Skip to main content

Full text of "The Journal of laryngology and otology"

See other formats 


>^.35 


|G^tbrarg 


of  the 


^tabang  of  (iHebtcine 


'^oxindtt 


Q 


x"^  ^-^ 


VOL.   XXXV.— 1920. 


THE 


Journal  of  Laryngology, 
rlilnology,  &  otology: 


A     RECORD     OF     CURRENT     LITERATURE 


RELATING    TO 


THE  THROAT,  NOSE,  AND  E'AR. 


PUBLISHED   MONTHLY. 


IC  0  n  i)  0  It : 
ADLARD   &   SON   &   WEST   NEWMAN,    LTD. 

BARTHOLOMEW    CLOSE,    E.C. 


ENIKREI)    AT    STATIONERS      HALL 


THE   JOURNAL    OF    LARYNGOLOGY, 
RHINOLOGY,   AND  OTOLOGY. 


Founded  in  1887  by  MORELL  MACKENZIE  and  NORRIS  WOLFENDEN. 


Editorial  Oommittke  : 


Sir     Chas.    A.    Ballance,    K.C.^r.G.,     C.B.. 
M.V.O.,  F.E.C.S.  (London).       {Pres.  Otol. 
Sect.  B.S.3I.) 
H.  S.  BiRKETT,  C.B.,  M.D. 

Brig. -Gen.  C.A.M.C.  {Montreal). 
A.  Brown  Kellt,  D.Sc,  M.D.  (Glasgow). 
A.  Ohe.\tle,  F.E.C.S. 

(Pres.  Otol.  Sect.  Internat.  Cong.) 

J.  S.  Fraser,  M.B.,    F.K.C.S.E.   (Edinburgh). 

Sir    James    Dcndas    (trant.    K.B.E.,    M.A., 

M.D.,  F.E.C.S.  (Lotidon). 

William  Hill,  M.D.  (London). 


W.    JoBsoN    Horne,    M.A.,    M.D.,   M.E.C.P. 
(Tjondon).     (Pres.  Laryng.  Sect.  R.S.HI.) 
J.  Macinttre,  M.B.,  CM.  (Glasgow). 
Sir  W.  Milligan,  M.D.,  M.Ch.  (Manchester). 
Sir  StClair Thomson, M.D.,  F.E.C.S.  (LoH(Zon). 
(Pres.  Laryvg.  Sect.  Internat.  Cong.) 
Herbert  Tillet,  M.D.,  F.E.C.S.- (Lowrfon). 
Logan  Turner,  M.D.  (Edinburgh). 
E.  B.  Waggett,  D.S.O.,  M.B. 
P.  Watson-Williams,  M.D.  (Bristol). 
Macleod  Yeaeslet,  F.E.C.S.  (London). 


V  \  ^  ^^  A  /^ 


Editor  : 
,N-   McKenzie,  M.D.,  F.E.C.S.E.  (London). 

Abstracts  Editor  : 


^  ecp    ^   £    OnflY  ^*    IfA^iKR,  M.C.(Cantab.),  M.B.,  F  E.C.S.fLondon). 


^, 


SuB-EdITOB  : 


^.  <  /O  . . ,  rx^^     ^--^RCHER  Etland,  F.E.C  S.E.  (London). 

^"•'••*~r**?"i*»^^'*^  TOITH   ■tnr.    CO-OPKKATION    of    rHK   .STiFF    of    .4^BSIK.lCrOKS: 

(D't^nSBsADr  fSydney,  N.S.W.),  John  Darling  (Edinburgh), 

J.  K.  MiLrrs  IDickie  (Edinburgh),  Donelan  (London),  Clayton  Fox  {London), 

Perry  Goldsmith  (Toronto),  Thos.  Guthrie  (Liverpool),  A.  Hutchison  (Brighton), 

J.  D.  LiTHGow  (EdAnburgh),  A.  McCall  (Bournemotith), 

Chichele  Nourse  (London),  Knowles  Eenshaw  (Manchester), 

LiNDLEY  Sewell  (Manchester),  Alex.  E.  Tweedie  (Nottingham), 

C.  E.  AVest  (London),  G.  Harold  L.  Whale  (London), 

Wright  (Bristol),  and  Wylie  (London). 


AXD    THE    AS8IS1ANCE    OF 


Mr.  George  Badgerow  (London),  Drs.  Grazzi  (Florence), 

A.  Brown  Kelly  (Glasgoiv),  E.  Law  (London), 

Irwin  Moore  (London),  Holger  Mygind  (Copenhagen),  D.  Paterson  (Cardiff), 

Urban  Pritchard  (London),  F.  A.  Eose  (London),  A.  Sandford  (Cork), 

Sendziak  (Warsaio),  Eaymond  Verel  (Aberdeen), 

E.  Waggett  (London),  Sir  E.  Woods  (Dublin). 


VOL.  XXXY.     N...  1  January,  1920. 


THE 

JOURNAL    OF    LARYNGOLOGY, 

RHINOLOGY,   AND   OTOLOGY. 


Original  Articles  are  accepted  on  the  co7idition  that  they  have  not  previously  been 
published  elsewhere. 

If  reprints  are  required  it  is  requested  that  this  be  stated  wlcen  tJie  article  is  first 
forwarded  to  this  Journal.     Such  reprints  will  be  charged  to  the  author. 

EditoiHal  Communications  are  to  be  addressed  to  "Editor  of  Journal  of 
Larynqologt,  care  of  Messrs.  Adlard  4*  Son  4'  West  Newman,  Limited,  Bartholometv 
Close,  E.C.  1." 


AN     INTRA-TRACHEAL    TUMOUR:    REMOVAL    BY    PERORAL 

TRACHEOSCOPY. 

By  Herbert  Tilley,  B.S.,  F.R.C.S. 
Surgeon,  Ear  and  Throat  Department,  University  College  Hospital,  Loudon. 

At  the  invitation  of  our  esteemed  Editoi',  I  am  glad  to  have  an  oppor- 
tunity of  bringing  this  case  before  a  large  circle  of  laryngological 
confreres,  not  only  on  account  of  the  rarity  of  the  condition,  but  also 
because  it  illustrates  the  value  of  the  direct  method  of  dealing  witli  a 
lesion  which  otherwise  would  probably  have  caused  the  death  of  the 
patient. 

Hitherto  I  had  never  seen  a  case  like  it,  and  probably  most  laryngo- 
logists,  even  in  busy  practice,  have  never  enjoyed  such  an  experience 
nor  ever  will  do  so.  Even  Chevalier  Jackson  with  his  unrivalled 
opportunities  has,  so  far  as  I  know,  only  published  one  case  with  some- 
what similar  clinical  symptoms,  viz.  "  Endothelioma  of  the  Eight 
Bronchus  removed  by  Peroral  Bronchoscopy  "  (American  Laryngological 
Association,  May  10,  1916). 

History.^ 

Capt.  El was  a  very  healthy  and    active  officer  until  he  fell  a  victim  to 

"mustard  gas"  on  March  21,  1918.  He  was  "gassed"  in  the  morning  and  only 
gave  in  the  same  night  when  his  "  eyes  closed  up."  He  was  in  bed  fourteen  days  and 
then  sent  home  for  some  twelve  weeks,  and  during  this  time  his  only  trouble  was 
a  sense  of  difficulty  in  breathing  when  he  hurried. 

'  I  am  indebted  to  Dr.  Macwhirter  Dunbar  (Claj)ham  Common,  S.W.),  for  the 
careful  notes  herein  reprodviced. 

1 


2  The  Journal  of  Laryngology,         'January,  1920. 

July  22. — Pulse-rate  on  exertion  increased  by  50  per  cent.  Some  evidence  of 
emphysematous  condition  of  lung  margins  in  front.  Blood-pressure  145  mm. 
Pulse  100. 

October  14. — Still  dj^spnoea  on  exertion.  Occasional  spitting  of  blood  in  the 
morning.  Eapid  heart  action  on  exertion.  Breath  much  affected  by  attempting 
to  wear  old  mask  impregnated  with  chloride  so  that  he  had  to  give  up  his  duty  as 
"  gas  instriictor. 

January,  1919. — Demobilised  as  CI  and  20  per  cent,  disability  though  still 
dyspnoeic  on  exertion. 

April  16. — Cold  weather  now  makes  him  unable  to  get  breath  to  speak.  Breathes 
like  an  old  emphysematous  man. 

May  16. — The  dyspnoea  now  makes  him  sick.  There  is  stridor  on  walking. 
Much  yellow  sputum  expectorated. 

June  10. — Marked  stridor.  Bent  back  and  resembles  an  old  emphysematous 
patient.  Feels  impeded  inspiration  and  expiration.  Coughs  for  eighteen  to  thirty 
minutes  on  lying  down.  No  cyanosis.  Kecession  of  both  supraclavicular  fossae  on 
inspiration.     Feeble  breath-sounds  over  root  of  right  lung  when  compared  with  left. 

June  12.— Ui'ine:  Sp.  gr.  1021;  heavy  trace  of  albumen;  no  sugar.  Ux'ine 
slightly  cloudy ;  deposits  a  few  hyaline  granular  and  epithelial  casts,  numerous 
decolorised  blood  discs  and  a  few  leucocytes. 

Sputum:  Moderate  amount  of  pus.  Considerable  number  of  blood-cells  and  a 
few  squames.  No  tubercle  bacilli,  but  numerous  other  organisms,  chiefly  coliform 
bacilli,  M.  catarrhalis,  sti-eptococci. 

Radiographer's  Beport  of  Chest  (June  13 — Dr.  Ironside  Bruce). — The  gistof  the 
report  is  :  "  There  is  evidence  in  this  case  of  some  infiltration  of  the  mediastinal 
contents  at  the  level  of  the  manubrium  stemi  which  results  in  pressure  on  the  trachea 
and  oesophagus,  but  there  is  no  evidence  as  to  the  nature  ot  the  infiltration.  No 
evidence  of  any  other  lesion  of  the  lung  or  aorta  is  available  in  this  case." 

Laryngoscopic  Exatnination  (June  16,  1919). — I  saw  Capt.  E —  to-day  with  his 
family  doctor.  Dr.  Macwhirter  Dunbar.  Even  the  slight  exertion  of  walking 
into  my  room  produced  a  noticeable  stridor  on  inspiration ;  but  for  this  the 
patient  appeared  to  be  a  strong,  well-built  young  man.  The  vocal  cords  were 
normal  in  action  and  in  colour.  By  making  him  stoop  while  I  knelt  below  him 
in  order  to  examine  his  trachea,  I  saw  that  its  lower  end  was  almost  occluded 
by  a  pale,  reddish-grey  tumour  which  moved  upwards  and  downwards  with 
expiration  and  inspiration.  It  was  obviously  attached  to  the  right  side  and  close 
to  the  opening  into  the  right  bronchus. 

It  was  decided  to  operate  without  delay  and  the  patient  went  into  a  nursing 
home  the  same  evening. 

Operation  (June  17,  5^.in.).  — At  4.15  p.m.  a  hypodermic  injection  of  atropine 
Too  S^-  ^^^  administered,  and  at  5  o'clock  Dr.  Felix  Kood  administered  "  open 
ether."  This  was  quickly  discontinued  in  favour  of  chloroform  because  of  the 
cyanosis  caused  by  the  ether.  The  patient  laid  on  the  operating  table  with  the 
head  and  shoulders  slightly  raised  by  a  hard  pillow.  When  the  reflexes  were 
sufficiently  abolished  I  jiassed  a  full  size  bronchoscope  (Briining's'  to  the  lower 
end  of  the  trachea  and  had  no  difficulty  in  seizing  the  tumour  in  a  long  pair 
of  Paterson's  forceps.  A  portion  of  the  growth  came  awa\-,  and  then  our  troubles 
commenced  because  of  the  very  free  bleeding  which  ensued.  Cocaine  and 
adrenalin  were  freely  aj^plied,  and  a  plentiful  supply  of  gauze  swabs  only 
helped  to  minimise  the  difficulties.  Not  the  least  of  these  was  the  spraying  of 
the  bronchoscope  mirror  with  coughed  up  blood  which  Dr.  Irwin  Moore  busied 
himself  with  keeping  clean.     His  assistance  was  most  timely. 

Furthermore,  some  of  the  blood  was  passing  down  the  bronchi  all  the  time, 
but  this  was  frequently  blown  upwards  through  my  bronchoscope  by  a  direct 
air-pressure  apparatus  which  Dr.  Eood  had  thoughtfully  provided.  Here  let  me 
pause  to  say  that  the  ultimate  success  of  the  operation  was  in  no  small  measru-e 
due  to  the  superb  judgment  and  admirable  skill  of  the  anaesthetist.  Time  and 
again  he  cleared  out  supei-fluous  blood  from  the  bronchi  and  then  gave  just  enough 
anaesthetic  to  allow  me  to  continue  in  my  effort  to  get  hold  of  the  pedicle  of  the 
tumour.  In  many  attempts  I  failed  to  do  this  but  each  effoi-t  enabled  me  to 
reduce  the  size  of  the  tumour  and  so  to  free  the  air-way.  At  last,  and  after 
some  forty  minutes  of  the  most  anxious  time  in  my  surgical  career — and  June  17th 
was  the  climax  of  a  heat-wave — by  increasing  the  flexion  of  the  cervical  spine 
I  managed  to  seize  the  pedicle  and  the  remaining  portion  of  the  tumom-  and  to 


January,  1920.J  Rhinology,  aiid  Otology.  3 

remove  them.  All  bleeding  ceased  at  once.  We  left  the  nursing  home  at 
6  o'clock,  much  exhausted,  and  hurried  home  to  get  into  a  change  of  dry  under- 
clothing I 

The  patient  recovered  without  a  symptom  and  left  the  nursing  home  on  the 
fourth  day  after  the  operation. 

Note  (September  28). — ^There  is  no  sign  of  recurrence,  and  he  expresses  himself 
a,9  being  "  as  fit  as  I  have  ever  been  in  my  life." 

I  sent  the  unique  specimen  to  Prof.  S.  G.  Shattock  for  examination 
and  in  my  note  suggested  tliat  possibly  the  "  gas  "  had  caused  a  localised 
ulceration  of  the  trachea,  and  that  the  granulations  forming  on  this  had 
assumed  the  formation  of  a  tumour,  which  had  become  pedunculated 
owing  to  the  traction  and  propulsive  influences  of  the  inspiratory  and 
expiratory  currents  of  air.  The  subjoined  report  which  he  has  sent  me 
would  seem  to  render  such  an  explanation  feasible,  and,  as  he  suggests, 
the  increased  opacity  which  the  radiographer  noted  around  the  root  of 
the  lung  may  have  been  due  to  inflammation  resulting  from  septic 
absorption  from  the  base  of  the  primary  ulceration. 

The  following  is  Prof.  Shattock's  report  on  the  specimen  : 

"  The  new  formation  (which  was  the  size  of  a  small  cherry  and 


Fig.  1. — Part  of  the  i^apillary  granuloma  removed  from  the  trachea  at  the 
level  of  its  bifurcation,  showing  one  of  the  clefts  and  the  finer  papula- 
tion of  the  surface.     (Twice  natural  size.) 

somewhat  pedunculated)  is  deeply  lobulated,  its  surface  being,  in  addition, 
finely  and  uniformly  papillary. 

"  Microscopic  examination  :  The  free  surface  is  everywhere  invested 
with  epithelium,  which  is  in  places  very  thin,  apparently  from  desqua- 
mation accompanying  proliferation  ;  where  intact  it  consists  of  a  deep 
columnar  series  of  cells  succeeded  by  squamous — that  is  to  say,  the 
normal  columnar  epithelium  of  the  trachea  has  been  replaced  by  one  of 
the  stratified  squamous-celled  kind. 

"  This  transformation  may  be  attributed  to  the  '  irritation  '  arising 
from  the  passage  of  air  over  the  eminence,  which,  by  diminishing  the 
calibre,  has  locally  increased  the  force  of  the  blast,  and  is  analogous,  e.  g., 
to  the  somewhat  similar  transformation  of  the  epithelium  on  internal 
piles  which  have  come  to  project  beyond  the  anus. 

"  There  is,  it  may  be  observed,  a  still  further  possible  transformation, 
or  metaplasia,  of  the  epithelium  of  the  respiratory  passages,  which  I 
once  saw  well  marked  in  a  simple  pedunculated  papilloma  which  was 
removed  from  the  vocal  cord  of  an  adult  past  middle  age,  who  was  a 
powerful  public  lecturer.  The  investing  epithelium  (as  is  the  rule)  was 
of  the  squamous-celled  kind,  but  it  was  furnished  with  a  stratum 
granulosum,  or,  in  other  words,  had  acquired  the  minute  structure  of 


4  The  Journal  of  Laryngology,        [January,  1920. 

the  epidermis.  This  epidermisation  has  its  parallel  in'other  positions, 
notably  after  inversion  and  protrusion  of  the  uterus  through  the  vulva : 
in  the  negress  uterine  mucosa  exposed  to  the  outer  air  may  in  addition 
become  pigmented  like' the  skin. 

"  To  return  to  the  new  formation  itself,  the  structure  of  this  varies 
according  to  its  depth.  Superficially  it  is  highly  vascular,  the  capillaries 
having  a  general  direction  at  right  angles  to  the  free  surface.  The 
substance  between  the  vessels  is  a  compact  collection  of  young  or 
immature  fibroblasts,  with  polymorphs  in  conspicuous  numbers  and  a 
certain  proportion  of  lymphocytes. 


Fig.  2. — From  the  mid-substance  of  the  jiapillary  tfi-anxilonia  removed  from 
the  trachea.  It  consists  of  intersecting  l^undles  of  fibroblastic  tissue, 
thickly  and  uniformly  infiltrated  with  polymorphs  and  lymphocytes.  A 
certain  number  are  divided  transversely.     (§  obj.) 


"  More  deeply  the  fibroblasts  lie  in  intersecting  bundles  and  have 
the  usual  spindle  appearance,  polymorphs  and  lymphocytes  being 
likewise  freely  distributed  amongst  them. 

"  Most  deeply  of  all,  through  the  plane  of  surgical  removal,  the 
structure  merges  into  compact  fibrous  tissue  resulting  from  the 
development  of  fibre  between  the  cells,  the  bundles  being  closely  inter- 
woven as  in  the  deepest  part  of  a  granulating  surface.  The  formation 
may  therefore  be  classed  as  a  papillary  granuloma  ;  and  its  pathogenesis, 
as  surmised  by  Mr.  Tilley,  may  be.  well  referred  to  damage  of  the 
tracheal  mucosa  brought  about  by  the  gassing  to  which  the  patient 
had  been  subjected. 


January,  1920.]  Rhinology,  and  Otology.  5 

"  In  the  accompanying  microscopic  figures  are  contrasted  the  charac- 
ters of  the  scar-tissue  composing  the  granuloma,  and  tiie  central  con- 
nective tissue  of  a  small,  recently  formed  gonorrhceal  wart. 

"  In  the  former  the  structure  consists  of  intersecting  bundles  of 
fibroblastic  tissue  uniformly  and  thickly  infiltrated  with  lymphocytes 
and  polymorphs. 

"  In  the  gonorrhceal  wart  there  is  a  core  of  common  connective  tissue 
furnished  with  well-developed  vessels.  Groups  of  small  cells  lie  in  the 
more  superficial  parts  of  the  tissue. 


Fig.  3. — Section  of  part  of  a  small,  recently  developed  gonorrhceal  wart 
from  the  female  genitalia,  which  was  excised  in  order  to  compare  its 
structure  with  the  preceding.  It  has  a  well-developed  core  of  connective 
tissue,  in  the  superficial  parts  of  which  groups  of  small  cells  are  distri- 
buted.     In  its  extreme  diameter  the  entire  wart  is  "8  cm.     (2  in.  obj.) 


"  Quite  recently  I  had  the  opportunity  of  examining  a  curious  forma- 
tion of  granulation-tissue  which  may  be  worth  citing,  since  its  structure 
is  almost  exactly  like  that  of  the  present  specimen. 

"  A  decalcified  chicken-bone  which  had  been  used  to  drain  ascitic  fluid 
from  the  abdominal  cavity  into  the  connective  tissue  was  removed,  as 
it  had  ceased  to  act.  On  examination  it  was  found  completely  blocked 
for  several  inches  with  a  firm,  solid  cord  which  had  grown  in  from 
one  end. 

"  Microscopically  the  cord  consists  of  intersecting  bundles  of  fibre- 


C  The  Journal  of  Laryngology,        [January,  1920. 

blastic  tissue  with  interspersed  small  cells,  furnished  with  a  few  capil- 
laries. The  tissue  has  made  its  way  into  the  Haversian  canals  of  the 
decalcified  bone  so  as  to  give  the  latter  a  remarkably  delusive  appearance 
of  being  still  living." 

In  bringing  this  communication  to  a  close  I  should  like  to  make  two 
observations  : 

(1)  The  value  of  the  "  stooping  position  of  the  patient  "  when  one 
is  endeavouring  to  examine  the  lower  regions  of  the  trachea  with  the 
laryngeal  mirror.  From  evidence  of  many  kinds  I  am  sure  that  this 
method  is  not  suflSciently  practised  by  laryngologists.  It  is  less  than 
three  weeks  ago  that  I  was  consulted  by  a  patient  for  difficulty  in 
breathing,  and  by  adopting  the  above  method  I  saw  that  the  lumen 
of  the  lower  end  of  the  trachea  was  bulged  inwards  on  the  left  side. 
Radiographic  examination  demonstrated  an  aortic  aneurysm.  Never- 
theless, a  confrere  had  missed  this  because  he  had  only  examined  the 
patient  in  the  sitting  position. 

(2)  That  such  an  operation  as  above  described  should  not  be  under- 
taken without  the  help  of  an  expert  assistant  and  an  anaesthetist  skilled 
in  throat  work.  In  many  little  ways  Dr.  Irwin  Moore  lent  me  valuable 
help,  and  I  am  sure  the  operation  could  not  have  been  completed  had 
not  Dr.  Rood  supplemented  his  instinctive  ability  as  an  anaesthetist 
by  such  accessories  as  an  oxygen  cylinder  (containing  oxygen  !)  and 
an  electric  rotary  air-pump  (Kelly's  intra-tracheal  ether  apparatus), 
which  did  not  refuse  to  work  when  called  upon.  To  both  these 
gentlemen  are  offered  my  sincere  thanks,  while  those  who  may  chance 
to  read  these  notes  will  be  not  less  gx'ateful  than  I  am  to  Prof.  S.  G. 
Shattock,  who,  with  the  infinite  pains  so  characteristic  of  his  genius, 
has  made  clear  to  us  the  pathological  nature  of  an  interesting,  rare  and 
dangerous  "  intra-tracheal  tumour." 


VINCENT'S    ANGINA    OF    THE    EXTERNAL    AUDITORY 

MEATUS. 

By  Arthub  Cheatle,  F.R.C.S. 

In  two  poorly-nourished  and  neglected  female  hospital  patients,  aboufe 
the  age  of  ten  years,  brought  for  discharge  from  the  ear,  ulceration  of  the 
cartilaginous  meatus  was  found.  The  granulations  of  the  ulcer  were 
flabby,  and  there  was  no  apparent  thickening  of  the  underlying  tissue. 
The  discharge  was  muco-purulent  and  offensive.  Glandular  enlarge- 
ment was  not  a  feature,  and  there  was  no  pain. 

Dr.  Emery  found  the  fusiform  bacillus  and  spirillum  of  Vincent's 
angina  in  the  discharge  in  both  cases.  The  nose  and  throat  and  gums 
were  also  examined  by  him  and  found  positive  from  the  gums  only. 

Healing  of  the  ulceration  quickly  took  place  under  mercurial  syringing 
and  instillation  (1-2000  perchloride  of  mercury),  leaving  a  perforation 
in  the  membrane  and  middle-ear  discharge. 

It  seemed  that  the  meatal  was  secondary  to  the  gum  infection  and 
conveyed  by  the  fingers  to  the  ear.  There  was  no  reason  to  think  that 
the  middle  ear  was  similarly  infected. 


January,  1920.)  RhinoIogYt  and  Otology.  7 

Nine  years  ago  a  case,  most  probably  of  the  same  nature,  though 
not  verified  by  microscopical  examination,  was  seen  in  private  practice. 
A  delicate  female  child,  with  discharge  from  the  left  ear,  was  found  to 
have  ulceration  of  the  anterior  and  inferior  meatal  walls  from  just  inside 
the  concha  right  down  to  the  membrane,  which  was  intact.  Nearly  all 
the  molar  teeth  were  loose,  and  the  gums  swollen,  soft  and  offensive. 
The  ulcer  healed  surprisingly  quickly  after  curetting  under  antiseptic 
precautions,  in  which  1-20  carbolic  acid  solution  was  used. 

The  condition  is  probably  not  uncommon,  for  after  the  first  case 
was  diagnosed  a  second  was  soon  found. 


REPORTS  FOR  THE  YEAR  1918  FROM  THE  EAR  AND  THROAT 
DEPARTMENT  OF  THE  ROYAL  INFIRMARY,  EDINBURGH. 

Under  the  care  of  A.  Logan  Turner,  M.D.,  F.R.C.S.E.,  F.R.S.E. 

Part  III. 

LUPUS  OF  THE   UPPER   AIR-PASSAGES:    A  REPORT  UPON 
128  CASES  TREATED  AS  OUT-PATIENTS. 

By  Russell  Webber,  M.D.,  Capt.,  M.C.U.S., 
Clinical  Assistant. 

Cases  of  lupus,  like  the  poor,  are  ever  with  us,  and  it  is  this  fact, 
coupled  with  the  knowledge  that  our  figures  difi'er  in  some  respects 
from  those  heretofore  published,  that  makes  one  bold  to  present  a 
subject  which  is  not  very  satisfactory  when  considered  from  the  point 
of  view  of  treatment. 

It  is  our  experience  that— certainly  in  the  vast  majority  of  cases — 
the  condition  first  appears  in  the  nose  within  the  nasal  cavities.  Of 
the  128  cases  recorded,  in  113,  or  88  per  cent.,  the  disease  began  either 
on  the  anterior  part  of  the  nasal  septum,  on  the  mucous  membrane  of 
the  outer  wall  of  the  nose  and  close  to  its  junction  with  the  septum,  or 
on  the  anterior  end  of  the  inferior  turbinate.  In  a  certain  number 
of  cases  there  was  an  extension  of  the  disease  to  the  mucosa  of  the 
hard  and  soft  palate,  the  pharynx  or  larynx,  without  evidence  of  skin 
lesion,  but  in  sixty-nine  (or  52  per  cent.)  of  the  cases  skin  involvement 
was  noted  upon  the  face. 

Glandular  involvement  occurred  in  forty-eight  cases  (37  per  cent.), 
the  glands  most  frequently  atiected  being  those  of  the  submaxillary 
chain.  It  is  worthy  of  note  in  this  connection  that  in  twelve  cases 
(10  per  cent.)  scars  showing  evidence  of  operations  for  old  submaxillary 
gland  trouble  were  remarked  (Plate  I).  The  inference  is  that  at  the 
time  of  operation  the  disease  within  the  nose  causing  the  glandular 
enlargement  was  present  but  overlooked. 

The  greater  number  of  the  cases  occurred  in  females,  as  most  previous 
statistics  demonstrate.  In  our  series  the  percentage  of  female  cases 
reaches  the  strikingly  high  figure  of  seventy- seven. 

It  is  during  the  second  and  third  decades  that  the  majority  of  the 
cases  have  been  noted.  It  seems  quite  likely  that  many  of  the  patients 
who  reported  during   the  second  decade  may  have  actually  had  the 


8  The  Journal  of  Laryngology,       [January,  1920. 

disease  during  the  first,  but  that  it  had   been  overlooked  until  there 
were  some  external  manifestations.     The  age-incidence  was  as  follows  : 


First  decade    . 

.     11 

cases 

— 8  per  cent 

Second  decade 

41 

32 

Third  decade 

34 

26 

Fourth  decade 

21 

16 

Fifth  decade  . 

9 

7 

Sixth  decade  . 

9 

7 

Seventh  decade 

3 

2 

Lesions  of  the  Nose. — ^Yhen  first  seen  the  patient  as  a  rule  complains 
of  a  blocking  of  one  or  other  side  of  the  nose.  Examination  shows  a 
certain  amount  of  crusting  on  the  area  affected.  This,  as  before  stated, 
is  usually  the  anterior  end  of  the  inferior  turbinate,  the  angle  formed 
by  the  septum  and  outer  wall,  or  an  area  on  the  septum  about  half  an 
inch  posterior  to  its  anterior  free  margin,  or  reaching  its  junction  with 
the  skin.  When  the  crust  is  removed  a  pinkish,  elevated,  granular 
surface  is  exposed,  which  bleeds  very  readily  when  probed.  As  the 
disease  progresses  and  the  perichondrium  is  attacked  the  septal  cartilage 
frequently  becomes  perforated,  the  soft  parts  of  the  nasal  vestibules  are 
infiltrated^  and  unless  checked  complete  destruction  of  the  alar  cartilages 
and  skin  covering  them  takes  place.  Extension  of  the  disease  in 
patches  may  be  observed,  often  traceable  along  the  course  of  the  lym- 
phatics which  accompany  the  facial  vein  (Plate  I).  If  the  submaxillary 
glands  are  examined  wlien  this  is  the  case,  almost  invariably  they  will 
be  found  to  be  enlarged. 

The  area  in  the  nose  most  frequently  overlooked  is  the  small  space 
formed  by  the  angle  between  the  septum  and  the  outer  nasal  wall. 
This  is  a  warm,  moist  hiding-place  for  the  infection,  is  not  readily 
disturbed  by  the  use  of  the  handkerchief,  and  altogether  offers  a  most 
favovu'able  site  on  which  the  disease  may  get  a  foothold.  Disease  in 
this  area  is  very  frequently  not  discovered  until  the  skin  of  the  nose 
itself  is  involved  by  a  direct  extension  through  the  tissue. 

Lesions  of  the  Tear-sac. — Eight  cases  (6  per  cent.)  with  involvement 
of  one  or  the  other  tear-sac  are  noted.  In  these  cases  the  disease 
began  within  the  nose  and  probably  spread  along  the  mucosa  of  the 
lacrymal  duct  by  direct  extension. 

Lesion  of  the  Alveolus,  Hard  or  Soft  Palate,  and  Uvula. — In  thirty- 
three  cases  (25  per  cent.)  these  regions  were  involved.  As  a  rule  the 
mucous  membrane  presents  a  more  granular  appearance  than  in  the  other 
regions  affected.  In  some  cases  there  are  discrete,  pale  pink  elevations 
about  the  size  of  a  pin-head  scattered  about  with  no  definite  grouping. 
In  others  the  lesions  are  of  larger  extent,  and  instead  of  presenting  a 
granular  appearance  have  a  smooth,  glistening  pink  surface,  sharply 
demarcated  from  the  surrounding  healthy  mucous  membrane.  Some 
of  these  areas  may  reach  the  size  of  a  threepenny-piece.  When  the 
uvula  is  attacked  almost  complete  destruction  is  quite  commonly  the 
result.  In  five  cases  (4  per  cent.)  one  or  the  other  of  the  tonsils  was 
involved  and  lesions  of  the  faucial  pillars  are  noted  in  eleven  cases 
(8  per  cent.).  In  none  of  the  cases  examined  was  disease  of  the  buccal 
mucosa  detected. 

Pharynx. — Involvement  of  the  pharyngeal  mucous  membrane  occurs 
in  fifteen  cases  (11  per  cent.).  It  is  the  posterior  wall  that  is  usually 
affected,  and  the  lesions  appear  as  small  nodules  varying  in  size  from  a 


JOURNAL    OF    LARYXGOLOGY,    EHINOLOGY,    AND    OTOLOGY. 


PLATE    I. 


To  Illustrate  Dr.  Russell  ^VEBBER's  paper  on  Lupus  of  the  Upper 

Air-Passages. 

Lupus  of  nasal  mucosa  and  vestibule  with  small  lupoid  nodules  dotted  along  the 
course  of  the  lymphatics  crossing  the  cheek.  A  long  scar  beloAv  the  jaw  is 
evidence  of  a  previous  operation  upon  the  Ij^mphatic  glands. 


Adlard  4-  Son  f  Weft  yeicman,  Ltd. 


January,  1920.]  Rhioology,  and  Otology.  9 

pin-head  to  areas  having  a  dianaeter  of  about  a  quarter  of  an  inch. 
Scarring  is  a  distinct  feature  in  this  region,  the  pharyngeal  wall  in 
an  old  case  having  a  large  part  of  its  mucosa  replaced  by  scar-tissue. 
There  is  only  one  reference  in  the  case-records  to  involvement  of  the 
mucosa  of  the  naso-pharynx  and  that  one  case  was  considered  as  very 
doubtful.  In  all  the  cases  the  naso-pharynx  was  carefully  examined 
with  the  posterior  rhinoscopic  mirror. 

Larynx. — Twenty-four  cases  (18  per  cent.)  are  recorded  as  affecting 
the  larynx.  In  five  of  these  cases  the  epiglottis  was  involved  alone, 
the  lesions  varying  in  severity  from  a  simple  redness  to  practically 
complete  infiltration.  When  seen  early  there  is  a  general  reddening 
of  the  mucosa.  This  may  go  on  to  nodular  infiltrations  and  eventually 
ulceration  along  the  free  margin.  It  is  quite  common  when  ulceration 
has  occurred  to  see  a  large  V-shaped  area  in  the  centre  completely 
eaten  away,  the  epiglottis  appearing  very  thick  and  twisted  and  of  a 
peculiar  clubbed  shape. 

In  fifteen  cases  (11  per  cent.)  there  was  infiltration  of  the  mucous 
membrane  either  of  the  inter-arytsenoid  space,  the  ary-epiglottic  folds, 
or  the  arytenoids  themselves.  As  a  rule  the  condition  appears  as  a 
heaping-up  of  the  mucosa,  which  shows  a  pale  pinkish  colour.  The 
false  cords  were  involved  in  four  cases,  the  true  cords  in  five.  In  the 
case  of  the  true  cords  two  showed  simple  redness  and  thickening,  while 
the  remaining  three  showed  definite  nodulation.  In  none  of  the  cases 
is  there  any  evidence  of  actual  ulceration  having  been  seen. 

Lymphatic  Spread. — As  lupus  may  spread  by  the  lymphatics  as 
well  as  by  direct  extension,  a  few  words  on  the  lymphatic  distribution 
are  called  for.  According  to  the  researches  of  Most,  the  lymphatics 
from  the  mucous  membrane  of  the  anterior  one-third  of  the  nasal  foss® 
carry  the  lymph  forwards  and  open  into  the  lymph-vessels,  which, 
following  the  course  of  the  facial  vein,  empty  into  the  submaxillary 
glands.  The  lymphatics  of  the  mucosa  of  the  posterior  two-thirds  of 
the  nasal  fossae,  on  the  other  hand,  drain  the  lymph  backwards  to  the 
post-nasal  space  and  the  retro-pharyngeal  glands.  Between  the  anterior 
one-third  and  the  posterior  two-thirds  there  is  quite  free  anastomosis 
of  the  lymphatics. 

The  post-nasal  lymphatic  network  communicates  freely  with  the 
lymphatics  of  the  pharynx  and  upper  surface  of  the  soft  palate.  The 
vessels  on  the  dorsum  of  the  soft  palate  further  anastomose  with  those 
going  to  the  under-surface  of  the  soft  palate,  the  uvula,  and  the  tonsils. 
The  lymphatics  of  the  alveolar  process  are  continuous  internally  with 
those  of  the  hard  palate  (one  source  of  spread),  and  externally  with  those 
of  the  mucous  surface  of  the  lips  and  the  cheeks.  The  lymphatics  of 
the  skin  of  the  cheeks  which  follow  the  course  of  the  facial  veins,  as 
before  mentioned,  have  afferent  branches  from  the  network  within  the 
nasal  vestibule.  The  lymphatic  network  of  the  larynx  anastomoses  to 
a  large  extent  with  that  of  the  pharynx,  the  mucosa  of  the  supra-glottic 
area  being  best  supplied.  Bearing  in  mind  the  possibilities  of  the 
infection  being  carried  in  the  lymph-stream  from  the  original  focus  in 
the  nose,  its  appearance  on  the  alveolus,  palate,  uvula,  pharynx  or  larynx 
can  be  easily  explained.  What  is  difficult  to  explain  is  the  fact  that, 
though  the  mucosa  of  the  areas  between  the  original  focus  in  the  nose, 
for  instance,  and  the  secondary  lesion  in  the  pharynx  or  larynx  is  freely 
traversed  by  the  lymphatics  which  drain  the  former,  there  may  be  no 
sign  of  disease  along  the  route.     Thus  but  one  case  (and  that  a  doubtful 


10  The  Journal  of  Laryngology,       [January,  1920. 

one)  is  recorded  as  having  lupus  of  the  naso-pharynx.  There  are  five 
cases  in  which  there  is  no  disease  between  the  anterior  one-third  of  the 
nasal  fossae  and  the  larynx,  in  which  the  secondary  lesion  was  located. 
Further,  there  are  five  cases  in  which  disease  of  the  larynx  was  associated 
with  disease  of  the  post-pharyngeal  wall,  but  in  only  the  doubtful 
case  before-mentioned  was  there  even  suspicion  of  disease  of  the  naso- 
pharynx. 

Treatment. — There  is  no  sovereign  remedy  for  lupus.  Treatment  of 
various  kinds  may  have  an  inhibitory  effect  and  even  a  curative  effect, 
but  the  latter  are  few.  Among  the  agents  we  have  employed  may  be 
mentioned — (1)  tuberculin  ;  (2)  salvarsan  ;  (3)  electrical  ionisation  ; 
(4)  curetting  with  or  without  the  application  of  lactic  acid ;  (5)  the 
electric  cautery  ;  (6)  Pfannenstiel's  treatment ;  (7)  use  of  X  rays.  The 
first  three  of  these  methods  we  have  abandoned  because  of  the  poor 
results  secured.  Lesions  of  the  palate  and  alveolar  process  we  quite 
often  treat  by  curetting  and  applying  75  per  cent,  lactic  acid,  and  we 
also  use  the  electric  cautery  for  disease  in  the  same  area.  For  lupus  of 
the  nose  we  have  found  Pfannenstiel's  treatment  to  be  distinctly  helpful. 
When  employed  the  diseased  area  is  carefully  scraped,  the  nasal  cavities 
packed  with  gauze  kept  soaked  in  hydrogen  peroxide,  and  sodium  iodide 
is  given  internally.  Nascent  iodine  is  produced  within  the  nasal  fossas 
and  acts  upon  the  bacilli.  Preliminary  scraping  of  the  diseased  area  is 
advisable  in  the  first  instance.  In  lupus  of  the  epiglottis  and  the 
laryngeal  mucosa,  removal  of  the  diseased  area  with  cutting  forceps  often 
results  in  the  cure,  or  at  least  the  arrest  of  the  disease.  The  X  rays 
have  been  used  in  the  treatment  of  the  associated  skin  condition  quite 
largely  in  the  past.  They  are  now  only  employed  in  selected  cases.  Of 
twenty-two  cases  of  lupus  which  subsequently  underwent  carcinomatous 
changes,  which  were  treated  in  the  Skin  Department  of  the  Eoyal 
Infirmary,  Edinburgh,  previous  to  1914,  seventeen  were  treated  with 
the  X  rays.  We  have  not  used  the  Finsen  rays,  but  at  least  two  cases 
which  had  had  this  treatment  previous  to  their  admission  to  the  Eoyal 
Infirmary,  Edinburgh,  said  they  were  much  benefited.  All  who  have 
had  much  to  do  with  lupus  will  quite  agree  with  Norman  Walker,  who 
in  an  article  on  the  treatment  of  lupus  says  in  conclusion  that  "  the 
great  remedy  for  lupus  is  perseverance."  No  matter  what  treatment  is 
selected,  only  the  closest  co-operation  between  the  patient  and  the 
person  in  charge  of  the  case  will  produce  the  best  results. 

Chronicity . — One  of  our  cases  has  been  under  treatment  for  thirty- 
two  years  !  Many  of  the  cases  have  been  coming  for  treatment,  more 
or  less  regularly,  for  five  or  six  years.  In  these  cases  very  often  cure 
takes  place  in  one  area  and  the  active  disease  spreads  to  another.  We 
have  at  the  present  time  several  patients  in  whom  the  orginal  lesion  in 
the  nose  is  quite  healed,  but  the  disease  is  now  in  some  other  area,  viz. 
the  palate,  the  pharynx,  or  the  larynx.  The  following  cases  illustrate 
the  chronicity  of  lupus  and  its  faculty  for  spreading. 

(1)  Catherine  M .     First  seen  June  9,  1914.     At  that  time  the  disease  was 

confined  to  the  nose,  and  a  note  says  that  there  was  no  sign  of  disease  elsewhere. 
On  November  23,  1915,  it  was  observed  that  the  left  arytenoid  was  swollen  and 
that  the  cords  did  not  approximate  well.  May  30, 1916. — "  Interaryta?noid  infiltra- 
tion increasing."  July  5,  1916. — L\xpoid  nodules  on  anterior  ends  of  cord, 
cauterised  under  suspension.  May  18,  1917. — Interarytsenoid  swelling  noted  and 
attacked  with  double  cutting  forceps.  July  18,  1917. — Patient  again  suspended 
and  cutting  forceps  used  in  inter-arytffinoid  space.*  January  16,  1919. — Under 
suspension  interaryta?noid  space  cauterised  with  chromic  acid.     April  4,  1919.— 


JOURNAL     OF     LARYNGOLOGY,    RHINOLOGY,    AND    OTOLOGY. 


PLATE    II. 


To  Illustrate  Dr.  Riisseli,  ^VEBBER's  paper  on  Lupus  of  the  Upper 

.^ir-Passages. 

(See  Case  2  on  opposite  page.) 


Adiai-d  .{■  Son  i-  Weit  y^swmaii,  Ltd. 


January,  1920]  Rhinology,  and  Otology.  11 

No  evidence  of  active  disease  in  laiynx.     Small  area  on  the  anterior  end  of  nasal 
septum  on  left  side  cauterised. 

(2)  Mrs.  Grace  W ,  aged  forty-nine.  First  seen  as  out-patient  on  Decem- 
ber 22,  1914.  Patient  complained  of  having  had  a  sore  throat  off  and  on  since 
August,  1914.  No  diflSculty  in  swallowing  ;  voice  gets  rough  at  times  ;  general 
health  has  not  been  good.  On  examination  lower  part  of  right  half  of  soft  palate, 
just  above  the  tonsillar  region,  showed  a  reddish  area  slightly  indurated,  studded 
with  pale  pinkish  nodules.  The  infiltration  passed  into  the  posterior  pillar  and 
involved  the  upper  two-thirds  of  the  right  posterior  pillar.  Tonsil  free  from 
infiltration.  Uvula  slightly  affected  ;  posterior  pharyngeal  wall  normal  (Plate  II). 
Larynx  normal.  Nasopharynx  and  nose  showed  no  evidence  of  lupus.  No  Ivijjus  of 
skin  of  face  or  external  nose.  At  intervals  between  Janiiary  8,  1915,  and  October, 
1915,  electrical  ionisation  was  tried,  but  without  much  success.  At  first  it  seemed 
as  if  there  was  some  improvement,  but  it  did  not  last  for  long.  On  February  28, 
1915,  a  small  piece  of  the  left  tonsil  was  removed  under  local  anaesthesia,  but  the 
laboratory  report  is  missing.  On  October  20,  1915,  it  was  noted  that  the  "lupus 
is  still  spreading."  At  that  time  it  was  decided  to  change  the  treatment,  and 
the  lupoid  areas  were  curetted  and  swabbed  with  15  per  cent,  lactic  acid.  At 
fortnightly  intervals  patient  reported,  and  each  time  curetting  and  lactic  acid 
were  emploj-ed.  On  February  1,  1916,  it  was  decided  to  try  the  effect  of  the 
electric  cautery.  Ever  since  that  time  at  intervals  of  from  two  to  three  weeks 
small  lupoid  areas  on  the  hard  or  soft  palate,  uvula,  or  the  pillars  of  the  faiices 
have  been  dealt  with  in  this  way.  Considerable  scarring  has  resulted,  and  at  no 
time  is  thex-e  ever  more  than  a  few  tiny  areas  of  disease.  When  the  patient  was 
last  seen,  on  May  30,  1919,  a  few  tiny  areas  of  lupoid  tissiie  on  the  hard  and  soft 
palates  and  right  posterior  pillar  were  cauterised.  Th^?  notes  state  that  the 
larynx  is  absolutely  normal  and  that  there  is  no  fresh  adhesion  in  the  pliarj^ux. 
On  looking  through  the  notes  of  the  case  there  is  no  reference  to  active  disease 
of  the  posterior  pharyngeal  wall.  This  shows  a  great  deal  of  scarring,  the 
I'esiilt  of  old  disease,  which  probably  healed  spontaneouslj'.  This  is  one  of  the 
few  cases  in  which  there  is  no  nasal  focus. 


SPHENOIDAL   SINUS    EMPYEMA   IN   CEREBRO-SPINAL 
MENINGITIS.i 

By  E.  a.   Peters,   M.D.,  F.R.C.S. 

Westenhoeffer  originally  described  the  sphenoidal  sinus  as  the  source 
of  meningeal  infection.  Later  observers  with  experience  of  meningococcal 
septicaemia  have  supported  the  view  that  the  meningeal  infection  is  due 
to  a  blood  infection  by  way  of  the  nasopharyngeal  mucous  membrane ; 
the  infection  of  the  pia-arachnoid  would  then  be  due  to  a  selective 
action  of  the  meningococcus  comparable  to  the  joint  infection  of 
pyaemia.  Sir  StCIair  Thomson  has  pointed  out  that  a  few  drops  of 
infected  pus  in  the  sphenoidal  sinus  may  result  in  a  fatal  issue. 
Symptoms  of  cavernous  thrombosis  are  commonly  the  first  observed 
signs  of  ordinary  sphenoidal  infection  by  thrombosing  organisms  and 
prove  that  organisms  do  enter  the  blood  by  this  route.  Watson 
Williams's  researches  point  to  absorption  from  these  sinuses  in  chronic 
diseases  of  the  joints.  In  the  recent  influenza  epidemic  sphenoidal 
abscess  has  been  found  in  fatal  cases. 

The  following  observations  were  made  in  the  cerebro-spinal  fever 
camp  at  the  Royal  Victoria  Hospital,  Netley;  D.  Embleton  carried  out 
the  pathological  and  bacteriological  work. 

Sphenoidal  empyema  was  found  in  (1)  acute  cases,  (2)  relapsing 

1  Eead  at  the  Summer  Congress  of  the  Larj'ngological  Section  of   the  Royal 
Society  of  Medicine,  May  2,  1919. 


12  The  journal  of  Laryngology,       [January,  mo. 

phases  of  the  disease.  The  abscess  when  seen  post  mortem  was  closed 
and  an  incision  through  the  bony  roof  caused  pus  to  spurt  out ;  the  pus 
varied  from  thick  yellow  cream  to  glairy  mucopus. 

(1)  Acute  cases  :  Three  cases  were  submitted  to  an  anaesthetic  and 
the  sinuses  explored.  The  patient  is  laid  on  the  left  side  and  the  left 
forefinger  is  placed  on  the  junction  of  the  nasal  septum  and  sphenoid 
after  the  insertion  of  a  gag.  A  rigid  probe  is  then  introduced  through 
the  nostril  and  guided  by  the  left  forefinger  to  a  point  \  in.  anterior 
and  J  in.  external  to  the  posterior  edge  of  the  septum.  The  rigid  probe 
distinguishes  the  ridge  between  a  lower  surface  and  anterior  surface  of 
the  bone  and  at  the  selected  point  the  egg-shell  character  of  the  bone 
compared  with  the  massive  posterior  bone.  The  probe  passes  through 
the  ostium  or  is  pushed  through  the  thin  bone  of  the  spheno-turbinal : 
the  opening  is  then  enlarged  by  a  curved  i-in.  gouge  and  a  nibbhng 
forceps  is  last  of  all  employed. 

The  three  acute  cases  so  treated  yielded  glairy  pus.  Exacerbation 
of  the  disease  followed,  but  the  course  of  the  disease  was  not  materially 
affected  and  all  three  patients  died.  Post  mortem  the  pia-arachnoid 
involvement  was  very  extensive,  and  it  was  evident  that  though 
sphenoidal  drainage  might  prevent  re-infection,  other  methods  must  be 
employed  to  secure  resolution  of  the  meningitis.  Such  a  result  was  in 
a  measure  obtained  by  thecal  tappings  and  intrathecal  injections  of 
Gordon's  polyvalent  sera.  On  these  data  I  cannot  appreciate  the  value 
of  sphenoidal  drainage  in  acute  cases,  though  in  %-ery  early  cases  it 
might  be  entertained. 

(2j  In  relapsing  cases  the  results  of  sphenoidal  drainage  are  definite 
and  encouraging.  The  following  is  a  resume  of  seven  consecutive 
relapsing  cases.  In  two  death  occurred  before  the  sinuses  could  be 
explored  and  unilateral  empyema  was  discovered  ;  in  the  other  five  the 
sinuses  were  drained  by  operation  and  all  recovered  from  the  disease, 
unilateral  empyema  being  present  in  all  five.  Two  of  the  cases  pre- 
sented signs  of  internal  hydrocephalus  before  operation  ;  one  of  these 
died  suddenly  two  weeks  later,  and  internal  hydrocephalus  and  menin- 
gitis serosa  benigna  were  found  ^jos^  mortem,  while  the  other  is  improving 
and  has  signs  of  diminished  pressure.  The  effect  on  two  of  the  patients 
who  recovered  was  remarkable  ;  previous  to  sphenoidal  drainage  throat 
swabs  were  negative  but  became  positive  after  the  operation.  There 
was  post-operative  exacerbation  of  the  disease  in  all  the  cases  but  in 
one  man  even  the  cerebro-spinal  fluid  became  re-infected. 

Embleton  and  Sohier  Bryant  have  shown  that  meningococci  are 
found  in  greater  abundance  on  the  posterior  pharyngeal  wall  in  a  line 
drawn  between  the  fossae  of  EosenmuUer  above  the  palate  level ;  this  is 
the  line  marking  the  junction  of  ciliated  and  stratified  epithelium. 
Below  this  level  the  excretions  from  the  nose,  pharynx  and  respiratory 
tracts  are  scavenged  by  movements  of  the  pharynx  and  palate,  assisted 
by  hawking  and  deglutition.  Stevens  observed  that  swabbing  the 
mucous  membrane  above  this  line  with  a  stiff  wire  gives  a  larger  number 
of  positive  results  when  compared  with  those  obtained  by  a  softer 
platinum  wire,  and  argued  that  the  crypts  of  the  mucous  membrane 
afford  an  habitat  to  the  meningococci. 

In  ten  positive  recovered  cases  I  endeavoured  to  discover  the  cocci 
by  passing  a  cannula  into  the  sphenoidal  sinus  and  introducing  a  small 
swab ;  all  the  swabs  so  obtained  gave  a  negative  result  and  it  would 
appear  that  the  sinuses  are  uninfected  in  carriers.     Adenoid  masses  are 


January,  1920]  Rhinology,  and  Otology.  13 

covered  by  stratified  epithelium  and  doubtless  would  collect  micro- 
organisms, but  we  had  not  the  material  to  proceed  with  this  point. 

An  investigation  of  the  relative  patency  of  the  sphenoidal  ostia  in 
recovered  cases  was  made,  but  many  factors  interfered  with  a  definite 
elucidation ;  the  experience  gave  the  impression  that  the  ostia  of 
recovered  cases  were  more  easily  entered  than  in  positive  contacts. 

The  meningococcus  lives  in  the  crypts  of  the  mucous  membrane  of 
the  carrier  above  the  palate  level.  Apart  from  general  factors  such  as 
sensitisation  of  the  individual  or  some  anatomical  peculiarity  of  the 
sphenoidal  ostia  which  I  have  not  been  able  to  indicate,  infection  of 
the  sphenoidal  sinus  provides  access  to  the  blood  and  meninges  and 
functions  as  a  source  of  re-infection  in  relapsing  cases. 

Cerebro-spinal  fever  has  been  described  as  a  disease  of  children  and 
soldiers.  Children  are  liable  to  pronounced  inflammations  of  the  naso- 
pharynx which  may  be  due  to  local  anaphylaxis  and  constitute  a  ready 
means  of  sinus  infection.  The  crowded  conditious  inseparable  from 
military  life  in  winter  encourage  the  transfer  of  micro-organisms  and 
catarrh,  resulting  in  infection  of  the  sphenoidal  sinuses.  Our  observa- 
tions are  insufficient  to  indicate  the  proportion  of  open  and  closed 
abscesses  except  that  the  closed  empyemata  were  found  post  morteyn  in 
our  fatal  cases. 

Finally,  from  the  prophylactic  point  of  view  I  would  urge  the  use  of 
an  antiseptic  oil,^  painted  into  the  anterior  nares ;  this  is  conveyed  by 
cilia  and  capillary  action  over  the  naso-pharynx ;  and  the  paramount 
importance  of  fresh  air. 


SOCIETIES'     PROCEEDINGS. 


ROYAL  SOCIETY  OF  MEDICINE.— LARYNGOLOGICAL 

SECTIOl^. 


March  1,  1918. 


President :  Dr.  A.  Brown  Kelly. 


Abridged  Report. 

Pedunculated  Carcinoma  of  Pharynx. — A.  Brown  Kelly.— The 

patient,  a  man,  aged  forty,  was  found  by  chance  to  have  a  considerable 
mass  attached  by  a  pedicle  to  the  upper  part  of  the  right  tonsil.  He  was 
unaware  of  the  presence  of  the  growth  and  had  experienced  no  difficulty 
in  speakiug  or  eating.  The  tumour  was  as  large  as  a  walnut,  the  suiface 
smooth,  the  colour  that  of  the  adjacent  normal  mucous  membrane,  and 
the  consistence  hard.  It  was  removed  by  snaring.  Subsequent  exami- 
nations— the  last  nine  months  after  operation — revealed  nothing  abnormal. 
The  patient  died  from  an  accident  about  seven  years  later  without  having 
had  any  fui'ther  trouble  from  his  throat. 

'  Ung.  hyd.  uit.  dil.,  3J  ;  menthol,  gr.  v ;  ol.  olivae,  ad  gj. 


14  The  Journal  of  Laryngology,       f  January,  ii.20. 

Dr.  John  Anderson,  pathologist,  reports:  "The  growth  is  pedunculated 
and  covered  with  mucous  membrane  showing  no  evidence  of  ulceration. 
On  section  a  denser  area  and  another  of  looser  fibrous  appearance  are  seen. 
Micioscopic  examination  shows  a  covering  of  stratified  epithelium  extei*- 
uallj,  Avith  areas  of  round-celled  increase  beneath.  Normal  glandular 
tissue  and  congested  vessels  ai'e  situated  more  deeply.  Beyond  these  and 
separated  from  them  by  fibro-muscular  tissue  is  the  principal  feature  of 
the  specimen — namely,  a  fibrous  stroma  with  cancer  areas  of  varying  size 
scattered  through  it.  The  arrangement  and  appearance  of  the  cells  are 
those  of  an  epithelioma  derived  from  the  priclcle  Malpighiau  layers;  a  few 
cell-nests  are  present.  Beyond  the  cancerous  zone  is  a  large  area  of  poorly 
cellular  fibrous  tissue." 

The  unusual  features  in  this  case  of  pharyngeal  cancer  are  the  pedun- 
culateil  form  of  the  tumour,  its  intact  surface,  the  healthy  state  of  the 
neighbouring  mucous  membrane,  the  absence  of  glandular  involvement, 
and  the  non-recun*ence  after  operation.  The  malignant  elements  were 
present  in  the  substance  of  the  growth  and  the  mucous  membrane  showe  J 
no  epithelial  iudippings. 

Was  this  tumour  originally  a  simple  one,  perhaps  a  fibroma,  with  a 
malignant  nest  beneath  the  mucous  membrane  ? 

Mr.  Frank  A.  Kose  :  I  think  the  growth  is  an  endothelioma,  and 
closely  allied  to,  or  identical  with,  a  parotid  tumour.  Neoplasms  similar 
to  parotid  tumours  grow  near  the  tonsil  and  in  the  palate :  this  is  an 
example. 

Mr.  TiLLEY  :  I  have  recorded  a  case  comparable,  but  not  identical  ^ 
The  patient,  a  ])oy,  had  a  sarcoma;  being  pedunculated  it  was  regarded 
as  non-malignant.  The  growth  recurred,  the  tonsil  swelled,  and  glands 
appeared  in  the  neck.  When  the  ]>edunculated  growth  was  microscoped 
Ave  were  told  it  was  probably  malignant.  Later  developments  proved 
this  to  be  so. 

Mr.  Norman  Patterson:  This  case  resembles  one  operated  on  fifteen 
years  ago.  The  jiatient  twelve  years  after  reported  with  a  pedunculated 
tumour  growing  from  the  left  side  of  the  nasopharynx  ;  it  Avas  diagnosed 
as  a  fibroma.  I  removed  the  tumour,  and  the  pathologist  stated  it  to  be 
an  epithelioma.  Rapid  recvirrAce  took  place  without  ulceration.  Mr.  Lack 
split  the  palate  and  applied  diathermy.  It  recurred.  Radium  and  X-rays 
were  applied,  the  latter  proving  more  beneficial.  The  pathologist  pro- 
nounced it  to  be  an  endothelioma. 

Dr.  D.  R.  Patbeson:  I  saw  a  case  of  a  pedunculated  mass  of  lymphoid 
tissue  projecting  from  one  tonsil.  When  first  seen  it  was  inflamed,  but 
became  gangrenous,  and  was  defiuitely  lymphoid.  It  must  haA'e  always 
existed  in  the  pharynx,  though  unnoticed.  It  was  the  size  of  a  walnut, 
and  close  to  the  stalk  where  it  was  snipped  oE  was  normal  tissue.  The 
case  shown  may  have  been  a  lymphoid  nodule  which  later  developed 
malignant  disease. 

The  President  (in  reply) :  The  following  points  are  against  the 
growth  being  an  endothelioma:  (1)  the  cells  are  dai'ker,  as  the  chromatin 
present  is  relatively  more  and  the  protoplasm  correspondingly  less ; 
(2)  the  blood  spaces  are  not  sufficiently  distinctive ;  (3)  epithelial  cell- 
nests  exist,  though  few,  and  the  arrangement  of  the  cells  around  the 
nests  ;  (4)  some  of  the  tumour-cells  are  of  the  prickle  type.  I  know  of 
only  two  or  three  cases  of  a  similar  kind,  in  Avhich  the  growth  sprang 
from  the  lateral  wall  of  the  pharynx  or  the  epiglottis. 

1   Trail*.  Laryng.  Sue,  1902-3,  x,  p.  140. 


January,  1920.] 


Rhinology,  and  Otology.  15 


Children  with  Congenital  Appendages  (Teratoid  Tumours)  of 
the  Nasal  Septum. — A.  Brown  Kelly. — Case  1  :  Female  infant,  aged 
two  months,  presented  an  outgro-wth  filling  the  right  nostril  and  pro- 
jecting ^  in.  beyond  it.  The  growth  was  of  fleshy  consistence  and 
covered  with  skin  which  was  continuous  with  that  of  the  columella  and 
upper  lip.  It  measured  antero-posteriorly  16  mm.  and  transversely 
15  mm.  Ehiuoscopic  examination  revealed  a  rounded  band  extending 
a  short  distance  upwards  beneath  the  mucous  membrane  on  the  right 
side  of  the  septum.  In  the  vestibule  the  band  widened  out  and  passed 
into  columella  and  half  way  down  the  upper  lip.  The  growth  was 
removed  but  inadvertently  destroyed  before  a  histological  examination 
was  made.  The  nostrils  are  now  asymmetrical,  the  right  measuring 
18  mm.  antero-posteriorly,  the  left  12  mm.  The  child  presents  no  other 
malformation. 

Case  2:  Male  infant,  nged  two  months,  presented  considerable 
broadening  and  flattening  of  the  lower  part  of  the  nose  and  a  vertical 
median  furrow  at  the  tip.  The  cokimella  was  very  broad,  and  from  the 
upper  part  of  its  right  edge  a  rounded  process  covered  with  skin  pro- 
jected and  occupied  the  anterior  angle  of  the  vestibule,  while  from  its 
base  outside  the  nosti'il  a  smaller  one  projected  upwards  and  outwards. 

Intrinsic  Cancerof  the  Larynx;  Laryngo-fissure  and  Semi-demi- 
laryngectomy  One  Year  after  Operation. — Sir  StClair  Thomson. — 

The  patient  was  aged  forty-nine  when  he  consulted  me  in  March,  1917. 
His  voice  had  been  failing  for  a  year  and  a-half,  and  had  been  quite 
hoarse  for  fourteen  months.  The  right  vocal  cord,  with  the  exception  of 
the  vocal  process,  was  replaced  by  an  irregular,  rough,  white,  slightly 
cauliflower  infiltration.  It  extended  right  up  to  the  anterior  commissure, 
and  there  was  a  subglottic  extension.     The  cord  was  almost  immobile. 

Laryngo-fissure  on  March  9,  1917.  General  anaesthesia  by  chloroform. 
Duration  of  operation  one  and  a-half  hours.  On  raising  the  soft  tissue, 
with  the  perichondriuin,  from  the  inner  surface  of  the  right  thyroid  ala, 
it  was  found  that  the  thyroid  cartilage  was  so  soft  and  eroded  that  the 
detacher  slipped  ttirough  it  and  was  felt  under  the  outer  perichondrium. 
The  right  thyroid  ala  was  therefore  removed.  Sections  of  the  growth 
show  a  typical  squamous  epithelioma  peueti'ating  deeply  into  the  small 
muscles.  The  removed  thyroid  ala  was  also  examined  histologically, 
and  the  pathologist  reports  :  "  No  actual  cancer-cells  are  to  be  seen  in 
any  of  the  cartilage  sections,  and  it  appears  to  be  eroded  in  advance  of 
the  actual  extension  of  the  growth."  Since  August  last  the  patient  has 
been  in  active  Government  service.  He  can  Idcycle  fifty-three  miles  a  day, 
feels  in  good  general  condition,  and  has  a  better  voice  than  he  had  just 
before  operation.  There  is  a  new  cicatricial  right  cord  and  a  roomy 
glottis. 

Extrinsic  Cancer  of  the  Larynx,  Four  Years  after  Operation 
through  the  Side  of  the  Neck.— Sir  StClair  Thomson.— G.  H 

now  aged  fifty-nine,  was  shown  before  the  Section  ^>u  February  2,  1917.^ 
He  had  a  malignant  growth  of  the  left  aryepiglottic  fold.  The  glands 
on  the  left  side  of  the  neck  were  removed  by  Mr.  Trotter  on  March  31, 
1914,  and  the  growth,  together  with  the  left  ala  of  the  thyroid  cartilage, 
was  removed  on  June  19,  1914.  The  patient  is  shown  again  to  demon- 
strate how  well  he  keeps  after  three  and  a-half  years,  in  spite  of  chronic 
bronchitis  and  abundant  tobacco. 

'  JouRN.  OF  Labyngol.,  Ehinol.,  AND  Otol.,  vol.  xxxii,  p.  325. 


16  The  Journal  of  Laryngology,        [January,  1920. 

Dr.  Dan  McKenzie  :  Recently  I  had  a  case  of  post-cricoid  cancer 
which  came  ahnost  into  view.  A  tube  of  radium  was  inserted,  and  it  did 
harm. 

Mr.  E.  D.  D.  Davis  :  In  Mr.  Trotter's  operation  access  to  the  pyrif orm 
fossa  is  good,  the  whole  of  the  ala  of  the  thyroid  cartilage  is  easily 
exposed,  and  removed  by  division  near  the  mid-line.  It  is  an  excellent 
operation  for  the  excision  of  the  growth  in  early  cases. 

Mr.  Gr.  W.  Dawson  :  These  growths  when  pronounced  to  be  extrinsic 
are  left  alone,  but  the  two  cases  described  show  that  more  should  be 
attempted,  and  one  would  like  to  know  more  about  Mr.  Trotter's  opera- 
tion, and  when  the  condition  in  the  pyriform  fossa  negatives  operation. 

Mr.  Lambert  Lack  :  For  these  eases  of  extrinsic  disease  diathei-my 
is  better  than  any  cutting  method.  It  is  easier  to  get  at  the  growth  and 
to  remove  it  thoroughly. 

Dr.  W.  Hill  :  I  treated  a  case  by  diathermy  three  years  ago.  The 
growth  is  pharyngeal,  not  laryngeal.  Unless  it  be  very  superficial  the 
pyriform  fossa  is  involved,  and  there  must  be  removal  of  half  the  larynx. 
At  times  there  is  a  good  deal  of  swelling  in  the  vestibule  of  the  larynx, 
and  that  may  need  tracheotomy.  My  small  experience  leads  me  to 
support  diathermy.  Radium  acts  capriciously.  Radium  should  never  be 
given  to  a  patient  who  is  going  downhill. 

Mr.  W.  Stuart-Low  :  My  experience  has  been  against  radium  in 
favour  of  diathermy,  especially  in  early  cases.  The  patient  can  be 
anaesthetised .  orally,  and  with  a  diathermy  knife  there  is  no  bleeding. 
In  some  of  my  cases  there  was  no  recurrence  for  months,  and  patients 
can  take  food  better  than  after  other  treatment. 

Mr.  E.  D.  D.  Davis:  Have  any  members  treated  a  post-cricoid 
epithelioma  by  diathermy  in  late  cases  when  the  up|)er  edge  of  the  ulcer 
is  seen  in  the  pharynx  and  behind  the  arytaenoids  ?  I  have  had  a 
number  of  these  cases  of  post-cricoid  growth ;  after  excision  of  the 
growth  follows  tracheotomy  or  gastrostomy.  They  finally  die  of 
broncho-pneumonia. 

Mr.  Lambert  Lack  :  My  experience  with  diathermy  has  been  bad  in 
post-cricoid  cases.  I  have  done  three,  but  I  shall  not  try  it  again,  for  it 
is  impossible  to  eradicate  the  growths  by  this  method. 

Mr.  Douglas  Harmer  :  At  St.  Bartholomew's  we  have  a  special 
electrode  about  the  size  of  a  penholder,  with  a  strip  of  metal  exposed  on 
one  side  only.  This,  before  the  current  is  turned  on,  is  passed  behind 
the  cricoid.  Afterwards,  by  rotating  the  instrument  first  to  one  side  and 
then  to  the  other,  the  growth  can  be  slowly  destroyed,  and  a  free  passage 
made  for  a  hxrge  bougie  to  pass  without  resistance.  Some  of  my  patients 
swallowed  better  for  a  time  ;  the  relief  was  transient.  Extensive  burning 
causes  oedema,  and  is  followed  by  septic  perichondritis,  which  does  not 
recover.  Although  diathermy  is  a  first-class  treatment  for  tumours 
of  the  pharynx,  especially  those  that  can  be  completely  enucleated,  it 
must  be  employed  with  the  greatest  caution  near  the  cartilages  of  the 
lai'ynx. 

Sir  StClair  Thomson  (in  reply)  ;  In  the  case  of  intrinsic  cancer  I 
had  to  remove  the  ala  of  the  thyroid  cartilage  as  it  was  destroyed.  I  left 
a  little  ledge  of  it  at  the  back.  The  case  of  intrinsic  cancer  is  Mr. 
Trotter's,  and  I  brought  it  again  so  that  he  might  have  it  discussed. 
Among  selected  cases  it  is  an  admirable  operation.  Recently  I  passed  on 
to  Mr.  Trotter  a  case  which  had  been  refused  operation  as  inoperable. 
The  result  is  yet  to  be  seen,  but  the  patient  has  at  present  a  very  good 
voice,  can  swallow  well,  and  has  returned  to  his  home. 


jannary,  1920.)  Rhinology,  and  Otology.  17 

Foreign  Body  impacted  in  the  Trachea  (part  of  the  Shell  of  a 
Brazil  Nut). — F.  A.  Rose.— A  male,  aged  thiity-seveu,  was  submitted 
to  tracheotomy  ou  account  of  urgent  dyspnoea.  The  foreign  body 
exhibited  was  found  impacted  in  the  upper  part  of  the  trachea.  An 
attempt  to  remove  it  through  the  larynx  failed.  It  could  not  be  moved 
although  the  forceps  gripped  it.  It  was  then  broken  into  two  pieces  and 
extracted  through  the  tracheotom\'  wound.  Attention  is  directed  to  the 
large  size  of  the  fragment  (measuring  over  an  inch  in  length),  which 
became  firmly  impacted  in  the  trachea  after  it  had  passed  through  the 
larynx. 

Extreme  Alar  Collapse. — William  Hill. — Female,  with  saddle- 
nose  (of  luetic  oi'igin),  together  with  jioteutial  occlusion  of  nasal  vesti- 
bule, the  anterior  nares  appearing  as  L-shaped  slits  (symmetrical).  The 
left  lumen  is  also  narrowed  by  a  falciform  cicatricial  band  above.  Injec- 
tion of  wax  temporarily  relieved  the  alar  collapse,  but  there  has  been  a 
relapse.     Advice  will  be  welcomed. 

Dr.  DuNDAS  Grant  :  A  simple  and  sometimes  effective  operation  in 
alar  collapse  employed  when  the  nose  is  very  narrow  is  to  detach  the  ala, 
•cutting  away  a  semilunar  piece  of  skin  external  to  it  and  stitching  the  ala 
at  the  outer  margin  of  the  raw  surface. 

Mr.  Norman  Patterson  :  This  case  can  be  benefited  by  inserting  a 
thin  layer  of  cartilage. 

Mr.  O'Malley  :  This  case  is  the  worst  type,  because  the  alar  cartilage 
has  kinked  inwards,  and  if  we  attempted  to  put  in  cartilage  to  act  as  a 
prop  there  would  be  nothing  to  cover  it,  the  cartilage  being  thin  and  poor. 
When  the  alar  cartilage  was  perpendicular  I  have  inserted  a  piece  of 
•cartilage  and  widened  the  nostril  to  give  it  a  wider  base  and  excellent 
respiration. 

Dr.  D.  R.  Paterson  :  In  similar  cases  I  have  removed  a  wedge- 
shaped  piece  from  the  alar  cartilage,  the  vestibular  side,  with  very  good 
results.  In  syphilitic  subjects  one  can  never  be  certain  after  operating 
that  there  Avill  not  be  subsequent  retraction,  even  when  the  syphilis 
appears  obsolescent. 

Dr.  W.  Hill  (in  reply) :  As  there  is  a  good  deal  of  collapse  of  the 
columella,  to  stiffen  the  columella  as  suggested  is  desirable,  but  I 
appx'eciate  the  danger  of  operating  on  a  columella  in  a  syphilitic  subject. 
It  is  better  to  use  a  piece  of  cartilage  from  someone  else.  After  I  had 
put  in  wax  on  the  vestibular  side  the  alar  collapse  disappeared,  but  the 
wax  has  now  disappeared.  As  a  general  rule,  when  one  puts  Avax  into 
the  nose  it  remains  and  the  case  is  pronounced  cured. 

Carcinoma  of  Fauces  treated  by  Per-oral  Excision,  followed 
by  Diathermy.^William  Hill  and  Norman  Patterson. — Patient, 
aged  seventy-three.  The  operation  was  carried  out  under  pharyngeal 
suspension.  The  external  carotid  was  first  ligated.  The  case  is  shown 
to  raise  the  question  of  the  advisability  of  this  as  a  routine  measure  in 
a  case  where  the  pillars  and  tonsil  are  involved  and  where  there  is  also 
slight  extension  to  the  base  of  the  tongue. 

Dr.  W.  Hill  :  It  was  a  question  if  we  should  ligature  the  cai-otid. 
Mr.  Patterson  had  a  death  from  secondary  haemorrhage  in  such  a  case, 
and  others  have  occurred.  Ligature  of  the  carotid  starves  the  growth, 
and  there  is  less  likelihood  of  I'eactionary  haemorrhage. 

Mr.  Norman  Patterson  :  I  know  of  five  cases  which  have  died  from 

2 


18  The  Journal  of  Laryngology,        January,  1920. 

haemorrhage.  Prelimiuai-y  ligature  of  the  extei'ual  carotid  and  ascending" 
pharyngeal  ai'tery  may  be  considered  under  the  following  conditions : 
(1)  Cases  where  the  blood-pressure  is  high.  (2)  When  the  arteries  are 
thickened  and  degenerated.  (3)  Extensive  growths  involving  the 
neighbourhood  of  the  tonsils,  soft  palate  and  pillars,  or  the  base  of  the 
tongue  and  epiglottis.  (4)  When  removal  of  glands  and  treatment  of 
the  primary  growth  are  undertaken  at  the  same  time.  The  advantages 
are :  (1)  Little  or  no  haemorrhage  at  the  time  of  operation.  (2)  No 
haemorrhage  when  the  sloughs  separate.  (3)  More  extensive  sloughing^ 
and  therefore  more  thorough  destruction  of  the  tumour.  (4)  When 
time  is  an  important  consideration  possibility  of  rapid  excision  followed' 
by  diathermy. 

Dr.  Ikwin  Moore  :  I  show  water-colour  drawings  of  a  patient  aged 
seventy-five,  suffering  from  epithelioma  of  the  tonsil  and  tongue.  The 
case  was  treated  by  diathei-my  after  ligature  of  the  external  carotid.  A 
large  cavity  is  seen  after  the  removal  of  the  growth,  and  the  drawing 
made  one  month  later  shows  healthy  tissue  without  cicatrices. 

Mr.  E.  D.  D.  Davis  :  I  have  seen  two  cases  of  fatal  secondary 
haemorrhage  from  the  internal  carotid  artery  following  excision  of  a  large 
growth  in  the  faucial  region.  In  lioth  cases  there  was  an  erosion  of  the 
internal  carotid  artery.  Tying  the  common  carotid  may  cause  hemi- 
plegia. I  had  one  case  of  malignant  glands  in  the  neck  in  which  the 
common  carotid  was  tied,  and  the  patient  died  with  hemiplegia.  The 
severe  hsemorrhage  in  such  cases  is  from  the  internal  carotid.  Ligature  of 
the  external  carotid  in  cases  of  removal  of  the  upper  jaw  makes  no 
difference  to  the  haemori'hage. 

Dr.  James  Donelan  :  The  common  carotid  should  be  tied.  Some 
years  ago  I  enucleated  the  left  tonsil  in  a  man  suffering  from  unsus- 
pected Banti's  disease.  Pressure  with  Spencer  Wells  forceps  con- 
trolled the  bleeding  untill  the  forceps  was  removed.  It  was  not  possible 
to  ligature  the  bleeding  vessel  so  the  common  carotid  was  tied ;  the 
bleeding  stopped. 

Dr.  D.  R.  Paterson  :  In  all  extensive  operations  about  the  tonsils 
the  external  carotid  should  be  tied.  Anyone  who  has  tried  both  ways 
will  not  hesitate.  In  cases  of  large  tuinouis  in  the  antrum,  in  which  much 
haemorrhage  is  likely,  I  frequently  ligature  that  vessel.  This  procedure 
gives  a  clean  field,  and  removes  fear  of  secondary  haemoiThage.  I  advo- 
cate it  in  extensive  diathermy  operations. 

Mr.  W.  D.  Harmer  :  Preliminary  ligature  of  the  external  carotid 
must  be  considered  in  every  case  of  an  extensive  operation  in  the  pharynx, 
in  the  region  of  the  tonsil  or  lower  down.  Tying  either  the  common  or 
the  internal  carotid  is  useless  because  if  the  growth  inv/jlves  either  of 
these  vessels  it  is  inoperable.  Operations  on  small  growths  in  the 
pharynx  do  not  require  preliminary  ligature  of  the  external  carotid 
artery.  Pressure  can  be  applied  and  if  necessary  the  vessel  ligatured 
should  haemorrhage  occur. 

Dr.  H.  J.  Banks-Davis  :  Unless  anaesthetised  the  patient  will  not 
allow  pressure  from  inside  the  mouth. 

Mr.  Norman  Patterson  (in  reply)  :  Some  of  the  cases  of  haemorrhage 
are  very  troublesome.  The  last  case  I  was  unable  to  deal  with  (he  was 
blue  in  the  face,  bleeding  severely,  and  would  not  keep  still)  until  I  did 
a  preliminary  laryngotomy.  One  can  never  tell  beforehand  what  cases 
will  bleed.  I  agree  that  ligature  should  not  be  done  in  cases  of  small 
growths. 


January,  1920.]  Rhinology,  and  Otology.  19 

Papilloma  of  the  Nose. — G.  W.  Dawson. — Man,  aged  thirty-six, 
came  under  my  care  last  November  with  a  history  of  bleeding  from  the 
nose  every  two  or  three  days  for  the  previous  six  months.  A  mulberry 
dark  rt-d  mass  was  seen  anteriorly  and  posteriorly,  tilling  up  the  left 
posterior  part  of  the  nose.  It  was  attached  to  the  septum  close  to  its 
posterior  margin,  and  was  firm  to  the  touch.  The  growth  was  removed 
under  a  general  anaesthetic,  an  attempt  being  made  to  strip  off  the 
mucous  membrane  from  which  it  grew.  The  bleeding  was  free  and  the 
bulk  of  the  tumour  much  laiger  than  one  expected,  being  sufficient  to 
fill  a  wine-glass. 

Pathological  report :  "  Section  shows  structure  of  papilloma.  No 
evidence  of  maliguancy." 

The  President  :  Nasal  papillomata  are  apt  to  be  confused  with 
papillary  hypertrophies  unless  microscoped.  To  the  naked  eye  the 
specimen  is  a  true  papilloma. 

Perichondritis  of  the  Larynx. — G.  W.  Dawson. — Man,  aged  sixty- 
five,  first  seen  last  June,  suffering  from  a  large  foul  ulcer  affecting  the 
right  side  of  the  pharynx  and  the  outer  surface  of  arytsenoid  region.  It 
was  at  first  thought  to  be  malignant,  but  the  ulcer  rapidly  improved  on 
20-gr.  doses  of  pot.  iod.  At  the  end  of  August  the  swelling  was  -noticed 
externally  on  the  right  side  of  the  neck  and  under  the  chin,  causing  some 
difficidty  of  bi-eathing.  The  right  side  of  larynx  and  arytsenoid  cartilage 
had  become  very  swollen  and  oedematous-looUing.  With  a  guarded 
MacKenzie's  lancet  I  punctured  the  arytsenoid  and  inner  surface  of 
larynx,  giving  exit  to  a  few  drops  of  pus.  On  October  2  the  breathing 
became  vei'y  difficult  and  I  was  obliged  to  open  his  trachea  in  a  hurry. 
He  stopped  bi'eathiug  l>efore  the  airway  was  opened,  but  revived  under 
artificial  respiration.  Pus  appeared  and  kept  discharging  from  the  upper 
portion  of  the  tracheotomy  wound,  and  a  probe  passed  into  a  track  up- 
wards and  outwai'ds  2  in.  The  swelling  on  the  right  side  of  neck  increased 
into  a  hard  la-awny  mass.  On  February  1  last  swallowing  became  difficvdt 
and  tlie  neck  became  more  swollen.  He  prefei'red  to  allow  the  abscess 
to  open  naturallv,  which  it  did  in  abovit  a  week.  The  swallowing  is  still 
difficult. 

Sir  StClair  Thomson  :  Prolonged  cases  of  perichondritis  of  the 
larynx  are  inevitably  fatal.  One  or  two  of  my  cases  were  evidently 
started  by  a  tracheotomy  done  too  high -and  the  larynx  became  infected, 
and  even  after  a  low  tracheotomy  was  done  and  the  other  opening  closed 
the  result  was  bad.  One  case,  a  man  aged  under  forty,  seemed  to  be 
going  downhill,  but  we  ultimately  found  the  disease  was  subglottic  and 
malignant.  We  do  not  know  whether  Mr.  Dawson's  case  is  malignant 
disease  or  whetiier  it  is  syphilis,  or  the  two  combined;  I  believe  nothing 
will  stop  it.  Dr.  Seguri,  of  the  Argentine,  told  me  such  cases  were 
common  tliere,  owing  to  tracheotomies  being  done  too  high  up,  and  that 
to  stop  the  perichondritis  they  excised  the  larj'nx — a  rather  drastic 
remedy. 

Dr.  JoBSON  HoRNE  :  In  one  of  two  similar  cases  I  have  had,  a  man 
died  suddenly  from  gumma  rupturing  into  his  larynx.  In  the  second 
the  patient  died  from  malignant  endocarditis. 

Mr.  Dawson  :  When  I  did  the  tracheotomy  I  found  the  cartilage 
much  ossified,  so  perhaps  a  better  name  for  the  case  would  have  been 
periostitis.  When  seen,  he  had  a  large  foul  ulcer  at  the  base  of  the 
tongue,   extending   to    the    arytsenoid    and   the    pyriform   fossa.      He 


20  The  Journal  of  Laryngology,        [January,  1920. 

improved  rapidlv,  the  ulcei*  healiuaj  under  iodide ;  it  was  exti'insic  to  the 
larynx.  As  it  was  about  to  heal  he  s:ot  this  swelling  limited  to  lialf  the 
larynx.  There  is  infiammatoiy  thickening,  and  an  abscess  forms 
occasionally. 

Tumour  of  the  Palate  in  a  Child.-  James  Donelan. — A  child 
aged  eii,dit  months.  Suggestions  as  to  treatment  desired.  The  swelling 
causes  some  intei'ference  with  suckling.  This  appears  to  be  the  youngest 
case  reported  of  torus  palatinus,  if  that  diagnosis  is  accepted. 

Dr.  Donelan  also  exhibited  a  specimen  of  negro  skull  with  large 
torus. 

Mr.  TiLLEY :  I  thought  the  swelling  was  rather  soft  mucous  membrane 
covering  a  very  hard  torus  palatinus. 

Dr.  Donelan  :  I  thought  it  was  a  torus  palatinus.  It  occurs  in  the 
foetus.  Komer,  in  the  Archiv  fUr  Laryngologie,  brings  the  literature  up 
to  1912.  He  gi'oups  the  ages  of  children  under  10  years  together  showing 
that  75  per  cent,  occur  in  boys  and  8  per  cent,  in  girls.  The  skull,  that 
of  a  negress,  lent  by  Prof.  Thane,  shows  a  torus  extending  the  entire 
length  of  the  interpalatiue  and  intermaxillary  sutures.  This  is  rare  iu 
negroes  but  common  amongst  Peruvians  and  Eskimos.  I  believe  it  starts 
most  commonly  at  the  intersection  of  the  two  sutures.  It  may  remain 
there  as  in  most  of  the  sketches  in  Sir  Rickman  Godlee's  paper,^  or  it  may 
extend  along  the  intermaxillary  suture,  or  in  a  double  form  representing 
the  hypertrophied  edges  of  that  fissure. 

The  President  :  This  appears  to  be  a  tumour  and  not  the  torus 
palatinus.  I  have  seen  the  latter  in  a  baby.  The  ages  given  in  the 
statistics  are  probably  those  at  which  the  torus  was  noticed,  not  of  its 
origin. 

Repair  of  Nose  by  ParaflBn  Injection. — James  Donelan.— Woman, 

aged  twenty-two,  shown  hei"e  about  tive  years  ago.  Saddle-back  nose 
from  congenital  syphilis.  Deformity  removed  in  great  measure  by 
pai'afiin  injection.  The  patient's  breathing  space  has  been  greatly 
improved  incidentally  and  she  is  quite  pleased  with  the  "  creation." 

Mr.  O'Malley  :  The  coodition  would  be  improved  by  putting  a  small 
piece  of  cartilage  iu  the  columella. 

Mr.  W.  StuaktLow:  It  is  a  very  good  result.  It  has  stood  well  for 
five  years  and  the  patient's  appearance  is  greatly  improved. 

Dr.  D.  E.  Paterson  :  In  a  former  discussion  a  member  of  the  Section 
related  cases  in  Avhich  paraffin  had  travelled  from  the  nose  to  the  cheek, 
producing  a  ridge,  and  from  the  mammary  region  to  the  groin. 

Dr.  Dan  McKenzie  :  I  have  tried  to  dissect  wandering  paraffin  from 
a  man's  nose  injected  ten  years  before.  The  paraffin  was  broken  up  into 
tiny  globules  and  disseminated  among  the  tissues.  I  could  only  remove 
small  pieces  of  tissue  containing  the  globules. 

Mr.  Wylie  :  I  had  a  case  in  which  the  patient  went  on  board  ship 
as  a  stoker  aftei-  having  had  pai-affin  injected.  The  paraffin  melted  and 
was  found  in  the  cheek. 

Mr.  Tilley  :  When  this  subject  was  first  mooted  and  paraffin  was 
being  used,  the  late  Sir  Henry  Butlin  said  the  only  experience  he  had 
had  of  paraffin  injections  was  in  dissecting  them  out.  1  have  had  similar 
experience  to  Dr.  McKenzie's,  spending  two  hours  dissecting  out  paraffin 
from  a  lady's  face  which  had  been  injected  by  a  Bond  Street  "  beauty 

1  Proc.  Roy.  Soc.  Med.,  1909,  ii  (Sect.  Surgery),  p.  175. 


January,  1920.] 


Rhinology^  and  Otology.  21 


specialist."  I  thiuk  the  use  of  strips  of  septal  cartilage  will  frequeutly 
take  the  place  of  paraffin. 

Dr.  Irwin  Moore  :  I  have  had  considerable  experience  of  injecting 
paraffin  wax  into  the  nose,  but  have  never  had  auv  trouble  from  its 
wandering.  I  use  solid  wax  — a  preparation  from  Paris— and  inject  it 
witb  a  powei'ful  syringe. 

Dr.  DoNELAN  :  In  one  of  my  five  or  six  cases  injected  over  ten  years 
ago  the  nose  retains  a  perfect  shape,  though  previously  it  was  quite  flat 
with  only  the  bridge  and  tip  slightly  projecting.  Another,  done  between 
five  and  six  years  ago,  has  remained  unchanged.  I  vise  paraffin  with  a 
melting-point  of  108'^  F.  It  should  not  be  fluid,  but  just  soft  enough 
to  move  through  the  special  warmed  syringe.  The  injection  is  made 
from  inside,  and  I  support  the  remains  of  tlie  septum  afterwards  with 
Adams's  septal  forceps,  covei-ing  the  puncture  and  retaining  the  paraffin 
while  the  nose  is  being  moulded.  An  assistant  grips  the  root  of  the 
nose  and  prevents  any  escape  towards  the  forehead.  It  sets  in  about 
half  a  minute ;  an  ice  compress-  is  applied  the  moment  the  desired  form 
has  been  attained.  Much  depends  upon  the  quality  and  melting-point 
of  the  paraffin.  In  all  the  cases  in  which  I  have  used  it  it  was  chosen 
on  account  of  syphilis,  and  it  seems  a  useful  method  when  other  surgical 
measures  are  inapplicable. 

Large  Malignant  Growth  of  Antrum :  Removal.  —  Herbert 
Tilley. — The  case  is  shown  to  illustrate  the  advantage  of  approaching 
the  field  of  operation  by  way  of  the  canine  fossa,  including  tiie  removal 
of  the  ascending  process  of  the  maxillary  bone,  and  thus  avoiding  the 
sc:ir  incident  to  lateral  rhinotomy.  It  is  an  extension  of  Denker's 
operation  and  affords  a  very  complete  view  of  the  antrum  and  ethmoidal 
regions.  GJ-eueral  anaesthesia  was  administered  by  the  "  intratracheal 
ether  "  method.  The  case  emphasises  that  in  malignant  growths  of  the 
antrum  it  mav  be  wiser  to  choose  this  mode  of  access,  because  you  get 
a  wider  field,  less  haemorrhage  and  no  deformity. 

Mr.  W.  Stuart-Low  :  I  have  operated  on  a  number  of  cases  of 
malignant  disease  in  this  way.  You  can  retract  the  cheek  freely,  and 
remove  the  whole  anteiior  wall  and  the  ascending  process,  and  the 
patient,  being  placed  higher  than  the  operator,  you  can  get  good  exposures 
and  conti'ol. 

Fixation  of  both  Yocal  Cords  ;  Tracheotomy.— E.  D.  D.  Davis.— 

A  widow,  aged  forty -four,  first  attended  the  hospital  on  October  9  last. 
Tracheotomy  had  been  performed  six  weeks  previously  for  laryngeal 
obstruction."  The  patient  then  stated  that  fourteen  months  aso  she  had 
an  attack  of  intluenza,  followed  by  loss  of  voice  and  difficulty  in 
breathing.  On  examination  the  right  vocal  cord  was  fixed  in  the  mid- 
line and  the  left  cord  was  obscured  by  swelling  of  the  left  ventricular 
band.  Both  arytaenoids  were  immobile.  The  thyroid  alae  were  normal. 
Chest  presented'  no  physical  signs.  X-ray  of  chest  negative.  Wasser- 
mann  reaction  positive.  Injections  of  salvarsan  and  administration  of 
mercury  and  potassium  iodide  produced  slight  improvement. 

Transplantation  of  Cartilage  into  the  Septum.— J.  F.  O'Malley. 

— The  septum  was  completely  re^^ected  to  free  the  airway,  but.  the  tip  of 
the  nose  had  no  siqiport  and  the  ridge  was  much  depressed.  Portions  of 
the  septal  cartilage  were  then  implanted  in  the  tissues  of  the  columella 
and  to  restore  the  ridge. 


22  The  Journal  of  Laryngology,       [January,  1920. 

Columella:  A  strip  4  in.  Avide  and  1  in.  Iod^^  (this  varies  with  the 
individual  nose)  was  taken,  and  after  making  an  ample  bed  for  it  with  a 
tenotomy  knife  and  blunt  dissector  it  was  inserted  and  the  wound  care- 
fully stitched. 

Ridge  of  nose :  The  tenotomy  knife  w^as  inserted  vertically  to  a  depth 
of  ^  in.  and  i  in.  from  tip  of  nose  and  then  pushed  up  to  nasal  bones  or 
upper  limit  of  depression.  It  was  then  withdrawn  and  pushed  about  jr  in. 
towards  tip  of  nose.  An  ample  bed  was  made  with  blunt  dissector.  The 
piece  of  cartilage  was  inserted,  pushed  upwards,  and  then  lower  end 
drawn  downwards  towards  nasal  tip.  This  small  manoeuvre  obviates  the 
need  for  stitching  the  skin  incision  and  prevents  the  lower  end  of  the 
cartilage  slipping  into  the  wound.  The  incisions  are  then  painted  over 
with  collodion. 

Mr.  Harmer  :  I  find  that  thin  pieces  of  cartilage  are  often  insufficient 
to  repair  a  badly  depressed  nasal  bridge.  In  such  cases  a  large  piece  of 
rib  cartilage  is  required. 

Tertiary  Syphilis  of  the  Pharynx,  clinically  resembling  Tuber- 
culosis of  a  Lupoid  Type. — Irwin  Moore. — Patient,  a  female,  aged 
forty -four,  upon  wliom  an  ui'gent  tracheotomy  had  been  performed  in 
May,  1917,  for  specific  .stenosis  of  the  larynx,  was  shown  on  June  1. 1917, ^ 
and  on  November  2,  1917,  to  demonstrate  the  i-esult,  in  one  month,  of  a 
single  injection  of  galyl.  This  cleared  up  the  infiltration  of  the  pharynx, - 
and  reopened  the  pharynx  so  that  the  patient  breathed  fi-eely  through  the 
larynx  with  the  tracheotomy  tube  corked.  Patient  had  been  lost  sight 
of  until  recently,  and  was  found  to  have  dispensed  with  her  tube  two 
weeks  ago  and  the  neck  wound  had  healed. 

'  In  the  report  of  tliis  case  the  date  admitted  to  hospital  should  read  May 
23,  1917— not  1916. 

2  JouKN.  OF  Lartngol.,  Ehinol.,  AND  Otol.,  vol.  xxxlv,  p.  201. 


January,  1920]  Rhmology,  and  Otology.  23 


ABSTRACTS. 

Abstracts  Editor — W.  Douglas  Harmer,  9,  Park  Crescent,  Loudou,  W.  1. 

Authors  of  Original  Communications  on  Oto-laryngology  in  other  Joumah 
are  invited  to  send  a  copy,  or  tico  reprints,  to  the  Journal  of  Lartxgologt. 
If  they  are  icilling,  at  the  same  time,  to  submit  their  own  abstract  {in  English, 
French,  Italian  or  German)  it  uill  be  icelcomed. 


NOSE. 


Fulminating  Ethmoiditis  with  Metastasis. — Ira  Frank.     "  The  Laryn- 
goscope," July,  l!)19,  p.  42-5. 

Frank  i^ecords  the  case  of  a  male,  aged  nineteen,  who  was  seen  twenty- 
four  hours  after  the  onset  of  an  attack  of  grippe.  The  following  day 
general  frontal  headache  was  complained  of.  By  the  fifth  moi-ning  the 
frontal  paiu  was  sufficiently  intense  to  suggest  sinus  disease.  Next  day 
the  nasal  secretion  became  slightly  blood-tinged  On  the  eighth  day 
cedema  was  appai'ent  in  the  upper  and  lower  lids.  Frank  was  now 
called  in  and  found  the  right  eye  completely  closed.  Fluctuation  was 
not  apparent.  Intranasal  examination  revealed  an  almost  total  occlusion 
■of  the  right  naris.  No  pus  was  visible,  but  there  was  an  ooze  of  pinkish 
aerum  from  the  swollen  turbinates.  After  careful  application  of  cocaine 
and  adrenalin  Frank  was  able  to  remove  the  anterior  third  of  the  right 
middle  turbinate.  This  freed  a  large  quantity  of  pus.  Oii  the  following 
day  the  temperature  reached  lO-i^^  F.,  and  there  was  no  diminution  in 
the  patient's  discomfort.  A  Killian  incision  was  now  made  over  the 
right  eye.  In  the  process  of  raising  the  periosteum  from  the  oi'bital 
plate  of  the  ethmoid  boue  there  was  a  sudden  escape  of  pus.  The 
-ethmoid  cells  were  thoi'oughly  curetted  and  a  large  quantity  of  pus 
liberated.  Relief  from  the  headache  was  almost  immediate,  but  the 
temperature  varied  between  100°  and  104^  F.  A  severe  pain  located  in 
the  left  shoulder  on  the  day  following  the  second  operation.  Blood- 
culture  proved  to  be  sterile.  The  shoulder  was  explored  with  a  needle, 
but  no  pus  was  found.  On  the  following  day  a  large  subinuscular 
abscess  aroiind  the  shoulder  was  opened  and  drained  (pure  culture  of 
streptococcus).     Patient  left  the  hospital  entirely  well. 

J.  S.  Fraser. 

Tuberculosis   of  the   Sphenoid   Sinuses. — John   D.   Kernan,  Jr.     "The 
Laryngoscope,'"  May,  I9l9,  p.  276. 

Kernan  records  the  case  of  a  female,  aged  thirty-one,  who,  six  months 
before,  had  been  seized  by  an  illness,  the  chief  symptoms  of  which  were 
prostration,  chills  and  fever.  Two  weeks  after  the  beginning  of  the 
illness  she  started  to  have  a  pain  in  her  head,  localised  chiefly  in  the 
occipital  region,  but  radiating  toward  each  mastoid  process.  Later 
it  extended  to  the  orbital  regions.  On  the  day  of  her  admission  the  pain 
became  more  severe  and  localised  itself  in  the  right  ear.  The  patient  had 
lost  twenty  pounds  in  six  months.  She  had  had  two  healthy  children, 
two   miscarriacjes  and  several  stillborn  children.       Examination  showed 


24  The  Journal  of  Laryngology,        [January,  1920. 

optic  neuritis,  more  marked  on  the  right  side,  with  total  loss  of  sight  on 
this  side.  There  was  pleural  thickening  over  right  upper  lobe  posterioi'ly. 
A  polypoid  mass  hung  in  the  region  of  the  posterior  end  of  the  right 
middle  turbinate  and  a  mucopurulent  discharge  appeared  far  back  in  the 
right  nasal  cleft.  On  transillumination  the  right  antrum  only  appeared 
dark.  A  rough  mass  having  the  appearance  of  adenoids  was  seen  in  the 
nasopharynx.  Left  drum  membrane  red  and  bulging.  X-ray  of  sinuses  : 
Frontal  and  maxilkiry  sinuses  normal.  There  was,  however,  a  distinct 
clouding  of  the  right  ethmoid  region,  with  dulling  of  the  bony  outline 
about  the  right  sphenoidal  fissure.  The  lateral  view  showed  marked, 
clouding  of  the  sphenoidal  sinuses.  Temperature  normal  to  101°  F. 
The  otitis  cleared  up.  Wassermaun  negative.  Posterior  end  of  middle 
turbinate  on  the  right  side  was  resected  and  the  anterior  wall  uf  the 
right  sphenoid  sinus  w.as  removed.  The  sinus  was  found  to  be  full  of  an 
extremely  friable  tissue  resembling  granulation-tissne.  On  section  this 
was  pronounced  to  be  tubei-culous.  A  Denker  operation  was  performed  on 
the  right  side,  the  anterior  and  inner  walls  of  the  right  antrum  being 
removed.  The  antrum  appeared  to  be  healthy  except  posteriorly,  where 
the  mucous  membrane  was  thick  and  cedematous.  The  right  middle 
turbinate  was  removed  and  the  posterior  ethmoid  cells  found  to  be  full  of 
pathological  material,  their  bony  walls  being  necrotic.  The  floor  and 
anterior  wall  of  both  sphenoidal  sinuses  were  in  a  similar  condition.  The 
vomer,  the  pterygoid  processes  and  perpendicular  portion  of  the  palate 
bone  on  the  right  side  were  all  involved.  The  mass  hanging  from  the 
roof  of  the  nasopharynx,  which  had  the  appearance  of  adenoids,  likewise 
proved  to  be  tuberculous  tissue.  This  was  removed  Avitli  an  adenotome 
and  curettes. 

Progress. — The   patient  was   free  from  ])ain  next  day.     The  wound 
in  the  mouth  healed  promptly.  /.  S.  Fraser. 

Orbital  Abscess  and  Exophthalmos  due  to  Intranasal  Suppurative 
Processes.— Derrick  T.  Vail.  "  The  Laryngoscope,"  May,  1919,. 
p.  263. 

Thirty  years  ago  nearly  all  abscess  formations  of  the  orbit  were 
diagnosed  as  either  primary  or  metastatic.  The  true  conception  seems  to 
be  that  the  abscess  process  first  begins  in  a  locked-up  accessory  nasal 
sinus.  The  least  resisting  wall  of  that  sinus  gives  way  and  the  pus  finds 
a  way  out  of  its  sinus  confines  into  the  adjacent  space.  If  the  pus  from 
the  primarily  affected  accessory  nasal  sinus  breaks  through  the  orbital 
wall  of  the  sinus  we  have,  first,  elevation  of  the  periosteum  of  the  orbit, 
and  later  on  perforation  of  the  periosteum  so  that  the  pus  is  free  to  flood 
the  tissues  of  the  orbit.  There  may  now  be  a  speedy  recovery  on  the 
part,  of  the  swollen  nasal  mucosa  so  that  the  turbinated  regions  as 
viewed  with  the  rhinoscope  are  not  very  abnormal  in  appearance.  The 
position  of  the  proptosed  eyeball  usually  declares  which  sinus  in  the 
nose  was  the  seat  of  the  primary  abscess.  Vail  records  four  cases:  (1) 
Exophthalmos  and  thrombosis  of  cavernous  sinus  from  sphenoid  abscess. 
Death.  (2)  Exophthalmos  from  abscess  of  the  posterior  ethmoid  sinus 
in  which  the  eyeball  was  pushed  straight  forward.  Eecovery.  (3)  Ex- 
ophthalmos from  abscess  of  the  anterior  ethmoid  sinuses  in  which  the 
eyeball  Avas  extruded  forward  and  towards  the  temple.  Death.  (4) 
Exophthalmos  from  abscess  of  the  frontal  sinus  in  which  the  eyeball  was. 
extruded  to  less  extent  and  pushed  downward.     Eecovery. 

/.  S.  Fraser. 


January,  1920.]  Rhiiiology,  and  Otology. 


25 


Reflections  on  the  Dangers  of  Radical  Frontal  Operations. — P.  Terrier. 
■•  Eevue  MJd.  Jf  la  Suis.se  Eoiiiaude,"  September.  1919. 

The  author  recognises  only  two  methods  of  radical  operation,  namely, 
the  Caldwell-Luc  and  the  Killian.  After  pointing  out  the  advantages 
and  disadvantages  of  each  of  the  operations  and  the  difficulties  and 
dangers  attending  them  (in  which  there  is  nothing  now)  he  reports 
a  case : 

Male,  aged  forty-eight,  witli  a  swelhng  at  the  left  intei-nal  orbital 
angle,  polypi  in  the  nose  and  very  free  discharge  of  pus. 

Operations  performed  : 

(1)  Removal  of  polypi,  which  was  followed  by  acute  tonsillitis. 

(2)  Caldwell-Luc  operation  on  both  antra. 

(3)  Killian  operation  on  left  frontal  sinus. 

Death  a  few  days  later  from  purulent  basal  meningitis,  most  marked 
round  the  sella  turcica,  the  optic  nerves  and  the  chiasma  and  extending 
back  to  the  base  of  the  cerebellum.  On  the  convexity  of  the  brain  the  pia 
mater  and  arachnoid  were  cedematous. 

Cerebro-spinal  fluid  was  purulent  and  tlie  sinuses  at  the  base  of  the 
skull  contained  clots.  No  lesion  could  be  foiiiid  in  the  bone,  no  fissure; 
the  lamina  cribrosa  was  intact  and  the  dura  mater  covering  it  normal. 

Arthur  J.  Hutchison. 

Submucous    Resection   of   the    Nasal    Septum.— John   A.   Cavanaugh. 
'■  The  Lai-yngoscope,"  August,  1919,  p.  468. 

Cavanaugh  describes  his  method  of  operating.  He  makes  the  usual 
incision  on  the  convex  side  and  elevates  the  mucoperichondrium.  He 
then  uses  his  "  cartilage  shave  "  to  remove  a  strip  of  cartilage,  leaving  the 
perichondrium  of  the  mucous  membrane  of  the  opposite  side  exposed. 
He  then  introduces  his  septum  forceps,  of  which  the  inner  surface  of  one 
blade  is  rouijlieued  and  the  other  smooth.  The  roughened  blade  is  intro- 
duced next  to  the  cartilage  from  which  the  mucous  membrane  has  been 
elevated,  while  the  other  blade  rests  upon  the  mucous  membrane  of  the 
opposite  nostril.  In  this  way  the  ethmoid  plate  can  be  fractured  in 
several  places.  This  portion  of  the  septum  can  be  "  freely  and  easily 
pushed  into  the  position  desired."'  The  "septum  shive"  resembles 
Ballenger's  swivel  knife  except  for  the  fact  that,  in  place  of  the  knife 
blade,  there  is  a  small  dredger  which  cuts  sideways  into  and  through  the 
cartilage.     The  article  is  illustrated.  J.  S.  Fraser. 


EAR. 

Anatomical  and  Clinical  Study  of  Osteitis  of  the  Tip  of  the  Petrous.— 
Lavage  of  Meningeal  Spaces  in  Cases  of  Meningitis. — Bellin, 
Aloin  and  Vernet.    "Lyon  Chirurgical,''  July-August. 1918,  p.  455. 

The  authors  present  the  following  case  mainly  to  explain  their 
method  of  washing  out  the  meninges,  but  also  as  an  interesting  example 
of  osteitis  of  the  tip  of  the  petrous  bone. 

A  soldier  was  admitted  to  hospital  Deceml^er  1,  1916,  with  wounds  of 
the  face  by  shell  explosion  causing  destruction  of  the  right  eye  and  a  left 
facial  paralysis  from  a  lesion  of  the  parotid.  In  addition  there  was 
diminution  of  sensation  in  the  left  cornea  and  face  and  stenosis  of  the 


26  The  Journal  of  Laryngology,       [January,  1920. 

left  auditory  meatus.  Curetting  of  left  mastoid  December  8.  Plastic 
operation  on  left  meatus  March  30,  1917.     Recovery  uneventful. 

In  June,  after  a  period  of  headaches,  sudden  signs  of  meningitis 
appeared,  Kernig,  stiffness  of  neck,  rise  of  temperature,  etc.  Lumbar 
puncture  showed  clear  fluid  containing  streptococci.  After  several 
punctui-es,  by  June  7  his  state  had  become  worse.  There  was  clouding 
of  his  mental  faculties  and  definite  true  aphasia.  Next  day  still  apliasic. 
Paralysis  of  the  right  arm.  Diagnosis  of  left  temporo-sphenoidal  abscess 
made.  Mastoid  reopened,  but  bone,  sinus  and  meninges  found  healthy. 
No  sign  of  pus.  It  was  decided  to  go  for  the  tempoi-o-spheuoidal  lobe, 
and  accordingly  a  fresh  incision  and  exposure  of  dura  in  temporal  region 
was  performed  under  strictly  aseptic  conditions.  Puncture  of  the  brain 
in  this  region  evacuated  about  1  c.c.  of  blood-stained  fluid.  Puncture  of 
the  ventricle  gave  clear  fluid.  The  same  evening  patient  recovered 
consciousness  and  could  speak  distinctly.  Had  one  or  two  Jacksonian 
fits.  For  several  days  the  improvement  continued.  Arm  merely  a  little 
feeble. 

On  12th  suddenly  much  worse ;  temperature  raised,  neck  rigidity 
aggravated.  Lumbar  puncture  showed  numerous  streptococci;  puncture  of 
abscess-cavity  gave  no  pus.  Ventricle  again  tapped.  In  view  of  the  bad 
prognosis  it  was  decided  to  attempt  to  wash  through  the  meninges,  and 
accordingly  some  serum  coloui-ed  with  methylene-blue  was  injected 
through  the  lumbar  needle.  In  a  few  moments  the  blue  fluid  appeared 
through  the  needle  m  the  ventricle.  There  was  a  slight  dyspnoea  at  this 
point,  which,  however,  did  not  last  long.  The  washing  was  continued  a 
few  minutes  and  the  wound  re-closed.  There  was  cousiderable  improve- 
ment in  every  respect  for  about  four  days.  The  cerebro-spiual  fluid 
showed  no  streptococci  for  some  days.  However,  the  symptoms  later 
reappeared.  Lavage  was  again  carried  out  but  without  much  improve- 
ment, and  the  patient  died  on  June  18. 

Post-mortem  examination  showed  slight  purulent  exudate  over  con- 
vexity of  brain.  Section  of  the  left  tem|)oral  lobe  revealed  an  abscess- 
cavity  2|  cm.  in  diameter  above  and  in  front  of  the  descending  horn  of 
the  lateral  ventricle,  with  which  it  did  not,  however,  communicate.  The 
cavity  was  empty.  The  right  side  of  the  brain  showed  nothing  special. 
In  the  region  of  the  lett  Gasserian  ganglion  there  was  a  false  membrane 
and  the  dura  was  here  very  adherent  to  the  bone.  After  removal  two 
abscess-cavities  were  found  in  the  petrous  bone,  one  near  the  carotid 
canal,  the  other  above  the  porus  acusticus. 

It  was  evident  from  the  post-mortem  findings  that  the  case  had  been 
hopeless  from  the  start,  but  the  improvement  after  lavage  of  the  ventricles 
was  so  marked  that  the  authors  regard  it  as  a  very  valuable  therapeutic 
measure.  When  it  is  remembered  that  the  meningitis  was  due  to  a 
streptococcus  and  that  lavage  caused  a  disappearance  of  those  for  several 
days  from  the  cerebro-spinal  fluid  the  case  must  be  regarded  as  distinctly 
encouraging.  The  point  at  which  the  brain  is  tapped  is  at  3  cm.  above 
the  external  auditory  meatus  and  midway  along  a  line  joining  the  nasion 
and  the  inion.  A  small  trephine  opening  is  made  at  this  point  and  a 
needle  with  an  obtui-ator  is  pushed  in  at  right  angles  to  the  brain  to  a 
distance  of  3  to  4  cm.  As  soon  as  the  ventricle  is  reached  a  flow  of 
liquid  will  occur  when  the  obturator  is  withdrawn.  A  lumbar  puncture 
is  next  performed  and  a  quantity  of  serum  coloured  w^ith  methylene-blue 
is  introduced,  preferably  through  the  lumbar  needle.  For  further  details 
the  reader  is  referred  to  the  original  paper.  /.  K.  Milne  Dickie. 


January,  1920.]  Rhinology,  and  Otology.  27 

On  the  Opportuneness  of  an  Early  Surgical  Intervention  in  Suppurative 
Otitis  accompanied  by  Meningeal  Reaction. — Caldera,  C.  "  Boll, 
di.  Prof.  Grazzi,"'  fasc.  8,  auuo  xxxvi. 

It  is  not  uucommon  to  get  symptoms  of  meningitis  in  the  course  of 
an  acute  otitis  media  in  children.  The  symptoms  rapidly  disappear  after 
perforation  or  paracentesis  of  the  drum  membrane  and  proper  drainage. 
This  syndrome  has  been  given  the  name  of  "  meningismus.'' 

The  author  reports  a  case  of  this  type  occurring  in  an  adult  in  whom 
paracentesis  was  carried  out  without  improwment.  The  symptoms, 
however,  disappeared  as  soon  as  the  mastoid  was  opened. 

The  patient,  a  soldier,  aged  twenty-seven,  was  admitted  to  hospital 
with  bronchitis  in  the  course  of  which  he  developed  suddenly  acute 
pain  in  the  left  ear.  After  four  days  of  pain  some  discharge  appeared, 
stopping  again  after  forty-eight  hours.  Admitted  to  otological  depart- 
ment May  15,  1918.  Examination  showed  a  good  deal  of  desquamation 
in  the  external  auditory  meatus,  and  reddening  and  bulging  of  the  drum- 
head without  any  visible  perforation.  Mastoid  tenderness.  Other  ear 
normal.  Paracentesis  of  the  membrane  was  carried  out  immediately 
under  local  anaesthesia  aucl  considerable  discharge  escaped  and  continued 
next  day.  However,  the  pain  in  the  ear  and  the  mastoid  tenderness 
continued  and  the  temperature  remained  above  normal  but  without 
rigors.  On  the  17th  the  condition  of  the  ear  was  much  the  ^ame  and  the 
patient  had  severe  headache,  rigidity  of  the  neck,  Kernig's  sign,  and 
vomited  several  times.  The  mastoid  was  opened.  Soft  parts  normal, 
cortex  of  moderate  thickness,  cells  healthy;  only  the  antrum  contained 
some  purulent  secretion.  No  granulations.  The  cavity  was  packed  with 
gauze.  Lumbar  puncture  was  performed  and  the  cerebro-spinal  fluid 
found  to  be  clear  and  under  normal  pressure.  Microscopic  contents 
normal. 

Next  day  the  temperature  was  below  normal.  The  patient  was  much 
improved  in  every  way.  The  Kernig  was  barely  perceptible ;  there  was 
no  headache,  no  neck  stiffness,  and  no  vomiting.  Recovery  was  uneventful 
•except  for  an  attack  of  sciatica  and  later  a  slight  pleurisy. 

Speculating  on  the  cause  of  the  meningeal  symptoms,  Caldera  suggests 
the  possibility  of  a  special  anatomical  peculiarity  in  which  the  purulent 
secretions  came  in  contact  with  the  dura  mater,  which  had  proved  a 
foarrier  to  the  infection  but  allowed  the  toxins  to  penetrate  it. 

/.  K.  Milne  Dickie. 

Chronic  Purulent  Otitis  Media,  Thrombosis  and  Suppnration  of  the 
Transverse  Sinus.  Extradural  Abscess  and  Cerebellar  Abscess; 
Operation  and  Recovery. — H.  Tanaka  (Takasaki,  Japan).  "  The 
Laryngoscope,"  August,  1919,  p.  491. 

Female,  aged  fourteen.  First  seen  August  14,  1918.  Chronic 
suppurative  otitis  media  (left)  after  sea-bathing  at  the  age  of  six. 
Several  attacks  of  vertigo  during  last  few  months.  Severe  chill  accom- 
panied by  a  rise  of  temperature  to  40°  C,  and  nausea  and  vomiting  on 
day  of  admission.  Examination  :  No  nystagmus.  Headache  severe  in 
left  frontal  region.  Mastoid  tenderness  present.  Operation :  Under 
local  anaesthesia;  duration,  five  minutes  {sic).  The  antrum  was  filled 
with  cholesteatoma;  sinus  exposed,  normal.  On  second  day  after  opera- 
tion patient  had  a  chill.  Five  days  later  Tanaka  exposed  the  transverse 
sinus.  It  was  yellow  and  showed  no  pulsation.  Puncturing  proved  that 
it  contained  pus.     Probe  inserted ;  brought  about  a  sluggish  bleeding 


28  The  Journal  of  Laryngology,       [January,  192c. 

(culture  sbowed  pure  Stcqjliylococciis  alhtis  from  sinus  pus).  At  the 
third  operation  pus  was  found  in  middle  fossa  (extra-dural  abscess).  A 
week  later  the  patient  fell  into  a  stupor  from  which  she  could  not  be 
aroused.  Pupils  dilated,  equal  on  both  sides  and  did  not  react  to  light. 
Horizoulal  rotarv  nystagmus.  Temperature  38^  C,  pulse  (55.  Neck  stiff; 
knee-jerks  absent.  Lumbar  puncture  showed  clear  fluid.  Slight  motor 
aphasia;  choked  discs  on  each  side.  During  next  six  weeks  Tanalca 
notes  severe  headache,  nausea,  vomiting  and  comatose  attacks  accom- 
panied by  opisthotonos;  speech  disturbance;  left  abducens  paralysis; 
amblyopia  on  the  right  side ;  slight  nystagmus  towards  the  left 
(diseased)  side ;  ataxia  of  left  extremities.  A  cerebellar  abscess  was 
evacuated  at  the  foui'th  operation.  A  month  later  the  wound  closed  but 
there  was  still  some  ataxia.  The  aljducens  paralysis  almost  entirely 
disappeared,  but  optic  atrophy  was  found  on  ophtbalmosco|)y. 

/.  8.  Frailer. 

The  Use  of  the  Pitch-range  Audiometer  in  Otology. — S.  W.  Dean  and 
C.  C.  Bunch.     '"The  Laryngoscope,"  August,  1919,  p.  458. 

Two  years  ago  Dean  decided  that  the  methods  of  testing  the  tonal 
i-anges  used  in  his  clinic  must  be  improved  upon.  Prof.  Seashore 
suggested  the  appointment  of  a  research  assistant  to  work  in  otology 
and  psychology  to  solve  this  problem.  Bunch  was  appointed,  and  the 
new  instrument  is  the  result  of  his  work.  Dean  admits  that  it  is  not  a 
perfected  machine.  It  is.  however,  far  superior  to  any  other  method. 
As  perimetry  has  developed  ophthalmology,  so  may  this  metiiod  develop 
otology.  In  Dean's  clinic  the  pitch-range  audiometer  lias  already  replaced 
the  tuning-forks.  It  is  a  great  time-saver.  The  instrument  was  vised 
during  the  war  to  test  men  for  radio  service,  and  many  unsuspected 
defective  individuals  were  found  who  had  passed  the  other  regular 
examinations  for  hearing.  The  audiometer  measures  the  tonal  range 
from  30  to  10,000  double  vibrations  per  second.  Defects  iinsus])ected 
after  an  examination  with  the  Bezold  forks  (covering  over  an  hour)  are 
detected  in  two  or  three  minutes  with  this  instrument.  A  tone  gap  of 
three  or  four  notes  only,  lying  in  an  ai'ea  between  two  tuning-forks,  will 
be  definitely  demonstrated  by  this  instrument.  The  findings  have 
been  confirmed  with  the  monochord  and  piano.  The  instrument  is 
excellent  for  rapidh'  and  accurately  determining  malingering.  Curves 
made  on  successive  days  should  be  identical  unless  the  ear  condition 
is  changing  or  the  patient  is  malingering.  In  testing  the  hearing  of  one 
ear  it  is  always  necessary  to  use  a  noise  apparatus  in  the  other. 

Dean  gives  a  brief  descrij)tiou  of  the  instrument.  If  we  take  a 
magnet  such  as  that  used  in  a  telephone  receiver  and  attach  to  it  another 
telephone  I'eceiver,  and  then  lay  a  nail  across  the  two  prongs  ot"  the  first 
receiver,  we  can  hear  a  click  in  the  other  receiver  when  the  nail  is  laid  on 
and  when  it  is  taken  off,  as  the  result  of  the  change  in  the  electro- 
motive force  caused  by  bridging  the  two  points  of  the  magnet. 

The  results  obtained  by  this  machine  may  be  compared  to  perimetry 
of  the  eye.  Certain  curves  are  suggestive  at  least  of  certain  lesions.  A 
machine  completely  standardised  would  give  the  same  results  in  Europe 
and  in  America.  If  we  mount  this  receiver  magnet  in  front  of  a  toothed 
wheel  so  that  each  prong  of  the  magnet  will  fit  snugly  in  front  of  one 
tooth  of  the  wheel,  then  the  wheel  becomes  a  bridge  as  the  nail  was  in 
our  first  illustration ;  the  magnetic  current  completes  a  circuit  from  one 
cog  to  the  other.     Now  if  the  wheel  is  revolved  slowly  the  cogs  gradually 


January.  1920.]  Rhinology,  and  Otology.  29 

recede  from  their  magnetic  points  until  they  reach  the  maximum  gap, 
iind  then  the  next  pair  of  cogs  will  gradually  make  the  bridge  as  before. 
The  pitch  of  the  tone  may  then  be  varied  by  vai-ying  the  speed  of  the 
revolving  wheel.  The  wheel  is  driven  by  a  direct -current  motor  so 
adjusted  as  to  produce  any  desired  speed.     (The  article  is  illustrated.) 

The  noise  of  the  machinery  may  be  eliminated  by  placing  the  motor 
in  some  distant  room  and  having  electric  control  for  the  experimenter, 
who  is  seated  in  a  quiet  room  with  the  patient.  The  patient  holds  the 
receiver  to  his  ear,  and  indicates,  by  some  noiseless  method,  that  he  hears 
the  tones.  The  experimenter  begins  by  throwing  in  the  shunt  a  certain 
resistance  which  will  give  a  strong  tone  in  the  receiver.  The  motor  is 
then  speeded  up  until  the  entire  tonal  range  is  covered.  A  convenient 
method  of  marking  the  graph  is  to  have  the  intensity  steps  for  the 
vertical  scale  and  the  frequencies  recorded  at  the  bottom  as  a  horizontal 
scale.  Fatigue  is  largely  elimiiiated  because  the  pitch  of  the  tone  is 
constantly  changing,  and  the  entire  test  should  not  require  more  than 
fifteen  or  twenty  minutes,  as  compared  with  one  hour  for  a  complete  test 
with  tuning-forks.  /.  S.  Fraser. 

Abducens  Paralysis  in  Acute  Suppurative  Otitis  Media  with  Mastoiditis. 
— Otis  Stickney.     •'The  Laryngoscope,"  July,  1919,  p.  o9o. 

Stickney  records  two  cases.  Case  1. — Girl,  aged  six.  A  simple 
mastoid  operation  was  performed.  The  cells  were  broken  down.  There 
was  no  carious  destruction  of  the  tegmen.  A  small  area  of  the  dura  was 
-exposed  and  found  normal.  The  child  began  to  improve  on  the 
following  day.     The  doul)le  vision  entirely  disappeared  in  two  weeks. 

Cage  2. — Female,  aged  thirty-four.  At  operation  the  small  cells 
contained  only  serum  and  granulations.  There  was,  however,  one  cavity 
filled  with  pus.  No  exposure  was  made  of  the  dura  or  lateral  sinus. 
Following  the  operation  there  was  no  improvement  in  the  ocular  con- 
dition. The  original  mastoid  incision  was  reojjeued  and  the  tegmen 
removed  as  far  forward  as  possilile.  The  dura  was  congested  and  very 
adherent ;  there  was  a  plastic  exudate  to  be  seen  in  this  region.  A  gauze 
drain  was  introduced  beween  the  dura  and  the  bone.  In  five  days  the 
ear  discharge  ceased  altogether.  Ten  days  after  the  second  operation 
there  was  decided  improvement  in  the  abduction  of  her  eye. 

/.  S.  Fraser. 

Lateral  Sinus   Endophlebitis    without   Thiombosis. — Daudin   Clavand. 
"  Journ.  de  Laryngologie,"  September  15,  1919. 

There  are  abortive  types  of  endophlebitis  which  never  proceed  to 
thrombosis,  and  in  these  types  the  diagnosis  is  extremely  difficult. 

At  operation,  on  laying  bare  the  sinus-wall  there  is  nothing  to  suggest 
thrombosis,  and  the  patient  recovers  from  all  signs  of  a  systemic  infection, 
although  the  sinus  is  not  incised.  Obviously  the  mastoid  operation  and 
sinus  exposure  has  not  been  useless.  The  explanation  probably  lies  in 
the  simple  drainage  of  septic  foci  which  are  incipient  in  the  extradural 
space  and  fully  developed  in  the  bone  itself.  This  conservative  method 
should  always  be  adopted  in  svich  cases ;  the  technique  makes  it  easier 
for  the  surgeon  to  open  the  sinus  later,  if  necessaiy,  without  delay  or  a 
long  anaesthesia.  H.  Laivson  Whale. 


30  The  Journal  of  Laryngology^       [jannary,  1920. 

TRACHEA. 

Tranquil  Tracheotomy,  by  Injecting  Cocaine  within   the  Windpipe. — 

StClair    Thomson.       Epitome   from    the   "  Brit.    Med.    Jouru.," 

October  11,   1919,  p.  460. 

This  technical  improvement  for  rendering  tracheotomy  quieter,  simpler 

and  safer  has  been  employed  br  the  author  and  his  pupils  for  the  last 

six  years,  so  that  the  method   has  been  well   tested  in  scores  of  cases 

before  being  published  in  detail,  which  is  now  for  the  first  time.     It  is 

equally  useful  if  the  tracheotomy  is  performed  under  a  general  or  a  local 

anaesthesia.  After  trials  with  a  5  per  cent,  solution  of  cocaine  it  has  been 

found  that  a  solution  of  2|  per  cent,  is  as  effective.  It  is  used  as  follows: 

An  ordinary  hypodermic  syringe  is  charged  with  about  twenty  drops  of  a 


2 1  per  cent,  solution  of  cocaine.  As  soon  as  ever  the  tracheal  rings  ai-e 
laid  bare  the  syringe  is  grasped,  as  one  does  a  pen,  with  the  forefinger 
about  one  inch  from  the  extremity  of  the  needle,  and  with  this  the  wind- 
pipe is  sharply  stabbed  between  two  rings.  The  middle,  ring  and  little 
fingers  are  resting  on  the  neck,  and  they  prevent  the  ])oiut  from  pene- 
trating more  than  a  ^  to  |  inch  within  the  lumen  of  the  trachea.  The 
cocaine  solution  is  injected  into  the  cavity  of  the  windpipe,  some  five  to 
fifteen  drops,  and  the  needle  is  sharply  withdrawn. 

The  liquid  in  the  windpipe  at  once  gives  rise  to  a  slight,  stuffy  cough. 
It  causes  no  spasm  or  distress,  and  as  it  trickles  down  towards  the  region 
which  endoscopists  know  to  be  the  sensitive  spot  of  this  area,  viz.  the 
carina  at  the  bifurcation  of  the  trachea,  this  tickling  cough  soon  ceases. 
If  there  is  no  great  urgency,  ten  minutes  should  be  allowed  to  elapse,  the 
time  being  occupii-d  by  clearing  the  front  of  the  trachea,  checking  all 
bleeding,  preparing  the  tube  and  so  forth.  At  the  end  of  that  time  the 
incision  can  be  made  into  the  trachea  and  the  cannula  introduced  with- 
out pain,  spasm,  or  even  the  slightest  cough  as  quietly  and  smoothly  as  the 
original  incisrDn  through  the  skin.  The  calm  with  which  this  proceeding 
takes  place  is  in  striking  contrast  with  the  agitated,  hurried  and  often 
bloody  and  dangerous  operation  of  former  days.  StClair  Thomson. 


January,  1920.]  Rhinology,  and  Otology.  31 

MISCELLANEOUS. 

Limitations  of  the  Diagnostic  Value  of  the  Skiagram  in  Diseases  of 
the  Nose  and  Ear. — Join  Guttman.  "The  Laryngoscope,"  August,. 
1919.  p.  47-2. 

Guttmau  comes  to  the  following  conclusions  as  regards  the  value  of 
the  skiagi-am  in  diseases  of  the  accessory  sinuses  :  (1)  The  skiagram  will 
prove  the  presence  or  absence  of  a  sinus.  (2)  It  will  show  the  form  and 
size  of  a  sinus.  (3)  A  skiagram  showing  a  clear  sinus  is  an  undoubted 
sign  of  a  healthy,  normal  condition  of  that  sinus.  (4)  The  pathological 
condition  of  a  sinus  can  be  corroborated  by  a  skiagram  when  the  usual 
subjective  and  objective  symptoms  point  in  that  direction,  but  the 
presence  of  a  shadow  alone  without  such  subjective  and  objective 
symptoms  is  not  sufficient  proof  of  the  existence  of  such  a  ])athological 
condition,  nor  is  it  in  itself  an  indication  for  operative  interference  on 
that  sinus. 

In  diseases  of  the  middle  ear  the  skiagram  is  far  from  having  the 
same  diagnostic  value  as  it  has  in  nasal  accessory  sinus  su])puration.  In 
the  accessory  sinuses  a  skiagram  is  of  value  mostly  in  chronic  ca.ses,  but 
in  mastoiditis  the  information  gained  from  the  X  ray  is  most  desirable  in 
acute  attections.  In  almost  every  case  of  acute  purulent  otitis  media 
there  is  a  ^existing  involvement  of  the  mastoid.  A  difference  in  appear- 
ance of  the  skiagrams  of  the  two  mastoid  bones  is  not  of  much  diagnostic 
significance,  because  when  b<,)th  mastoids  are  perfectly  normal  they  may 
appear  differently  on  the  skiagram,  this  difference  being  due  to  differences 
in  the  anatomical  construction  of  the  two  mastoid  bones,  one  of  which 
may  be  pneumatic  and  the  other  sclerotic.  Cloudiness  in  the  region  of 
the  antrum  or  mastoid  cells  in  a  case  of  purulent  otitis  media  is  not 
necessarily  an  indication  for  mastoidectomy.  Such  cases  may  become 
perfectly  well  without  any  operation.  Negative  findings,  however,  are  of 
value  because  they  show  that  the  mastoid  bone  is  not  involved. 

J.  S.  Fraser. 

Haemorrhage  in  Epidemic  Influenza. — M.  A.  Goldstein.  "  The  Laryngo- 
scope," August,  1919,  p.  447. 

In  the  recent  influenza  epidemic  a  violent,  persistent,  and  remarkably 
frequent  epistaxis  occurred  as  a  prodrome  or  as  an  early  symptom. 
Patients  complained  of  a  f ulnt  ss  in  the  head.  The  mucosa  of  the  upper 
respiratory  tract  presented  a  diffusely  congested,  slightly  swollen  and 
dark-red  injected  appearance.  The  site  of  this  epistaxis  was  invariably 
along  the  course  of  the  septal  artery.  In  sixteen  cases  blood -cultures 
were  made  from  this  septal  point,  and  in  five  the  presence  of  Streptococcus 
hcfmo/yticus  was  demonstrated.  The  cases  in  which  the  epistaxis  (jccurred 
seetned  to  be  those  in  which  the  most  intense  activity  and  more  serious 
complications  developed.  Wliei'e  this  epistaxis  w^as  violent  subsequent 
hsemorrbage  appeared  in  other  localities  of  the  respiratory  tract  or  in 
other  organs  of  the  body.  Where  epistaxis  was  found  pneumonic 
complications  were  quickly  presented.  Where  epistaxis  was  not  controlled. 
by  the  sero-logical  therapy  that  was  carried  out,  the  end-result  in  the 
large  majority  of  cases  was  fatal.  In  1913  Goldstein  conducted  observa- 
tions on  the  coagulation-time  of  the  blood  in  patients  ojierated  on  for 
resection  of  the  septum,  adenoids  and  tonsillectomy.  Goldstein  found 
that  even  in  hgemophiliacs  the  coagulai  ion-time  following  the  administra- 
tion of  10  c.c.  of  horse-serum  was   leduced  from  one  to  three  minutes. 


32  The  Journal  of  Laryngology,       [January,  1920. 

As  the  result  of  these  observations  a  general  order  was  issued  to  inject 
10  c.c.  of  noi-mal  sterile  horse-serum  in  all  ^patients  during  the  active 
"flu"  epidemic  as  soon  as  epistaxis  was  observed.  In  s-ixty  cases  in 
which  this  serum  treatment  was  promptly  carried  out  no  mortality  Avas 
recorded.  Even  where  severe  pneumonia  developed  the  patients  recovered. 
•Of  twenty-two  cases  transferred  to  the  pneumonia  wards  before  the 
serum  could  be  injected,  fifteen  were  fatal. 

In  eight  out  of  a  series  of  over  seventy  cases  of  so-called  myringitis 
hsemorrhagica  the  bacteriological  culture  of  the  contents  of  the  blebs 
showed  the  presence  of  Streptococcus  Juemolyticus.  The  fauces,  pharynx 
and  the  tonsils  in  almost  all  of  the  cases  exhibited  the  same  mahogany-red, 
intensely  injected  mucous  membrane,  and  swabs  from  these  throats 
demonstrated  the  presence  of  Sfrejjtococctis  licvmolyticus.  Within  twenty- 
four  to  thirty-six  hours  after  the  initial  symptoms  of  influenza  there  was 
admixture  of  pure  blood  with  the  sputum — an  indication  of  localised 
tracheal  bleeding.  In  the  women's  wards  menstrual  haemorrhage  occurred 
almost  as  early  in  the  symptoms-complex  as  epistaxis,  irrespective  of  the 
normal  menstrual  period  of  each  patient.  There  were  also  several  cases 
of  intense  hsematuria. 

Goldstein  believes  that  haemorrhage,  haemolysis  and  the  Streptococcus 
haemolyticus  must  have  seme  close  pathological  relationship  and  identity. 

J.  8.  Fraser. 


NOTES   AND   QUERIES. 

Db.  William  Hill. 

We  extract  the  following  paragraph  from  a  recent  number  of  the  St.  Mary's 
Hospital  Gazette,  London : 

"  By  the  retirement  of  Dr.  William  Hill,  after  the  completion  of  his  full  term 
of  office,  St.  Mary's  sustains  a  real  loss.  Dr.  Hill's  reputation  as  a  laryngologist, 
more  especially  in  the  domain  of  endoscopy,  e.xtends  far  beyond  the  limits  of 
his  hospital.  His  work  is  familiar  on  the  Continent  and  in  America,  and  he  is 
recognised  as  a  pioneer  in  the  more  recent  work  on  diseases  of  the  gullet." 


Mr.  Nicol  Eankin,  M.B.,  and  Mr.  Archer  Eyland,  F.E.C.S.E.,  have  been  appointed 
Assistant  Surgeons  to  the  Central  London  Throat  and  Ear  Hospital. 


The  American  Academy  of  Ophthalmology  and  Oto-Laryngology. 

The  Twenty-foiirth  Annual  Meeting  of  the  American  Academy  of  Ophthal- 
mology and  Oto-Laryngology  was  held  in  Cleveland,  Ohio,  October  16  to  18,  under 
the  presidency  of  Dr.  John  M.  Ingersoll,  of  Cleveland,  Ohio.  Three  hundred 
American  and  a  number  of  Canadian  physicians  were  present. 

The  Twenty-fifth  Anniversary  will  be  held  in  Kansas  City,  October  14,  15,  16, 
1920. 

Officers  for  1920  were  elected  as  follows :  President,  Dr.  L.  M.  Francis,  Buffalo, 
]^.Y. ;  Vice-President,  Dr.  Hal  Foster,  Kansas  City,  Mo. ;  Secretary,  Dr.  L.  C. 
Peter,  Philadelphia,  Pa. ;  Treasurer,  Dr.  S.  H.  Large,  Cleveland,  Ohio ;  Chairman 
of  Arrangement  Committee,  Dr.  Hal  Foster,  Kansas  City,  Mo. ;  Chairman  of 
Exhibit  Committee,  Dr.  J.  S.  Lichtenberg,  Kansas  City,  Mo. 


Otological  Section  of  the  Royal  Society  op  Medicine. 
The  next  meeting  of  this  Section  will  be  held  on  February  20,  1920.     Secre- 
taries :  Mr,  H.  Buckland  Jones  and  Mr.  Lionel  Golledge. 


Laryngological  Section  of  the  Eoyal  Society  of  Medicine. 
The  next  meeting  of  this  Section  will  be  held  on  February  6,  1920.    Secretaries : 
Dr.   Irwin  Moore  and  Mr.  Charles  W.  Hope. 


VOL.  XXXV.     No.  2.  February,  1920. 


THE 

JOURNAL    OF    LARYNGOLOGY, 

RHINOLOGY,  AND  OTOLOGY. 


Original  Articles  are  accepted  on  the  condition  that  they  have  7iot  previously  been 
published  elsewhere. 

1/  reprints  are  reqinred  it  is  requested  that  this  be  stated  when  the  article  is  first 
forivarded  to  this  Journal.     Such  reprints  will  be  charged  to  the  author. 

Edi'''^yial  Communications  are  to  be  addressed  to  "Editor  of  Journal  of 
LARTNGOLOGt,  Care  of  Messrs.  Adlard  4"  Son  4"  TFest  Newman,  Limited,  Bartholomew 
Close,  IJ.C.  1." 


OTOMYCOSIS. 

By  Arthur  Cheatle. 

In  the  past  cases  of  aspergillus  have  been  seen  in  private  practice  at 
rare  intervals  only,  perhaps  one  case  in  two  years,  but  during  the  nine 
months  ending  July  31,  1919,  I  have  met  with  seven — a  remarkable 
increase — and  I  should  like  to  know  if  others  have  had  the  same  experi- 
ence. In  all  of  these  one  ear  only  was  affected,  and  the  trouble 
involved  the  deep  meatus.  They  were  easily  diagnosed,  presenting 
text-book  symptoms  and  signs,  and  were  quickly  cured  by  text-book 
treatment.  The  clinical  diagnosis  was  verified  by  microscopical  exami- 
nation by  Dr.  d'Este  Emery. 

In  casting  about  for  the  origin  and  mode  of  introduction  of  the 
fungus  one  is  driven  to  the  conclusion  that  bath-water  is  the  only 
likely  means  whereby  it  could  gain  an  entrance  into  the  ear,  and  as  a 
side-light  on  this  theory  it  is  my  experience  that  otomycosis  is  much 
more  frequently  seen  in  private  than  in  hospital  practice. 

I  was  able  in  one  case  to  obtain  a  sample  of  the  water  from  the 
cistern  supplying  the  bath  and  the  following  is  a  report  thereon  by  Dr. 
Emery  : 

"  The  specimen  of  water  contained  a  good  deal  of  deposit,  mostly 
unimportant  crystals  and  various  forms  of  animal  life,  rotifers,  etc. 
There  were  no  algae  or  chlorophyll-containing  organisms,  due,  I  suppose, 
to  the  fact  that  it  was  taken  from  a  dark  cistern.  The  chief  component 
of  the  material  was  a  fungus,  occurring  in  the  form  of  matted  mycelia, 
without  indication  of  fructifications.  Cultures  were  made  on  maltose 
agar,  and  kept  for  some  days  at  the  room  temperature,  when  numerous 
black  fructifications  closely  similar  to  those  seen  in  the  material  from 


'54  The  Journal  of  Laryngology,       [February,  1920- 

the  ear  were  developed.  The  organism  was  undoubtedly  an  aspergillus, 
and  in  general  appearance  it  was  exactly  similar  to  the  pathogenic 
form.  There  were,  however,  two  small  differences.  The  mycelium  was 
decidedly  wider  in  my  cultures  than  in  the  material  from  the  ear,  and 
the  free  spores  were  colourless,  or  almost  so^  whereas  in  the  pathogenic 
form  they  are  decidedly  pigmented.  Whether  this  indicates  a  specific 
difference  I  am  unable  to  say." 

From  this  report  it  is  clear  that,  in  one  instance  at  all  events,  the 
cistern  water  was  more  than  suspect  and  supports  the  bath-water 
theory.  The  increase  in  the  number  of  cases  may  be  due  to  the  neglect 
to  clean  out  the  cisterns  owing  to  the  war. 

Material  from  another  case  in  which  epithelial  matter  without  pig- 
mented spots  filled  the  deep  meatus  and  without  middle-ear  infection 
was  reported  on  by  Dr.  Emerj-  as  follows : 

"  I  have  not  been  able  to  find  any  aspergillus  iu  the  specimen.  There 
is  a  very  unusual  organism,  the  nature  of  which  I  have  not  been  able  to 
determine  with  certainty.  It  is  a  fine  mycelium,  very  much  finer  than 
that  of  aspergillus.  It  shows  true  dichotomous  branching,  and  in  many 
places  the  protoplasm  is  divided  into  coccoid  masses  so  that  the 
thread  resembles  a  chain  of  streptococci.  It  is  exactly  like  a  strepto- 
thrix  (actinomycosis),  and  if  I  knew  that  organism  occurred  in  this 
position  I  should  unhesitatingly  diagnose  it  as  such.  If  I  saw  similar 
mycelium  in  pus,  etc.,  I  should  certainly  regard  it  as  actinomycosis." 

This  case  quickly  got  well  under  cleansing  and  perchloride  of 
mercury  and  spirit  instillation. 


REPORTS  FOR  THE  YEAR  1918  FROM  THE  EAR  AND  THROAT 
DEPARTMENT  OF  THE  ROYAL  INFIRMARY,  EDINBURGH. 

Under  the  care  of  A.  Logan  Turner,  M.D.,  F.R.C.S.E.,  F.R.S.E. 

Part  IV. 

CAECINOMA  OF  THE  POST  -  CEICOID  REGION  (PARS 
LARYNGEA  PHARYNGIS)  AND  UPPER  END  OF  THE 
(ESOPHAGUS. 

By  a.  Logan  Turner,  M.D., 
Surgeon  to  the  Ear  and  Throat  Department,  Eoyal  Infirmarj-.  Edinburgh. 

In  vol.  xxviii  of  the  Journal  of  Laryngology,  Rhinology,  and 
Otology,  pubhshed  in  1913,  I  gave  an  account  of  malignant  disease 
of  the  oesophagus,  with  special  reference  to  carcinoma  of  the  upper 
end,  based  upon  an  experience  of  68  cases.  The  facts  published  at  that 
time  were  obtained  partly  from  my  hospital  records  made  between 
1907  and  1912  inclusive  and,  in  part,  from  notes  taken  from  my  private 
books  from  1902  to  1912.  The  material  now  under  consideration 
includes  these  cases,  revised  and  re-arranged,  and  in  addition  72  cases 
observed  between  1913  and  1919  (first  three  months)  and  derived  from 
the  same  two  sources,  thus  giving  a  total  of  140  cases  of  tumour. 


JOURNAL    OF    LARYNGOLOGY,    RHIXOLOGY,    AND    OTOLOGY 

PLATE   I. 


Fig.  1.— From  a  woman,  aj^ed  fifty-nine. 
A.  Squamous  epithelioma  at  upper  end 
of  cesophajyus.  b.  Perforation  into 
trachea ;  pneumonia. 


Fig.  2.— Squamous  epitbelioma  of  the  post-cricoid  re.^ion  showing  infiltration  of  the  mucous 
membrane  covering  the  posterior  surface  of  the  cricoid  and  arvtwnoid  cartilages. 

To  Illustratk  De.  Logan  Turner's  Paper  on  Carcinoma   of  the  Post- 

Cricoid  Region. 

Adlard  4-  Sou  .f  Wesf  yeii-maii,  Ltd. 


February,  1920.]  Rhinology,  and  Otology,  35 

Anatomy  and  Pathology. 

Before  studying  the  clinical  aspect  of  carcinoma  of  the  upper  end  of 
the  gullet,  it  is  necessary,  in  the  first  place,  to  draw  attention  to  cei'tain 
anatomical  points,  and  then  to  examine  the  pathological  material  at  our 
disposal,  so  that  the  clinical  data  may  he  placed  upon  a  more  satisfactory 
basis.  A  malignant  tumour  is  the  most  frequent  cause  of  oesophageal 
stricture,  and  it  is  more  prone  to  affect  those  parts  of  the  tube  ■which 
present  anatomically  some  narrowing  of  the  lumen.  These  areas  are 
the  ostium  of  the  oesophagus  and  the  aortic,  bronchial,  and  diaphragmatic 
constrictions.  It  is  necessary,  however,  in  considering  the  question  of 
carcinoma  at  the  upper  end  of  the  oesophagus,  to  study  the  anatomy  of 
the  pharynx  with  which  the  gullet  is  directly  continuous.  The  portion 
of  the  pharynx  which  constitutes  this  section  of  the  alimentary  canal  is 
subdivided  by  anatomists  into  two  parts — the  upper  or  oral  pharynx 
which  intervenes  between  the  soft  palate  above  and  the  superior  aperture 
of  the  larynx  below,  and  the  laryngeal  portion,  pars  laryngea  ■pharyngis, 
which  terminates  at  the  lower  Joorder  of  the  cricoid  cartilage,  where  it 
is  continued  as  the  oesophagus.  The  anterior  boundary  of  the  pars 
laryngea  is  formed  from  above  downwards  by  the  epiglottis,  the  superior 
aperture  of  the  larynx,  enclosed  laterally  by  the  arytaeno-epiglottidean 
folds  with  the  pyriform  sinuses  lying  external  to  them,  while  lower 
down  the  arytiBnoid  cartilages  and  the  large  plate  of  the  cricoid  cartilage 
complete  the  anterior  boundary.  In  the  latter  situation  the  anterior 
wall  of  the  pars  laryngea  is  in  contact  with  the  cervical  vertebrte,  so 
that  the  canal  is  narrowed  and  constitutes  a  distinct  area  of  constriction. 
In  this  area  carcinoma  is  liable  to  develop  ;  consequently  it  is  necessary 
to  include  the  post-cricoid  region  when  considering  the  question  of 
malignant  disease  at  the  upper  end  of  the  oesophagus. 

The  examination  of  thirty-one  post-mortem  specimens  of  carcinoma 
of  the  oesophagus  throws  some  light  upon  the  proclivity  of  the  disease 
to  attack  these  different  anatomical  areas. ^  In  five  of  the  preparations 
the  tumour  implicated  the  pars  laryngea  pharyngis ;  in  two  of  these  it 
was  confined  to  that  area  (Plate  I,  "fig.  2),  and  in  the  remaining  three 
the  ostium  and  the  extreme  upper  end  of  the  oesophagus  also  were 
involved  (Plate  II).  It  was  difficult  to  determine  the  actual  site  of 
origin  of  the  growth  in  the  latter,  but  the  preparations  demonstrate,  as 
clinical  experience  also  bears  out,  that  the  disease  may  be  found  in  both 
these  situations  in  the  same  subject.  In  five  specimens  the  tumour 
involved  the  extreme  upper  end  of  the  oesophagus,  extending  downwards 
from  the  ostium  for  a  distance  of  1  to  2  in.  In  three  other  prepai'a- 
tions  it  was  situated  in  the  cervical  oesophagus,  the  upper  margin  of 
the  tumour  being  1,  1^  and  2  in.  respectively  below  the  ostium  (Plate  I, 
fig.  1).  As  regards  the  eighteen  specimens  of  intrathoracic  tumour, 
four  were  situated  at  the  level  of  the  aortic  constriction,  ten  at  and 
immediately  below  the  level  of  the  bifurcation  of  the  trachea,  and  four 
at  the  diaphragmatic  area  and  extreme  lower  end  of  the  oesophagus. 
It  is  evident,  therefore,  from  a  study  of  these  preparations  that  carci- 
noma has  a  predilection  for  the  anatomical  areas  above  described,  though 
it  may  occur  elsewhere,  as  is  shown  by  its  presence  in  the  cervical 
oesophagus. 

Statistics  have  from  time  to  time  been  published  dealing  with  the 

1  Preparations  from  my  own  collection,  from  the  Musenni  of  the  Eoyal  College 
of  Surgeons  of  Edinburgh,  and  from  the  Musee  Dupuytren,  Paris. 


36  The  Journal  of  Laryngology,      [February,  1920 

relative  frequency  of  malignant  disease  in  the  different  parts  of  the- 
gullet.  Thus,  von  Hacken  found  that  in  100  cases  the  tumour  occurred 
at  the  upper  end  in  10  per  cent.,  opposite  the  tracheal  bifurcation  in 
40  per  cent.,  and  at  the  lower  end  in  30  per  cent.  In  186  cases  collected 
by  Sauerbruch,  the  commencement  of  the  oesophagus  was  affected  in  26, 
the  level  of  the  tracheal  bifurcation  in  43,  and  the  lower  end  in  117.  It 
is  not  possible  for  the  laryngologist  to  give  from  his  clinical  experience 
reliable  data  as  to  the  relative  frequency  of  the  tumour  in  the  different 
areas.  He  appi'oaches  the  subject  from  the  standpoint  of  the  throat 
specialist,  who  is  consulted  mainly  by  patients  whose  difficulty  in 
swallowing  is  referred  to  the  region  of  the  larynx  and  cervical  oesophagus, 
though  possibly  the  more  extended  use  of  the  cesophagoscope  in  his- 
hands  may  bring  an  increasing  number  of  cases  of  intra-thoracic 
obstruction  under  his  notice.  The  140  cases  which  form  the  basis  of 
this  paper  are  grouped  as  follows,  according  to  the  situation  of  the 
disease :  Pars  laryngea  pharj'ngis,  with  or  without  involvement  of  the 
oesophagus,  98  ;  cervical  oesophagus,  19  ;  level  of  tracheal  bifurcation,  9  ; 
lower  end  of  oesophagus,  14. 

The  squamous-celled  epithelioma  is  the  most  common  variety  of 
malignant  tumour  met  with  in  the  esophagus.  It  constitutes,  accord- 
ing to  Butlin,  90  per  cent,  of  the  tumours  examined.  With  one 
exception — a  case  of  medullary  carcinoma — it  was  the  only  variety  met 
with  in  this  series.  As  a  rule  only  one  tumour  is  found,  but  the 
possible  occurrence  of  a  second  growth  at  some  distance  from  the  first 
must  not  be  lost  sight  of.  It  is  obvious  that  the  existence  of  such  in 
the  thorax  would  have  an  important  bearing  upon  the  question  of 
treatment,  when  the  removal  of  a  limited  cervical  or  post-cricoid  growth 
was  under  discussion.  In  none  of  the  preparations  just  described  was 
there  any  evidence  of  a  second  growth,  but  in  two  patients  with  post- 
cricoid  carcinoma  a  second  stricture,  separated  from  the  first  bj'  a 
distinct  interval  of  normal  gullet,  was  met  with  in  the  thorax.  As  na 
post-mortem  examination  was  made  upon  either  of  them,  the  precise 
nature  of  the  second  obstruction  was  not  ascertained.  It  was  left  in 
doubt,  therefore,  whether  the  stenosis  was  due  to  a  second  intrinsic 
carcinoma  or  to  pressure  upon  the  lumen  of  the  oesophagus  from 
enlarged  intra-thoracic  glands.  Had  the  patients  been  screened  and 
bismuth  administered,  further  light  might  have  been  thrown  on  the  con- 
dition. Morriston  Davies  has  described  the  post-mortem  examination  of 
a  case  in  which  the  main  growth  was  situated  in  the  cervical  lumen  and 
a  second  smaller  one  was  found  at  the  tracheal  bifurcation.  The  inter- 
vening mucous  membrane  presented  a  normal  appearance.  Davies 
points  out  that  two  tumours  are  found  sometimes  in  the  colon  and 
rectum.  As  the  decending  contents  both  of  the  oesophagus  and  colon 
are  solid,  cells  may  be  detached  from  the  primary  tumour  and  deposited 
lower  down. 

The  disease,  at  first  superficial  and  confined  to  the  mucous  coat, 
involves  a  limited  area  of  the  circumference  of  the  lumen,  but  as  it 
increases  in  size  it  encircles  not  only  the  whole  of  the  tube  but  spreads 
in  the  long  axis.  The  older,  ulcerated  part  of  the  infiltration  is  well 
depicted  on  Plate  III,  where  the  tumour  may  be  observed  making  its 
way  along  the  mucous  coat  in  advance  of  the  ulcerating  zone.  In  this 
case,  a  woman,  aged  forty-three,  the  white,  smooth,  raised  nodular  edge 
when  seen  through  the  cesophagoscope  gave  the  impression  of  a  fibrous 
stricture.     As  the  patient  had  been  the  subject  of  syphilis,  additional 


JOURNAL    OF    LARYNGOLOGY,    RHINOLOGY,    AND    OTOLOGY, 


PLATE    II. 


Squamous  epithelioma  of  tlie  upper  end  of  the  tesopliagus, 
involving  the  posterior  wall  of  the  pust-cricoid  region  and 
extending  into  the  right  pyriform  sinus.  On  the  left  side  the 
groAvth  has  eaten  through  the  wall  of  the  oesophagus  and  infil- 
trated the  tissues  of  the  neck,  where  an  abscess-cavity  is  seen. 
No  clinical  hi.story  is  attached  to  this  specimen. 


To  Illustrate   Dr.  Logan  Turnkr's  Paper  on   Carcinoma  of  the  Post- 

Cricoid  Region. 


Adlard  4"  Son  4-  Weit  Neuman,  Ltd. 


February,  1920.]  Rhinology,  and  Otology.  37 

^veight  was  given  to  this  view,  but  the  post-mortem  appearances  and 
the  microscopic  examination  revealed  the  maHgnant  character  of  the 
-condition.  With  the  extension  of  the  growth  not  only  round  the  cir- 
cumference but  in  the  long  axis  of  the  tube  a  considerable  area  of  the 
gullet  may  become  involved.  Our  post-mortem  specimens,  which  may 
be  regarded  as  illustrating  the  disease  in  an  advanced  stage,  demonstrate 
that  one,  two  or  more  inches  of  the  vertical  axis  of  the  oesophagus  may 
be  implicated.  In  two  preparations  in  which  the  disease  was  confined 
to  the  pars  laryngea  phargngis,  the  tumour  extended  from  the  mouth  of 
tlie  oesophagus  to  the  mucosa  covering  the  arytenoid  cartilages  and 
arytaeno-epiglottidean  folds,  and  in  one  of  them  the  right  pyriform  sinus 
was  filled  with  the  growth.  When  the  tumour  occupied  both  the 
oesophagus  and  the  post-cricoid  areas  or  was  confined  to  the  cervical 
portion  of  the  gullet,  from  one  to  two  inches  and  a  half  of  the  vertical 
axis  were  implicated.  Clinical  experience  furnishes  additional  evidence 
of  the  extensive  area  which  the  tumour  may  occupy.  In  two  instances 
in  which  the  oesophagus  was  exposed  with  the  object  of  performing 
oesophagostomy  the  lower  limit  of  the  growth  in  each  case  was  at  the 
level  of  the  suprasternal  notch,  rendering  it  impossible  to  introduce  an 
oesophageal  feeding-tube  below  the  tumour.  The  upper  border  of  the 
growth  in  each  case  could  be  seen  with  the  laryngoscope  as  a  projecting 
edge  of  infiltration  behind  the  aryttenoid  cai'tilages,  thus  incidentally 
demonstrating  at  the  same  time  the  combination  of  post-cricoid  and 
oesophageal  carcinoma. 

These  facts  furnish  ample  evidence  of  the  necessity  of  making  an 
-early  diagnosis,  if  success  in  treatment  is  to  be  attained.  But  the 
pathology  of  the  tumour  must  be  studied  from  another  aspect  than  its 
mere  intrinsic  development.  The  penetration  of  the  muscular  coat  of 
the  gullet  and  the  invasion  of  the  tissues  and  organs  in  its  immediate 
neighbourhood  are  factors  of  considerable  moment  to  the  surgeon. 
While  in  many  of  these  cases  the  rate  of  growth  is  comparatively 
slow  in  the  purely  intrinsic  stage,  and  the  tumour  can  be  dealt  with 
more  successfully,  both  its  progress  and  its  suitability  for  removal 
undergo  a  change  when  it  passes  outside  the  canal.  The  cervical 
lymphatic  glands,  which  hitherto  may  have  escaped  involvement,  may 
enlarge  upon  one  or  both  sides  of  the  neck.  An  analysis  of  the  case- 
records  in  117  cases  of  the  disease  in  the  cervical  region  shows  that,  on 
■examination,  enlarged  glands  were  detected  in  46,  noted  as  absent  in  26, 
while  in  45  cases  no  observation  on  this  point  had  been  recorded.  The 
possibility  of  glandular  infection  which  may  escape  detection  is  not 
improbable.  In  one  of  the  pathological  preparations,  the  tumour,  having 
made  its  way  through  the  wall  of  the  cesophagus,  had  caused  secondary 
enlargement  of  two  glands  lying  at  the  root  of  the  neck,  and,  being 
concealed  behind  the  right  subclavian  and  common  carotid  arteries, 
could  not  be  palpated.  In  addition  to  the  tumour,  infiltration  of  the 
surrounding  cellular  tissues  and  infection  of  the  lymphatic  glands, 
implication  of  the  recurrent  laryngeal  nerves,  of  the  sheaths  of  the 
large  vessels  and  even  the  vessel-walls  themselves  may  take  place.  The 
wall  of  the  trachea  and  the  framework  of  the  larynx  may  be  attacked, 
the  tumour  infiltrating  and  narrowing  the  lumen  of  the  air-passages. 
Perforation  into  the  trachea  in  a  case  of  malignant  stricture  of  the 
cervical  cesophagus  is  seen  in  the  illustration  upon  Plate  I.  Thorough 
palpation  of  the  neck  and  careful  consideration  of  the  appearances  seen 
both  by  indirect  and  direct  laryngoscopic  examination  will  assist  the 


38  The  Journal  of  Laryngology,      [February,  1920. 

surgeon  in  determining  the  extent  to  which  the  tumour  has  invaded  the 
surrounding  structures. 

Secondary  involvement  of  the  thyroid  gland  is  a  complication  which 
is  liable  to  be  overlooked  in  the  study  of  the  pathology  of  oesophageal 
carcinoma.  Consequently,  when  the  gland  is  the  seat  of  malignant 
disease,  the  possibility  of  the  tumour  being  secondary  to  a  primary  focus 
in  the  pars  laryngea  pharyngis  or  cervical  oesophagus  must  be  borne  in 
mind.  Morriston  Davies,  in  the  paper  already  referred  to,  lays  special 
stress  upon  this  point,  and  states  that  a  secondary  tumour  of  the  thyroid 
was  found  in  four  cases  of  carcinoma  of  the  cervical  oesophagus  treated 
in  University  College  Hospital  during  a  period  of  five  years.  In  six  of 
the  cases  in  our  series  definite  enlargement  of  one  lobe  of  the  thyroid 
gland  was  observed  ;  in  four  of  them  no  microscopic  examination  was 
made,  but  in  two  the  malignant  nature  of  the  enlargement  was  ascer- 
tained. One  of  these  was  the  case  of  a  young  woman,  aged  twenty-nine, 
who  presented  the  clinical  picture  of  a  malignant  thyroid  gland.  A 
feeling  of  fulness  in  the  throat,  accentuated  on  swallowing  and  accom- 
panied by  a  dragging  sensation  in  the  neck,  had  existed  for  some  months. 
Shortly  before  her  admission  to  hospital  a  slight  noisy  respiration  was 
noticed.  When  she  came  under  the  care  of  Mr.  J.  M.  Graham, 
F.E.C.S.E.,  she  made  no  complaint  of  dysphagia  and  was  able  to  take 
her  food  in  comparative  comfort.  As  the  respiratory  difficulty  was  not 
relieved  by  the  operation  upon  the  thyroid  gland,  a  laryngoscopic 
examination  was  made  ten  days  later.  A  sloughing,  ulcerated  infiltra- 
tion attached  to  the  posterior  pharyngeal  wall  was  disclosed  behind  the 
arytaenoid  cartilages,  the  malignant  character  of  which  was  demonstrated. 
The  second  case,  under  the  care  of  Mr.  J.  W.  Dowden,  F.E.C.S.E.,  was 
that  of  a  woman,  aged  thirty-one,  whose  thyroid  gland  was  enlarged, 
hard,  and  adherent  to  the  trachea.  The  patient  could  only  swallow 
liquids  and  had  become  considerably  emaciated.  Suspension  laryngos- 
copy revealed  the  primary  condition  behind  the  cricoid  cartilage  in  the 
form  of  an  irregular,  ulcerated  infiltration,  which,  on  microscopic 
examination,  proved  to  be  a  squamous  epithelioma.  In  cases  of 
malignant  disease  of  the  thyroid  gland,  especially  when  it  occurs  in 
comparatively  young  women,  preliminary  laryngoscopy,  and,  if  necessary, 
oesophagoscopy  should  be  carried  out  as  a  matter  of  routine  before 
operation  upon  the  gland  is  undertaken. 

Sex  and  Age-Incidence  of  Post-Cricoid  Carcinoma. 

The  more  frequent  occurrence  of  malignant  disease  at  the  upper  end 
of  the  oesophagus  amongst  women  and  at  the  low^er  end  in  men  has 
been  recognised  over  a  considerable  period  of  time.  In  thus  stating  the 
case,  however,  it  is  necessaiy  to  point  out  again  that  the  pars  laryngea 
pharyngis  must  be  included.  The  tumour  may  be  confined  to  the  latter 
area,  or  it  may  involve  it  and  the  upper  end  of  the  oesophagus.  It  may 
be  difficult  to  determine  the  exact  site  of  origin,  nevertheless  the  frequent 
occurrence  of  the  disease  behind  the  cricoid  cartilage  constitutes  a 
clinical  type  which  justifies  us  in  placing  these  cases  in  a  special  group. 
In  98  of  the  1-iO  patients  in  the  series  the  tumour  was  situated 
behind  the  larynx  ;  of  these,  85  were  women  and  13  were  men.  Table  I 
demonstrates  at  a  glance  the  relative  frequency  of  the  disease  in  the  two 
sexes  and  the  different  localities  affected. 


JOURNAL    OF    LAEYXOOLOGY,    RHINOLOGY,    AND     OTOLOGY. 
PLATE    III. 


Sfjuamous  epithelioma  of  oesophagus  at  level  of  bifurcation  of  tmchea. 
Nodular  infiltration  beneath  the  epithelium  extending  upwards  above 
the  ulcer.  Perforation  of  wall  with  abscess  extending  over  posterior 
surface  of  right  lung.  Female,  aged  forty-three.  Duration  of  symptoms, 
eleven  years.  Very  little  emaciation.  Fluids  swallowed  up  to  time  of 
death.     Posterior  mediastinal  abscess  and  pneumonia. 

To  Illustrate  Dr.  Logan  Ti'rner's  Paper  ox  Carcinom.a  of  the  Post- 

Cricoid   Region. 


Aiilard  4-  Suu  4-  Weit  Sewman,  Ltd. 


Febraary,  1920. 


Rhinology,  and  Otology. 


39 


Total  cases.  ■ 

Males. 

Females. 

98 

19 

9 

11 

13  (13%) 

11  (57%) 

6  (66%) 

13  (92o/„) 

85  (86%) 
8  (42%) 
3  (33o^) 
1     (7%) 

serve  that  in 

the  column 

tabulated  under 

Table  I. — Carcinoma  of  the  Post-cricoid  Area  and  G^sophagus 
showing  Sex-incidence  in  140  Patients. 

Situation. 
Post-cricoid  area 
Qilsophagus  (cervical) 

„  (aorta,  trachea) 

,,  (lower  end) 

It  is  interesting  to  obs 
"  males  "  there  is  a  steady  increase  in  the  percentage  of  men  affected 
as  we  pass  from  the  region  of  the  pharynx  downwards  towards  the 
stomach,  while  in  the  column  headed  "females"  exactly  the  opposite 
may  be  noted. 

These  facts  relative  to  the  sex-incidence,  showing  the  undoubted 
tendency  of  the  tumour  to  attack  the  pars  laryngea  pharyngis  in 
women,  led  me  to  investigate  the  sex-incidence  of  carcinoma  upon 
the  mucous  membrane  of  the  tongue,  fauces,  oral  pharynx  and  the 
stomach  along  with  that  of  the  larynx,  lying  in  such  close  proximity 
to  the  pharynx.  With  the  exception  of  the  stomach,  the  material 
selected  for  this  pui'pose  was  derived  from  the  same  source  and 
throughout  the  same  period  of  time  as  that  indicated  on  p.  34.  My 
information  regarding  malignant  disease  of  the  stomach  has  been 
obtained  from  papers  written  by  Eobson  and  Moynihan,  Osier,  James 
Langwill  (working  with  Prof.  F.  M.  Caird),  and  from  statistics  of  the 
Mayo  clinic.  The  facts  obtained  from  these  different  sources  become 
more  clear  when  shown  in  tabular  form  as  in  Table  II.  The  nasal 
pharynx  has  not  been  included  in  the  investigation  as  it  forms  part  of 
the  respiratory  and  not  the  alimentary  passage. 

Table  II. — Sex-incidence  of  Carcinoma  of  the  Tongjie,  Faiices, 

Oral  Pharynx,  CEsophagus,  Stomach  and  Larynx. 

Total  Cases:  859. 


Situation. 

Cases. 

Males. 

Females. 

Tongue  (primary) 

18 

16  (88%) 

2  (11%) 

Fauces,  soft  palate,  tonsils 

71 

66  (92%) 

5     {!%) 

Oral  pharynx 

26 

15  (57%) 

11  (42%) 

Post-cricoid  area 

98 

13  (13%) 

85  (86%) 

Qilsophagus 

42 

30  (71%) 

12  (28%) 

Stomach 

535 

372  (69%) 

163  (30%) 

Larynx 

69 

59  (85%) 

10  (14%) 

859 

571  (66%) 

288  (33%) 

It  is  clear  from  a  study  of  the  total  figures  and  percentages  on 
Table  II  that,  throughout  the  whole  area  under  review,  the  number 
of  males  suffering  from  carcinoma  exceeded  the  females  in  the 
proportion  of  2  to  1.  Closer  inspection  of  the  individual  areas, 
however,  brings  to  light  the  fact  that,  while  on  the  tongue  and  fauces, 
in  the  oesophagus,  stomach  and  larynx  the  males  greatly  predominate, 
on  the  pharyngeal  mucous  membrane  the  relation  of  the  two  sexes 
to  each  other  is  very  different.  In  the  oral  pharynx  the  disease 
attacks  the  two  sexes  more  equally,  57  per  cent,  of  the  cases  being 
in  men  and  42  per  cent,  in  women,  while  in  the  post-cricoid  region 


40 


The  Journal  of  Laryngology,       February,  1920. 


of  the  pharynx  the  whole  position  is  reversed.  As  we  have  indicated 
above,  the  women  are  affected  in  86  per  cent,  and  the  men  in 
13  per  cent,  of  the  cases.  In  other  words,  the  pharyngeal  mucosa  in 
women  appears  to  be  more  vulnerable  or  more  liable  than  in  men  to  the 
development  of  squamous-celled  epithelioma,  especially  in  the  lowest 
part,  whereas  in  the  rest  of  the  upper  part  of  the  alimentary  canal 
the  mucous  membrane  is  more  prone  to  this  form  of  tumour  growth 
in  men.  In  connection  with  this  aspect  of  the  subject  it  is  further 
of  interest  to  compare  the  figures  bearing  upon  the  sex-incidence  in 
the  post-cricoid  area  and  in  the  contiguous  organ,  the  larynx :  in  the 
former,  males  13  per  cent.,  females  86  per  cent. ;  in  the  larynx,  males 
85  per  cent.,  females  14  per  cent.  The  latter  figures  include  both 
intrinsic  and  extrinsic  carcinoma  of  the  larynx. 

Age-mcidence. — In  studying  the  age-incidence  of  post-cricoid  car- 
cinoma, we  find  that  along  with  the  greater  tendency  of  the  disease 
to  affect  women,  the  tumour  likewise  develops  at  an  earlier  age  in  the 
female  than  in  the  male  sex.     Table  III  illustrates  this  point. 

Table  III. — Age-incidence  of  Patients  with  Carcinoma  in  the 
Post-cricoid  Area. 


Casks:  98. 

Decades. 

Males. 

Females 

21-30 

0 

6 

31-40 

2 

27 

41-50 

1 

.       20 

51-60 

5 

26 

61-70 

4 

4 

71-80 

1 

2 

The  two  youngest  patients  in  the  series  were  women  aged  twenty- 
eight,  but  a  few  exceptional  cases,  in  which  the  disease  occurred  even 
at  an  earlier  age,  have  been  recorded.  The  youngest  was  that  of  a 
woman  aged  nineteen  ;  Herbert  Tilley  has  met  with  it  in  a  woman 
of  twenty-two,  and  W.  R.  H.  Stewart  has  published  a  case  in  a  woman 
aged  twenty-three.  In  fifty-three  of  the  women  in  Table  III  the 
tumour  was  present  before  they  had  reached  the  age  of  fifty.  The 
youngest  man  in  the  series  was  aged  thirty-four,  and  though  the  actual 
number  of  males  is  not  large,  the  majority  of  the  cases  were  met  with 
after  the  age  of  fifty. 

Table  IV  has  been  added  in  order  to  show  that  in  the  oral  pharynx 
there  is  the  same  tendency  for  the  disease  to  affect  women  at  an  earlier 
age  than  men. 


Table  IV. — Age-incidence  of  Patients  suffering  from  Carcinoma  in 
the  Oral  Pharynx. 


Cases:  26. 

Decades. 

Males. 

Females 

21-30 

0 

1 

31-40 

1 

3 

41-50 

1 

4 

51-60 

4 

1 

61-70 

9 

2 

71-80 

0 

0 

Tebruary,  1920.]  Rhinology,  and  Otology. 


41 


In  order  to  furnish  a  general  comparison  of  the  average  age-incidence 
of  the  tumour  in  the  two  sexes  throughout  the  different  regions  dealt 
with  under  "  Sex-incidence,"  a  fifth  table  is  given.  No  figures  deahng 
■with  the  stomach  were  available. 


Table  V. — Average  Age-incidence  in  the  Ttco  Sexes  in  all  the  Areas 

under  Review. 


Cases  . 

324. 

Situation. 

Cases. 

Males. 

Average  age- 
incidence. 

Females. 

Average  age- 
incidence. 

Tongue  (primary) 

18 

.      16 

61  years 

2 

51  years 

Fauces,  etc.    . 

71 

.      66      . 

59      „ 

5 

.      56     „ 

Oral  pharynx 

26 

.      15      . 

59      „ 

11 

.      45     „ 

Post-cricoid  area 

98 

.      13      . 

57      „ 

85 

.      45     „ 

CEsophagus    . 

42 

.      30      . 

55     „ 

12 

.      48     „ 

Larynx  . 

69 

.      59      . 

60     „ 

10 

.      56     „ 

The  above  table  requires  no  special  analysis  ;  in  every  instance  the 
average  age-incidence  is  less  amongst  the  women  than  the  men,  but 
the  difference  is  most  noticeable  in  the  oral  pharynx  and  post-cricoid 


regions. 


Duration  of  the  Disease. 


It  is  very  difficult  to  make  an  accurate  estimation  of  the  duration  of 
the  life  of  the  tumour.  The  only  basis  that  can  be  employed  for  this 
purpose  is  the  patient's  statement  as  to  the  duration  of  symptoms. 
This  is  not  free  from  fallacy,  and  furthermore  it  cannot  be  accepted  as 
reliable  in  every  case,  as  many  patients  are  uncertain  as  to  the  time  at 
which  their  symptoms  commence.  There  is  another  factor  which 
detracts  from  the  value  of  the  history  as  a  basis  for  estimating  the 
life  of  the  tumour.  Experience  shows  that  the  period  during  which 
symptoms  are  present  is  often  quite  independent  of  the  size  which  the 
tumour  has  attained.  Thus,  one  patient  will  assert  in  perfect  good 
faith  that  she  suffered  no  inconvenience  until  one,  two  or  three  days 
before  advice  was  sought,  yet  examination  reveals  extensive  tumour- 
formation  behind  the  larynx.  Another  will  give  a  history  of  difficulty 
in  swallowing  for  nine  months,  and  a  very  limited  area  of  disease  is 
found.  The  very  long  period  during  which  many  of  the  female  patients 
maintain  that  they  have  had  obstruction — in  some  cases  extending  over 
a  number  of  years — makes  it  extremely  improbable  that  a  tumour  could 
have  existed  during  the  whole  of  the  time  covered  by  the  history.  ^ 

There  is  not  only  a  great  difference  in  the  life-history  of  similar 
types  of  tumour  growing  in  different  parts  of  the  body,  but  also  in  the 
course  of  tumours  of  like  structure  arising  in  the  same  part  of  the  body 
and  under  apparently  similar  conditions.  Our  experience  suggests  that 
in  the  upper  part  of  the  oesophagus  the  squamous-celled  epithelioma 
shows  a  lower  grade  of  malignancy  in  some  patients  than  in  others,  but 
while  in  many  of  the  women  the  symptoms  cover  a  much  longer  period 
of  time  than  they  do  in  the  men,  probably  it  would  be  incorrect  to 
assume  that  the  degree  of  malignancy  had  a  sex  basis.  In  those  women 
whose  period  of  symptoms  is  unusually  prolonged,  it  is  possible  that  a 
condition  may  exist  which  favours  tumour  development  and  is  the  cause 
of  the  obstruction  in  the  earlier  stages  of  the  history. 


42  The  Journal  of  Laryngology,       [February.  1920. 

At  the  meeting  of  the  Laryngological  Section  of  the  Royal  Society 
of  Medicine  held  in  May,  1919,  Drs.  A.  Brown  Kelly  and  D.  R.  Paterson 
drew  attention  to  the  not  infrequent  occurrence  of  difficulty  in  swallowing 
in  women  due  to  the  existence  of  spasm  at  the  entrance  of  the  oesophagus. 
While  a  few  of  the  patients  are  neurotic,  and  as  such  mav  be  predis- 
posed to  this  affection,  the  majority  show  no  sign  of  such  a  tempera- 
ment. When  we  consider  that  the  majority  of  cases  of  cancer  at  the 
entrance  to  the  gullet  occur  in  women,  the  question  arises  whether 
there  may  not  be  something  at  this  site  peculiar  to  the  sex  which 
predisposes  it  both  to  spasm  and  to  cancer.  Whatever  direction  future 
inquiry  may  take  for  the  elucidation  of  the  subject,  it  appears  to  me 
that  we  should  not  lose  sight  of  the  fact,  which  our  figures  disclose, 
that  carcinoma  not  only  attacks  in  a  preponderliting  degree  the  mucous 
membrane  of  the  pars  laryngea  pharyngis  in  women,  but  it  shows  also 
a  considerable  tendency  to  affect  the  mucosa  of  the  oral  pharynx  in 
the  same  sex.  It  is  possible  that  an  investigation  into  the  sex-  and 
age-incidence  and  the  duration  of  malignant  tumours  throughout  the 
whole  length  of  the  alimentary  canal  might  throw  some  further  light 
upon  the  origin  and  historj-  of  the  tumour  in  this  particular  situation. 

If  the  history  be  compared  in  the  two  sexes  in  our  series  of  post- 
cricoid  carcinomata,  a  striking  difference  is  found  in  the  length  of  the 
period  during  which  some  interference  in  swallowing  is  complained  of. 
In  the  case  of  the  thirteen  men  in  the  series  the  duration  of  the 
symptoms  varied  from  three  weeks  to  nine  months,  while  the  average 
duration  was  four  and  a-half  months.  In  eighty-one  women  from 
whom  the  history  on  this  point  was  ascertained  great  variations  were 
observed.  On  the  one  hand,  the  case  of  sudden,  acute  obstruction 
dating  from  the  previous  day  presented  itself,  while,  on  the  other  hand, 
difficulty  in  swallowing  had  been  experienced  for  thirty  years.  Although 
the  latter  was  an  exceptional  case,  yet  the  long  duration  of  the 
symptoms  in  women  was  by  no  means  uncommon.  In  thirty  instances 
the  period  varied  from  one  year  to  two,  four,  six,  eight,  and — in  one 
case — twenty-three  years.  Four  women  stated  that  as  long  as  they 
could  remember  they  were  obliged  to  eat  slowlj^  explaining  the  fact  on 
the  ground  that  they  had  "  a  narrow  throat."  If  the  average  duration 
of  the  symptoms  be  calculated  in  the  women,  including  the  two  excep- 
tional cases  of  twenty-three  and  thirty  years,  it  is  found  to  cover  a 
period  of  two  years  and  four  months,  and  if  these  two  cases  be 
eliminated  the  period  is  reduced  to  one  and  a-half  years. 

General  Semeiology. 

While  we  have  dealt  at  some  length  with  the  sex,  age-incidence  and 
duration  of  the  symptoms  in  cases  of  post-cricoid  carcinoma,  the  picture 
remains  incomplete  without  refex'ence  to  some  further  points  in  the 
clinical  history  of  the  disease. 

The  Mode  of  Onset. — This  has,  to  some  extent,  been  indicated  while 
discussing  the  period  of  time  covered  by  the  symptoms,  but  it  is  still 
necessary  to  draw  attention  to  the  variations  met  with  in  their  onset. 
Obstruction  may  arise  suddenly,  following  upon  the  sensation  of  a  bone 
or  piece  of  meat  lodging  in  the  throat.  Prior  to  this,  the  patient  may 
have  been  quite  unconscious  of  any  uneasiness  referable  to  deglutition, 
though  the  tumour  has  attained  considerable  size.  The  difficulty,  or 
even  total  inability,  to  swallow  remains,  and  the  condition  is  comparable 


February,  1920.]  Rhinology,  and  Otology.  43 

to  the  sudden  acute  obstruction  observed  in  cases  of  malignant  disease 
of  the  bowel.  On  the  other  hand,  an  entirely  different  mode  of  onset 
presents  itself,  where  a  slow  and  gradually  progressive  diflBculty  is 
complained  of  during  a  period  of  weeks  or  months,  and,  in  some  cases, 
even  of  years.  There  is  a  danger  that,  in  both  of  these  types,  met  with 
more  frequently  in  women,  the  disorder  may  be  regarded  as  functional. 
The  inabihty  to  swallow  after  a  bone  has  lodged  temporarily  in  the 
throat  may  suggest  a  functional  disturbance ;  so  also  may  the  obstruction 
to  the  swallowing  of  solid  food  continued  over  a  very  long  period  of 
time.  No  diagnosis  should  be  made  without  a  careful  examination  with 
the  laryngoscope,  and  with  the  oesophagoscope  if  need  be.  Two  patients 
sought  advice  on  account  of  great  difficulty  in  swallowing.  Nothing 
was  found  on  oesophagoscopy.  Both  developed  later  the  signs  of  bulbar 
paralysis.  At  the  date  of  the  original  examination  nothing  was  observed 
to  raise  any  suspicion  of  a  central  nervous  disorder. 

Dysphagia. — Pain,  associated  with  the  difficulty  in  swallowing,  is  by 
no  means  uncommon.  It  may  be  absent,  however,  in  the  earlier  stages 
of  the  disease,  but  supervene  later.  As  a  rule  it  is  complained  of  at  the 
site  of  the  obstruction,  but  in  many  instances  it  is  referred  to  one  or 
both  ears.  The  question  of  pain  was  inquired  into  in  7-4  cases,  and  it 
was  found  to  exist  in  59. 

A  gurgling  noise  during  deglutition  when  fluid  passes  over  the  throat 
is  recognised  occasionally  by  the  patient,  and  the  surgeon  during  his 
examination  may  advantageously  test  for  this  phenomenon  by  asking 
the  patient  to  drink  water.  We  have  noticed  this  symptom  in  associa- 
tion with  the  regurgitation  of  food,  and  in  all  probability  both  are  due 
to  the  narrowness  of  the  stricture.  Bleeding  is  not  a  common  occurrence, 
though  occasionally  blood  stains  the  expectoration.  An  excess  of 
mucous  secretion  in  "the  throat  is  complained  of  very  frequently — a  sign 
which  is  strongly  suggestive  of  the  presence  of  an  organic  stricture. 

Cough  is  occasionally  a  troublesome  symptom.  In  one  case  severe 
spasms  of  coughing  were  the  first,  and,  for  a  few  months,  the  only 
symptom  for  which  the  patient  sought  advice. 

Hoarseness,  or  some  alteration  in  the  character  of  the  voice,  occurs 
either  as  the  result  of  involvement  of  one  or  other  of  the  recurrent 
laryngeal  nerves  or  from  extension  of  the  disease  into  the  larynx,  as  we 
have  pointed  out  in  discussing  the  pathology  of  the  tumour.  For  the 
same  reason  difficulty  in  breathing  may  supervene,  sometimes  of  such 
a  nature  as  to  make  tracheotomy  necessary.  In  thirty-three  of  the 
patients  suffering  from  post-cricoid  carcinoma  hoarseness  was  present 
when  the  patient  came  under  examination,  and  in  fourteen  some  slight 
respiratory  difficulty  was  noted.  In  several  cases  in  which  voice  and 
respiration  were  normal  when  advice  was  sought  laryngeal  symptoms 
developed  subsequently,  and  in  some  instances  tracheotomy  became 
necessary. 

Physical  Examination  of  the  Patiext. 

External  palpation  of  the  neck  and  of  the  larynx  and  trachea  should 
be  carried  out  in  all  cases.  Eeference  has  been  made  above  to  the  enlarge- 
ment of  the  cervical  lymphatic  glands  and  thyroid  gland  (p.  37).  It  is 
also  advisable  to  determine  by  palpation  as  to  whether  the  framework 
of  the  larynx  and  trachea  shows  thickening  indicative  of  the  extension 
of  the  disease  bevond  its  original  site.      In  several  cases  of  post-cricoid 


44  The  Journal  of  Laryngology,      February,  1920. 

carcinoma,  pressing  the  larynx  backwards  against  the  vertebral  column 
or  the  gentle  insertion  of  the  fingers  and  thumb  between  the  larynx 
and  the  sterno-mastoid  muscles  has  elicited  tenderness. 

Laryngoscopy. — The  laryngeal  mirror  is  an  essential  part  of  the 
clinical  examination  of  every  case  and  should  always  be  used  before 
proceeding  to  any  other  diagnostic  method.  Its  value  as  a  means 
of  investigation  is  illustrated  in  a  striking  way  in  the  cases  under  review. 
In  no  fewer  than  83  of  the  98  cases  of  post-cricoid  carcinoma — that  is,  in 
84  per  cent. — changes  from  the  normal  were  observed  in  the  mirror  of 
such  a  nature  as  to  make  it  possible  to  establish  a  diagnosis  of  organic 
disease.  This  is  a  large  percentage,  and  it  indicates  the  value  to  be 
attached  to  laryngoscopy  in  these  cases. 

The  changes  observed  may  be  subdivided  into  two  groups :  (1) 
Impairment  in  the  mobility  of  the  vocal  cords ;  (2)  alterations  in  the 
pharyngeal  mucous  membrane  behind  the  larynx  or  in  the  mucosa 
covering  the  arytaenoid  cartilages.  In  very  advanced  cases  tumour 
growth  may  be  observed  within  the  interior  of  the  larynx  or  upper  parfc 
of  the  trachea. 

Interference  with  the  mobility  of  one  or  both  vocal  cords  may  be  the 
result  of  a  partial  or  complete  paralysis  of  the  recurrent  laryngeal  nerve, 
involved  in  the  extension  of  the  growth  beyond  the  walls  of  the  alimen- 
tary canal  or  by  secondarily  enlarged  lymphatic  glands  ;  on  the  other 
hand,  the  immobility  of  the  cord  may  be  of  the  nature  of  a  fixation 
resulting  from  invasion  of  the  crico-arj'taenoid  joint  by  direct  extension 
of  the  disease,  or  possibly  from  inflammatory  changes  round  the  joint. 
Paralysis  may  occur  not  only  in  tumours  affecting  the  post-cricoid  area 
and  extreme  upper  end  of  the  oesophagus,  but  also  when  the  disease 
affects  the  lower  cervical  and  upper  thoracic  portions  of  the  gullet. 

Some  interference  with  the  mobility  of  the  vocal  cords  was  observed 
in  43  cases,  or  in  almost  one-half  of  the  series.  The  actual  changes  as 
the  result  of  paralysis  were  as  follows  :  Defective  abduction  of  the  right 
vocal  cord  in  7,  and  of  the  left  vocal  cord  in  o,  while  in  one 
case  there  was  bilateral  abductor  paralysis.  Complete  or  recurrent 
paralysis  of  the  right  cord  was  observed  in  5  cases  and  of  the  left 
vocal  cord  in  7.  In  the  remaining  18  cases  there  was  immo- 
bility or  fixation,  the  right  vocal  cord  being  immobile  in  8,  and  the 
left  cord  in  10  instances. 

As  regard  the  second  group  of  changes  revealed  by  the  laryngoscope, 
it  will  suffice  to  give  a  general  picture  rather  than  a  detailed  account  of 
what  was  observed  in  each  case.  Structural  changes  were  noted  in  66 
cases,  a  number  of  them  being  associated  with  impaired  mobility  of  the 
cords  already  described.  The  pathological  appearances  varied  from  a 
slight  fulness  or  cedema  of  the  mucous  membrane  covering  one  arytaenoid 
— an  alteration  which  might  escape  casual  observation,  but  which  is  of 
undoubted  significance  in  these  cases — to  a  definite  tumour-mass,  lying 
behind  the  arytaenoid  cartilages  or  even  extending  upwards  into  one  or 
both  pyriform  sinuses  and  infiltrating  the  ary-epiglottic  folds.  The 
picture  that  may  be  observed  between  these  two  extremes  varies 
considerably.  Occasionally  a  grey  or  greyish-yellow  slough  is  detected 
partially  concealing  a  slight  infiltration  of  the  lowest  visible  part  of  the 
posterior  pharygeal  wall ;  a  small  area  of  ulceration  may  be  observed  at 
the  edge  of  the  slough.  A  slight  swelling  of  the  mucosa  covering  the 
posterior  pharyngeal  wall  at  the  level  of  the  aryteenoids  may  be  visible, 
or  an  obviously  ulcerated  infiltration  extending  across  the  posterior  wall 


February,  1920.]  Rhinology,  and  Otology.  45 

of  the  pharynx  at  the  same  level.  The  pharyngeal  surface  of  the 
posterior  laryngeal  wall  may  show  evidence  of  tumour  invasion,  or  infil- 
tration sometimes  ulcerated,  involving  one  or  both  arytaenoid  areas. 

In  the  15  cases  of  post-cricoid  carcinoma  completing  the  series, 
the  laryngoscopic  picture  was  normal  as  the  tumour  was  confined  to  the 
lower  part  of  the  area.  In  these  cases,  and  in  those  in  which  the  disease 
is  situated  in  the  cervical  portion  of  the  oesophagus,  a  more  extended 
examination  must  be  made  before  a  diagnosis  is  possible.  If  any 
departure  from  the  normal  should  be  observed  in  the  mirror  when  the 
tumour  itself  is  invisible,  it  is  usually  of  the  nature  of  a  vocal-cord 
paralysis. 

The  rapid  manner  in  which  some  of  these  growths  may  extend, 
changing  the  laryngoscopic  picture  within  a  very  short  period  of  time, 
has  been  a  matter  of  observation  in  more  than  one  case.  Two  instances 
may  be  recorded.  A  young  woman,  aged  thirty,  complained  of  difficulty  in 
swallowing  solid  food  for  six  years,  with  an  aggravation  of  her  symptoms 
during  the  six  months  preceding  her  examination.  When  first  examined 
with  the  mirror  the  laryngeal  picture  was  normal,  save  for  the  accumu- 
lation of  mucus  behind  the  arytsenoids — a  very  common  appearance  in 
these  cases.  Both  vocal  cords  moved  freely  during  phonation.  Fifteen 
days  later  the  movement  of  the  left  vocal  cord  was  impaired,  and  at  the 
end  of  the  following  week  it  was  immobile,  and  the  edge  of  the  tumour, 
previously  invisible,  was  observed  behind  the  arytaenoid  cartilages.  In 
a  second  case  the  right  vocal  cord,  freely  movable  at  the  first  examina- 
tion, was  found  ten  days  later  fixed  in  a  position  closely  approximating 
the  middle  line. 

Suspension  Laryngoscopy  and  CEsophagoscopy. — The  introduction  by 
Killian  of  the  suspension  method  of  direct  examination  is  a  valuable 
addition  to  the  diagnostic  means  at  our  command.  Its  use  in  those 
cases  of  post-cricoid  carcinoma  in  which  indirect  laryngoscopy  has 
failed  to  reveal  any  abnormal  appearance  has  been  justified  on  several 
occasions,  while  its  employment,  even  in  the  cases  in  which  the  existence 
of  a  tumour  has  been  demonstrated  by  the  mirror,  serves  a  useful 
purpose.  It  gives  a  better  view  of  the  attachments  and  extent  of  the 
tumour,  and  it  enables  the  surgeon  to  remove  more  readily  a  portion  of 
the  growth  for  microscopic  examination.  In  both  classes  of  case,  there- 
fore, we  have  utilised  the  suspension  position  for  diagnostic  purposes. 
The  method,  however,  does  not  disclose  the  presence  of  a  growth  in  the 
post-cricoid  area  in  every  case.  When  the  disease  occupies  the  lowest 
part  of  the  pars  laryngea,  and  is  close  to  the  mouth  of  the  oesophagus, 
it  may  escape  detection.  The  cesophagoscope  should  then  be  inserted, 
without  removing  the  suspension  hook,  and  introduced  behind  the 
larynx.  It  is  unnecessary  to  describe  the  appearances  presented  by 
the  tumour  when  viewed  in  the  suspension  position.  In  most  cases 
the  description  would  correspond  to  that  which  has  been  given  under 
laryngoscopy. 

CEsophagoscopy  may  be  carried  out  without  any  preliminary  sus- 
pension when  the  patient's  symptoms  are  referred  to  the  lower  part  of 
the  neck  or  upper  part  of  the  sternum.  When  the  upper  limit  of  the 
disease  is  reached,  its  distance  from  the  upper  incisor  teeth  should  be 
calculated,  as  the  knowledge  will  prove  useful  when  the  question  of 
treatment  by  excision  of  the  tumour  comes  under  consideration.  It  is 
not  our  practice  to  attempt  the  passage  of  the  cesophagoscope  through 
the  cancerous  mass  in  order  to  learn  the  position  of  its  lower  limit. 


46  The  Journal  of  Laryngology,     [February,  1920. 

Such  a  procedure  is  attended  with  a  certain  degree  of  risk,  and  it  is 
preferable  to  rely  upon  the  information  which  may  be  obtained  from  an 
X-ray  screen  or  photograph  and  a  bismuth  meal. 

Carcinoma  of  the  upper  end  of  the  gullet  varies  in  its  appearance 
and  distribution  when  seen  through  the  cesophagoscope.  This  is  only 
to  be  expected  when  we  recall  what  has  been  said  in  the  section  on  its 
pathology  (p.  36).  As  experience  is  gained  in  the  examination  of  these 
cases  it  becomes  possible,  in  a  proportion  of  them,  to  determine  by 
inspection  the  true  nature  of  the  condition  under  observation,  but 
removal  of  a  portion,  when  that  is  possible,  is  a  wise  procedure.  In 
some  cases,  however,  a  piece  of  tissue  cannot  be  grasped  in  the  forceps, 
and  even  in  some  instances,  when  the  tissue  is  obtained,  the  microscope 
reveals  no  evidence  of  malignancy,  although  later,  proof  of  the  malignant 
character  of  the  disease  is  found. 

The  X  Rays. — The  employment  of  the  X  rays  along  with  a  bismuth 
meal  is  an  additional  means  at  our  disposal  for  the  investigation  of 
these  cases.  It  may  give  useful  information  regarding  the  position  and 
the  length  of  the  stricture,  though  in  early  cases  of  disease  it  may  prove 
disappointing.  It  will  serve  a  useful  purpose  in  determining  the  length 
of  the  affected  area.  Information  upon  this  point  is  required  if  removal 
of  the  tumour  is  under  consideration,  and  again,  as  a  preliminary,  in 
those  cases  in  which  the  surgeon  is  proposing  to  perform  oesophagostomy 
as  a  palliative  measure.  In  two  of  the  cases  in  which  the  latter 
operation  was  attempted  by  Mr.  David  Wallace,  it  was  found  that  the 
tumour  had  extended  into  the  thoracic  oesophagus,  so  that  it  was 
impossible  to  open  healthy  gullet.  Further,  the  use  of  the  rays  may 
assist  in  detecting  the  presence  of  the  rare,  but  not  unknown,  second 
stricture,  which,  as  we  have  seen,  was  present  within  the  thorax  in  two 
cases  in  the  series  (p.  36). 


Prognosis  and  Treatment. 

In  approaching  the  question  of  treatment  we  are  conscious  of  doing 
so  with  the  knowledge  that  the  removal  of  malignant  disease  in  this 
situation  does  not  promise,  in  the  majority  of  cases,  results  of  a  very 
gratifying  kind.  As  a  rule  only  palliative  measures  can  be  adopted, 
and  amongst  these  we  would  include  oesophagostomy  and  gastrostomy. 
The  choice  between  the  two  procedures  will  depend  upon  the  inclination 
of  the  individual  surgeon.  The  selection  of  oesophagostomy,  however, 
has  this  advantage — that  in  the  exposure  of  the  cervical  gullet  the 
operator  at  the  same  time  has  an  opportunity  of  investigating  by  direct 
inspection  and  palpation  the  extent  of  the  disease,  and  he  is  able  finally 
to  determine  whether  the  case  may  not  be  suitable  for  removal  of  the 
stricture. 

Successful  oesophagectomy  is  very  dependent  upon  early  diagnosis. 
Notwithstanding  the  advantages  derived  from  suspension  laryngoscopy, 
CESophagoscopy  and  X  rays,  recognition  of  the  disease  in  its  earlier 
stages  is  not  always  possible.  It  is  true  that  a  better  appreciation  by 
the  general  body  of  the  profession  of  the  clinical  types,  which  we  have 
sought  to  make  more  clear  in  this  paper,  might  lead  to  an  earlier 
diagnosis,  and  consequently  to  more  successful  surgical  treatment. 
Nevertheless  the  fact  remains  that  the  tumour,  in  a  proportion  of  the 
cases,  has  grown  to  a  considerable  size  before  the  patient  is  conscious 


Tebruary,  1920.  Rhinology,  and  Otology.  47 

of  obstruction  in  swallowing  or  feels  the  necessity  of  seeking  advice. 
This  will  always  prove  an  obstacle  to .  successful  removal,  in  spite  of 
better  knowledge  regarding  these  cases  and  improvements  in  the 
methods  of  diagnosis. 

Before  coming  to  a  decision  upon  the  question  of  the  suitability  of 
any  case  for  excision,  the  laryngologist  must  use  all  the  means  at  his 
disposal  for  estimating  accurately  the  extent  of  the  growth.  He  must 
employ  external  palpation  for  the  detection  of  enlarged  lymphatic  glands, 
thyroid  enlargement,  and  the  extension  of  the  tumour  beyond  the  mus- 
cular walls  of  the  tube  :  he  must  weigh  the  value  to  be  attached  to 
interference  w-ith  the  mobility  of  the  vocal  cords,  and  to  the  extent  of  the 
infiltration  of  the  pharynx  and  larynx  as  disclosed  by  his  direct  examina- 
tion, and  he  must  ascertain  the  lower  limit  of  the  disease  by  the  X  rays, 
-or,  if  he  sees  fit,  by  the  use  of  the  oesophagoscope.  In  spite  of  the 
information  which  he  may  be  able  to  give  the  surgeon,  the  latter  may 
find,  when  operating,  that  even  in  the  selected  case  the  conditions  prove 
to  be  less  favourable  for  successful  removal  than  were  anticipated, 
unless  he  is  prepared  to  carry  through  an  operation  involving  considerable 
mutilation,  such  as  is  entailed  in  the  removal  of  the  larynx  and  even  of 
a  portion  of  the  trachea. 

The  small  number  of  cases  regarded  hitherto  as  suitable  for  a?sopha- 
gectomy  is  apparent  when  we  look  at  the  statistics  of  operation  in  the 
series  with  which  we  are  dealing.  Of  the  98  cases  of  carcinoma  involving 
the'  post-cricoid  area  and  extreme  upper  end  of  the  oesophagus  only 
9  were  subjected  to  excision,  and  in  one  of  them  entire  removal  of 
the  disease  was  found  to  be  impossible.  In  more  than  one  apparently 
suitable  case,  however,  the  patient  declined  opei'ation. 

The  question  of  excision,  however,  must  be  considered,  not  only  from 
the  point  of  view  of  its  feasibility,  but  from  its  possible  advantage  to  the 
patient  both  as  regards  increased  comfort  and  expectation  of  life.  As 
regards  the  first,  there  can  be  no  doubt  that  the  patient  is  benefited. 
Even  if  a  primary  end-to-end  anastomosis  is  impossible — as  was  the  case 
in  the  eight  patients  in  the  series — the  introduction  of  a  permanent 
oesophageal  feeding-tube  into  the  divided  end  of  the  gullet  allowed  of 
suitable  nourishment  being  given.  The  removal  of  the  disease  and  the 
relief  of  dysphagia  were  followed  by  improvement  both  in  the  weight 
and  in  the  general  well-being  of  the  individual.  If  this  end  can  be 
attained  even  for  a  few  months,  the  patient  should  be  given  an  oppor- 
tunity of  coming  to  a  decision  on  the  matter. 

With  regard  to  the  expectation  of  life  after  oesophagectomy,  it  is 
interesting  to  compare  the  cases  operated  upon  with  those  in  which  no 
active  interference  was  carried  out.  In  the  latter  group,  life  was  pro- 
longed after  the  examination  and  diagnosis  had  been  made  over  periods 
varying  from  a  few  weeks  to  five,  six,  seven  or  even  eight  months,  the 
general  average  in  the  series  being  four  months.  In  the  eight  cases,  on  the 
other  hand,  in  which  the  disease  was  completely  removed,  the  duration 
of  life  varied  from  three  months  to  nine  years.  The  actual  figures  were 
three,  four  and  six  months  ;  one  year,  one  year  and  two  months,  and 
one  year  and  six  months.  The  two  remaining  patients  are  still  alive  at 
the  time  of  writing,  one  two  years  and  the  other  nine  years  after  opera- 
tion. The  last  case,  operated  upon  by  Mr.  David  Wallace,  F.R.C.S.E., 
illustrates  in  an  exceptional  manner  the  advantage  to  be  derived  from 
operating  on  a  tumour  of  small  dimensions,  situated  on  the  posterior 
pharyngeal  wall  immediately  behind  the  upper  part  of  the  cricoid  plate. 


48  The  Journal  of  Laryngology,       ^February,  1920. 

The  two  patients,  alive  six  months  and  fourteen  months  after  operation, 
were  well  at  that  period,  but  their  further  history  could  not  be 
traced. 

The  subjoined  notes  give  a  short  resiime  of  the  cases  in  which 
excision  of  the  tumour  was  carried  out.  I  desire  to  acknowledge  my 
great  indebtedness  to  my  surgical  colleagues  Mr.  David  Wallace,  C.M.G.» 
Mr.  J.  W.  Dowden,  Mr.  John  W.  Struthers,  Mr.  Henry  Wade,  C.M.G., 
and  Mr.  J.  M.  Graham  for  the  opportunities  which  they  have  given  me 
of  studying  their  cases,  and  to  thank  them  for  the  notes  which  they 
have  kindly  put  at  my  disposal. 

Case  1. — Mrs.  B ,  aged  thirty-seven.     Diu-atiun  of  symptoms  nine  months. 

Larynx  normal ;  a  small  ulcerating  mass  upon  the  posterior  pharyngeal  wall  on 
the  plane  of  the  upper  part  of  the  cricoid  plate.  The  tumour  did  not  implicate  the 
posterior  wall  of  the  larynx.  Microscope  :  Squamous  epithelioma.  Operation  by 
Mr.  David  Wallace,  November  22,  1910.  Patient  examined  in  June,  1919  :  in 
excellent  health,  still  wearing  her  oesophageal  feeding-tube. 

Case  2. — M.  P ,  female,  aged  forty-nine.     Difficulty  in  swallowing  for  four 

years  ;  a  cauliflower-like  infiltration  in  the  post-cricoid  space  with  cedematous 
swelling  of  the  mucous  membrane  on  the  posterior  surface  of  the  arytaenoids.  The 
vocal  cords  move  fi-eely.  Microscope :  Squamous  epithelioma.  Operation  by 
Mr.  J.  W.  Strxithers,  November  1,  1912  :  excision  of  li  in.  of  diseased  and  healthy 
mucosa.     Patient  died  eighteen  months  later  with  local  recurrence  of  the  disease. 

Case   3. — Mrs.    W ,    aged  thirty-eight.     Difficulty   in   swallowing  for  five 

months.  Larynx  normal.  An  ulcerated  nodular  infiltration  of  the  mucous  mem- 
brane covering  the  posterior  surface  of  the  cricoid  plate.  Eemoval  by  Mr.  David 
Wallace,  March,  1913.     Patient  died  four  months  later. 

Case  4. — Mrs.  G ,  aged  twenty-eight,  seen  in  consultation  with  Dr.  W.  T, 

Gardiner.  Difficulty  in  swallowing  for  two  weeks,  but  she  has  found  it  necessary 
always  to  masticate  carefully  and  eat  slowly.  Larj-nx  normal.  An  ulcerating 
infiltration  of  the  posterior  pharyngeal  wall  extending  just  above  the  plane  of 
the  left  arytenoid  cartilage  and  also  involving  the  mucosa  over  the  posterior 
surface  of  the  cricoid  plate.  Microscope :  Squamous  epithelioma.  Operation  by 
Mr.  David  Wallace,  November  29,  1913  :  Removal  of  a  circular  tube  2  in.  in 
length.  Patient  died  one  year  later  with  no  local  recurrence,  but  the  symptoms 
suggested  malignant  disease  in  the  thorax  with  rupture  into  a  bronchus. 

Case  5. — Mrs.  O ,  aged  fifty-three.     Difficulty  in  swallowing  for  two  years, 

but  with  choking  attacks  and  occasional  difficulty  in  swallowing  for  twenty-three 
years  ;  normal  larynx.  Disease  involved  the  lowest  i)art  of  the  post-cricoid  space, 
and  the  upper  part  of  the  cervical  oesophagus  was  adherent  to  the  trachea  and  the 
left  lobe  of  the  thyroid  gland ;  the  latter  was  removed  along  with  the  disease  by 
Mr.  Wallace,  December  3.  1913.  Case  not  satisfactory  on  accoiint  of  its  extrinsic 
character.     Patient  died  thi-ee  months  later. 

Case  6. — K.  C ,  female,  aged  thirty-one.     Difficultj'  in  swallowing  for  more 

than  two  years ;  vocal  cord  movement  unimpaired ;  swelling  of  mucosa  covering 
posterior  surface  of  left  aryta?noid  and  infiltration  of  mucous  membrane  on  pos- 
terior phai-yngeal  wall  at  lower  level.  Microscope  :  Squamous  epithelioma.  Opera- 
tion, August,  1914,  by  Mr.  Henry  Wade,  who  made  a  circular  resection  of  the 
diseased  area.  Patient  seen  fourteen  months  later  without  local  recurrence. 
Further  history  unknown. 

Case   7. — Mrs.   M ,   aged  twenty-nine.      Difficulty   in  swallowing  for  two 

j'ears.  Larynx  normal ;  a  circular  area  of  disease  occupied  the  post-cricoid  space,, 
infiltrating  the  mucous  membrane  covering  the  posterior  surface  of  the  cricoid 
cartilage  and  the  posterior  pharj'ngeal  wall.  Microscope  :  squamous  epithelioma. 
September  10,  1917,  operation  by  Mr.  J.  M.  Graham.  Patient  showed  no  signs  of 
recurrence  two  years  after  the  operation. 

Case  8. — E.    F ,   female,   aged   thirty-seven.     Complained   of  difficulty  in 

swallowing  for  six  months ;  slight  swelling  of  the  mucosa  covering  both  arj-- 
taenoids.  The  upper  edge  of  the  tumour  lies  across  the  posterior  pharyngeal  wall 
just  behind  the  aryttenoid  cartilages,  and  extends  downwards  behind  the  cricoid, 
involving  the  mucosa  covering  its  surface  as  well  as  the  posterior  and  right  lateral 
wall  of  the  post-cricoid  space ;  its  lower  limitation  was  the  mouth  of  the  oesophagus. 


February.  1920]  Rhinology,  and  Otology.  49 

Microscope :  Sqiiaraous  epithelioma.  Complete  excision  by  Mr.  "Wallace  on 
October  9,  1918.  Six  months  later  the  patient  was  in  good  health,  but  her  further 
historj'  has  not  been  ascertained. 

Bibliography. 

Turner,  A.  Logax. — Journ.  of  Lartngol.,  Ehinol.,  and  Otol.,  London, 
February,  1913. 

Davies,  H.  Morriston. — Brit.  Med.  Journ.,  London,  Februarj'  12,  1910. 

Brown-Kellt,  a.,  and  E.  D.  Paterson. — Jodrn.  of  Laryngol.,  Ehinol  ,and 
Otol.,  London,  1919. 

Waggett,  E.  B. — Tran.-<.  17 th  International  Congress  of  Medicine,  London, 
1913. 


SELLAR   DECOMPRESSION   FOR    PITUITARY   TUMOURS.^ 

By  Walter  Howarth,  F.E.C.S. 

Cases  of  pituitary  tumours  ^Yhich  have  been  approached  by  the 
trans-sphenoidal  route  have  from  time  to  time  been  mentioned  before 
this  Section,  and  it  is,  I  think,  our  duty  to  consider  whether  this  method 
can  take  its  place  as  one  of  proved  utihty  and  whether  it  can  be 
undertaken  with  a  reasonable  degree  of  safety. 

At  the  present  time  there  does  not  appear  to  be  any  general  agree- 
ment as  to  the  best  method  of  approaching  tumours  m  the  pituitary 
fossa,  and  opinion  appears  to  be  divided  between  the  fronto-orbital 
method  of  Frazier  and  some  form  of  trans-sphenoidal  operation. 

A  large  number  of  operations  have  been  done  by  the  trans-sphenoidal 
route,  and  there  seem  to  be  many  reasons  why  it  should  not  lightly  be 
given  up.  The  tendency  in  this  country  at  any  rate  seems  to  me  to 
incline  towards  discarding  it  in  favour  of  direct  approach  through  the 
cranial  wall.  I  am  not  competent  either  to  assess  the  great  advances 
that  have  been  made  in  cerebral  surgery  or  to  estimate  its  future 
possibilities,  but  it  seems  to  me  that  the  fronto-orbital  operation  must 
remain  for  some  time  a  formidable  undertaking. 

The  trans-sphenoidal,  on  the  other  hand,  should  not  present  any 
very  great  difficulties  to  those  of  us  who  have  a  long  and  intimate 
knowledge  of  the  surgery  of  the  sphenoidal  sinus,  and  with  increasing 
opportunities  and  skill  we  should  be  able  to  suggest  improvements  in 
technique  that  might  render  the  patient  less  susceptible  to  the  risks  of 
operative  misadventure  or  subsequent  meningeal  infection. 

I  do  not  for  a  moment  wish  to  imply  that  this  operation  should 
replace  that  of  direct  approach  through  the  cranial  wall  or  in  any  way 
detract  from  its  merits,  but  I  believe  that  it  has  a  definite  utility,  and 
could,  with  advantage  and  safety,  be  performed  at  a  much  earlier  stage 
of  the  disease. 

The  sella  tui'cica  can  be  approached  trans-sphenoidally  by  three 
satisfactory  methods  : 

(1)  Sublabial  septal  resection  method  of  Gushing. 

(2)  Endonasal  septal  resection  method  of  Hirsch. 

(3)  Paranasal  method  of  Chiari  and  Kahler. 

The  first  of  these  methods  has  been  employed  successfully  by 
Gushing  in  a  large  number  of  cases  (approaching  200j,  and  his  later 
cases  show  an  ever-diminishing  number  in  which  meningeal  infection 

1  Eead  at  the  Summer  Congress  of  the  Section  of  Laryngology,  Eoyal  Society 
of  Medicine,  May  2,  1919. 

4 


'^0  The  Journal  of  Laryngology,      [February,  1920. 

followed,  but  the  rhinologist  may  well  fail  to  see  what  advantage  this 
route  has  over  the  purely  endonasal  method,  and  may  object  that  the 
more  perfect  median  alignment  that  is  secured  has  the  disadvantage 
of  opening  into  the  septic  cavity  of  the  mouth.  The  question  of  room 
for  manipulation  in  a  small  nose  may  be  overcome  by  an  extension  of 
the  incision  downwards  into  the  lip. 

The  paranasal  method  does  not  appear  to  me  to  have  met  with 
sufficient  recognition. 

It  is  simply  an  extension  of  a  modified  Moure's  operation,  and 
affords  an  excellent  view  at  a  lesser  depth  than  the  septal  route ; 
moreover  a  greater  extent  of  the  front  wall  of  the  sphenoidal  sinus 
is  exposed,  as  the  most  posterior  ethmoidal  cell  is  plastered  against 
the  outer  part  of  the  face  of  the  sphenoid  and  necessarily  limits  the 
view  in  the  median  approach.  It  will  be  remembered  that  the  direction 
is  obliquely  inwards,  and  this  should  prevent  any  chance  of  entering 
the  middle  fossa  near  the  anterior  angle  of  the  cavernous  sinus.  It 
has  been  held  that  this  route  is  by  no  means  an  aseptic  one,  and 
that  it  opens  into  the  nasal  cavit5%  which  is  full  of  organisms  and  may 
traverse  infected  sinuses,  but  I  do  not  think  that  this  objection  carries 
great  weight.  There  is  no  necessity  to  open  into  the  nasal  cavity  except 
at  its  posterior  end  in  the  neighbourhood  of  the  spheno-ethmoidal 
recess,  whilst  an  experience  of  other  operations  in  this  region  does 
not  lead  us  to  anticipate  unsuspected  suppuration.  In  any  case  free 
drainage  can  be  readily  assured. 

There  are  few  cases  recorded  in  which  this  method  has  been 
employed,  but  it  is  worthy  of  notice  that  Chiari's  and  Kahler's  nine 
cases  were  all  successful,  and,  in  addition  to  two  of  my  own,  I  know 
of  at  least  two  others  that  were  operated  on  by  this  route.  The 
numbers  are,  however,  far  too  small  for  comparative  statistics  to  be  of 
any  value. 

Operations  on  the  pituitary  fossa  are  undertaken  for  symptoms 
which  are  due  to  intracranial  pressure,  e.  g.  headache,  mental  symptoms, 
etc.,  and  increasing  blindness  due  to  pressure  on  the  optic  nerves, 
chiasma,  or  tract,  with  marked  diminution  of  the  temporal  half  of  the 
visual  fields.  Unfortunately  the  cases  are  not  usually  seen  by  the 
surgeon  until  these  symptoms  are  well  marked  and  the  tumour  must 
of  necessity  have  risen  well  above  the  diaphragma  sellae,  but  if  the 
neui'ologist  and  ophthalmologist  could  send  cases  earlier  for  operation, 
better  and  more  lasting  results  would  be  secured. 

Fully  75  per  cent,  of  pituitary  tumours  are  slow-growing  adenomata, 
a  proportion  of  which  are  cystic.  Malignant  tumours  are  comparatively 
rax'e  and  are  usually  endotheliomata. 

In  my  opinion  the  trans-sphenoidal  route  provides  an  operation 
which  has  many  advantages.  It  enables  the  pituitary  tumour  to  be 
attacked  in  its  place  of  origin,  and  the  fossa  to  be  emptied  if  necessary. 
It  effects  decompression  satisfactorily  by  reducing  the  pressure  from 
below,  and  if  undertaken  early  may  prevent  or  hinder  the  upward 
extension  of  the  tumour  which  presses  on  the  optic  fibres. 

If  the  tumour  is  cystic  drainage  is  adequately  provided  for,  and 
a  good  chance  exists  for  the  removal  of  the  cyst-wall.  Eadium  may  be 
inserted  on  any  subsequent  occasion  if  this  is  thought  to  be  desirable 
in  cases  of  malignant  disease. 

My  own  cases  are  only  five  in  number,  but  present,  I  think,  some 
points  of  interest. 


February,  1920.]  Rhinology,  and  Otology.  51 

In  fom-  of  the  cases  the  diagnosis  liad  been  well  established  for 
several  years  before  the}'  came  to  operation,  and  accurate  ophthal- 
mological  observations  had  been  made  from  time  to  time.  They  pre- 
sented the  classical  signs  of  pituitary  tumour  and  hypopituitarism. 

One  of  my  cases  died  the  day  following  operation  from  hagmorrhage 
into  an  intracranial  cystic  extension  of  the  tumour.  Three  of  the  others 
were  markedly  relieved  for  varying  periods  as  a  result  of  the  decom- 
pression. This  relief  was  most  marked  in  regard  to  the  pressure  and 
cerebral  symptoms,  but  was  rather  disappointing  as  regards  the  visual 
symptoms.  This  latter  fact  is,  however,  not  very  surprising  considering 
the  length  of  time  that  the  optic  fibres  had  been  pressed  upon. 

Two  of  the  cases  proved  to  be  malignant  tumours,  one  perithelioma 
and  one  endothelioma.  This  was  established  by  microscopic  examina- 
tion of  the  portions  of  tissue  removed  at  the  operation,  and  in  these 
cases  it  was  thought  advisable  that  radium  therapy  might  with  advan- 
tage be  undertaken  on  future  occasions. 

In  one  malignant  case  50  mgrm.  of  radium  were  inserted  on  three 
subsequent  occasions  at  intervals  of  six  weeks  with  apparent  benefit. 
In  the  other  malignant  case  radium  therapy  was  not  instituted  until 
four  months  after  the  original  decompression,  as  the  patient's  condition 
was  so  much  improved  by  the  decompi-ession  that  he  could  live  an 
ordinary  life  and  he  was  unwilling  for  any  further  treatment.  In  this 
case  the  patient  survived  the  radium  treatment  for  six  days  and  was  up 
and  about  in  apparently  normal  health,  but  died  suddenly  on  the  seventh 
day.  At  the  post-mortem  examination  it  was  found  that  tlie  tumour 
was  an  enormous  one,  with  large  extra  extensions,  both  cavernous^ 
sinuses,  for  instance,  being  completely  filled  with  growths.  The  radium 
had  caused,  as  it  was  meant  to  cause,  a  local  necrosis,  and  the  lower 
part  of  the  tumour  was  reduced  to  an  almost  fluid  consistency.  Owing 
to  the  large  size  of  the  tumour  this  necrosis  probably  resulted  in  some 
sudden  alteration  of  intracranial  tension  that  acted  adversely  on  the 
vital  centres. 

Better  results  would  undoubtedly  be  obtained  if  the  ophthalmologist 
and  neurologist  sent  the  cases  earlier  for  operation. 

Case  1. — Mr.  C ,  aged  forty-four,  sent  to  me  in  1915  by  Mr.  Fisher,  who  had  had 

him  under  observation  for  five  years.  His  direct  vision  had  been  gradually  failing, 
and  in  1912  his  visual  fields  were  typically  bitemporally  hemianopic.  His  condition 
became  progressively  worse,  although  he  was  taking  pituitary  and  thyroid  gland 
extract,  and  when  I  saw  him  he  was  suffering  from  violent  headaches,  with  cerebral 
vomiting  and  occasional  attacks  of  coma. 

Operation,  June  11,  1915:  Sellar  decompression  by  Cushing's  stiblabial  septal 
route.  Pituitary  fossa  filled  with  firm  reddish  granulations.  Portion  removed, 
and  on  microscoi^ic  examination  proved  to  be  a  perithelioma.  Great  improvement 
as  regards  headache  and  cerebi-al  symptoms  resulted  immediately,  and  the  patient 
left  the  nursing  home  at  the  end  of  a  week.  In  view  of  the  malignant  nature  of 
the  growth  50  mgrm.  radium  bromide  Avas  inserted  for  six  hours  some  seven  weeks 
after  the  original  operation,  and  this  was  repeated  on  two  subsequent  occasiojis  at 
intervals  of  six  weeks.  Althoixgh  the  symptoms  were  much  relieved  vision  was 
only  slightly  improved.     The  patient  died  five  months  after  the  operation. 

Case  2. — Mr.  M ,  aged  foi-ty-two,  sent  to  nie  by  Dr.  James  Taylor  in  1917, 

had  been  under  observation  by  Mr.  Fisher  for  six  years.  As  early  as  1911  the  X- 
ray  photograph  showed  enlargement  of  the  sella  turcica,  and  the  left  optic  disc 
showed  advanced  primary  optic  atrojjhy. 

In  1913  he  went  to  Xew  York,  where  a  sellar  decompression  was  performed  by 
Mr.  Harvey  Gushing.  A  cyst  was  said  to  have  been  opened  and  some  solid  material 
removed.  Considerable  improvement  resulted  for  some  years,  but  in  1917  his 
vision  began  to  fail  and  he  was  becoming  fatter  and  drowsier,  with  some  headache. 


52  The  Journal  of  Laryngology,        February,  1920 

Operation,  July,  1917  :  As  a  sellar  decompression  had  already  been  performed 
by  the  septal  route  I  thoiight  it  advisable  to  employ  the  paranasal  roiite  on  this 
occasion.  Some  semisolid  chocolate-coloured  material  was  removed  from  the 
fossa  and  the  patient  left  the  nursing  home  in  a  week.  When  seen  five  months 
afterwards  he  was  thinner,  less  drowsy,  and  had  no  headache.  Vision  was  not 
improved,  but  remained  stationary.  I  have  since  heard  that  the  symptoms  again 
began  to  reappear,  and  that  an  operation  by  the  f  ronto-orbital  route  was  performed 
which  the  patient  did  not  survive. 

Case  3. — Mr.  H ,  aged  forty-foiir,  sent  to  me  in  1917  by  Mr.  Brewerton,  who 

had  had  him  under  observation  for  three  years.  Vision  began  to  fail  in  the  right 
eye  with  large  central  scotoma  for  white  and  coloiu-s.  Failure  was  progi-essive,  and 
at  the  end  of  a  year  the  left  eye  became  involved.  Other  signs  of  hypo-pituitarism, 
such  as  increasing  fatness,  absence  of  sexiial  desire,  absence  of  hair  and  general 
waxy  appearance  began  to  appear,  and  later  headache  became  a  marked  feature. 

Operation,  September,  1917 :  Sellar  decompression  by  the  endo-nasal  septal 
route.  Considerable  quantity  of  semi-solid  chocolate-coloured  material  removed. 
The  patient  progressed  satisfactorily  for  a  time,  but  died  the  next  day.  At  the 
piost-rnortem  it  was  found  that  the  tumour  was  a  very  large  one  with  large  extra- 
sellar  extensions  and  that  there  had  been  a  recent  htemorrhage  into  a  large  cystic 
extension.     The  tumour  was  designated  an  adenoma  by  Prof.  Shattock. 

Case  4. — Lce.-Sgt.  L ,  aged  twentj^-five,  was  sent  into  2nd  London  General 

Hospital  in  Februarj',  1918,  with  a  history  of  right  eye  divergence  occurring  sud- 
denly one  month  previously.  On  admission  there  was  right  ptosis  and  mydriasis,, 
very  severe  headache  and  crossed  diplopia.  Complains  of  postnasal  discharge  of 
thick  miicus  and  occasionally  of  severe  pain  in  occii)ital  region.  As  the  septum 
was  miTch  deflected  and  it  was  impossible  to  examine  the  sinuses,  a  submucous 
resection  was  performed  May,  1918.  Eeturned  from  auxiliary  hospital  in  July. 
Diplopia  and  dilatation  of  right  iKxi^il  still  present,  and  optic  discs  normal.  Head- 
aches progi-essive,  biit  eye-symptoms  unchanged. 

Operation,  September,  1918  :  It  was  decided  to  explore  the  left  sphenoidal 
sinus ;  this  was  found  to  be  uniuvolved,  but  the  posterior  wall  was  very  thin  and 
easily  broken  down.  A  considerable  quantity  of  growth  was  removed  which  was 
found  to  be  endotheliomatous.  Vision  after  the  operation  was  miach  woi'se,  but 
gradually  improved.  At  the  end  of  September,  1918,  he  had  completely  lost  all 
headache  and  felt  verj^  well.  He  could  go  about  London  to  theatres,  etc.,  quite 
normally.  Two  months  later  the  question  of  radium  thei'apy  was  considered,  and 
on  December  5,  1918,  50  mgi-m.  radiiim  bromide  was  inserted  for  one  hour.  The 
patient  was  quite  well  for  five  days  and  was  getting  up  as  usual,  but  on  the  sixth 
day  he  had  a  sudden  rigor,  became  delirioias,  and  died  in  three  houi-s.  At  the  post- 
mortem  examination  the  part  of  the  tiunour  in  the  fossa  was  semi-fluid,  but  there 
were  large  extrasellar  extensions  of  solid  growth  completely  filling  both  cavernous 
sinuses  and  extending  behind  the  dorsum  sellae,  which  was  partially  eroded.  It 
seemed  very  remarkable  that  such  an  extensive  tumour  should  have  produced  so 
few  symptoms. 

Case  5. — Mrs.  E ,  aged  thii-ty-six.     Sent  to  me  in  April,  1919,  by  Mr.  Fisher, 

who  had  had  her  under  observation  for  sixteen  yeai-s  previously.  In  spite  of 
pitiritary  and  thyroid  gland  extract  she  had  become  completely  blind,  had  grown 
very  fat,  and  mental  symptoms  were  well  marked,  more  especially  headache. 

Operation,  April  30,  1919  :  Sella  decompression  bj'  the  endonasal  septal  route. 
On  opening  the  pituitary  fossa  it  was  foimd  to  be  very  much  enlarged,  but  no 
fluid  or  gi-owtlis  could  be  discovered.  Convalescence  was  uninterrupted,  but  it  is 
too  early  to  say  whether  any  permanent  relief  is  likely  to  result.  It  is  possible 
that  in  this  case  one  was  dealing  with  a  suprasellar  tumour,  and  an  observation 
made  by  Mr.  Fisher,  that  in  the  early  years  of  the  disease  one  eye  became  practically 
blind  and  then  recovered  a  considerable  amount  of  vision  for  several  years,  is  of 
interest  in  this  connection. 

Note. — Six  months  after  operation  the  patient  remains  practically  free  from 
headache,  is  much  less  drowsv  and  her  general  condition  improved.  Ej-e  con- 
dition stationarv. 


February,  1920.]  Rhinology,  and  Otology.  53 


SOCIETIES'     PROCEEDINGS. 


ROYAL  SOCIETY  OF  MEDICINE.— LARYNGOLOGICAL 

SECTION. 


May  :i,  191S. 


President :  Dr.  A.  Brown  Kelly. 


Abridged  Report. 


Brain  from  a  Patient  who  presented  Nystagmoid  Movements 
in  the  Pharynx  and  Larynx. — A.  Brown  Kelly. — The  patient,  aged 
sixtv-thi'ee  when  first  seeu,  complaiued  of  occipital  paiu,  which  he  attri- 
buted to  his  uose.     This  was  suukeu  owing  to  tertiary  ulcei-atiou. 

On  examining  the  pharynx  nystagmoid  movements  of  («)  the  ])0s- 
terior  wall,  (li)  left  tonsillar  region,  and  (c)  left  half  of  the  soft  palate 
were  observed.  The  "  short  phase"  of  (a)  was  to  the  left,  and  of  (6)  to 
the  right,  so  that  the  twitchings  seemed  to  converge  to  the  lateral  wiill. 
The  movements  of  (c)  were  barely  discernible. 

In  the  larynx  similar  twitchings  were  pi-esent  during  quiet  respira- 
tion, but  on  phonatiou  were  lost  sight  of,  the  cords  being  approximated 
normally.  The  nystagmoid  movements  took  place  during  both  inspira- 
tion and  expiration,  and  were  greatest  at  the  left  vocal  pi'ocess  and  left 
arvtsenoid.  They  were  more  noticeable  during  expiration  when  the  vocal 
cord  was  swimg  inwards  by  a  series  of  four  or  five  to-antl -fro  jerks,  which, 
as  in  the  pharynx,  were  unequal  and  arrhythmical.  The  right  half  of 
the  larynx  was  affected,  but  to  a  much  less  degree.  Over  130  to-and-fro 
movements  were  executed  per  minute. 

The  man  was  examined  occasionally  during  the  next  two  years,  but  no 
change  was  noted  in  the  appearances  above  described.  Shortly  after  his 
last  visit  he  died  from  apoplexy. 

The  post-mortem  examination  showed  that  the  patient's  mental  state 
was  due  to  cerebral  softening  associated  with  cerebral  arteriosclerosis, 
and  that  death  was  brought  about  by  haemorrhage  into  the  cerebellum, 
with  pressui'e  on  the  pons  and  medulla.  Owing  to  these  gross  changes, 
which  were  long  subsequent  to  the  onset  of  the  nystagmus  of  the  vocal 
cords,  it  is  very  difficult  definitely  to  relate  this  rare  condition  to  a 
particular  lesion  of  the  nervous  system.  The  changes  mentioned  are, 
however,  to  be  attributed  without  doubt  to  disease  of  the  vascular  svsteui 


54  The  journal  of  Laryngology,       [February,  1920. 

represented  by  endarteritis  obliterans  and  thromltosis  of  the  larger  cerebral 
vessels,  and  fibrosis  of  the  capillaries  and  small  arterioles ;  these  lesions 
were  wide-spread  and  essentially  syphilitic  in  character. 

It  would  appear  legitimate  to  conclude  that  the  nystagmus  of  the 
vocal  cords  was  a  comparatively  early  external  manifestation  of  disturbed 
nervous  function  resulting  from  interference  with  the  blood-supplv  tO' 
the  nervous  mechanism.  The  site  of  this  circulatory  disturbance  was 
probably  in  the  cerebellum.  Capillary  fibrosis  was  particularly  marked 
in  that' organ,  and  there,  too,  the  final  disturbance  took  place  which 
terminated  in  death.  Further,  it  is  especially  deserving  of  note  that 
the  circulation  through  the  superior  cerebellar  arteries  must  have  been 
deficient  for  some  considerable  time.  At  the  points  of  origin  of  these 
vessels  from  the  basilar  artery  the  latter  vessel  was  almost  occluded  by 
a  thrombus  which  gave  evidence  of  age  in  well-advanced  organisation. 
The  thrombus  encroached  on  the  lumen  of  both  cerebellar  arteries,  but 
more  especially  on  that  of  the  right  side.  Both  vessels  were  at  the  same 
time  affected  "by  endarteritis.  Deficiency  of  circulation  in  these  arteries 
would  be  compensated  to  a  greater  or  less  extent  througli  the  anasto- 
mosis which  exists  between  the  superior  and  inferior  cerebellar  arteries. 
In  point  of  fact  the  inferior  cerebellar  arteries  were  noted  to  be  injected 
and  prominent,  especially  on  the  right  side,  whilst  the  branches  of  the 
superior  cerebellar  artery  on  each  side  were  small  and  empty  in  com- 
pai-ison.  Of  the  two  inferior  cerebellar  arteries,  the  posterior,  which  is 
derived  from  the  vertebral  artery,  was  especially  well  filled  with  blood. 
Compensation,  established  in  this  manner,  which  might  well  have  lieen 
ample  enough  to  prevent  extensive  softening  of  the  cerebellum,  such  as 
might  have  betrayed  itself  by  gross  signs  (vertigo,  ataxia,  vomiting,  etc.), 
was  yet  sufficiently  incomplete  or  irregular  to  give  rise  to  minor  functional 
disturbance. 

Mr.  Lambert  Lack  :  I  have  i>ublished  a  paper  on  this  subject 
reporting  two  of  my  own  cases  and  many  collectecl  from  the  literature. 
The  cases  were  divided  into  two  main  groups.  Most  of  them  developed, 
sooner  or  later,  gross  brain  disease,  generally  cerebellar,  of  which  they 
died,  but  in  a  large  number  of  cases  the  movements  ultimately  passed 
off.  The  movements  in  both  cases  were  very  similar,  and  in  the  latter 
class  they  were  usually  associated  with  some  irritation  of  the  throat,  such 
as  pharyngitis  sicca.     Nearly  all  the  cases  Ayere  iu  young  people. 

Simple  Method  of  Recording  Diagrammatically  Movements  of 
the  Yocal  Cords,  with  Special  Reference  to  Tremors.  (Epidia- 
scope Demonstration. )— A.  Brown  Kelly.— We  hope  to  publish  this 
item  as  an  original  article  in  this  journal. 

Epithelioma  of  Larynx  removed  by  "  Window  "  Resection  of 
the  Thyroid  Cartilage.— H.  Lambert  Lack.  The  patient,  a  male,  aged 
fifty-nine,  seen  in  March,  1917,  had  been  hoarse  for  four  months.  There 
was  a  growth  about  the  centre  of  the  left  vocal  cord.  A  piece  was  removed 
for  diagnosis  and  reported  to  l>e  epithelioma.  The  operation  was  performed 
bv  the  method  described  in  the  Lancet  of  November  11.  1916.  A  trans- 
verse incision  was  made  at  the  level  of  the  crico-thyroid  membrane,  the 
left  ala  of  the  thyroid  exposed  and  a  large  scjuare  piece  of  it  removed. 
The  larynx  was  then  opened,  and  tlie  growth,  with  the  left  vocal  cord  and 
the  surrounding  parts,  freely  removed.  The  wound  was  partly  sewn  up. 
No  tracheotomy  was  performed.     There  was  no  trouble  with  bleeding. 


February,  1920.]  Rhinology,  and  Otology.  55 

The  patient  made  an  uuinterrupted.  recovery  and  in  two  months  was  back 
at  his  work  as  a  commercial  traveller,  having  a  verv  fair  voice. 

The  second  patient,  a  male,  aged  seveuty-two,  first  seen  in  June,  1917^ 
complained  of  loss  of  voice  since  November,  1916.  There  was  a  large 
growth  in  the  centre  of  the  right  cord,  a  piece  of  which,  being  removed 
for  diagnosis,  was  found  to  be  epithelioma.  The  operation  was  performed 
in  the  same  manner  as  in  the  last  case  on  July  6  and  the  patient  made  a 
rapid  recovery.  In  sjiite  of  his  age  he  had  no  bad  symptoms,  but  has 
since  remained  well  and  has  a  good  voice. 

These  two  cases  are  shown  to  illustrate  the  method  which  I  advocated 
over  a  year  ago,  and  demonstrate,  I  think,  all  that  was  claimed  for  the 
operation. 

Dr.  Irwin  Moore  :  Mr.  Lack's  operation  has  restored  a  good  voice  to 
the  patients,  though  I  do  not  admit  it  is  better  than  in  cases  dealt  with 
by  thyro-tissure.  When  Mr.  Lack  drew  our  attention  to  one  of  his  cases 
in  1916  he  told  us  he  had  carried  out  this  modified  procedure  in  his 
earlier  thyro-fissures,  but  sttbsequently  adopted  the  "  usual  method." 
Dr.  Kelson  asked  him  why  he  had  allowed  such  a  long  interval  to  elapse 
before  reviving  it.  Mr.  Lack  claims  no  less  than  sixteen  advantages  for 
his  modified  operation  over  thyro-fissure :  I  shall  criticise  these  seriatim. 
The  first  advantage  stated  is  that  a  better  view  and  better  access  are 
obtained  :  but  we  can  get  all  the  access  that  is  necessary  by  thyro-fissure 
performed  in  the  usual  way,  especially  if  we  use  a  self- retaining  graduated 
retractor.  The  second  advantage  is  stated  to  be  that  there  is  no  occasion 
to  split  the  thyrohyoid  membrane.  I  have  been  associated  with  my 
colleagues  in  over  forty  thyro-fissures  during  the  past  twelve  years,  and 
have  not  known  a  case  in  which  it  had  been  necessary  to  split  that 
membrane.  Mr.  Lack  says,  "  Violently  pvilling  apart  the  two  halves  of 
the  larynx  in  thyro-fissiu-e  causes  discomfort  and  difiiculty  in  swallowing"  ; 
but  there  is  neA^er  any  foi'ce  used  and  no  need  to  draw  the  thyroid  alse 
violently  apart.  The  only  occasion  which  I  know  of  where  difiiculty  in 
swallowing  occurred  was  in  a  case  where  an  extensive  growth  involved 
the  arytseuoid  cartilage  and  necessitated  removal  of  its  greater  portion. 
Mr.  Lack  says  his  modified  operation  is  more  rapid  ;  but  on  a  previous 
occasion  when  I  saw  him  operate,  the  incision  across  the  neck  was  attended 
with  so  much  bleeding  that  it  took  considerable  time  to  check  it  by 
compression-forceps.  All  operators  agree  that  there  is  no  necessity  for 
haste,  and  success  in  thyro-fissure  depends  on  a  slow,  careful  and  deliberate 
operation.  Mr.  Lack  maintains  that  it  is  easier  to  control  haemorrhage 
by  his  method,  but  thyro-fissui-e  as  now  perfoi-med  is  practically  a  bloodless 
operation.  Endolaryngeal  htemorrhage  seldom  occurs,  but  if  there  is  a 
bleeding  point  it  is  generally  on  the  outer  side  of  the  arytseuoid  after  the 
growth  is  separated,  an<l  bleeding  can  be  stopped  by  gavize  or  pressure- 
forceps.  The  late  Sir  Henry  Butlin  stated  that  he  had  not  known  a  case 
in  which  hsemorrhage  gave  him  any  anxiety.  Mr.  Lack  says  there  is  the 
advantage  of  a  more  thorough  removal  of  the  underlying  cartilage.  Why 
does  he  depart  from  the  old-established  rule  of  freely  removing  the  whole 
of  the  growth  without  unnecessarily  sacrificing  healthy  tissue  "r'  Butlin 
pointed  out  that  the  perichondrium  acts  as  such  a  strong  resisting  barrier 
between  the  growth  and  the  cartilage  that  very  rarely  was  the  cartilage 
infiltrated,  and  if  it  were  it  sufliced  to  take  a  thin  slice  off  the  inner 
surface  or  to  remove  the  portion  of  cartilage  affected.  Mr.  Lack  states 
that  there  is  less  trouble  with  the  anaesthetic  and  less  danger  of  blood 
entering  the  lungs.     I  am  sure  any  ansesthetist  Avoitld  prefer  to  give  an 


56  The  Journal  of  Laryngology,        February,  1920. 

anaesthetic  for  a  laryngo-fissui-e  Avith  a  tracheotomy  tube  in  jjosition  than 
in  an  operation  carried  out  by  Mr.  Lack's  method.  I  have  spoken  to 
several  anaesthetists  on  this  question  and  they  agree.  In  thyro-fissure,  as 
usually  carried  out,  if  preceded  by  temporary  tracheotomy,  the  risk  of 
blood  entering  the  lungs  is  avoided.  Again,  Mr.  Lack  says,  if  packing 
is  necessary,  it  is  easier  to  introduce  and  remove ;  but  this  cannot  be 
admitted.  The  risk  of  cell-transplantation  is  said  by  Mr.  Lack  to  be  less 
by  his  method  than  in  the  usual  thyro-fissure.  Now,  Mr.  Lack  has 
published  an  important  paper  on  the  subject  of  cancer  re-infection,  yet 
in  his  method  of  performing  the  operation  the  serious  and  unnecessary 
risk  of  cell-transplantation  is  absolutely  ignored.  He  suggests  two 
modifications  of  the  operation  :  (a)  A  preliminaiy  thyro-fissure  followed 
by  resection  of  a  piece  of  the  cai'tilage ;  but  this  has  invariably  been 
carried  out  in  the  past  if  the  growth  has  infiltrated  the  cartilage.  (6)  A 
preliminary  "window  resection"  of  the  cartilage.  The  objection  to  this, 
however,  is  that  the  extent  of  the  disease  cannot  be  ascei'tained,  as  is 
possible  by  the  usual  thyro-fissure,  and  in  reflecting  the  cartilage  ofl:  the 
soft  parts,  by  undermining  it  with  the  dissector,  one  may  break  into  the 
growth,  which  may  have  extended  through  the  perichondrium  and  infil- 
trated the  cartilage,  and  so  cause  the  very  cell-infiltration  which  it  is  so 
important  to  avoid.  Mr.  Lack  says  no  necrosis  of  cartilage  occurs  in  his 
modified  operation,  but  no  necrosis  of  cartilage  should  occur  in  thyro- 
fissure.  It  has  not  occurred  in  any  of  the  forty  cases  I  have  been 
concerned  with,  since  the  days  when  stripping  the  external  perichoudrium 
off  the  cartilage  was  discontinued.  In  conclusion,  there  appear  to  be 
some  advantages  in  the  modified  operation  suggested  by  Mr.  Lack,  for 
1  agree  with  him  that  it  may  be  possible  to  remove  a  more  extensive 
growth  than  by  the  usual  method  of  thyro-fissure,  but  it  can  never  be  an 
alternative  to,  or  take  tlie  place  of,  the  present-day  method  of  performing 
thyro-fissure  in  those  early  cases  in  which  thyro-fissui'e  is  indicated.  If 
carried  out  only  in  advanced  cases  of  endolaryngeal  cancer  which  have 
passed  the  ideal  stage  of  thyro-fissure,  and  if  preceded  by  a  preliminary 
thyro-fissure,  Mr.  Lack's  modified  operation  should  prove  of  great  value 
and  take  the  place  of  hemi-laryngectomy,  because  the  framework  of  the 
larynx  is  left  intact,  thus  avoiding  the  risks  and  disadvantages  of  hemi- 
laryngectomy.  Mr.  Lack  thinks  that  his  suggestions  make  the  operation 
of  thyro-fissure  more  easy,  but  thyro-fissure  is  in  itself  a  simple  operation, 
the  difiiculties  met  with  being  mainly  post-operative.  Sir  StClair 
Thomson  recently  remarked  in  connection  Avith  thyro-fissure  that  the 
simpler  the  operation  the  more  perfect  it  is  likely  to  be,  and  that  we  have 
now  got  beyond  the  complications  which  were  formerly  experienced.  I 
think  that  we  have  now  overcome  with  our  present-day  technique  all  the 
difiiculties  which  were  formerly  associated  with  this  operation. 

Mr.  TiLLKY :  I  have  no  extensive  experience  of  Mr.  Lack's  "  window 
resection."  Since  the  matter  was  described  two  years  ago  I  have 
employed  it  in  two  cases,  and  I  did  not  see  any  particuhir  advantage 
in  it  over  the  ordinary  laryngo-fissure.  The  cases  did  well,  but  uo  better 
than  after  simple  splitting  of  the  lai'ynx.  I  agree  vrith  many  of  the 
points  made  by  Dr.  Ii-win  Moore  in  favour  of  laryngo-fissure.  The 
retraction  of  the  two  halves  of  the  larynx  need  not  be  violent,  and 
the  view  obtained  is  as  good  as  one  could  wish  for.  With  regard  to 
difficulty  in  swallowing,  in  a  case  I  operated  on  three  weeks  ago  both 
vocal  cords  were  extensively  diseased  and  both  were  removed,  and  there 
was  great  difficulty  iu  swallowing  for  three  davs.     Feedino-  was  carried 


Tebruary,  1920.]  RhinoIogy»  ^^d  Otology.  57 

on  per  rectum  for  forty-eiglit  hours,  and  afterwards  the  patient  could 
swallow  liquids  bv  the  mouth.  Of  eighteen  or  nineteen  laryngo-fissures 
which  I  have  performed,  that  was  the  only  one  in  which  there  has  been 
difficulty  of  swallowing.  Mr.  Lack's  operation  is  practically  a  hemi- 
laryugectomy,  just  leaving  the  upper  and  lower  borders  of  the  thyroid 
wing  to  support  the  parts  afterwards,  and  when  siicli  an  operation  is 
necessary  I  agree  that  Mr.  Lack's  modification  might  be  very  useful,  and 
also  when  one  is  not  siu'c  whether  the  disease  has  pierced  the  cartilage, 
because  I  feel  that  when  there  is  even  a  tiny  button  of  disease  to  be  seen 
on  the  outer  surface  of  the  cartilage  the  prognosis  is  not  good,  and 
recurrence  is  probable  unless  free  removal  of  the  disease  has  been  carried 
out. 

Mr.  W.  Stuart-Low  :  Mr.  Lack's  results  are  very  good,  aud  I  am 
particularly  pleased  to  see  he  did  not  perform  tracheotomy.  When  doing 
laryngo-fissure  most  operators  still  perform  tracheotomy,  but.  in  many 
cases  there  is  no  necessity  for  it.  The  operation  for  laryngo-fissure  is  a 
comparatively  simple  and  easy  one,  as,  if  the  incision  is  kept  in  the  middle 
line,  no  vessels  are  encountered.  Another  point  in  favour  of  dispensing 
with  tracheotomy  is  that  the  operation  is  quite  quickly  performed.  I 
know  of  cases  in  which  this  operation  of  laryngo-fissure  was  jirolonged 
for  an  hour,  but  I  cannot  see  why  this  is  at  all  necessary,  especially  if 
"tracheotomy  is  dispensed  with. 

Dr.  H.  J.  Banks-Davis  :  If  the  operation  is  done  with  only  local  and 
not  general  anaesthesia,  tracheotomy  may  be  dispensed  with.  But  if  the 
patient  is  aua?sthetisefl  it  is  safer  to  perform  tracheotomy,  because  there 
may  be  bleeding  when  the  growth  is  cut  into.  If  the  patient  is 
anaesthetised  he  cannot  cough  this  blood  up,  whereas  he  could  if  under 
local  anaesthesia. 

Mr.  E.  D.  D.  Davis  :  My  experience  of  Mr.  Lack's  method  gives  me 
the  impression  that  a  better  exposure,  particularly  of  the  arytseno- 
epiglottidean  fold,  is  obtained,  and  it  is  in  this  soft  tissue  that  a 
recurrence  takes  place  ;  also  in  the  position  of  the  ventricular  band.  It 
may  be  necessary  to  divide  the  thyrohyoid  membrane.  Difficulty  in 
swallowing  after  laryngo-fissure  is  due  to  removal  of  the  arytaeaoid 
cartilage,  and  severe  injury  to  the  arytsenoid  region  may  result  in  having 
to  feed  the  patient  by  tube.  If  the  growth  is  divided  with  a  sufficient 
margin,  leaving  the  arytsenoid  cartilage  more  or  less  intact,  the  patient 
does  better  and  makes  a  more  rapid  recovery. 

Dr.  J.  W.  Bond  :  The  voices  in  Mr.  Lack's  cases  are  unusually  good — 
better  than  we  generally  get  in  cases  where  laryngo-fissure  has  been  done. 
One  of  these  patients  is  young,  and  so  one  would  expect  a  good  recovery. 
I  have  done  laryngo-fissure  without  tracheotomy  ;  the  need  for  that 
depends  on  the  case.  I  have  tried  local  anaesthesia  once  or  twice,  but  it 
has  ended  in  a  general  anaesthetic  having  to  be  given  and  a  tracheotomy 
done.  Haemorrhage  in  some  cases  is  severe.  In  a  case  I  operated  on 
three  years  ago  I  put  eighteen  ligatures  on  before  I  got  into  the  larynx ; 
I  suppose  the  patient  had  some  arterio-fibrosis  ;  he  is  alive  yet.  I  think 
the  great  merit  of  Mr.  Lack's  operation  is  that  it  enables  the  operator  to 
obtain  a  good  view  of  the  parts.  In  laryngo-fissure  my  great  difficulty 
has  been  to  see  the  interior  of  the  larynx  sufficiently,  and  I  cannot  agree 
with  a  previous  speaker  that  one  readily  gets  a  good  view.  I  once  did 
the  operation  on  a  woman  who  had  an  inch  of  fat  over  the  larynx  and  it 
was  very  difficult  to  see  the  pai-ts  properly,  but  in  Mr.  Lack's  procedure 
one  can  see  through  a  large  round  opening.     As  to  operating  when  the 


58  The  Journal  of  Laryngology,       February,  1920. 

cartilage  is  affected,  I  had  a  case  of  malignant  disease  perforating  the 
cartilage  ;  I  did  not  do  a  hemi-larvngectomy  ;  I  removed  all  the  cartilage 
round  the  growth  as  well  as  the  growth,  and  the  patient  did  very  well 
and  is  still  alive. 

Dr.  Irwin  Moore  :  I  would  like  to  ask  Mr.  Lack  how  he  decides 
which  way  he  will  do  the  operation  in  any  particular  case,  whether  by 
preliminary  fissure  and  resection  of  cartilage,  which  is  what  we  do  now 
under  thyro-fissure,  or  by  preliminary  "  window^  resection"  of  the  cartilage 
without  fissure. 

Mr.  Lambert  Lack  (in  reply)  :  I  am  very  glad  that  this  operation 
has  met  with  criticism.  I  would  do  the  operation  in  the  way  I  have  last 
described ;  the  first  method,  which  I  showed  here  two  years  ago,  was  the 
first  step  which  led  on  to  the  second  and  better  method.  The  fiist  cases 
showed  it  was  possible  to  do  the  operation  and  get  a  good  result  by 
removing  the  cartilage.  That  simplified  the  operation  a  good  deal,  but 
the  treatment  I  now  carry  out  simplifies  it  still  more.  The  operation  is 
simpler  than  thyrotomy ;  there  is  no  need  for  tracbeotomy,  and  it  takes 
only  half  the  time.  There  is  no  question  that  by  this  method  the 
operator  does  get  a  better  view.  With  regard  to  its  being  a  more  com- 
plete operation,  I  think  those  who  spoke  rather  admitted  that  when  they 
said  it  might  take  the  place  of  hemi-laryngectomv.  If  that  is  so,  and  if 
it  is  suitable  for  cases  which  ai'e  too  advanced  for  thyrotomy,  it  is 
admittedly  a  moi*e  complete  and  a  better  operation.  I  showed  these 
cases,  not  to  discuss  the  operation,  but  to  show  that  the  after- results  are 
as  good  as  those  obtained  bv  anv  other  method. 


jebruary,  1920.]  Rhinolog'/,  and  Otology.  59^ 

ABSTRACTS. 

Abstracts  Editor — W.  Douglas  Harmer,  9,  Park  Crescent,  London,  W.  1. 

Authors  of  Onginal  Commxmications  on  Oto-laryngology  in  other  Journals 
are  invited  to  send  a  copy,  or  two  reprints,  to  the  Journal  of  Laryngology. 
If  they  are  willing,  at  the  same  time,  to  submit  their  oivn  abstract  {in  English,. 
French,  Italian  or  German)  it  ivill  be  u-ehomed. 


PHARYNX. 

Tonsillitis  with  Buccal  Spirochaetes.— Tretrop  (Antwerp).  "  Proc.  French 
See.  of  Larvngol.,  OtuL,  and  Pthiuol.,"  May  15,  1912. 
The  author  reported  three  cases  of  this  affection.  The  patients  had 
a  swelling  of  the  entire  pharynx,  which  was  copper-coloured  and  covered 
with  greyish  exudate  ;  glandular  enlargement  was  marked.  One  of  the 
patients  had  some  days  after  abatement  of  the  first  symptoms  an  abscess 
of  the  auditory  meatus  and  neck,  both  on  the  same  side  as  the  primary 
tonsillitis.     Protargul  seemed  in  these  cases  more  efficacious  than  iodine. 

H.  Clayton  Fox. 

A  Frequent  Complication  of  Adenoidectomy  Revealed  by  Bronchoscopy. 
— Guisez  (Paris).  "  Proc.  French  Soc.  of  Larvngol.,  (Jtol.,  and 
Pthinol.,"  May  15,  1912. 

The  author  reported  several  cases  of  broncho-pneumonia  with  dyspnoea 
and  elevated  temperature  following  adenoidectomy  -,  a  purulent  vomica 
generally  terminates  this  complication.  Summoned  to  a  child  suffering 
from  severe  dyspnoea  after  adenoidectomy,  the  author  performed 
bronchoscopy  and  found  a  large  adenoid  mass  astride  the  tracheal  spur^ 
which  almost  completely  obstructed  the  two  bronchi.  These  mishaps 
appear  to  be  pretty  frequent,  and  to  avoid  them  the  author  advises 
pressing  the  tongue  depressor  against  the  pharynx  and  to  incline  the 
head  rapidly  when  the  curette  has  cut  through  the  vegetations. 

H.  Clayton  Fox. 


NOSE. 

A  New  Contribution  to  the  Treatment  of  Ozsena  by  Nasal  Functional 

Re-education. — Robert   Foy    (Paris).      "Proc.    French   Soc.    of 

Laryngol.,  OtoL,  and  Pthinol.,"  May  15,  1912. 

In  this  communication  the  author  recalled  the  principles  of  the  method. 

After  a  period  of  nasal  infection  for  a  week  or  two  (injections  of  peroxide 

of   hydrogen,   powdered    boric    acid,   iodine    collunaria),   the   patient   is 

submitted  to  thoracic  and   nasal   respiratory  re-education  by  means  of 

cold  compressed  air  introduced  into  the  air-passages  under  regulatable 

pressure  up  to  100  kilos,  and  in  physiological  rhythm.     The  patients  are, 

moreover,  instructed  in  very  simple  breathing  exercises.     The  cleansing, 

drainage  and  mechanical  action  of  massage  which  this  method  involves 

re-awakens  the  sensibility  of  the  mucosa,  re-establishes  the  circulation, 

expresses  secretion  from  the  glands,  increases  functional  activity  of  all 

the  organs,  and  improves  the  general  health.     This  treatment  does  not 


<50  The  lournal  of  Laryngology,        February,  1920. 

exclude  the  usefulness  of  paraffin,  although  it  may  in  itself  suffice  in  the 
great  majority  of  cases.  Paraffin  still  remains  an  excellent  means  of 
completing  the  cure  obtained  in  the  first  stage  of  the  treatment.  Owing 
to  the  presence  of  paraffin  the  inspired  air  acquires  a  greater  pressure, 
the  expii'ed  air,  charged  with  aqueous  vapour  and  carbonic  acid,  acts  on 
the  mucosa  in  a  more  j^rotracted  manner,  and  lastly  uose-bh^wing,  and 
consequently  drainage,  are  facilitated.  The  author  estimates  that  60  per 
cent,  of  cases  are  cured  and  30  ]ier  cent,  considerably  improved  by  this 
method.  By  cure  must  be  understood  suppression  of  crusting  and 
odour,  re-establishment  of  good  breathing,  ability  to  dispense  with  lavage, 
and  improvement  in  general  health.  H.  Clayton  Fox. 


LARYNX. 

A  Rare  Case  of  Papillomatous  Laryngeal  Leucoplakia. — Etieiine  Jacob 
(Paris).  "  Proc.  French  Soe.  of  Larygol.,  Otol.,  and  Ehinol.," 
May  15,  1912. 

A  man,  aged  thirty-nine,  consulted  the  author  for  hoarseness  of 
fourteen  months'  duration.  General  health  good.  Neither  cough  nor 
wasting ;  no  syphilis ;  no  tuberculosis.  The  patient  was  a  moderate 
smoker,  but  over-used  the  voice  in  shouting  to  his  horses.  The  only 
functional  trouble  was  dysphonia  (voice  batonal).  A  tumour  the  size  of 
an  almond  covered  the  anterior  three-quarters  of  the  right  vocal  cord.  It 
was  in  appearance  greyish-white,  villous  and  horny  ;  the  jiosterior  quai'ter 
of  the  cord,  alone  visible,  was  red.  The  left  cord  was  very  hyperaemic 
and  ulcerated  at  its  free  border.  Both  cords  were  normally  mobile. 
Examination  of  a  portion  of  the  growth  revealed  a  leucoplasic  papilloma, 
with  extensive  proliferation  of  the  submucous  tissues,  eleidin  formation, 
and  considerable  thi(;kening  of  the  horny  layer.  On  January  2,  1912,  the 
growth  was  removed  intra-laryngeally  with  Ruault's  forceps,  followed  by 
deep  cauterisation  of  the  seat  of  im])lantation.  The  tumour  was  inserted 
by  a  narrow  pedicle  on  the  anterior  third  of  the  upper  surface  of  the 
right  cord.  Three  montlis  later  all  there  was  to  be  seen  was  a  cicatrix 
the  size  of  a  small  lentil,  slightly  retracted  and  a  little  greyer  than  the 
rest  of  the  cord.  This  case  is  interesting  (1)  from  an  setiological  point  of 
view — over-use  of  the  voice ;  (2)  the  considerable  size  of  the  growth  ; 
(3)  the  histological  structure  (abnormal  thickness  of  the  stratum 
€orneum).  H.  Clayton  Fox. 


CESOPHAGUS. 


Galvano-cautery  with  Protected  Blade  for  Dividing  Caoutchouc  Den- 
tures Impacted  in  the  (Esophagus. — Claoue  (Bordeaux).  "  Proc. 
French  Soc.  of  Luryngol.,  Otol.,  and  Rhinol.,'  May  15,  1912. 

The  author  exhibited  a  cautery,  the  shape  of  a  pruning-knife,  which 
had  been  of  great  service  in  dealing  with  a  denture  impacted  in  the 
oesophagus  about  24  cm.  from  the  dental  arch.  The  oesopbagoscope 
<iilator  first  used  thoroughly  dilated  the  oesophagus  above  the  foreign 
body,  but  not  in  the  situation  of  the  denture,  which  remained  fixed.  The 
cautery  was  then  introduced,  with  its  blade  on  the  flat,  against  the 
oesophageal  wall  until  it  arrived  beneath  the  bodv  :  the  blade  was  then 


February,  1920.]  Rhinology,  and  Otology.  61 

turned  so  as  to  engage  it.  Having  turned  on  the  current,  traction  was 
made  with  counter  pressure  by  means  of  the  cesophagoscopy  tube. 
Division  of  the  denture  was  easily  effected  and  the  two  fragments  Avere 
removed.  H.  Clayton  Fox. 


EAR. 

The  Reconstruction  of  the  Mastoid  Wound  Cavity  by  the  TJse  of  Bone- 
grafts  and  Chips. — Eagleton.  "  The  Larvugosicope,"  Mav,  1^19, 
p.  272. 

The  two  reported  cases  demonstrate  that  with  a  proper  technique  the 
infection  in  the  mastoid  ai-ea  can,  in  certain  cases,  be  sufficiently  eradicated 
to  allow  of  the  introduction  of  a  bone-graft  and  chips,  tilling  the  cavity 
with  tight  closure  of  the  soft  parts.  This  procediire  reconstructs  the 
mastoid  area  and  eliminates  subsequent  painful  dressings  with  the 
associated  danger  of  secondary  infection.  After  the  primary  (Schwartze) 
operation  the  wound  is  left  widely  open.  The  Carrell  Dakin's  method  of 
wound  sterilisation  is  instituted,  and  when  the  bacterial  count  shows  a 
surgically  sterile  wound  cavity  the  skin  and  granulations  are  excised, 
th»  latter  as  far  into  the  bone-cavity  as  possible.  One  large  bone- graft 
from  the  tibia  and  many  bone-chips  ai"e  placed  in  the  mastoid  cavity — 
enough  to  fill  it.  The  wound  is  sutured  in  layers — periosteum,  fascia 
and  skin — and  covered  with  a  light  dressing.  Upon  discharge  fi'om 
hospital  the  mastoid  area  was  flat,  the  scar  almost  imperceptible  and  the 
hearing  normal. 

Eagleton  appears  to  hold  that  his  bone-graft  method  is  better  than 
the  "  blood-clot."  He  states  that  blood-clot  oitce  infected  is  a  most 
favourable  medium  for  the  growth  of  l)acteria.  As  the  middle  ear  often 
remains  infected,  the  immediate  infection  of  the  blood-clot  is  so 
frecjuent  that  as  a  method  of  treatment  of  mastoid  wounds  it  has  been 
largely  abandoned.  During  the  war  it  was  demonstrated  that  an 
infected  wound  can  be  converted  into  an  aseptic  Avound,  and  then 
treated  as  a  clean  wound,  closed,  and  primary  union  obtained. 

/.  8.  Fraser. 

Fibrosis  of  the  External  Auditory  Canal  and  Mastoid  Region. — L.  W. 
Dean  and  Margaret  Armstrong.  "  The  Laryngoscope."  June, 
1919,  p.  365. 

Dean  and  Armstrong  record  the  case  of  a  male,  aged  twenty -two, 
who  ten  jears  ago  was  subjected  to  a  very  severe  pull  on  the  left 
ear,  which  seemed  to  tear  the  ear  loose  fi'om  the  head.  Smce  that 
time  the  ear  has  stood  out  from  the  head  very  prominently.  The  patient 
first  noticed  impairment  in  hearing  about  eight  years  ago.  One  week 
ago  he  developed  a  severe  pain  in  the  left  ear.  Hearing  in  left  ear : 
Whispered  voice,  2  feet ;  spoken  voice,  25  feet.  On  pulling  the  auricle 
up  and  back  so  as  to  open  the  external  auditory  canal,  which  was  closed, 
the  whispered  voice  was  heard  at  10  feet  and  the  spoken  voice  at  35  feet. 
There  was  swelling  over  the  mastoid  region,  but  no  tenderness  either  in 
the  canal  or  over  the  mastoid.  The  usual  incision  for  a  mastoidectomy 
was  made.  Underneath  the  skin  there  was  a  large  mass  of  soft  fibrous 
tissue,  intimately  attached  to  the  cartilaginous  portions  of  the  external 
auditory  canal.  Over  the  mastoid  this  fibrous  tissue  was  \h  inches  in 
depth.  Almost  all  the  fibrous  tissue  was  removed  and  the  antro-meatal 
mastoid  operation  performed.     A  few  months  later  he  returned  with  the 


62  The  Journal  of  Laryngology,      [February,  1920. 

ear  protruding  as  before,  and  the  same  kind  of  tumour  (?)  present. 
This  time  the  fibrous  tissue  was  followed  to  its  termination  in  all 
directions.  One  year  after  the  second  operation  thei'e  is  no  sign  of 
recui-rence. 

This  tumour-like  growth  was  no  doubt  a  fibrosis,  the  result  of  the 
injury.  /.  S.  Fraser. 


MISCELLANEOUS. 

Projectile  Impacted  in  the  Base  of  the  Skull :  Extracted  by  the  Bucco- 
pharyngeal Route. — Jacques  (Naucy).  "  Proc.  French  Soc.  of 
Laryngol.,  Otol.,  and  Rhiuol.,''  May  15,  1912. 

Radiography  has  rendered  great  service  in  the  localisation  of  foreign 
bodies,  but  simple  exploration  j)er  vias  naturales  is  sometimes  very 
useful.  In  the  case  reported  by  the  author  it  concerned  a  young  man 
who  had  received  a  revolver  bullet  of  6  mm.  calibre,  fired  from  a  distance 
of  2  m.  The  projectile  penetrated  the  cheek,  and  after  the  accident 
he  experienced  nothing  serious.  A  radiogram,  in  antero-posterior 
projection,  revealed  the  bullet  situated  11^  cm.  beyond  the  base  of  the 
maxillary  sinus.  It  Avas  difficult  to  localise  the  body  precisely.  Post 
rhinoscopy  enabled  the  author  to  see  the  orifice  of  entry  of  the  ball 
situated  in  a  mass  of  adenoids,  which  wan-anted  him  in  assuming  that 
the  bullet  must  have  glided  on  the  basilar  process  and  become  engaged 
in  the  occipital  condyle.  During  the  operation  the  author  found  nothing 
on  palpating  the  region ;  he  dissected  the  filirous  coverings  of  the  basilar 
process  and  then  felt  a  hard  body,  but  could  not  see  it.  Haemoi-rhage 
prevented  further  exploration.  A  landmark  was  placed  on  the  point 
where  the  foreign  body  had  been  felt,  and  the  next  day  a  fresh  radiograph 
Avas  taken.  It  was  then  possil)le  to  see,  in  lateral  view,  that  the  bullet 
was  situated  against  the  basilar  process,  1  cm.  from  the  landmark,  and 
that  in  antero-posterior  projection  it  coincided  with  it.  Extraction  was 
then  an  easy  matter.  Trouve's  probe  was  utilised  for  the  exploration, 
and  gave  every  satisfaction.  H.  Clayton  Fox. 


REVIEWS. 


Concerning  some  Headaches  and  Eye  Disorders  of  Nasal  Origin.  By 
GrBEENFiELD  Sludee,  M.D.  With  115  Illustrations.  London: 
Henry  Kimpton,  1918.     Pp.  272.     Price  35s.  net. 

Three  subjects  are  very  completely  dealt  with  in  this  handsome  and' 
well-illustrat(Kl  book,  namely,  vacuum  frontal  headache  Avith  eye 
symptoms ;  secondly,  the  syndrome  of  nasal  (naso-palatine)  ganglion 
neuroses ;  and  thirdly,  "  hyperplastic  sphenoiditis "'  and  its  effects  upon 
the  adjoining  nerves. 

All  of  these  are  matters  which  seem  to  have  been  generally  overlooked 
or  neglected — not  exclusively  by  British  workers  perhaps.  And  as  it  is 
noAV  twenty  years  since  Dr.  Sluder  began  to  draw  our  attention  to  the 
frontal  vacuum  headache,  it  must  be  admitted  that  he  certainly  has  grounds 
for  complaint  at  our  tardiness  in  recognising  this  particular  symptom- 


Tebruary,  1920.]         Rhinology,  and  Otology.  63 

group.  It  must  also  be  admitted  that  his  patience  must  be  like  that  of 
the  patriarch,  for  he  makes  no  complaint  whatever  !  And  yet  he  tells  us 
that  his  own  material  in  eighteen  years  amounts  to  no  fewer  than  580  cases. 

To  be  quite  just,  however,  we  ought  perhaps  to  add  that  cases  of 
vacuum  frontal  headache  probably  go  to  the  ophthalmic  clinics,  since  the 
headache  is  of  the  asthenopic  type  in  being  produced  by  eye  work.  But 
it  is  unrelieved  by  wearing  glasses,  and  it  is  associated  with  a  character- 
istic sign  (Ewing's),  namely  tenderness  on  pressure  at  a  spot  at  the 
upper  and  inner  angle  of  the  orbit,  at  or  near  the  attachment  of  the 
pulley  of  the  superior  oblique  muscle. 

The  headache  is  said  to  be  due  to  the  production  of  a  vacuum  in  the 
frontal  sinus  following  the  blocking  of  the  infundibulum  by  swelling  of 
the  cavernous  mucosa  around  its  orifice  in  the  middle  meatus  of  a  narrow 
nose.  At  all  events  it  is  generally  cured  hv  removing  part  of  the  middle 
turbinal  and  by  the  consequent  free  ventilation  of  the  spaces. 

The  subject  of  the  symptoms  induced  by  disease  affecting  Meckel's 
ganglion  is  also  one  of  great  interest,  especially  from  the  point  of  view  of 
treatment.  Full  anatomical  data  are  given  of  the  situation  and  relations 
of  this  important  ganglion,  and  we  are  surprised  when  we  come  to  realise 
how  near  it  lies  to  the  nasal  mucosa  and  how  accessible  it  is  to  acupuncture 
from  the  nasal  cavity. 

Surprise  also  awaits  us  in  the  final  chapter — that  dealing  with  the 
sphenoidal  sinus  and  the  adjoining  structures.  How  many  of  us  have 
ever  suspected  that  that  sinits  may  actually  come  into  contact  with  the 
Eustachian  tube  ?  The  bearing  of  this  fact  upon  Dr.  Watson- Williams' 
theories  of  the  origin  of  middle-ear  catarrhs  needs  no  emphasising. 

In  his  section  on  the  treatment  of  sphenoidal  sinus  disease  the  author 
indulges  in  a  general  survey  of  the  operative  surgery  of  the  nasal  acces- 
sory sinuses,  and  the  reader  will  find  much  to  interest  and  to  stimulate 
him  in  Dr.  Sluder's  suggestions  and  experiences.  Among  other  points, 
we  note  that  he  favours,  in  the  operation  of  nasal  antrostomy.  the  detach- 
ment of  the  inferior  turbinal  and  its  retention  after  the  artificial  opening 
has  been  made  into  the  cavity.  Theoretically  this  modification  appears 
to  have  many  advantages,  but  it  is  open  to  the  serious  objection,  as  the 
reviewer  found  some  years  ago,  that  although  the  main  blood-supply 
reaches  the  turbinal  from  behind,  when  that  body  is  to  any  considerable 
extent  separated  in  front  from  the  lateral  nasal  wall  it  may  subsequently 
undergo  sloughing  and  give  rise  to  rather  alarming  local  and  general 
phenomena. 

In  every  respect  the  book  is  well  detailed  and  thorough  ;  perhaps, 
indeed,  it  is  a  little  too  minutely  detailed  and  thorough  to  be  easily 
assimilated.  Ban  McKenzie. 

Oto-RMno-Laryngology  for  the  Student  and  Practitioner.      By  Dr.  Georges 

Laurens.    Authorised  English  Translation  of  the  second  revised 

French   edition,   by  H.  Clayton  Fox,  F.R.C.S.(Irel.)  ;    with  a 

Foreword    contributed    bv    J.     Dundas     Grant,     M.A.,    M.D., 

F.E.C.S.     With  592  illustrations.     Bristol:  John  Wright  &  Sons, 

Ltd.,  1919.     Price  17^.  6f7. 

Mr.  Clayton  Fox's  translation  of  this   popular   French   book  is   in 

every  way  excellent,  substittiting,  as  he   does  with  great   skill,  a  racy 

English  style  for  the  terse  and  pointed  French. 

We  have  already  reviewed  the  book  in  this  Journal  and  have  little  or 
nothing  to  add  to  the  praise  we  then  bestowed  upon  it,  and  more  particu- 
larly upon  its  eloquent  illustrations. 


<54  The  journal  of  Laryngology,      [February,  1920. 

The  book  is  intended  for  general  pi-actitioners,  but  such  readers 
should  avoid  looking  upon  its  dicta  as  representing  modern  British 
opinion.  Thus  verv  few  throat-surgeons  in  this  country  would  support 
the  author's  "  rule  "  on  p.  237  in  dealing  with  tonsillotomy :  "  Never 
employ  the  guillotine.'  It  is  strange  to  notice,  by  the  way,  how  slowly 
tonsillectomy  seems  to  be  making  its  way  on  the  Continent.  The 
ditficulty,  of  course,  lies  in  inducing  men  to  substitute  a  major  for  a 
minor  surgical  procedure,  but  there  is  no  doubt  that  total  removal  of  the 
gland,  with  all  its  dangers  and  difficulties,  has  come  to  stay. 

Dan  McKenzie. 


NOTES   AND   QUERIES. 

We  are  indebted  for  the  foUowinj^  note  to  onr  esteemed  contemporary,  The 
Medical  Press,  December  31,  1919. 

"  GUAIACOL    AS    AN    ANAESTHETIC. 

"  Dr.  Georges  Laurens  advises  the  use  of  guaiacol  as  an  ansesthetic  for  the 
more  ordinary  operations  on  the  ear,  nose  and  thVoat.  As  regards  the  ear,  and 
more  especially  pai-acentesis  of  the  drum,  he  employs  a  solution  of  synthetic 
guaiacol  in  oil.  The  latter  should  be  pi-epared  in  the  manner  recommended  by 
Lucas  Championniere.  Very  pure  olive  oil  should  first  be  treated  with  chloride  of 
zinc  in  order  to  get  rid  of  resinous  and  proteid  substances,  then  washed  with 
alcohol  to  remove  any  fatty  acids  formed,  and  finally  it  should  be  kept  at  a  tem- 
perature of  100^  C.  for  some  time.     The  product  thus  obtained  is  extremely  pure. 

"  Dr.  Laurens  at  first  made  use  of  a  1  in  10  solution  of  guaiacol,  but  he  soon 
abandoned  it  in  favour  of  a  1  in  20  solution,  as  he  found  that  the  latter  produced 
quite  satisfactory  anesthesia.  As  regards  the  technique,  he  follows  very  closely 
that  recommended  by  Dr.  Lermoyez.  The  ear  is  cleansed  first  with  tepid  sterile 
water,  and  then  with  a  solution  of  carbolic  acid.  Five  or  six  drops  of  the  guaiacol 
solution  are  next  introduced  into  the  ear  and  allowed  to  remain  during  fifteen  or 
twenty  miniites.  It  is  then  removed  by  means  of  a  tampon  of  cotton-wool,  so  that 
the  passage  is  quite  clear  and  the  operator  may  see  what  he  is  doing. 

"  For  the  operations  in  the  nose  and  thi-oat,  the  solution  is  applied  by  repeated 
paintings.     The  quantity  of  solution  used  has  never  been  more  than  2  c.c. 

"  It  is  important  to  note  that  anesthesia  is  obtained  much  more  slowly  than 
with  cocaine.  "With  the  latter  ten  minutes  sufficed,  but  with  guaiacol  one  must 
wait  at  least  fifteen  or  twenty  minutes." 

Otological  Section  of  the  Koyal  Society  of  Medicine. 
The  next  meeting  of  this  Section  will  be  held  on  February  20,  1920.      Notices 
and   papers   to  be   in   hand  not  later   than   February   8.      Secretaries :    Mr,   H. 
Buckland  Jones  and  Mr.  Lionel  Colledge. 


Lartngological  Section  of  the  Eotal  Society  of  Medicine. 
The  next  meeting  of  tliis  Section  will  be  held  on  March  5,  1920.     Notices  and 
papers  to  be  in  hand  not  later  than  February  28.      Secretaries  .-    Dr.  Irwin  Moore 
and  Mr.  Charles  AY.  Hope. 


BOOK    RECEIVED. 

Oto-Rhino-Laryngology  for  the  Student  and  Practitioner.  By  Dr. 
Georges  Lcnirens.  Authorised  English  Translation  of  the  Second 
Kevised  French  Edition,  by  if.  Clayton  Fox,  F.E.C.S.(Irel.)  ; 
with  a  Foreword  contributed  by  J.  Dundas  Grant,  M.A.,  M.D., 
F.B.C.S.  With  59-2  illustrations.  Bristol :  John  Wright  &  Sons, 
Ltd.,  1919.     Price  17s.  6d. 


VOL.  XXXV.     No.  3.  March,  1920. 


THE 

JOURNAL    OF    LARYNGOLOGY, 

RHINOLOGY,  AND   OTOLOGY. 


Original  Articles  are  accepted  on  the  conditioii  that  they  have  not  frevionslij  been 
published  elseivhere. 

If  reprints  are  required  it  is  requested  that  this  be  stated  when  the  article  is  first 
forwarded  to  this  Journal.     Such  reprints  ivill  be  charged  to  the  author. 

Editorial  Communications  are  to  be  addressed  to  "  Editor  of  .ToiiitNAL  of 
LARYN«or-OGT,  Care  of  Messrs.  Adlard  4"  Son  ^-  West  Neivman,  Limited,  Bartholomew 
Close.  ICC.  1." 


ADENOMATA  (GLANDULAR  TUMOURS)  OF  THE  LARYNX 

By  Irwix  Moore,  M.B.,  C.M.Edin. 

Of  the  various  growths  met  with  in  connection  with  the  larynx 
adenomata  are  perliaps  the  rarest.  Extrinsic  tumours,  it  is  said,  may 
spring  from  the  base  of  the  laryngeal  surface  of  the  epiglottis,  which  is 
their  favourite  site  ;  the  mucous  mejiibrane  over  the  arytaenoid  carti- 
lages;  or  the  ary-epiglottic  fold  (Krishaber)  (1).  Intrinsic  tumours,  it 
is  observed,  almost  always  spring  from  the  ventricle  of  the  larynx. 

Whilst  some  authorities,  e.g.  Bosworth  (2),  Jonathan  Wright  (3) 
and  Harmon  Smith  (3)  (New  York),  Gerhardt  (4)  (Berlin),  Schwartz  (5) 
(Paris)  and  others  have  never  seen  an  adenoma  of  the  larynx,  the  first- 
named  writer  considers  it  questionable  whether  adenomata  ever  occur 
in  the  larynx,  and  the  last-named  observer  expresses  the  opinion  that 
they  never  do.  _  Kyle  (6)  (Philadelphia)  thinks  that  there  is  not  much 
likelihood  of  a  simple  adenoma  developing  in  this  position  "  considering 
the  histological  structure  of  the  larynx."  In  view,  however,  of  the 
large  number  of  mucous  glands  in  the  ventricular  band  and  ventricle  of 
Morgagni,  it  appears  surprising  that  a  large  number  of  these  growths  do 
not  arise  from  this  neighbourhood. 

Morell  Mackenzie  (7),  Lennox  Brovi'ne  (8),  Fletcher  Ingals  (9) 
(Chicago),  Schmiegelow  (Copenhagen),  and  others,  have  expressed  the 
opinion  that  they  do  occur,  hitt  very  seldom.  Jonathan  Wright  (3)  and 
Harmon  Smith  (3)  remark  that  it  is  questionable  how  many  of  these 
tumours  have  been  observed.  Lefferts  (10)  (.New  York),  remarking  on 
the  rarity  of  these  growths,  says  "  you  can  go  on  for  a  lifetime  without 
seeing  such  a  case,  and  when  you  do  find  one  there  will  be  a  difference 
of  opinion  between  yourself  and  your  colleague  about  the  diagnosis." 


66  The  Journal  of  Laryngolo§ry,         [March,  1920. 

Semon  (11),  referring  to  10,747  cases  of  benign  growth  in  the  larynx 
observed  by  107  laryngologists  between  1862  and  1888,  says  that  "  the 
histological  structure  of  the  new  growth  was  of  the  nature  of  papil- 
loma in  fully  39  per  cent,  of  the  cases,  and  that  with  the  exception  of 
papillomata,  fibromata  and  cysts  all  other  benign  growths  are  so  very 
rare  that  they  may  be  looked  upon  as  pathological  curiosities." 

The  relative  frequency  of  adenomata  may  be  gathered  from  the 
statistics  of  benign  growths  which  have  been  compiled  by  various 
writers. 

Morell  Mackenzie  (7),  in  the  collection  of  100  cases  of  his  own,  with 
189  others  collated  from  medical  literature  as  far  as  the  end  of  the  year 
1870,  found  only  two  examples  which  were  regarded  as  of  this  character, 
whilst  microscopically  one  was  pronounced  to  be  an  adeno-carcinoma. 
As,  however,  he  says,  no  recurrence  occurred,  the  growth  was  probably 
a  simple  adenoma. 

Massei  (12)  (Naples),  in  his  collection  of  500  cases  of  benign  growths 
of  the  larynx,  found  only  two  cases  supposed  to  be  adenomata,  and 
these  he  considered  were  questionable. 

Fauvel  (13)  (Paris),  amongst  300  cases  from  1862  to  1875,  met  with 
none. 

Moritz  Schmidt  (14)  (Frankfurt)  refers  to  538  cases  of  laryngeal 
tumours  seen  in  his  clinic  during  ten  years,  amongst  which  no  case  of 
adenoma  was  recorded. 

Age. — These  neoplasms  have  never  been  observed  in  infancy,  the 
youngest  case  being  22  years  of  age  (Marsh  1  and  the  oldest  74  (Bruns). 
The  other  cases  ranged  between  25  and  68  years  of  age. 

Sex. — In  only  two  cases,  one  recorded  by  Schmiegelow  and  the 
other  by  Marsh,  did  the  growths  occur  in  women. 

Appearance. — They  are  sessile,  broad-based,  irregularly  outlined 
tumours,  having  a  mamillated  surface  and  a  more  solid  appearance  than 
a  cyst.  Morell  Mackenzie  (7)  remarks  "there  is  nothing  characteristic 
in  their  appearance." 

If  situated  on  the  vocal  cords  it  may  be  difficult  to  recognise  them 
clinically  from  malignant  growths. 

Histology. — The  growths  are  simple  glandular  hyperplasias  having 
their  type  in  the  acinous  or  tubular  structures,  and  are  composed  of 
glands  held  together  by  a  relatively  small  quantity  of  loose  connective 
tissue  and  covered  with  mucous  membrane.  They  may  become  cystic 
from  obstruction,  and  distended  with  mucin. 

Cornil  and  Eanvier  (15)  (Paris)  speak  of  a  diffuse  condition  which 
they  call  adenoma,  but  they  refer  to  no  case  of  proper  adenomatous 
neoplasm,  but  to  enlargements  associated  with  chronic  catarrhal 
laryngitis.  They  mention  the  fact  that  hypertrophied  glands  often 
exist  at  the  base  of  papillomata,  hence  polypi  of  the  larynx  are  "  mixed 
tumours." 

Morell  Mackenzie  (7)  also  says  that  acinous  gland  structure  is  often 
found  in  papillary  growths,  and  that  occasionally  the  entire  neoplasm 
consists  of  hypertrophied  racemose  glands  (as  in  his  second  case — see 
p.  67).  He  refers  to  Andrew  Clark  as  having  repeatedly  found  portions 
of  racemose  glands  in  the  papillary  growths  which  he  (M.  M.)  had 
removed  from  the  larynx. 

Jonathan  Vk'right  and  Harmon  Smith  (3)  consider  that  these 
growths  should  be  looked  upon  with  much  suspicion,  and  that  "  when 
apparently  entirely  benign,  according  to  conventional  histological  rule, 


March,  1920.] 


Rhinology,  and  Otology. 


Q7 


or  in  the  clinical  history,  they  often  go  on  to  a  malignant  course  subse- 
quently."  Again,  these  writers  state  that  "  all  those  presenting  glandular 
structure  have  turned  out  to  be  malignant  adeno-carcinomata."  This 
opinion,  however,  is  not  confirmed  by  recorded  cases. 

Differential  Diagnosis  from  Malignant  Disease. — Adenomata  are  dis- 
tinguishable from  glandular,  or  other  forms  of  carcinoma  in  that  the 
■epithelium  does  not  transgress  tlie  limits  of  the  basement  membrane 
and  invade  the  surrounding  tissue. 

Eecorded  Cases  of  Adenomata  of  the  Larynx. 

A  search   of   the   literature  reveals  only  thirteen  cases,  and   in    a 
•certain   number  of   these  the  diagnosis  was  said  to  be  questionable. 


Pig.  1. — Laryngoscopic  view  of  an  adenoma  beneath  the  anterior  commis- 
sure of  the  vocal  cords.  (Re-drawn  fi-om  Morell  Mackenzie's  "Growths 
in  the  Larynx,"  1871,  PI.  iii,  fig,  6,  p.  2.51.) 


Fig.  2. — Laryngoscopic  view  of  an  adenoma  of  the  epiglottis,  and  the 
tumoiir  after  removal.  (Ke-drawn  from  Morell  Mackenzie's  "  Growths  in 
the  Larynx,"  1871,  PI.  iii,  figs.  4  and  5,  p.  251.) 

Morell  Mackenzie  (7)  in  1871  described  two  cases — one  in  which  the 
growth  was  situated  below  the  anterior  commissure  of  the  vocal  cords 
(Figs.  1  and  2)  in  a  male,  aged  thirty-three,  seen  first  in  1869,  the  growth 
looking  like  an  ordinary  cauliflower  excrescence  (Case  79,  pi.  iii,  fig.  6, 
p.  251).  The  patient  suffered  from  a  constant  dry  cough  and  husky 
voice,  which  had  existed  for  two  years  with  occasional  attacks  of 
dyspnoea.  Jurasz  (16)  (Heidelberg)  refers  to  this  case,  and  states 
that  the  growth  consisted  of  gland-tubules  lined  with  cvlindrical 
epithelium.   ^^ 

In  the  other  case,  seen  also  in  1869,  the  neoplasm  grew  from  the 
left-hand  side  of  the  posterior  surface  of  the  epiglottis  (Fig.  2)  of  a  male, 
aged  fifty-one  :  was  an  irregular,  lobulated,  pedunculated  mass  as  large 


68  The  Journal  of  Laryngology,         [March,  1920. 

as  a  cherry,  and  had  very  much  the  appearance  of  an  hypertrophied 
tonsil  (Case  88,  pi.  iii,  figs.  4  and  5,  p.  251).  The  growth  Avas  very 
rapid  in  its  development,  and  was  considered  to  be  of  doubtful 
character.  The  patient  had  contracted  syphilis  eight  years  previously. 
In  both  cases  the  growths  were  of  a  pink  colour. 

In  the  first  case  the  growth  was  removed  by  laryngo-fissure,  and  in 
the  second  case  it  was  removed  through  the  upper  orifice  of  the  larynx 
by  a  guarded  wheel-ecraseur,  a  tracheotomy  having  first  been  per- 
formed. Tliis  second  specimen  was  1  in.  by  |  in.,  and  weighed 
50  gr.  It  was  exhibited  at  the  Pathological  Society  of  London  in 
1870  (7),  and  was  pronounced  by  a  sub-committee  to  be  a  case  of 
adeno-carcinoma,  but  this  was  not  confirmed  by  the  full  committee, 
hence  no  report  appears  in  the  Transactions  of  the  Pathological  Society. 
Schmiegelow  (20),  in  his  paper  on  "Adenoma  of  the  Larj'nx,"  refers 
to  this  case. 

Paul  Bruns  (17)  (Berlin)  refers  to  two  instances,  one  in  1868  and 
the  other  in  1878.  The  first  case,  which  is  the  first  adenoma  of  the 
larynx  ever  Recorded,  was  operated  upon  by  Schinzinger  (Case  64  in 
the  table).  The  patient  was  a  male,  aged  seventy-four,  who  was  first 
seen  in  1866,  and  suffered  from  hoarseness  with  dyspnoea  and  stridor. 
The  growth,  which  was  described  as  a  voluminous  glandular  polypus, 
originated  from  the  anterior  surface  of  the  left  vocal  cord,  and  was 
removed  endolaryngeally  by  avulsion  with  the  wire  snare  forceps. 
Jurasz  (16)  (Heidelberg)  also  refer  to  this  case  in  his  paper. 

The  second  case  was  operated  upon  by  Bockel  (18)  (Case  65  in 
table),  and  was  a  female,  aged  twenty-five.  The  growth  was  a  glan- 
dular polypus  the  size  of  a  nut,  and  was  situated  above  the  right  vocal 
cord.  The  exact  site  of  the  growth  does  not  appear  to  have  been 
determined.  In  this  case  it  is  reported  that  thyrofissure  was  performed, 
but  was  not  completed  "  in  consequence  of  ossification  of  the  thyroid 
cartilage." 

Herard  and  Cornil  (19)  (Paris)  refer  only  to  hypertrophy  of  the 
glands  under  the  influence  of  laryngeal  tuberculosis.  In  a  case  referred 
to  the  cul  de  sacs  and  ducts  of  the  hypertrophied  glands  were  covered 
with  cylindrical  epithelium.  Between  the  glandular  cul  de  sacs  very 
fine  areolar  tissue  was  found,  traversed  by  numerous  capillaries  ;  in  the 
areolar  tissue  there  were  a  great  number  of  granular  lymphoid  cells  and 
fusiform  corpuscles. 

Schmiegelow  (20)  (Copenhagen),  in  1891,  also  reported  the  case  of 
a  female,  aged  forty-six,  where  the  right  ventricular  band  was  the  seat 
of  a  large  irregular  growth  with  nodular  surface,  of  a  dirty  red  colour, 
here  and  there  ulcerated,  which  entirely  covered  the  right  vocal  cord 
during  respiration.     It  was  removed  by  laryngo-fissure. 

Microscojncally  it  consisted  of  well-developed  acini  with  hyper- 
trophy of  the  connective  tissue.  Excretory  ducts,  lined  with  cylindrical 
epithelium,  could  be  traced  to  the  surface.  There  were  no  cilia  on  the 
surface  epithelium. 

Massei  (12),  in  1885,  refers  to  two  cases,  the  first  in  a  male,  aged 
forty,  the  growth  originating  from  the  anterior  commissure,  the  second 
in  a  male,  aged  thirty-seven,  the  middle  third  of  each  vocal  cord  being 
the  seat  of  origin  of  an  adenoma — the  size  of  a  pea.  In  both  these 
cases  the  growths  were  removed  endolaryngeally. 

Lubliner  (21)  (Warsaw),  in  1893,  recorded  the  case  of  a  patient,, 
aged  sixty-eight,  where  the  ventricular  band  was  uneven  and  infiltrated. 


JOUENAL   OF   LAEYNGOLOGY,   EHINOLOGY,  AND   OTOLOGY. 


Fig.  5. — Coronal  section  thron<,'ir  middle  of  normal  human  (female)  larynx, 
showing  the  distribution  of  the  gland-tissue  and  the  lymphoid  tissue  of  the 
ventricle  (logwood  and  eosin  stain;  2-in.  obj.).  a.  Elastic  tissue  of  cord. 
B.  Gland  acini  lying  in  periphery  of  the  cord.  c.  Gland  duct,  near  surface 
of  summit  of  cord.  d.  Gland  acini  lying  in  elastic  tissue  and  in  an  area 
covered  with  squamous  epithelium,     e.  Lymphoid  tissue  in  wall  of  ventricle. 

{Frepnt-atioii  hrj  Pfof.  S.   G.  Shuffock,  F.H.S.,  fpecinlli/  draini  fov  Dr.  Iriciti  Moore.) 

To  Illustrate  Db.  Ikwin  Moore's  article  on  Adenomata  of  the  Larynx. 


Adlard  4-  Son  Jj-  Vent  Xeuma)i,  Ltd, 


JOURNAL   OF    LAKYN(.iOLO(jy,   KHINOLOGY,   AND   OTOLOGY. 


Fig.  ti. — Showincr  the  true  eoi'd  from  another  section  of  the  same 
larynx  stained  with  Unna's  acid  orcein.  The  elastic  tissue  is 
stained  a  deep  blackish-brown,  a.  Elastic  tissue,  b  Gland 
acini  lyin<^  in  elastic  tissue  and  in  the  area  covered  with  squamous 
epithelium,  c.  Gland  ducts  opening  near  the  summit  of  the  cord. 
D.  Gland  acini  lying  in  the  elastic  tissue  and  in  an  area  covered 
with  squamous  ejjithelium. 

(Preparation  hy  Prof.  S.   G.  Shaftocic,  F.S.S.,  fpeci'illy  draicii  for  Dr.  Iriri)i   'iloore.) 

To  Illustr.\te  Dr.  Irwin  Moore's  article  on  Adenomata  of  the  Larynx. 


Adlard  4'  Son  4-   tVett  yetcnian.  Ltd, 


March,  1920.]  Rhiiiology,  aiid  Otology.  69 

The  growth  consisted  of  small,  soft,  smooth,  slightly  red  nodules  on 
the  thickened  and  reddened  left  ventricular  band.  Part  of  the  tumour 
was  extirpated  by  means  of  a  sharp  spoon. 

Microscopically  it  proved  to  be  an  adenoma.  Recurrence  took  place 
five  months  later  in  the  posterior  part,  a  nodule  the  size  of  a  small  pea 
being  extirpated. 

F.  Marsh  (22)  (Birmingham),  in  189i,  described  a  case  of  multiple 
adenoma  in  a  ^Yoman,  aged  twenty-two.  There  was  a  cluster  the  size 
of  a  small  strawberry,  of  what  appeared  to  be  multiple  papillomata 
growing  chiefly  from  the  anterior  commissure  of  the  left  vocal  cord 
and  occluding  quite  two-thirds  of  the  opening  between  the  cords. 
The  growths  were  removed  by  thyro-tissure  without  preliminary 
tracheotomy. 

Microscopic  examination  by  Leedham  Green  showed  that  the  neo- 
plasm w^as  not  a  papilloma,  but  presented  a  typical  lyipphoid  structure, 
and  was  said  to  closely  resemble  that  described  by  Wolfenden  and 
Martin  (23)  in  "  Studies  in  Pathological  Anatomy." 

Corradi  (24)  (Verona)  reported  a  case  in  1895  in  a  male,  aged  thirty- 
four.  The  tumour  was  the  size  of  a  large  pea,  of  a  pale  pink  colour, 
and  with  a  slightly  nodulated  surface.  It  was  attached  partly  to  the 
anterior  commissure  and  partly  to  the  anterior  half  of  the  ventricle  of 
Morgagni  on  the  right  side,  and  its  base  was  attached  to  the  right 
vocal  cord.  It  had  been  previously  diagnosed  as  a  cyst.  Two  attempts 
at  removal  with  the  ecraseur  failed,  and  it  w-as  finally  removed  by 
means  of  laryngeal  forceps. 

Microscopical  examination  pi'oved  that  it  was  a  typical  adenoma. 
Corradi  refers  to  the  great  rarity  of  these  cases  and  quotes  the  opinion 
of  Billroth  and  Gottstein  in  confirmation. 

Zenker  (25)  (Koningsberg),  in  1909,  records  the  case  of  a  patient, 
aged  sixty,  with  an  adenoma  situated  between  the  right  vocal  cord  and 
ventricular  band.  It  was  a  spindle-shaped  broad  mass  of  a  greyish- 
white  colour,  and  measured  1-5  cm.  in  length  and  0-i  cm.  in  breadth. 
It  covered  the  right  vocal  cord  and  extended  subglottically,  thus  pre- 
venting approximation  of  the  cords.  It  was  apparently  a  ventricular 
growth,  and  was  removed  by  endolaryngeal  forceps.  ^licroscopically  it 
consisted  of  groups  of  glands  interlaced  with  connective  tissue. 

Tilley  (26)  in  1914  reported  a  case  of  adenoma  of  the  right  ventri- 
•cular  band  at  a  meeting  of  the  Section  of  Laryngology,  Royal  Society 
of  Medicine.  The  patient  was  a  male,  aged  fifty-two,  who  had  suffered 
from  hoarseness  for  from  ten  to  fifteen  years.  The  Wassermann 
reaction  was  negative,  and  there  were  no  symptoms  of  tuberculosis. 
The  growth  was  a  smooth,  pale,  globular  swelling,  covering  five-sixths 
of  the  anterior  surface  of  the  true  vocal  cord. 

Microscopicalhj  it  was  apparently  oi  the  nature  of  an  adenoma 
originating  from  a  crypt  in  connection  wath  the  ventricle.  In  a  discus- 
sion which  followed  Mr.  Rose  suggested  that  it  was  a  thickening  of  an 
inflammatory  nature,  whilst  Sir  Felix  Semon  considered  that  it  was  a 
tuberculoma. 

A.  L.  Macleod  (27)  (Leicester),  has  recently  recorded  (1919)  the  case 
of  a  male,  aged  fifty-seven,  who  was  first  seen  in  October,  1917.  He  had 
suffered  from  hoarseness  for  five  months,  accompanied  by  cough  and 
mucous  expectoration.  The  left  vocal  cord  was  inflamed,  fixed,  and  its 
central  portion  occupied  by  a  cauliflower  growth.  There  was  no  history 
of  syphilis  or  tuberculosis.     The  Wassermann  reaction  was  negative. 


70  The  Journal  of  Laryngology,         [March,  1920. 

In  May,  1918,  thyroid  fissure  was  performed  and  the  left  vocal  cord 
removed.  The  patient  unfortunately  died  six  months  later  from 
broncho-pneumonia. 

Microscopical  Beport  by  Dr.  Mackarel  (Pathologist  to  the  Eoyal 
Infirmary,  Leicester). — Two  sections  of  the  growth  were  cut:  (1)  A 
small  piece  which  shows  a  large  mucous-secreting  gland  which  appears 
quite  normal.  (2)  A  larger  piece  which  shows  the  squamous  mucous 
membrane,  and  the  submucous  tissues  full  of  round  cells,  and  deep  in  a 
large  mucous  gland. 

There  was  nothing  to  indicate  the  cause  of  the  inflammation,  and  no 
evidence  in  the  section  of  any  malignant  neoplasm. 

Further  Report  on  this  Specimen  by  Prof.  S.  G.  Shattock,  F.R.S. 
— Section  1  :  This  consists  of  mucous  glands  lying  in  adipose  tissue 
with  a  striated  muscle-fibre  here  and  there.  The  glandular  tissue 
corresponds  in  cliaracter  with  that  of  the  normal  larynx  in  the  imme- 
diate neighbourhood  of  the  elastic  tissue  of  the  vocal  cord,  i.  e.  with  the 
glands  lying  on  the  outer  or  ventricular  side  of  the  latter.  The  volume 
of  the  gland-tissue  and  its  compact  apposition  justify  the  classification 
of  the  lesion  as  an  adenoma. 

Section  2  :  This  consists  of  a  portion  of  the  cord,  infiltrated  with 
round  cells ;  the  preparation  includes  a  minute  fragment  of  glandular 
tissue  of  the  same  kind  as  that  in  the  other  section. 


Summary  of  Eecorded  Cases  of  Adenomata  of  the  Vocal  Cords. 

Amongst  the  13  recorded  cases  of  adenomata  of  the  larynx  referred 
to  in  this  article,  7  originated  from  the  ventricular  band  or  ventricle 
of  Morgagni,  1  from  the  epiglottis,  and  only  5  from  the  true  vocal 
cord. 

Of  the  5  cases  which  originated  from  the  true  vocal  cords,  in  the 
first,  reported  by  Paul  Bruns  in  1868,  the  growth  was  situated  on  tlie 
left  vocal  cord  ;  in  the  second  case,  recorded  by  Morell  Mackenzie  in 
1871,  it  was  situated  below  the  anterior  commissure  of  the  vocal  cords  ; 
in  the  third  and  fourth  cases,  recorded  by  Massei  in  1885,  the  seat  of 
origin  was  the  anterior  commissure  and  the  middle  third  of  each  vocal 
cord  respectively.  Dr.  MacLeod's  case,  in  which  the  adenoma  waS' 
situated  on  the  middle  third  of  the  left  vocal  cord,  appears  to  be  the 
only  other  which  has  been  recorded  in  medical  literature. 

It  is  interesting  to  note  that  amongst  these  13  cases,  8  of  the 
growths  were  removed  endolaryngeally  and  5  by  thyro-fissure. 

The  recent  case  of  adenoma  of  the  vocal  cord  reported  b}'  Dr.  A. 
Macleod  (27)  to  the  Section  of  Laryngology,  Eoyal  Society  of  Medicine, 
on  Februarj'  7,  1919,  in  which  the  question  was  raised  as  to  whether 
the  growth  arose  from  the  vocal  cord  itself  or  ventricle,  has  re-opened 
this  controversial  subject. 

We  know  that  the  most  characteristic  feature  of  the  ventricular 
band  is  the  presence  of  numerous  acino-tubular  glands,  which  open 
upon  its  median  as  well  as  its  ventricular  or  saccular  aspect,  and  that 
an  adenoma  may  arise  in  this  situation;  but  whether  or  not  an  adenoma 
may  arise  from  the  vocal  cord  itself  depends  upon  what  structures  the 
vocal  cord  is  considered  to  include. 

Some  authorities  assert  that  glands  occur  and  open  on  to  the  surface 
of  the  vocal  cords  themselves,  whilst  others  doubt  their  existence. 

Lennox  Browne  (8),  referring  to  this  question,  says  that  "glands  are 


a  Oj  o  V, 

•  -   ^  s    • 

■y    O  S 

5  s  M 

'^  2  p  =■ 

i£  >^  d   o 

P*  ?J  CD      • 

:-  r;    tg 


i  s  ;;  be     a 


3  .'tl    :5 


J* 


£0 


J3 

>■ 

a)  -u 

1^ 

-r^       S 

:; 

rJ<       > 

•?^ 

^ 

3      0 

'-^ 

^ 

r^      ffl 

-t^ 

-"^  S 

(5 

c 

■^      0 

_2 

CO 

,S 

M  O   fq 


March,  1920.] 


Rhinology,  and  Otology.  71 


certainly  not  very  numerous  in  the  cord,  and  that  their  disappearance  is 
doubtless  coincidental  with  the  differentiation  in  function  and  structure, 
since  they  are  more  numerous  in  the  lower  vertebrge." 

Chiari  (28)  (Vienna)  states  that  glands  are  not  found  in  the  middle 
third  of  the  vocal  cord.  If  by  this  is  meant  the  middle  third  as  seen  in 
a  coronal  section  this  accords  with  our  own  observations. 

The  difficulty  of  accurately  defining  the  boundaries  or  limitations 
of  the  vocal  cord  is  shown  by  the  varied  opinion  of  different  writers. 

Some  authorities  hold  that  the  vocal  cord  consists  of  only  the  apical 
portion  of  the  projection  of  elastic  tissue  covered  by  thin  adherent 
mucous  membrane  and  possessing  no  submucous  layer  or  glands  ;  others 
are  of  the  opinion  that  the  mass  of  the  internal  thyroid-arytaenoid 
muscle  should  be  included  and  that  glands  occur  in  and  open  upon  the 
surface  of  the  cord. 

For  example,  Schafer  (29)  describes  the  vocal  cord  as  the  inner  free 
and  "projecting  edge"  of  the  mass  of  triangular  tissue  in  coronal 
section  which  constitutes  the  inferior  thyro-arytgenoid  ligament.  The 
cords,  he  says,  are  continuous  with  the  adjacent  elastic  tissue  and 
elastic  ligaments  of  the  larynx.  He  refers  to  tubo- racemose  glands  as 
existing  everywhere  in  the  lining  membrane  of  the  larynx  except  upon 
or  near  the  true  vocal  cords.  Gottstein  (30)  (Breslau),  on  the  other 
hand,  describes  the  vocal  cord  as  consisting  of  the  inferior  thyro- 
aryt<finoid  ligament,  and  "  to  a  great  extent  "  the  fibres  of  the  internal 
thyro-arytaenoid  muscle.  He  refers  to  acinous  glands  occurring  "  some- 
times singly,  sometimes  in  groups,  and  being  particularly  numerous  on 
the  tubercle  of  the  epiglottis ;  at  the  angle  formed  by  the  epiglottis 
with  the  aryepiglottic  folds  ;  on  the  ventricular  bands  ;  and  within  the 
ventricles  "  ;  they  are,  moreover,  he  says,  "  irregularly  scattered  over 
the  posterior  wall  of  the  larynx  especially  in  the  neighbourhood  of  the 
crico-arytaenoid  articulations,  hiit  absent  on  the  dipper  siirface  of  the 
vocal  cords." 

B.  Fraenkel  (31)  (Berlin)  comprises  in  the  vocal  cords  not  only  the 
thyro-aryt£Enoid  ligament  but  also  "all  the  tissues"  projecting  from 
the  lateral  walls  of  the  larynx.  Glands,  he  says,  may  be  found  upon 
the  superior  and  inferior  surfaces,  but  those  of  the  superior  surface  cease 
at  a  distance  of  1-8  mm.  from  the  free  border  of  the  cord,  and  he  refers 
to  a  large  number  of  acini  which  dip  into  the  muscle,  and  are  closely 
connected  with  the  muscular  fibres. 

Desvernine  (32)  (Cuba)  defines  the  vocal  cord  as  being  the  whole 
ligamentous  system  constituted  by  the  thyro-arytseno-cricoid  fasciculi 
and  by  the  ascending  crico-thyro-arytaenoid  fibres.  He  says  the 
mucosa  of  these  bands,  therefore,  extend  interiorly  with  the  band  to  the 
upper  border  of  the  cricoid  cartilage  in  the  whole  ascent  of  the  cricoidal 
ascending  fibres,  and  that  all  the  glands  embedded  in  this  region  must 
be  considered  constituent  elements  of  the  glandular  apparatus  of  the 
vocal  cords. 

This  author,  in  contradiction  of  the  statements  of  Luschka,  Morell 
Mackenzie,  Gottstein,  Lennox  Browne,  etc.,  considers  that  "the  vocal 
cords  undoubtedly  possess  a  glandular  apparatus  constant  in  its 
presence  and  perfectly  well-developed."  He  attributes  the  priority  of 
having  demonstrated  this  fact  to  Coyne  (33)  (Paris). 

He  divides  the  mucosa  lining  the  vocal  ligaments  into  three 
segments :  (1)  The  ventricular  or  superior  portion ;  (2)  the  glottic 
portion  ;    (3)   the   infra-glottic   portion.     The   first   and   third   portion 


72  The  Journal  of  Laryngology,  [March, 


1920. 


alone  he  says  are  supplied  with  glands.  He  describes  the  distribution 
of  the  glands  as  follows :  The  glands  of  the  superior  surface  form  a 
group,  deeply  seated  near  the  thyro-arytaenoid  fibres  towards  their 
ventricvilar  border.  Their  excretory  ducts  are  directed  obliquely 
upwards  and  towards  the  glottic  border,  and  terminate  on  the  superior 
surface.  Their  position  is  variable.  They  may  be  very  deeply  seated 
in,  or  subjacent  to,  the  thyro-arytaenoid  muscle,  and  they  are  then 
absent  from  the  submucous  connective  tissue.  Their  number  never 
exceeds  three  or  four.  The  subglottic  region  is  plentifully  supplied 
with  glands.  They  are  always  here  embedded  in  tibro- elastic  structure. 
Their  excretory  ducts  are  directed  obliquely  upwards  and  inwards. 

Jobson  Home  (34)  considers  that  the  vocal  coi'd  should  be  defined 
as  that  part,  and  only  that  part,  which  is  covered  with  squamous 
epithelium,  and  states  that  glandular  tissue  does  not  exist  in  this  area 
but  only  immediately  outside  the  vocal  cord  boundary,  and  on  this 
definition  he  does  not  see  how  an  adenoma  of  the  vocal  cord  is  possible. 

Definition  of  the  Vocal  Cord. 

In  view  of  the  difference  of  opinion  as  to  the  proper  definition  of 
the  vocal  cord,  and  the  question  at  issue  in  connection  with  adeno- 
matous growths,  the  advice  and  assistance  of  Prof.  Shattock  was  sought 
by  the  writer. 

In  order  to  elucidate  this  matter  he  has  kindly  prepared  a  series  of 
microscopical  sections  through  the  middle  of  the  cord  and  ventricle — in 
the  coronal  or  vertical  transverse  plane.  These  sections  have  been 
specially  drawn  for  the  writer  under  his  supervision,  as  well  as  sections 
of  the  adenoma  recorded  by  Dr.  Macleod.  Since  the  investigations 
of  Prof.  Shattock  are  of  importance  in  connection  wnth  this  question, 
the  remaining  portion  of  this  ai'ticie  will  deal  with  his  opinion  and 
report. 

Shattock  (35)  says  that  "  the  occurrence  of  adenoma  of  the  ventri- 
cular band  and  of  the  .wall  of  the  ventricle  is  well  established,  and 
seeing  that  these  structures  include  a  striking  collection  of  mucous 
glands,  the  position  of  such  grow'ths  presents  no  difficulty.  The  subject 
of  adenoma  of  the  vocal  cord,  however,  is  by  no  means  so  straight- 
forward, and  whether  such  tumours  may  arise  in  connection  with  this 
depends  upon  what  anatomical  definition  is  adopted  of  the  structure  in 
question." 

The  Ake.^  which  may  be  Assigned  to  the  Vocad  Cord. 

Shattock  says  there  are  two  criteria  which  suggest  themselves  in 
this  connection  : 

(1)  The  Extent  of  the  Squamous  Epithelium. — As  is  shown  in  Fig.  5, 
the  free  edge  of  the  vocal  cord  is  covered  with  a  closely  adherent 
mucosa  furnished  with  papilla  over  its  summit,  and  invested  with 
squamous  epithelium.  Beneath  this  the  structure  consists  of  a  compact 
collection  of  fibrils  of  elastic  tissue  (viewed  in  cross-section),  into  the 
outer  aspect  of  which  the  deepest  fibres  of  the  thyro-aryttenoid  muscle 
(aryvocalis)  are  inserted  at  increasing  lengths  from  behind  forwards  ; 
these  bundles  are  likewise  viewed  in  transverse  section.  There  is  no 
difficulty  in  defining  tlie  superior  or  ventricular  limit  of  the  vocal  cord, 
as  the  spot  where  the  columnar  epitlielium  terminates  and  the  squamous 
begins ;    interiorly,    liowever,    the    squamous   epithelium  is   continued 


March,  1920.]  Rhinology,  and  Otology.  73 

downwards  over  the  subglottic  area,  further  from  the  vocal  ridge  than 
that  in  the  horizontal  plane.  The  junction  of  the  subglottic  squamous 
epithelium  with  the  true  columnar-celled  epithelium  of  the  trachea,  as 
shown  by  microscopical  sections,  takes  place  at  a  distance  of  7  mm. 
below  the  summit  of  the  cord. 

Shattock  (35)  mentions  in  passing  that  the  epithelium  investing  the 
inner — /.  e.  the  exposed — surface  of  the  ventricular  band  is  largely  of 
the  squamous  kind,  and  consists  superficially  of  a  few  layers  of  flattened 
cells  over  a  zone  of  polymorphous  epithelial  elements,  and  a  deeper 
series. 

He  refers  to  the  presence  of  a  squamous  epithelium  on  the  vocal 
cord  as  obviously  related  to  the  function  of  the  latter,  and  sa^'s  that 
whether  the  substitution  of  the  squamous  epithelium  for  the  columnar 
(which  covers  the  mucosa  of  the  ventricle  and  of  the  trachea)  has  been 
acquired  and  afterwards  inherited,  or  whether  its  presence  is  due  to  an 
antecedent  germinal  change  (or  "  mutation  ")  co-ordinated  with  the 
evolution  of  the  glottis,  is  a  problem  outside  the  present  subject.  But 
that  the  squamous  epithelium  of  the  vocal  cord  is  not  acquired  from  the 
use  of  the  glottis  in  each  individual  after  birth  is  easily  proved.  For 
Shattock  finds  by  means  of  coronal  sections  that  the  differentiation  is 
well  pronounced  in  the  human  fojtus  at  the  sixth  month — that  whilst 
the  ventricular  and  subglottic  ai'eas  are  covered  with  typical  columnar 
epithelium,  that  covering  the  vocal  cord  is  a  thin  layer  of  thesquamous- 
celled  kind. 

(2)  The  Extent  of  the  Elastic  Tissue. — The  precise  limits  of  the 
elastic  tissue,  to  which  Shattock  suggests  that  the  term  "  pars  elastica  " 
might  be  advantageously  applied,  may  be  demonstrated  by  the  use  of 
Unna's  acid  orcein,  which  stains  the  fibres  of  a  deep  blackish-brown,  as 
depicted  in  Fig.  6. 

The  amount  of  this  tissue,  he  says,  when  viewed  in  coronal  section 
is  comparatively  small  (much  more  so  than  is  frequently  imagined),  and 
is  disposed  somewhat  in  the  form  of  an  inverted  V,  its  angle  being  the 
thickest  part,  whilst  the  thyro-arytaenoid  muscle  lies  immediately  on  its 
outer  side. 

Superiorly  the  peripheral,  ventricular  limit  of  the  elastic  tissue 
extends  to  the  peripheral  limit  of  the  squamous  epithelium. 

Inferiorly  the  elastic  tissue  passes  into  the  thin  expansion  of  the 
lateral  portion  of  the  crico-thyroid  membrane,  wliich  is  fixed  below  to 
the  inner  edge  of  the  upper  border  of  the  cricoid  cartilage. ' 

The  Distribution  of  the   Glandular  Tissue  in  Relation  to  the 
Squamous  Epithelium  and  to  the  Elastic  Tissue. 

In  the  logwood-eosin  section  (Fig.  o),  gland  acini  are  seen  lying  in 
the  tissue  where  the  latter  is  invested  with  squamous  epithelium.  In 
the  orcein-stained  preparation  (Fig.  6),  gland-tissue,  at  the  same  spot, 
lies  fairly  enclosed  in  the  peripheral  limit  of  the  elastic  element  where 
this  is  spread  out  towards  the  floor  of  the  ventricle,  without  the  inter- 
vention even  of  muscle-fibre. 

There  is  no  gland-tissue  in  the  thicker,  apical  or  main  portion  of 
the  cord,  although,  as  seen  in  the  orcein-stained  section,  gland-ducts 
penetrate  the  connective  tissue  intervening  between  the  elastic  and 
the  squamous  epithelium,  close  to  the  summit  of  the  ridge. 

In  the  subglottic  area  glandular  structure  reappears  in  abundance. 


74  The  Journal  oi  Laryngology^         [March,  is2o. 

its  higher  portion  being  included  in  elastic  tissue,  and  the  epithelium 
of  the  suprajacent  mucosa  being  squamous-celled.  As  seen  in  Fig.  6, 
one  of  the  ducts,  lined  with  columnar  epithehum,  passes  upwards  to 
open  on  the  surface  of  the  cord  a  short  distance  below  the  summit  of 
the  ridge. 

Shattock  comes  to  the  foUmoing  conclusions  : 

(1)  That  the  area  which  may  be  assigned  to  the  vocal  cord  is  best 
described  as  from  a  point  at  the  periphery  of  its  superior,  horizontal 
or  ventricular  surface,  where  the  columnar  epithelium  ends  and  the 
squamous  epithelium  begins,  to  the  junction,  on  its  inferior  or  sub- 
glottic surface,  of  the  squamous  and  true  columnar-celled  epithelium 
of  the  trachea. 

(2)  That  an  adenoma  may  arise  in  the  peripheral  portion  of  the 
upper  moiety  of  the  vocal  cord,  whence  it  may  extend  so  as  to  involve 
the  more  prominent  edge  of  the  latter.  Or,  arising  in  the  adjoining 
floor  of  the  ventricle,  it  might  secondarih^  implicate  the  cord.  And, 
lastly,  an  adenoma  may  originate  in  the  lower  or  infraglottic  face  of  the 
vocal  cord. 

Bibliography. 

(1)  Krishabeb  (Paris). — "Diet.  Encycloped.  des  Sciences  Medicales,"  Paris, 
1867  ;  "  Sub-sections  Pathologie  Chirurgicale,"  p.  759  ;  also  "  Phthisie  pulmonaire," 
p.  92. 

(2)  BoswoKTH  (Xew  York). — "Diseases  of  the  Xose  and  Throat,"  1S92,  Amer. 
edit.,  p.  727. 

(3)  Wright,  Jonathan  (Brooklyn). — Article,  " Neoplasms  of  the  Upper  Air- 
passages,"  De  Schweinitz  and  Eandall's  "  Text-book  of  Diseases  of  the  Eye,  Ear, 
Nose  and  Throat,"  Philadelphia,  1899,  p.  727. 

(4)  Gerhardt,  C.  (Berlin). — "  Kehlkopfgeschwiilste,"  Nothnagel's  "Spec.  Path, 
und  Therapie,"  1896  ;  cited  by  Ballenger,  "  Diseases  of  the  Nose,  Throat  and  Ear," 
1908,  p.  518. 

(5)  Schwartz,  C.  E.  (Paris). — "Des  Tumeurs  du  Larynx,"  Paris,  1866:  cited 
by  Bosworth,  op.  cit.,  p.  727. 

(6)  Ktle  (Philadelphia).—"  Diseases  of  the  Nose  and  Tl  roat,"  1900,  p.  202. 

(7)  Mackenzie,  Morell. — "Diseases  of  the  Throat  and  Nose,"  1880,  i,  p.  313: 
"Growths  in  the  Larynx,"  London,  1871,  pp.  28,  52,  75  and  186  ;  also  iHeci.  Times 
aiid  Gazette,  1870,  ii,  p.  77  ;  Trans.  Path.  Soc.  Lond.,  1870,  xxi,  p.  51. 

(8)  Browne,  Lrnnox. — "The  Throat,  Nose  and  their  Diseases,"  1899,  pp.  27 
and  658. 

(9)  Ingat.s,  Fletcher  (Chicago). — "  Diseases  of  the  Chest,  Tluoat  and  Nasal 
Cavities,"  1899,  p.  467. 

(10)  Leffert.s  (New-  York). — Article,  "  Benign  Growths  of  the  Larynx," 
Intevnat.  Clinics,  1892,  i,  2nd  Series,  p.  345. 

(11)  Semon,  Felix. — "A  Clinical  Lecture  on  Benign  Growths  in  the  Larynx," 
Clin.  Journ.,  February  20, 1895. 

(12)  Massei  (Naples).— ^rch.  ital.  di  laringol,  Napoli,  1885,  v,  pp.  75  and  76 ; 
also  1897,  xvii,  pp.  110-120;  cited  by  Shurley,  "  Diseases  of  the  Nose  and  Throat," 
1900,  p.  563  ;  also  cited  by  Schmiegelow,  Rev.  de  Laryngol.,  1891,  xi,  p.  673. 

(13)  Fauvel  (Paris).— "Traite  pratique  des  Maladies  du  Larynx,"  Paris,  1876. 

(14)  Schmidt,  Moritz  (Frankfort).— "  Krankheiten  der  oberen  Luftwege," 
Berlin,  1909 ;  cited  by  Jonathan  "Wright  in  Schweinitz  and  Randall's  text-book 
of  "  Diseases  of  the  Eye,  Ear,  Nose  and  Throat,"  Philadelphia,  1899,  ii,  pp.  1075 
and  1104 ;  cited  also  by  Ballenger,  "  Diseases  of  the  Nose,  Throat  and  Ear,"  1908, 
p.  519. 

(15)  Cornil  and  Eanvier  (Paris). — "Manuel  d'Histologie  Pathologique,"  Paris, 
1869,  p.  289  ;  cited  by  Jonathan  Wright  in  Schweinitz  and  Randall's  "  Text-book 
of  Diseases  of  Eye,  Ear,  Nose  and  Throat,"  Philadelphia,  1899,  ii,  p.  1108. 

(16)  JuRASz  (Heidelberg). —  Heymann's  Handbuch  der  Laryngologie  und  Rhino- 
logie,  Vienna,  1898,  Bd.  i,  Abt.  ii,  p.  84. 

(17)  Bruns,  Paul  (Berlin). — "Die  Laryngotomie  zur  Entfernung  intralaryn- 


March,  1920.]  Rhinology,  and  Otology.  75 

gealer  Xeubildungen,"  Berlin,   187S,  Tab.  iv,  p.  56  ;  "  Polyiien  des  Kehlkopfes," 
Tubingen,  1868,  pp.  30-31 ;  Med.  Examiner,  1878,  iii,  p.  448. 

(18)  BocKEL  (Kiel). — Gaz.  Med.  de  Strasbourg,  1876,  No.  7,  p.  84;  cited  by 
Bruns,  02>.  cit.,  p.  56. 

(19)  Herard  and  Corxil  (Paris). — Cited  by  Krishaber,  sub-sect.  "  Phthisie 
pulmonaire,"  in  "  Diet.  Encycloped.  des  Sciences  Medicales,"  Paris,  1867,  p.  92  ; 
cited  by  Morell  Mackenzie,  "  Growths  in  the  Larj-nx,"'  1871,  p.  52. 

(20)  ScHMiEGELOW  (Copenhagen). — "  Un  cas  d'adenome  du  larynx,"  Rev.  de 
Laryngol.,  1891,  xi,  p.  673. 

(21)  LuBLiXEB  (Warsaw). — "Medycyna,"  1892,  No.  28;  absti-act,  Journ.  of 
Laetxgol.,  Ehixol.,  and  Otol.,  1893,  vii,  p.  196. 

(22)  Marsh,  F.  (Biriiiingham). — Journ.  of  Lartxgol.,  Ehixol.,  and  Otol., 
1894,  viii,  p.  504. 

(23)  "WoLFENDEN  and  Martin. — "  Studies  in  Path.  Anat.,  especially  in  Eelation 
to  Laryngeal  Neoplasms,"  1888. 

(24)  CoRRADi  (Verone). — "  Un  cas  de  Adenome  de  la  corde  vocale  droite," 
Ann.  des  Mai.  de  Voreille,  du  larynx,  etc.,  1895,  No.  1,  p.  60;  abstract.  Revue  de 
Laryngologie,  1895,  p.  1059. 

(25)  Zenker  (Koningsberg). — Article,  "Histologic  der  Oberen  Liiftwege,"  in 
Prankel's  Archiv,  1909,  Bd.  xxii,  p.  155. 

(26)  TiLLET,  Herbert. — "  Laryngeal  Tumour ;  (?)  Adenoma  of  Eight  Ventri- 
cvilar  Band,"  Proc.  Roy.  Soc.  Med..,  1914,  vii  (Sect.  Laryngol.),  p.  111. 

(27)  Macleod,  a.  L.  (Leicester). — "Microscope  Specimens  and  Eeport  of  a 
Case  of  Adenoma  of  the  Vocal  Cord  removed  by  Thyro-fissure,"  Proc.  Roy.  Sot-. 
Med.,  1919,  xii  (Sect.  Laryngol.),  p.  148. 

(28)  Chiari  (A^ienna). — Cited  by  Lennox  Brown,  "Throat,  Nose,  and  their 
Diseases,"  1899,  p.  27. 

(29)  ScHAFER. — "  Text-book  of  Micros.  Anat.,"  "  Quain's  Anat.,"  ii,  pt.  1,  p.  575. 

(30)  GoTTSTEiN  (Breslau). — "Diseases  of  the  Larynx"  (ti'anslated  by  P. 
McBride),  1883,  pp.  6  and  9. 

(31)  Fraenkel,  B.  (Berlin). — Arch,  fur  Laryngol.,  Bd.  i.  Heft  2  ;  cited  by 
Sajons,  Ann.  Univ.  Med.  Sci.,  1895,  i%',  D.,  p.  84. 

(32)  Desvernine,  C.  M.  (Cuba).— "A  Contribution  to  the  Normal  and  Patho- 
logical Anatomy  of  the  Vocal  Bands,"  "  Cronica  Medica  Medico-Quirurgica,"  and 
rewritten  in  English  by  the  author  (Havana:  Soter,  Alvarez  &  Co.,  1888) ;  review  by 
R.  Norris  "Wolfenden,  Journ.  of  Lart.ngol.,  Ehinol.,  and  Otol.,  1888,  ii,  p.  337. 

(33)  Coyne,  P.  (Paris). — "Eesultats  des  recherches  svu-  la  structure  de  la 
membrane  muqueuse  du  laiynx,"  Compt.  Rend.  Soc.  de  Biol.,  1874  (Paris,  1878), 
6th  Serv.,  i,  p.  13. 

(34)  HoRNE,  JoBSON.  — Discussion  on  paper  bj^  Irwin  Moore  and  S.  G.  Shattock, 
"  The  Normal  Histology  of  the  Vocal  Cord  and  Ventricle  of  the  Larynx,  considered 
in  connection  with  the  Development  of  Adenomata,"  P)-oc.  Roy.  Soc.  Med.,  1919,  xii 
(Sect.  Laryngol.),  pp.  199-208. 

(35)  Shattock,  S.  G.,  with  Irwin  Moore.  —  Vide  Irwin  Moore. 

(36)  LuscHKA,  H.  (Tubingen). — "Der Kehlkopf  des Menschen," Tubingen,  1871 ; 
"  Zeitschrift  fiir  rationelle  Medicin,"  3  Eeihe,  Bd.  xi ;  "  Die  Schleimhaut  des 
Cavum  Laryngis,"  Arch,  fiir  mikroskop.  Anatomie,  Bd.  v.  Heft  i. 

(37)  MooRE,  Irwin,  and  S.  G.  Shattock. — "The  Normal  Histology  of  the 
Vocal  Cord  and  Ventricle  of  the  Larynx,  considered  in  connection  with  the 
Development  of  Adenomata,"  Froc.  Roy.  Soc.  Med.,  1919,  xii  (Sect.  Laryngol.), 
p.  201. 

(38)  ScHEPPEGBELL  (New  Orleans). — "  Non-malignant  Tumours  of  the  Larynx," 
Med.  and  Surg.  Journ.,  New  Orleans,  1893. 

(39)  Schroetter  (Vienna).—"  Krankheiten  des  Kehlkopfes,"  1892. 

(40)  ScHWEiNiTz  and  Eandall  (Philadelphia). — American  text-book  of 
"  Diseases  of  Eye,  Ear,  Nose  and  Throat,"  Philadelphia,  1899,  ii,  p.  727. 

(41)  Shurley,  Ernest  L.  (Detroit). — "Diseases  of  Nose  and  Throat,"  1900. 

(42)  Stricker,  S.  (Vienna).— "  Manual  of  Human  and  Comparative  Histology  " 
(translated  by  Henry  PoAver),  Ke^v  Sydenham  Soc.  Trans.,  London,  1S72,  p  45. 

(431  Theisen,  Clement  F.  (Albany,  N.Y.). — "Adenomata  of  the  Upper  Part 
of  the  Trachea,"  Trans.  Amer.  Laryngol.  Assoc,  1906,  p.  271. 

(44)  Wolfenden,  Norris. — "'  On  Angiomata  of  the  Larynx,"  Journ.  of 
Laryngol.,  Ehinol.,  and  Otol.,  1888,  ii,  p.  337. 

(45)  Henle  (Gottingen). — "  Handbuch  der  systematischen  Anatomie  des. 
Menschen,"  Braunschweig,  1873,  "  Anatomie  des  Kehlkopfes,"  Bd.  ii. 


76  The  journal  of  Laryngology,  March,  1920. 


NOTE    ON    THE    ANATOMY    OF    THE    MEMBRANOUS 
LABYRINTH. 

By  J.  K.  MiLXE  Dickie,  M.D.,  F.E.C.S.Edin., 

Toronto,  Canada. 

(Late  Aural  Surgeon,  Leith  Hospital.) 

The  object  of  this  short  note  is  to  bring  out  a  few  points  in  the  minute 
anatomy  of  the  membranous  structures  in  the  vestibule  of  the  ear  which 
are  perhaps  not  very  generally  recognised. 

A  reconstruction  model  showing  the  middle-  and  inner-ear  structures 
was  made  some  years  ago  by  Dr.  J.  S.  Fraser  and  myself  (1),  and  shown 
at  the  International  Congress  in  London  in  1913.  The  model  on  which 
this  paper  is  for  the  most  part  based  was  reconstructed  by  the  same 
process  from  the  same  specimen  at  a  like  magnification  of  25. 

The  utricle  is  an  elongated  sac  with  which  all  the  semicircular  canals 
communicate.  It  lies  almost  in  the  horizontal  plane,  and  the  ampullar 
of  the  external  and  superior  canals  open  into  its  lateral  extremity.  At 
its  inner  or  medial  extremity  the  crus  commune,  the  ampullae  of  the 
posterior  canal  and  the  posterior  end  of  the  external  canal  join  it.  The 
posterior  or  inner  end  of  the  external  canal  does  not  communicate  by  a 
small  opening  with  the  uti'icle  as  is  generally  supposed.  The  canal  a 
short  distance  from  its  end  widens  into  a  flattened  cone,  which  joins  up 
with  the  inner  or  medial  end  of  the  utricle  at  right  angles,  i.e.  in  the 
antero-posterior  direction  (Fig.  1).  Just  in  the  angle  between  the 
ampulhe  of  the  posterior  canal  and  the  posterior  limb  of  the  horizontal 
canal  is  a  deep  groove  which  corresponds  with  a  ridge  projecting  into 
the  cavity  known  as  the  crista  quarta.  This  ridge  is  prolonged  upwards 
across  the  medial  wall  of  the  horizontal  canal  at  the  point  where  it 
joins  the  utricle.  It  is  covered  by  a  thick  layer  of  epithelial  cells.  In 
this  specimen  and  in  two  others  examined  no  hairs  nor  a  definite  cupula 
could  be  seen  though  the  crista  was  otherwise  quite  distinct.  The 
ridge  across  the  posterior  end  of  the  external  canal  was  equally  well 
marked  in  a  four-mbnths  foetus  (127  mm.  vertex  breech  measurement) 
which  was  examined  in  serial  sections.  No  definite  cupula  nor  hairs 
could  be  discovered,  though  the  cristae  ampullarum  showed  very  distinct 
cupulge  and  hairs.    The  maculae  also  showed  otolith  membranes  and  hairs. 

The  crista  quarta  is  a  fairly  well-developed  organ  in  lower  vertebrates, 
but  in  the  higher  vertebrates  it  is  present  in  only  a  rudimentary  form. 
It  was  noted  in  fishes  by  Retzius  (2),  who  regarded  it  as  a  macula 
rather  than  a  crista  and  named  it  the  macula  negiecta.  According  to 
Benjamins  (3),  it  is  present  in  most  mammals  as  a  small  round  hillock 
with  a  few  long  hairs  situated  near  the  ampulla  of  the  posterior  canal. 
A  small  twig  from  the  nerve  to  the  posterior  ampulla  gives  it  its  nerve 
supply.  In  the  mouse  and  the  pig  there  is  a  crista  quarta  and  also  a 
separate  epithelial  ridge  across  the  opening  of  the  horizontal  canal.  In 
their  embryos,  however,  these  two  structures  are  continuous.  Benjamins 
has  also  traced  the  origin  of  the  crista  quarta  in  developing  bony  fishes 
from  the  epithelium  of  the  macula  sacculi.  According  to  him  it  arises 
in  reptiles  and  mammals  from  the  wall  of  the  utricle  as  a  raised 
epithelial  hillock,  which  later  in  development  separates  into  two,  viz. 
the  crista  quarta  and  the  ridge  across  the  opening  of  the  horizontal 
canal.  In  all  animals  the  crista  quarta  develops  later  than  the  cristas 
ampullarum. 


March,  1920.] 


Rhinology,  and  Otology. 


11 


As  is  already  well  known,  the  superior  and  posterior  canals  are  both 
vertical  but  at  right  angles  to  each  other.  They  are  frequently 
referred  to  as  the  frontal  and  sagittal  canals  respectively.  This  is 
incorrect,  as  they  do  not  lie  in  those  planes,  but  in  planes  45  from 
them.  Thus  the  right  and  left  superior  canals  together  make  a  right 
angle  which  is  bisected  by  the  middle  line  of  the  head.  The  two 
posterior  canals  similarly  lie  at  right  angles  to  each  other.  In  other 
words  the  right  superior  canal  is  in  a  plane  parallel  with  the  left 
posterior  canal,  and  the  left  superior  canal  is  in  a  plane  parallel  with 


Fig.  1. — Membranous  labyrinth  seen  from  behind  and  from  the  inner  side. 
1.  Crvis  commune.  2.  Ampulla  of  superior  canal.  3.  Ductiis  utriculo- 
saccularis.  4.  Saccule.  5.  Ductus  reuniens.  6.  Crista  qixarta.  7.  Pos- 
terior canal.     8.  External  canal. 


the  right  posterior  canal.  The  two  external  canals  are  in  the  same 
plane,  which  slopes  downwards  and  backwards  at  an  angle  of  about  30^ 
with  the  horizontal  when  the  head  is  in  the  upright  position.  The 
external  canal  is  much  shorter  than  the  superior  and  posterior  canals. 
In  the  case  of  all  three  the  endolymph  canal  lies  against  the  outer  wall 
of  the  bony  canal  and  thus  the  maximum  circumference  of  them  both  is 
identical. 

With    regard    to    the    ampullae    of    the    semicircular   canals,   it    is 
noteworthy  that  each    ampulla  projects   inwards  towards   the   centre 


78 


The  Journal  of  Laryngology, 


"March.  1920, 


of  the  arc  formed  by  the  canal.  The  crista  ampullaris  lies  on  the 
outer  edge  of  the  arc — an  arrangement  by  which  any  movement  of  the 
endolymph  would  be  caught  by  the  crista  to  the  greatest  advantage. 

The  saccule  is  much  smaller  than  the  utricle,  and  seen  from  the 
front  is  roughly  circular  in  outline.  Its  posterior  surface,  however,  is 
prolonged  backwards  in  the  form  of  a  cone,  the  upper  surface  of  which  is 
in  contact  with  the  under  surface  of  the  utricle— in  fact  the  two 
structures  here  have  a  common  wall  separating  their  cavities.  The 
inferior  edge  is  prolonged  downwards  and  backwards  in  a  slender 
flattened  tube,  the  ductus  reuniens,  which  lies  on  the  terminal  part  of 


Fig.  2. — Membranous  labyrinth  seen  from  the  front  and  from  the  inner  side. 
1.  Ampulla  of  external  semicircular  canal.  2.  Ampulla  of  su|)erior  canal. 
3.  Utricle.  4.  Saccule.  5.  Ductus  reuniens.  6.  Ampulla  of  posterior 
canal.     7.  Ductus  endolymphaticus.     8.  Crus  commune. 

the  lamina  spiralis  ossea  and  joins  up  with  the  basal  extremity  of  the 
scala  media  of  the  cochlea.  The  ductus  reuniens  gradually  widens  into 
the  scala  media  at  its  furthermost  extremity,  with  which  it  is  directly  con- 
tinuous (Fig.  4).  It  is  usually  represented  as  joining  the  cochlear  duct  a 
short  distance  from  where  it  was  supposed  to  end  in  a  blind  extremity. 
I  was  much  interested  in  looking  through  Dr.  Albert  Gray's  book  (4), 
on  the  comparative  anatomy  of  the  ear,  to  note  that  in  his  photograph 
of  the  labyrinth  of  a  tiger  the  ductus  reuniens  was  of  the  shape  here 
described,  but  I  was  unable  to  trace  it  with  certainty  in  his  other 
illustrations  of  mammalian  labyrinths. 


March,  1920.] 


Rhinology,  and  Otology. 


79 


The  lumen  of  the  ductus  reuniens  is  very  small,  the  superior  and 
inferior  walls  lying  almost  in  contact  with  each  other.  According  to 
Anna  Kraut  (5),  the  ductus  reuniens  is  usually  closed  in  adult  man,  as 
also  in  rabbits,  sheep  and  dogs,  while  it  is  open  in  pigs.  However,  in 
this  specimen  the  lumen  could  be  seen  in  its  whole  extent,  while  in 
another  specimen  the  lumen  could  be  followed  from  the  saccule  to  a 
point  just  short  of  where  it  opened  into  the  cochlea.  For  a  short 
distance  the  walls  were  here  in  apposition  and  the  cavity  obliterated. 


Fig.  3. — Lateral  and  posterior  view  of  labyrinth.  1.  Posterior  canal.  2. 
Ductus  reuniens.  3.  Saccule.  4.  Utricle.  5.  External  canal.  0.  Superior 
canal. 


The  saccule  communicates  indirectly  with  the  utricle  by  the 
Y-shaped  ductus  utriculo-saccularis.  This  structure  forms  the  stalk  of 
the  ductus  endolymphaticus.  The  saccular  limb  of  the  duct  is  much 
longer  and  thinner  than  the  utricular  limb,  the  latter  being  only  half  the 
length  of  the  former.  The  ductus  endolymphaticus  thus  formed  runs 
inward  a  short  distance,  then  turns  abruptly  downwards  almost  at  right 
angles,  and  widens  into  the  saccus,  which  emerges  from  a  narrow  cleft 
on  the  posterior  surface  of  the  temporal  bone.  At  the  point  where  the 
duct  changes  its  direction  it  becomes  verv  narrow  indeed. 


80 


The  Journal  of  Laryngology.  [March,  1920. 


In  three  specimens  examined  the  maculye  could  be  well  seen.  The 
macula  utriculi  occupies  the  greater  part  of  the  outer  half  of  the  inferior 
surface  of  the  utricle.  It  extends  round  a  short  distance  on  to  its 
external  surface.  The  macula  sacculi  lies  on  the  anterior  surface  of  the 
saccule,  that  is,  in  a  plane  at  right  angles  to  the  macula  utriculi.  The 
maculae  are  very  richly  supplied  by  a  large  branch  of  the  vestibular 
nerve,    which   accompanies    the   nerve   to    the   external    and   superior 


Fig.  4. — Membranous  sti'uctures  in  vestibule  from  the  front.  1.  Nerve  to 
superior  and  external  ampiillse.  2.  Facial  nerve.  3.  Part  of  tensor  tympani. 
4.  Utricle.  5.  Footplate  of  stapes.  6.  Saccule.  7.  Scala  media  of  cochlea. 
8.  Scala  tympani.  9.  Ductus  reuniens.  10.  Nerve  to  posterior  ampulla. 
11.  Ductus  iitriciilo-saccixlaris  or  commencement  of  ductus  endo- 
lymphaticiis. 


ampullae,  and  reaches  the  saccule  and  utricle  from  above.     Between 
these  two  organs  the  nerve-fibres  form  a  dense  network. 

In  considering  the  structure  and  form  of  the  external  canal  a  few 
points  arise  which  require  further  investigation.  Why  does  this  canal 
differ  so  markedly  in  form  from  the  others  ?  Is  the  wide  posterior  end 
to  be  regarded  as  a  rudimentary  ampulla,  containing  as  it  does  a  small 
crista?  Has  the  crista  quarta  any  function  in  man  ?  I  have  not  been 
able  to  see  a  very  definite  cupula  or  hairs,  but  nerve-fibres  can  be 
distinctly  seen  to  reach  it. 


March,  1920.] 


Rhinology,  and  Otology. 


81 


In  conclusion,  I  wish  to  express  my  thanks  to  Dr.  J.  S.  Fraser  for 
placing  some  of  his  specimens  at  my  disposal.  The  work  was  carried 
out  in  the  laboratory  of  the  Eoyal  College  of  Physicians,  Edinburgh. 


md  J.   K. 


References. 
Milne  Dickie.- 


-Journ.  of  Anat.  and  Phys.,  vol. 


(1)  J.  S.  Fr.\ser 
xlix,  January,  1915. 

(2)  Eetzius. — "  Das  Gehororgan  der  Wirbeltiere,"  Stockholm,  18S1  and  1884. 

(3)  Benjamins,  C.  A.—Zeitschr.f.  Ohrenheilk.,  BdAxxiii,  1913. 

(4)  Gray  A.  A.—"  The  Labyrinth  of  Animals,"  J.  &  A.  Churchill,  19.07. 

(5)  Kraut,  Anna. — Zeitschr.f.  Ohrenheilk.,  Bd.  Ix. 


THE  SEMICIRCULAR  CANALS:  A  SIMPLE  METHOD  OF 
DEMONSTRATING  THEIR  RELATIVE  POSITION  TO  EACH 
OTHER  AND   THEIR   PLANES   OF   INCIDENCE. 

By  J.  D.  LiTHGOw,  F.R.C.S.Edin., 

Assistant  Surgeon  Ear  Department,  Eoyal  Infirmary,  Edinburgh. 

Diagrams  and  paper  or  card-schemes  of  the  semi-circular  canals  either 
fail  to  give  the  correct  planes  of  the  canals  or  their  relative  positions, 
so  in  spite  of  their  simplicity  are  misleading. 


Left   Vestibule. 

A.  Superior  semi-circular  canal. 

B.  Posterior  semi-circular  canal. 

C.  External  semi-circular  canal. 

D.  Utricle  (position  of). 
.    ,     .     •     '                        E.  Ampulla?. 

JV.B.— Cut  out  along  dotted  lines.     Then  fold  along  broken  lines  at  right  angles 
to  A  and  towards  you— first  C  then  B. 

6 


S2  The  journal  of  Laryngology,  March,  1920. 

Elaborate  models,  however  minutely  correct  and  carefully  studied, 
leave  one  without  any  clear  image  of  the  two  most  important  facts  they 
should  demonstrate,  namely,  the  planes  in  which  the  canals  work  and 
their  relative  position  to  each  other.  The  above  scheme  gives  a  clear 
after-image  of  both  these  points  and  may  be  easily  made  in  a  few  minutes. 
Paper,  cardboard,  tin  or  thin  brass-sheet  may  be  used.  The  model 
represents  the  canals  of  the  left  side,  but  if  folded  in  the  reverse 
way  and  looked  at  as  a  transparency  it  will  show  relations  as  of  the 
right  side.  The  same  effect  may  be  got  by  observing  the  mirror  image. 
A  model  made  of  wood  with  hinges  along  the  long  broken  folding  lines, 
and  painted  on  both  sides  and  marked  right  and  left  canals  respec- 
ti-vely,  makes  a  useful  class  specimen  for  handing  round.  You  will  see 
upon  making  the  above  model  the  exact  profile  of  the  canals  as  viewed 
through  the  transparency  of  a  corrosion  specimen  of  the  petrous  bone. 
This  profile  could  never  be  represented  by  the  three  sides  of  a  box  as  is 
usually  tried. 

Based  upon  the  above,  I  am  having  constructed  a  bilateral  model,  to 
fasten  on  a  patient's  head.  It  is  for  the  purpose  of  demonstrating  and 
recording  the  after-nystagmus  as  of  a  normal  control  under  similar 
rotation. 


CLINICAL     NOTES. 


DIGITAL     RETRACTION    OF    THE    EPIGLOTTIS    DURING    INDIRECT 

LARYNGOSCOPY. 

By  Archer  Eyland,  F.R.C.S.Edin., 

Assistant  Surgeon,  Central  London  Ear,  Nose,  and  Throat  Hospital. 

The  purpose  of  the  following  remarks  is  merely  to  emphasise  the 
occasional  value  of  the  forefinger  as  an  epiglottis  retractor  during 
indirect  laryngoscopy,  especially  in  those  cases  where  the  epiglottis 
proves  a  troublesome  obstacle  on  account  of  its  dependent  position,  or 
on  account  of  excessive  retroflexion  resulting,  for  example,  from  the 
presence  of  an  epiglottic  cyst  upon  its  lingual  surface. 

Excessive  retroflexion  of  the  epiglottis  is  of  not  infrequent  occur- 
rence. There  are  various  ways  of  dealing  with  it.  The  digital  method 
of  meeting  the  difficulty  is  only  brought  forward  now  on  the  ground  of 
its  extreme  simplicity  and  effectiveness. 

As  to  the  methods  already  at  our  disposal,  these  may  be  briefly 
summarised  as  follows : 

(1)  A  specially-designed  positional  relation  as  regards  patient  and 
observer. 

(2)  Use  of  a  suitable  tongue  depressor,  and  in  such  a  way  as  to 
force  the  whole  tongue  downwards  and  forwards,  thereby  lifting  the 
epiglottis  from  the  posterior  wall. 

(3)  The  employment  of  a  specially-devised  tongue-tractor — a  double 
right-angled  instrument — designed  to  exert  strong  forward  pressure 
aga'nst  the  base  of  the  tongue. 

(■i)  Direct  retraction  of  the  epiglottis  by  means  of  a  suitably-curved 
probe. 


March,  1920.]  Rhinology,  and  Otology.  83 

(5)  Insertion  of  a  ligature  through  the  epiglottis. 

(6)  Direct  laryngoscopy. 

Now  as  to  Method  1,  it  can  only  be  said  that  a  successful  result 
may  be  occasionally  attained.  There  will  always  remain  a  considerable 
number  of  cases  in  which  this  procedure  will  be  found  ineti'ective. 

Method  2  is  applicable  only  to  cases  of  moderate  retrofiection,  and 
its  success  rests  upon  the  assumption  that  glottic  traction  will  be 
adequately  imparted  to  the  dependent  portion  of  the  epiglottis. 

Method  3  implies  the  essential  manoeuvre  of  2,  and  it  is  sometimes 
successful.  Very  considerable  pressure  must  often  be  used,  and  the 
epiglottis  cannot  always  be  made  to  share  efticientl}^  the  passive  glottic 
movement.  It  is,  however,  usually  a  more  successful  procedure  than 
that  immediately  referred  to. 

Method  4  is  almost  always  practicable  in  adults  and  should  in  all 
such  cases  be  successful,  assuming  that  the  epiglottis  itself  is  not  the 
seat  of  disease  or  new  growth. 

Method  5  is  unique.  It  affords,  of  course,  the  great  advantage, 
given  by  no  other  method  here  referred  to,  of  liberating  both  hands  of 
the  observer. 

Method  6  would  find  its  application  in  those  cases  wherein,  for  one 
reason  or  another,  4  and  5  are  impracticable. 

The  method  now  advocated  of  dealing  during  indirect  laryngoscopy 
with  the  retroflexed  epiglottis  is  a  method  afforded  by  the  use  of  the 
forefinger. 

Local  cocaine  anaesthesia  of  the  base  of  the  tongue  and  of  the 
posterior  surface  of  the  epiglottis  is,  of  course,  necessary. 

Anaesthesia  may  be  thoroughly  completed  by  applying,  by  means 
of  the  finger-tip,  a  few  crystals  of  cocaine  to  the  posterior  epiglottic 
surface. 

The  forefinger  is  now  inserted,  and  the  upper  edge  of  the  down- 
folded  epiglottis  is  identified  by  touch.  The  terminal  phalanx  is  now 
carried  down  to  the  posterior  surface  of  the  epiglottis,  and  the  organ  is 
firmly  retracted  forwards  and  slightly  upwards  against  the  base  of 
the  tongue.  The  pressure  is  sufficient,  if  necessary,  to  carry  forward 
both  epiglottis  and  tongue,  and  this  is  an  important  respect  in  which 
the  method  offers  advantage  over  Method  -4,  the  one  most  usually 
employed. 

The  mirror  is  now  inserted,  and  the  retraction,  as  just  described, 
will  be  found  to  afford  an  excellent  visual  access. 

It  might  be  supposed  that  the  finger  itself  would  prevent  a  satis- 
factory view,  but  this  is  not  the  case.  Every  part  of  the  upper  aspect 
of  the  larynx  can  be  very  well  seen.  The  method  is  simple,  rapid  and 
efficient. 

Actual  digital  retraction  of  the  epiglottis  itself  is  not  necessary  in 
all  cases.  If  the  tip  of  the  index  finger  be  carried  firmly  down  on  to 
the  median  glosso-epiglottic  ligament,  and  then  used  as  a  depressor 
and  forward  tractor  of  the  tongue,  it  will  be  found  that  in  a  fair 
number  of  cases  the  epiglottis  will  adequately  follow  the  tongue's 
movement. 


84  The  Journal  of  Laryngology,  March,  1920. 

SOCIETIES'     PROCEEDINGS. 


ROYAL  SOCIETY  OF  MEDICINE.— LARYNGOLOGICAL 

SECTION. 

May  3,  1918. 


President :  Dr.  A.  Browx  Kelly. 


Abridged  Report. 

{Continued  from  j).  58.) 

Thyroid  Tumour  at  Base  of  Tongue. — H.  Lambert  Lack. — This 
patient,  an  adult  woman,  shows  a  large  smooth  mass  at  the  base  of  the 
tongue,  just  in  front  of  the  epiglottis.  It  is  presumably  an  aberrant 
thvroid,  and  the  case  is  shown  chiefly  as  a  rarity.  The  tumour  causes 
little  inconvenience,  but  any  suggestion  as  to  diagnosis  or  treatment 
would  be  welcome. 

Mr.  HowARTH  :  I  showed  two  similar  cases  before  the  Section  in  1913, 
when  I  looked  up  all  the  recorded  cases  and  found  that  they  are  not  so 
rare  as  might  be  thought.  I  found  that  up  to  the  end  of  1913  thei'e 
were  records  of  eighty-six  cases,  but  I  have  not  been  able  to  bi-ing  the 
statistics  up  to  date  because  of  the  war.  Both  my  cases  suffered  from 
difficulty  in  swallowing,  and  one  case  had  severe  dyspnoea  when  she  bent 
down.  In  both  some  operation  was  needed.  In  view  of  operation  it  is 
possible  that  removal  of  the  tumour  will  cause  myxoedema  or  thyi'oid 
insufficiency,  and  this  leads  to  the  question  as  to  whether  it  is  the  whole 
thyroid  or  only  part  that  is  aberrant.  I  think  that  it  is  usually  only  a 
part — that  part  which  is  developed  from  the  median  anlagc — and  it 
depends  on  how  much  thyroid  is  developed  from  the  lateral  anlage  as  to 
whether  the  patient  has  enough  thyroid  tissue  to  carry  on  with.  In 
both  my  patients  I  was  able  to  establish  the  fact  that  lateral  lobes  were 
present,  as  I  did  a  preliminary  laryngotomy,  it  being  before  the  days  of 
intratracheal  ether.  If  some  thyroid  tissue  is  present  in  the  neck  and 
the  symptoms  justify  it,  I  think  the  tumour  should  be  removed  through 
the  mouth.  Usually  there  is  a  good  deal  of  bleeding,  especially  in  those 
that  are  not  encapsuled.  External  incisions  seem  to  me  to  be  unnecessary. 
Operation  in  the  present  case  does  not  seem  essential,  as  the  patient  has 
no  special  symptoms.  One  of  my  cases  was  under  observation  for  eight 
years  before  operation  was  thought  justifiable.  These  tumours  may  be 
associated  with  other  abnormalities  of  the  thyro-glossal  tract.  I  recently 
saw  a  patient  with  a  thyro-glossal  cyst,  and  the  laryngeal  mirror  revealed 
a  small  tumour  at  the  base  of  the  tongue,  of  which  she  was  completely 
unaware. 

Mr.  "W.  Sttjart-Low  :  I  introduced  the  method  of  slitting  the  tongue 
from  tip  to  base  in  the  middle  line,  and  so  freely  exposing  the  tumour. 
The  tongue  is  then  rapidly  stitched  up  again,  and  healing  takes  place  at 
once.  I  showed  before  this  Section  a  case  in  which  this  had  been  done — 
viz.  that  of  an  adult  female  whom  I  saw  two  or  three  months  after, 
when  the  operation  had  been  in  every  way  successful,  there  being  no 
recurrence  of  the  tumour.  I  described  the  method  in  1909  in  the 
British  Medical  Journal  in  my  article,  "A  Contribution  to  the  Surgery 
of  Lingual  Thvroids." 


March,  1920.]  Rhinology,  and  Otology.  85 

Mr.  H.  L.  Whale  :  I  had  severe^  bleeding  in  a  case  of  this  nature. 
I  used  an  ordinary  needle-holder  for  curved  needles,  and  broke  four 
needles  in  succession  in  the  substance  of  the  tongue.  I  rescued  them, 
and  the  end  was  satisfactory,  though  the  patient  was  bleeding  all  the 
time. 

Mr.  Harmek  :  I  saw  the  late  Sir  Henry  Butlin  operate  on  several 
of  these  cases  as  long  ago  as  1896,  and  I  think  that  they  are  not  very 
uncommon.  He  performed  a  preliminary  laryugotomy,  as  suggested  by 
Dr.  Bond,  and  plugged  the  pharynx  so  that  blood  could  not  enter  the  air- 
passages  duriug  the  operation.  Tor  large  tumours  he  split  the  tongue 
from  the  tip  to  the  back,  to  secure  a  really  free  exposure.  One  of 
Butlin's  cases  developed  myxoedema  after  operation,  although  there 
seemed  to  be  a  normal  thyroid  gland  in  the  usual  situation.  As  he 
remarks :  "I  have  come  to  the  conclusion  that  these  tumours  should  not 
be  treated  bv  operation  lightly.  The  mere  cutting  oft'  the  tumour  at  the 
base  of  the  tongue  in  Seldowitch's  case  with  a  galvano-cautery  loop  was 
followed  by  symptoms  of  myxoedema." ' 

Submaxillary  Gland  Suppuration.— Dan  McKenzie.— The  patient, 
a  man,  aged  thirty,  has  had  trouble  in  the  left  submaxillary  region  for 
several  months,  and  he  removed  from  the  floor  of  the  mouth,  several 
weeks  ago,  what  he  supposed  to  be  a  displaced  tooth,  but  what  obviously 
must  have  been  a  calculus. 

When  first  seen  a  fortnight  ago  there  were  the  usual  signs  of  abscess 
involving  the  sublingual  and  submaxillary  regions,  and  pus  could  be 
plentifully  squeezed  out  of  Wharton's  duct  in  the  floor  of  the  mouth. 
Under  cocaine  the  abscess  was  freely  opened  from  the  mouth  and  has 
drained  and  dried  up.  But  the  whole  of  the  gland  remains  indiirated 
and  tender.  Calculus  was  looked  for  when  the  abscess  was  opened,  but 
no  debris  could  be  discovered. 

A  Large  Submaxillary  Calculus.— Dan  McKenzie.— This  stoue,  of 
a  roughly  spherical  shape,  measures  17  cm.  by  IS  cm.  (or  nearly  |  in.  by 
^  in.),  and  weighs  1-85  grm.  (or  29  gr.).  It  was  removed  for  the  relief 
of  pain  from  the  floor  of  the  mouth  of  a  man,  aged  fifty-six.  A  general 
antesthetic  was  given,  and  after  the  mucosa  had  been  picked  up  Avith 
forceps  and  freely  slit  up,  the  calculus  was  removed  from  its  bed  by 
means  of  a  Volkmann's  spoon.  It  is  entire  save  for  one  small  frag- 
ment. ^ 

Mr.  TiLLEY :  I  have  had  experience  of  these  submaxillary  gland 
suppurations  in  one  of  my  immediate  relatives.  In  this  instance  the 
patient  had  for  many  years  suffered  from  the  swelling  of  the  submaxillary 
glands,  which,  during  meals,  extended  downwards  nearly  to  the  clavicles, 
and  at  the  same  time  pain  and  irritation  were  intense.  Purulent  dis- 
charge could  be  sc]ueezed  from  Wharton's  duct.  There  was  no  calculus. 
The  operation  consisted  in  removing  the  submaxillary  glands  entirely 
from  the  outside.  When  cut  into  they  were  of  a  greyish-black  colour, 
and  very  foetid.  I  do  not  think  anything  short  of  removal  will  be  of  any 
use  in  i)r.  McKenzie's  case.  Since  removal  my  patient  has  not  suftered 
from  digestive  troubles  nor  from  a  dry  mouth.  I  presume  the  numerous 
other  glands  keep  up  the  necessary  secretion  of  mucus. 

'  Burghard,  "  System  of  Operative  Surgery,"  1909,  ii,  "  Operations  on  Tongue  " 
(Butlin),  p.  213. 

-  The  calculus  is  now  in  the  Eoyal  College  of  Surgeons  Museiini. 


86  The  Journal  of  Laryngology^         ^March,  1920. 

Dr.  Jewell  :  Four  months  ago  I  removed  a  submaxillary  gland  for 
a  similar  condition.  There  was  healing  by  primary  union,  and  the 
patient  has  remained  Avell  ever  since.  Her  pain  was  more  acute  than  in 
Dr,  McKenzie's  case,  being  at  times  almost  unbearable,  and  relieved  by 
the  occasional  passage  of  pus  from  Wharton's  duct  into  the  mouth.  No 
calculus  was  detectable  by  the  probe,  but  the  skiagram  showed  one  in 
the  gland  very  well.  The  gland  was  cut  and  looked  fibrous  to  the  naked 
eye,  and  contained  a  calculus  of  about  the  size  of  a  quarter  of  a  pea. 

Mr.  Harmer  :  I  agree  that  where  there  is  suppui*ation  in  the  sub- 
maxillary gland,  which  has  persisted  for  some  time,  there  is  only  one 
cure,  namely,  removal.  It  is  easy  to  carry  out.  If  the  patient  be  a 
lady,  one  has  to  consider  the  disfigurement  which  may  result. 

Mr.  O'Malley  :  In  a  parotid  gland  case,  the  patient  was  sent  to  me 
for  a  septic  condition  of  the  mouth  and  throat  associated  with  a  poor 
state  of  health.  On  examining  the  mouth  I  found  pus  oozing  into  it 
on  pressure  on  the  parotid,  the  left  parotid  being  enlarged.  It  was  a 
difiicult  problem  to  do  anything  which  offered  a  good  result,  but  I 
suggested  that  the  patient  should  get  some  chewing-gum,  and  chew  it 
half  an  hour  before  a  meal,  so  as  to  stimulate  the  activity  of  the  gland, 
and  then  wash  the  moi;th  out  with  a  solution  of  peroxide.  After  a  few 
months  the  doctor  reported  that  it  had  cleared  up.  It  has  not  recurred, 
and  that  is  over  a  year  ago. 

Mr.  E.  D.  D.  Davis  :  I  have  removed  the  whole  submaxillary  gland 
on  four  occasions — two  for  suppuration,  one  for  endothelioma,  and  a 
fourth  for  pain  and  inflammatory  attacks  following  the  impaction  of 
calculi  in  Wharton's  duct.  The  result  Avas  satisfactory  in  each  case, 
and  there  was  no  disadvantage  arising  from  the  loss  of  the  gland.  In 
the  case  of  a  girl,  in  spite  of  the  fact  that  the  wound  healed  by  first 
intention,  there  was  some  deformity  and  a  depression  owing  to  the  loss 
of  tissue. 

Mr.  H.  L.  Whale:  The  difference  between  the  treatment  of  a  sub- 
maxillary gland  case  and  a  parotid  gland  case  depends  upon  the  fact 
that  the  first  is  very  easy  to  operate  on,  whereas  the  other  is  formidable, 
because  of  the  liability  to  buccal  fistula. 

Dr.  Irwin  Moore  :  I  showed  a  similar  case  at  the  last  meeting  of 
this  Section,  together  with  a  skiagram  which  showed  a  calculus  in  the 
submaxillary  gland.  When  I  operated  I  foimd  the  stone  was  in 
Wharton's  duct,  and  it  was  easily  removed  through  an  incision.  This 
case  now  shown  may  have  another  small  calculus  in  the  gland  which 
would  be  difficult  to  feel,  and  might  account  for  the  induration.  In  one 
case  I  had  years  ago  I  felt  sure  there  was  no  stone  in  the  gland,  but  it 
turned  out  there  was  one.  The  present  case  has  been  improving  since 
the  operation,  and  I  think  that  if  no  further  calculus  is  present  ionisation 
to  the  enlarged  gland  would  cause  a  rapid  subsidence  of  the  swelling. 

Dr.  McKenzie  (in  reply)  :  My  personal  experience  has  been  the 
opposite  to  those  of  other  speakers.  Some  said  they  start  to  operate 
on  a  gland  in  which  they  do  not  expect  to  find  a  calculus,  and  they  find 
one :  but  I  have  started  to  operate  on  a  calculus  which  I  did  not  find. 
I  spent  an  afternoon  looking  for  a  calculus  which  I  had  felt  distinctly 
in  the  floor  of  the  mouth.  I  put  the  patient  under  an  anaesthetic,  and 
made  the  usual  incision,  and,  as  I  did  not  find  the  stone,  I  concluded 
that  my  knife  had  pushed  the  calculus  farther  and  farther,  until  I  found 
myself  under  the  skin  near  the  outside.  I  removed  my  knife  and  took 
a  bit  of  the  gland,  which  was  so  hard  that  I  thought  it  was  carcinoma, 
but  the  microscope  showed  it  to  be  simple  fibrosis.     The  patient  was 


March,  1920.]  Rhinology,  and  Otology.  87 

put  on  potassium  iodide,  and  did  very  well.  It  would  seem  tbei'efore 
that  fibrosis  of  the  submaxillary  gland  may  get  well  if  a  free  incision 
through  the  substance  of  the  gland  be  made.  The  salivary  gland  should 
not  be  removed  unless  it  is  absolutely  necessary. 

A  Large  Dental  Cyst  involying  the  Floor  of  the  Nose. — 
E.  D.  D.  Davis. — ^A  tailor,  aged  thirty,  attended  the  hospital  for  a 
discharging  sinus  in  the  position  of  the  right  upper  central  incisor. 
Six  years  ago  a  cyst  had  been  opened  and  scraped  at  another  hospital 
and  packed  with  gauze  for  a  long  period,  hence  the  sinus.  On  examina- 
tion a  large  cyst  was  found  occupying  the  right  palatal  process  of  the 
maxilla.  The  cyst  extended  from  the  first  right  bicuspid  to  the  left 
central  incisor,  a  width  of  1  in.,  and  its  length  or  backward  extension 
into  the  hard  palate  was  more  than  li  in.  An  opening  has  been  made 
between  the  cyst  and  the  nose,  and  the  floor  of  the  cyst  bulged  the  hard 
palate  downwards  on  the  right  side. 

The  exhibitor  i-emoved  the  cyst  on  April  18,  1918,  and  the  operation 
performed  was  as  follows :  The  right  lateral  iucisor  and  canine  were 
extracted  because  the  roots  of  these  teeth  projected  into  the  cyst. 
The  greater  part  of  the  bony  anterior  wall  was  removed,  and  the 
cyst -wall  was  carefully  peeled  out  and  detached.  The  bony  floor  of 
the  cyst  with  the  exception  of  the  alveolus  was  then  removed,  and  the 
muco-periosteum  of  the  palate  pressed  upwards  to  attempt  to  obliterate 
the  cavity.  The  hole  in  the  roof  of  the  cyst  communicating  with  the 
nose  was  enlarged  and  its  edges  shelved  off.  The  right  maxillary 
antrum  was  explored  and  found  to  be  normal.  A  section  of  the 
cyst-wall  is  shown. 

The  Result  of  the  Removal  of  Large  Dental  Cysts.— E.  D.  D. 
Davis. — Case  1. — A  w'oman,  aged  twenty-six.  had  a  large  dental  cyst 
occupying  the  left  premolar  and  molar  region  from  the  left  canine  to  the 
maxillary  tuberosity.  The  floor  of  the  antrum  was  pushed  up,  but  did 
not  communicate  with  the  cyst.  The  bony  anterior  wall  and  floor  of  the 
cyst  were  completely  removed  and  the  cyst  peeled  out. 

Case  2. — This  case  was  pi'actically  identical  in  position  and  treatment 
as  the  above. 

A  Dental  Cyst  Involving  the  Nose. — E.  D.  D.  Davis.— A  tele- 
graphist, aged  thirty-two,  complained  of  a  swelling  below  the  right  ala  of 
the  nose  of  five  years'  duration.  A  cystic  swelling  occupied  the  right 
canine  region  and  projected  into  the  nose  below  the  anterior  end  of  the 
right  inferior  turbinal.  The  wall  of  the  cyst  within  the  nose  w^as  thin 
and  translucent,  and  with  cocaine  anaesthesia  on  November  12,  1915,  this 
portion  of  the  cyst-wall  was  removed  with  punch  forcejis  to  establish 
drainage  into  the  nose.  The  cyst  has  now  practically  disappeared,  with 
the  exception  of  a  dry  sinus  within  the  nostril. 

The  President  :  On  what  grounds  does  Mr.  Davis  put  down  the  last 
case  as  a  dental  cyst  'i  We  know  that  dental  cysts  may  extend  to  the 
floor  of  the  nose  and  cause  an  elevation  there,  but  there  is  also  a  class  of 
cases  in  which  a  cyst  may  develop  in  the  soft  tissues  of  the  floor  of  the 
nose  and  be  unconnected  with  any  tooth.  Is  not  the  last  case  such  a 
cyst  f  With  regard  to  treatment,  I  have  peeled  out  many  dental  cysts, 
but  it  is  unnecessary,  as  you  can  get  good  results  by  taking  out  a  large 
segment  of  the  cyst  wall,  after  which  the  whole  sac  shrivels. 

Dr.  Paterson  (Cardiff)  :  I  agree  with  Mr.  Davis.    I  have  come  across 


88  The  Journal  of  Laryngology,  March,  1920. 

cases  ■which  have  been  operated  upou  before,  and  I  have  had  to  deal  with 
some  oE  my  own  a  second  time  too.  I  not  only  peel  out  the  cyst 
completely,  but  remove  a  considerable  part  of  the  bone.  Sometimes  there 
is  a  large  cavity  to  obliterate,  and  it  may  be  impossible  to  get  the  cavity 
to  shrink  until  one  has  dealt  with  the  bony  wall  and  removed  the  cyst 
completely. 

Mr.  O'Malley  :  My  experience  coincides  with  that  of  Mr.  Davis  and 
Dr.  Paterson.  During  the  last  year  I  have  had  six  of  these  cases,  which 
were  referred  to  me  by  dental  siirgeons  as  antral  cases.  I  had  some 
difficulty  iu  persuading  them  that  the  antra  were  not  involved,  but  was 
able  to  do  so  by  having  a  skiagram  taken,  with  a  probe  in  the  cyst-cavity. 
Some  came  to  me  after  the  cavities  had  been  opened  and  packed  with 
gauze,  and  were  in  a  filthy  condition.  Opening  must  be  fi-ee.  The  outer 
wall  should  be  taken  away  freely,  so  that  one  removes  the  projecting 
portion  of  distended  bone.  And  where  it  starts  from  the  upper  part  of 
the  cyst  you  can  easily  peel  away  the  lining  wall.  If  you  attempt  to 
dissect  the  lining  wall  of  the  cyst  from  below  it  is  more  difficult. 

Dr.  McKenzie  :  These  cases  may  be  easy  or  difficult  :  perhaps  the 
difference  may  be  due  to  their  size,  as  some  are  very  large.  In  a  patient 
of  mine  the  cyst  had  become  very  large,  tilling  the  wall  of  the  anti-um 
and  causing  great  Ijulging  forwai'd  of  the  cheek.  It  had  been  suspected 
to  be  malignant.  The  bony  covering  of  the  cyst  was  very  thin,  and  all 
that  could  be  done  was  to  obliterate  the  cyst- wall.  But  a  large  opening 
into  the  mouth  was  left.  Later  I  ti-ied  to  close  this  fistula  by  a  plastic 
operation,  but  it  re-formed.  The  final  result  did  not  please  me,  although 
I  cured  the  cyst.  But  only  a  pressing  back  into  place  of  the  greatly 
distended  and  distorted  bone  of  the  superior  maxilla  would  have  rendered 
the  closing  of  the  fistula  possible. 

Mr.  Lack  :  1  agiee  with  the  President  that  the  majority  of  these 
cases  do  well  after  free  opening  :  there  is  no  need  for  dissection. 

Dr.  H.  J.  Banks-Davis  :  I  have  had  such  cases  come  up  to  the  out- 
patient department  for  months  after  operation  Avith  large  holes,  and  I 
cannot  close  them  up.  The  worst  case  I  have  seen  was  that  of  an  old 
gentleman,  aged  eighty,  who  had  had  a  large  cyst  of  the  upper  jaw.  I 
removed  it  freely,  but  I  could  not  get  the  cavity  to  close,  and  he  worried 
about  it  so  much  that  he  was  removed  to  an  asylum,  where  he  remains. 

Dr.  Kelson  :  Patience  is  the  great  thing  with  these  cysts.  I  find 
they  take,  after  opening  and  removal  of  inner  wall,  three  to  six  or  nine 
months  to  fill  up,  but  that  the  end-result  is  satisfactory.  What  does 
Mr.  Davis  propose  to  do  in  his  first  case,  as  the  man  seems  to  be  in  a 
somewhat  parlous  condition,  with  a  large  hole  leading  from  the  mouth  to 
the  nose,  which  does  not  seem  likely  to  close  ? 

Dr.  Irwin  Moobe  :  I  showed  a  case  of  a  nasal  retention  cyst  at  the 
first  meeting  of  this  session.  I  made  up  my  mind  to  do  a  sublabial 
rhinotomy  and  dissect  out  the  cyst,  but  in  the  meantime  the  patient  Avent 
to  Charing  Cross  Hospital  to  have  his  teeth  attended  to.  There  the 
dental  house-surgeon  incised  the  cyst  and  treated  it  by  gauze  packings, 
which  resulted  in  a  cure. 

Mr.  E.  D.  D.  Davis  (in  reply)  :  The  last  case  is  doubtful :  there  was 
a  septic  canine  tooth  on  that  side,  and  the  cyst  was  at  the  apex  of  the 
root.  I  have  no  further  pi-oof  that  it  was  a  dental  cyst.  I  have  seen  a 
considerable  number  of  dental  cysts  which  have  been  opened  and  packed 
or  scraped,  and  the  residt  has  been  very  unsatisfactory  and  the  sinus  has 
persisted  for  years.  The  first  patient,  the  man  I  showed  to-day,  was' a 
difficult  case  and  the  cyst  had  been  packed  for  six  years.     When  I  saw 


March,  1920.]  Rhinology,  and  Otology.  89 

him  there  was  a  discharging  sinus  and  a  large  cavity  to  obliterate  and 
his  operation  was  done  only  fifteen  days  ago.  I  removed  the  floor  of  the 
cyst  so  that  the  niuco-periosteum  may  form  granulation-tissue  to  fill  the 
cavity.  I  agree  with  Mr.  O'Malley  if  one  removes  all  the  bony  anterior 
wall  the  cyst  is  easily  peeled  out,  but  if  you  attempt  to  peel  out  the  ovst 
through  a  small  opening  the  dissection  is  difiicult.  lu  the  cases  of  cvsts 
in  the  molar  region  the  cavities  healed  completely  in  two  months.  In 
my  experience  opening  and  scraping  without  removing  the  cyst-wall  has 
been  decidedly  unsatisfactory. 

{To  be  contmued.) 


ABSTRACTS. 

Abstracts  Editor — W.  Douglas  Harmer,  9,  Park  Crescent,  London,  W.  1. 

Authors  of  Original  Communications  on  Oto-laryngology  in  other  Journals 
are  invited  to  send  a  copy,  or  two  reprints,  to  the  Journal  of  Laryngologt. 
If  they  are  ivilhng,  at  the  same  time,  to  submit  their  ow?i  abstract  {in  English, 
French,  Italian  or  German)  it  will  be  welcomed. 


NASO-PHARYNX. 

Three  Cases   of  Naso-pharyngeal  Fibrous  Polypi. — Texier   (Nantes). 
"  Proc.  French  Soc.  of  Laryngol.,  Otol.,  and  Ehinol." 

If  specialists  be  generally  agreed  that  the  spheuo-ethmoidal  region 
is  the  point  of  implantation  for  naso-pharyngeal  fibrous  po'lyjji,  general 
surgeons  continue  to  hold  the  view  that  they  are  primarily  pharyngeal, 
arising  from  the  basilar  fibrous  investment,  and  invading  secondarily 
the  nasal  fossae.  This  persistence  of  opinion  arises  from  the  fact  that 
they  generally  operate  on  large  tumours  with  multiple  insertions,  and 
neglect  examination  of  the  cavuin  and  nasal  fossae  before  and  after 
intervention.  In  sujjjwrt  of  the  contention  of  the  former  the  author 
added  three  cases  to  those  already  published.  One  of  them  was  especially 
convincing,  since  it  was  possible  to  observe  and  remove  the  polypus 
during  its  eai'ly  development.  It  concerned  a  young  man,  aged  twenty- 
eight,  who  had  been  suffering  from  right-sided  nasal  obstruction  for 
several  years.  Tiie  tumour  was  purely  nasal,  and  occupied  the  choana 
after  the  manner  of  a  choanal  mucous  polypus.  The  cavum  was 
absolutely  free.  Extraction  Avas  effected  by  the  serre-noeud  at  several 
sittings.  Its  seat  of  origin  proved  to  be  the  anterior  wall  of  the 
sphenoidal  sinus,  which  was  freely  removed.  Histological  examination 
confirmed  the  diagnosis  of  fibrous  polypus.  The  two  other  cases 
concerned  extensive  growths,  in  one  of  which  there  was  a  pyriform 
prolongation  on  the  face,  the  size  of  an  egg,  which,  leaving  the 
maxillary  sinus  intact,  had  reached  the  cheek  vii^  the  spheno-palatine 
foramen,  the  spheno-maxillary  and  zygomatic  fossse.  In  both  cases  the 
seat  of  implantation  was  the  region  of  the  sphenoidal  sinus,  with  points 
of  attachmect  to  the  adjoining  ptergoid  process. 

Aboulker  (Algiers).  In  a  child,  aged  eight,  operated  on  for  naso- 
pharyngeal polypus  per  vias  nattirales,  the  author  clearly  observed    the 


90  The  Journal  of  Laryngology,  [March,  1920. 

insertion  of  the  growth  on  the  nasal  roof.  On  a  supei-ficial  examina- 
tion it  appeared  to  be  the  vault  of  the  cavum.  This  is  a  fact  almost 
unanimously  held  to-day  by  surgeons  who  operate  imder  control  of  the 
frontal  mirror.  What  is  less  disputed  is  the  point  of  insertion  of 
naso- pharyngeal  cancers ;  the  author  operated  ou  a  native  by  the 
trans-naso-maxillary  route  for  epithelioma,  which  appeared  to  have 
arisen  from  the  basi-occiput.  The  patient  died  three  weeks  subsequently. 
The  autopsy  revealed  a  tumour  of  the  splienoidal  sinus.  Posterity  will 
say  that  for  malignant  tumours,  as  well  as  for  naso-pharyngeal  polypi, 
the  place  of  origin  is  frequently  extra -pharyngeal. 

Sloure  (Bordeaux).  Eemoved  a  polypus  which  appeared  to  be 
inserted  at  the  postero-superior  part  of  the  pharynx,  but  which  was 
in  reality  attached  to  the  sphenoid  by  a  small  pedicle.  The  author 
thought  it  would  be  useful  to  know  whether  these  polypi  underwent 
involution  after  the  twenty-fifth  year. 

Jacques  (Nancy)  operated  ou  a  patient,  aged  twenty-two,  the  subject 
of  a  naso-pharyngeal  fibi'oma  of  rapid  development.  It  was  possible  to- 
extract  the  prolongations  of  this  growth  via  the  nasal  fossa  after  forcible 
traction.  H.  Clayton  Fox. 

Palatoplasty. — Castex  (Paris).     "  Proc.  French  Soe.  of  Laryugol.,  Otol., 
and  Rhinol." 

Palatoplasty  is  a  ticklish  operation  requiring  certain  operative 
"  knack."  Should  it  be  j^erfoi-med  in  one  or  two  sittings  ?  In  principle 
one  sitting  is  preferable  ;  there  are,  however,  some  cases  which  necessitate 
two  sittings.  The  author  exhibited  a  child  on  whom  he  had  operated. 
At  the  first  intervention  he  sepai-ated  the  flaps,  and  at  the  second  united 
them.  Operating  in  two  stages  is  indicated  in  a  child  under  five  years  of 
age,  because  at  this  period  the  flaps  are  thin,  and  the  inflammation 
resulting  from  the  intervention  thickens  them.  Rose's  position  is  to-day 
unnecessary ;  the  patient  can  remain  recumbent.  The  flaps  must  be 
detached  very  slowly  and  with  gentleness.  Revivifying  should  be  done 
after  detachment.  The  first  sutures  to  insert  are  those  nearest  to  the 
uvula.  All  kinds  of  sutures  can  be  employed  indifferently  ;  the  author^ 
however,  prefers  those  constructed  of  bronze.  When  the  sutures  are 
passed  the  author  only  makes  a  single  knot  so  as  not  to  risk  tightening 
too  much,  and  the  threads  ai-e  left  in  place  until  the  flaps  have  uniteil. 
Asepsis  in  this  operation  is  not  indispensable.  It  is  interesting  to  keej> 
the  patients  operated  on  under  observation  until  adult  age ;  if  the  opera- 
tion lias  succeeded  there  will  be  perfect  union,  if  there  has  been 
suppuration  the  tissues  are  badly  united.  H.  Clayton  Fox. 


EAR. 

Dilatation  of  the  Jugular  Bulb,  filling  the  Tympanum  and  Part  of  the 
Auditory  Meatus. — Lannois  (Lyons).  "Proc.  French  Soc.  of 
Laryugol.,  Otol.,  and  Rhinol." 

A  woman  with  a  history  of  seven  years'  aural  suppuration  presented 
a  polypoid  mass  obstructing  a  part  of  the  auditory  meatus.  Histological 
examination  showed  that  the  mass  was  not  malignant.  The  author 
curetted  the  ear  and  removed  some  fleshy  granulations  ;  some  time  after- 


March,  1920.] 


Rhinology,  and  Otology.  91 


wards  he  i-epeated  the  operation  and  noticed  a  large  purple  polyp,  which 
was  compressible  and  easily  returned  into  the  tympanum.  It  was  a 
dilatation  of  the  jugular  bulb,  bulged  through  a  carious  point  of  the 
bone,  the  result  of  neglected  suppuration  of  seven  years'  standing. 

H.  Clayton  Fox. 

Study  on  the  Structure  of  the  Mastoid  and  Development  of  the  Mastoid 
Cells  :  Influence  of  the  Constitution  of  the  Mastoid  on  the  Evolu- 
tion of  Middle-ear  Inflammation.— Mouret  (Montpellier).    "  Proc. 
French  Soc.  of  Laryngol.,  Otol.,  and  Ehinol." 
The  classical  division  of  mastoids  into  pneumatic,  spongy,  sclerotic  and 
mixed  types   may  be  retained   on  the  condition   of    replacing   the  word 
"sclerotic  "  by  that  of  "  compact."      Sclerotic  mastoid  indicates  a  patho- 
logical condition,  compact  mastoid  only  an  anatomical  one.     Density  is  a 
natural    condition  of  this  bone ;  instead  of  being  the  result  of  chronic 
suppuration  in  pneumatic  cavities  it  is,  on  the  contrary,  one  of  the  factors 
which  predispose  to  the  persistence  of  acute  otitis  and  its  passage  into 
the  chronic  state.     Eburnation  of  the  mastoid  tissue  depends  on — 

(1)  Non-pueumatisation  of  the  bone. 

(2)  The  inherent  tendency  which  each  individual  possesses  to  form 
compact  or  spongy  bone.  This  is  shown  by  the  fact  that  mastoids  in 
very  young  subjects  (one  to  two  months  old)  may  be  already  extremely 
compact. 

A  layer  of  compact  tissue  of  varying  thickness  always  exists  around 
pneumatic  cavities,  which  is  homologous  with  the  peripheral  stratum  of 
bone  termed  cortex.  This  pericentral  layer  is  pericellular  or  central 
cortical. 

So-called  mastoid  sclerosis  is  nothing  else  than  eburnation  of  all  the 
bone  intervening  between  the  two  cortices  ;  the  eburnation  may  be  com- 
plete or  respect  certain  parts  where  the  bone  remains  spongy.  Develop- 
ment of  pneumatic  cavities  accompanies  that  of  the  bone,  and  is  completed 
when  the  growth  of  the  bone  has  ceased.  Nevertheless  during  this  period 
of  growth  the  pneumatic  cavities  may  be  formed  early  or  late,  accoi-ding 
to  the  subject.  This  explains  the  divergence  of  opinions  expressed  by 
authors  who  have  occupied  themselves  with  the  question.  The  outline  of 
the  antrum  is  in  evidence  from  the  fourth  month  of  foetal  life.  At  the 
sixth  month  it  is  frequently  very  large.  Its  high  position  in  the  new- 
born depends  on  the  fact  that  the  mastoid  process,  which  is  in  full 
growth,  has  not  yet  carried  the  antrum  with  it  downwards  and  backwards. 
Highly  situated  antra  in  the  adult  are  always  small.  After  the  antrum 
the  earliest  cells  to  appear  are  those  which  are  developed  in  the  outer  part 
constituted  by  the  squamo-mastoid  ala,  which  the  squamous  bone  sends 
down  on  to  the  mastoid.  These  cells  may  be  well  developed  from  the 
seventh  to  the  eighth  month  of  foetal  life.  After  these  the  next  cells  to 
appear  are  those  of  the  outer  attic  and  tympano-antral  walls.  At  birth 
these  cells  may  be  very  pneumatic.  The  cells  of  the  squamous  bone  are 
thus  the  first  developed.  Then  the  cells  of  the  petrous  bone  appear. 
They  are  developed  in  the  entire  circumference  of  the  petrous  walls  of 
the  petro-antral  cavity,  in  the  mastoid  region,  and  in  the  petrous  portion 
surrounding  the  internal  ear.  All  these  cells  are  formed  by  invagination 
of  the  tympano-antral  cavity  and  communicate  with  each  other.  Those 
furthest  from  the  tympanum  and  antrum  are  the  last  to  develop.  Five 
months  after  birth  the  cells  of  the  subantral  and  peri-labyrinthine  regions 
may  be  very  advanced  in  development.     At  three  years  pneumatisation 


^2  The  Journal  of  Laryngology,         [March,  1920. 

may  be  complete  iu  the  base  of  the  petrous  povticjn.  The  petro- mastoid 
canal  is  independent  of  the  pneumatic  spaces,  but  in  some  cases  the  cells 
may  by  dehiscence  of  their  walls  open  into  its  lumen.  The  squamous 
and  petro-mastoid  cells  form  two  distinct  systems,  separated  from  one 
another  by  the  external  and  internal  petro-squamous  sutures.  Later  on 
the  separating  Avail  becomes  more  or  less  completely  absorbed  and  the 
two  groups  of  cells  communicate.  The  cells  are  usually  arranged  around 
the  antrum  and  tympanum.  In  certain  cases  these  cavities,  few  in 
number,  appear  disseminated  in  the  midst  of  osseous  tissue,  and  may 
thus  form  important  groups  situated  at  a  distance  from  the  antrum  and 
tympanum,  and  from  which  they  appear  isolated ;  but  however  remote 
every  cell  is  always  connected  with  the  others.  An  aberrant  cell  is  never 
isolated,  but  always  communicates  with  the  antrum  or  some  other  cell. 

Pneumatic  cavities  favour  diffusion  of  antral  infection  into  the  depths 
of  the  bone.  They  also  predispose  to  mastoid  complications,  but  the 
symptoms  of  inflammation  iu  pneumatic  mastoids  are  more  fulminating 
than  those  of  spongy  and  compact  structure,  and  in  consequence  attract 
notice  more  readily.  Tympano-autral  suppvirations  are,  on  the  other  hand, 
associated  with  milder  symptoms,  and  are  therefore  more  delusive,  and 
in  consequence  predispose  to  chronicity.  Spongy  and  compact  mastoids 
are  smaller  than  those  of'  pneumatic  structure.  Prolapse  of  the  sinus, 
a  highly  situated  antrum  and  sagging  of  the  cranial  cavity,  are  more 
fi'equently  met  Avith  in  these  types.  Thinness  of  the  tegmen  tympaui  et 
antri  is  also  more  frequent  in  non-pneumatic  mastoids,  hence  intra- 
cranial complications  in  chronic  aural  suppuration  are  more  often  met 
with.  H.  Clayton  Fox. 

Reflections    on    Some    Cases    of   Mastoiditis. — Mouret    (Montpellier). 

"  Proc.  French  Soc.  of  LaryngoL,  OtoL,  and  Khinol." 

Periostitis  and  temporo-mastoid  osteitis  as  sequelae  of  otitis  may 
occur  (1)  during  suppurative  otitis,  (2)  after  its  disappearance,  (3) 
where  there  has  been  tympanitis,  without  the  slightest  symptom  of 
suppuration.  The  osseous  lesions  may  be  situated  in  any  part  of  the 
mastoid  wherever  thei'e  are  cells  ;  they  may  also  occur  in  the  midst  of 
spongy  or  compact  tissue  in  the  vicinity  of  pneumatic  spaces,  and  even  in 
situations  remote  from  any  pneumatic  cavity. 

Periostitis  may  also  be  seated  in  several  situations.  The  author 
distinguishes  : 

(1)  ISuperficial  Temjjoi'al  Periostitis. — It  manifests  itself  on  the 
superior  wall  of  the  auditory  meatus,  aroiind  the  meatus  and  above  the 
insertion  of  the  temporal  aponeurosis  on  the  posterior  root  of  the  zygoma. 

Channels  of  infection  :  Notch  of  Rivinus,  Glasseriau  fissure.  Some- 
times the  petro-squamous  canal,  neighbouring  cellulitis  and  osteitis. 

There  are  two  varieties  — suppurative  and  granulating;  they  have  a 
tendency  to  spread  in  the  subcutaneous  tissues — temporal,  malar,  pre- 
auricular and  palpebral. 

(2)  Deep  Temporal  Periostitis. — Situated  in  the  deep  temporal  fossa. 
Routes  of  extension :  Temporal  ci'ibriform  zone,  petro-squamous  suture, 
supra-glenoid  zygomatic  osteitis  and  external  wall  of  attic.  Characteristics  : 
Diffuse  deep  fluctuation,  trismus. 

(3)  Antral  and  Sub-autral  Periostitis.—  Situeited  in  the  region  of  the 
squamo-mastoid  ala,  limited  by  the  squamo-mastoid  suture.  Way  of 
diffusion  is  ea.sy  over  the  auditory  meatus  towards  the  area  of  superficial 
temporal  periostitis. 


March,  1920/  Rhiiiology,  and  Otology.  93 

Chanuels  of  extension  :  Chipault's  cribriform  zone.  Dehiscence  of  the 
external  cortex.  Osteitis  of  the  antral  and  subantral  zones  and  from  the 
cells  bordering  on  the  posterior  wall  of  the  meatus. 

Characteristics  :  May  sometimes  be  mistaken  for  abscess  of  a  retro- 
auricular  gland  ;  effaces  the  retro-auricular  sulcus  ;  spreads  along  the  upper 
attachment  of  the  pinna  to  the  superficial  temporal  region. 

(4)  Superior  Mastoid  Periostitis. — Located  between  the  squamo- 
mastoid,  masto-parietal,  and  the  masto-occipital  sutures.  The  insertion  of 
the  posterior '  mastoid  muscles  on  the  outer  surface  of  the  mastoid 
coiTesponds  with  the  sinusal  and  cereljellar  regions  of  the  bone. 

Paths  of  extension  :  Mastoid  foramen  and  ^ein,  osteitis,  necrosis. 
Characters :  Less    tendency   to    suppuration ;   retro-auricular   sulcus 
preserved. 

(5)  Suh-masfoid  or  Diuastric  Periostitis. — Situated  between  the  styloid 
process,  posterior  border  of  the  digastric  groove  and  the  inner  surface  of 
the  apex  and  the  inferior  masto-occipital  suture. 

Channels  of  infection:  Stylo-mast oid  foramen,  chief  and  accessory, 
vascular  channels  of  the  digastric  and  occipital  grooves,  osteitis,  cellulitis. 

Characters :  Deep  submastoid  swelling ;  spreads  in  the  neck ;  to  be 
mistaken  for  Bezold's  abscess. 

Apical  pain  is  not  a  sign  of  periostitis,  but  only  of  osteitis  or  eudo- 
mastoiditis  of  the  mastoid  apex.  Even  in  the  absence  of  aural  suppui-a- 
tion  one  cannot  afiirm  that  periostitis  of  otitic  origin  is  unaccompanied 
by  osseous  lesions.  Wilde's  incision  or  any  other  similar  measui'e  can 
only,  therefore,  be  a  tentative  intervention,  although  sometimes  sufficient. 

H.  Clayton  Fox. 


MISCELLANEOUS. 


Haemolytic  Streptococci  in  the  Nose  and  Throat. — M.  S.  Tongs.    "  Journ. 
Amer.  Med.  Assoc. ""     October  4,  1919. 

In  this  interesting  paper  the  author  describes  in  detail  the  culture  and 
morphological  characteristics  of  the  haemolvtic  streptococcus.  Interest 
has  been  aroused  in  this  organism  since  the  outbreaks  of  interstitial 
broncho-pneumonia  following  influenza,  and  a  number  of  expei-iments 
have  been  carried  out  to  detenuine  the  frequency  of  the  occurrence  in 
the  mucous  membrane  of  the  nose  and  throat. 

Examinations  by  culture  were  made  in  567  dispensary  patients,  and  of 
these  67  per  cent,  showed  the  presence  of  the  S.  hxmolyticus  in  the  throat, 
while  in  only  5  per  cent,  was  there  a  positive  culture  from  the  nose. 
Most  of  the  positive  throat  cases  were  school-children  with  enlarged 
tonsils.  A  comparison  was  made  of  the  results  from  cultures  obtained 
from  the  surface  of  the  tonsils  with  those  obtained  from  the  crypts.  Of 
the  cultures  from  the  tonsillar  surface  60  per  cent,  were  positive,  while 
of  those  from  the  crypts  83  per  cent,  were  positive. 

Of  342  persons  examined  at  various  periods  after  tonsillectomy  only 
17  throat  cultures  and  10  nasal  cultures  showed  haemolytic  streptococci. 
Of  5  cases  giving  positive  throat  cultures  remnants  of  the  tonsils  were 
present. 

The  author's  conclusions  are  that  "the  tonsils,  especially  when  hyper- 
plastic, are  a  breeding-place  for  haemolytic  streptococci,  and  complete 


94  The  Journal  of  Laryngology,  [March,  1920. 


tonsillectomy  appears  to  be  followed  in  most  cases  by  the  absence  of 
hsemolytic  streptococci  from  tlie  throat." 

A  full  summary  of  the  literature  on  the  subject  is  included  in  the 
paper. 

/.  K.  Milne  DicJcie. 

Pituitary  Tumour. — A.  W.  Ormond.     "  Proc.  Eoy.  Soc.  Med.,"  August, 
1919,  Section  of  Ophthalmoloijy,  p.  37. 

The  jjatient  was  a  female,  aged  twenty-six.  When  she  came  to 
hospital  (August,  1918),  she  complained  of  inability  to  see  with  the  right 
eye  and  also  aching  ;  vision  in  upper  half  of  field  only.  About  a  month 
ago  her  eyes  started  twitching,  and  then  the  present  condition  set  in. 
Both  optic  discs  red  and  neuritic.  Ozsena.  Bad  smell  in  nose.  Suspicious 
streak  of  pus  in  naso-pharynx. 

On  September  30,  1918,  further  investigation  was  carried  ovit  as 
follows :  Exploration  of  right  antrum,  left  antrum,  right  sphenoid. 
Result  in  each  case  nil.  Removal  of  anterior  portion  of  each  middle 
turbinal. 

Ten  days  later  :  Pain  at  root  of  nose  and  over  inner  cauthus.  Head- 
aches. Discharge  from  both  nostrils,  blood-stained.  Attack  of  misty 
vision  both  eyes.    Optic  neuritis  with  ensheathing  of  veins  of  both  eyes. 

Three  days  later :  Still  offensive  nasal  discharge.  Headaches  per- 
sistent, and  recurring  almost  daily.  Still  gets  attacks  of  loss  of  sight. 
Is  putting  on  flesh.  Right  eye :  sees  above  and  to  outer  side,  but  not  to 
nasal  side  at  all.  Optic  neuritis  with  ensheathing  of  vessels.  Left  eye 
field  full  to  fingers,  but  things  are  not  seen  as  clearly  on  nasal  side  as 
on  temporal.    Optic  disc  is  red  and  slightly  neuritic.    Pituitary  tumour  (?). 

Skiagram  taken.  Sella  turcica  very  much  enlarged,  so  much  so  that 
the  body  of  the  sphenoid  seemed  to  be  eaten  away  to  a  great  extent. 

The  fields  also  are  atypical,  as  the  hemianopia  seems  to  be  more  on  the 
nasal  side  than  on  the  temporal,  and  rather  below. 

The  presence  of  optic  neuritis  on  both  sides,  the  fact  that  the 
patient  is  putting  on  weight  and  the  appearance  of  the  skiagram  all  seem 
to  suggest  pituitary  tumour — ])robably  malignant.         Archer  Ryland. 


REVIEWS. 


John  Coakley  Lettsom,  and  the  Foundation  of  the  Medical  Society  of 
London.  By  Sir  StClair  Thomson.  M.D.,  President  of  the 
Society.  Pp.  62,  with  4  plates  and  14  figures  in  the  text.  London : 
Harrison  &  Sons.     Price  2s.  6d. 

Sir  StClair  Thomson  is  here  figuring  in  the  congenial  role  of  praising 
famous  men  and  the  fathers  that  begat  us. 

Needless  to  say  his  brochure  is  pleasantly  wi-itten,  and  it  is  nicely 
illustrated  with  figures  of  more  than  antic|uarian  interest. 

To  laryngologists  the  following  excerpt  will  be  of  interest : 

"  The  name  of  Babington  is  of  particular  interest  to  myself,  in  common 
with  all  who  j^ractise  laryngology,  for  his  son  came  near  to  inventing  the 


March,  1920.]  Rhinology,  and  Otology.  95 

larynj2;oscope.  In  the  year  1829  Dr.  Benjamin  Guy  Babington  showed 
his  '  glottiscope '  to  the  Hunterian  Society  of  London.  This  consisted 
of  a  laryngeal  mirror,  very  similar  to  those  used  at  the  present  day,  on 
which  he  concentrated  the  sun's  rays  by  means  of  a  common  hand  looking- 
glass.  There  are  no  cases  recorded  in  which  Babington's  glottiscope  was 
employed,  although  he  nsed  it  on  many  patients,  and  a  method  v.hich  de- 
pended on  so  uncertain  a  lumiuary  as  the  sun — at  least,  in  this  climate — 
could  not  be  expected  to  secure  any  general  adoption.  Another  objection 
was  that  it  demanded  the  use  of  the  operator's  two  hands,  the  right  one 
holding  the  laryngeal  mirror,  while  the  left  manipulated  the  hand-glass. 
Still,  in  realising  that  the  one  mirror  would  suffice  for  reflecting  light 
downwards  into  the  larynx,  and  also  for  receiving  the  image  of  the  parts 
thus  illuminated,  Babington  made  a  great  advance  on  all  previous  efforts 
in  this  dii-ection,  and  thus,  by  twenty-six  years,  he  anticipated  G-arcia's 
invention  of  the  laryngoscope  in  1855." 

The  Babington  here  mentioned  was  a  Dr.  Wm.  Babington  (1756— 
1833),  who  figures  in  the  engraving  of  the  founders  of  the  Medical 
Society. 

But  for  these  and  other  matters  of  interest  we  must  refer  our  readers 
to  the  book  itself.  D.M. 

Diseases  of  the  Nose  and  Throat.  By  Herbert  Tilley,  B.S.Lond., 
F.E.C.S.Eng.  With  74  plates  and  numerous  text  illustrations. 
Fourth  edition.  London:  H.  K.  Lewis  &Co.,  Ltd.,  1919.  Price 
25s.  net. 

Nothing  shows  the  surprising  advance  made  in  our  speciality  during 
the  last  twenty  years  like  the  ever-increasing  bulk  of  text-books  such 
as  this  of  Mr.  Tilley's,  the  fourth  edition  of  which  now  lies  before 
us.  Still  maintaining  the  original  style  and  binding,  its  pages  have 
doubled  ill  number,  and  the  thought  naturally  arises  in  our  mind  whether 
we  may  look  forward  to  still  further  conquests  or  whether  we  are  at  last 
nearing  the  limits  of  what  has  been  a  wonderful  progress. 

Needless  to  say,  this  present  version  of  Mr.  Tilley's  work  keeps  up  to 
the  high  standard  of  previous  editions,  and  indeed  in  manv  respects  it 
shows  an  improvement  over  them,  not  only  in  the  subject-matter,  but 
also  in  the  illustrations,  which  seem  to  have  multiplied  both  absolutely 
and  relatively. 

Recent  developments,  such  as  suspension  lar\^ngoscopy,  the  radio- 
graphy of  the  sinuses,  and  diathermy,  receive  adequate  attention,  and 
supply  readers  with  a  clear  and  highly  accurate  account  of  these  modem 
developments.  In  this  connection  we  should  like  to  draw  the  author's 
attention  to  the  phrasing  on  p.  368,  which  reads  as  if  the  heat  around  the 
point-terminal  of  the  diathermy  apparatus  were  generated  in  the  terminal 
and  not,  as  it  really  is,  in  the  tissues  themselves. 

But  oversights  of  this  character  are  rare,  and  we  have  no  hesitation 
in  prophesying  for  this  edition  a  success  as  complete  as  that  which  has 
attended  the  former  editions  of  this  popular  and  readable  handbook. 

B.  M. 


96  The  Journal  of  Laryngologyt         [March,  1920. 


NOTES  AND   QUERIES. 

Section  of   Laryngology  of  the  Eotal  Society  of   Medicine  :    Summer 

Congress,  1920. 

The  Slimmer  Congress  of  the  Section  will  be  held  on  Thursday  and  Friday, 
June  24  and  25.  The  meeting,  which  will  be  devoted  to  a  discussion  and  the 
reading-  of  papers,  will  commence  on  the  Thiirsday  at  2  p.m.  There  will  also  be  a 
Museum  and  an  Exhibition  of  Instruments.  This  meeting  will  take  the  place  of 
the  usual  monthly  meeting  on  June  4. 

Members  who  intend  to  read  papers  are  requested  to  send  the  titles  not  later 
than  April  1 ,  and  summaries  of  their  papers  not  later  than  May  1 ,  to  the  Secretaries, 
Dr.  Irwin  Moore,  30a,  Wimpole  Street,  London,  W.  1,  or  to  Mr.  Charles  Hope, 
58,  Wimpole  Street,  W.  1. 

The  British  Medical  Association. 

The  first  meeting  of  the  above  Association  since  1914  will  take  place  this  year 
at  Cambridge,  from  June  30  till  July  3,  that  is  to  say,  on  the  week  following  the 
Summer  Congress  of  the  Laryngological  Section  of  the  Koyal  Society  of  Medicine 
(see  above  notice). 

At  the  Association  meeting  there  is  to  be  no  special  section  of  Oto-Laryngology, 
but  oto-laryngologists  may  attend  and  read  papers  in  the  surgical  and  other 
sections  if  they  so  desire. 

Otological  Section  of  the  Eoyal  Society  of  Medicine. 
The  next  meeting  of  this  Section  will  be  held  on  March   19.     Notices  and 
papers  to  be  sent  in  not  later  than  May  9.     Secretaries  :  Mr.  H.  Buckland  Jones 
and  Mr.  Lionel  Colledge. 

Laryngological  Section  of  the  Eoyal  Society  of  Medicine. 
The  next  monthly  meeting  of  this  Section  will  be  held  on  May  7.     Notices  and 
papers  to  be  sent  in  not  later  than  April  25.     Secretaries :  Dr.  Irwin  Moore  and 
Mr.  C.  W.  Hope. 


BOOK    RECEIVED. 


John  Coakley  Lettsom,  and  the  Foundation  of  the  Medical  Society  of 
London.  By  Sir  StClair  Thomson,  31. D.,  President  of  the  Society, 
Pp.  62.  With  4  plates  and  14  figures  in  the  text.  Price  2$.  6cl. 
London :  Harrison  &  Sons. 


VOL.  XXXV.     No.  4.  •  April.  1920. 


THE 

JOURNAL    OF    LARYNGOLOGY, 

RHINOLOGY,   AND   0T01>0GY. 


Original  Articles  are  accepted  on  tJie  cnndition  tliat  they  have  not  previously  been 
published  elsewhere. 

If  reprints  are  required  it  is  requested  that  this  be  stated  when  the  article  is  first 
forwarded  to  this  Journal.     Such  repriiits  will  be  charged  to  the  author. 

Editorial  Communications  are  to  be  addressed  to  "Editor  of  Journal  of 
Lartngologt,  care  of  Messrs.  Adlard  ^'  Son^'  West  Newman,  Limited,  Bartliolomew 
Close,  E.G.  1." 


LATENT   SPHENOIDAL   SINUSITIS    IN   CHILDREN   WITH 
RECURRENT   ADENOIDS   AND   APPENDICITIS 

By  p.  Watson-Williams,  M.D.Lond., 

Lecturer  on  Otology,  Rhinology  and  Laryngologj%  University  of  Bristol,  and  in 

Charge  of  the  Department  for  Diseases  of  the  Ear,  Nose,  and  Throat, 

Bristol  Koyal  Infirmary. 

Two  boys,  brothers,  aged  respectively  eleven  and  thirteen  afford  in- 
teresting examples  of  latent  sinus  infection  in  childhood,  and  are  possible 
examples  of  appendicitis  and  also  of  recurrent  adenoids  due  to  infection, 
having  its  main  soui'ce  in  the  sphenoidal  sinuses.  That  appendix 
infection  may  be  due  to  the  constant  swallowing  of  pyogenic  organisms 
seems  probable.  That  sinus  infection  is  or  is  not  a  causal  factor  in 
appendicitis  could  only  be  inferred  from  after-revisions  of  such  a  large 
number  of  cases  that  the  many  sources  of  error  can  be  fairly  eliminated. 
Hence  one  can  only  say  of  these  two  cases  that  the  coincidence,  however 
suggestive,  is  no  proof  of  interdependence.  But  I  have  known  of  so  many 
cases  of  recurrent  adenoids  on  the  one  hand  and  of  appendicitis  on  the 
other,  which  are  associated  with  nasal  sinus  infection,  that  I  am  driven 
to  the  conclusion  that  sinus  infection  is  one  of  the  causes  of  these 
clinical  complications.  Another  point  worth  noting  is  the  obvious 
chronic  sinvis  infection  of  the  father — a  parent  who  there  is  some  reason 
to  believe  may  have  infected  the  children  in  early  life. 

Boy,  W.  A.  S ,  aged  thirteen  and  a-half,  with  adenoid  facie's  and  buccal 

respiration,  had  been  developing  asthma  for  ten  months  and  was  very  i^rone  to 
colds  and  post-nasal  catarrh,  and  was  in  jjoor  health  and  suspected  of  latent 
tuberculosis  by  his  family  medical  attendant.  Had  apjjendicectomy  at  age  of 
five  ;  acute  suppurative. 

7 


98 


The  journal  of  Laryngology,  April,  1920. 


Examination. — Xo. enlarged  tonsils;  anterior  rhinoscopy  showed  a  few  strings 
of  mucus  in  his  right  nasal  passage,  endorhinoscopy,  a  few  streaks  of  mucous 
secretion  from  the  posterior  ends  of  the  inferior  turbinals.  Exploration  of  the 
maxillary  antra  by  the  author's  suction  syringe  yielded — right  side,  a  few  flocculi 
in  the  distilled  water  injected  and  then  sucked  back  ;  left  side  quite  clear.  The 
sphenoidal  sinvises :  right  some  nuico-pus ;  left  side  clear.  Cultures  by  Prof. 
Walker  Hall:  Eight  antrum.  Staphylococcus  alhus ;  left  antrum.  Staphylococcus 
albus ;  right  sphenoidal  sinus,  film,  polynuclears,  few  cocci :  left  sphenoidal  sinus, 
culture,  no  polynuclears,  no  cocci. 

Operation. — Both  maxillary  antra  and  the  right  sphenoidal  sinus  were  opened 
and  di-ained. 


'~\ 


Fjg.  X 


p.  Waiion-WUVmmi,  31. D. 
ad  iiaturam  del. 


rig.  2 


H.  M.  A.  S ,  aged  eleven,  frequent  sneezing  and  liable  to  recuiTent  colds  ; 

anaemic,  glands  of  neck  enlarged,  chest  retracted,  buccal  respiration.  He  had 
tonsils  and  adenoids  removed  at  age  of  three  :  at  age  of  six  appendicectomy ;  at 
age  of  nine  and  a-half  had  another  operation  for  adenoids.  The  mother  reports 
that  his  nasal  stuffiness  was  no  better. 

Examinafion.  — Fauces  normal,  a  few  large  pharyngeal  granules;  anterior 
rhinoscopy  showed  nothing  abnormal  except  a  slight  septal  spiir.  Endorhinoscopy 
showed  muco-purulent  secretion  in  the  posterior  ends  of  the  inferior  turbinals, 
and  some  secretion  in  the  roof  of  the  naso-pharynx.  Exploration  by  the  suction 
syringe  showed  — right  anti'um,  polynuclears,  and  excess  of  mucus,  and  right 
sphenoidal  sinus,  occasional  polynuclears,  and  Staphylococcus  alius  on  culture. 

Operation. — Both  sphenoidal  sinuses  and  both  maxillary  antra  opened  and 
drained. 


April,  1920.] 


Rhinology,  and  Otology. 


99 


The  father,  aged  fifty-nine,  had  had  a  stuffy  nose  as  long  as  he 
could  remember.  There  was  a  marked  deflection  of  the  septum  to  the 
left  causing  almost  complete  occlusion  of  the  left  nasal  passage.  Endo- 
rhinoscopy  showed  a  stream  of  muco-pus  in  his  left  middle  meatus  and 
muco-pus  on  the  posterior  end  of  the  right  inferior  turbinal.  Certainly 
the  left  maxillary  antrum  was  the  source  of  pus  on  the  left  side.  No 
operation  or  culture. 

The  two  boys  operated  on  recovered  very  rapidly,  and  soon  lost  their 
nasal  discharge  and  other  abnormal  symptoms. 


NOTES   ON   THIRTEEN   CASES   OF   AURAL   TUBERCULOSIS 

IN   INFANTS. 

By  Douglas  Guthrie,  F.E.C.S.E., 
Edinbui'gh. 

Tuberculosis  of  the  middle  ear  is  a  fairly  common  disease  of  infancy. 
Eecords  of  li3  cases  of  chronic  suppurative  otitis  media  attending  the 
Eoyal  Hospital  for  Sick  Children  (ages  0  to  12)  show  that  the  cause  has 
been  noted  in  79  cases,  and  these  may  be  tabulated  as  follows : 


Table 

I. 

Measles 

.     40  cases 

Tuberculosis 

.     13      „ 

Scarlet  fever 

.       8      „ 

Pneumonia  . 

•       8      „ 

Whooping-coi 
Injury  (?)     . 
Diphtheria  . 

igh 

5      ,, 
.       3      „ 
2 

Total 


79 


Age. — The  tuberculous  cases  form  the  subject  of  this  communication, 
and  it  is  interesting  to  notice  that  in  all  save  one  (No.  7)  the  disease 
made  its  appearance  during  the  first  year  of  life. 

If  the  term  "  chronic  "  is  to  be  applied  to  middle-ear  suppuration  of 
over  two  months'  duration,  then  this  disease  is  rare  in  infancy  apart 
from  tuberculosis.  The  chronicity  of  aural  suppuration  in  an  infant 
should  lead  one  to  suspect  aural  tuberculosis. 

Milligan  (1)  states  that  50  to  60  per  cent,  of  cases  of  suppurative 
otitis  media  under  the  age  of  six  are  of  tuberculous  origin ;  while 
Logan  Turner  (2),  reporting  sixty  cases  of  aural  tuberculosis,  estimates 
that  27  per  cent,  of  cases  of  suppurative  otitis  under  the  age  of  two, 
and  50  per  cent,  under  one  year,  are  tuberculous.  Henrici  (3),  who 
regards  aural  tuberculosis  as  primarily  a  bone  disease,  commencing 
in  the  mastoid  region  as  a  result  of  blood  infection,  and  secondarily 
involving  the  middle  ear,  is  of  opinion  that  one-fifth  of-  all  cases  of 
mastoiditis  in  childhood  is  due  to  tuberculosis. 

Symptoms. — All  the  cases  of  the  present  series,  with  one  exception 
(No.  11),  were  characterised  by  a  painless,  insidious  onset,  the  presence 
of  discharge  being  the  first  sign  of  the  disease.  In  three  cases  (Nos.  1, 
12  and  13)  an  abscess  had  formed  and  had  ruptured  through  the  skin, 
giving  rise  to  a  mastoid  fistula.  Facial  paralysis  was  present  in  seven 
of  the  thirteen  cases.    Enlarged  periotic  glands  were  noted  in  every  case. 


100  The  Journal  of  Laryngology,  [Aprii,  1920. 

Etiology. — There  is  little  doubt  that  the  infection  ia  milk-borne. 
Seven  of  the  infants  had  been  bottle-fed  on  unboiled  milk.  No.  4,  who 
was  breast-fed,  had  also  been  fed  on  bread  and  milk  (unboiled),  while 
unboiled  milk  formed  part  of  the  diet  of  the  child  (No.  7),  whose  trouble 
commenced  during  the  second  year  of  life.  The  mother  of  the  child 
(No.  11)  who  was  bottle-fed  on  boiled  milk  was  suffering  from 
pulmonary  tuberculosis.  The  onset  of  the  otitis  was  acute.  Of  the 
three  remaining  cases,  one  (No.  6)  was  breast-fed,  and  the  mode  of 
feeding  was  not  noted  in  the  other  two  (Nos.  2  and  8). 

The  results  may  thus  be  tabulated  : 

Table  II. 

Mode  of  feeding  noted  in       .         .         ,11  cases. 
Unboiled  milk  used  in  .         .         .         .       9     ,, 
Breast-feeding  alone  in  ...       1  case. 

Bottle-feeding  (with  boiled  milk)  .         .       1     ,, 

It  appears  probable  that  the  tuberculous  infection  is  primaril)^ 
implanted  in  the  naso-pharynx,  whence  it  is  conveyed  to  the  middle  ear 
by  way  of  the  Eustachian  tube.  Histological  evidence  of  tuberculosis 
in  adenoids  has  been  frequently  reported.  The  following  table  gives  the 
percentages  of  some  such  findings  in  adenoids  removed  from  children 
who  were  otherwise  healthy  : 


Table 

III. 

Author. 

No.  of 

Percentage 

adenoid  cases. 

tuberculous 

Dieulafoy  (4) 

70 

20 

Gottstein  (5) 

.       33 

12 

Brindle  (6)    . 

8 

12 

McBride  and  Turner  (7) 

.     100 

3 

Pluder  and  Fischer 

(8). 

.       32 

15 

Milligan  (9)  . 

— 

16 

Lartigue  and  Nicol 

(lOj 

.       75 

16 

Treatment  and  Besults. — In  nine  cases  the  radical  mastoid  operation 
was  performed,  and,  as  a  rule,  the  area  of  bone  necrosis  was  very 
extensive.  Diagnosis  was  confirmed  by  microscopic  examination  of  the 
scrapings  in  seven  cases. 

This  disease  affords  one  of  the  few  indications  for  the  performance, 
in  children,  of  the  radical  mastoid  operation. 

Of  the  operated  cases,  four  did  well  as  regards  the  ear  condition, 
though  one  of  these  died  of  pneumonia  two  years  later. 

Three  cases  were  fatal — one  week,  one  month  and  three  months 
after  operation.  The  cause  of  death  was  probably  meningitis,  but  this 
was  confirmed  (clinically)  only  in  one  case  (No.  13),  who  died  a  week 
after  operation.     Post-mortem  examination  was  refused. 

Two  of  the  unoperated  cases  died  ;  two  are  in  better  health  (two 
years  later),  but  with  the  ear  still  moist. 

Eeferences. 

(1)  Milligan.— JouRx.  oj-  Lartngol  ,  Ehinol  ,  and  Otol.,  March,  1903. 

(2)  Logan  Turner  and  Fraser. — Ibid.,  June,  1915. 

(3)  Henrici.— Zeifs./.  Ohren.,  xlviii,  1904. 


April.  1920.] 


Rhinology,  and  Otology. 


101 


g 

.'£ 

-.0 

1^ 

, — 

X 

^ 

X 

X 

y_, 

. 

>> 

ffi) 

It 

1 

to 

1^  'io 

c 

X 

^ 

c 

3'a 
=*-   to 

S 

1^ 

1« 
fa 

o 

.2  ^ 

si 
1 

i-    :^    C) 

3 

a 

ic 

.2 
_a 

a 

&I 

cS    3 

.ii  .a 
a  -< 
a  ~. 
S  § 

■"    C 
■-0    § 

3 

> 

> 

■*3  -iL 

IS 

-•^ 

w 

-kJ 

S 
^ 

M 

Cj    to 
a:    1 

p 
to 

.  Hi 

X 

■y. 

>. 

.3  "^ 

_. 

to 

>> 

to 

"> 
p 

"s  o  ^ 

a 

•j:  n  ri    "^ 

> 

a 

0 

a 

a 

a 

to    ■'    0 

^:s  a 

2'^   a 
a  in  a 

+3 
0 

a 

Q 

a     . 

~  .2 

.2 

§5| 

a 

13 

g 

^ 

3 

'0 

to 

-2  » 

"a 

a 
"a 

^ 

o 

0 

Z 

10 

0 
a 

^ 

a 

ti    c 

a 

a 

rO 

=^ 

0 

.c 

"5 

^ 

-O 

+2 

-fj  ^ 

-.2 

M 

5 

^3 

°Q 

b    ^ 

g 

'£ 

_a 

.„ 

o 

s 

'^ 

1 

1       1 

1    1  '3 

0    •'^ 

*c 

M 

r^ 

'"r^ 

^ 

n  r^'2 

o 

to 

>. 

^ 

1 

1 

1   1 

1    1  J 

to 

'3 

m   0 

a 
> 

c 

P 

3 

a 
"a 

a 

a 
=2 

CO  a 

to 

~  -I3  P 
a  to  p 
.®  ca  :i:; 

=4H    ^*-'    -*-! 

"o 
1 

> 

S 

^ 

— 

"p 
S 

0 

> 

a 

% 

Is 

s  a 

to   to 

a 

a 

a  :73 

3 
'0 

to 

HI 

Opera- 
tion. 

CO 

£i^ 

CO 

a 

CO 

in 

— 

CO 

a 

CO 

CO 

a 

.i«! 

^ 

"^  1 

o 

•72 

^ 

fT-"    *^ 

ti 

(S 

c 

®  -t^  ~ 

a 

„ 

^  +3 

0 

0 

0 

T? 

^^  5  ^-' 

'0  "p, 

:3 

-t^ 

■*^  ^" 

s 

-^  ^r: 

^ 

Ti  +5 

-^^ 

S      1 

o 

Cl. 

-t| 

"S-  -■  — 

a.. 

-tj 

4^ 
0 

0  i' 

70 

0 

I^ 

X 

_a  ^ 
^  "2 

X  rv^ 

'^^ 

00 

"3 '3 

•^  >-. 

to 

to 

o  JS 

CO     0    !0 

0 

to 

to 

0 

c 

0 

ID 

5,  o 

0  hi    OJ 

iz; 

a 

a 

^ 

^ 

^, 

to 

V5 

to    CO 

01    ai    za 

M 

CO 

CO 

to 

to 

CO 

o 

» 

QJ     ID 

<u    »    » 

a 

a 

a 

a 

a 

a 

d 

3 

>H 

>H 

>^>< 

.• 

t^>-tH 

;>H 

^ 

>H 

>H 

^ 

>H 

s 

S     1 

h:j 

P^' 

^i4 

«P^P3 

h^ 

P^ 

f4 

C5 

•4 

p4 

]CI 

_;ci^[ei_|ci 

lei 

«'«" 

3.2 

■"j^ 

•'i- 

"h  ^'H 

i-H 

1- 

-'i^ 

'*|^ 

K^ 

D^ 

■^ 

^jc. 

„C1 

,.,-1=' 

H- 

c;c. 

^■^ 

-'!.' 

^;« 

.-'-' 

^           1 

I— 1 

'^ 

^ 

*"* 

m 

1 

1 

g 

1 

i 

'3 

^ 

M 

mO 

b»  ;r>  kH 

;l, 

fc4 

0 

s 

w 

h-t 

>-i 

^ 

<ia; 

^■w-^ 

p4 

d 

^4 

<<■ 

d 

?i 

d 

^ 

N 

CC  -*i 

»o  CO  t- 

X 

Oi 

c 

^ 

Cl 

CO 

^ 

r-< 

■"* 

'"' 

■"" 

102  The  Journal  of  Laryngology^  [April,  1920. 

(4)  DiEULAFOT. — Bull,  de  VAcad.  de  Paris,  1905. 

(5)  GoTTSTEiN .—  Bed.  Min.  Woch.,  August,  1896. 

(6)  Brindle. — Bull,  de  I'Acad.  de  Paris,  May,  1895. 

(7)  McBride  and  Turner. — Edin.  Med.  Journ.,  May,  1897. 

(8)  Pluder  and  Fischer. — Arch.f.  Laryngol.,  1896. 

(9)  MiLLiG.\N.— B)-!f.  Med.  Journ.,  October,  1910. 

(10)  Lartigue  and  Nicol. — Amer.  Journ.  of  Med.  Sci.,  June,  1902. 


A  METHOD  OF  SUTURING  THE  PILLARS  OF   THE   FAUCES. 

By  Thomas  Guthrie,  M.A.,  M.B.,  B.C.,  F.R.C.S., 
Liverpool. 

Suture  of  the  faucial  pillars  in  order  to  arrest  htemorrhage  following 
tonsillectomy,  although  rarely  required,  is  a  procedure  which  anyone 
■who  removes  a  large  number  of  tonsils  may  find  it  necessary  occasion- 
ally to  undertake.  Of  a  number  of  different  methods  which  I  have 
tried,  the  most  satisfactory  appeal's  to  me  to  be  that  indicated  in  the 
accompanying  rough  diagram. 


rWUjyi^ 


Fig.  1. — Diagram  to  illustrate  method  of  siitiiring  pillars  of  fauces  by  means 
of  slot-eyed  needle  and  special  suture  carrier.  ( For  the  sake  of  cleai-ness, 
the  needle  is  shown  i^enetrating  the  pillars  only,  and  not  the  tissue  lining 
the  tonsil  fossa.  It  is  well  in  some  cases  that  the  needle  should  take  iip 
a  little  of  this  tissue,  but  usually  this  is  not  essential.) 

A  curved  slot-eyed  needle  is  passed  from  behind  forwards  through 
the  posterior  pillar,  then,  if  thought  necessary,  through  a  thin  layer  of  the 
tissue  lining  the  tonsil  fossa,  and  finally  through  the  anterior  pillar. 
The  suture  having  been  engaged  in  the  slot  of  the  needle,  the  latter  is 
"withdrawn  and  the  suture  disengaged  and  tied.  In  order  to  carry  the 
suture  and  facilitate  its  insertion  in  the  slot  I  have  had  a  special  suture- 
carrier  made  by  Messrs.  Down  Bros.,  as  shown  in  Fig.  2. 


April,  1920.J  Rhinology,  and  Otology.  103 

If  the  tonsil  fossa  be  very  deep  it  may  be  advisable,  as  is  often 
recommended,  to  pack  it  with  a  roll  of  gauze  before  applying  the 
sutm'es,  but  this  is  very  seldom  required,  and  is  never  necessary  if  a 
little  of  the  aponeurotic  tissue  lining  the  fossa  be  picked  up  by  the 
needle  as  it  passes  between  the  pillars.  I  employ  plain  catgut,  which  is 
absorbed  in  a  few  days,  so  that  the  sutures  do  not  require  removal. 


Fig.  2. — Suture  forceps. 

or 


It  is  not  in  my  experience  difKcult  by  this  method  to  insert  two 
three  sutures  without  an  assistant  even  to  hold  a  tongue-depressor 
a  point  which  is  sometimes  of  considerable  importance. 


ON    THE    ORIGIN    OF    THE    QUICK    PHASIS    OF    THE 
VESTIBULAR   NYSTAGMUS. 

By  Docent  Dr.  A.  Eejto, 
Budapest. 

It  is  known  that  the  endolymph  currents  in  the  semicircular  canals 
produce  the  slow  phasis  of  the  vestibular  nystagmus.  But  to  the 
question  of  the  origin  of  the  quick  phasis  we  can  only  answer  in 
negatives,  because  all  the  theories  about  this  question  are  disproved. 

Since  the  time  of  Purkinj6  we  have  been  searching  for  the  second 
energy  in  this  "  struggle  of  forces  "  which  acts  as  the  quick  phasis  of 
the  nystagmus. 

I  quote  Dr.  Brunner's  (1)  classical  study,  the  latest  treatise  on  this 
question,  to  exhibit  all  the  arguments  against  the  theories  commonly 
advanced.  A  perusal  of  this  paper  leads  us  to  the  conviction  that  the 
cortical  origin  of  the  quick  phasis  cannot  be  accepted,  neither  can  this 
phasis  be  considered  as  a  reflex  with  a  central  origin,  nor  yet  as  a  reflex 
caused  by  the  muscles  of  the  eyes.  Brunner  also  expresses  his  own 
opinion  to  the  effect  that  the  stimuli  of  the  environs  of  the  eyes  induce 
the  stimulus  of  the  quick  phasis  in  the  primary  nuclei  of  the  third, 
fourth  and  sixth  nerves. 

It  is  not  my  intention  here  to  propound  the  arguments  against 
Brunner's  opinion,  but  rather  to  make  an  attempt  to  prove  the  labyrinth 
origin  of  the  quick  phasis.  Many  investigators  have  looked  for  it  in 
the  labyrinth,  but  all  have  analysed  only  the  end-organ  of  the  semi- 
circular canals.  In  this  way  we  can  never  arrive  at  a  clear  explanation, 
for  we  meet  with  another  question  which  we  can  answer  but  vaguely,  and 
that  is,  how  can  two  effects  be  produced  by  one  endolymph  current  ? 
We  must  carefully  examine  the  anatomical  and  physiological  details 


104  The  Journal  of  Laryngology,  Aprii,  1920. 

of  the  labyrinth  to  find  there  another  basis  for  the  quick  nysta^mus- 
phasis.  Of  the  physiological  function  of  the  vestibular  nerve  we  know 
but  little  more  than  what  Prof.  Hogyes  (2)  wrote  in  his  paper  in  1882. 
He  says  that  from  the  eighth  nerve  reflex  stimuli  proceed  incessantly 
to  the  third,  fourth  and  sixth  nerves,  and  according  to  the  nature  of 
these  stimuli  they  result  either  in  bilateral  labile  equilibrium  or  in  a 
co-ordinate  bilateral  movement  of  the  eyeballs.  However,  we  now  know 
that  these  reflex  innervations  are  produced  through  the  medium  of  the 
cerebellum.  Hogyes,  as  we  see,  presumed  the  double  role  of  the  laby- 
rinth, first  the  rest-tonus,  and  secondly  the  compensatory  eye-move- 
ments. With  regard  to  the  latter,  we  know  that  the  different  endolymph 
currents  are  the  stimiili  of  the  semicircular  canals. 

Shambaugh's  (3)  law  says  :  Duration  of  nystagmus  =  duration  of  peri- 
pheral stimulation  =  duration  of  endolymph  current.  Tliis  means  also 
that  without  any  endolymph  current  there  is  no  peripheral  stimulation 
of  the  hair-cells  of  the  ampulla. 

For  the  second  function  of  the  labyrinth,  the  rest  tonus,  we  must 
therefore  seek  another  end-organ.  This  we  find  in  the  otolith  organs — 
the  macvilae  of  the  labyrinth.  Many  physiological  and  pathological  facts 
indicate  that  not  only  the  semicircular  canals  but  also  the  maculae  are 
in  connection  with  the  muscles  of  the  eye.  The  different  positions  of  the 
eye  when  the  position  of  the  head  is  changed  are  generally  explained 
through  these  connections.  I  think,  therefore,  that  the  rest-tonus  takes 
its  origin  in  the  maculae,  of  which  there  must  be  one  for  each  of  the 
three  planes  in  space. 

The  anatomical  details  help  these  speculative  conclusions  of  physio- 
logy. W^e  know  through  the  investigations  of  Wittmaack,  Panse  (4) 
and  others  that  we  have  indeed  three  maculae — (1)  the  macula  utriculi, 
(2)  the  macula  sacculi  and  (3)  the  macula  neglecta,  which  is  also  in  the 
sacculus.  We  also  know  that  the  maculae  utriculi  and  sacculi  are 
situated  at  right  angles  to  each  other.  (5)  It  is  to  be  supposed  that  the 
third  macula  is  in  the  third  plane  at  right  angles  to  the  other  two. 

The  precise  position  of  the  maculae  is  still  unknown  to  us,  but  this 
is  not  very  important  because  every  effect  of  the  maculte  can  be  con- 
sidered as  the  resultant  of  their  component  effects.  We  use  the  terms 
"  horizontal,"  "  frontal  "'  and  "  sagittal  "  macula  for  the  purpose  of 
facilitating  description. 

According  to  these  data  we  have  in  every  plane  one  pair  of  semi- 
circular canals  and  one  macula,  which  together  supply  the  double 
function  of  the  labyrinth.  The  stimulus  of  the  canals  is  the  endo- 
lymph current  and  that  of  the  macula  the  force  of  gravitation.  The 
semicircular  canals  produce  the  compensatory  eye-movements  when  the 
head  is  in  motion  ;  the  macula3  have  the  task  of  maintaining  these 
positions  of  the  eye  when  the  head  is  at  rest.  We  must  suppose  that 
every  macula  has  its  best  position  when  it  is  in  the  horizontal  plane, 
for  it  is  then  most  exposed  to  the  action  of  gravity,  and  gravity  acts 
on  the  otolith  mass  of  the  maculae  either  as  a  pulling  or  as  a  pushing 
force  according  to  the  position  of  the  head. 

After  this  digression  we  can  return  to  our  main  question.  Before 
the  examination  of  the  quick  phasis  of  the  vestibular  nystagmus  it 
seems  desirable  to  regard  the  optic  nystagmus,  which  consists  also 
of  one  slow  and  one  quick  phasis.  When  looking  at  a  moving  train 
or  at  any  large  moving  object  near  in  front  of  us  our  whole  field 
of  vision  moves  with  it.     If  the  head  follows  the  object  in  its  motion 


April,  1920.]  Rhinology,  and  Otology.  105 

there  occurs  no  nj-stagmus.  But  if  the  head  be  fixed  the  eyes  follow 
the  moving  object  as  far  as  they  are  able  to  turn.  In  the  moment 
when  the  muscles  of  the  eye  are  no  more  able  to  work  we  lose  the 
whole  field  of  vision.  The  slow  movement  of  the  eyes  is  the  result 
of  a  central  stimulus  ;  but  the  moment  we  lose  the  field  of  vision  this 
central  innervation  ceases  and  the  eyes  return  with  a  quick  movement 
to  the  rest,  or  middle  position. 

I  think  that  the  character  of  this  latter  force  which  holds  the  eye- 
balls in  the  middle  position  indicates  its  origin.  The  force  which 
produces  the  quick  phasis  of  the  optic  nystagmus  can  be  only  that 
of  the  rest-tonus,  which  comes  into  action  in  the  moment  when  the 
force  of  the  central  innervation  ceases  to  act.  The  second  phasis  is 
quicker,  and  this  characteristic  shows  us  also  that  here  must  be  an 
abrupt  cessation  of  force,  for  we  know  the  physical  law  that  after  the 
sudden  cessation  of  a  force  acting  in  a  certain  direction  the  diametrically 
opposite  force  works  with  increased  acceleration. 

Passing  now  to  the  labyrinth  nystagmus,  we  shall  consider  first  the 
well-known  phenomena  of  the  horizontal  plane.  If  the  human  body, 
with  head  erect,  is  revolved  in  this  plane  with  a  moderate  velocity, 
there  are  always  two  forces  acting  in  the  labyrinth — the  endolymph 
current  and  the  stimuli  of  the  maculae — because  during  this  movement 
the  endolymph  moves  and  the  position  of  the  otolith  organs  is  not 
disturbed. 

Thus  frona  the  labyrinth  there  arise  continually  two  stimuli,  one 
of  which  tends  to  pull  the  eyeballs  right  or  left,  and  the  other  which 
tends  to  retain  them  in  the  middle  position. 

The  question  here  arises.  How  can  the  two  stimuli  coming  both 
from  the  labyrinth  and  going  both  to  the  eye  muscles  cause  the 
nystagmus — that  is,  a  movement  consisting  of  two  phases  ?  It  is 
well  known  that  the  innervation  of  the  muscles  proceeds  in  a  rapid 
succession  of  impulses.  (In  this  connection  may  be  cited  the  works 
of  Exner  (6)  and  Hering  (7).)  It  is  a  wave-like  motion.  And  these 
two  waves  of  the  two  heterogeneous  stimuli,  according  to  the  physical 
law,  sometimes  strengthen  and  sometimes  weaken  each  other.  Thus 
we  see  in  the  slow  phasis  the  force  of  the  canals  and  in  the  quick  phasis 
the  force  of  the  maculae. 

In  case  of  revolution  at  a  high  speed  the  centrifugal  force  counteracts 
the  force  of  gravity  on  the  otolith  mass  and  the  stimuli  of  the  maculae 
cease.  We  can  then  see  only  a  deviation  of  the  eyes  resulting  from 
the  action  of  the  canals,  but  when  the  body  is  suddenly  brought  to  rest 
the  nystagmus  reappears. 

The  reactions  produced  in  the  case  of  the  body  revolving  in  the 
frontal  and  sagittal  planes  are  quite  different  from  those  in  the  horizontal 
plane.  It  is  extremely  difficult  to  make  observations  ;  therefore  I  will 
not  discuss  them  at  present,  but  only  remark  that  I  am  engaged  in 
experimenting  on  human  subjects  to  compare  the  results  with  those 
of  the  experiments  of  Prof.  Hogyes  on  animals. 

The  caloric  stimulation  of  the  labyrinth  shows  us  the  same  law. 
In  whatever  position  the  head  may  be  there  always  arise  two  hetero- 
geneous stimuli  from  the  labyrinth,  and  therefore  the  nystagmus  is 
always  present. 

The  hot  or  cold  water  produces  an  endolymph  current,  and  this 
stimulus  of  the  semicircular  canals  tends  to  move  the  eyeballs  in  a 
certain  direction,  which  depends   on    the   place    and  on  the  ampullo- 


106  The  Journal  of  Laryngology^  [April,  1920. 

petal  or  ampuilo-fugal  direction  of  this  current.  The  maculae  are 
always  at  rest  because  the  head  is  stationary  and  from  the  macular  arises 
the  rest  tonus. 

The  rnh  of  the  maculae  in  any  position  of  the  head  is  only  to  be 
understood  if  we  suppose — as  I  mentioned  above — that  the  pulling  and 
pushing  forces  of  the  otolith  mass  are  both  stimuli  of  the  hair-cells  of 
the  maculiB.  For  instance,  let  us  consider  the  horizontal  macula, 
which  acts  both  when  the  head  is  upright  and  also  when  it  is  inverted, 
for  in  both  of  these  positions  the  macula  utriculi  is  in  the  horizontal 
plane.  If  in  the  one  position  the  stimulus  is  caused  by  pushing,  then  in 
the  other  position  it  can  onW  be  caused  by  a  pulling  force. 

To  investigate  this  I  made  an  experiment  on  an  acrobat,  aged 
thirty,  in  whom  I  found  the  labyrinth  reactions  to  be  normal.  He  was 
swung  with  his  head  downwards.  His  eyeballs  were  in  the  middle 
position.  On  syringing  300  cm.  of  cold  water  into  his  left  meatus, 
after  some  seconds  he  received  a  horizontal  nystagmus,  with  the  slow 
phasis  to  the  right  and  the  quick  one  to  the  left.  Three  minutes  later 
he  was  turned  upright  and  placed  in  a  chair,  whereupon  the  nystagmus 
changed  its  direction  and  grew  stronger.  The  man,  who  had  never 
before  suffered  from  giddiness,  was  seized  with  nausea  while  sitting  in 
the  chair  and  became  giddy. 

The  change  in  the  direction  of  the  nystagmus  is  simply  a  consequence 
of  the  change  in  the  position  of  the  head  ;  but  the  two  facts  that  (1)  in 
the  inverted  position  of  the  head  the  rest  position  of  the  eyeballs  is  the 
same  as  when  the  head  is  upright,  and  (2)  the  quick  phasis  of  the 
nystagmus  appears  alike  in  both  positions,  show  us  that  the  horizontal 
macula  has  two  stimulant  forces — one  pulling  and  one  pushing. 

We  can  see  that  lahijrintlml  nijstagmus  only  supervenes  if  from  the 
labyrinth  there  arise  two  opposite,  heterogeneous  stimuli.  The  force  of 
the  quick  phasis  is  ahvays  the  rest  tonus  of  the  labyrinth,  which  I 
suppose  to  be  produced  by  the  macular  We  cannot  prove  this  theory 
with  the  direct  stimulation  or  with  the  extirpation  of  the  maculae,  for 
their  microscopical  dimension  precludes  all  such  experiments.  We 
must  see  if  the  theory  fits  in  with  the  physiological  and  patho- 
logical observations.  To  me  it  seems  that  the  theory  accords  with  the 
observations,  only  we  must  assume  that  the  stimuli  of  the  maculae  and 
those  of  the  canals  do  not  proceed  along  the  same  nerve-lines,  and  the 
stimuli  of  the  maculae  are  dependent  to  a  greater  extent  on  the  cortex. 

I  will  only  mention  the  circumstances  which  we  find  in  the  supra- 
nuclear paralysis  of  the  eye  muscles.  We  know  that  in  this  case  we 
cannot  move '  the  eyeballs  with  cortical  (centi'al)  innervation  in  the 
direction  of  the  injured  muscles,  nor  can  the  quick  phasis  of  a  nystagmus 
be  in  this  direction,  but  only  the  slow  phasis. 

This  indicates  also  that  the  force  of  the  slow  phasis  acts  through 
a  wider  range,  but  that  of  the  quick  phasis  only  up  to  the  middle  position 
of  the  eyeballs. 

References. 

(1)  BRVNNER.—Monatsch.f.  Ohrenheilk.,  1919,  H.  1. 

(2)  HoGTEs. — Pviblished  woi'ks  1881  in  Hungarian  translated  by  Dr.  M.  Sugar, 
M.f.  0.,  1912. 

(3)  Shambaugh. — Ninth  Inter.  Otol.  Congress,  Boston,  1912. 

(4)  Panse. — "  Patholog.  Anatomie  des  Ohres,"  1912. 

(5)  Nagbl. — "  Handbuch  der  Pliysiologie  des  Menschen,"  Bd.  iii,  1905. 

(6)  ExNER. — Pfi tiger's  Archiv,  1900. 

(7)  Cited  by  Brunner  in  (Ij. 


April,  1920.] 


Rhinology,  and  Otology. 


107 


REPORTS  FOR  THE  YEAR  1918  FROM  THE  EAR  AND  THROAT 
DEPARTMENT  OF  THE  ROYAL  INFIRMARY,  EDINBURGH. 

Under  the  care  of  A.  Logan  Turner,  M.D.,  F.R.C.S.E.,  F.R.S.E. 

Part  V. 
STATISTICAL  TABLES 

BY 

G.  A.  M 'Arthur,  M.B.(Melb.). 

Affections  of  the  Nose  (987). 
I.   The  External  Nose  and  Nasal  Vestibule. 


Nasal  deformity  . 

2 

Fracture  of  nose 

2 

Injury  to  nose 

1 

Collapse  of  ala  nasi 

1 

Dermatitis  of  vestibule 

35 

Furuncle  of  vestibule 

1 

Papilloma  of  vestibule 

4 

LiTiKis  of  external  nose 

3 

Rodent  ulcer 

2 

II.  The  Nasal  Cavities. 

Deflection  of  septum  to  right 

Deflection  of  septum  to  left 

IrregiUar  deflections 

Simple  ulcer  of  septum 

Simple  perforation  of  septum 

Ha-matoma  and  abscess  of  septum   . 

Septal  thickening 

Acute,  subacute,  and  chronic  rhinitis 

Inferior  turbinal  enlargement 

Polypoid  middle  turbinals  and  nasal  poly|)i 

Purulent  i-hinitis 

Fibrinous  rhinitis 

Atrophic  rhinitis  (non-fcetid) 

Atrophic  rhinitis  (fcetid)    . 

Rhinitis  sicca 

Rhinitis  caseosa  . 

Epistaxis 

Lupus  of  nasal  mucous  membrane   . 

Syphilitic  (tertiary)  disease  of  nasal  cavities 

Foreign  bodies  in  nose 

Rhinolith 

Nasal  neuroses  (incliiding  asthma)  . 

Anosmia  (influenzal) 

Abscess  of  floor  of  nose  (incisor  tooth) 

Cysts  of  floor  of  nose 

Tumours  of  nasal  cavities  . 

Shrapnel  in  nose 


51 


83 
127 

34 
1 
4 
3 
1 
142 
227 

86 
8 
5 

21 

26 

11 
1 

30 
7 

12 

10 
2 

86 
1 
1 
2 
4 
1 


936 


108 


The  Journal  of  Laryngology, 


>pril,  1920. 


Accessory  Nasal  Sinuses  (58). 
Acute  antral  suppuration  (1  Ijilateral,  1  I'iglit,  1  left) 
Chronic  antral  catarrh  (1  bilateral,  1  right,  1  left) 
Chronic  antral  suppuration  (bilateral) 
Chronic  antral  suppuration  (unilateral) 
Naso-antral  polyjii 
Dental  cyst  invading  antrum 
Aciite  frontal  sinus  catarrh 
Acute  fronto-maxillary  catarrh 
Acute  frontal  sinus  sui^i^uration 
Chronic  frontal  sinus  siappuration    . 
Chronic  ethmoidal  svxppuration 
Chronic  antro-ethmoidal  svippuration 
Chronic  fronto-ethmoidal  supi^uration 
Chronic  frontal,  ethmoidal  and  antral  sxippuration 
Chronic  sphenoidal  suppuration 
Pansinusitis         .... 
Ethmoidal  mucocele 
Malignant  tumour  of  antriim  (1  sarcoma,  1  epithelioma) 
Malignant  tumour  of  ethmoid  and  antrum  (sarcoma)  . 


3 
3 
1 
10 
13 
4 
1 
1 
0 
1 
4 
6 
3 
0 
1 
1 
1 
2 
3 


Chronic  dacxyocystitis        ..... 
Diseases  of  Naso-Pharynx,  Pharynx  and  Fauces  (1290). 


58 
35 


Adenoids  and  enlarged  tonsils 

Acute  tonsillitis  . 

Peritonsillar  abscess 

Diphtheria 

Acute  pharyngitis 

Chronic  pharyngitis,  including  granular  i)har 

Pharyngitis  sicca 

Keratosis  phaiyng-is 

Hypertrophy  of  lingual  tonsil 

Secondary  syphilis  of  fauces  and  pharynx 

Tertiary  syphilis  of  fauces  and  pharynx 

Malignant  tumours  of  fauces  and  pharynx 

Malignant  tumours  of  naso-pharynx 

Foreign  bodies  in  naso-pharynx  and  pharynx 

Post-dii)litheritic  paralysis  of  soft  palate 

Sensory  neurosis 

Vincent's  angina 

Eetro-pharyngeal  abscess  . 

Enlargement  and  ojdema  of  uvula 

Hei-pes  of  soft  palate 

Congenital  (?)  occlusion  of  choanse 

Miscellaneous 


yngitis 


1102 

20 

11 

4 

4 

35 

11 

1 

14 

27 

8 

8 

1 

20 

1 

7 

3 

4 

4 

1 

1 

3 


Diseases  of  the  Mouth  (59). 
Pyorrhoea  alveolaris 
Cleft  palate 
Superficial  glossitis 
Leucoplakia 

Tertiary  syphilis  of  tongue,  mouth  and  palate 
Carcinoma  of  tongue,  alveolus  and  palate 
Periodontal  abscess 
Abscess  and  cyst  of  lower  lip 
Telangiectasis  of  tongue  and  palate 
Neurosis  of  mouth  .  . 

Liipus'  of  hard  palate 
Simple  iilcer  of  tongue 
Traumatic  injury  to  soft  palate 


1290 
21 


11 
8 
1 
2 
1 
3 
1 
1 
1 


59 


April,  1920. 


Rhinology,  and  Otology. 


109 


Affections  of  the  Lartnx  axd  Trachea  (147). 

I.  Acute. 
Acute  eatarrhal  laryngitis 
Acute  cedematous  laryngitis 


II.  Chr 


Chronic  catarrhal  laiyngitis 
Laryngitis  sicca  . 
Vocal  nodules 
Pachydermia  of  lai-ynx 
Lupus  of  larynx  . 
Tubercular  disease  of  larynx 
Syphilitic  disease  of  larynx 


III.  Tumours. 
Simple : 

Papilloma 

Angioma 

Simple  tiimour  of  vocal  cord 


9 
1 

10 

1() 
9 
2 
2 
1 

12 
9 

51 


Malignant  .- 
Intrinsic 
Extrinsic 


IV.  Affections  of  Laryngeal  Nerves. 

Functional  aphonia 
Abductor  paralysis  of  right  vocal  cord 
Recurrent  paralysis  of  right  vocal  cord 
Eecurrent  paralysis  of  left  vocal  cord 
Bilateral  abductor  paralysis 
Sensory  neurosis 
Congenital  laryngeal  stridor 
Mogiphonia 


V.  Miscellaneous. 
Herpes  of  larynx 

Acute  jjeri chondritis  of  larynx  (septic) 
Subglottic  thickening  (unknown  cause) 
Laryngeal  vertigo 
Foreign  bodies  in  larynx    . 
Simple  and  exophthalmic  goitres     . 
Malignant  goitre 
Thyroglossal  cyst 
Tracheitis  and  bronchitis  . 


30 
1 
1 
4 
1 
4 
1 
1 

43 


1 
1 
1 
1 
2 
19 
3 


31 


Affections  of  Hypo-PHARrNX  and  (Esophagus  (32). 

Stricture  : 

(a)  Simple,  (?)  cardiospasm  .                 .  .1 

(h)  Malignant  (including  post-cricoid  carcinoma)  .  .       15 

Neurosis                .  :                .                 .  .4 

Foreign  bodies     .  .  .11 

(Esophageal  fistvxla  .                                 .  .1 


32 


110 


The  Journal  of  Laryngologry* 


[April,  1920. 


Affectioxs  of  the  Ear  (15-42). 


I.  The  External  Ear. 


Congenital  malformation  .... 

2 

Injury  to  ear        .... 

3 

Perichondritis      ..... 

2 

Cerumen 

175 

Fui-unculosis        ..... 

51 

Otitis  externa  diffusa          .... 

59 

HjT)erostosis        ..... 

Foreign  bodies     ..... 

Malignant  disease  of  external  ear 

Keratosis  obturans               .... 

Otomycosis            ..... 

Condylomata  of  external  auditory  meatus 

Suppiirating  mastoid  gland 

3 

307 


II.   The  Middle-ear  Cleft. 

Eustachian  obstruction 
Acute  non-suppurative  otitis  media 
Chronic  non-svippurative  otitis  media 
Acute  suppurative  otitis  media  : 

Eight 

Left 

Bilateral 
Chronic  suppiirative  otitis  media : 

Right 

Left 

Bilateral 
Sequela?  of  chronic  suppurative  otitis  media 

Eight 

Left 

Bilateral 
Acute  suppurative  otitis  media  with  mastoid  complication  : 

Eight 

Left  .... 

Bilateral 
Chronic  suj^piu-ative  otitis  media  with  mastoid  complication  .- 

Eight 

Left 

Bilateral 
Tubercular  otitis  media  : 

Eight 

Left. 

Bilateral 


184 
57 
63 

47 
44 
11 

105 

129 

80 

56 
60 
67 

13 

13 

0 

40 

41 

0 

1 
1 


1014 


III. 

Otosclerosis 

Mixed  middle-  and  inner  ear  deafness 


80 
25 


105 


April,  1920.] 


Rhinology,  and  Otology. 


Ill 


IT.  Infernal  Ear  Affections. 

Congenital  (ineludiug  deaf-umtism) 

Traumatic  (following  shell  explosion) 

Traumatic  (following  injiuy  other  than  shell 

Occupational 

Circnmseribed  labyrinthitis 

Acute  piirulent  laljyrinthitis 

Latent  labyrinth  suppuration 

Healed  labyrinthitis 

Congenital  syphilis 

Acquired  syphilis 

Senile  changes 

Leukcsmic  htemorrhage  into  labyrinth 

Unknown  caiises  of  nerve-deafness  . 


24- 

10 

explosion) 

6 

6 

1 

2 

2 

1 

3 

2 

1 

50 

116 


V.  Intra-cranial  Complications  of  Suppurative  Otitis  ATedia   (12). 

Four  complicating  acute  otitis  media. 
Eight  complicating  clii'onic  otitis  media. 

With  8  recovei'ies  ;  4  deaths. 
Extra-dural  peri-sinus  abscess  .  .  .  .3 

Extra-dural  peri-sinus  abscess  and  sinus  thrombosis     .  .         3 

Extra-dural  middle  fossa  abscess  (left)  and  general  oedema  of 

brain  .  .  .  .  .  .1 

Extra-dura  middle  fossa  abscess  (right)  with  temporo-sphenoidal 

abscess  and  meningitis  .  .  .  .1 

Temporo-sphenoidal  abscess  .  .  .1 

Purulent  lepto-meningitis  (one  Avith  recent  labyrinthitis)  2 

Purulent  lepto-meningitis  and  sinus  thrombosis  1 


Miscellaneous  Cases  (1-42). 

These  include  cases  sent  from  other  wards  in  the  hospital 
with  negative  findings,  enlarged  cervical  glands,  skin  diseases, 
headaches  of  obscure  origin,  mental  defects,  eye  cases,  carioixs 
teeth,  etc. 


Table  of  Operations. 

The  Nose. 

Fracture  of  nasal  bones  (rectified)   . 

Plastic  operation  on  nose  . 

Paraffin  injection 

Abscess  of  nasal  septum     . 

Abscess  of  floor  of  nose 

Submucous  resection  of  septum 

Turbinotomy 

Nasal  polypi  (including  return  cases) 

Curetting  (for  lupus) 

Foreign  bodies  removed  from  nose 

Intra-nasal  dacrocystostomy  (West's  operation) 

Nasal  cautery 


1 

1 

1 

2 

1 

79 

75 

159 

8 

35 
60 


429 


112 


The  lournal  of  Laryngology, 


'April,  1920. 


Accessory  Nasal   Sinuses. 

Proof  puncture  of  antrum 

Intra-nasal  operation  on  antrum 

Eadical  operation  on  antrum 

Naso-antral  i)olypi  (radical  ojjeration  on  antrum) 

Dental  cyst  invadincj  antrum 

Radical  operation  on  frontal  sinus    . 

Operation  on  ethmoid  cells 

Operation  on  sphenoidal  sinvis 


47 
11 
12 
5 
1 
1 
0 
1 


Mouth   cnid  Pharynx. 

Tonsils  and  adenoids  removed  (guillotine  and  curette) 
Tonsils  dissected  out  (scissors  and  snare) 
Peritonsillar  abscess  opened 
Eetro-pharyngeal  abscess 
Curetting  of  palate  for  lupus 


Larynx,  Trachea,  and  CEsopho.gus. 

Suspension  laryngoscopy  (examination) 
Suspension  laryngoscopy  (with  operation)  : 

Papilloma  removed 

Vocal  nodule  I'emoved 

Lupus  curetted  "  . 

Epiglottis  partly  removed 

Aryepiglottic  fold  incised 
(Esophagoscoi)}^  (examination) 
(Esophagoscopy  (removal  of  foreign  body) 
Direct  laryngoscopy 
Bronchoscopy 
Tracheotomy 


1054 

28 

15 

2 

3 

1102 


14. 


1 
1 
1 

21 
9 
4 
1 

11 


The  Ear. 


Furunculosis,  opened 
Paracentesis 
Aiu-al  polj-jn  removed 
Glandular  abscess  over  mastoid 
Sebaceous  cyst  of  auricle   . 
Foreign  bodies  removed  from  ear 
Schwartze  operation  on  mastoid 
Modified  radical  ojieration 
Radical  mastoid  operation 
Operations  on  labyrinth     . 
Extra-dural  peri-sinus  abscess 
Extra-dural  middle  fossa  abscess 
Temporo-sj^henoidal  abscess 
Operations  on  sigmoid  sinus 
Jugular  vein  ligated 


67 


15 

15 

13 

3 

1 
26 
3 
82 
4 
3 
1 
3 
4 
4 


Anesthetics. 


Ethyl  chloride     . 
Chloroform 
Chloroform  and  ether 
Local  anaesthesia 


179 

1118 

38 

177 

586 


New  patients  attending  =  3128 


1919 


April,  1920.-  Rhinology,  and  Otology.  113 

CLINICAL    NOTE. 


CASES  ILLUSTRATIVE  OF  THE  VALUE  OF  TREATMENT  OF  PAP1L= 
LOMA   OF   THE    LARYNX    BY    RADIUM    AND    BY    X    RAYS. 

By  Seymour  Jones,  F.R.C.S., 
Surgeon,  Birmingham  Ear  and  Throat  Hospital. 

(1)  Case  of  Papilloma  of  the  Larynx  Treated  by  Direct  or  Topical  Application 
with  Radium  Emanation  Tube. — A  girl,  aged  five,  was  referred  to  me  from 
Cheltenham  on  January  8,  1919.  On  arrival  she  was  found  to  have  urgent 
dyspnoja  and  cardiac  distress  with  marked  cyanosis.     Her  pulse-rate  was  165. 

It  was  elicited  from  her  mother  that  the  child  had  been  seen  by  a  consultant 
in  the  south  of  England  two  months  previously,  and  that  he  had  diagnosed  a 
papilloma  of  the  larynx  and  suggested  an  operation. 

The  child  was  admitted  to  a  nursing  home,  and  as  her  dyspnoea  was  so  acute 
a  tracheotomy  was  performed  the  same  night.  The  larynx  was  then  examined 
diu'ing  the  same  anaesthetic  with  a  bronchoscope.  Direct  inspection  revealed  that 
the  whole  interior  of  the  larynx  was  ojdematovis  and  the  cords  covered  with 
succulent  papilliform  growths.  Ko  attempt  was  made  to  prolong  the  short 
examination  as  the  child  was  in  a  very  critical  state. 

The  next  day  the  pulse-i"ate  dropped  to  120,  on  the  fourth  day  it  was  90  and 
the  cardiac  distress  had  disappeared.  It  was  decided  to  try  the  effect  of  i-adium 
on  the  growth  by  a  direct  application. 

On  January  22,  fourteen  days  later,  the  child  was  -submitted  to  ansesthesia 
and  a  radium  emanation  tube  was  introdiiced  into  the  larynx  by  the  following 
techniqiTe  ;  The  radium  tube  was  first  tied  by  its  attached  thread  to  a  small  rubber 
urethral  catheter  and  an  attempt  was  made  to  pass  this  through  the  glottis  from 
below  via  the  tracheal  wound. 

Finding  the  obstruction  impenetrable,  a  common  surgical  silver  pi'obe  was 
substituted  for  the  catheter  and  the  radium  tube  tied  to  the  eye  in  it.  The  probe 
was  thereupon  bent  in  a  semicircle  and  passed  up  through  the  stenosed  glottis 
from  the  tracheotomy  opening ;  it  was  now  grasped  bj'  a  pair  of  forceps  and 
brought  out  through  the  mouth. 

By  traction  on  the  string  the  radium  emanation  tube  was  drawn  up  into  the 
larynx  where  it  appeared  to  be  tightly  grasped  by  the  glottis. 

After  the  reinsertion  of  the  tracheotomy  tube  the  lower  silk  thread  was  wound 
round  the  barrel  behind  the  shield  and  tied  to  the  slot  in  it,  the  upper  thread 
being  affixed  to  the  cheek  by  American  strapping. 

For  twenty-eight  hours  the  emanation  tube  was  retained  in  situ  and  then 
removed  through  the  tracheotomy  wound.  Incidentally  it  was  found  that  the 
child  had  rui^tured  the  upper  thread  by  pressure  of  the  tongue  during  the  night. 

No  rise  in  temperature  or  noticeable  reaction  occurred  during  the  following 
week,  and  the  child  was  allowed  to  return  home.  Lime-water  was  ordered  for 
internal  administration. 

On  March  4  the  little  patient  was  again  brought  for  re-examination.  The 
parents  reported  that  the  child  would  not  tolerate  removal  of  the  tracheotomy 
tube  for  more  than  a  minute,  symptoms  of  suffocation  ensuing. 

Indirect  laryngoscopy  revealed  the  glottis  still  choked  vnth  papilliform  growths, 
but  there  was  no  oedema  present. 

A  second  application  was  suggested  with  a  radium  emanation  tube  of  increased 
strength.  This  was  introduced  by  the  same  procedure  as  before  under  general 
ansesthesia,  much  thicker  silk  thread  being  used,  however,  after  the  previous 
experience. 

Owing  to  the  inability  of  the  parents  to  meet  the  expense  entailed,  the  child 
was  not  brought  up  for  examination  until  three  months  later.  By  indirect 
examination  no  appreciable  change  was  discos' ered  in  the  extent  or  character  of 
the  papilloma,  which  covered  both  cords,  filled  up  the  sinuses  of  Morgagni,  and 
appeared  to  extend  down  towards  the  tracheotomy  wound.  In  other  words,  the 
growth  was  neither  reduced  nor  inhibited. 

The  parents  were  informed  that  the  radium  had  achieved  no  success,  and  a 
promise  was  made  to  take  the  child  into  the  Ear  and  Throat  Hospital  as  soon  as  a 
bed  was  available,  with  a  view  to  removing  the  growth  by  direct  endoscopy. 


114  The  Journal  of  Laryngology,  [April,  1920. 

A  few  days  later  the  mother  Avrote  to  say  that  the  little  patient  had  died 
suddenly  one  night  with  symptoms  of  suffocation. 

The  result  was  especially  disappointing  in  the  light  of  past  successes  in  the 
treatment  with  radium  of  sarcomas  and  endotheliomas  in  the  tonsillar  region  and 
nose  and  trachea  {vide  Joubn.  of  Lartngol.,  Khinol.,  and  Otol.,  August,  1918). 

(2)  Case  of  Recurrent  Papilloma  of -the  Larynx  Treated  by  Irradiation. — A 
woman,  aged  twenty-five,  presented  herself  in  the  Out-Patient  Department  of  the 
Ear  and  Throat  Hospital  with  a  papilloma  on  the  vocal  cord.  This  was  removed 
and  trichloracetic  acid  ajDplied.  Three  months  later  she  came  back  with  a  retium 
of  symptoms,  and  a  papilloma  was  seen  on  the  laryngeal  aspect  of  the  epiglottis, 
the  size  of  a  sixpence,  and  another  on  the  left  vocal  cord. 

She  was  sent  to  Dr.  Black,  an  X-ray  specialist,  and  had  over  twenty-four 
seances  with  irradiation  of  the  larynx. 

The  papillomata  underwent  no  recession,  but  showed  no  signs  of  extension,  and 
I  am  of  the  opinion  that  the  active  infective  agent  was  inhibited. 

If  an  inference  may  be  drawn  from  solitary  cases  it  would  seem  that 
little  is  to  be  hoped  from  either  radium  or  X-ray  treatment  in  papillomas 
of  the  larynx. 

Removal  by  direct  or  indirect  methods  remains  the  only  satisfactory 
procedure ;  it  is  possible  that  this,  combined  with  irradiation,  might  give 
a  better  pi-ospect  of  non-recurrence. 

It  is  generally  accepted  that  papillomata  are  caused  by  infection,  but 
how  this  is  actually  conveyed  to  regions  like  the  larynx  or  the  bladder  is 
not  yet  made  clear.  Given  a  suitable  soil  it  would  seem  that  a  papilloma 
may  arise  without  any  breach  of  surface  or  definite  local  irritation. 

It  is  claimed  by  some  that  a  deficiency  of  lime-.salts  makes  the  tissues 
non-resistent  to  the  infection,  and  cases  strongly  supporting  this  view 
have  been  published. 

These  cases  have  generally  been  treated  experimentally,  and  there  is 
abundant  room  for  scientific  reseaix-h  and  observations,  both  as  to  the 
deficienc}'  of  lime-salts  and  as  to  the  method  of  making  good  the  deficiency, 
to  cause  a  retrograde  change  and  disappearance  of  the  growth. 


SOCIETIES'     PROCEEDINGS. 


ROYAL  SOCIETY  OF  MEDICINE.— LARYNGOLOGICAL 

SECTION. 

May  3,  1918. 


President :  Dr.  A,  Bbown  Kelly. 


Abridged  Report. 

{Contimied  from  jj.  89.) 

A  Colony  of  Actinomyces  in  the  Crypt  of  a  Tonsil. — W.  Douglas 
Harmer  and  A.  C.  Stevenson. — Patient  was  a  boy,  aged  nine,  who  had 
suffei'ed  from  chronic  tonsillitis  for  six  months.  There  had  been  a  crypt 
in  the  left  tonsil  from  which  pus  was  constantly  oozing,  and  the  tonsillar 
Ivmphatic  glands  were  swollen,  the  largest  being  an  inch  in  length.  The 
tonsils  were  enucleated  and  sent  to  Dr.  A.  C.  Stevenson,  who  found  no 
evidence  of  tubercle,  but  in  one  of  the  tonsils,  lying  in  a  deep  crypt, 
there  was  a  colony  of  actinomyces.     The  section  was  shown  to  Prof. 


April,  1920.] 


Rhinology,  and  Otology.  115 


Sliattock,  who  reported  :  "  A  colony  of  actinomyces.  lu  a  Gram-stained 
preparation  a  few  normal  branching  filaments  occur  and  large  numbers 
of  coccus-like  forms,  well  stained,  which  may  be  taken  as  spores.  The 
periphery  of  the  colony  is  regularly  fringed  with  clubs,  but  these  are  all 
finely  granular.  In  a  logwood-eosine  preparation  very  little  is  stained, 
indicating  that  the  colony  is  largely  degenerate.  The  crypt  in  which  the 
colony  lies  presents  no  signs  of  invasion,  but  the  epithelium  is  here  and 
there  desquamating  and  at  one  spot  the  colony  is  invested  with  an 
exudate  containing  polymorphs." 

.One  week  after  operation  the  glands  had  almost  disappeared. 

Dr.  H.  J.  Banks-Davis  :  Six  months  ago  I  took  a  case  to  Mr.  Tyrrell 
Grray.  The  patient,  a  woman,  aged  fifty,  had  a  peculiar  condition  of  the 
tonsil  and  enormous  glands  in  the  neck,  extending  to  the  clavicle.  I 
asked  him  whether  it  was  malignant,  and  he  said  that  he  thought  it  was 
actinomycosis.  His  impression  proved  correct.  After  excision  it  cleared 
up.  The  pus  contained  actinomyces.  The  glands  had  got  infected 
through  the  tonsil.     The  patient  quite  recovered. 

Dr.  Irwin  Moore  :  These  cases  are  rare  :  I  have  looked  np  the 
references.  Arthur  Cheatle  and  W.  D'Este  Emery^  in  1904  were  the 
first  to  report  and  describe  a  case  of  actinomycosis  of  the  tonsil  in  this 
country.  Butliu,-  in  the  discussion  on  this  case,  referred  to  one  case  he 
had  seen  some  years  previously.  Jonathan  Wright^  (New  York),  in 
190-4,  was  the  first  to  describe  a  case  in  America.  He  refers  to  one  case 
reported  by  Lesin^  in  1895,  also  to  four  cases  described  by  Ruge^  in 
1896.  T.  K.  Hamilton^  (Melbourne),  in  1910,  reports  one  case  he 
had  seen. 

Mr.  Harmer  :  This  was  discovered  accidentally.  The  tonsil  was  cut 
for  tubercle,  but  no  tuberculosis  was  discovered.  Dr.  Davis,  a  pathologist 
in  Chicago,  has  investigated  this  question.  He  claims  that  in  examining 
130  pairs  of  tonsils  from  children,  actinomyces  were  found  in  30  cases, 
and  he  quotes  articles  by  others  who  also  declare  the  condition  to  be 
common.  I  bring  it  forward  because,  although  I  have  had  a  number  of 
tonsils  cut,  mostly  for  tubercle,  I  have  not  previously  had  a  report  of 
actinomyces,  and  I  wanted  to  hear  the  experience  of  others. 

Dr.  A.  C.  Stevenson  :  My  chief  difiiculty  from  the  pathological 
point  of  view  is  what  type  of  actinomycosis  we  have  here.  No  smear 
preparations  were  made,  nor  was  it  possible  under  the  circumstances  to 
attempt  cultivation  or  to  inoculate  into  test  animals.  In  some  ways  th^^ 
type  resembles  the  bovine  and  in  others  the  human  variety,  the  latter 
having  few,  the  former  many  clubs.  The  peculiar  sporulating  appearance 
at  the  edge  of  the  tumour  has  only  once  before  been  described  to  my 
knowledge — in  the  article  by  Dr.  Davis,  which  Mr.  Harmer  quoted.  Davis 
came  to  the  conclusion  that  the  nodules  in  the  tonsil  were  not  actino- 
mycotic in  nature,  as  he  only  got  the  BaciUus  fusiformis,  spirilla  and 
cocci  from  cultures  and  inoculatiqn  experiments.  It  is  probable  that 
even  after  washing  the  nodule  as  he  described  he  would  get  these 
organisms — common  elements  of  the  flora  of  the  mouth.    After  inoculation 

1  "  Specimen  of  Actinomycosi.s  of  the  Tonsil,"  Proc.  Laryng.  Soc.  Lond.,  1904, 
xii,  p.  5  ;  JouRN.  OF  Lartngol.,  Ehinol.,  and  Otol.,  1904,  xix,  p  679. 

^  Loc.  cit. 

^  "  Actinomycosis  of  the  Tonsil,"  Amci-.  Journ.  Med.  Sci.,  1904,  cxxviii,  p.  74. 

^  Wratsch,  St.  Petersburg,  Abstract  in  Centralbl.f.  Laryng.,  1895,  xi,  p.  901. 

«  Zeitschv.f.  klin.  Med.,  1896,  xxx,  p.  .529. 

''  "  The  Faiicial  Tonsils  and  their  Relation  to  Various  Local  and  General 
Diseased  Conditions,"  Austral.  Med.  Journ.,  Melbourne,  1910,  xv,  p.  329. 


116  The  Journal  of  Laryngology,  [April,  1920. 

of    guinea-pigs    with    tlie    nodules,    Lord,    of    America,    found    typical 
actinomycotic  lesions  present. ' 

Paralysis  of  the  Arytaenoideus  in  a  Woman,  aged  twenty-four, 
— H.  J.  Banks-Davis  — The  cords  meet  in  the  anterior  two-thirds  and 
gape  in  the  posterior  third.  Loss  of  voice  is  complete.  Paralysis  of  the 
arytsenoideus  is  very  rarely  functional.  In  this  case  the  thyroid  is 
enlarged  and  is  probably  the  cause  of  the  paralysis.  This  is  a  very 
difficult  condition  to  cure. 

Dr.  Smurthwaite  :  I  think  this  case  is  purely  psychic  in  origin  and 
can  be  cured  by  psychological  methods.  In  trying  to  phonate  she  brings 
the  false  cords  together,  showing  a  big  effort  is  being  made.  It  is  like 
what  I  see  in  many  shell-shock  cases  :  the  anterior  two-thirds  of  the 
cords  are  brought  together.  If  the  patient  can  be  got  to  breathe  deeply 
and  overcome  the  spasm  the  voice  will  return.  Dr.  Banks-Davis  says 
paralysis  of  the  arytaenoideus  is  very  rarely  functional.  If  he  means  the 
crico-arytaenoideus  posticus  this  is  so  —  an  abductof  paralysis  is  not 
functional.  This  patient  has  no  abductor  paresis,  for  the  cords  can  be 
approximated.  The  crico-arytaenoidei,  thyro-arytaenoidei  and  inter- 
arytaenoideus  are  supplied  by  the  recurrent  laryngeal.  If  the  thyroid 
disease  were  the  cause  of  the  patient's  loss  of  voice  we  should  expect 
both  recurrent  laryngeal  nerves  to  be  involved  and  consequently  all  the 
above  muscles. 

Dr.  Mark  Hovell  :  I  have  only  seen  one  case  of  paralysis  of  the 
arytaenoideus.  The  patient  was  under  the  care  of  Sir  Morell  Mackenzie 
at  the  Throat  Hospital,  Golden  Square,  and  is  mentioned  in  his  work  on 
"  Diseases  of  the  Throat."  The  affection  had  existed  for  several  years 
before  I  saw  her,  and  she  was  iinder  my  observation  for  upwards  of  forty 
years,  during  which  time  there  was  no  alteration  in  the  symptoms.  She 
died  in  January  last,  aged  eighty-eight.  I  think  the  present  case  is  not 
one  of  arytaenoideus  paralysis. 

Mr.  O'Malley  :  I  agree  that  the  important  factor  in  this  case  is  a 
functional  one  ;  there  is  considerable  straining  and  tightening  of  the 
larynx,  as  is  often  seen  in  soldiei's  who  have  shell-shock  with  laryngeal 
trouble— cases  of  functional  trouble  grafted  on  a  laryngeal  affection, 
such  as  catarrh.  My  plan  of  treatment  is  to  carry  on  the  examination 
and  use  friction  with  the  mirror  on  the  pharyngeal  wall  until  a  good  deal 
of  secretion  drops,  and  then  the  glottis  will  close  as  a  protective  effort, 
bringing  the  cords  into  firm  apposition.  The  next  deep  expiration  will 
produce  phonation,  which  will  at  once  convince  the  patient  there  is  a 
voice,  and  as  a  rule  there  is  no  further  difficulty  in  getting  him  to  speak 
distinctly  instead  of  whispering. 

Dr.  Donelan  :  I  think  this  is  a  case  of  functional  paresis  of  the  trans- 
versvis  in  a  hysterical  subject.  It  is  specially  interesting  in  that  the 
oblique  fibres  of  the  arytenoideus  which  bring  the  apices  of  the  arytaenoid 
bodies  together  are  not  affected,  as  shown  by  the  approximation  of  the 
cartilages  of  Santorini.  While  the  cartilaginous  glottis  remains  open  in 
characteristic  triangular  form  from  inaction  of  the  transverse  fibres,  the 
ligamentous  glottis  is  very  slack  fi-om  paresis  of  the  internal  thyro- 
arytaenoid.  I  have  looked  up  the  continental  literature  on  this  subject, 
and  I  find  there  is  general  agi"eement  that  the  arytaenoideus  is  very  rarely 
affected  except  functionally  or  as  a  myositis.  It  is  also  in  favour  of  a 
general  neurosis  that  the  patient  has  had  previous  attacks  of  loss  of 
voice,  has  irregular  menstriiation,  and  is  very  emotional. 


April,  1920.] 


Rhinology,  and  Otology.  H^ 


Dr.  JoBsox  HoENE  :  It  i.s  just  t^\-euty  years  siuee  I  first  wrote  on 
this  subject.  lu  1898,i  at  the  Auuual  Meeting  of  the  British  Medical 
Association  at  Edinburgh.  I  pointed  out  that  a  certain  group  of  cases  of 
so-called  functional  aphonia  were  myopathic  in  origin.  Under  the 
microscope  I  demonstrated  a  myositis  in  the  intrinsic  muscles  of  the 
larynx,  and  in  particular  in  the  interarytaeuoid  muscle.  The  specimens 
were  obtained  from  patients  who  had  died  from  tubeiculosis  of  the  lungs 
and  in  whom  the  larynx  presented  perhaps  no  gross  or  naked-eye  evidence 
of  disease.  I  further  pointed  out  the  danger  of  overlooking  pulmonary 
tuberculosis  at  a  time  when  one  could  be  most  useful  to  the  patient, 
through  labelling  a  case  of  loss  of  voice  as  "  functional "  aphonia  without 
taking  a  Avider  view  and  ascertaining  the  cause  of  the  "  functional." 
The  deduction  was  in  all  cases,  male  or  female,  of  loss  of  voice  so 
imfortunately  described  as  functional,  to  eliminate  as  far  as  possible  the 
presence  of  pulmonary  tuberculosis. ~ 

Mr.  Whale  :  I  have  seen  many  of  these  cases  in  the  last  year  or  two 
in  France,  a'ld  I  endorse  Mr.  0"Malley's  opinion  that  they  are  functional 
aphonia  grafted  on  to  a  subacute  laryngitis.  They  are  common  in 
France  in  men  who  come  from  the  line.  These  glottides  are  more 
common  than  the  diamond-shaped  glottis  of  hysteria.  I  have  seen  them 
in  men  who  are  recovering  from  gassing,  in  whom  there  is  no  other  sign 
of  congestion  or  inflammation.  I  should  be  very  sorry  to  think  that  all 
these  people  are  going  to  have  tubercle.  Our  treatment  for  them  is 
mental  therapy — persuading  them  that  they  will  get  well. 

Mr.  Lack  •  These  cases  are  rare  in  civil  life.  Mr.  Hovell  has  seen 
only  one ;  I  have  seen  the  same  case  and  another.  The  first  case  lived  to 
eighty,  and  did  not  develop  tuberculosis.  In  neither  case  was  there  the 
least  attempt  to  close  the  posterior  part  of  the  glottis  on  phonation.  The 
arytseuoideus  showed  no  trace  of  movement.  These  cases  may  be  functional, 
but  I  have  never  seen  any  benefit  from  any  kind  of  treatment.  On  the 
other  hand,  it  is  difficult  to  believe  that  the  paralysis  can  be  due  to 
pressure  on  the  recurrent  laryngeal  nerve,  as  pressure  on  that  nerve 
always  affects  the  abductors  first. 

The  President  :  I  agree  with  those  members  of  the  R. A.M. C.  who 
have  spoken  of  the  frequency  of  this  condition — in  fact,  in  the  functional 
aphonia  of  soldiers  this  transversus  muscle  is  the  most  frequently  affected 
of  all  the  laryngeal  muscles,  and  the  most  intractable.  I  hope  that  in 
our  next  month's  discussion  on  warfai-e  neuroses  someone  will  throw  light 
on  the  subject,  because  it  is  striking  how  paresis  of  so  small  a  muscle 
causes  so  much  vocal  disturbance,  I  have  not  always  been  fortunate 
in  the  treatment  of  these  cases. 

Dr.  Paterson  :  I  also  have  seen  these  cases  from  time  to  time.  One 
sees  them  from  France  suffering  from  aphonia,  some  of  them  after  gas. 
After  undergoing  local  and  other  treatment  for  months  with  varying 
.success,  one  has  had  not  infrequently  to  discharge  them  with  little  voice 
to  a  command  depot,  where  they  may  be  under  regulated  discipline. 

Mr.  Harmer  :  The  condition  is  common  in  soldiers,  the  number  I 
have  seen  probably  running  into  double  figures.  The  prognosis  is  bad. 
but  functional  aphonia  in  soldiers  is  very  difficult  to  cure.     I  have  also 

1  Lancet,  1898,  ii,  pp.  449,  .518  ;  JouRN.  of  L.^etngol.,  Khixol.,  axd  Otol., 
1898,  xiii,  pp.  -481-486. 

'  This  patient  lately  developed  aciite  mUmonary  tubercialosis  and  is  now  in  a 
sanatorium  ;  this  is  interesting  in  view  of  the  remarks  made  by  Dr.  Jobson  Home. 
— H.  J.  Banks  Davis. 


118  The  Journal  of  Laryngology,  [April,  1920. 

seen  sevei'al  officei's  with  this    condition  ;    they  have  been  sent  to  Mr. 
McMahon  for  voice-training,  and  their  voices  have  recovex'ed. 

Trichotillomania  with  Delusions  of  Nasal  Origin.— H.  J.  Banks 
Davis. — This  patient,  a  woman,  aged  thirty-seven,  was  transferred  to 
my  department  by  Dr.  Pernet,  whose  notes  on  the  case  are  appended. 

When  I  saw  her  first  six  months  ago  she  was  perfectly  reasonable, 
but  was  convinced  that  her  nose  was  infested  with  maggots ;  that  at 
times  they  crawled  up  through  her  nose  and  brain  on  to  her  scalp,  where 
they  commenced  devouring  her  hair,  and  she  pointed  to  the  condition 
there  as  the  result  of  this  invasion.  The  nose  is  narrow,  but  nothing 
abnormal  exists.  Unfortunately  a  septal  resection  was  performed  some 
years  ago,  and  in  her  mind  it  is  firmly  fixed  that  this  operation  was 
performed  for  troubles  then  which  she  alleges  she  suffers  from  now. 

I  have  seen  her  in  an  attack,  produced  by  "tickling"  the  septal 
tubercle  with  a  probe.  This  produces  intense  irritation  of  the  scalp. 
Her  anxiety  becomes  extreme,  and  she  rubs  and  plucks  at  her  hair  in  a 
manner  c[uite  absurd.  The  sensation  then  passes  oft'  and  she  points  to 
the  damage  done  by  herself  as  that  done  by  phantom  maggots  grazing 
on  her  scalp. 

Light  cauterisation  of  the  septal  tubercle  has  relieved  these  attacks, 
Avhich,  presumably,  are  entirely  of  reflex  nasal  origin. 

Dr.  Pernet's  notes  (abstract)  are  as  follows  :  "  The  patient  came  first 
to  my  skin  clinic  for  loss  of  hair  and  strange  symptoms  about  the  scalp 
which  she  attributed  to  '  live  things  '  ;  she  felt  them  start  from  her  nose 
and  crawl  up  inside  her  head.  The  hair  in  patches  was  short,  with 
broken  ends,  and  under  the  microscope  brush-like,  evidently  the  result 
of  bi'eaking  them  off  by  rubbing.  On  account  of  her  nasal  symptoms 
I  sent  her  to  Dr.  Banks-Davis.  Later  she  saw  me  again,  and  brought 
some  maggots  with  her  (larvae)  which  she  said  had  come  out  of  her  nose. 
This  was  in  June.  I  sent  her  to  Dr.  Grainger  Stewart  to  deal  with 
the  mental  condition  (disagregation  lyhysiolocjuiue)  and  the  delusions. 
On  January  16  she  again  insisted  on  '  live  animals '  crawling  through 
her  nose  on  to  her  scalp,  but  on  questioning  her  she  stated  that  no 
maggots  had  '  come  out '  since  she  had  brought  me  those  in  June 
— ('there  ai-e  none  at  this  time  of  the  year'). — G.  Pernet." 

Dr.  JoBSON  HoRNE :  The  case,  I  think,  affords  a  further  argument 
for  a  stock-takiug  of,  and  a  discussion  on  tbe  eH,f?-results  of,  submucous 
resection  of  the  nasal  septum. 

Left  Recurrent  Laryngeal  Nerve  Paralysis  in  a  Patient 
suffering  from  Tuberculosis.—Irwin  Moore. — Final  Notes,  tfxjether 
with  Post-mortem  Iteport  and  S])ecimen,  showing  the  Nerve  embedded,  in  a 
Mass  of  Caseatirig  Glands. — Patient,  a  male,  aged  forty-five,  was 
exhibited  at  a  meeting  of  the  Section  on  November  2,  1917,'  under  the 
title  of  "  Complete  Paralysis  of  the  Left  Vocal  Cord  due  to  a  Mediastinal 
Growth." 

He  was  first  seen  on  September  18,  1917,  when  he  complained  of 
slight  hoarseness  for  three  weeks,  following  the  impaction  of  a  piece  of 
meat  in  the  laryugo-pharynx,  and  since  then  he  had  only  been  able  to 
swallow  semi-solid  food. 

Examination  of  the  larynx  at  this  time  was  obscured  by  oedema  of  the 
arytaenoids  caused  by  impaction  of  the  foreign  body.  Two  weeks  later,. 
1  Proc.  Roy.  Soc.  Med.,  1918,  xi  (Sect.  Laryngol.),  p.  49. 


April,  1920.] 


Rhinologry,  and  Otology. 


119 


on  subsidence  of  the  oedema,  complete  paralysis  of  the  left  vocal  cord 
was  observed  (cadaveric  position).  An  imperfect  cough,  bovine  in 
character,  and  imperfect  phonation  following  the  exertion  of  speaking- 
were  present. 

After    November    2    patient's     condition     gradually  I  deteriorated, 
emaciation  became  more  marked,  with  high  temperature,  rapid  pulse  and 


Thyroid     glano 


CAVITY      OF    ABSCCJS 


ENI.AR6ED      LYMPHATIC 
CLAUDS  CD£EP   CCHYICAl) 


LlfT      WAGUS     NLftve 


T-  TUBcKCULAIi 
■^        CANITY   IN  APEK 

OF Luna 


Left  recurrent  laryngeal  jjaralysis  due  to  involvement  of  the  nerve  in  the 
abscess-cavity  of  a  broken-down  peritracheal  gland.  ( Dissected  by  Prof. 
Shattock,  F.K.S ,  and  now  in  the  Museum  of  the  Eoyal  College  of 
Surgeons.) 


respiration,  also  spasmodic  cough  and  increased  amount  of  sputum,  iu 
which  tubercle  bacilli  were  found. 

In  view  of  the  opinion  that  a  mediastinal  growth  was  encroaching  on' 
the  left  lung  and  was  probably  of  a  malignant  nature,  he  was  treated 
between  November  8  and  December  11  with  injections  of  colloidal  copper 
(cupraseo  c.c.) — six  in  number,  at  weekly  intervals— preceded  by  5  c.c. 
quinine  urea  hydrochloride  to  prevent  the  pain  of  the  injection.  Each 
injection  greatly  relieved  the  respiratory  distress,  reduced  the  temperature 
and  pulse-rate  and  improved  for  the  time  the  general  condition  of  the 


120  The  Journal  of  Laryngology,  :Aprii,  1920. 

patient.  Death  occurred  on  January  18,  1918,  nearly  five  months  after 
the  onset  of  tlie  first  symptoms. 

I  am  indebted  to  Dr.  Kelson  for  performing  the  post-mortem  and 
dissecting  the  specimen  now  shown. 

Post  mortem  Report. ^^The  body  was  much  emaciated. 

Larynx.— ^ot\\  vocal  cords  were  in  the  cadaveric  position,  the  left 
thinner  than  the  right ;  on  neither  side  w"as  there  ankylosis  of  the 
crico-arytseuoid  joint.  The  lower  deep  cervical  and  upper  mediastinal 
(posterior)  glands  were  enlarged  and  caseating,  some  having  quite 
broken  down.  The  left  recun^ent  laryngeal  nerve  passed  up  to  and 
became  embedded  in  the  mass.  Lungs. — Both  were  consolidated  at  the 
apices  and  showed  caseating  material.  On  the  left  side  was  a  cavity  as 
large  as  a  billiard-ball.  The  pleura  on  both  sides  was  thickened  and 
adherent,  but  did  not  involve  the  left  recurrent  nerve  (W.  H.  Kelson). 

The  case  is  of  interest  in  that — 

(1)  The  first  danger-signal  of  serious  disease  within  the  chest- wall 
was  the  sudden  impaction  of  a  foreign  body  in  the  laryngo-pharynx,  for 
which  patient  first  sought  advice. 

(2)  No  histoiy  could  be  obtained  of  any  early  symptoms  of  pressure 
on  the  recurrent  laryngeal  nerve,  such  as  paroxysmal  dvspnoea,  laryngeal 
stridor  or  paroxysmal  cough. 

(3)  The  syujptoms,  physical  signs  and  X-ray  examination  were 
compatible  with,  and  first  suggested,  a  mediastinal  growth  encroaching 
on  the  left  lung,  and  it  was  not  till  some  time  later,  when  tubercle 
bacilli  were  discovered  in  the  sputum,  that  tuberculosis  was  suspected. 

Dr.  Kelson  :  It  is  evident  from  the  dissection  that  it  was  an  actual 
case  of  paralysis  from  recurrent  nerve  involvement  in  a  mass  of  tuber- 
culous glands,  some  caseating,  some  broken  down.  Post-mortem  records 
of  these  cases  are  very  numerous  and  there  has  been  a  good  deal  of 
difference  of  opinion  on  the  subject. 

Double  Dacryocystitis.— W.  Douglas  Harmer.— Six  years'  persis- 
tent discharge  from  both  lachrymal  sacs ;  seventeen  abscesses.  Five 
years  ago  double  West's  operation.  Afterwards  less  muco-pus  for  a 
time.  April  9, 1918  :  West's  operation  repeated.  Sacs  are  now  shrinking, 
but  still  has  severe  epiphora  and  niuco  pus. 

Case  illustrates  the  failure  of  West's  operation  Avhere  there  is  eversion 
of  punctum  from  conjunctival  sac.  This  is  now  being  treated  by  cautery 
to  invert  the  puncta.  Sacs  will  gradually  shrink  when  normaf  position 
of  puncta  is  restore<l. 

N.B. — Patient  also  has  tubercular  glands  in  neck. 

Dr.  Paterson  :  This  indicates  and  illustrates  a  condition  which 
sometimes  seriously  interferes  with  the  success  of  the  operation.  I  was 
interested  in  seeing  that  the  treatment  was  the  cauterising  and  shrinking 
of  the  mucosa,  with  the  view  of  bringing  the  punctum  into  proper  line. 

'  This  specimen  is  now  in  the  Museum  of  the  Eoval  CoUeore  of  Surgeons. 


April,  1920.  Rhiiiolog'/,  and  Otology.  121 

ABSTRACTS. 

Abstracts  Editor — W.  Douglas  Harmer,  9,  Park  Cresceut,  LoiiJoii,  W.  1. 

Authors  of  Original  Communications  on  Oto-larynyologij  in  other  Journals 
are  invited  to  send  a  copy,  or  tivo  reprints,  to  the  Journal  of  Laryngology. 
If  they  are  ivilhng,  at  the  same  lime,  to  submit  their  own  abstract  (in  English, 
French,  Italian  or  German)  it  u-ill  be  welcomed. 


PHARYNX. 

Can  Granular  Pharyngitis  be  the  Cause  of  "Febricula"? — V.  Grazzi. 

"  Bull,  della  Mai.  deirOreechio,  etc.,"  May,  1919,  No.  5,  Ann. 
xxxvii. 

Prof.  Biiccaraui  in  1918  made  a  statement  that  many  "  febriculas  " 
generally  attributed  to  intestinal  intoxication  are  really  due  to  granular 
pharyngitis.  There  may  be  pains  in  the  region  of  the  ajDpendix  which 
he  regards  as  secondary  to  the  throat  condition.  The  author.  Prof. 
Grazzi,  in  the  course  of  a  long  experience  has  only  had  one  case  of  this 
kind,  so  the  conditions  cannot  be  regarded  as  common. 

A  lady,  affected  with  granular  pharyngitis,  had  been  troubled  for  a 
considerable  time  with  slight  rises  of  temperature.  After  cauterisation  of 
the  granulations  these  symptoms  disappeared.  After  a  long  interval  the 
patient  came  back  on  account  of  her  throat,  which  was  again  giving  her 
trouble.  She  was  also  having  slight  rises  of  temperature  and  some  pain 
'in  the  region  of  the  appendix,  Avliieh  came  on  at  the  same  time  as  the 
throat  trouble.  She  had  had  her  appendix  removed  contrary  to  the 
advice  of  Baccarani,  whom  she  had  consulted,  and  had  found  that  her 
fever,  instead  of  improving,  had  rather  got  worse.  After  treatment  of 
the  granulations  which  liad  reappeared  iu  the  throat  the  patient's  con- 
dition returned  to  normal. 

The  case  is  reported  more  with  the  idea  of  promoting  discussion  than 
of  attempting  to  prove  the  2:)resence  of  a  definite  "  febricula  pharyngea." 

/.  K.  Milne  Dickie. 


NOSE. 

Acute  Suppurative  Hypophysitis  as  a  Complication  of  Purulent  Sphenoidal 
Sinusitis.— T.  R.  Boggs  and  M.  C.  Winternitz.  "Johns  Hopkins' 
Hosp.  Reports,'  xviii,  1919. 

This  is  as  far  as  is  known  the  first  case  on  record  of  this  condition. 

The  patient,  a  woman,  aged  forty-three,  was  admitted  to  hospital 
June  17,  1915,  complaining  of  stiffness  and  soreness  of  the  neck  muscles, 
headache,  pain  beijind  the  eyes  and  tenderness  of  the  scalp.  The  illness 
began  with  an  ordinary  coryza  on  May  7.  On  May  20  had  soreness  of 
the  right  side  of  the  neck.  Feeling  of  ifulness  in  throat.  Slight  tender- 
ness over  both  mastoids.  Examination  of  ears  and  throat  negative.  No 
fever  till  May  21 ,  when  temperature  roseto  101 '  F.,  pulse  101 ,  respirations  20, 
blood-pressure  185.  Some  albumen  and  a  few  casts  in  the  urine.  On 
May  30  had  improved  a  little,  but  had  sudden  severe  pain  in  back  lasting 
a  day  or  two.  Had  a  second  attack  of  pain  in  neck  and  back  on  June  10. 
X-ray  showed  a  little  opacity  of  the  left  antrum.     On  June  17  had  pain 


122  ■  The  Journal  of  Laryngology,  [April,  1920. 

in  head  aud  neck.  Optic  discs  normal ;  inovement  of  eyes  caused  pain. 
Semicomatose;  no  paralysis;  no  Kernicr.  Temperature  104°  F.  Leu- 
cocytes 11,600.  Nitrogen  coefficient  in  blood  normal.  Blood-sugar 
0243  per  cent.  Urine  contained  2^  per  cent,  of  sugar  after  two  slices  of 
bread.  Acetone  and  diacetic  acid  +  -^  .  Orifices  of  nasal  sinuses  normal. 
Antra  and  frontal  sinuses  illuminated. 

On  June  19  the  patient  became  comatose  and  her  temperature  shot 
up,  rose  to  107°  F.  and  patient  died.     After  death  temperature  108-5°. 

There  had  been  no  strabismus  or  ptosis ;  no  convulsions. 

Post-mortem  examination  showed  purulent  sphenoidal  sinusitis  with 
an  extension  through  the  sella,  involvement  of  the  hypophysis,  subacute 
haemorrhagic  basilar  meningitis  and  acute  encephalitis  on  the  right  side. 
The  hypophysis  showed  as  a  dark  red  friable  body  with  pus  exuding 
from  the  sella  round  it.  The  vessels  and  sinuses  round  the  hypophysis 
were  occluded  by  thrombi.  The  anterior  lobe  of  the  pituitary  was 
infiltrated  by  polymorphs.     There  was  also  a  large  V-shaped  infarct. 

The  case  was  interesting  from  the  complete  absence  of  localising  or 
neighbourhood  symptoms. 

The  presence  of  hyperglycsemia  and  glycosuria  may  be  a  possible 
indication  of  involvement  of  the  pituitary  gland  in  a  person  previously 
not  glycosuric  who  shows  signs  and  symptoms  of  intra-cranial  in- 
flammation. 

The  normal  appearance  of  the  oi'ifices  of  the  nasal  sinuses  does  not 
exclude  sinusitis  of  the  severest  type,  as  is  shown  by  this  case. 

J.  K.  Milne  Dickie. 

Sphenoidal  Empyema  and  Epidemic  Cerebro-spinal  Fever. — D.  Emble- 
ton.     "  Brit.  Med.  Journ.,'"  January  3,  1920. 

The  association  of  sphenoidal  sinusitis  with  cerebro-spinal  fever  was 
first  noticed  by  Westenhoeffer,  who  found  it  in  one-third  of  his  twenty- 
nine  neci'opsies. 

The  primary  site  of  a  meningococcus  infection  is  undoubtedly  the 
nasopharynx.  Many  "  carriers  "  suffer  from  colds  and  nasal  discharge, 
and  it  thus  appears  that  the  meningococcus  can  give  rise  to  a  nasal 
discharge  catarrh.  The  frequency  of  sphenoidal  sinus  empyema  suggests 
that  this  might  be  the  determining  factor  in  the  onset  of  meningitis,  the 
infection  passing  by  way  of  the  lymphatics  from  the  sphenoidal  sinus 
dii*ect  to  the  meninges.     Infection  by  the  blood-stream  is  also  possible. 

The  author  found  empyema  of  the  sphenoidal  sinus  in  thirty-two  out 
of  thirty -four  cases  of  cerebro-spinal  fever  examined  post-mortem.  The 
sphenoidal  sinus  contained  pus  in  every  one  of  ten  cases  of  hydrocephalus 
following  cerebro-spinal  fever.  This  complication  is  probably  the  result 
of  a  chronic  infection  about  the  foramina  of  Luschka  and  Mageudie. 

Douglas  Guthrie. 

Congenital   Occlusion   of    the   Choanae.  — Prof.   Barraud.      '  Eev.  Med. 
de  la  Suisse  Romande,'  June,  1919. 

Two  cases  of  occlusion  of  the  choanae  out  of  seven  seen  by  the  author 
are  here  reported. 

Case  1 :  Female,  aged  thirteen.  On  examining  the  nose  the  right  side 
was  found  to  be  full  of  pus  and  polypi  and  to  be  obstructed  behind ;  the 
left  side  was  almost  normal  but  slightly  obstructed  by  a  soft  curtain  at 
the  back.  Posterior  rhinoscopy  revealed  complete  absence  of  the  right 
choaua  aud  paitial  obstruction  of  the  left.     With  a  probe  the  right  side 


April,  1920.]  Rhinology,  and  Otology.  123 

of  the  iiose  was  found  to  be  2  cm.  shallower  thau  the  left  and  the 
obstruction  bony.  The  child  had  frequent  severe  headaches,  often 
lasting  several  days.  She  had  completely  lost  the  sense  of  smell  on  the 
right  side  and  could  neither  breathe  through  nor  blow  it.  The  inferior 
and  middle  turbinals  in  both  sides  were  hypertrophied  and  the  septum 
Avas  markedly  deflected  to  the  right.  After  removing  a  considerable 
piece  of  the  right  middle  and  inferior  tui'binals,  Barraud  tunnelled 
through  the  osseous  obstruction  with  hammer  and  gouge,  then  enlarged 
this  opening  with  cutting  forceps  and  kept  a  drainage-tube  in  for  four 
weeks.  Tbe  result  was  good ;  thei'e  was  no  appreciable  retraction  and 
the  sense  of  smell  became  normal  on  both  sides. 

Case  2  :  Baby,  three  days  old,  with  copious  purulent  discharge  from 
both  nares  due  to  nasal  diphtheria  and  double  maxillary  sinusitis.  This 
was  treated  with  lavage  and  the  child  fed  from  a  spoon.  A  probe  could 
not  be  passed  through  either  side  of  the  nose,  air  could  not  be  blown 
through  by  a  Politzer's  bag,  and  some  drops  of  methylene- blue  run  into 
the  nose  did  not  appear  in  the  pharynx.  Four  days  later  Barraud 
perforated  the  left  choaua  with  a  trocar  4  to  5  mm.  in  diameter,  then 
passed  a  catheter,  Ijringiug  it  out  through  the  mouth.  A  week  later, 
although  the  discharge  had  ceased,  as  the  child's  condition  seemed 
hopeless  the  catheter  was  removed  and  the  child  sent  home. 

To  Barraud's  great  surprise  the  child  was  bi'uught  back  to  hospital 
still  alive  and  in  a  fairly  satisfactory  condition  three  months  later.  The 
artificial  choana  had  contracted  so  as  tt)  make  nasal  respiration  almost 
impossible.  Bai'raxid  then  enlarged  this  opening,  perforated  the  right 
choaua,  and  passed  a  catheter  from  one  side  of  the  nose  round  into  the 
other.  This  was  changed  daily,  and  after  about  a  mouth  nasal  respiration 
was  almost  normal  and  the  child  slept  with  its  mouth  shut. 

A  year  later  the  child  died  of  broncho-pneumonia  following  influenza, 
still  breathing  well  throusrh  its  nose.  Arthur  J.  Hnfchison. 


LARYNX. 

The  Prognostic  Importance  of  Tuberciilosis  of  the  Larynx. — Sir  StClair 
Thomson.     "  Lancet,"  1919,  vol.  ii,  p.  689. 

The  author  analyses  1750  patients  seen  at  Midhurst  during  the  last 
eight  years,  and  deals  with  833  seen  during  four  years.  He  divides  these 
cases  into  non-laryngeal  and  laiwngeal.  These  compared  show  that  the 
prognosis  as  shown  by  the  percentage  of  deaths  is  rendered  graver  in 
both  sexes  by  the  presence  of  laryngeal  involvement,  and  that  this 
increased  gravity  is  manifest  whatever  the  extent  to  which  the  lungs 
may  be  involved.  The  detection  of  a  lai'yngeal  lesion,  therefore,  renders 
the  prognosis  more  gloomy  than  in  a  case  of  more  advanced  pulmonary 
infection  with  a  free  larynx.  Macleod  Yearsley. 

A  Large  Cyst  of  the  Larynx. — H.  I.  Schousboe  (Odense).  "Acta 
Oto-laiyngologica,"  vol.  i,  fasc.  2  and  3. 
The  patient  was  a  woman,  aged  forty-five,  who  had  noticed  for  several 
years  the  sensation  of  a  lump  in  the  throat,  slight  interference  with 
swallowing,  but  no  marked  respii'atory  difl[iculty.  A  soft  fluctuating 
swelling  had  been  present  for  about  a  year  on  the  front  of  the  neck  in 
the  interval  between  the  hyoid  bone  and  the  upper  margin  of  the  thyroid 
cartilage.     The  left  pyriform  fossa  was  filled  up  by  a  smooth  rounded 


12-i  The  Journal  of  Laryngology,  [April,  1920. 

tumour,  which  pressed  the  left  arjtaenoid  aud  the  left  half  of  the  epi- 
glottis towards  the  midliue.  Bimanual  palpation  with  a  finger  in  the 
pyriform  fossa  and  a  finger  on  the  swelling  on  the  front  of  the  neck 
elicited  a  definite  sensation  of  fluctuation.  The  cyst  was  removed  entire 
by  external  operation  without  wounding  the  very  thin  mucous  membrane 
of  the  pharynx  which  covered  it,  and  the  patient  made  an  uneventful 
recovery.  It  proved  to  be  a  retention  cyst  arising  from  a  mucous  gland. 
The  author  suggests  that  this  method  of  removal  by  external  operation 
might  be  suitable  for  similar  cases  of  large  retention  cysts  in  the  pyriform 
fossa,  even  when  they  do  not,  as  in  the  case  he  describes,  present  on  the 
surface.  Thomas  Guthrie. 


TONSILS. 

Tonsillitis  and  Pharyngitis  as  a  Result  of  Oral  Sepsis. — H.  B.  Anderson 

(Toronto).     '■  Amer.  Med,"  vol.  xiv.  No.  9,  September,  1919. 

The  fact  that  tonsillitis  is  often  secondary  to  oral  sepsis  and  that 
marked  cases  of  the  latter  are  almost  invariably  associated  with  tonsillar 
infection  has  not  i-eceived  from  either  throat  specialists  or  general  prac- 
titioners the  recognition  which  its  practical  importance  warrants.  The 
author  tersely  points  out  that  it  is  not  even  mentioned  by  many  authors 
of  recent  standard  works  in  diseases  of  the  throat. 

The  author  for  some  time  has  made  it  a  point  to  examine  closely  the 
throats  of  all  office  patients  suffering  from  dental  infections.  Two 
spatulae  are  used — one  to  press  backward  and  outward  on  the  anterior 
pillar  so  as  to  extricate  the  tonsil,  while  the  other  spatula  is  used  to 
press  the  tonsil  itself.  Often  this  will  show  liquid  pus  Avhen  least 
expected.  The  appearance  of  the  tonsil  offers  little  indication  as  to  its 
disease.  Clipped  tonsils  and  tags  are  potent  factors  in  retaining  foci  of 
infection. 

In  an  analysis  of  330  routine  private  cases  where  cultures  were  made 
on  blood-agar,  the  Staphylococcus  alhus  was  found  in  66  per  cent., 
Streptococcus  viridans  in  24  per  cent.,  non-ha^molytic  streptococcus  35  per 
cent.  The  non-hsemolytic  strej^tococcus  was  found  most  frequently  in 
contrast  with  the  Streptococcus  viridans,  Avhich  is  found  most  frequently 
in  suppurative  lesions  about  the  teeth.  This,  the  author  thinks,  may  be 
due  to  transmutation  in  streptococcal  types  in  the  passage  of  infection 
from  the  teeth  to  the  tonsils.  While  the  type  of  streptococcus  varied 
considerably  in  different  mouths,  the  presence  of  pathogenic  bacteria  in 
the  tonsil  does  not  necessarily  mean  that  the  patient  is  suffering  from 
active  disease,  yet  if  pus  and  other  evidences  of  inflammation  are  present, 
it  suggests  an  active  infection  capable  of  producing  systemic  disease,  and 
improvement  of  the  latter  following  enucleation  of  the  tonsils  is  addi- 
tional evidence  of  the  virulence  of  the  organisms  isolated. 

The  author  asks :  "  What  is  the  surgeon's  proper  course  of  action 
in  cases  of  oral  sepsis  Avith  associated  tonsillar  infection  ?  " 

Obviously  if  tonsillitis  is  frequently  secondary  to  oral  (i.e.  dental) 
infection,  the  removal  of  the  latter  should  precede  operation  on  the 
tonsil.  It  is  possible  that  this  course  would  make  more  successful  our 
efforts  to  deal  with  tonsillar  infection  by  local  treatment  rather  than  by 
operation,  though  Billings  says  the  infected  tonsil  cannot  be  successfully 
sterilised  by  any  known  method  of  treatment,  aud  entire  removal  is  the 
only  safe  procedure.  Pernj  Goldsmith. 


April,  1920.J  Rhinolo§f7,  and  Otology.  125 

Tonsillectomy  in  Adults :  The  Advantage  of  Operating-  with  Local 
Anaesthetic. — Bryan  Foster.  "  Medical  Journal  of  Australia,"' 
vol.  ii,  1919,  p.  SW. 

Under  a  general  anaesthetic  hsemorrhage  is  frequently  alarming  and 
too  often  dangerous.  It  is  difficult  to  pick  up  a  severed  artery  in  a 
pharynx  rapidly  filling  with  bkiod.  By  blood  obstructing  his  view  the 
surgeon  is  guided  by  his  sense  of  touch  alone  in  his  attack  on  the  second 
tonsil,  whereby  damage  may  be  done  to  the  pillars.  Foster  regards  the 
Sluder  method  of  tonsillectomy  as  the  quickest  and  simplest.  It  is 
much  simpler  under  local  than  general  anaesthesia.  He  regards  the 
manoeuvre  of  counter-pressure  against  the  eminentia  alveolaris  as  of  some- 
what fanciful  value.  The  tonsil  can  be  pushed  through  the  ring  by 
counter-pressure  with  a  finger. 

Operation  under  Local  Anivsthefic. — -Anaesthetic  emploved  :  2  per  cent. 
novocain,  7'2  c.c. ;  1  per  cent,  adrenalin,  06  c.c.  Patient  sits  upright 
facing  light.  Nurse  su})ports  head.  Two  punctures  are  made  on  each 
side,  first  at  level  of  upper  pole,  second  aboiit  middle  of  tonsil. 
Injection  is  not  into  tonsil  but  into  peritonsillar  tissue,  as  close  to 
capsule  as  possible.  If,  in  making  the  upper  injection,  the  fluid  escapes 
through  supratonsillar  fossa,  the  needle  must  be  withdrawn  and  inserted 
further  out.  Not  more  than  72  c.c.  is  injected  for  each  tonsil.  Area 
is  anaesthetic  in  three  to  five  minutes.  Heath's  pattern  of  tonsillotome 
moderately  dull  is  preferred.  If  a  vessel  bleeds  it  is  tied  before  the 
other  tonsil  is  attacked.  When  the  removal  of  tonsils  is  finished 
the  pillars  are  stitched  together  with  a  plain  catgut  suture.  Foster  says 
the  operation  is  painless.  It  is  simplei*  than  when  a  general  anaesthetic  is 
used ;  haemorrhage  is  less,  and  if  it  occurs  it  is  more  easily  controlled. 

A.  J.  Bradij. 


(ESOPHAGUS. 

Foreign  Bodies  in  the  CEsophagus  requiring  (Esophagotomy  in  Children. — 
Colledge  and  Ewart.     "Lancet,"  1919,  vol.  ii,  p.  784. 

The  authors  record  two  cases,  a  female  child,  aged  two  years,  had 
swallowed  an  open  safety  pin.  It  was  impossible  to  extract  the  pin 
without  making  it  perforate  the  oesophageal  wall,  and,  the  point  being 
caught  in  the  mucous  membrane,  it  could  not  be  pushed  down.  It  was 
successfully  removed  by  oesophagotomy.  In  the  second  case,  a  male 
child,  aged  two,  tbe'  object  swallowed  was  a  piece  of  iron,  part  of  a 
toy  puzzle,  with  six  projecting  blunt  spikes,  all  at  right  angles,  so  forming 
a  cross  in  all  three  dimensions.  It  lay  just  below  the  level  of  the  cricoid, 
and  measured  |  in.  across.  It  was  easily  removed  by  oesophagotomy. 
Both  cases  are  well  five  and  four  years  later  respectively.  The  authors 
draw  attention  to  the  following  points  :  (1)  An  attempt  should  always 
be  made  at  removal  by  oesophagoscope  first.  (2)  In  the  rare  cases  where 
such  removal  is  impossible,  it  is  much  safer  to  make  a  clean  incision  iu 
the  oesophagus  than  to  risk  laceration.  (3)  The  oesophagus  when  exposed 
in  the  living  child  is  cylindrical  and  not  a  flattened  band.  (4)  By 
suturing  the  wound  in  the  oesophagus  and  lightly  packing  the  outer  part 
the  risk  of  spreading  cellulitis  of  the  neck  and  mediastina  is  reduced  to 
the  minimum,  (o)  A  clean  vertical  incision  in  the  oesophagus  does  not 
lead  to  stenosis.  Macleod  Yearsley. 


126  The  Journal  of  Laryngology,  >prii,  1920. 

EAR. 

Outline  of  the  Pathological  Physiology  of  Otitic  Sclerosis.— A.  Raoult 
(Nancy).     "  Proc.  French  Soc.  of  LarvngoL,  Otol.,  and  Rhinol." 

The  author  considers  the  initial  lesion  to  be  a  neuritis,  inducing  loss 
of  power  in  the  tympanic  muscles.  Consecutively  owning  to  impaired 
mobility  of  the  conduction  apparatus  the  circulation  is  no  longei-  normally 
affected.  Eventually  trophic  lesions  appear,  degeneration  of  tissue,  osseous 
lesions,  etc.  The  neuritis  manifests  itself  after  general  affections  (intoxi- 
cations, pregnancies,  overwork,  etc.).  It  may  involve  trophic,  motor  and 
sensory  nerves  and  the  terminals  of  the  auditory  nerve.  Motor  neuritis 
immobilises  the  ossicular  chain  with  its  consequences — ankylosis  and 
trophic  lesions.  In  chronic  tympanic  catarrh  tbe  author  admits  either  a 
myositis  or  neuritis  only  attacking  the  tensor  tympani,  most  exposed 
from  its  proximity  to  the  Eustachian  tube,  whence  relaxation  of  the 
membrane.  It  must  be  noted  how  this  relaxation  persists  in  chronic 
catarrh,  even  when  air  passes  into  the  tympanum  and  there  are  yet  no 
adhesions. 

Later,  on  the  contrary,  it  disappears  when  the  stapedius  has  become 
paralysed.  These  troublt^s  maintain  derangement  of  the  transmission 
ajiparatus,  whence  aural  pains  and  headache.  The  latter  is  often 
migrainous  in  character  and  is  undoubtedly  due  to  vaso-motor  troubles. 
Vaso-motor  disturbances  engender  acquired  trophic  lesions.  The  affection 
now  truly  enters  the  sclerotic  stage.  The  preceding  remarks  explain  the 
possibility  of  improving  audition  by  kinesitherapy,  which  the  author  has 
■experienced  bv  employing  the  Zuud-Burguet  a])paratus.  The  importance 
of  muscvilar  and  vascular  lesions  thus  accounts  for  the  lasting  improve- 
ment, even  when  the  treatment  is  ended.  It  therefore  depends  on  the 
condition  of  the  muscle-fibres.  H.  Clayton  Fox. 

Chloroma  Simulating  Mastoid  Disease. — E.  Catherine  Louis.  "  Lancet," 
1919,  vol.  ii,  p.  830. 
The  author  has  found  65  recorded  cases  of  chloroma.  The  case 
described  was  that  of  a  male,  aged  ten.  There  was  pain  and  dis- 
charge from  the  right  ear.  Temperature  99-6'' F.,  pulse  104.  Tender 
swelling  over  right  mastoid,  enlargement  of  right  upper  cervical  glands 
and  right  facial  paralysis.  Tuberculous  mastoiditis  was  diagnosed.  The 
antrum  when  opened  contained  pus  and  greenish-looking  granulation- 
tissue.  Improvement  followed  for  a  week,  when  retention  of  urine  and 
marked  constipation  appeared.  Blood-count  showed  appai'ent  condition 
of  lymphatic  leukaemia.  Sixteen  days  later  epistaxis  and  pain  at  the  level 
of  the  right  dorsal  spine  occurred,  and  sixteen  days  after  this  left  facial 
paralysis  developed.  The  inguinal  glands  enlarged  and  blood-counts 
showed  a  steady  increase  in  the  number  of  leucocytes.  Temperature 
fluctuated  and  death  occurred  seven  weeks  after  the  apparent  onset  of 
the  disease.  Autopsy  was  not  complete,  but  masses  of  growth  were  found 
about  the  bodies  of  the  dorsal  and  lumbar  vertebrae,  one  mass  pressing 
on  the  cord.  Other  masses  wei-e  found  on  the  ribs  and  right  femur, 
cardiac  surface  of  pericardium,  stomach,  duodenum,  large  intestine, 
pancreas  and  kidneys.  There  was  hyperplasia  of  all  the  elements  of  the 
bone-marrow,  with  a  variety  of  type  in  the  cells  composing  the  tumours. 

Macleod  Yearsley. 


April,  1920.]  Rhinology,  and  Otology.  127 


MISCELLANEOUS. 

Meningo-encephalitis  as  the  only  Manifestation  of  Mumps  :  Report  of 
Three  Cases. — Tasker  Howard.  "  Amer.  Journ.  Med.  Sci," 
clviii,  No.  5,  I).  686. 

This  paper  is  of  interest  to  otoloc^ists  in  view  of  the  association  of 
luuiups  with  the  sudden  onset  of  deafness. 

Metastatic  lesions  in  mumps  are  well  known,  testifying  to  the 
general  nature  of  the  infection.  Orchitis,  mastitis,  pancreatitis,  arthritis, 
encephalitis  and  meningitis  are  at  times  met  with.  Orchitis  is  occasionally 
recognised  in  the  absence  of  any  involvement  of  the  salivary  glands. 
Three  cases  reported  are  regarded  as  instances  of  mumps  meningo- 
encephalitis, in  spite  of  the  absence  of  inflammation  of  the  salivary 
glands.  They  occurred  in  the  presence  of  a  mumps  epidemic.  In 
two  of  the  thi-ee  cases  there  was  i-ecovered  from  the  spinal  fluid  a 
Gram-positive  diplococcus.  This  was  found  in  direct  smear  and  grown 
in  pure  culture  in  both  cases.  The  spinal  fluid  in  each  case  presented 
a  moderate  pleocvtosis,  characterised  by  a  pi'edominauce  of  mononuclear 
cells.  The  conditions  with  which  we  are  familiar  which  show  this 
picture  are  (a)  syphilis,  (6)  sometimes  tuberculous  meningitis,  (c) 
encephalitis  lethargica  and  (d)  mumps.  Two  of  the  three  patients  were 
certainly  not  syphilitic.  Tuberculous  meningitis  and  encephalitis 
lethargica  are  ruled  out  in  all  cases  by  the  clinical  course. 

/.  S.  Fraser. 

Enlarged  Thymus  Gland  and  some  Remarks  on  Status  Lymphaticus. — 
R.  C.  Newton  (Montclairj.  "Amer.  Journ.  Med.  Sci.,""  October, 
1919. 
The  case  described  was  that  of  a  young  man,  aged  twenty,  who 
suffered  fi'om  loss  of  muscular  vigour,  some  dyspnoea  and  a  soft  oedema 
over  his  neck,  upper  chest  and  shoulders.  X-ray  examination  showed 
the  thymus  gland  so  much  enlarged  that  it  covered  all,  or  nearly  all,  of 
the  anterior  surface  of  the  pericardium.  As  a  result  of  X-ray  treatment 
the  oedema  and  other  symptoms  disappeai'ed,  but  retui-ned  a  year  later, 
when  only  slight  and  temporary  improvement  followed  a  second  course 
of  this  treatment.  He  finally  developed  an  aortic  aneurysm  and  died 
as  a  result  of  its  rupture.  The  author  discusses  what  is  known  as  to 
the  minute  anatomy,  physiology  and  pathology  of  the  thymus  and  also 
the  significance  of  the  status  lymphaticus.  He  is  inclined  to  regard 
both  the  latter  condition  and  anomalies  in  the  structure  and  size  of  the 
thymus  as  due  in  some  way  to  defective  hygiene  and  diet,  and  so  perhaps 
allied  to  rickets.  Thomas  Guthrie. 


REVIEW. 


Compeyiditan    of  Medico-Legal    Oto-Rhino-Laryngology.      By   Drs.  Giro 
Caldera  and  Alberto  Balla.      Biella  :  G.   Testa,   1916.     Pp. 
278. 
A  great  deal  of  condensed   information  is  presented  by  the  authors 

in  this  book.      While    its    use  is    strictly  limited  in  English-speaking 


128  The  Journal  of  Laryngology.  [April,  1920. 

countries  there  is  little  doubt  that  in  Italy  it  will  fulfil  a  very  useful 
purpose. 

It  contains  an  excellent  vtsume  of  the  methods  of  detecting  malin- 
gerers, and  particulars  of  standards  of  fitness  required  for  military 
service  in  most  of  the  European  countries.  The  questions  of  life 
insurance,  compensation  for  alleged  injuries  to  the  ear,  etc.,  are  also 
dealt  with. 

The  book  is  useful  in  supplying  a  general  guide  to  the  assessment  of 
injuries  and  diseases  caused  by,  or  aggravated  by,  military  and  civil 
employment.  /.  K.  Milne-Dickie. 


NOTES   AND   QUERIES. 

Section  of   Laryngologv  of  the  Eotal  Socii;ty  of    Medicine  :    Summer 

Congress,  1920. 

The  Second  Annual  Summer  Congress  of  this  Section  will  be  held  on  Thursday 
and  Friday,  June  21'  and  25,  1920,  at  1,  Wimpole  Street,  London  W.  1. 

Members  of  the  Section  are  invited  to  contribute  papers  which  may  be  read  at 
the  Congress.  Papers  will  be  read  on  the  afternoon  of  Thursday,  June  2-4,  fi'om 
2.30  till  5.30  p.m.,  and  on  the  morning  of  Friday,  June  25,  from  10  to  1.  Not  more 
than  15  minutes  will  be  allowed  for  the  reading  of  any  paper. 

The  usual  Clinical  Meeting  will  be  held  on  Friday  afternoon  at  4  p.m.  Demon- 
strations will  be  given ;  also  there  will  be  a  Pathological  Museum  and  an  exhibition 
of  Instruments  and  Drugs. 

Those  who  intend  to  read  papers  are  requested  to  send  in  their  titles  not  later 
than  April  24,  and  the  abstracts  of  their  papers  not  later  than  May  24  to  the  Hon. 
Secretaries,  Dr.  Irwin  Moore,  30a,  Wimpole  Street,  London,  W.  1,  or  Mr.  Charles 
Hope,  22,  Queen  Anne  Street,  London,  W.  1. 

American  and  foreign  colleagues  are  cordially  invited  to  take  part  in  the  work 
of  the  Congress  as  Honorary  Members. 

The  Annual  Dinner  will  be  held  at  the  Cafe  Eoyal  on  the  evening  of  Thursdaj', 
June  24.  Members  are  requested  to  intimate  their  intention  to  be  present  to  the 
Secretaries  as  soon  as  possible. 

The  British  Medical  Association. 

The  first  meeting  of  the  above  Association  since  1914  will  take  place  this  year 
at  Cambridge,  from  June  30  till  July  3,  that  is  to  say,  on  the  week  following  the 
Summer  Congress  of  the  Laryngological  Section  of  the  Eoyal  Society  of  Medicine 
(see  above  notice). 

At  the  Association  meeting  there  is  to  be  no  special  section  of  Oto-Larj-ngolog^', 
but  oto-laryngologists  may  attend  and  read  papers  in  the  surgical  and  other 
sections  if  they  so  desire. 

Otological  Section  of  the  Eotal  Society  of  Medicine. 
The  next  meeting  of  this   Section  will   be   held   on  May  21.      Notices   and 
papers  to  be  sent  in  not  later  than  May  1.     Secretaries  :  Mr.  H.  Buckland  Jones 
and  Mr.  Lionel  Colledge. 

Laryngological  Section  of  the  Eoyal  Society  of  Medicine. 
The  next  monthly  meeting  of  this  Section  will  be  held  on  May  7.     Notices  and 
papers  to  be  sent  in  not  later  than  Ajjril  25.     Secretaries:  Dr.  Irwin  Moore  and 
Mr.  C.  W.  Hope. 


BOOK   RECEIVED. 

Atti  della  Cliiiica  Oto-Rino-Laringoiatrica  della  R.  Uuiversita  di 
Roma,  diretta  dal  Prof.  Gherardo  Ferreri.  Anno  xvi. — 1918. 
Eoma.  Tip.  'Le  Massime  " — Gruiseppi  Farri.     1919. 


VOL.  XXXY.     No.  5.  May.  1920. 


THE 

JOURNAL    OF    LARYNGOLOGY, 

RHINOLOGY,   AND   OTOI.OGY. 


Original  Articles  are  accepted  on  the  condition  that  they  have  not  previously  been 
published  elsexvhere. 

1/  reprints  are  required  it  is  requested  that  this  be  slated  when  the  article  is  first 
forwarded  to  tliis  Journal.     Such  reprints  will  be  charged  to  the  author. 

Editorial  Commu7iications  are  to  be  addressed  to  "Editor  of  JoniNAL  of 
Laictngologt,  care  oj" Messrs.  Adlard  ^  Son  4'  W'est  Newman,  Limited,  Bartholomew 
Close.  E.G.  1." 


CHRONIC  MIDDLE-EAR  SUPPURATION,  CHOLESTEATOMA, 
AND  MASTOIDITIS  COMPLICATED  BY  LABYRINTHITIS, 
SINUS  THROMBOSIS  AND  MENINGITIS. 

By  J.  K.  Milne  Dickie,  M.D.,  F.E.C.S.E., 
Toronto  ;  formerly  Aural  Siargeon,  Leith  Hospital. 

The  following  case  presents  some  rather  unusual  features,  and  on  this 
account  has  been  thought  worthy  of  being  placed  on  record.  It  was 
operated  on  before  the  outbreak  of  war,  but  the  microscopic  examination 
of  the  ear  could  not  be  carried  out  until  the  writer  returned  from  active 
service  this  year  (1919). 

The  patient,  D.  W ,  male,  aged  twenty-one,  was  admitted  to  Leith  Hospital 

on  May  29,  1914,  with  the  following  history  :  His  right  ear  had  been  running  for 
many  years  with  occasional  intervals  when  the  discharge  ceased.  In  March,  1914, 
he  began  to  have  pain  in  that  ear  and  the  discharge  recommenced.  In  April  he 
had  suffered  from  frequent  attacks  of  vomiting  and  giddiness  which  lasted  for  a 
fortnight.  He  was  admitted  on  April  27,  1914,  to  a  cottage  hospital,  where  he  was 
treated  for  stomach  trouble.  There  he  had  severe  thotigh  not  constant  headaches 
in  the  right  temporal  and  occipital  regions.  His  left  arm  had  been  completely 
paralysed  for  a  fortnight  and  his  left  leg  had  also  been  getting  weak.  He  also 
had  one  or  two  rigors  and  his  temperature  had  risen  to  103°  F.  on  several  occasions. 
On  the  day  before  his  admission  to  Leith  Hospital  his  temperatiu-e  was  102'  F. 

Examination  on  admission.  May  27,  1914. — The  patient  was  rather  drowsy  but 
quite  sensible.  Temperature  100'  F.,  pulse  80,  respirations  28.  Eight  aviricle 
protruding.  (Edema  and  redness  over  right  mastoid  with  pitting  and  tenderness 
on  pressure.  Eight  meatus  fvdl  of  pus.  Eight  tympanic  membrane  showed  a 
perforation  with  granulations.  Patient  coiild  hear  ordinary  voice  at  one  foot  on 
the  right  side  with  the  left  ear  closed  with  the  finger.  Noise-box  unfortunately 
not  working.  Xo  tuning-fork  test  carried  out.  There  was  spontaneous  rotatory 
nystagmus  to  the  left  of  the  third  degree,  i.  e.  seen  even  on  looking  to  the  right. 

9 


130  The  Journal  of  Laryngology, 


[May,  1920. 


Tongue  furred  but  protruded  in  the  middle  line.  Paresis  of  the  left  side  of  the 
face.  Left  arm  completely  paralysed.  Distinct  loss  of  power  in  the  left  leg 
though  paralysis  not  complete.  Abdominal  and  cremasteric  reflexes  absent. 
Knee-jerks  equal,  not  exaggei-ated.  Some  ankle  clonus  on  the  left  side.  Plantar 
Teflexes  flexor  on  both  sides.  Some  rigidity  of  the  neck.  Pupils  dilated  but  equal. 
Examination  of  the  fundus  revealed  choking  of  both  optic  discs.  The  vessels  were 
engorged  and  there  was  a  certain  amount  of  exudation  along  them.  The  field  of 
vision  was  defective  on  the  left  side.  As  far  as  could  be  made  out  by  an  examina- 
tion in  bed  the  patient  had  left  homonymous  hemianopsia. 

It  was  evident  that  the  case  was  one  of  mastoiditis  with  some  serious  intra- 
cranial complications,  probably  sinus  thrombosis  and  meningitis,  and  ojjeration 
was  decided  upon. 

Operation  on  day  of  admission  at  10  p.m.  There  was  no  subperiosteal  abscess 
but  the  superficial  tissues  were  inflamed.  The  cortex  was  thin  and  the  mastoid 
cellular.  The  cells  contained  much  pus  under  j^ressru'e.  There  was  extensive 
caries  of  the  trabecvilse  and  the  whole  mastoid  was  hollowed  out  by  disease.  The 
antrum  contained  cholesteatoma.  The  sinus  and  a  large  area  of  the  dura  of  the 
posterior  fossa  were  found  exposed  and  covered  with  granulations.  Examination 
of  the  pus  from  the  extradural  abscess  gave  Gram-positive  cocci  and  some  Gram- 
negative  bacilli.  The  ovxter  wall  of  the  aditus  was  removed  and  the  radical 
mastoid  completed.  The  granulations  on  the  dura  were  curetted.  The  lateral 
sinus  was  opened  and  found  to  contain  a  partially  organised  clot.  The  bone  was 
removed  posteriorly  nearly  to  the  torcular  as  the  clot  extended  right  to  the  torcular. 
The  internal  jugular  vein  was  exposed,  ligatured,  and  divided  above  the  common 
facial  vein.  The  wall  of  the  vein  here  appeared  normal.  As  the  patient's  con- 
dition at  this  stage  of  the  operation  was  not  very  good,  he  was  sent  back  to  bed 
without  any  investigation  of  the  functional  activity  of  the  labyrinth.  For  the 
same  reason  the  dura  of  the  middle  fossa  was  not  exposed. 

Lumbar  puncture  just  before  operation  gave  fluid  under  great  pressure  but 
clear. 

May  ;^0,,  1914 :  During  the  day  there  was  intermittent  jerking  of  the  left  side 
of  the  face  and  left  arm  and  leg.  Temperature  was  above  noi-mal  all  day.  Reached 
102°  F.  at  2  p.m.     No  vomiting. 

May  31,  1914 :  Wound  dressed.  Tissues  showed  no  reaction.  No  pulsation  of 
the  dura.     Neck  still  rigid.     Kernig's  sign  still  present. 

June  1,  1914:  Became  unconscious  this  morning.  With  lumbar  puncture  the 
fluid  merely  trickled  ovxt  but  was  still  clear.  Bacteriological  report  on  cerebro- 
spinal fluid  showed  presence  of  Micrococcus  tetragenous,  confirmed  by  culture. 
Patient  died  at  3  p  ui. 

Post-mortem  examination. — On  opening  the  skull-cap  the  dura  of  the  right  side 
of  the  cerebrum  was  seen  to  be  tense  and  bxxlging.  The  left  side  was  noticeably 
smaller.  Superior  longitudinal  sinus  contained  post-mortem  clot.  On  opening  the 
dura  a  thick  coating  of  greenish  pus  was  seen  completely  covering  the  whole 
right  hemisphere  and  hiding  the  convolutions.  No  opening  of  ruptured  abscess- 
cavity  seen.  No  pixs  over  left  hemisphere  nor  in  posterior  fossa.  Left  lateral 
sinixs  not  thrombosed.  No  macroscopic  erosion  of  tegmen  tympani.  Brain  jjut  in 
formalin  for  section  after  hardening  Owing  to  other  circumstances  the  brain  was 
unfortunately  forgotten  for  a  time  and  later  could  not  be  found.  The  right 
temporal  bone  was  removed  for  microscopic  examination. 

Microscopic  examination  of  the  right  ear  shows  great  thickening  of 
the  mucosa  of  the  whole  middle  ear  with  small-celled  infiltration  and 
cyst  formation.  The  tympanic  ostium  of  the  Eustachian  tube  is  almost 
completely  occluded  by  polypoid  thickening  (Fig.  1).  A  fine  track 
surrounded  by  cholesteatoma  membrane  and  granulations  is  seen  ex- 
tending through  the  tegmen  in  the  region  of  the  aditus  (Fig.  6).  The 
stapes  is  embedded  in  granulations  and  the  niche  of  the  round  window 
is  also  filled  up  with  granulations,  but  apparently  no  extension  of  the 
suppuration  had  occurred  through  the  windows.  An  extension  of  the 
septic  process  into  the  labyrinth  had  occurred  through  absorption 
of  the  bony  capsule  of  the  external  semicircular  canal.  There  are  two 
separate  erosions  of  the  canal  wuth  a  small  wedge-shaped  piece  of  bone 


May,  1920.] 


Rhinology,  and  Otology. 


]31 


Fig.  1. — Section  tliroutrh  the  centre  of  the  cochlea.  1.  Facial  nerve.  2.  In- 
ternal auditory  meatus.  3.  Jugvilar  bulb.  4.  Carotid  canal.  5.  Tym- 
panic osteum  of  Eustachian  tube  showing  thickening-  of  polypoid  degenera- 
tion of  the  mucous  membrane.      x3h. 


Fig.  2. — Section  a  little  farther  back  throvigh  the  vestibule.  1.  Facial  nerve. 
3.  Jugular  bulb  filled  with  organised  thrombus.  Trabecule  of  new 
bone  seen  extending  into  clot.  6.  Subarcuate  vessels.  7.  Vestibule  con- 
taining clotted  lymph.     8.  Tympanic  cavity,     x  3^. 


132 


The  Journal  of  Laryngolog^y, 


^May,  1920. 


between  them  (Figs.  4,  5  and  6).     The  edges  of  the  bone  have  a  worm- 
eaten  appearance  with  shallow  depression,  in  which  giant-cells  are  seen. 


Fig.  3.—  Section  a  little  farther  back  than  Fig.  2.    9.  Xiche  of  roimd  window. 

14.  Stapes,     x  3^. 


Fig.  4.— 10.  Posterior  canal.     11.  Ductus  endolymphaticus.      12.  Fistula.    x3i. 


The  fistula  altogether  is  3"3  mm.  long.  ^Yhile  at  first  sight  the  fistula 
might  be  thought  to  be  due  to  an  accident  at  the  operation,  the  appearance 
of  the  edges  and  the  fact  that  the  piece  of  bone  between  the  fistulte 
would  have  been  absent  are  enough  to  negative  that  supposition.      The 


May,  1920.] 


Rhinology,  and  Otology. 


133 


perilymph  space  of  the  canal  near  the  fistula  is  filled  with  cellular  exu- 
date but  the  endolyoaph  canal  is  fairly  clear.  The  rest  of  the  labyrinth 
contains  serous   exudate  extending  as  far  as  the  apex  of  the  cochlea. 


Fig.  .5. — Farther  back,    x  3-2 

12        i:i 


Fig.  6. — 13.  Fistula  throu'^h  tegmen.    x  3^. 


There  are  very  few  cellular  elements  in  it,  except  in  the  terminal  part 
of  the  scala  tympani  round  the  orifice  of  the  aqueduct  of  the  cochlea  and 
on  the  secondary  tympanic  membrane.  The  jugular  bulb  is  filled  by 
a  well-organised   clot  containing  new  fibrous  tissue  into  which  some 


134  The  lournal  oi  Laryngology. 


May,  1920. 


trabeculae  of  new  bone  extend  (Figs.  2  and  3).  In  places  it  is  separated 
from  the  tympanic  cavity  merely  by  soft  tissue.  However,  no  definite 
evidence  of  direct  infection  of  the  bulb  from  the  tympanic  cavity  could 
be  seen.  The  clot  in  the  bulb  was  probably  merely  an  extension  from 
the  clot  in  the  lateral  sinus. 

The  case  is  interesting  for  several  reasons.  In  the  first  place  a 
cerebral  meningitis  localised  to  one  side  with  paralytic  and  irritative 
symptoms  is  not  at  all  common.  Again,  with  a  large  extradural  abscess 
of  the  posterior  fossa  and  lateral  sinus  thrombosis  it  is  surprising  that 
there  was  no  basal  meningitis.  The  cerebro-spinal  fluid  was  clear  to 
the  end  although  oi'ganisms  were  found  in  it,  and  there  was  no  purulent 
exudate  round  the  base  of  the  brain.  With  regard  to  the  labyrinth  the 
process  remained  localised  mainly  in  the  external  canal,  where  it  was 
definitely  purulent,  but  in  the  rest  of  the  labyrinth  there  was  merely  a 
sei'ous  exudate.  The  character  of  the  fistula  in  the  external  canal  is 
peculiar  in  that  there  were  two  distinct  openings.  Erosions  of  the 
external  canal  are  usually  produced  by  an  absorption  of  the  bone  on  the 
projecting  part  of  the  capsule  from  pressure  of  a  cholesteatoma  mass. 
The  resulting  microscopic  picture  generally  shows  a  flattening  of  the 
prominence  of  the  canal.  The  infection  appears  to  have  spread  by 
several  routes  more  or  less  concurrently ;  thus  there  had  been  an 
extension  through  the  tegmen,  another  through  the  external  canal 
into  the  labyrinth,  and  a  third  from  the  carious  mastoid  into  the  lateral 
sinus. 

It  is  a  great  regret  that  more  accurate  functional  tests  were  not 
carried  out,  but  the  patient  was  so  ill  that  one  did  not  wish  to  trouble 
him  more  than  was  absolutely  necessary. 

It  is  unfortunate  that  the  possibility  of  intracranial  complications 
of  otitis  media  is  not  generally  present  in  the  mind  of  the  average 
practitioner  when  he  is  faced  with  a  case  the  symptoms  of  which  are 
obscure.  , 

The  mortality  of  acute  appendicitis  has  been  greatly  reduced  in 
recent  years,  due  mainly,  if  not  entirely,  to  the  prompt  recognition  of 
the  urgency  of  the  condition  by  the  general  practitioner.  This  was 
only  made  possible  by  the  insistence  of  surgeons  on  the  necessity  of 
early  surgical  intervention. 

In  the  matter  of  the,  intracranial  complicaticns  of  otitis  media,  it  is 
quite  exceptional  for  a  ixitient  to  he  sent  to  hospital  2cithin  a  fortnight  of 
the  onset  of  the  symptoms  unless  there  is  at  the  same  time  an  obvious 
mastoid  swelling.  Very  frequently  the  patients  have  been  treated  for 
acute  gastritis,  malaria,  or  cerebro-spinal  meningitis  for  several  weeks 
before  being  sent  to  hospital,  and  by  that  time  the  disease  has  progressed 
so  far  that  a  favourable  result  can  hardly  be  expected. 

Formerly  it  used  to  be  taught,  "  ^Yhen  in  doubt  think  of  typhoid" — a 
very  good  rule.  Probably,  however,  more  lives  might  be  saved  now 
that  typhoid  is  not  so  common  if  one  were  to  teach — "  When  in  doubt 
examine  the  ears." 

The  preparation  of  the  temporal  bone  and  the  microscopic  examina- 
tion were  carried  out  in  the  Eoyal  College  of  Physicians,  Edinburgh.  I 
wish  here  to  record  m}-  indebtedness  to  Dr.  J.  S.  Eraser  for  carrying  the 
specimen  through  the  earlier  stages  of  its  preparation  for  me  during- 
my  absence,  and  to  Prof.  James  Ritchie  for  placing  the  laboratory  facili- 
ties at  my  disposal. 


May.  1920.;  Rhinology,  and  Otology.  135 

THE   AQUEDUCT   OF   FALLOPIUS   AND   FACIAL   PARALYSIS^ 

By  Dan  McKenzie. 

{Continued  from  Vol.  XXXIV,  p.  387.) 

Part  II :   Facial   Paralysis. 

Historical. 

Considering  what  we  can  only  term  the  inevitable  publicity  of  uni- 
lateral paralysis  of  the  face,  it  is  certainly  very  surprising  that  so  little 
attention  was  paid  to  it  before  Sir  Charles  Bell's  discovery  that  the 
paralysis  might  be  peripheral  in  situation  and  due  to  a  lesion  of  the 
portio  dura  of  the  seventh  cranial  nerve. 

The  old  Roman  medical  writers  were  acquainted  with  the  fact  that  a 
lesion,  such  as  a  wound,  of  one  side  of  the  brain  produces  paralysis  on  the 
opposite  side  of  the  body,  and  they  were  aware  of  facial  paralysis  as  an 
element  in  a  hemiplegia.  But  they  do  not  seem  to  have  observed  crossed 
paralysis,  and  there  is  reason  to  believe  that  peripheral  facial  paralj'sis 
was  considered  by  them  to  be  nothing  more  than  unilateral  facial  spasm. 

This  is  all  the  more  remarkable  since  we  know,  from  the  Ebers  and 
other  Egyptian  medical  papyri,  that  quite  a  respectable  amount  of 
knowledge  was  current,  even  in  the  dim  centuries  prior  to  the  Greek 
civilisation,  regarding  such  diseases  and  deformities  as  affected  external 
and  accessible  regions  and  organs.  Paralyses,  we  know,  were  very 
naturally  ascribed  in  those  early  times  to  an  actual  physical  and  material 
blow  of  a  spiteful  or  outraged  spirit.  Hence  the  common  appellation 
of  "stroke,"  apoplexy  being  merely  a  Greek  word  of  the  same  meaning. 

This  belief  might  perhaps  seem  to  imply  that  early  man  had  become 
acquainted  with  traumatic  paralysis  from  a  nerve  wound.  But  it  would 
be  more  in  keeping  with  the  naive  mentality  of  homo  vulgaris  if  the 
underlying  idea  had  merely  been  the  common  experience  of  the  momen- 
tary loss  of  power  that  follows  any  sharp  blow.  At  all  events,  both  the 
paralysis  itself  and  the  sudden  nature  of  its  onset  are  connoted  in  the 
popular  term,  whether  English  or  Greek. 

There  can  be  no  doubt,  I  believe,  with  regard  to  facial  paralysis  in 
particular  that  the  physicians  of  ancient  times,  like  the  uneducated 
laymen  of  to-day,  when  confronted  with  this  malady,  supposed  the 
"  wry-mouth "  to  be  the  result  not  of  paralysis,  but  of  over-action 
or  spasm  of  the  sound  side.  "My  face  was  drawn  over  to  one  side," 
says  the  modern  patient,  describing  the  disease  as  he  experiences 
it.  And  with  this  view  of  the  paralysis  before  our  mind  we  find 
occasional  allusions  to  the  disease  in  popular  folk-lore.  Thus  in  Ireland 
it  was  believed  that  anyone  who  told  a  lie  after  being  sworn  on  the 
ancient  Clag  an  air,  or  Golden  Bell  of  the  O'Cahane  family,  would 
"have  his  mouth  twisted  on  one  side"  [The  Times,  August  13,  1918), 
and  similar  beliefs  existed  in  the  days  of  the  persecution  of  witches  in 
Britain. 

I  have  happened  also  upon  an  allusion  to  wry  mouth,  which  clearly 
shows  it  to  have  been  facial  paralysis,  this  time  in  English  medical 
literature,  and  what  is  of  particular  interest  is  that  the  reference  occurs 
in  the  "Select  Observations  on  English  Bodies"  of  John  Hall, 
Shakespeare's  son-in-law.     It  reads  as  follows  : 

"Observation    XXXVI.      Elizabeth  Hall,  my  only  daughter,  was   vexed   with 


136  The  Journal  of  Laryngology,  May,  1920. 

Torturia  Oris  or  the  Convulsion  of  the  Mouth,  and  was  happily  cured  as 
f  oUoweth :  ..." 

"  After  the  use  of  theise  the  former  form  of  her  mouth  and  face  was  restored. 
Jan.  5,  162-i." 

He  further  writes :  "  In  the  beginning  of  Apnl,  she  went  to  London,  and  return- 
ing homewards,  the  22nd  of  the  said  month  she  took  cold,  and  fell  into  the  said 
Distemper  on  the  contrary  side  of  the  face ;  before  it  was  on  the  left  side,  now  on 
the  right." 

The  fact  also  that  there  is  actually  a  condition,  not  at  all  uncommon, 
of  true  unilateral  facial  spasm,  tended,  doubtless,  to  deepen  and  to 
perpetuate  this  error. 

It  is  pleasant  therefore  to  be  able  to  indicate  that  Paulus  Aegineta 
(circa  a.d.  600)  realised  the  mistake,  since  he  says,  dealing  with  "  cynic 
spasm,"  the  name  anciently  given  to  this  same  facial  spasm  :  "  It  is 
necessary  to  know  that  the  jaw  that  appears  to  be  distorted  is  not  the 
one  which  is  paralysed  but  the  other  one  "  (Francis  Adams,  Trans.). 

Paulus  Aegineta  also  mentions  paralysis  as  affecting  the  eyebrows, 
for  which  he  recommends  "  anointing  the  eyelids,"  and,  "  at  last,  the 
operation  by  suture  called  '  anarraphe  '  " — which  may  have  been, 
probably  was,  what  is  now  known  as  "  tarsorraphy." 

The  era  of  vague  and  uncertain  knowledge  was,  however,  ended 
when  Sir  Charles  Bell's  epoch-making  discovery  of  peripheral  facial 
paralysis  was  made  in  182-i.  And  it  is  worthy  of  remark  how  detailed 
and  complete  his  description  of  the  different  varieties  of  the  disorder 
appears,  even  to  the  modern  reader. 

There  exists,  by  the  way,  a  remarkable  divergence  of  opinion  as  to 
the  date  of  Sir  Charles  Bell's  discovery.  Garrison,  in  his  "  History  of 
Medicine,"  fixes  the  date  as  1829.  Another  authority  would  make  it  as 
late  as  1838.  But  in  Bell's  "  Exposition  "  the  portio  dura  and  its  paralysis 
are  fully  and  clearly  described,  and  this  book  was  published  in  1824. 

Anatomy  and  Physiology  of  the  Facial  Nerve. 

The  cerebral  cortical  centre  for  the  face  is  situated  in  the  lower  end 
of  the  pre-central  (ascending  frontal)  convolution,  where  it  lies  in  close 
connection  with  the  centre  for  the  tongue — a  fact  which  has  been  cited 
in  support  of  the  operation  for  remedying  obstinate  peripheral  facial 
paralysis  by  anastomising  the  paralysed  facial  nerve-trunk  with  the 
hypoglossal,  rather  than  with  the  spinal  accessory. 

From  the  Betz  or  giant  pyramidal  cells  in  this  locality,  the  fibres  to 
the  nucleus  of  the  facial  nerve,  after  giving  off  the  usual  association  and 
commissural  collaterals,  pass  down  in  the  internal  capsule,  anterior  to 
those  for  the  arm,  and  thence  by  the  crus  cerebri  and  the  pons  Varolii, 
■where  they  cross  to  reach  the  facial  nucleus  on  the  other  side  of  the 
brain.  An  important  fact  is  that  while  the  great  majority  of  the  fibres 
cross  to  the  nucleus  of  the  opposite  side,  a  few  remain  uncrossed  and 
pass  to  the  facial  nucleus  of  the  same  side  (Melius,  Hoche),  and  it  may 
be  that  the  upper  facial  muscles  are  innervated  by  this  uncrossed 
bundle  (Bruce). 

The  nucleus  of  the  seventh  cranial  nerve  lies  for  the  most  part  in 
the  lower  pons,  but  some  of  its  cells  reach  as  high  as  the  nucleus  of  the 
third  nerve,  while  others  are  as  low  as  the  hypoglossal  nucleus. 

In  the  connection  of  the  facial  nucleus  with  the  nucleus  of  the 
oculo-motor  it  is  important  to  notice  that  Mendel  suggested  that  the 
orbicularis  palpebrarum  was  supplied  from  the  nucleus  of  the  third, 


May,  1920.] 


Rhinology,  and  Otology. 


137 


the  fibres  travelling  out  from  the  brain  in  the  seventh  nerve.  This 
supposition  has  received  support  from  a  case  recorded  by  Tooth  and 
Turner,  in  which  the  seventh  nucleus  had  undergone  degeneration,  with 
degeneration  of  the  fibres  of  the  seventh  nerve,  except  the  fibres  going  to 
the  orbicularis  palpebrarum.  As  Hughlings  Jackson  also  pointed  out, 
this  is  an  explanation  of  the  occurrence  of  paresis  of  the  orbicularis 
palpebrarum  in  ophthalmoplegia  externa,  a  disease  of  the  nuclei  of  the 
oculo-orbital  nerves. 

There  is  no  need  to  remind  the  reader  that  the  nuclei  of  the  motor 
cranial  nerves  contain  the  equivalent  of  the  motor  neurones  of  the 
anterior  cornua  of  the  spinal  cord,  just  as  the  geniculate  ganglion  of  the 
facial  and  the  Gasserian  ganglion  of  the  trigeminal  correspond  to 
the  posterior  root  (sensory)  ganglia  of  the  spinal  cord. 


Fig.  43. — Diagram  of  the  facial  nerve  (Cunningham's  Anatomy).  1.  Petrous 
segment  of  the  facial.  2.  Pars  intermedia.  3.  Geniculate  ganglion  and 
angle.  4.  Large  superficial  petrosal.  5.  Small  supei-ficial  petrosal.  6. 
Small  deep  petrosal.  7.  Xerve  to  stapedius.  8.  Aiiricular  of  vagus.  9. 
Posterior  aiiricular,  10.  Digastric.  11.  Stylo-hyoid.  12.  From  great 
auricular.  13.  Cervico-facial.  14.  Temporo-facial.  1.5.  From  auriculo- 
temporal. 16.  Chorda  tympani.  17.  Carotico-tympanic,  joining  on  left 
tympanic  of  glosso-pharyngeal,  and  on  right,  18.  Sympathetic  on  internal 
carotid  artery.  19.  Large  deep  petrosal.  20.  Vidian.  21.  Superior 
maxillary.  22.  Spheno-palatine  (Meckel's)  ganglion.  23.  Otic  ganglion. 
24.  Lingual.  25.  Chorda  tympani;  the  section  between  16  and  25  is 
removed. 


As  the  geniculate  ganglion  shows  us,  the  facial  nerve  is  not  entirely 
efferent  or  motor  in  function.  The  sensory  filament,  known  as  the 
pars  intermedia  of  Wrisberg,  enters  the  pons  between  the  seventh  and 
eighth  nerves,  and  divides  after  entrance  into  ascending  and  descending 
branches. 

The  motor  root  between  the  facial  nucleus  and  its  exit  from  the 
pons  undergoes  a  tortuous  course,  looping  close  over  and  round  the 
nucleus  of  the  sixth  nerve  like  a  whip-lash — a  relationship  which  explains 


338  The   Journal  of  Laryngology, 


[May,  1920. 


why  facial  paralysis  from  a  pontine  lesion  is  usually  accompanied  with 
abducens  paralysis.  The  combination  is,  of  course,  not  pathognomonic  of 
a  lesion  in  the  pons,  as  abducens  and  facial  paralyses  may  co-exist  from 
a  simultaneous  affection  of  the  respective  nerve-trunks.  This  has  been 
reported  as  occurring  in  purulent  otitis  media  (Tommasi). 

Emerging  from  the  brain  at  the  posterior  border  of  the  pons  the 
facial  lies  below  the  trigeminal  and  internal  to  the  auditory  nerve,  tlie 
pars  intermedia  being  interposed  between  it  and  the  latter.  The  audi- 
tory, the  pars  intermedia  and  the  facial  motor  then  enter  the  internal 
auditory  meatus  together,  the  facial  being  above,  the  auditory  below, 
and  the  nerve  of  Wrisberg  between. 

'  In  the  internal  auditory  meatus  the  pars  intermedia  sends  commu- 
nications to  both  of  its  neighbours,  but  it  is  supposed  that  the  branch  to 
the  auditory  separates  from  it  again  to  reach  the  geniculate  ganglion. 

The  geniculate  ganglion,  which  is  connected  centrally  by  its  descend- 
ing branch  in  the  pons  with  the  sensory  nucleus  of  the  glosso- 
pharyngeal nerve,  is  situated  at  the  point  where  the  facial  nerve 
bends  backwards  after  it  pierces  the  petrous  section  of  the  Fallopian 
canal  (Fig.  43).  Peripherally,  it  connects  (a)  with  Meckel's  ganglion 
by  the  great  superficial  petrosal  nerve,  which  joins  the  great  deep 
petrosal  nerve  from  the  carotid  sympathetic  plexus  to  form  the  Vidian 
nerve  ;  (b)  with  the  otic  ganglion  by  means  of  a  small  twig  which  joins 
the  tympanic  branch  of  the  glosso-pharyngeal  nerve  in  the  substance 
of  the  temporal  bone  to  form  the  small  superficial  petrosal  nerve; 
(c)  with  the  sympathetic  plexus  on  the  middle  meningeal  artery  by  the 
inconstant  external  superficial  petrosal  nerve.  The  geniculate  also  receives 
afferent  (sensory)  fibres  from  the  chorda  tympani  which,  coming  from 
the  lingual  nerve  and  passing  to  the  glosso-pharyngeal  nucleus,  convey 
to  the  brain  gustatory  sensations  from  the  anterior  two-thirds  of  the 
tongue.  The  cliorda  tympani  contains  also  efferent  (secretory)  fibres 
for  the  submaxillary  and  sublingual  salivary  glands. 

The  course  of  the  chorda  tympani  through  the  middle  ear  exposes  it 
to  frequent  injury  by  disease  and  operation.  It  leaves  the  facial  trunk 
in  its  mastoid  (descending)  segment,  and  emerges  from  the  bone  into 
the  tympanum  by  a  small  foramen  on  the  posterior  wall  of  the  tympanum. 
Crossing  the  upper  part  of  the  medial  wall  and  passing  above  the 
pyramid  it  comes  to  lie  between  the  handle  of  the  malleus  and  the 
incus,  where  it  may  occasionally  be  visible  on  otoscopy  as  a  fine  white 
thread  curving  across  the  membrane.  Its  destruction  by  disease  or 
operation  very  seldom  leads  to  any  complaint  of  loss  of  function. 

Coming  off  from  the  mastoid  segment  of  the  facial  nerve  also,  and 
proximal  indeed  to  the  chorda  tympani,  is  the  minute  nerve  to  the 
stapedius — a  filament  wiiich,  as  we  shall  see  later  on,  may  play  an 
important  part  in  helping  us  to  locate  the  site  of  the  lesion  producing 
peripheral  facial  paralysis. 

Before  leaving  the  aqueduct  the  facial  nerve  gives  off'  a  fine  com- 
municating branch  to  the  auricular  branch  of  the  pneumogastric. 

Issuing  from  the  Fallopian  canal  at  the  stylo-mastoid  foramen  the 
main  trunk  gives  off  branches  to  the  stylo-hyoid  and  the  posterior  belly 
of  the  digastric.  By  means  of  its  posterior  auricular  branch  it  supplies 
the  muscles  of  the  auricular  and  the  occipitalis  belly  of  the  occipito- 
frontalis  muscle,  and  this  branch  communicates  with  the  great  auricular 
and  the  small  occipital  of  the  cervical  plexus,  and  with  the  auricular  of 
the  pneumogastric. 


May,  1920.J 


Rhinology,  and  Otology. 


139 


The  main  trunk  passes  from  the  stylo-mastoid  foramen  forward 
through  the  substance  of  the  parotid  gland,  crossing  the  external  carotid 
artery  and  branches  of  the  temporo-maxillary  vein — posterior  facial — 
in  the  gland.  In  this  position  it  lies  nearly  on  the  same  level  as  the- 
lower  surface  of  the  conchal  cartilage  of  the  auricle. 

It  passes  on  to  the  face  over  the  vertical  ramus  of  the  mandible  and 
breaks  up,  still  in  the  substance  of  the  parotid,  into  a  temporo-facial  and 
a  cervico-facial  division,  the  maze  of  branches  and  communications 
being  known  as  the  pes  anserinus.  In  the  gland  it  communicates  with 
the  great  auricular  and  auriculo-temporal  nerves  (see  Fig.  44).  As  a 
matter  of  fact,  the  course  of  the  trunk  before  it  divides  is  very  brief. 


Fig.  44. — Distribution  of  the  facial  nerve  outside  the  skull,  and  communica- 
tions with  the  trigeminal  nerve  on  the  face  (from  Cunningham's  "  Text- 
book of  Anatomy").  Facial  Nerve. — p. A.,  Posterior  auricular  nerve  ;  s.h., 
nerve  to  stylo-hyoid;  d.i.,  nerve  to  digastric  (posterior  belly);  t.f., 
temporo-facial  division ;  t.,  temporal ;  m.,  malar ;  i.o.,  infra-orbital 
branches;  c.f.,  cervico-facial  division ;  b.,  buccal ;  s.M.,supra-mandibular ; 
I.M.,  infra-mandibular  branches.  Trigeminal  Nerve. — ophth..  Ophthalmic 
division;  s.o.,  supra-orbital;  i.t.,  infra-trochlear  ;  n.,  external  nasal;  l., 
lacrymal  branches  ;  sup.  max.,  superior  maxillary  division  ;  t.,  temporal ; 
M.  malar;  i.o.,  infra-orbital  branches  ;  inf.  max.,  inferior  maxillary  divi- 
sion ;  A.T.,  auriculo-temporal;  b.,  buccal ;  m.,  mental  branches  ;  s.c,  super- 
ficial cervical  nerve. 


The  temjjoiv -facial  division  has  three  branches  :  (1)  Temporal  to  the- 
orbicularis  palpebrarum,  the  frontalis,  the  corrugator  supercilii  and 
the  anterior  muscles  of  the  ear.  These  branches  communicate  with 
the  neighbouring  branches  of  the  trigeminal ;  (2)  the  malar  bi'anches 
supplying  the  orbicularis  palpebrarum  and  zygomaticus ;  (3)  the  infra- 
orbital branches,   which  form   a  plexus  with  the   infra-orbital    of  the 


140  The  Journal  of  Laryngology,  [May,  1920. 

superior  maxillary  nerve,  to  supply  the  orbicularis  palpebrarum,  the 
^lygomatici,  the  buccinator,  and  the  muscles  of  the  nose  and  upper  lip. 

The  ccrvico-facial,  the  lower  division  of  the  facial  nerve,  has  also 
three  terminal  branches — the  buccal,  the  supra-mandibular,  and  the 
infra-mandibular — which  supply  the  muscles  of  the  mouth,  chin,  and 
the  platysma  myoides,  everywhere  communicating  with  adjacent  sensory 
nerves  (Fig.  44). 

Thus  all  the  muscles  of  expression  except  the  levator  palpebrae 
superioris,  and  including  the  buccinator,  are  supplied  by  the  nerve — a 
fact  which  renders  its  paralysis  so  noticeable  and  so  objectionable. 

Tooth  and  Turner  proposed  a  division  of  the  facial  muscles  into 
three  groups  to  correspond  with  the  nuclei  which  govern  them.  The 
groups  are :  (1)  The  oculo-facial,  comprising  the  frontalis,  orbicularis 
palpebrarum  and  corrugator  supercilii,  which  is  innervated  by  the 
oculo-motor  nucleus  through  the  facial  nerve;  (2)  the  middle,  made  up 
of  the  zygomatici,  risorius,  buccinator,  and  elevators  and  depressors  of 
the  angle  of  the  mouth,  innervated  by  the  facial  nucleus  through  the 
facial  nerve ;  and  (3)  the  oro-facial  group,  composed  of  the  orbicularis 
oris,  and  "presumably"  innervated  by  the  hygoglossal  nucleus  through 
the  facial  nerve. 

It  is  to  be  noted  that  facial  movement  is  of  three  types:  First, 
voluntai'y,  such  as  the  purposeful  winking  of  one  eye ;  secondly, 
involuntary,  such  as  the  periodic  winking  of  both  eyes,  the  dilatation  of 
the  alse  nasi  during  deep  inspiration,  and  the  pricking  of  the  ears  at  an 
unexpected  sound  ;  and  thirdly,  there  is  emotional  movement,  which,  to 
a  large  extent,  can  be,  by  training,  successfully  brought  under  the 
control  of  the  will  as  inhibitor,  but  is  less  successfully  controlled  by  the 
will  as  initiator.  We  can  inhibit  the  expression  of  emotion  in  the  face, 
and  habitually  do  so.  But  we  find  it  difticult  successfully  to  force  an 
•expression  which  does  not  correspond  with  our  mental  attitude.  Thus 
emotional  movement  lies  in  the  borderland  between  voluntary  and 
involuntary  movement,  but  it  is  in  its  origin  involuntary,  and  its  control 
by  volition — always  imperfect — can  only  be  secured  by  more  or  less 
•conscious  effort,  and  by  training. 

Facial  Paralysis. 

In  addition  to  the  usual  ills  and  accidents  of  all  nerve  organisations, 
the  facial  is  specially  prone  to  injury  by  reason  of  the  fact  that  it  is  the 
only  motor  nerve  in  the  body  which  occupies  a  long  (3  cm.),  fine 
tunnel  of  bone  in  close  relationship  with  a  nmcosa-lined  cavity,  which 
is,  in  its  turn,  frequently  the  seat  of  disease.  The  facial  nerve  is,  in  fact, 
more  often  paralysed  than  any  other  motor  nerve,  and  it  is  my  thesis 
that  the  cause  of  this  frequency  is  to  be  found  in  the  close  contact 
between  the  tympanic  cavity  and  the  trunk  of  the  nerve. 

I  propose,  however,  to  touch  upon  all  the  varieties  of  facial  paralysis 
in  order  to  give  the  otogenic  types  their  due  perspective. 

Clinically,  facial  paralysis  is  divided  into  a  central  and  a  peripheral 
variety.  The  central  include  the  paralyses  which  are  produced  by  a 
lesion  of  the  neurones  and  axones  above  the  facial  nucleus  in  the  pons  ; 
Vae  peripheral,  those  which  are  due  to  a  lesion  of  the  nucleus  or  of  the 
nerve  distal  to  it. 


May,  1920.]  Rhmology,  and  Otology.  141 

Central  Facial   Paralysis. 

The  commonest  causes  of  central  facial  paralysis  are  haemorrhage 
destroying  the  facial  fibres  in  the  internal  capsule,  and  haemorrhage 
into  the  crus  or  pons  Varolii.  In  addition  to  these  lesions  the  facial 
motor  area  of  the  precentral  gyrus  may  be  destroyed  by  tumour,  by 
chronic  inflammation  or  by  softening.  It  is  necessary  to  remind  our- 
selves also  of  the  fact  that  central  facial  paralysis  may  be  otogenic  in 
origin,  since  it  is  a  not  infrequent  appearance  in  temporo-sphenoidal 
abscess  when  encephalitis  spreads  from  the  temporal  lobe  to  involve 
adjoining  convolutions  of  the  frontal  lobe.  As  in  this  condition  the 
cortical  motor  areas  are  involved  from  below  upwards,  the  sequence  of 
the  corresponding  paralyses  is  first  face,  then  arm,  and  then  leg,  as 
Macewen  pointed  out.  Facial  paralysis  from  a  supra-nuclear  lesion  is 
usually  associated  with  a  hemiplegia  of  the  same  side  of  the  body. 

It  differs  from  the  peripheral  paralysis  in  that  the  orbicularis  palpe- 
brarum, the  frontalis  and  the  corrugator  supercilii  muscles  are  not 
paralysed,  so  that  the  eye  can  be  closed.  Sometimes  the  patient  is  able 
to  purse  up  the  mouth.  The  reason  for  the  escape  of  these  muscles 
probably  is,  as  we  have  already  seen,  that  they  are  represented  on  both 
sides  of  the  cerebral  cortex. 

In  addition  to  the  partial  nature  of  the  paralysis,  the  trophic 
conditions  of  the  muscles  remain  unaltered,  and  the  electrical  reactions 
are  therefore  normal. 

Cortical  facial  paralysis  not  associated  with  paralysis  elsewhere 
(monoplegia  facialis)  is  very  rare. 

Peripheral  facial  parali/sis  is  due  to  interruption  of  the  nerve- 
fibres  from  (and  including)  the  nucleus  in  the  pons  to  their  distribution. 
It  may  therefore  be  induced  by  a  considerable  variety  of  different 
lesions. 

Affections  of  the  Facial  Nucleus  in  the  Pons. 

Destruction  of  the  facial  nucleus  produces  complete  paralysis  of  the 
"  peripheral  "  type,  with  subsequent  degeneration  of  the  nerve-fibres 
and  atrophy  of  the  muscles  supplied  by  them.  The  reaction  of 
degeneration  is  present.     The  destruction  may  be  acute  or  chronic. 

The  typical  acute  destruction  is  encountered  in  polio-encej^halitis 
acuta,  the  old  "  infantile  paralysis,"  attacking  the  equivalent  in  the 
pons  of  the  motor  neurones  of  the  anterior  cornu  in  the  cord.  The 
disease  may  occur  in  epidemic  form,  and  it  not  infrequently  attacks  both 
facial  nuclei,  producing  facial  diplegia. 

Sometimes  ophthalmoplegia  externa  is  combined  with  the  facial 
paralysis,  the  nuclei  of  the  ocular  nerves  sharing  in  the  disease,  or  some 
of  the  spinal  neurone  groups  may  be  attacked. 

The  symptoms  do  not  require  special  description.  There  is  the 
acute  onset  with  fever,  headache,  vomiting  and  convulsions,  followed  by 
irregular  motor  paralyses,  which  subsequently  recover  more  or  less. 
Sometimes  the  disease  spreads  to  the  bulb,  setting  up  acute  bulbar 
paralysis.  The  treatment,  after  the  initial  storm  has  subsided,  consists 
in  keeping  up  the  nutrition  of  the  facial  muscles  by  suitable  electrical 
applications. 

Of  the  chronic  processes  which  may  involve  the  facial  nucleus  in  the 
pons  we  may  mention  tumours,  chronic  softening,  haemorrhages  into  the 


142  The  journal  of  Laryngology, 


[May,  1920. 


pons,  and  chronic  polio-encephalitis  inferior.  In  these  conditions  there 
is  frequently  crossed  paralysis,  or  abducens  paralysis,  or  the  lesion  may 
interfere  with  both  nuclei  and  cause  facial  diplegia. 

An  otogenic  cerebellar  abscess  may  induce  the  paralysis  by  distal 
pressure  on  the  pons,   and  sometimes  an  abscess  develops  within  the. 
pons  itself  and  induces  crossed  hemiplegia. 


Lesions  at  the  Base  of  the  Brain. 

Between  its  point  of  emergence  at  the  posterior  border  of  the  pons 
and  its  entrance  witli  the  auditory  into  the  internal  auditory  meatus, 
the  nerve  is  exposed  to  injury  in  meningeal  affections  and  to  the 
pressure  effects  of  tumours  of  the  cerebello-pontine  angle. 

In  acute  meningitis,  whether  septic,  pneumococcal  .or  epidemic, 
facial  paresis  is  a  usual  but  generally  a  late  phenomenon.  It  is  also 
encountered  in  tuberculous  meningitis.  In  epidemic  meningitis, 
according  to  Gradenigo  and  Fraser,  it  may  be  set  up  by  a  retrograde 
development  of  the  inflammatory  process  into  the  Fallopian  canal 
through  the  porus  acusticus,  in  the  same  way  in  which  labyrinthitis  is 
produced  in  that  disease. 

Syphilis  affecting  the  meninges  of  the  posterior  fossa  may  also  be 
responsible  for  facial  paralysis. 

In  this  corner  are  found  cerebello-pontine  tumours  and  tumours  of 
the  auditory  nerve,  of  which  there  are  now  a  considerable  number  on 
record,  and  which  are  now  being  successfully  treated  by  operation 
(Gushing,  Forselles).  In  their  growth  these  neoplasms  nearly  always 
stretch  and  thin  out  the  facial  nerve. 

Besides  those  conditions,  facial  paralysis  occurs  in  otogenic  cere- 
bellar abscess  from  direct  pressure  upon  the  nerve  as  it  passes  into  the 
internal  auditory  meatus. 

Facial  paralysis  has  been  reported  by  Schwartze  as  occurring  in 
lateral  sinus  thrombo-phlebitis,  but  the  mode  of  its  production  in  this 
disease  is  not  clear. 

In  lesions  of  the  basal  meninges  and  the  other  structures  about  the 
cerebello-pontine  angle  the  auditory  nerve  is  usually  involved  along 
with  the  facial,  and  in  consequence  the  facial  paralysis  is  combined  with 
nerve-deafness  and  with  the  signs  of  irritation  or  paralysis  of  the 
vestibular  system. 

Tomka  states  that  the  facial  paralysis  may  appear  before  the 
deafness.  But  as  regards  tumours  in  this  region,  Gushing's  results 
support  the  general  opinion  that  the  rule  is  for  the  deafness  to  precede 
the  facial  palsy.  He  has  shown  that  the  growth  of  the  tumour  may, 
as  a  matter  of  fact,  produce  remarkable  distortion  and  flattening  of  the 
seventh  nerve  without  there  being  any  more  than  "  slight  expressional 
weakness  of  the  lower  face."  Indeed,  the  resistance  offered  by  the 
facial  nerve  contrasts  with  the  severity  of  the  interference  with  the 
function  of  the  two  constituents  of  the  auditory,  which,  although  it  may 
not  be  wholly  ablated,  either  in  the  cochlear  or  in  the  vestibular  side,  is 
nevertheless,  so  far  as  its  function  is  concerned,  very  seriously  and  very 
early  damaged.  For  further  details  on  this  sulDJect  the  reader  is 
referred  to  the  recent  monograph  by  Harvey  Gushing  on  "  Tumours 
of  the  Nervus  Acusticus  and  the  Syndrome  of  the  Gerebello-Pontine 
Angle." 


May,  1920.]  Rhinology,  and  Otology.  143 

Affections  of  the  Facial  Nerve  in  the  Temporal  Bone. 

Traumatism. — The  nerve  in  its  canal  is  very  frequently  exposed  to 
injury. 

In  fracture  of  the  base  of  the  skull  facial  paralysis  is  a  common 
effect,  as  the  majority  of  these  breaks  involve  the  middle  cranial  fossa 
and  many  of  them  traverse  the  petrous,  taking  the  line  of  least 
resistance  by  way  of  the  internal  auditory  meatus  to  the  antro-tympanic 
roof — a  route  which  frequently  involves  damage  to  the  facial  canal  and 
its  nerve. 

The  paralysis  may  be  immediate  or  delayed.  If  immediate,  we 
assume  that  the  nerve  has  been  directly  injured  by  the  fracture  and 
that  the  paralysis  is  likely  to  be  permanent.  If  delayed,  as  it  may  be 
for  two  or  three  weeks  after  the  injury,  its  onset  is  usually  supposed  to 
be  due  to  pressure  by  callus  around  the  seat  of  the  fracture.  Whatever 
the  cause  of  the  delay  may  be,  the  prognosis  is  better  than  when  the 
paralysis  appears  at  the  time  when  the  accident  occurs. 

War  Injuries. — Eitie  or  machine-gun  bullets,  shrapnel  or  shell- 
fragments  traversing  the  route  of  the  facial  nerve  naturally  produce 
immediate  loss  of  power,  the  prognosis  of  which  is  in  most  cases  bad, 
as,  apart  from  the  dangerous  nature  of  wounds  in  this  i-egion,  the 
shattering  and  tearing  action  of  the  missile  renders  spontaneous  union 
of  the  nerve-ends  impossible  for  the  most  part,  while  surgical  efforts  to 
identify  and  isolate  the  torn  ends  of  the  nerve  and  to  bring  them  into 
efficient  contact  are  seldom  crowned  with  success.  The  effort  should, 
however,  always  be  made  if  the  condition  of  the  patient  otherwise 
permits  of  the  operation. 

In  addition  to  paralysis  consequent  upon  direct  trauma  of  the 
aqueduct  from  a  missile,  we  encounter  cases  in  which  the  temporal  bone 
is  injured,  but  with  only  temporary  facial  paralysis,  movement  being 
completely  restored  within  a  few  weeks.  These  are  obviously  cases  of 
concussion — a  violent  blow  on  a  nerve-trunk  leading,  as  we  know,  to  a 
temporary  loss  of  conductivity — or  of  hsemorrhage  into  the  canal,  from 
the  violence  imparted  to  the  bone  by  the  penetrating  object,  without 
the  nerve  itself  being  actually  touched.  I  have  myself  seen  and 
operated  upon  one  such  case,  a  small  fragment  of  metal  being  found 
in  the  tympanum,  which  it  had  penetrated  from  behind  through  the 
mastoid,  its  route  passing  external  to  the  pyramidal  bend  and  within 
a  few  millimetres  of  the  nerve. 

As  we  shall  see,  we  encounter  similar  cases  in  operative  paralysis. 

The  interesting  observation  has  been  made  that  if,  following  a  wound 
or  exposure  to  shell  explosion,  nerve-deafness  sets  in,  the  prognosis  as 
regards  recovery  from  this  deafness  is  bad  if  the  facial  nerve  has  been 
injured  and  there  is  facial  paralysis. 

{To  be  continued.) 


144  The  Journal  of  Laryngology,  [May,  1920. 


ROYAL   SOCIETY  OF    MEDICINE— OTOLOGICAL 

SECTION. 


President:  Mr.  Hugh  E.  Jones. 


November  15,  1918. 


Abridged  Report. 

Acute  Osteomyelitis  of  Temporal  Bone;  Operations;  Recoyery. 
— Herbert  Tilley. — The  patient,  a  boy,  was  ailmitted  to  Uuiversity 
College  Hospital  for  acute  suppurative  otorrhea  (right)  of  some 
six  weeks'  duration,  associated  with  paiu,  pyrexia,  sleeplessness  and 
malaise.  The  mastoid  antrum  and  adjoining  cells  were  explored  in  the 
ordinary  way,  the  roofs  of  the  antrum  and  tympanum  were  found  to 
have  been  destroyed  by  disease,  the  dura  was  replaced  by  a  mass  of 
granulation-tissue  which  permitted  the  tip  of  the  little  finger  to  be 
passed  into  the  adjacent  region  of  the  temporo-sphenoidal  lobe.  The 
wound  was  left  wide  open  and  dressings  applied.  During  the  following 
three  or  four  weeks  the  soft  tissues  in  the  temporo-mastoid  regions 
became  swollen  and  (edematous. 

At  the  second  operation,  the  squamous  and  mastoid  portions  of  the 
temporal  bone  were  freely  exposed,  and  were  found  to  be  so  softened  by 
inflammation  that  large  portions  could  be  scraped  away  with  shai'p 
spoon  or  removed  with  forceps.  The  dura  mater  was  so  thickened  and 
unlike  the  normal  structure  that  it  was  ditficult  to  recognise  it  or  to 
differentiate  it  from  surrounding  infiltrated  tissues.  During  the  long 
convalescence  herniae  cerebri  made  their  appearance  on  three  occasions  in 
the  original  wound  over  the  mastoid,  and  on  each  occasion  they  were 
removed  by  division  of  the  stalk,  which  seemed  to  depend  from  the  brain 
in  the  neighbourhood  of  the  defective  roofs  of  the  antrum  and  tympanum. 

After  a  long  convalescence  the  patient  is  now  j^ractically  well,  except 
that  a  small  sequestrum  appears  to  be  making  its  way  to  the  external 
opening  of  a  fistula  in  the  lower  part  of  the  post-aural  wound.  In  the 
experience  of  the  exhibitor  acute  spreading  osteomyelitis  of  the  temporal 
bone  is  rare,  and  he  believes  that  most  of  the  recorded  cases  have  proved 
fatal.  It  is  possible  that  the  very  wide  removal  of  inflamed  bone  in  this 
case  accounts  for  the  successful  issue. 

Mr.  TiLLEY  (in  reply  to  several  members) :  The  description  of  the 
case  is  imperfect ;  the  notes  I  took  have  been  lost  in  the  hospital.  The 
father  says  the  boy  was  admitted  three  days  before  last  Christmas  Day, 
and  I  operated  on  the  day  following  admission.  On  the  day  of  operation 
the  tissues  were  swollen  and  oedematous  over  the  mastoid  region,  and  I 
think  the  osteomyelitis  had  commenced  at  the  time  of  the  operation. 
When  the  antrum  was  opened  the  roof  of  the  tympanum  was  found  to 
be  destroyed  and  its  place  taken  by  granulation-tissue,  so  that  one  could 
pass  a  probe  straight  into  a  subdural  or  even  a  temporo-sphenoidal 
abscess.  The  patient  was  put  back  to  bed,  but,  instead  of  the  oedema 
disappearing  in  a  few  days,  it  became  more  marked,  and  spread,  so  that 
in  two  or  three  weeks  it  had  extended  over  the  greater  part  of  the  left 
temporal,  parietal,  and  occipital  regions,  and  the  general  condition  had 
become  worse.     He  had  a  slight  temperature  every  night.     Therefoi-e  we 


May,  1920.]  Rhinology,  and  Otology.  145 

decided  to  opeu  the  wound  agaiu.  It  Avas  then  that  I  found  the 
squamous  portion  of  the  temporal,  and  a  part  of  the  lower  posterior 
portion  of  the  parietal  bone,  and  the  occipital  bone  in  the  region  of  the 
mastoid  process  involved.  The  bone  Avas  soft.  I  cut  away  into  healthy 
tissue  in  all  these  regions.  The  strange  feature  was  the  extraordinary 
appearance  of  the  dura  mater,  which  looked  like  pale  bacon  rind,  and  I 
dared  not  go  through  this  lest  I  should  expose  the  pia  or  enter  the 
cortex.  He  had  no  meningitis.  I  left  the  dura  to  take  its  chance.  In 
the  course  of  some  weeks  it  settled  down,  and  I  think  his  dura  is  now  in 
a  more  or  less  normal  condition.  I  must  try  Mr.  Stuart-Low's  cage,  for 
it  seems  to  have  advantages.  I  think,  however,  with  Mr.  Mollison,  that 
the  narrowiug  of  the  meatus  had  nothing  to  do  with  the  dressings  in  this 
case.  The  patient  Avas  in  hospital  some  six  months,  and  the  septic 
condition  of  the  wound  was  extreme,  and  lasted  for  weeks.  I  think  any 
soft  cartilaginous  tissues  would  be  apt  to  become  necrosed,  and  that  the 
present  anatomical  conditions  would  be  accounted  for  by  the  severity  of 
the  inflammation  and  consequent  cicatrisation  which  occurred.  Mr.  Tod 
pointed  out  what  probably  most  of  us  have  noticed  in  osteomyelitis  of 
tlie  frontal  bone,  viz.  the  low  degree  of  pyrexia.  This  boy  had  no 
rigors,  and  his  temperature  was  never  anything  remarkable.  Dr.  Paterson 
asked  Avhy  osteomyelitis  occurred  more  in  the  frontal  bone  than  in  the 
temporal  region.  It  may  possibly  be  explained  by  the  fact  that  the 
vascular  supply  in  the  tempoi'al  region  is  much  more  free  than  is  that  in 
the  frontal  bone.  If  you  open  the  frontal  sinus  in  a  chronic  empyema 
and  clean  out  the  mucous  membrane,  for  twelve  days  you  see  nothing 
there  except  a  mother-of-pearl-like  appearance  on  the  posterior  Avail.  On 
the  tenth  or  twelfth  day  red  spots  begin  to  appear,  aud  in  four  or  five 
weeks  the  frontal  sinus  Avill  be  fall  of  granulation-tissue,  whereas  in  the 
case  of  the  mastoid  antrum  you  can  see  plenty  of  granulations  at  the  end 
of  a  week.  Thei*e  is  a  better  vascular  supply,  a  better  leucocytic  infiltra- 
tion, and  a  better  defence  against  infective  organisms.  Dr.  Kelson 
asked  if  osteomyelitis  occurred  in  the  temporal  bone  Avithout  a  previous 
operation.  In  this  case  the  osteomyelitis  had  started  when  we  opened 
the  Avound,  because  the  roofs  of  the  antrum  and  tympanum  were  already 
destroyed,  and  the  condition  spread  until  the  second  operation  was 
performed.  Acute  osteomyelitis,  independent  of  operation,  does  occur 
in  the  frontal  sinus,  and  I  have  published  a  record  of  such  a  case.^  At 
the  time  I  operated  on  that  patient  the  osteomyelitis  had  spread  to  such 
an  extent  that  in  a,  week  or  two  we  had  to  take  away  nearly  the  whole 
left  frontal  bone.  The  patient  recovered.  Nevertheless  nearly  all  the 
cases  in  the  frontal  bone  which  I  have  seen  have  been  post-operative.  I 
have  seen  only  the  one  case  of  mastoid  osteomyelitis  which  I  show  to-day, 
and  hence  my  experience  of  the  complication  in  this  situation  is 
(fortunately)  rare. 

Epithelioma  in  a  Patch  of  Lupus  Erythematosus. — W.  Stuart- 
Low.— A  male,  aged  forty-five.  No  family  history  of  tuberculosis,  but 
of  cancer  on  the  mother's  side,  and  in  the  case  of  one  of  his  sisters  at 
the  age  of  forty-seven.  He  has  had  a  very  hard  life,  having  had  to 
maintain  himself  at  the  age  of  fifteen.  The  skin  condition  has  been 
present  ever  since  he  can  remember,  but  has  extended  more  rapidly  during 
the  last  few  years,  especially  on  the  scalp.  The  crusting  on  the  edge  of 
the  left  auricle  has  only  existed  for  six  months  :  it  began  over  a  small 

'  Brit.  Med.  Journ.,  July  7,  1917,  p.  7. 

10 


146  The  Journal  of  Laryngology,  May,  1920. 

beau-shaped  area,  and  has  always  had  a  blackish-brown  colour.  As  the 
crusts  are  removed  they  rapidly  re-form,  and  destruction  has  been  marked 
during  the  last  two  months.  Suspecting  that  there  might  be  an  element 
of  epithelioma  at  this  place  a  piece  has  been  removed  by  Dr.  John 
MacKeith,  whose  patient  he  is,  and  submitted  to  Dr.  Wyatt  Wingrave 
for  microscoi)ic  examination.  Dr.  MacKeith  has  very  carefully  studied 
the  case  from  the  point  of  view  of  possible  tuberculosis,  but  has  found 
no  corroborative  evidence  of  tubercle  bacilli.  Liquor  arsenicalis  has 
been  administered  in  increasing  doses  since  Dr.  MacKeith  first  saw  him 
in  August  last,  and  locally  the  ulcer  has  been  touched  up  at  intervals 
with  acid  nitrate  of  mercury.  He  complains  of  pain  in  the  ear,  especially 
in  cold  weather.  There  is  a  large  patch  of  lupus  erythematous  on  the 
outer  side  of  the  left  thigh. 

Dr.  Wyatt  Wingrave's  repoi't  on  the  specimen  from  this  case  states 
that  it  is  a  most  unusual  case  of  epithelioma  being  grafted  on  to  lupus 
erythematosus.  In  my  experience  this  is  unique.  I  would  like  an 
expression  of  opinion  as  to  the  best  treatment.  I  intend  to  amputate 
the  auricle,  and  will  show  the  patient  at  a  subsequent  meeting. 

Dr.  H.  J.  Banks-Davis:  I  thought,  judging  from  a  case  which  I 
reported  in  the  Proceedings  in  1914,  that  this  looked  like  epithelioma  of 
the  helix  apart  from  the  lupoid  condition  on  the  face.  I  removed  the 
entire  helix,  but  none  of  the  glands,  as  I  could  feel  none.  The  patient 
was  a  very  old  man,  and  I  did  not  remove  any  glands  at  the  time  of  the 
operation.  Several  members  predicted  a  recurrence — but  such  has  not 
taken  place.  Two  years  ago  I  showed  another  similar  case  in  an  old 
man.  The  eroding  surface  was  considered  gummatous,  but  it  proved  to 
be  an  epithelioma  and  the  auricle  was  removed. 

Double  Facial  Paralysis  due  to  Bilateral  Tuberculous  Mas- 
toiditis.— W.  M.  Mollison. — A  child,  aged  thirteen  months,  was 
admitted  to  Guy's  Hospilal  on  October  12  of  this  year.  Otorrhoea 
began  at  the  age  of  six  months,  and  has  been  considerable  ever  since.  A 
swelling  was  noticed  over  the  left  mastoid  process  the  day  before 
admission  ;  the  change  in  the  face  was  only  noticed  four  days  previously. 
From  both  meatuses  there  was  profuse  foul  otorrhoea;  theie  was  con- 
siderable swelling  over  the  left  mastoid  process,  and  tlie  skin  over  this 
was  red.  The  face  was  without  creases,  and  crying  produced  no  change. 
At  operation  the  mastoid  process  was  found  to  be  soft  and  necrotic,  and 
a  series  of  sequestra  were  easily  scraped  out  with  a  "sharp  spoon": 
the  dura  mater  of  the  middle  fossa  was  exposed  and  covered  with 
granulations.  Six  days  later  the  right  mastoid  was  operated  on  and  a 
similar  condition  found.     The  child  has  made  a  good  recovex'y. 

Mr.  Hunter  Tod  :  How  was  this  infant  fed  ?  Was  it  breast  fed  r  If 
not,  was  the  milk  boiled?  It  is  now  recognised  that  tuberculous- 
mastoiditis  is  nearly  always  due  to  infected  milk.  It  is  most  unusual  to- 
get  double  tuberculous  mastoid  disease.  Were  there  any  enlarged 
glands  ?  G-enerally  the  pre-auricular  and  cervical  glands  are  affected, 
and  then  the  question  arises  as  to  whether  they  should  be  removed. 
What  is  the  experience  of  Mr.  Mollison  and  others  with  regard  to  facial 
paralysis  ?  Tuberculous  disease  of  the  middle  ear  frequently  begins  in 
the  region  of  the  facial  canal,  and  if  facial  paralysis  occurs,  recovery 
seldom  takes  place.  Has  this  mastoid  completely  healed?  If  so.  there 
cannot  any  longer  be  tuberculous  disease.  These  cases  are  difficult  to 
treat,  and  we  know  comparatively  little  about  the  prognosis,  except  that 


May,  1920.]  Rhinology,  and  Otology.  147 

the  disease  cannot  be  said  to  have  been  eradicated  until  the  mastoid 
cavity  has  remained  completely  healed  for  a  considerable  period. 

Mr.  W.  Stuart-Low  :  Have  tubercle  bacilli  been  found  in  the  dis- 
charge ?  There  are  many  cases,  even  more  pronounced,  in  which  tubercle 
bacilli  cannot  be  discovered.  External  fomentation  with  Tidman's  sea 
salt — or  with  sea-water  if  the  patient  is  at  the  seaside — is  a  good  method. 
Iodide  of  lead  ointment  should  also  be  rubbed  in  for  a  considerable 
time. 

Dr.  Perry  Goldsmith  :  Mastoid  suppuration  in  very  young  children 
is  often  loosely  termed  tubercular.  Sometimes  the  tubercle  bacillus 
cannot  be  found  in  children  or  even  in  adults.  In  a  fairly  large  number 
of  cases  under  my  care  the  time  of  healing  was  far  prolonged  beyond  the 
six  weeks  taken  in  this  case.  The  mastoid  cells  are  scai'cely  developed  in 
a  child  of  this  age.  This  could  hardly  have  been  a  mastoid  abscess  as 
it  healed  up  so  quickly. 

The  President  :  I  recall  a  somewhat  similar  case,  in  which  the 
question  of  tuberculosis  was  a  prominent  one.  There  were  really  two 
cases,  twins,  aged  ten  months.  For  two  months  before  I  saw  them  they 
had  each  suffered  from  double  otorrhoea  and  enlarged  cervical  glands.  The 
source  of  the  milk  was  inquired  into,  and  was  supposed  to  be  quite  beyond 
reproach  :  the  cows  were  kept  by  a  gentleman  farmer,  who  specialised  in 
supplying  milk  to  babies,  and  bad  his  cows  periodically  examined.  My 
opinion  was  that  the  disease  was  tubercle,  and  inoculation  of  guinea-pigs, 
proved  it  to  be  correct.  We  put  the  medical  officer  of  health  on  to  the 
track  of  the  milk,  and  it  was  traced  to  a  tuberculous  cow  in  this  "  model 
dairy."  Another  case  cropped  up  in  the  practice  of  the  physician  who 
saw  my  case  in  which  the  child  died  of  meningitis,  and  the  milk  was 
traced  to  the  same  cow.  In  these  twins  there  was  only  one  of  the  four 
facial  nerves  paralysed,  and  perhaps  that  was  partly  my  fault,  for  it 
occurred  some  days  after  the  operation  ;  however,  the  case  recovered. 
Three  mastoids  were  operated  upon.  Both  these  children  put  on  weight 
during  the  whole  of  the  treatment,  and  never  went  back.  Tuberculin 
injections  had  apparently,  if  anything,  an  unfavourable  effect  on  the 
childi-en.  I  think  most  temporal  bone  cases  in  babies  are  tuberculous,  and 
are  due  to  the  milk,  and  I  do  not  regard  facial  paralysis,  though  fre- 
quently occurring,  as  by  any  means  a  necessary  concomitant.  The 
glands  were  removed  three  or  four  months  afterwards  by  a  geneial 
surgeon  :  tonsils  and  adenoids  were  removed  by  myself.  These  children 
are  now,  after  several  years,  both  strong  and  healthy. 

Dr.  Kelson  :  The  fact  of  rapid  recovery  need  be  no  argument  against 
the  condition  being  tuberculous.  I  have  had  several  such  cases,  and 
they  have  healed  with  marvellous  rapidity,  even  when  the  disease  has 
been  extensive.  But  the  trouble  is  that  the  disease  is  apt  to  reappear 
after  a  year  or  so.  I  showed  here  one  case  Avhich  was  operated  upon  by 
myself  three  or  four  times,  at  intervals  of  two  or  three  years,  the  first 
being  at  the  age  of  six  months. 

Mr.  MoLLisoN  (in  reply)  :  We  did  not  find  tubercle  bacilli,  but  the 
case  was  tuberculous  clinically.  There  Avas  a  thin  foul  discharge  from 
both  ears,  there  was  no  pain,  and  it  was  only  by  accident  that  the  swelling 
over  the  mastoid  was  discovered  at  all.  There  were  many  glands  on  both 
sides — pre-auricular  and  infra-mastoid.  With  regard  to  the  feeding,. 
one  child  I  know  about  had  been  fed  on  the  milk  of  one  cow,  which  had 
been  kept  specially  for  it  and  tested  by  tuberculin.  The  child  developed 
typical  tuberculous  mastoid  disease.     The  second  case  was  that  of  the 


148  The  Journal  of  Laryngology,  [May,  iP20. 

eighth  child  iu  a  family,  which  had  been  breast-fed.  This  child  was 
aged  eight  months,  and  the  mother  and  all  the  other  children  were 
healthy.  This  child  developed  what  appeared,  clinically,  to  be  tuber- 
culosis of  the  middle  ear  :  another  aural  surgeon  had  seen  the  child,  and 
had  diagnosed  it  as  tuberculosis,  advising  immediate  operation.  There 
may  be  other  paths  of  infection  besides  ingestion  with  the  milk. 

Necrosis  of  the  Internal  Ear,  causing  Sequestration  of  the 
Labyrinth  ;  Recovery.     (Sequestrum  shown.) — W.  M.  Mollison. — 

W.  S ,  aged  sixty,  attended  iu  the  Aui-al  Out-patient  De}»artment  at 

Ouy's  Hospital  on  account  of  pain  in  the  left  ear.  For  years  he  had 
suffered  from  left-sided  otorrhoea ;  for  three  months  he  had  had  head- 
ache and  attacks  of  vertigo,  but  had  continued  his  work  of  a  bricklayer 
till  three  weeks  ago,  when  he  felt  too  ill.  Recently  he  had  been  some- 
what delirious  at  night.  There  was  a  large  jjolypus  in  the  left  meatus 
with  a  foul  otorrhoea.  There  was  no  swelling  over  the  mastoid  process, 
but  a  little  tenderness  on  percussion.  He  looked  old  for  his  age  and 
pale. 

He  was  admitted  and  operation  performed.  On  opening  the  mastoid 
process  pus  was  found  and  a  sequestrum  ;  on  exposing  the  antrum  all 
anatomical  landmarks  were  absent;  the  region  of  the  external  semicircular 
canal  was  eroded  and  separated  posteriorly  by  a  line  of  necrosis  and 
granulations  ;  further  investigations  revealed  this  trench,  as  it  were, 
surrounding  the  labyrinth,  and  the  whole  labyrinth  was  found  to  be 
moveable,  and  a  very  slight  pull  brought  it  away  whole.  The  deep  hole 
thus  revealed  was  found  to  be  bounded  above  by  granulations  on  the 
dura  mater  of  the  middle  fossa,  and  behind  by  granulations  on  the 
dura  of  the  posterior  fossa.  The  facial  nerve  lay  across  the  hole  on 
granulations,  and  was  damaged  at  some  stage  of  the  operation.  The 
patient  still  has  paralysis.  For  a  few  days  the  patient  was  mildly 
delirious,  but,  as  cau  be  seen,  has  made  a  good  recovery.  The  condition 
was  not  tuberculous. 

Dr.  D.  R.  Paterson  :  To  what  extent  ought  one  to  undertake  cutting 
away  of  bone  for  the  delivery  of  the  sequestrum  ?  In  three  or  four 
cases  I  have  had  considerable  difficulty  :  the  petroiis  bone  is  too  hard  to 
break  up  in  situ.  I  contented  myself  with  loosening  it  under  an 
anaesthetic,  and  leaving  it  for  a  time.  It  was  impossible  to  deliver  it 
without  cutting  away  bone  considerably,  and  I  have  always  had  in  mind 
the  possibility  of  a  connection  with  the  carotid  canal,  or  thought  that 
the  sequestrum  might,  in  its  inner  part,  be  attached  to  the  auditory 
nerve,  and  be  in  communication  with  the  interior  of  the  skull.  Loosening 
it  in  three  or  four  sittings  made  it  possible  to  deliver  it  safely.  I  do 
not  know  how  far  one  can  venture  to  go  iu  the  forcible  extraction  of 
such  sequestra. 

Mr.  J.  F.  O'Malley  :  Can  syphilis  be  entirely  excluded  in  this  case  ? 
If  not,  the  case  must  be  regarded  as  one  of  septic  necrosis.  It  is  rather 
unusual  for  an  oidiuary  sepsis  to  isolate  the  labyrinth  in  that  way.  It 
is  more  likely  to  follow  syphilis. 

The  President  :  In  a  case  I  reported  to  the  old  Otological  Society 
many  years  ago  the  whole  labyrinth  and  cochlea  came  away  complete. 
In  that  case  the  original  trouble  followed  scarlet  fever,  the  child  being 
also  the  subject  of  congenital  syphilis.  The  fact  that  the  facial  nerve 
recovered  afterwards  was  surprising  to  me :  I  should  have  thought  the 
whole  part  of  the  facial  nerve  which  is  included  in  the  temporal  bone 


May,  1920]  Rhinology,  and  Otology.  149 

would  have  been  desti-o_yed.  The  recovery  was  first  noticed  because  the 
ffirl  had  had  double  facial  paralysis,  and  yet  coniplained,  three  weeks 
after  the  operation,  of  her  face  having  become  crooked.  This  was  due  to 
a  return  of  power  on  the  operated  side. 

Acute  Mastoiditis  followed  by  Thrombosis  of  the  Internal 
Jugular  Vein  as  far  as  the  ClaYicle;  Recovery.— W.  M.  Mollison. 

— A.  F ,  female,  aged  eight,  was  operated  on  for  acute  mastoiditis. 

The  temperature,  which  had  been  1036°  F.,f  ell  to  normal  in  two  days. 
On  the  third  day  after  operation  it  rose  to  102°  F.,  and  for  some  days 
fluctuated  between  100''  and  1025°  F.,  till  on  the  eleventh  day  the 
patient  had  a  rigor.  Operation  was  performed.  On  opening  the  wound 
pus  was  found  about  the  lower  part  of  the  lateral  sinus  ;  the  sinus  was 
opened  and  found  thrombosed.  The  jugular  vein  was  exposed  in  the 
neck  and  found  to  be  solid  with  clot  as  far  down  as  the  clavicle.  A 
piece  of  vein  was  excised  and  is  shown.  There  was  never  any  stiffness  of 
the  neck,  and  two  days  after  the  operation  the  child  sat  up  in  bed. 
Before  recovery  she  had  several  rises  of  temperature.  She  was  treated 
once  bv  injection  of  1  c.c.  of  collosol  manganese,  but  it  is  difficult  to  say 
whether  the  subsequent  fall  of  temperature  was  a  result  of  the  treatment 
or  merely  a  coincidence. 

Dr.  H.  J.  Banks-Davis:  Some  years  ago  I  showed  here  a  girl  whose 
internal  jugular  vein  I  had  to  excise  for  a  similar  disease.  It  was 
mistaken  for  enteric  fever.  She  was  sent  into  the  hospital  from  one  of 
the  fever  hospitals  with  a  large  swelling  in  the  neck.  The  sloughing 
wound  in  the  neck  was  treated  with  "  soap  solution,"  for  the  formula  for 
which  I  am  indebted  to  Dr.  Dundas  Grant.  It  is  made  into  an  emulsion^ 
and  cyanide  gauze  is  dipped  into  this,  packed  into  the  wound,  and  it  is 
astonishing  how  it  clears  up  the  condition.  The  formula  is  :  Potash 
soap,  1  dr.  ;  soda  soap,  1  dr.  ;  olive  oil,  1  dr.  ;  water  to  2  pints. 

Dr.  Perry  Goldsmith  :  Acute  mastoiditis  in  which  there  is  a 
teraperatui-e  of  103°  F.,  falling  to  normal  in  two  days  after  operation, 
and  subsequently  rising  to  102°  F.,  with  remissions,  always,  in  my 
experience,  means  exposure  of  the  lateral  sinus.  Often  there  is  a  peri- 
sinus  abscess,  which  has  been  unnoticed  at  the  operation.  Some 
American  surgeons  say  that  in  all  mastoid  operations  the  lateral  sinus 
should  be  exposed  as  a  matter  of  course.  I  do  not  agree  with  that,  but 
peri-sinus  abscess  occurs  often  after  such  operation.  In  the  note  it  says 
the  temperature  fluctuated  between  100°  and  1025°  F.  till  the  eleventh 
day,  Avhen  the  patient  had  a  rigor.  One  would  expect  an  unexposed 
sinus  case  to  have  a  rigor  by  that  time.  With  regard  to  ligature  of  the 
jugular,  a  person  can  have  thrombosis  of  the  lateral  sinus  which  will 
"look  after  itself  and  may  not  be  discovered  except  by  accident.  In  two 
cases  I  have  operated  upon  the  lateral  sinus  has  been  exposed,  and  there 
has  been  old  obliteration  without  trouble,  except  periodical  attacks  of 
old  mastoid  symptoms.  If  one  is  careful  to  get  the  flow  of  blood  from 
behind  and  from  below,  it  will  not  always  be  necessary  to  ligate  the  vein 
in  the  neck.  It  must  be  remembered  that  in  curetting  the  bulb  so  as  to 
get  a  flow  from  below,  we  are  liable  to  shift  the  clot  in  the  inferior 
petrosal  sinus,  which  is  a  protection  against  the  cavernous  sinus  becoming 
involved.  With  regard  to  removing  a  portion  of  the  vein,  it  does  not 
seem  good  surgery  to  remove  a  small  portion  of  the  vein.  What  can  be 
the  object  of  taking  out  an  inch  or  so  ?  Either  ligature  it  alone,  or  take 
out  the  whole  vein.     If  it  is  ligatured  at  the  lower  end,  the  upper  part 


150  The  Journal  of  Laryngology,  [May,  1920. 

should  be  brought  out  of  the  wound  :  otherwise  there  will  be  a  bag 
containing  a  clot,  which  is  sometimes,  though  not  always,  septic. 

Dr.  D.  R.  Paterson  :  I  have  had  a  similar  experience  in  a  clu'onic 
case.  Septic  matter  was  traced  away  down  into  the  cervical  region,  and 
it  was  impossible  to  follow  it  below  the  clavicle.  I  passed  a  probe  a 
considerable  distance  down  the  vein,  and  satisfied  myself  that  it  was 
quite  empty  for  some  distance  into  the  chest.  The  vein  was  excised, 
because  it  was  in  a  very  foetid  condition,  and  the  patient  was  returned  to 
bed  with  very  little  hope  of  it  doing  well.  Nothing  was  applied  after- 
wards except  an  ordinary  dressing,  and  yet  the  child  did  excellently. 

The  President  :  I  am  glad  to  hear  that  Dr.  Goldsmith  does  not  go 
as  far  as  some  of  his  neighbours  in  the  United  States.  The  impression 
I  have  had  of  most  American  otologists  is  that  they  invariably  remove 
the  whole  vein  in  the  neck,  and  occasionally  dissect  out  the  bulb. 

Mr.  MoLLisoN  (in  reply)  :  I  agree  with  what  Dr.  Goldsmith  says 
about  the  lateral  sinus  :  if  the  temperature  is  raised  in  a  case  of  acute 
mastoiditis  the  sinus  should  always  be  exposed. 

Radical  Mastoid  Operation  for  Cholesteatoma,  with  Preserva- 
tion of  the  Matrix  (Six  Months  and  Fourteen  Years  after  Operation 
Respectively). — J.  Dundas  Grant. — Case  1. — The  first  is  a  gentleman, 
aged  fifty-six,  on  whose  left  "  mastoid  "  I  operated  fifteen  years  ago  in  the 
presence  of  several  French  colleagues,  who  agreed  with  me  as  to  the 
singular  resemblance  of  the  matrix  to  an  unusually  delicate  skin-graft. 
The  progress  of  the  case  was  very  rapid.  The  patient  only  came  under 
my  notice  again  in  July  of  the  present  year  on  account  of  deafness  in  the 
other  ear  with  jingling  noises  and  giddiness.  The  ear  formerly  operated 
on  is  now  his  "  good  "  one,  and  he  hears  with  it  a  whisper  at  16  ft.  The 
cavity  is  a  typical  "  radical  mastoid  "  cavity,  but  smoother,  drier  and 
whiter  than  I  usually  secure. 

Case  2. — The  second  is  the  lady  whom  I  brought  before  the  Sectiou 
at  the  meeting  last  May,  about  a  fortnight  after  the  operation.  It  was 
then  nearly  dry,  the  osseous  ridge  being  alone  uncovered.  It  has  kept 
quite  dry. 

Mr.  J.  F.  O'Malley  :  Dr.  Dundas  Grant  had  an  excellent  result  in 
the  case  of  the  lady  whom  he  has  shown  here  before.  A  week  or  two 
after  that  occasion  I  got  a  case,  upon  which  I  operated,  and  found  a  huge 
cavity  filled  with  cholesteatomatous  material;  the  facial  ridge  was 
destroyed,  and  no  landmarks  were  left.  The  cavity  was  lined  with  a 
beautiful  smooth  membrane.  Acting  on  Dr.  Dundas  Grant's  advice  I 
left  it  completely  intact,  and  with  the  most  excellent  result.  The  only 
delav  in  healing  was  at  a  spot  posteriorly  on  the  inner  aspect  of  the 
wound  in  the  mastoid.  Thei-e  were  a  few  granulations  here  wliich  I  had 
to  suppress  by  applying  caustic.  Where  the  membrane  covered  the 
cavity  the  healing  was  perfect. 

Dr.  Perry  Goldsmith  :  I  was  present  when  Dr.  Dundas  Grant 
operated  upon  this  man.  The  French  visitors  discussed,  with  a  good 
deal  of  vigour,  the  leaving  of  the  matrix  behind  at  all.  Others  have  not 
had  the  same  good  results  from  leaving  the  matrix.  Why  should  the 
matrix  be  left  to  cover  the  disease  which  is  beyond  ? 

Dr.  D.  R.  Paterson  :  Following  Dr.  Grant's  suggestion,  I  have  left 
the  matrix  behind.  In  one  case  a  boy  had  very  extensive  disease  on  both 
sides,  long  continued,  and  a  vei'y  large  cholesteatoma.  At  the  radial 
operation  I  left  the  matrix  in  both,  and  there  was  an  excellent  recovery, 


May,  1920.]  Rhinology,  and  Otology.  151 

Avith  good  bearing.  In  the  dry  class  of  case,  leaving  the  matrix  turns  out 
•excellently,  because  there  is  not  a  huge  cavity  to  line,  and  one  escapes 
the  vicissitudes  which  accompany  ti-ying  to  line  it  by  grafts. 

Dr.  DuNDAS  Grant  (in  reply)  :  The  speakers  in  discussion  have  con- 
firmed my  views.  Much  depends  on  the  appropriateness  of  the  cases. 
You  cannot  have  this  formation  unless  the  case  is  of  veiy  old  standing  ; 
the  cases  are  not  now  allowed  to  continue  without  treatment  so  long  as 
formerly.  Dr.  Goldsmith  has  referred  to  the  question  of  disease  being 
still  below  the  matrix.  If  this  were  so,  the  formation  of  the  matrix, 
which  is  a  homogeneous  membrane,  would  be  interfered  with;  if  it  is 
white  and  adherent  one  can  be  pretty  sure  there  is  no  active  disease 
there.  The  question  has  often  been  discussed,  and  critics  have  quoted 
Kirchner,  who  contended  that  the  cliolesteatoma  extended  into  the  bone. 
He  had  made  only  one  observation,  and  published  it,  but  what  the  nature 
of  the  case  was  nobody  knows.  Katz,  among  others  of  his  countrymen, 
opposed  his  views,  and  showed  that  it  was  not  an  ordinary  nor  even  a. 
possible  occurrence.  I  think  everyone  is  now  agreed  that  the  chole- 
steatomatous  membrane  is  an  attempt  at  dermatisation,  and  is,  as  a  rule,  a 
•very  successful  attempt.  When  it  is  complete  it  should  be  retained. 
Mr.  O'Malley  has  referred  to  the  spot  where  he  had  a  little  trouble ;  that 
is  just  inside  the  posterior  margin  of  the  wound.  Those  with  experience 
-of  radical  mastoid  operations  will  always  be  on  the  look-out  for  that.  If 
the  little  mass  of  granulation-tissue  there  is  taken  away  the  cavity  dries 
up.  The  best  way  to  deal  with  that  is  to  puncture  it  with  a  fine  galvano- 
-cautery  as  recommended  by  Stacke  in  his  original  work.  It  causes  a 
limited  area  of  sclerosis  in  the  inflammatory  tissue.  One  does  not  know 
how  far  the  contraction  is  going  to  extend  if  nitrate  of  silver  be  applied. 

Chronic  Middle-ear  Suppuration  (?  Pension  Award).~John  F. 
O'Malley.— Private  I.  M -,  aged  twenty.  Left  ear  discharging  con- 
stantly for  over  two  years;  no  history  of  disease  in  childliood.  "  Pain 
for  about  eight  months  in  bone  behind  ear,  worse  at  night." 

This  case  is  shown  for  the  purpose  of  eliciting  expressions  of  opinion 
on  the  following  important  points  : 

(1)  For  the  purpose  of  a  pension  award  is  one  justified  in  stating 
that  this  ti'ouble  began  two  years  ago  and  not  previously  (see  right  ear)  ? 

(2)  Assuming  that  he  has  been  in  the  Army  over  two  years,  should 
his  condition  be  attributed  to  (a)  military  service,  or  (h)  only  aggravated 
by  it,  or  (c)  not  affected  by  it  y 

(3)  Is  a  radical  mastoid  operation  positively  indicated  ? 

(4)  AVhat  is  the  surgical  prognosis,  apart  from  the  function  of 
hearing  ? 

Dr.  Perry  Goldsmith  :  This  man  has  been  in  hospital  a  consider- 
able time,  and  it  is  necessary  to  assume  the  idea  that  it  is  a  psychic  case. 
There  is  no  objective  evidence  in  regard  to  his  pain,  and  he  is  coming 
before  a  Pensions  Board,  and  he  knows  he  will  be  paid  if  his  deafness  is 
due  to  service,  or  if  it  has  come  on  after  the  war  commenced.  One 
hesitates  to  question  the  good  faith  of  an  individual,  but  I  do  so  in  99 
per  cent,  of  cases,  otherwise  we  may  have  pitfalls.  This  man  says  his 
trouble  came  on  after  the  war  started,  but  he  admits  that  he  always 
sat  in  the  front  at  the  theatre,  and  he  would  not  be  likely  to  do  so  unless 
he  could  not  hear,  sight  being  normal.  He  says  that  within  a  short  time 
•of  enlistment  he  was  bathing  and  got  some  water  in  his  ears,  and  from 
■one  ear  he  had  a  discharge  without  pain  a  few  days  later.    That  is  not  the 


152  The  Journal  of  Laryngology,  [May,  1920. 

course  of  acute  middle-ear  suppui-atiou,  but  of  ordinary  chronic  middle- 
ear  suppui'ation,  in  which  there  is  perforation  lit  up  by  the  presence  of 
■water  in  the  middle  ear.     I  therefore  think  his  condition  was  aggravated 
by  war  service,  and  that  it  existed  before  the  war.     The  radical  opera- 
tion   does  not   seem  to  be  indicated,  but  I  do   not  think   he  will  get 
rid  of  the  pain  until  some  operation  cutting  the  skin  is  done.     His  pain 
I  regard  as  largely  psychic.     If  you  make  the  pressure  greatest  on  the 
right  ear,  he  will   still  have  pain  in  the  left.     There  is  possibly  some 
chronic  sclerosis  of  the  mastoid  which  clears  up  after  operation.     If  he 
has  a  cholesteatoma  and  a  matrix,  the  surgical  prognosis  is  very  good. 
I  see  no  reason  for  regarding  the  prognosis  as  unfavourable,  though, 
before   operation   takes   place,   it  would  be  well  to  know  how  far  the 
labyrinth  is  capable  of  function  and  what  is  the  perception  for  high  tones. 
Dr.   DuNDAS   GrRANT :    It   is   vmfortunate  that,  from  the  nature  of 
things,  men  had  to  be  taken  into   the  Army  withovit  being  examined 
closely  as  to  the  condition  of  their  ears.     If  that  had  been  done,  many 
in  the  Army  would  not  have  been  there.     We  have  to  give  the  man  the 
benefit  of  the  doubt,  and  unless  we  feel  very  confident  that  the  condition 
is  an  old-standing  one,  we  are  bound  to  accept  the  man's  statement  that 
his  ears  were  well  before  enlistment.     This  man  has  one  good  ear,  and 
"  sclerosis  "  changes  in  the  other.     If  there  was  old  trouble,  it  must  have 
been  very  slight.     This  detracts  much  from  the  force  of  Dr.  Goldsmith's 
argument,  for  when  he  sat  in  the  front  at  the  theatre  he  had  one  good 
ear.     I  agree  with  Mr.  O'Malley,  that  he  had  an  old-standing  condition 
which  was  re-awakened  since  he  joined  as  the  result  of  his  exposure,  and 
I  do  not  think  we  are  justified  in  penalising  the  man  on  that  account.  He 
has,  I  imagine,  a  disability  of  about  20  per  cent.     Everything  should  be- 
done  to  cure  the  suppuration.     Perhaps  30  per  cent,  would  be  fairer  than 
20  per  cent.     I  think  one  would  have  to  say  his  trouble  was  aggravated 
by  military  service,  that — beginning  as   disease,  it   was  aggravated   by 
injury.     He  gives  a  definite  account  of  shell-explosiou,  but  that  it  would 
produce  such  pain  as  he  has  had  I  think  doubtful.      I  hai'dly  suppose 
that  would  wake  up  inflammatory  changes.    I  expect  everything  has  been 
done  to  cause  the  discharge  to  cease.    I  examine  such  cases  with  a  suction 
speculum,  and  sometimes  with  a  bent  |»robe,  such  as  Mr.  Hxmter  Tod's. 
But  I  cannot  say  whether  the  discharge  hei-e  comes  from  the  antrum  or 
from  the  direction  of  the  Eustachian  tube.    If  from  the  antrum — and  one 
sees  the  formation  of  well-marked  cholesteatomatous  products — it  would 
indicate  old-standing  disease  and  operation  would  be  justifiable.     I  do 
not  know  what  the  hearing  in  the  affected  ear  is.     If  it  is  veiy  bad  a 
mastoid  operation  will  not  make  it  worse  ;  if  it  is  fairly  good  the   opera- 
tion will  leave  the  heaiung  only  moderate.     The  presence  of  pain  would 
be  a  further  indication  for  operation. 

Mr.  W.  Stuart-Low  :  We  have  seen  very  many  of  these  cases.  If  a 
man  had  discharge  from  the  ear  he  was  put  back  to  Grade  3.  If  the  ear 
dried  up  the  man  would  perhaps  be  taken  into  the  Ai-my.  Such  men 
ought  to  be  cautioned  not  to  bathe.  This  man's  trouble  was  re-started  by 
bathing.  I  do  not  doubt  that  the  condition  has  been  chronic  for  years. 
I  would  operate  because  the  discharge  has  gone  on  so  long,  and  is  likely 
to  continue.  Everything  should  be  done  to  favour  the  discharge  drying^ 
up ;  I  would  have  mouth  and  teeth  seen  to.  If  he  is  not  right  in  three 
mouths  he  should  certainly  have  the  radical  mastoid  operation  performed 
on  him. 

Col.  A.  D.  Sharp  :  There  should  be  no  difficulty   in    answering  the 


May,  1920.]  Rhmology,  and  Otology.  153 

questions  here  set  oixt.  The  disability  was  certainly  contracted  in  the 
Service,  and  as  certainly  was  it  aggravated  by  service.  But  I  do  not 
think  it  is  attributable  "to  military  service.  Dr.  Grant  has  summed  the 
case  up  correctly,  but  the  percentage  I  would  aAvard  would  be  15.  If  the 
man  says  he  will  not  be  operated  upon,  and  as  he  has  the  right  to 
refuse,  his  refusal  should  not  influence  the  Board  in  determining  his 
l^ension  claim. 

Mr.  J.  F.  O'Malley  (in  reply)  :  The  on.y  difference  of  opinion 
expressed  by  speakers  relates  to  the  question  of  an  operation.  We  seem 
all  agreed  that  the  man  had  disease  in  the  ear  prior  to  two  years  ago, 
and  also  that  the  condition  has  been  aggravated  by  military  service. 
The  fact  of  an  antecedent  discharge  would  enable  one  to  exclude  the 
heading  "  Due  to  military  service  alone,"  and  one  would  assess  the  dis- 
ability lower  than  if  it  had  been  entirely  due  to  military  service.  The 
man  showed  no  objection  whatever  to  an  operation.  He  came  to  me  and 
said  he  could  not  sleep.  After  questioning  him  pretty  thoroughly  I  put 
the  question  to  him,  "  Are  you  bad  enough  to  undergo  a  severe  opera- 
tion ?  "  He  did  not  hesitate,  but  at  once  said  he  would  like  it  very 
much.  One  can  see  a  distinct  focus  of  chronic  inflammation,  with  caries 
in  the  attic,  and  a  fairly  large  mass  of  granulations,  dependent  from  the 
meatal  roof.  I  think  he  has  sepsis  and  granulation  trouble  in  the  aditus 
also,  and  possibly  in  the  antrum.  I  should  operate  to  get  rid  of  it.  I 
asked  the  last  question  because,  apart  from  function,  I  wanted  to  know 
if  others  agreed  with  me  as  to  the  site  of  the  lesion.  A  localised  lesion 
in  these  cases  enables  one  to  give  a  more  promising  prognosis,  for  one  is 
likely  to  be  able  to  remove  the  whole  of  the  disease. 


ABSTRACTS. 

Abstracts  Editor — W.  Douglas  Harmer,  9,  Park  Crescent,  London,  W.  1. 
Authors  of  Original  Communications  on  Oto-laryrigology  in  other  Journals 
are  invited  to  send  a  copy,  or  tivo  reprints,  to  the  Journal  of  Laryngology. 
If  they  are  ivilling,  at  the  same  time,  to  submit  their  oivn  abstract  (in  English,. 
French,  Italian  or  German)  it  will  be  welcomed. 


NOSE. 

On  the  Modifications  of  the  Nasal  Flora  from  Plugging.— Caldera  and 
Santi.     "Arch.  Ital.  di  Otol.,"  vol.  xxx.  No.  3. 

The  nasal  cavities  of  a  number  of  dogs  were  plugged  under  aseptic 
conditions  with  sterilised  gauze,  and  the  secretions  obtained  from  the 
nose  after  twenty-four  or  forty-eight  hours'  plugging  were  injected 
subcutaneously  into  young  rabbits.  It  was  found  that  the  numbers  of 
bacteria  in  the  nose  increased  enormously,  especially  the  anaerobic  types. 
The  nasal  secretions  after  plugging  are  able  to  produce  when  inoculated 
into  young  rabbits  local  inflammatory  reactions  which  the  secretions 
from  normal  dogs  do  not  produce. 

Plugging  with  iodoform  gauze  does  not  cause  the  notable  increase  in 
the  numbers  and  varieties  of  bacteria  which  results  when  sterile  gauze  is 
used.  For  this  reason  the  authors  recommend  that  all  nasal  packing 
should  be  with  medicated  and  preferably  iodoformised  gauze  rather 
than  plain  sterile  gauze.  /.  K.  Ililne  Dickie. 


1^4  The  Journal  of  Laryngology,  [May,  1920. 

On  the  Modifications  of  the  Bacterial  Flora  of  the  Nose  in  Relation  to 
the  Atmosphere.— Caldera  and  Lesderi.  "Arch.  Ital.  di  Otol.," 
vol.  XXX,  No.  3. 

The  authors  have  carried  out  an  interesting  series  of  experiments,  the 
results  of  Avhich  are  given  below.  The  subjects  were  the  same  in  all  the 
experiments  and  had  been  ascertained  to  be  healthy  by  previous  rhino- 
scopic  examination.  Plate  cultures  were  made  from  the  nose  under  verv 
varying  atmospheric  conditions.  As  was  expected,  cultures  from  the  nose 
in  city  air  yielded  large  numbers  of  colonies.  Some  of  the  main  conclusions 
drawn  are  as  follows. 

"  The  nose  represents  a  cleansing  organ  for  the  inspired  air  and  the 
number  of  organisms  diminishes  from  without  inwards,  the  maximum 
number  being  found  in  the  vestibule. 

"  The  hygrometric  state  of  the  atmosphere  has  an  influence  on  the 
nasal  flora.     More  germs  are  found  after  a  jn-o longed  period  of  dryness." 

The  bacterial  flora  diminishes  gradually  in  the  same  subjects  in 
ascending  to  high  altitudes.  At  2000  metres  very  few  organisms  are 
found  in  the  nose,  while  at  3000  metres  the  nose  is  almost  absolutely 
sterile.  The  differences  between  the  effects  of  town  and  mountain  air  on 
the  nasal  flora  are  not  so  marked  in  Aviuter  as  in  summer. 

/.  K.  Milne  Dickie. 


TONSILS. 

Tonsillectomy  versus  Helio-electric  Methods.  —  Thos.  M.  Stewart 
(Cincinnati).     "  New  York  Med.  Journ.,"  January  4,  1919. 

This  paper  deals  with  the  results  of  fulguratiou  and  ultr.i-violet  rays 
as  an  adequate  method  by  which  to  reduce  enlarged  tonsils,  and  diathermy 
as  an  effective  measure  in  causing  a  resolution  in  the  tonsil  from  an 
unhealthy  to  a  healthy  condition.  A  consideration  is  also  given  of 
various  other  methods  of  tonsillar  reduction,  but  reference  to  the  work 
of  British  laryngologists  is  noticeably  absent. 

The  following  data  were  obtained  by  the  author  in  correspondence 
with  1000  physicians  in  Ohio,  Indiana  and  Kentucky  : 

Total  number  of  operations,  10,756 ;  deaths,  15;  deaths  in  five  out 
of  seventy-one  large  cities  written  to,  18 ;  primary  haimorrhages,  432, 
secondary  79 ;  ligations  for  liaemorrhage  at  the  time  of  operation,  488 ; 
haemophiliacs,  26;  prolonged  coagulation,  54;  voices  lost  4,  voices 
regained  2  ;  septic  cases  before  operation  252,  after  operation  9  ;  fatalities 
from  ether  2,  bromoform  1,  oxygen  and  ether  12 ;  diphtheria  after 
operation,  8;  pulmonary  abscess  after  operation,  1;  hyperpyrexia,  14; 
emphysema  of  face,  1  ;  skin  rashes,  8.  Definite  replies  as  to  dryness  of 
the  throat,  adhesions  of  pillars,  difficulty  in  swallowing,  and  ear  infection 
■were  not  elicited. 

The  author's  conclusions  were  as  follows  : 

(1)  That  tonsillectomy  does  not  insure  against  future  attacks  of  sore 
throat  nor  of  other  diseases  and  infections  for  which  the  operation  was 
performed. 

(2)  That  tonsillar  tissue  is  present  in  nearly  one-half  the  cases  after 
operation,  and  not  always  to  the  detriment  of  the  patient  nor  a  reflection 
on  the  operator. 

(3)  That  helio-electric,  fulguration  and  diathermic  methods  do  not 
accomplish  more  than  the  cutting  operation,  their  value  being  equally 
to  be  obtained  in  selected  cases  in  comparison  with  the  cutting  methods 


Tffiay,  1920.] 


Rhinology,  and  Otology.  155 


less  risk  to  the  voice,  and  of  death  fi-om  anaesthesia  or  uncontrolled 
haemorrhage,  and  without  shock  to  the  patient  from  undue  hemorrhage 
■when  the  latter  is  controlled. 

(4.)  That  badly  diseased  tonsils  should  be  enucleated,  whether  large 
or  small,  unless  some  unusual  factor  eontra-iudicates  tbe  use  of  general 
or  local  anaesthesia,  in  which  case  secure  the  best  results  possible  by 
helio-electric  methods.  Perry  Goldsmith. 


EAR. 
Brain  Abscess:  Operation  and  Recovery. — Wesley  Bowers.  "The 
Laryngoscope,"  September,  1919,  p.  556. 
Male,  aged  twenty-one,  had  had  a  primary  mastoid  operation  (left) 
two  months  before  and  a  secondary  operation  one  mouth  before  Bowers 
saw  him.  For  several  weeks  he  had  been  unable  to  flex  his  right  foot. 
His  father  stated  that  his  son's  disposition  had  been  entirely  changed 
after  the  first  operation.  He  had  formerly  been  very  quiet,  and  now  he 
had  become  hard  to  control  and  unreasonable.  Examination  showed  a 
granulating  wound  over  the  left  mastoid,  drum  membrane  thickened,  no 
meatal  discharge,  temperature  100-3°  F.,  pulse  80,  labyrinth  normal, 
hearing  10/20,  no  aphasia,  severe  headache.  Third  operation :  The 
antrum  had  not  been  entered  at  the  former  operation.  Necrotic  bone  over 
the  middle  fossa.  Dura  normal.  Not  having  any  localising  symptoms 
Bowers  decided  to  wait.  Headache  continued  with  mental  dulness.  On 
the  ninth  day  he  first  showed  amnesic  aphasia.  Fourth  operation : 
Temporal  decompression.  A  large  abscess  found  at  depth  of  1}  in.  in  an 
upward  and  inward  direction.  Cigarette  drain  for  tAvo  weeks.  After  two 
months  the  patient  was  apparently  normal.  J.  S.  Fraser. 


MISCELLANEOUS. 

Surgical  Treatment  of  Facial  Paralysis.— George  Fenwick.  "British 
Medical  Journal,"  November  29,  1919. 

Every  large  military  hospital  has  had  experience  of  traumatic  facial 
paralysis,  where  restoration  of  function  by  nerve  repair  or  nerve-grafting 
has  not  been  possible.  In  cases  of  comminution  of  the  petrous  bone  end- 
to-end  repair  cannot  be  effected,  although  gi-afting  or  anastomosis  may 
still  remain  practicable  ;  in  lacei'ated  parotid  wounds  the  main  trunk  has 
already  broken  up  into  the  parotid  plexus,  and  repair  of  the  diverging 
branches  does  not  come  into  the  realm  of  practical  surgery. 

The  deformity  is  a  very  terrible  one,  and  any  treatment  that  offers 
hope  of  cosmetic  impi-ovement  should  be  welcome  to  surgeons. 

The  treatment  is  that  of  grafts  from  neighbouring  muscles. 

Preliminary  to  anaesthesia,  the  non-paralysed  side  of  the  face  is 
inspected,  and  the  position  of  the  lower  half  of  the  naso-labial  fui-row 
mai-ked  in ;  a  second  vertical  marking  is  made  almost  in  the  centre  of  the 
cheek  in  the  position  of  the  dimple  that  becomes  evident  when  laughing. 
A  third  marking  is  made,  beginning  below  the  external  canthus  and 
taking  the  direction  of  one  of  the  lines  of  the  crowsfoot.  The  side  of  the 
head  is  shaved. 

An  incision  is  made  through  the  skin  in  the  hair  line  from  the  zygoma 
to  the  upper  limit  of  the  temporal  fossa,  directed  slightly  backwards  so 
as  to  be  parallel  to  the  underlying  fibres  of  the  temporal  muscle.  The 
skin  is  then  undermined  forwards  and  backwards  to  expose  the    temporal 


156 


The  Journal  of  Laryngology, 


[May,  1920. 


fascia.     Two  parallel  iucisions  are  then  made,  again  from  the  zygoma  to 
the  limit  of  the  temporal  fossa  through  the  fascia  aud  muscle  down  to  the 


^1*3-  1- — 2.  Denuded  ai-ea  in  tempoi-al  fossa,  t.  Slip  of  temporal 
muscle  inserted  into  orbicularis  palpebrarum,  m.  Slip  of  masseter 
inserted  into  orbicularis  oris. 


-  T. 


Fig.  2. — 2.    Denuded   area   in    temporal    fossa.      t.  Temporal   muscle. 
Ti.  Slip  of  temporal  muscle  inserted  into  orbicularis  oris. 

bone.     These  incisions  should  run  iu  the  direction  of  the  muscular  fibres 
and  should  include  a  strip  of  muscle   as  thick  as  a  man's  thumb ;  it  is 


May,  1920.] 


Rhinology,  and  Otology. 


157 


important  for  the  preservation  of  the  nerve  supply  and  for  the  cosmetic 
result  that  fully  this  bulk  of  muscle  should  be  used.  A  smaller  slip 
anterior  to  this  is  similarly  isolated,  and  both  are  detached  from  the 
underlying  bone. 

An  incision  is  now  made  under  the  eyelid  in  the  marking  representing 
one  of  the  lines  of  the  crossfoot,  the  skin  is  undermined,  the  anterior 
smaller  slip  of  muscle  drawn  through,  made  taut,  and  sutured  to  the 
fibres  of  the  orbicularis  palpebrarum  with  catgut  (Fig.  1,  t,  and  Fig.  3,  Tj). 

Incisions  are  made  in  the  line  of  the  cheek  furrow  and  the  lower  half 
of  the  naso-labial  groove,  and  the  skin  tunnelled  to  make  a  continuous 
passage  from  the  temporal  woimd  to  the  corner  of  the  mouth.  The  large 
slip  of  muscle  is  then  drawn  down  over  the  zygoma  through  the  chaune', 
sutured  with  catgnt  to  the  superficial  fascia  exposed  in  the  cheek  wound, 
and  to  the  muscular  fibres  of  the  orbicularis  oris  below  and  slightly  mesial 
to  the  corner  of  the  mouth  (Fig.  3,  Tn). 


Fig.  3. — 2.  Denuded  area  in  temporal  fossa,  t,.  Slip  of  temporal  muscle 
inserted  into  orbicularis  palpebraruna.  Tj.  Slip  of  temporal  muscle 
inserted  into  orbicularis  oris. 


The  facial  incisions  ai*e  sutured  with  horsehair ;  the  cut  margins  of 
the  temporal  muscle  are  brought  together  as  far  as  possible  with  catgut 
(it  is  extremely  difiicult  to  get  apposition),  and  the  temporal  Avound  closed 
with  silkworm-gut. 

Faradism  and  massage  should  be  employed  early,  and  the  patient 
should  daily  exercise  his  facial  expression  before  a  glass.  The  grafted 
straps  of  muscle  will  continixe  to  function. 

In  the  first  operation  he  attempted,  a  slip  of  the  tempoial  muscle  was 
grafted  into  the  orbicularis  palpebrarum  and  a  slip  of  the  masseter  into 
the  orbicularis  oris  (Fig.  1,  m)  ;  Stenson's  duct  was  guarded  by  a  probe 
inserted  and  tied  to  a  tooth.  Considerable  difficulty  was  experienced  in 
getting  the  slip  from  the  masseter,  and  there  are  no  compensating 
advantages.  He  has  performed  the  temporal  muscle-graft  without  making 
use  of  a  cheek  incision,   bnt  prefers   the   method   described,   and   the 


158  The  Journal  of  Laryngology,  [May,  1920. 

additional  scar,  lying  as  it  does  in  a  natural  skin-fold,  is  almost 
iinpei'ceptible. 

The  cavity  left  in  the  temporal  fossa  after  swinging  down  the  slip  is 
of  considerable  dimensions,  and  to  obliterate  it  by  approximation  of  the 
cut  edges  of  the  muscle  is  almost  impossible. 

Grood  results  in  paralytic  ectropion  have  been  obtained  by  means 
of  the  ordinary  Kuhnt-Dimmer  operation,  but  the  sling  of  living  muscle 
is  more  likely  to  ensure  permanent  improvement  than  the  mere  shortening 
of  the  lower  lid. 


REVIEW. 


Studies  in  the  Anatomy  and  Surgery  of  the  Nose  and  Ear.     By  Adam 
E.  Smith,  M.D.     New  York  :  Paul  B.  Hoeber,  1918. 

The  book  is  well  printed  and  neatly  produced.  It  consists  of  some 
150  pages,  and  is  copiously  adorned  with  illustrations,  of  which  a  great 
many  are  full-page  plates. 

A  number  of  lateral  vertical  skull  sections  are  depicted  to  show  the 
relation  of  parts  in  reference  to  the  nasal  cavities,  and  also  an  elaborate 
series  of  vertical  antero-posterior  sections  is  shown  to  indicate  the 
relationship  of  the  accessory  sinuses  to  the  nasal  fossae  and  to  each 
other.  That  portion  which  is  devoted  to  the  ear  is  profusely  illustrated, 
each  plate  being  supplemented  by  a  diagrammatic  "key." 

Some  parts  of  the  book  are  without  novelty,  as  Chapter  I,  which 
deals  with  the  importance  of  nasal  breathing,  and  expresses  in  the  main 
the  accepted  views  thereon.  We  say  "  in  the  main,"  because  in  one 
passage  here  we  find  it  stated  that  the  ingoing  air-current  on  the  side 
of  the  nose  which  happens  to  be  obstructed  by  a  deflected  septum 
causes  recession  of  the  outer  wall  of  the  nose,  and  therefore  asymmetry 
of  the  sinuses,  and  this  cannot  be  regarded  as  an  accepted  view,  much 
less  as  a  proven  one. 

On  the  whole,  it  may  be  said  that  the  author's  opinions  are  out  of 
harmony  with  the  views  and  practice  of  British  rhinologists. 

No  authorities  are  quoted.     Tliere  is  an  efficient  index. 

Archer  Byland. 


OBITUARY. 


Christian  E.  Holmes,  M.D.,  Cincinatti,  U.S.A. 

{Died  January  9,  1920.) 

Dr.  Christian  K.  Holmes  was  born  in  Copenhagen,  October  18,  1857. 
He  received  an  early  training  as  a  civil  engineer,  but  when  his  family 
emigrated  to  Cincinnati  he  took  up  the  study  of  medicine,  and  graduated- 
in  1886.  His  name  became  well  known  as  a  prominent  worker  in 
diseases  of  the  eye,  ear  and  throat.  He  was  a  member  of  the  American 
Laryngological  Association  and  a  frequent  visitor  at  medical  gatherings- 
in  Europe,  but  on  this  side  of  the  Atlantic  we  have  hardly  realised  the 
immense  work  he  did  in  consolidating  the  two  leading  medical  colleges 
of  Cincinnati  in  the  new  building  of  the  City  Hospital.  With  enthusiasm 
and  devotion  he  visited  and  studied  ail  the  leading  hospitals  of  Europe  ^ 


May,  1920.1 


RhinoIo§:y,  and  Otology. 


159 


and  America,  so  that  this  magnificent  hospital  in  his  own  city  is  now 
one  of  the  most  perfect  in  the  world  and  his  best  monument. 

Besides  meeting  him  in  European  congresses  many  of  our  readers 
enjoyed  his  gracious  hospitality  after  the  International  Congress  of 
Otology  in  Boston,  during  various  meetings  at  Atlantic  City,  and  on 
many  other  occasions.  He  undoubtedly  overworked  himself  during  the 
war,  while  his  own  sons  were  distinguishing  themselves  in  France. 
The  many  friends  of  his  devoted  and  charming  wnfe  will  feel  the  deepest 
sympathy  for  her  and  her  family  in  the  loss  of  one  of  the  standard- 
bearers  of  our  speciality.  StC.  T. 


NEW  INSTRUMENTS. 

A  Scabbard  for  Instruments. 


When  ethyl  chloride  is  given  for  curettement  of  adenoids  and  the 
enucleation  of  tonsils,  the  anaesthesia  period  is  short,  and  time  saved 
becomes  of  moment. 

I  have  had  in  use  for  some  time  a  new  "gadget  "  which  has  proved 
of  considerable  utility.  It  consists  of  a  double  scabbard  with  a  hook, 
and  can  be  slung  at  the  belt  or  over  a  bandage  secured  round  the  waist. 
It  holds  two  adenoid  curettes,  viz.  a  StClair  Thomson  cage  curette 
and  also  a  small-size  Beckenham  curette,  and  it  enables  the  surgeon  to 
lay  his  hand  instantly  on  the  required  instrument  without  groping  for 
it  on  the  table.    I  generally  place  it  a  little  to  the  right  side  of  the  bodv. 

The  woodcut  is  slightly  in  error  in  that  it  represents  two  StClair 
Thomson  curettes. 

Messrs.  Mayer  &  Phelps  will  supply  the  instrument. 

B.  Seymour  Jones. 

Birmingham. 


160  The  Journal  of  Laryngology.  [May,  1920. 

NOTES  AND  QUERIES. 

Section  of    Laryngology  of  the  Eoyal  Society  of   Medicine  :    Summer 

Congress,  1920. 

The  Second  Annual  Summer  Congress  of  this  Section  will  be  held  on  Thursday 
and  Friday,  June  2 1  and  25,  1920,  at  1,  Wimpole  Street,  London  W.  1. 

Members  of  the  Section  are  invited  to  contribute  papers  which  may  be  read  at 
the  Congress.  Papers  will  be  read  on  the  afternoon  of  Thursday,  June  24,  from 
2.30  till  5.30  p.m.,  and  on  the  morning  of  Friday,  June  25,  from  lu  to  1.  Not  more 
than  15  minutes  will  be  allowed  for  the  reading  of  any  paper. 

The  usual  Clinical  Meeting  will  be  held  on  Friday  afternoon  at  4  p.m.  Demon- 
strations will  be  given ;  also  there  will  be  a  Pathological  Museum  and  an  exhibition 
of  Instruments  and  Drugs. 

Those  who  intend  to  read  papers  are  requested  to  send  in  the  abstracts  of  their 
papers  not  later  than  May  24  to  the  Hon.  Secretaries,  Dr.  Irwin  Moore,  30a, 
Wimi^ole  Street,  London,  W.  1,  or  Mr.  Charles  Hope,  22,  Queen  Anne  Street, 
London,  W.  1. 

American  and  foreign  colleagues  are  cordially  invited  to  take  part  in  the  work 
of  the  Congress  as  Honorary  Members. 

The  Annvxal  Dinner  will  be  held  at  the  Cafe  Royal  on  the  evening  of  Thursday, 
June  24.  Members  are  requested  to  intimate  their  intention  to  be  present  to  the 
Secretaries  as  soon  as  possible. 

Otological  Section  of  the  Royal  Society  of  Medicine. 
The  next  meeting  of  this   Section  will   be   held   on  May   21.      Notices  and 
papers  to  be  sent  in  not  later  than  May  1.     Seci'etaries :  Mr.  H.  Buckland  Jones 
and  Mr.  Lionel  Colledge. 

Laryngological  Section  of  the  Royal  Society  of  Medicine. 
The  next  monthly  meeting  of  this  Section  will  be  held  on  May  7.     Notices  and 
papers  to  be  sent  in  not  later  than  April  25.     Secretaries :  Dr.  Irwin  Moore  and 
Mr.  C.  W.  Hope. 

Annual  Meeting  in  Cambridge,  June  30-July  3,  1920. 

The  British  Medical  Association  has  not  held  its  visual  annual  gathering  since 
July  in  the  fateful  year  of  1914.  The  forthcoming  meeting  at  Cambridge  promises 
to  be  most  interesting  and  a  great  success  under  the  presidency  of  Sir  Clifford 
Allbutt.  There  is  no  Section  of  Otology  or  Laryngology  this  year.  Ophthalmology, 
an  older  if  not  a  larger  speciality,  and  several  small  ones  are  in  exactly  the  same 
case.  We  understand  that  the  object  is  to  seciu-e  better  work  at  the  Sections  by 
giving  each  of  them  a  meeting  every  two  or  thi-ee  years  instead  of  annually. 
Oto-laryngologists  are  welcome  to  contribute  communications  to  the  surgical  or 
other  sections,  and  we  trust  that  many  of  our  readers  will  avail  themselves  of  this 
opportunity. 

It  is  hoped  and  expected  that  many  visitors  from  the  provinces,  the  over-seas 
Dominions  and  foreign  countries  will  attend  the  Summer  Congress  in  London  and 
go  on  to  the  meeting  in  Cambridge. 

CoNGRiis  Fran(;ais  d'Oto-Rhino-Lakyngologie,  Paris,  May  10-13,  1920. 

This  Congress  commences  at  9  a.m.  on  May  10  at  the  Hotel  des  Societes 
Savantes,  8  rue  Danton. 

The  two  subjects  for  general  discussion  are — (1)  "Radium  and  Radio-therapy 
in  Tumours  of  Ear,  Nose  and  Throat,"  to  be  opened  by  Dr.  Lombard  and  Dr. 
Sargnon ;  (2)  "  Paradental  Cysts  of  the  Upper  Jaw,"  to  be  introduced  by 
Dr.  Jacques. 

The  outgoing  President  is  Dr.  Bar,  of  Nice,  and  the  President  elect  is  Prof. 
Sieur,  of  Paris.  Quite  a  number  of  British  oto-laryngologists  have  arranged  to 
visit  Paris  for  this  meeting,  and  further  particulars  can  be  obtained  by  writing 
to  the  Editor  of  this  Journal. 

Central  London  Throat  and  Ear  Hospital. — Lantern  Demonstration  by 
Dr.  J.  S.  Eraser  (Edinburgh). 

Dr.  J.  S.  Eraser  is  giving  a  lantei-n  demonstration  of  his  slides  illustrating 
diseases  of  the  labyrinth  at  the  above  Hospital,  on  Thursday,  May  20,  at  5  p.m. 

Readers  of  this  Joiu-nal  are  well  acquainted  with  the  notable  work  on  the 
pathology  of  the  labyrinth  which  Dr.  Eraser  has  been  carrying  on,  to  the  high 
credit  of  British  otology,  for  many  years  past,  and  this  opportunity  of  a  general 
survey  of  the  subject  is  one  that  should  not  be  missed. 


VOL.  XXXV.     No.  6.  June,  1920. 


THE 

JOURNAL    OF    LARYNGOLOGY, 

KHINOI.OGY,   AND   OTOLOGY. 


Original  Articles  are  accepted  on  tJie  condilioii  Uiat  they  have  not  previously  been 
published  elsewhere. 

If  reprints  are  required  it  is  requested  that  this  be  stated  when  the  article  is  first 
forwarded  to  this  Jourtial.     Stich  reprints  will  be  charged  to  the  author. 

Editorial  Communications  are  to  be  addressed  to  "Editor  of  Jouiinal  of 
Labtngologt,  care  of  Messrs.  Adlard  Sf  Son  Sf  West  Newmaii,  Limited,  Bar  tholomew 
Close,  E.C.  1." 


A  SIMPLE  METHOD  OF  RECORDING  DIAGRAMMATICALLY 
MOVEMENTS  OF  THE  VOCAL  CORDS;  WITH  SPECIAL 
REFERENCE   TO   TREMORS.^ 

(EPIDIASCOPE   DEMONSTEATION.)       ' 

By  a.  Brown  Kelly,  M.D.  (President). 

In  order  to  record  diagrammatically  tremors  and  ataxic  movements  of 
the  vocal  cords,  a  chart  is  required  on  which  the  normal  excursions 
can  be  registei'ed.  For  this  purpose  it  is  necessary  to  know  the  length 
of  excursion  of  the  cords,  or  how  far  they  are  apart  in  their  different 
phases  of  Activity,  also  the  amount  of  movement  they  execute  in  a  given 
time. 

The  width  of  the  glottis  has  been  carefully  investigated  by  Sir  Felix 
Semon(l).  He  found  in  the  adult  male  that  this  on  an  average  amounted 
to  5  mm.  when  the  cords  were  in  the  cadaveric  position,  and  13-5  mm. 
when  in  the  position  of  quiet  respiration.  Accordingly  a  vertical  dotted 
line  is  drawn  to  denote  the  median  position,  and  at  distances  of  2-5  and 
6-75  mm.  lines  are  drav.-n  on  each  side  parallel  to  it  to  represent  the 
cadaveric  and  quiet  respiratory  positions  (Fig.  1).  The  position  of  deep 
inspiration  is  not  indicated  because  it  is  identical  with  that  of  quiet 
respiration,  excepting  possibly  in  a  small  percentage  of  individuals  to 
be  referred  to  later ;  an  allowance,  however,  of  2-5  mm.  is  made  in  the 
chart  for  special  cases ;  the  outside  lines  are  thus  16  mm.  apart.  Assuming 
the  frequency  of  respiration  to  be  normal,  viz.  18  per  minute  or  3  in  ten 
seconds,  and  the  ratio  of  inspiration  to  expiration  as  10:12  (Foster), 
the  movements  of  the  cords  in  relation  to  time  are  registered  by 
measuring  off  distances  of  10  mm.  and  12  mm.  alternately  at  the  side 
of  the  chart  to  represent  inspiration  and  expiration  respectively. 

'  Reprinted  from  the  Proceedings  of  the  Royal  Society  of  Medicine,  1918,  vol.  xi 
(Section  of  Laryngology),  pp.  143-149,  with  Supplement  written  for  the  JouRNAii. 
OF  Laryngology,  Ehinology,  and  Otology. 

11 


162 


The  lournal  of  Laryngologryt 


[June,  1920. 


A  chart  based  on  statements  found  in  the  text-books  would  differ 
somewhat  from  that  just  described.  Measurements  are  not  given  by 
their  authors,  but  it  is  stated  that  the  cadaveric  position  is  mid-way 
between  those  of  adduction  and  quiet  respiration,  and  that  quiet  respira- 
tion   is    mid-way    between    adduction   and    deep    inspiration.      Again, 


R    CMC  R 


/  In^n" 


3 

Resp' 

10  ^ 

Sees 


Insp' 
lOmm 


Exp" 

12  mm. 


Insp"" 

lOmm 


Exp" 

12mm. 


Insp" 
lOmm 


V 


Exp"' 

12mm 


Dl     RCMCR     Dl 


5 

3-5 
16 


5 
10 
20 


Fig.  1. 


Fi(i. 


assuming  the  glottis  to  be  5  mm.  wide  when  the  cords  are  in  the 
cadaveric  position,  it  will  measure  10  mm.  and  2Q  mm.  when  the  cords 
are  in  the  positions  of  quiet  respiration  and  deep  inspiration  respectively 

It  is  surprising  that  unanimity  does  not  exist  as  to  so  obvious  a 
matter  as  the  state  of  the  cords  during  quiet  respiration.  While  some 
authors,  especially  Semon,  state  that  they  are  motionless  or  almost  so, 
others   describe  the  glottis  as  enlarging  and   diminishing  with   each 


June,  1920.] 


Rhinology,  and  Otologry. 


163 


inspiration  and  expiration.  Tlie  careful  examination  of  the  larynx  of 
a  number  of  tolerant  subjects  soon  convinces  one  that,  as  a  rule,  the 
vocal  cords  are  at  rest  or  almost  so  during  quiet  respiration,  and  that 
only  exceptionally  do  they  make  extensive  excursions  synchronous  with 
inspiration  and  expiration.  On  deep  inspiration  further  abduction  does 
not  take  place,  the  distance  between  the  vocal  processes  remaining 
unaltered,  although  the  edges  of  the  cords  may  occasionally  be  drawn 
outwards. 

A  straight  or  slightly  wavy  line  coinciding  more  or  less  with  that 


Fig.  3. 


Fig.  4. 


Fig.  5. 


Fig.  6. 


of  quiet  respiration  therefore  represents  the  cord  during  quiet  respira- 
tion and  deep  inspiration  in  the  great  majority  of  persons  (Fig.  3).  In 
the  exceptional  individuals,  on  the  other  hand,  in  whom  the  cords 
swing  markedly  inwards  and  outwards,  it  will  be  seen  (Fig.  4)  that  this 
pendulum  movement  does  not  go  on  uniformly,  but  that  inspiration 
begins  with  sharp  abduction  followed  by  a  period  of  rest,  after  which 
gradual  adduction  takes  place ;  further,  in  these  persons  deep  inspira- 
tion may  cause  the  cords  to  be  abducted  beyond  the  position  of  quiet 
respiration,  but  on  this  point  I  cannot  speak  definitely.  Phonation  is 
represented  by  the  immediate  meeting  of  the  cord  tracings  in  the  middle 
line,  and  the  emission  of  voice  is  indicated  by  a  thick  stroke,  a  whisper 


164  The  Journal  of  Laryngology,  [June,  1920, 

by  a  thin  one.     A  heavy  arrow  at  the  side  denotes  the  moment  at  which 
the  impulse  to  phonate  is  given. 

From  the  above  data  it  may  be  concluded  that  the  chart  based  on 
Semen's  measurements  (Figs.  1  and  3)  corresponds  most  nearly  to  the 
normal  conditions  ;  this  chart  is  therefore  used.  In  order  that  the 
tracings  of  the  movements  of  the  cords  may  be  distinct,  the  lines  mark- 
ing the  cadaveric  and  respiratory  positions  are  omitted,  and  if  the 
movements  of  both  cords  are  alike  only  those  of  one  are  represented. 

In  passing  to  the  consideration  of  tremors  of  the  cords  it  has  first 
to  be  pointed  out  that  these  are  manifested  only  when  there  is  move- 
ment of  the  cords  during  quiet  respiration  ;  possibly  when  the  cords 
are  motionless  the  tremors  are  masked  by  the  tonicity  of  the  abductors. 
It  must  not  be  assumed,  however,  that  swinging  vocal  cords  are  always 
associated  with  the  diseases  of  which  tremors  are  a  manifestation  ;  on 
the  contrary,  the  vocal  cords  were  found  to  be  stationary  and  without 
tremors  in  some  patients  suffering  from  the  same  affections.  My  impres- 
sion, however,  is  that  the  pendulum  type  of  laryngeal  respiration  is 
relatively  commoner  in  persons  with  central  nervous  disease  than  in 
normal  individuals. 

Physiological  tremors  may  occasionally  be  seen  in  weak  or  nervous 
subjects.     They  are  irregular  and  usually  accompany  expiration  only. 

In  certain  diseases  of  the  central  nervous  system,  especially  insular 
sclerosis,  tabes  and  paralysis  agitans,  tremors  of  the  cords  are  not 
infrequently  met  with. 

In  insular  sclerosis,  in  one  case  marked  tremors  of  the  left  vocal 
cord  were  observed  during  expiration  (Fig.  5).  In  another  the  left  vocal 
cord  showed  tremors  during  expiration,  phonation,  and  after  phonation, 
while  the  right  showed  them  only  during  and  after  phonation  and  to  a 
much  less  degree  (Fig.  6).  In  a  third  patient  the  left  cord  (Fig.  7,  a) 
was  fixed  in  the  middle  line,  while  the  right  (c)  swung  around  the  cada- 
veric position,  and  marked  irregular  twitchings  of  the  left  arytaenoid  (b), 
involving  the  left  ventricular  band  and  to  a  less  degree  the  left  cord, 
were  noted. 

In  tabes,  expiration  was  interrupted  by  tremors  in  several  cases. 
In  one  patient  the  right  cord  was  motionless  in  the  middle  line,  while 
the  left  swung  around  the  cadaveric  position,  inspiration  being  accom- 
panied by  two  or  three  twitches  and  expiration  by  a  number  of  fine 
tremors ;  occasionally  involuntarj'  sharp  adduction  to  the  middle  line 
took  place  (Fig.  8). 

In  paralysis  agitans  a  detailed  examination  was  impossible  in  some 
of  the  patients.  In  several,  tremors  accompanied  expiration  only  (Fig. 
9) ;  in  others  they  appeared  only  during  the  relaxation  of  the  cords  after 
phonation  (Fig.  10).     In  all  cases  both  cords  were  atiected  alike. 

In  a  case  of  nystagmus  of  the  vocal  cords  which  was  under  my  care 
twitchings  took  place  during  both  inspiration  and  expiration,  but  were 
more  marked  during  the  latter,  when  the  cords  were  swung  inwards 
by  a  series  of  four  or  five  to-and-fro  jerks  which  were  unequal  and 
arrhythmical  and  more  distinct  in  the  left  cord  (Fig.  11). 

A  noticeable  feature  in  all  the  cases  referred  to  is  that  the  tremors 
were  most  frequently  observed  diu-ing  expiration  ;  much  less  often  when 
the  cords  were  going  apart  after  phonation,  and  still  more  rarely  during 
phonation ;  further,  that  when  present  during  both  inspiration  and 
expiration,  as  in  nystagmus,  they  were  more  marked  during  the  latter 
phase.    This  predominance  during  expiration  is  probably  to  be  accounted 


June,  1920.] 


Rhinology,  and  Otology. 


165 


for  by  the  fact  that  expiration  is  a  passive  movement  and  more  easily 
disturbed,  while  inspiration  is  usually  strong  enough  to  mask  tremors. 
In  support  of  this  view  it  may  be  mentioned  that  in  a  case  of  insular 
sclerosis  in  which  expiration  was  accompanied  by  tremors,  when  the 
patient  produced  blowing  expirations,  thus  making  expiration  active 
and  inspiration  passive,  the  tremors  were  found  to  be  present  with  the 
latter  only. 

The  material  at  my  disposal,  although  seven  large  hospitals  have 
been  laid  under  contribution,  is  too  limited  to  allow  of  generalisations  or 
attempts  to  associate  certain  kinds  of  tremors  with  certain  diseases. 


Fig.  8. 


Fig.  9. 


Fig.  10. 


Charts  may  be  constructed  in  the  manner  indicated  also  to  represent 
the  action  of  the  vocal  cords  in  shell-shock  stammering  when  phonation 
is  attempted.  Thus,  from  the  instant  when  the  effort  is  made  to  phonate 
(marked  by  an  arrow)  until  the  voice  is  produced,  a  considerable  interval 
may  elapse  during  which  the  cords  may  be  twitched  once  or  twice 
towards  the  middle  line  (Fig.  12),  or  they  may  swing  to  and  fro  and  an 
interrupted  voice  result  (Fig.  13),  or  they  may  slowly  approach  the 
middle  line  until  they  meet,  but  at  first  merely  a  whisper  is  produced 
{Fig.  14).  Again,  the  cords  may  present  frequent  fine  tremors  and  only 
after  prolonged  effort  tremulous  phonation  may  result  (Fig.  15),  or  the 
patient  may  even  be  unable  to  approximate  the  cords  completely  (Fig.  16). 


166  The  Journal  of  Laryngology,  june,  1920 

For  material  which  has  allowed  of  this  investigation  being  carried 
out  I  desire  to  express  my  grateful  thanks  to  Dr.  Mary  F.  Liston, 
Merryflatts  Hospital ;  Dr.  James  H.  Macdonald,  Hawkhead  Asylum  ; 
Dr.  James  Thomson,  Barnhill  Hospital ;  Col.  A.  Napier  and  Dr.  Ivy 
McKenzie,  Victoria  Infirmary ;  Dr.  McKenzie  Anderson,  Dr.  W.  E. 
Jack  and  Prof.  W.  K.  Hunter,  Eoyal  Infirmary ;  Prof.  T.  K.  Monro, 
Western  Infirmary ;  and  Capt.  James  Hamilton,  Fourth  Scottish 
General  Hospital. 

Brief  reference  may  be  made  to  several  of  the  chief  contributions 
to  the  subject  of  involuntary  and  ataxic  movements  of  the  vocal  cords. 
Observations  have  been  noted  in  hysteria,  paralysis  agitans,  multiple 
sclerosis,  and  certain  other  focal  and  toxic  diseases  of  the  central 
nervous  system.  Schultzen  (2)  has  collected  and  analysed  most  of 
the  cases  recorded  prior  to  1894  and  supplemented  them  by  personal 
investigations. 

In  hysteria  various  writers  (Mackenzie,  Lori,  etc.)  have  reported 
the  presence  of  tremors  of  the  cords  especially  on  attempted  phonation, 
but  the  movements  appear  to  have  been  inconstant,  irregular,  of 
different  kinds  and  without  any  characteristic  feature. 

In  insular  sclerosis,  intention  tremors  of  the  vocal  cords  have  been 
observed  but  not  in  all  cases.  Leube  (3),  who  first  made  a  laryngoscopic 
examination  in  this  disease,  found  that  the  cords  closed  perfectly  on 
phonation  but  showed  varying  tension  and  relaxation,  hence  the 
scanning  speech.  Eethi  also  noted  that  adduction  was  usually  perfect, 
but  occasionally  after  watching  for  long  the  cords  were  seen  to 
approach  the  middle  line  by  a  series  of  jerks.  Lomikowski  refers 
to  irregular  vibrations  of  the  cords.  Lori  observed  very  slight  fibrillarj- 
twitchings  at  the  commencement  of  phonation,  inability  to  hold  the 
tone  for  long,  and  if  the  effort  were  maintained  oscillatory  movements 
(intention  tremors).  Krzywicki  saw  in  one  case  at  the  beginning  of 
phonation  slight  twitching  of  the  vocal  processes  towards  the  middle 
line,  followed  by  general  tremor  of  the  cords  and  adduction  ;  in  their 
return  to  the  respiratory  position  the  cords  swung  twice  or  thrice 
towards  the  middle  line.  Schultzen  found  in  two  out  of  eighteen 
cases  marked  intention  tremors  both  on  phonation  and  voluntary 
deep  inspiration.  In  one  of  these  the  movements  of  phonation  were 
accomplished  uniformly ;  as  a  rule,  fairly  rapid  tremor  of  the  cords 
was  then  seen  which  continued  during  their  passage  into  the 
respiratory  position.  The  movements  of  ordinary  respiration  were 
only  occasionally  interrupted  by  twitchings ;  with  voluntary  deep 
inspiration  more  marked  tremors  usually  set  in.  Graeffner  (4)  em- 
phasises the  need  of  examining  patients  at  intervals  over  long  periods 
in  order  to  detect  tremor  and  ataxy;  he  considers  that  the  discrepancy 
in  the  results  reported  by  various  authorities  as  to  the  frequency  of 
laryngeal  disturbances  in  multiple  sclerosis  is  due  to  the  neglect  of 
this  precaution.  His  investigations  have  shown  that  neither  the 
presence  of  a  disturbance  of  the  cords  nor  its  degree  is  related  to 
the  duration  of  the  illness. 

Fr.  Miiller  (5)  was  the  first  to  describe  the  action  of  the  vocal 
cords  in  paralysis  agitans.  He  found  that  on  phonation  they  were 
quickly  and  perfectly  adducted  but  that  shortly  after  they  fell  apart, 
and  in  passing  into  the  respiratory  position  executed  two  or  three 
short  twitching  incomplete  movements  of  adduction  which  were 
symmetrical  on  the  two  sides.     During  respiration  the  glottis  was  wide 


June,  1920.] 


Rhinology,  and  Otology. 


167 


open  and  the  cords  at  rest.  If,  however,  the  patient  were  disturbed 
by  prolonged  examination  or  speaking,  rhythmical  movements  of  both 
cords  causing  partial  adduction  sometimes  took  place.  Eosenberg  (6), 
who  next  reported  a  case,  found  that  adduction  did  not  begin  imme- 
diately on  receiving  the  order  but  only  after  a  short  pause,  and  that 
the  cords,  although  promptly  brought  together,  did  not  long  remain 
so ;  further,  that  during  respiration  the  cords  were  usually  still,  but 
occasionally,  oftener  during  expiration  than  inspiration,  three  to  six 
successive  movements  of  adduction  up  to  the  cadaveric  position  could 
be  seen  :  these  movements  not  uncommonly  also  set  in  when  the  cords 


\ 


/ 


A 


Fig.  12. 


Fig.  13. 


Fig.  14. 


Fig    11. 


Fig.  16. 


passed  from  the  position  of  phonation  to  that  of  respiration.  Schultzen 
noted  involvement  of  the  laryngeal  muscles  in  five  out  of  tw^elve  cases. 
In  one  instance  the  tremor  was  more  marked  on  the  side  corresponding 
to  the  more  affected  half  of  the  body — an  appearance  that  had  previously 
been  mentioned  by  Eosenberg.  He  therefore  considers  that  involve- 
ment of  the  muscles  of  the  larynx  in  paralysis  agitans  is  by  no  means 
rare  and  usually  presents  a  well-marked  form.  It  may  set  in  com- 
paratively early,  but  assumes  a  decided  type  only  after  the  disease  has 
been  present  for  several  years.  Bodily  w-eakness  and  excitement 
appear  to  favour  its  recurrence.  The  muscles  of  the  larynx,  as  those 
of  the  extremities,  undergo  temporary  remissions  and  exacerbations. 


168  The  Journal  of  Laryngology,  [june,  1920. 

Ataxy  of  the  cords  is  seen  especially  in  tabes.  Burger  (7)  has  pointed 
out  that  during  quiet  respiration  the  pendulum  movement  appears  to 
be  suddenlj'^  interrupted,  the  cords  go  a  short  distance  in  the  opposite 
direction  and  then  suddenly  resume  their  original  course ;  in  deep 
inspiration  or  expiration  the  cords  make  two  or  three  to-and-fro 
movements  instead  of  one  ;  and  later,  in  phonation,  the  cords  are  jerked 
together  and  afterwards  jerked  into  the  position  of  quiet  respiration, 
whereupon  some  slight  movements  follow. 

In  chorea  twitching  movements  of  the  cords  are  occasionally 
observed,  but  tremors  very  rarely. 

Continuous,  rhythmical,  involuntary  movements  of  the  vocal  cords 
have  been  noted  in  a  few  cases  of  focal  disease  of  the  central  nervous 
system.  H.  E.  Spencer  (8)  first  described  the  condition.  He  found  in 
a  girl  with  cerebral  tumour,  besides  nystagmus  of  the  eyes,  rhythmical 
twitchings  of  the  superior  constrictor  and  aryt^enoids  numbering  about 
180  per  minute,  and  interrupting  the  swing  of  the  vocal  cords  both 
during  inspiration  and  expiration.  He  termed  the  symptom  pharyngeal 
and  laryngeal  nystagmus.  In  1909  W.  G.  Porter  (9)  reported  a  case  of 
nystagmus  of  the  right  vocal  cord  and  reviewed  the  literature  on  the 
subject  up  to  date.  The  writer  refers  above  (Fig.  11)  to  a  case  of  this 
nature,  and  reports  it  more  fully  elsewhere  (10). 

Tremors  due  to  toxic  affections  of  the  nervous  system  occasionally 
involve  the  vocal  cords  ;  Krause  has  noted  these  in  chronic  lead  poison- 
ing, Kussmaul  and  Schultzen  in  mercurial  poisoning,  and  the  latter  in 
alcoholism.  Schultzen  pointed  out  in  connection  with  his  case  of 
mercurial  poisoning  that  the  tremors  of  the  muscles  of  the  larynx  did 
not  show  the  same  characters  as  the  general  tremors,  for  while  those 
produced  by  the  muscles  of  the  body  were  of  the  nature  of  intention 
tremors,  voluntary  movements  of  the  muscles  of  the  larynx  (phonation 
and  deep  inspiration)  caused  the  tremors  to  diminish  or  disappear. 

Tremors  have  also  been  produced  experimentally  by  irritating  the 
laryngeal  nerves  by  the  Faradic  current,  as  noted  in  a  patient  by 
Gerhardt  and  in  animals  by  Neumann.  Further  information  on  this 
part  of  the  subject  may  be  found  in  Schultzen's  paper. 

Eeferences. 

(1)  Semon,  F.—Proc.  Roy.  Soc.  Lond.,  1891,  xlviii,  p.  -iOS. 

(2)  ScHVhrzKN.—  CharUe-Annalen,  xix  Jahrg.,  1894,  S.  169. 

(3)  LEVBB.—DetUsch.  Arch./,  klin.  Med.,  Bd.  viii,  1871,  S.  1. 

(4)  Graeffner. — Zeiischr.f.  Laryngol.  u.  RMnoL.,  Bd.  i,  S.  167. 

(5)  MiJLLER,  ¥.—  Charite-Annalen,  "xii  Jahrg.,  1887,  S.  267. 

(6)  EosENBERG,  A.—Berl.  klin.  Wochcnschr.,  1892,  No.  31,  S.  771. 

(7)  Burger,  Schmidt  u.  Meyer. — "  Die  Krankheiten  der  oberen  Luftwege," 
4te  Aufl.,  Berlin,  1909,  S.  641. 

(8)  Spencer,  H.  U.— Lancet,  1886,  vol.  ii,  p.  702. 

(9)  Porter,  W.  G.—Zeitschr.f.  Laryngol.  u.  Rhinol.,  Bd.  i,  S.  745,  1909. 

(10)  Kelly,  A.  Brown-. — Proc.  Roy.  Sac.  Med.,  1918,  vol.  xi.  Section  of  Laryn- 
gology, p.  141. 


June.  1920.]  Rhinology,  and  Otology.  169 

THE   AQUEDUCT  OF   FALLOPIUS  AND   FACIAL   PARALYSIS. 

By  Dan  McKenzie. 

(Continued  from  2J- ^^S.) 

Part  II :   Facial   Paralysis. 

Operative  Trauma  of  the  Facial  Nerve  in  the  Temporal  Bone. 

The  frequency  of  facial  paralysis  from  this  cause  seems  to  vary 
considerably  with  different  operators,  but  it  may  be  broadly  stated  that 
it  is  much  less  commonly  inflicted  to-day  than  it  was  even  twenty  years 
ago  before  the  course  of  the  nerve  had  been  so  closely  studied  and  had 
become  so  widely  known.  And  it  is  certainly  less  frequently  seen  in 
British  than  in  Continental  clinics. 

Grunert,  writing  in  1896,  reported  9  cases  of  facial  paralysis  and 
paresis  in  309  complete  operative  exposures  of  the  middle-ear  spaces — 
that  is  to  say,  nearly  3  per  cent.  Brieger,  in  1900,  reported  9  cases  of 
facial  paralysis  in  169  radical  mastoids — that  is,  over  5  per  cent.  Stacke 
saw  3  cases  with  complete  facial  paralysis  in  100  cases. 

Modern  British  operators  have  practically  excluded  complete  facial 
paralysis  from  the  operation.  With  a  personal  experience  of  many 
radical  mastoid,  labyrinth,  and  brain  operations  I  have  not  seen  one 
case  of  complete  permanent  facial  paralysis  resulting  from  the  opera- 
tion, excluding,  of  course,  cases  which  have  proved  fatal  within  a  few 
days  of  operating. 

It  is  necessary  to  add,  however,  that  statistics  such  as  these  are 
misleading.  We  shall  see  later,  for  one  thing,  that  trifling  and  evanes- 
cent paresis  of  the  orbicularis  palpebrarum  is  commoner  than  is  generally 
supposed,  while,  for  another  thing,  complete  and  permanent  facial 
paralysis  from  operation  is  decidedly  rare  in  any  case.  Furthermore, 
before  any  weight  can  be  placed  upon  these  figures  we  must  make 
allowance  for  the  fact  that  operators  vary  considerably  in  the  view 
they  take  of  the  relative  importance  of  the  integrity  of  the  facial  nerve 
as  compared  with  the  removal  of  the  disease.  It  frequently  happens, 
especially  with  caries  in  and  about  the  sinus  tympani,  that  one  is 
tempted  to  risk  the  paralysis  in  the  effort  to  eradicate  the  disease.  In 
this  matter  each  case  can  only  be  judged  on  its  merits,  but  unnecessary 
risk  to  the  nerve  is  to  be  condemned. 

Here  we  shall  bring  together  what  our  studies  of  the  anatomy  have 
taught  us  regarding  the  position  of  the  aqueductus  Fallopii  and  its 
contained  nerve  in  relation  to  the  operative  surgery  of  the  ear  and 
temporal  bone. 

In  the  adult  the  first  skin  incision  of  the  mastoid  operations  behind 
the  ear  and  the  subsequent  clearing  of  the  mastoid  process,  whether  the 
incision  is  made  close  to  the  auricle  or  further  back  through  the  hairy 
scalp,  does  not  endanger  the  facial  nerve  in  the  soft  parts  after  its  exit 
from  the  stylo-mastoid  foramen,  as  the  incision  is  not  carried  any 
further  forward  than  the  tip  of  the  mastoid  process.  Nor,  when  this 
incision  is  prolonged  downwards  into  the  neck  in  those  rare  cases  of 
lateral  sinus  thrombosis  in  which  the  jugular  bulb  has  to  be  opened  up, 
does  it  come  anywhere  near  the  facial,  since  the  nerve  lies  anterior 
to  the  obhque  line  joining  the  post-aural  wnth  the  neck  incision  along 
the  anterior    border    of   the    sterno-mastoid  muscle — that  is   to    say. 


170  The  Journal  of  Laryngology,  [june,  1920. 

provided  that  the  operator  is  careful  not  to  carry  the  incision  joining 
the  two  skin  wounds  unduly  far  forward. 

Such  is  the  state  of  matters  in  the  adult.  In  the  infant,  on  the 
other  hand,  until  the  growth  of  the  mastoid  and  the  meatal  portions  of 
the  temporal  bone  leads  to  the  covering  in  and  protection  of  the  stylo- 
mastoid foramen — that  is  to  say,  until  the  age  of  two  years — if  the 
lower  end  of  the  post-aural  incision,  or  dissection,  be  carried  as  far 
down,  relative  to  the  pinna,  as  in  .the  adult,  then  the  nerve  will  be 
endangered  near  its  exit  from  the  foramen.  It  is  to  be  remembered  also 
that  the  tip  of  the  mastoid,  the  landmark  for  the  lower  end  of  the 
incision,  is  either  entirely  absent,  or  is  but  slightly  prominent  in  infancy 
and  early  childhood  (Figs.  28,  30,  and  the  skiagrams  of  the  infantile 
bone).  Thus  if  the  operator  relies  for  his  lower  landmark  upon  the 
feeling  of  a  bony  protuberance  or  fulness  beneath  the  pinna  at  this  age, 
he  will  be  misled,  and  may  sever  the  nerve  before  the  operation  on 
the  bone  is  begun. 

In  the  simple  Schwartze  operation  the  steps  which  involve  the  bone 
do  not  endanger  the  facial  nerve  so  long  as  we  remember  the  depth  of 
the  mastoid  (vertical)  segment  of  the  nerve,  together  with  its  position 
relative  to  the  posterior  meatal  wall.  For  this  reason,  before  opening 
the  mastoid  process,  in  clearing  the  bone  of  its  periosteum  it  is  advisable 
to  expose  and  define  as  our  landmark  the  posterior  wall  of  the  meatus 
(Dundas  Grant). 

Attention  has  already  been  drawn  to  the  need  in  this  operation  for 
care  in  curetting  forwards  towards  the  position  of  the  Fallopian  canal 
where  a  highly  cellular  mastoid  has  become  diseased  and  broken  down, 
as  the  cells  occasionally  reach  as  far  forward  as  the  vertical  segment  of 
the  canal  (see  Fig.  11).  And  this  warning  should  be  particularly 
attended  to  when  the  mastoid  disease  is  already  associated  with  facial 
paralysis,  in  which  case  disease  in  those  cells  and  in  the  bone  bordering 
upon  the  canal  may  be  the  cause  of  the  paralysis,  and  being  softened, 
will  be  easily  broken  down  with  the  curette  to  the  prejudice  of  the  nerve. 
At  the  same  time,  we  must  add  that  facial  paralysis  from  disease 
attacking  the  mastoid  segment  of  the  nerve  must  be  rare  if  we  are  to 
judge  by  the  absence  of  allusion  to  it  in  the  literature. 

That  is  to  say,  in  performing  the  simple  Schwartze  operation  the 
nerve  is,  with  even  ordinary  care,  not  exposed  to  operative  injury..  As 
a  matter  of  fact,  it  is  in  performing  the  radical  mastoid  operation  that 
danger  is  incurred. 

First,  in  penetrating  the  upper  part  of  the  mastoid  to  reach  the 
antrum,  if  the  excavation  be  made  at  too  low  a  level  and  carried  too  far 
into  the  bone,  then  the  facial  canal  may  be  opened  and  the  nerve  injured 
by  gouge,  chisel  or  burr,  in  its  vertical  segment  (c/.  Figs.  3,  4,  8).  But 
this  is  an  error  which  only  an  inexperienced  or  careless  operator  would 
commit,  and  then  only  if  the  antrum  is  small  and  highly  situated  in 
relation  to  tympanum  and  meatus. 

Secondly,  after  the  antrum  has  been  reached  and  opened  behind,  if 
the  chisel  is  too  heavily  struck  in  breaking  down  the  "  bridge,"  it  may 
be  driven  on  and  impinge  upon  the  aqueduct  in  the  tympanum  just 
above  or  lateral  to  the  oval  window,  and  cutting  through  the  papy- 
raceous bony,  sheath  of  the  nerve  at  this  spot  it  may  sever  it  entirely. 

It  is  to  prevent  this  happening  that  Stacke's  or  Grant's  probe  is 
inserted  below  the  "  bridge "  before  it  is  broken  down.  To  the 
experienced  operator,  however,  such  protectors  are  unnecessary. 


June.  1920.]  Rhinology,  and  Otology.  171 

As  a  matter  of  fact,  neither  of  these  two  accidents  is  common. 
Indeed,  many  otologists  will  go  through  a  lifetime  of  operating  and 
never  see  them.  But  there  is  a  third  way  in  which  the  nerve  may  be 
injured  and  that  is  common. 

In  the  posterior  part  of  the  tympanic  cavity,  especially  in  and 
around  the  sinus  tympanicus,  granulations  from  caries  of  the  bone 
frequently  form,  and  the  operator  is  therefore  tempted  to  curette  these 
regions,  sometimes  rather  vigorously,  with  the  result  that  the  nerve 
passing  down  close  behind  this  region  is  injured  (see  Figs.  1,  7,  11,  16, 
21  and  45). 

The  fourth  method  in  which  the  canal  is  endangered  is  when  the 
posterior  wall  of  the  bony  meatus  is  being  planed  down  with  the  chisel 


Fig.  45. — Sketch  of  the  radical  mastoid  operation  cavity  in  a  bone  operated 
on  in  life ;  viewed  from  the  front.  The  roof  of  the  cavities  has  been 
removed  for  illumination,  a.  The  mastoid  cavity,  b.  Tlie  "  facial  ridge  " 
(the  posterior  ineatal  wall  planed  down),  c.  The  floor  of  the  bony  meatus. 
D.  Aqueductus  Fallopii  opened  up  in  the  tympanum  ;  just  below  its  outer 
end  is  the  sinus  tympani.  (Right  temporal,  adult.  The  specimen  is 
tilted.) 

in  order  to  expose  the  floor  of  the  aditus  and  the  posterior  tympanic 
region  (see  Figs.  45  and  47). 

Towards  the  outer  end  of  the  meatus  the  posterior  meatal  wall  (the 
"  facial  ridge  "),  already  partly  removed  in  excavating  the  bone,  may  be 
shaved  down  to  the  level  of  the  floor  of  the  meatus,  and  if  from  this 
point  a  gradual  elevation  leading  to  the  level  of  the  floor  of  the  aditus 
be  left,  the  nerve  will  not  be  injured,  as  it  lies  lower  than  the  floor  of 
the  aditus,  descending  vertically  from  that  point  as  we  have  seen,  so 
that  the  floor  of  the  aditus  may  be  taken  as  the  limit  of  safety. 

In  thus  shaving  down  the  posterior  wall  a  practical  hint  of  Dundas 


172  The  Journal  of  Laryngology,  [june,  1920. 

Grant's  may  be  mentioned.  The  chisel  may  be  used  reversed  so  that 
the  bevel  at  its  point  t-ends  to  plane  out  of,  instead  of  into,  the  bone. 

One  occasionally  hears  it  said  that  there  is  a  "  bulge  "  or  prominence 
caused  by  the  facial  canal  in  the  lioor  of  the  aditus.  In  none  of  my 
specimens  did  I  find  any  such  prominence,  and  the  only  bulge  I  have 
encountered  in  this  neighbourhood  is  that  of  the  external  semicircular 
canal  (confirmed  by  A.  Cheatle — personal  communication). 

Hugh  Jones's  Line. — This  landmark  in  the  radical  mastoid  operation 
is  described  by  Jones  as  follows  :  "If  a  plane  be  drawn  from  the 
prominence  of  the  external  semicircular  canal  to  the  highest  point 
of  the  floor  of  the  meatus,  and  parallel  antero-posteriorly  with  the 
antro-tympanic  axis,  everything  external  to  it  may  be  freely  removed, 
while  everything  within  it  must  be  treated  with  the  greatest  respect " 
(see  Fig.  46). 

In  my  specimens  I  have  investigated  this  statement  and  it  has 
stood  the  test.  In  no  single  instance,  in  adult  bones,  did  the  facial  canal 
pass  lateral  to  the  plane  of  the  Hugh  Jones's  line.  '  Mr.  Cheatle,  with 
his  large  experience  of  temporal  bone  anatomy,  agrees  with  this  finding 
(personal  communication). 

In  the  "  bridge  operation  "  on  the  labyrinth  the  facial  nerve  is  en- 
dangered. In  this  proceeding  two  openings  are  made  into  the  labyrinth 
spaces,  the  one  into  the  external  semicircular  canal  behind  and  above 
the  aqueductus  Fallopii,  and  the  other  in  front  of  and  below  the  aque- 
duct into  the  cochlea,  the  oval  window  being  enlarged  downward  and 
forward  at  the  expense  of  the  promontory.  The  distance  between 
external  canal  and  promontory,  as  we  have  already  seen,  gives  sufficient 
room  for  the  "  bridge  "  of  bone  conveying  the  facial  nerve,  but  the 
measurements  here  are  only  by  millimetres,  and  the  fine  canal  may 
easily  be  broken  if  manipulation  is  not  very  delicate. 

Next,  in  the  operation  for  draining  the  meninges  through  the 
internal  auditory  meatus,  which  is  performed  after  labyrinthotomy,  the 
internal  auditory  meatus  is  broken  into  through  the  modiolus  (Fig.  26), 
and  in  doing  so,  unless  one  keeps  low,  and  in  the  internal  meatus  near 
the  floor  of  the  canal,  the  facial  nerve  may  be  damaged,  and  this  is  par- 
ticularly prone  to  happen  if  in  the  effort  to  ensure  an  adequate  flow  of 
cerebro-spinal  fluid  the  canal  be  too  freely  curetted. 

The  facial  nerve  is  also  exposed  to  injury  in  operations  on  the 
jugular  bulb  as  we  have  already  seen.  In  order  to  prevent  damage  to 
the  nerve  in  this  operation  Pause  recommends  that  the  Fallopian  canal 
be  opened  up  in  its  vertical  segment  and  the  nerve  removed  from  it  and 
raised  out  of  the  way  of  the  operator.  After  the  operation  the  nerve 
is  left  free,  and  although  some  paralysis  may  follow  this  manipula- 
tion it  soon  passes  olf.  This  author  states  that  the  nerve  is  very  firmly 
adherent  in  its  canal,  and  must  be  freed  from  it  with  a  knife  or  the  teno- 
tome for  the  tensor  tympani  with  the  utmost  care.  The  removal  of  the 
nerve  stops  short  at  the  pyramidal  bend  lest  stapes  or  external  semi- 
circular canal  be  injured. 

All  the  foregoing  operations  involve  an  opening  up  and  an  exposure 
through  the  bone  of  the  deeper  structures  in  the  ear,  so  that  risk  to  the 
facial  nerve  is  not  surprising.  But  it  is  the  fact,  also,  that  the  presence 
of  the  nerve,  often  insufficiently  covered  by  bone,  in  the  wall  of  the 
tympanic  cavity,  exposes  it  to  danger  even  in  simple  manipulations 


JOURNAL    OF    LARYNGOLOGY,    KHINOLOGY,    AND    OTOLOGY. 


Fig.  46. — Hugh  Jones's  line.  a.b.  Line  of  membrana  tympaui. 
CD.  Line  of  vei-tical  segment  of  the  facial  canal — the  specimen  is 
tilted  and  this  line  is  unduly  oblique,  x.x.  Hugh  Jones's  line. 
(Right  temporal,  adult.) 


To   Illustrate   Dr.  Dax   McKenzie's   paper   on   the   Aqueduct   of 
Fallopius  and   Facial   Paralysis. 


Adiard  4"  Son'ci-  Wesf  Newman,  Ltd. 


June,  1920.]  RhinologTy,  and  Otology.  173 

carried  on  through  the  external  meatus.  In  the  operation  of  ossiculec- 
tomy, for  example,  for  the  cure  of  suppuration  of  the  middle  ear,  or  for 
the  relief  of  deafness  in  chronic  adhesive  catarrh,  facial  paralysis  is 
occasionally  produced  in  the  act  of  dislocating  and  removing  the  incus. 
I  have  myself  seen  one  case,  operated  on  elsewhere,  which  had  but  par- 
tially recovered,  and  several  others  have  been  reported.  This  operation 
is,  however,  practically  obsolete  nowadays. 

Similarly,  over-persistent  efforts  at  removing  foreign  bodies  through 
the  meatus  have  induced  permanent  paralysis  by  wounding  the  Fallo- 
pian canal,  and  even  such  simple  operations  as  snaring  a  polypus  may, 
if  the  polypus  is  attached  to  the  nerve,  be  followed  by  facial  paralysis. 


Fig.  47. — The  bone  cavity  of  the  radical  mastoid  showing  the  bony  meatus, 
the  posterior  meatal  -wall,  the  antrum,  the  external  semicircular  canal, 
the  facial  canal,  and  below  it  the  oval  window.  (Left  temporal  bone, 
adult.) 

It  is  perhaps  unnecessary  to  say  that  in  the  event  of  such  a  sudden 
mishap,  the  radical  mastoid  ought  to  be  performed  at  once  and  the 
lesion  in  the  nerve  sought  for  and  remedied  if  possible  (see  later). 

Facial  Paralysis  follotving  Operation  oji  the  Gasserian  Ganglion. 

This  is  an  infrequent  complication  of  an  infrequent  operation.  It  may 
either  be  partial  or  complete,  and  is,  when  it  occurs,  "  of  uncertain 
duration."  Harvey  Gushing  has  suggested  that  it  is  not  true  para- 
lysis but  only  a  loss  of  movement  di:e  to  the  loss  of  the  muscle  sense 
which  follows  the  destruction  of  the  fifth  nerve.     But  if  this  were  the 


174  The  Journal  of  Laryngologfy,  [jane,  1920. 

cause  the  loss  of  movement  would  surely  be  constant,  not  occasional. 
Jonathan  Hutchinson,  on  the  other  hand,  thinks  that  it  is  "  due  to 
detachment  of  the  dura  mater  from  the  upper  surface  of  the  petrous 
bone,  and  hence  to  blood  getting  through  the  small  openings  leading  to 
the  aqueductus  Fallopii." 

Evidently  the  mechanism  of  its  production  is  not  quite  clear.  But 
what  probably  happens  is  that  in  detaching  the  dura  from  the  base  of 
the  skull  as  the  operator  is  making  his  way  in  towards  the  Gasserian 
ganglion  lying  in  its  fossa  in  the  front  of  the  tip  of  the  petrous,  he  drags 
upon  the  great  superficial  petrosal  nerve  with  the  dura  about  it,  and  so 
pulls  and  may  conceivably  tear  the  trunk  of  the  parent  nerve  at  the 
hiatus  Fallopii.  Indeed,  in  some  of  the  specimens  I  have  examined  it 
would  be  difficult  for  an  operator  to  reach  the  Gasserian  ganglion 
without  actually  crossing  the  geniculate  ganglion,  the  bone  over  which, 
always  thin,  is  sometimes  entirely  wanting,  and  then,  of  course,  the 
geniculate  ganglion  would  be  open  to  direct  injury. 

Diagnosis  and  Prognosis  of  Traumatic  Facial  Paralysis. 

It  is  often  possible  to  hazard  a  conjecture  as  to  the  nature  of  the 
injury  and  the  cause  of  the  paralysis  by  noting  the  time  after  the  injury 
at  which  the  paralysis  appears,  and  by  observing  also  its  manner,  and 
particularly  its  rate  of  development. 

(1)  If  the  paralysis  appears  immediately  after  the  injury  has  been 
received — whether  it  be  a  bullet-wound,  a  fractured  base,  or  an  operative 
trauma — the  presumption  is  that  the  nerve-trunk  has  been  so  gravely 
injured  at  the  moment  of  the  accident  as  to  cause  an  immediate 
interruption  of  its  conductivity,  and  the  most  usual  character  of  this 
injury  to  the  nerve  is  division  of  its  trunk.  This  is  not,  of  course,  the 
sole  lesion  which  produces  instantaneous  paralysis,  since  the  transmitted 
impulse  of  a  high-velocity  bullet  may  induce  physiological  interruption, 
as  may  also  the  displacement  of  a  fragment  of  bone  in  such  a  way  as  to 
exercise  pressure  upon  the  nerve. 

In  operating,  the  mishap  may  be  suspected  if  in  the  course  of  the 
manipulation  a  chisel,  e.  g.  in  the  vicinity  of  the  Fallopian  canal,  slips 
and  at  the  same  moment  the  side  of  the  face  as  a  whole  twitches.  As 
the  patient  is  under  a  general  aucEsthetic  it  is  impossible  to  ascertain  at 
the  moment  whether  or  not  there  is  any  paralysis.  But  if  on  recovery 
from  the  anaesthesia  complete  pai'alysis  is  present,  then  it  may  con- 
fidently be  supposed  that  the  accident  has  either .  severed  the  nerve,  or 
has  displaced  a  spicule  of  bone  upon  it  so  as  to  cause  pressure 
paralysis. 

In  this  type  of  paralysis,  howsoever  produced,  unless  it  is  possible 
by  immediate  operation  to  remove  the  cause,  if  the  cause  be  removable, 
or  unless  it  is  possible  to  clear  the  severed  ends  of  the  nerve,  and 
to  bring  them  into  permanent  contact,  the  prognosis  is  not  good. 
Experience  shows,  however,  that  it  is  not  altogether  hopeless.  A 
certain  amount  of  recovery  is  usual. 

(2)  If  at  the  outset  facial  paralysis  is  definitely  observed  to  be 
absent,  and  if  no  indication  of  any  paralysis  appears  for  from  two  to 
eight  hours  after  the  accident,  and  if  in  its  development  it  shows,  as  it 
is  likely  to  do,  a  progress  which  is  only  gradual,  then  the  likelihood  is 
that  there  has  been  contusion  with  the  formation  of  haematoma.  It  is 
also  probable,  however,  that  a  blood  extravasation  into  the  canal  may 


June,  1920.]  Rhinology,  and  Otology.  175 

take  place  so  rapidly  as  to  induce  paralysis  instantaneous  in  its  appear- 
ance, and  it  is  in  this  way  that  we  may  explain  those  cases  which 
suddenly  develop  after  some  excitement  or  violent  emotion,  such  as  fear. 

The  nerve  fills  the  canal  very  fully,  and  obviously  will  be  easily  com- 
pressed between  an  effusion  and  the  rigid  bony  walls,  and  this  factor 
must  be  largely  responsible  for  the  frequency  of  facial  paralysis. 

(3)  If  no  sign  of  paralysis  appears  until  two  or  three  days  after  the 
exposure  to  injury,  then  developing  gradually,  the  diagnosis  of  neuritis 
may  be  made,  and  complete  recovery  anticipated  in  from  three  to  six 
w^eeks.  Quite  frequently  such  cases  never  progress  beyond  the  state  of 
paresis,  and  sometimes  indeed  the  defect  of  movement  is  so  slight  that 
it  escape's  observation  (see  later).  These  trifling  cases  recover  entirely 
in  a  few  days.  I  have  recently  seen  a  case  in  which  the  paralysis 
appeared  for  the  first  time  six  weeks  after  the  operation — a  Schwartze. 

Treatment  of  Traumatic  Facial  Paralysis. 

Facial  paralysis  from  a  fractured  skull  generally  receives  no  treatment 
other  than  that  for  the  general  trauma  and  for  any  facial  paralysis,  but 
a  case  has  recently  been  reported  in  which  the  ear  was  opened  up  and 
the  nerve  successfully  relieved  of  the  pressure  of  a  fragment  of  bone 
(B.  Agazzi). 

When  the  nerve  is  divided  in  its  canal  in  a  war  injury,  the  treatment 
will  depend  upon  the  genei'al  nature  of  the  wound.  If  it  is  recent  and 
the  ends  of  the  nerve  can  be  identified  they  should  be  brought  into  con- 
tact, and  perhaps  sutured  with  very  fine  catgut  passed  through  the 
sheath  only  and  avoiding  as  far  as  possible  the  nerve-fibres.  If  the 
route  of  the  missile  can  be  followed  up  and  is  seen  not  to  traverse  the 
Fallopian  canal,  nor  to  cause  fracture  or  splintering  of  the  bone,  no 
effort  need  be  made  to  expose  the  nerve  at  least  for  several  months,  as 
the  paralysis  may  be  recovered  from  spontaneously. 

When  in  the  course  of  a  mastoid  operation  the  nerve  is  known  to  be 
or  to  have  been  divided  in  the  canal  by  the  chisel,  an  attempt 
should  be  made  to  expose  it  by  removing  the  bone  carefully  and  then  to 
bring  its  severed  ends  into  contact — a  procedure  which  has  been 
employed  by  Sydenham  with  success. 

Suturing  of  the  nerve-ends  as  they  lie  in  the*  canal  is  out  of  the 
question,  but,  on  the  other  hand,  the  canal  will  act  as  a  bridge  for  the 
support  and  guidance  of  the  sprouting  nerve-fibres,  provided  that  the 
cut  ends  of  the  nerve  be  brought  into  contact  in  the  canal.  For  this 
reason  the  operative  exposure  of  the  nerve  as  ovitlined  above  will  be 
called  for  in  order  not  only  to  ensure  that  the  ends  are  in  contact,  but 
also  to  relieve  the  nerve  from  the  pressure,  it  may  be,  of  extravasated 
blood,  or  of  spicules  of  bone.  The  site  of  the  traumatic  lesion  will 
probably  be  known  to  the  operator  if  he  has  produced  it,  and  will  be 
found  in  one  of  the  localities  we  have  just  enumerated.  Otherwise  its 
situation  may  be  gathered  from  the  type  of  paralysis  present  (see 
later). 

These  directions  do  not,  of  course,  apply  to  facial  paralysis  which 
develops  slowly  after  operation  and  is  due  to  neuritis,  etc.  Such  types 
may  be  left  to  Nature  and  asepsis. 

It  is  important  in  all  cases  to  obtain  and  to  maintain  as  complete 
asepsis  as  possible. 

[To  he  continued.) 


176  The  Journal  of  Laryngology,  [June,  1920. 


ON  EWALD'S  THEORY  RELATING  TO  THE  AMPULLOFUGAL 
AND  AMPULLOPETAL  ENDOLYMPH  CURRENTS. 

By  Dr.  A.  Ee.jto, 
Docent  of  the  Budapest  University. 

There  are  some  details  in  the  physiology  of  the  labyrinth  which  need 
revision.  Among  these  is  the  question  of  the  different  effects  of  the 
endolymph  current  in  its  different  directions. 

The  direction  of  the  endolymph  current  appears  to  be  best  indicated 
by  the  use  of  the  expressions  "  ampuUopetal "  and  "ampullofugal." 
Ampullopetal  marks  the  direction  from  the  smooth  end  of  the  semicircular 
canal  to  the  ampulla,  andampullofugal  indicates  the  direction  from  the 
ampulla  to  the  smooth  end. 

Etvald's  theory  (1),  which  has  found  its  way  into  most  text-books,  is 
commonly  accepted.  The  theory  asserts  that  in  the  horizontal  canals 
the  ampullofugal  movement  of  the  endolymph  diminishes  the  rest-tonus 
of  the  labyrinth,  and  the  ampullopetal  movement  increases  this  tonus. 

It  will  be  shown,  however,  that  this  theory  is  untenable  in  the  face 
of  facts.  The  only  way  to  solve  the  question  seems  to  be  to  consider 
the  nexus  causalis  between  the  reflex  movement  of  the  muscles  and  the 
different  directions  of  the  endolymph  current. 

There  is  no  doubt  that  the  adequate  stimuli  of  the  end-organs  of  the 
semicircular  canals  are  the  endolymph  currents.  It  is  also  sure  that 
the  directions,  the  reflex  movements  observed  in  the  muscles,  correspond 
with  the  changes  of  the  endolymph  current. 

We  know  the  cause — the  endolymph  current's  direction — and  the 
effect — the  different  reflex  movements  in  the  muscles  ;  but  to  connect 
cause  and  effect  we  must  investigate  the  piath  of  the  forces,  for  each 
movement  can  be  considered  as  an  effect  of  the  increase  of  the  forces  in 
the  acting  muscles,  or  else  as  an  effect  of  the  diminution  of  the  forces  in 
the  antagonist  muscles. 

It  would  be  difficult,  and,  indeed,  superfluous,  to'consider  how  all  the 
muscles  of  the  body  are  connected  with  the  labyrinth,  therefore  I  will 
choose  one  group  of  muscles  acting  only  in  one  plane.  The  connections 
between  the  nerves,  muscles  and  semicircular  canals  are  the  most 
developed  in  the  eye-muscles  and  the  most  simple  in  those  acting  in  the 
horizontal  plane. 

In  the  case  of  eye  movements  in  the  horizontal  plane,  four  muscles 
come  into  action,  viz.  the  two  recti  mediales  and  the  two  recti  laterales, 
E.L.s.  +  E.M.d.  —  E.M.s.  +  E.L.d. 

In  considering  the  direction  of  the  reflex  movements  of  the  eye- 
muscles  we  must  not  confound  it  with  the  direction  of  the  nystagmus, 
which  is  commonly  designated  in  accordance  with  its  quick  phasis,  for 
we  know  that  only  the  slow  phasis  of  the  nystagmus  is  the  direct  reflex 
movement  caused  by  the  endolymph  currents  in  the  canals. 

I  have  already  shown  (2)  how  illogical  is  this  custom  of  describing 
the  nystagmus  in  accordance  with  the  direction  of  the  quick  phasis  and 
the  difficulties  arising  from  the  use  of  these  terms.  I  proposed  there- 
fore to  adopt  Hogge's  terms  and  designate  the  nystagmus  according 
to  the  direction  of  the  slow  phasis.  I  am  very  glad  to  see  in  Prof. 
Barany  latest  study  (3)  that  he  uses  in  his  tabellEe  the  direction  of  the 
slow  phasis  as  well  as  the  (quick-phasis)  nystagmus. 


Jane,  1920.] 


Rhinology,  and  Otology. 


177 


In  looking  now  for  the  connections  between  the  muscles  and  the 
two  labyrinths  we  must  return  to  the  study  of  Pi'of.  Hogyes  (4),  which 
was  published  forty  years  ago.  He  proved  by  experiments  that  the 
tonus  of  the  labyrinth  does  not  diffuse  to  every  muscle  on  the  same  side 
of  the  body,  but  it  goes  partly  to  the  muscle  groups  on  the  same  side 
and  partly  to  those  on  the  other  side,  according  to  their  agonist  or 
antagonist  functions. 

With  regard  to  the  eye  muscles  K.M.  and  E.L.,  Hogyes  showed 
that  after  the  extirpation  of  the  left  labyrinth  the  action  of  the  muscles 


E.L.s.  +  R.M.d.  ceases  and  only  the  E.L.d.  +  R.M.s.  act,  the  result  of 
which  is  the  "  deviatio  diagonalis  bilateralis  dextra."  In  this  state  he 
cut  off  the  muscles  of  E.L.d.  +  E.M.s.  and  the  deviation  disappeared,  a 
fact  which  demonstrates  that  the  deviation  was  caused  by  the  coyitraction 
of  these  muscles  and  that  the  tonus  in  these  muscles  was  greater  than 
that  in  the  E.L.s.  +  E.M.d.,  and  therefore  he  concluded  that  the  latter 
receive  their  tonus  from  the  left  labyrinth.  The  diagram  published  by 
Hogyes  shows  that  the  E.L.  muscles  receive  their  tonus  from  the 
labyrinth  of  the  same  side  and  the  E.M.  muscles  from  the  labyrinth 
of  the  other  side  (see  Fig.). 

As  these  connections  are  the  fundamental  basis  of  our  argument, 
we  must  thoroughly  examine  the  objection  of  Ino  Kubo  (5),  who  is  of 

12 


178  The  Journal  of  Laryngology,  [June,  1920. 

the  opinion  that  the  eonnections  supposed  by  Hogyes  are  not  sufficient 
and  that  each  labyrinth  must  have  its  connection  with  every  muscle 
of  the  eye.  Ino  Kubo  says  :  "  If  Hogyes'  suppositions  were  right, 
then  by  stimulating  the  ampulla  of  the  horizontal  canal  after  the 
tenotomy  of  the  E.L.  muscle  of  the  same  side  and  the  E.M.  of  the 
other  side,  we  could  not  get  any  movement  of  the  eyeball.  But 
the  actual  fact  does  not  support  this  view.  As  I  have  showed,  there 
is  always  a  movement  of  the  eyeball  perceptible  so  long  as  one  of  the 
antagonist  muscles  is  still  there."' 

The  fact  on  which  Ino  Kubo  based  his  opinion  is  the  following : 
He  cut  off  all  the  muscles  of  the  eyeball  but  one  (Mm.  rect.  sup.,  obi. 
sup.,  obi.  inf.  rect.  inf.,  rect.  ext.).  The  one  remaining  R.M.  (rect. 
med.)  could  alone  produce  nystagmus.  Ino  Kubo  thinks  that  if  this 
remaining  muscle  receives  its  labyrinthal  tonus  only  from  the  opposite 
labyrinth — as  Hogyes  supposed— then  no  movement  could  arise  through 
stimulating  the  labyrinth  of  the  same  side.  Hogyes,  who  made  many 
experiments  of  this  kind,  called  our  attention  to  the  errors  occurring  in 
this  method  of  vivisection — errors  due  to  the  convulsive  twitching  of 
the  trunks  of  the  eye-muscles.  The  above-mentioned  result  of  Ino 
Kubo's  experiment  seems  to  me  to  be  caused  by  the  convulsive  twitch- 
ing of  the  trunk  of  the  E.L.,  and  therefore  I  cannot  accept  his  conclusion. 

Even  if  we  suppose  that  it  is  not  an  error,  but  there  really  exists 
a  connection  with  both  of  the  labyrinths,  Ino  Kubo's  observation 
relates  only  to  the  R.M.  innervated  by  the  third  nerve. 

With  regard  to  this  nerve,  we  know  its  nucleus  has  some  connection 
with  the  nucleus  of  the  third  nerve  on  the  other  side.  Ino  Kubo's 
observation  does  not  relate  to  the  R.L.,  which  is  innervated  by  the  sixth 
nerve — a  nerve  which  has  no  connection  with  the  other  side. 

For  the  decision  of  the  question  under  discussion  it  is  quite  enough 
to  fix  but  one  connection,  and  therefore  we  shall  principally  regard,  in 
the  following,  the  connections  of  the  R.L.  muscle  because  this  muscle 
undoubtedly  receives  its  labyrinthal  tonus  through  the  sixth  nerve  from 
the  labyrinth  of  the  same  side. 

Let  us,  for  instance,  consider  the  course  of  events  when  the  head 
is  revolved  to  the  right  in  the  horizontal  plane.  The  slow  movements 
of  the  eyes  are  directed,  during  the  revolving,  to  the  left,  and  after  the 
sudden  cessation  of  the  revolving  to  the  right.  The  cause  of  these 
reflex  slow  eye  movements  are  the  different  endolymph  currents  in  the 
canals.  During  the  revolving  to  the  right  the  endolymph  current  is  to 
the  left  in  both  hoi'izontal  canals,  which  means,  with  regard  to  their 
anatomical  position,  ampullofugal  direction  in  the  left  and  ampullopetal 
in  the  right  canal.  After  the  sudden  stopping  the  endolymph  current 
has  a  reversed  direction — that  is,  ampullopetal  in  the  left  and  ampullo- 
fugal in  the  right  canal. 

Expressing  this  succinctly  we  have — 

During  the  revolution  to  the  right  in  the  horizontal  plane : 
^j  1    -D  AT   T     f  _  (ampullofugal  in  the  .snf.  canal. 

K.lj.  Sin  +  K.M.  dext.  _  \ ampullopetal  in  the  dext.  canal. 

After  the  revolving : 

-r>  ^     ^     ^     ,    -r,  1.1-     •  ( ampuUofugal  in  the  dext.  canal. 

E.L.  dext.  -f  E.M.  sm.  =  i^^^^Hopetal  in  the  sin.  canal. 

As  the  path  of  the  forces — that  is,  the  nervous  connections  between 
the  muscles  and  the  labyrinth — has  been  determined,  we  can  easily  decide 
our  question. 


June,  1920.]  Rhinology,  and  Otology.  179 

The  B.L.  sin.  receives  its  labyrinthal  tonus  froai  the  left  labyrinth, 
and  the  R.L.  dext.  from  the  right,  and  so  we  can  conclude  that  during 
the  revolving  the  increased  tonus  of  the  B.L.  sin  arises  from  the  left 
canal  in  which  the  endolymph  current  has  an  ampullofugal  direction, 
and  that  after  the  revolving  the  increased  tonus  of  the  B.L.  dext.  arises 
from  the  right  canal  in  which  the  endolymph  current  has  also  an 
ampullofugal  direction.  In  short,  the  endolymph  current  ichich  increases 
the  rest  tonus  is  the  ampullofugal. 

The  same  result  we  can  obtain  from  Prof.  Barany's  above-quoted 
stud}-,  where  in  the  Tabell.  II.  he  says :  "  Ampullofugal  endolymph 
current  in  the  right  horizontal  canal  =  innervation  of  the  R.L.  dext.  + 
Pt.M.  sin."  It  means  also  that  the  ampullofugal  current  in  the  right 
horizontal  canal  increases  the  tonus  of  the  B.L.  dext.  (+  R.M.  sin.). 

This  conclusion  is  directly  opposite  to  the  theory  of  Ewald,  who 
supposed  that  the  ampullopetal  current  is  the  one  which  increases  the 
labyrinthal  tonus. 

To  elucidate  the  question  we  must  consider  how  Ewald,  with  his 
•classical  experiments,  arrived  at  his  conclusion. 

The  experiments  Nos.  81  and  82  form  the  basis  of  Ewald's  supposi- 
tion. Both  of  these  he  made  with  the  help  of  his  "pneumatic-hammer," 
a  tiny  instrument  which  he  fixed  on  the  head  of  a  pigeon.  With  the 
help  of  a  little  rubber  ball  the  hammer  penetrates  into  the  opening 
prepared  on  the  semicircular  canal.  The  hammer  can  also  be  drawn 
back  by  means  of  the  ball. 

In  this  way,  and  with  the  aid  of  a  little  plug  in  the  canal,  Ewald 
was  able  by  a  stroke  of  the  hammer  to  produce  an  endolymph  current 
with  an  ampullopetal  direction,  and  by  drawing  the  hammer  back  an 
ampullofugal  current. 

Whenever  he  produced  an  amjjullopetal  current  in  the  horizontal 
canal  of  one  side,  the  head  of  the  pigeon  had  a  strong  deviation  to  the 
opposite  side  ;  and  whenever  he  produced  an  ampullofugal  one,  the 
deviation  of  the  head  was  towards  the  same  side,  but  was  always  more 
limited. 

Ewald,  neglecting  the  variation  in  direction,  that  is  to  say,  the 
qualitative  differences  of  these  movements,  investigated  only  the 
quantitative  differences.  He  always  found  that  the  ampullopetal  current 
in  the  horizontal  canal  produced  a  strong  reflex  movement  and  the 
■ampullofugal  a  iceak  one,  and  as  he  could  not  explain  this  difference  in 
degree  by  the  physical  conditions,  he  supposed — without  any  further 
basis — that  the  ampullopetal  current  produces  a  strong  movement 
because  it  is  a  "■  stiynulation,"  and  the  ampullofugal  produces  a  weak 
movement  because  it  is  "  hindering." 

This  supposition  seems  to  be  only  an  attempt  to  explain  the 
■quantitative  differences,  but  is  by  no  means  the  fundamental  law  for 
which  it  is  often  accepted  in  literature. 

The  strongest  argument  against  this  opinion  is  founded  on  the 
experiment  No.  82.  Performing  the  above-mentioned  pneumatic- 
hammer  experiment  on  the  posterior-vertical  canal  of  a  pigeon,  Ewald 
observed  just  the  contrary  quantitative  relations,  accompanied  by  tiie 
same  qualitative  results. 

The  ampullofugal  current  produced  always  a  strong  movement 
towards  the  same  side,  and  the  ampullopetal,  a  iveak  one,  toioards  the 
ether  side. 

According  to  Ewald's  supposition,  in  the  posterior  canal  the  ampullo- 


180  The  Journal  of  Laryngology,  [June,  1920. 

fugal  current  is  that  which  increases  the  rest  tonus,  and  the  ampullopetal 
that  which  diminishes  this  tonus.  It  is,  however,  difficult  to  imagine 
how  the  same  endolymph  current  can  be  stimulating  for  the  one  end- 
organ  and  hindering  for  the  other. 

Considering  the  qualitative  differences  in  the  reflex  head-movements- 
dui'ing  these  experiments  with  the  pneumatic  hammer,  we  find  results 
which  do  not  conform  with  Ewald's  conclusions.  The  ampullopetal 
endolymph  current  produces  in  the  horizontal — as  well  as  in  the 
posterior — canal  always  a  head  movement  toivards  the  other  side,  and 
the  a7np2illofu<jal  current  in  both  canals  towards  the  same  side. 

We  know  from  the  expei'iments  on  rabbits,  performed  by  Dr. 
Marikovszky,  that  the  abducens,  extensor  and  pronator  muscle-groups- 
receive  their  tonus  from  the  labyrinth  of  the  same  side ;  the  adductor, 
flexor  and  supinator  groups  from  the  labyrinth  of  the  other  side. 
Ewald's  experiments  on  birds  and  frogs  confirm  the  data  obtained  by 
Marikovszky. 

The  different  directions  of  the  head-movements  of  the  pigeon  shows- 
that  the  ainp)ullofugal  current,  producing  a  movement  toivards  the  same 
side — a  movement  which  is  an  abduction  from  the  medial  plane  of  the 
body — increases  the  rest  tonus  of  the  neck  muscles  on  the  same  side, 
and  that  the  ampullopetal  current,  producing  a  movement  toicards  the 
other  side,  diminishes  the  tonus. 

It  is  the  same  result  we  obtained  when  considering  the  nexus  causalis 
in  the  case  of  the  eye  muscles  :  the  ampullofugal  current  increases  the 
labyrinth  tonus  of  the  muscles  and  not  the  ampullopetal  current  as 
Ewald  supposed. 

The  quantitative  differences  have  their  explanation  in  the  artificial 
physical  conditions.  We  must  not  forget  that  when  we  make  an 
opening  on  the  osseous  semicircular  canal  the  perilymph  pai'tly  flows  off,^ 
and  therefore  the  membranous  labyrinth  is  no  more  under  the  tension  of 
this  fluid,  which  is  well  known  to  be  greater  than  one  atmosphere. 
Consequently  we  must  reckon  with  the  elastic  co-efficient  of  the 
membranous  labyrinth. 

The  two  kinds  of  artificial  stimuli — the  one  produced  by  a  stroke 
and  the  other  by  the  withdrawal  of  the  hammer — difl'er  in  intensity. 
When  the  stroke  is  made  in  the  opening  the  endolymph  fluid  acquires 
a  positive  pushing  force  and  the  endolymph  moves  in  the  horizontal 
canal,  approximately  in  the  horizontal  plane,  towards  the  ampulla  and 
utriculus,  where  the  fluid  comes  in  contact  with  the  large  elastic 
membranous  wall  of  the  labyrinth.  When  the  hammer  is  drawn  back 
an  ampullofugal  current  is  produced  by  the  force  of  the  negative 
pressure.  It  is  clear  that  this  very  short  and  narrow  canal,  working  as 
a  suction  pipe,  cannot  produce  a  current  as  strong  as  the  one  produced 
by  the  stroke,  and  thus  in  the  horizontal  canal  the  ampullopetal  current 
is  stronger  than  the  ampullofugal. 

In  the  posterior  vertical  canal  the  anatomical  conditions  produce 
quite  the  opposite  quantitative  results.  Here  the  ampullopetal  current 
is  the  weaker,  for  when  the  stroke  of  the  hammer  falls  the  endolymph 
must  act  in  the  ampullar  end  of  the  canal  upwards,  and  so  elevate  the 
mass  of  fluid  which  the  ampulla  and  utriculus  contain.  In  drawing 
the  hammer  back  this  mass  of  fluid  acts  with  its  gravitation  foi'ce, 
pushes  back  the  endolymph,  and  thus  strengthens  the  ampullofugal 
current. 

Finally  it  must  be  borne  in  mind  that  the  endolymph  current  arising 


Jane,  1920.]  Rhinology,  and  Otology.  181 

in  the  canals  closed  with  a  plug  is  quite  different  from  the  current  which 
arises  under  normal  circumstances. 

There  are  perhaps  other  physical  details  which  elucidate  these 
■quantitative  differences  more  clearly,  but  the  above  justify  us  in 
■saying  that  the  quantitative  differences  in  these  experivients  are  only 
the  conseqxiences  of  the  artificial  arrangements — a  fact  which  Ewald 
failed  to  appreciate. 

The  question  as  to  which  of  these  two  currents  is  the  stronger 
stimulus  may  be  answered  to  the  effect  that  under  normal  cix'cum- 
stances  the  ampullofugal  current  seems  to  be  the  stronger  physiological 
stinjulus.  Here  the  mass  of  fluid  of  the  utriculus  acts  on  the  end- 
organ  of  the  ampulla  through  a  short  course. 

In  the  case  of  the  ampullopetal  current  the  fluid  has  a  longer  course, 
and  the  friction  in  the  narrow  tube  of  the  canals  weakens  the  strength 
of  the  current. 


Odessa,  1918. 


Eeferexces. 


(1)  Ewald,   E. — "  Physiologische    Untersuchungen    iiber    das    Endorgan    des 
Nervus  Octavtis,"  Wiesbaden,  1892. 

(2)  Kejto,  a. — "Uberdie  G-leichgewichtsf unction  der  Bogengauge,"  Monats.f. 
Ohren.,  1917. 

(3)  Bar.\nt,  E.— "  Theoretisches  zm-  Function  der  Bogengauge,"  Klin.  Beit,  zur 
Ohren.  (Festschrift),  1919. 

(4)  HoGTES. — "  Cber   den   Nervenmechanismus    der    associirten   Augenbewe- 
gungen,  1881,  Ubersetzt  von  M.  Sugar,"  Monats.f.  Ohren.,  1912. 

(5)  Ino  Kcbo. — "  Uber  die  vom  X.  acusticus  ausgelostem  Augenbewegungen," 
Pfliiger's  Arckiv,  1906,  Bd.  cxvii. 

(6)  Marikovszkt. — "  Orvosi  Hetilap,"  Budapest,  1903. 


SOCIETIES'     PROCEEDINGS. 


ROYAL  SOCIETY  OF  MEDICINE.— LARYNGOLOGICAL 

SECTION. 


June  7,  1918. 


President :  Dr.  A.  Brown  Kelly. 


Abridged  Report. 

Demonstration  of  Specimens  and  Cases  of  Warfare  Injuries 
of  the  Larynx. 

Epidiascope  Demonstration  of  Specimens  from  Cases  of  War- 
fare Injuries  of  the  Larynx.— W.  Douglas  Harmer.— (For  detads 
see  the  Proceedings  of  the  Rot/id  Society  of  Medicine.) 

Cases  of  Gunshot  Wound  of  Larynx  were  shown  bv  W.  Douglas 
Barmer,  Hunter  Tod,  J.  Gay  French,  W.  S.  Syme,  E.  A.  Peters,  and 
W.  Stuart-Low. 


182  The  Journal  of  Laryngology,  [june,  1920. 

Discussion  on  Warfare  Injuries  and  Neuroses  of  the  Larynx. — 
W.  Douglas  Harmer  (Abstract). — The  statements  made  are  limited  to- 
a  description  of  gunshot  wounds  of  the  larynx,  and  based  on  investiga- 
tions of  the  histories  of  245  patients.  (Group  I,  ]08  cases:  Personal 
observations  and  results  of  letters  of  inquiry  addressed  to  eighty  laryn- 
gologists.  Group  II :  110  cases  treated  in  home  hospitals,  1914-15. 
Group  III :  twenty-three  post-mortem  specimens  from  the  Royal  College 
of  Surgeons,  and  four  fatal  cases  from  notes  supplied  by  Mr.  Lawson 
WhaleO 

Wounds  of  the  larynx  are  quite  rare  compared  with  injuries  of  the 
jaw.  The  commonest  place  of  entry  is  the  anterior  triangle  of  the  neck  ; 
transverse  wounds  are  more  common  than  oblique  ;  entry  wounds  in  the 
middle  line  in  front  are  very  rare.  Injuries  of  the  larynx  between  the 
level  of  the  vocal  cords  and  cricoid  are  the  most  serious.  Tracheal 
wounds  are  rare.  The  pharynx  or  oesophagus  is  often  included.  Extra- 
laryngeal  wounds  are  very  common. 

Perforating  are  more  common  than  j^enetrating  wounds.  In  108  cases 
the  wounds  were  stated  to  have  been  caused  by  bullets  in  58,  shrapnel  in 
20,  shell  fragments  in  16,  and  by  bayonet  in  1 ;  not  stated  in  13  cases. 
Bullet  Avounds  appear  to  cause  lighter  injuries  than  ragged  fragments  of 
shell.  The  course  of  the  wounds  was  from  left  to  right  in  26  cases,  from 
right  to  left  in  18,  right  only  in  13,  left  only  in  12  ;  middle  line  5. 

There  were  many  instances  of  passage  of  bullets  through  the  neck 
without  important  injuries  resulting.  The  healing  of  wounds  in  the 
larynx  is  generally  satisfactoi'y. 

In  many  of  the  cases  the  classical  symptoms  Avere  absent.  The 
principal  occurring  were  aphonia,  haemoptysis,  haemorrhage  and  dysj^hagia. 

Injuries  to  the  framework  of  the  larynx  are  difficult  to  determine : 
when  apparently  slight  they  may  prove  serious.  Laryngeal  injuries 
comprise  those  of  the  epiglottis,  fractures  of  the  hyoid  bone  and  of  the 
cartilage.  The  larynx  is  sometimes  shot  away.  The  cricoid  may  be 
fractured  or  perforated,  with  fixation  of  the  crico-arytaenoid  joint.  Peri- 
chondritis supervenes  in  nearly  all  wounds  of  the  cartilages.  The  vocal 
cords  are  often  injured  and  the  ventricular  bands,  if  wounded,  may 
become  so  swollen  as  to  obstruct  the  lumen  of  the  larynx. 

Paralysis  of  the  vocal  cords  after  gunshot  Avounds  of  the  neck  is 
noticeable,  generally  abductor  in  type— left  abductor  more  frequently 
than  right. 

Inflammatory  stenosis  is  common  in  the  early  stages,  due  to 
inflammation  of  the  mucosa,  cedema,  abscess  or  hsematoma.  Brown 
Kelly  has  reported  a  case  of  dilated  glottis. 

Laryngeal  injuries  are  often  complicated  by  wounds  of  the  pharynx, 
fatal  in  severe  cases  ;  the  cervical  portion  of  the  oesophagus  is  often 
l^erforated ;  foreign  bodies  may  traverse  the  trachea  ;  definite  injury  to 
the  carotid  arteries  has  been  recorded  in  three  cases  ;  wounds  to  the 
large  vessels  genei-ally  terminate  fatally. 

Treatment.- — In  the  early  stages  the  patient  must  be  prevented  from 
choking.  Tracheotomy  is  necessary  in  doubtful  cases.  Nearly  one-third 
of  the  cases  reported  required  a  tube  at  some  stage.  Crico-tracheotomy 
is  inadvisable  ;  high  tracheotomy  is  less  dangerous  than  low.  Prevention 
of  sepsis  in  Avounds  is  best  treated  by  excision  of  the  lacerated  tissues. 
Suturing  together  of  air-  and  food-passages  should  be  undertaken  on  the 
lines  prescribed  for  cut  throat.  Partial  or  total  extirpation  of  a  shattered 
larynx  may  be  necessary.     Tracheotomy  may  be  necessary  for  stenosis  of 


June,  1920.]  Rhinology,  and  Otology.  183 

any  kind ;  a  method  needs  devising-  ■which  will  both  dilate  the  stricture 
and  absorb  the  scar-tissue.  Moure  has  had  good  results  with  laryngo- 
toniy  or  larvngo-tracheotomy. 

The  lumen  of  the  air-passages  must  be  kept  patent  by  bougies, 
intubation-tubes,  or  upward-turning  tracheotomy  tubes ;  the  treatment 
must  be  gi-adual,  with  small-size  stenosis  cannulse. 

Mortality. — This  is  high.  There  are  many  deaths  at  base  hospitals 
in  France  in  the  first  week  after  the  injury,  but  in  cases  that  reach 
England  the  prognosis  is  more  favourable.  There  were  only  five  deaths 
in  the  108  cases  mentioned  above.  In  thirty-two  cases  of  fatal  larynx 
wounds  the  principal  causes  of  death  were  sepsis,  pneumonia  and 
haemorrhage. 

After-results. — -In  two-thirds  of  the  gunshot  injuries  of  the  larynx 
that  survive  for  more  than  a  week  recovery  is  complete  save  for  alteration 
in  the  voice.  Out  of  108  cases  normal  voice  vras  obtained  in  17  cases, 
strong  hoarse  in  24,  weak  hoarse  in  12,  falsetto  1,  whisper  15,  dumb  1  : 
not  stated  38.  Officers  generally  obtain  a  useful  voice  more  quickly 
than  men.  Some  of  the  patients  become  neurasthenics.  Some  cases  of 
abductor  paralysis  recover.     In  a  few  total  paralysis  supervenes. 

As  a  method  of  prevention  of  these  wounds  it  is  suggested  that  a 
band  of  steel  should  be  inserted  within  the  soldier's  collar,  reaching  to 
the  jaw. 

War  Neuroses.— H.  Smurthwaite  (Abstract). — My  experience  of 
laryngeal  neuroses  has  been  gleaned  from  262  cases,  classified  as  follows : 
Absolute  mutism,  13  ;  aphonia,  239  ;  stammering  and  stuttering,  10. 
Probably  the  great  majority  of  men  who  lose  their  voice  or  speech  at  the 
front  from  shell-  or  gas-shock  have  it  restored  in  the  course  of  a  few 
days  at  a  base  hospital  by  various  methods — e.  g.  electricity — or  it  returns 
suddenly  without  any  treatment  but  rest. 

I  shall  discuss  only  those  cases  of  long  standing  in  which,  in  spite  of 
time  and  vaiious  treatment,  a  more  or  less  complete  silence  persists 
month  after  month.  In  these  functional  cases  I  find  there  are  four 
distinct  variations  in  the  position  of  the-  vocal  cords  on  attempted 
phonatiou. 

(1)  Cords  elliptical.     Thyro-arytsenoideus  internus  paresis. 

(2)  Cords  can  be  freely  abducted,  but  there  is  no  attempt  at  adduc- 
tion ;  cords  in  cadaveric  position. 

(3)  Both  true  and  false  cords  tightly  pressed  together — a  spasm  of 
adductor  and  constrictor  muscles  of  lar^Tix. 

(4)  Cords  approximate  in  anterior  |,  triangular  space  in  posterior  I, 
paresis  of  inter-arytsenoideus. 

When  there  is  no  organic  mischief  to  account  for  loss  of  voice  and 
patient  can  freely  abduct  cords,  but  on  attempting  vowel  "  a  "  or  "  e  " 
brings  cords  into  any  of  these  positions,  we  can  be  more  or  less  certain 
that  the  case  is  functional.  It  is  very  important  to  exclude  early 
tuberculosis,  causing  myopathic  paresis.  We  must  consider  position  of 
vocal  cords  for  perfect  phonation.  Phonation  and  speech  is  a  matter  of 
pressure  and  resistance  equally  balanced  at  the  site  of  vocal  cords.  False 
cords  and  ventricles  play  a  great  part  in  voice  pi'oduction.  Whilst 
examining  so  many  of  these  aphonic  cases  I  have  noted  how  very  often 
the  false  cords  are  forced  together — that  is,  they  come  very  prominently 
into  plav  as  soon  as  the  true  cords  offer  excessive  resistance  to  the 
upward  pressure  of  air. 


184  The  Journal  of  Laryngology,  [June,  1920. 

yEtiology. — Purely  psychic.  We  have  to  appreciate  the  influence  of 
mind  on  the  various  bodily  functions —  how  feelings  act  upon  the  body 
causing  different  functional  troubles — emotional  fatigue,  fear,  etc.  Mental 
and  physical  over-exertion  prepares  a  soil  in  these  patients  for  the  final 
shock  producing  fright  and  anxiety — an  emotional  neurosis  in  form  of 
aphonia,  etc. 

Treatment. — (1)  Moral  in  form  of  persuasion  and  suggestion  ;  (2) 
Physical. 

The  moral  is  much  the  more  important.  The  patient  has  lost  his 
will-power  and  confidence,  which  we  must  restore  by  force  of  our  own 
energy  and  influence.  We  are  dealing  with  a  malady  of  psychic  origin, 
and  must  therefore  use  psycho-therapy  for  treatment.  The  patient  is 
lacking  in  the  power  to  make  an  initiatory  effort  to  bring  the  cords  into 
the  proper  position,  or  the  necessary  expiratory  blast  for  voice-production. 
We  instil  that  necessary  power  into  him.  The  moral  effect  of  one  cure 
is  a  great  helj)  in  our  efforts  in  subsequent  cases,  therefore  the  "  cured  " 
should  speak  to  other  patients  waiting  their  turn  for  treatment. 

Physical :  Physically  we  are  dealing  with  two  classes  of  cases  :  (1) 
Those  in  which  there  is  lack  of  sufiicient  obstructive  pressure  to  the 
expiratory  blast;  (2)  those  in  which  the  obstruction  is  excessive  and  the 
expiratory  blast  not  powerful  enough.  Without  exception  they  all  breathe 
shallowly.  They  never  seem  to  fill  their  lungs  with  air  preparatory  to 
phonation.  Some  of  them  attempt  to  phonate  during  air  intake,  especially 
men  who  stammer.  These  faults  we  have  to  correct.  I  make  the  patient 
expand  his  chest  two  or  three  times  by  deep  breathing.  Then  when  he 
is  able  to  breathe  deeply  I  tell  him  to  hold  the  breath  at  the  full  expansion 
of  the  lungs  and  make  a  quick  expiratory  effort  or  cough.  As  a  rule  we 
can  elicit  quite  a  good  note  by  this  simple  method,  and  this  fact  is 
pointed  out  to  the  patient.  The  simplest  class  of  case  belongs  to  (1)  and 
(2).  (1)  Where  the  cords  ai-e  in  the  elliptical  position,  that  is  lack  of 
tension  ;  or  (2)  in  the  cadaveric — that  is,  no  semblance  of  adduction  on 
attempted  phonation.  Often  in  these,  the  act  of  laryngeal  examination, 
the  tongue  being  forcibly  pulled  out  and  the  patient  told  to  say  "  ah,"  is 
sufiicient.  Here  we  have  both  a  suggestive  and  a  physical  foi'ce  acting. 
We  have  pi-epared  the  patient's  mind  previously  for  a  cure,  we  now 
suggest  a  vocal  sound.  The  physical  force  is  an  increased  tension  on  the 
cords  through  reflex  action  from  touching  the  pharynx ;  and  also  the 
pull  on  the  tongue,  pulling  on  the  epiglottis  tends  to  help  the  tension  of 
the  cords.  But  all  are  not  so  simple  as  this,  and  we  have  to  resort  to 
various  methods.  In  the  most  obstinate  cases  where  there  is  an  increased 
tension,  strain  or  tonic  spasm,  we  have  to  overcome  this  by  either  in- 
creasing the  upward  pressure  of  air,  or  in  some  way  making  the  patient 
relax  the  cords.  In  many  of  these  cases  I  vary  my  way  of  dealing  with 
the  patient.  Often  I  speak  most  harshly  to  him,  and  in  some  almost 
brutally,  but  it  has  its  effect.  I  make  the  patient  carry  out  the  most 
strenuous  expiratory  effort,  and  to  assist  him  in  this  I  place  my  hands 
round  the  lower  ribs,  the  thumbs  pressing  just  below  the  xiphoid  cartilage, 
and  use  pressure,  directing  him  to  use  his  abdominal  muscles  forcibly  to 
phonate  the  sound  "ah."  This  effort  is  first  in  the  form  of  coughing, 
and  by  degrees  he  takes  up  my  suggestion  of  the  sound  "  oh  "  or  "  ah." 
As  soon  as  I  get,  by  this  method,  the  slightest  semblance  of  a  musical 
sound  he  must  replace  the  "  oh  "  by  a  numeral,  proceeding  up  to  twenty, 
still  employing  the  expiratory  cough  effort,  and  gradually  he  phonates 
the  numbers  without  the  cough ;  that  is  gradually  lessening  the  expiratory 


June,  1920.]  Rhmology,  and  Otology.  185 

effort.  Faradism  is  worse  than  useless  in  these  obstinate  spasmodic 
cases.  Numbers  of  such  have  been  sent  to  me  aphonic  for  many  months, 
and  have  had  prolonged  internal  and  external  lai-yngeal  faradisation,  yet 
without  result.  I  have  never  yet  resorted  to  this  form  of  treatment.  It 
may  act  successfully  in  early  cases  of  Class  1  or  2,  and  probably  in 
malingerers. 

With  regard  to  ether  anaesthesia  in  the  hope  that  the  patient  will 
speak  normally  on  coming  out,  I  have  only  once  adopted  this  method, 
but  without  success.  I  much  prefer  to  rely  on  the  moral  effect  my  words 
will  have  on  the  patient ;  not  to  mention  the  time  and  preparation  a 
procedtu-e  of  anaesthesia  would  take  in  such  large  numbers  of  cases. 

The  i-esults  are  as  follows :  Of  thirteen  dumb  cases  all  regained 
normal  speech  except  two.  One  who  had  been  dumb  for  two  years  now 
speaks  in  a  loud  whisper.  The  other  speaks,  but  in  a  very  weak  and 
hesitating  voice— though  improved,  he  is  still  a  physical  and  mental 
wreck.  Of  the  239  aphonic  cases,  all  recovered  except  eleven.  The 
majority  at  one  sitting ;  iu  the  remainder  treatment  had  to  be  prolonged 
for  one  or  two  days.  Occasionally  I  find  that  a  case  having  recovered 
his  voice  under  treatment  at  the  out-patient  department  becomes  again 
aphonic  after  returning  to  his  unit  the  following  day  or  a  few  days  later. 
To  guard  against  this  I  make  the  patient  carry  out  vocal  exercises  before 
me  and  direct  him  to  continue  them  after  leaving,  until  he  gets  complete 
confidence  in  his  voice.  He  must  draw  his  tongue  out  forcibly  himself 
and  practise  the  sound  "  ah."  He  also  must  go  through  a  course  of 
deep  breathing  and  humming  a  tone.  Having  once  regained  his  voice 
he  is  thus  able  to  maintain  it  by  practising  the  natural  vibration  of  the 
vocal  cords. 

Considering  most  of  these  cases  had  only  spoken  in  a  whisper  for 
many  months,  the  cords,  or  rather  their  muscles,  require  a  proper 
exercise  so  as  to  increase  their  tonicity,  and  maintain  them  in  a  natural 
position  for  vibration.  By  humming  a  tone  we  get  a  musical  sound 
with  least  effort.  There  is  no  spasm  in  the  mouth,  pharyngeal,  or  laryn- 
geal muscles.  The  cords  are  quietly  approximated  and  a  continuous  and 
uniform  pi*essure  of  expiratory  air  keeps  them  in  vibration.  Having  got 
the  patient  to  fix  the  sound  in  the  mouth  and  nasal  cavities  by  this 
humming  practice,  I  next  direct  him  to  let  go  the  pressure  at  the  lips 
and  sound  the  vowels  "ah"  or  "oh,"  thus  making  it  "  ma  "  or  "  mo." 
Having  succeeded  in  this  he  next  phonates  "  ah  "  without  the  preparatory 
humming.  I  next  direct  him  to  count,  phonating  each  note  slowly, 
holding  the  note  so  as  to  keep  the  cords  in  natural  vibration — the 
exercises  which  they  require.  Having  counted  up  to  twenty  he  has  got 
more  or  less  confidence  in  his  power,  and  I  then  make  him  read  aloud. 

Dr.  Permewan  :  As  regards  shock,  I  am  inclined  to  think  that  there 
must  be  some  real  injury  to  the  nerve — e.  g.  haemorrhage  into  the  sheath — 
in  all  cases  where  there  is  organic  paralysis. 

Dr.  Smurthwaite  has  been  successful  in  treating  functional  aphonia 
in  soldiers.  My  own  experience  has  been  by  no  means  so  favourable ; 
but  probably  his  treatment  has  been  more  determined  than  mine.  Sir 
William  Milligan  tells  me  he  puts  these  patients  under  light  anaesthesia, 
provokes  a  sound  by  the  introduction  of  a  direct  laryngoscope,  and  that 
the  voice  often  comes  back  when  the  patient  has  recovered.  Has  Dr. 
Smurthwaite  any  experience  of  that  method  F  Many  of  these  cases 
suffer  from  other  nervous  symptoms  as  well  as  the  aphonia,  and  their 
■cure  is  more  in  the  sphere  of  the  neurologist  than  the  laryngologist.      In 


186  The  Journal  of  Laryngology.  [june,  1920. 

any  case  a  serious  attempt  should  be  made  to  cure  these  very  numerous 
cases,  and  in  particular  they  should  not  be  aggregated  together  in 
numbers  in  one  hospital,  or  they  react  on  one  another. 

Dr.  E.  A.  Peters:  I  showed  here  to-day  two  cases  illustrating  a 
method  of  treating  laryngeal  stenosis  in  gunshot  wounds  of  the  larynx. 
The  obstruction  of  the  larynx  is  due  to:  (1)  Solid  oedema  resulting 
from  vasomotor  change  and  inflammation ;  (2)  it  may  also  be  due  to 
secondary  cicatricial  change.  A  Durham  tracheotomy  tube  is  inserted 
into  the  trachea,  and  a  small  intubation  tube  is  placed  above  that,  with 
the  expanded  end  below.  The  intubation  tube  is  secured  by  a  thread 
passed  I'ound  the  neck.  The  tube,  in  the  first  instance,  did  not  reach  as  far 
as  the  interarytsenoideus :  the  glottis  is  so  tense  that  it  splits  if  even  a 
small  tube  is  passed  through.  So  a  shorter  tube  was  used,  and  tubes  of 
larger  calibre  were  gradually  introduced.  There  was  no  attempt  made 
to  dilate  the  larynx,  but  to  keep  a  certain  amount  of  opening  and 
induce  functional  activity.  This  was  further  encouraged  by  inserting, 
later,  a  Parker's  tube  with  an  upper  2>erf oration  above.  Later  cicatricial 
stenosis  of  the  cricoid  was  treated  by  introducing  a  piece  of  cartilage 
from  the  rib,  inserted  under  a  quadrilateral  flap.  This  cartilage 
provided  a  basis  for  the  contracting  material  to  adhere.  In  this  way 
a  fairly  good  result  was  obtained^  although,  as  Sir  StClair  Thomson 
pointed  out,  in  one  case  there  was  very  considerable  contracting  of  the 
glottis,  but  that  was  recent,  and  was  due  to  the  case  having  been  pushed 
rather  rapidly  through  these  stages. 

Mr.  J.  F.  O'Mallet  :  In  cases  of  unilateral  paralysis  of  the  coi'd  I 
think  there  must  be  a  physical  injury  of  some  some  sort  when  the  nerve 
is  involved.  The  possibility  of  a  shock  remote  from  the  nerve,  such  as 
wind  pressui'e,  causing  injury,  is  of  interest,  but  I  do  not  subscribe  to 
that  opinion.  Nearly  three  years  ago  I  wrote  a  short  article  on  the 
subject,  in  which  the  views  I  put  forward  were  largely  those  given  by 
Dr.  Smurthwaite  now.  I  was  interested  in  the  point  Dr.  Smurthwaite 
made  about  the  ventricle,  because  I  noted  in  many  of  the  cases  that 
when  the  patient  attempted  to  phonate,  the  true  cords  came  together 
with  sufiicient  firmness  to  give  a  phonatory  effect  with  the  expiratoxy 
blast,  but  it  seemed  to  be  damped  down  by  the  approximation  at  the 
same  time  of  the  false  vocal  cords.  My  idea  was  that  it  was  a  chronic 
inflammatory  thickening  of  the  false  vocal  cords.  I  think  they  are  in  the 
nature  of  chronic  laryngeal  cases,  rather  than  of  pure  neurosis. 

With  regard  to  treatment,  the  whole  key  to  the  treatment  of  a  pure 
case  of  neurosis  of  the  larynx  is  that  the  surgeon  should  act  the  part  of 
the  will-power  of  the  patient.  One  should  adopt  a  method  to  cause  the 
patient  to  approximate  the  vocal  cords  and  keep  them  in  that  position 
while  the  expiratory  air  passes  through.  If  sound  can  be  procured  in 
that  way,  it  will  be  a  basis  on  Avhich  to  tell  the  patient  he  can  be  cured. 
The  simplest  method  is  to  hold  the  tongue  as  when  examining  in  the 
ordinary  way,  and  with  the  pharyngeal  mirror  rubbing  up  and  down  on 
the  phaiyngeal  wall,  so  producing  considerable  glandular  seci'etion,  which 
drops  into  the  larynx,  causing  a  protective  reflex,  which  keeps  the  cords 
together.  If  at  the  same  time  the  patient  is  told  to  cough  and  finish 
the  coughing  effort  with  the  "  ee  "  sound,  phonation  will  probably  be 
induced.  A  pure  neurosis  case  can  be  cured  in  that  way  inside  three 
minutes,  but  not  a  chronic  case  with  an  associated  catarrhal  condition. 

{To  be  continued.) 


June,  1920.]  Rhinology,  and  OtoIo§ry.  187 

ABSTRACTS. 

Abstracts  Editor — "W.  Douglas  Harmek,  9,  Park  Crescent,  London,  "W.  1. 

Authors  of  Original  Communications  on  Oto-laryngology  in  other  Journals 
are  invited  to  send  a  copy,  or  two  reprints,  to  the  Journal  of  Laetngologt. 
If  they  are  ^villing,  at  the  same  time,  to  submit  their  oivn  abstract  {in  English, 
French,  Italian  or  German)  it  will  be  welcomed. 


TONSILS. 

Bacillus  Tuberculosis  in  the  Tonsils  of  Children  Clinically  Non-tuber- 
culous.— R.  S.  Austin.  '"Aiuer.  Jouru.  Dis.  Child.,"  vol.  xviii, 
No.  1,  July,  1919. 

This  paper  gives  the  resi;lts  of  a  very  extensive  investigation  of  the 
excised  tonsils  from  forty-five  children  for  the  presence  of  tuberculosis, 
using  a  special  inoculation  test,  and  also  making  use  of  histological 
examination  of  sections  of  cultures  in  Dorset  egg-medium  and  direct 
smears.  In  all  cases  the  histological  examinations  showed  no  evidence 
of  tuberculosis,  and  no  tubercle  bacilli  were  demonstrated  in  any  of  the 
cultures  or  direct  smears. 

Fifteen  of  the  children  were  from  two.  and  a-half  to  five  years  of  age, 
and  thirty  from  five  to  twelve  years  of  age.  All  were  fairly  well  developed 
and  nourished.  A  family  history  of  tuberculosis  existed  in  two  cases, 
Avhile  the  personal  history  of  all  the  cases  did  not  recoi'd  any  evidence  of 
tuberculosis,  past  or  present.  The  cervical  glands  were  enlarged  in  twenty- 
one  cases,  but  not  in  any  marked  degree  or  in  any  way  suggestive  of 
tuberculosis.     Physical  examination  for  tuberculosis  was  negative. 

The  inoculation  test  yielded  a  positive  result  in  only  one  of  the  forty- 
five  cases.  No  evidence  in  this  case  of  any  past  history  of  tubercle  was 
obtained  ;  a  von  Pirquet  test  had  been  negative,  but  a  history  of  otitis  was 
admitted  (no  mention  is  made  as  to  otitis  being  suppui-ative).  Guinea-pig 
inoculations  after  the  method  of  the  British  Commission  were  used. 

The  author  offers  an  explanation  as  to  the  differences  between  his 
results  and  those  of  Mitchell  on  tuberculosis  associated  with  the  milk 
supply  of  Edinburgh.  The  children  of  the  author's  series  came  from  a 
community  where  the  supply  of  cow's  milk  is  far  less  likely  to  be  con- 
taminated with  the  tubercle  bacillus. 

The  author  considers  that  although  tuberculosis  of  the  tonsils  in 
children  is  not  rare,  yet  most  of  the  cases  occur  when  there  are  tuberculous 
lesions  to  be  found  elsewhere  in  the  body,  especially  in  the  cervical  lymph- 
glands.  The  occurrence  of  the  bacillus  in  the  tonsils  of  chikh'en  without 
clinical  evidence  of  tuberculosis,  however,  is  not  frequent. 

Perry  Goldsmith. 

Mechanical  and  Physiological  Considerations  in  Tonsillectomy. — H.  C. 
Masland  (Philadelphia).  "New  York  Med.  Journ.,"  August  16, 
1919. 

The  author  points  out  that  with  the  accumulated  wealth  of  data 
regarding  the  results  following  complete  tonsil  enucleation,  there  has 
followed  a  reaction  by  which  too  energetic  surgery  in  this  region  is  meeting 
with  considerable  criticism. 


188  The  lournal  of  Laryngology,  [June,  1920. 

In  the  author's  experience  only  2  per  cent,  of  cases  are  free  from 
deformities  of  the  palate  or  pillars.  He  agrees  that  while  a  very  large 
proportion  of  cases  are  relieved  of  the  condition  for  which  they  were 
subjected  to  operation,  there  exists  still  a  goodly  number  of  patients  who 
complain  of  various  discomforts  in  the  thi'oat  and  adjacent  areas  which 
they  attribute  to  the  operation,  or  to  defects  of  the  speaking  or  singing 
voice. 

In  considering  the  mechano-physiological  formation  of  the  fauces,  he 
says  that  the  tonsil  swings  as  an  elastic  bumper  between  the  two  pillar 
muscles,  and  by  virtue  of  its  looser  attachment  to  the  superior  constrictor 
permits  an  accommodation  between  these  muscles  necessary  in  their 
varying  contractions.  All  tonsils  have  crypts,  and  these  crypts  constantly 
show  the  presence  of  micro-organisms,  since  the  tonsil  is  the  most 
exposed  of  all  lymphatic  glands,  and  thereby  more  constantly  liable  to 
infection.  Unless  the  tonsil  has  a  neutralising  and  destructive  effect 
upon  the  ever-present  organisms  the  throat  would  never  be  free  from 
disease.  When  the  crypts  become  diseased  their  function  is  lessened 
and  infection  occurs.  Then  it  is  that  operative  measures  are  to  be 
considered. 

The  author  advocates  the  retention  of  a  shallow  layer  of  tonsil  with 
the  capsule.  Some  crypts  remain,  but  they  are  shallow,  and  usually 
return  to  health ;  but  if  this  does  not  follow  a  wedge-shaped  piece 
removed  from  their  length  will  be  sufficient.  The  absence  of  scar-tissue 
greatly  enhances  the  operative  results.  The  paper  is  a  plea  for  the 
skilful  removal  of  the  major  portion  of  the  tonsil  in  most  cases  and  the 
removal  of  the  tonsil  and  capsule  in  a  small  minority. 

Perry  Goldsmith. 

Anterior  Dislocatiou  of  Atlas  following  Tonsillectomy. — Harold  Swan- 
berg.  •' Journ.  Amer.  Med.  Assoc,"  vol.  Ixxii,  ISTo.  2,  Jauuarv  11, 
1919. 

A  private  soldier,  in  civil  life  a  farmer  with  negative  family  and  past 
history,  was  admitted  to  an  American  base  hospital  suffering  from  measles 
and  acute  tonsillitis.  Tonsillectomy  was  performed  a  month  later,  and 
the  same  evening  the  neck  became  stiff  and  remained  so  ever  since. 
Five  months  later,  at  another  hospital,  X  ray  showed  osteo-arthritis  of 
the  first  and  second  cervical  vertebrae.  Fragments  of  tonsils  remained, 
and  these  with  some  septic  teeth  were  removed.  At  another  base 
hospital  from  which  the  case  is  recorded  he  was  found  to  still  have  a 
stiff  neck.  All  motions  restricted,  no  ability  to  rotate  the  head,  and 
pain  in  the  cervical  muscles  with  headache. 

Further  X-ray  findings  were  found  very  interesting.  There  was 
a  simple  complete  anterior  dislocation  of  the  atlas  and  skull  on  the 
axis  (epistropheus),  unaccompanied  by  fracture,  yet  with  no  symptoms 
of  pressure  on  the  spinal  cord.  No  evidence  of  any  osteo-arthritis  was 
found.  Palpation  of  the  naso-pharynx  revealed  a  large,  rounded  bony 
mass  occupying  a  lai'ge  part  of  the  cavity.  Attempts  under  general 
antesthesia  to  reduce  the  dislocation  failed  and  the  patient  declined 
further  treatment. 

Careful  investigation  of  the  history  and  details  of  the  first  operation, 
which  was  with  local  ansesthesia,  points  to  the  condition  not  having 
resulted  from  trauma.  This  case  illustrates  the  diagnostic  errors  following 
incorrect  histories,  and  the  care  one  should  take  in  the  interpretation  of 
an  X-ray  plate.  Perry  Goldsmith. 


June,  1920.]  RhinoIogTy,  and  Otology.  189 

Some  Clinical  Observations  on  the  Lingual  Tonsil  concerning  Goitre, 
Glossodynia  and  Focal  Infections. — Greenfield  Sluder  (St.  Louis). 
"Amer.  Jouru.  Med.  Sci.'" 

Acute  inflammation' of  the  lingual  tonsil  is  a  frequent  accompaniment 
of  acute  follicular  faueial  tonsillitis  in  both  old  and  young.  It  is  fre- 
quently overlooked,  chiefly  due  to  the  non-use  of  the  laryngeal  mirror.  It 
may  replace  the  acute  faueial  tonsillitis  in  cases  when  the  palatine  tonsils 
have  been  enucleated,  but  is  liable  to  be  less  frequently  recurrent. 
Lingual  quinsy  is  rare. 

The  evidence  of  the  acute  lesion  is  striking — e.g.  dysphagia,  fever, 
redness  and  swelling  of  the  mass  at  the  base  of  the  tongue,  with  or  with- 
out white  or  yellow  spots  marking  the  openings  of  the  follicles.  In 
chronic  cases  the  sensation  of  mucus  which  cannot  be  removed  is 
frequently  referred  to  the  naso-pharynx  or  lai-ynx — the  latter  more  fre- 
quently. In  acute  cases  pain  may  be  referred  to  the  ear,  while  in  chronic 
cases  a  feeling  of  stiffness  is  often  present  on  swallowing.  Sluder  has 
never  found  a  "gouty"  throat  with  a  normal  lingual  tonsil.  A  sensa- 
tion of  foreign  body,  falling  of  the  palate  or  long  uvula  are  frequently- 
described.  Lingual  varix  with  bleeding,  cough,  and  at  times  suffoca- 
tive symptoms  may  be  induced.  Difficulty  with  the  singing  voice  is 
more  often  due  to  the  lingual  than  the  faueial  tonsil.  As  a  focus  of 
infection  it  is  quite  as  important  as  the  palatine  tonsil,  and  may  even 
keep  up  a  rheumatic  infection  after  the  faueial  tonsils  have  been 
removed. 

The  author  is  convinced  that  thyroid  enlargement  is  a  frequent 
association  with  lingual  inflammation,  and  cites  a  case  in  his  own  family 
in  which  the  connection  seemed  very  definite,  the  thyroid  behaving  like 
the  cervical  glands  in  acute  faueial  infection.  Experiments  with  coloured 
pigments  and  injections  in  the  lingual  region  did  not  show  the  presence 
of  these  substances  in  any  thyroid  removed  two  weeks  later. 

Measures  directed  to  the  lingual  tonsil  have,  in  the  author's 
experience,  materially  benefited  some  cases  of  goitre  and  hyperthyroidism. 
In  the  treatment  of  the  acute  and  chronic  inflammation  of  the  lingual 
tonsil  nothing  has  been  found  as  satisfactory  as  applications  of  a  small 
amount  of  silver  nitrate  saturated  in  50  per  cent,  glycerine.  Salicvlic 
acid  and  alcohol  is  useful  but  not  so  efficacious.  The  applications  are 
made  daily,  or  less  often  as  required.  For  definite  enlargement  the 
galvano-cautery  or  the  guillotine  are  generally  required.  Haemorrhage, 
while  rare,  is  very  difficult  to  control.  Perry  Goldsmith. 


EAR. 

A  Study  of  the  Aural  Complications  of  the  Recent  Influenza  Epidemic 
with  Special  Reference  to  the  Clinical  Picture. — Frederick  T.  Hall. 
"The  Laryngoscope,"  June,  1919,  p.  351. 

Out  of  a  series  of  6870  cases  of  influenza  at  the  U.S.A.  General 
Hospital  No.  14,  there  were  only  120  cases  of  acute  suppurative  otitis 
media.  There  were  1600  cases  of  pneumonia  in  this  series  and  QQ  of  the 
cases  of  otitis  media  occurred  among  these.  Of  the  120  cases,  17  were 
bilateral,  21  cases  developed  "mastoids,"  1  case  developed  otitic 
meningitis  and  died.  In  practically  every  case  the  type  ran  true  to  form. 
The  onset  was  quite  sudden,  generally  occun'ing  on  from  the  first  to  the 
third  day  of  the  disease.     The  first  symptoms  were  intense  pain,  some- 


190  The  Journal  of  Laryngology,  [June,  1920. 

times  preceded  by  a  feeling  of  fulness.  The  headache  and  malaise  must 
be  attributed  to  the  general  effect  of  the  influenza,  and  the  temperature, 
which  ran  from  101°  to  104°  F.,must  be  considered  in  the  same  way.  (Otitis 
media  in  non-influenza  cases  ran  a  normal  temperature.)  Otoscopic 
examination  within  two  or  three  hours  after  the  onset  of  pain  shows 
vesicles  on  the  membrana  tympani.  In  almost  every  case  there  was 
marked  redness  and  some  bulging  of  Shrapnell's  membrane  (sic)  The 
superior  postei'ior  quadrant  showed  the  greatest  change  and  there  was 
frequently  a  large  haemorrhagic  bleb  bulging  outward.  Often  there  were 
two  or  three  of  these  blebs,  always  superior,  either  anteriorly  or  posteriorly, 
and  often  extending  to  the  wall  of  the  external  auditoiy  meatus.  There 
was  no  tenderness  over  the  mastoid  process  at  this  stage.  Incision  of  the 
blebs  evacuated  a  small  amount  of  bloody  serum.  In  the  older  cases  this 
could  be  expressed  from  the  vesicles  only  with  some  effort,  as  if  some 
slotting  or  organisation  was  taking  place.  In  one  case  the  bleb  became 
a  pedunculated  sac  of  considerable  length  but  narrow  pedicle.  This  was 
removed  and  gave  the  microscopic  appearance  of  mucous  membrane. 
Incision  of  the  membrana  tympani  in  the  earlier  cases  was  followed  by 
considerable  bleeding.  Later  this  became  a  profuse  sero-sanguineous 
discharge.  Pain  generally  subsided  about  two  hours  after  the  incision. 
The  sero-sanguineous  discharge  continued  profusely  for  several  days  and 
then  gradually  changed  to  a  thin  purulent  discharge  which  later  became 
of  thicker  consistency.  Nose  and  throat  examination  showed  congestion 
of  the  mucous  membrane  with  purulent  secretion  and  acute  pLaryngitis. 
Epistaxis  was  a  fairly  frequent  incident.  Occasionally  there  was  laryngeal 
involvement.     Two  cases  showed  haemorrhagic  vesicles  on  the  true  cords. 

In  other  cases,  in  from  ten  to  twelve  days  from  the  onset,  the  whole 
superior  canal  wall  became  flattened.  Usually  there  was  no  mastoid 
tenderness  or  oedema.  Hitherto  the  flattened  superior  canal  wall  has 
been  considered  one  of  the  most  reliable  signs  of  a  suppurative  mas- 
toiditis and  frequently  an  indication  for  operation.  Hill  found  the 
reverse  to  be  true,  both  by  clinical  observation.  X-ray  of  the  mastoid, 
and  also  by  operation. 

Cultures  upon  blood-agar  showed  streptococci  in  practically  every  case. 
Occasionally  an  admixture  of  staphylococci  was  also  found. 

Even  after  the  membrana  tympani  had  regained  almost  normal 
appearance  and  colour  a  certain  pei'centage  had  increase  in  the  discharge 
with  thickening  of  the  mastoid  periosteum,  slight  tenderness  and  oedema 
over  the  tip.  Of  the  twenty-one  cases  which  came  to  mastoid  operation 
one  showed  a  normal  mastoid,  two  simply  a  congestion  of  the  mucous 
membrane  of  the  cells  ;  the  rest  showed  a  haemorrhagic  cortex  and  more 
or  less  free  pus  in  the  cells.  The  bone  was  not  broken  down.  One  of 
the  cases  with  erosion  of  the  tegmen  developed  leptomeningitis  and  died. 
This  was  complicated  by  a  severe  pneumonic  process  involving  both 
lungs.  Many  cases  which  showed  a  flattened  superior  canal  wall  and  a 
cloudy  X-rav  of  the  mastoid  cleared  up  without  operation. 

/.  S.  Fraser. 

Severe  and  Uncontrollable  Haemorrhage  Following  Mastoidectomy  in  a 
Patient  Suifering  fi^om  Purpura.— Thos.  J.  Harris  (New  York). 
"  New  York  Med.  Jouru.,"  August  23,  1919 

The  patient  had  bilateral  acute  middle-ear  suppuration,  for  which  the 
membrane  was  incised  early.  There  was  a  family  history  of  haemophilia 
-and  a  personal  history  of  recent  arthritis  and  numerous  subcutaneous 


jnne,  1920.]  Rhinolog'/,  and  Otology.  191 

bleeding  areas.  Every  effort  was  made  to  avoid  operative  interference 
on  the  mastoid,  but  it  was  eventually  unavoidable.  The  pre-operative 
state  was  associated  with  chills,  fever  102°  ¥.,  nausea,  bleeding  from  the 
gums  and  pain,  with  swelling  at  the  tip  suggesting  Bezold's  mastoiditis. 
Operation  followed  transfusion,  which  was  repeated  the  following  day. 
There  was  no  unusual  bleeding  during  the  operation,  but  subsequently 
oozing  from  the  wound  followed,  wdiich  was  controlled  by  5  per  cent, 
coagulen  ciba.  Cousidei'able  bleeding  occurred  during  the  next  few  days, 
which,  not  being  controlled  by  packing,  necessitated  suturing  the  wound, 
which  accomplished  the  desired  result.  Even  the  transfusion  wound 
bled  as  late  as  a  week  following  the  operation.  The  bleeding  continued 
at  intervals  for  seventeen  days,  when  it  finally  stopped  and  the  Avound 
looked  normal.  The  subsequent  history  of  the  case  was  one  of  slow^  but 
<3om2)lete  recovery.  He  was  discharged  from  the  Army,  but  died  shortly 
after  returning  to  civil  life.  This  last  illness  was  brief  and  not  accom- 
panied by  bleeding. 

A  consideration  of  the  chief  distinguishing  features  between  haemo- 
philia and  purpura  follows.  In  the  former  there  is  added  to  the  element 
■of  heredity  a  deficiency  in  one  or  more  of  the  clotting  properties  of  the 
blood  which  results  in  prolonged  coagulation-time,  which  in  the  latter, 
representing  many  different  conditions,  is  associated  with  a  deficiency  of  the 
blood-platelets,  and  is  often  combined  with  subcutaneous  haemorrhages. 

Perry  Goldsmith. 


MISCELLANEOUS. 


The    Bacteriology    of   Mumps.— Russell    L.    Haden.      "  Amer.    Journ. 
Med.  Sci.,"  clviii.  No.  5,  p.  698. 

This  paper  is  interesting  to  otologists  in  conuection  with  mumps- 
deafness,  w^iich  is  probably  of  meuingitic  origin. 

The  organisms  recovered  from  the  blood,  the  parotid  secretion  and  the 
testis  have  been  quite  uniformly  Gram-positive  diplococci,  which  grow 
slowly.  Attempts  to  i-eproduce  the  disease  have,  however,  been  for  the 
most  part  fruitless.  Herb  reports  the  recovery  of  a  Grram-positive  diplo- 
<;occus  from  the  heart's  blood  and  tissues  of  a  patient  dying  subsequent  to 
an  attack  of  mumps.  This  organism,  when  injected  into  the  parotid 
gland  of  a  dog,  caused  a  parotitis  simulating  mumps.  The  injection  of 
cultures  intra-peritoneally  also  produced  an  orchitis. 

In  nine  cases  investigated  by  Haden  the  spinal  fluid  showed  uniformly 
a  pleocytosis  of  the  mononuclear  type.  Cultures  and  smears  were  nega- 
tive in  eight  cases.  In  one  instance  the  fluid  was  opalescent  and  smears 
showed  numerous  Gram-positive  diplocococci.  All  nine  patients  were 
clinically  cases  of  classical  mumps.  The  cocci  were  found  in  direct 
smear,  so  there  was  no  chance  of  contamination.  It  seems  reasonable  to 
conclude  that  the  organism  demonstrated  in  the  spinal  fluid  was  the  one 
causing  the  primary  infection — a  parotitis.  Blood-cultures  were  made  on 
all  cases  of  mumps  on  admission.  Of  the  twenty-five  cultures  taken 
nineteen  were  sterile.  Two  were  contaminated.  Eour  cultures  on  three 
diffei-ent  patients  show^ed  a  small  Gram-positive  diplococcus.  After 
several  transplants  it  grew  readily  on  all  media. 

Five  cases  of  mumps  are  reported  by  Haden  in  which  a  Gram-positive 
diplococcus  was  isolated  from  the  spinal  fluid,  the  blood  and  a  lymph- 
gland.     The  injection  of  the  organism  into  the  testicle  of  a  rabbit  pro- 


192  The  Journal  of  Laryngology,  [june,  1920. 

duced  a  severe  orchitis  in  ten  days.  These  findings  confirm  the  earlier 
reports  of  similar  organisms  from  cases  of  mumps.  Haden  concludes 
that  mumps  is  probably  caused  by  a  Gi'am-positive  diplococcus  and  not 
by  a  filterable  virus.  /.  S.  Fraser. 


NOTES  AND   QUERIES. 

A  New  Library  at  Manchester. 
We  understand  that,  in  connection  with  the  establishment  of  the  Ellis  Llwyd 
Jones  Lectureship  at  the  University  of  Manchester,  a  special  library  is  to  be 
founded.  The  lectureship  is  for  the  purpose  of  training  teachers  of  the  deaf,  and 
those  who  know  of  deaf  education  affairs  may  remember  the  very  curious  contro- 
versy that  arose  among  teachers  of  the  deaf  as  to  the  methods  employed  at  the 
election.  The  new  library  is  to  be  devoted  entirely  to  works  dealing  with  deaf 
education  and  matters  connected  therewith.  M.  Y. 

British  Medical  Association  :  Annual  Meeting  in  Cambridge, 
June  30-July  3,  1920. 
Although  no  special  section  devoted  to  oto-laryngology  has  been  arranged  for 
this  year,  we  are  pleased  to  see  that  Mr.  H.  Tilley  is  reading  a  paper  (by  request) 
before  the  Surgical  Section  on  Friday,  July  2,  at  12.15  p.m.,  on  '"Inflammatory 
Lesions  of  the  Nasal  Accessoiy  Sinuses  from  the  Points  of  the  General  Physician 
and  Surgeon,"  which  will  be  followed  by  a  discussion.  On  the  afternoon  of  the 
same  day  he  is  giving  a  demonstration  (by  request)  of  instruments  used  in 
endoscopy  of  the  lower  air-passages  and  the  oesophagus. 

CoNGRES  Fran(;ais  d'Oto-Rhino-Lartngologie. 

The  Annual  Session  of  the  Frencli  Society  of  Oto-Rhino-Laryngologie  was  held 
in  Paris  on  May  10,  11  and  12,  under  the  Presidency  of  Dr.  Sieur,  the  well-known 
professor  of  this  speciality  at  the  large  Military  Hospital  of  Yal  de  Grace.  The 
subjects  for  general  discussion  were  :  "  Radium  and  Radio-tliera2:)y  in  Tumours  of 
tlie  Ear,  Nose  and  Throat,"  introduced  by  Drs.  Lenoir  and  Sargnon  (L3'ons),  and 
"  Paradental  Cysts  of  the  Superior  Jaw,"  introduced  by  Dr.  Jacques  (Nancy). 
There  were  a  large  number  of  papers  on  various  subjects.  Another  case  of  spon- 
taneous escape  of  cerebro-spinal  fluid  from  the  nose  was  put  on  record  by  Dr. 
Constantin  (Marseilles),  and  an  interesting  series  of  patients  were  shown  by 
Dr.  Moure  (Bordeaux),  illustrating  the  admirable  results  obtained  by  laryngo- 
tracheostomy  after  stenosis  of  the  larynx  and  trachea  from  war  injuries.  In  two 
of  these  cases  the  vocal  cords  had  been  destroyed  and  yet  the  patients  had  fair 
voices,  pi'oduced  by  new  cicatricial  cords,  and  they  had  a  free  airway.  The 
average  treatment  had  been  twenty  to  twenty-four  months,  but  patience  and 
perseverance  had  enabled  them  all  to  dispense  with  the  tracheotomy  tube. 

Visitors  were  present  from  most  of  the  allied  countries,  including  Roumania 
and  the  Ukraine.  Thei-e  were  a  dozen  colleagues  from  Belgium.  Great  Britain 
was  represented  by  Messrs.  Brown-Kelly,  Albert  Gray  (Glasgow),  Paterson 
(Cardiff),  Watson  Williams  (Bristol),  William  Hill,  Haworth,  Wylie  and  StClair 
Thomson  (London).  All  of  oiu'  representatives  were  entertained  liy  the  Society  at 
the  Annual  Banquet  on  the  evening  of  May  11  at  the  Restaurant  Marguery. 

The  President  for  next  year  is  Dr.  Mouret,  of  Montpelier,  who  has  many  friends 
in  this  country.  StC.  T. 

Meetings  of  the  American  Special  Societies. 

This  year  the  Special  Societies  of  America  will  hold  their  Summer  Congress  in 
Boston  on  the  following  dates :  The  Laryngological,  May  27-29 ;  Otological, 
May  31-June  1;  Society  of  American  Endoscopists,  June  1;  Laryngological, 
Rhinological,  and  Otological,  Jvme  2-4. 

The  Scottish  Otological  and  Laryngological  Society. 
The  next  meeting  will  be  held  in  the  Royal  Inflrmary,  Edinbiu-gh,  on  Saturday, 
June  12,  at  4  p.m.     Visitors  are  welcomed.     Hon.  Secretaiy :  W.  S.  Syme. 


Amongst  the  names  of  British  subjects  recently  published  in  Paris  who  have 
been  awarded  the  Medaille  de  la  Reconnaissance  Francjaise  is  the  following ; 

Silver. — Sir  StClair  Thomson,  M.D.,  for  Valuable  Services  as  Specialist  in 
Laryngology. 


VOL.  XXXV.     No.  7.  July,  1920. 


THE 

JOURNAL    OF    LARYNGOLOGY, 

RHINOLOGY,   AND  OTOI.OGY. 


Original  Articles  are  accepted  on  the  condition  that  they  have  not  previonsly  been 
published  elseivhere. 

1/  reprints  are  required  it  is  requested  that  this  he  stated  ^vhen  the  article  is  first 
forwarded  to  this  .Totirnal.     Sncit  reprints  %vill  he  charged  to  the  author. 

Editorial  Comnmnications  are  to  be  addressed  to  "Editor  of  Jouknal  OF 
LAKTNGor.OGr,  care  of  Messrs.  Adlard  4"  Son  Sf  West  Neivman,  Limited,  Bartholomew 
Close,  E.G.  X" 


DENTAL    CYSTS    OF    THE    SUPERIOR    MAXILLA:     A    CON- 
TRIBUTION   TO    THEIR    SURGICAL    TREATMENT. 

By  Maurice  Sourdille, 
Assistant  d'Oto-Rhino-Laryngologie  a  I'Hopital  de  la  Pitie,  Paris. 

The  paodern  treatment  of  dental  (or  paradental)  cysts  of  the  superior 
maxilla  is  purely  surgical,  the  various  operative  measures  consisting 
essejatially  m  a  wide  resection,  by  the  buccal  route,  of  the  bony  external 
covering  of  the  cyst,  with  the  dissection  or  the  opening  and  curettage 
of  the  cyst-wall. 

But  the  closure  of  this  open  cavity  in  the  vestibule  of  the  mouth  is 
not  easily  accomplished.  It  tills  up  very  slowly,  and  during  this  process 
the  cavity  may  become  infected  and  form  a  fistulous  opening,  after 
which  there  is  no  further  tendency  to  cure ;  or,  at  another  time  when 
the  cyst  attains  to  the  size  of  a  filbert,  cicatrisation  prevails  over  the 
granulations,  and  the  buccal  epithelium,  penetrating  the  cavity  of 
operation,  carpets  first  the  orifice  and  then  the  walls,  and  renders  them 
permanent.  Thus  there  is  formed  a  diverticulum  of  the  vestibule  of  the 
mouth  in  which  food  tends  to  collect. 

In  order  to  avoid  this  inconvenience,  after  the  dissection  or  curettage 
of  the  cyst-wall  has  been  completed,  Jacques  advises  resection  of  the 
upper  bony  partition  which  separates  the  cyst  from  the  nasal  fossa  or 
the  maxillary  antrum  above.  The  two  lips  of  the  wound  in  the  mouth 
are  allowed  to  come  together  and  then  to  cicatrise.  The  packing  of  the 
cavity  during  the  succeeding  days  and  its  drainage  during  the  period  of 
repair  is  effected  by  the  nasal  or  the  antro-nasal  route.  Following  this 
technique  we  have  operated  on  and  cured  a  number  of  these  cysts. 

But  for  a  number  of  reasons  the  gingivo-labial  union  may  fail  and  a 
permanent  communication  is  then  left  between  the  vestibule  of  the 
mouth  and  the  nasal  fossa  or  antrum.  Such  cases  of  bucco-nasal  fistula 
are  by  no  means  rare,  as  was  shown  in  a  recent  discussion  at  the  Eovai 

13 


194  The  lournal  of  Laryngologry^  [jaiy,  1920. 

Society  of  Medicine,  London,  and  their  closure  is  difficult.  In  a  case  of 
this  kind  we  employed  a  plastic  operation,  which  proved  so  successful 
that  we  are  describing  here  the  technique  that  was  followed. 

Case. 

A  male,  aged  forty-one,  was  referred  by  a  dentist  whom  he  had  consulted  because 
an  upper  denture  was  no  longer  keeping  in  place.  A  marked  inflammatory  swelling 
of  the  left  anterior  half  of  the  vault  of  the  palate  was  found,  and  a  small  fistula 
situated  at  the  level  of  the  alveolus  of  the  first  left  upper  canine,  about  4  or  5  mm. 
above  the  alveolar  border,  which  was  also  the  seat  of  inflammation.  This  fistula 
gave  exit  to  quite  a  large  quantity  of  pus.  The  suppuration  dated  back  for  twenty 
years.  It  caused  a  continual  stickiness  in  the  mouth,  fcetor  of  the  breath  and 
gastro-intestinal  troubles.  A  probe  inserted  into  the  orifice  passed  into  a  large 
bony-walled  cavity  leading  backwards  under  the  floor  of  the  nose,  and  externally 
under  the  floor  of  the  left  maxillary  antrum.  It  was  as  if  the  cavity  had 
reduplicated  the  vault  of  the  bony  palate.  It  extended  to  about  4  cm.  posterior 
to  the  dental  arch.     The  canine  and  the  two  left  bicuspids  were  absent. 

The  patient  was  sent  to  us  for  nasal  examination  and  surgical  treatment.  On 
rhinoscopy  nothing  abnormal  was  found  save  a  slight  elevation  of  the  floor  of  the 
left  nasal  fossa.     The  left  maxillary  antrum  was  not  affected. 

September  10. — Operation  under  chloroform  :  Horizontal  incision  in  the  gingivo- 
labial  recess ;  separation  with  the  rugine  of  the  upper  lip  from  t"he  wound ; 
opening  by  the  gouge  at  the  level  of  tbe  left  canine  18  mm.  above  the  fistulous 
opening.  This  opened  into  a  large  cavity  1  cm.  high  at  its  anterior  end,  3  cm.  in 
breadth  and  from  4  to  5  cm.  in  length,  the  superior  and  inferior  walls  meeting 
posteriorly.  Pus  abundant  and  very  foetid.  Granulations  removed  with  the 
curette ;  superior  bony  wall  intact ;  inferior  wall  equally  bony  but  carious,  being 
easily  raised  with  the  curette,  until  all  that  was  left  of  this  wall  was  the  fibro- 
mucosa  of  the  palatine  vault.  Enlargement  of  the  anterior  opening  so  as  to 
include  the  fistulous  oj^ening  not  being  feasible  the  gum  was  freed  with  the  rugine 
and  that  part  of  bone  subjacent  to  the  fistula  was  removed  with  gouge  forceps. 
The  bony  alveolar  border,  however,  was  conserved  in  such  a  way  as  to  avoid  any 
depression  that  might  prevent  or  render  difficult  the  wearing  of  a  jirosthetic 
apparatus. 

The  operation  was  terminated  by  resection  of  the  upper  bony  wall  of  the  cyst — 
that  is,  of  the  floor  of  the  left  nasal  fossa  and  of  the  adjoining  mucosa.  In  this 
way  a  Avide  nasal  communication  was  effected,  and  this  constituted  tlie  route  of 
drainage  during  the  period  of  cicatrisation.  The  buccal  wound  was  sutui-ed  with 
catgut  and  the  nasal  cavity  loosely  packed. 

During  convalescence,  however,  the  tissues  of  the  gum,  which  had  been 
separated,  underwent  retraction,  the  sutures  cut  out,  and  a  large  orifice  resulted, 
2^  cm.  wide  and  8  to  10  mm.  wide,  making  a  fistulous  communication  between  the 
mouth  and  the  left  nasal  fossa.  The  buccal  orifice  had  epidermised  ;  the  cavity 
was  granulating,  but  was  far  from  being  obliterated.  It  was  being  tamponned 
daily  to  prevent  the  passage  of  food  into  the  nose. 

October  26. — Closure  of  fistula  attempted.  Local  anaesthesia  by  novocaine  to 
the  inner  lip  of  the  left  upper  lip,  and  by  cocaine  to  the  wall  of  the  cavity. 
Kefreshment  by  the  curette  of  the  lower  border  and  angles  of  the  bucco-nasal 
opening,  and  of  the  floor  and  lateral  walls  of  the  cavity  of  the  cyst.  A  thick  flap 
of  mucous  membrane,  rectangular  and  with  its  base  above  was  then  marked  out 
and  liberated  from  the  internal  aspect  of  the  upper  lip.  The  flap  was  situated 
exactly  opposite  to  the  orifice  to  be  obliterated  and  was  made  rather  wider  than 
that  opening,  while  it  was  from  2  to  3  cm.  in  length.  It  was  made  to  hinge  round 
the  fixed  point  of  the  upper  border  of  the  orifice,  and  it  was  brought  down  into  the 
cavity  with  its  mucous  surface  uppermost  and  its  raw  surface  below,  so  that  the 
latter  lay  in  contact  Avith  the  refreshed  inferior  wall  of  the  cavity. 

Three  sutui-es  placed  vertically  one  above  the  other  brought  the  two  vertical 
lips  of  the  labial  wound  into  contact  and  prevented  the  flap  from  springing  back 
to  its  original  position ;  the  simple  pressure  of  the  lip  against  the  dental  arch, 
together  with  its  weight,  sufficed  to  maintain  it  in  its  proper  place  in  the  cavity. 

Seqvelep  of  Operation.— (Edema.tous  swelling  of  the  lower  lip  and  of  the  left 
cheek  followed,  but  gave  way  to  hot  fomentations  and  frequent  washing  out  of  the 
mouth.     The  plastic  flaps  maintained  their  position. 


July,  1920.] 


Rhinology,  and  Otology. 


195 


Xovember  6. — Sutures  of  lip  wound  removed  ;  union.  The  flap  presented  good 
vitality  and  was  adhering  to  the  floor  of  the  cavity,  the  orifice  of  vs^hich  was 
•completely  obliterated. 

November  30. — Cure  complete.  The  scar  of  the  external  wall  scarcely  visible. 
The  flap  was  entirely  epidermised  from  the  vestibule  of  the  mouth  and  intimately 
adherent  to  the  circumference  and  floor  of  the  cavity.  The  scar  is  water-tight,  no 
liquid  passing  from  the  mouth  into  the  nose. 

From  this  case  the  following  conclusions  may  be  drawn : 
(1)  The  tissue  of    the  gum  is   highly  retractile   when    withdrawn 
from  its  bony  support. 


Fig.  1. 


When  we  have  to  do  with  a  dental  cyst  w'hich  is  not  suppurating 
we  ought  to  incise  as  high  in  tlie  gingivo-labial  recess  as  possible,  the 
cyst  being  opened  at  this  level.  If,  after  dissection  or  curettage  of  the 
pocket,  the  cavity  appears  to  be  large  and  likely  to  take  a  long  time  to 
become  obliterated,  Jacques'  technique  should  be  followed,  i.  e. 
remove"  the  bony  wall  between  the  cyst  and  the  nasal  cavity  or 
nasal  sinus  (antrum),  and  let  the  buccal  wound  close  as  in  the  radical 
antrum  operation. 

If  the  cyst  has  formed  a  fistula  into  the  mouth  it  is  absolutely 
necessary  to  remove  the  whole  of  its  outer  wall,  including  the  fistula. 


196 


The  Journal  of  Laryngology, 


[July,  1920. 


Eor  this  a  considerable  portion  of  the  gum  must  be  freed,  the  retraction 
of  which  will  be,  so  to  speak,  fatal,  and  the  wound  will  not  become  shut 
off  (from  the  mouth).  Dan  McKenzie  and  Banks-Davis  have  observed 
similar  cases. 

Is  it  necessary,  as  E.  D.  D.  Davis  advises,  to  limit  ourselves  to  the 
resection  of  the  bony  floor  of  the  cyst  so  as  to  facilitate  granulation  ?' 
According  to  this  author  we  may  have  to  wait  months  or  years  for  this 
to  happen ! 

We  believe  that  even  at  the  risk  of  making  a  bucco-nasal  communi- 
cation (which  is,  however,  relatively  easy  to  obliterate  by  the  method 


Fig.  -2. 

we  advocate),  it  is  necessary  to  preserve  as  much  as  possible  of  the- 
alveolar  border  in  order  to  prevent  an  exaggerated  deformity.  Further, 
in  view  of  the  secondary  plastic  operation,  it  is  necessary  in  the  course 
of  this  first  intervention  to  resect  the  upper  bony  wall  of  the  cyst  and 
to  create  in  consequence  the  nasal  communication. 

(2)  In  the  event  of  a  persistent  bucco-nasal  communication  we  may 
try  to  obliterate  the  buccal  orifice  by  means  of  a  plastic  flap  taken  from 
the  inner  aspect  of  the  corresponding  part  of  the  ugper  lip  or  cheek, 
avoiding,  in  the  latter  case,  the  orifice  of  Stenson's  duct.  The  gumi 
cannot  be  used  because  of  its  retractability. 


July,  1920.]  Rhinology,  and  Otology.  1^7 

This  operation  should  be  done  not  less  than  six  weeks  after  the  first 
intervention — that  is  to  say,  when  the  cicatrisation  of  the  first  is 
completed,  and  the  tissues  have  recovered  their  suppleness  and 
vascularity. 

The  flap  should  be  thick  ;  it  should  be  as  long  as  the  height  of  the 
lip  will  permit  of,  and  rather  wider  than  the  orifice  to  be  obliterated. 

The  operative  technique  may  be  summarised  as  follows : 

(1)  Refresh  the  inferior  and  lateral  surfaces  of  the  cystic  cavity  with 
the  curette,  including  also  the  inferior  and  lateral  borders  of  the  buccal 
oritice.     Do  not  touch  the  upper  border  (Fig.  1). 

(2)  Trace  and  cut  the  flap  from  the  lip  with  its  base  above. 

(3)  Push  down  and  engage  the  flap  across  the  orifice  to  be  obliterated, 
the  raw  surface  being  brought  downwards  against  the  freshened  floor  of 
the  cavity,  the  mucous  surface  being  uppermost.  This  goes  to  form  the 
floor  of  the  nasal  fossa  and  antrum. 

(4)  Liberate  the  two  vertical  lips  of  the  labial  wound  and  suture  with 
horse-hair  or  silk.  This  suture  prevents  the  flap  springing  back  into 
place  on  the  internal  surface  of  the  cheek,  and  the  pressure  of  the  lip 
against  the  dental  arch  maintains  it  in  the  cystic  cavity  (Fig.  2). 

After-treatment. — Do  not  be  disquieted  by  the  oedema  of  the  lip  and 
of  the  cheek  which  follows  the  operation.  On  no  account  should  the 
sutures  of  the  lip  wound  be  removed  before  cicatrisation,  or  the  flap 
will  resume  its  position  on  the  inner  surface  of  the  lip  and  the  success 
of  the  operation  will  be  irremediably  compromised.  After  assuring 
ourselves  that  the  scar  is  sound  the  sutures  may  be  removed,  one  by 
one,  after  the  tenth  day. 

Success  depends  upon  the  adhesion  of  the  raw  face  of  the  flap  to 
the  floor  of  the  cystic  cavity  and  to  the  lower  and  lateral  borders  of 
the  buccal  orifice.  The  raw  surface  of  the  flap  left  outside  of  the 
orifice  is  epithelialised  from  the  buccal  epithelium,  and  forms  the  inner 
wall  of  the  vestibule  of  the  mouth. 

The  mucous  aspect  of  the  flap  is  entirely  enclosed  in  the  old  cystic 
-cavity,  which  thus  becomes  a  diverticulum  of  the  nasal  fossa  or  antrum. 

(D.  M.,  trans.) 


CASE  OF  LABYRINTHITIS;  DIFFUSE  PURULENT  MENINGITIS; 
LABYRINTHOTOMY ;  RECOVERY  WITH  INTRA-YENOUS 
AND  INTRATHECAL  INJECTIONS  OF  COLLOIDAL  SILYER. 

By  p.  Watson-Williams,  M.D.Lond., 

Aurist  and  Laryngologist,  Bristol  Roj'al  Infirmary;   Lecturer  on  Otology, 
Ehinology,  and  Laryngology,  University  of  Bristol. 

The  patient  when  first  seen  had  chronic  mastoiditis  and  vertigo 
with  evidence  of  an  erosion  of  the  bony  labyrinth,  and  it  was  hoped 
that  under  rest  and  local  treatment  the  symptoms  would  subside 
sufficiently  to  observe  and  analyse  his  vestibular  reactions,  etc.,  and 
that  with  even  a  feebly  functionating  labyrinth  the  absence  of  evidence 
of  infection  extending  to  the  membranous  labyrinth,  a  simple  radical 
mastoid  operation  would  relieve  him  and  enable  one  to  avoid  any 
operation  on  the  labyrinth. 


198  The  Journal  of  Laryngology,  [juiy,  1920. 

The  fistula  test  was  positive  and  the  response  to  caloric  tests 
proved  that  the  labyrinth  was  functionating  at  the  outset,  notwith- 
standing the  loss  of  all  hearing  in  the  affected  ear. 

It  is  regretted  that  the  sudden  development  of  acute  meningitis 
prevented  fuller  observation  and  testing,  but  the  chronic  mastoiditis- 
with  the  diminishing  vestibular  response  and  nystagmus,  when  a 
vestibular  fissure  had  been  already  diagnosed,  led  to  the  conviction  that 
the  obvious  acute  meningeal  infection  was  of  labyrinthine  origin, 
although,  of  course,  there  could  be  no  proof  that  this  was  the  path  of 
infection  short  of  a  j^ost-viortem  exammation.  The  operation  revealed  no 
other  apparent  route.  It  was  felt  safer  to  proceed  at  once  to  uncap  tha 
vestibule  and  open  up  the  cochlea  without  delay  after  doing  the  mastoid 
operation. 

In  this  case  we  appear  to  have  a  definite  labyrinth  infection  with 
consequent  leptomeningitis.  On  draining  the  labyrinth  the  meningitis 
began  to  clear  up.  Ten  days  after  the  operation  there  was  an  exacer- 
bation of  the  headache  l)ut  no  increased  temperature.  On  lumbar 
puncture  the  cerebro-spinal  fluid  was  more  purulent  and  thicker  than 
hitherto.  The  cell-count  reached  16,800  cells  per  cubic  millimetre- 
with  90  per  cent,  polymorphonulears,  showing  phagocytosis,  and 
Streptococcus  brevis  was  identified.  The  recovery  from  this  condition 
was  extraordinarily  rapid.  The  technique  was  alternate  intrathecal  and 
intravenous  silver  injections,  until  it  was  observed  that  the  latter 
appeared  more  efficacious  when  intravenous  injection  only  was- 
practised. 

The  intravenous  injection  of  the  colloidal  silver  preceded  the  lumbar 
puncture  in  order  that  the  withdrawal  of  the  cerebro-spinal  fluid  should 
aid  the  passage  of  the  silver  from  the  blood  into  the  subarachnoid.  It 
is  noteworthy  that  there  was  a  temporary  but  marked  exacerbation  of 
the  headache  on  the  tenth  day  after  operation,  but  this  was  considered 
to  be  due  to  the  discontinuance  of  the  withdrawal  of  cerebro-spinal 
fluid  by  lumbar  puncture  for  a  few  days,  and  that  this  was  the  cause 
seems  certain,  inasmuch  as  with  the  resumption  of  daily  lumbar 
puncture  and  intravenous  injection  of  coUosol  argentum  the  headache 
rapidly  lessened  and  the  temperature  became  nearly  normal.  There 
was  no  evidence  of  any  fresh  infection  causing  this  transient 
exacerbation. 

E.  T ,  male,  aged  thirty-seveu,  admitted  to  the  Bristol  Eoyal  Infirmary  on 

September  23,  1919,  complaining  of  pain  in  the  left  ear  and  dizziness.  There  was 
a  history  of  purvilent  discharge  from  left  ear  since  boyhood,  more  foixl  recently, 
and  he  had  vomited  twice  during  the  previous  week.  The  fistula  test  positive  on 
the  left  side.  On  admission  temperature  was  100^  F.,  left  middle  ear  full  of  pus 
and  granulations ;  he  had  slight  tenderness  over  left  mastoid  and  slight  pain  in 
left  occiput.     Disinfecting  irrigation  and  drops  ordered. 

September  25. — Bilateral  occipital  and  supra-orbital  headache ;  vertigo  with 
tendency  to  fall  to  the  loft.  Spontaneous  nystagmus  to  left.  Left  ear  absolutely 
deaf.     Patient  too  poorly  for  further  vestibular  and  other  tests. 

September  26. — Feels  very  giddy.  Temperature  100' F.,  right-sided  decubitus. 
Caloric  test  (hot),  feeble  nystagmus  to  left.  A  slight  vertical  twitching  of  eyes 
to  left  on  distant  accommodation.  Too  ill  for  further  or  precise  testing.  Occipital 
headache  moi-e  marked  Avith  some  rigidity.  Lumbar  puncture :  40  c.e.  removed, 
turbid,  diplococci  present  (few  cells,  50  per  cent,  polymorphs).  As  the  patient, 
with  chronic  mastoiditis  and  a  vestibvilar  fistula,  had  evidently  developed  menin- 
gitis, an  immediate  radical  mastoid  operation  and  labyrinthotomy  appeared 
essential.  The  mastoid  antrum  and  cells  contained  pus,  and  the  inner  tympanic 
wall  was  covered  with  pus  and  granulations.  The  external  semicircular  canal  was- 
next  laid  open  and  followed  forward  from  the  fistulous  erosion  to  the  ampulla  and 


July,  1920.]  Rhinology,  and  Otology.  199 

backward  to  its  junction  with  the  posterior,  but  the  superior  canal  was  not  laid 
bare  in  its  entirety,  and  the  first  and  second  turns  of  the  cochlea  were  opened  up 
externally  by  burring ;  the  modiolus  was  not  removed.  The  wound  was  dressed  with 
coUosol  argentum  gauze  packing  (in  place  of  the  glj'cerine  of  carbolic  acid  drops, 
etc.,  hitherto  used). 

September  27. — General  condition  fair.  Head-retraction  and  rigidity  as  before 
operation.     Temperatiare  100' F.     Daily  dressing  and  lumbar  punctui-e. 

September  28.     Lumbar  puncture :  15  c.c.  of  definitely  turbid  fluid  withdrawn. 

October  2. — Headache  much  better.  Wound  clean.  Lumbar  puncture  :  Cerebro 
spinal  fluid  clearing ;  a  few  polynuclears. 

October  6. — Headache  to-day  is  again  severe,  with  some  neck  pain.  Tempera- 
ture 99"6°F.  Lumbar  punctui-es,  having  been  discontiniied,  now  resumed,  and  15  c.c. 
very  cloudy  fluid  withdrawn  under  pressiu-e  and  1  c.c.  coUosal  argentum  injected. 
Streptococci  cultered  from  cerebro-spinal  fluid.  The  exacerbation  of  headache 
appeared  to  be  due  to  the  discontinuance  of  lumbar  punctures  for  several  days. 
By  this  time  the  mastoid  wound  was  clean,  and  the  labyrinthine  area  covered 
with  healthy  granulations,  having  been  continuously  dressed  with  collosol 
argentum  gauze  packing. 

October  7. — Headache  less.  3  c.c.  collosol  argentum  injected  intravenously, 
followed  by  lumbar  puncture  and  withdrawal  of  28  c.c.  of  turbid  fluid  under 
pressure  (cerebro-spinal  fluid  cells,  leucocytes  95  per  cent.,  culture  sterile). 
Temperatvire  99°  F. 

October  8-17. — Daily  lumbar  puncture  preceded  by  intravenous  collosol 
argentum  3  to  5  c.c.  Cerebro-spinal  fluid  gradually  cleared  up.  Some  incon- 
tinence of  urine  from  October  8  to  17,  not  later.  Temperature  steadier.  Gradual 
convalescence. 

December  6.  —  Condition  generally  very  good.     Walks  with  no  vertigo. 
June,  1920. — Patient  is  at  work,  in  excellent  health,  and  a  clean  ear.     Facial 
paresis  practically  recovered. 


ANTRAL    INFECTION    AND    MANGANESE. 

By  E.  Watson  Williams,  M.C,  M.B.,  B.C., 

Late  Senior  Medical  Officer,  Antwerp  Base ;   Oto-laryngologist,  South  mead 
Infirmary,  Bristol. 

Since  its  introduction  in  1914,  colloidal  manganese  has  proved  valuable 
in  a  variety  of  coccal  infections,  especially  in  furunculosis  and  in 
gonorrhoea  (1),  (2).  McDonagh  has  formulated  a  theory  to  explain  its 
action.  Manganese  is  supposed  to  circulate  as  hydroxide  adsorbed  to 
colloidal  particles  of  lymph  protein.  Thus  it  is  enabled  to  exercise  in 
the  animal  body  the  function  which  is  normal  to  it  in  some  plants, 
namely,  the  setting  free  of  active  oxygen  from  organic  peroxides  (3). 
This  provision  of  active  oxygen  is  supposed  to  play  an  essential  part  in 
resistance  to  infection.  Colloidal  manganese  tn  vitro  has  no  appreciable 
germicidal  action  (4). 

In  subacute  and  chronic  infections  of  the  maxillary  antrum  and 
other  nasal  sinuses  it  is  often  of  considerable  benefit.  Especially  is  it 
useful  in  those  cases  where,  although  satisfactory  drainage  of  the 
infected  cavities  has  been  secured,  an  indolent  discharge  persists.  In 
addition  to  its  apparently  specific  effect  in  coccal  infections,  manganese 
stimulates  the  haematopoietic  function.  This,  and  the  slight  leuco- 
cytosis,  etc.,  which  the  injection  of  any  foreign  colloid  will  produce, 
are  doubtless  important  accessory  actions. 

The  technique  followed  in  these  cases  is  as  follows  :  The  two  stock 
solutions  (5)  are  mixed  by  drawing  an  equal  volume  of  each  into  a 
sterile  syringe  and  turning  this  over  once  or  twice.  The  colouration  of 
one  fluid  serves  to  indicate  when  admixture  is  complete.     The  solution 


200  The  Journal  of  Laryngology,  [juiy,  1920. 

is  slowly  injected  into  the  gluteus  or,  in  a  bed-ridden  patient,  into  the 
deltoid.  It  is  painless ;  sometimes  a  slight  stiffness  is  noticed  for 
twenty-four  hours.  Injections  into  subcutaneous  or  intermuscular 
tissues  are  not  free  from  pain.  The  drug  has  not  been  given 
intravenously. 

The  dose  ranges  from  05  c.c.  to  5'0  c.c. ;  the  average  is  1  c.c.  or 
2  c.c. ;  the  largest  dose  daily  is  perfectly  tolerated.  In  subacute 
conditions  injections  are  made  daily  or  every  other  day;  in  more 
chronic  cases  once  or  twice  a  week.  Four  to  seven  injections  usually 
give  the  required  result.  Post-mortem  examination  (in  a  case  of  double 
pyonephrosis)  showed  that  the  drug  is  completely  absorbed  within  six 
days,  leaving  no  trace.  In  no  case  in  this  series  was  any  disturbance 
following  administration  observed,  although  occasional  fever  and  renal 
pain  have  been  recorded  (2).  The  metal  is  stated  to  be  excreted  in  the 
urine  and  in  the  bile  ;  it  is  possibly  largely  excreted  also  by  the  colon. 

The  conclusions  one  was  able  to  draw  from  the  series,  of  which  some 
cases  are  quoted  below,  were :  (a)  Manganese  powerfully  increases  the 
resistance  to  antral  as  to  other  coccal  infections.  It  is,  therefore,  a 
valuable  adjunct  to  surgical  treatment,  {h)  It  is  especially  indicated  in 
chronic  conditions.      (c)  It  improves  the  anaemia  commonly  associated. 

Cases. 

Case  1. — A  man,  aged  forty-two,  with  a  mild  chronic  infection  of  the  antra, 
cacosmia  and  headache  ;  both  antra  were  opened.  Eight  days  later  temperature 
was  100°  F.  every  evening,  and  muco-pus  drained  freely.  Four  daily  injections  of 
1  c.c.  were  given.  On  the  thirteenth  day  temperatiire  rose  only  to  99°  F.,  the 
discharge  was  much  less.  On  the  sixteeenth  day  temperature  was  normal,  nasal 
washing  returned  clear,  all  symptoms  were  completely  relieved,  and  the  patient 
discharged  well  satisfied. 

Case  2. — A  patient  with  infection  of  left  antrum,  which  improved  after 
di'ainage  and  nine  months  later  relapsed.  Deafness  and  a  constant  discharge 
of  thick  muco-iDUs  were  principal  symptoms.  Thi'ee  injections  of  0"5  c.c.  were 
given  on  alternate  days,  then  four  of  1  c.c.  every  fourth  day.  The  discharge 
ceased  with  the  sixth  injection,  and  has  not  returned  four  months  later.  The 
deafness  is  improving.  Protracted  and  energetic  local  treatment  had  not  benefited 
this  patient. 

Case  3. — A  patient  with  infections  of  both  antr.a,  which  were  opened.  Three 
weeks  later  the  condition  had  not  improved.  Three  injections  of  I  c.c.  were  given. 
The  patient  felt  veiy  depressed  after  the  third  dose.  She  returned  home  a  Aveek 
later  feeling  better,  but  still  having  a  free  discharge.  One  more  injection  Avas 
given.  The  discharge  cleared  up,  and  although  it  returns  occasionally,  she  feels 
and  looks  very  much  better. 

Case  4. — Constant  rhinorrhcea  for  eleven  years,  with  headache  and  anosmia. 
Tliree  courses  of  vaccine  did  not  improve  the  condition,  but  improvement  followed 
free  opening  of  the  accessory  sinuses.  Eighteen  months  later  the  general  health 
was  better,  but  there  was  still  a  constant  muco-purulent  discharge.  Two  courses 
of  1  c.c.  weekly  for  three  doses  were  given  at  eight  weeks'  interval.  The  discharge 
cleared  up  completely,  the  headaches  which  had  troubled  him  disappeared,  and 
the  sense  of  smell  returned. 

Case  5. — A  woman,  aged  twenty-three,  with  history  of  nasal  trouble  from 
childhood.  The  accessory  sinuses  were  drained  seven  years  ago,  but  after  long 
freedom,  trouble  returned  in  the  wake  of  an  influenzal  attack  last  spring.  The 
patient  was  very  depressed  and  got  constant  discharge  from  the  nose  with 
cacosmia.  Lavage  improved  but  did  not  completely  relieve.  She  was  noticeably 
anaemic.  Red  blood  corpuscles,  .3,700,000;  white  blood  corpuscles,  8,000.  Four 
injections  of  1  c.c.  on  alternate  days  were  given.  At  the  end  of  the  course  she 
felt  much  better,  Avas  obviously  less  pallid,  and  had  considerably  less  discharge. 
Red  blood  corpuscles,  5,100,000;  white  blood  corpuscles,  12,500.  One  month  later 
the  patient  Avas  very  mvich  better.  All  lassitude  and  mental  confusion  Avere  gone 
the  colour  Avas  good,  the  discharge  nil. 


July,  1920.]  Rhinology,  and  Otology.  201 

Case  6. — Female,  aged  thirty-eight.  Admitted  complaining  of  swelling  on  left 
side  of  neck.  This  was  found  to  be  an  abscess,  probably  starting  from  an  infected 
gland  in  front  of  the  sternomastoid.  It  was  drained.  The  maxillary  antra  were 
both  full  of  pus,  and  they  also  were  freely  opened.  Staphylococcus  longus  was 
cultivated  from  all  three  collections.  Nine  days  later  the  sinus  in  neck  and  the 
antra  were  discharging  very  little  ;  temperature  was  normal.  A  week  later  still 
the  sinus  and  antral  discharge  persisted  ;  the  tempei-ature  showed  a  constant  rise 
to  about  100""  F.  in  the  evening.  The  skin  over  the  sternomastoid  became  red  and 
tender,  suggesting  a  spread  of  infection.  The  condition  got  gradually  worse  and 
worse  till  2  c.c.  of  manganese  were  given  intramuscularly  every  other  day.  After 
the  first  dose  the  temperature  rose  to  101°  F. ;  after  the  third  it  came  down  to 
normal  and  remained  down ;  the  sinus,  2j  in.  deep  four  days  before,  was  barely 
discoverable  ;  the  antral  discharge  ceased  completely.  The  patient  felt  better 
than  she  had  done  for  years,  and  was  undoubtedly  brighter  and  a  li<»tter  colour. 

Note. — I  am  indebted  to  Dr.  P.  Watson  Williams  for  permission  to 
publish  notes  of  these  cases,  and  to  the  editor  of  The  Practitioner  for 
permission  to  reproduce  certain  parts  of  this  article. 

References. 

(1)  Morris.— £rif.  Med.  Journ.,  April  20,  1918. 

(2)  McDoNAGH.— Practitioner,  1918,  i,  pp.  -il,  416. 

(3)  Starling.— P/ii/sioio5fi/,  1920,  p.  1159. 

(4)  Martindale. — "  Extra  Pharmacopoeia,"  1918,  ii,  p.  197. 

(5)  "  Collosol  Manganese"  (British  Colloids,  Ltd.). 


THE  AQUEDUCT  OF  FALLOPIUS  AND  FACIAL  PARALYSIS. 

By  Dan  McKenzie. 
Part  II :   Facial   Paralysis. 

{Continued  from  p.  175.) 
We  proceed  now  to  discuss — 

NOX-OPERATIVE    OTOGENIC    FaCIAL    PaRALYSIS, 

including  the  palsies  due  to  disease  of  the  ear  and  of  the  temporal 
bone. 

Congenital  Facial  Paralysis. 

This  is  a  well-recognised  if  rare  condition.  It  is  usually  associated 
with  hemi-atrophy  of  the  face,  and  also  sometimes  with  rudimentary 
auricle  and  congenital  auricular  fistula. 

Several  theories  have  been  advanced  to  explain  the  deformity,  but 
accurate  data  regarding  the  post-mortem  appearances  do  not  seem  to 
have  so  far  been  obtainable. 

Perhaps  the  initial  fault  is  a  mal-development  of  the  nerve  itself. 

Facial  Paralysis  from  Ear  Disease. 

Inasmuch  as  the  Fallopian  canal  runs  close  under  the  mucous  mem- 
brane of  the  tympanic  cavity  the  facial  nerve  is  exposed  to  the  action  of 
bacterial  toxins  generated  in  that  cavity  without  the  bone  of  its  sheath 


202  The  Journal  of  Laryngology,  [juiy,  1920. 

necessarily  being  diseased.  And  the  risk  will  be  still  more  free  when, 
as  frequently  happens,  there  is  a  dehiscence  in  the  bony  covering  of  the 
canal. 

Moreover,  inflammations  of  the  middle-ear  cavity  of  all  grades  of 
severity  from  mild  evanescent  catarrh  to  relatively  massive  gangrene 
and  bony  necrosis  are  extremely  common,  and,  as  we  shall  be  able  to 
show,  facial  paralysis  may  result  from  any  of  these  varieties,  the  mild 
as  well  as  the  severe. 

At  first  sight,  indeed,  one  would  naturally  incline  to  believe  that  the 
lesion  most  certain  to  produce  facial  paralysis  would  be  a  massive 
necrosis  of  the  bone  through  which  the  Fallopian  canal  runs.  But 
curiously  enough,  while  this  profound  disorganisation  does  induce  para- 
lysis, yet  it  has  been  reported  that  necrosis  of  portions  of  the  labyrinth 
including  the  Fallopian  canal  may  take  place,  with  the  sequestration 
and  extrusion  or  artificial  removal  of  the  sequestrum  without  there 
being  any  sign  of  facial  paralysis  w^iatever  !  And,  on  the  other  hand, 
facial  paralysis  may  attend  an  attack  of  catarrh  of  the  middle-ear  so 
extremely  mild  that  the  patient  himself  is  unaware  of  any  symptom  of 
ear  disease  such  as  deafness  or  tinnitus,  so  that  unless  a  special 
examination  of  the  ear  be  made,  the  real  cause  of  the  nerve  disease  is 
never  discovered. 

There  must,  of  course,  be  some  special  factor,  generally  absent,  occa- 
sionally present,  upon  which  in  the  milder  middle-ear  affections  the 
involvement  of  the  facial  nerve  depends.  Obviously  the  paralysis  may 
be  due  either  to  pressure  or  to  neuritis,  and  it  is  equally  obvious  that 
whatever  favours  the  occurrence  of  mechanical  pressure  or  of  neuritis 
wdll  favour  the  paralysis. 

A  search  for  this  factor  has  occupied  the  attention  of  many  observers, 
but  the  matter  is  still,  to  a  great  extent,  one  of  surmise  rather  than  cer- 
tainty, of  belief  rather  than  conviction,  and  the  position  to-day  is  almost 
precisely  as  stated  by  Lannois  in  1894 — that  in  acute  otitis  media,  with 
or  without  perforation  of  the  membrane,  facial  paralysis  may  be 
supposed  to  occur  either  from  direct  pressure  of  the  swollen  mucosa  or 
of  the  exudation  in  the  tympanum  upon  the  nerve  through  a  dehiscence 
in  the  tympanic  wall  of  the  canal ;  or  it  may  be  induced  by  an  extension 
of  the  inflammation  to  the  neurilemma  by  way  of  the  blood-vessels 
penetrating  the  bone ;  or,  lastly,  by  a  congestion  of  the  vessels 
supplied  by  the  stylo-mastoid  artery  compressing  the  nerve  in  its  rigid 
canal. 

The  mechanical  influence  of  effusion  or  exudation  into  the  middle 
ear  was  observed  by  Bezold,  who  saw  the  paralysis  and  the  effusion 
declining  2Mri  jMSSii  in  a  case  under  his  care,  and  by  Trautmann,  who 
found  the  paralysis  disappear  after  paracentesis  and  return  again  with 
the  return  of  the  exudate,  to  disappear  finally  when  the  ear  disease  was 
finally  cured.     Tomka,  also,  has  reported  a  similar  happening. 

As  regards  the  influence  of  a  dehiscence.  Panzer  has  remarked  that 
the  relatively  frequent  occurrence  of  facial  paralysis  in  infants  with 
otitis  media  is  probably  due  to  the  fact  brought  forward  by  Politzer 
that  the  canal  is  often  open  and  unossified  in  early  life.  There  is  one 
criticism,  however,  we  must  otter  to  this  statement — the  fact,  namely, 
that  the  vascularity  of  the  bone  in  earh'  life  encourages  the  spread  of 
inflammation  in  every  direction,  and  that  of  itself  would  be  sufficient  to 
explain  the  frequent  occurrence  of  facial  paralysis  in  infancy. 

Tomka  remarks  that  at  a  dehiscence  the  exposed  neurilemma  may 


July,  1920.]  Rhinology,  and  Otology.  203 

be  in  direct  contact  with  the  mucosa  of  the  tympanum.  Other  support 
for  the  influence  of  the  dehiscence  conies  from  Henle  and  ZuckerkandU 
the  former  having  found  the  opening  in  the  canal  above  the  oval 
window  to  be  "  almost  constant  "  at  all  ages,  being  analogous  to  the 
exposed  facial  nerve  in  the  tympanum  of  animals — and,  we  may  add,  of 
foetal  life  in  man.  Zuckerkandl  found  that  through  a  small  opening  in 
the  bone  at  this  situation  an  artery  passes  to  the  stapes. 

Jendrassik  believed  that  the  liability  to  facial  paralysis  depended 
upon  an  abnormal  fineness  of  the  Fallopian  canal,  manifested,  he  thought, 
in  certain  families.  As  already  mentioned,  however,  my  specimens 
show  a  remarkable  constancy  in  the  size  of  the  lumen  of  the  canal  at 
all  ages  and  in  both  sexes.  This  observation  of  mine  is  not  in  accord- 
ance with  that  of  former  workers  on  this  point. 

Facial  paralysis  may  accompany  the  following  ear  diseases : 

I.  External  ear:  Impacted  cerumen;    furunculosis;   foreign  bodies. 

II.  Middle  ear :  Acute  and  subacute  catarrh  ;  acute  and  chronic 
suppuration  ;  cholesteatoma  ;  tuberculosis  ;  epithelioma  ;  foreign  bodies. 

III.  Internal  ear :  Caries  or  necrosis  of  the  bone  of  the  labyrinth  ; 
purulent  labyrinthitis ;  labyrinthitis  from  epidemic  meningitis ;  and 
herpes  zoster  oticus. 

We  shall  take  these  more  or  less  in  the  above  order. 


I.  External  Ear. 

Impacted  Cenimen. — Hessler  found  in  the  literature  two  cases, 
reported  by  Kirk  Duncanson  and  Weil  respectively,  in  which  "  the 
pressure  of  epidermal  masses  "  had  opened  up  the  facial  canal  and 
induced  paralysis,  and  as  the  vertical  segment  of  the  nerve  lies  only 
some  3  mm.  posterior  to  the  postero-inferior  segment  of  the  meatus 
behind  and  slightly  medial  to  the  membrane  there  is  no  anatomical 
reason  why  this  should  not  at  times  occur.  The  extraordinary  dilata- 
tion of  the  deeper  parts  of  the  meatus  in  such  cases  is  familiar  to  all 
who  have  ever  inspected  Toynbee's  specimens  in  the  museum  of  the 
Eoyal  College  of  Surgeons,  London.  The  "  epidermal  masses  "  referred 
to  are  an  indication  rather  of  desquamative  external  otitis  than  of  simple 
impacted  ceiamen — a  condition  sometimes  known  as  "  cholesteatoma 
of  the  external  meatus,"  which  frequently  leads  to  great  dilatation  of 
the  bony  meatus,  without  necessarily  inducing  any  ulceration  of  the 
cutaneous  lining. 

Trautmann  has  recorded  one  case  in  which  the  facial  paralysis  was 
attributable  to  a  furuncle  of  the  external  meatus.  Nothing  was  found 
in  the  tympanum  to  account  for  the  paralysis  and  it  disappeared  after 
the  furuncle  was  healed. 

Under  the  name  of  p/;/e(7??io?;oz(.s  subcutaneous  periotic  oedema  Gelle 
described  cases  seen  by  him  of  rapid  swelling  of  the  ear,  neck  and  side 
of  the  face,  resolving  in  from  eight  to  twelve  days  without  pus  forma- 
tion. In  certain  of  these  cases  facial  paralysis  was  observed  together 
with  signs  of  "  deeper  disease  "  of  the  hearing  organ.  He  supposed  that 
the  inflammation  was  due  to  an  osteo-periostitis  of  the  petrous,  either 
limited  to  the  neighbourhood  of  the  Fallopian  canal,  or  of  wider  exten- 
sion. These  observations  do  not  seem  so  far  to  have  been  corroborated 
bv  other  otologists. 


204  The  Journal  of  Laryngology,  [juiy,  1920. 


II.  The  Middle  Ear. 

Acute  catarrh. — Facial  paralysis  from  acute  catarrh  is  generally 
consiclei"ed  to  be  one  of  the  less  conamon  varieties  of  otogenic  facial 
paralysis,  but  many  cases  have  been  recorded  nevertheless.  The  para- 
lysis is  usually  slight  and  transient,  according  to  Politzer.  I  have  not 
yet  come  aci-oss  any  record  of  persistent  facial  paralysis  from  this 
cause.  We  have  already  taken  note  of  the  cases  reported  in  which  the 
paralysis  disappeared  after  the  membrane  had  been  incised.  But 
although  the  catarrh  and  the  paralysis  often  seem  thus  to  subside 
together,  it  is  more  usual  to  find  that  the  paralysis  remains  for  a  time 
after  all  sign  of  disease  in  the  ear  has  disappeared. 

In  adult  life  acute,  and,  even  more  frequently,  subacute  catarrh  of 
the  middle  ear  may  come  and  go  without  giving  rise  to  any  symptom 
more  striking  than  slight  dulness  of  hearing,  and  it  is  easy  to  under- 
stand how,  if  the  defect  be  unilateral  and  if  it  occur  during  the  general 
upset  of  a  "  cold  in  the  head,"  it  may  easily  fail  to  attract  any  attention 
whatever.  It  is,  indeed,  not  unusual  to  come  across  people  who  have  been 
deaf  in  one  ear  for  years  and  yet  are  quite  unaware  of  any  loss  of 
hearing. 

In  most  of  the  cases  of  paralysis  recorded  as  catarrhal  the  loss  of 
power  had  a  sudden  onset ;  it  rapidly  became  complete  ;  and  it  cleared 
up  spontaneously  in  from  four  to  six  weeks. 

This  experience,  coupled  with  what  occurs  also  in  herpes  zoster 
oticus,  is  leading  otologists  to  believe  that  the  so-called  "rheumatic" 
facial  paralysis,  or  paralysis  due  to  "cold,"  will  in  most  cases  prove, 
when  properly  investigated,  to  be  due  to  disease  of  the  ear. 

Thus  H.  O.  Eeik  reports  that  of  twelve  cases  of  "  rheumatic  "  facial 
paralysis  he  had  observed,  no  fewer  than  ten  on  close  pressing  gave  a 
history  of  pain  in  the  ear  before  the  onset  of  the  paralysis,  in  four  of 
the  cases  the  pain  had  lasted  some  time,  and  in  one  case  acute  otitis 
media  had  occurred.  In  the  others,  signs  of  subacute  or  chronic 
catarrh  of  the  middle  ear  were  present.  In  four  there  was  effusion  into 
the  tympanum  which  was  evacuated  by  paracentesis  ;  once  it  was  puru- 
lent, once  bloody,  and  after  the  recovery  from  the  disease  in  the  ear  the 
facial  paralysis  disappeared.  Eosenbach,  in  three  recent  cases  of  what 
had  been  diagnosed  as  "  rheumatic "  facial  paralysis  with  deafness, 
found  catarrh  of  the  middle  ear  on  examination.  And  Berthold  has 
remarked  that  he  has  noticed  that  patients  with  "  rheumatic  "  facial 
paralysis  show  a  tendency  to  catarrh  in  the  ear  of  the  same  side. 
Similar  opinions  have  been  expressed  by  Tomka,  Stenger,  Fuchs  and 
others. 

In  conclusion,  we  may  say  that  if  the  opinion  is  correct  that  many  of 
the  so-called  "  rheumatic"  cases  are  really  due  to  catarrh  of  the  middle 
ear,  then  facial  paralysis  from  this  cause  is  probably  moi'e  common  than 
has  hitherto  been  supposed. 

We  shall  recur  to  this  question  later. 

Diagnosis. — It  is  obvious  that  all  cases  of  facial  paralysis  should  be 
submitted  to  an  otological  survey. 

If  seen  during  the  active  stage  of  catarrhal  otitis  there  will  be  found 
obstructive  deafness  with  reddening  of  the  membrana  tympani,  and 
perhaps  some  general  bulging  or  fullness  of  the  membrane,  through 
which  the  exudation  may  be  visible.    With  an  exudate,  perflation  through 


July.  1920.]  Rhinology,  and  Otology.  205 

the  Eustachian  catheter  frequently  produces  a  sound  of  moist  crackhng, 
audible  to  the  examiner  through  the  diagnostic  tube. 

Politzer  reports  having  seen  sero-mucous  exudation  produced  "  bv  a 
paralysis  of  the  muscles  of  the  palate  and  tube  caused  by  a  paralysis  of 
the  facial  nerve,  after  diphtheria,  owing  to  paralysis  of  the  soft  palate 
.  .  ."  Consequently  we  must  be  careful  not  to  mistake  such  an  effect 
of  the  paralysis  for  its  cause.  In' this  condition,  however,  the  membrane 
would  retain  its  normal  colour. 

Treatvient. — Perhaps  the  best  treatment  to  adopt  when  facial  para- 
lysis is  associated  with  acute  catarrh  of  the  middle  ear  is  not  to  tem- 
porize, but  to  make  at  once  a  free  incision  through  the  membrane  in 
order  to  give  exit  to  the  inflammatory  sero-mucous  secretion  in  the 
tympanum,  as  this  will  both  relieve  the  mechanical  pressure  on  the 
nerve  and  the  catarrhal  inflammation  of  the  tympanic  mucosa.  Doubt- 
less expectant  and  temporising  measures  will  often  be  followed  by  dis- 
appearance both  of  the  catarrh  and,  later,  of  the  paralysis,  but  a  more 
rapid  effect  will  follow  incision.  Care  must,  of  course,  be  taken  to 
operate  under  strictly  antiseptic  conditions. 

Voss  reports  a  case  in  which  the  paralysis  was  found  to  l)e  still 
present  three  months  after  the  membrane  had  ruptured  and  had  healed 
up,  with  restoration  of  hearing.  He  operated  on  the  mastoid  and 
found  the  neighbourhood  of  the  antrum  in  a  state  of  what  he  called 
"  spongy  hyperaemia."  The  antrum  itself,  however,  was  not  opened. 
Forty-eight  hours  after  the  operation,  the  patient,  a  child,  was  able  to 
close  the  eye,  and  in  foui'teen  days  the  paralysis  had  quite  disappeared. 

Voss  thinks  the  recovery  may  have  been  merely  a  coincidence,  but 
most  otologists  faced  with  a  similar  case  would  be  inclined  to  repeat  the 
experiment.  Indeed  one  might  even  go  so  far  as  to  advise  deliberate 
opening  of  the  antrum  in  any  case  in  which  prompt  improvement  in 
the  paralysis  did  not  follow  the  paracentesis  of  the  membrane  and  the 
cure  of  the  catarrh. 

Chronic  Catarrh. — Apart  from  those  cases  of  chronic  exudative 
catarrh,  when  during  an  acute  or  subacute  phase  of  the  disease  facial 
paralysis  may  appear,  there  has  not  yet  been  recorded  or  observed,  so 
far  as  I  have  found,  a  case  of  chronic  catarrh  in  which  the  palsy  was 
present,  and  showed  by  indefinite  persistence  that  it  had  been  caused  by 
the  chronic  middle-ear  disease. 

SuiJpuration  of  the  Middle  and  Internal  Ear. — (Acute  and  chronic, 
together  with  cholesteatomatous  disease  and  labyrinth  necrosis,  but 
exclusive  of  tuberculosis.) 

Frequency  of  Facial  Paralysis. —This  group  of  ear  diseases  is  the 
commonest  source  of  otogenic  facial  paralysis,  so  far  as  we  know  at 
present.  As  to  its  frequency  there  are  few  accessible  figures,  but 
according  to  Sir  W.  Milligan  facial  paralysis  occurs  in  from  2  to  5 
per  cent,  of  cases  of  suppuration  of  the  middle  ear.  Bezold's  estimate 
"was  1  per  cent.,  while  Wageuhauser  found  facial  paresis  or  paralysis 
four  times  in  142  acute  and  345  chronic  "  cases  " — that  is,  0-8  per  cent., 
which  is  practically  the  same  as  Bezold's. 

Pathology. — Andre  Thomas,  in  a  case  of  facial  paralysis  with  occa- 
sional spasms,  due  presumably  to  otitis  media,  found  a  perineuritis 
below  the  first  bend  in  the  Fallopian  canal.  The  nerve  showed  a 
neuroma  of  degeneration.  The  geniculate  ganglion  was  somewhat 
atrophied.  The  facial  nucleus  was  normal.  According  to  Tomka  the 
paralysis   is    due    to    a   perineuritis  of   the    nerve-trunk,  the  infection 


206  The  Journal  of  Laryngology,  [juiy,  1920. 

reaching  it  from  the  middle  ear  in  the  same  way  presumably  as  it  does 
in  acute  catarrh.  Bezold  states  that  the  inflammation  reaches  the  peri- 
osteum from  the  mucosa,  with  which  the  periosteum  is  closely  united, 
and  so  passes  to  the  bone  and  later  to  the  nerve.  It  is  also  believed 
that  the  infection  may  find  its  way  to  the  facial  trunk  along  the 
stapedius  nerve  or  by  way  of  the  chorda  tympani,  and  Hoffmann  has 
shown  how  after  destruction  of  the  tendon  of  the  stapedius  muscle  pus 
passed  into  the  facial  canal  through  the  eminentia  pyramidalis. 

In  this  group  also  we  must  include  facial  paralysis  from  Bezold's 
and  the  other  rarer  forms  of  descending  abscess  secondary  to  suppuration 
in  the  temporal  bone,  as  when  pus  passes  from  the  mastoid  cells  through 
the  vertical  part  of  the  canal  and  the  stylo-mastoid  foramen. 

With  regard  to  Bezold's  abscess,  which  is  a  collection  of  pus  within 
the  sterno-mastoid  sheath  close  to  the  mastoid,  facial  paralysis  is 
uncommon,  although  the  nerve  passes  quite  near  to  the  infected  area. 
Barth  suggests  that  its  rarity  is  due  to  the  fact  that  in  Bezold's  abscess 
the  pus  breaks  out  from  the  mastoid  generally  in  the  posterior  part  of  the 
digastric  groove  and  some  distance  from  the  stylo-mastoid  foramen. 
But  as  a  matter  of  fact,  an  abscess  in  soft  tissues  seldom  or  never 
induces  paralysis  in  neighbouring  nerves,  and  nerve-trunks  passing 
through  a  septic  area  in  soft  parts  show  remarkable  resistance  to  the 
infection.  The  vulnerability  of  nerve  in  bone  must  be  due  to  the  higher 
tension  around  inflamed  areas. 

Turning  next  to  cholesteatomatons  disease,  we  find  ourselves  dealing 
with  a  disease-process  like  cancer  and  tuberculosis,  which,  by  the  direct 
attack  it  makes  upon  bone  and  by  the  erosion  it  produces,  leads  to  an 
exposure  of  the  nerve-trunk.  But  although  resembling  those  other 
more  serious  diseases  in  its  destructive  action  upon  bone,  cholesteatoma 
difi"ers  from  them  in  more  frequently  sparing  the  nerve-trunk.  The 
facial  nerve,  though  often  exposed  ])y  cholesteatomatons  disease,  is 
relatively  less  often  paralysed  than  it  is  in  tuberculous  and  cancerous 
ulcerations.  Every  operating  otologist  has  seen  sometimes  considerable 
lengths  of  the  nerve  lying  exposed  in  a  cholesteatomatous  cavity  without 
any  paralysis  or  even  paresis  having  been  present. 

In  one  case  I  have  recorded  the  nerve  hung  like  a  loose  string,  the 
Fallopian  canal  having  been  totally  destroyed,  together  with  the  bone 
around,  from  the  geniculate  angle  to  the  stylo-mastoid  foramen, 
and  yet  the  patient  had  never  suffered  from  facial  paralysis.  These 
experiences  show  that  although  cholesteatoma  may,  and  often  does, 
•erode  the  bone  of  the  canal  and  expose  more  or  less  of  the  nerve,  some 
additional  factor  is  necessary  to  bring  about  paralysis.  This  would  be 
found  in  the  occurrence  of  a  virulent  exacerbation  of  septic  infection,  or 
in  a  traumatic  injury  of  the  nerve-trunk,  by  the  surgeon's  curette  for 
example. 

This  view  of  the  genesis  of  facial  paralysis  in  cholesteatoma,  I  should 
add,  is  not  that  generally  taught.  The  usual  opinion  ascribes  the 
paralysis  to  a  pressure-atrophy  of  the  nerve-trunk  exercised  by  the 
cholesteatomatous  masses. 

Cario-necrosis  of  Bone  Involving  the  Aqnceductus  Fallopii. — Frequency. 
—As  might  be  expected,  of  its  individual  causes  this  is  the  one  which 
is  most  frequently  productive  of  the  paralysis.  Bezold,  who  has  paid 
considerable  attention  to  the  subject,  found  facial  paralysis  in  83  per 
cent,  of  the  cases  of  necrosis  of  bone  he  had  investigated  and  collected, 
w^hile  Gerber's  figures  give  77  per  cent. 


July,  1920.]  Rhinology,  and  Otology.  207 

Pathology. — It  is  not  surprising  to  find  that  facial  paralysis  is  most 
common  when  there  is  sequestration  of  the  entire  bony  labyrinth,  and 
also  when  the  necrosis,  affecting  only  a  portion  of  the  labyrinth,  involves 
the  upper  section  or  that  part  of  the  tympanic  wall  which  contains  the 
Fallopian  canal.    It  is  less  frequent  when  the  cochlea  alone  is  necrosed. 

In  necrosis  of  the  labyrinth,  paralysis  may  doubtless  be  due  to 
•destruction  of  the  nerve  by  the  same  septic  toxins  which  have  killed 
the  bone ;  but  the  nerve  does  not  invariably  suffer  from  this  agent,  its 
escape  being  due  probably  to  its  independent  blood-supply.  Apart  from 
septic  disease,  the  paralysis  in  those  cases  may  be  due  to  pressure  of 
the  loosened  sequestrum  upon  the  nerve-trunk,  or  to  the  erosive  action 
of  the  demarcating  granulations. 

In  this,  as  in  the  other  forms  of  otogenic  facial  paralysis,  the 
paralysis  is  not  always  persistent.  It  is  often,  in  spite  of  the  gravely 
destructive  lesion,  merely  transitory.  Moreover,  as  all  observers  agree, 
relatively  large  sequestra  maybe  expelled  or  removed  from  the  near 
neighbourhood  of  the  Fallopian  aqueduct  without  paralysis  being 
produced.  Nay,  mox'e  !  Bezold  has  even  seen  a  sequestrum  containing 
the  luhole  of  the  Fallopian  canal,  intact  and  entire,  "  without  the 
slightest  disturbance  of  facial  innervation."  And  I  myself  on  one 
occasion  removed  by  mastoid  operation  a  similar  piece  of  bone  from  a 
mass  of  granulations  in  the  labyrinth  region,  and  this  patient  also  did 
not  have,  and  never  had  had,  any  facial  paralysis  whatever !  Bezold 
assumed  that  the  facial  nerve  must  have  been  torn  through  and  become 
regenerated  again.  In  my  case  I  could  not  believe  that  the  canal  in 
the  bony  specimen  was  actually  and  in  very  sooth  the  Fallopian  canal. 

Further  information  is  needed  on  this  point. 
.  Purulent  Labyrinthitis. — Facial  paralysis  was  at  one  time  regarded 
as  a  common  symptom  of  purulent  labyrinthitis,  and  it  was  also 
supposed  that  the  sheath  of  the  facial  nerve  supplied  one  of  the  routes 
taken  by  infective  agents  to  reach  the  meninges.  Both  of  these  beliefs 
require  re-examination  in  the  light  of  modern  discovery. 

The  Fallopian  canal  and  its  contained  nerve  are  everywhere  separated 
by  bone  from  the  labyrinth  spaces.  Thus  we  should  expect  that  laby- 
rinthitis could  exist  without  any  facial  neuritis.  Such,  indeed,  clinical 
•experience  proves  to  be  the  case.  In  those  forms  of  labyrinthitis, 
generalised  and  purulent,  where  necrosis  of  bone  does  not  occur,  but 
where,  nevertheless,  the  infection  destroys  the  labyrinth  and  threatens 
to  or  actually  does  invade  the  meninges,  facial  paralysis  is  not  a  common 
symptom. 

On  the  other  hand,  as  we  have  just  seen,  when  the  labyrinth  is 
involved  in  osseous  necrosis  facial  paralysis  is  a  common  event. 

Therefore,  when  with  the  signs  and  symptoms  of  labyrinthitis  facial 
paralysis  exists,  the  probability  is  that  osseous  necrosis  is  present. 

This  inference  may  only  be  safely  drawn  from  the  fact  of  complete 
paralysis,  not  from  paresis,  because  facial  paresis  is  not  uncommon  in 
incipient  meningitis  or  in  cerebellar  abscess  secondary  to  non-necrosing 
purulent  labyrinthitis.  In  labyrinthitis  with  necrosis,  paresis  also 
occurs  but  it  is  less  frequent  than  paralysis,  as  1  is  to  50  (Gerber). 

As  regards  the  possibility  of  the  facial  nerve-sheath  supplying  a 
frequent  route  to  the  meninges  I  confess  to  some  scepticism.  The 
possibility  is  undoubted,  at  least  when  the  petrous  segment  becomes 
infected,  but  the  cases  upon  which  the  belief  is  founded  do  not  appear 
to  be  quite  unequivocal. 


208  The  Journal  of  Laryngology,  [juiy,  1920. 

One  of  the  earliest  reports  I  can  find  is  that  of  Darolles  (in  1875). 
The  case  was  one  of  acute  purulent  otitis  media  ;  there  was  facial 
paralysis  with  acute  meningitis,  due,  it  was  said,  to  the  eruption  of  pus 
into  the  aqueduct  and  thence  into  the  internal  meatus.  Post  viortem 
the  nerve  was  found  exposed  to  "  the  place  where  it  forms  its  second 
knee  in  the  hiatus  Fallopii."  But  there  is  no  report  on  the  condition  of 
the  labyrinth  sj^aces. 

Here  is  another  account,  also  an  early  one  (Kothholz).  The  patient, 
aged  twenty,  died  of  cerebellar  abscess  secondary  to  chronic  suppuration 
of  the  middle  ear.  Facial  paralysis  had  been  noticed  "  some  time  " 
before  death.  There  was  a  large  defect  in  the  Fallopian  canal  which 
the  author  believed  to  be  natural  and  not  pathological.  The  facial  nerve 
lay  free  in  the  tympanum  but  was  neither  thickened  nor  reddened, 
"  while  from  the  geniculate  ganglion  to  the  internal  auditory  meatus  it 
was  thickened  and  reddish-grey  in  colour.  In  the  whole  of  this  part  of 
its  course  the  Fallopian  canal  and  the  internal  auditory  meatus  were  full 
of  pus  ;  the  acoustic  nerve  showed  the  same  appearances  as  the  facial 
with  which  it  was  united  in  its  entire  length."  Hence  the  author 
naturally  supposed  that  the  infection  had  reached  the  meninges  by  the 
Fallopian  canal.  And  it  may  have  done  so.  But  there  still  remains 
this  to  be  said  that  "  in  the  labyrinth  spaces  opening  towards  the 
tympanum  there  were  considerable  collections  of  pus."  Obviously, 
therefore,  one  cannot  be  sure  whether  the  meningitis  in  this  case  was 
secondary  to  the  labyrinthitis  or  to  an  invasion  of  the  meninges  by  way 
of  the  facial  canal. 

Another  consideration  that  tends  to  make  us  sceptical  is,  that  if  the 
facial  canal  wei'e  an  open  road  to  the  meningeal  spaces  suppuration  of 
the  middle  ear  would  surely  lead  more  frequently  to  meningitis  than  it 
does. 

In  any  case,  before  accepting  the  teaching  that  invasion  of  the  facial 
canal  by  septic  organisms  is  a  common  cause  of  meningitis,  one  would 
need  to  be  supplied  wuth  cases  in  which  pathological  examination  had 
shown  that  meningitis  had  originated  from  facial  neuritis  without  the 
labyrinth  spaces  having  been  invaded. 

Course  and  Termination. — Facial  paralysis  from  suppurative  disease 
of  the  middle  and  internal  ear  either  comes  on  gradually,  and  then  it 
shows  variations  in  severity  from  time  to  time  from  the  varying  conduc- 
tivity of  the  nerve-fibres  at  the  affected  spot,  or  else  it  appears  suddenly 
with  or  without  such  premonitory  phenomena  as  clonic  spasms  of  the 
face.  In  such  cases  as  recover  also,  whether  spontaneously  or  after 
operation,  the  improvement  does  not  as  a  rule  atiect  all  the  branches  of 
the  nerve  alika^lnd  at  once. 

When  facial  paralysis  overtakes  a  patient  with  suppuration  of  the  ear 
no  amelioration  can  be  looked  for  as  long  as  the  suppuration  continues 
or  the  ear  is  not  operated  upon. 

Diagnosis. — If  in  a  case  of  facial  paralysis  or  paresis  there  is  sup- 
puration in  the  ear  of  the  paralysed  side  the  latter  may  be  assumed  to 
be  the  cause  of  the  paralysis,  and  this  regardless  of  a  history  of  "  cold  " 
or  "  rheumatism." 

We  may  appropriately  recall  again  at  this  place  the  fact  that 
otogenic  abscess  of  the  temporal  lobe  of  the  brain  may  induce  facial 
paralysis  of  the  central  type  on  the  opposite  side  from  the  disease  in  the 
ear. 

Prognosis. — The  chances  of   a  facial  paralysis  due  to  suppuration 


July,  1920.]  Rhinology,  and  Otology.  209 

getting  well  spontaneously  are  obviously  not  so  good  as  when  it  is 
caused  by  catarrh,  acute  or  subacute,  although  cases  have  been  recorded 
which  improved  under  simple  treatment  (G.  Bacon),  and  it  may  also 
get  well  after  paracentesis  of  the  membrane  when  the  suppuration  is 
acute. 

But  with  suppuration  the  infection  is  to  begin  with  more  severe, 
and,  as  we  have  seen,  the  paralysis  in  a  certain  proportion  of  cases  is 
due  to  the  extension  of  the  disease  to  the  bone,  in  which  case  a  con- 
tinuance of  the  suppuration  is  inevitable  and  with  it  also  a  persistence 
of  the  paralysis.  Obviously  the  prognosis  as  regards  the  paralysis  will 
depend  upon  the  exciting  cause  of  the  paralysis,  and  it  is  seldom  that 
we  are  able  to  determine  from  the  phenomena  manifest  what  the  exciting 
cause  is  in  any  particular  case. 

Tomka  thinks  that  in  childi'en  on  the  whole  the  prognosis  is  better 
than  in  adults  ;  better  in  acute  than  in  chronic  suppuration  ;  better  in 
the  suppuration  of  measles  and  typhoid  than  in  that  of  scarlet  fever  and 
diphtheria. 

A  good  sign  is  a  long-continued  normal  response  to  the  galvanic 
current,  while  its  loss  is  a  bad  sign,  indicating,  as  it  does,  atrophy  of  the 
face  muscles. 

Further,  the  sudden  onset  of  complete  paralysis  is  matter  for  mis- 
giving since  it  may  mean  that  the  nerve-trunk  has  been  completely 
severed,  whereas  a  slow  and  gi'adual  onset  means  perhaps  only  an 
invasion  of  the  nerve-fibres  by  the  septic  inflammation  without  their 
disruption.  For  the  same  reason  a  paresis  is  of  favourable  import  as 
far  as  the  facial  palsy  is  concerned,  inasmuch  as  it  indicates  that  the 
nerve,  though  damaged,  is  not  destroyed. 

In  these  cases  the  responses  to  the  hearing  and  vestibular  tests  are 
important,  because  if  the  signs  indicate  labyrinth  destruction  the 
presence  of  facial  paralysis  suggests  necx'osis  of  the  labyrinth  bone, 
whereas  ixiresis  may  be  due  to  the  extension  of  the  septic  process 
to  the  internal  auditory  meatus  or  to  the  cerebellum  or  meninges. 

It  is  a  peculiar  feature  of  the  condition  we  are  dealing  with  that 
operation  influences  prognosis.  A  paralysis  which  persists  after  the 
radical  mastoid  operation  and  the  cleaning  out  of  the  antro-tympanic 
cavities  is  likely  to  remain,  Schwartze  fixes  the  limit  after  operation 
when  evidence  of  recovery  may  be  expected  at  one  year  ;  if  the  paralysis 
persists  unaltered  for  any  longer  than  this  length  of  time  it  is,  in  his 
opinion,  hopeless. 

On  the  other  hand,  if  no  operation  has  been  performed  the  chances 
of  the  paralysis  recovering  after  operation  are  considerable,  and  it 
would  seem  as  if  even  the  lapse  of  a  considerable  period  of  time  does 
not  necessarily  prejudice  the  chances  of  recovery.  At  I'^xst  Vohsen  has 
reported  a  case  in  which  a  paralysis  of  seven  years'  duiation  got  well 
after  operation  ! 

In  necrosis  of  the  labyrinth  with  exfoliation  of  the  cochlea  and 
certain  parts  of  the  canalicular  region  facial  paralysis  is  often  transitory, 
but  in  necrosis  involving  the  entire  labyrinth  or  the  porus  acusticus 
the  prognosis  is  unfavourable  (Tomka). 

As  regards  the  bearing  of  facial  paralysis  upon  the  prognosis  of  the 
suppuration  and  its  sequelae,  otologists  agree  in  looking  upon  it  as  a 
danger-signal,  since  its  presence  indicates  an  extension  of  the  septic 
infection  to  regions  which  lie  close  to  the  brain.  Consequently  facial 
paralysis  occurring  in  suppuration  of  the  ear  is  an  absolute  indication 

14 


210-  The  Journal  of  Laryngology,  [juiy,  1920, 

for  an  immediate  radical  mastoid  operation,  not  only  in  order  to  cure 
the  paralysis,  but  also  to  put  a  stop  to  an  advance  of  the  disease- 
process  that  is  fraught  with  danger  to  life. 

With  reference  to  the  question  of  the  recovery  from  this  type  of 
paralysis,  caution  should  be  expressed.  As  in  traumatic  paralysis,  so  in 
paralysis  from  suppuration,  if  the  face  has  been  wholly  paralysed, 
complete  recovery  is  frequently  either  delayed  or  never  attained. 
Improvement,  even  great  improvement  takes  place,  but  it  stops  short  at 
complete  restoration  of  function.  The  eyelids  can  be  closed,  but  not  so 
tight  as  on  the  sound  side  ;  the  naso-labial  fold  is  again  manifest  but  it 
remains  less  deep  than  the  other  ;  the  patient  can  purse  his  lips,  but 
the  affected  side  is  looser  than  the  sound  side,  so  that  he  cannot 
whistle  as  he  once  could  ;  and  so  on. 

In  the  recovery  of  the  individual  groups  of  muscles  considerable 
variation  is  manifested.  There  is  a  general  impression,  which  I  at  one 
time  shared,  that  the  orbicularis  palpebrarum  is  the  first  to  regain  its 
power  of  movement,  and  perhaps  this  is  true  of  the  majority  of  cases, 
since  even  when  the  recovery  is  but  slight  the  eyelids  always  seem  to 
regain  the  power  of  closure.  The  orbicularis  oris,  on  the  contrary,  often 
lags  behind  the  other  muscles. 

But  there  is  no  absolute  rule.  Sometimes  the  first  voluntary  twitch 
is  seen  in  the  eyelid ;  sometimes  on  the  side  of  the  nose. 

It  must  be  remembered  that  no  improvement  can  be  looked  for  until 
the  exciting  cause  of  the  paralysis  has  been  removed,  and  that  even 
when  the  cause  is  removed  recovery  is  not  invariable,  nor  is  it,  as  we 
have  just  seen,  always  complete. 

On  the  other  hand — and  this  aspect  of  the  case  we  shall  discuss 
more  fully  in  a  later  section — once  the  cause  has  been  removed,  a  certain 
amount,  a  minimum  of  recovery,  may  be  almost  always  anticipated. 

[To  he  continued.) 


SOCIETIES'    PROCEEDINGS. 


ROYAL  SOCIETY  OF  MEDICINE.-LARYNGOLOGICAL 

SECTION. 


June  7,  1918. 


President :  Dr.  A.  Brown  Kelly. 


Abridged  Report. 


{Continued  from  p.  186.) 

Mr.  Herbert  Tilley  :  I  want  to  bring  forward  a  method  I  have 
found  useful,  but  I  do  not  claim  that  it  is  new.  I  have  used  it  for 
stenoses  of  the  trachea  caused  by  bullet  wounds  or  other  injuries.  The 
mechanism  is  an  oidinary  tracheotomy  tube  with  a  perforation  about 
^  in.  behind  the  collar,  which  admits  a  pliable  and  hollow  lead  tube. 
This  extends  upwards  through  the  whole  extent  of  the  stenosis,  and  the 
calibre  of  the  tube  is  enlarsred   as   the  stenosis  becomes  dilated.     The 


Jaly,  1920.1 


Rhinology,  and  Otology.  211 


ti-acheotomy  opening  should  be  made  "well  below  the  stenosis,  and  then 
the  constricted  portion  opened,  granulations  and  connective  tissue  care- 
fully dissected  away,  and  the  tracheotomy  tube  with  the  lead  dilator 
inserted.  In  this  way  the  larynx  is  spared  functional  activity,  and  the 
lead  plug  can  not  only  be  taken  out  and  cleaned,  but  it  can  be  bent  to 
fit  the  parts.  The  difficulty  of  knowing  when  the  upper  part  of  the  lead 
tube  is  level  with  the  upper  part  of  the  stenosis  is  overcome  by  direct 
laryugo-tracheoscopy.  At  the  end  of  three  weeks  the  tube  is  taken  out 
and  replaced  by  a  wider  one.  Complete  dilatation  may  be  a  matter  of 
two  to  four  months,  which  one  need  not  apologise  for  in  this  difficult 
kind  of  stricture.  I  am  a  great  believer  in  doing  a  low  tracheotomy, 
and  W'ell  below'  the  strictured  parts.  Mr.  Harmer,  quoting  Kocher, 
says  the  higher  the  tracheotomy  the  better.  My  cases  have  done  better 
with  the  lower  opening :  the  patient  is  more  comfortable  and  the  after- 
treatment  is  easier.  Where  the  larynx  is  involved  and  there  is  stenosis 
and  ankylosis  in  the  arytsenoid  region,  I  do  not  know  any  treatment 
which  will  cure.  I  think  most  of  such  cases  will  be  condemned  to 
wearing  a  permanent  tracheotomy  tube. 

I  have  little  to  add  concerning  the  neurotic  cases,  but  I  agree  with 
Mr.  O'Malley  that  much  depends  on  the  personality  of  the  surgeon.  If 
the  latter  shows  or  expresses  any  doubt  about  effecting  a  cure,  he  will 
probably  fail  with  these  cases.  If  you  tell  them  they  will  be  cured 
immediately,  it  is  surprising  in  what  a  large  number  the  voice  is  restored 
forthwith,  and  does  not  relapse. 

Mr.  C.  E.  Jones-Phillipsox  :  I  have  treated  many  cases  of  laryn- 
geal and  gas  affections  in  the  past  two  and  a-half  years,  and  would  like 
to  say  a  word  on  conditions,  not  hitherto  spoken  of,  which  lead  to 
functional  aphonia.  One  is  when  two  sides  of  the  larynx  ai'e  not  acting 
in  co-ordination.  I  have  seen  this  in  six  cases  :  The  right  vocal  cord  has 
approximated  to  the  mid-line  in  attempted  phonation,  while  the  opposite 
coi'd  has  been  in  the  position  of  full  abduction,  or  at  any  rate  is  tucked 
away  beneath  the  false  cord.  When  this  cord  makes  for  adduction,  the 
opposite  coi-d  swings  out  to  the  position  of  full  abduction,  so  no  voice  is 
produced.  Another  condition  shows  extreme  over-adduction  of  the  cords 
with  full  expiratory  effort,  so  no  voice  results,  and  the  patieiit  turns  red 
in  the  face  in  the  attempt.  I  have  examined  patieuts  within  twelve 
hours  of  "  gassing,"  and  'seen  them  many  months  later.  The  first  stage 
is  one  of  acute  irritation  of  the  entire  respiratoiy  tract,  but  long  before 
the  acute  hypersemic  stage  the  patient  takes  on  a  whispering  voice,  due 
largely  to  the  irritative  cough,  which  is  the  first  symptom.  The  condi- 
tion of  the  larynx  and  pharynx  is  more  marked  within  the  first  forty-eight 
hours.  At  this  time  it  is  common  t  >  see  a  yellowish  wash-leather-like 
slough  on  the  pharyngeal  wall,  the  inflammation  from  which  spreads  to 
the  lai'ynx,  causing  swelling  of  the  arytsenoid  region ;  a  red  mass  in  that 
region  is  frequently  seen  coupled  with  a  muco-purulent  secretion.  I 
maintain  that  the  third  stage  is  productive  of  three  conditions.  Often 
as  the  first  sec^uel  there  is  a  chronic  laryngitis,  with  the  ordinary  paretic 
conditions,  of  which  the  most  common  is  the  elliptical  and  double 
arytsenoids.  Secondly,  the  vocal  cords  may  be  quite  normal ;  the  acute 
condition  having  svibsided,  you  find  pale  swellings  in  the  a ry tsenoid 
region.  The  third  sequel  is  true  functional  aphonia,  of  which  the 
paretic  varieties  are  many.  The  vocal  cords  may  be  of  normal  colour 
and  the  arytsenoid  swellings  may  have  disappeared,  but  there  is  a  pai-etic 
condition,  which  I  have  found  easily  curable  in  France  but  difficult  in 


212  The  Journal  of  Laryngology^  [jniy,  1920, 

cases  in  England,  from  which  I  gather  that  the  cases  sent  home  are 
either  the  worst  or  the  most  persistent  types,  or  too  many  of  these  cases 
are  crowded  into  one  hospital,  where  they  communicate  with  each  other 
in  whispers  and  never  improve.  I  had  a  case  of  recurrent  nerve  paralysis 
of  the  left  vocal  cord,  which  was  examined  by  a  physician,  and  no 
skiagraphic  evidence  in  the  chest  could  be  found  to  account  for  it.  He 
remained  in  that  condition  one  week,  then,  following  the  advice  of 
Mr.  O'Malley,  I  bnskly  rubbed  the  phar\-ngeal  wall  with  the  mirror,  a  id 
he  recovered  completely.  I  found  that  the  man  had  had  hoarseness 
some  months  previously,  and  it  had  suddenly  disappeared. 

Mr.  A.  E.  Hayward  Pixch  :  I  have  only  had  a  few  cases  of  gunshot 
wounds,  and  those  have  not  been  in  my  hands  for  radium  treatment 
more  than  three  months  at  the  outside.  To  get  away  scar-tissue  in  these 
laryngeal  cases  you  must  proceed  with  great  caution,  otherwise  there  will 
be  an  extensive  reaction  and  great  oedema  of  the  glottis,  possibly  requiring 
the  performance  of  tracbeotomy.  In  some  cases  nerve  may  be  involved 
in  scar-tissue.  Heavily  screened  applicators  have  to  be  used,  and  a 
considerable  time  must  elapse  before  beneficial  results  l^ecome  evident. 
I  can  tell  you  of  a  case  which  may  throw  some  light  on  the  subject.  In 
1912,  a  lady  singer  was  brought  to  me:  she  was  of  considerable  pro- 
fessional eminence,  aged  thirty.  She  developed  a  thyro-adenoma.  An 
eminent  surgeon  removed  it  with  great  skill.  All  went  well  for  twa 
months,  and  then  hoarseness  developed,  and  gradually  became  very 
pronounced.  A  laryugologist  found  definite  adductor  paresis  of  the  left 
vocal  cord.  The  idea  was  that  there  was  scar  implication  of  the  recurrent 
laryngeal  on  that  side  from  the  operation.  Further  opei'ation  was 
negatived,  and  the  surgeon  brought  her  to  me  to  see  what  radium 
would  do.  The  first  thing  which  struck  me  was  that  the  scar  of  the 
operation  was  becoming  keloidal,  and  1  thought  there  might  be  excessive 
scar-tissue  implicating  the  laryngeal  nerve.  Radium  applicators  were 
used  screened  with  1  mm.  of  silver.  I  gave  her  a  week's  treatment,  and 
she  came  back  in  two  mouths'  time  with  the  hoarseness  much  hss 
evident,  and  we  thought  there  was  slight  return  of  movement  of  the  left 
cord.  We  gave  her  the  treatment  on  three  more  occasions,  and  she 
recovered  her  voice,  and  is  again  getting  a  handsome  income  as  a  singer. 
Mr.  Harmer  has  sent  me  cases  of  gunshot  wound  of  the  larynx  to  treat 
with  radium,  but  the  greater  number  are  extremely  severe  ones,  and  I 
doubt  if  I  can  do  much  for  them.  But  in  one  of  the  cases  there  is  a 
mass  of  scar-tissue  in  the  inter-arytaenoid  region,  with  incomplete 
adaptation  of  the  cords,  and  as  it  is  partly  keloidal  I  ho]>e  to  get  a 
definite  result.  It  is  as  yet  too  soon  to  make  a  definite  pronouncement 
as  to  the  effects  of  radium  therapy  in  these  cases. 

Sir  StClair  Thomson  :  AVas  the  cord  of  the  lady  singer  seen  to  move 
again  ?  I  have  heard  people  siny  who  have  had  permanent  paralysis  of 
one  vocal  cord.  [Mr.  Pinch  :  The  point  has  not  been  raised  before,  Init 
I  do  know  she  is  again  singing  well.]  By  adaptation  and  l^enefitiug  by 
teaching,  these  cases  with  an  absolutely  paralysed  cord  can  go  on  the 
concert  stage  again.  In  connection  with  Mr.  Pinch's  remarks,  I  suggest 
that  the  laryngologist  should  not  be  hasty  in  blaming  surgeons  for 
cutting  the  i-ecurrent  laryngeal  nerve  at  operations  for  enlarged  thyroid. 
I  have  seen  this  condition  come  on  several  weeks  after  operation.  I 
think  it  occui-s  in  cases  which  do  not  heal  by  first  intention,  but  have 
suppurated,  and  the  recurrent  nerve  becomes  implicated  in  the  contracted 
scar. 


July.  1920.]  Rhinolo§:y,  and  Otology.  213 

From  such  a  -wealtli  of  material  we  ought  to  draw  some  general 
■deductions.  One  of  these  is  the  great  teudencv  of  scars  of  the  larynx  to 
contract,  such  as  is  seen  in  the  cases  of  web  formation  in  tlie  anterior 
■commissure.  In  many  instances  I  attribute  this  to  the  perichondritis 
which  occurs  and  the  subsequent  contraction.  The  next  general  deduction 
is  the  importance  of  resting  the  larynx.  "We  learn  it  not  so  much  from 
these  cases  as  from  what  we  learn  elsewhere.  There  are  a  number  of 
cases  of  lupus  of  the  larynx  which  get  well  without  any  other  treatment 
than  putting  in  a  tracheotomy  tube,  which  rests  the  larynx.  That  brings 
me  to  the  point  that  in  these  cases  tracheotomy  is  still  our  stand-by. 
Mr.  Harmer  savs  tracheotomy  "may  be  necessary  in  any  form  of  stenosis." 
I  might  almost  say  it  is  necessary  in  all  forms,  if  we  are  agreed  as  to 
what  stenosis  is,  for  there  are  various  degrees.  My  standard  is,  that  if  a 
patient  has  laryngeal  stridor  when  he  is  at  rest  or  asleep,  he  has  got  a 
•stenosis  which  requires  treatment.  Several  of  the  cases  in  the  next  room 
now  have  stenosis,  but  are  going  about  without  a  tube :  they  do  not 
notice  the  need.  I  am  insistent  not  only  on  the  need  for  tracheotomy, 
but  that  the  tube  should  be  inserted  low  enough,  and  that  it  should  not 
be  taken  out  too  soon.  The  top  of  the  tracheotomy  tube  should  be  just 
above  the  sternum.  The  first  reason  for  that  is,  that  it  is  a  tremendous 
convenience  for  the  patient :  the  lower  down  it  is,  the  less  is  it  subject  to 
the  various  movements  of  the  neck,  and  the  friction  and  irritation  in 
consequence.  A  tracheotomy  tube  low  down  does  not  irritate  the  trachea: 
these  cases  do  not  get  tracheitis  leading  on  to  bronchitis  and  death. 
Again,  it  is  easier  for  a  lady  to  hide  it  there,  and  for  a  man  also.  Also, 
it  is  far  awav  from  the  danger  region,  i.  e.  the  subglottic.  We  know 
the  rich  lymphatic  area  below  the  vocal  cords,  which,  if  wounded,  leads 
to  contraction.  When  tracheotomy  is  done  for  tubercle,  or  for  malignant 
disease,  the  farther  away  it  is  from  the  disease  the  less  likely  is  infection 
of  the  wound— if  it  occur  at  all.  I  would  only  make  one  exception — the 
lower  the  tracheotomy  tube  is  in  the  neck,  the  more  difficult  it  is  to  get 
the  dilator  up.  Mr.  Harmer  and  I  have  discussed  this  point,  and  we 
agree  that  if  we  know  there  is  stenosis  in  the  larynx  which  can  possibly 
be  dilated  later  on  from  below,  then  there  is  a  disadvantage  in  low 
tracheotomv.  If  we  have  a  discussion  on  the  subject  some  day,  I  could 
refer  to  an  old  lady  aged  eighty  who  had  worn  a  tracheotomy  tube  for 
fifty  years. 

I  am  disappointed  that  in  the  paper  and  the  discussion  we  have  not 
heard  more  of  the  results  of  two  other  methods.  One  is  laiwngo- 
tracheostomy.  I  have  no  experience  of  it,  but  I  would  like  to  hear,  from 
Mr.  Hanner  or  others,  what  the  results  are  and  whether  it  is  worth 
■adopting.  The  other  point  concerns  intubation  tubes.  If  I  had  known 
•earlier  in  life  of  the  work  of  Dr.  Eogers  and  Dr.  Delavan,  of  New  York,  I 
would  have  tried  more  to  carry  out  their  principle  of  long-continued 
intubation  for  these  cases.  In  this  country  we  are  apt  to  think  that  you 
■can  take  out  your  intubation  or  tracheotomy  tube  soon.  Several  of  the 
patients  in  the  next  room  wovild  find  out  they  were  starved  for  air  if  they 
were  to  rush  for  a  train  after  eating  a  hearty  dinner  or  if  they  were  to 
have  a  rough  cross-Channel  journey  and  were  sick. 

Another  point  concei-ns  repair  of  the  divided  recuri'ent  laryngeal 
neiwe.  I  mention  it  as  a  warning.  I  have  had  only  one  case  of  it — 
namely,  in  a  Dominion  officer  who  had  complete  paralysis  of  one  vocal 
cord  from  wound  of  his  recurrent  laryngeal  nerve.  I  saw  him  in 
•consultation  and  told  him  he  would  have  to  put  up  with  it  for  the  rest  of 


214  The  Journal  of  Laryngology,  juiy,  1920. 

his  life.  A  vouug  surgeon,  who  has  a  reputation  as  a  nerve  surgeon, 
said  he  would  cut  down  on  it  and  tie  the  ends  together.  Asked  if  it  was 
an  easy  job.  he  replied  he  was  used  to  tying  nerves  together  !  I  heard 
the  usual  sequel — he  never  got  hold  of  the  ends  of  the  nerve.  Paralysis 
of  the  recurrent  laryngeal  we  all  look  upo-n  as  due  to  some  in-emovable 
condition,  like  aueuiTsm  or  malignant  disease  of  the  cesophagus,  and  it  is 
only  in  recent  years  I  have  learned  that  it  can  be  recovered  from.  My 
experience  of  this  is  chiefly  in  one  walk  of  life,  and  that  is  seeing  tuber- 
culosis patients  at  a  sanatorium.  I  have  seen  six  or  eight  cases  of 
distinct  paralysis  of  one  vocal  cord  from  a  lesion  of  the  recurrent 
laryngeal,  no  doubt  due  to  tubercular  pleurisy,  in  which  the  movement  of 
the  cord  has  recovered. 

Dr.  Smui'thwaite  has  given  us  great  help  by  the  review  of  his  cases, 
and  I  should  like  to  know  more  of  his  method  in  functional  aphonia.  I 
learned  from  him  in  private  that  the  great  thing  is  to  get  the  patient 
alone  and  try  to  succeed  at  the  first  sitting ;  otherwise,  as  in  operations 
for  cancer,  one  may  succeed  with  a  first  try,  but  rarely  with  a  second. 

Mr.  Mark  Hovell  :  As  so  much  has  been  said  about  tracheotomy, 
and  there  are  present  to-day  so  many  surgeons  from  military  hospitals,  I 
wish  again  to  call  attention  to  the  great  comfort  to  the  patient  arising 
from  the  insertion  of  a  piece  of  elastic  into  the  tapes  which  hold  the 
tube  ;  3  in.  of  elastic  on  each  .'>ide  is  sufficient.  This  arrangement  was 
inti'oduced  by  Sir  Morell  Mackenzie  half  a  century  ago,  but  is  still  com- 
paratively unknown. 

Dr.  JoBSON  HoRNE  :  The  all-important  question  in  the  discussion  on 
warfare  neuroses  of  the  larynx  is,  What  is  "  functional  aphonia  "  ?  The 
term  is  bad.  In  all  these  cases  we  must  decide  Avhether  the  aphonia  is  a 
neurosis  due  perhaps  only  to  astlienia  or  not ;  we  must  exclude  organic 
diseases  of  any  kiud,  especially  the  aphonia  dixe  to  an  interstitial 
myositis,  following  upon  a  prolonged  catarrhal  condition,  such  as  the 
cases  which  came  from  Flanders  during  the  winter  campaigns.  And, 
before  all,  we  must  exclude  the  possibility,  liowever  remote,  of  tuber- 
culosis. In  the  absence  of  organic  disease,  I  do  not  think  there  is  so 
much  difficulty  in  bringing  home  to  these  people  the  fact  that  they  can 
speak.  If  it  is  not  a  neurosis,  then  by  trying  to  make  the  patient  speak 
we  are  doing  him  definite  harm. 

Mr.  W.  Stuart-Low  :  The  case  I  have  shown  emphasises  the  im- 
poi-tance  of  low  tracheotomy  and  also  of  leaving  the  tube  in  long  enough. 
What  I  find  useful,  and  what  military  men  may  also  find  so,  in  order  to 
get  rid  of  sepsis  and  to  prevent  and  diminish  cicatrisation,  is  to  attend 
to  the  teeth  by  means  of  mouth-washes  and  to  rub  ammoniated  mercuiy 
ointment  into  the  neck  regularly  for  weeks.  Also,  in  acute  cases  where 
congestion  and  oedema  of  the  larynx  have  occurred  dry-cupping  should 
be  applied  to  the  neck  over  the  outside  of  the  larynx  the  position  of  the 
cups  being  changed  from  side  to  side.  This  man,  who  came  in  such  an 
acute  condition,  was  treated  by  the  employment  of  the  dry-cupping 
method.  This  treatment  was  described  in  "  Dry-cupping  in  Laryngeal 
Affections,"  in  the  -Lance/,  January  23,  1915.  By  means  of  the  laryngeal 
mirror  one  can  see  the  diminution  of  the  vascularity  of  the  vocal  cord 
and  the  swelling  of  the  ventricular  band  and  arytsenoid  processes  visibly 
diminishing  while  the  dry-cupping  is  being  applied. 

With  regard  to  neurasthenic  cases  I  am  sure  these  men  smoke  too 
much.  One  of  my  soldier  patients  was  smoking  forty  cigarettes  a  day. 
These  I  cut  down  to  fifteen  and  finally  to  six,  and  then  I  let  him  out  in 


July,  1920.]  Rhinology,  and  Otology.  215 

the  sun  on  condition  that  lie  did  not  smoke.  Fresh  air  and  sun  are 
most  beneficial  to  these  neurasthenic  cases,  and  basking  in  the  sun 
together  with  tine,  nux  vom.  did  this  man  much  good,  and  greatly 
hastened  his  recovery.  Tobacco  dries  up  the  larynx  and  pharynx,  and  is 
a  soui'ce  of  harm  to  many  patients,  particularly  neurasthenic  cases. 

Mr.  Whale  :  With  regard  to  Mr.  Stuart-Low's  conclusions,  I  would 
like  to  criticise  the  first  point,  the  advisability  of  letting  shrapnel  rest  in 
the  tissues.  Of  course  Mr.  Stuart-Low  has  got  a  very  nice  result,  but 
I  do  not  think  it  is  safe  to  generalise  from  that.  During  the  last 
twenty-one  months  I  have  been  dealing,  almost  exclusively,  with  wounds 
above  the  clavicle  in  France,  and  many  of  the  men  have  been  wounded 
in  the  larynx.  I  cannot  remember  a  case  in  which  I,  or  anyone  else 
working  in  that  department,  regretted  opening  the  tissues  widely  ;  but 
I  I'emember  cases  in  which  patients  have  died  without  being  opened  up, 
and  would  not  probably  have  done  so  if  we  had  acted  differently.  Cases 
in  which  small  bodies  enter  high  in  the  head  or  neck  and  finish  low 
down  seem  to  do  well  for  a  day  or  two,  but  then  they  have  a  high 
temperature  and  a  running  pulse  with  extraordinary  fluctuations,  and 
asymmetry  of  pupils,  and  die  of  abscess  round  the  vagus,  the  process 
involving  also  the  sympathetic.  I  do  not  think  it  is  safe  to  leave  foreign 
bodies  in  the  neck  at  all.  As  in  civil  cases  you  get  ulceration  of  the 
carotid  sheath  by  leaving  a  tube  in  the  neck  three  or  four  days,  how  can 
it  be  safe  to  leave  shrapnel  in  that  neighbourhood  Y  It  seems  to  me 
quite  wrong. 

Mr.  Mark  Hoveli.  :  1  think  it  is  an  opi:)ortune  occasion  to  call 
attention  to  the  use  of  the  term  "functional  aphonia."  I  do  not  want  to 
carp  at  those  who  have  used  the  term,  as  it  is  an  accepted  term,  although 
obviously  incorrect.  The  function  of  the  voice  is  to  produce  sound, 
therefore  want  of  sound  cannot  be  functional.  I  suggest  as  an  alternative 
the  term  "  neurasthenic  aphonia,"  to  distinguish  it  from  loss  of  voice  due 
to  obvious  mjury  or  a  definite  nerve- lesion.  The  term  being  incori-ect, 
1  think  it  is  for  our  Section  to  say  so,  and  to  bring  about  reform.  The 
incorrect  term  is  copied  from  text-book  to  text-book,  and  thus  becomes 
of  common  use. 

The  President  :  I  wish  in  the  first  place  to  condemn  any  arrange- 
ment whereby  patients  suffering  from  neuroses  of  the  larynx  are  placed 
under  a  medical  man  who  cannot  make  laryngeal  examination,  or  who, 
without  such  an  examination,  proceeds  to  carry  out  treatment.  Dr. 
Jobson  Home's  remarks  lead  me  to  say  that  many  of  our  aphonic 
soldiers  are  not  suffering  from  a  functional  neurosis  but  from  the  results 
of  laryngitis  caused  by  cold  or  gas,  or  from  weakness,  exhaustion,  early 
tuberculosis,  or  organic  paralysis,  or  they  may  be  simulating. 

During  acute  laryngitis  some  patients  whisper  in  order  to  conserve 
thpir  voices,  and  after  the  inflammation  has  subsided  the  aphonia  persists 
until  they  are  taught  how  to  overcome  it.  A  partial  knowledge  of  this 
fact  is  taken  advantage  of  by  a  few  men  who  pretend  to  be  voiceless,  and 
it  is  difficult  to  distinguish  this  condition  from  real  aphonia  :  they  usually 
capitulate,  however,  to  faradisui  or  painting  the  larynx. 

Aphonia  may  also  be  due  to  a  variety  of  laryngitis  which  has  not 
been  mentioned,  viz.  exudative  or  fibrinous.  This  is  not  a  neurosis,  but 
it  can  be  classed  as  a  warfare  injury,  for  I  have  not  seen  it  in  civilian 
practice,  whereas  last  year,  after  the  cold  weather,  I  had  about  a  dozen 
cases.  The  vocal  cords  are  more  or  less  red,  and  on  the  middle  of  the 
ligamentous  portion  a  white  patch  is  present. 


216  The  Journal  of  Laryngology,  [juiy,  1920. 

The  action  of  gas  011  the  larynx  used  to  be  of  but  little  account,  but 
the  cases  which  come  into  hospital  now  suffering  from  the  effects  of 
mustard  shells  may  present  large  areas  of  exudation  on  the  posterior 
wall  of  the  pharynx  and  smaller  patches  in  the  larynx.  On  Wednesday 
I  saw  ten  such  cases.  Most  of  them  had  conjunctivitis,  and  were  sent 
from  the  eye  department. 

Reverting  to  neuroses  of  the  larynx,  I  have  been  surprised  that  so 
little  has  been  written  or  said  in  this  country  regarding  spastic  aphonia, 
which  the  war  shows  to  be  fairly  common.  Dr.  SinurtliAvaithe,  Mr. 
O'Malley  and  another  speaker  have  referred  to  this  class  of  cases,  with- 
out applying  the  term.  [Dr.  Smurthwaite  :  I  called  it  tonic  spasm.] 
In  future,  when  speaking  of  hysterical  or  functional  aphonia,  it  will  be 
necessary  to  distinguish  the  paralytic  from  the  spastic  variety. 

The  laryngeal  appearances  in  aphonia  paralytica  vary  greatly,  but  too 
much  attention  should  not  be  paid  to  what  muscles  are  involved,  for  the 
same  patient  may,  at  different  times,  present  an  entirely  different  picture. 
It  should  also  be  remembered  that  all  the  appearances  observed  in  func- 
tional aphonia  may  be  produced  by  whispering  :  thus,  in  one  person  the 
glottis  may  assiune  the  form  of  an  isosceles  triangle,  in  another  it  may 
be  elliptical,  and  in  another  merely  a  triangular  gap  in  the  posterior 
third.  Although  the  appearances  are  those  of  pareses,  pareses  as  such  do 
not  exist,  because  on  painting  the  larynx  in  most  of  these  cases  the  cords 
come  together,  but  on  asking  the  patients  afterwards  to  speak  they  are 
still  voiceless. 

In  spastic  aphonia  the  picture  during  phonation  varies  :  in  the  slight 
forms  the  anterior  portions  of  the  false  cords  meet ;  while  in  the  most 
marked  forms  the  epiglottis  is  depressed,  the  arytsenoids  drawn  forwards, 
and  no  view  is  obtainable  of  the  interior  of  the  larynx.  A  common 
variety  is  that  in  which  the  anterior  two-thirds  of  the  false  cords  meet, 
and  in  the  gap  between  them  posteriorly  a  small  portion  of  the  true 
cords,  also  slightly  apart,  is  seen.  This  condition  of  spastic  aphonia 
explains  the  cases  in  which  the  chief  or  only  feature  is  a  triangular  gap 
in  the  cartilaginous  glottis — a  case  of  the  kind  was  shown  at  our  last 
meeting  by  Dr.  Banks -Davis. ^  It  seems  to  me  that  the  small  triangular 
gap  is  not  due,  as  is  generally  supposed,  to  paralysis  of  the  ti-ansversus, 
but  to  the  excessive  action  of  the  thyro-arytaeuoideus.  When  this 
muscle  contracts  strongly  it  draws  the  epiglottis  and  the  arytsenoid 
together,  and  this  action  prevents  the  full  contraction  of  the  transversus, 
hence  the  gap.  It  has  been  suggested  that  the  excessive  action  of  the 
false  cords  is  to  overcome  the  opening  due  to  the  imperfect  action  of  the 
transversus,  but  if  you  work  at  a  case  you  can  get  this  opening  closed 
completely  and  still  the  patient  is  aphonic. 

X-ray  examination  of  the  diaphragm  sometimes  helps  one  to  under- 
stand the  nature  of  the  disability.  The  excursion  may  be  too  small 
during  respiration,  or  on  phonation  the  diaphragm  may  rise  very  quickly, 
showing  there  is  no  resistance  to  the  expired  air,  or  it  may  not  rise  at  all, 
showing  that  the  glottis  is  lirmly  closed. 

With  regard  to  treatment,  I  divide  patients  with  functional  aphonia 
into  two  classes  :  (1)  Those  easily  cured ;  (2)  those  cured  with  difficulty, 
or  not  at  all.  Most  laryngologists  have  a  favourite  method  of  treatment, 
which  they  try  first,  and  only  if  that  fails  do  they  try  another,  but  as  the 
majority  of  cases  are  easily  cured  and  yield  to  the  measure  first  employed, 
while  the  remainder  prove  obstinate  to  all  measures,  each  laryngologist 

'  Proceedings,  p.  163. 


July,  1920.]  Rhinology,  and  Otolo§ry.  217 

comes  to  regard  his  pet  method  as  tlie  best.  I  do  not  think  it  matters 
what  method  is  used,  provided  it  be  carried  out  with  decision  and  perse- 
verance. •  As  a  prehminary  to  the  treatment  of  cjuestiouable  characters 
it  is  useful  to  confine  them  to  bed  in  a  room  by  themselves  or  screened 
off ;  allow  no  visitors,  tobacco,  or  literature,  and  thei'e  is  no  hami  in 
occasionally  forgetting  a  meal.  I  cause  patients  to  intone,  and  in 
most  cases  a  cure  is  effected  at  the  first  sitting.  Faradism  has  only 
helped  me  when  simulation  was  practised.  General  ansesthesia  and 
massage  have  failed  in  my  hands. 

With  regard  to  the  treatment  of  stammering,  I  have  nothing  favour- 
able to  say.  I  had  five  patients  at  one  time,  and  I  got  a  highly 
experienced  lady  to  give  them  tieatment,  but  at  the  end  of  three  months 
they  were  no  better.  I  think  that  patients  with  shell-shock  stammering 
are  best  left  to  themselves. 

I  have  treated  eleven  mute  patients :  eight  were  cured  completely, 
two  stammered  afterwards,  and  one  had  to  be  discharged  from  the  Army 
still  mute.  The  last  referred  to  wrote  me  later  that  he  had  recovered  his 
speech  after  having  been  nearly  run  over. 

Mr.  CoRTLANDT  MacMahon  :  My  experience  in  shell-shock  stammer- 
ing has  been  largely  at  Palace  Green  and  at  St.  Bartholomew's  Hospital. 
I  read  a  paper  on  the  subject  last  year  at  the  Medical  Society  of  London, 
reported  in  vol.  xxxix  of  the  Society's  Transactions.  In  a  large 
number  of  these  cases  the  prognosis  is  good,  the  patient  soon  regains 
a  good  speech,  and  it  is  the  easiest  class  of  case  I  know  to  treat,  provided 
one  can  get  past  a  cei'tain  stage.  I  have  had  one  or  two  disappointments 
in  cases  which  had  been  goiug  on  well  until  upset  by  air  raids,  and  it 
became  useless  to  try  again  until  the  patients  had  been  sent  away  from 
London.  A  discharged  soldier  who  arrived  at  St.  Bartholomew's  three 
months  ago  with  stammering  is  back  again  in  the  Army.  Shell-shock 
stammering  seems  to  me  to  be  best  treated  by  counter- stimulation — 
namely,  stimulating  the  abdominal  viscera  by  the  strong  descent  of  the 
diaphragm,  so  that  the  blood-supply  to  these  organs  is  increased.  I 
agree  with  Dr.  Smurthwaite  as  to  the  importance  of  securing  relaxation, 
mental  and  physical ;  when  that  is  acquired  work  on  the  speech  is 
commenced.  If  a  man  has  been  a  stammerer  in  early  youth,  the  con- 
dition may  be  resuscitated  by  shell-shock.  These  cases  take  a  long  time 
to  improve. 

Dr.  ScANES  Spicer  :  I  cannot  think  Mr.  MacMahon's  views  as  stated 
are  cjuite  consistent  with  each  other  in  that  he  says  he  aims  at  inferior 
costal  respiration  and  yet  seeks  descent  of  the  diaphragm  on  inspiration. 
I  believe  what  he  really  does  in  practice  is  to  raise  and  fix  the  abdominal 
viscera  by  the  muscles  of  the  abdominal  wall  (recti,  obliqui,  etc.)  so  that 
these  viscera  form  a  fulcrum  for  the  centi'ifugal  action  of  the  diaphragm, 
quadrati  lumboruni,  etc.,  in  expanding  the  lower  mai'gin  of  the  thoracic 
cage — which  is  inferior  costal  inspiration.  Then,  on  expiration,  there  is 
a  conscious  contraction  or  willed  intensification  of  action  of  the  abdominal 
walls  which  compresses  the  abdominal  viscera,  tends  to  empty  the  portal 
system,  and  so  forces  on  the  blood  to  the  right  ventricle  and  later  on  to 
the  brain.  Hence  there  is  a  sticf  ion-pump  action  of  the  expanding  thorax 
in  inspiration,  and  a  force-pump  action  of  the  abdominal  muscles  on 
expiration,  both  acting  in  the  same  sense  of  pi'omoting  the  general  blood 
circulation  and  hence  the  blood-supply  to  the  brain,  including  the  higher 
co-ordinating  centres  which  in  functional  aphonia  and  stammering  are 
hors  de  comhat. 


218  The  Journal  of  Laryngology,  [juiy,  1920. 

I  fui'tlier  believe — a  matter  uo  one  to-day  has  referred  to — that  an 
essential  preliminary  to  rapid  and  lasting  success  in  overcoming  the 
neurasthenia  from  which  these  mute  and  stammering  men  suffer  is  the 
setting  up  of  the  human  machine  by  posture,  so  that  it  can  and  does  act 
to  maximum  advantage  as  a  machine,  and  that  all  breathing  and  other 
physical  exercises  and  training  are  done  in  and  from  that  posture. 

This  is  effected,  in  a  sitting  j)osture,  by  consciously  straightening  up 
and  stretching  up  the  spinal  column  to  the  fullest  extent.  The  effect  of 
this  is  the  enlargement  of  the  thoracic  cage  and  its  being  brought  into  a 
state  of  easy  poise  and  free  mobility,  and  to  replace  the  collapsed  and 
sagging  viscera  of  the  thorax,  abdomen,  etc.,  into  their  normal  position 
and  natural  relations. 

Neurasthenics  are  practically  all  in  a  state  of  physical  collapse  as  well 
as  mental  weakness.  Their  visceral  organs  are  (relatively  to  the  normal) 
in  a  condition  of  ptosis,  they  are  compressed  and  congested  with  the 
functioning  tissues,  channels,  vessels,  ducts  and  neiwe  tracts  obstructed 
from  tbe  abnormal  positions  and  altered  relative  pressures  of  the  organs, 
etc.,  upon  each  other.  Hence  the  ideas  of  "  Hold  up  your  head," 
"  Straighten  and  stretch  up  your  back,"  and  "  Sursum  corda  "  are  essential 
preliminaries  to  treatment.  The  patient  mvist  consciously  adopt  these 
ideas  and  carry  them  out  in  his  own  body,  and  the  breathing  and  other 
physical  exercises  should  always  be  done  in  and  from  this  posture,  at 
first  sitting  on  a  stool  of  the  appropriate  height.  Later  he  can  commence 
any  voice  or  speech  training  indicated  with  the  usual  "  ah  "  sound  both 
phonated  and  whispered,  but  his  attention  should  always  be  kept  off  his 
larynx.  The  rapidity,  progress  and  permanency  of  recovery  were  often 
quite  remarkable  following  these  measures,  not  only  in  voice  and  speech 
but  generally  in  neurasthenia  and  shock. 

I  do  not  share  Mr  Mark  Ho  veil's  objection  to  the  term  "  functional 
aphonia,"  since  it  merely  serves  to  contrast  and  define  aphonia  due  to 
some  derangement  of  function  in  centre  or  nerves,  as  opposed  to  aphonia 
due  to  structural  disorders  of  the  vocal  mechanism,  so  I  think  the  term 
may  well  be  retained. 

Mr.  Harmer  (in  reply)  :  Paralysis  of  a  motor  nerve  may  be  due  to 
division,  involvement  in  scar-tissue,  to  toxaemia,  to  shock.  The  neuro- 
logist apparently  recognises  shock,  by  which  I  understand  him  to  mean 
a  condition  where  there  is  nothing  demonstrable  in  the  nerve  itself  after- 
wards. Mr.  Tilley  said  I  had  referred  to  Kocher  as  having  said  a  low 
tracheotomy  is  more  dangerous  than  a  high  tracheotomy.  He  read  more 
meaning  into  that  than  I  had  intended  in  my  paper.  Kocher  was  pointing 
out  that  in  the  accidents  after  tracheotomy,  for  whatever  it  Avas  per- 
formed, thei'e  is  more  danger  with  low  tracheotomy  than  with  high,  and 
he  quoted  a  number  of  cases  in  which  haemorrhage  had  occurred  from 
large  vessels  at  the  root  of  the  neck.  I  found  that  this  was  correct  when 
I  was  Avriting  an  article  for  Burghard's  "  Operative  Surgery."  But 
tracheotomies  for  warfare  injuries  are  often  performed  when  inflamma- 
tion has  subsided  as  delibei-ate  operations,  and  are  therefore  unlikely  to 
be  attended  with  the  same  risks  as  in  the  class  of  case  he  was  describing. 

With  regard  to  Sir  StClair  Thomson's  complaint  that  evidence  has 
not  been  brought  forward  as  to  the  comparative  results  of  laryngo- 
tracheotomy  and  intubation,  I  am  disappointed  myself  that  I  have  not 
been  able  to  obtain  enough  evidence  to  be  able  to  lay  down  any  general 
rules.  I  think  thei-e  is  a  tendency  to  perform  laryugo-fissure  too  often 
and  too  early.     It  must  be  wrong  to  take  a  man  who  is  suffering  from 


July,  1920.]  Rhinology,  and  Otology.  219 

acute  laryngitis,  perichondritis,  etc.,  and  perform  a  laryno-o-fissiire  without 
giving  the  inflammation  time  to  subside.  There  is  evidence  in  the  cases 
that  I  have  quoted  to  show  that  well-known  laryngologists  have  said, 
"  This  man  vnll  never  be  able  to  live  without  a  tracheotomy  tube  unless 
laryngo-fissure  is  performed,"'  and  yet  a  year  or  two  later  the  stenosis  of 
the  larynx  had  disappeared.  These  were  cases,  not  of  scar-tissue  which 
had  contracted,  but  of  a  general  oedematous  infiltration  of  the  tissues, 
which  later  disappeared  entirely.  In  many  cases  of  scarring  I  am  still 
doubtful  whether  you  cannot  obtain  the  same  results  by  intubation,  if  it 
be  carried  out  for  long  periods.  There  remain  the  very  sevei'e  cases  such 
as  Moure  classes  as  circular  stenosis,  which  I  think  nothing  but  an 
external  operation  will  cure.  Sir  StCLiir  Thomson  also  asked  me  whv  I 
said  that  tracheotomy  may  be  necessary  in  any  formcf  stenosis.  I  meant 
stenosis  in  that  sense  to  apply  to  recent  inflammations  and  paralytic 
forms  in  which,  by  waiting  a  little  time,  it  may  be  possible  to  avoid  the 
performance  of  tracheotomy. 

Dr.  H.  Smurthwaite  :  With  regard  to  Mr.  Mark  Hovell's  remarks 
in  connection  with  the  term  "functional  aphonia,"  if  it  is  thought  neces- 
sary to  change  it  I  would  suggest  "  psychogenic  aphonia  "  for  this  class 
of  case,  thus  indicating  that  the  loss  of  voice  has  a  psychic  origin. 

In  answer  to  Dr.  Permewan  I  have  not  found  it  necessary  to  use 
electrical  treatment.  On  the  other  hand  I  have  restored  the  voice  in 
several  who  have  had  electrical  treatment  previously  for  some  weeks 
before  coming  under  me. 

In  answer  to  Dr.  Jobson  Home,  I  may  say  that  I  made  special 
reference  to  the  necessity  of  accuracy  in  diagnosis  in  these  cases  ;  that 
the  aphonia  might  be  due  to  a  myoj^athic  paresis  of  the  cord  muscles — a 
harbinger  of  early  tuberculosis.  In  fact  I  have  sifted  out  quite  a  number 
of  tubercular  lung  patients  from  among  the  aphonia  cases  sent  to  me. 

In  reply  to  Sir  StClair  Thomson,  I  am  sorry  that  in  trying  to  cut  my 
paper  short  while  reading  it  I  should  have  skipped  the  part  where  I  refer 
to  treatment.  In  the  first  place  I  rely  to  the  greatest  extent  on  the  moi'al 
effect  my  words  will  have  on  the  patient.  I  convince  him  that  he  really 
has  no  disease  in  his  throat,  and  that  without  a  shadow  of  doubt  he  will 
leave  the  room  with  his  voice  restored.  I  then  tell  him  to  breathe  deeply 
several  times,  and  at  the  end  of  a  deep  inspiration  to  hold  his  breath  and 
cough.  This  will,  as  a  rule,  elicit  some  sort  of  note.  Next  I  place  the 
laryngoscope  in  the  pharynx  and  tell  him  to  say  "  ah,"  and  in  many  cases 
I  am  able  to  get  the  normal  vowel  sound,  purely  by  suggestion  and  from 
the  fact  that  his  mind  has  already  been  prepared  and  he  is  expectant. 
If  this  fails  I  make  him  cough  forcibly,  gradually  getting  him  to  sound 
the  vowel  "  ah  "  and  then  "  oh."  Following  this  he  must  cough  the 
numbers,  "one,"  "two,"  etc.,  and  by  degrees  I  succeed  in  making  him  say 
the  numbers  without  the  cough.  I  also  aid  his  expiratory  effort  by  com- 
pression with  my  hands  on  the  lower  ribs.  This  forced  expiratory  effort  on 
the  patient's  part  is  practically  that  carried  out  by  Kaufmann,  which  he 
described  in  a  paper  m  1916  in  the  MUncliener  med.  Wochenschrift. 

To  some  of  the  most  difficult  cases  I  have  given  much  time  and 
trouble  ;  often  as  much  as  three-cjuarters  of  an  hour  have  I  battled  with 
a  single  case. 

Finally,  I  will  say  that  everything  depends  on  the  mental  force  I  can 
put  into  it,  and  for  this  reason  I  am  only  really  successful  when  I  am  not 
too  tired  and  can  bring  the  whole  force  of  my  will  and  energy  to  bear  on 
the  case. 


220  The  Journal  of  Laryngology.  [juiy,  1920. 

ABSTRACTS. 

Abstracts  Editor — W.  Douglas  Harjier,  9,  Park  Crescent,  London,  W.  1. 

Authors  of  Original  Communications  on  Oto-laryngology  in  other  Journals 
are  invited  to  send  a  copy,  or  two  reprints,  to  the  Journal  of  Laryngology. 
If  they  are  willing,  at  the  same  time,  to  subinit  their  own  abstract  {in  English, 
French,  Italian  or  German)  it  will  be  welcomed. 


EAR. 


Inflaenzal  Mastoiditis. — Jacques  and  Daure.  "  Rev.  de  Laryngol., 
d'Otol.,  et  de  Rhinol.,"  August  31,  1919. 

A  large  proportion  of  cases  have  been  notable  for  tbe  formation  of 
remote  abscesses  in  fascial  planes  of  the  neck — not  as  in  Bezold's  type, 
Imt  far  back  towards  the  ligaraentum  nuchae.  Such  septic  foci  may  be 
multiple,  appearing  at  intervals  one  after  the  other. 

The  signs  and  symptoms  referable  to  the  ear  itself  may  be  trivial. 
But  the  remote  sequelae  above  referred  to  may  be  serious  and  protracted. 

H.  Lawson  Whale. 

Presentation  of  Mastoid  Cases,  with  Remarks  and  Lantern  Slide 
Demonstration. — Major  Christian  Holmes.  "Annals  of  Otology," 
&c.,  xxviii,  p.  1. 

These  cases  occurred  at  the  Base  Hospital,  Camp  Sherman,  Ohio,  and 
numbered  fifty  .  The  author  considers  that  to  keep  down  mortality  from 
pachymeningitis,  serous  meningitis,  leptomeningitis,  sinus  thrombosis, 
and  brain  abscess,  every  discharging  ear  must  be  looked  upon  as  one  that 
may  lead  to  fatal  complications,  and  every  symptom  watched  for  prompt 
interference  if  necessary.  Macleod  Yearsleij. 

Spontaneous  Haemorrhage  from  the  Lateral  Sinus  occurring  six  days 
after  Simple  Mastoid  Operation. — F.  T.  Hill,  "  Annals  of 
Otology,"  xxviii,  p.  29. 

Patient  was  a  man,  aged  twenty-one.  The  case  appears  to  support 
generally  accepted  opinion  that  thrombosis  of  the  lateral  sinus  is  due  to 
necrosis  of  intima  of  vessel  wall.  This  may  be  manifested  by  haemorrhage 
from  the  sinus.  Therefore,  it  would  seem  decidedly  indicated  in  a  case 
showing  this  sign  to  operate  immediately  rather  than  wait  for  the  classical 
two  chills  and  septic  rise  of  temperature.  Macleod  Yearsley. 

Toxic   Delirium  following  Mastoidectomy. — J.  A.  Robinson.     "Annals 

of  Otology,"  xxviii,  p.  86. 

Patient  was  a  woman  aged  fifty,  who  had  been  in  urgent  need  of 
operation  for  two  weeks.  Temperature  after  operation  varied  from  99° 
to  103°  F.  on  the  twelfth  day.  Facial  paralysis  developed  on  the 
morning  of  the  operation.  Delirium  began  two  clays  after  opeiatiou  and 
lasted  several  months.  The  author  considers  the  condition  to  have 
been  due  to  absorption  of  toxic  products  from  the  mastoid. 

Macleod  Yearsley. 


jaiy,  1920.]  Rhinology,  and  Otology.  221 

Gas- embolism  of  the  Lateral  Sinus  after  a  Mastoid  Operation. — 
Baraud  (Lausauue).  "  Rev.  de  Laryngol.,  d'OtoL,  et  de  EhiuoL," 
August  31,  1919. 

We  no  longer  regard  pulsations  of  the  lateral  sinus  as  indicative  of 
thrombosis.  Either  a  healthy  or  a  thrombosed  sinus  may  behave  in  either 
fashion — pulsate  or  not  pulsate. 

The  pulsation  of  the  siuus^healthy  or  otherwise  — is  not  communicated 
cerebral  pulsation  ;  it  is  not  synchronous  with  either  pulse  or  respiration. 
It  is  due  to  the  resultant  of  two  forces  of  negative  aspiration,  one  being 
the  negative  pressure  in  the  right  auricle,  and  the  other  the  negative 
pressure  of  the  thorax  on  inspiration,  and  the  point  which  the  reporter 
seeks  to  emphasise  is  that  these  two  forces  are  both  obviously  more  potent 
if  the  lateral  sinus  be  closed  off  above.  Hence  the  old  idea  that  pulsation 
signified  thrombosis,  and  was  communicated  from  the  underlying  brain. 

In  the  particular  case,  described  in  lengthy  detail,  the  sinus  bled 
fourteen  days  after  the  mastoid  operation  ;  the  sinus  had  been  deliberately 
exposed  in  the  course  of  evacuating  an  extradural  abscess.  At  the  moment 
when  the  bleeding  occurred  the  wound  was  being  dressed,  with  the 
patient  in  the  sitting  position. 

The  reporter  had  instinctively  closed  the  bleeding  point  with  his 
finger.  But  the  patient  took  a  deep  breath,  and  fell  to  the  floor.  The 
reporter's  finger  naturally  slipped  from  the  sinus,  but  the  latter  ceased 
to  bleed.  Almost  immediately  bleeding  recommenced,  and  the  sudden 
stertor,  cyanosis,  dyspnoea  and  audible  pulmonary  gurgling,  which  had 
a  moment  before  ceased.  The  patient  recovered,  and  the  reporter 
emphasises  the  probability  that  his  fall  from  the  sitting  position  (by 
allowing  blood  to  regurgitate  up  along  the  jugular  and  expel  much  of 
the  air),  was  instrumental  in  saving  his  life.  H.  Laivson  Whale. 


CESOPHAGUS. 


(Esophageal  Strictures  in  Children  due  to  Lye  Burns.  — George  F. 
Keiper.  "  The  Laryngoscope,"  September,  1919,  p.  548. 
Keiper's  paper  refers  to  strictures  of  the  oesophagus  which  the 
general  practitioner  or  surgeon  is  unable  to  dilate  with  the  ordinary 
instruments  after  "blind"  attempts.  The  case  is  referred  to  the 
laiyngologist  as  a  last  resort  before  gastrostomy  is  done  to  relieve  the 
patient  of  water  hunger.  The  aetiology  of  strictures  of  this  sort  lies 
primarily  in  gross  carelessness.  Too  often  concentrated  lye  in  solution 
is  left  within  easy  reach  of  small  children  after  the  kitchen  sink  has  been 
cleaned.  The  inquisitive  child  investigates  the  contents  of  the  vessel  and 
very  often  drinks  it.  The  usual  distressing  results  follow  and  sooner  or 
later  there  is  difiiculty  in  swallowing  food  or  drink.  A  thimbleful 
of  lye  is  sufficient  to  cause  stricture.  These  lyes  are  corrosive  poisons, 
and  a  druggist  must  affix  the  poison  label  with  the  skull  and  cross-bones 
as  well  as  information  as  to  the  antidote.  The  grocer  next  door  sells 
them  without  these  precautions  and  with  impunity.  Keiper  has  also 
had  two  cases  of  poisoning  due  to  hydrochloric  acid,  which  is  used  to 
burn  warts  off  the  legs  of  horses  and  cattle.  In  neither  instance  was 
there  a  stricture  of  the  oesophagus,  but  the  mucosa  of  the  stomach  was 
in  large  measure  destroyed.  Haste  in  dilating  strictures  of  the  oesophagus 
after  the  ingestion  of  the  corrosive  fluid  is  to  be  deprecated  for  fear  of 
perforation.     The  stricture  may  take  several  weeks  to  form.     No  attempt 


222  The  Journal  of  Laryngology,  [July,  1920. 

sliould  ever  be  made  at  bouginage  until  two  sets  (lateral  and  antero- 
posterior stereoscopic)  of  X-ray  plates  have  been  made  to  locate  accurately 
the  site,  extent  and  character  of  the  stricture.  No  bougie  should  ever 
be  passed  except  under  direct  inspection  through  the  oesophago scope. 
As  large  an  oesophagoscope  as  possible  should  be  passed  in  order  to 
render  as  easy  as  possible  the  location  of  the  ofttimes  very  narrow 
opening.  Keiper  believes  frequent  general  anaesthesia  to  be  highly 
dangerous.  We  may  need  to  make  as  many  as  sixty  dilatations  before 
we  can  dismiss  the  patient  as  cux-ed.  The  child  is  therefore  pinned  in 
a  sheet  or  blanket  and  laid  flat  on  the  operating  table  while  the  assistant 
holds  its  head  over  the  end  of  the  table.  A  nurse  holds  the  body  of  the 
child  in  position  on  the  table.  Tickling  the  fauces  with  a  fine  probe 
introduced  between  the  teeth  quickly  causes  the  mouth  to  open.  When 
the  child  once  realises  what  is  demanded  of  him  it  is  surprising  how 
docile  he  becomes.  These  strictures  are  often  multiple  and  tortuous. 
For  dilating  the  former  the  two-prong  dilator  of  Jackson  is  valuable. 
For  tortuous  and  tight  strictures  Keiper  likes  the  Guisez  instrument,  in 
different  sizes.  Keiper  reports  the  following  case,  pronounced  imper- 
meable by  the  general  practitioner  and  surgeon :  Male,  aged  three ; 
regurgitates  his  food  and  is  losing  flesh.  Four  months  before  he 
swallowed  a  thimbleful  of  lye  solution.  Steps  were  taken  to  neutralise 
the  poison.  AVithout  any  anaesthesia,  local  or  general,  a  fairly  large 
oesophagoscope  was  passed  down  to  the  stricture.  Keiper  located  the 
entrance  into  the  stricture  and  was  able  to  pass  the  smallest  sized 
Jackson-Guisez  instrument  right  into  the  stomach.  At  frequent  intervals 
larger  and  larger  sizes  were  introduced,  until  at  the  end  of  six  months, 
and  after  thirty  such  seances,  Keiper  was  able  to  pass  the  largest  size. 
Infrequent  dilatations  were  made  for  three  months  longer.  Many  of 
these  cases  need  subsequent  help  at  long  intervals.  /.  S.  Fraser. 


MISCELLANEOUS. 


Malignant  Disease  of  the  Pituitary  Body,  with  Comments. — G.  Maxted. 
"  Proc.  Roy.  Soc.  Med.,"  August,  1919,  Section  of  Ophthalmology, 
p.  42. 

The  patient,  a  well-nourished  man,  aged  twenty-five,  was  admitted  to 
hospital  in  March,  1918,  on  account  of  diplopia  which  had  persisted  for 
about  a  month.  This  was  preceded  for  about  eleven  months  by  occasional 
slight  attacks  of  epistaxis,  never  severe,  and  also  intermittent  headaches. 
The  onset  of  the  diplopia  was  said  to  have  been  sudden.  The  patient 
stated  that  at  the  beginning  of  the  attack  the  divergence  of  the  right  eye 
was  extreme,  and  that  it  was  now  much  less  than  at  the  commencement. 
The  right  pupil  is  semi-dilated  and  fixed.  The  epistaxis  was  reported  to 
be  due  mainly  to  a  chronic  phaiyngitis.     Wassermann  negative. 

In  May,  1918,  an  operation  for  deflected  septum  was  undertaken. 
In  June  the  patient  was  sent  to  an  auxiliary  hospital  for  five  weeks, 
during  which  time  he  complained  of  almost  continuous  blood-stained 
mucus  from  his  throat.  On  his  return  to  hospital  he  still  complained 
of  headaches  and  the  diplopia  persisted ;  still,  no  decided  pathological 
change  in  the  discs  was  apparent.  Repeated  examination  of  nasal 
sinuses  showed  no  fiu'ther  evidence  of  sinus  suppuration.  The  anaemia, 
if  anvthing,  seemed  to  have  become  more  severe.  On  August  12  it  was 
noticed  that  there  was  some  weakness  of  the  left  external  rectus  muscles, 


July.  1920.]  Rhinology,  and  Otology.  223 

as  well  as  partial  third  uerve  paralysis  of  the  right  eye.  On  lumbar 
puncture  the  fluid  escaped  uuder  pressure,  but  was  quite  clear  and 
revealed  no  pathological  changes.     Wassermann  negative. 

September  12  exploration  of  right  sphenoid  sinus.  The  cavity  was 
found  to  be  full  of  a  soft,  very  haemorrhagic  mass  resembling  growth, 
with  destruction  of  the  posterior  wail  of  the  sinus.  Microscopical 
examination  revealed  sarcomatous  growth,  probably  tumour  of  pituitai'v 
body.  On  recovering  from  anaesthetic  the  patient  noticed  that  he  was 
almost  blind,  and  by  the  following  morning  the  blindness  was  complete, 
remained  so  for  five  days  and  them  began  slowly  to  disappear. 

Skiagram  showed  destruction  of  the  sella  turcica  with  the  anterior 
and  posterior  clinoid  processes  and  lack  of  definition  of  all  that  area  of 
the  base  of  the  skull.  The  fields  of  vision  showed  a  very  striking 
bitemporal  hemianopsia,  the  nasal  side  of  each  field  I'emainiug  nearly  full. 
The  headaches  were  considerably  relieved  by  the  operation ;  the  discs 
became  slowly  and  progressively  more  pale  and  atrophic.  The  hsemor- 
rhagic  discharge  from  the  nose  continued  and  the  patient's  antemia 
became  more  severe. 

On  December  5  the  nose  was  again  explored  in  the  sphenoidal  region 
and  soft  vascular  gi'owth  i-emoved  ;  a  fresh  opening  was  made  in  the 
sphenoidal  sinus  and  100  mg.  of  radium  insei'ted  for  three  hours.  Five 
days  later  he  became  delirious,  collapsed  rather  suddenly  and  died. 

Post  mortem. — A  large  growth  was  exposed  in  the  region  of  the  sella 
turcica  with  much  erosion  of  the  surrounding  structures  ;  the  optic 
chiasma  and  the  optic  nerves  were  stretched  over  it  and  flattened  out, 
resembling  pieces  of  tape.  One  lobule  of  growth  occupied  the  angle 
between  the  two  nerves  and  was  compressing  the  right  nerve  rather  than 
the  left.  Both  cavernoiis  sinuses  were  distended  to  about  three  times 
their  normal  size  with  masses  of  the  tumour.  The  growth  had  not 
penetrated  their  dural  sheath,  which  was  stretched  smoothly  over  them. 
The  anterior  clinoid  processes  had  disappeared  and  the  lesser  wings  of 
the  sphenoid  wei'e  becoming  eroded.  The  growth  was  very  hsemorrhagic 
throughout  and  the  colour  almost  of  chocolate  hue.  On  removal  of  the 
growth  it  was  found  that  all  the  clinoid  processes,  the  sella  turcica  and 
its  walls  were  completely  destroyed  and  no  trace  of  the  pituitary  bodv  as 
such  was  visible.  There  was  recent  haemorrhage  into  the  growth,  which 
was  the  probable  explanation  of  his  apparently  sudden  collapse  and  death. 

Pathological  report :  Section  of  growth  removed  at  the  operation 
shows  a  carcinomatous  tumour  of  the  pituitary  body  undergoing  cvstic 
degeneration.  Archer  Byland. 

Pituitary  Tumour  (Hypopituitarism). — L.  V.  Cargill.     "  Proc.  Eoy.  Soc. 
Med.,"  August,  1919,  Section  of  Ophthalmology,  p.  41. 

Patient,  a  male,  aged  twenty -two.     Duration  of  disease  not  stated. 

The  family  history  is  unimportant,  and  he  has  always  had  good  health. 
History  of  present  attack  :  "Was  working  at  a  telephone  switchboard  last 
Christmas  when  he  discovered  that  he  could  only  see  half  the  board  with 
the  left  eye. 

Complete  temporal  hemianopia  left  eye,  the  nasal  field  being  encroached 
upon  some  15°  from  vertical  below.  Wernicke's  sign  present.  Right 
field  contracted,  to  temporal  side  especially.  Both  optic  discs  pale, 
simple  atrophy.  Looks  younger  than  his  age,  having  the  general 
appearance  of  a  youth  of  sixteen.  Very  little  hair  on  face.  Weight 
5  St.  2  lb.     Sexual  organs  and  pubic  hair  normal. 


224  The  Journal  of  Laryngology,  [juiy,  1920. 

Skiagram  shows  enlargement  of  sella  turcica  in.  antero-posterior 
diameter  ;  depth  about  average.  Anterior  clinoid  processes  undermined  ; 
posterior  clinoid  processes  look  partly  effaced. 

Cranial  nerves  (apart  from  optic)  normal.  Speech  normal.  Motor 
power,  co-ordination  and  sensation  good.  Arm  and  abdominal  reflexes 
cood.  Knee-jerks  exaggerated.  Left  ankle  clonus  ;  none  right.  Plantar 
reflex  not  obtained.     No  sphincter  trouble.     Chest  nil. 

The  case  was  thought  to  be  one  of  hypopituitarism,  which  may 
possiblv  depend  on  destruction  of  the  pituitary  body  by  a  cystic  growth. 

Archer  Byland. 

Herpes  Zoster  of  the  Glosso-pharyngeal  Nerve. — C.  T.  Neve.  "  Brit. 
Med.  Journ.,"  November  15,  1919. 

Two  days  after  a  long  and  cold  motor  journey,  Miss  M ,  aged 

fifty-seven,  complained  of  vomiting  and  malaise,  of  deafness  in  the  left 
ear,  and  of  pain  behind  the  left  ear  and  in  the  left  side  of  the  neck. 

The  temperature  was  100°  F.,  the  left  facial  nerve  was  paralysed,  and 
there  was  a  herpetiform  eruption  on  the  left  side  of  the  soft  palate. 
The  left  tympanic  membrane  was  of  normal  appearance  and  the  skin  of 
the  auricle  was  unaltered,  though  the  acoumeter  was  heard  at  2  in.  only. 

All  the  symptoms  passed  off  within  ten  days. 

The  writer  suggests  that  the  lesion  on  the  palate  was  due  to  a  lesion 
of  the  ninth  nerve  ganglion,  that  the  pain  behind  the  ear  and  the 
vomiting  resulted  from  involvement  of  the  tenth  nerve  ganglion,  and 
that  the  pains  in  the  neck  indicated  lesions  of  the  second  and  third 
cervical  ganglia.  The  picture,  therefore,  was  that  of  a  posterior  polio- 
myelitis of  the  ganglia  of  the  seventh,  eighth,  ninth  and  tenth  cranial 
nerves,  and  of  the  second  and  third  cervical  nerves,  the  infection  being 
most  acute  in  the  upper  ganglia.  In  support  of  this  contention  the 
views  of  Ramsay  Hunt  are  quoted.  Hunt  did  not  describe  any  cases  in 
which  he  found  evidence  of  herpetic  inflammation  of  the  glosso-pharyngeal 
ganglion,  though  he  mentions  the  possibility  of  its  occurrence.  He  had 
one  case  of  herpes  auricularis  in  which  stiffness  of  the  neck,  frequent 
vomiting  and  slow,  irregular  pulse  indicated  that  the  vagus  might  be 
involved.  Douglas  Guthrie. 


NOTES   AND   QUERIES. 

Sir  James  Dundas-Graxt,  K.B.E. 

Among  the  recipients  of  the  recent  Birthday  Honours  we  are  interested  and 
pleased  to  observe  the  name  of  Dr.  J.  Dundas  Grant,  who,  for  notable  and  highly 
successful  services  in  connection  with  the  treatment  of  ear  disease  in  pensioners, 
has  received  a  Knighthood  of  the  British  Empii-e. 

Readers  of  this  Journal,  which  for  many  years  he  edited,  v.411,  we  are  sure,  be 
pleased  to  imite  with  us  in  offering  to  Sir  James  Dundas-Grant  our  warmest 
congratulations  uj^on  a  well-deserved  honour. 


SociKT^  Belge  d'Otologie,  de  Ehinologie  et  de  Lartngologie. 

The  Twenty-sixth  Annual  Congress  of  this  Society  will  be  held  in  Brussels  on 
July  10-12. 

The  general  discussions  will  be  on  (1)  Diphtheria  and  its  complications,  and 
on  (2)  The  operative  treatment  of  laryngo-tracheal  stenoses  of  diphtheritic  origin. 
There  will  be  a  demonstration  of  patients,  specimens  and  instruments. 

On  July  12  there  will  be  an  excursion  to  the  Domaine  de  Mariemont  and  the 
rich  collections  of  the  Fondation  Warocque. 

The  President  of  the  Congress  is  Dr.  Ernest  Delstanche,  and  the  Secretary 
General  is  Dr.  A.  Capart  fils,  rue  d'Egmont  5,  Bruxelles. 


VOL.  XXXV.     No.  8.  August,  1920. 


THE 

JOURNAL    OF    LARYNGOLOGY, 

RHINOLOGY,   AND  OTOLOGY. 


Original  Articles  are  accepted  on  the  condition  that  they  have  not  previously  been 
published  elsewhere. 

If  reprints  are  required  it  is  requested  that  this  he  stated  when  the  article  is  first 
forwarded  to  this  Journal.     Such  reprints  will  he  charged  to  the  author. 

Editorial  Communications  are  to  he  addressed  to  "Editor  of  Journal  of 
LARYNaor.OGY,  care  of  Messrs.  Adlard  4'  Son  iSf  West  Neivman,  Limited,  Bar  tholomew 
Close.  E.C.  1." 


THE   EAR   IN   RELATION   TO   CERTAIN   DISABILITIES 
IN   FLYING.i 

By  Sydney  Scott,  F.R.C.S., 
Late  Temporary  Major,  E.A.M.C. 

Preliminary. 

On  February  26,  1918,  I  received  a  request  from  the  Director-General 
A.M.S.  to  give  up  my  civil  duties  and  proceed  to  France  "  to  investigate 
certain  questions  connected  witli  the  special  disorders  of  flying  . 
Accordingly  I  rejoined  the  B.E.F.  for  about  four  months.  While  in 
France  I  examined  upwards  of  300  flying  ofiicers,  more  than  half  of 
whom  were  affected  by  one  or  more  of  the  following  complaints :  deaf- 
ness, discharge  from  the  ear,  rhinitis,  pharyngitis,  tonsillitis,  Eustachian 
obstruction,  cerumen,  tinnitus,  vomiting,  vertigo. 

The  other  150  include  officers  who  were  examined  whilst  on  duty 
with  their  respective  Air  Force  Units  in  the  field.  They  comprise 
normal  individuals,  those  who  complained  of  headache  after  flying, 
faintness  in  the  air,  and  others  who  had  been  concussed  by  a  crash,  etc. 
They  include  pilots  who  were  making  bad  landings  without  crashing,  as 
well  as  flight  commanders  and  leaders  who  possessed  exceptional  flying 
and  fighting  ability :  a  number  of  these  volunteered  to  serve  as  controls 
in  comparing  the  results  of  rotation  and  other  special  labyrinth  tests. 
Some  flying  observation  officers  who  were  applying  to  be  trained  as 
pilots  were  also  tested. 

All  officers  admitted  to  hospital  were  systematically  examined  by 
the  medical  officers  attached  to  the  Air  Force  before  being  sent  to  me. 
The  majority  were  seen  in  co-operation  with  Lt.-Col.  James  L.  Birley, 
the  late  Capt.  (and  afterwards  Lt.-Col.)  C.  Dudley  H.  Corbett,  Capt. 

I  From  the  Reports  of  the  Air  Medical  Investigation  Committee,  National  Health 
Insurance. 

15 


226 


The  Journal  of  Laryngology,         August,  1920. 


H.  C.  Bazett,  M.C.,  or  Capt.  James  Wyatt.  "S\'hen  an  ophthal- 
mological  examination  was  necessary  it  was  undertaken  by  Capt.  Foster 
Moore,  Capt.  H.  P.  Gibb  or  Capt,  Juler,  ttie  ophthalmic  medical  officers 
in  the  Administrative  Area.  The  majority  of  those  seen  in  the  field 
were  examined  in  conjunction  with  Capt.  Porteous,  medical  officer  to 
the  11th  Wing. 

A  routine  examination  was  made  of  the  ears,  nose  and  throat, 
including  the  Eustachian  tubes.  Seventy-five  officers  were  submitted  to 
special  labyrinth  tests  in  the  rotation  chair.  After  analysing  the  data 
from  a  series  of  sixty-two  cases  the  rotation  tests  were  abandoned, 
because  the  results  were  considered  to  show  these  tests  were  unnecessary 
for  the  purpose  of  investigating  the  special  ailments  attributable  to 
flying.  Incidentally  it  was  inferred  that  the  rotation  tests  did  not  serve 
to  discriminate  qualities  either  favourable  or  unfavourable  to  individual 
flying  ability  (see  Part  2). 


Table 

A. 

A. 

B. 

C. 

A. 

B. 

C. 

mm. 

mm. 

mm. 

mm. 

ft. 

Hg. 

Hg. 

ft. 

Hg. 

Hg. 

370 

390 

10,000 

530 

230 

20,000 

380 

380 

9,000 

550 

210 

19,000 

390 

370 

8,000 

570 

190 

18,000 

100 

360 

7,000 

590 

170 

17,000 

410 

350 

6,000 

610 

150 

16,000 

420 

340 

5,000 

630 

130 

15,000 

430 

330 

4,000 

660 

100 

14,000 

450 

310 

3,000 

680 

80 

13,000 

470 

290 

2,000 

710 

50 

12,000 

490 

270 

1,000 

740 

20 

11,000 

510 

250 

Sea-level 

760 

0° 

A.  Altitude  in  feet. 

B.  General  barometric  pressi^re  in  mm.  Hg.    approximate). 

C.  Excess  of  pressure :  compressing  the  tli-iim  when  the  Eustachian  tube  fails 
to  open  dui-ing  descent  from  the  altitude  given  in  Column  A  to  sea-level.  (Approxi- 
mate.) 


1.  Abnormal  Appearance  of  the  Tympanic  Membrane  resulting 
FROM  Flying,  especially  after  Eapid  Descent  from  High 
Altitudes,  due  to  Imperfect  Action  of  the  Eustachian 
Tubes. 

Many  airmen,  after  flying  to  high  altitudes,  are  liable,  under  certain 
conditions,  to  be  temporarily  affected  to  some  extent  by  deafness,  dis- 
comfort or  pain  in  the  ears,  headaches,  dizziness,  nausea,  fainting  or 
vomiting,  on  returning  to  the  denser  atmospheric  pressure  of  low 
altitudes.  In  these  circumstances  an  inspection  of  the  airman's  ear 
with  mirror  and  speculum  imviediately  after  landing  shows  a  marked 
change  from  the  normal ;  the  fundus  is  bright  red,  owing  to  distension 
of  the  blood-vessels  in  the  tympanic  membrane  and  mucosa  of  the 
middle  ear.  In  extreme  cases  the  tympanic  membrane  is  strongly 
invaginated^  into  the  tympanum  ;  the  membrane  closely  embraces  the 
neck  and  handle  of  the  malleus  and  the  short  process  of  the  incus  and 

'  I  suggested  the  term  "  invagination "  as  representing  the  extreme  displace- 
ment of  the  tympanic  membrane,  which  I  met  with  among  high-flying  airmen. 


August,  1920.]  Rhinology,  and  Otology.  227 

incudo-stapedial  joint,  and  is  evenly  moulded  over  the  edge  of  the  fossula 
rotunda.  Occasionally  globules  of  mucus  can  be  observed  through  the 
invaginated  drumhead  within  the  cavum  tympani. 

Keference  to  the  accompanying  table  (Table  A)  will  serve  to  recall 
that  the  atmospheric  pressure  at,  say,  18,000  ft.  is  approximately  400 
millimetres  of  mercury,  as  compared  with  760  millimetres  at  sea-level ; 
assuming  the  Eustachian  tubes  open  regularly  while  ascending  but  fail 
to  open  during  the  descent  from  18,000  ft.,  there  would  be  an  excess  of 
gradually  increasing  pressure  on  the  outer  surface  of  the  tympanic 
membranes  over  the  pressure  within  the  tympanic  cavity,  which  would 
attain  a  pressure  equal  to  360  millimetres  of  mercury  on  returning  to 
sea-level. 

Some  aviators  who  had  not  learned  how  to  prevent  discomfort  and 
misery  on  returning  from  high  patrols  have  actually  given  up  flying,  and 
others  similarly  affected  have  contemplated  doing  so.  After  being 
taught  the  effect  of  auto-inflation  when  starting  to  dive,  and  repeating 
the  self -inflation  frequently  during  the  descent,  many  added  a  new  lease 
to  their  flying  career. 

When,  for  the  purpose  of  this  investigation,  I  was  making  a  descent 
from  between  19,000  and  20,000  ft.,  I  became  aware  of  the  increasing 
atmospheric  pressure  on  my  ear  drums  at  about  16,000  ft.  The  relief 
from  self-inflation  at  this  height  lasted  down  to  about  13,000  ft.,  when 
self-inflation  again  removed  all  trace  of  discomfort.  While  descending 
below  10,000  ft.  the  increasing  pressure  on  the  ear  drums  became  notice- 
able more  and  more  quickly,  for  swallowing  did  not  suffice  to  open  the 
Eustachian  tubes  rapidly  enough  to  prevent  this.  By  repeating  the 
inflation  at  every  1500  ft.  descent,  and  then  every  1000  ft.,  even 
the  slightest  discomfort  and  traces  of  deafness  disappeared,  and  after 
self-inflating  again  while  a  few  hundred  feet  up  I  was  able  to  land  free 
from  any  abnormal  sensations  in  the  ears. 

In  an  unbroken  ascent  we  meet  with  auditory  symptoms  only 
occasionally.  An  officer  with  Eustachian  obstruction  was  more  comfort- 
able at  between  -4000  and  5000  ft.  than  near  sea-level,  but  became 
affected  at  11,000  ft.  ^ ;  another  with  bilateral  obstruction  complained  of 
ear  distress  at  11,000  ft.  On  attaining  11,000  ft.  in  a  flight  which  had 
then  taken  nearly  a  quarter  of  an  hour,  I  became  suddenly  and 
unexpectedly  conscious  of  a  desire  to  "clear "my  ears;  the  sensation 
resembled  that  experienced  during  the  earlier  stages  of  a  descent,  though 
swallowing  did  not  give  the  expected  relief.  I  realized  the  sensation 
must  be  due  to  the  tympanum  being  relatively  too  full  of  air  owing  to 
the  expansion  of  the  air  within  the  middle  ear,  which  corresponded  to 
the  falling  atmospheric  pressure  in  the  external  ear.  My  Eustachian 
tubes  did  not  open  when  swallowing  to  relieve  this  sensation,  but  a  very 
carefully  graduated  self-inflation,  just  sufficient  to  open  the  tubes, 
caused  the  feeling  of  fulness  in  the  ears  instantly  to  cease,  nor  did  it 
recur  during  flight,  even  when  climbing  nearly  9000  ft.  higher  still. 

Function  of  Eustachian  Tribes  lohile  Flying. 

Normally  the  Eustachian  tubes  open  once  only  during  each  act  of 
swallowing  :  any  difl'erence  in  atmospheric  pressure  within  and  without 
the   tympanic    cavity    is    thus   equalised.     Even    when   the  tubes   act 

^  This  case  I  described  in  detail  in  the  Proceedings  of  the  Royal  Society  of 
Medicine,  vol.  xi,  Otological  Section,  p.  21. 


2^8  The  Journal  of  Laryngology,         [August,  1920, 

normally  it  is  necessary  to  swallow  repeatedly  and  frequently  to  keep- 
pace  with  the  continuous  and  often  rapid  changes  of  pressure  which 
take  place  during  descents.  When  flying  at  great  height  for  long,  and 
especially  if  engaged  in  the  exertions  of  aerial  combat,  airmen  are  liable 
to  breathe  with  mouth  open.  The  throat  is  then  apt  to  get  parched,  and 
swallowing  becomes  positively  fatiguing  or  well-nigh  impossible.  If 
this  occurs  and  the  normal  regulating  mechanism  for  opening  the 
Eustachian  tubes  prove  unequal  to  the  task,  the  airman  experiences 
considerable  discomfort,  often  intense  pain,  and  sometimes  is  in  great 
distress.  The  symptoms  may  be  only  momentary  or  they  last  for  some 
time  after  landing  :  one  frequently  sees  airmen,  just  returned  from  high 
flights,  put  the  fingers  to  the  ear  and  press  on  the  tragus  several  times, 
or  else  try  to  self-inflate  the  ears  after  landing  ;  I  found  the  drums 
invaginated  in  these  cases.  Swallowing  is  often  ineffectual  in  opening 
up  the  lumen,  probal^ly  owing  to  swelling  from  hyperemia  of  the 
mucosa  lining  the  Eustachian  tube.  Sometimes  this  occlusion  of  the 
Eustachian  tubes  lasts  for  hours,  days,  or  weeks,  during  which  period 
flying  increases  the  deafness  and  discomfort  or  pain. 

Clinical   Becords. 

Case  17. — Lieut.  H.  H.  S.  F was  a  flying  officer  of  one  and  three- 
quarter  years'  experience,  with  200  hours  flying,  including  150  on  active 
service.  In  February,  1918,  when  on  a  Sopwith  Camel  (Bentley  rotary 
170  h.p.  engine),  while  chasing  an  enemy  machine  he  dived  with  engine 
on  from  18,000  to  1000  ft.  He  was  conscious  of  greatly  increasing 
pressure  sensations  in  his  head  and  deafness,  which  he  failed  to  relieve 
by  repeatedly  swallowing  as  usual.  The  pressure  caused  pain  in  the  ears, 
which  became  more  and  more  intense.  He  felt  "  as  though  his  head 
would  burst,"  and  being  incapable  of  catching  his  enemy  broke  off  pursuit, 
and  returned  to  his  aerodrome  in  such  pain  that  he  at  once  went  to  a 
casualty  clearing  station.  Unfortunately  the  medical  officer  had  no 
instruments  to  examine  the  ears,  but  he  recommended  him  to  have  them 
syringed  ;  however,  this  gave  no  relief.  He  endured  the  pain,  which 
lasted  four  or  five  days,  and  there  was  a  slight  discharge  which  lasted 
a  few  weeks.  Subsequently,  when  on  leave  to  England,  it  was  discovered 
that  the  right  tympanic  membrane  was  ruptured.  In  April  the  rupture 
could  be  seen  in  the  quadrant  nearest  the  Eustachian  tube ;  I  kept  this 
officer  under  my  care  until  the  rupture  healed,  and,  having  taught  him 
how  and  when  to  self-inflate  both  ears,  allowed  him  to  return  to  duty 
with  his  squadron  near  Dunkirk.  There  was  then  no  obvious  deafness, 
and  the  hearing  tests  showed  the  merest  defect  in  the  right  ear. 

Hearing  tests.                           Eight.  Left. 

Tone  range. 

Lowest        .  .         .16  d.v.  16  d.v.     ( Bezold-Edelmann, 

Highest       .  .         .0-3  0-2           (Galton-Edelmann 

m  .,  whistle. 

Tone  acuity. 

(Mixed  sounds)  Watch     10  in.  15  in.  (normal — 15). 

(High  pure  tones),    c"'  fork — 2  seconds    normal. 

Weber's  test,  fork  on  vertex  heard  louder  in  the 

right  ear. 

I  was  informed  by   Lt.-Col.   Birley  that  this   ofiicer  subsequently 

did  well  after  resuming  flying  duties  and  had  no  further  trouble  with  his 

ears,  which  he  was  careful  to  inflate  during  descents. 


August,  1920.] 


RhinoIogrVt  and  Otology. 


229 


Laboratory  Tests  of  the  Effect  of  Compression  of  Air  in  the  External  Ear. 

To  test  the  sensations  of  variable  air-pressure  on  the  drum  I  adapted 
a  mercurial  sphygmomanometer  and  connected  it  by  thick-walled 
rubber  tube  to  a  nozzle  which  accurately  fitted  the  external  auditory 
meatus.  With  this  arrangement  one  could  compress  the  air  in  the 
external  auditory  canal  on  to  the  drum,  and  read  the  pressures 
attained  in  millimetres  of  the  column  of  mercury.  Having  first 
tested  the  effect  of  compression  on  myself  I  applied  it  to  others,  and 
soon  found  the  tolerance  to  pressure  varied  among  different  individuals. 


330mms  ■ 


Tap  'fb  control 
pressure  /'n  oppos/te  £ar 


Some  could  not  bear  more  than  140  mm.^  on  the  first  occasion  without 
pain,  but  after  repeated  trial  the  threshold  was  raised  to  170  mm.^ 
Others  found  280  mm.^  the  first  time  quite  tolerable.  The  first  symptom 
of  increasing  pressure  was  deafness  ;  as  the  pressure  was  raised  the  dis- 
comfort passed  on  to  acute  stabbing  pain  in  the  ear. 

A  few  individuals  noticed  distinct  dizziness  when  high  pressure  was 

'  This  would  correspond  with  the  excess  of  atmospheric  pressure  on  the  drum 
prodiTced  by  a  rapid  descent  from  about  6000  ft.  to  near  sea-level,  with  Eustachian 
tubes  remaining  closed. 

-  Corresponding  to  descent  from  nearly  7000  ft..  Eustachian  tubes  keeping 
closed. 

=*  Corresponding  to  descent  from  nearly  13,000  ft..  Eustachian  tubes  keeping 
•closed. 


230  The  Journal  of  Laryngologyt         [August,  1920. 

applied  to  one  ear  at  a  time,  but  no  dizziness  when  both  ears  were 
equally  compressed, 

A  pressure  limited  to  320  mm.  Hg.  was  insufficient  to  rupture  the 
drum  of  the  cadaver  (both  ears  were  tested  in  ten  cases  to  ascertain 
this  point). 

The  rapid  descent  from  18,000  ft.  which  caused  the  drums  to  be 
ruptured  in  the  flying  officer  whose  case  is  described  above  would  cor- 
respond to  a  pressure  of  about  350  mm.  Hg. — a  pressure  not  applied  in 
the  laboratory. 

A  Case  of  HcEmorrhage  of  the  Drum  due  to  Rapid  Descent. 

Case  4. — Second  Lieut.  C.  E.  C had    flown  about  50  hours  in 

France,  and  110  hours  in  all.  He  was  flying  Sopwith  Camels  (La 
Rhone  engine),  had  been  in  six  combats,  and  hoid  shot  down  one  enemy 
aeroplane.  During  an  air  fight  in  the  middle  of  March,  1918,  when  he 
had  a  cold  in  his  head,  he  dived  nearly  vertically  with  engine  on  at  200 
m.p.h.  from  15,000  to  3000  ft.,  becoming  conscious  of  great  pressure  on 
his  ears,  and  with  a  feeling  as  if  his  head  would  burst.  The  pain  in  the 
left  ear  was  severe  for  two  days  :  it  passed  off  gradually.  Three  weeks 
later,  when  I  saw  him,  he  still  had  a  small,  dry  clot  of  blood  adherent 
to  the  antero-inferior  quadrant  of  the  drum,  but  there  was  no  perforation. 
He  had  recovered  from  the  cold  in  the  head  and  could  now  auto-inflate 
both  ears.    Soon  afterwards  he  returned  direct  to  his  squadron  in  France. 

Conditions  similar  to  those  met  with  in  Cases  17  and  4,  recorded 
above,  have  been  erroneously  regarded  as  being  due  to  otitis  media,  the 
result  of  a  "  cold  in  the  head,"  instead  of  what  they  primarily  were, 
namely,  traumatic  rupture  from  excessive  air-pressure  on  the  outer 
surface  of  the  drum,  the  "  cold  in  the  head  "  having  prevented  the 
regulating  function  of  the  Eustachian  tubes. 

Appearance  of  Tympanic  Membrane  after  Descent  from  17,000  ft. 

(a)  When  Eustachian  tubes  fail  to  open. 

(b)  When  Eustachian  tubes  open. 
Exemplified  by  Case  98. 

Flight  Sergeant  W.  F.  P was  a  test  pilot,  who  was  considered 

by  his  fellow  officers  to  be  "breaking  up"  in  health  and  would  have  to 
give  up  tests  above  12,000  ft.,  because  he  always  seemed  to  feel  so  "  bad  " 
^vhen  he  landed.  They  supposed  this  was  due  to  "heart  trouble,"  but 
the  medical  officer  found  the  heart  normal. 

On  May  9,  1918,  at  7  p.m.,  I  saw  him  land  a  Bristol  Fighter  in 
which  he  had  been  up  to  17,000  ft.  for  an  hour.  He  admitted  to  his- 
friends  he  felt  "  off' colour,"  but  to  the  medical  officer  said  "  he  felt  alright " 
except  that  "  his  head  was  throbbing  a  bit "  and  "  of  course  "  he  was 
"  deafish."  This  was  not  obvious  during  conversation,  but  he  could  only 
hear  a  watch  when  within  4  in.  of  the  right  ear  and  8  in.  from  the  left, 
which  was  one-quarter  and  one-half  the  full  hearing  distance  for  this 
particular  watch.  He  was  persuaded  to  allow  me  to  examine  the  drums 
of  the  ears.  I  found  they  looked  bright  red  ;  the  blood-vessels  could  be 
seen  to  be  distended,  and  the  whole  drum  was  tensely  invaginated  and 
moulded  over  the  ossicles  and  inner  wall  of  the  tympanic  cavity,  in  the 
lower  part  of  which  three  or  four  small  globules  of  clear  fluid  could  be 
seen.  (Similar  cases  had  been  sent  to  me  with  the  diagnosis  of  "  chronie 
perforation" — "  drum  destroyed.") 


August,  1920.1  Rhinology,  and  Otology.  231 

He  tried  unsuccessfully  to  intiate  the  ears,  holding  the  nose  and  blow- 
ing by  Valsalva's  method,  but  desisted  because  this  made  the  pain  in 
the  ears  worse.     (I  found  this  a  very  general  experience.) 

He  had  no  intention  whatever  of  "  going  sick,"  nor  was  it  suggested 
that  he  should.  He  gave  me  the  impression  of  being  cheerful,  stoical, 
and  regarded  the  discomfort,  defective  hearing  and  throbbing  in  the 
head  as  "nothing  unusual,"  and  declared  he  would  probably  be  all 
right  the  following  day.  He  readily  submitted  to  be  a  subject  for 
further  examination,  and  when  it  was  found  that  Politzerisation  failed 
to  open  the  Eustachian  tubes  he  allowed  me  to  pass  the  Eustachian 
catheter  and  inflate  the  ears.  The  pain  in  the  ears  was  removed  and 
the  drums  were  seen  to  have  returned  to  the  normal  attitude ;  his 
instant  relief  was  obvious. 

He. quickly  learned  to  self-inflate  both  ears  at  will,  whether  flying  or 
not,  and  found  by  this  means  he  could  prevent  what  now  he  admitted 
had  been  intense  discomfort  and  pain,  sometimes  lasting  for  days, 
though  he  had  hitherto  regarded  these  "  unpleasant  feelings  "  as  neces- 
sarily associated  with  high  flying.^ 

A  spirit  of  determination  to  tolerate  discomfort  uncomplainingly  was 
the  rule  in  the  same  unit,  for  four  out  of  the  other  five  test  pilots  were 
found  to  be  similarly  affected,  returning  from  flights  to  16,000  and 
20,000  ft.  with  deafness  and  drums  invaginated. 

They  were  treated  in  similar  manner  and  were  taught  how  self- 
inflation  prevented  this  distress  :  and  were  enabled  to  make  flights 
to  20,000  ft.,  returning  quite  free  from  the  ear  symptoms,  and  with 
normal-looking  drums  and  feeling  fresh,  so  that  they  no  longer  had  to 
go  and  lie  down  after  flying.  It  was  particularly  striking  in  one  test 
pilot  who  made  two  ascents  to  20,000  ft.-  with  no  rest  in  between,  which 
he  had  never  done  before  in  his  life,  without  experiencing  the  discomfort 
and  headache  he  had  hitherto  regarded  as  inevitable  after  each  altitude 
test. 

Vertigo  and  Inco-ordination,  and  Unilateral  Eustachian  Obstruction. 

Case  6. — Summary  :  Eecently  dived  from  11,000  to  1000  ft.  :  deaf. 
Later  found  flying  difficult  and  apt  to  get  into  a  spin.  Vertigo,  stagger- 
ing gait.  Eustachian  obstruction  and  middle-ear  deafness.  Eecovered 
after  catheterisation. 

Lieut.  I.  B.  C was  a  flying  officer  who  had  been  in  France  two 

and  a-half  months,  during  which  time  he  had  flown  about  sixty-five 
hours.  On  one  occasion,  when  returning  from  patrol  duty,  he  made  a 
side-slip  dive  from  11,000  to  1000  ft.  and  the  ears  felt  "  as  if  they  were 
plugged."  After  this  he  had  found  even  ordinary  flying  difficult,  and 
had  returned  from  flights  unusually  tired  and  sleepy.  He  had  especial 
difficulty  in  co-ordinating  his  controls,  "  always  putting  on  too  much 
rudder  and  not  enough  bank,"  and  was  losing  self-confidence.  Faulty 
flying  had  caused  him  to  come  down  in  a  spin,  though  he  managed  to 
pull  out  in  time  to  prevent  a  bad  crash,  staggered  to  his  hut,  and  was 
later  seen  by  the  medical  officer,  who  sent  him  to  the  hospital.  I  found 
he  had  rhinitis  and  obstruction  of  the  left  Eustachian  tube.      He  could 

1  I  ascertained  that  subsequently  this  officer  tolerated  high  flying  without  the 
discomforts  and  ill-effects  he  had  experienced  formerly,  and  which  threatened  to 
terminate  his  flying  duties. 

'  Cloctwork  barographs  were  carried  on  these  machines  to  record  the  heights 
attained. 


232  The  Journal  of  Laryngology,         [August,  1920. 

not  auto-inflate  the  left  ear  but  he  could  inflate  the  right ;  doing  so 
made  him  feel  giddy  and  he  nearly  fell  off  his  seat. 

The  tympanic  membrane  of  the  left  ear  was  then  only  slightly  in- 
vaginated  and  a  dusky  red  reflex  showed  the  mucosa  of  the  middle  ear 
to  be  hypervascular.  When  a  catheter  was  passed  into  the  left  Eus- 
tachian tube  and  air  was  blown  into  the  middle  ear  he  suddenly 
exclaimed  "  I'm  going  off,"  shut  his  eyes  tightly  and  gripped  hold  of 
the  chair,  but  his  lips  were  not  paUid  and  his  pulse  was  strong.  At 
the  same  time  forced  movements  of  the  head  and  neck  muscles  com- 
menced, causing  the  face  to  turn  toward  the  left,  with  flexion  of  the  head 
to  the  left  and  backward  extension.  He  felt  "as  if  he  was  falling  to 
the  right,  and  that  the  room  was  tilting  down  to  the  left."  All  these 
sensations  passed  off"  in  less  than  a  minute.  He  recovered  from  the 
rhinitis  and  Eustachian  obstruction,  and  was,  on  account  of  enlarged 
tonsils,  recommended  for  leave  to  England  before  returning  to  duty. 

Unilateral  Eustachian  Obstruction  causing   Vertigo   loith  so-called 

Nerve-deafness. 

Case  21. — Vertigo,  vomiting,  so-called  nerve-deafness,  nystagmus, 
Ehombergism,  forced  reeling  gait.  Eustachian  catarrh;  complete  re- 
covery, and  return  to  active  flying  duties  as  test  pilot. 

Lieut.  A.  B.  T a  Canadian,   was  a  test  pilot  who   had  been  in 

France  about  two  months.  He  had  a  slight  cold  in  the  head  and  had 
merely  tested  the  air-speed  of  a  Sopwith  Camel  at  between  2000  and 
3000  ft.  without  rolling  or  spinning  the  machine  ;  on  landing  he  felt 
sick  and  giddy,  and  afterwards  went  to  his  quarters  and  lay  down  for  a 
fev/  hours.  In  the  evening  he  was  well  enough  to  go  into  mess.  After 
breakfast  the  following  morning,  while  in  an  S.  E.  5,  warming  up  the 
engine,  he  again  felt  giddy.  He  switched  off  the  engine,  climbed  out  of 
the  machine,  staggered  to  his  hut,  and  vomited.  He  remained  in  bed 
for  twenty-four  hours  without  food,  the  giddiness  persisting,  and  being 
worse  when  he  moved  his  head  or  attempted  to  get  up.  Five  days 
later  he  was  sent  to  hospital,  where  he  was  overhauled  by  the  late 
Lt.-Col.  Corbett,  who,  finding  he  could  not  hear  a  watch  with  the 
left  ear,  asked  me  to  examine  him. 

As  he  entered  the  room  I  noticed  he  walked  slowly  with  outstretched 
arm,  apparently  apprehensive  of  falling.  ^Yhile  seated  he  incHned  the 
head  to  his  left,  though  he  said  he  was  quite  unaware  of  doing  so. 
While  I  held  his  head  straight  he  said  it  felt  inclined  to  the  right,  and 
I  observed  both  eyeballs  slowly  rotate  about  an  antero-posterior  axis, 
clockwise,  to  the  left  to  take  up  their  original  position  in  space.  More- 
over, when  the  eyes  were  deviated  towards  the  right,  fine  rotary 
nystagmus  appeared  with  the  rapid  jerk  counter-clockwise,  i.  e.  upper 
meridian  of  the  eyeball  to  the  right.  There  was  no  nystagmus  when 
the  visual  axes  were  directed  towards  the  left.  When  released  the  head 
again  slowly  inclined  to  the  left,  resuming  its  original  position  of  left 
lateral  flexion. 

On  attempting  to  stand  with  eyes  shut  with  feet  close  together  the 
patient  fell  towards  the  left.  He  also  lurched  heavily  to  the  left  when 
attempting  to  walk  straight,  with  eyes  closed,  the  line  followed  being 
some  45°  degrees  away  from  the"^  straight  line  he  had  intended  to 
follow.  There  was  nothing  else  abnormal  discovered  in  the  general 
neurological  survey.     The  tympanic  membranes  icere  perfectly  normal  in 


August,  1920.]  Rhinology,  and  Otologry.  233 

appearance,  with  absolutely  no  displacement  inwards  or  outwards  and 
no  hyperaemia.  However,  he  could  not  auto-inllate  the  left  ear,  although 
he  could  inflate  the  right,  by  Valsalva's  well-known  method. 

Tone  range.  Right.  Left. 

Lowest  audible      .         .     16  d.v.       .     24  d.v.  (Bezold  fork). 
Highest  audible    .         .     0-6  mm.     .     1-6  (Galton  whistle). 

Tone  acuity. 

(High  pitch  watch)       .     8  to  12  in.  .     7ii7  (normal  12  to  15  in.). 

c^  fork  .         .         ,         .     normal       .     —  sec. 

Schwabach  conduction      normal       .     Slight  loss  of  bone-conduction. 

(Einne  method)  air-conduction  better  than  bone  on  each  side. 

(Weber's  method)  bone-conduction  from  the  vertex  louder  in  the 
right  ear. 

The  tests  indicated  a  condition  often  so-named  "  nerve-deafness  " 
in  the  left  ear. 

Air  was  inflated  through  a  catheter  into  the  Eustachian  tube  on  each 
side,  first  the  right,  which  increased  the  hearing  acuity  for  the  watch, 
but  produced  no  effect  on  the  giddiness  ;  when  air  was  blown  thi'ough 
the  cathether  into  the  left  Eustachian  tube,  fluid  rc'ile  was  audibly  pro- 
duced in  the  left  middle  ear.  The  blowing  was  continued  until  the  rdie 
was  displaced  by  the  clear  sound  of  air  entry,  and  the  catheter  was  then 
removed.  The  patient  immediately  exclaimed  that  the  giddiness  had 
ceased  :  as  evidence  of  this  he  could  stand  and  walk  straight  with  eyes 
shut,  there  was  no  lateral  flexion  of  the  head,  and  it  was  seen  as  objec- 
tive evidence  that  the  nystagmus  had  disappeared.  The  hearing  for 
lowest  tones — 16  d.v. — was  equal  on  the  two  sides,  and  in  Weber's  test  the 
bone-conduction  was  equalised,  but  the  hearing  for  high  tones  at  first 
improved  hardly  at  all.  Next  morning  the  symptoms  of  giddiuess, 
together  with  all  other  signs  described  above,  recurred ;  and  again  the 
left  ear  could  not  be  inliated  without  the  catheter,  which  on  this 
occasion  also  put  an  end  to  the  giddiness  instantly.  The  catheter  was 
necessary,  for  the  same  reasons,  on  the  third  day,  after  which  the 
patency  of  both  Eustachian  tubes  came  under  the  patient's  control,  for 
he  was  now  able  to  inflate  both  ears  equally  and  has  ceased  to  be 
troubled  with  giddiness  since.  Instead  of  his  being  transferred  to 
England  as  an  invalid,  I  recommended  that  this  officer  be  allowed  to 
return  direct  to  flying  duties  without  restriction,  and  a  few  days  after- 
wards he  ferried  a  captured  Hanover  two-seater  to  Farnborough, 
bringing  back  a  new  S.E.  5  two  days  later,  and  subsequently  carried 
out  his  ordinary  test-flying  up  to  16,000  and  20,000  ft.  without  any 
recurrence  of  symptoms. 

Two  points  in  his  history  were  brought  out  afterwards.  Firstly,  he 
had  had  a  cold  in  the  head  about  a  fortnight,  and  for  ten  days  had  felt 
slightly  giddy  when  flying  without  having  complained.  His  fellow 
officers  told  me  they  had  noticed  he  was  not  flying  as  well  as  usual  for 
ten  days,  and,  in  fact,  had  told  him  that  he  would  crash  because  he  was 
flying  and  landing  with  the  left  wing  loicer  than  the  right  even  ichen 
direct  into  the  tvind.  Aitev  the  treatment  described  above  he  flew  quite 
level,  as  I  saw  for  myself.  These  observations  fully  tally  with  the  signs 
of  inco-ordination  and  forced  movements  which  I  noticed  when  became 
to  the  hospital.  The  importance  of  the  foregoing  case  in  connection 
with  crashes  of  unknown  origin  deserves  full  recognition. 


234  The  Journal  of  Laryngology,         'August, 


1920. 


Vertigo  and  Nystagmus,  associated  with  Obstinate  Eustachian  Obstruc- 
tion, reproduced  by  Pressure  Changes  in  the  Middle  Ear.^ 

Case  129. — Lt.  G.  F.  S .     This  officer  was  sent  to  me  on  account 

of  deafness  in  the  left  ear,  which  was  worse  after  flying  and  had  been 
increasing  for  some  months  past.  He  had  also  had  occasional  attacks 
of  pain,  especially  during  descents,  and  he  had  felt  dizzy  several  times 
when  landing.  He  had  been  in  France  since  March,  1918,  with  a 
squadron  engaged  principally  in  artillery  observation  and  rarely  flew 
above  9000  or  10,000  ft. 

At  the  time  of  examination,  in  May,  1918,  he  had  no  pharyngitis  or 
rhinitis,  but  the  Eustachian  obstruction  was  so  marked  that  for  a  week 
it  defied  all  attempts  to  blow  air  into  the  middle  ear,  in  spite  of  the  use 
of  the  Eustachian  catheter,  bougies,  and  the  application  of  cocaine, 
adrenalin,  atropine,  menthol  inhalations,  and  the  administrations  of 
iodides  and  aperients.  The  right  ear  was  always  easily  self-inflated 
and  there  was  no  special  difficulty  in  introducing  the  catheter  into 
either  Eustachian  tube.  Every  day  the  drums  were  inspected  before  and 
after  these  attempts,  but  the  left  drum  remained  unmoved  in  a  position 
of  invagination :  the  mucosa  of  the  middle  ear  could  be  seen  to  be 
hvpertemic  through  the  transparent  membrane. 

On  the  eighth  day  air  blown  through  the  catheter  could  be  heard 
entering  the  tympanum  by  means  of  the  auscultatory  tube.  At  the 
same  moment  the  patient  felt  giddy,  and  there  were  manifest  forced, 
jerking  movements  of  the  head  and  nystagmus. 

When  the  inflation  was  weak  the  head  was  inclined  and  face 
turned  to  the  right,  and  the  n^'stagmus  (combined  horizontal  and 
rotatory)  was  to  the  left. 

Stronger  inflation — distending  the  tympanum — caused  the  forced 
movements  of  the  head  and  eyes  to  be  reversed. 

It  was  over  three  weeks  before  this  patient  succeeded  in  self- 
inflating  the  left  ear  and  he  was  afterwards  transferred  to  England, 
and  though  he  flew  again  he  was,  I  understand,  eventually  invalided 
out  of  the  Air  Force,  owing  to  the  persistent  ear  trouble  and  impossi- 
bility of  self-inflating  the  left  tympanum. 

Conchiding  Remarks  to  Part  I. 

The  foregoing  clinical  cases  are  selected  from  over  300  records  of 
officers  examined  in  France.  They  serve  to  illustrate  the  outstanding 
importance  of  efficient  Eustachian  tubes,  whereby  an  airman  should  be 
able  to  correctly  regulate  and  equalise  the  continuous  changes  of 
atmospheric  pressure  experienced  in  flights  from  low  to  high  and  from 
high  to  low  altitudes. 

These  cases  also  serve  to  show  that  the  deafness  and  distress  in  the 
ears  which  occur  through  flying  are  the  result  of  inefficient  Eustachian 
tubes,  and  that  these  symptoms  are  preventable.  And  lastly  that 
vertigo,  and  vomiting  and  forced  movements,  which  interfere  with  the 
proper  control  of  an  aeroplane,  are  sometimes  induced  by  the  unequal 
pressure  in  the  ears,  resulting  from  unilateral  Eustachian  obstruction, 
and  that  such  symptoms  are  overcome  by  removing  the  cause. 

1  By  permission  of  the  Director  General,  I  was  permitted  to  i-ecord  this  case  in 
the  JouRN.  OF  Laetngol.  Khinol.  and  Otol.,  February,  1919,  vol.  xxxiv. 
No.  2,  p.  51,  where  a  fuller  account  would  be  found. 


August,  1920.]  Rhinology,  and  Otology.  235 

Hoiv  to  Prevent  Giddiness,  Deafness,  and  Earache,  due  to  Descents 
from  High  Altitudes. 

The  following  rules  were  proposed  to  Lt.-Col.  Birley  as  a  result  of 
my  experience  among  airmen  in  France : 

(1)  That  airmen  should  not  fly  with  a  cold  in  the  head,  sore  throat, 

or  when  unable  to  inflate  both  Eustachian  tubes  at  will. 
N.B. — Airmen  with  large  bilateral  perforations  of  the  tympanic 
membrane  did  not  feel  the  ear  symptoms  experienced  by 
those  with  normal  drums.  Contrary  to  the  usual  practice 
I  recommended  they  be  permitted  to  continue  flying  duty, 
which  they  carried  out  with  success. 

(2)  Airmen  who  can  open  the  Eustachian  tubes  at  will  by  swallowing 

should  use  chewing  gum  to  stimulate  the  flow  of  saliva,  and 
keep  swallowing,  especially  while  descending. 

(3)  Airmexa  who  cannot  rely  upon  swallowing  to  open  the  Eusta- 

chian tubes  repeatedly  and  rapidly  should  make  a  rule  of 
self-inflating  the  ears  by  Valsalva's  method,  and  should  begin 
to  do  so  at  the  commencement  of  the  descent — repeating  the  pro- 
cedure once,  say,  everj^  1000  ft.,  and  not  wait  until  they  land. 

(4)  All  may  practise,  though  few  succeed,  in  the  following  procedure  : 

Open  the  mouth  slightly  while  trying  to  maintain  the 
lower  incisor  teeth  as  far  in  front  of  the  upper  as  possible. 
The  effort  can  only  be  strongly  sustained  for  a  minute  or  less  : 
one  should  be  conscious  of  tightly  contracting  the  muscles  of 
the  palate  and  upper  pharynx  at  the  same  time.  If  the 
procedure  succeeds,  one  can  pass  through  considerable 
changes  of  atmospheric  pressure,  without  having  to  swallow 
or  inflate  the  ears,  as  the  walls  of  the  Eustachian  tubes  are 
kept  apart  for  an  appreciable  time  by  this  voluntary  muscular 
action  alone. 

2.  Part  played  by  the  Semicircular  Canals  in  Aviation. 

It  has  been  assumed,  but  never  proved,  that  a  pilot  is  dependent 
upon  the  sensitiveness  of  the  semicircular  canals  to  maintain  equili- 
brium when  flying.  Yet  a  person  whose  semicircular  canals  have  all 
been  removed  on  both  sides,  can  run  and  ride,  dance  and  turn,  hop  and 
jump  with  eyes  open  or  shut,  and  presumably  could  learn  to  fly.  These 
extreme  views  we  shall  have  to  reconsider  in  the  light  of  investigations 
made  on  airmen  in  the  Air  Force  in  France  during  the  war. 

The  clinical  methods  of  investigating  the  semicircular  canals  have 
been  applied  to  airmen.  The  tests  employed  in  clinical  practice  depend 
upon  the  fact  that  normal  semicircular  canals  can  be  so  stimulated, 
artificially,  that  they  set  up  certain  characteristic  reflex  movements 
which  differ  in  intensity  in  different  individuals.  Semicircular  canals 
destroyed  by  disease  are  of  course  irresponsive  to  even  the  strongest 
stimulating  agents.  We  can  thus  ascertain  whether  each  canal  is 
responding  to  stimulus  or  not,  and  so  can  recognise  diseased  conditions. 
The  methods  of  stimulating  the  semicircular  canal  system  employed 
clinically  are  as  follows  : 

1st.     Eotation  with  sudden  deceleration. 

2nd.    Thermal  (hot  or  cold  water  or  air). 

3rd.    Pressure  (limited  to  certain  conditions  only). 

4th.    Galvanism. 


236  The  Journal  of  Laryngology,        [August,  1920. 

Clinical  methods  have  been  applied  to  airmen,  in  order  to  ascertain 
and  compare  the  intensity  of  the  reactions  which  are  so  set  up,  and 
\Yhich  are  described  later,  probably  in  the  first  instance  on  purely 
hypothetical  grounds. 

For  we  must  believe  that  the  assumption  was  that  a  pilot  depended 
largely  on  the  semicircular  canal  system  to  maintain  his  own  equili- 
brium and  that  of  his  aeroplane.^ 

In  investigating  disorders  of  the  central  nervous  system,  and  of 
certain  diseases  of  the  ear,  it  is  often  necessary  to  employ  all  these 
methods  before  an  accurate  diagnosis  can  be  made.  In  this  paper  I 
shall  confine  my  observations  to  rotation  and  caloric  tests  as  applied  to 
airmen,  because  these  tests  have  been  employed  by  other  medical 
officers  in  the  selection  of  candidates  for  the  Flying  Services  and  in 
grading  flying  officers  according  to  the  different  reactions  displayed. 

Normal  Phenomena  produced  by  Botation. 

The  individual  is  rotated  in  a  chair  or  a  turning  stool,  or  a  seat 
suspended  from  a  beam,  or,  failing  these  appliances,  simply  on  the  feet, 
round  and  round,  a  certain  number  of  times  at  a  certain  rate  and  then 
suddenly  stopped.  This  sudden  stop  after  turning  (i.  e.  deceleration)  causes 
dizziness,  which  varies  in  degree  and  duration  in  different  persons,  and 
is  accompanied,  according  to  the  strength  of  stimulus,  by  forced 
movements  of  eyes,  head  and  limbs. 

The  direction  and  character  of  nystagmus  and  other  forced  move- 
ments and  the  kind  of  subjective  sensations  depend  upon  the  position  of 
the  head  while  being  turned,  and  on  its  being  maintained  in  the  same 
constant  position  throughout  the  turning  and  at  the  moment  when  the 
head  is  brought  to  a  sudden  standstill. 

The  rate  of  rotation  should  not  be  less  than  one  turn  in  four  seconds, 
otherwise  the  stimulus  is  insufficient  to  evoke  the  phenomena  sought 
for.  As  a  rule,  from  five  to  ten  turns  are  necessary  to  produce  a  definite 
eftect.  The  same  rate  should  be  observed  in  making  both  clockwise  and 
counter-clockwise  rotation. 

Three  different  positions  of  the  head  during  turning  are  adopted : 

First  Position :  Head  erect.  Care  should  be  taken  that  the  chin  is 
depressed  (the  mouth  being  closed)  and  the  face  is  not  elevated  ;  other- 
wise the  superior  semicircular  canals  will  respond  in  place  of  the 
external  canals.  For  instance,  a  normal  subject  with  head  in  position 
for  stimulating  external  canals  will  deviate  to  the  right  after  clockwise 
rotation,  whereas  if  the  head  is  too  erect,  so  that  the  superior  canals 
receive  part  of  the  stimulus,  he  will  deviate  and  lean  to  the  left  after 
clockwise  rotation.  After  being  turned,  six  to  ten  complete  revolutions, 
the  individual  attempts  to  walk  straight,  with  eyes  shut ;  it  can  be  seen 
that  many  individuals,  when  told  not  to  resist,  will  tend  to  walk 
•circus-wise,  where  space  permits,  in  the  same  direction  as  the  rotations 
were  made.  Instead  of  attempting  to  walk,  he  may  try  to  point,  as 
Barany  explained,  in  a  prearranged  direction  with  hand  or  foot,  when 
the  "  normal  error  of  deviation  "  due  to  rotation  stimulation  can  be 
observed. 

The  nystagmus  is   "  horizontal  "   and  greatest  when  the  eyes  are 

'  "  Vertigo  and  Equilibrium,"  by  Major  Isaac  Jones,  M.D.,  American  Aviation 
Service  (Lippincott,  191S). 


August,  1920.]  Rhinology,  and  Otology.  237 

voluntarily  turned  opposite  to  the  direction  of  rotation  ;  its  duration 
varies  in  different  persons. 

Second  Position  :  Face  directly  doicmcards.  Five  turns  in  fifteen 
seconds  usually  suffice  to  produce  a  response.  On  stopping  the  turning 
as  before,  the  individual  rises  with  head  erect  and  is  directed  to  try  and 
walk  straight.  Some  will  succeed,  with  eyes  open  or  shut;  others  will 
stagger  to  the  ground,  unable  to  rise  for  perhaps  half  a  minute  or  longer. 
The  nystagmus,  which  must  be  sought  for  quickly,  will  be  seen  to  be 
fine  and  rotatory,  with  the  more  rapid  jerk  of  the  upper  meridian  of  the 
eyeball  away  from  the  direction  towards  which  the  previous  turnings 
were  made.  There  is  a  considerable  difference  in  the  duration  of  nystag- 
mus, in  seconds  of  time,  among  different  groups  of  individuals  in  health. 

Instead  of  attempting  to  walk  directly  after  being  turned,  the  subject 
under  examination  can  try  to  hold  the  head  erect,  with  eyes  shut,  and 
extend  both  arms  laterally  level  with  shoulders  ;  he  will  involuntarily 
hold  one  arm  more  or  less  above  and  the  other  below  the  horizontal 
level,  the  head  and  trunk  showing  a  tendency,  more  or  less  marked,  to 
incline  laterally  towards  the  lower  side.  The  sensations  to  an  airman 
somewhat  resemble  those  associated  with  banking. 

Third  Position  during  Flotation:  With  the  right  side  of  the  head 
doivmvards,  and  face  forwards,  the  sagittal  plane  of  the  head  being 
maintained  as  horizontally  as  possible.  The  turnings  are  made  first 
counter-clockwise,  the  face  travelling  forwards,  and  then  clockwise. 
Five  or  six  turns  in  ten  or  twelve  seconds  are  usualW  sufdcient  to 
provoke  a  response  and  reaction,  for  directlj^  the  head  is  raised  into  the 
erect  position  after  stopping,  emprosthotonos  or  opisthotonos  is  set  up, 
according  to  the  direction  of  rotation,  counter-clockwise  or  clockwise. 
The  nystagmus  is  of  short  duration,  and  is  upwards  in  the  former  and 
downwai'ds  in  the  latter  case. 

The  sensations  of  the  normal  individual  produced  by  rotations  in  the 
third  or  lateral  position  have  been  compared  by  airmen  to  those 
experienced  in  "  zooming  "  on  the  one  hand  and  "  nose-diving  "  on  the 
other  as  soon  as  the  head  is  raised  to  the  erect  posture. 

Among  any  considerable  number  of  normal  persons,  we  shall  find 
some  who  experience  no  disagreeable  sensation  whatever  after  being 
turned,  with  head  in  any  position.  Others  are  intensely  giddy  only 
after  being  turned  with  face  down  or  up. 

The  result  of  turning  in  the  erect  position  is  an  unreliable  indication 
of  the  degree  of  reaction  likely  to  be  produced  by  turning  with  face  down 
or  sideways ;  in  consideration  of  this  point  it  should  be  remarked  that 
it  has  been  the  custom  to  alter  the  position  of  the  head  and  resume  the 
erect  position  after  turning  in  the  second  and  third  positions,  whereas 
the  head  is  maintained  in  the  same  position  in  relation  to  space  both 
during  and  after  rotation  in  the  first  position.  (In  reapplying  clinical 
tests  this  point  will  probably  need  further  investigation.) 

The  above-described  phenomena  are  the  usual  result  of  hyper- 
stimulation  by  rotation  in  normal  persons.  They  do  not  occur  after 
destruction  of  both  vestibular  end-organs,  and  they  are  markedly 
asymmetrical  in  patients  who  have  unilateral  destruction  of  the  semi- 
circular canals. 

Caloric   Tests. 

As  is  well  known,  the  application  of  cool  or  tepid  water  to  the  drum 
of  the  ear  abstracts  heat  from  the  tympanic  cavity,  and,  more  slowly, 


238  The  Journal  of  Laryngology,         [August,  1920. 

from  the  outer  wall  of  the  labyrinth :  the  endolymph  and  perilymph  will 
condense,  and  so  convection  currents  are  set  up  in  the  superior 
semicircular  canal  when  the  head  is  erect  (and  in  the  external 
semicircular  canal  if  the  face  is  either  upwards  or  downwards). 

The  reactions  obtained  by  these  caloric  tests  with  head  erect  are 
similar  in  character  to  those  obtained  by  rotation  stimuli  with  the  head 
in  the  face-down  position  (see  p.  237). 

The  caloric  test  can,  however,  be  applied  to  one  side  at  a  time,  and 
the  reaction  obtained  can  be  compared  with  that  provoked  by  applying 
the  test  to  the  opposite  ear. 

Normal  individuals  with  normal  drums  and  normal  Eustachian 
tubes  react  equally  strongly  whether  the  right  or  left  ear  is  stimulated, 
provided  the  temperature  of  the  water  and  the  rate  of  flow  is  constant. 

When  I  went  to  France  I  found  some  airmen  who  had  been  admitted 
to  hospital  with  giddiness  associated  with  deafness  had  been  already 
subjected  to  the  caloric  tests,  even  when  the  drums  were  intact, 
the  method  employed  being  that  of  irrigating  the  external  auditory 
canal  in  the  usual  way  with  tepid  water  for  one  or  more  minutes 
until  nystagmus  or  dizziness  was  induced,  the  head  being  kept  erect. 

It  so  happened,  however,  that  in  the  airmen  mentioned  above,  the 
reaction  was  unequal,  being  stronger  in  some  when  the  test  was  applied 
to  the  affected  ear  as  compared  with  the  normal  ear  and  in  others 
weaker  when  applied  to  the  affected  ear. 

I  was  already  aware  that  any  person  whose  drum  was  invaginated 
reacted  more  readily  to  the  caloric  test  applied  to  that  side  than  to  the 
normal  side,  for  the  simple  physical  reason  that  the  drum,  being  closer 
to  the  labyrinthine  wall,  the  heat  was  abstracted  more  quickly  by  the 
irrigating  stream  than  when  a  cushion  of  air  intervenes. 

Further,  hypervascularity  of  the  drum  or  lining  membranes  and  the 
presence  of  mucus  in  the  tympanum  retard  the  reaction  to  the  caloric  test. 

It  was  for  these  reasons  that  I  did  not  employ  this  test  as  a  routine 
in  the  case  of  airmen — although  it  is  one  of  great  service  in  the  investiga- 
tion of  the  labyrinth  in  diseases  of  the  central  nervous  system  and  in 
some  cases  of  suppuration  in  the  middle  ear,  when  we  desire  to  ascertain 
simply  whether  there  is  a  response  or  no  response. 

Results  of  Rotation :     Tests  in  France. 

In  order  to  obtain  first-hand  data  on  the  relation  between  rotation 
reactions  and  flying  ability  by  the  application  of  the  clinical  labyrinthine 
tests  to  flying  men,  I  made  notes  of  a  series  of  sixty-two  pilots  and 
observers,  among  whom  were  twelve  high-grade  and  experienced 
pilots,  all  of  whom  volunteered  to  submit  to  the  examination. 

I  relied  chiefly  upon  the  tests  to  observe  the  activity  of  the  forced 
movements,  in  so  far  as  rotation-deceleration  interfered  with  the  attempt 
to  walk  straight,  immediately  after  turning. 

The  sensations  of  disturbed  equilibrium  and  of  induced  giddiness  were 
also  inquired  into  and  noted. 

It  seemed  unavoidable  that  a  mathematical  formula  must  give  way 
to  some  such  convention  as  can  be  expressed  by  the  terms : 
Forced  movements — absent  or  slight :     Group  1. 
Forced  movements — moderate  :     Group  2. 
Forced  movements — strong  :     Group  3. 

In  Group  3,  shown  in  Table  I,  "  strong  forced  movements  "  after 


August.  1920.] 


Rhinology,  and  Otology. 


239 


rotation,  cases  are  included  in  which  rotation  caused  the  individual  to 
collapse  to  the  floor,  from  which  he  could  not  rise  for  several  seconds  at 
least ;  and  those  who  staggered  so  much  while  attempting  to  walk  that 
they  failed  to  approach  a  previously  selected  mark.  It  is  interesting  to 
notice  that  this  group  included  some  "  crack  "  airmen,  who  will  be  further 
alluded  to. 

Table  I. 
Eotation  Forced  o-aa- 

type.  movements.  (riddiness. 

A.  .  Absent  or  slight      .         .  Slight 

B.  .  Moderate        .         .         .  Slight 

C.  .  Strong    ....  Slight 

D.  .  Absent  or  shght      .         .  Moderate 

E.  .  Moderate        .         .         .  Moderate 

F.  .  Strong    ....  Moderate 

G.  .  Slight  ....  Intense  . 
H.  .  Moderate  .  .  .  Intense  . 
J.  .  Strong    ....  Intense    . 

First-grade  pilots,  12  :  observers  and  other  pilots,  50. 

The  first  group — "forced  movements:  absent  or  slignt " — was 
designed  to  include  those  who  walked  rapidly  to  the  chosen  mark, 
without  showing  more  than  a  mere  waver ;  tliis  also  included  some  of 
the  best  fighting  airmen  of  their  day.    (See  A.,  D.,  G.,  Tables  I  and  II.) 

The  "  moderate  group  "  included  those  who,  after  a  definite  detour, 
managed  to  gain  the  point  sought  for  without  an  apparent  struggle. 
(See  B.,  E.,  H.,  Tables  I  and  II). 

In  estimating  the  individual's  category,  most  reliance  was  placed  on 
the  result  of  the  face-down  test. 

In  Table  I  we  notice  that  giddiness  was  not  always  in  proportion 
to  the  "  activity  of  the  forced  movement."  It  is  certain  that,  as  in  type 
C,  there  are  always  some  individuals  who  are  averse  from  admitting 
feeling  giddy,  while  in  Type  G.  we  meet  with  others  who  feel  giddy  and 
every  motion  when  in  the  air  as  in  the  rotation  chair  and  are  regarded 
as  "  temperamentally  unfit,"  though  they  do  not  show  strong  "  objec- 
tive "  reactions  in  the  rotation-chair.' 


Number 

tested. 

21 

17 
8 


6 

2 

3 
4 
1 
62. 


Total 
slight 


T.\BLE   II 

. — First  Grade  Pilots  only. 

Rotation 

Forced 

Giddme.^s 

Number 

type. 

movements. 

tested 

A. 

Absent  or  slight 

Slight        . 

6 

Capt.  No.  1,  Capt.  No,  15, 
Capt.  No.  55,  Capt.  No.  16, 
Capt.  No.  64,  Gen.  L. 

B. 

Moderate 

Slight       . 

3 

Capt.  No.  19,  Capt.  No.  42, 
Capt.  No.  43. 

C. 

Sti-ong 

Slight       . 

— 

— 

D. 

Absent  or  slight 

Moderate 

— 



E. 

Moderate 

Moderate 

— 



F. 

Strong- 

Moderate 

1 

Capt.  No.  25. 

G. 

Absent  or  slight 

Intense- 

— 



H. 

Moderate 

Intense     . 

1 

Capt.  No.  14. 

J. 

Strong.     . 

Intense    . 

1 

Major  No.  81,  ' 

1  The  chair  employed  was  lent  by  the  United  States  of  America  Aviation 
Medical  Service  through  the  courtesy  of  Lt.-Col.  Isaac  Jones,  and  was  similar  to 
that  in  use  in  America  by  the  medical  officers  for  the  examination  of  candidates 
for  the  Air  Service. 

-  I.  e.  giddiness  with  shock  reactions,  pallor,  clamminess,  small  pulse — headache, 
nausea  lasting  a  qiiarter  of  an  hour  or  longer. 


240 


The  Journal  of  Laryngology,         :Angust,  1920. 


<^^^ 


rs        ■="  -?    S  =^H    vri  .^   ,r:  Iz;  •- i5  'Z 


.2-2 

2I 

Q 


0 

io 

1  Si  -^"^  c  i 

"    S  8 

T 

1 

>-, 

>5 

^            X  ^ 

T5 

TS 

'c  .-^  fe  '3 

Tl 

=;:;  =t"  5  =w 

6C 

6£ 

ri  -— 

>> 

>5 

>^sa>^ 

i^i 

rt 

j^ 

0 

S3 
0 

2 

n 

0  ■§<.-*  5 

0 

0 

§ 

s 

S  "■  ^ 

i  w   O  o  5^  Ji'  o  ^ 


C  32    O; 


5 


S    i    ^       ^       ^^zZ.^^ 


*^     '[    T.  "''  SO 

-^  -^  CM  -JJ 

c  o  o  a 

s  rH     c  >  ^  ^  > 

-  bc-lf  •-  c  o  .s  o 
&„     o  o  2  ijr  o  g 


a     4:^^ 


%^ 


^ 

r, 

^  ,5 

^  's 

C*H 

0 

to 

3  tc 

a 

0 

-ts  ^_^ 

.^ 

'i  ^ 

©M- 

"5:  2 

=i^ 

S 

9,  s 

a 

—  be 

3! 

«    -r, 

0 

tc    ^ 

^ 

iH-l 

o^  o 
P5      s: 


fe  |ii  02 


5yc5.5-       ?-= 


'T  >.      - 


Si    " 


o  3  "~ 


02       s 


CC  CC  »  ^ 


H 

0 

0 

GO 

-«^ 

-i^ 

it's 

fcciS 

5  sc 

I S 

0 
;2; 

0 

.STc 

'i-£ 

.£  ^ 

5  £ 
i-i  0 

"^   '^ 

cS 

[i^  ^ 

li  S 

fe 

fe 

tf 

•     01    S 


R  o      S 


or. 


o 


or 


00° 

S^  ^  Q 


pc, 


be  o        be  o 


'  .~ 

0 

1— 1 

^' 

<a 

CO 

J2 

o 

c3 

i 

H 

GQ 


O 


^ 

Fh 

CJ 

1 

■tj 

►-> 

i^ 

HH 

c; 

UJ 

,_r 

iJ 

0 

a 

QQ 

<i 

ri 

EH 

sc     t 


o  __. 


Q 


^  ^    &  .be 

c  3  9  c 
tn  a  ^  TI 


1^1^ 


tC       be 

"S  _jj  "m 

;2'-=;^-^    I 
■:r.-f   b£  - 


©    I    o   c 
m    ij   w    w 

o  o  _o  o 


i  s  :^ 


0  T 

S  o 
o  o 

0-3 


[i4 


^        ^    ^^    ^ 


o     -w  'C  -ti  t;   , 
^       Sac  o  5a)® 


I 


August,  1920.]  Rhinology,  and  Otology. 


241 


CO     OQ 

a  ? 

S  fcJO 

®  .2 
'C  ^ 
00  ;-i 

.  s 

<U   o 

9  t 
153  -g 


Or? 


0-3 


O    3 


35 
§.^ 

bcS 

^   p 
O  bo 

O    eg 

ago 


»"  s 

jj     CO 

a) 

2  3 
5  S 


o 


i<  o  =4-1 

'->  ^    o 


^  ^  c  a 


'*'£, 


(^ 


^  I    ■ 

1)  s  2  o  ? 


^  r—     ^ 


§  ^  §  i  "itt 
.2  ^  ^ » ^  ^ 

3;  >,^  o  Sp^ 
Ph  a  o  ^a  ^ 

O    "  ^^     ^     —    f-* 


a  o 


'^    .  = 


^  -te." 


c  a  "^  ' 

^  a  CO 

be-   -'^ 


a) 


o 


«  a  Qj 
%  Ji  a  -5  ??  '-e  J4 


^^ 


-p  -;f  'S,  a  2  "ft 


"^     CO  ^ 

u  a 


5  ^ 


>  '^. 


<! 


"  =«  r-( 

35  .  ^ 


^  c3  g'.s  j:  ^c, 

4>  P  -,  a^  o  ^5    ■ 

~^  '^  .3  +2  '3 

.    .    .  .a  -^e  a  i 

00    M    CO    rl    a    O    g 

-S  -g  -S  -^  'o  a  » 

8  S  8  3* 
to  CO  to  a 
bcbOi^O       -,_  _ 

a.S  a      Z^^.  ^ 
'■S  "S  ^  £'  o  c2  ^   -w 

n   -   -OH"*^ga 

^  ^  ~  's    •>'^  "a  a 
a  c  X  a  o  .„ 

•^  a  s^^  s  "^-tJ 

5  a  o  o  a  -B  g 

a  a  ^  "*^  a  r^  -t^ 

_o  _S  _o  ^  a  o  '"'  be 


5J  O 


"^  .i^   "     0)  ._. 
-*^  +^  -^^    i,    ci  -t=    £0 

rC  -a  ^  -■  -t-  .j::  ,., 

r3  -^  -^  -1^  W  ;^  -(J 

ft|-  !i<  &H  &, 


O  lO  O 
J>  IM  CO 

Tji  CO  ;o 


>o 


006 

0  ^"  \n 


Q 


o 


> 
K 


:^  aS  &^  g^  % 
'TL  '3  bi;  a  cj  "3  0)  Pi'pi 
fea-r;^^jHr-^j;5 


;!^    o 


o 


Q)  a  += 


-e  a  s  fcc4^  _  ^  _  ^ 
«  o       bx)  g 


o  Q  c:^ 


.  ■=;  -(3  a  rs  ^  £, 
^  ^  9  bc^  ^  I  ^  ^ 
a  ^  S;S3  S  S  bc>, 
o  a  cr  br  c  a  be;:::  a^ 
o  o  t> 


m 


o  « 

.  a 
o  s 

;z;5 


0.2 


J^cS  t« 

a  cs 
2  ^ 


fee; 


02 


M 


O 
3 


1     <D    © 

=^  o  a 
o  o  o 
^135 


H      H 


t<     CO 

^•5 

as 

1   a) 
i<   ta 

a  0 
0  0 

0 

0 

=4-1 

=tH 

a 

a 

0  a 

?: 

OJ 

fi 

tp  fe 

0 

'^ 

0 

'C  0 

nS 

'm 

"^ 

■S-^ 

0 

-u 

T3 

-tJ  t3 

ra    eS  ^    cS 
be  *   be  S 


16 


242 


The  Journal  of  Laryngology,  August,  1920. 


o 


o 
© 


►2 


fC 

li; 


^ 


> 

< 


CON 

'^    O 

-  » 

s 

'S   . 


-^  S  « 

O    3    to 
l4    C3    o 

..S  -« 


C    C   e3 

03  t:  a 


fa  kD . 


o 


<-'   eS   ^    - 

4^    «    >    O 
E-'    CD 


-ti"  c2 


CO    <U    O 


be 


bDrG-j; 


<D    P< 

a  as 

!2i     . 

to 

04 


f       ^ 


bi:  - 


EH 


CO 


Os  S 


o-  bcS 


cn 


;:  ai 


Pq 


-»-    ^     ^    CJ 

C      O      rH      > 

>   »         C   CO 


y  ^  "  ^1 

^    3    O    re    o 

01 ::;  -1-2  ■— 

SfrS 


ftn 


f>-         ^   la  ^ 


~^o  X      eg 


-^  -^      ->2 


goo 


o 


>i  _Q 


c3 


J^. 


0  0 

c  0 

CQ  ,ij 

en  jj 

^  =s 

J^-^ 

^  "  .2 

y 

re     '-   = 

ri      --H    3 

- 

bJD-if -^ 

■bkt!^ 

c 

>■. 

>» 

^  bl  S 

bcs; 

^- 

'  «- 

■   ^ 

>-.—   > 

>,■"  > 

— 

'  15 

'^ 

;-!  t—  0 

CD 

Cs 

0 

!>• 

0  CD  CO 
> 

-*:> 

-u 

-u>  ti  -p 

bo 

^       0 

0 

0 
0 

_bD 

0 

,2      ®    r2 

be 

c 

*^ 

r-^ 

be  a  S 

a  a 

CT*. 

a 

CO    « 

c 

5 
0 

p 

c  >  ^ 

■g  c  ,2 

0 

'■r 

'~'i  ^ 

br 

> 

^  2 
8- 

>■ 

•p-P^'SL 

■"  bt  S 

CO 

= 

q 

b£ 

m    s  4^ 

^ 

jr.^  ^ 

■" 

c 

Ic 

t: 

'c 

-% 

■"^  ■i:  t" 

Q 

:-     §'-S 

<:m 

^S 

2    5=2 

sS 

ci  a  -^ 

a 

q 

rt 

ee  0 

J3 

3 

0 

c-  .-ti 

0 

-4^ 

02 

0 
0 

0 

,i5 

0 

0 

0 

©'5   cS 

"i 

-'-='  ,a  ^^ 
'3  ^  cs 

'5 

-p 

4^  p, 

M 

M 

fo 

fe 

(X* 

[<4 

&I     -p 

a      s 

-«      ? 

s       0 

-*3 

-p 

^-"^  ^ 

^ 

0 

[S) 

_&E 

^  ^^ 

-^ 

-u 

to 

-t; 

T. 

ai 

'r      '^  S 

•■r. 

-P 

-p 

0       r"  > 

n 

C£ 

be 

CO 

CO 

0 

1 

'P 

0 

0 

s 

1 

-s 

CO 

"S 

'3 

s 

tS 

rw 

r^ 

'e 

0 

0 

^■ 

0 

r3   -  T3   a-     1 

jM 

jM 

rl^ 

a  =  a  S 

50-0 

"3 

a 

"3 

rt 

5  -  ;:;  -i^ 

^ 

^ 

B: 

r> 

C  =*-    0    CO 



B 

m 

0 

0 

-p 

bet   SD-C 

o'5 

M   S 

0 

!5 

c 

-P 

-P     " 

-p  -p 

a  S  a  £ 

21S| 

t;  «• 

-  c 

-*■         ;2 

c  J: 

~ 

~ 

~ 

^S- 

Vj 

® 

0    3> 

■   a> 

S       1  ® 

m 

i, 

CO     CO 

u   m 

22       S-  oo 

Ij 

'? 

B 

r? 

-p  ^ 

5        a)  'g 

r« 

s 

^  ^ 

a  ^ 

ri^       a  ^ 

■s^ 

0 

p 

<^  9 

0        So 

Po 

0 

0 

0  ^ 

0  0 

0      00 

.S  t. 

p 

5 

0 

00 

0-3 

5     0-3 

=»-'       "S 

0 

1 

a 

a 

0  a  ®  a 
®  ^  ®  ^ 

c     ■ 

1  t^ 

i:i 

c 

0 

■TS  0  ^  0 

.si 

1    0 
« 

0 

c 

-« 

'w  "^     CD  '^ 

•-  2 

H 

fe 

1 

-P  '2  -p  r:       1 

a 

1 

•2  « 

cS  ()C 

1         f-H 

?^ 

CO 

■* 

IS       ;o 

0  -^ 

P3 

August,  1920.]  Rhinologry,  and  Otology.  243 

Table  X. — Rotation  Type  H.    First  Grade  Pilots.    (See  Table  II.) 

Name.               Hours  flowii.  Remarks. 

14.  Capt.    .     700  at  least                   Has  flown  since  1915.     Credited  w-itli  at  least 

twelve  E.A.'s.  Fine  pilot,  but  is  not  "  fond 

of  spinning."  Prefers  other  manoeuvres. 

Table  XI. — Botation  Tijpe  J.    First  Grade  Pilots.    (See  Table  II.) 

Name.  Remarks. 

81.  Major  .     Long    experience  .     Fine  war  pilot,  leader  and  instructor  of  scout 

and  a  squadron  flying  and  figliting.      "  Nearly  always  sea-sick 

commander      of  on  sea ;  never  while  flying."     A  keen  dancer. 

.  S.E.  o's  in  1918  He  considered  the  eft'ect  m  the  rotation-chair 

far  exceeded  any  induced  by  evolutions  when 

flying. 

Table  II  shows  the  results  obtained  from  the  First  Grade  Pilots 
only. 

We  find  three  exceptionallj'  good  scout  pilots  who  showed  strong 
forced  movements  or  distressing  giddiness  after  slow  turning.  I  would 
draw  especial  attention  to  Captain  25  (Tables  VI  and  VII)  ,  who  had 
already  shot  down  twenty-nine  enemy  aeroplanes,  and  latei"  was  credited 
with  nearly  as  many  more.  When  this  officer  was  turned  five  turns, 
even  slower  than  was  the  average  rate,  he  collapsed  to  the  floor,  after 
the  face-down  test,  and  struggled  vainly  to  rise  for  fully  half  a  minute. 
But  he  showed  no  signs  of  distress  such  as  pallor,  or  clamminess  of  the 
skin,  and  had  no  headache. 

Two  other  distinguished  pilots  with  long  war-flying  experience 
closely  resembled  Captain  25  in  the  reaction  shown  to  hyperstimulation 
of  the  labyrinth  by  rotation,  viz.  Captain  14  (Table  IX  and  X)  and 
Major  81  [Table  XI] . 

Both  officers  were  absolutely  normal  men  in  their  best  flying  form. 

In  contrast  with  the  three  above-mentioned  officers,  Nos.  25,  14,  and 
81,  who  reacted  strongly,  we  can  refer  to  the  Groups  A  and  B,  which 
include  those  whose  responses  were  normal  but  the  reactions  were 
moderate,  slight  or  absent. 

None  of  these  twelve  pilots  appears  to  have  derived  any  assistance 
from  the  semicircular  canals  to  estimate  position  in  space  while  flyings 
for  they  all  admit  losing  the  sense  of  position  in  dense  clouds. 

Conclusion. 

Consideration  of  the  data  pi'esented  in  the  above  tables  appears  to 
show  that  the  reactions  to  rotation  may  be  excessive  in  some  individuals 
and  suppressed  in  others,  but  in  neither  case  do  the  reactions  of  the 
semicircular  canals  serve  to  indicate  an  airman's  probable  flying  ability. 


244  The  journal  of  Laryngology,        [Angnst,  1920. 

THE   AQUEDUCT   OF   FALLOPIUS  AND   FACIAL   PARALYSIS. 

By  Dan  McKexzie. 

Part  II :  Faciai/  Paralysis. 

(Continued  from  p.  210.) 

Treatment. — -The  onset  of  facial  paralysis  in  suppuration  of  the  ear 
should  be  followed  without  delay  by  operation  on  the  ear. 

In  mastoid  suppuration  where  the  cells  are  the  chief  seat  of  the 
disease  and  where  operation  shows  the  lesion  of  the  nerve  to  be  situated 
in  its  vertical  segment  (a  rare  variety,  as  we  have  seen),  and  likewise 
in  facial  paralysis  from  Bezold's  abscess,  the  limitation  of  the  operative 
proceedings  to  the  mastoid  process  and  its  immediate  neighbourhood 
may  be  sutticient  to  cure  the  ear  disease  and  also  the  paralysis.  But  in 
all  other  cases,  and  also  in  simple  mastoid  abscess  where  the  site  of 
the  nerve  lesion  cannot  be  determined,  the  radical  mastoid  must  be 
performed  and  the  antro-tympanic  cavities  fully  exposed  and  cleared  of 
their  contents,  subsequent  proceedings  being  guided  by  what  is  there 
found.  Polypi  and  loose  sequestra  are  removed  with  due  care  not  to 
expose  the  nerve  to  any  further  damage  than  it  has  already  received. 
The  most  usual  situation  for  bony  caries  and  granulation-tissue  formation 
in  cases  with  paralysis,  is  in  the  postero-external  wall  of  the  tympanum 
either  in  or  about  the  sinus  tympani  or  the  oval  window,  and  here 
curetting,  if  ventured  upon  at  all,  must  be  very  gently  done,  since  the 
disease  is  almost  certain  to  have  exposed  the  nerve,  and  a  few  vigorous 
strokes  of  the  curette  would  sufltice  to  tear  through  its  last  remaining 
fibrils. 

If  the  nerve  can  be  identified  and  if  it  has  been  severed  by  disease, 
its  ends,  if  possible,  should  be  brought  together  and  laid  in  contact, 
without  any  packing  of  gauze  being  inserted.  Antisepsis  can  be  assured 
by  using  B.I. P.  paste. 

When  previous  examination  has  shown  the  labyrinth  to  be  inert, 
and  particularly  if  there  has  been  any  sign  of  intracranial  complication 
in  the  presence  of  cervical  rigidity  or  leucocytosis  of  the  cerebro-spinal 
fluid,  the  labyrinth  spaces  should  be  opened  and  drained. 

As  a  matter  of  fact,  in  most  of  the  cases  operated  on  it  is  impossible 
to  discover  the  site  of  tlie  nerve-lesion,  even  after  the  middle-ear  cavities 
have  been  as  fully  displayed  to  view  as  it  is  possible  to  get  them.  Often 
we  may  suspect  where  the  lesion  is,  but  seldom  can  we  be  certain.  But 
the  more  carefully  search  is  made  the  more  likely  is  the  surgeon  to  find 
the  exposed  tract  of  the  nerve.  The  most  usual  site  is  just  above  the 
oval  window  (see  Figs.  45,  46,  47,  48).  Search  can  be  made  with  a  probe, 
watch  being  kept  on  tlie  face  for  twitches,  as  they  indicate  when  the 
nerve- trunk  is  touched. 

Polypi  are  sometimes  attached  to  the  nerve,  and  cholesteatomatous 
disease  may  have  led  to  its  exposure,  as  we  have  already  seen. 

After  operation,  if  there  has  only  been  paresis,  improvement  may 
be  noticed  in  as  short  a  time  as  two  weeks,  but  if  there  has  been 
complete  paralysis,  three  months  is  likely  to  elapse  before  any  voluntary 
movement  can  be  detected,  but  an  interval  of  from  six  months  to  a  year 
is  by  no  means  unusual  before  the  first  twitch  heralding  the  return  of 
power  is  observed.  As  we  have  already  said,  the  paralysis  may  never 
entirely  disappear.     On  the  other  hand  it  seldom  persists  unaltered. 


August,  1920."' 


Rhinology,  and  Otology. 


245 


Tuberculosis  of  the  Ear. 

Frequency. — Facial  paralysis  is  a  common  and  early  symptom  of 
tuberculosis  of  the  ear.  According  to  Milligan  it  is  present  in  45  per 
cent,  of  the  cases.  Hence  the  clinical  rule  that  chronic  painless 
suppuration  of  the  middle  ear  with  facial  paralysis,  especially  in  child- 
hood, is  almost  certainly  due  to  tuberculosis. 

Pathology. — The  disease  in  most  of  the  cases  reported  was  found  to 
have  reached  the  nerve  through  the  usual  defective  area  above  the  oval 
■window.  But  in  tuberculosis,  although  the  attack  on  the  nerve  will  be 
facilitated  by  the  presence  of  a  defect  in  the  bony  canal,  the  erosive 
action  of  the  disease  upon  bone  is  so  great  that  the  osseous  sheath  of 
the  canal  can  confer  but  little  protection  upon  the  nerve-fibres.  The 
tuberculous  caries  exposes  the  nerve,  and  its  fibres  become  infiltrated 


Fig.  48. — Right  temporal  bone  of  child  displaying  i-elationshii)  of  facial 
canal  to  oval  window,  a.  Antrum,  b.  Facial  canal  at  geniculate,  c. 
Processus  cochleariformis  with  the  oval  window  beyond,  d.  Remains  of 
tympanic  membrane. 


■with  tubercles  which  ulcerate  and  destroy  the  nerve  entirely,  con- 
siderable lengths  frequently  being  involved  in  the  disease.  The  invasion 
of  tubercles  is  generally  preceded  by  neuritis,  probably,  in  the  first 
instance  septic. 

Hessler  reports  a  case  in  which  considerable  lengths  of  the  tympanic 
segment  of  the  nerve  were  exposed  by  tuberculosis  in  both  ears,  in  only 
one  of  which,  however,  had  the  disease  produced  paralysis,  and  Grunert 
and  Leutert  report  another  almost  precisely  the  same.  Such  cases  are 
exceptional. 

Prognosis. — The  prognosis  of  facial  paralysis  in  tuberculosis  of  the 
middle  ear  is  unfavourable  as  regards  the  chances  of  recovery  from  the 
paralysis. 

Treatment. — The  radical  mastoid  should  be  performed  as  soon  as 
the  diagnosis  is  made,  for  although  the  results  of  operating  in  developed 
tuberculosis  are  not  good,  early  cases  may  be  rescued  by  timely  inter- 
ference. 


246 


The  Journal  of  Laryngology.        [August,  1920. 


Cancer  of  the  Ear. 

Frequency. — Cancer  of  the  ear  is  not  a  common  disease,  but  a  number 
of  cases  have  been  recorded,  mostly  by  British  observers.  It  occurs  in 
two  sites,  the  auricle  and  the  deep  meato-tympanic  region,  the  latter  of 
which  tends  to  implicate  the  facial  nerve  at  an  early  stage. 

The  disease  is  characterised  by  severe  pain,  a  tendency  to  exuberant 
granulations,  and  offensive  discharge. 

Most  of  the  cases  reported  have  been  epithelioma,  but  a  few  sarco- 
mata are  on  record,  one  in  a  child  of  two  and  a-half  years,  by  Cheatle  in 
1898. 

Zeroni  reports  a  case  in  which  twitchings  and  tonic  spasm  preceded 
the  paralysis.     Paresis  may  usher  in  the  paralysis. 


Fig.  49. — Section  of  outer  labyrinth  wall  of  riq^ht  ear  showing  early  tuber- 
cular disease  of  the  ear.  Invasion  of  vestibule  through  oval  window  ; 
erosion  of  promontory  ;  niche  of  round  window  filled  with  tubercular 
granulation  tissue.  1,  membrane  of  round  window  ;  2,  tubercular  erosion 
of  promontory  ;  3,  head  of  stapes  ;  4,  tubercular  tissue  in  niche  of  oval 
window- ;  5,  facial  nerve ;  6,  vestibular  nerve  to  utricle,  external  and 
superior  canals ;  7,  footplate  of  stapes,  eroded  and  displaced  towards 
vestibiile-.  8,  vestibular  nerve  to  ampulla  of  posterior  canal ;  9,  tubercular 
tissue  filling  up  niche  of  round  window.     (From  J.  S.  Fraser.) 


III.  The  Internal  Ear. 

We  have  already  discussed  the  influence  of  purulent  labyrinthitis  on 
facial  paralysis.  There  still  remain  for  attention  labyrinthitis  from 
epidemic  meningitis  and  herpes  zoster  oticus. 

Epidemic  Meningitis  frequently  leads  to  a  disorganising  purulent 


-A.ngast,  1920.] 


Rhinology,  and  Otology. 


247 


labyrinthitis,  ■which  in  cases  that  recover  ends  in  absolute  deafness.     It 
is  one  of  the  common  causes  of  deaf-mutism. 

As  in  the  other  forms  of  meningitis,  facial  paresis  and  paralysis  are 
not  uncommon,  either  as  a  result  of  the  exudate  in  the  meninges  or  of 
the  meningeal  inflammation  in  the  sheaths  of  the  nerves  in  the  internal 
auditory  meatus  (J.  S.  Fraser).  Judging  from  cases  which  after 
recovery  come  to  our  ear  clinics  we  ma}'  say  that  the  facial  paralysis, 
unlike  the  labyrinthitis,  is  entirely  recovered  from.  The  difference  in 
■their  ultimate  fate  is  due,  no  doubt,  to  the  wide  difference  in  vulner- 
ability between  the  highly  specialised  and  delicate  structures  in  the 
Jabyrinth  and  the  portio  dura  with  its  motor  axones. 


iFiG.  50. — Section  of  right  tympanum  and  outer  labyrinth  wall  showing 
results  of  advanced  tiibercular  disease  of  the  ear.  Vertical  section 
through  posterior  part  of  petrous  bone.  The  outer  wall  of  the  vestibule 
has  been  removed  partly  by  the   disease   and   partly   by   the   surgeon. 

1,  large  gap  in  wall  of  labyrinth ;  the  ampullary  end  of  the  posterior 
canal,  both  parts  of  the  external  canal  and  the  facial  nerve  are  absent ; 

2,  ampullary  end  of  superior  canal ;  3,  tubercular  infiltration  in  fossa 
subarcuata;  4,  smooth  end  of  superior  canal:  5,  smooth  end  of  posterior 
canal ;  6,  saccus  endolymphaticus :  the  tubercidar  infiltration  reaches  to 
the  outer  wall  of  the  saccus.     (From  J.  S.  Eraser.) 

{To  be  contimied.) 


248  The  JoLxrnal  of  Laryngology,  August,  1920. 

SOCIETIES'     PROCEEDINGS. 


ROYAL  SOCIETY  OF  MEDICINE.— LARYNGOLOGICAL 

SECTION. 


November  1,  1918. 


President :  Dr.  James  Donelan. 


Abstract  J^eport. 

President's  Address. 
BRITISH  LARYNGOLOGY  AND  RHINOLOGY. 

By  James  Doxelan,  Ch.M.,  M.B., 
Chevalier  and  Officer  of  the  Crown  of  Italy. 

It  seems  that  the  time  is  fully  ripe  for  considering  how  far  British 
laryngology  and  rhinology  are  in  a  position  to  take,  how  far  do  they 
deserve,  a  leading  position  in  the  great  scientific  movement  that  will 
shortly  be  taking  place.  What  have  we  accomplished  in  the  past  ?  What 
promise  does  it  ail'ord  for  the  future  ? 

It  is  not  my  intention  to  attempt  a  detailed  survey  of  the  history  of 
British  laryngology.  When  one  looks  back  on  even  the  thirty  odd  years 
I  have  myself  been  connected  with  it,  one  cannot  help  seeing  that  so 
much  has  been  accomplished  that  anything  like  an  adequate  survey, 
even  a  catalogue  raisonnc,  would  take  up  more  than  the  whole  time  at 
our  disposal  this  evening.  I  hope,  however,  to  refer  to  our  scientific 
progress  in  such  a  form  as  to  show  at  this  critical  moment,  when  the 
world  is  about  to  take  stock  of  everything,  that  British  laryngology  and 
rhinology  have  ever  been  in  the  van  of  progress,  and  that,  if  we  owe 
something  to  Germany,  it  has  chiefly  been  the  systematisation,  not  to 
say  exploitation,  of  ideas  that  very  often  had  their  origin  not  only  in 
these  islands  but  in  this  Section,  or  in  the  societies  that  were  its 
forerunners. 

I  also  propose  to  put  before  you  some  of  the  many  suggestions  that 
have  been  kindly  offered  to  me,  so  that  we  may  consider  at  some  more 
convenient  time  in  what  way,  if  in  any,  we  can  improve  our  organisation 
and  keep  it  fit  to  maintain  the  reputation  I  am  told  we  enjoy  as  the 
most  energetic,  hard-working  and  enthusiastic  section  of  this  great 
society. 

It  seems  only  natural  that  the  country  which  is  the  parent  home  of 
laryngoscopy  should  be  a  leader  in  all  that  has  resulted  from  the 
invention.  Everyone  has  his  own  view  as  to  whom  the  credit  of  the 
invention  belongs.  I  do  not  intend  to  discuss  it  now ;  I  will  only  briefly 
mention  the  facts  that  go  to  prove  that  this  is  the  parent  home  of 
laryngoscopy. 

Though  mirrors  have  often  been  used  for  seeing  round  awkward 
corners,  no  one  seems  to  have  thought  of  using  a  mirror  for  examining 
the  larynx  until  the  beginning  of  the  last  century.  A  mirror  "on  a 
long  shank "  for  examining  the  larynx  was  first  demonstrated  on 
March  18,  1829,  before  the  Hunterian  Society  by  Benjamin  Guy 
Babington,  afterwards,  like  his  father  before  him,  Physician  to  Guy's 
Hospital  and  founder  of  the  Epidemiological  Society.     In  the  words  of 


August,  1920.]  Rhinology,  and  Otology.  249' 

the  account  in  the  Hunterian  Transactions,  "  the  doctor  proposed  to  call 
it  the  glottiscope."  It  is  much  to  be  regretted  that  the  cholera  epidemic 
of  a  year  or  two  later  induced  him  to  turn  his  great  talents  to 
epidemiology,  which  was  then  by  no  means  ripe  for  scientific  study, 
instead  of  to  diseases  of  the  larynx.  Babington's  invention  was  not, 
however,  lost  sight  of,  as  is  commonly  supposed,  for  a  laryngeal  mirror 
or  "a  mirror  such  as  dentists  use"  is  recommended,  quite  as  a  matter 
of  course,  in  works  on  general  surgery — Liston,  for  instance,  in  1840 — 
as  a  simple  means  of  examining  the  larynx.  It  was  this  simple  means, 
or,  as  Manuel  Garcia  says  in  the  paper  read  on  his  behalf  at  the  Eoyal 
Society  in  1854,  "  the  method  that  I  adopted,"  that  he  employed  in  the 
study  of  his  own  larynx.  In  that  paper,  entitled  "  Observations  on  the 
Human  Voice,"  Garcia  makes  no  claim  to  having  invented  anything, 
and  though  I  knew  him  fairly  well  and  had  many  talks  with  him  on  this 
subject,  especially  between  the  years  1887  and  1891,  as  I  am  not 
discussing  it  now,  I  will  merely  say  that  he  was  undoubtedly  the 
inventor  of  auto-laryngoscopy.  As  Manuel  Garcia  was  domiciled  here 
for  some  sixty-five  years  of  his  long  life,  and  had  worked  as  a  professor 
of  singing  at  the  Royal  Academy  of  Music  for  several  years  before  he 
made  his  communication  on  the  human  voice  to  the  Royal  Society,  I 
think,  whatever  views  we  may  hold  as  to  the  inventor  of  the  laryn- 
goscope, whether  Babington  or  Garcia,  we  may  fairly  claim  that  this  is 
the  parent  home  of  laryngoscopy,  although  the  credit  of  first  reporting 
any  clinical  work  done  with  it  appears  to  belong  to  the  Hungarian, 
Johann  Czermak,  the  teacher  of  Morell  Mackenzie. 

Czernak  pubhshed  the  first  edition  of  his  book,  "  Der  Kehlkopfspiegel 
und  seine  Yerwerthung  fiir  Physiologie  und  Medizin,"  in  1860.  A  copy 
of  this  very  rare  first  edition  is  in  the  Society's  library.  I  do  not  find 
that  Czermak,  amongst  his  many  subsequent  writings,  published 
anything  in  connection  with  laryngology  except  reprints  of  this  one 
work.  In  1863,  three  years  after  Czermak's  book  appeared,  his  pupil, 
Morell  Mackenzie,  had  already  founded  the  Hospital  for  Diseases  of  the 
Throat  in  Golden  Square,  being,  1  believe,  the  first  institution  ever 
devoted  to  the  objects  of  our  special  study.  It  was  there  he  did  all  his 
best  work,  and  there  he  collected  the  bulk  of  that  immense  material  for 
those  works  on  every  department  of  our  study  which  at  once  placed 
British  laryngology  in  the  very  front  of  the  scientific  progress  of  the 
world. 

The  time  has  happily  gone  by  when  English  text-books  dealing  with 
every  department  of  our  subject  could  be  written  with  scarcely  a  mention 
of  Morell  Mackenzie's  name,  when  a  veil  of  silence  was  allowed  to  fall 
upon  every  reference  to  the  work  of  the  father  of  British  laryngology 
even  in  the  recognised  centre  of  that  science,  or  when  it  could  be 
lumped  together  with  that  of  humbler  workers  and  contemptuously 
dismissed  as  the  effort  of  an  anonymous  pioneer. 

Morell  Mackenzie's  writings  will  always  be  amongst  the  classics  of 
our  special  literature  in  English. i  They  are  a  remarkable  achievement 
for  one  man — a  man  harassed  from  his  boyhood  by  almost  continuous 
attacks  of  spasmodic  asthma — when  one  remembers  that  it  is  all  based 
on  over  twenty  years'  personal  pioneer  observation,  of  his  own  cases 
and  a  wide  reading,  probably  unique  in  its  extent,  of  the  cases  of  others. 
If  his  "Diseases  of  the  Throat  and  Nose"  has  not  attained  to  succeeding. 

■  See  JouRN.  OF  Lartngol.,  Ehi.nol.,  and  Otol.,  vol.  xxxiv,  pp.  181  and  278. 


250  The  Journal  of  Laryngology,  [August,  1920. 

editions  like  other  text-boolis  of  proved  value,  it  was  because  he  was 
cut  off  while  preparing  the  second  edition.  It  would  have  contained 
much  new  matter  and  some  corrections.  The  references  in  this  work 
compass  the  history  of  our  speciality  from  the  earliest  records  up  to  the 
year  1884.  It  is  not  a  dead  bibliography,  however,  for  the  views  of 
almost  every  writer  of  importance  are  discussed  or  commented  upon. 
Scai'cely  any  author  is  omitted,  certainly  none  intentionally. 

"  Diseases  of  the  Throat  and  Nose  "  was  commenced  in  1872.  The 
first  volume  appeared  in  1880  and  the  second  in  1884.  The  writer 
•explains  the  slow  rate  of  progress  and  the  changes  owing  to  the  rapid 
development  of  a  new  speciality  that  took  place  while  the  book  was 
being  prepared.  Even  the  second  volume  was  not  completed  according 
to  the  design  of  the  author,  as  the  "  Section  on  Diseases  of  the  Neck  " 
had  to  be  omitted.  This  section  was  to  have  included  his  chapters  on 
goitre,  of  which  I  myself  brought  the  references  tip  to  1891.  These 
chapters  then  existed  only  in  a  single  set  of  galley-proofs,  which  have 
since  been  lost.  Besides  the  usual  exhaustive  history  of  the  diseases  of 
the  thyroid  gland  from  the  earliest  times,  Mackenzie  had  previously 
brought  the  literature  up  to  about  1884.  l^e  did  not  limit  his  view  of 
the  causation  to  geological  peculiarities  of  the  water  supply,  but,  from 
evidence  furnished  to  him  mostly  by  Indian  medical  friends,  held  that 
it  would  probably  be  found  that  the  water  was  infected  by  the  excreta 
of  goitrous  persons.  This  view,  as  many  of  you  are  doubtless  aware, 
has  been  taken  and  its  truth  brilliantly  demonstrated  by  Col. 
McCarrison,  of  the  Indian  Medical  Service,  in  the  epoch-making  work  he 
published  last  year.  I  should  strongly  recommend  those  who  have  not 
yet  had  an  opportunity  of  studying  this  work  that  they  should  not 
omit  to  do  so,  and  especially  the  pages  on  the  relation  of  subthyroidism 
to  enlargements  of  the  pharyngeal  tonsils.  They  are  bound  to  have  a 
considerable  influence  on  present  treatment. 

It  is  of  interest  to  recall  the  excellent  pioneer  work  recorded  by 
Mackenzie  in  his  second  volume  in  relation  to  oesophageal  diseases. 
The  results  of  his  examinations,  with  very  imperfect  means,  of  a  large 
number  of  cases  have  a  permanent  value  even  in  these  oesophagoscopic 
days.  Mackenzie's  other  works  in  relation  to  our  speciality  are : 
The  series  of  "  Essays  on  Throat  Diseases,"  including  "  Hoarseness, 
Loss  of  Voice  and  Stidulous  Breathing  in  Relation  to  the  Nervo- 
muscular  Affections  of  the  Larynx  "  ;  "  Growths  in  the  Larynx,"  which 
will,  I  think,  always  be  the  universal  classic  of  that  subject,  although 
somewhat  marred  by  the  unfortunate  tone  of  the  Durham  controversy. 
Other  essays  were:  "Diphtheria,  its  Nature  and  Treatment";  "The 
Use  of  the  Laryngoscope  "  ;  "  Hay  Fever  "  and  "  The  Hygiene  of  the 
Vocal  Organs."  All  these  works  were  most  favourably  received  by  the 
medical  profession  and  press  throughout  the  world.  Nowhere  was  the 
chorus  of  approval  louder  or  more  enthusiastic  than  in  Germany,  where 
the  book  was  anxiously  awaited,  and  where  for  many  years  after  it  was 
done  into  German  it  was  the  principal  and  indeed  the  only  good  text- 
book of  our  subject. 

In  considering  the  scientific  value  of  Morell  Mackenzie's  work  it 
•should  never  be  forgotten  that  the  bulk  of  it  was  pioneer  work.  The 
most  remarkable  thing  about  it  is  that  his  views  and  conclusions  have 
stood  the  test  of  time,  and  have  been  so  little  affected  by  modern 
progress  or  even  improved  statistical  research.  Some  doubts  have  been 
expressed  of  the  value  of  Mackenzie's  statistics,  but  the  best  proof  of 


August,  1920.J  Rhinoiogy,  and  Otology.  251 

their  reliability  is  that  the  most  modern  figures  tend  only  to  confirm 
them.  It  has  also  been  said  that  Mackenzie,  especially  in  his  later 
years,  did  not  keep  case-notes.  From  my  own  personal  knowledge 
I  can  say  that  this  is  simply  not  true.  As  in  most  other  practices  the 
bulk  of  his  cases  had  but  little  special  interest,  but  even  of  these  he 
kept  a  brief  note  of  the  names,  ages,  dates  when  seen,  treatment 
ordered,  and  the  result.  He  kept  fuller  notes  of  all  cases  of  any  special 
interest.  In  bis  case  as  regards  material  he  suffered  rather  from  an 
embarras  de  richesses  which  w"as  really  beyond  the  physical  powers  of  a 
not  very  strong  man  to  deal  with  adequately'. 

I  have  devoted  so  much  time  to  the  scientific  work,  hitherto 
neglected,  of  the  father  of  British  laryngology  that  I  can  refer  only 
very  briefly  to  the  contributions  of  other  British  pioneers  and  workers 
who  are  dead.  The  work  of  Dr.  Edward  Woakes  has  been  of  permanent 
value  in  furnishing  a  useful  working  theory  of  the  causes  of  intranasal 
suppuration  and  polypus  formation,  and  I  believe  there  are  good  grounds 
for  regarding  him  as  the  first  Englishman  who  wrote  a  scientific  account 
of  diseases  of  the  pharyngeal  tonsil,  and  that  at  a  time  before  Meyer's 
paper  had  become  known  to  him  or  to  other  English  readers. 

Lennox  Browne,  too,  besides  being  the  founder  of  the  Central 
London  Throat  Hospital,  accomplished  work  of  the  highest  value  in 
laryngology  and  rhinology,  and  those  labours  find  a  worthy  monument 
in  the  second  edition  of  his  text-book,  in  which  he  was  assisted  by 
the  regretted  Dr.  Cagney.  The  work  of  Spencer  Watson,  Adams 
and  Walsham  will  be  remembered  especially  by  our  senior  members. 
Durham,  whose  tracheotomy  tube  is  still  unrivalled,  will  never  be 
forgotten  so  long  as  humanity  wants  to  breathe  in  spite  of  opposition. 
It  is  hardly  necessary  for  me  to  recall  the  work  of  Henry  Butlin,  or  of 
Cresswell  Baber,  whose  contributions  stand  in  the  front  rank  of  the 
literature  of  our  subject  of  this  or  any  other  country. 

Passing  to  the  work  of  living  laryngologists,  almost  all  of  whom  are 
members  of  this  Section,  I  hope  none  of  them  will  think  me  discourteous 
if  I  follow  a  recommendation  given  me  and  refer  only  to  British  work 
without  the  names  of  the  workers.  Look  at  what  has  been  done  in  this 
country,  most  of  it  pioneer  work  of  the  highest  value,  in  the  study  of 
diseases  of  the  nasal  accessory  sinuses,  and  especially  in  regard  to  the 
operative  treatment  of  frontal,  maxillary  and  sphenoidal  abscess ;  the 
significance  of  paresis  of  the  larynx  as  a  forerunner  or  early  symptom 
of  phthisis ;  the  great  improvements  in  the  diagnosis  and  treatment  of 
nasal  lupus  and  tuberculosis  of  the  larynx,  which  enable  us  to  approach 
such  cases  with  far  more  confidence  of  success  than  twenty  or  even 
fifteen  years  ago.  Take  what  has  been  done  here  to  advance  the  study 
of  malignant  disease  of  the  larynx  and  to  perfect  the  technique  of  the 
operations  for  its  treatment — technical  advances  which  have  made 
thyrotomy,  for  instance,  one  of  the  safest  instead  of  one  of  the  most 
risky  of  surgical  enterprises.  Let  us  also  recall  the  immensely  valuable 
investigation  of  the  innervation  of  the  larynx  and  of  the  symptoms  to 
which  the  various  paralyses  give  rise ;  the  treatment  of  deformities 
of  the  nasal  septum  ;  the  improvements  in  submucous  resection ;  the 
introduction  of  submucous  turbinectomy.  The  magnificent  work  done 
by  our  fellow  countrymen,  and  especially  our  fellow  members,  in  relation 
to  diseases  of  the  oesophagus  and  pharyngeal  pouches  is  unequalled  in 
any  country,  while  if  Briinings  invented  the  bronchoscope  it  was  only  by 
the  application  of  principles  discovered  by  Newton,  Dolland  and  Harris, 


252  The  journal  of  Laryngology,        [August,  1920. 

and  these  had  been  made  use  of  long  before  him  by  Fisher,  of  Boston, 
Desormeaux,  of  Paris,  and  Sir  Francis  Cruise,  of  Dubhn,  in  the  invention 
of  the  endoscope.  Above  all,  at  the  present  time,  consider  the  admirable 
successes  achieved  by  members  of  our  Section  in  war  surgery,  and 
especially  in  the  repair  of  facial  injuries. 

It  is  useless  to  attempt  to  conceal  the  names  of  those  who  have 
accomplished  all  that  is  included  in  this  long  record  of  progress.  They 
are  indissolubly  associated  each  with  its  subject,  some  with  more  than 
one.  You  will  find  them  in  any  bibliography  of  our  w^ork,  especially 
in  those  bibliographies  in  German  publications  where  their  ideas  are 
not  only  acknowledged  but  taken  as  the  guide  to  further  developments, 
to  which  German  names  are  attached  and  then  sent  back  for  the 
adulation  of  those  who  do  not  trouble  to  find  out  where  they  first 
came  from. 

It  is  for  you  to  consider  how  all  tliese  advantages  can  be  put  to  the 
best  possible  use  in  the  time  of  reconstruction  that  is  now  upon  us. 
Golden  Square,  as  the  first  of  throat  hospitals,  the  scene  of  the  work  of 
the  Father  of  British  laryngology,  will  no  doubt  always  remain  the 
Mecca  of  all  interested  in  our  subject,  with  Gray's  Inn  Eoad  as  the 
Medina,  or  place  of  only  slightly  less  sanctity.  But  what  about  all 
the  other  hospitals  ? 

A  suggestion  that  has  been  made  to  me  and  which  seems  to 
commend  itself  to  workers  in  other  sections  is :  That  the  Eoyal 
Society  of  Medicine  should  become  a  centre  where  any  medical  woman 
or  man  arriving  in  London,  or  living  here  with  some  time  to  spare  for 
professional  self-improvement,  could  at  once  find  out  how  and  where 
he  can  best  employ  that  time  according  to  his  own  wishes.  We  could 
have  here  in  the  office  for  inspection  a  more  complete  diary  of  forth- 
coming lectures,  demonstrations  and  operations.^  In  the  case  of 
private  operations,  if  such  were  included,  he  could  communicate  with 
the  operator  and  obtain  his  permission  to  be  present.  This  w^ould  save 
the  latter  from  being  sometimes  inconveniently  crowded  through  his 
and  his  patient's  generosity  and  wish  that  an  instructive  occasion 
should  not  be  missed,  while  it  would  leave  the  decision  as  to  the 
number  invited  in  their  hands.  An  important  item  in  this  programme 
is  the  improvement  of  the  Journal  of  Laryngology,  Ehinology,  and 
Otology. 

As  regards  the  Eoyal  Society  of  Medicine,  Fellows  and  Members 
should  do  everything  in  their  power  to  make  it  widely  known  that  this 
is  the  central  representative  body  of  British  medical  science.  It  is 
purely  a  scientific  body  and  does  not  meddle  in  medical  or  other 
politics.  Persons  who  give  large  donations  to  individual  hospitals  are 
not  aware  of  the  fact  that  a  similar  donation  to  this  Society  is 
equivalent  to  a  donation  to  every-  hospital  in  the  country,  since  it 
advances  the  science  that  is  the  foundation  of  their  usefulness  to  those 
for  whom  they  were  instituted.  The  Eoyal  Society  of  Medicine  is 
eminently  worthy  of  public  support,  and  it  is  to  be  hoped  that  now 
that  medical  science  is  becoming  more  adequately  represented  in  the 
councils  of  the  nation,  it  will  soon  receive  an  annual  grant  from  the 
public  purse  to  facilitate  its  beneficial  work.  In  Germany  such  a  body 
would  have  been  one  of  the  first  cares  of  the  State  from  its  inception. 

'  This  has  now  been  done.— En  ,  Journ.  of  Laetngol.,  Rhinol.,  .\nd  Otol. 
(To  be  conthuicd.) 


August,  1920.]  Rhinology,  and  Otology.  253 

ABSTRACTS. 

Abstracts  Editor — W.  Douglas  Haemer,  9,  Park  Crescent,  London,  "W.  1. 

Authors  of  Original  Communications  on  Oto-laryngology  in  other  Journals 
are  invited  to  send  a  copy,  or  tv:o  feprints,  to  the  Jourxal  of  Laryngologt. 
If  they  are  willing,  at  the  same  time,  to  submit  their  own  abstract  (in  English, 
French,  Italian  or  German)  it  tvill  be  welcomed.  . 


EAR. 


Location  of  the  Lateral  Sinus  and  Mastoid  Antrum  from  External 
Markings. — Prentiss.  "'  Annals  or  Otolos^y,  etc.,"  March,  1918, 
p.  116. 

Prentiss  states  that  the  position  of  the  lateral  sinus  may  be  gauged 
by  determining  the  position  of  the  supramastoid  crest — i.  e.  third  root  of 
the  zygoma.  If  this  crest  runs  obliquely  upwards  the  sinus  is  well 
posterior  to  the  field  of  approach  to  the  antrum,  and  a  horizontally  placed 
crest  indicates  that  the  sinus  is  close  to  the  field  of  operation. 

The  external  auditory  meatus  may  run  in  from  the  cortex  at  a  vei-y 
oblique  angle  or  at  a  right  angle.  In  the  first  case  it  keeps  away  from 
the  sinus.     In  the  second  case  it  approaches  the  sinus. 

The  antrum  is  in  a  plane  horizontal  with  the  attic,  and  therefore  is 
above  but  posterior  to  the  upper  wall  of  the  external  auditory  meatus. 
This  relation  does  not  vary.  What  does  vary  is  the  depth  of  the  middle 
cerebral  fossa.  The  supramastoid  crest  varies  in  its  position  to  the 
external  opening  of  the  external  auditory  canal.  It  may  run  backwards 
well  above  this  canal  or  run  backwards  just  tangent  to  the  canal.  In  the 
first  case  the  cone  of  api)roach  may  be  made  with  little  likelihood  of 
exposing  the  meninges.  In  the  second  case  the  approach  must  be  made 
well  below  the  crest  and  even  in  the  horizontal  plane  of  the  meatus.  The 
apex  of  the  cone  of  approach,  however,  must  always  point  upwards  to 
reach  the  antrum,  which  is  above  but  posterior  to  the  meatus.  If  we 
went  hoiizontrtlly  inwards  we  would  miss  the  antrum,  but  hit  the  vertical 
part  of  the  seventh  cranial  nerve.  The  depth  of  the  antrum  may  be 
determined  by  ascertaining  the  depth  of  the  meatus.  The  distance  to 
the  antrum  cannot  exceed  the  depth  of  the  meatus,  as  the  middle  ear 
approaches  the  cortex  as  it  passes  backwards.  /.  S.  Fraser. 

The  Value  of  X-ray  Examination  in  Mastoiditis. — Dixon.  "Ann.  of 
OtoL,  Ehiuol.  and  Laryugid,"  December,  1917,  p.  986. 

Dixon  records  several  illustrative  cases  :  (1)  Acute  suppurative  otitis 
media  (left).  A  clear  pneumatic  mastoid  was  found  on  the  right  side. 
The  left  mastoid  was  a  "  hazy  to  cloudy  "  pneumatic,  but  there  was  no 
evidence  of  breaking  down.  Dixon  reported  :  "  Not  operative  at  present." 
The  case  cleared  up  without  operative  interference.  (2)  Complained  of 
■earache  (left)  soou  after  sea-bathing.  Had  a  large  clear  pneumatic 
mastoid  on  the  right  side.  Sinus  about  the  usual  position.  Left  side 
had  aj^parently  also  been  of  pneumatic  type,  but  it  was  thoroughly  dis- 
organised. There  was  no  question  as  to  its  being  an  operative  case,  and 
it  was  thought  that  a  large  perisinus  abscess  and  probably  an  epidural 
would  be  found.  Operation  showed  a  perisinus  abscess  at  the  knee  and 
a,  sinus  covered  with  granulations.      Six  other  cases  are  recorded,  in  all 


254  The  Journal  of  Laryngology,         [August,  1920. 

of  which  the  operative  findings  confirmed  the  reading  of  the  X-ray  plate 
sent  by  Dixon.  In  several  instances  the  infecting  organism  was  the 
Streptococcus  mucosus  capsulatus.  J.  S.  Fraser. 

Indications  for  the  Mastoid  Operation  in  Acute  Otitis  Media. — Bench. 
"  Journ.  Amer.  Med.  Assoc,"  September  15,  1917,  p.  878. 

Dencli  reminds  us  that  the  mastoid  is  simply  one  part  of  the  middle 
ear,  and  every  case  of  acute  middle-ear  inflammation  is  really  a  mastoid- 
itis. A  middle  ear  acutely  inflamed  and  properly  drained  by  free  incision 
of  the  drum  membrane  recovers  spontaneously.  If  drainage,  either  on 
account  of  the  severity  of  the  inflammatory  process,  the  particular  topo- 
graphy of  the  mastoid  in  the  individual  case,  or  the  extreme  virulence  of 
the  infecting  organism,  is  insufficient,  then  a  mastoid  operation  is 
indicated — that  is,  it  is  necessary  to  drain  the  middle  ear  through  a 
posterior  incision  rather  than  by  an  incision  through  the  drum  membrane. 
Indications. — If,  after  free  incision  of  the  drum  membrane,  ^xu'/i  in  the 
ear  persists  for  from  twenty-four  to  forty-eight  hovirs,  and  is  sufficient 
to  require  the  administration  of  an  opiate,  Ave  have  a  sufficient  indication 
for  opening  the  mastoid.  In  such  cases  the  mastoiditis  is  of  the  haimor- 
rhagic  variety  and  the  mastoid  cells  are  extensively  developed.  Tempera- 
ture.— The  temperature  is  apt  to  be  more  elevated  in  infants  aud  young 
children  than  in  adults.  A  persistent  high  temperature  or  a  remittent 
temperature  with  exacerbations  calls  for  exploration.  Many  cases  run  an 
afebrile  course.  Absence  of  temperature  is  no  contra-indication  to  opera- 
tion. Local  tenderness. — The  mastoid  may  be  exquisitely  tender  within 
twelve  hours  after  the  inception  of  an  acute  otitis.  This  early  teuderuess 
is  not  an  indication  for  operation.  The  situation  of  the  tenderness 
depends  on  the  particular  topography  of  the  mastoid  in  the  individual 
case.  Many  of  these  cases  recover  without  operation.  After  tympanic 
drainage  has  been  established  tenderness  will  gradually  disappear. 
Antrum  tenderness  is  a  much  more  valuable  sign.  Recurrent  tenderness 
is  a  very  significant  sign,  and  ordinarily  indicates  an  involvement  of  the 
mastoid,  which  will  be  relieved  only  by  posterior  drainage.  Otosco/dc 
examination. — Narrowing  of  the  canal  at  the  fundus — that  is,  a  persistent 
bulging  of  the  upper  and  posterior  portion  of  the  drum  membrane, 
together  with  a  sinking  of  the  corresponding  adjacent  meatal  walls — is 
an  almost  pathognomonic  indication  for  operation.  Bacterioloejic  exami- 
nation.— It  is  advisable  to  make  a  smear  of  the  aural  discharge.  A 
Streptococcals  capsidatus  infection  must  be  watched  with  exceeding  care. 
No  such  case  should  be  considered  safe  until  the  middle  ear  has  returned 
to  a  perfectly  normal  condition.  Many  cases  came  to  operation  from  two 
to  six  months  after  the  drum  membrane  had  healed.  The  amount  of 
discharge  or  sudden  cessation  with  the  signs  indicative  of  interference 
with  drainage  are  indications  for  immediate  operation.  Duration. — A 
very  profuse  discharge  persisting  for  more  than  three  weeks  after 
incision  of  the  drum  membrane  is  also  an  indication  for  operative  inter- 
ference. Persistence  of  aural  symptoms. — After  all  discharge  has  ceased 
the  patient  comes  complaining  of  certain  indefinite  symptoms,  such  as 
headache,  malaise,  loss  of  flesh.  The  hearing  is  ordinarily  much  impaired, 
the  ear  feels  full,  and  there  may  be  some  slight  disturbance  of  equili- 
brium. These  are  frequently  cases  of  Streptococcus  capsulatus  infection. 
Dench  recommends  an  exploratory  operation,  aud  has  never  failed  to 
evacuate  pus  from  the  mastoid.  Repeated  incisions  of  the  drum 
membrane  must  be  condemned,  as  they  simply  relieve  temporarily  the 


August,  1920.]  Rhinology,  and  Otology.  255- 

tension  within  the  tympauo-mastoid  space.  Iiiqiairment  of  hearing. — 
Whenever  we  find  a  persistent  profound  impairment  of  function  this  is 
in  itself  an  important  indication  for  operative  interference.  Involvement 
of  the  static  labyrinth. — Veitigo  and  spontaneous  nystagmus — usuallv 
toward  the  diseased  side,  more  rarely  towai'd  the  opposite  side — usuallv 
mean  extensive  infiltration  of  the  bony  structures  surrounding  the 
labyrinthine  capsule  and  call  for  operative  interfei'euce.  Meningeal 
synq)toms. — Localised  headache  usually  indicates  an  extradural  abscess. 
Severe  general  headache  is  a  much  more  dangerous  symptom.  Spinal 
puncture  helps  us  in  diagnosis  in  these  cases.  Fluid  under  pressure, 
with  an  excess  of  globulins  and  a  failure  to  reduce  Fehling's  solution,  is 
not  necessarily  an  indication  of  general  meningitis.  These  signs  ;ire 
an  imperative  indication  for  a  complete  mastoid  operation  and  also 
for  the  exposure  of  a  large  ai-ea  of  dura  about  the  mastoid  wound. 
Rontgenoscopy  is  of  great  value  in  obscure  cases.  Dench  has  never 
failed  to  find  pus  in  the  location  shown  in  the  rontgenogram.  The 
value  of  rontgenogram s  in  the  earlier  cases  is  perhaps  not  so  evident. 
Cases  of  acute  otitis  show  a  cloudy  mastoid  within  the  first  ten  days. 

/.  S.  Fraser. 

Application  of  the   Carrel   Method   in   Acute  Mastoiditis. — G.   Mahn. 
"  New  York  Med.  Journ.,"  May  26,  1917. 

The  author  recommends  careful  removal  of  all  diseased  tissues,  followed 
by  irrigation  of  wound,  meatus  and  operative  field  with  Dakin's  solution 
and  suture  of  the  upper  three-fourths  of  the  wound,  i.  e.  leaving  an 
opening  of  3  cm.  below.  Through  this  opening  a  drain  is  introduced  of 
the  calibre  of  a  goose  quill  and  15  cm.  long,  closed  at  its  extremitv  with 
a  silk  ligature,  but  perforated  Avith  small  openings  throughout  the 
embedded  portion.  Before  introduction  the  drain  is  covered  with  a 
small  gauze  compress  folded  back  along  it  like  a  paper  filter.  The  end 
of  the  drain  must  not  reach  the  bottom  of  the  wound.  Outside  aie 
placed,  above  and  below  the  drain,  two  additional  small  pleated  gauze- 
compresses,  and  covering  these  more  gauze  and  wads  of  cotton,  held  by  a 
slightly  elastic  bandage.  The  drain  is  fastened  to  the  dressing  with  a 
sterile  safety-pin,  and  is  purposely  held  kinked  at  this  point  with  anothei- 
bandage  to  cut  off  communication  of  the  wound  with  tl)e  external  air. 
Every  two  hours  one  or  two  leaspoonfuls  of  Dakin's  solution  are  run 
into  the  wound  under  a  pre.ssure  of  60  to  80  cm.  Subsequent  daily 
dressing  consists  in  cleansing  the  margins,  and,  if  necessary,  the  open 
wound  with  Dakin's  solution,  taking  all  possible  aseptic  precautions. 
The  meatus  should  likewise  be  washed  out  until  the  discharge  ceases.  At 
each  dressing  a  little  discharge  should  be  aseptically  collected  at  the 
entrance  of  and  within  the  wound,  and  examined  on  slides  after  drying 
and  staining  with  1  in  1000  phenolthionin  solution.  When,  in  a  few 
days,  but  one  bacterium  on  the  average  is  to  be  noted  in  a  whole  micro- 
scopic field,  the  patient's  general  and  local  condition  meanwhile  remaining 
satisfactory,  the  rest  of  the  wound  may  be  closed  with  aluminium  bronze 
sutures,  inserted  as  deeply  as  possible.  Immediately  before  this  the 
operation  field  should  have  been  carefully  cleansed  with  ether  and 
alcohol  and  the  interior  of  the  wound  washed  out  with  Dakin's  solution. 
Any  remaining  dead  space  is  filled  by  an  appropriate  pressure  dressing. 
In  the  author's  cases  suture  was  possible  after  from  two  to  fifteen  days 
of  sterilisation.  Complete  healing  was  thus  obtained  in  about  one-third 
the  time  required  with  ordinary  dressings.  /.  8.  Fraser. 


256  The  Journal  of  Laryngology,        [August,  i  20. 

Post-operative  Treatment  of  Mastoiditis  by  the  Carrel-Dakin  Method. — 
P.  Moure  and  E.  Sorrel.  "  Eev.  de  Larvng.,  d'Otol.,  et  de 
Rhinol.,"  October  30,  1917. 

The  surrouudiuo;  skin  must  be  protected  against  irritation  by  sterile 
vaseline,  paraffin,  or  other  greasy  substance.  Irrigation  should  begin 
tAvo  hours  after  operation,  and  be  repeated  every  two  hours.  The  dressings 
should  be  changed  at  least  every  second  day.  As  a  sequela  of  irrigation, 
even  with  cold  solution,  labyrinthine  irritation  has,  in  the  Avriter's 
experience,  never  occurred.  The  unpleasantness  caused  by  occasional 
peneti'ation  of  liquid  through  the  Eustachian  tube  is  only  transitory. 
A  bacteriological  control  is  kept  by  the  systematic  enumeration  of 
organisms  collected  in  a  drop  of  pus  in  a  platinum  loop.  If  the  microbic 
count  rises  during  treatment  an  intracranial  complication  may  be  sus- 
pected ;  the  authors  quote  a  case  where  this  application  of  tlie  method 
led  to  the  discovery  of  a  cerebral  abscess.  An  arbiti-ary  figure  of  one 
micro-organism  to  every  two  microscopic  fields  is  given  as  indicating  that 
healing  is  well  under  way.  As  a  means  of  checking  post-operative  pro- 
gi'ess  the  microbic  count  is  more  informative  than  a  leucocyte  count, 
which  should,  however,  in  all  cases  supplement  the  former  at  regular 
intervals.  The  Carrel-Dakin  treatment  in  a  majority  of  cases  aborts  the 
period  of  cicatrisation  and  leaves  a  much  smaller  scar ;  the  dressings  are 
painless.  /.  S.  Fraser. 


CORRESPONDENCE. 


To  the  Editor  of  The  Journal   of   Laryngology,   Rhinology,    and 

Otology. 

Sir, — In  order  to  avoid  misunderstanding,  I  write  to  inform  you 
and  the  subscribers  to  the  Journal  that  I  have  resigned  my  Fellowship 
of  the  Royal  Society  of  Medicine  and  consec^uently  the  Presidency  of  its 
Laryngological  Section,  for  the  reason  that  I  consider  the  Society  to  have 
acted  with  reprehensible  disregard  for  the  national  interests  and  national 
sentiment  in  retaining  upon  its  list  the  names  representative  of  G-erman 
medicine. 

I  am,  Sir, 
London  ;  Yours  very  trulv, 

July  15,  1920.  E.  B.  Waggett. 


BOOKS    RECEIVED 


Plastic  Surgery  of  the  Face,  based  on  Selected  Cases  of  War  Injuries  of 
the  Face,  including  Bui-ns.  with  Original  Illustrations.  Bv  H.  D. 
Gillirs.  C.B.E.,  F.H.C.S.,  Major,  R.A.M.C,  with  a  chapter  on  The 
Prosthetic  Problems  of  Plastic  Surgery,  by  Capt.  W.  Kelsey  Fry, 
M.C.,  R.A.M.C,  and  Remarks  on  Anaesthesia,  by  Capt.  B.  Wade, 
R.A.M.C.  London:  Henrv  Frowde  ct  Hodder  &  Stoughton,  1920. 
Price  ^3  3.^.  net. 

L'Anaesthesie  Locale  et  Regionale  en  Oto-Rhino-Laryngologie.  Par  les 
Docteurs  Georges  Canuyt  et  /.  Rozier.  Preface  du  Professeur  Moure. 
Librairie  Octave  Doin  (Gasttn  Doin,  Editeur),  8,  Place  de  I'Odeon, 
Paris,  1920. 


VOL.  XXXV.     No.  9.  September,  1920 


THE 

JOURNAL    OF    LARYNGOLOGY, 

RH1N0I>0GY,   AND  OTOLOGY. 


Original  Articles  are  accepted  on  the  coiidition  that  they  have  not  previously  been 
published  elseivhere. 

If  reprints  are  required  it  is  requested  that  this  be  stated  when  the  article  is  first 
forwarded  to  this  Journal.     Such  reprints  will  be  charged  to  the  author. 

Editorial  Communications  are  to  be  addressed  to  "Editor  of  Journal  OF 
Labyngoloqt,  care  of  Messrs.  Adlard  (^  Son  4'  West  Newman,  Limited,  Bartholomeio 
Close,  E.C.  1." 


TOTAL   LARYNGECTOMY:    INDICATIONS   FOR  AND  RESULTS 
OF   THE   OPERATION.' 

By  Sir  Charters  J.  Symonds,  K.B.E.,  C.B., 
Consultincr  Surgeon  to  Gny's  Hospital. 

The  steady  diffusion  of  our  knowledge  of  the  early  stages  of  disease  of 
the  larynx,  and  the  success  that  has  followed  removal  of  malignant 
growths  while  still  intrinsic,  have  diminished  the  number  of  cases 
demanding  total  extirpation  of  the  larynx.  To  the  attainment  of  this 
satisfactory  position  I  venture  to  say  that  the  British  laryngologists 
have  contributed  more  than  others.  Especially  have  three  former 
Presidents  of  this  Section  of  the  Royal  Society  of  Medicine  or  of  its 
predecessor,  the  Laryngological  Society  of  London,  taken  a  foremost 
part — Sir  Henry  Butlin,  Sir  Felix  Semon,  and  Sir  StClair  Thomson. 
From  time  to  time,  however,  cases  arise  where  nothing  but  complete 
extirpation  of  the  larynx  can  afford  any  prospect  of  immunity.  It  is 
with  a  view  especially  of  indicating  how  such  an  operation  can  be  most 
successfully  performed  that  I  have  been  induced  by  your  Secretary  to 
offer  my  experience,  scanty  as  it  is. 

The  first  danger,  as  in  all  operations  where  the  alimentary  canal  is 
opened,  is  contamination  of  the  wound ;  the  second  special  to  this 
operation  is  contamination  from  the  septic  secretions  of  the  growth, 
some  amount  of  which  must  escape  when  the  trachea  is  divided.  Of 
the  two  the  latter  is  by  far  the  more  important.  Saliva  gives  very 
little  trouble  unless  mingled  with  food  or  materials  rejected  from  the 
stomach,  and  against  both  these  protection  is  possible. 

'  Paper  read  at  the  Second  Annual  Congress  of  the  Laryngological  Section  of 
the  Eoyal  Society  of  Medicine,  June  24,  1920. 

17 


258  The  Journal  of  Laryngology,     [Septemiaer,  1920. 

Infection  from  laryngeal  secretions  can  be  minimised  by  postponing 
the  opening  of  the  trachea  till  as  late  a  period  as  possible,  and  dis- 
pensing with  a  preliminary  tracheotomy ;  next  by  protecting  the  opened 
intermuscular  spaces  by  gauze  packing  prior  to  division  of  the 
trachea  ;  by  closing  the  cricoid  ring  as  quickly  as  possible  by  a  gauze 
pack,  and  keeping  the  divided  trachea  protected  with  gauze  during  the 
later  stages  of  the  operation  ;  and,  lastly,  using  a  fresh  scalpel  after 
dividing  the  trachea.  The  escape  of  mucus  and  saliva  from  the 
pharynx  cannot  be  altogether  prevented,  but  provided  the  gauze  pro- 
tection has  been  properly  employed  does  no  harm.  It  would  be  quite 
safe,  though  it  would  cause  delay,  to  leave  the  pharynx  unsutured. 
Lastly  comes  the  prevention  of  secondary  infection. 

When  the  pharynx  is  free  from  infection  a  primary  union  can 
usually  be  obtained,  and  all  danger  of  secondary  infection  avoided. 
Nevertheless,  looking  to  the  possibility  of  the  catgut  sutures  yielding 
should  vomiting  result,  it  is  never  safe  to  omit  the  gauze  packing, 
which  I  look  upon  as  an  essential  part  of  the  dressing.  When  the 
epiglottis  is  removed  it  is  difficult  or  impossible  to  effect  complete 
closure  of  the  pharynx  just  below  the  hyoid,  and  at  this  point  a  special 
drain  should  always  be  inserted. 

I  need  but  refer  to  the  necessity  of  great  gentleness  in  the  handling 
of  the  various  structures,  as  in  all  operations,  and  to  the  preservation  of 
arterial  and  nerve  supplies  whenever  possible. 

In  this  operation  there  is  the  special  risk  arising  from  the  entry  of 
blood  into  the  trachea — a  complication  avoided  by  first  postponing  the 
opening  of  the  trachea  till  all  the  external  steps  of  the  operation  have 
been  completed,  and  all  vessels  of  any  moment  secured ;  next  by 
suturing  the  trachea  in  the  lower  angle  of  the  wound,  and  inserting  a 
large  enough  tube  to  close  the  lumen. 

Details  of  the  Operation. 

Ether  given  in  the  ordinary  way  and  preceded  by  morphia  and 
atropine  is  the  proper  aneesthetic  until  the  trachea  is  divided,  when 
chloroform  is  administered  by  a  Junker's  apparatus. 

The  vertical  incision  should  begin  at  the  upper  border  of  the 
hyoid  and  reach  to  a  point  f  in.  above  the  upper  borJer  of  the 
sternum.  It  is  well  to  mark  this  point  before  the  neck  is  extended. 
The  suggestion  to  bring  the  trachea  through  a  transverse  incision 
favours  septic  infection  and  diminishes  the  space,  and  I  have  never 
employed  it.  The  transverse  incision  should  extend  well  beyond  the 
ala  of  the  hyoid,  so  as  to  give  free  access  to  the  upper  cornua  of  the 
thyroid  cartilage.  The  skin  and  deep  fascia  must  be  reflected  suffi- 
ciently to  expose  the  muscles  above  the  circoid.  The  incision  is 
deepened  in  the  median  line  down  to  the  cartilages,  and  the  thyroid 
isthmus  divided  and  any  superabundant  median  portion  removed. 
Simple  division  with  a  scalpel  is  best,  the  small  vessels  in  the  capsule 
being  secured  in  the  ordinary  way.  To  facilitate  access  I  think  it  is 
better  to  divide  the  sterno-hyoid  2  in.  from  the  hyoid  bone  and  to 
suture  it  later.  The  sterno-hyoid  and  thyro-hyoid  are  next  divided 
•close  to  the  thyroid,  unless  there  be  any  extension  through  the  cartilage, 
when  a  wider  removal  will  be  called  for. 

The  lobes  of  the  thyroid  gland  are  separated  from  the  trachea  and 
the  inferior  thyroid  arteries  secured.     The  parts  can  now  be  retracted, 


September,  1920.]  Rhmology,  and  Otology.  259 

and  an  important  step  in  tke  operation  is  .undertaken,  viz.  to  separate 
the  attachments  of  the  constri.etors  from  the  thyroid  and  cricoid  car- 
tilages, define  the  posterior  border  of  the  thyroid  cartilage  and  the 
thyroid  ligaments  (I  sometimes  cut  off  the  lip  of  the  upper  corner  of 
the  thyroid  cartilage).  Nest  to  expose  the  upper  border  and  inner 
surface  of  the  thyroid  cartilage,  securing  at  the  same  time  the  superior 
thyroid  artery. 

This  completes  the  extrinsic  portion  of  the  operation,  and  if  freely- 
carried  out  the  oesophagus  should  be  visible  and  the  larynx  completely 
moveable. 

A  10  per  cent,  solution  of  cocaine  is  now  injected  into  the  trachea 
immediately  below  the  cricoid ;  gauze  is  packed  on  either  side  of  -the 
trachea,  and  up  by  the  sides  of  the  larynx. 

The  trachea  is  divided  between  the  first  and  second  rings,  and  a 
plug  of  gauze  inserted  into  the  proximal  aperture.  The  distal  portion 
is  now  separated  from  the  oesophagus,  brought  forward  and  sutured 
into  the  sides  of  the  lower  angle  of  the  wound,  and  the  special  tracheo- 
tomy tube  introduced  and  fixed  by  tapes.  Through  this  chloroform  is 
now  administered.  The  separation  of  the  larynx  from  the  pharynx 
proceeds  from  below,  and  should  be  carried  out  equally  on  both  sides. 
The  cavity  of  the  pharynx  is  first  opened  behind  the  arytgenoids,  and  the 
division  carried  up  on  each  side  close  to  the  attachment  to  the  thyroid 
■cartilage.  Coming  to  the  upper  border  of  the  thyroid  cartilage,  it  is 
well  to  divide  below  this  border,  to  secure  as  small  an  opening  as 
possible.  If  properly  carried  out  the  aperture  is  quite  small  and  easily 
•closed.  The  mucous  membrane  should  be  examined,  and,  if  necessary, 
a  further  removal  carried  out.  Should  it  be  necessary  to  remove  the 
•epiglottis,  and  this  is  decided  upon  before  the  operation  begins,  the 
pharynx  should  be  opened  below  the  hyoid  and  above  the  attachment 
of  the  epiglottis  and  the  division  carried  down  to  meet  the  ascending 
incision. 

Closure  of  the  Wound. 

The  pharynx  is  closed  by  three  rows  of  sutures,  each  continuous. 
The  first  should  turn  in  the  mucous  coat  and  be  a  No.  0  twenty-day 
-chromic  catgut ;  the  second  and  third  take  up  the  muscle  of  the  pharynx. 
The  gauze  packing  is  now  removed  and  a  small  strip  of  gauze  placed 
behind  the  trachea  and  another  in  front,  and  the  trachea  further  sutured 
to  the  skin  until  the  edges  of  the  skin  meet  above  the  trachea.  A  strip 
of  gauze  four  or  six  layers  thick  is  laid  along  the  pharynx.  The 
transverse  wound  is  completely  closed,  the  skin  of  the  rest  of  the 
vertical  closed  by  two  salmon-gut  sutures.  Lastly  a  small-sized  rubber 
•drain  surrounded  by  ribbon  gauze  is  inserted  below  the  hyoid  down  to 
the  pharynx.  The  best  dressing  is  moist  gauze  covered  by  a  layer  of 
jaconet,  which  should  be  a  good  inch  narrower  than  the  gauze,  and 
this  by  wool.  Three  strips  of  bandage  tied  in  front  are  sufficient  to 
secure  the  dressing — a  plan  facilitating  the  change  of  the  compress. 

A  thin  rubber  tube.  No.  10,  containing  a  silver  wire  is  then  passed 
through  the  mouth  into  the  oesophagus.  The  wire  is  tied  to  the  lower 
•end  of  the  tube,  into  which  a  lateral  opening  has  been  made. 

After-Treatment. 

The  most  comfortable  position  is  that  obtained  by  propping  up  on 
pillows.     Movement  does  no  harm  arid  should  be  allowed.     As  saliva 


260  The  Journal  of  Laryngologry,     [September,  1920. 

must  be  swallowed  no  evil  results  from  swallowing  water  as  soon  as  the 
patient  can  do  so,  and  should  be  freely  allowed  in  small  quantities  at  a 
time.  The  large  gauze  pack  is  removed  in  forty-eight  hours  as  a  rule 
and  replaced  by  a  smaller  piece.  If,  however,  adherent,  it  is  better  left 
till  the  fourth  day.  and  even  then  a  small  piece  should  be  introduced. 
The  other  piece  and  the  upper  drain  can  also  be  removed  on  the  fourth 
day.  Should  there  be  any  evidence  of  leakage  all  drains  must  be 
replaced.  The  feeding-tube  can  be  dispensed  with  after  the  fourth  day 
in  any  case  and  milk  and  other  fluids  allowed. 

Modifications  of  the  Operation. 

Early  infection  of  lymphatic  glands  is  happily  a  very  rare  complica- 
tion. In  one  case  in  which  I  performed  successfully  hemilaryngectomy 
the  diagnosis  was  doubtful  until  glands  appeared  in  the  parotid  triangle  : 
on  removal  these  showed  malignant  growtli.  This  man  remained  well 
for  some  years  and  resumed  his  duties.  He  developed  an  epithelioma 
in  the  skin  below  the  umbilicus,  which  was  removed,  and  later  died  of 
some  lung  condition  complicating  influenza. 

When  the  disease  has  penetrated  the  cartilage  a  wide  removal  is- 
required.  In  the  specimen  taken  from  the  patient  shown  to-day 
(Case  2)  fifteen  years  after  total  removal  the  growth  is  seen  to 
involve  the  muscles.  In  the  operation  these  were  removed,  together 
with  the  left  lobe  of  the  thyroid  gland  and  the  underlying  lymphatic 
tract.  It  seems  to  me  necessary  to  remove  the  thyroid  lobe  in  such  cases. 
In  another  case  (No.  4),  alive  and  well  nine  years  after  operation, 
recurrence  took  place  in  the  glands,  and  these  were  removed  together 
with  the  thyroid  lobe  twelve  months  later.  In  a  lady  who  survived 
twenty-two  years,  the  laryngeal  disease  was  so  extensive  that  I  deemed 
it  necessary  to  remove  the  entire  thyroid  with  surrounding  fascia  and 
lymphatics.  She  required  thyroid  extract  for  some  time,  and  was  able 
to  carry  out  her  duties  for  some  yea,rs. 

The  lobe  is  removed  before  the  trachea  is  opened  and  the  space  then 
filled  with  gauze. 

I  have  in  an  earlier  part  of  the  paper  referred  to  the  difficulty  it> 
closing  the  pharynx  when  the  epiglottis  is  removed.  The  fistula  always 
closes,  and  interferes  but  very  little  with  tlie  taking  of  food. 

Secondary  Infection  of  the  Wound. 

Taking  a  consecutive  series  of  six  cases  tiiere  is  one  showing  this 
complication,  and  it  was  the  last  submitted  to  operation — February, 
1920.  The  patient,  an  officer  who  had  been  a  lecturer  and  teacher  in 
photographic  matters,  was  under  Sir  James  Dundas-Grant.  The  disease 
was  largely  subglottic,  and  as  both  cords  were  fixed  it  was  not  possible 
to  ascertain  the  condition  of  the  growth.  On  dividing  the  trachea  dark 
and  septic  material  escaped  from  the  larynx.  It  was  removed  as^ 
quickly  as  possible  and  the  cricoid  ring  plugged.  Fearing  infection 
special  attention  was  given  in  removing  this  danger.  On  dividing  the 
larynx  after  removal  we  found  the  subglottic  region  covered  with  black 
necrotic  growth,  which  is  shown  in  the  specimen.  Severe  infection 
followed,  with  pyrexia  and  acute  tracheitis.  The  wound  was  opened 
up  and  dressed  with  wet  packs.  Superficial  sloughing  of  the  fascia 
took  place,  all  sutures  gave  way  and  the  pharynx  was  opened.  The 
danger  was  over  in  two  days,  no  downward  extension  taking  place.     A. 


September,  1920.]         Rhlnology,  and  Otology.  261 

feeding-tube  had  to  be  employed  for  about  two  weeks.  For  some  time 
a  fistula  remained  below  the  hyoid,  which  closed  after  the  application  of 
the  cautery. 

The  limitation  of  the  infection  must  be  set  down  to  the  gauze 
drainage  and  the  partial  closure  of  the  wound. 

Indications  for  Operation. 

(a)  When  the  whole  interior  of  the  larynx  is  involved,  I  doubt  if 
anything  short  of  complete  extirpation  offers  a  good  prospect  of 
immunity.  In  the  last  case  this  was  the  decision  arrived  at  by  Sir 
James  Dundas-Grant  and-  myself,  so  that  a  preliminary  opening  of  the 
larynx  was  dispensed  with. 

(6)  When  a  disease  chiefly  unilateral  has  penetrated  the  cartilage 
and  involved  the  muscle  it  seems  wiser  to  remove  the  entire  structure. 

In  one  case,  that  of  J.  B ,  I  set  out  to  do  at  most  a  hemi-laryngo- 

tomy,  and  opened  the  thyroid  to  find  the  cartilage  penetrated  and 
muscles  invaded.  Total  removal  together  with  the  high  lobe  of  the 
thyroid,  was  followed  by  a  primary  union,  and  the  man  is  here  to-day, 
fifteen  years  after,  in  good  health  and  able  to  follow  his  occupation. 

(c)  When  there  is  infection  of  glands  in  the  carotid  triangle  a  partial 
removal  may  suffice,  if  the  disease  be  confined  to  one  side  of  the  larynx. 
I  have  only  once  met  with  such  an  association,  as  in  the  case  referred 
to  earlier,  where  the  man  remained  free  from  disease  for  many  years. 

In  many  cases  decision  can  only  be  reached  after  division  of  the 
thyroid.  A  growth  which  infiltrates  and  fixes  the  cord  and  looks 
removable  locally  may  be  found  to  involve  the  subglottic  region  exten- 
•sively.  Even  then  the  success  which  has  attended  local  removal  freely 
carried  out  must  give  pause  before  involving  the  patient  in  so  serious  a 
mutilation  as  total  removal. 

When  movement  of  both  cords  is  impaired,  this  may  be  due  to  a 
limited  disease  of  the  less-involved  cord,  affecting  one  commissure 
chiefly.  Under  such  circumstances  local  removal  may  still  be 
successful. 

An  inspection  of  the  four  specimens  will  show,  I  think,  that  in  all  the 
disease  was  extensive  or  had  perforated. 

Brief  Notes  of  Six  Cases. 

Longer  accounts  of  the  first  four  will  be  found  in  the  Lancet  for 
March  20,  1920. 

Case  1.— Mrs.  G /when  first  seen  in  1897,  was  wearing  a  tracheotomy  tube, 

obstruction  having  been  serious  for  some  time.  The  orifice  of  the  larynx  was 
filled  by  growth  so  that  complete  removal  offered  the  only  prospect  of  success. 
This  was  carried  out  and  both  thyroid  lobes  with  undei'lying  lymphatics  removed. 
She  died  twenty-two  years  later  at  the  age  of  seventy-six. 

Case  2. — J.  B was  operated  upon  in  1905.     The  disease  affected  chiefly  the 

left  side  and  there  was  some  fulness  externally.  On  opening  the  larynx  it  was 
seen  that  only  the  anterior  part  of  the  left  cord  was  free  from  disease,  and  on 
attempting  to  reflect  the  thyro-hyoid  muscle  growth  was  exposed  in  its  substance. 
Total  .removal,  together  with  the  left  lobe  of  the  thyroid  gland,  was  carried  out. 
A  primary  union  resulted  and  he  has  remained  well.     The  specimen  is  on  the 

table,  and  ilr.  B has  come  before  you  to  demonstrate  what  he  can  do  in  the 

way  of  speaking.  He  is  now  sixty-seven,  and  carries  out  the  duties  of  a  tax  collector 
in  a  country  district  and  with  the  aid  of  his  tube  can  make  himself  heard  at 
committees. 

Case  3. — Mr.  T .      It  is  noteworthy  that  this  man,  though  holding  the 

position  of  a  bank  manager  and  having  lost  his  voice  for  two  years,  and  been 


262  The  Journal  of  Laryngology^     [September,  1920. 

obliged  in  consequence  to  discontinue  his  duties  foi-  a  year,  had  never  had  his 
larjmx  examined  until  this  "was  made  by  Mr.  Heath  in  October,  1907.  In  this 
month  the  growth,  which  involved  the  greater  part  of  one  cord  and  part  of  the 
other,  was  removed  after  laryngo-fissure.  Hecurrence  taking  place,  complete- 
larjTigectomy  was  performed  in  February,  1908.     Tlie  specimen  is  on  the  table  and 

shows  extensive  gi'0\\i:h.     ilr.  T has  come  to  the  meeting  to  demonstrate  his 

powers  of  speech. 

Case  4. — Mr.  McC .     Seven  years  before  (1904)  he  was  sent  to  me  by  the 

late  Sir  Barclay  Barron,  of  Bristol.  One  cord  had  been  removed  for  suspected 
growth.  In  1911  the  larynx  was  again  opened  and  some  gro^vth  removed.  This 
was  preceded  by  tracheotomy.  Less  than  two  months  later  the  tracheal  tube  had 
to  be  i-eplaced  to  relieve  dyspncea.  Wearing  this  he  came  under  my  care.  With 
so  long  a  history  it  seemed  advisable  to  make  certain  as  to  the  nature  of  the- 
growth.  A  piece  was  removed,  and  proving  to  be  malignant  the  whole  larjTix  was 
removed  and  healing  without  escape  of  saliva  followed,  so  that  he  was  able  to 
return  home  in  three  weeks.  The  specimen  shows  the  whole  interior  of  the  larynx 
to  be  covered  by  a  hard  growth.  Recurrence  taking  place  in  the  h'mphatics,  I 
i-emoved  a  year  after  the  fii'st  operation  several  infected  glands,  parts  of  the  sterno- 
hyoid and  sterno-mastoid  muscles,  the  left  thjToid  lobe  and  the  internal  jugular 
vein,  with  surrounding  lymphatics  from  the  styloid  process  to  the  sternum. 
He  returned  home  in  ten  days  and  has  remained  well  ever  since,  i.  e.  just  upon 
nine  years. 

Case  5. — Miss  B .    This  lady,  a  patient  of  Dr.  Routh'^s,  of  Southsea,  suffered 

for  some  years  from  chronic  laryngitis,  followed  by  thickening  of  the  cords. 
Recurrence  taking  place  after  local  removal  and  now  both  cords  being  fixed  and 
obstruction  increasing,  it  appeared  a  question  of  the  permanent  use  of  a  trache- 
otomy tixbe,  leaving  the  growth  to  take  its  course,  together  with  loss  of  voice,  and 
complete  extirpation,  with  a  good  prospect  of  immianity  and  freedom  from 
unpleasant  discharge  from  the  growth.  She  was  over  seventy.  One  breast  had 
been  removed  for  carcinoma  less  than  two  years  before  and  she  suffered  froni' 
relapsing  iritis.  The  operation  was  well  borne  and  was  followed  by  rapid  union 
and  recovery. 

Case  6.— Capt.  B .     This  officer  was  a  patient  in  hospital  lander  Dr.  Menzies 

and  Sir  James  Dundas-Grant.  The  history  is  regrettable.  A  public  lecturer  in  the 
science  of  photography  he  was  employed  on  the  R.A.F.  staff  and  had  to  talk  loud 
on  many  occasions,  especially  when  flying.  In  1917  his  voice  showed  signs  of 
weakness.  By  the  middle  of  July  he  could  scarce!}'  speak  and  was  sent  to  hospitaL 
The  larynx  was  examined  in  Aiigust  and  the  right  cord  said  to  be  thickened.  He  was- 
advised  to  rest  and  use  a  sjjray,  and  was  told  that  the  voice  would  return.  He 
was  allowed  to  leave  the  hospital  with  consent  of  the  larj'ngologist  attached  to 
this  hospital  and  very  soon  resumed  his  duties.  He  lectured  once  or  twice  each 
day.  Sometimes  his  voice  failed  entirely.  He  carried  this  on  for  three  months. 
In  March  of  1918  he  was  aerial  photographer  in  the  Grand  Fleet,  and  diu-ing  the 
early  summer  the  voice  became  considerably  stronger  so  that  he  could  converse 
with  ease.  He  then  commenced  to  train  pilots  to  fly  for  line  and  mosaic  photo- 
graphs, and  for  this  piu-pose  he  occupied  the  rear  seat  and  often  found  it  necessary 
to  stand  up  and  shout  directions.  As  they  were  frequentlj-  flying  at  high 
altitudes  with  the  temperature  below  zero  F.  and  that  while  standing  he  got  the 
wash  from  the  propeller  his  voice  became  weaker  and  finally  disappeared 
altogether. 

A  cough  became  troublesome  in  December,  1919.     In  January,  1920,  the  larynx 

became   swollen  and  difficulty  in  breathing  was  experienced.      Capt.  B now 

came  under  the  care  of  Dr.  Menzies  and  Sir  James  Ditndas-Grant.  The  gi'ounds 
for  operating  without  preliminary  laryngo-fissure  were,  that  both  cords  were  fixed,, 
the  right  showed  nodular  growth  and  a  piece  removed  the  characters  of 
epithelioma.     Through  the  narrowed  glottis  subglottic  disease  was  visible. 

On  dividing  the  trachea  sei)tic  material  escaped  from  the  larynx,  and  though 
care  was  taken  to  ward  off  infection  this  occurred  and  gave  anxiety  for  two  days. 
The  pharynx  reopened  and  the  escape  of  saliva  delayed  union,  which  was,  however,, 
complete  in  the  end. 

The  larynx  specimen  exhibited  shows  a  necrotic  growth  covering  the- 
subglottic  portion  and  both  cords  to  be  involved. 

The  history  is  given  at  some  length  to  show  that  even  now 
insufficient  attention  is  given  by  many  to  the  importance  of  loss  of  voice^ 


September,  1920.]         Rhinology,  and  Otology.  263 

After-Condition  of  Patients. 

The  two  men  exhibited  to-day  illustrate  very  well  the  method  of 
speaking,  one  by  lip-movement  over  the  small  amount  of  air  taken 
into  the  mouth — this  sound  proves  sufficient  to  conduct  conversation 
in  the  house,  and  even  out  of  doors — the  other  by  lip-movement  over 
a  current  of  air  carried  to  the  lips  by  a  tube  from  the  trachea  ;  this 
sound  is  found  to  be  sufficient  to  enable  the  man  to  make  himself 
understood  to  a  number  of  people. 

One  of  these  patients,  Mr.  B ,  holds  an  official  position  as  a  tax 

collector  and  attends  meetings  of  the  committee.     The  other,  Mr.  T , 

looks  after  home  matters,  shopping,  post  and  so  on.  He  might  well 
have  carried  on  work  as  a  bookkeeper,  having  been  a  bank  manager. 
A  fuller  account  of  these  and  others  will  be  found  in  the  Lancet  for 
March  20,  1920. 


THE   ORIGIN  OF   SPORADIC   CONGENITAL   DEAFNESS. 

By  James  Kerr  Love,  M.D. 

Twice  during  the  past  ten  years  the  writer  has  tried  to  show  that 
hereditary  deafness  is  Mendelian  in  incidence.  On  neither  occasion 
did  he  definitely  include  as  Mendelian,  cases  of  "sporadic  congenital 
deafness,"  although — if  we  exclude  cases  of  deafness  due  to  congenital 
syphilis — such  sporadic  cases  are  clinically  identical  with  true  hereditary 
deafness.  The  present  paper  is  meant  to  show  that  such  sporadic  cases 
are  not  only  clinically  but  genetically  identical  with  the  hereditary 
cases :  that  sporadic  congenital  deafness  is  hereditary  and  that  such 
heredity  is  Mendelian.  I  am  going  to  assume  that  the  reader  is  familiar 
with  Mendelian  phenomena  as  displayed  by  the  crossing  of  tall  and 
short  peas  and  the  subsequent  self-fertilisation  of  the  resulting  hybrids. 

Hereditary  Deafness. — It  has  long  been  recognised  that  deafness 
runs  in  certain  families. 

Dr.  Graham  Bell,  of  telephone  fame — once  a  teacher  of  the  deaf — 
Dr.  Fa}',  of  Washington,  a  teacher  of  the  deaf,  and  many  others  have 
urged  the  heredity  of  many  cases  of  congenital  deafness.  The  present 
writer,  nearly  a  quarter  of  a  century  ago,  wrote  similarly  after  an 
exhaustive  examination  of  many  hundreds  of  deaf  children  and  an 
extensive  review  of  the  literature  of  the  subject,  and  yet  many  people 
doubt  the  heredity  of  congenital  deafness,  and  the  deaf  themselves  either 
do  not  believe  in  the  heredity  of  deafness,  or  act  as  if  they  do  not  believe 
in  it.     Why  is  this  ? 

1.  Because  as  a  rule  congenitally  deaf  parents  have  hearing  children, 
and — 

2.  Because  hearing  parents  often  have  deaf  children. 

It  was  all  very  puzzling,  and  however  convinced  one  is  in  his  own 
mind  can  he  blame  the  deaf  ? 

Take  the  Ayrshire  family,  a  copy  of  whose  family  tree  is  given  here 
(Fig.  1).  Amongst  over  forty  deaf-born  children,  in  only  two  cases  can 
deaf  parents  be  shown.  In  every  other  instance  the  deaf  children  come 
from  hearing  parents.  There  is  no  doubt  about  the  fact  that  deafness 
belongs  to  the  family.  Why  and  how  this  unexpected  distribution  ? 
We  do  not  know  whv.     But  we  begin  to  know  how.     That  is  the 


264 


The  Journal  of  Laryngology,     [Septemijer,  1920. 


C5 

l-H 


s 

_ 0 

0 

■J 

i 

e 

1 

if 

0-2 


II 

■Sii 


September,  1920.]         Rhinology,  and  Otology. 


265 


position  with  most  sciences.  From  astronomy,  -^hich  is  an  old  and 
fairly  exact  science,  to  psychology,  which  is  a  new  and  a  rather  nebulous 
one,  we  have  no  answer  to  why,  but  a  good  deal  of  reply  to  how.  So 
in  the  science  of  heredity,  an  important  part  of  the  still  newer  science 
of  eugenics,  we  begin  to  answer  how,  but  cannot  tell  why. 

Let  us  glance  at  the  accompanying  tree,  which  is  imaginary,  but 
every  fact  of  which  is  present  in  the  Ayrshire  tree  or  on  its  supplement 
(see  "  Mendelian  Tree  of  Hereditary  Deafness,"  Fig.  2).  A  hearing  husband 
marries  a  hereditarily  deaf  wife  and  two  deaf  children  result.  Two  hearing 


Fig.  2. — Mendelian  Tree  of  Hereditary  Deafness. 

c?— • 


Not 


Pure  tails 
in  peas. 


B' 


C 


Carrying 
deafness. 


D' 


No  deaf 

Some 

Some 

AU 

children 

deaf 

deaf 

children 

or  deaf- 

children 

children 

deaf. 

carrymg 

or  grand- 

or  grand- 

children. 

childi-en. 

children. 

o 


Hybrids  probably  one  in 

four  deaf. 
One  in  four  dwarf  in  peas. 


Pvu-e  dwarf 
in  peas. 


None  deaf,  but  half 
carry  deafness. 

O  =  Hearing. 
•  =-Deaf. 


Half  deaf  and  half 
carry  deafness. 


S   =  Male. 
$   =  Female. 


members  complete  the  family.  (It  might  quite  well  have  happened 
that  all  four  were  hearing  and  that  the  deafness  appeared  in  grand- 
children.) 

The  oldest  boy  (A)  hears  and  does  not  carry  deafness  (like  the  pure 
tall  pea).  Deafness  never  appears  in  this  family  so  long  as  no  member 
marries  into  a  deaf  family.  The  second  child  (B),  a  deaf  girl,  and  the 
third,  a  hearing  girl  carrying  deafness,  marry  hearing  partners,  and  all 
have  some  deaf  children  or  grandchildren.  They  are  hybrid,  and  were 
the  families  large  enough  about  one  in  four  would  be  deaf.  In  such 
small  families  this  ratio  cannot  be  expected.  In  any  individual  family 
all  may  hear  or  all  may  be  deaf,  but  on  the  whole  the  ratio  is  observed, 
and  accounts   for  the   fact  that   hereditary  deafness   forms    a  pretty 


266 


The  Journal  of  Laryngology,     [September,  1920. 


continuous  stream  from  one  generation  to  another  without  much 
tendency  either  to  increase  or  diminish.  The  average  families  of  deaf 
fraternities  are  five  or  six  and  all  do  not  reach  adult  life,  and  of  these 
who  do  all  do  not  marry.  All  this  I  see  can  be  paralleled  in  the 
Ayrshire  tree.  Look  now  at  the  fourth  child  D.  A  hereditarily  deaf 
man  marries  a  hereditarily  deaf  woman  as  in  the  C — g  family  of 
Edinburgh  and  all  the  children  are  deaf  (Fig.  3). 

We  are  not  done  with  the  parallelism  of  the  pea  and  the  child.  A 
pure  tall  A'  may  be  crossed  with  hybrid  tall  B'  and  then  all  are 
tall  though  half  are  hybrid,  and  as  long  as  hybrids  meet  anv  pure  tails 
only  tails  will  result.      But  whenever  a  hybrid  meets  another  hybrid  or 


Fig.  3. — C — g  Family  (Edinburgh). 
$ ?  $ 


0000000000 


O 


•  •  •  •  • 

$  =  hearing  male.  O  =  hearing  person, 

?   =  hearing  female.  sex  unknown. 

#  =  deaf-mute  person,  sex  unknown. 

For  the  above  case  I  am  indebted  to  Mr.  Illingworth,  of  Edinburgh.  No  doubt 
all  the  children  are  deaf.  But  even  if  they  be  pure  recessives,  which  is  quite 
uncertain,  they  must  each  marry  pure  recessives  if  no  hearing  children  are  to 
follow. 


a  dwarf  then  the  dwarfs  appear.  So  it  probably  is  with  deafness.  So 
long  as  hearing  people  carrying  deafness  meet  pure  hearing  people,  no 
deafness  results.  But  if  by  any  chance — and  the  chance  is  bound  to 
come — two  hybrids,  hearing  people  carrying  deafness,  get  together, 
deaf  children  must  follow.  This  would  liappen  were  B'  and  C  to 
unite.  Lastly  C  and  D'  may  unite ;  in  this  case  half  the  peas 
will  be  dwarf  and  the  other  half  tall  but  carrying  deafness.  In  the  case 
of  children,  half  would  be  deaf  and  the  other  hearing  but  carrying  deaf- 
ness (hybrid).  The  importance  of  these  two  classes  of  union  will 
appear  when  we  come  to  study  sporadic  congenital  deafness. 

At  the  risk  of  a  charge  of  reiteration  let  me  now  tabulate  these- 
results. 

There  are  six  possible  combinations  in  the  pea  family.  T.  means 
tall,  D.  dwarf. 


September,  1920.]         Rhinology,  and  OtoIo§:y. 

Table  of  Unions  bettveen  Tall  and  Dark  Peas. 


267 


Nature  of  union. 


No. 


The  double  letter  shows  the  nature  of  the  parents 
responsible  for  the  individuals  here  united. 


Result. 


Pure 
tails. 


Hvbrid  tails. 


Dwarfs. 


1. 

T.  T.  X  T.  T. 

Pure  tails       . 

100 



— 

2. 

D.  D.  X  D.  D. 

Pure  dwarf    . 

— 

100 

3. 

T.  T.   X  D.  D. 

— 

100 

— 

4. 

T.  D.  X  T.  D. 

Hvbrid  tall    . 

25 

50 

1         25 

5. 

T.  D.  X  T.  T.  . 

50 

50 

1         — 

6. 

T.  D.  X  D.  D 

— 

50 

1         50 

The  above  table  is  altered  from  the  late  Mr.  A.  D.  Darbishire's  book, 
"  Breeding  and  the  Mendelian  Discovery." 

Corresponding   Unions  heticeen  Deaf  and  Hearing. 

Look  now  at  the  possible  union  of  hearing  and  hereditarily  deaf  people. 
H.  means  hearing,  D.  means  carrying  deafness  of  the  latter  ;  some  are 
deaf,  some  hearing.     Of  the  former  all  hear  and  none  carry  deafness. 


Nature  of  union. 


Result. 


No. 


The  double  letter  shows  the  nature  of  the  parents 
respon.sible  for  the  individuals  here  united. 


Pure 
hearing' 


Hybrid  hearing' 
carrying  deafness. 


Deaf. 


H.  H. 

D.  D. 
H.  H. 
H.  D. 
H  D. 
H.  D. 


H.  H. 

D.  D. 
D.  D. 
H.  D. 
H.  H. 
D.  D. 


Pure  hearing 
Pure  deaf     . 

Hvbrid  hearing 


100 


25 
50 


100 
50 
50 
50 


100 
25 
50 


All  these  unions  actually  occur  in  the  human  family  with  the  kind 
of  result  above  shown. 

Comment  on  the  first  table  is  unnecessary.  It  is  a  statement  of 
fact  which  comes  true  every  time.  Comment  on  the  second  table  is 
necessary.     Let  us  take  the  classes  one  by  one. 

Class  1. — A  hearing  man,  both  of  whose  parents  heai'd  and  did  not 
carry  hereditary  deafness,  marries  a  similar  woman.  No  deaf  children 
can  result.  This  is  the  case  in  far  more  than  ninety  in  every  hundred 
marriages.  There  is  only  one  deaf  to  every  two  thousand  of  the 
population  in  England,  and  the  half  of  these  are  born  hearing  and  have 
been  made  deaf  by  disease  after  birth— a  type  of  deafness  with  which  we 
have  nothing  to  do  here. 

C7a.ss  2. — A  deaf  man,  both  of  whose  parents  are  hereditarily  deaf, 
marries  a  similar  woman  and  all  their  children  are  deaf.  This  kind  of 
union  is  luckily  very  difficult  to  bring  about,  as  we  shall  see  presently. 
But  it  has  been  done  (Fig.  3). 

The  following  is  an  example  (Fig.  4).  It  occurs  in  the  records  of 
the  Doncaster  Institution  for  the  Deaf  and  Dumb,  and  was  communicated 
to  me  by  the  late  Mr.  Howard,  the  Headmaster.  It  was  published  by 
me  in  1896  before  Mendelism  had  been  heard  of.     See  also  Fig.  5. 


268 


The  Journal  of  Laryngology,      [septemiier,  1920. 


Fig.  4.— G— y  Family  (Halifax  District). 

?  • 


died  unmarried. 


•  •  •  •  • 

<?  =  hearing  male.  $  =  hearing  female. 

#  =  deaf  miate — sex  iinknown. 

Here  again  deafness  may  be  looked  on  as  recessive.     G y.  senior,  or  his  wife 

carrying  it,  ti-ansmit  it  to  G y,  junior,  in  whom  it  is  expressed.     The  latter 

meets  the  same  type  of  deafness  in  his  wife,  who  comes  of  an  entirely  deaf  stock, 
and  all  their  children  are  deaf. 


Fig.  5. — Supplement  to  Ayrshire  Tree. 

A 

-? 


illegitimate. 


?    cousin 
of  A 


•        •         • 

• 

died 
under 

• 

• 

? 
died 
under 

(?  =  hearing  male. 

2  years. 

1  year 

?  =  hearing  female. 

•  =  deaf-mute— sex  unkno 

vn. 

A  and  her  cousin  belong  to  the  Ayrshire  family.  The  father  in  this  generation 
was  hearing  like  the  mothers,  but,  I  suspect,  carried  deafness.  This  man  makes 
the  interesting  experiment  of  marrj'ing  two  women  who  are  cousins,  and  who  both 
cax'ry  deafness.  One  of  these  women  has  already  an  illegitimate  child.  All  the 
children — except  two  Avho  died  so  young  that  the  condition  of  their  hearing 
miist  have  been  doubtful — are  deaf.  In  this  familj^  it  is  calculated  that  there 
are  now  about  100  deaf-mutes.  There  are  several  being  educated  in  the  Glasgow 
Institution  now. 


September,  1920.]         Rhinology,  and  Otology.  26^ 

Class  3. — A  pure  hearing  person  marries  a  pure  deaf-mute  and  all 
the  children  hear,  and  the  deaf  turn  round  and  say,  "  Well,  you  see  here 
is  a  deaf  mother  who  has  no  deaf  children."  Yes,  but  look  at  the 
peas.  In  the  first  hybrid  generation  there  were  no  dwarfs.  Why 
should  there  be  deaf  children  here  ?  In  Mendelian  terms  hearing  is 
dominant  to  deafness.  We  need  not  shelter  ourselves  behind  terms. 
Look  at  the  Ayrshire  tree.  So  far  as  my  records  go  that  was  how  the 
tree  started  in  one  branch  at  least.  A  hearing  man  married  a  deaf 
"woman  and  all  the  children  were  hearing.  But  several  of  the  grand- 
children were  born  deaf. 

Class  4. — A  hearing  man  carrying  deafness  marries  a  hearing  wife 
carrying  deafness,  and  both  deaf  and  hearing  children  follow.  Again 
the  opponents  of  the  heredity  of  deafness  object,  "  Why  do  deaf  children 
nearly  always  come  from  hearing  parents  ?  "  Because  the  parents  were 
hybrids  like  the  first  hybrid  generation  of  tall  peas.  Deaf  children  must 
follow  if  the  family  be  large. 

Class  5. — A  hearing  man  carrying  deafness  marries  a  pure  hearing 
woman  and  no  deaf  children  will  result.  But  half  the  children  will 
carry  deafness,  and  if  any  of  these  wander  into  classes  2,  3,  4  or  6  deaf 
children  will  result,  and  they  are  sure  to  wander  there  unless  guided  by 
the  kind  of  knowledge  Mendelism  gives  us.  Even  with  that  knowledge 
they  will  sometimes  wander,  for,  as  we  shall  see,  we  cannot  experiment 
with  and  label  children  as  we  can  peas.  Did  these  hybrids  always 
marry  pure  hearing  partners  no  deaf  children  would  ever  follow.  But 
I  think  this  kind  of  marriage' is  common,  and  when  the  hybrid  hearing 
marry  the  hybrid  hearing  many  of  the  puzzling  cases  of  sporadic 
congenital  deafness  may  be  accounted  for.  This  kind  of  marriage  is 
common  because  hearing  hybrids  are  by  the  deaf  themselves  so  often 
drawn  together. 

Class  6. — A  hearing  man  carrying  deafness  marries  a  pure  deaf 
woman.  Half  the  children  are  deaf,  and  all  the  children  carry  deafness. 
This  is  a  common  type  of  marriage  amongst  the  deaf.  The  deaf  and 
their  hearing  relatives  are  necessarily  thrown  much  into  common 
society,  and  unions  producing  deaf  children  are  the  result.  It  will  take 
much  study  of  the  deaf  and  much  education  of  them  to  solve  this 
problem.     But,  as  we  shall  see,  the  solution  is  not  impossible. 

Sporadic  congenital  deafness,  according  to  the  view  developed  above, 
is  due  to  the  meeting  of  two  heterozygotes — hearing  hybrids  carrying 
deafness.  After  eliminating  congenital  cases  arising  from  syphilis — and 
these  are  really  cases  of  acquired  deafness — we  get  a  simple  classifica- 
tion of  deafness  as  indicated  in  the  italics  which  follow. 

True  Hereditary  Deafness  and  Acquired  Deafness  due  to  Disease. — 
The  question  of  how^  to  eliminate  hereditary  deafness  would  require 
more  space  than  I  dare  expect  to  get  within  the  limits  of  a  single  paper, 
but  it  is  clear  that  any  measures  to  be  eflective  must  be  applied  not 
only  to  the  deaf  but  to  the  hearing  hybrids  or  heterozygotes. 

It  woi;ld  be  interesting  to  know  the  conditions  of  the  semicircular 
canals  in  cases  of  undoubted  hereditary  deafness.  Looking  to  the  com- 
parative anatomy  of  the  ear,  it  is  unlikely  that  disturbance  of  the  factor 
for  hearing  would  involve  disturbance  of  the  balancing  apparatus. 
There  is  no  hearing  organ  in  the  fishes.  With  a  view  to  settling  the 
question  raised  here,  I  asked  Dr.  Gavin  Young  to  test  various  classes  of 
deaf-mutes — and  particularly  cases  of  true  hereditary  deafness  helonging 
to  the  Ayrshire  family — by  rotation  and  by  hot-  and  cold-water  syringing. 


270  The  Journal  of  Laryngology,     [September,  1920. 

I  do  not  wish  to  anticipate  his  results,  which  will  be  published  later, 
but  I  may  note  here  that  these  are  in  the  direction  of  expectation  that 
in  true  hereditary  deafness  the  balancing  apparatus  is  intact. 

Eeferences. 

(1)  Darbishire,  a.  D. — "Breeding  and  the  Mendelian   Discovery,"   Cassell, 
1911. 

(2)  PuNNETT,  E.  C.—"  Mendelism,"  McMillan,  1911. 

(3)  Lock,  E.  H. — "  Variation,  Heredity  and  Evolution,"  Murray,  1911. 

(4)  Eeid,  G.  Archdall. — "  The  Laws  of  Heredity,"  Methuen,  1910. 

(5)  Bateson,  W. — "  Mendel's  Principles  of  Heredity,"  Cambridge,  1909. 

(6)  Hartmann,  a.— "Deaf-Mutism,"  Bailliere,  Tindall  &  Cox,  1881. 

(7)  Mtgind,  H. — "  Deaf-Mutism,"  Eebman,  1894. 

(8)  Love  and  Addison. — "  Deaf-Mutism,"  McLehose,  Glasgow,  1896. 

(9)  Love,  J.  Kerr. — "Lectures  on  the  Causes  and  Prevention  of  Deafness," 
National  Bureau  for  the  Deaf,  London,  1913. 

(10)  Love,  J.  Kerr. — "Diseases   of   the   Ear   in  School   Children,"  Wright, 
Bristol,  1919. 

(11)  Fat,    E.    a. — "  Mai-riages    of    the    Deaf    in    America,"   Volta    Bureau, 
Washington,  D.C.,  1898. 

(12)  Bell,  A.  Graham. — "  Memoir  on  the  Formation  of  a  Deaf  Variety  of  the 
Human  Eace,"  1883. 


CAN  ACQUIRED  DEAFNESS  LEAD  TO  CONGENITAL 
DEAFNESS? 

By  Macleod  Yearsley,  F.E.C.S. 

The  following  family  history  was  obtained  about  eight  years  ago.  It  is 
interesting  as  an  instance  (the  only  one  I  am  at  present  aware  of)  in 
which  a  family  with  a  history  of  acquired  deafness  {i.  c.  deafness 
appearing  after  birth)  produced  offspring  that  were  born  deaf.  It  is 
important  to  note  that  the  deafness  was  probably  otosclerosis  and, 
therefore,  of  hereditary  character. 


B(?X0A  <?X? 


Some 


hearing        |  |  |  |  |  I  I  I  I  I  I 

brothers.     (5         0        ©        (i)F,?x?EO         O         O         O         O 


I  I  I  I  I 

+  G+ 

O  =  Normal.       0  =  Acquired  deafness.       ^  =  Born  deaf. 

A,  the  grandmother,  I  did  not  see,  but  I  was  told  by  her  daughter 
in-law  (e)  that  she  became  deaf  "  when  a  young  woman  "  and  had  two 
sisters  "  deaf  like  her."  a  married  b,  a  man  without  any  family  history 
of  deafness.  They  had  several  children.  The  youngest  (f)  was  the 
husband  of  e.  He  had  "  some  hearing  brothers  "  and  four  sisters  who 
became  deaf  between  the  ages  of  twenty  and  thirty.  I  saw  two  of  them 
(c  and  d),  and  they  were  cases  of  otosclerosis.  The  children  of  F  and 
E  were  five,  two  girls  and  one  boy  hearing  and  two  girls  born  deaf.  I 
saw  the  younger  (g).  She  was  aged  seventeen,  and  had  been  educated 
on  the  oral  system.     She  had  the  typical  "  deaf  "  voice.     Adenoids  had 


September,  1920.]         Rhinology,  and  Otology.  271 

been  removed  when  she  was  ten.  Both  tympanic  membranes  were 
thickened  and  indrawn  shghtly.  Nose  and  throat  showed  nothing  note- 
worthy. Careful  testing  show^ed  no  perception  of  sound.  I  could 
-obtain  no  response  to  either  bell,  Galton  whistle,  voice  or  tuning-fork. 
She  could  not  perceive  the  sound  of  a  fork  by  bone-conduction,  although 
she  volunteered  that  she  could  feel  the  vibrations. 

I  could  not  obtain  an  examination  of  her  sister,  but  I  was  informed 
that  she  was  "  equally  deaf." 


THE   AQUEDUCT   OF   FALLOPIUS   AND   FACIAL   PARALYSIS. 

By  Dan  McKenzie. 

Part  II :   Facial   Paralysis. 

{Contimied  from  p.  247.) 

Herpes  Zoster  Oticus  and  Facial  Paralysis. 

Historically  the  point  is  worthy  of  mention  that  the  late  C.  H. 
Fagge  was  one  of  the  first  to  observe  the  association  of  herpes  of  the  face 
with  facial  paralysis  ;  he  mentions  the  case  in  a  footnote  in  his  "  Text- 
book of  Medicine."  The  paralysis  he  thought  was  "  reflex."  A  case 
was  reported  by  Hammerschlag  in  1898,  and  another  early  case  was  that 
of  Cheatle  in  1901.  It  was  Korner  who  in  1904  conferred  upon  this 
variety  of  herpes  the  name  by  which  it  is  now  known,  while  recently 
Eamsay  Hunt,  of  New  York,  has  worked  out  the  distribution  of  the 
herpetic  rash  in  the  disease. 

Along  with  the  facial  several  of  the  other  cranial  nerves  are 
commonly  implicated  in  the  disease,  more  especially  the  vestibular  and 
the  cochlear. 

Pathology. — The  subject  of  herpes  of  the  cranial  nerves  is  one  of 
great  interest,  but  it  lies  somewhat  outside  of  our  province.  Suffice  to 
say  that  herpes  is  supposed  to  be  due  to  an  inflammation  of — in  spinal 
nerves — the  posterior  root  ganglia,  and  in  the  cranial  nerves  of  ganglia 
such  as  the  Gasserian  of  the  trigeminal  or  the  geniculate  of  the  facial, 
which  may  be  regarded  as  the  equivalents  in  these  cranial  nerves  of  the 
posterior  root  ganglia  of  the  spinal  nerves. 

Herpes,  as  a  rule,  when  it  attacks  a  patient,  selects  more  than  one 
nerve,  but  for  some  unknown  reason  the  nerves  it  selects  are  generally 
all  on  the  same  side  of  the  body. 

It  is  not  yet  known  whether  this  destructive  disease  may  attack  the 
cochlear  ganglion  apart  from  the  facial,  but  the  possibility  is  obvious, 
and  so  it  may  be  responsible  for  some  of  the  cases  of  sudden  and 
inexplicable  nerve-deafness  we  now  and  then  encounter. 

In  like  manner.  Bowman,  as  long  ago  as  1869,  described  the 
association  of  optic  neuritis  and  atrophy  with  herpes  of  the  trigeminal, 
and  the  question  also  arises  whether,  if  the  retina  contains  the  neurons 
•equivalent  to  a  posterior  root  ganglion,  retinitis  may  not  also  be  induced 
by  the  same  disease  without  the  betraying  herpetic  eruption. 

In  the  case  of  the  geniculate  ganglion  of  the  facial  the  paralysis, 
although  it  is  complete,  is  merely  a  secondary  and  apparently  an 
accidental  effect,  being  due  to  the  proximity  of  the  motor  fibres  of  the 
nerve  to  the  seat  of  inflammation  in  the  geniculate  ganglion. 


272  The  Journal  of  Laryngology,     [septemi)er,  1920. 

SymiUoins. — The  nerves  attacked  are  not  affected  simultaneously. 
First  one,  then  another  is  involved,  the  evolution  of  the  case  occupying 
a  period  of  a  week  or  ten  days. 

As  in  herpes  zoster  elsewhere,  severe  pain  is  one  of  the  earliest 
symptoms,  being  felt  deep  in  the  ear.  The  next  symptom  is  the 
herpetic  eruption,  and  it  varies  in  severity  from  a  few  inconspicuous 
spots  on  the  auricle,  cheek,  or  side  of  the  tongue  to  a  series  of  angry 
clusters  which  are  a  source  of  much  discomfort  and  even  pain. 

The  areas  attacked  by  the  herpetic  rash  correspond  to  the  distri- 
bution of  the  sensory  elements  of  the  seventh  nerve,  and  these  include, 
according  to  Ramsay  Hunt,  "  the  central  portions  of  the  auricle,  viz. 
the  concha,  the  external  meatus,  tragus  and  anti-tragus,  incisura  inter- 
tragica,  anti-helix  and  fossa  of  the  anti- helix,  and  the  upper  portion  of 
the  external  surface  of  the  lobule."  He  beheves  also  that  the  geniculate 
may  share  with  the  trigeminal,  the  glosso-pharyngeal  and  the  vagus  the 
sensory  innervation  of  the  external  auditory  meatus  and  the  membrana 
tympani. 

A  herpetic  rash  on  the  anterior  two-thirds  of  the  tongue  correspond- 
ing to  the  chorda  tympani,  and  in  the  peri-tonsillar  region,  probably 
corresponding  to  the  great  superficial  petrosal  nerve  through  Meckel's 
ganglion,  may  also,  according  to  the  same  authority,  be  referred  to  the 
geniculate. 

The  herpetic  rash  on  the  skin  manifests  the  visual  sudden  efflorescence 
and  quiet  subsidence  and  disappearance  of  herpes  in  general,  but  the 
spots  on  the  tongue  and  tonsil  rupture  soon  after  their  appearance,  and 
come  to  look  like  small,  shallow  ulcers  w'ith  a  yellowish  floor.  On  the 
tonsil  they  are  liable  to  be  mistaken  for  the  spots  of  a  lacunar  tonsillitis. 
The  facial  paralysis  sets  in  shortly  after  the  herpetic  display,  and  it 
is  gradual  in  its  onset,  but  it  usually  becomes  complete  in  a  few  days. 
The  patient  feels  and  looks  very  ill.  The  cerebro-spinal  fluid  shows 
a  lymphocytosis. 

The  other  symptoms  depend  upon  which  ganglia  are  attacked. 
Vertigo  of  the  vestibular  type  will  indicate  the  implication  of  the 
vestibular  ganglia,  and  nerve-deafness  that  of  the  cochlear  ganglion. 
The  two  are  generally  but  not  invariably  attacked  together.  If  the 
vagus  participates  there  may  be  slowing  of  the  pulse,  and  perhaps 
vomiting,  with  paralysis  of  the  corresponding  side  of  the  larynx. 

After  the  disease  lias  reached  its  culminating  point  fresh  symptoms 
cease  to  appear,  but  the  effects  last  for  months,  and  may,  indeed,  be 
permanent. 

The  facial  paralysis,  if  complete,  remains  unchanged  for  about  six 
months,  and  then  begins  slowly  to  show  signs  of  improvement ;  but 
progress  is  sluggish,  and  as  much  as  two  years  may  elapse  before 
complete  recovery  is  attained.  Sometimes,  as  in  other  varieties  of 
facial  paralysis,  recovery  is  never  complete,  a  certain  perceptible 
weakness  of  the  muscles  of  the  face  remaining  for  life. 

The  nerve-deafness  may  be  mild.  Sometimes  it  is  severe.  In  the 
cases  I  have  seen  it  has  been  permanent,  and  the  loss  of  the  vestibular 
reaction  has  also  been  permanent. 

Diagnosis. — Probably  most  cases  of  herpetic  facial  paralysis  are 
never  recognised  as  such,  but  go  to  swell  the  numbers  of  so-called 
"  rheumatic  "  paralysis. 

In  all  recent  cases  of  facial  paralysis,  therefore,  a  search  should  be 
made  for  traces  of  herpetic  spots,  and  in  older  cases  the  patient  should 


September,  1920.]         Rhinology,  and  Otology.  273 

be  cross-questioned  on  the  possibility  of  such  having  been  present  at 
the  outset.  Tiie  significance  of  a  supposed  "  tonsillitis,"  or  "  sore 
throat  "  should  not  be  overlooked. 

If  seen  during  the  acute  stage,  when  there  is  earache  with  swelling 
of  the  walls  of  the  meatus  and  some  sanious  discharge  from  ruptured 
vesicles,  the  disease  is  apt  to  be  mistaken  for  an  acute  suppuration  of 
the  middle  ear  with  mastoiditis  (Urban  Pritchard).  The  distinction 
depends  upon  the  character  of  the  discharge,  the  absence  of  pyrexia, 
and  the  presence  of  herpetic  clusters  on  the  auricle. 

The  auricle  may  be  the  seat  of  herpes  without  any  facial  paralysis 
developing.  In  that  case  the  disease  is  attacking  the  posterior  root 
ganglia  of  the  upper  cervical  nerves,  and  the  auricle  is  involved  through 
the  posterior  auricular  nerve  (H.  J.  Banks-Davis).  But  it  has  also  been 
stated  that  true  geniculate  herpes  may  occur  without  facial  paralysis. 

Prognosis. — The  prognosis  of  herpes  zoster  oticus  is  good  as  far  as 
life  is  concerned,  unless,  indeed,  it  affects  a  debilitated  or  aged  person. 
The  prognosis  as  regards  the  facial  paralysis  is  not  so  good ;  recovery 
may  be  anticipated,  but  it  will  be  slow,  and  it  may  only  be  partial.  The 
prognosis  as  regards  deafness,  if  that  is  severe,  is  definitely  unfavour- 
able. 

Treatment. — During  the  acute  stage  the  patient  should  be  kept  in 
bed  until  it  is  seen  that  the  development  of  the  several  herpetic  and 
paralytic  phenomena  has  come  to  a  standstill.  The  pain  may  be  so 
great  that  anodynes  and  analgesics  are  required.  Of  these  perhaps 
drugs  of  the  aspirin  group  are  the  most  suitable.  The  skin  of  the 
auricle  and  meatus  should  be  kept  dry  and  clean,  the  spots  being  dusted 
with  boric  acid  powder. 

After  the  herpes  has  faded  no  attempt  should  be  made  to  apply 
electrical  treatment  to  the  face  until  after  the  lapse  of  several  weeks. 
Then  the  faradic  or  galvanic  current  is  used  according  to  the  response 
obtained,  and  it  may  be  employed  once  or  twice  a  week  until  the 
muscles  begin  to  show  signs  of  returning  activity,  when  it  may  be 
stopped. 

It  seems  to  be  the  custom  to  administer  arsenic  internally  in  herpes. 

Geniculate  Neuralgia. — Ramsay  Hunt,  Wilfred  Harris  and  others 
have  drawn  attention  to  the  existence  of  this  condition.  It  consists  of 
severe  paroxysmal  pain  in  the  depth  of  the  ear,  the  anterior  wall  of 
the  external  meatus,  and  a  small  area  in  front  of  the  ear.  In  Wilfred 
Harris's  cases  the  pain  "  began  with  the  throat  or  posterior  palatal 
region  on  one  side,  and  spread  into  the  ear  and  in  front  of  the  ear  on  to 
the  cheek  and  down  the  side  of  the  neck." 

In  a  case  mentioned  by  Ramsay  Hunt  the  operation  of  intracranial 
division  of  the  facial,  including  the  pars  intermedia  of  Wrisberg,  the 
sensory  root  of  the  facial,  was  undertaken  and  successfully  carried 
through  by  Clarke  and  Taylor,  with  cure  of  the  neuralgia.  Facial 
paralysis  followed  the  operation,  but  a  year  later  movement  had  returned 
to  a  considerable  extent. 

Facial  Paralysis  from  Lesions  of  the  Soft  Tissues  Distal  to  the  Stylo- 
mastoid Foramen. 

Birth  Paralysis. — Facial  paralysis  occurring  in  the  act  of  birth 
may  be  either  central  or  peripheral,  the  former  being  due  to  cerebral 
haemorrhage,  the  latter  to  pressure  by  the  blades  of  the  midwifery 

18 


274  The  Journal  of  Laryngology,     [September,  1920. 

forceps  upon  the  truuk  of  the  nerve  at  the  stylo-ruastoid  foramen,  which, 
as  we  have  seen,  lies  upon  the  surface  of  the  skull  in  a  situation  exposing 
the  nerve  to  such  injuries. 

The  paralysis  is  noticed  as  soon  as  the  child  begins  to  cry,  and  it  is 
complete,  but  in  most  cases  it  disappears  in  about  six  weeks.  When  it 
is  first  observed  immediately  after  birth  the  seat  of  the  injury  will  be 
manifested  by  the  mark  of  the  forceps  on  the  skin  around  the  auricle. 
"With  a  little  bland  ointment  this  area  should  be  gently  rubbed  and 
massaged  for  a  few  minutes.  Thereafter  the  case  may  be  left  to  Nature. 
Faradism  is  sometimes  advised. 

Occasionally  it  happens  that  recovery,  as  in  the  other  forms 
of  peripheral  facial  paralysis,  is  incomplete,  and  then  the  patient 
manifests  for  the  rest  of  his  life  a  slight  weakness  on  one  side  of  the 
face. 

In  a  few  rare  cases  the  paralysis  persists  unaltered,  and  in  these 
patients  we  may  have  an  opportunity  of  estimating"  the  influence  of  the 
musculature  of  the  face  upon  the  facial  skeleton,  to  which  Lambert 
Lack  has  drawn  attention.  In  consequence,  apparently,  of  the  absence 
of  the  normal  moulding  action  of  the  facial  muscles  upon  the  underlying 
bone,  the  alveolar  and  palatal  processes  of  the  upper  jaw  may  undergo 
excessive  development  and  lead  to  considerable  deformity  on  the 
paralysed  side  of  the  face. 

We  have  already  alluded  to  facial  paralysis  from  otogenic  abscess  of 
the  soft  jxw/s  (see  p.  203). 

Facial  Paralysis  in  Diseases  of  the  Parotid  Gland. — Facial  palsy  has 
been  reported  as  an  occasional  complication  in  mumps,  due  presumably 
to  the  pressure  of  the  swollen  gland  upon  the  nerve-trunk  and  branches 
that  traverse  its  substance.  The  prognosis,  if  the  case  be  one  of  mumps, 
is  good. 

The  other  diseases  of  the  parotid  which  are  liable  to  induce  facial 
paralysis  are  septic  parotitis  with  abscess  formation — what  is  sometimes 
called  "  parotid  bubo  " — and  parotid  tumours,  the  latter  especially  when 
they  are  malignant.  In  fact  the  early  appearance  of  facial  paralysis  in 
the  course  of  the  development  of  a  parotid  tumour  always  raises  fears 
of  malignancy. 

Gowers,  by  the  way,  has  described  a  case  of  fatal  peripheral  neuritis 
in  which  septic  parotitis  seemed  to  be  the  effect  rather  than  the  cause 
of  the  facial  paralysis. 

Traumatic  Paralysis. — In  addition  to  the  birth  palsy  we  have  just 
been  describing,  wounds  in  and  around  the  parotid  region,  whether 
accidental,  operative,  or  received  in  warfare,  are  liable  to  sever  the  main 
trunk  or  one  of  its  divisions  or  branches. 

The  branch  most  exposed  to  injury  and  most  frequently  paralysed  is 
the  lower,  the  cervico-facial.  Its  destruction  immobilises  the  depressors 
of  the  mouth  and  the  muscles  of  the  chin. 

If  the  nerve  is  found  to  be  torn  or  cut  immediately  the  wound  is 
inflicted,  as  in  operating  or  in  war  injuries,  the  two  ends  should  be 
brought  into  apposition  and  sutured  through  the  sheath  with  a  fine 
small  needle  and  catgut.  The  wound  should  be  cleansed,  if  necessary, 
as  particularly  as  possible,  since  the  chances  of  union  of  the  nerve 
largely  depend  upon  whether  or  not  an  aseptic  wound  is  secured. 
Tension  should  be  relieved  by  arranging  and  maintaining  a  permanent 
inclination  of  the  head  and  face  to  the  affected  side  until  the  wound  is 
healed. 


September,  1920.]         Rhinology,  and  Otology*  275 

Peripheral  Facial  Paralysis  from  Caiises  other  than  tliose  above- 
mentioned. — The  facial  is  occasionally  attacked  along  with  other  nerves 
in  the  toxic  neuritis  of  alcohol  and  of  arsenic,  but  the  diagnosis  is 
facilitated  bj-  the  fact  that  the  neuritis  is  multiple. 

In  lenkamia  facial  paralysis  occurs  in  about  10  per  cent,  of  the 
cases,  according  to  Yidal  and  Isambart.  It  is  interesting  to  recall  that 
leukaemia  also  may  induce  nerve-deafness  from  haemorrhage  into  the 
cochlea.  I  am  not  aware  whether  its  mode  of  producing  facial  paralysis 
is  known.     Facial  paralysis  is  also  met  with  in  beri-beri. 

Functional  Paralysis  of  the  Face. 

Although,  like  the  other  cranial  motor  nerves,  with  the  notable 
exception  of  the  vagus  in  functional  aphonia,  the  facial  is  seldom 
affected  by  functional  paralysis,  the  condition  is  nevertheless  not 
unknown,  and  it  may  even  closely  simulate  an  organic  paralysis  by 
appearing  as  a  monoplegia,  limited  to  the  face  and  to  the  face  only. 
And  again,  though  still  more  rarely,  functional  facial  paralysis  may 
be  found  in  company  with  the  typical  hysterical  hemiplegia,  hemi- 
anaesthesia,  and  bemi-analgesia.  In  functional  facial  paralysis  the 
muscles  do  not  as  a  rule  show  the  complete  atonicity  commonly  dis- 
cernible in  organic  paralysis ;  the  electrical  reactions  are  normal,  and 
there  is  no  real  muscular  atrophy. 

Occasionally,  also,  after  recovery  from  a  mild  attack  of  organic 
paralysis,  especially  in  women,  a  degree  of  flattening  of  the  affected  side 
of  the  face  is  preserved  for  an  indefinite  period  by  the  patient,  the  rapid 
variability  of  which  from  time  to  time  is  sufficient  to  betray  its  functional 
nature. 

Facial  paralysis  has  been  known  to  follow  emotional  shock.  Gowers 
saw  one  case  in  a  woman  in  whom  it  appeared  after  she  had  been 
watching  a  cancer  of  the  mamma  being  dressed,  and  Leonard  Williams 
has  informed  me  of  a  case  he  had  under  his  care  of  a  woman  in  whom 
the  paralysis  made  its  appearance  immediately  after  she  had  nearly  let 
her  baby  fall  out  of  her  arms. 

Apart  from  the  "  functional"  or  "  hysterical"  explanation  of  these 
cases,  and  allowing  for  the  tendency  for  patients  to  connect  two  striking 
events  as  cause  and  effect,  one  might  explain  them  as  due  to  the 
pressure  of  a  haemorrhage  into  the  strait  Fallopian  canal  from  a  sudden 
rise  in  blood-pressure. 

We  conclude  this  section  by  saying  that  in  no  form  of  paralysis  so 
much  as  in  facial  paralysis  is  the  onus  prohandi  so  heavily  laid  upon  him 
■who  ventures  to  make  the  diagnosis  of  functional  disease. 

Facial  Paralysis  from  Unknotvn  Causes. 

Into  this  group  I  propose  to  place  "rheumatic"  paralysis  and 
paralysis  from  "  cold,"  of  the  existence  of  which  as  pathological  entities 
many  otologists,  including  the  writer,  feel  very  serious  doubts.  These 
doubts,  however,  are  not  yet,  apparently,  shared  by  medical  men  in 
general,  although  it  must  often  be  difficult  to  trace  the  connection 
between  the  onset  of  the  facial  paralysis  and  an  exposure  to  cold  that  is 
not  also  capable  of  setting  up  a  catarrh  of  the  middle  ear. 

It  is  suggestive  to  note,  as  Hammerschlag  informs  us,  that  there 
was  even  at  one  time  a  "rheumatic"  deafness  recognised  that  was 
considered  to  accompany  the  "  rheumatic  "  facial  paralysis  ! 


276  The  Journal  of  Laryngology,     ^September,  1920, 

Frequency . — Stenger  quotes  Philip  as  saying  that  of  130  cases  of 
facial  paralysis,  5-4  per  cent,  were  due  to  trauma,  6-2  per  cent,  to  ear 
affections,  and  72-3  per  cent,  to  "  rheumatism "  ;  but,  as  Stenger 
remarks,  those  figures  are  vitiated  by  the  fact  that  in  the  last  and 
largest  division  are  slumped  all  the  cases  of  unknown  causation. 

A.  Fuchs,  out  of  600  cases  of  facial  paralysis  in  ten  years,  reports  that 
a  definite  cause  was  found  in  93,  and  that  of  these,  43  were  associated 
with  ear  disease.  Eeduced  to  percentages  these  are  15-5  per  cent, 
from  known  causes,  7'1  per  cent,  associated  with  ear  disease,  and 
77'4  per  cent,  from  unknown  causes — practically  the  same  as  in  Philip's 
statistics.  How  manj'  of  these  cases  had  been  submitted  to  a  methodical 
otological  examination  we  are  not  told. 

Pathology. — The  absence  of  definite  and  precise  knowledge  has  not 
prevented  the  production  of  theories  to  explain  facial  paralysis  of 
unknown  cause. 

Waterman,  out  of  335  cases  neither  traumatic  nor  otogenic,  found 
that  "  exposure  to  cold  "  was  the  most  definite  factor,  and  he  found 
that  the  disease  is  naore  frequent  in  winter  than  in  summer.  So,  by  the 
way,  is  acute  and  subacute  otitis  media. 

As  regards  the  influence  of  age,  it  was  found  at  all  periods  of  life, 
but  especially  during  the  thirties  and  forties ;  36  per  cent,  of  the  cases 
were  between  twenty  and  thirty  years  of  age.  It  was  less  frequent  in 
later  life,  but  moi-e  severe. 

Among  the  suggestions  ofi'ered  to  explain  the  disease  are  that  it  is 
"an  infectious  process,"  "a  neuritis,"  "a  primary  degeneration  of 
the  nerve  within  the  Fallopian  canal." 

A  pathological  investigation  has  been  undertaken  in  one  case  of 
facial  paralysis  from  cause  unknown  by  Andre  Thomas — the  trunk  and 
nucleus  being  examined.  Death  occurred  eighteen  days  after  the  onset 
of  the  paralysis.  A  parenchymatous  degeneration  downwards  was 
found  from  the  "  first  bend  "  in  the  aqueductus  Fallopii  with  almost 
entire  loss  of  axons.  Above  the  geniculate  ganglion  the  axons  were 
less  altered.  The  cells  of  the  nucleus  were  swollen,  and  presented 
chromatolysis  and  eccentric  nuclei.  The  cells  of  the  opposite  nucleus 
were  normal.     This  appearance  suggests  some  disease  of  the  nucleus. 

But  it  is  perfectly  clear  that  there  is  in  the  problem  of  the  causation 
of  facial  paralysis  a  large  gap  waiting  to  be  filled  up,  and  that,  before 
we  can  tackle  the  subject  with  any  confidence,  we  require,  in  the  first 
place,  more  information  regarding  the  pathological  condition  of  the 
nerve  in  disease ;  and  secondly,  in  any  statistical  inquiry,  the  assurance 
that  the  cases  classified  have  all  been  submitted  to  satisfactory  otological 
examination. 

In  concluding  this  section  of  our  subject  I  may  be  permitted  to 
express  once  more  the  conviction  that  a  more  careful  clinical  examina- 
tion of  the  cases  will  lead  to  a  much  greater  weight  being  laid  upon  the 
influence  of  ear  disease,  including  herpes  zoster,  in  the  production  of 
facial  paralysis  than  has  hitherto  been  the  fashion. 

{To  he  continued.) 


September,  1920.]         Rhinology,  and  Otology.  277 

SOCIETIES'     PROCEEDINGS. 


ROYAL  SOCIETY  OF  MEDICINE.— LARYNGOLOGICAL 

SECTION. 


November  1,  1918. 


President :  Dr.  James  Donelan. 


Abstract  Report. 


[Continued  from  p.  252.) 

A  Tooth-plate  impacted  in  the  (Esophagus  divided  by  Irwin 
Moore's  Cutting  Shears. — Somerville  Hastings. — A  soldier,  aged 
twenty-three,  was  admitted  to  hospital  on  August  14,  1916,  with  the 
history  that  the  same  moruiug  he  had  swallowed  a  vulcanite  tooth-plate. 
This  plate  had  originally  held  four  upper  incisor  teeth,  but  these  had 
been  broken  off.  There  were  also  two  partly  broken  from  the  back  part  of 
the  plate.  An  X-ray  photograph  showed  the  denture  at  the  level  of  the 
aortic  ai'ch. 

In  the  late  afternoon,  under  cocaine  anaesthesia,  the  cesopbagoscope 
was  passed  and  the  tooth-plate  easily  seen.  It  was  impacted  across  the 
cesophagus  and  held  so  firmly  that  neither  side  of  it  could  be  moved  by 
forceps.  It  was  therefore  divided  into  two  slightly  unequal  halves  by 
Irwin  Moore's  cutting  shears.  For  this  two  cuts  only  were  required,  as 
the  instrument  held  firmly  and  did  not  slip.  The  smaller  half  at  once 
slipped  down  into  the  stomach  ;  the  larger  was  seized  by  forceps,  but 
while  being  disimpacted  also  slipped  down. 

The  next  day  both  pieces  of  the  denture  were  seen  in  the  abdomen  by 
X-ray  examination,  and  a  few  days  later  they  were  passed  per  rectum 
without  diflficulty. 

Tooth-plate  impacted  in  the  (Esophagus  for  Eight  Weeks  ; 
Three  Unsuccessful  Attempts  at  Removal;  Death  from  Perfora- 
tion into  the  Pleural  Cavity. — C.  E.  Woakes. — A  male,  aged 
fifty-seveu,  presented  himself  at  hospital  on  June  10,  complaining  that 
six  weeks  previously  he  had  swallowed  a  portion  of  an  upper  denture, 
composed  of  platinum  with  one  tooth  and  two  metal  hooks  attached. 
There  was  considerable  pain  and  difficulty  in  swallowing  food  and  saliva. 
A  skiagram  showed  that  it  was  impacted  in  the  oesophagus  at  the  level  of 
the  aortic  arch.  On  June  11  an  oesophagoscopic  examination  was  made, 
but  the  denture  could  neither  be  seen  nor  felt.  A  second  attempt  on 
June  13  also  failed,  although  Hill's  expanding  tube  was  used. 

A  thii-d  attempt,  occupying  one  and  a-half  hours,  was  made  on  June  20. 
The  denture  was  located  and  grasped  three  or  four  times  by  its  edge  with 
Irwin  Moore's  forceps,  but  so  firmly  was  it  fixed  that  each  time  extraction 
was  attempted  a  small  piece  of  the  denture  broke  away  in  the  forceps 
blades.  On  one  occasion  the  denture  was  firmly  grasped,  but  since  it 
could  not  be  loosened  it  was  considered  unadvisable  forcibly  to  extract  it 
and  risk  tearing  the  oesophageal  wall.  The  difficulties  of  extraction  were 
also  complicated  by  considerable  bleeding. 


278 


The  Journal  of  Laryngology,      September,  1920. 


Further  attempts — e.g.  bv  cutting  up  the  plate — were  postponed  on 
account  of  the  patient's  condition.  Death  unfortunately  occurred  two 
days  later.  At  the  autopsy  it  was  found  that  the  denture,  which 
measured  H  in.  in  its  broadest  diameter,  was  embedded  by  two  hooks  in 
the  anterior  Avail,  and  that  there  was  an  ulcerated  track  through  the 
oesophageal  wall  into  the  right  pleural  cavity,  causing  general  sepsis, 
pyo-pneumothoi'ax  and  coUajjse  of  the  lung.  The  perforation  was  not  of 
recent  date. 


Specimen  of  the  cesophagus  with  the  denture  in  situ. 


Scarf-pin  in  the  Stomach ;  Gastroscopy ;  Expelled  by 
Yomiting.     C.  E.  Woakes. 

Pin  in  Bronchiole  of  Posterior  Lobe  of  Right  Lung;  Failure 
to  Remove  it  by  the  Bronchoscope  ;  Pin  coughed  up  Eighteen 
Months  later. — Hunter  Tod.— This  is  the  further  history  of  a  girl, 
aged  twelve,  shown  at  the  Section  un  March  2,  1917.'  Several  attempts 
had  been  made  to  remove  the  pin,  but  it  was  out  of  reach  of  the 
bronchoscope.  A  surgical  colleague  was  anxious  to  remove  the  pin  by 
pneumonotomy,  but  I  felt  that  there  was  less  danger  in  leaving  the  girl 

'  JouRN.  OF  Lartngol.,  Ehinol.,  AND  OxoL.,  vol.  xxxiil,  p.  180. 


•September,  1920.]  Rhiiiology,  and  Otology.  279 

alone  than  in  letting  lier  incur  this  grave  procedure.  Consec[uentlv  the 
girl  left  the  hospital. 

On  January  14,  1918,  the  girl  was  readmitted  to  the  hospital 
complaining  of  pain  in  the  right  chest,  with  sudden  onset  of  cough  and 
dyspnoea.  The  patient  looked  ill ;  the  temperature  was  103°  F.,  respira- 
tions 40,  pulse  120.  On  examination  there  were  signs  of  consolidation  of 
the  right  base.  Bearing  in  mind  the  previous  history,  it  was  suspected 
that  the  pneumonic  condition  might  be  the  result  of  the  pin  still  present 
in  the  lung.  An  X-ray  photograph  showed  that  the  pin  had  hardly 
moved.  The  course  of  the  lung  infection  was  typical  of  pneumonia,  the 
crisis  taking  place  on  the  seventh  day,  after  which  the  patient  got 
rapidly  well,  and  was  discharged  from  the  hospital  on  February  1,  1918, 
fourteen  days  after  admissiou. 

Four  months  later  (June,  1918)  the  girl  came  up  to  my  Out-patient 
Department  bearing  in  her  hand  a  pin  35  mm.  (If  in.)  in  length  saying 
that  she  had  coughed  it  up  the  night  before.  In  order  to  confirm  this 
statement  another  X-ray  photogi'aph  was  taken  which  showed  that  the 
pin  had  vanished  from  the  lung. 

At  no  time,  not  even  during  the  period  of  pneumonia,  was  there  any 
offensive  expectoration  suggestive  of  an  abscess  of  the  lung,  and  all  the 
X-ray  photographs  confirmed  this  by  their  negative  results.  To  what 
extent  was  the  presence  of  the  pin  the  cause  of  pneumonia  ^  If  the  pin 
was  indeed  the  predisposing  cause  of  the  pneumonia,  why  did  the  latter 
run  a  typical  course  Avith  complete  resolution  instead  of  leading  to  a 
pulmonary  abscess  ^ 

The  President  :  The  pneumonia  appears  to  be  incidental,  and  to 
have  no  direct  relation  to  the  presence  of  the  pin  so  long  befoi'e  and 
after. 

Dr.  Wflliaji  Hill  :  I  think  the  general  advice  was  to  leave  it  alone. 
There  are  always  dangers  in  leaving  foreign  bodies  in  the  bronchi — more 
danger,  I  think,  than  when  they  are  in  the  gullet.  Here  the  procedure 
has  been  justified  by  the  result,  probably  because  a  pin  is  not  a  very 
septic  body. 

Tooth-plate  in  (Esophagus;  (Esophagoscopy ;  Removal, — 
Hunter  Tod. — The  patient,  a  sturdy  young  police  constable,  came  up  to 
the  hospital  early  one  morning  complaining  that  during  the  night  he  had 
swallowed  his  denture,  which  was  a  small  one,  consisting  of  two  upper 
incisor  teeth.  Apparently  he  did  it  when  half  asleep  and  did  not  realise 
what  had  happened.  He  had  a  certain  amount  of  pain  in  the  neck  and 
vomited  whilst  attempting  to  take  his  breakfast.  I  saw  him  in  the  Out- 
patient Department  the  same  morning  and  at  once  had  him  put  under 
the  X-ray  screen.  The  plate  was  localised  at  the  upper  level  of  the 
clavicle.     The  same  day  he  was  given  an  anaesthetic. 

On  passing  the  cesophagoscope  the  plate  could  be  seen  lying 
horizontally  across  the  oesophagus  with  the  teeth  pointing  forwards. 
One  of  theclasps  was  seized  with  a  pair  of  forceps,  but  broke  off.  This 
procedure  tilted  the  denture  so  that  it  was  possible  to  seize  its  posterior 
margin  with  the  forceps.  On  withdrawing  it  over  the  posterior  surface 
of  the  larynx  it  projected  forwards  so  that  the  teeth  got  fixed  in  the 
interarytsenoid  region.  The  patient  at  once  got  dyspnoeic.  It  was  a 
very  uncomfortable  moment  and  I  thought  I  should  have  to  do  tracheo- 
tomy. Before  doing  so  I  took  a  short,  stout  j^air  of  forceps,  and,  getting 
on  to  a  stool  so  as  to  be  well  above  the  level  of  the  patient,  I  passed  the 


'280  The  Journal  of  Laryngology,      [September,  1920. 

forefinger  of  the  right  hand  clown  until  it  could  feel  the  plate,  and  with 
the  forceps  in  the  left  hand  got  a  firm  grip  of  one  of  the  teeth,  and  pulled 
the  denture  out.     Tbe  patient  made  a  complete  recovery. 

Dental  Plate  removed  from  the  CEsophagus.— J.  Gay  French.— 

The  patient,  a  man  aged  fifty,  was  knocked  down  at  1  p.m.  on  March  28, 
1915,  and  Avas  taken  to  hospital  in  a  dazed  condition.  He  was  put  to 
bed,  and  in  a  couple  of  hours  recovered  his  mental  powers.  It  was  then 
found  that  his  dental  plate  was  missing,  and  he  was  observed  to  bring  up 
some  blood-stained  sputum.  He,  however,  complained  of  no  discomfort. 
It  was  thought  that  the  plate  must  have  slipped  down,  and  he  was  there- 
fore X-rayed.  This  showed  the  dental  plate  "to  be  fixed  in  the  oesophagus,. 
just  below  the  cricoid. 

At  eight  o'clock  the  same  evening  the  man  was  given  an  anaesthetic 
(chloroform)  and  I  passed  down  an  oesophagoscope.  A  small  portion  of 
the  dental  plate  was  then  found  to  be  showing  just  above  the  cricoid 
cartilage.  This  was  seized  with  a  pair  of  Briinings'  forceps,  but 
was  found  to  be  firmly  fixed.  The  cricoid  was  gently  pushed  forwards, 
and,  after  considerable  manipulation,  the  plate  was  freed  and  removed 
Avhole.     The  man  left  the  hospital  two  days  later,  quite  recovered. 

Foreign  Body  in  CEsophagus,  occurring  at  a  Royal  Naval  Base 
Hospital.— J.  Gay  French. — A  young  deck  hand,  R.N.E.(T.),  aged 
twenty-two,  awoke  suddenly  during  the  night  of  November  30,  1917, 
with  a  feeling  of  suffocation  and  alarm.  He  at  once  missed  his  dental 
plate,  which  carried  two  teeth,  the  central  and  lateral  incisor  of  the  left 
side,  upper  jaw.  Contrary  to  his  usual  practice  he  had  gone  to  his 
hammock  with  the  plate  in  sitff.  He  awoke  at  about  4  a.m.  and  started 
vomiting  food  in  small  quantities,  and,  later,  could  only  breathe  with 
difficulty— apparently  from  spasm.  Attention  was  then  drawn  to  the 
absence  of  his  false  teeth,  and  he  was  brought  ashore  at  10  a.m.  for 
medical  aid. 

On  entry  into  the  hospital  patient  was  suffering  from  shock  and  had 
a  pulse  of  120,  was  pallid,  and  had  a  rather  anxious  face.  Voice  rather 
weak  and  husky;  temperature  99-4°  F.  On  examination,  digital  pressure 
over  the  anterior  triangles  of  the  neck,  in  a  lateral  direction,  produced  a 
pricking  sensation  on  the  left  side  of  the  "  throat."  This  was  found  to 
have  been  caused  by  one  of  the  lateral  hooks  with  which  the  plate  was 
fitted.  X-ray  examination  with  the  screen  revealed  the  plate  lying  low 
down  in  the  oesoi>hagus,  opposite  the  invertebral  disc  between  the  last 
cervical  and  first  dorsal  vertebrae.  The  teeth  were  lying  on  the  left  side, 
the  hooks  on  the  right  side,  viewed  from  in  front,  the  patient  lying  on 
his  back.  The  shadow  moved  "up  and  down"  with  deglutition,  and 
could  be  seen  to  move  "  with  "  the  oesophagus  on  lateral  pressure  applied 
from  the  neck,  being  obviously  wedged  in  position.  No  food  could  be 
taken,  not  even  a  drop  of  fluid,  as  it  at  once  produced  reflex  spasm 
and  I'etching. 

I  went  down  to  the  Eoyal  Naval  Hospital  on  Sunday,  December  2, 
when  the  man  was  given  an  anaesthetic,  consisting  of  intravenous  saline 
and  ether.  On  j^assing  down  the  oesophagoscope  I  found  the  plate  fixed 
very  low  down.  The  mucous  membrane  was  considerably  inflamed  and 
cedematous.  I  found  that  it  was  quite  impossible  to  move  the  plate, 
and  therefore  passed  down  one  of  Irwin  Sloore's  shears,  clipping  off 
the  side  of  the  j^late.     This  enabled  one  of  the  catches  to  be  turned 


September,  1920.]         Rhinology,  and  Otology.  281 

round,  and  the  plate  was  then  removed,  a  small  portion  slipping  down 
into  the  stomach. 

At  the  time  of  operation  the  man  had  a  temperature  of  102^  F.  ; 
this  dropped  the  same  evening,  but  on  the  following  marning  was  again 
102°  F.,  when  he  was  given  an  injection  of  atropine  sulphate.  The 
temperature  subsequently  dropped,  and  the  man  made  an  uninternipted 
recovery.  After  the  removal  of  the  plate  the  patient  was  fed  rectally 
for  twenty-four  hours,  and  then  by  the  mouth,  small  amounts  of  fluid 
only  being  administered. 

X-rav  photograph  and  denture  shown. 

Foreign  Bodies  Impacted  in  the  Food  and  Respiratory 
Passages  recorded  at  the  Section  of  Laryngology  of  the  Royal 
Society  of  Medicine  since  1908.— Irwin  Moore.— The  total  number 
is  111,  made  made  up  of  three  in  the  pharynx,  sixty  in  the  oesophagus, 
one  in  the  stomach,  and  forty-seven  in  the  respiratory  passages. 

(1)  Food  Passages. 

Of  the  three  in  the  pharynx,  one  was  extracted  by  oesophagoscopy 
and  two  by  suspension  laryngoscopy.     There  wei'e  no  deaths. 

Fifty-tliree  of  the  sixty  patients  who  had  foreign  bodies  in  the 
oesophagus  recovered,  and  seven  died. 

In  the  fifty-three  recoveries,  the  foreign  body  was  successfully 
removed  by  oesophagoscopy  in  forty-seven  cases,  in  five  it  was  released 
by  the  passage  of  the  oesopimgoscope  (two  being  vomited  up — ^one  through 
the  oesophagoscopic  tube  and  the  other  after  removal  of  the  tube,  whilst 
three  were  later  evacuated  jje»-  a  mini).  In  only  one  case  was  the  foreign 
body  removed  by  oesophagotomy. 

Two  of  the  seven  deaths  were  due  to  injury  caused  by  the  previous 
blind  use  of  the  bougie,  two  to  previous  ulceration  and  perforation  into 
the  trachea,  and  one  to  previous  abscess  and  perforation  into  the 
mediastinum.  In  these  five  cases  the  foreign  body  was  extracted  before 
death.  There  was  one  case  where  the  foreign  body  was  not  removed, 
the  patient  dying  as  a  result  of  previous  iilceratiou  and  perforation  into 
the  pleural  cavity.  There  was  only  one  failure  to  find  by  oesophagos- 
copy— after  location  by  X  rays,  with  perforation  later  into  the  posterior 
mediastinum. 

So  we  may  say  that  out  of  the  total  sixty  cases  of  foreign  bodies 
impacted  in  the  oesophagus,  fifty-eight  were  either  x-emoved  by  means  of, 
or  as  the  result  of,  the  employment  of  the  oesophagoscope,  and  that  no 
death  or  failure  could  be  attributed  to  its  use— a  very  creditable  record. 
The  only  foreign  body  reported  in  the  stomach  is  that  of  the  scarf-pin 
shown  at  this  meeting.  It  was  spontaneously  expelled  after  the  first 
introduction  and  removal  of  the  oesophagoscope. 

(2)  Eespiratory  Passages. 

In  eight  cases  of  a  foreign  body  in  the  larynx,  six  of  them  were 
extracted  by  direct  lai-yngoscopy,  and  one  by  suspension  laryngoscopy. 
In  one  case  which  had  been  diagnosed  and  ti-eated  for  diphtheria  a 
collar-stud  was  iound  jJost-mortem  impacted  in  the  larynx. 

Of  three  foreign  bodies  in  the  trachea,  two  were  extracted  by  peroral 
tracheoscopy,  and  one  was  removed  through  a  tracheotomy  incision. 
There  were  no  deaths. 

1  Proc.  Roy.  Soc.  Med.  (Sect.  Laryng.),  1908-18. 


^82  The  Journal  of  Laryngology,      September.  1920. 

Of  thirty-six  foreign  bodies  in  the  brouclii,  twenty-uiue  were  extracted 
by  peroral  bronchoscopy  and  only  two  by  tracheo  bronchoscopy.  Three 
were  spontaneously  coughed  up  (one  through  the  brouchoscopic  tube 
while  171  situ,  one  following  operation  for  pulmonary  abscess  and 
empyema,  and  one  two  years  after  failure  to  find  by  bronchoscopy 
although  located  by  X  rays).  In  one  case  thoracotomy  was  successfully 
performed  after  failure  to  find  by  bronchoscopy  though  located  by 
X  rays.  There  were  no  deaths.  One  autopsy  was  reported  where  a 
foreign  body  was  discovered,  after  death  from  empyema  and  gangrene, 
but  this  case  was  not  referred  during  life  to  a  specialist  (endoscopist). 

These  remarkable  results  show  the  splendid  work  which  has  been 
achieved  in  this  country  by  British  endoscopists. 

In  connection  with  Mr.  Hunter  Tod's  remarkable  case,  I  have  collected 
the  following  similar  cases  : 

Some  Statistics  and  Results  of  Pins  Accidentally  Inhaled  into 

THE  Lungs. 

(These  include  only  ordinary  and  glass-headed  pins,  and  not  safety- 
pins.)  Fifteen  of  these  cases  have  been  reported  by  Chevalier  Jackson  ^ 
(Philadelphia);  three  by  Fletcher  Ingals  -  (Chicago);  one  by  Costa  ^ 
(Madrid)  ;  and  eight  by  ]. resent  members  of  the  Section  of  Laryngology 
of  the  Eoyal  Society  of  Medicine.^ 

Of  these  twenty-seven  pins  recorded,  ten  were  definitely  stated  to 
have  entered  the  right  lung  and  sixteen  the  left — i.  e.  nearly  two-thirds 
were  found  in  the  left  lung. 

Sixteen  Avere  situated  in  the  bronchi  of  the  upper  or  middle  lobes, 
and  wei-e  all  extracted  without  difficulty  by  bronchoscopy,  whilst  eleven 
were  in  lower  lobe  branches.  Of  these  only  four  were  successfully 
extracted,  while  seven  could  not  be  found  by  bronchoscopy,  although 
located  by  X  rays. 

The  seven  failures  to  find  were  all  in  posterior  branches  of  the  lower 
lobes  (three  on  the  right  side  and  four  on  the  left).  Of  these  five 
recovered  and  two  died. 

Of  the  five  recoveries,  thoracotomy  was  performed  in  two  cases,  the 
foreign  body  was  coughed  up  in  one  case,  the  pin  after  a  time  disappeared 
in  one  case,  Avhilst  in  the  fifth  case,  when  last  reported,  the  pin  was 
gradually  working  its  way  towards  the  periphery. 

One  patient  died  after  thoracotomy,  and  the  other  of  pulmonary 
abscess  one  and  a-half  years  later,  the  patient  having  refused  oj^eration. 

It  will  thus  be  seen  that  out  of  the  total  twenty-«eveu  cases,  the 
foreign  body  was  successfully  removed  by  bronchoscopy  in  twenty  cases, 
and  in  only  one  case  was  a  pin  spontaneously  coughed  up  (Hunter 
Tod's  case). 

Postscnj)f. — Since  summarising  these  cases  I  have  come  across  a  case 
reported  in  1886  by  Colquhouu  ■'  (New  Zealand),  where  a  pin  1^  in.  in 
length  was  coughed  up  after  sixteen  years'  sojourn  in  the  right  lung. 
It  had  been  inhaled  at  five  years  of  age,  and  had  caused  no  symptom  for 

'  ChevaUer  Jackson,  "  Limitations  of  Bi-onclaoseopy,"  Trans.  Amer.  Laryng. 
Assoc,  IQl-i,  p.  51 ;  also  "  Peroral  Endoscopy,"  1915,  pp.  373-378. 

-  Fletcher  Ingals,  Trajis.  Amer.  Laryng.  Assoc,  1914,  p.  112  :  also  discussion  on 
Chevalier  Jackson's  paper,  "  Limitations  of  Bronchoscopy,"  op.  cit.,  p.  60. 

^  Diego  Gnigon  y  Costa,  Revista  de  Medicina  y  Cirugia  Prrtcticas,  September  28, 
1912.     Abstract,  Brit.  Med.  Journ.,  1912,  ii  (Epit.),  p.  li. 

■*  Proc  Roy.  Soc  Med.  (Sect.  Laryng.),  1908-18. 

'"  Austral.  Med.  Journ.,  1886,  n.s.  viii,  p.  489. 


September.  1920.]         Rhinology,  and  Otology.  283 

fifteen  years,  wheu  iuflauiniatiou  of  tbe  luugs  occurred,  followed  by  acute 
phthisis.  A  few  days  before  death  the  pin  was  coughed  up  iu  three 
pieces,  much  eroded  aud  very  brittle.  No  autopsy  was  held,  heuce  the 
actual  position  of  the  pin  was  not  ascertained.  Botella  ^  (Madrid)  has 
also  reported  an  interesting  case  of  a  pin  in  the  base  of  the  left  lung. 
All  attempts  both  by  peroral  and  tracheo-bronchoscopy  failed  to  locate 
it.  A  strong  electro-magnet  was  also  used.  The  final  result  of  this 
case  is  not  recorded. 

Mr.  Herbert  Tilley  :  In  my  earlier  cases  I  found  difficulty  in 
removing  foreign  bodies  because  I  used  too  narrow  a  tube.  We  ought 
to  employ  the  largest  tube  which  it  is  possible  to  insert  with  safety  into 
the  oesophagus.  When  we  remember  the  size  of  the  boluses  of  food  that 
are  passed,  we  may  conclude  there  is  no  inherent  danger  in  the  passing 
of  a  large  tube.  In  the  earlier  days  of  endoscopy  it  was  thought  that 
the  smaller  the  tube  the  easier  it  was  to  pass,  aud  the  less  the  danger 
attending  its  passage.  Further,  those  of  you  who  have  not  had  an 
extensive  experience  in  direct-vision  instruments  should  not  try  to  pass 
the  oesophageal  tube  immediately  behind  the  arytaenoids,  because  that 
will  mean  disappointment  for  yourself  and  possible  harm  to  the  patient 
if  it  is  i^ersisted  iu.  The  correct  method  is  to  pass  the  end  of  the  tube 
first  into  the  pyriform  fossa,  and  then  sweep  it  into  the  middle  line,  Avhere 
it  will  enter  easily  into  the  gullet. 

Dr.  D.  R.  Paterson  :  If  the  foreign  body  is  in  the  upper  third  of 
the  CEsophagus,  or  immediately  below  the  cricoid,  it  can  he  treated  in  a 
different  manner  to  a  foreign  body  lower  down.  If  further  down  it  is 
practically  outside  the  domain  of  external  operation.  I  have  been  present 
at  an  attempt  to  remove  a  tooth-plate  which  had  long  been  impacted 
behind  the  cardiac  area,  where,  after  he  had  got  to  it,  the  surgeon  found 
he  could  not  remove  it  on  account  of  the  dense  cicatricial  tissue  in  which 
it  was  embedded.  In  the  case  of  foreign  bodies  which  are  immediately 
below  the  cricoid,  we  ought  not  to  forget  that,  under  certain  conditions, 
it  may  be  impossible  to  remove  them,  or  at  all  events  that  there  is  some 
danger  in  making  the  attempt.  We  should  then  consider  the  external 
method.  That  is  impressed  upon  my  mind  particularly  by  two  cases 
occurring  during  the  past  eighteen  months.  From  one  of  the  cases  I 
showed  the  specimen  here- — a  bone  of  considerable  size  with  a  very  sharp 
comer  which  had  become  impacted  below  the  cricoid.  It  hdd  been  there 
three  or  four  days  when  I  saw  the  patient,  and  the  swelling  was  great. 
We  used  Dr.  Irwin  Moore's  shears,  but  it  was  difiicult  to  get  a  hold.  I 
take  it  the  instrument  needs  some  counter-resistance  behind  it  in  order 
to  get  the  blades  to  bear  on  the  foreign  body.  The  man  had  a  very 
short  and  thick  neck,  and  it  was  unadvisable  to  do  an  external  operation. 
At  the  risk  of  damaging  the  structures  it  Avas  extracted  after  disengaging 
the  sharp  corner,  but  septic  trouble  ensued  after  a  few  days.  Eight 
months  later  I  had  another  and  similar  case,  the  foreign  body  being  a 
broken  vulcanite  tooth-plate  which  had  become  impacted  four  days 
before.  Pressure  on  the  gullet  appeared  to  be  considerable,  as  there 
was  much  swelling,  aud,  what  I  always  regard  with  suspicion,  a  distinct 
odour,  which  I  take  to  indicate  some  ulceration.  I  made  a  very  cautious 
effort  to  cut  the  plate,  but  was  afraid  to  apply  mucli  j>ressure.  As  this 
patient  had  a  long  thin  neck,  I  had  no  hesitation  in  opening  from  the 

1  rra?is.    Seventeenth  Internat.    Cong.   Med.,  London,   1913    (Sect.    XV,  Ehino- 
Laryngology),  p.  91. 

-  JouRN.  OF  Lartngol.,  Ehixol.,  AND  Otol.,  vol.  xxxi,  p.  1-49. 


284  The  Journal  of  Laryngology,     [September,  192 

outside.  When  I  had  cleared  the  oesophagus  and  put  my  finger  down 
to  locate  the  foreign  body,  the  wall  perforated  ;  the  sharp  point  of  the 
body  had  worn  the  gullet  through  to  such  an  extent  that  even  slight 
pressure  produced  the  rupture.  The  man  did  well.  I  call  your  attention 
to  the  two  different  kinds  of  neck.  In  the  case  of  the  man  with  the 
short  thick  neck,  it  may  be  a  very  dangerous  operation,  whereas  in  the 
case  of  a  thin  neck  it  is  a  reasonably  safe  one.  Of  course  the  character 
of  the  foreign  body  has  much  to  do  with  one's  decision  as  to  what  to 
attempt,  as  has  also  the  length  of  time  it  has  been  impacted ;  but  in 
particular  one  has  to  take  note  of  the  amount  of  swelling,  and  whether 
or  not  there  is  iilceratiou.  I  remember  the  peculiar  odour,  specially  in 
the  case  of  a  soldier  from  whom  I  removed  a  piece  of  bully-beef  tin  the 
size  of  half-a-crown  ;  the  pressure  of  the  body  on  the  gullet-wall  alone 
had  caused  considerable  ulceration  as  no  attempt  at  extraction  had 
been  luade. 

Dr.  W.  Hill  :  In  one  case  a  denture  had  become  lodged,  and  I  could 
not  get  it  out  on  account  of  the  liooks.  The  body  had  been  there  some 
days,  and  thei-e  was  an  odour  in  the  neck  and  the  tract  was  blackish- 
gi'een.  The  patient  died  of  pleuro-pneumonia  following  mediastinitis 
due  to  the  perforations  Avhich  had  taken  place  beforehand.  I  tried  to 
remove  the  denture  by  the  direct  method  but  failed,  and  then  I  resorted 
to  external  oesophagotomy,  regarding  it  as  a  point  of  honour  to  remove 
foreign  bodies  in  a  situation  in  which  they  may  be  dangerous.  It  was 
below  the  level  of  the  clavicle,  but  I  was  surprised  how  easy  an  operation 
it  was. 

Sir  StClair  Thomson  :  Mr.  Hunter  Tod's  cases  are  important. 
There  has  been  a  little  undue  tendency  to  try  to  i*emove  at  once  every 
foreign  body.  We  must  take  into  account  ,the  nature  of  the  body — 
whether  it  is  a  metallic  substance  like  a  pin  or  a  tin-tack.  We  remember 
Chevalier  Jackson's  case,  for  instance,  in  which  a  woman,  in  order  to 
gain  admission  into  the  wards  and  elicit  sympathy,  used  to  pass  tacks 
into  her  mouth  and  inspire  them  into  her  bi'onchi.  And  she  never  died 
of  it !  I  show  you  a  foreign  body  which  had  a  long  sojourn  in  the  oeso- 
phagus for  two  and  a  half  years,  and  yet  the  patient  was  fairly  well. 
Sometimes  in  trying  to  take  an  article  like  a  penny  from  a  child's  gullet 
we  are  apt  to  dislodge  it,  and  it  descends  into  the  stomach.  Thei'efore, 
if  we  are  nervous  about  bringing  a  foreign  body  up  from  the  oesophagus, 
we  may  i*emember  that  it  may  be  wise  to  pass  it  downwards.  And, 
thirdly,  as  in  Mr.  Tod's  case,  when  Ave  cannot  remove  a  foreign  body  we 
should  not  give  up  hope. 

Dr.  Irwin  Moore  :  This  is  a  unique  collection  of  cases  of  impacted 
foreign  bodies  shown  here  to-day.  After  searching  the  literature  I  find 
that  Mr.  Somerville  Hastings'  case  is  the  first  recorded  Avhere  a  tooth- 
plate  has  been  cut  in  half  in  the  oesophagus  with  any  cutting  instrument. 
Killian'  reported  in  1900  a  case  in  which  he  separated  a  vulcanite 
tooth-plate  into  three  pieces  by  burning  with  a  s[)ecially  devised  cautery 
knife,  l)ut  this  was  a  most  dangerous  procedure.  Mr.  Hunter  Tod's 
case  is  a  unique  one,  for  Chevalier  Jackson  says  that  although  a  few 
foreign  bodies  may  be  coughed  uj)  from  a  lower  lobe  bronchus,  yet  it  is 
practically  impossible  for  a  pin  to  be  coughed  up,  and  the  five  cases  of 
failure  to  locate  by  bronchoscopy  to  which  that  authority  refers  were, 
as  in  this  case,  pins  in  a  similar  situation — i.  e.  in  a  posterior  branch  of 
a  lower  lobe  bronchus. 

1  Deut.  med.  Woch.,  December  20,  1900. 


September,  1920.]         Rhinology,  and  Otology.  285 

Mr.  SoMERViLLE  HASTINGS:  Dr.  Paterson  said  he  found  that 
Dr.  Irwin  Moore's  forceps  frequently  slipped  in  his  hands.  That  was  not 
nij  experience  in  the  case  I  have  recorded  to-day.  The  notches  on  the 
blades  seemed  to  catch  on  the  tooth-plate,  and  the  shears  cut  very  easily. 
I  have  tried  the  shears  with  other  objects  and  I  have  not  had  any 
difficulty  owing  to  the  shears  slipping. 

[Dr.  Paterson  :  I  was  referiug  to  them  slipping  on  a  round,  smooth 
piece  of  bone.] 

Dr.  Irwin  Moore  (in  reply)  :  In  reference  to  the  cutting  shears,  they 
do  not  recjuire  resistance  behind  them,  for  they  are  designed  to  draw  up 
the  tooth-plate  as  they  cut.  But  the  great  point  in  using  them  is  to 
twist  slightly  to  the  left  whilst  cutting.  Again,  if  possible  a  tooth-plate 
should  not  be  cut  through  the  centre,  which  is  the  thickest  part,  but  at 
the  periphery.  The  first  attempt  to  cut  through  an  impacted  tooth-plate 
with  these  shears  was  made  by  Dr.  Peters^  in  1912.  The  first  cut 
disimpacted  the  tooth-plate  and  held  it  so  firmly  that  he  was  able  to 
withdraw  the  denture  without  further  cutting.  The  denture  showed  that 
if  the  cut  had  been  completed,  the  widest  diameter  of  the  plate  would 
have  been  reduced  by  i  in.,  and  it  would  have  been  easy  to  turn  it  into 
its  narrowest  diameter,  but  owing  to  the  secure  grasp  of  the  shears  this 
was  not  found  necessary  for  its  safe  removal. 

Demonstration  of  some  New  Instruments  recently  Designed 
for  the  Removal  of  Foreign  Bodies  from  the  Lungs  by  Peroral 
Endoscopy. — Irwin  Moore. — (1)  Universal  Non-slijjjiing  Forceps. — 
These  are  applicable  to  all  types  of  foreign  bodies.  They  are  a  facsimile  of 
the  exhibitor's  oesophageal  forceps,  but  adapted  for  lung  work  by  reducing 
the  diameter  of  the  shaft  and  blades. 

(2)  Bronchial  Dilating  Forceps. — These  were  specially  devised  for 
difficult  cases  of  a  foreign  body  tightly  impacted  in  a  bronchus.  With 
them  a  bronchus  may  be  dilated  whilst  the  blades  of  the  forceps  are 
passed  downwards  and  around  the  foreign  body  so  as  to  grasp  it  securely. 
They  are  invaluable  for  round  objects,  e.  g.  glass  beads  and  fruit-stones, 
also  for  those  which  are  cube-shaped  and  for  this  reason  difficult  to  seize. 
On  account  of  their  shape  the  blades  cannot  be  appi'oximated  much 
nearer  than  the  diameter  of  the  foreign  body,  hence  breaking  it  up  into 
fragments  is  avoided.  They  are  therefore  specially  useful  for  friable 
bodies — e.  g.  swollen  beans  or  oval  seeds,  or  partially  disintegrated  bodies. 

(3)  Ring  Forceps. — These  are  suitable  for  teeth  inhaled  with  their 
fang  directed  downwards  and  then  impacted,  e.g.  incisors  or  canines. 
These  are  adapted  from  Cuthbert  Morton's  modification  of  one  of 
Killian's  forceps. 

(4)  Single  Curette  Forceps. — These  may  be  passed  down  between  an 
impacted  foreign  body  and  the  bronchial  wall,  so  disimpacting  and 
retrieving  it  from  behind  forwards.  These  are  adapted  from  Quer's 
aural  curette. 

(5)  Curettes  of  Aural  Type  for  the  Same  Purpose. 

(6)  Hooks. — These  are  of  three  patterns,  and  are  designed  to  take  the 
place  of  those  dangerous  examples  supplied  with  the  present  endoscopic 
outfit,  which  may  get  caught  in  the  bronchi. 

'  By  personal  commvinication  to  aiithor,  IrAvin  Moore :  "  The  Removal  of 
Foreign  Bodies  from  the  (Esophagus  and  Bronchi,"  Lancet,  1916,  i,  p.  996. 

{To  be  continued.) 


286  The  Journal  of  Laryngology,     [September,  1920. 

ABSTRACTS. 

Abstracts  Editor — W.  Douglas  Hakmer,  9,  Park  Crescent,  London,  W.  1. 

Authors  of  Original  Communications  on  Oto-laryngology  in  other  Journals 
are  invited  to  send  (t  copy,  or  tivo  reprints,  to  the  Journal  of  Laetngology. 
If  they  are  ^villmg,  at  the  same  time,  to  submit  their  oivn  abstract  {in  English, 
French,  Italian  or  German)  it  ivill.be  v:elcomed. 


EAR. 
Cure  of  Subperiosteal  Abscess  of  the  Mastoid  by  Paracentesis. — Salinger. 
"Ann.  of  OtoL,  Ehinol.  and  Laryngol.,"'  September,  1917,  p.  758. 

The  author  records  two  cases  of  this  condition  in  children  of  two  and 
four  years.  He  holds  that  patency  of  the  sqi;aino-mastoid  suture  was 
undoubtedly  the  potent  factor.  This  suture  is  supposed  to  be  closed  by 
the  end  of  the  i?ecoud  year  of  life.  During  the  course  of  the  second  year 
of  life  the  mastoid  becomes  fairly  distinct  and  consists  of  two  portions — 
(1)  the  antero-superior  or  squamous  portion,  presenting  a  smooth 
exterior,  and  (2)  the  postero-inferior  or  mastoid  proper,  whose  surface 
is  rough  and  irregular.  The  persistence  of  the  squamo-mastoid  suture 
has  been  investigated  by  a  number  of  authors.  Kisselbach  examined 
twenty-six  bones  from  children  aged  one  to  two  years,  and  found  that 
the  suture  was  entirely  or  partially  open  in  46  per  cent.  Even  up  to  the 
age  of  nineteen  the  suture  may  be  partially  open.  Kiischner  found 
completely  open  sutures  in  5  per  cent  of  all  cases.  Kanasugi  examined 
4000  skulls  and  found  260  cases  with  both  sutures  partially  open. 

Another  important  factor  is  the  remarkable  resistance  of  the  drum 
membrane  in  young  children  as  compared  to  adults. 

These  facts  explain  the  frequent  development  of  subperiosteal  abscess 
of  the  mastoid  in  the  absence  of  any  marked  evidence  of  middle-ear 
disease.  If  the  squamo-mastoid  suture  can  transmit  pus  from  the  antrum 
to  the  cortical  pei'iosteum,  it  can  also  transmit  pus  from  the  mastoid 
cortex  through  the  antrum  into  the  middle  ear.  It  is  only  in  an  acute 
case,  where  the  drum  has  not  been  perforated  and  the  middle  ear  drained, 
or  Avhere  the  perforation  is  inadequate,  that  one  may  counsel  conserva- 
tism, and  then  only  with  the  proviso  that  there  be  no  other  threatening 
symptoms.  Where  drainage  through  the  tympanic  membrane  has  been 
effected,  and  the  fluctuation  and  oedema  of  the  mastoid  fail  to  promptly 
disappear,  there  can  be  no  question  as  to  the  necessity  of  immediate 
incision  into  the  bone.  /.  S.  Fraser. 

Subacute  Mastoiditis. — Blackwell.  "Ann.  of  OtoL,  Rhiuol.  and 
Laryngol.,'"  December,  1917,  p.  999. 
According  to  Blackwell  the  acute  period  of  mastoiditis  may  be  said  to 
cover  anywhere  from  a  few  days  to  a  week  or  more.  As  the  acute  bone 
tenderness  disappears  earache  and  throbbing  cease,  the  temperature 
falls,  and  the  condition  becomes  subacute,  without  the  quantity  or  quality 
of  the  aural  discharge  having  undergone  any  alteration.  Mastoid  tender- 
ness is  not  a  very  prominent  symptom  in  subacute  mastoiditis.  It  is 
usually  conspicuous  by  its  absence  or  by  being  noted  only  on  deep 
pressure.  Subjective  imin  is  a  variable  factor.  Headache  is  much  more 
constantly  j^resent  than  during  the  acute  stage.  It  is  chiefly  nocturnal 
and  usvially  intermittent.  Discharge  is  the  least  constant  factor  in  sub- 
acute mastoiditis.     It  may  be  profuse,  thick  and  pulsating,  it  may  be 


September,  1920.,         Rhinology,  and  Otology.  287 

a  thin,  scanty,  mucous  or  serous  exudate,  or  it  may  be  entirely  absent. 
Audition  :  In  cases  requiring  operation  the  hearing  in  the  affected  ear  is 
very  much  lowered.  External  auditory  canal :  The  drumhead  may  present 
all  the  evidences  of  a  severe  mastoid  suppui'ation,  or  may  appear  almost,, 
though  never  quite,  normal.  The  cause  of  premature  tympanic  resolution 
in  subacute  mastoiditis  is  the  formation  of  a  thick  plug  of  organised 
granulation-tissue  in  the  antrum,  which  tightly  seals  it.  The  drumhead 
and  tympanum  may  thus  appear  more  or  less  normal,  although  mastoid 
suppuration  continues  undrained  until  it  (1)  ruptures  spontaneously 
again  into  the  tympanum  and  re-establishes  the  aural  discliarge,  (5) 
terminates  in  a  solution  of  a  table  of  the  skull  or  (3)  a  spontaneous 
cure.  The  inflammation  in  the  mastoid  may  present  in  the  posterior 
bony  canal,  giving  all  the  appearance  of  a  furuncle  of  the  posterior  wall 
of  the  external  auditory  canal.  The  swelling  may  be  cone-shaped,  coming 
to  a  point  and  sloping  away  evenly  in  every  direction.  From  the  apex 
the  pus  discharges  drop  by  di-op.  Behind  this  appearance  a  resolved 
drum  may  be  seen.  /.  S.  Fraser. 

Carrel-Dakin   Solution  in  Mastoid  Surgery- — S.  Berggren,     "  Nordisk 
Tidsskrift  f.  Oto-Ehino-Laryngol.,"  Bd.  ii,  No.  4,  1917. 

In  six  cases  of  acute  mastoiditis  the  post-operative  treatment  was 
carried  out  by  means  of  Carrel-Uakin  solution.  From  three  to  eleven 
days  afterwards  secondary  suture  of  the  mastoid  wound  could  be  made, 
and  in  five  cases  there  was  primary  healing  of  the  wound.  Before 
suturing  it  is  essential  to  determine  the  bacterial  content  of  the  wound. 
In  employing  the  Carrel-Dakin  solution  it  is  also  essential  that  the  fluid 
come  in  direct  contact  with  the  walls  of  the  wound  cavity.  The  use  of 
the  solution  in  chronic  otitis  media  and  in  acute  otitis  media  was  without 
i-esult.  In  complicated  cases  of  mastoiditis,  e.  g.  in  the  presence  of 
pyaemia,  septicaemia,  sinus  phlebitis,  etc.,  Daure  recommends  the  Carrel 
treatment.  /.  S.  Fraser. 

Is   a  Modified  Radical   Operation   Justifiable? — Kaufman.     "Ann.  of 
Otol.,  Rhinol.,  and  LaryugoL,"  June,  1917,  p.  548. 

The  author  notes  briefly  that  the  operation  has  for  its  object  the  cure 
of  suppuration,  the  repair  of  the  drum  membrane  and  the  restoration  of 
hearing.  It  has  been  asserted  that  a  case  requii'ing  radical  operation 
will  not  get  well  with  a  "  Heath,"  and  that  a  case  that  does  get  well  with 
a  "  Heath  "  would  have  made  eciually  good  recovery  with  a  simple. 
Kaufmann  agrees  that  this  is  true  to  a  certain  extent.  Indications  .-  (1) 
Certain  acute  cases  which  have  gone  too  far  to  yield  to  a  simple  operation, 
and,  on  the  other  hand,  do  not  demand  a  radical.  (2)  Chronic  cases  with 
the  disease  confined  to  the  antrum  and  mastoid  proper,  and  the  ossicles 
in  place  and  a  goodly  portion  of  the  membrane  remaining. 

J.  S.  Fraser. 

Pathology   of    Chronic    Middle-ear    Suppuration. — G.   W.   Mackenzie. 
"  Journ.  Ophthal.,  Otol.  and  Laryngol.,"  April,  1917. 

In  spite  of  local  and  general  treatment  a  minority  of  cases  of  acute 
middle-ear  suppuration  will  either  develop  mastoid  or  other  complications 
or  else  become  chronic.  The  combination  of  factors  that  operated  to 
produce  the  oi'iginal  acute  suppuration  may  or  may  not  continue  to  plav 
a  role  in  the  chrouicity  of  the  process.  Clinically,  any  discharge  that 
finds  its  way  through  a  perforation   in  the  drum  membrane  and  which 


288  The  Journal  of  Laryngolog:y.      [Septemijer,  1920. 

lasts  over  a  prolonged  period  may  be  referred  to  as  a  chronic  middle-ear 
suppuration.  The  Eustachian  tube  pla.ys  a  role  in  the  aetiology  and 
pathology  of  chronic  suppurative  otitis  media.  Narrowing  of  the  tube 
will  produce  retention  of  secretion  in  the  middle  ear  at  a  time  when 
drainage  by  this  route  is  very  essential  to  the  healing  of  tbe  perforation 
in  the  membrane.  A  tube  that  is  over  patulous  permits  secretion  from 
the  nose  to  be  blown  into  the  middle  ear  more  readily  than  a  normal 
tube. 

Chronic  mastoiditis  is  important  in  the  pathology  of  chronic  middle- 
ear  suppuration.  Cholesteatoma  is  one  of  the  big  factors  which  tends  to 
keep  a  case  of  middle-ear  suppuration  chronic.  A  cholesteatoma  after  it 
has  once  begun  never  ceases  growing  so  long  as  the  matrix  remains. 
Polyps  are  frequently  found  in  a  middle  ear  that  is  aifected  with  chronic 
suj^puration,  the  favourable  locations  being  in  the  attic-antrum  region 
and  high  up  on  the  promontory.  Grrauulations  may  be  found  in  any 
part  of  the  tympanum  or  its  adnexa.  In  caries  and  necrosis  the  ossicles 
are  more  freciuently  involved  (anvil  the  most  frequent),  but  no  wall  of 
the  tympanic  cavity  is  exempt  from  ulceration  and  necrosis.  The 
pathology  of  chronic  middle-ear  suppuration  has  little  to  do  with  the 
mesotympanum,  for  the  reason  that  primary  mesotympanic  conditions 
tend  toward  si»ontaneous  i-ecovery  because  of  the  favourable  drainage 
through  the  tube  or  by  way  of  the  perforation  in  the  membrane.  The 
tendency  to  chronicity  is  favoured  originally  by  the  extension  of  suppura- 
tion to  the  more  remote  recesses,  while  the  process  of  suppuration  is 
maintained  by  inadequate  drainage  and  ventilation.  /.  8.  Fraser. 

Technique  of  Examination  for  Cholesterin  Crystals.— G.  W.  Mackenzie. 
"  Journ.  Ophthal.,  Otol.  and  Laryugol.,"  July,  1917. 
G.  W.  Mackenzie  finds  that  the  presence  of  cholesterin  crystals  is 
pathognomonic  of  cholesteatoma.  They  were  found  in  all  of  127  cases 
examined.  Technique. — The  ear  should  be  cleaned  with  an  ordinary 
syringe,  or,  better,  with  a  Hartman  canula,  directing  the  stream  of  water 
into  the  attic  and  antrum  region  and  collecting  the  washings  in  a  black 
basin.  The  particles  are  then  put  on  a  clean  glass  slide  and  covered 
with  an  ordinary  cover-glass  and  pressed  down  gently.  No  addition  of 
water  is  necessary,  as  there  is  usually  sufficient  water  clinging  to  the 
mass  examined.  No  staining  is  necessary.  Using  a  i  or  ~  objective 
the  specimen  is  examined  under  the  microscope.  The  secretion  in  chronic 
cases  usually  shows  leucocytes,  large  epithelial  cells,  motile  cocci  and 
bacilli,  and  where  cholesteatoma  is  present  in  the  ear  spaces  cholesterin 
■crystals.  These  are  flat  and  rhomboidal  in  shape,  occasionally  with 
corners  broken  off.  They  are  usually  found  in  clusters,  rarely  singly. 
They  are  colourless,  but  in  large  groups  may  present  a  very  light  lemon 
tint.  J.  S.  Fraser. 

Oas   Bacillus   Infection  of  the   Mastoid.— W.  W.  Carter.      "  Medical 
Eecord,"  July  21,  1917. 

The  interesting  features  of  this  case  are — (1)  The  rarity  of  gas 
bacillus  infections  of  the  mastoid.  (2)  The  unusual  route  through  which 
the  infection  gained  an  entrance — namely,  through  the  middle  ear.  The 
usual  mode  of  entrance  of  this  bacillus  into  the  body  is  through  an  open 
wound  or  abrasion  into  which  earth  has  been  ground.  (3)  The  prompt 
recovery  following  operation — an  unusual  sequel  to  gas  bacillus  infections, 
which  usually  succumb  very  quickly.  /.  S.  Fraser. 


VOL.  XXXY.     No.  10.  October,  1920. 

THE 

JOURNAL    OF    LARYNGOLOGY, 

RHINOLOGY,   AND   OTOI.OGY. 


Original  Articles  are  accepted  on  the  co7idition  tliat  they  have  not  previously  been 
published  elseivhere. 

1/  reprints  are  required  it  is  requested  that  this  be  stated  when  the  article  is  first 
forwarded  to  tins  Journal.     Such  repri7its  will  be  charged  to  the  author. 

Editorial  Communications  are  to  be  addressed  to  "Editor  of  Jouknal  of 
LARYNGOLoaT,  Care  of  Messrs.  Adlard  4*  Son  ^  West  Neimnan,  Limited,  Bartholomew 
Close,  E.C.  1." 


A  METHOD  OF  LATERAL  PHARYNGOTOMY  FOR  THE 
EXPOSURE  OF  LARGE  GROWTHS  IN  THE  EPI- 
LARYNGEAL     REGION. 

By  Wilfred  Trotter. 

The  operative  treatment  of  malignant  disease  of  the  pharynx,  although 
admittedly  difficult  and  far  from  having  attained  a  complete  technical 
evolution,  must  be  recognised  as  already  constituting  a  valuable  branch 
of  surgery  and  as  already  yielding  under  favourable  circumstances 
satisfactory  results.  Such  success  as  has  yet  been  attained  seems 
to  depend  on  the  recognition  of  certain  guiding  principles,  both  general 
and  technical.  Among  such  principles  we  may  mention,  first,  the  need 
for  attentive  study  of  the  different  clinical  types  in  which  malignant 
disease  occurs  in  the  pharynx,  for  it  is  only  familiarity  with  all  forms 
and  situations  of  the  disease  that  can  lead  to  early  and  confident 
diagnosis  and  the  selection  of  suitable  cases  for  operation.  A  second 
important  general  principle  is  the  supersession  of  the  formal  anatomical 
operation  by  an  operation  designed  for  the  removal  of  the  tumour 
in  the  given  case  and  directed  by  its  pathological  peculiarities. 

In  order  that  the  tumour  shall  be  removed  in  a  way  that  gives  the 
best  chance  of  cure,  it  is  necessary  that  it  should  be  freely  exposed 
before  the  removal  is  begun.  Since  practically  all  the  tumours  in 
question  are  epitheliomata  adequate  exposure  means  exposure  of  the 
mucous  surface  from  which  the  tumour  is  growing.  It  has  been  a 
defect  of  much  operative  work  that  the  exposure  and  the  removal  of  the 
tumour  have  not  been  designed  as  distinct  procedures  comparatively 
independent  of  one  another.  A  satisfactory  operation  on  the  other 
hand  will  consist  of  two  comparatively  separate  steps — first  the  exposure 
of  the  pharyngeal  cavity,  and  secondly  the  removal  of  the  tumour. 
Now  the  first  of  these  step  constitutes  a  series  of  definite  formal 
anatomical  procedures,  and  it  is  with  such  that  we  are  concerned  in 

19 


290 


The  Journal  of  Laryngology,         October,  1920. 


this  paper.  Some  definite  method  of  opening  the  pharynx  will  be 
appropriate  to  every  tumour  met  with  and  can  be  applied  as  a  matter  of 
course. 

Experience  has  convinced  me  that  the  best  method  of  opening  the 
pharynx  to  obtain  access  to  growths  and  permit  of  their  removal  is 
through  the  lateral  wall.  The  decisive  advantage  of  this  route  is  that 
it  has  no  natural  limits  above  and  below,  so  that  the  whole  length  of  the 
tube  and  even  of  the  cervical  oesophagus  as  well  can  be  laid  open 
by  mere  extensions  of  the  technique,  and  without  essential  alteration  of 
plan. 


Fig.  ]. — Incisions. 


Generally  speaking  a  limited  exposure  in  the  longitudinal  direction 
is  adequate,  and  it  is  convenient  to  recognise  an  upper  and  a  lower 
lateral  pharyngotomy. 

Superior  lateral  pharyngotomy  consists  essentially  in  dividing  the 
mandible  immediately  in  front  of  the  masseter  and  then  incising 
the  superior  constrictor  in  front  of  the  tonsil. 

Inferior  lateral  pharyngotomy  consists  in  removing  the  great  corun 
of  the  hyoid  and  the  ala  of  the  thyroid  cartilage  after  reflecting  the 
middle  and  inferior  constrictors  from  these.  Thus  the  aponeurosis  of 
the  pharynx  is  freely  exposed. 

The  superior  operation  gives  access  to  tumours  of  the  tonsil,  the 


Octo"ber,  1920/ 


Rhinology,  and  Otology. 


291 


anterior  faucial  pillar  and  the  pharyngeal  part  of  the  tongue.  The 
inferior  operation  gives  access  to  the  ary-epiglottic  fold,  the  arytaenoid 
cartilage,  the  pyriform  sinus,  the  post-cricoid  region,  and,  with  simple 
extension  downwards,  the  cervical  oesophagus. 

There  is,  however,  a  region  intermediate  between  the  territories 
of  these  two  operations  to  which  neither  gives  completely  adequate  access. 
This  is  the  region  of  the  epiglottis,  a  common  situation  for  tumours 
which  demand  the  very  freest  access  for  proper  removal.  Again,  very 
large  growths  involving  the  whole  upper  laryngeal  opening  are  very 
common.     Now  such  large  tumours  anywhere  else  in  the  pharynx  would 


Fig.  2. — Flaps  reflected. 

quite  rightly  be  regarded  as  inoperable,  but  these  epilaryngeal  growths 
as  I  have  called  them  are  so  benign  relatively  that  an  attempt  to  remove 
even  the  very  large  ones  is  frequently  justifiable. 

To  deal  then  with  the  region  of  the  epiglottis  and  with  large  tumours  of 
the  upper  laryngeal  opening  some  fuller  access  than  that  of  the  upper 
or  lower  lateral  pharyngotomy  is  necessaiy.  This  exceptionally  free 
access  I  have  satisfactorily  obtained  in  a  number  of  cases  by  com- 
bining the  upper  and  lower  operations. 


The  Operation  of  Combined  Lateral  Pharyngotomy. 

(1)  Preliminarij   Tracheotomy .—li  the  isthmus  of  the  thyroid  body 
is  met  with,  it  should  not  be  displaced  but  a  piece  of  it  should  be  cut 


292 


The  Journal  of  Laryngology,        [October,  1920. 


out.     The  trachea  should  be  opened  not  by  a  longitudinal  incision  but 
by  the  removal  of  a  small  disc  (J  in.  in  diameter)  from  the  anterior  wall. 

(2)  Incisions. — (a)  Along  the  sterno-mastoid  near  its  anterior  edge 
from  the  lobule  of  the  ear  to  the  cricoid. 

(b)  Vertically  through  the  middle  line  of  the  lower  lip,  over  the  chin 
and  then  along  just  below  the  lower  border  of  the  jaw  to  join  the  first 
incision.  The  incisions  in  the  neck  should  be  made  and  the  neck  dis- 
section carried  down  to  the  pharyngeal  wall  before  the  lip  is  divided. 

(3)  The  JSIeck  Dissection. — The  edge  of  the  sterno-mastoid  is  defined 
and  the  muscle  retracted.  A  limited  gland  dissection  is  now  done  in  the 
parts  exposed,  including  the  submaxillary  triangle,  anterior  triangle  and 


Fig.  3. — Steruo-mastoid  sutured  across  vessels.     Jaw  and  digastric  divided. 


the  region  beneath  the  sterno-mastoid.  In  this  dissection  the  follow- 
ing structures  passing  to  the  pharynx  are  divided,  namely  : 

(«)  Muscles  :  Posterior  belly  of  digastric  ;  stylo-hyoid. 

{b)  Vessels  :  Common  facial  vein  ;  anterior  branches  of  external 
carotid  at  their  origins  (superior  thyroid,  lingual,  facial). 

(c)  Nerves:  Superior  laryngeal,  hypoglossal,  lingual.  A  stitch 
should  be  passed  through  each  end  of  the  divided  hypoglossal  to 
facilitate  suture  at  a  later  stage. 

When  all  these  structures  have  been  divided  it  will  be  found  that 
the  larynx  and  phai'ynx  can  readily  be  displaced  forwards  and  the 
carotid  vessels  equally  readily  displaced  backwards.     This  allows  the 


t)ctoi)er,  1920.]  Rhinology,  and  Otology. 


293 


sterno-mastoid  to  be  folded  inwards  over  the  great  vessels  and  stitched 
to  the  prevertebral  muscles.  Thus  the  carotid  region  is  cut  off  from 
the  area  of  the  operation — an  extremely  valuable  precaution  against 
spreading  infection  and  secondary  hemorrhage. 

(4)  Exposure  of  the  Pliarpigeal  Wall. — The  infra-hyoid  muscles  are 
detached  from  the  hyoid  and  thyroid  body  and  turned  backwards.  If 
the  upper  pole  of  the  thyroid  body  is  at  all  prominent  it  is  removed. 
The  middle  and  inferior  constrictors  are  detached  from  the  hyoid 
and  thyroid  and  turned  back.  The  great  cornu  and  thyroid  ala  are 
separated  from  the  underlying  pharynx  and  removed,  the  former  being 
separated  at  its  joint  with  the  body,  the  latter  being  divided  about  \  in. 


Fig.  4. —  Lateral  wall  of  phaiynx  fully  exposed. 

from  the  middle  line  after  the  crico-thyroid  joint  has  been  opened.  The 
pharyngeal  wall  has  now  been  freely  laid  bare  but  it  is  still  intact. 
Through  it  the  tumour  can  be  readily  felt  and  its  size  and  distribution 
roughly  ascertained. 

(5)  Division  of  the  Mandible. — The  incision  through  the  middle  of 
the  lower  lip  is  now  made  and  the  flap  thus  outlined  is  turned  back- 
wards off  the  bone  as  far  as  the  masseter  muscle.  During  this  pro- 
cedure the  mucous  membrane  is  divided  well  away  from  the  jaw  so  as 
to  leave  a  fringe  attached  to  the  bone  to  facilitate  suturing  the  flap  back 
in  position.  The  jaw  is  drilled  for  wiring  and  then  is  sawn  through 
just  in  front  of  the  masseter.     The  fragments  are  drawn  apart,  and  as 


294 


The  Journal  of  Laryngology,        [October,  1920. 


they  are  gradually  separated  the  lingual  nerve,  the  styloglossus  muscle 
and  the  lingual  part  of  the  superior  constrictor  are  divided.  The  flap  in 
the  bone  is  held  open  with  an  automatic  retractor  and  the  whole  lateral 
wall  of  the  pharynx  is  incised  throughout  its  length,  care  being  taken 
to  avoid  an}^  lateral  extension  of  the  tumour.  Complete  exposure  of 
the  largest  growths  of  the  epilaryngeal  region  is  thus  attained. 

This  completes  the  formal  anatomical  stage  of  the  operation,  and 
before  going  on  to  make  any  remarks  upon  the  actual  attack  on  the 
tumour  itself  it  may  be  well  to  add  a  few  comments  on  the  operation  of 
exposure  in  itself.  It  may  seem  that  this  is  a  very  drastic  measure  to 
undertake  merely  to  obtain  access  to  a  growth  that  may  after  all  prove 


Fig.  5. — lucision  in  pharynx.    , 

to  be  inoperable.  As  a  matter  of  experience,  however,  its  severity'  as 
judged  by  post-operative  shock  is  by  no  means  great.  Moi'eover,  if  it 
is  decided  after  all  not  to  attempt  to  deal  with  the  tumour  itself  the 
pharynx  can  be  closed  again  without  difficulty.  In  this  connection  also 
I  would  remark  emphatically  that  no  absolute  certainty  as  to  the  oper- 
ability  of  a  given  case  can  be  reached  without  full  exposure  of  the 
growth.  Although,  its  is  well  known,  the  disease  usually  proves  to  be 
more  extensive  than  had  been  expected,  there  is  an  encouraging  number 
of  cases  of  epipharyngeal  growths  in  which,  while  the  clinical  appear- 
ances are  most  formidable,  a  curative  operation  quite  unexpectedly  is 
found  to  be  feasible. 


October,  1920.]  Rhinolog'/,  and  Otology.  295 

The  ilivision  of  the  jaw  is  often  regarded  as  a  serious  addition  to  the 
severity  of  these  and  similar  operations  on  account  of  the  frequency  of 
troublesome  necrosis  of  the  bone.  Necrosis  undoubtedly  occurs  quite 
commonly  if  any  teeth  are  present,  but  it  is  my  experience  that  if  the 
patient  has  been  rendered  edentulous  and  the  gums  are  soundly  healed 
before  the  operation  necrosis  never  occurs.  It  may  be  added  that  for 
other  reasons  it  is  quite  unjustifiable  to  undertake  any  grave  operation 
on  the  pharynx  without  a  preliminary  clearance  of  the  mouth. 

(6)  The  ^Removal  of  the  Tumour.— It  is  no  part  of  my  intention  in 
this  paper  to  deal  in  any  detail  with  the  actual  removal  of  these  large 
epilarj'ngeal  tumours.  I  shall  therefore  limit  myself  to  laying  down 
certain  principles  which  I  regard  as  fundamental  in  dealing  with  them. 

If  it  is  decided  in  a  given  case  after  careful  examination  that  the 
tumour  is  removable,  it  should  be  excised  with  an  adequate  margin 
everywhere  surrounding  it  and  regardless  of  what  structures  have  to  be 
removed  with  it.  Such  an  excision  in  the  cases  we  are  concerned  with 
usually  includes  the  whole  or  the  greater  part  of  the  upper  opening  with 
the  epiglottis  but  does  not  commonly  encroach  on  the  larynx  as  far  as 
the  vocal  cords — frequently  at  any  rate  one  cord  is  left  intact ;  it 
includes  usually  large  segments  of  the  pharynx  and  quite  commonly  the 
whole  circumference  of  it  in  the  tubular  (post-cricoid)  part.  There  is 
thus  produced  a  huge  defect  in  a  part  functionally  very  complex  and 
the  surgeon  is  faced  by  the  necessity  of  providing  for  the  restoration  of 
the  three  functions  of  respiration,  speech,  and  deglutition.  Complex  and 
difficult  plastic  procedures  have  therefore  to  be  devised.  Where  the 
tumour  has  been  large  and  the  defect  correspondingly  great,  restoration 
may  have  to  be  undertaken  in  several  stages. 

Of  the  three  functions  that  have  to  be  considered,  respiration  is  the 
least  exacting  in  that  a  permanent  tracheotomy,  if  the  voice  is  i^rescrved, 
is  not  a  very  serious  disability.  The  preservation  of  the  continuity  of 
the  air  passage  with  the  pharynx  is  most  important  since  it  secures  the 
retention  of  the  voice.  Generally  it  is  not  difficult  to  provide  a  small 
upper  laryngeal  opening  under  the  overhanging  posterior  part  of  the 
tongue.  Such  an  opening  will  be  safe  from  the  intrusion  of  food  during 
swallowing,  and,  though  often  too  restricted  for  free  respiration,  will  be 
quite  adequate  for  speech. 

With  regard  to  deglutition,  the  restoration  of  the  lumen  of  the 
pharynx  by  skin-flaps  is  now  a  comparatively  familiar  matter,  and  it  is 
a  weil-estabHshed  fact  that  a  segment  of  the  whole  circumference  of  the 
pharynx  may  be  reconstituted  out  of  skin  and  is  perfectly  compatible 
with  satisfactory  deglutition. 


296  The  Journal  of  Laryngology,  October,  1920. 

THE   AQUEDUCT   OF   FALLOPIUS   AND   FACIAL   PARALYSIS. 

By  Dan  McKenzie. 

Part  II :   Facial    Paralysis. 

{Continued  from  p.  276.) 

The  Phenomena  of  Facial  Paralysis. 

(The  following  description  is  based  upon  the  excellent  account  given 
by  Sir  Purves  Stewart  in  the  fourth  edition  of  his  "  Diagnosis  of 
Nervous  Diseases,"  1916.) 

Owing  to  its  branches  coming  oft'  at  different  levels,  it  is  often 
possible  to  diagnose  the  site  of  the  lesion  in  the  nerve  by  a  carefully 
detailed  examination  of  the  paralytic  phenomena. 

(1)  We  shall  begin  with  a  description  of  the  paralysis  following  a 
lesion  of  the  trunk  distal  to  the  giving-off  of  the  chorda  tympani  and 
the  stapedius  nerve — that  is  to  say,  between  the  upper  part  of  the  vertical 
segment  of  the  Fallopian  canal  and  the  pes  anserinus  in  the  face. 

The  common  lesions  here  are  mastoid  suppuration,  injuries  by  direct 
trauma  such  as  bullet-wounds,  the  pressure  of  epidermal  masses  in  the 
meatus.  Outside  of  the  bony  canal  the  nerve  may  be  paralysed  by 
tumours,  by  cutting  wounds,  and  by  forceps  pressure'at  birth. 

The  symptoms  consist  in  complete  loss  of  voluntary  movement  in  the 
corresponding  side  of  the  face.  At  rest,  the  paralysis  is  less  noticeable 
than  during  attempts  at  movement,  and  in  children  and  young  people  it 
may  not  be  observed  at  all  until  the  patient  is  seen  to  wink  the  eyes  or 
to  smile  or  cry.  In  older  people,  however,  in  whom  expression  has  dug 
its  furrows,  the  asymmetry  between  paralysed  and  healthy  side  will  be 
perceived  even  when  the  "face  is  at  rest,  in  the  flattening  "of  the  cheek 
and  the  smoothing  out  of  furrows  in  the  brow. 

When  the  occipito-frontalis,  contracting  under  the  influence  of 
surprise  throws  the  skin  of  the  forehead  into  wrinkles,  one  side  is  fixed 
while  the  other  responds.  In  frowning,  the  vertical  furrow  between 
the  eyebrows  is  formed  on  the  sound  side  only.  Owing  to  the  absence 
of  tonus  in  the  paralysed  orbicularis  palpebrarum  the  palpebral  fissure 
is  wider  than  on  the  active  side  and  the  weight  of  the  unbraced  lower 
eyelid  drags  it  away  from  the  eyeball,  so  that  the  red  palpebral  conjunc- 
tiva is  visible,  and,  the  puncta  lacrymalis  being  withdrawn  from  contact 
with  the  eye,  tears  are  constantly  trickling  down  the  cheeks  and  may 
excoriate  the  skin  over  it.  The  patient  cannot  close  the  eye.  When 
asked  to  shut  his  eyes  the  sound  lids  meet  and  close  normally,  but  those 
on  the  paralysed  side  remain  motionless,  although  the  eyeball  itself 
turns  upwards  and  outwards,  or  upwards  and  inwards  under  the  upper 
lid. 

(Ptosis  is  not,  of  course,  a  phenomena  of  facial  paralysis,  as  it  is  due 
to  paralysis  of  the  levator  palpebrae  superior! s,  which  is  innervated  by 
the  third,  the  oculo-motor  nerve.) 

Two  special  ocular  phenomena  are  to  be  noticed.  One  is  the  levator 
sign,  and  is  elicited  as  follows  :  The  patient  looks  down  and  tries  to  shut 
both  eyes  slowly  ;  as  he  does  so  the  upper  lid  on  the  paralysed  side 
moves  up  a  little,  "  owing  to  contraction  of  the  levator  palpebras,  which 


October,  1920.]  Rhinology,  and  Otology.  297 

normally  acts  synergically  with  the  orbicularis,  but  is  now  no  longer 
antagonised  by  it." 

Another  sign  is  the  "  hyperkinetic  sign  "  of  Negro.  The  patient 
looks  upward  to  the  full  extent,  and  while  he  does  so  the  globe  of  the 
paralysed  side  will  deviate  outwards  and  then  come  to  lie  at  a  level 
higher  than  the  normal  eyeball,  "  probably  owing  to  over-innervation  of 
the  superior  rectus  muscle"  (Purves  Stewart). 

There  is  a  third  sign  we  may  mention  known  as  Eevillod's  "  orbicular 
sign."  At  a  certain  stage  of  paresis,  not  complete  paralysis,  the  patient, 
if  able  to  close  the  eye  at  all,  can  only  do  so  if  both  sides  are  simul- 
taneously innervated. 

A  troublesome  effect  of  the  immobility  of  the  eyelids  is  produced  by 
dust  finding  its  way  into  the  conjunctival  sac,  where  its  irritation 
induces  conjunctivitis.  The  corneal  reflex  is  abolished — a  point  that 
must  be  remembered  if  the  patient  has  to  be  anaesthetised  for  any  reason. 
The  constant  conjunctival  iiTitation,  again,  causes  lacrymation  and  the 
vision  is  blurred. 

Although  the  eye  cannot  be  closed  when  the  patient  is  awake,  it 
may,  all  the  same,  close  spontaneously  when  he  falls  to  sleep  and  the 
levator  palpebral  superioris  relaxes. 

The  skin  of  the  lower  eyelid  is  often  lax  and  may  be  pouched. 

The  naso-labial  fold  is  shallower  than  on  the  sound  side,  and  the 
corresponding  ala  nasi  is  no  longer  distended  but  lies  motionless  or 
flaps  passively  in  and  out  during  deep  breathing.  The  angle  of  the 
mouth  droops  so  that  saliva  runs  out  at  the  corner.  When  the  patient 
smiles  no  movement  is  seen  in  the  paralysed  cheek  or  mouth  save  that 
the  mouth  as  a  whole  is  drawn  over  to  the  healthy  side  and  gives  the 
physiognomy  a  distorted  and  one-sided  appearance.  On  trying  to 
whistle,  the  lips  on  the  healthy  side  purse  up  to  form  the  round  orifice, 
but  the  paralysed  side  of  the  mouth  remains  slack  and  open.  The 
articulation  of  the  labials,  p,  b,  m,  is  impaired. 

Some  discrepancy  of  opinion  seems  to  exist  regarding  the  position 
of  the  tongue.  According  to  Osier,  the  tongue  when  protruded,  looks 
as  if  it  were  pushed  to  the  paralysed  side,  but  on  taking  its  position 
from  the  incisor  teeth  it  wull  be  found  to  lie  in  the  middle  line,  the 
deviation  being  apparent, merely,  and  due  to  the  drawing  of  the  lips  to 
the  sound  side.  According  to  Hitzig,  on  the  other  hand,  when  the 
patient  puts  out  his  tongue  it  deviates  to  the  sound  side. 

The  paralysis  of  the  buccinator  muscle  leads  to  the  accumulation 
of  food  during  mastication  between  the  teeth  and  the  cheek,  and  the 
mucous  membrane  of  the  cheek  or  lip  is  often  bitten.  If  the  patient 
is  made  to  blow  forcibly  fthrough  the  lips  the  paralysed  cheek  puffs 
loosely  out.     The  power  of  moving  the  auricle  is  lost. 

The  affected  side  of  the  face  sweats  less  than  the  healthy  side 
according  to  Purves  Stewart,  but  Koster  and  other  authors  have  failed 
to  satisfy  themselves  of  the  truth  of  this. 

Among  other  rarer  symptoms  may  be  mentioned  great  hyperaemia  on 
the  affected  side. 

When  the  site  of  the  interruption  in  the  nerve  lies  distal  to  the 
stapedius  branch  the  "  stapedius  hum  "  may  be  audible.  This  is  a  low, 
droning,  subjective  tinnitus  produced  on  attempting  to  close  the  eyes 
forcibly.  It  is  due  to  overflow  from  the  paralysed  nerve,  but  it  is  also 
frequently  audible  in  health.  In  paralysis,  however,  the  stapedius 
hum  may  follow  loud  noises   (Wagenhauser).      When    the    stapedius 


298  The  Journal  of  Laryngology,         [October,  1920. 

nerve  is  paralysed,  or  when  the  stapes  itself  is  immobilised  by  disease, 
the  stapedius  hum  cannot  be  produced  ;  and  on  the  other  hand,  it  may 
be  loud  in  certain  forms  of  middle-ear  disease,  such  as  exudative 
catarrh. 

(2)  A  lesion  of  the  nerve-trunk  in  the  tympanic  segment  between 
the  geniculate  angle  and  the  origin  of  the  chorda  tympani  is  produced 
by  middle-ear  disease,  by  operative  trauma,  by  fracture  of  the  base  of 
the  skull,  by  foreign  bodies  in  the  ear.  It  is,  according  to  Purves 
Stewart,  the  most  frequent  form  of  facial  paralysis. 

The  symptoms  are  as  detailed  above,  with,  in  addition,  the  signs  of 
chorda  tympani  and  of  stapedius  paralysis. 

Chorda  Tympcmi  Paralysis  is  denoted  by  loss  of  taste  in  the  anterior 
two-thirds  of  the  tongue,  together  with  a  slight  loss  of  ordinary 
sensation  at  times.  There  may  be  also  experienced  subjective  sensations 
of  taste.  The  submaxillary  and  sublingual  gland  secretion  may  either 
be  diminished  or  increased.  Deficiency  of  taste  or  saliva  may  induce 
furring  of  the  anterior  part  of  the  tongue  up  to  the  middle  line. 

Stapedius  nerve  paralysis  renders  the  ear  hypersensitive  to  loud 
sounds  (hyperacusis),  since  when  they  fall  on  the  ear  the  reflex  protec- 
tive apparatus  of  the  stapedius  levering  the  stapes  out  from  the  oval 
window  is  no  longer  in  action. 

(3)  A  lesion  of  the  motor  root  of  the  nerve  between  its  exit  from  the 
pons  and  the  geniculate  ganglion  may  be  due  to  (a)  tumours  of  the 
cerebello-pontine  angle  (fibromata,  neuromata,  sarcomata,  etc.),  to 
tuberculomata,  meningitis,  cerebellar  abscess,  or  necrosis  of  the  bony 
labyrinth. 

The  symptoms  are  the  same  as  those  already  described  under  (1)  and 
(2),  together  with  additions  due  to  the  anatomical  site  of  the  lesion. 
Thus  in  most  of  the  cases  the  auditory  nerve  is  involved,  as  we  have 
already  seen,  and  there  is  grave  nerve-deafness  and  often  vestibular 
nystagmus.  The  general  signs  of  brain  tumour  or  other  disease  will  also 
be  present. 

If  the  auditory  apparatus  is  intact,  hyperacusis  from  stapedius 
paralysis  may  be  complained  of. 

(4)  If  the  lesion  be  situated  within  the  pons  taste  and  hearing  are 
unalifected,  but  abducens  paralysis  is  often  associated  with  the  facial 
paralysis  because  of  the  proximity  of  the  facial  fibres  to  the  nucleus 
of  the  sixth  nerve. 

Haemorrhages  into  the  pons  give  rise  to  "  crossed"  paralysis,  ipso- 
lateral  facial  paralysis  and  hetero-lateral  hemiplegia. 

Paralysis  of  the  Soft  Palate. — Gowers  and  Hughlings  Jackson 
denied  that  the  soft  palate  is  paralysed  as  a  result  of  lesions  of  the 
facial  nerve,  and  Horsley  and  Beevor  showed  that  these  parts  are  inner- 
vated by  the  accessory  nerve  to  the  vagus. 

Nevertheless,  cases  have  been  and  still  are  occasionally  published, 
particularly  abroad,  in  which  paralysis  of  the  soft  palate  is  described  as 
accompanying  facial  palsy. 

Facial  Diplegia  (bilateral  facial  paralysis)  results  usually  from 
pontine  lesions  ;  from  meningitis  and  other  diseases  of  the  base  of  the 
brain  ;  from  diphtheria  ;  and  more  rarely  from  a  simultaneous  affection 
of  both  nerve-trunks  from  ear  disease.     It  is  a  rare  condition. 

The  paralysis  being  bilateral,  the  expression  becomes  mask-like  and 
the  whole  face  is  immobile. 

The  Degrees  of  Facial  Paralysis  and  their  Electrical  Phenomena. — 


October,  1920.]  Rhiiiology,  and  Otology.  299* 

The  electrical  reactions  of  paralysis  clue  to  peripheral  lesions  vary  with 
the  severity  of  the  lesion,  and  thus  the  prognosis  may,  to  some  extent, 
be  estimated  from  those  reactions,  provided,  of  course,  that  the  lesion  is 
not  of  a  progressive  character. 

The  following  degrees  of  the  paralysis  based  upon  the  electric 
responses  were  first  defined  by  Erb  and  are  those  generally  followed. 

If  there  is  no  change,  either  faradic  or  galvanic,  the  prognosis  is  good, 
and,  the  lesion  having  been  repaired,  recovery  may  be  expected  in  from 
fourteen  to  twenty  days.  If  the  faradic  and  galvanic  excitability 
of  the  nerve  is  only  lessened,  that  of  the  muscle  to  the  galvanic  current 
being  increased  and  the  contraction  formula  being  altered  (the  contrac- 
tion sluggish — An  C.  >  C.C.)  the  chances  are  relatively  good,  and 
recovery  will  probably  take  place  in  from  four  to  ten  weeks.  When  the- 
reaction  of  degeneration  is  present,  that  is  to  sa}',  if  the  faradic  and 
galvanic  excitability  of  the  nerve  and  the  faradic  excitability  of  the 
muscles  are  lost,  and  "  the  galvanic  excitability  of  the  muscles  is  quanti- 
tatively increased  and  qualitatively  changed  and  if  the  mechanical 
excitability  is  altered,  the  prognosis  is  relatively  unfavourable,  and  the 
recovery  mav  not  occur  for  two,  six,  eight,  or  even  fifteen  months  " 
(Osier). 

There  is,  perhaps,  no  need  to  re-state  the  fact  that  the  nature  of  the 
lesion  causing  the  paralysis  is  a  much  more  weighty  factor  in  forming  a 
prognosis  than  the  electrical  reactions  can  be.  In  the  absence  of  precise 
knowledge  as  to  the  lesion,  however,  the  electrical  reactions  may  be  of 
some  help  in  enabling  us  to  conjecture  the  degree  of  severity  of  the 
lesion. 

Facial  Contracture. — As  in  other  forms  of  paralysis,  so  in  facial 
paralysis  a  spastic  or  contractured  condition  of  the  muscles  is  apt  to. 
supervene  when  the  paralysis  has  been  severe  and  if  recovery  is  tardy. 
It  is  often  as  the  voluntary  power  is  returning  that  the  phenomenon 
appears. 

The  mouth  when  at  rest  appears  drawn  back  and  the  palpebral 
fissure  is  narrower  than  on  the  healthy  side,  while  the  lines  of  expression 
appear  to  be  deeper.  Thus  while  the  face  is  at  rest  it  is  the  healthy  side- 
that  seems  to  be  fiat.  But  when  the  face  becomes  animated  the  balance- 
is  more  than  restored,  what  had  appeared  to  be  the  more  mobile  side 
now  showing  its  pai'alysis  or  feebleness. 

During  this  period  there  is  a  tendency  during  voluntary  or  emotional 
movement  for  the  muscles  to  manifest  exaggerated  contraction  amount- 
ing to  hemi-spasm  of  the  face.  When,  for  example,  the  eye  is  closed, 
then  the  mouth  also  is  drawn  outward,  and  on  showing  the  upper  teeth 
the  eye  closes.  At  this  stage  fibrillary  tremor  may  be  observed  in  the 
muscles,  and  tapping  the  forehead  over  the  supra-orbital  nerve  will  bring 
about  a  reflex  contraction  of  the  muscles. 

Secondary  contracture  is  only  seen  when  the  recovery  is  incomplete. 
Totally  paralysed  muscles  are  quite  flaccid  (Purves  Stewart). 

Facial  Paresis. — General  facial  paresis  or  enfeeblement  of  the 
muscular  movement  is  seen  in  lesions  of  the  cerebral  cortex  involving 
the  facial  area,  and  in  such  diseases  as  meningitis  and  cerebellar  abscess 
where  the  conductivity  of  the  nerve  is  impaired.  It  is  very  familiar  also 
to  the  operating  otologist,  as  it  not  infrequently  follows  minor  operative 
trauma  of  the  nerve-trunk. 

In  the  mildest  varieties  it  is  apt  to  escape  notice  altogether,  as  its 
only  manifestation  is  a  slight  delay  or  lagging  on  the  part  of  the  eyelid 


300  The  Journal  of  Laryngology,        [October,  1920. 

•of  the  affected  side  as  compared  with  the  other  in  the  ordinary  involun- 
tary periodical  winking  of  the  eyes.  The  appearance  is  slight  and  may 
last  a  few  days  only,  but  it  is  unmistakable. 

Them  there  are  the  more  obvious  types  in  which  the  paresis  slowly 
spread-s  from  the  eyelids  to  the  rest  of  the  face  and  in  from  two  to  four 
"weeks  slowly  disappears. 

It  is  worthy  of  note  that  a  trauma,  such  as  curetting  the  nerve-trunk, 
may,  like  a  bruise  from  a  probe,  produce  either  paresis  of  part  or  of  the 
whole  face,  or  paralysis  of  the  whole  face.  What  one  does  not  see, 
however,  is  a  paralysis  limited  to  one  region  of  the  face,  the  rest 
escaping  entirely.  The  reason  for  this  no  doubt  is  to  be  found 
in  the  tenuity  of  the  facial  thread.  Traumata  may  doubtless  at 
•times  sever  part  of  it  and  leave  part  of  it,  but  the  injury  must  affect 
the  whole  nerve  more  or  less. 

There  is  one  symptom  of  facial  paralysis  and  of  the  more  severe 
-types  of  paresis  which  always  attracts  the  patient's  attention  and  is  a 
useful  aid  when  we  are  trying  to  date  the  onset  of  the  paralysis,  and  that 
is  that  the  soap  gets  into  the  eye  of  the  affected  side  when  the  patient 
is  washing  his  face. 

Another  sign  of  paresis,  mentioned  by  Hughlings  Jackson,  is  that  if 
the  patient  closes  his  eyelids  firmly  it  is  impossible  for  the  observer 
with  his  fingers  to  force  the  normal  eyelids  apart,  whereas  those  which 
are  paretic  can  be  opened. 

Dui'ing  operations  on  the  ear  the  surgeon  frequently  apprehends  the 
appearance  of  post-operative  paralysis  because  some  of  his  manipulations 
irritating  an  exposed  facial  nerve  have  evoked  twitches  in  the  face,  and 
frequently  his  fears  will  be  realised.  But  not  always.  Quite  often  a  twitch, 
■or  indeed  for  that  matter  several  twitches,  may  be  produced  without  any 
paralysis  or  even  paresis  afterwards.  On  the  other  hand,  the  paresis 
or  paralysis  may  appear  without  any  warning  having  been  given  and 
without  any  indication  that  the  nerve  is  exposed.  In  such  cases  I  have 
suggested  that  the  paralysis  may  be  due  to  concussion  or  to 
haemorrhage  into  the  narrow  aqueduct,  and  I  have  remarked  that  it 
readily  follows  an  operation  in  which  blunt  chisels  necessitate  relatively 
heavy  blows  with  the  mallet. 

Diagnosis  in  Facial  Paralysis. — The  diagnosis  of  facial  paralysis  as 
such  should  present  no  difficulty.  But  it  is  less  easy  to  determine  the 
■cause.  Attention  to  the  points  we  have  detailed  under  the  different 
varieties  will,  however,  clear  up  many  of  tlie  cases.  When  the  cause 
remains  unknown  it  should  not  be  assumed  to  be  "  cold "  or 
"  rheumatism." 

rivgnosis. — Facial  paresis  which  does  not  proceed  to  complete 
paralysis  in  a  week  will  probably  remain  paresis  unless  the  cause  is  some 
intra-cranial  lesion  such  as  a  cerel)ello-pontine  tumour  or  a  cerebellar 
abscess,  in  which  the  progress  of  events  may  be  very  slow. 

Generally  speaking,  slight  facial  paresis  passes  entirely  away  in  from 
one  to  two  weeks,  but  the  more  severe  cases  may  last  for  as  long  as 
eight  weeks  before  recovery  begins,  and  sometimes  paresis  may  be 
permanent.  As  we  have  already  seen,  complete  facial  paralysis  may 
undergo  improvement  only  up  to  a  point  and  there  may  remain  a  degree 
■of  paresis  persisting  for  the  rest  of  life. 

The  prognosis  in  general  naturally  depends  upon  the  cause  and  upon 


October,  1920.]  Rhinology,  and  Otology.  oOl 

our  abilit}'  or  inability  to  remove  it.  Once  the  cause  has  been  removed 
recovery  may  be  looked  for  even,  apparently,  in  severe  and  protracted 
cases,  and  this  applies  particularly  to  suppurative  and  traumatic  cases. 

But  while  it  is  true  that  suppurative  and  traumatic  paralysis,  the 
cause  being  removed,  is  generally  recovered  from,  it  is  also  true  that 
the  recovery  is  not  seldom  incomplete,  the  affected  side  never  regaining 
entirely  its  power  of  movement,  whether  voluntary  or  emotional.  Of 
the  affected  muscular  groups  the  orbicularis  palpebrarum  seems  to  be  the 
most  ready  to  recover  completely,  although,  as  we  saw,  it  is  not  always 
the  first  to  show  signs  of  recovering.  After  it  come  the  muscles  of  the  ala 
nasi  and  the  mouth.  In  my  experience  the  frontalis  and  the  corrugator 
supercilii  are  the  most  tardy  and  not  uncommonly  remain  immobile. 

Even  a  partial  recovery,  however,  such  as  that  we  are  discussing,  is 
nevertheless  quite  sufficient  to  relieve  the  patient  of  his  ever-present 
sense  of  deformit\',  as  paresis  is  only  perceptible  when  the  patient's 
face  is  animated  with  lively  emotion. 

I  have  elsewhere  suggested  that  the  reason  for  recover}''  after 
operation  trauma,  even  when  there  has  been  complete  section  of  the 
nerve,  may  lie  in  the  fact  that  the  facial  nerve,  passing  as  it  does 
through  a  fine  canal  in  the  bone,  may  be  divided  without  the  ends  of 
the  nerve  being  widely  separated  from  each  other,  and  as  the  inter- 
vening gutter  or  canal  of  bone  may  serve  as  a  bridge  or  guide  to  the 
sprouting  nerve-fibres,  their  ultimate  union  is  probable. 

On  the  other  hand,  the  failure  of  complete  recovery  may  also  be 
ascribed  to  the  narrowness  of  the  tunnel  in  which  the  nerve  lies.  If 
the  trunk  has  been  severed  the  granulation-  and  scar-tissue  which  forms 
at  the  site  of  the  wound  will  to  some  extent  block  the  passage,  so  that 
while  some  of  the  sprouting  fibres  will  succeed  in  regaining  functional 
contact  with  the  distal  segment  of  the  cut  nerve,  others  will  be  unable 
to  traverse  the  obstacle  presented  by  the  granulation-  and  scar-tissue, 
and  so  the  restoration  of  facial  movement  will  only  be  partial. 

There  are  one  or  two  facts,  or  apparent  facts,  in  connection  with  the 
recovery  which  are  difficult  to  account  for.  One  is  the  readiness  with 
which  the  power  of  closing  the  eye  is  regained.  This  particular  move- 
ment, to  be  sure,  is  an  important  reflex,  involuntary  in  character,  and 
therefore  the  fact  of  its  ready  recovery  is  quite  on  a  par  wnth  the  facile 
restoration  of  similar  reflexes  elsewhere.  But  even  so,  it  is  difficult  to 
imagine  that  the  fibres  which  bridge  the  gap  in  the  cut  nerve  should  so 
often  be  those  supplying  one  particular  muscle-group. 

Again,  we  have  the  restoration  after  what  looks  like  the  loss  actually 
of  a  length  of  the  nerve,  or,  indeed,  the  failure  of  any  paralytic 
appearance  of  any  kind  under  such  circumstances.  This  is  mysterious 
indeed,  and  one  would  like  to  have  further  confirmation  of  an  event 
which,  if  substantiated,  would  necessitate  a  revisal  of  our  ideas  on  the 
innervation  of  the  facial  muscles.  I  beg  to  direct  attention  to  the  need 
of  clearing  up  this  point. 

The  place  of  the  electrical  reactions  in  prognosis  we  have  already 
discussed,  and  we  proceed  now  to  indicate  the  value  of  treatment  and, 
inferentially,  its  influence  upon  prognosis. 

Treatment  of  Facial  Paralysis. 

In  addition  to  removing  the  cause  of  the  paralysis  when  that  can  be 
accomplished   and   also  when    it  cannot,    the   nutrition   of   the   facial 


302  The  Journal  of  Laryngology,         :october,  1920. 

muscles  must  be  sustained  by  electrical  stimulation,  that  form  of  current 
beinc  employed  to  "SYhich  the  muscles  respond  most  readily.  A  seance 
of  ten  minutes  twice  a  week  is  sufficient  for  this  purpose. 

Nerve  Anastomosis. 

This  method  of  coping  with  irremediable  facial  paralysis  has  been 
practised — one  can  scarcely  speak  of  it  as  having  been  in  vogue — for 
over  twenty  years,  but  there  seems  to  be  considerable  hesitation  among 
surgeons  and  otologists  to  adopt  it  generally.  The  reason  seems  to  be 
that  while  the  operation  as  such  is  successful  enough,  its  results  have 
not  been  so  satisfactory  as  to  lead  to  its  general  adoption.  The  difficulty 
lies  in  the  fact  that  after  operation,  although  the  tonus  of  the  facial 
muscles  is  recovered  and  the  face  can  be  moved  voluntarily,  that  move- 
ment is  usually  associated  with  movement  also  of  the  muscles  supplied 
by  the  nerve  into  which  the  facial  has  been  implanted.  Further,  while 
voluntary  movement  may  be  restored,  emotional  movement — the  play 
of  facial  expression — is  apparently  not  regained. 

Facial  anastomosis  was  first  performed  by  Faure  of  the  Hopital 
Laennec  in  1898,  acting  on  a  suggestion  of  Furet,  the  spinal  accessory 
being  the  nerve  selected.  The  operation  was  introduced  into  Britain  by 
Kennedy,  and  later  Ballance  proposed  and  carried  out  anastomosis  with 
the  hypoglossal  in  place  of  the  spinal  accessory. 

Whichever  nerve  is  selected  the  distal  end  of  the  severed  facial  trunk 
is  implanted  wnthin  the  sheath  of  the  other.  And  after  healing  it  has 
been  found  that  when  the  patient  moves  his  shoulder  in  the  case  of  the 
spinal  accessory,  or  his  tongue  in  the  case  of  the  hypoglossal,  at  the 
same  moment  the  face  is  twitched,  and  we  read  of  patients  who  are 
unable  to  hold  up  an  umbrella  or  to  work  a  sewing-machine  without  at 
the  same  time  producing  a  succession  of  grimaces.  On  the  other  hand, 
when  the  patient  wishes  to  smile  that  can  only  be  effected  if  at  the  same 
moment  he  shrugs  his  shoulders. 

One  advantage  of  selecting  the  hypoglossal  is  that  the  associated 
movement  of  the  tongue^  taking  place  as  it  does  inside  the  mouth,  does 
not  attract  so  much  attention.  Another  suggestion  favouring  the 
selection  of  the  hypoglossal  is  that,  as  we  have  already  seen,  the  cortical 
centre  for  the  muscles  of  the  tongue  lies  nearer  to  the  centre  for  the 
face  than  it  does  to  the  centre  for  the  shoulder,  and  so  it  was  hoped  the 
education  of  dissociated  movement  would  probably  be  easier. 

We  must  not,  however,  omit  to  mention  that  some  cases  have  been 
reported  in  w^hich  a  certain  amount  of  dissociated  movement  was 
restored.  Kennedy  of  Glasgow  has  recorded  one,  for  example.  In  his 
case,  which  was  operated  on  for  the  cure,  not  of  paralj'sis,  but  of  facial 
spasm,  facial-spinal  accessory  anastomosis  having  been  performed,  the 
patient  in  course  of  time  was  able  to  close  both  eyes  without  any  move- 
ment of  the  shoulder.  Sir  Charles  Ballance,  also,  has  reported  a  case. 
But  these  seem  to  be  exceptional. 

Perhaps  the  chief  advantage  obtained  from  the  operation  is  the 
restoration  of  facial  tonus,  in  consequence  of  which  the  flat  expression- 
less look  of  the  affected  side  is  rendered  less  noticeable. 

The  indications  for  the  operation  would  thus  seem  not  to  be  quite 
clearly  defined,  nor  is  the  best  time  for  intervention  quite  easy  to 
determine.  On  the  one  hand,  if  it  is  postponed  until  all  muscular  con- 
tractility has  entirely  disappeared,  it  may  be  undertaken  after  all  power 


October.  isi2o.]  Rhiiiology,  and  Otology.  303 

of  muscular  regeneration  has  passed  away.  As  a  matter  of  fact,  the 
date  at  which  this  happens  does  not  seem  to  be  known.  At  all  events, 
Ballance  found  in  one  of  the  cases  operated  on  by  him  that  it  was 
possible  to  evoke  muscular  contraction  by  the  electric  current  passed 
through  the  nerve-trunk  some  time  after  the  power  to  do  so  through 
the  unbroken  skin  had  been  lost,  and  the  same  author  reports  recovery 
of  muscular  movement  after  anastomosis  in  a  case  which  had  been 
paralysed  for  three  years. 

In  weighing  the  pros  and  cons  the  character  of  the  paralysing  lesion 
would  naturally  have  to  be  taken  into  account.  Thus  the  knowledge 
that  a  portion  of  the  nerve-trunk  had  been  lost  or  removed  would 
encourage  early  recourse  to  anastomosis.  On  the  other  hand,  if  the  onset 
of  the  paralysis  had  been  delayed  for  some  hours  after  a  supposed 
trauma  had  been  inflicted  one  w'ould  patiently  and  confidently  postpone 
any  operation  for  one  or  even  two  years.  And  in  any  case,  operation 
would  be  contra-indicated  if  signs  of  spontaneous  recovery  were  pre- 
senting themselves,  since  even  a  partial  recovery  would  seem  to  be  more 
acceptable  than  the  best  results  of  the  anastomosis  operation. 

Thus  the  class  of  case  for  which  the  operation  is  really  suitable  is 
quite  a  small  one. 

The  facio-hijpoglossal  anastomosis  is  undoubtedly  the  most  suitable. 

Operation. — The  head  is  turned  to  the  opposite  side  and  the  pinna 
pulled  forward.  The  incision  runs  from  a  point  in  the  auriculo-mastoid 
angle  opposite  the  middle  of  the  posterior  wall  of  the  external  auditory 
meatus,  down  along  the  anterior  border  of  the  mastoid  process,  and 
thence  along  the  anterior  edge  of  the  sterno-mastoid  muscle  to  the 
greater  cornu  of  the  hyoid  bone.  Sometimes,  to  obtain  more  room,  a 
second  incision  is  made  at  right  angles  to  and  starting  from  the  centre 
of  the  first  incision  towards  the  angle  of  the  jaw. 

The  parotid  gland  and  the  margin  of  the  sterno-mastoid  muscle 
having  been  separated  from  each  other  by  blunt  dissection,  the  gland  is 
displaced  well  forward  so  as  to  reveal  the  posterior  belly  of  the  digastric 
crossing  the  space.  The  upper  end  of  the  muscle  is  cleared  and  the 
facial  sought  for  above  it.  Bleeding  from  the  posterior  auricular  vein 
may  require  ligature. 

The  nerve  crosses  from  behind  forward  obliquely  above  the  upper 
edge  of  the  digastric.  After  it  has  been  found  and  cleared  it  is  raised 
and  divided  by  a  blunt  tenotome  at  its  exit  from  the  stylo-mastoid 
foramen,  and  its  end  is  brought  down  to  the  hypoglossal  (or  spinal 
accessory). 

The  landmarks  for  the  hypoglossal  are  the  digastric  and  stylo-hyoid 
muscles,  from  under  which  it  emerges,  passing  forward  towards  the  tongue, 
and  looping  round  the  origin  of  the  occipital  artery  from  the  external 
carotid.  It  is  then  traced  upward  beneath  the  digastric  at  this  point. 
The  digastric  and  stylo-hyoid  should  be  divided.  When  the  nerve  has 
been  cleared  a  slit  is  made  in  its  sheath,  the  nerve-fibres  being  as  far  as 
possible  left  intact,  and  the  cut  end  of  the  facial  inserted  into  the  slit. 
Finally,  the  sheaths  of  the  nerves  are  sutured  by  fine  catgut  and  with 
fine  needles,  all  wounding  of  the  nerve  proper  being  carefully  avoided. 
Manipulations  must  be  delicate  and  the  nerves  must  not  be  freely  and 
forcibly  gripped  with  forceps. 

The  wound  is  sutured  and  dressed,  the  head  being  inclined  to  the 
affected  side. 

Facio-Spiyial  Accessory   Anastomosis.  —  The   course   of   the   spinal 


804  The  Journal  of  Laryngology,        [October,  1920. 

accessory  nerve  is  roughly  indicated  by  a  line  at  right  angles  to  and 
bisecting  another  Hne  joining  the  tip  of  the  mastoid  with  the  angle 
of  the  jaw.  It  pierces  the  deep  surface  of  the  sterno-mastoid  muscle 
about  a  couple  of  inches  below  the  tip  of  the  mastoid. 

Operation. — A  sandbag  is  placed  beneath  the  shoulder,  and  the  head 
is  extended  a  little  and  turned  to  the  opposite  side.  The  skin  incision 
is  the  same  as  for  the  facio-hypoglossal  anastomosis. 

The  anterior  edge  of  the  sterno-mastoid  having  been  defined  the 
deep  cervical  fascia  is  opened  in  front  of  it  and  the  muscle  drawn  back. 
The  posterior  belly  of  the  digastric  crossing  the  wound  obliquely  down- 
ward and  forward  having  been  made  out  and  its  lower  border  cleared, 
the  nerve  will  be  found  emerging  from  beneath  it.  The  digastric  and 
stylo-mastoid  muscles  are  divided,  and  the  anastomosis  completed  as  in 
the  other. 

(Further  details  of  these  operations  may  be  obtained  in  Cheyne  and 
Burghardt's  "  System  of  Surgery.") 

{To  he  continued.) 


CLINICAL     NOTE. 


IMPACTION   OF  A    LARGE   FISH=BOi\E   IN   THE   LARYNX. 

By  Archer  Eyland,  F.E.C.S.(Ed.), 
Assistant-Surgeon,  Central  London  Ear,  Nose,  and  Throat  Hospital. 

Mrs.  A.  J ,aged  sixty-eight,  was  admitted  to  the  Central  London  Ear,  Nose, 

and  Throat  Hospital,  complaining  of  severe  pain  in  the  throat,  weakness  of  voice, 
and  inability  to  swallow  jjroperly. 

She  stated  that,  the  day  before,  she  had  swallowed  a  fish-bone  while  eating 
some  plaice,  and  had  suffered  the  above  symptoms  ever  since.  i 

The  patient  was  found  to  be  in  obvious  pain  and  distress.  The  voice  was  veiy 
much  impaired  and  almost  aphonic.  Swallowing  was  painful  and  difficult,  and 
there  was  an  accumulation  of  frothy  saliva  at  the  iipper  orifice  of  the  larynx  and 
cesophagns. 

By  indirect  laryngoscopy  a  long  and  narrow  foreign  body  was  seen  lying 
obliqiiely  across  the  glottis,  superficial  to  the  true  cords,  and  with  each  extremity 
ai:)parently  biu-ied  in  a  lateral  wall  of  the  larynx.  The  left  extremity  of  it  was 
overlain  and  concealed  by  the  left  ventricular  band,  and  tlie  right  exti'emity  was 
similarly  concealed  by  tlie  right  ventricular  band  near  to  its  posterior  attachment, 
and  also  by  tlie  right  arytaenoid.  In  other  words,  the  long  axis  of  the  body  passed 
obliquely  across  the  cords,  having  each  of  its  extremities  buried  in  a  ventricle 
of  the  larynx.  These  facts  could  onlj'-  be  fully  established  by  means  of  data 
supplied  by  the  actual  extraction  of  the  foreign  body  and  by  its  ascertained 
measurements,  together  with  careful  scrutiny  of  its  shajje  after  removal,  because, 
at  the  first  examination,  each  of  the  false  coixls  and  the  right  ai"j'ta?noid  were 
distinctly  reddened,  swollen  and  congested,  and  therefore  encroached  medially  to 
such  an  extent  that  not  more  than  three  or  four  millimetres  of  the  length  of  the 
foreign  body  could  be  seen. 

Extraction  was  easily  effected  by  means  of  direct  laryngoscopy  and  Patterson's 
forceps.  A  greenstick  fracture  of  the  bone  was  produced  at  the  point  at  which 
the  forceps  seized  it.  This  fact,  together  with  the  degree  of  traction  found  needful 
to  extricate  the  bone,  showed  that  its  impaction  had  been  firm. 

In  the  general  appearance  of  its  uppermost  surface  as  it  lay  in  the  larynx,  that 
is  to  say,  in  colour,  breadth,  outline,  and  surface  markings,  the  bone  bore  quite  a 
striking  resemblance  to  an  inflamed  vocal  cord. 


October,  1920.]  Rhinology,  and  Otology.  305 

It  lay  almost  at  the  same  level  as  the  cord.  Of  course  its  obliquity  of  position 
at  once  revealed  its  triie  nature— that  of  a  foreign  body.  One  end  was  sharp  and 
pointed,  the  other  end  was  blunt  and  abrupt  and  carried  a  small  cartilaginous 
splinter. 

The  actual  measurements  of  the  object  were  as  follows  :  Length,  3~5  cm. ; 
avei'age  breadth,  "25  cm. 

When  first  seen  the  patient  was  suffering  some  i-espiratory  embarrassment. 
It  was  slight.  The  cause  of  it  was  a  moderate  reactionary  oedema  in  the  lar\-nx, 
together  with  stasis  of  frothy  saliva  about  the  laryngeal  orifice.  The  breathing 
was  not  substantially  relieved  by  the  removal  of  the  foreign  body,  and  the  face 
remained  a  little  cyanosed. 

On  the  day  following  the  extraction  of  the  bone  the  temperatvu-e  rose  to  99'5°  F., 
the  breathing  remained  somewhat  laboured,  although  there  was  never  anything 
approaching  an  actual  stridor,  and  the  cyanosis  persisted. 

On  the  fourth  day  following  the  operation  the  patient  rapidly  sank  and  died. 

Post-mortem. — Extensive  pleuritic  adhesions  of  both  lungs.  Lungs  themselves 
congested.  Pericardial  effusion.  The  heart  itseK  appeared  normal.  Larynx : 
Larvngeal  walls  intact ;  no  lesion. 


SOCIETIES'     PROCEEDINGS. 


ROYAL  SOCIETY  OF  MEDICINE.— LARYNGOLOGICAL 

SECTION. 


November  1,  191S. 


President :  Dr.  James  Doxelan. 


Abstract  Report. 

{Continued  from  p.  285.) 

Sarcoma  of  Maxillary  Antrum ;  Lateral  Rhinotomy ;  Recur- 
rence in  Glands ;  Radium  Treatment. — Irwin  Moore.— Further 
notes  of  a  female  patient,  a^-ed  fifty,  upon  whom  lateral  rhinotomy  was 
performed  for  sarcoma  of  the  right  antrum.  Previously  shown  at  a 
meeting  of  the  Section  on  November  3,  1916.' 

Summary  of  Treatment. — Lateral  rhinotomy,  September,  1916. 
Recurrence  in  the  right  pre-auricular  gland  first  observed  in  March, 
1917.  Eadiuui  treatment,  March  and  April,  1918.  Recurrence  in  right 
orbit,  July,  1918.  Radium  treatment  again  in  July,  1918.  Growths 
dispersed. 

I  am  indebted  to  Dr.  Lynham,  Radium  Institute,  for  the  following 
later  notes  of  the  case  : 

"  Lateral  rhinotomy  was  performed  on  September  18,  1916,  by 
Dr.  Irwin  Moore,  for  removal  of  a  round-celled  sarcoma  from  the  right 
antrum.  The  growth  had  arisen  apparently  from  the  ethmoid,  and  had 
almost  filled  the  antrum,  penetrating  its  bony  wall,  and  extending  into 
the  soft  parts  of  the  cheek,  but  not  invading  the  skin.  The  floor  of  the 
orbit  was  intact,  and  proptosis  was  attributed  to  upward  pressure  of  the 
floor,  and  not  to  any  invasion  of  the  orbit.  The  growth  was  thoroughly 
removed,  together  with  the  ethmoid  cells  and  a  portion  of  the  muscular 

'  JouEN.  OF  Lartkgol.,  Ehinol.,  AND  Otol.,  vol.  xxxii,  p.  102. 

20 


306  The  journal  of  Laryngology,        [October,  1920, 

tissue  of  the  clieek.     Tlie   section   showed    round   cells   with  a  fibrous 
stroma. 

"In  July,   1917,  the  patient   noticed   some   swelling  in   the  parotid 
region,  and  this  has  slowly  increased,  without  any  pain. 

"  "At  date  (March  19,  1918)  the  patient  looks  healthy.  The  operation 
cicatrix  is  scarcely  noticeable.  There  is  no  sign  of  active  disease  in  the 
nose,  cheek,  or  zygomatic  or  temporal  fossae.  There  is  some  degree  of 
proptosis  of  the  right  eye.  In  front  of  the  right  ear  is  a  smooth  oval 
tumour,  4'3  cm.  by  5  cm.,  firm,  fixed,  not  adherent  to  the  skin  :  not 
tender  or  causing  pain.  A  shot-sized  gland  is  felt  at  the  right  extremity 
of  the  hyoid.  Treatment  by  radium  carried  out  on  four  successive  days, 
March  20  to  23  inclusive  ;  applicators  containing  160  mgrm.,  and  screened 
with  1-5  mm.  of  lead,  being  applied  for  sixteen  and  a-half  hours, 
distributed  over  four  consecutive  days.  April  10,  1918 :  The  tumour 
has  subsided,  leaving  the  pre-auricular  gland  larger  than  a  pea  with  a 
trace  of  diffuse  infiltration  round  it.  I'reatment  cari-ied  out  on  four 
successive  days,  April  10  to  13  inclusive,  on  the  same  lines  as  previously  ; 
applicators  containing  100  nigi'm.,  and  screened  in  similar  fashion,  being 
applied  for  twelve  hours,  distributed  over  four  consecutive  days. 
July  16,  1918 :  The  gland  is  now  shot-size,  but  still  palpable.  Patient 
recently  has  had  further  diplopia.  There  is  some  induration  above  the 
right  inner  canthus  firmly  adherent  to  the  side  of  the  nose,  and  extending 
up  to  the  margin  of  the  orbit  above  the  canthus.  There  is  a  second  hard, 
moveable,  almond-sized  mass  felt  above  the  right  eye,  between  globe  and 
orbit,  pressing  slightly  on  the  globe.  The  eye  seems  a  trifle  more 
prominent,  but  the  photograph  taken  in  March  does  not  confirm  this. 
Treatment  carried  out  on  five  successive  days,  July  22  to  26  inclusive, 
applicators  containing  75  mgrm.  being  api'lied  for  twenty-five  hours 
on  the  same  lines  as  on  the  previous  occasion,  and  distributed  over  five 
consecutive  days."  Patient  reports,  August,  1918  :  "The  lump  over  the 
top  of  eye  has  entirely  gone,  and  the  one  at  the  side  is  only  very  slight 
now.  The  double  sight  has  quite  gone,  and  the  sight  is  much  clearer." 
The  patient  is  shown  to  demonstrate  the  advantages  of  radium  treatment  in 
cases  of  recurring  saicoma. 

Mr.  Herbert  Tilley  :  I  wish  members  would  try  opening  the 
antrum  underneath  the  cheek  in  these  cases.  The  incision  should  reach 
from  the  malar  process  to  the  median  line :  turn  up  the  soft  parts,  open 
the  canine  fossa,  separate  the  soft  tissues  from  the  vestibular  aspect  of 
the  ascending  process  of  the  superior  maxilla,  and  remove  that  structure 
with  strong  bone  forceps.  That  gives  at  once  a  large  opening  into  the 
antrum :  you  can  see  the  ethmoid  region,  and  even  the  sphenoidal  sinus. 
Only  those  who  have  tried  this  method  can  have  any  idea  of  the 
extraordinary  good  field  of  operation  which  it  affords.  At  the  close  of 
the  operation  the  soft  parts  fall  into  position,  two  or  three  stitches  are 
inserted,  and  rapid  healing  occurs.  If  my  colleagues  will  try  the  method 
I  do  not  think  they  will  revert  to  the  external  operation  of  lateral 
rhinotomy. 

Mr.  W.  Stuart-Loav  :  Two  years  ago  I  showed  some  cases  here  in 
respect  of  which  I  contended  that  the  antral  route  was  much  the  best. 
With  the  patient  well  above  you  and  using  a  good  light  you  can  see  the 
whole  area  of  operation.  Take  the  whole  of  the  inner  wall  of  the  antrum 
away,  and,  if  necessary,  remove  the  ascending  process  of  the  superior 
maxilla.  You  can  remove  everything  to  the  base  of  the  skull  if  I'equiied 
bv  that  method.     There  has  been  no  recurrence  in  mv  cases  so  treated 


October,  1920.]  Rhmology,  and  Otology.  307 

It  is  a  complete  operation,  aud  leaves  no  outside  mark  or  scar.  I  have 
operated  by  this  method  in  cases  of  epithelioma  aud  sarcoma  of  the 
maxillary  antrum,  and  in  similar  conditions  of  the  nose  where  the  antrum 
has  become  affected. 

Mr.  W.  M.  MoLLisoN  :  Surely  Mr.  Tilley  did  not  intend  to  recom- 
mend the  antral  route  for  carcinoma  ?  It  is  in  many  cases  not  merely  a 
matter  of  taking  away  the  growth  and  bone;  subcutaneous  tissues  must 
often  be  removed  as  well.  In  the  cases  of  carcinoma  upon  which  I  have 
operated,  it  would  have  been  impossible  by  this  means  (the  antral  route) 
to  have  removed  growth  far  enough  back.  Of  the  three  sarcomata  upon 
which  I  have  operated  one  might  have  been  done  in  that  way,  but  the 
others  might  have  been  torn.  By  the  external  operation  the  growth 
could  be  shelled  out  without  damaging  it  at  all. 

Mr.  Tilley  (in  reply) :  A  growth  which  has  penetrated  the  bony 
walls  aud  infiltrated  the  soft  tissues  would  not  be  suitable  for  the 
method  I  advocate.  I  recommend  it  for  a  localised  growth  in  the 
antrum,  where  the  bony  walls  are  intact  aud  where  the  symptoms  point 
to  malignancy.  It  is  especially  suitable  for  growths  involving  the  inner 
antral  wall  or  the  neighbouring  ethmoidal  region. 

Dr.  Irwin  Moore  :  Can  anything  more  be  done  for  this  patient, 
because  since  I  saw  her  in  August  she  has  been  complaining  of  terrible 
headaches,  and  says  her  sight  is  deteriorating.  Dr.  George  W.  Thompson, 
who  kindly  examined  her  for  me,  rejiorts  that  there  is  pressure  on  the 
right  optic  nerve,  and  I  tbink  there  is  no  doubt  that  this  is  due  to  some 
recurrence  in  the  ethmoid  region  on  the  right  side. 

Carcinoma  of  the  Maxillary  Sinus ;  Lateral  Rhinotomy ; 
Recurrence.— Irwin  Moore. — Specimen  (right  side  of  face)  of  a 
female,  aged  sixty-two,  upon  whom  lateral  rhinotomv  was  pei-formed  for 
epithelioma  of  the  right  maxillary  antrum  in  November,  1916.  Patient 
was  shown  at  the  meeting  of  this  Section  on  February  2,  1917,'  three 
months  after  operation,  to  show  the  satisfactory  results  obtained;  the  face 
wound  had  healed  in  five  days,  and  everything  appeared  to  be  going  on 
well.  Recurrence  was  observed  three  months  later,  rapidly  extending 
from  the  zygomatic  fossa  to  the  orbit,  necessitating  removal  of  the  eve. 
Patient  died  in  November,  1917,  one  year  after  the  first  operation. 

Post-mortem. — The  growth  was  found  to  have  spread,  involving  the 
remaining  portions  of  the  antral  and  orbital  walls,  and  extending  back- 
wards into  the  sphenoidal  sinus.  The  side  of  the  cheek  had  sloughed 
away  and  left  a  large  cavity. 

These  two  cases,  operated  upon  at  the  same  time,  and  kept  under 
observation  side  by  side,  are  interesting  as  illustrating  the  greater  degree 
of  malignancy  of  epithelioma  in  this  situation  as  compared  with  small- 
celled  sarcoma. 

Photographs  of  the  patient  three  months  after  operation  are  also 
shown. 

Incipient  Singer's  Nodules  in  a  Vocalist. — J.  Dundas  Grant. — 

The  patient,  a  young  lady  student  of  singing,  complained  of  huskiness, 
of  about  a  year's  duration.  At  the  junction  of  the  auterior  aud  middle 
third  of  each  vocal  cord  was  a  minute  projection ;  during  phonation  the 
vocal  slit  was  thus  divided  into  an  anterior  and  posterior  segment,  and  on 
separation  of  the  cords  a  small  string  of  mucus  stretched  from  one  nodule 
to  the  other.     The  voice  could  not  be  carried  above  the  middle  "  C,"  on 

'  JouRN.  OF  Lartngol.,  Rhinol.,  AND  Otol.,  vol.  xxxii,  p.  355. 


308  The  Journal  of  Laryngology,         octoi^er,  1920. 

which  the  transition  usually  takes  place  between  the  thick  and  the  thin 
register.  She  has  been  instructed  how  to  practise  the  "  pmawing " 
exercises  devised  by  Curtis.  It  is  anticipated  that  as  the  nodules  are  at 
the  very  earliest  possible  stage  in  development  they  will  subside. 

Mr.  W.  M.  MoLLisoN  :  The  inability  to  sing  certain  notes  is  possibly 
connected  with  a  very  slight  chronic  affection  from  above,  such  as  post-nasal 
catarrh.  There  are  septic  tonsils  and  glands  on  both  sides  of  the  neck, 
and  it  might  be  worth  while  enucleating  the  tonsils  and  exploring  the 
sinuses.  I  saw  a  slight  irregularity  of  a  cord  on  one  side,  but  that  may 
have  been  due  to  mucus. 

Dr.  Grant  -.  It  was  my  intention  to  draw  attention  to  the  condition 
of  the  upper  air-passages  and  tonsils,  because  much  sejjtic  material  can 
be  squeezed  out  of  the  tonsils,  and  these  should  be  treated  in  addition  to 
the  rest  of  the  voice  and  the  exercises  devised  by  Holbrook  Curtis,  which 
are  very  well  kuown. 

[Later  Note. — The  projections  are  already  less  prominent  and  the 
string  of  mucus  is  much  diminished.  She  can  sing  with  much  gi-eater 
ease,  and  can  already  produce  a  number  of  notes  above  the  middle  "  C  " 
without  difl&culty.] 

Method  of  inducing  Cough  and  Expectoration  by  the  Inhala- 
tion of  Oleum  Siuapis. — J.  Dundas  Grant. — This  is  a  useful  method 
of  getting  a  little  expectoration  at  the  time  of  examining  the  patient.  A 
few  drops  of  aromatic  oil  of  mustard  are  placed  in  an  empty  6-oz. 
bottle,  where  they  volatilise.  The  patient  sniffs  this  from  the  neck  of  the 
bottle :  he  soon  begins  to  cough,  and  will  in  many  instances  bring  up 
expectoration,  which,  otherwise,  it  would  he  difficult  to  procure  at  the  time. 

Sarcoma  (?)  of  the  Left  Tonsil. — Andrew  Wylie. — Patient, 
female,  aged  fifty-six,  complains  of  a  swelling  in  the  left  tonsil, 
growing  slowly  for  seven  years.  There  is  no  pain,  no  real  difficulty  in 
swallowing  or  breathing.  It  is  fairly  moveable,  elastic  to  the  finger.  The 
soft  palate  is  slightly  adherent  to  it.  This  swelling  was  punctured 
several  times,  and  found  to  be  of  a  solid  nature.  No  improvement  with 
potassium  iodide.  Slight,  but  not  definite  enlargement  of  cervical 
glands.  Exhibitor  considers  that  the  growth  can  be  removed  fairly 
easily,  and  the  exact  diagnosis  made  by  a  pathologist. 

L)r.  H.  J.  Banks-Davis  :  I  think  there  is  pus  in  the  palate  as  well. 
These  cases  often  get  it,  and  when  an  incision  is  made  to  release  it  from 
the  palate  the  growth  fungates  through  the  incision,  making  subsequent 
operation  more  difficult. 

Dr.  W.  Hill  :  If  it  is  sarcoma,  it  is  a  very  good  ca?e  for  the 
application  of  radium.    If  it  is  a  fibrous  tumour  it  should  be  shelled  out. 

Dr.  Grant  :  This  may  be  a  "  mixed  "  tumour  between  the  layers  of 
the  palate,  such  as  can  sometimes  be  shelled  out.  If  it  were  sarcoma, 
probably  the  patient  Avould  have  enlarged  glands.  If,  however,  it  turns 
out  to  be  sarcoma,  the  opening  made  for  the  scooping  out  would  do  for 
the  introduction  of  radium  tubes. 

Mr.  O'Malley  :  As  stated  by  Dr.  Grant,  this  probably  originated 
in  the  lavers  of  the  palate  as  an  adenoma.  I  have  shown  two  cases  of 
that  type,  but  the  condition  had  not  progressed  to  the  extent  here  seen. 
Owing  to  the  length  of  time  it  has  been  growing  it  has  depressed  the 
tonsil.  When  you  get  the  patient  to  open  her  mouth  the  mass  beneath 
the  jaw  disappears,  but  when  the  mouth  is  closed  the  mass  can  be  felt. 
There  does  not  appear  to  be  involvement  of  glands  outside. 


October,  1920]  Rhiiiology,  and  Otology.  309 

Mr.  HowARTH :  I  had  a  similar-looking  case  two  years  ago  which 
turned  out  to  be  an  endothelioma.  It  was  more  extensive  than  at  first 
appeared,  and  it  extended  along  the  internal  pterygoid  plate  to  the  base 
of  tlie  tongue.  As  a  block  dissection  of  the  glands  was  being  done  I 
was  able  to  deal  with  it  bimanually. 

Dr.  JoBSON  HoRXE  :  The  growth  is  probably  more  extensive  than  it 
appears  to  be  when  viewed  from  the  mouth.  I  do  not  think  it  would  be 
a  simple  matter  to  remove  it. 

Three  Dental  Plates  removed  from  (Esophagus. — A.  Brown- 
Kelly. — These  plates  were  extracted  through  the  mouth.  In  two  other 
cases  the  plate  slipped  into  the  stomach,  and  was  passed  per  rectum, 
and  in  another  it  was  removed  by  oesophagotomv.  In  each  of  the  six 
cases  the  patient  was  a  young  man,  the  plate  was  swallowed  during 
sleep  and  became  impacted  in  the  upper  part  of  the  gullet,  and  i*ecovery 
was  uneventful. 

Absorption  of  the  Pre-maxilla  in  Tertiary  Syphilis  of  Nose. — 
Dan  McKenzie. — The  patient  is  a  male  who  came  to  hospital  six  months 
ago  because  of  the  "  shrinking  of  his  jaw."  The  history  was  that  two 
or  three  months  pi-eviously  the  gums  about  the  upper  incisors  began  to 
shrink,  and  these  teeth  loosened  and  dropped  out.  After  they  had  been 
shed  the  shrinking  still  went  on  until  none  of  the  gum  was  left.  He 
was  unaware  of  any  disease  in  the  nose. 

Examination  bears  out  the  patient's  complaint.  Not  only  is  the 
alveolar  process  but  also  the  whole  of  the  anterior  arch  of  the  palatal 
processes  of  the  superior  maxilla  considerably  reduced  in  size,  the 
mucous  membrane  and  submucous  tissues  of  the  gums  being  thrown 
into  ridges  and  folds  thi'ough  the  shrinking  of  the  underlying  bone. 
There  is  no  ulceration  in  this  part  of  the  mouth,  but  high  up  in  the 
gingivo-labial  recess  in  the  left  canine  fossa  there  is  definite  firm  infiltra- 
tion with  a  fissure  running  through  it.  The  incisors  of  the  lower  jaw 
pi'oject  beyond  the  shrunken  upper  jaw  by  about  an  inch,  and  the  upper 
lip  has  fallen  in,  giving  to  the  patient's  face  an  unsightly  underhung 
appearance. 

The  nose  is  the  seat  of  active  tertiaiy  syphilis.  In  the  region  of  the 
bony  septum  and  floor  of  the  nose  there  is  a  sequestrum  embedded  in 
densely  infiltrated  tissue  showing  a  nodular  surface.  AVhen  he  first 
came  to  i^s  this  piece  of  dead  bone  was  still  quite  firm,  but  it  is  now 
beginning  to  loosen,  and  I  anticipate  being  able  ere  long  to  remove  it. 
At  first  sight  the  bony  absorption,  coupled  with  the  nodular  or  "tuber- 
cular "  characters  of  the  infiltration  in  the  nose,  bi'ought  to  mind  the 
possibility  of  leprosy.  But  the  patient  has  lived  in  England  all  his  life ; 
the  "Wassermann  reaction  is  positive,  and  microscopic  examination  of 
the  nodular  infiltration  in  the  nose  shows  dense  fibrous  and  granulo- 
matous characters  with  the  vasciilar  changes  of  syphilis.  Presumably, 
therefore,  the  absorption  of  bone  in  the  pre-maxillary  region  is  due  to 
destruction  of  the  nasopalatine  nerve,  and  also  perhaps  of  the  dental 
liranches  of  the  superior  maxillary  nerve,  from  involvement  in  the 
extensive  infiltration. 

The  patient  is  receiving  vigorous  anti-syphilitic  treatment  (novarseno- 
billon,  mercury  and  potassium  iodide). 

Dr.  W.  Hill  :  I  have  had  two  cases  in  which  the  premaxilla  gave 
trouble.  In  one  it  came  away  as  a  sequestrum,  in  a  case  of  congenital 
syphilis.     In  the  other  case  I  did  a  Eouge's  operation  in  order  to  get 


310  The  Journal  of  Laryngology^        [October,  1920. 

away  a  sequestrum  from  the  antrum.  But  Rouge's  is  a  bad  operation, 
especially  in  a  syphilitic  patient,  and  this  was  a  boy,  aged  sixteen.  The 
last  stage  of  that  ease  w^as  worse  than  the  first.  I  got  the  sequestrum  up, 
l)ut  half  the  premaxilla  came  away  ;  there  w^as  a  hole  from  the  lip  into 
the  nasal  cavity,  and  there  was  more  depression  in  the  nose  than  when 
I  started  operating.     That  was  many  years  ago. 

Mutism   of   Ten    Months'    Duration. — J.   Dundas  Grant. — The 

patient,  a  soldier,  aged  twenty,  was  blown  over  by  a  sliell  on  December 
30,  1917.  when  in  France,  w'hile  making  an  attack.  He  was  unconscious 
at  first,  but  does  not  remember  for  how  long.  When  he  recovered 
consciousness  he  was  voiceless  and  speechless.  He  went  first  to  a 
hospital  at  the  base,  then  to  one  in  London,  and  then  to  another  military 
hospital,  and  from  there  went  to  the  West  End  hospital  on  October  29  of 
this  year.  I  saw  him  two  days  later,  and  on  laryngoscopic  examination 
found  the  vocal  cords  sepai-ated  to  the  utmost  possible  extent.  By 
means  of  the  application  of  faradism  to  the  neck,  and  of  persuasion,  his 
voice  was  restored,  though  his  speech  remained  stammering. 

[Later  Note. — On  November  5  the  stammering  was  greatly  subdued 
by  the  prolonged  application  of  fai-adism  to  the  submental  muscles,  and 
when  seen  on  the  7tli  he  could  speak  quite  well.] 

Functional  Aphonia  of  Three  Months'  Duration. — J.  Dundas 
Grant. — The  patient,  a  soldier,  aged  twenty-nine,  stated  that  he  was 
"  gassed  "  in  July,  1918.  He  went  straight  to  the  casualty  clearing 
station,  and  when  there  his  voice  got  weak,  and  after  two  days  it  quite 
disappeared,  remaining  so  till  I  saAV  him  yesterday  (October  31),  when 
the  voice  was  completely  restored  by  laryngoscopy  and  a  very  mild 
application  of  faradism  to  the  neck. 

Functional  Aphonia  of  Ten  Months'  Duration,  with  Laryngitis. 
— J.  Dundas  Grant. — The  patient,  a  soldier,  lost  his  voice  suddenly  on 
January  -26,  1918,  when  in  Italy.  A  bomb  fell  outside  his  billet  in  the 
night.  He  was  restless  and  lost  his  power  of  speech.  On  February  1 
his  temperature  rose  to  104'6°  F.,  and  went  up  and  down  for  a  fortnight 
owing  to  an  attack  of  broncho-pneumonia.  He  w^as  in  the  casualty 
clearing  station  for  three  weeks,  and  during  that  time  was  so  weak  that 
he  had  to  be  fed  with  a  spoon.  He  was  then  sent  to  a  general  hospital, 
and  had  inhalations  for  two  months  ;  he  was  next  sent  to  another  hos- 
pital in  France,  where  he  remained  for  six  weeks.  He  was  sent  back  here 
in  May,  and  has  been  in  a  London  military  hospital  ever  since,  wdth  the 
e.xception  of  a  fortnight  in  a  V.A.D.  hospital  at  Willesden.  I  saw  him 
for  the  first  time  at  the  West  End  Hospital  for  Nervous  Diseases  on 
October  31. 

The  vocal  cords  are  pink,  shiny,  and  swollen,  and  do  not  approximate 
in  their  interaryta^ncnd  portions,  though  they  do  in  the  middle  third, 
where  they  are  somewhat  "  bellied."  His  muscles  are  weak  and  flabby, 
and  in  view  of  the  possibility  of  his  being  a  subject  of  tuberculosis  I 
have  postponed  any  energetic  treatment  for^  the  functional  aphonia  till 
his  sputum  has  been  examined  for  bacilli. 

[Later  Note. — I  have  to  report  that  I  saw  him  again  on  November  5, 
when  the  vocal  cords  had  lost  their  tumidity ;  his  voice  had  returned 
shortly  before  my  expected  visit ;  this  w^as  probably  due  to  the  persuasive 
effect  of  the  electrical  and  other  suggestive  treatment  on  his  companions. 
There  were  no  tubercle  bacilli  found  in  the  sputum.] 


October,  1920.]  Rhiiiology,  and  Otology.  311 

Dr.  Andrew  Wylib  :  If  Dr.  Grant  were  to  reiuove  the  tonsils  and 
adenoids  in  two  at  least  of  the  patients,  even  if  the  operation  did  not 
c-m-e  the  aphonia,  the  uioi-al  effect  would  do  so. 

Mr.  O'Malley  :  If  these  tonsils  are  removed  the  patients  will 
probably  talk  very  well  on  recovering  from  the  angestlietic' 

The  President  :  In  one  of  these  cases  the  vocal  cords  are  still 
very  red  from  congestion. 

Mr.  W.  M.  MoLLisoN  :  All  functional  cases  recover  by  suggestion. 
Three  days  ago  I  saw  one  of  these  cases  of  functional  aplionia  :  he  had 
been  dysphonic  since  February,  and  after  ten  minutes  of  suggestion  he 
talked  very  well.  His  cords  were  red,  but  when  I  saw  him  again 
two  days  later  the  redness  had  already  decreased.  The  redness  of 
the  cords  in  the.se  functional  cases  is  due  to  the  patients  having  used 
their  voice  wrongly. 

Dr.  Smurthwaite  :  To  treat  all  these  cases  of  aphonia  as  if  they  were 
functional  is  to  invite  serious  mistakes,  as  many  of  them  turn  out  to  be 
tubercular.  Out  of  400  cases  in  the  last  three  years  I  have  selected 
fifteen  Avhich  were  tubercular.  To  treat  even  suspected  functional  cases 
without  L)oking  into  the  larynx  is  madness.  I  agree  that  functional 
cases  can  be  cured  by  psychic  treatment.  I  always  look  into  my  patients' 
larynges  and  satisfy  myself  that  I  have  to  deal  with  a  functional  case 
before  I  start  my  intensive  stiggestion  process.  In  pureh'  functional  cases 
there  is  no  reason  why  the  patient  should  not  speak  before  he  goes  out 
of  the  room. 

Mr.  O'Mallet  :  All  my  treatment  in  these  cases  consists  of  a  method 
of  suggestion  I  have  already  described.  With  regard  to  not  examining 
an  aphonic  case  before  treating  it  liy  suggestion,  I  will  give  an  instance 
of  a  striking  pitfall  in  a  case  which  was  sent  to  me  with  the  note  that 
already  the  patient  had  had  three  injections  of  salvarsan,  and  asking 
whether  there  was  a  serious  lesion  in  the  throat  to  prevent  him  speaking. 
After  two  or  three  friction  movements  of  the  laryngeal  mirror  he  spoke 
well.     It  was  a  case  of  simple  aphonia. 

Dr.  Perry  Golds^iith  :  I  remember  one  case  of  cure  after  Major 
Hurst  had  failed  by  his  method,  and  it  was  after  laryngeal  examination. 
A  man  may  have  aphonia  as  a  symptom  of  some  other  disease.  If  yoti 
believe  a  case  to  be  functional,  you  niu.st  make  the  patient  realize  you 
yourself  have  faith  in  the  process,  and  that  he  must  have  faith  in  it  too. 
And  to  carry  out  the  method  you  must  have  him  by  himself  ;  you  will 
not  get  a  good  result  if  you  try  it  in  a  spectacular  way.  for  all  the 
ward  to  see. 

Dr.  Grant  (in  reply)  :  I  have  not  had  a  case  of  functional  aphonia 
tinder  my  care  which  has  not  been  ciu-ed.  The  cases  I  have  brought 
to-day  present  different  points  of  interest.  One,  a  healthy  looking  man, 
had  been  aphonic  for  some  months,  and  yesterday,  after  a  few  minutes,  I 
had  him  talking  perfectly  well.  A  more  unusital  case  is  the  one  of 
complete  mutism,  in  which  the  cords  were  widely  abducted.  He  is  now 
at  the  stage  of  stuttering — a  stage  often  resulting  immediately  after 
restoration  of  the  voice.  The  third  case  is  the  most  interesting  of  all, 
because  the  vocal  cords  are  thickened  and  red  and  bellied,  and  the 
condition  has  lasted  some  fotirteen  months.  The  man's  musculature  is 
particularly  soft ;  probably  there  is  some  wasting.  He  had  suffered  from 
broncho-pneumonia,  therefore  I  made  him  expectorate  a  little.  Until  I 
have  excluded  tuberculosis  I  shall  refrain  from  attempting  to  hustle  him 
into  restoration  of  voice. 


312  The   lournal  oi  Laryngology,  October,  1920. 

ABSTRACTS. 

Abstracts  Editor — W.  Douglas  Harmer,  9,  Park  Crescent,  London,  W.  1. 
Autliors  of  Original  Communications  on  Oto-laryngology  in  other  Journals 
are  invitedy  to  send  a  copy,  or  t^co  reprints,  to  the  Journal  of  Laryngology. 
If  they  are  u-illing,  at  the  same  time,  to  submit  their  own  abstract  {in  English, 
French,  Italian  or  German)  it  will  be  v:elcomed. 


NOSE. 

Treatment  of  Hay-fever  and  Paroxysmal  Rhinorrhoea. — Morley  Agar. 
"  Brit.  Med.  Jouru.,"  July  24.  Ut^n. 

A  new  method  is  described  wliich  consists  in  rubbing  into  the  skin 
of  the  vestibule  of  the  nose  an  astringent  lotion,  namely,  argent,  nit. 
gr.  XXX  to  the  ounce.  In  making  the  application,  which  must  be 
thoroughly  and  systematically  carried  out,  particular  attention  is  paid  ta 
two  spots ;  the  first  is  high  up  on  the  outer  wall,  and  the  second  is  on 
the  floor  about  half  to  three-quarters  of  an  inch  behind  the  orifice.  The 
mucosa  is  not  painted. 

Before  making  the  application  the  vestibule  should  be  examined  for 
fissures  or  sore  spots  (in  order  to  avoid  them  r — D.  M.). 

The  author  claims  to  have  cured  all  cases  of  nasal  rhinorrhoea  so- 
treated. 

In  hay-fever  the  results  have  not  been  so  good,  but  some  improvement 
has  been  obtained. 

In  this  disease  he  does  not  use  the  silver  nitrate  at  first,  but  applies 
the  following  ansesthetic  solution  "to  the  vestibule  and  a  wide  area 
around." 

l;c    Acidi  carbolici niiij 

Aq.  menth.  pip.    ......     v\\j 

Spt.  vin.  rect.        ......      5iv 

Misce.     Fiat  pigment. 

After  a  few  minutes  lotio  calaminae  shoidd  be  applied  "to  an  even 
wider  area  of  the  face." 

Both  in  paroxysmal  rhiuorrhoi^a  and  in  hay-fever  the  application  of 
the  silver  nitrate  is  followed  by  a  definite  reaction  with  sneezing,  running 
from  the  nose,  and  sometimes  cough  and  tightness  in  the  chest.  It  lasts 
for  from  half  an  hour  to  twelve  hours. 

In  normal  j^eople  reaction  is  absent.  D.  Jf. 


EAR. 

The  Radical  Mastoid  Operation. — Morrissette  Smith.     "  The  Laryngo- 
scope," August,  1918,  p.  584. 

According  to  Morrissette  Smith,  the  first  conception  of  the  radical 
mastoid  operation  was  indicated  by  Nature  when  she  converted  the- 
mastoid  process,  antrum,  middle  and  external  ear  into  one  cavity  and 
lined  it  with  skin.  Bacon,  Whiting,  Dench  and  Kerrison  strongly 
advocate  the  procedure,  but  a  number  of  men  not  only  refuse  to  commend 
the  operation,  but  actually  condemn  it.  There  are  three  reasons  for 
this  :  (0)  The  operation  has  been  recommended  in  many  cases  where  it 
was  not  indicated  ;  (b)  it  has  been  attempted  by  men  who  have  not 
taken  the  trouble  to  thoroughly  familiai'ise  themselves  with  the  technique^ 


October,  1920.] 


Rhinology,  and  Otology.  31S 


consequently  their  results  have  been  poor ;   (c)   proper  attention  has  not 
been  given  to  the  after-treatment. 

Chronic  infections  of  the  middle-ear  cleft  should  be  divided  into  three 
classes:  (1)  Those  cases  of  intratympanic  [and  tubal.— Abs.]  infectious 
with  little  or  no  involvement  of  the  attic.  (2)  Those  cases  involving  not 
only  the  tympanum,  but  the  attic,  antrum,  and,  to  a  limited  extent,  the 
mastoid.  (3)  Those  cases  involving  the  intratympanic  attic,  antrum 
and  mastoid  structiu-es  as  Avell.  The  infections  in  Class  1  are  mucous 
membrane  infections  rather  than  an  implication  of  the  bony  tissues,  the 
discharge  (usually  coming  from  the  Eustachian  tube)  being  of  a  mucoid 
character;  the  hearing  is  usually  good.  The  condition  is  in  no  way  a 
menace  to  the  patient's  life.  These  cases  rarely, if  ever,  require  a  radical 
operation.  2.  These  cases  are  of  the  border-line  type,  and  require 
quite  a  little  study  and  judgment  in  deciding  whether  or  not  operation 
should  be  performed.  We  must  consider  the  amount,  character  and 
duration  of  the  discharge,  the  evidence  of  bone  destruction,  as  indicated 
by  polypoid  tissue,  foul  odour  of  the  discharge,  roughened  bone  dis- 
closed bv  probing,  the  amount  of  hearing,  the  subjective  symptoms,  as 
l^ain,  headache,  dizziness,  and  the  result  of  conservative  treatment. 
(3)  In  Class  3  the  radical  operation  is  most  frequently  indicated. 
These  cases  are  generally  seen  in  the  clinics  of  the  large  cities,  the  otitis 
having  been  acquired  from  some  of  the  infectious  diseases  of  infancy  or 
earlv  childhood  and  neglected  through  a  number  of  years.  It  is  in 
these  that  we  get  many  of  the  facial  paralyses,  intracranial  and  labyrin- 
thine complications.  The  hearing  is  generally  very  poor,  the  tympanum 
filled  with  foul-smelling  pus  and  granulation -tissue,  and  the  ossicles 
necrosed.  All  cases  of  cholesteatoma,  facial  paralysis  and  intracranial 
complications  call  for  immediate  radical  operation. 

In  ten  consecutive  cases  operated  on  the  hearing  remaiued  the  same 
as  before  operation  in  three,  was  improved  in  two,  and  much  improved  in 
five  instances. 

Technique. — Eichards  holds  that  a  step  in  the  operation  which  is  of 
extreme  advantage  is  the  shaving  down  of  the  convexity  of  the  anterior 
wall  of  the  bony  auditory  canal.  Tuis  widens  the  antero-posterior 
diameter  of  the  apex  of  the  cavity  and  prevents  an  epithelial  septum 
from  later  pigeon-holing  the  apex  from  the  main  body  of  the  cavity — 
an  unfortunate  and  very  common  occurrence.  Further,  we  secure  a 
splendid  view  of  the  region  of  the  tube,  and  therefore  do  not  have  to 
make  an  unnecessarily  large  cartilaginous  meatus.  The  removal  of  the 
lip  of  bone  overhanging  the  mouth  of  the  tube  is  very  imporiant.  In 
addition  to  this,  it  has  been  Eichard's  practice  to  evulse  the  tensor 
tympani  muscle  so  as  to  enlai'ge  the  tubal  opening  and  permit  a  thorough 
view  and  curetting. 

Dench  has  always  been  an  advocate  of  the  primary  skin-graft  in  the 
radical  operation.  He  had  sent  many  patients  home  two  or  three  weeks 
after  a  radical  operation  in  which  a  skin-graft  was  used.  Dench  advises 
that  one  graft  should  be  made  to  cover  the  entire  "radical"  cavity  and 
the  mai-gin  of  the  enlarged  meatus.  The  blood  beneath  the  graft  should 
be  withdrawn  with  a  pipette.  Dench  on  occasion  uses  a  little  chip  of 
bone  to  close  the  tube.  In  many  cases  failure  to  obtain  a  dry  ear  was 
due  to  the  external  auditory  meatiis  not  being  made  wide  enough  to 
ventilate  the  cavity.  Morrissette  Smith  does  not  believe  in  employing 
grafts  when  the  dura  is  exposed  ;  there  is  a  danger  to  the  patient  from 
meningitis  when  skin  is  put  into  such  a  cavity.  /.  »S'.  Fraser. 


'B14  The  Journal  of  Laryngology,        [October,  1920. 

New  Method  of  Dressing  Mastoid  Wounds. — Daiire.   "  Presse  Medicale," 
July  23,  1917. 

At  tlie  time  of  the  operation  the  wound  behind  the  ear  is  entirely 
closed,  the  meatal  plastic  having  been  carried  out.  The  iodoform  gauze 
previously  placed  m  the  mastoid  cavity  is  in  part  drawn  out  through  the 
meatus.  The  special  treatment  employed  thereafter  is  begun  between 
the  fifth  and  eighth  days,  and  consists  in  daily  introduction  of  sterile 
ambrine  from  a  five  to  ten  c.c.  beaker,  previously  kept  warm  on  a  water- 
bath.  The  patient  is  so  placed  that  the  floor  of  the  operation  cavity  is 
horizontal,  and  the  meatus  spread  open  with  a  nasal  speculum.  Ambrine 
is  now  poured  in  to  a  depth  of  two  or  three  millimetres  and  allowed  to 
solidify.  A  small  cord  of  sterile  gauze,  three  centimetres  long,  is  then 
inserted,  and  a  fresh  layer  of  ambrine  introduced  to  a  point  just  so  far 
from  the  meatus  as  to  permit  of  packing  in  a  gauze  wick  to  maintain  the 
lumen.  The  dressing  is  easily  removed  merely  by  traction  on  the  gauze 
cord  embedded  in  the  ambrine.  The  cavity  is  cleansed  each  time  with 
boiled  water  or  saline  solution,  dried,  and  dressed  as  before.  These 
dressings  are  carried  out  for  a  period  averagiug  from  fifteen  to  twenty 
days.  Thei'eafter  daily  irrigations  with  aqueous  iodine  solution  or 
insufflations  of  powerful  boric  acid  are  employed.  /.  S.  Fraser. 

End-results  of  the  Radical  Mastoid  Operation. — Harris.     "New  York 
State  Jouru.  ]\Ied.,"  1917,  vol.  xvii,  p.  17. 

Harris  has  analysed  the  results  of  the  operation  on  24  patients. 
Concerning  the  discharge,  it  was  found  that  48  per  cent,  were  perfectly 
dry  and  52  per  cent,  still  discharging.  Hearing  improved  in  only  8  per 
cent.,  unchanged  in  70  per  cent.,  and  worse  in  20  per  cent.  The  ear  was 
found  fully  epidermised  in  14  cases,  partly  in  3,  while  granulations  were 
found  in  5.  Two  cases  were  still  under  treatment.  The  tube  was  closed 
in  11  cases. 

The  results  are  by  no  means  uniformly  good,  partial  or  complete 
failures  occurring  in  a  considerable  percentage  of  cases. 

/.  S.  Fraser. 

Vertigo   and  its  Treatment   by  Adrenalin. — Maurice  Vernet  (Paris). 
"  La  Presse  Medicale,"'  July  lU,  192U,  p.  462. 

Analysis. — The  vertiginous  sensation  springs  from  an  upset  of  the 
labyrinthine  equilibrium,  whether  it  occurs  in  the  vestibular  apparatus, 
the  vestibular  nerve,  or  in  the  connections  with  its  centres. 

The  author  is  of  the  opinion  that  there  is  at  the  biu>e  of  every  verti- 
ginous sensation  a  labyrinthine  vasomotor  or  toxic  phenomenon;  and 
therefore  a  symjjathetic  or  endocrinian  phenomenon,  of  which  the  cause 
may  be  local,  central  or  peripheral. 

Adrenalin,  the  hormone  of  the  chromafiine  system,  is  for  this  reason 
a  medicinal  substance  capable  of  favourably  modifying  vertigo  when  the 
primitive  cause  allows  it. 

The  vertiginous  sensation  is,  in  fact,  essentially  a  phenomenon  of  the 
labyrinthine  irritation,  mobile,  and  fugitive  like  the  cause  by  which  it  is 
brought  on,  and  like  the  variations  ot  vasomotor  kind  in  the  sphere  of 
the  sympathetic  and  vagus  nerves. 

All  otologists  know  that  vertigo  disappears  when  the  labyrinth  has 
been  destroyed,  and  that  an  irritation  of  the  membranous  duct  of  the 
semicircular  canals  is  necessary  to  provoke  it. 


■October,  1920.) 


Rhinology,  and  Otology.  315 


The  isc'hsemia  of  a  limb  brings  on  ana?stliesia ;  it  is  the  passive  or 
active  cougestiou  of  the  ear  which  more  often  induces  labyrinthine  hyper- 
sesthesia,  and  through  it,  vertigo.  However,  it  is  not  clear  whether 
IschEemia  cannot  sometimes  provoke  a  hyperexcitability— momentarily  at 
least — of  the  vestibular  nerve. 

Vasomotor  congestion  in  the  capillary  sphere  of  the  vestibular  artery 
mav  provoke  the  vertiginous  sensation  apart  from  all  other  manifestation. 
Vertigo  takes,  then,  all  the  alternative  forms  of  this  type  of  congestion. 

It  is  well  to  remember  the  favourable  action  obtained  on  the  laby- 
rinthine congestion  by  ice  applied  locally,  leeches,  ergotin,  parasy'nthesis, 
tepid  washings,  and  intestinal  derivatives. 

Deafness  and  tinnitus  without  vertigo  are  of  frequent  occurrence. 
Vertigo  may  be  associated  with  them,  although  it  may  exist  separately, 
and  it  is  not  necessarily  dependent  on  the  same  cause. 

There  exist  as  many  causes  of  vertigo  as  there  are  causes  of  laby- 
rinthine vasomotor  ^nodification,  causes  of  toxic  or  endocrine  modifications 
— local  causes  acting  by  reflex  vaso-congestions  ;  general  causes — organic, 
neuro-glandular,  central,  acting  equally  by  the  sympathetic  system 
medium. 

It  is  so,  for  instance,  if  we  consider  the  endocrine  disorders  which 
seem  to  be  at  the  base  of  every  diathesis,  and  if  we  consider  the 
connections  of  the  sympathetic  system  with  those  internal  secretion 
glands. 

Vertigo  due  to  the  menopause,  to  chlorosis,  Graves's  disease,  arthritis 
and  gout  is  a  congestive  vertigo  through  active  or  passive  vasomotor 
disorders,  dependent  on  the  alteration  of  internal  secretion  glands. 

Regarding  central  causes  we  have  congestive  vasomotor  disorders  of 
the  paralysed  regions  (rising  of  local  tera})erature,  exaggeration  of  sudoral 
secretion,  ecchymosis,  oedema,  etc  ). 

The  collateral  phenomena  associated  with  the  vertigo  are  essentially 
those  of  the  sympathetic  or  the  vagus  system  (nause  i,  vomiting,  perspira- 
tion, mydriasis,  vasomotor  disorders).  Tliey  are  also  met  witli  in  the 
painful  syndromes  of  intestinal  iri'itation. 

The  author  wonders  what  are  the  relations  between  the  labyrinthine 
vasomotor  disorders,  the  general  arterial  tension,  and  the  tension  of  the 
endolymphatic  liquid. 

Instability  of  the  A'asomotor  system  in  the  capillaries,  or  the  remark- 
able variations  from  one  moment  to  another  of  its  effects,  show  how 
difficult  it  is  to  discover  a  rigorous  rule  in  its  connections.  In  short, 
something  must  be  remembered  :  the  rupture  of  the  vasotonic  equilibrium 
of  the  capillaries  seems  to  be  wonderfully  influenced  by  adrenalin,  the 
effect  of  which  is  exclusively  vascular. 

This  rupture  seems,  in  fact,  to  be  nioi-e  frequently  a  passive  vaso- 
dilatation. 

It  is  possible  to  battle  against  vertigo  by  means  of  adrenalin  without 
any  appreciable  modification  of  the  general  arterial  tension. 

The  author  puts  aside  the  various  causal  treatments  of  which  a 
successful  result  is  undeniable  (such,  for  instance,  as  the  removal  of  a 
cerumen  plug,  the  expulsion  of  taenia,  etc.).  He  looks  only  upon  vertigo 
"  without  any  obvious  material  cause." 

He  recognises  the  excellence  of  the  sedative  and  non-intoxicative 
medications,  but  he  refuses  to  adopt  the  quinine  medication,  of  which 
the  sad  result  is  injury  to  the  hearing.  It  is  also  the  same  with  the 
sedative  medications. 


316  The  Journal  of  Laryngology,  :october,  1920. 

Adrenalin,  ou  the  contrary,  lias  a  triple  function,  wliich  allows  a 
struggle  against  the  labviinthine  vasomotor  disturbance  :  elective  excita- 
tion of  the  endings  of  the  sympathetic  nervous  system,  regularisation  of 
the  blood-pressure  and  antitoxic  function. 

For  the  lact  four  years  a  great  number  of  vertiginous  patients  have 
been  successfully  treated  by  the  author.  He  eraj.loys  Clin's  solution  at 
1  to  1000,  by  giving  5  to  20  drops  twice  a  day  by  the  mouth,  interrupting 
this  treatment  every  ten  days.  Doses  must  be  administered  procrressivelv! 
Vertigo  generally  quite  disappears  in  a  few  days  under  this  treatment.  " 

Author  s  abstract. 


REVIEW. 


THE    PLASTIC    SURGERY    OF    THE    FACE. 

Plastic  Surgery  of  the  Face,  based  on  Selected  Cases  of  War  Injuries  of 

the  Face,  inchidinfj  Burns.     With  original  Illustrations  bv  H.  D. 

G-iLLiEs,  C.B.E.,  F.E.C.S.,  Major  E.A.M.C. ;  with  chapter  on  the 

"  Prosthetic  Problems  of  Plastic  Surgery,"    by  Capt.  W.  Kelsey 

Fey,    and    "  Eemarks    on    Anaesthesia,"     by  *  Capt.     E.    Wade. 

London :  Henry  Frowde,  Oxford  Universitv  Press,  and  Hodder 

&  Stoughton,  Warwick  Square,  E.G.,  1920.  '  Price  ^£3  3s.  net. 

Majoe  H.  D.  Gtillies  has  now  crowned   his  work  on  the  plastic 

surgery  of  the  face  with  a  book  which  is  in  every  way  worthy  of  that 

woi'k. 

As  everyone  knows,  and  as  most  have  personally  experienced,  the 
late  war  brought  with  it  many  new  and  strange  problems  for  our 
solving,  and  while  there  were  departments  of  national  activity  in  which 
our  efforts  did  not  reach  so  completely  and  rapidly  as  they  might  have 
done,  the  high  level  of  success  we  had  hoped  for,  it  will'  on  the  other 
hand  be  generally  conceded  that  in  the  realm  of  medicine,  with  one  or 
two  exceptions,  the  results  attained  by  Bi-itish  Avorkers  were  unsurpassed 
either  by  our  allies  or  by  our  enemies!  And  in  the  Vjook  now  before  us  we 
have  the  record  of  one  of  our  successes,  the  reading  of  which  amply 
explains  how  it  came  about  that  the  Queen's  Hospital,  Sidcup,  was 
eminentlv  one  of  the  things  to  see  in  England  during  the  war.  Here 
Major  Cfillies  and  an  enthusiastic  band  of  coadjutors  and  assistants 
were  reconstituting  with  extraordinary  and  unlooked-for  success  the 
features  of  those  unfortunate  men  whose  faces  had  been  so  torn  asunder 
by  the  cruel  wounds  of  modern  warfare  as,  in  many  cases,  almost 
entirely  to  lose  the  semblance  of  the  human  countenance!^  The  problem 
of  building  these  ruins  up  again  was  a  new  one,  because  never  before 
■were  so  many  soldiers  deformed  in  this  way,  since,  apart  from  the  over- 
whelming increase  in  numbers,  in  former  wars  most  wounds  of  this 
severe  shattering  character  must  necessarily  have  been  fatal. 

At  first  sight,  surely,  no  type  of  deformity  could  have  appeared  to 
the  novice  in  plastic  surgery  to  have  been  so  hopeless  of  remedy  with 
the  slender  means  formerly  at  his  disposal.  And  in  191-i  even  the 
experienced  rhinoplastic  surgeon  was  a  novice.  Now,  thanks  to  Gillies 
and  his  fellow-workers,  he  knows  that  much  more  can  be  done  than  he 
ever  dreamt  of,  and,  what  is  more,  he  knows  how  to  do  it  in  such  a  wav 


October.  1920.]  Rhiiiology,  and  Otology.  317 

as  to  rid  liis  patieut  of  the  bauutiug  sense  of  a  deformity,  which  other- 
wise would  render  it  impossible  for  the  victim  ever  to  appear  in  a 
public  place. 

We  mav  pause  here  to  congratulate  ourselves  upon  the  fact  that 
when  the  possibility  of  experimenting  in  the  repair  of  traumatic  facial 
deformities  occurred  to  the  chiefs  of  the  R.A.M.C.,  it  was  to  the  rhino- 
logist  they  turned  as  being  the  specialist  most  likely,  by  training  and 
experience,  to  solve  the  problem  successfully.  How  accurate  was  this 
forecast  we  may  gather  from  Major  Gillies'  book.  But  to  be  just  we 
are  bound  to  add  that  not  only  was  the  speciality  correctly  chosen, 
but  the  right  man  was  also  hit  upon,  and  that  we  can  only  call  a  stroke 
of  good  luck.  Moreover,  in  the  apportioning  of  credit  for  work  well 
done  we  must  not  forget  how  much  the  surgeon  was  indebted,  at  ahnost 
everv  turn,  to  the  wonderful  ingenuity  and  skill  of  the  modern  ortho- 
dentist. 

Turning  now  to  deal  with  the  book  itself,  we  must  warn  our  readers 
at  the  outset  that  it  is  impossible  for  us  to  do  more  here  than  to  glance 
brieflv  at  some  of  the  principles  animating  the  methods  of  repair,  the 
principles  which,  in  the  course  of  his  experience,  Grillies  has  been  able  to 
formulate  for  the  guidance  of  himself  and  others.  For  details  in  the 
treatment  of  cases  of  this  kind,  each  one  of  which  is  necessarily  a  special 
pi-oblem  by  itself,  the  reader  is  referred  to  the  book,  where,  both  by 
graphic  description  and  by  a  lavish  display  of  illustration,  the  author 
enables  us  to  follow  the  steps  by  which  results  so  surprisingly  good 
wei'e  obtained. 

Tbe  principles  enunciated  by  the  author  in  the  introductory  section 
are  the  I'esults  of  much  thought,  of  many  experiments,  and  of  not  a  few 
failures.  And  it  is  impossible  to  refrain  from  admiring  the  frankness 
with  which  failures  were  recognised  and  the  rapidity  with  which  the 
lessons  they  contained  were  assimilated  and  utilised.  What  strikes  the 
critic,  indeed,  is  the  sui'eness  and  apparent  ease  with  which  the  fitting 
operation  or  modification  of  operation  seems  to  have  been  found  for  each 
particular  type  of  deformity. 

As  an  example  of  this  kind  of  advance  we  may  iustauce  the  lining  of 
the  new  nose  with  a  skin-graft  instead  of  leaving  its  internal  surface  raw. 
This  change  was  tried  when  it  was  found  that  new  noses  formed  according 
to  the  old  methods  were  apt  to  undergo  ulceration  and  to  be  destroyed. 

Another  point  worthy  of  our  attention  is,  that  in  the  case  of  injuries 
to  cavities  like  the  mouth  or  nose  destroying  more  or  less  of  the  wall 
and  leaving  a  gap  or  defect,  no  attempt  should  be  made  by  the  surgeon 
who  sees  the  wound  while  it  is  still  fresh  and  recent  to  close  the  gap  by 
dragging  normal  tissue  across  it  and  fixing  it  there.  Normal  tissue 
should,  as  far  as  possible,  be  replaced  in  its  normal  position,  and  the 
remedying  of  the  defect  shoitld  be  left  to  the  plastic  surgeon.  At  the 
same  time  viable  tissue  should  not  be  lightly  sacrificed,  and  this  applies 
particularly  to  tags  of  mucous  membrane,  which  may  be  preserved  by 
attaching  them  to  any  raw  surface  available  in  their  neighbourhood. 
Here  the  rhinologist  in  us  recognises  an  old  friend  derived  from  the 
experience  of  submucous  resection,  when,  in  spite  of  what  seemed  to  be 
devastating  tears  in  the  mucous  membrane  flaps,  the  careful  retention  of 
the  shreds  and  their  as  careful  replacement  gave  us  a  much  better  septum 
than  we  had  ever  expected — or  deserved  perhaps  I 

Another  point  of  importance  in  dealing  with  facial   defects  at  the 


318  The  Journal  of  Laryngology,         [October,  1920. 

outset  is,  that  if  the  hole  cannot  be  obliterated  without  stretching  the 
tissues  around  it  undulj,  not  only  should  it  be  left,  but  the  skin  and 
mucous  membrane  should  be  sewn  to  each  other  round  the  margin  of 
the  defect  in  order  to  prevent  the  sprouting  of  granulations  and  the 
consequent  production  of  thick  scar-tissue,  since,  if  there  is  much  of  the 
latter,  when  the  case  reaches  the  plastic  surgeon  he  will  be  forced  to 
excise  it,  and  so  to  re-constitute  the  original  wound  before  he  is  able  to 
proceed  with  his  remedial  measures. 

In  this  connection  we  may  note  that  Grillies  has  found  that  the  buccal 
mucosa  brought  over  a  raw  edge  of  the  lip  and  sutured  to  the  skin 
retains  its  colour  and  takes  the  place  of  the  normal  prolabium  very 
satisfactorily. 

Before  he  proceeds  to  the  repair  of  a  facial  deformity  the  first  duty 
of  the  plastic  surgeon  is  to  ascertain  as  precisely  as  possible  what 
structures  are  deficient — whether  skin,  fat,  cartilage,  or  bone,  or  any 
combination  of  them — and  to  plan  his  arrangements  for  making  good  the 
losses  in  such  wise  that  each  constituent  tissue  absent  shall  be  replaced 
by  as  nearly  as  possible  a  corresponding  amount  of  its  like — cartilage 
by  cartilage,  bone  by  bone,  fat  by  fat,  and  so  on.  Permanent  artificial 
supports  of  dead  material,  of  metal,  solid  paraflin  and  the  like  have 
proved  to  be  unsatisfactory  and  are  now  no  longer  employed.  But 
temporary  supports,  usually  constructed  by  the  dentist,  are  in  many  cases 
indispensable. 

Generally  speaking,  where  permanent  supports  of  skeletal  tissue  are 
required  Grillies  prefers  cartilage  to  bone,  but  grafts  of  the  latter  are 
employed  in  making  good  defects  of  the  maxillary  and  malar  bones. 
When  cartilage  is  to  be  employed  he  obtains  it  from  the  ribs,  taking  as 
much  as  he  is  likely  to  need,  and  paring  and  cutting  it  to  the  shape 
requiied.  What  is  left  over,  if  more  will  be  required  at  a  later  date,  he 
buries  in  some  accessible  locality.  An  ingenious  adaptation  of  this  device 
is  made  in  burying  cartilage  under  the  skin  which  is  destined  later  on 
to  become  the  new  wall  of  a  cavity.  It  is  often,  for  example,  inserted 
under  the  skin  of  the  forehead  and  turned  down  at  the  proper  time  along 
with  the  skin-flap  to  make  the  bridge  of  the  new  nose. 

Subcutaneous  fat  is  chiefly  employed  in  the  raising  of  depressed  and 
adherent  scars.  The  scar  having  been  freed,  and,  if  necessary,  excised, 
a  sufficient  pad  of  fat  in  the  immediate  neighbourhood  of  the  wound  is 
loosened  and  rolled  under  the  skin-wound  so  as  to  separate  it  from  the 
deeper  structures.  Fat  grafts  transferred  from  a  distance  do  not  seem 
to  answer  so  well. 

We  come  now  to  the  use  of  skin-grafts  and  skin-flaps,  and  here  we 
find  a  large  variety  of  different  devices,  ranging  from  the  familiar  Thiersch 
graft  and  the  less  familiar  Wulfe  graft  to  Grillies's  ingenious  "  tubed 
flap." 

Thiersch  grafts,  as  we  have  already  remarked,  are  used  not  only  for 
covering  raw  areas  on  the  surface  but  also  for  lining  mucous  cavities, 
where  the  new  heterologous  epithelium  seems  to  accommodate  itself 
Avonderfully  well  to  the  novel  conditions  of  warmth  and  moisture. 
Indeed,  even  hair-growing  skin  has  been  used  to  line  the  inside  of  the 
cheek  without  causing  the  patient  any  discomfort ! 

The  application  of  the  Thiersch  graft  in  wdiat  is  called  the  "  epithelial 
inlay  "  or  "  outlay  "  is  an  adaptation  which  ought  to  be  widely  known. 
Its  particular  use  is  in  the  reconstituting  of  deep  pockets  which  have 
been  obliterated  by  scar-tissue — such  pockets,  for  example,  as  lie  between 


October,  1920.]  Rhinology,  and  Otology.  319 

the  cheeks  or  the  lips  and  the  alveolar  process.  When  the  recess  is 
filled  with  scar-tissue  and  lip  is  glued  to  alveolus,  after  the  knife  has 
been  used  to  deepen  and  so  to  re-form  the  cavity  or  pocket,  a  Thierscli 
graft  is  inserted  into  it  and  is  retained  there  by  "  Stent,"  which  is  a 
moulding  material  used  by  dentists.  The  whole  pocket,  including  the 
"  Stent/'  is  then  shut  off  from  the  cavity  of  the  mouth  by  sutures  passed 
through  the  mucous  membrane  of  the  orifice,  and  including  the  edge  of 
the  graft.  Eight  or  ten  days  later,  the  sutures  having  been  removed, 
the  '^  Stent "  is  taken  out  and  the  graft -lined  cavity  is  left.  Grillies  has 
applied  the  same  method  to  the  troublesome  ectropion  of  the  eyelids 
with  quite  admirable  results. 

The  Wolfe  graft,  so  called  from  the  Grlasgow  eye-surgeon  who  first 
employed  it,  consists  of  the  whole  thickness  of  the  skin.  Grillies  advises 
that  subcutaneous  tissue  also  should,  if  possible,  be  included  in  the  graft. 
Otherwise,  the  separated  skin  will  become  cedematous  after  it  has  been 
sutui-ed  into  position,  as  a  result  of  incomplete  lymphatic  drainage,  and 
it  is  then  apt  to  perish. 

A  Wolfe  graft  is  used  foi-  closing  the  gap  left  in  the  forehead  when 
flaps  are  cut  therefrom  to  re-form  the  external  nose.  It  is  measured  and 
cut  to  pattern  as  accurately  as  possible,  and  it  is  stitched  into  position  in 
such  a  way  that  there  remains  to  it  a  certain  amount  of  tension. 

We  may  interpolate  heie  the  remark  that  facial  plastic  surgery 
demands  from  its  votaries  not  only  scientific  precision  and  patient  method, 
but  also  native  ingenuity  and  the  gift  of  the  artist's  eye  if  satisfactory 
results  are  to  be  obtained.  At  the  Queen's  Hospital  the  artistic  element 
Avas  supplied  by  a  modeller,  who  made  plaster  casts  of  the  faces  of  the 
patients,  upon  Avhich  the  members  of  the  surgical  staff'  were  wont  to  plan 
and  to  trace  their  subsecjuent  operative  steps  ! 

In  principle  the  difference  between  a  Wolfe  graft  and  a  skiu-flap 
proper  is  perhaps  more  a  distinction  than  a  difference,  but  in  practice 
there  is  a  real,  and,  indeed,  a  vital  difference  between  them,  seeing  that 
the  Wolfe  graft  is  entirely  detached  from  its  locality  of  origin  and 
carried  to  a  "distance,  Avhereas  the  "flap,'"  being  formed  from  the  skin 
adjacent  to  the  defect,  retains  its  anchorage  and  maintains  its  direct 
connection  with  the  circulation.  As  we  shall  see,  by  means  of  his  "  tubed 
flap "  Grillies  has  cleverly  contrived  to  combine  the  freedom  of  the 
Wolfe  graft  with  the  nutritive  advantages  of  the  "flap"  proper. 

This  matter  of  the  nutrition  of  the  flap,  to  say  nothing  of  the  equally 
important  lymphatic  drainage,  is  obviously  of  prime  importance,  and 
another  ingenious  modification  adopted  by  Gillies  is  to  use  a  flap  cut 
from  the  temporal  region  in  such  a  way  as  to  include  the  superficial 
temporal  artery.  But  "there  seems  to  be  no  end  to  the  possibilities  of 
the  flap.  Flaps  cut  from  the  hairy  scalp,  for  example,  are  employed  to 
furnish  eyebrows  and  even  moustaches  I 

We  come  now  to  one  of  the  most  original  novelties  in  this  gallery  of 
novelties — the  "  tubed  Qap."  This  is  formed  by  making  two  parallel 
incisions  a  few  inches  apart  of  varying  but  equal  length  through  the 
skin  and  subcutaneous  tissue.  The  skin  between  those  incisions  is 
undermined  so  as  to  convert  it  into  a  strap  or  bridge.  The  two 
raw  edges  of  the  strap  are  then  turned  in,  forming  thus  the  "  tube  "— 
it  is,  by-the-way,  only  a  potential  tube  — and  these  edges  are  sutured, 
the  one' to  the  other,  along  the  greater  part  of  their  length.  Thus  there 
is  formed  a  tubed  process  or  tongue  of  skin  and  subcutaneous  tissue 
(the  "  pedicle  ")  extending  from  the  near  neighbourhood  of  the  defect  in 


^20  The  Journal  of  Laryngology.        [October,  1920. 

the  face  as  far  as  seems  to  be  necessary — it  may  reach  to  the  root  of 
the  neck  or  even  to  the  chest.  The  still  attached  skin  at  the  distal  end. 
of  the  tube  is  the  graft  or  flap,  which  is  subsequently  to  l)e  dissected 
free  and  transferred,  still  maintaining  its  union  with  the  tube-pedicle 
until  its  connections  in  the  new  situation  on  the  face  are  established. 
It  remains  to  be  said  that  the  mapping-out  and  the  formation  of  the 
tube  is  carried  out  at  least  three  weeks  before  the  flajj  is  freed  and  trans- 
ferred to  its  new  quarters.  Moreover,  after  the  transference  of  the  skin 
from  the  distal  end  has  been  accomplished,  the  tubed  pedicle  itself  may 
be  partly  reopened  and  applied  again  to  another  area  to  supply  a 
further  11a]). 

The  following  are  the  advantages  claimed  by  Gillies  for  bis  tubed 
flap  (personal  communication)  : 

"  (1)  The  blood  supphj  is  induced  to  run  parallel  along  the  flap  from 
its  base  to  extremity  ;  it  is  fully  protected  from  exposui'e  and  infection 
by  the  healing  of  the  two  skin  edges. 

"  (2)  Ability  to  transfer  skin  from  a  distance  to  the  face  or  elsewhere. 

"  (3)  The  flap  itself  may  be  partially  tubed  in  addition  to  the 
pedicle,  thereby  further  safeguarding  the  nutrition  to  the  flap. 

"  (4)  Advantage  of  reducing  the  time  of  operation  at  any  one  sitting. 

"  (5)  Utilisation  of  flap  is  easier  when  same  has  been  carefully  tubed, 
i.  e.  when  the  flap  and  pedicle  is  opened  out  the  skin  lies  quite  flat. 

"  (6)  The  pedicle  of  such  a  flap  can  be  kinked  and  twisted  with 
impunity." 

Many  other  principles  and  details  of  importance  are  described  by  the 
author  which  we  cannot  specify  here.  For  these  the  reader  is  referred 
to  the  book.  In  like  manner  it  is  quite  impossible  for  us  even  to  allude 
to  the  details  whereby  this  great  series  of  deformities  and  defects  have 
been  remedied.  Their  numl>er  is  legion,  their  variety  multiform,  com- 
prising as  they  do  operations  for  deformities  and  defects  of  the  nose, 
mouth,  chin,  cheeks,  eyes,  auricles  and  maxillae.  The  reconstitution  of 
the  nasal  cavity  is  itself  a  chapter  of  the  gi'eatest  interest  to  all 
rhinologists. 

But  there  remains  still  one  aspect  of  the  subject  to  which  we  must 
draw  attention.  It  would  obviously  be  a  great  mistake  to  regard  this 
development  of  surgery  as  a  war-time  speciality  only.  In  civil  life  and 
in  the  times  of  peace  a  great  future  lies  before  this  kind  of  work. 
What  the  war  has  done  is,  as  in  so  many  otber  departments  of  human 
activity,  to  give  a  fillip  to  the  development  of  a  branch  of  surgery  which 
was  already  budding  prior  to  the  war  in  the  work  of  Joseph  and  Halle, 
of  Berlin.  So  that  it  requires  no  great  effort  of  imagination  to  foresee 
that  this  type  of  plastic  surgery  will  in  the  future  be  applied  not  only 
to  remedying  the  results  of  accident  in  civil  life,  and  to  repairing  the 
ravages  of  disease  like  syphilis  and  lupus,  but  also  to  the  removal  of 
natural  blemishes,  such  as  excessively  prominent  and  protuberant  noses, 
and  to  re-fashioning  with  a  delicacy  and  precision  hitherto  unknown 
features  which  are  asymmetrical  or  unsightly. 

This  development  of  his  art  the  modern  rhinologist  cannot  afford  to 
ignore,  and  for  that  reason  he  ought  to  become  the  possessor  of  this 
handsome  volume,  which  contains  the  experiences  and  records  the 
methods  of  an  indefatigable  and  ingenious  pioneer  who,  unlike  many 
pioneers,  has  been  able  to  bring  his  work  to  a  very  high  point  of 
perfection  and  finish.  Dan  McKenzie. 


VOL.  XXXV.     No.  11.  November,  1920. 


THE 

JOURNAL    OF    LARYiNGOLOGY, 

RHINOLOGY,   AND   OTOLOGY. 


Original  Articles  are  accepted  on  the  condition  that  they  liave  not  j^revionsly  been 
pnhlished  elsewliere. 

Jf  reprints  are  required  it  is  requested  that  this  be  stated  when  the  article  is  first 
forwarded  to  this  Journal.     Such  reprints  will  be  charged  to  the  author. 

Editorial  Communications  are  to  be  addressed  to  "Editor  of  Journal  of 
LARYNaoLOQT,  care  of  Messrs.  Adlard  ^  Son  4'  TFest  Neivman,  Limited,  Bartholomeiv 
Close,  E.C.  1." 


THE    EARLY    DIAGNOSIS    OF    CARCINOMA    OF    THE    ORAL 
AND    LARYNGEAL   PHARYNX.' 

By  Edward  D.  D.  Davis,  F.R.C.S.Eng., 
Surgeon,  Nose,  Throat  and  Ear  Department,  Charing  Cross  Hospital. 

It  is  hardly  necessary  to  emphasise  the  importance  of  the  earhest 
possible  diagnosis  of  carcinoma  of  the  pharynx  in  order  that  these  dis- 
tressing cases  may  be  successfully  treated  by  excision.  Early  diagnosis 
in  cases  of  carcinoma  of  the  tongue  has  been  established  with  great 
success  by  Butlin,  but  unfortunately  it  has  not  been  done  in  cases  of 
carcinoma  of  the  more  inaccessible  pharynx.  Waggett  and  Trotter,  at 
the  International  Congress,  1913,  urged  the  necessity  of  early  diagnosis, 
and  with  that  object  in  view  I  have  kept  careful  notes  of  fourteen  cases 
of  growth  involving  the  base  of  the  tongue  and  pharynx,  thirty-one 
cases  involving  the  pyriform  sinus,  and  twenty-four  of  post-cricoid 
growth,  and  also  studied  twenty-five  selected  specimens  of  such  cases 
in  the  different  museums  of  the  London  hospitals.  Cases  of  growth  of 
the  upper  end  of  the  oesophagus  which  have  extended  to  the  pharynx 
have  not  been  included. 

There  are  three  types  of  cases  of  carcinoma  of  the  pharynx  frequently 
seen  by  the  laryngologist : 

(1)  The  carcinoma  in  the  region   of  the  base   of  the  tongue  and 
epiglottis. 

(2)  The  pyriform  sinus  carcinoma. 

(3)  The  post-cricoid  epithelioma. 

^  A  paper  read  before  the  Svimmer  Congress  of  the  Section  of  Laryngology, 
Royal  Society  of  Medicine,  London,  Jvine  24,  1920. 

2X 


322 


The  Journal  of  Laryngology,     [November,  1920. 


1.  Cabcinoma  of  the  Base  of  the  Tongue  and  Epiglottis 

(14  Cases). 
The  cases  in  this  group  with  one  exception  all  occurred  in  men, 
and,  in  spite  of  the  accessible  position,  the  growth  had  not  been 
diagnosed  until  inoperable,  and  in  3  cases  the  symptoms  were  attributed 
to  neurasthenia.  In  others  the  patients  reported  with  a  mass  of 
malignant  glands  at  the  angle  of  the  jaw,  and  were  sent  to  the 
laryngologist  for  a  search  for  the  primary  growth.     The  exact  site  of 


/   ^  4 


Fig.  1. — An  early  epithelioma  of  the 
base  of  the  tongue.  Man,  aged 
fifty-three.  Indefinite  history  of 
eighteen  months'  duration. 

Fig.  2. — Advanced  excavating  epithelioma 
^  of   the  base  of  the  tongue.     Man,  aged 

forty-seven.     Seven   months'  history  of 
sore  throat  and  dysphagia. 

origin  of  this  growth  is  often  difficult  to  ascertain,  but  cases  have  been 
observed  to  commence  as  a  small  ulcer  in  three  definite  situations  : 

(1)  The  junction  of  the  anterior  pillar  of  the  fauces  and  the  tongue. 

(2)  Immediately  below  the  tonsil  at  the  junction  of  the  lateral  wall 
of  the  pharynx  and  the  tongue. 

(3)  In  the  vallecula,  either  on  the  base  of  the  tongue  or  on  tlie 
anterior  surface  of  the  epiglottis. 

The  growth  excavates  the  base  of  the  tongue  and  rapidly  extends 
to  the  surrounding  structures,  and  the  deep  cervical  and  submaxillary 
lymphatic  glands  of  both  sides  are  soon  involved. 

The  early  symptoms  are,  persistent,  severe  pain  on  swallowing  located 
by  the  patient  to  the  root  of   the  tongue,  with  blood-stained   frothy 


November,  1920.]  Rhinolog'/,  and  Otology.  323 

expectoration  and  slight  enlargement  of  the  deep  cervical  gland  or 
glands  at  the  angle  of  the  jaw.  Occasionally  a  chronic  paroxysmal 
cough  is  the  first  symptom.  Later  the  movement  of  the  tongue  becomes 
limited,  as  shown  loy  incomplete  and  painful  protrusion  of  the  tongue  to 
one  side,  and  this  incomplete  protrusion  with  the  accompanying  trismus 
impedes  laryngoscopic  examination.  All  these  cases  were  inoperable 
when  first  seen,  in  spite  of  the  fact  that  the  growth  is  within  easy 
reach  of  the  palpating  finger,  and  does  not  require  a  skilled  laryngo- 
scopist  or  endoscopist  to  detect  and  gauge  the  extent  of  the  growth. 
In  the  later  stages  haemorrhage,  more  or  less  severe,  occurs. 

2.  Pyriform  Sinus  Carcinoma  (31  Cases). 

All  the  cases  of  this  type  occurred  in  men,  and  the  growth,  so  far 
as  can  be  ascertained,  commenced  in  the  majority  of  cases  as  an  ulcer 


A   ■ 

: 

f 

/ 

^'■\ 

fjS 

\  . 

Jl^ 

Fig.  3. — An  early  pyiitorm  .sinus  carcinoma. 

on  the  arytaeno-epiglottidean  fold,  or  in  others  on  the  floor  of  the  fossa, 
and  sometimes  even  lower,  on  one  side  of  the  posterior  surface  of  the 
cricoid  and  crept  upwards  to  the  pyriform  sinus,  involving  the  same 
side  of  the  larynx  with  fixation  of  the  vocal  cord  and  the  characteristic 
oedema  of  the  false  cord  and  that  half  of  the  larynx.  In  late  cases 
the  base  of  the  tongue  and  epiglottis  are  involved,  and  by  downwax'd 
extension  the  lumen  of  the  pharynx  is  surrounded.  The  first  symptoms 
are  sore  throat,  followed  by  a  characteristic  hoarseness  or  roughness  of 
the  voice,  with  a  copious  frothy,  blood-stained  expectoration.  The  deep 
cervical  glands  are  soon  enlarged,  and  the  neighbouring  tissues  of  the 
neck  are  infiltrated,  as  shown  by  the  fulness  of  the  ala  of  the  thyroid 
cartilage  on  the  same  side.  Complete  dysphagia  is  uncommon,  as  the 
growth  does  not  occlude  the  lumen  of  the  lower  pharynx  except  in  a  few 
advanced  cases.  Haemorrhage  is  frequent  and  tracheotomy  occasionally 
necessary.  This  type  of  case  is  usually  inoperable  at  the  first  inspection, 
and  any  attempt  at  removal  means  a  laryngectomy  with  excision  of  a 
large  area  of  the  pharynx. 


324  The  Journal  of  Laryngology,      [Novemijer,  1920. 

3.  The  Post-Ceicoid  Carcinoma  (24  Cases  :   22  Women  and  2  Men). 

This  growth  is  frequently  a  slow-growing  superficial  tumour,  which 
appears  to  commence  on  the  lower  portion  of  the  posterior  surface  of 
the  cricoid  cartilage  and  well  below  the  area  seen  in  an  ordinary 
laryngoscopic  examination.  It  may  also  commence  on  the  posterior 
pharyngeal  wall  at  the  level  of  the  cricoid  or  a  little  higher,  and  in  this 
position  is  more  easily  seen.  It  tends  to  surround  the  lumen  of  the 
pharynx,  and  spreads  upwards  to  form  the  whitish,  warty  upper  edge 
seen  in  the  later  stages  behind  the  oedematous  arytaenoids.  These 
patients  first  complain  of  a  soreness  or  pricking  sensation,  with  radiating* 
pain  in  the  ears  during  swallowing.  Pressure  of  the  larynx  backwards 
against  the  spine  or  lateral  movement  of  the  larynx  produces  pain  in 
practically  all  cases.  Dysphagia  occurs  early,  and  when  these  symptoms 
are  present  without  a  satisfactory  explanation  the  patient  should  be 
examined  by  suspension  laryngoscopy  or  by  the  oesophagoscope.  The 
laryngoscopic  mirror  will  not  show  any  signs  in  the  early  stage,  and 
when  the  upper  edge  of  the  growth  is  visible  the  disease  is  advanced, 
and  matters  are  still  more  hopeless  when  a  vocal  cord  is  paralysed. 
Neither  is  the  growth  within  reach  of  the  longest  finger,  and  the  passage 
of  a  bougie  is  valueless  and  even  harmful.  In  the  absence  of  physical 
signs  the  dangerous  diagnosis  of  neurasthenia  is  still  made,  but  such  a 
diagnosis  should  never  be  concluded  until  the  presence  of  a  growth  has 
been  eliminated  by  a  direct  examination. 

I  have  not  seen  any  condition  which  could  be  called  precancerous, 
and  the  glazed  atrophic  mucous  membrane  and  tongue  described  by 
Patterson  was  seen  in  one  case  in  which  syphilis  was  not  excluded.  It 
is  advisable  to  have  a  Wassermann  reaction  done,  as  I  have  seen  two 
cases  of  syphilis  which  closely  resembled  a  post-cricoid  growth,  but  of 
the  24  cases  in  this  class,  \vith  the  one  exception  mentioned  above  there 
was  no  history  of  syphilis,  and  the  Wassermann  reactions  were  negative. 

The  great  majority  of  the  above  cases  of  carcinoma  were  associated 
with  very  septic  teeth,  and  tliere  is  no  doubt  that  the  growth  is 
aggravated  by  this  sepsis ;  moreover  it  has  been  proved  by  the  Imperial 
Cancer  Research  that  the  cachexia  of  malignant  disease  is  the  result  of 
added  sepsis  and  is  not  a  sign  of  cancer  per  se.  The  removal  of  the 
septic  teeth  is  not  only  an  essential  preparation  for  operation,  but  it 
improves  the  patient's  condition,  and  can  be  done  at  the  time  of  the 
examination  by  the  direct  method. 

The  problem  of  early  diagnosis  is  intensified  by  the  fact  that  cancer 
in  itself  does  not  produce  any  specific  clinical  signs  or  symptoms,  and  it 
is  only  when  the  cancer-cells  form  a  tumour  that  a  series  of  mechanical 
symptoms  and  signs  appear.  These  symptoms  also  develop  slowly  and 
insidiously,  and  it  is  unusual  for  tlie  patient  to  coi^.sult  a  doctor  until 
such  symptoms  are  well  marked,  and  often  too  late  for  a  successful 
removal  of  the  growtli.  It  is  true  that  most  of  the  cases  of  post-cricoid 
growth  are  inoperable  when  first  seen,  and  only  5  of  the  above  24  cases 
were  subjected  to  operation,  two  of  which  died  of  mediastinitis  in 
four  days ;  a  third  did  well  for  ten  months,  and  then  died  of  media- 
stinitis following  the  removal  of  a  recurrence  of  the  growth.  The 
fourth  survived  operation,  but  a  recurrence  occurred  within  twelve 
months.  The  fifth  was  successful,  and  remained  well  for  twelve  months, 
and  then  died  of  an  apparent  recurrence  in  the  cervical  glands.  Logan 
Turner  recorcjs  8  cases  in  which  the  tumour  was  excised,  and  in  six  thQ 


November,  1920.]        Rhiiiology,  and  Otology. 


325 


results  were  decidedly  encouraging.  Though  these  results  are  by  no  means 
satisfactory,  the  tumour  is  often  superficial,  of  slow  growth,  metastases 
are  late,  and,  except  for  its  position,  the  tumour  should  be  most  favour- 
able for  excision  provided  an  early  diagnosis  is  possible  and  the  technique 
of  the  operation  is  improved  by  experience. 

The  success  of  excision  depends  on  the  depth  of  the  growth.  Some 
growths  are  warty  and  superficial,  and  do  not  invade  the  submucous 
tissue  or  surrounding  structures  until  late.  Others  are  more  infiltrating, 
and  rapidly  extend  into  the  submucous  tissue,  as  is  shown  by  the 
paralysis  of  a  vocal  cord  from  involvement  of  the  recurrent  laryngeal 
nerve,  and  when  this  occurs  the  case  is  inoperable.  I  have  not  seen  a 
case  in  which  the  growth  has  penetrated  the  constrictor  muscles  and 
invaded  the  surrounding  structures,  and  even   during  operation  it  is 


Fig.  4. — An  early  post-cricoid  epithe- 
lioma. A  larynx  excised  by  Major 
E.  B.  Waggett,  D.S.O.  A  womam, 
aged  thirty,  with  six  months'  history 
of  dysphagia.  (Case  mentioned  in 
text.) 


/'i 


Fig.  5. — An  ulvaue'-'l  pust-cricoid 
epithelioma. 

difficult  to  detect  the  superficial  type  of  growth  by  palpation  when  the 
constrictor  muscles  are  intact. 

Secondary  growths  in  the  deep  cervical  glands  along  the  jugular 
vein  are  a  late  manifestation  and  when  present  contra-indicate  operation. 
The  lobe  of  the  thyroid  gland  may  be  pushed  forward  and  made 
prominent  by  the  underlying  growth,  but  secondary  growths  in  the 
thyroid  in  the  true  post-cricoid  growths  are  rare,  and  are  more  common 
when  the  upper  end  of  the  gullet  is  involved.  The  duration  of  the 
symptoms  and  growth  are  very  variable,  and  cannot  be  taken  into  con- 
sideration in  ascertaining  the  advisability  of  operation. 

A  direct  examination  by  suspension  laryngoscopy  or  by  the  cesopha- 
goscope  should  be  made  to  ascertain  the  character  and  extent  of  the 
growth.  When  the  growth  surrounds  the  lumen  of  the  pharynx  the 
lower  limit  cannot  be  determined,  because  it  is  difficult  and  not  safe  to 
pass  the  oesophagoscope  through  the  annular  growth,  but  such  cases  are 


326  The  journal  of  Laryngology.     [November,  1920. 

inoperable.  A  piece  of  the  growth  can  be  removed  for  section,  hut  the 
pathologist  is  rarely  satisfied  with  the  examination  of  so  small  a  piece 
of  tissue  usually  obtained.  Unfortunately  when  the  growth  is  exposed 
by  operation  it  is  often  found  to  be  more  extensive  than  expected  in 
spite  of  careful  examination  by  the  direct  method,  and  it  is  claimed  by 
Trotter  that  clinical  evidence  obtained  by  examination  with  the  laryngo- 
scope or  direct  method  has  proved  to  be  misleading,  and  the  only  means 
which  can  give  exact  information  is  the  direct  observation  of  these 
tumours  in  their  early  stages  at  operations  undertaken  for  their  removal. 
This  observation  can  also  be  made  if  cesophagostomy  is  done,  but  in  my 
experience  cesophagostomy  is  unsatisfactory,  and  I  understand  that  it 
is  not  done  in  the  Cancer  Wards  of  the  Middlesex  Hospital.  Hence 
it  is  up  to  the  laryngologist  to  prove  his  value  by  making  an  early 
diagnosis  and  by  giving  an  accurate  estimation  of  the  possible  success 
of  operation. 


ENDO-LARYNGEAL  HAEMORRHAGE  DURING  OR  AFTER 
THYRO-FISSURE  IN  THE  REMOVAL  OF  THE  VOCAL 
CORD  FOR  INTRINSIC  CANCER  OF  THE  LARYNX,  THE 
CHIEF   VESSEL   CONCERNED,   AND    ITS    CONTROL. 

By  Irwin  Moore,  M.B.,  C.M.Edin., 
Surgeon  to  the  Throat  Hospital,  Golden  Square,  London,  W. 

(Eevised  with  additions  from  the  Abstract  of  an  Epidiascopic  Demon- 
stration given  before  the  Section  of  Laryngology,  Royal  Society  of 
Medicine,  on  May  7,  1920.') 

Sir  Hknry  Butlin-  stated  that  in  liis  experience  during  the  operation 
of  thyro-fissure  he  liad  never  seen  bleeding  which  could  occasion  the 
least  anxiety,  and  Sn-  Felix  Semon''  records  that  he  had  only  lost  one 
patient  from  secondary  haemorrhage,  followed  by  pneumonia,  and  this  he 
attributed  to  the  use  of  adrenalin.  Those  of  us,  however,  who  have 
had  a  larger  experience  than  these  surgeons  have  realised  that  haemor- 
rhage may  at  times  not  only  unexpectedly  occur  and  give  rise  to 
serious  anxiety,  but  also  tax  the  ingenuity  and  skill  of  the  operator. 

Haemorrhage  may  occur  either  during  removal  of  the  growth, 
immediately  following  removal  or  some  hours  after  the  operation. 

HAEMORRHAGE    DURING    REMOVAL,  OK    THE    GrOWTH. 

During  removal  of  the  growth  a  considerable  amount  of  bleeding  may 
at  times  occur,  but  this  can  generally  be  easily  controlled  by  gauze- 
pressure,  dry  adrenalin  gauze  being  the  best  for  the  purpose,  and  if 
there  is  a  bleeding  point  artery  forceps  may  be  necessary. 

Persistent  oozing  frequently  occurs  after  separation  of  the  muscular 
attachment  round  the  arytaenoid  cartilage,  and  a  small  vessel  may  be 
found  between  the  arytenoid  and  lateral  wall  of  the  thyroid  cartilage, 
which  occasionally  spurts  and  may  give  considerable  trouble.  It  should 
be  picked  up  with  pressure-forceps  and  may  perhaps  require  ligaturing. 

1  See  Proc.  Roy.  Soc.  Med.,  1920,  vol.  xiii,  pp.  132-13.5. 
-  "  The  Opei-ative  Surgery  of  Malignant  Disease,"  1900,  p.  191. 
^  Discussion  on  E.  D.  D.  Davis's  Case  of  Laryngo-fissure  for  Epithelioma  of  the 
Eight  Vocal  Cord,"  Proc.  Roy.  Soc.  Med.,  1914,  vii  (Sect.  Laryngol.),  p.  198. 


November.  1920.]        Rhinology,  and  Otology.  327 

For  bleeding  in  the  larynx  the  galvano-cautery  has  been  advocated  by 
some  American  writers,  but  it  is  only  mentioned  here  to  be  condemned. 
After  cauterisation  haemorrhage  may  recur  as  a  result  of  sloughing  and 
the  surgeon  may  not  be  on  the  spot  to  deal  with  it,  and  the  patient  may 
be  lost  before  anyone  can  get  to  him.  Again,  as  a  result  of  the  cauteri- 
sation of  the  laryngeal  tissues,  extensive  inflammatory  reaction  and 
cicatrisation  may  follow,  causing  narrowing  of  the  airway,  and  it  has 
been  shown  that  the  voice  is  not  so  good  afterwards. 

Post-Operative  H.emorrhage. 

After  removal  of  the  growth  care  should  be  taken  not  to  close  the 
wound  until  all  bleeding  has  ceased  and  if  possible  the  inside  of  the 
larynx  has  become  dry  and  glazed.  However  carefully  any  bleeding 
may  be  controlled  before  closure  of  the  larynx,  a  reactionary  or  secondary 
haemorrhage  may  possibly  occur  in  from  four  to  six  hours.  It  is  more 
likely  to  take  place  in  full-blooded  or  alcoholic  subjects  or  in  those  cases 
where  the  growth  has  extended  deeply  into  the  subglottic  or  posteriorly 
into  the  arytsenoid  regions,  necessitating  considerable  excision  of 
muscular  tissue.  If  the  patient  is  restless,  with  only  slight  oozing  of 
blood,  an  injection  of  morphia  (gr.  ^)   may  be  all  that  is  required,  but 


Fig.  1. — Absorbent  nasal  splinting. 

great  care  should  be  taken  in  its  repetition,  in  view  of  the  susceptibility 
of  some  patients  to  narcotics,  and  the  danger  that  a  too  large  or  too 
frequently  repeated  dose  may  prevent  the  return  or  incomplete  return  of 
the  cough  reflex,  cause  locking  up  of  the  secretions,  and  the  patient  may 
"drown  in  his  own  mucous  secretions."  A  secondary  haemorrhage 
may  be  due  to  a  general  oozing  from  the  raw  surface  and  be  continuous 
and  severe  enough  to  necessitate  reopening  and  gauze  packing  of  the 
larynx,  or  it  may  arise  from  the  vessel  in  the  arytaenoid  region  and  be 
due  to  slipping  of  a  ligature  applied  before  closure  of  the  laryngeal 
fissure. 

If  secondary  haemorrhage  should  occur  and  an  injection  of  morphia 
is  insufficient  to  check  it,  the  larynx  should  be  reopened  without 
further  delay  and  vaseline  gauze  impregnated  with  bismuth  packed 
down  upon  the  tracheotomy  tube,  as  recommended  by  John  McKenty  ' 
(New  York)  after  hemi-laryngectomy,  a  small  drain  being  inserted  into 
the  lower  corner  of  the  larynx.  In  this  way  the  larynx  is  drained  of 
secretion,  which  is  prevented  from  getting  into  the  trachea  and  causing 
pneumonia.     The  gauze  is  removed  from  the  larynx  in  two  days. 

William  Hill  has  inserted  strips  of  compressed  nasal  splinting 
(Fig.  1)  into  the  larynx  in  a  case  where  bleeding  seemed  likely  to  occur, 
and  where  he  had  to  leave  the  patient  in  unskilled  hands.  The  larynx 
was  left  unsutured.  This  packing,  which  should  be  anchored  in  position 
by  silk  ligatures,  acted  most  satisfactorily  and  was  easily  removed  next 

1  Trans.  Amir.  Laryngol.  Assoc,  IQl-i,  p.  43. 


328 


The  Journal  of  Laryngology,      [November,  1920. 


day,  after  which  the  larynx  was  closed  by  sutures.  The  patient  made 
an  uninterrupted  recovery. 

Hasmorrhage  is  less  likely  to  occur  in  those  cases  in  which  a  tracheo- 
tomy tube  has  been  left  in  situ  for  a  few  hours,  since  the  quiet  and  free 
respiration  which  follows  relieves  the  larynx  of  considerable  strain  and 
reduces  the  risk  of  post-operative  haemorrhage. 

The  question  of  removal  or  otherwise  of  the  tracheotomy  tube  after 
completion  of  the  thyro-fissure  is  still  a  debatable  point.  If  it  is 
removed  and  obstruction  to  breathing  occurs  through  bleeding  or 
oedema  of  the  laryngeal  tissues,  it  may  be  difficult  to  find  the  opening 
hurriedly  and  reinsert  the  tube,  especially  into  the  deep  trachea,  when  a 
low  tracheotomy  has  been  performed.     If  the  surgeon  is  not  on  the 


Fig.  2. 


-ImnKuliati.'  rt'-openii);^' of  the  trachea  aiul  insertion  of  a  tracheotomy 
tube. 


spot,  dangerous  dyspnoea  may  suddenly  occur  and  the  patient  may 
become  asphyxiated.     (See  W.  G.  Porter's  case,  p.  330.) 

Moure^  (Bordeaux)  says  that  no  hard-and-fast  rule  can  be  laid  down 
applicable  to  all  cases.  The  opinion  of  the  writer,  after  considerable 
experience,  is  that  the  tube  may  be  permanently  withdrawn  in  the 
majority  of  cases  after  operation  without  much  risk,  whilst  in  a  few 
cases  its  immediate  removal  may  seriously  endanger  the  patient's  life. 
It  is  safer  to  retain  it  in  those  patients  who  have  a  high  blood- 
pressure  or  where  considerable  oozing,  difficult  to  control,  has  occurred 
during  removal  of  the  growth,  or  may  be  likely  to  recur,  or  where  the 
patient  is  out  of  immediate  reach  of  the  operator. 

On  account  of  the  more  superficial  position  of  the  trachea  in  the 
extended  operative  posture  of  the  neck,  as  compared  with  that  of  the 
normal  sitting-up  or  lying-down  position,  if  a  tracheotomy  tube  is  to  be 

'  Brit.  Med.  Journ.,  1903,  vol.  ii,  p.  1148. 


November,  1920.)         Rhinology,  and  Otology.  329 

retained  for  twenty-four  hours  after  operation,  clue  allowance  should  be 
made  for  this  difference  when  choosing  the  length  of  a  tube.  A  tube 
which  may  fit  accurately  in  the  operative  posture,  with  its  flange  level 
with  the  skin,  will,  after  the  patient  is  placed  back  in  bed,  be  too  short, 
and  may  easily  slip  out  of  the  trachea  into  the  soft  tissues  of  the  neck, 
causing  pressure  on  the  front  of  the  trachea,  and  a  condition  of  extreme 
gravity  may  in  some  cases  suddenly  arise,  especially  if  any  complication, 
such  as  haemorrhage  or  oedema,  occurs.  The  operator  may  be  out  of 
reach  and  no  one  on  the  spot  capable  of  dealing  with  the  situation.  A 
number  of  such  cases  have  occurred. 

This  can  be  avoided  by  using  a  short  tube  for  the  operation,  and 
replacing  it  by  a  longer  one,  say  3  in.  in  length,  before  the  patient 
leaves  the  operating-table. 

The  depth  from  the  surface  in  a  low  tracheotomy  varies  considerably 
in  each  individual.  H.  S.  Birkett  and  A.  G.  Nicholls^  (Montreal)  report 
a  case  where  unusual  difficulty  was  met  with  in  tracheotomy  owing  to 
the  great  depth  of  the  trachea.  It  was  found  to  be  3h  in.  from  the 
surface  and  an  unusually  long  tracheal  tube  was  required. 

In  view  of  the  difficulty  which  sometimes  occurs  of  finding  the 
tracheal  opening  when  a  tracheotomy  tube  has  to  be  hurriedly  reinserted 
after  operation,  especially  where  a  low  tracheotomy  has  been  performed 


Fig.  3. — Herff's  metallic  suture  clips. 

and  the  tracheal  opening  is  deep  down  in  the  neck,  Fletcher  Ingals^ 
(Chicago)  has  made  a  valuable  suggestion  which  might  be  made  use  of 
in  these  cases.  If  a  strong  ligature  is  passed,  one  through  each  side  of 
the  cut  edge  of  the  trachea  at  the  time  of  the  preliminary  tracheotomy, 
and  the  ends  knotted  together  on  each  side,  forming  two  loops,  the 
trachea  may  be  held  open  at  any  moment  by  drawing  on  them. 

After  a  thyro-fissure  is  closed  and  the  tracheotomy  tube  withdrawn, 
these  ligatures  may  be  left  in  position  for  twenty-four  hours,  and  if  the 
necessity  should  arise  of  reintroducing  the  tube  these  ligatures  may  be 
made  use  of  in  place  of  tracheal  dilators  or  hooks  to  draw  apart  the 
tracheal  incision. 

If  any  difficulty  in  breathing  should  occur,  due  to  bleeding  into  or 
oedema  of  the  larynx,  the  nurse,  by  drawing  upon  these  strings  on  each 
side  of  the  neck  in  place  of  a  tracheal  dilator,  may  immediately  re-open 
the  tracheal  wound,  so  that  the  impeded  respiration  may  be  relieved 
and  the  patient  tided  over  until  the  surgeon  arrives. 

MacKenty2  (New  York)  recommends  that  this  precaution  should 
always  be  taken  in  low  tracheotomies,  and  that  strong  silk  threads 
should  be  used  with  the  object  of  controlling  the  tracheal  opening  in 
case  the  tube  should  get  displaced  or  fall  out. 

The  present  writer  advises  that  Herff's  metallic  suture  clips  (Fig.  3) 

•  Montreal  Med.  Journ.,  May,  1899 ;  abstr.,  Jotjrn.  of  Lartngol  ,  Ehinol., 
AND  Otol.,  1899,  vol.  xiv,  p.  430. 

-  "  Diseases  of  the  Chest,  Throat,  and  Nasal  Cavities,"  1899,  p.  423. 

'  Journ.  of  Lartngol.,  Ehinol.,  and  Otol.,  1918^  vol.  xxxiii,  p.  340. 


330  The  Journal  of  Laryngology,       [November,  1920. 

should  be  employed  in  closing  the  wound  after  thyro-fissure  in  place  of 
silkworm  gut  suturing,  allowing  the  larynx  to  be  immediately  reopened 
in  any  case  where  haemorrhage  should  unexpectedly  occur.  These 
clips  require  no  forceps  for  applying  or  I'emoving,  as  in  the  case  of 
Michel's  sutures,  and  may  be  sterilised  and  used  again  and  again. 

Eecoeded  Cases  of  Hemorrhage. 

W.  G.  Porter  ^  in  1910  reported  the  case  of  a  female,  aged  fifty-nine, 
on  whom  he  performed  thyro-fissure  for  epithelioma  of  the  larynx, 
preceded  by  tracheotomy.  On  completion  of  the  operation  the  tracheo- 
tomy tube  was  removed,  and  the  skin-wound  closed  up.  The  patient 
was  placed  in  bed  in  the  sitting-up  position.  At  first  she  was  congested, 
and  couglied  up  fresh  blood,  but  she  gradually  became  quieter  and  the 
bleeding  ceased.  An  hour  later,  however,  a  sudden  attack  of  asphyxia 
occurred  ;  the  wound  was  quickly  opened  up,  and  the  tube  re-inserted. 
The  following  day  the  tube  was  removed.  Three  days  after  the  operation 
symptoms  of  pneumonia  supervened  and  the  patient  died  on  the  sixth 
day.  He  remarked  that  in  future  he  would  remove  the  tube  and  leave 
the  wound  open,  so  that  a  tube  could  be  easily  re-inserted  if  necessary. 

Felix  Semou  ~  in  1914  records  one  case  (previously  referred  to). 

Schmiegelow  -^  (Copenhagen)  in  1914  mentions  that  amongst  thirty- 
three  thyro-fissures  which  he  had  performed,  five  died  from  pneumonia 
due  to  post-operative  htBmorrhage. 

Kichardson  *  (Washington)  in  1914  refers  to  a  case  in  which  he 
removed  a  large  growth  extending  down  into  the  subglottic  region, 
followed  by  persistent  oozing  of  blood,  from  the  angle  between  the 
arytenoid  and  lateral  wall  of  the  thyroid  cartilage,  necessitating  the 
reopening  of  the  wound. 

•Also  he  refers  to  a  second  case  in  a  patient  aged  seventy,  in  which 
the  bleeding  occurred  from  the  same  position. 

Fitzgerald  Powell  ■'  in  1914  (in  discussion)  confirmed  Semon's 
experience  of  tlie  risk  of  secondary  haemorrhage  after  the  use  of 
adrenalin.  He  referred  to  one  or  two  cases  which  he  had  had,  in 
which  considerable  haemorrhage  followed,  before  the  wound  was  closed. 
In  one  case  a  very  bad  secondary  haemorrhage  occurred,  which  he 
attributed  to  the  use  of  adrenalin. 

StClair  Thomson  ^  in  1914  referred  (in  discussion)  to  much 
hsemorrhage  that  was  difficult  to  control.  Also  in  1918  he  reported 
two  cases  in  which  sharp  hiumorrhage  occurred  a  few  hours  after 
operation,  controlled  by  the  application  of  ice  to  the  neck,  and  an 
injection  of  morphia  (gr.  ^.).  Fortunately  in  both  cases  the  tracheotomy 
tube  had  been  leit-m  sUu,  so  that  a  hasty  re-introduction  was  un- 
necessary. 

J.  W.  Bond  "  in  1918  remarked  that  in  some  cases  haemorrhage  is 

1  "Eeport  (for  1908)  of  the  Ear  and  Throat  Department  of  the  Eye,  Ear  and 
Throat  Infirmary,  Edinburgh,"  Journ.  of  Lartngol.,  Khikol.,  and  Otol.j  1910^ 
vol.  XXV,  p.  179. 

■■2  Proc.  Roij.  Soc.  Med.,  1914,  vol.  vii  (Sect.  Laryngol.),  p.  198. 

=*  Lancet,  1914,  vol.  ii,  p.  301. 

■*  Trans.  Amer.  Laryngol.  ^ssor.,  1914,  p.  40. 

"  Proc.  Roy.  Soc.  Med.,  1914,  vol.  vii  (Sect.  Laryngol.),  p.  198. 

6  Ibid.,  1914,  vol.  vii  (Sect.  Laryngol.),  p.  197  ;  Journ.  of  Laryngol.,  Ehinol., 
AND  Otol.,  1919,  vol.  xxxiv,  p.  151. 

'  Ibid.,  1918,  vol.  xi  (Sect.  Laryngol.),  p.  153. 


November.  1920.]  Rhinology,  and  Otology. 


331 


severe,  and  that  he  had  operated  upon  a  case  in  1915  in  which  it  was 
necessary  to  use  eighteen  Hgatures,  probably  owing  to  the  fact  that  the 
patient  was  suffering  from  arterio-fibrosis.  From  the  report  of  the  case 
it  is  not  clear  whether  the  bleeding  occurred  from  the  superficial  vessels 
in  the  neck  or  from  the  inside  of  the  larynx. 

Bellamy  Gardner  i  in  1919  referred  to  one  patient  who  was 
"  drowned  "  by  after-haemorrhage  in  the  night,  the  tracheotomy  tube 
having  been  removed  immediately  after  operation. 

William  Hill  -  in  1919  recorded  a  case  where  a  spurting  vessel  in 
the  arytcenoid  region  required  ligaturing  after  removal  of  an  extensive 
growth  which  had  spread  to  the  subglottic  region.  The  tracheotomy 
tube  was  removed  immediately  after  the  operation,  and  haemorrhage 
occurred  six  hours  later,  either  from  slipping  of  the  ligature  or  from 
general  oozing.  Before  the  danger  was  realised  and  the  tube  re-inserted 
S 


Fig.  4. — Dissection  of  the  left  side  of  the  laxynx,  with  the  superior  laryn- 
geal artery  and  its  branches  injected.  (Natxiral  size.)  Specimen  195, 
Anatomical  Series.     From  Museum  of  the  Eoyal  College  of  Surgeons. 

the  patient  died  from  aspiration  of  blood  into  the  lungs.  Hill  remarks 
that  if  he  had  kept  in  the  tracheotomy  tube,  a  house-surgeon  would 
not  have  hesitated  to  reopen  the  laryngeal  cavity  and  pack  with  gauze. 
Another  case,  personal  knowledge  of  author,  recently  occurred  in 
the  hands  of  a  colleague,  but  has  not  been  published.  Tlie  patient 
was  aged  fifty-six.  During  removal  of  a  large  growth,  which  had 
extended  into  the  subglottic  area,  considerable  bleeding  occurred,  and 
was  followed  two  hours  later  by  a  sudden  haemorrhage  through  the 
tracheotomy  tube,  which  had  been  left  in  position.  Folloioing 
spontaneous  stoppage  of  the  bleeding  an  injection  of  morphia  (gr.  \) 
was  prescribed,  which  produced  drowsiness  in  the  patient,  diminution 
in  the  normal  cough  reflex,  and  locking  up  of  the  secretions.  Septic 
pneumonia  supervened,  and  the  patient  died. 

^  Personal  communication  to  author. 

-  Trans.  Med.  Soc.  of  London,  1919,  vol.  xlii,  jj.  105?. 


332  The  Journal  of  Laryngology,       [November,  1920. 

Tilley  ^  has  also  recently  referred  to  haemorrhage  difficult  to  contro- 
from  the  neighbourhood  of  the  arytgenoid.  "  If,"  he  remarks,  "  you 
cannot  stop  the  bleeding  from  the  vessel  by  direct  pressure  on  the 
bleeding  point,  you  can  secure  the  vessel  just  before  it  enters  the  larynx 
by  turning  back  the  skin,  etc.,  from  the  outer  wall  of  the  thyroid 
cartilage." 

From  the  above  records  it  will  be  seen  that  in  recent  literature 
seventeen  cases  of  serious  haemorrhage  have  been  reported  with  ten 
deaths.  In  a  number  of  these  cases  the  bleeding  was  observed  during 
operation  to  occur  from  a  spurting  vessel  in  the  arytenoid  region. 

These  cases  indicate  the  necessity  for  the  surgeon  to  be  either  on 
the  spot  or  close  at  hand  to  cope  with  any  reactionary  haemorrhage 
which  may  unexpectedly  occur,  and  may  endanger  the  patient's  life. 

With  a  view  to  ascertaining  the  main  source  of  htcmorrhage,  i.  e. 
the  exact  position  and  course  of  the  vessel  in  the  arytaenlid  region,  so 
as  to  permit  of  better  control  during  or  after  operation,  the  assistance 
of  Prof.  S.  G.  Shattock  was  obtained,  and  the  result  of  our  investigations 
will  now  be  recorded. 

Fig.  4  shows  a  dissection  of  tlie  larynx  made  from  the  left  side  with 
the  arteries  injected  (Specimen  No.  195,  Anatomical  Series,  from  the 
Museum  of  the  Royal  College  of  Surgeons).  This  has  been  especially 
drawn  for  me  by  kind  permission  of  Prof.  S.  G.  Shattock,  and  under  his 
supervision.     He  has  also  supplied  me  witli  tlie  following  description  : 

The  left  ala  of  the  thyroid  has  been  removed.  The  posterior  crico- 
arytaenoid,  and  above  this,  the  thyro-arytaenoid  muscles,  are  shown 
passing  to  their  insertion  into  the  arytaenoid  cartilage.  The  ventricle 
of  Morgagni  has  been  opened  from  the  external  aspect,  and  above  it 
lies  a  portion  of  the  sacculus.  The  artery  of  which  the  lower  end  is 
cut  across  is  the  superior  laryngeal,  and  from  it  there  arise  in  order 
from  above  downwards  —  (1)  From  the  inner  and  posterior  aspect  a 
short  bi'anch  which  subdivides  into  one  branch  directed  upwards  to 
the  mucous  membrane,  and  the  other  crossing  the  site  of  the  arytenoid 
cartilage  and  distributed  to  the  mucosa,  etc.,  behind  the  posterior 
arytaeno-cricoid  muscles.  The  tortuosity  of  this  vessel  is  noteworthy, 
and  may  be  referred  to  the  rotatory  movements  of  the  arytaenoid 
cartilage  over  which  it  runs.  (2)  Proceeding  dow-nwards  there  is  a 
branch,  cut  short,  from  the  front  of  the  main  artery,  followed  by  (3)  a 
long  offset,  passing  forwards  and  do^vnwards  to  the  thyro-arytgenoid 
muscle.  From  this,  a  short  way  from  its  origin,  there  is  a  branch, 
which  is  cut  short,  and  probably  represents  the  anastomotic  branch 
between  the  superior  and  inferior  laryngeal  arteries.  -  Next  in  order 
comes — (4)  a  branch  passing  inwards  to  the  thyro-arytaenoid  muscle 
in  the  neighbourhood  of  its  insertion.  And  finally  the  vessel  terminates 
by  bifurcating  to  supply  the  posterior  part  of  tlie  lateral  crico-arytaenoid 
muscle. 

Fig.  5  represents  a  horizontal  section  of  a  normal  larynx  from  a 
man  aged  twenty-four,  who  died,  cyanosed,  with  heart  disease  ;  the 
veins  are  distended  with  blood.  This  specimen  was  specially  prepared 
by  Prof.  Shattock  for  the  purpose  of  these  investigations.  The  section 
is  made  through  the  processus  vocalis  and  vocal  cords,  and  shows  the 

1  Pr'oc.  Roy.  Soc.  Med.,  1920,  vol.  xiii  (Sect.  Laiyn^^oL),  p.  122. 

-  A  coloured  illiistration  showing'  the  distribution  and  anastamoses  of  the 
laryngeal  artei-ies  will  be  found  in  Lusclika,  "Der  Xehlkopt  des  Menschen,"  1871, 
Taf.  viii,  fig.  1. 


November,  1920.]         Rhinology,  and  Otology.  333 

mass  of  the  thyro-arytaenoid  and  crico-arytaenoid  muscles  occupying 
the  space  between  the  cords  and  alae  of  the  thyroid  cartilage.  In  the 
more  posterior  part  of  the  muscular  mass  there  is  shown  on  the  left 
side  the  transversely  divided  superior  laryngeal  artery,  lying  close  to 
the  perichondrium,  and  on  the  right  side,  in  a  corresponding  position, 
but  somewhat  more  deeply  in  the  muscle,  there  are  three  small 
arteries,  derived  from  the  same  source.  The  veins  in  the  thyro- 
arytaenoid  muscle  in  the  angle  on  the  outer  side  of  the  processus 
vocales  are  conspicuous  in  number. 


Fig.  5.  — Horizontal  section  of  O' normal  larynx.  .\.  Kepresents  the  superior 
laryngeal  artery  or  its  branches.  (Natural  size)  Specially  prepared 
by  Prof.  S.  G-.  Shattock,  F.R.S. 

The  conclusion  we  may  draw  from  these  investigations  is  that  in 
those  cases  in  which  it  is  necessary  to  cut  through  a  considerable 
amount  of  muscular  tissue  close  up  to  or  including  the  arytsenoid 
cartilage  the  superior  laryngeal  artery  may  be  cut  or  injured.  Since 
this  vessel  enters  the  larynx  above  the  thyroid  alae  and  runs  vertically 
downwards,  and  in  this  situation  lies  close  against  the  perichondrium, 
further  separation  of  the  perichondrium  from  oli'  the  thyroid  ala  is 
indicated,  so  as  to  allow  the  vessel  to  be  more  easily  seized  by  pressure 
forceps  and  securely  ligatured.  I  think  we  shall  find  this  practical 
point  of  considerable  service  in  future  cases  which  come  under  our  care. 


TUMOUR  OF  THE  ACOUSTIC  NERVE;  OPERATION;  RECO- 
VERY; SUBSEQUENT  DEATH. 

By  E.  p.  Poulton,  M.D.,  and  W.  M.  Mollison,  M.Ch. 

The  following  case  was  sent  to  Dr.  Poulton  by  Dr.  Peers  of  Yarmouth, 
and  at  operation  a  small  tumour  was  removed  from  the  left  auditory 
nerve,  or  at  least  from  close  to  the  nerve.  The  operation  relieved  the 
woman's  symptoms,  but  she  subsequently  developed  mental  symptoms 
and  died  after  returning  home. 

Mrs.  T ,  aged  forty,   was  first  seen  by  Dr.  Poulton  at  Guy's 


3.34 


The  Journal  of  Laryngology,      [November,  1920. 


Hospital  on  December  14,  1917.  Her  main  symptoms  were  headache, 
retching  at  times,  staggering  gait  and  diminished  vision. 

Headache  had  begun  in  February,  1917.  The  pain  was  described  as 
a  dull  ache,  mainly  in  the  left  parietal  and  occipital  regions  ;  it  had 
become  severe  latterly. 

Eetching  came  on  about  once  a  month  and  lasted  about  half  an 
hour  at  a  time.  She  had  a  reeling  gait  and  tended  to  fall  to  the  left 
side  when  walking. 

The  right  eye  had  always  had  less  good  sight  than  the  left,  but  both 
were  rapidly  getting  worse.  Optic  neuritis  was  present  on  both  sides ; 
Dr.  Johnson  Taylor,  of  Norwich,  was  of  opinion  that  relief  of  intra- 
cranial pressure  was  the  only  hope  of  retaining  even  a  modicum  of 
vision.  Nystagmus  was  present  in  both  directions.  Later  examination 
showed  nystagmus  more  marked  to  the  left  side. 

Dysdiadokokinesis  present  on  left  side.  Tliere  was  no  tremor,  and 
the  sense  of  position  in  space  was  normal. 


X-ray  examination  of  the  skull  showed  the  pituitary  fossa  normal. 

Though  the  patient  was  excitable  and  voluble  she  showed  no 
symptoms  of  mental  derangement.  Lumbar  puncture  was  performed 
and  the  fluid  escaped  under  increased  pressure,  but  it  was  clear  and 
contained  no  cells  on  microscopical  examination.  Wassermann's  test 
applied  to  it  gave  a  completely  negative  result. 

Examination  of  the  ears  showed  normal  membranes  ;  there  was  no 
abnormality  in  the  nose,  nasopharynx  or  pharynx ;  the  Eustachian 
tubes  were  normal.  The  hearing  of  the  right  ear  was  normal ;  the  left 
ear  appeared  to  be  deaf  for  all  tones. 

Caloric  (cold)  stimulation  of  the  labyrinth  gave  reaction  with 
vertigo  and  contralateral  nystagmus. 

The  clinical  picture  indicated  some  lesion  in  the  left  posterior  fossa 


November,  1920]         Rhinology,  and  Otology.  335 

and  the  deafness  made  the  diagnosis  of  acoustic  nerve  tumour  possible. 
Exploration  of  the  posterior  fossa  was  decided  upon. 

Operation  on  January  11,  1918. — The  cerebellum  was  approached 
through  the  occipital  bone  forming  the  floor  of  the  posterior  fossa. 

A  skin  flap  was  turned  down  behind  the  ear  and  the  attachments  of 
the  suboccipital  muscles  stripped  from  the  bone.  Bone  was  removed 
as  high  up  as  to  expose  the  lateral  sinus  and  as  low  down  as  possible 
towards  the  base  of  the  skull. 

The  dura  mater  of  the  posterior  fossa  was  under  much  tension, 
though  it  was  noticed  that  the  lateral  sinus  collapsed  on  inspiration. 
The  dura  was  opened  by  an  incision  convex  upwards  ;  after  the  escape 
of  cerebro-spinal  fluid  the  cerebellum  was  held  aside  and  a  small 
rounded  swelling  was  seen  on  what  appeared  to  be  the  eighth  nerve. 
With  a  "spoon"  part  of  this  was  removed;  it  showed  yellow  spots, 
which  were  almost  gritty.  The  tumour  felt  firmer  than  the  surrounding 
brain.  The  dura  mater  was  partly  sutured ;  green  protective  was 
inserted  into  the  anterior  part  of  the  posterior  fossa  to  act  as  a  drain ; 
the  skin  was  sutured. 

The  following  day  the  patient's  condition  was  very  fair  ;  she  still 
had  some  anaesthetic  vomiting  ;  there  was  now  no  nystagmus  to  the 
left  as  there  was  before  operation. 

During  the  next  few  days  the  temperature  was  raised,  but  steady 
progress  was  made.  The  headache  had  disappeared,  and  she  could 
hear  whispered  words  at  six  inches  from  the  left  ear.  This  extra- 
ordinary improvement  in  hearing  must  point  to  one  of  two  conclusions: 
either  that  the  almost  complete  deafness  beforehand  was  in  part 
functional,  or  that  the  tumour  was  only  pressing  on  the  nerve  and  did 
not  actually  involve  the  nerve. 

The  patient  was  able  to  get  up  three  or  four  weeks  after  operation 
and  was  taken  home  to  Yarmouth.  Subsequently  she  developed 
mental  symptoms  and  died.  Microscopically  the  growth  was  found  by 
Dr.  Nicholson  to  be  "  a  soft  fibroma  with  granular  matrix." 


THE   AQUEDUCT   OF   FALLOPIUS   AND   FACIAL   PARALYSIS. 

By  Dan  McKenzie. 

Part  II :  Facial   Paralysis. 

{Continued  from  'p.  304.) 

The  Palliative  Treatment  of  Facial  Paralysis. 

Electrical  stimulation  of  the  paralysed  muscles  should  be  continued 
as  long  as  any  contraction  can  be  obtained,  that  form  of  current  being 
employed  to  which  the  muscles  most  readily  respond.  A  seance  once 
or  twice  a  week  is  probably  sufficient  and  it  may  be  combined  with 
gentle  massage. 

The  care  of  the  eye  requires  attention.  On  the  dry,  unswept  cornea 
dust  is  apt  to  hnger  and  conjunctivitis  may  ensue  and  even  ulceration. 
In  order  to  avoid  this  awkward  complication  castor  oil  may  be  dropped 
periodically  into  the  conjunctival  sac,  and  the  eyelids  should  be  kept 
closed  by  means  of  a  pad  and  bandage  if  necessary. 


336  The  Journal  of  Laryngology,      [November,  1920. 

Tarrsoraphy  has  sometimes  been  employed  to  reduce  the  gaping 
palpebral  fissure  in  incurable  cases.  It  consists  in  rawing  the  margins 
of  the  upper  and  lower  lids  in  the  neighbourhood  of  the  external  com- 
missure and  in  suturing  the  lids  together  for  some  distance.  Another 
plan  consists  in  shortening  the  lower  lid  by  the  excision  of  a  wedge. 

H.  D.  Gillies  also  has  endeavoured  to  overcome  the  paralysis  of  the 
lids  by  the  implantation  of  a  fine  lamina  of  cartilage  close  to  the  palpebral 
edge  of  the  upper  and  lower  lids. 

A  Splint  for  Facial  Paralysis.— C  E.  Dennis,  in  order  to  prevent 
overstretching  of  the  paralysed  facial  muscles  by  the  active  muscles  of  the 
healthy  side  has  suggested  the  use  of  a  splint  consisting  of  a  piece  of 
malleable  German  silver  wire,  bent  so  as  to  hook  into  the  corner  of 
the  mouth  and  over  the  ear  of  the  affected  side,  like  the  curl  side 
of  spectacles.  Properly  adjusted  it  does  not  makd"  the  mouth  sore,  and 
it  is  greatly  appreciated  by  the  patient. 

Muscle  Transplantation. 

Of  recent  origin  also  is  the  palliative  treatment  of  facial  paralysis 
by  muscle  transplantation.  Slips  from  neighbouring  muscles — usually 
the  temporal,  but  occasionally  the  masseter  (Somerville  Hastings) — are 
employed. 

In  the  case  of  the  temporal  "  an  incision  is  made  in  the  hair  line 
from  the  zygoma  to  the  upper  limit  of  the  temporal  fossa,  directed 
backwards  so  as  to  be  parallel  to  the  underlying  fibres  of  the  temporal 
muscle.  The  skin  is  then  undermined  forwards  and  backwards  to  expose 
the  temporal  fascia.  Two  parallel  incisions  are  then  made,  again  from 
the  zygoma  to  the  limit  of  the  temporal  fossa  through  the  fascia  and 
muscle  down  to  the  bone.  These  incisions  should  run  in  the  direction 
of  the  muscular  fibres,  and  should  include  a  strip  of  muscle  as  thick  as 
a  man's  thumb.  ...  A  smaller  slip  anterior  to  this  is  similarly 
isolated,  and  both  are  detached  from  the  bone,"  but  are  left  attached  at 
their  lower  end  (Geo.  Fenwick).  H.  D.  Gillies  advises  the  removal  of 
the  temporal  fascia  covering  these  slips. 

The  next  step  consists  in  undermining  the  skin  of  the  face  in  two 
directions — first,  to  the  lower  edge  of  the  orbit ;  and  second,  as  far  as 
the  corner  of  the  mouth.  In  making  the  second  of  these  tunnels  it  is 
necessary  to  avoid  penetrating  the  buccal  cavity,  and  the  tunnel  should 
pass  anterior  to  the  orifice  of  Stenson's  duct. 

A  modification  which  I  have  adopted  enables  us  to  anchor  these 
muscle  strips  in  their  new  positions  with  little  or  no  scarring  of  the  face. 
To  the  free  end  of  the  temporal  muscle  slip  a  long  thread  of  silk  or 
catgut  is  firmly  secured  and  left  with  two  long  ends.  Each  of  these 
ends  in  turn  is  threaded  through  a  long  straight  needle,  and  the  needles 
arfe  passed,  one  after  the  other,  to  the  mouth  or  eye,  as  the  case  may  be, 
through  the  tunnel  which  has  been  made  in  the  face.  The  first  needle 
is  pushed  through  the  skin  from  within  out  to  emerge  on  the  surface  of 
the  face,  and  it  is  followed  by  the  second  needle  ;  but  the  second  is 
brought  out  about  a  quarter  of  an  inch  from  the  point  of  exit  of  the  first. 
There  are  now  two  threads  on  the  face  emerging  from  needle  punctures 
about  a  quarter  of  an  inch  from  each  other.  After  the  threads  have  been 
well  pulled  so  as  to  bring  the  end  of  the  muscle  slip  to  which  they  are 
attached  through  the  tunnel  to  its  destined  situation,  the  two  punctures 
are  joined  by  an  incision,   and  the  incision  is  deepened  to  the  sub- 


November,  1920.]         Rhinology,  and  Otology.  337 

cutaneous  level.  Here  the  two  threads  are  firmly  tied  together  and  cut 
short,  the  knot  being  buried.  Finally,  the  edges  of  the  tiny  incision  are 
brought  together  with  a  single  suture  of  horse-hair  and  sealed  with 
collodion.  The  resulting  scar  is  almost  invisible,  and  yet  the  end  of  the 
muscle  slip  is  quite  firmly  secured. 

Muscle   transplantation    is  still   on   trial.      (See    also    Jourx.    of 
Laetkgol.,  Ehinol.,  and  Otol.,  May,  1920,  p.  155.) 

The  End. 


SOCIETIES'    PROCEEDINGS. 


ROYAL  SOCIETY  OF  MEDICINE.— LARYNGOLOGICAL 

SECTION. 


December  6,  1919. 


President :  Dr.  James  Donelan. 


Discussion  on  Dilatation  of  the  (Esophagus  without  Anatomical 
Stenosis.' — William  Hill. — Diffuse  dilatation  of  the  oesophagus  without 
anatomic  organic  narrowing  in  the  region  of  the  cardia  is  usually  in  its 
early  stages,  at  all  events  of  the  spindle-shaped  type,  though  later  lateral 
lobulations  may  develop,  especially  near  the  phrenic  level,  where  there  is 
sometimes  an  abrupt  obtuse  termination  of  the  dilatation.  The  ectasia 
is  in  most  cases  limited  to  the  thoracic  gullet,  though  in  very  advanced 
ones  the  cervical  oesophagus,  the  pharyngo-oesophageal  orifice,  and  even 
the  lower  phaiwnx  are  much  enlarged.  In  a  few  observed  cases  some 
elongation  of  the  gullet  has  been  demonstrated  in  addition  to  great 
increase  in  calibre,  the  viscus  then  taking  a  sigmoid  course  in  the  chest. 
There  is  stasis  of  ingesta  due  to  its  passage  being  distinctly  impeded  at 
the  level  of  the  diaphragm,  but  when  the  dilated  gullet  in  these  cases  is 
removed  and  examined  post-mortem  the  lumen  of  the  phreno-cardiac 
segment  is  found  to  be  not  subnormal,  and  in  certain  and  rare  cases,  to 
be  alluded  to  later,  it  may  even  here  be  actually  enlarged.  We  have  to 
do  generally,  therefore,  with  a  normal  potential  lumen  of  the  gullet  at 
the  phrenic  level  and  immediately  below  it,  in  combination  with  a 
functional  stenosis  and  arrest  of  food  at  the  phrenic  level  and  ectasia 
above. 

In  some  instances  the  cause  of  this  stenosis  is  obvious — e.  g.  in  cases 
of  either  hernia  or  of  eventration  of  the  diaphragm  in  which  the  stomach 
assumes  a  thoracic  position  considerably  higher  up  than  normal  under 
the  left  ribs,  thus  pi'oducing  angulation  or  kinking  of  the  subphrenic 
oesophagus. 

Dilatation  of  the  whole  of  the  gullet,  including  the  phreno-cardiac 
portion,  has  exceptionally  been  observed  in  cases  of  hour-glass  constriction 
of  the  stomach  and  in  marked  pyloric  stenosis  of  long  standing.  This 
latter  group,  like  the  previous  group — viz.  that  due  to  upward  displace- 

1  W.e  reg-ret  that  lack  of  space  prevents  the  insertion  of  anj'  more  than  a  portion 
of  this  interesting  discussion. — Ed.,  Joukn.  of  Labtngol.,  Ehinol.,  and  Otol. 

22 


338  The  Journal  of  Laryngology,      ^NovemiDer,  1920. 

ment  of  the  stomach — can  be  differentiated  by  the  aid  of  the 
X  rays  from  the  ordinary  type  of  dilated  thoracic  oesophagus,  in  which 
there  is  neither  external  pressure  nor  angulation  nor  intrinsic  anatomic 
narrowing  of  the  lumen  below,  and  in  which  the  inability  of  the  food  to 
pass  freely  through  a  potentially  normal  lumen  appears  to  justify  the 
term  "fuiactional  stenosis."  Tlie  latter  condition  presents  a  constant 
X-ray  picture  as  the  bismuth  meal  in  well-mai-ked  cases  of  oesophagectasia 
is  seen  arrested  at  the  phrenic  level,  not  passing  immediately  into  the 
stomach.  The  same  picture  is,  however,  observed  in  fibrous  stricture  and 
other  forms  of  true  anatomic  stenosis  of  the  phreno-cardiac  gullet,  and 
the  differential  diagnosis  can  only  be  certainly  made  by  endo-oesophageal 
inspection  of  the  phreno-cardiac  region  by  means  of  large-sized 
endoscopic  tubes.  I  employ  an  oesophagoscope  18  mm.  in  diameter  for 
choice,  and  if  such  tubes  can  be  passed  into  the  stomach  there  is  no 
anatomic  stricture.  Blind  bougieing  has  been  much  relied  on  in  the  past 
in  order  to  ascertain  the  non-anatomic  character  of  the  stenosis ;  and 
when  a  large  bougie  passes  readily  into  the  stomach  it  is  strong  presump- 
tive evidence  in  favour.  But  a  sense  of  stricture  due  to  spasmodic 
gripping  of  the  bougie  behind  the  cricoid  sometimes  leads  to  error. 
When  a  soft  rubber  hollow  bougie  of  large  calibre  filled  with  mercury  is 
seen  with  the  aid  of  the  X-ray  sci-een  to  pass  without  impediment  into 
the  stomach  this  test  can  be  relied  on  as  pointing  to  the  absence  of  an 
organic  stricture ;  but  if  the  gullet  presents  a  truncated  and  lobulated 
dilatation  at  the  phrenic  level  the  nose  of  the  bougie  may  fail  to  bit  off 
the  entrance  to  the  phreno-cardiac  gullet  ;  the  test  then  fails  to  differ- 
entiate between  a  functional  and  an  anatomic  organic  stricture  in  this 
region,  so  that  the  superiority  of  the  oesophagoscopic  method  as  a  certain 
method  of  diagnosis  and  applicable  to  all  cases  is  evident. 

Most  physicians,  surgeons  and  radiologists,  even  at  the  present  day, 
speak  of  the  site  of  the  stenosis  being  at  the  cardia  ;  we,  however,  of 
course  know  that  the  X-ray  findings  show  that  the  arrest  of  the  bismuth 
is  at  the  level  of  the  diaphragm.  Chevalier  Jackson  was,  I  think,  the 
first  to  call  attention  to  the  correct  level,  and  he  discarded  Mikulicz's 
term  "  cardiospasm  "  as  applied  to  these  cases,  and  substituted  that  of 
''  phrenospasm  "  in  the  first  edition  of  his  book.  Cardiospasm  is  a  term 
that  was,  and  still  is,  employed  m  reference  to  two  types  of  obstruction 
near  the  lower  end  of  the  gullet,  viz.  (1)  to  cases  of  hypertrophic 
anatomic — i.  e.  organic — stenosis  with  ectasia  of  the  thoracic  gullet 
above,  which  are  supposed  to  have  originated  in  pure  hypertonic  spasm 
of  the  cardiac  circular  fibres  and  with  subsequent  hypertrophic  muscular 
narrowing  of  the  lumen  ;  and  (2)  to  cases  of  spasm  of  these  fibres 
without  subsequent  hypertrophic  anatomic  stenosis.  Whether  the  first 
sequence  actually  occurs  is  now  being  questioned  in  some  quarters,  but 
many  hold  not  only  that  it  does  occur,  but  that  long-standing  cardio- 
spasm is  always  followed  by  hypertrophy  locally  and  ectasia  above,  and 
that  the  absence  of  hypertrophy  in  functional  non-anatomic  stenosis 
necessarily  excludes  true  cardiospasm.  Some — e.  g.  Brown-Kelly — 
however,  who  up  to  recently  employed  the  term  "  cardiospasm,"  were 
careful  to  explain  that  they  only  meant  a  state  of  non-relaxation  of 
the  circular  fibres  of  the  cardia  which  should  normally  occur  as  a  part 
of  the  neuro-muscular  co-ordinate  act  of  swallowing.  Hurst,  believing 
that  a  true  spasm  leads  to  hypei'trophic  stenosis,  therefore  substituted 
the  term  cardiac  "  achalasia "  for  that  of  "  cardiospasm  "  where  only 
functional  stenosis  was  inferred  from  the  free  passage  of  a  large  mercury- 


November.  1920.]         Rhinology,  and  Otology.  339 

filled  tube.  This  terminology  is  more  acceptable  to  many  than  the  old 
one  of  cardiospasm,  and  it  may  perhaps  be  that  this  explanation  of  want 
of  relaxation  is  a  correct  one  of  what  occurs  in  some  few  cases,  though 
personally  I  have  not  satisfied  myself  that  the  stenosis  has  been  at  the 
cardiac  level  in  any  of  my  patients.  The  term""^'  cardiospasm  "  I  have 
discarded  for  the  same  two  reasons,  and  in  addition  it  may  be  pointed 
out  that  the  special  mark  of  a  hypei'tonic  spasm  in  the  alimentaiy  canal 
is  painful  ci'amp  or  colic,  which  as  a  primary  phenomenon  is  not  evident 
in  my  experience,  though  frequent  enough  as  a  secondary  symptom  when 
food  is  impacted  or  arrested. 

Holding  that  there  is  no  convincing  evidence  that  either  cardiospasm 
cr  cardiac  achalasia  ever  exist  as  primary  phenomena,  and  seeing  that  the 
level  of  stenosis  is  not  at  the  cardia  but  at  the  level  of  the  hiatus 
cesophageus  of  the  diaphragm  (where  the  gullet  is  embraced  by  the  crura, 
which  constitute  a  potential  extra-oesophageal  sphincter),  I  regard  these 
terms  as  likely  in  course  of  time  to  become  obsolete.  In  reference  to  the 
phrenospasm  hypothesis  of  Jackson,  it  may  be  said  that  as  a  secondary 
symptom  we  are  all  familiar  with  it,  but  if  Jackson's  former  views  had 
been  correct  then  we  should  have  had  to  assume  in  the  majority  of  these 
functional  cases  a  primary  spasm  of  the  crural  fibres  without  the  usual 
mark  of  diaphragmatic  spasm,  viz.  hiccough.  I  do  not  know  if  Jackson 
has  advanced  matters  very  much  in  his  new  edition  by  throwing  over  the 
term  "  phrenospasm  "  and  substituting  that  of  "  hiatal  oesophagismus," 
meaning  apparently  thereby  both  an  accentuation  or  spasm  of  the  normal 
tonic  contraction  of  the  crura  surrounding  the  gullet  at  the  hiatus 
cesophageus  of  the  diaphragm,  and  also  of  the  circular  fibres  of  the  gullet 
itself  at  that  level.  As  a  mercury-filled  tube  in  these  cases  passes  readily 
through  the  gullet  at  the  hiatal  level  there  can  certainly  be  no  powerful 
hypertonic  spasm  of  the  crural  fibres  or  of  the  circular  fibres  of  the  gullet 
itself,  and  no  very  obvious  evidence  of  any  distinct  obstructive  tonic 
contraction  which  is  assumed  by  him  to  occur  here. 

All  these  hypotheses,  be  it  noted,  proceed  on  the  assumption  that 
general  ectasia  of  the  thoracic  gullet  is  secondary  to  primary  obstruction 
of  one  or  other  portions  of  the  phreno-cardiac  segment  of  the  oesophagus 
brought  about  by  muscular  action  or  overaction. 

I  tentatively  suggested  some  years  ago  that  there  might  possibly  be  a 
block  or  impediment  to  the  free  passage  of  food  due  to  an  opposite 
<jause — viz.  neuro-muscular  paresis  and  absence  of  co-ordinate  active 
opening  up  of  the  phreno-cardiac  gullet  during  the  act  of  swallowing. 
At  rest  the  gullet  is  collapsed,  not  open  at  the  hiatal  level,  being 
embraced  and  possibly  gripped  by  the  crura  ;  at  the  same  time  the  hole 
for  the  passage  of  the  gullet  through  the  diaphragm  (hiatus  cesophageus) 
is  a  naiTow  lanceolate  slit ;  during  the  act  of  swallowing  the  hiatus 
enlarges  and  its  margin  assumes  a  circular  form,  and  a  wider  cross- 
section  brought  about  by  phrenic  and  possibly  sympathetic  nerve  action 
on  the  muscular  crura  ;  and  instead  of  a  collapsed  oesophageal  lumen  at 
the  hiatal  level  the  gullet  here  follows  the  expanded  hiatus,  and  thus  we 
have  an  open  tube.  The  exact  sequence  of  events  and  the  factors  involved 
in  this  neuro-muscular  effect,  resulting  in  the  active  opening  up  of  the 
phreno-cardiac  gullet  during  the  act  of  swallowing,  has  not  been 
satisfactorily  elucidated,  but  paretic  abeyance  of  this  normal  act  of 
active  opening  up  of  the  lumen  by  muscular  action  would  necessarily 
lead  to  a  less  free  passage  of  food.  The  difficulty  in  the  way  of  securing 
acceptance  for  an  alleged  strictly  localised  paresis  in  this  circum-hiatal 


340  The  Journal  of  Laryngology^     [November,  1920. 

neuro-musculai"  mechanism  is  further  increased  by  postulating  that  the 
derangement  producing  such  chronic  and  far-reaching  and  gross  results 
is  pi'imarilv  of  a  purely j^uuctional  character,  seeing  that  it  occurs  equally 
in  males  and  females  and  not  especially  in  neurotic  subjects.  On  the 
other  hand,  there  is  no  evidence  of  a  primary  organic  paralysis  of  the 
phrenic  nerves  which  would  account  for  such  interference  with  the  co- 
ordinate act  of  swallowing  at  this  level,  such  as  would  tend  to  stenosis 
and  secondary  dilatation  of  the  gullet  above.  If  a  localised  neuro- 
muscular "block"  really  occurs  at  this  level,  however  loth  I  am  to  fall 
back  on  the  functional  neurosis  explanation,  I  can  find  no  other  likely 
pathogenesis  at  hand.  I  regard  the  neurosis  as  extra-oesophageal  rather 
than  instrinsic — i.  e.  it  is  not  in  the  actual  oesophageal  musculature,  as 
has  been  generally  assumed  by  others,  but  probably  referable  to  the 
crural  fibres  surrounding  the  hiatus. 

Mr.  Shattock,  in  a  discussion  on  a  paper  by  Batty  Shaw  and  Woo,^ 
states  that  he  is  led  to  the  hypothesis  that  o?sophagectasia  "  is  due  ta 
an  inco-ordiuation  of  the  nervous  impulses  transmitted  by  the  vagus 
during  deglutition,  which  impulses  should  normally  cause  contraction  of 
the  tube  above  and  an  active  dilatation  of  tlie  cardia."  This  explanation 
nearly  corresponds  with  that  of  H.  D.  Rollestoii  and  of  Hurst.  Whilst 
agreeing  that  the  essential  primary  cause  in  these  cases  is  of  the  nature 
of  neuro-musculai-  inco-ordination,  I  regard  the  enlargement  by  criu*al 
action  of  the  hiatus  in  the  diaphragm  (for  the  oesophagus)  as  of  much 
more  importance  than  mere  relaxation  of  the  cardia.  If  the  peccant 
mechanism  is  really  in  the  diaphragm,  then  Mr.  Shattock  is  wrong  in 
asserting  that  dilatation  of  the  oesophagus  is  idiopathic  and  due  to 
sympathetic  and  vagal  vagaries;  it  would  largely  be  secondary  to  an 
extra-oesophageal  phrenic  factor  in  the  complex  co-ordinate  act  of 
deglutition. 

The  older  authorities,  even  up  to  and  including  Zenker  and  Morell 
Mackenzie,  felt  no  difiiculty  in  regarding  dilatation  of  the  thoracic 
oesophagus  without  anatomic  stenosis  below  as  a  primajy  idiopathic 
condition,  and  due  to  a  sort  of  myasthenia  or  diminished  contractile 
power  of  tlie  musculature ;  as,  however,  hypertrophy  rather  than 
muscular  atrophy  is  a  fairly  constant  feature  except  at  the  site  of 
greatest  dilatation,  where  there  may  be  partial  atrophic  thinning  of  the 
muscular  coats,  this  hypothesis  was  generally  abandoned  even  before 
the  introduction  of  X  rays  demonstrated  that  fairly  strong,  though 
ineffectual  because  not  Avater-tight,  peristaltic  contractions  occurred 
when  bismuth  paste  was  swallowed.  This  shows  that  the  circular  fibres 
remain  active,  so  primary  atony  is  apparently  ruled  out.  It  is  interesting 
to  note  that  Zenker  and  von  Ziemssen,  in  their  well-known  contribution 
on  "  Diseases  of  the  Qi]sophagus,"  not  only  regard  the  ectasia  as  primary 
in  cases  where  there  is  no  anatomic  stenosis  immediately  below,  but  they 
do  not  suggest  any  purely  functional  stenosis  below  as  entering  into  the 
pathogenesis  ;  spasm  they  describe  as  a  separate  morbid  entity,  but  state 
that  it  does  not  lead  to  subsequent  ectasia.  They  state  that  in  addition  to 
stagnation  ectasias  above  an  anatomic  organic  stricture  there  are  also  "rare 
cases  with  considerable  and  occasionally  enormous  ectasiae  in  which  there 
is  no  underlying  stenosis  whatever,''  thus  apparently  excluding  functional 
stenosis  not  only  of  a  spasmodic,  but  also  of  a  paretic  nature.  The 
circular  fibres  are  supposed  to  be  innervated  by  the  sympathetic,  and  it  is 
curious  to  note  that  so  far  back  as  1895  H.  D.  Rolleston  suggested  that 

'  Proc.  Roy.  Soc.  Med.,  1916-17,  vol.  x  (Sect.  Med.),  pp.  16,  17. 


iTovember,  1920.]  Rhinology,  and  Otology.  341 

the  paresis  primarily  affected  only  the  longitudinal  fibres  which  are 
supplied  by  the  vagus,  and  that  this  vagal  paralysis  "would  allow  dilata- 
tion of  the  tube  to  occur,  and  at  the  same  time  by  interfering  with  the 
opening  of  the  cardiac  sphincter  would  induce  hypertrophy  of  the  circular 
muscular  coat."  *  How  paralysis  of  the  longitudinal  fibres  innervated  by 
the  vagus  exactly  interferes  with  the  opening  of  the  lower  end  of  the 
gullet,  aud  alternately  what  part,  if  any,  the  longitudinal  fibres  play  in 
tlie  active  opening  up  of  the  phreno-cardiac  oesophagus,  Eolleston  does 
not  explain,  but  I  have  long  thought  that  there  is  nothing  inherently 
improbable  in  the  suggestion  that  the  longitudinal  fibres  of  the  gullet  and 
the  longitudinal  and  oblique  fibres  of  the  stomach  possibly  play  some 
accessory  part  in  the  opening-up  during  deglutition  of  the,  at  other  times, 
closed  phreno-cardiac  gullet. 

Jackson  has  pointed  out  that  with  a  large,  dilated  atonic  stomach 
filled  with  gas  there  is  sometimes  dysphagia,  which  is  at  once  relieved 
when  the  patient  has  got  rid  of  the  flatus  by  eructation ;  and  I  have 
observed  tl^at  in  cases  with  phreno-cardiac  stenosis,  whether  organic  or 
functional,  some  patients  testify  that  they  can  swallow  better  after  they 
have  succeeded  in  relieving  the  wind  in  the  stomach  by  belching.  These 
facts  have  led  to  the  suggestion  that  affections  of  the  stomach  other 
than  those  noted  earlier  in  my  remarks  niay,  by  producing  angulation  of 
the  subphrenic  gullet,  be  the  primary  cause  in  some  cases  of  cesophagec- 
tasia  without  intrinsic  anatomic  stenosis.  In  several  of  my  own  cases 
there  has  been  not  only  a  history  of  chronic  gastric  disorders,  but  in 
some  marked  gastroptosis  has  been  seen  by  the  X  rays.  But  Shattock 
states  that  there  is  no  post-mortera  evidence  of  angulation  of  the 
subphrenic  gullet  in  these  cases,  and  I  may  add  that,  though  I  .have 
looked  for  it,  I  have  never  seen  such  angulation  by  the  X  rays ;  the 
bismuth  passes  either  in  a  straight  or  else  in  a  slightly  curved  stream, 
not  in  the  least  approaching  a  kmk.  Whilst  hesitating,  then,  to  accept 
the  hypothesis  that  gastric  disorders  (especially  where  there  is  dilatation 
and  fermentation)  are  a  primary  cause  of  functional  stenosis  of  the  lower 
gullet,  followed  by  ectasia  above,  I  admit  that  these  disorders  aggravate 
the  condition  when  established,  and  that  treatment  of  the  stomach, 
especially  by  lavage,  relieves  to  some  extent  the  dysphagia  and  is  an 
important  part  of  the  treatment. 

Dr.  Brown  Kelly  will  deal  more  especially  with  the  question  of 
treatment ;  but  successful  methods  of  treatment  sometimes  give  clues 
which  help  to  clear  up  obscure  points  in  aetiology,  and  I  must  make 
some  remarks  from  that'  point  of  view.  As  functional  stenosis  has  been 
held  to  be  due  to  paresis,  it  might  be  expected  that  the  therapeutic 
application  of  electricity  would  supply  some  corroborative  information. 
This  is  not  so.  The  faradic  current  only  acts  on  striped  muscle,  which 
does  not  extend  much  beyond  the  upper  third  of  the  gullet.  The  use 
of  the  ordinary  constant  galvanic  current  is  contra-indicated  in  a  moist 
tube  like  the  gullet  on  account  of  the  danger  of  electrolytic  action. 
The  sinusoidal  current  is  safe,  but  in  the  only  case  in  which  I  tried  it 
it  failed.  It  is  generally  held  that  the  alleged  functional  stenosis  at  or 
near  to  the  lower  end  of  the  gullet  with  ectasia  above  is  best  and  more 
or  less  successfully  treated  by  the  same  methods  of  dilatation  of  the 
phreno-cardiac  portion  as  are  appropriate  to  unequivocal  organic 
strictures.  Personally  I  have  not  obtained  the  uniformly  gratifying 
results  recorded  by  others  by  bougieing  and  other  dilatation  methods 

1  Trans.  Path.  Soc.  LoncL,  1896,  vol.  xlvii,  p.  39. 


342  The  Journal  of  Laryngology,      [November,  1920. 

in  cases  where  the  diagnosis  of  absence  of  anatomic  stenosis  was  unequi- 
vocal— i.  e.  where  a  mercui-y-filled  tube  easily  passed  into  the  stomach, 
clearly  demonstrating  that  the  lumen  of  the  phreno-cardiac  gullet  was 
not  merely  potentially  but  actually  normal.  This  test  appears  to  me  not 
only  to  demonstrate  a  normal  kmien,  but  to  exclude  intrinsic  spasm  and 
probably  also  achalasia  of  the  circular  fibres  of  the  gullet,  both  at  the 
hiato-phrenic  and  cardiac  levels,  and  also  spasm  and  achalasia  of  the 
crural  fibres  (at  the  hiatal  level  of  the  diaphragm).  The  effect  of 
dilatation  by  large  bougies,  hydrostatic  and  pneumatic  bags,  and  by  the 
passage  of  endoscopic  tubes  of  large  calibre,  is  of  course  very  beneficial 
in  cases  wrongly  assumed  to  be  purely  functional,  but  in  which  actual 
intrinsic  anatomic  narrowing  is  present  ;  but  the  milder  form  of  the 
same  treatment — viz.  bougieing — might  be  expected  to  prove  useful  in 
paretic  conditions  by  exercising  a  stimulating  effect ;  but  it  is  hardly 
to  be  expected  that  such  mechanical  stimulation,  more  especially  by 
bags  and  divulsors,  would  relieve  spasms  and  other  contractile  derange- 
ments. I  agree  that  the  "bougie  effect"  sometimes  does  temporarily 
improve  to  a  substantial  extent  some  cases  of  non-anatomic  stenosis, 
but  the  improvement  in  my  experience  is  more  often  only  slight  in 
unequivocal  cases  of  functional  stenosis,  and  such  improvement  as  is 
obtained  I  regard  as  due  to  stimulation  and  relief  of  the  inertia  of  the 
crural  neuro-muscular  mechanism  in  the  region  of  the  hiatus,  by  which 
the  collapsed  hiatus  and  gullet  are  induced  to  open  up  widely  at  this  site. 
When  Sir  StClair  Thomson  was  advised  last  year  in  this  Section  to 
dilate  up  with  large  bougies  a  case  of  oesophagectasia  with  a  widely 
open  phreno-cardiac  gullet  as  seen  with  the  oesophagoscope  in  position, 
he  pathetically  inquired,  "  What  am  I  to  bougie  ?  " 

Mr.  Shattock  suggestively  asks  if  "  there  may  not  be  a  fault  on  the 
side  of  the  mucosa  which  fails  to  supply  a  proper  afferent  stimulus"  for 
the  requisite  active  opening  up  of  the  lower  portion  of  the  gullet.  He,, 
however,  makes  no  suggestion  that  the  inertia  or  block  is  localised  at 
the  hiatal  level  and  concerned  with  the  impaired  action  of  the  crural 
fibres  of  the  diaphragm  as  I  hold,  but  he  accepts  the  usual  view  that 
there  is  wrong  action  of  the  circular  fibres  of  the  cardia  supposed  to  be 
innervated  by  the  sympathetic  nerves  of  the  plexus  gulee.  The  improve- 
ment in  the  relief  of  dysphagia  in  my  cases  I  have  attributed  just  as 
much  to  accessory  methods  of  treatment  as  to  such  dilating  methods  as 
the  passage  of  bougies. 

Bags  and  divulsors  I  have  discarded  as  there  is  no  evidence  forth- 
coming that  either  actual  inflammatory  rigidity  or  adhesions  of  the 
mai'giu  of  the  hiatus  exists  in  these  cases.  I  teach  the  patient  in  the 
early  stages  of  treatment  to  pass  all  food  directly  into  the  stomach  by 
means  of  a  soft  rubber  stomach-tube,  when  the  orifice  of  the  phreno- 
cardiac  gullet  is  easily  hit  off',  or  failing  that,  by  a  gum-elastic  tube. 
He  or  she  is  taught  to  wash  out  the  dilated  oesophagus,  and  also  the 
stomach  when  there  is  dyspepsia,  before  taking  a  feed  though  the 
tube,  and  if  the  obstruction  is  so  great  as  to  lead  to  a  considerable 
accumulation  of  saliva  in  the  gullet  this  is  removed  between  feeds  as 
well,  so  as  to  relieve  straiu  and  help  the  relaxed  walls  to  gain  tone. 
This  lavage  further  helps  to  cui-e  the  sodden  state  of  the  mucosa,  and  to 
prevent  the  formation  of  erosions  and  ulcers  which  tend  to  result  from 
continued  stasis  of  stale  food.  After  three  weeks  short  drinks  are 
permitted  by  the  mouth,  but  any  fluid  remaining  after  ten  minutes  is 
removed  by  the  patient  with  the  rubber  oesophageal  tube.     The  improve- 


November,  1920.]         Rhinology^  and  Otology.  343 

ment  is  sometimes  so  marked  that  soft  food  and  even  ordinary  well- 
masticated  meals  can  be  swallowed  either  directly  into  the  stomach  or 
else  they  pass  more  gradually  through  without  much  delay.  Care  must 
be  taken  to  eat  slowly  and  little  at  a  time,  and  the  presence  of  stasis 
must  be  frequently  tested  by  the  patient  by  suction  or  lavage  through 
the  oesophageal  tube.  I  have  never  known  a  real  cure,  but  the  improve- 
ment may  be  so  great  that  the  disabiUty  is  undetected  by  others  present 
when  meals  are  taken,  and  the  patient  swallows  fairly  normally  provided 
he  does  so  carefully,  deliberately  and  forcibly.  In  some  cases  the  relief 
is  only  moderate,  possibly  due  to  the  treatment  not  being  religiously 
adhered  to  ;  relapses  at  all  events  ai'e  frequent. 

Some  cases  improve  scarcely  at  all  imder  any  method  of  treatment, 
and  in  these  instances  Mr.  Shattock  has  suggested  that  it  might  be 
justifiable  to  excise  the  subphrenic  gullet,  and  make  an  end-to-end 
junction  between  the  dilated  thoracic  oesophagus  and  the  stomach.  I 
think  the  fixing  of  a  non-slipping  vulcanite  or  rubber  intubation 
apparatus  in  the  phrenocardiac  gullet  would  be  a  feasible  procedure  if 
made  in  two  portions,  the  lower  one  inserted  and  joined  up  thi'ough  a 
gastrotomy,  and  it  would  be  less  dangerous  than  excision.  I  have  tried 
Guisez's  apparatus,  but  it  slips  up  out  of  position  just  as  does  a 
Symonds'  funnel  here. 

In  conclusion,  let  me  state  that  I  fully  realise  that  there  is  still  a 
possible  doubt  as  to  whether  oesophagectasia  without  anatomic  stenosis 
below  is  a  primary  or  a  secondary  condition,  and  it  cannot  be  claimed 
that  any  of  the  explanations  given,  including  my  own,  are  anything 
more  than  unproven  hypotheses  and  perhaps  all  very  wide  of  the  mark. 
I  think,  however,  that  the  phrenic  factor  in  the  deglutitory  act  to  which 
I  called  attention  in  1911  cannot  be  ignored,  as  appears  to  be  the  case 
at  present. 

^Etiology. 

With  so  much  obscurity  as  to  the  essential  nature  of  these  ectasiae, 
even  as  to  whether  there  is  an  underlying  functional  stenosis  or  not,  it 
necessarily  follows  that  nothing  much  is  really  known  as  regards  the 
predisposing  and  exciting  causes.  There  is  no  sex  predomination,  and 
only  a  small  proportion  of  the  patients  affected  can  be  classed  as 
neurotic.  The  condition  is  not  limited  to  any  period  of  life.  Some  few 
cases  observed  in  the  very  young  have  been  held  to  be  congenital. 
Zenker  is  probably  wrong  in  his  statement  that  "  ectasiae  seem  to  be 
developed  more  frequently  in  youth  than  at  any  other  time,"  even  if 
those  following  cicatricial  stenosis  are  included  in  the  statement.  There 
is  no  reliable  information  regarding  the  exciting  causes  of  the  condition. 
Claims  made  by  reporters  of  individual  cases  of  the  supposed  influence 
of  lifting  heavy  weights,  imbibing  large  draughts  of  hot  water,  and  the 
impaction  of  hot  dumplings  and  other  ingesta  are  not  convincing. 

SYMPTOilATOLOGT. 

I  have  devoted  so  much  time  to  the  obscure  question  of  pathogenesis 
that  I  feel  deterred  from  dealing  at  length  even  with  the  commoner 
symptoms,  much  less  the  occasional  and  exceptional  ones.  Suffice  it  to 
say  that  the  commoner  ones  are  more  or  less  identical  with  those  met 
with  in  other  varieties  of  ectasiae,  viz.  those  developed  above  a  cicatricial 
stenosis ;  the  X-ray  pictures  are  also  identical,  and  the  essential 
difference   is    only    brought   out    hy  the  cesopliagoscopic  findings  and  hy 


o44  The  lournal  of  Laryngology,     [November,  1920. 

bougieing,  on  which  the  differential  diagnosis  ultimately  depends. 
Dysphagia  varying  in  degree  is  nearly  always  a  late  symptom  in 
oesophageal  stenosis  of  any  kind,  as  the  lumen  can  be  considerably 
i-educed  without  interfering  much  with  deglutition.  In  this  form  of 
functional  dysphagia,  however,  some  difficulty  is  noted  comparatively 
early  before  marked  secondary  dilatation  has  occurred.  It  is  often 
intermittent  in  the  early  stages,  with  quite  prolonged  periods  of  normal 
deglutition  followed  by  relapses. 

Later  regurgitation  is  added  to  mere  dysphagia..  The  dilated  gullet 
when  overfilled  from  above  and  unable  to  empty  itself  sufficiently  quickly 
below  necessarily  tends  to  cause  an  overflow  into  the  pharynx,  and  when 
this  is  accompanied  by  peristaltic  actions  the  accessory  muscular  actions 
nsually  associated  with  gastric  vomiting  may  be  called  into  play,  and 
thus  we  get  what  is  known  as  oesophageal  vomiting.  Eegurgitation  is 
often  involuntary,  but  on  account  of  the  discomfort  felt  in  the  overloaded 
chest  the  patient  frequently  reinforces  the  involuntary  act  by  a  voluntary 
one.  Coughing  and  even  deep  breathing  may  lead  to  regurgitation  when 
the  gullet  is  filled  .or  nearly  filled  with  fluid  or  other  form  of  nutriment. 

The  questions  of  waterbrash  and  of  rumination  occasionally  observed 
in  oesophagectasia  I  am  precluded  from  dealing  with  at  length  now. 

A  dilated  gullet  which  is  at  the  same  time  over-filled  is  made  evident 
to  the  patient  by  symptoms  varying  from  mere  discomfort  to  evident 
distress  and  up  to  genuine  pain.  The  pain  is  of  the  nature  of  a 
secondary  spasm,  or  cramp,  or  colic,  or  angina,  and  is  brought  about  by 
hypertonic  muscular  action — i.  e.  violent  peristalsis  in  an  inetfectual  effort 
to  force  impacted  food  through  the  stenotic  lower  end  of  the  gullet. 
Violent  pain  may  last  from  a  second  or  two  to  fifteen  minutes.  With 
the  throat  mirror  frothy  fluid  can  often  be  seen  in  the  pyriform  fossae, 
and  where  there  is  increased  salivation,  as  often  happens  in  well- 
established  cases,  much  saliva  which  has  been  first  swallowed  and  later 
regurgitated  in  a  frothy  form  has  frequently  to  be  expectorated. 

As  regards  loss  of  weight  it  is  exceptional  to  find  marked  and 
dangerous  emaciation,  even  in  cases  of  long  standing,  though  a  few 
patients  have  been  gastrostomised  for  symptoms  bordering  on  aphagia, 
and  cases  have  even  been  allowed  to  succumb  to  asthenia  from  starvation. 
In  these  instances  a  proper  investigation  should  have  established  the 
correct  diagnosis,  and  led  to  the  employment  of  so  simple  a  remedy  as 
the  stomach-feeding  tube  long  before  such  a  state  of  affairs  had  become 
established.  There  is  usually  a  history  of  some  loss  of  weight  in  long- 
standing cases  even  when  the  patients  look  healthy  and  well  covered  ; 
a  patient  often  states  that  he  lost  a  stone  or  two  to  begin  with  in 
the  course  of  six  or  twelve  months,  and  then  managed  by  careful  degluti- 
tion to  maintain  a  constant,  though  below  par,  weight  for  succeeding 
years.  When  the  amount  of  nourishment  which  gradually  trickles 
through  from  the  dilated  gullet  into  the  stomach  is  large  compai-ed  with 
the  amount  regurgitated,  the  patient  may  manage  to  maintain  normal 
Aveight  and  strength  for  three  or  four  years  or  even  more  after  the  o7iset 
of  the  dys])hagia.  The  main  point  is  that  there  is  not  usually  in 
functional  stenosis  the  steadily  progressive  loss  of  Aveight  such  as  is  met 
with  in  organic  (i.  e.  anatomic)  stricture. 

(Dr.  Hill  showed  a  number  of  skiagrams  illustrating  functional 
jihreno-cardiac  stenosis.) 

{To  be  continued.) 


November,  1920.]         Rhinology,  and  Otology.  345 

ABSTRACTS. 

Abstracts  Editor— \N .  Douglas  Hakmer,  9,  Park  Cresceut,  London,  W.  1. 

Authors  of  Original  Comimmications  on  Oto-laryngology  in  other  Journals 
are  invited  to  send  a  copy,  or  two  reprints,  to  the  Journal  of  Laryngology. 
If  they  are  willing,  at  the  same  time,  to  submit  their  oivn  abstract  {in  English, 
French,  Italian  or  German)  it  tvill  be  welcomed. 


NOSE. 

The  Endonasal  Route  in  the  Operative  Attack  of  Frontal  Sinusitis— Dr. 
J.  Bourguet  (Paris).  '•  Ptev.  de  Laryngol.,  d'OtoL,  etde  Khinol.," 
October  15,  1919. 

The  author  surveys  the  treatment  of  frontal  sinusitis.  In  decrying 
the  usual  method  of  attack  (Killian)  as  l)eing-,  although  the  most  radical, 
nevertheless  the  most  disappointing,  he  -will  find  many  sympathisers 
among  British  specialists. 

Before  the  Great  War  the  persistence  of  a  post-operative  fistula 
prompted  a  soul-searching  inquiry  on  the  part  of  the  operator  as  to 
whether  he  had  not  committed  some  grave  error  in  technique.  But, 
during  the  war,  just  as  his  cases  have  passed  on  to  other  surgeons  and 
hospitals,  so  have  the  patients  of  others  arrived  under  his  care  in  various 
post-operative  stages,  and  he  learns  that  he  is  in  no  wise  isolated  in  his 
experience  of  this  Ijumiliating  sequela. 

Briefly,  the  author  attributes  this  frequent  source  of  disappointment 
to  a  progressive  narrowing  of  the  infuudibulum  by  granulations  and 
scar-tissue,  so  that  the  sinus  becomes  a  closed  empyema.  He  has 
observed  an  entire  closure  of  the  f  ronto-uasal  canal  in  patients  subject 
to  re-operation. 

A  further  disadvantage  is  the  external  scar.  Technically,  the  endo- 
nasal operation  described  corresponds  closely  to  that  familiar  to  British 
rhinologists.  The  author  considers  that  the  drainage  obtained  dispenses 
with  any  need  for  the  curette. 

The  paper,  especially  the  first  part  detailing  arguments  against  the 
"  bridge"  opei-ation,  should  be  read  in  detail. 

H.  Latvuon  Whale. 

Treatment  of  Ozaena  by  Zinc  Chloride.— Prof.  H.  Lavrand  (Lille).— 
"  Eev.  de  Laryngol.,  d'OtoL,  et  de  EhinoL,"  September  30,  1919. 
The  treatment  recommended  consists  in  swabbing  the  middle  meatal 
region  fairly  briskly  with  a  solution  of  zinc  chloride  in  glycerine,  1  part 
in  30.  No  lengthy  or  wearisome  lavage  is  required.  The  good  local 
results  bring  in  sequence  a  happy  influence  on  the  general  condition. 
In  prolonged  cases  curettage  of  the  vinderlying  bone  may  be  instituted 
as  an  adjuvant.  '  H.  Lawson   Whale. 

Rare  Case  of  Retention  of  Projectile  in  the  Nose.— F.  Brunetti.  "  Arch. 
Ital.  di  Otol.,"  XXX,  No.  4. 
A  soldier  was  wounded  on  the  left  side  of  thenose  in  May,  1916.  A 
simple  dressing  was  applied  at  the  time  and  the  wound  healed  up.  Since 
then  till  seen  by  the  writer  in  December,  1918,  he  had  complained 
repeatedly  of  nasal  obstruction,  but  a  rhinoscopic  examination  had  never 


346  The  Journal  of  Laryngology.      [November,  1920. 

been  made  or  even  suggested.  Finally  an  X-ray  plate  was  taken  which 
showed  a  foreign  body  in  the  nose.  External  rhinotomy  was  suggested 
but  declined  by  the  patient.  On  being  referred  to  the  author  the  foreign 
body  was  at  once  seen  blocking  the  Avhole  left  side  of  the  nose.  It  was 
extracted  without  any  difficulty,  and  was  found  to  be  a  circular  plate  of 
metal  measuring  about  2  cm.  in  diameter  and  9  mm.  in  thickness. 

/.  K.  Milne  Dickie. 

Hoarseness  caused  by  Thjrro-arytaenoid  Interni  Paresis  with  Symptoms 
Simulating  Acute  Pulmonary  Tuberculosis  due  to  a  Sinus  Infec- 
tion.— Lee  Myers.  "The  Laryngoscope,"  December,  1919,  vol. 
xxix,  p.  720. 

Male,  aged  thirty.  Four  weeks  before  examination  had  contracted 
cold  which  gradually  became  worse.  Hoarseness,  loss  of  weight,  chills, 
daily  rise  of  temperature,  persistent  dry  cough  and  loss  of  appetite.  An 
X-ray  of  the  chest  suggested  pulmonary  tuberculosis  ;  sputum  negative. 
Myers  found  the  cords  congested,  swollen  and  somewhat  glazed  in  appear- 
ance. The  cords  abducted  normally,  but  did  not  approximate  in  the 
centre.  He  applied  cocaine  and  adrenalin  to  the  nose.  Using  negative 
pi-essure  with  a  suction  of  28  in.  by  the  vacuum  gauge  he  obtained  large 
amounts  of  pus  from  the  sphenoidal  sinuses.  In  three  weeks  the  ])atient'& 
voice  returned  to  normal.  /.  S.  Fraser. 


EAR. 

The  Eustachian  Tube :  Its  Significance  in  Otology. — Douglas  Guthrie. 
"  Edin.  Med.  Journ.,"  June,  1920. 

This  paper  supplies  a  review  of  our  present-day  knowledge  of  the 
Eustachian  tube. 

Since  the  time  of  Eustachius,  anatomists  have  repeatedly  raised  the 
question  of  whether  the  tube  is  normally  open  or  closed.  Toynbee 
showed  that  a  closed  tube  was  necessary  for  perfect  hearing,  and  his 
views  are  generally  adopted  to-day.  Reference  is  also  made  to  various 
researches  on  the  comparative  anatomy,  development  and  histology  of 
the  Eustachian  tube. 

The  pathology  of  this  structure  has  received  scant  attention,  although, 
since  the  introduction  of  the  uaso-pharyngoscope,  interesting  clinical 
observations  have  been  made  by  Holmes,  Wood,  Yearsley  and  others, 
with  results  which  are  here  summarised.  Many  curious  cases  of  foreign 
body  in  the  Eustachian  tube  have  been  reported. 

The  Eustachian  catheter  was  discovered  in  1724  by  Guyot,  a  post- 
master at  Versailles,  who  relieved  his  own  deafness  by  pumping  air 
through  a  bent  tin  tube  introduced  into  the  naso-pharynx  by  way  of  the 
mouth.  Later  investigations  led  to  the  adoption  of  the  present'form  of 
instrument.  In  1862  Politzer  advocated  the  method  of  ioflation  Avhich 
bears  his  name,  stating  that  a  greater  effect  could  be  obtained  by  this 
means  than  by  the  catheter  or  Valsalva  method.  The  direct  treatment 
of  the  Eustachian  tube,  under  the  guidance  of  the  naso-pharyngoscope, 
has  had  a  great  vogue  in  certain  quarters,  and  encouraging  results  are 
claimed.  Finally,  the  closure  of  the  Eustachian  tube  by  curettage,  as 
suggested  by  Yankauer,  has  been  followed  by  cure  in  about  half  the 
cases  of  chronic  suppurative  otitis  which  were  thus  treated. 

Author's  abstract. 


November,  1920]         Rhinology,  and  Otology.  347 

The  Answer  to  the  Opponents  of  the  Radical  Mastoid  Operation. — 
Wesley  C.  Bowers.  •'  The  Laryngoscope,"  ISTovembei-,  1918, 
p.  790. 

The  author  holds  that  there  ai-e  men  doing  the  radical  operation 
without  knowing  the  indications  for  operating  or  the  local  anatomy,  and 
without  having  acquired  a  technique.  Loss  of  hearing,  facial  paralysis, 
failure  to  stop  the  discharge,  or  death  in  several  consecutive  cases  give 
rise  to  distrust.  The  radical  mastoid  operation  is  not  a  simple  one,  either 
in  its  technique  or  its  indications.  It  is  not  an  operation  for  curing  a 
chronic  infection  limited  to  the  middle  ear  and  Eustachian  tube,  except 
in  very  exceptional  cases.  It  is  for  curing  infection  in  the  tympanic 
vault  or  mastoid  bone  or  both.  Occasionally  the  X  ray  will  help  us. 
Many  cases  of  chronic  discharge  from  the  middle  ear  can  be  cured  by 
local  treatment.  In  time  Nature  herself  will  cure,  in  some  cases,  by 
producing  a  picture  very  much  like  the  cavity  produced  by  the  radical 
operation.  It  is,  however,  much  more  common  for  Nature  to  destroy 
bone  over  the  dura,  sinus,  or  labyrinth,  causing  serious  complications. 
If  we  can  be  sure  that  all  the  infection  is  limited  to  a  certain  part  of  the 
vault  or  mastoid,  then  a  modification  of  the  radical  is  justifiable.  Such 
cases  are  few.  The  modified  operation  has  shown  little  if  any  better 
functional  results  than  the  radical  when  the  radical  is  properly  done. 

The  number  of  persons  who  have  good  hearing  in  the  infected  ear 
after  a  prolonged  middle-ear  discharge  is  relatively  small.  When  a 
patient  hears  mainly  with  the  affected  ear  it  is  not  justifiable  to  do  a 
radical,  except  in  cases  in  which  the  symptoms  are  very  ominous.  These 
patients  should  be  instructed  in  all  the  symptoms  of  danger. 

It  is  objected  that  the  radical  mastoid  fails  to  stop  the  discharge. 
The  chief  causes  of  failure  are — (1)  failure  to  so  modify  the  bony 
meatus  as  to  produce  the  best  possible  facilities  for  drainage  and 
inspection  of  the  middle  ear.  The  external  portion  of  the  bony  meatus 
can  be  enlarged  by  removing  a  portion  of  the  floor,  posterior  wall  and 
anterior  wall.  It  is  generally  possible  to  remove  completely  the  convexity 
upon  the  posterior  and  inferior  walls  of  the  meatus,  but  occasionally  the 
anterior  wall  is  so  very  convex  that  it  is  impossible  to  remove  enough 
bone  without  exposing  the  fibro-cartilaginous  wall  of  the  mandibular 
joint.  (2)  Failure  to  perfectly  clean  out  the  various  recesses  of  the 
middle  ear.  (a)  The  post-tympanic  space  (sinus  tympani  ?)  is  sometimes 
very  deep,  and  generally  lodges  a  considerable  quantity  of  unhealthy 
granulations  and  serves  as  a  pocket  for  the  retention  of  secretion.  If  we 
first  get  a  good  exposure  of  the  bottom  of  this  space  by  the  removal  of 
the  meatal  floor,  we  can  remove  every  particle  of  necrotic  tissue  with  the 
least  chance  of  any  injury  to  the  facial  nerve,  (b)  The  floor  of  the 
middle  ear  with  the  annulus  tympanicus  is  often  very  deep  and  serves  as 
a  pocket  for  secretion.  If  the  convexity  of  the  floor  has  been  removed 
sufiiciently  the  bottom  of  this  space  should  be  on  a  higher  level  than 
the  floor  of  the  meatus.  (c)  Omission  to  thoroughly  clean  out  the 
Eustachian  tube.  Many  Eustachian  tubes  are  surrounded  by  a  con- 
siderable number  of  cells  which  may  extend  as  far  as  the  isthmus. 
These  cells  should  be  curetted  with  just  as  much  care  as  any  cells  in  the 
mastoid.  The  carotid  artery  lies  very  close  below  and  behind,  but  with 
care  there  is  little  danger  of  injuring  it,  even  though  we  expose  it.  If 
we  have  properly  taken  away  the  convex  anterior  meatal  wall,  the  mouth 
of  the  Eustachian  tube  will  be  plainly  visible  and  much  easier  to  treat  at 
future  dressings.     The  successful  application  of  a  primary  skin-graft  into- 


348  The  Journal  of  Laryngology,      November,  1920. 

the  tube  will  do  much  toward  closing  it  off  from  the  middle  ear.  (d)  An 
inadequate  fibro-oartilaginous  meatus.  This  must  be  large  enough  to 
admit  a  fair-sized  finger,  (e)  Omission  to  instruct  patients  in  the  proper 
after-treatment  of  the  cavity.  They  neglect  to  have  the  desquamated 
epithelium  and  Avax  removed  from  the  cavity  at  suitable  intervals. 

The  great  majority  of  cases  never  have  a  post-operative  temperature 
above  101°  F. ;  the  temperature  seldom  lasts  more  than  four  or  five  days. 
We  must  endeavour  to  avoid  any  traumatism  to  the  stapes.  It  is  wiser 
to  leave  some  granulations  around  these  parts,  provided  they  appear 
healthy,  than  to  take  too  great  a  chance  of  injuring  the  membranes 
covering  the  windows.  It  is  wise  to  make  sure  that  the  stapes  is  not 
bound  down  by  adhesions  and  that  it  moves  freely  in  its  niche.  Anything 
we  can  do  to  prevent  the  formation  of  dense  fibrous  tissue  and  adhesions 
around  the  windows  will  be  likely  to  produce  better  heariug.  The 
annulus  tympanicus  is  entirely  removed  by  means  of  a  curette.  The 
jugular  bulb  is  sometimes  exposed  in  the  floor  of  the  middle  ear. 
During  the  procedure  of  cleaning  out  the  middle  ear  time  spent  in  the 
application  of  adi-enalin  is  well  expended,  as  much  less  sponging  is 
thereby  required.  If  the  cells  surrounding  the  tube  are  diseased  they 
are  curetted  and  the  processus  cochleariformis  removed.  Bowers  turns 
up  a  meatal  flap  and  dissects  the  cartilage  and  subcutaneous  tissue  from 
the  skin-flap.  The  flap  is  sutured  to  the  subcutaneous  tissue  or  peri- 
osteum in  order  to  draw  it  well  up.  Before  grafting,  the  wound  is 
again  packed  firmly  with  adrenalin  ^auze.  Bowers  uses  the  primary 
skin-graft  in  all  cases,  except  those  in  which  (1)  the  dura  or  sinus  wall 
are  actually  inflamed;  (2)  a  fistula  is  present  in  a  semicircular  canal  or 
other  opening  into  the  labyrinth  ;  (3)  there  are  symptoms  of  labyrinthine 
or  meningeal  irritation.  In  some  of  these  cases  he  uses  the  graft  in  the 
parts  not  under  suspicion.  Some  of  the  cavities  are  dry  in  two  weeks, 
while  others  go  two  or  three  mouths  before  they  become  dry.  The  recent 
average  time  for  Bowers'  cases  is  three  to  four  weeks.  The  time  required 
to  obtain  a  dry  cavity  depends  in  part  upon  the  patient's  age  and 
constitutional  state. 

Bowers  reports  on  112  cases  operated  and  cared  for  by  himself  within 
the  past  two  years.  Deaths,  0  ;  complete  facial  paralysis,  0  ;  partial 
facial  paralysis,  1.  Of  107  asked  to  report  for  examination,  28  failed 
to  respond.  From  the  84  who  reported  the  following  particulars  were 
learned:  Discharge — none,  63  ;  considerable,  5  ;  occasional,  16.  Hearing 
—  much  better,  13  ;  better,  38  ;  same,  28  ;  worse,  5.  The  bad  results  were 
mainly  in  his  first  nine  cases.  J.  S.  Fraser. 

Lateral  Sinus  Thrombosis  (Symptoms  and  Treatment). — D.  H.  Ballon. 

"  The  Laryngoscope,"  June,  1918,  p.  464. 

Ballon  records  three  cases  of  lateral  sinus  thrombosis  following 
chronic  middle-ear  suppuration.  Tbe  thrombus  Avas  on  the  right  side 
in  all  cases.  The  symptoms  were  characteristic,  sliowing  the  iisual 
triad — chills,  iutermitteut  fever  and  sweats.  There  was  a  marked  flush 
of  the  right  cheek  onh%  i.e.  the  side  of  the  lesion.  Blood-cultures, 
lumbar  puncture  and  eye-grounds  were  negative  in  all  cases.  X-ray 
showed  small  sclerosed  mastoid  with  the  sinus  far  forward,  but 
apparently  no  thrombus.  Operative  findings. — In  all  cases  the  mastoid 
was  sclerosed,  but  very  vascular  and  pulsating  pus  was  present  under 
tension.  The  lateral  sinus  was  superficial,  very  far  forward,  gangrenous, 
-or  covered  with  lymph  and  granulations.    All  diseased  bone  was  removed 


November,  1920.]         RhinoIogT/,  and  Otology.  349 

until  apparently  healthy  sinus  was  reached  in  both  dii-ections.  Ballon 
holds  that,  where  the  thrombus  can  be  removed  and  free  bleeding 
obtained  at  both  ends,  the  jugular  vein  need  not  be  ligated.  This  was 
the  treatment  in  two  cases.  /.  S.  Fraser. 


OESOPHAGUS. 

Extreme  (Esophagectasia.— H.  Batty  Shaw.  "  Proc.  Koy.  Soc.  Med.,"^ 
Clinical  Section,  December,  1919,  p.  9. 

A  female,  aged  sixty-six,  came  for  treatment  because  she  had  become 
so  wasted  and  had  a  cough.  There  was  a  history  of  dyspepia,  which  took 
the  form  of  pain  occurring  shortly  after  taking  solid  food.  The  act  of 
"  vomiting  ■' relieved  the  pain.  For  yeai's  she  had  lived  on  liquid  food, 
which  caused  her  no  pain  or  vomiting. 

The  taking  of  solid  food  was  followed  by  the  following  symptoms  : 

(1)  Pain  at  the  epigastrium. 

(2)  This  pain  was  accompanied  by  what  she  called  vomiting,  but 
what  was  really  regurgitation  of  food. 

(3)  The  act  of  taking  the  solid  food  soon  provoked  a  cough. 

(4)  Occasional  breathlessness,  especially  after  attempting  to  take 
more  solid  food  than  usual. 

(5)  Liquid  food  caused  none  of  these  symptoms. 

She  was  radiographically  examined,  with  the  result  that  diagno:?is  of 
an  extremely  marked  cesophagectasia  Avas  estal)lished.  On  the  adminis- 
tration of  the  bismuth  meal  a  sharply  defined  pencil-like  portion  of  it 
was  shown  to  I'each  the  point  of  contraction  at  the  lower  end  of  the 
oesophagus  into  the  stomach. 

The  case  showed  an  extremely  marked  dilatation,  and  further,  it 
demonstrates  that  it  is  possible  when  the  above  five  clinical  manifesta- 
tions can  be  defined,  to  diagnose  almost  with  certainly  a  condition  which 
in  the  absence  of  such  symptoms  would  be  missed  by  a  physician  and 
would  only  be  discovered  by  a  radiographer,  who  in  the  routine  examina- 
tion of  cases  in  which  bismuth  meals  were  being  investigated  paid  attention 
not  only  to  the  behaviour  of  such  meals  as  they  passed  through  the  stomach 
and  intestines,  but  also  through  the  oesophagus.  Archer  Ryland. 

MISCELLANEOUS. 

Chronic  Disease  and  its  Association  with  Focal  Sepsis. — Sydney  Pern 
(Melbourne).     '-  Med.  Journ.  Austr.,"  March  13,  1920. 

The  focal  infections  are  classed  imder  the  following  headings  :  dental, 
nasal,  tonsillar,  gonorrhoeal,  prostatic,  middle-ear. 

As  bacteria  do  not  thrive  in  the  blood- stream,  it  is  important  to  know 
if  there  is  a  focus  which  can  constantly  supply  bacteria  to  it,  or  one  in 
which  the  blood  gets  only  a  casual  invasion.  The  immunity  mechanism 
which  deils  with  infections  has  a  limit  to  its  possibilities,  and  sooner  or 
later  breaks  down.  When  organisms  gain  entrance  to  the  blood  there  is 
a  tendency  to  group  in  one  type  of  tissues  at  a  time — for  instance,  in 
rheumatoid  arthritis  the  joints  are  attacked ;  the  other  tissues  are  left 
alone. 

Observations  on  578  cases  of  some  form  of  focal  infection  are  tabulated 
in  ten  tables.  The  site  of  the  primary  focus,  the  tissues  involved  in  the 
secondary  invasion,  age-incidence,  etc.,  are  considered. 

A.  J.  Brady. 


350  The  Journal  of  Laryngology,      [November,  1920. 

OBITUARY. 


Emerich  von  Navratil  (Budapest). 

(Born  1833.     Died  March,  1919.) 

Prof,  von  Navratil  was  the  doyen  of  Hungarian  laryngologists.  He 
was  an  able  surgeon  and  inclined  to  surgical  methods  even  in  the  days 
when  laryngology  was  simply  a  medical  speciality.  He  was  Liber-dozent 
in  1885,  Extraordinary  Professor  in  1872  and  Ordinary  Professor  in 
1892.  He  published  articles  on  general  surgery  as  well  as  on  the  surgical 
side  of  our  speciality.  He  was  one  of  those  who,  at  one  time,  took  great 
interest  in  the  innervation  of  the  larynx. 

He  belonged  to  many  foreign  medical  societies,  and  many  of  us  will 
remember  his  distinguished  presence  and  courteous  manner  at  the  Inter- 
national Congress  of  Medicine  in  London  in  1913. 

Adolph  Onodi   (Budapest). 

All  who  have  met  him  will  recollect  the  joyous  and  genial  manners 
of  this  distinguished  Hungarian  colleague.  He  was  born  at  Nikolos 
(Hungary)  on  November  7, 1857,  and  graduated  in  1881.  He  was  Assistant 
in  the  Anatomical  Department  of  the  University  of  Budapest,  and  in  this 
capacity  he  was  sent  to  study  at  the  well-known  Acquarium  in  Naples, 
which  was  then  under  the  direction  of  Dohrn.  Here  he  had  as  a  com- 
panion the  celebrated  Nansen,  and  in  this  cosmopolitan  school  on  the 
shoi'es  of  the  Bay  of  Naples  he  spent  many  happy  days.  A  few  years 
ago  he  returned  there,  whezi  stricken  with  tuberculosis,  in  search  of 
health,  but  he  found  neither  his  health  nor  the  Santa  Lucia  of  former 
years. 

In  1890  he  started  a  clinic ;  in  1898  he  was  made  Extraordinary 
Professor  and  in  1919  Ordinary  Professor. 

Onodi  was  a  strenuous  and  enthusiastic  worker  and  a  great  writer. 
His  chief  researches  were  connected  with  the  innervation  of  the  larynx 
and  the  anatomy  of  the  nose  and  its  accessory  sinuses.  I  came  in  close 
relation  with  him,  as  I  brought  out  an  English  edition  of  his  well-known 
"  Atlas  of  the  Nasal  Cavities  and  Sinuses  "  in  the  year  1894.  This  Atlas 
had  already  been  translated  iuto  Italian  and  other  languages. 

Onodi  was  very  fond  of  England,  and  had  many  admiring  friends 
among  his  British  colleagues. 

Arthur  von  Irsay  (Budapest). 

Hungary  has  lost  another  distinguished  laryngologist  in  Prof.  Arthur 
von  Irsay,  who,  by  one  of  the  ironies  of  life,  died  from  cancer  of  the 
larynx  during  the  war. 

He  was  born  at  Budapest  in  1855.  He  wrote  a  good  deal  and  was  a 
man  of  friendship  and  hospitality. 

Prof.  Paul  Gerber  (Konigsberg,  Germany). 

Those  who  possess  photographs  of  the  last  International  Congress  of 
Medicine  in  London  in  1913  will  see  in  the  front  of  many  of  them  the 
typical  Prussian  figure  of  Prof.  Gerber,  his  face  slashed  with  the  gears  of 
student  duelling.  But  although  he  had  a  mailed-fist  appearance  he  was  a 
man  of  general  culture,  for  he  first  studied  the  arts  in  his  own  native  city  ; 
he  Avrote  an  article  on  the  ear  of  Mozart,  and  under  the  pseudonym  of 


NovemiDer,  1920.]  Rhinology,  aiid  Otology.  351 

Heinricli  G-aribei't  he  -wrote  two  small  volumes  of  verse.  As  has  been 
said  of  him  by  an  Italian  colleague,  "  Under  the  cloak  of  a  biologist  he 
presei'ved  the  spirit  of  a  poet." 

He  was  born  at  Konigsberg  in  1863,  and  there  he  died  in  October 
last.  He  was  Assistant  to  Michelson,  and  on  the  latter's  death  in  1891 
he  became  Director  of  the  University  Polyclinic  and  Professor  later  on. 

He  was  a  gi'eat  worker  and  writer,  and  both  his  works  and  his 
writings  were  of  good  quality.  He  particularly  studied  scleroma, 
lupus,  syphilis  and  leprosy.  I  have  had  occasion  to  quote  his  excellent 
researches  on  the  complications  of  frontal  sinusitis.  He  also  published 
two  beautiful  atlases,  which  are  well  worthy  of  a  place  in  every  library. 

B.  Baginskt. 

(Bom  May  24,  1848.     Died  November  24,  1919.^ 

Dr.  Baginsky  was  the  doyen  of  Liber-dozents  of  oto-laryngology  in 
Berlin.  He  first  practised  as  a  general  physician  in  one  of  the  most 
populous  quarters,  and  it  was  only  in  1880  that  he  interested  himself 
particularly  in  oto-laryngology.  He  wrote  little,  but  taught  well,  and 
was  much  esteemed  bv  all  who  became  closelv  acquainted  with  him. 

StC.  T. 


REVIEWS. 


The  Medical  Annual :  A  Year-Booh  of  Treatment  and  Practitioner's 
Index  for  1920.  (Thirty-eighth  year.)  Pp.639.  Bristol  :  John 
Wright  &  Sons,  Ltd.  London  :  Simpkin,  Marshall,  Hamilton, 
Kent  &  Co.,  Ltd. 

The  "Medical  Annual"  is  ever  fresh  and  as  interesting  as  it  is 
instructive.  It  is,  if  possible,  moi'e  stuffed  with  good  things  than  usual. 
Our  specialty  is  dealt  with  by  Dr.  Watson- Williams,  of  Clifton,  and 
Dr.  Fraser,  of  Edinburgh.  The  former  gives  much  information  in 
regard  to  the  nose  and  throat.  Among  other  practical  points  he 
describes  the  treatment  of  ozaena  by  applications  of  glycei'ine  and  liquid 
glucose  with  approbation.  The  abstracts  of  articles  on  acromegaly  of 
the  larynx,  associated  paralyses  of  the  larynx,  cancer,  tuberculosis, 
and  war  neui'oses  of  the  larynx  are  of  special  interest. 

Dr.  Eraser's  abstracts  are,  as  usual,  most  complete,  and  their  value 
is  considerably  enhanced  by  his  crisp  and  judicial  comments.  The 
vestibular  tests  formulated  by  Jones  are  described  in  detail,  as  also 
Ernest  Sachs's  note  of  warning  regarding  the  reliability  of  the  results 
claimed  for  the  examination  of  the  vestibular  apparatus  and  Dench's 
reminder  as  to  the  variations  coming  within  the  normal  standard. 

French  writes  in  praise  of  the  vaccine  treatment  of  hay-fever.  Under 
the  heading  of  X-ray  diagnosis,  cardiospasm  is  said  to  be  an  exceed- 
ingly common  affection.  Reference  is  made  for  full  information  on 
this  condition  to  Hill's  paper  on  "  Dilatation  of  the  (Esophagus  without 
Anatomical  Stenosis,"  and  the  discussion  on  it  in  the  Section  of 
Laryngology  of  the  Royal  Society  of  Medicine. 

Other  branches  of  medicine  and  surgery  are  reported  on  in  such  an 
attractive  way  that  the  specialist  is  led  to  regret  that  his  scope  is  not 
the  wider  one  of  the  general  practitioner,  with  whom,  according  to  Sir 


352  The  Journal  of  Laryngology.      [November,  1920. 

James  Mackenzie's  well-known  views,  the  future  of  medicine  rests.  The 
regular  study  of  flie  "Medical  Annual'"  will  certainly  help  the  general 
practitioner  towards  the  development  of  the  commanding  status  which 
Sir  James  Mackenzie  postulates  for  him.  J.  D.-G. 

Handhoolc  of  Diseases  of  the  Nose,  Throat,  and  Ear:  For  Students  and 
Practitioners.     By  W.  S.  Syme,  M.D.,  F.E.F.P.  c«c  S.G.,  F.E.S.E. 

In  this  little  handbook  the  whole  field  of  the  diseases  of  the  uose^ 
throat  and  ear  is  reviewed  in  just  over  300  pages.  The  page  is  small, 
and  the  type  relatively  large.  It  will  therefore  be  readily  understood 
that  hardly  more  than  a  hurried  outline  of  the  triple  subject  is  presented, 
and,  indeed,  could  be  presented  within  the  limits  of  a  scope  so  narrow. 

Dr.  Syme  rigidly  confines  himself  to  facts  and  conclusions  derived 
from  his  own  wide  experience,  but  few  authorities  are  quoted,  and  no 
space  is  devoted  to  theory  or  to  themes  of  a  controversial  nature.  The 
result  is  a  clear  and  safe,  but  cursory  view — sometimes,  it  may  be  objected, 
too  general  and  remote — of  the  whole  ground,  but  valuable  to  those  who 
are  about  to  begin  their  training  in  these  subjects. 

.  The  relative  importance  of  some  parts  of  the  speciality  is,  perhaps, 
not  suflBciently  brought  out,  for  we  find  the  whole  subject  of  intrathoracic 
endoscopy  enclosed  within  ten  or  eleven  pages,  and  illustrated  by  two 
plates. 

In  the  section  devoted  to  diseases  of  the  nose  the  author  shows  a 
preference  for  the  intranasal  treatment  of  the  suppurating  frontal  sinus, 
the  external  operation  being  denounced  as  "  a  very  severe  and  prolonged 
procedure."     / 

It  is  interesting  to  observe  that  the  author  has  applied  treatment  by 
means  of  In-onchoscopy  in  dealing  with  many  cases  of  spasmodic  asthma, 
and  '•  with  very  beneficial  results." 

The  little  book  is  supplied  with  a  good  index.  Archer  Ryland. 


NOTES   AND   QUERIES. 

Royal  Society  of  Medicine  :  Otological  Section. 
The  next  meeting  of  this  Section  will  be  held  on  Friday,  November  19  next. 
Notices  and   pa^jers   should   be   sent    in  not   later   than   Tuesday,    November   2 
Secretaries  :  Mr.  Lionel  Colledge  and  Mr.  Norman  Patterson. 


Royal  Society  of  Medicine  :  Laryngological  Section. 
The  next  meeting  of   this  Section  will  be  held  on  Friday,  December  3  next. 
Notices  and  papers  should  be  sent  in  not  later  than  Tuesday,  November  23. 


BOOKS    RECEIVED. 


Anaesthetics  -.    Their    Uses    and    Administration.     By   Dudley    Wilmot 

Buxton,  M.D.,  B.S.     Sixth  edition.     London :    H.  K.  Lewis  &  Co. 

Ltd.,  1920. 
Handbuch  der  Speziellen  Chirurgie  des  Ohres  und  der  Oberen  Luftwege. 

Herausgegeben    von    Dr.    L.    Kat~  and   Pruf.   Dr.    F.    Blumenfeld. 

Leipzig  and  Wurzburg,  1919. 
Ohrenheilkunde  fili^  den  praktischen  Arzt.    By  Prof.  Dr.  Rudolf  Leidler. 

Berlin  and  Yienna,  19'20. 
Jahrbuch  fiii'  Kinderheilkunde  und  Physische  Erziehiuig.     92  and  93, 

der  dritten  Fok-e.     Berlin,  1920. 


VOL.  XXXY.     No.  12.  December,  1920. 

THE 

JOURNAL    OF    LARYNGOLOGY, 

RHINOLOGY,   AND   OTOLOGY. 

THE   JOURNAL   OF   LARYNGOLOGY. 

It  is  now  my  duty  to  intimate  that  with  the  publication  of  this  issue 
and  the  consequent  completion  of  the  present  volume  my  editorship  of 
the  Journal  of  Laryngology,  Ehinology  and  Otology  comes  to  an 
end.  Naturally  it  is  impossible  for  me  not  to  feel  deep  regret  at  the 
severance  of  a  tie  which  has  lasted  so  many  years.  But  with  the  regret 
is  mingled  not  a  little  relief !  With  an  ever-lessening  amount  of  spare 
time  at  my  disposal  the  pressure  of  the  work  has  become  so  great  that 
I  can  no  longer  retain  the  office  with  credit  to  myself  and  with  profit 
to  the  Journal.  It  is  undeniable,  moreover,  that  after  the  lapse  of  a 
decade  a  transference  of  control  is  advisable  if  staleness  is  to  be 
avoided,  progress  secured,  interest,  and,  above  all,  enthusiasm  sustained 
For  these  good  and  sufficient  reasons,  therefore,  I  am  sure  that  a  change 
is  necessary. 

In  bidding  farewell  to  the  wide  circle  of  readers  among  whom  the 
Journal  circulates,  I  should  like  to  express  to  them  my  best  thanks  for 
their  long-continued  and  steady  support,  and  to  the  band  of  voluntary 
workers  who  have  loyally  and  ably  assisted  me  I  offer  a  most  cordial 
expression  of  gratitude  for  having  lightened  a  burden  which  otherwise 
would  have  been  overwhelming. 

My  successor  in  the  editorial  chair  is  Dr.  A.  Logan  Turner,  of 
Edinburgh,  to  whose  eminent  fitness  for  the  post  our  columns  bear 
eloquent  testimony,  and  I  have  much  pleasure  and  every  confidence  in 
wishing  him  success  in  his  undertaking. 

At  this  juncture  a  word  on  the  future  management  of  the  Journal 
will  not  1)6  considered  out  of  place.  Since  1911  the  Journal  has  been 
'the  property  of  the  present  publishers,  Messrs.  Adlard  &  Son  & 
West  Newman,  Limited,  and  it  is  my  pleasant  duty  to  express  to  them 
the  cordial  thanks  of  the  Speciality  for  keeping  the  Journal  alive  and 
active  throughout  the  gloomy  period  of  the  war  when  so  many  other 
similar  publications  died  of  inanition.  But  it  is  felt  that  a  scientific 
periodical  such  as  this  should  belong  to  the  community  it  serves,  .and 
taking  advantage  of  the  opportunity  afforded  by  the  change  of  editor, 
the  Editorial  Committee,  in  purchasing  the  Journal  from  Messrs. 
Adlard  it  Son,  have  taken  a  step  which  will,  they  hope  and  expect, 
enable  this  ideal  to  be  realised. 

For  the  future  it  is  to  be  noted  that  the  Journal  will  be  published 
for  the  Editorial  Committee  by  Messrs.  Oliver  and  Boyd,  of  Edinburgh. 

avctc  atquc  valctc ! 

Dan  McKenzie. 
23 


354  The  journal  of  Laryngology,       December,  1920. 


ASSESSMENT   OF   AURAL   DISABILITY   RESULTING  FROM 
MILITARY    SERVICE. 

By  Archer  Eyland,  r.R.C.S.EoiN., 

Assistant  Siu-geon,  Central  London  Ear,  Nose  and  Throat  Hospital :  Aiirist, 
Ministry  of  Pensions  Special  Aural  Boards. 

The  necessity  at  the  present  time  for  making  an  accurate  estimate  of 
the  impairment  of  hearing  in  the  case  of  men  who  have  served  in  H.M. 
Forces  during  the  war  has  seriously  directed  inquiry  as  to  what  really 
are  the  best  means  and  methods  at  our  disposal  to  attain  this  end. 

The  importance  of  the  subject  is  no  doubt  obvious  to  many,  and  it 
must  be  especially  apparent  to  all  who  are  intimate  with  the  actual 
problems  involved. 

The  financial  award  is  based  upon  the  degree  of  aural  impairment. 
^Yhat  is  the  degree  of  aural  impairment,  and  how  may  it  be  accurately 
defined  ?  The  answer  to  that  question  implies  the  main  purpose  of  the 
present  paper. 

Of  the  total  of  cases  that  appear,  before  the  Ministry  of  Pensions 
special  boards,  it  has  doubtless  been  the  uniform  experience  of  the 
members  of  those  boards  that  the  great  majority  of  cases  is  made  up  of 
aural  disabilities.  The  vast  majority  of  aural  disabilities  are  naturally 
those  that  arise  from  impairment  of  hearing. 

The  aural  cases  that  appear,  fall  to  a  very  large  extent  into  three 
main  classes.  These  are — chronic  non-suppurative  middle-ear  deafness, 
chronic  suppurative  middle-ear  deafness,  and  "  concussion  "  deafness. 
Other  varieties  of  aural  disease,  of  course,  occur  from  time  to  time,  but 
they  are  so  relatively  rare  as  to  become  almost  negligible  for  the 
particular  purposes  of  this  paper,  the  object  of  which  is  merely  to 
discuss  the  means  and  methods  at  present  used  in  order  to  attain  a 
reasonably  accurate  estimate  of  the  degree  of  auditory  impairment. 
This  is  a  matter  which  needs  the  closest  attention,  for  it  must  be 
i-emembered  that  whatever  the  aetiology,  whatever  the  prognosis,  what- 
ever the  promise  that  treatment  may  offer,  and  whatever  the  finding  of 
the  Board  as  to  "  attributabihty  "  or  "  aggravation  "  by  military  service, 
the  actual  assessment  of  disability  is  based,  not  perhaps  exclusively, 
but  to  a  very  great  extent,  upon  the  degree  of  auditory  impairment  in 
the  ex-soldier  as  contrasted  with  the  normal  power  of  hearing  for  the 
spoken  voice. 

Now  it  is  obvious  that  this  kind  of  investigation  is  in  several 
important  respects  in  marked  contrast  to  the  routine  aural  investigation 
of  private  practice  or  of  a  hospital  clinic.  In  these  spheres,  although 
the  problem  of  motive  can  hardly  be  said  to  exist,  the  personal  element, 
nevertheless,  is  certainly  of  importance.  But  in  the  sphere  of  pension 
assessment,  where  the  problem  of  motive  figures  so  largely,  the  personal 
element  becomes  of  transcendent  importance. 

The  patient  who  merely  seeks  relief  is  prone  to  hear  better  than  he 
really  can.  The  claimant  for  pension,  by  virtue  of  a  very  natural  and 
easily-conceived  prejudice,  is  prone  to  hear  much  less  than  he  really  can. 
It  must  be  remembered  that  whatever  scientific  tests  are  employed, 
the  ultimate  ground  upon  which  we  can  safely  conclude  that  a  man  has 
defective  hearing  must  be  the  ground  of  his  impaired  ability  or  of  his 


December,  1920.]  Rhinology,  and  Otology.  355 

intibility  to  hear  the  spoken  human  voice,  for  his  Hving  and  his 
chances  of  employment  will  depend  upon  that. 

Any  or  all  scientific  tests  are  to  be  used,  but  at  the  last  we  are 
dependent  upon  the  response  of  the  examinee  to  the  spoken  voice.  The 
question  of  wilful  deception  is  not  for  the  present  under  view.  The 
foregoing  remarks  are  merely  intended  to  apply  to  the  ordinary  man, 
inaccurate  by  habit,  but  essentially  honest  by  nature,  and  in  whom 
response  sutlers  deviation  by  virtue  of  a  natural  bias. 

The  study  becomes  rather  one  of  personality  than  of  tuning-forks. 
It  is  not  so  much  a  matter  of  tuning-fork  or  monocord  against  the 
middle  ear  or  cochlea.  It  is  a  case  of  mind  against  mind,  of  wit  against 
wit,  of  skilled  interrogation  of  a  brain  degraded  in  some  degree  by 
prejudice.  No  elaborate  power  of  psycho-analysis  is  necessary,  but 
common-sense  mind-reading. 

We  are  dealing  with  human  nature,  with  the  problem  of  human 
motive,  and  steel  prongs  of  varying  power  in  vibration  are  but  poor 
equipment  with  which  to  confront  the  Betz  cells  of  the  higher  cortex 
and  the  "  sin  that  after  all  dwelleth  in  us." 

It  may  be  said  that  with  respect  to  any  given  case  the  examiner 
will  be  justified  in  presupposing  a  certain  tendency  in  the  claimant  to 
suggest  in  some  way  or  another  such  a  version  of  the  facts  as  is 
intended  to  read  in  his  own  favour.  It  is,  after  all,  only  natural  that 
this  should  be  so.  The  attitude  adopted  by  the  claimant  does  not 
amount  to  one  of  pure  voluntary  deception.  Generally  speaking, 
habitual  accuracy  of  mind  and  statement  is  rare,  and  such  a  quality 
even  if  present  has  all  the  less  chance  of  receiving  expression  when  a 
possible  result  of  it  may  be  the  unfavourable  revision  of  a  pension. 
Moreover,  for  the  purpose  of  properly  timed  and  accurate  response  to 
some  of  the  tuning-fork  tests,  it  must  be  remembered  that  a  certain 
degree  of  observational  skill  or  of  natural  mental  accuracy  is  needed, 
and  this  accomplishment  cannot  always  be  assumed  to  be  present. 
Even  if  it  is  present,  it  is  quite  certain  that  with  regard  to 
tuning-fork  tests  the  claimant  will,  with  an  easy  liberality,  give  to 
himself  the  benefit  of  the  doubt. 

At  the  outset,  then,  foremost  in  the  mind  of  the  examiner,  as  the 
result  of  his  own  reflections  and  as  the  result  of  his  own  practical 
experience,  is  the  fairly  grounded  expectation  that  the  claimant  is  in  all 
probability  about  to  overstate  his  case,  or  to  over-act  his  part. 

When  we  turn  to  consider  possible  anticipations  in  the  mind  of  the 
claimant,  we  naturally  allow  to  him  the  same  liberality  of  reasoning 
that  we  permit  in  ourselves. 

Now  his  attitude  may  well  be  this  :  "  I  know  that  my  hearing  is  not 
what  it  should  be,  and  it  will  most  likely  be  the  aim  of  the  examiner 
who  happens  to  deal  with  me  to  prove  by  tests  which  I  do  not  under- 
stand, and  wdiich  may  lie  totally  inapplicable  in  my  case,  that  my 
hearing  is  tolerably  good.  Therefore  I  must  be  all  the  more  careful  to 
insist  upon  my  deafness,  and  to  secure  my  rights  I  must  claim  a  little 
more  than  I  really  should  in  order  to  balance  a  discount  which  I  feel 
sure  in  any  event  is  very  likely  to  be  made." 

In  brief,  the  claimant  will  decide  for  himself  what  his  deafness  is, 
and  naturally  wuU  set  out  to  carry  his  point.  Evaluation,  then,  of  the 
personal  element  in  work  such  as  this  becomes  all-important,  and  very 
considerable  practice  and  experience,  together  with  the  use  of  every  aid 
that  is  available,  are  necessary  in  order  to  attain  equitable  decisions. 


356  The  Journal  of  Laryngology,     [December,  1920. 

Tuning-fork  investigation  is  helpful  to  some  extent,  but  it  should  be 
borne  in  mind  that  the  results  of  it  inform  us  only  as  to  qualitative 
defect  of  hearing,  and  no  estimate  of  deafness  in  such  cases  of  those  at 
present  in  view  should  be  based  too  exclusively  upon  the  power  of 
response  to  forks. 

Great  help  is  afforded  by  perusal  of  the  man's  documents,  containing 
such  essential  records  as,  for  instance,  his  condition  on  enlistment, 
stations,  transfers,  and  nature  of  service  both  at  home  and  abroad.  A 
careful  scrutiny  of  all  the  military  documents  of  importance  precedes, 
of  course,  the  clinical  examination. 

Only  those,  perhaps,  who  have  been  long  engaged  in  this  particular 
work  can  realise  what  prolonged  and  close  attention  is  often  necessary 
in  order  to  arrive  at  sound  and  just  conclusions,  and  also  how  many 
and  various  may  be  the  errors  into  which  it  is  possible  to  fall. 

In  some  difficult  cases,  even  after  a  long  sitting,  the  conclusion  may 
be  found  to  be  still  in  suspense  between  a  long  list  of  pros  on  the  one 
side  and  a  long  list  of  almost  equall}'  plausible  cons  on  the  other.  The 
conclusion  must  then  be  founded,  not  upon  one  finding  or  even  group  of 
findings,  but  simply  upon  the  predominance  of  evidence— in  which- 
soever direction  it  may  lie—  evidence  based  upon  the  man,  his  demeanour, 
his  individuality,  the  results  of  the  clinical  examination  and  the  sense 
of  the  relevant  documents. 

In  such  cases  as  these,  the  "call-back"  test,  which  will  be  referred 
to  more  in  detail  later,  is  often  very  valuable.  Much  importance 
attaches  to  the  order  of  procedure,  and  it  may  be  proper,  therefore,  to 
state  in  brief  the  steps  of  a  routine  method,  together  with  certain 
practical  suggestions  of  which  the  value  has  been  proved  in  actual 
practice. 

(1)  The  examiner  should  sit  at  desk  or  table ;  he  should  be  occupied, 
or  have  the  appearance  of  occupation,  as  in  completing  notes  of  the 
last  case  or  arranging  papers.  He  should  be  careful  to  conceal,  or  to 
avoid  upon  his  own  part,  all  appearance  of  alertness,  and  he  should 
refrain  from  giving  to  the  claimant  any  impression  that  he  is  being 
especially  observed.  It  is  a  good  plan  to  arrange  chairs  so  that  the 
preliminary  conversation  is  carried  on  across  an  interval  of  4  or  5  ft. 
for  while  the  conversation  voice  may  be  readily  heard  at  five  feet 
during  this  stage  of  proceedings  when  nothing  particular  is  being  done, 
and  no  explicit  test  is  being  applied,  it  will  most  likely  l)e  impossible  to 
obtain  an  admission  of  hearing  even  at  2  ft.  when  the  formal  test 
is  being  carried  out  later.  It  is  better  to  maintain  this  distance,  and  to 
raise  the  voice,  if  necessary,  than  to  allow  the  claimant  to  draw  up 
closely  and  crane  forward  with  hand  to  ear.  het  speech  be  as  loud  as 
may  be  necessary  at  first,  and  subsequently  lower  the  voice  by  gentle 
degrees,  until  the  level  of  ordinary  conversation  is  regained. 

The  demeanour  of  the  different  individual  types  soon  comes  to  be 
known  by  those  who  do  much  of  the  work.  The  man  who  fumbles 
laboriously  in  many  and  strangely  remote  pockets  for  decaying  docu- 
ments, frayed  at  the  edges,  and  falling  asunder  at  every  crease,  in  order 
to  support  statements  that  are  irrevalent,  upon  matters  that  are  trivial, 
is  not  perhaps  for  that  sole  reason  to  be  laid  under  suspicion  of  bad 
faith,  since  there  is  such  a  thing  as  the  veneration  of  the  wholly  illiterate 
for  handwriting,  when  the  written  word  bears  reference  to  themselves. 

There  is  another  type  of  claimant,  and  he  is  well  known.  He  is 
generally  an  old  soldier.     He  replies  to  questions  in  a  voice  unnaturally 


December,  1920.]  Rhinology,  and  Otology.  357 

loud  and  prompt,  seeking  somehow  to  convey  an  impression  of  deafness 
by  his  shout,  and  of  honesty  by  his  alacrity. 

The  application  of  a  hand  as  a  sound-wave  collector  to  the  side  of 
the  head  is  more  often  a  mimicry  of  the  deaf  than  a  genuine  attitude 
of  those  really  atiiicted.  Observation  will  often  show  how  fallacious 
this  mimicry  may  be.  In  cases  that  are  genuine,  the  hand  is  applied  by 
instinct  or  by  experience  in  precisely  the  effective  manner,  while  in 
cases  that  are  not  genuine  it  is  often  obvious,  from  the  nature  of  the 
attitude  assumed,  that  no  real  resistance  is  being  conferred.  On  one 
occasion  the  writer's  attention  was  called  to  an  instance  in  which  the 
hand  was  actually  applied  to  the  side  of  the  head  in  front  of  the  ear 
(T.  B.  Lay  ton).  It  is  well  to  question  the  man  early  in  the  interview 
as  to  which  is  the  deafer  ear.  He  may  reply  that  the  right  ear  is  the 
deafer  one,  and  not  improbably,  later  on  in  the  conversation,  he  may  so 
far  forget  himself  as  to  be  found  craning  forward  with  head  turned  and 
hand  to  auricle,  straning  to  hear  with  the  right,  i.  e.  the  deafer  ear.  All 
such  little  points  as  these,  minute  or  trivial  as  each  probably  appears, 
may  become  of  much  importance  in  the  aggregate.  They  are  put  to 
the  test  in  actual  practice  at  the  beginning  of  the  interview,  and  with 
much  greater  rapidity  than  that  with  which  they  are  recorded  here. 

(2)  The  next  step  comprises  the  usual  aural  examination  by  means 
of  otoscopy. 

(3)  And  the  next  comprises  all  other  clinical  observations  that  it  may 
be  necessary  to  record,  both  general  and  special,  the  latter  generally 
including  notes  on  the  buccal,  nasal,  pharyngeal,  and  naso-pharyngeal 
regions. 

(■i)  The  fourth  step  is  the  determination  of  the  qualitative  defect  in 
hearing.  With  regard  to  the  tuning-fork  test  of  hearing  by  bone-con- 
duction for  one  ear  only,  a  small  point  may  be  noted.  It  is,  that 
simultaneous  contra-lateral  use  of  the  Barnay  box  at  the  meatus  will 
always  completely  prevent  the  perception  of  sound  by  bone-conduction 
for  that  ear  to  which  the  box  is  applied.  The  machine  will  not 
materially  affect  the  ear  which  is  being  tested  for  bone-conduction.  ' 
The  writer  has  in  mind  of  course  that  class  of  case  in  which  bone- 
conduction  of  sound  passes  across  the  skull. 

(5)  The  estimation  of  hearing  power  for  the  spoken  voice  is  the  next 
step,  and  while  experience  proves  it  to  be  the  most  difficult,  it  is  also 
unquestionably  the  most  important,  having  regard  to  its  bearing  on  the 
final  assessment.     The  test  may  be  conducted  as  follows  : 

A  clear  distance  of  at  least  25  ft.  is  selected  in  an  ordinary  room, 
and  since  it  is  the  power  of  hearing  amid  ordinary  every-day  con- 
ditions of  life  and  work  that  is  required  to  be  known,  no  effort  is  made 
to  obtain  conditions  of  absolute  quiet.  The  claimant  is  requested  to 
stand  presenting  the  right  side  of  his  head  and  body  to  the  observer. 
Into  the  left  external  auditory  meatus  is  then  inserted  a  compressed 
pledget  of  damp  cotton-wool.  A  hand-towel  is  folded  into  eight,  and 
then  held  over  the  left  ear  in  firm  contact  with  the  side  of  the  head  by 
an  assistant.  The  assistant  stands  immediately  in  front  of  him,  and  it 
is  also  his  duty  to  hold  a  small  cardboard  or  paper  screen  to  the  right 
side  of  the  man's  head  so  as  to  shut  off  the  right  eye  and  upper  part  of  the 
face.  The  mouth,  and,  of  course,  the  right  ear,  are  left  uncovered.  It  is 
now  the  assistant's  chief  function  to  watch  the  man's  eyes,  because  on 
hearing  himself  spoken  to  by  the  observer  the  eyes  will  be  apt  to  deviate 
towards  the  direction  from  which  the  voice  comes. 


358  The  Journal  of  Laryngology,       [December,  1920. 

Such  a  response  gives  evidence  of  the  voice  having  been  heard,  but 
not  necessarily  of  the  individual  words  having  been  understood. 

The  writer  holds  to  the  view  that,  with  regard  to  the  power  of 
hearing  for  the  voice,  the  soundest  and  fairest  test  is  the  test  of 
hearing  for  ordinary  conversation.  The  observer  now  opens  a  con- 
versation. It  is  important  that  the  man  should  be  got  to  hear  from 
the  first.  Therefore  it  is  well  to  address  him  at  a  few  feet  only,  and 
whatever  his  deafness  may  be,  to  speak  loudly  enough  to  be  heard 
and  to  gain  a  reply  without  ^  prolonged  latent  period.  For  it  is 
an  important  tactical  error  for  the  observer  to  open  his  campaign  at 
too  great  a  distance,  for  not  only  will  he  have  to  repeat  question  after 
question,  without  being  able  to  elicit  reply,  but  the  man  will  quickly 
imderstand  the  advantage  he  has  thus  gained  at  the  outset,  will 
endeavour  to  improve  it,  and  will  also  readily  detect  for  what  it  is  worth 
to  him  this  proof  of  lack  of  skill  in  the  questioner.  The  man  must  be 
thoroughly  aroused  from  the  beginning ;  he  must  be  interested  ;  he 
must  be  stimulated ;  he  must  be  deprived  of  the  initial  advantage  of 
remaining  dumb  from  the  outset.  The  questioning  should  be  interesting, 
continuous  and  varied.  It  should  not  be  broken  by  pauses,  and  above 
all,  should  be  so  managed  as  never  to  give  rise  to  the  thought,  "  He  is 
thinking  what  to  ask  me  next."  The  conversation  should  proceed  along 
such  lines  as  engage  his  interest,  self-love  or  affections.  Be  careful 
that  a  pause  in  the  talk  does  not  happing  to  coincide  with  stepping  back 
in  an  audible  tread  for  five  or  six  spaces. 

When  the  voice  is  heard,  the  eyes  of  the  listener  will  in  all  proba- 
bility deviate  towards  the  direction  of  the  voice.  Such  an  event  is 
closely  watched  for  by  the  assistant,  and  when  it  occurs  the  fact  is 
telegraphed  by  him  to  the  observer,  simply  by  raising  the  forefinger 
from  the  outer  surface  of  the  small  screen  which  he  is  holding  to  the 
side  of  the  man's  head.  This  ocular  response  means  that  a  voice  is 
heard,  but  of  course  does  not  mean  that  the  words  have  been  appre- 
hended. 

The  following  little  mana?uvre  is  often  of  value,  but  merely  as  a  test 
of  "  good  faith  "  or  the  reverse.  It  is  found,  let  us  say,  by  the  examiner 
that  his  conversational  voice  is  not  being  heard  at  a  distance  at  which, 
reasoning  from  previous  deductions,  it  should  be  heard.  In  such  case 
remove  the  plug  from  the  closed  good  ear  and  let  the  assistant  apply 
the  pad  only  very  lightly  to  it,  and  let  this  be  carried  out  quickly  and 
quietly.  In  brief,  restore  the  previously  closed  good  ear  to  a  practically 
normal  condition.  Now  continue  with  the  questions.  The  examiner 
can  now  be  certain  that  whatever  the  response  may  be,  his  words  are 
being  heard  and  understood. 

The  details  of  the  above  general  routine  method  were  first  worked 
out  and  applied  with  success  by  Dr.  J.  E.  MacDougall,  and  to  him  the 
writer  is  indebted  for  kindly  allowing  him  to  refer  to  this  and  to 
other  points  in  his  own  efficient  and  excellent  technique.  Having 
tested  the  right  ear  in  the  above  manner,  the  claimant  is  turned  round 
and  the  hearing  power  of  the  left  ear  is  interrogated  in  the  same  way. 
It  remains  to  point  out  certain  fallacies  which  may  be,  and  often  are, 
implied  in  the  above  method — fallacies  against  which  it  is  most  careful 
to  guard. 

The  most  important  of  these  is  inadequate  closure  of  the  good  ear. 
Suppose  that  the  right  (impaired)  ear  is  being  tested  and  that  the  left 
(normal)  ear  is  artificially  closed.     It  is  quite  possible  that   a   conver- 


December,  1920.]  Rhinology,  and  Otology.  359 

sation  voice,  even  under  these  conditions,  may  be  heard  in  the  left 
(normal)  ear  at  a  distance  of  10  ft.  or  more.  Anj-one  who  will  practi- 
cally test  this  statement  for  himself  will  quickly  be  convinced  of  its 
truth.  The  problem,  then,  is  to  eliminate  function  in  the  ear  that  is 
not  being  tested. 

Such  a  condition  may  be  attained  by  one  of  several  means,  and  we 
shall  mention  the  most  important. 

(a)  Manijmlation  of  the  Pinna  by  the  Palm  of  the  Hand. — The 
central  portion  of  the  palm  of  the  hand  is  laid  flat  over  the  pinna  and 
in  firm  contact  with  the  whole  of  it.  A  rapid  and  somewhat  vigorous 
rotary  movement  is  made  of  the  hand  so  placed,  carrying  the  whole 
pinna  with  it  through  its  range  of  movement,  care  being  taken  that  the 
palm  of  the  hand  does  not  slide  or  rub  upon  the  pinna,  but  that  it 
remains  in  firm  contact  with  this  organ  and  with  the  tragus. 

{h)  The  Castanet. — This  instrument  merely  produces  a  succession  of 
loud  noises,  with  intervals  of  silence  between  them.  The  latter  provide 
an  obvious  source  of  fallacy  and  make  the  instrument  unreliable. 

(c)  Gravitational  Syringimi  of  the  Meatus. — The  writer  has  made  no 
extended  use  of  this  method.  The  temperature  of  the  water  or  saline 
used  must,  of  course,  be  carefully  adjusted  to  body-temperature,  so  that 
labyrinthine  reactions  are  not  excited.  During  the  process  of 
syringing  the  homolateral  auditory  function  is  stated  to  be,  for  the 
time  being  and  for  all  practical  purposes,  abolished.  The  method  is 
cumbrous  and  often  unpleasant.  Apparatus  is  necessary,  and  means 
must  be  adopted  for  maintaining  the  fluid  at  a  precise  temperature. 

{d  I  Of  all  appliances  for  the  purpose  in  view,  the  Barany  noise- 
machine  is  the  best.  The  writer  is  convinced  that  in  many  cases  the 
power  of  hearing  has  been  seriously  over-estimated,  through  failure  to 
employ  this  simple  control.  The  use  of  the  Barany  apparatus  is 
imperative  in  those  cases  in  which  one  ear  has  normal  hearing.  In  all 
such  cases,  blocking  ^f  the  meatus  in  any  conceivable  manner,  either 
digitally  or  by  means  of  plugs,  is  fallacious  and  therefore  worse  than 
useless. 

It  is  w"ell  to  remember  that  a  short  period  should  be  allowed  for  the 
confusing  effect  of  the  clockwork  at  the  ear  to  pass  off,  and  for  the 
patient  to  acquire  familiarity  with  and  toleration  for  the  noise.  Once 
this  is  established,  the  opposite  ear  is  able  to  respond  to  stimuli  with 
unharassed  function. 

More  will  be  said  in  a  later  section  about  the  application  and  uses  of 
the  Barany  machine. 

So  much,  then,  for,  the  main  fallacy  and  for  the  elimination  of  the 
main  fallacy  involved  in  the  routine  procedure  described.  A  second 
fallacy  of  some  importance  may  be  as  follows :  Instead  of  hearing  the 
whole  question  addressed  to  him,  the  claimant  may  hear  only  a  few 
words  of  it — the  key-words — upon  which  certain  phonetic  emphasis  has 
been  laid.  From  these  key-words  his  intelligence  may  enable  him  to 
reconstruct  the  whole  sentence.  Take,  for  instance,  such  a  question  as 
"  How  old  are  you  ?  "  There  is  a  natural  emphasis  upon  the  second 
word  u  —  u  u  ? — the  second  word  is  the  longest  quantity  in  the 
rhythm.  It  corresponds,  indeed,  to  the  one  and  only  long  quantity  in 
the  musical  phonic  foot.  Also  tliese  words,  even  if  no  one  of  them  be 
distinctly  heard,  yet  carry  with  them  the  tone  of  interrogation.  The 
listener  wall  in  all  probability  gather  that  the  words  addressed  to  him 
are  a  question  and  that  the  question  contains  four  words.     Now  this. 


360  The  Journal  of  Laryngology,      [December,  1920. 

together  with  the  prolonged  suspension  of  the  second  quantity,  afford 
obvious  data  from  which  the  w^hole  sentence  can  he  reconstructed. 

Again — "Are  you  a  married  man?"  uuu/  —  u  —  ?  The  same 
points  are  equally  obvious  here,  and  need  no  further  elaboration. 

We  must  be  careful,  therefore,  that  the  man's  deafness  is  not 
unjustly  estimated  simply  because  he  happens  to  be  intelligent.  Forms 
of  words  such  as  these,  are,  in  the  light  of  reasons  just  stated,  not  wholly 
reliable,  and  it  is  important  to  keep  in  mind  how  they  can  lead  to  error. 
In  a  different  respect  their  advantage  is  obvious,  simply  because  they 
are  the  manner  of  address  most  likely  to  engage  the  man's  kindness 
and  interest,  and  where  feeling  and  affection  are  kindly  engaged 
suspicion  and  reticence  tend  to  dissolve.  The  man  is  likely  to  reply 
with  something  like  alacrity  and  spirit  to  reasonable  and  humane 
questions  regarding  the  age  and  sex  of  his  youngest  child,  but  he  is  not 
likely  to  respond  with  vivacitj-,  and  who  will  blame  him,  to  the  harsh 
stage-whispering  of  fantastic  or  irrelevant  syllables  as  those  of 
"  Jemima,"  "  banana,"  u  —  u. 


Surprise  Tests. 

Of  the  surprise  tests  we  shall  mention  only  those  which  have  been 
found  most  useful  in  actual  practice.  As  a  matter  of  fact  in  every  case  of 
difficulty,  or  of  probable  deception,  tests  of  this  nature  should  be  in  silent 
operation  from  the  outset.  For  example,  the  observer  can  find  occasion 
to  cross  the  room  for  some  ostensible  purpose  or  another,  and  then  can 
suddenly  address  the  claimant  by  name.  Such  petty  strategy,  though 
certainly  not  beneath  consideration,  as  it  may  elicit  important  results 
in  a  very  short  time,  needs  no  further  notice.  It  becomes  merely  a 
matter  of  practice  and  skill. 

Needless  to  say,  heckling  of  any  kind  is  absolutely  unjustifiable,  so 
also  are  disparaging  remarks,  or  the  employmerft  of  any  plan  that  is 
likely  to  arouse  the  slightest  resentment  or  indignation.  Such  method — 
if  method  it  can  be  called — merely  proves  the  absence  of  that  skill 
knowledge  and  insight  by  which  alone  the  facts  are  to  be  elicited. 

The  cochleo-palpebral  test  is  one  of  great  use.  It  can  be  applied  in 
cases  of  either  unilateral  or  of  bilateral  deafness.  In  the  former 
instance  it  is  of  course  necessary  to  use  the  Barany  noise-apparatus  in 
the  good  ear. 

The  test  can  be  applied  with  the  eyes  open  or  shut,  and  it  can  be 
applied  as  a  complete  surprise  test,  or  as  a  partial  surprise  test.  In  the 
complete  surprise  the  test  is  applied  as  follows  :  The  observer  takes  his 
seat  opposite  the  claimant,  whose  eyes  remain  open.  The  frequency  and 
character  of  his  physiological  "wink  "is  observed  for  a  few  moments. 
At  a  suitable  instance  the  observer  gives  the  word  to  his  assistant,  who, 
standing  unobserved  close  behind  the  claimant,  thereupon  makes  a 
single  loud  noise  by  clashing  together  the  under  surfaces  of  two  metal 
dishes.  The  reflex  wink  of  course  supplies  evidence  that  the  sound  has 
been  heard.  This  is  a  good  method  of  applying  the  test,  because  in  this 
form  it  can  be  planned  and  completely  carriec"  out  in  secret.  Another 
method  is  to  close  the  claimant's  eyes,  and  for  the  observer  to  gently 
maintain  the  closure  by  keeping  up  slight  pressure  in  a  downward  and 
outwai'd  direction  by  means  of  the  thumb  upon  each  upper  lid.  This 
method  has  the  advantage  of  eliminating  to  some  extent  the  involuntarv 


December,  1920.]  Rhinology,  and  Otology.  361 

wink.  The  twitch  of  the  upper  b'p,  which  occurs  when  the  sound  is 
heard,  is  distinctly  felt  by  the  pahnar  surface  of  the  terminal  phalanx  of 
each  thumb.  Whatever  method  be  employed,  it  is  wellto  remember  that 
in  those  cases  where  the  hearing  is  suspected  of  being  much  better  than 
is  admitted,  the  surprise  noise  should  at  any  rate,  in  the  first  instance, 
be  quite  a  moderate  one.  In  other  words,  the  test  has  a  more  extended 
application  than  in  merely  ascertaining  the  existence  or  non-existence 
of  absolute  deafness.  It  can  be  used  to  some  extent  to  determine  the 
degree  of  auditory  impairment.  Some  observers  prefer  the  whistle  as 
a  source  of  noise  rather  than  the  clang  of  metallic  surface. 

When  the  cochleo-palpebral  test  is  being  applied  in  a  case  of  uni- 
lateral deafness  the  good  ear  must  be  rendered  functionless,  and,  seeing 
that  the  only  reliable  way  of  affecting  this  is  by  means  of  the  Barany 
machine,  the  very  use  of  this  machine,  it  must  be  admitted,  robs  the 
test  to  some  extent  of  its  surprise  element.  Therefore  the  soundest 
conclusions  from  the  cochleo-palpebral  test  can  only  be  drawn  in  cases 
of  bilateral  deafness. 

Among  the  many  uses  of  the  Barany  noise-machine  we  may  mention, 
under  this  heading  of  surprise  tests,  tlie  following  simple  but  ingenious 
little  plan  devised  by  J.  E.  MacDougall,  and  which  has  often  been  found 
extremely  valuable  in  practice.  Place  the  Barany  apparatus  in  the 
sound  ear,  and  tell  the  claimant  to  begin  reading  a  passage  from  the 
newspaper.  After  a  few  moments,  say  to  him  in  an  ordinary  voice 
(carefully  withdrawing  any  possibility  of  lip-reading) :  "  Stop  !  That 
will  do !  "  It  is  not  proposed  to  present  here  a  complete  analysis  of  all 
the  uses  of  the  Barany  apparatus.  It  will  suffice  to  state  more  or  less 
aphoristically  the  most  important  practical  uses  which  experience  has 
shown  it  to  possess,  and  to  dwell  upon  one  or  two  practical  points  in 
the  use  of  it. 

It  is,  of  all  instruments,  perhaps  the  most  essential  for  the  accurate 
assessment  of  aural  disability  in  a  lai-ge  number  of  the  class  of  patient 
we  are  now  considering.  The  test  differs  radically  of  course  frorn  the 
interrogation  of  the  tuning-fork.  The  reply  to  this  instrument  is,  in 
the  main,  not  what  the  patient  says,  but  what  he  does.  It  is  essentially 
a  surprise  stimulus,  eliciting  action  as  its  response. 

Perhaps  the  most  frequent  use  of  the  instrament  is  for  eliminating 
the  sound  ear  when  the  impaired  ear  is  being  tested.  In  the  writer's 
experience,  and  observing  certain  simple  precautions,  the  use  of  the 
instrument  for  this  purpose  has  not  been  found  to  incapacitate  the 
sound  ear.  The  instrument  has  not  been  standardised,  or  if  it  has  been, 
it  is  still  frequently  iound  that  the  standardisation  is  not  accurate. 
Some  instruments  are  much  more  noisy  than  others.  It  is  best  to 
work  with  an  instrument  that  produces  only  a  moderate  noise. 

Give  the  patient  a  few  moments  in  order  to  get  used  to  the  noise, 
and  do  not  insert  the  ear-piece  too  firmly  into  the  meatus.  It  should 
be  applied  quite  lightly  to  the  ear,  in  such  a  way  as  to  reduce  dis- 
comfort and  distraction  to  a  minimum.  When  the  observer  is  speaking 
at  a  distance,  the  patient  may  hold  the  instrument  in  position  for 
himself.  If  these  precautions  are  observed,  the  hearing  in  the  sound 
ear  will  be  unhampered. 

It  may  be  remembered  that  when  used  for  ehciting  Lombard's  voice- 
raising  reaction,  this  test  is  not  infallible.  The  noise  may  be  well  heard, 
and  yet  in  a  certain  number  of  cases  voice-raising  will  not  occur.  In 
one  case  tested  by  the  writer  the  voice  was  actually  lowered,  but  this 


362  The  Journal  of  Laryngology,      [December,  1920. 

was  a  case  of  over-actiug  the  part  of  wilful  resistance  to  a  stimulus  of 
which  the  nature  and  usual  effect  were  probably  not  unknown.  The 
stimulus  may  cause  (1)  voice-raising ;  (2)  voice-quickening  ;  (3)  voice- 
stopping  ;  (4)  voice-dropping ;  (5)  no  effect. 

It  is  not  unusual  to  find  that  the  first  three  of  these  phenomena  all 
occur  as  different  phases  of  the  response  in  the  same  individual,  and  in 
the  order  of  voice-stopping,  voice-raising,  voice-quickening.  The  first 
result  is  momentary,  and  is,  of  course,  due  to  the  sudden  impact  of  the 
sound,  provided  of  course  that  the  reading  begins  before  the  apparatus 
is  brought  to  the  ear. 

Voice-dropping  is  very  unusual,  but  instances  in  which  no  effect  is 
produced  do  occur,  as  has  already  been  stated,  from  time  to  time.  And 
it  is  by  no*  means  certain  that  this  negative  result  can  be  always 
explained  on  the  ground  of  previous  familiarity  with  the  stimulus. 

If  Schwabach's  test  is  being  applied,  say  on  the  right  side,  then  the 
Barany  machine  at  the  left  meatus  will  prevent  the  left  ear  participating 
and  thereby  in  all  probability  falsifying  the  result. 

It  is  hardly  necessary  to  say  that  the  fallacy  arising  from  lip-reading, 
when  voice  tests  are  being  applied,  must  always  be  kept  in  mind. 

My  thanks  are  due  to  Mr.  J.  Lawson  Dick,  M.D.,  F.E.C.S.,  deputy 
commissioner  of  medical  services,  and  medical  officer  in  charge  of 
special  boards,  for  his  unfailing  kindness  in  giving  valuable  and  ready 
advice  on  all  occasions,  to  Dr.  J.  E.  McDougall,  whose  minute  precision 
and  untiring  patience  have  raised  the  work  almost  to  the  level  of  a  fine 
art,  and  to  Mr.  T.  B.  Layton,  D.S.O.,  M.S.,  from  whom,  by  personal 
communication,  I  have  learned  the  value  of  many  important  observations. 


NOTE    ON   THE   SPINOSE   EAR   TICK    (ORNITHODORUS 

MEGNINI  DUGES)   IN   THE   HUMAN   EAR   IN 

SOUTH   AFRICA. 

By  E.  Broom,  M.D.,  F.R.S. 

The  spinose  ear  tick,  whicii  is  a  native  of  America,  has  been  for  some 
years  introduced  into  South  Africa,  and  has  spread  over  the  drier 
parts,  especially  the  Northern  Cape  Colony  and  Orange  Free  State. 
It  is  chiefly  parasitic  upon  calves,  sheep  and  goats,  but  is  also  found 
in  the  ears  of  horses,  donkeys,  dogs,  cats,  ostriches,  and  not  infrequently 
in  man. 

A  good  account  of  the  life-history  has  recently  been  given  by 
G.  A.  H.  Bedford,  F.E.S.,  in  the  Journal  of  the  Department  of  Agriculture 
(South  Africa),  July,  1920,  from  which  the  following  account  is 
condensed  :  "  The  female  ticks  lay  their  eggs  under  stones  on  the  veld. 
.  .  .  The  eggs  hatch  out  in  about  22  to  56  days  and  give  rise  to 
six-legged  larvae,  which,  as  soon  as  they  have  hatched,  craw^l  about  in 
search  of  a  host,  and  as  soon  as  they  find  one  they  get  into  its  ears  and 
there  commence  to  feed.  .  .  .  After  engorging,  which  takes  about 
5  to  7  days,  they  become  quiescent,  and  are  then  unable  to  move  until 
they  have  cast  their  skins  and  become  nymphae.  The  length  of  time 
the  nymphae  remain  on  their  host  varies  considerably.     .     .     .     Hooker, 


December,  1920.:  Rhinolog'/,  and  Otology.  363 

in  America,  has  observed  a  nympha  to  abandon  its  host's  ear  35  days 
after  the  larva  had  been  introduced,  and  in  other  cases  the  nymphae 
remained  attached  after  98  days  had  elapsed.  Nymphae  have  also 
been  observed  at  Onderstepoort  to  remain  in  the  ears  of  their  hosts  for 
3  months.  When  engorged  they  leave  their  host  and  crawl  about  in 
search  of  some  sheltered  spot  where  they  can  change  into  adults,  which 
takes  place  in  from  7  to  31  days.  They  then  fertilise,  and  then  the 
females  commence  laying  eggs,  after  which  they  die." 


X  3. 


When  a  tick  has  got  into  a  human  ear  the  patient  at  once  realises 
that  there  is  something  alive  in  his  ear,  and  comes  to  a  doctor  with 
the  diagnosis  already  made  that  he  has  a  tick  in  his  ear ;  and  when 
the  ear  is  examined  there  is  usually  little  difficulty  in  seeing  either  the 
tick  or  some  of  its  legs.  In  one  case  in  a  child  of  live  which  I  saw 
the  whole  inner  end  of  the  meatus  was  blocked  with  the  engorged 
tick,  and  had  I  not  suspected  a  tick  I  might  readily  have  taken  the 
obstructing  object  for  a  polypus.  Except  in  this  case  I  have  never 
experienced  any  difficulty  in  catching  the  tick  with  forceps  and  removing 
it  entire,  and  though  there  was  no  difficulty  in  the  child's  case  the 
tick's  body  had  to  be  burst  before  it  could  be  removed. 

Beyond  the  irritation  caused  and  redness  and  swelling  of  the  tissues 
little  temporary  trouble  is  produced,  and  apparently  no  permanent 
injury.  In  calves,  sheep  and  goats  the  irritation  seems  at  times  to 
produce  death. 


SOCIETIES'     PROCEEDINGS. 


ROYAL  SOCIETY  OF  MEDICINE.— LARYNGOLOGICAL 

SECTION. 


December  6,  1919. 


President :  Dr.  James  Donelan. 


{Continued  from  p.  3ii.) 

Discussion  on  Dilatation  of  the  (Esophagus  without  Anatomical 
Stenosis  {continued). — A.  Brown-Kelly. — Treatment:  The  preliminary 
part  of  the  treatment  of  cardiospasm  is  carried  out  by  aid  of  direct 
inspection.  If  the  oesophagoscope  is  to  be  passed  for  the  first  time  a 
general  anaesthetic  should  be  given,  otherwise  the  nervous  strain  caused 
by  the  examination  may  aggravate  the  disease.  In  introducing  the  tube 
more  resistance  than  usual  is  encountered  at  or  near  the  mouth  of  the 
gullet.      This  experience,  together  with  the  fact  that  these  patients  often 


364  The  Journal  of  Laryngology,      [December,  1920. 

refer  their  dysphagia  to  the  cricoid  region  and  not  to  that  of  the  cardia, 
indicates  that  obstruction  at  the  lower  end  of  the  gullet  may  be  associated 
with  spasm  at  the  upper  end,  just  as  pyloric  stenosis  sometimes  gives 
rise  to  reflex  spasmodic  stricture  of  the  ceso]jhagus. 

If  the  patient  is  lying  on  his  back  with  the  head  slightly  lowered, 
which  level  is  the  best  position  for  the  examination  of  the  cardiac  end  of 
the  gullet,  a  quantity  of  cloudy  grey  fluid  runs  out  of  the  tube  as  soon  as 
it  enters  the  gullet.  More  may  be  drained  off  by  further  depressing  the 
head  and  shoulders.  The  masses  of  soft  food  in  the  lower  parts  are  then 
removed  and  the  walls  of  the  dilatation  inspected. 

The  hiatal  and  subhiatal  regions^  are  now  examined.  These  are  in 
the  axis  of  the  oesophagus  and  easily  found  if  the  dilatation  is  spindle- 
shaped.  Most  dilatations,  however,  are  flask-shaped,  and  in  advanced 
cases  there  may  be  considerable  sagging  of  the  wall  to  the  right  and 
downwards,  so  that  the  hiatus  comes  to  be  situated  on  the  lower  part  of 
the  left  lateral  wall  while  the  fundus  of  the  dilatation  is  at  a  lower  level. 
Under  these  conditions,  instruments  introduced  along  the  axis  of  the 
cesojjhagus  impinge  on  the  floor  of  the  sac,  and  to  reach  the  epieardia 
they  must  be  directed  well  to  the  left  and  passed  beneath  the  great 
bulging  produced  by  the  heart.  It  seems  to  me  that  oesophagoscopy 
in  such  cases  affords  a  particularly  favourable  opportunity  of  studying 
movements  of  the  heart. 

The  first  point  to  note  for  future  use  in  regard  to  the  hiatal  gullet  is 
its  distance  from  the  upper  teeth.  In  reports  of  cases  of  cardio-spasm 
striking  measurements  of  the  gullet  are  sometimes  given,  but  I  am  .not 
aware  of  any  statement  to  the  effect  that  its  abnormal  length  is  a  constant 
feature  of  this  disease.  The  chief  conditions  affecting  the  length  of  the 
normal  gullet  are  sex,  height  and  age.  In  the  male  of  medium  height 
the  distance  from  the  upper  incisors  to  the  cardia  is  40  cm.  on  an  average 
and  in  the  female  38  to  39  cm.  The  following  table  shows  the  sex  and 
height  of  the  patient  and  the  distance  to  the  hiatus — i.  e.  to  a  level  in 
the  gullet  3  to  4  cm.  above  the  cardia.  It  will  be  seen  that  while  no 
individual  is  above  medium  height  and  several  below  it,  the  gullet  in 
most  is  considerably  elongated  ;  this  lengthening  was  greatest  in  the 
severer  cases.  The  increase  in  length  becomes  more  striking  if  to -each 
of  these  measurements  at  least  3  cm.  be  added,  which  is  the  distance  of 
the  hiatus  from  the  cardia  (Table  I). 

Table  I. — Hiatal  Esophagus. 
Case.  Se.x. 

1  .  F. 

2  .  F. 

3  .  F.  . 

4  .  M.  . 

5  .  M.  . 

6  .  M.  . 

7  .  M.  . 

8  M. 

9  .  M.  . 
10                    M. 

Average  distance  in  males 

„  „         female 

The  aspect  at  the  hiatal  oesophagus  (or  hiatus  cesophageus  as  commonly 

but  wrongly  termed)  next  calls  for  attention.     Some  writers  maintain 

that  it  is  normal ;  others  that  it  is  normal,  but  with  the  folds  of  mucous 

membrane  more  firmly  pressed  together  so  as  to  close  the  lumen  ;  others 

1  Dr.  Wm.  Hill's  terminology  has  been  largely  adopted  in  this  paper. 


VAJ.3Vr         AIWVI    ^   O. 

Distance  from 

Age. 

Height. 

upper  incisors. 

19 

5  ft.  2^  in. 

37  cm. 

60 

5  „  4     „ 

42    „ 

56 

— 

— 

58 

5  „    7     „ 

48   „ 

33 

5  „    5      ,, 

47  „ 

24. 

5  „    7h   „ 

47  „ 

18 

5  „  4     „ 

37  „ 

59 

5  „  7      „ 

43    „ 

41 

5  „  6     „ 

43    „ 

22 

5  „   Oj    „ 

44  „ 

males 

.     40 

cm. 

females 

.     39 

„ 

December,  1920.]         Rhinology,  and  Otology.  365 

that  it  is  peculiar  to  cardiospasm  and  may  differ  in  slight  and  severe 
cases ;  aud  lastly,  there  are  several  who,  iu  discussing  this  disease,  have 
omitted  to  describe  the  hiatal  oesophagus,  probably  having  come  to  no 
conclusion  as  to  its  typical  appearance,  or  regarding  this  as  not  different 
from  the  normal. 

In  most  of  my  cases  the  lumen  of  the  hiatal  oesophagus  was 
surrounded  by  a  stellate  arrangement  of  folds  of  mucous  membrane 
(Figs.  1  and  2)  ;  in  others  it  was  V-shaped,  or  merely  a  slit  with 
a  prominent  cushion  iu  front  aud  behind.  J'lie  size  of  the  lumen  was 
constantlv  changing,  enlarging  with  inspiration  and  contracting  or  closing 
witl)  expiration.  (All  the  patients  had  y^^  gr.  of  atropine  injected  hypo- 
derniically  before  being  anaesthetised.) 

The  appearances  and  movements  just  mentioned  were  noted  while  the 
oesophagoscope  was  about  3  cm.  above  the  hiatal  level.  From  this  view- 
point the  aspect  of  the  liiatal  oesophagus  iu  my  cases  of  cardiospasm  waf; 
therefore  normal.  But  as  soon  as  the  instrument  was  introduced  a  little 
farther  and  came  into  contact  with  the  parts  around  the  hiatus,  this  at 
once  was  closed,  and  remained  clo.sed  vmtil  the  tube  was  withdrawn  a  few 
centimetres,  when  the  rhythmical  opening  and  closing  of  the  epicardia 
recommenced.     This  secjuence  of  events  could  be  pi'oduced  over  and  over 


again  in  five  of  my  cases  ;  it  was  absent  in  one  in  which  the  patient  had 
almost  recovered,  and  was  not  observed  in  the  others,  which  were  examined 
before  this  heightened  I'eflex  activity  had  attracted  my  attention.  In 
patients  suffering  from  affections  other  than  cardiospasm  iu  whom  the 
sensation  has  been  testeol,  it  has  invariably  been  foimd  that  the  opening 
and  closing  of  the  epicardia  continued  iu  spite  of  its  being  touched  by 
the  tube,  auol  ceasecl  only  when  firm  pressure  was  applied  to  the  parts 
immetiiately  surrounding  the  orifice  ;  even  then  the  movements  occa- 
sionally persisted.  The  number  of  examinations  I  have  made  of  patients 
with  and  without  cardiospasm  in  reference  to  this  feature  is  still  too 
small  to  warrant  the  statement  that  it  is  pathognomonic  of  cardiospasm. 

Various  writers  mention  that  in  cardiospasm  firm  closure  of  the  gullet 
at  the  level  of  the  hiatus  follows  any  attempt  to  pass  a  tube  through  it, 
but  they  do  not  contrast  the  normal  aspect  and  movements  it  presents 
when  untouched  with  the  spasmotlic  closure  it  undergoes  from  slight  and 
olistant  irritation,  nor  do  they  appear  to  have  met  with  the  hyperaesthesia 
as  constantly  and  over  as  large  an  area  of  the  gullet  as  I  have  indicated : 
and  certainly  none  of  them,  so  far  as  I  know,  has  ascribed  the  cardiospasm 
to  this  hypersesthesia. 

These  observations  help  to  reconcile  the  apparent  discrepancies  in 
the  descriptions  of  the  hiatal  oesophagus  iu  carcliospasm,  and  show  that 
the  varying  statements  really   correspond  to  the  varying  conditions  of 


366  The  Journal  of  Laryngology,      [December,  1920. 

the  opeuiug.  Further,  they  carry  us  a  step  onward  in  our  knowledge 
of  the  nature  of  the  disease  hy  proving  the  presence  of  a  byperaesthetic 
reo-ion  for  some  distance  above  the  hiatal  level.  Irritation  of  this  legion 
is  seen  to  pioduce  contraction  or  spasm  of  the  oesophageal  wall,  and  not 
compression  such  as  might  be  caused  by  the  action  of  the  crura  of  the 
diaphragm.  Illustrations  of  the  oesophagus  at  the  hiatal  level  in  cardio- 
spasm that  have  been  published  also  give  the  impression  of  contraction 
and  not  compression.  If  these  observations  and  deductions  prove  correct 
we  mav  discard  the  term  "  cardiospasm  "  and  adopt  that  of  "  suprahiatal 
hypereesthesia."  Both,  however,  merely  mark  stages  in  the  progress  of 
our  knowledge  of  the  pathogenesis  of  oesophageal  dilatations,  as  did  the 
other  names  that  have  been  successively  applied — namely,  idiopathic, 
paralytic  or  atonic,  s]>:i  ,  o genie  and  cardiospastic.  We  are  still  ignorant 
of  tbe  piimai'V  cause  vi  the  disease;  whether  the  next  clue  is  to  be 
■night  in  an  undue  irritability  of  the  autonomous  nervous  system,  and 
this  in  turn  in  a  disturliance  of  some  internal  secretion,  or  of  certain 
constituents  of  the  blood,  must  meantime  remain  in  the  realm  of 
speculative  pathology. 

The  drugs  chiefly  recommended  for  the  affection  iinder  consideration 
have  been :  bromides,  valerian,  belladonna,  atropine  and  papaverin.  I 
have  not  used  the  first  two  as  none  of  my  patients  has  been  of  a  neurotic 
type.  Belladonna  or  atropine  I  have  occasionally  tried  on  the  assumption 
that  the  underlying  disturbance  was  vagotonia,  but  without  obtaining 
any  appreciable  improvement.  Papaverin  is  said  to  be  of  assistance  in 
slight  cases. 

The  systematic  washing  out  of  the  dilated  gullet  with  an  alkaline 
solution  will  be  useful  if  the  lining  membrane  is  inflamed  or  otherwise 
unhealthy,  but  I  have  found  it  necessary  only  exceptionally  owing  to  the 
stretching  treatment  employed  having  nearly  always  beeii  followed  by 
cessation  or  amelioration  of  regurgitation.  On  the  other  hand,  some 
patients  use  a  stomach-tube  frequently  in  order  to  evacuate  the  contents 
of  the  dilatation  before  going  to  bed,  or  to  open  the  cardia,  or  even  to 
introduce  food  into  the  stomach  if  the  spasm  is  sj^ecially  troublesome. 

The  food  taken  should  be  thoroughly  masticated  or  soft  and  swalloAved 
slowly.  The  disease  is  said  to  have  been  caused  in  some  instances  by 
bolting  food.  The  patient  should  neither  eat  nor  drink  anything  likely 
to  irritate  the  wall  of  the  dilatation. 

At  one  time  the  local  treatment  consisted  chiefly  in  the  passage  of 
sounds  and  bougies.  In  slighter  cases  this  may  suftice.  Thus,  two  of 
my  patients  have  been  cured  for  seven  and  two  and  a  half  years 
respectively  by  having  had  metal  or  ivorv  olives  passed  twice  or  thrice 
(Tables  II",  III,  and  IV). 

Table  II. — E.  B ,  aged  nineteen. 

1911. 
June  1       .         .     Dysphagia  for  seven  years  ;  subsisted  for  past  year  on  biscuits, 
Benger's   food,  eggs,  etc. ;    regurgitates  very  little ;    weiglit 
6  St.  11  lb.  12  oz. 
June  28     .         .     Passed  small  olives. 
July  5       .         .     Passed  larger  olives. 
July  12     .         .     Can  swallow  meat. 
Augiist  1  .         .     On  ordinary  diet. 
September  27  .     Very  stout ;  being  overfed  ;  weiglit,  9  st.  9i  lb. 

1912. 
October  2  .     Very  Avell ;  weight,  9  st.  11  lb. 

1918. 
September  3     .     Has  had  no  recvirrence  of  dysphagia  or  regurgitation. 


December,  1920.]  Rhinology,  and  Otology. 


367 


Table  III.— F.  T- 


AGED    SIXTY. 


1916. 

June  21     . 

June  30     . 
July  5 
July  8 
July  12     . 

1918. 
November 


Dysphagia  for  one  and  a  half  years  ;  occasionally  complete  tor 

four  or  five  days  ;  has  lost  1  ^  st.  since  onset. 
Food  measured  {see  Table  IV). 
Olives  passed. 

Deglutition  improved ;  no  regurgitation  ;  olives  passed. 
All  food  swallowed ;  no  regxirgitation. 

Can  eat  anything ;   never  regurgitates  ;  has  gained  3  st.  since 
June  21,  1916. 

In  most  cases,  however,  the  amouut  of  stretching  produced  by  even 
the  largest  bougies  or  olives  is  insufficient  to  dispel  the  cardiospasm. 
An  important  contribution  to  the  treatment  of  this  affection  was  made 
in  1898,  when  Dr.  J.  C.  Eussel,^  of  Southport,  described  the  condition 
we  have  under  discussion,  and  recommended  for  its  cvire  the  stretching 
of  the  cardia  by  means  of  silk-covered  rubber  bags  of  increasing  size. 
Unfortunately  this  paper  was  generally  overlooked.  Plummer,  however, 
refers  to  it,  and  gives  Russel  the  credit  he  desei'ves. 

Five  years  later  v.  Mikulicz  demonstrated  the  benefit  obtained  by 
oA'erstretching  the  muscles  around  the  cardia.  He  accomplished  this  at 
first  with  two  fingers,  later  with  specially  constructed  forceps,  introduced 
through  the  stomach. 

In  order  to  obtain  the  same  effect  without  gastrostomy  Grottstein  and 
Geissler  devised  an  instrument  for  introduction  through  the  mouth 
consisting  of  a  tube  fitted  at  the  lower  end  with  an  hour-glass-shaped 
distensible  bag.  When  the  constricted  part  of  the  bag  was  embraced  by 
the  cardia,  water  or  air  was  injected  until  the  desired  amount  of  dilatation 
had  taken  place.  The  success  that  attended  the  use  of  this  instrument 
led  to  the  construction  of  various  modifications.  In  some  of  these  the 
distensible  bag  has  been  retained,  as  in  Plummer's  apparatus.  In  other.s 
it  has  been  replaced  by  two  or  more  metal  blades,  which  can  be  separated 
to  the  desired  extent  by  a  graduated  screw  (Abraud,  Mosher)  or  a 
dynamometric  spring  in  the  handle  (Lerche,  Briinings). 


Table 

IV 

.— F.  T- 

,    AGED    SIXTY. 

Breakfast. 

June  30, 

1916. 

Dinner. 

7  a.m.     .     Porridge    . 

Milk  . 
7.30        .     "Water 

oz. 
.     6 
.     4 
.     4 

12.30  p.m.     Soup 

Chicken  and  potatoes 
Jelly  and  milk 
Cup  of  milk     . 

oz. 
.  3 
.  2 
.  4 
.     6 

Total  . 

.   14 

Total  . 

.  15 

Regurgitated 
Retained 

.     8 
.     6 

Regurgitated 
Retained 

.     8 

.    7 

Tea. 

Slipper. 

3.30  p.m.      Tea  . 

Bread  and  buttei- 

.     1 

7  p.m. 

.     Milk 
Water 

.  6 
.     3 

Total  . 

.     6 

Total  . 

.     9 

Regurgitated 
Retained 

Totals  :  Swallowed, 

2 

.     4 
44 ;  regurgitated 

No  regurgitation. 
Retained 
i,  18  ;  retained,  26. 

.     9 

'  BHt.  Med.  Journ.,  1898,  i,  p.  1450. 


368  The  Journal  of  Laryngology,       [December,  1920. 

Guisez  iu  191 1  had  used  Gottstein's  balloon  in  fifteen  cases  and  had 
obtained  improvement  in  all.  He  advised  that  the  bag  be  distended 
until  its  diameter  Avas  6  to  7  cm.  He  had  found  that  the  capacity  of 
the  dilatation  diminished  rapidly  after  treatment. 

Plummer,  who  probably  has  had  greater  experience  than  anyone  in 
the  treatment  of  this  aifection,  employs  a  dilator  connected  with  a  water 
tap  and  furnished  with  a  gauge  indicating  the  amount  of  pressure. 
This  is  gradually  raised  at  successive  treatments  until  satisfactory  results 
are  obtained.  In  one  case  unusually  high  pressure  caused  rupture  of 
the  oesophagus.  In  1912  he  published  his  results  in  ninety-one  cases  of 
diffuse  dilatation  of  the  oesophagus  without  anatomic  stenosis.  Of  these, 
seventy-three  were  completely  relieved  of  dysphagia,  eleven  were  not 
completely  cured,  four  had  died  and  three  could  not  be  traced.  Most  of 
the  patients  with  extreme  inanition  needed  only  one  treatment  to  effect  a 
cure.  In  three  patients  he  found  that  the  dilated  oesophagus  had  retui-ned 
to  the  normal  size. 

Chevalier  Jackson  considers  that  it  is  difficult  to  place  dilating  bags 
accurately  by  blind  methods,  and  therefore  prefers  a  mechai.ical  divulsor, 
such  as  Mosher's,  which  can  be  introduced  through  the  oesophagoscope 
and  the  action  of  which  can  be  regulated  by  the  sense  of  touch.  His 
53  cm.  oesophagoscope  is  passed  into  the  stomach  and  afterwards  the 
divulsor  through  it.  Under  guidance  of  the  eye  the  oesophagoscope  is 
withdrawn  until  the  expansile  portion  of  the  divulsor  in  exposed  and  its 
greatest  diameter  placed  in  the  hiatal  oesophagus.  It  is  then  expanded 
to  about  20  to  25  mm.  and  kept  in  for  from  five  to  ten  minutes.  As 
divulsion  is  painful  he  advises  ether  aDsesthesia.  He  finds  from  one  to 
six  divulsious  at  inteivals  of  a  week  necessary. 

I  have  used  Gottstein's  instrument  almost  exclusively.  The  method 
adopted  is  as  follows :  Having  obtained  d\iring  the  oesophagoscopic 
examination  the  distance  from  the  upper  teeth  to  the  hiatus,  this  is 
measured  from  the  middle  of  the  bag  along  the  stem  of  the  instrument 
and  marked  with  a  thread  or  a  sliding  piece  of  rubber  tubing,  which  also 
serves  to  protect  the  bougie  from  being  bitten.  Before  introducing  the 
instrument  the  coutents  of  the  gidlet  are  removed  by  suction,  or,  if 
thick,  washed  out.  Patients  unaccustomed  to  the  procedure  will  at  first 
be  cocainised,  but  they  quickly  learn  to  dispense  with  this.  The  dilator 
is  then  passed.  It  may  meet  with  slight  obstruction  at  the  hiatus,  but 
if  gentle  pressui-e  be  n)aiutained  for  a  few  secouds  it  glides  onwards. 
When  the  measurements  indicate  that  the  Viag  is  in  position  it  is  gradually 
distended  by  water.  In  the  instrument  I  use,  four  to  six  syriugefuls 
are  usually  injected  before  the  patient  begins  to  complain  of  pain,  whei-e- 
iipon  the  injection  is  stopped.  Sonu'times  the  distended  bag  is  left 
i7i  sifn  for  a  few  minutes,  after  which  the  water  is  allowed  to  escape  and 
the  apparatus  withdrawn. 

A  method,  by  means  of  X  rays,  of  determining  whether  the  bag  is 
in  position,  is  to  place  a  small  lead  square  or  circle  over  the  site  of  the 
stream  of  bisnuith  passing  from  the  gullet  to  the  stomach,  and  afterwards 
to  use  a  dilator  the  lower  part  of  which  contains  a  lead  rod.  The  latter 
is  watched  crossing  the  lead  window  and  the  distance  estimated.  It  will 
usually  be  found  to  pass  considerably  to  the  left  in  entering  the  stomach. 
One  or  a  few  dilatings  may  produce  a  cure,  or  improvement  lasting  for 
months.  In  more  obstinate  cases  I  have  repeated  the  dilatation  at 
intervals  of  a  few  days  over  a  period  of  several  weeks,  but  the  benefit 
obtained  has  not  been  proportionate  to  the  amount  of  treatment.  The 
dysphagia  as   a    rule   is   immediatelv  relieved,    and  the  day   following 


December,  1920]  Rhiiiology,  and  Otology.  369 

the  first  streteliiug  the  patieut  eats  a  hearty  meal  such  as  he  has  not 
enjoyed  for  mouths  or  years.  He  quickly  gains  weight  aud  vigour,  and 
may  remain  well  indefinitely  or  for  a  variahle  period  (Table  V). 

Table  V. — H.  M ,  aged  fiitt-eight. 

1913. 
May  14  .  Dysphagia  seven  years  ;  weight  under  10  st. 

May  27   .  Passed  thick  stomach-tube. 

June  18  .  Swallowing  soft  food  :  no  regiu-gitatiou  for  ten  days. 

August   .  .     Weight.  10  st.  8i  lb. 

191-4. 

May  3  .     Dysphagia  returned  three  weeks  ago  ;  complete  for  one  week. 

Dilator,  two  and  a  half  syringefuls. 
May  17   .  Dilator,  three  and  a  half  syringefuls. 

May  18   .  .     Greatly  improved. 

'  1916. 

May  3     .  .     AVell  imtil  fortnight  ago  :  all  regurgitated  since. 
May  15   .  Dilator,  six  syringefuls. 

Mav  31    .  .     Better  than  for  vears. 

'  1917. 

February  28  .     Very  well ;  no  regurgitation  ;  weight  list.  12  lb. 

November  .     Died  of  pneumonia  :  took  food  well  till  last  illness. 

Table  VI. — Mrs.  M'A ,  aged  sixty-two 

191-4.  Total  swallowed  Res:urcritate(l.  Retained. 

October  25     .  .97  oz.         .  86  oz.         .  11  oz. 

October  26     .  .       36    „  .  26    „  .  10    „ 

Cardia  dilated. 

October  30     .  .89  oz.         .  16  oz.  .  73  oz. 

„        31     .         .         .     108    ,,  .  17    „  .  91    „ 

November  1  .  .     113    „  11    „  102    „ 

November  2  .         .         .     105  oz.  22  oz.  83  oz. 

The  regurgitation  also  ceases,  or  is  distinctly  diminishe<l  (Table  VI). 
Sometimes,  however,  there  is  retention  without  regurgitation,  and  the 
presence  of  food  and  fluid  in  the  dilatation  may  escape  notice  unless 
looked  for.  The  contents  of  the  oesophagus  may  be  removed  by  the 
Senoran's  suction  apparatus  :  and  the  quantity  obtained  from  time  to 
time  gives  an  indication  of  the  progress  towards  recovery.  Another 
method  of  determining  the  presence  and  amount  of  retained  fluid  is  to 
cause  the  patient  to  swallow  a  capsule  three-C[uarters  full  of  bismuth 
which  floats.  In  one  of  my  patients,  from  whose  gullet  about  300  c.c. 
ot:  fluid  could  usually  be  withdrawn,  the  capsule  could  be  seen  about  the 
level  of  the  episternal  notch  moving  up  and  down  with  respiration. 
Although  the  amount  of  retained  fluid  in  this  case  was  so  considerable, 
the  patient  suifered  but  little  inconvenience  from  it  and  often  was 
unaware  of  its  presence. 

There  appears  to  be  no  doubt  that  the  dilated  cesophagus  occasionally 
returns  to  its  normal  size :  several  authorities  have  made  observations 
bearing  on  this  point. 

I  shall  say  nothing  about  gastrostomy  excepting  to  recommend  it  for 
patients  who  have  been  reduced  to  a  moribund  state  by  prolonged  fasting, 
and  in  whom  an  examination  with  the  cesophagoscoije  and  dilatation 
treatment  would  meantime  be  contra-indicated. 

The  only  deatli  I  have  had  directly  due  to  cardiospasm  was  that  of  a 
woman,  aged  fifty-six,  who  had  suffered  from  dysphagia  for  twenty 
years.  Four  weeks  before  death  the  obstruction  at  the  cardia  had 
suddenly  become  almost  complete.  She  was  first  examined  by  me  five 
davs  before  her  death,  when,  on  intruducino-  the  oesophagoseope,  a  large 

24 


370  The  Journal  of  Laryngology^      [December,  1920. 

quantity  of  bismuth  in  suspension  was  drained  off:  this  had  been 
swallowed  six  days  ))revionsly  for  X-ray  purposes.  A  tube  was  passed 
into  the  stomach  under  direct*  observation,  and  left  iiisiiu.  After  having 
been  fed  through  this  for  two  days  she  withdrew  it.  She  was  then  able 
to  swallow  a  little  fluid  naturally.  The  same  evening  she  died  of  heart 
failure.  At  the  post-mortem  examination  the  gullet  was  found  to  be 
greatly  dilated.  There  was  no  anatomic  stenosis  at  the  lower  end  and 
no  sign  of  malignancy  anywhere  (fig.  2,  p.  365). 

S.  Gr.  Shattock  :"At  times  the  oesophagus  will  pass  entirely  through 
the  right  crus,  and  it  is  conceivable  that  under  such  circumstances  an 
anatomical  variation  might  lead  to  obstruction.  In  one  such  case  which 
I  have  seen,  however,  dissection  showed  that  the  oesophagus  above  this 
abnormal  entry  was  not  dilated. 

With  regard  to  spasm :  There  have  been  put  as  alternatives  that 
spasm  may  be  one  cause  of  this  obstruction,  and  that  the  other  may  be 
inco-ordin'ated  action,  that  is  to  say,  a  want  of  co-ordination  between  the 
descent  of  the  contents  of  the  oesophagus  and  the  dilatation  of  the 
cardiac  orifice.  If  we  accept  the  observations  of  Dr.  Browu-Kelly — and 
I  think  they  are  most  important — we  have  a  very  simple  and  satisfactory 
solution  of  the  cause  of  the  obstruction. 

I  have  long  held  myself  that  a  hypera?sthetic  condition  of  the 
mucosa  furnishes  the  most  satisfactory  explanation  of  hypertrophic 
stenosis  of  the  pyloric  canal ;  so  that  the  mere  passage  of  food  over  the 
membrane  excites  a  spasm  in  the  muscle,  which  may  completely  prevent 
the  passage  of  food.  That,  therefore,  is  a  theory  congruous  with  Dr. 
Brown-Kelly's  observations  upon  the  oesophagus.  There  is  one  difference, 
anatomically,  in  the  case  of  the  pylorus :  there  is  au  overgrowth  of 
muscular  tissue  at  the  site  of  obstruction.  That  we  do  not  see  in 
cesophagectasia.  In  an  excellent  preparation  at  St.  Thomas's  Hospital, 
e.  g.  in  which  a  man,  after  thirteen  years"  obstruction,  died  of  inanition, 
there  is  no  muscular  thickening  Avhatever  at  the  cardia.  This  may, 
therefore,  in  the  minds  of  some,  still  make  for  the  theory  of  neuro- 
muscular inco-ordination  ;  for  the  closure  beyond  the  area  of  excitation 
might  have  been  due,  not  to  au  active  spasm,  but  to  a  failui-e  of  the 
co-ordinated  dilatation. 

When  we  cast  about  for  somewhat  analogous  conditions,  one  of  the 
nearest  perhaps  is  that  of  the  urinary  bladder.  There  are  certain  cases 
of  idiopathic  dilatation  of  the  urinary  bladder,  male  and  female,  in  which 
one  can  find  no  trace  of  urethral  obstruction.  I  have  examined  some 
such,  and  they  have  been  described  also  by  others,  and  what  is  more, 
they  occur  in  the  foetus.  They  might  be  thought  to  be  cases  of  infection 
and  of  spasm  incited  in  the  urethral  muscle  by  the  passage  of  urine 
over  an  inflamed  mucosa,  but  the  fact  that  the  conditions  may  occur 
before  birth  will  exclude  such  a  view.  There  is  one  example  in  Guy's 
Hospital  Museum,  another  in  the  College  of  Surgeons,  of  female  children 
whose  bladders  at  birth  Avere  greatly  distended  without  discoverable 
cause  of  obstruction.  That  some  such  are  due  to  neuro-muscular  inco- 
ordination may  be  guessed  from  the  phenomenon  of  what  Paget  called 
"  stammering  "  Idadders,  where,  after  the  escape  of  a  few  drops  of  urine, 
a  complete  block  will  ensue,  which  may  last  long  enough  to  lead  to 
painful  distension.  In  reflecting  upon  this  subject  ^  I  considered  tlie 
possibility  of  there  being  not  a  hypersesihetic  but  a  /;;/^;oa?sthetic  state  of 
the  vesical  mucosa  (pharyngeal  bypoaesthesia  or  complete  ansesthesia  is 
>  Proc.  Roij.  Soc.  Med.,  190S-9,  ii  (Sect.  Path.),  p.  98. 


December,  1920.]  Rhinology,  and  Otology.  371 

well  knoTvu  iu  hysteria).  The  xievr  seemed  to  me,  moreover,  applicable 
as  an  explanation  of  megacolon,  where  the  colon  slowly  dilates  without 
any  trace  of  organic  obstruction,  and  this  commencing  in  the  pelvic 
portion  where  there  is  no  anatomical  sphincter.  In  connection  with 
this  subject  I  devised  the  following  experiment :  Into  the  bladder  of  a 
female  cat  a  little  cocaine  solution  was  injected  through  a  fine  catheter. 
After  a  few  minutes  the  bladder  could  be  indefinitely  distended  with  salt 
solution,  none  of  which  escaped  by  the  side  of  the  instrument,  as  it  did 
before  the  local  aueesthetic  was  used.  Obviously,  one  of  two  things 
liad  happened  :  either  the  mucosa  had  been  rendered  anaesthetic  and 
had  failed  to  furnish  the  proper  reflex  for  the  excitation  of  the  detrusor 
uriuae,  the  spljincter  remaining  co-ordinately  contracted,  or  the  cocaine 
had  reached  the  muscular  tissue  and  produced  motor  paralysis.  And 
this  leads  me  to  conclude  by  suggesting  that  one  way  of  discovering 
whether  we  are  dealing  witli  an  extraneous  factor  like  the  constriction, 
actual  or  vii-ti;al.  of  the  diaphragm,  or  with  the  intrinsic  factor  of  jii'oper 
spasm  or  achalasia,  might  consist  in  the  use  of  this  local  anaesthetic.  I 
am  sure  the  skill  of  laryngologists  would  enable  them  to  cocainise  the 
cardiac  orifice  or  the  cardiac  end  of  the  oesophagus.  You  will  either 
anaesthetise  the  mucosa,  or,  better  still,  ]:>aralyse  the  musculature  of  the 
cardiac  orifice.  And  then,  if  it  were  found  that  the  obstruction  Avas 
removed.  Dr.  Hill's  view  that  all  these  cases  are  due  to  phrenic  conditions 
would,  I  think,  be  negatived. 

I  may  add  this  further  criticism  :  that  if  the  obstruction  is  really 
where  Dr.  Hill  suggests  it  is,  a  study  of  the  preparations  on  the  table 
will  show  that  the  dilatation  later  on  proceeds  down  to  the  actual  orifice 
of  the  stomach  ;  on  his  view  this  should  not  be  so.  For  let  us  assume 
that  the  dilatation  started  at  the  diaphragm  ;  as  it  proceeded  it  would 
overcome  the  obstruction,  and  on  reaching  the  cardia  the  obstruction 
should  be  i-emoved.  But  that  is  not  the  case.  The  dilatation,  in  these 
preparations,  ends  only  at  the  gastric  orifice,  and  we  must  conclude,  I 
think,  that  we  are  dealing  either  with  spasm  of  the  cardia  or  with  a 
form  of  obstruction  due  to  inco-ordination. 

The  President  :  Before  Dr.  Brown-Kelly  replies,  will  Dr.  Hill  say 
what  is  the  value  of  the  researches  which  have  been  made  on  the  in- 
nervation of  the  oesophagus  r  S'iveu  or  eight  years  ago  I  heard  Dr. 
Guisez  deal  with  this  subject  at  the  Hotel  Dieu,  and  he  mentioned  that 
the  dilatation  of  the  cardiac  end  of  the  oesophagus  was  due  to  the  special 
dilator  branch  of  the  vagus.  On  referring  to  Guisez'sbook  I  find  that  it 
was  Oppenchowshi,  of  Dor  pat,  who  demonstrated  the  special  dilator  nerves 
of  the  cardiac  end,  and  it  was  he  also  who  showed  the  action  iu  con- 
stricting the  opening  of  the  branches  of  the  sympathetic  through  the 
great  splanchnic.  That  seems  to  be  the  mechanism  which  is  irritated 
and  which  produces  the  closure  of  the  orifice  in  these  cases.  In  Mr. 
Harmer's  case  we  saw  that  the  presence  of  aA'ery  small  foreign  body  in 
the  oesophagus  will  excite  spasm  quite  out  of  proportion  to  the  size  of 
that  body.  In  this  discussion  there  has  been  no  allusion  to  the  superior 
constrictor  of  the  oesophagus — I  mean  the  circvilar  fibres  around  its  upper 
end,  and  their  share  in  the  mechanism — which  is  only  second  iu  importance 
to  the  closure  of  the  lower  end  in  these  dilatations.  Nothing  was  .said  as 
to  the  mode  of  opening  of  the  mouth  of  the  oesophagus,  except  that  it 
was  passive  to  boluses  of  food,  whereas  it  has  now  been  demonstrated 
that  an  active  dilatation  takes  place  in  anticipation  of  the  bolus  through 
the  action  of  dilator  filaments. 


372  The  Journal  of  Laryngology,      [December,  1920. 

W.  Hill  (iu  reply):  Mr.  Shattock,  Mr.  Howartli  aud  others  have 
failed,  to  grasp  my  meaniug  as  to  what  takes  place  at  the  hiatus  of  the 
diaphragm  during  the  last  stage  of  the  deglutitory  act.  In  the  same  way 
that  the  opening  up  of  the  upper  orifice  of  the  gullet  is  dependent,  not  ou 
any  intrinsic  oesophageal  action,  bi;t  on  the  pulling  away  of  the  larynx 
and  cricoid  plate  from  the  spine  by  the  hyoid  and  tongue  muscles,  so  the 
opening  up  of  the  lower  region  of  the  gullet — the  phreno-cardiac  portion — 
is  not  mainly  brought  about  by  the  intrinsic  oesophageal  musculature, 
but  is  mainly  actuated  by  the  musculature  of  the  crura  forming  the 
margins  of  the  hiatus.  I  draw  on  the  blackboard  an  inferior  view  of 
the  hiatal  region  at  rest  when  it  appears  as  a  long  lanceolate  slit  enclosing 
the  collapsed  laterally  compressed  gullet.  I  maintain  that  whether  or 
not  there  are  inhibitory  nerves  which  bring  about  dilatation  of  the  cardia, 
the  intrinsic  gullet  musculature  is  powerless  to  make  the  margins  of  the 
hiatus  in  the  diaphragm  assume  a  circular  or  elliptical  form,  which  is 
a  necessary  antecedent  to  the  expansion  or  patency  of  the  previously 
collapsed  and  compressed  gullet.  If  this  phrenic  mechanism  is  at  fault 
it  would  explain  functional  stenosis  at  the  hiatal  level.  There  is  no  proof 
that  hypertonic  contraction  or  spasm  occurs  in  these  cases,  for  the  endo- 
scopic appearances  are  normal.  As  regai'ds  the  draAvings  of  Starck  aud 
Guisez,  their  pictures  when  they  are  not  within  the  limits  of  normality 
are  purely  fanciful.  Achalasia  may  possibly  be  a  factor  in  functional 
stenosis  at  the  hiatal  level,  liut  in  my  view  the  phrenic  factor  is  necessarily 
of  far  greater  importance,  aud  has  been  too  long  ignored. 

S.  Gr.  Shattock  (in  further  comment)  :  One  can  imagine — indeed  one 
is  disposed  to  believe — that  those  phrenic  fibres  which  surround  the 
opening  are  inhibited  in  their  contraction  as  the  oesophageal  contents 
pass.  It  is  so  in  the  case  of  the  urethra.  When  the  bladder  contracts 
to  empty  itself  the  compressor  urethrse  relaxes,  but  the  urethra  does  not 
exjjand,  as  Dr.  Hill  would  suppose  in  the  case  of  the  oesophagus;  it 
merely  relaxes.  But  given  such  an  inhibition,  there  is  no  reason  why 
the  aperture  should  be  made  round  instead  of  remaining  as  an  inert  slit. 

A.  Brown-Kelly  (in  reply)  :  I  have  endeavoured  to  deal  with  the 
si;bject  from  a  practical  standpoint.  In  lOl'i,  at  Liverpool,  I  discussed 
the  various  theories  that  had  been  brought  forward  with  regard  to  the 
tetiology  of  this  affection.  The  opinions  I  have  expressed  to-day  are 
founded  on  observation,  and  it  remains  for  you  to  put  them  to  the  test. 

The  Pathology  of  (Esophagectasia  ( Dilatation  of  the  (Esophagus 
without  Anatomic  Stenosis  at  the  Cardiac  Orifice)  was  illustrated 

by  a  uuicpie  series  of  specimens  collected  by  Irwin  Moore. 

Eemarks  by  Prof.  S.  Gr.  Shattock  :  The  following  comments, 
which  have  received  the  approval  of  the  two  openers  of  the  discussion  on 
<£sophagectasia,  have  been  drawn  up  with  the  object  of  indicating  what 
conclusions  are  suggested  from  a  study  of  the  specimens  exhibited  at  the 
meeting. 

The  Thickening  of  the  Muscular  Coat. 

As  shown  in  the  specimens,  this  varies  in  degree  in  different  cases  ; 
and  even  in  the  same  specimen,  in  different  zones,  or  at  different  levels 
of  the  dilatation.  There  is  none  in  which  the  muscular  wall  is  atrophic 
— i.  e.  absolutely  thinner  than  the  wall  of  the  normal  oesophagus.  Iu 
some  the  amount  of  muscular  thickening  is  not  merely  proportional  to 


December,  1920.]  Rhiiiology,  and  Otology. 


o/ 


the  increased  capacity  of  the  tube,  but  is  absolutely  above  the  normal. 
The  overgrowth  of  muscle  is  to  be  viewed  :is  of  a  secondarv  or  com- 
pensatory kind,  brought  about  by  the  obstruction  below.  In  all, 
therefore,  a  paialytic  condition  of  the  tube  may  be  excluded  as  an 
explanation  of  the  dilatation  :  although,  of  course,  such  an  setiologv 
might  obtain  from  disease,  either  peripheral  or  central,  of  its  vagal 
supply  ;  for  it  may  be  so  proi.luced  experimentally.  That  an  atrophic 
condition,  however,  might  be  merely  a  secondary  pihenomenon  is  not 
to  be  ignored  in  this  connection.  As  long  as  the  blood  supply  of  the 
dilating  tube  remains  good,  the  muscular  overgrowth  would  be  main 
tained  ;  when  this  fails,  as  from  disease  of  the  supplviug  arteries 
immediate  or  remote,  the  dilatation  would  proceed  with  atrophy.  These 
results  would  be  strirtly  comparable  with  those  which  occur  in  the 
muscular  wall  of  the  bladder  in  obstruction  due  to  enlargement  of  the 
prostate. 

Comparison  between  the  Xorjial  Pyloric  and  Cardiac  Canals. 

I! 


Fig.  3  a. — Xormal  cardia  from  ;i   well- i.  ^       .VMiinsr  male  adult  (the  same 

subject  as  Fig.  3  c).     The  crura  of   the   diaphi-agm  are  shown  in  their 
position  ;  they  lie  immediately  above  the  sphincter. 

One  of  the  interesting  things  arising  out  of  the  examination  of  the 
specimens  is,  that  in  one  there  is  a  well-defined  and  pronounced  hyper- 
trophy around  the  terminal  part  of  the  oesophagus.  The  overgrowth  is 
confined  to  the  circular  fibres. 

[On  the  ground  that  there  is  evident  hypertrophy  of  the  phreno- 
cardiac  portion.  Dr.  Hill  would  not  include  this  as  a  case  of  functional 
stenosis  without  anatomic  lesion.] 

The  only  otiier  specimen  suggesting  an  overgrowth  of  the  cardiac 
sphincter  is  one  from  the  London  Hospital,  figured  by  Sir  Hugh  Eigby 
in  Choyce's  "  System  of  Surgery."  The  figure  there  given  is  somewhat 
misleading,  however,  in  that  the  parts  have  not  been  straightened  out  to 
show  their  proper  relations.  "When  this  is  done,  it  is  seen  that  the 
thickened  circular  muscle  lies  almost  entirely  above  the  actual  constriction, 
and  in  the  wall  of  the  lowest  part  of  the  dilated  oesophagus.  In  this 
specimen,  the  thickening  of  the  circular  muscle,  if  regarded  as  a  sphincter 
hypertrophied  in  thickness  and  in  length,  is  now  incorporated  in  the 
dilated  termination  of  the  oesophagus.     This  apparent  anomaly  can  only 


374 


The  Journal  of  Laryngology,      'December,  1920. 


be  explained  bv  supposiutf  that  the  chief  part  of  the  sphincter,  which 
may  at  one  time  have  closed  the  cardiac  orifice  or  canal,  has  slowly  ijiven 
Avay  lender  the  distending  force  from  above.  It  is  therefore  remarkable 
that  the  musculature  of  the  terminal  portion  of  the  canal  below  has 
sufficed  to  maintain  the  obstruction. 

[It  may  be  observed,  in  passing,  that  the  sphincter  vesicae  in  the 
cat's  bladder,  although  insignificant  in  size,  is  sufficient  to  prevent  the 
distended  bladder  being  empjtied  Ijy  firm  pressure  made  with  the  hand. 


Fig.  .3  b.— Normal  cardia  from  a  well-developed  female  of  middle  age.  The 
white  a'sophageal  epithelium  is  shaqjly  demarcated  from  the  gastric  ;  the 
sphincter  embraces  portions  of  both  areas. 


Fig.  3  c  — Normal  jn-lnric  canal  from  a  well-developed  male  adult. 

Natural-sized  drawings  from  specimens  specially  dissected  and  prepared 

by  Prof.  S.  G.  Shattock,  F.E.S. 

when  the  extrinsic  action  of  the  urethral  muscle  in  front  is  excluded  by 
the  passage  of  a  catheter  through  the  urethra  but  not  actually  into  the 
bladder.  ' 

As  tlie  exact  position  and  dimensions  of  the  cardiac  sphincter  are 
matters  of  importance  in  connection  with  the  subject  of  oesophagectasia, 
two  anatomical  specimens  have  lieen  specially  prepared,  male  and  female, 
and  accurately  drawn  in  order  to  elucidate  the  subject.  Fig.  3  a  (p.  373) 
IS  from  a  well-developed  young  adult  male,  who  died  after  an  operation 
for  cerebellar  tumour.  The  parts  were  carefully  dissected  after  removal ; 
a  narrow  cylinder  of  wet  cotton-wool  was  lightly  drawn  through  the 
lower  part  of  the  oesophagus  from  the  stomach ;  and  the  specimen,  laid 
on  cotton- wool,  was  hardened  in  formol  solution,  and  afterwards  bisected 


December,  1920.]  Rhiiiology,  and  Otology. 


o/o 


iu  the  ooroual  piaue.  Fig.  3  b  is  a  similarly  prepared  specimen  from  a 
well-developed  female  of  middle  age,  who  died  suddenly  from  pulmonary 
embolism  after  hysterectcimv. 

One  thing  noticeable  in  making  the  preparations  was  the  ease  with 
which  the  cardia  could  be  displaced  through  the  opening  between  the 
crura,  the  connection  of  the  structures  concerned  being  of  the  most 
delicate  kind.  Attention  may  be  drawn  to  the  thickness  of  the  crura  as 
well  as  to  their  close  apposition  to  the  lower  eud  of  the  oesophagus,  the 
relative  positions  of  the  different  structures  being  carefully  preserved. 
A  study  of  the  drawino;s  will  show  that  the  thickening  of  the  circular 


Fig.  4. 


-Hypertropliic  stenosis  of  the  pyloric  canal,  from  an  adult.     (In 
tlie  Museum  of  St.  J-'homas's  Hospital.)     Natural  size. 


fibres  formmg  the  sphincter  embraces  part  of  the  stomach  as  well  as  the 
eud  of  the  oesophagus,  and  that  it  lies  quite  below  the  diaphragm.  In 
Fig.  3  B  the  dividing  line  between  the  oesophagus  and  the  .stomach  is 
sharply  brought  out  by  the  greater  opacity  of  the  thicker,  squamous- 
celled  epithelium  of  the  former.  The  sphincter,  moreover,  is  not  a 
simple  ring,  but  a  fusiform  thickening  of  sufficient  length  to  justify  the 
use  of  such  a  term  as  the  cardiac  canal  rather  than  that  of  cardiac  orifice. 
If  compai-eol.  with  the  pyloric  sphincter  (Fig.  oc),  the  latter  has  an 
abrupt  termination  on  the  distal  aspect,  where  it  produces  an  annular 
elevation  within  the  lumen ;  but  on  the  proximal  siole  the  thickening  of 
the  circular  muscle  tails  off  arounol  the  pyloric  canal,  much  as  in  the  case 
of  the  caroliac  sphincter. 

If  overgrowth  of  unstriped  muscle  be  taken  as  an  indication  of 
abnormally  forcible  contraction,  the  dilatation  in  the  case  from  University 
Oollege   referreol   to    may   be   ascribed   to    caroliospasm    "in   the  sense. 


376  The  Journal  of  Laryngology,      ;;December,  1920. 

Dr.  Hill  remarks,  in  which  Mikulicz  emi>loved  the  term — viz.  hyper- 
trophic stenosis  following  on  a  primary  functional  spasm]. 

The  hvpertrophy  in  this  case  is  remarkably  like  that  met  with  in 
hypertrophic  stenosis  of  the  pyloric  canal  as  seen  in  infants  ;  and  more 
so  when  this  stenosis  is  found  in  the  adult.  Of  the  last  there  are  two 
examples  in  St.  Thomas's  Hospital  Museum.  In  Ixjth  the  mucosa  is 
intact ;  the  muscular  thickening  is  confined  to  the  circular  fibres  ;  and  in 
one,  certainly,  the  stomach  has  been  dilated  from  pyloric  obstruction.  Of 
No.  948f  a  drawing  has  been  introduced  (Fig.  4).  It  came  from  a 
man,  aged  sixty-one,  admitted  for  mitral  stenosis  ;  he  had  had  malaria, 
and  there  was  a  history  of  rheumatic  fever ;  nothing  in  regard  to  gastric 
trouble  is  mentioned  in  the  notes.  In  the  case  of  the  University  College 
specimen,  the  patient  was  fifty-five  years  of  age  ;  symptoms  had  existed 
for  eighteen  years.  In  Sir  Hugh  Eigby's  case  the  patient  was  forty-two, 
and  symptoms  had  been  present  "  for  many  years."  "Whether  hyper- 
trophic stenosis  of  the  pyloric  canal  may  not  arise  at  a  later  date  than 
usually  assumed  is  a  matter  needing  further  observation  ;  if  so,  the  two 
conditions  would  be  still  more  parallel.  No  similar  overgrowth  of  the 
cardiac  sphincter  is  present  in  any  of  the  other  specimens.  In  explana- 
tion of  these,  a  want  of  co-ordination  lietween  the  propulsive  action 
above  and  the  relaxation  of  tlie  sphiucter  below  may  be  the  more  correct 
explanation,  and  it  is  this  which  tin-  term  "  achahisia "'  is  designed  to 
connote  :  for,  clinically,  there  is  no  palpaVde  hindrance  to  the  passage  of 
the  bougie  through  the  cardia.  "When  the  two  phenomena  are  compared, 
there  is,  perhaps,  no  very  great  difference  between  them.  In  the  second 
case  the  obstruction  is  due  to  the  tonic  contraction  of  the  cardiac 
sphincter;  and  in  the  first,  the  contraction  is  augmented,  or  hypertonic — 
i.  e.  it  is  a  proper  cardiospasm.  Nevertheless  it  conduces  to  accuracy  to 
draw  the  distinction  if  there  are  grounds  for  making  it. 

Next,  in  regard  to  the  part  played  by  the  diaphragm.  AVhatever  can 
be  distinctly  conceived  is  possible,  and  it  may  be  that  the  neuromuscular 
fault  in  certain  cases  lies  in  the  diaphragm  and  that  the  obstruction  is 
extrinsic.  The  skiagrams  tmdoubtedly  demonstrate  the  presence  of  an 
undilated  segment  of  the  cesophagus  above  the  stomach,  the  upper  limit 
of  which  segment  corresponds  with  the  superior  surface  of  the  diaphragm. 
This,  it  may  be  sul)mitted,  however,  does  not  prove  that  the  diaphragm 
is  the  cau^e  of  the  obstruction.  The  obstruction,  one  may  still  think,  is 
below  at  the  cardia,  the  tone  of  the  diaphragm  disallowiug  the  dilatation 
of  the  included  part  of  the  tube.  When,  in  the  course  of  time,  the 
increasing  pressure  of  the  accumulation  above  overcomes  this  extrinsic 
support,  then,  as  shown  by  the  skiagrams  and  specimens,  the  dilatation 
involves  the  whole  of  the  canal  as  far  as  the  sphiucter,  which  neverthe- 
less remains  capable  of  holding  up  the  oesophageal  contents.  The  term 
"  phreno-cardiac  segment,"'  as  used  by  Dr.  William  Hill,  is  very 
appropriate  as  applied  anatomically  in  the  present  discussion.  That  an 
inhibitory  relaxation  of  the  diaphragm  immediately  around  the  cesophagus 
accompanies  the  dilatation  of  the  cardiac  sphincter  is  not  improbable, 
judging  by  analogy  from  what  occurs  in  other  positions ;  and  it  may 
prove  that  failure  in  the  second  is  accompanied  with  failure  in  the  first, 
although,  per  se,  the  tone  of  the  diaphragm  would  be  ineffective  as  a 
cause  of  obstruction. 

That  a  reflex  may  arise  in  the  st<>mach,  which  will  prevent  the  entry 
of  ingesta,  may  be  taken  as  established,  and  is  illustrated  by  such  a  case 
as  the  following  :  A  patient  was  in  St.  Thomas's  Hospital  suffei*ing  from 


December,  1920.]  Rhinology,  and  Otology.  377 

a  gastric  ulcer.  Following  a  bismuth  meal  a  skiagram  showed  that 
after  much  had  passed  into  the  stomach,  the  material  was  held  up  in  the 
oesophagus,  which  became  dilated,  the  dilatation  terminating  inferiorly 
immediately  above  the  diaphragm.  Here  the  achalasia  arose  as  a  reflex 
transmitted  from  the  stomach.  There  is  no  evidence,  however,  that 
gastric  conditions,  either  organic  or  functional,  are  necessary  aetiological 
factors  in  producing  neuro-muscular  oesophagectasia.  On  the  contrary, 
the  direct  observation  ma<le  by  Dr.  Brown-Kelly  proves  that  the  reflex 
fault  may  lie  in  the  o?sophagus,  since  the  experimental  irritation  of  the 
mucosa  above  the  cardia,  in  place  of  being  followed  by  relaxation  of  the 
sphincter,  as  it  is  normally,  was  followed  by  its  closure. 

Lastly,  amongst  the  drawings  there  is  inserted  one  showing  a  distinct 
and  wide-spread  muscular  hypertrophy,  especially  of  the  circular  layer, 
but  unaccompanied  with  dilatation  ;  the  heart  was  much  dilated,  and 
weighed  18j  oz.  A  similar  condition  is  shown  in  a  second  specimen 
from  Gruy's  Hospital  Museum,  described  by  Dr.  Newton  Pitt.i  Here 
the  heart  was  likewise  enlarged.  The  muscular  thickening  of  the 
oesophagus  was  most  marked  an  inch  above  the  cardiac  orifice.  Such 
results  have  been  attributed  to  obstruction  caused  by  the  pressure  of  the 
enlarged  heart.  Aortic  aneurysm  may  undoubtedly  produce  oesophageal 
obstruction  and  some  local  dilatation  of  the  canal  above. 

In  connection  with  muscular  hypertrophy  of  the  oesophagus  without 
dilatation,  it  is  enough  to  point  out  that  it  may  represent  a  completely 
compensated  achalasia,  or  even  cardiospasm — a  possibility  already  con- 
ceived by  Dr.  BrDwn-Kelly.-  This  could  only  be  established  by  finding 
such  hypertrophy  unassociated  with  aortic  aneurysm,  enlargement  uf  the 
heart,  or  otlier  extrinsic  organic  obstruction. 


ABSTRACTS. 

Abstracts  Editor — W.  Dololas  Harinier,  5^,  Park  Crescent,  London,  W.  1. 

Authors  of  Original  Communications  on  Oto-lanjngology  in  other  Journals 
are  invited  to  send  a  copy,  or  tico  reprints,  to  the  Journ'al  of  Lartngology. 
If  they  are  xcilUng,  at  the  same  time,  to  submit  theif'  rni-n  ohstroct  {in  English, 
French,  Italian  or  German)  it  u-ill  be  welcomed. 


PHARYNX. 

Researches   on   the   Pharyngeal  Reflex. — A.    Croce.      "Arch.    Ital.  di 
Otol.,"  XXX,  No.  4. 

The  author  examined  a  large  number  of  people  with  a  view  to 
determining  the  constancy  vv  otherwise  of  the  pharyngeal  reflex.  The 
sensitiveness  of  the  pharynx  was  supposed  to  be  diminished  in  the  case 
of  hysteria.  Croce  examined  64  cases  of  hysteria,  24  of  aphonia,  and  10 
mutes.  In  none  of  these  was  there  any  anaesthesia  of  the  pharynx  and 
the  normal  reflex  was  present  in  all.  Eighty-eight  healthy  persons  were 
also  examined  and  the  reflex  found  present  in  all.  The  reflex  is  weak  in 
thyroid  hypertrophy  and  in  old  age.  Diseases  such  as  tabes  cause 
abolition  of  the  reflex.  /.  K.  Milne  Dickie. 

1    Trans.  Path.  Soc,  1888,  xxxix,  p.  107. 
-  Brit.  Med.  Journ.,  1912,  ii,  p.  1047. 


378  The  Journal  of  Laryngology,       December,  1920. 

Enucleation  of  Tonsils  with  Local  Anaesthesia.— Elbyrne  G.  Gill.  "  The 
Lavvngoscope,"  December,  1919,  vol.  xxix,  p.  715. 
In  deterniiuing  whether  the  operation  shall  be  done  under  local  or 
genei-al  anaesthesia  the  age  of  the  patient  is  obviously  a  decided  factor. 
No  local  anaesthesia  under  fourteen  years.  Patients  of  an  extremely 
nervous  temperament,  with  sensitive  throats,  should  Lave  a  general 
auaisthetic.  A  patient  should  not  be  persuaded  against  his  will  to  have 
a  local  anaesthetic.  Probably  90  per  cent,  can  have  tonsils  removed 
successfully  and  without  pain  under  local  anaesthesia.  Gill  uses  the 
Hurd  evacuator  for  examination  of  tonsils.  This  consists  of  a  glass 
cannula  with  an  opening  large  enough  to  fit  the  tonsil.  It  is  connected  to 
a  small  rubber  bulb.  Suction  draws  the  tonsil  into  the  mouth  of  the 
glass,  and  if  any  pus  or  "  cheesy  material "  is  present  it  will  readily  be 
seen.  If  definite  symptoms  of  focal  infection  be  present  and  no  evidence 
is  revealed  by  use  of  the  evacuator,  Gill  takes  a  culture  from  each  tonsil 
l>efore  deciding  that  the  tonsils  are  not  diseased.  After  applying  alcohol 
to  the  outer  surface  of  the  tonsil  a  sterile  platinum  wire  is  introduced 
into  the  crypts  and  culture  media  inoculated.  If  he  gets  a  pure  culture 
he  feels  that  the  technique  was  properly  carried  out.  Operation  must 
always  be  done  in  hospital.  A  careful  examination  is  made,  including 
a  record  of  blood-pressure  and  a  blood-coagitlation  test.  Preparation  and 
local  anaesthesia  as  usual.  Gill  begins  the  dissection  at  the  junction  of 
the  tonsillar  capsule  with  the  converging  pillars  at  the  superior  angle. 
He  then  inserts  the  closed  ends  of  the  scissor-blades  into  the  opening  and 
separates  the  posterior  pillar.  Then  with  the  blades  of  the  scissors 
opened,  one  blade  is  carried  around  the  anterior  surface  of  the  tonsil, 
thus  separating  the  mucous  membrane  of  the  anterior  pillar  from  the 
capsule.  Gill  now  everts  the  tonsil.  If  it  is  not  lifted  from  the  fossa, 
the  dissection  can  be  completed  by  placing*  the  Hurd  tonsil  separator 
behind  the  capsule  of  the  superior  pole  and  gently  lifting  the  tonsil  up, 
making  firm  traction  on  the  tonsil  forceps  at  the  same  time.  Lastly, 
the  pedicle  of  the  tonsil  is  snared  off  with  the  Tyding  snare.  Gill  has 
not  found  ligatures  necessary.  Haemorrhage  is  controlled  by  making 
pressure  with  a  sponge  in  the  fossa  for  three  minutes,  which  is  the  time 
required  for  blood  to  coagulate.  After  all  oozing  has  stopjied  for  at 
least  five  minutes,  Gill  applies  a  3i  per  cent,  iodine  solution.  The  ice- 
bag  is  immediately  applied  to  the  patient's  neck.  Three  hours  later 
morphia  (}  gr.)  is  given  Avhether  there  is  pain  or  not.  Gill  has  had  no 
post -operative  haemorrhage  in  a  series  of  sixtv  cases. 

Gill  reports  two  cases:  (1)  Infected  tonsils  with  chronic  laryngitis, 
cured  by  the  above  operation ;  (2)  septic  tonsils  with  latent  pulmonary 
tuberculosis  and  profuse  night-sweats,  which  gave  an  equally  satisfactory 
result.  "  /.'  8.  Fraser. 

LARYNX. 

Intrinsic  Cancer  of  the  Larynx.— Sir  StClair  Thomson.     '•  Lancet,"  1920, 
vol.  ii,  p.  183. 

Sir  StClair  Thomson  publishes  his  ol>servations,  based  upon  forty- 
four  cases  treated  by  laryngo-fissure,  on  impaired  mobility  of  the 
affected  cord  in  diagnosis  and  prognosis.  He  concludes  that  (1)  impaired 
mobility  is  not  a  necessary  or  frequent  symptom,  and  is  met  with  only 
in  a  minority  of  cases.  (2)  It  is  more  likely  to  be  seen  in  an  early  c^se 
when  the  growth  is  embedded  in   the  end  or  growing  into  it  than  in  a 


0 


December,  1920.]         Rhinology,  and  Otology.  379 

distiuctlj  sessile  or  even  jiedimculated  tumour.  {\)  Wheu  present  it  is 
a  very  valuable  symptom  in  distinguishing  a  malignant  from  an 
innocent  tumour.  It  is  misleading  in  the  diagnosis  of  malignant 
growth  from  tubercle  or  syphilis.     (5)  It  is  unfavou)'able  in  prognosis. 

Macleod   Yearshi/. 

EAR. 

Paralysis  of  the  Facial,  Cochlear  and  Vestibular  Nerves  from  Shell- 
Burst. — C.  A.  Torrigiani.  "  Arch.  Ital.  di  Otol.,"'  xxx.  No.  4. 
The  author  reports  a  case  of  paralysis  of  the  above  nerves  from  the 
blast  of  a  shell.  The  patient  fell  as  if  he  had  j-eceived  a  blow  on  the 
head.  He  did  not  lose  his  senses  but  was  very  giddy.  He  noticed 
almost  at  once  that  he  could  not  shut  his  moutb,  vomited,  and  had  loud 
hissing  uoi.ses  in  the  head.  A  little  blood  came  from  the  right  ear. 
The  giddiness  was  so  severe  that  the  patient  could  not  raise  himself 
in  bed. 

On  examination  there  was  complete  paralysis  of  the  right  side  of  the 
face  and  mixed  nystagmus  to  the  left.  S'une  blood-clot  was  seen  in  the 
right  meatus,  and  the  tympanic  membrane  was  completely  destroyed. 
The  right  ear  was  found  to  be  totally  deaf,  and  the  caloric  test  w^as 
negative.  Romberg's  sign  gave  falling  to  the  affected  side,  the  direction 
of  falling  being  influenced  by  the  position  of  the  head.  There  was  a 
spontaneous  pointing  error.     An  X  ray  picture  showed  no  fracture. 

The  author  evidently  considers  a  foreign  body  excluded  though  he 
does  not  specifically  say  so,  and  gives  as  the  probable  explanation  of  the 
case  a  tearing  of  the  nerves  at  the  point  of  their  emergence  from  the 
medulla,  where  the  fibi'es  have  less  support  than  elsewhere. 

J.  K.  Millie  Dickie. 

Larvae  of  Sarcophaga  Carnaria  in  the  Ear. — P.  Caliceti.  "  Arch.  Ital. 
di  Otol.,"  xxx,  No.  4. 
The  author  reports  two  cases  of  maggots  in  the  ear.  The  first  case 
was  that  of  a  peasant  who  had  been  sleeping  in  the  open.  He  woke  up 
one  morning  with  very  severe  pain  in  the  right  ear.  The  pain  continued 
and  was  follov\-ed  by  the  appearance  of  bloodstained  discharge,  which 
later  became  ]>urulent.  There  was  a  feeling  of  something  moving  in 
the  ear.  Aftei"  syringing  out  the  pus  the  larvae  were  seen.  The  second 
case  was  a  woman  with  a  similar  history.  The  larvae  were  removed  with 
considerable  difiiculty  Avith  strong  forceps.  From  the  one  case  five  and 
from  the  other  two  mag-gots  were  removed.  Antiseptics  have  little  or 
no  elfect  on  them.  They  can  live  for  six  to  eight  hours  in  5  per  cent, 
carbolic  or  8  per  cent,  formalin.  They  are  nearly  19  mm.  long  and 
about  4  mm.  in  thickness,  and  are  furnished  with  two  strong  hooks  at 
the  anterior  extremity.  .7.  K.  Jlilne  Diclcie. 

Two  Years  and  a  Half  of  Oto-Laryngological  Medico-Legal  Service  in 

the  XII  Territorial  Corps.— S.  Pusateri.     "Arch.  Ital.  di  Otol.," 

xxx.  No.  4. 

Out  of  12,328  patients  9347  complained  of  their  ears,  1373  of  their 

nose,  and  1608  of  their  throat.      There  were  610  ear  malingerers,  and  of 

the  total  number  of  patients  (12,328)  only  11,363  had  any  discoverable 

lesion.     From  these  figures  the  high  proportion  of  malingerers  is  very 

striking.     Self-inflicted  lesions  of  the  ear  accounted  for  47  per  cent,  of 

the  ear  cases.  /.  K.  Milne  Dickie, 


380  The  Journal  of  Laryngology,      [December,  1920. 

OESOPHAGUS. 

On  a  Case  of  Foreign  Body  in  the  (Esophagus  with  an  Impending 
Breach  into  the  Trachea.— G.  Holmgren  (Stockholm).  "Acta 
Oto-larviiLjolooica.""  i.  fasc.  1. 

The  patient  was  a  man,  aged  thirty,  in  whose  cesophagus  a  piece  of 
meat-boue  had  become  impacted  at  a  distance  of  20  cm.  from  the  upper 
teeth.  The  symptoms  were  pain  in  the  back,  dysphagia,  cough  and 
bloody  expectoration.  E.xamination  of  the  ti'achea  showed  its  posterior 
wall  at  a  point  somewhat  below  the  larynx  to  be  red,  swollen,  and  bulged 
into  the  lumen.  On  oesophagoscopy  a  bone  was  found  with  its  more 
pointed  end  perforating  the  anterior  wall  of  the  oesophagus  and  its  thicker 
end  fixed  in  the  posterior  wall.  The  thicker  end  was  grasped  with  forceps 
and  the  boue  removed,  the  patient  making  an  uninterrujjted  i-ecovery. 

Before  coming  under  the  author's  care  the  case  had  been  treated  by 
the  blind  passage  of  bougies.  He  considers  that  the  serious  nature  of 
the  condition  which  he  found  was  due  to  this  cause,  and  rejtorts  the  case 
as  a  good  illustration  of  the  danger  of  random  attempts  at  removal  of 
foreign  bodies  impacted  in  the  oesophagus,  and  of  the  comparative  ease 
and  safety  with  which  this  can  be  accomplished  by  means  of  the  oeso- 
phagoscope.  Thomas  Guthrie. 


MISCELLANEOUS. 

Functional  Diagnosis  of  Polyglandular  Disease  in  Acromegaly  and 
other  Disturbances  of  the  Hypophysis. — C.  P.  Howard  (Iowa). 
"  Amer.  Journ.  Med.  Sci.,'"  December,  1919. 

In  the  six  cases  of  disease  of  the  pituitary  body  which  form  the 
material  of  this  paper,  the  author  applied  the  methods  devised  by  Karl 
Cscpai  for  investigation  of  the  diseases  of  the  endocrine  glands.  The 
metJiods  and  the  author's  conclusions  as  to  the  value  of  each  are  briefly 
as  follows  : 

(1)  Decreased  sugar  tolerance :  This  Howard  found  to  be  pi-esent 
in  five  early  cases,  and  he  considers  that  in  the  jjresence  of  other 
symptoms  of  disturbance  of  pituitary  function  it  justifies  a  diagnosis  of 
increased  activity  of  the  pars  intermedia.  On  the  other  hand,  in  the 
later  stages  of  hypophyseal  disease  when  the  ]:>ars  interm^|iii  has  been 
destroyed  by  pressure  or  invasion  has  occurred,  as  in  one  of  his  cases, 
increased  sugar  tolerance  may  be  expected. 

(2)  Conjunctival  "adrenalin"  test:  Three  drops  of  a  1  in  1000 
solution  of  "  adrenalin  "'  normally  causes  a  blanching  of  the  conjunctival 
sac,  which  persists  from  ten  to  twenty  minutes,  while  in  cases  of  acro- 
megaly the  blanching  remains  from  thirty  to  forty-five  minutes.  In 
Howard's  cases  the  persistence  of  the  blanching  was  normal  in  three, 
slightly  prolonged  in  one,  and  decidedly  prolonged  in  two.  He  concludes 
that  the  test  may  be  of  positive  value  in  certain  cases  of  dy.'^pituitarism 
in  demonstrating  a  hypofunction  of  the  chromaffin  system. 

(3)  Subcutaneous  Adrenalin  test  :  Cscpai  found  in  some  cases  of 
acromegaly  an  absence  of  the  rise  of  blood-pressure  and  pulse-rate 
which  noi"mally  follows  subcutaneous  infection  of  5  mg.  of  adrenalin. 
He  also  found  variations  of  the  leucocytosis  v.'hich  follows  the  injection 
of  this  substance  in  normal  jiersous.  In  Howard's  experience  this 
test  was  of  verv  doubtful  value. 


December,  1920.]  Rhinology,  and  Otology.  381 

(■i)  Tests  of  a  similar  uatui-e,  both  conjunctival  aud  subcutaneous, 
carried  out  -nitli  pituitrin  Howard  found  to  be  quite  unreliable. 

He  also  found  that  the  internal  administration  of  pituitary  extract, 
either  of  the  whole  gland  or  the  anterior  or  posterior  lobes,  appears  to 
exert  no  detiuite  influence  upon  the  symptomatology  of  the  disease. 

Thomas  Guthrie. 

Jugular  Phlebitis,  Siaus  Thrombosis.  Ulcerative  Endocarditis. — W.  S. 
Laurie  (Melbourne).  •'  Med.  Journ.  Austr.,"  March  13,  1920. 
The  case  recorded,  which  ended  fatally,  was  that  of  a  young  woman, 
aged  twenty-seven.  There  was  no  histoi'v  of  ear  disease,  past  or  present. 
The  source  of  infection  was  possibly  the  tonsils,  which  were  somewhat 
large  aud  spongy.  A.  J.  Brady. 


OBITUARY. 

Adam  Politzee. 
By  the  passing  away  of  Prof.  Adam  Politzer  in  the  eighty-tifth  year  of 
his  life,  the  otological  world  is  deprived  of  one  of  its  most  distinguished 
figures.  The  unhappy  war  has  broken  up  many  associations,  and  there 
is  probably  none  more  regretted  than  our  long  and  intimate  association 
wnth  this  outstanding  otologist.  His  visits  to  this  country  were  sources 
of  profit  and  pleasure  to  the  guests  and  the  host  alike.  The  welcome 
he  received  here  was  always  warmly  reciprocated  to  those  of  us  who 
visited  Vienna,  and  his  hospitality  was  to  some  so  profuse  as  to  be 
almost  embarrassing.  Such  remembrances  make  the  regrettable  events 
of  the  last  six  years  all  the  more  regrettable. 

The  older  members  of  the  present  race  of  British  otologists  owe 
what  is  soundest  and  best  in  their  knowledge  to  the  teaching  of  Politzer, 
but  he,  on  his  part,  attributes  the  pathological  basis  of  his  teaching  to 
Toynbee,  whose  work  and  specimens  he  came  to  London  to  study  in 
the  earliest  days  of  his  career.  Those  who  met  him  at  an  inforxnal 
gathering  at  Sir  Wm.  Dalby's  house  in  Savile  Eow'  will  remember  his 
looking  round  and  recalling  his  visit  to  Toynbee  amid  the  same 
surroundings. 

The  incidents  of  his  life  are  such  as  would  be  expected  of  a  man  of 
his  purposive  and  artistic  nature.  They  are  narrated  so  clearly  and 
sympathetically  by  Sir  StClair  Thomson  that  our  readers  will  welcome 
their  reproduction  here  from  the  pages  of  the  British  Medical  Journal : 

"  Adam  Politzer  was  what  the  French  call  a  grand  maitre  in  modern  otology. 
Possessed  of  a  charming  individuality,  he  was  thoroughly  equipped  in  his  j'^outh, 
and  started  early  on  a  career  in  which  he  became  so  distinguished.  He  was  well 
advised  by  his  teachers,  who  appreciated  his  talents,  and  he  directed  his  attention 
to  otology  from  his  earliest  j-ears,  realising  the  opening  there  was  for  this  speciality 
at  Vienna.  Hence  he  passed  several  years  travelling  over  Euroj^e,  studj-ing 
acoustics  with  Helmholtz,  histology  with  Kolliiier,  and  physiology  with  Ludwig. 
In  Paris  he  worked  in  the  laboratory  of  Claiide  Bernard,  and  then  he  came  to 
London  to  stud}'  with  Toynbee.  There  can  be  little  doubt  that  it  was  his  English 
teacher  who  insphed  him  with  his  appreciation  of  the  pathological  anatomy  of  the 
mastoid.  Politzer  returned  to  Vienna  in  1861,  and  it  was  sufficient  for  him  to 
show  his  teachers  the  results  of  his  scientific  journeys  for  them  to  create  a  Chair 
of  Otology,  and  he  was  elected  as  professor.  He  was  not  yet  thirty  years  of  age.  He 
only  had  foiu-  pupils  m  his  first  course,  but  it  is  interesting  to  recall  that  one  of 
them  was  Lucae,  who  afterwards  was  the  well-known  professor  in  Berlin.  His 
name  soon  became  known  throughout  the  otological  world,  as  it  was  early  in  his 
career  that  he  discovered  the  method  of  '  Politzerising '  tiie  ear.    His  reputation 


382  The  Journal  of  Laryngology,        December,  1920. 

as  a  teacher  became  so  well  known  that  there  are  few  aurists  who  have  not  based 
themselves  upon  his  teaching,  taking-  his  career  as  an  example  and  his  ideals  as  an 
inspii-ation. 

"  He  Avas  a  model  teacher.  Neat  and  dapper  in  his  appearance,  with  sparkling 
intellectual  dai-k  eyes  and  a  musical  caressing  voice,  he  quicklj'  gained  the  good- 
Avill  and  admiration  of  every  puijil ;  and,  in  return,  he  did  not  forget  his  piipils,  to 
whom  he  was  devoted.  Although  I  only  worked  with  him  for  one  semester,  he 
presented  me  with  a  beautiful  dissection  of  the  middle  ear,  made  with  his  own  hands, 
as  a  souvenir,  which  I  still  treasure.  He  was  enthusiastic  and  patient, and,  although 
he  only  had  eight  l^eds  and  had  to  give  his  lecture  in  the  middle  of  a  ward,  his  classes 
were  always  crowded.  These  classes  were  held  every  day  of  the  week,  except 
Saturday  and  Sunday,  from  12  to  1,  and,  although  he  had  a  private  practice,  to 
which  patients  flocked  fi"om  all  over  the  world,  he  was  seldom  five  minutes  late, 
and  often  remained  xintil  1.30  and  nearly  2.  The  course  lasted  six  weeks,  and  cost 
20  florins — or  at  least  it  did  so  Avhen  I  attended  it  in  1893.  As  Anglo-Americans 
formed  a  large  part  of  these  classes,  most  of  his  teaching  was  given  in  excellent 
English,  but  I  have  heard  him  speak  fluently  in  German,  French,  Hungarian, 
Bohemian  and  Italian  during  tiie  one  lesson.  He  had  other  talents  :  he  wrote 
much  ;  his  text-book  and  his  methods  are  known  throughout  the  civilised  world ; 
he  was  always  courteous  ;  he  hail  charm  ;  he  was  a  traveller  :  he  Avas  an  artist  of 
talent ;  he  was  a  collector  and  connoisseur  in  art,  and  his  skill  with  the  pencil 
was  a  valuable  asset  in  his  teaching.  His  hosi:)itable  home  in  the  Gonzagagasse 
illustrated  the  two  sides  of  his  life :  there  he  delighted  to  show  his  superb 
collection  of  pictures,  and  also  to  demonstrate  his  anatomical  specimens. 

'•  He  loved  to  do  the  honours  of  his  museum,  to  show  bric-a-brac  he  had  i:)icked 
up  in  his  many  visits  to  Italy,  and  to  demonstrate  his  innumerable  jneces  of 
normal  and  pathological  anatomy,  dissected  mastoids,  preparations  of  the  laby- 
rintli,  or  microscopical  sections.  He  was  an  immense  worker;  he  had  a  lovable 
nature,  and  his  life  was  full  and  happy ;  but  doubtless  his  latter  years  were 
clouded  with  the  horrors  of  war.  No  one,  particularly  with  his  wide  international 
friendshii^s,  could  have  deplored  the  war  more  than  Politzer.  While  it  was  in 
progress,  I  had  news  of  the  old  professor  from  a  Scandinavian  colleague  who  had 
been  in  and  out  of  Vienna  several  times  during  the  war.  He  told  me  coal  was  so 
scarce  in  that  city  that  Politzer,  for  the  sake  of  warmth,  had  betaken  himself  to  a 
boarding-house.  Every  day,  during  the  war  winters,  he  walked  from  his  boarding- 
house  to  his  beautiful  apartment.  There,  in  spite  of  his  four-score  years,  he  still 
occupied  himself  with   art   and   research   in  otology.     .     .  He  was  indeed  a 

(jrand  maUre." 

The  number  of  Prof.  Politzer's  contributions  to  every  department 
of  otology  is  enormous,  as  will  be  brought  home  to  anyone  who  glances 
over  the  list  of  literary  references  under  his  name  in  such  a  work  as 
Jacobson's  "  Lehrbuch  der  Ohrenheilkunde."  As  examples  we  may  note 
as  very  early  ones  a  paper  on  "  The  Movements  of  the  \\v  in  the 
Eustachian  Tube  and  the  Variations  of  Air-Pressure  in  the  Tympanic 
Cavity"  (1861),  another  "On  the  Mode  of  Formation  of  the  Light- 
Cone"  (1364).  Those  who  studied  his  small  work  on  "The  Membrana 
Tympani,"  published  in  an  English  version  in  1869,  would  find  in  its 
comparatively  few  pages  an  enormous  amount  of  compressed  otology, 
and  in  its  twenty-four  chromo-lithographs  a  valuable  condensed  atlas 
of  otoscopy.  It  is  scarcely  possible  to  over-rate  his  "  Atlas  der 
Beleuchtungs-Bilder  des  Trommelfells  "  (1896),  which  we  presume  to 
1)0  in  the  possession  of  most  self-respecting  otologists.  ^Yhatever  subject 
he  approached  he  illuminated,  and  many  will  remember  the  light  he 
threw  upon  the  much-debated  "  dry  catarrh  "  of  Troltsch,  when  he 
described  the  pathological  condition  underlying  it  as  "  Primary  Disease 
of  the  Capsule  of  the  Labyrinth,"  now  placarded  as  otosclerosis.  In 
1897  he  published  a  description  of  the  "  Diseases  of  the  Outer  Attic," 
which  must  have  saved  many  from  the  "  radical  "  mastoid  operation. 
He  touched  on  all  the  minutiae  of  intra-aural  interventions  with 
enthusiasm  tempered  by  the  caution  which  results  from  experience. 


December,  1920.]  Rhinology,  and  Otology.  388 

His  work  on  the  "  Zergiiederung  des  Gehororgans  "  was  translated 
with  loving  care  b}-  George  Stone,  of  Liverpool,  and  has  been  unsurpassed 
for  the  minuteness  of  its  directions  for  the  dissection  and  preparation  of 
the  ear  by  every  method,  including  that  by  means  of  corrosion. 

The  "Lehrbuch  der  Ohrenheilkunde"  has  gone  through  five  editions 
— the  last  in  1909 — and  lias  demonstrated  the  progressive  mentality  and 
maintained  activity  of  this  remarkable  author.  His  "  Wand-tafel  zur 
Anatomie  des  Ohres  "  figure  on  the  wall  of  every  school  of  otology,  as 
they  did  on  those  of  his  own,  absurdh'  too  small,  clinic  in  Vienna.  In 
this,  however,  room  was  found  for  life-sized  portraits  of  Wvlde  and 
Toynbee.  Those  of  us  who  in  early  days  made  a  thorough  study  of 
Politzer's  text-book,  as  translated  by  Dr.  Cassells,  of  Glasgow,  will,  like 
the  present  writer,  always  owe  a  deep  debt  of  gratitude  to  the  author, 
who,  while  acknowledging  his  indebtedness  to  the  inspiring  influence  of 
Toynbee,  placed  before  us  the  science  and  art  of  otology  as  based  on  a 
sound  pathology  tested  in  the  light  of  vast  clinical  study  and  experience. 

One  of  the  labours  of  love  of  his  lifetime  was  his  masterly 
"  Geschichte  der  Ohrenheilkunde,"  of  which  a  review  appeared  in  this 
Journal  in  1907.  The  work  is  full  of  antiquarian,  classical  and  historical 
lore,  and  should  be  a  cherished  treasure  to  whoever  is  fortunate  enough 
to  possess  it. 

Politzer  was  an  artist  in  every  way.  Paintings,  curios,  travel  were 
hobbies,  and  it  may  be  said  in  all  reverence  that  in  all  his  relations  of 
life  the  artist  sliowed  himself.  He  strove  for  efficiency  ;  his  speeches 
and  papers  in  many  languages  were  obviously  prepared  with  care,  and 
not  left  to  the  chance  of  the  moment.  His  care  of  his  health  and 
strength  was,  in  a  sense,  an  art,  and  his  remarkable  preservation  of 
mind  and  body  could  only  have  resulted  from  great  original  physical 
strength  maintained  by  the  exercise  of  care,  wisdom  and  courage. " 

He  was  the  greatest  aurist  in  the  world,  and  most  will  admit  that 
his  place  is  not  as  yet  filled.  James  Dwidas- Grant. 


NOTES   AND   QUERIES. 

Paris. 


Dr.  Bourgeois  has  been  appointed  to  the  post  of  Oto-Ehino-Laryngologist  at 
the  Laenuec  Hospital,  left  vacant  by  the  death  of  Dr.  Lombard. 


Dr.  F.  Leniaitre  is  organising  the  service  of  oto-laryngology  at  the  St.  Louis 
Hospital— the  fourth  service  of  laryngology  in  Paris. 

Dr.   Georges  Laurens  is    conducting  classes   of  practical  iiistriiction  in  Oto- 
laryngology at  the  Hopital  Saint-Joseph. 


Dr.  Wyatt  Wingrave  sends  the  enclosed  cutting  from  the  Qunrterly  Bevieic 
(circa  lS-i.3)  : 

AcciDEXT  TO  Mr.  Brcxel. 

"  Mr.  Brunei,'  the  celebrated  eugineei-,  had  several  narrow  escapes  with  his  life, 
but  the  most  extraordinary  accident  which  befel  him  was  that  which  occiirred 
while  one  day  plaj-ing  with  his  children,  and  astonishing  them  by  passing  a  half- 
sovereign  through  his  mouth  oixt  at  his  ear.      Unfortunately  he  swallowed  the 

'   Sir  Isambard  Brunei  of  Great  Western  Eailwav  and  *•'  Great  Eastern"  fame. 


384  The  Journal  of  Laryngology,      [December,  1920. 

coin,  which  di-oi:>pecl  into  his  windpipe.  The  accident  occurred  on  April  3,  1843, 
and  it  was  followed  by  frequent  fits  of  coughing,  and  occasional  iineasiness  in  the 
right  side  of  the  chest ;  but  so  slight  was  the  disturbance  of  breathing  that  it 
was  for  some  time  doubted  whether  the  coin  had  really  fallen  into  the  windpipe. 
After  the  lapse  of  fifteen  days  Sir  Beniamin  Brodie  met  Mr.  Key  in  consiiltation, 
and  they  concurred  in  the  opinion  that  most  probably  the  half-sovereign  was 
lodged  at  the  bottom  of  the  right  bronchus.  The  day  after,  Mr.  Brunei  placed 
himself  in  a  prone  position  on  his  face  upon  some  chairs,  and,  bending  his  head 
and  neck  downwards,  he  distinctly  felt  the  coin  drop  towards  the  glottis.  A 
violent  coiigh  ensued,  and  on  resuming  the  erect  posture  he  felt  as  if  the  object 
again  moved  downwards  into  the  chest.  Here  was  an  engineering  difficulty,  the 
like  of  which  Mr.  Brunei  had  never  before  encountered.  The  mischief  was  purely 
mechanical ;  a  foreign  body  had  got  into  his  breathing  apparatus,  and  must  be 
removed,  if  at  all,  by  some  mechanical  expedient.  Mr.  Brunei  was,  however,  equal 
to  the  occasion.  He  liad  an  ajiparatus  constructed,  consisting  of  a  platform  which 
moved  upon  a  hinge  in  the  centre.  Upon  this  he  had  himself  strapped,  and  his 
body  was  then  inverted  in  order  that  the  -coin  miglit  drop  downward  by  its  own 
weight,  and  so  be  expelled.  At  the  first  experiment  the  coin  again  slipped 
towards  the  glottis,  but  it  caused  such  an  alarming  fit  of  convulsive  coughing 
and  appearance  of  choking  that  danger  was  apprehended,  and  the  experiment 
was  discontinued.  Two  days  aftei',  on  the  25th,  the  oi^eratiou  of  tracheotomy  was 
performed  by  Sir  Benjamin  Brodie,  assisted  by  Mr.  Key,  with  the  intention  of 
extracting  the  coin  by  the  forceps,  if  possible.  Two  attempts  to  do  so  were  made 
without  sviccess.  The  introduction  of  the  forceps  into  the  windpipe  on  the 
second  occasion  was  attended  with  so  excessive  a  degree  of  irritation,  that  it  was 
felt  the  experiment  could  not  be  continued  without  imminent  danger  to  life. 
The  incision  in  the  windpipe  was,  however,  kept  oijen,  by  means  of  a  quill  or  tube, 
until  May  13,  by  which  time  Mr.  Brunei's  strength  had  sufficiently  recovered  to 
enable  tlie  original  experiment  to  be  repeated.  He  was  again  strapped  to  his 
apparatus,  his  body  was  inverted,  his  back  was  struck  gently,  and  he  distinctly 
felt  the  coin  quit  its  place  on  the  right  side  of  his  chest.  The  opening  in  the 
windjjipe  allowed  him  to  breathe  while  the  throat  was  stopped  by  the  coin,  and  it 
thus  had  the  effect  of  preventing  the  spasmodic  action  of  the  glottis.  After  a  few 
coughs  the  coin  dropped  into  his  mouth.  Mr.  Brunei  used  afterwards  to  say  that 
the  moment  when  he  lieard  the  gold  piece  strike  against  his  upper  front  teeth 
was,  perhaps,  the  most  exquisite  in  his  whole  life.  The  half- sovereign  had  been 
in  his  windpipe  for  not  less  than  six  weeks."— Quarterly  Revieiv. 


Royal  Society  of  Medicine:  Otological  Section. 

The  next  meeting  of  this  Section  will  l)e  lield  on  January  21,  1921.    Secretaries  : 
Mr.  Lionel  CoUedge  and  Mr.  Norman  Patterson. 


Royal  Society  of  Medicine:   Lakyngological  Section. 

The  next  meeting  of  this  Section  will  l)e  held  on  February  4, 1921.    Secretaries : 
Dr.  Irwin  Moore  and  Mr.  C.  W.  Hope. 


Some  Specialization. 

Two  Rotarian  "  Docs."  met  by  chance  in  the  Fifth  District  "  Hostility  Hut." 

"  Good  morning,  I  see  you  are  a  doctor." 

"  Yes,  are  you  r  " 

"Yes— a  specialist." 

"  So  am  I — the  nose." 

"  Really  ? — W  hich  side  ?" 

The  Rotarian,  August,  1920. 


INDEX    TO    VOLUilE    XXXV,    l!)-2ll 


SUBJECTS. 


PAGB 


Acoustic  nerve  tumour  :  operation  (E.  P.  Poiilton,  W.  M.  Mollison)  .     3o3 

Actinomyces  in  crypt  of  tonsils  (W.  D.  Harmer.  A.  C.  Stevenson)  .     114 

Adenoid  obstruction  revealed  by  bronchoscopy  (Guisez)              .  .       59 

Adenoids  and  appendicitis,  latent,  with  latent  sphenoidal  sinusitis  (P. 

Watson-Williams)     .                  .                  .                  .                  .  .97 

Adrenalin  for  treatment  of  vertigo  (M.  Vernet)            .                 .  .314 

Air-passages,  upper,  lupus  of;  128  cases  (Capt.  R.  Webber)      .  .         7 

foreign  bodies  in.  .see  Foreign  bodies. 

Antrum,  mastoid,  and  lateral  sinus,  external  location  (Prentiss)  .     253 

maxillary,   infection    of ;     colloidal   manganese   in    (E.    Watson 

Williams)    .                 .                 .                 .                 .                 .  .199 

large  malignant  growth  ;  removal  (H.  Tille}')     .  .       21 

sarcoma  of ;  i-adium  treatment  (Irwin  Moore)    .  .     305 

see  also  Sinus,  maxillary. 


Aphonia,  functional  (J.  Dundas  Grant)  ....  310 
Aqueduct  of  Fallopins  and  facial  paralysis  (Dan  McKenzie)      .  135,  169. 

201,  244 
Aryta^noideus,  paralysis  of  (H.  J.  Banks-Davis)  .  .  .     116 

Audiometer,  pitch-range,  in  otology  (S.  W.  Dean.  C.  C.  Bunch)  .       28 

Auditory  canal,  external,  and  mastoid  region,  fibrosis  of  (L.  W.  Dean. 

M.  Armstrong)  .  .  .  .  .  .61 

meatus,  external,  Vincent's  angina  of  (A.  Cheatle)         .  .         6 

Aural  disal>ility  from  militai'v  service,  assessment  of  (A.  Ryland)  .     354- 

Aviation  disabilities  connected  with  the  ear  (Sydney  Scott)        .  .     225 

Baginsky  (H.),  obituary  notice  .....  351 
Brunei's  case  of  foreign  body  in  bronchus,  note  on     .  .  .     384 

Oarrel-Dakin  solution  in  mastoid  surgery  (Mahu,  Moure  and  Sorrel) 

255,  256,  287 

Cerebro-sijinal  fever  and  sphenoidal  empyema  (D.  Embleton)  .                 .  122 

Chloroma  simulaiiug  mastoid  disease  (E.  C.  Lewis)    .                 .                  .  126 

Cholesteatoma  and  mastoid  operation  (J.  Dundas  Grant)           .                  .  150 

Cholesterin  crystals,  technique  of  examination  for  (G.  W.  Mackenzie)     .  288 

Choanse,  congenital  occlusion  of  (Prof.  Barraud)          .                  .                  .  122 

•Cocaine  injection  in  tracheotomy  (Sir  StClair  Thomson)             .                  .  30 

Colloideal  manganese  for  antral  infection  (E.  Watson-Williams)                .  199 

silver  injections  for  lal)yrinthitis,  etc.  (P.  Watson- Williams)         .  197 

Congres  Fran^ais  d'Oto-Rhino-Laryngologie,  notes  on  .  160,  192 

Cords,  vocal,  diagrammatic  records  of  movements  (A.  Bi-own  Kelly)        .  161 

fixation  of;  tracheotomy  (E.  D.  D.  Davis)            .                  .  21 

Cricoid  (post-)  region  and  upjier  end  of  cesophagus,  carcinoma  of  (Logan 

Turner)       .  .  .  .  .  .  .34 

Dacryocystitis,  doiible  (W.  D.  Harmer)  ....  120 
Deafness,  acquired,  can  it  lead  to  congenital  deafness  ?  (Macleod  Yearsley)  270 
sporadic  congenital  (J.  K.  Love)        ....     263 

25 


386  Index. 


Dental  cyst  involving  nose  (E.  D.  D.  Davis)  .  .  .87 

result  of  removal  (E.  D.  D.  Davis;       .  .  .87 

cysts  of  superior  maxilla  (M.  Sourdille)  .  .  .     193 


Diathermy  in  carcinoma  of  fauces  (William  Hill  and  Norman  Patterson)  11 

Dundas  Grant  (Sir  James),  note  on                ...                 .  224 

Ear  complications  in  influenza  (F.  T.  Hall)  ....  189 

internal,  necrosis  of ;  sequestration  of  labja'intli ;  recoveiy  (W.  M. 

Mollison)     .  .  .  .  .  .  .148 

labyrinth  of;  Ewald's  theory  on  endolyniph  currents  (A.  Kejto)  .  176 

middle,  suppuration,  chronic  (.^  pension)  I  J.  F.  O'Malley)  151 

(G.  W.  Mackenzie)       .                 .                 .  287 


—  cholesteatoma  and  mastoiditis  with  many  compli- 
cations (Milne  Dickie)  .  .  .  .  .129 

—  polypoid  mass  in  (Lannois)  .  .  .  .90 

—  relation  of,  to  aviation  disabilities  (Sydney  Scott)  .  .     22.'* 

—  Sarcophacja  carnarht  larvas  in  (P.  Caliceti)        .  .  .     379 

—  semicircular  canals ;  method  of  demonstrating  relative  position 

and  planes  of  incidence  (J.  D.  Lithgow)  .  .  .81 

—  tick,   spinose    (Ornithodorus  megnini,  Duges),    in   South  Africa 

(R.  Broom)  .  .  .  .  .  .362 

—  tuberculosis  of,  in  infants  (D.  Guthrie)  .  .99 
vestibular  nystagmus,  quick  phasis  of  (A.  Rejto)            .  .     103 


Edinburgh  Royal  Infirmary  Keports  for  year  1918  from  Ear  and  Throat 

Department  .  .  .  .  .7, 34,  107 

Empyema,  sphenoidal  sinus,  in  cerelno-sjiinal  meningitis  (E.  A.  Peters)       11 
Epilaryngeal  region,  lateral  pharyngolomy  for  exposure  of  large  growths 

(W.  Trotter)  .  .  .  .  .  .289 

Ethmoiditis,  fulminating,  with  metastasis  (Ira  Frank)  .  .       23 

Eustachian  tube  ;  significance  in  otology  (D.  Guthrie)  .  .     346 

Ewald's  theory,  aee  Ear,  labyrinth  of. 

Facial  paralysis  and  the  aqueduct  of  Fallopius  (Dan  McKenzie),  135, 

169,201,244,271,296,335 
sui'gical  treatment  (G.  Fenwick)  .  .     155 


cochlear,    and   vestibular   nerves,    shell-shock    paralysis    (C.    A. 


Torrigiani)                  .                 .                 .                 .                 .                 .  379 

Fauces,  carcinoma  of ;  peroral  excision;  diathermy  (W.  Hill.  N.Patterson)  17 

pillars  of;  method  of  suturing  (T.  Guthrie)                       .                  .  102 

Focal  sepsis  and  chronic  disease  (S.  Pern)    ....  349 
Foreign  bodies  in  air-  and  food-passages,  17,  60.  125,  277.  278.  279,  280. 

281.  285,309,345,380 

instruments  for  removal  from  lungs  (Irwin  Moore)           .  285 


body,   rubber   denture,   in   oesophagus,  use   of   galvauo-cautery 


(Claouc)      _.  .  .  .  .  .  .60 

in  skull  base;  bucco-pharyngeal  exti-action  (Jacques)       .       62 

.     350 

.     224 

64 


Gerber  (Prof.  P.),  obituary  notice  . 
Glosso-i)haryngeal  nerve,  herpes  zoster  of  (C.  T.  Neve) 
Guaiacol  as  an  anaesthetic  (note)  (Laurens)  . 

Hay-fever  and  paroxysmal  rhinorrhcea ;  treatment  (M.  Agar) 
Helio-electric  methods  rersits  tonsillectomy  (T.  M.  Stewart) 
Hill  (W.),  and  St.  Mary's  Hospital  (note)      . 
Hoarseness,  paretic,  simulating  acute  tuberculosis  (L.  Myers) 
Holmes  (Christian),  obituary  notice  .  . 

Influenza,  hasmorrhage  in  (M.  A.  Goldstein) 
Irsay  (A.  Von),  obituary  notice 


312 

154 

32 

346 

158 

31 
350 


Journal   of    Laryngology,   Rhinology  and  Otology,  future  of 

(Editorial)  .  .  .  .  .  .  .353 


Index.  387 

Labyrinth,  membranous,  anatomy  of  (Milne  Dickie)  .  .76 

Labyrinthitis,  meningitis,  etc. ;  colloidal  silver  injections  (P.  Watson- 
Williams)   .......     197 

Laryngeal  nerve  paralysis  in  tuberculosis  (Irwin  Moore)  .  .     118 

Laryngectomy,  total :  indications ;  results  (Sir  C.  J.  Symonds)  .     257 

Laryngo-fissure  for  intrinsic  cancer  of  larynx,  one  year  after  (Sir  StClair 

Thomson)   .  .  .  .  .  .  .1.5 

Laryngoscopy,  indirect,  digital  retraction  of  epiglottis  during  (A.  Ryland)       82 
Larynx,  adenomata  (glandular  tumours)  of  (Irwin  Moore)  .       65 

epithelioma  of ;  "  window "'  resection  of  thyroid  cartilage  (L.  Lack)       54 

extrinsic  cancer  of,  four  years  after  operation  through   side  of 

neck  (Sir  StClair  Thomson)     .  .  .  .  .15 

intrinsic  cancer  of  (Sir  StClair  Thomson)        .  .  .     378 

laryngo-fissure,  etc.,  one  year  after  (Sir  StClair  Thomson)       15 

large  cyst  of  (H.  I.  Schousboe)  .  .  .  .123 

leucoplasic  papilloma  of  (E.  Jacob)  .  .  .  .60 

papilloma  of  ;  radium  and  X-ray  treatment  (S.  Jones)  .  .     113 

perichondritis  of  (G.  W.  Dawson)     .  .  .  .19 

tuberculosis  of  ;  prognostic  importance  (Sir  StClair  Thomson)    .     123 

war  injuries  and  neuroses  (W.  D.  Harmer,  H.  Smurthwaite)     182,  183 

see  also  Pharynx. 

Lupus  of  upper  air-passages  ;  128  cases  (Capt.  R.  Webber) 

simulated  by  tertiary  syphilis  of  pharynx  (Irwin  Moore) 

erythematosus,  epithelioma  in  (W.  Stuart-Low) 

Manchester  University,  note  on  new  library 
Mastoid  disease  simulated  by  chloroma  (E.  C.  Lewis) 

gas  bacillus  infection  of  (W.  W.  Carter) 

operation ;    brain   abscess :    further   operations ;    recovery    (W 


Bowers) 


zoo,  z. 


Carrel-Dakin  solution  in        . 

bone-grafting  after  (Eagleton) 

gas-embolism  of  lateral  sinus  (Baraud) 

in  acute  otitis  media,  indications  for  (Dench)     . 

lateral  sinus  haemorrhage  (F.  T.  Hill). 

new  dressing  for  wounds  (Daure) 

—  radical  (M.  Smith) .... 

answer  to  opponents  (W.  C.  Bowers) 

end-results  of  (Harris) 

for  cholesteatoma  (Sir  J.  Dundas  Grant) 

—  modified  ?  justifial3le  (Kaufman) 

structure  and  development;  influence  on  inflammation  (Mouret) 

subperiosteal  abscess ;  cure  by  paracentesis  (Salinger)  . 

Mastoidectomy,  seveie  haemorrhage  after,  in  purpura  (T.  J.  Harris) 

toxic  delirium  (J.  A.  Robinson) 

Mastoiditis  (Ma,ior  C.  Holmes)       .... 

acute;  internal  jugular  thrombosis;  recovery  (W.  M.  Mollison) 

influenzal  (Jacques,  Daure) 

subacute  (Blackwell)  .... 

tuberculous,  causing  facial  paralysis  (W.  M.  Mollison)  . 

value  of  X-ray  examination  (Dixon) 

varieties  of  (Mouret)  .... 

Maxilla,  superior,  dental  cysts  of   . 

Meningitis,  cerebro-spinal,  sphenoidal  sinus  empyema  in  (E.  A.  Peters) 

lavage  in  (Bellin,  Aloin  and  Vernet) 

Meningo-encephalitis  as  only  manifestation  of  mumps  (T.  Howard) 
Mumps,  bacteriology  of  (R.  L.  Haden) 

meningo-encephalitis  in  (T.  Howard) 

Naso-pharynx,  fibrous  polypi  of  (Texier) 
Navratil  (Prof,  von),  obituary  notice 

2b^ 


7 

22 

145 

192 
126 

288 


155 
56,  287 

61 
221 
254 
220 
314 
312 
347 
314 
150 
287 

91 
286 
190 
220 
220 
149 
220 
286 
146 
253 

92 
193 

11 

25 
127 
191 
127 

89 
350 


388  -  Index. 


Nose,  bacterial  flora  of,  experiments  on 
■ collapse,  extreme  (W.  Hill) 

dental  cyst  involving  floor  (E.  D.  D.  Davis)     . 

papilloma  of  (G.  W.  Dawson) 

saddle  back  ;  repair  hy  parafiin  injection  (J.  Donelan) 

septum  of.  submucous  resection  (J.  A.  Cavanaugli) 

teratoid  tumours  in  children  (A.  Brown  Kelly). 

transplantation  of  cartilage  into  (J.  F.  O'Malley) 

— — —  supj)uration  causing  orbital  abscess  and   exophthalmos  (D. 

Vail)  .  _     .  .  .  . 
tertiary  syphilis  ;  absorption  of  pre-maxilla  (Dan  McKenzie) 

and  ear  diseases,  limitations  of  skiagram  diagnosis 

and  throat,  ha?molytic  streptococci  in  (M.  S.  Tongs)"     . 


15 


PAGE 

3.  154 
17 
87 
19 
20 
25 
15 
21 

24 

309 

31 

93 


Obituary:    Dr.    Christian   Holmes.  158;    Prof,    von   Navratil.  350;    A 

Onodi,  350;  A.  von  Irsay,  350;    Prof.  P.  Gerber.  350;  H.  Bagiusky 

351  ;  Prof.  A.  Politzer 
(Esophageal  strictui-es  due  to  lye  burns  (G.  F.  Keiper) 
(Esophagectasia.  extreme  (H.  Batty  Shaw)  . 

see  (Esophagus,  dilatation  of. 

(Esophagus,  dilatation  without  anatomical  stenosis  (W.  Hill)   . 

upper  end.  and  post-cricord  i-egion,  carcinoma  of 

Oleum  sinapis.  inhalation  of,  for  inducing  cough  and  expectoration  (Sir 

J.  Dundas-Graut)      ..... 
Onodi  (A.),  ol)ituary  notice  .... 

Orbitiil  al:)scess,  etc.,  due  to  intranasal  suppui-atiou  (D.  T.  Vail) 
Osteitis   of   tip  of   petrous :    lavage   in    meningitis  (Bellin,    Aloin   and 

Vernet)       ...... 

Osteomyelitis,    acute,    of    temporal    bone ;    operations ;    recovery    (H 

Tilley)         . 
Otitic  sclerosis,  pathological  physiology  of  (A.  Raoult) 
Otitis  media,  acute ;  indications  for  mastoid  ojjeratixsn 

mastoiditis;  al)ducens  paralysis  (O.  Stickney) 


suppurative  ;  early  surgical  intervention  (C.  Caldera) 

chronic ;    sinus   thrombosis,    etc. ;    operation ;    recovery 

(H.  Tanaka)  ..... 
Oto-laryngological  record  of  Italian  Army  Corps  (S.  Pusateri) 
Otomycosis  (A.  Cheatle)  ..... 
Oza;na,  treatment  by  nasal  functional  re-education  (R.  Foy) 
by  zinc  chloride  (Prof.  Lavrand) 


381 
221 
349 

337 
34 

308 

350 

24 

25 

144 
126 
254 

29 
27 


379 
33 
59 

345 


Palate,  tumour  of  (J.  Donelan)      .                 .                 .                 .  .20 

Palatoplasty  (Castex)       .                  .                  .                  .                  .  .90 

Paraflin  injection  in  repair  of  nose                 .                 .                 .  .20 

Pharyngeal  reflex  (A.  Croce)  .....     377 

Pharyngitis,  granular,  ?  cause  of  *'  febricula  "  (V.  Grazzi)          .  .     121 

Pharynx,  oral  and  laryngeal,  carcinoma  of;  early  diagnosis  (E.  D.  D. 

Davis)          .                 .                 .                 .                 .                 .  .321 

pedunculated  carcinoma  of  (A.  Brown  Kelly)                  .  .       13 

tertiary  syphilis  of,  resembling  lupus  (Irwin  Moore)      .  .       22 

and   larynx,  nystagmoid   movements   in ;    brain  conditions    (A. 

Brown  Kelly)             .                 .                 .                 .                 .  .53 

Pituitary  body,  malignant  disease  of  (G.  Maxted)        .                 .  .     222 
tests  f<jr  disease  of  (C.  P.  Howard)      .                 .  .380 

tumour  (A.  W.  Ormoud,  L.  V.  Cargill)             .                 .  94,  223 

sellar  decompression  for  (W.  Howarth)               .  .       49 


Politzer  (Prof.  A.),  obituary  notice  ....     381 

Radium  and  X-ray  treatment  of  papilloma  of  larynx  .  .113 


Index.  389 

PACK 

Reviews  :  Sluder's  •"  Headaches  and  Eye  Disorders  of  Nasal  Origin,"  62  ; 
Laurens"  "  Oto-Rhino-Laryngology "  (Fox's  translation).  63;  Sir 
StClair  Thomson's  "  John  Coakley  Lettsom.  and  the  Foundation  of 
the  Medical  Society  of  London.'"  W ;  Tilley's  "  Diseases  of  Nose  and 
Throat,"  95 :  Oaldera  and  Balla's  '•  Compendium  of  Medico-Legal 
Oto-Rhino-Laryngology.""  127 ;  Smith"s  -  Anatomy  and  Surgery  of 
Nose  and  Ear.""  158 ;  Gillies'  "  Plastic  Surgery  of  Face.'"  316 ; 
'■  Medical  Annual."  1920,  351  ;  Syme"s  "  Diseases  of  Nose.  Throat 
and  Ear "    .  .  .  .  .     350 

Royal  Society  of  Medicine.  Laryngological  Section.  13.  53,  84.  114.  181. 

210,  248,  277,  305,  337,  363 

Summer  Congress  (notes  on)   .  .       90,  128.  160 

President's  Address  ....     248 

discussion   on   "  War  Injuries  and  Neuroses   of 

Larynx"  .       '  .  .  182,     210 

Otological  Section  .....     144 


Scabbai-d  for  adenoid  instruments  (B.  Seymour  Jones)               ,                 .  159 

Sellar  decompression  for  pituitary  tumours  (W.  Howarth)         .                  .  49 

Singer's  nodules,  incipient  (Sir  J.  Duudas  Grant)       .                 .                 .  307 

Sinus,  fi-ontal ;  dangers  of  radical  operations  (P.  Terrier)          .                 .  25 

lateral,  endophlebitis  without  thi-ombosis  (D.  Clavand)                   .  29 

thrombosis  (D.  H.  Ballon)     ....  348 

and  mastoid  antrum  :  external  location  (Prentiss)             .  253 

maxillary,  carcinoma  of   Irwin  Moore)              .                 .                 .  307 

see  also  Antrum,  maxillary. 

sphenoidal,  empyema  in  cerebrospinal  meningitis  (E.  A.  Peters)  11 
tuberculosis  of  (J.  D.  Kernan)              .                 .                 .23 


thrombosis,  jugular  phlebitis,  etc.  (W.  S.  Laurie)  .  .     381 

Sinusitis,  frontal ;  endo-nasal  operation  (Bourget)      .  .  .     345 

sphenoidal,  latent,  in  children  with  recurrent  adenoids  and  appen- 
dicitis (P.  Wat  son- Williams)  .  .  .  .97 

with  hypophysitis  (T.  R.  Boggs.  M.  C.  Winternitz)  .     121 


Skiagram  limitations  in  diagnosis  of  nose  and  ear  disease  (J.  Guttman)  .       31 
Societe  Beige  d'Otologie.  etc.,  note  on  Annual  Congress  .  .     224 

Sphenoidal  empyema  and  cerebro-spinal  fever  (D.  Euibleton)    .  .     122 

Status  lymphaticus  and  enlarged  thymus  gland  (R.  C.  Newton)  .     127 

Submaxillary  calculus,  large  (Dan  McKenzie)  .  .85 

gl-.'.nd  suppuration  (Dan  McKenzie)  .  .  .85 

Teratoid  tumours  of  nasal  septum  in  childi-en  (A.  Brown  Kelly)  .       15 

Thyuius  gland,  enlarged,  and  status  lymphaticus        .  .  .     127 

Thyro-fissure  ;  control  of  haemorrhage  (Irwin  Moore)  .  .     326 

Thyroid   cartilage,    "window"   resection   of,  in  epithelioma  of  larynx 

(Lambert  Lack)         .  .  .  .  .  "     .       54 

Tongue,  thyroid  tumour  at  base  of  (Lambert  Lack)    .  .  .84 

Tonsil,  sarcoma  (■'}  of  (A.  Wylie)  .....     308 

lingual,  and  goitre,  glossodynia  and  focal  infections  (G.  Sluder)  .     189 

Tonsillectomy  followed  1>y  dislocation  of  atlas  (H.  Swanberg)  .  .     188 

mechanical  and  physiological  considerations  (H.  C.  Masland)       .     187 

versus  helio-electric  methods  (T.  M.  Stewart)  .  .     154 

with  local  anesthetic  in  adults  (B.  Foster)      .  .  125,378 

Tonsillitis  and  phai-yngitis  after  oral  sepsis  (H.  B.  Anderson)  .  .     124 

with  buccal  spirochaates  (Tretrop)     .  .  .  .59 

Tonsils  of  children  clinically  non-tuberculous  containing  bacillus  (R.  S. 

Austin)       .......     187 

Trachea,  tumour  of  ;  removal  by  peroral  tracheoscopy  (H.  Tilley)  .         1 

Tracheoscopy,  peroral,  for  removal  of  tumour  (H.  Tilley)  .  .         1 

Tracheotomy,  tranquil,  by  injecting  cocaine  into  windpipe  (Sir  StClair 

Thomson)   .  .  .  .  .  .  .30 

Trichotillomania  with  delusions  of  nasal  origin  (H.  J.  Banks-Davis)        .     118 


390  Index. 


rA.QZ 


Vertigo,  treatment  by  adrenalin  (M.  Vernet)  .  .  .     314 

Vincent's  angina  of  external  auditory  meatus  (A.  Cheatle)        .  .         6 

X-ray  examination,  value  of,  in  mastoiditis  ....     253 


AUTHORS. 

PACK 

Agar  (Morley),  treatment  of  hay-fever  and  paroxysmal  rhinorrhoea         .  312 

Anderson  (H.  B.),  tonsillitis  and  pharyngitis  after  oral  sepsis                 .  124 
Austin  (R.  S.),  Bacillus   tuberculosis  in  tonsils  of  children  clinically 

non-tuberculous         ......  187 

Ballon  (D.  H.),  lateral  sinus  thrombosis     ....  348 

Banks-Davis  (H.  J.),  paralysis  of  aryttenoideus          .                .                .  116 

— trichotillomania  with  delusions  of  nasal  origin                 .                 .  118 

Baraud.  gas-embolism  of  lateral  sinus  after  mastoid  operation                .  221 

• (Prof.),  congenital  occlusion  of  the  choanse      .                 .                 .  122 

Bellin,  Aloin   and  Vernet,  osteitis  at   tip  of  petrous ;    lavage  in 

meningitis  .  .  .  .  .  .  .25 

Blackwell,  suljacute  mastoiditis                  .                 .                 .                 .  286 

BoGGS  (T.  R.),  and  Winternitz  (M.  L.),  hypophysitis  with  sinusitis      .  121 

BouRGET  (J.),  endonasal  operation  in  frontal  sinusitis               .                 .  345 

Bowers  (W.),  brain  abscess  (after  mastoid) ;  operations,  recovery           .  155 

on  ojiponents  of  radical  mastoid  operation      .                 .                 .  347 

Brady  (A.  J.),  abstracts  ....     125,  349,  381 

Broom  (R.),  spinose  ear  tick   (Ornithoclorus  megnini,  Dngi's)  in  South 

Africa  .  .  .  .  .  .  .362 

Brown-Kelly  (A.),  three  dental  plates  from  oesophagus          .                 .  309 

Brunetti  (F.),  retention  of  projectile  in  nose              .                 .                 .  345 

Caldera  (C),  early  surgical  intervention  in  otitis 

■ and  Desderi,  experiments  on  nasal  flora 

and  Santi,  modifications  of  nasal  flora  from  plugging  . 


Caliceti  (P.).  larva*  of  Hurcopliaga  carnaria  in  the  ear 
Cargill  (L.  v.),  hypopituitarism  .... 
Carter  (W.  W.),  gas  bacillus  infection  of  mastoid     . 
Castex,  palatoplasty       ..... 
Cavanaxjgh  (J.  a.),  submucous  resection  of  nasal  septum 
Cheatle  (A.),  otomycosis  .... 

Vincent's  angina  of  external  auditory  meatus 

Claoue,  rubber  denture  in  cesophagus  ;  use  of  galvano-cautery 
Clavand  (D.),  lateral  sinus  endophleliitis  without  thrombosis 
CoLLEDGE  and  Ewart.  oesophagotomy  for  foreign  bodies 
Croce  (A.),  researches  on  pharyngeal  jjliarynx 

Davis  (E.  D.  D.),  dental  cyst  involving  nose 
early  diagnosis  of  pharyngeal  carcinoma 

fixation  of  l)oth  vocal  cords  ;  tracheotomy 

Daiire,  new  method  of  dressing  mastoid  wounds 
Dawson  (G.  W.),  papilloma  of  nose 

perichondritis  of  larynx      .... 

Dean  (L.  W.)  pitch-range  audiometer  in  otology 

and  Armstrong  (M.),  fibrosis  of  external  auditory  canal  and 

mastoid  region  ..... 

Dench,  indications  for  mastoid  operation  in  acute  otitis  media 
Dickie  (J.  K.  Milne),  abstracts     .  .      27,93,121-2,153-4,345, 

anatomy  of  meml»rnnous  labyrinth  . 

• chronic  middle-ear  suppuration  with  many  complications 

Dixon,  value  of  X-ray  examination  in  mastoiditis 


27 

154 

153 

379 

223 

288 

90 

25 

33 

6 

60 

29 

125 

377 

87 
321 
21 
314 
19 
19 
28 

61 

254 

377-9 

76 
129 
253 


Index.  391 


DoNELAN  (J.),  presidential  address  at  Laryngological  Section 
■ repair  of  nose  by  pai-aflBn  injection  . 

tumour  of  palate  .... 

Dundas-Grant  (Sir  James),  functional  aphonia 

incipient  singer's  nodules 


PXGB 

248 

20 

20 

310 

_      .  .  307 

inhalation  of  oleum  sinapis  for  inducing  cough  and  expectoration     308 

obituary  notice  of  Prof.  Politzer       ....     381 

radical  mastoid  operation  for  cholesteatoma   .  .  .     150 

Eagleton.  bone-grafting  after  mastoid  operation       .  .  .61 

Embleton  (D.),  sphenoidal  empyema  and  cerebro-spinal  fever  .     122 

Fenwick  (G.),  surgical  treatment  of  facial  paralysis  .  .     155 

Foster  (B.),  local  ana?sthetic  for  tonsillectomy  in  adults  .  .     125 

Fox  (H.  Clayton),  abstracts  .  .  .  59-62, 89-93, 126 

FoY  (R.).  treatment  of  oza^na  by  nasal  functional  re-education  .       59 

Frank  (Ira),  fulminating  ethmoiditis  with  metastasis  .  .       23 

Fraser  (J.  S.),  abstracts,  23-32,  61-2, 127, 155,  189-92,  221,  253-6,  286-8^ 

312-14,  346,  347-9,  378 
French  (J.  Gay),  foreign  bodies  in  oesophagus  .  .  .     280 

Gill  (E.  G.),  enucleation  of  tonsils  with  local  anaesthesia  .  .     378 

Goldsmith  (R.),  abstracts  .  .  .  124,  154, 187-91 

Goldstein  (M.  A.),  ha-morrhage  in  epidemic  influenza  .  .      31 

Grazzi  (V.),  can  granular  pharyngitis  be  cau.se  of  "  febrieulu  "'  'i  .     121 

GuiSEZ.  adenoid  obstruction  revealed  by  bronchoscopy  .  .       59 

Guthrie  (D.).  abstracts  .  ....     122,224,346 

'    '  '    99 
346 


aural  tuberculosis  in  infants 

significance  of  Eustachian  tube  in  otology 

Guthrie  (T.),  abstracts  .  .  .  123.  127,  380-1 

method  of  suturing  pillars  of  fauces  .  .  .     102 

Guttman  (J.),  limitations  of  skiagram  diagnosis  in  nose  and  ear  diseases       31 

Haden  (R.  L.),  bacteriology  of  mumps         .                 .                 .  .191 

Hall  (F.  T.).  aural  complications  of  influenza             .                 .  .     189 
Harmer  (W.  D.).  double  dacryocystitis        ....     120 

war  injuries  and  neuroses  of  larynx                  .                 .  .     182 

and  Stevenson  (A.  C),  actinomyces  in  crypt  of  tonsil  .     114 

Harris,  end-results  of  radical  mastoid  operation       .                 .  .     314 

Harris  (T.  J.),  severe  haemorrhage  after  mastoidectomy  in  purpura  .     190 

Hastings  (S.).  tooth-plate  in  oesophagus  ;  division  by  shears   .  .     277 

Hill  (F.  T.),  lateral  sinus  haemorrhage  after  mastoid  operation  .     220 

Hill  (W.),  dilatation  of  oesophagus  without  anatomical  stenosis  .     337 

extreme  alar  collapse          .                 .                 .                 .  .17 

and  Patterson  (N.),  carcinoma   of  fauces;    peroral  excision; 

diathermy  .  .  .  .  .  .  .17 

Holmes  (Major  C),  mastoid  cases  ....     220 

Holmgren  (G.).  foreign  body  in  oesophagus  .  .  .     380 

Howard  (C.  P.),  functional  diagnosis  of  polyglandular  disease  .     380 

Howard  (T.),  meningo-encephalitis  in  mumps  .  .  .     127 

Howarth  (W.),  sellar  decompression  for  pituitary  tumours     .  .       49 

Hutchison  (A.  J.),  abstracts         ....  25,  123 

Jacob  (E.),  papillomatous  laryngeal  lencoplakia         .  .  .60 

Jacques,  projectile  in  skull  base ;  bucco-pharyngeal  extraction  .       62 

and  Daure,  influenzal  mastoiditis    ....     220 

Jones  (S.),  treatment  of  papilloma  of  larynx  by  radium  and  X  rays        .     113 

Kaufman,  is  a  modified  radical  operation  justifiable  ?  .  .     287 

Keiper  (G.  F.),  oesophageal  strictures  due  to  lye  burns  .  .     221 


392  Index. 


Kelly    (A.    Brown-),  In-ain  from   case   of    nystagmoid  movements  in 
phaiynx  and  larynx  ..... 

■ pedunculated  carcinoma  of  pharynx 

■ simple  diagrammatic  records  of  vocal  cord  movements 

teratoid  tumours  of  nasal  septum 

Kernan  (J.  D.),  tuberculosis  of  sphenoidal  sinuses    . 


PAGE 

63 
13 
161 
15 
23 


Lack    (H.   Lambert),   epithelioma  of    larynx   removed  l)y   "'  window " 

resection  of  thyroid  cartilage                  .                 .                 .  .54 

thyroid  tumour  at  base  of  tongue     .                 .                 .  .84 

Lannois,  polypoid  mass  in  ear       .                 .                 .                 .  .90 

Lavrand  (Prof.),  treatment  of  ozaaia  by  zinc  chloride               .  .     345 

Lewis  (E.  C),  chloi'oma  simulating  mastoid  disease.                  .  .     126 

Love  (J.  K.),  origin  of  sporadic  congenital  deafness  .                 .  .     263 

LiTHGOW  (J.  D.).  method  of  demonstrating  relative  position  and  planes 

of  incidence  of  the  semicircular  canals                   .  •         .  .81 

M' Arthur  {G.  A.),  statistical  tables  of  Ear  and  Throat  Department, 

Royal  Infirmary.  Edinburgh  .....     107 
McKenzie  (Dan),  absorption  of  prenuixilla  in  tertiary  syphilis  .     309 

abstracts  ......     312 

large  submaxillary  calculus  .  .  .  .85 

submaxillary  gland  suppuration        .  .  .  .85 

the  aqueduct  of  Fallopius  and  facial  paralysis.  135,  169,  201,  244, 

271,296,335 

Mackenzie  (G.  W.),  pathology  of  chronic  middle-ear  suppuration         .  287 

technique  of  examination  for  cholesterin  crystals           .                 .  288 

Mahu  (G  W.).  application  of  Carrel  method  in  acute  mastoiditis             .  255 

Masland  (H.  C).  tonsillectomy     .....  187 

Maxted  (G.),  malignant  disease  of  pituitary  hody      .                 .                 .  222 
MOLLISON   (W.   M.),   acute  mastoiditis;   internal    jugular    thrombosis; 

recovery      .......     149 

facial  paralysis  from  tuberculous  mas-toiditis  •  .     146 

necrosis  of  internal  ear  ;  sequestrum  of  labyrinth  ;  recovery         .     148 

see  also  Poulton  (E.  P.). 

Moore  (Irwin),  adenomata  (glandular  tumours)  of  larynx  .  .       65 

carcinoma  of  maxillary  sinus  ....     307 

foreign  bodies  in  air-  and  food-passages,  i-ecorded  at  Section  of 

Laryngology  since  1908  .  .  .  .  .281 

■ in  lungs,  instruments  for  removal        .  .  .     285 


recurrent  laryngeal  nerve  paralysis  in  tubei'culosis        .  .  118 

sarcoma  of  maxillary  antrum  ;  radium  treatment           .  .  305 

tertiary  syidiilis  of  pharynx  resembling  lupus                  .  .  22 

thyrofissure,  control  of  endolaryngeal  Invmorrhage         .  .  326 

MouRET,  reflections  on  mastoiditis  .  .  .  .92 

structure  and  development  of  mastoid;  influence  on  inflammation  91 

Myers  (L  ),  paretic  hoarseness  simulating  acute  tuberculosis  .  .  346 

Neve  (C.  T.).  herpes  zoster  of  glosso-pharyngenl  nerve  .  .     224 

Newton  (R.  C),  enlarged  thymus  gland  and  status  lymphaticus  .     127 

O'Malley  (J.  F.),  transplantation  of  cartilage  into  septum      .  .       21 

Ormond  (A.  W.),  pituitary  tumour  .  .  .  .  .94 

Pern  (S.),  association  of  cln-onic  disease  with  focal  sepsis         .                 .  349 

Peters  (E.  A.),  sphenoidal  sinus  empyema  in  cerel'ro-spinal  meningitis  11 
Poulton  (E.  P.)  and  Mollison  (W.  M.),  acoustic  nerve  tumour,  oi)era- 

tion              .......  333 

Prentiss,  external  location  of  lateral  sinus  and  mastoid  antrum             .  253 

Pusateri  (S.),  otolaryngological  record  of  Italian  army  corps.                 ..  379 

Raoult  (A.),  pathological  physiology  of  otitic  sclerosis  .  .     126 


Ind 


ex. 


393 


Rejto  (A.).  EwakVs  theory  concerning  eudolynipli  currents 

Robinson  (J.  A.),  toxic  delirium  following  mastoidectomy 

Rose  (F.  A.),  foreign  body  (nut-shell)  in  trachea 

Ryland  (Archer),  abstracts  .  .  .  .94,  22 

assessment  of  aural  disability  from  military  service 

digital  retraction  of  epiglottis  during  indirect  laryngoscopy 

large  fish-bone  in  larynx     .... 

Salinger,  cure  of  subperiosteal  abscess  of  mastoid  by  paracentesis 

ScHOUSBOE  (H.  I.),  large  cyst  of  larynx 

Scott  (Sydney),  the  ear  in  relation  to  disabilities  in  ilying 

Shaw  (H.  Batty),  extreme  oesophagectasia  . 

Sludeb  (G.),  lingual  tonsil  and  goitre,  glossodyuia,  and  focal  infections 

Smith  (M.),  radical  mastoid  operation 

Smurthwaite  (H.),  war  neui-oses  . 

SouRDiLLE  (M.),  dental  cysts  of  supei-ior  maxilla 

Stewart  (T.  M.).  tonsillectomy  versus  halio-electric  methods 

Stickney  (O.).  aliducens  paralysis  in  otitis  with  mastoiditis     . 

Stuart-Low  (W.),  epithelioma  in  patch  of  lupus  erythematosus 

SwANBERG  (H.),  anterior  dislocation  of  atlas  after  tonsillectomy 

Symonds  (Sir  C.  J.),  total  laryngectomy  ;  indications  ;  results 

Tanaka  (H.),  otitis  media;  sinus  thrombosis,  etc.;  operation;  recovery 
Terrier  (P.).  dangers  of  radical  frontal  operations    . 
Texier,  naso-pharyngeal  filjrous  polypi 
Thomson  (Sir  StClair),  abstracts 

extrinsic  cancer  of  larynx 

intrinsic  cancer  of  larynx 

one  year  after  laryngo-fissui-e,  etc. 

prognostic  importance  of  tul)erculosis  of  larynx 

tranquil  tracheotomy  by  injecting  cocaine  in  windpi^je 

Tilley  (II.), acute  osteomyelitis  of  temporal  bone;  oi^erations;  recovery 

lai"ge  malignant  growth  of  antrum  ;  removal  . 

removal  of  intra-tracheal  tumour  by  peroral  tracheoscopy 

Tod  (Hunter),  pin  in  bronchiole,  couglied  up  later 

tooth-plate  in  oesophagus  ;  cesophagoscopy  ;  removal     . 

Tongs  (M.  S.),  ha^molytic  streptococci  in  nose  and  throat 
ToRRiGiANi  (C.  A.),  shell-lmrst  i^aralysis  of  facial  and  other  nerves 
TretrOp,  tonsillitis  with  liuccal  spirochaites 
Trotter  (W.),  lateral  pharyngotomy  for  growth  in  epilaryngeal  region 
Turner   (Logan),  carcinoma  of  post-cricoid  region  and  upper  end  of 

cesophagus ....... 

Vail    (D.    T.),   orbital   abscess    and   exophthalmos   due   to   intranasal 

suppuration  .  . 

Vernet  (M.),  abstracts   .  •  . 

— — — -  vertigo  and  its  treatment  by  adrenalin 

Waggett  (E.  B.),  and  the  Royal  Society  of  Medicine  (correspondence) 
Watson-Williams  (E.),  antral  infection  and  manganese 
Watson-Williams  (P.),  latent  sphenoidal  sinusitis  in  children  with  re 

current  adenoids  and  appendicitis 
Webber  (Capt.  R.),  liqjus  of  upper  air-passages,  128  cases 
Whale  (H.  Lawson).  abstracts      ....   29,  220- 
WoAKES  (0.  E.),  tooth-plate  in  cesophagus;  death 
Wylie  (A.),  sarcoma  (?)  of  left  tonsil 


PAGE 

176 
220 

17 

,349 

354 

82 
304 

286 
123 
225 
349 
189 
312 
183 
193 
154 
29 
145 
188 


89 

30 

15 
378 

15 
123 

30 
144 

21 

1 

278 

279 

93 
379 

59 
289 

34 


24 
314 

314 

256 
199 

97 

7 

1,  345 

277 

308 


Yearsley  (Macleod),  abstracts      .  .  .  .123-6,  220,  378 
can  acquired  deafness  lead  to  congenital  deafness      .  .     270 


ADLARD    AND    SOX    AND    WEST    NEWMAN,    LTD.,    IMPK.^    LONDON    AND    DOKKING. 


SERIAL! 


1 

v.3$ 


The  Journal  of  laryngology 
and  otology 


GERSTS