT:* though very coinumn paiiksite, esjiecially in fxrrtons 
suffpriiij; fnini rtrborrhoca (page 51). It lia.s no coimeclioii with 
tlic origin of coineilones. 

Throng the irritation exercised by the thicketiftl anil retained 
seeretton of the glands, enrnedones often cause a certain kind 
of intlaniuiatian of the follick's, tending to Kuppuralion. Tliis 
is then calleil "acne vulgaria." 

Treatment. — Comeilones are removed hy e.tpreswuig them 
with the clean fingers or si)e**iftl iustnjtiient«. It is useful to 
prcviouiJly soften the skin by washing it witli soap and warm 
water. In order to prevent retention and blocking by the 
secretion.*! various means rnay lie resorted to. all of which serve the 
pnqxitfe of Removing the sujXTficial layer.*! of the epidermis and 
freeing the mouths <rf tlic sebaceous glands. Sulphur ointment 
(precipitated .sulphur 3 parts. lanolinc SO parts) is smeared over 
tlie respective imrt al night; and on the following morning is 



wiwlied off witJi soap aiiil water or benzine. Of similar effect 
U Uie following ointitiwil: 

B. iiowiTiiM 3.0 lo 5.0 

Zinc^i oxidi 

Aiiiyli iriiid 4.Ba 12.5 

V;i«r!Jti. llnv ad J0.0 

M. Fiii pa«!». 


R. SutphurLx ilepumt 5.0 

KAMTCnii - -'i^ 

VB«liii. flaw V . . .ad 50,0 

Tn some lonK-siaiiiliiig rjwf'-i corrosive sublimnte 1 per writ., 
externally applletl, lia.s a goutl vlTeet; care niiisL be taken, how- 
ever, that it does not come in contact mth the eyeball. All 
thr abovt-iiamml rcmeilies rthouM !)p stopped if the nkin shows 
nmrli irritation from thpir ti^. The ilewpiaraation may be aided 
by an indifferent (rmtment (zinc or bjToIine). Very obstinate 
acne may Ix* covered with a nierenry plaster. Tlie use of a 
iiirtrhle wiap f20 %) or sulphuretted and camphorate<I soap is 
highly rcconiniended. 


This affection, whirh occurt cm the ncwe and forehead, is cauned 
by hyiMTHCcretion of the sebaceous glands. The skin ha*" a 
>4nny, fatty ap|)earanee. a.-* if it were anointed (wborrhoea It is often acconipan-ied by comedones and eruptions 
of acne. 

Treatment ran only consist in cleaning and wa^ihing the skin. 
Tyiliiicd spint of wine is very iwefiil for this purixwe. 


Freezing of the now* frequently occurs in anaemic persona 
Mtwtly, tlip lirnt stagr- of frost-bite is met with. The nose, cspe- 
cittlly the point of the nose. \s blulsli-rctl ; and on pressure, round 
white patclies readily appeiir. wlii(^h soon re.sunie tlie colour of the 
neighixxiring part.**. The diwcoloreil skin itches, bums, or is pain- 
ful, and lhi.s especially at the transition from a eokl into a warmer 
temperature. In long-standing cases after many relajKes— 
if once fra«t-bitt«i it is inclined to Ix-eome froet-bitten again — 
t!ip nose k apt to bo much disfigiuxH-l, and, like the hand aiul foot, 



liablfi to cliilblains (perniones). HlUters and sloughing, as is so 
ir<'(|ucnt ill the cilso of tliecar, is not ofien met with in the nose. 
Treatment consist* in the application of a lon'tc ointment 
(canjphoiae trit. 5.00 atl vasel. Jlav. 50.00). rubbcil in at night 
und before going out. Aiw aa ointment of chloride of calcium 
is VL'ry Huccesaf 111 : 

I|. CbIc. diloridi 1,00 

Ung. poraff ■,., 9.00 

F. ung. 

A small piecR is to be rubbed in morning and evening for five 
minutes and then covered with impen'ioua material fgutta- 
juTcha pajxT). It i« useful to cover the frozen part>ipven,- evening 
for ten to twenty iiiirnitcs with small pie<'(ai of rotloii-wool 
soaked in hut diluted vinegar II t!tliU*s|N^on to ^ I.) and aftor 
that, ajiply the ointuipiit. It gotw without Haying tliat the 
general health of the |ialienl is of the utnmwt imiwrtance, and 
[irophylaxi.'s sliould not be ncglcct^Nl. 

(Copper NoMi ErylhetDA: Anxcjom^: Acne Roucc^i Pendulous Nou.) 

The name of red or copper nose is not a scientific one. It 
moauH UiedilatAtion of all the small, and smallciit, VRssel.t of the 
hslsmI skin, wIn'dnT thi' conditions bo transitory or [H'rniHiicnt. 
, Erythema \t a jwitchy i>r dilTuwe re<, caused mostly at the 
point of the nose by venotw or artcKal hyjjeraemia, as a con- 
secjuence of clironic inflammation of the inside of the now, 
of previous frost-bites fvide above), or— ami this is the most 
common— a more transitory erytkenm fuijax. due to retiex action 
of the vasomotor nerves. This Meeting redne.-^ h oft^-n met with 
in young women or girls; frequently in connection with nienstni- 
ation. All kinds of stimuli may produce llus reilness of the 
nose, as also transition from cold to room-temperntiire. mental 
or psychic a^tation. and last but not lea.-*!, the drinking of hot, 
but not neeessarily akoliolic, lieverages. The patients are mueh 
distressed by the eompiainti as they are often exposed to unjust 
suspicion. The affection is of a very Imntdess nature. 

Treatment, which is of vert' little avail, must take into coa- 
sidui'ation tlu! cause, and endeavour to ctTcct a remedy. 






Telangiectasis (aaevus) is the persistent ciilalationor capillary 
hltiod-vesids, ami i.s found iu tlie skill ami iiiu<^ous mc-inljmne 
of till" nose. Tliv siU- of ronimoiiesl c)c<;iirrence in tin- mucous 
niemlirane over the anterior ami lower part of the cariilaginous 
sepUim (lorus KiesR-llmchii). Not infretjucntly tho tortuous 
vessels encroat-h on the Uocir of the nose, where thfy are iliHicult 

to see. 

If tlieae naevi arc morp proniinpnt.and of a more tumour-like 
appearaiiop. they are called angciomata. Both forms are eon- 
genit&l, but may also bo aequirecl; in the latter case from 
passive hyperaeinia in the natal cavity clue to general or local 
di(*eaflr-s; for inst-anre. from heart disease, plethora, constipation, 
etc. If they are scateti on the f^eptum 
nasi, they are a frequent cause of nose- 

Treatment — Tlie treatment of these 
naevi on the external nose i.« done by 
repeated scarifieation with a small knife, 
to the effect thni the dilated vessels be- 
come subsequontly obliterated. I use 
for this purpose a needle commonly 
u»c«i for paracentesis, l^argcr vetwcls 
must be intrif«e<l; /^nA•^■fl^ \isc» an electric 
rificatiir. lu casi's of flat naevi where 

ic rethii'-ss \« even, ihi- cHivanie current 
ii iwful. Tlie I'icftrode,-! are put on and 
a current of 2 to 3 mn. sent through, 
sitting, ivhieii ninwl be repeated twice or thriee a week, laiita 
from teJi to twenty ininute.s. Matten* eiui he helped by washing 
tlie jrnrlH alternately with hot and icy eolil water. Drugs are 
of no avail. Uniler alt cireum-^tanees the underlying malatly 
must be treate<L (For tlie treatment of the naevi of the nasal 
septiunsee p. 6(>.) 

Acne Rosacea ("Blotchy Fac*"j Angeiectatic Erythema^.— Acne 
rosacea attaek.-* aluiost tiiily [lit- skin of the nose, mDn- rarely 
the Deighbourinjr parts of the face. It is merely ii redneiw having 
heeonie jiennanent and ^ta1ir>nary throuj^h the angc-ieetaiic 
dilatation of the blood-veaaels. and isalniowt always aecompanietj 

Rp. 30.— IJilatalieni of 
thf>vfwifUi)n ilio project- 
irif •cptiim imsta npti). 
PS, (orralinricnecl part of 
the^ .■wpUirii; S. iDnilus 
1 Horrowwl ) : M, Iom-ct 
conchft; MF, odgo of tlia 
wiiig; C, crislaeepti. 

The duration of the 


' "by oonc and complicated by hypprplastic growth of connwiive 
li«siic, wliicli gives rise to the affection kiiuwii a» rtniio|)liyina 
(bull)ous nose). In this stage the n«te is vejy nmcli tinrkened 
mid c-iilargeti, but to the touch alwaj-s soft. It niiglit Iw very 
oxulH-rant ami coverptl with nodes anii lumps, and of a bhie- 
rofi nolor; the dilated vesspls are often found of the size of a 
kiiitting-ni'odle and very prominent. In Uiia way, extraordi- 
nary disfigurement may bo pmduced. 

Etiolo(jij.— The most conitnou cause is alcoholic excess; but 
teetotalers may also suffer from it. Further, chronic indi- 
gestion, catarrh of the stomach or ijit^sline, frost-bite, and in 
women diaeasi^ of lh<r sexual organf% iiicturbanros «f jxiriods, 
aiirl uteriiu- dir^-ajtw may pirty a great part in rxcilitig it. Pos- 
sibly Uicre K also some congenital pre<lispn«tion, which Lassar 
sougbt in the imconuiiotily capnciou.s auv of the ducts of the 
sebaceous glands. The bulbous nose is tm-t with mostly in men. 

Dinjfiom. — The diagnosis is not difficult. Localisation dis- 
tinguishes acne rosacea from acne vulgaris, which latter is seldom 
limited to the nosie. Confusion with sy]>hililic diisoase or hj'per- 
trophic lupVLs fliould not occur, for acne roeiaeeiv never becomes 
ulfcratxsl. The bulbous nose, if it is very large, might be con- 
foundftl 8omotinif« with rhinnsclrrnma, hut can always be di&- 
tinguiflietl from it by itw soflncs^, whiTca-s rhinosclcroma i.s as 
hanl a-s ivory. On pressure with tJjt; fingcr.-i cmiu'dtinen might 
be exprcMsed from t!ic former. 

I'Togmtsix, — The prognosis is not uiifavouraMc, if nrdy the 
treatment is cnntinuLiI for a long ttiiu_*, ami if it .suctreds in 
removing the exciting cause-s. 

TTfotment. — Tlie treatment aim.« at eounteraeting thp causes. 
In the milder cases, e-Hpeciiilly if arnp i,-* a pnntiiru'iil feature, 
the sulphtu-ous or resorcinous ointments win be resorli-d to, as 
in acne \'ulgaris. (Sec p. 51.) Eotatic vessels liave lo be scari- 
fied or inciscrd. Tito rhinophynm can be successfully removed 
with the kuifr, under lucal anaesthesia (basal ilixorticatiun). 
Tlic left index-finger is paslicd up iiiU) (he nostril to expand the 
fikin; and a nonnal m».sr, so to say, can Ik; jieelai out. Then 
under a cover of an iodofortu drcs-ting. recovery soun takes i)Iace, 
and a new skin is formed frouL the ej/ithelial celbt mmaining in 
the glands. 




Malfoniiutiiiiis of tho noso, such as alisence of the wholt! orpui 
or partsof it, (.luulileiioHe, ami eoiigi>nital fiM4uri>(i,n(>ciirs(i twit lorn 
thai wct'iin hore oinit a tii-si'iinsioii of these unoinalii-s. Of prac- 
tical importance are: ( I ) Atllii'sions (synechia aiid atrejiaa nasi); 
(2) dcforiwatious of the seplimi nasi. 


They rcprcwnt riioiiihruiiuus or otjwouj*, rarely cartilaginous, 
conupolioiiw iK'twceii (ipiKisiiig jm-rt-s of llii- nasal cavity, and are 
Itiiowii ii,s .-iT/HP-r/iTw, if till- I'fiiiiici'tion is foiinot by a haixl-likc 
ur striiig-iiki- ctmruirtivi' li.>«»ur; aiiil HMitri-Niu, if llicy hJofk more 
or 1e«M completely the nasal cavity like a Kcpntating wall ur 
tliaplira^in . 

Synechia*. — Ailhesiuns are foimil in various parts of the 
nasal eavlly ; iho most cujinmoii 18 that Ix-tweeD the lower eoneha 
and the septum. Harely t'OiiKetiitHl, they are produeed oftener 
through ulceration from syphilis, ihphtheria, lupun, and slill 
oftener, they are met with after cauterization and operations, 
if the two opposing fiarts of inueons membrane come in contact 
«ith each other after they have hecti deprived of their epithelium. 
At first the two siirfaees stick together, and by organization of 
the connecting tissue, a ]K-niianeiit ailh('sion Is foniied. Small 
aynechiae produce littlK or no trouble. More exlensve adhe- 
fflons may iniiiedc ihi^ rf>;|iir»rion, and give nsi- to varioiu* di«- 
turbancee, as headache, a!>thnia, sneezing, coughing paru.\ysiiis, 

Dingmm. — Tlie diagnosis can be made by anterior rhinos- 
copy, eventually by the probe, ami with the aid of cocaine and 

7Veu(r/(c?ii.— Small adhesions, which do not eauite any trouble, 
are better let alone. Ijirger ones, however, have to he divided 
with na-sal .scis.sor.s (src l-'ig. 40). a small knife, or g.ilvano-i-au- 
t«ry. 0»»i?ous mymjchiae should l>e severed by hammer and 
chisel. We must not be .satisfieil witli the simple sei>aration, 
hut endeavour to cut off a portion uf the mlliesioiw In order to 
prevent a rfvadherenee. 



For the (iftcr-trwitrncnl, U is sufficient to proscribe a men( 
preparation or the daily application of ronofomi. 

[}. Mf-ntludl 


Oet. in vitro flaro. 
S. — 'lliTW (ltri|]s M^vtral 
^QiITull up. 



llrn« djiilj- lo he pounil on llw jxlm and 

Evpntiifll ri'-aillu-sumn imwt he wparatctl by the probe. In 
certain casps it is iiei't-srva-ry to put Iwlwepji the Iwn cut ends, 
by meaiLs of a dressing forLTiJS, a pUt^ of tin-foil or suitably 
out jjiece of cardboani. of oourse properly ilisinfecled, and 
clmiiKfil pvery Bprotiii day. 

Atresiae.— Occliufion may occur at both anterior and poste- 
rior opeuings of the nose. Occlusion of the anterior o|icriing. 
though uncoinmon, miRhl lm|)i)en conKcnitally or throiigli Kj'ph- 
ilis, lupu«, aftiT bums, ami after camerizatjon. Troatnient 
consist.-* in the ilissolullon of the occlusdon by knife or chi!«:l, 
and afterwards in kpc|jing apart the cut surfaces. 

The occluaon al»o of the |K]»t«rior ojwiiing. atrona of the 
c-hnaiiap, dops not often occur. Atrrvia may be unilatpral or 
bilal^ral; roniplel-i* or inroniplt-te. It is mostly poiif^enital niid 
(MBeous, but also aciiuired. esjwcjally throu>;!i syphilis, rbinowler- 
onia, or injun,', With unilateral osseuu'* occluaon nmy very 
often bo noticed affv'mmetrj- of the palate, face, and even the 
whole half of the body. Zarniko thinks that the eonRt-iiital na- 
ture of the clionnal occlusions js not proved, and sees mere coind- 
dc-nres in the said anomalies, 

,<ijmi>tomx. — In trmva where both choanae are occluded, rcjtpiniF 
lion (hroojrli the nose is prevented; the patieat cannot snwie, 
the sense of smell is lost, and taste irnix-rfect. Sfjeeph has a 
niLsal sound (rhinolalia clauna). All these sj-niptonm arc much 
leiis pronounced if the occlusion is inconi|)lete or only unilateral. 
Sometimes the patients learn how to overcome these defects. 

iJwflnom.— Tlie dinfrnosi.'i can be made by anterior iliinoseopy, 
it the nose be roomy eaou^i, with aid of cocaine ; belter reaults, 
however, may be obtained by posterior rhinoecopy and digital 
examination of the naao-pharj-nx. The probe will decide the 
nature of the occlusion, if osseous or fibrous. The following 
points must be considered: the impcr^'iouaiess of one or both 



(rtuMiuiu^ to air ami water, the luss of smell aiiil Xa»ie, tJi« diili- 
cillly or disability of siiwzlng. 

Tre'itntenl. — This oaii uiily bu of an oi^crative' iialurp. A iiit-tn- 
linuious occlusion f-aii be cut tlirougli by kiiife or giUvaiio- 
cautt'ry ; an osseovw occhbuuii I)y hammer aiul chisel, The open- 
ing must Iw piilargml and tliu st'imralt-U ."iirfaces kept apart. It 
iJ* often neco^saiy, in order to niake the place of ojjoration inuro 
a(!ceA"^il»I(^, to witlen thfl ailitus by |>artial rc-tct-tion of tlic turhi- 
natc. bones. Uf-a^lhe-iioiis and re-narrowing of tin- oix-nitrnl 
pfirLs may Ik; [>rnvi'iit«l by the in»i*rtioii of .siiiall iiidin-ruliIxT 
tiibt^ or swabs, which iiuist Ik* changed every sitoikI day. The 
dilliciillies of the aft<^r-treJltinetit oft«ii frustrate the success of 
tlie operation, and may render a second operation necessarj'. 
It is therefore belter, ef*in'eially if the discomfort complained of 
by the patient ia only slight, not to oixrale at all 


Alteration in the fonn of the scptuni nasi may be clawifiml 
as: (a) simple deviations, where the w^pttmi deviates from tlie 
middle line in sucli a way that the convexity on the one side 
corresponds with aeoncavity on theotlier. (h) I'rotulK-rances, or 
partial thickenings (cristae et s])inae) if the septum is thiekened 
by osseous or cartilimiiioas excreseetices. fc) Combinations of 
both deformities, where the protniding part sliowsalso thickening 
in addition. 

ffdotojy.— According to Schech, there is scarcely any person 
without H deviation of the septum. Thisis|)ro!Mibly anexjiEgera- 
tion ; in any case, however, iIevialion« are very fnrqueiil ; 1 found 
71 percent. ; and. a« Zucktrhitmil hua «liown, KurojM-anM are more 
often afTecletl lliaii nnn-Kuro[)eiins; 8o al--to an* maU^s more often 
than rpiuali^. Varinii-s explaruil ions of it.s origin have been 
brought forward, hi must ntses it is due to an une<|iial growth 
of the nasal nkeleton: the septum, growuig more (|uickly than 
the other bones, and being fixed alsive and U-luw, has to deviate 
to one or either ,iide. The caiise of lhi.s mie<]ual growth is not 
known, but the acceptation of such a physiological deviation 
eerveA to explain why deviations of the septum are relatively 
seldom found in children. The ja^^'s, indeed, grow quicker from 



Uie beginning of the second dentition, i. e., from the sevcoth 
yi-ar of life. A wcuiiil wtuse may be f<»iitid in iujuries, such as 
ji blow, ibni5t, or f«JI ui>on die nt»si>. In severe HCt'i<lcntal de- 
viations oi iliL- cariilagmous «pium a diylocaliou of the meiu- 
branous portion of the septum from the caililaginous portion 
Kimu;tinii\<o™ui-s(di.-<li)catio!«pti na-si). Finally, adt-vinlicBi may 
be brougiit about, in woiiir caries, thruu^i tlierirectof pR-ssun- by 
either physiologically or [jathologiiailly hypcrlroplii«l turbinals. 
Prominences and prot uberatK^e*! of iIk^ septum are niasily of 
traumatic origin ; hut they may also originate, a* do situ pie de- 
vialions, in unequal growtli. 
Anatomy. — IJeviation occurs mostly in the cartilaginous por- 
tion; frequently, the septum protrudes 
ton,*ards both ?ide5, like an 5. or it is 
;Jia|Hrd like a terraee and ;:radually slo^ics; 
in tither caw's it .-^lows ridgcw orst'rralioris, 
and HoiiictiniM it is sharply bent, fonuing 
an juigk". The proiuiuciiccs or protuber- 
ances are of a spine-like or eoniejil sliapi> 
(spina M'pti), or they run as a crest or 
ridge, curif>|K)ndiiig to the \\yi\ycT marpn 
of the as vomer, from lK*h»v anil in front, 
upwani^ and l>aekwardn (crista septi). 

i^ymptomf.. — Small deformities are usu- 
ally without anysj'mptoms and are discov- 
ered accidentally. Great thickening and 
excrcscenccH often cause much difficulty m 
naaal respiration. Tlie patient is \mable to blow through the 
narrowetl side, has to retract the secretions into the throat, has 
frec|uent resort to the use of the handkerchief, and apcech be- 
comes more or less nasal. Tlie sense of smell is diminiHhe<l, and 
in time, hearing is completely !o«t. Many nervous reflex sjTllp- 
toms complete the picture. Very prominent de\'iation8 or pro- 
tru>!ions may cover the opposing turbinal, displace or flatten or 
even become eoutinuous mth it ii"\g. 31). 'ITic Dose itself is 
often oblique, ospceially if the deformity is in tlie lower or 
anterior part. On the uthor hand, the thirsum of the no«! may 
fomi a straight line, though the deviation may be extreme. 

KiR. 31. — Eltviation 
in 1h« luw<>T ■epluin 
t4>witnU Itio ritEliC- 
Dislocutio scpli tuui. 



Diagncns. — Frontal inspection and probing ar*" mostly suffi- 
cient to recognize the deviation, Greater is the liifficuliy, at 
least for the incx()erience<l, if the deviation is seatetl ii^ar to Ihe 
entrance, wlien by its red colour it gives tlie impression of a tu- 
mour. In such a case the inspection of the nasal cavity is aUo 
made difficult, if not impossible. Otherwise a confusion of de\ia- 
tions with any kind of tumour or polypus of the mucous mem- 
brane is hardly possible, as both are of a much softer 
fc«on8lstencTy. It is also possible, by cHrefiilly sounding, having 
prp\'iously applifti cocnine-aiirenalin, to decide 
what is septum and what he- 
longs to the lateral wall. 

Flg,32.— (^iliiriKf»n*p« ('i/Cr (rTiin- 
waUi'.'itni .ycJtcn ) . 

Fig. SS,— Naa&I saw {SehotM). 

Tlrcnlntcni, — Treatment of the excR'sceiiees anti deviations is 
frequently ver>' troublesome anil unsatisfactory; ajid therefore 
we recommend o|KTative procedure only in stringent cases, viz., 
where the complaints of the patient are urgent, llie crests and 
spines, if they are cartilaginous, are removed with a probe- 
poinied knife, or with Grnnutild'» cutting forceps (Fig. ;i2), or 
wiUi the saw, s|joke-shave, chiael, or. double chisel of SeiiAtz, 
Krauss, CoTiiex (Figs. 3S, 'M). The saw must be used from 
below and directed upwards. 

In the after-treatment syneehiae or re-atUiesion must be 
preveiited. This is a tedious business. Plugpng of the niwe 
(p. 66) is only necessary in severe haemorrhage. Tin; io<iafonn 



or xerofonn plugging sliould remain Trom one to three days. 
If the ojjpiation wan done under iiitUtration anaealhcsia, after 
Hchleich, it is alftiiys wt'II to jilug, on ttccouni of tiie expected n'- 
JUJtiouary after-bleediug. \\'lif'rcverit is jxwsiblo, plugging sliould 
not be done, for it is not only very trouhlesonu' in the doing, but 
often found nioru incunwiiiwil U> thi- patioiit than the operation 
ittself, and is also not witliout dftngcr oji account of retention of 
the secretions, infection of the middle car, and retartlation of 
the process of hejJiiig. 

The irealinerit of the deviation may le done by operative or 

Orthopaedic treatment, whicli siiouhl be tried in rnrtilajrinous 
deviations in youthful {ULlicnl.s, has not Iwen foimd a lasting 
success. Chiklrcii cuu never tolerate, for any length of time. 

Kig. .-i-l.—Doublv chiwl. 

the stiff tubes or ivory roils which are inserletl into the narrowed 
passage. Nrither can 1 recommend the use of the pressure for- 
ceps, designetl by Jxirasz for the pur|5ose of fixing the septum in 
a straight line. M. Hchmidl makes the statement that he saw 
necrosas follow its applirflfion. I think it iinich belter to 
post;xinp the treatment of deviations in children to a later age, 
if the CAST is not urgent. 

Operative Meihods. — \. Method oj inlraction: The <leviation 
is ilividwl by a iwrtirular niethofl of cutting; it is then straight- 
eneii and kept in the right |iot<itirjn by stiff tuiies or a laniptjn. 
1 iL'*e successfully ^scA« cutting forreiis. This ronsii'trt of ft 
smaller roncave anil a broader convex blade. Tile hollowed 
Miialler bls<!e is inserted into the narrowed, the convex one into 
tJie wi<ler, noKtril. The Ijone is cut crosswise, put straight with 



i^^^ire rrirfppfiiand ilicn kppt in position by tubes or \iilRajiite 
sufih as are used for liraijiagi'. In tlie vciy proniinont ami low- 
acAlt^l deviations, it is often very dilftcult, not to say im]>ossil>le, 
to introduce the aiiall blA»le over the convexity of the septiun. 
Rfthi iw^s (or the crosii-cuUtii); a rtiiall Munt-pniiitiii knife. 

Rexcclion: Tlila was recomnH-tuliii hy Hartrnann and /'eler- 
ten. irnprovpd Uter by Krieg; anil niotlifift! by Cholevm, Honn- 
inefh/xUK, KUUnn, Ziirniko, and others. Tlie imu-tiiis iiH'inbrani? of 
Ihf* tiarrowoti side is nil cunilinearly or anguhirly, the biiw of the 
angle lieing din-otal backwarils, and lhi> iimeous metnbraae 
is then piishwl aside, togt-ther with the |t<'ri- 
chondriuin. Then the cartilage is carefully 
perfoialetl with a gaIvano-rauter>* or goupe. 
80 as not to damaji^c the mucous inembrane 
of the other !*ide, winch by means of a raj^i)- 
atory or elevator, is likewise detached, to- 
gether with the perichondriiini. Then the 
piece of cartilage thus freed and laid bare 
is removed with a IJeifniann's sharp cu]t[teil- 
forceps (Fig. 3")). A small perforation of tho 
mucous membrane of the other Ceoneave) 
side is of no sif^ificanee. There is usually 
free hemorrhage, and to stop it, a siilfieient 
number of swabs should have lieen prepared. 
The method ii«rintea»y,bnt ba>s the advantage 
of nf)t ref|uiririp any sfweial aftcr-trfatinent. 

Injury to the Nose. In spittr i)f il.s protni- 
iient ])OKilion, in the ver>- exact swiw^ of the 
worti, the nnsc relalivrly doe.*! not very often 
suffer injury. Coiiluworis or c»|X'n wuuiuIm are easily reeog- 
nixalJe and treated on general lines. Fractures of the nasal 
bones are divided by fler;;»junH into Irajisverw and comminuted 
frao-tiin"). In llin foniier. di-splaeemetit is often absent, and ran 
then be treated entiservatively; if their be displacement of the 
fractured part,"!, they phould be replaced, and kept right by fixing 
the bones, by inean.« of ]»luff3 within the nose. Comminuted 
fraeluifa ref^uire o]>eration. 

Great force usually injures the septum, mostly the cartilagi- 

I'iie. 3.1.— Wrv- 
miinii'x sliarp 



nous part of it. HauiiiitiMiui, ilrviiitiimM, difslocations, and frac- 
tiiiTS of the scpti nasi Imvr Ih-cii uhsrrvnl. The Iiaematouia, 
oil iLC-couiil of an infective fucus iii the inucous luembruie, 
ricjiily nKvays IratLs to: 

Abscess of the Septum. — Some authors have nceawonally 
observed a pui-ulent |icrichondritis iis a eause of — not traumatic — 
septal abscess. One finds the dorsum and the entrance of the nose 
infiltrated, swollen, red. and tender; the re^lness may al'^o spread 
over the iieifjhliounng f*kin of the fare. The anterior itait of the 
scjitum bul^'.-* forivards, mostly on both gides; the swelling, 
being tense aiid elastie, blocks more or less the additns ad na- 
sum. If pn'wHure 8]iiilie<l to the one side ejiuscs the other side 
to bulge more, it is a sign that the cartilage has been [xTforated. 
In acute eases fever may be [iresent; but not in the more 8ul> 
ae;ite or elirniiie eases. 

Tre4itmpnl. — Treatment eonsists in freely oi>ening the abscess 
and disinfecting and aftorwanU tamponading. Haematotnas 
shouKI also be incised, as otherviso infection can barely be 

Deviations, Dislocatioos, and Fractures of the Septum. — 
These are not always pas>' to recopii^ie on account of the accom- 
[wnyinK swelling of the i>artrt. It is not eoninion for these ea-se-s 
to rome under ohservatiou hoon after the aeddent; usually, only 
ihe after-effects— the peniianent deformities — are seen; and it is 
only ixissible fiom the histor\' to infer that there has been an 
arcident, ami liecaiise the nose bled, etc., that tlie deformity 
orijrinaled in an hijury. 

Trentmenl.—Trcaiment aims, as in other frnetures and diislo- 
ca1i'>n>*, lit the replacemenl of the (Mirls and nl keejMUg them in 
the right position, by means of phifigirig the nose. To put the 
fractured parts straight, closed pressure-forceps, a probe, or 
rjithcter may be used. 

Bleetling from the nose, havinjj re^gard lo the exposed .nitua- 
lluii of the organ and grcnt vii-st^ularity of the mueoit* meiubraiie, 
is very eon]inf)n, (InicniUy, young |»Tsons nn- iiioiv subject 
to it than their elderx. Vt'v may divide haemorrhages into: 



A. Hacmoirfuujex into or uiuler the mucous ttiembraiic (cci-hy- 
mosis, haciniitunia, etc.)- 

B. Free haemorrhage. 


Ecchymoses do not often occur in the nase. Their presence 
]M)ints to a general disease of the ciirculalon." organs. Of more 
ini|)artanee practieatly ure hiietnutotriax, which are astially due 
to the traumatisms before nieotioned. Tliey appear aa dusky, 
red, or even black, tumours of a smooth, tense, and elastic surface, 
on both ados of the sc))tum. They may be fo large tJiat Iho 
entrance of the nose may Ijocnmc entirely b!ock«l. As to their 
treatment aiid their leading to Mippuratiuu, see al>ovc. 


This is produced either by local or fjeiieral causes. Local 
eause» are: injuries, through impact, thrust, fall on the nose, 
noee-picking, operative maiiipuliitionfi, foreign Txxlies or ca- 
tarrh of the mucous membrane, ulcers, naevi. vascular tumours, 
such as jHilypi. mrcomata^ etc., and also by fractures of the 
base of the Kkull. 

Generai cwmeK arc: diseawr of the einnilatory organs, heart, 
lung; iiephritifi, especially chronic graiudar kidney, cin'hosiH 
of (he liver, art<'rio-sclcrosi.s ; diseaws of the blood, such as hw- 
nio|ihiliH. scurvy, chlorosis, peniirious anaemia, leukaemia, 
psueiloleiikaeinia ; further, jwisoning from phtwphoruii, lead, 
ctx;.; acute infections, for instance, influenza, scarlatina, measles, 
whooping-cough, typhoid, tyiJius, smallpox, septicaemia, etc 

IJlewliiig in Ihese cases is due to high arterial pressure or pas- 
sive hyperaemia or ditteasi' of the walls of Ihe blood-vefwels. 
The nasal mucous membrane i<eenis to be the stat of predilection. 
A .ludden lowering of llie out,side atnioi«|ilieric pn*s»urc may 
causi* tilcdliiig from the mtsc, as is obwrx'ed sonictimea in 
mountaiji-cliniliers, aeronauts, and cais»on-la!»«un-r!«. 

Not infrequently nri»e-bli*c<ling takcff ptace in connection 
with ahnnrinal proccwtes in (lie wxnal organs. It may oi-rnr 
during dislurbaiici's of the menses, and sunietimit- ri'plaee.'' 
tliem altogether (vicarious menstruation) ; it may disappear, 



howi'vcr, if prrgiiaiioy inl.<Tvcnfs. 11 here perhaps I'elieves 
rcfiex hyptTiiciuia of thr iitiNil mucous membrane, as in some 
foniis of sexual eKce»ie8. At times nuse-blewling may prei^lc 

A curious case observed by Wwisch may bp quotwl liere, in 
which sliglit blee<linR of the nornuil tonsil iimnediately prece<ied 
each nionstruiiiion. 

By far the most eointnon cause of nose-hltH-dinir is an infunj 
to ectaik, dilated blcod-vesscls of the cartiiapinous septum. (St^e 
p. 53.) These naevi correspond to thoBr M-ssels despribed ljy 
KiesseJhach as (KTurring at the Itiwer anterior part of the 
septum, and which appear U) form a kind of cavernous tissue, 
03 in the lower turbinate body, and are also found sometimes 
on the floor of the nose. Tliese vessels are so nimierous and 
BOated so superficially that a relatively slight injury is; sufticient 
to cause them to bleed, as, for histanee, through eouphinp, 
sneezing, stooping, etc. Tight collars also cause hyperaemia 
by i)rewure on the blood-vessels of the net'k. Young people are 
often ver>' much pestered by habitual nose-bleoding. According 
io Donotfdtiy. thi^ is due to atrophy of the nasal nuu-oiis iiinn- 
branent the locus Kiesselharhii (rhinitis nicca anterior)^ produced 
by repeated ratarrhH, and hacniorrhiyres ver>' fre(|Upntly occur 
just in this spot, as the n-siilt of custaiiiary picking of the nose. 

Symptoms. — The none bleeds in nni^/f rfro/w, wlience the name 
epistaxis is deriveil; or the bleeding is in the nature of a more 
continuous flow. It may stop after a while, and sometimes 
recur without vi.'^ible cause, espeeinlly if the patient is careless. 
If the bleeding is profuse, inueh of the hlood flows backwards 
into the throat and the patient then swallows it or spit? it out, 
or it finds its way out through the other nostril by way of the 
chojiniic. It may hap[Hm to reach the larynx, when it will catiw^ 
irritation and |iaroxyMija! coughinp, luid i.-^ then cxix-eloraleil. 
In some ca.-'es epi.stuxis is (luitc suddrii; in others, especial ly in 
plethoric persons, it is preceded by symptamM of congestion or 
hy|ieraeniia, headafhe, dullness, vertigo, ami tinnitus; here 
tlip lileeding a good effect, like a venesection or tapping. 
?k.'vere hueiii»rrhage may he followed by acute anaemia, fainting, 
and even death has been recordeil. 




Magnosia.— ivp ."houKi Jihvjiy.s I'mli-avnur to tliscovpr the 
source of tlip bleetliiig. T3»i.s will In- mostly lomvi lo be some 
torn vessels at the Iwus Kie-ssi-lbacliii. In order to see it, the 
speculum must be introiluceil willi the blailes directed upwaitis 
and ilownnvanls. If we ilo not see the patient until sonio lime 
after the bk'ediiig, \i'e will litive no difficully iti recognizing the 
dilated vossols of tlio septum. Neverlheless, such vcssob arc 
also founii in healthy noses. .Vftcr the septum, the floor of the 
nose niiiM ab=o lie insi>octrd. If here again nothing is detected, 
the entire nasstl cavity mast htr I'xarniiicd. Oecasiimally .'Umc 
scabs arc founil, whirh will iiidinato tJie «yit of the hiieinorrhage. 

If a pfitient hn-s to Im' exaininnl while In- is dleeding. the hlmKl 
sliouJd be carefully spongtx! or dai)lxHi up without \viping or 
rubbing, or we may phig the spot for a short while. It is 
alwaj's well to clean the eartilaginoiis septum before we make 
our examination; but with all our gentleness in handling, we 
must be quick, and having again removed the tampon, we must 
make a diagnosis, so to speak, at a glance. 

If we fail to discover any source of bleeding within the nosp, 
wc iimsl enilcavour to find out if the blood dwv not conic from 
the IhnMkt. wtomaeh, or lung. Not iidrwivK'ntly, a« haa been 
alreaily [ncntioncd, Ihc oozing blocKl Hows baekwards down into 
the thnHtt, csij^'cially if the palient n-riincs his hea<l. and then 
from llic ihrout it may rcacli the lung, or it may be swallowed 
and bniiight up by cfKighiiig or vomiting. For this reason we 
should always ln.<|iei't the nose in eAses of doubtful haeniat- 
enias'is or haeinnplynis. 

Prognosis. — No.'»'-blpeding shouUl not be lightly regarded, 
especially in anai'mic or weak persons. Prognosis is based, of 
course, on the cause of the bleeding. It is almost always favour- 
able. .'Jiould the bleeding ho from the eartiliiginous .'W'ptum, 
and in this vnt^e it can lie ea.'fily treated. It i.s more uncertain, or 
even unfavourable, in cases of general di-sease. like haeninphilia, 
arterio-.'*clero!*is. or cirrhosis of the liver. It is an ominous sign 
in fracture of the of the skull. 

Treatment. — In plethoric [tatients, or if substituting nienstrua- 
Uon, nose-bleeding has a Itenefielal effect ami neeils no local treat- 
ment, if it is not ven- severe or does not last too long. I'nder 




rhrsp cirpuinstarippsa hot foot-bath unci a. close of an ajK-riont 
mim'tiil waUT art^ all thai iii nwfSJtin*. It Is well to add to the 
hot wat^-r for the foot-bath one or two haudfuts of c<Mtuiion 
salt or inui?taril. As it is mostly the anterior jiart of the etep- 
tuiii which bleeds, a piecft of fottoii-wKol may be intixKiucwJ 
into the resfiective liOHtril, luul tin-n thi' nofse can be ccnipresaed 
with the fingers. This will sinin stop the bleeding. Cotton- 
wiMit Koakcil ill cldiirittr uj iron is niiE to lit- rerotim tended, though 
sonii'tiiiHvs usi'fii], for it has an undeniably irritant effect. To 
hasten Uie cessation of the bleeding, one may use ferroiA/rin 
instead of chloride of iron, which is eleancr and not an irritant; 
or rerwjorm vonl may hf applied with advantage. 

Cold applications, Enilliiigupieewater.ora.'^lnngcnts arc of little 
avail, if, indwnl, they do not serve to asgravato the trouble. It i8 
often Ije-nl tfiHcat the patient quietly, with the head erect, or ligtilly 
U'lit forward}!, avoiding entirely sneezing or blowing the, 
or wiping, and then to change the plug only if it is fully .wturated 
with blood. The changing of the tanijjon must be done vcr>' 
gently and without haste; the same ailvice applies to doctor 
and [MLlient alike. If the bleeding spot hiie in .sotue way or 
other been discovered, a small pledget of cotton-wool steepetl 
in aifivnalin fir.'it, and then another in cocaine, fihould be presw'd 
agaiiiKt the part. The fjilr Ls then cautcrizeti with chromic add 
or trkhloraceiic add, or with the Hat-pointed galvano-caulcr)', 
CSi'c rig. 28.) After cauU-rizalion the [latient frequently sneezes, 
but usually this doifi no hami. for the i-srhar is tiuHicicntly secure. 
In flight haemorrhages. Mniplc iusulilations of rermfnrm Hlmuld 
Ijc sufficient. The powder mixes with thtt oozing lilood and 
fonn.-* a sort of coagnluni, ami it has. besides, a styptic eftcct, 
on account of its containing lulrenalui. 

Post-operative haemorrhage often ceases of its own acronl 
if the patient only keeps quiet; otherwise the nose must lie 
tampona<lcd. This can be |>erforiiipd through the anterior or 
posterior narcfl. Tamponading, however, which is nut entirely 
hftnnle.'i.'!. and is certainly trnublew>me, shonld not Iw reaortwl 
to except in wiw^w where one cannot tiiid the bleeding point, 
or if i>l(rding is so severe tliait one ha« no I Jnie (o spun- and other 
measures have failed. Luckily, however, this hapix.'ns hut sol- 



dom. For plugging through the Biitprior iiieatiis onp intrtxhircs 
with a (Iresang forceps simill !*lri|«t of iu<li>f(iriii or xcrtifnnii gaiizi". 
The former is, however, apt lo irrilatf mid la caiLse .tnt'i^zinfj. 
It 18 often quiti> sulTicieat to prc»a a simple tampon against the 
hleetliiig [Kiint. 

ir bk^etling rantinuctj, the whole nose must he fillwl 
witJi gnuzn, atuL care iniut lie taken tliat tlic gauze dloen 
not fall down l)ehiinl into the [Mstna-sal eavity. The tain|x>n 
nnwt l)p retiioved after two ilay?*, and If it tiftVrs iiuirh resist- 
aiii'p, only a part of the gauze nnist he withdrawn and «?ul (iPT. 
Tlie rest rati remain in situ for another day orso, luilll it heeonies 
loitse juid nUppery on arcouiil of tht? nasal fiecretions. i.uiilm- 
»ki iiitrcMiiices, in wvere eaws of hleeiiing, h folded strip, 2 rni. 
broad, of dcrniatol gjtuze into the nose. The ends of this slrip 
are left depending (rom the nostrils, wliile the folded portion 
lies ill the depths of the nai*al cavity, which is then also entirely 
fillet! with afjeplic wool. 

Plugging from behind alioiild Ix? done only in case of urgeney, 
i. e., where anterior tam[«>natle has failed. 

It is eustomary to use for posterior tamjHJnading lielloeq's can- 
nula Bound. Unfortunately, this fretpienlly fails in an emer- 
gency, and is not always sleruler enough to pass a narrow or 
irn^gular meatus. It is, therefore, lietter to use a long elastie 
ealJu'tiT, whrcli is piishe*! through the lower nifatus inl<i tlie 
postnasal cavity, until its end becomes virible behind the soft 
palate; it is then «'ize<l with forceps and pulled forward i*o 
far that a tampon of aseptic <'ottoti-wnol. envelope<l in iodoform 
gauze, can be tied to it. The tani|>on should be at lea^t half 
the length of the patient's thumb, and before it is used, it must 
he lieil in the niidflle nf a strong silk thread alnjut frf) cm. long. 
The next step now is to attach one end of the thread to the 
catheter by passing it into the eye erf the catheter and tymg it 
fimdy. The catheter w then slowly drawn back throu^i the 
nose, and in thiw way the tampon is pulled into the ehoanoe- 
Ab a rule, it will be well to aid this procedure by the hiiger 
from behind, in order to pilot the tampon into its place. The 
catheter is now mthdra^s-n. and the niwal end of the thread 
is held taut, whilst and until the whole nasal cavity is packed 


from in front. Finally, ilie niisal rikI ural ends of thp thread 
arp knottoil, and tlic loop plurtvl Ix-himl ihe [jaticin's rar. 
IS one u; in possession of waxtxl silk thread, tliis can be pii*lied 
thrwigh Uifr whole lonpth of the catheter, until it appears at its eye; 
it can then be peiznl ami tiril iilunil 30 rni. from itf <'n<l round 
a Iwnpon ; and the rest of lliiw prorccding i« Ihen the satiic as 
in the previous one. The oml etifl of the silk thn-ad is very 
apt to cause ehoking. It Ls, theifforc, better to soinotinics tic 






Fig. 36. — PoMtJon of the lampon {after floehtjwyg). 

both ends of the thread to the cHlheter anil to guidr both of 
them through the nose, liocheneyg, in such a case, in order 
to firmly fix the choanal tampon, ties the t«'o en<ls over a pod 
of cotton-wool placwl in front of the nostril. The tampons 
slioulil not remain in situ longer than forty-t'ight hours, other- 
wiee they are liable to give rise to inflamination of the middle 
ear, or even menin^nti?, throufdi retention of the na«ii secretion. 
If necesaapi', tamponade may he rejxyitod. fSi-e Rg. 36.) 
In dange^oa'^ bleeding injectionjt of .gebitin may be tried; 

UHlNrnS AfTTA. 60 

20 to 30 cc. of waroi fiunl gelatin are to be injected into the nose. 
Il here set* quickly under the cool current of air. 

InU'nmlly, extractuni secalis ctirnuti or ergotin (8:200 of 
water), of wliicii out' tables poonful (nery two Injurs may be 
given; or Ijydrastis canadensis, 2J> dropB three times daily; 
or stypticiji, 3-5-S tabloids a day, may be given. 

Any possible underlying sj'steinic disease should be boroe 
in mind and treated according to medical iiKlicatioii£. 



The acute inflanmiatory jjrocesses of tlie niL-wl mucou.s mem- 
brane offer, in -spite of tbeir common occurrence, no lillle dilli- 
cully n-s regards their U'niiiiiotuigy. None of their claj^rtificH lions, 
sensu strictiitri, is exact, neither clinically nor etiolopcftlly. 
For practical purposes it is |)crbap^ best to regard tbetn from 
the etiological stand[ioint, if Ihifi is adnusr;ible. 

Etiology. —Acute rhinitis arises from many causcA In llic 
imagination of the public, and often alto of live pliy.siciaii, 
cold plays the cbii-f role. The srj-called "cold in iJic hcatt" 
(corj'ZH, rhinitis catiirrhalis acuta) is sup|Kisctl lo lie always a 
coHBequeiice of "cAlcbing cold," though it would often be 
difiicult to jjrovc It. AVhat generally is eniletl '" snuffles" is 
probably always an infectious diseaM>, due to inicro-orgnnisins. 
The '■cold"provii:ie.s only the predw|)08ition, prejiai'ing, through 
alteration of the circulation, the soil for the invading lioctcria; 
as we likewise sec it in other infectious dii*ra*<e}i. though we 
catuiot always prove it by experiment. In siiii]>le coiyza 
artilicial Iransinbwion — if we except the one case published 
by Ikrkniaitn fU)02)— has not been BUcccsafulIy established; 
neitlier hnn a s|)ecial mlcrotie lieen found; probably Iwcause 
(he di.<i'a.'*c called corj'za Is cauited by many an4l various organ- 
isms. In any case, that many niernbers of one family, one 
after the other, often l>ecomp ill, the eoiiponiitant diflturlmnee 
of general health, top'tber with enlargi'iuent of the ►spleen 
{noticed by /'nVrfnVA), all seem to point to the infectious nature 
of rhinitis acuta. 



Thotijih coryiA nmy, iu a certain sense, be a disease of cold, 
like Riipim, it oftpn prevails in the wanner seasons of the yvnr, 
i'sinrially as, (iiiriuj; coiiiiiuiously drj' wcaiher, dust, and wi(b 
it baKtcriu, are von* much incrpiLseti. 

During wanner wejither we also take less care of ourselves, 
and expose ourselves more to"refreshnicnt," which often means 
sudden change of temperature. Thi.s would help to explain the 
Ct>niiui>ii uireurreiicc of the " wild " iti spring and summer. It is 
easy to aec tliat children liccoine affccieti oftener than adulle. 
Perflins who hiivc once ^ufTi-nil frotu "colds in their head" 
are, mi t*> s|)cflJt. predisiKitfetl. and contract it, sometimes quite 
rpf^larly, in (lie tranititor}' sscntioiis. 

There can be no deiiyuig the infectious nature of those colds, 
which appear as pyinploms or coriiplieations of other infectious 
Ubiettses (scarlet fever, measles, s(iiall|X)X, influenza, etc.). 

Chemical or niecijanieal irritations may cauM coryza. Of 
ehemicala are: esjircially iotline, in its varioui' medicinal fonns, 
and the va]K)urw of various* giuscs or acids, whicrh jinKluc^- it, 
without eaufuiig general symptoms. Of purely meehanical 
action are moot and dust ("railway coltl") and nuuiy other 
substances of orpinic or inorjjauir nature. Fn'<jiieiitly both 
aclions are cotnbinwl, as, for liifla.nrp, in certain trades and 
professaons. Thus wo often hear of "coryxa profes.'yonalis.'* 
Roepke records not less than I-tO varinii.t trndes or professions 
where thorse practising them may giM. an acute catarrh of the 
upper air-pftspage.«. leading sometime? to profound alteration 
of tJic ttssun; fulci^iition. ixrforatlon of the septum, etc.)* 
PhigKing, caulerizalion, and other oi)eratioii.'( may also Iw 
res])on.sibIe for acute catarrh ; e\-en a ?evi-ie blow njn>n tlic 
nose may give rise to an attack of coryza, most proliably by 
reflex action. (See p. 126.) 

That form of coryza which occurs tlinnigh the aspiration of 
pollen duflt, and known as "hay-fever," a.s al-fn tlie "cold" 
frequently ol>ser\'ed in neurasthenic or hysterir-al persons, and 
passing under the name of "nervous coryza," will Iw furlher 
conH<icrr<l liclnw. 

Symptoms and Course.^Acule rhinitis is often prectnlMl by 
general p>'mptoms, as general malaise, giddiness, footing 



pniii, hcatLftche, or even an increase of temperature. At the 
same time with these, or following them, the patient complains 
of a burning sensation or irritalion in tlie throat, of ihyne-ss 
ill the nose, or rather at llie hack of ihe iiosh, and anwzes fre- 
quently. The discharge at first is watery and thin, aiul cm 
account of its containing ammonia, is acrid and irritaliiig. 
.Vfter one day or so the secretions become opmiue, more visams 
or mucopurulent, and of a more yellowl?li-grc-pn colour; linally 
the quantity again ilccre.aHe» until it ceases entirely. While 
the catarrh Is at il.-n hi'iyht, Uwiv }u»l wmell are liimiiiifJiwl or 
even Inst. Itrspiratiou througli the nasi-, in ctinwHiuencc of 
the swelling of the mucoiK membrane, is unpciletJ or even 
impossible; and the voice becomes nasal frliinolalia clausa) 
on account of the olwtrnclion. This fretjuently (weiirji nn Iwlh 
sides; hut just as ofb'n one side only is afTeeU'd. and it may 
tJien "jump" over to llie other ade. Il is curious that in open 
air !lit> nose feels freer tlian in a close room, where again it eoon 
becomes blocked. 

Coryza lasts only a few ilays, oft<n not more than twenty-four 
hours, hut may also persist for 8onie weeks, esiiecially if tlic 
catarrh spreads as well to the iiciplilioiirin}; mucouis ni(nnbrane«. 
r<)iii[)IiKation.s are sore thrimt, r].s<ur(t*, ami pustules iil llie 
entrance of the noae or eezema on tlie liiw ('"ehapix-ir' lips), 
larhrj'iiiatioii. eonjunclivitiH, tonsillitis, diwHw of the middle ear, 
of llii> frontal arifl etliiiioidul .>iinuses and aiilrum, catarrh of the 
upjH-r air- passages, lironchilis, Iaryti(;pti.s, etc. 

Pathology. — The nasal inuettus membrane is stvollen ami red, 
flotnetiuies utcf-rated ; and the vessels are tortuous and dilated. 
The tuvsal pas^wKes are full of .secretion, which, according to the 
stajp; of the disease, shows diflferenex« of contdsteney and colour. 
Microsco|)ica!ly there is at first hy|M'rarrnia nnd niund-n-llitl 
infiltration. Sulxs(='niiently, orir (indfi the tissue oedemata pus 
an<l showing lowi of surfaw epilhelium. The disrlmrjces in Ihe 
hegimiing show a large quantity of epithelial cells aiid Ijinpho- 
cytes; later on. the nuietius et'lli tlu>ri>in aiT more numerous, anil 
in time there may nven he jui adniixl\ire of blood. 

Diagnosis. — .\eule rhinitis is, after all, eaay to recognize. 
DitficullieH are oidy poesible at the beginning as regartU the 



etiologj'. Tbe decision whethor there is present only an cmJi- 
nary eold or a nervous form of the (liseaw ; whether the rhinitis 
only moaiiB the onset of an infectious dii^cat<e, a^ in measlea in 
children. CAn only bo made after a certAiii lapse of time. Nei^ 
V0U8 rhinitis is ctiaractorizeil by the eliortness of the attack, 
wliicii coincs like a Hash and disappcarH as quickly, together 
with Uie presence of other uerx'oas symptoms. 

In infants, long-trtsnding snulHing should make us suspirious 
of hereditary syphilis; and in older children, of adenoids. If 
there Is frontal headache, with a feeling of tension anrl pressure 
at the root of the nose, complications in the region of ihe fi-oniat 
fdnus arc very likely, and difficulties of hearing or noifie^ in tlie 
heail point to affection of the middle car. Otitis, on the other 
hand, nifiiiifosta itself nearly always by the sudden onset of 
pain behind the ear, often at night. Investigation will tell us 
that the patient has sneezed or blon-n his nose violently, or has 
snifTcd up some solution. In children the ear S? much oftener 
affected thaa in adults, for the reason that the Eustachian tube 
in eliUdren is relatively shorter and wider. 

Prognosis. — Tlie prognosis is mostly favourable. A transition 
from the acute to the chronic fonn often occurs. It is less 
favorable if iietghlwuring organs Ijceonie affeetetl, but here also 
recovery, after a tinio, is mostly complete. In infancy acute 
rhinitis alway.'^ means a serious di.'^; the same may be said 
of old people who are liable 1« broncho- prieunioitia, elc. 

Treatment. — In the treatment of acute ralnrrh, we slioukl 
always remember that a cure nin only !«■ effectiHl l)y tlic nnlural 
forces, and that we have, therefoR-, to leave matters to the 
resources of the organism. The tn*atnient cssenlially of acute 
rhinitis, then, is only directed in a hygierdc and tUptetic way, 
vii., by removing or abstaining from all niiiKaiici's ur irritants 
which could interfere with the reestablishmeid of heallhy 
conditions. It ia not necessary to keep to the room or bed if there 
in no fever or other complication. In mild attacki*, going nut 
of doors should ahvays lie allowed, for the jmtient i.« much Iietler 
in tlie open air tJmn in a clowii room. We niu.«t not, t>f course, 
expect too much by tJiis method, yet local treatnirtit -will not 
accomplish more by itself. In mowt catti-s a "cold" r(*co\-er8 

ACUTA. 73 

by itecif without any treatment, or in spite oE it; therefore, it is 
belter to abstain from being too oilicious. An early hot bath 
might, pcrliaps, cut short the cold. 1 have often seen beneiit 
accrue from [ihenacetine (1 gramme do«es every two or Ihr&e 
hours), whereas the niuch-praiseii opiLUn has been of no use. 
Recently Bier\'{ treatment, as 1 have obser\*(Mi in my ouTi case, 
and m tliat of other patients, has shown itself very fllicaeious. 
An claatii! band or india-ruliber tubo is passed round the neck 
just (M.) tif^hlly that the cireulalion in tbedeeperveins and arterie« 
should not l>c inlMcretl with. This means a pressure of about 
25 to 30 K\m., and tlic band remains round the nock for from 
two to five hours. A handkerchief insteail, however, might be 
employt'd. Tlirough this bandaging, a hyperaemia of the head 
is pr(Hluced, which very soon shows itself by the flxiahmg of 
the face ami conspicuous swelling of the veins. Another method 
which is supposed lo have an abortive result, but is difficult to 
carry out, consists in eliminating all fluids of whatever kind 
from the diet for two (lays. In very troublesome jiatienta 
only a toblesjKwnful of t«a or milk or a wineglossful of water 
should t)c nllmved. 

Tlio Ireatniont should mostly bo directed to relieve the trouble. 
The most unpleasant .«yniptom, the obstruction of the nose, 
can be rclicvnl, at temporarily, by enKfing a jHiwdcr 
CompustHl as follows: 

^ Menlhol 0.1-O.2 

Pulr. oubclx 

Acid, baric. Si O.S 

Pulv. tHJci 10.0 

Sio. — SuilT up u pinch Ihrougli both uostriln. 

Very useful i.s a Rondiinalion of montbol andcocaijie, suchas: 

II. Ooo.nin. hv<lrocIilor. 

Mttnthri! JU 0.1-0.2 

Sacch. luct. lul L0.0 

One tan also reconimenri renofom* powder. If the patient, 
owuig Id tlie )-wi'1Iirig uf the iiiucous menibrane. haH a dilficnlty 
in (snifling up llit> jKJwiler, it is advisable to administer inhala- 
tions of menthol. fSee p. 56.) Sometimes painting the part5 
with adreiinliTi I : 1000 or cocaine 5 lo 10 per pent, affords momen- 
tary relief. Tlie use of eocaiiie, however, is not always hariuless. 


FiirmiuiP wool, wliich is so r>rtcn a(lverli.<in3 and praiswl, aa also 
pulvc-iizptl Ijoilc lu^iii, in Hciiiicwhat muri' irrituiiL If the si'cm- 
lioii be(;onii^s Uhj cniMims, it U adviwtlilc ti> aniiiiii the U(»»lrils 
and up}M'r U|) with lAiioliiie or boric va^ieUne, aiid Ui loiig-stAiuliiig 
catarrh the a)iplimli(Hi of silver iiilrale will .siHiieliiiicti <ln good. 
liifaiiU who huITm' fmiii m-iiU^ rhinitis nri' utmltle lo suck, 
and fed by a sijoon. Hctb sointliines iiiKlillation of 
hquid partrtin, 1 yr 2 droj).? irto each iKwtril, or ?iiiall pl^Hlp^la 
of cotton-wool steopml iii aiiramUn and applied three or four 
tiiues n day for two or three minutos, will iiuprove the breathing. 
NaegcU rfcoiniin'nd« instillation of a cht)p of cocaine-glycerin 

R. Cocain 0.2 

Aqiiu- deM. 

Glyrerin M fi.O 

Sia. — One drop in each nMlril. 

Tracht'otouiy niiglU have to be performetl in very dpsporate 

All ifljectionM, or the very po|)ular aiiitiiiig up of fluids, or 
forcible "blowiiift." niu-st be forbidden. 

Treatment of the Complications.^Acute catarrh of ll»e other 
cavities subsiric^ pin' jmssit with the acnte rhinitisv ronj\metiv- 
itis tiiipht be Lreateil by iastilliitions of sulphate of zinc or 
fomentations with a Bolulinn of boric acid. In disease of the 
middle ear lli?e hot fonienliili<itw over the ear, and, if ni-cpftMin,-. 
[XTform paracenlopis. In simple Kprous catarrh of the middle 
ear *' I'lijitzering" may be beneficial. 

Prophylaxis.— As to prni)hylaxis, a rea.'^onable hardening 
proces-s bii.s to I»e aimed at; workers or traders in substances 
which are known to irritate Ihe mucous membrane should pro- 
test the nose by respirators or by light pIuKginfi- lihinitis 
caiwwl by iodine i)reparali()na usually subsides if the drug is 


Tn the chronic inflnninmlionH fchronic rhinitis, ozaena) it is 
still more dilTieult than in llic acute inllummatory processes 
of the nasal mucous nienibraue to make a classification answering 



all reqiiircmcnl^, as all ])ossil>lo tliscaws, wiieihpr only sUgfiily 
or artitieialiy connected with each olber, gti under this headinf;. 
In tJi(! strict sense of the term, chronic infiflimnation, only one 
process diould he uniicrstooil; lliat is, a cliruiiir piucc-wi charao 
terixed by Bwellmg and abnormal exudation, l-'or pracliral 
purposes, however, it seems advisable lo dislbigui-sli Wtwwn 
simple chronic rhiniiis, where llie sweUing of tlie tnueutis mem- 
brane ia more equally diffuse and moderate, and chronic liyj^er- 
trojAic rhinitis (rh'nitijt byperjAastica), where tJie swelling is 
more patchy and often veiy TOnsitierable. Both forms may 
pass from one into the other, ami are the opposite of atrojMc 
rhinUii {rhinitis atrophica), which !att<-r, however, many authors 
res^rd as a terminal stage of the two former. This does not 
mean, though, that hypertropliic rhinitis invariably ends in tlie 
atrophic form. Tliere are many cases in which botb hyper- 
trophy and atrophy may coexist. In the following section we 
uliall discuss together the sample chronic and hypertrophic 
rhinitis, which reprf-Kenl only difTcn*nt degrees of the same 
disease, and vdU treat tlie atrophic form in a separate chapter, 
as it is held to be pathologically a separate disease, sui gmieriit. 


Etiology. — Persons aeipiire chrfinic catarrh of the nase who 
have suffered reiieateiily from acute catarrh and live undi'-T 
unfavorable hygienic conditions, as, for itistancfv in dusty or 
smoky atmospheres, or are extjowed I« irritant vajwurs or solid 
substances iu minute diviwon, etc. Narrowing of the na^al 
passages or deviations of tht- nanal septum predtaposc lo it, 
because of the obstruction and disturbance of the circulation 
(M. Schmidt). Clironic rhinitis occurs in conjunction with, or 
as a consi'iiuence of, disease in the neiglibouring cavities fempy- 
ema of the antrum, adenoid vegotatioas, etc.). Chronic catarHis 
are encouraged by a certain ratanhal pn-dlspa'ation, rlue 
probably to some di:sturbaiice of the circulation, as we find it in 
chronic alcoholism, diseases of ibe heart, kidney, or liver, 
[but also in struma and anaemia. Tlie male sex itt more prone 
I suffer. 


PISEASI3 OF Til & N08K. 

Pathologj'.— In aniplo diffuw rhinitis the luual mucou£ 
iiH'iiibrauc is r(!il(l<-rii'il anil thickened m tolo. In the hyix-r- 
tnipliic form Uit- middle and lower conchac (turl>iuala) arc 
the parts most concerned. In thi* fomity the swelling la caused 
princiimlly by increjiscd hyperaeitiia, whlfli, under Tavourable 
Conditions (see below), teJids to rtH-overy. In the latter fonri 
there is a permanent inerwuie of the vohnne rif tissue; a more 
or less permanent srvellinfi, due to the new formation of connec- 
tive tissue. Microscopically, one finds small round-celled infil- 
tratioDj especially near the surface, ami a gnat incrcaee of new 
fibrous tissue and veBscle. Vcrj- n-markable is the dilatation 
of the cavernous apaoes, the walLi of which arc very much 

The posterior, but also the anterior, ends of the conchae, 
e8ix?cially the lower one, may be conJcally eiilarginl, or may be 
|)far-sliH|)«l, or lliey may sliow a mnootli, warty, or indented, 
raspberiy-like mirface. Tliese slruetures may he so niueh 
enlarKod eh to simulate a tumour, and are of a duxky red; and, 
if the epilheliuni is very thick, of a somewhat whitish colour. 
On the middle concha it often gives nM> to the so-called mucfnts 
"pohjpi (hcc p. 114), whicli iriaiiy riTgard an tuinoun' ; Init, a« ZitcJcer- 
kandl has proved, are nothing else tlian hypcrtro|)luc foniia- 
tions of the mucous nieniltraiio, t. g., hiflammatory jiroducta 

fFig. 37). 

On examination, these papillary or warty swellings are very 
dillieult to di^^tinguish from polypi. Tlie broatl-ba&ed swellings, 
which are also usually harder, are known a;* jMlijpoid hyper- 
tntphy. in contradistinction to the more movable, Ptalked, 
jelly-^ike, and viscid mucous polypi. It is quite true that the 
latter give the impression of a new-growth, and in any case 
tliey are rItriicaUly t*o distinct that we arc juslified in diacuasing 
them later on in another paragraph, Sometimes we find besidca 
swelling of the concha, the cartilaginous septimi also; and in 
some ver\' advanced ca^'k even the bones hypertn)phie<l. 

In such va>vs bullous blistery enlargements may Ije observed, 
pnncifially at the anterior ends of the conchae, but also on the 

Kxudation is copious, seldom thin or water}*, oftener mucous 

RHnnrrs chroxica. 

or mitco-puruLent, and llien of whitis}i or appeuvDOO, 
but almost always devoid of odour. 

Symptoms. — The [mlient cuniplains iiiiwtiy of a f<instiiiit or 
"mteniiittpnt obstruction of the nose and of ■"accumuliition of 
phlrnni" (iiui«oiTho<>ii). TUesp are the chief 8>'niptoais, and of 
any others there is little or no complaint. 

The amount of obstruction dojM-nds on the dcjirec of swelling 
of the mucouR membrane. It wnietinips " juinpe" over to the 
other .side or cbanpes within a ."bort time on the sante Fide. 
actuH'diiig to the conditions of fiUlucsa in the cavei'nous tissues. 


r ^ 

Rr. 37, — PbJyp' "' '*•* antericr *Bit of mi4'll« win^^hft. Pnlvpoirf hyp*T>- 
lr«)ph^ at tlio noatfrinr nnd of tlic middle anil pupillmy hypprl miihy of tlio 
pTMtorior end at th* lowtr mntriin ilt'it *nh'). 

Tins condition again dei(end.s much on p6>'c]iic inflviencc, d«p 
1o reflex nrurosi-s (rhinitis vat^oinotoria. p. 125). When lyiiip 
doMTi. the .siilc ii-tiially lain u])on is the one obstructed, lii 
marked hyjuerirophic rhinitis, njuwl oUstniction is maitly more 
or loss constant. 

Miicorrhota is a troublrsomc sj-niptom. Ttie jmtient u.'^'.** a 
great many handkerchiefs, because he has to blow his nose very 
oft*n. or he complains of it only frc>m hearpay, brcaasp he drawn 
the nasal spcrctionh backwartls into the throat. Patients are 


oftpn forcietl to Hieezc, to clean the nose, and complain of a 
wriHHliun of ilrj-neas or burning in tin- tlintat, L'spccially in tlie 
morning, its tlie uasnl secretions llow down inlo (he Uiroat 
during the night and remain thore anil Ixieome (M)nceutrat«i. 
TTiis produces the sensation as if a foreign Ixxly wero Imlgpd 
ill the throat. ParapsUii-nias, sueli a» );rirking and buniinp, 
an- mostly present. In tinio the mucus di-ami . IjackwartU 
or swallowetl may caua- unpleasani clioking or vomiting. The 
sen.'*p of srnoil is in many cases diminislied or lost. Other 
.sj'mptoniR are caused by the nasal obstruction or by the sjiread- 
ing of the fatarrh to other organs. The voict* gt-ts a nasal tone 
(rhinolalia ctausa) and the tip uf the nose reddens fp. 52). 
fVHijunctivitis, epiphora, catarrh of the other cavities, ear 
diwa.-*, hemlaclie, and luwrrinp of llie general health by reason 
of the psychic deprpsaon are not uncommon (p. 31). 

Diflgnoas. — ^The diugiiosis is niatlr by anterior and posterior 
rhinifcicopy. On examining from behind, the hyperlropliietl 
conchae arc seen, often protruding into the naso-pharynx. 
We mu8t satisfy ourselves by the probe whether the promi- 
nences are hard fotwcoiw) or soft (swellings). I'racti rally, 
it is of value to ascertain if we have only to deal vritli swelling due 
to hyjwraemia or with a real hypertrophy. For this purpose 
we paint the swollen parts >vith cocaine or cncaine-adrenalin. 
If, after painting, the swelling subsides or diminishes conspicu- 
ously, we can I» quite sure that it was due to hyjieraemia and 
greater filling of the cavonious tissues. On the other hand, if 
the swelling does not subside or dimjnishes only a little, we know 
that there Is real hyi»ertrophy. Its mobility we also test by 
pnibing. It is not uncommon in ner\'0Ufl patients that a hyper- 
aemic swelling nulwidct on the mere touch of a probe. The 
reflex irritability Ls here so much aggravated that the slightet^t 
stimvili pmve amply HufTicient to produce changes in the 
conditions of swrlHng (nee Reflex Neurosejs), 

Prognoras. - Iniprnvenient, sometiniPB even cure, ean he pfital> 
hsliod by proper treattnent, though (he di.wase is obstinate and 
very hard to contend with. I^ra favourable is tlie prognosis in 
thnwe cases of diffuse inllanimation with nervous complications. 

Treatment.— Treatment aims aL tlirce purposes: (1) Tht 


influence on the general health; (2) th« treatment of eventual 
iiiiderlyin^ disease; {3) restitution of the local romlition to that 
of health. As reRards the general treatment, we refer to what 
we have said on hygiene and prophylaxis elsewhere (p. 44). 
In thlH matter a suggestive or psychie treatment is of great 
imi»rtanef. Patientii suffering from ehronie nasal diseaws 
aix- often upurasthenics <ir hy)MK'liomlriacs, aiid readily reftign 
theinKclvca to the sinalt inconvenlena^j^ of their RufTcrinKs if 
we can assure them that they have not any dangerous disease, 
or that there is no dL-^poaition to tuberculosis, cancfj, etc. 

General di»ea»K», such as anaemia, struma, and cnn.sttfmtion. 
must be Irejited on gciieral lines. AdenoJ*! vegetations ami 
affection.s of the neighlHiunng cavities require sjiecial treatment. 

In the milder forms, local treat- 
ment consiiils in the application of 
astringents. 1 use chiefly 3 to 10 
per cent, nitrate of silver, whirii I 
paint on. usually every second or 
third day, after locally anaesthet- 
izing. Aslringent powders I con- 
sider HuiKTlltmuM, Ihcciiii^ it is 
often not ijossihle to apply them 
to the exact sjxit. Hut in order 
to facilitate ihe remtival of rnucus 
and the clearing of the nose, 1 order 

the inhalation of menthol (fluid or vapourized) fpp. SGandTS). If 
this method of cleaning i« insufficient, the secretions can 1>p care- 
fully wa«li(Hl away ip. 3S). In eases with scanly M>crelions, 
inclined to scab fonnation, painting with iodine is useful. In 
all these procoduroa the postnatml cavity muni not be nf^lerted. 

In ca.<*e of more marked hypertrophy ftronger renjedies must 
be applied. The previously anaesthetizeil part is cauterized 
wilh lapis infemalis, chromic or trichloracetic acid, or with a 
galvani>cautcry. If one de.'dre-'* to obtain a deeper effect, the 
pointed galvano-caiitery is stalil»«l into .several places, or .slight 
grooves an? made in the di.'ipa.'*ed part; and. in a<ldilion,'into the 
grooves so niadi', one of the above-niuned acitls can be niblrtei.l 
in. Hy this inetjiod couaderable scarring is effectetl. In the 

Pig. 38. — Ptdypoid nnci pap- 
illnry liyjiertroptiy o( Die «init 
[if ttiv i-i>rii-li:t it) tliff |KMt-rliirH>* 
scoptr pirlurc 



■ilor-treatment syiipchiae or readliesioos should be prevrat 
(sec pp. 55 57j^ which, how(>ver, is not aii easy matter. 

it sonietiiiips happens tliat two or tliref days after tlie cautor- 
izalion, pspecially galvaiio-cautorkation, syiiiptorus of angina 
tonsillaris iT)nk<' their appearance. Acctirding to B. Friinkcl, 
this is (lup to ihc in\'asioa of infoftious genus hito the ivnund 
and to their spreading into tho hTuphatic tissue of the tonsils. 
Scheiler and Slerujer liavc shown niicro-organisnis in the tonsiJs 

Fig. 39. — Pnlypiw anare (^after 

Fig. iO.—HrfkmannU nasnl Bcisaor*; a, For 
the lower, b, (or the ralddlf!, (vni^ha. 

after operation, which they had found before opemtion in the 
mipa] cavity. 

In onler to remove larger circumsprihed hyjiertrophiea from 
the conchae, the cold snare or, if the swelling is more broatHy 
seatprl. the nasal scissors, arc uwrl. fSee Fips. 30 and 40.) 

Krmise's snare is used in the lollowing way: the ihumb is put 
into the hinder, the index-fingcT into the U|)per, and the middle 
finger into the lower, ring; the upper and lower ring being elose 
lo the guide hiiw. A loop of wire just long fnough to enelrelo 
the hyixTtrophy to be removed U then fornie<l, and threaded 





thrnujth the guidp tube. TikIit the miulant'p of a siwpiiliim 
ihe iiLtitruiueut in pautioufiiy iiilrtxiuci^l, llip loop h<>inK nearly 
perpondicular. It m then putdiHl as fa.r a^ potviltJe mitil the 
hypertrophy is reached <it Ls sometiinea necessary to turn th« 
handle). The hand must be steady and quick. Then the eledfie 
is now pullttl hack towards the tJimub ring, and thus the hy|Jer- 
Iroijhy \!i raugiit and cut off. 

In order to rtiach the [XBterior eotla of the roncha it might be 
necessary to reniovp swellings, spines, or enlargpinents which 
block the way. If wv want to put ihe snaic romiil the ixwUfrinr 
end of the concha, it must Iw Ixmt a little ftideways. For this 
purp( II inodificnlioii of A.>(ii/x«'« snare is very useful, which 
is constructi'^d in .'*uch a way 
that the loop is fomietl and 
bends by itself. 1 reconi- 
nipnd Juenkke's snare, which 
is intnxlucfd with the loop 
closed, and then the loop is 
oi)ened at the ilesircd spot. 
If we intend to removo a 
larptr piece of the hyiicr- 
trophied lower concha (con- 
chotomy), a practice which 
is recommended in luirrow 
deviated noses, Bechnann's 
scissors may he used with advantage. fSee Tig. 40.) The in- 
Btrunient is introduced in suoh a way that the ends of the blwic* ' 
pass beyond the hinder entl of the concha. The sfX^cuhmi is 
tlicn carefully withdrawn; the stcissors are now opened, and the 
end of the concha cut away. Sonietinies the cutting na.-^d fcii-- 
ceps of Grilnu-ald (Tig. 32) are employed. In certain rasi^i, if 
a part of the hone must lie removed, nartmann's conciiotoine, 
which ia made in three different sizes, serves the purpose equally 
well. (See Fig. 41.) 

We strongly iwlviso the operator not to remove loo much 
from the concha, for othcn*ise tlie way is opened to atniphie 
proceasea, which amounts to substituting one evil for another. 
Wc al»o strongly condeom the o|XTaliou mania of someapecial- 


Fig. ■W.^llarlmnnn'g conchoComo: 
a. Cuttint! liuriMJia^Iy: li, cuttiug 


dibea»f:r or tiif: nose. 

wt.s who, pcrha])s wihout ^inijxT indicHiionp, always pinch and 
cut aliout tlir inner nose. All tlii.s ovcroperaling is alsti vprj- 
apt to Hiaki- the [MitieDt a neurasthenic person. It is perhnpe 
not superfluous here, if we rlirect alteiuion to the fact that all 
instruiiH'iiial manipulations or opcralions should be performed 
according to the strict rules of antisepsis aiul asepfiie; and that 
we should endeavour to perform all ojx-nitions, causinR as little 
imiii as possible, by means of the application of cocaine-adrenalin. 
Ill tr5'ing to remove swellings wnled far back, we should take 
care Ibat the drug is not paiiitnl on loo far bark, for the hy|ifT- 
trophy may, by this inea.ris, be so much reduced that thp wire loop 
always y\\\vi off. It is sufficient to [laint in sueb rases the 
part of the mucoufl membrane just in front of the hyperlroi)hy; 
and tliia has, moreover, the advantage of rendering the intro- 
duction of a speculum easier and thus the ends of the conchae 
can be more readily inspected. For the use of alypin in certain 
caaea see p. 22. PlupKing the nose ia only necessary in rare 
CaBCe. where there is severe after-bleeding. 

Tlie galvano-eauatie snare has no advantJiges over the cold 
one. ItsstyplicefTsct, which U so much vaunted, is often want- 
ing, and, besi<le.*i, there is little or no haemorrhage if, as many 
authors advise, the swelling is first constricted by the cold 
wire for a few moments and then cut thnnigh slowly and with 


Etiology and Pathology.— The origin of atrophic rhimtie, 
especially that form which is accompanie^ii by foetor (oKaena), 
is stitl a question wailing to be solved. Many authors consider 
Ibis form to be the sec(Hid stagi' of hyperlrophic rhinitis; Ilie 
previously hyperti-opluc mueon*i menibnme uiulcrgoing atrophy, 
at first at isolated 8[)ots, and then, later on. in its entirety, in- 
volving also the osseous ami cortiiaginous skeleton of the nose 
in the retrogressive metamorphosis. 

Others again see in ozaena, a special infectious disease causetl 
by a sjwcific organism, the '"ozaenocoeeus," and if this be so, 
the foelor must then bo eaused by a mixed infeelion. Zarniho 
bclievce that omens, is due, not to au extraneous but to an 


miixiTjR nmoNiCA. 

intrinsic rniisc. namely, to a trophoneurosis. Grumaald «Efnics 
Uii- geiiiiiiie cliartirtcr of rhinitis atropliica focticla. luul IioKls 
thai ii is a symptom of suppuration of llie iieighliouring (.-avilK-s 
or |)!iaryiij5fa[ t«nsil (focal llieory of (Irunwcdd). 

Another series of iiivcstigalwrs !<«'k to solve the problem by 
Ijiologioal methods, ami tniee the iitrophic rhinitis to failurt* in 
devcEopniciit of the priuiiitive organ; or to congenital obnor- 
inaUti<>i4, e. ft., congoDital stnallncss of the conchao, iliminishe*.! 
resistant*- of the mucous mcmbrAnc, molnplagitt of the epitholiiiiii, 
etc. Siebenmanit and Meisi^er duT^ct attention to Ibr formation 
of the face, and, acconliiig to them, it is duu to the brond [tab 
nose ('platyrrhinia) usuidly met with in [XTsons wilh hnuwl fari-s 
(chaiiiaeprosopift ) in connection with the congeiiilal tiietHplai<ia 
of epithetiiini. IJesidea these theories referred to, there are 
others, which aim at explaining pathogenetically some one or 
other of the prominent sjTikptoms. 

Some of thctn, however, do not at all explain ttic fact that 
OMcna sometimes occurs unilaterally. The great numlxr of 
theories, which are often sharply o))ix>sciI to one another, even 
though wicli may contain a grain uf truth, eliow that none of 
tliem is free from objection. I'or Ihis reason, and bcotuse of 
my long experience. I hnve nunc to the conclusion lliat ozaena 
is not a primary single dise«se, but iiiauifrsls itself as a com- 
plexity of symptoms which is produced by a mrietif oj palhohgicol 
jjrocessex on the xubxtrattim tij jrredispmniion; e. g., suppuration of 
the neighbouring cavities, primary hypertrophy, syphilis, etc., or 
congenital anomalies. 

In this connection belongsnlsoa kind of artificial atrophy, which 
ia not so uncoininon and \s seen only after extensive resection^; of 
jwirts of the coiiehae or after rejx-atctl ejiuterizatinnij; but the 
offensive shu-II, liuwever. sometimes f>bserve<t in these cases, is 
probably due to micro-organisms. Frejfe says that the micro- 
organi.ims ciinccrned are the same as producing decom- 
IKwitioM of albuminoids. The same author found substances in 
the wcretioiis arl-ang from atrophic rhinitis, which occur as the 
result of decompo.«.ition of albuminoits matter, namely, imlol, 
(ikatnl, jjienol. sutphun'tted hydrogen, and a RTcat quantity of 
volatile fatty acids. Of the same result was aa exaniination of 



"ozaf^ous" scabs in a case nf tprliary sj'philis. We can thoro- 
foreijcrw'ive thattho" 02af nous" smell is not a uniqufor six-cifie 
one, but a "bouquet" of various pei-f tunes. This view is also 
held by M. Schmidt. 

Whether we arc jiistifiwl in assuming a "morbiw sui generi*" 
in tliuw' infrequent cases in which we totally fail to rcro^txf a 
cause, I do not venture to answer, and ae the matter now stands, 
the assumption of a Irophcineurosia would, in my opinion, 
certainly meet it Im'-sI, lliongli by this hyi)othp,eis not innch 
is gained. 

The cunfusion whidi still exists concerning the onpin and 
nature of atnipliic rhinitis might perhaps have its reasttn in Ihat 
we do not know much concerning its actual commencement 
andcoursb. It isa slow and insidiousproeese. which comes under 
observation usually for the firt^t time at puberty, when already 
all the symptoms are fully manifci-t. There are numerous 
obeer^'ations on recortl Uiat tJie ilij^ea^e may have ali-eatly l»epim 
in early childhood. I myself was able to ascertain the existence 
of a pronounced ozacna i]i a child of two anil one-half years, 
and an older sister, and the mother as well, suffereii from the same 
disease. This eireiunstance, as also the observations of other 
authors, tends to diow that heredity participates among the 
causes. Ozaeuft is more often met with in the lower elaases, 
who live under more unfavourable and unhygienic conditions, 
than amongst those cla*!so8 of better worldly circumstances. 
Females also suffer more coiimionly than do males. 

Anatomy. — Both sides arc usually affected, rarely one side 
only. It is often the lower concliae which is alone atrophied, 
while the middle may even, show hypertrophy. In the ati- 
vanred oases only, fraiement.'i of the eonrhae may Iw- Irfl behind. 
The mucous membrane is pale and yellowish, or gr«y and more 
or less thinned, as if it had been shrimk by adrenalin. 

•Ml jMU'ts of the mucous memlirane become atrophied; ihe 
normal epilhelium is often changed into that known as stratified 
and conipous in the superficial layers; the glands unilergo fatty 
<tegeneration ; the cavernous tissue shrinks, and the osseous 
gtructures also sliare in the peneral atrophy. At first there is 
round-celled infiltration, wliich is later on followed, by the 

RKixrrts cnnowrcA. 


formation of fibrous connective tissue. Viccmtion never take* 
place. It Is essentially ti clinmic iiiflaniiiintioii. Irailing (o 
sclerosis of llie mucous nicniliriiiic. Tlic atrophy i;f the iK-rios- 
tpum and bone can be explKinwl by tlii' aecoii!|mnyii p pntliirU'r- 
itb and endophlebiiis oblitemiiM. 

The ppcrotion is verj* .scanty. In ihc tresli state it is creamy 
and ycllowkh-green. It w)oii driw aii(i then fonris dull git-en, 
yeIli>wi4i-gTMn, blackish, or, through admixture of blood, 
brown or mldisli-bn)wii, hard scabs, which stick fowt to the 
mucous membrane, like wall-pajx-r, or are mouUEed and [innly 
wetlged in the lumen, fonning real cosLs of tht- cavity; on the 
niurul surface they often show, how(.'ver, a punilent film. 

The wcretion may be — this is certain — without any smell, 
buimiJKtIy, aiid.asarule, atl the cases with tlieitiaiked funnation 
of hfahs, |)0BHe8S a smell difReutt to be described, but which, 
OHM' ex|H'n<-ncod, mil never again be forgotten. From this 
wnell alone the diagnosis is often made. It is this kind of 
atrophic rhinitis which commonly goes under the name of 
osaena ("Mink now"), A bettor and more refined term is 
rkinxli» nlropkica Jwtidn, in contradistim^linn to that kind 
of atropllic rhinitis whicli slums ver>' little or no nitiludnntus 
secretion. Smplc atrophic rhinitis often affects the anterior 
part of the cartilaginous septimi Mocus Kies.selbachii), am) 
praiuces there a site of pre<lilection for ''nope-bleeding" (rhinitis 
anteriora sicca). After reix>«teil haemorrhages, the mucous 
membrane is often imbue<l with blood there, resulting in a sort 
of pigmentation of a dirty yellow or rusty color, dcscrilied by 
Zuekerkandt a^ xantliown of the nasal mucoiu* membrane. A 
small amount of secretion always reniainn and dries, and fonia 
small crusts there, giving rise to itching or bundng, and, if thenc 
cni»t« U- picked ofT, bleeding sets in. 

Xiuilhnsis may be found. thouEli Ies.s often, on other ijarta 
of the mucous membrane Ijesides the locus Kiesselbachii. 

Symptoms. — The patients, though their noses may appear 
abnonnally wide, with little or no secretion, com|)lain of chronic 
olistruclion It is often an easy matter to ascertain that tlie 
now is perfectly free and pervious to the air-eurrent, and that 
the sensation of blocking arises from the dr>'nes8 m the noue 


simulating obfitruction. This (ir>'ness is (lietinclly felt in Ihe 
tliroat (plmryngilis sicca). Others again eo[ii])lain of fuilnnitfi 
in the foreheati, of headache, deficiency of or loss of the Bense of 
amell. The sooietinies obtruavely offensive smell, if supinira- 
tion of the neighbouring cavities is not present, is scarcely |)erw|>- 
tible to the patient himself ; Iiut is mo]'e so to {lersons asKiriating 
with liiiu. who think that it eonio* from the ))alient's moulli. 
Only a pj-ofcssional examination ahou'H that the suiell comes 
from the nose, and not from bail t^eetb or the stomach. Many 
patients, on account of this horrible foetor, avoid society and 
become doprewicd. Sonictinios the patient hiinsolf reports that 
smaller or larger crui-ts or ewibs art reinovt^d from the nose, 
while endeavouring, not without difficulty or blecLliog. to clear 
his nase. On externa! examination the broad, yet relatively 
small and low, nose, wliicli looks as if it had prematurely ceased 
growing, with its [xiint directed upwanls ("saddle-nose"), is very 
noticeable. If we approacli the patient the smell becomes more 
obtrusive and always indicates the fonnation of crusts. Indeed, 
if we introiiucp the ppeeuluni, we find one or both nostrils filled 
with crusts and Bcabs, which can only be roniovwi with diliiculty. 
Tim done, tho najyil passages appear wide ; and the upper margin 
of the choanae, the posterior wall of the plmr^nx,— fonietimcs 
covered with ]>us or wabs.— the mouth of the FuistAchian tubea, 
atnl the prominence of the levator vt-li palati, a^^endiIlg duriug 
speechor swallowing (proniincnccof/''«.s/t(i[Y]n/), and in rarecaseSj 
tlie anterior surface of the sphenoid Ujne. can be clearly seen. 
I-e.-* ob^Hoiw w ihis s[ in simple or jMnl ial atrophic rliin- 
ilis. The midiile ronclia presents a peculiar npiwaiajiee, which, 
with its bull>ou.s anterior end (operculiun), looks not unlike the 
etlgo of a blimt-pointed knife. Small scabs are often seen cover- 
ing the anterior end of the concha like a cap. The e^'il smell is 
much lewHTniii or reduced after removal of the scalitf or crusta. 
Diagnosis. — WlK-never we find a more or lew marked sliriiiking 
of the nmcoiLs membrane and hone. and. in roTmeclion with it, a 
more increased widcncs.-* of the na.^al cavity, we are justified 
in diagnosing simple atrophic rhinitis, and if we encounter foetor 
ex naso, rhinitis atrophica foclida. To make the diagnosis 
solely on the foetor alone BceniH to me risky, though it is often 


characteristic, for the s&mv odour may aris(> fruiii .suppuration 
in a neigbbouriiig cavity fnnii foreign liodict^ or uli^prslinii within 
the nose. Hut in thcso caMp^i it tKies not disappt'ar aft^r removal 
of the discharg(« and secretions, as it does iii atrophic rhinitis; 
and the atrophy, whioJi is so characteristic of rhinilip, is wanlinff. 
If, on the other hand, these processes art* of long-staniling duration 
or they have been cured, the picture that reniniiis is not any 
different from that which wc see in uncomplicated atrophic 
rhinitis; and it is then finite justifiable to siH-ak clinically of a 
ample or foetid atrophic rhinitis. But if one coiiwivesi rhinitis 
atro]>hica foetida fozaena) as a iHsease fui generis, then tliis 
tei'in mu!it then only be applieil to tliosp caBtw where any other 
eaujw cannot lie found. 

Ulceration »/ the ttose in connection with atrophy is nearly 
q/hxi;/5 due to suphilis. 

Prognosia.^Inveterate coses of simple for genuine) atrophic 
rhinitis are iTicurable, because a restitution of the destroyed 
rt^ons is impossible. The loss of smell is often permanent^ 
Slighter cases are, though frequently only transitorily, amenable 
to cure. With advancing age the foetor aotl tlic scabs Ireciuently 
disapjiear of their own accord. 

Treatment. — Here, our first task is to remove the evil-smelling 
scabs antl to prevent the re-occiirrenee of fresh ones. C)n first 
examination we remove all wcahs as much as wc are able to with 
forceps, even if it ho only for the purpose of ensuring a diagnosis. 
Later on the removal of the scabs must be done by irrigation of the 
nose witJi a na^al flouche. AVe must irrigate wth a lukewarm 
solution of cfiinuion «ih fsoiUum chlori<lc) or bicaihunatc of 
aotla, borax, or boric acid. For the technique trf the pnH^eeiiing 
see p. 38; and the douching niu-st Ix; done twice dully, 
and oft4'ner in more severe cases. These irrigations soon 
result in the relatively quick disappearance of the terrible 
foetor. We may increase the effects of the irrigHtioiij! by ]«itting 
into the diseased nostril small pledgets of rotten-wool, and if 
twth rfdes are <li.seasoil, into both nostrils. With a little practice 
the patient hiincelf learns to pusli into the nose patls of cotton- 
wool 4 to o cm. long, which arc rolled in the fonn of a cigarette, 
80 far backwards and upnantt) lluit the lower part of the nasal 


cavity remains frf« for inspiration. This is the ao-eaUed GoU- 
«tein's method of plugging. (Soc p. 37.) The me and thick- 
neea of the roUa defxind ou the width of the nose, and care must 
be takfij that the pad does not press too much on the mucous 
iiieinbratK*. Tu intrddui'i; the ri)li» we iniiy iiiic the forceps, 
or the wool is wouiivl on a GitlMein'n tamiwii-hokler. Having 
pushed the plug far enough into tlie nose, tlie iitslrunient can be 
wtthclraft-n l»y twisting it in the reverse way. Tlie roll may r^ 
main for several hours — soiiietiriifs a tjuarter of an hour is quite 
sufficient to loosen the scabs, so that, by the act of sneozing, 
they are discharged. Inste-aii of plugs of cotton-wool From 
BrUek reeommon<ls stnall stri|>,« of folded gauze, which should 
reniatu so long that they arc thoroughly moistened by the 
secretions. GotUitein's method of plugging, consistently pw- 
foriiird, aUrrimtingnn the one fade and then the oilier, or on 
l>uth sides isoftcn siifiieicnt to ]>revMit the re-fonuution of fresh 
Bcabe; and tlirough the narrowing of tht^ lumen by the plugs, 
tlie drying and ex.siccation of tlie seci-etion in a]«) inipedwl. 
More recently .■iubniucous injections of {laraOin have Ih-pii tried 
in order to produce narmwing; and in certain ca-sew improve- 
ment and even cxire are reixirted. Tiit? cuppiug ((rongF.^iive) 
method, after Bi>r (pp. 23, 24), energclieally applied, is reported 
to have ha<.l gotxl results. 

In any case, the application of the tamponade, in combination 
with douching, has given valuable result*!, and in a ehort time 
the scabs and foetor vHIl disappear. Mawtage of the mucous 
inriiibranc is also lienelicial ; and thU is done by the method 
referrwl to on p. 40. For the lubrication, of the dressed 
tani])()n-h older, liquid paraffm or glycerin may be use<l (p, .17), 
or any iiulifferent ointment- might serve the same purpose, as also 
in Giiltxtein's method, ^^'e can massage dailyj or every alternate 
day, for two minutes at a time. 

IJeBiiles local treatment, we must also treat the entire constitu- 
Uon; a.^, for iustanee, by ordering iron, arsenic, or ioiiide of 
iron, suitable diet, etc. If the disease of the nasal cavity is only 
the sequel or complicJition of a ^lisca-^e in a neighbouring 
jjart, this latter must be treated beforehand. 





Ulceration may occur in the septum as a pyniploin of a gr-ncral 
diseasi', and be due to tuberculosis, syijhilis, gliuulcrs (malleus), 
etc. They often load to iierforatiou of the cartilaginous sepluin. 
Innainmation of the mucous membrane mjiy, liowcver, in due 
course extend in depth aud into the cartihiginous wpluin, so 
caunhig uleeration and iH-rforatlon (idloptitliic ulcer; ulcus 
(K^pli pt'rfcirans). Tlie rliiiiitis sicca anterior before descriljcd 
not infrequently leails — if the imtient, from constjint irritation, 
picks the nose and thereby injures the mucous mcmbraiu^ — to 
An infective inflammation, which slowly and gradually spreading, 
in time causes necroaa and finally perforation of the septum. 
The [lerfuration shows sharp, and, as it were, pared away and 
thinned eilges. In certain trades perforation is conduced to by 
local nasal irritation (workers in dye, in cement', clieinicaJ 
works, etc). Perforation does not cause much inconvenience, 
and is oft^n only incidentAlly discovered. 

Diagnosis. — Diagnosis dc[x?nds on the typical site of the ulcer 
on Ilu' eartiUiginouB fW-ptum, on its round or oval sliape; further, 
the signs of inllammation arc usimlly absent. 

Syphilitic ulcer is not, or very usually not, IxniiltHi to the carti- 
laginous septum, and there are mostly other signs of s\'philis. 
The uloT itself is coveral with a grayiuli fdm, and is easily 
influencetl liy tiiercury or ioilidi's, whcreaw the idioi>athic iilcer 
reacts verj- little tn the application of thi-sc ^ix-cial drugs. 
Tuberculous ulcers show granulations and undemiinnl eilgcs. 

Ulccnition or uloem having been cured, distinction l)etween 
the various Jdnds of Tilcprs often Ixroniew ImpcMwible. We may 
also mention that |K>rforation sometimes follows an operation 
for deviations of 1hi3 septum. 

Treatment.— Ar long as perforation has not actually taken 
place, treatment consists in cauterizing the ulcer with lapis 
infemaliH, and ap|)lying a neutral ointment. After i»erforation 
hOR really occurred we must limit our action to doncliing and 
anointing. Prophylactic niea.-iure.s coni^iwt in removing, a.-* much 
as possible, any haniiful irritation. Picking the noiK must be 


stripiiuoiisly forbiiidcn. and itehing can he rflicvod hy anointing 
tho parUi Willi tlu' fullowing ointment: Ing. diachyl.; hyUrarg. 
oxyd. (hydrarg. oxyd. flav., 0.2; vaseUni, 10.0; ft. ung.). 


Also called Boniock'A catarrh, after Boslock, who first described 
it. Is still sub judiue in regard to its pathology. 

Symptoms,— 1 1 makes its a[)]jearaiice ujider thp climeat jjicture 
of a violent fold, (liotigh not necessarily with fever. Its most 
prominent synii)toni.s are severe coujimclivitis, obstruction o£ iho 
nasp, co|)iouK watery discharge, and paroxysms of sneezing. In 
nmre severe eases, which may develop from slight ones after re- 
peated attacks, Uie catari-h spread.4 to the other air-passages, 
the larynx, trachea, and bronchi, caiwing ditfitulties in breathing ; 
and the so-calKtl "Imy asthma." Hay-fever occurs periodically, 
wht'ii the gra.-iM, llawcrs, and the eoni bloom (say, from May to 
end of June), and it. only attacks pernons who are speciaily 
predL-^po-scd to it or who are overworked or nm down in tlieir 
general health. The attacks last from a few hours (which is 
seldom) to five or six weeks. 

On rhinoseoplc examination we find nothing eharact^riBtic 
of (he dinease. !>uring an acnte attack the mucous membrane 
is swollen ami nmch injected. 

Etiology and PathoIogy.^ — Helmhdtz maintained tiiat it was 
an acute specific disease, lUie to i«[>eeific germs. His opinion, 
however, doe.s not find many adlirrent.". The general trend of 
opinion of prewnl ohserver^ \^^ that hay-fever is soimr kind of 
rhinitis on a nerA-ous hnsis, ami an attack is provoked by the 
irritation caused by aspiration of graminaceous pollen. 

Ihinimr and hi.s pupils, in a long serie-s of investigations, have 
.shottTi {hat we here have a .'ipeeifie diwa.«e, viz., that it is a 
poisonous proteid matter which is cofitaine*! in the starchy 
ro<[Hnf the pollen of cerlain graniineae, — lhe."0-pal!e<l fjollen toxin, 
— which produces the ehanicleri.'^lie. syniptomn of hay-fever. 
According to Dunbar's theory, hay-fever would thus i-eprewnt 
an idios\iicra.«)* of certain persons towards the pollen toxin of 
varinuM phiiit.-<; indeeKl. a specific p(ii.«uning. In .Vmerica, where 
tile dist^ase is much more conmion than in our country, there are 



eomr plants which blossom in the fluuimn, ami which cftiiso the 
(liwjiwt^ known as "autumn fever" (^atarrhu^i iiu1uiiirmli«i. 

Diaenoais. — 'Hie diagnosis dept'iitis on (hi- piTiiMlirily of tlic 
syniptoniB. Difficulties may arL>!ie if we have to iliscriniinate be- 
tween "hay asthina"and ordinary bronchial aKtlinui. Netctiirnal 
attacks of asthma, however, are generally bronchial; Hitacks 
during the day, ou the other hand, may Iw "hay asthma." 
In doubtful cases we may try to provoke im attack by exhibiiing 
pollen toxin. 

Prognosis. I'ro^notiis is, quoad vitam, always favourable; 
less so fls regards ultimate complete cure. 

Treatment. -Dunhnr, on thir groiiml of hia pollen theory, has 
indii-jit^'d a wt-ciillai HiK'cifie In-utitiwt. l-'nmi the lymph of 
aiiinuiLs, who liavi; iKi'tt tix'at^it with polli'ii toxin, be had i nude 
a hay-fcver antitoxin, which is u^xxl under the name of " jmllan- 
tin," either liquitlor jjowilcred. /^iinfeor advises thid tlic jwiwder 
tt» a preventive slitmid I)e brought with a bru.><b in etnitart with 
tlie eonjunetiva of rlie lower eyelid in the early incirtiing, hi very 
small doses. Also that a sinall ijuantity of the powder, alxnit 
the size of a lentil, .should be laiilTcd up or put into ihc nnse with 
a small scoop, or, in.stead of the jxiwder, the Ruid preparation 
may be used, "Pollantiu" has encountered a varieil reception, 
anii many favourable report-s ai-e at hand; but at pres^ent a final 
jmlginent in imijosiible, iVcichuTxll haa brought another serum 
on the market, calletl "Graniinol," which he makes from the 
noniial Iym]»h of gi-aniinjvorous aniinnls at the time of the 
bloswHiiing of tlie graniineae. AeconVing to M'otff-Eixner, 
the |jiillen toxin is not a real lo.icin, but merely a proleld. which, 
like all proteid toxins, haa the tpiality of producing an inereasiil 
"reeeplibility,"but no immunity and uofommtinn of antitoxin. 
Tlie elTecl of the hay-fever w-runi, resi)eclively, nf jtolkiutin 
and graininol, is, therefore, neither sfK'cifii' nor aotUoxic, "but i» 
OuU iif n ci'lloiil biith/. like the andjyrenpitim." 

If the resoureeii of the patif'nt aJlow it, we send him, during tho 
critical f*eo*on (May-June), to a place free from iiollen 
(lleligolami, St. Htasiuft in tlic Black Forest, Oberhof in 
Thuringia, Oaslein in Sulzbnrv. Cortina in the eoiith of T>to1) 
or on a sea-voyiigtr. Or, on ibe other hand, he must stay in 



his nxmiK, with the wmtlows shut, as long as ii is not impleasant, 
and avoid flowering meadows, and should, if he vvalk^ in tlii' opai 
air in the ucif^hhourhond of nipadows or coni-JWUls, wear a 
protective apparatus di'sigiicd by jWoAr (see I'ig. 42), which is 
realty only Hchmidthuiten'n nasal winp elevator ?cru'ned with 
cottOD-wool to filter ofl tlie impurities ol the air. 

Denker, LrbauUchitscft, and others, having the idea that a 

local dia|>oialiou id necessary in order to acquire hay-fever, 

desire todiminuih thisprpsiippoc*e<l irritability 

»of the mucoiw membrane by massage h !a 
Gtilixlein or by tai eleelric vibrator. The panic 
object, liowRVcr, ean be earried out by paint- 
ing the niucoiw membrane with cocaine or 
_ „ ^. , , We cannot recommend operative manipu- 
mitr (alter MtAr). liiliong, siieh a» cautermitinii or palvano- 
raiiterization, for they an- tjot only useless, 
but positively injurious, for tiie reason that they rendw the 
patient more ner\'ou5 than he wa.t Ix-forc. 

Tt is of great Itnporlance to strengthen the patient's genej-al 
health by general tiTiitnieiit (hardening, and forUdding aJc<Aol 
aniJ the excessive us*e of tobacco). 



Of the acute exantliernatntm diseases, warlet fever and small- 
pox mostly, and ineadew always, are ac<tntipnni)Hl by an acute 
catarrh of the na-sal mucous mernliraiic. The catarrh often, 
especially in scarlatina, si>readsto theannexefl cavities, Knplik's 
t^IKits, so ebaracteristic in meastos, make their first appearance, 
according to Calli, m the nose, and not in the mouth; and often 
in conjunction with bleeding. In enteric fever in young patienta 
epistaxis is a frequent pjinptom. Generally speaking, the nasal 
catarrh is only port of the g^-neral infection, anti, if the accesMry 
cavitic8 are not eeriousjy implicated, l-herc is no need of special 



In "la grippe" or influenza wc have to deal clinicBlly with 
on acute nasal catarrh. Tliis calarrh of infiuenza, howpver, 
shows such iiiarkctl eymptonis of its own that we have to coa- 
sitlcr it separately. Here complications of the acccssorj* ca\'i- 
iicA, ino.«illy of the frontal »m\i», and violent neuraljpui; (headache 
and frontal mniraljiia) are vcrj- coiiiiiion. TIh'w latter are often 
the acwHiipaiiiiiHinl.t of the itiiplirntioti of the aceessiirj- rji.vili<'s, 
oriiiay be due to ijilluitiHintioiiof the iiirves (peripheral neuritis). 
l^arlial or eomplt^t*'. loss of smell aiuli'iHslMxis eomplete the picture. 
After the catarrh has sulwadeil, tlie neuntlKia may still continue 
to exi.1t for a long time- 
Treatment can be onlysyriipi«iiiatir,as rn other cases of coryaa, 


Rhinitis gonorrhoica (blennorrlmicji) is rarely met with in 
adults, not so seldom in infants, %vliu have licen infected during 
their cntratiw into the world by the vagiiml secretions. It oecurs 
always in eonjunetion with gtHinrrhoi-nl conjunctivitis (blennor- 
rhoca neonatonmi). In such caws the tnuco-purulont secretion 
is very copious and will mostly be found to contain gonococci. 

Treatment.— Treatment must follow the aaine lines as for other 
acute catarrliH. 


Ktlology and Pathology. — lliphllifria of the nasal iniicnus 
menibrniM- is in nowise difTerent fnnti pharynj^r-jd diplulierilio 
inllaninmtioii, for it ih, in the f;n>at majority of eaM», only n part 
of the whole disease. Diph theria of the jAarj-nx may be priniar>-, 
anil then the diseajie spreads into the nasal cAvity, serondarily, 
or, what is prol>ably less common, the di-teaae begins in Uie noae 
primarily and from here invades the pharynx. 

Sclieller and SteiKjer think that the begi'iiiing of llie (nsi'n.''e 
in (he nose is, indeed, common t- noiif^h, In wjiiie ejises. infection 
of the entire boily taken place throimh ihe now without atTecting 
the latter. There the bacilli may remain quiescent or dormant 
for a long time, and only be^n their dreailed work, if there has 



been fomir<l a lorus minoris resistant iae—iu a case rp|)ortGd !>y 
Scfielter aiiil Stenijer an intranasal operation was followoti I>y it. 

It is <li(Tfrcnl with the fibrinous (crouiJous) form of rhinitis, 
which i» TpgaTiitKl hy ntnny authors as a mitigated fomi of dipti- 
tlieria cnusiMl hy a primary infection of the nasal mucous metn- 
bi-une by the Klebs-Loeffier bacilli. 11 is of a local and l)onign 
character, anil rcniimls i:s of those c^a^cs of mild phar>'ngfal 
diphthma whrre the dispaw does not caiisf gi-neral symptoms 
wmI is limited to the- lonf^ils alone. \\v should likr. however, 
to point out ihut llu* di|)hih(>na luicilli have not Ixm found in 
all caw-s of IihrinoiLs na.sal iiidainrnatioii — according to (/erber. 
in 75 jjer rent, of all Ihe cattes, the Imcilli fomid have shown 
themselves to he. of low virulenre; aiid also Uiat other organians, 
siicli as slaphylocoofj, were present. 

On tJiP wpi(ilit of this evidenw we may reasonably eonchide 
thai infection by diphtheria Ijat-illi may be secondary to that 
cauactl by others. This circumstance finds its analogy in that 
we oft«i find other pathofjenic niicro-orpjaniams, e. tj., pncumo- 
WM-ci or rncninKococci, in the oimpany of A7ebs-A<«^«''.f bacilli, 
which lattt^r seeoiiuKly ast<umc only the role of saproiJij'tce 
in relation to their hmnan hwt. Those cases of fibrinoiLs rhin- 
itis takf a wiwrate rank where the fonnation of fibrinous mem- 
hrannt Is prcMlucwl by chetnical or galvanic cauterization. 

I think, after all that has been said, we are on the fiafe side if we 
do not eJassify, for the time l)ein^, fibrinous rhinitis as a tli»ttinct 
disease; at least we must recof^ize a mikl and a virulent form; 
and in practice it i« ^e to make no distinction at all, and to 
isolate each ra.'^e of fibrinous rhinitis as long as we find, on micro- 
scopic examination, that Klehs-Loejfier's l)acilli arc present. 

Both variations ai-e met with mostly in childi-on. 

In infants wc sometimes ohsen'e a kind of diphtheritic inflam- 
mation which is not caused by Kkhs-Loeffler'fi bacilli, but liy 
streptocorei, i. e., throtigh septic infection from Ihe matenial 
genitals during the pueri^rium or from dirty and infectious 

Sjnnptoms and Course.— Hbrinous rhinitis begins like an 
cmlinan,' acute cor\-za, fever not always iK'ing [)r(vent. The 
diecfaai^, at first mucous, becomes, later on, muco-purulent {UkI 



1-Btained, anJ leads quickly to obetructioD of both 
mdes — sekiain of one sule only — of the nose. On pxaiiiitmtuin 
we (iucl in tin? nose a grayish, or yellowish, gplatiuoiis, more or 
1p«s thick, false membrane, which atUioros liniily to the mucous 
membrane, and cannot be separated from it ivithout great 
difficulty. Any false mcmbraiicB removed are soon reproduceti. 
The procciss of recovery usually take« several weeks; and the 
false membrane ceafcs to form the stKJiier the leas we tlisturb it. 

True diphUieritic rhinitU begiiis also with the sj'mjitoms 
of an acute catarrh, and in certain mild ca,ses may stop short 
&t this. The true character of the disease is only discovered 
by the ocea.'qoiial disfharge of false membranes or through iiiiero- 
scopic examination {Klebs-Loeffler'^ baeilli). But mostly, from 
the very first onset, the general health is greatly disturbed: 
the nose is blocked; the copious secpetions, at fim watery, 
later on muco-purulcnt, cause erosions at the narcs and on the 
upi>or lip. The nose bleeds frif^ly, and grayijih faW membraiien 
are disfiharj^ed with the act of sneejiing or blowing. In cases 
where a mixed infection ha.s taken place (slapljyiococci ami 
atreptocncxi, Ik-miIcs diphlhrria bacilli), the mucous membrane 
may become gangrein)u.'i. The broken-down and necrosed 
ahretb or faW mendjranw have a horribly foetid odour. 

In secondary nasal diphtheria the symptoms are, Irora the 
onset, masked by the pharyngeal disease. 

Diagnosis. — In alt doubtful ca-sea a microscoi>ic examination 
.sliould l>e made and the character of the discai?e proved by the 
presence or absence of Ktehs-fjoeffier'A bacillus, though, as we have 
seen, it is not an aksolutc t<'jit. ITie clinical feature.^ of the 
disease are also deeejjtive, save in cases where the aj'mjrtoma 
have reached their acme or the rhinitis is !*eonndar}' to an orifrlnal 
faueial dlplitheria or a primary rhinitis spnatis and invades 
the pharj'nx. 

Prognosis,— In the simple fibrinous feroupoiw) form the 
prognosis b* mostly good, but it is serious in diphtlieritic inflam- 

Treatment. — In ^twjTiowsrfti'ni/jlf following chemical orgalvanic 
cauterization all local treatment should be stopi^etl, ami. in 
other foi-ms of the disease also, the mechanical removal of the 



Bbrinousmombranes shoukl ftlli>Ketlier be avoided. In diphther- 
itic rhinitis all that it is necossarj' to d() is to apply locally, everj' 
two or thrcfi hour**, .small loinpons of colton-wool w>akod in snli- 
cylicoil, 1 ]x^rw:nt,,ornipntlioloil, 1(1 jier wnt. That stmicUnictj 
rcliL'vojs the nose, aiui ijaiiitiiij: alsi) with adrwialin will sfimctimcs 
free tht* nasal paxsa^*; then aftorwarcls a 4 jkt a-nt. solution of 
boric add or 0.1 jwr c«nt. of pernianganat,<; of potarfi, in order 
to deotloria?, may he cautitiui«ly mjectofl. Uiif«rtunately, the 
local tre&LiiK^nt dot^s not often liave the dt^tiired rctiull. In ihe 
Qou-Hcptic cBse», we have it in our handfl to avert dangerotut con- 
sequences by tin; early bijpction of aiitidiphtheritic scrum. 
There exist two sera, a simple one aoil one of hi^h value, the 
application of which is guided by the dejijec and i>eriod of the 
discaee and by tlie age of the patient. Generally, it is l)cal to 
inject at once the larger dose, and to rejieat the injections in 
order to saturate the toxin circulating in the blooti anil to ncutral- 
he that which has already become absorbed into the various 

The host place for an injection, which is sometimes followed 
l)y a ranh, i.s tJie chest or thigh. 

Local treatment is not rendered superfluoua by the injections 
of aeruin. Great attention nutft be ^ven to the general treat- 
ment, especially to the condition of the patient's heart, which 
often requires stimulants. 

It Koes without .'!a>'inR that the patient should be isolated, 
and the fUsoharge and secretions of the nose and mouth be made 
innocuous as quickly as possible. 

Tubereulc»i.>t an<l lupus of tlie nasal iiuicous membrane are 
relatively rare. Though both are cau.sed by Koeh'a bacillus, 
clinically they show a different course. How this difference 
i« cAUsed, and whether the tubercle haciUu.** is modified by the 
KTcwtioTiB of the mucous membrane, is not yet decidetl. Tuber- 
culosis of the nasal mucous membrane is usually secondary 
to ttmt of the lungs or laniLx, but it may also occur primarily 
in the now. as when the mucous membrane has been infected 
by dirty linen or by the linger. 



ipus of the mucouii mcml;ran<? i» always associated with lupua 
erf ^i£ Bkin. It i.s then difTirult to say whicli Ls the piimar)' 
seat of liiaea-se. It is a curioiLs fuel tlutt womai more often suffer 
from lupus of the ruxse ihuii tiifii. 

Etiology and Pathology. — Ttie pjwenlial fpaturp of tuberculous 
dis»^as«Mi]!iipusis tlu'lulwri-li', a lit tlf gray »rycllow-gray nodule. 
The lUHliilt-H rtooii break tJown, foriiiiiiK u!«t?rs, which may coalesce 
to fonn IarK(.'r ulcers. Or they give nm to iiililtratioii»i; rounded 
or oval, redUiuh iniillraltra. which appear ae circumscribe<i, 
elevated, easily bleeding, friable papules (tuberculoma). The 
infiltralions and tuberculomata soon break down, however, and 
fonn tarpe ulcerated areas. 

The nodule of lupus Is the same thing as the tubercle, but 
it has leas tendency to break down, and not mfrequently atrophies. 

On microscopic examinations one finds ronnd-cellctl infiltration 
and pant-cells, especially ammul the blood-vessels. Tubercle 
bacilli, however, are generally scanty. 

Symptoms.— At first there is little to be seen; later, if infil- 
tration and tulwrculomata have grown up or ulceration super- 
venes, the noae is obstructed, and there m a copious purulent, 
blood-fltftinetl tliacharRe, with ample formation of crtists and 
scalwi. 'ITie disease causes little iwiii. and the general comfort 
is little disturbed, except other iuiportajjt orgarif^, finch a.s the 
lungs or larynx, become affected. The diseaw is so in.siilimia 
and unobtrusive that patients do not usually consult a physician 
unless ulceration has occurred. Then one finds ulcers covered 
with crusts or scabs at the nares, on the septum, or pi'rfnration 
of thesepluin. On removal of the crusts, iri-egular notclieil ulcers 
can be seen, with their edges thickened, corrugated, undermined, 
and covered with granulation tissue. In the adjacent mucous 
membrane miliary tuberclfs are vi-^ible. 

"nieskin of the nares and upper lip sometimes ahows inflam- 
matory iiifiltratioti and is covered with cru-sts; conjunctivitis, 
from obstruction of the nai(»-lachr\'nial duct, make*! its &\y- 
pearancv; atul the cervical and subnmxillary glands become 
enlnrgcil — signs wliich are often suiinnarized under the tt'Tva 

But hi truth, they are really a distinct form of infantile tuber- 

DISEASES or nii: nose. 

culoss, ami (he tonn is often crroiu-ovwly appliwl to tboee cases 
where a chronic nasal catanh with copious liischarge, ecxaiia, 
aitd intUtratiutiof upixr hp and iiart-ti, and swelling of the glamlfi, 
is associated nith adenoid vegelatioas. 

In lupiis of the mucous iiieiiibiHne we see nculules of the size 
of a millet seed, often coveretl with erasts antl airaiigwl singly 
or in cltistcrs; at a later period ulceration has occun-ed. 

In many eases there is little or no difference betwwn tuber- 
culosis and lupiis; the latter shows more tendency to sbrlok 
and atrophy, and tlie fonncr tends more to break down. If we 
d«arc to Ik- safe, we will confine tlie diagnows of lupus to thoee 
viii^'^ when; the affection of llur inuwms inendtranc is asftjcistlcd 
with lupu."! of the skui of the nose or facc^ or where we see the 
nodules so rharacterislic of hipus. As regards our procedure, 
then' is no difTereTice If it Ije either lupus or tubercle. 

Prognosis.— Propioas seems to be somewhat better in lupua. 
RelRi)sif< are fre<|uent in both <liseaj!es, 

Diagnosis.— Diagnosis will be easy if the akin of the nose or 
face is also disea^rd, Tuliercle at its comnienoenicnt might 
oc«i.*ionally bo niLslidicn for lymph foUieles. Tliem-, howTver, 
an.' nothing but an aceunudalion of lytnph c('llis, which have no 
inclination to break down. Tubcrciiloniatn, if Uiej- are very 
large, may anudate malignant tumors fsaretnim!). and in such 
a ea^* the micrwicoije will wxrn -setde llie qutwtion. Greater 
difficulties arise in the diagna-^ls between tubercxiIou*i an<i syphi- 
litic ulcer. Tvhercfilmis ulfers are in general much more indnleiii 
Own s^pfiititic utcrrs. In the former the ailjaeent mueous 
membrane Ip little Infiamed or aflccted, the discbarge smells 
little or scarcely at all. and pain is mostly, if not always, absent. 
Sypti Hit ic ulcers are always purroiuitlct I by a wall of infiammation ; 
the diwhai-ge h a beastly smelling secn-tiiHi. and thi-rt- is often 
acute neuralgia in the area supplied by the trigeminal nerve. 
Tuberpulo«i*( is niO(«tly localize*! and liniili'd to the earlilaginouf* 
septum; syphilis fretpiently affects the osseous septum. Diag- 
nosis is ajderl bv other sigjw of the respeetive disease in other 
organs, by the mieroseopic examinations, or cr iwiyjufAua, by 
the effect of iodine. But it should not Ix- forgotten that both 
diseafiCfi may occur jointly in the same place. 

kcmt ANO cBnoKtc isrEcnous diseases. 


The idiopathic ul<wr of the upturn shows smooth, ihinnecl 

Treatment. ^Isolii let! gnumlomata (tubcrculoniae) can be re- 
moved, after previous local anesthesia, by the snare; broadly 
seatfxl ones, as well as ulcers, must be eiiet^tically scrapeil out, 
dou'ii to the healthy tlsiue, with a sharp scoop, and then cawler^ 
iawi with laetie acid (.'JH to SO per oeat.) or the galvmio-eauteiy. 
In lupus Ike hot-air treatment may be highly reconiniended. Ill 
inlvanced cases, where the general health is also aflerte*!, treat- 
ment should aim at cleaning the ulcc-rationi?. in regard to the 
treatment of lupus of the skin, we refer the reader to the text- 
books on skin dieeajsee. 

Local and general treatment must always go hand In hand. 


Following the usual gi-oiiping, we also find in the nose primarj', 
secondary, and tertiary affeelions; the various forais, however, 
eaimot always be sharply separated from each other, and often 
ipstm insensibly from the one etage into the other, or are con- 

ia) The primary affection (initial sclerosis, hard chancre) is 
not often found on the noftp, more often at the entrance or on 
the septum of the nose; that is. on those places where a trans- 
mismon of the syphiMlic virus, Uirougli the finger, ld»>, or hand- 
kerchief, etc., is nia<lc easy; or it may be found in the naso- 
pharyngeal spare, near the ostium of the Eustachian tube, 
through iiifeetion from unclean catheters. 

Hani ehaiuTf of the introitiK is chanicterized by a hanl, 
intlurated, Hat Infiltration slioning a shiny, red, smooth surface 
under a Ihin erust. It soon breaks down into an nleerwith hard 
infiltrated edges and .scanty discharge, and is co^*e^ed with a 
shiny grayu<h or yellowijih d6bri.<i. On the wptum or naiK>- 
phaPrTigeal »\y&t^ chancntf apix-ar as red. haixl, rait-ttl infdlra- 
tion.^ eovereil with a Mhiny rual. r(irn\"*r»onding hi Ihe seat of 
the primary arfectifm. "till- nnsc rnay be «woilrn and olwtniPte<l; 
heailaelie and fever may lie present, or, in ndro-naNal rhanerp, 
diniiimtiori of hearing. Ilie regidnnl lymi)liatie glands {cervical 
and suliniaxilhir\') an- alwavH hwollen. 

disEabes of tee nobe. 

{b) The secondary stage, as elecwhcre, is charftct«ri2<^ by U»e 
two types of st-condan" sypliilis, viz., crylheinatous aiid japular 
eruption. This shows itself in the nose as syphilitie calanh and 
coiwlylonia; tlm latter, of very rare oixurrcjice. 

Syphilitic coryza, clinieally. is vf-ry little iliffertnt from the 
anipk', non-Hpeeilic variety, ami is, for that rt-ason, oftfn not 
recognized, but lasts niueh longer. This obstinacy is aUo veiy 
marked in specific catarrh of ui(ants — so-called snuffles of the 
nipw-borQ (coryza syphilitica neonatorum) which, in Lesstr^s 
opinion, no child affected by hcreditan' sjphilis escapes. Every 
long- lasting cold in a physically badly develojied infant, especiallj' 
if accompanied by blood-stained secretion and diiicharges of 
crusts and scabs from the nose, is indicative of sj-philis. Later 
ulceration occurs, followeil by necrosis and dcfeclji of the osseous 
fllnicture of the nose (saddle-nose}. It is of no consequeiin^, 
if one attribulcfi tliesc timnifenitatioiiH of [hp H?condary or ter- 
tiary stages to the result of pmunatous ulernition, for the treat- 
ment is verTi' much the same. These ailvaneeil lesions are sonie- 
timea observed in nuirli older persons, the i-ruptinns ajid mani- 
festations of parlier youth liHvinj» pas.-^d over without leaving 
a trace. 

Tlie papular syphilide and broad condyloniafa at the entrance 
of the nose apiX-'ar iis small brown or browni-^h-red fjiitches or 
papules. Tliey t-end to break down and lead to painful cracking 
of the ti.«isues (fissures and rhagades), mostly in the posterior 
angle. Oji the inueimw UH-iiibraw they show Ihcnu-^lvcs as gray 
or yellow oj>acilies in fJu> i-pithclimn. chiefly on the mucous 
membrane of the septum and flour (jf the mwe. 

(c) The most coumion niaiiifewtation^ of syphilis in the nose 
belong to tho tertiary stage. Tlicy are reprcNnntHl by the gumma 
or gummatous inliltralions, and are of a more dilTuw? cliaracter, 
or are more or less circimiserilied. Microscopieally, ohe; finds a 
sniall-eelleil intiltration. The gumma orlginati's either in the 
mucous membrane or grows from Ihf periosteum or perichon- 
drium of the nasal skeleton. It leads, by necrosis, to extensive 
destruction if it be not interfered with. Tlte gumma of the mu- 
cous membrane soon breaks down nuil forms an ulcer, ihi-- floor 
of which is gray and .slimy ; il-scdgi! is pimcliwl out. indiiraUnl.and 



'liiiarply put. It invmlrs llu' underlying strurture. cartilage or 
'Boiie, or bolh, according to iU [xjisitioii. If it is priTiiartl.v sealed 
ui th(r bone or cartilage, ihis will be destroyed by necrosis and 
aLropliy, and is disehargei.) lu^ .si:>que.stra. In tliis case, the muraiis 
nismbmne will be destroyed from \ritliin outwards. 

On the oihor haml, yypliilis iiiay Icati to sclerosis and hyper- 
plastic processes of the bone, in particular of tlic etlitnoidal 

Symptoms and Cour«e.— The beginning of the tertiary stage 
frer|Uently escapes obwrvation. The |)alicnte are seen when 
ulceration and sequest ration liavi- taken place; then the nose is 
obstruct&l, and esiwcially if tlic hones an' affecteil; discharges, 
foul-ameliing pus, and blood-stairuHl secretion, headache and 
neuralgia are coinuion ami unpleasant atlditions. The septuni 
is tlip most ooninion seat of tertiary *^'phihs, and ulceration of the 
oasoous septum can bo considered aa pathognomonic. 1 1 is likely 
to spreatl m dcplli and to perforata the hone, which is destroyed 
and ultiinatdy discharged in the fonn of a sequestrum. Caeca 
are recorded whore the whole (=eptuni had been destroyctl, yet, 
neverlhclcss. the nose prcscrveii il« extcnial ^lhapc■ for a long 
period. Sinktng-in of the bridge of the now if- not cniised through 
the loss of the septum, which really doi-s not support it. but 
through the cic:»tricial retraction and filu'inking in at a later st.ige 
of the fibroiLs tissue, which pulls and retracts ihe carlitages 
and mucous menibraue coniieclpd with the nasal bones. In this 
way the disligurement so oflpji seen in s^'phililie [X'l'soiis, called 
"saddle'' iiru\ '■ lorijnelte" nose, m\mt be explained. A wnihi- 
luition of both deformities is the so-called " Inill-dog" nose, where 
the cose is. so to pay. withdrawii inio the pyrifomi na.*al &\ier- 
ture. (See Fig. 43.) 

Besides being on the wphnn. we also find gunimatA on the 
floor of the nose, where tliey form spherical swellings tending to 
ulceration, and finally to jwrforation of thehani palate. Tnsuch 
a case 8[x?ech Iweonie.-i iiacal in sound, and not infrequently food 
may he driven into the nose (hiring the act of chewing. Tlie 
conchae may siilTer in the general destruction, which may Ivceome 
very wriouR if Ihe neighbouring hones are implicated, and the 
dtspaac spreacb into the intorior of tlic skull; causing meningitis. 

Fig. 44. — &v'philstic Baddlo-ntwc. neon by ftnterior rhinoerop^' IbroUKh lli« 
l«ft nostril. Tn* seprurn ie entirely <losrroypd, and only n •ntmU splinior ol 
bone iB left (Sp) heiviifn ihfi rliuiitmr. The wholi- tiiinnl i-!iviiy win («• Bcm 
Trom oai'h no«iril. A fnijjtiiicnt of ilip lefl itifpritir turbiiiiitp mniHiiis tM), 
wljioli eovers ijip left ostiuni of the Kiij>lar>lil:iii ttihc, mtu frtwii tlifi k-(t no«. 
tril; tlir riiiht luhnr iiKtiuiti irTC/), with the fiilmr wall, \s vei^' ilietiiietly vini- 
hie. iSplintrr of the septum iiml roHf of iho noNe covered with icabs {it) 
»lu)»ine alrojiliic post syjihilitic Thlriih. 

tliU way aillKsions (syiiccliiflr) anil con.'*trictioiis f.-'tPiiCM'**) 
of the natal i-avities ucciir, iitu! in some inaligna,nt ciises, when 




both extprnal and internal parts of the nose are diseaseil, the 
ensuing iip«triu^tion may be of so great an extent that, of the 
whole noae, nothing but the cavity remains. 

It sometimes happcntj that the process comes to an end by 
itwif, aft^r the discliargc of all the necrowni ])art8. Usually the 
result ia atrophic rhinitis. The fibrous elements of the mucous 
membrane imdergo hypertrophy and hyijcrplasia, which, in tlirrir 
turn, give place to relrogn-wive nii'lAiiiorijluiiscs. siiriiik. and 
atrophy. The secretions dry up and funii .sctJi,Li.s and itilsU, 
anil assume the same odour as in "genuine uzawm" (rhiniLis 
atrophica syphilitica foetiJa) (syphilitic ozaetia). 

Ill a third cla»s of eases no scabs are formed, Btid the very 
fl|jaeii>us nasal cavity shows only tlie signs of simple atrophic 

On rhinoscopic examination we find a most varied picture. 
Rarely do we see the infiltrations, mostly ulcers, covered with 
cruste and scabs on Uie iiarte aforementioned, dilTii^ins sn In- 
famous odour. On applying a probe we encounter bone, denmleti 
of its i)erio.«teum, rough, and ultimately movable. The mucous 
membrane i(«'[f w red and swollen, ami tn the later sCiipes we find 
exostoses or adhesions fosseout* or fibrous), or the nasal cavity 
forms a wide hollow space, wliieh .shows only traces of "decayed 

Diagnosis.— Primary ehanere often passes unrecognized until 
tlie regional lymplmtlc glands are swollen and eruptions of Uie 
skin hiu'e made their appearance. In the seeondarv- stage, the 
aigns and symptom.^ in the nose are the same, and are always 
associated with tlK»*«e an other jmrLs of the Uidy. Tertiary 
HV'philis is, for the mast part, ea^^y to diagnose, and more so 
the further mlvanccd the )>r()rcss, Tn the first .il.ipr wr may 
have dilhculty in di:iy:in)sis. e.sjx'M'ially if anamnesis and (ibjeelive 
examination are uncertain. Later, the destruction of the osseous 
nose and the odour will rcvi-al Oii' nature of the disease. 

With regani to ihc difTermlial diagnosis f»etween tuberculous 
and sypliililie ulceration, we niu-^t refer to the previotus chapter, 
and in doubtful caws a resort to iodide of [wtassiuni will sooner 
or later decide. Whether wp are justified in reI>itigonabncterio- 
logwal exiuQiiiatloQ cannot yet be OEScrtcd with ccrliunty. 



TheSpiroclxBcta pallida, discoveretl by ScHaudinn and Hoffmann^ 
is not yet generally accepleil as the caiisa ngens of syphilis. 

Prognosis. — rropiosis \s favourable if a sjx'cific trealnient 
is undcrl4Lken. Unfortunately, there are cases which, in spite 
of the best Irentiiimi. assume nialigimnt character; and others, 
again, which frequently relapse. 

Treatment— Treatment must be local and general. Id the 
ca^e of hard chancre it can uoly be local. If it is seated exter- 
nally, it can b« covered with a mercury plii.strr, or, if ulcerated, 
n'anlu^l with alodium chloride eolutiun, and iiftcrwanls dusted 
with calomel. If it is found on the septum, or even farther in, 
the ^la^al cavity can 1)0 douchi-d widi a 0.1 jut cenl. solution d 
peniuuigaiLiiv of {lolaKli oruiE^utllait^l with caloiiiet. The same 
tn?atiiiKnt can be appllf^l lueally in the secondary Htnge. Fiasuree 
niay be covered with while precipitate fmercurj') or may be 
cauterized xvith chromic arid. Tlie general treatineni of secon- 
dary fij'iJiilis consists ui the o.^hihition of mercury, either as 
inunction or intramuscular injertion; or if either or both is in- 
adrnisKibte, then in the fomi of pilla; as: 

K. llydrnrg. tjinnip. oxyHiil- 2.0 

Il^ic .iliim. eilinite 6j0 

(Uycwin q.*. 

(■( (, iiil. N«. xtx. 

Hlo. — Two pills hIUt niciiU three time* (lailjr. 

In whatever form mercury is exhibited, the utmost care and 
altcjitirtii tiluiuld be exorciwd iu kee]>ing the mouth and teeth 
clean and iu onler. 8o ax to avoid mercurial stomatitifi, which 
is ver}' apt to retard or complicate the treatment. The teeth 
shoukl be put in order before the commencement of mercurial 
treatment. Hie whole oral cavity and the throat fihoukl be 
cleanseil and waiihod as often as poFsiblc. As a moulb-wash 
or gargle the liquor aluniini acetati diliiti^l llturmv'^ solution), 
or pi!rhy<lrol, 1:10, may be used. For the fame purpose tincture 
of myrrh (20 drops in a tumbler of water) or a wdution of 
|)ennai!ganate of potasii may W applied. The t**th must be 
cleanwHl after meals by the tooth-hruiih and powder. In the later 
Btapw, mercurial treatment is effectually aided by iodide of 
potaSBiuin. Infants miii-t be batheil daily, for a quarter or half 
an hour, in a warm bath (a wooden l>owl). lo\^iicli l.(X) bichloride 


mcrcurj' U added, while internally caloniol is pvrn. In 
U-niarj-ftyphili!* itxlitle of potassium is lilt? rtovfrelgiirwtmly. One 
Kiv(?s it til solution of 8-10-15: 200, of whitdi a tables jxionful in 
tiillk aitcT me&h is taken tliree times daily, ariil whidi may be 
suitably foinbincd with a mercurial inunction. To jw^rsons who 
cannot starni ilm iiHti of iodide of |iata«siiini, and wlio soou get 
coryza, or eruptions, the <loi3es niiut be reduced, and an alkali 
added; still better in such cases is iodipin, an organic comjKJimd 
of iodine with sesame oil: 

H. Calomel 0.002-0.01 

Socdi.lart 0,30 

But. — Oiii! iHfwder liiree times tlaiiy. 

It- ludipin (lUpfir omit.) 100.00 

01. mcntli. pip. £lt. iij 

M. Fl. Biu. — One (ablcdpociiful tlireo ilmee dnQy. 

The general treatment, such as we have outlined, is in most 
ca.«es sufficient; it may be supplernentetl with wa.shing out or 
douching the nose, but local trealnient is mostly unneceasarj', 
if it be other than for the remo\-ing of necrosed bone. ITiis, 
however, should bo extraeteil only if it is completely movable; 
and also requires special skill, if it has to be removed from the 
roof of the nose. 

The treatment of the various conditions, as pynechiae. formation 
of Jtcalii". and nziwiia, h the same a^ in nun -syphilitic eases, and 
we rcfi'r tlie reader to Chapter V fp. 82). IJisuing facial dis- 
figurement fsaddlc-niisir. buU-tlog nose, etc.) can be rectified by 
thi" iuji'ctiiMi of li(|uid hiird parailin. This procedure is not 
always hannh-ss, and it.s lH><(inf; I'ffwt doubtful, for the paraffin 
is slowly, but for (lie nio«L part. absorWl. 


The disease, which \» very chronic in it.s ctjunse, ibtually bcjpns 
in the nose, but also occurs primarily in any part of the upper 
atr-pa«aage». It would, therefiire, be Ijetter to K]>eak generally 
only of ficleroma, and to preser\-e the name rhinoswleroma for the 
affections of the ntjse solely. 

TTie disease seems to occur mostly in eastern Europe, and in 
persons of middle age, living under ini[)orfect hygienic conditions. 
It is probably catised by the "scJeronia bacillus," diacovcrcd by 



Frisrh, whicli ajipcars to be a abort, tbick IjacUlus, enveloped 
by a ra[i<<iile, simUar to FriedlAiider'tt ha<'illus. 

Symptoms and Course. — Tlit' bi-giiiriing ls usually that of nasal 
catarrii, with a dweharge of aloimjiis jwcretions and fomiation 
<rf scabs. l{hino8Copi(!alIy, tJip iiasaJ navity shows rhinitis 
atrophica. Gratkially the nose Ijecoiues obstructed, and this 
is due to iniiltratioii of the mucous membrane, at first circtun- 
scribed and nodular, later on becoming more diffiiw, and situated 
at the conuitenceuient mMtly in the anterior part of the floor 
of the nose, but oftener m the naeo-plmrynx. It then spreads 
on all sides to tlie external nose as well as thi' ]i]», face, and fors' 
head. Al first soft and red, the itiFdlratioii later l»eeomes as 
hard as cartilage, jwiles, and undergoes atrophic processes, e. g., 
shrinks and forms scars, producing adhesions, constrictions, 
and diafigumnient. Kinally, the none apjiears thickened, like 
a bulb. There is never any suppuration. 

In its further course Uic scleroma inxTwles the naso-lachrymal 
duct, annexed cavitiep, throat, and other air-papsages. 

Microscopically, one finda round-celled infiltration inter- 
spersed with larger cells, which pIiow colloid degeneration and 
contain the scleroma bacilli. These Ijear the name of Mihitia'a 
cells. In the later stages, new formation of connective tissue 
is conspicuous. 

Diagnosis. — ^Thediagnosis i^ based on the particular localization, 
on the extremely slow development, the con-spicuoas hardness, 
and on the absence of uleeration. 

.\t the beginning it nii^t lie confused with .sarcoma, carci- 
noma, or gumnuL, as long as the outer skin is intact. Sarcoma 
and caj-cinoma, however, are seldom bilateral, and gummatous 
infiltration h aim mostly unilateral. In doubtful cases the 
trial of i(.x!ide of potassium or a pn>l)Btionary exci^on, with 
microseopical examination, would ensure the diagnosis. The 
flintinrtion between- rhina-wleroma and rhinopbynm offers no 
difficulty. (See p. TA.) 

Prognosis.— Prognosis Is unfavourable, as the tlisease is incur- 
able. If it spreads to the lar>*nx, it is then directly danj^rous. 

Treatment.— This is hopeleiw. Transitor.' n'lief can bi* rendered 
by opcrati^'e meastires on the obstructing parts of tlie tumour, 



or by the introduction of Imugics in order to prevent adhesions. 
If the latter have already dccurriHl, Uiey must be broken down 
by WHiir iiifthod. Mmv nrriitly, r-rays and i''(n«c«-liKbt 
treatment have shown tht-uiscives very valuable, but it is doubtful 
whether this treatment has any lasting effect. 


CHanders is an infections disease, pernliar t<> horMw, and is 
caused by the Baeilhis nudlei. It is someliineM trajismiltcd to 
men who come into intimate eontuct witli horses, an husiilers, 
grooins, stable helpers, etc. It Is characterized by clreuinscribed 
and n{>dular, rTiorc wldom ditTuso, infiltration.s, which have a 
temleiiey to break down and fnrrTi uleer« and abfeertse.'*, TllC 
bai^lli art* trausniitk'd tlinmgli lis.siircsor eni.sitinxcf the tnucniiA 
membrane or skin, but the investigatitjiw of Itabeit sb»»\Y tiiat 
infection can take plaee through the intaet mueous membrane of 
the nose and mouth. 

The LliBensc is acute, chronie, or of great vnrietj', as the ease 
may bo. The affeetion of the nose, albeit often rart-ly absent, 
is often insignificant. The now is seen to Iw? morn or less 
swollen, Bs in, erysipelas. There is a eopiouf, pundent, evil- 
unelliii^ di^char^-; and on rhimit^ropical cxjunination, one finds 
here and thi-n- little yellow jiapvdcs or pustidctt whieh later im 
ulwrate. Tlie ulrers .show a hard, infiltrated tilp-. and Ifnd 
to (Hrnetrate in depth, destroying the bone and cartilage. In 
the ehronie fonn of the disease, which may last a long time, — 
memlhs and even years.— the symptoms and sipis in the nose 
antl other "rjnins are far pmnouneed. Flere a recovery is 
possible; but, as often happens, it becomes acute, and then, ag 
A rule, it ends fatally. Acute "planders" ne.nrly ahvaya termi- 
nates* in dcaili by intercurrent pyaemia and septicaemia. 

Malleus begins in some cawfl. according to Babeff. with a 
chronic dr>' rhinitis, llien iiubiratrd intiUrntions are formed, 
which, however, .fliow little trndency to break do'wn. yet here 
the baeiili lied<irtiiarit forn long lime. until sudden !y,5ubsec|uently 
to any trauma or acute disease, they are liljerated to begin 
their ileadly work. 

Diagnosis. — Diagno-sis is difficult in all cases where anamnesis 





Etiology. — Foreign IxHlirs gain acocss to the nasal cavity 
IB various ways, most coimiioiily thrniigh the uo^trils, less often 
from tlie )K)sterior narcs, niiil mrt-l;,' througli accklcntal gajw 
in the naj*al walls, rbjlilren, or al timw insane [ATSons, put 
all sorts of tilings into their noses — f^as, beans, stones, buttons, 
coins, l)Ga»ls, iiaper, etc. In ailults, one soinclinies finds pieces 
of cotUm-wooI, gauze, or plugs, which hatl I)een left there and 
forgotten. Sonietitiip-s, from speaking whilst eating, or from 
swallowing '■ ihc wrong way " Cdysphaffia}. oe vomiting, particles 
of foot! may reach the nose through the choanae; or by injury; 
broken blftties, splinters, bullets, etc., may penetrate into thenose. 

Pathology and Symptoms.— iSiiiall. slipper)', smooth, mobile 
foreign boiliea are often removed by the act of sneezing nlone. 
Larger ones, esjiecially if the pas.'^es of the nose are narrow, 
remain most commonly in the lower meatus, where they rest 
and cause no other symptoms save slight atrophy through pres- 
sure. In time, however, they eause inllammation ; the nose, 
on the side in whiph is the foreign body, becomes obstructed, 
and a discharge, at first thin, later more purulent and evil- 
sniolling, appears. Associated with this there may be headache 
and other nervous symptoms, and in children oven convulsions 
or delirium. The neighliouring cavitii'S or organjt may Im,' affected 
(the lachrymal apparatus, the eye, ear, or antrum). If the for- 
eign boily is not then rcniovcd. erosions at the anterior ntires 
or on the upper lip, or granulations and ulcers, may Ik- foniied, 
resulting in necrosis and dcstmclion of the mucous membrane 
and cartilage, f>n the other hand, deposits of chalk and niag- 
nesia are foniied round the foreign boiiies, which are then con- 
verted into nasal calculi (rhinoliths). 

In some cases the foreign body in the center of the rhinnlifh 
was overlooked: and in others, dried secretions or bloorl rinigula 
have Imvu found; maa-ses aWi of Ifptniiirix, were olwerved. 
Tlie salt.-- are derive*! from the naso-lachrymal secretions. 

Na.'ial calculi may grow tn a very large size. Zurkcrknndl de- 
scribes one 5 cm. in length and 2.5 cm. in breatlth. Their shape 



varies acttonling to Uie sliape of the nasal caviiy; their surface 
may be smooth, or uneven or spinous; and they show a great 
variety of colours. In cementrworkers, a special kind of cal- 
culus has been found. 

It may be iiientioDed tliat aljcrraut teeth have I)eeii found m 
the cause of ''stone iii the nose" (aiid in die ajitruin). This can 
only be explained by a congenital Inversion of the ilental germ. 

Diagnosis. — 'ITie diagnosis is made l>y ihinnse<»pic' exarinua- 
tion, and with th)? aid of a probf; for tlie j)ittienL may iioi know 
that a foreign body lias reaeJied his not»e, or has forgotten the 
fact as to when atid how it came to Ix- there. Cliildren verj- 
often, from fear of punishment, do not tell the truth: and it is 
just in children that we meet with the greatest difficulty in 
makhig our diagiioKJs, 

A oiie-!Hidcd, evil-smelling dlsic^haige from the nose in chilrlren 
points mostly to the presence of a fiireign lio<ly. IJsually it is 
the right nasal half which is affected, and is exphiined by the 
right-handedness of the chiltlrcn. Obstinate chiUli-en must 
be kept under proper control, in order to examine and remove 
the foreign lioily; narcosw, bouevtT, will seldom \tf required 
for the pur|»ofle. The remiltant blocking by aecretiona must 
be rcniovftl by cautious syrinpnu, ami we nni«t examine as 
speedily as poeeiblc. In adulta we can usefully employ cocaine- 

The distinction between a calculus or necrosed bone (seques- 
trum), or a soft foreign body ami a deconipoang tumour is some- 
times not very easj-. I nil animation of the accessorj' cAvities 
can seldom Ijc misconstrued. In certain cases the x-rays intist 
be resorted to. 

Treatment. — The removal of foreign bodies from the nose 
must be liono instrumentally. Other methods, as pressing 
in air by means of a FoUlzer hag, or sjTinging the healthy side, 
arc uncfTtflin. and are liable to cau^se inflammation of the middle 
car. \\'henever it is pos.-'ible, l>efore attempting removal, one 
ahould get information aljout the size, seat, and nature of the 
foreign body, resorting eventually to local anfle.tthe>iia with 
cocaine and adrenalin. It is best to intro<iiice a strong probe, 
bent at the end. push it behind the foreign bixly. and strive to 



lever it fonranJ, and »o out of ihc nnr'tril. Cliililrrn mit»t he. 
fintily lifkl by an assistant or t*onn: unt' vbtc wlio tjikt's tlu* 
small patient upon his lap and keeps tlie IcgH Wlween his knee?*, 
preBscs the hcaii against his o«ti forehead or chpst, ami at the 
same time prevent** ntruggling hy holding him finidy in his aniw 
(Fig. 45). 

In ease of need, an anaesthetic nuyt be em]>loyod. Pioces 
d paper or cotton-wool <:an be seizeil under guidance of a 


Fig. 43, — Itemoviil of a foreign liody from Uie lower maalus. 

speculum with the forceps, and imparted bodic« grasf**! with 
the Hcymann'g cupped forceps, aiul extracterl. lu stime cases, 
as in lar^ rhinolith.-s. extnu^tiuti Ls only {KKiyilile after ciiiahin^ 
the stone. U i.s Imrdly perniiwiihle Iti pu»li the foreign bixly 
backwanid iiittj the naso-pharyngeal space, but if tliere is* no 
other poswiliijily of removal, one must be careful to prevent the 
fcffcipi IxMly from slipping into the lan-nx by insertiiiR Hvo 
fingers into the post-nasitl cavity through the nioutJi. 


3. PA£ASIT£S. 

Animal parasites are not often obsen-eil in our country, but 
more frwjuently In the tropics, "nien-, the lan-ac of some 
kimis of tlies or other insects are found, whith, sttracleil by tiie 
sniell ()f the secretions, lotlge their eggs widiin Uie noH- ^myiasis), 
and into the nose of persons tvho sleep in the open air; or it 
consiPtsof larKftranimaIii,of the clai^ <A Seolopendrum {centipede), 
ascaris, hinuido (leech), which perchance may have cniwlcid 
into the noee. 

Symptoms. ^The syni]>tonia are those of irritation, sneezing, 
discharge, headache, fevei-, etc. In tnyiaais ulceration may 
occur, nithilestruction of the nose, and even death from menin- 
gitis ha.« foUowpil. 

Dlflgnosis.— Dia^o^ils is hatted on the finding of parasites. 
Tlu' lan-ae niay tie found in the (liscimrge or in the nose itself, 
wliere they can be recognizwl by their movementi?. 

Treatment.— Syringing the now with diluted chloroform 
(chloroform and diatillwl wat^r equal parts) or extraction of 
the parasites by nieiuis of iagtnunents. Inhalations of vapours 
of a mixture of menthol and chloroform fchlorofonn, 5.0; men- 
thol, 0.5) have been recommended in order to stupefy the ani- 
mals anti thereafter to remove them from the dilated passages. 
Roordn Smit reeonunends, as a sure and quick renicily in niyi- 
asas, the insufflation of calomel into the nose. 

Vegetaljlc, more rarely than animal, para-sites are found in 
the nose, The Oidium albicans (thrush), which has been ob- 
served, has probably spreail from the mouth into the nasal 
eavity, but it is only found in unclean children who are very 
aerioualy ill. Some spircies of Ai^pergillufi glaucus and ^luecilo 
have al!<w bi-en foimd in the nose. 

In .such a ca,s<' friable white or gray or darker patches are j*een ; 
they are, with the exception of the thrush fungus, clinically of 
no slgiiifirancp; the nature of these patches is easily recognized 
under Mie niicroscoi* Cp. 21.'^). 

Treatment. —This eonsists in loosening the patches bj- probe, 
removing larger conglomerations by forcepe. and in jiainting 
the affected parts of the muootis membrane with borax or chino- 



Jin (sotlii biborat,, 5.0, ad glycerin, 25.0); (chinolin, 0.4; gly- 
cpriii (ukI spiritua viui, && 10.0). 


The p'rin of thistiiscasc, wliieli iimy commonly be Bcen on the 
ears of com as the fungus, actiuomyces, usually enters the body 
through the mouth (cariou.s tfcth, through Uic gums, or lacunae 
of tile tonsils). In tin- nas(\ anthioniycosi.-i is ver>' rare. In a 
case de,scnbtxl by de Simuni, ihv inuial cavity wa.s filletl with 
a reddish, ilediy, and n-julily tiJcitling mass, which was adherent 
to the middle and lower tiirh'mjil and tlie floor of the eavity, and 
bulged the cheek and palate forwai'ds. In the middle of the 
hai'ti palate a small ulcer was noticed, through ivliieh a probe 
could lie pushed into tlip nasal cavity. 

Diagnosis. — As regards diagnows, tuberculosis, syphilis, and 
malignant new-growth must be confiidored. The diagnoBia is 
ensured by the microscope; when one will find the characteristic 
conglomeration of threads and dubs fonnal by the thickcjied ends 
of the mycelium. 

Treatment. — This con-sisfs in scraping off the fungoid patches, 
opening the abscesses, ami giving intenially large doses of iodide 
of potassium. 

(n) Mucous Polypi. 
Etiology. — Of all the new-growths oceurruiK in the nasal cavity, 
the mucous polypus, or, as usually designated, nasal polypus, 
i,-* thtr most common. They occur oftener in men thai] in women, 
anil seldom in children. The polypi, as well as the jiolypoid 
hyiK-rtmithies before mentioned tsee p. 77), are most proliably 
always the result of chronic inflammation, an<l we are often able 
to see both present together, at the same time. In chronic nasal 
catarrh, Ihe one merging into the other. Clironie sujipuration 
or a forpign l)ody very often gives rise to polyjmid growth^?; 
and st>meliiiieH a malignant tumour may he the cause, or no dis- 
charge at all may even ho notteed, hut in such cases, however, 
the etiology is miknown. Wo do not know, also, why, in one 



of chronic inflaiiinifltion, polypi arc formed, anil in wioUipr, 
ho pucli tliins liapprns. 

Pathology. — Xftnal polypi arc of agray,gray-yclluw, orgrayitii- 
red, glazed colour. They are soft anil jelly-like In consisU'iicc, 
aiid ai-e freely movable, as tliey mostly possess a pi'tlicle. They 
almost always arise from the middle concha (Kiji. 3", p. 7"), 
or the edge of tlic hiatus sciiiikmaris, more rarely from the 
roof; and in some unique eoscs, from other pnrt-s of t!ie imsal 
cavity. Not iiifrM|ucnlly, however, they come from tlie acces- 
sory cavities, and m particular from the ethmoidal cells. 

At first the polypi have a globular or conical shape; but later 
on their growth is regulated by the configuration of the nawal 
cavity. If the lumen Ije wide, the pear-slm]Mil fiinii prevail-s; 
and in a narrow lumen the |x)lypi are more (iut, like a hag or 
cockscomb. 'Hiere is f^cldom only a wilitary polyp; mostly, there 
are several, often dozens of them, though only a fi-w largi-siz("(J 
ones may be seen at the first examination. Tlieir mobility 
depends on the lengtli anil thickness of their pedicle, which 
may be round, like a strinp, or broad, like a band ; and sonietimos 
several polypi deiymd from one stiilk. At times lliey grow 
backwanls into the post-nasal cavity. In the majority of 
canes they occur in l>oth sailee. 

Naaal polypi apix^ar a« oedemnlous, [lcgenersto<l, eircnm- 
scHIkkI, liy)K'rtnipliie outgrowths of the nti»ul mucous mem briuic, 
covered in .simie ptace-s with nliateil epithelium, at other pinres 
with stratified epitlirlial cells. They consist of a loose connec- 
tivf^-tJRsue network, imbued with oedema, and which, in some 
cases, hIiow.s cyslic cIcgeiierHtinn or eveii rewl, deriveil from 
dilat«(l nnicous glatids. In rare ca.«es the glandular tissue pre- 
ponderatefj, and thus true adenomntH (fihroadenomata) arefonnib 
Tlie oetiematoiw fluid, which we must consider as the prwiuct 
of a passive serous transiidalion, contains large quantities of 
albumin, but no mucin, and hence the usual name, "diu«ous 
polypu.**," is a misnomer. 

The jXHliele contains many blooil-veaKrlH. and that is the 
reason why we meet with .severe l>Ieeding if we cut through the 
polypi at their fiase, whei-eas then' Is hardly any bleeding If 
we cut through them more periiilierally. 



Symptoms. — Sniall polypi do not give much cause for pom- 
plaint. There is irritation in the nose, causing frequent sneez- 
ing, H (liscliarge of thin, water)', clear secretion, or a slight frontal 
hemiaclie — all gymptoms which many persons can put up with 
uiiconijjiainingly. In larger siztxi polypi, however, respiraliou 
through the nose becomes hampc-rcd, Tsith all its conj^quenccs 
(headache, giddinej*, depression, irritability, dn,ii(rss in the 
thrrmt, nasal sjwcch, losn of tantc and pnicll, etc.). Secretion 
i« incrfaw'd, and llie ijatients thcmsi'lves have the sensation of a 
I)ody n<j«ling to aiul fro durmg respiration. For the connection 
iH'twrecn na-sal polypi and asthma see p. 128. 

Diagnosis. — .■Miiiunnally large polypi appear, in neglected, al the nostrils, where they can be seen without any diffi^- 
culty; otherwise riitnoscopy, either from the front or back, and 
probing will afford us ever>" information we desdre with regard 
to size, tonaistcncy, colour, and mobility. Difficulties may arise, 
i( the niM«e is narrow, or if thon- aiv pnitnL«ioiiri or iloviaiionsof 
the sc'ptuin. In fiuch raMett we arc much aided by painting with 
wlrcnalin. We must also a.'*ccrtaiu whotluT wr have tn deal 
witli simple imconijilicatcd polypi or whether Ihey are only 
si'condarj' to a primary disease (wippuralion of an accessiory 
cavity, foreign Ijody, malignaul growth, etc.). Purulent secre- 
tions or even evil-Knielling seen'lion flowing Iwtwoen the [M)lypi 
over tlie conchae; or if we touch on miigli Ixine; or tJunild the 
polypi bleed on gentle touch with a [robe — sliould all caum us 
to suspect complications. 

We should make it a matter of routine to examine both sides, 
although the report of the patient may point to one ?ide only. 

Prognosis.— .\m far ax relief or cure of the comjjlainl is oon- 
wdcred, pn>giiosis i.t good ; but it is somewhat ajit to lie db^turbed 
by tlic liability of the jMilypi to recur. I'ven though we may have 
removed them and destroyed their site of origin completely. 
If, on the other hand, we can remove the cause (chronic catarrh, 
catarrh of aiilrum, etc.), a railical cure may be established. 

Treatment. — The Iwnl moans of removing nawil ]wly|ii is by 
the cold snare. HaWng anaej?l he listed the mucous membrane, 
Kratufc's snars is introiluced in the same way as we have de- 
scribeii for tlie treatment of [Milyjwid hypertrophies (p. SO). 

Fig. 47-— Removing a oawl polyput. The Wiw-k drttWiDg Aows the 
intrwlui'tion of lli« Hniin', witii ihf loup in (lie vprtipa] pxjtlon (platie). Tli« 
red (Inkwfne nhau-H Ihu tumiiiii o( Hit l<>(>[> ititti lJi<- liurixoriiiil plane: the fMinh- 
inguiiuiinln In the*ca[, of ori^n; juid the uoiutrtdLun u( tlielci»|i. 

its stalk, is torn off; and ia oft«n accompanied by the niatrlx. 
(Sep Fijt. 47.) In any ca-w, the iiifthiwl of ti-arinp h mow \mt- 
crahle and inori- radical Ihaii (!ihI. (if crultiiiK, which is much 
recommended. The ii|X'rati<)n is fjidnfiil, hut never thyU-ss ho 
quick that wp may well risk the [inin and eventual jKissilile 
hapin(irrh;i)»p. In certain <!a«eH| es|)pcially where tlii'iiitriHiu('li(Hi 



of the snare meets witli great tlifHcuIty or the ixilypuj* offers 
much resislaiict* to the pulling ofT, we may take ^■eflI^Ie in the 
cutting tlirmigh jiroeesg. The smaller tlie polyiji and the hifjher 
up thfty aru seated, tJie more diffieult is it to fit on tlie wire loop. 
In sueli €&^s, we may s-umetimes jiiiccee*.! by ueing vrry 
lliin wire to form tlie loop, and l.y making it as small as poMaihle. 
Smaller polypi and the e\'entual remaius of larger ones can 
Rfterwards bv nipiM-d utT with Hetftnmm's force[»t. It often 
liapfwiis that tlie c)|)(Tatioii iriur^t he interrupted on aecnuiit 
of the hat'morrhage, or strveral siHings are required. In Mich 
it is a gtHMi plan to make short interruptions and U) aller- 
lialp ttip KJiics. c)]K'raling niiw on the one, then on the othi'r. side, 
and s«) on. Om^ slumld alno, for tactical reaHOiitt, n-rnove at the 
lirst sittiiiR as luueli as iwesible, in order to relievo at least one 
eide of the previously obstructed nose. If tlu- ethmoidal bone 
is found implicated, tlic ethmoidal ccU^ mui^t be o|)€iied, and 

Fig. 48.— lAnge's pboanftl liook. 

eventually fiarts of r)r the entire middle turbinate lK)ne must 
lie re.sected or amputated. (.See the chapter on the lliseases of 
the Kthmoida! labyrinth.) 

Special difficulties arise at the removal of polypi growing 
into the naso-pharyiigeai space. Here we often fail to fit the 
loop. In such a case the choanal hook of Lange (see Fig. 48) 
can be used willi advanta^-. This is introduced, with the point 
directed downwartls, close up lo and along tlte septum; the 
point is then turned lalrrally. so that it engages round the 
pedicle of the polypus, and it is tlieii pulletl, in short jerking 
movements. With the finger of the other hand we can suitably 
guide the hook from behmd. 

In the more tough or broad-seated polypi we enn use the 
hot (galvano-eaustic) snare with greater advantage. After 
removal, it is very important to destroy the matrix by cauter- 
ization with the galvano-cautery. chromic or triehloraeetie acid. 
in order to prevent recurrence — unfortunately, howeverj not 




always with siicwss. Tn somtr ca-scs wi: roroive rho impression 
tliat on arcdUiiL of Uhi ciicrgftic trcutiueiit. Uie growUi of the 
polypus hiis been stiiimlatnl. 

Bewicm Tumours of Special Kiijd. 

WliiiL vic liave isaiil in previous drnpLurK conci^riiing the |M)Iy- 
poitl ^rnwt]i.s on tii<^ (■miciiai.', ami in [Nirti»ular on the lowi>r 
one, it is not here tiecPMSiiry to rt'peat, and \v<>, ihcrpforp, n-t'cr 
Ihe Trailer to Chronic ttliinilis (ecr ptiKe 7(j). The hypertropJiic 
growths Ihfre {lescrtbed, which have their favourit'C seat on the 
lower concha, are variously naniwl by liiffereiit aulhorB. Tliey 
are ffllleil Hoft piijiillnnia, if the surface ispniooth and lobulatcd; 
or filiro-angci<Jiiiii or aiigijuitia, if thi-y sliuw great vascularity 
aDd are cotiSMjuenlly more re<l anil tlo^y in appearance. 

The hlefillmj jmly/ms of the seiiUtm, which also allows intense 
vaseiilarity, is iiol, in its apiKfararn-e, distinguishable from a 
vawuliir liy|MTtro[)liir polypnld jjrowth. -Tt apiwars &n a growth 
of the sizp of a pea or walnut, with smooth r>r lobulatwl Burface, 
and IK nearly Hlwayn broad haBPil upon the anterior part of the 
nasal septum, where it gives rise to obslruction and blredinjf. 
31 is said to occur more frequently on the left wde than on the 
ripht; and oftener in women than in men. 

From the soft papilloma the true hard papilloma ffibroirm) 
nuLst be dintinguislied; ihe latter oecurs as a warty ouljrrowth 
at the entrance of the nose or septimi. seldom in othtr |>arts 
of tlienose. It consists of a network of fibrous eonneetive tissue 
intersjiersed with epithelial eells. 

Occasionally, lipoma, chondroma, and osteoma havelieen ol»- 
served as oecurriiig in the naml cavity. 

Treatment. -Treatment e^nsists in removal of the tumours, 
cither by means of the hot or cold ynare. 'ITie ehondronia and 
osteoma, however, are mostly too large to admit of an operation 
eolely through the nose. 


Malignant growths in the nsfal cavity are, on the whole, 
nol often found, lielatively, the most common \s sarconm; 
less frequently, cjircinoma, and verj' rarely, Ij-mpho-sareoina, 


DlSKAfilCS or Tilt: NUtSK. 

whirh probably always spreads from tlic nas()-pliaryiix into 
the; nasal cavity. Usually, the tumour comes uiiiler our notice 
if it has ])ro(lucetl iiiarknd cliiueftl sjiiiptotiis, i. «., at a time 
wh<'n it has «.!r»wly giuuii so large as to lill llic nose. Il is 
then often imiJossiWe to say wlmt is the primary seat of tiie 
tumour, whether it originated in the nose primarily or grew into 
it secondarily from the vicinity. These tumours, And in particu- 
hir sarcoma, take their origin mufitly from the upjier riarb^of the 
nose, especially fnmi tiie U])ixrr of the jx-pliini. 

Sarcoma oeeui'S mostly in youth and middle age; eareinoiua, 
mostly in i-lderly iwoplc. 

Symptoms. — Syntploiiis consinil in obstruetion of the nose, 
pain, neuralgia, nose-bleeiling, and later, if the new-gronl.h 
incroaseti in size, of disturbances of the auditory a]>|jaralus 
(iliflienltirR of hearing, tinnitus in the ear, ete.), or it iiiay invade 
till' orbit and causi' displacement of the eye, exophthalmos, 
paralysis of the oeuliw muscles, even amblyopia or blindness. 
The tumour often ulcerates, and there is then a foul-smelling 
diseliarge from tin; nor<i'. Caioinoina has a greater tendcni;y 
to ulri-iatioti than sarcoma. 

E.\tcmally, we at once notice a liroadcning of the nose, and 
exophtlialiiHw. tir bulging of the cheek or the hard palate, may 
bi- depressed hs a e<>iise(p«'iu'f. 

On rhinoseopicftl exariitnation one fimls large broadly seated 
niai<ses with a himpy or warty, and free lOcoding on 
touch. Mucous polypi ciui often be si^en in the neighlmurhood, 
and in such numbers that they may conceal the tuniour to the 
ins|>ecting eye. Tlie surface of the tumour shows ulceration 
and is roated with n slimy, fmil discliargr'. 

Diagnosis. — The diagnosis of miilignunt tumour is not always 
eas>' at iirst. The surgeon must beware of mistaking it for 
syjihilitic or tubercular processes. MiemscojMcal cxauiinatioii is 
likely to decide any doubt, but it must be hnrne in mind that 
round-eelled sarcoma shows micro'^copicftlly the -■yiiiif slnieture 
a.« a gumma. In such a ease a trial with iodide (pf pc)ta.»*ium 
would bo justifie<l. Later on Iho rapid growth, the sim-ading 
into all the atljacent tissues, and the affection of the general 
h(alth will leave no doubt as to its malignant nature. 



Prognosis.— IVovideil that tlie cause \e not already too far 
atlvaiieeil and is tiiwovfrtxl in rooJ tinip, sarcoma iiiiglit f^we 
a better cliance of cure tliaii carcinoriia; both arc, of coiu'sc, un- 

Treatment. — If we have ihe opportunity of seeing the tumour 
at its eomniencemen t, we niiisl, by all means, enileavour to destroy 
or reiuovp it, even with the heahhy tissues iii its neighbourhood. 
Thp nialvftiio-cauterj' or the hot anare is best us«l for ttiis pu> 
pose; electrolysis is also sjwken of favournbly. Internally, 
arsenic (in pills or Fowler's solution) may be given. 

But if tlie new-growth be of larger size or be seated high up 
in the nasal eavity, a radical ojH'ration iw imJirttK-nsibk' frescrdtiim 
of part or the entire none or of liie upprr iimxillary brHic. e(r.). 
It is often h)t> late for operation, antl tlipn we an- cDmiJcUfd 
to limit our help to palliative Ireatiiient fdoucliing, loejil wia*^ 
thetics, narcotics, attention to general liealtli, etc.). 



The sense of smell may be diminished, cumpletely lost, pathtt- 
logically increased, or otherwise altered. Ufiually, the palhi)- 
loj;ical alteration of smell is only syniptoniatic of anuthiT piiinary 
ili.'fease of the nose or its aecesBor*' eavitie-S, but it may Hp|X'ar 
an a genuine disease, a inoHnw sui generis. 


Etiology. — Diminution (Iiyposniiai and loss of smell (anosmia) 
are due to — (I) respiratarif, (2) local, (3) central, causes. 

(1) Respinilory hy|X)smia is produced by the odoumus sub- 
stances not being allowed to n^ch the regie olfactoria. a.« in 
syncehiae, adhesinns. sweHing of the mucous membrane in 
catarrh, deviation of the septimi. tumours, and adhesions of 
the alae na.-^i. (2) I^jcal causes of hyposniia are diseases of 
the rcgio olfaetiiria and of the nmcous membrane, mch as atrophy 
of the pigment of tlie olfactorj' cells, due to poisoning feocaine, 
morphine, nicotine, atropine); or are due to douching with 
certain strong fluids or repeated ex|X)sure to noxious vapours 



(trade anosiiii»). Aiioitipr clajw of causes nn' ixTijthcra! nciiritifi 
(an in iiilluciimi) hiiiI ilegenenilion (atropliy in oiiroiiu- rliinitiR). 
SoinPtinitwaiiKsiiiiaUoftrauiiialJc origin. (3) Cwilral liyiKisinia 
aiii) anosmia — usually the latter — is chilswI by dijsea** of the 
oirai'tory n^rve (itsplf or of its cereWal centrT of origin). To 
tliii* olawtf belong the frequently unilateral anosmia hysterica, 
the anosmia due to traumatic ncurosia ftraunialic hyttteria), 
cliniactcrK' and congenital uno-sinia. 

Symptoms. — I^cjsw of sinrll i:* eitliiT coniplctr. or is only alxtfJlt 
for (HTtairi sulwtancra f|Kirtijit anosmia), or tbere rxi.sts |taraa- 
niia. Anostiiia, luid esiK't-ially 1iy)70Kniia, \» often not apparent 
1(1 the jatieiit hiniMi'If. Itliino-sropicnUyf we find nothing save 
in respiratoiy or atrupliic hyposinia. 

4 A 

Fig. -Id. — Niual elevntor: (a) Fefitbauscb-Rctli; (b) SrJimiitthuism. 

Diagnosis.— ^^'e examinf tbe power of sinell by tho method 
iH'fore dc.s(Til)Cil (m-c p. 1(1). Distinctions iK-tween the varioiw 
(on[\ii of ani»sniia ran only be made if we have a Kuffieient hisd^ry 
of the case, fmiii the resulting objective examination, «nii la*-t. 
hut not U'li-st, p<T exciusioni;in. 

Prognosis. — PrognoHis is not always bad, and depends on the 
primary cause; it is best in respiratory and M'orse in central anil 
long-Htanfling cases. 

Treatment.— Should aim at removing eventual eaa-ses (olv 
ptnictinn. catarrh, deviations, etc.). In order to relieve the 
discomfort oocaetonecl by tlie nasal wing Ijccoming pinched on 
fort^ihle inspiration. Feldltau^h-Iiolh^ or Schnn'(Hhuij<€n's ele- 
vatons arc vei^- useful (see J'lg. 49). In i^philis we may give 



iotlkles, and in hysteria wo apply the galvanic current iwo or three 
tinips weekly; one cleclrtxle is plaeeil on the neck Einrl the other 
in the nose. In sonic cases iiisu(Hation of fltrj'ehi.ine (0.05 to 
10 aniyluni) has a powl effect, given twice or tlirce limes daily, 
snutTeii up or in>sulMa(r<l. 

<6) Hypekosmia. 

Iftlteacutenessof the sense of i^tnt'II isintcnsifinl. the condition 
is s[Mikcri c]f as hyperosinia. .^s aciitrness of smell varies within 
cvitaiii phy.'dologieal Uniit«, hyix'nistnia may be pliysiolnginil. 

Symptoms. — lUs symptoms, himrver, are at times so ninrk*'<l 
that the sufferers feel themselves very inconveiiiejiceil l)y it 
anrl its consequenee-s (henihiehe, vornitiiiR, fiiililiness, etc.). It 
is mostly in hysl^ericfll or neuraslhenie perstms or pregnant 
women Uiat we meet with high degix-es of hypcrostnia, ofl<;n 
accompiinied by parosmia. 

Treatment.— Bromides may be K'ven internally, but of more 
imiH>rlance i.-* the general treatitient (diet, rei«t-eure, and general 

Locally, painting with a weak solulion of cocaine aonielimes 
does good. 

(c) Parosmia. 

The condition is that of |iarosniia if certain scents are per- 
ceived in a wrong way — mostly unpleasant (subjective caea*»- 
mia) — or if persons |ierceivc a smell where, de facto, there iano 
smell (olfactory hallucination). 

Parosmia, like the previous hyperosmift, oeeurs mostly in hys- 
terical or neurasthenic jiei-sons. But it ha** also been observed in 
influenza and acute coiyza, as also in varioiw mental disorders. 
It might sometimes occur as a sjinptom of suppuration in the 
antrum, foreign bodies or malignant growths in the nose, an<l 
is then callod ohjiK^tive eacosinia. 

Prognosis and Treatment. — As reganls prognosis and treat- 
ment, there is not mucli to be said, for they depend on the 
primary causes. 

DisEAsra OP Tire nose. 

Tin? iiaml mucous membrane is generally vciy wneitive, 
liecaijse c>f the ab\uii.!ant supply of non-os. .Ul sorts of manlp- 
ulalioni?, even a .slight loudi of Uir probe, txeit(w, if not always 
pain, anj'way mi|)lfa.siiiil M-asalion ; never tlirU'-ss, Uie interior 
of liie nose, esi»cially the lower purl, in reniarkaUly loli-nuit of 
pathological pniccK-^Cit. Tliis is why we hanlly ever oIwct^t 
])ain aft<T upiTative niani[jula!ion. it can now Ilk* easily undtT- 
sUxvl why it is often dilTiciill to say whether the sensibility of 
the mueoiu! metnlirane is diminished or increawd. Besides, 
it dejjeiids on so iimny individual cuialitie-s. It is, hott-ever, 
relatively raniple to a-seertain total insensibility. 

(a) Anaesthesia. 

If anftC!3ttie»ia oocrurs alone and on one Mde only, it poinUs 
atnioKt cextainly to liy.«terin, and ia ilue to [x-ripheral or centml 
funelional J)Qn^•'i8 of the fifth nerve. Lotw of wjisibility is not 
oft^-n nolioeil. jmiliably for the rea-son that the jiatient has 
nothing of wliirli to roniplain. On exaniiiiHtion, one is surprised 
to And the niucouK menil>rane in»pnidlive. Annnirtia, often 
reported I>y tJie |)atieiit, is in sxieJi a caw ilue to tlie non-jienvp- 
tion of such acrid sniisianeen (vinegar, sal aninioniac, etc.) as 
normally stimulate the triKeminal nei-ves. (See p. 15.) 

Artificial anaef«thefia can be produced by certain drug? (such 
as cocaine, aiyinn. etc). 


Increased eenwbility may Ik so intennifieii as to amoimt to 
neuralgia, though the latter is rarely limited to tlie nose, and 
tiie pain in that ca^ alway.s radiates into the ncighlwuring organs, 
eyes, teeth, jaw, and forehead. Hyijerat^thecia is a stigma of 
hysteria and neurasthenia, and i.s the cause of many reflex neu- 
roses in those diseases. 

(*■) Paraesthxsia. 
Pai-ae.ttlieaia i« far more fre<iuraitly olwen-ed in the throat 
than in the na«e. Tlie patient complains of fe-eling hot or cold, 
or has a sensation of a foreign iMxIy. or of itching, in the now. 



It oftpn happens tliat the palipnt docs nut know how to dcserilie 
or local*' ilie stranp' soiiailions. AnuUiiiiical tthaiigi's are 
usually aliwnt ur pio slight that the urgt-ncy of the syui|)ioui8 
complainetl of caimot be fxplained by Lheiii. 

Treatment.— Treatmi'iit Jti all lliisf ra«>fl of paracsthesia 
must Im- yuiilwl liy the jiriiuury laiu.-'c ( Uy.-'toria, catarrh, etc.), 
and our chief aLtt'iilioii slioultl lit- ilirectt'd to ameliorate the 
gencrat health hy pnipiT diet aiiil dtange of climate, araenic, 
and last but nut leiut. MUgj^HKtion. 


Etiology and Pathology.— It ix well known that, by stinnilalinp 
MTtain orRanr!. as, for instance, the uteru.?, intestuiet!, sole of the 
font, larynx, and auditor)- nieatiu, we are able to excite a reaction 
iu other, sotnetirnej? quite distant, organe, which, within pby- 
«()liiy;iral limits, concrmn ehiefly tlic iiai-strular, vai^oinolor, or 
secrt'tory spherew. It. is tlie nimk; with lln- mm: 

(a) As of first iniptirtance, we imist enumerate snwiiing and 
lachryiiiation. Ih) Hespiration ami eanliiie funetion an- iiiflii- 
eneetl by reflex action frrmi the nose, fr) I,iu»!tly, the iiicreas*" 
ami decTeaw iif swelling of the cavurniins tiiwiies in the now? are, 
after all. but reflexes. 

In persons* who, by heredlUry preJispositinn. by overstrain, 
or by exhausting maladies, have become generally or locally 
hyt*rsen3itive (bcc previous chapter), ihe irritability of the 
nai^l mucous nienibmne might be «o mueh exaggerat*>»l that 
ifktively infiKnificant stinmli are, indeed, Knffieieiit to excite 
in the nose or other organs reflex syniplonis of a niu.'a'ular, 
vasomotor, or secn^tory nature. CVrtain other irritative .'*yin]>* 
lorns in I he sensory j^phcn* fnenrnljiia of the irigeiniiial. Iieailaehe, 
etc.), olMft'r\e(l in rhrunie rliinilis, arc not cahspcI by pni-e n'flex, 
but must Iw conniclered bk concomitant nianifenlatinns or rlirect 
eoiiipiieation.4 of the primary diseaw. 

It is always well to examine carefully if (in apparent dij^nnier 
is not due to anatomical changes. For in our "nervoius age " 
*' neuroMs '' having become part and imrrel of the mast varied 
ami every po^ible diseainr all the world <iver, irnieh mils under 
tltc flag of "na.^ reflex ncurusi.i" which, tu my mind, ha» to 


DUE.^6E8 OF THE N06K. 

bo s(*pflrftt«l fmrii it. cntirply. Indpwi, "iiaj*al roflrx npuroscs" 
arc much h'Sis coininoa liiati sonic (.'iilliuKiaxlji would have ua 
believB at jursiiit. 

BpsmIiw a psychopathic predispoitition, n [lalliolopcal rpflex 
aclioti 1-Piiiiire.s an exciting cause. This can Ih- most coiiimonty 
ftmiul ill iiicrbHiiiciil irritation of the liftli ricrvc hy polypi, 
cftUurh, tunivurs, forcipi bodies, toudiiiig. probiiiR. dust, etc. 
Or tlic irritation might be caused by two oppopinp folds of mu- 
cous membrane (m cata.rrhal affection) riibbiiig ajrain.*! each 
other, or the cavcriion.s bodies miglit easily swcJI and calabliwti 
the contacl, so to speak. 

Stiiiinlation niiglil I>e chemical or thermal, or, finally, olfac- 
tory. In the latter case, the olfactory- nerve forms theaffen'nt 
|)ftth. We speak, iu such a case, of idiosyncrasy for certain 
odours (flowers, especially ro««, fruits, and ilrugs). A rpflex 
may be excited, and this is generally accepted, from all jiarta 
of the mucous mcnibratie, but most easily froni certain irritable 
zonea. (Sec p. 15.) 

SymptoTOE.— 'Hie olimcal tninptoms of the nasal reflex neiiro- 
ses VHPi' according lo thi- two cniLs of the rcHcx arc. iJolh stim- 
idation ami reaction may take place in tlic na.-vil cavity, or one 
may be in Ihe nose and the other in a different, soiiietimcs ()tiite 
di^itant. organ. 

\Vc may, for practical purposes, divide the reflex neuroses 
into two groups: (1) Where Iwth n-ilex arid slinmlation are in 
Ihe noee; (2) where the one or the other affectK a different orpm. 

Intranasal Reflex Neurosis. 

Hervous Cold.— The general practitioner who wishes to 
orientate luiiinelf in the dilficult gnjimd of reflex neuraVi? miglit 
well tftke nervous conza as a paradigma for Ihe whole class 
of fiimiUr di^nrdere. 

Sifmjiiomx. — Nen'ourt coryza if characterizerl by the folloning 
jymijtonuj: exee*«ve swelling of the cavenums lurhirial ti.-«ue, 
profuse discharge of a clear watery secretion, ])Hroxysm« of 
sneezing, and lachrynialion. All these symptoms, however, 
are not always preivnt at (he same time, nor in the same degree. 
Sometimes one, eometimcs another, may prevail, or one symptom 



atone may ho so pronounooil as to donunato the wholp picture, 
and K<.i fonii a vupicty of the discusc. [" Hay-fover," which in its 
clinical apfx-aroiicc rescmblofi rcliex ncurogis so much, cannot 
be coneider^il as fiudi, for Dunbar has showTi that it is protluccil 
by a speciiic cause. We have, tiiereforc, treated "hay-fever "as 
a separate disease. (See p. 00.)) 

Nervous corj'za may be distinguished from the ordmary 
in6aminBtory cold by lis sudden onset; that it occurs in parox- 
ysms; and sometimes quite regularly at a certain hour; lastly, 
that tliG spen-tion ia always clear, never purulent. 

'Hie pxciting stimuli are manifold. We mention the various 
Mentf". especially roses CTopp." "jx^ach," an<l '■stable'* colds); 
Ijartieles of dus^t ahw), which have rcaclicti the nose may be con- 
ftidered, though it would here be ditlicult to draw the line between 
inHainmalury eatarrli and ncrvoiiK eoryza. ICxtmnawil Ktinmli 
are: suilden co<jling of certain parts of the rdttn (i. e.. thnnigh 
wetting tlie feet), st'xual exciUmicnt, drinking quickly wann 
alcoholic luniors. iniligestion, Hashing r)f a briglit light, etc. 
lieltttivcly. tin* li-ast trtiubli? is cauM^l by the congi^'s)«-ii intra- 
nasal cavcrnon.i ti.ssue, which may only be h symptom by itself, 
but may also be the exciting cause of R-flex action. It may, 
however, lead \o (xruHinent swelling of the concha. Very 
troublesome, indeed, are [mroxysins of sneezing, which some- 
times occur very frequently and follow each other rapidly; 
they TO&y, by the bursting of a blood-vfs««el, provoke epislaxia. 

One of the author's jiatients, when he left his warm bed every 
momiaiK, waa subject Ui iiO to fiO attacks of aiwjsing. A spina 
septi, which irritated the turgid conclia, "waa diNcovereil to Ix; 
the caH.'<e. After removal, the atlaeks eeasiiHl [H'mianently. 

Very unple.a»ant, indeed, ia the c<»piiiii.s. .•uintetimeN excessive, 
watery secn*tion from the nose (hydmrrhoea nasalis) which \» 
often a»4ot-iattHl with intense lAchryniati<in or headache, rough- 
ness in the throat, migraine, and trigeniiiml neuralgia. 

En/titema of the Kztertutl Xoxe. — Mere, as in the exoeeave 
sweUing of the eaveniuus Iwdies, itisof the nature of uvasomolor 
reflex neurosis. (See p. 52.) 

Influence of the Sexual Sfitiere on tlte A'mre. — It is difficult to 
decide whether noso-bleeiling, which occurs occa^onally during 



or jjost coitum, or in aliusus aexualis, masturbation, anil coitus 
interruptus, U due to reflex or to the bursting of snioll vwsi'Is 
from inereosed biood-iirossure, Vicarioufi noso-blpwling might 
be explainoil somewhat as a reflex action. The relations between 
the female sexual organs an(i now are illuslrated by the fact that 
iDtranaJ^I manipulation during the time of the period causes 
more prof ufe haemorrhage. This is why we should operate only 
in urgent cases during the lime of menstruation. According to 
Kiitiner's and the author's ohsen'ations, menstniation, in the 
majority of cases, during its courae, continues unaccompanied 
by any subjective or objective change in the nose. 

Rbpi^ex Nburosbs m Other Orcans. 
Astbina. — Bronchial asthma is a real reflex neurosis, which 
is brought on, acconiing to Frdnkel, by three difTerent pro- 
oceeea, viz.: (1) Spasm of the ilia{)hragm; (2) s)>a^ni of the 
bronchial muscles; (3) catarrhal inhltration of the hmg. The 
efferent neurons run, therefore, in the phr^-iiic, vagiis, andfij-mjw- 
llietic iKTV'i-s, The ])erij)Iu'rttl Iwuw excitationis lies in various 
place?!, not the least eoiiinion being in tlie nose. In such a case 
tlu> iLsthiiia is sjuken of as " n)u«I asthma. " ur. a.s IiicJihar:il tenns 
it. ''a-sthtiia bnincliialf ex hhmi." Local irrJtatiun.s which T*'nd 
to prtxiuce '' na.-flil a.sthma" are uf the witne category as those 
m«ntion(-(.I in (he prpvious cliajiter. Certain lathologic-al changes 
in the nose, however, such as turgid eonchae, deviations of the 
septum, fl(lhe.sions or atresiae, e,'^IM■cially polypi of the mucous 
membrane and foreign bodies, axv i>upposei.l to be the malificcDt 
agents, which, by pressure or other irritation, cause the asthma. 
It is as well not to jum|i to a conclusion too quickly as to the 
real coimection of thcst^ circuni stances with asthma, for one 
firals tJiat, among the great number of patients suffering from 
naxal polypi and other diseases, there are only a very few in 
whoiu ail asthmatic attack can l>e artificially jirovoked, on the 
occasions of either diagnostic or thera|)eutic intranasal manipu- 
lation. But it slioultl also l>e borne in mind that an original 
"nasal asthma" after a longer or shorter [leriod of time may 
change its characters, m that, linally, all possible varicttes of 
extmncouE irritations may provoke an attack. 



There is no solitary imrlioular spot, but many places in the 
no&c from wincli an asUiuiatic attack might bo cxciUxl. 

t. The asthmatic attack often begins with an aum, e. g., 
some (general) forebodings or warnings known to tiif patient, niul 
in otiier cases it is preceded by a prodromal stJige of tickling, 
paroxysms of sneezing, or nasal hytlrorrhoea.. 

2. S])astnodic C'o»f//r.— Mechanieal irritation of the luunal 
mucous mcnibraJie is apt to cause in some nervous persons 
paroxysms of cougliing. This no«ii or trigeminal eough is 
(listiiiguishfxl by its lack of any e.\])cctoration; the larj-nx, 
throat, and trachea being jwrfcclly free of the same. This 
nervou.-' cough ran be the nion- easily provwked Ly touching the 
por5tfrii)r wall of thi- pharynx with a probe. 

3. Caniiac NetiToxeit. — In tliew.JHst as under nonnal circum- 
stAiircs, ilie heart cnii be sli!l easier iiifluciicr^l from the iioj* hi a 
neumiiathic individuab Onethusot>serves palpitation, oppression 
and apprelienMonsj pain or zona, etc., hut it Is. himever. not at 
all certain whether these .symptoms are always n?flex, or some- 
tiinejf funetionul. 

4. Dy.wworrhoea.—Thc fact, first reported by Fliess, that 
dy«nicnorrhoca can be beneficially influenced from the nose, 
has Im-cii assert^-d by many authors, though not in so large a 
tneft.^iire a.s maintained by i-'licss. Dysmeriorrlioeic pain in the 
bw^k ofl^ni cea-^-fl. if the tuliiTcula wpti. and iilerine colic if the 
lower conehae, an* jjuintol with cnca.ine; and it ha,-! been reportcti 
tliat they wn»e|»crniaiieiitly if these "gi-Tiilnl s(xil.s"arrrnuttTiwd 
with trirhlfirat-elic ju-id or the galvaiioeautery. It has Urn 
found that tliet* rpsidts ean aUo be achieved by thecuiployment 
of i]uite different means. 8nme authors conse(]uently deny the 
s])et'ific i-fTeet and aserilje it tv suggestion. 

5. Other Xeurnttcs. — Tn sonic unique ca.'ies— whether right 
or not, we do not desire to asscrt^spasins of the glottis, of the face 
C'tic convulsif"), niigraine. cpilejtfy and hyst<Tioal fits, an<I 
aalivation, have liet-n described as lieing capable uf being tytcitcil 
or iufluejiccil from tlic " spotw" hi the nose. 

Diagnosis.— It Ls alwoyrt dillicult (o prove that any neurofia 
m cjucrttion ha* its origin in the ni):<<'; nntl we slumld never — 
within certain limiti'^^lM* satisfied if we do not succeed in exciting 


t)19i:A8F» OF THK NOSE. 

an attack by touching the naaal intorior with a prolw*, an<I then lo 
stop i\io same by painting th<- particular s;xit with focainc. 
Till' iiatnting is done by spnn^ug the mucous membrane with a 
pi(TC of cotton-wool soaked in a lo jmt a;nt. wlution of cocaine, 
or liy spraying the nose wiib a 10 jht (-(^nt. solution. 

T\w positive clTifUt uf coraiiiiizntioii in not always an aliaolute 
pruof that the nervouN diKordcr is dnpnndent ou a Icjuon in tiie 
nose; for it is inipci'^ible to exclude tin- (■Imin.'nl uf "suggi-stion." 
On the other hand, also, a positive experiment with the pro!* is 
not an abaolute tost, bocaaic in hysterical i)eri*ons these 
attacks can Ik> simulated ami easily cxcite<l {KuUttet). The 
iicipitive result, r(]Uiilly. nf [■(nirw, in IkjIH exix^rimeDt**, jiroves 
nothing, .Still lew rcitnlil<* tire then-Mult-^of (n' success 
'\» <)ften due to " suggestion" or must Ix? ascribed to tlie inliibitory 
efTeet of eoimtirirrttalion. 

Dift^tiosis is aided hen' by aiiunitiesis (nee p. 31); by the 
iiegalive result of examination of the other orgaiuf, and the c*>n- 
curreiiw of other various reflex disorders. Xa,«jil diwase is not 
in itself a pmof that the iieunwin Ih of a nawil elianieter. If all 
methcxls of examination have failed, and other caa-^cs cannot 
be found, then wc are ju.-»tifieil. havinR discovered a na;*al disrju«ft, 
in making a diagnosis of i)roliable na^l reflex neurosis. 

Prognosis.— Progn (wis is Ijertt in those coi^s where we find 
pathoIoi^cAl changt'.s in the nasal caxity, .'*o tliat, by treating 
or removing ihein, we can cun? the reflex neurosis. Imleed, in 
some eases we are able, by an ojwration, to {lefmitcly cure. B»it 
in long-(Jtaiiding cotnplicAtml cam-R the vhaiie<>s of (establishing 
a lasting cure are very small, and in very nervous patients 
prognosis for those reawns is l«id. 

Treatment. — Treatment ma'^t he general and local. Locally, 
we tr>* to exclude ilie ends of the afferent neuroD. This 
can be done by destroying them r]ieniieall>' or by galvano- 
cauterir-atioii, or by removing the exciting abnormalities, e. ff.p 
polypi, syncchia<',adhe-<ions, etc., by tlH-niethodxlH-fonMlescrilwrl 
fp. 55, et aef].). How much of tJie therapeutic succtsw miL<t be 
atiributed to"!<uggi>(ition" wedonoi care to ray. In wmie canes 
the effect of oi>en»tion apjM-ars much later, is sometimi's misfied 
altogetlier, or has ju«1. the opjxisite effect to that wliidi we ex- 


ptctetl, namely, by prochicUig ja-*! the reflex action wc cle»irc(l 
Ui eure. We must, therefore, not forget that nervoiLs jiatieiits 
rcaet diiTerently after ojjeration, and, tht-refore, we must not 
he tfio rash or hasty iu cur local treatment. It is in thase not' 
too elear cases ijatholoj^ieally, under tlie idea that an intranasal 
operation winild net iw an i-ffcetive tinjtgiwtion, that one may 1* 
imluced lo [xTforiij all snrL< t>f t<uf>i>rllii()us or even senseleiw 
manipulations, and in whom the galvano-(rauter>', which hai* evpr 
made a deep impression on the palienl, 15 used more often than 
is upcpssary or beneficial. We certainly do not deny th&t 
galvano-cauterizalion may be useful, even if it does sometiniea 
«n!ra superfluous, yet wc should not allow ourBclvea to be 
too optimi.-*tie as to it.s sueeess. 

In bronchial a,tlknia lonp-eontinuwl treatment ran only lie 
lienelicrial if free reMpiratiun thrtm^i the nose w established. Here 
wi- must taki- jtn-jil pains tn find any partieular spoln from which 
the n'flexe« ean be excilixi. 

The general treatment is, perhaps, Ihp most impoTtant of all 
ia these kinds of disorders, and we need not discuss it here, for 
it is contained in the text-books on Internal Merlicine or Nervous 



The diseases of the at<*(K-^<try cavities are. on the whole, the 
s&iue &a those of the maii) cavity, but ttiey are (lislingui»hed by 
certain ppciiliarities whiclj liiid their explanation in the anatonii- 
caJ conditions, especially in ihc [HtsitJuit and sliafx* of their open- 
ings and in their relation to important structures, i. e., eye, 
Iirain, ear, teeth, etc Of the greatest interest to us in r^&rd 
to the above are the inflainmaton,' affections, whieh are now 
better recognized because of the iniprovGfiient In their diagnosis. 


t«i) GENERAL. 

Etiology and Pathology.— In the eliologj' of the various 
intJamniatonf- processes of the accessory cavities, infectious 
(iispftsps, and especially iniluenza and acute corj'za,— the infec- 
tious nature of which can lie no longer doubled,— pneumonia and 
scarlet fevfr in childhood, take the foremost rank [freyf^inq, 
Lanffe). Tlu; only qiietition it^. how do the infectious grniis reach 
the accesfliirj' caviti«^«? Possibly the iiiflmnmation of the anlml 
mucous nietnbrane is prwluced by extension from the uiu'n] 
mucous menihrane as the result of eonlimiity. I-Jjually probahlf 
Is it that infection of the accessory cavities has taken place at the 
same time as that of the main nn^nl cavity, just as we likewise 
see it in disease of the inid^ilc ear and nia.stoid antrum. Here 
and there, then, tlie disease, from it* commencement, would be 
<lue to the virulence of the micro-OTganisms or to unfavoumble, 
general or local, pomatic conditionH. 

Other causes are: Injuries, foreipi bodies, para.-'it**, new- 
growths, gummatous processes, which spread from the nose into 
the %vall of the cavities, and alveolar j^riostitis (carious teeth). 
Sometimes violent blowing of the nose, whereby infectious 



matter may be fnrciHl into the antrum, may be the origin of the 


Sii|)i)iiration {infliunriiaiiori) of aii aceessory cavity beeomes 
chronic if tho discharge of llie stcrelion k obstructed or impeded, 
viz., tliroitgh tlui secretions becoming lliick, the cpcmugs U'ing 
narrow or occlmUil, ileformiticit of the nasal cavity (H(?ptum}, 
poty|)i,orhyiMTtrop!iie-.t beiiiff formed in the neighbourhood of the 
ostia, ID consequence of the constant irritatioD of the mucous 

In long-standing suppuration of an accpwory cavity the miilille 
coneha shows hypertrophic swelliiiR and polyfKwl gmwth ; later, 
on ncwuiit of Ihe rodent effw-t of the purulent secrelion, the 
inferior eoncha also becomes involveil and atrophies. In time 
the Atrophic proee.^^^ spread.*? further and further, implicating 
the previously hypcTtrophied str\ictiire« a« well, vuitil, finally, 
the nose sliowf* atrnphif; rhiiiitir^, with or without foi'Ifir, In 
this case the ozaeiia is certikinly w^rondary to a priinarv siipjHim- 
tion of an accessory cavity. But there are many authors who 
maintain that the .suppuration of the aecessory cavity would 
be secondary to a priniar>' owiena. Repeateil acute attacks 
of catarrh predisjxB*' tlie suppuration to become chronic. Some- 
tiiues, however, suppuration, even though it might have lasted 
for a long time, docs not liecoinc chronic In such a ea.-'e the 
secretion of the antruiu dries up, or becomes changed into a 
chcwry matter, and so forms a kind of foreign body, which 
quickly (lisii]ii)earN after thorough washing out. 

Pathological Anatomy.^ln acute inflammation the mucous 
membrane is more or Ics^ reddened, swollen, and in some ca^^es 
so much 90 that it is sejmrated from the wall of the cavity, a« in 
ohemosis of the eonjiuictiva. Sometimes, however, tliere iy no 
exudation; in otherv:, again, the si^erelion is serouw, nmcoiis, 
mueo-purulent, or purulent, rarely fibrinous; and cystic degejier- 
ation has also been obper\'e<l. 

Tlie chronic inflammatory procew shows two stages: (1) at 
first, thr mucous membrane is oedematous; i'2) later on it as- 
sumes a more iibrous rharacter. with villous or warty excrescences 
then-on. The mucous glands soon degenerate and form cystsu 
The Ijonc becomes implicated, is thit'kened, and osteo])Iiyte» 



(exoatosefi) are formed, making the siirfac** spinous or tuberous. 
Tho exudation \» not often bltous, hut mostly purulent, and be- 
comes thi(J( and foetid tf it has the opiK)rluiiily to decom|x»tc. 
The Iwne may he eaten away (carier*), but this latter is deniwl 
by some authors, or bt^comes stroiJiieil, bulged, and ihinnwl 
out, like |)arc!linifnl, so tlial on prohltig il shows theuell-kmnvn 
sjinptoms o( •■ ijarchiiH'iit erackliTig" (sinuatis cum dtlatatione). 
Tf the ostium is oceludcd for a longer time, a mucoci'le may 
bo fonnctl if the secretion has been mucous; or an empyema 
(pyoex'le) in punili*nt exudation. Tlie cavity is frequently 
diliitol through the formation of cj-stsor polypi. 

Tlie objective sipis are detemiinct.1 by the weretion aiitl com- 
plication of other organs. \\'e have alremly, from a general point 
of view, discussed this matter (see Chapter I\'., p. 75, et seq.) 
Here we sliall treat the details in accordance with Ihe spedal 
condition of each aeeesiiory cavity. 

Diagnoas. —The diagnosis of the inflammation of the accessory 
cavitiep is not ca^y, especially if we have before us what is called 
a latent empyema. The esj)re!wion between latent and manifest 
empyema is not happily chosen; for, strictly siM-aking. latent 
empyema tan only be a suppuration in a flose<l cavity, making 
no subjective or objective symptoms whatever, and is only 
discovered by men? chance on examination, liut in rllnical 
jargon, the temi has been accepted in the sc^nst- that il signifies 
a supjjuration in an accessory caviiy, without causing much 

x\s has already been raentionetl, the subjective eyinptoms can 
be vcr>' little relied on and the objective signs are extreiiieiy 

If the patient complains of headache, es]>eciatly on one side, 
and in thr' ft)rc:liiiul, over the root of the n<K*e, antl if thet«* heail- 
aches are paroxysmal or jjcriodiral. accompanietl by lachrymatian 
and r^msidrRdilc purulent discharge from the now, and |>erhap« 
al^rj wicosmia, then the jimlmliiliiy is great that we liave to deal 
with suppuration in an accessory cavity. In aeute cases the 
amuimesis will stnmglhen our susjneion, Rxaminaticin of ihe 
puilent U c<indueled by anterior, and then followed by posterior 
and medial, rhinoscopy. (.Sec p, Iti,) .\ny copiou-s collection 



of pus must be cIwirhI away by douclitng ami sixinging the nasal 
cavity. If, soan iiftfr tlie clean in g, fmsli pus appears in thf upper 
parts of tlic nose, in particular in the region of tlic hiutiw iWinii- 
luiiaiif;, and 11 the jjus, moreover, ^ows pulsation, then tho 
iliiignoKiw gains still more in iirobability. It is further 8ui(i>ortml 
if. Uy(»iii-t)f the already dewribnl luetbods (see p. 23), secretion 
Ls uspirutfil aiiil tuiwleviwiblein tlu- previously clean nasal cavity. 
But we niiLst admit that the apiKrarance of pus on the apiJication 
of aspiralioii by the method (h'^crilMhl does not neeesaarily |»oint 
to l\\f in flan una lion of any particular cavity. Diagnosis can 
only be aitt<urt<(l if, by probing or .^y'rin^g an accessory cavity, 
ami Iheii, after llie probatioiuiry eleaimiiig of the now, wo find 
pus. If a probationary ifj-riiiging throiigli tlie natural opening 
is liilficull or i»ii>os^il)le, then an exploratory puncture, followed 
by aspiration or cleansing, will be ilecisive. 

TraiisUluiiiiliatioii is not absohitely rebabie fsee p. 30). but it 
is always worth a trial, aiul will aid the diagnosis. 

This will liecorae a puzzle in all those where a combined 
empyema exists, i. c, in suppuration of several acccRsoiTr' cavities ; 
and it will prc-ient tlie utmost dliKculties of solution if several 
acces,■^orJ■ cavities are diseaseil on both sides. In such cases 
we ttill perba|i9 sueejHtl in ascertaining from where tixe pus eomee 
by exclusion of the cavities concerned seriatun. A cavity 
call be excluded in the following way: A little jjail of cotton-wtxjl 
is presscti into or over the respective ostia. This segregation, 
however, of the various cavities is rather difficult, and there re- 
mains nothing eW but to wmreh for the pus in the i?everal cavities 
by the inethiMis of punrtun- junt dcMcriljed fst* above). 

It Is well, in perfunniiig thi.-» explitratifin, to follow a certmn 
fAan or order. If pa-* appears to collect in the hialufi. laternlhj or 
itmrsxdiatrty betow (he inirlith concha, it points to an aftectitha of 
the rijiugex jritiuUed touxtrds the front (antrum of Hvjhmare, 
frontal sinu-s, anterior ethinoidnl cells). In sueh a ea.* the 
iiiaxillarj' eavity, which is that moat commonly affe*rteil anil 
ea.«iest aeci'ssible, must be explored first, ami the ethmoidal cells 
next ;aiK!.la.slly,thefroritnlsinus. which offers the niostdiffieultiee. 
If the pus «tH.iii8 to collcet in llie more pwteritv jwr(* o/ the nasal 
cai-ity, or in the naso-pharifiujcal space or <Afactary chinkt i. e.. 


if it appoanj somcwliat afmv unii mesialhf from the middle coneha, 
our fillMilion iiiusi bp rJirectetl Uwiirds the upper (wslfrior 
ciwilips {posterior ethmoidal and sphcnoiJal cells), and we must 
attend first to Ihc sphenoidal siims, and tlicii finally to the pos- 
terior ctlinioidal cells. 

Most pnibiibly the dingnosif* of a coinbinal empyema will 
not be Hssurni before an opi-ratii»n on one of the numerous 
cavities has alreaily been conunenceti. 

In eases of foi;ttd discharge a ilifferenlial diagnosis must be 
made betw-f-en foreign bodiej-, nawil calculi, tumours, and tertiary 
sypliilis. Acute nasal catarrh, though very often aeconipanied 
by purulent diseharge, probably never shows foctor ex naso. 

Pr&gnosis.— Acute inflanitnatory processes, albeit with ■copious 
puniient discharge, for the most jiart recover spontaneously. 
The chronic inflammatory alTection.s an> cured or, at least, 
much ameliorated by proiHT tri-sitniriil, eon ipli rations not being 
often oljwrveil. But it luis biipiK-md that in ehrouie cases 
the infiammation has sprea(l into the nclgblKmrlng tissues and 
orpnns (eye, orbit, etc.), or, by eiirnmehing on the cranial 
cavity, has Iwl to death from iiieiiiiij^tis. 

Treatment .^In acute fiuppunilioii of the aeceiwory ca.vit.ies 
the best treatment is the expeelant method; and the ]>hy.sician 
must procee<i .symptom at ieally, just as in a of aeute rhinitis. 
In chronic sujipuration our Ireatnient must be striclly individual, 
and it is higtdy objcfltionablo to ojiorat* wthout du<tinct in<lica- 
tion. It w just in the field of suppuration in the acw.'wiry 
Cflvitioft. that, encouraged by llie progrefy* of diagnosis, a more 
rsdiejd method of Ipeatmcnt has been adoptoil, wliieh overstejiH 
considerably tlie limits dniftii by functional needn or cosmetic 
consiflpriilioiis. Life in, as we have already saiil. very little 
endftiipercd by eumjiliealioiis, and it is just tlie ra^liejil o|)exa- 
tions which have resulted in iutrflcranla! affections. Bpsides, 
the (rain by radieal operations is often finally not jfreater than 
by more conservHlive mellKHls. We slmuM, therefure, ntlaek 
dironic «uppuration. which causes httle or no trouble, only 
by mild <loucliinp or intranasal operative methods. To lay 
bare Ihr' suppuration, after (he methods described in the fulinw- 
iiig section, is only jx-nnisaible where Uie patient complains of 



serious trouble, and where he is prcvwited from following hjg 
occupation, or complications arc thront^'iiiiig. In this sphere 
surgical technique is iitili tcnUtive, and a wise and dctcnuiDcd 
restraint b here desirable, bccau^; of the many methods of 
oiKTation. It is certain that iiiucli ha." hore In be niCKlificil, rur- 
rectwl, or eliminated, as numerous (|UKstioiJs »lill wail to be 



EtioIogy.^The causes of inflamination have aJre&dy been 
indicatwl in the K'-niTal section. (See p. 132.} Here we only 
desire to show the r(\!e the teeth jilay in the etiology of the in- 
flamniatioii of the inaxillaiy cavity. The anatouiicAl relations 
between the floor of the antrum and the dental alveoli ile- 
wrilK'd in the general section (see [t. fi) explain clearly why 
infifttuinatfin,' pmeejises about tlie dental roots, e. ij., alveolar 
p^'riiislitin, d^'ntal ryHts, or abscesses, etc., so often lead to infec- 
tion of the maxillary cavity. Most comniouiy the fajiRs of the 
first and second molar teeth set up the trouble. I'ncloan in- 
etrumcnts used for extraction of the teeth may be the «ium- (if 
an infection, and intranasal oiDeratinn? likewise. I have myself 
observed an acute suppuration of the antrum on which 1 was 
called upon to operate whicli followetl a partial resection of the 
middle concha. 

Chronic inflammation of the maxillary cavity, in the majority 
of cases, follows on the acute stage, under conditions already 


Symptoms. — It may 1m? taken for granted that not a few acute 
or chronic inllammations of plight dcpree show clinically little 
or no symptoms; in yet other cases, however, the rtyrnptimis or 
signs arc unmistakable. These symptoms are: (1) local; (2) 

Lftrni tijinptnms are manifestc*! by a feeling of lension in the 
afTected region, sometimes combined with temlemess in the 
facial wall. Hadiatuig pain occurs frequently on blowing llie 
nose, coughing, or on 8too|)ing; the nose is obptrueteil and there 
is ejMphora <Iaehrj*mation). Diseliarge, nin.stly mueo-purulent. 


di8i<:as]»;s oy 


or, if the inflammation is caused by earioxis ipelh, a discharge of 
footifi socrptioii from llie nose, miiy be noticed. The discharge 
is not eontinuouij, 1)ul jH-riwIical, and i^i Ui^iially [oUnwoi Ijy 
iwiin ami tension in the nose being relicvcil, At oUht timn 
ii appears if the patient bends tin; bi-atl towanls tlie healthy 
si<le. The constant Lrritalion kept up by the suppuration gives 
rise to swelling of the muams membrane, f)oly]K)iit growth, 
hypertrophies, etc., in the vicinity of the ostium maxUlare; in 
other cases atrophic pHH-esses prevail, or one finds hy|»cTln)phy 
and atrophy \'j"ing witli each other. In vt-ry ehnmie ca«es, if 
Uie niaxiDiirj- osUmn is blocked, the nasal wall of the antrum 
is liable to bulge, 

Gcntml sifwptonis, fever, giddiness, weakness, and so on, are 
rarely absent if inilanmiation is pronounced. 

Course. — The course ia variable. Acute inflammation of the 
maxillarj' sinus often recovers spontaneously in two to three 
weeks, but not infrequently it passes into the chrome stage. 
In chronic inflammation changes for Ihe better or worse follow 
each other, ami exacerbation often follows acute nasal catanh. 
Complieationfi are rare. Sonieliiiies the abscess perforates into 
the orbit; at others, there is exophthahuos, contraction of the 
field of vision, or amblyopia oeeurs. 

Diagnosis.— In pronounced eaws, and particularly in acute 
oneii, the dl-'eafle is easily recognized by tiie Apparejit s>Tnptonis. 
Tlie ijiagiiusis depends on this and on the result of rhinoscopic 
c-xaminatiun. Tlie purulent Heeretion mostly appears in the 
hiatus fipmilunBris ami flows down over the middle meatus and 
lower concha to the llnor of the nose; or if the bulla elhmoitlalia 
is of a lai'gc size or the mid<lle concha enlarged, the discharge 
may flow Iwckvrards into the naw>-pharj-ngeal spaer. In long- 
standing P\ippuration the mueoun meniliraiie covering the pro- 
cessus uncinalus ai>i)ears conspicuouFly swollen and the lateral 
fold of mucous membrane (Kauftuann), under th<*c circum- 
stances, sometime.-* jHishei* the middle concha inwards towards 
the najtal .septum. In winie eai^es the method of ahpiration and 
transillumination will prove useful, and in doubtful cases an 
exploratory puncture or proliationary washmg-out will lielp. 



The two latter methods, moreover, cerve as useful ihorapcutipal 
measures, especially in the aeule condition. 

The warfiinp-out of the niHxillarj' iiavity diould be ilnne, if 
possil)lp, thnmph Oip natural openinp. and must Im» preceded 
by examinalion with the probe. (See Fig. 30.) 

For this purpose a rigid probe is used, which is bent to a riftht 






F\$. SO. — rrotiine at the fronta) and moAiUary simiii and of Ihv Anterior 
c4faini(ndal cella m/frr Uaick): «, l'i>*ii<t» of Ihc xoiiml in ibe [ruiiLk] sinua: 
ft, in the uilrnur vHiMoidul c«IU; r, in ih« mnxillaiy cuv^ly; «. /., frontal 
sinus: o.'-ifKiiutii ethinoiibilc: r.m., mirliU^omdm (rut); f.»,,mijifTioTeoaeii&; 
t.t. p, mnrhasiiprenuijr.r p,,|H»itoriorflliiiiin<liU wll (ii[nii»I>; h, Mph..f![Aw 

angle 1 cm. from the end. Having prevlmihtly anaemized and 
an&<*sthelized the whole lateral wall, the middle nieatat i» 
caulious'ly explored with tJie prolie mitii we reach the infuiidil»- 
ulum, mto which the end of the probe sinks. If, now, the 
prolx; is slightly and very gently f^hifted forwards or lack- 
ft-ards, one can feel how the (nrohe Hinks still deeper and is 



caught at a particular .sjm)! ; this is the osiiuiii nmxilUre. 'Ihe 
probiiijc of ail arcesMiry fi>raiiii>ii is sonif tiiiifs much fjuuer Ihan 
tliat of Ihe infiUKlibular oijeiiiiij;. lYobiuK iw foUowwl by tlie 
introduction of Harimtmn'H \u\ie iu Uie Hune manner as vas 
followpd in tlic pruliiiij; (Fig. 51). 

The conic&l tnd of tlic faiheUr is jtMned to an india-rubber 
tube, which, after the imroduction of the ealheter, is connt^ted 
with a syringe or india-rubber bug. The patient V head it* Ixait 
slightly forwards, and under low pn■^sll^(■ lukewann st^-rilir^ 
waltT, to which a little eoniirioii .-salt or boric aci<l or peniian- 
ganate of potassiini may Ije adtled, is slowly sj'ringed in. 

I-lxploni lory puncture will Isf* ivwirled to wherp washing out 
through the natural or accessory ofx-ning !.•* inaiiniissible, by 
reason of the narrownesfi of the hiatus swuilmiaris; abnormali- 
ties in tlie configuration of the middle nieatiK; hypertrophic 

swelling of the middle concha; de- 
formities of the septum, or snmll- 
ness and unfavourable iiosition of 
the natural openings. One will 
sometimes surceed in tliew cast's 
if the anterior end of the niid<jle 
conclia is resected by nipans of 
the snarp, sciwiors. or Iwnc forceps (Griinwdld's), a prxjceeiliiig 
which cjiri Ix" rwoniniendeil, as it aUo 8er\e.s a iherapeutic 
purpose and if) often sufficient to secure the {lermanejit diseluirge 
of the eecretion. 

Exploratory puncture ought always to l>e made from the 
ioxcer meatus. A small pad of cotton-wool soakixl witli L'O per 
cenL cocaine is pressed into the lower meatus and against the 
lateral wall of the nasal cavity. Having thus made the mucous 
membrane insensitive and tesfeti the insensibility, a cannula, 
nufTiciently long, thick, antl curved, is here Introduced aa far 
as die middle of the lower meatus, and tilled iipwarrls af; far as 
poNiiblf towards the attadiment of the lower concha, mid here, 
abnut vf em. from the anterior end of the lower concha, is thrust 
thruugfi the latr-ral lM>ny wall, which at this spot is very thin; 
and now. by slight niovementi-, it is made sur** that the point of 
the tannula is actually in tlie ma.xillary caWty. (See Fig. 52.) 

Fif. SI.— Cdthrtcr iulw tor 
wikH))iiti; uui lli« maxillary canty 
(o/(<' Hiirlmaiin}, 


Puncture is difficult or impossible if it is tried at a spot too 
far foraanli-, U'ciuim- tlu* liony wall is there too Ihirk. liad 
accitietits, e. (/.. tUrufflitig the cmuiula inlu Iht; o]i|)OMt4! wall (tli(r 
ca\'ity iaeing small) or ixrforating the orbit, are very rare. 

'llie puncture niigiil Iw coniljini'd with aspiration by uttacliing 
the cannula to a yVnmz .syringe of a capacityof 2 c.c. Iti \\ rase 
when? the accretion is very thick or folds of lliH nuirous nieni- 
lirano are aspirated, the whole procedure of a*j)iralioii fails, and 
in such a case washing-out hivi to be per- 
fomiMi. Aftpr washing; out, air, by means of 
a fl>Tinge or india-rubljcr bag, is pressed into 
the niaxillarj- cavity for wo long a time until 
the clcfttisiiig lluid m cmptiwl out ami the 
cavity dried. 

Prognosis. — Tlie prngnosis is good in the 
niajorily of case:?, and rhninic inflainmations 
also heal up under pnt[«T treatinenl., or, at 
least, arc so much improve"! that the patient 
ceases to couiplain. In chronic ca-ses, how- 
ever, it must be adniitUnl Iliat ihe process of 
healing is very slow, even after radicftl opciv 

Treatment.— The Ireatnient deiieiiila essen- 
tially (in tile duration of tin- <li.s('ji.s(>. 

{a) In nrntc infhtmmatwn of the maxiilnry 
sinus the cxiHxtajit symploinatic treatment, 
tm ttlreatly indirated, is mostly .suflieient, but 
if it lines not succeed after a eertnin time, 
we mui^, in order to prevent the ease liecoming ehronie, lake 
into con.-'idenit ion certain mea'siire-j which we have alreaily nien- 
tionwl lis valuable in regard to Ihe diagnot»is. Tliese measures 
arc the wcL-ihing out of the Mniis and the partial resection of the 
middle turhinal. 

To remove the anterior end of the middle turbinal the tmsHi 
scissors are intrndurt-d into the anall s|iace between the latpral 
wall and middle turbinal, and. nitli the t)ladcsdtn>('tei1 obliipiely 
backwanLs, so as not to injure the lamina cribrosaj a piece of 

riiiiw fur llio ex- 
Iilonitor)' fiiincture 
of ihfl niaxltlanr 
ravity (after A/. 



Uic hiHiy altadiment of thr UiTl;iiial (a-b. Fig. 53) is cut 

The guido-tube with the snare bent down is then pushed into 
the space formed by the cut (6), and tlie loop ia thereby ad- 
jil<;UhI into [Kwltioii <a» b c b), and then tigliteneil. lii pval 
hyi^Tlropby (if Ihi^ ant«>ri(ir end the snare eaii. however, be 
pa.isf>d over the turbinal withoiil any previous cutting. As n 
last resort, a piece of the uncinate<l process a]so must be resected 
by thnisting poinl«l sciasors througli the middle of the proorss, 




Fig. 53,— Rcsecliofi of Ihe kntcrtor «n<i of thr ini<Mlc turUiul (dinpBin- 
tnatic): a-b, CVti by fCiMor* in end of mkJdk lurbiu&h b e. - .b, postioo of 
the omre paved oT«r tk* turbitiAJ: r, guido-iutM* far itw stwrc 

aitil rutting upn-Hitis and dotvnvTanls the lateral fold of the 
uiiicous [uenibrane nith its bony support. 

Tn cases where the secretion is very profuse or thick, the MxJi- 
naiy oiniinln of IJ to 2 nnn., wliich is usod for waAing out, is 
act sinte-l to drain the anlruni. Tliitf being the case, the opcoiiig 
in the inferior nicatiLs L^ made wth ft larger sizetl trocar (w« 
Fig. 'A), or the Mniis ean l>c attacked from the outside thn>u^ 
Ihe r&nine fo:«a. If the suppuration is caused by a carious 
tooth, this must be extracted, and the antrum can tlicn be 



Fig. M.— Tn>- 
cnr for lunxillnfy 


Oipenctl through the alv-eolus. These three methods will be db*- 

cusscil hitiT on. 

f6} Sinu.viti-'< MnriUaris Chronica (Chronic 

IntUtmirmtion o} the Masiliary CViirjiy;.— The 

trcatiiient of chronic mliajimiation of the 

niftxilliiry wmir* is, in the lirst place, dircctetl 

to delivering the sinus of it*< wiilciiU. This 

is done, as alrejidy indicated, by wasliing out 

per via.s lULlunilefi (p. 140), and ultimate ini- 

podiiuents, for instance, hy]>frtn>phifjs, [xily- 

poid gruwlhs. enlargotl p<jrlions of the coik 

eliae, nuL-'t Ih? remyved. If the wa.'^hiiiK out 

throuRh the natural opening; prove diffiotdl or 

iniixw^blc, the arUTiim must l>c opened in the 

inferior Meudw liy oieaiisof a trocar {Mikuiicz, 

KratW€, Nollcimi^s, Ucille) hy tin- satm; wiiy iis 

we have descriU-d fur thi- t'X|ilorat(iry punc- 
ture. Some authors atlvise nmking the opening in the middle 

rneatiLS. The inferior meatus, however, hH.-* thus advantage that 

the piuiclunsl opening can be enlarged, if it l>e desirwL For 
this latter purpose cur\'eti punch forceps lU'e 
used, wliich remove the lateral wall by cut- 
ting hack^-arda from the opening (Sonwn- 
thai, Spie--iS, Wafie'ier). For this purpose a 
very practical typre of punch forceps is de- 
aigin-d by Omnii, which h:u^ a wlmrp point at 
the tip anil so can U- u-snl iilsii as a trocar. 

All the methods of w;i**hing ovit descrilK'd 
till now have this drawback, that the patient 
hhurtclf can seldom leani how to perform it. 
For him it is much belter if the cavity is 
opened from the alveolus of an extracted up- 
I>cr niolnr tooth by means of a sjwcial gimlet 
(Ilartwann, Hajek-) under local anaesthesia. 
Tlii« method i« P|MTially alivi^iablc■ in vtun's 

where the second bicuspid or tlic molar teeth an; cariou« and 

have to be sacrificed ; and. (w a la-^t nw<)ri., a licalthy tooth haw to 

go. The extraction h foUowt^ by the opening of the alveolus, 

Fig. 55. — Ginri- 
lel for (lonlal il1- 



and thrti afliTttanls llii^ [mtjent U tHAo to treat himself unaided. 
The «iiial] u|Krrlurf, liuwtni-r, .sucli a.s tiial iiiadc in the inferior 
nicatiLs. is not lyisily kopt ojh-ii. I'or a «imilor rcnson a small 
irniia-ruWicr «(«p]j(T niuat be put into ihe alveolar opening, wliich 
ket^ps it [KiK^nt &111I at the !«aiiit> tiine s^huU it ofT. 

In (iai pslatf.f iiiiil wide alveolar processes Jvrasz adopts the 
following nietliod: I'ndor lucat aiiiio«the«a by cocaine and 
adrenalin, he makes & broad opening into the antrum from a 
carious upi>er bicuspid or molar tooth by means of a <lental 
drill, ami, if ncet^seary, cutting away a small jiart of the faeJal 
wall of the upper maxillary bone. The opening ib occluded with 
a sterilizahle pl»1e of sheet iron, which is only tjikni off far Ihe 
purpos; of wa.'ihing out. This "radical " opening of the alveolar 
process is said to enable the introduction of the little finger for 
purposes of exploring and for seraiMng out the antrum with a 
small »eoop. 

I'nder these methods of washing out, which at firt«t are done 
daily, later every second day, many eases heal completely in 
a jihortor or longer time. Unfortunately, in very numoroiw 
eaa-K the mueou.'j nn-mbrane Is ^u much altered that only a broad 
OfieniTig jrom the outside Uiroiifik the canine Joitm can be sttc- 
cessfiil. Only by this latter nielhixl are in!«iH'ction of the cavity 
or examination with the finger and radical renutviil of pe>lypi. 
praiiiilatiiHis, etc., jKi-s.-'ible. Tliw niethal, first drscriljed l>>' 
Demuh-Kunler, has lattfiriy l»een niodifietL 

The oj.K'n»tioD is don*> unih-r local or geni'ral ana^thrsia. 

I1ie angle of the mouth is drawn outwaI^lH and upwiml.^ ; a big 
swal) b> put at tlie back, in the i>ocket of the cheek ; the mueou» 
meiiibrone is then cut througli horlKontally alnive Ihe alveolar 
niarpn down to the bone ; the periotiteum is then pushed back 
with a ra»])ator^', care l>eing taken not to injure the infia-orhital 
nerve, and a hole is made in the thin bony wall with a j!:ougc. 
Ha\'iiiK stopped the haemorrhage, which is fretiuently eopioitf, 
tlip a(ierture is eJilarged with a Hajek-Claiis ]iunch forceps (Fig. 
36), e.«jtecially oiitwarihi and upwards towards the xygnmatio 
proccsw. This done, the cavity is inspectetl and f)aljiate«l in 
turn anil idl [nthohipleal matter removed by the eiiretle. Healthy 
mucuiiH miiid)ni]ie nbouli] not lie taken awav. 



The oavrty is now thoroughly cloanwl and fiUctl with xero- 
fonii gaiizr, or. in cawt; "f marked foetor, with iodoform /icauze; 
Ijul not loij liniily, so tu^ not lo (uuw U)o gtfui mi utrdcnia of tlie 
check. The first tampon remains in from four to five days. 
The after-lreatnient consi-sts in rr-giilnrly washing out, at first 
dally, later on, evcrj' second or third day, ivnd then always 
following it by packing with conicAl tampons eiiveIu|K*d in (i«iizf . 
Those tampons allow the envity to contract, but are sufHcient 
to keep it patent and to j)crrnit ofTpctive control. 

Unfortunately, the Desault-Kualcr method of operation m 
also not freo horn hlanic, which, how- 
ever, does not concern tltc operation 
itself, but the after-treatment, in that 
it takes a very long time before cicatri- 
zation is complete and a cure e«(al>- 
liahed. Sometimes a fistula remains, 
which refuses to close of itself. Thire 
is no doubt that this is due to the con- 
stant irritation kept up by the repmted 
packing. The after-treatment, by con- 
tinual packing of bony cavities with 
rigid walla, oix-ned by oiKTation, only 
tiX) often mcan-s a hoj)e]es3 fight againxt 
the oft-recurring granulations. We 
must, tliereforc. make it a rule not to 
pack too firmly and for too long a 
period. It would \k the I>est to oper- 
ate in such a way that after ratlieal 
curetting the post-operative packing 
could bo avoided, without hindrance to the outlet of the 

These roquircmenta are fulfilled by the method of CaUtaell- 
Luc, by which the maxillary cavity, opcneil from the canine 
foaaa, i» aluit t^^iwanls the nirmth and drainetl into the nasal 
cavity. 'Hn- facial wall is fn-ety opentx] from the canine fossa, 
anil the floor curetted to remove all diseased tissue, as previously 
described: the lower part of the inner wall of the niaxillarv' 
cavity, which corTe»[jonils tn the inferior meatus, is now removed 


Fig. 56. — Long punch 
(iir«;)B for ihi^ niiULiUiiry 
c«vity (nftcrllajtk-CkiuMi. 


■by light fitrokea "nilh a cliicd. Care must be taken to preserve 
__^thf riuK'OUM mcmbmnc. From wJUiiii the nuBc a blunt proljc 
j^tt uilrrjrluced intc the inferior meatus a« far in as poe«ible. and 
Uie iiiucou-s iiienibnuie is pushc(.l outwards towards the maxillary 
cavity; the protruding portion is then inci!*ed and the cut carried 
through the iiiucoua membrane, correspomliiigly with the attaeh- 
ment of the lower concha. This done, a vertical cut ia made id 
front and behind dowTi to the floor of the nmxillar\' cavity ; ant! 
so a flap of mucous membrane, formed in the region of the lower 
meatus, is reflected towards the niaxillan,- cavity, thereby cover- 
ing its floor. 'ITie part of the lower concha in front of the opening 
is then cut away by wiissors, and the niaxillar>' eavity loosely 
fidled with gauze, the ends being brought mil tlirough the nose. 
The oral woun<l is closeil by interrupted sutures, which may be 
removed after eight tlays, atul tlur gauze may also remain for 
eight days or longer. No further packing is necessar)', and 
instead of it, iodoform may be insufflated several times, or, 
if need be, the cavity can be washed out 

Although all irritative nianipidation isavoidetlby this method, 
nevertheless, it takes a long time before the cavity is covered 
with new epithelium, Besides this, there is the di«i<lvaiitage 
that the field of operation is not as open to inspection as in the 
former mcthiHl. Infection from the nose, as we know by ex- 
perience, is little to be feared. 


Inflammatory processes in tlie frontal sinus almost always 
involve the anterior ethmoidal cells, and this is not surprising 
when rejiard is taken of the intimate relation of the frontal sinus 
with the ethmoidal cells. (See p, 8.) We shoukl, therefore, 
as KiUian iwints out, speak rather of cellulo-anusitis frontalis. 

Etiology. — Thi- etiologv' is the same a.s in acute inflammation 
of the maxillary sinus, wilh the exclusion of dental causes. 
Clhronic inflammation usually ori^nate." from the acute, if un- 
favourable local conditions pn-vent the escape of the-serretions 
from the inflamed frontal sinus. 

Symptoms and Course. — Vtiv .lywi/Jtonut are, mutatis miitandiSf 



verj' similar to those of the innxillaiy cavity. Characteristically 
frequent, however, is the agonizing frontal headache, which 
occurs in the acute or acutely exacerbat«I chronic cases; somo- 
timen, lik<» attacks of neuralgia, in the first part of the day, ami 
aggravatwl by every movement of the head, rendering the jia- 
tieiit quit* iiiea|>Bble of any physica.1 or menial work. In exc*j>- 
tional cases pain is absent. Tht> region of the foreheatl, and 
especially the upper and loQcr &nglc of the orbital wall, is often 
abnomially tender, and sometitnes llie skin over the eyebrow 
is red aiiti oetiematous. 

The secretion varies in quantity. If the esit be blocked, it 
might even entirely cease, an 
occurrence which usually ag- 
gravates ihe headache. 

Tbe eye and orbit are 
mostly implicated; there oc- 
cur epiphora, photophobia, 
aBthenopia, etc. 

The conrjse is mainly dptcr- 
mincd by the com plica tiunn, 
which, though on the wliole 
infrequent, yet occur ofttmer 
than in itiHamniation of the 
antrum of HUjhmnrs. and arf 
accounted for by the ijeciiliar 
anatomical relatiouH of the 
frontal anus. C(nnpripation.s 

arc: (o) Piatention and dilatation of the sinus; (b) ulceration 
and perforation of the wall and spreading into the vicinity. 

(a) Dilatation of the sinus is ob»cr\-ctl only in the chronic 
casc«. It is prfitluced by the exit bi-coiuing pt-nriaiiiTitly or 
periodically hloekcrd. The orbital wall is mostly ronccnu-d, and 
bulges forwards like a tumour and displaces the giolw down- 
wards and ))iitwnnls. The prcitnidlng part of the Immic becomes 
thinned by alisnrjilion, and tins sometimes so much tJiat it 
crackles like pan-hment. (Si* Fig. 57.) 

Till' eontent-i of the dilated sinus are rarely serous Oiydrope), 
oftener mucoid, ur punilent (mucocele or empyema). 

0^' n 



l-'ig. ST. — ("hmiiii 
left fronlttl uniip, 
[irolnmion of Hip m 
t&l wall (ajlffr Haji 

vW the 
(iiiwr ori>i- 



(6) ncoration ami perforation have also been obscrx'ed in 
the aciile siage; ami this was sometiiin-s followed by Bprea<!ing 
in the neighbourhood as the result of Liiroiiibosed veins. The 
most liable spot here also is the orbital wall. Much loss fre- 
quently is the anterior wall implicated, and, fortunatt-jy, Ptill 
rarer is the cerebral wall alTccled. 'Hie soiiueliu- an? hstulae, 
phlegmon of the orbital cellular tissue, *lisplaccinent of (he 
oyo, wiUi diplopia, and Immobility, o«lematous .swelling of the 
lida, exophtliiihiion, etc. But meningitis also, and abscess of 
the bniin, ils well as thrombosis of the ca\wnou8 sinus, have 
been obsi-rved. 

Diagnosis. — In acute eases frontal headache, esjierially if 
localized just above the nose, with lentlemess of the upper ami 
iimer angle of the orbit, will direct our attention to tlie frontal 
sinus, the more so if the patient is suffering or has sufTereti 
recently from acute rhinitia. Oi examination of the nose by 
rhinot^copy we notice the pus running down from the anterior 
and upper part of the middle nieatui?. The diagnosis may be 
coiiipletei.1 by the probe. 

In chronic cases the diagnosis is often very difficult. Confu- 
sion with trigemmal neural^, hysteria, giunniatous periostitis, 
inflammation of the maxillary and ethmoidal sinuses, and malig- 
nant tumours have frequently occurred. Transillumination is 
quite luireliftble. In order to make a differential diagnosis 
between maxillar>' or frontal ^as disease one should notice if 
pus escapes more readily in the inclined or in the erect porition 
of the head; in Ujc first case, it i.s the antrum of Highmore; in 
the latter cft(« it i« the frontal simw which is affcct^^l. But 
this examination 15 not free from error, and the method may 
entirely fail if the rf'^[K'ctive iwtia are blocked or if there is a 
multiple affection. Wt- ensure the diagnoKis, however, by prol>- 
ing the frontal sinu.-<. I'nder local anae»the!«ia with cocaine and 
adrenalin a probe iM'nt at itj* anterior end is piL-Jied laterally 
from the anterior end of the middle concha straight upwards. 
If. now, tlie handle of the pmlip be lowerRl, the upper t'lvl can 
be dircclfid more towards the front and the midrllc line;all these 
movementft fthould lie done gently and without using any force. 
In order to aea-xtmn if the probe la actually in the frontal anuB 


(aee Fig. 50), the manoeuvre is repeated in exactly the sBnic 
niatmiT with a sccoml probo, bent in the saine way and of 
iilnitical length and cur^'cs, outside, ou the dorsum oi the uose, 
and then comparetl as to direetion and Irngth from the nostril 
upwaals, aiul tlien notice is taken Bs to wliether the end of the 

Pig. 58. — Oa.thet«r for waahing out the frontitl titina {afler KiUim), 


external probe lies above the orhital margin. This manoeuvre 
can be controllwl by x*rays. 

Dijjiculties Mel Wilh in l^robinf}. — With respect to the anatom- 
ical relations between the frontal sinus and ethmoidal cells, wo 
shall not be surprised to find that the jirolie ia easily caught in 
one of tlie cells, an event, however, which does not count for 
much, especially if pus is found, for the reason that suppuration 
of the frontal sinue. as has 
been said, is nearly always ac- ^ 

coni|«iiiici| by implication of 
tile infimdibulivr cells. Greater 
dilfieulties arw' in probing 
fnim any markcrl deviation of 
the .'M.'ptum. from an exces- 
sively large bulla ethnioiilalis, 
or an abnomially narrow in- 

The matter will be mtule 
caaer in many cases by reuee- 
tion of the ftiitcriiir cud of the 
middle condui, mul tlie n;nioval of excrescences and hyt)erlro- 

Tlie diagnnflis i.t certain if pus run.'* along the probe, or if, on 
sj'ringing, piw in found in the return flow. In rare cases only 
the anus bus lo Ix»oppne«l from without. 

Tliis is done in the folliwing way : A cut ia made in the eye- 
brow it.«i'lf {on the margin of the tuft of hair), U^giiuiing at the 

I-'ig. ,'><l. — Kxploratniy Apnning oS the 
fniiitul ditiUH ill Ihi? i>ypbRiw. 



incisura nfisofronlalis, and U carried along for from 3 to 4 cm., 
culling through all thp soft parts ilowu to the Iwno; thp [lerios- 
tt'uin i& now pushcii upwardit towanls t]it> f^tabella with an ele- 
vator, an«] a »nal) hole h made iininecltatcly below Uip iiasal 
eiul of tlie cycljruw by iiiHans of a cliiwel, carefully advancing as 
it is deepened. Thie opcuiing wiU scn'e a three-fold purixise: 
firstly, to ensure a diagnosis ; secondly, it is theraix-utically of 
value Irtit^use it cstablislies a rca<ly escape to the aociunulalwl 
pus; and, lastly, in dmmiu ca«fl it can be easily enlarged for the 
purpose of a radical operation. 

Prognosis. — ^Tlie majority of cases of acute binanntiation 
heal s|>ontaneoiisly in the course of a few days or we*k«. Tran- 
ation into a chronic condition is relatively rare. It has already 
been pointed out that com plications are here more frequent 
than in disease of the maxillary cavity. Lon£-etandin£ and 
obdurate chronic suppuration can only be cured by means of 
a radical operation. 

Treatment. — (a) In acute inflammation, as in acute rhinitis, 
8J^nptonlatic treatment ia »uiBcient (sec p. 72). In cases of 
persistent secrt^tion a <lessertspoonful of a sokition of iodide of 
ptjtassiuni i) : 200 given mtemally twice or thrice daily will 
|je found useful; and in severe headache hot fomentations will 
prove very licnefieial. In time, aspiration or the rescelion of 
the anterior end of the niJdille cfmcha will start the pus flowing. 
In very serious cases the sinus must be opened from in front, 
as flescribed above (p. HO). 

(i) Chronic SiniD^iiiK. — ^In milder canw wc can secure the 
permanent exit of the secretion by resecting the swollen parts of 
the mucous membrane in the anterior portion of the middle 
mealAls, es|>ecially by cutting an-ay the oijerculum of (lie middle 
concha or an excessive bulla ethinoi<ialia or existing pol>'pi. 
Sometimes the oiiening of the anterior ethmoidal cells wll be 
refniipc*!; and this is done with a suitably bent pair of (hun- 
rmld's revolving nasal forceps fwe Fig. (iO). 

By this method pain Ig instanlly relieved and secretion di- 
minished; eventually, reflection of the operculum has to follow, 
and a onall catheter is tbeii introduced into the sinus, in order 


to wash out the frontal cavity regularly; in the eame way aa ia 
(lone in maxillary suppurntion. 

If by tins tTeatiiifiit tlip tiiaease ia improved, we have no 
excuse to abandon it. But if the patient, on account of the 
prolonged anti troublesome manipulations, becomes Boraewhat 
ini[mtient and nervous, and if he demands to be spewiily 
lilteraliod from his troubles, or if this intranasal treatment fails 
on account of the discharge remaining foetifl, or on account of 
complications and acute exacerbations, we must resort to oper- 
ative treatment, viz., to open the frontal sinus sufHciently 
freely for the purpose of inducing atrophy (occlusion) after the 
removal of the discaseil nmcou« mcnd>raiic. Ttiere exist many 


Rg. 60, — Gmnwald'a rotatoiy ua«nl furwps. 

methotls of o|)eration whitTh aim at the resection of either the 
anterior or lower portion of the frontal wall, or of Ixith of tliein, 
in onler to aft^-rwarxU clraui, either ihnmgh llu' luxse or directly 
outwards. By otlier methoda a flap of hone and pi>riosteum 
is formed which, aft^T the curetting of the .linus and etlimoitlal 
cells, mast be replanted. 

By KiUian'e radical operation the frontal cavity is mB<le into 
one single flat groove by cutting away al! the sejita and partition*!, 
and overhanging or olwlructidg part.-*. T!ii.s demand, indisiien- 
sahle a« it in froiti the mirgiral point of view, is fulfilletl by sac- 
rificing the anterior and lower portion of the frontal sinus and 
by tlie nwcctioii of thi: frontul proe-i-ss of ihi' upjxT nmxillar)* 
bone. In order to avoid a lati-r .^inking-iii of tlie foreheatl and 


DtsGAaGs or Tua nosi:. 

Uu! coiisequeot iJiffigiirempnt, the upjxr margin of the orbit 
is left ii.s a Hiiiall britlgv of hone.* 

Iq deep radical sinus ojicrations, the cosmetic effect leaves 
mudi to Ite ilesarai, but we possess in the injection of paraffin 
a means of inii>roving a later consequent depression of the fore- 
head. Some nutliors, however, deJiy the value of Uipki- injeo- 
tione because the paraffin in lime becomes absorbed or altered. 
In order to avoid any dt-jiresfion whatever of the foreliead, 
Rilier has proposed to always oi)en the frontal sinus from the 
orbit, and to make only a small o|)ening in the outer farial waJl, 
at a point correiiponding to the highest point of the cavity. 
Tlie sinuK is then scrajjwl t)ut with a suitably curved stroop. 

Various writers liave [K)iiili?d out that atrophy (occlusion) of 
the frontal cavity '» not necessary for the establishment of a per- 
manent cure, and that less nulical operations can claim the 
same f^uod result. Indeed, m not a few eases operation, after 
Luc-Ogi<ton, may prove sufficient, and the forehead keep its 
nonna! confiifuration, as follows: A cut is made along the inner 
third of the orbital margin; the periosteum is pushet! towarda 
the fortrhead and orbit; the frontal sinu*; for alxiul 1 cm. (or a 
little more) in diameter, w o]^ned a little laterally from the 
middle line; tJie oiH-niag is then followed by a tlionnigli enlarge- 
ment of the nasofrontal <luct, and the oixriiiig of all the aiit^-rior 
ethmoidal cells ivhieh may lay in front of it, by niean.s of the 
i^arp scoop. Having thus established a fn?e conmiunication 
betwwn the frontal and nai=at cavities, a drainHK<^1ul>e or tam- 
pon is put into the nose from the fronlui sliuis, aiid the external 
wound closed. The dressing may be left in situ for eight days. 


Etiology. — As to tlie cause, we again refer the reader to what 
we have alresuly said in the jfeneral section of this chapter. 

Pathology.— Tlie pathological changes also reficet generally 
the conditions relate*! in the general section. 

It should Iw noted that, owing to the greater dcstructibility 

• For furiliiT ilclails sw Arrliiv filr Lnri-nuoloKic, 1902. vol. Jtii. and 
V«ifaMi(Uunerii slkcJilfUlndier Ltu-yiigolugco, IWH. 

of tlie mucou!] itiembrane, the Ijony imrts of the frontal cavity 
ar<' liable to become involved early in the attack, so that hyper- 
pluAlic ami alroplik procetees, and, more rarely, necropie, are 
n'liitively soon encoimtered. It is also remarkable how easily 
thr imicous membrane, owinK to ita loose structure, can hecome 
swollen by ijedematous infiltration, which is the mo&t comnion 
cause of the growth of [jolypL Hence the almost regular oc- 
currence of |K]lypi in Iht^ longer standing case» of inflanimatiou 
of the inueous menil>i"an« i>f the I'lhmnidal sinuses. Intlaninia- 
tion and ocdernatoiis infiltnition of the elhtnuiilal raueoiw 
nicrabr&ne, however, are not always due to an irritKtion caused 
by «ccrelion of an accessory cAvity Jlowing over it, as there 
an- many othnr causoji. The presenfte of imsal mucous jiolypi, 
thcn-fon-, ijften, hut nut alwayw, iinlicates a aupitiu-atiun in 
the accessorj' cavities. 

Tbrre are certainly cases where at no lime an acceesoiy 
suppuration could be discovered; this nieaiLs that th« fornifr- 
tion of polypi i» the outcome of a general inflammation of t]ie 
nasjil mucous membrane (rhinitis hyjx'rtnjphittt) {nee p. 75). 
In the latter case the fjolypi are not quite 80 numerous, but, 
as if to make up for the sniailer nunilRT, arc of larger size ami 
show little inclination to recur after removal. On the other 
hand, in .fuppuration of the acceR.sor>' eavitie-i the app<*Ariuicc 
of n gn-at ina.s.s of muuII (ir the Kinall(vst [)oIy|>i, with a Rn-jvt 
disposition to recur, in conspicuous. B<-twwn th('f<e numerous 
polypi pu$ h stoutlily oozing, when')i.s in non-suppurative or 
Bunple polypi piw is scanty or entirely absent. 

One .Kinple oell alone may be afTeeted at one time, or the 
hyiXTtrophiwl middle concha itself, or the bulla elhmoididis; 
less (iftrn the ant<^rio^ and weliloTn, .'M^TntnKly, Ihe poflerior 
cells limy lieconie affectwl. In some unique cases the entire 
ethtuoi<lal labyrinth miRht be ooncenied. 

Sjfmptoms.— In intlammalion of the ethmoidal cella, c?ix'eially 
in the ehriHitc form, lite .subjcrlive sj-uiptornK an; little rimrkiHl. 
On examination one will somi'tiincs (ind (endrniess over the 
foot of tlip nose, and ix'-rhnjis, in lonj^-standiiig di-tcAine, some 

In Mii|i|iuratiou of ihe [MiKterior cellis, but ako in that of ihe 

aiitrrior, if the pus has lo make its rscttpc backwanis because of 
the bJwking uf the antcridr piLsyajit-. Ihe signs of the naao- 
phanngeal cmnrrh, kept up by constant irritation by pumlrat 
secretions, are prevalent; and that i.s why wc iJioiild be aJwaja 
on the lookout for suppiiratitui of an Acw'fisory cavity in every 
CIIS4' of naso-phar\-iigfttl cat«rrli. 

Diagnosis.— The diagnosis tiejiends. of course, on the rhinDsco}MC 
resuilt*, and, aa regards this latter, it is often erroneous, especi- 
ally if then? be laleut suppuration or if the pus is shut in, e. g., 
Ijecauae it cannot esea]»o luid jK»rhai>s pniduees distention of 
the bony wails only (mu«oeelp, empyema). On the other 
haiiii, it is just in caws of retained pyppuration that wo arc 
able to find pigne, which unmistakably iwint in a certain direc- 
tion; e. g., dislocation of the eyeball, swelling at the inner 
orbital angle, etc. 

In open suppuration, where pus h discharged into the nasal 
cavity, we must notice^ from which part or section of the 
nasal cavity the pus is deriveii. If pus shows tt«elf in the 
middle meatus, when suppuration of the maxillary or frontal 
suiufi can lie Gxeluded, then disease of the anterior ethmoidal 
cells can be assumeil, though we must not be afraid to mention 
that suppuration of the frontal sinus is often combined with 
anterior ethmoidal suppuration. 

We have now to dctermino exactly the focus of origin of the 
pus. This can Ircst ijc done by probing. If the niidille concha 
is found to be swollen, britllii, (x-ndcr, or even nmgli ; and if the 
probe, on pushing gently, readily sinks in at this spot, causing 
pus to emerge; and if, in atldition, jwlypi are met with, Uie 
diagnosis cannot be doubtful. 

It shoidd be renieiTilien'd that the iineven-eilgeil, thin, and 
liritlle walls of the etlmioid bone itii|i:irt alsti, utidiT normal 
circimistances, especially on somewhat forced jintbing, the 
sensation as of crude bone. A markedly distended bulla 
ethmoirfalUi &\so, in combination with an atrophic rhinitis in the 
inferior meatus, will din-ct our altfiition to a pO!*.sil)le chronic 
suppuration of the ethmoidal cells. It i« sometime« only necwi- 
sary to lift the mid<lle concha somewhat in order to at once 
see the pus flowing out. In some cases polypi or jmrt of the 


middle concha must be removed in order to clear the field; 
and this will also prove of valup, as thcrt-liy tlii; nion- are 
the abscesses opened. It often happens that, tiii reniijviiig a 
polypua with the snare, Uie osseous matrix is abro torn away, 
and when the imprisoned pus commences to flaw, then we 
know that wo have opened a cave of suppurative diseBso, 
Scabs on the niidtile iconeha should be removal with foreeps, 
and if pus oozes out, we wiU probably find its site of origin 
with the probe. 

Sounding the normal typical opening of Ihc anterior eth- 
moidal cells, in the hiatus semilunaris, only suei-cedi^ in ran- 
cases (Ilajek). If the secretion shows itself in tin- rima olfac- 
toria. that is, mesiaUy from the middle roncha, or in the hinder 
part of the nose or in the |)ostnasal s])a(v, then we have to deal 
with an afTection of the jmsterior etkvioidal ceih or of fhe uphennitlal 
cavity or of hath of them. 

By removing a pan of or the eiitire miditle nonelia we are 
enabled to follow up the pus to it* origin. We should not for- 
get, however, that [Jus foimtl in the pOHtrasal space may. under 
certain conditions (see p. 13o), come from the anterior cavities. 

In some cases the method of aspiration will show us whether 
the pits ts derived froin the anterior or posterior section of 
the ethmoidal labyrinlli. 

Prognosis. — This dejx^nds on the complications or not of other 

Bursting into the orbit or even into the cranial ea\ity may 
take pliice in the acute and ehronie stApre. 

Treatment. — The intranasal opening of the e*'lls is the rule; 
and only in exceptional cases, where complications of other 
organs require it (fistula or abscess of orbit or brain, etc.), or 
if the intranasal treatment Is inatlmiswble, \a the labyrinth to 
be opened from the outside. 

In combined disease Cfmntal and ethmoidal suppuration) 
A'i7/iVi«'^ tiii'thiKl of nulical oijcrstion should be adopted. Olher- 
wi«- 1 lie labyrinth can be opened from the orbit after the method 
of Kuhnt or Griinwald. 

(irummld nmkes an incision immediately below the eyel)row, 
and, beginning at the iiiidiUe of it, carries the cut eircularly 



towards the root of the oose; tJiciice he turns downwards to 
the middle of ihi' nasal Ixmc. The ^•up^l-orhita! nervi' *iiou!d 
be mved or paslied a*klc. 'J'he whole Hap,, oontainmg nk'in 
fljid periosleuni, is now puslied downwards with a ras]j(itory, 
thus lajnng free the inner orbital wall. Ileneo, frfan below, 
an<I as imirh as ijos^ble away froiu the region r>f Uie lachiynial 
Iwne, the labyrintli is penetrated by niearw of liic chisel. Ktthnt 
operates in a similar way. 

The intranasal opening of euppurating cells is fn>qupnny 
Uic same as we liave ad\'i8ed for the puri)Ose of securing a diag- 

Ffc 61. — Bajtk'g iiwtntmcnl* ivt ayvn'mn and Rcnipin^ out the elhmdilttl 


nosis (removing of polypi, reseetion of middle concha and of 
the bulbi elhmoithtlis). In ioealiiswl sxippumlion, these measures 
are quite sufheient to establish a permanent cure. 

In other eases the walls are broken by means of //ojM-'s 
hooks (Tig. 01). the 0[^>enings enlargeil witli \»mv forwps, and 
the cavity 8cra|ied out with a sharp sroop. 

Tlipse manipulations nuuit, of course, be very carefully done, 
berauite of tlie thinnoNii of tlie os planum (lamina impymcea). 
The posterior cp1I« can only !>e reaphed after remonng the 
middle concha. Ilaeninrrhage is not cunsideraUe, and plugging 
is nearly always uiigierfluous. 



tTnfortiuiutfly, tho intlftuasal man ipulal ions have to be often 
repeateU, antl treatment, which is even coutinuctl for months, 
affords only amelioration, but no pcrmaiiccit cure, because 
we do not succeed by them in removing the eutirc mucous 
membrane lining the ethnioitlal cells. 

Whether in such cases an opening from the outside will finally 
be required, depends much on the anatomical comiitions, and 
chiefly on the jMitient himself fserioUBnesa of syraptoms, defor- 
mities of the nose, consequent tUsfiguromeat, cte.). 


Etiology and Pathology.— Is mainly of the same nature aa 
in iiiHanirnation of tlu- pi^terior otJimoidal celb^ which arc very 
often in direct comnuuiication witli the «i)heboiilal cavity, 

Symptoms.— The syniptmns itiiinlly give littii'; rjiuw for Mpt-rial 
consideration : the subjci-tive ones, brctausc they arr little cliarac- 
teristic save for a dull pain in the back or top of the heatl ; Uie 
objective ones, because they resemble altop-thi-rtluwe discussed 
m inflammation of the posterior ethmoidal tuAU. As in the latter, 
the usual scanty secretion flows down into tlte postniuaU cavity, 
tiicrc to dr}'_up and fonn scabs (retronasal catarrh). 

1110 special clinical rank which the sphenoidal sinus holds 
is in a great measure due to its relation to iniporlant structurca 
in its neighbourhood, viz., base of the brain, optic and oculfe* 
motor ner^'CK, cavernous sinufi, internal carotid artcr>', <!tc. 
Destruction of the walls of a large sphenoidul cavity it* apt to wrious complications, such aa meningitis, thrrmilKisis of 
the cavernous ainu«, wrt^bral alj.tces«, amblyopia or aniauroNis, 
Optic neuritifi, [paralysis of ocular niUMcIex, etc., or even ccn-hral 
apoplexy, ami Miniethnes, indin^tl, tlie pus may uveji hunit into 
the elhinoiflal labyrinth or maxillar}' sinus. 

Diagnosis. — The diagnoHis tiiust dejwnd only on the rhinoMcopic 
results, for ilic subjective symptoms are far too uncertain. 
The discharge from the sphenoidal ainus appears correspondingly 
to the position of its ostium, respectively, in \iic oljaelory chink, 
having run over the middle concha, or in the nasophart/nff&U 



\\ ith anterior rhinosenpy we Kuccewi only wh«i the Daeal 
cavity is widp, as tliR olfa^ton- rhiiik, IwiriR Inrgc, it 15 poseible 
to see tlie jLntcrior wall of Ihft s|>ln'nuidal sinus with its ostium, 
wtii thft pus oozing from it. liventually aii apiiaratus for 
uiusjil aspiration inuy be UBOtl, or a probft or shihII catheter in- 
trocluctil after having previously cleatusca the nose. If fresh 
pas comes tlimn soon after the chink ha-s Ix'i-ii cleared of pus, a 
siippuralion of the sphcnoiiJal sinus is probable. We then 
have sliU to prove whether tht- pib* i.^ derivetl from the sphenoidal 
or posterior ethnioidal sinus. Here tin- loiig-bladed si>c-euluui 
of Kiliian (inidcile rhinoscopy) renders good service, for by its 
introduction we are cnablwl to o|x'n the rinia olfactoria so wide 
that the sphenoidal otstiuni becomes viable. Othentisc it would 
be neceeaary to resect the nii<!dlc con dm in order to follow up 
tlie pu.s to its origin. It is & good thing to tcm[»orarily plug 
the sphenoidal ostium, i^r if thi« caiuu)M>i' found, the reci-ssus 
sphpniw'tlimoidalis. If. aiti-iwiLrds, jnis collects in front and 
beliind the plug, a oornbiiied .-stippu ration must l)e presejit, i. e., 
of the sphenoidal and po^lpnor ethmoidal sinus. 

If we do not succeed by any of these metliocU in observing 
directly the outflow of the pusi, the sjihenoitkl sinus must l>e 
sounded or wa^ed out, which must al»o lie done if the ostium 
is visible. (See I-'ig, 62.) 

Tlie path from the anterior opening of the none to the ajjhe- 
noidal sinus is marked by a line which papses from the anterior 
nasal spine l)ack^vartls over (hi middle of Ihe iotccr margin cf 
the middle turbinal. By gently piitshinK the protw in this 
direction between the ftcptuin and the middle turbinal back- 
waiils and upwards, (he anterior wall of the sinus is reached. 
The bhmt pouit of the jirolie nuLst be curvrrl downwards and 
outwards, for it will the more easily succeed in finding the ostium 
by this little contrivance, and also avoids the thin lamina crib- 
rosa. In any case, great care must be taken not to pu.<h the 
probe upwaids too nmch in front of the free maripv of the lurbiiuil, 
because then- will In; tlie danger here of penetrating the lamina 
eribrosa and entering tlie cranial cavity. If the probe has ad- 
vanced in the indicated ilirection for ~i to Si cm., it might be 
assuineil that the pcjinl lies in the sphenoidal ainua. 


By anterior riiinogcopy, the seconUarj- changps of the nasal 
mucous menibranp can t* noticed. Polypi are very Tare in 
sphenoidal suppuration. Hut frcN^uently the nafal niucoa'* 
membrane of the mesial face of the middle turhinal and opimsijig 
septum is sH'ollen, and in advance<l stages i^ows atrophy and 

Posterior rhmoscopy always shows scabs on the roof of the 




tJfii ft 


/.., ■'^ ■ 




F!g. B3. — Prohntory examinaticn at the sph^noirlal einus: c.i., Conpha 
loTerior: t. m., eancba media: f. *-, concha HUperiar; n. «. ph., siihenoiiial 
mtitim: ». t., Mclla tiin'ii'.<t; «. /., friiutal HiiiiiH; n. »fih., Hiihpiii>iiln) kiiivih. I'Iil- 
blark line shows th<- rielU iiiMitinn of the prubt-, (i; tin- diillr^l lititvt I, 2, ^, 
4, tfa« wrong dircclioiui (aTtct llajek). 

iia!>o-i)haryiix, and farther down, on the jKislorior wall of the 
]>barynx. It Ja (jomctimes |X)S8ibIe to see in the mirror the out- 
flow of pus from tlip sinus. SeaKt are also met with in the now, 
AA has l«'pn already nirrdiimrd, jiiid tlir fin-lid Mrirll fnmi 
scabs, in conjunction with thi- udvimeing uti-ophy of tJie niuruus 


l)l8KASf:S or TIIK N06B. 

uienibrane. account* for tJie complex syniptomB, mtixwtlvcly, 
of rhiniiiK luid of a rhino-pharyngitis atmpliica foetida. 

Prognosis.— The progiioBw is not unfavourable, but is mucli 
iti(]ufiict>Ll by tJic difliculties of diagnosis and treauiipjit iiiwl 
wilJi and by the frequent seriou.-! con i plications. 

Trftatment.— (o) lu acute iiillarniimlion of tho uphenoidal 
ainue treatnient is like that in acute inflammation of any other 
cavity—f xpeciaTit and syinptouitttic. In some cases the method 
of aspiration sliould be tried. In othrr case*, should the com- 
plamta continue with unahatnl insisli-ncc on the part of the 
patipnt, or should coniplicatiorw become ineiiacing, then the 
sinuM must Ijc opcrie.1 from in frrHit. 

(h) In chroDir anusitls th4' Invst thing to do is to make a 
path for the free escajK* of the secretion by the nwection of the 
middle concha, uidess tliis haj* alrw^ly Imh-h done for diagnostic 
pur]x>sc«. or by thf removal of any jxilypi, or by the method 
of aspiration. The foroj^oing procinlun* will relieve the patient 
80 much Oiat any jiirtfier me<ixure'< 'irc ojten iintteressary. Whon- 
ever it is po-ssihlc, wasliing ciul sliouM be perronncd through the 
natural ojK-ning. In some caees it will become ncceswry to 
enlarge the sphenoidal o.>*tiura, which may be done by pulling 
with fiUfijek's hook at the lowpr edge of the oi»eningdownwanls 
and forwards. The hook must be intro<luced with thv [^xiinl 
tunnii backwards and domiwards, eo a.s not to endanger the 
lamina papyracea. Having rendered the ca\ity more aoej^ssible, 
it shoulii be lightly packetl for a week or so, in onlor In prevent 
recIosun> of tlie o|Miing, and the edges of the ostiimi sliouki be 
cauterized afterwards with trichloracetic aeid. Keeping the 
opening jjatent is often more difficult than the making of an 
opening into the ninuF in the first place. The secretion often 
diminiwlies by this procedure, and aiwunies a more mucoid charac- 
ter, but hardly ever cieases entirely. 

In more severe cases one haw to determine on more radical 
treatment, viz., resection of the intennediary wall of the posterior 
ethnn>-8phenoidal cells (Hajek). 

Hajek's hook, io the manner de-scribed above, is introduced into 
the olfactory chink, and is pushed upwards towanls the upjwr 
part of the anterior wall of the sphenoidal sinus. Then, liy tuniing 



the hook outwanls, the Lnnpr wall of the pthmoi{iKl siniisj is 
caught, and lli« luwer |)art of the inner wall, togolhcr with Ihe 
mi<ldlo conclia altachod to it. is tora away by a f^wA pull. 
The broken part*? are removed with suitable forceps, and the 
baemorrhaK« stopped with nfwab^. Thus the anterior wall of 
the sphenoidal sinits is laid open in iti? whole length. Now, the 
aphenoidal ostium can be eniargeil by the hook, and the whole 
anterior wall can he removed by way of the ostium by means of 
!s'oebeL's punch force|is (rreently modified by ilajek), eutting 
upwards and downwanls f Fig. G3). 
The cavity is packet! daily, and the granulating edges of tlie 


Fig. 63. — Re^-olving punch fonwpn far rcMv^tJng anterior wall of iphonoiclAl 

til 111 N. 

opening ditjktiy eaiitiTijscd with lapia inffmalis or trichloracetic 

The caulerizatioii can he continued eveij" six or eight days 
until till' iiiargins apiK-ar llmroii^hly t-icalrized. At the time 
of cauUrrizatiun Ihe sinus may be inspected, and all suspicious 
matter scooiieil out — care must be taken not to endanger the 
upper ami lateral wullg. 

By keeping Ihe si.nus o^ien in this way, the affected mucous 
membrane may be healed up. or at least jnit into good condition. 

If the sinusitis is combined with empyema of the frontal sinus, 
the radical operation (after Ki//i'arj) (seep. 151) can b»' jirrfonncd. 






Beffldes the polypi, which, strictly ^jK-aking. arp not ncw- 
giowths, but the prmlucts of inllfuiiniation, tlu- tunioura which 
we now have unilcr our consiileration are cysta. They often 
occur in great nuniljciv, and fn^quenlly in astwciatioD with 
inflamiualioii of the cavitit-s; but appwir also indejjemiently of 
infiainniation; at It-ast, there arc many cases on recortl where 
inflaniiualion could never bo discoverei.1, or was already abated, 
long fM-fort' the appearance of ihc cyst. Sometimes the maxil- 
lary cavity is entirely occupied by one single large cyst. 

They form tmnslucent, yellowish or whitish, sometimes 
pedunculated tumours, of spherical or hemispherical Khajje. 
They contain a serous or more or less viscous fluid, many ceLular 
cleiiients, and detrilu-s. 

The condition, known as hydrojB of the antrum of Hujhmore, 
viz., the fre(5 a^cuimilatioti of scrou-s fluid in the inaxillari" 
siiiu-s, i.f pnilmbly always due to cystic foniiatinn, if not idi-ntical 
willi it. 

In the frontal sinu."* hydrops and tiuicoc4)ele liavc Wen repeat- 
edly observpti, more rarely, cystx. It liaKhapp-ned ihai eyslic- 
ally (legeiieratetl anterior ellunuidal cells grew iiiln the friintal 
sinus. The maTilUmf or denM cynt niuat not be confoundetl 
with the true cystf<,of the mwcous nieinbraJie. Tliey are mostly 
conpetiital cysts, which, if \mchecked in their growth, puah the 
bony wall forwards, either towards the mouth or towards the 
face. In the latter ca.'*c the facial wall might become so thin 
that it shows signs of parchment crackluig, or the cyst bursts 
through into the canine fossa. 

Symptoms.— ^The symptoms are little marked. If a large 
ajKt his burst, a larije quantity oj serous fluid might he discharged 
from the 

Diagnosis. — Diagnosis offers some difficulties in making a 
distinction between empyema, nuicoue cysts of the membrane, 
and alveolar ('maxillRr\') cysls. The formation of a fistula in 
the canine fossa jiouita rather to maxUlaiy cya\ than to empyema 

N'EW-GROWTH». 103 

of the sinus; so also cLoes btilgiiif; of the facial wall. In tlie 
latter case one !»hoiiIU not overlook a possible nialijB;nant tumour. 
Wc must make sure that the simis is miifieiently ojx'noLl. 

Hydnifrt and mucocoele of the frontal sinus fref|uently ex- 
pftiitl towaixis Uie. orbit, tlisplacing ami dislocating the globe, 
as dot's al^it ciiiiiyeiiia of the frontaJ sinus. 

Treatment. — If tlie cysts give rise to scxious fi>'iiiptoms, 
tliey must be wnioveil by a. free opening from the outadc. 

To the beniffti tuinnurs belong also the ost^'omata, which 
orij^natf pn-fcraMy in the frontal sinus, but occur also in other 

They p-ow very slowly, an<l if of larger sixe, displace the 
neighbouring organs (eye, et«.). I'suflUy they exist unthout 
s)-rnjiIonis, and are not noticed until they have already attained 
eonsiderable size. They are then easily rocognizc<l by their 
hardnoHs anti lumpy surface. Treatment ean only consist in 
their removal, whieh is not always an easy inatlcr. Occasioti- 
ally fibroniata, ]>apilloroata, and aiigcioniata are found in the 
accessorj- cavities. 


TTie maxiUary and frontal sinus art^ the scat of predilection. 
It is doubtful whether the sinus is always the primary «eal of 
the tumor, for it often comes stj late lo the notice of the physi- 
cian that the question cannot be decided. 1 niys-lf rcmt'inber 
a case of fiarcoma of the maxillary sinus the origin of whieli 
could bo traced into the basis eranii. In some cases not the 
antrum, but the body of the upper maxillarj' bone, is the origin 
of the new-growth (mostly periosteal sarcoma). 

At the beginning, little will I* noticed, and the paliente often 
complain only of nfuralgia in the face or teeth or forehead. 
After a time, when tlie tumour has prown ami Ihen-by dcjitmyeci 
the respective nerves, anaesthesia will Ix' confipieuous. which, 
taken in connection with the previous neuralgic pain, iwrvex to 
direct our siispicion to a neoplasm (Killian). If, now, an ex- 
ploratory pimeture is negative, and, on the other hand, tranwl- 
lumination gives a positive result, doubt will become certainty. 
Lat<'r on, the new-growth breaks down an<l causes a terribly 



foetid suppuration, aiul Uic fonnatioii of polypi in the nose, 
bcliimi which ran be fi-H tin- fn-^-ly hlfediug luinour, 

InothtToLsi-jiiihffaeial wall is Imlgi'ii forwards or burst through, 
or llietuniour grows ihrtiugli ttiehard ptilak',ortowanU the orbit, 
displacing tlie eye ur the nose towards the healthy aide f^'irog 

In Bonic cases the nature of the growth can only be ascer- 
tained by microscopic examination of particles excised for 
this purpose or dificluirgcd »puntaiitx)usly from llic noi^. 

Prognosis. — The prtignoMJs is ainiiwt always bad. 

Treatment, — If It. can be of any avail, early removal m the 
only po^ible reaource. 


The maxillary and frontal iiiiiuso--=, whioh arc more exposed, 
are accordingly oftfncr_ injure*! tluiii Uie ethmoidal and sphe- 
noidal cavities. If the bony walls have met willi an accid«it, 
haeniorrliage often occurs into the cavity and is a fertile soil 
for all sort.'? of pathogenic bacteria, resulting in abscess, suppura- 
tion, fistula, and necroas. Sometime.^ an emphysema, under 
the skin of the forehead, eyelid, or check, occurs aft^r blowing 
the nose, if the bones have been fractured by accident. 

Treatment. — The treatment follows the general rules of 


Foreign bodies reach an accessory cavity by accident or by 
the fault of the surgeon. All wirt* of foreign boilie« have been 
founil, n\ich tui bullets, broken knife-blades, brtjken teetii, wplin- 
tprs, drainagfvtuIx'K, tampons, gauze, U;'nt'i, broken iunlriuuent*i, 
etc. Tliey mostly c-ause suppurative inflammation, or do not 
allow an existing inflammation to recover. 

Diagnosis.— The diagnogis must rely on the history of the 
case, examination by probe, and eventually by jr-rays. 

Tre^i7nent.—lf we have ascertained the presence of a foreign 
body, it is our duly to remove it by the natural opening, rither 



3y mpfljis of ftirrc'ps or hook or syringing, etc., otherwise Uie 
CHvity IjH opt-iieil hy o[»Talwu. 

Parasites.^Piirasiics, viz., womis aiid insects, have been 
found in the frontal wiitis, but only in corpses. 


Tuberculosis. — ^Tuberciilo.'us of an accessory cavity occurs 
still more rarrly than in tlie main cavity, and probably is npv^r 
priniar)', but mostly an affection which lias spread from a tulx'i^ 
cular process in the ■vicinity. Tubercle bacilli have sometimes 
been found in the pus of an empyema of the nntrum. 

Sjrp&ilis,— Syphilis of an aoccsaorj' cavity is likewiw, in the 
majority of pases^ to l>c traced to a syphilitic process in the 
ncighboiirhooil, as. for instance, tryphiiitic caries of th« vomer 
may i-iLsily wpn-ai! to tbc anterior wall of the sphenoidal cavity; 
but. it cannot be denietl thai, in the accessory cavities, syphilis 
niiglit also primarily appear especially as a pininiatous process. 
Thi-s, however. Iia-^ not yet been recorded. We certainly admit 
that ever)' suppuration of the antrum or frontal sinus in a syphi- 
litic person niui^t not ncceiivarily be considered as caused by tlie 


Diseases of the Mouth. 

Diseases of the Mouth. 



The oral cavity is ilivulctl iiilo two portions, the sniallcr lui- 
terior one, lying botwi>cn the lip», mucous mcinbrano of tlic clicrk. 
Olid Iccth, is culleJ the vefitibuluni oris,-^antl the larger portion 
is cnclosal, above, by the hard palate, Irt-himl by tlie wjft [jnlad.', 
below by th*' Hour of the mouth ami tlic tongue respcrtively, 
and is catlLni the oral cavity pro|i« (eaviun oriR). Both weiions 
comiimiiioate by a gap, which Ues between tlie last itiolar Iwth 
aiul the coronary prowsw of thr h)WPr jaw. 

The lips ore attachwl to the Kunis iu the median line by a fold 
of the mucoiw membrane (frenulum labii superioris et inferioris). 

TIk- tongue is fixetl Khiefly to the inner surfare of the ehin 
and tiJ the body (corpus) of the hyoid bono, and is in conjunction 
with the lowf^r jaw ht all directions by means of itt coat of nui- 
coas membrane. Onedi!«tiiij;i]i.«(hpK the jxiint or tip; tlio dorsum, 
divided by tin? median groove (suK;iLs mwliaiuw), intii two equal 
parts; the latx'ral bonlorH, and the rrx)t. which broadens at tlie 
bftHt towanis the epiglottis. Tlie tongue is eimneeted with 
the floor of the mouth by a fold of the mucouB mpmlsrane, (he 
frenulum linguae. Another fold of mucous membrane connects 
the middle of the r<x>t with the epiglottis, and is calleil the Uga- 
mCTitum gloaso-epiglotticum medium. At both sides of this 
foM are the vnllfTulac, which again are bordered laterally by 
the lateml glossti-epiRlottie ligament* (ligamenta glosso-epi- 

Tlie entire back of the tonpie aa f ar as the isthmus faucium 



is occupied by thp muiicrous organs of taste and touch, «. y., the 
small liliforin papilLae f|japillaf filifomies), intersiKTsed with 
the more fungifonii or conical |mpillae (papillae fimgifoniies), 
which Ipnd to the surface its |^-anular. villous appearance. The 
foregoing are Uinited behind by the large circunivallated {japiltaf? 
(papillao circunivallalae), which are from S to l.> in number, 
and are arrango<i in tlio tihape of a V, with the a]>ox backwards. 
Juist behind the point of this V the blind foranicn (foramen cae- 
cun]} i^ founil. Further back, towiinlj< the rpiglottir^, lies an 
accunmlalion of follicular glands which fiirm a part of the 
"lymphfltic ring " encircling the isUinius fauciuni. Knim their 
acinoiLs structure the glands are sometimes also catlal the 'Min- 
gual tonsils " (tonsilla lingimlis). 

On the lateral margins of the tongue, just in front of the an- 
terior palatine arch, an organ, mostly elpvat**d, flat, or grooved, 
of Iho size nf a lentil, is found, anti \vhieli is palM the foliated 
papillae (papilla fnUar-H}; it is an organ of la'ite. 

The MuscleB of the Mouth. — (a) A/uM-fcs cj the Lips. — ^Thc mus- 
cles w^ich forni the lips are either entirely a part of, or enter, or 
are only inserted into. them. The orbicuUris oris niiL^^cle is 
the sphincter of the mouth. Other niusrles dilate or open the 
oral fissure in iliRerent ways, thus contributing lai"gely to the 
iiiinietie action of the face. Tlie most iiniwrlant of tJiese is 
the huceinator. also called trumpeter muscle (lHiecinfliloriu.s), 
for its aetion of pressing air out of the mouth. The nia*»pter, 
temporal, external and internal pterj'goid muscles serve the 
aptiini of chewing. 

f(^) A/iwrW oj Die Floor cj the Mouth and of the Tonijiie. — 
The floor of the mouth is chiefly fornieii by the niylohyoideiis 
muscle, which expands like a fan between the two halves of the 
lower maxillary bone alwve. being attached below to the hyoid 
hone; the genio-hyoideus niusete. which lies in the middle hne 
between the chin and the hyoid lione; and the anterior head of 
the digtistrie niusele Im. biventer. sen dlgastricus). 

The miLSfles of the tongue are dividetl into two groups: The 
one group, tJie intrinsic lingual muscle, properly so palled, runs 
within the ImmIv of the tongue in longitudinal and trans^-erse 
biuiitles (m. Inngitudinak's et trails versales), and tlieir action is 



to modify the shape of the tooguc. Tlic other group, gcnio-hyo- 
gloasus, hyogloftsus, styloglatwiw iiiuwies, move tlie tongue as 
a whole. Botli grou|)a, by variously inten-rossinfj and by joint 
action, produce the adniirable mobility of the Umf^ue which may 
in some cases be of aji acrobatic character, so to .^peak. 

The mucous membratte is lineil with i^evcral kyer^ of Htratiiietl 
epithelium, and is contbiuous with the skin on the outer side 
of the lips; the Wder is deiinetl by a sharp Uno, ami tiiis lip- 
margiii is catlwl tlie"red of the lip.'Mjecause of its colour. Oii 
the hard palate and the dental alveoli, where it fonris the gum 
(gingiva), the mucous membrane is finnly attached to the peri- 
osteum and CAiinot tie folded. On the middle line of the hart! 
palate it forms a whitish ridge, called tlie mphi^; and on otlier 
places the mucoiis membrane is only loowly attached to the 
underlying structures. The mucous membrane of the tongue 
is thin, and is clotnely attached to it. At the side of the mcilian 
sulcus or median raphe, on one or lx)th sides, small invaginations 
of mucous membrane, like culs-dc-sac, are foimd, which, by 
anxious jHitientft, are sometimes looked upon an defects. 

The Glands. — ^I'here are ver*' niunerous mucous glands in the 
mouth, and the salivary glands, three in numtier. — the parotid, 
utibpiaxillary, and std}Iingual glands. — open into the cavity. 

The .submaxillary and .sublingunl gland.i are considered by 
some authors to be " mixed glands/' e. g., glands which produce 
mucus and saliva. 

Blan4in-N uhn'H glands arc foxmd at and beneath the tip of 
the tongvic, and open onto the fimbriated fold (plica timbriata}, 
and are stiil under »hMC\Ls.sion in rcxitcct to their secretion. 

The mouths uf the miicovx rilnndt can be seen an the surface 
m .small point.** of the size of a pin-h4'jul. and on the li[>s their 
acini are visible ihroiigh the niticous ineinbrane. 

The parotid (fiand liea hi front and below the ear, reaching 
down as far as the angle of the jaw. Its dnct (ductiw Stciu}- 
wimiijs— Stenonian duct) runt; forwards below the zygomatic proc- 
ess over the nia.swtcr, pierces the buccinat^ir muscle, and it[jeiis 
in the mouth opposite tlie uptjer second molar tooth. The place 
of its oponini; appears as a nuTuite dark point, often overhung 
by a little conical elevation. It can be sometimes recognized. 



only by moans of a verj' thin (hair) probe or by tho appearance 
of a jet of saliva. 

Tlie nubmaa-iilary glaiid Ucs on the suporiicial (eutancoiis) 
surface of the mylohyoid miwcle, between the lower jaw aiitl 
the (wo hprnls of the ilign-stric niuwdc; itn iluct (ductus Whar- 
it»ntafnis^Whartoniaii duct} runs, accomismicd by a lolie of 
the gland, over the deep surfaee of llio mylohyoid muscle in- 
wards and forwards, aiuS opens close on the side of Hngual frenu- 
lum on a little warl-Iike elevation called the sublingual caruncle 
(cariinculfi sublingualis). 

The sublingual gland lies on the (upper or deep surface) mylo- 
hyoid muscle, at the inner aide of tlie jaw, innnedintcly under 
the mucous membrane of the floor of the mouth. It consists 
of a conglomeration of glands, and semis a variable nnmljcr of 
ducts (ductus liWm'i—liimni's duel) ujiwanLs, whieh open either 
directly along llii- plirji suliUngiitiltK ov ji»in to fnriii UnrtfiniinV^ 
duct (ductiLs liarlliuliniani), togetluT willi the Ulmrtonian 
duct, or st'iwrately from the latter, on to the carujiclc. Soiiie- 
times the liartholinian duct is theconnnomluctof all the salivary 
glands below t he jaw. 

The Innsilin Unrjvalis is not a real gland. 

Blood-vessels.— The arteries are derived from the facial artery 
(arteria facialis submaxillaris externa), which also gives off 
branches to the check and Ups, llie externa! carotid al-^o nharea 
iix tlie blc>oil-supi>ly of the tongue; the tenipurnl and intomal 
maxillnry arteries, which latter supplies the twth with arterial 
blood (arleriae alvcolares). llie lingual artery from the external 
carotid (arleria liiigualis) supplies the root of the tongue and 
tlie floor of the mouth by gniall (muscular) brandies and enters 
tlie tongue a.s the deep lingual artery or ranine art-cry fiirteria 
pn)fuiiila linguae), and eotirsos tom-anU the tip of the tongue 
at tile side of the frenulum. 

The i*jH* empty into the anterior and pofterior facial veins, 
and partially into the internal jugidar vein. 

Lymph-vessels. — Tlie Mnphatic vesKels form dense plexuses 
in the Upw and tongue, and join witli tliosc of the pliarynx to 
fomi small eannliruli, which enter chiefly into the suhniaxillaiy, 
cervical, and jugular lym[)lmtic glambi. 



Nerves. — Tin' vinti/r ritfntK arc ilfrivcd from Iho Iiypftglowus, 
vvliicli, niiiiiiiig jiloiig willi the lingual artery, supplies mainly 
tJif lingujil imisi'Ies. Tin* thin! (subtiiaadllary) tllvisiuii of the 
trigmiiiital iien-e SJid Ihe facial nurve also take part in the 
ner\'e-supply of the imuvcleH, 

'file sermrry ttenvs come from tlic Ungual nerve (tliird tlivision 
of fifth nerve). 

The sperifir nfr^va nf tnMe nre derivpd from the glosso-phaOT" 
gea! aiid lintrual nervt-s and from llie chorda tymponi (a liranch 
of the facial nerve running within the lingual), whidi supplies 
llic part not supplied by the glQ9eo-phar>'iigi'al nerve (point 
and marpn of the tonp:ue). 


The function of the oral cavity is of a threefold nature. At 
one time it forms the first part of the digestive tract, where, 
so to say, the first act of the digestion is played. The food 
is masticated aiid imliued with the sccrtrtion r)f the salivar>' 
glands, the saliva, the object of whirh is lo make the morsel 
slipjtery, anil to convert the .starch of the food iuto dextrin and 
sugar by tlie action of the ptyalii]. 

I*\irther, the mouth coiitaiii.^ thf chief organ of ta-ste. the 
txMigue, ami the ternuiiaticms of tlie iienes whicli serve the 
sense of t^ste, i. e., the taste-buds, which are, however, found 
not only on the point and margin of (he tongue and on the 
hinder part of its dorsum, but also on both sides of tlic soft palate, 
on the epiglottis, and inside the larynx. In children the entire 
dorsum of the tongue serves the wnse of taste. 

The bulk of the gustatory cups (ta-sle-burlsl are found on tlic 
papillae, and are most nmnerous in the walli-d-in i)npillac (jta^ 
pillae circurnvallalaeV On the point of the tongue are the 
fungiform, ami on the margin the foliated, papillae, tlie carriers 
of the tast^Miudw.. 

Of the gustatory nerves, the glowo-pharyngcal nerve supplies 
the root of the tongue and soft palate; the chorda tympani, 
derived from the facial, ami niniiing within the lingual nerve, 
supplies the point and inai^in. The taste-buds of the epiglottis 



and larynx are probably siipplinl by the vagus nerve (nervua 
vagus). Tilt! imths in wtiidi tlic iicrvci* of luatc run are veiy 
complex, beeaiLse of llie many ai^Lstonioses betwircui the glosso- 
phan-ngwil, trigeminal, and facial nerves, and which am subject 
to individual variation. Only thus can the niauy contradictory 
reports of tJic various nrumses be explainwl. 

The taatabie substjuiccs must come in contact with the 
gustatory ciiiw in order to act as adequate stimuli. We discern 
generally four kinib of taste: flour, sweet, bittor, anil saline, and 
all other sha.(lo.s of taste can bo made up from combinations of 
these. Nevrrtholc-'B, as has already been nicntional, smell 
has a great influence on the sense of tast*;. The various kinds 
of taste are, howi-ver, not [wreeived equally by all the gustatory 
cups; the various [lapillae, so to say, show special selection, and, 
indeed, sweet HuliRtances are better tasted by the point, and 
bitter subfttaiices betttT l>y the base, of the tongue. Mechanical 
and thermic stimulation are without influence on the or^fans 
of taste. C>n the other hand, one siwaks of a eo-called "electric 
taste, " which is jjerceiveti if an electric current flows through the 
tongue, viz., a perception of .loumesw on the anode and bilter- 
ncjw on the kathode (sharpness or alkalinity). The so-called 
after-taxte is to be explftineil by some particles of the sulwdAiice 
remaining on the tongue or papillae, especially on the circuinval- 
late [japillae. 

I-^astly, the mouth forms, together with the |)harynx, the reson- 
ator for articulate speech and singing- This resonator 19 altered 
in its shape by juuwular action, in i^articular by the tongue and 
soft palate, but alao by tlie lipe and cheekf:, and ia thus very 
important for the formation of sounds, vowels as well as con- 
sonants. It siTVCM also as a mouth-piece, motiifying the sounds 
suitably. In producing consonants, the nioulh-piece at one 
or other part is either shut or narrowed, and the passing of which 
by the expirated air produces a noise; here the mouth-piece 
actually fomis the soimrl. In lx>th groups, consonant and vowel 
speech, the soft palate is ilrawn up towanls the nasal caWty, 
which, however, is not completely diut off from the mouth; 
whereas in the production of the socalled nasal cousonaots or 



Bemi-vowde, m, n, and iig. flip soft palate hangs rlouTi flaccidly, 
BO that the air-co!uiuii in the nasal rsvity vibrato*; alw). 

Zamiko points out that all sounds of speech can be produced 
Trith jMirffct purity, even in ineoinjdete closure of the palatine 
velum, i. e., with naaal resonance. As the use of nasal reson- 
ance affords the greatest. eff<'ct with the least effort, he maintains 
that speaking and singing with the palatine veil coixespondingly 
opened is the only natural and ititentional way. Accoitling to 
M. Schmidt, a complcto closure is necessary for the production 
of pure vowels, 

Tho niochanisni of swallowing, which only takps placo in tlip 
mouth in a r^inall mea-surp, will be discussed ia the chapter on 
the Physiology of the Pharynx. 


A. Method o( Examination.— In the examination of a pa- 
tients mouth the first thing is insix-ction. In the peconil place 
comes palpation and the detection of any imnatural odour, and 
in many cases the examination must lie completed by chemical 
an'_l microscopic testa of the secrelions and morbid tissues, and 
by a correct estimation of the patient's sen)* of taste. 

^\e (lirectly in.spect the cavity by either natural or arti6cial 
light. Tlie latter is jxrhaps preferable, and we throw it into 
the month by means of a reflector, using a spatula or tongue 
deprpflsor for the purpose of keeping down the tongue and push- 
ing away the cheek, In order to inspect the floor of the mouth 
and uncirr surface of the tongue the patimt is directed to open 
the mouth widely and to put the point of the tongue on the 
upper teeth. Slioultl the patiftnt \yo. too inex]X^rt, or the tongue 
Ik too short and thirk. (he point eaji 1m' si-izcd with a clean 
cloth and held in llie position n-tjiiired. The hinder jmrl of the 
back of the tongue is best viewed by means of a throat- mirror. 

Palpation with the finger steps in, or completes inxpeetion 
where wo are not able to set?, anil if we desire to awertain the 
consistence or dimensions of c-i-rtain parts, i. e., tinnour, foreign 
bodio8, etc. If possible, pal])Hlion should be biinanual — one 
finger outa<lo and the other inside. 

^\'e examine the sense of taste in sucli a ^'ay that a HnioU 



(D tXlLIHS? 


quautity of iw^tablo matter in solution is brought into contact 
with thp tonguo. 

B, The Course of Examination. — It is important to inquire 
as to the historj' or anamnesis of the «ise, and as to thcsul^jcctlvc 
symptoms. With respect to the arwin miosis, v.t can refer to 
what we have xaiil previously in regani to the nose. 

The patient may rejxjrt and complain of trouble in speech, 
respiration, swallowing, and jierhaps secretion, and also ol dis- 
onlers of serisihility and taste. 

Di^vrders of -S;x(«'A.— Artieulation may be affected by reason 
of inflanmialory processes, tumours, and paralj'sis in the region 
of the mouth (|xrriphorai), but al.=o through ditseasc of the central 
nervous sj'sleni, e. g., disweminated sclerosis, progresbivc raus- 
eiilar atrophy O'ulbar iwralysit*), etc. Speaking apijoars diffi- 
cult, and the K]»eech itself miglit apiwar heavy, clunisj-, inartic- 
uUlcil, indi:'tiiiet, iiitcrnipttHi, or retanled. 

li-isimhT.t (ij (he TC^piration are seldom due to pathological 
proe^'sscK of the cavity of the mouUi, and are only prochieed by 
excessive s\velliiig of parts at or alwiiit the entranee of the larjTix. 

Su-uUmrinij is soinetiiiies dilliciilt in various aeutr inflainnia- 
lory proeosses of the nmeous nieinbrane, in partieuiar of the 
tongue and saUvarj- glands. Indeed, it might be so severe that 
eating is almost impo.'sihle. 

Anomalies of the Secretion.— /n(Tc«.i(:rf wtretion (li vfM:- )■,■<« liva- 
tioii, ptyntisni) asually aocoiiLptuiii'^ iuflitiii unit ion of the oral 
mucous nienibraiie. It is oftoii a symptom in certain forms of 
poisoning fnnTriinr-, iiHiiriP, pilocarpine, etc.). or oooitrsiiftrr par- 
taking of various spii-cs; or ll TdIIows the introduction of instru- 
ments for diagnostic or tIierR]jeutie purposes. In other eases 
it is a reflex symptom, due to divers irritations, a« from dyppopsia, 
intestinal parasites, pregnancy, emotion, and is also often ob- 
aerved in ner\*ous or hysterical persons. 

The panifytic salivation observed in biil})ar paralysis, paraly- 
sis agitiinH, imd varioui* psychoses is probably caused by the 
(•ceretinn being imcontrnlled, and in some of these the 
salivation is often |)eri<Klical. 

The diminiilinn nf the snh'T^ry secretion occurs after the 
taking of sulatanees (drugs) wliieii paralyze secretion, e. g., 




alropine, in Incomplptc or pomplcio ob^lruction of the akliTary 
dact.s by tumours in the vicinity, sitlivur)' cflleuli; in diKiaee 
causing specific deviation of body fluids, as in high fever, dia- 
betes, chronic Uright's disriisc;, onterilis, c-tc. Okl people and 
lieuraslhciii*^ liiid hyuteriofil (.terwoiis often complain of drynt^s 
of llur iiioulli {xcroHtoiiiia), ii consequence; of the diminislicd 

DvitmUr.-! of «pn,vi7/j7(Vy and /o.«te are often complained of, 
espcmlly by nervous patients, p. g., as of Buffering pain while 
speaking, smoking, or eating. Or there are eoru]j|aints of cer- 
tain iianu'slhesiae (tingling, burning, numbness, etc.), mostly 
at the ])oint of the tongue. 

Examination Ix-pju with tlie inpp(rction of the lips, which arc 
gently separated from each other; Iheji of the twth. gums, hard 
palalc {1h« head being well i-ecUned) ; furtlier, Iwjlh pockcti- tjc- 
tween the leeth and cheek and the cheek Itself, anti last, but 
not least, the tongue. At the same tmie any particular o<lor 
miLft he noticed. 

In the majority of cases fi-Ior ex ore can l>e explained by 
Cftrioiw teeth or ileeomposcd n-niains of the food between or 
in hollow teeth, or from tartar, ulceralions, and injuries, etc 
If one cannot find the cuusw of the I»a<l «mel] jo the mouth, the 
tciisil?i or Ihr nose must be exaniinwl. In a few cases bronchitis 
foetiila may \x- diwcovereil. 

On examinimj the tongue, attention siioukl l>c giveji to the 
color, which es.«entially di-|ienii3 on the staU- of hf-nlth. .Wer- 
tflin whether the dorsum of the tongue he rtrfj mwk furred, 
ps]»epia!]y if the hmder part appears while, yellow, or gni-nish. 
Tlie !«ha<le of the tongue is often influenn-i! by llii- food jNi-ssing 
over it: therefore it is always well T« inquia- concerning the foal, 
drinks, or ilrugs taken prior to the examination, in onler to avoid 

Some i^eople. such Hf smokers or drinkers, always have a 
furml tongue. This film ffur) conMsts mainly of niicroorgan- 
isina, epitheUal cells, and MhuB. The tongue also shows nor- 
mally much unevenness. If it is much furrowwl (sometimes a 
congenital abnormality), one .*!j)eaks of a lingua diswctata. On 
its margin the impressions of the teeth may ofteji be seen. On 



the olht-r liariil, cli'feias, trhangcs in the surface- hy .-icarn, by in- 
Hamiiiatory processeti, c. j/., in ^'philis, cancer, lupuf, cysta, 
riai'vi, etc, may be obaerved. 


The raicroorganisins wtucli eriLcr the moulh iluriiig rtwpira- 
■f.ioit ami witli the food art" a ooiistaiit. mii«' iif ilrcwiiiRifiitimi 
ajid putrefaction ia the rrgioii of tlic tci-ih. Tlic fur coat of 
the tongue, which contains so many iiiicrobeei, also plays an 
important ri')lo, which is often not sulHcipiitly rcr(>(;nim!tl. Wg 
should, tliorcfore, insist strongly on a regular cleansing of the 
mouth an<l tcoUi, particularly with respect to the remaining 
particles of food, which are such a good nidus for the develop- 
ment and iiicn'a.'^r of bactrria. 

Tliul i]i)t the most scrupulous purification of iJie mouth would 
hif sufficient to sterilize it, even for u short (itne, wt need not 
CflpiTially eniphasize. We can only, hy a thonnigh cleansing, 
check the further development of the niicroorgaiiisnis within very 
modest liniit.s. 

"Hie mouth sliould be cleansed at least every nioniing and 
evening, and also after meals, and this is done by first removing 
all remains of foo<l with & goose-r|uill toothpick or by a waxed 
dental Uireml; secondly, by washing the mouth and throat with 
tepid water, to which is addeil a little cooking «all; tidnlly. by 
eleansing the teeth in front and hark, alx>ve and below, I)y a 
t«oth-bru«h, with tlcntal .soap or powdiT, nuidt- up of elialk ancl 
carlionatetl niagnewa; fonrthly, by olean.sing the bfwk of the 
l/mgue with a sfrrajxT; iitul fiftldy. by re|X'a1ed misliings as in 
nuinlK-r two. It is taken for granti^l tlmt all the applinncos 
tthould Ix' kept clean. 

Wlicther the luoutli-wash is fJavortnl with aromatic essences 
instea<l of ludng simple wilt sohili<in is really only a matler of 
lawle, but we will not deny that they have a refreshing and 
deodorizing eflfcct. "Wc should desire, however, to warn m to 
the use of too .'^trong disinfectant's, because of their corrosive 
action. Disin fee taut nu»ufh-wa.-(lieis are only to be used in 
special iliscaM^s and not uiilesH ordered by tliu physician. 



Artificial teeth shoiild be taken out duriiip the night anil put 
in salt wilutioD, otherw'ise they shoiikl be ireatol as air* the 
natural teeth. For details with regartl to the care of the teeth 
sec text-hooks on otlontologj*. 

Children shoxild be trained from early youth as to the proper 
cleansing of the teeth and mouth. The niitk teeth muHt be 
taken care of in just the same way aa the permanent teeth. In 
tlie sucklinp iwriod it is l>e9t not to interfere too much with the 
mouth if there is no need for it. 



Etiology and Pathology. — Malfonimtions aTid defomiities arc 
either i^ungfiiiuil or arcpiireil. TIip (irst are due to disliirliancc 
of developnu'nt in the enihrj-ii, and the latter are cauw'd by 
injuries, uleenitlon, and tlip rctraetion of scars. 

(fi) In Oie IJps.^T\»' clpft-lip nr Imn^-lip (inhiuni leixirinum), 
as it is called, is a Vi'ry cominori oceurrence. It in found ofU'ner 
on tlie left than on tlic right side, and is more often imilateral 
than hilateral. It ie eometimes indicated by only a .'(light notch ; 
In other again it extends to the noj* and i.s fiombined with 
a oleft jaw and eleft jialate, Hare-lip it* always congenital, but 
occasionally the lip is dividetl by a cut or thmsl-woimd. 

Of other anomalies, tliere are: Ihjftertrophy (eiephantiasis; 
macrocheilin) of the upi)pr lip i« due to hy|MTtrophy of the 
labial glanda or U\ rhronic infiltratiiin from rei>cated nasal 
eatarrhs ; as we sep it go ttf ten in scrtjf ulosis, esjM'cially in the 
cnldnr seanon. The lip is, in these eaws, oftpn eranked, fissured, 
aiiil everti'd. The reverw? is the eji.w in ehililn'H, who are ao- 
cuatoined to breathe through the mouth, and whose upjwr lipo 
are small and shortene<l, with the lower lip everted. 

The double lip occurt* when the upper lip ia divided into two 
more or lees broad parts by a deep fiasiu^. 


Entire absence of tips (adteitia), (^mormal smaUness (mvcTO- 
cJteiiia), nnd loriLiy adhexions 0/ Uie lips to each olbfir or to Uic 
pim (stfTtcJieifi/t. anil .si/na-Jiia), aro also occasionally encountf nil. 

(b) In (>w Palate.— Clc(l-[m\fiio. ([mlatuin fiasum) js citluT 
liniiletl to the soft or to the hani jwdate, or it extends througliout 
both. The cleft is mostly sinj^ts ami on tlu; ]pft siiU' of the vonwr, 
which in such a case shows lieviatioii towanis the rIghl-JiancI side; 
in the soft palate the cleft iilways nlll^ in the nutliaii liiie. If the 
cleft is <ioul>lc, e. g., on both sides of the vomer, it is spoken of 
as wolj's throat. 

The vault v/ ihe hard palate may very often deviate from the 
iiunnal. An abnonually high-vaulted jialate is sup]Ktsctl to 
Ih' a Htigiiia of dt-griK'nitioii, luid is w-wi in a»»ociation with iiifuiy 
mental diseast-s (epihrpsy) ; hut it Lt also wtui in children who 
breathe through the mouth, th(r naHul n-spiratiiui hi-ing (tlj- 
structwi by adenoid K'^)wths. In tin'«^ latU-r a hiph-vaultni 
palak'isofU*n seen, and \» then associatetJ with abnonnal position 
of the tt't'th. 

(c) In the Torufiie.—dmfxfyn'ital almommlitips are rare. An 
abnonnally large tunfjue (niaciroglosriii, protrusion of the tonpue), 
due toaconjienital enlnrKenienlof theIyniph-vesscl9fl>Tiii)homa), 
may be seen in idiots. The opiwsito comlition, a tonguir of 
such very small mze as to be almost entirely absent (niicrogloB- 
sia), has alsfj been obwerN'eil. Adhesiou-s of the tnnpiie arc 
mostly ac([itired. Of mure imju^rtanee, thongli often exaggci^ 
atpil. iw an abnormally long or short fretnduin. 

(d) In the Jati: — Congenital malformations are very ran', and 
if they oecur. are always part of a genera! nialfoniialion of the 
skull. Tlie jaw-cleft may lie menlioriwl as rmining betnwn 
tho Hectmd incisor and thr> canine tooth, and in always asno- 
ciated with other abnonnalities. Of the ft(i(]uired dpfomiities, 
there is ihcfibromunkylom, which is caused by fibroa" adhesions 
due to ulcerative i>rocees>s on the inside of the check and in 
the vicinity of tlie joint ; this fibrous ankylows fankylopis fipuria) 
is to bt^ diatingviishefl from tnie (bony or fibroii»<) ankyloaa in 
the joint itself. 

Symptoms. — The aynipfonis var>' much accoPLling to the .seat 
and nature of the anomaly, and the moat important sjinptoin 


is difficulty of speech. Clofl-noljile renders ftmliiig cUfficuH, 
oikI 0!<j)f'(;i.illy Huckling, as the tluiil i-carJu-s the ik>«c, fmni which 
it bubbles forth. An abnormally lung freimliiiii is eonwtinifa 
act;uwcd of being the cause of faulty swalldwing; the toDgiU" <Uir^ 
hiiig Uie act of sm:kliiig is ilrawTi Imek and wpwartls anil is said 
to c* choking liy rlepn-ssing the e|)iglotlis. Abnormally 
short or rigid frenulum (ankyhiglossum) may hinder suekling 
and spoakingj fyr the |xjiiit of the tongue catmot be raised above 
tlie lower teeth. 

Diagnosis. — Is generally easy. 

Pri^nosis. — The pnjgriosis depemls on the degree, cause, and 
nature of the deformity, ami on the posability of remedying 
them by tiperation. 

Treatment. —The frenulum can be severed — which should be 
done only in stringent caws — in such a way that it is seixed 
between the fore ami middle finper of the left hand, the tlorsuin 
of the hand T*eing direeled upwuni.'i, rir it can Im^ pu-siieil onto 
the notch of the handle of a prolw an<l then cut through with 
Coo}irrr's Fcipflora, the curvmi l>lades being directetl downwards, 
in onler to avoid injuring the ronine artery. The other nial- 
fonnations rei|Hlre osteo])lB.!<tic operations {.-we text-books on 
surgery). It \si taken for grantcil that accom{mnying malmlies, 
Kuch &» rhinitis, adenoids, etc., must be properly treated. 


The clflfiyifiealioM of the acute, ami— as we would like to point 
out at once — -the chronif InHnmmations of the oral cavity, 
nif^'ls with conniderable ditlieulty ; as the clinical |>icture is such 
a tiiverse one, and ehangw Ufi character eo quickly nn<l often 
by affecting first one, then another, feclion of Ui»^ mouth, or run- 
ning now more HUj)erfici!illy, thm iiiore dei-ply, iiit*> Ihe liseuiw. 
The classification earned uul in llu- folltjwing pagf.-*. though 
not free of all objections, will, I hope, praclically aatLsfy the 
need for lucidity. 




Etiology. ^Acute inflammation of the mouth Li due to me- 
chanical, chemical, and thermic irritation.", whicli an*" cutting " 
of tofth, carious tepth, too hot or too cokl fowl, too spicy or 
too harsii foo<i, spiritK, tobacco, atustics, atid other drug*. In 
infanta tho use of dirty "comforters," the ■want of elojinliness, 
and &Uo the overanxious cleaning of tlie mouth may cause 
intiaimnation of the delicate mucoa^ membrane. St'conchiry 
catarrhal stomatitis is found as a constant accompaniment of the 
acute infectious diwjwc^s (sci- p. UWI). tn imlipestion, iji i>ui30uing 
from some driig>i, e. g., indiii. Iratl, luid ni(^rciirial trfatmi-iit, 
wlicn it is c-ncounigcd by iiidividiiiLl idiosyncrasy and by lui- 
clfanltne-ss with rrgan! to the; mouth. It is ofl<'n in Uiusc^ latter 
caw-s, wpi'fi.illy in jiK-rt-unn,! stomalilrs, that lh(; morbid prtH'csji 
spreails into tlie ilet'|X!r tissue aiid oft^n assumes an ulcerative 

Symptoms.— Tiie piitient complains of discomfort, which 
esptTiaJly occurs while eating solid ur warm food; and for this 
reason small cliil^lrcn often cr>' and roliL**> tlie breast or lK)ttle. 
The tonguR is furred and taste diminished ; saUvation is increased, 
or the mucous membrane apjioars dr>* or covereil with a viscous 
secrt^tion. Other .symptoms which may occur are those caused 
by the various priuiar}' diseases. 

On examination one finds the mucous membrane affected 
either m its whole extent, or oidy the gmns (gingivitis): but 
w^ldom the tongue alone. The mucous niembraiie is swollen, 
F(hI, and covrml diffusely or in isolated s<.'Ctioiis and tracts 
with mueuH. The tongue is usually coateil on it-s dorsum with 
a yellowish or whilisli fur, whereas the point eontrasts conspicu- 
ously by its bright red color. On tlie umrgins of the tongue 
and on the clieck the impressions caused by the twth arc very 

, Sometinies the root of the tongue is the part more afTecteil, 
and there the lingual tonsils might Ix'come disea.**ed. Tlie proc- 
ew is known as tonsillitis sive angina prae-epiglottioa; and with 
all the symptoms and characters of follicular angina, similar 



1(1 tliose found in follicular innainnialioiiii of the pabitiae 

Holh often occur in conjunction, but as ihe syniptonis caused 
by ttie latter are iiRiially [irtxloniinant, thr tnflainination of the 
Ungual tonsil is mostly overlook*"*! (Ki'e Pari Til, pitp,' 2R2). 

Prognosis. — Tlic proKnosis niiisl W wtiniali'd according to the 
determining cause. Slight inilaininatiou mmally miKsidcs after 
a short lime, with or without treatment, but other cjuicm sliow 
a gn^ater jjcrsistence, anil it might become a tH-riouw matter for 
KuckHnRS, who, on account of the [lain. will rrfum* fotxi. 

Treatment. — It b essential to remove or jjrt^ent all irrilaiion 
which ix apt to kpcp up or to renew the uiflaniniatiori. Tlie 
fcxjd, at least in the beginning of the disease, slioulil consiwt of 
Cold fluid or pap (milk, barley-water, cold soup, eggs, jam, gni4>l, 
rice-milk, ?tc.);antl infants must be fed by spoon on cold milk. 

J^cal treatment oupht not to l)o exapgeratwi, for all the clean- 
ingii and patntmgsonly cause unpleasant resultfi. In ^Ujdit cases 
<Uctary pre5crtptions and a .moutli-wash con^iiting of a t«pid 
infikiion of camomile, to which a tcas[)oon of Jitirotc's solution 
may lie added, is sufficient ; or a mouth-wasli of tincture of myrrh 
(2.J dro|)8 to i Utre) can be used. I usually prescribe, in cases 
of 8cverc pain, the following mouth-wash: 

I{. Tinct. myrriM. 

Tirici. rl<afiui M 10.00 

Tinrt, lliolaiin. SJM 

Sio. — To nialce a tnouth-viuh , julil 75 drops to a tuuiblttr of mid water. 

The raoulli-wash sliould not be used a» a gargle, but only as 
a mouth^wn.'Oi, i.e.. a r|tiaiitity laketi into the month and tlien 
moved to and fro within the cIoi^hI cavity by nlighily blowing 
out the cheeks. In infants it is beat to cleanse the mouth cau- 
11011."^* with a clean swab dipped in a weak solution of borax 

In adults it might lie neccasaT>' to paint tlic mucous membrane 
witti silver nitrate (0.5:100). 

Etiology. — Phlegtnnnous inflammation often affeels one or 
other i>ari of the nuicoiw mend>raiie, and tJie moet common site 
for the phlegmon is thv tongue. 


Among the causes, injuries by fisli-lxjiu's, biles, stings, etc, 
followed by iiiffctiori frnjti si-ptic or infectious gcnii:*, i»!ay the 
chief part. .Sometimi^s ooiisiiLutioiial di.-wase (Jyscrasic ulcers) 
form the basis of a severe pli legman ous process, or the latter is 
only ft sj'mptom of severe general disease, e, g., scarlet-fever, 
8raall-|X)x, typhoid, anthrax, etc. 

Symptoms. — ,\1ut ^t ings from insects, burning or scalding oftf n 
ftpixyirs in a very short time, and Uic parts conccmecl become 
swollen and ettoniiously iTiJillratni, which, however, *ifH)n sul)- 
sides spun tan eoa-^ly or under proper treatment, an»t seMuin gow* 
on toabaceasfoniiation. I'limlent inflammation isalmost always 
unilateral, ^nd most commonly afFects the root of the tongue 
and the linfjual tonsil ; the abscess is of the size of a ]jea, but may 
assume larger proportions. 

In such a case the tongue is so swollen that it does not find 
room enough in the mouth and may protrude; it is moved with 
difficulty or is entirely amobile, and is always thickly furred. 
Al tiic .saiup time there is violent iKiin on speaking and swallow- 
ing: great salivation ; the regional lymphatic glands are swollen; 
and if the adilus ad laryngpin is implicated, there is difficulty 
in breathing, espi'cially at night Cm the reclining position). 

Diagnosis. — The diagnosis is matle from the sj-niptoms, in- 
spection, and, if suppuration takes place, by palpation. The 
abscess is not alivays easy to l>e felt, because of its deep-seated 
position and the tenderness and tension of the affeeted parts; 
but it ia just the tenderness which will guide us in making our 

PrognoMB.~Thc prognosis in ample phlegmon ia favorable, 
but if the disease has extended over a large area or if suppurac 
tion ha.s taken place, there is clanger of asphyxia or sepsis 
and [ivMeiiiia, 

Treatment. -.Vt the commencement (he diet must be regulated 
(cold fluid food), and applications of ice, as well as the swallow- 
ing of .-iinall pieces of ice, and leeches to the angle of the jaw, 
must U* applied. fthouM this treatment prove insuflieient, 
the inflammation must Iw acwleratrd by hot-water fomentation; 
a mouth-wash must l>e used finfu*?ion of camomile to which a 
teaspoon of Bvrnxp's solution is addetl); and where fluctuation 



is foiiiHl or *in tlio site of the grraiest tcntlpmess, an incisaon 
iiiusl Im* made. Spvctp heinorrhage is slopped by plu^ng. 
For Uic aftPi'-IrDaLment, thorough cleansing of the moiilli is 
very iiii[H)rLaut. Sometiiups a certain degree of intluration of 
th« tunguc reinaiui;. 


I-lxudative stoinatitii^ i.-* oliaracteriiMHj hy the fwmation of 
eero-puruk-iit or hftenionliiigic vceick* or bullfie, and in otiicr 
caseti by a libriiious exudation. We Jiiid an eruption of voa- 
iclca in herpes and ]K*nipliigus, after RcaUling or Inmiing. in 
prj'sipolas, fofit-antl-iiHiiith disease, variola, and variccllii; lo 
this class also Ivt'longs urticaria, which occurs on (lie iniicnus 
membrane of the nioulh. Kibrinous exutlation characlcrizos 
Htoiiiatilis ajjhthosa (a]»hlh,'U'). 

(a) Herpes labialis et buccalis (Stomatitis Herpetics; Herpes 
of the Lip or Cheek), --KHoIih/j/.- — Among On- cjuikcw ciiuini-mtcd 
are inU'stlnal disorders, some acute infeolions, as roryita, 
infiueiim, pneumonia, epidemic cerpbrosphial meningitif), etc. 
(compare Part III, p. 272). 

Symptome. — The vesicle-sof hcrpe-s are of t!ie sizft of the head of a 
pin to a ix'a, and occur mostly on the Uiw. often in a&sociation with 
othei-s. on th(^ facial skin, and sometimes also on the in^^ide of 
the pheck. on the hard )jnlale, or on the tongue. The eruption 
ahrays occurs in nUisters, and is often followed by febrile 
syniptoniB. Tlipw arr- often several attacks, and at first the 
contents of thp vesicles are clear and trans|jarent, but later 
they beeome turbid, and the vt?sipU'S ten^l to dry up after a few 
days and leave little cniRts or scabs which, if removed, aw ro- 
newnl. In the nmeoufl membrane of the mouth the vet*ieles 
nearly nlwayw hurst. jW) early that one only finds in their place 
small circular, at first bhiod-nlaincd, and later on yellowish, 
excoriationc. which are surrounded by a well-niarkcil n-A zone. 
Hei"e also the eruptions arc arranged in groups, and are always 
hniiteti to one niile only thrmiglossitis her]}etica^one-si(ietl 
herpetifonn glowilLs). It is probable that this diwaae is, like 
herpes 20Rt<'r of the skin, a irophoneuroHB in tJie regicm supplied 
by the trigi^niinal nerve. 



Hie subjective syiuptoms iu hcrt>cs labialLi uro insignJiicaiit, 
and there nilKht be a feeling of t(-n.*ion oi- lu-ol. In ln*r|x'8 of 
tlie iiiuoous HHiiil)raiit!, <ju tin* othrr hiuul, jxiin, f^jH-ttially on 
eating, might be v«rj' distrptaing. 

Coune. — Till' coui-si* umujiIIv luniti from a fi'W diiys to a few 
Wfi-ks. f5()mfr chnjnje foniis liavt; l^cn (Icscrilicd wliirli rr-liiiwe 
fniiii tiiiii^ tu liiim. 

(b) Pbmphigus.—Elwhrry. — WhHIht [X'tiiphigus is a iroplio- 
Tipunjui.s !iki^ Ju'qx^H zoster or wlietliHr it Ik an iiifectiona diseane 
is nut yd irtTtain. 

Symptoms. — It occurs nioKtly in rui^kllc-agwl or t-lilerly peo- 
ple, llie fonnation of vceicles or bullae often efteft{)es observa- 
tion, as in t!ie previoijs iliscape. One t^t^cn on the poft iialate 
or diw'k, but not so firquently on the tongue, large, weil-tlefiiied, 
gray or excoriations which still show tlie remama of 
the hurst (■]»!» icniii.s, ami which hi-al without scar. Swallowing 
IS very luunful, ami then' is salivation and an abominable 
footor. Tlie (lis(>aH> 8lHm>; great inclination to rpla|is(!, aiid by 
ihLs pirtniiiistaiu'e fidcrly [K'uple may become so weak that they 
eaitily Kuecisnih to »ii iiili'retirn'nt imdady. 

(c) Aphthae (Stomatitis aphthosa seu fibrinosa ; Aphthous 
Stomatiti8).^£r()>>^iif;i/,— The ofipn of aphthae raiwt be traced 
to infection, 'rid^ is prnvetl by its contagiousness, for not 
only ^-veral childn-n. but alao tlie julults of the same family, 
may be QfTeotinl by the i lisca-sc. diildren an; very Uable to eon- 
tract it, p»(X'ctally during dentition, Ix^tween the first and third 
year. It is fosterfxl by want of eleaidinesB, gaatrio disonlers, 
febrile tliseasfs, etc. 

Symptomx.—li occure with febrile symptoms on various 
places in the tnontli, sueJi ns in the vpslibnluni, in the pdeket."* 
of the cheek, and on the floor of the mouth. Spots or pla<)ues 
are sceii which, at firi"t Wvidly re<l. are later on pomewhat 
whitish or yellowish, and are surrounded by a red area of infil- 
tration. In sonic ea!*e.f 1lii*!«r* sjmts or iiWiiie.-* are wcardy ; in 
otherH, they are very nmiiemuj*. and multiply thenist'lvos fo form 
8i'Veral crofif*, and have also a tejidcncy to unite. In wmie eases 
Uie more jxjsterior (wrtions of the mouth and the tonsils are 



The cmptions do not fonu vosicUwt, but im* from tlie first 
onset fibrinous exudations which exist in the epithelium itself. 

During the first Ihreedays thea])hthaf'iiicrea>ie, and areaaxjm- 
{tanied liy oniple Ralivation and contiideralile fMun; tlie Ftibniax- 
illarj* glands are swollen, ajid tliore Ih foetor ex ore. Tlieii the 
injeetioii of the mueiuis membrane subsides, the cxtidate shrinks 
and 18 discharged, leaving rwl .spols beliind which gradually dis- 
appear. There is no formation of scars. The whole iiroceas 
may be very severe and spreail over w» \vi<le an an-a Omt the 
little patients are liable to become di*bilitut«il ituring \if course. 

(d) Foot-and-mouth Disease (Epidemic Aphthous Stomatitis; 
Haul- und Klauenseuche). — Ktiolotjy. — Thp di;«'tLSf Ik epiziK>tic, 
ami occur?! in eallle, rows, she^p, pigs, and horses, whcnoe it 
can be lranKmitle<l tu man thrtKigh tht- milk or by contagion. 
The sijecifie gemi has not yet been diKeovered. 

SyfTnjflmns. — After a stage of iiieulmtion, lasting from five 
to ten days, the disease begins with fever, often with a rigor; 
the patient feels verj- weak, Kiddy, and com]>lainfl of pain? and 
aehes in the back and Moinaeh; of nauwa. anorexia, etc. Small 
yellowish vesicles the fizc of a heni|J-seerl are fonuetl on the 
lijw, gimis, or tongue, seldom on the hard jmlate or jxisterior 
pharynx. Tlie content* of the ve.ticles arc at first quite clear, 
I)ut later on l)econie turbid. The vesicles soon burst, leaving 
Ix'hirul dusky i'n)si()ns or 8ui>erfieial ulcers. The whole mucous 
nienibrane ia swollen, (here is sahvation, and eatuig is rendered 
vcr>* jminfid. In many (raye» a vewicular eruption also apjxwra 
on the external skin, which sometinieii sliows a purpuric char- 

The disease nioctly runs a course of several weeks, ejiding in 
complete reroveri', but (h-ath has occurretl in some caees. 

Diaf/tidsis. — The itijignosis of the various forms of exudative 
stoiiiatttis, and es|)ecially the difTerential diagnosb, is not always 
ca*iy. for the efJIoreseenees show a most varied clinical ])irture, 
S])ecial difTirultiejf not w-ldom arise in making a distinction be- 
tween the herpetic and aphthous forms of stomatitis, and some- 
tjmce, if the historj' is doubtful, between these two diseases and 
epidemic stomatitis. Syphilid is not often to be confoumlcil with 
them, as (he acute course of the exuilativc proceas alone would 

SToMATrns nmoxicA. 


ronclcr oil trrror inipi'obalile. Sometimes in (H|ilitheria »niikr 
fiQrmptoina urcur, but here a bactonological exaiiiinution on the 
one hand, and, on the othfir hanil, r^inie typical horjx^iic or 
ftplithoiis i>l;ii(|i]cs wliioh art! never wanting, will insure the 
(iiagnasis. In certain cases sitnilar tniptJons on the extfrnnl 
Kkiii will HtTvc as a ginxl i;uiil(> .-w to th^ nature tif the disease. 

Trealnif-nt. — With regard to trealnieiil, one ehief re<jiiiretnent 
i-s indisix'nsable, 1 e., 8crii|>iiluiis eli'anUneiS uf thy rnoiiUi; 
in adults), by disinfectant nioiitli-wa^lnng (aluniiniun acelnte, 
peroxide of hydrogen, permanganate of ]X)ta.sli), and in ehililren 
who cjinnot EarRle or dean their mouths, by painliiiK or bru-siiing 
with borax, 5, to glycerine, 25, or chinosol or chinolin, 0.4, spir. 
vinielglyeerin.aa 10. For tJie painting, a canieiVhair briLslican 
be ut<od. Heubrier advises a 3 jkt cent, solution of carbolic acid ; 
the brush i.s aioisteneil with the -dilution so as not to drip, and 
then each single sixit is touchcil with it. In more severe ca.'aa a 
2to 10 [>er cent, solution of silver nitrateoraoliil lapis iiifernallH 
may be usieil. In severe pain, painting with eocain or alypin, 
6 to 10 per cent., is useful, in order to render eating loss paitifiil. 
For the rest we refer to what has already been said with regard 
to catarrhal jttomatitis. 



Etiology.— The ehronie form "f catan-h in the mouth w often 
found in aliiwrs of aleohol and tohaccn, with oariou.'* teeth and 
unclean habits. Sometimes the intlainmation in liinitetl to 
thejtiun'5 (in pregnancy), which protrude between the teeth. 

Symptoms.— iSave from di?turl)ances of taste and sahvation, 
there is very little cAuse for complaint. The mucous membrane 
on the back of the tongue or on the cheek is infiltrated, slimy, 
and here and there excoriated and atrophied, and the vessels 
are much ililnted. 

A variety of this ehronir catarrh is that form described by 
SchecA as stomatitis sieeji (dry stomatitis), and is found only 
in older or uraemie |ien*ons. Here the mueous membrane is 


much injcctetl, alibiy, and covoml with ft glassy orviscouf secre- 
tion. Tlic patients cninplain of unpleasant dryness in the mouth 
tjr throat, of difSciiliy in t^ijoakinp aiul swaUotting. The disease 
w not to !» confounded with xerostoma, whcrt^ iuHammation is 
watitingoralisent. (Seep. 188.) 

Prognosis.— The prognosis is favoralilc, Init the course may 
lake yimrs, if i\w causes cannot be reniovcd. 

Treatment.— Must be eminently causal. The local treatment, 
to a eprtaiii degree, is I he same as in the a<!iitc catarrh. As the 
mucou-s membrane i.s often to a larg(> extent inwnsitive. painting 
with silver nitrate or lapi.s infernalis U oft™ benefieial. Great 
benefit also atrrues iroxn the use of c;ertain nitneral waters fSalz- 
bnuin, Vichy, Kms, Kissingcn, etc.). 


(a) Leucoplakia Oris (Psoriasis sive Ichthyosis Oris; Leuco- 
plakia; Buccal Psoriasis).— ^V»i/<*f^/.^Ciironi(: ^-ujM■rli^naI in- 
naitimation of the itiurou.s ineinliruni" is pruduwd by ainlinued 
imtatiori, eBpecially by excessive smoking; that is why we so 
often sec it in men. Imch] (surh ft.s an abnoniial deliracy of 
the naicmw mcnibrain*} or gtnii'ral pn'(lis|M>sitinn f!n,'philis) 
contributes mxtch to the occurrence. Ijeuc-oplakia is not neces- 
sarily a s\'m|itum of syphilis. This is provwl by persons who 
never harl syplnlis t^howing white patches in the nioiitb; and, 
furtlicr, thai in sonie ca-ses tnereurlal iiiiiiH'tions were of little 
avail, and that, foUowmg upon long-continued mercurial 
treatment, such leucoplatjue^ (leucomas) occur, which dieapjjear, 
however, but show a distinct inclination to rela|>se, in o]>poaition 
to the primary leucojdaque?, which are very resistant and not 
amenable to (n-atuK-nt. On no account refer these leucoplaques 
to an existing syphilis, for they are not a sjTnptom of it. hut the 
sequelae of anlisj/phiHHc tradment. \\1i<>re such white ]»atclie» 
are found without other sigiiji of »yphili.i, it would be a great mis- 
take to euVjmit the putient to mercurial treatment, for it would 
only aggravate the evil. 

Sytnploms. — The tongue usually, flomelimea also the lii* and 
cheek, arc covered \\ith white or bluisli patches, of various sizes 
and irrcgiidar in t^ajx-; sometimes sharply defined, in other easea 



diffusely pasainR o\'er into normal mucous membrane, oft*n 
divuled into several patches by fi&.-'un'fi (ir fiin-mvfi. In whuc 
caaca imv Umlut tt^lamls uf tiorniat rc<l niucoun nintibnuie rnrlnsrij 
iiisucb (iclilsof whiU" ]3atrlws, c's|KTiallycin tlic lunguc. In Iniig- 
slaiiiiiiig casc-R tlii^c \Yliite jMitches arc Uiickeneti, <'lt'vat<*tl, 
uneven, or c-rackcd. 

Thp [wlk'tiU* tlo not usually wiinplaiii if the disease has not 
sprpail far, ami evwi in hdhk? advanced and long-standinjr ca^ea 
tlie sulijective syniptimis an? relatively Kli^lil. Tlierp is a sen- 
fiation of ilrynei^ or roMf;im(>»i in the nioiilli, speaking, Kwailow- 
inR, and chewing iirp wnderwl uiieom for table, and hot and spiced 
food, particularly, is mo^t disliked; but the whole mouth beconiea 
in time ver>' sensitive, and if the mucous membrane hecon>es 
fiseiurd or in places loses its epithelium, the symiHoma are 

Diaffnosis. — The discrimination from syphilis is not always 
easy. If the white patches sliow marked resistance, increa^ig 
and altering very slowly, we then diagnosis leueoplakia; whereas 
nypbilitic patehes are characterized by the papules apiwaring 
and i!i»ap|H'ariiig ivlatively (|uiekly. Tliere will also lie other 
sigDS of syphilis, and mercurial treatment wilt soon settle the 
question. Syphilitic plaque* ver\' seldom leave scars behind 
<£->&'« syphilitic scars, p. 208), but leueoplakia nearly always 

Besides syphilis, in other cases, iidien -planus must be con- 
sidered. In this disease, also, while imtclieHappear on the mucous 
membrane of the moutli. These patclics are. for the most jinrt, 
much smaller, more Mlvery, shinier, are raiser! and distinctly 
arrang(i:l in striijes or striae. In the skin we will pmlmbly not 
fail to discover the same eruption of liclien ruber planus, which, 
however, soon sulisitles uiuler the influence of arsenic. 

pTognosix. — 1-eucoplakia is always a very tedious disease, 
aifl takes years to heal. I'ropmsis in, therefore, somewhat 
unfavorable, and might bt'conic scrinus iHTans^' of its pn'diwpo- 
tition to the growth of epithelioma, though lhi^i liability is oft<i» 

.\n epilhi'lioma growing on the site of a leueoplakia is .said io 
be much te^ malignant than other carcinomatous tumors in the 



region of the mouth. According lo Retlus, this is iliic t« the 
iimcdBn lussiuning in t<'UcoplBkiji nil tin' diaract^Tistics of the 
skin, and the cancroids of which, as \s kuowTi, are far less ma- 

Tretitmcrit. — ll is jiiokI cssf-ntial to pn-vent any further iriita- 
tioii of Uic inucDUs iiK-itiljraiic. Smoking, ihiiiking, ami mercu- 
rial trc&tmriit ituu^t be diKcntitiiiurd, tinil all carious Uxth iiiu^t 
!)(' pxtracteil or put in onlcr. Ijoral Ireatmeiit is not very 
suroi'ssful; tliouf^h pniiitiiig wilh lactie acid (20 lo .% per cent.) 
or with a mixture of palicylic acid, 1.00, Hpirit of wine, 5.00, 
(Ijtyirerin. 10.00 (fteTefffizdszy'.t mixture), will [Mrhnps l»o useful. 
Till.' iMiintiiiR !.■* to be done every two to three days, and iii the 
meanwliile the mouth should be washc<l or garglwl with pcro.Kide 
of iiydropi>n (a teaspoonful to a glass of water). I-xjually gootl 
are weak solutions of .■'ilv(Tniln»f<' l5 to 10 |KTCeiit.) or rhnjinic 
acid (i to 3 \)cr a^iit.).* StrmipT .solutionis hr- not itdviHrtLilc, 
for Ui£*y not only aggniviilt- the evil, hut fonU'r tJie prwli-sposition 
to a subsequent caiircr. 

(ll) ITigrities linguae (Lingua Nigra; Black Tongue; Hairy 
Tongue). ^AVjy?f»yy. — Like IcucoplHlkia. di(> diwaw now lo be 
deseriU'd is alw paused by a sujierfieial innHnimation of iIk> 
toiipif. The superficial Inyen* of tin? efiitlu'lium and the lili- 
fonn jMipillae hypertrophy suid ln't-omt; eoniciiuK and as-sume 
a yellow f>r brown color U^herh). Tlie process iii that of keratosis. 

Other writ<Ts look u|»on it not a;* a kemtosis, but seek to ex- 
plain it as n pipiienlary degenerfltion of myfotio origin. 

Sijniplonifi. — There arc n.vually no c<iniplaints on the part of 
the patients, or they may remark on a feeling of ilrj-new, 
hairiness, .sometimes in eoinbinatinii, witli diminution of ta.ste and 
an evil smell fmm die mouth. If oneex.^minesthe tongue, it will 
l)e found tliickly coated with a dusky brown or black fur. winch 
i.s nothing elw than the hair-like hypertrophia! eomcous and 
pigmented filiform pftpillao. By scraping ^\•i(h n spaiuta, fnim 
l)eforp backwards, the jjapillac can he made to sit up like fine 

•Trnn-HlnlinirKdltor'H footnote; PaintiTijE thcKtlr" with PliiniliiSiilmi^e- 
tnti? Korl., nmt thrn rinsinj! Hie monlb at once has \vK-n fourri mo^t cffienrioiiB 
inthfciiitor'sexpt-ririK-p. This trtfttmont ha* pnovM useful In pujum uf smoker'* 
irriliihl(>, fnp, miiltirlc papillDriiuta of thu Iiaitl pulntc, the result of peniMcnL 
pipe Miioking.— F. W, K. R. 



Kpiiies, so tlial. llie back of iho tongue has an opix'arancp «milar 
lo tilt? toiigiK' of a VS.I. 

T>ift{inojiii<. — Mistakes an> possiblfi only in artiiicial diaeolora- 
tion, as may occur after the taking of claret, certain <lrugd (iron) 
or fruits, or chomlate ; or even from tlic licking of ink. 

/*rw/nfw).f.— (looil, thougli the disease is ver>- tedious anU 

Treatment.— Carctul attention to the mouth is a matter of 
couisp. Uiinn recoil inicntl 8 local jminting of the discolored 
jMirtions with snlicylateil «r rctsoreinated ether (resorcin, 10.00; 
collo<lioii. 5.1X); wlher. 100.00), an<l afternaals sjxjn^ng with 
peroxide (if hyilrojifn. Caiislirs or instrumental removal should 
only be employed In very iieriouf* csm^h. 

If the discoloration is int^iguificant. and the discomfort of the 
patient sli(^t, it U< best to leave things alone. 

(c) Lingua geographica Cexfoliatlo linguae areata] (Geograph- 
ical Tongue; Aimulus Migrans). — K(ioU»fif nud l'ulholo<irj- — Tins 
afft'c.lion Li characterizwl by the apijcarance of circukir excoria- 
tioiLS of the mucous membrane. \i» cause is not yet kiio^ra: 
probalily it is due to a «U|W'rficiaI inftaniination. It« ajJiK-arance 
.closely resemble-i 8y|)bilitic iilmjueji, but it lias no eoniifetion 
whatever willi Hyphilis. Anaemic or dyspeptie wjnditions are 
»npl»<>s('d to play a |irpiiini>ri>iiiip part ; and dentition also i.s said to 
pn>dLspo«e to thewe " idinpalhio pla^iuen " of the mucous mem- 
brane, for tliey are mostly met with in young children. 

Symptoms. — The tongue show-s red ]iatrlj(>« fiirroiuidiMl liy a 
yfilowirth or whitish yellow luargtn of doubled etintour. 
patches occur on various i>IaceK. anil are sjmetimes here, and 
sometimes there, and this tpiiek "migration" is characteristic 
of the disease. Patient'! sulYfr little; somelimes there pxinitt 
an intolerance of acid and spicwl fooils, and tobacco, spirits, etc., 
in older persoog. 

Diai}nosu.- Syphilis is most likely to he mistaken for it. The 
exfoliations are loealiKefl only to ihe tongue, whereas ?j*philitic 
plaques are seUioin limited to the tongue alone, and are usually 
also found on otJier places in the mouth (soft pahile, tonsils, Hps, 
checka). The "migration " of the plaques i« ijathogiioinonic 


194 DisBAaea of tub uottrn. 

Prognosis. — Tlic iliseaiic is not a srrious one, but b< \TTy 
ob«l bate. 

Trr-niment is of little avail. Vnna rticouiiiieiidii a special 
moutli-wasii : 

^. \(\. mib. ciUptiuroaa. 

Ai|. uicmti. |ii[i U lOO-tX) 

Klot. wiJpli, 

S>T, ■impl Al aiJX) 

lYagacanili 2.00 

To roatke a muulli-n-aali, to ba eliakeo before uae. 

The patient is orJercil to clwuise the tnoutb thorou^ily three 
times a day for 6ve minutes. Small children are painted with 
borax or ciiinolln, 

\\. Svlii InliorAi; SXIO 

(Ujrmu 2S.00 

Cliinolin 0.i 


sptrii. vini aa 10.00 

fd) Moeller's Glossitis Superflcialis.— This affectioQ. railed 
after its (ir.-it ot)sor\'iT. i.«, like tlie geographiral tongue, char- 
aiittTiwfJ by rhronio cxporialions, which, however, are not siir-« 
roumiwl by a double foiitoured margin, but show an evenly dis- 
tributttl n,'dm*sM anil remain stationary in tlu-ir jmmary place 
or site of origin, in ecutradistiiiction to those on the geuKmphical 
loniiiue, where the exfoliations quickly diaiige from place to 
place. The disease occurs in adults only, and is ver>" ijainful, 
wlierea.s lingua geographica is found chiefly in children, without 
catisitig any }Miin. 

TrenimetU. — ^Tlie same as in chronic catarrhal stomatitis. 


Etiology and Pathology. — Marroglonsia i« often congenital, 
as alrcfl'ly montioiiwl fp. l-si). In rare cases it is aequiral, and 
is then the non.*4'quence of oft-repeated inflammation of the 
tongue. (Se« Fig. 65.) 

Symptoma.— Hie enlargement of the tongue, which may attain 
great ]iroiK)rtion8, Ls liable to imjiede speaking, eating, and even 


Cirrtitiwenbod, welUlpfined, nodulju* pnlargpnients may be 
Boiuptunes siicecssfully lrpat«i by pnintiiig with tmcture of 
iotiUi or by cauterUation va\h solid sUver uitratc. 



Ulceration of the tooguw occure in viirious forms: 

(a) IdiofvUhic ulcer shows a localised pharactor, the cluiical 
fcatua-rt ciiiuigiiig with Uic iliffcifnl (yiu«-« or microbes. To 
Uiis class t)cIong the idiopithic iiln-r («tomacAca), the stoma^ 
tilis iilwaT)ii»'nibnuic)«a {njigiiia of PlaiU-Viticent), and the 
ajjlitluu' t)f Hrdmtr. 

\i>) >^y»ifiiom(Uic t^^rcr.— Here the affection of the mouth is 
only u [jart of a general iliseased condition, such as scurvy, dia- 
Vjetes, leuknciiiia. (Diphthtriu mid wphilis, which Also produce 
ulcenilioii in the mouth, will be discussed later ou.) It occurs 
3ubsw(iueiiily to a Ketieml cachexia, the mouth being the locus 
miuarU restseentiae; lastly, Tollowing on the poisoning from 
various drugs, e. g., inercur>', hisuiulh. lead, ar«unc, et«. 

(c) Traumatic ulcer, e. g., from whooping-coii^i or from bad 


Etiology. —Idiopathic ulcer never occurs in the mouth of 
fuckliiigs or of loothlcfw old iKHiplc; thi.s circumstance indicatea 
that the toeth fcarifsl piny a part ia the (li.-*ease. It is met with 
mi>.-(l cummotdy in childifn, but adults also are not immune 
from it. Somelinirjt it ha.s be«'n foimd epidemic (in barracks), 
and thin l('inl>i to the opinion thai the diseajw may profwiily be 
CrtnlngiouB. wiiieJi ha.'J boon certified in various cases by bacte- 
riological investigations. 

Until nmv no specific germ has been discovered. It is rattier 
more prohal^to that the dl?easr is iheeflfeet of wveral saprophy- 
tic micrnorganiHm^ of putrefaction which are always present 
in the mouth. 

llad hygienic condition;*, and debility rbir lnillne#w or conva- 
lescence after infectious dinvrafies are the pnilisposing factors. 



Symptoms and Course. — The disease begins with an acute 
onset, mostly near oiirioiis teeth. The gum swells, l«'coiiios 
discolorcii, and bleeds on being touched. Aft^-r a few (lays, 
or rarely after a few wet^ks, it shows a grey Idi -yellow jiateh, 
covered with a clieesy, evil-smelling eoat. which soon ukfr;ito». 
The teeth looii*en, fall out, or are renioveil without |jiuii. There 
is ptyalistn and swcllbig of the submaxillary glan<l:i. I'Vrding 
and speaking are painful. The ulceration frequently spreads 
inlo the mucous nienihrane of the U|is and ehrelc, anil iti ne- 
glected cases may lead to gangrenous destruction, which may 
even alTect the bones. If the process is so far a^lvaneed, general 
sepsis develops and finally terminates In <leatli. Usually, 
however, the general health is not much affected save from 
the frequently severe imin. 

Diagnosis. — It iriay be: confoiimltHJ with scanty and mcrciirlal 
Stotnatitis, e.sjx'eiutly at llw* hei^inning. Htoniaeaeii. ir; nearly 
always a local affeetimi, whcn-as neun'y is a ciwiHtituiioniil dis- 
ease aiu! never sJiows greyisli-yellow patches on Uie giun. Mer- 
curial stomatiti.'i. which may show tlie same clinical picture, 
is detHnninwl by the previous liistor}-. 

Prognosis,— If the is projwTly treated, tiie prognosis 
is always gwxi. 

Treatment. — The treatment follows the wuae lines as in 
catarrhal stomatitis. Uenhner mainlaius tliat cauterizing the 
ulcerated jiarts with pure carbolic acid is vcr\' ('ffective. He 
uses a glaj*s rod for this purjiose. A\'e prefer to rc^connnend as 
a disinfectant and tleoilorant fonnic aldehyde, especially in the 
form of fomianiiiit tabloids. Fornminint is a compound of sugar 
of milk and fonnic alchiliydc, of which several talilets are taken 
daily. Chlnralc of |Nit-asshini. which is still in use. should not 
be given, on aceniuit of its danger. It is a matter of eouree 
that the month and teeth be regularly cleaned. 

Attenthm sliould be dirretwl to the hygienic conditionp and 
to the general health by -strengthening the body, with concen- 
trated footl, such as egga with ;*ugar and wine, coffee witJi milk 
and sugar, etc. 


PtSBASKs ov 'Tim uoirru. 


Etiology and Pathologj'.— This disL-aw, which has mctntly 
occupied the attention of tht* mcKlical world much, is an afTection 
of the mouth and tliroiil tviused hy wrlain spindli'-jOiaiJcd or 
fusifiinii Iwicilli, first (k'Siriliod by J'laut and Vincenl, aad liy 
spiroehwlw; tJie latter, howevpr, play only a minor part in 
pjuimlion. Both microorgftiiisins nrr oprapionaliy foun<l as 
saprophytes on the healthy mucous niembi-anc of the mouth, 
hut may Ureoiiio pathogeutc aftf^r long ilhic-^ii, general or local 
ftlTcctions, carious l«'-th, etc. Then' if* no iiin^'enicnt as to Uie 
eantupous iinlun- nf the di-ii'ttse. thougli i-pideinirwhavc ncc-tirrc<I. 

Aceonliiig to Viricnul, the (lisi-a;^' ooruns at any age and atuung 
all rIa.-w'Mof iKK)iil<';i«'t(loin, however, after the thirty-fifth year. 

Symptoms. — The aiTecti^si is eharHeterized 1>y the fonnation 
of uleiTK uiul nieiiibratien, which in the one form an> nion' nit- 
nierouK on the iiiucouk mend)ran(> of the mouth, near eiirioufl 
teeth, Hiid in otlier fonna am locahzci) nwtv to the soft palate 
or tonsils, spreading winetinies down to the taiyiix. 

The ulcers show an irregular, hard, crater-?hapcd ed|5e, and 
with, the tendency to spread into the dee|)er tissues more than 
along the purfflce. Ttie adjacent mucous membrane is inflamed 
and swollen. There is salivation, foetor, and sweUing of the 
suhmaxillan' gland:<. 

The affeclion is mostly limited to one side, and does not much 
affeet thi- p'neml health. In some cases complications of the 
kidnt'VH have U-cn objierx'wl. 

DiagnoBis.— Tlie dineai^e must l>e distinguiRhed from diph- 
theria and gvphilis. This can in any cape t»e done hy the mipjv>- 
ecopic diceover>' of the fusiform bacilli and ppiroehaetae in the 
cheesy delritu« takrn from the ulcers and stainwl with carbd- 

Prognosis.^s usually Rood, but the course in. in contradistine- 
tion to stoniarjifrt, very tiflions and obstinate. 

Treatment.— CariouB teeth must be removed, and the mouth 
and thnmt cli-anssed and disinfected by mouth-wa^hefj or gargkw 
or tahletH of fomiamint. Kventtially, caustics (diver nitrate 



or chromic acid) have to be used. (Sec p. 40.) The patit-nl 
may be isolatetl in order to prevent contagion. 


Etiology and Pathology. — Tiie (iiscftsc is only observed in 
iiifaiils. .\11 uKret' in that it is caustwl by djunaf;itiK or injuring 
the delicate mucous meuibranc by rough or unskilful wiping 
of the little onn's mouth. Tfie hinder and more lalerai parts 
oj die harrl ixthUe, whfn- the muciniw niriiibmiie iw tirmly al- 
tachixl to its bHM-, an- always and exclufdvcly atkcttd. The 
excoriatioHH tlieu form the patli of cntranoe of tlie slapliylocowa. 

Symptoms. — The niucoiLt niwnbratie on both sides of the 
mi'dian ntpln- and in fnint of the attadiniinit of the Hoft palate 
sluiws sylimii'iriiially small, flat uUv-rs, wlur-h a|jjK'ar tike small 
yellow patcJies, rounded or oval in shape, with red and well- 
defined edjp'!*. 

The affection cauisca little or no disturbance of health, save 
in the rare ca-ses where the dii* also invatle:* the Koft jwilate 
or toneJU, Icailing to septic iuTcction, or is complicat«-d by 
thrufh or di|)htheria. 

Diagnosis. — U founded on the seat of tlie ulcers and on tlieage 
of the patient. 

Treatment.— It is often only .'Judicient to forbid wiping the 
nioutli, wlicn the affoction will heal np within a few days. In 
other «ai«« light and careful painting wiiSi 1 to 2 ()er cent, nitrate 
of silver may lie tried. As there is no danger of contagion, 
brcast-fe<.l children need not be weaned. 


Etiology. — Scurvy, which is not oft^n obwrvixl at the present 
day, is probably an infectious disease, the oulhn-ak of which 
is encouraged by l>ail hygienic conditions ami pHrlioularly by 
feeding on salted meat or ini]>UFe food. 

Symptoms. — After the prixlronml stage (lanpior. oppression, 
palpitation, excruciating jwiiri in the legs, fever, etc.), ecchv- 
nioees in tlie tikiii and mucous membrane occur, and siniulta- 
neouflly the gums become affected ; they become swollen, painful, 
and discolored. The parU between the teeth es|)ecially swell 



Symptoms,— It begins with all the sjiuptorns of a catarrh, 
but is suon distinguished by its tendency to spread l<i the dt'epcr 
tissues ami to bocomL- ulctTntod. In this resj^'ct it lian much 
tlie saiue diaractcrs as stoinacaca. Salivation is a conspicuous 
is>'mi»t(»!ii. {See page 196.J 

Diagnosis.— lla\*ii^ due pc^rd to the etiology, the diagnosis 

Prognosis.— If the affection ia not very far advanced, the 
prnpitisis w giiod. 

Treatment. — In stomatitis from medical treatment the epe- 
cifif ntusc can l>e tlisconthmed, save in very severe cases, 
Wyrkers in incrcurial works must suspend their work, and by 
sweating (hot bathn, tic), the nwtal is in this way eliminat«L 
Under proper lo<^al treatment the stomatitis then soon sui>- 
adcs. It is of great importance to have the teeth put in order 
and to keep the mouth well clraneeil before undergoing mercu- 
rial treatment or before going to work in mercuriaJ factories. 


Under this terra is comprisctl a group of ulcers which owe 
their origui to injur}', and arc rharaclerizcd l)y the ulncr being 
always markedly liniittM) in extent; that is, if no secondary 
infcrlioii fnini .'^■plic nmtU-r MiixTVi-nt'S, As ctiologirAl fiirtora 
may l>c onuTueruinl lilting thr tongue, or injury by a sliarp 
tootJi, fon-ign liodie:*. scaldingand hurning, etc. 

In whfHiping-eongb an idwr may Ix' found on the freniim, 
more si'ldom on tlif side of the tongue, and which is eovereil with 
filirinous fxiidHtion, wid h iirobihly tlue to the rubbing of the 
tongue (Ml the idiarp etige of the lower teeth during the reijeatiMJ 
attacks of coughing. In infanta a .similar ulcer at the point of 
the tongue may be seen, which i-s caused by the irritation from 
an emerging lower tooth — the so-called "dentition ulcer"; 
even the breaking through of a molar tooth might cauw ulcera- 
tion. Such small ulcenn, as a rule, soon heal, as iloes also the 
"dentition ulcer"; otherwise slight painting with nitrate of 
olver will be found sullicient. 




Etiology.— It in piill imctrttiiji whelher ihe diwaao is that 
known as an kiiopaliiiL: one, i. e., cuusnl by a sj>ecific niicro- 
orgimisiii, or whether it owes its ori^n to an infection by various 
niicrobps bastxl upon a conslitutknial dyscrasia. It was main- 
tained at one time llmt iioiniiliwl a certain relation to diphtheria. 
'Hiat it is infectious there is little doubt, for endnuic^ have been 
observed ; and the liijwase oecurs also on other [MU-Is of tJie body, 
Fiich as tlie scrotum, vagina, as well as m the oral nnicovi? mem- 
brane. Tlie dia'a-st- oceiirs preferably in diililreii, and particii- 
lariy in young girls of from lliree to twelve years of age, i\iiose 
health is much debilitated tJirougli previoua illnesses, or infectious 
tlifttasos, rncasles. whooping-cough, tubrreulosis, etc. Some- 
tiiiWd ulcerative processes in the mouth, such as stomocaca and 
mercurial stomatitis, are followed by noma. 

Symptoms. — Noma is not often seen at its verv comm^nee- 
meut. It origiiialeK usually in the mucous membrane of the 
check, near the angle of the mouth. A hard uifiltration of the 
size of a hazel-nut first apjiears, whieh soon softens and breaks 
down, forming an ulcer eoverpd with a slimy (ihn, and which 
tends to spreaii in its vicinity. The lymphatic glan<Js art- swol- 
len, salivation and foetor ensue, >'el the subjective comfort is 
not nmeh disturbed, save for a marked apathy. Ijiter the 
whole external cheek swells, becomes oedenuitous. shows at one 
or other s]M>t a hard bluish infiltration, which aUo breaks 
doftTi and iK'Comea blaek and gangrenous. Then the cheek 
becomes (icrforateil in jicveral places, and (here is practically 
no arresting of the terrible pangrenoits proces-. which spreads 
further and further, destroying the facial skin up to the forehewl, 
and even down the neek, leading only stinking miuases of a black 
color; the tn-ixiUari" and nasal l>onos also become implicatwl; 
the teeth fail out ; and, finally, after a few days, death concludes 
the terrible difeai>e, with signs of general sepsis. 

Diagnosis.— ^'I'lie diagnows offers no iliftietilty after tlie first 
few hours. 

Prognosis. — ^llie prognosis is always bad. It i-s seUloni that 


the gaDKretie siJontaDcously liitiits itself by a line of tleniarualiuii 
ant! the ulceration becomes clean. Recovery may tiu-ii lake 
plan', leaving an unsightly disfigurement beJiiml. Kmiciion 
may iirtcnvanls be grwitly disturbed. 

Treatment.— C)n the jH)ssil>ilily of noma having i*ome coun<w- 
tioii willi iliplitherift, an iiijtTtion of antitoxin umy be Uitil. 
For tlie ra-it, the mouth sliould be i'n-qui-iitly iliHiiifectitl, aiid 
foiiientatir>ris with pure alcohol or fBiiipliumtol spirit onlravil. 
The slouKhiiig jmrtfl muHt hp removed. The gaiigreiiou.v place 
itself must b«> very thoroughly cauterized with chloride of zinc, 20 
per ccnl.. or ehromic acid, and, still Ix'tter, bcoo|xhI out or de- 
stroyed with the thermocautery. The keeping up of the strengtli 
of the patient pn'.seiit.s many (tifficulties; it .should I* kepi up 
by fiHiling her elfieicntly, moat possibly by stomaeh-tulx' or liy 
nulrii;iit ftieiiuitii,, mid by the cxhibitif}!! of stimulatit:^ aiid frtyaii 
air. Sometiiiicif, if called in early enough, we may suceit'd in ar- 
resting the pniei'jw hy ruUing out the morbid pwrt, kifping well 
within the hi-ahhy tissue, and then eewing tlie cut surfaees to- 
gctlier {v. Ranks). 



Measles. — In measle.". and iil«) in German measles (rulx>ola), 
we see small white [jalehes on the mucous membrane of the 
cheek, especiiilly near the angle of die tnoulh, — first descrilied 
by Kojilik, — which are pathoKiioiiionic- of tlie diw-ane in il« first 
stage, and precede the eruption on the skin. 

Ttie tongue in the acute exanthematous tii9ea.*es, just as in 
all infections, ia furrcil, and this depends on the peculiarity, 
duration, and height of llur fever. In measles (he while, creamy 
coat la thrown off during tin- eruptive stage in fjimll ragged 
flakes, am) the nmcoai membriuie midenieath then apjiears red 
and smooth. 

Scarlatina. — In sirarlel fcvi-r the papillae are mostly jtwollen 
and of a light red (" raspbfrry tongue"; " scarlet tongue"). 

F«ver. — In higli fever the tongue is covered with a brown, 



focUd, "futigiMus " coat, which has a slimy or vamishwi ap- 
pcaraiiw {yitenmotiia, typhoid). 

Variola and VariceUa.— In sniall-{M>x anil chickpit-pox a ves- 
icular or jHiBtuJur cruptitfu may nlsij be srcu oil Uie paJate {\y. 
186), tin: piLHiulrj^ hhciving Uic cliaractfristic (Ifprn'ssion or uiii- 
bilicatioii, sa vUewhoro Lii liiiiiill-pox. 


Gonoirhoeal or blernorriioe;i! stomatitis has nwasirmally twwi 
seen in iiew-buru intants, ami is eausetl, liki- goiiorrh(*a! rhinitis, 
by infection at birth from the vaginal secretions of the mother. 

The inueous meml>ranu is swollen, injected, and at some places 
denudcil of its epithelium, or shows eupcrfieial ulceration. Jn 
the secretions and tissnies Koiiococci tnay be found. Kvery 
stomatitis in new-bom infants with mucopunilenl secrcLionniust 
Bwakm our suspicions as to gonorrhoeal infrction. 

Treatment. —This consists in cleansing the mouth by cautious 
swabbing out with a 10 per cent, solution uf borax anil touching 
tbe ulcers with lapis infernal is. 


The mucotts membrane of the mouth ia not often affected 
by diphtheria, and if it be. it ih u.simlly seeondary U> severe 
diphtheria of the tonsls and tlmial. It ia in nowise different 
from the latter. 

Sjnnptoms. — ^There are the rliHrai-lcriwIic formation.'* of diph> 
theritie merabranes, foetor, sahvatiuii, and jiain on eating and 

Diagnosis. — The diaRiiows slioultl offer no diRicullieR, consid- 
ering die whole clinieal picture. Kventually, the finding of 
KMta-LoejjJer bacilli will .xt^tile the question. 

Prognosis. — Prognosis depeods on the cJiaracter and severity 
of till- atiaek. 

Treatment.— The same as in. diphtheria of the throat (see 

Edology. — Tul>erruIosis and liipu.i of the mouth are, on tbe 
whole, rare itffectiuns. If at the same time tuberculosis can be 



found in the lung, we. will then Ik- iti liouhl wJiicii is the primary 
scat of the infet^lion. The gciii'ml opiiiitm is tiiaL ihe iiiuulh, a;* 
well Bn the throat, is a wwdidan.' Konnrciui'iiet" of di-swisc In the 
tunfB. But probably the tubf-rculuiLs infection of small wountls 
in tlic region of the nioulh and throat <loos not occur no scUtoiii 
as is thought; and the Iii[)nrrlc liaeiUi an* then asiiiratoil into 
the lungs or bronnhi and thru load to a scrondant' iriri'cliori of 
these orgnus (Beilzke). 

We do not deny that occasion ally onlinary iilrpw. for instann", 
thns* on thp Riiinj*, may l^fcornp tuttt-n-idar In tiaturr. 

Lupus, &!i a rule, xprrads into the mouth from tlie outside and 



■■■- .:]■-'.'-■' 
Kg. 06.— 'l\ibcrculoais d th« lonpie (HochtmgaX 

occurs mostly on tlic lips, but somttimcs also on the gums or 
bun! (Kilalc; rari-ly, on Ihr toiieui'. 

Symptoms. A.s in tiibi'ri-iil<ms rhinitis, the paliaitHsuiTcring 
fnnii tulxTt^ulouH or hiftoiil Htoniatitiit iinually vi»ita phynictian ui 
the iirst place, even if ulccralion has alrcmiy ln^jiui. One then 
find.s at the root rmargins), or on \iw frenulum of the tongue or 
on the cheek and gums, Hat, superfieJaJ or tieeper. crater-sliaped, 
ainuouH ulcrerw, which are pr(nluc«i by the breaking domi of 
miliary tuherele«. 

Some miliary tuliercles, of the aae of a millet-sced, may be 



seen on tho wlgea ol tlip uIcpfb. Iii other cases, whore the tutier- 
ciilosi.s ii|)[N--ursas uodular mtiltratioiis (tulierciiluiuala). larger, 
sinuous, unclernimal ulcers of an atonic character occur. In 
some itistaiicf'K the angles of the mouth are liasumi and crarlced. 

In lupiLS, small iiihUiU^'* of the size of a pin's lie-iiil occur, ivhirh 
look like graiailaliuii.-i, furniiug clusters, auii sooner or later uIot- 
ate. The ulcers shows nodular or condylonialous granula- 
tions on their eilges and Hurfaces. 

There is very little subjeci-ive discomfort at first. I^ter on, 
if ulcenition him occurrol, csiK-cially in miliary- lulx-rculosis, 
pain, salivation, and foetor arc very Iroublescanc. 

The regional lymphatic glands arc ofleii, tliougti not much, 

Diagnosis. — Dif-tinclion between tulxrcriilous, gummatous, car- 
cinomatous, anri actirinniycnlie infiltration is not always ea.-^', 
and still more diflieuU is tlie dislinctJon between the various 
kinds of ulcers. TiifMrculur vJcers sOiow an atonic character, 
spread myn- tuiptTficially than in deplh, and tend to form granu- 
lations. Thej* are seated oftener on tiie uTider surface, whereas 
syphilitic ulcers, on the other band, arc, as a rule, on the upper 
surface (dorsum of the tongue). 

In lupus the tiicerti are painless, granulating, antl show a mul- 
titude of sitiall notlules, whirli, at times, heal s|>ontjuictm.sly with 
tlie fonnatlnn of scan*. 

Swelling of (he regional glands is niucli less in tul>ercular 
than it is in xy|jhilitie or carcinomatous processes. Oiaraeter- 
isltc of earcitwma are the sitootuig [lains whicli toon arise front 
its presence. S'ever omit to examine the whole body for »ifmp- 
tornn of lubereiilmis and xypkUix. In doubtful eases, moreover, 
the decistion will depend on a microscopic examination, which, 
however, as we mui^t admit, is not always jxwiitive. A brief trial 
of iodid of pota-^i^ium mil materially hel)) dia^oFis ex juvantjbus. 
Tlierc are also so-ealWl mixed forms of sj'philis and tuberculosis. 
These are inihienced favourably at first by iodid of potaawiun. 
but Uter on the drug fails, and then the tubercular character 
becomes api>an'nl. 

Prognosis. -Miliar^' luberculoBis of the mouth often leadw to 
a fatal ending, for it almost always exists in conjunction witJi 



ic H!im(! affection of other organs; the nodular form, on the 
other huEul, ims a »lu»*, cliruiiic cuurHc, atid out inlrequently 
improves or heals up c«iiipU;t«ly. 

For ihe rest, prognosis* must dcpciui oti the general health 
(conililion of the lungs). 

Treatment.— Wo must apply general ani] local treatment. 
The larger tubercles (tubereulucimta) are lo be removetl by 
excision ami iinmeihiile suturing; smaller infiltmiiousand ulwrs 
are to Iw scraiwd out thoroughly, riHht iniu (be healthy tissue, 
by a sharp ;«poon. and then cauterized with lactic acid f80 per 
cent, or pure). Instead of the scoop, the giilvftiio-caule-ry, antl 
inHtead of lar.tic acid, triehloracelic iir rlirninic iirid, may be 
used. i'Vii" the pitin, brasluiig with (■(»rain or idypin bi-fure meals 
is useful. The mouth must Ije purified wilii u tlisinrectant tnouih- 
wash or by tablets of forinatniut. 


Tlip mouth, as well as the throat, is a »eat of predileetion in 
syphilis, esix-eially in the secondary' sta^-s. 

(fl) Initial selerusis (hanl chancre, [jrimary sclerosis) often 
oceurvi on the lower lip. and more »>liloni on the tongue, still 
rarer on the gums or dieek. The infection is tranpniillod by 
contact, e. g., kisses, and by infected inBtruments or utensilc 
or other accidents, difficult to explain. Sucklinf^ an^ di%>nt<etl 
by infected wet-nuraes or tcata. The primar>' hard sore pooh 
breaks down, and fonns either a su(ierficial or deeper ulcer with 
hard edges, and is covered with a shmy film or fru!<t. The 
regional glands are always swoUm anil jmiiiless; healing is slow, 
and the usual duration is six weeks; but the chancre can some- 
times still be seen when secondary s^Tnptoms are already present. 

(b) Secondary symptoms in tiie mouth are of an erythe- 
matous, papular, or ulcerative nature. Tlic most common are 
the pa[)ule« or brond eon<lyloiiiala, called "plaquea muqucusee" 
(mucous patches). They are found as small or larger sized. 
round or irregular, greyish-whitr patehiM — (a) vn the left edge 
of the tongue; (fr) on Uie under mirface, near the tip: in the 
niucrous membrane, or .■^oinewliat rai.-ied ahovr il, ami ej*pen»lly 
cm tlie inside of llie lips, where one can sec the papules of the 



outer skin passing into the "plaques nuiqiicuHet* " of the labial 
hiucouj; menibmrie. Tbey ocpur frcquvnlly also on the mucous 
moinbrane of the check, at the angle of the mouth, on the tongue 
and lingual tonsil. Sinmltaiicoiisly with them the toneils. 
|i}mryn.\. anJ soft [mlate anr wftoii alfectiHl. (Spp p. 313.) 

The iiiut'ous membrane anmml Ihe plaque* is conspicuously 
reel, and this is pathognomonic, but this symptom is aimetimea 
missing. The papules quickly disHppi'ar !*pontaneousIy or under 
treatnient; sometimes, however, ihcy ulcerate and then leave 
email depressod scars behind— the po-ealled scars of Erb. They 
show a great tendency to relnpw-, often after a long interval. 
Under tiie infliu-nor of vftrioiiii irritations, for instance, tobacco^ 


Fig. 67. — PUuiuca muqu«u«e*: (a) On the left «d)te ot longiic; (b) od the 

uniitir 8tir(ii<«. 

alcohol, hot food, etc., they incline to uleeratc. llie edges of the 
MUpcrhcial ulcers arc sharply cut aini indurated; the floor is 
im-guliiT and is covered with a dirty, gn^visli-Vfllow lilm. The 
aiigleaof the mouth are fissured or crackal, whicJi shouki always 
give rise to a .suspicion of syphilis if tho fissures w-ill not heal. 

Theedgesof the tongue, also, owing to tiie constant irritation 
fn)m sharp-wlged teeth, often sliow a fiwured or corrodetl surface, 
8o that the mucous patches seate<i on the margins of the tongue 
prc.«riit a cracked or raggwl apjxjaranee. The superfieinl layers 
of the ei>illieliuta having been (partially) cast off, the mucous 



mcmhranp appears in various plnccs, rod and Btnooth, as thoufdi 
shnvwi, ami bU-iHif frrcly whrn touched. Aftor Iho syphilis has 
disii[)j)oamJ, nrtcii yviir» jifiirwiirds, SHiall, rdurid, white |mlchw, 
so-called U'uajmata, occur on the lips and tonpUR, in the r^ion 
of Erb's scari, whicli must Iw coiisidenxl as tlie seqtiolac of the 
previous mercurial tn-alincnt, t. c, as a form of "hyilrargj-- 
roais," and are qiute haniiles*. They should not cau^ anxiety 
on the part of the quondam patiotit, nor is there any reason 
to renew nierciirial treatment, as some ovcrdian'ful physicians 
would assert, for mercury would only aggravate iJie condition. 
Wait calmly until all the wluto, though nomewhat obstinate, 
patchtw have disappeared, avoid irritation, and if something 
must he done, Iheii i>aint with a weak solution of nitrate of Mh-er 
or chroriiiiT acid. In simple jNipular syphilidea the patients 
do not complain. On the other hand, there iamuoh discomfort 
if the broatl condylomata break down, causing |Miin and saliva- 
tion. If tlie angle of the mouth is fissured, 0{X}ning of the jaws 
beeonie-S V(^ry jiainful. 

(c) Tertiarj- gyphilides are characterized by diffuse infiltra- 
tion or more or less weU-defined, circumscribed, tumour-like 
gumniata, and are seated mostly on the tongue, palate, and nioro 
seldom on the lips, angle of the mouth, or dieek. They appear 
some long time after the infection, but may also apiwar quite 
early, especially in neglected coses, or, as I have reason to »U|>- 
poec, in agreement with Ihpmann and Chiari, in persons run 
down in health and trcateil too long ami loo mucli with mercury. 
The gununa (either Bingle or multiple) is of Lhc size of a pea, 
or hazel or walnut, fimi in eonsisteney, and tlic surface is jsmooth 
and lies in or under the mucous uiembrane, which Is prominent 
over the jiart eoneemed. The gumma breaks down and forms 
a flat, sharply cut ulcer, with sinuous, indurated etige-s; or if ihe 
prooess begins in the dee|)er tissues, the n'sulting ulcer is deepand 
crater-*Jia])ed. showing of1<»n only small fissures on it.? surface 
(fissured ulcer of Foumier). The ulwrs. sometimes when heal- 
ing, fonn large scars, which shrink and give the tongue a 
tuIxTous or ragged appearance (gloaaitis s>*philitica induratiw). 
We must fijiecially mention that the phar>'ngenl ton.-sil may 

also be tJie Beat of tertiary syphUis, which is often overlooked. 



\Mi('thcr the BO-aillcd smvoth atntfjhy of Otc root of the totiffiie 
ifl a syiiiptom of late .syphilis i.s tloulilfiil, for it is seemingly found 
in old peopli! who have never litul syphilid. 

On the fiard jnihle. teriiaty «yphilis oft«n affecta the bone, 
leading to its ulfjemtioii and ilpstructioii; so that the oral and 
nasal cavity are brouijhl inu> aiininunicaiion. lii other cases the 
process bspns in the nose (see p. 103). In Bmall inhltmtioDS 
there m not mxicb of which to complain, but there is niorf, how- 
ever, after ulceration has taken place. The palate Ix-ing per- 
forated, the spi>ccli Ijeeomos tiiisal, ami food miglit n-acli the nnae. 

Diagnosis.— A hunt chancre may be mistaken for careimima 
or gunuiia. In thr prinmn,' afTcdiim the rrgionni lymphatic 
^andfi are always swulU'ii and paiiile-ss, hut iti eareinunia the 
glands are also swollen, but are very tender, whereaj* in gumma 
any Hwelling of lIh' glands is entirely atweiit. Be->ddei< the gumma 
■oft^QS and hrc-aks down much earliiT and more dee[)ly. Tlie 
prcsenee of secondary eruptions will l(>ave no doubt aa to the 
nature of Ihe afrectiuii. 

Broail condylomata in the mouth are unmistakable, esjieeially 
if in aaeociation with other signs or ?\-mptonis of syphilis (swollen 
^ands, raphes, fissuree). The differential <liagnosis between 
syphilitic plaques, Icucoplflkia, and lichen planus has been 
diacuflBed f^i-e p. 191), Aa regards chronic hydrarg^'roNS, see 
above (p. m)). 

Aphthous and herpetiform ulcers are also liable to be con- 
foundeil with syphilitic ulcers, but tlipy usually run a morn? 
acute eourw, are mostly painful from the first onset, and are 
BUfToundeil by a more or less bright-red areola, whereas syjihi- 
litic papulf'fi and ulcers show a more subacute eoiirw, arc painless, 
and no euch arcolation is seen. In herpes the vewcular eruption 
would hanlly escape notice, and aphthae is a childn-n's disease, 
seldom occurring in adults. The distinction between stomatitis 
mercurialts and stomatitis syphilitica secundaria sometimes 
offers difficulties. However, the mercurial stomatitis is always 
arute in its onset, and Is accompanied by salivation and foetor; 
the pecidiar affection of the gums and posterior i»arts of the 
check jJiould Ite suRieient tn Insure a ililTerential diagnosis. 
Occasionally Ijoth may be associated, and then the diagnoHB 



must be secured ex juvaiitibuA. e. ij., with iutlidt- of pulassiurti. 
Tertiary syphiliil'-H somelimm present gn-al diiriculiics in regard 
to diognosU. GummalA niny Ive miHtaktm for tumours, cysl^, 
d«!p abwH-siKTs, and, lastly, for carcinonia. 

If w(; fiiiU thi^ regional glands swollen, we tnust be on ourguani 
and rtiwppct (uirriuoina rather than bt-aign tumours or gimiuiala. 
Multiple guinina-like tumours indicate t>yphiUs. Benign tumours 
are pcrhapH .sofl-t*r and more elastic than gummata, aixi thcxkm 
or mueous luwiibraue covering them can Im? moved. For the 
diagnosis between primary and tftrtiary ulcers set? p. 209, ami 
between sypltiltlic and tubcruiilar uleers scp p. 2(K». 

Carcinomatous ulceration is eonwidf-rably banlej Uiaii pun- 
matoug ulcemtion, uiiil '\\» scat uf predilection i^ tbe mnrghi of 
the tongue; the edges of the ulcer are thickened and turmil 
outwards. It liat^ Imp[X'ned that a carcinoma lia^ arlM^n on (lie 
site of a xyiihilitin ulcer. It may ali>o be mentioned tliat cancer 
JH a discasi' of older persims. wberea-s sy|»hilis i.s a disi'a'*e of 
younger pcuple. in certain ea.-«-s the liislury and ihe examina- 
tion of tlie whole iKidy will guide at; and in many others wc must 
deix'nd on tlie mieroweopicjd or barltriological examination, and 
on the ('ffeclof a shiirt rrinlwitli mercury or iodide of [wlasnium. 

Prognosis and Treatment.— Witli regard to prtignoeis and 
treatment, wc may refer to what we have already smd in Part 
I. in retti>eot tn the .same affection of the noee. Here we shall 
only in<licatr .i^mto t-[.H'ciul points. Condylomata, erofions. antl 
ulocre of the secondary tvtage are best IreateiJ by cauterizing 
tliem with clinitnic iirirl. which can l>e repeatetl as often ka need- 
ful. We must ^vani the patient not to swallow witli the saliva 
any of tJie eanierizing agent, on account of its irritant enielic 
action ; and we .sliouKl. therefore, immediately after caulerizalion, 
imBsk\ or rlcanM' the Kiirface with water. 

Secondary sypliilis, especially the secretions of the "plaques 
mufiueuses," is very infectious, and great attention aliould Iw 
paid in regard to this matter. Kis.'^ing must l>e forbidden; 
towels ami other utensils (wd by the patient mujit l>ckeptf*ei)a- 
mteil and for liis ^v)I^• use. Any irritation is to !>e avoideil, and 
tlie mouth wiLstie^l juid cleaned carefully, a» has already lieen 
pointod out. 



Ill guniniatous affections of the mouth, local lrcalni«it is 
unneceaaary and worse than useless, becauisr any cautmration 
which might he appUeil wouKI only tend to accelerate ihc aoften- 
uig and thus also the destruction of the tissues. 


Malleus and anikrai are seldom Uciitcd to tlie inoutli. In 
malleus one linds, in conibiiiation n-ith a siniitar afTefitiou of the 
nose, small yellowisli ndduh-s or piLstiitrs; Inti-r ulceration and 
sweUing of the regional lymphatic glaiuLs. 

Anthrax simulates the pictiin- of gaiiKTCiious glossitis. 

fjeyra occurs prefpralily c»u iIih lijis, and aUo on tlip gums and 
palato; and iiior(> often H\p pharj'nx hIiows white, noihitar infil- 
irfllitms of firm eonsistpiute. 

DiagooBis and Treatment. ^W it h reganl to diagnoeis and 
treatment see Part I for tlie same diseases of the noae. 

Amont; tiie parasites which give rise to niycotic disease of tlie 
mouth the vegetable kingdom puis forth the most, nmiierous 
agenta. Occasionally also animal parasites; are Found, 6uch as 
cysticercus cellulosae. echinococcus (hydatids), trichinae, filaria. 
and dracunculus medinensis (guinea-worm). 

Etiology and Pathology. — Thrush is paused by a fungu-i, tJio 
Oidiuin aibiean-s, whicli thrives l)est on squamous epithelium ; 
it is, therefore, often found in the mouth of unclean infants, or 
in persons who are laid up with seven- illness and are not Jccpt 
clean, as, for instance, in pnemnonin, typluiid, conMimplion. 
dialietes, etc. It is often transmitted to cliiklreu during birth 
or in childbed, or by dirty utenals (teat.s). It is well known 
that starchy food, whieh botlle-fed infants are usvially given 
(at too short intervalB), on account of its liability to femientation, 
forms a fertile soil for the fungi. As contagion F[>reatls easily, 
epidemics, so to speak, sometimes break out among foundhng 
children or in lyi&g-iu hospitals. 




Symptoms and Course. — The disease begins with white patches 
Uke a pin's hea^l, which unite, and soon or after a few days form 
grt'JiltT ones of somewhat uneven surface. The patches cannot 
be i«sily Be))arated, and are very soon renewal. The raucous 
membrane underaeBti is red, softened, and bleeds easily. 

The onset is very ofteo overlooked, as it causes no troul)!e; 
lat^r on, pain occure, whicli renders Uk- takuig of nmirishment 
difficult. With the disease of the nioutli dyspejisia or gastro- 
inlestinal eatarrti it^oft^-n aiwoeittto!, and is pwbably dui' lu (lie 
funpi being swallowed with the food. On the otlier hand, a 
preexisting catarrh of the digos- 
tive tract iniglit have jirotfuccd 
a pralinpfirtitiuii to the growth 
of the fillip in tlie tiiouth. 

It often happeiis, especially 
if the cnsf^ be neglected, that 
thrush spreads into the 
t, gullet, \\t\ft}, and laiynx, 
and even to the lungs or 
alomaeh. Hut tlie most sevore 
eases are those in which the 
fungus, trespassing on the at^ 
tachment of the epithelium, 
grows into the connective li»- 
Bue or blood- or l>Tiiph-vei»8els, 

and la carriett away uito the brain or kidney, where it produces 

Diagnosis. — The disease, if pronounced, is easily recognizable. 
Should any doubt exist, a microseopical examination can be 
made and sets the matter Wyond question. 

One sees a network of many doulile-eontoured threads, which 
form a chain of many links and sometimes show at their ends a 
club-shaped thickening. Intersfwrse*! between the network 
(mycelium) smaller or larger chistors of rountl or ovai cells, of 
high refractile ixnvcr, are wen (spores or eoriidia). 

Confusion with remaining particles of milk, which can bcfwily 
wifieil jnvayand nevcrfonii continuous patehrs, whould not occur. 
DipJittirritic membranes never have such « white appt^ranct, 


Fig. C8,— Funijiia of ihrufli or OiJiUTO 
atbicaua, pr«|iiuv(] iii givufrtii. 



but look ouire of a greyish or bj'on'iii.'ali wliite, umuhUv show & 
diffepent localuwtioii, ami bpsiiles, tlii'it- is fevx-r, and Ute general 
health sulTorf; greatly. 

Prognosis is always favorable if the disease is treatect in time. 
In weaklings, badly iiourished, t»r iii children soriotisly ill, llie 
disease might become serious, and iu adiilt£ al^ ihrusii is ajways 
Q serious ^luptom. 

Treatment. ^Abovo all coiiic.-i pnjphylaxit*. In the lirst place, 
fn'Mli iiir iiiiirit bo adiniltcd into the sick-room, (lie mouth must 
\h- kept fh'Hii and wt-ll wasbcii. (Scr jvp, 179 ami 184.) But 
in infant,-) it is not g(XKl to overdo the cleansing of the mouth, 
sii as to avdifl caaKiiig liednart aphthae. FocMl-stuRs which 
are known lo breed the fungi f^bould he avoided, e. p.. sugary 
and starchy infants' foods. Complications must l)e tn-atpd on 
genenil lines; and if the thrush is discovered in the oesophagus, 
vomitmg should be encouraged. 


Etiology.— Tlie etiolopy hju-i been already ili-^cussed. (See 
Part I. p. 114.) The' bc^ns with small, hanl, nodular 
swi'lliiig.-;. which may for a lung time remain quiet and painle^ 
but finally soften and snppuratp. The abscesses do not often 
break .s|x>n(rtnpr)ii.sly: the ibin pus is usually discharged after 
incision, and ulinws under the niicrnscoiie, or even to the naked 
eye, llieeJiaraetPristic yellow, clubbed fimgi. The process may 
abate, leaving simply a fistul.1, or retrogre-w, and end in scarring 
with retraction, while in other [tlaeey the process of softening 
begins anew. It is mostly the lower jaw. especially the region of 
the salivary glands, which is affected, but the cheek also and 
tJie tongue anil the tonsil may be imiilirated. From 1 he lower 
jaw the proer-ss may spread into different regions, sometimes 
simulating phlegmonous inflammation. 

Diagnosis.— The yellow " sulphur grains " in the pu^ tad 
the microscopical finilingof amycelial filamentwilh clubbed ends, 
are unmistakable. As lung a.t the tumour-like swellings are 
intact, they might be miPtaken for phlegmons, gunnnata, or 
tubercular processes, and even for malignant tumours, It is 
advisable to search for actinomycosis in all those cases where 


we find a dental fistula whicii will not heal, or where we see on 
the lower jaw thow chronic, insidiovi^ ntHlulcs which eliow no 
tendency to progress, ami, being paiiile»», occasionally soften 
nnd suppurate. 

Prognosis. — The prognosis (lejx'nds on the scat and extent of 
the disease. If this \)f \orn\\y.*'i\, prof^iiusis is not unfavourable, 
but it lieeomes bad if other itnjxirtaiit organs are afTtH^eti. 

Treatment. — The trentment consists iii opejiing aiid thor- 
oughly scrapirifi out the absceswt's, and giving i(M[i<te of potassium 
intt^mally. Carious tcctb should be removed if ihey do not 
fall out. 


Occasionally leptothnx imd mrcinae have been found in the 
mouth; th(; latter Mpecially, umU-r the same conditions as the 
thrush fungi, i. e., in s<Tinii.sly ill and cachectic persons, but no 
discomfort is causi^ Ihcrrby. 

IjCptoUiriz jiH'fers to attack the root of tlte tongue, near the 
C-nti'iuire to the Inrynx (Iiirisillilis lingiialis h-ptotJirica); but 
attacks also the tonsils, the pharj'nx, and the teeth, in wh<»«; 
carious cnvlties llicy pn)w in cnnniious iniufses. Thpy fonn nn 
the niUfrnns njcirdiruiie white or yellowish, hard or soft jKjintn or 
conefi, whicli are not easy to reinovp. 

Soreinn prowK oti the mucous membrane of the (ongMC or 
throat as tliin, fine, white patches, not unlike those produecd by 
thrUfKh. It has also been found in the sioliva and in the stoinaeh. 

Diagnosis. — ^The diagnosis is not difRrult willi micrcscopicnl 
examination. Leptothrix shows a vcrj' densi' inyccliinn, coii- 
aiating of thin, fine threads or fdanienLs lying elasc tn eaelmtlicr 
in himdles. Sarcinae consist each of four cells, arrangtnl like 
bates of cotton. 

Treatment. — The treatment is the same as for tlirush. (See 
also PliJiryngouiyRost^s, p. 317.) 

Etiology. — We find tumours on the lips and alveolar marf^in 
at the gums ; nioiit frequently on the tongue, i. p., on those ])arts 
which are most exjMsed to injury and irritation. 


OF THE Mourn. 

what rfile acute or chronic inflanmmtion, in the ttidpst s«ise 
o( (he term, plays in the ptiolog)* of tumours is not quite ascei^ 
tained. Von fianscmann suggests that matigiuuit tumours are 
generated on a predisposed site by external irritation. Other 
invest igator« consider that cancer, whieJi occurs so often on the 
lips and tongue, is iUia to [Mira."(it<rs. In any case this fact is 
certain : tlmt eiuieer of the Ujw and tongue is veiy common with 
smokers, and tliat on the site of quite innocent erosions uleers 
and tumours develop which are freqvienlly exposed to irritation 
througli the sharp etlses of twth, Iml food, caustics, etc. Syph- 
ilis and leueoplakia also are said to predispoiae to the develop- 
ment of careiiioma. Cysiic new-growths are usually retention 
tumours caused by the blocking of the salivar)- ducts. 


Besides the rare niuc<hfyst.'< on the inner side of the lip and the 
fbromola, a& also certain congenital or acquired hypertrophies, 
we have mostly to deal here with angioma and carcinoma. The 
former is usually seateci at the angle, the latter, more towards 
the centre of the lower lip. 

Cancer of the lower lip begins as a small node, which, however, 
soon softens and forms an indurated ulcer with a fissured or 
crack(»i! surface. The regional glamis swell early. 

Diagnosis. —Confusion is ]x)s.'^il>lewith^ — (a) hard chancre (which 
never shows such a cracked or fisRuretl surface) ; (b) with second- 
ary syphilitic \dcer fless hard, seated on the angle of the mouth, 
other secondary syphilitic signt; present) ; (c) arumaiouji fuisure^, 
showing Bometiines hard Ltlgcs. but no £ii:vUing of ilie glaiuix. 

By pressure on the carcinoma one is often able to prtsss out 
the so-called cancerous milk, viz., small white cylindrie or conical 
masses of epithelial cell's, as in conictlones. In any nasi' micro- 
scopical examination of excised portions of tlie tumour will reveal 
its nature. 

Treatment eonsi.«ts in early extirpation and aftenvards plastic 
operation. In recent times r-rays and radium treatment have 
been successful in those cases where the cancer was not very 
advanced and not complicated with glandular s^vcllings. Tlie 


thermo-caulcry and 50 per cwit. cliromic acid (Blaschko), as 
also arsenic in solution iutonially, have been uaed, 

Tiimours of the gum whicii spring from iUv [jpriosteiuii of the 
alveolar process are gruiiixnl wjiiii-what sumniarily under tlie 
collective name of epulis. Tht-ir stnicmre is ilial of a fibnjnia, 
sarcoma, or carcinoma. They can be seen in Uie mouth as 
aniallpr or larger luriiours, stalked like a mushruoiii or ^-ssile. 
The tumours grow aroiuitl the ti-otli, which an' at length looseDcd 
and fall out. Occasionally, dpntd cysts oc^ur ; and quite seldom 
odontomatti which develop before the second dentition has 
finished. (Sec p. 162,) 

KpuliH may he confounded with the panilis, commonly ealleil a 
"gumboil." The latter is a aubgingivol, subperiosteal abscess, 
due to p^riostitia in dental earies, and can be felt as a tender, 
at first tense, later on fluctuating, swelling outside the alveolar 
margin. It is nearly always accompanied by oedcnm of the 
cheek, and in extreme caws, oedema of the eyelids. 


Lyinpho-ciivemonia (niacroglossia) has been already men- 
tioned (p. 194). There occur also angioma, lipoma, fibroma, 
etc., and niixetl tumours. They do not cause much discomfort; 
but this depends mainly on the size of the tumour. 

Treatment. — The treatment consUts. according to size and 
scat, of removal of the tumour by scis.'sors, knife, or snare. 

The rysls of the tofu/uc ami hypertrophy of the lingiinl ImxsU, 
thougli the latter is not really a tuniour, scnsu strictiori, will 
now be iliscussed fHrjuiratoly. 

(«) Cysts. ^IJndriTii'Jith the Umgue. on thefloorof the riiouth, 
and u-suaily on one side of the frwnum, a grey-white, traiLs- 
lucent, and fluctuating tumour is sonietimP« foimd, which is 
teniicfl a ranula ('liltk' frogV tuinourl. and the patluilogi.' of 
which is utill in question. Wc have probably, in mo-st ca.'fes, lo 
deal with a conj^enital fomiation or witJi a retention cyst of the 
salivarj- glaiiils. 

The tongue is putihed upwards, «> that speaking and chewing 



or ovpD rpspiration may be impeded. Other cystic forniatiooB 
arc sebaceous and <!crmoi(l cysts, hydati(i8, (ccliinococcus cysts). 
Treatment. — Conastd of exci^on of the whole cytit. Ihiw will 
be (<ucc(«sful if the cyst-wall is tliick eiitmgh ; otJierwipe, a« in 
ranula, liu- cyst w incised ami IIk^- conlciits are let out, and then 
a portion of the cyst-wall is excised. 'Hic margins of the cyst 
are then stitched to the cut eilges of the wound of the mucous 
membrane. The sutures are reniovetl after four or five days. 
Instead of wwmg aa above, one may plug the cyst daily with 
sterilo giiuz*'. 

(ft) Hypertrophy of the Lingual Tonsil. — Etiology, — Hyper- 
trophy of the lingual tonsil is due 
to frequently rei>cat«l inflamma- 
tions or chronic irritation in the 
posl*'rior n'gion of Uic mouth. 
Most miiinionly the hy[K'rlriiphy 
of Uir lingual tun.sil i.s unly a ]]!irt 
of t}iechronic inflaintnation, which 
is alsn seen in other -sL-ctioiis of 
the pharyngeal lyniphalic tissue. 
Wo find, thr-rcfore, Bwi-lling of the 
lingual tonsil in scrofuloug struma 
of the "^ fliildreii, ill women at the age 
of pul>frty,()r »l Ihc etiinacteric. 
Apparently, the lingual tonsil is 
oftencr enlar^d in adult;? than in chililren, in opj^sition to the 
faucial toHKils, which are moflt commonly enla^iCed in childhood. 
This difference can, jxThaps, be cxplainnl by the circunititance 
that the hypertrophied lingual l-onnl In children is less often 
sought for than it is in later years, owing to the lack of nervous 
or other complications. 

Sjfmptoms, — ^The patients complain usually of a sensation 
of tickling or fulness in the neck, of irritation in the throat which 
makes them cough, of retching, or of "hawking ami spitting," 
and of becoming tire<l when sjjoaking. In women, all sorts of 
nen-ous troubh's occur (globus hystericuii, etc.). In other cases 
all symptoms are wanting, and the hypertrophy is discovered 
only by cliaiice. (Sec Fig. 69.) 



09. — H yj*r I ni pi ly 
tiiigaaJ U>u«il. 



On oxaiiiinfttion, having the tongue suffieiontly tloprpsscd. 
one sees either directty, or, still better, indirectly by the throat 
mirror, angle or several globular or jK'ar-shaped Bwcltings cloee 
to each other, wlii(;h, in oxtreitic ca.«es, fill Inilh vallcculae and 
may compress the epiglotti?!, cjnising diiricully in using the voice, 
especially in aiiiging, Kdallc juhI vuricow veins arc often S(!cn 
on the swollen part^. and tlu-w- veins occasionally buret and 
thus ^ve rise to liaeniorrhage. 

Diaf}}wm. — The diagiuwis* is easy, as one is able to palpate 
with the finger-tip ihe himlish proiniiicneej!. Tht-y are not. likely 
lo be niistiiken for real new-growths or atjerrant lobules of 
tliyroid glan«J, both of whieh are oreasiimally found. 

Profftwsu. — The prognoeis is favorable, for the lingual tonsil 
18 freely aecespiblc. 

Trvalrnent. — .\n hyix-Vtrophy, discovered by chance, should 
be left al<pni-. Should therr; Ix- cymptoniH of Iroiilile, n[)iTative 
measun-.s are far luid away the best, as painting or brufJiing are 
very annoying anil mostly usrleiw. Possible varicflst; or cctatic 
veins nuist In- avoided. Acronling to the extent of the enlarge- 
ment, scissors, double curette, tonsillotonie, or the snan? may 
b(> used. In Hmie ea-scs ibc hyp^-rt ro])hy can only be removed 
inecenieal or during several sittings. 

Maucnant Tumours. 
Sarcoma of the tongue seklorn uecurs, but cancer is compara- 
tively f rec|uent. 


Etiology ha.s nlri'udy Ijci n diseuswd. 

Sjrmptoras and Course. It is not often that the carcinoma 
at the out-'?»'l nni^f* a-s .1 tumour in the substance of the tongue, 
and then grows towards the surTace, where it is prominent, and 
finally softens and uleerates, the ulcer being induratetl. its 
edgeti thiekcnod, hard, and j)ail-!ike;but much more commonly it 
arises originally from a ftR<UR>. scar, or wound, or from a jMipU- 
loma as a result of carcinomatous degeQpration. On the one 
hand, the cancer start?, ab initio, as an ulcer: on theotherhand, 
the ulaTatioa is the result uf breaking donn of a distinct tumour. 



The malignancy of the new-growUi shows itJiiclf by Uic iiicrpai«ing 
imlunition cf its base and by the swelling of the rt^nnal 
(cervical) plands, whidi latter, however, may not occur uiilil 
comparatively late in the disease. The ulceration unceasingly 
flpreeds ati<t deKtrciVH the tongue, &s ksH as invadiiif* a'lja(><-nt 
organs. Tlii-n> i>t aho eont^iderabli' ]iain at night, wliU-h ra'liatcs 
into the ear, and foetor ex ore appears. Speaking and feeding 
are rendered difficult, and salivation and occasionally also 
haemorrhages, occur. Increasing cachexia or a pneumonia finally 
put* an eud to the miser}' in the course of one year to eigliteeu 

Diagnosis. — If the clinical symptoms are doubtful, raicn^ 
Boopieal examination wi]l decide the riuestion. (See p. 210.) 

Prognosis. — The ]>rogno3i8 is bati, for even after eariy opera- 
tion, recurroncps are ver>' frequent. 

Treatment.— ^^'e must eudeavour, as early as possible, to rad- 
ically remove alt the niorhid growth right down into the healthy 
tissne.^ if necefisark'. by amputation of the tongue and extir|>otJon 
of all visible lymphatic glands. In inojx^mblc cases, besides the 
wua.\ symptomatic Ireattuent, x-rays or radium treatment can 
he administered. 

Prophylactic insix'clion of the tongue in regard to |)0(«ab1e or 
existing ulcer* or losses of substance or otlteT jiatholopcal ap- 
pearanoes is desirable. 

Every wound or wart which does not heal after two or Uiree 
weeks after the caiipative fuel on* (sniokitip. alcohol, sharp- 
edged teeth, etc.) have Ix-en removed, jmnicularly in oMer peo- 
ple, should be iwtically excised or de«lroyeti tiy the thenno- 
cautety. Too fretjuent painting with caustics sliould Iw avoklod, 
because it is likely to i lotcrmine the outcome of a carcinoma. 




(a) Ageusia and Hypogeusia.— Complete altolition (ageunla.) 
and diminution tbypogeusia) of taste are due to either periph- 
eral or central leHiun». I'eripheral causes are; Diseases of the 



vral mucous merubrarte, and, eomeiftiently, flml 0} the termwal or- 
gans of tasif: dueaxeg of the none, wliicli diminisli through u&Ai 
obt^tructioii, Uic so-called gustatory smcUiiig (sec p. H}, and, 
owinE to dr>'ne88 of thi^ (iiucnux niciiihraiic of Uic niaulh, rcndcx 
gustatory stimuiatioii diliirvill;r/rWn.v<r^ of the midt^kniT. which 
affert the cliorcia tyiiipani (tml the plexus lynipaiiiciis; liyxpcpiria 
(througli furrwl tongue); lesions aj lU (juMaiary cups (lii-i;ctly 
through too hot or cold food or beverages, drugs (coceuic, 
gj'iniiemfl, ftp.)- 

Central oausrs are: fntracranial diseases in the region of the 
fifth ncrvp, hysieria, and traumatic neurons. 

Disturbance of taste varies according to the seat of the lesion, 
and ifl unilateral or bilateral, and concerns the anterior part and 
margin of the tongue if the lingual ners-e and the chorda tympani 
are affected ; or it occurs in the poelerior part (root) it tin' glosiw- 
pharj'ngeji! nerve is diseasefl. The sensation of the various 
shades of tiisle may be affected in unequal degreeg, 

(6) Hypergeu&ia. — An exaggerated guatatory sense U often 
only an increase of the nonnal sense of taste, but occurs |>atho- 
lo^cally alw, especially in hysterical [it-reons. 

(c) Parageusia.^licrc certain shades of tast-e are distin- 
guiwhcd in a faulty manner, and mostly unpleasantly. It is 
mostly a certain quality, ^hich ahrays recurs. All things 
taste bitter, salty, or foul. It is often, met viith in hyxtwia and 
pregnancy. In other caaes this is due to febrile and gastric 
disorders in which the tongue is heavily furred. lastly, tJiere 
are crrlain menial diseases which are acct>m[)anie«I by hallu- 
cinations in the sphere of taste, or thf latter form only the stage 
of irritallon preceiling the onset of paralysis (ageusia). 

Diagnosis. — For examination of tsste, in the way already de- 
scribed, with regard to the sense of smell fsee p. 16). A more 
accurate tliagiiosie in respect of the cauw and seat of the lesion 
can only lie made after longer olwervalion. 

Prognosis. — The prognosis deix-nds on the cauw? anti si«l of 
the lesion. 

Treatment. — lake uito account the caiiso, anti local treat- 
ment, if at all .successful, could only waisiitt m the a*] ministra- 
tion of tJie electric: current. 


DlttlCASKS OK rub: lUUl'TM. 

(n) Anaestheaia.— Complpte abolition or iliminution of sensi- 
bility on-urs aluioat only in bysteria tuid in certain ijisca.'^s of 
the hrajn or in periphn-al [laralyses of the second and thini 
divisions of ihc trigeminal nerve, and are usually ajisociated with 
di(Minlcrs of wnell. Ilysteripa! and [*ripbpral luiaeslhesiae are 
moHlly unilateral, and CHUtral inaralyKi-s ott<'n bilateral. The in- 
sensitive tongue is easily cauglit between the tcetli and bitten, 
thus allowing lesions; jmrlieles of the food remain, without at- 
tracting notice, on the tongue, Ijetween the clieek and Icrth. 
^viiigrise todeconi[XJsition; andevpndiPfemiccsof tcinpcraturr 
are not jxirrrptiblc to the patient. 

(b) Hyperaesthesta, which is often veryaculein the tongue, and 
may even reach the flegree of neuralgia, known as glossodjiiia 
or glossalgia, is less frequently due to hysteria or eentral disease, 
but is more often eaused i>y neurosis of the fifth nerve: in sonic 
cases it takes the form of radiating pains, the cause of which can 
Ix.' lrar«! to affections of the throat. ». e., lateral pharj-ngitis or 
in enlargement of the foliate<t papillae. GIog80fl>Tiia has aleo 
been observed in gastric or rheumatic troubles and in cases of 
chlorosis anil anaemia. 

Glossodynia occurs in paroxj'sms. spoil taneoualy, or cm the 
attempt to si)eak ; or it is continuous and sometimes disappears 
by itself. , 

(c) Paraesthesia is cliaracterized by various unpleasant sen- 
sations in the tongue, e. g., numbness, heat, cold, tingling, itrfi- 
uig, iMUS Olid DeetUes, etc., and is umially associated with other 
ncrvou-s trouljles. 

Treatment.— Is unavailing if the cause is inacccsMblc. (Hfe 
also p. 125.) 


(a) Paralysis.— ^Paraly^is is cither complete or there is only 
a defect in motility fiKin-sia). 

Etioioffij. — Pandysis of one or »?veral muscular groups la oftina 
of central origin, viz., due to iliKcasoof the brain, as in a)iople.\y, 
tumour, 8\'phili3, ete,, or of the me<!ulla oblongata CbuU«ir ]iar- 
alyos, locomotor ataxia, and dijJitlieria) (?). J'eri])lieral [>aral- 

ysFs in the region of the inoutb, with Uie exception of the Up», 
seldoni occuc- 

SymptoniK. — Paralysia of the labial inu»clcs, usually miilatpnil, 
renders spt^akiiig dilTiciiIt, and blowing up the cheeks im^iossiblp-. 
The angle of tho mouth droops, and the saliva runs out. 

In {iara]y«irt of tlif muscles of niaaticitlion the patient haH 
difliculty in chei\ing, and in bilateral pnralyeis the lower jaw 

J'aralysis of Ungual muscles, oft-en the first sign of bulbar 
Ijaralysis (paralysis glosso-labiorphar>'ngeii}. inhibits articulation, 
chefting, and swallowing; the tongue itw'If lies dabby and flat 
on the floor of the mouth and is thickly furred. Hec^u-se the 
tongue can not be elevatoil, food ofU'n slides forwaals from the 
pharynx in swallofting. Paralysis of lon^r duration leatls in- 
fallibly to atrophy. 

In |)areflis, which often precedes [laralysis, the symptoms are 
less marked. In unilateral paralysis the tongue is pa^ied over 
towards the paralysed ade, and small tibrilkrr" twitching of the 
muscles may often l)e noticed. 

Prognosis. — ^Thc i>rognosiB is in any case doubtful, and the 
more so, the greater the difficulties we exijericnce in rcmovbig 
the caa**, and the longer and more complete (he [MiralyMH. 
Hj/Kteriad and syphilitic )ianilyses have lietter rhimn-a of rv- 
covery; the same may be said i)f those due to apoph-xy, which 
somplirncfi disap|X'ars|iotitaiieouaIy. Periplieral paralyses a'<ually 
allow of a more favourable prngnosix. 

rrffl/m€/i(.— Must take into cousitk'ration the causes, and locally 
the electric current may be appUed, 

(6) Spasms.— Glome spasms (of short duration and inter- 
nipteil by filiort intervals) in conjunction with tonic fcontinuous) 
spasms, occur in the lijjs aiul tongue in various ncr\'oii.-* diseasea 
(«. if., epilejisy, chorea, hysteria, etc.). Idioiwthic spaamaof the 
tongue alone, on the other liand. an* vf-ry rare. In such cases 
the tongue wagK, U painful, and pm'wed towards the |>alate, and 
6pRakirig and Hwallowing are ren<U>rf?d itilDeull or impossible. 
Tonic sjia-smsof the mastieatory muscles {trismus, lock jaw) occur 
in tetanus, epilepsy, or nieningiti.^, and both jaws are el<?iiched 
finidy together. The clonic form (masticatory facial spasm) 



parotitis ("mumps"), which occurs mostly in children or youiig 
adults, and never suppurates. 'ITie secondary, or Oietastatic, 
infianmiation occurs as a coinpIicAtion of serious infectious 
diseases, e. g., typhoid, scarlet (ever, pneiuiionia, pyiiemift, tuber- 
culoHs, and nho iii carcinoma, and nearly always leads to Uie 
fonnation of an abscess. In both groups the genns of infection 
probably invade the glaml through ihe Stejumian duct from the 
mouth. The incubation in the epidemic form ocoupies from 
three to twenty days. 

Sj/mptorm and Course.— The discai* begins oftOJi, but not 
always, with slight pn^Jronial fever, a feeling of tonwon and pnin 
below and in frnnt of the ear. A swelling soon apijcap* liclow and 
in front of the car, wfilch reaches behiiui to tlie mastoid pmress, 
below to the angle of the jaw, thus broadening ami di-sliguring 
the face. Tlie oilier glands are somi^tlmes involved. esjietMiilly 
the Bubniascillary and Kublingual glands. Tiiere are ease.s in 
which the disease is locatised even to the subnmxillan,'. and it 
may happen that in one family one member gets a swelling of 
the parotid and the other only of the submaxlllan,- gland. 

Tlic aubjoctivo syiiiptom;^ an- a feeling of tension and pain, 
e«<pecially on the attempt to ojien the mouth, nuliating into tlie 
neigh bourliocKl, and tlie neck \s i^tiff, or the heail may cveji lie 
drawn to one side. There ia sometimes salivation or stcmatitis, 
owing to the mouth Ijfing inetliciently cU>an»e<.) because of the 

Tlie coimae is always short; fever is mrMlerale, and increases 
only if the otlier glands are affeclwi or other organs are impli- 
cateil. The mowt eonmion compiicalion Ls an inflammation of 
the testielPH (orchitis); usually one testicle only, and mostly 
the rijcht, \e affectal; sometimes also the epididymift. The 
orchitis, though often very painful, never jMUsfeH on to suppura- 
tion, but sometimes atrojihy, and consequent imijotenee, may 
follow the inflammation. 

In women an analogous swelling, though not no frequent, is 
founil in the breasts, and of the internal and external genital 
organs, efljjeeially of the ovariew. We ntJll lack the explanation 
of the connerlinn l)et\veen the parotid and genital glandx. Other 
eompiicatioiis are occasionally ubservvHl am the renult of pret^ure 



DKKASEfi OF THE uocra. 

on thr M-i^bouritig organs or vpf»>l5, e. g., biunng noiees in the 
mr, difficuliy of hearing and in sn-allowing, faowsenen, dysp- 
noea, etc Further coniplications again, e. g., endocardilis 
ftod pericarditis, artfantis, menin^tis, are probaUy doe to the 
wiK infection. Such Kvere compUcations, hown'cr. very seklom 
occur, aitd the averaf^ coura? (A the dismse takce from «d^t to 
fourteen (!&>% but oflcn not 90 long. 

Metastatic parotitis takes, irom thr onset, a much more smous 
coone. It usually leads to suppuration, and involves the facial 
nerve. The aliAoeas, if noL artificially emptied, bursts outiranlly 
or into tlx- car, or tiic yuppuralitHi afTrct« other nei^bouring 
orgBn!>, li-juling to smouM coniplicattoiui. 

Dioffnims.— The diagnosis, witfi due respect In what we have 
nid, is eaity. 

TreatmeTU. — Epideniic parotitis does not rH|uin* t<pe«na] 
treatment, apart from eon 1 plications. In onler to relieve the 
tension, on ointm^tt of olive oil or other ranbrocation can be 
rubbn) on. AIjsckwsps sliould be early incised, care beinft taken 
to avoid the facial nen.-© and blood-vessels, laolation of the 
patient may be desirable. 

(b) Inflammation of the SubmaxUlaiy and Sublingual Glands 
(Lymphadenitis Submaxillaris et Sublingualis). —The inflamnta- 
tioii (if tin- .submaxillary giiuul, concomitant with or replacing 
epidemic parotiti.s has been de^tcribed in the previous chapter. 
(See p. 224. > 

\\V ive Fiubmaxiltary lymphadenitis frequently occurring in the 
counte of acute infectious diseases, as in scarlet fever, measles, 
anpna. ilijihtheria, stomatitis, etc., ceixvialty in so-called mixed 
infectinnit, and it leadfl eoin|iaratively often to suppuration. 
The t<ublini;ual gland itf lem fretguentiy alTeetod. 

Titatment.— The treatment at the TOramenccment must con- 
sist of tJie application of hot fomentations, especially in the sub- 
lingual inHammation, al^DO in the ti.Be of warm ^i^lcs. I have 
in many ca.scs obivrved the subsidence of the glaiulular swelling 
after the use of Bier's treatment. Abscesses must be opened 

(c) Pfeiffer's Glandular Fever. — Etiolotftj and Pathology.—' 
"Glandular fever" is an infectious dia«sc jicculiar to children. 


wbicli is cliaracteriSKi by an iutiamiualor^- Bwelliog of the super- 
ficial and the deep lympbatk glands of the back and front of the 
neck. The pathogenic pfnn is not yet known. It is pnjliahly 
due to streptococci entering the body by the tonfsil, or more 
probably tlirough the a<lenoid tissue of the nasopharj-ngeal 
atmcc; [X'rhaiH the influenza bacillus plays a part. This 
would at least explain the epidemic occurrem-e of the tltsease. 
Hocfmmjer and Zupj^erl consider glaiiduliir fever as the result of 
an Iriflaiimmtian of the pliaryngeal I.ont^il. 

SyiJtptom^. — The disease coinniwices vvilli high fever, vomiting, 
and shooting pains, and sometimes inilefinitc jjain in tlie neck. 
The neck is stiff, or the hcaii is turned to one or other side. 
If we examine the throat, nothing almomml except 
dtn Ik fouiui; but the jugular and cervical glands, esiK-cially 
those which lie in front of or behind the stemo-cleido-mastoid 
muscle, are swollen and tender. Tlie submaxillary glands may 
alst) l>c involved, but tlie swelling of the lateral and posterior 
cervical Rland* U characteristic, and tlusaccountsforthewTV-neek. 

Profinofiix. — Tlie course is always favourable. After a few days 
the fever al)at*>H, the swelling of llit? glaiuls sulwidea, though 
relapses are not inrn-quent. It oftpn h!ipi>ens that one or other 
swelling jKraists for a long time and simulates scrofulosis. 

rrea/nienf.— According to Henbncr, the course of the disease can 
be shortened by a "sweating cure," and the juhninist ration of 
quinine i>er oreni or rcctutn for two or three ilays continuously. 
I prefer aspirin. J to I tablet jxTdicni (S-grain tablet). 

(d) Angina Ludovici (Ludwig's Angina; Cellulitis of the Floor 
of the Mouth ).^tViV)/f)|7y niid i'dlhohgy. — ^This disease, first lie- 
scribed by Ludfng, a Wiirtemburg phytdcian, in 1836, and 
eailefl after him, is a phlegmonous inflammation of the fltmr of 
the mouth, caused by pyogenic organisms which enter the hiidy 
by a wound of the oral mucous membrane or by ciirious teeth. 
Tlio submaxillary gland is often implicated. 

SymploimandCoursf. -The disease commences with a swelling 
in llu* region of the submaxillary gland, aeoompanie' I , or offener 
unaccompanied, by fever. The swelling quickly Bprea^ls over the 
whole floor of the mouth ami nriphbiiuriiig jMirl of the neck, and 
is very tense; opening of the month and swallowing become 


difficult, and rpspiratioD may bp inippded by comprcasion or 
oetlema of the entrance to the Inrjiis. The akin over tiio sn-oIUng 
reddens, sortcDK, and tiiially gives way, and pus is discharged 
flpontancously or anificiaUy outwardsor into themouth (cynanchc 
gangi^u(K^). In raix^ rami's Uio inllannnatioii subsides nithout 
tlip formation of piL& 

Diagnosis. — The diagnosis Ls easy; I he physician must not, 
kouxver, confound thtr dise-asc with isolates I plilegmon of the sub- 
maxillar}- gland or actinoiuyposis. In the foniier the swelling 
Is conliiio 1 tu the gland, and in the latter a microscopical exomi* 
nation wUl prove decisive. 

Prognoins. — The earlier we can do something, the more favour- 
able it will be. In ver>* acute, but, fortunately, not frequent, 
cascfl, death has occurred with signs of pyaemia or wpticaeniia, 
and in other cat^e?* cold abscftascs have followed in the neck. 

Treatment.— M the c^»nnienc<Mnent we may try to chrrk the 
process by the apphcatifMi of ire, but this in usnally of little avail, 
and then we have six»n to resort to softening methods by warm 
application!* and nn enrly incision. In cases nf oedema of the 
larjTix threatening suffocation tracheotomy might 1» required. 


Etiology and Pathology. — Salivan." calculi, of the size of millet 
seeds to that of a walnut, are hard masses, conflisting of lime 
salts, and ore usually found in the ducts of the subniaxillaiy or 
Bublinguftl. and more seldom of the pamtitl, gland. Usually 
small foreign botiies. which have gained access from outside or 
from the mouth, give rise to the formation of calculi, or the ex- 
uting cause \& a fungus (leptothrix buccalis), especially if patho- 
logical citange:^ in the glands or their ducts footer tlic colonisa- 
tion of the fungi. 

Symptoms.— 01 istmciion of the fwiivnry durta leiwls to painFul 
swelling of the ghindic. eating i-s reiKJcnil difTicult, [lartirutarly 
in (Msv^ of calculi in Wharton 'k duct. If tin? cnlcnlu.s is not dis- 
cliarged inpontaneoit'Oy or removed artificially, suppuration, with 
the fonnntlon of a fi«;tula, may ensue. 

Diagnosia. — Tlie diugnut'is! v^ ba'Wf) on the finding of hard, tuher- 
0U8 masaes, eiUicr by paljxitiou or by probing. If Wlwrton't 


duct is blocked by a calculus, the l*iiigiie is pushed up, anj the 
pwn occurs paroxysmal ly. Calculi in the sublingual duct are 
eoiuetinics visible underneath the tongue, as white, hard, sliiiiy 
bodies, which rarely cause pain. They are not ea«ily mistaken 
for tumours. 

Treatment.— Exp rpssioa of the concretions by massnge or 
direct preiwure rarrly succectls, aud it is mostly neoeiiwiry to 
make an incision. Sometimes the incision of an absocss cauHud 
by a calculus will also serve to remove the calculus. 


Benign tumours occurring in the parotid gland arc cystw and 
chondromata; mnfu/nnnt ijroMhs are sarcoma and careinoma. 
The other s;ili\'!irj' glands are rarely the seats of new-gn)wlhs. 

Symptoms. — Tumours of the parotid disfigure tht* face and 
render the taking of food painful aud dJdicult, or involve adjacent 
organs (facial paralysis, doalness, etc.)- 

Diftgnosis.— The diagnosis is not always easy. On the whole, 
tumours of the parotid simulate, to a certain degree the hyper- 
trophir fiilargeiiipnt of the gland. 

Prognosis. —Tlip progrio.sifi rorrfS|xmds to the siae, and nature, 
and duration of the new-growth. 

Treatment. -^Must probably always Ix' surgicaJ. With regard 
to the rhaiiees of actinolhcrupy, not much can at present be 


Diseases of the Pharynx. 

PART in. 

Diseases of the Pharynx. 



Tlie tihroat (pharynx) forms a tube, which lies in front of the 
vertchru.! cohiiim, and is attached to it by loose connective lissue 
(fascia prae vertebral is), and narrows towards its lower end 
like ft funnel. It rpacJies from tlie hase of the skull to the oesoph- 
agus, and coitiiiiunicalcs in front with the nose, Eustachian tubes, 
mouth, and larynx. Oiie acconlingly di«tiupuishes thrpe sco- 
tioni?, the xippLT or nasal jjurl (iiaso-[)harjiigml si^ace, cavum 
pharyngonasale, epipharj-nx), the middle or oral part (pars 
oralis, meaopharynx), and a lower, so-called larjugeaJ part 
(jmrs laryngea, hypopharynx), 


The na.sal part of the pharynx tonus a space var\'ijig in size — 
in adulta it is of about tlie capacity of a walnut. Its upper wall, 
the roof of the pharynx ffomix pharj-ngis), is firnJy attached 
to the fibnj-mrtilagr) hafilsris (baea! cartilage), and, forming 
an arch, is continuous with the posterior wall, which corresponds 
to the alias and axis. The anterior arch of the atlas often pro- 
jects into the lumen of the naso-pharyngeal 8i>ace, which circum- 
«tann- might sonietimea mislead when making a posterior 
rhinoscopy or in digital examination. 

It is in communication in front with the nasal cavity through 
the ehoanae; below these is the soft palate (velum jmlatinurii), 
which, if contracted^ fonn*' the lower wall of the epipharynx. 
If the soft palate is flaccitlly hanging down, the n&=ial part of 
the phar>iix is continuous with, or payees directly into, the 



The EustacJiinn tut* (lubn KuiiUiphii) opens into the iatcial 
wall by Ji siimll triangular or cliink-Iiko opcmng (ostium pharvn- 
geurii liibue), whicli lies surrounded by a pa^klcd ijiomuience, 
thf' torus tubarius, i cm. bi-hiiicl the atUwJimeiit of the lower 
turhiiiiil bone. The tonis tubarius, which contnina the lubar 
cartilaKr(carlilago tubaria). projects somewhat into the pharjTix; 
uDiJ behind it a groove or depression may be seen, calleii the 

Fumut pbatyagm 

RbrvcftifiloSM bBwUi* 

Blnti* aiitivDuklKlu 

Toiuill!* T'larsnOM 

Dims [ibnryiiEea 'A'kt.] 



Blaatiu naii cnwliui- 

Couchik nuklis _ 

inl*riu r 

Paluiun ifurum - 

PUea ulplnfB.]MtBtmn 

Tulnruaiiy taittnl hy ' 

iuVM1r<r [inllll 

VVIuni iinUiiiiuin 
I'ariBB laterdifl pbujagU ' 


i»iiei» ;tbiir>'iiBi'ln'*l>rt» 

RMVUla [>h<irvig|Kiii 
(RoMnniiillvn i 


b Oatlum pbkTyiiBntm 

lubmi nuuiltvir 


LlVI3(jlitftl|B aillOLTIIJir 

ParlcB donalb 

■ prB«vcrtebr»Ita 

Artnu p liM >[!■»■ 


Fig. 71.— Tlie n&so-pliaryngcal space (after Tobti) (riglit latersl vIpw>. 

pharj'iiEeal recess, or HoscnmUlleT'e recess (recessus phar^iigeus 
seu liasenrtnWer!). 

From tlie piwterior. ihieker, and more prominent part of llic 
torus (labium postpriiw) the pliea Ralpingo-iiharynRea (tubo- 
pharynEoal fold) passes domiwjiniR, the lower part of whieh 
can be peen as a rcvi ftriix* on the lateral wall of tlie pharj'iix 
under patimlopical conditions. From the anterior and smaller 
branch of Ihe torua Clabiuni onterius ppu hook) descends the 
plica nalpinpo-palatina or hook-fold, ending on the back (dorsal) 
surface of the soft [lalate. (Sec Fig. 70.) 



The m. levator veli palatini projects like n ptut from Mow 
into the nicho furmet] by tlie two foklR (einineiitiA m. levfttum). 
(S<'e Fig. 71.) 

The mucous membrane of the naso-pharj'iiffoal space, in the 
region of the fornix, is covered nith ciliated epithelium, and 
shows an tutrnoid, i. e., honeycombed arrangement, containing 
many lyniph-crypts composed of leukocytes and lymphocytes 
or follicles. It forms there a soft cusliion, divided or split up 
sagittally into numerous processes or projections, which, iu 
pariicular casfs, unite suixrlicially and thus form a pocket or 
bursa (bursa jiliaryngpa). This 8|)lit-up [wrtion of the mucous 
tnenibraue in lernipcl pharyngeal irr tiiird tonsil (tonallfl phaiyn- 
gea or £,ii.fcW'n's tonsil). 

The pharyiif^l tonsil is mostly found in children; at the 
age of puberty it begins to atrophy and is rarely met witli after 
thirty. In adultn several recesflcs may be scon, representing 
tlie vestiges of the pharyngeal tonsil. 


The oral part of tlic pliaryiix reaches downwaKls to a plane 
taken through the hyoid hone, and commmiicatesuith the mouth 
in front by the isthmus fauciuin. The isthmus is formed above 
by the soft palate wllh the uvula; ])elaw, by the root of the 
tongue with the lingual IciiLsil; ami laterHlly, diverging from the 
u^Tila, by the palatine arches. One distinguislios the two pos- 
terior arches (arcus phan-ngo-palatiiii), which pass towards 
the vertebral colunm into the lateral walla of the pharynx, and 
tlie two anterior arches (arcus glosso- palatini) wliicli pa-ss on 
to the edges of the tongue somewhat higher and nuin* laterally 
than tlie fii-Nt two. Uetwcen liolh archrs at each side lie^ tlie 
tonsil (Ivn-silla palatina), in the ^mns tunsitlaris, which is ilcejKjr 
aljove the tonsils and form.i tlien' the fossa sriprat^insillaris. 

Tlie j«>ft palate, the rlirwt continuation iif the lianl jwlate, 
is rornu^i by a dnplicatim' of the murous ineiiihraiir'. which 
contains between its layers bundles of muscles, and which also 
sends a process of varying length downwards — the umla. The 
anterior Hurfaceof soft palate is coveri'd hys(]uanH>us epithehum, 
carrying some taet^-bude. The mucous membrane contains 



many nmrous glands, and wiUi tlicir mouths stiowiDg small 
elevations, frequently covered with a drop of Eiiuciiti. (.>n the 
up]«'r (dorsal or iiiLsal) fturface tlie mucous iiu-iiibrane of the 
velum nhou's filiated pjithpliuin. which is continuous with tlie 
squamous eptlheliutn of the uvula. 

The Cpialatine) tonsils are romiml l»y conglomerations of 
adeiioii) tisHue aiid art? a {tart of the lymphatic ring of the 
pharynx. They vary very much iii size and shape. Their 
surface ehowB, like a sponge, numerous round or slit-like 
openings, leading intoequally nuinerouacrj'ptsor lacunae. The 
occurrence in them of cartilaRinous or osseous fragments can 
frequently be noticed; and luuHcular fibres also have iM'en found 
in the ton.sils. 

Acconling to StGkr, under phyaiolo^cal conditions, there i.-; a 
constant migration of leukocytes or lymphocytes tlirough the 
lacunae or sjiaees of the epithelium; and by tlie same way bac- 
teria may |ienetrate into the tissue. Thus the (palatine) lon.'^ils 
form the main gate for the entrance of pathogenic genns {strep- 
tococci, diphtheria and tubercle bacilh). 

Woldcyer's lymphatic ring, which encircles the isthmus faii- 
cium, is* etwcntially oom|K)8ed, as we have seen, of the pharyngeal, 
palatine, and Ungual tontdls; and in these, the lymphatic tisstic 
of the throat is mostly accumulated. But we can also tind 
lymphatic tissue further afield frnm the pharj'ngcal tonsil, pjir- 
ticularly in Roxenmuller^x foMsa, and also in the ptwterlor pharyn- 
geal wall, and not infrequently, some eoxeond>-*diaj)pil ri*Nle.s of 
ailenoid tl.^tiie from the palatinal gland on to the mot of the 
tongue, right t^i the lingual tonsil, thus actually closing the 
lymphatic ring. This, however, occurs mostly in those cases 
in which the a<lenoid tissue is hyperplastic, and exceeds the 
physiological limits. The lymphatic granulations, frerjuently 
found on the posterior pharjiix, nearly always indicate a hyper- 
plastic phar>'ngeal tonsil. 


The larjiigeal jiart of the pharynx pawies into the wsophngus 

at a plane which is taken through the lower margin of the cricoid 


cartilago. The anterior wall of Uic hypophanr-nx is partially 
fdniifit by the iKKsterior wall of llie larynx, whicli roimnunicatea 
wilh liw- tliroftt by tin; iidilii-s krj'ngif^, cuvrrtil by iJic epi- 
glottis. At vaxii Kide of tlie aililUH li&i ii pocket formed by 
the mucous mciiibninc, ralicii .sinus or n-ressus pyriforniis, 
wliirh leatls into itir oc-suphngus: a folil ran be seen in each 
dinii^. callml plica nervi laryjigfi siiperioris (fold of the superior 
laryiifieiil nerve). The pharyiigiM-piglottic liRanients (Ugo- 
meiitapharyngoepiglottipa) extend fn)iri thi' cjilplollip to the 
Intend pharyngeal wall, forming tiie bunier-Iine belweoi the 
valleculae and the pyrifonn sinu.*». 

Muscles of the Pharynx. — 1. ConMrictores Phar]/ngi«. — ^There 
an- tliiT't; (;^^nMt^i<^t^)rs: MM. constrictoros pharj-ngis superior, 
nii'dius, et Inferior. Their action is to constrict or narrow Uie 
pharj-nx. and thus to effect the gliding down oi the morsel of 
fiKid. The up|ier fibers of the suixrior constrictor have a sfjceial 
function. They form, by contraction, a cun'ed projection on 
the |>osterior wall of the phaiyiLX, tlie so-callerl pad of /*rw- 
naiKint, against wf lich the soft palate is lifted by the eontraelion of 
them, levator vi'li |>alaliai, and pi-e.'weil; and «o. by the joint 
action of these two muscles {levator [lalatini and siijierior con- 
strictor pharyngis), tho naso-pharyngeal ffpacc is effectually shut 
otT from the mouth (pars oralis ])lmryripis). 

2. M. Slylopiiarijntjeus. — It isattacliixi to the styloid process 
alwvc and is inserted Ijelow — by one (superior) portion, into the 
lateral wall of the pharynx; and by the second (inferior) portion, 
onto the epiglottis anti upper margin of the thyroid cartilage. 
The muscle enters the pliari,nix between the superior and middle 
constrictor of the pharj'nx. 

3. M. VeliPalalini. — Thn soft palate is moved by five muscles: 
two of (hem, the levator and tensor, arise from the base of the 
skull. The levator arises from the apex of petrous pyramid antI 
the tensor from the spbenoidnl bone. The action of the latter 
(tensor) i.s i o render tense the velum, by shortening its tendon, which 
is reHecte<l roimtl the haniulnr ]»rDces3;the fornicr i levator) acts 
as an elevator. By their attachment to the Eur^taehian lube 
they are able to dilate or constrict tlu-s structure. The levator 
forms' a iirojcottoii on the lateral wall of the [iJiaryiix, called 



the levator |)arl, alreaciy mentioned. The small m. glosso-imln- 
liiius and the broad or palato-phanTigeus nins iii the bouiuny- 
moiiH art'-hf^s, or pillars of the fauces, and Uieir action In f^aid to 
prevent ajiy oveniistention. 

Tlic III. azygoH uvulae- is ftttni'hrvl to the a|ioneuroM9 of the 
hani piilalir, and it* insertpd into Uil- uvula, aiul acts as an ele- 
vator and sliortcner of the uvula. 

All these muwilcs cross a:id intersect intricately within the 
\'eluin. and by joint contraction exerd:iic pressure u|)oii the glands, 
interspersed between their fibers, and thus they also have a 
mechanical, ^MX■.rctiun-^■XI}eliulg fiuiction. 

Vessels.— Till! arU-ries are derived from the external carotid, 
viz.. several branches of the superior thyroid arler)'. The 
internal niaxJIlary arterj' pves off the descending palatine artery, 
which RUppHes the ^oft and hard jmlnte wHlh blooil. The facial 
(extenial anaxilliiry) arterj' gives off the a.^cen^hng (inferior) 
palalinearlery for tlie velum palatinuni and the tonsillar artery 
for the palatine tonsil. The ascending pharyngeal, a direct branch 
of the external carotid artery, ascends with it along the Intend 
pharj-ngcal wall, and ."mppUes the lateral ijarts of the pharj-nx 
&nd Hic KuRtachion tube, and also ^nds brandies to tJie ftoft 
palate. Tlic spaee is suppUetl by branches of the in- 
tfrnal maxillary, viz., pharyngea Buprema. Vidian arten,-, and 

Of great practical iniportanre is the relation of the palatine 
tonsilKof thoneck. (See p. 170.) Tlie internal carolid artery riins 
I| cn». behind and a little laterally to the ton.sil, separateil from 
thp latter by muscles, fat, and loose connective tissue. In the 
nonnal course of the arterj- there is »io dnnficT of injurinf/ Ihe 
v<4sel during loniiUotomy: besides parenchymutous bleeding 
from tiie tonal, the toneiUnr oriery, which is very variable in 
itH origiti and course, is more in danger of being injured by the 
knife. The cxternni carotid lictt '2 cm. from the tonsU; that is, 
^ cm. furtiier off than the internal carotid. 

The veins form two plexuses— the pharyngeal plexus oUl«de 
the wall of the phnr>'nx, and the jialatine plexus, lying in the 
soft ]Kdatc.aiid which i».sul»tlivid(*d into an anterior and |(osterior 
{^exuM. Tlie anterior jmlatlne jtlexus conununicatca with the 



lingual veins, thf poBterior wilh tJie nasal veins. All the vnins 
are-' finally collected to open iiilo the interaal jugular vein. Tlie 
lymph-vpsspls show a similar arrangi"inent to tlie veins. They 
run to a plexus of lymphatic glands, which are situated high 
up on the ixjsterior wall of the pharynx, at the bifurcation of 
tlie common carotid arteri,' ajitl laterally to the lafjiix. 

Nerves. — The nerve-supply of the pharjux is very complejt. 
The sensory nerves are derived from the pharyngeal plexus, 
whioh is formed by tlie pharjugeal branches of the vagus, 
glosso-pliaryngeal, superior larj'tigcal, and superior cervical 
ganglion of the sympathetic nerve; partially, also, from the 
second division of the trigeminal, whirh, by the rami palatini, 
suppliea the anterior face of the soft [jalate. 

llic motor ncr\'CR arc di'Tive<I from various sources, which. 
are still thesubjectaof disagnfincnt Iiotwecn various authorities. 
The II). tciL^r palati is supplied by lite third division of the 
trigeminal (otic ganglion); the re^t of Uie puhitine muscles by 
the facial and spinal acccftscyry nerve; and, according to lUihi, 
by the pharyngeal plexus alone; the latter prrjvidcs also the 
moUjr nerv<'-supply for the muscles of the ]>har\'nx {constrictors 
an<l Ktyloi^iarjTigeus muscles). 

The secretorj- nerves are deriveti from the facial nerve through 
the chorda tympani. 


Apart from it« inKigniticaiit nlmre in the seniiie of taete, the 
chief function uf the phar}-nx lies in respiralion, deglutition, and 
j^onalinn, and it is cKseiitially its complicated muscular appar- 
Utiui which performs tlu'w duties. 

In normal, qiiiet respiration through the nose the current 
of air [inss^s thmugli the phar>'nx. whereby the root of the tongue 
and the soft palate approach each other; in respiration llirou^h 
the nioutli the tongue and the velum ]«ihttinuni >v|)anite, the 
latter apprnaching more or less closely to the posterior wall of the 
pharjnx {pad of PasMvant). 

In reganl to digeslion, the phaniix is efmeemwj in the action 
of swallowing (tlf^lutition). Tlie luortH-t, niaiiticaled luid salt- 



vated in the mouth, is pushed backwards by the tongue pressing 
it against the hanl [talato. Simultaneously, (lie nasal cavity 
is sluii off by the jaiat contraction of tlie levator paUiti and 
suixTJor constrictor. (SSee p. 238.) The necessary clo.'iuri' of 
the lar>'nx is efitectwl in the following niannpr: the kn-nx i« 
Uftcd upwards and forv\-ardi>; ihc hise uf tlie tongue is drawn 
downwanls and backwarda;an(i the epiglottis is dcpn'ssed against 
the entrance of tlie Iar>'nx. In this way the danger of faulty 
swallowing is avoideil. The swallowed niaxs, epille inimalerial 
if it be solid or fluitl, is. so to sj»eak. MTiiigfd with grnal velocity 
down into the stomach through a hollow s^iacp i^ut on all skies. 

The signifieanee of the pharynx in iJintintion (sjH'nking and 
singing) has been rcterreil to in the physiology' of the oral cavity. 
(See p. 175.) 

The function of the lymphatic ring is still a matter of contro- 
versy. .\ccQrilinp to Sdiocncmann, the tonsilmare in their physio- 
logical function equivalent to the other peripheral lyinplmlic 
glands, an<l muBt be regardcil as organs of ahsor|)tion : he con- 
siders the phaiyngeal tonsil as the most atlvanceij outpost of 
the lymphatic system of the neck. The enlargement of the 
]>Iiaryngeal tonsil so often .seen in chiltlren as a product of hyjier* 
plasifl, but not of infiammalion. would then — at least v«ry often 
— nierelv aiii^wer the purjxxso of increased function required 
iluring childhood. The pharyngeal tonsil, on the other hanil, 
acconiing to Srhaenemann, may also enlarge without such need 
on the part of the organism, and here the byporpla.'^ia would bo 
ooneideivil as a dif^ase sui generis, requiring operation if it 
causes trouble. 

Briegcr, in any cas' of liyjierplaaia of the iiharyngeal tonsil, 
(iecs, from a lelrolitgical |)oiiit of view, a useful institution of the 
body, '"an cidargeuicnf nf tlie organ for tlte purjwsc of inc-ti-a-sed 
function," but thp "Increaseii function." in his opinion. 18 not 
that of flbKorption, but. in agreement with Stdhr. an increased 
spcrelion. This .secretory fimetinn is not exhausted by the dis- 
eliarge of fluid Heeretion; but there is, in addition, an abundant 
pnxhiction of leukocytes and ljnnphoc5'te8; the former act as 
destroyers (phagoeyte.i); the latter a* agents, perhaps, of the 

antibodies (antitoxine) circiUating in the blood. That would 


Diai:At)i:s of tuk niAitYNx. 

ftKn-i- ivith the fart that the pharjiipeal tonsil is at its hriglit of 
ilevelupmwil in chililliofHl, where a protective power is most neces- 
sary ag«iii(it hai'tcrial invasion, and that it is subject to involu- 
tion ut a laU*r ag(% wht^n a certain immunity a^iriKt infectious 
diwases ix'ciiliar ti» chllilhooil lias been ac>niir«{. Thoenormous 
rpgenerative ixwr-r aluo uf tlu' atk-noii! liwiup, as (foerke cm- 
phasiae3,wouUaKreewilhth(.'a«?ujnptionofa protective function. 

The relapses, which are apjan-nUy often met with after nwlicaJ 
removal, woultl thus, acconling to (lotrke, not be conMdeiwl as 
true relapses, but only as a respotinive endeavour of the lymphoid 
lisaite to increase according to the need for protection.* But 
what does not fit in with Brkgcr'n theory of Ifie protective func- 
tion of the pharyngeal tonsil is the fa-ct that the pharj'ngeal 
tonsil, as well as the sister or^i^ne, the palatine tonsils, very often 
ft)nii the iloor to palhtigenic germs, and that they themselves 
an> verv' often subject \o disease. 

\Vilh ret4[3ect to these theories of Schoefiemann and Brietfer, 
therapt'uticAlly it would Iciid to the necessity of leaving a hyper- 
plastic pharA*ngoal tonsil untouched beoiasc of Its utility a.s an 
organ of si'cretion or protoctive absorption, and to operate 
only if it has grown so larRe tliat it causes obstruction or other 
disturliauwjs (see p. 281); and this standjxiint, luider those cii^ 
cunistannes, sefnia the otdy one justifirtl. 

Perhaps tJif tonsils play a oertain jiart in the digestion by 
moistening the fooil with their mucous sec-n-tioTi. We leave 
it an o[K!n question whether the h'nkoeyl<'.i and lyrnphoeytes 
emigrate I from the tonal;*, are the carriers of a saccbarising 
ferment, or whether they form a pnit*Rtive army in the sense 
of phagotytows; hut in any casp wp will do well not to ovrreflli- 
mat(! this protective power of the tonpil-i. Of gn'ater value ia 
die view tliat the lymphatic ring plays a tMo in the formation 
of blood. To this points, at least, the histological structure, 
whicJi is similar to that of the spleen and (he lymphatic glands, 

* TVaoAl&T iiiK olitor's fcxitnntjt: An uppAn^nt iiratif of IhlH {s the fact that, tt 
a child will) llu- plinrytiKcnl totmil obntnirtivcly nypiTtmnliiril, hoe it n-inuvml; 
anil i[ ut (hat time ihr palatine tonsils be nut ciuartcctf orcvini viniblc. then 
ft>llowinj( on tlio uptrutii^ii. ill u-bout llirt.'o uiuttllui, the palalino loiwiU will 
iiMimil;^ hxvt licpom* irnich hypcrl ropliicil, fr«iucnlly i^o mucli m as to 
nece44iCut4^ rfmovn.1 in lh«r (urn.— !■'. Vi. K. K. 



and also the fact that tlit Ijiiiplmtic ring is greatest in children 
ainl luvolutes wlirn ihc marrow of the bones is able to assume 
llii,s function after puberty is rejiclied. 


Pars Nasalis Pharyngis. — Tlic niotiHMls of cxarntiialioii here 
cuiK'irni'd an- puftcrinr rliinowcupy and digital jmlpatiun of tlip 
naso-plmrviipnil «pan\ Tlicy liavc Urn IrratHi in the firet 
part of tliis book. {See p. 24, et Rcq.) 


Mesopharynx.— Tlii-s is perfonned by pIiaryiiEOSCOpy, inspec- 
tiijn, and pal|mlion, Kor inspectii>n, daylight is sufficient, 
either used directly, or, better, reflected into the mouth by 
a reflecting mirror. A thorough examination is, however, 
mostly ordy popaible by artificial light. In order to get a good 
view, it will be generally nec-e.sHiry to depress the tongue with 
a spiilula or with the handle of a sixxin. etc., which should be 
done carefully but firmly, and with all due regard to the patient's 
anxiety nr excitability. In spite of everj'thiug. it. will often 
happen that the paliml retches, a circumstance which compli- 
cates the exaniination, although soniotinies it is not unfavourable, 
because it might then allow of a (luiek sur\'ey. The examina- 
tion beeometi vor^' uii|i!casiuit iu those cnses where the patients 
arc so sensitive that even Ihe simple opening of the mouth causes 
retching. On the other hand, it is an easy matter with those 
polinits who arc able to keep the tongue dcnti flat without any 
artilifrial means. In onler to ins|>ect and pmbe the lateral [larls, 
rs[HTially the region of the tonsillar sinus, fully, it is necessary 
to turn the patient's head suitably or to look at it from the siile. 
It will sometimes he necessar\' to push a-side the anterior jmla- 
tine areii; in the .aame way a long uvula has to be pushed out 
of the way by a prol>e. 

In resistant rhiltiren, who clench their jaws, one can succeed 
by cloning the nostrilw. or allowing a third person to do this 

until the children are forced, by Biint of breath, to open the 
tnoulh; a spatula cjin then l>c quickly intrwlucwi. 

In casee of need, a way may be found by means of the gap 
behind and bc!tvvc('n the molar teeth and the jaw. 

The jiars oraliw ran In* digitally pal|Miti'ii, and also by means 
of the probe.'. I'or tiie riglil »idi' of lltr jiharyiix iiitrotluci- llie. 
right finger; and for the left side iiitnxliu'e the left finger. In 
the digital exatninatioii of eJiildreii precautions slioiild be taken 
to protect the finger from being bitten. (See p. 26.) 


The ex^amiiiiitinii of ihiw |>ari also aini|iri6es miijieetion and 
palpatiuri. Iiw|,ieetion is done in the same way as laryngoscopy, 
u e., by the aid of & laryngeal mirror. Usually the inspection 
of the root of the tongue is coinbinetJ with this examination. If 
the tongue it* suHicieidly preiv*e(l domi. a part of the epiglottis 
liecomes viable, In adults we can reaeli. by the introduction of 
the index finger, usually as far down as to the fifth vertebra. 
The hyoi<i bone and tlie epiglottis can be ]>al])ated best from 
the front. For the lowest part, of the pharj'iix, wn Kiclen and 
Gerher recently flescribed .sjjeeial methods. 

The first has devised a so-called laryngeal le\*0r, a firm 
tit/^l laryngeiil proW. Having previously aiinesthetijMxl all 
du' pnrts. the straight proximiil jiortioii of tlic prubo '\n pressed 
against the upixT molar teeth, or should these be wanting, against 
the corresponding part of the upper jaw, which latter acts as 
fulcrum ; and the distal blunt end being [jufhed througli the vocal 
eordii a? far down a.-* the cricoid cartilage or tracheal rings, and 
llir larynx is then drawn forwiinl. (Sec Fig. 72.) 

For (he sueceNsful jicrfiirniitiicH' nf hypoplinryngosenpy it is 
iinportaiil that the anicriur imisclc* of the neck sliould lie 
relaxeil, and this can he attained by a slight forward inelina- 
tion of the head. (7erA*T makes the exniiiination. which he 
ealLs pharyngo-laryngoscdpy, liy rncan.s nf a sjmtida lH>nl at 
till* forward end to an obluw angle, the introduction of which 
JR made easier if the patient swallows. 

By both these methods the larynx, without any great incon- 
venience to Che [jatierit, i* drawn fyrwanl from the vertebral 



jective sj-mpfonis rofor not only to the throat, hut n!Bo to the 
nose ami mouth, lus the disease of the throat is verj' often in 
direct connection wUk ^at in the nose or mouth. Tliereforo 
tiic patient naturally complains of the sanie symptoms, as we 
hdvi- alreaily drficrilioil, in the resjyective sections of Parts I 
and II. We will here mention only the subjective s>*mptnms, 
which refer to the affections of the throat; these are; general 
syiiiplonis, disonlen* of sensibility, of nutrition, an<l of respira- 

(a) General Symptoms. — Tlie acute inflanimatori' processes of 
the thnmLanMisiEally aecniiipanicil liy fever, which may some- 
times Ik" very bi^h. or tnanifp.»it itself by rigors, lassitmie, pains 
in llie head and tindis, nii<l Iosh of apfir^tite. Tlic local a]>- 
pearanccfl 4lu nut always correHpoml with the E^'mptoms, and 
may Ik:- estremely iii^ipnlHcant. 

(6) Disorders of sensibility mostly occtir aa various forms of 
pain, e. g., dy.sphagia. This may be continuous or appears on 
swallowing fooil (soliil or fluid); it may be still oftencrcsiuHcd by 
the mere niovenienti* of swallowing, and may radiate towanls the 
ear (through the auricular branch of the vagus); in other cases 
tlie patients complain of various abnonnal sensations, r. g., 
buniing, itching, soreness, feeling of a foi-eigii body. etc. Such 
sensationj*. however, would iwint to nouraiithenia or hysteria, 
if the result of the examination were negative. Xorv'ous or 
hypochondriacal pationt? prefer to localise in their throats many 
of their complaints; but the localisation is usually veiy indefinite, 
eomelimes even very i}cr\'erse, and not the lea«l of the.** is the 
fear of cancer or consumption ; and often 8>'pl)ilitic men. haunteil 
by their fears of syphilis, worry themselves and the jJiysiciau 
concerning their throats. 

(c) Disorders of Swallowing.— The patients complain tJiat 
they cannot swallow, or can swallow only with difficulty, nnd 
that the morsel sticks in the throat; or that lliey swallow tlm 
W7«ng way, which means that pari of the food reaches the larjmx 
or now. The first points to new-prowih. affections of the 
tonsils, or rotropharyngeAl abecesa; and in the latter, to defects 
of the hani or mft palate, paralysis of Uic soft jialate, bulbar 
paraly»i6, or oUter diseases. 



(d) Disturbances of Respiration. -The cause of obstructwl res- 
piration iiiiglit U* fuiiiiJ ill tlic nUM>-pliar>'ngeal s|»icc, e. g., 
alrnokl vt^rlations, turriouns, iulhesjoiis, etc.; t htm the patient 
may ctHiiplitin of riasal r)!>«trurtn>ii. If tht- ini])('(!iiiicnt lies 
in the oral or larjrigi-iil [mrt of Uu- 111 rout (al>sces8. tonsiUar 
afTcctiotw, oXc), bix-atJiiiig mJso lliroiigli tlii' mouth is obstructed, 
ami Hie jiatipiit ('(niiplaiiw of want of breatJi, which, OR|)eeially 
ill UiH rfc.umbi'Ut i^xj^itiijii, iiitjihl aiiiount to & sense of choking. 
(See a]so Part I on Oriil lii^spiration and on Disturbances of 
Voice aiKl Spwch. See j>. 33.) 


I. Pharynx.— The examination begin.** witJi inepcclion of the 
section which Is most easily seen, t. e., oral [lart. At Ihe mine 
lime, fetor will U? [xTreivfU, and we next iiispecl. the na.-tal 
jjart, anil lastly tlu^ laryngeal part. KxHinlnation i.s conipletetl, 
if oeetl !», by paljialion, and in sixrial raises by a microscopic 
examination of tlie .--ecretions or Ibwues. 

(a) Oral Part. — \Ve look also, en passsant, at the ant**rior 
portion of Ihe mouth, for in many di-seaaea Ijoth regions are 
affected. The hue or colour of the mucous membrane depends 
much on the kind of illumination. In daylight or incnndeftcent 
ga^ilight Ihe nmcou.4 membrane looks Ughter, iK-riiajw even a 
liUlc anaemic. With oibLmijis or electric light il api^cars 
more yellowisli. Tlie anterior iialatine pillars and the uvula 
are generally brighter than the rest of the phar>-nx. and the 
posterior pharjTigeal wall, as well as the jjnialine velum, are 
usually darker and sliow greater injection, which rontra.sls 
vividly with the lighter colourttl neighbouring parts. We nuist 
estimate the<listance by insjieetion as toshow bow far aftart are 
the palatine velum and thcposteriorwaUof Ihe pharynx. If the 
distance I>e comjwirfttively hirge, we think of new-growth in the 
naso-p]mr>"ngea] f\>!iro or of mienoid vegetations. The re^on 
of the palatine tonsil sliimld Ik* carefully examined. (See p. 2-13.) 
In order to have a lietter view of Ihe poisterior pharyngeal wull, 
we may ask (he patient to say "e" or "a," which is also a good 
test for the function of the soft palate. 

We must observe tlie a-cretionj?, lh«r quality aiul quantityi 



and any alteration of tlieni. /Hmenwd .Ktrretion ts found in all 
kindsot Ht'ut<'u"d cliroiiic hy]»«*rlrupIiircatHrrhal indamiiialiuris, 
in iitflatiinialioii of the txHii^I^, and in new-giTjwtbs uf tlu> phanr'nx. 

Dimimiiion of ^creiipn occiirs in all intlainnmliims accompanied 
by alrojAy. 

■^^'p rnuMt note if thf .secretion is wator>'i muooiw, niueo-p\iru- 
lent, or if it han iJu- inclination to dry U)X)u the [KKtterior pban'n- 
geal wall, forming scjdis ur rrii-sts (jiarticularly in breatliing 
through lilt iiKiutli.lii alropliir prwce^stt*, in infianmiatiojiof tin- 
main nastal or ItK areesitur)' cavitieii, and when the see retiontc flow 
down into the pharj'nx). (Sen p. 135.) This is often aecotn- 
panied by a seusaliun of ilryiH^ss, of huniing and irrilalion, vma^ 
ing cou^i, ele. Tlie nasal [lart of the pharynx is usually 
more markedly nflfected lliaii Ihe oral part. The seoretions 
may be found at times blootl-stained in cases of ulceration, 
tumoure, or abscess, and any admixture of soot makes it grey 
or blaek. 

On inspection of the oral part we must also ascertain if there 
exurts fetoT e phanjnire. In the region of the jJiar>*nx, tonsillar 
concretions, ulcer, or gangrene of the tonsils anil naso-pharynx, 
decomposing tumours, or abscesses are all eaw*es of a foul smell. 
One must also, of ctjurse, look out for possible causes of fet<M' 
ex ore (dental caries, affections of mouth and tongue) or for 
rhinitiii foetidu. (See p. 33.) 

(6) Nasal Part.— For |wsterior riiinoRcopy and digital cxam- 
imHion of the naso-pharnigeal spaec see p. 24. The mucou-s 
membrane of the opiphar}'nx \a usually of a brighter red than 
the oral )>arl. 

(c) Lar^-ngeal Part.--We notice on inspection afTeetions of 
tlic base of tin- tongui' and of the inlniitus larj'ngis. As to 
(hi! value of hyoirfiaryiigiwcopy, we refer to what we have sakl 
above. (See p. 244.) 

Digital examviat ion muMt always follow where we e«nnot gel 
a complete oltser^-alion of Oif pharynx, and in other cast's, in 
(Htler to examine the eonsislency an<l exlen«on of a tumour 
or an abBCPw*, or in < Uiubtful oa.'»es. lo uncertain the size and i'eat 
of a foreign Iwly. Occasionally the prol)e here renders good 




A grpat ruiniberof the dis('iist'.s of the throat arc, as has already 
bet'Ji iiipiitionptl, of wcoiulary nalurp, following or complicating 
an afTeclioii of llu' or mouth; as it is rare for a tjiftoa-st- 
of tlie lltroat to t^pn-atl into the nose or oral cavity. MuE*t 
coiuiuonly the mouth and throat are ntTectal at one and t!ie same 
time. In any cat* the nope should never be forgotten. The 
car is often involvetl in disca«t!t» of tlie naso-phar\Tix. (Witli 
reference to this and the com plieati oris of tlie larynx aiirl trachea 
see Part I, p. IJfi, et seq.) 

Lastly, we desire to mention (he faet the most variwl 
reflex actions and reflex disorders ean be excited in the throat 
in just the same way as we have recounted conccming the nose. 



As in disoases of the nose, so in thnse of the throat, with due 
consideration for the etiologie:!! factors, general treatment will 
often be the pivot of our medieiil rcMJvirees. 

In many cases wc can try to prevent disease, a?, for instance, 
liy hyilnijiatliic methods. In other ca(*es climatic treatment 
ill combination with spa pures may he resorted to. 

Climatic health resorts, for our purpose, are those places 
which are free from dust, and arc protected against sudden 
changes of temperature, and arc of Httte relative huniitlity. 
Tor dry eatarrh of thi' Ibrnat, on the other hand, a more humid 
eliniato, especially the wuMide, is very siiitablp. 

Bathing or mineral-watiT cures jJiould be undergone on the 
spot, where the eliniate and hygienic eonditions are eompara- 
tively best; if this is impossible for some reason or other, the 
particular "water"may be used at home. The "waters" ought not 
only to \v. drunk, but also iiaed for local treatment in the form of 
inhalations or garghng. The local treatment, if such isneccs«ir>', 
miL-^t not lie neglected even at a " spa" (bathing place) itself. 
Tor the simple and not too long-standing catarrlis of the throat, 
the alkaline or alkalo-saline springs are most beneficial fSaU- 



brunn. Ems, Vichy). In the dry affections, "catarrh «ec," 
wliidi arc often aix-ouiijanittl hy digestive disorders, the saline 
waliTs of Hoijiburg, Kissingen, Soden, Wieshadon. etc., are used, 
and they act here as solvents and stimulants lo the secretions. 
In the more chronic catarrhs of a congestive niiture, tJie sulphiu-- 
etted waters are indicated (Ulsen, VVeilbach, Aix-Ies- Bains, 
and other place*), an«.[, in some ea-se-t of marked anaemia or 
clilorwuj!, the steel springs of PjTiuonl, yranxensbad, Scbwal- 
I>ach. St. Moritz. Tara.-^p. As an afler-curo in dn* affections, I)ut 
even also an a priniarj- cure, we may very approj>iial»rly resort 
to the seafflde. The taking of " waters " ii* most suitably c<imhiiicd 
with inhalations in spraying {drv'ing) houses (Salznngen, Reicli- 
eiihall, Orh, etc.). 

rinally, in the diseases of the tJiroat, &s the place where tlie 
respiratory tract crosses that of ulinienlultoii, special atteiition 
should be pnitl to the ([uiility and qiisuitjly of ftHxl and drink. 
Naturally, all irrilaliuii, hy toohol or.upicy eoiidimentsanil ftKids 
or bevenigcs, must be avoided, and alcohol and tobacco cut off; 
but one must not lose the substance fur thi' slmdow in very chronic It is jiust in these cases that the indivi<iuRl pa=ceptibUity 
fur tolmcco and alcoholics is very different. A moderate quan- 
tity of ppiritB or one or two mild cigars a day, in many caees, 
not only do no harm, hut would probably, on account of their 
|M>wer of atiiimlaling secretion, be beneficial. "Tcetotalisation" 
of [laticnts often makes hypochondriacs of them. 

(a) Applications and Fomentatioas. — Cold Applications. — For 
(hie purpose linen compresses soaked in cokl water are need. 
Wring out the compress well, and iK'tween the layers place small 
pieco« of ice, or an ice-bag, or ice collar, both wxapixxl or 
rnvclo|Xtl in linen, may be put upon the pn-viously anointet] 
skin. Cokl appticationa arc indicated in all forms of acute 
irilliunniatiim, pldcgnionous or rliphlheric procr.s«'s. esppcially at 
tile ('(innnciicenirnt of the di.sea.sie, when tlicy will relieve psiin. 
They arc matf rially aidetl by administering ice internally, which 
may lie pven at greater or les.«<T intervals a.« lumps to be sticked 
or MWidlowed or takeu as cnuJied ice (icc-cnaun), etc. 




'arm fovientniiom^.—X linen coinjirpss, about 4 cm. 
broaii, soiiked in coltl water and well wTiiog out, is put rouiwl 
the neck (irregular folds must be avoided), and this is to be 
protected wnlh a layer of ini])crvious inattrial, such as oil silk, 
nnd then covered with a flannel tmndagc, (^li-. Some physicians 
objc<?t to the water-proof layer, and cover the cold compress 
dircelly with the flannel bandage. Each oover should overlap 
the underlying layer by 2 cm. (1 inch). The coniprcsR can be 
changpd cvct>' tAVfi or three houn*, but u&i\ not be taken off 
during thenigliL If it causes itching oreczenia, it imist tlien he 
discontinue)!, or used only at greater intervals, and in the niean- 
titne the skin should In? dufted with powder. 

Irritation of the skin can, in great measure, 
be prevented by anointing the skin previously 
to applying tlio fomentation. The wanu fomen- 
tatioQB (called, in the fonn above <lertcril)ed, 
FriesmiU cataplasms) act by causing hyper- 
aeraia and thus eflect a dispersal. WhetJier 
the hy|.ieraemia produced acta after the manner 
of Bier's treatment we do not exactly know. 

Friessnitz^s cataplasms are indicated in all 
fonnsof phar>ngeal inflammation, in the aeute 
and later stapes; and esjx'cialiy if the jiatient 
docs nut toleiTite the cold application. As a 8ul>- 
stitute for these somewhat intricate cataplasms, 
ready-maiie bandages or felt |Mids may lie used. 

Hoi foment(itions.~Vor this kind of fomentation, hot linseed 
or camomile poultices are applied. They act well as resorbcnts 
and to foster suppuration in phlegmonous proceascs. Cata- 
plasms of lint oil are fupcriUious. 

{b) Treatment by Congestion.— The use of Bicr'» treatment 
by inducing hy|)eraemia has already been sjwkcn of. It has 
\irvn »p]>li('il in the various forms of acute inflamniatinri of the 
(Jiroat, i«rticular!y in angina and diphtheria, witJi j^remingly 
pood results. For the tonsils, flattened cups, fitted with a tube, 
are iL-^ed, an<l if they ai-e a{)pliwl once or eveii several times a day 
for five to ten minutes at a lime, are said (o soon relieve the 
complaints. A final coQclusion has not yet been arrived at as 

Fig."3.— Suo- 

tloii a|i|utrntuii fur 

til« [UIIHJl. 



to its value; but. anyway, it is worth while to tty it as a helpful 
agent in casiv^ of st'ViTo angina. 

(c) Treatment by Drugs. — Wo apply drugs to the niucoiw 
membrane of the throat as fluiiis, in Uic fonn of gariglf?s; by 
brushing, or by irrigation, by ina-ssjige, or us atoniia%J vai«oure 
or sprays for iulialation; or as soUd tablet.'-, ijastilli-.s, lowng(?.s 
ur jxiwck'rs. 

Gargifs, which only come in ronlacl with the anterior surfarr 
of tht- [lalatino veluni, with llic tonsils, and jwrhajts with u 
small portion also of the posterior pliaryngi^al wall, may be givcii 
in affections of the mcsopliar>'nx, especially in the various fomis 
of tonsillitis. In order to convey the gargle thoroughly to the 
back the patient ?liindd recline the head and allow the water 
to How liaekwards, and then, just Wfore a swallowing nioveinctit 
lakes plaee. to <|iiiekly ?pit it out by abniptly throwing the head 
forwarvls. yonic jMitients are so skilful as to Ite able to eject 
the fluid through the nose. 

With reganl to ibe temperature of the gargle, it should 1* the 
same as WHS said of the foini'n tat ions; and hiTiM'six-rieriw is often 
Ibe Iwst leaeher. We wouI(l, however, wani iigaiiist oveiiloing 
the gargling business, espoeially in painful affections; also as to 
iLsing too strong solutions, which ouglvt to Ik; avoided, par- 
tieularly in cliiklren, liecause of the tlanger of nii.s-swallowing. 

Daiicliiiiij is done with a s|H>cialIy eniistnieleil apparaliifi 
througli tlie nose. It* effe<;t coneenus the naso-pharyngeal 
spaw nbielly. Tlie thrnat likewise ean U- dinirhefl effectually 
by means of sprays tlinnigh the nose, or directly through the 
mouth. (For the various methods of douehing or irrigating, 
and eautions necessar)*, see Part I. p. 38.) 

Irikalfllions siTv, on the whole. Iietter .suited for diseases of the 
larynx than for the throat. Atoniieed fluids, vapours, or gases 
are inhaled. If none of the many inhalation apparatus on the 
market are at hand, one ean very suitably improvise surh by 
a jug filled with boiling wat-er anil eoveietl by a funnel, towel, 
or paper bag. 

We must not l»e ioa sanguine with reganl to the therapeutic 
value of all these measures; for the mucous membrane comes 
in contact wltli tlte drug or solution eniployeil fur too short a 





time, and only within a very luiiital area. All that wo can allain 
is a certain looscniug of the sceretionrf and a cli'jui^-ing of the 
niucotii5 Diriiibrmu', yi-l lliis is even wifiicicnl, iti many caw^, lo 
cure the dit%*a%. Tfi£ a-jpjiHciUiim oj drvgs i.v much riurrc effectual 
in the i\ry fonii, as tablets, pastilles, and lozi'iiges, which are riu*- 
golveil in the nioiilh and de|>osi1 tlirir medieinsil 
agents djreetly on to the mucous membrane. 

Tke method of painlinii (W brushing ts still beUer, 
lw?cftuse of Jt.s iriedicinal as well as it^s mechanical 
value; for the same reasons inaK«agc is also useful. 
For painting, brushing, or massapr, Hart- 
mann's or Ba^nnh/x s(MHige-liold«r in 
iiwed (see Fig. 74). and wliieh may be 
eiutily inwrlcd into the nii,su-pluirjiigeal 
spair. Thesjiongr- fjjad of wool, swab, 
ete.) must not he too much saturatetl, 
for ilie lluiil is apt lo fiow ilown into tlie 

In eatnrrhs with copious secretions 
astringents must he Ui«ed, and most use- 
ful of all is silver nitrate (2 to 5 per 
cent). In the dry forms of calatrh. solu- 
tionei of ioilinc in glyp.erine are applied, 
e. g.: 

n, Toili piiri 0.5-1.0 

I><itB».ii>tlidi.... 1.0-2.0 

Clywriii 3(t.O 

Ol. menih, pip, , gtt, ij. 

In acute inflainmalion, jxiinting is best 

Powdered driifp* are not often iisi>«l, 

and then mostly for (he purpose of 

oauterising. Superfluoiu? naustic is easily removed by gargling 

with water or wiping with nioistenwl wool. Tilts will h' un- 

inTerwiir\-, however, if only a little of the caustic material has 

Ixi-n used. 

•TranjiUitiiiK I'llitnr'j" Eiicitnnle: It. i» well to wiro ngnitwl the ifUvffloHon 
pouflfTi. c«prrinlly aitlrin^cnt atirl i|iifuii-raustic powdm. iiKthcrrrnn liHrttly 
doiiln liial wiiiifcasttt or acute I)n:nirluriii.uinlLtiiiwil|nic\]it»jiiui, folltminK 
lullljil iiiii (rcjitnimt, bnve tieri) tlite to thuntC'il rt.'iictiini;llic<irvt>rrn>pira- 

totv pomfasr* und iftling up irritation foUgwcd ilivn bvbnctF-rialinroction.— 

P. W. V. H 

74,— B|x>ii|[«- 


bolder for the throat iukI 
0, llarltnann'i: b, Ba^ 



(d) Electrical Treatment. — Under this liniding comes tHe" 
applicHlitiii of Lb(^ galvuiiic or Taradic runriit in ciuc-s of inasculur 
paraly.'Sfji or tiiwnlera of sensibility. 

(g) Operative Treatmeot. — With regard to local anaesthesia 
or ppueml uarrosi-;, the same which has heeii said for the nose Is, 
Cftoris jmrilm*!!, apjtlieatile to the moutli. Tlio applicniion also 
of the galvaiio-cauten' and of electrol\'¥is follows the same rules 
and principles (more thereon in the special section). 


The tlimiifold niiatomii-al ami f)li\>i(»U)giral rdalions lictweMl 
the not*- and Ihc throat make it cli-ar that hygic-nic and prophy- 
lactic measures suitahlc for Uie one, will be also of much avail 
as reganls tlie otlier; at least, so far as penpral measures are con- 
cerned. Tlierefort', it only rciimins to n!fer in brief to the 
question of " hardeninR" and air liygienc, to the use of aleoholiot 
and toljacco, etc The hygiene of the oral cavity, taken al! 
in all, is idetiticid also with that of tlic phan'nx, at any rate 
of the oral |jart of the phar>iis, which in reality forma an entirety 
with tlic mouth. 

The cleansing also of the oro-pharj-nx follows the same lines 
as that of mouth and teeth. As thet* latter should lie kept 
clean from early HiiKUiood, so shoulil children, as early as possible, 
be taught to gargle. They Icam it soon if they are asktxl to 
take a half-mouthfiil of boih-d water and to Iceep it in the mouth 
whilst they arc told to recline their heatls backwards, and at the 
same time to try and sound a long-ilrawn "r." 

The bo«t habit of eating or drinking too hot or too spiey food 
or drinks is often the cau.«e of diseases of the throat. The aver^^ 
temperature should be for l>eer an'i hock, Uf to lo" (', (TiCf* to 
60°F.);fordaret, 18^0.(04.4" F.); for chamjwgne, S** to 10* C. 
(46° to 50" F.); water. IT ('. (fiS^ F.); tftble-waters, U» C. 
(57.2° P.); coffee or tea, Mf C. (HH" F.); souiw, 30° to 50° C. 
(96.S° to 122° v.); for puddings, roasts, etc, 37° to 42* (0S.0° 
to 107.0° v.). 

Generally speaking, all food or drink is injurious whieh ia so 
hot that it causes burning, or so cold that it produces a wn.4atioD 
of pain in the teeth. 



Etiology. — Malfomialions and deformities of the throat are 
eitluT roiigcnilAl or acqiiii-ed. The fonuer represpnt anomalies 
in growth (inhibitions of growth); the latter are naused by 
ulcrfrative processes (syphilis, diphtheria, tuberculoas, scleroma, 
biinis, or cniiterizfLtionsi, etc.), and are thus characterispil by 
adhpi<inii!^ or strietmrs, 

1. AbnonnaJities of Growth.— To this class belong the cIcfU in 
the region of the soft palatt, which have been already mentioned 
anionfi the uialfi)niiatioii:< of lh« mouth (p. 180). The deft 
is oft<ui liinitwl to tlip uvula (uvula bifida). The lower ends 
of the uvula may, in ouch cases, be .separated from eacli other 
or lie so clow; togethf^r that only tlie probe discovers the cleft 
between them. Sometimes the cleft reaches as far a.s the base 
of tliu uvula, or it is only fahilly indicated by a p"oove. In other 
c&»*'-a tJip uvula is abnonnally small or entirely absent, winch 
latter often poiiit-H to ik'structivc processes or to the operative 
zeal of some (jhyficians. 

Tilt' reverw niiglil also be foiuid; namely, an abnormally long 

In rare cases defects are seen on the soft palate: occjisionoliy 
on one side only or sjtimietrieally on Ijoth sides of the [lalatine 
arches, and are oval or slit-shaixnl. It is doubtful if Ihey are 
always congenital. The scars which reniain after syphilitic or 
dijjhtheric ulcers arc ofU-n sio small aiul indistinct that they 
are overlooked. T myself observed a case of syinnietriral rle- 
fect of the soft iMilate, which was uuniistakahly due to a pre- 
vious diphtheria. 

The tonailg may be mdinientally <leveloj)ed or an? absent, 
OP there may be a supemumeraiy tonsil (tonnilla acccssoria), 
or the ton^-il may hang by a pedicle (tonslU pendula). 

Cftiseij of cxccjwivc growth are backward prolongation of the 
$e)}tuin nariunt into the na^-phuryngeal tipnce; prolongation 




of the etyloic) proccasos ns far as the U«isiln; projection of the first 
two vertebrae lo sucli a degree that the lumen of tlieiiaao-pharjTi- 
gcal space is verj- much iiftrrtiwcd. Also, atresia of the choanac, 
iiicnfioneii b I'art I, wmiltl Im^Ioiie to this class. 

The congenital (bniiichiiil) fistuUc of the neck arc due to a 
persistence of the brniichial clefts, and are altogether of rare 
occurrence. They mostly (jjjeii externally near the stemo- 
clekio-msstoid nniscle, and internally in the region of the tonsils 
or root of the tongue. Of similar oripn are the diverticula of the 
phar}'nx. The niucAUs membrane of the pharj'nx sometimes 
bulges out kterally betwocn the muscles, or [wsteriorly through 
the ix^slcrior wall, forming ptickotrshaixtl or eafciform sinuses^ 
whicli are known a!< diverticuia, and arc; liable to become very 
iriucli i-nlnrg(^i by the pn-ssunr of re-spinition or stafiiialing foo<l. 
'Hie divertiriila seateil in the lowest part of tlie |>hai>"nx, and 
olkserveil mostly in elderly people, Ihe >4i-cftl!nl .senih: dii^erlicula, 
really belong to tlie ocjioj^hagiis, and an* usually acquired. 

Symptoms. — Many of tlie-te almonnalitifs xhow no symptoms 
xvhaU'Ver, and may only be diseovend by accident. In other 
caries speech, reitpiration, and feeiiing are tlistiirl>ed. Cle/t 
palate and other ilefects of the velum palatinum prevent the 
closure of the naao-phajs'tigcal space, causing the speech to 
beconve nasal (rhinolalia aperta), and particles of food find their 
way int» the nose, A tonsilla |K^ndala irrilntc-s tlie throat anrl 
causes coughing and n-trhing. Prolongation of the slyhad 
processes causes disturbances in swallowing. Diverticula, c»\ic~ 
ciaily those atuated lower down, ea-iily liecome filleil with 
food pnine to decomposition, and which rausen a nensatinn of 
choking. Lateral diverticula are often palpable or visible from 
outside, and if they are filled with food, they Inijjart the im- 
pression of a dougliy tumour; if expandetl by air, that of a com- 
pressible cyst. 

Diagnosis. — Many of the anomalies will be recognised on 
simple inspection; other cases have to !» examined by probe, 
palimlion, or iwnterior rhinoscopy. Sometimes the question will 
be diHicult lo deride whether the abnorrnnlity present is con- 
genital tir Hc-ijiiired. In deeply situatnl divcrlirnia laryngoscopy 
or oesophagoscopy will be necessary, but caution is advisable in 






bougie, which Levbe 
bemi at tlic lore end. Soniftinics diverticula can be lelt or aeen 
from the outside (see above). 

Prognosis.— Tho prognosis with regard to rertitution ad integ- 
rum cjfpeinis «n tlie seat aiid the size: of Uif abnonnality; quoad 
\itan], it is always favourable, save from cleft palate in infants, 
and in rare cases of perfdratctl diverticula. 

Treatment. — Some of the said anomalies are a veritaLle noli 
me tangere; others, such ae cleft palate, have to be treated 
according to surgical nile. Pendulous tonalU are seized with 
forceps and cut off, and likrwisp an excessively long uvula, whieli 
causes great irritation. A prolonged 

styloid procciss which can be felt a? an • / 

elastic body from lH?hind the tonal can 
be broken by digital prcs.-iure from 
nithiu outwartla, or after excision of 
the tonsil can be diasectal out with a 
blunt inntnunejit antl then cut off. 
The larger diverticula which are visible 
from tlie initHido may Ik- fxciKed from 
tlie outside; sometJmpji the ]iationts 
leani by thcmselvealiow to empty the 
diverticula liy massage from below 
upwanK Small diverticula may l>e 
cauteriaetl or atrophied by the gal- 

2. Adhesions and Strictures. — Ad- 
hesions occur in various jiarta of the throat, most frwiuently 
in the naso-pharyngcal apace, but al*o in tlie lower regions of 
the tbmat . 

Symptoms. — ^The soft palate is the part chiefly concerned. 
It may have uiiital partially or wholly with the pharj-ngeal 
wall, cither on one side or bilatt-rally ; asnally the patato- 
liharyngeidarrhcsaro firmly at taciicd to Ihe iKiwIerior |Jiarjnigea] 
wall, so that in marked cjlsch the oral part of the pharynx is 
completely sluit off from the nasii-pliar\rigeal space. In other sinuses or folds or strictures an- fanned by the retraetion 
of scars, which alter, more or less, tiie .sliajie of the »oft jialatc. 



plinryiix (aftpr.^cftw/ii; iiiPin- 
Dratioua liaiiil-KlmpKi edhfr- 
sioiis of the loiteiie to i]i« 
poalerior wall o( jjliarynx. 

a, Knot or Ihe ton^t; b, 
iDomtn-ano: e, opniing in tho 
ni*nihri»ne; d, liiini Shaped 
■dlifwiuii of (rin lifick of (lie 
loDgiio lo Uio oTal part of 



In one of iiiy v»mv Um riglit. |«ilal()-pliiir)'nge«l arch was fiitin^ly 
lost Uiroiigli jxwWii|)iit.licrilic ftiriiiatioii of scars. (Sct Fig. 75.) 

In tlie lower part of the pliaiynx the fibrous batwU usually 
extend from beJiiiid or laterally to ihp root of the tongue or to 
the epiglottis. In lliw latter case they nmy covt-r tlie aditus ad 
larip'ngem, leaving only ft snittll afjertureCBtrictureof llie pharynx). 
The iiiconvciiietice dejx'ndsnuich on Ilie extent of tlie luihesions. 
Siuali adhesions in the uaso-pharyngcal sjmcc cause no trouble 
at all, or betray tlicmsclvcs only by a slight nasal intonation. 
In larger adhctn'ion8 the s>'mptoin>! of nasal olMrurtion or of 
iinj)ede(l nasal respiration Ijetwnio nlivioiis. fSer I'jirt I, p. H2.) 
The ear is very often implicated, espi'clally in occhwiuii by .scars 
of the pharyngeal o|>ening of the Ea'Stachian tul». 

Strictures or adhesions in the lower |mrt of the pharjTix caujw 
trouble In swallou'ing, to which di.sturbanees of r(>.Kpiralicni may 
be superadded. 

Diagnosis. — The diagnosis offers no tlifficulties in pronounced 
cases, though exiunination — possibly hyiKi|>h(ir\'ngoscopy -has 
to be oftcji repeated in order to get a clear idea of the morbid 

Prognosis. — Depends on the ftito and circuinfcrraiBp of the 
adlicnitins, aiid is often unfitvourahlr. for tin; reajsou Uiat art iftcially 
dilated fibrouM strictun'-s •ftiuw a gn-al iiicliuation to n-cur in spite 
of earefiil and long-con tinuw I treatment. 

Treatment. — Slight adht^ioiis do not require treatment. 
More extensive or total adhesions justify openilion only if the 
aufferiiig caused by theiu is gn-at enough. Sometimes separation 
of tJie ailhesions by means of knife or soisstors succeeds; in other 
cases the palatine velum has to be carefully separated, and to as 
far an extent as jjoywhlc from the postt^rior wall, and then be 
kept wparatt'd by the insertion of a Ijougie or reiwated dilatations, 
nie operation can be fnt-Ililftf^'d by ini^erliiiK a blunt prolie 
through the nose into the nn^o-pharynx, and tJien pushing or 
buigitig tlownwards the fibrous band. Then the deprcaseti dome 
produced by the prolx! is incised, and the IneiKJon can then be 
eaalj' enlarged by lateral cuts. Keunlon inunt Ix* prevented, 
according to Ilojek and A/. Srhviidt, by systemati(!ally stretching 
tlie edges of the wounils. 



In tlip lower part of the pharj-rix ndhcaons should be eovercd, 
under the giiidaiii^e of the larjTiposcops. ^y means of a blunt- 
IKjin ted knife, iluuhlrrun'tte.urpalvano-cauter}-, and rcadhen-nce 
prcvent<xl by speeially constructed tube-shaped (lilalors (after 
V. Sclirdtttr, Micfuitl, and Jaoibson). Ilypophan'ngoscopy often 
amplifies niotlera, and the disjxjsition to recurrence of adhesions 
is, on the whole, much less in tjie lower reaches of llie pharynx 
than in the upjier na-sal [larts. 

Injuries to thh Throat. 

The phBfjTix is not often PxjMiwcd to injury, bernuw of its 
protect*"*! Hituation; the most common injuriet* (wcurtlirou^i un- 
intentional swallowing of a foreign body. (See p. 318.) Would-be 
suicides usually cut themselves at the lowest part of the phan-nx, 
jui^t 1h-1ow the hyoid bone; ptiil oftenor they hit the larip-nx or 
trachea. Tin- largevcsaeb are fre<iurntly nii«sed. for the miicidal 
essayi^t.«t nearly always cut from in front, while they hold the 
head n-tracteil. 

Sonii'times the pharynx sufJers injury from operation, particu- 
larly by the Icmg and unguarded handling of instruments in a 
nerv'oun, fidgety patient. 

Prognosis. — Depends on the nature and ate of the injury and 
on the coniplicationn (septic fever). 

Treatment. — Iti slight caw-!* tlie expectant methodn are ju.'<ti- 
fied. Ice to suck and jiwulhiw aiul disinfectant garplea, etc., 
arc onlered. For seiiouB injuries, see text-books on swgery. 


The lUvisirm of iJie acute inflommationfl of tlie pban-ngeal 
mucous membrane offers the same diffieultie? as the same diiwases 
of the mouth. Processes of the Hame etiolog)- sliow clinically 
the most diverse pictures, ami their course also varies an to the 
if^nn in which they are fieate<i, and whethiT the superfidal or 
dec'ixT struclun's are aflfected. I have chosen, for the sake of 
gn'ater cleamfxK, the Hinie principle of clasnfication as for the 
diseast.-8 of the mouth. 




Etiology. — Tlie caii«* of acute catarrh of the pharynx are, 
on the whole, the same- as (if atriitp ratarrha.! rhinitis. The dlt- 
ea608 of the nose are, as we know, iii miimat.o cotmwikui with 
those of the throat ; acute cor>-za ver>' often begins in the poet^ 
□aaal ^pact-, or koou h^preads into the latter from the nose. In 
acute rhinitis, as well a« in acutP phar\'ngitis, Itacteria are the 
main cause of ihctliseariO, ami art; rhielly ."In^ptucocciaiui staphyl- 
ococci ; apart from thow otlwr cauj*(*», such as lliemiic, ehcinical, 
and meclmiiica] irritation, which [ilay a not in^jniiHrant r61e. 
In some cases decayed teetli. and jjerhaps even dejitition, inay 
^vc rise to inflammation (denial angina). 

Cliildrcn and young jktsoiis arc verj- liable to get pliarj'n^tis, 
because of their lymphatic apparatus being more easily upect; 
80, also, arc weak or e\hau,stf>d iM>ntan.s, and one could ali^j H]X-ak 
of an individual dispo:qtiiin of jxTdona who .siilTer once or several 
tinu*."^ ill the year from luigina. 

The common !n*lief tliat phao'npti.s occurs oftcner in the 
colder seasons (iocs not apj)ear to U' Imwil on fact, for it is just 
in the wann aeaitona of the year, ei^peeially of continuous dry 
weather, that we obser\'e actual epidemics of phan.Tigea! in- 
flammations, and whirh could only be explained by the inhala- 
tion of greater quantities of dust, the carriers of bacilli and 
source of mierolteji. Iti pure air. free fromdust, as on high moun- 
tains, angina rarely occurs. Tlic infectious character trf the 
disease is also marked by its endemic or epidemic occurrences, 
by the more or less severe disturbance of the gencrd health, 
and, laiitly, by the relation of angina to a whole scries of infec- 
tioiLs (lifvafifts (fM-arlatina, typhoid, polyarthritis, and certain 
erj'theniatous and purpuric diseases, etc.). 

Equally is angina due to the invasion of bacteria, which sui^r- 
vcnc after intranasaJ operations and the use of the galvano- 
cautery. (See p. 80.) 

Several French authors of the present time point out that 
tonsillar angina ImppetiB fre*|uently to one and the same person 
{habiuml amjinn}, and might l)C due to the inefficiency of the 



■thyroid gland [hypoliiyntidism). Accortling to this ;Lheory, 
one would hnvp to cidiisider the thyroid gland as a rej^ulating 
factor of the iiiitil)odie.s or femipnt'S productid by Hw urgauitjni 
for defence against infection. j 

Symptoms and Course.— The subjective and objective symp- 
toms arc ditftrent in proportion to the extent of the inllamnialion, 
that is, if the inflaiiiitiitlury prowe? has affeetcjl the whole or 
only a part of the piiaryiigcal mucous memhrane. It must, 
however, l.* aclmitled that the border-line lietween tlie healthy 
and the affected area is never distinct. 

(a) RhinopTiaryngitis Acuta or Pharyngitis Retronasalis i Re- 
tronasal Pharyngitis ; Acute Catarrh of the nasopharyngeal Space). 
— Of all the tonus of ]>har>Tigitis. this tUcoase is the most 
frequotit in awociation with acute rhinitii*. 'i'he nnimus nem- 
branc is covered witli a copious tiecretion, under which if appears 
reil and swollen after rotiie trouble in R-moviup the prcretions. 
U (he pharyngeal tonsil is chiefly afTccled fpliaryngotonMllitis), 
amilar sigiLS will be found as in acute [mlatDtansillitis; i e., 
be«4les a simple catarrh, a joUinilar inflammation occurs, in 
which whitish nodules or small ulcers due to the sloughing of 
the l_\^nphatie follicles can be swn ; and there is also a lacunar 
form, which makes its appearance if the crj-pt*. sinuses, and 
lacunae are affected, leading to the foniiation of yellowish -white 
calculi or cxmcn'tions, which project from tliese lacunae and are 
oft^n confluent. 

Lacunar angina of the phar>ngeal tonsil (angina phar>ngea 
laeimariB seu phan.'np(>tonsitlitis lacunaris) is certainly more 
common than is believeil. Il i.s owing to the greater difficulties 
of posterior rhinoscopy in the eases of acute inflammation lliat 
il 80 often escapes notice. 

Perhaps eome cases of glandular fever with no clear etiology 
might have their origin in such a lacunar tonsillitis (see p. 227). 
All the fij-raptoms may be concealed by a concomitant acute 

(ft) Pharyngitis Acuta (Acute Pharyngitis; " Sore Throat")-— 
Acute pharj'ngitis is the name of the inflanunation of the mucous 
membrane of ihe (iral i»u-t of the pharv-nx. viz.. of the jiosterior 
pharyngeal wbII and |x)xtcrior surface of the velum [MJalinum. 

2G2 4 

m8EA8E8 OF THE PirAn\.VX. 


h™^ alf' 

The JiiUWrns riicmhraiie hrn^ also w ruil and ewollcn in vjuying 
(IcgHs;, tfitd the st'cretious are at first scanty ami viscous, Imt 
latiT on ticcomc more aljUDilaitt, lluid, glairy, or muMi-puruleiit. 
If the suit palate is alTectetl, it contrasts markecjly, by its dilated 
and tortuous vp.sseis, with the hanl palate. SoinetiniBH the 
latt'ml wftUs are cJiielly cuiicvnicd ipfiari/ii^is hiemlig), or 
the follicles Ihernwlvcs or the [)prifollii'ular area is affected. 
In those cases one perceives brij^ht-red islamls, and within them 
small lowra of .«ub?tanw. e. g., eroaons or uInts, caiiscil hy the 
dcstnuliot) of llii- niurou.^ glaitdt; and follicles. 'Hic uvula, if 
involved, becoiiu-s (fcdcnialoUH. 

(c) Tonsillitis Acuta TAcute Tonsillitis ; Angina TonsiUaris). — 
One distinguislie;* — ll) simpk catnrrlml, (2; }nU-irtiliir. and (3) 
iacunar tonsillitis ; if tliere is present, as the case may lie, a simple 
general retlilening and swelling or an affection of the follicles or 
of the laeunae. 

(I) In simple catarrh, at first mostly iuiilat*ral, the tonals 
arc covered with secretion, swollen and reddened, as is also the 
adjacent raucous membrane of the soft palate an<l its arches. 

C2) In loUmdar arujintt one may notice, besides the j^ignw of 
ample catarrh, yellowish-white specks and pointfi, ecatterwl 
over the whole Murftici*, or arraii^nl more closely tof^ethcr. or 
confluriit. rorn-sponiling to the s^ip|)unding foUides still covered 
by iiiucuuH iiicinbrane, and so fortiiing superficial ulcers. 

(3) In Inciinnr nntjina yell owisti -white eoneretions.or aetiumu- 
lations are fduiid. \%hieh origjrmte in the laeunae and consist of 
leukocytes, epithelial cells, bacteria, and df-bris. They project 
from the crj'pts and often unite on the surface, forming a kind 
of psoudomenibrane, which, however, has nothing to do with 
diphtheric or fibrinOius membranes. 

Diplitberia and lacuntir timwillitis are two quit^e distinct dis- 
eaijc:!*, which ofttai, however, on accfjunt of their resemblance, 
can only be distinguished by the discovery, microscopically, of 
Ldf]la-'s bacilli. 

It may be doubted whether we are justified in distinguishing 
these threeforms of tonsillitis, and especially in classifying lacunar 
tonsillitis (the so-caltetl streptococcal angina) on a separate plane, 
and so treat the hitter as a specific infectious disease. It is 


probably morp accurate to ircBt iheni as one disease, different 
only in the kind of infection, cbiotly by reason of the streptococci, 
but abio by staphylococci an<l pnt'imiococci. The difference 
in the sjtnptoms and complications (arthritis, nnwciilar rheu- 
matism, erythema, purpura, endocaniitis, osteoniycJitis. and 
pyaentiii) are dependent on the quantity, quality, and viru- 
lence of the bacteria and tlielr toxinst 

Even a simple angina, with slight injection of the lnn«ls, under 
particular circumstances, may assume a pyaeinic cbaraoter 
(rigors, arthritic pains, etc.), and it iw certain tliat laciuiar ton- 
allitis isvery often followed by ccjm plications. Hence we shall 
not makes mistake if weconsider this [larticnlar form of tonsillitis, 
and periiaps idso the other forms, as the result of a local infection 
by pyogenic microbes, which, of course, is venr' prone to impli- 
cate the whole organism by way of the circulation. 

Symptoms.— General »!/m.ptonis arc never missing where an 
infection is the cause. The fcv(T might be low, and only iien^ist 
for one or two days, but it may, particularly in children, reach a 
high degree, or begin with rigors and hv followefl by convult*ions, 
all di-jieiidiiig very much on evcntmd complications. Indivitl- 
Uttl predisposition 'm a very .strong factor. There are people who 
siiow M higlii degree of fever for a niiniinal affection of the tonsils, 
and others who, in the severe.'it attacksof tonsillitis, suffer from 
only ulighl fever and general disturbance. 

In cases of high fever prostration is vcPr* pronounced, and is, 
moreover, complicatal by pains in the hca<l or limbs. 

The subjedive sijmptoms generally depend nmoli on the wat 
and extent of the diseaHe. Pharyngeal tonsillitis (acute retro- 
na'wl catarrh) causes accumulation of mucus in tlic throat and 
nose, nasa] obstruction, and renders sjx^ch and swallowing diffi- 
cult: wherett-s, in acute palatotonsillitis pain on swallowing, 
railialiiig often to the ear, ia most pronounced, particularly at 
the riiiTe atlenipt at deglutitinii. The nuhmaxillarj* glands are 
tender, the voice raucous and niufned,and Ihere may be difficulty 
in breathing if the tonsils are much swollen, especially in cliildren. 

Comj^icalimK are, on the whole, not frequent, but it may 
be often oiiftervcd that an acute jirocetw of Ihe na'^o-phan.Tix 
eucroaclica on tJie region of the luistachian IuIk: and the middle 





ear, which i^ tnamreslal by tinnitus, difficulty of hearing, or, 
in w\'ere cases, by agonising pain in the region of the <'ar aiul 
by (li>icharge from it. In some cafes of slrpplococoal infrcliou 
nict4Lsttu«s in other origans hare been noted (»ec alxive), and 
iiifiaiiimation of the palatine tonfiils may sprea<l into llm pcri- 
lonsilinr lissuo, gJvmg rise to a jx'ritoneillarabsw'ss. (Sec p. 260.) 

The course is dptermllied liy the complicationa, and if not 
oomplicatetl, the cases take from five to eight days to recover. 

Dinfino-tis. — ^The (ibjoptiveaml subjective ^niptonisari> mostly 
uniiiistHkable- U the syuipuiiiifi are not very proiKjuiiceni, an 
affection of the pharj-iifieal tonsil should be remembered. Of 
great importance ie the differential diapioas between lacunar 
tonsiUitis and diphtheria. There are cases, especially iu chil- 
drtrn, where the rlistiiietion is very difficult, and even a micnj- 
scopieal examination does not always serve to elucidate niatt4.>r!s, 
ami we are then surprised if a subsefjuent |"iaralysirt reveals the 
true nature of an angina, which, in the iirst place, we conj»dered 

It Is perhaps liest to tn>at any doubtful case of lacunar ton- 
allilis as if it were true di[>hLheria, ami thus* we prcuccl ourselves 
i^iiLst surprise and repnwieh. In peiieni] we miRht treat any 
caec as diphtheria, even if microscopical examination is nrg;a- 
tive, where the fur or coat i." dtrty and slimy, and et^reads from the 
tonMis onto the neiRbbauriug tifwues, and in which, fnnri tlie ont*t, 
severe eymptonis, such as high fever, Rinall and fn^jucrit pulse, 
ai!<i prostration, etc., apjx'ar. 

Prorfnom ia niOKtly favourable, but, after all, we shoidil not 
be ratii in fon'telling m\ al)Ni)hitely favourable eounte, because 
severe corn plications might occur at any lime, even when, at 
Bret, the disease' was slight, for a diphtheria is not infrequently 
concealed tJiruuglmut. 

Tnatmmt. — Copious diaphoresis sometimes suceectls in arrest- 
ing or, at least, in shortening an attack of acute tonsillitis. Ttiis 
is done by means of hot drinks and hot jiacking the whole 
body, tisually, however, we are called in loo late. .Aspirin, 
ftalipyrin, phenacetin, pyramidon, etc., arc very useful at the 
beginning, and so, also, may be a pui^tlve. 

Ice, at fintt, applied internally and externally, and later on. 


Priejssniiz^s cataptasnis, ought to be administered. For gargles, 
I prefer the liquor of aluminium acetate, one or two teattjiooufiils 
in a tumbler of coUi or tcpiii water, or a simple solution of com- 
mon salt, one teaspoonful to a glass of water. 1 also prefer to 
preseribe fomiamint tablets, every one to two hours one tablet, 
anil menthol lozenges (four or five ilaily), for the pftitis tm swal- 
lowing, or AveUi's angina pastilles, whicli emisist of atitipyrin 
and cocaine (caution with rospect to antipyriii rarfies!). 

Jn scanty or viscous wcrttion a solution of boric acid in 
glyeerine is very beneficial (acid, boracic, 2U.(H); ad glycerin., 
2()0.tH>; a tablospooiiful to a glass of cold water). 

In the mililer cases and in children, liesidea general Bystemio 
treatment, fomentations and gargles will be all that ari- rcrpiirwl. 
Food niUst be, at least at the beginning of the diseaw, cold and 

Complications must be treated as the ease may require. 
Prophylaxis should be directed to a reasonable hardening, in 
order to reduce the disposition to tonsillitis. If the angina 
shows a tendency to recur, removal of tJie enlarged tonsila is 
justified, though it does not always grant absolute bnniunity. 
In gc'iiiTid, one i^liould delay any tonsillotomy in acute angina, 
as witli all or>erations, until the inHanmiation has entirely sub- 
aded. ftir there is danger of exacerbating by again stirring up the 
germs of the disease, which were jierhaps already declining. 
Severe cafies of lacunar angina should be isolated. 


Etiology and Pathology.— The seal of a phlrgnionous inflamma- 
tion may be the mucous inembrajie, but it is chiefly the subuuicous 
tissue All parts of the pharynx may be affected, l)Ut the S'at 
of predilection, however, is the loose connective tissue around 
the tonsil, or in the retrophan-ngoal tisBue. Less frequeDtly 
the Iflti.^il-- themwlvc.'^ are affectwi, resulting in tonsillar abseepses. 
Senator has flp,«cribefi a form of infectious phlejnnon and er>'- 
aipelaa of the pharj-iix which are closely related to each other 
in regard to elinlog.v, and are ditlcrcntiated only, perhaps, by 
the varying virulence of their gennt>. 



AU ilieee cases ar*- t-auwHl hy aii iiifiwlion wiili pyogenic buy 
tcria, cncounmwl or fftvourHti i»y cariouB twih, prypiK, or Poncrp- 
lioiis of lilt' tonsil ur by intranasal ur iKiwMiawal oixratiuns. 'ITiis 
miglit help to explain the Ufiik>ncy of the plilpRnion to recur, 
which i« «i cimspicuous a feature in peritonsillar atx*wje. Tliere 
caiiitut 1)1.' any ilinilil liut tb&t analj»eeK:4 of tJie tojisil might cjiUKt 
a jKTilon.sillilis; iiMially, however, the inflaiimiation is priiiianly 
Cditabli shell in the {M>riton.sil)ar tissues. 

The lymphatic: glaiuLs in the prevertebral conneelivo tissue 
at the level of the seeoiul ami ihinl vertebrae, and whieh Utpn 
to atrophy alxml thn fiflii year, play an iniixirlaril [lart in the 
etiology of the retro pharyngeal abseess obs(?n'ei] wmietitnes in 
infants. The ghuitls areallackwl by various niiei-obes ami l)e- 
coine iiiHaimtl and swollen, like a bubo ( retro phar}'ngeal 
lymphadeoitis). Apart from this so-tailed priVriarj or tidtopaMic 
retroj'haryniteal tib:<fess, there comes under obser\"alion a t^ec- 
oiidary (orni of al), which has ita origin in soine tubercular 
or syphilitic epondylilis. 

Erysipelas o} the throat is caused either through iJie direct 
invasion of tlie cocci of erj'sipelas into lesions of tJie pharj'ngeal 
mucous membrane, or by contact infeetion from tlic* face; but 
it is very coraraoo for ti^'sipelaa of the pharjiix to migrate 
thiTJLigli the tiose or mouth outwanls onto the face. 

Symptoms,— Th(? clinical picture varies according to the seat 
and extent of the process. 

{a) Tonsillar Abscess <Tonsillitts s«u Angina Phlegmonosa). — 
AbsccHS of the tonsil in rare— at least much rarer than periton- 
sUlar abecetu!!, and is mostly unilateral. The tonsil is enhu^al, 
swollen, and redtlened, and t^ows more or le-sa distinct fluctua- 
lion, with oft^'n the same deimsits as in follicular or lacunar 
tonsillitis. The uvula is dragged to one side, or, if both tonsils 
are afTecl^d, behind or in front of the narrowetl isthmus. TTie 
adjacent tissue often escapes iraplieation. Tlie subjective symp- 
toms are the same ae in follicular or lacunar non-euppurative 
tonsillitis, but are much more severe and pronounced. 

(&) Peritonsillar Abscess (Peritonsillitis). — ^To what extent 
the (XTitonsillar connective tissue of the phar>'ngeal tonsil is 
affected often escapes our notice, on account of the ditficultiea off- 


ered to thorough exaniiiialion bysudi a case. On thcotluThiuitJ, 
the peritonei I liir tissue of the palatine tonsil is fn><iiifntly ihe 
seat of phlegmonous processes, mostly unilaltml mid .siniifwhat 
above and to the out-er side of the IodmI, aiid oc<'AsioiialIy also the 
IXJStcrior jialatine arch is affectwl. 

Thp ilispa«e liegins with severe pcnt-rnl sj'uiptoms, such as 
fever, rigors, lassitude, aiid prostralioii, to wlilcli, .sooner or 
later, [jaiu oh swallowbig is added, whicJi iJicn radiatoa towards 
the ear. 

Oi\ inspection one sees, at first, only a slight injention of the 
anterior aich of the palate, while the tonsil it*clf i:* noniml, ami 
also later on reniai]i8 itself comparatively uiialtercxl. The pa- 
tient complains of stilTlle^4,s. or a feeling of tension, which is due 
to the great infiltration tif the wjft tissues; he avoids niovenieiitsof 
thehea^l, and kee|w it turned towards the affected side, so as to re- 
lieve tlie tension. Opening of the niuiith and swallowing are rend- 
ered iMiinful, and, (iiiaUy, the patients are sntisfieil with merely 
sipping some fluid. Collections of nuiciL^ in tlie mouth are 
troublesome and arc got rid of witli pain ; the tongue ia thickly 
coatetl, and the patients become quickly '"run down " and look 
very miserable. 

On inajx-ction, an enormous swelling of the soft palat*-, pai^ 
tifularly of the anterior arch and adjacent parts, is conspicuous. 
The uvula and [jart of tlie palatine velum are oetleniatous. In 
some cases the oedema is so markeil that the whole affectcil side 
looks like fi jelly-tumour, Morking the istlmius fauciinn and 
thereby causing diffieulties in Im'alhiiig. Tlie tonsil itself Is 
usually only slightly injected and cuneealed Ix'hind the swelling. 
If the posterior arch is aJTectod, it &\m bulges forwards. 

Inspection is often ren<lered difficult or even iniposable if the 
patient eleiiphes his jaw.s, a» \n Iri^'mus. Then we must be sat- 
isfieil with seeing otdy that which itt |>ot«ihIe, even only a small 
area of bright red and gktssy soft palate. In such a case, how- 
ever, the di.sra'*e may Ik* meognised, without exainlnation, from 
the fxtinjjil and draicn Imik, the stiff hent}. Ihe thick, clutitsy speech, 
in eomhinaiion with the impossibHiti/ of o-jKming the mouth. (See 
Fig. 70.) 

If the pus is not evacuated artificially, the abscess bursts after 



a few (lays, or in some caseDt even one week, itito the mouth or 
ihroat. ConiplicAtions are rare, but miRration of the pus, ool- 
latcral oc-leiim of iJie head, erosion of ihe cjiroliil arlcrj- with 
consequent fatal liaeniorrtiagc or the foniialion of a BjiuriouH 
anrurj'Rm, have occum;i.l. 

Soinelimes tite phlegmon encroaches on the neighbouring part£, 
f>r R])reftd8 externaJly to lhef>kin or the mouth (angina Ludovid 
proclunwl by it; see p. 227). The pujs having heen tiii^cliarged, 
recoven' quickly takpf* place. 

(r) Retropharyngeal Abscess. — The onset of this disease is either 
acute, ami L< acconi[i«nieil by fever and pain on d^lutition, or it 

Fig. 70- — U-f(--."rt^i i--in-i; ..U^<_^i. Indnon. 

l>pjiing more insidiously witli synipioiiiH wliieh, espt'cially in 
chiltlrea, have no peculiar characteristic. The Uttk patients 
are restlcas, hold llicir lu-a<I .^tilfly, aiul en- when it is movral, 
refuse food, or invallow tlic T^'^ong way, so tJuit they cougli and 
fluid n-gurgilate-s tliroufdi llie nose. Older childnti also rom- 
pUiin s]jocil«nuoiusly or on interrogaljon of [jain on swallowing. 
Tlu>t« symptoms are soon dominated by signs of impedtnl n»* 
piration. The deeper the scut of the abscess is, the more difficult 
beeorm's; the breathing. Particularly during sleep. Ihe breathing 
18 very noiijj', stertorous, or panting, ami in naso-ph&ryngeal 


abscwis nose-brc'aOiiri^ may Iir rotiiplctcly olislriicloi. The 
tiigns of tlyspnw-a ai>pf»r; fyanosit* cif tin- Inn-, .swfllinji; irf the 
jugular veins and dUht vessels of llie ticek ; ihe wings of llic nose 
move, and the lower ribs are drawn in at ejich hispiration; and 
the voice assunipfi a nasal sounil. The Iniiphatic glands of the 
neck are alstj swollen. 

In llie si'condary absce-SMfi stifTnetw of the neok aiid twuicniess 
of the spiniil processt'-'* arc \'pn- nmrked. 

It is clear that uodcr these circumstances the general health 
auffew greatly. 

The examination i« often very difJinilt in ehildirn. Iii!*prc- 
tinn docs n<»t [x-rniil a full view, esiweially in <lH'ply si-ateil and 
Kinall uIjsw'ss. In siirh a ca«e palpation is more reliable ami 
will reveal a unilateral, tense, elastic tumour; small abs^cesMv 
may. larpfr aliweesHcs n/imiy^, itiirtume. In older ehildreii or 
adullM Ilie aliKCPrts mighl be in>;pi'ele4l by means of the larj'ngo- 

If the ftise-ase is not reeoKnisRl and therefore not treated, 
deulh from atiphyxla may occur, either by the afUlus ad larj*n- 
gcm being occluded, by colbteral oedema, or by the ab.-'eens 
ileelf, or it may hapjion that duriog sleep the aliecess bursts and 
tlie pus is asjurated. The increasing ilebiltty, espeeially in the 
more chronic serfHnlarv abscesses, is also a dangennis factor. 

(d) Erysipelas Pharyngis (Angina Erysipetatosa ; Ec>'stpelas 
of the Pharyni ; Eiysip«latoua Angina). — Krj-sijielas of the 
pharynx sei.s in. just an cutanimus erysi[»«'la«. with high fever, 
and to tlii-'^ is added great ]>ain in swallowing. Tlu' pharyngeal 
niuRoutt nieinbruiie. and, in |tarticular, that of the faucen, sliows a 
(lurtky, shiny, varnished ap|)eamnci', and is oedemalous. Thn 
process rr-seiiil>les that of the skin; it migrates and affecte all 
ncighl muring [larts. and if the larj'nx )k' attacked, there is great 
danger of asphyxia through oeilema of the glottis. In other 
caM» it migrates on to the outer skin, if it ha.<^ not originated 
therefrom. Somiiimej* the cedenin o'<.tnmf.t a fiullous character. 

(«) Acute Infectious Phlegmon of the Pharynx (Pharyngitis 
Acuta Phlegmonosa Infectiosa). — ^This diseaae nhows tlie same 
fealnn's as erysi jiela.". to wliieh it is ver\' akin. But the fever in 
usually not so high a« in er}'»npeIaB,. while the inueouD iiieiiibraiie 


dise:asrs op thr pharynx. 

is more taise aiul mort; Hwnilcn. Deglutition is, curiously 
enough, not so much impedetl, but hoarseness aud tlyapiim-a arc 
early praminriil, and tlic fjeat prosiraliuu of the |)aticiit. passing 
on into coma, is vcrj- tLliirniiug. The cimrHt* Ls rapid; dcadi 
ensues — sometinn-s iiuitir uiii'xi»erUHily — with ^giis of heart- 
failure. The [wjstniorteiu revivals jmruk-nt tiifiliralion of tlie sub- 
mucous ajid deeper tissues, and in other organs and 

Diagnosis. — Dvvfnoyv/ of the Pblef^morums Jnliamvmtitms. — 
Peritonsillar abact^ss. of all die vnrious fonns of phlegnionoutj 
plmryugeal inflammation, offers the k'-ast <)il!iculticA in diagnof;is. 
Its wmptorns are very characterihtir (sei' bi-I«w). An error 
would be (possible oidy at the eoniniencenicnt, when only a 
slight injection of the anterior palatine arch is present, perhajis 
a.tsociated with pain on swallowing or a feeling of stiffness on 
one side. 

Will-never such a series of symptoms occurs, one stiould thhik, 
first, of peri tonsillar aliscess, more es|>ecially if the jjatient reports 
that he liHs alnwiy suffered from a ^iiiniSar attack, or ha.'* been 
"cut for an abscess in the throat."' ,\ linear scar in the region 
of the soft jmlate, especially above the ontei-ior arrJi, moetly 
jxiiiits to a previous incision, and will .itreiigthcn onr suspicion. 
Diagniwis might he somewhat more diihcult if the whole proecss 
is jtomrwhat mure [xiaterior in .situation. But in siicli a case 
also, the clinical features are quite characteristic. 

Toiwillor rihsre.s.s U rare. Here the ]»cntonKilInr ti.-wuf* is little 
affected, whereas in |X'rilonsilUtis the tonsil itself shows little 
or no alterntinn, if it is at all visible, and is not hidden from 
inspection by the swelling of the surrounding ti.'<sues. 

Relrofbarynrienl abaceaf', especially in small children, is often 
overlooked or not recognised. One .should, therefon*, maki- it 
a matter of routine to always palpate the throat in cases where 
little children are restless at night, snore, refuse fond, or niis- 
sivallow. and to use, -if it is necessarj' for this puriwse, a general 

Eri/sipeinx iifid oaite jthleffiunn are eharaelflrised by their 
rapid eoursi''. In the Ixigiiming one may doubt whether one 
tiHK tu deal witli an aeutt! cellulitis (phlegmon) or erysipelatous 




angina. If thrre is high fever from thp onset, and .stiouM the 
luviwms uieiiil»nuii» sliuw the duf-k}', varnislial lustre, ami if ihe 
[wocpss niigmlf'.s fmin* one sitle to tho other, uiid perhaijs to the 
larynx, then we are no loti^^r in tloubl as to the nature of the 

In acute phlegmonous inflamnuktion thn local figns arc not 
GO pronounced, oeitlier is the fever a» liigh as In crj'sipelaj*. On 
Ihc other hand, the eonstitulional clmnges are more predonunant, 
audi HA prostration, drowsine-vi, coma, etc. 

Prognosis.^The prognosis ia usually good in ttmsillar and 
peritonsillar aLn>c*-SK, but niight, imieed, bceomc toss favourable 
from intercurrent eon i plications. (See p. 2G8.) 

Retroplmryngeal abscess also is anienal^le to recovery if prop- 
erly treated, but here the prognosis may be less favourable on 
account of tlie pririmr>' diwaw isporidylitis, etc.). 

KryHipela.s is a verj' wriuu:^ disease, and acute infectious 
jAlcgiiKHi nearly always cnd.s fatally. 

Treatment. — In erysipela.-^ and acute phlegmonous inflanmia- 
lion the general treatment is the most important. Roborants 
and stimulants are iirfn-nlly reiiuired ^strong wines, yolk of egg 
and wine, ice, fruit-ices, iced milk, etc.). In threatening dvfr 
pnoca tracheotomy must be perfomieii. 

An ahsMses of the tonsil or a peritonsillar abscess should bo 
opened. In pcriton^itis, however, we must not incise too early, 
for we do not, in the Ijeginntng, always fitid pus, though we make 
our inci.'non on the" typical" plac<\ i. e.. I an. above and pjirallel 
to the anterior palatine arch. Tlie iwticnt is thi-n disnp|j<nritcd 
if no pus but blood is ilischarged, altlioXigh he may feel relieved 
from tension, which, however, i.s not very luiting. Sometimes 
the abscess will burst through Uie artificial opening, but that 
is the exception. 

It IB better, tinder those circxmistances, to orrfpr iwirm or hot 

.JDHiBBfttfifWHf and gargles (aitnomite ten), and not to incise until one 

mr fmod fhtetuation in a d^jinite fpot, which is often situated 

quite Uterally. I never kuw any disadvantage arising front tliis 

rxpectani attitude nl the }>ef/inmn/j of the diietifc. 

Wherever it is admiisable, a distal examination should 
be made. In trismus the probe can bu u^tl, and by tins even, 



quil« a umall area of fluctuation may thus be found, as the ten- 
dpmesB is grmtest when this arwi is loucheiL A Uouble-odgwl 
bistoury is used for thp inctsiun, and is guarded as far^as 1 cm. 
from the point with cot ton-wool or adhesive j^astcr. Thcinciaon 
should nut \)€ too small, and .should be afterwards dilatf^l by for- 
wpB in onk-r to prtjviili' a .-^ulficiont exit for the pus. It will soinp- 
limes be necessary to sligtilly rpopnn ihr chi«rtl wound, on the 
next day. with a Wunt proU-, in onlcr to Icl <m( any ni'<»lttTlioD 
of pus. The after-lreatiiKiit cooiiuLi in gargling willi warm 
camomile tea, to whlcl) salt or Buroir's solution (acetate of 
aluminium) is addnl. If the i^'oUing does not <)uiclLly ^uMde, 
wo mitst repeat the incisions, for t here exists relen I ion somewhere 
or other. The clanger of injuring larger vessels by incising the 
abseeas is not an ima^nary one, but should ac\-er deter us if wc 
make it a rule lo incise only when- Ihirtuation i." prer*nt. The 
endeavour to arrest an abscess by ice applicalioii \ir ahnwt alna^'S 
tuutuccessful. Hence warm applications are by far the better 
method of treatment. 

Treatment of a retro|)harj'ngeal abscess is similar. The 
glianled knUe is introduced under the guidance of the left 
finger, and a timall opening only is at first made, fio as not to 
allow the pus to giwh out vehemently: the oijcning may (hen be 
eiilargeil. while the head of the patient is bent forwards in order 
to prevent the pus Bowing down into the lar>-nx. Here also in 
some cases we have to reopen the wound on the following day 
with a blunt probe. Gaigles can be ordered for aftcMreatment- 
in a«lult8. 

Flxudalive inllammations of the pharynx are to be ooiudflcred 
on the same lines as those of the mouth. A'enr' often it is the 
iamc process which is localised simuhaneoivily in t>oth parts, 
or lias spread from the one to the other section. {Wc refer, 
Ihcrefore, to wliat we have alrcatiy said on the eubject in Part 
II, p. 186, et seq.) 

(a) Herpes Pbaryngis f Angina Herpetica ; Herpetifonn Phar- 
yngitist. — Elinii/gj/ and J'nthnlotfy. — i'liiiryngeal heqws occurs 
sitnultaneousty with or following a labial or buccal herpes. 



More often it is a dispose sui generis. In many cases it is a 
sort of reflex oeurosis, excited by a chUl, omotioQ, or dya- 
moaorrhoea, Tiiore are some women who always suffer from 
hoT]^s of the mouth mi'l pbarj-nx at the conutienceuient of 
iiit-tit^tnuition. Toxic fiubstuiic^-s al«> may give rii*e to an enip- 
liun uf li(T]x«, as it can be ectii tu certain infectious diseaseB 
or iiiilip'!*tii)ii. 

STpnpUint.^.—Tlic gyniptoiiis inueh resemble other forms of 
herpes. (Sop p. 1S6.) Tlie .soft palate, tlie palalme arcljcs, ton- 
sils, and uvula are llip most c/Hnmon scat of tlie eruptions. 
It may be noU-il, liowcver^ t-hat paresis of ihe soft palate and a 
panilysis acfoinjjauied hy ataxia have been obi*r\i:fl after 
her]jelie angina, wliich eerlainly points to the effect of some 
toxic sulwtiuice. 

(b) Pemphiguft.— Thif« diwase may W localised in the phar>-nx 
alone, e. y., on the soft jtalate. SimiUr eruptions al«) arc mostly 
seen in Ul(^ mouth or on the skin. (See p. 187.) 

fc) Aphthae fPharyngitis Aphthosa).— Here we also refer to 
that whieh we have ainwiy said of tlie same afferlion of the 
mouth, for it is very sddoni the disease i(t tiitiited to th» 
pbarj-nx only. 

Benitfti ulcer (ulcus pharj'ogis bonignum) is related to the 
apblhovw uleer of the phar^-nx, and is descrilied by Hcryng. 
It usually occurs «ngly and unilaterally on the anterior palatine 
Arch, immediately al>ove the tonsil; the ed^ arc sharply cut, 
and the Hour i^ coiit^d with a gniyisli iihn, which cannot lie 
easily removed. Alt the s^'niptoms are similar to a slight attack 
of follicvdar toiisiHitiK. The ulctT usually lakes from ten to 
twelve day.s to heal. 

(d) Other Exudative Processes. — Occasionally eruption** of 
urticaria, erythema noilosuni, and erythema multiforme Iwve 
been ol)«er\'ed. They fomi re«I, sliplilly elevated [>ateJie« or 
papules, usually m a'*^ociation with f^iniilar eruptions on the skin, 
or lljcy precede them. The patieiUp complain of pain on swal- 
lowing, salivation, and sometimes dyspnoea. 

i>uvjnftyi» and Trvmlnietii. — As regaixis these, we refer to what 
wc have already Kaid of exudative stoinatitis. (See p. 185, et 





Etiology. — Chronic iJmryngitis originates in repeated acute 
attacks of citarrh of the [jharynx, which may become chronic, 
Rspccially if they have beun Ilegk'cl^?d. Chronic catarrh is 
common in pi-rsons who are wont to breathe through the 
mouth, and in those with an abnormally wide na-sil easily; for 
the mucous menibmno of the throat in such cases comes into 
contact with inspired air, which is not sufficiently wannetl pny 
viously, and is, moreover, laden with dry dui*t and Imcteria. It 
is particularly by tiie foregoing that they explain the uccurpeneo 
of chronic piiaryngeal catarrh iti North Ajiicrica. Oilier causes 
are the abuse of alcohol and tobacco, the habit, of eating too hot 
or too spicy food, continuous and frequent speaking in the open 
air or in a dusty and draughty atmosphere, and ihe aspiration 
of mechanically or chemically irritating substances ^workers' 
catarrh, as in cotton or wool factories, grinding works, chemical 
laboratories, etc.). 

Chronic pharjTigitis oft^n occurs in eonjimction with chronic 
rhinitis, the chronic catarrh having thread from the now into 
tfie throat, or the noxious agents may have affectwl Iwth regions 
flinnjltaneoiiflly from the commencement. It can be easily luider- 
stood that the niuco-pundent secretions, which nm iloftu 
the posterior narcH, adhere to or are retainetl by the numerous 
furrows and recesses of the phaf>Tigeal lonsil. and there becom- 
ing decomixjsed. give ri^e to and maintain an inflammation. 
G'rtain constitutional diseases, which diminish, so lospeak, the 
vitality of the body (anaemia, diabetes, tuberculosis, sj'philis, 
gout, etc.), act as kinds of predispoang factors. Diseases of the 
heart , lungs, and stomach act in the Kamc way by causing chronic 
hypcraenua or plethora. A certain prodippoation to chronic 
catarrh wems to he iiiherilerl. but J venture to say that this so- 
called inherite<I prwlispopition is, for the most part, nothing 
else than finherited) lowered vitality, the result of constitutional 
diseases. This goes to explain how in some families chronic 
pharyngitis is af firmly establi*^eil as an heirloom. 

The malf sex of middle age is far more subject, to this disease, 
for the reason that they are also more exposed to tJi(> various 
noxious agencies caunng tt. 



Symptoms. — Chronic plmrj-iigitis presents varioiw sjiuptoms, 
all of which ai'i? determiaicd liy the comlilioii of thp mucous 
membrane and its secrptioiis and iiy ihest-at and (extent of Ihe 
disoase. Division into {lilTcJcnt fnnnd of pharyngitis climnica is 
artificial, for, d« fartu, thoy iuitj^c onp into the utliiT. 

Strictly yi>ftakin(;, chrniitt: ratarrh in prt'-ienl only where the 
mucous membrane shows hyperirophy fswelling?) and abnormal 
secretion. liynertrophy of the muwuis nienibnuie lat<^r on 
changps into atrophy, wbirii is then spoken of as atTojthir pfuvr- 
yngitis, anil the ftccretiona may then dry iiiwn the tmicous mem- 
brane, imparting to it the ap|)earaiioc of a vaniislwd [jaiwr — 
dry phanjiuntis ( phanjtujllta >nrai); this \» often a<'eoiiipaiiie«l by 
atrophy of the niueoujt mcinbrajie; but it is also found associati-d 
with hyjuTlroplutt pharyngitis. M. Schmidt mftintaiiis that 
real atro|il)y of the* [)har}'nx only occttm in old age, mid that it \» 
often only ftppfireiit; that is, if Ui<? mucous membrane is le-ss 
congested in ortain places it then contrasts conspicuously wth 
the other hyperaemic or hypertrophic parts, and so appcAr, 
by contra'st, paler and atrophic in relation to the other more 
hy|Xiracniic [wrtions. 

Chronic phar>iigitLt, as also does acute [jharyngitis, may affect 
the whole pharynReal mucous membrane (pharyngitis chronica 
difTii-sa, ilifTusp chronic pliarynpiti!*) ; or single regions or sections 
only ail' atTfcted, and «huw a different cluiical picture. 


Tlie fiiwase is Hcldoin lucalistHl in the nafO-phflrjugeal sjmce 
only ; Uic oral jmrt in moiit (Yinunonly alTtrcted at the same time. 
In tht' [josl-nasid .span- it is ciiii-lly (lie phnryngcal tonsil which 
is dis*']u*cd. (hi insijcctinii, oni* .sees nn ihr |Hj»t4-nor wall »:f the 
pharynx a dirty grey or gn" muro-pundent «*crction. which 
can be traced up to the KKif of ihe pharynx. The wcretion 
in many cases is derived from the niiiny Mnuws of the pharyn- 
geal tonsil, and c^-pccially from the reccssus j>haryiigcus niedius 
(bursa pharyngca), and from which il ran be seen oozing.* 

[^TfionttroliH'a asBortion lli»l llii' luidilJu 
teaJnMy liciilone KlTeoliHl, il 
T<> iMKiini'' an iwihitcil liiinuti 
tlicTftore, justified.] 

thai llic luidillu pliriryii{{eKl rwfM (him 
, indepeniiciilly of nthcrnnrts, in not. very 
al plmryttgcii] catarrli {JnoTnrivldl'a diatM 

eHl i*rpi« (hima idunyn- 
(tiaour) is not, 



The miitrou? mMiibrHiH', which may bf wf n if the mnriis is 
rcmovoi, ai)[>ears swollen, rnl. or evrn in a slate of cystic ilcgMi- 
cration. Tbr tubar pads purtiripatr (tu^leti■ll(^8 in tlie swell- 
ing, and iK^tniy it by noises in liic far ami inipainnl hearing. 
The piiHtHrior jturface of the velum palaljnuni w ird and swollen, 
and ius vvj*i>1s arcdilalwl; jd«», tlw mucoas membrane cover- 
ing the \'anipr may' be foumi relaxed and confirsted, and even 
the posterior emln of the conchne ni;iy be swollen and hyper- 
Irophicd. In a great nuiuber of casks the »Hrrt>tion is Bcanly 
and dries up. fonntng walw, which cover the pharyngeal roof 
or rftaeh further d(wn along the postciior wall (rhinopharj-ngitis 
wcca). Tliis fonii of pharyngitw i? ahnoat always a.'^^eiated 
with a dr>' fomi of rhiniliR. and iJic muccnLs iiteiidimiie l(iokF« as 
if atrvphied, but really it is oftener hyprrtro|)lm<d. If tliere 
also exist* a foetid atrophic rhinitis (()zacna>. the seaKs in the 
naso-tiharh'Ugeal ^i^ace evince the ^inc unpleA-sant qualities. 


This term is re.Herved for ilie chronic affeclions of the oral 
l«u1 of the ]>har\'nx, ajid is analogous to the acute process. 
It may l» doubted whether, aa Srhech eUktee, it occmrs oftener 
here than in other pBrti< of the pharynx; in reality, tt im only 
nion- fre<iiJonl!y t«een becaase of the oral part beuig more easily 
and more frequently examined. 

The nuicous membrane is either diffiuiply or in isolated patches 
mldened in varying ilegrees, and is swollen, lo<jks fihiny. and is 
covered with secretion varj-ing in ijtiantily. Tht^ changes are 
often very Hlighl, as, for instance, in anaemic |)enH>ns,aiidoontra8t 
conspicuously with tlie subjeetivo wyniptoms. In .•miokers or 
lirinkere, the mucous membrane appears bUiis^ rod and con- 
get*ted, and present;* dilated and tortuous vewtelit. 

Id other the lymph-follicles enibeilde<l in the phar>-ngeal 
mucotLs membrane an* the seat of infianiniation. One sees 
larger or smaller, niuniie<l or oval-ahajMxl prominenres on tho 
mucousmembrane. of abright colour, thexocalled "granulalimui" 
(pharynffiivt granulosa), which may unite at times 1o fonn taj^ 

Sueli granulations are also 8eeD In healthy individuals and may 



not muse <!ip least hful sj'niptonis, fttifl must here be consid^Ti^I 
ns alx-rranl [Rtrtioiis (i( Uif lyiiiplmtir rinp; (sec p. 237), liut 
lh»(y are very consiJifiious in cliildrcii with adenoiil growihs. 
Hence the lietluciioii ik not to assuirit' phnrj'ugjtiB always, where 
such gi'an Illations lire deleeU'd. Tliey aiv most frwjucntly 
disfovenH! on Uie posterior wall, hiii are found alno on tJie 
jwsterior palatine arches aiid uvula. 


On examination of the pharynx one notices at the p\tu^ where 

the iKisterior |iasses into the lateral wall, on one wie, or oft^'ner 

bilatt'rally,hinhlycolouredstripes or ridges, wIiitJiniaylH^fcilluwwI 

up to the [x>sU?rior portion of the torus tuhariuM. This is a oon- 

ditiun of hyiKTtrophy of the «ilpingo-phar>'ngeal folds (plii-ai* 

nalpinp<vpliaryiigeae), due to intiannnation of the lymphatic 

follicles, which are embwlded in these folds. These h>7>er- 

trophied folds project niarke<ily, (vpceially durinp im-aUomng 

movements, an*! Iheir surface liaf a graiiifnl (chagrinetl) ap|iear- 

ance, due to hypertrophy of llie riunicrous "granulations." 


Tliew formatitiiiM. the cignifieancL- of whieh was fomterly 
iniieii nnderratiid, an" the [iroducts of chroidc catarrh in On* 
refcion of the tonsillar erypts or laeunae. They are coniiKwed of 
niinrate<l leucoeylew, cpilhelial rclU. SBltff nf lime and iiaetcria, 
and fonn chewy, pninular. wliilb^h or yeilowL•^h, foul-wnelliiiK 
conBlomcrales, which stick fast m the lacunae, dilating them or 
projecting fmm them, and sometimes gluing riso to great dis- 

Tin- tonjiiN are more or less swollen and reddened; the con- 
cretions Ixing themselves a prwiurl of inflarm nation, often act 
as irritant fnrripi iMwIlfs, and may Ihcni-selves pve r\>v to hyper- 
trophy or iiillainniation of the tonrdlK; or, on the other hand, as 
theresultof theinvaHioudf streptijcocc.i, a lacunar lonfiinilin or 
a peritonsillnr ah^eefis may arisp. It cannot he denied Ihnt any 
toxlni^ foniicil hy the ooiicrctiuns may tic pa^flMl from tlieni into 
the circulation. 



Od the other haml, tlie tousila nrc not necessarily enlargHl, 
and the ooncmtioiis arc ol'lcn diricoverofl by mere clianoe, (or 
Lhcy may exist for ycara without cauising any trouble at alL 
These yellowiah particles or crimiiis am not iufrequently only 
discovered if one searches about in llic crypts with a probe; 
their seat of prwlilectioii is usually iinitiediately behiud the 
anterior palatine arch. 

Symptoms.— The ^iuhjective symptoms tlo not always depend 
on the I'xltnt of tlie diaiiges. There are patients who aK hanlly 
ever troubled by their catarrh, and others who feel very anxious 
and complain verj* nmch, though they obviously show only 
flitpht changes, yet who inia^ne Ihat thry sufinr from cancer, 
coiif^uiiiption. etc. It is a fact that many hypochondriai's are 
found among patient,s suffering from chronic plinryiig^tia. 

The drif cntarrh.'' generally cau--^ marc discomfort tlian the 
moist catarrhs. The sensation of dryness is iHirticularly dj»- 
treBsing in the morning, when " the whole neck" seems dried up, 
and the patient has to cough and "hawk" in order to clear his 
throat from the sticky mucu>i, which not infreqiicntly ehokcu, 
and causes him to releh and vomit {wmiitt^ malutinus). In the 
nwut Jorms */ catarrh the sensation of mucoid hypcrgecntion 
premilx. hut the patient?, however, do not always give a correct 
account concerning Ihcir scnHatton»; and it is remarkable bow 
often per\Trse a'n«iliiiii.s figim' in the symptomatology of the 
chronic pharyngitis, nnniely, such as a fwling of foreign bocliea, 
tickling, buniing, itching, sorctics.s, etc. 

Concrelions in the ton.sil.s often, but not always, betray them- 
seK'es, cspedally if one or other of the concretions separates 
by itself and is dischnrge*! ; nml also by a i«ul taste in the mouth, 
of which patients complain. This Imd taste may also be accom- 
panied by an e^•il odour from the mouth ffoctor ex ore). 

In laleral pharynfjUvi actual pain may occiir, because the 
inflamcti lateral ridges will bi; »sqtKTzr<| or j)reflsed upon by any 
contraction of tlic snpi-rior constrictor pluuyngis (c. g., as 
in swalloning). Concretions also may sometimes be responsible 
for causing pain in the ear and al«o <htring deglutition. 

Cnufihituj is a ver>- common reflex sjTnptom. It can be easily 
excited in granular pimiyngitis by touching the granules with 

PHARTXcms rraioincA- 


a prolM>, ur a »i1iglit tickling of Uie haup of the tougue and eju- 
^ottis by .111 eluiigal4>il uviila may cauKC paroxysmal lilSdrmuKli- 
ing ur cliukiiig. Al othcj tinivs th(! cougli in uxt-Uecl by Uie 
mupuH flowing down into Uic larynx. 

tHgorders of vtnce and speech are very common in chronic 
pharj'ngitis. Tlie palit-nla, iii imrticular tlioso who havf; to ubo 
their voice a great deal, frequently cottiplain tlial Ihey mmhi pi*t 
tirttl of ((peaking or singing, or that tlic voice often 8ucltle-nly 
alters. The Kwehing of t]ie niueoii"* nmiihnuie, es|jfeiiilly of tlie 
najiu-pliaryngtail spiu^e, and Uie rckx:iti<m of the nmscles, are apt 
to alter iJic rejnonaiic(\ Thcvoiec luse.s lis pure tiinbn', and easily 
becomes Ured out, and the more so If it is strained in order to 
overcome the tnijx^limeiit. An aeeonipanying irritation, oreven 
intiainination, of the larj-nx eontributes niueli to this result, 
by which the voice becomes hoarse, or what is calJetl in\purc 
or veiled. (See Tart IV, Chapter U.) 

Cmnpliailion«. — The inllanunation of the nawv pharyngeal 
space pometiines spreads tn (he Eutitachian tube, causing otistrue- 
tjon by the swelling of its nieinl.iranous parts, anfi also leatls 
by the formation of scabs to inflainiimtion and obstruction of 
the tube or middle ear. One often sees patients suffering from 
chronic naso-phar>Tigeal catarrh who complain of car troubles, 
such as noises, fuUieas, or impoircil hearing, 

The UiTynx is ver>' often imi>lieated by the descent of the catarrh 
int-o it. One finds, e(i(x^eially on the jxisterior wall of the lar>'nx, 
the mucous membrane swoUen, duo to the constant irritation 
from the downfiow of the secretion and, in dry eatarrlis, fmtii 
some dricd-up secretion, and scabs on the vocal cords, whicli 
tend to alter the voice considerably. 

Tonsillar concretions encourage bacterial invasions, which are 
very prone to eventuate in all sorti* of acute inflsBimations. 

Pathology and Anatomy. — The epithelial layers, in |3arlieu]ur 
(rf the posterior pharyngeal wall, are thickened, so that the mucous 
mendirano looks c|uito grey at some spots, and the enlargeil 
papillae often extend into the upper eiMtholial layers. There is 
augmentation of the connective ti£«uc and a round-ccllc<l infiltra- 
tion al)Out the vessels and glands. The vcesds tbenieclve« and 
the glandular ducte are dilated. In granular pharj-ngitis tlie 


I^inpliaUc lis»ue is hyperplustic luiil accuniutat<>(l aruunt) the 
ducts, and Uie epithelial strata covering th« granulaiioas are 
mostly very thin. 

Diagnosis.— Tliv diagiuieiiK Etltould itot prove dilhcult, if oue 
takes into poiisi<leratiau tiie Huhjeetiv'i- aiul objective eymptoma. 
The reports of jjatieiit^i in rejnird to their sensations and pains 
must not Ik* taken t<K/ literally, for the locahsatioii i» itut aceu- 
rate, in eome cases even jjaradoxical. It is sometimes, however, 
not easj- to ascertain whrther the »ec-re1ion aceuiiuilatai in 
the upper piirt of the niLsophiiryiigcal space uccrurtl froiti the 
pharyogeal tonsil or from the nose. If it in possible (o trace it 
conivuioiisly to the nose, then the isecration must neeet^warily 
Gonie, at least to a great extent, from the nose or iiii aeeessorj' 
cavity. Rut if there is an an-a belwetii the clioimae ami the 
fornix pharyngls tuiafT<>c!ed and free of setreHon, the latter 
niunt then have it^ origin in the naso-phar>'ngeal space. In any 
caw Ike no,'^ aitd its acctfsary iravHieit should altmys he eubjeded 
to thirroufjh vjdinination. 

Prognosis. — The pDignosis as to life i.s favourahle, but as to 
restonitioii to n status quo anU', 1,-* unfortunately often unfavor- 
able. Hestoration t*) health may, however, take place after 
a long time. RelapM'S anil exaoerljalions are voiy frerjueut, 
because tlie patientK do not ur cannot lake proper care, and in 
many eases carry tlli'ip"bit of ealarrh "for decades. 

Treatmeot.— Having r«'gani to the gittil iuiiwrlance of the 
rftle played by wrtnin hygienic and dietary factors in the etiology 
and courj^:. we tJiouM firt>t of all try l« |>lnee the iiatient umler 
tlie Ixwt iKWwible liygii^ii*- conditions, t'n fori unal ply, here we 
often uKfet with iiwuia-rable ofwtaeles in the material position 
or unrhniigf'able habita of the jwitienl, 

Sonietiincs, however, the noxious tnide or profeswion can 1* 
alMmdonrtl in favour of a innrc wiitable one. Tiitmeen and alro- 
hol should be forbidden, or, as ^ueh an order would lianlly be 
ol>eyed and in liable to prodiiec hypochoadrinrs, reslraint at 
least f^iouUI U' inculcntetl. Our advice must also he direct«I 
to the foo<l, vwcc, etc. (fjffbidding of too hot or spicy food, 
aliandoning of njK^king and singing). AfTections of the none 
atul its appurtenaneee, and cfmet^uiumai diftOM, must be treated. 

Local trcalmenl fulfils two objects: removal of secretions an<I 
th<: IreAtiiif-nt of the mucous membranes. The secrf^tiojia are 
iiTiiuviil, as has alreaily bw-ii <ipHcnI)«l iu tht- Rtucrul M-clion 
(»PC p. 252). hy washing out ttiroufdi tiw nope by moans of s]x-cial 
(!ouch»* or sprays, usually m tlu* laoroinK anil rvrjiing. or by 
gni^liug i»r iiiiialfttioii. Douching (lot-a most hcttefit to tbe naso- 
pharj'iij£ie»t KpHct*; garjilrs btwl wrve the oro-pharyngiiil section. 
In dr^' ciilarrUs iorlid uf putiuv^'iuni {5 : 'JOI), J to 1 tablcspoonrul 
after meals in wanii milk rliricp liaily) i* vcr}- tiseful in onier 
to loosen or di^olvc the <iri<Nl secretions or scabs. In the bypt-r- 
trophicanij sensitivft conditions, more astringent appIicationB are 
suitablo, which alw niluc^- the i^enHtivcnwM!. GcJierally. wciik 
Bolutionsnf sodium ehloridcnr birarU)iiatr of wmIb M teasjxjonfiil 
to a tumbler of water) will be suilicii'iit.; or a mixture of borax 
anil soda. 

H. Sodii bicarb. ... n.OO 

9oJ. l»bor»( 2:..t» 

M. (. p, 

SiG. — ()nc t«a»poonful to a tumbler of walcr, tnoniitig aad ercriing, fnr 
doubling and grueling. 

Glycerin is likewisn vm' useful in mu*k of spiisitive |}atieiit& 

!{. Arid lirtrac. \i0.m 

«'.|y»'*inn 200.00 

Ski. — A tubIew|wonful to a. tumbler of rold water. 

Til uiatiy wat<»rin(;-p!aee!< the springs aJiil their jjuIIs Jii-e taken 
internally, ami are also appliwl locaUy. (For llie plaees anil 
Rpriugs conrMTonl fioe p. 250.) I onler the water to l>e drunk 
thrice daily licforp meals, and o imuilt f/iumlity tn tte gnrtjlvd. 
For dour-hing and inhalation the natural water or its salts aj-e 
iiiiod in c;ertaiii proiM>rtion?orooneciitrfllion8 (ut:ually Iheaccom- 
[Minying mea*'ure-gla.'<j'rul to a tunililer c:f water). 

Tlie mucous menibraue nui Im* tn-ated by juiintinp or bruiJi- 
ing; tbeiliffii-si'hyjM'rtropliiefonii, with a-.VIO percent, soUitiou 
of nitrate of tiilver or iutio-glyrerin. 

R. Imiipiir 0,S-t 

l*MaM iod. 1-2 

Olyrprin ...>'••<'•'• 11" 

01. mcnili. F^p .git. ij, 



TfiP strength of solution and the interval between the sittings 
(thn'e or foiir tiays) dojifntl on the sensitiveness of the niueoiis 

We must paint the naso-iiharyngoal and oro-pharjTig<»al 
n^ions onergetically^sDiall haeinorrliages do not titalter. In 
sonic caifn-s, if tlie hyjiertniiihy is more circumscribed ordolincd, 
cauKtica or the golvano-caulery or cutting iniftnmicnts must 
be used. 
Granulations found on the [Kwterior wall are only attacked if 
tliey ari.' tender to the touch with a 
probe or cause actual pain. Having 
^^L ^1 cnoainiswl them, one applies lapis in- 

Yj ^w fenialis, Irichloraeetic or clirrmiic acid 

I^ rl (see p. 40), or tlu^ palvano-eauiery, 

•^ «■ the flat point of which sliould be Iwnt 

rectanpularly. I .ai^cr (rranulalions 
may be removed with a j^liarp <louble 
curct tc, like that usol for inlralarjTigeal 
operations, or they may be cut away 
with long curved sciwwrs bent on the 
fiat. (Sec I*'ig. 77.) Both instnunents 
con be employed for hypertrophic 
lateral pharjTigitis, but if \)w^ lateral 
pfttls un' of modemte size, (hen caustics 
or the (jalvano-cauterj" may he used. 

It is impossible to remove all the mor- 
bid tis»«ucsat one sitting::, fori he rcaHUi 
that it is not adviiokble U) r.nutrrisc or 
cut too much at once, on account of tin- violent n-actioti. It is an 
im{H)rtArit [Miiiit to follow the lidcnd striiw or ndgtw .sufficiently, 
Imlli upwanl.'* and downwards a;* far as powiible; half measures 
are of no use. On tlie other hanti, one ^loukl not proceed too 
rigidly and selieniHtically, and cut away each snuill granule and 
destroy each .'slij^it trace of a lateral ridge. Here, more than 
ever, each c&iu* must !«' ircate*! acconling to its own i)cculiaritie8. 
If the plinryngeal tousil is the seat of disca.«c and the sccreticm 
Biisos from one or more rcc<rs.»»e?, otic achicvcjn the Ijeft cure 
by operation. {See p. 290.) The appUcation of caustics, n-hich 

Fig. 77. — PhaiyngPal w'la- 
aan with lli« bfcadea bcnl on 
Uwllnl ivdttrConU*). 



haabeen recomiiwnded, is Lrouljlcwjiiic, aiid Uic 

usp of tlie pnlvano-cautery not witlumt. darigiT. 
The uvula slimild not he cut away, unlc-ss it 

is so mudi enlHr^Ml iliai ii luuclws tiie back of 

the tongue or tht- t']>inlutli.s, cautiinK ciiujiliiiiK or 

retching. In order to perionu uvuIoUhhv or 

kiotoniy, tho uvula is seizctl with the forceps and 

cut ofi' with Coofier's ttciaeore, leaving a little 

stump 1 ciii. iu length. BleediuK is insipnififiuit. 
Aftor-tniatinont here, a» in other caiL'*tic or 

gmgiriil manipulations, consists in the adniiuis- 

trHti(}ii of cold fluid foal, ice, and disiiiff^diiig 

giirgleji for two or three days. Conpn'tlons iu 

tlu> tonsils aro treaU^l after Narlmann'ii niethoil, 

by prtawitif^ on tlie tounil with a squeezer in 

differtMit dirfctionn, especially on the anlerior 

palatine arch. (See Fijc. 78.) 
By this means a sero-purulpnt fluid or cheesj' 

matter Is i^tiueezed out. Should the di-^jiosilioD 

lo fonn concretions continue aJter this maiiomivrt; 

has been repeated several times, the laciuiae in 

which the concretions are liKlfrcHl can lie split up 
by an instrument which hax the fiin\ic of a blunt 
hook (M. Schmidt). Tlio little hook is inserlcd 
into the lacunae and the tiRsiH' ton) downwards; 
thus the lacunae are ehanfi^-^t into open channels. 
Recently the puctiun metluHi, after Jiicr, has bccii 
appliwl for the removal of the concretions. In 
very obstinate ca{»e8 the concretions, together 
■with the lacunne, can be taken off by Kmnfe- 
IJcryng's double curette or tlartnitmji'.i conelio- 
tome, or the tonsils may be resected in toto 

Fig. TR.— Ton- 
sil n I] U C C 2 e 
(utlcr Hart, 

Fig. 7^»-— Ton- 
sil s|)lint'r falter 

M. SrhmitH). 


Etiology. — .\denoid vegetations, the inipoH- 
imoe of wlucli for ndoie.'tccnuf was lirsl pointed out by the DiuuhIi 



physician, Wiihelm /l/z-ytr (1S73-74), occur mostly in chiltlhood, 
b(:twet'ji the fifth autl Uh- liXtcenih year. During this period tlic 
lymiJiatic tiPSUc-«, oa wc Imvc ulrwwly mentioned, aliuw jn-cat^r 
irritaliility. They are, howt-ver, i<onietimc8 found io infants, 
whereas after the twontict-h >Tar they aro leiw frefjiient, ilpcreaae 
in frefjueney thereafter, and aft*T the tliirtielli ycwr are only met 
with in rare eases, their rhsapiicttrflnci' corrcspondiaB with the 
|)hy!*inli»>?nd ivtrijfiressioii of the phnrjiigeal t<>nsil. Statifticsof 
their tifpurrence are very douluful ; thoy ascillate Iwtweeii hx and 
20 |M'r cm i. ; ruiil exact invest igat ion, accordijig to Hurler, shows 
a still hirRiT jjorcpnlage, vix., 'AX) ix-r rent. 

As rr-ganlt* the caiwes, then- is not yet a elrfir miiM-iition. 
Climate ha^ no inlluenee, acmmling to my ex|xTifiice. I'u- 
faviM-ahle hygifnic concHtions seem Io phty a certain nMc in the 
ctiologj" of thtT a«lenoid prowl hw, jis is jihown by their frwpwnt 
occum'Tice amonp the wj-ralletl kiwcr dashes. Iteix'aled colds, 
chills, and na«Ll t-atanliK may lead Io hy |x'rplii.sia of (he pliaryngi-al 
tonsil, perhaps on account of the in\'Hsion of bacteria. In that 
«wo the vegetations would be the product of chronic inflamma- 
tion. On the other hand, many consider them a» nien'ly an 
abnormality of growth or ni>uriHlimejit, i'. c, as a gcnuhip hom(>- 
plastic hyperplasia «if the nonrial oiyan iSrhm-naunnn, s<'e p. 242). 
Henihty may play it.sjMirt. as there arp familiei^in which, ihroiif^i 
several geiicrHliims adenoid vegetationx' are found. T-ven 
witliln one family, if, for instance, tlie falht^r haj* xufTerH! from 
adetioiils, then the ehihlren who rpsenible the father will also 

Pathological Anatomy. — A<lenoid vegetations ofieiir in two 
forma; as a broadly seated, flat or globular, rather hard growth, 
allowing a lobulatcd surface due to numerous more or loss deep 
fiteure.- (simfitc tiyiHTitlaHia «/ the pharyngeal totmls) ; or it ia 
of a more soft conMPlenc\-. showing an accumulation of conical 
or villiform excrescence-t (ndcnmdivtfclatvmx, jnroi>rrhf .-iO ctiUcel). 
Both forms arc not always distinct, and can nicrge, llie one into 
the other; their e^olor is gi-eyish red, MiKlologiejilly, one finds 
in both forms the name structure as in the normal adenoid tissup, 
viz., a reticulati"*! nmneclivn lisnue with round-eells iM'tween the 
meshes, and numeroue foUiclct;, llic whole coveretl with eiliatwl 


or9([uuinousopiUiL>liuin; and in olderaiid banter hyporpluaiua the 
structural cuiiuective tissue is also increased. 

(jiaiil>-a<IU and tubercle bacilli, wiiicii have been fmmd in |.ltL< 
texture of the adenoiib, are probably <lue to latent tubcrtuikisis of 
iJif iilmr>*iiKea] tonhil. The question whether It here rcvcal.s a 
primary in(<H:tion of the tonsil or a eecondar)' invnsion fnjin 
another ([uarUT o( the body still awaits an aiiswer. 

S]rmptoms. — In the forefront of the syniptonis stands obslnic- 
tion of nu.sal rcspimtinii, wliit-h \s tin- inon^ nmrked in diroci pro- 
portion to the blocking of the ptiHlcrior nares. Tlie consefiuenci'Sj 
of continuous niouth-hreii tiling art- disciutecd in Part I. fSec p. 
SJ.) Tile ijcnnancutly open mouth, in conjiuirlion wilh the 
shortened upjMT lip and Ihe i-elaxed facial niuj^'leM, frivcf the face 
a vacjuit ur stupid ajifx-jtrancc. Cliildren t-minol lilciw Ihe nose, 
and arc re.sllewn in bed at nijdit, owing to the larynx U-ing barmJ 
by tin- retraeti'tl tongue. They wnon' or pant and MifTer from 
niglitinare (]iavar nocttmnis), and l<M>k very lired and xleepy in 
conwHiuenee of tlicir l)n)keji slwp. Tlie voiue has the clutracter 
of riiiiinlrtliii. rUuL'ia. (Sen p. 33.) 

The plmnation of the hnlf-rtmsonniits is rhanged, and some- 
timt's stutt^rinu or stainrnerinK niay be cause<l, The air-eurrc-nt 
entering through the mouth is apt to exMceate tJie plmrj-npeal 
niurniif* nwndiranc, tliuw pvinj; risfr to catarrh of tin- throat 
and larynx ; the latU;r. however. \n mostly due to tlic irritation 
exrr«M,'«-d by the wTretiuns llnwing i1o\mi from the naRHpliartTi- 
gi-al tsfwiee. ^lu* nost^ may alwj sliow catarrhal change.v, usually 
of a hyjjertn)phic, niorp rHrely of an atrophic, naliirc. The 
litlle pntienls suffer, as it is e-nll«l, fmni a "stuffy cttld"; the 
weretioii running down from (he now over Uie upper lip gives 
tiw t« eezema of the entranee of the nose or to erosions and 
swelling of the Up, which eir<?uinstance i.s often nnstnkeii for 
acrofulosis. No^te-bleeding. which is re]K)rt/Hl hy varinus aw- 
thont, Hid not come under my observation, and i« denied by 
Zamiko nnd Tbait: T am inclinei! to attribute it to an artificial 
bleeding resulting from no!*(>-)iicking, a habit into which children 
fall if (he nose irritates from eczema of the entrance. 

ObKtmelion of the nose remlers FPRpiration Kuperficial, and 
thereby limits the cxjianHion of the chest, which in due eourse 


T)IBRA8Kg OF Tlir: niAltli'NX. 

Ipiuls to luiaoniia and aggravatt-a tlie disposition to mflammAfion" 
of Uie bniiu;hi. 

Other consequences or changes associalal with thcni art*: 
(lefoniiiiiep of the nose, high vaulted jmlale, ileviatioii of the 
GCptuin iiafli, and anonialios of thn growth and position of the 
teeUi. (Set^ p. ."ifi.) l)(?formitips of the palate and drailal 
caries, however, are not pathognomonic, for some children with 
adenoid vegetationsoftcnshow broad, Hat palates and also have 
good teeth. 

One uf the most frequent toniplicationw is diisease of thft auili- 
tory apparatus. ,\bnonimlly large vrgetations may, liy block- 
ing tlic oriticr- of thr ICiwIachian lube, niustr ratarrh i)( the liilie 
or middle ear, or intlanunalion of the ear might be prrKlurcd 
by the direct extension thereto of the inflammatory proeesws 
existing in the naso-pharj-ngeal space. Even moderate atlenoid 
vi'gelaijoris fonii a dmigerous focus for the ear close by, anil very 
ofU^n diffifuliy in hearing in children, i.t the only t-yvipiom jioiTiiing 
toadeiundfiT'ouihs. Rei^ated iiiflanunatiousof the middle enr or 
periotlical ditliculty in, hearing in childhood should always tuni 
our alleiitioii to the f*[)8<«. The ajmjaexia of 
the authors, that i:^, inatiility to direful the cliild'H attention to 
one ixvint, can hr explaini-d In many eases hy the impain-d heat^ 
ing. Other authors sugg^t that apniscxla is due to eongewtinn 
in the cerebral veins and Ipnplmtic v<'Jiisels. Tliese eliildrrii 
are athnittedly inert, lazy, ill-tern pere^I, indisposed to Icani, 
and arc backward, and sometimes ereule the impres-'^ioii (hnt 
they are stupid. On the oilier hand, there are many children 
who, in spite of ciioniious mlenoiil growlhi*, are line scholars. 

Lately, "adenoid vegetations " have been described as a 
reflex exciting organ, for instance, nocturnal cnureMs has l)erii 
brought into eonncetion with it. Hul it may be (|iiestioneil 
whether tlii« ttonncction actually exists or whether tlie nightly 
wetting of the Ijcd is only a sequel of a neuroixithic condifion, 
pnxluei-il and kcjit up hy the vegetations. Olher neun)ses also, 
such as chorea, asthma, laryngismus, etc., have been attributed 
more or less correctly to adenoid growths. 

Objective symptoms can only be found by posterior rhinos- 
copy. (See Fig. SO.) 



It is important to ascertain wlidher Uie eiilarppiJ pliart'iigeal 
toiisi! forni.s a more liitTusc, even enlargement, vr is of a luore 
lubulated, tiasurcd, and villous character; whether it is seated 
ill the centre or more laterally, and whether the voiikt aiwl 
choojiae arc involved ; but one must not also allow one's wlf to 
l)e dcccrived Ijy the image in the mirror, which shows hII jwrls 
fomsliortened. It very often happens that ifsetatioiis are 
ku^r after removal than one wati disjxjwil to hksuiik' during 
CTcaiiiination. In niany eases the Kiirface of tJie growtli is cov- 
ered with fluid or driM! secretion and scabs. 

Diagnosis.— If wp art- calletl upon to examine a child who is 
suppose«l to suffer from obstructed nose for a long time, ia 
restless at night, f^ores, or hears bailly at certain times, we at 
once presup[KPse adenoid vegeta- 
tions. And tlii.-* pn-f^upiMKsition - 

will gain in strenglli if the child ■'^"'^ 

a]«o fdiowd the s(i-callecl "adenoid 
fades," \\x., stupid look, o]mi 
mouth, de/ormitles of ])alttt£> and 
teeth, etc. 

Theappe-aranoe.however, may -^ 

be deceptive. There certainly -^q;^^ -^^ - 

fire children with adejioid vege- Fig. so.— Adenoid vt^tutiona. 
tutioHK in wham thr adenoid 

habitus is missing, anii others who. in spite of the typieal adenoid 
a]>|>cjinuice, tki not .vliiiw a tract* of adt-iioid hyinTiilHsiii. TIjIs 
circmnptance would very well agn-e witJi the eontenlion of some 
authors, according to whom the aforementioned (lefunuities 
of the skeleton are Dot in reeultant conneetion with the adenoid 
growthfl, but have to bo considerctl together with tlie Uilter 
as a sign of a f^eneral physical and psychical degeneration. 

To further insure Ihe diaKno««, the voice should be testwi 
as to it« souml ^naMill, and the oral fmrt of the phartTix in- 
apeetwl, which is not ditTieult, even in siriall ehiklren. The com- 
paratively great distanee between the velum iwlalmuni an<l 
posterior wall of the pharynx is at once to be noticwl. and one 
uiay be able t« see soliiarT,- or multiple granulations or follicular 
swelling on the posterior wall, which form quasi-outjxists of 



the adenoid vpgptations. Their size U in direct proportion to 
the adenoid vcgfln lions. In rare eases the tatter may reaflh 
BO far down that they oin be seen by infijjection from the mouth. 

If the ananmfffls aiid external inspection, ss well as the 
])hflrj-ngo8copy, bIiouIiI leave \x» m doubt, we may tr>' anterior 
rhiii(j.scopy. There is no difiiculty in aceiiig ailcuoid vc-gctationM 
from in front if the nose is wide eaiou^i. Oneseesin tlio depths 
of the nose, on botli wch-s, more ofteji in one sitle only, a mass 
with a sniootli or ruugh suiface, usually with convex lower 
margin, whi«U, on swallowing or intonation of "i" or *'u," 
moves slowly upwanlw, &h can Ik* (ilwrvod by the reflected liglit. 
Thf probe will prove verj* useful in some cftfles. wpeeially in 
iwft, spnnpj- vcKotations, in onlcr to a"?ccTtain their coii!=ifitcney. 
Unfortunately, (he nose is niMtly narrowfil or blocked (swelling 
of the concha, dcfomiitios of the septiuii, poiy|)i, etc.). so that 
proi)ing and anterior rhinoscopy mv imix.issib!e. In thoae cn-ses 
we Bfflist ourselves by postcriur rhinoscopy. Wherever we can, 
in adults and children, we .shoulil tr>" to [x-rfonu paslerior rhino»- 
cop}', b^eaua? it gives the best result. If this should almo fail, 
[Milpation mu>;t lie resorteil to. Tliis, however, ih a eonu'what 
crude method, and not infrnfiuently oaufjes a little blewluig, 
making the children still more nerv'ouB ami resistant, and not 
giving such exact result*; as is usually Bupposwl. Indeed, it 
econw to nie that palpation is only sure in cases with larger 
sized vegrttttions, which, moreover, betray tJieir presence by 
other signs. 

Differrittial (hagtiosia must sometimes lie made between vege- 
tations and other tumours of the naso-pharyngeal space, viz., 
typical naR(i-phan,'ngeat [julyj)! fsee p. .124), sarcoma, and 
lymphosarcoma. Consislency and appearanet? may here lie 
very deceptive, and only a microscopical examination of excised 
portions will elenr up the matter in doubtful casea. Zaniiko 
mentions the jxJssibiHly of mistaking leukaemic infiltrates for 

Prognosis. — The prognosis in general is favourable, but one 
shouM Ix'ar in mind that adenoid vegetations constitute a certain 
danger to varinus organs and to the entire health. Besides this, 
the pimrt'ngeal as well as the ]mlatinc tanf>il must be ronsidered 



as the cfiief J5alc of entrance for the sevoral bacteria of tuber- 
culosis and otliLT infectious diseases. On thv utlu-r liand, oper- 
ative rt'iiioviil, if proiMTly jxi-funiitti, lian a ruarvollous olTtTl 
QU the dcvclopmeiit of ciiildrcti, and in lulults also n wrie.-* of 
troubleeomo catarrlial sj-mptoms are often rciicvf^] iiy it. Uv- 
curreucfl«, howiivw. ititiy lisppen. 

Treatment.— 'J'lic one and only relialjle means of curing the 
disease is tlie removal of the vegetatioDH (adeiiotamy). 

Induuitioiix and dunirmitdiiiitinm oj AilmnUimy.'^i^uMiW a<le- 
noiils wiiic'li d(j not cauw trouble and arc only di-scovcrod pt-r- 
riiatiffl' may vory well be let alone, as thcj' niay possibly fulfil 
a useful function f.^ee p. 242), and laliT on fall into atrophy 
by tlieinarivos. But if tlm viiictaliotit* are on inipcdiiiH-iit to 
rcHpiration or a source of influinniation, or if th(T caii:>(- Ihe 
patient to sufTer from nil Horts of catarrhal, n(T>'oib4, aiui other 
com plain tN, then removal, wltluiut n-gani fotlie agi- r>f the jia- 
ticiit-, ifi iiitlicatetl. The (([.icration is cotitniindienled \i\ acute 
fex^r, in K-vere anaenna, haernorrha^ic diatliesi.s, ami inflamma- 
tion of tlie middle ear in the first or acute pta^e. On the other 
hand, in lonfi-standinp or Mip[iiiralivp otitis media, adenoloniy 
is beneficial, a.s well as in catarrh of Ihe Eustachian tube and 
middle ear. 

The folUiwing points arc of imporlance for the jwrfomiance 
of the o{»-rutIuii, which should be done, if [xi^wiblo, on mi empty 
stotnacli : 

(ri) J s.'ci.v^onrf?. ^Without profier a^xlAiiec the operation, 
which ha.** to he done i|iiiekly and enerjictically, \» ini|x>ssiMe. 
An assistant !«>alt^l on a chair has to keep the palieiit firmly, 
as we have alreajly de«crili«l for llie n»moval of a foreign botly. 
(Seep. ilO.) 

(6) Annexthey-ia.^K kockI assistant will render anaeethegia 
supcrfhioa-) in Pinull manu^ablc childr^i, anil alno in ndulte. 
If the paicnls especially dcitire it, and older chiklrcn if they are 
vert' re.»(istaiit, may Iwive cblorofonn adloini,itered. Bui the 
anaesthesia sliouKl only be lipht, s(» Ihnt the reHex of eoiighinf; 
and mvallowing slioulil not be abolished, in order tliat the blood, 
which miglit |>n«sibly run into the throat, may l>e coughed up 
and e.xj)ertiirated. 
I 'J 




Kthyl bromide may aLsn I>p uwxl. (See p. 42;) Tfie anaiw- 
thetic is administwrti (a ihe cliiltl in a rocumbcnl or n«liuing 
positifiH, aiul for tli« purpuseuf opcraiion Uie child is made to sit 
up. In fact, narntjMis will only he lUTCssary in obstinate 
childpon, if Mie pharrfnifptil nrul palatine ton>nls lia^-p to be re- 
niovtxi At the same time, fur Lbe sake of both 0])cra1ion and 

(c) fndrumenis.-~Oi all the iiuincrous ini^trunients, the 8o-aUlctl 

adtnoUniiefe (ring-shaped knives) are 
most suitable. (Sec J-'ig. SI.) 

I myself excliL-avely upe lieckmann's 
arienolutiie. which l« a modifieation 
of GoUslein's nasal eurette. ^\sa rule, 
tlip largest sized irislruinents should 
be employed. The larger the instru- 
nicDt which one is able to introiluce, 
the iiuirf railical i.s tJir i;fTcrt of the 
operation. The tongiic is depn'twed 
by means of a tonguo dcprcjwor or 
firm spatula ; thi- jaws, whieb are often 
rlenched, iiuikI. Ik* kept open by a gag. 
In many cases one wilt guceeed in 
o]M>ning the nioulh by roiiipressing 
the n<]ftrils. I-'or severing any por- 
tions of vegetation left liehind, fiey- 
man's forceps (see Fig. 35) or cun*cd 
scissuRi, or a snaro. may be iisml, 
and, of course, all these iiislrutntDtfl 
must bo sterilJEcd and kejit handy befon- oix-ralion. 
The ojieralum w jXTformed in the followinj; way f«>e Fig. 82): 
The Ofxrator, with tlie reflector on his forehead. Ls iseated in 
front of the patipjil and intnHhie^s Beekmann's ring knife behind 
the soft palate, while the longHP is kept well depressed in such 
a manner that the hand!c is* direclwl dowTiwanlc. The soft 
palate is pulletl firmly fonvards, and then, by p\i!»hing the instni- 
ment as far upwards m possible towards the fornix pharyngis, 
the adenoids are then cut aivay by sweeping it firmly Imrkwards 
and domiwards. And now. without removing or turning the 

FIk. 81.— Adenoioma (afUr 
oithnanR), in various Htxm. 



through, one knows by the peculiar crunching i<»un<l. One 
succoihIs in numy cust-s in gpUiiig the ]>har>Tjgoal tonsil out in 
one ]WCO or tUviilfxl, uj- il iiiay \n^ coiiglutl out. In ulUvr raws 
ttic tonsil may \m^ n*Uiiticil tlinitigh »nuv. kind of Kponn of the 
soft palate. jlhiI is ca.-'t (lul lat<T tlinjujjh tin; nioutli ur nosr. 
The whole operation tmist ho nipiilly tiom-. liniiuxliatply nfltr 
the knife is wiUnlrawn the he:i<l of the patient is quickly tiltocl 
forwanls, on account of tlie considerable liucmorrhage which 
uiif^l follow, tuit this, liowover, soon cca.«es. I-'inally, the pa- 
tient is requcslwi to blow separately each nosiril, if circumstances 
allow of it, in onicr to remove all coagula, but this, however, is 
not urgent. 

Ajlcr-trtntmcni. — ^Thc operation Ix-ing finiwheii, llie child is best 
put into bed for one day. and sliould Ite given at Hret nothing 
but cold fluids to take, such as milk, lemonade, yolk of egg 
with sugar, or fruit-ice. or. if the pain is great, lumps of ice to 
wick, and externally cold fomentjitions. On the second or thinl 
tlay foal may he lukewarm and sloppy. The little patients 
usually feel all right after their fii^t sleep; all manipulations 
aftcrwartis in the nose and naso-phar>'ngeal space are super- 
fluous or even Uanuful, and should, therefore, be avoided. 
Children who are able to blow their nuses should be told to (lo so 
with their fingers (Jl la paysan) in order not to endanger the car. 
ChJldreji atlending school nnist be kept away for from four to 
five (lays, according to how they process. 

Complications. — (a) During Operation. — It often hapiiens that 
a [lortion of the tonsil ia not cut through and still hangs !»y 
a thread of tissue swijiging or louehtng the tongue. Tliis 
is always the caw if the patient, after operatiou, chokes and 
coimhs, and if the haetnorrhage has been ver>' pe^-ere. Such 
a ]Mece must I>e cut away by scitwors or snare or may be pinched 
off by forceps. It must not., however, l»e jwUed off, berau.-w the 
posterior wall of the phar>-nx might Ik- Uierrby endangered. 
Haemorrhage usually ceases as the n^ult of (his small after- 
ofieration. Sometimes the jmpcp cut ciff lian Inrn swalloweti 
during the operation and will he vomited subsecpiently along 
with thp bloiKl which ha^ also ace(impanie<l it. 

(b) After the Operation. — After^i»iewling is rare, antl sJioukI 



it occur and be severe, tamjioning of the naso-pharj-ngeal «}««• 
may be necessiirj*. (Sec p. 67.) Woitnd tiifcclioiis, [irt>vidcHl 
the ij|ifnition was properly done, ai-e still moro stliioni, Some 
cases of glandular fever are p(?rhaps due to post-operattvo in- 
fection. Of other complications, 1 may name, from my own 
irxpc'rii'iicn, a case of nTy-iicck and two cases of paralysis of Uic 
vdiuu |ialaliiiiiiu. 

Thcn!Kultof tlieo[)cnLtJonmanir(^Utit.w]f almotftt iminedialrly. 
The cliildren slwp l>elt<fr, (lie v<iicp loses iU ix-cnriar s<tnn(l, 
etc, OUier symptoms, of course, disappear laler. Breatliiitg 
throufcti tlie nose !;liU remains inipedetl for a time, on account 
of the roftctioniiry su'elling, luul in ccrlain cases, if the niisnl 
cavity itself is olxslruct^H.!. it will mit subsequcnlly pel brtt«T. 
Children freqiicnUy Imve to he. tauRhl again how to breathe 
through Uie uosl- ; aimI tlit-y mut;l lie taugiit I>y Ky-btenmtir exercif<PH 
to bn'titlie throiigb tho noru- willi the itioutb hIiuI, by Mrirt in- 
structions, I'veiitually by bintling up tJn- jaw liuring tlif niglit. 

Complications or consequences whicli arc already present 
before the operaticm, and do not suUsi'le by iheniselvrs after it, 
must be Ireatetl according to ru!e. Relapses or remaining por- 
lioUH rcqijire a repetition of the adenotomy, provide*! that they 
cause trouUc; or if the nose ia wide cnoiigli and the patient 
allows it, they can be rcniovcd with the snare from within the 


Etiology. — Tlie [uilatine, like tlie pliaryngeal, tonsil m child- 
hotxl, ps{M'vii\Uy if there fxinlji a h/mpftalir tendfney, is often 
subject to hyperplastic chaiigeH. Hcreility seems aUo to play 
a causU role, and reiwated ealarrlis are very apt to produce 
tonsillar hyixrlrophy. 

Patholoeical Anatomy. —The i-nliirf;i-iitent of the |>alatine 
tonsil having bc<roinr- ."(ationary, may hv (:on^id^•nNl as a product 
of chronic inRammation of Ittt entire sjruetunr. If the adenoid 
tissue is ehiefly cnnremed. the enlargiil tomtil \» soft and of a red 
or dirty phik colour; but if ilie connective tissue lh in eacess, as is 



inoHtSy foirnil in adults after repoateil attacks of angina, the con- 
sistency is Imrdcr. tlit! tonsil Is [lalo. showing ou the suiiact- a ticU 
work of white iibres, aiid lielweeii which the dilated oiiciiings of 
the lacimae are visible. lu siicJi r.asej< liie tonsil shows a fissured 
surface, and is often adherent to the palatine arch. Concretions 
are oft^'U found, aiul tlieJr ini]xjrtain-e vvitli regard to tonsillar 
hypertrophy has been alrcaily ileKeribed (see p. 277); but it might 
also be ixjssiblc for the concretion to have been produced at a 
later Mage in the dilated larunaf^. 

Symptoms.— 'i'hr rymptuiits artr, for the most [mrt, the same 
as those hi adenoid vegirtalions, which, aw we have eaid, are vciy 
often asHocinted in rliildln)0<l with tonsillar Iiyix-rlrophy. In 
cases of very enlarged (jjnsils the impedeil breathing may become 
so aggravated as to amount to dyspnoea. Ctiildren are restless 
and snore dtuing sleep at night ; the voice is guttural anil thiek, 
the enlarged masses impede the free display of the soft [mlate, 
and fluid will «omctinies regurgitate iliroiigli the nose. 

On examination we find both tonsils, as a rule, swollen, the 
one sonK'times more than the other, aiul the enlargement may 
reach as far as the middle line or exceed it. The tonsils project 
still further forwards during movenientfl of swallowing, which ad- 
mits of an estimation as to how far backwarrls the hyperlropliy 
reaches. In some cases only single portions of the tonsils are 
enlai^pd; the surface then apiwars uneven and lumpy, particu- 
larly if it has already been the subject of ©iieration. Tlie poste- 
rior pharyngeal wall, as far of it is viHible, als^o shows aecumu- 
Ifttioiis of foUieU's fpranulations}; the lateral folds (bands) may 
be hyperplastic. The glands in the neck are often swollen as 
a consequence of several jirevioun attacks of angina. 

Diagnosis.— The diagnowi.s never offers any difTirulty, hut one 
-sliould Ixjir in mind thai sj-philis, which \k so prone to attack 
tlie lymjjhatic tissu4-. likewise pnxluees hyi)pr[>liL<ia of the tonsil. 
It may also be menttoneil that leukaemia may cause- tonsillar 

Prognosis.— The prognosis, apart from the leukaemio form, 
is always good. We must not forget, however, that the en- 
larged tonsil, with ita unevennc^'^es and rrv-pts, is a good nidus 
for bacteria, and, is, so to sjH^ak. the l>rL-cdiiig-ground of angina. 



There is, moreover, quite a large uunibcr of people who, in spite 
of tonsillotomy, arc subject to rejjeated attacks of angina, with 
or without concretions in the stumps which are left. 

Treatment. — If the tonsils are so large that they form an 
obstacle t,o respiration, or if tliey have botm r['])oatrvlly the seat 
of inflajmnation and concretions, 0])erttlivc rciiinval, viz., 
tunsillotoiny, is jiwtifialjk'. This eaii 1m' qui«kcst done with 
a tonttillotonif. I prefer the ingtruracnt of 
Mathku-Fahmrtstofk, which I ijow^css in three 
azes. {Hft! Kigs. 8:i and 84.) Whilr the tongue 
is iU'pre««iHl, Uie oval or ring-si uip*-*! knife in 
sUpjKfi 0.1 f(a- 08 po»ifible over the tonsil; the 
adjacent structun'-s (arches) must be pushed 
asidej and cure shrmld also be taken that- the 
lower eilgc of the tonsil is well within the ring. 
Then the sliding ring-kjiife is firmly puUed for- 
wartls. By this nmnocuvre the tonsil is trans- 
fixed by the harpoon of the instrument, and 
the tonsil cut off hy the Ting-sha}>ed krifo, by 
as much a& hail prcjject«l U-yoml the palatine 
arches. (See Kig. 84.) 

With a little practice a double tonsillotomy 
can he completed in a few .seconds. Should the 
tonsil !« mueh fissured and soft or concealed, 
a polyjjiis snare may oceasionally lie used. Some 
aA.\\«i- tliiU Uie tonal be pressed from outade 
towards the median line; thU seejns lo we wpr- 
/luo'w, and not without danger with regard to the 
large vessels in this region. 

Complications During and After Operation.— 
<fi) Bleediriff. — The miiKt uripleaf«int., lint luckily 
rare, eompUoation is the injuring of a large vessel. Experience 
shows thai bleeding is grpaler in the hanl tonmla of adults, 
Ikeeaav (ho veHsels emlwdded in ihe hanl fibrous tissue do not 
retrnct and are the easier kepi ga[)ing. Injury film to the [Mila- 
tine aiT-h may Baa-*e bleeding. lIiu»rnorrhage sometimes oceure 
several hours after tlie oiyration. 

The iM'st tn-fttnienl for severe haemorrhage ia digital corn- 

Fig, to.— Tod- 

•illotome (after 
M athifu-fah- 


OF Tiir: piiai;ynx. 

preasioQ of the bloc?dinR B|)ot, For this objoct tlic finger is 
amied witti PotUwi-wool, which may be dipiwd in j)crchloriil 
of irtm oj- [rt'i-oxiii of hydrogen. Tlic «ii\iiiiary ulyptics arc lui- 
rc'iinblp. Proehdiiuj lifls (KinstriK'tod n it]yfda\ form n( prcssuiv 
fnrwiw For toiiwllarhawiKirrimgi'. Scwiiiie (ogfthrr the |ialatinp 
arclips, transfixinii aiwl t<ir>ioii of llic bicrding sit^, htc alt «nii- 
|)liciil(Hl pnH'iiUiri'jf. LigRtiin* of thr rw!|i<*rlive canilid artrry 
would hnve to Ix- coiwiilcrpd as sii iiltiiimiii refugium.* It hiw 



Fig. 8-1. — Application of the toiLiillolomv. 

ftlrcftdy bc-ftn liniic in Kov(*ral ca-st-i*, aiid whs not follnweil by niiy 
unlowjinl n-sult. Slight. Wrcihng ri!a«-s of it«'U if nv^t liiid ire 
an* aj»pli«Hl. Toiisilhitumy slumld hr avokiitt iii Imi-iiiuphiliii, 
and do^tnietion by the galvaiio-caulpry would be tlie best 
siilwtilute in such a i'i*j*p. .1/. ^clmiidt advisi?s iht* iise of llio 
giilvaiio-caulr'ry mrv siiart'. 

*Traniliilin^ pdKnr's footnoti>: It woii3(l afipear from experiDDOP tl^nf if 
hall a ton»\] l»e gibavr^l oil. Um- Htutii|> w tm^n- jimiii' M> Mt-nl tliiin ihe fitiunpof 
n thrce-(jiiartiT nr si-vcii-oinhth* rritiovii]. Tin".-' licinE rhf raw, if liai'iimrrhaKi" 
provw IroMhlnsonic, it has tx*n known to al once oca^c by rcmovinit a (iirtlifr 
l>i)rlion of llic Mt-oJiuK (oiiBil by Kuillutiiir or piincli [iinv|i(i; or tlit- bimling 
4lumfi may bp l-vuIikhI; Hie blcc^linK then vovti cruacei. — h. W, F. K. 



(b) Jnfedvm is also rare; but diphtheria has Ixxrii eecn, and 
we would rftcomniend rather to |>08t|K)m; a tonsiUoLomy durmg 
ail cpidaiiic- of diphtheria or scarlet fever. It doe> not seldom 
hapijwi that llie girji.-Ji-whito llbriiiuus lilni, which is often de- 
pc)siU>d oil the wound surface after operation, is tliought to be 

Exndsion. —Various authorM, and recently Wincklcr also, advise 
evulsion of the tonsils (sliellins out the tonsils), especially if the 
latter an; ri.s«iire<l, deeply seated, and are often gubj(«t to ui- 
flanitittilioiiH. The »relie.s an- se|)aralii1 an imirh as posrable 
fniiii the tonal, and thwi Iho ton.sil Is wia-d by a forceps and 
freed l>y means of an elevator without cutting. This done, the 
whole ton.sil e«n Ih'. >*e|mrated by rotating the forei-ps, aided 
Rlilrfitly by the elevator, Children and !ier\'(jus patienl^i are 
anai'slhetist^i (Winclcler) . Evulsion takes eiglit to twelve days 
to recover, but is said to have a goo<l influenft? U|Kin the voice. 

The aftrr-trenhnenl consists in the applieation of ice, cold aifU 
licpiid food, and gan^les eontainitig disinfectant.'. Gargles, 
however, t<houId not b« forced, for the formation of tliruiubi 
may k>c impedctl by it. 



In measles, we very ofhai set* die mucous membrane of the 
hard aiHl HoTt [lalate afTc>(>ted with a similar exaiitJiem, whi<!h 
pwceiles that of the .-fkin, ami enables tis, in eoiijiinetion %vitli 
*' KopHk'e spots" (see p. 20;j), to make an early diagiiosis and 
lo isolate the iMitieut in lime, a eirciimstanee which is very 
ini|Kirt:uit in n-six-et to prophylaxis. 

Scarlatina.— The first (prodromal) stage of cearlet fever is 
domumt«l by angina. In doubtful cases an luipua will alwa>'s 
(jpiide UR towards scarlet fevw. Measlea mostly iK^ius witii 
por^'xa and conjunctivitis, sphlom with aiipina. 

In searlet fever Ihe nn^ina shows two forms: (a) a benign 
form, in which the patholopical chanpes are atuated in the super- 
fidal lA>'eTB, and (b) a malif^ant fonn, in which the mort»d 



cooxu^tent a kiml of <lip)itlit>rtc iiiflHiiiiiiatinii, which, like Uip 
piosliilps, may give rise lo liic fomialion of ulcers. Pain on 
swallowing and salivaticin an* ncvwr abycnl.. 

Chicken-pox (Varicella).— Here the 8>i«])tonis arp inucli 
milder, anJ we usually see onlj* reflness aiu{ swelling (raljirrli) 
of tlie mucous membrane, and, in rare casfs, papulos or 

Diagnosis. — In all these fonns of angina the iliagiiosiH shunld 
offej no difllrultifw if one takes into considiTatioii the wlidle 
state of gpricral diseasa*, esjw'ciitlly die eiuuillaneous, <ir shortly 
following, oulburst of a siiiiiiar cruplion on the skin, luid llie 
local signs, which are afl*n (nieai^les, scarlet fever, smallpox) 
chamcleriptic. In scarlatinal anpna. moreover, a mlcrosoopical 
examination will put the matter lieyond doubt. 

Treatment. - In .■flight sj-mptoms local trratment i.« Miiierfluoai, 
or it is suflicieiit to clean anil diHUifect the moutli anri throat 
as usual. This is, liowever, not to Ik* neglected, mon* iiarlini- 
larly in scarlatinal angina, 

Hon? the drinking of aridulated lemonade is of great l)enefit 
to ehildren, and older chililren eouki also use it iw a pargle. 
Solutions of aluminium acelale (1 to 2 \\ot eiflit.) or peroxide 
of hydrogen 3 per cent, may also be used as mouth-waslics. 
Catli praises the atomisirE of sublimate solution 1:50(X) three 
or four times daily; and in the case of .small (children, touching: 
the respective parl.s with .swabs of cotton-wool dipptxi in a con- 
centrated solution of sublimate [I:1000>. He has never had 
a CHse of |x>isoninp or bad areidrnt from it. Ueiihner oniers 
cleaning with water, to be followed afU-rwards by gargles of 
ichthyol, and small children who caimol gargle are to be douched 
with ichthyol. the heiul being inchnetl forwards. 

In serious ciises of angina and pseudo-tliphtheria Hmhner 
advises submucous injections of 'i per cent, carbolic acid. Half 
a Praraz s>Tinge (0.5 c.c), twii-e daily, is injected on each side 
(into the tonsil, arch, or soft |)alatc) through Tnube's cann\ila 
fixed on the syringe, until the urine shows the carlwhiric colour 
(brown fir fanoky). Ice iippliea lions arnuml the neck may lie 
useful in the be^nmng, but in ra-scMof necm.'<a.f and suppuration 
ice is less appropriate. Enlargcil lymphatic glamU which do 


not quickly subsulo on Ihp application of ice slioulcl be softoied 
hy liot full ltd tattiMiK and then incitHsl. 
Injections f,f serum (diplitheria antitoxin) are jtwlified in those 
'-- i^;??<T*« liacilli liavc been founiL 

At the beginning uf typhuiil fever a calaiilial nugina is not 
a mre occum-iiw. AceordinR to I'reiich authors, the mucous 
roejiibrane shows soinelinios here a rough, uneven, ecaly a]>- 
pearanw (angina pultaeea), ilue to the peeling oflf of the e]>itlK- 
hum. Suiwrfieial necrosis may occur in the region of the 
iJian-rifiCHl niueous inembrane, jMirlJcularly that of the ijalfttinn 
arclics, where sn^all nmnd or oval, sharply defined ulcers are 
formed, with a groyish film rnvwing Ltit- l)ase. The patients com- 
plain of \mn on swallowing. Tlie pn'scnc^? of such ulcers, which, 
however, soon heal, should din^-ct our attention to typhoid in 
atl <loubtful casus. 

Etiology and Pathology. — Plmr\iige«l diphllieria filiphtheria 
faucium; aiinina dipUtlieriea) repi-esenti* the most iinportftnt, 
often the only, loi-alisalion of a «j»cific ilisease cauactl by the 
Klebs-lMJpcr liacilhw, and tierurw mostly in eliildrcu, .*fldom 
in ailldt-^. Infection takes plan; by eiHitjipun from |K'i-Min tu 
person, the diwuisi' sliowing llie cJiarncteristiw of an rpitinnie 
or endemic. The geniw also eJing to inanimatt; iii.itrrla!s 
(foniites), such a.*- clothes, toys, frmd, and for a limp-r j»fri<wl on 
moist than on dry material. Of grejil importjuiee is the cir- 
eumstance that many persnns themselves earry the liaeilli 
about in their nioulhs, without Iieing tlieniselve.«; nffoetcd 
by diphtheria. Such ixTsoas may transmit the bneilli to other 
more susceptible Tteople, the tmnimiilters themseh'es being 
immune, 'this is jHThiif^w due to certain antilKxIiew circulating 
in their blood, or tliey suiTcr only from m flight catnniial or 
follicular angina. As a nistter of fact, iliphtheria may he dis- 
guised under the mask of sudi an anpina. Thus it may be 
explained that (lerRons Imvinji been in contact with patients 
sufTering from diphtheriii eaii tran.sniit the disease to otliers 



iio Btc more susceptible to it, wilhoul tlicmselves hring ill. 
This susfwptibility is(le])en(lent on some ccrtaiti, locul or general 
disposition, viz., age, ijrevioiis diseases (measles, whooping- 
euiiRh, elc.), hjfwrplafitic tonnlLs, a^lenoiJ growths, olc. 

In the majority of cases, wijceially iJi the graver forms, a 
liiixei-l infection has taken pLiee; i. e., Iwsicles the di|ihlln'ria 
bacilli, other microbea (etreptococci) liave OKtahlislip^l Uieni- 
selvea in the body. It is, howewr, not yet ascerlaineil how far 
fJie general iliwast^ in these eases is depenJent on the action of the 
strejitococci ; mid, moreover, sucli a mixed infeption in the 
siTJou-s ca«(« of iliphthcria luw been recently denit-il, ami all the 
grave Kyiiiptiiiiis have U-c-n ascrilwil to the formation of toxins 
by llu'- LoJPct'k liiieilli (Genernu-fi, r. Hnnke, Vffenfieinter). Tliin 
toxin, which cim Ik* isolated an<l has beeji used for experimente 
by RwHX anil Yersin, is thatwbieli priKlmi'n tlie grave gitieral 
s)'mptonis, and \&st, but not leii^t, the perjUymng action on the 
heart and nervous systom. 

Death from heart failure is thus the effect of the diphtheric 
toxin. Tlic ^yt^u^ toxin, not the baeilliL**, is the rau^e of 
the dipIitluTie meinbranen in the tljroat, as Rmcr and I'tT-wi 
liave pn)ve«i. and ihe.str jwiine niendiriuies als(i are aide to block 
th<> air-|msMiges (in d»<(>4>ndiiig iti[>litheria of ttii; Iar}-nx) and 
eaiiN4' death by asphyxia. 

Fi\fnm>nx. I^luirymjitis. — A fibrinous exudation aneoinpanied 
by fever oecure in the throat, espeeially oti the tonsils, as well 
as in the nose, ami forms false nieriibranes, which can Liisily be 
HCparated, but after removal eoun rociira. After the applieation 
of the galvano-cautery. and more especially of caustics. .«uch libriii- 
oimdcp()wt»may be (««'n. Tliesedeixisits consist of fdirin. leuco- 
cytes, epithelial (i-ILs, and rnierolK'S. Though KUhs-LiiflhT'x hacijli 
are said not to U- pn-senl, <Hie would act wisi-ly in treating >urh 
a of filirinotis angina an if it were difihtlieria, no matter 
however slight it may be. The iliseftse sometimes lasts (Several 

Pathological Anatomy.— In true diphtheria fibrinous intlam- 
mation is combined with necrosis. If the pT«c«as is ntiuited 
in the ituperftcial tisKuej--, the ^-esscls degetierale and a fibrinous 
exudation takes place umlcr and upon the epithelium. Then 


UiaKASeS OF tub PlIAIilXX. 

the superficial epiUiolial strata undergo necrosis, to form the 
characlt'rintic ciit4c;olourwl greyisli-whitt' peeu(Jo-mfnil>nuK'S, and 
which consist of a network of fibnn (fibrinous hlfljucute;), and 
between the mcahes of whicli cclhilar dements may be found. 
These pseudo-tnwiibranfw ari; liniiiy aillicivnt to the lUKierlyiiig 
mucous membrane, and cannot be separated without caUBJug some 
bleeding. If, on the other liand, the proress occurs in the deeper 
tissues, a fibrinous exutlatioii followed by necrosis takes 
Under the necroswl tissue the mucous meuibrane is inflamed 
and shows round-coUed infiltration ; the vessels are dilatal, an<l, 
finally, suppuration sets in, and the jiaeudo-membraoe, as well 
ae the necrosed parts, is cast off and discharged. 

Symptoms and Course.— The disea;?* shows in the beginning, 
with regard to the general and local CTmptoms, the same picture 
as in simple angina. (See p. 203.) On inspection also it would 
be difficult to Lliscover a difference. Only a careful survey or a 
bacteriological investigation would reveal to iis the true nature . 
of the diaease, though not always. In pronounced cases in- 
spection of th'O throat would probably not leave us in (loul)t. 
One sees on one or both tonsils finiallor or larger siKod greyisli- 
whit*' patcliew, wliieh cover, as the case may be, more or less of tlie 
whole tonsil, and sprcatl onto the mljaeent part^, more especi- 
ally onto the palatine arches, uvula, the lateral, and leae fre- 
quently the iwsterior, ]>liary3igc'al wall. In certain cases the 
membranes are covered with discoloured muco-punilent fluid. 
The |).s{-uilo-membrane8 loosen after three or four day.'*, and are 
Ihen di.scharged, and are either spat out or coughed up or, 
as the case may be, swallowed. The defects causeti by the de- 
tacluneut of the pseud o-iiiembrane are rejisired, or the pseudo- 
membrane is again renewed, until, finally, after two or three 
recriidt'sci^iice-S, recovery is establishetl. 

In severe eaww t-he process from the outset shows a tendency 
to cattend in surface and depth. Here the loss of substance 
is much more extensive, and only heals with the formation of 
soars, owing to the mucous membrane itaelf being affected; 
afterwanls arlheaions 3nay often be seen. The infiammation 
sprea^ls upwanls into the naso-pharyngeal sjmce and nose 
(see p. 93), to the Eustachian tube and middle ear (in certain 



c&scs the disease iiiay probably oiiginate from the naaopharynx), 
or it may iiivade the nioutli or extend do^vllwanl8 into tli« larynx, 
IrtichL-a, aiid bronchi, and, with signs of severe dyspnoea, brassy 
coutili, and liniirM-ncss, lewl to suffocation if n(»t fniickly inter- 
fert'd with. Tlit? progrisis and involveinwit of aildilioiial regions, 
as well as the renewed fonnatioii of |)sr>iidi>nienihnuies in the 
throat, are on such occasion uslieroii in by an irwrease 0} temper- 

Ilie most severe forms of diphtheria are characterised by 
eignji ctf ga7i(p-ene and scpsia. 

IiigutigR-iiuiLsiliphlJicriaall l}i<>HffiTtcd paj^^.andln particular 
the tonsils, arc very much swollen. The diphtheric mi-riibmnes 
appear of a gn'yisli-grwn, dark-grey, or hrowniali colour if rnixwl 
or mtaiiie*! with tlie blooil. TIh- cpilhi-liiun is sejjarated, blebs 
occur, ami extensive necrosis of all the tissues miperveJieH, mak- 
ing itself evident by a luirrihle f<H'lor ex ore. If we examine the 
throat, we experience difRcuIty in recognising the confiRuration 
of the pharyngeal organs; the inspection is, moreover, impcfled 
in many case* by haemorrhages from the various necrosed tissues. 
Ilic lyniphatJi; glands in the neck ore, m a rule, enumiouMly 

The gangrenous form may originate from the pspudo-mem- 
branoiw fomi. The iliphtlieria must have alreiuly existed for 
several days, or even weeks, before the gangrene supervenes, 
and it is only in rare cases that the gangrene exists from the 
outset. The pjitient^ die nipi<lly with nit the signs of sepsis, 
or an erosion of a large vessel in the neck may prove fatal. It 
may happen, however, that the gangrene is Umitod, and a line 
of demarcation is shown; thus reeovcrj- takes place after the 
separation and discharge of the foul and iU'M\ matters, leaving 
behind them scars or adhemons, such as arc usually and only 
seen in severe sj-phitis. 

llic septic form of diphtheria is characterised fnmi the Iwgin- 
ning by the severeness and intensity of the general syiiiplonis, 
high fever, small and feeble pulse, apathy, and drowsineKs; 
whereas, on the other hand, the pain on swallowing is iiiueh lew 
marked 'ban usual. The IjiJiphatie glands are very 
much swollen, and ecchymoses of the skin and mucous memlimne 



soon app**Jir. Th(i septic form originat^'s either from, or is 
ai5S(»ciaUyi witli. tlic gangrenous furni. or it itevelopa directly 
From the iiseuilo-iiieinliranous fonii, wiUioiit tlie interciirrence 
of gangrene. Tlie |»atiein.s usiwlly .siiccuml) in fruni two to lliree 
clays luid deatli often ensues wilJi » subnormal tfuiijerature niij 
with th[> evidence of severe cerebral disturbance or by heart 
faibire or •x'dema of tlio lungs. 

Complications.— ( 1 ) Sose, MouVi, Ijxrynx. — The diiihtheric 
affection of tlic nose and mouth is usuaJJy an extension from 
that of the throat, and if* w^Idom it«clf priniarj- ; and, as ha« liecn 
alreiuly ^t»tl>ll, laryngeal diptitheria will be discussed later on 
in Part IV. 

(2) Heart. — As has been already said, the heart is very often 
affected in diphtheria. The patients die of cardiac laralysis, 
and pven also in scpmingly mild eases, and jxrhaps (luring c-on- 
valescence agaJii, faJltin' of tho hoarl, with froqurnt and wiiall 
pulw, might occur, and then death ensues. 

If tho pulse-rale increaw^H to over JOO without a \Tsible e^use, 
affection of the heart is to be expected, and calls for Uic KiTat/- 
est precaution. In other cases the debility of the hmrt is 
more gradual; the children become more and more ai>athetic 
or somnolent, and finally die from exhaustion. In the rapid 
cases of i^aniiac failure we must attribule tt to the effect, of tlie 
toxiiiK on the vagus and eanliae ganglia, and in the more graihial 
CAfles we imually lind degeneration of the myocartlium and 

(31 Kuirieyx. — A slight cloud in the xirine is always prewnt 
as the tosult of the fever. In the nion^ serious rapes a large 
amtiurit of albumin in the urine indicates a )>arenehyniatou8 

(4) Skin. — It sometimes happens tlmt by inotnilation of the 
vims into nutancou-s fissures or excoriations the skin becomes 
affected, and the diwase is apt to extend superficially, as well 
as into the iWper tissues. 

(5) Eye. — Diphtheric con jimct iritis is not often observed ; and 
for the sjinptoms and treatment see text-book on Diseases of 
the ICye, 

SequeUe. — With regard to the matter of afteT-affections, 





76 are mostly called U|X)n to dftal witJi |iaralys(s, which tat- 
probably the result of peni)licral neuritis, due to the diphtlieric 
toxins. Post-diphthf'ric paralyses usually occur about the be- 
ginning of the third vs-eek of the disease, but aometintes still 

J'tiritli/sis oj Ok soft jmlate is the most common, and nianifrata 
itself by the regurgitation of food through the nose, and by 
rhinolalia ujktIa, the vchuii i>alaLiniini lieiiig imniobile ihiriiig 
intonation or six^aking, and kIiowh also tnarked anacstbma. 

Very coinnioii, likewise, tbouf^i pierlmps less frequuil than the 
forcRoinp, is the paralysis of accommodation, cftusing inability to 
rend or see ckw^rly (paralysis of the ciliary body). Other ocular 
iiiusciew iiijiy be pandyscd, CHpccially tlic external rcctii.s. Paral- 
yivs nj the t^ocal cords have been observed — unilab-ral as well m 
bilateral. If the sensory liranches vj the iarfpiijeol utrfe fsupe- 
rior laryngeal nerve) are paralysed, the danger is great, for the 
patients, owing lo the abolished reHex aetion, are prone to 
niisswaJlow (dyspha^a), and become subject to "foreign body 
pneumonia." Paralyties of the xlcrletal muscles or Nmba arc lea^t 
often observed, as elwo is ataxia, viz., a dipturlmncp of coor- 
dinated movements. The ]>atient8 are not paralyfle<l, but their 
movements arc ataxic, elunity, and unskilled, llie hiee-jerks 
are often abolishetl, at least for a certain time. Many of these 
motor and sensory lowions may be combined. 

Paralysis of the myomrdium, which may also occur during the 
convalescent stage, has already been mentioned. Paralyns of 
the muscles of respiration, which is luckily verj' rare, causes 
death by asphyxia. 

.Ml these nervous Icwions in penoral mostly occur in severe 
forms, but may also appear in the milder forms. 

Diagnosis.^ — Ivvery exjierienccd practitioner will agree that 
there are caaos which are difficult lo diagnose, and can be eluci- 
dal«l only liy microscoi)icnl fxamiimlion. viz.. finding of l^ffler's 
bacilli. Many ca-^cs of follicular c»r lacunar angina (see p. 264) 
may iyp. niistjiken for [liphthcria. or sliglit eases of di|iithpria 
niiHtaken forfollictdar angina. If a larleriotogical examination, 
whether by culture in n twt-tube or on a specially pn-jmnHl 
nutrient plate, or by tJie niicroscop*' alone, is not rcjuiily 


oli(itinal»l» or iw impossiblp, Ilipn il is as w^U to trrat each 
tloublful caw, especially in times of opideinies, as if it were 
ivally (liphllit-ria, and isolate it. The paihogiiomonic membranes, 
which cannot be seiiaraletl without tjctin.' force ami without 
l>lfftling, taken in iCdniljiaation with tie whole gcucnil piclufr 
of the disease, will aclniit of a diagnosi.-*. Si-vere cases, m an 
advaucoil slJige, or if followed by complications, are not easily 
inistakcn. .\>i to fibrinous pharj-iiptis, «>e p. 301, 

Prognosia.^Generally speaking, the prognosis is less favourable 
III children than in adult*, and it is still more so the younger 
they are. On the whole, it depends much on the character of 
the cpiiicniic, on tlic "gnuis epidi-niinifi." which ilsflf again 
depends on the vimlcnco of tin- bacilli. Tlicrf an- ^liglll casm, 
healing in froiti one to two weeks, and more serious ones, which 
n*quire three or four wrrka and iiiurr for rewvpry. If the proc- 
ess phows a tendency to spread and th(* inenibranes are found 
on other regions as well as on the tonsils, tlie prognosis becomes 
graver; and it is bad if the process extentis lo the deeper air-pas- 
sage-s flarvnx or Iraehea), The septic niiil gangrenous processea 
likcwiw render the prognosis bad, and itis*-till worse if the glamla 
are much swollen, if the fever is high or subnomial, and if the 
pulse-rate is subject to great oscillations, a circumstance the 
iiii[xirtaiice of which cannot l>e overraled. A feeble and frequent 
pulse, but alMo a slow and irregular pulne. always points to daiiger 
from c-ardiac failure. Patients whose hearts have already been 
weakened by a previous inferfious disease are, in my opinion, 
worse off should diphtheria attack them. 

The prognosis lias been improvni as the result of the intro- 
duction of serum -therapy, at least in the opinion of the majority 
of physicians, providwl that the eenuii is applied at an early 
stage of the ditwasc anrl in sufficient strength anti quantity. 

Diphtheric paralysis u.-'ually affords a good prognosis. It 
l« only tile tw^ralyses of the n-spiratory, jihrenic. and laryngeal 
museli's that are dangeriius. 

Treatment.— fa) Sertim-Oiemjuj.— The intnKJuction of theanW- 
diphlheria serum inakcn it our duty to inject it in each case of 
iissuritl diphtheria. Il cannot be deniwl that many cases would 
have recovered even without the WTLmijaiul it is just these mild 



cases in whit-h tlio uscfulnctw of the wruni has bc-cii ibubted ; 
hut one should nrvcr frirgft that tliphtlicria is ti disease wliiHi 
iw iiicalcukhlt' in its roursc, aiwl tlmt tlie wruin is tJie less valu- 
al)le thp later it is applied, and the longer the Iwdy has suffered 
from the deleterious inilueiiee of the diphtheric infection (as 
to the nietliod of apphralioji, see p. 9(V, el ye(|.J. 

We here desire to say only a few words ou theUoeage. Tn the 
milder casen, and in diiUlren under tliree years of age, oUO units 
of antitoxin arc sufficient. 

In older children, up to mx years, 600 toKKWunitsarerequirtKl. 
In imiients over six and in advancal caaes ir>(Kl uiiils should lie 
injectetl at onra?. Severe cases rexiuire the immediate injection 
of 2000 to 300(1 units. The injection must be rc[(eated,aml on 
re[)etitiou a smaller dose is required, and, a* the may 
be, this may l>e yet once more rcpr-ated. The effpct of the injec- 
tion is often astonLshing. llie local process beeomes liniittxl, 
the fwi'ud(MneiiibrH.iies are east off, the fever abates, and after 
twenly-foiir hniirs convalescence is well establislied. 

(b) itfca^Trcnimen;.— ^Theuueofantitoxininoallyretidereevcry 
other form of treatment superfluous, but if it is found necessary, 
tlisiiifeclant gargles ur moutJi-wadics may be onlered. Little 
chiklren's throats can be sprayed or ilouched with lini<^water 
or aluiiiiniiiin acetate (one t('a.s|x)onfuI in a tumbler of wattT); 
the hi':ul Ix-ing jiredined, tliis ccrljunly render* fuxling easier. 
For older children and aduU-s 1 am acoustonied to pre-scribe 
fomiamint tablcti. Tee applications around the neck are very 
ust'ful in sevens cases. 

In any case carejvl attentitm mvM be fmdto ihe heart. In threat- 
ening syncope stimulants are retjuired, such as wine, cftffein, 
cainphor ft U) I si.'ringe of camphor oil). Above ail. the heart 
must be atrenglhenwl by a strongly nourishing diet fmilk, mcat- 
juiec, wine with egg-yolk, etc.), and children tnu/it be kept quiet 
in bed as lonij ojf possible. 

Complications and sociuebe must be treated acconling to 
tlie rfvpiirenieMs. In tie[)hriiis, a .'Suitable diet is most ini{>ortant 
(milk, Wildungen .spring, etc.), and tepid, and later hot, baths 
are very useful, Paralyses are treated by electricity. (For 
the treatment oi laryiige.Hl diphtheria, see I'art IV.) With 



regard to prophylaxis, strirt iisolaliim of the palirnt Is nfcr««ry, 
«Ji"i *iisiufc:ct.ion u( llic sick-ruom imlisix-Jif^ibU-, aiiil in lliis 
•^"spcct also all the jiiirroum lings (loy.s, linen, books, etc.) which 
"nve bei-ii used hy tlje patient must be disinrecteil. Children 
U-'longing to the same family attending school ought to be kept 

The question as to the preveniive value of Ifehring's scruiu 

not yet flettlc<l; anyhow, a prophylactic ijioculation nan Ijc 

rccomnwnded, although Lhr- immunity drrivod thcrrfnnn liista 

niy from ono to two wii-ks. For the jmrjMiso of iinimuiizing 

childrt-n, 200 to 3(X) units of antitoxin scrutu arc rw|uirwl. 


Etiology. — Lfsions of the epitholiiiin or catarrhal changes of 

o nmcous moinbrane of the pharynx and na.'^o-pharjTigeal space, 

ftnd especiiiiiy of the tonsils, in children, are much favoured 

by the genn« of tulKT(Mi!(t.--iH ajid Iuihim.* Thes*! affections are 

Uhiiallj- i)f secondary njitiirc, as in tJie case of tuberculosis follow- 

"g that of the lungs or larynx, and Ihc lu[Hjid affrctionn u^«ually 

spread from the nose or exU-mul skin into the pharynx. The 

throat, however, may also be tlie primary seat of tulierculoj-is, 

Although it might be difficult in a given cajw to discover luiy 

other IuIktcuIous lesion. Tins diseasf occurs at any ape. I .npus 

sw'nis to occur more frequently in yuuiig persons, while children 

are comjmratively immime. 

Pathological Anatomy.— The reader is referred to the same 
disease of the (Sec p. i)7.) 

Symptoms and Course.— (1) Tubercuionis is mostly found on 
the velum polatimmi, on it.s arches, and on the uvula; it wotno 
Unies occurs on the [m^itfrior phar^^l|?:enl wnl! and Lateral f<»lds; 
aeMorii, apparently, on the tonpil?. though thp>re organs, iis has 
been said, form the entrance gate and nidus for the bacilli. In 
the pharyngeal tonsil the tidiereular process is often Intent; 
neither does it sliow any marked symptom, even if seated in 
tlie palatine tonsjla (See Fig. 85.) 

♦Crwlep injPcK^d fine Clitnftt* tnk Into tlw tmwb of rsbhita. and allowed Hie 
(rannp(!iinn bolwecn ihc idtuilH luiil tlir tyiiiphatloqrtletn u( lljo iici'k, Htesi, and 





Tf an opportmuty oc:cur« to observe a cas.^ in its early stage, on 
iiisp<?ctiou, the mucous tiHmibraiK; is hcuii to be rctUlenpii and 
liilillmictl by a gelutiiioufi liuid, aiid scattered anioiig wliich 
are the tubercles, sliining ilirough like jKJppy or millet seeds, as 
greyish or yellowisli nodules. 

LatCT on, thpfiiv nodules can be observed breaking down to 
form sinall flat ulccni with irrf-gular noldiwl edges. On the 
margin of these "lenticular ulcers," or in their vidnity, other 
nodules or ulcers may be noticed. 'Hie ulcers become confiuent, 
and unite to fonii larger-sized ulcers or infiltrates. The ulcers 
appear atonic, i.e., ehov little inllaiiimatiun, and have a ten- 







Fig. 85. — Tuberculosis of «of( puUt« (from the Vienna loiTncoki^nl cliaM;), 

dency to spread wipfrricially, therefore, the fonnalion of a tulwr- 
culonia is verj' rare. 

As a rule, the jmticnt comes to the phyficion when a more or 
IcKw extensive ulceration haa taken place. Aeeimlingly, jiain 
radiating to tJic car in very troublcjionic, and various fonns of 
previous paracsthcsifl-s arc mostly dlsn-ganicd and not mentioned. 
The [will l>eeonieM more severe in pro|xirtion to the spreading of 
nim'ration, and is apt to Inndpr feeding. Tlie frpe motion of tlie 
soft palate is impeded, the voice becomes na'ial. and fluif! regurp- 
tatea through the nose. Tlie hnnphntic glands in the neek are 
swollen, and fottor ex ore may cjust. Tlie ulceration sprradB 



along the baf>e of the tongue, and it* liable to extcml from thcrft 
onto ihc iaUral walls of the pbarj'nx and larj'nx. The general 
liailili ituffcrM much, the patirait soon Ih-coiiic-m run <Jown, (spe- 
cially on accoiiiit of deficient nouridimcnt and fe\'er, anil other 
tahcrcular disonses (lungs), as well as the agonising p^is, soon 
cxiiaust the patient, 

(2) Luptts fallow's a niiklcr course. Small nodiiles, vhich 
look almost like granulation?, clustered and in great nunil>ers, 
may be seen. Any portion which lireaks tUivm temis In fnnn 
shallow little ulcers, which have tJie saine atonic ainiearanoe 




Y\f. 80,— Liipiworcbeimll palate (Tank). 

as do onlinary tubercular ulcers, but can bp (lisliiiguishei I from 
than by tlie great number of newly formed nodules on their 
tna^ina. In long-standing cases the formation of near tisBue, 
whieh has a great tendency to contract, and iasituateii between 
the iiodiiirs and uIcitm, is eonnpieuous. 

The wihjcetive Pjinptoms are much Ipw pronnuiicetl in lupus 
tliaii in tiiljort'ulopis. and the progress of the disease is also much 
slower. (See Fig. Sfi.1 

Diagnosis. — In some cases the dcei?ion, whether we have to 



Jeal with tulicrctilusi.s or Iupu.s, nr if there is aiiy other idccmtive 
(pyphiliticj proct-«i present, especially if the exaiiiiiiatiim of the 
bmly i» negative, is not cosy. Tttbercular atut lupoid iilrtrntiom 
da not spread in depth, ns do the syphihiic lesions, and havo 
always a more or less alonic appearance, and are (ihanutcriNcd 
by tfie nodules on the vtaryins. In doul>tfiil ca^-n tiiicrijw«pi<ad 
exariiirmtidii aud ioiUde of potassium will aid the diagnosis. If 
tlie external skin allows no lupus, distinction between tubercu- 
losis and lupus might be imiKtssihle. h'lmnntion of scars in- 
clines opinion m fatiour of it beinij Ivpvs. 

Prognosis. — Pharj-ngeal tuborculosis, on the whole, posaesBes 
an unfavourable prognosis, althouRh if priiiiurj', recovery- is not 
excluded; but mostly the dccrcaiiing powers, the progressive 
inanition, and tubercular proex^-sses in other oi^hk soon lejul to 
(linHolutioii. The diwcovpry of giant-e^llw or tuljcrclc bacilb 
in an excised phnryngeal tonsil ought not to !ia\'c any infliiriice 
on our judgment, for a latent tuberniln,s-is of the pliaryngeal 
tonsil does not seem to be a source of infectliin for other organs. 
Lupus, perhaps has a better prognosis, but is in<^lined to relaixse. 

Treatment- — If the disease is not yet too far advanced, the 
ulcomtions may bo thoroughly seraped away by means of thfi 
sharp scoop, and aft'onvards eauteriBed with lactic aeid f30 to 80 
per cent.), provi<led that the imtieiit s state of health admit}> of 
such roi^h handling. Otherwise we must treat aymptomatically ; 
€. g., relieve pain by painting with coca.ine (5 to 10 per cent.), or 
menthol (20 |wr cent.), or insuiHation of equal parts of ortho- 
form and iodol. UoUdndrr rrcommentls iodide of soda twic*- daily 
inlemally ant! the in^uillatinn of calomel. This is said by flolr 
l&nder, who does not make a prineipal difference between lupus 
and tuberculosis, to have a wleelive caustic effect and, at the 
same lime, to saturate the ti.^sue.'* with ioiiino, which issupjKiaed 
to have a sjK'cific effect upon tubercular [iroccsses. General 
measures of treatment are of the greatest importance. 


The pIiarjTix is so often subject to sj'philitic disea,** that, one 
should Ufvcr omit the examination of the pharynx of a person 
who is afTlieted with or is suspoele<l of having sypldlis. Tliere 


DISIl:A8^;H of tiik pharynx. 

sre only a few cases in which ihi- i)har)'nx shows no mnnifcstfi- 
liorw of aecombiry syphilts; whprH llies? seem t(j Im" ol>sent, they 
arc iirobably ovvrlookwl, owing to tlipir eaimn^ very little <ii&- 
coitifort. The late secondary stages or tertian,' eymptonis an- not 
m frequent, yet are common enough; on the other haml. how- 
ever, the primary Iwuon is w-ldom Eoimd localiawl on the pliaryii- 
geal mucous iiiemlimnc. 

(a) Primary U-xion (hnlinl Sort; Hard r/rnHm-).— Tlie usual 
seat of the initial affectidn is the tonsil. It hiTn funns & suikt- 
ficial erosion or ulcer, the e<lgps of which an- indural^'d ajid 
rolled over like a Imm ; its floor in eovcrwl with a .sniear>- grejish 
film, and it a^iaally causes no trouble, though in some few cases 
pain on swallowing is very consiilerable. The glands on the 
same r<ide of the neek ns the cliancre are always .woitrn and indo- 
lent (For the chancre of the tubar ostium see p. Xf9.) 

(b) The nerondnnj (tjVpw are lumlogoua to Uiosc in the like 
condition of the moulh (isoi^ p. 2()7). 

The erj'thematous (niacular) syphilid ocrurs as part of the pic- 
ture of .*^p/i{Wrcnfij/t)m. Ttiescjft paktearnl tonsils arediffusely 
reddened, contra^iiny shnr}f}y with the jmler, hcallliy tissue, and 
they cause little or no pain. Tlie spneifie nature of the angina 
eould not bo recognisoil if it were not for the connoetion with 
symptoms and signs elsewhere on the body (swelling of the 
lymphatic glands, painiessneiw. and other s>'philids). Syphilitic 
angina is marked by ita obstinacy. 

The papular form i» represented by the*'pla<iue«nLU(iuouM'«." 
which in apix-aranci; cxafitly rewinble tlio-seof the oral mucous 

They occur most commonly on the imlatine arches, uvula, 
tonsiU, and less conimonly on the liiipwl 1i>nBilK, and sometimes 
on the posterior ]>har\7igeal wall. Tlie oral tiuicous membrane 
also is nearly always implicated, but it does not rarely oeenr that 
only a part of the anterior palatine arch or tonsil is affcctwl, 
flhowing irregular yellowish-white patches, not <lissiniilar from 
pseudo-membranes. Buch cases Bomptimes offer dilliculties 
in diagnosis. The condylomata having subsided, the tonsil shows 
a tuberous, Irregular .surface, especially if there was ulceration 
from the breaking down of tlie jiapulcs. 




(c) Tertiary symptnms art? alw) usually associatnd with pucli 
OS arc in ttiR tiioiith. In tlw iiawFphai'yiigml spaw- iKolatctJ 
gunuimta Hoinetiim's occur, i'speoially on the posterior surface 
of the velmn palati. If we only have tho slightciit Buspicion 
of s)'philia, in eawrs of pjiiii on swallowmg. rAflialiiig to the car, 
together with a p!iri-si« of tin- soft piilatc, il. is our duty to 
examine hy piwt<Tior rhinoscopy, and shoulcl (his prove iinpos- 
sible, to tiHCfTtAin ex juvantibus the specific natxire of tlie dis- 
ease by hirjn; tlows cf io<iide of potassium. 

If U»e above is not done, one may wait, only to sec the softening 

of the gumma, which i\all 

lead to perforation of the soft 
palate and the extensive dc- 
fcet.<i tJiercof. (See Fig. 87.) 

('■omparatively little dis- 
comfort is caused by a ifuinma 
of the hard palate. The postc- 
rwr pliaryngeal u^Il is some- 
times also theseatof a gumma, 
without giving any trouble; 
and it is then the ulceration 
itself which lemis to a correct 
diaguotiis, or one may be only 
able to sec the ulcer alone, 
with ittf crater-shaped and 
niduratwl alg(> and fibncil 
floor. It is necessary, In some ra-ses, to lift (he velum with a 
probe in onler to at^e more clearly the ulcer,' which usually haw 
a tentlency to spread upwards. 

The scars remaining aftpr the ulcpration has cleared up arc 
white, glossy, and ratliating, and canst? more or less (MHisiilcnible 
dcfomiilies by their eonlrnctions, or are followed by adhesions 
or olwtruction if they form fibrous bands and coimections lie- 
tween the surfacrp conccme<l. 

Diagnosis, — Hani clianrm of the tonsil may be ralslaJien 
for carcinoma, gummatous ulcer, or nerrowng diphlheria- 
With repard to the diflVrfntial (liagnofiiH lietween gunmiatoUi* 
and carcinomatous ulcer aiiti cliaiicre the same holds good. 

Fie. 87. — tlummitous iilrpniiinn of 
the M)iF pulaie iu left t.onait, tind ttie 
pcwicriur [ilmrj'mfwil wall (Tiimk). 



mutatis iiHLtiuidis, as was said ou pof^ 210. Diphtheria is 
mostly bilateral and presents a more rapid course. 

W'ilh rcKard to Llie ^mndary mamjesUUtoiis, we may refer 
to what has been said preWously. 

PliKjufs iiiuqiieuBe.s, if localisrd on the tonsil;*, arc ditHciilt 
to liiscriiiiittiitc frmn other aneouons, and arc often not retrug- 
nised; and it is juNt the Miinc^ witJi r<y|itnlitir angina. As in 
otlier localisations of CTphilis, Uie dla^nusis is, in many eases, 
only made after longtT olwi-rvatiou or from the effects of mercu- 
rials or iodides. 

The difficulties in the diapnosis of the tertiary symptoms have 
been diKcusw^d in Diwa-^a of the Mouth and No«<>. to which 
we refer. Then* in now hardly anytliiiig to be mided. llie 
inii^irtanee of posterior rhinowopy lias hern pointeil ont. In 
general, syphilis slioiiI<i lie always our firet thought if we have 
to deal willi ulrcrflljon in the pharj'iix existing for a more or less 
prolongwl |K'ri(Ml, es[x*cially if eauHiiig no trouble, nor pain, nor 
fever. A certain polymorjihism, as to ehange and alteration of 
the appf^aranees, and also as lu size and seat, is characteristic 
of syphiliK, 

Prognosis and treatment have been alrea<ly discussed in variou."! 
chapters. The treatment of poet-syphiUtic adhe.-;ion.< and 
(k'fonnilies haa been treated in the chapters on Malfonnationa 
and Deformities. 


Phar>Tigo,scleronia nearly ahvayH ocieurs in association with 
rhinoscleronia, and is either a continuation of the iia.'*al process 
or is a primary affection of the nai*o-pharj'ngeal 8)mee, spreading 
into the nose and down the throat. 

Etiology and pathological anatomy have lKv?n discusswl in the 
chapter on Rhinoseleronia. Here it remains only to eiK'ak 
of the changes with respect to the special anatomical conditions 
of the phar\-nx. 

One linds here alw, ae in tlie nose, nodules of welWIefined or 
more diffuse infiltrations, the fonner Ix-ing more frequent than 
the latter. These iiifillratioiiH art' fnuiid m varidUH place?, most 
frequently on the Inlrral pharyngrnl w.'i]l. velum palati, and its 



arches. Later, the infiltrations undergo atrophy and shrink, 
with the fonnation of scars and fibrous bands, wliich Jiiay load 
to gross distortionH, adhesions, anil defomiitics of the n-speclive 
part«. The soft palate ih drawn backwarde, so ihal the view 
of the naso-pharyngeal space iit blacked, and the uvula may be 
found piillwl right up on to the soft palate. If (lie process 
sprcmls lo llie anterior jialatino archey, Uie ton};no becomes 
involvetl and fixed, and if ibe cheek is implicated, fixity of the 
jaw may result from the fibrous ankj'Iosie. 

The discomforts are directly dej^ndcnt on the size and i-xletit 
of the infiUrations and alirinkages. Breathing Ihroiigli the now; 
may be iniiieded or entirely obstructed, and speaking, trhrwing, 
and stt'allowinK may l>e considerably inhibited ; hearing also may 
be impaireil, and there are often buzzing noixes in the i-ar. 

Diagnosis. — Tlie diagnosis woulil hardly offer difliciillit'M in 
pronounced cases, though it might be nonfomided with tertiarj' 
or gunnnatoiis innilraliuna But tlie course of the guinina is 
always much quicker than that of stloronia, and, Iteeides, gum- 
matoas infiltrations never show the hardness and resistance that 
scleromatous ones do. In doubtful cases a trial with iodid of 
potassium and a microscopical examination, viz., the finding 
of scleroma l»acilll, will be decisive. Tlie distinction brlwoen 
syphilitic and scleromatous scars is more difficult. Generally 
s[)eaklng, syphilitic defects are usually greater and more e.xtensive 
than tluiKc jiroduced by scleroma. 

Prognosis. — Tlie prognosis is klentical with lliat t>f rhino- 

Treatment is also the same, and i« principally pyniptomatic 
and of little avail. (We refer to tlie chapter ou Itlmioijcleruina, 
Bee p. :050 

Manifestations of malleus in (Jie throat have no jeatiires dwtmct 
from the nasal disease of tiie same name, which follows on or 
occurs at the same time with it. There are small ulcers on the 
posterior pharyngeal wall, and, less often, nodular or 
infiltrations. For the rest, we refer to what wo have said on 
malleus of the mouth and nose fsee p. 107). 




According lo Bergent/nin, tuhtrvujs Ipprosy never, aiicl anaai' 
theiic lopTDsy seldom, (HTiirs on the phaniigeal mucxjus mpiiil)rane. 
The pharynx and naso-pliaryngeal »na(«? are usually affectwl Ix^ 
fore the larj'nx, bul later llmii the nuse. The waL of pn'<Iilc4!tiun 
ia the soft palalt" and uvula. At Ih'st. catarrhal Kyni]itonin are 
prevalent, but later on infillrationii occur and are more or less 
hiinl, knotty, or no<lu]ar, and which arc prrftcily anae-slhetic 
an<! tend In Imvik ikivvn. In very marktni rases tJie pharvnx 
has a certain rewniblaiici^ to a ^italactitic protto. llie mucous 
membrane, whieh isnt first moist, and shiny. later on becomes very 
dry, and the knots and nodules break ilomi, and so result 
in oxteriMtve de-struction, and (inally ihe fomiation of sojirs 
follows the iilceralion. 

Diagnosis. — The diagnosis should offer no difficulties if we 
take into consideration the whole picture and other »lgns and 

Treatment is s>'raptomatie (see p. 108). 


]. THRUSH (German. Soor). 

'Hie thnish fimgus, tho iiathologj- of which wp havp already 
described in a previous [lart (p. 212), is occasionally found 
in the pharynx, whence it i^preads from the mouth and sometimes 
causes pain on swallowing. 

Diagnosia.^Thc differential diagnoHis must be made from 
diphtheria; the latter, however, Bhowa a much more rapid course. 
The iiseudo-mcnihrancs of diphtheria cannot 1)p separated wilh- 
out causing bleeding, while the tufts of thmsJi van he wi|ie(l off, 
although some force ha« to 1* used without producing blewling. 
Tlie diagnosis will be a-ssurr-d by a microscopical examination. 

Prognosis and Treatment. — As to prognosis and treatment 
Bee chapter on Tlirusli in Moulh, p. 212, et seq. 






Etiology and Pathology. — As in an analogous ciitscajK- of the 
mouth, so heif, it consists of the invasion of the Ipptotlirix fimRt, 
which, togetlicT Willi the wriieous epithelial ccJls, fomi i^pinous 
excrescences and soft or hard concretions or cones, which project 
from tlic luiitfiilar lacunar, but may also be founii at the base 
of iJie toiigiii-, ill the rc^uii of tlie hiiguiil tonal, or on the lateral 
or jMJsti-rior pharyngeal wall. The lateral folds sometimes ajijK'ar 
as if strewn with them. The mucous membrane in the vicinity 
fhows a normal appearance or is slightly injected. 

Symptoms. — There arc few complaints on the part of liie 
patient. Sometimes a ner\'ous i^ationt is upset at having die- 
oovered something white in his throat, or he may feel a sensation 
of dryness, or tickling or burning, or have the eensation of the 
preftence of a foreign body in the throat. 

On examination, one finds the concretions and cones, which 
must not, however, be confounded with (hose arising from in- 
flammatory processes in the tonsils. These are fimdy adherent, 
difficult to remove, and are soon renewed. 

Diagnosis.— 'PharjTipo-myeosis may bo distinguislied from 
diphtheria, as it is afebrile, *^Iow in ite progresf, and causes no 
discomfort. The mycotic eones or concretions do not change 
their form nor unite. 'Die differential diagnosis between myooflis 
and tonsillar concretions is more difficult. The latter, however, 
are soft and are localised to the region of the tonsils, which, 
moreover, show sipis of previoas chronic iiifljuumation. 

Prognosis i-i characterised by the obtlurate course and lUs- 
posilimi t(i roIa[Lsp. In some cases, however, the disease spon- 
taneously disappears. 

Treatment is powerless, and, therefore, superfluous where 
no Inmblefl are cmnplaineil of. W. Frdnkel, wliu firfit descrihwl 
the diseas.', recommends painting wiih pure alcohol. Koxenberij 
maintains thai women are more subject to it than men, which 
would seein 1o rfiow that tobacco plays a certain n'>h: Indepil, 
fniioking has In-en fidvi^r-d fl.s a remedy. This looks like exor- 
cising llic devil by the aid tif Beelsebub! 




Tinder tliis hcatliiig inay be mentioned jtbaryngontjfoma 
mrrinim, due lo the sarciiia Ixingus, and yharyiiyomyams 
OKptrtjillina, caused by the various kinds of a*[X'rgiIliis. Sai^ 
cina is found c(>in|)arntivc!y often in (he threat and mouth. 
AjfiXTgilltis grows ppiniarity rnoKtly in the riDW, and is of very 
rare occurrence. It forms white or grey patches, hut rauaes 
IittI^^ or no trouble. 

Treatment, if of any value, conaiata in gargling or jiaintiDg 
willi dixinfcctAnts. 


Eti(^ogy. — roR'igii liotii<'s reach the throat by way of the 
nioulh. They con-sisl usually of piece-s of food, tt-s, f<tr instance, 
a morse! l>econiing imjiacted in t!ie throat, or iiidipestible and 
hard substances, such as pieces of bone, fisli-bones, kaneift, 
fruit-stones, or splinters of wood, paper, ete., which jxrchaiitie 
have boen mixed with Iho foot!; or lliey comprise other lUiiipj, 
such as DcedloE, pins, and niuls, which by a nnilc-spread thoufi^i 
ba»l habit are commonly held between the te«tJi; bristles from 
tuoth'bru.'iihes, istalkt', coni-liuskK, coin^t, bidtoiLv, t^toDi-s, artificial 
Itt'th, etc. In»ectfl may al«i fly into the tlmmt. 
Sometimes particles of ftHMJ arc thrown into the miNo-pharj'ngcjiI 
space during the act of vomiting or in paralysis of the 8(jf t palat*' ; 
they are usually flung into the nose. Again, it seldom happens 
that foreign bodies reach tlie throat by way of the nose; and 
still yet more seldom, from the car or through the soft parte, 
in a ciiPC of injury. 

Symptoms and Pathology.— Pointed or sharp-edgetl foreign 
Ixxliea are often loilgeil in the tonsils or root of the tongue, but 
also in the vallrculae and deeper portions of the pharynx, the 
entrance to the larjTix, oesophagu-s and pyriform anuaeft 
Larger foreign botlies are prone to filip dominanlf*, and imdor 
certain circumstances are wwlgml fa«t, in such a way that they 
are liable to eaujie death by sufTnralton, liy sudden comprcswon 
of the larynx or (be atlitus ad liuyngeui. Very 8liar]>-pointed 



ftirfrigii boilieH, eucli as fish-Ixjiica ftntl bristles, are sonuttiiiics so 
ilix-ply burifd m the toiij*il or niot oi (he tongue tliat lliey ilis- 
ap])ear entirely within it, or project only a very little way from 
ihi? surfacej and in oilier cases they are lodged trangversely 
at^ruKM Hie pharynx like lino tbrcadHiif niumu. 

Pfttienla ctmiplaiii of pain on swallowiiiK; of a sensation of 
pricking, which, however^ caaoot be always cjtaclly localisi'il. 
Tlic ;^K)wcr of localiHuliion is in genera] very imsatisfacUirj-. 
The |mtient.s, who are usually very much excited, often report 
that they feel the pricking or the pain caused by tJie foreign 
body in this or that region, though no foreign body can he dis- 
covered there or in the vicinity. It oven hapiwns tliat tlu- foreign 
Ixidy has ah"eatly boen ejected and the |iatient still feels it or 
iin^tne^ tliat he feelti it, whereas he can only feel the pain 
caused by the injury to the respective parta. After a few days 
these sensations have usually passed away. Infective foreign 
bodies, or such as remain in rUu for a long period, are apt to 
excite phlegnionoua inflammation, or (he jiatients may scratch 
or acrajK" with their nails in the throat until they have injured 
and infeet*Hl thejnst^Ives. Ocrifiionally serious haeiiiorriiagc 
may occur through injury or t-nwiun of a lat^ blcHKl- vessel. 

Diagnosis. — If tJif* patient. i.s lujt loci excited and js sensible, 
he can be examined wilhout dilTicully. Tlie parts which are 
mostly concerned must be thoroughly inspected under a good 
illumination, i. «., tonsil.^, root of the tongue, vallcculae, and the 
sinus pyrifonnis. A lan,Tigenl mirrorwill be found useful. l-,arger 
foreign l>odieM will bi- rawily di-srnvt-nil. Dilliriiltii^K may, how- 
ever, arise during the warch for liristles, fifJi-lMines, needleii, 
etc. If lliey wuinot be wi-n. the part.-* sliould \>r. thornugidy 
pal]xited. If. nevertheless, notliing can be di.scovered, we 
might calculate on the posability of the foreign bo<ly having 
been alreatly tliromi out and that tlie pain complainci.1 of is 
that due to the slight injury of the mucoue memlinme. But, 
wc should alfio bear in mind (hat a man may have swallowed 
two fish-bones at once, or that one portion of the forcrign bo<ly 
may lie reniove<i, and yet the other part still remain behind. 

Any examination is difficult in overexcited jiersoriH, or is 
made difficult by the choking on tlie {lart of the patient. Thi^f 


"ffff^il^' OF THE PIURVKX. 

often happens in patwnts whoee mucous membrane has become 
hypf;R«cnt<itivc, (hrou^i iJic K-pcatcJ anit futile endeavours at 
extmctioD. In a case such a? (his, a firm, quiet attitude must 
be [jrcsen-wl and cocaine applied. In urgent caaes the j^rays 
will he found very useful, though they will not reveal eveiy' 
kind of foreign htxiy. 

Progoorfs.^Is mostly favourable. Tlie subjective and ol)ject- 
ive syuiptoiii.s u-svmlly diwip|)par with the. foreign body, provided 
that no infection or gn-ater lesion ha« taken place. 

Treatment. — If a foreign body is discovered, it should be re- 
moved at once, and for this purpose a Buitably bent twc«Bcr 
or forceps may l>e used, or tlie foreign body, if lodged in the upper 
part of tlie jilmrynx, can be extracted mth tJic fingej. If a 
rounded object sticks in the pj-rifonn siniw, it must Ik- looseneil 
ami brouglit into a suitalile jjosition for extraction. Rut great 
care sliouUl Iw taken not to allow it to |ia>w into the larynx. 
Never try to push potntwl or sharp iMxlies into the oesniJiagus, 
in onlcr to avoid dangrrous injuries. In eases of ihrealened 
sutTocation we must ixTfonu iraeJicotoniy if attempts at ex- 
traction of the foreign body do not quickly suc«ed, and in 
some cases phar3*ngotoniy wilL be required. 


Calculi. — Etiology. — Calculi of the tonals resemble the cod- 
cit'lions alreaily mentioned, and are the products of chronic in- 
flainniation. They are c^useil by the drying up of the accreticm 
and the dep<\«dtion of lime salts in the lacmiae. 

Patholoffieal Anatomy. — The stones or calculi consist chiefly 
of carbonate and phosphate of linio and organic matter. They 
may attain the size of a hazel-nut, are either smooth or pimI^, 
and of a white, grey, green, or brownish colour. They act like 
a foreign body, i. e., as an irritant, and may cause, or arc associ- 
ated with, altscess of the tonsil. 

Symptoms. — ^The chief tniubles are <ierivcd from inflammation 
or suppuration of the tonsil. The patient romplaiiw of pain on 
swallowing, wbieh may also exist wilhnut tiitlainmatton, and of 
a jieeiiliar M'lisaticiii nf tejudiin in the fidf iif the neck. 

rHatpi(m.i id ea.'fily niBile by [wlpation and probing. It might 



occur, however, that the tonsil shows ossification in v»rioiis 
places, owing to ossifying metamorphosis of the fibrous Ussue, 
or are due to ossified vestiges of the foetal branchii, or tliat an 
abnonually long styloid process has perforated the (oiisil. 
(See p. 255.) In the latter case the bony procens can Ije traced 
upwards and latoraliy, above the tonsil. 
rrca/m<rn( must bo operative, and the calculi must be removed. 



Some of the so-called benign tumours are congenital. To 
this class belong the teratomata, and hairy epidermoid [xilypi 
of the posterior pharyngeal wall and velum palali. 

Other non-malignant growths are the jKtjnllmfia, fibroma, 
angioma, Upoma, and enohondroma, the fibroma heiiig the most 
common of them all. 'Hip fibroma in foimd, eingle or multiple, 
in the oral part of tho plmrjux, viz., on the uvula aiid palatine 
arches, where it foniis rouinl, wiiooth, orcaulillower-Iike growths 
froni tlie size of a pinVlicad to that of a pea. They may be 
pcdunciiLiUnl or sessile, and in the latter case are immovable on 
touching with the probe. 

The papilloma originates less frequently in the tonsil. Here it 
consists of a sliort, stalked fibrous growth, showing the structure 
of the tonsils, t. e., lymphadenoid tissue (eder^oid jioljfpi). Tliese 
represent the same tumours, which we alrea,dy know by the name 
of tonsiiia pendula. (See p. 255.) Crivcrtious angimruiUi are seen 
on the uvula and palatine arches, but alao on the posterior and 
lateral phar\'ngeal wail. They form duflky or bluLsh-blaclt tu- 
mours, which sometimes attain considprahle size. Cystic forma- 
tuntu are occasionally seen on the roof of tlic naso-plmrj'ngeal 
spa<«'. where tlic retention of secretion due to the hlocking of a 
tonwllar n-oess (huTxa jiban/nfiea) may give rise to the formation 
of a retentiim rysl. (See p. 270.) 

"We must e«|ji>e.ially mention a ecrtain class of tiunourenca[>- 
milatetl Iwtween the two Inniinae of the palate, and known aa 
intramiirnl (ummin^. Their structure is that i>f a fibn.iins, myxo- 
ma, lipoma, or chondroma, and theec are ori^nally deiived from 




tho endothelium of t!ie lymph- orbloocl-vcsspls. Tliey are saM to 
sonieliiiies assume a malignant (sarcomatous) eharacUir. They 
are scatctl mostly on tho liard or at the Une of junction hetwten 
hard and soft palate, are of a globular shape, are more or less 
soft in consifitfiicy, luid can Ijc distinctly moved under the intact 
mucous membranp, which is very often thinned out over them. 
In rare caaes Uie thinned-out mucous membrane gives way and 
uiccratfs. and In such a state conspicuously resembles a gum- 
matous growth. 

Symptoms. — The symptoms caused by these tumours deiwiwl 
on the size and «eat of the growth, and very much upon the 
irritabiUly of the patieut. Small lumoure on the soft palate or 
tonsils cause no discomfort and are usually discovered perchanc-e; 
if the tumour, however, is larger an<l pendulous, it causes coughing 
or choking, by touching the root of the tongue or epiglottis; the 
[laticnt has then a sensation of tickling and as of a foreign body; 
he has frequently to retch, and the voice might aUor and evai 
the respiration be obstructetl. 

Diagnosis might only prove difficult in the case of an intrap- 
mural growth. Here the confusion tnth ti gtmiviu is verj' jtanlon- 
able. However, gummata are mostly multiple, are not, or voiy 
Utile, nioval)Ie, and show marked roaetion with |X)la»sium iotlide. 
MoUijn'int tumours grow rapidly, break down early, and are 
motitly acconiijonied by swelling of regional giaiwls, which rarcJy 
occurs in the ouk of benign intramural endotheliomata. Amur 
rysms occur very seldom in this region, and. moreover, would 
sliow puIi*ation. If they occur, they are foimd on the posterior 
pharyngeal wall, and are perhaps not true aneurysms, but are 
|WobabIy only abnormally large-.sized brandies of the ascentJing 
pharyngeal art43y. which, under normal conditions, lies im- 
mediately under the mucous raenibrane, where it can be felt 

Prognosis is good. 

Treatment.— Angiomatacaasing no trouble are best left alone; 
otherwi^ they must be removed by scissors or aiare. Bnmdly 
seated tumour* riuisl Ik- scraped away or dcstroycfi by the gal- 
vano-cauteiy. Intramural tumoim* only require tho covering 
mucous membrane to be inci<«d, and are then easily shelled out. 



The typical naso-phnryngcal polypi aii«I rPlropIiarj-Tipcal 
goitre are usually cla&siiiod with benign tuiiioiirs. Willi rtwjx'ct 
to their structure this is justifiwi, thp. more bo as they noviT 
pnxluce luetastasea in other nrgaiis. But a certain malignancy 
cannot bo dcuiod lo them, bceaa'W of iLeir jnccsssant growth, 
whereby important organs are endangered, and of tlwir 
changing t-lioir choraoter by saiTomaLous or cancerous degen- 
eration. For this reason we will reserve for them a special 

(a) Typical Naso-pharyngeal Polypi (TTaso-pharyngeal Fibro- 
ma). — Etioloffy and PalhoUujy. — Naso- pharyngeal polypi usu- 
ally arise from the fibrocarlilaginous baaHaris (hnj^l eartiliigo 
of the occipital bone), at the roof of the naso- pharyngeal space, 
and seldom sj>ring from the vicinity. They are almost exclusively 
mot with in males at the time of puberty, a state of affairs which 
13 perlmpfl connected with some conditions of developinejit of the 
skull, and is [K-culiar lo iiicri. After Uic twenly-lifUi year Iht-y 
often undergo spontaneous atrophy. 

PaOiohgicdl Anntmmj. ~h\ uiicoinpIicat«I caws the naso- 
pharyngeal polypus is a round, globular, rather hat\l. but never- 
thelens elastic, tumour, of yellowi."b-wbile or pinkish colour, \\\\\\ 
a smooth or sliglitly uneven .-iurfae*-. Usually single, it fillB the 
naso-pbaryngeal space, and becniLS<> of its incessant and rapid 
growth, displaces the neighbouring part* luid organs. It soon 
softens on the Rurfaec, giving rise lo ulceration and adhesions, 
and invades the f^kull by jjcnding out processta along pn-formed 
or self-created path.*;, a.s it growt*. 

IIi»tologically, it consists of denrsc fibrous tissue and more or 
leas agglomerated cells. Its blood-vessels are veiy numerous 

SymjitomH and Course. — The patients are usually first seen 
whcji the growth has already been in existence for a long period. 
]n the forefront of the Hymptoms stands oimtrnvtimi 0} die jiose 
vdih its consequences: rhinolalia clausa, moulh-brcathing, 
snoring, dryne-sji* in the throat, discharge from the nof*e, etc. 
Througli occliL^iou of tlie Eu.^'laehlan tulH* hearing i.s in>|«ired and 
noi!*e8 arise in the ear. If not interfered with, the tumour goes 
on growing, puslies forwuni tlie :juft palate, iiivailcs tlic neigh- 



bouring ca\'itir-s, Icarling to (lisfigvircuiciit and expansion of the 
nose aiut face, ami e^pt^ially in tht> regoin of the t«mple and 
check; t-auwea pxopli thalmiw, ami, fniftlly, leafls to severe cere- 
bral symptoms, such as intrwraiiinl prcwJiirp. giddinpss, vomiting, 
somnolomv, oplic nntirilis, diwhirliances of vision. Ptn. If the 
polypiiH y^nmv downwanis, clysptiagia and dyspiK'ea, due to the 
blocking of the a<litii3 lamips, are the poospqwnee«. It may lie 
noted that haemorrhajiiee of a thrpaloninp and severe character are 
frequent. ChvinR to oft-repeate*! haemorrhage*, the tly(«phagia, 
and disturbed sleep, the patients become very weak, so that they 
may die from exhaustion, if not from au intercurrent meningiti.-*, 


FIc. Sfi. — ^T^plnd naM)-p1iiir}'ng«iil [lolyputi (Hfihtijln). 

or an attack of dyspnoea finishes him. In some (ra.«es the tumour 
bcoomes sarcomatous; in others, it ia tlie subject of xiuntanr-ous 
retrogrerwivc nii-tamorphuMis. 

Diftffnnfn.i.— ]n B<lvanced ca-'ses, where the obstruction of the 
nftie is marked, and the voice has Ix-conie thick and the face dia- 
figured, tlie diagnosii; will not long Ite doubtful. One examines 
the nose and finds it fillwl with a red tumour, which is covered by 
a niumid secretion, sJhow^ iH'rhatw uh'cration, anil provi* to be 
resistant but elastic to the touch vnih a probe. If the slijditest 
force were«l while sounding, unpleasant haemorrhage might surpruc On inspection of the pharjitx the ^cluiii [>alati 



will be found pushed or buljietl forwards and paretic. Or pcrhai>8 
the tumour is acctt (lepcinlint; from the roof (.lown into the oml 
aection, or. if still eoiuparativoly sniaU. is discovered by ijosterior 
rhinoscopy. (See Fig. 88.) 

In unique cases one finds only one mngk- vai mass complfiely 
filling the nasopliariiix, covered by the .siiuidth iTiuenii:* nieni- 
brane, or showing ulreration at various places, and toatitl with 
viscous secretion; but we here also observe tlic twwc clastic 
quality. It may Iw difficult to ascertain ivhrrc the tumour is 
attached, and how far it lias undergone ailheslons to the neigh- 
bouring or rtiljneent tiswnes. 

It is also verj- diffieull to <li.stinguish between ordinary naso- 
pharjTigeal polypus and .^arcoina, for histologically they are both 
very much alike. We ailiiiil that many iia,-io-pharj'ngeal polypi 
may be reganlcd as imreonia. 

PrwjTMidn. — On account, of their rUsposition to continue grow- 
ing inccs.'iantly imd rajwdly. and their inclination to saroomatous 
degeneration and recurrence, tiie |irognnsis cannot, from what 
has been said, be called a gcxxl one, iliough there U always the 
chance of spontaneous involution. 

rrea(rHeR(.— There are two motii ojxrandi: (a) Conser- 
vative, by attacking the tumour and leaving the adjacent parts 
and atructures, by the natural way from the nose or mouth, 
and so desli'oying or removing it; (h) radical, by laying ojx'n 
the area affected by means of a preiinmiary operation cither 
by opening the nose or by division of the palate or resection of 
the upper jaws. 

One iivuid be likehj to refrain from. the. laiter method, which, 
to say the least, caiLses serious loss of blood if one has to operate 
on small tumours, which cans* no particular trouble, if the patient 
is near to ihr" completion of the period of bodily growth, and thus 
near to the period of involution of the tumour, antl, finally, if the 
general state of the patient's health forbids any serious operation. 

The radiml method is indicatwl if we must lose do time, 
owing to tlin'atriiing coniplientions or dangers, or if the histo- 
logirnl examinalion lias a-tsured us of the sarcomatous nature 
of the new-gniwth. 

In certain eases one could try to place a galvano-canstic snare 



over the polypus tbrou^ the nose or mouth, ami sever it from 
its base. This, however, is tochnjcally a (UiSeuli niaiUr, &ikI 
docs not succeed unless two fingers are uu^Tled behind the si^t 
palate, and are used to guide the scare inlo the rifibt position, 
and thia can only be under the condition that the luniour is free, 
not too large, and there are no aigna of invasion of the nc-i^bour- 
ing ca\'ilies. It often liap[jens that we remove onlj* a portion of 
the tumour by ihe siare, and if thbt Im* the caae, the ksH must be 
removed later on in the same way or destroyeil by the galvano- 

The most safe, as regar^lshaeroorrhagp, and the leajtt dangerous, 
but ftlso the meet tedious, method, is removal by eleetroly.iis. 
(See p. 43.) This wiU be undertaken in patients broken down 
in health, and if there ii^ a di^^position to haemorrhage, M. Schmidt 
usee currents of 30 to 40 niilliamp^rcs; KuUner, even 70 to 92. 
Between the sitting^s, which la^t from ten to twenty minutes, 
intervabtmu-st lie allowed until the tissue is destroyed and doughs 
have been off and ilbicliarged. The tiunour may alsobeinade 
to atropliy by deeply piercing into it the pMnted burner of an 
electro-caustic apparatus. All these methods may be suitably 
combined, aeeonJing lo circumstances. As to the ja^Uminary 
operations above mentioned, we rder to text-books on general 

Cbl Strusu Retropharyngea iStnima Ketrovificeralis nre 
AccesSOria; Retropharyngeal Gx>itn).—Etioioffif and I'athdogy. — 
This consists of a tumour behind the lowcrseetion of the pharynx, 
in the so-called retro viscera! space, ari^ng from a lateral lobe of 
the thyroid gland, which, in some cases, is not necessarily in 
connection with the tumour any longer. In this latter case the 
ttmiour takes its oripn from the outset as an aberrant part erf 
the thyroid or in an aceessory th\Toid gLnrul. 

.Sympf<»ms.— The slow growing timiour does not cause trouble 
until it has arrived at a certain aze. and m bulgee forwards 
the posterior pharjTigeal wall. Then dysj^agia and dyspnoea 
arc tlic mi>st prominent symptoms. Inflammatory processes 
may set in. causing severe dyspnoea and hfarsene**, which ur- 
gently iw^uire operation. The tiunour. I>eing veri* va^w-ular, gi\*es 
rise to haemorrhages, which may be nii.<taken for haemoptysds. 



Oil phar)-ngoscopy or hyi>ophar\'ngo8copy one may ob*tpr\-e 
tlie posterior wall of the pharynx at the level of the laryux lo be 
bulging forwanis on one si<lp only ; there n globular t uiuour pwi be 
dctcct^^J with a smooth and vastrular nurfa«H, <'liinlir, anil quite 
insensitive to touch, and which niovt« upwiinlson swallowing. The 
larj-nx h displacocl, the rima glottidis apjiears narrowwi, tho 
ai^'t^noid cartilAges are concoalwl, as partially also are thv \oc,i] 
corde.* If presBure is esercifiwl on the tuniour, one fimlK (hnl it 
can be moved on one side only in the direction where it in in con- 
nection with the thyroid <ilavd, and produces, niitside the neck, a 
■projection at the letxl uf the thyroid cartilage. 

Diaipums. — If on*^ only thinks of llie poKsibility of such a 
tuniour, diagnosis should not be too difficult, consdering Ihe 
whole complex of wniptoms. Retropharynpeji.1 ahficoss and 
other timiours are movable to both sides. In the case of a real 
atwrrant goitre, where the palliating fiiiRer is not piided by tlie 
conrieeting bridpe antJ the tumour can be moved in all directions, 
diagnosit^ might be inifxissible. 

Pro(jnof!U. — Owing to scrluiis conipUeation-s, prognosis is 
usually doubtful. 

Treatment. — If the troubW r3Usi*d by Ihe tumor an' consider^ 
able, the tuiiior nmst be cxcisetl frutn Llie outside. If i^uffocation 
is thrratening, tracheotomy is required. In sli^it^ c&rps a 
trial phoulfl l>e made with ioiHnc in the form of thyroid lablet8 
or iodolhjTin tablets. lotlo-vasogrn (OpcrceDt.) is also useful 
in some cases, aiid I order it for external and internal use: ex- 
ternally, as ointment; intcnmlly. 5 drop« three times daily. 
The (low ip increaflcd until 15 dntps arc taken thricr daily after 
meals in water or niilk. Injections into tlie tumour arc harmful 
and objectionable. 


Tlie pharynx \s not as Heldom the seat nf a malignant growth 
as was at one time suppowd. Sarcoma, ejurinonia, and lympho- 
sarcoma, or, as it is still calk^l, malignant lyiuplioina, ant 

• Tlift niitlinr, thmuKlinitl lliis wrork lines Ihe term " voeat lipn " in pl»«c of 
Itir Mitntnonly usw! lirm ' iv^a/ cfd ' U is iiinvimillv more uwiinilrly doe- 
cripti%'e of the itruniireji, but for lixe coavenience o( the readeni of truiwla- 
llon, Lli« woni "cord" is iijk^. 


olisorved,. The Iftller, on Ihewlmlt* rare, will 1« separately tlis- 
cibwod on accDUiil of ius iK'ttiiliiirilicK. 

(a] Sarcoma and Carcinoma.— Of tlii> variuiLS pjirt-s of the 
phamix, Uio tousils are moat coniinoiily Uifj seal of inaJiKiiaiit 
new-growth; more rarely, the deeper parts, viz., tlie pyrifotra 
ainue and pastcrior phnmigcul wall. Occa.«ioially malignant 
tumours have been seen urir^iriy from tlic uvula, soft palate, and 
other parts, but considering the great rarniiicatiou of the growth, 
it would be difficult to ascertain the exact origin in any given tu- 
mour. Neoplastnaof the neighbouring organe, e. .9.. of the tongue 
and its root, of the larj-nx, and of the lymphatic glands, may 
also grow into the i)h&rynx. Again, we desire to |K>int out that 
9omo of ttie inlramural (palatal) growths may show tlienifiplves 
to be sarcomata. Malignant tumours observwl in the na30phar>'ii- 
geal ?paco are often primarily seated in the nose or mesophanriix, 
antl have grown clown from there into the throat. 

Sympliiiint and Course.— \i the commrncement the symptomfl 
are not ver>' pronouncetl, and only the swollen glands — less 
in sarcoma than in carcinoma — would point to this ominous 
disease. Hut sooner or \a,\vr definite symptoms do not fail to 
present themselves, such as dislurbanees of speech and KwaJlow- 
ing.whieh increase and become nggravat4?il until they cause violent 
pain. The latter oft^n radiates towards the ear of the affected 
Bide. If ulceration has taken place, an offensive sni pi I from the 
mouth occurs, and it i« somotinics this eircunintanct? which com- 
pels the patient to consult the physician. I-'eoding becomes 
difficult, the patient constjuitly swiullowf* the foul and ])utrefying 
maases, loses weight, and cachexia sets in. and then, with jmln 
and long-tlrawn-out suffering, the [latient dien from exhaustion. 
In other cases a pnciunonia caused by the aspiration of decom- 
posed particles, or a haemorrhage or an attack of dyspnoea, puts 
an end to the suffering. Death in rarely (-aust?!! by nietastaaes 
in other organs. 

DiagnoaxA. — fn making the tliagrosis one should rrmemher 
that mrwma lendi< to form a tumour mo-ss, while carcinoma .shows 
more tendennf to vkeratii-e dealrurtion. Parcijioma wprrad-s nioro. 
into the adjacent tissues, and the glaiuls are early BtTecled 
(swollen) and form large masses, in com[)arison with which the 




primary tumour might be infiignificant. Sarfioina has r more 
aniooth surface, is softer and less tuberous or lumpy, thau carci- 
noma. (Seelig. 89.) 

Ulcerating new-growth, especially careinomatouN iileerfl, can 
easily Ik* corifourHleil with ^iiiiiiiatxiUK or tiilMTriilttr iiicrrntioii. 
Tlie (lifferentiBl iliagiiosis l»etween clinncrc of llie tonsil aiid car- 
cinoma also would often he dilfiPHll. Mere the same p(jlnts 
are available as in aralogou.s (3isease.s of llie mouth. In doubt- 
ful cases trial with potassium iodide and microscopical and 

Fig. 8U.~l'kvralitig cnrcinunu of the Icfl tonul (Tdrvfc), 

eventually bacleriologieal examination, woiJd be of great servioe. 
Unfortunately, round-eelled sarcoma is very like n gumma 
under the mienweujie. A j^areuma uf tlie tonsil, softened in tho 
centre, sometimes conspicuously resembles a pcritonsillapabfjeesa. 

/'rof??i(3siv.— If it if* possible to remove the tumour and all the 
afTcetr-d jrland-s rndirally. pnigiiowis riiight hv fair, hut we must 
not Ik* Ion ra-sh. for reriiiTf-ncrs are verj' frequent in »\Mv of 
radirjil and successful n]>eration (Kroenlein). 

Trtntment. — If the disease has IxM^n recognised early, a cure 


may he possible, &a, for instance, by amputation of the Mvnla. 
or ton«iI. The ojM-ration will be very dilRcult if the tunmur is 
large mid tin; n'{;iuntil giaiul« are afffttiti. As to llir riHiuiitrtl 
operation, see tc-xt-lxmLs on gcjierai surgory. Iiioix-rablc t».-«-s 
may be trral«I by clrc truly sis or the galvano-oiutt'iy; and in 
some cases arsenic in incn'iising ihK<i\s, and eventiijtily .siibrutane- 
Gusly, has been of win h; benefit; at least, varions authors have re- 
ported good results. Taken all in all, Uiese measures are only pal- 
liative and may render the patieul'R condition more l>eanible, at 
least for a time; but often, not even \h\s. Will radium, ix.'rbaps, 
properly api>lied, or the r-rays, prove a success in the future? In 
the advanced stages of the diwjisc the phyf^iciiuii liasa ver>' dilH- 
cult and sad task to fiiUil. The pain may be relieved by iiainting 
with cocaine, and the horrible foeU)r<Iinihiisli«l by ileodouriziiig 
gargles. Ijiter the oesophagi-al tube and nourishing enetnala 
will have to be used, and gastrostomy p<'rfornied in onler to 
prevent the unfortunate sufferer froiri dying of star\'a1ion 
and from suffoeation, which will entail a tracheotomy, or both 
operations may have to be i)erfonned. Finally, life niay be 
rendered supjiortahle, sit venia vcrlxi, by injeetioiis of morphine. 

(b) Lymphosarcoma (Malignant Lymphoma). — Klwlofjy and 
Pathology. — Lymphosarcoma originates in the lymphatic tissue 
of the pharjTX (tonsils and lymph-follteles); the tumour usually 
arises from the pharyngeal tonsil, aeconUng to Slorf;, and 
also from the uvula, the palatine arches, and the epiglottis. 
Metastases are likewise met with only in lymphatic organs 
(glands, spleen, and intes(iiies). llistologieally, hnnphusar- 
coma shows masses of small round-cells (IjTiiphocytes), which 
are contained witliin the meshes of a very densely retieiiliited 
connective tissue. It ejin l)e distingnifihed from the nonnal 
adenoid tissue by its homogencoiis stnicture and the absence 
of lymph-foUieleR. Thus it shows the same .structure as rovmd- 
crileil sarcoma. In what relation lyniphosarrnnia stands to 
teiikwniitt and p'^eudo-lenkarnuH may lie (piestioneil. Mikulicz 
susjKTts the lymphosarcoma to be a special phaoiigeal form 
of pseudo-leidcaeniia. 

Sympinms. — The sj'mptoms are those of a softened and 
ulcerated tumour. Tlie IjTnphatic glands of the neck are sn'ollen 


at an early stage of the t!is«ase. Curiuunly mougli, some of 
Mu'Sf' RWf>lliiigs arr lijiMc to shrink afterwanls sprmljinTOUsly. 
but iLSually, and suuii aftiT, refiirrence-s foUow or irv>A\ tumours 
occur in the nt'iglibourlicHxl or in a more Jistant region. Thp pa- 
ticnl siipcumbs ckIibusIw] or dies from suffocation or intra- 
cninml lesions. 

Diagnosis. — ^Thc diagnosis is not always easy at the lirginning. 
Mi^tukoM witli ailenuiil vcgt^tationi^, or If uJci-ration hsm already 
taltc-n plarc. viilh ^iiiiutiiitoiiH (ir cantiiionialous iilcrrs. an- oftni 
miitlc. 'Ilie 5)'pliilitic iijiliin- of a gmwtli might pi-rliaps lie 
asciTtained by (he effect of largt- dowH of iodide of potassium. 
Carcinoma and sarcoma can be histologicAlIy distinguishwi from 
lymphosarcoma, but not so thr round-wOletl sarcoma. 

Prognosis. — ^Thrso cases of lymphosarcoma, wliicli, forlunati'ly, 
are of rare occurrence, are ver>- grave, for relapse and metas- 
tasis cannot be prevented in spite of all therapeutic or sponta- 
neous rotrogrcasioiis. 

Treaimenl.~V.:i{amvc operations, owing to tlic uufavourablo 
prognosis, have no nemsc or juKtifipalinn, but itmigiit be well, 
for the sake of the toniporarj' relief, to exrisr one nr other part 
of the tumours. In any arMcnic should Ix- given intrrnally 
or subcutaneouflly, a.* vpry goorl re.sults and iniprovenient have 
been obser\'ed to follow; alwj RnnUien rays and radium iniglit 
be applied wliere the circiunstances pt^nnlt. 


(a) Anaesthesia. — i\) Central aiiu-iv.-<u{ pliaryngcal anaestheioa 
are: HysU-ria (mo.stly unilateral), baaal meningitis, gmuina 
of the ba-sis cranii, disstininaleil sclejasis, bulbar paralysis, 
hacinorriiagi', locomotor ataxia, inrnouni. (2) Peripheral causes 
art-: Diphtheria; artificial anacKthcf-ia locally produced, e. g., 
by cocaine, alypine, menthol, or Ijv the internal (Milicutaneous) 
use of bromides, chloral, and morphine. Anaej<thi*nia does not 
usually cause any trouble, save for a certain peculiar wnijation 
of roughness in the throat. If, on the other hand, the pharcn- 


dise:as£8 or tub i-iuhtnx. 

gwd muscles or larynx are also paralysetl, then the sulyective 
Hyiiiptoms arc really very ooDHdcrable. In this case tlic danger 
of uiissvvalluwiiig and froui the pneumonia cbu;^'i1 by it is veiy 

(h) Hjfpcmeathesia is ofU'n prtxlucwl by dironic calarrfi. and 
iiiaj' Ix! frenut-ntly obsenxd in smokers or <iriiikers, but also in 
persons who neither snioke nor drink, and whose hyporsensi- 
tivenet» of the Uiroat, though unacconipanitxl by catarrh, in the 
MRn of a gfnpral nervousness or ncunvslhcnia. Beaidcs the 
Iiy])erae»ithesia, thtre also exist other rellex disturbances which 
may he hmuglit out t»y touching certain sensitive sjiots. 

(c) PaTae-fihetnu.—yai'iaus fonus of [laraesthcsia are foiuid 
in chroniR calnrrh. ewpeeially in aiwjciatton with tonsillar con- 
cretions or calculi, or in the dn,' fonii of pharyngitis (pliar\-ii- 
gitis sicca), and cause the most perverse sensation (see p. 
27S). Paraestheaa is often symptomatic of hyjtertrophy of 
the luiguat tonsil (sec p. 218), and after injuries by foreign 
bodies (see p. 318). In some cases it is an early sign of pul- 
monary tuberculosis; it is also frwjiient hi hy.steria (globus 
hystericus), anaemia, and chlorosis. The jiatients tiiwiiKelves 
report the niont eimous things as to the site and ehararter of their 
must unpleasant »>nt«tiontt, and many become real hyp<H>h(m- 
driac& Thf anatomiral ehaiiges, moreover, are f n*i]ueii lly iii«ipii- 
ficant or are altogether uiiswd. In the latter cast' the probe will 
help us a good deal in finding out the spot or region of the al>- 
Donnal senfiation— a very tedious and difTieuIt hu-sineiw. 

Treatment rtiait in all cases be directed against the oauseM of the 
disease. Local treatment (treatment of Ihe i-xisliiig catarrh, 
removal of tonsillar concretions or hypertniphicd tonsils, etc.) 
must be aided by all general meHMires (diet, change of air, liytlro- 
patliic cures, tonic and antisyphilitic treatment). 

In anaesthesia and paraesthesia the electric (galvanic or 
farwiaie) current is useful. In hyperaesthcMa the local appli- 
cation of cocaine is pomclimefl required, hut we should not bo loo 
liberal with the use of cocaine; and mmlhollozengef, for the moat 
port, are quite patisfaetory. In purely nervous hyperaewthrvia 
(lie pnlvano-oiutery or ranterisalion with chromic or trichlor- 
acetic acids proves very useful. Whether these remedies ilcstrto^ 

Nsaroro disordebs. 


amall foci, or whctlur they act as ]x>werfitl Kuggfwtivp agi-nls, 
b open to qu<9itiun. In soiiip other hyperaeethc-tie casRs also, 
which ]x'rlm]j« is nothing ehe than a variatiou of paraeutht-tita, 
cauterisation is veiy sucoogsful. 


(a) Paralysis.— We are here chiefly concerned with Uie 
paralysis of the soft palate, which in cither complete or partial, 
bilalcrul ur uuilntiral. 

Btuilofjy. — Paralysifi of tlic vcluni palati is either ocDtral or 

. {]) Centrnl paraly-nx (wcurs mostly in grown-up prrpons, and 
is caused by inflaiiiiiiatory or tlcpenerative procw^ses in the bmin, 
nuKlulia oblongata, or spina) oorU, e. g., progres«ivo muscular 
atrophy, amyotropliic lateral sclerose, tabe«, hullmr jaratyns 
(paralysis glosso-Iabio-pharj-ngca), l>asal nicningilis fpumnia), 
an<l Hvphilitic diK-aM; of the Lraiu (gumma and eudarivritis 
obliterans, et'C.)- 

(2) Peripheral paraiysis ta frequently due to diphtheria, 
and \s chiefly met with in childnai or juvenile patient*, but it has 
occurred also after infuema. In facial jiaralysin also the velum 
palati may W jiaralysnl if the seat of the lesion is at or alwve 
thi- iienieulatp ganglion (the motor nerves of Ihe velum [lalati 
run with the great ijetrosal ut^rve (De^^■us pelrosus superficialis 
major), which is a branch of the geniculate ganglion &Dd helps 
to form the Vidian ner^-e (n. vidiajius), the latter being a branch 
of the facial (seventh cranial), to A/crAei's ganglion (spheno- 
palatine ganglion). RometimeA |iaraly.stft of tlie vagufl (infeiior 
laiyiig(«l nerve) i>i a.'vturiated with {ULralyMis of the soft palate. 
which goes to show that the vagus, or at least ftrnte of its 61a- 
montii in the pharjTigeal plexus, has a sliare in the supply 
of the palatine mtutcles. 

From pure mechanical reasons inflammatory procesees are 
liable to more or less disturb the mobility of the soft palate; 
for instance, toa'^illar and [X'ritonfillar ahecesscs, collateral 
oedciiia. and also adenoid vegetatioas. linnours, or cnlaiged 

Sjfmptoms. — In marlcod paral>-sin the naaal cavity is not diut 


nidEASE:8 or this fhaiiynx. 

off (hiring siieech, whicli, therefore, becomes elrongly nasal 
(riuiiulalia aiKTia); iluids regurgitate through the nose, and all 
fuiictiouM or actions, which can only he ptTionncd if tlie aaft 
palate Ik uiulisturlieil in its niovements, are more or less iahibited, 
as, for iriHtaiiPi', gargling, blowing out tlie cheeks, .sucking, etc 
liisufiicicnl action of tlic jialalinc muscles, which, as »ve know, also 
act as (Ulaiora of the Kustachian tube, lead to contmclion 
or occlusion of the tube and to serous transudation into the 
middle ear, con.scqucnt on the diminution of tJic air-prcasure 
in thceavum tymijaiii,a.sitihydroi>scxvacuo. [Sec p. 35, et seq.) 

I recently had a yoimg woman under treatment who got 
a |)aralysia of the wift palate after influenza, and consequently 
a bilateral exmlative catarrh of the middle ear, which subsided 
along with the paralysis. Kxaniiiiation showed a great itn- 
[Miinnent of hraritig, ami behind the ilruni one could distinctly 
BCG hubbies in lh(^ contaiiird lluid. 

The phar>-ngo3copic examination is veiy diaracteristic. , 
In unilateral paralysis the velum palati is asj-mnietrical. The 
affected side dn)])«, and is lower and more forward tlian ti»e other, 
and the arcus is Ic-^s curved. On intonation the paralysed side, 
together with the uvula, is drawn towards the healthy side; 
in bilateral paralysis the soft palate hangs llacciilly down and 
b immobile. In paresis all these symptoms arc less prominent 

Paralysis of the velum palati is usually combined with that 
of tlie phar}'ngcal constrictors, which can be recognised by the 
mucous membrane remaining smooth, even during swallow- 
ing or retelling. If the lower part of the constrictor is paralysed, 
food cannot be swallowed and sticks at the root of the toQgue 
in froDt of the epiglottis, sonictimrs causing not inconsiderable 
dyspnoea, ami ha.« to l)e roughe^l out or raked up with tlic finger. 
If, in addition, tlic otber phar>'ngoa! iTuuscles are pnrnlywil, as 
is »o oftt-n tlie case in pnigrcHsive iiLu.'*cular atrophy or bulbar 
])arttlysis. the epiglottis cannot be .shut dtrtvn during swallowing, 
and food is lialilc U> pas* into the lari-nx. Anotlier complication 
in bulbar paralysis is the paralysis of the tongue, which nggra- 
\'at«« still more or even iidiibits articulation and the taking 
of fuixl. 
' Ditigrtam. — ^The diagnosis can be easily made if one takes 

nehvous niaoRPF.Ra, 


int« consideration the wtiole clinictvl picture. An inroniplcte 
paralysis may be easily overlooked if the nasal sjjPGch is Llie only 
symi)tom. The cause of the paralysis is in niaiiy wises rather 
(JitTiRult Lo at^eerlain. If the cause 'm an acute infeetiout; disease, 
e8|x.'eially if the patient has sufTtniHl frum iliplulieria or infiuenza, 
we can tlicn a.«.sui!ie, without liesilation, a peripheral paralysiii 
due to neuritis. In jieripheral parclym, moreover, the nprves 
and mufich'.s, after one or twi.> wecikt*, show tlie typicial reaction 
of tlcgrniTtttiun, t. c, they do not react at all to famdic and very 
little, or not at all, togfilvnnic stimulaLioii.aiiiJ undergo atrophy. 
In central j)iirnly.'ng, on tlie other hand, Lhe electric irritability 
is undislurlx'd and no atrophy sujx^rveiies. That a paresis 
niijd' t l)e Kinuilnt^'d by ft nK'chuniejd impediment, as the result of 
loe«l inflftiMJimtory and other processes, has already been men- 

Profpinfia.—^hc proKnosis is favourable in peripheral parnlyas 
an<l unfavourable in a central lesion, save from syphilitic or 
hysterical diseases. 

Tre<ihnenl.~lf we have rwison to su.speet syphilid, anti- 
syphilitic treatment must Ix? applied, t. e., a (•oiidiined eun: wiUi 
mercurial ointment and potassium iorlide (unfruciituni eiiiennim, 
4 grammes i)er diem); and [lotassium iodide. Ii> to 20C) (one 
tahIes[)oonful three times daily). Peri[iheral {mralyse-s, es[»eci- 
aJly ((ostdiphtlii^ie [laralyses, recover, afti?r a time, without 
treatment, but, better still, and quicker under ro!)orant diet, 
which may be greatly ansirtleil by brine batJis and electric 
treatincut. The electric current is generally, and in all eases of 
paralysis, very iiseful. The ancxle ie put upon the neck or chest ; 
the button-sliaped cathode, idiich must be so constructeil that 
the current mny be openeil or closed acconling to the will of the 
oixrat^jr, on the paralysed muscle, after previous coeaiiiisation, 
if this is required. In very ner\'oua and resistant patients both 
electrodes, fitUxl with a broatl pad, are put outside on the neck. 
In hysteria electric tn-atment works wonders, but improve- 
ment is tlxw more lo ifiijij^eiftion than lo the current, and in sorae 
CAftpH KUpBeHtive or hypnotic tn'atnient may be reported to. In 
complete jiaralysi^ we must feed the patient by an opjtophageal 



(b) Cramps (Spasms). — Irritative motor lc!Uoiis cause tonic 
or clonic t^pataus or rhythmic tuitching (conlrsctious}; in niaiiy 
casee all the [thai^Dgoal muscles and those of the neighbouring 
orgaDs, viz., tongue, larynx, oesophagus, ami e«r, are attacked 
hy crampe, ami ver>* rarely only *>ne single group of muscles. 

Etioloffy. — OccaaioDally transient toDic spaanu of the ooa- 
Btrictors and muM^CTt of the Eustachian tube arc excited if we 
inwrt a catheter inti) tiie tube; also, a morsel of food swallowed 
too hastily is liable to caa-* spaams in the jJian-nx or guUeU 
In verj* nervous and excitable (hysterical) patients inflanmiaiory 
proeeaBW, e. g., pliar>-iiKitig lateralis or hypertrophy of the Ungual 
tonal, arc apt to excite sposinit. Central cauw-s are imncipally 
byMcria and robica. In rabies rhy<lrupliobia) tonic spaama 
are roflexly set up at each entieavour to sw-allow, and even at the 
mere siglrt of wat<T. Clonic spaisms an; not infn>fn«rntly caused 
by irrilation of tlin trigejiiinal ncn'c. When; and how the nfr\'e 
is irritated often c-wapes our kiiowli^dge. Among other eaiL'CS 
of clonic .sjiaMns may bemenlionwi: liystrria, jmralyjaji agitanii, 
diKseminatwl sclerows, poisoning by lead, mercury, and alcohol, 
<liw*ye (if the occipital IoIk-s of the brain, atid occasionally 
clonic spasTHH are associated with cramps of the facial niUM^c 
(tic convubnf). 

Symptoms. — In tonic gpaam of the pharyngeal eonstrictors 
dysphagia is vcr>- marked. The morsel of food sticks fast in the 
throat or gvillet, and causes a |>ainf ul M-usati(Mi lieliind the ster- 
num, and n'giirp:ilBtion fre<|uenlly occiir«. "Globus hystericus" 
is |>roliiably nothing irW Uian a tonic t-oiitrnclitHi of the oesoph- 
agus and phar>-nx. moving up and clown, and is excited by 
psj'chic or loral irritation (hyjMTtnijjhy of lingual tonsil, phar>Ti- 
gitis, etc., see p. 218). 

In tonic npasin (rf the velum palati the soft palate is firmly 
pressnl against llie posterior jjharragi'al wall, and tlie I-!ustaehtan 
tul)e, in consi^mcnee of Ihe Ionic contmetion of the levator [lolati, 
remains open, and the patient hears his own voice inueh louder 
tJian usual (autophony). 

In clonie j*i«vsm.s tlic velum palati makes jerky movements, 
and the [latient and his ltstenrrr> hear a peculiar clicking or 
crackling noise, caused by tlie quick alternations of opening and 


closing of the tube. In such a case one may see the tympanic 
drum moving alternately, backwards and forwartls, that is, 
alternately retracting and bulging outwards. 

Tonic spasms do not usually last long, but the clonic spasms, 
on the other hand, are very persistent, although they are not 
usually the cause of much complaint by the patient. 

Diagiwuis. — The diagnosis of clonic spasms is mostly easy. 
The tonic spasms are Hable to be mistaken for fibrous stricture. 
But while in the case of tonic spasm of the constrictors transient 
narrowing is caused, in stricture, however, the narrowing of the 
lumen is jx-rmanent, so that in spasm a bougie may be introduced, 
without hindrance, into the stomach during the free inter\'al, 
l)ut in the case of stricture the insertion of the oesophageal 
prolje will always be difficult. Hysterical sjiasms may be recog- 
nised by the presence of otlier signs of hysteria. 

Prof/nosif! depends on the true cause of the spasms. 

Treatment. — In treatment also the cause will Ire our guide. 
The reflex excitat>ility may be iliminished by bromides and other 
.'sedatives. The diet must be regulated, and it should be fluid, 
sloppy, and not too wanii. In long-persisting spasms feeding 
through an oesophageal tube may be required. 


Diseases of the Larynx and Trachea. 

PART rv. 

Diseases of the Larynx and Trachea. 



The lar>Tix is fonnwl by a j^keleloti of oartilngos suspended 
from the liyoid bone, arid cuiiueutai with one another by lifja- 
nients, and rmdered movable by inuscloB. Wh^en at rest, the 
larynx lies betwwai the upper marpins of the thinl and thi- 
Iowt?r niannn of tJie sixUi cenical vertebrae. The ujumt iiper- 
ture, coverod by Uie laryngeal lid (epigiottis), ortininunicati* 
nitJi the laryngeal [lart of the [)har}'nx (nditiis ]ar>'n(rifl). 
The ]an,Tipeal part of Ibe pharynx (hyixjpliarj'nx) is xituated 
liehiml iJic I«n,'iix, so that its anterior wall fonns the posterior 
wall of the larj'nx. (Sw p. 237.) The lower aperture lendit into 
the Irachcii, with which the hitynx \s eontinuous. On both 
ades of the larj'tix are situated the lower hyoid nmsclcs (mm. 
Ptcrno-, tliyro-, onie>-, hyoidci). all of which are t-nsheathe^l by 
the ilwp fase.ia of the iie<!k (faxeia colli 1 : the large vesw-ls and 
nerxes of the mrck are found still more lalenilly. The thyroid 
gland al«) partially eovers its lateral wall, and not infretniently 
a middle lolje (pyramitl), arising from the pland, pa-iscs upwards 
in front of the larynx. The anterior wail of the larynx is covcrefl 
by the median fibers of the above-named muscles, but in the 
middle line itself the lar>Tix is only covered by two laminae 
of the fase.ift colli and the skin. 

The Cartilfigiaous Skeleton.— Cn) CnVmW Cartilage.- The 
bane is formed by the ttirjnet-ritttt-sbnjiefl cnrtiUige (cartilngo 
cricoidea. cricoid cartilage), the broader jiostrrior plate of which 
has two articular facets on i1« upi>er ninrgin for articulation 
with the two pitcher-nhajwd cartilageK, and near the lower mai^ 




gin on eiUitr siiie one faa-l fur nrticulalion «itli tin.- iiilmor 
c«nina of tlie Lliyroid cartilage. Tke tliinner arc of the cricoid 
cartilage m dii'cctetl forwurJ^. 

{6) Tlie Thyroid Cartilage. — The shield-ifkajied or Ihyroid 
cartilage (tiartilago lliyroidea), wMcli hy its size ami configura- 
tion outlines tl>e shape of the litr\nix, consists of two plates 
(alae or winpg), unit-ed in front bI an acute anjde. Its upper 
border is irr^jrultirly cur\'c(l and is notchod in the midd!c lino 
by the easily palpable incisura thyroidca. Tliis -pan projects, 

Tutt«ni>itv (4 itiv 

-— " Canila^t of WtubcfK 

Cui. SaQMrial 

' Cul. Btr>"nnkl(« 

MuwuUr praesadf th< 

^ Cut. CTaoniiU* 
Curiiu iiiCrrliit 

('&rfiUeln« trtitrhnile 

Fig. TO. — Ttip larynx, viewed fiom behind, the miuclea t)«ng removed. 

especially in thiti men, more than in women, and ii^ kno^^ti as the 
promineiitia larj'ngca or Adam's apple fijonium Adami). Tho 
posterior vertical bonier of the thyroid plates cmls above in the 
superior cornua. anil below, in llic inferior comua. 

(f) The Epi{ilotlijt. — ^Thc lid (epiglottis) is attached by its 
petiolus or apex to the margin of llie incJ!<ura tliyruidea. and 
forms there a iiad-llke projection towards the lumen of the 
larynx, wturii is siwken of as the tubereulum opiglotliiUs or 



r-piglottic cushion or pad. The broad and free upper mHrgin 
vf ibc ejMglnttis ia fUrectciJ liarkwanls. and variwt much in 
shAjx^, a rircuinstaucc of grcal un|iortaucc during Ur^'iifccjil 
cxajiiinalion. (See Fig. 90.) Beudes these thre^^ i^uigle, there 
arp alwi Uirw pairol. ca,rtUagPS. 

id) The Arytenoids. — Tho pitcher cartilages (arj'lctioid car- 
tilages, eartilagines sr>'t4;noldcac) are the most important as 
regards the functions of the lamix, because they dilate or 
narrow the rima glottidiA, according to their portion. They 
have the slmp>G of small, three-^ded p>'Tauiid8, with Ihetr apices 
directed upwards and a little backwards, and their bases 
articulating with the posterior plate of the cricoid cartilage 
(see above). Of the three sxirfaces, one looks inwarils, another 
looks outwartis, and the third looks backwards. The base of 
the p>Tainid ends in front as the vocal process; and outwanily 
and posteriorly it become* the muscular proeexs, giving attach- 
ment to the mm. erico-arv'tcnoideuB lateralis and posticus. The 
vocat process (anterior angle}, however, which is covered with 
muoou.^ membrane and is of a yellowish, glistening colour, has 
attaclicd to it the true %ocal c*)nl (ajid the m. tbyro-arj'tenoideus). 

(c) Cartiltiffines Santorini el Wrutlxrgii.— On the apices of the 
arj'tenoid cartilages, and atlacbcd to them, are the small carli- 
Inffinrs Santirrini (corniculii larjTigis or cartilagines corniculatae), 
ami situated somewhat more laterally, the cnrtihiyinfs Wrifhergii 
(cartilages of Wrisherg or cuneiform cartilages). Both pairs 
are contained in the arjit-no-epiglottidean folds of mucous 
membrane CpHca nrj'cpiglotlica) which bound laterally the 
ttdltus lar>Tigis, U'a\Tng a small notch free posteriorly, called 
the posterior commissure fincisura seu pars interarytcnoidea). 
The [X)stcrior coniniissurr, on phonation, appears as a i^iall 
chink, and on quirt re.'^iiiralion, when the arytenoid cai'tilagt-a 
rteparati: thcnii^elves as a flat groove which corrcaponils (o the 
posterior liiryngi-al wall {sec p. .'MS). 

(/) Stvamoid Cartilages.— SllH more inMgnificant than the 
cartilages of Santorini and Wrttberg are the sesamoid cartiUujes, 
which mnietJmeK^not always — arc found on the lateral 
margin of the ar}ienoid cartilages and on ihe anterior end of 
tlie vocal cords, and are here of a yellowiali lu-sier. (See Fig. fll.) 



Lieaincots of the Larynx. — Tht* mombrnnous niul lij^ainen- 
toiis ap|>araliiri of Ihe larynx is, owing to tho cum plica toti 
function of (his organ, equally com]>lirAt«i. (See Fig. 92.) 
Between the hyoid bone and tli}Toiil cartilage arc the th\TO- 
!iyoi«l li^amails t!ig. thyro-hyoideiini), wilh a hrotul miiMIc 
rwriion and two narrower lateral jwrtions, the latu-r being 
attached to tl«r .superior comua of the thyroid cartiUige. The 

VallMulk \ 

Uaata Uiar. 

lis. t>tiW7'n0>-«I>i- 
Jllitl I ICUlll 


Wtbbtn ' 
Can. ttaMiailiil- 

Smm plritbnnSi - 


fUtlK llnguM 




Owap ^ W " 


I'lica cMTin ItfTDcri nip<«li«i> 

Fig. 91. — The aditiis bt>ji;^. . .i i:<l I rum U-liind. Th« poateiior mil of 
(li« |Jiar>n!i in cut lengitiwine and titrDn] oulwartk (arlcr ToUi). 

space lietween the lateral and middle thyroid ligaments is 
fillofl in I>y the (]iynjhyoid membrane (mcmbrann thyro- 
hyoidea), which is [lerfnmted by the superior laryngeal nerve and 
artpry. Tlif lateral ligaments each eontain a nodule of carti- 
lage — the cartilagines triliccae. 

Between cricoid and thyroid cartilage imippch the strong elastic 
Ug. orico-thyroideum medium b. tonicum. Tlic arieria crioo- 



thyroidea runs in front of ami acrosM the lig. conrpum, which fact 
is of surgical importancf . Frpquently a wnal) lymphatic gland 
and a uiodian lobe of Ihc thyroid gland or tho n^niaiiis of such 
a lobe may be found lying on the tigainwil. Uotween tbc 
cncoid cartilage and trachea extcuda the lig. crico-tracheale. 
The lig. arylcno-ppiglottica arc not true ligaments, but oidy 
raluplications of the mucous membrane; bq also arc tlie lig. 

Hanibmift hiro-thvoiijM 


Body o) bruid bona 

Ijlt hj'o-cpiflotticmn 

Buna ■iniM'uli 'i«nD* 

■Lit. ■bym-c|ii(liiiii«uni 
Ijg. wiiiritubre 


tig. rowla 

iiicil. 'wu rwDicunil 

Lia. mib'i>li>ryti(«iun 

TunUa aitHMU pharyasb 

.GIftn<lulM> irnfliMlc 

Fig. B2.— Llgwneota of tb« Wyox. The led. Lalf of the larynx, viewed from 

withii) {T<JtB). 

pli&ryngo-cpiglotlicfL f^^* p. 238) and lig. gloRKO-cpiglottica 
fp. 169), niiieh, rnsppctivply, crainoct the ppiglottis with the 
latpral phflrj-ngnil wall and nH>t of (lie tongue. All thw* last 
are. therefore, call<xl plicae, or folds. 

The capsules of tin* various joints are strengtheneil by numer- 
ous small Iiganienl». and only the joint l)etween the crieoid 


cords to the th>Toid cartilage iimiiedialely below the epiglottic 
tuliercle (epifjlottic pad) is knou-n as the anterior cotiini insure. 
The aiiUrior purtion uf llie "glottis," ailuateil hctwirn the 
vocal cords, is callcci jiars nienihnuiacea, aiul the i)ostcrior part, 
eiluattnl hetwren the arvt4-noi(I earlilaRW, is cnlkil the pars 
cartilaginea. On phonatioii. both vocal corrls approach each 
other, and (he rinia plotudis forms a Htraight cliiiik. Dur- 
ing respiration, however, the vocal ■cnnls separal* from each 

FUsi vy-vpiclottitw 

• I'nrTiUcu niigloiiica 
^.VMrtibuliim [arvustt 

, Vinrnrillvn 1w7B^s 


I'lim viKuJii 

Lotiium rri4ale 
Tiinioi oiiiDiiHt lar)>n(i* 

Cbvum larya^ 

TunUa (Tiukmi tmdiM* 

Clnniluliie ttssbfoln 

Cnrliltcinn Irncliealc 

ruin Biauibnnuviii Iraclioiu ' 

Fig. 04. — Sa^ttalHCliaii of lurynx It-fl gido (Toldt). 

Other, anJ the rima glottidia now forms a triangle, the ai)cx 
of which is dircctctl towards the anterior comuiissure, with 
the base towards the i)o&terior larj'ngcal wall. The miks of 
this triaiifiie an* not straight lines, huwevi-r, but allow a more or 
less marked eurvnture, according to the shape of the vocal 
processes. The i-entrirtilnr /olds fjilicae ventriciilares), wliirh 
are situated immediately alwve Uie voca! condo, arc thiek putls, 



SUB." Hchiml this muscle the fibers of the m. arj'tenoidcu^ 
obliquus. shortly called "■ oblitjuus." cross obliquely, anil which 
arise on both sidea from the miwcular processes of the aiyte- 
noid cartilage, to run obliquely across to the oth<T side, and 
to be inserted into the aryepiglottic fold atid the epiglottis (in. 
arj'opiglotticus) (soo Fig. 1)7). 

Action of the irajisvcrsus: approximates the arytenoid car- 
Ulage«, thuH closing the bai>k lart of the glottic. (To close 
the entire glottis the lateralis aud traiisversus must act to- 

.\ction of the obliquus: aids the transversiis in closing the 
glottis, constrict^* idso the entrance 1o the lar>"nx, and deprcssCB 
the epiglottis, and Is, therefore, also called the constri^^iorvwtib- 
uli lan,'iigi.s. Of special im[x>rtance is the m. thyro-arytenoidous, 
which is fixal between the thyroid and arytenoid cartilages, 
ami is [Mirallel to the vocal conls. It consists of two fwrtions — 
fl) Of the three-edged, prismatic. Ihyroaryteiioideus iiitornus, 
shortly called "iiiternus," siiualcd within the "vocal cord, "the 
m.vocalis, pro|)crly so-called, and (2) m. lhyro-ar>'tpnoidcu»exler- 
nus. whose f]l)erB unite with Uie inner jjortion and the " lateralis." 
The *'tnf(.T«n/" portion is inserted into the vocal process, the 
"extfrn^l" portion into the muscuhr jrroee^. The action of 
the m. thyro-arytenoideus is not yet satisfactorily explaiueil. 
The extenial iKjrlion, which shows some variation and joins the 
'Mnteralis," draws the muscular processes of the arytenoid 
forwards and thus helps in closing the glottis. The internus 
also takes part in this action by shortening (i. e.. broadejiing) 
the vocfll cords, which arc thus brouglit closer to each other. 
.\t the same time, by its graduatcrl contractions, it brings 
nlnnil the exact intonation of the voice and various registers 
(see next chapter). This action is ])rohably aitlcd by fibers 
which hclotig to the superior thyn>-ar>tcnoiii ligaments (nh 
thyro-iirytenoidcus sujx-rior or vrritricuhiris). 

3. The tensor of 0\e meal cord is the m. crico-thyroideus,- 
shortly calleil "ant^-rior." It arisen from front and side of the 
ericoiil arch, and is inwrted in a fan-like manner int<» the kiwt-r 
and initer bonier of the thyroiil cartiliige uid inferior eornu. 



Its action is to make the voral cord by elongating ihe dis- 
tance Iwtween its too fixed extremities. 

How this elongation i.-* pnidui-eil is still a mattfr of conlrovers}'. 
One opinion is ihat the ihymiil eartiliiKe, as the movable part, 
18 rotated around a tninwenut' axis in .^uch a way that its anterior 
port is inovwl dowTiwards and towards the cricoid cartilage. 
Another suggestion is that the thyroid cartilage, being (ixetl 

Uc. byo-thyKiklcuin launle 
Mwiibriinn hro-lbyroiilM I 

0> bymtUum ■ 

lie. liyi>'th]rrui<Je)un. 

rnnilaca Iritio 

Cwtiloco (hyTnid«> — - 

Forwnpn Ihymltkum 


lif. atMo^hyroidcuin 

M. critCKthymKloiu 

f I'an reel a 
(.Pan ubliqii» 


Fiif. 98.— M. crico-tlij-Toideue, viewctl from in front and Ml side (Toldl). 

by the iniisela*! of the neek attat^hed to it, the erieoid cartilage 
is move*! arounil a tmnsvei-sp axis in nueli a manner that its 
anterior part (are) is approxiniatwl U[)wai-ds to thp thyroid, 
while its plate f|Kwterior part), together with the arytenoid 
cartilage?, move? downwanle. In both ca-^'ee the thyroid and 
arjtenoid cartilages are sejiaratetl from each other and thereby 
the vocal coifb* are made tense. 

The eourse of its fibers would suggest that perliaps tlie m. 
crico-thyroideiL^ exi'rei.'*es a pressure ujion each side of the 
thyroid cartilage, with the result that the transverse diameter 




of the larjTix becomes ahortencti, and consoqucntly the sagittal 
diameter is elongated; this would, of cours«', also produce & 
separation of the thyroid ami aryt^-iitiid cartilages, and thus a 
tfiiHion and approximation of the \wiil i*on!s. The tenrfon of 
t}w. voc'jil cords is augnieiit^l to a cprtain degree by strong coii- 
tmclion of the mm. crico-arytenoidei postici. 

The action of the laryngeal muscles can thus \>c i)rought into 
the following schetue: 

Narrowing orclodiig (iLdductor): 

Diluting (abductor}; 

M. crico-arytpnoiil: UtentUit. 

M. Arj'it'iiiiicliriin truiisvcreiis et obltquus. 

M. lti}To-:(r}-tctioid:rxtemusaiidin(emus. 

M. cn(^[>-thyroideiis. 

M. criPfVBiylCTioideiw po4t{cil>. 
f Crirt>-i livToid/Tw. 
\ M. iTi''r(>arylpnaid(nis posticus. 


Tt m absolutely nncesfwry. for tho knowl«lf(c of eertnin patho- 
logical oonditioDS, to know exactly the action of ilie various 
laryngeal muscles. Under phjfsiologieal eonditwrn isolated ac- 
tion of a single muscle does not come into consideration, a* 
sevard mutidea ahcays act togetliiT in aws<triation. either in 
concert or as antagonists*, as i« tlie case in movements of the 
vocal curds). 

The Nerves of the Laiynx (See Fig. 00). — The sensory 
«.•( whII .>ls inc»i(ir iiervi-s are (lerival from the pneumogastric 
Various auihorf!, however, maintain that the motor nerves arine 
from thi:- Kjmul aire.tnart/, viz., from that )Hirtion of the nervo 
which join.s the vagus after the exit from the jugular fommeii 
(ramus int*niu.s aeceswrii; the c-vU^mal rainiia Hupplies the 
mm. stemo-cleido-mastoideus and trapezius). 

The rn<7w.v Mippties the larynx by two branches — superior 
and inferior larj-ngeal nerve. 

The superior Uiryngml imttc divides into an internal and 
an external branch; the interna! liranch enters the larj-nx 
togetlier with the stijKTior laryngeal arter\" by an aperture in 
the th\Tohyoid meiiibraiie (see p. M-W. and runs underneath 
tho nuieous membrane of the pyrifonn sinus (plica ner\i laryngei : 
see p, 21^8); it. is the sensory nerve of (he mucous membrane 
which is particularly sensitive, espisjiully iti the i>ars intcrarjtiv 
noitlca. The external branch supplies the ni. crieo-thiiToideus ; 





but sometimes the latter muscle is also supplial by the recurrent 
lar)"ngoal nerve (inferior larj-ngeal). 

The internal branch communicates by the ptcxvs Galeni witb 
the inferior larjugeal. thus supplying with Bensory ner\'es the 
deej^r parts of the larynx ami the upper part of the trachea. 

Tlie inferior Itirymjeal nert'e (recurrenl laryngeal, itcrvus rectir- 
rens), whieh i« ver>' important in the pathologj' of larj'iigeal 
laralys**, arises, on the right side, from the vagus at the lewl 
of tlip flp'x of tlic lung, just below the subelnviau arterj'. and 
winds round that artery from before backwards; on the left 
side, the recurrent arises furthex down, below the arch of tiie 
aorta, and winds around it from l>efore backwards, lioih 
nerves ascend along the groove Ix^tweeti the trachea and the 
ocstophapuR, to reach the lower posterior surface of the larj'nx, 
and are diBtribute<l to all the laryngeal mu'iclea except the crico- 
thyroideus (see above), givuig uff. in their course, cardiac, 
oesophageal, tracheal, anrl pharj'ngeal branches, aiid, finally, 
communicate with the superior laryngeal ner\'ea (sen above). 

The ilifferent course on the two sides of the body explains 
why the right n'current is so often involved in diseases of the 
apex of ihe lung ami subclavian arterj', while the left is often 
implicated in diseases of tlie aorta, pericardium, and uicdiasti- 
nuni. .1/. Schmidt has pointed out that there are variations from 
the nonual courses of both nerves. 

The vessels of the larynx arc derived from the superior and 
inferior thjToid art<>rie8. The first named gives off: the sttpe- 
rior hxrynqml artery, which reaches the interior of the lar>'nx 
by the opening in the thyrohyoid membrane, together with 
tlie superior laryngeal nerve fsee above), sending a small branch 
along the side of the epigloltis; and the cricO'thi/rmd artery 
{s. lar^Tigeii media), which crosses in front of Ihe Urynx on 
the surface of the lig, crico-thjToidoum s. conicum, and anas- 
tomoses with its fellow artery of the other adc, sending, during 
its cout^ie, small branches through the ligament to the iuiiide 
of the laryux and to the vocal conls. 

Tlic inferif/r thyroid artery (of the subclnvtan) gives off the 
small larj-ngca infcrir)r. which ascends, togetherwith the recurrent 
laryngeal nerve, to Uie lar>'nx. 



The veins slimv tlie same arranfiemcnt, ami anastornose largely 
with those of other organs, ami finally [wur ihcir blood into 
the int<':niivl jugular vein. 

The mucous membrane of the larynx is tlie direct continua- 
tion of Lhal uf the [pharyngeal, and, lining the inside of the 
larynx, fornw folds and dupliratioiiK whieh have alrea^ly been 
deseribed. It is firmly attached to the whole anterior larynf{e«I 
wall and Ui tin; jKistPnor (laryngeiil) surface erf the epiglottis, 
and also to tlie eilge of tlie vocal conLi. On the posterior laryn- 
geal wall, and tdso on the intcrar>'tenoidal part, the ."ubmuoous 
lis5ue is more ample, so that the mucous niemhrane is movatitc, 
and folds on closure of the vocal cortl.t. Also in the ventricular 
folds, and in particular on the lingual {antenorj surface of the 
epiglottis and ar>'epiglottic folds, the submucous tissue la very 
loose antl well develoixnl. This Is the reason why we so often 
fmil inflamnmtorj' or cgngeslive oedema in these situations. 
Where llie niueouH membrane is exposed to mechanical frictions, 
i. 9., (HI both surfai*e!)of Uie c>piglottis, on tlie arj'epiglottic folds, 
and parg interarylenoidea, and eveji also on the inner surface of 
the ar>'tenoid cartilages and vocal cords, it is lined with squam- 
ous, at other parte, however, \tith ciliated, epithelium. In the 
area where it is covered with squamous epithelium, numerous 
papillate may be found, which form ridges running sagtttally 
along the vocal cords (H. FTanlicI). This explains the frequent 
oecurrrace of papillary tumours in this region. 

Glimds' are ver\' numerous, — mostly acinous mucous glands, — 
and ihcy are sjieciaUy numerous on the larj-ogeal surface of the 
e|Mglotti8 and it* petiolus, on the \-entrieular folds, and posterior 
lar\'iigeal wall. On the mucous membrane of the vocal cords 
they are scanty, 

Lymph've-'^setti of the upper section of the larynx drain into a 
glaitLl 8ituat(xi lietween the major horti (comu majus) of tho 
hyoid bone ami the upjKT iimrpn of the thyrrnd cartilage: 
the iyniph-vessels of the middle mid lower portion drain into the 
glands situated at tlie »de of the trachea. 

The occurrence a/ tasle-buds is worth mentioning in the region 
of the »|UHmous epithelium, viz.. on the epiglottis and inidde 
the larjTix, on the inner surfaces of the arj'tenoiil cartilages, 



rartilajcinoua niiRB, which are conncutM with oach othw by 
tcr[ii<r- clastic hands. The iliftiiicU-r measures in children fn)iii 
5 W ll! null.; in men, 14> to 2'2 iiiiu. ; in wuineii. Ui In 16 

Tlie cartilaginous rings are not compleU-ly clast'd, Imt. are 
liorscfifnx; .sliajiiiil, aiid fomi only the anU'rior aiifl lalcrul 
wall of the Iraehfa, while iKWteriorly tlie truche-a is sliut by an 
elastic {ihr«!ular wall whidi in free from cartilages and 
nuirkedly llatteiirtl. The iiiiieoiiH miTiibraiie projeeN fJiHiiewlial 
like ;i Kpur into the lumen at the site of bifuradion, which pro- 
jection is called the cariim trachea. Of the two bronchi, the 
right one ia wider, shorter, and straightcr than the left. This 
differetH^e is ver>' well shown in the drawing (Fig. lUO), which 
rt-pre.serita a fusible inelal preparation by SalUi, ami explaijis 
why foreign bodies much more often reach the right bronchus. 

liehind the trachea, the oesophagus passes domi. and in the 
groove l)elween the two structures the recurrent larj-ageal 
nerve ascends (siv above). In front of the trachea, Iwtween the 
s(*eoncl and fourth rings, lies the isthmus of the thyroid gland, 
whilst the laU^ral lolws of this gland flank the trachea and npso- 
pliagns, fljui further upwards, the tlivroii! cartilage. Fmni the 
isthmus a middle lobe sometimes a^^cnds in the mesial line, 
which miiitt be avoided in (Superior tracheotomy. (See p, .'HI.) 
Many lymphatic glands may be found in the region of tlic 
tracheal bifurcation. 

Tlie mucous membrane \h firmly attached to the trachea, 
and is rich in acinous mucous glands. 


Tht' fuuetions of the lar\'rix are those o( rc8i>iration and 
profluction of the voice (phonatlon). 

With regard to respiration, we may consider the larynx as an 
organ intersecting the air-passage hke a tap, in order to regulate 
the entrance and exit of the air. During quiet respiration the 
glottis forms a triangular space, which is lai^est during deep 
inspiration, when it permits the bifurcation of the trachea to 
be seen. 


Above the entrance to ihp InrjTix the air and food paths 
cross each other; hence there is a poRsiliility of food particles 
reaching the nir-passoges. In order to prevent such an occur- 
rence tlie larynx shuts it.self diirinn the act of swnllnwing. 
The vocal cords npproiicb each other closely, as also the ventricu- 
lar folds, the clofiure of which is madr- still more secure hy the 
jxtirjhis c'piglotlidifl. It i« ni>L yrt certain whether the cpiglotlts 
plays an active rftle in the clowire of the larv-nx, either liy Wing 
puslicil ilowiiwanis hy tlic fofxl-hdlas gliding over it, or whether 
it is dniwn downwanls l>y the action of the in. aryepiglottiniM. 
Anyhow, the contribution of the epiglottis to tlie act of closure 
Bet!nis not to be very inipr>rlanl, for there are persons wlio can 
sxvallovv without any difficulty, although their epiglottis is very 
rigid, ininiohile, or even entirely nhsent. .Acconling lo von 
Brims, Waldcycr, and M. Schmidt, the food-bolus does not gliile 
over the aditus lar\Tips at all, but the epiplottis is supposed 
tlien to be the vehicle, lending the foo<l-l}i)!us along its rolleil-in 
edge int^i the ijyrifunii siiiuw, which is adniill-cil to \h'. the iiJUNsiigc 
for fluids. 

If. nevertheless, particles of food or foreign bcKlies are a«pi- 
mted, then the sligjitest toueliing of the verj' stinsilivc inticous 
meinbmne produces the reflex .vhutltng of the rimagiotlidis. 
Tlie increase of the iilr-pressure in the lung then causes the 
ritnn to he explosively opened, which is known as eoughing. 
Not only foreign hiHlies, whiel] may aeeidentally Imve reached 
the lar>'nx, but also secretion from the lower air-passages, are 
thus flung out by coughing. nr)S\ire of the rima glntlidis may 
also he r<;flexly provoked l)y strong rotitnicurrenl and irritant 
vapours. The reflex runs frcHn the snijcrior laryngeal nerve to 
L!ie medulla, and from there centripet^ily to the inferior laryn- 
geal nen'e. 

The larynx plays thus, with respect to respiration, the n^le 
of a nnuhtrUtr prr the ntrrent «/ rexpired ah, and also that of a 
guard far thf hnttrr ntr-jtassa^es. 

With respect to voice production, the larynx may be com- 
pared to a double membranous reed-pipe, The reed of the 
pipe is represented by the two voeal oords, which, in order to 
pro<luce a sound, must be caused to vihrate by a suRicie-ntly 



Strong expirfltor>* currpnt * niutt Ue clo^y ap|)roxinial<Hi, aiKl 
in a certttinstatpof tension. If thctwovoaili'or(lsari>peparat«l 
for more tiian 2 nun., hoai^euoss ami even aphoiiia «i.-:ue. The 
moisture of the %'ocal cords, which ia necessary for satipfactori* 
vibration, Ik affonlcd i>y the mucous glajids of ytorgagni's 
vciitrick', whirii also affords th« ni-cossary room for the vibrationa. 
Tliat it is tJie vocal conls which product- the scjuml may be ob- 
sen'ed froni the circumstance that tlie pnxluclioii of sound is 
at once lost if Uie air esca[x« below the riniii glottidis, c. g., 
att«r trarht*otoniy. Tl. may be ailmitled, however, that by 
forced approxiiiialt{)n of both ventricular folds, as i£ sornetimos 
seen in nervous [tatients, at the first laryngoscopic examination, 
a sound may be produced, but it is only of a noisj', rougli. and 
rattling character. How the closure of the vocal cords is per- 
formed has been describeti in the previous chapter. Aa to tlie 
part whicli the na.sal. oral, and pharyngeal cavities play as 
resonators, we refer to what we have said Ix^fore (s* pp. 15 
and 278). 

The bunion voice is jwiged by three different qualities: 
{\) Vigour; (2) (imtre; (3) ;>i/rA (lieiglit or depth). 

1. VigoiiT (strength) is din^etly deiiendcnt on the pressure of 
the e.xpire<l ciirreiU of air and the length (amplitude) uf the 
waves of vibration. 

■J. Timbre (etiade, nuaiice), which provides Uie individual 
character of voice, is determined by the kind of vibration, 
this again being defined by the anatomical configuration of liic 
larvnx and its resonators, .^s regards the eon figuration of the 
resonator, the voii-e may apjiear clear, dull, nasal, or rattling. 
Age and sex also have a dctemibing influence on the timbre 
of voice. 

3. PUeh (height and depth) or register depends— if settuig 
aside the prcwure of the expired air— on the numlier of vibra- 
tions, I. e., on the length of tlie vocal enrrb and iliwr tension. 
The higliest pitched soiuids are produced by the cliild with ite 
shortest, and the lowest pitehetl sounds by the adult man with 
hie longest, voeal cords. At the time of puberty the larynx 

* Within certain limits, nW>, insumtion mnv produce some noisM, or 
lioane and esvLlinK aMiiidt, u* e. g.. in riogullUH (liicooiigh). 



growa rrifltivcly raore quirkly, and this pircumstojifp, cotinhinwl 
j)orhfl[is with iiyi*oraeniift in young males, ca^.■H-■^* .some kind of 
l^lly^il>l(lgi(;al diMinirr uf the voire. .Viionialiet* of viliraLioii 
accordingly occur, and so the impure, rougli, "cracked" voice 
is often producii'*!. This is called "chansp of voice," or "hri-ak- 
ing," wliicli niay for from one to two aiid oven for llircK 
years. No change of voiw takej* place in oa-^trates. As rrgards 
regisif'r in iiicti, liass, baritone, and tenor, ami in women, altOj 
mezzosopnino, and so[)raao may lie diHtinpuinheil, Kjich of 
these quulificHJiutis ha« it« special limitations, wliich, how- 
ever, arc not sharply defined, and, by training and exerdsc, 
may lie cnlarRwl more or leas towanls both extremes of the 

Within the various voices different registers an? di.stingnisliable. 
The chief registers are the heatl voice, or falsetto, and ihf chest 
voice; between them lies the middle voice, and Ik-Igw them 
again is the basso or deep voice. 

In the chest voice the lar>'nx is in its lowest ]H)sil.ion, and tlae 
voice sounds full and strong, and the vibrations can Iw felt 
in tlie chest. Tlie rinia glottidis fonns a sniall longitudinal 
chink ; the voeal cords vibrate regularly and to their full nxlent. 
In fieadrw^ the larynx is drawn up, the voice issoft, the resonator 
reverberatef strongly, and the vibrations of the fkiill may lie 
felt more or less distinctly; only the inner, free niai^in of the 
vocal cord-i vibrat<'«. According to various authora. the rimii 
plottiilis, especially in it.** anterior third, is not so close as in the 
chej«t voice. The epigiottis is erecteil during high-pitehei! 
sounds, and sink;? back tlitring the low ones; sometimes so much 
so as to prevent ins|3ection. This, however, is not applicable 
to all The action of the epiglottis and vocal cords is 
subject to vsrj'ing iniUvidual jieeiiliarities, which depend oft iho 
configuration of the hir^'nx and training of the voice. 

In tvhisperinti roice, or, as one should rather say, in wktAptring 
fpeeeh. the vocal cords arc exchi<l(ii fnjm voice production. 
The air-curn-nt [jaysing through the larynx is ushI only for 
voiceless noises, proiluced by the resonatnr brought into a suit- 
able and comrt jxinition. Whispering, therefore, is possible 
where voice is lost, e. g., on accoiuil of disease of the vocal corda. 



Finally, a few worxls on llio centra! innervation of the larynx 
may lie s&\il. {Soo Fif^. 101,) 

Wc- Imve seen tlial Ihe Inn'nx servos phonntion, which really 
mcana the closing of the rima glottidis, and also i^ubsen-ee 
respiralion la such a way that the glottis o]x-iii< im bispit'ation. 





Fig. 101. — ninEraminiiiic rrprcscntatian of ilir centers of reipiraiion and 
plioiiatiorL ill llic brain and nicdulb ohloiigatn am] their Iracl* (alter ftiTM"). 

Till" corlirnl pcnti-r itf plmtialion {l'^ Ik hinclioii.'illy innrp impoMniil, ninl, 
thereloro. better developwl, than Ihe corlii:;il cpnter of respirtilioit. r; on ihe 
other liaiiil, ihv nieduJhry (Imllwr) M-nlfr o( rc.-|iir:iiii>ii, N, i« fmictiorinlly 
of RTPHtpr iin porl.'incc rlum tin- tncdtilliiry crnli-r <'f pimfinliori, ft. Tlie inortt 
ini|N)ri.ant ccmcrH nro lima marked wilh cjipitjd Ifticr^; titc minor p«nlcrs.tviil) 
nnin]l letterti; llif hhu:k iujii iriii-m]rie'l btxoB (S, s) ahon the mup* uf iha 
hbcnf for ilic namuxrv,t\m lincat 0,o, Ihwiw (dotted) lor Ihv dilatara of Ihu 

Botli functions have a central reprewntation, and wc may at 
once note that the r|«estion of the central innervation of the 
lan-nx, wliirh if ?n iitijx^rtant iu certain |>atliolo|iical caws, is 
still in the fccus uf di«cui?tu(jii ; nur uii account of the difHcultics 


of investigation is It surprising that Lbe opinion of authors on 
iiijLiiy jMiinls if^ still in o|iixisitiori. 

Iti (]ui('tjius well ftM ill f(itcc;il, ^^■^i)i ration, acconling to Kutiiwr- 
Katzensicin, all the luryuKi-al iiuisclos, illlators, anti narrowcrs 
— not only the crico-iiryt4'iiiHilcu« po^ticu^ alorif — are innerx'ated 
simultaneously and coiislJiiitly; during inspiration the opeoiers 
get the stronger irnpuls*?, while in expiration tlic narrowors gain 
in energy. 

Quiet Tf'-jnTalinn, m a pure reflex aetimi, has its pf-ntcr ui the 
floor of the fourth ventricle. This automatic nicduUarj' center 
acta qiiito independently of the othw center situated in the 
cortex in front of the siipm-iirhital (inferior fronted) fismure, 
which nih-sovcr/woffi rc-^jdrathn. the latter being a. voluntary 
action. As for respiration, .so also for phoniitiijn. there exist h 
medullary and a cortieal center. The nieihillary center, on which 
we believe that the lurj'ugejil reflex actions dffpend in certain 
emotional expreewions, siieli iv.s crying, latiglung, coughing, el«., 
is fiitual^l in the fourth ventricle, very cloae to the automatic 
craiter of respiration. Analogous to this wc find tlie cerebral 
center of voluntary sjioech ami voice very close to the center of 
voluidary (t. e., forcwlj nvpinitton. 

It is characteristic of the central iiuiervatinn of the larynx, 
in reajwct to respiration and jilicmalion, tliat Inilh sides arc 
stimulate*! .■^inuillajiefiu-'ily. Then^fun- paralysis of one center 
only (on one wile) has no innuence on the iiiovenieiit of the 
voeal corIs, for the other center at once takoK up the aolion of 
thi- olUr-r. 

The cortical fiben', w il U awuinwl, run from the corlex to 
the int-emal eapaulo. Ilirotyih the corona radiatn, and finally end 
in the me^lullary ganglia. Stimulation of these fibers has also 
a bilateral elfect. 


A. External examination of the larynx ami neighl)ouring 
Inspection and luilpalton. 



B. Internal examioation. 

1. 'IVstiiig of fmu-liuii. 

2. Iiis|XK:tion. 

(a) Imlirect (larynposcopia indirccta— shortly, "laryngos- 
(6) Direct frlirect loniigOMopy, auli:>scopy). 

3. Palpation (digital palpation and sounding, prolmig). 


This must coiudst of tcsiinfr of the lanTix as to its air per^ 
nitifthilily, by insjK'clioii, palpation, and auscultation, and 
witli rpgard to the imHluclion of voice, by tlie car. 

(a) Indirect Method Uiidirect Laryiujoscojnf) . — By tlie in- 
direct method, which is the most in)[M)rtanf- uicaiis of fxaniina- 
tion, we do not got a lUrect view of th? inwdf, hut only an image 
(tf it. For thitt pur]X)se w(> use a Kiiiall plane mirror fixnl to a 
king handle, held somewhat obliquely under Ifie uvula, wliile 
light is thrown onto it by a rcflci'lor (we Hg. 102). 

Fig. 102. — I-aiyngcnl mirror. 

The source of the light an^l the Toflcctor have already l>ceji 
discussed in anterior rhinosoupy. fSee p. 16.) Tin-. liU^-ngcal 
mirror to be introtlueeil int« the mouth is of a romjd fJiapc, 
anil is fixed to a long liiuidlc. Mirnirs of si-viTal si>ie:s. wliieh 
can be screwecl on to the handle, niu-jt be kept handy Tht; 
larger the mirror, the largtT will be the image whidi we perceive. 
Small mirrors must be useil in examining eliildreii or in cawa of 
great stenosis of tlie isthmus fnuclum. Disinfection of the 
mirror is necessary, but is dilTicull. as the best mirror suffers by 
being boiled. Vnder onlinary pircuinstanccs it is suHieieJit to 
put the mirror for a while into a 5 per cent, carbolic acid solution. 
Separate mirrors, which ^louhl be marked, ought to be set apart 



for ]>alientir witli inffCliouB dispaws, viz., tuberculosis and 
syphilis of th<' Uirviix. 

Techiic nf J.itn/ttijusrojiy. — TIic |X)sition of t]ie physician antJ 
patient is the same as in ritinoscopy, but patients in becl should 
bo raised up, if possible, or, at ]ea^:t, their heads must be lifted. 

The distance of the reflector from the patient's mouth is 
usually \a mi., and from the mouth to the uvula, 7 to S cm., 
aiid from uvula to the glottis, 7 to 8 cm., so that the whole 
distance from the redcetor to the glottifl, ibfrefore, will Iw 
about 30 cm. ; tliat is, the distance of goml near vImoii in an 
emniptrnpii:; eye. 

The patient is dirertwl to oiwn the moutli as wide as he can, 
for tliin gives us also the 0]>iK)rlunity of insjieetinp (he pHrts 
situated in front of the lar>nix, viz.. moulh and throat, aud all 
false t«eth should Im> removed. The patient reclines his head 
soinewliftt, and the light is then reflected on to the uvula. While 
the examiner keep.s his head steady, he seizes the patient's 
tongue, coveretl with a clean handkerchief, with ihe left thumb 
and imlex-finger. the thumb being upiwrniost and the index- 
finger undeniiost. and pulls it outwards and dovvnwanls over 
the lower jaw. (See Kig. 103.) 

It is not good practice to allow the patient to hold their ovm 
tongues durinji the first examination, because they do not hold 
it fimdy enougli and i>eriiiil tlie tongue to slip backwards. 
Hut the patients must subsequently Ix' made to get used to 
holding their ovni tongues, in ortlcr to allow the physician the 
free u.-^* of t>ol.h hands. 

The laryiigfid mirn)r is held like a pen (both the right and 
left handi) nhould be weJI trained), and wanned over a lliunc 
with the face d<iwiiw!inl.s, in i»r4l('r U> pn-vent any Itedi-wing 
liy ilic wanii cxjiirati'd air, and tinni teslrd t*> sit- if it be loo 
warm. Having corivinei-d himwlf ngaiii that the uvula is well 
ilkiinlnatcd, the exiiniirier imw iutrmbici'S the mirror face down- 
wards Ijetween the ttmgtH' iiiid palat*;, taking cam not to touch 
either, and presses the tnirnn- iig.iinat tin- uvida, pushing the 
latter gentJy upwanis nnd backwards, at the siune time directing 
the p'ltient t« say "eh"<ir"ehe" whilf the handle of the mirror 
is placed ill the comer of the mouth (left). 



Thp mirror should be placed agiiiriwt Ihc hoac of the u\'ulti, 
and not on its lower end. fur tlu- uviilii would then riiaily lOip 
ill front of the mirror. After Uie fintt introduction of tlie mir- 
ror the patient must be given a rest and ordered to breathe 
("(uiotly, and it is best then to show him how to do so, as weJl m 
how to phonate. Then he is required U) aj^niii inlonalo and 
again to breathe, and so on. It in quite wrong t/j endeavour to 
cause him tc phonate continuously. 

Instead of warming the mirror, which, with electric light 
and in repeated introduction, is somewhat troublesome, the 
mirror can be dipped in i per cent, lysoform, which, however, 
does not render clisinferfinn suin-rflvious. After an examination 
the mirror must be thorouglily cleansed and dried, in order to 
prevent any mucus from drying thereon. 

fXfficuUies During Exnviinulum. — (a) Unshilfulness of the 
ExatniTter. — The beginner iismdly proceeds too limidly or loo 
roughly. In Iwth cases relehing will Ije the nsnilt — Id the 
former, by touching the tongue; in the latter, by the rough 
handling of the uvtila or soft palate. Pulling iHm too imVh on 
the tongue is apt to lead to retching and to the patient interrupt- 
ing the examination. The examination must be performed 
with quiet finnneas, but >Tt with a ctjtain gcnllene«3. Practice 
on the artificial larynx (phantom) is of no real practical value, 
and it is best to practice on a willing person of slight 
tivenesH. If one noticejt that the light is diaplacefl and does rtot 
illuniiuato the right spot, viz., the uvida, the mirror sliould lie 
withdrawn and the light eorreelly adjuslt-d before the examina- 
tion is repealed. This is far better than to obtain correct illumi- 
nation by movements of the head, for the jiglit oiJy flickers 
alK)ut and the patient becomes tired and chokes. The same 
result is to t)e feared if one holds the mirror too long on the same 
spot. It is iipces8ar>' to collect the entire view by alight moviv 
uientfi uf the handle, and often, undimbledly, one patient will 
stand examination better than another, frul it is thoroui/hhj 
vrong to insisi, and to think, tiuU m any case one must finixfi an 
ejamination u-i'/A the fint inirodudion o/ the mirror. Practice 
makes perfect. It la certainly better to make n-pealed sliort 
introductions in nen'ous pereons, and so to take, as it were, 




snapshots, which, taken in tho agjercgnte, vnSi give a complete 

C6) FouUy AHUurie of the Patient.— Hero we have to take inlo 
ooneidrratjon the mental or psychic conditions on the side of the 
piitii'nl; e. g., fear of [iniii, opf^mtion. inflation, nflcx iiritaliil- 
ily, which is very ofl^-n round in m-n-oiLs pcrtwns or (ilcoholic*. 
Tlicstr difficulties slioulil he overcome by calming the patient 
and by cxphiiniiiji In h\ut thjil which wr divirc to do, antl hust, 
but not k'jist, by .scrii|iiilnTis clrimliiH-ss with rcgiinl lo the mirror. 
It is a vory clever manoeuvre to put the mirror for the first 
tinii' merely onto the hard pa.lnte. and then lo pretend to have 
lUroady seen all quite salisfnctorily. Iliglily nervous piitients 
should be required to breathe abruptly, especially if retching 
occurs on phonution. Thus the epiglottis is drawn well up at 
eaeh expiralion. ami iicmiitM of a full view, tf choking occurs, 
the niirror nmst hi* at once witlidmwn. Locid anaesthrada 
should be u»fd only as an uitimttm Te/iiffiiim , niid for this purpose 
tho Iwi.'**' of the longiie niid all purls which conie in contact with 
the niirror must be |iiiiiiti.-d with a 10 per rriit. coenin or a 10 
pfr ct'iii. alypin «)lution — a prtjceiw, however, which does not 
always overcome the difTieulites in question. In souu^ tt^lt- 
ouH cases line must not lost- jKitii-iiPC, hul nuisl jinwci'il step 
by stej). The tonffue w at first pulU-d out. iunl tlic pntient then 
required to repeat in the fwme manner as U'fore the gotmd, 
half spoken, half sung, e. g.. "eh," "ehe," eo as to get him used 
to phonation. Then Ihe mirror may l>e reintroduced. Some 
piitionts hold Iheir brenth on the introduction of the mirror, 
and here also the patient has to be trained not to do so. When 
it U possible, such exercises should be gone tluough whilst fast^ 
ing. Many patients involuntarily approximate the lips during 
aa examination more and UKire, so that they must he reminded to 
keep their mouths open, although not go wide as to produce a 
subluxation of the jaw. 

Children arc difiieult to use the laryngoscope on, and in poN 
ticular, if they have not been, tmined to permit inspeetion of the 
mouth or are badly brought up. If all the arts of friendly 
pcreua«ion prove in vain, nothing remains than that the child 
must be ftrmly held (sec p. 112), and laryngoscoi>cd with the 

Fig. 104.— I.aiyii{{<i>m|iiit Indirecta. Examination by mltror (Ulcral TiewJ. 

a deep brcalli whiht crying. Nartotia hardly cwr needs be 
applied: the tltn-ct method should rather Iw rwortwl to. 

(c) Abnormal Anatomical Conditions. — If the toiigiie » short, 



or the frenulum rigid, it is itiwi difRpult to f^isp the tongue 
fimily. Here one should tako grwil. euro not lo jtijuiv or tear the 
froniJum by pulling too strongly. This eaii also be prevented 
by putting a swab of cotton-wool over the lower incisor teeth. 

A too Beshy tonpie often list's up fo nmrh in the numlh that 
the mirror cannot be introduced wilhnut being soiled. In 
8ueh a ease the tongue must be depressefl with a spatula, which 
rwjuins some foree and gtval skill. 

A too long uvula easily slips in front of or on to the mirror, if 

Fig. 10.1. — Onie';ri»-«lin|)«l qiiglnitite. 

Fig. ICS. — K<ttrAHcxptl vplglotiis. 

this be too small or has not been plaeed against the base of the 
u\-ula. (See p. 367.) In cwses of hypertrophy of the tonsils 
a small mirror is more suitable, or a preliniitiaiy tonsillotomy 
might be required. 

In lordosis of the centira! spine it is necessary, in order to place 
the mirror suffieieiilly far bnrkwiird.'" and upwards, together with 
the uvula, to bend the head fonvards, or the mirror must be 
introduced and placed somewhat more lulerally. 

The epiglottis also often prc£«nts a great olietacic: either 

Ftg. 107. — Holder of llie e|Mg)ottifl (after Rftchtrt). 

owing U> i\s being HlioomiaHy sha|M*d like An fi (omega) (see Fig. 
105), or it diii-M not ram- it-self sufiieinitly (aec Pig. 106). 

In general, the higher the phonation, the more the epiglottis 
rises (see p. 361 ) , ami also the mon- the tongue is pullt^d forwards. 
But an exiiggeruttxl pulling on the tongue is not permisttible, and 



poKtorior (lar>Tigcal) surface or a Retcherl'e spatula (stx" Fig. 107) 
is fimily inserted into the epiglottidean valleculac mid the cpiglol^ 
liw aiilrflwrted. If the latter he compressed sideways or strongly 
rollini over, the image of the larynx may be gathered aiid com- 
liincd hy various [xisitioiis of the mirror. 

The IxiryTUjoseopical /nintje. — A« thr- mirror, placwl against 
the uvula, is inclined at an nnple of 45 licKri-cH lowawLi tht^ hnri- 
«)ntai plane, so all that which actually lii^B in front appears in 
the upper part (»f the niimir. wtid iill that actually lies poste- 
riorly, at the lower pjirl of the iniase. Itut that which 
is to the right remains also on ihr right in the mirror, ajid that 
on the Iff t n-iiiainson the left; if is also tenned "left and right," 
although il !ip|K'are — viewed fnim the point of view of the ol> 
server—" right and left." {ikv Fig. lOS.) 

Fig. 10(1. — Vooal CUN.S diiriirg jiliona- 


Fig. 110. — 'V\it Minie (turiTiKrcj<)Hra> 

The aevcrnl piirts—aiitl ihiw the lK*giiiner musi Ix-ar in rnhid— 
ar(r drfinrti, a** they n-prcsent themselves In the patient, not as 
we sec thfiii in the mirror. 

When iwing the larynjptweope the bi'ginner sees, at firet, 
the base of the tongue and the epiglottis, and theglosso-epiglottic 
lipnmeiit stivteheti nut in the middle line, connecting them 
Ijoth, with the valleeniae on l)oth sides. Then the poetcrior 
(below in the mirror) parts, the arytenoid cartilagi's, and inter- 
an,'tenoid notch (roninii.s.s-ur:i i«)stt'rior) will be seen, and 
laatly — in pftsy cnHew even sU the first trial— a view of the interior 
of the larynx is gained, either on n-«[)iratioii or phonation. 

The vocal cortU are the most coiifipieuous parts, which approxi- 
mate closely together on phonation. while on respimtion ihey 



outlinft a triangular space, which pnlargt-s on clrcp inflpinUitm 
and admiU, iitider favorable conditions, ii viuw still further dovm 
into the tra*hea. (Si-r Figs. 109. 1 1 0. 1 1 1 .) 

The vocal proci-sscs fri-tjuctitly pnijwt sonipwhiit angularly or 
curvilincarly into tlit- lutnrii. witlml tlic vocal rord.-* do not ;dways 
present a stniiglit Hue. Tin- alxluction of the vocal cords is less 
pronounced during oxpimtion. During forced respiration the 
voeal cords can somelimcs be seen performing short rhythmic 
opciiinj; and closing movements. 

Laterally, and a little above the vocal cords, the ventricular 
folds may be swn, and between both the small chink leading!; into 
the sinus of Morgngni. Ehtring forced irfpiralitm Ihc racut Cfrrds 
sometimejf dumppeitr umler rmvr of the i^iirU-uUir/uULs, wluTi'liy 
the triaiigulnr shape oF the glntlia 
assumes a more polygonal, or fvcn 
circular, outline. 

The beginner oncnlwles himself 
quickest if he searches for the 
image during phonation, because 
then tlie cpiglollis offers the least 
obstruction, and the white voeal 
cords in the middle of the field 
cannot eawly be overlooked. In 
some cuw«, if the eiidiavour to 
intonate excites retehing, examination during respiration will be 
prefiTal)Ie. Tliis mii.s| In- learned by exix-rienre. 

A.S a, nile, the liinjttx ^huuid he examined during phonalion as 
wrll as respiration. 

It is often very difficult to bring the anterior commissure 
into view, but this is indiH(M'nKibIe for the reason that it is the 
usual site uf new-growths. (I'or the n^atioiis of the various 
parts see Fig. 112.) 

It is difficult for the beginner to get, by means of such an 
image, a con-ect idea, of the accurate distances of the varioua 
parta from each other, more cspt^cially the distance between tht; 
epiglottis and rima glottidis, which is very frequently under- 

VaritUionx of Indirect Ixtryngosoipy. — Owing to the peculiar 

Fig. 111. — Haiuc during tinep ii>- 



fomi of lh(- Urj-iix, the indirect method is not nlways sufficient 
to gain a fuU viKW of the larynx, although one rotates the mirror 
in different directions. Therefore we niust resort to some other 
method or nimllHcjition which admits of the ins|>ection of special 
part-s not «i.sily wen by the usiuil method of laryngoscopy. 

1. hvif)edion of the Poslerior LnTtfngeal Wall. — The posterior 
wall of the larynx iipijenrs (by usual hiryogosoopy) very foreshort- 
ened and small; it may be made visible to n large extoot down 
to the bifurcation of the trachea, by Killian's mcihotl of examina- 
tion; Whilst the patient is f^t.-indiiig and beiuU; the hwid right 
clown on the chest, the physiciikti, being seated or kneeling, 


Fetiolu* foi. 

QutiUic ol V/iMiert 


Lc(l viic«l 

fit Ih* v*(itn- 
f1« ■>! klur- 


Cvt Skaiaiioi tUin» Ptoelpriir 


lory in 

Vme, VQodit 


Fig. 112. — Laiyngoetcopic imago (enliinp-J), 

thiti^^-s the licht into his throat from below and places a large 
mi rn)r hnrizonlalUj and a Utile farOicr /Qncords than usuid again-st 
the soft pahitP (wt:- Fig. 114). An electric head-lamp is very 
useful for this proceeding. This method of examining allows the 
posterior WJil! to be .teen rif:ht d<i\vn Ut the bifurration, and ie 
cHlIed KiUinn'x method of indirect xuj^riiir irurhefhfcojiy. (Sec 
FigH. II."*, lU.Il-'j.) The niethnils of Rnuclifvss, Rosaiherg, and 
ter Kicile, which aim at the smie iHir|)ose. are more complicated. 
A small mirrtir on a very long h.-unlle is iiis«'rl4Ml into the glottis 
it.'H-lf, po that the image of the [MiKterior wall and of the Bul>- 
lai^'ugeal (lower) .surface of the voeal cords is refleeted on a large- 



comer of the throat. By this nieana the lateral margins of the 
vt«:;il coril.s jvml vi'iilrieiilar folds, as also the ventricles of Mot- 
ijagni, <'iiii hi- "mspiicttd. The r'mm glottidis iheu appeaTB to be in 
a slaiiling position. 

3. Iiupection of the Suhgl/Mie Region {Lar^tgoaeopia Snb- 
glottica). — Under pood illuminnt'ioii a Uirge mirror is introduced 
with the left hajid and placed against the u\-ula, just as in 
ordinary Iar>'ngoscopy. Then, with the other (right hand), a 
.siii;ill [iiirror is inserted into the rinia plottidis. The patient is 
onliTetl to take a deep breath, and at this moment the mirror is 
i|uirk]y intn)diK*ed through the opened rima, and the under 
surface of the voeal cords is inspected by shifting and sliglilly 

FIr. 1 1.5. — Pfviierior laryiii^eal 
wiiU mid bifuruition [KiUian'a 
Doethod of oupcrior tjrachooecopy>. 

Fig, 1 18. — iiuticlultic lnry>iKO)H-n))y, 

rotating the mirror in the frontal and sagittal directions. The 
mirmr is of an oval shajH', and is fixed on a long and suitably 
bent handle. For each side a separate mirroi is luwcssary 
[(ierber-Magnus). Tlie aditus larynps and vocal coriis must be 
anaesthetised. Gn-ber has recently desij^ued a mirror, amilar 
to Rosenberg's mirror, which, when in situ, can be unfolded by 
a special 

The subglutlie ri-RHtu of the Iar>lixc»ri at«i be iimiwif^fl through 
the wound after iraehcotouiy by niesiiw uf a small mirror wllich 
is insc-rted into the wound (t'nrftrert in/erior tracJieotcopy). If 
the mirror, face downwanl.-*. is snitahly rolaied^ the whole 
trachea down to the bifurealion may Ih? uiK]iect«d. Seen from 




bolow, the vocal cortis api>ear iiol as while baiidij. bu( iis pinkish 
or nil pad3. 

{?*) Direct Laryngoscopy (Autoscopy). — A'trstein was the 
firet to describe this method, which allows the laoiix and 
its various parts to bi- directly inspwted without the ;iiJ of 
a mirror in their natural ponitioii. Tlie examiner stanib In 
front of ihf* jNitient, who bends forwards the uppT pai't of 
his Ixidy. at- the same time that the head is l)cnt back- 
wanls. A Bpiitula, fixrd at right Hiigli-H to a haiullc, and lii>tit at 
its front wid (spi! Fig. 117), is iiitnKJueeii river llic ukM of the 
tongue, so far as to reach tlie vallepulae, and the tongue de- 
pressed tinuly downwards and forwards, bo that a jrroove is 

formed and the epiglottis erected. 
By tbls nuinipuhition a chanQcl 
is shaped, through which the ex- 
aminer^— by means of Kirfitein's 
be3id-l:inip^-can inspect the luside 
of the larynx, 

Autoscopy requires great prac- 
tice, mid is vcr\' often felt as an 
unpleasant experience by the pa- 
Fig. 117.— Bpatulfl of A'i>»rWn. ticnt,especiallyif hebeverynervous 

and be possessed of a thick, fleshy 
tongue. Women and children arc easier to autoscopc than men. 
(See Fig. IIS.) 

Home pcrwiHiw evt-n eaniiot be examined by /\iWcin'« method. 
Aiitnscopy iy fncililjited liy the lubjfitnn «paliila of Killinn 
(\iitrS\iirytigni\ fjmtulii). wliich may al,-io be used as a dinrting 
staff for bronchoscopic tubes. (Sec Fig. 1 19.) Ri-eently the 
unM'CT'.ffl/ itenum^'lration elerfrn-ifojje nf Cnsper-Kilh'an him come 
into use, which oirrits on tlie upper end (jf tlu- liimdle a siiiiill 
electric lamp, ami may be fixed to the iiilmlaryjigenl tnliifomi 
spatula, (See l'"ig. 120.) 

By direct hm-nga^icopy the [lostcririr regions and |inrts of the 
lar>iix, and far down into the trachea, may be made visible; 
the anterior ports, however, are more difficult to in?pect. 

In any case direct examination of the lnr\'nx is a vnhmble 
means and supplcmeiU to ordinary Iiir>'ngo8copy, parlicidarly in 


Fig. [20.- rmvcrsa] doinonatrnlion okclroacope (after Ca«p#>^-K>U><in}. 

seated with the body inclined forwards and the head bent we^l 

The first thing to do is to cocainise the IhroBt, base of the 
(nnjElie. snft palate, and the hirjiix, and bnvi- ihr [jtitient scatrd 
on :i low bench or foot-stool. According to /\ijlian, all the iwrLs 





an? first pamt€<] with a 10 jut rent, waten.' solution, am) thi^ii 
with a 25 piT pt'nt. alcobolir solutiun, to which 
two drops of ndreiiiilin (1:1000) i* added; very 
cxeitJiblp persons must hi.' given an iiijiMitioii of 
mcri'hiiic about fifteen minutes before the ex- 

Then the tubifonn s|)atula {FIr. 119), wanned, 
over a flanir, am! lubriraliMl with fluid poratTin, 
is inrwTtcd undor the guidmicc of I hi* rye and 
fiiigtT well barlt, and iw far a.s [Kissible betwceii 
the epiglottin a:id jKwterioi' pha.ryngeal wall, iind 
at the nioiiH-nt nf dfi'p iiusplration Is pUfJiMl 
through thi' cipfjicd glcjllbj. Tht* trHi-hi-w is 
now cocainised liy nipftiis of a long titrnight 
sfmnge- holder isi-e Fig. 121). Through lh« tubi- 
fonii i«pa1iila a tube, likewise wanned and lubri- 
eatc<l, of 7 to 9 mm. in diameter, is now passed 
down, the length of it varying from 15 to 25 
cm, for trachen?copy, and 30 lo 45 em. for 
bronchoBcopy (flee Fig. 122). If one desires to 
insert the long tube directly, the patient must 
recline with hejul hanging downwards. 

In ortler to reach the bronchi beymid the bifu-f 
cation it is necc-wary, Iiaving eociiinised the 
bronchi, to push thetii so far towiirds the middle 
line iinlil the angle foniied by them and the 
Iriurhen has disiippciired. The right bronchus, 
owing to its stniighter course, is caster to ex- 
amine. Mueus, which might obstruct the \ie^v, 
may be remo^-ed by a apeeially designed syring(^ 
(StH- Fig. 12;{.} The hroncho«eopie lubes are 
perfomted nt the side, so as not to hinder 
re.'fpinition. In miixrinr brrniehoseopy genenU 
anaesthesia is often rwjuired, and here also the 
recuinherit (xiwitioii is nwessary. 

(b) ('hildren tnuNt tie examined in the ro- 
eumbent position, with the head hanging down, 
and under genenU aiuu-siliewa; in oliler children local anaesthesia 

Fig. 131.— r^oiic 
fur fucit) XD- 



isoflLii siiHicioTit. Tiil>c-s iin- viwd «>f 5 to 6 inni. in diaim-UT, 
aud 10 to 15 v.m. iti length (or ihe tnichiTa, ami 15 to 25 em. 
for ihu bruochi. 

Fig. 122.— Tube for bronchcwoopj. 

Inferior traeheosropy (iml hTtinrhomnpy is much simpler. 
Narcosis \s not iieccssiin,-. but caroful local anaesthesia of the 
tracheal opening und mucous membrane. The bend of the 
patient is retracted ; the chin is turned towards the aide, and the 

Fig. 123. — KQlvin's tyiinp) for siflpiiiUion uf llic mucua from the trachea 

or bronchi. 

tube, having hwn warmed and lubricated, psuwed down. Tlie 
length of ihe tube may be considerably shorter than for superior 
tracliooaoopy or bronchoscopy. 

Palpalioti with the disinfected finger is of small value and is 
little used. It is onjy in children that diKital palpation is of any 
use, on account of llieir reeistaJice to the niiri'or and probe. 



The finger mostly proves too short in adults, as it reaches oiUy to 
tht L'piglottia. 

The laryngeal pnilji', made of flrxibln nictnl, in introduced 
only under the guiiJiiiicc of Ihe mirror. (Hct^ Fig. i24J The 
handle is seized like a |irn-holdiT. mid iiiwrti-Kl lirtwccii Umguu 
and palate JUt far backnuriLs unlil tlie hiittcm on Uie i>ntbv iqj- 
pears in the mirror: the handle is now lifttnl so that the probe 
is pemiittrd to slip mlo ihe larj'nx. The sounding of the 
various parts of the larynx under the guiclaiiee of the mirror 
is very difficult for the beginner, owing to the altered per- 
spective in the image. But it should be practised as dtlt- 
pently and aaaduously as possible, for skill and di-xtcrity with 
regard to intralaryngeal mnnipnlatinns can only be acquired 

Fig. 134. — laryngeal probe. 

by practising sounding on a willing and locally Anaesthetised 

For the purpose of local anaesthesia cocaine is used, and n 10 
per cent, solution is sufficient for esnniination; but for ver\' 
sensitive persons, a 20 per cent, solution may be used; a 10 
ppr cent, dilution of alypin C^^e p. 22) may also Ik- applied. 
In ccrtjiin fiuscs it is iisft'id to coiiihint- li>cjd aiiarsthcsia with 
artificial anaemia by nicAns of adrenalin solution 1:I(KX). The 
tcclmic of local luiacsthesia will be discussed Inter on. 



1. fier&lily. 

2. General rundUionx of life, occupation. 

3. Prttriou* diaermes: Previous diseases of the larynx often 

•Hie proc««diii(pi lii-rc follow the nine Uhcb m in Pari I on Rhintwcopy. 
Oniiif; to ihc inlimnto relittion of Ihroat. nine, ami larynx, rrpptitiooit arc 
unnviiifinhln. K is. liow-ever. IvMw, nor i<i refer eon8t«iitlj to former dMctip- 
lioiu, liut lo giv« hero m coia\>\tile account. 


or Tuc uxm jun tkacbxa. 

Invp hdiiwl B cfiipaatiao to Anther aStttJotm. lUi may mfao 
N< MwJ of aiaie ipnwnl <£«■■«•, ioeli m bflMnn, vfaoapn^ 

4, fmtnt diatofe: Duration, eounr, oripn: cold, ocnqitttion 
or trade Jniuric* <duit, rapoora, powdeml p«Jtide». overstrain 
of voic4*, etc.); b»4 b*bit« (tobacco, aleobol, apices, often com- 
bifwxJ): medicinca (kxline, nimnify, arsenic, kad); infectious 
djKaaai; tlta»jKiiof nci>;htiouhngoni;aiu(D09L-. phamix.tnouth, 
thyroid Rtaml. iniUet, nrrvtw, etc) whirh an- liable to aStxi the 
taryni; itijiiritw; ami f/retnmu treatmetU. 

5. Siii/jeftive iqpTfptomM: (a) I/i*ortlers oj Senxilnlity. — Com- 
plaint rrf {initi in iiftim niadc, altltou}^, on th^ whole, \esi often 
limn ill urTittMiiui of Ihi- fjliaryiix; vix., pain on speaking, eough- 
inf, or evm on Im-athiiiK; oftener on su-alloning. Dv'<t{)bagia 
UNuiilly indkutcri uii ulTcction of the throat ; hut if nothing can be 
iliwovi-nil in lln- pharynx, one should always aUo txaniint- the 
Inrynx, cNiK-riully if the patient himself localises his pains monr in 
llir Inwer w-ction of the throat, in the n-gion of the laOTix, or in 
thr tiiiddle or mtU- of the neck. Aecurate localisation is often irn- 
IMMNihle. 'rill' pniuH an' often due to an affection of the aditns 
InrynRJn, ami railintti t<)wartl»i tht'carhythe^way of tlie auricular 
hmn''h *if tin* viik'im. Si-verc dysphaRia : i. e., pains which innke 
ff^tHlitiK II ioi'tun- or iiiif)ow<ihle, lUiould li-ad us to inH|x>ct the 
pontcrior lnr>'np>iJ wall, which is exceedinRly flwisitive. 

In many ca«ea pain is ahsent, and the patients complain only 
nf mrioiiM KpriHatioim (pnrnefilhesiae), siirh as burning, tickling, 
min-newi, etc, Tliefi' jin* niiiflly due la iiiflunimatoiy pmccaaes 
nr liyHtcria, mid in tuberculoHiw of the lung also each fwHiigs are 
ofti-n njM.rtcd. (See Hart III, pp. W!) and ;W1). 

(h) [HlJiaiitieit o] simlhwing are often combined with pain dur- 
ing ttw»llfimng,ain'atly rneiilioiied. Here also the phari'iix must 
hm pxamiiied liiwl (see p. 245), and if found healthy, then the 
l«p\iiv. Hut it whmild he hnme in mind that many diseases 
iiui«inKilyfpli!iKla utillicultiesorpiiin on sivnllowini;, niisswallow- 
injt— pp. 2IU and XVi) may affcrt the Ihrojit and lariiTix at the 
oanie tinie (diphtheriii, hulUir patidytiis, etc.). Paralysis of the 
hTum'iil nerv'e is often combined with ixiral\'si8of the velum 

coi;r8e or kxaiiin'ation. 


(c) Want aj Breath. — Never, or vci-y wldoni, can a diafciiosia 
be matlc as to \hv site of the cause of d>'BiJnoca from Iht- alle- 
gation. Jti laryngwil dyspnoea iTU/Hro/wn is of ten vcr>' difficult. 

((f) Genemt xympUmut are found iti phlegmonous processps 
ttiitl in affections of tlu' kr^'nx wliich follow or aif com plications 
of infectious diHciiwK General syiiipIciinKan^ often very viiriithlc, 
and depend much un the icidividual H'ii«iliveiie£s and on tiiu in- 
tent and seat of the disease. 


A. External Examination. — (1) iufpediov: firoadming of the 
laryngeal region. In goiter, tumours, uijuriee, disjAofemcnl of 
the larj'nx (marked by the position of the ".\diirn')* apple"). 

Respiniivry MotiemnU«.— \u larj'ngcjtl stenosis the kir\p\x con- 
spicuously descends on inspiration, while on expiration the 
larynx again goes up; in trachea} stenosis these movements of 
the larynx an- often abnenl, or ouly alight. 

(2} PaljKilion irt a good su|iplenieiit lo insiXTtJon, for the 
moveraenla of the larynx during swallowing and n-npiralinn arc 
often better felt than they can he wen. Tin- "stridor" pn-.'icnt 
in stenosis is also often ijcrccived by placing one's finger on the 
larynx. Examination of consistency and tendonicRs (very 
marked laterally in perichoridritls of the arytenoid cartilages); 
crepitation (in fraetun-s), which should not Ix* coiifouiided 
with the normal grating si'nsations souietimes felt on movements 
of the larjTix (due to the friction of the superior horns of the 
thyroid cartilages with the vertebral column). 

I. Testing the Function.^fa) Air PermeahUity. The air- 
passage of the larynx and trachea may ho. narrowed or blocked. 

1, Suddenly, by the m^pimlion of fon'ign Ijodies, spasms of the 
vocal conls in talK'.s, etc. 

2. Within a reUitiveltf short lime, in acute inflammations 
(phlegmon, oedema, or diphtheria) . 

^i. Gradually, in chronic afTcctioits fluberculosifi, syphilis, 
aclcronia. in hilateral paralysis of the "postici," and compression 




of the tmphca). (For dclails of lan,*iigral nntl tnicheal stenosis 
see yper.ial Part, p. •lOS.) 

Narrowing of tho air-passapp- rcsiiltK in dyspnoea, which is 
the moH! severe the gi-cater the ohMlnicltnn ami tlie qiiickpi' it 
is developed. In a slow and gniduai lievehipineiil, tlic subji't^- 
tive symptoms are comparaliv('ly mild, and in obvious contrast 
to the objc'Ctive iinditiga, provided that the patient has remained 
quitt. The patioiit uauaily adapts himself t« the frraduaJ reduc- 
tion of air supply. But any bodily effort, i. e., runninR up and 
doiiVii staire, dottiestic work, etc., at once causes dyfipnoea, owing 
to the gn'fttcr netrd for oxygen; and then the dyspnoea may 
be incrwiaod to cyanosis and even occasion asphyxia. The greater 
the dj'spnoea, the more pronounced are the signs: The move- 
ments of the hirynx are greater and are more easily seen and 
felt (see above). On inspiration a .stridulous noise can be observed 
(panting, "sawing"), the so-called "stridor," which is duo to the 
friction of the air, and can be felt at the place of origin as a 
" f remisscmmt cataire." Ry this sign the site of stenosis may 
often be determined. In marked dyspnoea respiration is deeper 
and slower, and i» combinc^d with the action of all the auxiliary 
nuisole* of the nose, neck, and thorax; the noistrils arc blown 
out at wich cx|)iration and dniwn in during iiispiRilion, and Ihi5 
jugular fo.s.sii, the costal margin, ami (tie eiisifonii pnice-ss an? 
all drawn inwards. If the stenosis ixrnysts for a long time, the 
heart heenine.s involved and show-s signs of incom[)i!t<*nce; 
respiration lii'cornes sliallimiT, its rate is inereaseil, and thf pulse, 
at the beginning full and slow, becomes rapid and feeble. 

(fr) Examinntiim of the Voire. — The [ibj-siologieal laws of voice 
production teach us that we must expect an allemtion of this 

1. If the vocal cords do not vibrate stronj^y enough, because of 
the blast of expirnted air being too we^k, e. g., in generaJ debility; 
in diseases of the organs of the thomx or abdominal cavity, which 
are apt to impede or shallow the respiration, in tnicheal stenosis, 
in diaordei-s of mobility of thejarynx, etc. 

2. If the vocal cords are not approximated closely enough to 
each other or vibrate in a faulty manner, either from mefluinirat 
hindrances, e. g., malformations and deformities of the vocal 




conls thcmselvps or of nelghlx)umig organs, in particular, of ihe 
posttMior hir^'iigesJ wall; in swelling, iximour, aud dcposils; 
or in hinclranRt?s of a paraltjtie nature, e. g., paratysis of the 
adductors or tcnaore. \'ery often aevcraJ of these caus(« act 
in comlilnation. 

The alteration of voice may be very slight, but in other caacs 
again is so pronounced and characteristic that on experienced 
physician is at once enabled to a diagnosis fnjni il. Thus 
one speaks of koar^cnr^!* (piiniphoTiy, rauecdu), if the voice is 
accompanied hy noises or if it smuruls iiiipun-. rough, hiir>ili, or 
obscured; of aphmiia, if no voice at nil can be prodiiceiJ; of 
double wire {diphtlioniii. diplophnnla), if two Rniinis can be 
heard sinuilluneously; of tfeakneati of (he voire (phunasllienia), if 
thevoieesoundswejik, tired, tunelt-ss: of piiihologicid "ea«tnile" 
voice, or pathological fulKetlo, if the voice in mm fn'tpn-nlly 
changes from the ordinary chest voice to the high-pitched fal- 
setto or head voice, or sounds constantly so. 

Apart from tracheotomy, aphonia is met with in lesions of the 
motor nerves, imrticularly in hysteria ; or in marked anatomical 

Double voice (diphthonia) occura in tumours or more or less in 
circunuicribed thickening or swelling of (he vocal Hpa, which are 
thus divided into two sections, vibrating differently and in- 
dependently of each other. 

Phonasthenia is frequently caused by severe general disease; 
but apart from this it points with great probability to a motor 
lesion {pan-.si8 of the recurrent nen-e), and in the latter case the 
voice is weaker, owing to the Wivstc of air during plionation 

Wliilr we are occupied with the examination of the voice, wc 
imisl. :dso notice any cougliing which may be present. 

Coughing is a defensive reflex action against foreign bodies, 
aceuniul«t*'il secretioiis, or other impediments of respiration 
(set- p, ;151>). In catarrh of the larynx the stimulus to cough, 
apart fruin hidiviilual sensitiveness, is greater and nioiv fn-- 
quent, while the coughing itself is more forceful and sj^as- 
modic in direct relittion to the drymcss of the ejitarrh, vi/,., [he 
less secretion to be removed. In that sense the cough is spoken 



of as dry, in comra-xt tn a humid, moist, or loose cough, whrreby 
masses of (wrrt^tion are liischargvd. Diy cough souniLi empty, 
hnllow, and roitf;)i ; u loose cough sounds more full . 1 1 is not jxissi- 
ble to judge by the smnd wheth<?r the rough is Linriigeal or of 
d«'[MT origin or is excited by other o^nns (dosc, pharynx, ear, 
uterus, eic). 

In the I»rynx it is the posterior wall, the intcrar>-teiioid piirt, 
which is the most irritable: hence the severe cough in diaea»c of 
this region. Xext ui order of iniportoiice comes the n-gion of 
bifurcation of the trachea as being specially irritjible. I^ir>-ngeal 
cough "is distinguished by its dryntws ('braxMinrss'), it is more 
like a scraping to clear (he throat." A raucoiw, loud, Ix-Ilowiiig 
cough points to aubglotlic changes, and an aphonic cough to 
excc?ssivo swelling of the vocal cords or to bilateral ]wnilysi.s of the 
recurn-nt ner^-e. in hysteria, coughing rctnahis loud and full, 
while the voice might Ijp roiiuced to aphonia. Some patients 
cough only at night, when in bed and King down, owing, perhaiis. 
to the collection or shifting of secretion: others chiefly on 
changes of temperature or on inspiration of vitiated air. " Ner- 
vous cough'' is vcr>* obdurate, and tends to uicreasc if the pa- 
tient knows himself to be under observation, and then it diniin- 
itihcs if hisattention be distracted: during sleep it ceases entirely, 
though not always. 

2. Internal Inspection. — Tlie examination must begin with 
an exact exploration of the mouth and Ihroat. and, in particular, 
of those parts cldw to theadifualarjaigis. 

(a) huHncl LaryngoH'opy. — One should not direct the atten- 
tion exclusively to the vocal cords, a niistnko which is committed 
by all beginners, though they arc, by their sinewy white appear- 
ance, the most conspicuous parts. The lateral (outer) margins of 
the vocal cords, on thenthcrhand, which piu« towards the ventricle 
of Mirrgagni. appear, if they arc at all visible, of a velvety red. 

In smokers, drinkers, and people who s|)eak much, the vocal 
cords are of a morereddish-grcycolor.ljut, on the whole, the color 
depends on the source of light which is employed: marked pal- 
lor, due to anaemia, points to tuberculosi.". TTie margin of the 
epiglottis often shows well-defined white r)r yellow sfKits, cor- 
rcHiioniliiig to the cartilage shining through the mucous mem- 



branc, or to the mouths of nmcoiis glands, which nrc often 
mistaken by the incxpcrit^ncpd for "tubercles/' 

It has boon already ix>inted out that the vocal cords must be 
cxa:iili]i-d during ri->i|)iriUioii and phoimlioii, so that by ttiis way 
the nwtility of thi«i> iiiii«)rl«nt Ktrut^turi's is tvwted niiJ it is 
asrcrlnincd ■vvhrtln-r Imlh vorti\ cords act hannoiiiau>Jy, or 
whether (irie Kigs behind in adduction tir abduction, or is iUto- 
gelhcr iiiiiiitibili', or is fixed in a certain ptwitiim. Immobility 
of oiii' voeal cord occurs in diwase nt the corresponding ary- 
tenoid ■cartihige or its joint, and in |i;iralysis; sometinuw also 
in gr(>8*isfti'llingof llie jMsU'rior hiryngc'd wall. 

Tlie serrelum nuiel be noticed. Nonnully only a small amount 
of nuicoiis eeeretion is discharged. In patholoEical conditions 
the accretion alters, ^mall ma-^scs of mucus may frequently 
be Been on the vocal cords, or threads of mucus are stretched from 
one lo (he other. The secretion may dry up, forming crusts or 
scabs, which may be seen covering the vocal corils and jxisterior 
laryngeal wall, causing hoarseness, pain, and even dyspnoea. 
In such cases the secretion is mostly derived from the nose or 
pharynx, and mainly from an atrophic rhiiitipharj'ngitis. Acute 
larjTigitis at the beginning also is liable to such a painful exsicca- 
tion of its secretion. If haemorrhage is found, the lungs and nose 
must be examined, as the larynx here plays a secondary part. 
.Small haemorrhages |)oint to erosion or ulceration; an ofTensive 
smell, to diToniposing or gangrenous processes (carcinoma). 

IndiaK-t larj'ngoscopy is sufficient for the majority of cast*. If 
there areehangeson the ix)stcriorwalI, Killians method will have 
to he einployt^l. In tilt ratio n.s m- ulcers on the [josterior wall 
are ino^tly lulxtrculur in natun-. 

Only in unique instnnces will the technicidly difficult methods 
of Rosenberg, ler Kuile, and Oerber have to be resoiled to, 
e. g., in subglottic lurnonrs or angiomas, causing haemorrhage, or 
in disorders of the voice which cannot be satisfactorily explained 
by what is found above the voeal eords. Tbc number of cases 
suitable for that kind of examination is ven,' small. 

(6) Avtweopy. — ^Direct laryngoscopy (sec p. 378) is used 
chiefly in children if examination by mirror is impossible, and 
also Id adults, if a view by the mirror caimol beaHained.csiMtfi- 



ally if the jaws cannot be openwl wide enough (lockjaw), or on 
arcouiit nf rftrophar}'uge-al liiniours pnijfctiiig too much and 
obstructing the vien-. 

Tracheoacopif (see page 379) is indicfited in tmehoal stonows 
(goiter, intratraeheiil tumour). Tracheoscopy ulono pc-miils of a 
clear idea of the site iind degree of the obstruction, and whether 
an operation is necessary or not. Inspection or palpation from 
outeidc is not always satisfactory. 

BToncfuttcopy (sec p. 379) up to now was only used in those 
cases where, according to the anamnesis aiuiccrtAJn other signs, it 
wa« assumed that a foreign body had become lodged in one of the 
bronchi, liefore performing' Imiiichoscopy, the Rdntgen rays 
should be applied. How far bronchoscopy is ustrful in other cases 
is a question for the future. 

3. Palpation of the Interior of the Larynx. — Palpation, in 
the fonn of probing, in order to teat the consistency, mobility, 
and seat of some new-growth, is a useful su|)plenient to inspec- 
tion; this should be done mider local anaesthesia. Tendt-niess 
can also lie discovered by the probe, but this, of course, without 
local anaesthesia. 


I- Hose; Houth; Throat. — Disea-M-s of the larynx are often, 
in just the same way as pharj-ngeal affcetions, of a secon- 
dary nature. They fnijneiitly fnllow an affection of the nionlh 
or throat, or are continued fmni the nose or imst)phnrynge)d 
apace. We must bear in mind this efjnneetion, and combine the 
jarjiigoftcopic examination with an inspection of the mouth and 
lliniat {S£i^ p. 3B-I). Freciuently the affection of the larynx and 
traehi'H only forma a part <tf a descending catarrh of the u]j[ter 

2. Lungs. — The relationship between larynx and lung appear.'* 
in I uben-ulosis. The conditions of the lungs in many cases 
gives UK lh(' first indication of the true nature of the laryngeal 
affection. In haemorrhages one should never omit an examina- 
tion of the Unig.H. Larger quantities of blfKHl, which, for instance, 



exceed a toflsjxjonful, nrc seldom derived from the laryiix it=elf, 
hut mostly from the lung or nose or misopharynx. 

3. Central N«rvous System .^Ncr\'ous disorders, sensory as 
well ae iiioLor iftfionti, are very often due to ccn-bral, medul- 
lary, or spinal disease. Hyfllcriu pluys a gii-al role in laryngeal 

Besides the central nervous syst^cni, various other organs also 
in the region of the neck and clicst, owing to tht^ larger an*a 
supplied by the vagus, are someliines the ejiuse of rier%'OU« dis- 
orders in the larynx. In sueh a case one nuisl tiiseover it by an 
exaiiiiruUion of the entire body. 

4. Reflex Disorders. — The laryiLx, like the nose, i.t also apt 
to excite reflex neurosis and disorders in other organs, although 



Ill lnr>-nj;eal and tracheii] iiffeetions, as in those of the nose ami 
throat, general treatment is of p-eot iin(>ortancc, often render- 
ing local treatment piiperduoiifi. if, indeed, as m the first stago of 
eatarrh, local treatment be not n-ally hiinnful. In many cases it 
suffices, and this is markedly so in nffectiona of the laiynx and 
trachea, to exelude every eaiise of irritiit ion. —change of tempem- 
ture. alcohol, tobacco, etc.,— in order to procure restoration to 
health or at least great improvement. We must here emphnsise 
again the need of eare, so as not to be misled into overdouig local 
treatment in the too cireuniseribfd jmriiew of the speeialist, or 
else the same fate will overtake one, as it did that lar^Tigolojiist 
who once, to a eirclc of his colleajrues. showed with proud self- 
ealisfuetion the lar>iix uf a i)hthi.<?icjd patient which he had 
treated by caustics and curette, and concluded his demonstra- 
tion with the wonla, "the larynx is cured; but — (Ac pcUicnt 

We do not. mean to say nnvihing against reasonahlfl local 
treatment in a given case; certainly let it be "est modus in 
rebiw." It I* just the rhinologist and larjmgnlogist who should 
resist the U'niptalion of an instruniental techuic, which is 


growing so vastly just now in the field of their specialty. One 
must never lose sight of the connection with general medicine. 

Among the general measures to be taken in diseases of the 
brynx and trachea, especially in eatarrfwtl affections, balneofher- 
apy must be nietitiom-d first. Tliis is almost traditional. 
Climatic and hydrotherupt-utic and mincnil water treatment are 
the rule. The some principles as in the treatment of phar\-ngeal 
disease are here available, but wc should like again to point out 
that all thcsf! cures have mostly the efTect cf only changing 
and Vx'ttering the general conditions of life, and so act indireetly 
on the ejisily influeiici^ larynx. 

Willi rcRanl alwi lo diel, we nuist refer to previous chapters. 
The larynx coniew («j tnuch in contact with the food that regula- 
tion of the diet, just as in nfI(?ctions of the pharj-nx, is necessary. 
The protection of the larj-nx here stands liefore everything, 
and thi.i ix applicable not only to exli'tniil, but also to internal, 
causes of diiwrdcr. Hparing (he vniee, thert-fon-, is Ihe most 
important, and is only contra-indicated in functional distur- 
bances arising from an hy.sterical Ijasis. 

A word on the taking of inttlicines. Sedative-s and narcotics 
nmy l)e used against eough, pain, and spaam; expectomiits, to 
facilitate or loosen secretion, and also emetics and purgatives and 
sudorificfl. Opinions arc di\ided as to the usefulness of "sol- 
vent" and "irritative" expectorants. 1, for my part, do not 
value them nmeb, but somehow or other one cannot do without 
them, and one may prescribe them in eombination witli morphine, 
codeine, and aqua laurfjcerasi, etc.: and eonsequently wc must 
always l>ear in mind that it is the narcotic substance which 
abalt* iiiflanmiation by reducing irritation and coughing, and 
thus indij-ectly diminimlies soeretion. A really useful solvent 
is potassium iodide, which, in many eases, afTords relief. It, however, be cautiously given, as it dlsagreey with many 
people. It may be given {;j-4 in 200 of walcrj, one tcaspoonful 
even,' two houi-w lo adults. 

The following arc useful prescriptions: 

% Inf. rnd. ip^^t'ue ..,„ 0,5:170.0 

I.L(|. nmmoti. nniKftt 5.0 

Morph. nmrijil O.CW-O.CIi 

Syr. allli. ii.l 200.0 

F, M. tiwi. — Uiit; tublmpcxiiiruleviriy iKtilioura. 

TRBATMENT. ^^^^ 39.1 

B, Decoct, md. eenegu - - ■ 10-00 : 175.00 

Lii. uiiinj-on. «ni>. 

Aq. nmycil. .Ha A.O 

Syr. ainipl ad 200.0 

F. M. Sia. — One tableiipooiiiiil evety two hours. 

3. Amroon. chlorid 5.0 

fiiicri. biiwirir. (glycyirhisae). 2.0 

A<|,.Ii^till iid20O.O 

Ilixturn nolvctw. (To this cnn be added 0.03 O.Ofi tnoTph. or 0.2 
oodeia. plioenhat.) 

F. M- Slu. — One l«bleBpi>i>riful wery two lioixm. 

}). Ui). iiiniiiuii. artia., . &.() 

Atj. amygcl. amar. lO.O 

¥. M. Sin. — mflren dro|M in a glam of wnrai stigar vatcr.tliHM daily. 

({, Morpli. rtmriat .ft.16 

Aq. jiiiiyRd. siinar .,.,,Ii.O 

F. M. Sm.— nfiwn dropi Ihrice dniljr. 

H. Codeia. phosph 0.3 

Tiiici. WUiul. ,i.O 

Ar|. nniyn'' «"""■.. 1-VO 

F. M. SiG.— Twontj drops IhrioB dailjr. 

^. Pot. lod 3,^4.0 

Aq. tlMl 200 

F. M. Sio.— One tableqwooful every two houn. 

R. ln(. md. ipwnp O.S : 180.0 

Pot. imiid %XI 

Hyr. winpl. jkL. , 200 

F. M. Sio. — One tab Iwpotm fill every Wo hours. {^JtJumt ) 

In feverish patients who sufEer at the eame time from indiges- 

}|, Apoinoriili. niiir fl.'i 

Mi>rpli, niur ... 0.03 

Acid. mur. OJt 

t^yr. niitiiJ 2llXt 

Aq-dctill ad 200 

F, M. In vitro ftftvo. 

8)o. — Om tablespoonfid every two houn. 

I|. Sol. ftrid.plioflplior. iltt S.O : 180,0 

Cmlein. plinsjiliat. . .O.S 

Syr. mil. iilaci Inuplwrnl lymp*.. 'HhU 

F. M. Siu. — One tablesiwouful llireu tiinesd^ly. (Eicfi/wrsi.) 


B- Inf. rad. ipwac 0.1&-0Ji : lOO.O 

Liq. amnion, aiiia. O.-VS.O 

Syr. oimpl 20.0 

Sio.— OiM- il<<itwrt spoonful ftv^rj- two Imhum. 

If. [>racl. nd, Ktnc^gsit j.O : 100.0 

Lin. ammon. aniiint. ....,.,.,,. ,,...... 

Syr. alth. ad '. I20fl 

Sia.^<>ne de<«^rtHiHHiTi[ul ereny tn<o hniint. 

• Analoguu* to ayniiHiH iiiori (wild niapberr)*).— TruiMfcKflr"* ffalt. 


It. Sol. pot. ioiL l-V-XO : IOOlO 

Ag. nenlh. pip — . 3X0 

Sta. — One Jew "rttpoowhil four tuna dai^. 

Q. Godtia. phmphat. OuOl-OOS 

Aq.<lMim... ad 50.0 

F. U. 8m. — One t««iipoonfiit m ttrt^ttntd tnXtr foor timn du)7. 


(ft) Fomentations .^The technic and indicAtious Tot cold, 
womi, and hot fomentatitnis have hcen described m E'art IQ, 
p. 2>5(), el :fcq. ft'hat has been saiii then- with n'^n) to«Ibea5ES 
of tht' {ih;tr}'nx in |x:^iuciit, cetcm paribus, to uffi'ctiuns of the 

0») Light Treatment. — The use of sunlight. isjieruiUy cer- 
tain Icinds' i»f niys. for tn-Htm<-iit i.'^ slit) in (ho lt>nlative stage, 
and in n'giinl Ut thf^ !ar\-iix, it rtnimiiL*! with th<' future whether 
it viU bv used to an)- greater extent, t'p to the pnseut, re- 

Fig. 125. — l^aryitgeal pWtrodff. 

flwted sunlight has been used in the treatment of laryngeal 
tuberculoeis (.Soryo, Kvnutild). The Hi'mlgen rays idso have 
been tri(Kl in tuberculosis and ninligtiant Itiniours of the larynx. 

(c) El8ctriciiy.— The fnradic and, more seldom, the gnlvanic 
current is applied either in the milder fomi extralarjiipcally, or, 
for stronger action, intnUarj-ngeftlly. In the former the elec- 
trodes are usually placed one on either side of the thyroid cartil- 
age. (See rig. 125.} 

In the intnikryiigral appUwition Ihe one (plate) eWtrode is 
placed outside on the larynx, or on the sternum, and the other 
(button) electrode, which must have an amingemeni to intenupt 
the current, is introduced under guUiance of the mirror, and with 
local anaesthesia, into the larjiix. The current is tnade to act 



after the button of the intraliirvngi'jil t-IiTlrodc* has Wvn Iimiight. 
iiito t!ic exact position di-siinHl. Al fii-sl t.lii' lii-utinciit unisL 
only last for a few seconds, bul lulf-r on the attiiig iiiay be 
extended in duration. 

(rf) Treatment b}f Drugx. — Mwllcaiiients arp hitroducpcl into 
the larynx, in either n fluid sliite, l)y pHinting, or inslilL-itioii, 
or in the solid form by iutnifTUiliun, and for cuutcrifiatitjii; or, 
ngain, atomised or vapourisod by sprays or by inhalation. (Sec 
Fig. 12(i.) 

The Ittripix in painted uiidi-r the guidance of the mirror, and 
very nervous ])atient« ought to Ik* treated — 
at least al the hegiiniing— by Imving the lai^ 
yiix pre\-ioLJsly cotwnised. Painting, which 
w done without the aid of the mirror or by 
the {latient hirnseU, i» nothing but u^ii'h^ss 
torture; the brush pmbitbly never enterfi the 
larynx, whieb may In.' considert'd, with due 
respect to the crudeness of such nianipular 
tion, u mlher lucky circunistiince. Owing 
to the difficulties of clcajiJng a brush, it is 
better to ust^ in itri plaee small swabs of eot- 
toii-wool which arc souktxl with the mediea- 
nient and fixed on a holder. (Sec Fig. 12)4.) 
tin-at care iuumI In- taken in intnidueing the 
Hponge-holder lu aa not to touch the tongue 
with the unpalatable fluid. On siH-itig the 
swab in the image, the handle of the liolder 
niuiit l)o lifted, and while the patient phon- 
atea, (he Hwab is quickly inwrted into the 
lar>iix and brought int^ contact with the 
part to be painted (see Fig. 127). 

In oi-dor to augment the effts-t, the itustniment may lH^ ninvetl 
to and fro. and so the Huid is thus bmught into more iiiliniatc 
contact, with the parts conecnied. and I ventun- 1o sjiy that 
the massage exercised by this latter modus ojwraiidi lum al«) in 
itself a beneficial influence. 

LvktT afipnoves very nuich of the therapt^utie valup of this 
intrnlarjiigetU ninssiige, particularly m eaaes of ehitjniu catarrh. 




a b 

fig. 126— Spongfc 
lioUlpr fur llip 
larynx: a, Af- 
Iw Hrryng ; U, 
aflcr liaiU 


the niodicfimcnt drop by drop (e. g., for local nnapsthosia), or 
ill ordor to inject a larger quantity of fluid at once, e. g., menthol 
in tulM-nmiur lUci-rs, or tfpid water for the softening of cnists. 
(.See Fig. 128.) 

insulation is done with a suitably bent meufflator: but I do 
not think that this can replace painting, for it dooe not allow, 
as has btieu already pointed out (see p. 253). an exact localisation 

Fig, I2S, — LarytigMil syringe. 

of the application. I only use iiisufflution of the larynx in caace 
of widi'ly spread ulceration.* CSce Fig. ]2i>.) 

The larynx, as i.s also the now, may be cauterised by silver 
nitrate, chromic or trie 111 oracetlc aeiii, under local imaiwthi'Kia, 
and guidance of thp mirror, by nieanB of s|H'cial cauteriserM. 

Complicaiions FolUnring I.nnil Methods. — The hirynx rrwta 
to aJI thwjt iiitnilarynm-al manipulations in laure or less viuUint 


Fig. 130. — Ijiryiigval insiifllucor. 

matuier, «. j;., by cough, xometimce so aggravated as to eauae 
vomiting; by severe irritation, a sense of seratching and burning 
in thtr larviix, and t4|iii>-tii of thtr glutti.-?. CVaighing iiK-ans that 
the inedicatncnt lui-s rejilly ronic into contact with tlie ]ar\'ii?t. 
If, however, the patient roughs very much or complains of a 
8cn."!Bition of turning, he must Ije onlcred to take mmu- pepjKT- 
niiut tablclv or menthol [Mtstilij. Spiistn of the glottis \s some- 

*Scc ttlao fool-aote. p. 253. 



what alanninji, b\it not danEorous; the chief thing to bear in 
tiiiiul is that the physician sktiuid not lose kix head; hv ehoukl 
ritliii thtr paticiiit, and siuack him vn Ihi- Ijocii, pat his t^houlders, 
etc.; uiid if the iittark dot-s not (juickly piis-* inviiy, lie should 
compress tht' patient's nostrils while the latter is riinde tn take 
sevemi dei^ii liri'atha. ]n other vases the [mlieiit should bu«i to irtoi> breathing as long as he can, or lo take ii 
mouthful of unler. As a rule, all ihcsi' roi9i|)lieatioiiR riecur 
only in very inTVuus palienls on llie first oeeasiaii i»f Ircjitrnent; 
and coti!!HH)ueiitly, previous anaesthesia of tht; niiieoiiK tiietiibmiie 
is to be stroiijjiy reeommondi'd. The Utrynx Utier an becomes 
very tolerant of all manipuliitions, and docs not any longer 

react even by coughing. The 
patient ia adviacd to keep 
silent for alwut a quarter of 
an hour after the painting, or 
he is ilirecitcd to »[K-ak. only in 
a whiK])er. 

Inkalnlion — (n) of atomized 
fliiidn \» (lone by means of 
special Hprnys worked by two 
bulbs; but, better etill, by 
one of the numerous steam 
inhalere, which make steam 
the vehicle of the fluid (at- 
omised) medicament. The inhalatoria existing in eo many 
watering-places aiid health-resort.s work on thi.'^ stme principle. 
There are many apparatus coiistnjctwl for inhalation by Bitlh- 
ing, W'assntufh, Henjng, Nicnlai, etc., eaeh of which is sjiid to 
have special advantages, \\hvn inhaling, the patient should 
bend his head hark and streteh his tongue out, but, nevertho- 
IcKi, the greater part of the ^Tiijourised fluid will not reach tho 
la^>^lx at all, but will be retained on the nmcous niembnine of 
the pharmx. If it a'aches the larynx, coughing will be excited. 
After the iiihalation the patient should remain in the room 
for a short while 

(fc) Of <fa.s€s, is generally easier and more cfTective, because 
the raucous membrane of (he air-pass:iges is brought into inti- 

Fig. 130.— Apparatus for inhalulion. 



mate conract with the inspired air (gae). The mcdicanipnts 
arc volatilised, (vapourised) by proper instruments iSanger'i, 
Ronenberti's, etc., vnpouriHer). 

Tlip bcnnfit nccming from inhalation must not lie ovprratod, 
mon* CNpocially the inhalation of atomiscil nirdimtcd Huids. 
Their chief i-PTifl is due to the heated va|»urs. It i>, lliert-fore, 
quite siipi'rflutms to [m\seribp all possible sorts of substimccs 
for the imrpose of inhalation, but one should eiuloavour to assifit 
(lie Holvciil ttelinn nf the steam. If one deHii-es Ut stimulatP 
weri'lioii or to ioowii tlie Bi*ai)s and thuH iiflfeird ii nmw fn-e 
rcvpimtion, a little nUt of Knis or common flalt may be added 
to tlic water in the inhalation apparatus; or a 1 t^o 2 per cent, 
solution of bicarbonate of soda or borax or tar-water (aq. picia 
and pure water part, acq.) may be ortk-rcd. The effect of 
inhalation of menthol and thymol is astringent, and, at the same 
time, slightly disinfeetant and dcodoumnt. Peruvian balsam, 
oil of turpcniilie, and eucalyptus, etc., and lately inhalations of 
lignosulphite, have been much recommended; and the vapours 
of menthol have also a decidedly analgi-sic cflTect. 

The Renend practitioner, who hjis no inhahitoria at his dis- 
iwsal, will satisfy himself with ortlering an inhalation apparatus 
for the puqxiBp of atomi[»ing, or in speeial eases, where the deeper 
nir-passages are effective, a volatiHwer, Ainonp the poorer classes 
a jug filled with boiling water, to which some useful drag (turpen- 
tine, etc.) is added and covered with a funnel, will be found 
oflicient. One may alsfj Improvise a ui^efiil inhaler by means of » 
kettle, which, being hfdf filled with water, is heated over the 
fij-e-grate or a spirit-lamp, and then a long paper tube can be 
adjusted over the spout. 

(e) Operative Treatment. — (1) Local Anae^thefna. — For the 
local anaesthesia of the larjTix, just as for the nose, cocaine or 
alypin in 10 to 20 per cent, solution is useful ; the weaker solution 
for the slighter manipulations, such as pain ling, eauterisation, etc. ; 
the stronger solution for more extensive operations; and in cer^ 
tidn ciis^'s, even a .'JO per cent, solution is sometimes necessary. 
To Increase the effwt of the cocaine, and also in order to econo- 
mise the drug, it is well to onaemiso the parts concerned prior to 
iht application of the cocaine by means of adrenalin nolution 



(1 : 1000). I amac w towned to iaalilAfovdrofwor bothdni^ 
into the- larynx by meuM of • eynnge and, alt«r a while, to test 
the roueotifl rocmbraDc with a lairn^cal probe a£ to its sensibflity. 
The etfcet of the drug on the patient is a fecfing of numbne^ or 
"a himp in the ihrnat," which, bow^'^er, docs not tivubli- him 
ao much 80 thi- inainlity to svallow.* If, after five minutes, 
Ux anarathcaia bf nut coniplpte, the tnsCilblion is to be rrpcaied, 
if necewarj-, ttcwnJ titm^. If one dcairs to avoid kII unplcaaant 
inddent«, it ii« good prarticp aJw to render the epiglottis und the 
pharynx (v(4unt polati, tonsils, posterior waS) insensitive. Iii^en- 
sitiventtK of the mueous itiembnuie usually lasts for {I've to seven 
nunut{<«, ami rom>iderHbly longer if adrenalin has bct^ used, 

Al>iHn is Icje poisonous than cocaine and docs not ooutract 
the bloocl-vpssteU, It i«, therefore, very useful if one de- 
nrefi to remove siiuUl tumours nhich arv difficult to attack if 
shnmkco, and in l hit event adrenjilin will also be uiidtisirable. 

Submucous injcrlioiu are supi*riliiau9. 

Poisoning by cocaine sctms to be morr fniiuenl in laryngeal 
applieatioitf than in the nasal ones, and. acconhng to Schtch, 
the poisoning Is due to some [xirliim of ihe solulitm — in spite 
of all pn-caution — having Ixt'ti swHilowi-d and altworlKil by the 
digfxtivi- itrpnas. I have never wen poisoning by aly[)iii. For 
the ayniptonis of nx-ainc ixtiwining »-e p. 23. 

(2) General anne^lhe^in is only induced in exceptional caws, 
where local anaesthesia is not aulficient, e. g., in children. (See 
p. 42.) 


Many instnmients am in IitryiigolngiaU pmct icr, and coni- 
pri«e, apart fn>ni thr pilvano-cAuten.' and othi-r eli-ctnilytlc in- 
Blruments, various kinds of knives, curettes, fnrcri)ji, punch 
forrcps, snares, etc., all of which are fixed on suitably lient 
hatidU'jt and ought to be as slender as permissible, so as not to 
hinder the \-iew of the lar^Tix. 

With n-gard to gjilvano-cfluteriwition and electmlj-sis, the 
same U hen- pertinent that has been said in the analngous 

* Tu hp on the aaf« «id«, and in order not lo be oltmiod by the patient, 
0111- Kbould fwinl QUI tt* him Ihiil kucIi und such n ditcomfort will occur but 
will pajw uKujr. 



chapters on (he nose. (See p. 42, et swi.) As a rule, one floes 
iii)t cifU'ii US' tho paJvano-cautcrj' iii the larynx, if fnr no other 
it;i,soii thiui for the great i-eaetioii it causes; ami ihjiL electro- 
lysis is so difficult to a)>p!y to the kiyiLX, and its pfTect wi slow, 
that it \ti only resiirled to vi-ry orcaiiionaJly. (Sw Tigs. 131 
and 132.) 
Qalvaiio-cauti'risatioii aud (•leotrolyslfi arc chieHy indicated 

Fig. 131. — GKU'sno-eaiuttc bumcr far Uiynx. 

incases \rith viwcular tumours; telangiectases (iiaovl) aiw) readily 
yidd lo the caustoplior. Hrryuij rccoirniirnds elect mlysi-s for 
the purpose of <Ieslroying hard, dirfiisc, tunioiir-Iikc infiltrations 
of a tubprpulHr iiatun*. 
The [iHrlicuIar instruments required will bo described in the 

Fig. 132. — Doublr ncodic for clvctrolyiis. 

special part. Here we desirf only to inipresB eome important 
points in regard to intralaryngeal surgery. 

The patient must l» "trained" before every operation, lie 
must Itecome used to permit the introduction of a large mirror, 
and also if this be done with the operator's left hand; he must 
learn to hold his tongue himself, and to breathe quietly and 



(Ippply and ptionate properly. He must gel used to thi! intra* 
Itiryngi-al probe — »?ventually with the aid of cocaine, etc. 

TTit; iiiBtrurneiits should be sterilised in the ordiiinry manner, 
Aud wanned before introduction. Tlie littter must be done 
always uucUt guidnnccof (he niin-nr, same instruments used for 
dilatation being excepted. One shouUI jilwnys make suro that 
the in.stnimpnts "work" propiTly, tha,t they arc safely fixitl 
to their handli\s, so that they will not refuse to work, or elip 
away ni the c-ritied psyoholcgictU moment. 


In the previous three Parts, ;vhich treat of the diseases of 
the nasal, oral, and pharj'ngeal cavities, a whole series of im- 
jxirtniit [Hiiiit.s ivfcrring to hygiene and prophylaxi.-! have Invn 
dirwu.sfird, which, diffctly or indirectly, an; also applicable 
to the larynx. This can cjisily be undcrsto*>d, considering the 
intimate relations mentioned on various uccaaioiis exi.sting 
between the several portions of the air-piLSsngcs. and it sufilccs 
only to H'fer the reader to the previous chajilcrs (pp. 44 anti 
254). Here we desire only to say somethin); coneeming matters 
which are neei'.s«irily connected with the larynx as the organ of 
voict! pnidufjtiiHi. 

It is quito remarkable how little the voice is eared for gen- 
erally. If there is such a thine as "vocal hygiene," it is mostly 
and chiefly for the appreciation of its artistic value, and may be 
also that the actor is allo\yed to share the benefits of rational 
voice production. That the voice should be carefully watched 
and protected from childhood, only few will believe: and many 
physicians even neglect this very important question. Parents 
think il right, from the pedagogic point of view, if their offspring 
yells as much as he likes. ''Yelling is healthy and expands the" is the u.sual saying. This is, however, true only to a 
certain extent, and the physician should not miss the opjjortunity 
of making it clear to the parents and all eoneerned that, owing 
to tlie great delicacy of the youthful larynx. a.ny continuous 
strain of the voice during tender years produces damage lasting 
for a long [jcriotl, if not forever. This is applicable not only 



to infants, but stUl more to older children. Many children 
fall into the habit of shouting on every occasion and uf yelling 
while under the excitement of playinR. They love hi iniitfile 
the of aiiiimilB, and ai overetrain their own voice, and 
when they have to attend school, do so with an already injured 
vocJil organ. 1 myself remember sevcnil children with nodular or 
diiTuse thickening of the vocal cords who had obviously mal- 
treated their voices by overluud speaking and Mnguig, without 
their parents thinking it necessaiy to restrain them. The 
evil is .igRnivated when, hiter on, m school, the chiidreu with 
such irritable and tipoiled voices have to attend einging. Under 
normal conditions there is no objection lo singing cxerctsta 
in the school-i, for they arc, 80 to say, a form of health gymnastics 
with the objcel of expanding the lungs. Hul 1 consider it wrong 
to com|K'l little children, and, si ill earlier, at home, in the kinder- 
garten, or "infants' &choob," to sing exercises, for there is 
aljsolutely no tmce of a correct utilisation of (lie natural means, 
for all exercises are only play, and the child should sing for its 
own enjoyment. In my opinion the question whether children 
should attend singing exercises or not before tliey go to school 
niu«t be decided in the negative. 

The pmctilioncr'sattitudetowards singing in school is different, 
provided that the vocal org^iiiB of the children arc healthy. 
Unfortunately, voice production in sehools often leaves much 
to be dc-^ired, and it is particularly so with singing in chorus, 
which cnuM-4 a great Btmin, which some children arc not able 
to Ijear with due n-gard to their vocal organs. 

Tf the physician ntjtices signs of vocal fatigueor other disortlers, 
or if his attention is directed to this circumstance by the parents, 
then he should not hesitat* to pmhibit the child from the regular 
attendance at singing, temporarily or permanently, us the case 
may be. 

During (he time of mutation ("breakingof the voice") singing 
should be entirely alwtaincd from. To refrain, however, from 
sp<'al(ing, is not only unnecessary, but it is useless, provided 
that no real signs of irritation, in any degree, are appan-nt.iis 
may easily hjippen. Shouting, of course, should be forbidden. 
and if one is asktxl for atlvice, the adoption of the hw rqjisltr 


is lobe Ttcommended. ■ Sjiccial tn-atmcnt is unncccasar>*. Mak- 
ing fun of or laughing at "iiiuUHting" boys or girls has bad 
coiiscquciirw, Ixk^iusp thry ihcii tr>' to correct what they believe 
to be their own fault, iin<t thereby moru and more stmin thoir 
voice, and so an> likely to spoil it for nil time. Tbey must 
be relieved from the obligntion of school singing, and not bo 
pormitlcd to 3ing until the change of voice is completely finished 
and u definite voice (register) has developed. 

In later years the advice of the physician ia not much wught 
with regani to the rare of the healthy voire, and in [xithological 
caiH'K altso the ph^'Kician haA often to lake a Kctruiulary place to 
the teacher of singing or elocution. Then* is mi old feud be- 
tween physician and "voice prndueer," with the n'siilt that the 
lifltunil developtiierit of thi* voice, and the instmction in sing- 
ing, elocution, and rhetoric, .suffer a gn'at deal. We admit that 
a physician volunteering advice lo his palienl* with regarxl to 
"voice production" slimild not only know thoroughly all the 
physiological anil hygienic aspects, but should also be endowed 
with the reqviired musical gifts and be well versed in the rulea 
and terhnic «if eloi-ution and singing. If he cannot fulfil these 
requireinenld, he should Innil liiiiisi.*1f to advining his palieiits 
■mply concerning hygienic mutters. 

And hen' we atv not coneenutl with the hirynx only, but 
with the entin' apparatus of n'S|)ir«tion and |»honation, a.** can 
easily be understood. In examining the body we certainly 
have tn conBider the condition of the re8pinitor>' organs and 
that of the resonator, which modifies so largely the timbre of 
the voice. (Sec p. IHV.).} Hrat of all, we inuyt consider wliethcr 
brenlhijig thnjugh the nose is easy and cffieirait, and then 
further advice hh to mode of life cim Iw given. A person who 
iimt* his voire on thi" sljige, as a sliigiT or aclor. in public, on 
the bench, in parliatnenl. in Ihe field, or otherwis)-, must l>e in- 
fiimicd that urmuital>le clothes hinder n'spiration. and so in- 
directly weaken tbe ueei-sNir)' blnt«t of air (tight jind high col- 
lars, corsets, etc). (iynimisticH. however, ri'iisonabiy [lerfonned, 
WT very advantageous, ^'lalaii sjH-cially n-eommends rowings 
which is a simple means of allowing a gnuhial and hamionious 
llinrwi-''e of eni'igy in all Ihe muxeh'", mul (■iiU!'i*« the lungs to be 



well ventilatt'd. Cycling, howcvt-r, I do not allow under nny 
circunistttiicos, ami I disagree herein wit h Flalau, because cycling 
is alwnys overindulged in nnd, as Irnhofer rightly says, the 
dust-clouds of the streets, however salubrious they may be, are 
not very beneficial to the respiratory organ;?. The benefit of 
hardening, the consequence of excess in alcolujj and lobacco, 
is flgaiii worth montioiiiiig. A]>ropo» of aJcoliol. I should like 
to say that total abstention fn»rii it, in pcr«3n« who value partir.- 
ularly a glass of \v\i\v or htrr, is rvi! advice, provided thai 
it be not contniindiealcd on account of any chitmic catarrh of 
the upper air-iiassagrs. I have never seen any disadvantage 
from moderate drinking. 

The laws of corrt^el respiration nnJ intonation, the exact 
coordination of the vocal oi^ans, the training and preserx'ntion 
of the voice, the proper use of (ho tliffcreiit registi'K!— these 
and other technical questiong should be read up in epccial 
technical works on the subjecte. 



MalforniatioiiB and defonuities of the larjiix are either con- 
genitid or accjuired. The former are due to anomalies of develop- 
ment, the latter arc caused in extra-uterine or later life, as the 
result of pathological processes in the 3arynx and trachea or 
in ncighlniuring organs, umially resulting in narrowing (stenoas) 
of Ixitli the parttf conccmcil. 


The female larynx is smaller in all its diinetisions than that 
of the male. Nevertheless, men arc sometimes found whose 
testicles have not been fully deveJoiicd, with a suiall infantile 
larjTix and consequently with high. Wyish voices ("tartrate" 
or "eunuchian" voice); on the other liand, tliere are not a few 


womtni who an- poneased of un unusually laific larynx and low, 
dofop, innnly voices. Dt^ecis or tho fomiAtion of fia^ums aot 
infrwtuwitly occur iti (hp p|)iplottiif. ilw margin of which then 
apprnrst notrhed nr bifid. I rfirii>nii>rr n pntietit vrhoso epiglottis 
luid the shaiH! of a myrtle leaf. The om*-ga (iJ. jew's-har;>-) 
i^pcd cpiglotlta baa heen oJready mcntJODed as a himlnuicc 
to laryngoscopy. Maiiy other altt'rations in sbniM- are not 
cungenitid, bub are acquired aa the result of ulccruliou or 

Tho thyroid cartilage is somrtimcs dc\'iatcid or itlti»i'it unequa] 
dfv<^[opnieiit of its wings, so that tho larynx lias Cjuile an asyvt- 
inflripjil fomi. In suth a rose the rinta glottidis L< more or 1ms 
oblique, and this is brst seon during phoiiation. This "physio- 
lo^cal obli(|uily" must not he confoundc-d with :i petholojincal 
one, seen Boniclinu-s in unilateral piiralj'sus of the n-currcHt 
neive. In the tatter ca» obliquity of the hma is caused by the 
budthy vocal cord encroaching on the middle I'me during phurur 
tion, in order to effect a better closure of the glottis, and this 
may go so far tlint an actual crwifing of the two vocal conls takes 
place. Such an overcroasing of the vocal conls may also occur, 
however, under nontiul conditions, as I have noticed on several 

The arytenoid cartilugi-s then stand, not side by side, but bohiini 
one another. 

Diapkragma /^n/nj7i>.— Sometimes, and nearly always at 
the snlcrior conmiissurc between the vocal cords, and still more 
frc<iucntly underneath thcni, » membranous fold may be noticed 
M-ith itc free concave wlgr dircetr<l iKickwunlw. Acconling to 
V. llnrwrmimn, thi.s coiigiiiitaJ fornuition (larj'ngenl diaphnigm) 
is the pniduct of inlra-uteriiie iiiflanmmtion. Other authors 
maintain that it n-pmscnls the orgimised n-maindcr of the 
epithelial mass, which, arwrding to Rnth. fills the foetal larjiix 
up to the n'ginii where, later, tlie rinia glottidis appears. Ro^'en- 
berg reports of a ease of double diaphrc^mi that one of them 
wiw expanded between the arj-epiglotfic folds, and the other 
Ix'neatJi it, bctwwii Ihe vocal eords. The larj-ngeal diaphragm 
does not cause any trouble, espocially if the mcmbnine lies 
below the vocal cords and sinks dois-nwards like a pouch during 



phonatiou. If the dinplirngm ievciy large, extending far back- 
wards, plionation and respiration will suffer. The troubles 
caused by acquired membranous adhesions (through syphilis, 
diphlhcria, scleroma, ctcj arc vtsiuJly much more pronounced, 
for the membranes are tiiorc rigid than the congenital ones and 
impede, not only tlic abihielion necessary for respiration, Ijut 
idso the adduction of phoiiation. One case of a congenitai 
rrietnbrdne on the posterior larj'ngeal wall haJ! iM-en recorded. 

Vetiirimlar Laryngoetlc. — Morgatjni's vcnlrieU- has bi'i'iii found 
enlarged like a pouch on one or iifith sides, and Imlglng Hko a 
heniia into or outside the larynx on pressure or coughing. 
A supemuniernry ventricle (vcntriculus tcrtius) of the anterior 
laryngeal wall is also on record. 

rracAfi(j<:eie.— Formation of asac isoftcn found in the tracheal 
wall. Two forms may be dialinpiishcil: in thecongenital tracheo- 
cele (diveriicuhim trocl)eae)a part of tbi' traeheiil mucous mem- 
brane is seen to bulge or insinuate itself between a gap in the 
cartilages, or it may be a real rudimentary bronchus, wtuated 
as such always on the right side, and showing all the con- 
stituent parts appertaining to the tracheal wall. There is also 
an acquired fomi of the tracheocele, which, is due to injuiy 
(punctured wound) of the traeheac; or it is a cystically degener- 
ated mucous gland, occurring sometimes in chronic bronchitis, 
and ia «nglc or multiple. 

The diagnosis of tnichcoceI(? nmy bo made if wc find a soft, 
round tumour bulgitig out from thi' trachc-a during roughing 
or on pressure exercised on the trachcn ; nr should wirh a tutnour 
be already presmt, it will incn-twe oti coughing.nnd if compn-ssed, 
will colhipso with a sibilant sound. 

Treatment. — Many (if ihe tnalfomiations desprilied arc only 
aecidentally discovered, perbajw at a postmortem. This 
showB that they need not necessarily be treated. Traeheiicele 
and diaphragmatic fonnations, if Ihey eau-w tiymptonis of steiio- 
ffls or impede the voice, may be oijcrated upon. It is often 
suHici(^nt l<» divi<le the membrane and aftcr\^•ards to melhoclically 
dilate the larynx. (See later, p. 427.) At. SrhmitU recommends 
the removal (if tlie edgf-s of the membrane after division, by 
means of a double curette, and then to continue with dilata- 


tion If the membrane (diaphnigm) is not too large, simple 
dilatation is quite sufficient. 

Wo h: 



iL' n;ive already iwintcid n»(. tiiat crnRpritfl! mnlformations 
Ctltni)hr.iK"'n tinynRi?') simi'times also give rise to ctenosts, 
Imt ill the great majority of ca»w stenosis is acquired as the 
nwilt of piitliiilogieal processes in the larynx or traehe-n in extni- 
utfriiie life. 

LnryiigenI stenoges are nlmoet alwayis due to iiitralarynge^il 
causes: extmlaryngeal processes very exceptionally lead lo 
stenosis, but tend rather to displace the whole Iar57ix. The 
trachea, on the other hand, being much more clastic tlian the 
lar^Tix, and this elasticity is still more increased by its muscular 
post^^rior wall, yields sooner to the pressure of extratracheal 
tumoura, particularly if the latter surnnind the trachea, which 
then becomes narrowed. But simple displacement also of the 
trachea is often observed. 

]n the following table wo have endeavoured to arrange the 
etiologieal points into groups in order to elucidate the sun'cy: 

(a) Aspiration of Form^n Jiodies. — 1, Derived from the out- 
side, e. g., coins, buttons, stones, pins, uctHlles, bones, fish-bones, 
fruit-stones, teeth, etc. 

2. Derived from inside, e. g., blood, food (vomiting during 
general anaesthesia), pcdiclcd polypi in the neighbourhood of 
the aditus laryngis, etc. 

ib) Injuries.—l. External, e. g., contusion, fracture, wounds, 

2. Internal, e. g., causticSj scalding, operative lesions, etc. 
Injm"ies do not often directly cause stenosis, but lead indii'eetly 
t<» it by their consequences, \\i., haemorrhage, absc^ess, oedema, 
emphysema, formation of membranes, cicatricial contraction, 
adhesions, etc. 

(c) Diseases of the lAmpntfeal WaUx. — 1. Inflammation of the 
mucous membrane, particularly the phlegmonous, exudative, 
fibrinous, and subglottic forms of bnammation. 

2. Oe<lenm. 

3. Periehondriti*. 


4. Infiltrative and ulfci-ative procpssc*, e. g., tubpfpulosis, 
syphilis, typlidid, malleus, loproay, scleronm. 

5. Npw-Krinvth. 

(d) (JranitUition and scars. 

(e) Nenvus Disorders.— 1. Spasm, e. g., laryngismufi etridulus, 
spaani of the glottis, tabetic crises. 

2. Piii-alyacw (Ijilalrml iK)Stiou» paralysis). 

if) J'athni<Kfical prtice.'i.sen in neitjfihourituj organs which caiae 
stenosis l>y pa'wurxr on l.nichcn or jarynx, 

«. Of the adituM liu'yugis, e. g., inflainmation or tumour of 
the base of the tongue, foreign bodies pressing on the epiglottis, 
n-tropharyiigeal abscess, and tumour of the laryngeal part of the 

p. Of llie larynx (very seldom). 

r. Of the tmchca. 

1. Strumous tumour (gnitrfi). 

2. Ace\irisni£ (of the aortic arch). 

3. Abscofis (rctroviscrral abscesses). 

4. Ne\v-(jrowlh (of the oesopha^^us, etemum, vertebral column). 

5. Swelling of lymphatic glands. 

6. Ilacniatonia or haeinorrhage. 

7. JVrsistrnt thynuis. 

Pathology. — How .stenosis is produeal by Ihe above various 
pmeesse^s, .iriil in wlmt fonii it pnwntti itself, will be shown ui the 
following eliaplcrs on ibcw^ sixtial disie-ases. 

Coneemirig the iinrnnving or olistruetion of the adittu 
laryngis we n-fer to Parts II and III of this Ujuk. We sliatl 
herE> only ileal with tboso fnnns of laryngeal and tracheal sl^no* 
8W which present dislinet features as the consetjuence of previous 
processes, viz.: 

1. Stenosis from granulation. 

2. Stenosifi from scar^. 

3. Stenosis from coniprcssion. 

These three gi-oups reidly Ix'long to the great department of 
internal medicine and general surgerj', but we will discu-ss them 
here Ijecause they may oonie b<'for[* the sjjecialist for laryii- 
gos<'opie or Iraeheoseopie examination. 

1. S/eiMww ResuUintj from (JranuUitiom. — After tmrheotoiny 



wc fn'tiur-nlly sec jTraimlHtions nri>iing in tht' subglottic region 
or in Hie aiif^ln «jf tlic waiiiuLs, which owe tht^'ir origin to ihi* 
irritation ciiuwd by a Iik) long or ii bjully fitliiig fnniilii. These 
griuiulatioiis are apt t« huidor i.hc> wii-htlriLwat of tlifi cimula 
(deratiuleiiieiit), or they may obslruct, ilu' traclini to siich a. 
dcgTL'e after the rciimva.! of tho csuiula tliat f«'v<'r«.' dyspnoea 
a:id even death from suffocation might occur. These granula- 
tions are prone to be aepiratt-d into the trachea by tht- current 
of inspired air, whore they art; then liable to suddenly mveU and 
become oedeniatous, a? a contjcquence of the negative pressure 
present m the air-tubee during inspiration. In other cases gran- 
ulations are formed, in necrosis of the miieoua meuibmne. as 
th(; result of the constant pressure exercised by the canula, or 
they are the consequence of ulcerative processes, usually of 

Fl|[. 133.— FitiroLiit Imnds in the 
trncbcu (nftur Tiircfc). 

Fig. 134. — Aiitiiilir vIciionU of the tra- 
ctiea lithix Tank). 

diphtheria. Fin.Hlly, the gninulations undergo nlrojihy and 
shrink, leading to stricture and 8t<?noHi8 fnim tJjp formation of 
scar tissue (see below). 

We desire to again emphiiKise that the trachehl cartilages, 
divided in tracheotomy, ai-e drawn inwanln like a valve with the 
in«piratory air-cuiTent, and thus are liable to cause stenosis, 
iiiorir eK|x«-ially so if the ineipion has been made too lengthy or if 
the cartilages have become atrophied and softened from pi-o- 
longed pn'Hrtiire lif the cnnula fehnndromalacia). 

2. Stetwsis Jrmn Srnr Tissue (Strictures, Fibrous Stenoins) . — 
Tn tlie larynx as weJl aa the trachea strictures oreur almost 
always as tJie result of syiihilitie ulceration. The ]ar\7ix, 
however, is nuieh oftener subjwt to strietuH' than ihe Iraelica. 
(Sw Kig.t. 133 and 134.) 



The scars may he. wjiti-il in \\iv kiokI, vjirird places; they 
may form a kinci of diaplmtgm bftwrui \\u: vanil iMinls, ami 
further down, tkrcp in tin: trnt^liwi, whicii they iii:iy nsin-ow 
in an annular nianiuT or obstruct so as to leave only a sniidt 
apprture. In some piilienls of my own, who had bin-n thn siib- 
ji'cts of tmchi-oloniy whih? still young, the fibrous bimd prajfclfd 
more or less from Iho anterior tmcheul waU into the lunit'o. 
In one of these cast's there was, in addition, such a thickening of 
the epithelium of tho posterior loirngoal \vall that the lumen 
was constricted to a wniall conical oix-ning. .Stiniotirncs Ijoth 
organs flao'nx and trachea) arc affected, and 
1 he distortion pnidncrd by the- fibrous scars 
might be so pronounced that oiientatioa is 
reudercd difficult. 

If the trachea alone is diseased, stenosis 
mostly occun* above the bifurcation. Tuber- 
culosis, ulcenition duo to enteric fever or 
diphtheria, less often give rise to cicatiiciol 
contractions and strictures. In tho case of 
cntcrica it is tht- perichondritis which leads 
to atcnosts fniin the fornialion of cxtcn»vc 
scar*. Injuries also which have cniLsed con- 
siderable lesions are iijihhi to eon.slrict the 
tmcheji or larjnx by reason of the shrinkage 
of resulting .scars. 

.S. Stenosis Throutjh Compreyy-imi of the 
Trochee. — In tho first line stand heiv the 
diseases of the thyroid gland, particularly 
the cystic goitres, which in n^ird to their scat give rise to 
compmspion of the upper or lower .section of the tmehea. If 
both lohi's of till- gland arc enlargi'd, the tmcht-a is conipiv.«iS»-d 
on both sides like n «wnnl wablmnl (.■^•alilrarH form). (Sec Ftg. 
I.'JS rl «*/.) The lunien of the trache.i thru foniis a wnall 
clliprical space or chink. If only one lolie is hypertrophinl, 
(hni the corrcsixHiding side of the trachea alone is coinprvxscd, 
and, moreover, is also bent angiihtrly — ilue to adhewons to the 
neighlwuring tipsue.i. (Sw Kifi- i'-iT.) h\ nnilal;Tal fitnnnii 
(goid'C) the trachea not infre<|uenlly it; merely dwplaoed lalcntlly. 

Fig. 135, — Srab- 
btinl-Hliapptl mtn- 
presHiuii v\ tntctiea 




without showing signs of conjprpssion. TIip continuous prpssxire 
yxcrt'iHi^d by the tumour finally causes the cartilages to atrophy 
and soften, aiul m teiub to aggravate the existing stenosis. 

Malignant tuniourK of the thyroid gland arc prone to grow into 
the trachea, as tlcios aim rarciiionia of thi' guile;!. Aneurisms 
are apt lo coniprcss the wiiidpljw, i'S[X!(!ially luu-urisms of the 
aortic arch on the jKistcrior wall of thw aorta, at the »[X)t where 
the aorta, so t(j K]«'ak, "hriilgi-s" over the Imeliea mid left 
bronchus, and the piilsjition nf (he aneurism is transniiCled 
to the mucous nienibrane, u'hich bulges and is reildene*! at the 
site of comprciwion. 

There is no denying that h^^w^t^ophy of a persistent thyniuB 
gland is lialile to produce sicnosiB. How the pudden death 
BQinetimes occun-ing in small children may be explained by 

Fig. I3Q. — Bilateml f.,n,|.ii mn of 

trachea (iitiugc J ■J''itci.i. 

Fig, 137. — (VinipiyHBiiri nf ihr Irft 
«de seen aa iiiiag« i^SchnttfT). 

Buch a eoiiipression due to hypertniphy of ihe thymus we do not 
prclcnd to discuws. 

Symptoms. — .4s lias tM*on aln»ady [xiintod out in the Cleneral 
Part (ace p. 386), stenosis of the windpipe may occur suddenly 
or in a relatively short tinie. or gradually. At the fame |ilace 
(stje p. 3S6) the Hubjective jmd objective symptoms have been 
discussed. Uere we shall only speak of those t^ymptoms which 
are not directly eonceme^i wilh thesleiitifiiH, hut are in connection 
with the cause of it. niori' eKpecially with the cause of eonipres- 
sion »4lenost!4 of llie tnichea. 

Tile long^lniwTi-out course of the recurrent nerves makes it 
feaaibh- (hat not only the trachea, b\it also the ncr\'cs themselves, 
are ea.sily exposed to pressure from dis-eapes in the neighbourhood 
of the trachea, e. g., in the mediastinum. In the neck both 


recuimit iiRrvcs run in the ktoovr bctwron the ORsophagua and 
the trachea, and are, therefore, better protected against pntwure. 
Hence we may observe that the signs of paralysis of the inferior 
laryiigL'iil nerves are oftener seen in compreaaion of the intra- 
thoracic part of the traehea, e. g., pandysis of the left v(ieal cord 
inaneurvKiH of thenortic areh. Stenomn /«t se lines not altiT the 
voice if it 1k' not eunibinini with pariilvMin or pathological ehaiiges 
of the vocal cords. In deei>-seated stenosis an area of dulhie-is 
on percussion may be often noticed over the niantibrium stenii, 
corresponding to the primary* seat of the lesion and expanding 
over the vicinity. If the stenosis lasts for a longer time, other 
fflgna of distui-bwi respiration are ninnifcst, e. g., emphystima 
and atelectasis of certain parts of the lung, hypertrophy and 
dilalation of the heart, cte. 

Diagnosis. — In making a diagnosis we must anan-er three 
queKtions: 1. Is there really stenosis of the air^passogea? 
or, in other wonls, Ih the exisleiit dyppiioea to be referred to 
HtenomB? 2. Where is the seat of the aVenosis? 3. What is 
the cause? 

The first will be answered without difficulty if the pre\iou3 
hifllor>' and manifest symptoms are carefully considered (stridor). 
As regards the second ((uestion, as to whether laryngeal or 
trachea] stenosis be present, this «'ill be stifely decided iiy lar>ii- 
goscopy or tracheoscopy (indirect and direct method). In 
many cases external insiM-etion will have already given u« 
the right clue, e. g., if we find a tumour pressing on the trachea. 
The other external signu, f. g., movements of the larynx on 
itiflpiratirm and expiniiion and tlie |»osilirni of the hcail an- not 
reliable, because thoy vary in different cawe. I remember 
two eases of undoubted tracheal stenosis due to goitre which 
showed vcr>' conspicuously the respiratory ascending and descend- 
ing of the larynx, which is usually taken for a sign of laryngeal 
stenosis. And, bejddoa, in many cases of short neck, as in 
women, the movements of the larynx caimot be obper\'eil at all : 
•ind we should also reriiendMT that larynx and trnrhea may be 
simultaneously strn05«ed, ae, for instance, as the result of syphil- 
itic proccBses. The conditionsof voice arc not alwayschanieteris- 
tic. Here again larj-ngoscopy will facilitate the recognition 



tm lo whether or imt ihe Menoxif in in the rrtjion nf Ihe farynx, 
and if t \u'. lArj'DX \» ruund fn«, lh(> nlht^r nipthods of <-xanim»tion 
{Killian's dirwt and iiidiroct method of tracheoecopy) will show 
us ihp Ril« of stenosis in the tmehea. 

V. ICirMen maintains that only tracheoscopy alone will admit 
of exjirl rceogiiition uf scat, size, and kind of slrieiure istt-nosis). 
Unfortunately, autoscopy requires great technical skill, apart 
from the fact that it is contraincUcatcd in ancuriem on-liig to the 
grr-at risk nf injuring the ancurisniAl sac. Severe dyspnoea 
va very Hkely to jjrevent. even tJic introduction of o simple niirmr. 
In such caj*cs one must cwiit^-iit one's «'lf with the nmiaining 
signa luid sj'mptonis, wiiieli dti iio|, prove to a certainty, hut 
faute <fe mieux, in their enlin-ly, will prove enough for a di.ngno- 
818. Lately, the Rfmlgen ray8 have l)ecn resorted to by KilHan, 
in order to aseerlain trru-heal stenosis. 

The differential diagnosis Iwtween tracheal and bronchial 
stenosis is not difficult for those who can nianage tracheoscopy 
and bronchoscopy; otherwise an unaided physical exajninatiun 
alone must serv-e to decide. The "stridor" w Icjw loud in 
bronchial elenoeis than in tracheal etcuosis, and both an inspira- 
tory and an expiratory stridor should be felt and heard at the 
eitc of the stenosis. In cases of long-standing stenosis of the 
bronchus the movements of the corres[ronding half of the thorax 
is less marked, and the respiratory sound (bruit) is reduced, 
the fremitus weaker, and the other lung shows signs of comp>cn- 
8ator>' enlargement (emphysema). (For stenosis due to foreign 
bodies see Cliapter VII.) 

Diagnosis.— Wp must now consiiler the diagnosis of the pri- 
mur>' disease. In lar\-ngeal stenosis laryngoscopy will at once 
clear up the matter, but, on the other hand, the whole arma- 
mentarium of internal medicine will I>e required to ascertain 
the nntnrf of a tracheal stenosis. Fibrous strictures Jire almost 
alway.s due to syphilLs. and A. Frd-nkel contends that syphilis 
slionld always be our first thought if we have to deal with a 
patient who shows the signs of a giadually developed stricture 
of the trachea. But iHrnnre of mistakitu) fihroui^ strictures far 
stenosis causal by autside iiresmtre. In the former a dark hole 



flr ^mk nwy be seen with u-hUe edge^; in Ihc latter, a more 
rotund projitiiierwe. (Sets Fig. 138.) 

If w:r have oaccrlaiiiLHl that wc have Ijcforc us a coniprfiwioit 
stenosis, our mind is ul once dirctted to the* thyi-oid gliiiul if 
the fitciirisLs hi scalfil somewhat high up iii the tnirhcn. Di-cpcr 
si-alnl slwHwis jM)iiit3 to rrtr(»sti;ni:i! goitre tir aortic niK-urisrii. 
Tlie rctruKtumal goitre tiomc^llnifft prcspiitK ilmAi in a form 
tlial l.s fijmki'ii iif in Ocnimii a« "Tiiiiphkn»|iF' (divirij; gtiitii'), 
for thi< ri>:i.s)ii llial thv nMnistomul lhyn>icl loht' is drawn into 
th(> ttiorax by each inspiration, and aRCt'iids during each expira- 
tion, and still nuirpw) is this the eaiw on couKhing, when it ite- 
comcs visible in the jugular foseo. Naturally, stenosis and 
dyspnoea are augtiiented if the goitre filips behind the stenmrn, 
for the resistance of the bone oiJy 
pennita the goitn- to move back- 
wards towardn the trachea, and so 
the tracheal lumen is usually nar- 
rowed until it fonus ooly a trans- 
verse ehink. Aneurism of theaorlic 
arch ofttn jiroduees iiaralysis of the 
left voeal lip; besides, a viable 
piilsatioD and an area of percussion 
dullness over the sternum, an in- 
equality of the radial pulses, and 
the protrusion of the red and 
pulsating tracheal mucous membrane seen in the minor com- 
plete ihe pjrluri' of symptoms. Chiori, however, reminds us 
also that, iinnnally, pulsation may be visible on the lower section 
of the left traeheal wall, and of the spur (see p. 358), but then 
the ntUu'SS and pndnuaoii of the mucous membrane are not 
present, as in stenosis due to aneurism. Malignant tumours grow 
into the tniehea or oesophagus, causing either tracheal or oesoph- 
ageal strielure, or fjoth simultaneously. On tnicheoscopic ex- 
amination wc then find the prominence or protrusion eaust-d 
by the tumour, the mrfocc of which might be smooth, but is 
inorcoftcaiuiie\'en, tuberous, or lumpy, and the age of the patient 
also, and the eompamtively nuiek development of the stwiosis will 
aid us 'm diagnofus. Benign tumours never perforate the truelica. 

Fig. 138. — Tractieal rompreB- 
Hiuu liy a rr In. Hie null lliyrtiid 
piitK". Ttipluiiifinof tliclmclic* 
IS aarrowttl to mi otmoat tnuis- 
v«nul chink by tliL-preBmire ex- 
erciaed froto in front (TOncA). 



ProguoBis. — The danger of soffocation is so much th^ gTY>Ator 
the nanxjwcr the wiiidtjipe is untlf^r normal conditions, v\z., 
in childrcD, and the quicker the stenosis has been developed. 

But one should not forget that- many a gradually bcreasdng 
fitcDOflis may unexpectedly become urgently aeute. For this 
rmson il will be well to be prepared for such a poesibility; for 
example, if we have to treat a patient suffering from tubt-reular 
infillnitions or a compressing tumor (goilrc). 

Tim dreadtxi death as the outcome of goitre, which may 
occur like a thunderbolt from the blue, is not yet quite 
explained. The patient collapses suddenly on making n rash 
movomontofthehead. Hose's opinion of this is that the trachea 
of these patient*, owing to the softening and atrophy of the 
tracheal eartilages, is easily kinked, and that the hesit, already 
weakened by the respimtory and circulatorj' distuitAnoes, is 
powerless to overcome the sudden stress. 

An intercumwit catarrh may al.«n give rise to an acute attack 
of dj-spnora. This danger of nipid sufTocation is less or not at 
all to be f«tn-d in filinnifi sfrictum?. Tl«-se usually remain 
stationary-, and even in nmrked tendency to contraction, sud- 
di-n suffocation hanlly ever occurs. 

GentTsiJIy sTijcaklng, thf progitn?iis dnjiends on the site of the 
stenosis and the chnnieter of the priniarj' cause. The higher the 
place of stenosis, the more '\s it found to be amenable to proper 
treHtiiirnt, If dilatation by one or other method fiiils in un- 
coinplit'iitt'd laryngejU or high tracheal stenosis, traeht?otomy 
will always fiuve the situation. In acute or rapidly developing 
stenoses tracheotomy might even establiah a p<Tnmn™t cure. 
Ill the stenosis gradually prfidiircd by mmv coiislitiitional 
disease tracheotomy is only palliative. Prognosis becomes 
worse the further down the trachea the seat of the stricture may 
be. and it i.t Imd if I he primary cause is of a malignant natun* 
(carcinoma, aneurism, tulMTculnus glands). Ryphiliy !ig.iin offers 
better ehanecs, iix it allows of ati antisyphilitic tivaltiieiil or 
systematic dilatation. 

In any t^Hse prognnstn quoad vitam et restitutlonem is very 
bad, if in loiig-st audi tig stricture the lung and the heart have 
become irreparably affected. 



Treatment. — I^-fnrr all yhc- stands the iiidieatio vitnlts. ^"iz., 
the prevKiition of wuffocalioti — prc)]>hylaxis. All the other 
mt-iLsurps as to the tn'fltiiit'nt of ihv sti*tiosis itsfJf and its cause 
come int» the soooml line in {Xjint of imix>rtance (iudicatio cau- 

A. Prophylaxis (Pr«ventive Treatment). — In threatpnnig 
sutTocalion, the question arists whether we can expect t« re- 
move tht etenoshiK or olwrtructing factor quickly, by operation 
through the mouth, eo as to recstnblieh again the natural con- 
ditions and to fliminate the menacing danger. P'or example, a 
foreign body so situated that it can be reached with the forceps 
through the mouth or even with the finger, orif there In- nii «!)- 
scesH or oedema in the region of the :iditus laryngts. i.s it easily 
accessible to the knife, or does it take the form of oedema which 
can Ix- reduced by scarification? in and similar eji-ses tx)th 
purpose-s. the indicsitio vitali-'J et niusjilis, may be dealt with. 
In other eiu^i.'S, if the danger of sufTocntion is iinminent, it is our 
duty to free the air-ptuwage either (1) by openition, involving 
the opening of the windpifK' (tracheotomy), or (2) by other 
expedient methods, such as the insertion of a tube into the 
narrowed passage by way of the mouth (intubation or cathe- 

I. Tracheotomy. — \Vhether we perform superior or inferior 
traehcotomy, viz., above or below the ir^thmus of the thyroid 
gland, depends on the site and character of the stenosis and 
on ihf lne.ll ooiulitions. If it can be done, the traehea should 
be opened below the seat of stenosis. Superior tracheotomy, 
in, however, owing to the lesser vascularity in. this area, easier to 
perform, although the field of openition ja limited; yet it should 
be given the preference, generally speaking, in adults. Never- 
theJcas, great care must be observed not to divide the cricoid 
cartilage itself, beeausc the "decanulement" later on is long 
delayed, and n<K'roMi.'« vi-ty e^wily sot.* in, owing to the pressure 
of the cjuuilu on the rigid cartilage, but which, on ihv other 
hand, might n'sult in cicatricial rctraetion. In children, in whom 
the thyroid gland U umially higher than in adults, inferior 
tracheotomy is preferable. 




Hcferring to the texUbooks o[i .-nirgcry, wc dcaro to cinphn- 
sisc hvnr only certain points* 

The oprraiiori shcmld be ]it'rfonucd un(UT general niiac»thcsia, 
bccaiisf rt-.spiration is thon quieter, and it also |>enKit.s n surrr 
opemlion. If narru-'is ia diilicult to inclucf, the rulHneous 
incision, which is the most painful \*niX, imiy hv Join* under 
local nuAcMhi-sia. In casef of urgctiey, where itomitolence has 

Fig. 13&.— Ttw^cbI diktor. 

already appeHrt^d, one can omit any prpliminary ana<-sthfMa, 
for the sciisiMIity hiis alrcjidy become reduced by the scinino- 
lence. ITlc incision should he at hvu^t 4 em, {2 inches) long, 
rather longtr than shorter, and strictly confined to ihe middle 
line, while Oie }iesid mu»i he ivetl mtracled. In suiwrior trache- 
otomy the cutanwjiis incision U^jjins from the conic ligament 
[somewhiit below the thyroidal notch (incisurn thyruidea)J, 
and must be carried downmuils over the 
isthmus of the thyroid f^land. In inferior 
tracheotomy the hicision must begin just 
above the isthmus, and is continued douii 
nearly to the cpistenml notch. The suiwr- 
ficial fascia must Ih; made 1i*ii.w by means of 
twoforcep.'*,aiKl divided throughout the whole 
length of the eutanenus incifiion, or if ade- 
quate nssUtance is not at hand, it must be 
"snipped" and then divided alonj; h din'elor. 
The nmsclefl (Btemo-hyoidei. stenio-thyroidei, and the erieo- 
thyruidci) arc separated, and any bleeding veins carefully 

* The tcxt-bouks on laryik^logy, with few «xceplwit», onul any Jiscwmoq 
of tru-heotoniy und iln «jn!Kviu(Micft<. •n-hcrwi* Ihcy P^o pxteriMve iipo« to 
intiibftlion, I pnnAiHfrr thin qiiit.» wronjj, and itm nf ih*. npinion ihat ovety- 
boJy ocnipyin^ hiinqelf uitli Ihls spFcialisun and looking up a lexI-l)i>ok on 
Inrjmgology i> jiiMlifiol In »Tp«cling. at Icajt. thai (lio chic^ points in ui 
operation nliicli iiIjith hi iuijiort.iol h jiari in w itiuny ilisMLMvi will be cll»> 
runed, und rerlititily i( !■ n< iNiinirlani » int.utMtioii, which i* dninied by 
the IktTTigoto^sta as their inoJicnuult! ptrrquiaile. 

Fig. l-IO.— TmHieaJ 
caniiln {l.titr). 



Hgntctl. The th\Toid gland, which in childi'cn is often sitiintocl 
hii:h up, must Ijc carefully sc-parated mid pushed do\unviird». 
acccrduig to Bose, by dividing the deep fascia below the cricoid 
cartilage (fascia thyro-Iaryngea) tmnsversely by a sniall in- 
cision, and iht^n the glimd cfin be easily separated with a blunt 
instnimcnt from the trnchea, and the isthmus pushed domiwai'ds 
and kept dowi, in superior iraehmiomy, and drauni upwards 
nnd kept up, in inferior tracheolomy. On account of the abun- 
diint v;us(!ul;irity uiid the n-Iation of the anonymous artery, 
\\\i\fh rnjswi-s tlic tr.ichi^ft, this dissecting and scpanition must 
l)(^ ilonc very carefully, esijecisdly in inferitrr iTarhcotomy. 'Fhis 
done, the trnchea npiicnrs jw b bltiifh-whito Iiand, and all the 
bleeding vessels having been secun-d, it can now be o|>piied. 
The Iniehi-a, fixed and lifti'd up by means of a liook, is punc- 
tured at the lower Hngle of the culanenuN incision and opened 
up by futtin^ from In-low upwanls. Tlu! edgcj? of the nound 
aiv liien kept n|)art by means of a dilator (sec Fig. l.'J9) or 
retractor, an(i the canuUi (see p. 418) inserted. The touching 
of the tracheal mucous membrane always excites some Rpos- 
modic fits of coughing, which cause the air to escape with a, 
loud hi»^'uig noise, neconipanied by some blood-atatued nincUK. 
A short pause in the respiration {apnoca) frequently follows 
the first fit of coughing, especially in patients with considemhle 
RtenoHs, due, probably, to the suddenly increased supply of 
oxygen. This pause in the respiration, though short, has a. 
fitratige, not to say perturbing, effect. 

In piises of urgcney and extreme need, tracheotomy must be 
performed with veiy* priniilive instruments, even as r. Berpnann 
hinted, with a pocket-knife. A piece of india-rubber tubing 
may be used as a canula, threjided at one end, in order to 
fix it ; hair-pirn may take the place ol n^tmctors or hooks. 
In such a case we mtwt not concern ouiBoIvca loo much nlxiut 
the bleeding, in order not to lose much valuable time while the 
[Milieni Is in danger of snfforaling. Bleeding veins often vvtxs*- 
blc-eding after the trachea lias Ix'cn opened, and any other 
vei«els may be secured after the oiK'nition is finished. 

The ennula should l»e large, not too short, and fixed or lied 
mth a tape lutpund the nock; the shield of the canula must Im» 



padded underneath with cotton-wool, and the operation finished 
by packing the cutaneous wound. 

If it is at all possible, the trachea should be opened below the 
stenosis, as, if wi: do mj, thi: danger of suffocation is at once 
averted and irrilatioii of the narmwcd region by the cnnula 
avoided, rnfortunately, in tracheal stenosis situiitiHl far down 
one will often be forced to open the trachea above tlie stenositi.* 
If the tracheotomy is undertaken in order to remove a foreign 
body or obstmetiiig membranes or any 
other iiitratraehcal hindrance, simple 
iraeheotomy and a simple cnnula will 
be sulTicient. In other caiiics, for ex- 
ample, in substenial goitre, a long canula 
ilionUfg tracheal canula) must be applied 
(sec Fig. Ml)', or even a catheter, ct«. 

Tracheotomy must be followed by sys- 
teiuatic dilatation of the stenosb if the 
case is a suitable one. 
CompUcaHons. — Bleedwg during and 

after the operation may become cbinger- 
0U8. Kniphj-Hema of the subcutaneous 
tissue, to a greater or lesser extent, some- 
times arises from severe coufching, after 
blocking, or if the eaniila falls out, and 
is of no consequence. Difficulties met 
with >vhen inserting the eanula niay tx^ 
Fil m.-Kffniff'« long owrconie by dilating first the wound or 
imeiiTOl c«imla. Separating the edges by means of dilators 
or retractors. More unpleasant are the 
complications cftUS(Hl by the pn>»wuro of the caniJa or as the 
result of dclayctl "dceauulemenl."' Gi^nerally speaking, the 
canula should remain for at Ittast two days, but not longer 
Ihfiii five diiyH, contiinioiwly; the inner canula. however, must 
Ix' cluuiged daily, so that no ol)8truction may occur. If thi^ 
canula remains in the woimd for too long a time, if it fits 
badly, or it has a sharp edge somewhere, it will load, by the 

* Whcpp (ho CiLUiw of strno^is can be remoi'oil Ijv a miiical opemtion [m 
in goitre), ttiis opcr&tion atiould be tukeu intu ctKuiifeniiiciii. 



pressure it exercises, esppcially about the stenosed jmrt, to 
necrosis of the mucous int'iiibrttiK', {. e., dccubiluHf which mani- 
fests itself by pain, fi'ver, find blood-stained expectoration. In 
such a case iiiatltTS may he sometimes amended by changing 
the canuliL for a sliorter one, or by replacing it by a soft tube, 
or even a dminiigt^lube. A badly fitting or imlating eanula 
may also give rise tn gruniilatioiis, and so again to etenoeis, 
which may render the n-inoval difficult. (ric<- p. 409.) The n>- 
moviU of the canula ("decanulKmont") may also prove difficult 
on accoiuit of deviations of tho tnichca or displaccini-iit of »nmc 
cartilages or parts of cai'tilajgis, iluc to faulty method of o|K'mtioii. 
TIh-w fiiiilts iniLvt he removed hy siirgiral means, (inirmlalinns 
niay be rjiuteri.sed liy nitrate of silver, the ciirett**, or snare. 

Final " iJecamitemenl." — ^Thc complications mentioned alwve, 
and which cannot wKtietimes be avoided in spile of the greatrtit 
can^, make it ilesinible to fuially withdraw lli(> cauula m Roon 
as [xjssible. This is especially so in a c:u«! when? the st<?nnids 
h:is again become dilated, m that the nir-eurront in now rendered 
siiflipicnt. Tliat the steniwis ha-s iH^corne niori! free eau be 
proved by clofflBg the canula ttuiporarily with the finger or 
with a cork, while the patient is required to breathe (luictly. 
In ncr\'ouB patients and in children it not infrMiiiently happcua 
that a fresh attack of dy«ijnoca at once occurts on pmhatory 
closure, not perhaps btxrnuw of the slcno»i« i«till persisting, 
but becaiise of the jMychic rcfiex irritability. M. Schmi<U 
explains IhU rcHuuTpnt dysiaioea xs (wing due to simsmif. Chil- 
dren have frequently liwt llie habit of bivathing through the 
glottis and of automatically alnlucting the vocal Ups. Here, 
nn intubation once performed will wuccivd in n-inducing normal 
free respinition. IVmaturt- n!naival of the canula is a mialake, 
and must be avoided in order nut to again produce the pre- 
existing dangerous conditions. The canula being finally with- 
drawn, the cutaneous wound won closes under a protecting 
bandage, and fistulas which may persist may be caused to close 
by refreshing their i-dges and sc\ving them together. 

2. intubation and " Cathelerifation" of the Air-fossages.* — 

• It wmil'f bp well (oiJmpihclcrm "luhsEo" i" pn-frn'tn'e for "rtittiftcriia- 
tion" in onicr to uvuiJ tmntiisjou of th« (ortns "lufxige" and "intut»UDii." 



Inliibnfioti, after tlie nicihod of O'Dieyer, is performed under 
the (guidance of the fiiigcr with straight nictal or vuimnitft 
tubes; while cathdcrism , after Schrolter, is execulcil with iho 
aid of the mirror by means of cathcfc'r-likv tubes uf vulcanite. 

fntubatitm is t-hicfly apjilied in 
stenosis fnjtti acute iiiflanmiiLlions, 
a^ in dii>htiieria, hence it ih mostly 
uscil ill children. Cnlheierixalvm, 
on the other hand, is chiefly con- 
cerned wnth adults. But we desire 
at cure to say that 0'l>v'yer'is tubes, 
in 8uital>le ?iz*'s, nrc alstj occasion- 
ally u.*t*d in adults for aculo iiiHain- 
matory stenoses, mid that Iwth 
kinds of tulx-s might be infnidiiced 
into the lurytix for the puqxKse 
of diialing chronic steiiosiy. One 
should be very careful in introduc- 
ing tubes into the wiiid|)i|K* in cases 
of ficute infiuniiniktion, iis llie pres- 
sure caused by the tube upon the 
- jff ^H most irritable muooiL'* nieinbrnne is 

^^^^ WM apt to aggnivalc ihi': inllatnniiition, 

or even to cau.<i- tin- inii;iiiiina.tory 
process, which was |>crliaps already 
abating, to become aggravated. 
An cxci-ption therefrom, however, 
mudt In- iMiuU' in iliphtheria, which, 
as we have said alwvo, is coinmonly 
and chiefly treated by O'lhvyer'a 
hiEK'.*. but here also we must take 
into acrniint a jx).s.sible negative re- 
sult, and must, ihcrcfiirt', be pre- 
pared to perform trachcotoniy after 
:iny intubation if neccssiry. 
(a) fnlnbolUm of (be Lnri/nx After O'Dxcyer.—In children, it 
IN perfoniit'd with slender oval tut)eii, I he size of which is adapt ed 
to the age (jf the child. In adult-t lubes of vulcanite are chosen 

FSg. 142. — Iiinlnimrnls for in- 
tubalion (nHcr O'Dv-ttcr): a. 
Tube: 6, mrrodtircr Willi the 
obturotor \(ii>r., Man-irin). 



bpciiuse mptftl tiilics woulil be foil to Iw too hea'vy. The one 
pml of t'HC'h lube is broadened like a ^kuU, and it is provided 
with an obtumtor (Gcr.. M/indrin), which projects from tho 
other (lower) end so as not to injure the mucouA membrane 
when the tube is iiurDduccii. The intubatinn iw done in the 
following way ; Thi- child — we will su))ii«st5 that i)ur [Kiticnt 
is a rhild — is held firnily (us i« ile-scrilxxl ou p. 112), and its 
mouth kept open, iT need be, by a gag. 






Fig. lis.— Intubation {ftft«-r0'0(/iiw) (ephCTnatic). 

Thi' left rorefinpicr is inserted iH-himl [he epiplotti.s and |>n'SSod 
forwartlN against, the nf the timgue (.see Fig. H.'J), ihtii a 
tithe of suitable size, the head of which \» threadetl with a double 
.nilk thread. i.s iritnidiice'd by means of an introducer, always 
fnllrwing llie left forefinpiT liki-wise iM-biud the epiplottis (see 
FiR. 143) ; the Iminlle of the introducer h now slightly elevated, 
HO that the end of the tutx- doeit not slip backwards and down- 
wanLi into the gullet ; and the tnlw is then gently inserted 
forwards and Uowiiwartie into the larj'nx betAs-eeu the rinia 



glottidis. While the left forffinger fixes the head of the tube, ii 
order to prevent its sliding backwards, the introducer, togethei 
with the obturator, is now wthdrawn through the mouth. Ir 
order to free the iiitroduecr together with the tnotulrin, it is nece» 
sary to push thp bolt fixed to the handleof the introducer forwards, 
If the tubi- is ill the right [xisition, one may at once roct^iis*? it bj 
the hissing noise cauited by the respircKl air, and also by th« 
respiration itwif h(*oming quieter. If this is the ease, tho akull- 
shapcd broadeuiuK of the htad of the lube then lies alwve the 
glottis and on the ventricular folds; -whereas the smaller ueck 
of the tube below the head lies betwcai the vocal cords, and 
the broader body of the tube litw Ixdow thi-ni. If the dyspnoea 
does not decreiisc. tlien the tulw^ bus Utii a*emingly inserted 
into the oesophi)gu.s * and in such a ruse the tube must be nitb- 

rift. m.— Eximctor for O'thi'ytf'a lube. 

drawn by the silk thread and then reintroduced. The tube 
being now in the right position, the silk thread is tied to the ear, 
or, by means of adhesive plastiT. to the cheek. In order to 
reniovethetuljc.if the little patient hiis bitten through the thread, 
an extractor must be uwed, Tlti« i.s an instrument shaped like 
laryngeal forceps, whlrb is insiTtcd in (lie .siiiiie nmnner as the 
introducer, with tlie blade?* elosed. bebind (hi- epiglottis, and 
then into the head of the tube. A little pres-inre on tlie lever of 
(he instniment is now sndiriiiit to opi-n the claws, and so 
gnuij) the tube and extniel it. (See Fig. 144.) 

Tlie entire inanipiibttioii n-i|uire.t .'viiiie ttvhTiical Hkill, and M 

• Ttnnalalinff pdilni'g fiMl-nolc: Hr. :ii; snmn timet luipiMOi, ihr tubo 
been ingerled nelweea Uie (raolu^ wall and Ihc diphtheritic mtinnM Bti 
bmiie.-F. W. F. K. 






particularly difficult to pilot the clan-s of the extractor into the 
tube. The extractor, however, is indispensable in cases where 
the thifads, as has been said, are bittfii through or hnvr had 
to he I'emoved hy thf physician hini-ii*If, on account of ihf child 
continually tugging at ihoni. This may also he ]>revented, 
as is advised hy Ganghofer, hy lying the hands of the ehihi. 

The tulio should Iw watched hy the physician or hy trained 
nursfts, and left in the larynx as long as rc-ipiration rcniainfl 
free ; but under no circ\inwt ances should it be left t here longer 
than twenty-four to thirty-flix hour*, because necrofis and 
ulccmtion are easily produced by the pressure of the tul>e on 
the vocal cords, which in turn may lead loextensiv-e destruction, 
resulting finally in stenosis. If, after withdniwing the tube, 
dyspnoea n-eun. or if it him alrrady shown itself before extuba- 
tion, then intuhaticin must he repeatitl. If seA-eral R'intuha- 
tion8 are made without the wishitl-for n-sult, then tracheotomy 
niust !>»■ p4'pronni'd. 

Complications. — Owing lo uiiskilfnlneRR on the part of the 
0|>erat.or, hijuries of soft parts are not infivquent; but even the 
most wkilfid and ean-ful manipulations, however, may not 
prevf^nt diphtheritie menibraiies being separated and pushpti 
on ahead by the advancing tulx-, and these membranes are then 
liable to block the trachea to such a degnre that tmcheotoniy 
must be quickly performed. Ha^•ing in.'itTted the tube without 
any injury and aecidenl, coughing, however, may soTiietinies be 
80 violently excited that a tube which does not exactly fit 
may !«* flung out. At the time of the attempt to withdraw the 
tulie, it may nffen Impijcn that it i.t piwhed into the tmehea, 
and this in particular luipp-ns if the tube was smaller than the 
lumen. If this ai^idenl oeeum, Irarhtwtomy must I«* pi'rfonne<l 
withiHil delay, Krorioiis and ulcers eaused by the pres.sure 
uf ihe lulw have Ijeeii mentioned. \'(>ry unpleasant sometimes 
is the diffieulty of feeding children while the tube is itiBide the 
larynx. The children often "swallow the wrong way," and 
the fluid, which easily reaches the deeper air-pass!\ges by way 
of the tul>e, may excite \*ioIent f)arox>'Mns of eoughuig, and 
e\'en pneumonia has been oliservcd to follow the misswallowcd 


Although some of Iht-sf i-vils may be nvoidwl by skill, care, 
and expt'iimcc, yr). tlirn- an- tiwmy (Iis:ii]v:int;igi's — not the 
least of these is tliat ihf. installed tuUr Ims to \>ct constantly 
and permanently watched — wliich would justify the raising of 
the question us to whether traeheoUiniy in the loiij( ruii would 
not be pR'fenible. Surgeons will ecrltiinlj' luistttT in llic afhrina- 
tivc, though Iraeheotoniy itself \n not at all free also from un|jli^- 
sant incidents. On the other hand, it should he renicinlwred 
that intubation is a bloodless operation, for which permismon is 
readily givon; also that it roqiiirea much less time for recovery, 
and that its naiilts are bctl«r in the stenoses due to dii)hthcria 
— at least, according to American and German statistics. But 
again we desire to remind that iL'mally oiUy in the severe cases 
of diplitheria. where the procwB is already far advanced and 
has spread into the deeper air-passages, is tracheotomy strongly 
indicated. Generally speaking, in tlineateiiing stenosis of the 
lower air-passages iraelieotomy is prefemblo, and for tht> reason 
that the stonoscd region is rendered din^ctJy aecpssible by open- 
ing the trachea, and the oix-ning itself, moreover, may be easily 
dilated if this is re<iuirod. 

Jntubation is contraindieaied — (I) In the cane of fortign bodies, 
for these would oidy be driven furthcJ: down into the trachea; 
(2) in ofdi-niji of the larynx, Inninnc the .swollen parts are likely 
to cover, and thus oliHt met, I he head of the tuEKr; (3) in tuljcrcu- 
losia, because in the U-ginning (stage of infiltnition) the condi- 
tions are mostly aggravatixl, and later, if fibrous stricture has 
develo|X'd, we may luivi^ to reckon with the exacerlmtion of 
old encapsulalcfl abseesiscs. 

(6) Caihettrimtion ofOte unmlpijfe, afl^-r SchrSllcr, is performed 
H-ith suitably curved tubes of vulcanite. {.See Fig. 145,) Thi-se 
tubes have a length of 2(i cm., and their oral end is circular, 
while their Iar>'ngeal end convsjKjnds to the shape of the glottis 
and is triangular, and shows, like all catheters, tu-o oval eyes. 
Having previously anacpthetiscd the lar>Tix. the catheti-r, under 
guidance of tht^ inirnir, is introduced into the larynx in the 
ordinary manner (p. 3S3). It will be necessary, however, to 
press slightly in order tn pet past the stenosed site, and here 
also one tnay ivi;c>gni.-*c that the catheter is in the right pusitioa 


by the hissing noiac of the pscapiiip; iiJr; utul that it hiis not 
slipped into the* pullet hy mistake. At tht- hegiimiiig of the 
treatnicut the tube only renjaina for some tuiimlos, laU-r uii, for 
an hour or longer. The setisitivenc.-* of the niueoiis membnine 
aoon, yit'lds, so ihat later aimeathesia bwoiiies ^•u|)^'rfllKm8. 
Many patients, indeed, leam to eatheterise tlieniwl \'es. 

Complications are mainly the suno as in intubation, hut iis the 
eatheler only remains for a short linu*, Ihey 
are far less serious. Here also, ae:;iin, tracheo- 
tomy will somptimos Iw npcessarj-. 

fi. Causative Treatment. — If there is no 
immediate ilanger to life, one should always 
endeavour 1o attack the BtcnosiB or its cause 
directly. This may occasionally be done by 
dru^ (caustics, for example), but usually 
much better by operation. 

(1) TTealmenl h// Drugx. — Tlie greatest 
contingency for this treatment is fumiahed 
by the sj-philitic stenoses. Even in very 
long-standing narrowing of the; larynx or 
trachea caused by syphilitic ulceration a trial 
with oiitii^yphilitic treatment is not only 
justified, but iilso useful, lu'cauw n Kuiii- 
matous mfihndion may Ik; pn-sTnt, which 
exercises a certain influence U[)on the stcii- 
osia. In stenoses clue to goitre of slight ilc- 
g;ree, io(Jine, given intenuilly iiiid cxlcnijdly, 
may ]>mvi' beneficial. The prepiirations of 
the thyroid gland, praised so eiithasiasti- 
cally, arc less cfheicnt than the todidiw and 
iodo-vafiogen (6 to 10 jxr cent.), the use of 
which I have tested, both internally and 
exlemnlly (see p. 327). If the troubles increase, however, 
nolhitig but an o|ier.'itioii will be of any avail. ]ii aiu-urtsriiM, 
which Hometiines al.-** ciriginate fnim a syphililie dcgi'iicnition 
of the vessels, thi^ iodine and mercurial treatment may likewise 
he imdertnken. ./. Frflukel reports several succc.<wes he achieved 
by this treatment, either by relieving the symptoms or even 

cuilielei-iutticKi (atiw 



removing them nJtogcthor for a time. In some cnaca of aneurism 
iotiirie may Ix; ei)iitiiiuoiL>J,v given (mornings aiitl evenings, 
0.2&-0.5 Bodiuni iodiiii- fur llirci; weeks and n'|icaled) and a suit- 
alilc diet (milk, vegetaWcvs, white moat) may be nble to arrest 
tb; enlargement of the aiieurisni. 

In <Ie.siHT!itc cjiscs nuirijhiiio must l»e ndministert'd. 

(2) Suryiml Trmlment. — Here exlra- and inlralaryngea! 
opi'ralions are |M^rfonned. The extralarj-ngeal and extra- 
triiehpal operations leave i\w larynx and tmehca intact, aa is 
the case in o|>eraliony for gnitn-; uv one or ihe olht-r of the two 
organs hax'C to be opened, as in lar>-ngotoniy or a trachfo](lastic 

Intralaryngeal and intratrarheal operations vary very much 
according to the t*ite and kind of the disease. If one needs to 
operate for intratraehenl hindrances, such as fibrous bands, 
scars, or poly])!, etc.. dxTtet sujierior and inferior Iracheascopif 
will prove theniseJvea very useful, accordijjg to the method 
employed, viz., if one desii-es to operate through the mouth or 
from the tracheal wound. Further remarks thereon \vill lie 
found in the 8|)eei!il chapters. Here wo vvish to n|>eak only 
of the method of dilatation of chronic stenoses, which is difTerent, 
just accordingly as tracheotomy has been previously performed 
or not. 

(a) tf tracheotomy has not b&en performed on patientn,Schrdtter's 
method of cathetcrisation, as has lx;en described above, is 
the nile, although' no insiinnoimtahle objection against O'Dxeyerx 
iiUubation run Ije advanced. At the commencement, soft 
catheters, anned with an obturator, should be usetl. because 
their introduction is nnich easier; later on, more rigid tubes 
of vulcanite niu.«t be used. Ciiiidnally, thicker catheters aro 
employed, and ihey may at fiiBt remain in position for a few 
minutes; later on. for half an hour or longer. Increasing the 
size (humiImt) of Ihe catheter too quickly niay be followed by 
very untowanl incidents, and if such be the case, cathetcrisation 
must at once be stopped. Having dilatcil t he lumen to n rei-tain 
size, catheterisation should yet be continued, at inter\-als, for 
a shorter or longer perioi'.. so as to jiiwont any n^lapse. Such 
relapses frequently occur in stenoses due to shruiking piwcesscs. 



Tt is vt-ry convenient, if the patient liiniself N'linis to intro- 
(lure ihi" tulieK; this, Ivjwcver, is only i«js.sibl« ill Schritlfer's 
tiH'llHHl, hut ni'ver in O'Dwyer's. The O'Dwi^er's tubes should 
aJwa)^ be withdm^ii, if possible, by the silk thi'eada attached 
to their hpjuL'*, as this isii much more simple procedure than the 
use of an cxtriiclor: Ijesides, in adults, 
we need not be afraiJ that the thread 
will be dcljiched. la stenoses siluattfJ 
f:ir ilowni. Schroiters IuIk-s of \"u]cHnitt( 
must be elongated by nieaiix nf stretch- 
ing them in hot water, in order to insure 
that the eatheter has reaehrd as far as 
the narrowed region, vvlicn passed from 
the mouth. 

(6) // trackefilomy has been perfantied, 
the stenosis (if liir\iiKeaI) may be dilated 
by way uf the moulli or through the 

In order to dilate through the mouth, 
Schroiter's dilators of tin, which are in- 
tended to gTfuIually dilate the larynx 
(obturation of the larynx), are intro- 
duced. The tin dilators (Ixilts) fitted 
with an eye on the upper, and with a 
knob on the lower, end {Figs. 146, 147, 
14S, 149) arc introduce<I in the same 
maimer a-1 tho tubea, under guidance of 
the mirror or finger, into tho laryn.x by 
nieans of a special iiitriMiuccr, until the 
kiKib (button) njifx-ars in the ewiniia, 
%vhich is fene-ttniled in ils up[X'r wall 
for tliis special ]iuri>o-'<c> The knob is 
retained ui this ixwitiini by rm-ruis of a 
minute presHure f[>ree[)!*, nr. oUat lieryti^, 

by a suiftll slut in the upjH'r wall of ihi- inner eanula. This \ul\vr 
(inner amula) is inserted by Henjng after the knob of the 
tin d'lator hiis passed tlirou(;h the ej-v in the wall of tho outer 
canub. The eye of the diklor Is armed with u silk thi-uid, 


Fir, H«.-Tiii dilutor 
(tioli ) /or (•hliir;iiii>ri ol 
th« IjirVTixftud iiuroiIU'CAr 




which hangs out from the mouth. The dilator remains for 
twenty- four houw if thi^ paliait is not himlcrctl in swKilowing. 

ThroiKjh t}\€ tracheal vmind, ticrcB'-shapwi tlilat<)rti arc intro- 
ducal (very i»iconifort;ihlf), or duniury or T-shiiiHtl t-nimlHP. 
In using the rhiinncy ninula, tin- chimney piffc is first iiitro- 
(IucihI, Mil} tlicii tlio IrHchcul canulu U luf^rteil tlirough it 
into the trachea: in the T-shajx^d caniila, aftPr Drtpuix. both 
halves lire ciich inserlcil supsirately, and then joined together 
in situ. 

If the stenosis is below the wound, it niny be dilatinl through 
the wound with cathctore or lubes ill IhriiiafniiTdcwrilKHi above. 

Generally spealiing. the effect of this systematic dilatation of 
very narrow fibmua stenoses is not too promising, apart from 

Vi nor.Qc 

Fig. 147. — Caniiln fitted 

Willi SchrMUr's tin bolt. 

Via. 1 18,— CiiimtiL-j-- Fig. 149.— T 
caiiuTa lafier liu/mtn} canula. 

(one-hnlf natural siscj. 

— T-riinp«d 

the fact that the patience of both the physician and the patient 
is rather intirh tried; relap-se.* rrp(]uen(ly occur just when the 
treatmeni, hits come to an end. Finally, we may come to tl»c 
conclusion and advisft the patient that he would be far better 
off if he [leniiilted an openition, so that the stricture could be 
excised from the outside, and subswiuently catheterised, if this 
be found necessary. 





Etiology.— AcutR catarrh of iht; krj"nx Arises from the same 
cau-scji :i.s do acute rhinitis ami acute pharyngitis. Here, as 
wHl Hs there chemical, mechanical, and thcmial irritations an* 
concerned. "Oilds" play an important nlle, at least ina.'^iuuch 
as they prepare tlic will for lh« invasion of the bacterial intrudt'n*. 
I do not propose lo here af^ain n*peat wliat has already been said 
iti the diswussiiin of all thi-se fac1x)r8 in the chapters on the various 
lUscawv, mul only tl(^r« lo siy a few words on some features 
peculiar to the etiology of laryngeal catarrh, t. e., iho over- 
Btraiuing of the voice professionally or on cenaia occasions. 

Laryngitis occurs, as does also rhinitis, in the course of infec- 
tious diseases. This uniformity in the etiology serves to ex- 
plain the fact that catarrh of the larynx is so often seen in 
association with nasal and pharyngeal catarrh. It is then 
ajwkcn of as descending catarrh of (he upper air-pnssaf;i"s, 
which starts in the nose, and gnuinally «pn?a<ls downwards 
stop by step. Strictly speaking, one should call it secondary 
laryngitis, though it would be difficult to deiine it clinically, 
for all the three foi-ms of catarrh may occur simultaneously. 
On the other hand, it cannot lie dente<l that isolated laiyngcal 
catarrh occurs, e. g., after overstniimng the voice. The bulk 
of the cases, however, partake of the imturr* of a {li(Tu.5c catarrh 
of the upper ri-spimtorj* tract, the symptoms of which show 
themselves at the scat of the locus niinoris rcsistcntiae; some- 
times in one, somtrtimes in the other, organ or part of an organ. 
I'sually, the catarrh does not stop at the larynx, but continues 
onward into thi* Lniehea and lironehi, and vcrj* often the signs 
of a laryngd-tnicheitis arc stU! present when the catarrh of the 
upper tract has for .some time subsided. In eomo caws, pprhafw 
in subglottic laryngitis, the pmci'ss mny have poaecd from the 
trachea into the larjTix. 

Men are usually more prono to Inr>Tigenl catarrh than women, 
becauw they are more exposed lo profeswion.-d anil tmdr injuries, 
and indulge much more m the abuse of aJwhol juid tobacco. 


mKAJca or the lAsrax aks tkacbea. 

of tile hzrneeml aad tndnl 
tfiffeRot dcpeef «f taxeut lad inteD- 
jity. Tie iB^ttcr (irgiee n diancteriaed bjr h jp»— fwitn of dtt 
■neoiii naniifaBe and aamtj weemkm; the uor mvtre 
fom, bjr rwiitfTOng, and beqamtiy, ihoog^ not ahntjn, bjr 
MfdUng of the nneoiuB nxxnbraiie vith fayperaemtioa and 
looaaiiiig, or ■cteaUy daqwiimiion of the cpJthdhiin. Inaocuc 
cues hunimfaagn nay even be notioed. We may i wn twn as 
a fact worth nsaeabamg that the mfiltntioa of the liaeua 
with the mflanunaioty produeta nay go on to acute oefkma. 
It is proljaijle that in such a case oot only the muoMs moo- 
braiiL-, but, the subaiucouB tiasoe, is also afTectetl Id difftne 
jpflamniatioD of the UryBgeal mucous membrane the redncw is 
evenly (liittribui(.fl, though it is more conspicuous in the n^ioa 
of the VfjTjJ Conk, lx*caU8e nlhenrisp thesie cnntragt strongly 
by their white, g]i)4lening colour. Circumtjcriiifti infliunmation, 
aa can eaaJy be UDtierstood* occurs in those parts vhicb are 
most commonty exposed to noxiouti influences, t. e„ yxtcal 
corda febonbtif)), and more eddom the epiglottis fepi^ltitts). 
Not infr«iucntly the lower (under) eurfare of the voral conle, 
etthcT alone or in association nnth other parts of the larynx, 
become inflamed ^subglottic lanneitie). The secretion here, 
as a rule, is scanty, mucoid, and glaxsy. In more severe inflam- 
mation the secretion is more abundant, turbid, yellowish green, 
and (Iriiw nn wjme placcB, forming crusts and ncahs, which may 
here and there show hlood-stains. In the latter case the larj-n- 
fptifl is spoken of as dry hnemmrhnffic lajytiffitis (laryngitis haora- 
orrhagica sicca). Thia ari^e^ chiefly, in my otpmence, on the 
baoia of fonner pathological changes, such as are found in pcr- 
BOiifl Buffering from atrophic rhinophar>'ngiti.«, i. e., it is mostly 
an acute exacerbation of a long-staitdiiig chronic catarrh. The 
secretion adhcrea m firmly in this fonii of iHrj-ngitis that patients 
experience great difficulty in bringing it up, and ci)n.iequently 
thift occasionally causes a Uttie bleeding, which ^(tain.s the 
expclli'rl mucus ami scabs brown. Kor the macroscopic change?, 
we refer the rwidcr to the description of llie lan,-ngeal mirror 
exftHiination (see below). Microscopically, one finds the nigns of 



inflammation, viz., round-celled iii61tratian, byperaemia, ilUata- 
tiiiil rif vessels, etc. 

Symptoms and Course. — These diffw aetortiing lo the 
scvfiily of ihy cilsl-. 

In the ihiki ctxscs the oni^'l in usually Buddeo; there is a »ensa- 
lion of tickling and Boreucijs or irriliilion in the iur^'ris, which 
causes the ]>atient to cough or cviai aggravates actual paroxysms 
of coughing. The secretion is scanty: only a httle glassy and 
viscid mucus is hrouglit up, nr st>cretion may Lie entirely ahwnt. 
The voice sounds impure and lioarsc, and soon becomes fatigued. 
The general heallli is but little disturbed, and the laryngitis, 
after ii few days, usually subsides. 

In the more severe cases all the symptoms described above 
occur, but are so much inort'ased as to occasion painful s(riiaa^ 
tions. Tlie patienfH are much troubled by a feeling of "raw- 
ness," of burning and smarting in the IurjiL\, and, if the I rachca 
also is affected, the fiensutions arc refcrrrd to the upper part of 
the sternum. Then^ is a short dry cough, csixrcially aggravated 
at night-time. At tlur onset here, al»), the sirretion is scanty, 
bul later on it incn-a-sew in quantity, ami the cxpixtoratcd mass 
may bo mucoid, nuicopvirulenl, and sometimes even blood- 
stained. The voice is always disturlH-il, and all the stages from 
hoarseness lo complete aplionia may be experienced. Patients 
complain that "something stick.s in the larynx," and that speak- 
ing and eating are piiinfiil. Thegonenil health is often dislurl)cd, 
and the entire course of diseast* extends for about three weeks or 
more, and the voice especially is thslurbed for a \'cry long 

It is unmTe#wftrv lo insist that lioth foj-ms of larytigiti.-* arc 
not really distinct or scparalt-- varieties, but that they merge 
one into the other; hence the great diversity of the laryngo- 
scopir images. 

In the mild mxex the mirror shows rhangi-s. nioslly in the 
ri'gioii of (he voenl eonls only. The vocal cords appear diffui!4'ly 
n'ddeneii, or only on the edg(« or in patches, /n tei^ere lar^iQifis 
the vwal cnrds an- allen-d nito thick, rt-d, fleshy pad**, which 
appear at first dry, and may i-ven wvm to be fissured, while 
later they look more humid and glistening. The \'cntricular 





ginttidis. Wliilr the K-ft fon'finger fixoB thr licutl of the lube, in 
order tii jiri-vnit its sliding backwiirilrt, tin; introducL-r, together 
with the obtumtor, is now witlidniw-u through ihe mouth. In 
order to freetJieiiitrtKlucertogelhi'r with the monrirm, it is neces- 
sary to push the bolt fixed to the haiidh'of theiiilroducerforwnrds. 
If thetuljeisin the right [xjsilton, one niiiynt once recognise it by 
thf hissing noise caused by the respired atr, and also by the 
respiration itself becoming quieter. If this is the case, the skull- 
shuped broadening of the head of the tube then hos almve the 
glottis and on the ventricular folds; whereas the snudlcr neck 
of the tube below the head lies betweftii the x-ocal corda, and 
the broader body of the tube lies below them. If thi> dyspnoea 
does ]iot decrease, then the tube has Ix-cti sci-niiiigl}' iiiwrti^l 
into the oesophagus * and in such a case the tube must be with- 

Ftg. 144.— Extractor for O'Dwrj/tr't tube. 

drawn by the silk thread and then reintroduced. Thft tube 
being now in the right jKisition, the silk thread is tied to the car, 
or, by means of adhesive plaster, to the eheek. Tu order to 
remove the tube, if the Itl tie iratient has bitten thrrjugh the Ihread, 
an extractor must be used. Thb is an instrument shaped like 
laryngeal forceps, which is in.'^erted in the same manner as the 
introducer, with the blades closed, behind the epiglottis, and 
then into the head of the tube. A little pressure on the lever of 
the instrument is now sufficient to open the claws, and so to 
grasp the tube and extract it. (See Kig. 144.) 

The entire manipulation requiri's some technical skill, and it is 

•TmimlaHnc editor's fooi-note; (Jr. ns sometimM hnpppin, the tube has 
been IritiPriml liflu-i«ij the imclical wall and the diptilheriiic niuroiu man- 
brsim-.— F. W. F. H. 



particulnrly diffioult to pilot the claws of the extractor into the 
tube. The extractor, however, is indispensable in cases where 
the threads, as has been said, aif bilten through or have had 
to be removed by iho [jhysiciim himself, on account of the child 
continually tugging at thorn. This nuiy also be preverilod, 
as is advised by Oanghofer, by tying the hands of the child. 

The tube should he watched by the physician or by trained 
nurecs, and loft in the larynx as long as respiration remainfl 
free; but under no circiimatanccB should it be left Ihcre longer 
Ihjin twenty-four to Ihirly-six hours. Ikthusp necrosis and 
iilocrjition are easily pRiduccd by the pressure of the tul>e on 
thevocai cords, wliich in turn may lead tocxtenMive destruction, 
ri'sultiiip finally in .s-ttnui-siM. If, aflcT withdrawing the tube, 
dyspnoea riTui-s, nrif it hasaln'ady shown ilwlf before extuba- 
tion, then inluliiilioii nuisl lie reiM-ati'd. If «'veral reintuba- 
tions an? made without the wishtrd-frjr result, then trachwitomy 
must Ik- perfomii'd. 

Complications. — Owing to unskilfulncss on the part of the 
operator, injuries of soft parts arc not infrequent; but even the 
most skilful and careful manipulations, however, may not 
prevent diphtheritic membranes behig separated and pushed 
on ahead by the advancing (uIh-, and the«- nu-nil.tranes are then 
liable to block the; iracliea to such a degree that tracheotomy 
must be quickly prrforrned. Having inserted the tube without 
any injury and aceiilent, ctnighing, however, may wjmetitnes Ix' 
80 violently excited that a tulK- which dm-s not exactly fit 
may be flung out. At the (inie of the flttempl to withdraw the 
tube, it may often hap[Krn that it is imshed into the trachea, 
and this in particular hMp[>ens if the tube was smaller timn the 
lumen. If this acetdent occurs, trachootomy must Iw [H-rforrat'd 
without delay. Kmsioiis and ulcers caused by the pressure 
of the lube Imvc been mentioned. Very unpleasant sometimes 
is the difficulty of feeding children while the tube is inade the 
larjTix. The children often "swallow the wrong way," and 
the fluid, which easily reaches the decjier air-passapts by way 
of the lube, may excite violent [ianixy.siiis uf coughing, and 
c\'cn pneumonia has been ob»er\'cd to follow the rniNtwallowed 



hours, imd ihtii iho child brrakK out into u copious porspimtion; 
ihc dyspnoea and respiraton- oppression subside, and the 
wholu aiiack is over, soiiietimes forever, but uaually only 
to be repeated on the following night. There art- children, 
especially thow; of lymphatic appearance, with liy[HT[ihi»ia of 
the pharyiigi-al and iwlatinc].s, whi» are fiTipH-ntly visited 
I)y sui'li alaniiing attitcks. TliLs iiiliiinit of chitiln^ii, originating 
in the sub^oitic swcllhig desrrilwd, iho syni])toni9 of which are 
similar to thoftt* cf ivaJ diphthcrilic "rmup." has hmi termed 
" pseudixnmp." Tliis iiiucli, howi-vcr. is ctTlain, rhitt nut unly 
the xiihghitic sweUt'iig, but every other kind of sweUing in the 
region of tlii' larynx, is prone to excite these attacks of ''iwinnliv 
croup" in cliiltlrcn, on aecoinit of the natural narrowness of 
theinfantilo larynx, though I do admit that the "cmupouHCounh" 
is more liable to occur in subglottic catarrh than in other affec- 
tions of the larynx. 

It is not altogethi-r beyond doubl whether the mechanical 
inipediineiit 6f respiration, due in mihgluttic swelling, ia suf&- 
cient to excite Ihenortunial attacks uf " [tsen(lo-<:roup." It may 
be quite possible that jnst in the nTUinlwnl )*osiHon — exactly 
as in the case of the lliwal ravemovis tissue — some kind of infiltra- 
tion of ihc nuieons and suhtnueons tissue ocTura. which rauscB 
transient cihstniction of the respiration. Tlic sugK*'-*<ti™i 'Iwit 
the fieeretions are inorf liable to dry during tin- niglit, and so 
conso(]ueutly would block the riina glotlidis, is snmewhat far 
fetched. It is mthcr *iue lo ihe grealer liryness of the inurous 
membrane at night (hat a spasm of the glottis is excited by a 
reflex,— more es[W(!ially in l>7npl»atic and irritable children 
than in ather», — a]id that the loud cough, as Gotlstein points out, 
may hi- explained by the explosive cxpiralor)' aepamtion of the 
q»aniodieally closed glottis. 

Lar)Tigitis sub^oitica is. in my experience, not infrequently 
met with m adults as part also of a genera! catarrhal laryngi- 
tis. This might in some cases, perhaps, Ix- due to inflammation 
•spreading more deeply, t. c, int^ the submucous tissue. (See 
p. 439.) 

Other chronic ppoecsses also, such as ttiberculopis and ecl&- 
rouiH, are often awociated with subglottic inllamniation. 



DiaED03is.^AltlimiK;li (hi- anamnesis and sj'mptoms alone 
will v[:r_v i»fk-ii iicniiil »if di:ignosis. only the niirrDr will show 
us the L*xa«^l cxttiil and intensity of the disease. The subjee- 
tive and uljjtH^live syniptonis. however, need not always be 
in direct pntixirtion to what we find Ijy the liiryngosoope. One 
person will s|K'!ik wril, tlumgh liis vueal eonts nuiy be verj' rod, 
and nnother \vill cotn|ilain very much of functional and other 
disordei-s yt*t. we iniiy not be able to discover any very marked 
chanRe.". M. .S'fAmtrf( contends Ihat the functional disturhanccs 
in the latter case arc due to muscular incompetrney. (.See p. 
5S6.) In some cases the diaRiiosis is less easy if thi>re are erowiuns 
or if only eerlaiii eircurnscribed [mrtions are swollen. If there 
is niily a uniladrnl ^uvlling of the focal cords, the ilinejise it usw 
oily not a simple catarrh, CleneraJIy. catarrhal larytigitis doea 
not often lead to defects of any \'en»' marked depth, and we should 
bear in mind that such deeper affections are murk tnore/retpiently 
caused by iubereuloJiix, yypltili.s^ and similar ''dyscrasias," etc. 
The greatest difficulty that we ex|)erienoe is met wth In young 
children, because of the re-sislance they offer to laryngoscopy, 
although we niuy succeed much ofteiier than we cxju'Ct. Dur- 
ing an attack of dyspnoea introduction of a mirror is, of course, 
forbidden. From the attack itself and the diflforrntial diagnosis 
we will l>c abh' to decide whether we have to dotd with a cafic of 
" pseiHld-cnnip" or diphtheria, and (he diagnosin, thiTefore, nnint 
lie ma^le by other means than by (he mirror. If th<' rt-hitions 
n'|i«trl thai the little patient was (juile well befon! the iioetunial 
attuck, if we do not find the ominous membranes in 
mouth or throat, and if the lymphatic glands arc not swollen, 
then it is probably a case of " pseudo-croup" with which U'c have 
to deal. 

Prognosis. — The prognosis of acute larjTjgitis is iwually good, 
though the tendency to pass into & chronic laryngitis is not 
excluded, more especially if Ihe pntient is cureless and the disen.sp 
frer|Uenliy recurs. The alaniiirig |wudo-ertmp also iwrmiis a 
fnvoumbk; piogiiosis. 

Treatment. -Ai* reganl« general treatment, the same niles 
an- available :is for ariite rhinitis. In the tnon.- severe cases, 
however, the palieni should n-inain at home, anil if then: be fever, 



should !>€■ kept ill bed. In mild rases these measures am not 
nocessarj', but b inclement weather the patiait is certainly 
belter at home. For the rest, sweating or /Viessnitt cataplaatii* 
niay he ordered, and the i»ilietit advised to speak att tittlf as is 
in'pe.^san.'. iind then only in whispers, and tobaeeo and aleoholica 
filso iimst be discontinued. Beveniges ought to be neither (oo 
hot nor loo culd, and in severe infliininiation iee at the begiiming 
18 ver}' useful. As elsewhere, so in thepc matters concerning 
laryngitis, I'xpenencc tenches. In marked irritation narcotics, 
and in dr>' catarrh expectorants, mut<t l)i- prtwcribiil. I pn'fc-r in 
the latter ease to prescribe, according to EichhorH, nn infusion of 
ipecacuanha with iodide of jxitassiuni. mid luti-r on. cither mor- 
phine or codeine. (See p. ;i[(3.} In onler to stimulate necrt-lion, 
inhalations will be found beneficial. (Sr e p. 39S.) Some patlciita 
again experience marked discomfort fmni inhalations, and alito 
cough more. If this l>p so, then inhalations must be discon- 
tinued. On the whole, it is well to abstain from ordering and 
prescribing too mueh.ns in any other acute infiamnmtion, for it is 
veiy likely to irritate ihoninrennd to only retard recovery. Gar- 
gles, whicli have, »n to speak, beeonie traditional in the treatment 
of acute phar;*ngo-lan.iigitis, must be forbidden, because tbcy 
intirfcre with the rciwise of the larynx, apart from the fact that 
gargles iK-ver come into contact with the laryngeal mucous 

Many cjwe.s of acute laryngitis recover without any local treat- 
ment. If, aftiT the siilwidcnce of the acute stjige, there arc still 
»niw remaining |n>u})hw, such a-s buming or Jrritatioii, or should 
the mucous membrane not assume il8 foniier appearance, 
only then may one Irj- to paint or brush the mucous membrane 
over with a 2 per cent, or 21 per cent, solution of silver nitrate 
twice or thri«' jkt urek; and should this fail, then resort, must 
be had to stronger solutions. For the crusts and scnbs, the 
application of todtde of potassium w best. A weak soluti(ni, 
&» is wed for pharyngitis, is prpferatilc. (See p. 253.) 

In children acute laryngitis ought to be treated somMvhat more 
actively. Under all circumstances they must be kept in bod, 
and Ihe room ought to be well ventUated and moistrncd by 
means of boiling water or by sheets soaked in Kuter and hung 


up. Pries«nUz's cataplafims should bu ordered only where "il is 
{lossihle to kcfp llu-iii in tlic right positiori, and inhalations 
should not bt! onk-rud at nil. For U-vcrages, much wami 
milk, with or without mineral water, and k-inonade, etc., are 
mosi KuitaI)Io. 

If it is neeessai-y to pre.scribe jwriit'thing, an expectorant or 
a weak solution of iodide of jxitiissium niiiy be given, and in 
eases of nmrkwi irritation, ciwieine may be ordered. 

An ^(tapk of " pseudo-cKUjj" is best treitted by local deriva- 
tivct^, \'iz., hot sponges placed on both sides of the neck. Of 
ccurao, the water used for the sponges must not be so hot as 
to wLUse any scalding. If one cun indure the child to partake 
of reivlly wann drinks, then l\m in .■iLso apt to shorten the attark 
by stimulating the perspiration. I'>iietie-s arc .-iu peril uous, jind 
intubation or traebcotoiny should never be ri-sorled to, as the 
prognosis ia always gOfjcl. 

Etiology. — Plilcj^inonous laryngills, which not only involves 
the nmi'ourt nienibnine, hut chiefly the submucous tissue, is due 
to inflation by pyoj;enic baelcria which have immigrated from 
the eurffloe or neighbouring organs, or even from far-distant 
parts of the body. If we notice distinct gaps in the epithelium 
of the mucous membrane, we ehouliJ not hesitate to assume 
that infertion has taken place from the surface. Thus is ex- 
plained the phlt^fmonous inflammation which womctimea occurs 
gid)sef|iiently to tubercul<>u.s. diphtheritic, or typhoid ulcera- 
tion, or after injuries or bums. We should not, however, 
forget that even minute lesions of the epithelium, unrecognisable 
by the larjmgoscope, are capable of admitting inflammntor>' 
germa which may enter the larynx by air-current or othenvisc. 
The various stimuli which play a role in the etiology of simple 
Inryngeal catarrh tend to foster the entrance of mici'o-orgttnisms. 
A priori, it may be assumed that cvcr>- laryngeal catarrh is 
capable in due eourec of spreading into the submuoous tissue, 

*Thc tonii lar^ngttU siibmuooaa wtuIa (hcul^ aubmupniiii UrynRitEO 
xfctDH to me \vH» Huitnl>le llmii larynfEiliit pliIegmoniMft, lici-.iiini> not only th« 
subinucou* liiwic, but th# inucoiu membnine, u aUo nfT«c(«d. 



ajid this fact is corroborated by experience. One frcc|Uontly 
sees, in persons suffering from lan,Tigeal catarrh, who mal- 
tK-at their voices and siuoke and drink <-xcc8sivcly, that 
their catarrh bcconira tt-orae, which fact jKiints to a eprcatling 
of the process uito the deciKT tissues. 'Hie deeper spreading 
of the inflanmitition into the subniucous tisiiuc, with the sub- 
Bi-qucnt ensuing increase of intcnsiEy,nisy be due to the fact that 
an extensive infection of bacteria has taken place under the influ- 
ence of the new stinmH, and that their viralenee hiis been 
intensified. Another source of infeelioii exi.sts in nny 
occurring in neighbouring organs, e. g., angina, periloneillitis, 
glossitis", paretitis, and angina Ludoviei, Larj'Tigilis, following 
or in Hseociation with ncutc infectious diseases, is probably of 
haeinatogenic or lyiiiphog<}nic origin. Tho grrmn in these 
types of disease are apt to produce sui)puration, either by them- 
selves or in conipiaay with streptococci and staphylococci (ao- 
collcd "mixed uifeclioii"). 

Pathology. — The submucosa is the part most concerned. 
It is infiltnited by scmpurulent or only piiriileiit exudation, 
which in the latter ease leads to abscess. The mucous mem- 
brane, where it is iiiflametl, is swolJeTi, dusky, and very frequently 
ocdematous. This " inflammatory ocdi'nia/' whieh must be con- 
sidered merely as a tJ^TUjitoin of submucous or pi'riehondritic in- 
Haitiirutliori, huA bvvjt foniicrly dcwcriU-d as a disi-a.'if sui generis, 
probal)Iy because, as it was the most conspicuous change, it 
was scon, whereas the deeper pro<'esg escaped observation. 
According to the investigations of Kutlncr and P'dix 5«M(m, 
this " inflanuuatory oedernii." wliich is caused by scropunilent 
exudation, must be distinguished from the non-inflammatory 
''congrstive" oedema, which is (lie result of a simple serous 

The " congestive" or " laiyngeal oedema" (wr /f^/iii-) occurs, 
just us does till' wt'll-knnwii cut!intf>us iiedcnia in the region of 
the Jtnkles (»r pyelitis : in all di.';rjL«<'s which favrmr the oecurrenco 
of oedeiria, both gencpally and locally, e.g., in diseases of the 
hwirt, of the kidneys (often as the first symptom), in. anaemia 
and cachectic conditions, and in processes whea* the venovis 


blood flow in the neck is obstructed, as in goitiv, glamiiilar 
BWcUinga or tumours, aneurisnis, and new-growths. 

To this class of "congestive" optlemn liclongs alwi thfi ocdwna 
observed after prolonged use of iodide of potaif^iuni, and the 
oedema sometimes oreurriiifi during the flow of the nienseB or 
duiTJiR lh«' elinweterie. Sinifnmj hiis di'scriljcj a wirt of anffio- 
neurolu' tmtema of I he tari/tix which tnanifi-Hls ilwlf hh a kind of 
urticaria and is usually associated with a similtir eruption on 
the skin.* 

The phlegmonous inflammtUion tmturally selects the best 
conditions afforded for sljirting and eonlinui:ig to spn^d, and 
therefore tends to occur just where the subinueous tissue is nor- 
mally in greater quantity: or, in other wonis, where the mucous 
membrane is only largely altaehcd to underlying struetures. 
(See p. 356.) The same remark is appliealile to "congestive" 
oedema. We therefore find n-rtain silos of predilection, viz., 
the anterior (lingual) wurfncH of the epiglottis, thf arj-epiglolUc 
folds, and the arytenoid cartilages in the first line, and in 
second line come the ventricular folds and the subglottic region. 
In former times the oedema occurring at the aditus Inryngis 
VSA commonly called "oedema of the glollif," though actually 
"(he gloHin," in its old sense, that is, the rinia glottuIU, never is 
the xcat nf oedema. Hajek has demonstrated, by injections 
imidc on the corpse, thiit the phlegmonous oedema or submu- 
cous infiltration is regulatctl, by the lines of developmenlal 
attachment of the submucous tiswies. Thus he proved that the 
ocilcriiaToiijj iiifiltmtions of the anterior Hingual) surface of the 
epiglottis ni'VET ]t}i,s«?.s over the fn'e margins of the eartilagi.' 
into the insiiJe uf tiie larynx, while that of the aryepiglottic 
fold again i.s kept back by the pharyngo-epiglotlir ligament 
from spreading in front; so that it quickly extends on to the 
posterior wall and pyriform sinuB. 

SubgloUic pklegmonow infiltralum fphlegmonous Mibglottic 
lflr>'ngitis) often oecuits indcpetulailUi of any other ili-tea-M' fin 
marked contrailislinction to nubnioftir cutarrh), or in conjunction 

* It miidit nrilApa bo doubtnl vrdclher thr x>c<Icnia rollnn-ios the une of 
iodine U aienjjr eonflestivc, or nhflhcr i< iiiiKliI tiut l)e uf an iaflammutoiy 
nalurv, Iik« ihe cor^ia nlao arinnic from th« uk uf iodine. 




with an inflanimation of th*> (rechca. Phiet/monom oedema iii 
fiubinucDU!* inflammation is usually localiscft lo the «1^' of iii- 
flammation or to th»' ininiotliattHy .surniiuiclitig tissue; but 
*' amgesiive" oedema, on the other han*I, is diffu.tetl arid not 
ItmUed to one locality, and is inclined to spivad further and 

Symptoms and Course. — ^The syruptorns and course differ 
acex>i*ding to whether the phlegmonous iiiRanmwtion is dtffuite, 
or ivhelher it is hcafhj defined. 

(I) Circyni-scribed phlegmonous inflammoHon may sillisidc 
spontaneously, or lead to the formation of an alwieesa. The 
epiglottis is the part most eonimoiily uRcptcd. (See Figs. 151^ 
152.) Sonietinics it originates or is excited by a slight injury 

FiK. 151.— "Contp-slivc" ofdcinii 
of arytenoid carfilagca ainl urjcpj- 
glottic loltiv. 

nosA cimimatn'ipta. Abscess o{ e|ki- 
iJottie {.Turtk). 

received when eating, and either commences in the base of tha 
tongue, or it pprwulfi from the lingual surface of the epigiottis on 
to the root of the tongue {plosso-epiglottiu phh-gmon), or again, 
on to the aryepiglottic folds. h\ other cn^Cfi the Aryepiglotlic 
fold? are the primary bcM of the inflaiiiiniitioii, or yet ag&in 
the ifgion nf the aryU-noid earliliiges, Ic-^s frequently the vcn- 
trieular folds, and. least often, the vocal eonls. 

The disease stflrt*! with fever, ]>»in on swallowing, and hoarse- 
iiess, and sonn enuws dyspnor-a if it spreatls further. By the 
lar^'ngi.isc<»pe one is utile U) note, more or less well de^nixl, a 
ciretnimacriheil n-dne.'is and swelling, which Honii incrrasea and 
is HceomiMniied by <ie<lema of (he adjaeeiit tissue, and leads to 
abace9@ formation. If (he epiglottis is affected, it flp|x>»r>< bright 
red and eiionnuusly sn-oUcn. llic vaUcculae and the ary- 



opifiloltic folds show oeflema, which is manifcstiHl by their 
glassy, trajisluoenf, pclatiiiouH, or inucoua-polypun-Iik<? apiicar- 
ance, and vibration during respiration. Thy view iiiin the hiiynx 
obstructed or rendered imposablc. The oedenaatouB pads, is 
cepccially ihosc of the aryepiglottic folds, iirc aspirated into the 
larynx by the inspired air-current, and agRravate the existing 
dyspnoea. In some rnst^ the yellowish. ti'anBlucent pus ciin 
be seen bulgiitR. Theabseess usually bun*t8 at the margin of the 
epiglottis or on its lingual surfaee, or scnu'titnes a little nearer 
to the tongue. The pus being thus discliargetl, the inHammation 
quiekly subsides. 

(2) Dif^tixe niFipnonoux fnfammoHfm. — The onset of the 
diffuse phlegmon is more or less aeute and ^lent, and is 
characterised by pain on su'allowing, radiating towards the 
ear (which, however, in unilateral infianuiinlion need not be 
excessive), hoarseness, and rapidly increasing d.vspnocn. On 
examination one finds the mucous membrane to a varying extent, 
on one side only or bilaterally, enormously swollen and red; 
and Inter on, perhfl|». ulcrrati'd. In t^ubglottic inflanimation 
the same itxi pads underneath the voeal cords, as in subglottic 
catarrh, are visible, but are much more swollen and n-rf, and so 
may considerably narrow the rima gtottidis. The affctlion may 
here also he limited to one side only. 

Entsiiielas and the so-eulled acute phlegmon have been con- 
sidered as Fpeeial forms of the dilTust^ phlegmonous inflamma- 
tion, as is the case with the pharyngeal phleginon. It was pro- 
nounced eryxipelas if the iuHaiiuTiation started with high fever 
and was accompanied by an extensive collateral oedema, but 
without any tendency to suppuration. Chi the other hand, it 
was i«aid to be anitc jJilcrjnion if. in npite of nimlerate fi-\i*r, the 
general nyniptonis and prostration were very marked, and if the 
mucouH membrane wan more taist- mid showed punilent infiltra- 
tion, lioth these processes are difficult to difftiiigiiish and to 
difTerentiale fnmi other iihlegmonous affeetion.'i). One i.s, how- 
ever, justified in ajMuming the pn-seneo of erysipelas if other 
organs, viz., the *kin, show ery«i[.H'latou« disease. Practically 
speaking, all ihtwe fine flislinctions are not of any great Im- 
ponance. Fiilfgiiioii of the trachea is of rare occurrence, and 



consistii mostly of a dm-ct eontlnualton domiwaKLs of a like 
condition already (.'xiutiiig in the lar^-nx. 

Diagnosis. — As the clinical syn^ptoinB are not very char- 
acteristic, diapioeis can only be aiwurcd by the use of the mirror. 
Unfortunately, the liirynKcal ex:imination is often retidcred im- 
possible because of the sweUuig in the aditus laryiigls; but in 
some cases phaiyngoscopy might help, as it is possible thai, by 
depressing the tongue sufficiently, the epiglottis may bocoi 
transiently visible, and so admit of an inspection, at least for a' 
few momfint*. \\'here, however, laryngoscopy can be per- 
formed, it must be done, and it will give ua the information wa 
need as to the objective symptoms imd th<'ir site and extent. 
Oedema is not to be easily mistal-;en, for it presents quite char- 
acteristic featurcF, viz., the oedemalous parts look jclassy, trana- 
pari-iit, and imparl the 8CJi.satiou of a soft Imt ela.slie coitcistency 
if the pn)bi; i* aj>plii*d. More difficult to decide is thvi c]iKwtion 
whether there i« " inflammatory" or mere "eongeative" oedema. 
Ill iTifamnmtitry oedema other signs of inflammation are UKually 
present besides the signs of oedema, whereas cojiaestife oettema 
U distinguished by its pallor and :ibwnce of inflammatory symp- 
toms,- It is, however, very important, in order to arrive at a 
definite conclusion, that the whole body should be siibmilled 
to a tliiirough physieai examination, especially the heai't, kidneys, 
and lung^. 

Prognosis. — Phlegmonous inflammation is alwaj-s a scrioua 
disease, and one which may end in death by suffocation, and in 
less rapid, but, nevertheless, progressive processes, as septic 
inflnmmation within the mitliatitinuni, pleurisy, pneumonia, or 
genera! Hepiieaenrm. Tiic- fatjil exilus may aometimcs occur 
quite suddenly find unexpectedly, espceiiilly in oedema of the 
aditus laryngis or in subglottic inllanunation. 

The proifnoxw is af»«>iutrly bad if lh(r primary cause of the 
inflammation or of Ihe ciuigi'slive oedema i.s itself incundile. 

Treatment. — Thn incalculable rapidity of the course of the 
disease requires ean-ful watcliing. If theiv is danger of suffo- 
cation, no time ninsl he lost in pcrfunniiig irHchciiUnriy. Iniit- 
bation, which has been suggesled, v< amlm-indiailed in oedema. 
(See p. 425.) For the rest, one must conader, if possible, the 



etiology, e. g., if there is any suspicion of a foreign body, this must 
be sought for, or an ab«'cjw in iUv neighbourhood must tje in- 
cised, etc. Treating Hyniptomaticiilly, wu may at first try 
antiphlogistic methods, i. «., ice applieationfi, iced bcveragrs, 
and fnifihed ice internally (iee pitl.s). etr. 

Menthol pastilles are sometimes very useful in some cases, at 
least, in th4> milder ones, and insufllation of rcnoform powder 
is worth a trial. Should the patient ohjwt to cold applications, 
then Friesanils's cataplawns an; a better substitute, while Iwches 

6 c 

nU.Bf. / y A 

Fw. IM. — l^ngu^Lrdpt] lui^n^oa.) knivca (aft«r 
fl. Fr^inktl): u, Lam-et-kiiik- ,witb movable 
haiiillo(««irtrii>u.tur);t>, loiij* Iii.i)«>t'L(nif« : ^, short 
iatiPfl-kniti-; ./, riRhl mining knife; <•, Ml cut- 
liii)! knife: /. jioinipil kiiKo, I'ullitnj furwiirtlB: 3 
liUMiiiii'il kiiiUo. i-ulttitK roru'^inls; h. buttoned 
knife, liiii.-k\v:Lnfi>. 

Fin. lM,«I 
Iftntieca] knifo (after 

and mercurial ointnienl rubbed into the skin over the lar>-nx arc 
of no practical value. The patient niiLst keep abwilutely silent. 
Sli^l inJlammatiui) may Kui)»ide under this treatment. If an 
hbscew* is foniiing, wann ii[}plii'atifiii.s and ixrhapM gjugles may 
beonlerrd. Hut if Ouetuatioii ha.s Inen found, (he ab«'e.«fi must 
in- inciw-d without delay by niefttis of u lar>iigi-:U knife under the 
guidanci; of the mirror. .\cconlinK to SchTiiller, llie cpigloltis 
should be tnei-sed fmni alx)ve ilownwards, while the arytenoid 


niSEASBs or -niE larysx ani> tkachea. 

cartikgt* shoiilil Iji- puiifitmHl stmiglu iihead iind tlu' punoturo 
dilfttPil iMickuanlii or liitcmlly tnuiiixLs ilic arj-cpifilnlliL' fokts. 
If the swoIliiiK <J(x« not at once .tutmiiU', thf oedt'inmuus parts 
must be gcarifiod wiih n Inn-ngc-al scarificator, after prcWotie 
local anaosthcffla. In cases of urRCDcy a Ions; bistourj- may lye 
usttl whose edge h&s bcpii guarded to J cm. froui the ixjiiit with 
plaster. (See Figa. 1a1, 154.) 

The "congestive" oedema, which wc have discussed hen? only 
for the sake of convenience, must hv treated on the sjime lines ns 
"iiillammatory" oedema. Uul it is veiy im|X)rtant to attend, 
secundum arlem, to the primary disease, as the case may I>o, 
which has given rise to the "congestive" oedenia. 1 1 is very 
nwcssaiy that the Ixiwels he made to art properiy, and we will 
find ii useful to help that aetion by .salines ("bitter salt"). 
In any case the condition of the heait denimids our greatest 


Exudatu^ infiammotions of the larynx air altogether of rare 
occurrence, and if they occur, lliey are usually continuous or in 
conjunction with those of the oral and pharyngeal mucous mem- 
brane. As has been diseu.'<sed (see pp. 1S6 and 272). it consisls 
of n separation of the epithelium in fonn of larger or small-sizt^ 
vi'.sielr.s, the conlentsof which are either serous or purulent, and. 
stiU rarer, are haomorrhagic. Similar to the eruptions on other 
mucous membranes, ami in contradistinction lo those on the 
skin, these x'esicles show very Htlle persistence, and btiret ao 
80011 that one iloi-s nut usually see them in their first (un- 
broken) stage; l)ul they conieuuderour observationas erosions 
orsnmll ulcers after biweting. Vnique cases have been reported 
in which the lar>iigcal affection, e, g., herjx's, pemphigus, etc., 
has occurred in the larynx only, or was a primary disease of 
the larynx.* 

In herpes and pemphigus the eruption very often ivniains 
localised on the epiglottis or arytenoid cartihiges, and at other 
limes the entire larjiigcjJ mucous membrane might be affirted. 

Symptoms. — Apart from general symptoms corresponding to 

• KibrirTtniH iiifluniriiut ioit and |wcU(Joiiiei]il>ninoiu (iliplitlieritic) coo- 
ditioM will 1n> (tiscuHMKl Ul«r on. 



the seat of tlie eniption, there an- h^j.-irsem-ss, ilyspliagia, and 
prtin on sivnllowing; soinetiinc!*, however, all the symptoms arc 
verj- mild, and only a stnisalion of soreness is compliiined of. 
Dyspiioen niight hv prt'seiit tn ii slight or more scvpit ilegroe. 

Diagaosis. — Owing lo the tninsieiit imlure of the nffeetion, 
diagnosis is often difficult. In numy cases severe catarriiiU or 
even phlegmonous laryiigitis, — and if patches, or pseudomem- 
branrs arc preMnl whirh unit<' together,— diphtheria, sj-philis, 
or the effirl «if fauwUes may be simulated. We should tuil fail, 
however, to miike a. diagnosis by noticing the presence of 
vesicles or analogous eruptions mi the skin or other mucous 
membraneji; and by its coui'mp also wo will be able to eoiue to a 
correct coneliisdon. 

Treatment. — Treatment can only be symptomatic, and will 
be almost the same as in the analugoiis diaoaKcs of the mouth and 
pharjux. If the sorein»->« in very unpleasant, menthol paistiUes 
and inhalations of menthol oil may be oniered. Should a simple 
steam inhaler be at hand, a vapourisation of peppennint oil may 
be prescribtJ: 

B- 01. tnonih. pip. 2,00 

Spiril. vini .. .20.00 

F. .M. Sia. — Twenty-five drop* ta lli« pint of hot wntnr tor inhalation. 

In Special cj»«es pa.Lnting the ufTected parts with weak solu- 
ticBifl (I t^) 2 per cent.) of «il\Tr nitmtc may be tried. The 
voiee ini].st Ik- restccl and spared iis much as possible. In pem- 
phigus arsenic has provL-d very beneficial. 


Etiology. — In the majority of cjlh-.s rhronie laryngitis is 
associoted with chronic rhiniti.'5 and pharyngitis. The sjinp- 
toms eiuised, howi-ver. by the chronic lnr.'ngeal eatiirrh anr often 
8o marked and pretlominatirg, antl an- so much more complained 
of by the patient, owing to the greater diswnifort of the. larymgeal 
afFeetioiis, that the sinnillaneous eatarrh of the nose and pharj'nx 
an?, for the most part, overiooked. If we lake into conj«iIera- 
tion the atmlomieal and pathologieal relations, wc can easily 
sec that iho same Irritant agents which cause the noee and 



thf pharynx to become diseased will also act upon tho lurynx. 
Tlie Ptiologv- of chronio lamigcjil oalarrh is, tlu-irftire, idwilioal 
wiih tiutl of ohronic rhinitis or phannptia. As hi the two latter, 
80 also does a chronic laryngitis ariw out of an acute eatarrh if 
thfi Inlier liaa liad no previous np|x)rtunity to g\-i wdl. On tho 
other hand, chronic catarrh conu-s undtr our notice, even 
though an arutc stage was not previously noted, mostly as the 
eonsequcncL* of chmiiic coiiEcstion of the mucous membrane, if 
it. has l)een constimlly exposed to irritation, no matter how 
triviiil. I'rofcssional use or abuse of the Xxice is one of the 
most fre<|uent causes of chronic (.irvtigeal cat:irrh. From the 
foregoing it may easily be understood why men, esjaerially those 
of middle age. are more subject to Inryngeal eatarrh. 

We should like here to say again that the secretions from 
nasal and pharyngeal *li.«ease, flow-ing backwards, often rnn 
down into the Urjus, where they keep up a sort of chronic 
irritation of the lo-nTr air-passages. This is fostered by the 
eircuni.stance thiil in chronic na.sal and pharjnigcal crttarrh 
mouth-brealhing i.s vc-ry cummon. Chnmic iiifi-ctiou.-' diseases, 
such as lubemilosis. sj-philis, and congestive (plethoric) condi- 
tions, aggra^-ate the pn-disiHisilion lo chrrjnic IJL^\^lgilis. 

Pathology. — Cb:ir;iel eristic of iltninic Inflaiuuiations are 
the hypcrtiijpby and liyperpla.sia of the tts-sucM, whirli an' either 
diffuse, i. e., common t« all pnrlj? of tlio mucous membrane, or 
opcur (inly in certain pmiions. In wime cjtscs the vessi'ls are 
chiefly concerned: they arc dihited and varicose, and especially 
80 on the cpiglotli.'* (phlebeetasia laryngis). In other cases the 
q)ithclium is more affected, and is thickened, scattered over 
with excrescences, and fhrnvs warty or irregular growth.*? (pachy- 
dermia laryngis). Pachydermia is mostly seen in the tracts 
<rf Btratified epithelium. vi»., on the inner surface of the ary- 
tenoid eartUages. on the vocal cortls, and on the po-Herior 
larjTigcal wall: but even the ciliated epithelium niny also be 
affected, and assimie an epidemioiil character a* the result oS 
metajjlasia. The nmcosa, and if the process tie more advanced 
the subniucofiii also, is infillnited with round cells, and the 
connective tissue, at one place or Hiniibcr, U augnieiited in 
quality and quantity. Thus the indnniniatdry hyj)erplastic 




process, more cspccJidiy in Iht- rt'gion of the much-abused 
vocal corils, leads in due course to a scries of changL'« which 
must be distinguished according to their site and appoaranei?, 
but yet are of the same nature, as we have sooii. These changes 

(1) Chordiiis htberosa (tuberous inflamnmtion of the vocal 
corcis, also called trachoma of the vocal cords), is characteriBcd 
by tho lumpy or tuberous surface of the vocal cords. 

(2) Chorditia nodom (nodular inflammation of the vocal cords), 
tlie HCJ-callcvl "singer's nodex,'' is seated on one or both edges 
of the vocul cords, and is produced by a circumscribed hj-per- 
plasia of ihe epithelium iiiid sidiepitliehal layers. 

(3) ChontUii hypertrophkn superinr (upper hj'pertrophic in- 
flammation of the\'oca] conl«), starting originally from a h}'per> 
trophic catiirrh of the veotrieular fold«, and spreading on to 
the upper surface of the ^'ocal cords, leading to thcfonnation of 
l>nds and polypi projcctmg into the larj-nx. This condition 
IB also called "prclapsus ventriculi Morgagni," because it simu- 
lates & bulging out of the sinus. 

(4) ChordUii hjpcrtrophica inferior (lower hypertrophic in- 
flammation of the ^-ocn! conJs; also callctl chrorn'r .•^uhjhiitir laryn- 
gitis), which U characterised by hyperplastic enlargement of the 
subglottic R'^on. .\11 these four forms, :us well as pachtjtlermia 
lari/ngis, n-present the results of chronic inflamnuilJon. and are 
to bo considered as varietiea of chronic inflammation although 
the ''s-ingcr'.'i nodef:" and the ventricular enlargements show the 
appearance of new-growths elinieally, and tho subglottic thieken- 
ing \a described by some authors as a fonn of scleroma. 

As in acute catarrh, so also in chronic catarrh, the muscles or 
groups of niuHclcM Ixcomc affcctitl. arid this nmnifests itself by 
piin-sis or paralywi^ of the sjieeial niuwular fuuclinns. 

The sccn-tions difTrr in quality and rjuantity. If the nceretion is, 
for the most jKirt, piinilnit, Ihi- catarrh Ik then.tiMiken of as being 
a chrimcf bU'nnorrhm (Stork) : but it may ]iki'wi,«r p(;rii;ij>s lie of a 
scleroniatfnis na(un.\ Kxsjccation and thickening of thew-cretion, 
and funnation of crusts and scabs, arc the feiUun^ of dnj caforrh 
(laryngitis sicca). The .^i-eretions may hf derived from the 
larynx or trachea; and tho mucous membrane of these jmrls of 





iliL' uir-passagp then shows ihc same alterations and changes as 
arc found in the mucous membrane of the nose and phar^tix in 
atrophic rhinopharjiigitis, fo«tiJ or not foetid (ecc I*art* 1 and 
III, |)j). 75 and 194). It Is, h(nvi-v*T, not yr-t proved whclhcr 
the hiryiigeal muenus nu'riitmun- IxTdiiies actually atrophic, but 
having reganl to its appi-aniiice, one would 1)0 inclineti to assume 
that it was. Occasionally, cases of "hrynyeal ozaena" have 
heeu described. In long-standing catarrh the vocal corxLs and 
ventricular folds may indeed become thinner, so that the inlen'al 
between them (the o|Rrning iutn Morgtujni's sinus) might gape 
widely; and in this ease the epiglottis and arj*o pi glottic folds 
may likewise become attenuated and thimier. It may, however, 
be dotibtcd if this is really the result of a chronic catarrh tcndiiije: 
to atrophy; or whether all these thinned parts have not been 
actually thinner than normal, and less developed from the vcr\* 
beginninK. There are many persons, quite healthy, audsliowing 
neither signs nor sj-mptoms of catarrh, who, however, present 
a veiy thin and small epiglottis and arj-epiglottic folds. 

According to M. SchmitJi, there is a certain comiection be- 
tween dry catarrh and jtachydermia. The thickening of the 
stratified epithelium of the jjosterior wall and of the arytenoid 
cartilages is due 1o the constant irritation caused by the dry 
secretions and the straining as the result <if frequent coughing. 
Jtf . Schmidt has observed packydermic, which he aptly tcrvaa 
"come of the larjTigeal mucoua membrane/' but almost only in 
long-standing rhino pharmgitis. 

Erosions do not often occur in chronic laryngitis, and if ulcers 
an* found, it nearly alwajf" means tuberculosis or syphilis, though 
this might be diflicult to pmve in any given case. 

Symptoms and Course.— The subjective symptoms are more 
pronounced in the dry than in the secretory form. Generally, 
there arc complaints of drytiess. irritation, tickling or burning in 
the lar>-n.\. which becomes still more marked during speech and 
singing, and gives rise to frequent cough. If the phai^Tix is also 
affeetiMl, the discomfort is mcreased. 

The patients do not mind so much the alteration of the voice, 
provided they are not iKirsons who, by their ])rofession, have to 
live by their voices. Disturbances of the voice are usually 


milder in the chronic than in the acute catarrh, but, naturally, 
the scantiiT the wrrctions, the greater the tendency to exsicca^ 
tion and ihe formation of scabs, the more the voice will be 
altered, even to the extent of comjilete aphonia. But setting 
this aside, it may be said that the voice i\-ill suffer in greater 
proportion the nmn' pronouneod the pathological changes of the 
vocal I'ordsandihfimirc Iht- voral cords have lost thpir capability 
of normal vil)ratinn. Diffuse, or still more so " iraehomalous," 
thickening of the vocal conie and extensive pachydermia are all 
much more apt to alter the voice than the so-called "singer's 
nodes," which latter, however, disturb the voice only when 
speakuig softly or singing, because it is easy, by a certain amount 
of straining, to overcome the slight hindrancp and so to close the 
rima glottidis. 

It has been already pointed out that inefficiency of single 
muscles or groups of muscles must alter the voice; and this is 
probably one of the chief causes of hoarseness in acute or chronic 
oatarrh. The voice, in the morning especially, ia veiy raucous, 
!is during the night the secretions have accumulated in the larynx, 
iind relief is only obtainitl whcTi the mucus has been brought up 
by coughing or after gargling with warm gargles or drinkuig hot 

LarvTigoRTopie examinntion shows a series of pictures exartly 
rorrei<l«iiid'uig Ui th<- anatomical changes. In the mild cases, 
only insignificantiy abnormal signs can be discovered, and a 
very strong light is re<]uired in some cases in order to discover 
anv alterations at all in the colour of the vocal cords, or an 
isolated swelling or redness in the region of the arytenoid cartil- 
ages, or a thickraing of the posterior larj-ngeal wall. 

In other eases it is just this thickened ridge on the posterior 
larjTigea] wall which is most conspicuou.^, anditmaybeeotosucfa 
a degree that the adduction of the vocal cords may be impeded, 
or that, on the attempt to close the rima glottidis (phonation), 
they become folded into numerous lit lie pleats, which appear 
almost as if they were t-xcreseenccri. Hvit that Ihey arc not ex- 
crescences of tlic posterior wall can be seen by the fact that 
these pleats unfold and hccomr smooth diiring deep in-spiration. 
Occasionally, an erosion might be chseovered on the jsosterior 



wall, which, as we have said, is especially cxposwi to tncrhaiiical 
irritation. It is such au erosion which corrwiKiiids to the 
"rupture of the mucous membrane' [Stork). I, myself, liavi* 
only twice seen anything whieh could bt intcrprcled as such a 
"fijigura m!(co.sff." The results of ehroiiic l:tmigit.i.t, mentioned 
nbove, require a aejjaratc description of their respeetlvc laryiigo- 
scopic pictures, 

(1) Pachydermia ianjnffif is often limited to the hindermost part 
of the mHrgiiiK of the vocal eortls. Om? then wch, nn the one 
yide, a rowidcd, oval <ir irn'j^nlnr, a warl-}Jliii[K'il or euKhion-shajx^iJ 
jrrajertion of a f»rcyiph or grcytsh-whito eolour; and, on the other 
side, the corresponding dcpi-ession on the thickened vocal cord. 



Fig. 155. — Pnfhydprmin l«T7,*ngiB. ThirkminK of thp rrtithdlum of tiM 
poflteHor end of tite vucal ponU. Fail-liko {inijectlon (>( cnepOiUffter wall, 
expending icj ihe k-ti vomrirubr (old — lu ) on rcupiratiDn: (,fri on pliDriaiioo. 

One almost has the impression, for the sake of comparison, as if a 
little plate had hecn stuck on to the vocal proecsa. In other 
circun^stanccs the thickening extends niorr fonvnrd, but oflencr 
on to the posterior ■w:»ll (see Fig. 155). The hard and brittle 
epithelium is very liable to bceomc fissured and eroded. In 
very marked cases one may be able to sec a projection, cracked, 
fissured, or \rillou8, which looks at the first glance like a tumour. 
(2) "Singer's Nodes." — ^Tbeae are protuberances of the size 
of a pin's head, round or somewhat triangular in shape, nearly 
always seated sj-ramotrically on the junction of Ihe anterior 
and middle third of the vocal cords themselves, jind iirc uf tho 
same colour. (Sec Fig. 156.1 Usually, one only notices a 
spindlo-shajK-d thickcninp of the edge of the vocal conis, which 
apparently does not iNjrtakc much of the nature of a hyjKjr- 



plasia, for it di8api)fai-8 on closure of the glottis. Thy "nodes," 
howcvt'r, prvwiit the accurate closure cif the vocal rnnls, more 
<-s]jiTiiilIy if tht'y occur on hoth sldt^s, and thus eaust' ilyspliuiiia 
or diphtlirjiiia. (Sw p. 449.) 

A similar thickening of the vocal cortis — nodular or spiiuilc- 
shapt'd — \s not infrequently found in childrwi. I have obsvn'ed 
it in several ca-'w-s of children, who, so to speak, have overstrained 
their voices from their first breath. (See p. 402.) The children 
are often or arc coristanlly hoarse, and cause a lot of anxiety 
to their part^nls, although the pmgnosis is [lot unfavourable. 
Painting the "node-s" i.s nf no viJm-, a fact of which I have 
thoroughly assured myself. It is best in children to avoid all 
local treatment and to exhort the parents to trust in and tn look 

Fig. \X. — CliorditJvDixlHTen (singers 

JIr. 157. — Clwrdii is hypt-rifo- 
pliii'-H wipt^rior (.prolafwHB veiitriculi 

forwanl to the futun*. "Wilh advancing agi> the difTeiviiow will 
lieeunie eiinalised, and so the disorder of the voice wilt disap|)ear. 

(3) Frolapsu/i venlrieuli Morrjagyii must not be misinterpreted. 
That it does not ooiisisl of a bulging out of the vaitricle, but (hat 
it is really a hyperplastic thickening of the mucous membrane 
which projects into the lumen of the lai^iix, has already been 
Raid, The vocal cords are wimctitnes concealed by the n-d and 
oiedciiiHtDu.'s ventricular pails if the afTcction is bilateral. On 
iiKspiratiou the piids tectde a little, i. e., they tajHT slightly: 
while on phnnation they increase and become more prominent. 
It is, mon-over, [jossible to replace them by means of the probe. 
Occasionally they are oedeniatoua and then liave a glassy ap- 
pearance and may show vibratory movements, 

(4) inn/nji/i's mihijlottinz rliTnnica (inferior or subglottic 
hypertrophic lamigitL»*) shows similar apt«'arances to the acute 



subglottic Iar>Tigitis (due to nitarrh or phlcBriionous inflatiima- 
tion) (sec Fig. lijO), with flu* clilTcn-mT (hat ihc stenosis of the 
glottJs produced by thu imtU proJL-cting fruni below \^ not so 
gniit as in the acute discasf. In sonii- paaw subglottic ihicktii- 
ilig is ossociatcj with iMifhydcmiia of Iht' vncal cnnls. 

Tlie larvTignspopio pictiiri- in drycjilarrh need not Ix'seprimtcly 
described, and it only sufliwii to ivfor lu tlu? pHlhoIogical rh!mgt.w 
discussed alyive (see p. 451). 

Diagnosis. —Owing to the circumstance that the cUnical 
syrniilonis arc vcn,' often indefinite, diagnosis must be made by 
mcnns of the laryngoscope. Hut one should not fall into the 
habit of ilcckrinE every "discolouration" or every "dilated 
vein" to be .n rhronie catarrh, even if the patient coniplaina of 
laryngcjil disctinifort. The patient's — it has been repi"atc<lly 
emphasised — capability of referring or localising his sensations is 
uncertain, and all the troubles complained of by the pjiliont 
might have their source in another neighbouring organ; while the 
lurjTix itself may be quite sound save for the slight "discoloum- 
tion" or a ''dilated vein." On the other hand, we should not 
be satisfied with the diagnosis of "chronic caLarrli" alone, but 
should aim at asccrta'ming whether the catarrh is independent ol 
any other di^t-asc, or whether tuberculosis or syphilis, etc., it 
ihi: primary cavusc. The distinction of a iiachydcnnic thicken- 
ing nf the ixistonor wall from a tubercular iiinilraliuu will sonic- 
tiincs be diffioultr inort* so, (mrticularly, if the tliickening keeps 
within moderate limits. In such a caac, if anaemia of the mu- 
cous membrane lie present, vi?.., if the nmcous membrane is 
pide, and if theiv is paraeslhesia (see p. 331), our .'flispicion of 
tuberculosis must be excited, and we shoulcj, therefore, never 
forget to examine the Junps. In some cases Kiliian's method of 
examination of the iwsterior wall will show us an ulcer behind 
the supposed pachydermia, which at once gives another aspect 
to the matter, and shows the tuberculous nature of the diseiise. 
A probationary excision of some portion will need to be con- 
sidcn^d only in a .sirverir villous hy|K'd rophy which pK^vents every 
function. Microscopic examination, however, if ImciUi, or giant- 
cells, or miliary tul)erc]e« cannot lie found, will prove nothing. 
Here only the coursi; of the disca-str will clear nvmy our doubta. 

'CHKtoSlc lAnYNnms. 


So also is the distinction between laryngejiJ ciircinonia aiid pachy- 
dormiii, — not alvrays a Cfrtiiiii dwision if nnc hua only excised 
a small portion for miproswipic I'xiiinination. In jmckydermia 
the epithelium is eometimc's very niin-h (hickcncd, mid conical 
processes are founti grow-iiij; into the deeper tissues, and which, 
under the niieroscope, may very closely resemble the "epithelial 
liearls" ("cell nests") found in carcinoma. It is, therefon?,of 
Rreat importance to remember thai pachydermia mostly, and car' 
ditoma never, occurs on Ike vocal processes. 

Prognosis. — If wc set aside certain forms of subglottic inflam- 
mation in children, and especially serious exacerbations, the 
prognosis quoad vitam is favourable; quoad restitutioncm, 
however, leaves much, if not ever.'tbing, U\ be draired. Nolh- 
nagcl maintains that a catarrh of one month's duration is seldom 
amenable to complete cure. Mild cases, it is true, may be cured, 
but, unfortiuiately, they frequently relapse. There arc many 
imtients, however, who become accustomed to the continual 
discomfort, and so resigned to it. But there are others who be- 
come real hj'poehondriaes. Persons again who have to live on 
the "gold of (heir voice" have much to put up with from their 
sufferings. Kvery treatment, unfortunately, is hampered by the 
impossibility of removing them from their surroundings or of 
even merely mitigating them. The prognosis is still more un- 
favourable^ if pachydennia or muscular parcscs have been added 
to a long-standing catarrh. 

Treatment.— Aim VI' rvery thing, the etiology must lie taki-n 
into considemtion. .Ml hannful agencies oujjht to be eliminated, 
though it is not necessary to (];c> so far as in acute catarrh. ICxist- 
ing affections of the naflc-phar>*ngcal tract, which arc likely to 
maintain a laryngeal catarrh, must be treated. For the rest, 
one should abstain from too severe prcscriptionfl, so as not to 
produce a hypochondriac out <if the patient, but to tT>- to adapt 
to Ihc psiticnt's conditions the hygienic-ilirklic measunw which 
hIiouKI tend to spare and rest the larjTix. Naturally, singing, 
speaking, drinking, smoking, and reinnining in smoky or dusty 
atmosplH-n's should he forbidden, or at least pn'vcnted to the 
utmost, I'SfHTially in the cases of iktsoiis who have to use their 



voice more than UKual, as, for instance, in actors, singers, preach- 
ers, teachers^ etc. 

If we have ascertained that the chronic catarrh is only a jiart 
of a (CCTieral congestive disposllion, cathartics, such as purp:ativi- 
salines, are very useful, or a "drink-cure'" at KiBsingen, Marien- 
bad, Ueustrich, and Weilbach may be advist^d. In addition, 
alkaline, alkalimuriatic, and saline spruigs prove very beneficial 
to catarrfi of the upper air-passages. Under certain conditions 
these mineral wafers might also be taken at home, but in any 
case the "cure at the springs" is always pmferable on account of 
the entire change luid alteration of the habits of life. The ab- 
stention from all the agents harmful to the larynx, which is 
assured in most watering- pi aces, hcliw the therapeutic action of 
the spring; and, indeed, is often the sole factor. If one looks at 
the hygienic measures as regards the alteration of the mode of 
life, having regard to their tiaie value, one will soon come to a 
decision whether it is preferable to send patients to the nioim- 
taina or to the seaade. If the ]>atient has the opportunity of 
moTOig about in the o]xti air and of resting W\s lar>-nx, then H. is 
not so ini]iortant where he goes to. As an exception therefrom 
are the dr>' catarrhs, which generally do better in a someivliat 
humid, i. e., seaside, climate. 

Tile central pivot of all treatment, in the bulk of cases, lies, 
however, in locnl (real)nenl. Here astringents are most useful. 
I use silver nitrate (2 to 10 per cent.) for painting in such a 
manner that, according to the irritability of the mucous mem- 
brane, I paint ever>' two or three days and gradually increase 
the concentration of the solution, while adapting the tn-atniejit 
to each particular case. In dry catarrh iidialations arc pre- 
scribed, in order to loosen the secretion, and aftenvards tlir 
mucous mrml)rane is then |iainted. .\s in pharyngilut (spo 
p. Qua), 8o also in dry lariTigitis, iodine is very ujfeful and may 
be given internally and externally. Towards the end of the treat- 
ment the intervals between the paintings are to Ix- lengthened. 

Circumscribed thickenings or erosions can be cauterised (under 
local anaesliiema) »1th la]>is infernalis, chromic acid, ct«.; and 
for this purpose a suitably bent and guarded caustophorc mtutt 
be used. 

aoid, Irifhloniprtic npid). If 
this fails, it will become npccs- 
aary- to procepd on surgienl 
lines, if the subjective 8ytn|h 
toms arc vc-ty disti-t-^sitig (pain 
on swallowing, dyi^piiooii, altcr- 
uiion of the ^iiiocV The pada 
(»r (iiir tliirkcniiiip; tiuiy l"' fx- 
OLscd liy nicans of ii duublc 
ciirt'tte, nmil{'<«) cut viTt.ica,lly. 
{Sen Fig. 158.) 

AfliT till' <)|K'r.'i(inii, it is 
nli-sfilult'ly lu'ccssiiry tlijit the 
jMitiwit shoiikl nwt his voice 
I'oiiiph'tcly for some weeks at 

"Singer's nodff," if IwiRe 
cnoufch to cause dietoitifort, 
ae in artore or emp:T8, niay 
host be removed by means 
of a sharp seooped forceps. I 
prefer Itosnthcrtj'x instninient, 
which can Iw fixnl to Krmix^s 
univcrsiil h:m(!le (see Fig. I.")?)), 
and follow M. Schnidi's in- 
stnictions, who only snips off 
the iKxle if it cannot Ik* esisily 
excised, l^us any uniatcn- 
lional injun* may be avoided, via., a pinching off of the nmcflua 
incnil>miK' vf Ihc vocal cor<l«. I con^■id^■^gJdv:ln^>-ca^l^(Tis;^tion 
tiiiLst unsuitable, if not even hjinnful. Hen- also fiilciicc tiiiisl he 
prc^Twd after the oixration, until cvTry sign of reaction has 
(tubsided. In s^mc cases such a "silent cure," in eomhination 

Fig. I.W.— IXnihlcmreliecmiitigv^r- 
iically Iwftor /.niu/flrn/-Krnrijir). 



witli pnintin^ MJth »lvcr nitrate, \s sufficient to remove small 
pmmmrnci-N: mid anyhow it is ^ortb a trial. In children such 
"iKxh's" should \k \n alone. 

Prolapmu \Tiitriculi and the faibglotlic pnds may nko be 
operated on by means of Rosenberg's scooped forceps or u small 

tig. 1^9.— Scooped fortvps fatter Itotnberjf). 

douMe curette. In thrent<?iied suffocation from pubglottie swell- 
ing, trachpotomy or intubition, tu; n'cotnmpndcd by Schrdtter or 
O'Dvyer, might be necessary (r/. with what is said of treatment 
in acloroum] . 


Etiology.— The cmise of laryngenl iM'richnndritis, inflamma- 
tion of the jierichundrium, as of phlepnonous litr\'njEritis. is a 
bacterial infection, mostly, if not exclusively, due to staphylca- 
cocci and streptococci inuniRrated from the surface. But simple 
lar>Tipti8 alw) is finally brought about by micrD-orpinisriis. 
As to why, in Ihe one ease, only tbc superficial layers, and in 
another cast^ the .submucous tissue, and in yet another the [x^ri- 
chondriuni, become affected, it would be difficult to exidain. 
Possibly here, as clftewhere, general or local anatomical conditiori.s, 
and the nature and virulence of the micro-organisms, eontributti 
towards the decisive result. How the infection takes place in a 
certain numlwr of cases is not easy (o soy, These piinicular 
inpiancf-s have hw^n groupwi together and termed ca»cs of idio- 
jmihic or primary ]xwlwndritis, and, for want of another or 
belter explanation, they were trac^ to a specially severe " chill " 
or to overstrainiiiK the voice. In face of this swmewhiit ohsciire 
view we must adhere to our opinion, and again einpliusisc the 


stttti'mcnt, t.hnt perichondritis is cauacd by mirroftocwil infec- 
tion. Il would Jk' Ix^tti^r to altngf thpr give up Ihc old t railitinnal 
fliiflsMfiwition rif itliopathU': (priniiiry) and symptomulic (st't-oiid- 
iiry) pcrichoiniritis, and lo spi^ak wmply of fierichoiuhrilis. 

Tn most cast's the guti" of entrance for the bacteria is not diffi- 
cult ti> discover. It is cliiefiy in di3c;vws which arc lu-com- 
psmied by nr lead lo ulceration, and, al>ovc ail others, tubercu- 
losis and syphilis, whci-p the ulceration is the intemicdiarj' of 
srcondary infection. In a similar way perichondritis ran be 
explained, which sometimes arises from an inj'ur>' or foreign 
body in the iatyn-x. Naturally, the dcejicr the loss of substance 
is situated, the easier it is for the perichomirium to become 
denuded, and thus affected. Associated with these charges in 
the carlilaginous skeleton is always an inflamniaiury oedema of 
the soft parts of the affectetl organ or its adjacent tissues. 
Oedema and perichondritis, therefore, a.^ we havt- seen, arc con- 
coniilant occurrences : the oedema is the proccssfiirtliest advancpd 
on (he surfivcc of the mucous mendjnme, and the perichondritis U 
the affection which lias spread deepest into the underlying tissues. 

Less frequently than from surface lesions, infection occurs by 
the way of the blood- or lymph -vessels. Such a metastatic 
perichondritis is occasionally met with in pjtietnia, acute poly- 
:ii*llirilis. typhoid, etc. 

Pathology. — Infection by Ijucteria leads to inflammation of the 
p4Tichiindriuni and subsaiuently to suppuration between it and 
the cnrtilage. Tlie perichondrium isscparated from the cartilage 
arnl Snilgi's forwarrl.*: but as the cartilage is then ben.-fl of its 
blnod-siipply. it imist ijecomc subject to nccrosix to n greater or 
less (fxti^nl. In the case of internal (Innpigml) j)ericIiotulrilv<, tlie 
nliseesH projects towards the lumeu (laryngeal .side) of thrlamix; 
III external jierichonifritin, viz., in an affeclioii of tKe cxtc'nial peri- 
chondrium. sui>puration tends outward through the skin. There 
nre also cases whcn> the pus burrows through from the one side 
to the other (from within outwards or vice versi). 

The liur!<tin(] of the ahxce.-^K littriinli the insiiie ii^uaVij takes 
place ftoon if it was formed as the rcmdt of an ulcer, and in this 
cast* there iw not much projtvtion; otherwise the bulging might 
be \cry conaiderable l)cXore it opens. 




The ate of bursting depends, of course, on the seat of the ab- 
WCS3. Xpcmspd ejxrtUiigc can often bo seen projecting from (he 
ahftCftw cavity, aiid if it is separalfn], it will be diischargi-d by 
roughing; and li is even i)cssiblc, in somernsea, lonTegiiisethe 
origin of the cartilage from its shape. ]n other riuses the loos- 
ened cartilagt* may he caught between the riniaglottidis and cause 
severe J^-tspiioea or even denth from fiiUTocalion. The same dan- 
ger of siiffoealioii iiiipht I)e tlireateneil if the cartilages are ne- 
crosed to a veiT great exteiu, and the larynx, after the discharge 
of the iifentsctl pjirts, ti-ncis lo eollajise. 

In external periehondritis the resistance of the partB cover- 
ing the outside of the larynx may be sometimes so great that 
the pus docs not find a direct pathway outwards, but tends to 
form a migrating abscess. 

In bilnleral pcrickandritis, if ihe pus burets through the skin, 
a* well !is inU) the himitn of the larynx, a comjtlcle fiKtuh will be 
e.stablislicil. Sueb a larj'rigiid fist ula, it« a rule, (Jiows a tortuous 
course, owing to the fact that the outer {x^rforation is usually on 
a lower level than (he inner ojK-ning. 

Symptoms. — Perichondritis is mostly limited to one cartilage 
only. Most commonly it w the aryltaioid cartilage which is 
alTeeti^l, for it is also most frequently the seat of ulceration. 
After it comes the erieoid cartilage, and, not infi-equently, in 
conjunction with the arj'tenoid. Tlie thyroid cartilage alao, ajid 
least often the epiglottis, may be the seat of perichondritis. 
Hence the objective symptoms differ according to the seat of tho 

(1) Perichondritis Arytaioidea. — ^The disease is more frcfjuent 
on one side only than bilatcnilly. (Seo Fig. 160.) Litryngo- 
Mcopically, one sees mi (>c-di'iii:itous swelling in the region of the 
arytenoid, covirriMg Nonictinirs in excessive cases a portion cf 
the vocal cord, and thus concealing laon? or less an ulcer which 
mighr Iiappen to be pii'senl, Tlic oedema sjin-ads into the 
arj'cpiglottic fold. Mobility of the vocal cord is restricted or 
ejntirely abolished. Neornsed cartilage may he vlidble, and then 
a small <|uantlty of pus appears, es|K>eially if gejitle pressure be 
made from the outside. 

(2) Perichondritis Criootdea.— This very often has its origin in 



: on tlie posterior laryngojil wall, for example, from tuber- 
cnlnas or typhoid. (Sec Fig. 161.) If, a» is often the case, iho 
criroid plate ami Iho ai^'letioid cartiliig(> are »ituuUaiieously af- 
fected, the iiiirror shows a ewelliug over the region of the aryte- 
noid and also over the posterior wall to a varjing extent, some- 
times right Uo\vD to the subRlaitic space. If the external 
perichondrium of the cricoid is affected, the swelling can be seen 
ill the pbar>'nx and px-riform sinus. In the caw of the anterior 
arch of the cricoid being diseased, the anterior region of the neck 
is prominent and verj" tendi-T. li the scat of the disease is in the 
region of the crico-arjtonoid joint, then mobility of the corre^ 
pondmg vocal cord is materially iiUiibited. 

Fis. IGO.— Higbc-«i<)«l pni- 
chonilrili!) nrylpnoidM {Ttireic}. 
The swellini! of th* iifyt«noid 
canibigR luiii iir}'(ipi(;l()t I lu fold 
of ilw riEht sjfip rtjvf'rn a hi- 
bcrndar ulcer. IcaWng oiHy a 
small ara& of It viaible. 

PiK. 161.— Lcll-eided prriclioodritis 
mcat<1«a iT-iret). On ■h(> left wlc w 
conHi<icmliI<! ciibfflotiic nw-Hllnf;, ettm- 
pijwnding la tiu> iN'rifhoiiilriliK ol (bt 
cricoid: tb» subglottic swelling is SMD 
spTMuling on lu llif iHMivnur bryngetl 
wall. (h-flriniildimsw-i'IlinKnf led iin'tiv 
noid ixmi Irfi nr}-rpieiol t Ic fold, "rbc 
glotiifl is grcnily nanowed. 

(3) Perichondritis Tkyroidm. — If the pxlemal surface only is 
afTccted. a unilatcnU or bilatcml, soft and very tender s\vel]tng 
may he noticed in Ihe fnmt of the turck. Inflammation of the 
lamigi^al jK-richoridrium shows ilailf, arcortling to its seat, as a 
swelling in the region of the anterior commissure or on one 
side only. In the latter case the .swelling might I>e so con-sider- 
able that the ventricular fold, ventricle, and vocal cord are each 
hardly distinguishable. 

(4) Peridimidritis EpigJoitica. — Tlie periehondrium of the 
epiglottis is so firmly adherent to the earlilage that it cannot be 
8e[ianiLed from it by a collection of pus. Ii so happens mtliur 



that the cartilage itself is eroded and nccrose<l hy tubercular, 
and stiti more frtqucnlly by syphilitic, ulceration. It is pos- 
sible in Buch a case to see the irregular wigesot the eroded cartil- 
agi\ The adjiicent slructures, of couree, also show here tnarkiit 
oetleiimtoiis swelling. 


The subjective symptoms of jwrichondrilis are not ven chitr- 
aeteristie, as theR' may be hoarseness, which, however, iti cx- 
tcniaj jxtrichondritis might be altogether absent, pain on swal- 
lowing, and dysimooa. Hoarseness is often caused by the pri- 
marj- disease itubcrciilosis, s\*phiUa, etc.), or it may be due t.o a 
mcchftnJoa] hindrance of the mobility of the vocd cords or to 
the mttsclex I>rin£ tmpliciited. The pain on swiillonnng fre- 
quently nidiates towirds the cur, and may he agonising, espe- 
cially if the aPi'tenoid, ericoitl. antl epiglottis areafferted. Kx- 
tenial pressure ui)Oti the tliwased pnrl is very painful, and it is 
just this loealised lendeniess which will i)ften giitdeusasto the 
correct seal nf the disease. Dyspnoea m the gn-ater the narrower 
the lumen ia renderifd by the swelling, and it may assume the 
most dangerous degree iij consequence of an abseeas having 
burat into ihe larynx, or a necrosed part of a cartilage being 
caught in the glottis (sec above), or, by the fixing of the vocal 
cords bi the attitude of approximation. 

The course is either acute or chronic, according to the under- 
lying dLseasr. e. (/., acute in typhoid or after injury, chmiiic in 
the uleenitive pntcessf-s of a tuberculou.s, .syphilitic, or carcino- 
matous nature. In the latter case it not infrecjurntly takes same 
time before the cartilage is sepjiratctl and di.^r barged, and the 
pus which runs down into the lower air-{Huwagc-« may cause 
gangrene of tlie lung. In all these cases intercurrent compliai- 
tions may hapjien and aggravate the |>reexisting danger, or 
even cause death from sufTiK'ation. In ver>' favourable eases the 
necrosefi cartUngeif are discharged, and rwovery may take jjiace 
with the formation of acais, leading to immobility of the cartil- 
ages and stciioeis. 

Diagnotis. — Internal perichondritis cannot be diagnosed with 
certainty unless one is able to sec or touches with a probe ne- 



crosed cartilage, or if such a part has been roughed up. On the 
other hand, arytenoid perichondritis, for instnnee, can easily be 
mistaken for an infiltration over the arjtcnoid cartilage, par- 
ticularly at the commencement of the disease. The subjective 
symptoms arc of little vahie if the primary cause, i. c, the under- 
lying disease, has already produced various disturbancea. Wc 
may, however, a^wllln<•, with a. certain dcgnie of piobability, that 
\w have to deal with an arytenoid [xrrichondrili?!, if, following on 
a Hlniigliing process, fcvi-r and [Wtin, [M-riiajis dysjnioea, arc 
accotiipuilcd by a swelling in the n-gion of the arytenoid cartit- 
agc, and the trorrcijionding vocal coni Ls inijx-ded in its move- 
rnenls. If a [wrichoudj'itic aliseess has liuiNt into the larynx, wc 
sometimes .seer by the laryngosco[»e that pus is oozing from a 
certfihi spot if we exercise a little ])rP8surr from outside. At the 
same tune them* id a eoitsptcuously isolated tendemews on pressure 
from out(*idc or on touching the i^pot with the probe from iimide. 
Such tcndemeea, however, is Dot pathognomonic of perichou- 
diitis, but can also be found in inflammation of the crico-aryte- 
noid joint. 

Kxtemal perichondritis may be confused with auppurating 
lymphatic glands, new-growths, or gummata. 

It is vcrj' hnportant, but also very difficult, in a given case to 
ascertain the primary' cause of the perichondritis. In doubtful 
cases, especially if hoarscjiess has previously existed for some 
time, luberculosis and .syphilis should be home in mind, for 
these diseasi's are the most frequent causes of perichondritis. 

Prognosis. — ^Tlie nmnifold complications and dangers which 
ioonwr or later occur make tlin prognosis very serious. It is 
absolutely unfavourable in tuberculosis or carcinoma, a little 
belter in syphilis, and e\'cu in the mildeet cases severe functional 
disturbances are the rule. 

Treatment.— Causal ive treatment can only be considered iu 
cases of syphilis where an energetic aniLiyphUitic treatment may 
be applied. On the other iiand, symptomatic treatment rrniy ilo 
some good, though within moderate limits. At the commence- 
ment the larynx must be absolutely rested, and ice applied ex- 
ternally and internally. Soon, howe\Tr, the ice must be re- 
placed by warm fomentations. If one has found fluctuation, the 



absc4?ss must be incised by means of ii guiinicd lanTigeal knife. 
A caniljigimms sc'iut'-struiushnuUI lifn-movi-d.i. *■,, extracted by 
means of a forceps if it is mo\'abIe. Grwit nliention must bo 
directed to respiration, and if this is threatened, tracheotomy 
sliould be pcrfoi-mcd without delay. Tor the rest, one nuiv try 
to allevifttc the suffering by the instillation of menthol oil. 20 to 
50 percent. cooAinc, adrenalin 1 : 1000, or Darcotica. Ultinialely 
st^nows, whirh might resull, he treated by l!ic methods 
previously described. (Stu p. 408, rt scij.) 


Etiology. — Until recently diseases of the larynpeiU joints have 
not often been made Ihc subject of exact investigation, and in 
some text-books an" not oven nicntioiicd. ^\liethtT Ihcy are of 
rare occurrence may be doubted, though some authors incline to 
(hat opinion. Tliis ncgltvt may be partiaJly explniiud i)y the 
difficulty met with in interpreting the indrfinite symptoms 
inlni vitaiii, and partifdly by the lack of stiflieient postmortem 
investigation. This may esi)ecially lie said of the acute in- 
flammatory pnirecKes of the joints, which cause few subji?t?live 
or objiTiivi- synipliims, and soon get well. Such iunamniations 
aw, pprhaps, more frequent than is usually thought, and there 
is usually sorai- ]>araestheaia, some indefinite sensation of pain in 
the region of the larynx, which may finally be traced to disease 
of a laryngeal joint, just aiuUogous to those slight joint affections 
as occur in the eounsc of acute rheumatic arthritis. 

It is, indtH-d, the acute polyarlhritis which plays a chief rfile 
in Iar>ligeal joint, discaw. Wi' leave it oi>fn as to whr-ther Mjch a 
joint disi'S-w in the larynx must he cont*idfi-i-d as Ix-ing mctaa- 
iatic, :is, for instance, in the casw of gonorrhoea, where it ha«aIao 
been observed. Much eo\dd Ix" said in »up]K)rt of this view 
if one conceives the acute polyarthritis aa being a mitigated 
pyai'mia. Besides rheumatic and gonorrhoea! arthriiis, there are 
also other infectious diseases which involve the laryngeal joinin, 
e. g., typhoid, diphtheria, variola, tubereulosis, and syphilis. In 
some of tliese forms of arthritis the inflammation runs from the 
outaet a somewhat chronic course, a« it also docs in gout and 



likcwiw in those cases whrrt- a phlt^gmonous or pcrichondritio 
inflamnutltoii spn^atk Into the L-ir)'ngeaJ joints. 

Pathology. — Tlic crico-arj-lenolcl joint is the ono most often 
poneeniod. It may he «JT(?t;tt?<l in thi> eourae of a true poly- 
iirthritis, toKcthLT with olhi-r joints of the body or alone. In 
some casH's the oricoarj'Ionoid arthritiH \s, ho to sjsoak, tho 
forerunner of other joint afTcctions. There is at first a serous or 
Beropunilent cxmlation mto the joint, but not infrequently the 
peri-articular tissue may also be infiltrated. Inflaninutlon may 
occur on one or on Ijoth siiles. Iflhc inflannnalory procejw is of 
a more chronic fomi, it finally leads to ankylosis and to a true 
ankylosds if it is intnieiiiwular, and spurious ankylosis if it. is 
exlnicapsular. Tn the jjitlercase the ankylosis ts occasioned by 
cicatricial tt.ssne, fibrous thickening, or adhesions. 

Symptoms. — Tn ihe mild cases of rheunialie arthritis patients 
eoinpliiiii of :in unpleasant feeling of IciLKiori, which is localised 
in tlu" lateml n'j*ion of the larynx duriiiR siieech and swallow- 
mg, and this soiisation is aggravated on touching the spot with 
the pmlK* orfinfjer. In more severe eases, however, the pain may 
be very considerable and radiate towards the ear. It is accom- 
panied by hoarseness and sometimes even by dyspnoea. The 
pains arc more pronounced in the recunibent jMsilion. If one 
exercises a RentJe pn-ssun- on I he upjKT and iKick part of the 
thyroid carlilagc, a crackling noisi; may lie heani and felt, which 
is supposed to be jsilhognoinonie, jis Gr&mmltl points out. It is 
hcjinl »f till" same place wJiich causes pain on pressun'. The 
crepitation is due to the frietiou of the inflamed and roughened 
synovial nietnhranes. 

Tlie lamigospopic examination is not always eharact eristic, 
ospeeially if there is nothing but a sim|)lo exuiiation into the 
joint. In severe cases, on the other hand, reddening and swelling 
over the arytenoid cartilage may be found; the mobility of the 
vocal corti is reduced or inhibited, and may sometimes I» seen 
to b« quite inunobile in the poutton of respiration or phonation. 
In bilateral acute or chronic inflammation the picture is more 
complicated. The ^■ocal cords are then symmetrically fixwl in 
nliduction or adduction, but more often asymmetrically, and then 
an unequal mobility of lK)th cunls is most conspicuous. In some 



cases the ar>'tciioici cartilage swms to b<r Ui«locaU-<I and li(?s at 
a quite imusuiJ angle; at aiiiitliiT tinii- it might he passible to 
see scars and adhrsion:^ which would at once permit tbe rocog^ 
nition of a spurimis anltylosis. 

Diagnosis. — If one is able to see by tlie laryngoscope mldcn- 
ing and swelling in the region of l}ie arj.'tenoid cartilage, which is 
accompanied by immobility, nr, at least, a reduction of mobilily 
of the vocal cords, in association with pain on swallowing and 
pressure, then a jicri -arthritis is t}ic nexl thing to think of, i". e., 
an infiltration in the neighbourhood of the Joint; or a perichon- 
driti.s fshouhl be I>onu' in mind. But if there are other joints of 
the Ixidy iLff(vti'i.l, it niay be assumed, with some degR* of cer- 
tainty, thai we have also to deal with an inBanunation of the 
crico-aryt4^noi(I joint. If in doubt, await the course of events. 
In 8U[)crficial examinations a mistake with hysterical paracsthesin 
may arise. The differential diagnosis between paralysis of the 
vocal cord and jouit affection in difficult. Acute inflammation 
might betmy itself by its course, the eliaract eristic pain on . 
pressure, anJ vcrj' frequently by the crepitation before men- 
tioned. SUll more difficult is the diifcrcntiation between chronic 
arthritis and paralysis. Here one can only arrive at a correct 
conclusion by carefully weighing the auamncas and the prc\Hous 
course, together with the laryngoscopic finding, e«i)ccially if 
thenr are scars and adhesions present. In jMimlysia due to 
disease of the rierx-es or muscle.'*, th(r patients usually never conv- 
jjlain of pain, .\jiyhow, diagnosis in cases which liavc already 
run their course is veiy uncejlain. 

Prognosis is favourable in the acute joint diseases, especially in 
rheumatic arthritis, though rela|)ses are fnK|uent, and the condi- 
tion may even pass into the chronic stage, with nwulting anky- 
losis. If there already exhin a chronic inflanmiatioii or luikylo- 
sis nf the joint, prognosis is, to say tlie least, doubtful. If the 
v-ocal cords arc fixed in the mesial line or near to it, stenosis, as 
in tSTjicnl paralysis of the posticus, may occur. 

Treatment.— In acute arthritis the larynx must be completely 
rested, and lec or Prioi^tz's cataplasms applied, and aspirin or 
salicylic ariil administered internally. Chronic inflammation, if 
baaed on syphilis, must be treated by mercur)* and iodide of 




potassium. If il piwe neccssan', the sciini!, iidhfsioiis, or tliick- 
cnings which arc visible and acoessiWi' m:iy be oix'raU'd on; 
and stenosis must Ix; (.lilatod after thv method previously de- 
scribed. Unfortunately, this is very unsati?f actor)'. In sudden 
threatening dyj^pnocn. luckily not very Iroqucnt, tracheotomy 
should be at once pcrforiiHid. 



Measles. — The lar>Tix and trachea, as well as the pharj-nx, 
fhow, during the first few days of measles, a blotchy redness of 
the mucous mcmbrajic, analogous to the cutaneous rash. A]>art 
from this appearance, the whole n-spinitory tract Is afTccted, 
fthowing symptoms of eatarrlial !anr'nj:f)-triieheitis (hoarwiieas or 
other disturbane(¥ of voice, coughing, expectoration of mucus, 
etc.). If the secretion is copious, dyspnoea might ensue, es- 
j>ecial!y if the sulifilottle rcgtoii is swollen. If svirh is the, 
it is pnibahly due to a pyogenic iiifirtinii, which itiijihl lead to the 
formation of an abscess or |>eriehondritis. In (illier eiiscs, and 
then mostly in the stago of the ffliiing of the rash and di'SnuanL-i- 
fion, real fiscudomembranes may bi- fonned, which nn- cvi- 
lieully caused by secondary iiifwlion from diphtbrrui ba^Mlli. 

Searief Fever. — The larynx and trachea arc much less often 
affected than the phan'nx, but it not infrequently hapiK-ns that 
the diphtheria- like scarlatinous angina spreads on to the aditus 
luryngis, and, as has been observed in various eascB, down into 
the trachea. Nephritis, which occ\ir8 so often in acarict fever, 
may cause congestive opdenia of the laryn.x. 

.SiMo//-;)oj.— Apart from a catarrhal lar\'tijptis, pustuK-s or 
fibrinous exudations, and phlegmonous inflammation also, may 
occur in the region of the larynx, leading to perichondrilis or 

Diagnosis. — In nil the foregoing diseases the diagnoms ^ould 
offer no difficulties if the whole sjiidrome of sjnnptoms is tnken 
into consideration, especiiUly having n-gurd to the cutaneous 



Treatment. — Tlie trciitniont is usu;illy syinptorua.tic. Loral 
tri?atmr'iit w nt-arly alvviij"?* !*U]K'rf!uoiis, In severe cases, liovr- 
cvtT, tracheotomy tnifrht Ih-cohu' tirt-t^swry. 


^\"hooping-cou^h is :i ncui-osisof the upjxr air-passngcs caused 
by some infectious perm not ypt asccrtaintHi. It is alvrays ac- 
corapnniod by some catarrh and oharactrrislir iwroxysns of 
coughing. Two stages arc dislingiuslmlilrr: the first is a simple 
catiinlml sstagc, which sliows the usuaJ symptoms and signs of 
an ordinary catarrh of the upjx'r air-iwissagi's: this then passes 
on into I he siToiid stage, which is coiu-ulsive, and i« eharacter- 
ispd by tlie typical .spasmodic attacks of ])aroxy«na! coughing. 

The coughing |>an).vysms are especially alarmuig and more 
frequent during the night. The sborl coughs follow each other 
ro|Hiily m series, and are charaeicrised by nilerval.i of loud in- 
spiratory "whoope." T\ic attacks occasion great cyanosis tuul 
congestion, which may lead to nosc-hlecding, cotijun(;ti\-al or 
retinal liaemorriiages, or ccchymosJs beneath the lamigcaJ mu- 
cous ijifinliniiir. etc. 

Tho ii:spimtory stridor is probably due to spasm of the adduc- 
tors of the vtK'jil eonls. The cause of the paroxj'sms themgolves 
is nut yet exactly known, and tlie lar\Tignscope gives us no clue. 
Vcrit' oflni notliing ]«Uliological can Im- seen, and the redness 
sonu'linies found in the larynx is probahly the result, not the 
cauw, of the coughing. Tii stimo swere «i«'s secondary diph- 
theritie infwMion mid real .'ipasm of the glotti.s, necompanicd by 
g**neral convulsions, have been ohser\'ed. We refer the rwider, 
however, to text-lxioks on medieino for fuller information. 

Treatment.— This must abstain from all tiianipula lions of the 
upper air-i>a8Kagfs, es|«H-iaJ]y as there an* no local changes. Of 
uli the ntunerous specific dmg^, none has provc<l infallible, as 
any one will admit who is sufficiently miprejudieed. Morphine 
and codeine in combination with bromides are likely to mitigate 
the parox>'snis, but axe without any cfTect on (ho courae of the 
disease. I desire lo recommend, however, the um of oil of 
cypress (oleum cupressi), which has been so much praised by 
Bmvo imd Sohmann. It is best to drop an alcoholic solution of 


the oil {1 : 5) upon the bolster, pillow, sheets, and body linen of 
the children. The Ruid la uaetl four times a day and once or 
twice during thejiight, about i ounce in all. The aromatic sniell 
of the oil is usually liked, and the only disadvantagta an,' the 
yellow stains which remain. How this exjxrisive drug acts is 
not yet a-sceriained. 


The catarrhal form of influcnzu Is ahnoBt always nssotiated 
with laryiigo-trachcitis, and shows the deaquaniation of the 
ppithclium in the region of ihe vocal cords already descrihetl in 
acute laryngitis. These eroRions present themselves as oimque 
patches whiph contrast vividly with the bright-rod surroundings, 
and impart to the vocil cords a conspicuously pat«hy appear- 
ance. Various authors ascribe this appearance to a fibrinous ex- 
udation. In some cases the process might spn'ad into the deeper 
tissues and, indeed, might lead to a submucous infiltration, peri- 
chondritis, abscess, and imralysis of the posticus. 

Symptoms. — The syniptoni.s depend mainly on the seat and 
nxt«int of the disease, which very often is most resistant and 
shows great tendency to relapses. 

Trfatment can only be symptomatic. 


Etiology and Pathology.^l*har>'ngeal diphtheria not infre- 
quently spreads down into the larjiix and trachea, and even 
beyond this into the bnmchi, esiieeiaJly in weak, scrofulous, or 
tuberculous children (des(rendiiig diphtheria}. Exceptionally, 
diphlhcria begins in the larynx or trachea, or even in the lower 
n^-giuns of the ;iir-p!issagc«, and mounts upwards into the pharjii-ic 
(ascending diphtheria). Sometimes the affection bt limited to the 
larynx and Irachctt only. The disease is caused by the Kleb»- 
LiilJler baeiUus, whose Inologieal n-lalions have l>een discussed in 
the chapter on Pharj'ngejil Diphtheria. (See p. 300.) 

Diphtheria occurs us a secondurj' complication in various in- 
fectious diseases, such as tyjihoid, measles, whooping-cough, 
scarlet firver, i-tc, or in severe eachexias. 

LaTifugeal diphiheria is sometimes also called "croup." This 



teim was originally iLst-cl to signify merely a vi-ry eonB[>icuc 
symptom, namely, thf roiiph. loud, muroxb; ("bijissy'') eoii^h. 
and tilt' »ob;y,fflbila]»t rrspiralion. Later, n-Iyiiipon the authority 
of Rol'i I ftnxky mu\ rj'rf//ou,tli(»r'X]>re*«ioiiwMsi»pj)lic'(itothepnlh- 
ologieal anatomical ohaoge, f. e., to a proepss whicli is character- 
ised by fihrinouB exudation upon the surface of the niiicous mem- 
brane, and to the formation of Io(i«c winovablc tniMnbrancs, in 
contradistinction to true diphthoria, whca- the fibrinous exuda- 
tion takes place into the epilholium and dw[xT |Kirtionw of tiir 
niucoiia membrane, causing it to necrose. Afcordinp to this 
difTerence, "croup" anil "iliphtln'ria" must be clinically st-jja- 
ratcti. Cnrelul invest igntiou, however, will sliow that surh a 
distinction cannot lie curried out, cither anatomically or clinic- 
ally. Croup and iliphther'ui arc jKilhoIogically identical, ami 
may perhapK be consiclernl only as varyinjr tlcjirt'cs of one and 
the siime disease cnusi^l by ihe Klelx-Liifper bacillus. It is 
perhap.s best lo entirely drrjp the term "croup," which has 
given rise to such e!inie«l ami aiuilomical confnsioTi, and, more- 
over, to complicate the matter yet more, must be distioRuished 
from " pseudo-croup." {See p. 434, ct acq.) In its proper place 
one shouM only ppeak of mild or severe diphtheritic inflammat ion 
of the larynx, or shortly, of "hrj/tigeal dipklheria," - 

True fibriiimtji exudation on the surface admittedly occurs as 
the result of mechanical, chemical, and thermic irritations. 
This so-called fibrinous lanpigilif, scnsu strictiori, is analuginis 
to the fibrinous process sometimes oljservcd in the nose and 
phar^iix. It is ufiually due to scalding or burning or an tuim* 
tenlional injury during intralaryngcal giilvano-causlic opem- 
lions. Certain micRjcrx-ci are supp(x«ed to play a pari in fibrin- 
oug larjTigitiHjand we leave ii an open rpicstion whether they are 
the actual cause, or are later secondarj- imiwriations. It is 
certain, in any caee, that in the Inrjnix. as well a.i in the nose and 
phAr>i)X, fibrinous exudations which do not coDtain diphtheria 
bacilli arc found. Ncgat ive findings, however, are no proof, tuul. 
practically Dpcaking, otm nhould act wifely if one consideml a 
caMG of fihrinouH lar>'njnti)* as Ruspicious of diphtheria, and abould 
iitolale it, that ix, if it cannot tie traced to a galvano-caustJe 
operation or to other chemical or thermic cause. 



Pathology. — The chanRcs mot with in laryiigcflJ diphthma are 
rssciitially the same as in thr phnniippal (iiphthpritic tli.'ii^w?. 
(See p. 300.) Aa a rule, the diphtheritic pmccss, if It occurs in 
thp IftTvnx, does not spread na much into the deeper tissoies aa it 
does in the pharynx, but, on the other hand, it shows a distinct 
iiicHnation to spread along the surface — at times so much so 
thai aetually exact easts of the lar\*nx, trachea, or finer hroii«hi 
(ire formed. .Hereio also lies the great danger of a descending 
diphlheria, in that all the air-passages may lM>pfinic blocked. 
The lungs may suffer in, two ways: they may be infiltrated, as in 
pneumonia, by the fibrinous exudation, or they may become 
ntelectiitic, hwause of the Itlocking of the supplying hnmchi, and 
Bu I )s( fluently to this a vicarious emphysctiia may dc-vdop in 
other parts of the- lung. AVrj' im|Kirtaiit ai-e nlso Lhi- mntUtions 
nf the glottis. The pscudomi'nibrane.s which udlific inorc 
finiily lo llic si ratified cpifhfUuin than to ryHudrical t'pifheliuiii 
may here wion stenosp the larj'nx in a dangenius dpgrep, and 
this danger of suffocation is still more uiereased by any sub- 
gloltie swelling. In some cases it is not the formation of [woudo- 
nienilimne iu thoglotlisalimt', but the siihglottie and suhiimcous 
oedi'malniw iiitiltration, which constitute the roal dangi'fs. 

Symptoms and Course. — Laryngeal diphtheria usually starts 
in thii' way: with and after certain symptoms, pharj'ngeul diph- 
theria invad{« the liu"ynx. The symptoms which characterbe 
this invasion are increase of temperature , koarhvness, "brassif" 
(rnvcouii) caurj/i , and dijspnoea. 

Whenevrr, in the course of phaPpTigi-af diphtheria, this sj-n- 
droiiw of symptoms occuni, a descending diphtheria may be aa- 
sumed, with the gn'atest probability as to correctne-ss. I say 
with all the gn*fttK»t frrohabiHiy, not certfiiniy; for .severe catar- 
rhal laryngitis or phtcgnionous Inllaninmtion may iiLso cause the 
same symptoms, such as hoaraencsH, dyspnoea, and " brassy" 

I desire once again to call attention to the need of bearing in 
mind subglottic lar^nigilis. (See p. -135.) One must he in 
doubt whether it imrtakcs of diphtheria or not, e8|)ecially in 
those cases where t'he .'o.'mptoms above mentioned are still 
present, while the phaiTp-ngeal diphtheria has already subsided, or 



at least is hardly any longer rwopiisuhle, or if Hit- diphtheria has 
arisen in the lan-nx primarily. To the foregoing may be added 
tho fact that iu some eases one or other sj-mptonis may be al- 
togpther missing, viz., if the glottis and the subglottic r^on are 
free. But in all these cases the further eoursp of the disease wilJ 
soon clear up the matter. IH'spnoea, which ptThnps occure 
from the first, like a danger-signal, in brief paroxystus, soon 
increases and bears witness of true laryrige-nl and Imcheid olv 
atruction.accorapnnicd by the characteristic stridor. (Sec p. 386.) 
I'»<u(lonu-niI>raiies or iiorlions of them are jxrhaps brought 
up by an attack of couching, which then frees the larynx for a 
while and (hi- child may fal3 aslw*]). Soon, however, the attacks 
of dyspnoea n'cur. which Ihea strain all the auxiliary musclt-s 
of respiration in the neck and thorax to the utmost, thus deep- 
ening or lengthening the efforts 



162.— I^iyngftkl diphthmii 

at respiration. Paroxysms of 
, jr Mir^TL 'm,'^^ - violent dys|>noea rouse the chil- 

li ^£m^- H V^Vl^V ' dren, n-ho, in their uigent 
Y ^K^^®jJtJj^»^ desii-o for aid, clutch wildly al 

* ^^" ^*. .i^^ their throats. Thcst^piirDxysma 

altcmatt with exhaustion; the 
voice becomes aphonic; the 
cough lows it* sound; and, 
finally, the httJe ones huccumb. 
The respiration becomes rapid ami shallow, but seemingly fnwr; 
the pul.-fc quick, ftn-ble, luid im-giiL-ir. or \:\v\\ iiitcniiils for 
flomc monii'iits. and with the .Kigiir> of |irt)fuund cyaiiasis and 
stupor the child dies from suffocation or exhaastion. 

In the rart- ciinos of adull.s who sulTf>r Tmin diphlheria stcmieis 
doee not usually appear before the bmtichi have alwi bwonie 

The larjiigoecopic jHcturc is a vcr>* varjnng one. At firet, 
patches may be seen on the lar^iTigcal surface of the epiglottis 
or on its edges, or on and between the arytenoicl cartilage.^, on the 
ventricular folds, or on the vocal cords. Later on f^se mem- 
branes may be <ibscrvcd, which arc often partially separated 
at one or the other place, cs|iecially in adults, and are then seen 
i1oa(it}g or moving atmut. At the point where such a pseudo* 



iiiciiihraiH^ littw U'cn cnst off the imicoiis niemhrarit' appt'iirs much 
retldi'jied, and is soiiii'tiiiics seeii to Ix* slightly bltwJing. The 
subglottic pa(U braeath the vocal-cords at times project a (treat 
deal into the lunten. 

There arp cases where the whole procwe is localised, and 
n-maiiis limited to the larj'itx. In the gif-al majority of caaes, 
Iwiwever, white patches or jxseiidoinembranes may be alao ob- 
served in the trachea during n>s|>irali(in. 

If the disease subsides, ihi- ixseudoniejiibianes are cast off and 
pxiKvloratwl. Oiving tt» its small teiidein'V to peiietmlc thi>diKr|X'r 
tissues (see above)^ restitutio ad integrum usually ensues. On 
the other hand, if the iiifiK ration was severe, or if ulcers have 
developed, then soars and adhesions arc the consi-quence, whieh 
lead to stenoas on account of their retraction. Poet-diphtheritic 
paralysis in the region of the larynx has been discussed in the 
chapter on rh:ir>'ngeal Piphtheria. (See p. 300.) 

Diagnosis.— If laiynfical diphthorin occurs in association with 
phao'ngeal diphtheria, a mistitke can hardly be made, even if a 
laryngoscopic cxanunation cannot be made. But there might arise 
some difficulty in diagnosis if, a-s ha** already been pointed <mt . on 
examination of (he jiharynx nothing can be found chanieteriMtic 
of diphtheria. In (hat cnae some items of tho history of the case 
will [x>int to it; or, on tho other hand, if the larynx'^-as the pri- 
mary seat of diphtheria. Should laryngoscopy fiiil, then a differ- 
ential diagnosis between the prognostically favourable catarrhal 
" i)8eudo-croup" and a phlegmonous laryngitis could be inferred 
from the clinical appearance*. As hiis been said previou.'Oy. the 
onset of "pseudo-croup" is midden and occure iji previously 
healthy children or in those who are only slightly ill (see p. 433); 
while dipblhcria manifests itself by distmct premonitory 8ym]> 
toms. The differential diagnosis from phlegmonous laryngitis 
is sometimes verj' dillieult or even imi»8sib]e, and often can only 
be made by observuig the eouree of the disease. At times our 
attention ia directed to diphtheria by othrr cases oecurring 
einiultaneously; or the coughing up of membranes or the presence 
of Kl^s-lJiffler'f^ bacilli will reveal the nature of the disease. 
Fibrinous exudations caused by caustics or burning are almost 
always piuiied by fever. 




In adults, laryivftoecopy, as a rule, is decjsivi!. Plaul-Vineeni'^ 
anpina {p. 19S> may occaeionally spread into tho larj-nx and form 
iticmbranos which strongly resemble diphtheritic ppcu<lomom- 
branes. Uecenlly Reiche has described a cose where the fusi- 
form bacillar>" angina van limited to the larynx, — larjTiKitis 
ulceramembranosa, — and when- no other bacillus than the fusi- 
form kind was found. It Is necessar>' to bear in mind this com- 
paratively benign disease, although its occurrence may be rare. 

Prognosis. — Diphtheria is alwtys a serious disease, and the 
more sn if the child has bitii weakeneil by a pifviou* illness and 
hn« n small lan,Tix. By its descending into the lower air-paa- 
8Hges the prognosis iKt'oines wnrs(\ and even hopeless, if respi- 
ration becomes obslrueteU. (Kor the rest see the cluiplcr on 
Pharyngeal Diphtheria.) 

Treatment. — With regard to treatment, more partirulariy 
(hat by inj<«tiotis <>f w'mni, \vc mv^t refer to what hjis heci\ ai- 
rcady said in previous chapters. (See pp. ;100, 306, cf stt|.') 
Owing to th<' gra\'ity of the disease, a large dose of serum .thould 
be iiijcrled at once. The fuj'ther treatment nnwt be syinplo- 
niatie and anti])hlogistic: ice applications, crushed ice to suck 
(ice |)iUs), and basma with boiling water may be |)hiced close 
to the Ijed, and at iniulants and restoratives administered. Local 
tii«lri!ciit sei'niH su|»'rflu(ius, if not actually uijurioiis. 

If ttteuotjLs is thrL'aleiiing and k m.'uiife^ting itseti by the 
inspiratory drawing-in of the lower part of the thorax, thcD in- 
tubation or tracheotomy ifi required. Oenerally speaking, in 
dii>htheria, intubation, according to 0'])uryer's metho«l. is pnf- 
erable, provided that one can manage it and trained nurses arc 
at liand. But if asphyxia has already supen-ened and if the 
disea/te shows a niiirkod tendency towards gangrene, or if it hati 
spread furthr-r doM-n into (he trachea, then only tracheotomy is 
justifiable. Trachpoiomy must likewise be performed if tntuha- 
tion fails or has had just the opposite effect to that which was 
expected, m, for uislance, by the tube having seiKirated |jseudo- 
menibranes and then ha\ing pu^ed them before it while it was 
being iulroduccd. (See p. 425.) Unfortunately, there arc many 
cases where tracheotomy failw, either bcrftuec the diphtheritic 
process cjontinucs to spread duwnu-ards below the woimd, or 



liki-wisf! in those cases where; a phlegmonous or perichoinlrilic 
inflaminntioii spreads into the laryngeal joiuts. 

Pathology.— The crico-aryfenoid joint is the one most often 
eoncenied. It may he atfectcd in the course of a true poly- 
arthritis, together with other joints of the body or alone. Id 
some cases the crieo-aryteiioid arthritis is, so to speak, the 
forerunner of other joint affeetions. There is at first a serous or 
seropumlcnt cxuiUition mto the joint, but not uifrequently the 
pcri-artieular tissue niayalso be infiltrated. Inflammation may 
occur on one or on both sides. If the inflammatory process is of 
a more chronic form, it finally leads to ankylosis and to a true 
ankylosis if it is IntracaiK^ular, and spurious ankylosis if it is 
(>xtrac-a|)siilar. In the latter case the ankylosis is occasioned by 
cicatricial tissue, fibrous thickening, or adhesions. 

Symptoms. — In the mild cases of rheurnafic arthritis patients 
complain of an unpleasant feeling of tension, which is loealised 
In the lateral region of the lai-jnx during speech and swallow- 
ing, and this sensation is aggravated on touching the spot with 
the probe or finger. In more severe cases, however, the pain may 
be very considemble and mdiate towards the ear. It is aeeom- 
panied by hoarseness and sometimes even by dyspnoea. The 
pains are more pronounced in the reeiinihent position. If one 
exercises a gentle pressure on the upper and Ijack part of the 
thyroid cartilage, a cnickling noise may be heard and felt, which 
is supixised tfl be imthognomonic, as Grunwald points out. It is 
heard at the same place which also causes jmin on pressure. The 
cre|iitjiti(»i! is rluc to the friction of the inflamed and roughened 
syni)\nal membranes. 

The laryngoscopic examination is not always rharacteristic, 
especially if there b nothing but a simple exudation into the 
joint. In severe eases, on the other hand, reddening and swelling 
over the arytenoid cartilage may lie found; the mobility of the 
vocal cord if* reduced or inhililted, and may ponietitnes bi' seen 
to be quite iinmoblle in the position of respimtion or phonation. 
In biintend acute or chrunic inflammation the picture is more 
coniplienti'd. The vocal cords are then syiiiinetrically fixed in 
afKluclinn or adduction, but more often a.'jj'mmetrically, and then 
an ujiequal mobility of both corila is most conspicuous. In some 



The noftspecific piwcsBcs are chanu-terisctl, in their mildeRt 
forms, by a patchy rt-dness. such as occxirs in catarrh. Through 
the Invasion of staphylococci or other microbes a suiJerficial ma- 
crons sets in and leads, especially on the epiglottis, to ulceration* 
which do not show the undermined, thickened edges as do typical 
enteric ulcers. 

Both kinda cf ulcers heaJ, if they have not gone too far, with- 
out the formation of scars. But sometimes it hapiH-ns that they 
IK'netratc in depth, from the action of the pus-organisms, and 
then they cause pcrichondritif alTectimis of the arytiaioid or 
cricoid cartihiKCB. imd m (ithcr caws idwccsw-s juTonipjuiirti by 
oediTiia nmy sujKT\'cnr iiml n-wult in iiecrasis, with the formation 
of cicatrices, sind c»msi'f]Ucntly in stenosis. 

Occiwionidly a scconthiry infwtion by diphtheria bacilli 
ofcurs, IpjiditiR to (lie formation of pseudonieinbnmos, and some- 
tiinw also to parulysis of the voeail cords. 

Symptoms.— In mild CHsre the subjective symptoms arc in- 
significant; in seven.' typhoid, however, they are not usujUly com- 
plained of, on account of the coma : othcra-ise the patient reports 
pain on swallowing or slight hoarsi-iiess, which [Kiiiits to a laryn- 
p'al complication. In snvere caaca, where th<^ laryugral ohangt-s 
are spread over a large area, the swelling amd oedema arc very 
pronoumrcd, or |KTichtmdritis or ab«ce«.s may sii(M'rv»?ne, and 
stenosis even, with all its con.sequencfM, may result. 

The non~Sf>ecific cliangeiii usually occur between ihe sixth and 
seventeenth day. The xim-ifir rlumges iti the adenoid tissues 
occur belweeii the eighth and tent h day, and exactly correspond 
with similiir changi^ in the iiitwtines. Severe conipUeations, 
such as iK'riehondritis or ahtieeBa, on the other hand, only occur 
comparatively late in the course of the enteric fever. 

Diagnosis, — The typhoid lar>-ngilis is often overlooked because 
a larjugoscopic examination is often impoa^iblc in the caees 
of highly fe\'erish and comiitose patients. In other cases, 
perhaps oftener tlian is thought, the sj-niploms arc nuisked by 
the a|Mthy of the patient, esjjecially if they are not very m.irked. 
The changes, anti in particular the ulcers, are, however, so char- 
acteristic that their discover}* in a patient, feverish from an iin- 
kjiowi) cause, sliould always direct our attention to enteric fever. 



Oil the other hand, the typhoid nature of the hiryngitis ought 
not lo be nuMtakeii if all the other general sytnptwtiis are tjikcii 
into considenition. 

Prognosis. ^Thy prognosis is not altogether uiifavourHble. 
Superricial ulcers often, and deeper ulceration nejirly always, 
healupin the course of the discast- or afterwards. But wcshouhl 
always be prepared to see very unpleasant complications, such 
•IS audden oedema, if the ulceration is extensive. 

Treatment.— With regard to the patient who is serioudy ill, 
any loc-u] treatment should be avoided, and the main thing is to 
a.ttend to general treatuient. Periehondritic abscesses ought 
to be opeiiPtl by means of a larjTigeal knife. Severe dyspnoea 
rwpnri'M Iraeheotomy. Stenosis caused by contracting scars 
must be trusted according to the lines already indicated. 


Etiology. — Ljirj'ngeal and rrjichcjil lubereulosis do not often 
occur piiiiiarily, and they nearly always follow tuberculosis of 
the lung in iilxnit a thin! of all the chhcs of pulnunmrj' diwjuto. 
The larstj-x is affected by tuberculosis in various vvays, but most 
frequently by the secretion derived from diseased lungs, which is 
iipt to stick in the [mckets and folds of the j)osterior laryngeal 
wall, where it is supjHised to cnuse ivlaxation and erosion of 
the surface of Ihe mucous membrane, thuj* pn-ijariiig the 
way for the ubiquitous tubercle bacilli. The invasion of tubi-rrle 
bacilli is, however, not necessarily the result of the erosive action 
of the sputum. 

It has been shown that the male sex suftcrs morp than the 
female from liirvngeal tubereulnsis, especially between the 
twentieth and foriieth yean? of age, when ihe larynx is supiwsed 
to be uiost exiwsed to external harmful agenciee, viz., alcohol and 
tobacco, which are said to set up irritation, which subsequently 
r(wilt.s in Icsious »f the muniujt nu-nilmuu-. It has further 
bwn coiitfiided thai )mt«oiik Mifl'ering fmiii lung tlist'«*e are pre- 
disposed to ctilJtrrliiil larjiigitis, which i.s jfoipposcd to ulter the 
epithelium in some M'ay or other. Tlicjir altrnitions may be so 
insignificant that they escape notice, and rliis is probably the 
reason for the statement that tubende bacilli are caj>able i>f 



pcnetratinp through the inliwt i-pithcliuin, a viow which is m 
ngrwmpnt with the rccpnt tlii-ory of Hehrini} explaining infnniilo 
intcstinnl inffctbn. Actwrcling to ivwi liehring, the so-oalliKl 
primnr^' tuberculosis of the lung in nduhs is linnlly to ho tmciHl 
to an invasion of tubercle bneilli, which is suppowxl to have 
taken iJacc during infancy: having entered by the intestine, 
chiefly by the agency of impure milk, the bncilli mAde their 
way throiigli Ihc '*ifirge ptrret^" of the intestinnl epjthelivnn, 
and vrvn- thiw ultimately InuiKniittrtl by the lympb-slrcain into 
the hmg. 

However thl« may Iw, one may take it as certain that the 
infeefion by tubercle (jaeilU (ake« \thcv. ahiiiist nlways .if tht; 
posterior larj-ngeal wall. Thi« hanndnisitt with the fact lliat 
this i-egion is the >teal of predilection of lulipj'eidiir changes, and 
often rcniaiiia for a long time the tmly pari affected. In some 
other oises, as, for int^tanee, in railiiiry tuberrulnsis of the larynx, 
the tubercle bacilli are tmnemittod by way of the blood or 
lymph-vespelB from tubercular glands in the neck or bronchi. 
Such also would be the result— e. g.. infeetion by way of thr 
l>Tnph- vessels — in those cases of unilatenJ laryngeal tubercu- 
losis where- the lung is likewise luiilaterally or is chiefly affected 
on one side only.* Some authors siiffitjest that pulmonarj' and 
laiyngenl tuberculosis also is due to aeriiJ affeetion of the bron- 
chial glands, i. e., by the pulmonarj- lym[)halic glands at the root 
of the lung. 

Pathology.— The tuberele bacillas displays its sjtecific action 
in the .-subepilhelial layer of mucous membrane, where it leads 
to the formation nf "tubereles" of the size of a millet-seed— the 
so-called miliarj* tuberculosis, which has been already described 
in tulwrriilo.^i.* of the nose. The lubiTtrlits are emfwddrd in a 
vawular granulation liKHue, wliich also penetnites into the sub- 
nuicous ti.'wues and Ix'twern the glands and intrinsic nni.'scles. 
The glan<ls and vessels undcTgo varimis changes, and are dis- 
placed, or even destroyed. The tubercles coalesce and form in- 

"W« y.'vth to eniphntiaiUy point out llml in left-«idod affection ol tho 
luiii; thp riulil *ii\r ■>! ihf Inrynx niiKlil if idTMrlm). luul vln- vitk.^, iiimI ttist 
inunilnlprxl uibercnlfwisof ibe iunithoih h»lv«i of lliplsfynit may hr riiscMpd; 
nPvcnIielcNS, il i-- possiVilc in iiliserve. in a ercnl nisjorily of cases. ili;ii llio 
rel!lI)CCli^T affcctiotin nhon ivrlaiii ututormily wiUi reganl (o Ijie dde ;ifTecied. 



filtrations which diffusely per\-iule the tis«ue3 or arc more defined 
and cinniniscribed, forming tho tumour-Ukc prommciiccs, or tu- 
b(>rrul(imata. These undergo retrogressive do^enrmtion, woftcn, 
bn'iik down, and give rise ton euscoufl material. Thi-ovt-rlyirig 
epitliciitim aJso aofteus, becomes fattily degenerated, and is thm 
ciuit oiT, and thus smaller or larger sized craterifonn ulcers are 
proiiuceil, nrrording to whether only single iiui)erficial niilinry 
IiiIhtcIis ur larger eoiiglomemtions have bi'on eonet^nied. Tho 
single scnitti-nil ulcers are also deseribed ns "lentieular." These 
small uleenj [iiay unite and so produce an extensive uleeralion. 
Tlie uk'er3 show undemiined edges, owing to the faet that the 
gubmucous tissue breaki? down (luickcr than the nmcosa, and 
the edges of the ulcers are notched or serrated, be<^ause they art? 
Ihe seat of fresh tubercles, which in their tuni sooner or later 
also break down. The foniiation of granulation tissue is com- 
mon to all tuberculaj- ulcerations, on their floor, as well as on 
the edges of the ulcer. One may, therefore, see the margin of 
tubercular ulcers occupied by either .sjuall yellowish tubercles 
or ri'd granulations, or both together. The red gi-anulations 
nol irifrequr-iilly grow so abundantly, that rhey fomi actual 
papillary oxcrescencttt which have the apiieanmco of being 

If the process advances, it also penetrates in depth, and may 
attack ihe [icrichondrium, causing perichondritis, which dciuides 
Ihe cartilage, and since Ihia is consequently bereft of its nnurixh- 
ment, it then becomes necrotic. This process Is u-sually accoiii- 
I>anied by oedemntous swelling of Ihe adjacent tif«<ui.s. Peri- 
chondritis and chondritis must be laid to the account of the 
pyogenic cocci, which cause ttecondary iiifeelion and act either 
alone or in comiMiny with the tuboifle bacilli. Tlie sevetVP 
forms of tuberculosis are nearly always caiwed by sutih a mixed 
infection. . 

If tho intonnuacular and intramuscular tissues become infil- 
trated, the muscular substance itself dcgeneratet«, which causes 
disturbances of the voice, but even the nen-es themselves may 
also Ijecome affected. 

In tlie (rnvhea, tuberculous infiltmtion. owing to the firmer 
adherence of the mucous menibrouo to the trachea, is not as 



conspicuous as it is in the larynx. Licere may be preseat in smaU 
number, but of large «ie; or they are multiple and then mostly 
small, and are widely distributed over the surfnce, The trachea 
is usually not seriou»ly rtlterod, unless the lar)^lge^^I and pul- 
monary disease is fnr lulvjintied, ami it \» for this resson tliat the 
pathological changes produced by tuberculosis have been studied 
rnthor on the post-niortorn tublc than intra vitam. Per so, 
they hardly exercise any marked influence upon tho course of 
the disease; which is, however, defini^ by the larj-ugeaJ and 
pulmonary affection. 

The chief iion-specilic alteration, afiart from the [K-rtehondritis 
and chondritis caused by a secondaiy (mixed) inflection, are 
considered to be the conspicuous anaemia of tlie mucous mem- 
brane and the chronic lanTigeal catarrh. Both evidently In 
my opinion are the effect of ii dyscru&ia due to the lo.viiiH. Piih- 
sibly the catarrh has already bc-cii in existence in many cases, 
and has fostewd the specific infection (see aljovp). Anyhow, it 
is certain that chi*onic laryngitis is a regular accompaniment 
of laryngeal tuberculosis, and frequently also of pulmonary tuber- 
culous dificaee. (Hcf pp. 454 and 477.) haxya^tlB is very often 
the only pyiupt-oni in llic cour»e of "conpuniption" pointing to 
an infection of the lar>iix, and is usually distinguished by its 

flisto!og{col Changes. — The epithelium over an infiltration 
is very little altered; but sometimes it may Ije found to be thick- 
ened and warty, cs|K'cially if the infiltriition is close under the 
epithelial layer. In such a case single or multiple round-celled 
accumulations may be seen immediately Ik'Iow the epithelium. 
These arc the well-knoi,\ii "tubercles," which usually contain 
one or several giant-cells among the round-cell*. 

The "tubercles" are Ihcniselves situated in an area of small 
mund-ccll.'*. which surround the vessels and glands. An ulcer. 
of course, shows loss of epithelium, and the snudl-celkd infil- 
trations acconiingly look as if thpy were " dug out" or puckered. 
Barilli arc not always discovej-able in quantities, and they are 
the U'fin numemuH in ]in:i|»ortion to the greater number of gianU 
cell;* .^eeii. 

Symptoms and Course.— Liir^Tigcal luberculosis begins with 

acute: and CHJtOMC INFECnOVS DlgEASKe. 


& aeries of symptomn which, ne>ithcr Hulijeetive^y nor objectively, 
oSer anything eharactemtic, and arc often ma^ed by the 

co'existiiif piilmoD^ry disease. JPatienta now and then complftin 
of some hoai-scnesa or only of slight roughness of the voice, 
" hartlly worth 8|icaking of," or that the voice soon becomea 
fatigued. They ex]KTicnce various sensations in the larynx, 
such as a feeling of pressure as of a foreign body in the neck, of 
soreness, burning, or tickling, irritation, etc. To account for 
all these manifold se-nsations, nothing but a marked pallor of 
the mucous membrane can bo discovered latyngoseopically, 
though this may often bo already obviouB in the pharynx, and 
is often, (hough not ahvays, accompaniwl by slight s>inptonis 
of pharyngciJ catarrh. In my opinion, as ala-ady [winted out, 
the pallor in the Hiwl nianifestalion of the effect of a disturbance 
of niit.ritiun due to tlit- toxins, but ycl not of a ih-citially sixritic 
naluR'. In due course the symptoms gain in inttimity and 
bwflnie more distinct. 

(A) Subjedii^ Sifmpt(im». — They arc naturally dcpi-ndcnt on 
the seat and extent of the tuberculous process and an the lesions 
ihercby pnidueed. The voice, which at first was perhaps only 
inipure. becomes rough, hoarse, or even aphonic. Tliis is due 
to the put hnlngica] changes on the vnenl eortls, ventricular folds, 
or arytenoid cartilages and ixisterior wiill of the liir>'tix, which 
impede the noniml vibration or adduction of the vocal oonis, 
though the musclea theinm-lvert might be degtrnerated or the 
n-cunviit nerve be i)ar!il>'fled a-i the ivaiilt of pn-ssurc from 
swolU'U IdiHicliial glaiidss or lubrnruluu« processes in the a|M'X 
of the lung. At fii'st it is u-sually dm- to paresis and weakness 
of the niUsclcM on iirrnunt of ihi- pidbr of the mucous membnme 
by which tin- voice \h altciied, and the cough in mainly caused by 
the coexisting hmg disease. Next afttjr this alteration of the 
voice, swallowing Iweomiw painful (dyspliagia). This arises 
from didust- infill hlI ions on t he efiigloi tjii, but .still ofteiier 
fmm uicery on the epiglottis, aryteiioidw, and |jo«tC'rior laryngeal 
wall, or even from perichondritis. It may oasume such a 
degree that feeding may become exceedingly painfuJ and difficult, 
so that only a certain amount of fluid food can be painfully 
evaltowed. Moreover. miaswaJlowing is very common, or the 



prior pntipnts, with painful coughing and retching, vomit up 
nil that {hf-y have prnlnki-n nf. 

In unilateral disoaso the pnin mdiniwt towards the cftr of the 
some side, and in bilatoral affection into both kits. In advruicwl 
cases every single cough ami pvm' soimd nuide is painful. 
The whole «tatr of suljjcclivo disromforl is nivich agpravalpd 
if dysjjnoi'a (iimksi. Partially ra\iftril by thr hmg nfTixtion, 
tlip (K'sptiCM'si iHfciiiics very much woisc if (he larynx, on armunt 
of oiticnm and iiifiltmtion, Ixtihiuw iiarrmvttL As has invn 
laid in thir gen