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MANUAL OF DISEASES
OF THE
EAR, NOSE AND THROAT
Uniform in Style and Binding with Kyle's "Ear, Nose and Throat."
OPERATIVE SURGERT
By J. F. BIKNIE, A.M., CM. (Aberdeen)
MP /-/Surgery, /.,.■ .•.*<■ Amrricm*
SMtgtemi Aitmiittien
SECOND EDITION— REVISED AND ENLARGED
Willi 567 Illustration*, I mmilicr being colored. I2mo; x -f- 655 pages.
Full Morocco, Gill Edges and Round Corners. Ktt S3. 00,
PATHOLOGY
GENERAL AND SPECIAL
B\ A. E. THAYER, M.D.
Hrtftiurr o; : , 'livrrjiiytj lt.1.11 ; /"• mtrly Amsl.inl IklIi utile in .' .,
*fy..Corrnit MeiitcaJ Scktwii I'alhtlogist tit the Lily Hespit\ii. AVtk I imi • itf, etCi
With 151 Illustrations, nmo; 711 page-, lull Morocco, Gilt Edges
end Round Cornels, Net $2.50.
PRACTICE OF MEDICINE
By DANIEL E. HUGHES, M.D. .
iMr Chief Httidtnl Pkjrttrtam, rhiU.it/piim /!.-:
■ [ON
DtTRD, REVISE P AND ENLARGED
Hv SAMUEL lioKTON BROWN, M D,
Aiiiifiin/ Dmumttiqriti, Phllaitiphia ttotfilal; AttiHant Drrmaielogitt,
Univ.
; 785 [»gex. l-'ull Morocco. Gill Edges and Round Corners, Net £2.50,
MEDICAL DIAGNOSIS
By CHARLES LYMAN GREENE, M.l>
/.•r of iMr Theory and Pratt if e v/ Mt ■$. At-
tending t > • <-r'j M'j/fAi.'. ' nr •' :ty Hospital , and SI . taut' x I've*
rhifrm.ir, tttmtrr tf Ike AiMtcimtion •</ itmrriau riimeimm, The Amtri-
• ' 'tJir*l A/tiu iittitt 11, Aii'i-ricnn A*tacimii0H fpr lite Aiiranrt:. •
Sctemte, MftNUMtm Aiaileoiy «f Attain nr >
BxMmimatiem/irr Lift humrmntt ••"it ft* Attciated
Climi.-.i! M*A*A I
With about 12 Colored Plates and 200 Illustrations. In press.
P. Blakiston's Son & Co., Publishers, Philadelphia.
MANUAL OF DISEASES
OF THE
EAR, NOSE AND THROAT
BY
JOHN JOHNSON £YLE, B.S., M.D.
Clinical Professor of Otology, Rhinology and "Laryngology in the Medical College of
Indiana, Department of Medicine of Purdue University ; Otologist, Rkinologist
and Laryngologist to City Hospital, St. Vincent's Hospital and City Dispen-
sary, Indianapolis ; Fellowof the American Academy of Ophthalmology
and Oto-Laryngology and Member of the American Laryngolog-
ical, Rhinological and Otological Society: Late Major
and Surgeon, U. S. Vol.
IKHitb 160 lllustrattone
PHILADELPHIA
P. BLAKISTON'S SON & CO.
IOI2 WALNUT STREET
I906
Copyright, 1906, by P. Blakiston's Son & Co.
run or
Tiff In Era Pmame Commit,
Lakastm. Pa
icAt.'M -Av.,vV-"
\90fe
PREFACE.
It has been the effort of the author in the succeeding pages
to give to the student and general practitioner of medicine
part of the essential information relative to diseases of the ear,
nose and throat. The methods of treatment, seemingly some-
what dogmatic, are those which, from personal observation,
have been most successful.
In the preparation of the embryology, the text-books of
McMurrich and Heisler have been followed very closely.
The pathology of the upper air passages has been given spe-
cial attention and the sub-divisions and classification of tumors,
are in accordance with the teaching of Langerhans. The au-
thor has also quoted freely from Zeigler, Warren, Thayer,
Orth and Senn.
Special acknowledgment is made to the following well-
known authors: Politzer, Gruber, Gruenwald, Turner, Killian,
Grunert, Burnett, Knight, D. Brayden Kyle, Shurley, Hovell,
Bosworth, Coakley, Grayson, Bishop, Dench, Bacon and
Whiting.
The numerous journals devoted to the diseases of the ear,
nose and throat have been freely consulted, and much of the
contents herein have been gleaned from this prolific source of
valuable information.
The thanks of the author are due to Dr. Helen Knabe for
assistance in the preparation of the original illustrations and
to Dr. Jane M. Ketcham for aid in the correction of proof.
John J. Kyle.
226 Newton Claypool Building,
Indianapolis, Indiana.
February 15, 1906.
CONTENTS.
CHAPTER I.
EMBRYOLOGY OF THE EAR, NOSE AND THROAT.
I. Embryology of the Internal Ear i
The Organ of Corti 4
The Macula Acustica Utriculi 4
The Macula Acustica Sacculi 4
The Ampulla: of the Semicircular Canals 4
The Auditory Nerve 4
The Membranous Labyrinth 4
The Bony Portion of the Internal Ear 4
The Cochlear Duct 6
The Saccula Vestibuli 6
II. Embryology of the Middle Ear 7
Tympanic Cavity • 7
Eustachian Tube 7
Petrosa of the Temporal Bone 8
The Malleus 8
The Incus 8
The Stapes 9
The Aditus ad Antrum 9
The Mastoid Cells 10
The Membrana Tympani 10
III. Embryology of the External Ear 11
IV. Embryology of the Nose and Throat 11
Nasal Pits 12
Processus Globularis 12
Nasal Fossa; 12
Septum of the Nose 12
Turbinated Bodies 13
Accessory Sinuses 13
Olfactory Pits 13
Oral Pit 14
The Tongue **
vii
VIII CONTENTS.
Thyro-gIo»8us Duct (Canal of His) 15
Eustachian Tube 16
Rosenmiiller and Tonsillar Fossa 16
Pharyngeal Tonsils *. 16
Faucial Tonsils 16
The Larynx 17
CHAPTER II.
ANATOMY AND PHYSIOLOGY OF THE EAR.
I. The External Ear 18
Auricle 18
Muscles of the Auricle 18
Cartilage of the Auricle 18
Concha x8
Auditory Canal 18
Skin Covering the Auditory Canal 19
Tympanic Membrane 20
II. The Temporal Bone 22
Squamous Portion 22
Petrous Portion • 22
Tympanic Portion 22
Spine of Henle 22
Squamo-mastoid Portion 22
Structure of the Mastoid 23
Depth of the Antrum 23
Internal Surface 24
Superior Petrosal Sinuses 24
III. Facial Nerve 25
Stapedius 26
Chorda Tympani 26
IV. The Middle Ear or Tympanum 26
Mucous Membrane 26
Ossicles 27
Attic 27
Arteries 28
Veins 28
Muscles 29
V. The Internal Ear 30
Osseous Portion 30
Membranous Portion 31
CONTENTS. IX
Mucous Membrane 38
Lymphatics 38
CHAPTER III.
NOSE AND NASAL FOSS/E.
Subdivision 39
Nerve Supply 39
Septum 41
Attic 41
Turbinated Bodies 41
Meatus 42
Vestibule 42
Olfactory Region 43
Olfactory Nerves 43
Glands 44
Nasal Nerve 45
Blood Supply 45
Lymphatics 46
CHAPTER IV.
ACCESSORY SINUSES.
Subdivision i 48
Mucous Membrane 48
Function 48
Glabella 52
Ophryon 52
Ostium Frontale 52
Ethmoid Cells 52
Bulla Ethmoidalis 5
Sphenoidal Cells 5
Number 5
Size 5
Accessory Air Cells 5
CHAPTER V.
ANATOMY AND PHYSIOLOGY OF NOSE AND THROAT.
I. The Pharynx 64
Subdivision <»S
X CONTENTS.
Mucous Membrane 65
Functions of the Naso-pharynx 65
Mucous Membrane of the Naso-pharynx 65
Division of the Cochlea 32
Blood Supply 35
VI. The Eustachian Tube 36
Length 36
Composition 37
Shape 37
Gland Structures 65
Pillars 66
Lingual Tonsil 67
Faucial Tonsils 67
Function 68
II. The Larynx 69
Cartilage 70
Adam's Apple 70
Cartilage of Santorini 71
Cartilage of Wrisberg 71
Epiglottis 71
Muscles 71
Vocal Cords 73
Nerve Supply 74
Blood Supply '. 74
Speech. Area 74
Classification of the Voice 76
CHAPTER VI.
BACTERIOLOGY AND PATHOLOGY OF THE EAR, NOSE
AND THROAT.
Cocci in Inflammation Involving the External Ear 78
Cocci in Inflammation Involving the Internal Ear 78
Cocci in Inflammation Involving the Nose 79
Cocci in Inflammation Involving the Mouth and Pharynx 79
Cocci in Inflammation Involving the Teeth 79
Klebs-Loffler Bacillus 8o
Immunity gz
Natural g2
Acquired g2
Hyperemia g2
CONTENTS. XI
Active 83
Passive 83
Inflammation 83
Causes 83
Ductless Glands 84
Forms 85
Parenchymatous 85
Interstitial 85
Exudative 86
Hypertrophy 87
Hyperplasia 87
Atrophy 88
Tumors 88
Subdivision 89
Etiology 89
Varieties of Sarcomata 91
Varieties of Carcinomata 93
Non-malignant Tumors 95
Fibroma 96
Myxoma 96
Lipoma 96
Chondroma 97
Osteoma 98
Neuroma 98
Cystoma 98
Adenoma 98
Angioma 99
Papilloma 99
CHAPTER VII.
METHODS OF EXAMINATION OF THE NOSE, THROAT
AND EAR.
Record 100
Light 100
McKenzie's Light Condenser 102
Allison Chair 103
Nasal Speculum 104
Tongue Depressor 104
Rhinoscopic Mirror 104
Palate Retractor "^S
XII CONTENTS.
Salpingoscopy 106
Laryngoscopy 107
Autoicopy 109
Otoscopy 109
Eustachian Catheter no
Method of Inserting the Eustachian Catheter in
Auscultation 1 12
Tests of Hearing 113
Whisper Test 113
Watch Test 114
Tuning-fork Test 115
Weber's Test 115
Rinne Test 115
Acoumeter 117
Scli wabach Test 117
folic Test 117
Bing Test. 117
Galton Whistle 118
Konig's Rods 118
CHAPTER VIII.
SPECIAL INSTRUMENTS AND THERAPY.
Hand Atomizers 119
Office Atomizers 119
Compressed Air Cylinders 119
Hard-rubber Sprays 120
Fountain Cuspidor 121
Alkaline Sprays 123
Antiseptic Solutions 124
Astringent Solutions 125
Oleaginous Solutions 126
Inhalations 130
Gargle , 132
Douche 132
Paraffin Prosthesis 133
Massage 135
Thermic Agents 138
Cold 139
Moist Heat 140
Moist Cold 139
CONTENTS. X111
Heat 140
Poultices 140
Electricity 141
Faradic 142
Galvanic 142
Static 142
X-Ray 142
Electro-cautery 142
High Frequency 143
Illuminating 143
Electro-trephine 143
Electrolytic Bougie 144
Radium 144
Finsen Light 145
CHAPTER IX.
SUPERHEATED AIR, SOLUTIONS, VAPORS AND BOUGIES
IN THE TREATMENT OF THE EUSTACHIAN TUBE,
MIDDLE EAR AND ACCESSORY SINUSES.
Superheated Air 146
Injection of Fluids into the Eustachian Tube 147
Injection of Oils into the Eustachian Tube 148
Injection of Vapors into the Eustachian Tube 150
Insertion of Bougie into the Eustachian Tube 150
Catheterization of the Accessory Sinuses 151
Frontal Sinuses 151
Maxillary Antrum 152
Ethmoid Sinuses 153
Sphenoidal Sinuses 153
Intertympanic Irrigation 154
CHAPTER X.
GENERAL THERAPEUTICS.
Local Anesthetics 156
General Anesthetics 159
Post-operative Treatment 163
Local Depletion 165
Natural Leech 165
Artificial Leech \(>(>
XIV CONTENTS.
Diaphoretics 166
Inunctions 166
Constitutional Treatment 166
Hydrotherapy 167
Foot Bath 167
Turkish Bath 167
Cold Water Bath 167
Warm Water Bath 167
Depletents 167
Astringents 167
Preparations of Mercury 169
Pastilles 170
Lozenges 170
Aural Suppositories 171
Nasal Suppositories 172
Aids to the Hearing : 174
CHAPTER XL
DISEASES OF THE EXTERNAL EAR.
Diseases of the External Ear 176
Injuries of the Auricle and Auditory Canal 176
Incision 176
Laceration 176
Contusion 176
Gun-shot 176
Keloid of the Auricle 177
Exostosis and Hyperostosis 177
Tumors 178
Foreign Bodies in the External Auditory Canal 179
Disorders of Secretion External Auditory Canal 181
Hypersecretion 182
Deficiency of Secretion 183
Hyperemia of the Auricle 184
Traumatic Dermatitis of the Auricle 184
Dermatitis Erysipelatosa 185
Dermatitis Phlegmonosa 185
Dermatitis Gangrenosa 186
Dermatitis Congelationis or Frost Bite 186
Dermatitis Combustionis or Burn 187
Eczema of the Auricle 187
CONTENTS. XV
Lupus Vulgaris 190
Impetigo Contagiosa 190
Acquired Syphilis of the Auricle 191
Congenital Syphilis of the Auricle 192
Herpes of the Auricle 194
Otomycosis of the Auricle 194
Perichondritis of the Auricle 196
Cholesteatoma of the Auditory Canal 196
Acute Circumscribed External Otitis or Furuncle : 197
Chronic Circumscribed External Otitis 199
Otitis externa Crouposa 199
Otitis externa Diffusa 200
Otitis externa Diphtheritica 201
CHAPTER XII.
DISEASES OF THE MIDDLE EAR.
Injuries of the Membrana Tympani f 203
Injuries of the Eustachian Tube 204
Hyperemia of the Drum 205
Acute Myringitis 206
Chronic Myringitis 207
Acute Catarrh 209
CHAPTER XIII.
DISEASES OF THE MIDDLE EAR, CONTINUED.
Diseases of the Middle Ear, continued 213
Chronic Catarrh or Hypertrophic Middle Ear Catarrh 213
Stricture of the Eustachian Tube 221
Simple Acute Otitis Media 222
Acute Otitis Media Purulenta 227
Chronic Otitis Media Purulenta 233
Tuberculosis 240
Otitis Media in General Diseases 241
Diphtheria 242
Measles 242
Scarlet Fever 242
Influenza 243
Typhoid Fever 243
IA
XVI CONTENTS.
Tuberculosis 244
Pneumonia 245
Diabetes 246
Syphilis 246
Pernicious Anemia 247
Leukemia ,, 247
Actinomycosis 247
Acute Eustachian-Tubal Catarrh or Acute Salpingitis 247
Chronic Eustachian Tubal Catarrh or Chronic Salpingitis 248
Ulceration of the Pharyngeal Orifice of the Tube 249
Acute Mastoiditis 249
Chronic Mastoiditis 254
Osteosclerosis of the Mastoid 255
Radical Mastoid Operation 256
Stacke Operation 260
Jansen Operation 263
Methods of Closing the Retro-auricular Opening 267
CHAPTER XIV.
COMPLICATIONS OF MIDDLE-EAR SUPPURATION.
Granulations 270
Polypi 270
Necrosis of the Ossicles 272
Facial Nerve Paralysis 273
Cholesteatoma 274
Caries and Necrosis of the Temporal Bone 276
Meningitis 279
Serous Leptomeningitis 280
Purulent Leptomeningitis 280
Thrombosis of the Lateral Sinus 280
Extra-dural Abscess 284
Abscess of the Brain and Cerebellum 285
CHAPTER XV.
DISEASES OF THE INTERNAL EAR.
Anemia of the Labyrinth 289
Hyperemia of the Labyrinth 289
CONTENTS. XV 11
Hemorrhage into the Labyrinth 290
Meniere's Disease 290
Diseases of the Auditory Nerve 291
Neurosis of the Auditory Nerve 291
Hyperaudition 291
Hyperesthesia >. . 292
Tinnitus Aurium 292
Inflammation of the Labyrinth (otitis interna) 294
Panotitis or Inflammation of both the Middle and Internal Ear. 295
Syphilis of the Labyrinth 296
Osteosclerosis or Spongification of the Labyrinth 297
Paresis and Paralysis of the Auditory Nerve 299
CHAPTER XVI.
INJURIES OF THE MASTOID PROCESS AND FRACTURES OF
THE TEMPORAL BONE.
Injuries of the Mastoid Process 301
Fracture of the Temporal Bone 301
CHAPTER XVII.
MALFORMATION OF THE HEARING APPARATUS AND
DEAF-MUTISM.
Malformation of the Hearing Apparatus 303
Deaf-mutism 303
Simulated Deafness 305
Ear Diseases in Life Insurance 306
CHAPTER XVIII.
DISEASES OF THE NOSE.
Acute Rhinitis 308
Simple Chronic Rhinitis 312
Hypertrophic Rhinitis 314
Turbinectomy 317
Turbinotomy 321
Atrophic Rhinitis 323
Fibrinous Rhinitis V-S
XV111 CONTENTS.
Diphtheritic Rhinitis 326
Specific Rhinitis 328
Congenital 328
Acquired 333
Tertiary 334
Gumma Tumor 334
Nasal Hydrorrhea 337
Ozena 338
Glanders 339
Lupus 341
Rhinoscleroma 343
Tuberculosis 344
Epistaxis 346
Rhinoliths 348
Foreign bodies 348
CHAPTER XIX.
DISEASES OF THE NOSE, CONTINUED— NEUROSIS OF THE
NOSE AND NASAL FOSSES.
Motor Neurosis 350
Sensory Neurosis 350
Anosmia 350
Hyperosmia 350
Parosmia 350
Disturbance of Olfaction 350
Anesthesia 351
Hyperesthesia 351
Paresthesia 351
Reflex Neurosis 351
Cough 351
Stammering 351
Hay-fever 351
Asthma 356
CHAPTER XX.
DISEASES OF THE NOSE, CONTINUED.
Neoplasms 359
Nasal polypi 355
Papilloma 362
CONTENTS. XIX
Adenoma 362
Angiomata 363
Fibromata 363
Chondromata 367
Lipomata 367
Osteomata 368
Malignant Neoplasms 368
Erysipelas 369
Furuncle 371
Deformities of the Nose 373
Fracture 374
Paraffin Prosthesis 375
Internal Adhesions •. 376
Congenital Occlusions. 377
CHAPTER XXI.
DISEASES OF THE NOSE, CONTINUED— DISEASES OF THE
SEPTUM.
Deflection 379
Abscess 384
Ulceration 385
Perforation 386
Spurs 387
Dislocation of the Columnar Cartilage 388
Fracture 389
CHAPTER XXII.
DISEASES OF THE ACCESSORY SINUSES OF THE NOSE.
Acute Catarrhal Inflammation of the Frontal Cells 390
Chronic Catarrhal Inflammation of the Frontal Cells 392
Acute Purulent Inflammation of the Frontal Cells 393
Chronic Purulent Inflammation of the Frontal Cells 396
Mucocele 402
Foreign Bodies in the Frontal Cells 403
.Fracture of the Outer Plate <yn
Tumors of the Frontal Cells V=A
XX CONTENTS.
CHAPTER XXIII.
DISEASES OF THE ACCESSORY SINUSES OF THE NOSE, CON-
TINUED—ETHMOID CELLS.
Acute Ethmoiditis 405
Chronic Inflammation of the Ethmoid Cells 407
Suppuration or Ethmoidal Sinusitis 409
Neoplasms 418
Syphilis 419
CHAPTER XXIV.
DISEASES OF THE ACCESSORY SINUSES OF THE NOSE, CON-
TINUED—SPHENOIDAL CELLS.
Acute Catarrhal Inflammation 421
Acute Empyema 422
Chronic Empyema ,. 424
CHAPTER XXV.
DISEASES OF THE ACCESSORY SINUSES OF THE NOSE, CON-
TINUED—MAXILLARY ANTRUM OR ANTRUM OF
HIGHMORE.
' Acute Catarrhal Inflammation 428
Chronic Catarrhal Inflammation 429
Acute Purulent Inflammation 431
Chronic Purulent Inflammation 433
Foreign Bodies 440
Mucocele 440
Tumors 440
CHAPTER XXVI.
DISEASES OF THE NASO-PHARYNX.
Acute Naso-pharyngitis 44$
Chronic Naso-pharyngitis 447
Naso-pharyngitis Hypertrophica Lateralis 450
Chronic Naso-pharyngeal Bursitis 451.
Hypertrophy of the Pharyngeal Tonsil, or Adenoid Growths 453
CONTENTS. XXI
CHAPTER XXVII.
DISEASES OF THE ORO-PHARYNX.
Acute Pharyngitis 463
Chronic Pharyngitis 464
Acute Follicular Pharyngitis 467
Chronic Follicular Pharyngitis or Clergyman's Sore Throat 468
Atrophic Pharyngitis or Pharyngitis Sicca 469
Acute Infectious Phlegmonous Pharyngitis. . . .• 471
Erysipelatous Pharyngitis 472
Scarlatina Angiosa 475
Gangrenous Pharyngitis 475
Hemorrhagic Pharyngitis 476
Pharyngitis Ulcerosa 477
Diabetic Pharyngitis 479
Tuberculosis 479
Lupus 48 1
Glanders 483
Syphilis 484
Actinomycosis 487
Retropharyngeal Abscess 488
Pharyngomycosis 489
Urticaria 490
Herpes 491
Pemphigus 492
Membranous Pharyngitis 493
Diphtheria 494
Intubation in Diphtheria 501
Neurosis 502
Anesthesia 502
Hyperesthesia 50a
Paresthesia 503
Spasm 503
Neuralgia 503
Neurosis of Motion 503
CHAPTER XXVIII.
DISEASES OF THE UVULA.
Deformities 504
Acute Uvulitis VA
%%%% CONTENTS.
I Atrt ilinii* 505
kUmfcati'M 506
CHAPTER XXIX.
DISEASES OF THE TONSILS.
font* Tfrtitilliti* 508
( ht'tn'u- '1 (HMtilliii* 512
Vf * M»)»f mum* '/'oridi I li t in 514
tft^umtHir nr (Unity Torwillitis 514
fi* 1 fret ii- Toimilliti* 516
fot'tinimytm'n 516
( ,,o\e*le-4tin,r4 5x8
f'etittriitiUxr Aliwew or Qllinzy 518
< 1 f+ ration* lor the Removal of the Tonsils 521
CHAPTER XXX.
DIHKASKS OF THE LINGUAL TONSIL.
A< ule Inflammation 526
Myoerjilania 527
A t*r*»» 528
M y«:o»i» 529
Lingual Varix 529
CHAPTER XXXI.
DISEASES OF THE LARYNX.
Acute Catarrhal Laryngitis 531
Chronic Catarrhal Laryngitis 533
Hypertrophic Laryngitis 537
Laryngitis Sicca 539
Membranous Laryngitis 541
Edema 543
Syphilis 544
Tuberculosis 546
Epiglottitis 552
Chondritis and Perichondritis 553
Fracture 553
Non-malignant Neoplasms r,±
CONTENTS. XX HI
Papilloma 555
Fibroma 555
Cystoma 555
Angiomata 555
Myxoma 556
Enchondroma 556
Lipoma 556
Adenoma 556
Malignant Neoplasms 557
Carcinoma 558
Sarcoma 559
CHAPTER XXXII.
DISEASES OF THE LARYNX, CONTINUED— NEUROSIS OF
LARYNX.
Laryngismus Stridulus 562
Aphonia Spastica 563
Laryngeal Chorea 564
Laryngeal Vertigo 5(4
Paralysis 564
Anesthesia 568
Hyperesthesia 569
Paresthesia 570
CHAPTER XXXIII.
FOREIGN BODIES IN THE TRACHEA AND BRONCHUS.
Tracheotomy 573
Bronchoscopy 576
Esophagoscopy 576
LIST OF ILLUSTRATIONS
PAGE
i. Reconstruction of the Embryo 2.1 1 mm. Long. (Eternod and
McMurrich.) 2
2. Reconstruction of the Otocyst of an Embryo of 13.5 mm. (His,
Jr., and McMurrich.) 3
3. Right Internal Ear of Embryo of Six Months. (Retzius and
McMurrich.) 5
4. Traverse Section Through a Semicircular Canal of a Rabbit
Embryo of Twenty- four Days. (Von Kolliker and Mc-
Murrich.) .'. 6
5. Semi-diagrammatic View of the Auditory Ossicles of an Em-
bryo of Six Weeks. (Siebermann.) 7
6. Horizontal Section Passing Through the Dorsal Wall of the
External Auditory Meatus in an Embryo of 4.5 cm. (Sie-
bermann.) 8
7. Sagittal Section of Head of Fetus at Eighth Month 9
8. Stages in the Development of the Pinna. (His and Mc-
Murrich.) 10
9. Face of the Embryo of 8 mm. (His and McMurrich.) 11
10. Face of the Embryo After Completion of the Upper Jaw.
(His and McMurrich.) 12
11. Sagittal Section of Embryo of Three Months 14
12. Sagittal Section of Head at Eighth Month 15
13. The Floor of the Pharynx of an Embryo of 2.15 mm. (His
and McMurrich.) 16
14. External and Middle Ear. (Deaver.) 19
15. Outer Wall of Tympanum. (Heath's Anatomy.) 21
16. The Temporal Bone. (Broca.) 23
17. Section Through the Mastoid Portion and Tympanum of a
Man Aged Thirty. (Gurber and Hovell.) 24
18. Sagittal Section of Temporal Bone, Showing Course of the
Facial Nerve. (Randall.) 25
19. Section Through the Mucous Membrane of the Inner Wall
of the Tympanum of the Adult. (Schwalbe after Brunner.) 27
20. The Ossicle. (Holden.) 29
21. Otaeoui Labyrinth of the Right Side. (Holden. ) v>
xxv
*
ii. Diagram of Membranous Labyrinth. (Heaver.)
Portion of the Cochlea. (Heaver.)
24. IcfctfM of 'lie Right Bony and Membi >byrintli.
(fpeJcdiolflO 34
i|f JEuuisliln lube 36
*6. I "I ilir Vestibule of the Auricle (Internal Surface.)
JF , I OIMO tad Delamere ) 37
17. Smt and Nasal Fossa; 39
al. Sagittal SriiM..i nl ific Head 40
ay, ffgffaf] rhroogb Mucoui Membrane of Respiratory Region
'.1 Child'* None. (Piersol.) 41
I • I itr.al \V:ill iif the Right Naaal Cavity, Showing the
Arinir*, (Zurkerkandl, and Lamb.) 44
jr. Retropharyngeal Glinda. (Poirier. Cuneo and Delamere)... 4*;
If . Accesumy llniaju. (Turner.) 49
1 III Kr l» lion of the Accessory Sinuses to the Base of the Skull,
Viewed from the Cranial Cavity. (Killian.) 50
34, Sagittal Section "I "lie Head Showing Middle and Superior
ii"".r.i'' Removed 51
If, 'I he .'h iiiiimc in their Relation to the Nasal Fossa?.
'Killian 1 53
Jfi. Sagittal Seiii'in of Skull, Showing a Freeman's Sphenoidal
Bougie in Position 56
37. Sagittal BflCtton ol Head Showing Middle Turbinated Body
Removed 58
38. Vniiml COTi "ii Through Both Nasal Chambers and
Maxillary Antra. (Turner.) 59
37. Anterior View of Mouth. (Dcaver.) 63
40. Posterior Wall oi tb< Pharynx, (Luschka.) 64
41. Diagram of Waldeyer- Lymphatic Ring and its Connection
with the Lympaihic Glandular System. (Escac.) 66
42. Vertical Section of the Tonsil. (H. E. Clark.) 68
43. The Larynx. (Holdeo.) 69
44. The Muscles of the Larynx Viewed from Behind. (Sappey.) . 70
45. View of Interior of Larynx as Seen During Inspiration.
(Morris.) 75
46. View of Interior of Larynx as Seen During Vocalization.
(Morris.) 76
47. Klebs-Lottler Bacillus 80
48. Small Round -Collrd Sarcoma. (Thayer.) 91
49. Large Round-Celled Sarcoma. (Thayer.) 92
50. Spindle-Celled Sa rcoma 93
51. Epithelioma of the Naso-pharynx 94
LIST OK ILLUSTRATIONS.
X X V II
Fibroma 95.
Myxoma 97
Head Mirror and Band 100
Mi Kenzie's light Condenser and Refleclor 102
Allison's Treatment Chair 103
Mykt1 Nasal Speculum 104
Pynchon's Nasal Speculum 104
Andres-Pynchun Tongue Depretatt 105
While's Palate Retractor 10s
Beck's Salpingoscope . 106
ler^uson's Boi table Throat Mirror* 107
Autoscopy 108
Sirgle's Otoscope xio
Polilzer Bag 111
Toynbee's Diagnostic Tube 11a
Randall's Clinical Set of Tuning Forks 114
Gallon* Whistle 118
DeVilbis» Atomizer 119
DeVilbis* Atomizer no
Stein's Air Filter 121
Fountain Cuspidore 122
DeVilbis* Nebulizer 126
Smith's Paraffin Syringe 134
Burnett*! Modified Siegel'i Oioscopc ■ . 13s
l.ucac's Pressure I'robr J37
Deneh's Middle Ear Vaporizer J49
Hartmann's Frontal Sinus Bougie 152
Freeman'* Frontal Duct Bougie . 152
Freeman's Sphenoid Bougie * 55
Hovell's Tympanic Irrigator 1 S4
Speaking Tube 174
1 Mophone* 175
Aspergillus Niger Heads with Conidia. (Siebermaun and
Hovell.) 193
\. bacharumow'i Dilator tor the Eustachian Tube 217
The Area of Operation in Simple M:i*ioide«-i"iiiv 256
McKetooii 1 Curette 257
Stacke Guide 258
Kerrison's Tympanic Forceps 2J9
First Position of Knife in jansen Plastic Operation 262
Knife pasaea into the Auditor) Canal Preliminary to the
Downward Stroke for llie Formation nf the Buttonhole in
the Membranous Wall. (Heine.) *^
XXVIII
I i I I Ol 'ill
108
Bj I ■> in .1 1 m ii . i,i Posterior Membranous Flap. (Heine), it
showing I'li'inioi Membranous Flap in Position. (Heine.). i<
Plamir ( hmira "< Ptraiattnt Pott-auricular Openings. (Modi-
i trtti Masstig Moorhof.) 267
Ptanir damn »f Peraliteni Post-auricular openings. (\i
lire] jfln Mocslig- Moorhof.) 267
Plaatfa (SoNN of Persistent Post-auricular Openings. (Modi
ned after Moestig Moorhof.) 367
Plaatfa Cloture ol l'i iM-inii Post-auricular Opening*. (Mbdi-
1 -'i ttei Mocftig-Moorhof.) 367
Plastic Cloture of Persistent Poat-anricular Openings. (Traut-
mann. ) 26S
1 l<i-uir of Persistent Post-auricular Openings. (TVa
"i.iihi., .. . 26$
Plastic Cloture of Persistent Post-auricular Openings. (Travit-
rnaim. )
Showing ilir Relations ••( the Lateral Sinus to the Outer
Wall of the Skull ami the Position of the Trephine. Open-
ing for Exploring it. (Jacobson and Steward, and Bal-
lanre.) i$6
Whiting's I'.ni.TphaloM'upe 28$
Horfaootal Bection Through the Labyrinth in the Region of
the Stapes and I'ppcr Portion ol the Cochlea. (After Sir-
beriiiann, by courtesy of Dr. Henry J. Hart*. » 29!
Holmes' Saws 320
Jackson's Turbinate Scissors ja
I' r rrin. in \ Fact Shield
Congenital Syphilis of the Nose in a Boy Twelve Years
»f Age 32
Profile of the Uo> thown in Fig. 107, Showing Slight De-
formiiv 3
Tertiary Syphilis of Nose 3 ja
Lupus of the Now aii<! Mouth
Wright's Snare
Ollier's Operation. (Esmareh, Kowalzig, Jacobson k
Steward.) ... . 366
Martin's Bridge in Position 373
liallenger Septum Knife
Hajck's Mucoperichondrial Elevator
Ballenger* Swivel Knife 383
Jackson-Freer Transillumination for Frontal Sinus and An-
trum of llighmore . J07
! IS! OP 1! i i 5TR ITIONS.
Killian's Nut] Bpeculi +06
Luc'* Middle Turbinate Forceps. 41J
Sagittal Secrinn i)f Mead 414
Sagittal Section of Head 41 $
Gruenwald Punch Forceps in Position for the Removal of the
Posterior Portion of the Superior Turbinate and Posterior
Ethmoidal Cell fc 416
Coakley's Sinus Curettes 418
\lvles' Nasal Cutting Forceps 41X
Antrum Through the Interior Meatus. (Holbrook Curtis.).- 43<
Removal of t'pper Jaw. (Jacobsuti and Steward.) 441
Removal of Upper Jaw. (Jacobson and Steward and Heath.) 44J
Congenital Cleft of the Pharynx or Thornwaldt's Disease.
( Dunbar Roy.) 4.51
Adenoids of the Rhino-pharynx. (Gruenwald.) 45+
QMtBttilk'l Adenoid Curette 458
(inKstein's Adenoid Curette, Showing Sin and Shape of
Blades 459
Brandegee's Adenoid Forceps , . . . 460
Doyen-Kyle Post-nasal Biting Forceps 461
Lupus of the Pharynx. (Birkctt. I 481
Evacuation of a Retro-pharyngeal Abscess. (Veau.) 489
O'Dwyer's Intubation Set 501
Bifurcated Uvula 504
Sajou's Uvula Scissors 506
Evacuation of Tonsillar Abscess. ( Veau.) sri
Ballengcr's Tonsil Forceps 520
Beck's Til la r Scissor* 520
Pynchou's Tonsil Knives 521
McKenzie's Tonsillotome 521
Hubert's Tonsil Scissors. 524
Butts' Tonsillar Hrtnnst.it 524
Hypertrophy of the Lingual Tonsil. ( Gruenwald.) 52(1
Tuberculosis I 11 mors. ( Gruenwald.) $47
Tbtmenlnaia of the Larynx. (Schnitalei and Knite.). ...... S47
Papilloma of the Larynx. (Gruenwald.) $55
Laryngeal Forceps . $$6
Bilateral Paralysis of the Internal Thyroarytenoid*.
(Knight.) S65
Paralysis of the AryttnoideuB. ( Knight.) 566
Complete Right Recurrent Paralysis of Phonotion. (Knight.) 467
Paralysis .if the Internal Thvm-arvtrnoid* and of Aryten-
oideu*. S«*>
XXX LIST OF ILLUSTRATIONS.
155. Laryngotomy in the Adult. (Veau.) 573
156. Incision for Tracheotomy Above the Isthmus in the Infant.
(Veau.) 574
157. Killian's Head Lamp 576
158. Killian's Foreign Body Hooks 577
159. Killian's Foreign Body Forceps 577
160. Killian's Bronchoscope 577
ERRATA.
Page 60, top line, instead of ' Nasal ' read nose.
Page 223, top line, instead of 'Pathology' read Pathology and Symp-
tomatology.
Page 231, fourteenth line from bottom, instead of 'inflammation ' read
inflation.
DISEASES OF THE EAR, NOSE
AND THROAT.
CHAPTER I.
EMBRYOLOGY OF THE EAR, NOSE AND THROAT.
To appreciate the fully developed ear, nose and throat of
', it is necessary for a brief reference to be made to those
organs as embryological structures. The three germinal layers
from which the structures of the body develop, arc the ectoderm,
rndoderm and mesoderm.
From the ectoderm is developed the mucous membrane lining
of the mouth, nasal cavity, pharynx, Eustachian tubes, middle
ear, mastoid antrum, digestive and respiratory tract. The
larynx is lined With epithelium from the endodcrm. The car-
tdaginous portion of the nose, larynx and ear, and the bony
structure oi the nose and ear arc derived from the mesoderm.
During the very early development of the embryo as it
rests upon the yolk-sac, the oral fossa is observed to be a
well-marked depression, slightly behind and below the head
region. In the Hoor of the oral fossa arc found the branchial
arches which have a direct influence upon the arrangement of
the organs of the head. Some of the branchial arches are con-
verted into the special organs and others riisapp
Internal Ear. — The internal ear is the first portion of tin-
ear to be formed. It takes its origin, as described by Heisler,
from a circular patch of ectoderm on the dorso-lateral surface
of the head region of the embryo near the dorsal wrmvwaOvwv
i i
k
Reconstruction Off tiik Kmhmvo 2.11 mm. Lone.
ni, AUaoMia; «. amnion; fl, belly -Ktalk; .-'1. chorion; h, heart: mt, m*io-
dermic somite; as. or.il font; i>h, pharynx'. ,, rl)unV.iiic << otk<nc.
(After lite mad and McMnrrith.')
small prolongation (Fig. 2) on the dorsal surface of the
otocyst develops and forms the ductus endolymphatic^. By
a process of enfolding and constriction of the two extremities
of the otic vesicle, the semicircular canals and cochlear dud
are formed, the latter finally becoming the cochlea. At the
origin of the ductus emlnhmphaticus. unequal constriction ts
place, forming the utricle. From the superior portion of the
utricle spring the semicircular canals. The saccule, a much
EMBRYOLOGY OF EAR, NOSE AND THROAT.
3
Soulier pouch, rak.es its origin from The utricuhis by a process
of consrrietion. The constriction at the origin of the ductus
endolymphaticus is sufficient to make rhis tube the only avenue
of connection between the utricle and the saccule. As remarked
by Heislcr, the beginning of the cochlear duct fails to keep
pace with the other parts, and, in consequence, we have formed
Fig. 2.
dc
1/
■ MtucTiox or the Otocyst or a* Ensure or 13,) mm.
4-*, Cochlei; de, cndolvmihatic duel; K, tctnicircular canal. (After Hit, frH
and AfcMhrrich.)
the canalis reuniens, the small canal connecting the sacculus
with the ductus cocblearis. Were it not that certain cells of the
st have the faculty of growing into neiiro-cpithelium,
known as sensory cells, the car as a perceiving organ wuuld
be forever lost.
J.M.M.AM S -M l;,\R, MJSK .AND THROAT.
The organ of Corti, which is highly developed new*
epithelium, extends the entire length ol the scala media of
the cochlea and becomes the great perceiving organ of the ear.
The macula acustks Utricuii is a circular patch oi special-
ized neuro-epithclium, located on the lateral and anterior wall
of the utricle.
The macula acustka ssicculi is a continuation of the same
form of neuro-epithclium as in the utricuii and organ of Corti
and is located on the median surface of the recessus sacculi.
The ampullffi of the semicircular canals contain the crista-
acustica; and resemble in neuro -epithelium that of the utricle.
The mucous lining of the membranous labyrinth is made up
of flattened polyhedral cells and the neuro-epithelium takes
on the form of modified columnar cells.
The auditory or acusttc nerve takes its origin primarily
from the acustico-farinl ganglia, situated on the dorsum. Qt
root, of rhr hind brain and is in close proximity to the otic
vesicle.
The acustico-facial ganglia subdivides into facial ganglia
the acustic ganglia. The facial ganglia extends itsell
and finally becomes the facial nerve. The acustic ganglia
again subdivides and gives rise to wo ganglia, one finally be-
coming the connectinc link with the macula; acustica and the
other with the crista- acusticae. Thus the axis cylinder of the
nerve is developed from the ectoderm and the enveloping por-
tion from the mesoderm.
The fully developed membranous labyrinth (Fig. 3) is
made up of semicircular canals, utriculus, sacculus, ductus-
endolymphnticus, canal is reuniens, ductus cochlcnris, nerve
srmcture and endolymph.
The bony portion of the internal ear springs from the
mesodcrmie layer and completely surrounds the nerve struc-
ture. The accompanying illustration (Fig. 4) will give the
reader a clear conception of bow the internal ear is formed.
Surrounding the otocy<t or membranous labyrinth is a fibrous
layer. Next to this is a gelatinous layer which success
>sively
DMBA8E8 OP • Ut, \nsi. AMD fHRDAT.
tensely inf. nst i.iu. In the early stage, according to Heisler
anil m tier*, the epithelial cochlear duct is short and tapering.
Aitr: iffcation of the petrous bone, the duct lengthens
ii'- spiral. The cochlear duct coils itself about a
'■i'. or modiolus, which, before ossification, was com-
posed of deoM connective tissue, afterward changing into car-
tilage iitnl finally into bone. This portion of bone extends
outward in a sc r«-\\- -shape from the modiolus, subdividing the
BOdlltt bltO tWO parts at each spiral turn, which become the
Kill vr.tilnili ami the scala tympani, and are lymph spaces
mi log perilymph. The cochlear nerve contained within
Fie. 4.
T«A» rut* TllMUOH A SaMICI»CUI-A» CAKAI. 01 A Ra»»IT KmbbVii Of
Twinrv-coL* l)AV».
• 'iode cartilage; */>, fibroua n» ncath the epithelium of the canal;
». |>ericaon<lri<iin ; /, »i""*lty tiaauc. (After Von KQUiktf and McMurrich.)
the modiolus, an extension of the auditory nerve, sends branches
n, the duct at each spiral turn of the cochlea enclosed within
the scala media.
The scala vestibuli is subdivided by the membrana vestibu-
laris. The base of the triangle is composed ol fibrous connective
tissue and extends from the two surfaces of the lamina spiralis
ossea to the external wall of the cochlea, thus forming, with the
membrara vestibularis, the scala media.
The scala vestibuli and scala tympani communicate at the
EMBRYOLOGY OF EAR, NOSE AND THROAT. 7
apex of the cochlea. The seal a ivmp.mi extends to the inner
wall oi tlu- middle ear filling the space sm rounding the fenestra
rotunda and the fenestra malis. The meinluanous semicircular
finals are nut surrounded by the perilymph but are attached
directly CO the surrounding bony wall.
Middle Ear. — The middle ear is composed of the tympanic
•> . mastoid cells and Eustachian tube and takes its origin
Fig. 5.
A
-.
(
k-
y
SfHI'MAGOtAMKATIC Vir« or 71 Ossein or *x Rmuvo or Six
Wl 1
im; J, jugular vein; m, mallcm; me, Mrckcl'j. cartilage; oe, capsule
of otocyit; H, cartilage oi the sccoiul branchial arch; jf, stapes; Vll, facial
from the endodcrmal layer of the first inner visceral furrow or
branchial cleft. The inner visceral furrow, by a process of
evagination of the primitive pharyngeal cavity, is prolonged
upward, forming the tympanic cavity, while the tubo-tympanic
sulcus connecting the middle ear with the pharyngeal cavity,
grows together at its edges, forming the epithelial lining of tta
8
DISEASES OF EAR, NOSE AND THROAT.
Eustachian tube. Broadly speaking, surrounding the evaginased
cavity, as in the internal ear, is the embryonal, mesodermic, con-
nective tissue, which successively changes into cartilage and
bone, becoming the " petrosa of the temporal :
rn,i
I'IC. 6.
HotuoxTAt Section Pamimo T1mr.t-f.71 tiik Dot swi. Wm.i or tiik Rxtmk.m
Assrqm iSxkxaa in an Ehmto or «.j ex.
c, Coclilra: . •ndolympbaiic duel; i, incut; Is. lateral Btnuv. ifl, malli-u-,:
me, meatus auditonua RtflraHa; me', cavity of the meatus; «, sacculu*.
koruontaJ aemiiii. lift) eAlMl; ■■'. posterior semicirculai stapes; I,
tympanic cavity; u, <m Qem. | \ficr Sicbermann.)
The (Fig. 5) mall t us and incus are formed by a constric-
tion of embryonic cartilage of the first branchial arch, which
partially forms the roof of the tympanic cavity. Upon ossifi-
EMBRYOLOGY OF EAR, NOSB AND THROAT. 9
cation, the thin bones are separated, becoming respectively the
malleus, incus and stapes, and with the development of the
tympanic ring and petrosa they are drawn into the natural
position in the middle ear.
The stapes and stapedius muscles both take their origin
from the second branchial arch. The first :n.d BCCOnd arches
meet in primitive life about the tympanic cavity, forming
Fig. 7.
.V't
1 Eiot 1 ii Ma
r. Section of the posterior semicircular canal: .-. tympanic cavity: ?. mcoi-
lirana tympani; 4. »tapc»; $, llipcfli :■■:... 1 llic
common canal.
the roof; within the spongy mesenchyme of the roof, the
les are imbedded. Near the end of fata] life, the mucous
membrane wraps itself about the ossicles as a result of spongi-
iication and absorption of the mesenchyme. The middle car
is fully developed at birth.
The arlltus ad ant rum and antrum are formed : nation
of the mucous membrane of th< ear into the tcuvpwc^l
L6U IS THE DEVELOPMENT UP THE 1'INN.S.
.•:, Bntnya oi n "mi,; ft, o( 13.6 mm.: C, of 1$ mm.; L>, at the h^gtmring
of trw thinl month; /;. fetu» of 8.5 cm.; A", fctu* at term ; /. tragus; t-l, helix;
1, am || ell | lie. (After Hii and McMnrrich.)
The membrana tyrnpani and external ear are formed from
the ectodermal groove of tlic first branchial cleft. Upon study
oi Fiji, (j the reader will notice the funnel-shaped, darkened
area coi responding to the position of the external auditory
canal. About the second month of fetal life, an ingrowth
EMBRYOf.OGV OK EAR, XOSE AND THROAT.
II
takes place, pushing itself inward against the gelatinous meso-
derm of the middle ear. 1 Ins disk-like structure continues to
develop until the seventh month of fetal life, when it is com-
pletely formed. The auditory canal is formed by a process of
OUtWttrd growth. 1 'ic membrana tympani is, in consequence,
COTCrcd with endodermal epithelium in the inner side and by
ectodermal epithelium on the outer side.
Fie. 9.
FACE Of Embiyo or 8 M*/.
pi ft. processus gJob«itjri*.
(.M1..1 Hit and McVurrich.)
External Ear.— The auricle or pinna takes its origin
from six little elevations of mesodermic tissue covered with
dens (Fig 8) lituated upon the posterior edge of the
first and the anterior edge of the second arch, beginning about
the fourth week of embryonic life and by a process of growth
and differentiation of the layers of each tubercle into cartilage
1 pithelium. we have formed the auricle or pinna.
Nose and Throat. — Situated on the oral fossa and appear-
II
DISEASES OF PAR. NOSE AXD THROAT.
ing before the third week, are two plates, which are the be-
ginning of rhe nasi! fossae. At about the twenty-eighth day,
flw plates become depressed from growth of tissue and br\
the nasal pits (Fig. 9).
i-'i.. ra
Fac* or Kmmvo Ann ra > now of the I'fpek Jaw. (After Hit
tiwj McMvrrich.)
Separating the two nasal pits are the two processus globularis,
which are thickened growths of the nasal process (Fig. 9).
The oral fossa is bounded laterally by the maxillary process,
which unite! with (he globular processes (Fie. 10) and foi
the nasal fossa. The nasal pits become canals connecting the
two anterior narcs with the primitive mouth cavity.
By gradual shrinkage, the broad nasal process becomes the
septum of the nose. The palate shelves gradually grow to-
EMBRYOLOGY OF BAR, NOSE AND THROAT.
**
gether at the median line separating the mouth from the nasal
cavity.
The turbinated bodies are observed first as ridges on the
lateral walls of the nasal pits. By a process of evagination of
the eetodermic layer of the cavity, thin folds are formed. With
each fold is a layer of mesodermie tissue, which changes into
cartilage and subsequently into bone, becoming the thin tur-
binated bodies. By a continuation of evagination and absorp-
tion nt tissue within the superior maxillary growth of the
alveolar process* the two antrum* of Highmore are formed.
The maxillary sinus or antrum of Highmore is formed dur-
ing fetal life by a process of evagination of the mucous mem-
brane of the nose and absorption of bone within the superior
maxillary bone. At birth, the antrum is a- small slit in the
maxillary bone. The growth of the maxillary sinus is con-
temporaneous with the growth of the maxillary bone, reaching
its full development about the twentieth year of life.
By i process trj evagination of the nasal mucosa after birth,
absorption of spongy bone in the ethmoid and sphenoid bodies
takes place, forming the ethmoid and sphenoid sinuses. The
frontal cells form by a like process of evagination and ab-
sorption of spongy portion in the frontal bone. The accessory
cavities are lined with a pseudd stratified ciliated epithelium
of the same character as the respiratory region of the nose.
According to McMurrieh, in the human embryos of the
rta VFCek " the Cells lining the upper part of the olfactory
pits show a distinction into ordinary epithelial and sensory
cells, the hitter when fully formed being elongated cells pro-
longed peripherally into a short, narrow process which reaches
the surface of the epithelium and proximally ^ives rise to an
inder process which extends up toward and penetrates
the tip of the olfactory lobe to come into contact with the
dendrites of the first central neurons of the olfactory tract.
These cells constitute a neuro-cpithelium and in later stages
of development retain, in the most part, their epithelial po-
sition. A few of them, however, withdraw into the svib-
1 4
DISEASES OF EAR, NOSE AND THROAT.
jacent mesenchyme and become bipolar, thejr peripheral pro-
Ionizations ending freelj among the cells <ii the olfactory epi-
tlirlium. These bipolar cells resemble closely in form and
relations, the cells of the embryonic posterior root ganglia and
thus form an interesting transition between these and the
neuro-epithelial cells."
Fie. 11.
n <>r Em live op ; -.115.
/, Mlilcll* 1 |Cil wall: ,?, pharyngeal opening of
OTUehlan (tlfctj I ■>•• inf the beginning of ossification
,. 1 in 1 iIjiw i«ti ■!!■■ film I borl> '•, rcimpncC frontal region,
Hy I ■ Pi '. 'i. the mouth, which was before
ttw third weal the oral pit, la observed to be a five-sided fo
ihe mi n frontal process, laterally by the
id below by the mandibular arches. The
palate h formed ibout the third month from a growth back-
Mi fiiii! tDWIItl 1 hi line m» the shelf-like portion of
• IV \ liti product - cleft palate. The
1 the poaterioi the soft
palate which < ■'■ 1 1 .1 ..1 the thud month.
The t ntlaj ;s formed by
a Ml inl •••'in (In ph 1 1 < 1 > \ Hit anterior
BOrfbfl "i In i mil ihr 111 n impar, situ-
EMBRYOLOGY OF EAR, NOSE AND THROAT.
'5
ated in the anterior wall of the pharynx. The posterior and
lateral segments of the tongue develop simultaneously with the
tip from the second branchial arch, the line of union in the
adult being the circumvallate papilla?. By the process of evagi-
Fic. 12.
2 3
i i tttuto kl En;iiTii Month.
•-. middle turbinated body; 4, in-
fetloi hni. f\ 5, spongy bone forming the ethmoid body.
nation and fusion of the three portions of the embryonic
tongue, a canal is formed, extending from the junction of the
pints by a median line backwards down to the middle of the
thyroid body, and known as the thyro-glossal duct or canal
of His. This fetal structure closes, as a rule, the remaining
evidence being thr foramen cecum of the adult. Sometimes,
however, this canal remains and becomes manifest in adult
by the formation of a «u at the thyroid isthmus, or about the
base of the tongue.
The pharynx in the embryo is the cephalic end of the
primitive gut-tract. Within this region arc the pharyngeal
pouches or throat pouches in counter distinction to the outer
visceral clefts. The tissue covering the pouches is made uo
I ft
MS OF 1AK. • > THROAT.
1,1 fhr ectoderm, Which COmei in contact with the endoderm
and fori riti.tr-, thr closing membrane.
The Kustachian tube and middle rar are formed from the
idermi] groove <>l the first branchial cleft of the pharyn
pouch by a process of growth outward and infolding of the
wall* of the first groove.
'J Kt groove goes to make up at its lower portion
the groove of Rosenmuller and the tonsillar fossa. The
Fie. 13.
-/■
I hi 1 1 m.„ 1 I'imvKi nriis Ernnvo or .-15 mh.
etttai I, mcdUn portion of tonuue, (After His and MdlurrichJi
■ibes of the thyroid bodies arc developed from the third
groove.
I he pharyngeal tonsil is made up of lymphatic tissue and
is situated beneath rhc mucous membrane nf the posterior wall
of the pharynx, above the Kustachian tubes. It is presumably
an histological structure disappearing about the twelfth year
01 lift- Its development after birth is dependent upon an in-
herited lymphoid diathesis and infection of the lymph patch
from pathogenic organisms.
The faucial tonsils are lymphoid structures, found in the
fetttS IS small budding epithelium, located upon the lateral
wall of the pharynx and within the tonsillar fossa, containing
blood vessels and undeveloped crypts. The follicles are formed
at birth, by the cvagination of the mucous membrane. The
Tw
EMBRYOLOGY OF EAR, NOSE AND THROAT. 1 7
size of the tonsils depends upon the infection and infiltration
of leucocytes, which cause the tonsils to take on a morbid
growth and thus reach the varied sizes observed.
The Larynx. — A reference to Fig. 13 will show the larynx
as it takes its origin from about the third branchial arch. Ex-
tending downward and laterally are the arytenoid ridges.
With the development of the embryo, the arytenoid ridges
separate by a vertical slit which finally become the vocal cords.
The thyroid and arytenoid cartilages develop from two centers
of chondrification and the cricoid from one. Fusion of the
halves of the thyroid and the halves of the arytenoid with the
complete formation of the larynx takes place about the fifth
month of fetal life.
CHAPTER II.
ANATOMY AND PHYSIOLOGY OF THJ
The External Ear. — The external ear is composed of the
auricle or pinna and the auditory canal or meatus auditorius
externus. The auricle is a single cartilage composed of >ellmv,
- I- itic, fibrous tissue, over which lies the perichondrium. Cov-
ering the perichondrium is the skin proper, containing swear
and sebaceous glands and a number ol hairs, The muscles
of the auricle are divided into extrinsic and intrinsic. The
extrinsic are those at the side of the auricle and :ue the attol
attrahens and rctrahens aurem. The intrinsic are those within
the boundary of the pinna and are the antitragicus, tragk
lielicus major and minor, transverse auricula; and obliqu B
auris. The function of the pinna is the collection and condui
don of sounds.
The cartilaginous elevation surrounding the pinna is called
the helix. It terminates at the lobule, the most dependent part
of the ear. 'I he lobule consists of fat and areolar tissue.
Within the helix and extending down to the antitragus, is the
antihelix. In the superior and anterior portions of the anti-
helix, is a deep n - i. known as fossa of antihelix. Anterior to
the antihelix and looking into tbe auditory meatus, is a deep
cavity, called the concha. Anterior to the concha and pro-
jecting hood-like over the meatus is the tragus. Below the
tragus and anterior to the antitragus, which is a small promi-
nence on the antiln-liv, i-. a notch called incisura intertragira.
The audit I '- composed of a cartilaginous and bony
portion. The r.irtilacinous portion is an extension from the car-
tilage of the pinna. It is about one-half inch in length and
18
DISEASES OP BAR, NOSB AND THROAT.
■lightly iii cbamctei as it merges upon the usseus porcior
Along the up | km' wall we find a great number of ceruminous
-.!■,, the (unction of which is the secretion of a lubricating
oil, (ailed cerumen. These open into the duct beside the
bail follicles. The meatus is thicklj studded with cilia,
which, by a vibrating motion, aid in expelling glandular set
tii»ii :iinl minute foreign particles, which may find entrance
■ the canal. As age increases, the cilia multiply and often
grow tO sonic length. The integument of the meatus is thin
and is firmly attached to the underlying parts. The skin
ring of tin- osseous portion of the canal is a continuation of
thai covering the Cartilaginous portion, differing from the latter
in that it contains neither glands nor hair. Slender papillae ate
found i» the Vicinity of the tympanic membrane.
The nuiiiljiiiuii fyin/'itiij. ht d i 'inn-head, forms a part of the
OUter wall cif I he iv mpariiini. Ii i-. composed of three layers:
tin external Or cutaneous, the middle or lamina propria and
the internal or mucous layer. The external layer is made up
of itratifi A squamous epithelium and is formed by an extension
of the cuticle of the external auditory canal. The layer is
devoid of papilla- and detachable from the middle layer or
lamina propria;.
The Strang middle layer is composed of two distinct, iibrous
layers and external or converging fibrous lamella: originating
in the periosteum of the auditory canal and converging toward
the center of the tympanic membrane. The inner layer is com-
posed of fibrous bands which have a circular course and are
more numerous at the external periphery of the membrana
propria. In addition to the two distinct layers as enumerated,
two sets of fibers are present, known respectively, as descending
and arborescent fibers. The former radiate to the handle of
the malleus from the superior segment of the tympanic mem-
brane and later from the periphery.
The interna] layer which is in direct contact with the middle
layer and inseparable, is composed of permanent epithelium and
is a combination of the mucous membrane of the middle ear.
AXATOMY OF THE EAR.
21
The character of the epithelium of the tympanic cavity changes
:it the annulus fibrosus. The dram is somewhat oval 01 elliptic
in form, inclining downward and inwajd at an angle of about
seventy-five degrees and ending peripheral!] in the shallow
groove of the sulcus tympanicus.
The membrane is 10 mm. in length, 9 mm. in width and
0.1 mm. in thickness (Brtihl). The color <>f the dium viewed
externally through the auditory canal is pearly gray. Three
dis.tim-t landmarks are visible : (1) The short process of the
I IG 15-
.
J ;
' M
■
\.
11 :» Wau. on rut 1 vsir.witH. (From Httth't Amu.
i, Anirum; ■. ligaments of malleus; .,•. head <•( maltetui t. ti ndi a dI
latSOl tymptai; j, chorda tympani; rt, membrai I g|; ;, handle of
malleus; 9, facial nerve in aqu llIopU,
malleus; (2) the manubrium or long process of the malleus
and umbo; (3) the light spot. The drum, or membrana lensa,
ivided into quarters or quadrants: two superior
0 inferior quadrants. Above the superior quadrant and
the short process ot the malleus is situated the membi;iii.i II. h
or Shrapnell's membrane. The tympanic membrane in this
portion is composed of two layers onh, the external ut cm&sc&k
22
"I- l-.AR, NOSE AND THROAT.
;iriil the 1 1 1 f «- r 1 1 : 1 1 01 mucous layers. A small foramen is SUj
i.m ,,( tu exist in the membrana rlaccida.
I • i ■ the inner surface, the short and long processes of the
malleus are found, fixed to the membrana propria. The long
l>"«i- may he seen extending backward and downward, end-
ing m-.ii the '.enter of the drum, from which is given off a tri-
angular light spot, or cone of light extending downward and
forward. The short process is more oi less conspicuous, de-
pending upon any pathological change in the drum or middle*
ear. The drum membrane, on account of its attachment to
the malleus, is not evenly stretched. The function of the
drum membrane is the transmission of sound by vibration.
rhoe .iluai:uns number from sixteen to forty thousand per
■•• ond. 'J he drum membrane is not essential to hearing.
The Temporal Bone. — The temporal bone is a large, ir-
regularly shaped bone, situated on either side of the skull, articu-
lating fa front with the great wing of the sphenoidal and
frontftl bones, above with the parietal and behind with the
Occipital bone, '1 he apex of the pyramidal or petrous process
articulates with the sphenoidal and occipital bones.
The temporal bone is anatomically divided into three por-
tions: (i) Squamous; (2) petrous; (3) tympanic. The squam-
ous portion it a thin plate of bone, which when viewed laterally,
FCular in outline. The zygomatic process of the temporal
Iwme has two origins, one anterior to the meatus auditorial
and the other superior to the meatus. The supra-mastoid ridge
is a prolongation of this root, and, as a rule, is situated a little
below the floor of the middle fossa of the cranium. Below the
.' mastoid ridge and slightly above the back of the meatus,
is the spine oi Henle. This important landmark is present, as a
rule, upon examination of the temporal bone. The experience
oi 1 numba of writers would lead 11s to depend upon the sup
mastoid (bsm as a guide to opening the mastoid, rather than a
literal dependence upon the small spine of Henlc.
I he unction ol the squamous R"d petrous portions is called
the squamo-mastoid suture. The mastoid process is situated
ANATOMY OF THE EAR.
23
posteriorly and interiorly to the external auditory meatus. This
is a structure (Fig. 16) of great importance to the student
for herein is located the antrum and mastoid cells. The struc-
ture of the mastoid process varies in childhood and old age.
The external wall covering the mastoid antrum may, as in
Fig. 16.
The Temporal Bone.
H, The spine of Henle; c.s.m. and s.m.s., the two ridges, supra-mastoid and
mastoido-suuamous; L, the lateral sinus; Cond., the bony meatus. (After
Br oca.)
infants, be thin like tissue paper. In one adult subject, it may
be of great density while in another it is of hard, thin bone.
It will be observed that the pneumatic condition, which is usu-
ally found in the mastoid process of the adult, has a great
tendency to disappear in the aged, which accounts for a
loss of bone conduction. The depth of the antrum varies.
Broca, who is freely quoted in the preparation of the anatomy
of the ear, mentions the antrum in one case being situated 11
mm. from the surface, in another case, 15 to 16 mm. and in an
extremely old case, 25 to 29 mm. No fixed rule cax\ V>t fowvA
24
ShS ()!•• iiAR, NOSB ANT) THROAT.
-i . :in anatomical guide to the depth of the antrum. The usual
depth ut the* antrum is from [2 mm. to 1,5 mm.
Mn il,r internal surface of the temporal hone is situated
ir petroui portion, presenting a three-sided pyramidal appear-
ance. It supports and protects more organs of vital importance
Q any other portion of bone in the framework of the human
body. T\u anterior border, assisted by the sphenoid bone, forms
Fie. 17.
J
tininu rmotimi Tin' Mastoid Pii«tiob and Tvmpanum or a Mam
TfOUtrt. (After Grubtr and Hovell.)
I ■JMBtUBI .li'i, mucoid antrum; I'm, mastoid process with l.s, pm-u-
mniic qtacca.
the foramen laoenim medius, the lower part of which is closed
by fibro-cartilage. which is pierced by the vidian nerve, a
meningeal branch of the ascending pharyngeal artery and an
. ary vein. Into the upper part of the outer and anterior
waits open the canal for the carotid artery and vidian nerve
The upper border presents a groove, which lodges the inferior
petrosal sinus; the posterior border lodges the inferior petrosal
sinus and jugular foramen (Bruhl). Through this foramen
pass the glosso-pharyngeal, vagus and spinal accessory nerves,
also the inferior and lateral sinuses, forming the internal jugu-
lar vein. The auditory nerve, artery, vein and facial nc
pass into the posterior and superior surface of the bone, through
the internal auditory canal.
Near the middle of the pyramid on its superior border, an-
terior to the groove of the superior petrosal sinus, a bony
w itomy of the ear.
25
ridge will be note*!, which defines the position of the superior
semicircular canal. External to the ridge is a depression be-
neath which is located the antrum and roof of the tympanic
cavity. Through tin's thin plate of bone, pus frequently p:i
into the middle fossa, as a result of necrosis of the bone. The
pOStertOE wall, which separates the jugular fossa from the
maitoid cells may also be thinned by suppuration, allowing the
entrance of pus into the fossa or involving the outer covering
of the cerebrum at its attachment to the posterior wall of the
pyramid internal to the ridge of the jugular fossa. An ab-
l in this region can be opened and drained without injury
to the lateral sinuses.
Facial Nerve. — At the bottom of the meatus auditnrius
interims the facial nerve enters the aquediictus Fallopii, cutting
Fie. tS.
"X
*..«..
koJbftiftM
VofStmaaSiuS
\
ttrtttd Ar.
Eiiaftictmn
?:
n i
Sii/la.ii MnnSi'
■S
'Si
r Practl
Siape tltas
Facta I 'A'tne
I KMPOHAL I'.- .P.BVe-
■ • . i t. i and outward, making rts exit at the stylo-mastoid
foramen. Two important branches of the facial nerve arc
off in its through the bony structure, the sta-
DISEASES OF EAR, NOSE AND THROAT.
pcdius and the chorda tympani. The function of the
pedins is T < • supply the motor libers to the stapedius mm
The function of the muscles is to lift the hase of the stapedius
out of the oval window. A paralysis of the nerve is usually
followed by a decrease of hearing on that side from the stapedius
being forced into the oval window by the tensor tympani
The chorda tympani is given off from the nerve as it curves
downward into the stylo-mastoid foramen, passing upward
■ad forward across the" tympanum, joining the lingual brand]
of the fifth nerve for a short distance, it then divides, one
branch going to the tongue, and the other to the submnxillary
ganglioo. The sensory fibers of the chorda tympani are vaso-
dilators. The motor fibers antagonize the stapedius and tend
to hold the foot plate in the oval window.
The position of the nerve in relation to the tympanic
cavity is well shown in the illustration. The position of
the facial nerve, after its entrance into the internal auditory
canal, becomes of special interest, on account of its frequent
injury in tympanic and mastoid operations. The course of the
nerve is across the inner wall of the tympanic cavity, and is
observed lying in a bony eminence above the stapes, anterior to
the horizontal semicircular canal, on a plane drawn through
the neck of the malleus and the short process of the incus. A
very thin partition, or wall, separates the nerve from the tym-
panic cavity. The wall is so thin that a sharp instrument
will readily wound the facial nerve. In operating for aba
of the mastoid and the removal of necrotic bone in the tym-
panic cavity, by carefully avoiding this region, no danger of
wounding the facial nerve is incurred.
The Middle Ear or Tympanum. — The middle ear or
tympanum, is a small irregular cavity, oblong in character, situ-
ated in the petrous portion of the temporal bone, between the
external meatus and internal ear. The mucous membrane of
the middle ear is a simple pseudo stratified ciliated epithelium.
closely connected with the periosteum. Within this chamber
are found the malleus, the incus and the stapes, covered
ANATOMY OF Tllli 1:AR.
27
with the same variety of epithelium, wirh the exception of
the ciliated variety, which are lacking to a ureal extent. The
superior portion of the tympanum, beginning with a line drawn
through the short process of the malleus, is the attic and lu»
free communication with the mastoid antrum. The middle car
is of special importance on account of its peculiar structure
Fig. 19.
\nts&
1 he Mucous MtiiiUA.se 0? rue Ixsrn Wall or thb
Tvmimnum or an Auult. x 350. {Sdiuxtlbf. after Iiiunr,tr.)
Itiated epithelium; .', basal eelb; ... connective riant of tba dm
• 1 a nc.
and its relation to the mastoid cells. The attic lodges the
greater portion of the ossicles. It is hounded externally by
Shrapnell's membrane and by a bony wall, and superiorly, by
the roof of the tympanum, which separates it from the middle
cranial fossa. The posterior wall is important, for here is
found the canal connecting the attic of the middle ear with
thr mastoid antrum, called the aditus ad antrum. The in-
ternal wall is in close apposition to the semicircular canal and
the facial nerve. On the superior portion of the anterior wall
ihe tympanic opening of the Eustachian tube.
• The (Mail \t» arc covered with a fold of mucous membrane
which dips down between the ossicles and the chorda tym-
pani nerve." PruSSak's space is formed by such n told rind is
ted between Shrapnell's membrane and the neclc of the
2S
DISEASES 01 BAR, HOSE AND THROAT.
malleus, above the lateral ligament. Small pouches of this
character, efcuated in the attic, often communicate with each
other. We may have suppuration from some portion of the
attic emptying through the superior border of Shrapnrll's mem-
brane or pars 0MB, without involvement of the tympanic ca
Hruhl mentions the likelihood of pus draining from the upper
incudo-malleolar space into the antrum or into Prussak's space
through a perforation in Sfarapnell's membrane, or into the
tympanic cavity, followed by perforation lower down. It ■
for this reason that many cases of chronic suppuration, with
perforation in the lower quadrant of the tympanic membrane,
are slow to therapy. Piercing the tympanic cavity and espe-
cially the roof of the tympanic cavity, are lymphatics and
veins through which infection may he carried to the brain cavity,
causing abscess of the cerebrum or cerebellum, thrombus of the
superior petrosal sinus, sigmoid sinus or meningitis.
The Blood Supply of the Middle Ear is from the tym-
panic branches of the internal maxillary and internal carotid
arteries, stylo-mastoid branches of the posterior auricular, the
petrosal branch of the middle meningeal and a branch of the
ascending pharyngeal artery, which passes up the Eustachian
tube. The veins empty into the temporo-mavillary, superior
petrosal, the lateral sinuses, the internal jugular vein and the
pharyngeal sinus. Numerous small veins pass through the teg-
men tympani, communicating with the veins of the dura mater
( I Vaver).
The Ossicles. — The ossicles arc three in number, articu-
lating in such a manner as to completely connect the mem-
hr.in.i tympani with the fenestra ovalis. The stapes consist nf
a head, neck, two crura and a base. The cartilage-tipped
head articulates with the long process of the incus. The two
rging crura connect th< head with thcbase.which is attached
to the oval window ml of elastic fibers which have their
origin from the periosteum of the surrounding bom structures.
The incut is tinuU rapported in the fenestra between the malleus
and stipes It po iro processes. The short process
is
AN ATOM V OF THE EAR.
20
attached lightly to the posterior tympanic wall. The long
process continues backward, parallel to the malleus and articu-
lates with the stapes by the intervention of the os orbiculare.
The position of the incus and its attachments are of special in-
terest, I'n account oi the ray frequent indication for the re-
moval oi this bono. The malleus is the larger of the ossicles.
It connects die incus and membrans tympani, completing the
Macular chain. It possesea 1 bead] neck and shaft and two
processes, the long and short.
The articulating surfaces oi the ossicles are covered with
hyaline cartilage. The function oi the ossicular chain is the
transmission ot sound waves. " This is effected by oscillation
V'<
0.S
tott o
1 i.illru*; C, neck; Pbr, short process; Phi, long process;
M, iD.inuhriiim ■■ icm; (7, articular surface; h, short
and v. Uuiv; pWKfllli 0 od lenticular ossicle; Cr, head rf llic stapes;
ix, interior; f, posterior limb OB cms; P, plate of the stapes. (After Heldtn.)
of rhe bone or molecular vibration of their particles, or prob-
ahly both " (Kirke). Foster takes exception to the theory of
molecular vibration, believing only in the oscillation of the
small bones.
The stapedius and the tensor tympani are the two muscles
of the middle ear.
The stapedius muscle takes its origin from the eminentfa
pyramidal w: its tendon passes into the tympanum through an
aperture in the apex of the pyramid and is inserted at the V\ca&
3°
DISEASES OF GAR, NOSE AND THROAT.
of the stapes. The nerve supply is from a branch of the
facial nerve. The function of the stapedius is to count
the action of the tensor tympani muscle, preventing undue
pnaOK of the stapes in the oval window, thus regulating
the pressure against the rndolymph and perilymph.
The tensor tympani muscle takes its origin in the posterior
portion of the cartilaginous Eustachian tube, adjoining the
surface of the sphenoid bone and carotid canal and is lo-
cated in a small, bony canal parallel to the Eustachian tube, it
winds about the processus cochleariformis, passes into the tym-
panum and is inserted into the inner margin handle of the mal-
leus. The function of the muscle is to increase the inter-
labyiinthian pressure by drawing the membrana tympani ami
ossicles inward and to equalize the retraction uf the Stapedius
muscle.
According to Politzer, the two muscles "regulate the de-
•)t tension 0l the heating apparatus."
FtC. 21.
'' Latuisintii or the Rjciii Side.
;. The superior semicircular canal; l, the posterior semicircular
8 external semicircular canal; 4, common opening of the superior ami
posterior scinii irml.n etnah; 5. nqueductiu ventlhull; rt, annolurttis cochlex;
7, fovea hcrni-ellipuVa; 8, fovea liemi sphcrlca; 9, scnla tympani; 10, scala-
■ lioldeix.)
The Internal Ear. — The internal ear consists of an osseous
and membranous portion, respectively, named the osseous and
/, S-; p ilia ,' l«| ertoi
MOUctl Ml; 6, scala media of cochlea: ,*, canalis reuniens: *, utricle:
5>. ductus endolymphatic^; 10, ampulla: i/. external acmirircular canal. (After
the lubd e of the brain by way of the sheath of the
auditor)- nerve. As viewed in the ligure (Fig. 21), the osseous
portion possesses a vestibule, semicircular canals (three in num-
ber), distinct ampulla, fenestra rotunda, fenestra ovalis and toawj
3*
UI.SE ASKS OF EAR, NOSE AND THROAT.
ic.-i. '1 hfi osseous labyrinth is lined with .1 tlu'n layer of
periosteum covered with endothelial cells. In the normal con-
ilifion the inner surface is smooth and compact. The mem-
branous labyrinth contains the endolymph and (Fig. 22) is
.iiiilly the organ of perception, tor herein terminates the
auditory nerve, in a manner hereafter to he explained.
I lie membra nous labyrinth differ* from the osseous in this
■■■( t : In place of ;i vestibule, two sacs arc present, the utric-
uliis and the MCCulua, connected by the utriculosaccular duct.
The saccule 1 •nmiminicates with the cochlea bjr means of the
canal 11 reuniens. The utriculus is continuous with th<
circulai C&nal. Within the membranous labyrinth is found
tin endolymph, whose function is the transmission of vibra-
tion previously received from the perilymph, to the audi-
epithclium of the eristic and macula-. The auditory nerve
enters through the foramen auditorium interna;, and there it sub-
divides. One branch passes to the ampulla of the semicircular
I and the utriculus, the other branch to the sacculus
1 be cochlea. It is supposed that the portion of the auditor)'
Ing to the semicircular canals, maculae of the utricle
and of the Bacculac plays a very important part in the control
of the equilibrium of the body. "The portion of the nerve
going to the cochlea carries auditor) impulses only1 (Foster).
Viewed transversely, the cochlea presents three distinct sub-
divisions: (' 1 ) Scala vestibuli, (2) scala tympani, and (3)
canal is cochlearis. The cochlear branch of the nerve passing
Upward through the lamina spiralis ossea distributes terminal
fibers to the organ of Corti. The lamina spiralis ossa or
madiotuSj is a spiral, osseous structure with many perforations,
extending from the base of the apex of the cochlea. From this
median spiral canal, nerve filaments are given off to the spiral
cochlear canal. The spiral cochlear canal is divided into two
spaces by a bony and membranous septa, known respectively as
the zona ossea and the zona memhranacea or membrana basilaris,
the latter connecting with the outer bony wall of the cochlea.
Originating from the zona ossea and extending upward and
AhT ATOMY OF THE EAR.
33
nut \v:in!. g ;i thin membrane known as Rnssnrr's membrane
or mcmbiana vestibularis. The small, triangulst space thus
formed b] mbraoe of Ressner and the memhrana basilaris
is known as the ductus cochlcaris or scaln media and contains
the organ of Corti and endolymph. The organ of Corti is sup-
ported by the membrana basilaris.
Viewed in a cross section, the organ uf Corti consists pri-
marily of two sets of modified epithelial cells, the inner and
_
v. ,^,
".-
I a 3 4
, , , ,i po| | i ,. |i i i ,.
cnnjil .>!' tin.- mndtolu*; ;. modiolus; ■>. irr
mini "i '■■ ■ ■ 'i imina ipli *fi*!
7, scab vvstibuli. (Aftei
outer ro.K oi Corti, and rests DA the basilar membrane. They
unite above and form a membrane supporting upon its inner
and ■ >■ i rt-r aspect, and under the arched membrane, epithelial
cells possessing hair-like pro signaled the inner and nufcr
hair cells; Hcnrath tin hair cells and extending UQWttA *cA
4
0 7
3 4
ik .ir mr Rxem Bowtr mid Uskbiasous Labyrinth. (After Spaltc
P«M**ra vr»iil re; , ivum tympanit ^. fen ffl
5, ductus |in iK mpbatti 118 , (5, tpnlium peril) mphsllcum of the TestlbtttuBI
,*. ductus reunions (Ihnsici); 8, saceulua: y, eealn tympana: ro, scola vop
lihuli: i;, ductus cochlearis; ;/. helicotrcma; i.,\ cecum cupularc; l<, hone
.'4, dura mater enccphali; JO, hccus cndolymphaticiis; ;;, ductus cndolym
iS. ampulln membranacea superioi ro, <liitlu* utriculoaai
jo, ductus Mfnlcii id si pm\ rlor; canalls semicircular!* superior (spa
tiura pcrilyinphatieum): It, utriculus; *j. ductus scmicircularia post
.'I, canalis semicirctilaris posterior (spatium peri lymph aticura) ; tj, ampulla
memlji
leave the spiral ganglion art* stripped nf their medullary sheath
and enter the organ oi Corti as naked axis-cylinders and become
the highly sped&lized sense organs, with the projecting hair
cells oi Corti as their termination. This is especially true of
the inner hair cells.
ANATOMY OF THE EAR.
35
The membranous semicircular canals are three in number and
are the superior, posterior and anterior, all communicating with
the utricle. These semicircular canals are made up of three
distinct layers and are designated the external fibrinous layer,
membranous layer and epithelial layer. The vestibular nerve
which arises from the ganglion of Scarpa situated in the audi-
tory meatus, sends branches to the utricle and to the ampul be
of the three canals. The separate nerve fibers penetrate each
ampulla, which poillt is designate*] the crista ncustica. The
point 03 distribution of the nerve in the utricle and the saccule is
known M the maCUME acttsticti. The hair-like processes at the
maculfl -un-tica, arc covered with small crystals of calcium
carbonate and are known as otoliths, tin- function of which .
presumed to control the vibration oi the hair cells.
Vibration of the endolymph influences the bail cells of the
organ oi Corti in such a W»y as to stimulate certain specific im-
pulses, which are often very complex. These impulses range
from sixteen to forty thousand vibrations to the second.
The Blood Supply. — The blood supply of the conducting
apparatus is derived from the external and internal carotid.
The auricle is supplied by brain lies of the occipital, tin- pos-
terior auricular and a few small twigs from the temporal
,i it, -ries. The internal maxillary artery gives off the tym-
panic and middle meningeal, which supply the greater amount
of blood to the osseous portion of the external canal, the drum,
the mastoid and the antrum. The superficial petrosal leave!
the middle meningeal in the cranial cavity, turns downward
through the petrous portion of the temporal hone and supplies
the malleus, stapes and incus, a branch supplying the floor
of the tympanic cavity and the annulus tympanies. The veins
empty into the external and internal jugular. The external
iuiMilar derives branches from the lobe and auditory canal.
The internal jugular is of special mteresl on account of its
p oximit) to the tympanic cavity. Very often, as demi
strated by Dench, operations within this cavity may wound the
jugular vein. The lymph supply is abundant witlviw \Vi\s
v.
DISEASES OF EAR, NOSE AND THROAT.
on, anastomosing with those oi the pharynx, mastoid, tym-
panuiii and external auditory canal. The arterial supply to
the perceiving apparatus or internal ear is derived from the
infernal auditory, which is a branch of the basilar artery. It
divide*, into two h ranches, the cochlear and the vestibular,
PU1 25.
Tuts.
As the cochlear brand) enters the modiolus it subdivides
at 1 he first spiral turn 01 the cochlea into from twelve to four-
fern twigB. These are successively given off to the lamina
tpiralts ossss, thence to the substance of the lamina spiralis,
I he vestibulary branch accompanies the auditory nerve to the
utricuius and sacculus, being distributed in the form of minute
capillaries.
The Eustachian Tube. — The Eustachian tube (Fig. 25)
is about one and tWO-fifths inches in length, extending from
the tympanic cavity downward and inward through the petrous
portion of the temporal bone to the nasopharynx. The Eu-
stachian tube is divided into an osseous and cartilaginous por-
tion. The osseous portion is about one half inch long and the
cartilaginous portion nearly one inch. I he point of junc-
tion is called the isthmus of the tube, and is 2 mm. in diameter.
ANATOMY OF THE I \K.
37
The cartilaginous portion is funnel-shaped at its pharyngeal
ending. The mucous membrane of die osseous portion is of
the pscudo-st ratified ciliated variety, pointing inward, contain-
ing no glands. The mucous membrane of the cartilaginous
portion is likewise <>l the pseudo-st ratified variety, much thicker
Fie 26.
%
l.m \ ■■ ■■■'•■ \i»ini (Imuml SunrACK).
!!,ilni|- t r 11 11 U ~ 1.1 I hi .mm !■ . i. gterUO-fl
sroiipi ; J. itlatii] of ll il jugular ctuun; ••. H4W0
■1.1 gland (internal giaup, internal jngulai > • ■ ; f, sub-hyoid ab. 1
i phased in the iour« of llic cfTetrnl vc*»cl* of llic siil.niriU.il glands.
than that found in rhc osseous portion and contains goblet
cells and lymphoid tissue. At the pharyngeal orifice the
blood supply is greater and the mucous glands are numerous.
'I*he cartilage proper of the tube is shaped after the m.n \tu
the letter "S" reversed and forms the posterior wall, the
upper border bending downward and forward. l'"ihsw» «c\&
3*
Dl&HASBS OF EAR, NOSE AND THROAT.
muscular tissue fill up the anterior space completing the canal.
The mucous membrane, with the exception of the upper half
of the tube, is in contact, forming irregular valves. The
function of the Eustachian tube is to conduct air to tin
tympanic cavity and to act as a drainage canal for the middle
rar. The muscles of the tube are abductor or dilator of the
tube, sphcno-salpingo-staphylinus ( tensor-pal ati mollis) and
the levator veli palati. The salpingo-pharyngeus is a thin
muscular layer, classed by some as fascia, connecting the pos-
terior pharyngeal end ot the cartilage with the posterior wall
of the pharynx. The abductor muscle arises from the inferior
surface of the sphenoidal bone, pterygoid process and the car-
tilage of the tube. It passes downward attaching itself along
the convex border of the outer cartilage along its entire length,
ending in the soft palate and side ot the pharynx. The func-
tion of the muscle is to assist in opening the tube. The
levator veli palati originates on the lower surface of tin
petrous portion of the temporal bone, at the border of the
entrance of the carotid canal. It is attached to and parallel
with the floor of the membranous portion of the canal and ends
in the soft palate. Its function is to assist in shortening and
widening the tube.
Lymphatics. — The deep cervical chain (Fig. 26) is the
great conducting lymphatic of the external ear, mastoid gland -
and auditor) canal. The position of the chain of gland) k
beneath the sterno-mastoid muscle and in the subclavian tri-
angle.
Conducting vessels empty into this system, according to
Poirier, Cuneo and Delamere. from the tongue, part of the
oaso-pharynx, all the lymphatics of the middle and inferior
portion of the larynx, the vault of the palate and soft palate.
nasal fossae and cervical portion of the trachea.
By a Btlldy of the illustration, we can understand how
in infection of the organs enumerated we have enlargement
i.t the lymphatic glands of the neck. Some of the lymphatics
of the tympanic cavity and Eustachian tube empty into the
mro-nharyngeal glands.
CHAPTER III.
THE NOSE AND NASAL FOSS-ffi.
"lit ii nose is the beginning of the respiratory tract and is
Situated in the median line of the middle third of the face.
Two subdivisions are at once apparent, viz.: anterior narcs and
nasal fossa. It possesses two parallel chambers, opening an-
teriorly to the nostrils and communicating posteriorly with
the naso-pharv nx. The lateral surfaces of the external nose
are triangular, although it will be observed that racial charae
(eristics play a conspicuous part in moulding the shape of the
Fie. 27.
SESAMOID
CARTILAGES"
-CARTILAGE OF SEPTUM
-UPPER LATERAL CARTILAGE
-LOWER LATERAL CARTILA&E.
n08e< At the root nt the nose or at the joint of articulation
with the frontal bones arc the two nasal hours and thr two
nasal processes of the superior maxillary hones. Below and
outward on the lateral surfaces arc situated the upper and
lower lateral cartilages. Posterior to the lower lateral car-
tilages are the sesamoid cartilages, below which are situated
the cell tissues, covered externally with normal skin. The
nerve supply is from the nasal infra-trochlear and infra-orbital
39
DISEASES OF EAR, XOSE AMD THROAT.
Fig. i8.
Sagittal Section or the Ueah.
■vct turbinated body; t, middle turbinated body; J, superior tur-
MnaU • -M.ild cell; 5, ostium tuba; t. anterior extension ol
THE NOSE AND NASAL FOSS/E.
■»'
nerves, with bunches from the facial nerve. Sebaceous
glands are freely distributed over the .surface. The base
of the nose presents two apertures separated by the sep«
mm. extending Mltero-posteriorly. The septum is formed by
the perpendicular plate of the ethmoid bone, the vomer and an
anterior cartilage, hyaline in character. The attic, or roof,
i-v rnrnml In the horizontal plate of the ethmoid, nasal bone
Fig. 29.
Kiwion or Ciiii.u's Nose.
!•, tunica propria; c, ftuhmticotis connective
rkici "i gland* opening on fret Miriace; f, III I v. •,*]*.
! Ml.
nasal spine of the frontal bone. The posterior portion of
the n niiKil by the anterior wall of the sphenoidal cells.
The OUtei trail is formed by the frontal, ethmoid, lachrymal
ones. Three distinct scroll-shaped irregularities
are observed on the outei walls of the nasal fossa, the superior,
inferior and middle turbinated bones (conchse nasi) (Fig. 28).
The niperioi turbinated bone is situated far back in the
' attic chamber. The meatus of the superior turbinated
bod\ dosed in front, opening backward into the spheno-
ethmoidal recess. The middle turbinated body is somewhat
lower down and extends inither forward. The meatus is
4*
DISEASES OF EAR, NOSE AND THROAT.
open its entire length and on account of the numerous ostea
opening into it, becomes an important structure in nasal diseases.
The Lower turbinated body extends practically three-four rh>
of the length of the outer wall of the nasal fossa. The
meatus extends backward and downward. It receives the
ii ret ions from the lachrymal gland and duct. Its connec-
tion with the floor of the nose makes it an important drainage
canal of the nose. The first two turbinated bodies are ex-
tensions of the ethmoid bone. The lower turbinated bone is
.1 distinct bone, articulating with the superior maxillary, and
varying in length from 20 to 50 mm. The recesses below the
turbinated bones arc correspondingly called superior, middle
and inferior meatuses. The nasal cavity is divided regionally
into the vestibular, respiratory and olfactory regions and the
accessory cavities.
Reeinning with the vestibule, which is that part of the
nose opening anteriorly, is the Schnciderian or pituitary mi
branc, otherwise known as the mucous membrane, which is
continuous with the accessory sinus and Eustachian tube.
The vestibular region is covered with stratified pavement epi-
thelium, which contains sweat and sebaceous glands and nu-
merous hairs or vibrissa;, which guard the entrance. Slightly
below the entrance, the glands and hairs gradually disappear
and the mucous glands appear. The respiratory region be-
. relatively speaking, at the anterior end of the lower tur-
binated bone, extending upward as far as the edge of the
perior turbinate. The epithelium changes at the inner margin
of the vestibule to the pseudo-stratified ciliated variety con-
taining goblet cells. The tissue covering the surface of the
r turbinated hone is irregular in outline and contains
cavernous spaces of erectile tissue. The mucous, serous and
lymphatic glands are present in great numbers. The mucous
membrane is, in consequence, much thicker and more vascular
than that of the olfactory region. The mucosa of the middle
turbinated bone gradual h changes in density from its lower
border upward and contains a lessened amount of blood supply
ami cavernous tissue.
THE KTOSR .AND NASAL FOSS.'E.
43
The olfactory region is that portion of the nasal fossa above
the dependent portion of the superior turbinated bones. The
epithelium covering this region, both septa] and turbinal, is
made up of a single layer of cylindrical cells, the nuclei of
which lie at different levels (Szymonowitz and McCallum)
and differs distinctly in color from that observed in the res
piratory region, being of a yellowish tinge rather than of a pale
pink. The mucosa is thin and, to a certain extent, non-
vascular.
According to John A. Fordice. " the mucous lining of the
oral and nasal cavities and the conjunctiva is developed from
the ectoderm and is therefore not a true mucous membrane-
hut resembles in structure the skin rather than the true mucosa
of the deeper digestive tract which takes its origin from the
rndoderm. The diseases of the oral and nasal cavities are, there-
fore, logically related to those of the skin, because of the com-
mon r-mbryological origin of the respective tissues. The outer
layer of the epidermic covering of the mouth, which consists
of stratified squamous cells and is continuous with that of the
skin and pharynx, is kept constantly moist by the mucous and
salivary secretions. The cells, unlike the stratified horny layer
of skin exposed to the atmosphere, do not lose their nuclei
as the surface is approached. On the lips, where the skin passes
into the mucous membrane, the epidermis becomes greatly
thickened, while the connective tissue grows thinner. The
hair follicles disappear but the sebaceous glands persist near
the angle of the mouth and in the upper lip."
The Olfactory Nerves. — The olfactory nerves enter the
al fossa through the cribriform plate of the ethmoid bane
by twelve or more branches from the olfactory bulk They are
subdivided into three portions, the inner, middle and outer,
The inner portion is distributed to the septum at its upper
third, the middle portion to the roof of the nose, and the outer
to the surface of the superior and middle turbinated bone and
the anterior surface of the ethmoid bone in front of them
(Gray).
\\ i i
iWING *HI
I \Iim irt*rftm4l and L*«aK)
well K» the im<Mlc Uirbiaal: .1 b, brantlm
»t the potrtenor end ot llic lowc:
! ih idjc
f «|m> mtiMlf 1 i .. ! cha la
,ihmai>lft1 »rtc:y: f. x
wtlb '" (be posterior
MMl i»l»tine fonurn with
1 ||i rid ,! I '" upplj the mucosa with a serous
. moiHI -in. ! in a condition (f)
ti will be noticed that a
dryini up ol !i i '""«> &tronh> oi the small elands
THn KOS£ .WD N'ASAI. FOSS/E.
45
bn
go
<)7 obstruction <il tlie lumen of the ducts from active or passive
li\ pc-rcniia. is a potest cause of anosmia.
The Nasal Nerve. — The nasal nerve, which is a branch
oi the ophthalmic division of the fifth nerve, passes into the
nasal fossa through the slit at the side of the crista galli, thence
downward an i, supplying the sensation to the tip
of the POSe and to the outer surface of the anterior nares and
septum. Branches from the anterior palatine are distributed
to the inferior turbinated bone and its meatus. The superior
nasal nerve supplies the middle and superior turbinated bone,
t lit- posterior part of the septum and the posterior ethmoidal
The nasopalatine, a branch of the Meckel's ganglion,
supplies the middle portion of the septum. The vidian nerve
unites with those from Meckel's ganglion. These nerves are
part of the sympathetic system. The sphenn-patatine of the
sympathetic (Meckel's ganglion) sends branches to the upper,
middle and lower turbinated bones and to the posterior por-
tinii oi the Septum. The anterior palatine nerve extends itself
ird upon the middle ear and inferior turbinated body.
The fibers control the vascular and secretory system of the
The antcro-superior dental branch of the su-
perior maxillary nerve supplies the inferior turbinated bodies
and the inferior meatus.
The blood supply of the nasal fossa is from the spheno-
palatine artery, a branch oJ the internal maxillary. Tun
branchrs are given off from the spheno-palatine. the internal
>ing to the septum and the external to the lateral walls,
ethmoid cells, frontal -inns and antrum of Highmore. The
anterior and posterior ethmoid arteries, subdivisions of the
ophthalmic. suppK short branches to the attic, ethmoid cells and
frontal sinuses. Tin superior coronary sends short branches
to the anterior portion >>f the septum. The descending pala-
.vhich is a branch of the internal maxillary, sends branches
to the posterior region of the outer wall.
The veins of the nasal cavity form a plexus beneath the
mucous membrane, emptying into the pharyngeal ptaojft, w^\x-
\6
DISEASES OK EAR, NOSE AND THROAT.
tlialm i vein, veins emptying into the superior
longitudinal linus and the intra-cranial vein.
The lymphatics are very numerous. They cover the sur-
face, forming a continuous network. They are more numer-
ous over the posterior part of the middle turhinatcd body.
There are two connecting trunks, anterior and posterior. The
lie. 31.
"
It' I I m. I- II
•i b. 1 -'lienl elands; <•, lnterro|>ting glandular nodule, pi.,
tiic tonne of the afferent veaael* of these gland*; ./. gland «l tbe deep cer
chain; e, efferent veuvl of retro pharyngeal gland*, poMing in front o;
internal carotid artery; /. afferent of I lie letro -pharyngeal «land» paaaSllg
behind the right retina capitis •■ 11 ; r. lymphatic of t tic pharynx.
ptMing directly to a gland of the deep cervical chain; h, afferent Of the
retropharyngeal gland. < Iftl I MJtM end Drlomrrt.)
anterior trunk, aCCOfding to Poirier,. Cuneo and Dclamere,
tonninata in tfaa rabmaxillaxy glands. The posterior trunk
" const itutes thr principal lymphatic channel of the nasal fossa?.
They take their origin 11 the junction of the nose and naso-
_
THE NOSE AND NASAL FOSS^. 47
pharynx and empty into the retro-pharyngeal glands. A de-
tailed study of the lymphatic system is necessary to a thorough
'appreciation of the constant absorption into the lymphatic sys-
tem of diseased products from the nasal cavity and their influ-
ence upon the health of the individual."
CHAPTER IV.
ACCESSORY SINUSES.
I'jik accessory sinuses of the nose arc those cavities or pneu-
matic air spaces which arc in direct relation, by one or more
Opening!, with the nasal cavity. They consist of two frontal,
two ethmoidal and two sphenoidal sinuses, with two antra
of I [ighmote (flinus maxiilaris). The mucous membrane cov-
ering the sinuses is of a pseudo-stratified ciliated variety and
pole pink in color. The mucous membrane lining the cells
k iii direct opposition to the bone, varying in thickness in the
different sinuses. The mucous glands of the epithelium arc of
the simple tubular variety.
The function of the accessory sinuses is principally to lighten
the weight of the skull ami to contribute an uncertain influ-
ence to the resonance of the voice. As the mucous surface is
supplied with glands and a plexus of blood vessels, a certain
amount of mucus is furnished to the surface of the nasal cavity
and contributes moisture to the inspired atmosphere. The
theory of Halle, of Berlin, is that the air passing in and out of
the nose sucks out the air and secretion within the Btnu
In making a lateral section of the adult skull, as shown in
the accompanying illustration (Fig. 32), the frontal sini
are first presented for observation. At the end of the first
; the two halves of the frontal bone unite at the fru:
SttturO. About this time the frontal sinuses begin to develop
The general opinion is that these sinuses are not formed until
alter the eighth or tenth year. (See Embryology of Nose.)
The frontal cells are normally two in number, though ex-
ceptionally] thej may be entirely absent or consist of only one
cell, varying in size. The two normal cells are separated by
ACCESSORY SINUSES.
•I"
B thin mesial septum. There is seldom any connection between
the two cells. Occasionally one or more perforations are ob-
served in tlie thin septum. Perforations of this character
and faulty development are in accordance to a law of cmhry-
ological development. In the Caucasian the cells are more
Fig. j*.
'
ii
: .'. rectus spin- .!, cellul* ethmoidals
poatcrins; 4. cellular ethmoidal!* anteriun; i, sinus frontalis; 6, ductus naso-
fcDiiialin; 7, ia&indibulutn; h. bulla ethmoidal!*; p, hiatus semilunaris,
|inxtHii> nnrinatin; rx, concha Inferins; / tuba Euatachioa; 13, meatus
super.
developed in men than in women. The marked irregularity
..1 1 In- cells can h shown by Wood's metal cast, which is made
by melting a preparation of lead and pouring it into the sinuses
through a small opening at the superior extension of the si'hum ■-,
the naso-frontal duct being primarily closed. The boat \»
5©
DISEASES OF EAR, NOSE AND THROAT.
afterward exposed to a solution of caustic potash and after
boring softened, is dissected from the cast. The same process
may be carried out in securing casts of other sinuses or of the
middle or internal ear.
28
Fie. j3.
27 20 25
29
-I
->3
36
10
8 9
The Kkmtion op Tim Accessory Sinpsm to the Bare op the Skull, Viewed
p«om tub Cranial Cavity. (Aftei K ilium.)
1, Trochlear nerve; t, oculo-mntoi nerve; ,;. trigeminal nerve; 4, abduccui
j }, sella turcica; 6, abducens nerve; 7. oculo-motor nerve; 3, trigeminal
nerve; p, region of hypophysis cerebri; 10. trochlear nerve; ;/, trochlear nerve;
It, cavernous sinus; 13, right sphenoidal sinus; 14. frontal nerve (trigta.);
r$, ocuto-motor nerve; 16, cell of highest meatus; tj, superior nhlirjup; it.
levator palpebrzr supcrioris; /<?, superior rectus; jo, upper intermediate cell
• 1 <1 1 c meatus; it, ascending cell of superior meatus; it, orbital recess of
(rental Ainu*; }}. fourth frontal cell; 14, second frontal cell, J$. frontal sinus
(third frontal cell); t6, superior longitudinal sinus; -V. frontal sinus (third
frontal cell): tS, olfactory fissure; fO, anterior ethmoidal vessels and nu
jo, upper intermediate cell of middle meatus (cell of ethmoidal bulla/ ;
ascending cell of superior meatus; 31, cell ol highest meatus; 33, po*i
ethmoidal vessels; $4, sphenoethmoidal recce; 35, optic nerve; 36, left
sphenoidal sinus.
52
DISKASKS OF BAB, NOSS '.Mi THROAT.
I
Two surfaces of the frontal bone are presented, the outer
and the inner. On the outer surface, above the roof of the
nose, fn a median line, is situated the glabella. To the right
and left of and below the frontal eminences, are situated the
superciliary ridges. Their convexity at the junction of the
glabella is often very great. This convexity gradually fades
away as they arch upward. The comparative size of the eon-
vi vity of the glabella and of the superciliary- ridges is an indi-
cation of the size of the frontal cells, which :ire situated immedi-
ately beneath them. The cells are bounded posteriorly by the
inner tabic.
The ophryon is the concavity situated above the glabella
and indicates the median vertical extension of the sinuses. The
floor of the frontal cells is formed by the orbital plate of the
frontal bone curving upward and outward in conformity with
the supra-orbital ridge. The inner table and the floor of the
sinuses are very thin and in the young are susceptible to marked
J intension from exudation. When in this condition they crowd
uutward into the orbital cavity or displace the floor of the
ethmoid cells downward into the nasal cavity.
The Ostium Frontale or the Fronto-Nasal Opening.—
The opening is funnel-shaped and is situated at the inner and
most dependent portion of the floor. The wall of the thin
septum forms a part of the canal. The natural course of the
canal is slightly backward and downward. The nasal opening
is situated beneath the middle turbinated hone in the anterior
middle meatus. The fnfundibulum, as shown in the figure
iiml as described by Gray, is a long flexus canal, situated an-
teriorly to the bulla ethmoidalis and on the outer wall of the
middle meatus. It is often found immediately connecting and
forming a part of the fronto-nasal duct. Its mission is to
act as a drainage canal for the anterior ethmoidal cells.
The Ethmoid Cells. — The ethmoid cells (cclluUe eth-
moidalis) begin to develop five years after birth and are di-
vided by some authorities into three sets, anterior, middle and
posterior, and by others into two sets, the anterior and pos-
The Accesaoiy Sini-sks is Their Rklvtion to thk N'aml Fqux.
(Alter
;. Palatine nerves n I '. maxillary sinus: 3. alveolar recess of
maxillary sinus; 4, floor of nasal cavity: JS. lower margin of inferior turlmi.il
hone; 6, opening of lachrymal canal; •, basilar lamina of lower lurbinal bone;
S. prelachrymnl recess of maxillary sinus: t>, opening of maxillary sinus: 10,
iitfundihulum of middle- meatus; it. ethmoidal bulla; 1;. first frontal cell:
13. second frontal eel • tier's space: 1$, frontal »inu- (tbjrd frontal
celli. rcccM «f middle meatus; tf, opening o! Frontal alnua) U,
i v. 111111li1.tr « <-l I "f iiiiilill. mi. .In. 1,,
, ascending cell of superior meatus; il highest mentos:
u, sphenoidal sinus: 1$, opening oi sphenoidal rinus: .•,'. highlit antrum; t$,
irbinal bone: lt>, superior meatus; .<;. basilar lamina of middle UkV
btui bone; tS, lower margin of middle turbine.1 bone.
54
DISEASES or EAR, NOSE AND THROAT.
tenor. Turner defines their position more dearly when
says: "All the cells- which communicate with the meatus
of the nose, below the line of the origin of the middle tur-
binated hones, are anterior ethmoid cells, and those which
communicate with the superior meatus above the middle tur-
binated bones are posterior ethmoid cells."
The lateral mass of the ethmoid bone, containing the eth-
moid cells, is bounded anteriorly by the lachrymal bone and
nasal process of the superior maxillary, and posteriorly by the
sphenoid and turbinated bones and the orbital process of the
palate bone. The outer wall is formed by a thin perpendicular
plate, the os planum. The lamina eribrosa forms the superior
boundary and separates the nasal and cranial fossa?. The
internal wall, which constitutes a part of the upper and outer
wall of the nasal fossa, is formed by the middle turbinated
bones. The superior and middle turbinated bodies are the inter-
nasal projections of the ethmoid bones, differing in this respect
from the lower turbinal, which is an independent bone articu-
lating with the superior maxillary bone. The middle turbinate
bears the greatest pathological relationship to the ethmoid cells.
Within the middle turbinated body, which normally consists
of thin scroll-shaped bones, are sometimes found cells resem-
bling histological structure. In one thousand cases observed
by Lattison, ten contained cells. The cells are formed more
frequently in the anterior half of the middle turbinal. They
may exist independently or connect with one of the ethmoid
cells. The ostia of the turbinal cells may open on the ex-
ternal surface, cither in the middle meatus or the lateral ridge.
The cells arc susceptible to disease, varying in no respect from
the pathology of sinusoidal infection. The relative position,
size and number of the anterior air spaces of the ethmoid body,
will van' from one to five in different individuals. They usu-
ally consist of one or two chambers, although cases have been
noted in which seven or eight have been found (Turner).
As a general rule, the anterior cells outnumber the posterior.
The communication of the anterior cells with the middle
ACCESSORY SINUSES.
55
meatus, is through several small ostia. The ostia of the an-
terior cells open into the intundibulum and drain into the
hiatus semilunaris, which is directly beneath the bulla eth-
moidals and above the uncinate process of the ethmoid bone.
The ostia of the posterior cells open directly into the superior
meatus. In a normal skull the posterior ethmoid cells extend
downward from the attachment of the middle turbinated bone
to the thin wall separating the sphenoid cells. As a rule, there
is no communication between the ethmoid antrum and the
sphenoid cells.
The posterior ethmoid cells, composed of one, two or three
spaces, varying in size and position, open into the superior
meatus through one or both ostia. The mucus and pus from
the posterior ethmoid cells may, according to the position of the
head, drain backward over the posterior surface of the middle
turbinated bone into the nasopharynx or flow forward over
the anterior margin of the middle turbinated bone.
The general shape of the posterior cells may vary in indi-
viduals, sometimes extending into the sphenoid bone forming
;i sphenoethmoidal cell, As a rule, the posterior cells open
from one ostium situated in the superior meatus. The mu-
cins membrane covering the ethmoid cells is of a stratified
ciliated variety, containing mucous glands.
'I lie bulla etlunoidalis is situated in the meatus semilunaris,
and is part of the anterior ethmoidal cells. It is a small, round,
boOJ prominence, with the convexity downward and forward,
ne or more cells which open on its superior sur-
face into the middle meatus.
The Sphenoid Sinuses. — The sphenoid sinuses are two
in number, n the .interior portion of the body of
the sphenoid hone below and anterior to the optic commis-
sure and posterior to the ethmoid cells. Separating the two
cavities is a vertical bony septum. The sinuses are fully formed
about the tenth year of life. The cavity is irregular in form.
Its transverse diameter corresponds to that observed in the
posterior wall of the ethmoid cells. The height of the cells
varies from six to twelve mm.
5^ DISEASES OF EAR, NOSE AND THROAT.
Fic. 36.
•
^^^^v ^VT^fr*r~l
1 '*m£ V
V^3K\tf «• ^B^^^jb
\ %.'■»■
ft! rv TC>fM
\1\ - *
1
\V - -^
1 -i_ i-
S
agityai. Section m Si Showjxc a F mem ax's Sphenoidal Doucie
Position.
IX
The plate of bone separating the cells from the cranial
iv is very thin, often less than one mm. It will be observed
that the more dependent portion of the floor of the cell is lo-
cated at its junction with the ethmoid bone. The ostium is
situated in the anterior wall above die floor, draining into
ethmoid recess. The thickness of the wall vanes
iii individuals. As a rule,- it is very thin and easily perforated.
epithelium covering the sinus is the same as that found in
the edunoid cells. The position of the sphenoid cells is of
especial interest Jrom a surgical standpoint, on account of the
important organs in dose proximity.
Above the cells are found the optic commissure and pitu-
dy. The internal carotid, cavernous sinus, superior
maxillary nerve and ophthalmic vein, all pass near the lateral
wall.
The Accessory Air Cells of the Sphenoid Bone. — The
-sory air cells of the sphenoid bone have been especially
ribed by Hajek and Zuekerkandl. H. Bcman Douglass
and others in his country have called special attention to the
i rtance o! the small accessory sinuses situated in
the Wing of the sphenoid bone, distinct from the sphenoid
cells proper and emptying into the posterior cell or iccesses
ipheno-ethmoidalis.
The great importance of the knowledge of such accessory
.:; in those cases <>t suppurative inflammation
of the if 'uch we are reasonably
■ i-rtain to have cured but from which a purulent discharge still
That rlii- cells are easily located or may be opened
out danger, is t" state a had proposition and the young
operator would lx under such circumstances to trust
the operative ■ to men skilled in the surgical technique
of this region.
The Maxillary Sinus. — The maxillary sinus or antrum
of Highmore is formed during feral life by a process of evagina-
rinn ot the mucous membrane and absorption of bone within
the upper jaw. This continues up to about the twenty -ftirk
year of life.
ACCESSORY SINUSES.
59
At birth the antrum is simply a vertical slit in the maxilla.
The mucous membrane is like that of the respiratory region
of the nose and is of the pseudo-st ratified variety, containing
goblet cells. The inner layer is in direct opposition with the
■ acting as a periosteal covering. The avenue of communi-
kJv
I
=5T
II 10
Vimicai. ( < Tins thsovmi both Nasal Cbambbm and Maxillary
j, Su'.cui oil" act.; .*, posterior ethmoid cell; .?, frontal ainus; 4, optic nerve;
5, posterior ethmoid cell; 6, middle meatus; ,». middle turbinated tody; X.
maxillary ainus; turbinated body; 10, firs' molur; it, nasal aevlum.
Turner.')
■■■■ ;th the nose is through the maxillary ostium (Fig,
37) situated within the middle meatus. The size of the ostium
varies in individuals. Its location is just beneath the roof of
the antrum. The maxillary antrum may be provided with
more than one ostium, due to an accident in cmbryological
growth.
The average dimensions given by Turner, are: Vertical
CHAPTER V
THE FUNCTION OF THE NASAL AND ACCESSORY SINUSES.
I hi-, function of the nasal and accessory cavities, as de-
scribed by Burnett, are (i) respiration, (2) olfaction, (3)
resorption of the voice, and (4) regulation of the atmospheric
pressure in the middle ear.
The air, as it passes through the nasal cavity, is warmed,
moistened and purified and is thus prepared for reception into
the lungs. Moisture is furnished from the mucous surface;
heat is generated by the muscular activity of the body; The air
is purified by the long hair of the vestibule, which acts as a
sieve. Abnormal atmospheric pressure upon the mucosa of the
nose and naso-pharynx, will disturb its molecular equilibrium
and quickly affect nutrition of the Eustachian tube and pneu-
matic function of the middle ear. The reflex action of sneez-
ing and a slight bactericidal property of the nasal secretion,
an! in preparing the air passage into the lungs. The sense
of smell, in enabling us to avoid noxious air, also aids greatly
in respiration. Since inspired air demands such radical altera-
tion before entering the lungs, it is at once apparent why
month-breathing is so detrimental to health. We can also
Conclude how quickly an alteration in the size of one or the
other of the nasal cavities, sufficient to prevent the air from
reaching the greatest possible surface of the cavity, may also
. ribute to a disease of the upper and lower air passages.
The respiratory region of the nose is not a fixed one and de-
pends upon the shape and size of the nostrils.
Many expeiimenters believe that the respiratory current
t-s above the lower turbinated bone. e\en to the olfactory
region, tatlu-r than below the turbinated bone, as is so often
descr
61
6i
DISEASES OF EAR, NOSE AND THROAT.
The quality or timbre of the voice depends greatly upon the
character of the nose and accessory cavities. Any interfer
cnce with the sound waves, in their passage through the nose,
destroys the natural resonance of the voice. To a great meas-
ure, the size of the accessory cavities affects the quality of the
voice.
The olfactory sensibility is necessarily dependent upon the
normal condition of the mucosa f<>i jitniospherie waves to pro-
ducc their impression upon the hair cells of olfaction. The
sense of smell is dependent upon the olfactory nerve with its
fil. Mucinous distribution over the mucosa lining the upper pari
of the septum, the attic, the superior and middle turbinated
bodies.
Olfaction is dependent not alone upon a normal condition
of the nerve but upon the bony structure of the ethmoid bone
or cribriform plates of the ethmoid and raucous membrane
through which it must pass to reach the periphery. Con-
genital and acquired deformities of the intra-nasal Structure
frequently interfere with the function of the olfactory nerve.
Suppurative inflammation of the accessory sinuses and nasal
cavity may involve the mucous membrane surrounding the
auditory filaments, partially destroying the hair cells of the
olfaction.
Within the vestibule of the nose are a number of short
hairs or vibrissa, the function of which is to act as a filter for
the inspired air. Within the region are found sebaceous
glands emptying into the hair follicles and at the level of the
cartilage, mucous glands. The function of the glandular sc-
i retinii is to moisten the surface and lubricate the cilia.
Within the tunica propria of the olfactory region of the
nose, arc situated Bowman's elands, which are tubular glands
lined with round pigmented epithelium, secreting mucus.
They sometimes extend into the respiratory epithelium of
the nose.
Within the respiratory mucous membrane of the nasal cavity
are situated the muciparous glands, the function of which is to
.; *, ala of none; .;. anterior pillar of fauces; 4, recess of fauces;
M pillar of fauces; 6, tongue and median raphi; 7, tonsil: S, posterior
wall of tbc pharynx; v, uvula; 10, soft palate; 11, hard palate; is, anterior
nam. (After Dtover.)
The ttfnl secretions are slightly antiseptic, exercising a
mild germicidal influence upon bacteria, which are constantly
present in the nasal cavity.
64
DISEASES OF EAR, NOSE AND THROAT.
Normal respiration is through the nose. Warmth k gen-
erated sufficiently to bring the inspired air up to " blood beat
during its passage through the nose.
The Pharynx. — The pharynx is that portion of the res-
piratory tract posterior to the nasal fossa and buccal cavity,
anterior to the cervical vertebrae, bounded above by the basilar
Ftc. 40.
1 9 ? T
7— I
: Wall or \iie Pharynx. (After Lmchkj.)
Splendid; I, vomer; ,;, posterior end 01 .. nit •■dgr of
U n.iinl.iT»ne: 4. 41. opcnjnii of Eustachian tube; 5, opening of median
or bursa I'haryngca; 6. (/. rcccacui iilmryinfeiis lateralis; 7, adenoid
• I pharynx.
process of the occipital bone and extending downward to an
imaginary horizontal line drawn through the base of the
cricoid cartilage and sixth cervical vertebra; and is continuous
with the esophagus and larynx.
The blood supply is derived from the external carotid artery-.
The facial artery gives off the ascending pharyngeal, the ton-
sillar and the ascending palatine. The superior thyroid is
distributed to the upper portion of the larynx and the inferior
thyroid to its lower portion.
The pharynx is subdivided into the nasopharynx, the oro-
pharynx, and the laryngo-pharynx. The nasopharynx Ex-
tends to the edge of the soft palate; the oro-pharynx from
this to a line drawn through the horn of the hyoid bone; the
laryngo-pharynx extends; from this termination to a plane
drawn through the base of the cricoid cartilage.
The mucous membrane covering the naso-pharynx is of the
stratified ciliated variety. The oro-pharynx is lined w iih
squamous epithelium, and the laryngo-pharynv with squamous
and ciliated epithelium.
The stratified squamous variety of epithelium covers the
vocal cords, arytenoid cartilages, columnal cartilage and the
remaining portion. The conglomerate and follicular glands
arc both numerous in the naso-pharynx. The conglomerate
glands are numerous over the pharyngeal surface of the soft
palate and the posterior wall of the Eustachian meatus.
The follicular elands, or the tonsil of Luscka, often spoken
of as the third tonsil, occupy the vault of the pharynx and fre-
quently extend downward, encroaching upon the Eustachian
Orifice. They are present at birth but should undergo atrophy
about the tenth year of life.
kosenmullei's fossae are situated on each lateral wall of
the pharynx, about midway between the Eustachian orifice
and the post-pharynea) wall.
I he function of the naso-pharynx is that of a resonant cham-
ber for voice modification, the preparation of warm, moist air
tor the middle car and lungs, and drainage for the nasal cavity.
The mucous membrane of the oro-pharynx is supplied with
COW glands. Two important glandular structures, which
part ">f Waldyer's Lymphoid ring, the pharyngeal and lin-
gual tonsils, are present in this region of the oro-pharynx.
The posterior opening of the mouth and connection with
the oro-pharynx. arc called the fauces or isthmus faucium
( Fig. J9)« Within ibis chamber and constituting a part
thereof, is the uvula, which is a part of the soft palate,
the anterior and posterior pillars, the two pharyngeal tonsils
UN OF WAUIEVK'S LvmPKATIC RlXC AKD ITS C'ONHKCTIOM WITH TBI
Lymphatic Gi-*i«i>i"t-*B SvsriM. (A (let Elcot and Lamb.')
l, V- i.ii.i; J, lateral pharyngeal; 4, behind stcrno-
mantoid; 5. bifurcation; 6. in front of gtcrno-mastoid; 7, angle of jaw; t,
nyoid; o. subhyoid; />. pharyngeal; t, tubal; a, feudal; /, lingual KM
The anterior pillar of the fauces is formed by the palato-
glossus muscle, which has its beginning at the palatine aponiw
rosis and its ending at the side and hack of the tongue. The
••ritir pillar is formed by the palato-pharyngeus muscle,
win iruni the soft palate, passes downward and back-
FUNCTION OF NASAL AND ACCESSORY SINUSES.
67
ward from rhe tonsil, joining the stylo-pharyngcus and with
that muscle is inserted into the posterior border of the thy-
roid cartilage, under the superior cornu. The epithelium cov-
ering the two pillars is n continuation of that of the oral and
pharyngeal cavity.
Lingual Tonsil. — At the base of the tongue, above the
glosso-epiglottic fold and back of the circumvallate papilla?,
is situated the Lingual tonsil, which is composed of true adenoid
tissue, secreting a serous and mucous liquid. Small crypts,
lined with stratified pavement epithelium, are discernible
throughout the tonsil. On account of its peculiar position,
irritation of this region is frequently observed. In disease
of the lingual tonsil, large, venous blood-vessels or varices may
be frequently observed covering the base of the tongue and
lingual tonsil.
The Faucial Tonsils. — The tonsils (amygdala?) are two
in number and are situated on either side of the fauces between
the anterior and posterior pillars. Their size is variable. They
arc composed of true lymphoid tissue, being a part of Waldyer's
lymphoid ring and are almond-shaped in character. On the
inner side are twelve to fourteen openings or follicles, covered
with stratified epithelium, which dips down into the glands.
The nerve supply is from Meckel's ganglion and from the
HO pharyngeus. The arterial supply is from the facial,
which gives off the lingual, palatine and tonsillar, the ascend-
ing pharyngeal from the external carotid, the descending
palatine and a sprig from the small meningeal, both being
branches from the internal maxillary. The most impor-
tant artery of the ton-.il and the one from which hemorrhage
is most frequent, is rhe tonsillar, which enters the tonsil near
the center of the attachment to the lateral wall. The severe
hemorrhage following tonsillotomy or tonsillectomy is usually
from this artery. In those past middle age a sclerosis of the
:y sometimes occurs, which makes hemorrhage certain, fol-
lowing the removal of the tonsils.
68
DISEASES OF EAR, NOSE AND THROAT.
The venous supply ends in the tonsillar plexus on the outer
side of the tonsil.
The lymphatic supply of the pharynx is very profuse, bcinu
(fig- 3i) located more especially within the mucous mem-
brane and is more numerous in the superior and posterior wall.
The pharyngeal tonsil is, according to Poirier, Cuneo and Dela-
mere, very rich in lymphatics. The laryngo-pharynx has little
or no lymphatics. The ducts empty into the retro-pharyngeal
glands or the internal jugular chain.
Fig. 42.
\ Intl.- 1 Stetl >M ur nil To»»ll 1 Wier H. E t I
;, llilum with vrs-scl entering it; .', cpithetinl external ItJWt •. mcWW
cr>i>t; 4, lymphoid nodule; 5, submucous tissue of the fauces terminating
in the tonsil; 6, interstitial connective titsne.
The function of the tonsils is imperfectly understood. By
•.dine they are thought to be ;i primogcnial source of the
lymphocytes and leukocytes. The function of the tonsil is
presumed to be the digestion of microorganisms, which find
their way into the tonsils and to furnish a secretion to moisten
the tonsils and pharynx, and by so doing, aid in deglutition.
HON OF NASAL AND ACCESSORY SINUSES.
69
Above the tonsil and between the anterior and posterior
pillars is situated the fossa supra-tunsillaris. It is triangular
in shape, its border being the anterior and posterior pillars. It
is (if especial interest on account of the frequency of peritonsillar
inflammation. Frequent attacks of inflammation of the tonsils
may lorm adhesions with the pillars, producing pouches or
pathological culture tubes for the propagation of infectious
microorganisms.
The Larynx. — Within the region of the laryngo-pharynx
i« situated the most important organ (if voice and speech, the
Fie. 43.
IM
t$
O.A., Ot-. Hyoide*; C\ th., thyroid cartilage; Carp trit., eorjraa tritirciim:
rtibfC; (it, tracheal cartilage; Lig. ihyr-hyoii .-«.-. / mi. Mir
! ig. ii< ';. In.. Literal thyro-hyoid ligament; Lit:, crnv
tkyr, m^.i.. mi.! ligament; Lie. cric.-rro. ichcal liEn-
' . lhyn>hyoidcu« mutclc; M tt.-th , jiirim ihyroideus muscle;
.•*., cricc-lhyroidcu« muscle. (After KolJcH.)
7°
DISEASES OF EAR, NOSE AND THROAT.
larynx. It is composed of hyaline cartilage, is situated below
the base of the tongue and is in direct connection with the
trachea, at the base of the cricoid cartilage.
The larynx is composed of the cricoid, thyroid and arytenoid
cartilages. The cricoid cartilage is so called from its resem-
blance to a signet ring. Its vertical measurement is one inch
on its lateral wall and rests upon the anterior superior surface.
The triangular upper half of the thyroid cartilage extends out-
ward, varying in individuals and forms the Adam's apple
(pomum Adam!). The superior margins of the an til
Tig. 44.
, - -
The Muscles or cm: Laevkx Viewed hoii Bxkikd. (After Sopfff and
J, Epiglottis; 1, srylcno-cpiisloTtidcus; J, superior cornu of thyroids 4. obliuue
fiber* of arytcitoidcii*; £, »ryteno-ej;iglottid«an fold; 6, deep fibers of arytco-
oidcus; f, corniculum laryngis or cartilage of Sanlorini: 8, muscular angle of
arytenoid; 0, thyroid cartilage; JO, erico-arytt luiiikus i>ualiiu»; //, arltcul
of cricoid with thyroid; i;, trachea; 13, cricoid cartilage.
1 urve gently backuard and end in the long projection, known
at the right and left superior cornu of the thyroid. The lower
; Lrins curve in a like manner, with the exception of the
towef projection, or the lower cornu, which is short and blunt.
To the superior cornu are attached the lateral thyro-hyoid
ligaments. The inferior cornu, as shown in the illustration,
arc attached to the median lateral wall of the cricoid by the
FUNCTION OF NASAL AND ACCESSORY SINUSES. /I
posterioi superior ceraro-cricoid and the posterior teratoid liga-
ront, at the elliptical space, the two cartilages are
i nnnii. ted l>y the median cricothyroid ligaments. The ary-
tenoid cartilages are two in number and triangular in form.
They occupy a position OH the superior margin of the posterior
part of the cricoid cartilage, to the right and to the left of the
median line. Their height is usually one-half inch and their
diameter one-quarter inch at the base. The apex of each pyra-
mid is capped by a small cartilage, the cartilage of Santorini.
To the outside and (Fig. 45) slightly above the cartilage of
Santorini are situated the cartilages of Wrisberg. Their ana-
tomical position is interesting on account of the liability of this
region t<i tubercular and syphilitic infections.
The epiglottis is a fibro-cartilaginoufl structure, situated in
the median lit [G at the base of the tongue and projects over the
n\ like a valve. Its apex is attached to the median notch
of the thyroid cartilage by the thyro-epiglottic ligament. It
is connected to the posterior surface of the os hyoides by the
hyo-epiglottic ligament. Laterally, two folds of mucous mem-
brane connect the epiglottis with the arytenoid cartilage.
The aryteno-epiglottic folds continue backward] enclosing
the cartilage of Santorini and filling the space between the
upright walls of the arytenoid cartilages. The anterior sur-
face of its apex is attached to the base of the tongue by the
three piglottic folds.
The BHudes Supplying the larynx are both intrinsic and
extrintIC The extrinsic are those found outside the larynx
and are stcrno-hyoid, sterno-thyroid, aryreno-hyoid and thyro-
hyoid, the function of which is the depression of the hyoid
bone and the elevation of the thyroid cartilage, and the glosso-
hyoid. ni) lo-hyoid, Btylo-hyoid and hyo-glossus, whose function
is to elevate the lam
The intrinsic tnu5> les, or those within the larynx, are eleven
in number, arranged in five pairs with one in the middle.
The cricothyroid muscle is attached to the outside portion
ol the thyroid cartilage and passes downward and forward tu
72
DISEASES OF EAR, NOSE AND THROAT,
the anterior portion of the cricoid cartilage, and by a pi
(.'! drawing upward the anterior portion with the attached
arytenoid cartilage is tilted backward and downward, thus
making the vocal cords tense.
The nerve supply is from the external laryngeal nerve. A
paralysis is presumed by Gowers to have some influence upon
the production of high notes.
Fibers of the thyro-arytcnoid pass from the posterior surface
of the thyroid cartilage at its angle parallel with the vocal
cords and are inserted into the anterior surface of the ary-
tenoid cartilage. The muscle at its inner surface joins the
vocal cords. The muscle is subdivided by anatomists into the
thyro-arytenoideus cxternus and the thyro-arytenoideus in-
tcrnus. The two muscles are inseparable. The former is I
broad muscle, situated externally and in close apposition with
the crico-thyroid membrane. It is inserted in the outer border
and muscular process of the arytenoid. Some of the fibers arc
continuous with the arytenoid muscle. The muscle draws the
outer portion of the arytenoid cartilage forward and this turns
the inner portion of the arytenoid cartilages close together and
adducts the cords.
The thyro-arytenoideus internus is a slender muscle in close
apposition with the vocal cords. It takes its origin at the angle
between the two ala; of the thyroid cartilages and with the vocal
cord is inserted into the outer portion of the processus vocalis.
The muscle shortens the cord. A paralysis renders the cords
concave.
The crico arytenoideus posticus passes from the outer surface
of the cricoid cartilage upward and outward to the muscular
process of the arytenoid cartilage. The function is to draw
the outer portion of the arytenoid cartilage downward, thus
separating or abducting the vocal cords. The muscle is sup
plied by the laryngeal nerve. A paralysis of one or both muscles
approximates the vocal cords.
The fibers of the crico arytenoid lateralis pass from the
upper border of the cricoid cartilage to the outer portion of the
FUNCTION OF NASAL AND ACCESSORY SINUSES. 73
arytenoid cartilages, draw the cartilages forward and approxi-
mate the cords.
The arytenoid is a single muscle passing posteriorly from
one arytenoid cartilage to the other and has its attachment on
the posterior concave surface. The function of the muscle is
the adduction of the cords.
The vocal cords are composed of yellow clastic tissue ex-
tending from the inner angle of the thyroid cartilage to the
ptOCSSSUS vocal is of the arytenoid cartilage. The outer sur-
• is in direct apposition to the internal part of the thyro-
arytenoid muscle. The size and length of the vocal cords
vary in individuals. The normal voice, with its complete
nmge oJ tone, is essentially dependent for its production upon
the vocal cords. The general physiology of the voice will be
considered under a separate subdivision.
The ventricular bands, or false vocal cords, are so named
because it is supposed they have no influence upon voice produc-
tion. There are two crescent ic folds of mucous membrane
enclosing the superior thyroarytenoid ligaments parallel to the
true vocal cords, slightly above and to the outer margin of the
cords. They project into the larynx from the lateral wall and
with the true vocal cords form the two lateral ventricles, which
are named the ventricles of Morgagni. The functions of the
ventricle", of Morgagni, which contain many mucous and serous
Is, is to supply moisture to the vocal cords. The ventricles
contribute in ■ slight measure to voice production and aid in
preventing the escape of air from the lungs (B run ton and
Cash).
The mucous membrane of the greater portion of the larynx
. vered with a stratified, columnar, dilated epithelium rest-
ing upon a thick submembrane. Goblet cells arc contained
a ithin the epithelium. The epithelium covering the true v.xal
cords, part of the arytenoid cartilages and the free margin of
thr epiglottis, is of the stratified, squamous variety.
The sudden change in the character of the epithelium, as
- ,1 ..ut by Frederick of Leipzig, in a measure accounts for
74
DISEASES OP EAR, NOSE AND THROAT.
the slowness with which acute catarrhal inflammation extendi
from the oro-pharynx into the larynx, and for this
acute laryngitis and pharyngitis seldom extend to the upper air
passages.
The nerve supply of the larynx is received from the superior
and inferior or recurrent laryngeal nerves, branches cd the
vagus. Sensory fibers from the superior laryngeal branch fur-
nish acute sensibility to the glottis. These fibers carry impres-
sions to the medulla oblongata while motor impulses are trans-
mitted by the inferior laryngeal. By this mechanism, foreign
bodies and irritating gases are prevented by closure of the
glottis from gaining entrance to the lungs.
The inferior laryngeal is supposed to supply motor impulses
to all the muscles with the exception of the crico-thyroid, which
receives motor impulses from the superior laryngeal.
The arterial blood supply is derived from the superior and
inferior thyroid arteries. " The venous supply empties into
the superior thyroid veins. The capillaries are very line and
lie directly beneath the epithelium." The lymphatic network
is situated beneath the capillaries.
Voice and Speech. — The purity of the voice is dependent
essentially upon the vocal cords. The loudness, pitch, quality
and timbre are dependent upon the normal condition of the
upper air passages. The voice is produced by certain vibra-
tions of the vocal cords, previously approximated and tense.
The force of the expired air is controlled by action of the
phrenic and intercostal muscles.
The speech area is situated in the base of the third frontal
convolution. From this area emanate impulses which pass
along appropriate fibers of the pyramidal tract of the bulb and
these produce impulses by which the word is spoken (Fo
In coordination of the muscular movements of the larynx,
paralysis of the different conducting fibers, diseases of the cor-
tical centers or diseases of the vocal cords may result in partial
or complete loss of voice.
One great essential to the production of voice i- a «.lt:ir
HOY OF N'ASAI. AND AlCHSSORY SINUSES.
75
understanding of the function of respiration. Three methods
of breathing are universally known, clavicular, costal and dia-
phragmatic or abdominal. Among singers all these methods
have been extensively advocated. The clavicular probably has
a advocates than the other two. The diaphragmatic
hod offers the greater* advantage in the production of pitch
and quality in the voice. In the abdominal method of brcath-
FiC. 45.
VntW Of M Srts During Inspiration.
• -1 longlWi >. median glosso-upiglotlidean fold; 3, epiglottis; 4, fossa
ttidcnn Fold: X cartilage of Wrisberg; 7, cartilage
of Sanlorini: S. pharynx . y, vallecula; 10, cushion of epiglottis; 11, true
vocal eordi '•'. rima glottis; ;.?. sinus pyriformis; 14, arytenoid commissure.
If an . ,
ing, a greater amount of air is taken into the lungs, and steadi-
ness, power and volume are added to the force of the expired
air. The greater the number of vibrations in a given length
of time the higher the pitch of the voice.
The larynx is seen to be open during rest. This is also the
normal condition during respiration. The cadaveric condition
is that seen in death, when t he larynx is partially open. The
glottis is much narrower at this time than in the living subject.
76
DISEASES OF EAR, NOSE AND THROAT.
The vocal cords with the cartilages of Santorini are more o
less approximated, according to the note sounded or the word
spoken. It is only by assuming a rigid position that the cords
arc set in vibration. When the recurrent laryngeal of one side
is cut or paralyzed, the shape of the glottis changes, the cord
on that side remaining at rest while' that of the opposite side
approximates the median line in phonation. In bilateral paralj
sis the abductor muscles fail to respond to stimulation, inspira-
tion is disturbed and the voice is Inst. When the recurrrnt
laryngeal is stimulated the cords are brought into apposition.
Frc. +6.
'
— —
14'
v or Interior op Larynx as Skew During Vocalisation.
f. Epiglottis; /, cushion of epiglottis; 5, ventricle; 1, aryteno-cpijti
Mil; i, cartilage of Wrisberg; 0, cartilage of Santorini; 7, m > Huniii
mi sail re; 8, haae of tongue; p, median g1na*n-c|>igIottidean fold; 10. foMR
innominata; it, true vocal cord; u, sinus jiyrlformi*; i-;, processus v>
tj, pharynx. (After Mart it.)
Voices arc classified, according to range, into soprano, mezzo-
soprano, contralto, tenor, baritone and bass. The range of
tone of the voice is dependent upon the size and length of the
vocal cords, combined with the peculiar coordination of the
muscular structure of the larynx, which necessarily varies in
FUNCTION OF NASAL AND ACCESSORY SINUSES. 77
individuals. The old theory that the difference in the bass
and tenor voice is dependent upon the length of the vocal cords
is, in a great measure, erroneous.
The size of the larynx varies, being larger in men than in
women. At the age of puberty in boys, the voice undergoes
rapid change in pitch. During this metamorphosis more or
less congestion of the mucous membrane is present, all of which
accounts for the peculiar tone of the voice. It is also apparent
that the tongue, palate, with its varied arched conditions, nasal
and post-nasal spaces, teeth and lips, all on their part, add a
well-observed character to the voice.
" Speech is a combination of vocal sounds, which are classi-
fied as vowels and consonants and are joined together to make
syllables. Speech may be distinguished from singing, partially
by the fact that the sounds in the first case are more especially
articulate or formed in the mouth, while in the latter their
quality is only modified by the mouth.
" In singing, the tone is sustained at the same pitch for
a considerable length of time, while in speaking, the voice
is continually sliding up and down the vowel sounds " (Henry
Sewell).
BACTERIOLOGY AND PATHOLOGY OF THE EAR, NOSE AND
THROAT.
Ox account of the cutaneous covering of the external car,
there is little to be said in regard to bacteriology of this region,
The most frequent organisms causing disease of the auricle
are the staphylococcus pyogenes aureus, seen in furuncles, and
streptococcus pyogenes, found in erysipelas.
The cocci involving the middle ear are of greater variety
than those involving the auricle. They usually find their en-
trance through the Eustachian tube or through the membrana
tympani from traumatism. It was shown by Preysing in 1899
and later demonstrated by Hasslauer that bacteria are not
found in the normal middle ear. The cause of this immunity
is supposed to be due more especially to the cilia of the Ell
chian tube, which constantly moves toward the pharynx during
the acts of breathing, swallowing and eating, thus preventing
materially the entrance of microorganisms into the middle
ear. Among those found as active causes of inflammation of
the middle ear are the streptococcus pyogenes, occasionally the
tubercle bacillus, pneumococcus of Frankel, Pfcifrcr's bacillus
of influenza, the bacillus of Friedlander and the staphylococcus
pyogenes albus and aureus. Loeffler's diphtheria bacillus, the
oolon haiillns and the bacillus pyocyancus (Gouhcr), also found
by Stern in suppurating car, pseudo-diphtheric bacillus in
croupous otitis (Schilling), actinomycosis (Laufel). bacterium
aerogenes (Scheibe), blastomycetes found in serous exudation
following paracentesis (Barrago-Ciarelli), and the bacillus coli
(Stern). Levin believes that in the great majority of cases
of diphtheria of the middle ear following pharyngeal diph-
78
BACTERIOLOGY AND PATHOLOGY.
79
theria, are due to the Toxins circulating in the blood and not to
the extension of the disease through the tube. Leutert believes
the streptococcus to be the cause of scarlatina otitis. Just how
the infection of measles and scarlet fever readies the middle
tax is a subject on which authorities differ, many believing the
avenue of entrance to be through the Eustachian tube, while
Others believe the blood stream to be the means of entrance.
The form of infection more frequently found in abscess of the
mastoid is the streptococcus. In sixty -three cases of abscess
of thr mastoid following acute suppuration of the ear, Leutert
found streptococcus thirty-eight times in pure culture, pneumo-
coccal s eleven times in pure culture, staphylococcus five times
in purr culture, tubercle bacilli two times in pure culture and
Bed infection in the other cases.
In the nose may frequently be found the staphylococcus
pyogenes aureus, streptococcus pyogenes, diplococcus of Frankel
Weicbselhaum, tubercle bacillus found (a those living
with tubercular patients and the Klcbs-LofHcr bacillus of diph-
theria. These bacteria are innocuous, though at any time a
lowering of vitality or irritation of tin- tissues may cause them
to become a source of active inflammation. Thus it is neces-
sary that we rake tin* same precautions in preparing our crises
for any surgical operation in the nose and after dressing as
the abdominal surgeon would in laparotomy.
The mouth and pharynx are open to infection through the
medium of food and water, through the air, breathed din
into the mouth, or through the nasal cavity.
The mouth is deprived of ciliated epithelium or vibrissa?,
whose function is to antagonize the entrance of bacteria, con-
sequently, when open and especially in mouth-breathers, great
numbers of organisms find entrance.
Within the teeth and tonsils food particles often find lodg-
ment, which give off ptomains which are potent factors as a
cause of acute pharyngitis and laryngitis.
We previously called attention, under Anatomy of the Ton-
ro the presence within the tonsils of polyformed nuclear
So
DISEASES OF EAR, NOSE AND THROAT.
leukocytes, which in a measure destroy bacteria which in.i\ btW
found entrance into the crypts of the tonsils. The crypts QJ
the tonsils in apparently healthy individuals amy not infre-
quently contain many tubercle bacilli and other microorganisms.
Within the mouth and pharynx, in active catarrhal or ulcerated
conditions, may be found the streptococcus pyogenes aureus,
albus and citreus.
Fir. 47
A
\\
\
* Ik
X'%
\
bm LSma Baciu.ii>,
The diphtheria bacillus was discovered in 1883 by Klebs and
Loffler. The bacteria is the exciting cause of diphtheria {Fig.
+7). The Klebs-Loffler bacillus is non-motile, short, thick,
club-shaped and slightly curved, from two to six mikrons in
length and two to eight mikrons in breadth. It stains with
Ziehl's aniline-oil-water-gentian-violet and with Loffler's alka-
line methylene-blue solution. Ncisscr's stain may be used when
differentiation from the false diphtheria bacilli is necessan.
BACTERIOLOGY AND PATHOLOGY.
Si
With a platinum loop, heated and subsequently cooled, a
small particle of the exudation from the mucous membrane
affected is spread upon a cover glass, dried and stained. It is
frequently necessary to grow a culture of the bacilli as micro-
scopical examination may be negative. For this a solidified
blood serum, furnished by Parke, Davis & Co., Mulford &
Co., and other bacteriological laboratories, in culture tubes
should be used. The platinum point is again heated, cooled
and passed over the infected area. The adhesive particles are de-
posited upon the blood serum, gently rubbing the platinum point
over the surface of the blood scrum. In twenty-four hours in
a warm temperature, the growth is observed as a round, grayish-
white, glistening elevation, about the size of a pin head. If
exposed longer than twenty-four hours the grayish-white ele-
vation becomes yellowish.
The disease may be transmitted from one individual to an-
other by kissing, coughing and through the clothing.
The organisms may remain in the ear, nose or throat for a
number od Weeks after the inflammation has passed away.
In tonsillitis the streptococcus pyogenes, the staphylococcus
or the bacillus of Friedlander is frequently present. In those
cases suffering from tuberculosis of the lungs the tubercle bacillus
may sometimes be found in great numbers. The bacillus of
typhoid fever may often be present in the mouth of those
suffering from typhoid fever; the leptothrix in the teeth is pre-
sumably a cause of mycosis tonsillaris, the ray fungus a cause
of actinomycosis and the bacillus of glanders associated with
glandc [eneraj dtsi
Mongardi, in a series of experiments on infection of the
mouth, nose and pharynx, makes the following report:
" The organisms used were staphylococcus albus and micro-
ns tetragenus from a peritonsillar abscess; staphylococcus
aureus from a furuncle of the external auditory meatus; strep-
MODCCIM from die caseous material of a tonsillar crypt during
•rious angina; staphylococcus albus and cereus obtained
from skin furuncles, from pus of the ear, from the nose, and
7
S2
DISEASES OF EAR, NOSE AXD THROAT.
associated with streptococcus from a tonsillar exudate; gtap
lococcus aureus from a case of noma; streptococci from a ton-
sillar exudate; and streptococci from catarrhal tonsillitis. The
staphylococci injected under the muCOUS membrane in the nose
and under the gums of clogs had no effect. Injected into the
tonsil of a dog the animal showed a dejected state, with mod-
erate fever the first day and swelling of the submaxillary
glands. All symptoms disappeared in two or three days. The
culture injected into the antrum caused some fever with some
swelling and slight exophthalmos. On the third day the tem-
perature fell. Streptococci injected into the tonsil of a dog
produced phlegmonous angina, obstinate engorgement of the
ganglia and high fever for some days. The ganglia remained
painful and fluctuating for twenty days when they resolved.
The bacillus pyocyaneus had no effect in the nasal cavity of the
dog or when injected under the mucous membrane of the tur-
binate. In the antrum there was great depression and fever
for four days and a lively reaction of the ganglia which per-
sisted. In the rabbit, in tonsillar infection, there was death
in eighteen hours, while submucous inoculation was fatal in
twenty-six to thirty hours. The micrococcus tetragenus had
no effect."
Particles of dust entering the larynx are expelled by the
ciliated epithelium. By the sudden closing of the glottis, for-
hoiJies si:'' ■■■!..'- the larynx and the accumulation of miKUS Bit
reflex act of coughing. The larynx is freer from
cria than any other portion of the upper respiratory tract.
The trachea is presumed to be free from organisms in health.
I In- blood may be one avenue of infection. Weiber and Lid
have called attention to the inflammation of the middle ear.
due to malaria. Metastatic abscess of the external auditory
Canal may follow gonorrheal infection.
Hyperemia is recognized as an increase of blood to a part,
due to an irritation affecting the vaso-motor system. Hyper-
emia may be active or passive. Tn active hyperemia the mucous
membrane of the nose and throat in place of being pale pink
BACTKRJOLOGY AND PATHOLOGY.
S3
veae
in oolot is bright red. This discoloration may be confined to
one or both sides of the nose. If affecting the drum, there
will be a mild blush confined to the periphery or extending
over the entire drum. Active hyperemia may continue long
enough to bring about a structural change in the vessel wall,
the condition being considered, however, a temporary one, the
blood-vessels retracting with a complete return to the normal.
There are seldom any conspicuous symptoms of active hyper-
emia. The patient may complain of a slight burning sensa-
tion in the nose or, if tin- internal ear is involved, tinnitus
aurium with vertigo and nausea.
Closely allied to hyperemia, especially in the uvula and
; . we frequently unserve a sudden dilatation of the blood-
t:ls with exudation of m-iuiii, producing a condition known
as edema.
Active hyperemia may quickly pass into simple inflammation
or end in spontaneus recovery. Among the exciting causes of
hyperemia of the ear. nose and throat, are exposure to cold,
in hating gases, dust, ingestion of full doses of quinin or the
salicylates, alcoholic liquors, exanthematous diseases, indiges-
tion, bacterial toxins and nervous disturbances.
In passive hyperemia there is a greater or less obstruction
to the flow of blood through the veins. A very good example
of passive hyperemia is the hemorrhagic extravasation into the
mucous membrane of the soft palate and faucial pillars, which
sometimes follows removal of the tonsils.
Inflammation, a< defined by Warren, is " a lesion in the
mechanism of nutrition, owing to which its efficiency is im-
paired, but which, if not so severe as to cause death, produces
conditions favorable for the protection and repair of the part."
According to the rapidity and character of the lesion, inflam-
mation may be acute or chronic.
Among the many causes of inflammation are heat, cold,
trauma, chemical agent ns, leucomains. toxins, toxalbu-
nn'ns and bacteria. These agents all act in a manner quite
similar and are irritants to the tissues nf the body. As a te«.\A\.
s4
DISEASES OK KAR, KOSE AND THROAT.
of irritation an alteration is brought about in the supply of
blood to the part, which if continued for any length of time,
brings about a congestion of the internal organs with paralysis
of the constriction fibers or a stimulation of the vaso-dilators
of the peripheral blood-vessels with a rapid flow of blood to
the parts, followed by a slowing of the current and, as de-
scribed by Cohenheim, an exudate of the elements of the
blood stream by a process of leakage through the vessel wall
with all the symptoms so well known of inflammation. The
role of autotoxins and internal secretions in the causation of
inflammation of the upper air passages in sufficiently understood,
thanks to the researches of Sajous, Vaughn, IJnuehard and
others, to be classed as important agents. Certain bacteria pro-
duce toxalbumin and toxins which lower the viral ity of a part.
Ptornains, from the presence of non-pathogenic bacteria in
dead animal matter, are evolved during disturbed dige&l
and autotoxernias resulting from inherited or acquired dia-
thesis, arc conditions acting very much alike in a disturbance
of the nutrition of the upper air passages. The effect of the
toxin and toxalbumin is well shown in the direct relationship
of acute gastrn-intcstmal disturbance and acute coryza.
The relation of the anterior and posterior pituitary bodies
to the adrenal glands and the influence of the adrenal secretion
upon the cellular metaholism is probably a great factor in
causing many of the functional and organic changes which are
constantly going on in the structure of the organs under con-
sideration. According to Sojous, " drugs, toxins, physiological
toxalbumins. etc., stimulate the adrenal system when the pro-
portion of these agents in the blond did not exceed a certain
limit and that when this limit was exceeded, /. e. . when
dose administered or the amount of toxins secreted by the
'Ha, etc., was excessive, it cither inhibited or arrested tin-
function of the system."
The adrenal secretions have a direct influence upon
quantity of the blood and blood plasma and cellular metabolism.
If influences known and unknown are of sufficient potentu
BACTERIOLOGY AND PATHOLOGY.
85
to disturb the equal balance of the adrenal system, local or gen-
eral pathological changes take place.
The treatment in the future will be closer attention to the
racter Of tfae secretions from the nose and throat and chem-
istry of the internal secretions and their influence upon the
is membrane of the upper air passages.
Since the discovery of the influence of bacteria in diseases,
Inflammations art- subdivided into non-infective and infective.
With tin- constant presence of bacteria within the bod; it is
.-rry difficult to conceive of inflammation without the active
.■>r remote influence of bacteria.
Heat, cold, chemical agents, toxins which are classed by
some as chemical substances, are non-infective agents.
Diseases that may be produced by non-infective agents are
acute and chronic catarrh, osteosclerosis, arteriosclerosis, laby-
rinthitis, sinusitis, hypertrophy, edema and atrophy.
[nfective agents arc all known as pathogenic bacteria. The
staphylococcus and streptococcus are the most frequent exciting
causes of inflammation and suppuration of the upper air passages.
Among the various diseases due to bacteria are croup, diphtheria,
L-t fever, mtasleS) syphilis, tuberculosis, acute and chronic
otitis media, suppurative otitis, septicemia, pyemia, malignant
edema, furuncle, acute and chronic sinusitis.
According to the character of the lesion, inflammation is
divided into parenchymatous, interstitial and exudative.
In the parenchymatous form of inflammation, according to
Langerhans, the exudation is taken up by the cells of the organ.
Active changes in the blood-vessels do not necessarily occur;
sometimes ischemia from pressure of the swollen cells may oc-
cur. Changes of this character may be noted in enlarged
tonsils.
In acute interstitial inflammation we have an acute suppura-
tive change in the structure of an organ, sometimes thrown out
upon the surface. Among the many examples of interstitial
inflammation are peritonsillar abscess, abscess of the pharynx,
and tonsillitis.
S6
DISEASES OF EAR, NOSH AND THROAT.
In chronic interstitial inflammation there is a proliferation of
connective tissue cells, which finally ends in atrophy.
In the exudative form of inflammation we have, accordion
to Langerhans, the following classification of the exudate:
i. Mucous Exudation.— Thrown out from the surfaces cov-
ered with cylindrical epithelium, classed as catarrhal exudation.
2. Fibrous Exudation. — Thrown out upon the surface in
nose and throat, Eustachian tube and middle ear. Inflammation
of the fibrous exudate, a coagulation may take place from croup-
ous membrane. A diphtheritic membrane is formed by a co-
agulating necrosis of the exudation and tissue composing the
mucous surface.
3. Cellular Exudation. —
{a) Epithelial cells: desquamative.
{b) Colorless blood corpuscles: purulent.
(c) Red blood corpuscles: hemorrhagic exudate.
4. Icliurous Exudation.
Immunity. — In a discussion of inflammation, the influence
of bacteria, their proteid substances and toxalbumins have been
mentioned. Since the discovery by Jenner of the prevention of
srnall-pox by vaccination and later the researches by Pasteur in
regards to fermentation, up to the present time with Beh ring's
discovery of the serum for the mitigation of the severity of
diphtheria and the prevention of the disease in immunized indi-
viduals, the subject of immunity has been of the greatest interest
to physicians the world over.
The term immunity signifies a natural or acquired resistance
against pathological bacteria or their products.
By natural immunity is meant a condition of resistance to
pathogenic bacteria from the constant presence within the I
of a chemical physiological substance, the absence of which is
necessary for the growth of microorganisms. Acquired im
m unity against one kind of bacteria results in two ways:
1. The injection of a small quantity of bacilli sufficient Rl
cause a slight inflammatory reaction, one injection being all
that is necessary to immunize the patient or animal. The
required for immunity to establish itself is one week.
2. From injection of the scrum of the blood of the individual
or animal immunized by the injection of the bacteria or their
toxins.
The Lst i- the method most frequently employed in immuniza-
tion against such diseases a.s bubonic plague, dysentery, yellow
fever, diphtheria, etc. By the injection of the antitoxin of diph-
theria in a child exposed to diphtheria we bring about a condi-
ttiii oi passive immunity, i. e., an immunity limited in its dura-
tion. Active immunity follows an attack of certain diseases, as
boid [ever, variola, yellow fever, erysipelas. In active im-
moflitj we may have, as in passive, a limitation of the duration
of the immunity.
I acfa organism must possess its own peculiar antidote; in
other words, the streptococcus serum can have no influence un
B disease produced by any other organism. The antitoxin of
diphtheria will have no influence upon a throat affection due to
streptococcus or staphylococcus infection. Immunizing serums
are especially directed to the neutralization of toxins of bacteria
within the body. Wasserman of Berlin has discovered a serum
which has a direct influence upon the bacillus of diphtheria,
killing the bacilli in loco. Sera acting directly upon the bacteria
are known as bactericide sera, in counterdistinction to anti-
toxic sera, which only acts on bacterial toxins. With the
methods of Behrinj; and Washerman we can neutralize the
products of the bacilli of diphtheria, kill the source
of the toxins, i. i.. the bacteria, and prevent greatly the spread
of tie
Hypertrophy of a tissue •" an organ is due to an increase
in the size of the cells, caused by inflammation, excessive use,
inherited conditions or vasomotor disturbances.
Inflammation probably plays the most important part in
ling hypertrophy of the mucous membrane of the ear, nose
and throat.
Hyperplasia is understood to he an increase in the number
ri a given organ. The underlying cause is not unlikely
•ame as for hypertrophy. Hypertrophy and hyperplasia are
ss
DISEASES OF EAR, NOSE AND THROAT.
closely allied. It is in the turbinated bodies that tlic two con-
ditions are easily differentiated. The turbinated bodies arc strfl
in hypertrophy and shrink approximately to the normal si/.r
under cocain or suprarenal extract, whereas in hyperplasia the
turbinated bodies are firm to the touch and little or no shrink-
age takes place under cocain or suprarenal extract.
Atrophy of an organ or tissue is a lessening in the size
and thickness, with change of color and partial or complete
loss of function, due to a decrease in the number of component
cells. It is thought that atrophy is first preceded by hyper
trophy. This metamorphosis is brought about by inherited
dyscrasia, suppurative diseases in contiguous parts, old age,
nutritive disturbances and operative measures by which the
mucous membranes are unduly exposed to infection and irri-
tation from extrinsic influences.
Tumors of the Upper air passages are like those in any
other portion of the body, and according to Zieglcr, are a new
formation of tissue, apparently arising and growing indepen-
dently, having a typical structure, possessing nu function of
service to the body and showing no typical termination to their
growth.
Tumors are more frequent in the nose and throat than in the
ear. This is accounted for by the structure and position of the
Organ! and their exposure to irritation and inflammation.
Tumors, with the exception of malignant growth, are gener-
ally speaking, homologous structures, that is, they spring from
like tissue and are hyperplasias of the normal tissue (Langer-
hans). surrounded by a limiting capsule. Tumors which devi-
ate from the normal or mother tissue, are classed as heterol-
ogous and are usually malignant growths. Non-malignant
tumors are so named because in their growth and structure thev
are not antagonistic to life, other than by interference with
the function of an organ by pressure. They grow by a process
of cell proliferation and have no tendency to distribute germ
cells to other portions of the body by a process of n
They have no tendency to recur after removal, even if a small
part remains. They are somewhat self-limited in growth. Tu-
mors which deviate from the mother tissue are usually classed
as heterologous or malignant. The greater this departure of the
tumor cells from the tissue within which it originates the
.tcr the malignancy and the disposition to metastatic forma-
tions. Those which are highly vascular are always the most
malignant (Langcrhans). Tumors of this character are prone
to rapid recurrence, providing any of the diseased tissues arc
left in loco.
According to Virchovv, from the anatomic-genetic standpoint,
tumors are subdivided into three groups.
i. Extravasation and exudation tumors. Tumors of this
character found in the organs under consideration are hema-
toma and cysts.
2. Dilation and retention tumors, i. t„ all tumors of a
cystic character, which take place in a preexisting space (Langer-
lians), are cysts of the thyro-glossus duct, mucous cysts of the
antrum of Highmore, etc.
3. Proliferating tumors which are subdivided into: (<z)
Histoid tumors or those growing from connective tissue or the
supporting framework and are fibroma, myxoma, osteoma,
chondroma or enchondrnma, sarcoma, neuroma or neurofibroma ;
(A) organoid tumors or those composed of both epithelium and
connective tissue and classified as adenoma, cystoma and carci-
noma; (t) teratoid or tumor-like formations occurring in tissue
unlike cellular structure. Tumors of this character are
cholesteatoma, found in the middle ear and tonsils (Norval
Pierce), hairy polypi of the nose or throat, and dermoid cysts
of the ttost and aurieir. All tumors of the nose, throat and ear
are, clinically speaking, neoplasms.
Etiology of Tumors. — Non-malignant growths may result
from traumatism, infection, trophic disturbances, malnutrition,
irritation, metastasis ami hematogenetic influence or any other
condition which will produce an increased cell activity result-
ing in an atypical structure.
The exact etiology of malignant growths is still a disputed
9°
DISEASES OF EAR, NOSE AND THROAT.
question. The following are some of the theories general I >
accepted :
1. Traumatism, irritation prolonged in character or chronic
ulceration of the mucous membrane.
2. Cohenheim advocated many years ago the theory that cer-
tain embryonic cells foreign to the place in which they are
found persisting without function in an organ or structure would,
under favorable circumstances, develop into malignant growth*
Cohenheim's theory of fetal inclusion, thus accounting for the
presence of cells within any tissue different from that normally
found there and their tendency to malignancy.
3. The theory of Kelling [Mtmchener mtd. WochMtckrift,
June 14, 1904) lately advanced that certain embryological cells
of different animals may be carried through the blood or de-
posited upon wounds by insects and carried into the tissue, where
they proliferate and become malignant tumors. Kelling ad-
vances the theory in substantiation of the foregoing of sp<-<
precipitation by which tissue of different kinds could be differ-
entiated by the use of the specific precipitations fot blood. Tu-
mor tissues were precipitated with the different serums. Ir
was found that chicken serums produced the greatest amount
of precipitation. From this result Kelling suggests a possible
relationship between embryonic chicken cells and malignant
growths.
4. As to the parasitic origin of cancer, as advocated by
Steinhans, no absolute proof has been offered. A few inveati-
gators claim to have found in cancerous growths a protozoon
which was presumed to exert an influence in causing the disease.
Johannes Orth, probably the greatest authority on cancer, says
that no one at the present time has produced proof chat carci-
noma n <>t paniMtfc origin, and that there is no necessity to pre-
sume such an etiology in carcinoma.
Malignant growths are subdivided into carcinoma and sar-
coma. Sarcoma is composed of embryonic types of connective
tissue which continues to grow independent of surrounding
tissue, following, frequently, the course of the blood vessels.
rEUOLOGY AND PATHOLOGY.
9*
The varieties arc large and small spindle-celled and giant-
ed, all types of embryonic connective tissue. The inter-
cellular substance is usually very scanty, the cells being clustered
>■ together. Malignancy decreases with the increase of inter-
cellular substance. Changes in the intercellular substance are
frequently found, the tumors then becoming a mixture of the
Fig. 48.
- • ■*. J i »
•'v
"A
SVAU KivSD-CBLltt SaBCOMA. (After T^nyer.)
■ . known as myxosarcoma or fibrosarcoma, etc The blood
pi] of tumors of the sarcomatous type is usually very
profuse.
The small round-celled sarcomata are made up of small round
ous blood-vessels. There is very little inter-
cellular i I Fig. 4S ) .
The large round-celled sarcomata differ from the former in
size and increased amount of protoplasm in the cell. Between
02
DISEASES OF EAR, NOSE AND THROAT.
and surrounding the groups of cells are bands of connective
tissue with blood-vessels (Fig. 49).
The spindle-celled variety is most frequently observed. It
is made up of long spindle-shaped cells with very little inter-
cellular substance. In some cases, however, the amount of
Fig. 49-
m
M
Lakoc Hound- celled Sarcoma. (After Thayer.)
intercellular substance is very great and the tumor, taking on
the character of the intercellular structure or gray substance,
is then classified as fibrosarcoma, myxosarcoma, angiosarcoma,
lymphangiosarcoma and osteosarcoma (Fig. 50).
Sarcoma may spring from the connective tissue of the
naso-pharynx, larynx, soft palate, tonsils, auditory nerve, inner,
middle and external car.
BRIO LOGY AND PATHO) 0O1 -
93
Carcinomata pi cancer 1b a malignant tumor springing from
epithelial structures and containing more or less connective
i.'. The epithelial cells are atypical with a tendency to in-
filtrate by branching into typical structures. The growth
proliferates and spreads more especially by way of the lym-
phatics, though remotely through the blond-vessels.
Fie. 50.
^
k?&
SriVDlt-CELLID Saiodma.
1 he atypical cells are seen to he in close contact, appearing
in groups, surrounded by alveoli of connective tissue nr glandu-
lar tissue, poorly supplied with l>iui>d \c-vls. Tumors of this
;tcter reproduce themselves wherever a small portion re-
mains after operation tor removal (Fig. si).
Carcinomata, according to the character of the epithelium
and the glandular structure, .ire classed as flat-celled, cylin-
drical-ieiled, adenocarcinoma and carcinoma glandular solidum.
94
DISEASES OT EAR. NOSE AND T»*OAT.
Flat-celled carcinoma arc
spoken of as epi-
thelioma and involve those structure* oarered with flat or
squamous dl rated epithelium and occur on the skin or junction
of the skin and raucous membrane, mouth or air ot the nose,
pharynx. larynx and auride.
Fac
EriiatuoM* ca tax
Cylindrical-celled carcitvomata develop from mucous
membrane. covered with cylindrical epithelium as in the mu-
cous membrane of the nasal cavity, accessary sinuses, naso-
pharynx, tonsils, portions ot the larynx and the Eustachian
rube, A squamous cell may change into a cylindrical cell and
vice versa, thus a squamuus-crllcd carcinoma may appear in a
m * am surface covered with cylindrical cells.
inuaiata usual l> appear late in life, differing in this
m, which occurs at any
BACTf.RIOUX.V AND PATHOLOGY.
95
Experimental inoculfttioa -.hows that cancer may he trans-
mitted among annuals of the >aui<- speciex only. Dagonet claims
to have nans:: : a from man to a rat, producing
a like histologic structure.
Adenocarcinoma are tumors of glandular epithelium in-
filtrating the parent tissue. Histologically, the structure ex-
hibits a parenchyma composed of polymorphous cells arranged
Fig. 52.
FmtuWA.
in alveoli, which often anastomose wide!] an.': .-ur separated by
connective tissue stroma ( IleLtoen-Reismen).
Tumors of this character are found in the sebaceous glands
of the auricle (Politzer) and the salivary glands.
it rumors of the ear, nose and throat may be
classified acc< Q the ground substance from which the
tumor springs, as fibroma, myxoma, chondroma, oste-
96
DISEASES OF EAR, NOSE \SD THROAT.
oma and neuroma. A combination of two kinds of Ct&ttt
tumors gives rise to fibroadenoma, neurofibroma, ere.
A fibroma is a tumor consisting of ordinary connective tis-
sue and may occur on the skin, mouth, nasal cavity, naso-
pharynx, larynx, tonsils, middle and internal car (Fig. 52).
They sometimes undergo degeneration, breaking down with
the formation of an ulcer.
The blood supply varies: in cases observed by the author
there was little hemorrhage upon their removal.
Tumors of this character have a broad base 01 may be some-
what pedunculated. As to their density, they may be soft or
hard.
A myxoma or mucoid tumor is composed of mucoi
sue, soft and jelly-like, containing mucin, springing from con-
nective or mucous tissue.
If an increase of fibrous tissue occurs in the submucous
structures, the tumor becomes more linn in consistency and is
designated myxoma fibrosum. A familiar example oJ mj KOmata
is a fibrous polypi of the nose.
Location of such a tumor is usually in the superior or
middle meatus of the nose. Suppuration of the accessor}' sinuses
is classed as an exciting cause of myxomatous tumor. There
is still a doubt in regard to the transposition "f a myxomata
into a malignant growth, though myxomata may be combined
with either a sarcoma or a carcinoma.
Myxomata may be single or multiple, sessile or pedunculated
(Fig. 53).
Under the microscope the tumor appears as myxomatous
substance in a reticule of connective tissue with broken-down
epithelium and other debris. Tumors of the myxomatous type
m.iv be found in the nose, accessory sinuses. larynx and external
and middle ear.
In the middle ear the formation of these tumors is preceded
by an acute or chronic purulent inflammation of the middle
ear. with destruction of the drum.
Lipomata are described as lobulated growths of fat cells
BACTERIOLOGY AND PATHOLOGY.
97
springing from connective tissue and are found more often be-
neath the skin of the auricle of the nose. The fat cells occur
in groups surrounded by areolar tissue and differ in no wise
from normal fat. They may spring from the arytenoepiglottic
fold, as described by Bosworth. This author also mentions one
Fig. jj.
W/ :
( ^kv
*r>
Myxoma-
of lipoma of the larynx described by Burns. Theisen re-
ports one Case oi lipoma springing from a crypt of the tonsil.
Chondromata are cartilaginous tumors and are subdivided
into the hyperplastic and heteroplastic form*.
The hyperplastic are outgrowths from preexisting cartilage
especially along the cartilaginous septum of the nose.
The heteroplastic or cm Imndromata are isolated patch*
cartilaginous tissue, sometimes resulting from cartilaginous
BtTUCtORSj which have railed to change into bone They may
develop from a Don-cartilaginous matrix.
98
DISEASES OF BAR, NOSE AND THROAT.
Chondiumara occur mure often in the ear, nose, larynx and
trachea. Late in life chondromata have a tendency to calcify
or ossify.
Osteoraata are bone tumors developing fruin pefUM
bone cartilage or other connective tissue. In histological strm-
ture they resemble true hone. They may become mixed with
other connective tissue tumors forming osteofibroma or osteo-
chondroma.
Two forms are recognized, hyperplastic and heteroplastic.
Exosttisis belongs to the former classification and is a growth
from the surface of bone or cartilage. Heteroplastic are bone
tumors in organs of other than bone or cartilaginous structure.
Osteomata may be found in the auditory canal, auricle, nasal
cavity, accessory sinuses, larynx, pharynx and tonsils.
Hereditary disposition, trauma and syphilis arc presumed to
be important factors in the etiology of the disease.
Neuromata are tumors derived from nerve structures. Tu-
mors of this character are usually mixed with fibrous tissue and
are exceedingly rare. Fraenkc! and Hunt report (Annals of
Surgery, 1904) an Interesting case of neurofibroma of the
acoustic nerve.
Cystomata, or cysro-adennmara. begin usually as an adenoma
whose glands become cystic from accumulation of fluid. They
may have an epithelial origin. The writer recalls a case of
supposed cystoma of the larynx in a man of forty years of age.
Upon laryngeal examination and spasm of the throat, the tumor
round, bluish in color and about the size of a guinea egg, would
spring into view, completely filling; the laryngn-pharynx. Dr.
G. V. Woolen, of Indianapolis, removed the tumor and found
its pedicle attached to the posterior wall of the cricoid cartili
Adenomata are tumors composed of glandular, tissue situated
within the glands or mucous membrane. Tumors of this
character are very closely allied to carcinomata.
According to Ziegler, " the chief characteristics of the ade-
noma is the formation of new glands which depart more or
less from the typical glands of the affected organ." They may
BACTERIOLOGY AND PATHOUKA .
99
be observed in the sebaceous {land of the nose and ceruminous
glands. <>f tlir auricle Of springing from the mucous glands of the
and mucous polypi, as fit>t discovered by Billroth.
Angiomata are tumors composed of new-formed blood-
vessels. They may occur m tin: skin <>r subcutaneous tissue and
appear as circumscribed elevations or a diffused infiltration
within the subcutaneous tissue. They are very often infiltrated!
with connective tissue leading to the formation of angiofibroma.
It is probable that angioma develops from dilation and diffusing
-it arterial or venous capillaries. To the eye, hemangiomata
appear as red or dark bluish infiltrations.
" Mother marks," or ncvi, belong to one of the classifications
iL'iuma. Deep or light reddish, congenital discoloration of
the car, nose or mucous membrane of the pharyngeal pillars,
characterize the affection.
Cavernous angiomata are usually acquired conditions and
arc vascular tumors formed by the conversion of thickened mu-
cous or submucous tissue into cavernous tissue by the dilation
of irtnOUS capillaries. Tumors of this character are dangerous
to life from accidental rapture.
Papilloma is an epithelial tumor appearing on the skin or
mucous surface.
The tumor b made up ol epithelial cells, which proliferate
tr.ui: :i hu.-di/cd area, appearing as u art-like tXl rrscences, singly
or in i
The character of the epithelium composing the tumor varies
according to the location. The color and density of the tumor
is dependent upon the amount of connective tissue present and
its blood supply.
PapiUomata may be either soft or hard. The former is
: uiti.l in the middle ear. nose, mouth, pharynx and larynx
and arc usual Ij covered with cylindrical cells. Tumors
of this character may Ik- sessile or pedunculated. They may
i ;; age.
iecount of the diffuse blood supply in the soft variety,
ng is a very frequent complication.
CHAPTER VII.
METHODS OF EXAMINATION OF THE NOSE, THROAT
AND EAR.
BEFORE beginning the examination of a patient a record
sliciuiii be made of the name, address, history and subjective
symptoms, bur this :i card system (see page IOl), simple in
character is greatly in vogue.
Following the examination a complete history should be
recorded, with diagnosis, treatment, and drawing of any mk
scopical lesions.
A satisfactory technique is necessary in the examination of
the ear, nose and throat. Manuel Garcia, well named the
Fio. 34.
/
IIfah Mi*kOk amd Band.
Father tti Laryngoscopy, designed a mirror in 1854 for the
observation of the larynx. About 1S58 Czermak improved upon
the method of Garcia, substituting artificial for natural light
This was reflected into the larynx by an ordinary ophthalmo
scope. It was but a short step from the plan of the ophthai-
100
METHODS OF EXAMINATION.
IOI
-i Nouvana
•u NOi-Lvuna
a
X
o
H :
*
a* : J
E :
ui ;
a •
ac •
ui .
o : _
k :
CO :
< :
ro2
DISBASB9 OP BAR, NOSE AND THROAT.
moscope to the head-mirror, which is in universal .use to-day
for tin; illumination or the ear, nusr and throat (Fig. 54).
The ordinary head-mirror is round and concave, two and
one-half to three inches in diameter, with a central opening.
A great variety of head-bands can be had, designed to suit the
tastes of all.
The electric head-mirror, on account of the amount of heat
generated, is unsatisfactory for prolonged examination or tt
ment of patients.
McKenzie's light condenser, with mirror attached to a slender
rod, is preferred by iuany (Fig. 55) to the ordinary head-band.
Quality of light in illumination, whether it be direct or in-
Fie. 55.
■ft
y
MtKexziK's Lieiri Commhss* and Rem
direct, is the first essential to an accurate observation. Tln-
dtrect light from the sun", rays, on account of its uncertainty.
is of little practical value, while artificial light with room
darkened fa the must satisfactory method of illumination. The
Wclsbach burner probably furniMic- a» satisfactory light as
any other. We should aim to secure as near a white light as
possible
Electric laryngologtcal lamps can be had through any instru-
ment bouse. They arc so constructed that reflection of a solid.
METHODS OF EXAMINATION. 103
white center takes the place of the reflection of the filament,
which destroys the usefulness of the ordinary electric lamp.
For those intending to engage in special work, the Allison
lir is comfortable to the patient and is so constructed that
1 In- operator can elevate, lower or SWlOg the patient to the
Fie. 56.
Ff«QUtON, PHILA.
Al.ltsix's TaKATMBHl C iiai a,
right or left with rase. In examination of the nose and throat,
the light should be slightly behind and on a line with the pa-
tient's ear, to the right or left side, according to the custom of
the operator. The head of the patient should be on a line with
the perfectly erect body, facing the operator. Following \ta
104
DISEASES OF EAR, NOSH AND THROAT.
examination of the nose and throat, by revolving the chair.
the ear can he examined without necessitating a change in the
position of the operator.
In examination of the anterior nares a great number of
specula are available, that designed by Miles, self-restraining,
Fig. st,
Mvuts' Nasal Speculum.
•
and Pynchon (Fig. 58) are quite as satisfactory as any others.
The tongue depressor, designed by Andrews and modified by
Pynchon (Fig. 59), on account of the width of its blade at
its extremity and the shortness of the handle, which enables
the operator to rest the point of the index finger against the
Fig. 58.
Ptkciiob's Nasal Speculum.
chin of the patient, gives a double advantage in depressing the
tongue in obstinate cases.
The rhinoscopic mirror of Fraeukcl is so constructed that
the small mirror can be pushed behind the soft palate on
a line with the tongue and when in position, elevated at
an angle sufficient to bring into view the whole of the post-
nasal space. By this method we detect the size of the posterior
hypertrophies, adenoids, tumors, the condition of meatus, of the
Ml TIIODS OF EXAMINATION.
'°5
1 UStftcbi Boor of the posterior nares, uvula and tonsils.
In passing the mirror into the posterior nares or pharyngeal
!, on account oi the tendency to cause retching care should
he taken to prevent touchinji any part of the throat.
Fig. S9.
ASDK! . I .,.! 1 III I'KFSSiiK.
In examination oi the pharynx our attention should be di-
rcctri! 10 the lips, teeth, roof of the mouth, condition of the
tongue and oral mucous membrane, tonsils in their outer, inner
and upper aspect, postnasal space and pharyngeal wall. It fre-
quently occurs that the muscles of the soft palate arc in a
1 . 60.
Wane's Palaix Retractor.
condition of involuntary contraction procluding posterior rhi-
noscopy. Under such circumstances a four per cent, solution
of locain should be applied about the soft palate and uvula.
It thi ' suffii icnl to control the spasm, a palate retractor,
'•rahly a ' ■ • i\^l,'\ {Vi^. 60). The curved hook
of this instrument is passed behind the soft palate, after which
io6
DISEASES OF EAR, NOSE AND THRfiAT.
the anterior wire luops are pushed backwards until they ar
in contact with the floor of the meatus of the nose. By mak-
ing gentle friction on the stem of the instrument the uvula is
brought forward. By turning a small screw in the base of the
anterior loop the stem is fixed in position.
For the satisfactory differentiation of morbid growths in the
post-nasal space, tongue and tonsils, it is frequently necessary
to use the finger. With the mouth gag in position, the finger,
with palm upward, can he quickly passed behind the soft
Fig. 6i.
Buck'* S»i.r n-i
palate and into the post-nasal space. In the examination of
tongue or tonsils the index finger of the right or left hand I
be used.
Salpingoscopy is a term given by Valentine to the method
of examination of the ostium of the Eustachian tube by a sal-
pingoscope, which is a modification of the cystoscopc. The
technique of the examination, according to Joseph C. Beck, is
as follows (Fig. 61) :
" Place your eye to the eye piece and make contact by turn-
ing on the switch and you will find, if the button (white) is
situated toward the lateral side, you will see the vicinity of the
tube illuminated and by moving the instrument gently forward
METHODS OF EXAMINATION.
IO7
Fig. 62.
and back, you will get the outline of the ostium tube with its
anterior and posterior lips and the dark shadow of the opening.
It must not be forgotten that we are looking through a prism,
therefore the object is inverted or, rather,
an inverted image. Also, that parts situ-
■ted near the prism appear very large
while those away, extremely small, as
Valentine shows in his picture, that is, the
velum of the palate very large and the
larynx miniature-small. However, the
lateral wall of the post-nasal space which
wc arc now examining is not markedly
lied in size, because its distance is
about medium from the prism. One may
uine both openings of the tubes
through one nostril, however, as raid
above! one will look very much smaller
than the other. Cocain is not necessary
BO] more than passing a catheter, that is,
in extremely irritable, hypersensitive
eubjec
The method of examination of the
larynx is known as laryngoscopy. For
it is necessary that one of the mirrors
as shown in the illustration be selected
(Fig. t»2) The size necessarily varies
in individuals. The one most frequently
!-; No. 5. The larger the mirror the
inn the image. With the
BOQth wide open the protruding tongue
Id be grasped between the thumb and
index linger, covered with a napkin. Care
I be taken to avoid too much trac-
Injoring the frcnum of the tongue. In this
the minor is 1 ... ,| into the oral cavity, backward until
Ina die base of the uvula, which is pressed slightly uowaul
BooAita
Throat Mikkokx.
"OS DISEASES OF EAR, NOSE AND THROAT.
and backward as the occasion may demand. Uy having the
patient repeat the letter " a " the larynx is litted upward ami
exposed to view. In a few cases, the base of the tongue may
obstruct the view; to obviate this, Kirstein designed a special
tongue depressor. The spasm of the pharynx, which some-
Fic. 6j.
MOOT.
times prevents the immediate exposure of the larynx, may
be often overcome by temporarily holding the KM ;■ KM
seconds before trying to insert the mirror.
If this process is unsatisfactory the throat and naso-ph.
should be sprayed with a four per cent, solution of cocain.
The beginner will find some difficulty in learning the art of
laryngoscopy. It is only with patient efforts that obstacles
can be overcome.
METHODS OF EXAMINATION.
The art of direct examination of the larynx is known as
autoscopy, first described by Kirstein of Berlin in 1895 (Fig.
63).
In the method of examination as recommended by Kirstein,
the physician stands in front of the patient. The patient
teaftedj bend* slightly forward and elevates the chin, bring-
ing the neck and mouth on a line drawn through the larynx.
The autoscope is grasped with the left hand and passed di-
rectly into the mouth. The spatula is directed backward
and downward until the " tip catches in the groove between
the tongue and epiglottis." The handle is elevated, bringing
the hood in contact with the teeth. The electric light should
be turned on before the instrument is introduced, so that
the mouth and larynx are under direct observation. The
autOSCQpe may be used in the direct removal of morbid growths,
foreign bodies accidentally sucked into the larynx and direct
medication. A variety* oi instruments are recommended by
Kirstein for autoscopic operations.
In the examination of the ear the same rule in regard to
Illumination and head-mirror is applicable as in examination
of the nose and throat.
After a complete history of subjective symptoms has been
recorded, the external ear should first be recorded, followed
by inspection of the meatus, auditory canal and membrana tym-
pani. In the negro the canal is unusually straight and large.
By lifting the pinna and retracting the tragus the entire canal
Exposed. In the Caucasian, however, the examination is more
difficult on account of the hair about the meatus and curve
of the canal. To obviate this and to aid in inspection of the
ordinary canal, a variety of ear specula have been devised. That
designed by Boucheron has many advantages over those de-
signed by Gruber, Toynbee and others. They should be made
ut bSvCI and sterilized before being used.
For the estimation of the mobility of the drum the Sicgle
pneumatic OtOSCOpe is of practical value (Fie. 64).
For the determination of the mobility of the ossicles and
I to
DISEASES OF EAR, NOSE AND THROAT.
membrana tympani, Sickle's pneumatic speculum is emph
The speculum is made of plated metal itr hard rubber, covered
by a thin plate of glass at its
F|G' 64- wide extremity. For thi-4 a
nipple projects over which a
M .ft rubber tube connects
with a small rubber tube in
turn connected with a small
rubber bulb. The speculum
should be covered with a small
piece of rubber tubing WntCn
should be moistened before-
being inserted into the ear.
With the light from a fore-
head mirror carefully adjusted
and the speculum id po
by a gentle compression and
relaxation of the hand bulb.
the movements of the mem-
brana tympani and n
be observed.
In the examination and
treatment of the Eustachian
tube, a German silver catheter
is necessary-. Four sizes are
to be had, numbers two and
three being more often used.
The curve may be altered to
suit individual cases. lr w ill
be noticed that the ostium tuba
varies in its position and size.
Siaou'i otuscoml The transverse diameter of
the pharynx is not always the
same and in consequence, the amount of curvature of the can-
nula will vary in individuals.
METHODS OF EXAMINATION.
Ill
The nasal cavity should be sprayed with a one per cent,
solution oi cocain before attempting to pass the catheter. A
k u operators pass the catheter without the use of cocain. In
the use of all instruments about the ear, nose and throat it is a
very good rule to remember that the confidence of the patient
and willingness to carry out the physician's instructions de-
pends to a great extent upon the minimum amount of pain
caused at each treatment.
The catheter can be dipped in boiling water, pure alcohol
or carbolic acid for sterilization and should be oiled and any
debris dislodged by forcing the air through it before any attempt
is made at catheterization.
Fig. 65.
I'DLITZLK H.Vi.
Pulitzer, Gruhrr ami Lowenburg have laid down respective
methods for the introduction of the catheter. In the Politzer
method the catheter is held in the right hand, the curved tip
pointing downward and inward. It is quickly passed along the
floor of the nose until it reaches the posterior wall of the naso-
pharynx and is then brought slightly forward and turned out-
ward, again carried forward across Rosenmiiller's fossa?, when
turned outward and upward into the mouth of the Eusta-
chian tube.
In the Gruber method the tube is passed quickly backward
] 12
DISEASES OF EAR, NOSE AND THROAT.
until it strikes the naso-pharynx. It is then rotated to tin-
septum and brought forward until it strikes the sort palate,
when it is turned outward and passed into the Eustachian tube.
The Lowenburg method resembles the method of Grubcr in
that the catheter, after reaching the wall of the naso-pharynx,
is turned on its axis and brought forward until it strikes the
posterior end of the septum, when it is rotated downward and
outward into the tubal opening.
In addition to the catheter, the soft rubber Politzer bag of
six to eight ounces should be provided with a soft rubber tube
twenty-five to thirty inches in length joined to a hard rubber tip
which fits the catheter.
The auscultation tube of Toynbee (Fig. 66) should always
be used in inflating the Eustachian rube and middle ear. One
Pic. 66.
IIB'S DlAGXOSTIC TttM.
end may be placed in the ear to he catheterized and the oTher
in the physician's car. Only by this method can we tell abso-
lutely when the catheter is in position or the character of the
sound produced by inflation. A wide blowing sound is an
indication of an open tube. A high pitched sound is suggestive
of a constriction in the tube. A whistling sound suggc»i
perforation of the drum. The absence nf sound indicates the
catheter is not in position or that the Eustachian tube is com-
pletely closed.
The Polii thod of inflating the middle car C0i
in placing the tip of the Sag in the anterior narcs after giving
METHODS OF EXAMINATION.
the patient a small swallow of water with instructions to hold
the lips tightly closed until instructed to swallow. At the count
of three the patient should swallow ; at the same time, with the
opposite side of the nose closed, the physician makes a quick
pressure upon the bag, forcing the air into the middle ear.
allowing, the tensor palate is relaxed, which opens the Eu-
stachian tube. G ruber suggests that instead of using water,
the child should be instructed to say :' hick " or u hack." The
letter "k" may also be spoken. Sometimes by puffing out the
lips air may be forced into the nose and then into the middle ear.
For the last method the Pynchon small inflator may be attached
to the spray cut off and used with more case and success than
with the Politzer bag.
Deformities of the nasal fossa or morbid growths may so
obstruct the canal as to prevent the introduction of a catheter.
Small obstacles may frequently be passed if care is taken to
gently find a new direction. Deformities of this character de-
mand surgical measures for their removal.
Tests of Hearing. — Sonorous vibrations reach the auditory
nerve at its termination in the labyrinth by way of the audi-
tory canal, the Eustachian tube and through the bones of the
head. For detecting the amount of hearing power by each of
the channels enumerated, the following tests are recommended:
Whisper Test. — Unless the examiner exercises great care
in the choice of words, letters, numerals, pitch of voice, room
and position of patient results will be very inaccurate in this
method. It is best for the examiner, from repeated tests upon
normal ears, to establish a fixed distance for recording tests of
this character. Variations in this position will be eagerly
watched by the patient. The patient should be placed at a
certain distance with the eyes bandaged.
Many years ago Oscar Wolf gave to rhe world his investi-
gations of the voice as a test of hearing. The letter " R " is
taken as the lowest in the scale, having one hundred and
twenty-eight vibrations per second, and the letter " S " as the
highest number of vibrations, having from five thousand four
"I
DISEASES OF EAR, NOSE AND THROAT.
hundred to ten thousand eight hundred and forty vibrations
per second. " Thus may lie tested from the lower to two octaves
of the higher musical tones." Thus in disease of the middle
ear or auditory canal, those letters of low number of vibrations
will be lost, while in labyrinthian disease low vibrations will
he heard and high vibrations lost. The voice test should be
used only with residual air.
Watch Test. — Like the voice, this test is subject to inac-
curacy. The ordinary watch test is heard from thirty to forty
inches. As in the voice and tuning fork, it must be remem-
bered, those of high pitch are hest heard when there is middle
car disease and low pitch when there are labyrinthian compli-
cations. Two watches are used, one with high pitched ticker
and the other Jow pitched.
In recording this test the normal distance is taken as denomi-
nator and the distance at which the watch is heard as the
Fie. 67.
R»xn*Li.'« Cumcm. Sn o* Tl'hirc Fo«k».
numerator, thus, if heard at fifteen inches, the record should
read 15.40. if upon contact only, watd The watch
may also be applied to the mastoid or malai bone. LoM of hone
.METHODS OF EXAMINATION.
1 '5
;, Miction suggests internal ear disease. 1c must be rcmetn-
hcred that secretions in the middle ear or temporary loss of ten-
sion may partially destroy bone conduction. Lnder such con-
ditions the middle ear should be inflated and watch reapplied
and if bone conduction is still lost other tests may be applied
for the detection ot the trouble.
Tuning Fork Test. — The Hartmann set of five tuning
forks, C, C— l. C a, C >. C 4, varying in size from one hun-
dred twenty-rive t<> two thousand forty-eight vibrations per
second, arc more often used in making the Weber and Rinne
tests (Fig. 07).
For making a complete test, in addition to the Hartmrmn
set of tuning forks, the Iiezold-Ldclman set of forks and whistles
with a range from sixteen to forty-eight thousand vibrations,
the norma] range of hearing for individuals under fifty years
of age, is the best.
The ends of the fork should be provided with movable clamps
to prevent overtones and to govern the pitch of the instrument.
In the Weber Test, the tuning fork, preferably 256 V, is
placed in the median line of the skull. If there is disease ot
one or both ears involving the Eustachian tube, middle enr or
stoppage of the external auditory canal, the tuning fork will be
heard loudest on- the diseased side; if one. side only is diseased
vibrations will alone be heard on that side. If the vibrations
are heard only on the side of the good ear. disease of the laby-
rinth is indicated. Where we have diseases of both the middle
ear and labyrinth we have two opposing conditions. The test
is not so reliable in bilateral as in unilateral deafness.
In the classical Rinne Test, introduced by Rinne of Prague
in iSss.. wc discover the relative hearing power by bone and
air conduction. In the normal car the vibrations of the air
are heard from fifteen '" twenty seconds longer than through
the mastoid. In the use of this test the position of the tuning
, .■-.<■ \ . upon the mastoid and movements of the fork to
the auditory canal must be considered, likewise the age of the
patient, as bone conduction is sliyhtlv diminished in those ov«
is of age.
fi6
DISEASES OK EAR, NOSE AND THROAT.
This test is of such practical importance and is BO little
understood by the student that an effort will be made to sim-
plify it, stating the proposition so that it may be practical])
applied.
This test is formed by placing the fork upon the mastoid,
noting the length of time vibrations are heard and then quickly
transferring before the ear and noting the revival of vibratior
and length of time.
If the vibrations last for fifteen to twenty seconds we registe
" Rinne normal." If, say five seconds, we register " Rt'nne
(positive) 5." If the vibrations are not heard through the air,
we register 'Rinne — (negative)."
Advisedly speaking, diagnostic signs of this character arc
not infallible. By this knowledge and conductive reasoning Wt
arrive at a clear understanding of the character of the <\ •
The following proposition is a modification of the one
forth by Dnndas Grant and wrill possibly give the student
clear conception of the application and value of the test. It is
to be remembered that the Rinne test gives more accurate
knowledge of the sound-conducting apparatus than the pcT-
ceiving apparatus.
AC = Air conduction.
BC = Bone conduction.
AOD = Aero-osseal difference, or 20" (20 secon
S.t'lD Normal aero-osseal difference.
JC—BC (bone conduction) + 20".
\ /OD = 2o". Rinne positive, 1. t„ conducting apparatt
normal.
\ !0l) — 10" = Rinne positive but shortened, conductive
apparatus is one-half affected.
SAOD — 20" =0. Rinne negative, the conductive apfM
ratUS considerably affected.
S.IOD — BC = Disease of the perceiving apparatus.
S.IOD — (BC -f IO" ) Partial disease of the per
apparatus.
METHODS OF EXAMINATION.
"7
NJOD — [BC -f- 10") — (AC -f 10") = Disease of per-
ceiving apparatus.
In the test recommended by Gardner Brown, the tuning
fork is applied to the bridge of the nose; if the vibrations can-
not be heard as long by the patient as by the finger of the
operator, there is loss of bone conduction. In this method,. the
finger of the operator must be trained to the test.
An acoumctcr was devised by I'olitzer for examining the
relative hearing distance. It is an instrument tuned to a
certain pitch with no variations in intensity. It is supposed
to be heard at forty feet, which number is taken as the de-
nominator in recording the test.
Schwabach Test. — This test is made by ascertaining the
number uf seconds the fork is heard upon the mastoid and
through the air and comparing with the normal register of the
fork. Thus an increase of bone conduction over the normal,
would indicate disease of the conducting apparatus; below the
normal, disease of the perceiving apparatus. When both air
bone conduction is below the normal, there is probable
disease of both middle ear and labyrinth.
The Gelle Test. — In this test the air in the external audi-
: il is compressed and the fork placed upon the vertex.
In the normal ear, the vibrations are diminished. If there
is ankvlosis of the foot plate, according to Gelle, there will
be no change in vibrations. If labyrinthian disease is present,
there is marked diminution of vibration with each COmpresaiOIL
Bing Test. — " This test is also used to differentiate between
middle ear and labyrinthian affection. This experiment is
based upon the fact that when the tuning fork ceases to be heard
upon the mastoid it is heard anew when the external meatus is
closed with the finger. In cases with pronounced deafness, if
log the meatus does not develop the tone anew, it is, accord-
ing to Bing, a sign of middle ear disease, whereas, if it is heard
again (in cases of pronounced deafness), it is a sign of laby-
rinthian disease" (Ballrneer).
2. " This test is thus referred to for the sake of comrenicrtcc
.rS
DISEASES OF EAR, NOSE AND THROAT.
in reference and refers to what Bing calls the " entotic ' OSC
of the speaking tube. The purpose of the test is to differentiate
between ankylosis of the foot plate of the stapes and adhesive
bands or other pathological conditions which hinder the malleus
and incus in transmitting sound waves. The test is made by
comparing the hearing of the patient through a speaking tube
applied to the Eustachian tube by means of a suitable attachment
fitting into the Eustachian catheter. If the patient hears better
through the speaking tube by way of the catheter than he does
through the externa] meatus, the inference is that the foot plate
is freely movable while the malleus and incus are fixed i>r hin-
dered in their vibrations. It such is the case, a rational sort of
treatment is at once suggested, i. e., either the freeing of the
malleus and incus from the adhesions or other hindrances or
removing one or both, perhaps preferably only the incus. The
sound waves might then reach the foot plate through the vibra-
tion of the air in the tympanic cavity and hearing be materially
improved" (Ballenger).
The Galton Whistle. — With this instrument, which acts
as a dosed Organ pipe, the vibrations frum sixteen to i<
thousand per second arc produced. With it relative tests fbl
Fie. 68.
Galtom'j Wi
low tones are registered (Fig. 68). If the high n
are detected and the low notes lost, it is suggestive <>i middle
rar complications. If high notes are lost and low notes de-
tected, disease of the internal ear is probable.
Konig's Rods. — Konig'g rods consist of a series of
steel cylinders of various lengths. With this method, the upper
tone limit is more accurately determined.
CHAPTER VIII.
SPECIAL INSTRUMENTS AND THERAPY.
In the home treatment of the upper air passages, hand atom-
izers an: in universal use. Many of these are badly constructed
and in consequence, patients complain greatly at the incon-
venience occasioned by their getting out of order.
Fig. 69.
,'•'•
NS It.
1»- \ II III \ MIZBB.
The hand atomi/cr «if Dc Vilbiss (Fig. 69) is of metal
and is easily taken apart and cleaned. The tip of this spray
on be adjusted to anj direction, a great advantage in spray-
ing the laryngo-pharyiix.
The form of atomizers for olhce use are those known ris the
Davidson, De Vilbiss ant I Sass (Fig. 70).
riders for 'ompressed air should possess an air meter so
that the air pressure injected into the nose and throat can W
modified to the individual demand. The methods followed
by many practitioners of trying to regulate the pressure by the
cut-off is unsatisfactory- and unscientific. The air supplied to
the cylinder is usually through hydraulic or hand pumps, though
119
120
nisi \sr.s or ear, nose and throat.
many offices are now supplied with air pumped from a central
union. Under such circumstances the pressure is so strong
that it can be controlled only by cylinder and air meter.
Fig. 70.
[GS.2
--":--•
N954
l>K VlL»l^« Ath«1»(.«.
Ail iilters, as recommended by Oreo J. Stein, are especially
recommended to prevent dust and water from reaching air
cylinder (Fig. 71 ).
The Davidson hard-rubber -prays for cleaning are in uni-
versal use. For cleansing the post-nasal space, the post-nasal
tip is of great advantage. By this method, the stream is thfl
in a tan shape, spreading out over the entire fossa. The tip
being large, it is more easily passed behind the palate, acting, if
necessary, as a retractor.
The. hand nebulizer offers the advantage of cheapness over
the multiple nebulizer. One or the other is indispensable in
the medication of the middle ear. By this method of treatment,
medicines two or three times stronger than those used in the
ordinary spray can be forced to points where fluids cannot.
A heater of value for keeping solutions at a uniform tem-
perature is one designed by L. C. Cline. The source of heat
is a small electric light globe. Warm fluids injected into the
nose and throat are more quickly absorbed and less likely to
irritate.
122 DISEASES OF EAR, NOSE AND THROAT.
porcelain. Those of hard rubber are very light, while those of
porcelain have the advantage over the others in that they are
not easily broken and do not lose their shape if left in boiling
water, as do those of hard ruhher or marhr.
Fig. 72.
fllll'IH—
In using the hand atomizer (Fig. 69), the patient should
be instructed to hold the atomizer directly in front of the face,
the tube of the atomizer being on a line with the long axis of
the nose. The spray tip should be inserted within the vestibule
SPECIAL INSTRUMENTS AND THERAPY. 1 23
of tlic nose, ar the same time gently lifting the end <ri the nose.
Core should be taken that the tube is not turned to the right
or left, for by so doing, injury is caused to the mucous mem-
brane covering the septum or turbinated bodies by the force of
the spray. Bleeding frequently occurs from faulty direction
of the spray tube, followed by mild infection. It is nearly im-
possible for the patient to cleanse the attic of the nose with a
hand atomizer. There is a distinct advantage gained by the use
of the atomizer, in that the t-olutions are absorbed and have a
direct influence upon the inflammation and exudation.
The aqueous solutions frequently prescribed for home treat-
ment for cleansing, are all mildly astringent and antiseptic
and are as follows:
1? fodgteM^Vji 4QOgm (3i)
Sotlii bibor.. I
Phenol (cry»t»), 1.00 c.c (gtt- xv)
Glycerin i, 30.00 c.c. (3 0
Aquas, ad q. s.
M.
Sign a. (For Dobell's solution.) Add lo quart of water and
Aquar, a. d. qs. 120.00 c.c. ($ iv)
fa) IJ Glyccro-thvmol, 120.00 c.c. (5 iv)
Signs. Add uiie teaspoonful tn four tablMpflODfnll of water and
use in atomizer.
B Sodii bicarb., "1 -- . ,- ...
Sodu bibor., '
ShI. BntUeptlcJ (lister), 140*0 c-c. (3 riii]
lini. 750,00 cc. (J xxiv)
Aqua-, <0 xxiv)
SlglMi lor I'ynrlinn solution (98 a-b).
.tS gm. (gr. iii)
Z.OO cc. (gtt. XXX )
jo.00 cc- (5 i3
.30 gm. (gr. v)
4*0 cc. (3 i)
30*0 ex. (5 •)
12.} DISEASES OF EAR,
NOSE
AND THROAT.
\i Tinci. iodi corap.,
4.00 c.c. (5 i)
Phenol (crypt),
1.16 Km. (gr, xviii]
Glyccrini,
75.00 c.c (J iiss)
Aq. dot.,
3CMX1 r.c. (5 i)
(Bolton)
B Ichthyol,
2.00 c.c (5 •»)
Aqua:,
.
120.00 c.c. (5 iv)
The following antiseptic solutions are often recommended 10
suppurative inflammation, ma
lignant
growths and fracture of
the nose.
B Resorcin,
.iS c.c. (gr. iii)
Glyccrini.
4.00 C.C. (5 i'l
Aqua:,
B Phenol,
.30 gm. (gt
Glyccrini,
4.00 c.c. {Si)
Aquae,
30.00 c.c. (5 i)
B Potass, permang..
.06 gm. (gr. i)
Aqua:,
30.00 c.c. |
]i Formalin (40%)
.30 cc. (gtr. v)
Aqua:,
30.00 cc (5 «)
(4) B Soilii bicarb.,
30.00 gm. (5 viii)
Sodii hihor.,
30.00 gm, (5 viii)
Sodii ben 20a t is, 1 gg
Sodii sal icy la lis, '
T.20 gm. (gr. xx)
Eucalvpiol.
Thymol, /
.60 gm. (gr. x)
Menthol,
.30 gm. (gr. v)
Ul. gaultheria-,
.36 c.c (gtt. vi)
Glyccrini,
45.00 c.c. (3 viij»s)
Alcohol is,
60.00 cc. (3 ij)
Aqua-, q. s. ad.
8.00 liters (Oxvj)
M. For Seller's solution.
Signa. To he u*rd in an atomi/er.
(5) B Arnmoni chloridi.
2.4 10
4.8 gm. (gr. il bone)
Aqua: menthol!
240.00 c.c. (J viii)
Signa. To be used in atomizer.
(Recommended by Sliurley as
a cleansing and mildly Btimubrin-
solution.)
SPECIAL INSTRUMENTS AND THURAl'V.
■-5
(6) # Sodii ben?., 15.00 gm. (3 ss)
Aqua: ralri\ 240.00 c.c. (3 viii)
I Recommended by Shurley for cleansing is acute coryza.)
(7) 1J Sodii chlnricli,
Sodii bicarb.,
Borolyptol,
Aq. destill., q. ft, ad.
Signs. To He tttd in atomizer.
.30 gm. (gr. v)
•36 gm. (gr. vi)
r<;.<x> c.r. (5 *»)
30.00 c.c. (5 i)
Astringent solutions are vegetable and mineral and are in-
dicated in evudativc inflammation of the nose and throat.
Among the formula frequently recommended for use in atom-
izer at home and in the physician's office are :
B
1 rlyeerol tannic,
4.00 c.c. |
Aqua:, ad.
30.00 c.c. fj i)
I-
Argcnti oitratit,
.18 gm. (gr. iii)
Aqus,
30.00 c.c. (5 i)
»
Argenti nitram,
.03 gra. (gr. 'A)
Aq\iT,
30.00 c.c. (3 i)
1-
Alumeniis,
.60 gm. (gr. x)
Aq. hamamelU dot.,
8.00 (3 ii)
Ai|u.t, q, s. ad.
30.00 c.c. (3 i)
9
Zinc sulpli .
.34 gm. (gr. iv)
AtfitB,
30.00 C.C. (3 »)
9
Zinc ptiei]ol.iul|iliunatc,
.12 gm. (gr. ii)
Aqua:,
30.00 c.c. (3 i)
9
loimalin (40/),
I -SO C.C. (qt. xx)
A qua:,
30.00 c.c. (3 i )
M.
For tubercular laryngitis.
In addition to the aqucou*. scilutiotis, titany solutions
posed of refined albolene as a base, with one or more chemicals
in solution are indicated after cleansing End direct medication
to the nose and throat. It is necessary that some preparation
of this character he sprayed into the nasal cavity to cover
protect the denuded mucous membrane. Otherwise, infection
I 2b
DISEASES OF EAR, NOSE AND THROAT.
or hyperemia results, which may lead to an attack of rcuK
coryza. This is especially true when the patient goes immedi-
ately out of doors after treatment.
Oil solutions may be used in the ordinary spray or in a
nebulizer (Fig. 73).
In the treatment of the upper and lower air passages, nebu-
lizers manufactured by the Globe Nebulizing Company and
Ue Vilbiss are in great favor.
There is a distinct advantage in using the nebulizer over
the atomizer in that stronger solutions can be used.
Fig. 73.
N949.
II MM NmH'I.I.'I U
It is to ho remembered that an oil spray, if used tor a
great length of time, may fill the glands of the mucous mem-
brane, hringing about a functional anil strurtur.il alteration.
The following solutions are frequently used in atomizer and
nebuli/ri :
B
Camphor,
Menthol.
Albolcnc.
.34 Rin. (Rr. iv)
-i* gm. fgr. iv)
30.00 e.c (3 i)
SPECIAL INSTRUMENTS AND THERAPY.
I27
5
Thymol,
.12 gm. (gr. ij)
Menthol,
.12 gm. (gr. ij)
Albolene,
30.00 c.c. (3 j)
(Brown)
B
Thymol,
.60 gm. (gr. x)
Menthol,
1.20 gm. (gr. xx)
Eucalyptol,
1.20 c.c. (gtt. xx)
01. cubebae,
.60 gm. (gtt. x)
Benzoinol,
180.00 c.c. (f^vj.-M)
(Douglas)
B
Choloretone,
.42 gm. (gr. viiss)
Camphors,
4.50 gm. (gr. lxxv)
Menthol,
4.50 gm. (gr. lxxv)
01. cinnamon!,
42 c.c. (gtt. viiss)
01. petrolina;,
90.00 c.c. (3 iii)
(McClintock)
5
Acetoform,
.60 c.c. (gr. x)
Camphor, \ ^
Menthol, >
1.20 c.c. (gr. xx )
Eucalyptol,
.30 c.c. (gtt. v)
Petronol (Lilly), q. 8.
120.00 c.c. (5 iv)
(Masters)
8
Acetozone,
0.50 gm. (gr. viii)
Chloretone cryst.,
0.50 gm. (gr. viii)
Ol. petrolatum,
90.00 gm. (3 iii)
8
Olive oil,
8.00 c.c. (3 ii)
Aristol,
1.20 gm. (gr. xx )
Signa
u Dissolve, and add to the following:
Acetoform, •
.60 gm. (gr. x)
Camphor,
1.20 gm. (gr. xx)
Menthol,
1.20 gm. (gr. xx)
Eucalyptol,
.72 c.c. (min. xii)
Albolene,
60.00 c.c. (5 '')
M.
The above solutions are applicable as a routine measure in
the treatment of acute and chronic catarrhal and acute and
chronic purulent affections of the nose and throat following
direct medication.
128 DISEASES OF EAR,
MOSS
AMD TIIFU>V1.
The following solutions are
indicated in the treatment of the
enumerated affections of the upper and lower air passages.
IJ- Menthol,
Albolene,
.60 gm. (gr. x)
60.00 c.e. (3 ij)
(Brown)
In chronic pharyngitis:
IJ Menthol,
Ol. caryoph.,
Albolene,
-35 Km> fS'- vi)
.67 co (gr. xi)
30.00 c.e. (5 j)
( Brown )
IJ Thymnl,
Menili"],
OI. anisi,
Albolene,
.06 gm. (gr. j)
.35 gm. (gr. ri)
8.00 e.c. (5 ij)
30.00 c.c. (3 j)
(Brown)
B 01. menth. pip.,
Albolene,
4.65 c.c. (3 jJ4)
30.00 c.c. (5 j)
In nasopharyngeal catarrh:
R Thymol.
Menthol,
Eucalyptol,
01. cubebje,
Beasolooli
.65 gm. (gr. xi)
1.3a gm. (gr. >o
1.30 c.c. (gtc XX )
2.50 c.c (gtt. xll
178.00 e.c (J vj'l
For general use after alkaline
spray-
# Crrawiti,
Ol. picis. liquidae,
Allmlcnc,
♦.00 cc (3 j)
i.aj cc (gtt. xx)
15.00 cc. (J n)
In laryngeal tuberculosis:
8 Camphorse,
McinluW,
Ol. santali,
Albolene,
.06 gm. (gi
.14 gm. (gr. iv)
-JO «• (*««■ vi
30.00 cc (
In rheumatic pharyngitis:
SPECIAL INSTRUMENTS AND THERAPY. 1 29
Ifc Ol. gaultheris, .12 c.c. (gtt. ij)
Camphor-menthol, ) ^ j% fcfc ( .. }
Ol. eucalypt, ■>
Cocain. hydrochloratis, .13 gm. (gr. ij)
Benzoinol, 30.00 c.c. (3 j)
Use with a spray for acute laryngitis, pharyngitis, coryza, etc.:
Camphor-menthol, .12 gm. (m. ij)
Ol. eucalypti, .18 c.c. (gtt. iij)
Benzoinol, 30.00 c.c. (3 j)
Signa. Use in spray for chronic catarrh, adenoids, hyper-
trophy, etc.
Among formula in common use with the Globe nebulizers,
are the following:
IJ Ol. eucalypti, .92 c.c. (gtt. xv)
Menthol, .32 gm. (gr. v)
Benzoinol, 30.00 c.c. (5 j)
Signa. Use with a nebulizer for simple catarrh of the nose,
throat and bronchial tubes and after the first stage of all acute
inflammations.
•
5 Ol. caryophylli, .46 gm. (gr. vij)
Creasoti (beechwood), .97 gm. (gr. xv)
Ol. picis. liq., .97 gm. (gr. xv)
Iodi, .46 gm. (gr. vij)
Benzoinol, 30.00 c.c. (5 j)
Signa. Use with a nebulizer for pulmonary and laryngeal tuber-
culosis and in any condition requiring an active antiseptic.
5L Creasoti (beechwood), 1.00 c.c. (m xv)
Ol. picis. liq., 1.00 c.c. (m xv)
Benzoinol, 30.00 c.c. (3 j)
5 Eucalyptol, ~|
01. cassia;, L-- ,- .,
Creasoti, J " *°° "■ (° j)
01. picis. liq.,
Albolene, q. s. ft. 120.00 c.c. (f 3 >▼)
Signa. Use with nebulizer in pulmonary and laryngeal tuber-
culosis. Healing and antiseptic.
■32 gm. (gr. vi
c. (in xv)
2.00 c.c. (gr. xxx )
i -oo c.c. I M 1 1
30.00 i:.c. CS '})
130 DISEASES OF EAR, NOSE AND THROAT
k lodi,
()!. pick liq..
Camphor-menthol,
01. gaultlieri.T,
A I bole ne,
Signs. Oh with nebulizer for chronic, naso-pharyngcal and bron-
chial catarrh. Alterative and antiseptic.
]$ Acetczone crystals, .50 gm. (gr. viiii
Chloretone crystals, -50 gm. (gr. viii)
Refined bland mineral oil, 90.00 c.c. (J iii 1
Signa. For chronic bronchitis; antiseptic.
Inhalations.— This form of treatment for the mucous
branes of the upper air passages has. for a long time, received
the universal recognization of the medical profession. Numerous
instruments of simple and complicated construction, all on
the s.-une principle, are on the market. They consist of a
spirit lamp, water reservoir and bulb-tube, midway of which
is placed a sponge in which the fluid to be inhaled, is placed.
The steam from the boiling water, in passing through the
sponge, is impregnated with the medicine and by deep in-
halations, is' carried into the larynx anil bronchi. A mudi
cheaper instrument, known as a hot-water inhaler, con
of an ordinary cup with a long tube for inhaling the 9b
and may be had for the sum of twenty-five cents. Where the
perfected instrument cannot he had. the benzoin inhaler will
prove a very good substitute.
The principle involved is that certain drugs in boiling water
"i Iteam, thus impregnated, can he carried deep into the l.-i
bronchi, Inhalations are of special value in treating laryngeal
affections. Those remedies recommended, especially, possess the
virtue of being antiseptic, astringent and sedative, among which
are:
Tincc. benzoin i tump..
A.pi.r, q. t.
$ Phenol,
Aqua:, <[. ».
15.00 C.C. ($ »)
480-00 r.r. (5 xv j)
.92 c.c. (gtt. xv )
480.00 c.c. (3 xv j)
SPECIAL INSTRUMENTS AND THERAPY. 131
# Tinct. iodi, .42 c.c. (gtt. xv)
Aqua;, q. s. 480.00 c.c. (5 xvj)
5 C re a sot i, .92 c.c. (gtt. xv)
Aqua;, 480.00 c.c. (3 xvj)
Ifc Tinct. opii, 3.75 c.c. (3 j)
Aquae, 30.00 c.c. (5 j)
5 Ferri perch lor idi, .12 C.C. (gtt. ij)
Aqua:, 30.00 c.c. (5 j)
IJ Zinci sulphatis, .12 gm. (gr. ij)
Aquas, 30.00 c.c. (5 j)
The following formulae are from the London Throat Hos-
pital:
5
Creasoti,
Magnesii carbonat.,
Aqua; destill.,
2.10 c.c. (gtt. xxxij)
3.75 gm. (5 j)
30.00 c.c. (5 j)
5
01. cubebas,
Magnesii carbonat.,
Aqur destill.,
.06 c.c. (gtt. j)
1.30 gm. (gr. xx)
30.00 c.c. (3 j)
5
Ol. pini sylvestris,
Magnesii carbonat.,
Aqua; destill.,
2.50 c.c. (gtt. xl)
3.75 gm. (3 j)
30.00 c.c. (3 j)
s
Spt. camphorx,
Spt. vini rect,
Aqua; destill.,
3.75 c.c. (3 j)
i-95 cc. (gtt. xxx)
30.00 c.c. (3 j)
Sedatives:
S
Ferri sulph.,
Aquas,
•97 Rm- (f?r. xv)
30.00 c.c. (3 j)
R
Ferri et ammon. sulph.,
Aqua;,
.97 gm. (gr. xv )
30.00 c.c. (3 j)
B
Iodi,
Potassii iodidi,
Aquas,
1.92 gm. (gr. xxx)
.32 gm. (gr. v)
30.00 c.c. (3 j)
U
Acidi hydrocyanic!,
Aquae,
3-75 gm. (5 j)
30.00 c.c. (3 j)
Signa. Teaspoooful of the above formula; to a pint of water.
l$l DISEASES OK EAR, NOSE AMD THROAT.
Gargle. — Unless used scientifically, solutions prescribed for
rhis method of treatment are of little value, especiall] in the
treatment of the posterior pillar of the tonsils, pharynx and
larynx.
Investigations bj Pope, nf San Francisco, with methylene
blue, mucilage and magnesia, when used as a parglc, shows tli.it
the pharynx remains untarnished, while the tongue, hard palate
and anterior pillars were covered with the pigment
Should it be found necessary to recommend gargles, patients
should be instructed to fill the month with the fluid, dose the
nose tightly, throw the head far back ami gargle. By this
method, fluids will reach the pharynx and posterior walls of the
tonsils. The following arc some of the formula- frequently u
B ISorolyploI, 30.00 e.C (3 >>
I'hcnol, .96 gm, (gr. xvj)
Glyeerinl, 8.00 c.c. (5 i|i
Aqua mcnlhoHs, q. «. ad. 120.00 c.c. (5 h
M.
Signa. Antisepiic gargle.
B Acldi tannic!, > u , ,,
., 240 gm. (gr. xl)
Ahimrn, I
A<|. 1 120.00 c.e. (5
M.
Si>{iia. Am a jjarnlc in hemorrhage following tonsillotomy.
b' To. tcni cMor., 4.00 c.c. (5 J)
Patau, ehloritis, 2.00 gm. (gr, not]
' Hyi erioi, 4.00 c.c. (3 ii
Aq. debt., jo.00 ex. 1
M.
Signa. Follicular tOQBlls.
K Zinci phenobulphonatis, .30 gm. (gr. v)
Gijroerini, 4.00 ■ . i J)
Aqutaococholi*, 30.00 oc. (\ i)
M
Signs. For acute pliarvnuitin.
Douche. — This form of application of medicated 9
:ially to the nose, has in recent years been almost relegated
11 EC1AL INSTRUMENTS AND TMhRAI'V.
'33
to the past. For cleansing am! treating the nasal cavity, it was
first introduced by Weber of Halle, Germany. The author of
;!ii. u rili, i, | recommends th.it the reservoir should not be elt-
vated above the eyebrows. This is done in Order to lessen the
liability of the entrance of fluid, during the act of swallow ing,
into the Eustachian tube where it might pass into the middle
ear, causing severe inflammation. The danger of using the
douche must not be underestimated, since disturbances in the
ise of smell, headache and suppuration of the middle ear
;:u\ be occasioned,
e Weber introduced this method, a great many douches
have been devised. I he Kirkpatrick and Birmingham douches
are inure highU recommended. Those instruments should be
held gently in the nose, allowing the fluid to flow naturally' and
without the assistance of the patient in snuffing through the
tiuse. The lone-continued use of the douche is to be condemned
8S it may act as an irritant and thus aggravate rather than palliate
disease.
l.ichwitz recommends that the douche should only be used
when there is something to remove, such as Increased secretions
and crusts. Following this mode of treatment, the nasal cavity
should be carefully cleansed with cotton and probe, after which
smile bland application should be made. The solutions usually
prescribed for a douche are the same as used in an atomizer.
Paraffine Prothesis. — Paraffine prothesis Cor the corrci
■ •t detormin of the nose and auricle, has become a routine
practiceg judging from the abundance <>t literature on the subject,
since its introduction bj • fersung, in iqoo.
Specially prepared paraffine can be had at any of the instru-
ment houses, but that prepared by Charles N. Leigh, chemist,
StW York, under the direction of Dr. Herman Smith, and
:-rd of in small tubes, is specialty recommended. The
ge designed by Dr. Smith is a valuable one, meeting all
requirements (Fig. 74.).
Paraffine prosthesis is recommended for the correction of
saddle nose, atrophic rhinitis ( Helsmortic I . deformities resulting
».H
DISEASES OF EAR, NOSE AND THROAT.
from operations upon the frontal sinuses (Broeckaert), and de-
formities of the external car following the r.! op-
eration (Alt).
Whether or not the paraffin, which becomes encapsulated,
will hrcak up and become disintegrated, is a matter for future
investigators. At the present time it is believed that it will
FlC. 74>
PARAFFIN SYRINGE
JWi'tW1
Smith's PAHArriu M'tiKCi
remain encysted the same as a bullet or small shot. On account
of the lightness of paraffin, gravity will play but little part
in displacing the hardened paraffin.
According to Eckstein, the paraffin should have a high melting
point beyond that possible for the tissue to reach under
pathological condition, thus avoiding the possibility of an em-
bolism ever being detached. The melting point of the paraffin
recommended by Dr. Smith is i 10* K.
Technique. — The cutaneous tissue should be (Crabbed with
soap and water, followed by pure alcohol. It within the MMC,
cleansing with a mild antiseptic spra] The needle
and s> ringB should be sterilized in boiling water. The sterilized
paraffin should be brought to the melting point and drawn into
the warmed syringe, where it is allowed to cool sufficient'.
make a line white thread as it is expelled from the syringe. In
Mfc condition, the needle is inserted to about the farthest
SPECIAL fN STRUM I- NTS AND TJI l-RAl'V.
•35
rreiniry of the tissue to be pushed our and by slowly twisting the
\v plunder of the syringe, sufficient amount of paraffin is
injected into the parts. During the process of injection, the
injected paraffin should be moulded into the desired shape. The
amount of paraffin injected will depend upon the size of the de-
formity. Over-correction should be avoided. Local ancstln
i\ not always necessary in the correction of saddle nose and
auricular deformities. A great many patients make but little
complaint without anesthesia. The Schleich's mixture may be
uw\ in those cases demanding local anesthesia. If within the
nasal cavity, a four per cent, solution oi cocain may be applied
to the mucosa, followed In adrenalin.
Massage. — A great variety of massage otoscopes are recom-
Inl. Since this Conn of therapy is constantly demanded in
the treatment of many diseases of the ear, the choice of a durable
ument is essential.
Those with the motive power furnished with electricity and
air do not, in the end, prove as satisfactory M those manipulated
by hand, such as the Siegle, Bishop, Ballengcr or Delstanche.
i>
l-.u. 75.
MomriiD Sikgljc's Otoscope,
Ill the latter, the advantage and danger of having the drum
obscured ■ remedied by having it attached to the Siegle otoscope.
This rami <>t therapy of the car is especially indicated when
the membrana tympani is very much retracted and drawn inward
136
DISEASES OF EAR, NOSE AND THROAT.
as a result of stenosis of the Eustachian tube, inflammatory
changes within the middle car and slight fixation of the stirrup
in the oval window. My a process of rarefaction with the
Siegle pneumatic speculum (Fig. 75), the air, by gentle pre*
sure upon the small rubber bag, is gradually driven out of the
auditory meatus and in so doing, the membrana tympani is, if
adhesions are not too great, drawn outward. In the use of
different massage instruments, it is necessary that we avoid un-
due vibration or stretching of the drum; otherwise, congestion
may result. To prevent the inward collapse of the drum, after
it has been drawn into its normal position, a large plug of cotton,
dipped into collodion, should be inserted immediately within
the meatus.
Politzcr recommends dipping the wool in oil and placing
in the meatus for a gradual rarefaction of air within the external
meatus. Hommel recommends for gentle massage of the drum,
pressure with the finger upon the tragus. By alternately pre
inward, there is condensation and rarefaction of the air in the
auditory canal. The different methods mentioned not only favor
retraction of the drum but act as a mild stimulus to the mu-
cous membrane of the middle ear, causing an increased flow of
blood and lymph through the parts and absorption of catarrhal
exudation.
Gentle massage is very effectual, if applied with Conservatism,
\\ hen we have connective tissue deposits within the middle car
with partial or complete ankylosis of the ossicles or anesthesia
«>f the tensor tympani muscle. Massage, especially in young
children, should he used with great cue. mi aCQOUnl «>t the
liability of producing atrophy of the drum. This form of
treatment should be administered two or three times weekly,
for a period of from BIX to eight weeks. Conspicuous red
Hg the malleal plexus or mem brain ll.ucida should umnter-
indicate the treatment
I. mac- (Fig. 7<j) pressure probe is now and then 11 1 > ■
» l.i'ii the ossicles, are completely ankylosed. Thai inatrornem is
so applied as to press inward the short pn cess of the malleus.
SPECIAL INSTRUMENTS AND THERAPY,
'37
(ientle pressure is made with this instrument four or five times
at one application. Manipulation of the pressure probe some-
times produces some reunion and severe p;iin. This lurm of
massage is indicated, according to Lucae, when we have a nega-
Kinric. with a loss ©J hearing tor speech.
Fig. 76.
Lucas's Pressure Psonr.
As a therapeutical measure in the treatment of the upper
air ; massage has not met with as favorable use in this
country as in Europe. Dr. Baun (Trieste) in 1891, first advo-
cated vibrator) massage of the upper air passages and demon-
strated his method before the International .Medical Congress
at Berlin. In the words ot the author:
I employ two principal forms of movement in massage of
the mucous membrane of the nose, naso-pharynx, pharynx, larynx
and the upper part of the trachea: They are stroking and vibrs
t i<.n. and the two are combined in such B way that each part of
the mucous membrane is thoroughly stroked and masss
Copper probes of three sizes with olive points to correspond to
the parts to be treated, as the Eustachian tube, naso-pharynx,
pharynx, larynx and trachea, are used. To manipulate the
probe, it is held as a pen: four hundred vibrations are thus givi n
per minute: hand manipulation being too slow, an electric
vibrator gi\ fng two thousand vibrations per minute may be used.
The point of the probe is < .uvfully wrapped V, ifh COttOn saturated
with the rei: and carefully applied to the whole
mucous membrane
Dr. Dionisi (Turin). Journal of Rhiaofogy end Otology,
Vol. VIII., itvj-4, described a bag made of India rubber to be
introduced into the nasal cavity and blown up with air, wfoidl
es it to come in contact with a vibrator bj the tube. The
vibrator consi la chamber of air, vibrations being transmitted
of a piston.
*■
DISEASES OF KAR, NOSB AND THROAT.
As in other parts of the body, massage produces a greater
physiological activity of the parts. Braun remarks, " That the
diminished sensibilities produced by maaaagt give to the mucous
membranes a greater resistance against agents which it i upon
it harmfully." He recommends the following:
B Menthol,
Vanolin,
1$ Balsam peni,
Vasolin,
B. Sol. hydra rp.,
Alcoholis,
Lanolin i, I --
Iodi-glycerini, J
to per rent.
10 per rciit_.
I-I.O0O
10 per cent.
Massage is contraindicated in acute inflammatory conditions
and indicated in all chronic inflammation of the nose, throat and
Eustachian tube, as hay-fever, nasal asthma, trigeminal neuralgia,
atrophic nasal catarrh, ozena, chronic pharyngitis, chronic ton-
sillitis, chronic laryngitis and laryngeal paralysis. Unless ap-
plied systematically, little good may result. It should be ad-
ministered daily until requirements are met. Stroking is the
form of massage indicated in the cervical region. The patient
sits with the bead thrown slightly backward ; the operatoi stands
facing the patient as in the Gerst method. If the patient stands.
the operator stands behind. The strokes are downward and out-
ward with a moderate degree of pressure. In children, the
patient is laid upon the lap of the operator and nurse, operator
taring the child. With head thrown slightly hack, the neck is
grasped with the fingers On the vertebra- and the thumbs to the
larynx, and the downward strokes are made with the thumbs.
Thermic Agents. — Heat and cold arc two terms well know D
to the profession and to the laity, yet their rational applical
is not always based upon sound |>hiloviph\ 03 experience.
" The application of extreme degrees of heat and cold is practi-
cally identical and consists in the destruction <>i I
freezing and burning may produce somewhat similar appear-
SPECIAL INSTRUMENTS AND THERAPY'.
139
anccs of the tissue and cause like symptoms. Slightly lower
degrees of heat still act much like extreme cold, tending to co-
llate albumin, to stimulate involuntary- muscles, to contract
lood -vessels and thus check bleeding, to lower the action and
vitality of tissues and microorganisms and to retard metabolism "
( Friedcnberg). The rcai tion is 10 dim t ratio to the intensity of
the heat and cold.
Cold applications may be subdivided into dry and moist cold
and when applied, cause contraction of the blood-vessels, lower-
ing of temperature, preventing or altering the exudation of in-
flammatory products, thus acting as a slight antiseptic and
dyne, Care should be taken that the cold applications are
not continued for too great a length of time, for fear of causing
necrosis or increased irritation.
Dry cold is best applied to the ear or throat by means of
cracked ice in bladders, rubber bags or ice water passed through
the Letter tube, which is more often used than any other
method. This is especially indicated in mastoid inflatnma-
:i: that the tube can be moulded to lit the parts. In acute
in fluiinii.ir ic.ti nl the mastoid, it should not be. used to exceed
Eght hours. In the absence oi the Leiter tube, resort may
be had to ice bags. To excite contraction of the carotid artery,
L rbantschitsch recommends Winteruitz's India-rubber neck-bag,
through which ice water is kept flowing.
t cold is applied by irrigation or by dipping soft towels
into iced solutions and then applying them directly to the nose,
at or ear. The application of moist cold being disagreeable
to both the patient and nurse, the dr) cold is recommended.
In chronic inflammation of the throat, a sudden application
of cold water to the throat externally acts as a stimulant. In
patients predisposed to catarrhal troubles during cold and
damp weather, sponging the chest and neck with cold water
in a great many cases, has a beneficial effect in preventing such
trouble, if used with regularity upon arising. This is reoom
mended in children as well as adults. The cold tub or plunge
bath is especially recommended upon arising for individuals with
I j c .
DISKASBS 01 EAR, MOSI KWD PHROAT.
a catarrhal predisposition. This form of bath will frequently
bfJflg about a marked resistance (if the mucosa ol the nose and
throat to recurrent attacks of acute coryza. In a tew isolated
cases, the shock of a cold plunge is tOO great) BUCu cases should
In- content with the cold sponging of the neck and chest.
In acute inflammation of the throat, in the very beginning of
the trouble, ice packs externally and Dobell's solution (iced) or
cracked ice in the mouth, is indicated. Ordinarily, the ice bags
should not be applied more than a half hour at a time. How
ever, they may be repeated at short intervals.
The application of heat may be subdivided into two town-.
dry and moist.
Dry heat is more pleasant tn the patient than moist heat, M
it is more constant, eas] oi application and soothing in effect.
In the application of moist and dry heat, the surgeon must be
governed by the condition of the case. Dry heat may be ap-
plied by hot water bags, hot sand or salt bags, hot water bottle,
Japanese hot bOXj constant temperature of water through tubes
and hm llaunrls. Heat, when applied dry, has the faculty oi
increasing the circulation and thus facilitating and encouraging
the absorption of inflammatory products, as in acute inflamma-
tion of the middle car, lessening of the tension and acts as an
anesthetic to irritated and paintul nerve terminals.
Moist heat is best applied to the car or throat and covered
with rubber Of thick cloth to prevent evaporation. Heat in tins
form stimulates the localization o! pus by softening the ti-
One disadvantage experienced in its application is the in
sisteticv oi temperature.
Poultices are now, as of old, a universal method of app
moist heat to the surface. Certain unguents such as antiphlo-
L'istin, etc., are noommended in the form of poultices a
lhni.it and mastoid. They should be thoroughly heated Inrforc
applying. The Inn may he best maintained by the addition "i
I hoi water bottle (0 the poultice. The hydroscopic effect OJ the
glycerin tlj the potent factor oi such poulticca< Others
are ground llax-sccd, ground barley from breweries, bread crumbs
-I'HIAI. IVSTRirMliNTS AND THIRU'Y.
141
moistened with milk, and fat neat, so often used in country
districts. Jt is essentia] that poultices he covered with oiled silk
or greased paper that the even temperature may be more easily
retained*
Electricity. — Electricity is closely allied to massage. The
host results of massage are frequently dependent upon electricity
as an auxiliary (Hawse).
1 lectricitj .1- 1 massage is to be considered as adjunct to other
therapeutical measure*) such as medicine, rest, etc
It is especially indicated in the ear in chronic catarrhal in-
flammation in anemia of the labyrinth, inflammatory exudations
within the labyrinth and middle ear. It is indicated in torpidity
he endothelial lining of the middle ear, tympanum and Eu-
stachian tube, want of auditory nerve activity or partial paralysis
stenosis of the Eustachian tube, hyperesthesia of the labyrinth
ami neurasthenia,
In sclerosis of the middle ear, Dundas Grant recommends
..inn al vibration to thr spine between the shoulders, as
direct current causes indirect massage nf the stapedio-vcstibular
joint.
There is great disparity of opinion relative to the efficiency
of electricity, brought about in many cases by want of knowledge
of the pathology of the case or the obscurity of the disease, to
terminate its indication. Furthermore, to secure results, an
taut Instrument must he used, combined with knowledge
of electricity as applied to medicine.
As applied to therapeutics, thr following forms are Deed:
faradic, galvanic, electro-cautery, static. X-ray, high frequency
current and advisedly, illuminating and electro-trephining.
The ampere is the unit of the rate of galvanic current flow.
The number of ma. obtained as a dose in proportion to the effect
the rate of current Rowing through the tis
sue. Increase indicates the intensity of action on the nei
and muscles. Kate of movement is an equally important factor
in practical work with all the different currents. Tn BtS
currents, the rate of morion is the all-important factor.
DISEASES OF EAR, NOSE AND THROAT.
The faradic. as all understand, is characterized by being
alternating and interrupted, while in the galvanic, the current
is constant and continuous. The faradic has low amperage
and high voltage, while the galvanic has greater amperage and
low voltage.
" Faradism is indicated where wc wish to excite the motor
or sensor)* nerves and to increase the volume of the muscles.
This is accompanied by exciting contraction, which increases
the temperature and at the same time increases the nutrition.
To relax a tense muscle or to loosen a peripheral contractor,
single shocks from a strong current are generally more useful
than a galvanic" (" Electro-therapeutics," llauias).
The taradic current is especially indicated lip to about three
ma. in facial paralysis, following operations upon the mastoid
01 ossicles, sclerosis of the middle ear, hyperesthesia of the
auditory nerve, hyperemia of the labyrinth and tinnitus when
it i-. not dependent upon change of the circulatory system.
The faradic current for tonic effect should he generated from
a fine, high tension coil, about eight thousand feet in leu
Up to a certain point, the faradic current is a builder of
tWUC When it reaches the point of irritation, it acts as a
destruction to tissue.
Galvanic. — The galvanic current is more especially indi-
(I where we wish to produce stimulation of the whole
muscular and nervous system. A mild galvanic current is
soothing to irritated nerve filaments.
Static electricity, generated, as a rule, from specially con-
structed machines, is administered in the form of a bath, breeze
or induction coil, and is recommended in those disorders asso-
ciated with disturbances of the trophic system.
The X-Ray is generated from a static machine or induction
coil and is indicated in the treatment of cancer, chronic ulcers,
eczema, lupus, for the location of foreign bodies in the Larynx,
trachea and those imbedded about the auricle.
Cautery. — The point of the cautery should he heated faff.
all purposes to a cherry red and applied to the aflect.ed parts.
SPECIAL INSTRUMENTS AND THERAPY.
'43
It is especial I) recommended in hypertrophy of the turbinates,
applied directly to the mucous surface or driven deeply into the
thickened turbinates. In withdrawing the point it is necessary
that it remain heated; otherwise, it will adhere to the tissue.
Following the application of the cautery point, suppuration im-
mediately takes place to the depth equal to the amount of de-
struction. 1 1 the OpetatOf exercises due care, as a rule, results
Wiy satisfactory and on the other hand, if we cause too
great destruction of the tissue, the function of the mucous
membrane may be entirely destroyed, and :m atrophic degenera-
tion result It is especially recommended in phlyctenular
pharyngitis chronica, with varicosities of the small blood-
vessels, in hypertrophy of the tonsils, in hemorrhage following
the operation for the removal of the tonsils and in neoplasms
of the respiratory tract.
" On account of the edema produced, the cautery should not
be uafld about the uvula, the faucial pillars, arytenoid region
or on the glosso-cpiglottie fold. It should not be used on the
middle turbinates or the tissue above. Its application to the
posterior end of the inferior turbinate is best avoided ; likewise,
cauterization of the septum."
I tro-trephine may be used for the removal of spurs from
the septum, opening into the antrum of Hightnore, mastoid
and frontal cells.
Apptittitihti of Electrodes. — In a given case demanding stimu-
lation by die galvanic current, the negative pole is applied
to tin- affected part and the positive to the nape of the neck.
Where a sedative influence is demanded, the positive pole is
applied to the affected part and the negative to the nape of the
neck. Bishop's ear electrode will be found very convenient
for use in aui
Time of Treatment. — The seance should not last over five
minutes and the current should no! be over three ma. in
i_'th.
Cautery Snare. — I'scd for the removal of enlarged tonsOi
or hypertrophies within the nose, care should be taken that the
'44
DISEASES OF EAR, NOSE AND TH1
wire is kept at sufficient hear to sever the tissue without pro-
ducing hemorrhage.
E£speciali] constructed handles arc adapted to the use of the
physician. The current can be turned on or off instantU b]
means of a trigger.
The electrolytic bougie designed bj Duel Eoi the oblitera-
tion of Btrictures within the Eustachian tube and the promotion
of absorption of exudates from the middle ear, are made of
solid gold and are of three sizes. An insulated cord connects
the gold bougie with a negative pole of the galvanic bat*
An insulated Eustachian catheter especially constructed is '"
sary. Tin- cathetei should be beat at a sHghtlj create] angle
than few ordinary catheterization. The tube i> passed into
position and firmly held while the small, gold bougie is passed
through the Kustachian catheter into the Eustachian tube. As
soon as a stricture is met there is an obstruction, which, it very
thin, will be readily passed. The positive pole, or sponge-
electrode, B placed M the nape oi the neck 01 held in
tient's hand. The current necessary to promote absorption of
a stricture is from three to five ma., which should he turned on
as soon as the electrode is in position and should not be con
tinned for longer than three CO five minutes. The elei t
should he extracted while the current is still Oft. The current
should not he turned on Stronger, on account of rhe deStSUC
Hon of tissue which follows the burning. There is no pain
enmpanying or immediately following rhe treatment. Tin-
form of treatment may be continued once weekly until all stric-
tures are easily passed. The Eustachian tube should not be
inflated immediately after rhe electrolytic bougie has been passed.
However, the patient should return the following day and
init to a gentle inflation "t the Eustachian tube.
Radium. — This substance is obtained from pitchblende,
found in joachimsthal, Bohemia, and was introduced to the
medical profession as a bromide or chloride of barium, In Prof,
and Mme. Curie, of France. Radium lias the property
jiving off heac and light and may be had in small tubes, which
SI'ECTAl, INSTRUMENTS AND THERAPY.
' IS
arc placed in small ruhber holders and inserted against the
Lie under treatment for from five minutes to half an hour
daily. Beck reports radium as a distinct analgesic in a case
of sarcomata of the nose, in a woman sixteen years of age. The
effect of the radium was noted after the fourth day's treat-
ment. Rftd.iuflQ is highly recommended in the treatment of
tiuiit tumors.
Finsen Light. — To Finsen is due the credit of separating
the chemical rays and the calorific rays from the sun and the
application of the chemical rays 10 the cases of lupus, epitheli-
oma, lupus vulgaris, tuberculosis of the nose and larynx, ami
acne. The action of the chemical rays is to destroy the
parasitic or clicmic agents producing the disease and a restora-
tion of the lowered local metabolism. In the method of Finsen,
rhe caloric arid luminous rays are separated from the solar rays
by passing the latter through a solution of copper sulphate and
diluted ammonia water. The strength of the solutions is so
regulated that the heat rays are reduced to a point of tolerance
and the chemical rays are stimulated to their highest intensity.
The duration of the treatment is from one to two hours. The
patient experiences on uncomfortable reaction from the treat-
ment other than a slight itching >ensation. Xo add to the
■•Hi< •••(!( ;, "i the treatment) Finsen recommends that the parts
lie rendered » anemic as possible, and this is accomplished by
OOOlpre&siOO or an application of ice.
A PidSen instrument may be secured through any of the
large instrument supply houses.
Lamps tor the concentration of the chemic rays from the
arc lamp are recommended as a substitute for the Finsen light.
The arc light, to possess any virtue, should be one consuming
from seven ro fifteen amperage.
I
SUPERHEATED AIR, SOLUTIONS, VAPORS AND BOUGIES IN
THE TREATMENT OF THE EUSTACHIAN TUBE,
MIDDLE EAR AND ACCESSORY SINUSES.
Superheated Air. — The following, relative to the appli-
cation erf hot : i i i" in the treatment of diseases of the car, nOBE
and throat, is copied from the summary proceedings of the
International Medical Congress, August 5, 1900, and reported
to the Laryngoscope, January, 1901, being a report of the
research of M. Lermoycz and G. Mahu, of Paris.
We propose to apply to circumscribed areas of the mucous
membrane currents of dry air, superheated to a temperature of
8o° to too0, a method which recalls those employed by Hol-
lander and Jaylc in dermatology and gynecology. The supply
ot air under pressure is furnished by steel tubes containing tin-
air under pressure of 120 atmospheres; the latter is heated in a
metallic worm and is conducted to its destination by supple
metallic tubes with a double coating of asbestos. At the end
of this tube arc screwed canulas of various size and shape, ac-
cording as it is desired to apply lint ail to the turbinates, at the
Eustachian openings or in the ear. At the base of the camda*
there is attached a regulator of the temperature and pressure.
Applications of hot air are made under the control ol the
violin, with 1 head mirror and speculum; sitting lasts two n
utcs. and is repented two or three times a week. As |
from eight to ten sittings arc necessarj to obtain 1 good 1
I his treatment ■ perfect!} painless. The entrance ol the hot
air brings about an intense retraction of the mucous membrane
which is soon followed bj abundant, watery, offensive srerc-
ulii'h cease in a feu- moments. The value and effect
146
produced by this treatment shows itself next; at first tem-
porary, it tends to become permanent. Applications of hot
air have especially succeeded with us in cases of chronic con-
gested coryza, with intermittent nasal obstructions. It gives
results remarkable as well as lasting, provided there is not
mgiomatous degeneration of the nasal mucous membrane.
It rapidly suppresses the sneezing and other nervous symptom-
of spasmodic CQiyza. It dries the How of nasal hydrorrhea,
and brings back the nasal mucosa to its normal objective state.
In hay-fever, in which our experience is still more recent, it
seems to relieve the attack. Finally, they give good results in
aural troubles, deafness and tinnitus, associated with catarrh of
the IUMC and naso phamix ; otolgia gives way to them almost
immediately.
An attempt to make this treatment the panacea of all diseases
of the DOM would be to condemn it to rapid loss of considera-
tion. \\V believe it useful to state chat it has, up to the present,
given no results in ozena, purulent catarrh, nasal and naso-
pharyngeal diseases which j list i f > .uij>>:il treatment.
For making an application of heated air to the Eustachian
ihr heater devised by Scclcy is inexpensive and thoroughly
Heal. A hard-rubber catheter an<l Pynchon's inrlator com-
'■<■ outfit.
hard-rubbei catheter, being a poor conductor of heat,
In- used longer than one ol solid metal. In the Pynchon
mflator is placed a small piece of sponge saturated with equal
parts of menthol, camphor and tincture of iodin. The hot air
impregnated with the fumes is forced into the Eustachian tube
ami middle ear.
I he carried to the Eustachian tube and middle
ear by being forced through the Eustachian catheter by a
moistened bougie passed through a metallic catheter or injected
through a long flexible Eustachian catheter attached to an
nrdlnarv hypodem •. after the plan designed by Cleven-
>horr rubber tympanic catheter.
ntroduction of fluid into the tube without its cxttcv
H6 MSBABB8 OF EAR, NOSE AND THROAT.
ing the tympanic ca\ ity, l'olitzer (p. 272) recommends the
following:
" An air douche having first been administered, eight to ten
drops of the solution are injected into the catheter with a
Pravez syringe; the head of the patient is now bent to the side
and a little backward, by which means the fluid flows from the
catheter into the tube. In this manner concent™ red solutions
of zinc sulphate (2: 10), and Bu row's solution, as well as
weak solutions of tannic acid (l/j per cent.) or a few drops
(5-10) of sterilized liquid vaseline ( Delstanche) may be ap-
plied to reduce the swelling in the tube. The author has found
the latter, combined with zineolein (0.3:30-0), beneficial in
marked swelling of the tube. In Obstinate CtatS, astfUlgl
are sometimes successful only when preceded by injections of an
ammonium chlorid (1: IO-20) or soda bicarbonate ( ?: 10-20)
solution. Steam and ammonium chlorid vapor, as recom-
mended by V. Trolstch and Iiurkner, rarely reduce the swelling
of the tubal mucous membrane. Turpentine vapor (oleum
rercbin) aspirated from the vial by means of an air-bag and
forced through the catheter into the mi. Kile cur, baa pn
more useful. Bronner (,-ln-h. of Otnlngy, 1891, vol. \\.)
recommends the vapor-; of the nils of eucalyptus and menthol.
I he author has often found the latter drug very serviceable in
marked swelling of the mucous membrane of the tube. Hart-
mann introduces a few drops of iod in -glycerin (iodt'n pur.
kali hydroiod. 3-0, glycerin, pur. 10.0-20.0) by means of the
catheter in obstinate forms of swelling of the tube. Alt speaks
highly of the effect of hot air inflations in marked swelling of
the tube (p. 106) and claims that they have a very beneficial
influence in alleviating troublesome head symptom-
Sterilized oils and solutions may be injected into the Eu-
stachian catheter in situ sad « ith compressed air forced directly
into the Eustachian tube and middle ear. Indications fw ■
jectioos mto die Eustachian tube and the middle ear must be
well marked and solutions sufficiently diluted tu avoid any
violent reaction.
SUPERHEATED AIR, SOLUTIONS] VAPORS, BOUGIES. I.|y
The following arc some of the solutions frequently used tnd
their indication:
R Protarjjol,
l£ Solution nitrate ui si Kit,
20-so per cent, solution
I/2-1 per cent.
Five to ten drops of one of the above solutions should be
injected into the catheter in situ anil with compressed air or a
Pulitzer bag forced into the Eustachian tube and is indicated in
acute and chronic catarrhal inflammation. In pronounced syphi-
litic affection of the middle car, Politzet iccommends the
following:
9 Potassii iodidi, .30 gra. (gr. v)
Aqua;, 30.00 c.c. (.si)
M.
Signa. Ten to twenty drop* for one injection, combined with
aiitinypliililii- treatment.
B 'A per cent, camphor-menthol in albolene.
M.
Signa. Ten to fifteen drops to b« injected while warm into the
Eustachian tube and middle ear.
Fie. 77-
[tDDLI E.VB VAPi.BIJfK.
Indicated in acute and chronic catarrhal inflammation of the
Eustachian tube.
'5°
D1SHASES QJ BAR, NOSE AND THROAT.
I. Sodii bicarhonalis, .60 gm. I gr. x)
Pilocarpine murialii, .12 gm. ( gr. ii
Albolini, 30.00 c.c.
M.
Signa. Ten drops to be injected in adhesions of the F.usu
tube and adhesive catarrh of the middle ear.
Vapors. — For the injection of vapors, the Dench middle
esc vaporizer (Fig. 77) is of great efficiency. Medicated
vapors are i-spceially indicated as a mild stimulant in chronic
hypertrophy and adhesive middle car catarrh. The following
are recommended by Dench:
K Menthol, 1 --
Camphors, /
Alcoholis,
}'
lv Menthol,
Camphorx,
Tinct. iodi,
Q Ol. rucalypinl, \ .-
Ol. pini, I
8 01. caryuphylli,
Alcohol,
3.90 gm. (5 j)
30.00 c.c. (J j)
3.90 gm. 15 j)
30.00 c.c (5 j)
15.00 c.c. {5 iv)
1.90 c.c. (m. xxv )
30.00 c.c. (." j)
Bougie. — This form of treatment for the dilation of the
Kustachian tube was first introduced by Bonnafont and Kra-
mer. The bougie maj be used as a diagnostic measure in dis-
covering the peiTBeabOirj Of the tube, as a mihl OUBSSge to the
mucous membrane, reduction of stricture and for medication of
the mttCOUS membrane. For dilatation tin- bougie should remain
in position from siv. to ten minutes, followed by inflation. As
a mild stimulant , it may be gently passed in and out a few
times (<t one minute. For medication, the bougie may be
dipped in a solution, and while moist, passed into the tulic
through the canula. The length of the Eustachian tube should
always be kept in mind in passing the bougie so that wc may
then avoid injury to, <»r rupture of, the drum. The amount
neci reach the middle car vi CCOrdttlg to
SUPERHEATED AIR, Soil Tho.v VAPORS, BOUGIES. 151
the si/.c of the obstruction. In the normal case, an Eustachian
bougie should pass without any effort. In strictures of some
gijtc, slight force may be necessary and as soon as the stricture
is passed the bougie will slip along very easily.
Iimj much torn- is to he condemned, as a false passage may
be made or mi much destruction to the mucosa brought about
that stenosis is encouraged.
Bougies arc made of hard rubber and are filiformed m
character. A number of sizes are to be had, all small enough,
however, to he passed into the normal middle ear. The com-
parative- value <it bougies oi this kind, and the electrolytic
bougies of Duel, LS still a disputed question. Some ancsthei
prefer the ordinary bougie, believing it possesses all the virtue
of the electrolytic. Personally, I believe the electrolytic bougie
has many advantages in the relief and cure of stricture of the
Cube. From the nature of things, the negative current applied
as in this method should add just as much more influence in
promoting absorption of exudates.
CATHETERIZATION OF ACCESSORY SINUSES AND INTER-
TYMPANIC IRRIGATION.
Frontal Sinuses. — With the nasal mucosa round about the
■ frontal dud anesthetized with a four per cent, solution
ider good illumination, in from approximately forty
to fifty per cent, of cases, the catheter can be placed within
rental sinus (Fig, yS).
Hypertrophy of the middle turbinate sometimes makes it
necessary to remove the anterior end before the catheter can
be placed. The presence of the catheter within the sinus may
be shown by transillumination OI bj measuring from the meatus
of the nose t>> above the supra-orbital ridge along the outside
The Hartroann canula (Fig. 78) is more frequently used.
I ader good illumination, it is directed into the middle meatus.
The handle of the canula is lowered and the point is directed
PMEMAN't Frontal Duct Bovctta.
The Maxillary Antrum.- The position of tin- ostium varies
in individuals. Normally, it empties into tin- middle meatus.
On BOCODIH of flu- wiltiofM in list of the ostium and hyper-
trophy of the middle turbinated body, the rizc of the turbinated
SI PERU HATED AIR, SOLUTIONS, VAPORS, BOUGIES. 1 53
body and large bulla, it is frequently very difficult to success-
fully irrigate through the natural opening. Under good illumi-
nation and cocain anesthesia, the Hartmann canula or the
F ret- man irrigation tube is passed into the middle meatus
digfctlj beyond the middle third. The opening may be per
reedy round or slit-like in the bony wall, where the point of
the tube is bent at an angle. It is turned outward and down-
ward into the ostium. Catheterization is indicated for the diag-
nosis "f exudation within the antrum and treatment of acute
and chronic inflammation of the maxillary antrum.
Ethmoid Sinus. — On account of the anatomical structure
• it the ethmoidal cells, it is impossible to irrigate unless the
middle turbinated body is removed. For the cleansing of the
attic, the De Vilbiss single barrel spray is very efficient.
Sphenoidal Sinus (Fig. J5)» — : The sphenoidal sinus can
be reached in about forty per cent, of cases, through the natural
Opening! The distance from the anterior nares to the ostium
I'.UM
is from two and one-half to three and one-half inches (St.
1 Thomson). With this in mind, the Grunwald sphen-
oidal canula should be passed up between the middle turbinate
• i the nose at an angle of forty-five degrees,
until ii strikes the rood of the nose. It i- now gently guided
downward and haiku aid when it passes into the sinus. If the
canula is in the ostium, according to Griinwald, it can not be
'54
DISEASES OF EAR, NOSf. AND THROAT.
moved downward. In the greater number of cases, tree ao
to the sinus is only gained by the removal of the middle tur-
binated bone.
With the camila in the ostium, mucus and pus may be
blown out by attaching a Pulitzer bag or Irrigating with a
jyringe. If the ostium is small, there is usually a great deal of
pain following irrigation. Remotely, the ostium will be found
very large and easy of access.
Intertympanic Irrigation. — For the cleansing of the Eu-
stachian tube and tympanic cavity where there is a per lor.it inn
of the membrana tympani, irrigation with mild antiseptic and
astringent solutions are frequently indicated.
Fie. 8 1.
ll-'VI'l.'s Tvill'ASIC Iltl'
The catheter should be placed in position at its greatest
curve, as shown In auscultation and with a IOO c.c. syringe,
fluids can be forced through the Eustachian tube and out of
the external meatus. There is no pain accompanying tins form
of therapy and the patients experience a great deal of relief
from irrigation in ehrank purulent disease of the middle ear.
SUPERHEATED AIR, SOLUTIONS, VAPORS, BOUGIES. 155
For irrigating through the external meatus or middle ear,
a syringe or Hovell's tympanic irrigator is necessary (Fig. 81).
With large ear speculum and good illumination, the perfora-
tion in the drum can be passed through with the point of the
irrigator. Cleansing solutions, and astringents can be applied
to all the parts of the tympanic cavity. Warm Dobell's or
Seiler's solution may be used for irrigation.
CHAPTER X.
GENERAL THERAPEUTICS.
Local Anesthetics. — In tlic daily use of cocain it should be
applied and so masked that the patients arc none the wiser for
its use. It will be observed that a great many patients display
a wonderful; amount of knowledge relative to this drug and in a
number of cases object to its use. For operative use in the nasal
cavity a four per cent, solution, freshly prepared, is more often
selected. Very few operations in the nose require a stronger
solution. In dissection of the tonsils ten to twenty per cent.
is recommended, while in paracentesis of the tympanum, a few
drops of a ten per cent, solution should remain in the ear for
at least ten minutes preceding puncture. For diagnostic pur-
poses in the nose, a two per cent, solution is sufficient. The
anesthetic effect is accompanied by drying of the mucous mem-
brane and contraction of the blood-vessels. Its continued use
is harmful to the mucous membrane. Cocain solutions should
be frequently sterilized, as they rapidly deteriorate, being most
effective when applied fresh and warm to the mucous surface.
It may be applied cither by cotton wrapped on a probe or by
spray.
" The best antidote for the toxic effect of this drug is amy!
nitrate and ordinary wine, placing the patient in a recumbent
position." The application of the anesthetic value of sub-
arachnoid injection of cocain in the nose, throat and ear surgery,
is still undeveloped. Payne, of San Francisco, reports two
simple mastoid operations and one Staclce operation under spinal
analgesia.
The tnjCCtion is made between the third and fourth lumbar
Vertebra*. The patient is placed in a reclining position with
'56
CiliNliRAI, THERAPEUTICS.
'57
the back slightly bowed. The skin at the site of the injection
is thoroughly cleansed and the surface is anesthetized by spray-
ing by ethyl chlorid. With a glass syringe and a specially
constructed needle, twenty drops of a sterilized solution of
ii u injected into the subarachnoid space.
Stovain is a new anesthetic of French origin, which may be
called chloralhydrate ot aunlin, and is highly recommended in
oto-rhino-laryngnlogy by Dubar. chief of the Oto-rhino-Iaryn-
gological Clinic, in the Maison-Blanehe, and by Rectus, Chaput,
ami Tutfier, as a spinal analgesic.
Dr. Tapi;i, Madrid, in a report of an experimental tnvesti-
lotl of the drag as compared with cocain, says stovain is less
toxic, is the equal of cocain, is a good antiseptic and on account
of a mild diuretic property, is quickly eliminated frnjn the
-I si cm.
Stovain may be used in the same strength of cocain. In
the- ablation of adenoids, Dubar especially recommends stovain
because it docs not contract the tissue as observed under cocain
anesthesia.
ain introduced as a substitute for cocain in the nose and
throat, m;i\ be used in five to ten per cent, solutions. Two
preparations are dispensed: eucain alpha and eucain beta. The
latter is Bald to be three and seventy-live nnc-hundredths times
leas toxic than the former.
As previously remarked, solutions of cocain deteriorate while
those of eucain retain their virtue indefinitely, though they de-
mand occasional sterilization. The contraction of tissue is not
istlnct. consequently, as a diagnostic remedy applied to the
turbinate. euCaifl is of little value, but when used hypo.ln
; . qua] to • ocain.
For anesthesia of the nasal cavity, a four to five per cent.
DOB. i< indicated. For tonsillotomy, a twenty per cent.
solution may be applied directly to the tonsil. In the removal
of adenoids, a fifteen to twenty per cent, solution is indicated
ran is a white, odorless, tasteless powder; a local
anesthetic, which is slow in action but lasting in effect, covering
I
i?S
DISEASES OF EAR, NOSE AND THROAT.
a period of thirty-six to forty-eight hours. Since it is abso-
lutely non-toxic, it may be applied ail libitum, being especially
recommended in the relief of pain in wounds, burns, excuna-
rions, also after cauterization in tin- nose and throat) in dys-
phagia and cough due to tuberculosis and in tilcerated conditions
of the pharynx, larynx, carcinoma and abscess of the larynx.
after operation on the mastoid, eczema of the car and about
the nan in hay-fever.
Freudcnthal recommends the following emidsiori:
# Menthol.
Ol. amygdalae dulcis,
Vilelli 0\ i,
Orthoform,
Aqua: (ieslill., q. a
As a powder.
W
Orthoform,
Mriiilml,
Zinci stcaraii B,
10.00 gm. (5 ijst)
15.00 c.c. (5 «)
15.00 c.c. (3 s»)
12.50 gm. (3
100.00 cc. (3 I ■ j >
4.00 gm. (5 j)
2.00 gin. (gr. ux)
4.00 gm. (5 i)
Many drugs, though not so classed, possess more or less
anesthetic properties. For instance, in operating for paracente-
sis of the drum, the application of pure carbolic add along the
line of intended incision, renders the operation as ncarK
as if obtained under cocain and the caustic effect in no ■
interferes with the healing ol the drum. In dissect inn of the
tonsils or cauterization of the throat, the application "t a ten
per cent, solution of carbolic * :d has a marked anesthetic effect
Bonain recommends the following, which is an anesthetic:
\i Phenol, -I
Menthol.
(ocainx lvydfochlor.it . '
1.0 gm. <«« gtt. xvi
and
lv Phenol,
Menthol.
Coeainac hydrachlon
which is .in anesthetic and caustic.
1.0 gtn. (gtt. xt)
0$ (" gr. viijl
GENERAL THERAPEUTICS.
'59
These solutions, as remarked by the author, meet various
affections of the ear. In the nose they may be used in ex-
ploratory puncture of the maxillary sinus, in galvano-cauteri/a-
tion of the turbinates, for ulcer or epistaxis, for reduction of
Inflamed tissue and lastly for anesthesia of the anterior orifices
of the nasal fossa.-, a region upon which cocain has no action.
They should be applied every eight to ten minutes. They
arc valuable in the cauterization of hypertrophicd adenoid tissue
in the oro-pharynx and at the base of the tongue, where cocain
is often inefficient. In the larynx, the anesthesia has been used
for galvano-cauterizatton of the epiglottis and arytenoid emi-
nences when infiltrated. It is efficacious when combatting the
dysphagia of tubercular ulcers of the pharynx and larynx, pro-
ducing complete anesthesia, lasting at times for days. Bonain
further recommends the caustic solutions for destroying tubercu-
lar vegetations. Guiaco], in oil, is recommended as a local
rlietic to the turbinated bones and in the removal of polypi
of the nose and ear. For operations upun the tympanic mem-
brane, Bonain recommends the following formula:
K (.maiol,
Menthol,
Coeainr liytlrodihiruiis,
.6 gin. (gr. x)
-3 B">- (Rr- v)
•3 gm. (gr. v)
After cleansing the auditor] canal, the above is applied by
is ot a pledge! oi cotton. A complete anesthetic effect is
obtained in three minutes,
Antipyrin in aqueous solutions or in oil has a peculiar anes-
thetic effect Upon the mucosa oi the turbinated bones. In acute
COryza it is recommended in spray of one per cent, solution.
\nli[.vrini,
Tr. !
A'pix (Icalill.,
1.90 gm, (gr. xxv >
.60 gm. (gtt. x)
90.00 c.c. (J iij)
an anesthetic, it may be used preceding cocain <>r eucain,
mUCOUS membrane thirty minutes before operating.
Narcosis. — Narcosis, as applied to surgery, is a condition
general unconsciousness, produced by irrespirable gases, more
i6o
DISEASES OF EAR, NOSE AND THROAT.
especially chloroform, ether, nitrous oxid gas, or ethyl bromid.
Two conditions are essential to a safe narcosis, f. e.. the
BOUIld physical condition of the patient and an experienced
anesthetizer. Considering the fact that anesthetics are given
by hundreds of physicians throughout the country, who arc
little versed in the skillful use of the same, we must oooffe
such physicians possess an element of luck, that so few deaths
occur by this means. Only in the hands of those skilled in the
administration of anesthetics should he placed the chance of the
life of the patient and the reputation of the operator. Too
many young physicians go out into the world with a poor con-
ception of the danger of using anesthetics. The specialist, start-
ing on a promising career, should be guarded in the choice of
those who are to administer anesthetics to his patient.-.. The
physical condition of the patient must not, except in emergency
cases, he overlooked. The mere lact that his heart beats are
rhythmic and urine normal should not outweigh the general
physical condition of the patient.
" Those with so-called lymphatic temperament, neurasthenics,
anemics, chlorotics and leukemics, stand anesthetics and opera-
tions poorly" (Hamilton Fish).
A> between ether and chloroform, the majority of the op-
erators regard chloroform as the safer anesthetic Got children
and because there is less hemorrhage accompanying operations
than from ether. As the scale of life advances, ether pron
the less risk to life. In laryngectomy and other operations upon
the larynx and trachea, chloroform promises the best results.
Likewise in mastoid operation and in the extraction of foreign
bodies from the external auditory canal. Asch operation, 1 1.
Chloroform is regarded by Weyth. as especially dangerous to
children under twelve years of age. on account of lymphatic
diathesis, which at this age is most prevalent. Kalisko reports
that in children dying from chloroform narcosis, a condition
described as " habitus lymphaf icus " exists.
Ethyl bromid is a modem chemical discovery obtained by a
distillation of a mixture of ethyl alcohol sulphuric acid and
C.F.NERAL THKRAHELiTICS.
ll>l
potassium bromid. In its pure state- it is a colorless liquid, hav-
ing an odor similar to chloroform. It is dispensed in one-
ounce tubes, one of which is sufficient to cause narcosis lasting
one-quarter of a minute. It is of especial service when oper-
ating upon children for adenoids and removal of tonsils. The
child is held m the nurse's arms in an upright position,
wrapped in g sheet to guard against struggling. The small
glass point <>f the bottle is broken off and the contents poured
on a napkin and held over the mouth and nose of the child.
Narcosis is soon produced. Where ;i more lasting narcosis is
necessary, the combination of chloroform and oxygen is recom-
mend r-il.
The position of the child and adult depends upon the length
oi the narcosis desired. If prolonged, as in the Asch operation,
the paticnr i-. placed upon a table with the head dropping over
the edge. In many operations upon the nose and throat, removal
of malignant and non-malignant growths, resection of the
maxilla, etc., the Trendelenberg position is essential. In this
way, the probability of blood passing into the larynx is avoided,
for, as remarked by Dr. Keen, " Blood will not flow up hill
any more than water."
In major operations, as the Asch operation, resection of the
maxilla, cleft palate, tracheotomy, laryngotomy, etc., chloroform
is more often indicated.
In the removal of tonsils rind adenoids, a general narcosis is
exceedingly dangerous; the pain of the operation in children is
so small as compared with the greater danger of the anesthetic,
that only in the exceptional cases should other than a local
anesthetic be used.
profound obstruction of the nasal space from
adenoids, the A.C.E. mixture offers the minimum amount of
danger. The child should lie flat on its back, with head and
neck slightly elevated. In operating, the child's head should be
gently dropped over the end of the table. The mouth gag
should be previous!] inserted in giving the nitro-oxid gas or
.62
DISEASES OF EAR, NOSE AND THROAT.
ethyl bromid. In the administration of ether or chloroform the
gag may be inserted after partial anesthesia.
Post-operative Treatment. — Following an operation under
local or general anesthesia, the patient should be put in a
comfortable position, compatible with free drainage. After
the removal of tonsils or growths within the nasal cavity under
local anesthesia, the patient, if in the office of the physician,
should remain perfectly quiet for from one to two hours.
Turhinectomy or curettement of the sinus should be done in
a hospital. To prevent hemorrhage, iced spray of adrenalin
1-5,000 in 1-4 Dobell's solution should be sprayed into thj
nose every hour. The patient should remain in bed from fifteen
to twenty-four hours, with the head and shoulders slightly
iied.
Iced liquid diet only should be given patients for the first
day, followed on the second day by soft foods, with a com-
plete restoration of diet in forty-eight hour-.
After the removal of spurs from the septum it is better to
prescribe cold liquids for the first meal following the OB
(-ration.
Following paracentesis, the patient may become faint and
nauseated, requiring stimulation with brandy or whiskey.
After general anesthetic as in the AseJl operation, operation
upon the mastoid, etc., more or less shock and collapse may
result, which demands hot-water bottles to the feet, elevation
of the foot of the bed, attention to the respiration or the admin-
istration hypoilermically or per os of brandy and strychnin
sulphate.
In the Opinion of the author, it is a bad polii | to administer
a general anesthetic in the physician's office. It is dangerous
to perform tonsillectomy and tonsillotomy where there is a
probability of subsequent hemorrhage, in the private office of
the physician. The grosser operations should be done at the
private apartments of the patient or in some well-equipped
hospital, BO that then Can be no demand foi exertion on the
part of the patient after thr operation. Severe hemorrhage ma]
GENERAL THERAPEUTICS.
163
follow turbinectomy or tonsillotomy and occurs more often in
patients who are allowed to spend an how or two in the effort
to reach home. In operations of any proportion, where local
anesthetics hav€ been used, it is wise to put the patient to bed
immediately.
Afttt ail operation upon the nose or rhroaf, the patient
should lie flat upon his back, with head and shoulders slightly
elevated. For the first twelve hours cracked ice dissolved in
the month will aid 10 checking hemorrhage. If it is from the
not* 01 tonsils and becomes profuse, cracked ice to the nape of
the neck ami hut-water bottlcS to the feet are recommended.
ding and during op« ral ion, especially when cocain or eucain
is used as an anesthetic, many patients become faint and nause-
ated. To the uninitiated, these symptoms tend to rob the opera-
tor of a certain confidence essential to good work. This nausea
is very often due to a psychical condition rather than to the nar-
cotic effect of the Local anesthetic The patient soon re
under stimulants and words of encouragement from the operator.
many operations, tainting is not a bad condition, some-
times bring nature's relief tor what otherwise might be a
fatal hemorrhage*
Vomiting may follow local or general anesthesia. The
patient suddenly becomes prostrated, pale and nauseated, with
profuse excretions of saliva. The ejected matter is often the
stomach contents, food substance, saliva, gastric juice and
bile. Relief of depressing symptoms quickly follows emptying
of the stomach. Where the vomiting becomes obstinate, we
must resort to some therapeutic remedy for its relief, such as:
1$ Acetanilidi, .97 gm. (gr. iv)
;i bicarb., 1.30 gm. (gr. xv)
Caffeinx eitntttt, .32 gm. (gr. v'l
Fiat chart No, \
1. Om powdfil wiili :i littli i-Tiickcil ire or brandy and repeat
in oor hour if necessi ../;/./ tmer!can Medical Association).
'.- hot water 01 the other extreme, iced champagne or
Apolllfl etimes brings relief." Mustard to the cpi-
gatti'iuui is aJ 1 raroended.
164
DISEASES OF LAR, NOSli AND THROAT.
Rectal enema of hot water, six to eight ounces, to v
is added a little brandy, will relieve the marked thirst whii
sometimes accompanies severe vomiting. Morphin hypodei
niatically and oxalate of cerium i? efficacious.
Hiccough may he relieved by the use of morphia <ir :.
champagne. Some recommend forcible extension ot the tongue.
The bladder should not be forgotten. If resort to the catheter
is necessary, it should be sterilized previous to use. Hm
cations to the bladder will often relax constricted muscles,
After opening the mastoid, turbincctoiny, operation upon the
septum, removal of the tonsils, tracheotomy, etc., all solid foods
arc contraindicated. Fluids, soft and lastly solid diet, ail
their natural course, are indicated as the severity and character
of the operation demands. If, after the second day, there is
not free evacuation of the bowels, resort to enema or gentle
laxative is imperative.
Hemorrhage may often follow operations upon the nose am;
throat. To prevent hemorrhage from the nose, it is best to
spray the nose with a solution of adrenalin chlorid (l-IO,00O).
This should be repeated every half hour until all tendency to
hemorrhage has passed away< It is sometimes necessary to pack
thp nose wirli strips of iodoform or bichlorfd gauze, previoi
saturated with a solution of campho-mcnthol in albolene. Cam-
phor and menthol are both slightly stimulating and the albolene
will prevent the saturation of the gauze with blood and serum
and lessen the liability of the gauze fibers adhering to the
wound.
When small spurs have been removed from the septum, a
thin strip of gauze saturated with the campho-mcnthol solut
< .m be carefully placed over the wound, and this, in turn, cov-
ered with thin strips of gauze. A safe rule to follow is that
of never allowinc the dressing to remain in the nose over fori
eight hours. When the septum is especially dressed, as described
above, the small gauze strips covering the wound may remain
for fiftp-tWO hours, the nose being irrigated frequently with
warm DobcH's solution. Hy this a secondary hemorrhage
!
t
I
:
fiEXI-RAl. TIIFRAI'KCJTICS.
may he prevented. The annoying feature oi many operations
upon the DOM is hemorrhage following the removal of the
first dressing. To prevent this, adrenalin 1-5,000 may be ap-
plied as far as possible, to the mucous surface about the wound.
The nasal mucosa should he partially anesthetised with a solu-
tion of cocain before the dressing is removed.
Rise of temperature after operation upon the car, nose and
throat is tare. If the operation has been accompanied by shock,
we may look for reactionary rise of temperature. If the tem-
I'-r.Ltuic continues elevated, an investigation for the cause is
necessary.
Local Depletion. — By this term we universally imply the
extraction oi vitiated blood from inflamed tissue. This is best
accomplished by rhe natural or Henrteloup's leech.
I be natural leech is a spindle-shaped worm, dark olive-green
n color. They are best known by the name of American, Ger-
man and Spanish leeches. In all acute inflammations of the
mastoid and middle ear they are in universal favor. In apply-
them to the surface it is best to prick the skin so that the
b may more readily attach itself. For convenience, the
leech b placed kO R two-drachm bottle with its head directed
toward the opening of the bottle and in this position it readily
takes hold after which the bottle is quickly removed. Before
using, ir is beat to past the leech through pure, clear water, free-
ui h as possible from all extraneous matter. Leeches
■ -in L themselves full, finally relax and drop off. From
one to two drachms of blood are usually extracted by a single
leech. Leeches should not be used a second time. Formerly,
leeches were applied to the inside of the nose and conjunctiva,
they ai pplied to the temple, siile of the nose,
I, as mentioned, to the mastoid. It the amount of
blood extracted is insufficient! the continuation of bleeding can
be encouraged by thr application of hot water. As a rule, the
hemorrhage from the wound is rather profuse and continues
often for hours. Mechanical and chemical measures can be
d to for its stoppage.
mar
mas
z
1 66
DISEASES OF EAR, MOSI AND THROAT.
Artificial Leech. — The artificial leech of Hcurtclnup is
best explained by the illustration. It is in many respects
very unsatisfactory and should not be used when the natural
leech is at the disposal of the surgeon.
Other local measures in inflammation are applications of
tincture of iodin to the throat and mastoid, tincture of tur-
pentine and the dry cup. Cantharidal collodion is also i
now and then as a blistering liquid to the mastoid and temple.
Diaphoretics. — " Indications to stimulate superficial circula-
tion, the elimination of morbid products through the skin, the
promotion of metabolic changes and reabsorption of exudates."
Those now in universal favor are pilocarpin muriate, given
in one-tenth grain hypodermatically and others such as jabur-
andi and salicylates. The latter are often disagreeable Mod
should be disguised by giving; in menthol waters. In addition,
we have the dry pack (where patients are wrapped in woolen
blankets and given jaborandi), hot-air baths, electric baths and
steam rooms which are useful, therefore, in syphilitic affections,
rheumatism, sclerosis of the middle car, tinnitus and chronic
conditions of the middle ear.
Inunction. — [miftctions of mercury are more especially ap-
plicable in the treatment oi syphilis. For COI ■ e. the
mercury is carefully mixed with pure lanolin and dispensed in
capsules, one capsule containing four grains of mcrcun . thai
amount being sufficient for one treatment. The nurse should
protect her hands with rubber gloves, otherwise, before th
of inunction is complete, she will in all probability, suffer from
the absorbed mercury. The inunction should be administered
to the inner surface of the arms and legs and to the abdomen
and cheat This should be continued daily, until the symptoms
of mcrcurialism arc produced. Daily hot baths will be very
efficacious in bringing about immediate results. While the
cycle of inunction is in progress, due care should be given the
teeth, keeping them perfectly clean. It is best to wash the teeth
frequently with a weak solution oi potassium chlorate.
Constitutional Treatment. — The constitutional treatmenr
GENERAL THERAPEUTICS.
167
espei
,hr"
COtltbtS in the administration of those remedies which are indi-
cated to combat anemia, syphilis and general debility, among
which preparations are hypophosphitcs of lime, soda and arsenic,
potassium iodidj iron, quinin, cod-liver oil.
Hydrotherapy. — l'oot Baths. — In many acute inflammations
of the nose, throat and car, warm foot baths are of great use
in affecting the circulation to these parts by relieving congestion.
Mustard meal may be added to the water to stimulate the skin
circulation. The bath should last for one-half hour. Tlje pa-
tient is then put to bed, wrapped in blankets with hot-water
bottles to the feet to guard against reaction.
Turkish Baths. — With this form of bath we have free
sweating and mflSMg« of the muscles. This form of therapy is
especially indicated in many affections of the ear, nose and
at, especially when there is a chronic exudation within the
es nt the nose, chronic pharyngitis, laryngitis, exudation
within the labyrinth, etc.
Cold Baths. — Cold baths are valuable as a general tonic to
the skm and mucous membrane of the nose and throat. They
should be taken upon arising and thus aid in preventing colds.
Baths arc of value as a general tonic in hysterical neurasthenia
or general debility. Patients should take a cold tub bath or cold
sponge bath and if the shock of the cold tub bath is too much
the patient may apply cold water with a sponge or towel to the
neck and chest.
Warm General Baths. — Warm full baths should be given
at a temperature of 100-1 io° F. Sea salt may he added to the
water. This bath given daily will have a beneficial effect upon
children suffering from a scrofulous diathesis, chronic purulent
rhinitis, erzematous condition and general debility.
Astringents. — Probably among the mineral astringents, nt-
aore often indicated.
Protargoli in varied solutions, is in general favor. It is a
silver albumose containing eight per cent, of metallic salt. It
was first discovered by Chemist Eichengrum and introduced as
a therapeutic agent by Benario. It differs from the nitrate oi
r6S
DISEASES OF EAR, NOSE AND THROAT.
silver in that the nitrate is dependent upon its power to pre-
cipitate albumin from the epithelial layer with which it comes in
contact. In this way the epithelium is detached and with the
contained bacteria is destroyed (Hirschberg). While protar£c»I
does not precipitate albumin, it penetrates deeper into the
cellular tissue, thus acting as a deep astringent, antiseptic and
bactericide without irritating properties.
Argyrol, in a strength varying from five to fifty per cent., is
equally as efficacious as protargol and less irritating and is
especially indicated in the treatment of ulceration and acute and
chronic purulent inflammation of the car. R08G and throat.
In acute and chronic catarrhal conditions of the nose and
throat, the following Solutions arc universally used:
Argentum nitratis,
Argentum nitratis
Argentum niiraiis,
Argentum nitrate,
Argemum nitratis,
Argentum nitratis,
Protargol,
Protargol,
Protargol,
Proiargol,
Protargol,
Argyrol,
rol,
ArRyrol,
' per cent.
i per rent.
2 per cent.
S per c-enr.
8 per cent.
25 per cent.
2 per cent.
5 per cent.
8 per cent-
20 per cent.
50 per cent.
5 per cent.
25 per cent.
CO per cent.
In purulent inflammation of the middle car with perforation,
on account of the germicidal action, solutions of five per cent,
protarjiol or twenty-five to fifty per cent, argyrol, are well
borne and are of great value.
Argyrol, in fifty per cent, solution, is especially efficacious
as a local application to the mouth of the Eustachian tube in
chronic catarrhal inflammation of the tube and middle ear.
In acute rhinitis, a two per cent, solution of ether sprayed into
the nose, often produces a beneficial e£
Argon in, like protargol or argyrol, is a compound of silver
r.LN'fckAL Tlll:k.U'.hl TJCS.
169
salt, a while powder, non-irritating, soluble in hot water. It
is a powerful bactericide in solutions of 1-1,000 and 1-5,000.
It is especially indicated in Hushing tin- middle car m acute and
chronic otitis media purulcnta. Drs. Gray and ' Thompson
recommend it in two to five per cent, solutions to stimulate
Ite of perforations of the tympanic membrane.
Among other astringents to be mentioned are chlorid of zinc.
Sulphate of tltlC, OXld of zinc, iodid of zinc, alum, alumina, bi-
carbonate of sodium, biborate of sodium, sulphate of sodium
and sulphate of copper. Many combinations of the above are
HOW «n the market, classed BC newer remedies, such as borol,
horicin, etc., possessing more or less value as astringents, practi-
cally, however, adding no great advance to the therapy of tin-
diseases under consideration.
Oleo-stcaratc of zinc, which is prepared by precipitating
stearates of zinc in benzoinated liquid albolene, is especially
efficacious, in the dry treatment of affections of the ear, as in
ma, as a sedative astringent to the mucous membrane of
the QOSe n.i-.M pharynx, pharynx and larynx since it clings for
I long time to the surface. The following combinations are on
the market: oleo-stcaratc of zinc, plain; oleo-stearate of zinc,
with balsam Peru : oleo-stcarate of tine, with liquor phimbi
subacctatis ; oleo-stcaratc of zinc, with boric or carbolic acid;
oleo-srearate of zinc, with iodin ; oleo-stearate of zinc, with
orthochloral -phenol; oleo-stearate of zinc, with camphor and
menthol; oleo-stcarate of zinc, with acetanilid; oleo-stearate of
zinc, with oil pinus pumilio and eucalyprol : oleo-stearate of
zinc, with oil pinus pumilio; oleo-stearate of zinc, with antipyrin.
Preparations of Mercury. — The four forms of mercury
more commonly in use are calomel, bichlorid, oxycyanid and yel-
low oxid. The first is more especially used as a purgative, as a
topical dressing in ulceration of the septum and eczema of the
external car.
Bichlorid of mercury, or corrosive mercuric chlorid, as an
nptk and antiparasitic, since 1H70, has been recognized as
the fin-de-siecle of all germicides.
170
DISEASES OF EAR, NOSE AVD THROAT.
In those possessing caustic properties, we are limited to very
weak solutions: 1-5.000 is more often used, t-2,O0O is very
irritating and painful, 1-10,000 is devoid of any painful reac-
tion and may be continued indefinitely without ill results,
Yellow oxid of mercury is used in the form of ointment in
two, four, six and eight grains to the ounce of bonzoate of lard
or lanolin and is a mild astringent and stimulant.
Pastilles. — A very delightful way of prescribing many drugs
for local use in the pharynx, larynx and in the tonsillar affec-
tions, is in pastilles. Those prepared in Tate de Jujube arc
palatable and soluble.
Among those frequently prescribed are ipecacuanha, menthol,
cocain and red gum, benzoinuted voice, chlorate of potash and
borax, red gum, eucalyptus and cucain, codein, compound eu-
ralyptus, compound rhatany and cocain, red gum and chlorate
of potash, chlorate of potash, bora\ and cocain, eucalyptus nil,
menthol and rhatany, tannin, cayenne and black currant, tannin
and black currant, menthol and eucalyptus.
Lozenges. — The following lozenges are after the formula
of Sir Morel 1 Mackenzie and are known as Bosworth's London
Hospital throat lozenges. These lozenges, with the exception
of those containing carbolic acid, are made with black cm:
and red currant fruit pastes and arc prescribed for their im-
mediate local effect. Most of the lozenges contain seventy to
eighty per cent, ot fruit pastes, one tO tWO per cent, powdered
tragacantb, foul per cent, sugar and varying quantities of the
aments, according to the formulae given.
The excipients used in these lozenges allay irritation and
the p'oper action of the medicine,
TROCHISCI ACIDI BENZOWL—
\ must valuable stimulant and "voice lozen
TROCHISCI POTA88JE CHLOR.tTIS —
I '■: Stimulating and antiseptic.
TROCHISCI ACIDI T.IXXICI.—
I'se: Strongly astringent.
GUJIJC T.IWIS. -Tannin l gr.
nrVF.RAI. THERAPEUTICS. r 7 f
TA WIN AND CHLORATE POTASS/!.— Tannin i gr.;
chlorate potassa 2 gr.
•
CAPSICUM.— \ gr.
MIR.
■iMMuSIA AND GUAIAC—i p.. each.
TR0CH18CI CUBEBJE.-
i Each
lozenge contains J4 Rr-
cubebfc) Marked C. B.
I m:
\ 1 1 v serviceable in d
iminish
rig cucssive secretions of
mucue t
mm pharynx, larynx and trachea.
TROCHISCl (HAIACL-
( £» li
lozenge contains 2 gr.
gii.'iiaiurn resin.) Marked G.
Use:
A specific for arresting excrescent inflammation of the
tonsils and pharynx.
Aural Suppositories. — In
many
affections of the external
auditory
canal nr middle ear.
the following: prepared supposi-
tones arc recommended:
"
Bismuth! Milntit.,
.06 gm. <gr. 1)
Ac. benzoic!,
.06 gm. (gr. i !
R
Blimutbl subnii.,
.t2 gm. (gr. iji
i»cnzoici.
.06 gm. (gr. j)
lodoformi.
.06 gm. (gr. j)
Ac. tanas t,
.12 gm. (gr. ij)
'■-
Zinci sulphocarb,
.12 gm. (gr. ij)
/inn ratph.,
.06 gm. (gr. j)
9
Hjdrarg. oxidi flavi,
.06 gm. (gr. j)
»
tg. oxidi flavi,
.i3 gm. (gr. iij)
»
Hv.lrarg. chlor. mi.,
.06 gm. (■••■
■■■ .I1I..1. mite,
.06 gm. (gr. j)
it
Hydrargi chloi 1
.cxri Km. (v.r. ,',. 1
Hydro, chlor. iniic.
.ia gm. (gr. ij)
Ac. salicylic!,
.06 gm. (gr. j)
Ac '"
.06 gm. (gr. j)
Ac. taninVi,
.06 gm. (gr. j)
9
Ac. Hlicylii i,
.12 gm. (gr. ij)
Ac Imrici,
.06 gm. (gr. j)
Ac. tannic!,
.ij gm. (gr. \\\
I/2 DISEASES OF EAR, NOSE
A Nil THROAT.
]J Thymol,
1 ucalyptol,
Chloral hydrate,
-°3 gm. (gr. ss)
.06 c.c. (M j)
.06 gm. (gr. j)
JjS Morphine sulphate,
Atropine sulph.,
.008 gm. (gr. !■£)
.0002 gm. (gr. jfo)
$ Cocaine hydroch.,
Morphine sulph.,
.001} Em. (gr
•008 gm- (gr- 'A)
9 Cocaine hydrocli.,
Morphine sulph,,
.06 gm. (gr. j)
•0023 gm. (gr. A)
Smelling Salts. — Indicated for acute and chronic congestion
nl the upper air passages:
# Phenol,
Ammonii carbonatis,
Pulveris carbonis lignin.,
Olei lavandute,
Tr. benzoini com p.,
Keep in well-stoppered bottles and
inhaling.
gr. xxx
1 j
3 J
M xx
5 M-ME
only remove the cork when
Jjt Phenol, 5 j
Aminunii carbonatis, 3 ij
Pulveris carbonis ligni, 3 ij
Tr. benzoini romp., 3 j
1 jI lavandule, . M vj
A<|. ammonie fort., q, s.-M
(Hall)
Somewhat stronger than the preceding.
Nasal Suppositories. — The prescribing of suppositories for
the nostrils is not universal. The indication tor tin's form of
therapy is frequent and tno often neglected hy the rhinolo;
1} Potassii chloral.,
Thymol,
.12 gm. (gr. ij)
-03 gm- (gr- *»)
5 Potassii chlorat..
Thymol,
.18 gm. (gr. iii)
.03 gm. Igr. n)
B Bismuth, suhnit.,
Eucalyptol,
.06 gm. (gr. ))
.06 c.c. (in. j 1
GENERAL THERAPEUTICS. 1 73
# Iodoform!, .06 gm. (gr. j)
Thymol, .03 gm. (gr. ss)
IjE Iodoformi, .06 gm. (gr. j)
Ac. tannici, .12 gm. (gr. ij)
$ Hydrarg. chlor. cor., .002 gm. (gr. TV)
Potassii chlor at., .06 gm. (gr. j)
Ifc Hydrarg. chlor. con, .002 gm. (gr. 3*5)
Potassii chlorat., .12 gm. (gr. ij)
Ifc Ac. borici, .06 gm. (gr. j)
Sodii biborat., .12 gm. (gr. ij)
Thymol, .03 gm. (gr. ss)
1> Ac. borici, .12 gm. (gr. ij)
Sodii biborat, .18 gm. (gr. iij)
Thymol, ■ .06 gm. (gr. j)
I£ Ac. benzoici, .12 gm. (gr. ij)
Iodoformi, .06 gm. (gr. j)
Hydrochlor. cor., .002 gm. (gr. A)
Cocaine hydroch., .002 gm. (gr. jV)
5 Cocaine hydroch., x>6 gm. (gr. j)
5 Cocaine hydroch., .0012 gm. (gr. j\y )
Morphine sulph., .008 em. (gr. %)
5 Cocaine hydroch., .06 gm. (gr. j)
Morphine sulph., .03 gm. (gr. -ss)
Atropine sulph., .0006 gm. (gr. TJu)
5 Cocaine hydroch., .001 gm. (gr. ^B)
Eucalyptol, .06 c.c. (M j)
Thymol, x>6 gm. (gr. j)
5 Morphine sulph., .008 gm. (gr. \i)
Zinci oxidi, .12 gm. (gr. ij)
5 Morphine sulph., .03 gm. (gr. ss)
Zinci oxidi, .06 gm. (gr. j)
Bismuthi subnit, .12 gm. (gr. ij)
Ijfc Bismuthi subnit., .18 gm. (gr. iij)
Cocaine hydroch., .016 gm. (gr. %)
B Ac tannici, .12 gm. (gr. iij)
Iodoformi, .06 gm. (gr. j)
Cocaine hydroch., .01 gm. (gr. %)
'74
DISEASES 01- EAR, NOSH AND THROAT.
Aids to Hearing.— Various devices have been introduced,
from time to time, as aids to hearing. It is essential that the
physician knows something of the relative value of such in-
struments.
The conversation tubes are powerful conductors of the hu-
man voice. They consist of a hard ruhber, trumpet-shaped
mouthpiece, of variable size, to collect the sound waves, a small
earpiece of hard rubber, a conical, elastic tube of spiral wire
covered with rubber and woven silk or mohair (Fig. 82).
Fig. 82.
«UYB„*.TI 0. 1.
SrrAKiitG Tube.
The car-phone is one di-used by Professor North. With
this instrument the patient can hear voices at a distance, such as
lectures, etc. This can be used either with or without the
extension tube.
The London hearing dome is made in four sizes, of metal
used in the manufacture of musical Instruments, possessing su-
perior acoustic properties. The dome is applied to the ear
u itfa the open end directed to the sound. This instrument pos-
mnny superior advantages and is in universal use.
Ear trumpets are of much cheaper material, bunglcsomc and
very conspicuous.
The otophone, No. i, i- of polished black rubber, light and
convenient, being carried in the pocket. This InstntmeDt
GENERAL THERAPEUTICS.
'75
placed against the car and is not inserted. The wave sounds
do not strike direct against the drum heads but are interrupted
by means of a diaphragm, as fa the telephone receiver (Fig. 83).
The sounds are dearer and mure distiner.
The otophone No. 2, is constructed merely for conversation.
It consists ol a mouthpiece, tube and transmitter. This is very
effective in those profoundly deaf.
Politzer b&9 designed an instrument shaped like a hunting
horn to he inserted into the auditory meatus. The instrument
is mi constructed that the convex portion resls upon the inner
F:c. X}
11
side oi the tragus and the Opening is directed towards the
cochlea. Politzcr believes that the sound waves are heard more
distinctly where the tragus is enlarged backward.
Artificial ear drums consist of a thin, soft-rubber disk, gold
or metal stem. They arc adjustable to the exposed malleus.
1 I u-v possess more or less efficiency. Sometimes a small pledget
i.t cotton against the malleus will enhance wave sound.
The aiiiliplione is a fan-shaped disk ol vulcanized rubber and
.1 ue in mart] cases. The convex surface is presented
to the sound and the edge of the fan is held to the teeth. It is
recommended in sclerosis, etc.
CHAPTER XI.
DISEASES OF THE EXTERNAL EAR,
Injuries of the Auricle and Auditory Canal. — Injuries
in this region are classed as incisions, lacerations, contusions, and
gun-shot wounds.
Incised wounds, providing they arc clear cut, heal as a
rule, without leaving any deformity. The treatment of incised
and lacerated wounds is very much the same and consists in
carefully cleansing the pinna, stitching the parts together and
dressing with gauze and cotton.
Laceration more frequently follows from some foreign body
striking and rearing the pinna. The laceration may extend to
the meatus. In fracture of the temporal bone, the auditory
canal may be torn both in ir- anterior and posterior wall. I
•der such circomstances, the hemorrhage may be very prol
and must be controlled with gauze and compresses. Stricture
of the canal, which 90HKtUHC8 follows a !
by packing with gauze. In addition to the general treatment.
the canal and auricle should be irrigated once daily with l
solution of lysol in a strength of one-half drachm of lysol to a
pint of warm water. Lacerated wounds of the pinna do not
heal as readily as incised woum.k, because <>1 the injury to the
tissue and tin- greater liability of infection,
Bites of the pinna are especially prone to become infected.
There is usually more or less deformit] resulting from a b
Contused wounds, when due to a fall, kick 01 Wow upon tin-
side of the head, in which the cartilage la broken, are usually
followed by deformity. The effusion of blond and serum may
be very small or sufficient to produce a hematoma. Deformity
DISEASES OF Till-: EXTERNAL BAIL
'77
more often follows a hematoma. Suppuration seldom follows
a bruise except in those with a debilitated system.
Symptomatology. — The symptoms of contusion are tender-
ness, swelling and some pain in the auricle. Hemorrhagic
flotation more frequently occurs in the lobe of the ear.
Treatment. — The treatment in contusion consists in wash-
ing the pan, n in w irm lysol, one-half drachm to a pint of hot
water, or bichlorid solution 1/3,000 and dressing with gauze
and cotton. Incision is demanded should an abscess form. If
a slough forms, it should be irrigated twice daily with warm
lysol solution and dusted with aristol. Exuberant granulations
may be touched with nitrate of silver, sixty grains to the ounce
of water.
1 1 i here is rupture ot the drum, accompanying injury of the
auricle, the auditor? canal should be cleansed with a cotton-
tipped probe dipped in a warm solution of lysol. If there is
evidence of exudation within the labyrinth, in addition to the
and irrigation, the patient should be given hypodermatically.
pilocarpin one-tenth of a grain, once daily, and potassium iodid,
ten to fifteen grains, three times daily in water.
I r nose and throat should be irrigated twice daily with a
u:iim antiseptic solution to prevent, as far as possible, infection
extending to the middle ear through the Eustachian tube.
Keloid of the Auricle. — Keloid of the auricle is a hard
nodule <>r Bat growth of the skin, composed of dense fibrous
tissue, developing more especially on the lobule of the ear and
is due more oiten to injury from piercing the ears. The growth
is slow and without pain, though tender to the touch. The
negro race is reported to be more susceptible than the Caucasian
race. The has a tendency to recur.
Treatment. — The X-ray is highly recommended in the treat-
ment of keloid. Dr. A. N. Cole reports a case of keloid the
size of a small marble, behind the ear, relieved after forty treat'
s ot the X-ray, extending over a period of eight months.
I- the _'tnu th is very large, surgical treatment is necessary.
Exostosis and Hyperostosis. — Upon examination, tta
«3
■ 7S
DISEASES OF EAR, NOSE AND THROAT.
character of the growth is usually diagnosed by hardness and
peculiar nodular appearance. The growth may be single or
multiple and is covered with normal skin. Bony growths of
this character arc usually the result of a syphilitic or rheu-
matic diathesis.
In exostosis there is a history of a previous inflammation
of the meatus or of the canal, whereas in hyperostosis the growth
is usually slow and without previous inflammation.
Exostosis makes its appearance usually near the junction of
the bone with the cartilage of the canal and is pedunculated
and somewhat mobile. It is somewhat variable in form. Hyper-
ostosis appears in the bony portion of the canal. Sometimes the
canal is completely occluded by the characteristic hard and
mobile tumor. It may grow independent of any previous in-
flammation of the external auditory canal or middle ear.
Symptomatology. — The subjective symptoms are a sensation
of obstruction in the auditory canal, with a constant desire to
pick the cars. Partial deafness may result, not alone from the
size of the obstruction, but from the impaction of cerumen and
foreign substances, which may gain entrance into the canal.
Treatment.— Burnett advises the extraction of exostotic
growths by surgical measures. His general advice in hyper-
ostosis is to let the growth alone, especially if the canal is not
illy obstructed' When removal is indicated, it is accom-
plished by the electric drill. Burnet! also remarked that bony
\ilis in (his position ate tar more frequent than is SUPPOSCd-
Tumors. — Tumors (see fcthologj of Tumoral of the ex-
ternal car may be both malignant and benign. Epithelial tumors
of the squamous variety may take their origin at the site of
ulceration, polypi Ot necrosis of the middle ear and involve the
external auditory canal and pinna.
Carcmama may begin externally, frequently at the- lobe od
the pinna and extend inward. Carcinoma, or cancer, of the
accessory cavities of the nose may involve the middle ear ami
even the brain cavity. Carcinoma usually occurs late in life*
Numerous cases of both sarcoma and mixed tumors are re-
UISlfASliS OF Till: EXTERNAL EAR.
179
ported in current literature, involving the auricle, meatus, middle
ear and hony struuure of the temporal bone. Sarcoma and
mixed tumors may occur :it BIS] time of life,
Dirigrn/sis. — Familiarity with certain clinical symptoms will
triable the physician to differentiate the presence of a tumor.
Then may he some resemblance between carcinoma, syphilis
and tubercular ulcerations. Syphilis may be excluded, if in
doubt, after giving heroic doses of iodic! of potassium and
men ury.
The histological finding is frequently the only way to differ-
entiate sarcoma, carcinoma and mixed tumors. 'J lie specimen
oi rlic tumor with the complete histon ot the case and the
I location from which the specimen was removed, should,
by those who do not care to carry out a careful historical exami-
nation, be sent to a pathologist for differentiation.
Treatment. — If the disease is confined to the pinna, early
operative measures h ill frequently bring about a complete cure.
On account oi the great destruction of tissue, which frequently
i- before the patient consults the physician, operative treat-
ment is only palliative. On account of the lymph supply round
It the meatus and middle ear. carcinoma readily extends by
a process of metastasis. Sometimes benign tumors bring about
nit ion of the hearing apparatus by pressure. In the re-
moval of benign or malignant tumors, bearing may be neces-
sarily sacrificed, as well as a certain amount of symmetry of the
pinna.
Local treatment for carcinoma consists in the application of
the X-ray. which should be applied twice or three times weekly
for a period of from five to ten minutes.
Foreign Bodies in the External Auditory Canal. —
Among the foreign bodies frequently placed in the auditory canal
whiten, are coffee beans, pebbles, beads, berries, small par-
ticles of wood, slate pencils, grains of wheat, flower buds, etc.
Insects ii ;.'• crawl into the auricle of children or adults, during
The position of the foreign bodies varies. If pushed
■e istlur... frequently come into direct contact
DISEASES OF EAR, NOSE AND THROAT.
with the drum. Schmeigelow reports a case in which a small
stone was pushed into the middle ear, through the auditory
canal.
Symptomatology and Diagnosis. — In the majority of cases
the presence of foreign bodies in the ear is curly detected by the
parent. If the foreign body remains in the ear for any length
of time, the child may complain of deafness and irritation, with
a desire to pick, the ear. A diffuse inflammation of the canal
may supervene, accompanied by severe pain.
Cases of obstinate cough, nausea and epilepsy are recorded at
being due to foreign bodies in the ear. Moths and small bodies
in the deeper part of the meatus may be hard to discover.
Treatment. — In the extraction of foreign bodies from the
car care should be taken to avoid injury to the canal and the
membrana tympani. While extracting a foreign body from the
ear the skin may frequently be torn sufficiently to cause bleed-
ing. The meatus may be swollen and inflamed from previous
efforts on the part of the patient or parent to extract the body.
If the canal becomes swollen, one may be compelled to delay
operative measures until the inflammation is reduced by hot
irrigations. A fountain or large aural syringe should be used
for irrigation. The water should be warm and directed, as
tar as possible, in the extraction of foreign bodies, to one portion
of the canal. This method pwn ing unsuccessful, a small
curette may be gently passed behind the object, thus dwlod
and changing its position, after which it may be removed with
a blunt Curette, goose-neck forcep or by irrigation.
Politzer speaks highly of the agglutination method of Lowen-
barg) which consists in drying the object with cotton and after-
ward inserting a camel-hair brush, previously dipped in ;
and applying it to the objret.
In cases without inflammatory exudation, the brush may-
adhere with sufficient force to rnable the ohject to be extracted.
It is often necessary to administer an anesthetic n chil-
dren, on account of their resistance. Chloroform ia more in-
quently used for narcosis. The anesthetic should not be carried
■ F THE EXTIiRXAI. EAR.
1S1
to a state of ( omplece narcosis. A child may be supported in the
arms of the nurse or placed prone upon the operating table.
With a head-mirror and light from lamp, candle or drop light,
after partial narcosis, a blunt hook or straight curette may be
pushed between rlu- wall of the Caaa] and the foreign body. As
a rule, a single quick, pull dislodges the foreign body. The
ear should now be cleansed With :i uarm antiseptic solution,
preferably lysol, one drachm to a pint of u aim water, dried and
dusted with stearate of zinc or aristol.
Live insects, when they reach the membrana tynipani, cause
DOOM excruciating pain in the ear. It is frequently impossible
to remove the insect as a whole. After a few daily irrigations.
small adherent particles of the insect will be washed away.
Bugs may crawl into the ear, die without causing pain, after-
ward become covered with cerumen and are found when the
Cerumen i- washed away. Live insects may be killed by blow-
ing the fumes of chloroform into the canal. A convenient
method of forcing the fumes of chloroform into the canal, is by
saturating a pledget of cotton with chloroform and placing it
in the bowl of an ordinary clay pipe, the stem of the pipe being
placed in the auditory meatus and the fumes of the chloroform
forced through the stem by blowing into the bowl of the pipe.
Cotton or gauze may be placed in the ear and forgotten.
The author recalls a case in whiih the gauze had remained in
the eai KM fifteen years. The epithelium of the canal had ex-
■ rated into the meshes of the gauze.
Lar< Mned, according to Politzer, by the in-
stallation of oil or glyceTin, t<» which is added a few drops
of i' :. turpentine or ethereal oil. After a short time the
larva* crawl out of the meatus.
Disorders of Secretion of the External Auditory Canal.
— The wax glands occupy about two-thirds oi the auditory canal
and are more numerous in the upper and outer portion. In
health, the secretion is disposed of by evaporation and expulsion
of wax bj cilia ot the canal and movements of the jaws
in talking and eating.
iSa
DISEASES OF EAR, NOSE AND THROAT.
Etiology. — Adults more frequently than children, suttVr
ceruminouB plugs. Any constitutional disease, local irritation
or catarrhal inflammation of the middle car that may obstruct
the free exit of cerumen or change the consistency of the secre-
tion, may bring about impaction. Picking the ears with pins
may cause an exfoliation of the skin, which, mixing with the
glandular secretion, may cause the formation of a plug. Rail-
mad meil and factory nun arc predisposed to impacted cerumen,
On account of the dust mixing witli the car wax. In washing
the ear with soap and water, the patient will frequently force
a sufficient amount of soap into the ear to start the formation
of a plug. The consistency of the plus varies and is dependent
upon the amount of moisture contained. It may be soft or hard
and glistening, varying in color from a dark to a very i
brown.
Symptomatology.. — Sudden deafness, without any other symp-
toms, such as pain or vertigo, is g '>: impacted cerumen.
Sea bathing has a rendenn to sullen the wav which may he
adherent to the canal, forcing it against the drum, which pro-
duces sudden deafness and pain in rhc ear.
A feeling of fullness and discomfort in the ear with more
or less deafness and general nervousness and irritability, arc
suggestive symptoms. Among the nervous symptoms accom-
panying and sometimes dependent upon impacted cerumen, are
oough, vertigo, hallucination, vomiting and facial paral
Diagnosis. — There is usually no trouhle in diagnosing im-
pai ted cerumen under good illumination from a head-mirror
:i 1 1 ■ ] i In- .ml nf an ear speculum. When the impaction is light
in color and very hard, it may be mistaken for a morbid growth
or keratosis obturans.
gnosis. — There is always a tendency to a recurrence of
rhr trouhle. '. Im cases give a history of recurrence dal
hack many years.
If the impaction is due primarily to some mechanical irrita-
tion to the epithelium, prospects tor a complete cure are \
good. In young children in which the impaction is influenced
DISFASES OF THE EXTERNAL EAR.
183
by hypcrtrnphfed tonsils and post-nasal obstruction, a cure can
only result after the complete removal of the obstruction in the
nose and throat.
Treatment. — The treatment consists in the careful removal
of tlie impaction by disintegrating with hydrogen pernxid,
which is left in the ear for a few minutes, followed by a warm
r irrigation.
The following is frequently pre* ribed to soften the impaction
preparatory to irrigation:
It Sodii liicarln>n;iii\ 1.30 gin. (gr. xx)
15.00 c.c. (aa 3 ss)
s.-viii biearbooAtls,
Glycerini, J M
Aquae desril]., '
M.
Signa. Drop three or four drops in ear, three times daily for
from one lo two days.
In irrigating the ear, the water should be at a temperature
comfortable to the hand. A teaspoonful of bicarbonate of soda
should be dissolved in a pint of warm water. In using the aural
syringe or irrigating tube care should be taken that the stream
thrown well into the meatus and in one direction. Too
much force is to be avoided for fear of injuring the membrana
tympani or producing syncope. After the ear wax is removed.
the canal is dried with a fifty per cent, solution of alcohol, fol-
lowed by the application of an unguentum of the yellow nxid
of mercury (eight grains to the ounce) or dusted with iodol.
The canal should be examined every two or three months to
prevent a possible rcaccumulation.
Deficiency of Secretion. — This is a condition of dt
01 the aoditOTJ canal from insufficiency of ceruminous secretion,
due to some trophic disturbance. Atrophy of the glands may
;r from cc/rm,i of the canal, general inflammation of the
canal or middle ear catarrh. The patient complains of a dry-
ness in the car, itching and a desire to pick the ears.
Treatment. — An ointment of yellow oxid of mercury, eight
grains to the ounce of lanolin, may be applied to the canal once
The meatus may be gently massaged with an aucat
ucal
iS|
DiSSASIS OF EAR, HOSE AND THROAT.
vibrator for a few minutes every other day for a lew weeks. If
complete atrophy of the glands takes place, the canal may be
moistened every tew days with an unguentum oi yellow oxid
of mercury.
Hyperemia of the Auricle. — Hyperemia of the auricle may
be active or passive and is more frequently due to some vaso-
motor disturbance and quickly passes away. There is an in-
crease of blood to the auricle, causing redness and a sensa-
tion of heat without exudation. Active hyperemia may result
from friction, exposure to heat or cold, eczema or trauma.
Hyperemia of the meatus may be due to inflammation of the
tympanic cavity and surrounding tissue.
Passive hyperemia is chronic in character and is more often
due to a stasis in the blood stream from valvular heart lesion
or traumatism of the auricle. Other predisposing causes of
passive hyperemia are certain forms of eczema, seborrhea,
quamation of epithelium and ulceration with the formation
of scars.
Treatment. — For the relief of hyperemia of a purely nervous
origin, treatment is directed to building up the debilitated nerv-
ous system and the correction of any constitutional dyserasia.
In hyperemia of the meatus due to inflammation of the tym-
panic membrane and mastoid antrum, the treatment is neces-
sarily directed to the cure of that disease.
Local treatment in passive hyperemia constat in gentle
massage of the auricle and painting with a mild solution nt the
acetate of lead.
Traumatic Dermatitis of the Auricle. — Traumatic der-
matitis is an inflammation of the skin covering the auricle, re-
sulting from a blow, fall, bite of insects, irritating ear rings,
telephone receiver, parasitic infection, etc.
Symptomatology. — The symptoms vary from a slight irri-
tation of the skin, with redness and swelling, to a circumscribed
cutaneous gangrene. There is inure or less pain and feeling of
fullness at the point uf injury, varying according to the severity
of the disease.
DISEASES OF THL EXTERNAL F.AR.
'-
Treatment* — The treatment consists in the removal of the
cause and the application of campho-phenique to the surface
and i.| covering it with a thick roll of antiseptic cotton.
A lead and opium wash is highly recommended in the mild form
of the disease. Hot antiseptic poultices are indicated in the
grenotu form of tin- disease.
Dermatitis Erysipelatosa. — This form of inflammation of
the auricle is due to infection from the streptococcus erysipe-
latosa of Fehleisen, which finds entrance into the surface from
scratch, abrasion, cut) bite of insects, etc. The disease is more
often secondary to a facial erysipelas. The disease may extend
to and involve the niembrana tympani or the middle ear.
Symptomatology. — The disease may be ushered in with a
chill followed by high temperature, anorexia and headache.
The auricle becomes red, swollen and glistening about the
point of infection. The discoloration rapidly spreads over a
part or the whole of the auricle. Vesicles, filled with a serous
late, may form over a part or the whole of the auricle.
Treatment. — The infected area should be painted with pure
carbolic acid and neutralized with alcohol. After applying the
carbolic acid, sufficient time should elapse to allow a whitish
idoration of the inflamed surface to take place before the
alcohol is applied. One application is usually sufficient to
bring about a resolution. An ointment of twenty per cent,
iihthyol in lanolin is highly recommended as a cool inn and anti-
septic application.
Did ifaouM be restricted and bowels regulated with calomel
:ii>r-t [eni v. aters.
Dermatitis Phlegmortosa. — Dermatitis phlegmonosti it in
infection spreading to the deeper structures of the auricle and
treptococcus erysipelatis, streptococcus or staphy-
lococcus pyogenes.
Symptomatology. — There is a high fever, swelling and deep
redness of the auricle, pain of a throbbing and beating character
with the formation of pus, ending in suppuration and destruc-
tion of cartilage. Gangrene may sometimes supervene.
i86
DISEASES OF EAR, NOSE AND THROAT.
Treatment. — Hot antiseptic poultices arc indicated in the be-
ginning of the disease. As soon as pus is suspected from the
swelling and palpation, a free incision should be made and per-
fect drainage established. The wound is afterward treated
with, hot antiseptic irrigation.
The debilitated system, which frequently precedes the disease,
should be treated with general tonics.
Dermatitis Gangrenosa. — The various forms of this dis-
< are seldom seen affecting the auricle. It may follow op
tion on rhe mastoid, from trauma or from frostbite.
Ttiiitnu-nL — The treatment consists in the removal nf ne-
crotic tissue and an active effort to secure asepsis. In the early
_i » warm stimulating applications are valuable in restoring
circulation and metabolic change. The pain may frequently
Controlled bj dusting with aristol and orthoform, in equal
parts. Isolation of the patient and sterilization of clothing,
towels, dressings, etc., arc demanded.
Dermatitis Congelationis, or Frost-bite. — On account ..!
the exposed situation of the auricle and close attachment of the
skin, want of subcutaneous fat and lessened blood supply, the
auricle is predisposed to frost-bite.
I 1-iMiir im severe cold will bring about a contraction of
blood-vessels anemia and numbness of the parts. If the severe
cold is continued longer, the parts may be completely frozen,
the auricle remaining bloodless, and dry gangrene occurs. A
portion or the whole of the auricle may separate at the line of
demarcation.
After reaction, the vessels dilate, the tissue covering the
CSTttlage Swells and sometimes cracks open and the pain may be
inlld or vet] severe. Moist gangrene may occur.
Chilblain is a condition verj closely allied to frost-bite and
is an erythematous inflammation of the auricle due to cold. It
is more often observed in children and those poorly nourished.
Recurrent attacks occur with each succeeding eXDOSUft W OOld
weather. The symptoms of chilblain arc itching and burning
of the ears, produced I re to cold and sudden change to
a warm room.
DISEASES Or THE EXTERNAL EAR.
187
a/mmt. — The treatment in frost-bite consists in the ap-
plication of ice bagSi snuvv or cold water to the auricle, allow-
ing a gradual return to the normal temperature of the body.
Should excoriation take place, the auricle must be thickly
covered with benzoinated zinc ointment or ichthyol, one part
to adeps benzoate seven pan-.
Il dry gangrene occurs, separation may be hurried by apply-
ing hot antiseptic poultices or by cutting necrotic tissue away
and afterwards dressing with aristol and oiled gauze and
protecting with cotton and bandages.
Dermatitis Combustionis or Burns.— In burns of the
auricle, \cr> often the neck is involved at the same time. Se-
vere burns of the nerk and car may result from not infrequent
accidents.
Treatment. — The object of the treatment is primarily to
lessen the p:nn :md prevent excessive connective-tissue forma-
The dead and charred tissue should be removed at once.
Pcroxid of hydrogen is highly recommended as an antiseptic and
cleansing agent. When the skin of the neck or auricle alone
is involved, the parts should be cleansed with a solution of
inmate of soda and covered with the following:
1} Zinc oxidi,
Qrihoform,
Adeps benaolnatis,
7,80 Km. (3 ij)
3.90 gm. (3 j)
31.10 gm. (3 j)
r followed by a dressing of soft lint.
For superficial burns, equal parts of lime water and linseed
oil may be used. For the prevention of infection and pain,
when the deeper structure is involved. Muench recommends
I ninety-fire per cent, carbolic acid as a local application, which
immediately washed away with alcohol. The wound is
trefoil] dressed t«> prevent infection.
Eczema of the Auricle. — Eczema of the auricle is more
often observed in children than in adults and is an acute, sub-
acute or chronic inflammation of the skin of the auricle or
meatus, characterized by itching or burning, with a catarrhal
iSS
DISEASES OF EAR, NOSE AND THROAT.
exudation and the formation of crusts or dry scaling of the skin.
Etiology. — Eczema of the auricle is more frequently associ-
ated with an acute or chronic purulent inflammation of the
middle ear of children with a strumous or syphilitic diathesis.
Not infrequently will it be found as an accompanying condition
of acute myringitis, cither in the young or in the adult, or ex-
tending from a seborrheic eczema of the scalp.
The disease may follow chronic irritation of the pinna or
meatus, piercing of the ears, cheap ear-rings, frost-bite, irri-
tating dust, iodoform dressing, constitutional dyscrasia, atmu
spheric conditions and excessive use of soap and water.
Pathology. — The disease is presumed to be a catarrhal COB
dition of the skin closely associated with other tonus '" |!|,;
matitis, due to some extrinsic irritation, and subsides with the
removal of the cause without leaving a scar.
Symptomatology. — The whole or part of the meatus or auricle
in the acute form of the disease, may be red and swollen and
covered with a thick, moist crust, with here and there a leakage
of scrum through the skin. The skin has a tendency to craclt
open, especially at the floor of the meatus. There is itching
and a desire to pick the cars. Frequently a chronic, purulent
inflammation of one or both ears exists, with all the clinical
symptoms <»l some inherited dyscrasia.
In the chronic form the disease varies greatly and may bt-
limited to the meatus or involve the entire auricle. The skin
may be reddened, dry', exfoliated and thick and smooth to the
touch.
Diagnotis. — As a ride, the disease is very easily diagnosed.
Differentiation between syphilis of the auricle, erysipelas and
dermatitis may be necessary.
Cause and Prognosis. — In the acute form of the disease, as
a rule, the recovery is very rapid with the relief of the exciting
cause. A chronic eczema of the auricle, associated with a tifa
condition of the h»CC, may continue indefinitely. If dependent
upon a purulent otitis media, with inherited syphilis, the relief
is sometimes quite magical under the iodides.
DIM-'ASFS OF Till- tXTERNAL EAR.
189
Treatment. — The treatment is first directed to the exciting
cause of tin- disease. Tf n constitutional cfyscrasia exists, a
general treatment is indicated.
The local treatment consists in cleansing the surface of all
accumulations and crusts by the local application of cold cream
or oil, followed by a local application of nitrate of silver, sixty
grains to the ounce of water. This should be applied once daily
with some degree of force to the surface and cracks in the skin,
followed hy a local application of yellow oxid of mercury, eight
grains to the ounce of lanolin.
Fur the relief of itching, W. A. Hardawaj recommends the
following;
k Phcaol,
Glsreriiii,
Alcohol!*,
M.
,. in hr h(-c[i:ciith- mopped on the car.
&,oo gm. (3 iiV
15.00 C.c. 13 ^s)
236.00 c.c. f3 TUBS)
Jaqucl recommends Thigenol, a compound of sulphur, as a
sedative and antiseptic, in the following formula;:
B Thigenol,
4..00 c.c. (3 i
Zinri oxid, 1 --
3.00 gm.
Atnvli, J
Glywrini, X jj
Aquae, 1
1. 00 c.c.
Qng. glvctfiini,
8.00 gm.
M.
Signa- To he applied
once
daily.
As a rule, healing i& encouraged by the avoidance of water
to the ear.
Campho-pheriique or vinegar of cantharides may he applied
in full strength every two or three days, followed by the daily
application of benzoinated oxid of zinc ointment.
When iron and sulphate of magnesia are indicated, the fol-
lowing is reconiTiniilcd by Hyde:
ioo
IXM.AMS (>r FAR, NOSE ANl> i'MRUAT.
U Magiifv lulphlt,
Acid lulphui . dii .
Ferri sulpli.,
Sodii chloriJ.,
Cardamom, tinct. ctiiiin.,
At|. desr.,
60.00 go. i.> ii)
8.00 c.c. (5 ii)
.66 gni. (gr. x)
4.00 gm.
4.00 c.c. (3 i 1
256.00 c.c. (ad. Q i
The general treatment must be governed by the character
of the dyscrasia*. The rules of personal hygiene should be
enforced.
Lupus Vulgaris. — Lupus vulgaris is a chronic tuberculosis
of the skin <>j the auricle, either primary or secondary to lupus
q{ the face. The disease begins as a pin-hcml-si/ed, dull reddish
or yellowish spot, deep in the skin, on a line with or elevate!
above the surface. The dull reddish nodules arc sometimes
years in developing. The growth becomes soft and " apple-
jelly-like," as described by many authorities. After a time the
tubercles or lupoma undergo absorption or degeneration, thus
presenting all the varieties of the disease.
Course. — The course of the disease is exceedingly chronic.
A part or the whole of the auricle may be involved. After
absorption of the lupoma, the auricle becomes shrunken and
deformed.
Diagnosis. — The diagnosis is made by the history of tuber-
culosis in the family, origin of the disease in early life, reddish
brown, " apple-jelly-like tubercles," and chronicity of the disease.
It may be necessary to differentiate the disease from eczema,
:•', I'li'l!-. ii nc rosacea or epithelioma.
Treatment. — The general treatment consists in securing good
hygienic surroundings and the administration of cod liver oil
or iodid of potassium and Fowler's solution of arsenic
The local treatment consists in the evacuation with ■ sharp
spoon 01 dermal curette, as advised bj Volkmann, Hard;,
and others. The guarded application oi the \ ray is recom-
mended by many. The X-ray should be applied from eight to
ten minutes even- other <1av.
Impetigo Contagiosa. — Impetigo contagiosa is an acute
DISEASES Of THE EXTERNAL EAR.
lyi
contagious disease of the skin, beginning as small discrete or
confluent vesicles, " sometimes developing to the size of a twenty-
li'.c tent pWCo" (Hardaway). The disease may attack the nose
or auricle primarily or iua\ spread to the nose or auricle from
contiguous parts. Impetigo contagiosa is more especially within
the domain of the dermatologist ; on account of the ear involve-
ment, however, space is given to the disease,
Ptit/irtlngy. — So far, no specific organism has be'en discovered
as a cause of the disease. Its transmission from one individual
to another suggests some contagious organism.
The lesion begins in one or more discrete or confluent vesicles,
which rupture and leave a dry. granular surface resembling, as
remarked by Hardaway, vaccinia. The disease may occur at
any age.
Diagnosis. — The disorder may he differentiated from eczema,
by history, course, presence of slightly umbilicated vesico-pus-
ttilcs, which drying, leave flat granular crusts, and by the run
tagiotttOCSS of the disease.
Prognosis, — Recovery usually results within a few days,
when a strict treatment is instituted.
Treat mi at. — The surface should be cleansed with a solution
of surgeon's soap and lysol, one drachm of the latter to a pint
of hot water and soap, twice daily, followed by a local appli-
tatSon of ammoniated mercury and lanolin in equal parts.
Acquired Syphilis of the Auricle. — The pinna may become
primarily infected by kissing, injury in tout ball, scratch oi a
pin or bite.
Secondary and tertiary stage--, will be more frequently en-
tered.
Diagnosis. — The primary lesion or hard chancre, may be ob-
served and is a small ulcei With hard indurated base and ed
appearing a few weeks after the injury. The period of incu-
bation a considered twenty-one days, varying, however, from
ten days to two months. The initial lesion more frequently con-
forms to the papular type
The lesion ta governed by the character of the trauma and
KJZ
DISI ISES OF EAR, NOSE AND THROAT.
may be formed as a fissure, ulcer, or an erosion. However, tile
base hardens with the growth of the induration.
Ulcerations frequently manifest themselves about the lobe
and the meatus of the ear. The lymph glands of the neck are
swollen.
The secondary period of the disease may occur as a general
syphilodermata, limited to a portion of the body.
The diagnosis is, as a rule, easy. However, it is very tieces-
•sary that the diagnosis be perfectly clear before antisyphilitic
t refitment is begun.
The tertiary lesion may appear as a gumma or an ulceration,
located on the anterior or posterior surface or on the lobe
The diagnosis of a gummatous ulceration of the auricle in
the absence of a history- of syphilis, is frequently difficult. It
may resemble lupus or epithelioma.
Trraimmt. — The treatment of syphilis of the auricle varies
in no wise from syphilis in any other portion of the body. |
Treatment of Syphilis of the Nose.)
Congenital Syphilis of the Auricle. — (Sec Syphilis of the
Nose.) Syphilis of the auricle may be observed as a secondary
or tertiary lesion. Lesions of the car frequently accompany a
like condition of the nose and eyes.
In a case observed by the author, the ill in a child
run years old, associated with a chronic, purulent otitis media.
The eruption around the auricle and meatus resembled eczema.
Krownish crusts coveted the surface. The inflammation and
purulent discharge from the ear reacted quickly to small doses
of mercury Mid the iodicl of potassium.
It is interesting to know at what age, approximately, after
birth, are we to expect indications of inherited syphilis. Dr.
Prince A. Marrow, in his valuable* work <»n ^philography (p.
632)1 say-:
"'An important question comes up, a- whether the indica-
tions of an inherited disease appear imtned'i or after
birth, and, if the latter, how soon after,
belief was current that syphilis was manifest at birth -
DISEASES OF THE EXTERNAL EAR.
193
few clays subsequent. Rut farther investigation shows that,
while this is true in a large majority at cases, many instances
■ in winch the manifestations or syphilis are delayed tor
several months. Roper (Union Mc/licale, 1 865) collected two
hundred and forty-nine cases from several sources; Diday, one
hundred and fifty-eight J Dc MenV, twenty-eight; Mayer, forty-
nine; Rogers, fourteen; In two hundred and seventeen of
these, syphilis appeared before the end of the thitd month and in
thirty two cases it came later. Sifting these cases still closer,
I ill be seen that, although a very large percentage occur in
cxtra-utcrinc life, there were several cases in which the mani-
festations (A tl ted disease were delayed long beyond the
usual three months. Thus, in Diday s cases (Syphilis des
Nouveau-Nes), syphilis appeared before the first month in
eighty-six cases; before the second month in forty-five cases;
before the third month in fifteen cases; at the fourth month in
seven cases ; at the fifth month in one case ; at the sixth month in
one case; at the eighth month in one case; at the twelfth month
in one case; at the twenty-fourth month in one case. Or rinse
one hundred and fifty-eight case-;, syphilis appeared in one
hundred and forty-ox before the end of the third month, leav-
ing twelve cases in which the outbreak nf the disease was
laved till later. Taking these one hundred and forty-six cases
in which syphilis appeared before the expiration of the third
month, it was found that eighty six of them took place before
the end of the first month and one hundred and thirty-one be-
fore the end of the second month."
• nling to Marrow, there are three periods in the life
of the subject of inherited -\ phila, at which the disease is likely
to appear: birth, pnbeitj ai d at the close of middle life.
Diagnosis. — The diagnosiv of inherited syphilis is bj a process
claaton. 1 I: general condition of the mucous membrane
of the nose and other portions of the body, with ulceration and
the i n of a crust over the lobule of the ear and general
debilitated condition are all suggestive diagnostic signs of the
ise. A further diagnostic sign is the persistency of the
i94
DISEASES ni EAR. NOSK AND THROAT.
disease and failure to respond to other than antisyphiliri«
treatment.
Treatment. — The treatment consists in inunction of men. \w.
or mercury by the mouth m 1 1 it- earl) stages of the dis
In the later stage, the mercury should be combined with iudid
oJ potassium.
The personal hygiene of the child, as a rule, demands warm
salt-water baths, out-door exercise, clean underclothing and
nutritive diet.
The local treatment consists in antiseptic washes and the
application of some stimulating ointment, preferably the yellow
oxid of mercury, ten grains to the ounce of lanolin.
Herpes of the Auricle. — Herpes Is an affection of the skin,
characterised by the formation of one or more vesicles filled with
a clear scrum, due to some nervous disturbance.
Symptomatology. — The vesicles appear singly or in groups
about the lobule or over the helix, accompanied by fcvtt, -light
p;iin, heal :uul itching over the auricle. The skin k red, swollen
and tender to the touch.
The course of the disease is very short, the vesicles, in the
mild form of the disease, being absorbed at the end of two
weeks without leaving a scar.
■nnsis.— A sudden appearance of clear, whitish vtgicla
on the surface of the ear, with redness and burning. BUg
the disease.
Treatment. — The febrile symptoms may hr treated with pur-
gative-, and antiseptics. The surface should be washrd twice
daily with hot water and dusted with stearate of zinc or an-
ointed with oxid or zinc salve. It is frequently advised to
open the vestclea \i they become purulent, after which the sm-
may be dusted with calomel or aristol. Hypodezmic LB
tion ot morphia may become necessary should the pain and
burning be. QQ31 -.-verc.
Otomycosis or Mycosis of the External Auditory Canal.
— This is a parasitic inflammation of the external auditory
meatus, usually due to the Aspergillus niger flavescens, fumi-
MSB ISBS OJ r:i, i- v rBRt U, EAR.
'95
gat us and trichothccium roseum. The disease frequently
accompanies a chronic inflammation of the external auditory
canal (Fig. 84).
Symptomatology. — The disease begins with the symptoms
of a general otitis externa, with itching, tinnitus and pain. If
Fie 84.
AW1WgW.Pl Nn;m: Rubs WITH Comidia. x 600. (After Siebenmann mid
the canal is much obstrui bed from act umulations of the parasite*,
tlicrc will be more or less deafness.
Diagnosis. — The surface of the meatus appears to be COYCied
with a whitish mass sprinkled over with brownish or black
plaqw ■>. After the removal ol the whitish mass, the skin ap-
pears ir. i and indurated.
Treatment. — The treatment is directed to cleansing the canal
with alcohol and i [,000 hiihlnrid solution in equal part'-,
followed by a dusting powder of stearate of zinc. Maurin
recommends application twice daily of a solution of pcrman-
..xc of potassium l/l,ooo to 2.1,000, and reports twenty-
196
DISEASES OF EAR, NOSE AND THROAT.
lour cases cured by this method. Oxygenated water, twenty
prr cent., is recommended as a daily application.
Perichondritis. — Perichondritis is an acute or chronic in-
flammation of the perichondrium of the auricle, due to direct
trauma or operation on the mastoid.
Symptomatology. — In the acute form, there is redness and
swelling of the skin and pain extending deep into the meatus.
After exudation takes place, the parts are uneven and fluctu-
ating. The exudation may first resemble a serous fluid, later
becoming purulent.
Course. — The disease is sometimes very protracted, ending in
deformity of the auricle. Ossification of the auricle may sub-
•.(•(|iiiiitly occur, as in the case of Knapp, referred to by Politzcr.
Treatment. — In the early stages of the infection, iced applica-
tions to the auricle are indicated and should be continued for
twenty-four hours. After that time, moist or dry heat should
be applied. As soon as fluctuation is discovered, the parts should
he incised and any necrotic curtilage removed.
The subsequent treatment consists in warm irrigation once
daily, dusting with aristol, packing in oiled cotton and appli-
c ration of a pressure bandage.
Chronic perichondritis is a chronic inflammation of the car-
tilage of the auricle from repeated irritations, observed in boxers
and wrestler;..
The treatment of chronic perichondritis is directed to the
removal of the irritation, dry heat and the antiseptic dressing
of any excoriations of the surface.
Cholesteatoma of the External Auditory Canal. — This
is a desquamative process of the epidermis lining the external
MiditDfy canal, occurring as a primary or secondary disease
and characterised by the formation of scale-like epithelial ceOl
arranged in layers containing cholesterin. Sometimes the
case may occur secondary to a purulent inflammation of the ex-
ternal auditory canal or middle ear. The masses filline the
Canal are then cheesy-like, foul smelling and bathed in pus.
The disease occurring secondarily to a chronic purulent in
DISEASES OF THE EXTERNAL EAR.
197
Hammation of the middle car, may extend to and involve the
middle ear and accessory cavities. In the primary form, the
disease may also extend to the middle car or to the mastoid cells
by pressure, which destroys the osseous wall or membrana
tympani, causing a disintegration of normal structures.
Symptomatology. — Pain, tinnitus and deafness, in proportion
to the amount of pressure in the canal, with sometimes a puru-
lent discharge from the ear, are some of the symptoms. In
extension of the disease to the middle ear and mastoid, there
may be headache, dizziness and nausea, with symptoms of inter-
1 raniul involvement.
Diagnosis. — In the primary form, layers of glistening epi-
thelial cells will be seen firmly adherent to the canal, differing
thus from simple exfoliations of the epithelium, or eczema.
Microscopically, the scales are made up of horny cells or squam-
ous epithelium without a nucleus.
In suppurative conditions of the middle ear, cholesteatoma! a
may be seen extending through the perforation in the drum or
found in small clumps in the pus exuding from the meatus. The
I may be partially or completely occluded with the epithelial
formations.
Treatment. — The treatment is directed to the removal of
the cholesteatomatous masses from the canal by softening with
hydrogen peroxid and afterwards irrigating with a warm, anti-
septic solution. A small blunt curette may be necessary to a
complete removal of the scaly masses.
The cure of any suppurative complications in the middle ear
and mastoid process is necessary to a complete cure. The attic-
may sometimes be freed of cholesteatoma by Irrigation with a
Blake middle ear syringe and daily application of a fifty per
cent, solution of alcohol.
Acute Circumscribed External Otitis or Furuncle. — A
tin uncle is an acute circumscribed inflammation of the external
auditory canal, due to infection from the staphylococcus
Pathology. — Tin organisms find entrance thrcm^Vv x\\c \\fc\i
iyS
DISEASES OF liAR, NOSE AND THROAT.
follicles or sebaceous glands and, on account of trauma produced
by picking the cars or instrumentation and feeble resisting
power of the tissue, a local inflammation is produced, which
frequently ends in a circumscribed necrosis. The cocci may
spread to other follicles along tin- surface or through the lymph
channels. With the destruction of the hair follicles and sur-
rounding connective tissue, a core is formed, which sloughs
am ay, leaving a granulating surface.
Course and Symptomatology. — On account of the closely
adherent skin, pain is usually violent in character, throb!
and beating and extending over the temples and to the throat
and teeth. The pain is aggravated by eating and talking and
is more severe at night. The disease runs its course in from
to ten days. The severity of the disease is variable in indi-
viduals, depending upon the intensity of the infection and
resistant power of the tissue, violent cases ending in suppuration.
Diagnosis. — The diagnosis of the exact location of the area
ni Infection, on account of the swelling of the surrounding tissue
and the inability to place the speculum, is sometimes wr\ diffi-
cult. The disease may be associated with acute otitis media,
acute myringitis Or diabetes.
Treatment. — If seen early, effort should be made to aboit
the attack by vigorous purging, cold applications and pair
with campho-pheniquc or salicylic acid and collodion.
canal should be freed of any debris by syringing with hot solu-
tions of corrosive sublimate, 1/5,000. Sack, of Moscow, recom-
mends cleansing the auditory canal ami a tamponade of carbo-
lated glycerin, tightly filling the canal, in the early stages of the
disease. Randolph, of Baltimore, recommends a two per cent.
salicylic acid ointment, to every ounce of which is added fifteen
drops of carbolic acid. The tampon saturated with the oint-
ment is chanced every day. The treatment is continued even
after incision for the relief of pus, as an antiseptic. Leeches to
the distended parts are often indicated. After the disease has
advanced hot applications must he made in the form of hags
at lu>i>-, salt, Japanese hot box, cleansing with peroxid of hydro-
DISEASES OF THE BXTERKAL I \R.
'99
gen and controlling the pain with hypodermic of morphia, in-
ternal administrations of calcium sulphid, two to five grains in
^nation with benzoate of soda, ten grains, three times daily.
Anj accumulation of pus should be evacuated by making a deep
incision with t cataract knife. The canal should be carefully
treated antiseptically, for the reason that so long as the staphy-
lococcus pyogenes is present on the surface or in the epithelium,
a recurrence of the condition in any portion of the canal is
probable. Tonka and alteratives are usually indicated for a
tew weeks alter the onset of the disease.
Chronic Circumscribed External Otitis. — Chronic cir-
cnmscribed external otitis is a localized area of chronic inflam-
mation, following ■ like acute condition due to an extension
oi infection from dw surface to the deeper tissue, especially in-
volving the sebaceous glands.
Treatment, — The treatment is directed to the free incision
oi the sebaceous cysts with the curettement of the contents and
the lining membrane, fallowed BJ dfiiij cleansing of the canal
and tampon of gauze saturated in twenty per cent, aqueous solu-
tion of icbrhvol.
Otitis Externa Crouposa. — This is an acute inflammation
Ol the CXtemal auditor] canal, characterized by a croupous
iiiiin. described bj Wilde, Besold and others, and may
be associated W ith 'iritis media or otitis externa.
tptontatclogy. — There is violent pain in the ear, slight
fever and tinnitus, With the formation of a yellowish-white
exudation over the bony portion of the canal and tympanic
ane.
Diagnosis. — The exudation, examined microscopically, is com-
: ■ gulated fibrin. There may be a like exudation over
the tonsils. It is easirj detached and afterward frequently
recurs. ITie disease runs its course in a few days and ter-
minates favorably.
. - I In-- consists in the removal of the exudation
with a cotton-tipped probe and dusting the canal with trypsin.
The patient should be instructed not ro pick the car im itr-xx sh
ing a double or mixed infection.
DISEASES OF EAR, NOSE AND THROAT.
Otitis Externa Diffusa. — This is a general inflammation
of the external auditory meatus and may be produced by a
diffusing of the circumscribed form of the disease, pyogenic
microorganisms, foreign bodies in the canal and trauma. The
disease may accompany a purulent inflammation of the middle
ear with perforation of the drum.
Symptomatology. — As a rule, the disease begins with severe
pain in and about the ear, fever, with redness and swelling
of the skin covering the meatus, scaly exudation, followed in a
few days by a serous or viscid exudation upon the surface. In
the deep or phlegmonous form, there is swelling and edema of
the osseous portion with hyperemia of the drum and pain about
the auricle and mastoid, tinnitus and deafness.
Pu8 filled with desquamated epithelium and micrococci
fills the osseous portion of the canal. The odor from the canal
fa usually offensive. According to Hovcll, abscess may form
in the memhrana tympani, causing perforation.
Course. — In its milder form, the disease may run its course
in from three to folic days, ending in complete recovery. In the
severer form, a chronic purulent inflammation may fol;
Not infrequently granulations form on tin- posterior and su-
perior walls of the canal, which, if neglected, (PS] ]>:•>
cicatricial hands and attt
Diagnosis. — It is frequently difficult, on account of the
swelling of the canal, to different!; neral inflammation
a priori from middle ear disease. The pain, bJfttOfJ "l inflam-
mation in the canal and tenderness assist in arriving at a correct
diagn<
itmettt. — Exudations in the canal should Ik" removed
with hot lysol douches, one-half drachm to the pint of water,
followed by the careful removal of de ted epithelium
with a cotton- tipped probe. Where there is marked swelling
of the canal, dry heat may be applied. Dry heat applied with
a Seely or Beck instrument is highly recommended. Argentum
nitrate, twer.ty grains to tl of water, may be applied to
the surface, followed by d listing with iodol or stearate of zinc
DISEASES OF Till- EXTERNAL EAR.
JO I
A deep incision, wirh antiseptic precautions, into the swollen
canal may be necessary to relieve the engorged subcutaneous
r issue.
Granulations of the auricle can he touched lightly with
trichloracetic acid, twenty per cent., or touched with a sixty
grain to the ounce solution of nitrate of silver.
The discharge may become chronic after the cessation of
the acute symptoms. Stricture of the canal may follow ossify-
ing periostitis or adhesion of the walls of the canal.
The general treatment is directed to a correction of any
constitutional dvscrasia or lowered vitality, mild purgation with
calomel, followed by a saline and morphia hypodermatically,
it tin- pain is severe.
The use of alcoholic liquor should be dispensed with, on
unr of the tendency to increase the uric acid condition of
the Mood and hyperemia of the canal.
Otitis Externa Diphtheritica. — This is an acute inflam-
mation of the meatus, characterized by the formation of a
necrotic membrane due to the bacillus of diphtheria. Irritation
ol the meatus is presumed to be essential to infection.
Symptomatology, — The disease seldom originates primarily
m the meatus arid is more often due to an extension of a like
n of the fauces. The external auditory canal may be
found involved during epidemics of diphtheria.
disease begins with a marked constitutional reaction,
pain in the ear and the formation of a whitish or grayish-white
exudation, which adheres to the wall of the canal. When
detached, the surface of the meatus is perceived to be excoriated
and bleeding.
In primary diphtheria, the meatus is exceedingly tender to
the touch, the surrounding tissue being red and swollen. The
cervical lymphatics are swollen from the absorption of toxins
and arc tender to the touch.
When the disease is secondary to a like infection of the
middle car there i* ;m absence ol pain. In this form of the
202
DISEASES OF BAR, NOSE AND THROAT.
disease the prognosis, according to Bruhl, is less favorable than
in primary diphtheria of the meatus.
Course. — The disease may run its course in a few days.
There is a gradual detachment (if the membrane and healing
the ulcerated surface. However, the membrane may remain
adherent for a number tit days and when detached, quick])
reform. The ulcers and excoriations ot the surface may be
obstinate in recovery, frequently forming sloughs, resulting in
stricture of the canal.
Diagnosis. — The clinical diagnosis of the disease is depen-
dent upon the history of an epidemic of diphtheria, pain in the
car, adherent grayish membrane and bleeding surface upon
detachment <>f the membrane. The bacteriological examination
nt the exudation shows the bscilloa "f diphtheria.
Treatment. — The constitutional treatment differs in no wise
from that of diphtheria of the throat.
The local treatment consists in irrigating the canal with
lime water or 1/1,000 bichlorid of mercury solution and dust-
ing with trypsin. One-tenth per cent, pcrchlorid of iron in
glycerin is highly recommended as a local application. The
patient should be isolated and all cotton and gauze used about
the ear should be burned.
CHAPTKR XII.
DISEASES OF THE MIDDLE EAR,
Injuries of the Membrana Tympani. — Injuries of the
tympanic membrane are direct or indirect. Direct injuries
of the membrana tympani may be due to foreign bodies acci-
dentally or maliciously being forced into the middle ear. Pol-
ItZCT reports two rases of Shafer, in which molten iron and
lead were forced into the auditory canal. A sudden condensa-
tion of air within the auditor] canal by a blow in boxing or
slapping the side "t the face and car, frequently ruptures the
drum. Explosions of heavy fire crackers, artillery or rifle fire
may produce rupture of the drum by increasing atmospheric
pressure within the canal.
Schade reports the case of a nineteen-year-old merchant who
swallowed a bent nail. Twelve days later the patient suffered
otitis media. Three days afterward t lit- nail was re-
moved through the auditor] canal. It was twelve mm. long
and one mm. thick.
Hurkers, divers ami balloonists are predisposed to
ure "i iiic drum from change of air pressure.
Direct injury to the drum head may result from fracture of
the skull, contre-coup or by the irradiation Theory ot Aran.
I he Budtoi tvi alls i case of indirect rupture of the drum in
an office! "f the American army, while on target range at
Matan/a-. Cuba. After firing a Krag-Jorgensen a number of
from the right shoulder, he complained of pain, rin^in^
and roaring in the left ear. Upon examination, a complete
t c»i the d •- observed, extending through the pos-
terior half of the drum.
203
20.]
DISEASES OF EAR. NOSE AND THROAT.
I'ritchard reports a case of fracture of the handle of the
malleus by indirect force.
Gunshot wounds of the mastoid or temporal bone may pro-
duce rupture of the drum by jarring and increased atmospheric
pressure within the auditory' canal.
Symptomatology. — The subjective symptoms of rupture or
injury of the drum, arc pain, vertigo, tinnitus aurium, deafness
and slight hemorrhage from the canal. After rupture of the
drum, the hearing is seldom completely restored. Sometimes
the patient is unable to distinguish the direction of sounds;
however, during the process of healing, this condition gradually
passes away.
The objective symptoms arc slight hemorrhage from the
canal and if the injury is produced by a blunt or sharp instrn
ment there may be more or less injury to the wall of the
Canal. The drum is very red and there is usually more or less
blood at the rupture, varying according to the character of the
injury. It ■ sharp instrument has passed into the brain there
may be an escape of cerebrospinal fluid.
Treatment. — The treatment for both the direct and indirect
injuries is quite the same. Prevention of infection is the sine
qua noit in the treatment of injury of the tympanic membrane.
The canal should be carefully mopped dry with a cOftOQ*
ripped probe dipped in a two per cent, solution of lysol or a
twenty per cent, solution of alcohol, dried and tamponed with
antiseptic gauze. Providing no intYaion takes place, healing of
i In ..I rum is usually very rapid. Partial deafness may result.
Injuries of the Eustachian Tube. — Injuries of this char-
octet tnaj result from the forcible passage of I ron stab
gunshot
Canwrer reports s case in which a blade of straw was forced
through the Eustachian tube into the middle ear. The or
of the tube may be injured in eurettement of the vault of the
pharynx leading to partial steno
Treatment. — The treatment is directed to the careful in-
spection of the tube, the extraction of the foreign body and
DISEASES OF THE MIDDLE EAR.
spraying the nose with a warm alkaline and antiseptic solution.
Should the middle ear become involved, the treatment will be
the same as for acute otitis media.
Hyperemia of the Membrana Tympani. — Hyperemia of
the drum membrane may be active or passive and is a vaso-
motor disturbance due to a local or general irritation. The
severity of the hyperemia is dependent upon the cause. It
the irritation is continued for any length of time, inflammation
may result.
Among the exciting causes of hyperemia are exposure to cold
winds, acute OOiyza, massage of the auricle and membrana tym-
pani, injury of the drum from sudden condensation of air in
the auditory meatus and some pathological irritation within
the middle ear or external auditory canal.
I •■ ' hymosis, or rupture of a small blood-vessel, may occur
from mechanical irritation, sudden rarefaction or condensation
of the air in the external auditory canal. Upon inspection of
the drum, the- membrane will vary in appearance from a mild
pink.'>li discoloration about the periphery to a deep reddish dis-
coloration of the entire drum. The blood-vessels following the
handle of the malleus appear distended and very red. Even
with great discoloration of the membrana tympani, the blood-
vessels covering the malleus may be increased in size and small
anastomosing branches may start out from the periphery.
■.ftomulology. — The symptoms vary from a mild itching
in the canal to a severe pain. Patients frequently suffer severe
pain in the ear from hyperemia induced by exposure to cold
winds.
Treatment. — The treatment is directed to the removal of
the cause, which may be due to local irritation, constitutional
dyscrasia or occupation. Hyperemia produced by firing guns
or heavy artillery may be partially controlled by placing cotton
in the ears. For the immediate relief of hyperemia, a twelve
and one-half per cent, solution of carbolic acid in glycerin
should be dropped into the ear two or three times daily, fol-
lowed by the application of dry heat for fifteen to twenty
zo6
OISHASI.S ()!•' I AR, NOSE AND THROAT.
minutes. The disease has a tendency to disappear epontaneoi
without producing any structural change in the drum.
Acute Myringitis. — As the name implies, this is an acuta
inflammation ol a part pf the entire structure of the tympanic
membrane due to some form of infection.
Etiology. — The greatest form ot Inflammation is
of trauma, induced l>y bathing, acute coryza, picking the
and instillation of oils, followed by infection from some pafh-
ologlC organism.
Symptomatology. — The disease is usually ushered in by pain
in the ear, which increases in severity, fcelirijj of fullness in the
cars, tinnitus aurium and rise of temperature. Inflamm.i
of the outer layer is more frequently observed. With the in-
crease of the irritation, the outer layer may become distended
from a serous or a bloody infiltration, followed by rupture of
the dermic layer. A general ulceration may occur from the
id of infection and even abscesses may form in the deeper
layer. According to Polit/er, an abscess at the point of in-
fection may appear reddened and ccchymntir, resemblirl
pustule encircled by a red areola. The symptoms in the seven
form increase in intensity until a rupture of the dermal layer
takes place, with the discharge of serum from the canal
In the milder form of the disease, the pain lessens in a day
or two and the serous exudate is absorbed. Following acute
myringitis without rupture, on account of the slowness of the
absorption of the exudate, the drum may remain thickened with
marked reduction of the hearing.
In the severe form of the disease, the irritation passes away
in a few day*, mth or without complete restoration of the
transparency of the drum and hearing power.
Pi ognosht— On account of the varied changes which may
occur in the drum during the progress of the inflammation and
the possibilit) oi atrophy or hypertrophy which ■ometnna '"I
low, the prognosis, unless in the very mild form, is necessarily
led.
Pus QttJ break through in the middle ear, causing acute
DISEASES OK THE M1DD1 E EAR.
207
otitis media, with the formation of a perforation in the drum.
[trices ami calcareous deposits sometimes form permanently,
altering the normal movements of the drum.
Diagnosis. — In many respects, the disease resembles acute
otitis media. In acute myringitis, on auscultation there is
clr blowing sound, imliuir ive of a normal Eustachian tube.
In the mild form of the disease, the bearing is usually normal,
differing in this respect from acute otitis media.
Treatment. — Rest in bed, free purgation with calomel, fol-
lowed by magnesium sulphate, Kutno's powder or Hunyadi
water is indicated. For the relief of the local symptoms, twelve
and one-half per cent, carbolic acid in glycerin should be in-
stilled every half hour into the ear, with the head gently turned
to the opposite side, followed by dry heat in the form of hot-
water bottle or Japanese hot-box.
If blebs arc detected, they should be incised under anti-
septic precautions, followed by flushing the ear with a hot
Ivsi.l solution, one half drachm to a pint of hot water.
For thr relief of the pain in the beginning of the inflam-
mation, it may be necessary to administer one-eighth to one-
quarter nf a Brain oi morphia hypodermatically.
et rupture oj ilie lilebs, the ear should be irrigated twice
I] with tySOl Solution, after which it is dusted with aristol.
peat additional infection reaching the already infected
lOuld he worn in the meatus.
The absorption of the fibrinous exudate into the drum may
be encouraged, after the acute symptoms have passed away,
on of dry heat and gentle massage of the drum and
intern input ii inflation with the fumes of camphor, menthol and
iodin.
Chronic Myringitis. — Chronic inflammation of the mem
brana tympani more often follows an acute attack. When
there has been a previous rupture of the drum, the disease is
1 1 led to scute otitis media.
■ .Somatology. — The patient complains of a sense of full-
ness and irritation in the ear of the affected side, tinnitus and
20S
DISEASES OF EAR, NOSE AND THROAT.
more or less deafness. The discharge from the ear is exceed-
ingly variable in quality.
The discharge covering the il rum and floor of the canal may
be scanty and can be detected by passing a cotton-tipped probe
into the meatus. The odor from the discharge is sometimes
very offensive. The staphylococcus is hequently found in
abundance. The color of the drum, where there is no dis-
charge, is a whitish yellow, the short and long processes are
obscured and the drum is observed to be slightly bulging out-
ward. The drum head may hi- covered by granular excrescences,
varying in Btse from a pin-head to a pea, which mrn occur
singly or in groups and resemble small polypi.
Diagnosis. — As in the acute form of the disease the frredom
of the Eustachian tube and middle car involvement is ascer-
tained by inflation and auscultation, Likewise the presence
absence of a perforation is established. With a cotton-tipped
probe under good illumination, the drum may be cleansed of
any debris and the condition of the drum exposed to view.
Microscopic examination of the secrerion and pus, which is
frequently present, as a rule, shows thr presence ol atapl
coccus. The odor of the secretion maj be vet) offensive. A
perforation of the drum may be one or long Standing and
should de differentiated from an acute rupture.
Prognosis. — The disease runs a slow course and rarely ends
in a complete restoration of the drum to the normal. The
drum may become hypertrophicd with deposits of calcareous
matter, when there will be reduction of hearing.
Treatment. — The secretion may first be loosened from the
membrana tympani by the application of four or five drop
pcroxid of hydrogen, followed in a few minutes by irrigation
with a warm solution of lysol, one-half drachm to a 'pint
of water.
The canal is dried with a cotton-tipped probe and any re-
maining debris removed.
Camphoroxal in fifty per cent, solution of sulphate of zinc,
ins to one ounce of a fifty per cent, solution of alcohol,
DISEASES OF THE MIDDLE EAR.
209
may be applied three times daily with a dropper. The ear
1 dd be cleansed daily by irrigation until recovery is complete.
The excessive use of alcoholic liquors is interdicted and
art] constitutional dyscrasia must be corrected.
uulations on the drum may be destroyed by the appli
cation oi a tuenty-per cent, solution of nitrate of silver or a
fill] pes cent, solution oi chromic acid.
Acute Catarrh of the Middle Ear. — Acute catarrh of the
middle car is an acute inflammation of the mucous membrane
of the middle ear, characterized by a catarrhal exudation.
'"fy-— The causes are both predisposing and exciting,
and are syphilis, so-called catarrhal diathesis, unhygienic sur-
' ndings, gastro-intestinal disorders, insufficient clothing, uric
add diathesis, irritating gases, scarlet fever, measles, pneu-
monia, small-pti\, typhoid fever, tuberculosis, operations within
the 0O8C and throat, canter 1/ 11 100 <>f the posterior turbinated
bodies, exposure to cold, hypertrophied lower turbinated bodies,
i laryngitis, adenoids, enlarged tonsils, bad teeth
and pathogenic micrococci. Subacute coryza, hypertrophy of
the lower turbinated bodies and adenoids are probably the three
most important factors in the causation of acute catarrh of the
middle ear.
Pathology. — The disease is more often due to a primary in-
volvement of the Eustachian tube and is characterized by swell-
ing oi the mucous membrane of the Eustachian tube and middle
ear, engorgement of blood vessels and transudation of serum
and a few leucocytes, exfoliation cit broken down ciliated
irlitim and exudation of inticus from the goblet cells of the
epithelium. The organisms more frequently associated with
the catarrhal process arc the diplococcus pneumoniae, bacillus
pneumo-bacillus of Friedlander, staphylococcus
cetera libra, the bacillus pj the micrococcus terra-
neous. Suppuration seldom occurs, the disease ending in reso-
lution and absorption of the exudation.
'■tnmaiology. — The symptoms are I variable.
) be entirely absent or quite severe. The patient com-
212 DISEASES OF EAR, NOSE AND THROAT.
should be removed. Small, unoffensive-looking tonsils are fre-
quently as great, an irritant as large ones. Cold tub bath,
upon arising, is one of the greatest prophylactic measures that
can be prescribed.
CHAPTER XIII.
DISEASES OF THE MIDDLE EAR— CONTINUED.
Chronic or Hypertrophic Catarrh of the Middle Ear.
— This is a chronic non-suppurative disease of the middle ear.
characterized by exudation, deafness and structural changes
in the mucous memhrane. The disease is frequently associated
with a like condition in the Eustachian tube, nose and naso-
pharynx.
Etiology. — Among the many predisposing and exciting
causes of this disease arc cxanthematous diseases, adenoids, hy-
pcrtrophicd tonsils, chronic nasal catarrh, syphilis, climatic
conditions, over-indulgence in tobacco and alcoholic liquors,
inherited catarrhal predisposition and recurrent attacks of acute
nasal catarrh and simple acute otitis media.
The changes in the middle ear are frequently due to a
primary disease of the Eustachian tube. Alteration in the
lumen of the Eustachian tube from disease interferes with com-
plete ventilation of the middle ear and in consequence, the
mrmbrana tympani is driven inward and a passive hyperemia
is produced.
Pathology. — In the hypertrophic or moist form of the dis-
ease, there is a swelling of the cells of the parts, increase of
blood supply and exudation of serum and mucus, which is
sometimes visiMc through the membrana tympani. The mu-
cosa may be involved either in its entirety or with certain limi-
tations. Frequently the mucous membrane covering the ossicles
and middle ear becomes involved. The swollen mucous mem-
brane about the ossicles becomes adherent from the fibrous exu-
dation, permanently binding the ossicles. The same condi-
tion extends to the tympanic membrane and floor o( \X«, <ax\&3ta.
«3
2I4
DJSEASliS OI BAR, NOSE ASV THROAT.
car. Progressive alteration or the gland slruulura and
ncctive tissue elements may OCCUr, producing the hyperplastic
or dry catarrh of the middle ear.
SymptomatQlogy^—Tbt disease may manifest itself at any
age, though more frequently in youth and middle age. One or
both ears may be affected, the left more frequently than the
right. The sexes are equally liable to rlic disease. A per-
manent deafness in one 01 both ears may follow an BCUtC in
flainmafion of the car. Frequently dealings of one s i . 1 < ■ i
slow progress ;uul is only discovered by accident, the par I.
unconsciously accommodating himself all the while to the
gradual change. Progressive deainess is usually the one symp-
tom that causes the patient to consult the physician. A crack-
ing sensation in the ear in swallowing or blowing the nose may
be one of the early symptoms of the disease and is caused by air
being forced through the mucus as ir passes in and out of the
Eustachian tube. The patient complains of tinnitus, especially
in well-advanced cases of the disease. Sounds in the car may be
Continuous or intermittent and occur at long or short inter-
vals. Parcusses Willissii may be present. The patient COIDpi;
of an increase of deafness and fullness in the ears on expose ,
damp weather and attacks of acute con /.a. l.pon inspection, the
tympanic membrane appears to be dull and opaque, w it li some-
times a deposit of lime, especially in patients of a tubercular or
uric acid diathesis. Around the periphery may be observed an
opacity resembling the arcus senilis of the cornea. There is
usualh retraction of the drum and posterior of the short process
of the malleus. The lnn<> pi >,r. may occupy the normal
position or may be drawn up somewhat horizontally. The
membrana flaccida may be hyperemic or grayish in color and
retracted. The cone of light may be- diminished or entirely
absent. In atrophy, the drum will be wrinkled anil trans-
parent and when the middle ear is injected with air, small
bulging areas may appear on tin- outet or posterior quadrant
and frequently in Shrapne-!l\ membrane. With the Sirgle'<
otewope, the drum will l>< etely or only slightly mov-
DISEASES OF THE MIDDLE EAR.
"5
able, The movements may be entirely confined to Si !i r-ipiifU's
nit-uil>:;im . I he immobility of the drum is especially due to
tin- thickened bands "t connective tissue binding the drum to
the ossicles and the inner wall and anklynsis of the ossicles.
Where there is an absence of ankylosis, the malleus will be
seen to vibrate upon suction with the otoscope.
The Eustachian tube is usually affected at the same time and
is swollen and partially or completely occluded by adhesions, ac-
cumulations of mucus and hypertrophy of the mucosa. The
caliber of the Eustachian tube varies distinctly in damp or cold
her; the patient complains at tin's time of a fullness in the
region of the Eustachian tube, mental depression and ringing
in the ears. Gaping, widely opening the mouth, swallowing
and pulling the lobe of the ear forward will be indulged in
frequently by the patient, in the vain effort to restore the
patency of the Eustachian tube. In stenosis or closure of the
Eustachian tube and middle ear, an increase of hearing usually
tollows PolitzeTfttion or inflation through the Eustachian
I. prin salpingoscopy or inspection ol the ostium tuda
With a Prankels rbinoscope, the condition of the ostium tuba
is discernible. In the early stapes of the disease, the mucous
membrane about the ostium will appear swollen and covered
With a viscid secretion. As the disease becomes more chronic,
the mucous membrane of the tuba appears pale and shrunken
and covered with an exudation, especially along the floor of the
tube.
The disease is frequently progressive in character and more
especially so in patients subject to recurrent attacks of cor
whkh is more often due to a chronic hypertrophy of the tower
turbinated bodies cither in the anterior or posterior portion.
I ndet favorable treatment, the deafness frequently becomes
star .1 even improves. The most favorable cases for
;iment are those in which the structural change is in the
tchian tube rather than in the middle ear.
In the Weber test, the bone conduction will be more distinct
the affected side providing there is no disorder oi vVkA^wj-
!
216
DISEASES OF EAR, NOSE AND THROAT.
rinth. If both sides are affected, the bone conduction will
be more distinct on the side in which the deafness is more
pronounced.
The Rinne test is partially or completely negative. The
watch will be heard through the mastoid when there is no in-
volvement of the labyrinth.
Speech, whisper and watch tests will all show marked dis-
turbance of the hearing.
High pitched musical tones and words will be more dis-
tinctly heard than low tones. The patient complains of in-
ability to catch certain low tones, and in the confusion of
words, while in conversation with a number of people, the ears
may suddenly open up and the hearing be quite restored for a
short time. The patient may hear better in a loud noise, due
to the movement of the inflexible auditory ossii les u hich cause
the auditory nerve to be set in motion (Pulitzer).
Course and Prognosis. — The course of the disease is
ally slow. Treatment may cut short the progress of the dis-
ease and even bring about a marked improvement. Frequently
the disease continues to grow worse, producing partial or eom-
pli ■re deafness. Recurrent attacks of acute coryza and acute
salpingitis, predisposing catarrhal diathesis and syphilis render
the prognosis unfavorable. Improvement of hearing, upon
Politzeration or catheterization, may be considered a favor-
able sign.
Diagnosis. — The diagnosis with the foregoing enumeration
of symptoms in chronic moist catarrh of the middle ear and
Eustachian tube is comparatively easy. Upon auscultation, the
character of the rales will aid in differentiating the disease from
chronic myringitis. The disease may be differentiated from
sclerosis of the middle car by symptoms which will be enumer-
ated under that subject.
Treatment. — In the treatment of secretive middle ear catarrh,
Mime form of inflation of the Eustachian tube and middle ear
is indicated^ cither by the Politzer method or through the Eu-
stachian tube. The Politzer method must be used in children.
DISEASES OF THE MIDDLE EAR.
217
(Sec !'"lu/'i Method) P- 112.) A great many operators object
t<> the inflation of the middle ear by 0)6808 of tin- Lustachfan
catheter, believing iluit the point of the catheter Becessfl
brings about trauma of the ostium tuba and predisposes to in-
flammation and hypertrophy. Randolph with many others
believes that catheterization is the most valuable of the me-
chanical methods in the treatment of chronic middle ear catarrh.
Where the Eustachian tube is much swollen about the
isthmus, the catheter is required to force air into the middle ear.
The frequency and length of treatment with the. catheter de-
pends upon the progress of the am ftt a rule, inflation should
.
m&
L.D.MEVrtOWlTZ
N.r,
MOw'l DlLATOI WOW TBI ElJlTTACM t AK TuBt-
be used every other day. After a few months' trial, provided
the patency of the tuhr is normal, negative results should
u intra indicate the use of the catheter. If air is forced into the
ED an air cut-off, it should be filtered and the pressure
should not exceed twenty pounds. Intervals of rest from infla-
; in chronic cases, should be recommended. Inflation of
the ear may be induced by puffing out the lips and forcibly
3l8
DISEASES OF l-.\R. tfOSE AND THROAT.
injecting air through the nose at the same time, as in rlu-
Politzer method. This method is especially recommended in
the treatment of children.
Dr. Ai Iim liar nmnuV metliod for dilating the Eustachian
tube is favorably mentioned by Dr. D. B. St. John Kuosa.
The directions for its use are as follows:
" When used by the patient himself, the two air bags
83) are placed upon the table with the tubing. The n<
piece is then adjusted to one nostril and the other closed over
with one hand so as to be absolutely air-tight. This being
done, with the other hand pressure is made upon the air bag
No. 1, for say a dozen times or even more, until the MCOOd or
1 voir hag is well distended. Rapid pressure is made upon
it, care being taken at the same time not to omit keeping the
olive-shaped nose-piece well in the nostril and closed over so
that it may be air-tight. There seems to be no ill effect from
the use "t this apparatus for some minutes twice daily. In
certain cases of chronic swelling of the tube, with consequent
want of proper ventilation of the tympanum, it seems for self
use at least to be preferable to Pulitzer's apparatus, but just
how much its value is, remains as yet unsettled." (The Pott
Graduate. )
Medicated vapors are recommended where the mucus per-
sists in the Eustachian tube and middle ear. The vapors of
chlorid of ammonium are highly recommended for dissol
the exudates. Instruments for generation the chlorid of am-
be had at any instrument house. The vapors,
be applied for two or three minutes twice weekly. A con-
venient method for the injection of medicated vapor is with a
Dench middle ear vaporizer. In children and those in whom
the Eustachian catheter cannot be used, a few drops of drugs.
which easily evaporate, nich as chloroform, ether, turpentine
or iodin, may be dropped into the Politzer bag, and the air
thus charged with the vapor maj be injected by the Polii
method. In chronic catarrh, the direct application of fluids
through an Eustachian 'inula, to the Eustachian tube and
DISEASES OP THE MIDDLE BAR,
219
middle cur is decidedly dangerous. The reaction which fol-
lows iii.i) accentuate the disease. Advisedly speaking, fluids
should only be injected into the middle ear when there c\ists
a perforation of the drum.
A graduated amount of Quid may he injected into the
Eustachian tube through the catheter. Among the solutions
recommended arc bicarbonate of soda, two to three grains to
the ounce of water, chlorate of potash, two to three grains to the:
ounce of distilled water, sulphate of zinc, two grains to the
ounce oi water, nitrate of silver, one to three grains to the
ounce of water, iodid (if potassium, five grains to the ounce ot
water.
Warm, sterilized, medicated alholene, preferably a two per
cent, camphor-menthol solution, may he used with freedom in
the Eustachian tube and middle ear. Ten to twenty drops
be mire icd into the catheter with a syringe. With the
Pob: ot compressed air, a few drops may be sprayed
1 the middle car. This form of medication is especially
efficacious when there is swelling in the tube.
Rarefaction of air in the external auditory canal as recom-
mended by Delastanche, is valuable in selected cases (see
Massage, p. 135}, In cases where there is a perceptible vibra-
tion of the drum, malleus and membrane, judiciously applied
massage will increase the blond and lymph supply to the parts
and aid in breaking up adhesions in the ossicular chain. Mas
ontraindicated or of little value when the vibration is
1 ned to Shiapnell's membrane. Frequent massage is con-
traindicated in young children, on account of the possibility
using atrophy of the drum.
The removal of the mcmhran.i tyrapani and ossicle for the
relief of chronic catarrhal deafness is, as a rule, a very unsatis-
factory proceeding because of the marked cicatricial adhesions
wh; OUently follow. Temporary relief may follow
the operation, though after a short time the patient becomes
eery much worse. The division of the tensor tympani muscles,
b] Webei Liel, is recommended when thett
220
nrSF.ASES OF EAR, NOSE AND THROAT.
is groat retraction of the drum, but, as a rule, the results arc
unsatisfactory. Siaphedectomy and partial resection of the
drum are also recommended. However, results are again
very unsatisfactory.
Plicotomy, or incision of the posterior fold, is a simple op-
eration and is highly recommended by a few, for the relief of
the subjective symptoms.
Luck pressure (see Fig. 76) probe is especially recommended
to aid in breaking up adhesions in the ossicles. The instrn
mrnt should be made directly over the short process of the
malleus and for a few seconds every three or four days.
Vibrator}' massage with a pneumatic aural vibrator, applied
to the meatus and about the auricle once daily is pleasant to the
patient and of some value as a stimulant, especially following
inflation of the middle ear.
The high frequency current may be applied directly to the
meatus and the membrana tympani, the warmth of which will
aid in stimulating the absorption of fibrinous exudations. It
should be applied once daily for a period of from ten to fifteen
minutes and continued until sufficient time has elapsed to
demonstrate its value. The nose, naso-pharynx and throat
should be carefully inspected for any pathological changes. A
BpOQg9 condition of the lower turbinated bodies is frcqucntU
present in patients with a history of recurrent attacks of coryza
and closure of the Eustachian tube. Adenoids or remnants of
adenoids and hypertrophy of the tonsils predispose to the disease.
Perfect nasal breathing is distinctly essential to free ventilation
of the middle ear. "With this in mind, the first step in the
treatment is the removal of all obstructions in the nose, naso-
pharynx and pharynx, which may possibly affect the functions
of the F.ustnchian tube. The immediate good of such radical
measures may not be apparent, but after a few months or a
year, the patient usually observes a lessened susceptibility to
colds and freedom of the Eustachian tube and middle car from
the annoying fullness, tinnitus and ever-conseiousness of irri-
tation in the car. Alkaline washes arc indicated for the relief
DISEASES OF THE MIDIJI-E EAR.
of any catarrhal inflammation. Excessive use of tobacco and
alcoholic liquors is interdicted. For hypertrophy of the ostium
tuba and increased glandular secretions, fifty per cent, argyrol
solution should be applied once daily with a curved, cotton-
tipped probe, to the mouth of the tube. The probe should
remain inserted in the tubal opening for five minutes.
A hard-rubber filiform bougie may be dipped in a solution
of argyrol in the above strength and passed through a large
catheter up to the isthmus of the Eustachian tube. The bougie
not only carries enough of the silver salt to the mucous lining
of the tube, but tends to break up any stricture of the Eu-
stachian tube. The bougie may be dipped in argyrol solution
lllowftd to dry, after which it is passed into the tube and
allowed to remain for five minutes or until the argyrol is dis-
solved. The whale-bone bougie or bougies made of silk worm
tiut arc used. The bougie is passed through a large silver
catheter into the middle car, care being taken that the drum
is not punctured. The bougie should be marked approximately
the length of the tube. Care should be exercised to prevent
traumatism of the mucosa in passing the bougie. In the
normal Eustachian tube, the bougie is passed into the middle
ear without friction and with little distress to the patient.
Where a stricture cannot be probed without great pressure, the
electrolytic bougie of Duel is indicated.
Stricture of the Eustachian Tube. — Stricture of the tubes
is often due to a swelling from a catarrhal inflammation of the
middle ear or the nasopharynx. Small connective tissue bands
varying in thickness and size are observed. The site of the
stricture is more often in the cartilaginous portion. The caliber
of i be 18 demonstrated by auscultation. If the stricture
is ilue ri !.j not to simple swelling, repeated ap-
plications of the bougie and an inflation with superheated air
absorption of the new tissue and restore tlir
patency of the tube. Failure by this method will necessil
i-e of electrolysis.
Insulated Eustachian catheters especially constructed for this
21£
DISEASES OF KAR, NOSH AND THROAT.
work are to be had at any instrument house The gold elec-
trode of Duel is attached to the negative pule and carefully
passed through the rubber-covered catheter until it strike! the
stricture, when the current is gently turned on: the positive
pole to the neck, the strength being three to five ma. There
ta no pain accompanying 01 immediately following this treat-
ment. The treatment should be continued weekly until re
fs secured. The Eustachian tube should not be inflated imme-
diately after the electrical treatment
The internal treatment in chronic catarrhal deaffl
rectcd to building up the system and the correction of any consti
tutional dyscrasia. Thiosinamnin is highly recommended b
few, in one-half grain doses three times daily, to promote absotn
tion of exudation, hypertrophy and adhesions in the miiui-;,'. In
larger doses the drug causes headache and vertigo.
Simple Acute Otitis Media. — Simple acute otitis
19 an acute inflammation of the mucous membrane of the
middle car. due to thermic or cbemic agent or a mild form of
infection, in which there is seldom any destruction of the t:
or perforation oi the drum.
Etiology. — The disease fm|i..ntl\ results from some local
disturbance of nutrition, acute or chronic naso-pharyngitis. acute
/.i, exanthematous disease, typhoid fever, whooping rough,
fluids forced into the ear by blowing the nose, sea bathing, nasal
douche, turhinectomy, tonsillotomy, cauterization of the 1"
turbinated bodies, etc. Any one of the above condition
directly or indirectly alter the (unction of the tubal epithelium
and epithelium lining the middle ear and induce die symptoms
of inflammation independent of pathogenic organisms. Inj
of the epithelium of the middle ear and Eustachian tube |
permit pathogenic microorganisms to reach the middle ear and
produce the disease. According tn (Irunert, it is probable that
some forms of otitis are due to a hen tion. The
disease, is more often obsen hildren than in adults
is, according to King, Lermoyez and others, considered ■ con
li
DISEASES OF THE MIDDLE HAR.
223
Pathology. — Following local injury anJ infection from ther-
mal, chemical or bacterial agents, there is a swelling of the
mucous membrane of the middle ear and infiltration of leuco-
< v 1 1 - which produces an edema or an exudation into the
middle ear cavity. The exudation is serous or fibrous in ch.ir
RCtOI and later on may contain blood -i ells, pus, epithelial
cells and roiexooorganisms, In addition to the swelling and
exudation, we have heat, pain and partial loss of hearing. The
pneumococcus is the most frequent organism found as the
•■of the disease (Nadoleczny). The streptococcus
pyogenes follows, next in frequency. In addition, infection may
occur from the staphylococcus pyogenes, aureus and albus, ba-
cillus pyocyaneus, bacillus coli and other microorganisms.
Resolution frequently takes place without a perforation of
i!:<' drum. The mucous membrane of the Eustachian tube
and middle eai is predisposed by the disease to hypertrophic
• banges.
The patient complains of a fullness in the ears, deafness,
tinnitus aurium, autophonia, subjective noises in the ear, some-
times pulsating in character, and quite frequently, acute coryza.
Itching about the drum and a tendency to pick the ears,
followed by severe throbbing and aching pain in the ear, which is
continuous and accentuated at night, are some of the symptoms.
The ear symptoms frequently follow an acute coryza or naso-
pharyngitis and the forcing of water into the middle car while
bathing. The severe pain, which lessens somewhat after the
datum, may cause .1 rise of temperature and even
convulsions in children. An elevation of temperature, head-
ache and general malaise may accomp:m\ the disease in adults.
■i<i Prognosis. — The course of the disease is some-
what va lends upon the cause and tissue resistance.
The pain continues from a few hours to a number of days.
\\ tli the absorption of the exudation, the discoloration and
Jin ol 'lie drum p iy, Provided the drum
has not ruptured there is a complete amelioration of all the
itomi in from one to two weeks.
"4
DISEASES OK EAR, NOSU AND THROAT.
Recurrent attacks or prolonged subacute inflammation p
disposes to the formation of adhesive hands In the middle ear
and a hypertrophic catarrh of the middle ear and Eust:iclit
tube.
Treatment. — In the beginning, the treatment is directed
the alleviation of the severe pain in the ear. For this, three
or four drops of a ten or fifteen per cent, solution or encain may-
be dropped into the ear every hour, after which the meatus
auricula: is scaled with cotton dipped in collodin.
Andrews recommends a twelve and one-half per cent. - I i
tion of carbolic acid, three to four drops warmed, to be in-till
into the canal every fifteen miuoto, until the pain is relieved.
Dry heat in the form of hoi water bottle <>r hot flannels shoul
be applied continuously to the ear as hot as tan be convenient!;
borne by the patient.
According to Randolph, the drum should i | as
as the other measures for the relief oi the pain have failed an
more or less bulging of the drum is present. The free
ation of pus should be encouraged by the application of dry heat.
following paracentesis, the car should be irrigated twice
daily with a warm solution of lysol, one-half drachm to dk
pint of water.
After the active inflammation has subsided, a mild astringent
may be instilled into the ear, following irrigation and drying
with cotton.
:
9
Ziiici jiilpliat.,
Acid boracic,
Alcoholic,
Aq. desiill., i|.
s. ad.
.36 gm.
.90 gm.
4.0.
(g»
tgr.
(5 i>
vil
M.
s
igna
. Four or five
the
ear
twice dail)
'.
The nose and naso pharynx should be sprayed or mopped
with a two per cent, solution of cocain, followed by an appli-
cation of adrenalin chlorid l. l.ooo, to the mouth tti rhr Ku
Btachian tube once or twice daily.
I he patent of the tube and middle car is quickly na
blst-.ASES OF THE MIDDLE EAR.
22!
after tlic congestion has slightly subsided, by Polirzeration or
In the use of the Eustachian catheter. A continuous current
of superheated air forced through the Eustachian catheter for
a few minutes daily, is highly recommended. When the pain
M intense, three or four leeches should be applied to the front
of the tragus. Leeches should not be applied in anemic or
diabetic patients. One-eighth to one-quarter doses of morphin
may be given to adults and a much smaller dose to children
when the pain cannot be controlled by local treatment. Aconite
Bid in aborting the attack. This should be given even
hoar m one dfOp doses until there is a tingling sensation in the
tongue which is indicative of the constitutional effect of the
drug. Krst in bed and a BOft diet should be followed by the
internal administration of hen /oat e or salicylate of soda in ten
grain doses three times daily and calomel in one-tenth grain
doses hourly until free purgation results.
The nose and throat should be sprayed three or four times
daily with a warm DobelTs or Seiler's solution.
The patient should guard against exposure to cold and damp
Breather and imperfect protection of the body after eonvales-
e H established. Cold tub baths upon arising should be
amended to patients with a catarrhal tendency. In chil-
dren, the rink and chest should be sponged with cold water at
the moming bath as a substitute for the cold bath. Personal
rue B1U81 be impressed upon the patient as in all affections
of the upper air passages. Constitutional treatment is recom-
mended in debilitated patients. When the exudation within
the middle car is slow of absorption, vibratory massage applied
to the external auditory canal for a tew seconds each day will
aid in stimulating the blood supply to the parts and absorption
of the exudation. Adenoids and hypertrophied tonsils or any
abnormal obstruction should be removed and the patient taught
the faculty of normal nasal respiration,
Paracentesis or incision into the memhrana rympani is, when
indicated, performed under very rigid rules of antisepsis. The
external auditory canal is irrigated with a solution of lysol, ont
tz6
DISEASES OF EAR, VOSF. AND THROAT.
drachm to a pint of warm water, or a one-half per cent, solution
of carbolic acid to which has been added a small amount of bi-
borate of soda. In the absence of a large aural syringe, an ordi-
nary fountain syringe may he used for irrigation. The reservoir
of the Syringe should be elevated two or three feet above the
head. The nozzle of the syringe is placed well up into the
meatus and a pus basifl OT bowl is placed against the auricle in
close apposition with the cheek and neck. The ear is dried
with pledgets of cotton on a probe following the irrigation.
Paracentesis may be performed with but litde pain to the
patient where there is marked distention of the drum, but a
local or general anesthetic is necessary in the greater number
of cases. With the head of the patient resting upon tin-
pOBIte side, a fifteen per cent, solution of cocain dropped into
rhe auditory canal will bring about a local anesthesia in about
ten minutes.
Equal parts of carbolic acid, menthol and alkaloid of cocain
is a favorite combination tor bringing about anesthesia of the
drum. Three or four drops arc instilled into the canal or
applied directly to the drum with a small pledge! "' COtl
Anesthesia is practically complete aftei five 01 ten mil
I In- membrana tympani should he completely exposed to \
In the aid of a licnl-miitor, car speculum and natural or
fatal light A riyht-anyle paracentesis knife may lie used
tm Lnctskm 03 puncture of the drum, With the speculum in
position and under careful illumination, the point ol the
knife is carried to the site of the buliiinu of the drum, the
drum is punctured by gentle pressure and the incision car-
ried downward to the floor of the canal, following the curve
of rhe periphery of the drum. The drum is very rhin and
transparent and is easily punctured. With this in mind, .
should be exercised to prevent the point of the knife cuttinc
too deeply into the inner wall and puncturing the internal ear.
Paracentesis is much more difficult in children than in
adults. A long needle mav he used ifl the absence nf a suitable
knife. Following paracentesis, the canal should be clcarc.
DISEASES OF THE MIDDLE EAR. 227
blood and anj serous exudate with a cotton-tipped prpbe and
afterward tamponed witfi a strip of sterilized gauze for drain-
ami the prevention of infection entering the canal. Dry
heat should be immediately applied to the ear to encourage
exudation and the alleviation of pain, which frequently con-
t iiuies lor a few hours.
Acute Otitis Media Purulenta. — Acute otitis media puru-
lenta i> an acute purulent or muco-purulent inflammation of the
mucous membrane of the middle ear, due to infection.
Etiology and P/uhology. — According to the researches of
Preysing and Hasslcur, the middle ear is free from bacteria.
On account of the natural immunity and the anatomical posi-
tion of the tympanum, inflammation follows from an extension
of infection through the Eustachian tube and the blood stream.
H<v.old and Rudolph have shown that there is always a
middle-Car inflammation accompanying measles. Diphtheria
of the throat may involve the middle ear by' extension from
I muity of tissue. According to Levin, the toxins of diph-
theria circulating in the blood may also produce inflammation
of the middle ear.
Among the predisposing causes of middle car inflammation
an- OCttte iilliir n/.i. .u.uir and chronic nasopharyngitis,
syphilitic dyserasia, tubercular diathesis, exanthematoui disr
tip! . enlarged tonsils and adenoids. The tubal epi-
thelium is presumed to prevent infection from reaching the
N 1 ■■ .. however, any traumatic or chemical agents which
injure the epithelium will predispose to the disease
e otitis media of the new born and otitis media ot
nurslings ^ "' profound interest on account of the great num-
ber of eases thai ore unrecognized or receive no attention from
rem 01 physician.
Out "I sixty five cases examined at post-mortem by Ponlik,
ig under MM year of age of diphtheria, scarlet fc\cr. in-
flammation of the lungs, purulent meningitis, gastroenteritis,
furunculo srysipelas, only seven had normal ears. There
is still some doubt as to the exact etiology of middle eat \VkfakW\-
238
DISEASES OF EAR, NOSE AND THROAT.
mation jn the new-born. It is argued bj come that the Ji
is due in a great measure to the entrance of the amniotic fluid
into the middle ear and the failure >>t this to be absorbed after
birth brings about the formation of pus. Other investigator*
believe the microorganisms eater the middle ear in the new-born
u ith mucus of the naso-pharynx and, on account of the v.
resistance Of" the mucous membrane of the middle eai
embryonal influences, bring about an acute inflammation.
Ponfick calls attention to the nutritive disturbances of the
system which are due to the absorption of toxins eliminated
from the infection of the middle car. Pus drains own readily
into the throat from the Buddie car of infants than in adults,
on account of the shortness of the Eustachian tube, and
sarily firings about gastro -intestinal disorders upon entering
the stomach.
The milk decomposes quickly, the patient refuses nourish-
ment and rapidly becomes emaciated.
Grunert tersely puts the proposition to the physician when
he says, " That every nursling with general symptoms, with
intestinal disease, with catarrhal disease oi the Lungs, "ith dis-
t nutrition, etc., should have it* cars carefully cxamineJ,
even when no symptoms on the part of this organ seem to indi-
cate an examination of the same."
The variety of microorganism found in otitis media is
quite the same in infants and adults. The severity of the dis-
ease is dependent upon the power of resistance of the tissue
and the microorganism producinn the infection. As a rule, in-
fection is mono-bacterial in all acute inflammation of the middle
ear. Polyhacterfal infection may follow rupture of the drum
and exposure of the middle car to organisms already in the
canal or to those which may subsequently find lodgment therein.
I In- organisms which most frequently bring about supp
n'on in the middle ear an. I in the order of their frequency, are
the streptococcus pyogenes, pnenmococcus. Jtapl >.-us
and all I typhoid anil tiihrrilr bacilli.
Symptomatology. — Acute otitis media in infants may run its
DISEASES OF Tllfc MIDDLE EAR-
2 2Cj
entire course without any cons] .i. um;> symptoms other than
the cachexia and general catarrhal condition of the child. In
re cases of acute inflammation of the middle ear, the child
cries Constantly, turning its head from side to side and sleeping
unly when completely exhausted Or under the influence of
Opiates. The restlessness of the patient ceases only with the
Cessation of die inflammation or rupture of the drum. The
infant may suffer from high fever and sometimes delirium and
the symptoms of a meningeal affection before the spontaneous
rupture of the drum or paracentesis.
Patients old enough ro express themselves complain of
severe throbbing and beating pain in the ear, which radiates
to the teeth and throughout the head and is continuous. Move-
ments uf the JBWS while talking and eating and pressure on the
tragus aggravates the pain in the car.
I In disease frequently comes on at night and the patient is
■wakened with a severe pain in the ear. The ear symptoms in
nthenatous diseases may be masked by the general symptoms.
Chi':>.! ■ . uentl) have middle ear complication when suffcr-
■in gome exanthemata.
Objective symptoms before rupture are intense redness of
the drum which is followed in a short time by bulging of the
drum, SOmetimC8 in its entirety but more often in the posterior
SUperiOl (fuadranti When the inflammation is confined to the
attic of the tympanic cavity, the bulging may be confined to
pnell's membrane. The epithelial covering of the osseous
portion of the auditory canal is frequently intensely hyperemic.
The reduction of hearing varies according to the amount of
serous exudate into the tympanic cavity and may be partially
or completely negative. Crepitant rales are heard upon infla-
tion and auscultation.
The membrana tympani in the otitis of influenza is covered
with an exudate or by a hemorrhagic bullae (Politzer). Hem-
orrhagic bulla! may cover the osseous portion of the auditory
canal in otitis of influenza, as observed by the author.
The site of the perforation varies, being more often to the
23°
DISEASES OF EAR, N'OSE AND THROAT.
posterior and superior quadrant It may be difficult to sec the
perforation when spontaneous rupture has taken place* Puis:;
tion of the fluid at the point of rupture may disclose it-; IOCS'
tion. The external auditory canal will he round to lx- filled
with a tenacious muco-purulent secretion or pus, which con-
tinues to he profusely secreted for a week or ten days.
Couru- tut,i Prognosis. — The course of the disease necessarily
varies according to the character of the infection and the
/issue ile resistance of the patient. However, it is agreed that
recovery is very much slower in those cases in which the drum
ruptures spontaneously than where paracentesis is performed.
The prognosis is Mri SO favorable where the disease is con
'"MiiT.mt with otorrhea chronica as it is in a simple acute in
Hammation.
The time of the rupture of the drum after the onset of the
disease may vary from a few hours to a day.
Under favorable circumstances, the duration of the set
is from one to three weeks. The closure of the drum follows
very quickly the cessation oi the inflammation and exud
with partial or complete restoration of the hearing.
Mastoid complication, due to infection with the pneum >-
tuny manifest itself after the otorrhea has passed RWS)
(. I.eutert).
The disease may terminate in any one of a number ot
in complete recovery, progressive catarrhal inflammation ot the
middle ear, chronic purulent otitis media with necrosis of the
ossicles or mastoid abscess witli or without cerebral com-
plications.
Diagnosis. — It is frequently difficult to differentiate acute
purulent inflammation oi tin- middle car from simple ao
inflammation or myringitis, previous to rupture of the drum.
There is no difficult)' in making t gnosis after the
rupture has taken place. Bulging of the drum outward
gestive of an accumulation of fluid in the middle ear. The
ter of the exudation behind the drum may be detected
b] the discoloration of the drum at the point of bulging.
DISEASES OF THfc MIDDLE EAR.
23I
Treatment. — The culv treatment of the disease differs very
little from that of .simple, acute inflammation of the middle ear.
The general treatment consist! In rest \n bed, the adminis-
tration of repeated dose* of calomel until free purgation results
ami die control of pain In opiates if necessary. Leeches should
I-- applied ED the tragUB and a blister behind the pinna.
I lie local treatment is directed both to the tympanic mem-
brane and the relief oi any inflammation in the post-nasal space
or Eustachian tube. Four or live drops of a twelve and one-
halt per cent, solution of carbolic acid in glycerin instilled into
the auditory canal every half hour followed by applications
oi dry beat to tfae external car may he ordered for the mititia-
Hon ot pain in the ear before rupture or paracentesis. Dry heat
ma\ be bad from a hot-water bottle, Japanese hot-box, electric
light bulb, hot plates wrapped in woolen cloths, etc., the appli-
cation being as hot as the patient can bear. The nose and naso-
pharynx may he sprayed ever) three or four hours with either
Seiler's or Dobell's solution.
A tuuii\ t'j tliirtv pei cent, solution of argyrol may be ap-
d t<> r In- ostium with a cotton-tipped probe. Three or
;ii the inflammation has begun, the middle ears
ild In gentlj in Bated bj the Politacr method or Eustachian
1 tthctcr, oner daily. The inflammation has g tendency to re-
store rhr patency of the middle ear and Eustachian tube so that
drainage from the middle car ma) take- place.
When the pus or exudation has formed and forced the drum
: paracentesis IS at once indicated. The discharge fol-
lows (Cestesia may contain blood and serum, followed ill
a few hours by a profuse inuco purulent or purulent discharge.
This condition continues tor a week or ten days, ending in a
plea cure in favorable cases. The auditory canal should
be irrigated twice daily with a warm lysol solution, one-half
drachm to a pint of warm water, at a temperature slightly
above that of the body. Every effort should be made to prevent
a mixed infection, and with this in mind, in addition to irri-
gating with a warm antiseptic solution, the folds of the auricle
I
•-' i-
DISEASES OF EAR, NOSE AMD THROAT.
and the meatus should be cleansed with absolute alcohol, once
daily.
The cotton or antiseptic gauze placed in the auditory canal
should be changed whenever infiltrated with the secretion. In
severe cases where the discharge is profuse, care should he taJcCfl
to frequently cleanse the meatus, thus preventing any dam-
ming back of pus.
The drum may remain thickened and hyperemic lor a feu
weeks after cessation of ail inflammatory symptoms.
General Tonics ;ire frequently indicated with the
ot any catarrhal condition of the nose ami rtaSO pharynx
For the control of pain which sometimes continues after
paracentesis, dry heat may be applied continuously and a ten per
cent, solution of cocain, or twelve and one-half per cent, carbo-
glycerin may be instilled in tin- auditory canal ever] two q|
three hours. A mild astringent may be used as an instillation
twice daily after the discharge has continued for a few days.
The following is recommended for this:
Zinc sulphate, .60 cm. (gr. x)
Alcohol, 4.00 cc. (3 i)
Sat. sol. acid lunacies, » .-„-, _„ „j ..-^ „,. /* :\
■"■'p. ad. 30.00 cc. (ji|
Aq. destill., '
•: 1 1 1 ;i ( ions whiih form on the drum at the site of the
rupture W incision, should be touched with a twenty per cent.
solution ill nitrate of silver or a ten per cent, solution
trichloracetic acid followed bj dusting with stearate of zinc.
This should be repeated after two or three days if necessary.
After the perforation in the drum (.loses, local application to
the ust mm tuba of a thirty tu fifty per cent, solution of arg]
and the occasional inflation of the tube ami middle ear by air
douche. Politzei method 01 with the Eustachian catheter «s
indicated) until the hearing is restored ami the drum appears
perfectly normal. Aftrr all discolorations oi the drum have
passed iwq and the hearing remains uibnormaJi inflation is
i providing the tube remains patent.
DISEASES OF THB MIDDLE BAR.
\s a piopbylactii t, the patient should be warned
against exposure to irritations known to have produced the
disease.
A guarded application of a fifty per cent, solution of trichlo-
racetic acid should be made to the periphery of the perforation
oner weekly, where the perforation »f the drum fails to close.
A small amount oi tin- solution reaching the middle ear will
bring about a renewal of the discharge. Following the ap-
plication of the trichloracetic acid, favorable results are fre-
quently observed.
Chronic Otitis Media Purulenta. — Chronic otitis media
puralenta is b chronic purulent inflammation of the middle
car following acute perforating inflammation.
Etiology. — Among the predisposing causes of the continuance
of a purulent discharge from the middle ear are syphilis, tu-
bercular or Mriimous diathesis, malnutrition, naso-pharyngitis
and adenoids.
The exciting cause of clnonic purulent inflammation is
smallness of 1 1 tt- perforation and its unfavorable position lor
drainage, granulations within the tympanic cavity, necrosis of
the ossicles, mixed infection, retention of gauze or cotton in the
canal and neglect of treatment.
Pathology and Morbid Anatomy. — The microorganisms most
frequently found axe the (Streptococcus pyogenes, staphylococcus
pyogenes aureus and alhus and saprophytes.
In the structure of the middle ear there is constantly going
on a destruction of tissue, w Inch may he circumscribed or dif-
fused and maj extend to the accessory cavities.
According to Pulitzer (p. H>5), "There is usually a de-
struction of ciliated epithelium with a general thickening from
infiltration of round cells, dilation of and ecu formation of
■els.
Dvering the thickened mucous membrane are irregular
tungifoi: I which may fill the middle ear. Within
mucous membrane are situated cyst spaces,"
■ i.! al-o lr. Zeroni, "lined with cylindrical epithelium and
filled with epithelial cells, leucocytes and deU\l\l&."
DISSASSS OS BAR. NOSH AKD THROAT.
As a rule, there is more or less destruction of the membraua
tympani. Tlie size of the perforation varies and is often situ-
ated in the posterior half of the membrana tympani. The drum
may become totally destroyed where the discbarge has con-
tinued for a long time.
Of the ossicles, the malleus and incus arc more frequently
destroyed in suppuration ol the middle ear, as reported by
Swartze, Grunert and others. According to Grunert, the incus
is more often destroyed than the malleus. Suppuration and
necrosis of the ossicles may continue until they are completely
carious, when they are dissolved in the pus and washed n
Khurnation may occur at any time in the stage of necrosis or
a rarefying otitis ending in destruction of the ossicles or forma
tion of osteoplastic deposits, as observed by Kat/.
Suppurative changes have a tendency to extend to cont:
parts and the epithelium of the auditor? canal may invade the
middle ear anil mastoid process, producing cholesteatoma.
In addition to the local change, toxins arc constantly elimi-
nated which are taken up by the lymph and blood Pill
U1S more or less into the naso-pharynx causing B systemic
infection.
Symptomatology. — In the beginning of a chronic purulent dis-
charge, the car is usualh tree from pain. The discharge <>t pus
from the ear is the one symptom <>t which the patient eompla
Headache may be complained of and is due to absorption of
toxins, to bone involvement and meningeal irritation.
Deafness is variable, being slight or quite profound. If
profound, there is usually some involvement of tin- labyrinth.
Tinnitus or dizziness very frequently accompany involvement
of the labyrinth. Paralysis of the facial nerve may follow caries
of the internal wall.
The tuning fork placed upon the vertex is heard best on the
affected side. Rhine's test is totally or partially negative.
Where there is involvement of the labyrinth, bone condu- t
Will be partially or completely lost on the affected side. I "pun
examination of the external auditory canal, it is usually found
DISEASES OF THE MIDDLE EAR.
235
filled with pus. In old syphilitic crises, the pus will frequently
be Scanty and form thick ill -smelling crusts in the deeper part of
the auditory canal. The color of the pus varies, depending
upon the microorganisms and composition of the exudation and
may be white, yellow, greenish-yellow, blue (from the infec-
tion with the bacillus pyocyancus), and reddish or brown from
mixture with blood.
The secretion may be free from odor, mild OJ intensely fetid,
depending upon the presence or absence of putrefactive bacteria.
Ilir niriulu.in.i tympani may appear h\percmic and thickened.
A graj isli ring will be frequently observed around the perfora-
te of the perforation varies from the size of a pin-
point to complete destruction of the drum and exposure of the
tympanic cavity. Granulations may form about the perforation
and in old cases '. aliamuis deposits may be delected. Where
the drum r- destroyed] granulating tissue may be detected
clustered about the entrance to the Eustachian tube or inner
wall ot the tympanic cavity. Scarlet polypi may frequently
he observed extending through the perforation. Advisedly
speaking, this condition is more often observed when the sup
puratinn is through Shrapnell's membrane.
Perforation through Shrapnell's membrane is usually indica-
tive of a chronic suppuration in the attic of the tympanic cavity.
According to Burnett, the perforation indicates disease of the
r.aso-pharynx if located in the anterior part: suppuration in the
oid cells, if located in the posterior part: bone disease of the
external auditon canal, if located centrally. The presence
of a perforation through the pais ihmid.i is detected by illumi-
nation rathei than by auscultation, which is made impossible
mil of adbesii 1 elling, etc., which prevent air reach'
the attic (Morpurgo, Politzer). The general appearance
of the drum proper becomes altered with the suppuration vvithn
the attic and becomes hyperemic or dry and thickened.
The lymphatic glands of the car and neck are frequently
enlarged and tender to the touch. A dermatitis of the auricle
the disc ially in strumous children.
!
33<5
DISEASES OK EAR, NOSE AND THROAT.
Course and Prognosis. — The course of chronic Otitis media
is exceedingly variable: spontaneous recovery may take place
with or without closure of the perforation in the drum,
long as the perforation in the drum remains, the patient is
predisposed to a recurrence of the infection.
The presence of granulating tissue and polypi are
of involvement of the osseous structure and will prolong the
disease indefinitely, if allowed to remain.
A chronic purulent discharge is frequently from the mastoid
antrum. Adhesive bands forming pockets between the rnem-
brana tympani and the middle ear structure for the retention
of pus draining from the attic or mastoid antrum, should be
destroyed by the removal of the drum and ossicles, other.
a discharge may continue indefinitely.
After cessation of a purulent otitis media, a new conn
DC hand may he formed which, after a long time, hccOMM
infiltrated with calcareous deposits and permanently alters the
hearing.
The alteration in hearing is dependent upon the amount of
destruction of tissue and adhesive processes formed within the
middle ear. Ankylosis between the malleus and thr incus Bj
equal!', destructive to the hearing.
The frequent presence ol syphilis must not be overlooked a*
a factor in the proiongatiof] oi a chic ttttis media ponuV
As long as pus remains n the tympanic cavity, it bmj !*•
taken as an axiom that a rirulent accentuation of the morbid
process ami extension to contiguous Structures may occur at
any time and unless checked by surgical methods, ends in the
death of the individual.
Diagnosis. — The diagnosis of a ehronir purulent inllamn
of the middle car is comparative])! simple under good ilium
tion. As a rule, there is a history ol discharge from the ear
covering a period varying from a few months to a number of
years.
I'ii can he detected upon inspection, which is variable in
both color and odor. As a rule there is no difficulty in
DISEASES OF THE MIDDLE EAR.
-37
tecting the presence of a perforation, since by inflation and aus-
cultation a peculiar whistling sound is heard and the air passing
through the auscultation tube is felt in the ear of the operator.
/ reatment, — The treatment is both local and general. '1 he
general treatment is directed to the correction of any consti-
tutional disease which might influence the local condition,
such as syphilis, tuberculosis, diabetes, strumous or tubercular
diathesis.
The presence of adenoids and enlarged tonsils should In-
sought for in young children and it present, removed. Iiuoiii-
pletc drainage is an important factor in the prolongation of
chronic purulent inflammation, and with this in mind, our at-
tention is directed to the enlargement of small perforations in
the drum, especially in those situated in the superior portion.
Small perforations in ShapneU's membrane may be enlarged
anteriorly or posteriorly. In suppuration in the attic of the ear,
ay be filled with pus, which can only be
emptied by irrigation! A perforation large enough to freely
admit the point of a middle-ear syringe is necessary to irrigate
the attic successfully. In irrigating the middle ear, especially
through the Eustachian tube, a small perforation may so retard
the flow of the fluid mixed with the pus as to cause a portion
to he washed into the antrum and anterior attic of the middle
ear and predispose to infection in those parts. In those old
enough to submit to the procedure, irrigation of the middle ear
is best accomplished through the Eustachian tube. The struc-
tures are cleansed, as far as possible, of any secretion by this
method.
The patient may depend upon the irrigation of the tympanic
cavity through the external canal for cleansing at home. The
great majority of syringes used by the laity are totally useless
and the patient should be instructed to use a fountain s\ rin^e.
The reservoir of the syringe should be elevated from one to
two feet above the head and the nozzle inserted into the ear.
The current can be regulated by the elevation or lowering of the
reservoir. Too much force should be avoided on account of the
to produce dizziness and syncope.
a.1«
DISl \SES OF EAR, NOSE AND THROAT.
Before the ear is irrigated, the pus in the Eustachian tube
and middle ear should be forced out by gentle PolitzeriZSl
OX by inflation through the Eustachian catheter. The pneu-
matic otoscope h also recommended for the withdrawal of pus
from the middle ear. One of the following solutions slightly
above the temperature of the body may be used for irrigar
N I.ysol.
Ai|. clotill.,
B Sol, hydro rg. hichl
B One per cent. sol. carbolic acid.
B Normal salt solution.
2.00 c.c. i
480.00 c.c.
1/5,000
To facilitate the drying of the membrana tympani or ;
cavity alter irrigation, a twenty-live pel cent solution of alco-
hol should be dropped into the ear. The canal and middle ear
arc afterward dried with a pledget of cotton on a probe or
ordinary wooden toothpick. If the tympanic mucosa is visible
and there is a red granular appearance, a two to four per cent.
solution of nitrate of silver may be applied with B cotton-tipped
probe to the mouth of the Eustachian Tube and the mm
membrane.
The patient maj Ik- ordered the Following tor bome treat-
ment:
I.' Hydrogen peroxid,
Signa. Four ot five drops lo be instilled into the car morning
and night.
Alter the boiling sensation in the ear, following the applica-
tion of the peroxid of hydrogen, has passed away, the potj
should dry the auditory canal and drop three or tout I
the following Into the car:
Zinci sulphali*.
Ali-oholis,
- lini.
\i| ileMill., q, *. ad.
J4 gm. (er it)
8.00 r.r. (3 H)
4.00 c.c I
30.00 c.c. (J i)
DISEASES OF THE MIDDLE EAR.
339
Thi olution Dt the bichlorid of mercury is conrraindicatcd
in children on account of the danger of the fluid passing into
the throat and thus causing intestinal irritation. In both chil-
dren and adults, solutions of bichlorid of mercery have no
effect as a germii id* in the strength well borne and in stronger
solutions are very irritating to the mucous membrane.
The fetid secretion is combated by dropping into the car a
solution of menthol and distilled water equal paits, three or
four times daily and closing the ear with shinlon-napluhol gauze.
Hotz speaks very highly of camphoroxal and menthoxal,
where other remedies liave failed to give relief in the treatment
mi chronic Otorrhea. J his may be diluted one-half with steril-
izrd water and injected into the middle ear by means of the
intrarynipanic catheter. The ear should be treated once a day
with camphoroxal in full strength and for home use. a solution
of equal parts of camphoroxal and water should be used in
the ear twicr daily. When the site of the perforation is in the
attic and the perforation is in the membrana rlacctda. in
tion of the attic by means of the Blake middle-ear syringe H
often ven beneficial. Camphoroxal diluted one-half may be
syringed into the attic once daily. When the discharge has
continued lot some time, necrosis of the ossicles with the forma-
tion of granulating tissue or polypi may demand surgical meas-
ures. For the removal of polypi, an application of a fifty per
cent, solution ot chromic acid or curcttement is demanded.
( J ran 11I. -it ions may gradually disappear under the application
Bsnphoroxa] in full strength. Necrotic areas in the bony
structure si the middle ear may disappear under thorough
cleansing. There is b proliferation of new bone cells and repair
takes place as in suppuration in any other bony portion. In
many cases repair will not take place until after ossiculectomy
or the radical mastoid operation with the complete removal of
all necrotic I ithin the middle ear and antrum. A
catarrhal condition of the nose and throat should have frequent
attention. A warm antiseptic gargle once or twice daily
in keeping the Eustachian tube patent, which is necessary for
rarefaction of air in the middle car.
240
DISEASES fir KAR, NOSE AND TJ1ROAT.
It may occur that aqueous solutions are not well borne in
the ear. With this in mind, the dry form of treatment may br
substituted. This consists of cleansing the car as above recom-
mended, drying and dusting the middle ear with aristol.
form, stcarate of zinc or boracic acid.
In many casts the perforation, if not too great, may close
a few weeks after suppuration has ceased. If possible, the
orifice in the membrana tynipani should he closed to prevent
reinfection bom the externa] auditory canal. The most satis-
factory and expeditious method of closing a perforation is by the
careful application to the periphery of the perforation of a
fifty per cent, solution of trichloracetic acid, as recommend
Okuners. Hy the stimulation and oscharotic effect of the acid,
the infolding epithelium may be destroyed and new granula-
tions form.
Tuberculosis of the Middle Ear. — (Sec Tuberculosis of
the Ear in General Diseases.)
Etiology- — Tubercular inflammation of the middle ear is
so named because of the presence of the tubercle bacilli. I
tubercle bacilli may reach the middle ear through the blood
stream or the lumen of the Eustachian tube and BJC forced into
the middle ear in douching or in blowing the nose. The meta-
bolism of the tube and middle ear may be disturbed by ColdL
post-nasal catarrh, adenoids and diseased tonsils.
The disease may originate </'«• novo or he secondary to an ex-
isting lesion elsewhere.
The tubercle bacillus is found as the exciting ran
puration or secondary to an acute simple otitis media or an acute
otitis media purulenta. The tubercle bacilli have been known
to be present in a non-suppurative otitis media, as rej
by Wingravc.
A t'lUii k dysensia 01 lowered vitality from infection in
some portion of the body, predisposes tin 0 infec-
tion from any of the pathogenic organisms which ma
entrance to the middle ear.
The toxins of the bacilli circulate in the blood and ma
DISEASES OF THE MIDDLE EAR.
a very important part in tin* causation of suppuration in
the middle car.
Primacy tuberculosis is frequently seen in children. On
>iint of the greater patency and shortness of the Eustachian
tube in infants, secondary tuberculosis of the middle ear is
frequently observed and is produced by the tubercle bacilli
being forced into the tube and middle ear by the acts of cough-
ing and blowing the nose. The deafness is not infrequently a
niliiry affection arid is a result of tuberculosis or the lungs.
Diagnosis. — The detection of tubercle bacilli in an acute
ur chronic otitis media purulcnta, accompanying or secondary
to a tuberculosis of the respiratory region, is hardly necev
for the differential diagnosis of tuberculosis of the middle ear.
For the diagnosis of primary tuberculosis of the middle ear, the
detection of tubercle bacilli is necessary for the differentiation
of the disease.
According to Levy, the cai complication may manifest itself
at the very conception or the general disease. A tentative diag-
nosis of tuberculosis may be given to a suppurative ear accom-
panying a genera] tuberculosis.
ptomaiology, — The ear symptoms frequently appear after
the lung complications are established. There may be tinniru-.
followed by deafness and painless rupture of the drum and a
thin mucous or mucopurulent discharge. On the other hand, the
symptoms may vary in no wise from simple acute otitis media.
Prognosis. — The prognosis is usually unfavorable. Neerosis
traction of tissue progress very rapidly. Local and
Surgical measures 018) SU] the disease, though the discharge is
seldom relieved in cases with severe general tuberculosis. In
the mild form of the disease, both local and general, the ear
symptoms may be cured.
'.■11, /./.—The surgical treatment is the same as for acute
branlc otitis media. Out-door exercise and nutritive diet
essential.
Otitis Media in General Diseases. — The frequency of
middle-ear complication in general diseases has been mentu.
•7
-•I"
IS i IF EAR, NOSE AND THROAT.
in a consideration of the etiology and pathology ot acute and
purulent inflammation of the middle ear.
Diphtheria, measles, influenza, scarlet fever, typhoid
tuhcrculosis, pneumonia, diabetes, syphilis, pernicious anemia
and leukemia are diseases in which middle-car inflamm.v
may occur.
The pathogenesis of the ear infection differs somewhat in
each c:im\
Diphtheria. — Diphtheria is due to an extension of inn
through the Eustachian tube, external auditory canal and blood
stream. The disease is more often observed in children on
account of the dilated tube. The symptoms <>t a concomil
otitis are those of a simple acute otitis media.
Lomel, in the report of twenty five port-mortcms, came to
the conclusion that middle-ear infection was a part of the
general infection ami was not due to an extension of the disease
through the Eustachian tubfe
Diagnosis* — The diagnosis is made bj the pain in the ear
and inspection of the drum.
Treatment, — The treatment is the same as tor arm.' otitis
media-
Measles. — As shown by the investigations oi Bezold, the
middle ear is always affected in patients suffering from measles.
In consequence, the ear should be inspected daily for sympti
of inflammation and the necessary steps taken to forestall in-
flammation by attention to the post nasal space and ostium tuba
and instillation into the external auditory canal of a twelve and
half per cent, solution of carbolic acid in glycerin. Bulg-
ing of the drum must be treated by free paracentes
Scarlet Fever. — The frequency of involvement of the middle
ear in scarlet fever is vet] great. According to liurkner. qui
by Hiuhl-l'olii/er, twelve per cent, of all chronic middle-ear
luppucation and man] if deaf-mutism are directly due
to scarier fever. At the end "t the desquamative period and
while the child is about, the sympton te otitis media may
become manifest.
DISEASES OF THE MIDDLE EAR.
■43
lataneoua perforation of the drum may occur with or
n ithoul great pain in the ear. The ear involvement occurring
during the eruptive period of the disease is usually more viru-
lent and frequently ends in a chronic purulent inflammation
with necrosis of the ossicles and later a mastoid involvement.
The symptoms and treatment are the same as in acute otitis
media puralenta.
The thioat and BOM should be frequently sprayed with Do-
bell's solution and a hot gargle of Dobell's solution should be
i in relieve the congestion of the Eustachian tube.
Influenza. — Aural complications in epidemics of la grippe
gO insidious and far-reaching that the first symptoms of nr
involvement must not be underestimated. The mastoid and
cerebral involvements may manifest themselves after all the
■ • symptoms have passed ;uva\.
I Em symptoms of middle-ear involvement vary and may be a
mild infection ending in a few days in spontaneous recovery or
in rapid infiltration of the mucosa exudation and all symptoms
of a severe purulent otitis media and mastoiditis.
Triutmcnt. — Where there is great pain, the treatment con-
in the instillation of a twelve and one-half per cent, carbo-
nri solution and dry heat to the ear. There should be no
delay in making an incision in the drum from the superior and
posterior quadrant down to the floor of the canal, thus estab-
lishing tree drainage. If the inflammatory reaction in the ear
onounced, it is unnecessary to wait until bulging of the
drum has occurred before incision is made. Intercranial com-
plications frequently occur from extension through the tegmen
tvmpani or mastoid process.
Typhoid Fever. — The aural symptoms arc dependent upon
the severity of the- primary disease. The inflammation is due
to the toxins of the disease circulating in the blood or to the
of the bacterium coli into the middle car. The rests
of the tissue becomes so reduced during typhoid fever
that a mixed infection within the tympanic cavity from the ac-
cumulation of bacteria in the naso-pharynx is always a possi-
344 DISEASES OF EAR, NOSE AND THROAT.
bility. Day mill Jackson ( The Laryngoscope , December, i«k)+i
describe three distinct types of purulent acute otiris media in
typhoid fever: the hemorrhagic, the slow and the fulminating.
The disease is sudden in Its onset and except in the glow form.
is characterised by intense pain in the ear. The pain may con-
tinue four or five days, ending in slow recovery or rupture of
the drum. Day and Jackson report that in ten cases observed,
no inflammatory symptoms were present twenty-four to forty-
eight hours previous to spontaneous rupture of the drum.
Symptomatology.* — The symptoms are of a mild or revere
inflammation of the middle ear with frequently I slight ten-
derness over the mastoid. " Hcmoi rhagfa blebs may t'orm Qfl
the drum and auditor] Cafial, followed later by a purulent
middle-car inflammation' (Day and Jackson). The ear 0
plications begin about the third or fourth week of the disease
and are more frequent in children.
Treatment, — The treatment is directed to frequent cleansing
of the nose and throat with a mild alkaline spray. As soon
aa the drum is distended by accumulation of mucus and blood,
free drainage should be established by paracentesis. Spontaneous
rupture is to be forestalled by incision of the drum, on account
of the tendency ol the inflammation to lapse into a chronic
purulent mitis used ia after spontaneous rupture.
The ear should he irrigated With a normal salt solution or I
ted horacic acid solution a few hour-; after paracentesis
This should he repeated twice daily. A tampon of bichlorid
gauze should be pushed deep into the canal and as soon as it
becomes moist with the secretion, it should be removed BOi
new one introduced.
Tuberculosis. — On account of the width of tlo
children, tuberculosis ol bhe middle isilf brought about
by infection of tubercle bacilli being forced into the middle ear
ill the act of coughing and blowing the nose. In adults as well
as in children, the avenue of infection is through the Eustad
tube or blood stream, and may be a primary or secondary in-
fection.
DISEASES OF THE MIDDLE EAR.
245
aci
It is known that a predisposition to tuberculosis may exist
and in consequence of this lowering of the tissue resistance of
the middle ear, the tubercle bacilli may find lodgment and bring
■bout a load inflammation. The process of the disease ia
variable and may be noninflammatory or inflammatory. The
former is characterized by the formation of deposits on the
mucous membrane, containing the tubercle bacilli. Ulcera-
tions may occur after a long period, with extern*] changes in
um ami canal.
In the inflammatory form, active ulceration and rapid ne-
"f the tissue frequently extend to the temporal bone and
mastoid with a formation of fetid and caseous pus. Mixed
infection in the ear is more often tin; rule for the reason Chat
the majority of cases occur in children and adults who fre-
quent charity clinics and are proverbially tardy in seeking relief.
Adenoids and hypertrophied tonsils, on account of the
frequency of pi unary infeuion, predispose to the disease.
Among the tin h 1- complicated symptoms arc loss of hearing,
tinnitus, absence of pain, discharge of pus from the ear, necrosis
of the ossicles, cachexia, swelling and sometimes suppuration
of the glands of the neclc. frequently paralysis of the facial
irom necrosis of the inner osseous wall, one or more per-
10ns in the drum, and nasal catarrh.
Treat mtiit. — The general treatment is directed to building
up the system hv tonics and abundance of fresh air.
Tin local treatment is the same as for chronic otitis media
enta. 1 be contagiousness of the disease should he upper-
OBOBl in the IDind "I the physician. Cotton or antiseptic gauze
be wont constantly in the ear and when moistened with
1 > m 1 . should be removed and burned.
Pneumonia. — The pneumococcus or some other infection
the disease maj be forced through the Eustachian
tube during the act of coughing 01 blowing the nose. Otitis
media often accompanies bronchial pneumonia and occurs during
the stage of resolution.
Treatment. — The treatment is the same as recnmmeo.dt& Wi
acute otitis media.
246
DfSEASES OF EAR, NOSE AND THROAT.
Diabetes. — The presence of glycosuria may so disturb the
nutrition of the mucous membrane and bony structures of the
ear as to predispose to hemorrhagic extravasations of the drum,
middle or internal car inflammation and fulminating perforative
otitis media.
Gruncrt reports the appearance of glycosuria secondary to
otitis with brain complications. With the operative treatment
of the middle ear and brain involvement, the glycosuria enti
passed away. The question of the advisability of operative
procedure on the ear in well -developed cases of Bright"s disease
is questionable. Operative procedure is dangerous on account
of the possibility of fatal coma.
Syphilis. — Cutaneous eruptions of syphilitic origin may occur
Ofl the membrana tympani, as reported by Gruber. ActltC
Catarrhal inflammation and acute suppurative inflammation of
the tympank cavity maj occur from ulceration in the ton
pharynx and orifice of the Eustachian tube. The tubal epi-
thelium becomes diseased, thus permitting the entrance of
pathogenic organisms from the throat. In the early i-
sxphilis, the mucous membrane of the naso-pharynx will be
seen red and edematous ami secreting a muco-purulent
nee. The inflammatory condition may spread to the
of the Eustachian tube from continuity of tissue, or the :•
from the disease and tin toxklg produced by continued supp
tivc inflammation in the throat may irritate the □ iu lining
of the ear, predisposing to infection from any organism v.
may find lodgment. A chronic suppuration of the middle ear
accompanying secondary and tertiai is not infrequent,
1 he destruction Oi tissue in the ear accompanying syphilis i-
greater than in an ordinary infection. The course of syphi
inflammation of the middle ear is variable. Adhesive catarrh
and suppuration with involvement oi the labyrinth i- often
observed.
Treatment. — In addition to the treatment recommended for
hypertrophic catarrh of the middle ear and acute or chronic
suppuration, mercury, iodid of potassium and nut; | are
indicated and alcoholic liquors contraindicated.
DIM ASES OP THE MIDDLE EAR.
247
Pernicious Anemia. — Ear complications in pernicious
anemia are infrequent or heretofore unobserved. Schwabach
reports one case with pathological findings. The treatment is
purely subjective.
Leukemia. — Purpura of the mucous membrane of the
middle ear, as in other mucous membranes of the body, may
occur, tar complications require but little treatment other
than patience, as most cases die in one To three years.
Actinomycosis. — According to Bruhl anil Politzer, the dis-
IS rarely primary in the middle ear and is more often jec-
Ondtry to Infection in the jaw. (See Pathology of Actino-
i&tS, 1
Acute Eustachian Tubal Catarrh or Acute Salpingitis.
— Acute tubal catarrh is an acute inflammation oJ the mucous
nttmhrane of the cartilaginous portion of the Eustachian tube.
Etiology. — The cause of the disease is acute cory/a, acute
nasopharyngitis, infection from some pathogenic microorgan-
ism, trauma of the tube, irritation from the post-nasal douche
or spray, adenoid vegetations, hypertrophied tonsils or the
entrance of water into the tube while bathing.
Symptomatology. — The tube becomes swollen, hyperemic and
covered with exudation of serum, minus and hroken-down epi-
thelial cells. The congestion of the ostium tuba may be ob-
served upon post-rhynoscupic examination. Upon inflation by
the Polirzer method or catheter, mucous rales are detected
and the hearing, which is very much reduced, is temporarily
increased The patient endeavors to open the tube by swallow-
ing and pulling the lobe of the ear.
Course /mil Pfognosit. — The disease usually runs its course
in a fortnight, the progress being favorable in simple, uncoui-
itcd salpingitis There is a great tendency of the di$
ncrjic into a chronic salpingitis, where post -nasal catarrh
and obstruction in the upper respiratory passages are present.
I be disease is differentiated from acute catar-
rhal inflammation of the Eustachian tube and middle ear and
from acute otitis media by the normal coloring of the drumv
-:-|s
DISEASES OK EAR, XOSE AND THROAT.
retracted light sputs, fullness in the ears and continuous itching
and irritation in the region of the drum and around tlic ori
ot the Eustachian tube.
Treatment. — The treatment consists in the careful cleansing
of the post-nasal space with Dobcll's solution and the applica-
tion of argentum nitrate, ten grains to the ounce, to the tubal
mouth by means of a cotton-tipped probe. In blowing the nose
following the use of the douche i>r spray, the patient should be
instructed to make pressure upon one side of the nose onl] :
doing this, free exit of air is permitted and the probability of
forcing nir or liquids into the tube or middle car is reduced to
a minimum. As a rule, the patency of the tube can be nstorcd
by gentle inflation with the Politzer bag and catheter. The
1'olitzer bag alone is used in children. Alter the tube is
opened, it may be treated hy means of the Bishop improved
in Mai or or as recommended Ivy Dench, if the condition has
failed to improve after ten days, stimulating applications ill th<-
form of vapors arc indicated. This is done by means of a
middle-ear vaporizer or Scclcy's hot-air applicator with 1
chon's inrlator attached.
The administration of ten grains oi Dover's powders in the
beginning of the disease with a hot foot bath previous to re-
tiring will lessen the severity. The passage of bougies is seldom
indicated for opening the canal.
Chronic Eustachian Tubal Catarrh or Chronic Salpin-
gitis.— This is a chronic inflammation of the entire structure
of the mucous membrane lining the Eustachian tube.
Etiology and Pathology. — The neglected acute salpingitis may
become chronic, bringing about a hypertrophy of the mn
membrane with stenosis of the tube. Chronic inflamm; it
changes of the nasal mucosa predispose to i chronic ralpin
of the mucous membrane. Sclerosis maj Bubiequentl] 00
Course and Symptomatology. — Chronic catarrhal tnfls
tion gradual!) extends to the middle ear, bringing about I
m ni" hyperplasia ol the mucous membrane and resembles
sclerosis of the middle car.
DISEASES (M THE MIDDLE EAR.
249
Treatment, — Stricture of the tube should be destroyed by
inflation or electrolysis or hard-rubber filiform bougie. The
bould not be passed oftener than once weekly. Where
the ostium tubfl is swollen or covered with a mucous exudation,
a fifty pet tent, solution of argyrol should be applied to the
mouth of the tube with a cotton-tipped probe or two or three
(Imps injected into the catheter with a syringe and forced into
the Eustachian rube with a Politzer bag. Where mucus con-
tinues to occlude the rube, the fumes of sal-ammoniac may
be injected twice weekly. An oil solution of camphor, menthol
and iodin may be injected into the Eustachian tube through the
catheter twice weekly few five or six weeks. The Eustachian
tube should be inflated once weekly during this period, unt'l
recovery is complete or the progress of the disease is brought to
a standstill. External massage to the neck is recommended.
Airy abnormal condition in rhe nose and throat should be
1 orncted.
Ulceration of the Pharyngeal Orifice of the Tube. — Ul-
ceration of the orifice of the tube may be due to infection,
syphilis, tuberculosis, diphtheria and carcinoma.
The course of the disease is variable and depends particularly
the early detection of the ulceration and the cause of the
Marked destruction of the orifice may occur if the
ulceration is very great, bringing about adhesions, scars and
atresia.
Treatment. — The treatment is both local and general.
The general treatment ta directed to the correction of any
ional dyscrasia. Simple ulcer of the tubal orifice
uched twice- weekly with a fifty per cent, solution
of trichloracetic acid, followed by a spray of a two per cent.
lion of camphor and menthol in albolcnc. The patient
should be Distracted to spray the nose and naso-pharynx twice
1 a warm Dohrll's solution.
Acute Mastoiditis. — Acute mastoiditis may be a primary or
lulary inflammation. Inflammation of the mastoid as a
disease a one seldom observed and is due to infectiorv
250
DISEASES OF EAR. NOSfl AND THROAT.
finding its way t<> the periosteum or the pneumatic spaces hum
the naso-pharyn.x or through the blood and lymph (
The exciting causes are syphilis, influenza, trauma and micro-
cocci.
As a secondary disease, it is the sequela of acute or chronic
serous or acute or chronic purulent otitis media. Among the
predisposing causes are inflammation of the middle ear. ex
anthematotis diseases, la grippe, tuberculosis, syphilis and path
ogento infection.
Pram continuity of tissue. " the mastoid cells are more or
less involved in every case in inflammation nt the middle ear":
abscess of the mastoid cells as a secondary infection is foil
mlely the exception. Excessive discharge of pus from the
middle ear may so fill the external auditory canal and bom the
want of free exit he forced back into the aditlll n>l antrum with
sufficient force to destroy the mucous membrane by pressure;
infection follows with necrosis of the contiguous bond
According to Politzcr, abscess of the mastoid may exist foi
months without subjective or objective signs.
Symptomatology. — The symptoms of acute prima
tin's of the mastoid are heat, redness and swelling of the skin
behind the auricle. '1 tin and tenderness upon pressure.
The disease terminares in three 01 hiur days in recovery or in-
\ulvcmcnt of the deeper Structures with the formation of an
abscess, The symptoms Ol acute inflammation of the mast .id
cells is the same as in the secondary variety with the exception
that there is no middle-ear involvement.
The symptoms in the secondary form vary in individuals,
manifesting themselves before 01 after parsj • 01 toon
ttneOUl ruptUfl of the drum. Tenderness, persistent or remit-
tent pain and redness and swelling over the mastoid and bulging
of the Superior and posterior auditory canal are the most promi-
nent symptoms. The temperature varies from the normal to
ii>4 I', and 1- much higher in infants. If the east pvtd
before rupture, the drum will be seen bulging in the posterior
and superior portions. The discharge from the ear is usually
profuse after the rupture of the drum.
IMSKASES OK THE MIIH)L£ EAR.
251
Iii simple inflammation of the mastoid, especially in chil-
dieti. the pain complained of is often very slight. This is espe-
cially true in those cases amenable to abortive treatment. In
cases of more viruleiuv, the pain over the mastoid increases
hourly and is not relieved until the cells aie opened and drained.
A sudden CCSSStiofl OJ the discharge from the ear with tender-
DVCr the mastoid is suggestive of serious mastoid complica-
tion. The presence of streptococcus infection is indicative of
rapid necrosis and is an indication for an early operative
procedure.
Course and Prognosis, The disease may terminate in re-
:y in a week or ten days or in the formation of pus and
destruction of hone and not infrequently meningitis, brain ab-
. facial paralysis, sinus phlebitis and thrombosis.
The prognosis in simple, uncomplicated mastoid inflammation
is favorable, but when complicated with influenza, tuberculosis,
diphtheria, scarlet fever, etc.. the prognosis is uncertain.
a mnit. — The treatment of acute abscess of the mastoid
process is divided into medical and surgical.
My medical is meant the use of minor surgical methods and
application of antiphlogistic remedies u I11VI1 aid in the
irpttOD of morbid products thrown out into the pneumatic
(Daces. When the case is seen early, an effort should be made
to abort acute inflammation of the mastoid. Cold application,
by means ot the Leitcr coil or cracked ice in rubber bags, is
espccialh indicated. This should be continued for twenty-four
hours without interruption. The patient should be absolutely
confined to bed, given light diet and gentile purgative, If the
pain and inflammation continue after forty-eight hours, mastoid-
ectomy is indicated. For the elevation of temperature, acetanilid
in five-grain doses should he repeated hourly until fifteen grains
have been taken (Dench). The drum should be incised if
the drainage is not complete, the incision extending from Schrap-
nell's membrane to the floor of the middle ear. Constant at-
tention should be directed to freeing the middle ear of any
purulent discharge, by irrigating with a warm lysol soluticwv,
25 2
DISEASES OF EAR, NOSB YNU THROAT.
mie halt drachm to a pint of warm water. The pneumatic
otoscope may enable us to remove a gnat BBMHBII oi DUB from
the middle ear.
Two surgical procedures are at our disposal when there is
abscess formation with necrosis; the simple and the radical
mastoid operation. (Sec Technique of Radical Mastoid Op-
eration.) The great majority of eases of suppurative mastoid-
ttU require only the simple mastoid Operation, that i- the open-
ing of the abscess cavity without opening the antrum. The
KSuttS of this operation are more satisfactory, the wound beau
more quickly, leaving a small scar.
I li.' instruments necessary for the simple mastoid operation
(ScbwartZC mastoid operation) arc a scalpel, artery
periosteum elevator, scissors, two large retractors or speculum,
three small gouges, 3, s. 6 mm. wide, small curette, small blunt
probe, bone forceps, metal hammer filled with lead. .\Lkewcn*s
small curette and seeker, Stacke's guide, ligature, Curved needle,
antiseptic gauze anil bamla^e.
The operation is performed under chloroform or ether nar-
cosis with the most rigid antiseptic precautions. The side of
the head should be shaved a few hours preceding the operation,
washed with soap and hot water, followed by washing with
pure alcohol. The external auditory canal should he irrigated
with bichlorid solution 1/5.000 and tamponed with iodoform
gauze. A tampon dipped in bichlorid i 1,000 should then be
placed over the site of the operation. With the exception of the
knives, the instruments should be boiled for one-half hour in a
one per cent, solution of carbolic acid and soda. The knife may
be cleansed by dipping in pure alcohol and in formalin solution.
In the simple mastoid operation, an incision is made beginning
at the middle of the tip of the mastoid procc--. extending up-
ward and backward in a curved line one-half to three-quarters
of an inch behind the auricle to the superior auricular at-
tachment and then forward to the anterior attachment
the helix. On account of the severity of the bemorth;
we should avoid severing the linea temporalis. '1
DISEASES OF THE MIDDLE liAR.
*53
incision should be down to and through the periosteum.
The edges of the wound are then separated with a retractor
and the bleeding VC88e] limited or compressed. The periosteum
is then separated ; the site of election for opening into the cells
and also the antrum is above and behind the external auditory
meatus, rive millimeters behind the spine ot Henle and anterior
to the mastoido-squamous suture. A portion of the cortex one
cm. W ide ami one and one-half cm. long is chiseled away with
n ill chisel. The thickness of the cortex varies in individuals
as dors also the amount <>f pneumatic suture; in children espe-
cially the pneumatic suture may be opened at the first incision
of the knife. The abscess is Minn reached, as shown by the
pfettflCe of pus. The bony cavity is enlarged in the direction
of the abscess <..tvity. The necrotic tissue with granulations
is scraped away with a spoon and the wound tamponed with
iodoform ^au/e. The question of opening the antrum at this
time is decided by the condition of the wall separating the
.ivitv, which condition 9 easily demonstrated by the
U Maceucn curette and seeker. Should soft, necrotic bone
be observed, a direct opening is 11-1 aliy made into the antrum
with a sharp curette without resorting to the gouge. The an-
trum and middle ear are then thoroughly disinfected by irriga-
tion and tamponed with iodoform gauze. As recommended by
Whiting, a layer of semitrnnsparerir fenestrated rubber tissue may
be so placed beneath the gauze as to line the mastoid cavity and
prevent the gauze from adhering to the granulations. Strips oJ
lofotn gBOZe ore placed in the external auditory canal ami
bandage applied. The patient is put to bed and the wound in-
Cted in twenty-four hours. If the wound is found to be free
retion xnA the patient complains of no pain or disturb-
ance, fhr dressing is left in place for four or five days, when it
lid be removed and a new tampon and gauze dressing ap-
plied. The patient may be allowed to sit up after twenty-four
n about the ward after fifty two boms. The
time of recovery Varies from three to ten weeks. Complications
be such as continued high fever with dizziness, vomit-
I
254
DISEASES OF EAR, NOSE AND THROAT.
tag and radiating pain over the temple, which are suggi
symptoms of meningitis, pachymeningitis or sinus phlebitis.
I fader such circumstances, the wound is reopened and the
radical operation performed with the exposure of the sinus or
dura mater. (See Pust-opcrative Treatment, p. 162.)
Chronic Mastoiditis. — Chronic mastoiditis IS 9 chronic pur-
ulent inflammation within the antrum and the mastoid cells,
the sequelae of acute purulent inflammation of the middle ear.
The slow form of suppuration with necrosis of the epithelial
cells lining the mastoid cells and subsequent change in the
osseous structure is brought about by the imperfect drainage.
New bone tissues may be formed as a result ol the suppun.i
which partially (ills the antrum, bringing about a condition
known at osteosclerosis. From necrotic change in the walls,
rupture may occur on the external surface or in the cranial
cavity. Pus from the antrum is usually thick and fetid.
Course. — The course of the disease is variable. Many pa-
tients go through life with a chronic slow form of necrosis in
the mastoid without serious inconvenience other than the dis-
charge from the middle ear. In others, a sudden onset of pain,
redness and swelling of the mastoid with elevation of the
peraturc, bulging of the upper and posterior walls, head.
anil nausea will suggest grave complications and an immediate
Operation for the evacuation of pus, granulated DSSUC and rie-
c rotic bone in the antrum and middle car. lJi//iiirv«
sluggish pupils, thread) pulse with slight elevation of tempera-
ture are suggestive symptoms of inter* ranial pressure demam
the radical mastoid operation.
Diagnosis. — The retention of pus in the antrum from im-
perfect drainage during sleep ma; produce headache, pain over
the frontal region and temple ot the affected side, dizziness
and nausea upon awakening. (See Slumbering Mastoiditis.)
By transillumination with a high candle power diagno
lamp covered with a rubber hood designed by Andrews, a
diseased condition of the mastoid will be detected by the im-
perfect illumination of the auditory canal, viewed through an
ordinary car speculum.
DJS£.'\SliS OF Till: MIDDLS EAR.
*55
Treatment. — In chronic, purulent mastoiditis without active
inflammatory conditions, when all forms oi therapy have been
unsuccessfully tried, two methods of operative procedure are
at our disposal ; ossiculectomy and tlie radical mastoid opera-
tion. When active inflammatory changes have taken place in
the antrum and cells or there is involvement of the cranial
wall, the radical mastoid operation is the only alternative.
The operation of ossiculectomy consists in the complete re-
moval of the ossicles and drum membrane through the auditory
canal (sec Ossiculectomy, p. 272). Many cases oi chronic, puru-
lent inflammation of the middle ear and antrum are cured by
this comparatively simple operation. The results of this opera-
tion arc sometimes very slow and there is a liability of recui n
Thfi fafit that the diseased ntri, is obscured from observation
prevents thoroughness of t-urcttenienr oi the necrotic Initio. In
itnmeflding this operation, which cannot be considered good
try, uncertainty of a cure must not be overlooked.
Osteosclerosis of the Mastoid. — Osteosclerosis is the fbt>
mation of new bone within the antrum and mastoid tells. It
may be localized or general. A localized area of new bone is
called cnostosis. The formation of new bone is often a part of
an acute periostitis, in which there are deposits of new layers of
spongy bone. The accumulation of spongy bone brings about
an ebumation oi osteosclerosis. In addition to inflammation
i\ we may have senile change, tuberculosis, syphilis and
1 ized ulcerations.
Symptomatology. — There is a loss of bone conduction, neu-
ralgia of the mastoid and temporal region and sometimes a fetid
discharge from the attic of the tympanic cavity. There is
!l> a history of a discharge from the middle ear which
ntinued for onlj a short time 01 foi an indefinite
period. Wlu-rc there has been no discharge from the middle
car for a long period, objective >\ mptoms may be entirely absent.
Acute or chronic abscess of the temporal lobe may be a sequela
of the disease, due to extension of infection through the roof of
the antrum or middle ear (see Symptoms of Abscess of Tem-
poral Lobe).
256 DISEASES Of EAR, NOSE AND THROAT.
Treatment. — The complete removal oi the spongy from the
compact bone should be made according to the lines laid d
for the radical mastoid operation, with die exception thai it la
unnecessary to remove the anterior osseous walls of the antrum
or enter the middle ear. The post-auricular wound should be
allowed to heal by a process oi granulation.
Fig. 86.
Tlir Akea AyntUtXATI BfO IRHMKnHTi
r, Anterior wall of the Uniy mi ti [«tn ■ miate area
for removal of ncccswry cells of Ujc martoiil protest: .?, Bplnc of Hctile;
4, mpn DSAoid rulsc: S. the rvguma.
Radical Mastoid Operation. — The indications rot rbt
radical removal of all cell spaces oi rhe mastoid anil
the middle ear should be well marked before resorting to this
procedure. Cases oi chronic, purulent inflammation ol the mas-
toid cells may recover by a process of oste" It is well
to remember the great danger which may momentarily result
DISEASES OF THE MIDDLE EAR.
»57
from the presence of pathogenic infection so near the brain and
fully acquaint patients with this condition.
Among the alarming symptoms indicating the radical mastoid
operation in chronic otitis media purulenta, arc headache, py-
rexia, pain radiating to the supra-orbital region of the affected
Bide, temple and neck, optic neuritis, cholesteatoma, excessive
polypoid formations, paralysis of the facial nerve, dizziness,
fistula of the mastoid, offensive discharge from the middle ear
with general septic infection and Bezold's disease, i. e., rupture
of the mastoid abscess in the inner side of the apex into the
..trie fossa and beneath the stcrno-mastoid muscle.
The existence or non-existence of a perforation in the drum
head should have no significance where there was a history of
purulent discharge from the ear and there remains pain in the
mastoid, tenderness upon pressure and headache, which have no
tendency to rapid disappearance.
Fie. 87.
The true radical mastoid operation consists in the laying
bare of the entire accessory cavities of the ear. Grucning has
modified the Schwarze operation somewhat and recommends
the removal of the pneumatic spaces and cells at the superior
root of the zygoma. Whiting especially recommends this pro-
cedure and says:
' That these osseous structures, investigation of which is
usually disregarded! contribute to the necessity for second
operation with a degree of frequency greater than is commonly
bed to them, the writer thinks an entirely warrantable as-
sertion, since in ever) Instanci where secondary operation has
been required in his service (after the tip has been removed «x
18
25S DISEASES OF BAR, NO&B AND THROAT.
the primary operation), the offending agents were found with
uniform regularity, both by means ot probing and later by in-
spection upon reopening the wound, in the anterior superior
angle of the supramcaral triangle; in other words, in that por-
tion of the temporal bone which constitutes the posterior root
of the zygoma."
The preliminary procedure differs in no wise from the simple
mastoid operation with the exception that immediately follow-
ing the separation of the cartilage, the bony meatus is widened
in the superior portion by chiseling away a small amount of
bone to give .1 better view of the field of operation. The small
square opening is gradually enlarged in a funnel-shaped fashion
directly into the antrum, found at a depth varying from one-
eighth to three-quarters of an inch.
Fig. 88.
—J
ca«i"«owiTi k v
Stacks Guidk,
The opening into the antrum is gradually enlarged, the
iui<l tells opened by the removal of lUCCCSsivc layers o! !•
close to the posterior wall of the meatus, forming the initial
groove. As the I bone are chip] arttted a
with a sharp spoon, exploration should he made tor sinuses
leading to collections ol pus. The characteristics oi tin
which flows from the bone varies somewhat and when pulsating
suggests disintegration of hour down to the dura oi the bi
When great epiantities of pus pour out, there is probably in-
volvement of extensive areas of bone. Under strong illumi-
nation from a head-mirror and a Stacke's guide in the adit us
as a protection against injuring the facial nerve and the
all debris. Any granulations about the Eustachian tube should
be curetted away. In severe cases |n-;<.re oimplerinu the oper-
ation the rooi tri I he antrum and the hone covering the sigmoid
sinus should be carefully examined for any dark patches or
perforations which arc present in extra-dura] abscess in the
tempo ro-sphenoidal lobe or about the sigmoid --in us. All debris
and septic material should he washed away with a hot *a.twt*te&.
solution of boric acid. The hony cavity is lined after the manner
or Whiting, with fenestrated rubber tissue and packed with
g»UZfc Two Of three stitches may he taken in the upper and
lower lips of the wound, leaving the wound sufficiently open
for easy packing. The dressing may be changed after twenty-
four hours (Whiting) provided the rubber tissue is used.
When gauze alone is used to pack the wound, it may remain for
five days provided it does not become SOggy and mixed frith
pus, when it should be repacked. The dressing should now be
changed daily until recovery. Healing takes place by a process
of granulation from the bottom upward. In consequence of
the great deformity following the radical operation, plastic opera-
tions are recommended as a substitute for the method of plug-
ging the post-auricular wound with strips of gauze. In the
plastic operation the post-auricular wound is closed and healing
takes place by first intention. By this method, little or no de-
formity results from the operation and recovery is much quicker
than in the retained post-auricular opening.
In the Panse plastic operation, the posterior wall of the car-
tilage is split medially and a cross cut is made at right angles
at the external meatus and the corners stitched into the post-
auricular wound, which is immediately closed so that the open-
ing into the excavated bony cavity is wide and easil]
for subsequent dressing and packing with iodoform gauze. The
floor of the IVOUnd is gradually covered with epidermis from
the attached edge of the membranous canal.
In the Korner operation, two parallel incisiuns are made in
the external wall, one at the superior portion of the membranous
canal and the other at the lower portion of the canal. A
tongue is formed by a vertical incision at the inner portion
of the membranous canal. The tongue or flap is placed in the
0SMOUB canal and packed with gauze. The tongue quickly
adheres ID the bone and by a process of extension soon covers the
exposed portion of the canal. S r dressings are the
same as in other plastic operations,
The Stiickc Operation. — The St.-icke operation under the
niSKASF.S OF TIIF. MIDDLE F.AR.
26l
most rigid antiseptic precautions, consists in making a curved
incision from the tip of the mastoid to the superior margin of
the auricles, then forward to a line drawn vertically through
the meatus. The incision is carried down to the periosteum.
I'lic hemorrhage is controlled with hemostatic forceps. With
an Andrews speculum the lips oi the wound are widely sepa-
rated, the periosteum is separated from the bone, and the
posterior wall of the canal is separated from the bony cavity
down to die drum, with a periosteum elevator. Search should
be made for the mastoid fossa or the spine of Henle and when
once located, should be a guide into the mastoid antrum. With
a leaden mallet and chisel (chisel varying from five mm. to
eight mm. in width) with a Stacke protector in the tympanic
cavity to prevent injury to the facial nerve, the upper and outer
wall of the meatus is chiseled away directly into the attic tym-
panicus without completely opening into the antrum. The
cavity is illuminated by electric head-mirror. The ossicles and
granulations are removed with small goose-neck forceps and
Curette. The antrum and cells are then opened in a reverse
manner arid necrotic tissue removed. There remains but a
singh- cavity when the operation is complete. The membranous
meatus is split in the posterior portion and placed against the
ossemis meatus and retained in position by tampons of iodoform
or bichlorid gauze. The posterior wound is closed and subse-
quent dressing is made through the meatus. The auricle and
posterior wound are carefully dressed with a thick layer of
gauze and cotton held in position by a bandage. The after-
treatment is directed to keeping the wound in an antiseptic
condition. 1 be gau/c dressing should be removed twenty-four
hours following the operation and the wound dusted with iodo-
form and repacked. This treatment should be continued daily
until repair is complete, which time varies from m\ to ten
ks.
AniOng the unfortunate accidents which may accompany
anterectomy arc wounding the facial nerve, the horizontal semi-
circular canals and the lateral sinus. Only a close study ^
262
DISEASES OF EAR, NOSE AND THROAT.
the posit ion of these organs and a knowledge of the possible
deviations from the normal will assist in preventing this .
dent, which is not an uncommon one.
Facial paralysis from neuritis may come on a few days
after this operation and pass away in a very short time. A cum
plete severing of the facial nerve will bring about paralysis
which is usually permanent.
Accidental Opening of the lateral sinus is not if] ItSelf danger-
oil's t-ci life and the hemorrhage 'a easilj controlled b) 1
Flfi. 70.
r KnirK iu Jamm* I"i-v*tic OrcaAtiox.
rloi border of post-auricular ironnd; b, anterior border of port-.:
wouriil. (After Heine.)
of bichloii.l .!'i/c '! he uspension of operative n may
be neceaury, though the majorit) • with
this accident tampon the wound and complete the operation.
DISEASES OP THfi MIDDLE EAR.
*3
Jansen's Mollification of Stack/j Operation. — Among the
foreign operators recommending a plastic operation with a re-
tention of the pOSt-auricular opening are Panse, Siebenmann,
Kretschmann, Schwarze, Jansen, Passow and Reinliart (Heine).
According to Heine, Jaiisen'v modification of Stackc's opera-
tion, as in the classics)! operation, consists in a cut in the skin
parallel with the external ear, one-half cm. away, beginning
at the upper attachment of the auricle and extending downward
Fie. <)t.
7
fin* Picvm Show* tut Kxira Pauso iNtu rm \ >. i ism Pulimi
»A»y to tiis DowmvAU SiaoKi roi rai I'obmation or nut
HMUHOtn Wall.
a and b. Same as in foregoing figu ■•: ii border of ptrpwdteaiif la-
Heine.]
to the tip of the mastoid, through the skin and periosteum
at ime incision, and if there is a large abscess, a small incision
should be made to allow the escape of pus, after which the cut
i an Ik: made through the skin and periosteum. This is fol-
2 (1.1
DISEASES OF EAR, XOSl- ANT) THROAT.
lowed by a search for any fistula: which may lead to pockets
of pus. The boundary far the operation is in front of the- pos-
terior bony wall of the meatus or anterior wall of the mas-
toid. The posterior boundary is an artificial one and a vertical
line can be drawn from the tip of the mastoid to a line ilia an
through the horizontal temporal line (Fig. 90). This boun-
<i;i:\ only holds good :'t the beginning ol the operation. Ex-
Fig. 92.
r *■
KC
j. b. r. Same ai in I'm. yi; d. median border of perpendicular inritton:
r. line of boriaomal IscMon I'" Formation of fl»i>»; fiC, posterior meinbrmom
wall; KG, part cif poaterior bony wall of auditory canal; fit. U<iiUi>nt>l semi-
circular canal. (After Heine.)
tract largB but thifl pia CS oi bone, always chiseling from behind
forward, thus avoiding the possibility oi going into the lateral
sinus. All diseased bone and debris oi bone must be removed
for a small splinter of bone may find lodgment in the nni
DISEASES <,y THJ3 MIDDLE BAR.
2r>5
\\ ben the sinus is Dpened there will be great bleeding. If
there is pus in the dura, it will come out pulsating. If there
is much destruction of bone covering the dun, it should be
removed as far as possible with hone forceps. It there is
present a Bezdd abscess, U should be opened and evacuated
before proceeding with the radical mastoid operation. After
cleansing the auditory canal and the wound of all diseased bone
granulations, etc., the pinna is bent forward with a sharp
knife from behind (Fig. 91), an incision is made from the
roof of the meatus at the junction ol the meatus with the
pini; _!i tli<- M>ft part down tO the Hoof, and the wound
is made to gap by stretching the wall outward and backward
(Fig. 92)- The tampons are removed and a straight pair of
Strong St IsSOrs inserted through the vertical cut into the meatus,
one blade in the meatus and the other in the external wound
in such a way as to include as much as possible of the skin of
the meatus; with one cut the skin is severed horizontally at
boundary of the posterior and superior wall of the meatus
in its long diameter. Bleeding, which may be profuse for a
short time, is controlled with a clamp. If the lateral part of
the flap is too thick, some of the soft parts may be removed
down to the skin after the held is cleansed of blood.
With a pair of forceps, the flap is carried backward and
inward and spread upon the bone extending into the hollow
of the bone as Jar as possible. The flap is kept in tin's posi-
tion by tamponades. Care should be taken not to divide the
pinna too far forward. Tampons should be applied quickly
tO prevent oozing of blood which is quite free. The tampon 9
in the drum arc removed, and with forceps strips of iodoform
gauze netted into the post-auricular opening with the
right hand, the lamina being held in position with the left.
The hollo-.-. ,,) j In- operation is mow tamponed until full to the
The ear is turned back and several strips of gauze arc
inserted into the meatus, which press against the lamina.
The piastic operation cannot always be done when the bone
>l the condition of the bone is not perfectly sound.
266
DISEASES OF EAR, NOSE AND THROAT.
The flap will not heal and will probably suppurate, where
gangrene, or a septic disease of the hone, is present.
Post-operative treatment depends upon conditions. Svphilis.
inherited cachexia and exanthematous diseases accompanying
the disease I'i'iiwirc special treatment.
Fie. 93.
rh
*!
a, b. c. •!, /'x. Same as in l-°i)i yj. /. interior bonier; r. posterior border
•>( horizontal inciali 1 'J. .-. g) i» laid back: J, lateral; e. posterior;
tC. median bOlttel •■' Dap; Si, •' i U ft)
The first dressing should not be changed foi eight days and
the patient should he confined to bed foi thai length oi time.
Fever, pain, discharge and Iodoform eczema may in
earlier change of dressing. A little variation erf temperanne
dors not amount to much and is not Suggestive ol infection.
rid dressing should he made after tliv
after that once daily. Do not tampon too tightly. The dress-
DISEASES OF THE MIDDLE EAR. 269
Under careful antisepsis, a tongue-shaped incision is made
below the retro-auricular opening, slightly larger than the
original opening. The author recommends that the size of
the flap be outlined with a pencil before incision is made. A
groove is dissected around the periphery of the opening, as
shown in Fig. 95, with a sharp, pointed knife. The flap is
turned upward with the epidermis pointed inward and stitched
into the wound with four stitches. The skin at the site of the
dissection of the flap is brought together by stitches as shown
in Fig. 97. The raw surface of the flap is covered with
Thiersch's graft or allowed to heal by cicatrization.
In Trautmann's method, the skin is anesthetized with
Schleich's mixture and an oval incision is made about 4 mm.
distant from the periphery of the opening as in Fig. 98,
forming two flaps. These are turned inward and retained by
sutures, as shown in Fig. 99, the epidermis is thus opened
inward. The external flaps are brought together as shown
in Fig. 100. This method may be used in both large and
small openings.
CHAPTER XIV,
COMPLICATIONS OF MIDDLE-EAR SUPPURATION.
Granulations in the Middle Ear and Mastoid Cells.—
Granulation tissue frequently appears during the course of
middle-ear suppuration. In structure, the granulations are
made up of round cells and new Mood-vessels and covered
u ith Hat or columnar ciliated epithelium, sometimes contain
rng crystals of cfoolesteriu.
Deep, red granulations stand out distinctly and have a
tendency to bleed upon pressure with a probe. In tubercular
inflammation, the granulation tissue may appear pale, glisten-
ing and edematous. The site of the granulations varies and
may cover the entire surface of the middle ear or may be
limited to some portion of the mucous nu-mliranr of the v.
the mouth of the Eustachian tuhc or the ossicular chain.
Treatment. — For the prevention of granulations and their
removal, alcohol in increasing strength beginning with a twenty"
live to fifty per cent, solution, should be applied once or r
daily. By a process of graduation, the patient trill rrequenrlj
be able to use the alcohol in full strength. The granulai
may be destroyed by cauterization with a fifty per cent, solu-
tion of chromic acid. The caustics should be applied dirt
on the granulations and not diffused over the surface of the
mucosa. The surface should be anesthetized with a four per
cent, solution of cocain previous to the application of the cans*
txa ox galvaiK) auteiy. A very satisfactory method for removal
of granulations is curettement with a sharp spoon devised by
O. Wolf. Curettement should be followed b\ the instillation
of a saturated solution of boracic acid in fifty per cent, alcohol,
until recovery IS complete.
Polypi. — Two fundamental forms of polypi of the ear are
170
COMPLICATIONS OF MIDDLE-EAR SUPPURATION*.
described by Gorke .is granulation tumors and mucous polypi.
They may become encysted, containing giant cells and some-
times ehoiesterin crystals (Manasse). Polypi are the product
nt ;i desquamative inflammation and occur more often in middle-
ear suppuration. From the two fundamental forms described
by Gorke, may be developed myxomata and angio- fibromata.
Polypi may take their origin in any portion of the middle
ear or membrana tympani, but more frequently from the inner
wall, ossicles or attic and infrequently from the external audi-
canal. They may be single ui multiple in number and
tile or pedunculated. Zaufal and Gottstein report the oc-
currence of polypi in the tympanic cavity without perforation
ui the drum (Polkzer). As a rule, polypi are detected pro-
truding through the perforation in the drum and are deep
ied and glistening in appearance. The growth may be moved
about and differentiated with a blunt-pointed probe.
Symptomatology. — The symptoms are more often those of
chronic otitis media purulenta. Where the polypi protrude
through the membrana tympani or Shrapnell's membrane, pus
may be dammed back into the attic and the patient may com-
plain of headache, dizziness and nausea from absorption of
toxins and pressure of accumulated pus.
Diagnosis. — The external auditor) canal is first freed of
all pus and debris by irrigation with a warm lysol solution and
dried with cotton, after which the diagnosis of aural polypi is
comparatively easy. The diagnosis is not always simple as
TB by the report of a case by Schult/e, of aneurism oi the
carotid, which was mistaken and operated on for polypus.
The character of the growth may be differentiated under
nation with a blunt-pointed probe. The applies?
:imii of D ise a small and pedunculated polypus to
shrink and recede through the perforation of the drum.
..'men). — The most sadsfactor" method of removal is
by curettrment with a W oil's spoon, followed by the daily
appHi itioo "i alcohol in increat ngth, beginning with a
twenty to fifty per cent, solution. A Blake's snare may be
-72
DISEASES OF EAR, NOSE AND THROAT.
used when the tumor Is large. The application of perchlorid
of iron by means of a probe is highly recommended.
Alcohol in full strength will frequently bring about com-
plete shrinkage. The alcohol is to be instilled into the ear
twice daily until the polypus is destroyed.
Necrosis of the Ossicles. — Necrosis of the ossicles may
be partial or complete and is more often found in the incus, the
malleus beiQg involved next in frequency. The loot plah
the st.-mc- IS infrequently diseased. Wry often when the per-
foration is through Shrapnel I 's membrane, the head of the
malleus only will be involved. The necrosis may only invade
to the incudo-stapedial articulation. If there is total de-
struction of the menrbrana tympani, free access is had to the
attic of the middle ear.
Trtatmtnt. — When local treatment has failed to cure the
purulent discharge in a chronic, purulent inflammation without
involvement of the mastoid antrum, ossiculectomy should be
performed. Ossiculectomy consists in the complete extirpa-
tion of the ossicles. The operation may be performed IUX
a local or general anesthetic. The auditory ranal is first
thoroughly cleansed with a warm solution of bichlorid of
mercury, 1/5,000 or a solution of lysol, one drachm to a pint
of warm water. The canal and middle ear are then dried with
cotton, followed by the application of adrenalin, 1/1.000, to
prevent hemorrhage. As a local anesthetic, cocain in a 20 per
«-<-nt. solution a recommended. F01 a genera] anesthetic chloro-
form nf nitrous oxid gas may be used- An incision is made with
an angular knife extending from tbe postei quadrant of
the drum, following the periphery upward to the short process
and then curving downward to the middle of the drum along
the long process of the malleus. By turning down the Hap. the
incudo-stapedia] articulation is brought into view. Tin-
severed with a small, pointed knife. The incision is then
extended into the anterior periphery of the tympanum to
the membrana Baocida, which is incised together with the
terior and posterior ligaments binding the malleus. The
C< IMPLICATIONS OP MIDDLE-EAR SUPPURATION.
273
malleus is thrn grasped below the short process by McKay's
lorccps and by gently rocking back and forth, it is detached
ami extracted. The incus is next extracted. It may drop
iluw 11 into the tympanic cavity and can then be removed by a
short) curved, blunt hook. If it is desired to remuve the stapes,
the short-hooked instrument is inserted into the foramen of the
stapes, which is extracted by gentle traction to avoid fracture.
The ty&rpanic Cavity is thoroughly dried, dusted with iodoform
and iodoform gauze is inserted for drainage. Subsequent treat-
ment ia directed to the dressing and cleansing of the car until
civ is complete.
Facial Nerve Paralysis. — Etiology* — The etiology of facial
paralysis of an otogenous variety is, as demonstrated in the
previous consideration of the disease of the ear. due to acute
otitis media, chronic or acute otitis media purulenta. exfolia-
tion of the cochlea, necrosis and caries of the temporal bone,
paracentesis, trauma from opening the accessory cavities of the
middle ear. rumors and entrance of foreign bodies through the
external auditory canal or gunshot wounds of the temporal bone.
Paiholngy. — The wall of the canalis Fallopi:c and facial
nerve within are injured or exposed to infection from disease or
trauma. The perineurium or nerve sheath enclosing bundles
<tl fibers may become infiltrated with hemorrhagic extravasa-
tions OJ PUS, producing partial or total paralysis from destruc-
tion of nerve libers.
iftomOSology, — Paralysis of the facial nerve may be
partial or complete. There is a distortion of the face and
drawing to the opposite side, the upper eyelid droops and the
patient may be compelled to open the eye by lifting the upper
lid with the finger. The soft palate is drawn to the opposite
side. There may be disturbance of the taste and dryness of the
mouth, both conditions due to the involvement of the chorda
tymnani nerve. Deafness and tinnitus may be due to paralysis
the stapedius muscle, which permits the foot-plate of the
pea to be driven deep into the oval window by the tensor
pan! muscle.
«9
-:\
DI8BASBS OF EAR, XOSE AND THROAT.
Count and Prognosis. — The prognosis is more favorable In
iliiMn-n than In adult?.. The prognosis is unfavorable where
tliere is complete destruction of the nerve from suppuration.
In partial injury to the nerve, recovery will often be complete
in from six to ten weeks.
Treatment. — After the removal of the cause, the course
of the treatment is very satisfactory. Strychnin hypodermat-
ic-ally ill one-thirtieth grain doses, once daily, faradic electri
as an adjunct to surgical measures and constitutional treat-
ment are recommended.
Cholesteatoma of the Middle Ear and Mastoid. — There
is at present a division of opinion in regard to the pathogenesis
of cholesteatoma of the middle ear and accessory cavities.
In 1838 Johannes Midler accentuated the investigation of
Cruveilhier. who was the first to call attention to the pearl
like formations by discovering that the pearly bodies con-
tained cholesterin and were made up of laminated squamous
cells.
Ilabcrmaii, Hc/.uld and most writers believe that the pres-
ence of the layers of squamous epithelial tells within the
middle car is due' tu migration of the cells from the external
auditory canal.
According to Virchow. Bostrom and others, the presence oi
squamous cells in tissue of unlike structure is due to % pi.
of fetal inclusion.
Politzer believes cholesteatoma maj originate in the middle
ear ami cites the case reported by Luce. However, he says
that the great majority of cases arc second
There is a well-grounded belief that the migration of cells
into the middle car may have taken place during an early attack
of inflammation of the middle ear followed by perforation, in
which the perforation subsequent!) d
Cholesterin growths in the auditory canal may involve
the mastoid process by pressure and a Otl the bone
and a like growth of the mastoid process may break through
the posterior wall of the auditory canal.
COMPLICATIONS OF MJUUl.k-J-.AK SUPPURATION.
2 75
Grunert reports ;i case of i Imlestcatoiiia which destroyed
the anterior bony wall of the canal and passed into the fossa
glenoidalis of the lower jaw. The case of Harmck is men-
tioned by Grunert {A muds of Otology, Rhinoiogy and Laryn-
gology, June, 1904), in which a cholesteatoma of the mastoid
was changed into a cyst containing blood.
Cholesteatoma are divided into primary and secondary; the
primary form originating in the auditory canal, middle ear,
mastoid process or meninges independent of any previous in-
flammatory changes.
As the name implies, the secondary form is a sequence of
some inflammatory change at or near the site of the lesion.
Etiology. — The exact etiology of cholesteatoma is somewhat
life. The primary form of the disease is probably induced
i>\ tBKBC local or general irritation or by some trophic disturb-
ance. The secondary form is induced by a persistent inflam-
mation which brings about a proliferation of the epithelial
cells of the meatus with the formation of laminated non-
nucleated cells arranged concentrically.
Diagnosis. — The disease may continue for a very long time
without bringing about irritation by pressure. When ob-
struction of th-; auditory canal, middle ear and mastoid is es-
tablished, the patient complains oi deafness, tinnitus aurium.
dull pain in the car or side of head, and in severe cases, nausea
and vomiting.
Examination of the auditory canal may show the choles-
teatoma filling the canal or protruding from some portion of
the tympanic membrane. The patient complains of a foul-
iing discharge from the ear where the disease is secondarj
to a chronic inflammation. Examination shows the mass to
he cheese like, somewhat round and of a pearly whiteness or
yellowish-white appearance. The washings from thr ear may
appear string)' or clumpy.
Microscopically, the mucus contains cholesterin, crystals of
fatty acid, 0011 tted, laminated, squamous epithelium and
276
DISEASES OF EAR, NOSE AND THROAT.
Prognosis. — The disease seldom or never disappears spon-
taneously and in consequence of the tendency to grow and
destroy important structures, the prognosis is grave unless the
disease is completely removed by mechanical means. In in-
volvement of the temporal bone, there is always the possibility
of lateral sinus involvement, meningitis and a cerebral abscess.
If the disease is confined to the external auditory canal with-
out involvement of the osseous structure, the prognosl
favorable. The disease shows a tendency to mm.
Trtatmiat. — Provided it cannot be removed by softening
with pero.xid of hydrogen and irrigation, it may sometimes be
possible tu curette the mass away. The radical tympano-
mastoid operation is necessary in suppurative affections oi the
mastoid.
As in the case of Dudley, where the chulestcatomatous masses
involve the external auditory canal and mastoid prOCC88j the
mastoid and auditory canal may he opened and curetted of
all the disease without entering the tympanic cavity.
The lines of the operation will be suggested by the position
and extent of the disease in every case.
The local treatment consists in flushing the diseased area
nitli .1 fifty per cent, solution of camphoroxal, which has a
tendency to check the epithelial desquamation.
Caries and Necrosis of the Temporal Bone.-
and necrosis are more frequently a concomitant condition of
acute or chronic suppuration oi flu- middle ear, in which there
was pnmar\ involvement of the bone accompanying Inflamma-
tion of the mucous membrane. ( >tber causa of disease of the
bene are trauma, syphilis, osteomyelitis, gunshot, diabetes: and
tuberculosis oi the bone. Caries more often attacks the can-
cellous, and necrosis the compact portion of the hone. The r
tions of bone nunc frequent!) involved are the mastoid process,
ossicles, posterior and superior walls, roof or tegmen tympatn
and superior half of the auditor) canal. I be BUS, from rrtcn
riori or pressure, may burrow its waj through the attic or 1
men tympani into the middle cranial fossa, the labyrinth, and
COMPLICATIONS (>r MIDDI.lMi.AR SL'l'I'l. RATION'.
-'77
the Mjtr ttSSUC about the ami. Irs, into the nasu-pharynx or
lateral nnas.
The amount oi destruction oi tissue is variable, depending
Upon the exciting cause and the course of treatment and may
1».' nrily a small superficial sequestriuin or extensive destruction
of ti(SU& The fluids of the labyrinth may escape, producing
total deafness, wheal the externa] wall of the labyrinth becomes
necrotic. The bead of the malleus and incus are often involved
in caries of the trgmen tympani. They may slowly dissolve
in the pus or become detached and are washed away in irrigating
the ear.
Symptomatology. — Pain is often present in and about the
auricle and is due to retention of pus and inflammation of the
bone, being more pronounced at night. The discharge from
the ear is copious and usually fetid and is due to the entrance
of saprophytic bacteria.
In necrosis of the labyrinth, the patient may complain of
nausea, vomiting, tendency to fall to the affected side, facial
paralysis and neuralgia. Pain may be very slight or absent in
caries and necrosis due to tuberculosis. Bone sands may be
thrown down by precipitation. The temperature may vary
from slightly above the normal to 1050. Where there is
marked necrosis as in acute osteomyelitis, the pain is of a deep
boring character. Tinnitus and deafness are usually present.
Upon inspection of the auricle, there is a thick, profuse,
fetid discharge with ulceration of the mucous membrane about
the tympanic ring and possibly collapse of the superior portion
of the osseous wall of the canal with one or more fistulous open-
ings. Granulations and polypi are usually present. Pus may
reach the parotid gland and the anterior portion of the ear and
angle of the jaw through the fissure of Santorint. Complica-
tions <>l sctei are not infrequentij observed in children.
Diagnosis. — Deep boring pain about the auricle and side
of the head arc suggestive of bone involvement in chronic
otitis media. After irrigation of the auditory canal, the con-
dition of the middle ear and osseous portion of the auditory
2?S
DISEASES OF EAR, NOSB AND THROAT.
aJ should be explored with a cotton -tipped probe. The
cotton-tipped probe enables one to detect necrotic bone by the
grating sensation produced by the cotton catching on the
spicula of bone.
A condition of slumbering necrosis may involve the mastoid
after all discharge from the canal has stopped and the perfora-
tion closed. This condition may continue for an indefinite
period with slight symptoms of pain in the mastoid and tender-
ness upon pressure. The drum head may Subsequently, rup-
ture from accumulation of pus in the middle c:ir, only to close
agaill in a short time.
Incision and exploration of pus sacs about the auricle will
favor the detection of necrotic bone. Care must be exercised
not to injure the dura mater with a probe in the examination.
Recurrent and severe attacks of peritonsillar abscess on the site
of aural infection should be looked upon with a suspicion of
necrosis in the bone about the middle ear. Involvement of
the labyrinth is detected by the loss of bone conduction, d
nesS| vomiting, staggering gait and paralysis ot the seventh
nerve. Fistulous opening of the mastoid may permit explora-
tion with a probe and the discovery of a sequestrum.
In involvement of the antrum, there may be bulging of the
superior and posterior osseous walls.
Granulations and polypi usually follow necrosis and may be
seen filling tin- meatus. In the absence of temperature, the
possibilities arc that the leucocyte* will be below the normal
in number and more or less anemia will be present. Leuco-
<ytrs of the polymorphonuclear variety IVul be rOUIW Ifl
with rapid necrosis and high temperature.
Prognosis. — In the absence of brain involvement, the prog-
nosis is favorable. Sequestra may be thrown off and the bone
entirely healed by a process of granulation. The prognos
doubtful in necrosis and caries as shown by the blood examina-
tion and indications oi brain involvement, pyemia or meta-
static inflammation, ratal hemorrhage may DCCUI lioni
vasion of the carotid canal. leptomeningitis may occur from in-
COMPLICATIONS OF MIDDLE-EAR SUI'I'U RATION.
279
vasion of infection into ami involvement of the carotid wall,
producing death. Necrosis of the carotid wall occurs more fre-
quently at the Wte <>f the change of the direction of the carotid
! r < «i 1 1 the vertical to the horizontal direction, known as Hassler's
site of predilection.
Treatment. — The general treatment is directed to the build-
ing up of the usually debilitated system by rest in bed and the
administration of tonics and alteratives.
I Ik local treatment is first directed to the removal of all
accumulation in the auditory canal with a warm lysol .solution,
one drachm to the pint of warm water, followed by drying
with a cotton-tipped probe.
Exuberant granulatiops and polypi should he removed with
a curette.
Fistulous abscess about the auricle should be opened and
inspected for dead bone, all of which should be curetted away.
Afrrr the establishment of free drainage by the removal of
granulations and necrotic tissue in the middle ear, the spread
of infection to the pharynx, parotid gland, etc., may be pre-
vented by the spontaneous healing which takes place in the
nel of communication.
The ear should be irrigated twice daily with a warm lysol
solution and tamponed lightly with antiseptic gauze. The
radical mastoid operation (described in the previous chapter) is
indicated where there is involvement of the mastoid process
and tegmen tympani.
When the outer wall of the mastoid process has been re-
moved, the subcutaneous injection of paraffin will somewhat
I Be the deformity which follow-..
Meningitis. — Meningitis is subdivided into pachymeningitis
or sub-dural abscess, and leptomeningitis or diffuse, septic
meningitis. The latter only remains for consideration.
The avenue of infection in leptomeningitis is often through
the tegmen tvinp.-ini. the sigmoid sinus, the carotid channel, the
labyrinth ial canal or the lymph sheath of anastomosing
blood ve-wcl* and is due t" erosion of hone from otvtv* mt&iL
2.So
DISEASES OF EAR, NOSE AND THROAT.
purulenta. Leptomeningitis is subdivided into two forms,
mioiis and purulent.
Serous Leptomeningitis. — Serous leptomeningitis of an
otic origin is characterized by a local or general bypettfl
followed by a serous exudation into the pia mater. The ven-
tricles and dura mater become distended from an increase of
cerebro-spinal fluid. Suppuration in the labyrinth is a frequent
Cause of serous meningitis (Jansen and l'olitzet).
Purulent Leptomeningitis. — In purulent leptomeningitis
the serous exudation becomes filled with leucocytes, changing
rapidly to sero-pus. The brain substance may become infiltrated
and softened.
Symptomatology. — The important symptoms in the course
of middle-ear suppuration are a rapid polynuclear leukocytosis,
headache, which is at first remittent and localized, final Iv
becoming severe, persistent and generalized, restlessness, in-
somnia, hyperesthesia of the cutaneous nerves, full and rapid
pulse, rise of temperature and loss of consciousness. The
pupils are retracted and do not react to light. The pulse
is slow in the later stages of the disease, becoming rapid
in the last stage. The pupils become dilated, with involun-
tary voidance of urine and feces. General paralysis super-
venes, followed by death.
Course. — The course of the disease may be rapid or slow.
Meningitis following acute purulent middle-ear inflammation
is more rapid, ending in death in two or three days. Follow-
ing a chronic purulent inflammation, death may occur after a
number of weeks.
Prognosis. — The prognosis is favorable when operation is
performed early in the disease. Purulent leptomeningitis
without operation usually ends in death.
Treatment. — The treatment is the same as for pachymen-
ingitis or subdural abscess. Lumbar puncture will frequently
give immediate relief. This should be repeated when relief
follows this form of treatment.
Thrombosis of the Lateral Sinuses. — This condition
rwvii'i.KWTIONS Dl Mii'Di.i. i-.,\u si i ■ i m ration.
281
more frequently results from necrosis of the inner wall oi the
antrum and subsequent phlebitis and formation of a thrombus.
There is always danger of pyemia and metastatic abscess from
;ion reaching the blood stream.
Symptomatology. — The following group of symptoms are
those enumerated by Ballame, and when present arc pathogno-
monic «it septic thrombosis. (1) The history of purulent dis-
charge from the ear for a period of more than a year; (2) sud-
den onset of the illness with headache, vomiting, rigor and pain
in the affected ear; (3) the oscillating temperature; (4) vomit-
ing, repeated day by day; (g) second, third or more rigors;
(6) local edema and tenderness over the mastoid or in the
course of the internal jugular; (7) tenderness CM1 pressure St
the posterior border of the mastoid and below the external oc-
cipital protuberance; (8) stiffness of the muscles of tlie side
of the neck; (9) optic neuritis. In addition to the above, the
examination of the blood shows a rapid increase of white cor-
puscles varying from sixteen thousand to twenty-five thousand
or more.
Diagnosis. — On account of the frequent complication of and
resemblance to meningitis or cerebral abscess, the diagnosis is
somewhat difficult and is dependent upon the symptoms as
enumerated above.
Treatment. — The treatment is necessarily operative and con-
sists as far as possible in the complete exposure and removal
of the focus of infection and the prevention of extension of
infection through the circulation. Operative measure! should
be instituted as soon as the surgeon is convinced that the septic
thrombosis exists. The question of early ligation of the in-
ternal jugular vein for the prevention of the spread of infection
ia still an open question. According to Bacon, the general
IUM is in favor of tying the vein in all cases in which the
sinus Contains puti id material, pus. disintegrated thrombus,
as well as in those cases in which the presence of the thrombus
in the internal jugular is evident from the cord-like induration
felt under the border of the internal mastoid must
2S2
DISEASES OF EAR. NOSE AND II1KOAT.
1 be following BUrgica] procedure is recommended by Jacob-
son and Steward, page 257, and is copied verbatim:
" This is carried out by first turning back an appropriate
Hap, freely opening and clearing out the mastoid cells and
then enlarging the opening backward to the point in Fig. 102.
'It is usually found one-quarter of an inch, chough it may be
only one-twelfth of an inch from the surface. It is thus m
more superficial than the antrum. The anterior line of the
sinus is situated from one-eighth to a quarter of an inch behind
the case-line of the supra-meatal triangle' (Macewen).
soon as the groove for the sinus is opened, foul pus or gas may
escape. The condition of the sinus is investigated, the ques-
tion of plugging being cleared up by an exploring needle, which.
when withdrawn, may smell foully, though empty. I f a th ;
bus is present, before the surgeon proceeds further he sbo-.d.l
tie the internal jugular vein, at the level of the hyoid bone,
with two chromic gut ligatures, and divide the vein between
them. If the vessel is thrombosed at this point, the ligature
ghould be placed lower down at a point beyond the clot: but
the prognosis is here less favorable. The bony outer wall of
the lateral sinus having been thoroughly cut :\\\ av. the sinus
itself is opened with sharp scissors and all the offensive clot
within reach cleared out by the sharp spoon, curette or a
syringe with a fine nozzle. If after this is done, blood begins
to flow from either end, it is per se a favorable sign, as it
shows that the clotting does not extend far into the collateral
vessels. There will be no difficult) in dealing with any hemor-
rhage from the lateral sinus pro*, ided there be room for dealing
with it by means of a sufficient opening in the skull. Firm
plucgiriLi with strips of iodoform gauze wrung out of carbolic
acid ( 1 in 20), and over this a dressing of aseptic wool and a
knotted bandage, will arrest any hemorrhage, however free:
as occurred in one of my lib hemorrhage may recur
freely during tin- first fen dressings but without any ultimate
untow.-ird result. Constant irrigation with noercurj pen-hlorid
solution ( 1 in 4,000) should be employed and iodoform thor-
oughly used."
COMPLICATIONS OF MIDDLE-EAR SUPPURATION".
283
In one of Ballence's cases, though the patient's condition
was greatly improved 1>\ the. operation, the evidence of pyemia
( blood-Stained expo toration and swelling of soinc of the joints)
persisted. Ten days after the first operation, as pus could
lie forced out of the opening in the sinus by pressure on the
neck, an incision was made down to the vein, at the lower
border 01 the parotid gland. The vessel was opened and pus
came out; the sinus ami vein were then irrigated with per-
rlilori.l solution, the stream passing in either direction and
bringing away offensive clots. The man recovered.
The following directions for dealing with the sinus are
given by Professor Macevven ( 10c. supra dr., p. 309) :
" Frequently, in opening the sigmoid groove, granulation
matter protrudes from the dura mater covering the sinus, and
often alone; with this, there is oozing of pus. If it be con-
sidered advisable to open the sigmoid sinus and turn out its
disintegrating contents, then fully a vertical inch of the sinus
ought to be exposed before opening it, in order to facilitate the
operation and the measures necessary for its obliteration. Oc-
casionally the wall of the sinus next to the bone is ulcerated
and, the sigmoid groove being opened, the contents of the
sinus become exposed to view, when the disintegrating matter
may be removed with the aid of a small spoon or washed out, —
the former is the safer. Any space existing between the sigmoid
groove and the sinus ought likewise to be cleared out and
rendered aseptic. Granulation rissue protruding from the
dura mater ought first to be carefully examined with a probe,
Im it surround a sinus communicating with the cerebellum
and lending into an ahscess. If such a sinus exists it requires
to be Opened and the cerebellar abscess dealt with. If there
be 1 "he granulation tissue ought to he removed, as it
is apt t'i barboi Infective matter.
'T11 obliterate the lumen of the sinus Eta externa] walk,
wrfaid eviouslj split, are t'oldcd inward. A quantity
boracic si id powder, sufficient to fill the in-
terior <it the cavity existing between the obliterated sinus and
DISEASES OP BAR, NOSE AKD THROAT.
the bore, is introduced, care being taken in so doing not tn
exert so much pressure as to strip the sinus or surrounding
dura from the skull. As in these cases an infective wound ii
being dealt with, the external portions of it are best stuffed
with iodoform ^au/.e, so as to permit free drainage and healing
by granulation tissue. To obliterate the sigmoid sinus over
about an inch of its extent with influx of blood from the lateral
and superior petrosal sinuses is arrested and the efflux through
the mastoid vein is likewise cut off."
Extra-dural Abscess. — According to Politzer, extradural
abscess occurs more frequently in acute than chronic middle-
ear suppuration and is olten due to influenza.
Etiology. — The cause of an e\tra-dural abscess is the exten-
sion ot infection from the middle ear and accessory cavii
necrosis of bone or infection through the blood and lymph
streams. The size of the abscess and the amount of caries of
bone varies in individuals. Extra-dural abaCEM may occur
synchronously with abscess of the middle ear, yet independently,
the affection originating in some other locality.
Symptomatology. — The symptoms of extra-dural abscess
are somewhat obscure and it is often difficult to differentiate
the disease. Severe pain and tenderness oxer (In- temporal
region or mastoid process in acute and chronic suppuration of
the middle car, with a rise of temperature to 103-1040 F.,
cold and clammy condition of the skin, constipation, stupor.
which sometimes passes to a point of coma, dizziness, vomiting
and occasionally optic neuritis are suggestive symptoms of
pachymeningitis, in which case an exploratory incision for the
detection of an abscess is altogether advisable.
Treatment — The incision behind the auricle is the same as
that for antercctotny. In involvement of the temporal lobe.
the incision should br carried upward, forward and anterior to
the supenm insertion of the auricle, permitting the auricle to
be turned forward and downward. The temporal lobe may be
directly exposed by trephining primarily through the temporal
bone above the bony meatus or secondarily by exposing the
COMI'LKWTIllNS OP MIDDLE-LAR SLT'l'L RATH »N .
antrum and removing the roof of the tympanum, u in the
Stacke operation (see Treatment of Mastoid Disease).
Abscess of the Brain and Cerebellum. — According to
\ em Bergmann, autogenic brain abscesses are either located in
the temporal lobe of the hemisphere or the cerebellum of the
diseased side. Korner reports that in one hundred cases of
abscess of the brain, secondary to diseases of the car, sixty-two
were located in the cerebellum, thirty-two in the cerebrum and
Ifl both the cerebellum and cerebrum. The disease is fre-
quently observed in chronic purulent inllammation of the
middle car and is due to necrosis of the bone and extension
of septic infection into the brain tissue. The white substance is
more often involved and may be acute or chronic. Among the
various organisms found in brain abscess are the streptococci,
staphylococci, diplococci, bacillus pyocyaneus, colon bacillus,
bacillus meningitis purulenta and occasionally saprophytes.
Symptomatology. — The symptoms of cerebral or cerebellar
I '.-ss accompanying chronic purulent inflammation of the
middle ear arc rhr sudden rise of temperature which lasts for
a short time followed by normal or subnormal temperature,
intense headache, vomiting, more or less stupor, slowness of
speech and mental dullness, which may end in coma. Con-
vulsions and paralysis sometimes ovist. Babinski's sign may
be present. The temperature is seldom very high and is more
often subnormal. Tenderness is discernible upon percussion
from the mastoid or squamous portion of the temporal bone.
Exploration of the cerebellum through the mastoid antrum is
indicated upon failure to hnd pus upon exploration in the
temporo-sphenoidal lobe.
Treatment. — Certain well-established rules are laid down
for trephining a temporo-sphenoidal abscess. By referring to
. 101 (Jacobson and Steward), the student will get a cor
reCC idea oi the line laid down by Barker. The side of the
head should be rendered aseptic as far as possible, by shaving
and washing with soap, water and alcohol.
The incision should extend from the tip of the mastoid to.
2»6
DISEASES OF EAR, NuSt AMI THROAT.
the superior insertion of the auricle and somewhat forward.
The mastoid cells are opened and cleansed oi *nj necrotic
Fie. ioi.
%
Thb Fmvm Shows rai RswTion o to tu« Oirrn
Wau <^ i Posrrum or me T«tntix«.
| Ifl mm., ij. m< Est I OMKQ rr.
Reid's base Him 1> Aown paving through u>r middle of the externa) audi-
tory meatus and touching tlie low* BfWl x x indicates the «rle
ol tin- ten' ii i» in relation to ilit- outer w»ll 01
The aiiicii'" I •lions the potat where It* I
attached to the upper herder of the petrous bone, a, Trephine ■■■ vpotc
lateral sinus, it* center bcim: tncfc behind Idd onc-auartcf inch above tbe
center of the BKMtM. This Opening eon easily be enlnrccd upward, backward,
downward and forward (see dotted lines] by suitable angular forcevs. It
is always well to extend it forward *•■ lie mastoid antrum, c
h. Trephine opening lo explore the anterior surface of the petrous bone, tbe
roof i'f tin- tj i vure, its center being «ilu
osed a short Inch above the center of thi meatus. At tbe lower margj
trephine opening, a probe CM listed between the dura and ll>e booc
.mi! m.i.t. in lean h i In a hole of i lu
i abi.ivc and bchii' d
center "i Ihc m idol abscess
(Itarlcer), one ami one quartet inch b< T'»
needle should be directed at first inward, and a little downward and forward.
r. Trephine openina, For cerebellar abtccs*. one and onc-lalf inch behind and
rich below llie meatus. The anlei il be
just under oMCf i>f ' ■■< the mastoid process. Such an
opening is well i«m unus. and a no sited
ifd. inward nnd upward, would enter an abscess oecsurrine the Mh
lateral lobe ol tbe cerebellum, the usual site of an abates* in
art ot (II- BaUanre, fotobtou am J Stem,
COMPLICATIONS OK MIDDLE-EAR SUPPURATION. 3S7
A search should be made with a Macewen seeker for
any fistulous track connecting the roof of the antrum and the
tympanum with an abscess of the temporo-sphcnoidal lobe. Ac-
cording to Macewen, the opening may sometimes be enlarged
and the abscess drained through the fistulous opening. No
fistulous track existing, the trephine may be applied to the skull
at a point indicated in the illustration. After trephining, the
dura mater will bulge forward without pulsation in a wcll-
dcveloped abscess "t the brain. Small, deep-seated abscesses
may exist, according to Macewen, at a deeper level without any
diminution of the cerebral pulsation. In extra-dural abscess,
will be readily drained upon the removal of the bone button.
When- the dura bulges, a " groove directore " is plunged into
the brain in the direction of the abscess for a distance of from
1 i" ;\\" and one-half inches. Search should be made in
different directions until the pus is located. After locating the
pus, the brain tissues should be incised with a knife. The
abSGCSS cavities should be curetted and irrigated with a hot
saline solution and a soft rubber drainage rube inserted and the
lesion allowed to heal by granulation.
For a more thorough examination of the wound and abscess
cavity. Whiting has designed the encephaloscope, with which
the character of the abscess, whether acute or chronic, can be
overed and the wound completely explored. With the
encephaloscope the wound can be easily packed without injury
to the normal brain tissue.
The wound should be irrigated once daily and the drain-
age tube gradually withdrawn by shortening at each dressing,
until recovery is complete. The wound may be packed with a
strip of iodoform gauze, previously saturated with a solution
of peroxid of hydrogen 1-4. The dressing should be changed
once daily until all traces of pus from the brain cavity disappear.
when the wound in the dura may be allowed to close. The
post-auricular wound should now be allowed to granulate and
fill as after the radical mastoid operation. The general treat-
ment consists in the correction of any constitutional dyscrasia
CHAPTER XV.
DISEASES OF THE INTERNAL EAR.
Anemia of the Labyrinth. — Etiology. — Anemia of the
labyrinth may result from simple or pernicious anemia or
profuse hemorrhage from some portion of the body, neoplasms
Di the brain interfering with the blood supply to the ear, endo-
carditis, osteosclerosis, or embolism of the auditory artery.
Diagnosis. — If following a profuse hemorrhage from injury
during operation, parturition or pernicious anemia, the patient
complains of tinnitus, dizziness, nausea especially upon as-
suming a sitting position, partial loss of bone conduction and
more or less deafness, the diagnosis is quickly established.
Treatment. — The treatment consists in the attention to the
general condition of the patient5 the administration of fer-
ruginous tonics, strychnin, burgundy wine at dinner .and
favorable hygienic surroundings.
Hyperemia of the Labyrinth. — Hyperemia of the laby-
rinth may result from middle-ear inflammation, exanthematous
diseases, mumps, some intcrcnuiial disease, cessation of men-
struation, disease of the heart) excessive use of alcoholic liquors,
quinin, amy] nitrate, prolonged irritation from the use of the
telephone receiver and vaso-motor disturbances. .
Symptomatology. — There Is present a sensation of fullness
in the ear, with ringing and roaring sensations an.] sometimes
giddiness, nausea and vomiting. The symptoms are somewhat
intensified by the horizontal position.
The auiicle and auditory canal and the long process of the
malleus may be hyperemic.
Diagnosis. — The diagnosis is based upon the subjective symp-
toms as enumerated. There is a diminution of bone conduc-
aS9
290
DISEASES OF EAR, NOSB AND THROAT.
tion and more or less deafness. The deafness and dizziness arc
intensified by inflation of tlic middle ear.
Prognosis. — Deafness is permanent as a rule, where a small
exudation of blood takes place in the labyrinth, especially in
the cochlea. Suppuration of the labyrinth may occur from in-
fection, ending in complete destruction of the labyrinthine
structures and sometimes in death.
Treatment. — The treatment is local depletion, pilocarpi!!
one-sixth to one-eighth grain daily by the mouth, the adnunts
trntion of bromid of potassium, contraindication of all stimu-
lants ami the afoidance of any sudden physical exertion.
Hemorrhage Into the Labyrinth. — Following hyperemia
of the labyrinth, small extravasations of blood may occur
within any portion of the membranous labyrinth. In add''
to the above cause, we may have a blow upon the head, fall,
fracture of the skull, concussion from explosion and degenera-
tion of the blood-vessel walls.
Diagnosis. — Sudden deafness, unilateral or bilateral, with
dizziness, nausea, tinnitus and a tendenq to fall to the affected
side following any of the above conditions recorded, is Wfr
.<■ of hemorrhagic extravasations within the labyrinth.
Prognosis. — If the extravasation is very small, absorpi:
may rake place in a few weeks with restoration of the normal
hearing. Should the exudation undergo fibrous degeneration.
partial deafness will be permanent. Progressive deafness may
continue until there is complete loss of function.
Treatment. — Iodid of potassium may be given in ten to
fifteen grain doses for six to eight week-. The iodides shnuld
be pushed to the utmost if there is a history of syphilis.
Pilocarpin in one-tenth grain doses twice daily m 1
given. After a few weeks, in addition to the iodid of potts
Stum, quinin can be given in small doses to increase the i:
to the parts and the absorption of the exudation. In
the beginning, attention is directed to the diet, free cantharsis
and rest in bed.
Meniere's Disease. — Meniere's disease b presumed to be
DISEASES OF THE INTERNAL EAR.
291
an acute, serous or hemorrhagic extravasation at the nerve
CfldingB of the auditory nerve within the semicircular canal.
Symptomatology, — 1 be symptoms characteristic of Meniere's
disease are sudden noises in the ears, followed by more or less
deafness, pallor, nausea and vomiting. The patient may com-
plain of dizziness and fall to the ground, falling to the affected
Mile, if only one side is diseased. The nausea, dizziness and
loss of equilibrium may last for only a few minutes and may
recur at longer or shorter intervals.
Dtagnoris. — Sudden deafness, staggering gait, nausea and
vomiting without symptoms of disease in any other organ of
rhe body, negative bone conduction and positive Rinne, are
diagnostic signs of Meniere's disease. The disease should not
be confounded with epilepsy or disease of the brain.
Treatment. — Treatment rarely results in any good. Rest
in bed with cold applications to the mastoid, cathartics and
liquid diet, iodid of potassium and pilocarpin as in labyrinthitis
may <~\crt favorable influence. Diluted hydrobromic acid,
fifteen drops thiee times daily, is highly recommended.
Diseases of the Auditory Nerve.— Diseases of the audi-
tory nerve may be hyperemia, hypertrophy and atrophy of the
nerve and may be secondary to inflammation and suppuration
in the middle ear, meningitis, encephalitis and intercramul
growths.
The pathological changes are seldom observed during the
life of the individual. Where the origin of the nerve is only
involved, deafness is the one symptom complained of. Where
the peripheral portion of the nerve is involved, the symptoms
vary but little from those enumerated in otitis interna (see
Symptoms of Nervo-fibroma of the Auditory Nerve).
Atrophy of the auditory nerve does not necessarily follow
from suspension of function, as observed in the optic nerve.
Neurosis of the Auditory Nerve. — Neurosis of the audt-
9 subdivided into hypcraudition, paracusis, and
tinnitus aurium.
Hypfrauditiox. — Hypcraudition is an occasional increase
20*
DISEASES OF EAR, NOSE AND THROAT.
of the hearing power for all sounds or for (pacific sounds and
tones.
The affection may be the forerunner of some cerebral disease.
Cuitif. — The exciting cause of the affection is presumed to
be cerebral hyperemia, due to excessive indulgence in alcoholic
liquors.
Treatment. — The treatment is directed to the mil.:
gestion of the brain by the enforcement of rest, mild purga-
tives, cold baths, static electricity and the interdiction of alco-
hol and tobacco. As a rule, one drop of purified tincture of
gelsemiuni combined with ten to fifteen grains of bromid of
sodium, administered every three hours, has a beneficial effect.
Paracusis.3 — Paracusis is a disease or a condition of the
perceiving organs, characterized by the perverted perception of
sound, due to some disease of the nerve of the middle ear.
Sounds which are heard as double tones are known as para-
cusis diplacusis. Paracusis loci is an inability to locate direc
tions of sounds. Sounds heard better in the midst of a loud
noise arc classified as paracusis Willisii. Politzer describes
the increasing of hearing in a loud noise as being due to the
movements of the ankylosed ossicles.
Treatment. — The treatment of paracusis is directed to the
removal of the cause which is usually dry catarrh or sclerosis
of the tympanic mucosa.
Hyperesthesia Acustica. — This is a condition of acoittii
mtUS in which there is a painful sensation in one or both
rars produced by the perception of certain sounds, particularly
noticeable in nervous or hysterical individuals, those suffering
from headache, severe general disease in convalescence or in
acute inflammation of the middle car or labyrinthitis.
TiMNtTUS Aurium. — Sounds vary in individuals and under
! IVudokousma i* a condition cloaely associated with paracu*'
is according "-' Kvylc, a false perception of pitch in one or both ear*
for air conduction. The bone conduction remains normal. The treat-
ment is directed to the relief of the middle-ear catarrh, which i» usu-
ally present.
DISEASES OF THE INTERNAL EAR.
293
varied parhological conditions. As a rule, they are classed by
the individual according to the sounds most familiar to them,
i. e., whistling, roaring, buzzing, cracking, blowing, chirping,
as that of a cricket, musical sounds, etc.
Sounds of tin's character may be high or low pitched, con-
tinuous r ,r interrupted. As to intensity, they may be so loud
OB to disturb sleep, oftentimes bringing about insomnia which
may lead to suicide. On the other hand, the sounds may be
only faintly heard at intervals and then only for a short time.
The varied changes in the weather may have a great influ-
itii ■(• upon the character and intensity of sounds, especially when
the individual is suffering from a catarrhal condition involv-
ing the Eustachian tube and middle car.
Sounds are not alone confined to one ear, but may involve
both simultaneously. A great many individuals experience a
slight ringing and roaring in the ear which may last only for a
few moments and return after long intervals and which is
hardly indicative of disease. Tinnitus aurium is not atone due
to disease, but may be superinduced by such drugs as quinin,
salicylic acid, calcium sulphid, etc.
As a rule, sounds are classified as intrinsic and extrfnsli ,
ntrinsic is meant those sounds which are located within
the ear. The patient may, from habit, change extrinsic sounds
1 intrinsic. Extrinsic sounds are those which are supposed
by the individual to have their origin external to the ear.
Many sounds in the beginning of the disease are extrinsic,
but the knowledge of the patient soon places the sounds within
the ear. Gowers mentions a case sending a message to his
next-door neighbor asking that a clock be removed, the loud
striking of which annoyed him. The patient was convinced
that tht sound was only subjective after finding no clock in
the 1 I
Sounds may be located in the head and hecome very acute
under certain conditions, for instance, in petit mal patients
often speak of the warning due to the central disturbance.
The pathology of tinnitus aurium is directly that of tVvt
294
DISEASES OF EAR, NOSE AND THROAT.
disease producing the subjective symptoms. Many and varied
are the diseases which may bring about some temporary or
permanent alteration in the central nervous system, the audi-
tory nerve, the labyrinth and the conducting apparatus.
Acute and chronic inflammatory changes may involve any of
these organs, bringing about the one symptom of tinnitus.
Among the many causes which produce this one condition arc
alteration in the blood stream to the ear, anemia, intcrcranial
aneurism, alteration in the calibre of the blood-vessels of the
ear, the direct influence of toxins upon the labyrinth and middle
ear, osteosclerosis, and such diseases as mumps, scarlet fever,
typhoid fever, malarial fever, diabetes, rheumatism, gout, etc.
1 Elective ventilation of the middle ear. an important factor
in the cause of the disease, is due to obstruction in the nose or
lessening of the calibre dI 1 1 it- Custflcfalan tube from catarrhal
i'm illation.
Suppurative inflammation of the middle r;ir and ohstt
in the external auditory canal from foreign bodies, impacted
cerumen and morbid growths, over-indulgence in alcoholic
liquors, tea, coffee, drugs and tobacco are also exciting causes.
Syphilis is presumably one of the diseases productive of alter-
ation in both the perceiving and conducting apparatus of the
ear. Concussion of the brain, tumors, cerebral aneurisms and
meningitis are all factors productive of tinnitus.
With so many diseases recognized as producing this one
symptom, it is necessary in diagnosis, to go dcepU into the law
of exclusion in ferreting out the patholog) oi this condition.
Inflammation of the Labyrinth (Otitis Interna). — In-
flammation of the labyrinth is usually secondary t<> disease of
the middle ear or mastoid, caries and necrosis of the temporal
bone, diphtheria, scarlet fever, measles, mumps, fracture of
the skull, blow upon the head, or the " sequels! of menu
purulenta or meningitis cerebro-spinalis rpidrmica " (Polit/er).
Symptomatology. — The patient complains of a sudden roar-
ing sensation in one or both ears. As a rule, within two
(bur hours, the patient ly becomes extremely dizzy with
a tendency to fall to the affected side Vomiting is present in
DISEASES OF THE INTERNAL EAR.
"95
severe cases and may continue for several hours. The sounds
arc high-pitched and continuous. "1 he patient is compelled to
remain quietly in bed lor fruni one to three weeks un account
of the dizziness. No objective symptoms are present other
tii;m i slight hyperemia of the drum.
Diagnosis. — As a rule, the diagnosis is very easy. Partial or
i Oroplete loss of bone conduction and hearing, high-pitched
sounds on the affected side with marked disturbance of equi-
Iduium, all indicate the site of the lesion.
Prognosis. — \N here the effusion or metastatic infiltration has
remained in the labyrinth for any great length of time without
any apparent absorption aa manifested bj a change for the
better, the prognosis is usuail] had. deafness remaining. The
prognosis is more favorable in primary than in the secondary
form of the disease.
Treatment. — '1 he treatment consists in rest in bed, local
depletion. leeches to the tragus, hack of the auricle and mastoid,
application of the Leiter coil or ice bags to the mastoid, morphia
internally and liquid diet. With no relief of deafness after two
in, thfl internal administration oi huge doses of iodid of
BodlUtn "s indicated. Elimination should be encouraged by daily
hot baths.
Panotitis, or Inflammation of both the Middle and In-
ternal Ear. — Panotitis, or inflammation of both the middle
and internal ear occurs more often m children than adults and
is accompanied with marked constitutional symptoms, due to
acute, severe, infectious diseases, such as scarlet fever, diph-
theria, measles, etc. Necrosis of the thin wall separating the
labyrinth from the middle ear ma\ occur, causing total deafness*
<..4'y. — The d eas is usuallj ushered in with a
high fever, eclamptic seizures, delirium and sometimes loss of
consciousness, which varies from a few hours to a number of
The patient may complain oi tinnitus, vertigo, stagger-
Bait, purulent discharge from the middle eai and complete
Inflammation of the facial nerve or facial paralysis
It from the extension of infection through the osseous
396
DISEASES OF HAR, NOSE AND THROAT.
wall of the Fallopian canal. In perineuritis, the patient may com-
plain of pain along the course of the faua! nerve jfol a number
of weeks after the acute symptoms of the disease have passed
away.
Treatment. — The treatment consists in rest in bed, the hypo-
dermic administration of pilocarpin, free purgation and iodic"
of potassium. The middle ear should be cleansed twice daily
by irrigating with a hot solution of lysol, one-half drachm to
a pint of water, followed by the instillation of a mild astringent.
Syphilis of the Labyrinth. — Syphilis of the labyrinth may
be congenital or acquired. If present in young children, con-
genital syphilis involves both ears as a rule and usually pro-
duces deaf-mutism. Congenital syphilis of the labyrinth may
manifest itself either in infancy or adult life.
Acquired syphilis of the labyrinth is normally a tertiary lesion
though involvement of the labyrinth may take place during the
secondary period of the disease.
Labyrinthitis may be primary or secondary to syphilis of the
middle ear.
Pathology. — The disease is due to a periostitis with infiltra-
tion of the round cells into the membranous and osseous struc-
ture and change of the endolymph into a scro-bloody fluid.
according to Barratauv.
Caries of bony tissue may take place from suppuration sub-
sequently involving the middle ear.
Following the exudation from the inflammation, a general
sclerosis may occur, completely destroying the function of DM
internal ear.
Symptomatology. — The disease begins with a continuous Ion
ringing and roaring in the cars, whidi become high-pitched
with the progress of tin disease. The disease is sudden in its
St, progresses rapidly and ends in partial or complete deaf-
ness. There may be slight vertigo, differing, however, from
the profound vertigo of Meniere's disease. There is an ab-
sence of inflammatory Bymptoms other than an intermit
pain deep in the ear.
DISEASES OF Tirn INTr.RNAI. F.AR.
397
Deafness is rapidly progressive, both by air and hone.
Weber's test is more distinct in the ear least affected. Low
tones are first lost, followed by the loss of high tones.
Diagnosis. — The disease should be differentiated from
Meniere's disease, suppuration of the labyrinth and tumor of
the brain.
Absence of peripheral symptoms of brain disease, history of
syphilis, rapid onset of the disease, continued and progressive
deafness and loss of bone and air conduction are diagnostic
sijzns of the disease.
Prognosis. — Deafness is usually progressive and frequently
ends in total deafness, provided the most profound anti-
syphilitic treatment is not quickly and systematically instigated.
Treatment. — The general treatment consists in the daily
inunction of mercuT) for ten days and the internal administra-
tion of iudid of potassium, followed by the mixed treatment.
Pilocarpin in one-tenth grain dose to the adult with correspond-
ing decrease of the dose for children should be given hypo-
dermatically for ten days. A blister in the form of cantharidal
collodion should be applied to the post-auricular region and
should be repeated after four or five days.
Irrigation of the auditory canal twice daily with a hot normal
salt solution is highly beneficial in stimulating lymphoangiectasis
of the middle ear and labyrinth.
In addition to antisvphilitiV treatment, tonics, attention to
personal hygiene and out-door exercise should be prescribed.
Th<- may be somewhat controlled and often perceptibly
improved after a week to ten days' treatment. The length of
time necessary for constitutional treatment varies in no wise
from that of syphilis in any other portion of the body.
Osteosclerosis of the Inner Ear or Spongification of the
Bony Capsule of the Labyrinth. — This is a condition of
fixation of the stirrup by a rarefying ostitis of the labyrinth
and middle car. especially about the oval window, occurring
in individuals over eighteen years of age and reaching a
climax about the patient's twenty-eighth or thirtieth year.
29S DISEASES OP EAR, NOSE AND THROAT.
Etiology. — Heredity is presumed to play an important part
in the causation of the disease. Advisedly speaking, other
causes are inflammation of the periosteum of the middle ear,
syphilitic, gouty, rheumatic ami, ;is suggested hy Katz, neuro-
paralytic or trophoneurotic diathesis.
Fie. 103.
Horizontal SxctjOH I'm. . \jvkimii iji nit RCOIOH or tax Siawi
i'm'»:k Pdmiom
Showing bony fixation of the stupe* and hyperplasia, of the capsule of
the labyrinth. A, Tensor tynpani; B, capsule of cochlea; C. normal bone;
D, central axis of cochlea; C, ganglionic canal; P.
acuaticux; //, facial nme; /, stapes (anVyloscrt) ; /, stapes, foot plate (anlty
losed); K. hyperplastic bone; L. vestibule. (After Swbcnmann. Hy courtesy
..1 . 1 Htm
Pathology. — The pathology of osteosclerosis is still a subject
of investigation. Siebermnnn's theory of spongifkatibn is that
the disease is one due to faulty fetal development and that the
bone tissue of the labyrinth takes on a process of prop
spongification instead of changing into smooth, compact bone.
Katz reasons that the disease is purely one of an in flam ma-
ton- nature, that it is periostitis of the middle ear and
qucnt involvement of the labyrinth.
Pulitzer believes the disease ro be a circumscribed primary
inflammation of rhe bony labyrinth about the oval window
with the formation of new hone substance and complete anky-
losis of the stapes, due to the action of osteoblasts. He found
bone corpuscles to be more numerous than in normal bone.
The bony spaces were greatly dilated and filled with connec-
tive tissue, rich in cells and enclosing large and small blood-
vessels and in some cases giant cells, osteoblasts and osteoclasts.
Symptomatology.— The patient complains of progressive
deafness, a constant ringing and roaring in the ears, usually
high-pitched and sometimes deep pains to the car alternating
wirh a Sensation of constriction about the head. A slight
.li/zinrN- n-;iy he present at intervals.
Dittg/iosis. — The Eustachian tuhe is usually found open irnl
the drum membrane resembles the normal. There is a loss
• it hearing fat low tone;, and a negative Rinne. There is little
or no Improvement upon inflation of the middle ear.
Treatment. — The treatment is essentially constitutional and
ommended by Siebenmann, confined particularly to
piloiatpin one-one-hundredth to one-twentieth of a grain, three
times daily. The tinnitus may sometimes be relieved by vibra-
tory massage ol rhe meatus. Catarrhal conditions of the nose
and nasopharynx, which might complicate the disease, should
be treated. Sea bathing, Outdoor exercise and general hygienic
measures should be advised. The symptoms are usually ag-
gravated by physical exhaustion.
Paresis and Paralysis of the Auditory Nerve. — Paresis
and paralysis of the auditory nerve may he due to hemorrhagic
extravasations, necrosis of the temporal bone, trauma, angio-
neurotic, rheumatism, hysteria, tumors of the brain, measles,
Syphilis, locomotor ataxia, mumps, exanthemaroos diseases and
meningitis.
Sjmptomntnlogy. — The symptoms vary somewhat according
the ixirtiim of the nerve involved. If the cochlear portion
of the nerve is diseased, there is n loss of hearing and bone
conduction. If the portion of the nerve going to the semi-
.v»
DISEASES OF BAR, NOSH AND THROAT.
circular canal is involved, there is nausea, staggering gait and
a tendency to fall to the affected side. During the course
of the disease, the hearing varies somewhat in acuteness ac-
cording to the variations in the temperament of the patient
and surroundings. If there is present also a facial paralysis.
the site of the lesion is usually within the internal auditory
canal. The loss of hearing in tabes may, according to Gowers,
be sudden or gradual in onset, transient or lasting.
Diagnosis. — It is very difficult to differentiate the disease
from interlabyrinthine diseases. Partial loss of function and
sudden restoration of the hearing frequently enables a differ-
entiation of the disease from diseases of the labyrinth, which
are slow to recover. The toning roA will be heard on the
opposite side in the Weber test. There is usually deafness 'i!:
high-pitched sounds, as shown by the Galton whistle. Rinne
is positive and shortened in partial paralysis. Hone and air
conduction is entirely lost in paralysis <>f the nerve.
Treatment. — The treatment for paresis or paralysis of the
auditory nerves depends upon the duration and cause of the
disease. The general treatment consists in the administration
of alteratives, rest in bed, hot foot baths, saline purgative or the
application of galvanic current by means of the ear electrode!
with negative pole to the ear, continued for sis to eight min-
utes as strong as can be convenientlj home.
INJURIES OF THE MASTOID PROCESS AND FRACTURES OF
THE TEMPORAL BONE.
Injuries of the Mastoid Process. — Injuries of this char-
: tat anally due to a fall, blow upon the mastoid, gunshot
wound or stab. Contiguous parts may or may not be involved.
In times of war. army surgeons may be called upon to treat
injuries ol this region.
irding to Makin (" Surgical Experiences in South
Africa ") wounds in this region from gunshot usually produce
complete paralysis of the seventh nerve. In a number of cases
reported by Makin, there was also paralysis of the auditory
nerve and rupture of the drum.
Stab wounds in the mastoid may involve the cells of the
antrum. The point of the knife may break off and remain
embedded as in the case of Ustmann, in which the point of
the knife remained twelve years without producing any ir-
ritation.
Wounds of the mastoid, provided there is not a complete
crushing of the mastoid, heal without other treatment than
irrigation and antiseptic dressing. If the tip of the mastoid is
crushed it may be necessary to incise the parts, extract the small
particles of bone and drain with a strip of gauze.
Fracture of the Temporal Bone. — Fracture of the tem-
poral bone frequently accompanies fracture of the occipital
hone and is due to a fall upon the forehead, blow upon the
side of the "head or occiput and penetrating wounds.
The line of least resistance of the petrous portion of the
temporal hone H (Him the jugular foramen to the tegmen
tympani ct antri," and in consequence, it is at this point that
3»«
3°2
DISEASES OF EAR, NOSE AND THROAT.
fracture more often occurs. The line of fracture must vary
according to the direction of the blow and the nearest fos
the impact.
Fractures of the temporal bone may be simple or com-
pound. In compound fractures, we have a rupture of the mu-
cous membrane of the dura, hemorrhage into the middle ear,
rupture of the drum and escape of the cerebro-spinal fluid.
Blood serum differs from cerebro-spinal fluid in this respect:
blood serum dries quickly and is highly albuminous while
cerebro-spinal fluid is of low specific gravity, dries slowly, con-
tains chlorid of sodium and frequently sugar.
The hemorrhage from the ear in compound fracture of the
base of the skull is very profuse in some cases. The patient
may become exsanguinated. The flow of the cerebro-spinal
fluid may continue for a number of days.
A serous discharge with fracture and rupture of the drum
may have its origin in the middle ear and mastoid CC
Blood may escape by way of the Eustachian tube.
Paralysis of the seventh nerve may or may not occur. The
labyrinth frequently escapes injury but, should the labyrinth
be injured, deafness is usually permanent.
Prognosis. — A guarded prognosis shoidd always be given.
Cases with severe ear complications frequently recover. Late
unconsciousness and high temperature or a continued subnorn1.1l
temperature without reaction are had prognostic signs. The
nausea and dizziness pass away in a short time in favorable
l .IM'S.
Treatment. — In addition to the general treatment as pre-
scribed by the surgeon, the ear should be cleansed n itfa a warm
solution of lysol or diluted alcohol. Irrieation should be
sparingly indulged in on account of the liability of carrying
infection from the auditory canal into the meningeal ca>
The car should be tamponed lightly with antiseptic gauze which
should be frequently changed. The nose and throat should be
msed twice daily with Dobcll's solution tO prevent, as far
as possible] infection from reaching the middle ear through the
Eustachian tube.
CHAPTER XVII.
MALFORMATION OF THE HEARING APPARATUS AND DEAF-
MUTISM.
Malformation of the Hearing Apparatus. — A reference
to the embryology of the ear will demonstrate how it is pos-
sible for the auricle to be deformed from want of development
in one or all of the primary germinal cells. The meatus and
auricle may be absent, imperfectly developed or abnormal in
Size and position. A blind canal opening on the external 08
inner portion of the helix is sometimes observed, known as a
fistula tours congenital. It the auditory canal is closed, deafness
results. Malformation of the Eustachian tube, middle and in-
ternal car frequently accompany like conditions of the external
ear. The mastoid antrum, mastoid cells or the rympanic mem-
brane ni.-n be absent or partially developed. Grunert men
tions a case of KaufTman's in which the hammer and anvil
I as a single bone. The internal ear may be
gbceffi or partiall) deformed while the auditory nerve may be
atrophied or undeveloped.
I'ltoimertt. — 1 :' ;i|hm';i of the canal exfett ami perception
be heard through bone or through the Eustachian
Cube, as in the King test, operative measures for opening the
canal may he indicated.
Plastic operation or resection of the cartilage of the pinna
be undertaken for the correction of any abnormality in
" position. In the great majority of cases, operative meas-
n either rontraindirated or the patient refuses to submit
to any effort at correction.
Deaf -mutism. — Deaf-mutism is a condition of congenital
or acquired foat of hearing and power of speech.
303
3°4
DISEASES OF EAR, NOSE AND THROAT.
Etiology. — Deaf-mutism may be inherited or acquired. The
exact status of heredity as an etiological factor is imp. a
understood. The marriage of first cousins is thought to pre-
dispose to the disease.
Hartman reports a case in which a deaf mute was born to
parents whose grandparents and great-grandparents were closely
related.
Two or more deaf mutes may be born to parents in whom
there is 00 liisrory of the disease. Deaf mutes seldom beget
ikaf-mute children. The intermarriage of deaf mutes should
be prevented, as far as possible.
The disease may result from faulty cmbryological develop
ment of the ear, diseases in early life, cerebrospinal meningitis,
mumps, primary inflammation of the internal car and injury.
The disease is more frequent in Switzerland that in any
other country and occurs more often in boys than in girls. It
is presumed that the high altitude of Switzerland predisposes
to the disease.
Pathology. — There is an arrested development in the audi-
tory nerve and its termination in the labyrinth, from the pa-
tient having suffered, not infrequently, an attack of intra-uterinc
meningitis, syphilid or tubercuknw.
Among the pathological changes noted in the car of deaf
mutes at post-mortem, according to Pulitzer, Mygind, Moos,
Steinrugge, Bezold and others, are atresia of the external
auditory canal, absence of the middle ear, osseous degeneration
around the round window, faulty development of the internal
ear, absence of the nerve in the lamina spiralis and various
changes within the osseous structures of the internal ear.
Prognosis. — According to the observations of Bezold, one-
third of nil the children confined in deaf-mute institutions have
a slight degree of hearing. If this could be detected by the
otologist in charge, and all institutes should have a visiting
otologist of repute, the child might be taught to speak and
hear. If there is no hearing, the child cannot be taught to
speak.
MALFORMATION OF HK.1RING AI'IWRATUS.
3°5
According to Bezold, the greater proportion of deaf mutes
become so about the second year of life.
Unless children who become deaf mutes about the eighth year
of life are constantly drilled in speech, they may forget that
uhii.h they have already learned and depend upon the sign
language.
Diagnosis. — -Unfortunately, it often occurs that children sus-
pected of deaf-mutism are neglected or the pride of the parents
prevents a disclosure of the disease. It is extremely difficult to
tell in a young child who is presumed to be totally deaf,
whether or not any hearing exists. Only by the most careful
test of the hearing and observation of the countenance of the
child during the test, can one positively disclose the presence
of hearing. In children old enough to possess some intelligence,
examination can be conducted with a greater degree of precision.
If the faculty of speech has been forgotten, a quicker response
to tests of hearing will be elicited than in those without any
previous knowledge of speech.
Trent merit. — With the advance of institutional work and
the work of the otologist in such schools, a great deal has been
accomplished in purely a surgical way in the relief of many
deaf mutes with a remnant of hearing, especially in those with
adenoid vegetations and enlarged tonsils. In those with con-
genital deafness, the trouble may be due to the accumulation
in the Eustachian tube and middle ear, adhesions, etc. Local
treatment has accomplished a very great change in the quality
of hearing.
Politzcr reports the case of Jacqucmart, who brought a cure
of a deaf mute in whom there was a retraction and cloudiness
of both tympanic membranes by the inflation by the catheter of
the Eustachian tube and middle ear. The majority of children
should be sent to institutions for the training of deaf-mutism
where systematic exercise of the acoustic nerve may be had
and instructions given in expressing thoughts by the lips, sign
language and writing.
Simulated Deafness or Malingering. — It is not infre-
306
DISEASES OF EAR, N'OSE AND THROAT.
quent that malingering cases come under the observation d
physicians connected with great corporations, with the army
or the United States Pension Department.
The ear should first be carefully examined for impacted
cerumen, catarrhal inflammation of the middle ear, perforation
of the drum, syphilis ami diseases of the middle ear.
Hummel lias devised a scheme for detecting simulate^
sided deafness. He has a speaking tube fitted tightly into each
ear. Then two persons with similar voices talk at the gm
time. They may use the same sentence, a slight!] different sen-
tence or the word may be entirely different. The one sided
deaf repeat correctly what one person says while the simulator
will he confused.
In suspected malingering, the eyes should be carefully Inn
dageel so that the relative position of the examiner canmif
be observed.
When the tuning fork is placed upon the vertex, the
will he heard in both ears and the patient may so express
self. The sounds will bo- intensified if both ears are stopped
up. If the car presumably deaf is dosed, the patient may say
he cannot detect the sound, whereas, the sound is intensified
on that side.
Voltolini recommends Stopping the affected ear with a per-
forated cork, the sound eat being closed el the mom tin
Significance of Ear Disease in Life Insurance Exami-
nations.— In examination of ears of induvidtUds, the source
of any discharge from the ears should be carefully investigated.
A watery discharge from the ear may follow from eczema
and is not of sufficient gravity to impair the risk. I
aminer should remember that chronic myringitis may sometime
give rise to an offensive discharge and independent ot an1.
middle-ear complication. A disease of this dwractei il
relieved, and upon its relief, the risk is not impaired.
Perforations of the drum are suggestive of trauma or acute
exudative inflammation of the middle ear. A perforation oi
the drum may he congenital and the drum be entirely absent
MALFORMATION OB HbARINO APPARATUS.
307
as shown by Kauffman. The external ear and auditory canal
may be absent or deformed, in no wise affecting the life of the
patient. Deformity may be observed in patients of :i tubercular
diathesis. Where the perforation is of long standing and there
has been an absence of a purulent discharge from the ear dating
back a number of years, the risk is only slightly impaired.
A history of chronic discharge and radical mastoid operation
for its relief with a complete cessation of the discharge covering
a period of one year does not impair the risk.
If there is a hiftttry of recurrent attacks of discharge from
the ear, the hazard is considerable. An applicant with an acute
<>r chtonic discharge from the car is entirely hazardous. Deaf-
ness (tOta catarrh or paralysis of the auditory nerve, independent
of a history tti syphilis is a good risk. A patient with a history
Wenierc's disease is a hazard and should have special rating
or be rejc
Tinnitus aurium is a subjective symptom and in many cases
is of no consequence. It may indicate epilepsy or carotid or
basil lar aneurism. Osseous tumors in the canal are not dan-
gerous, though special rating or rejection is necessary. Tu-
mors of the ear make a risk hazardous.
CHAPTER XVIII.
DISEASES OF THE NOSE.
Acute Rhinitis. — Acute rhinitis is an acute catarrhal in-
flammation of the mucous membrane of the nasal fossa;, other-
wise known as a cold in the head.
Etiology. — The causes of acute rhinitis are both predisposing
and exciting. Among the many predisposing causes are urk
acid diathesis, inherited or acquired dyscrasia, occupation, un-
sanitary surroundings, woolen underclothing, nervous exhaus-
tion, malformation of the septum and adenoids. Chronic in-
flammation of the mucous membrane, polypi and poor slcejv
car ventilation are especially predisposing causes of the disease.
Iodid of potassium, internally, produces a discharge from the
nose, resembling symptoms of coryza.
Among the many exciting causes arc the sudden and pro-
longed exposure of the body to draughts, damp or cold weather,
after violent exercise or turkish bath, exposure to irritating
gases, extension from a like condition of the pharynx or post-
nares and, as advocated by many, the presence of pathog<
microorganisms. The disease is probably infectious.
Pathology. — The pathology of acute rhinitis is essential I v
the same as that characterizing acute inflammation of any 01
mucous membrane. There is a paralysis of the vaso-constrictor
fibers of the capillaries or an irritation of the dilator fillers,
with swelling of the venous capillaries and U
reution of glandular contents, which is followed by a reaction
and extravasation of leucocytes, mucus, scrum and lymph, wit*1
broken-down epithelium which is hastened by the previous dis-
•i of the cells. The discharge gradually changes I
serous or water}' character to a thick, viscid secretion and in
the last stage it becomes imico-purulcnt. If the sinuses an*
308
DISEASES OF THE NOSE.
309
involved from extension of inflammation, the mucopurulent
character of the secretion may continue for a number of days
after the nasal secretion has stopped. The pathology varies
considerably when abortive measures arc employed. The blood-
\c-ssels gradually regain their natural tonicity after five to ten
days. Absorption of the exudation within the intercellular
spaces takes place and a return to the normal ensues.
Symptomatology. — The disease may be preceded by a chill
or chilly sensation, lassitude, indigestion and loss of appetite.
The swelling of the mucous membrane produces sneezing and
difficult breathing. One or both sides of the nose may be
occluded. The swelling frequently shifts from one side to the
other, due to gravitation of blood.
In extension to the frontal sinuses, there will be frontal
headache, mental dullness and otophonia. The Eustachian tube
may be involved at the same time, especially in those cases suf-
fering from a chronic naso-pharyngitis, producing a fullness in
the region of the ostium tuba and a slight deafness. There
may be a temporary loss of taste and smell. There is little or
no discharge from the nose in the early stage of the disease.
The patient frequently attempts, however, to dislodge a wp
.1 accumulation of secretion by blowing the nose. The
orifices of the nose may become very red, excoriated and tender
to the touch during the stage of exudation. The ocular and
palpebral conjunctiva may become red and the lids slightly
swollen. In the second stage or stage of exudation, a thick
whitish secretion is present, which is with difficulty blown
from the nose. A profuse quantity of thick, yellowish, stringy
mucus is discharged from the nose during the third stage of
the disease. There is a like secretion in the vault of the
pharynx, especially upon awakening. The patient may com-
1 of a slight cough, dryness of throat and mouth breathing
at night. Eczema to id dermatitis is frequently associated with
the disrate anil is often due to uric acid, a primary cause of the
continued inflammation of the mucous membrane.
Diagnosis. — With the enumeration of the foregoing symp-
I
JIO
DISEASES OF EAR, NOSB AND THROAT.
toms, the diagnosis of acute rhinitis is comparatively easy. In-
spectioo of the mucous membrane is not always . to |
COITOCt diagnosis
Prognosis. — In uncomplicated cases, the disease runs it*
COUXse in from a week to ten days, ending in complete re
or in an accentuation of an already existing chronic nasal
catarrh.
Treatment. — The treatment resolves into curative and
prophylactic The curative treatment consists in the applica-
tion of those agencies indicated for aborting the attack and the
relief of the engorged mucous membrane. If seen in the con-
ception of the trouble, the local application every two hours •
adrenalin chlorid to the mucous membrane, with the internal
administration of suprarenal gland, five grains every three
hours and ten grains of Dover's powders at bed time, with hot
foot bath, may, if not entirely aborting the attack, so mitigate
it that subsequent treatment is made comparatively simple. A
mild purge is usually indicated in the beginning of the disease.
Large quantities <>f distilled water or Apollinaris water should
be consumed for the relief of the uric acid condition, which is
frequently present. When the patient can be confined tC- the
house, a turkish bath given once a day. restores normal
librium and therefore is a great curative agent. This measure
is seldom in the reach of the Ordinary patient, and in conse-
quence is of little practical value.
The iiil lowing is highly recommended:
R Ext. belladonna,
Herein,
i .iniphcirr,
Quinine^
< lacarin,
•008 gin- (gr. 14)
•003 gro. (gr. 5\,)
•01 gm. (v
erf, gin. 'gr- i)
.004 gm (gi
Sign*. One capsule every hour for four nr five doac*, and after-
ward one capsule even '''ire boura
Two to four per cent, solution of cocain relievos the en-
gorged condition of the blood-vessels much better than adrena-
lin and aids in restoring the weakened valla. A prescription
DISBASES «)!■ THE NOSE.
calling for cocain should never be given a patient. If it eg
thought advisable to give a solution of cocain to the patient for
home treatment, the physician himself should supply the patient
with the solution. The following may be given for home
t reatment :
K
M.
I nr;i in ll \ ll I I M"ll .,
Witch hazel.
Sat. sol. icld boradd, q< s. ad.
•24 g«>». (gr. iv)
8.00 c.c. (5 ii)
30.00 c.c. (.1 i|
na. To be MiufFed into ll>c nose from a saturated rollon-tippo!
probe tinv iimi hour*.
During the second and third stages, the office treatment
consists in first spraying the m>sc with a uarm, one per cent,
solution of cocain. After the mucous membrane has become
depleted and shrunken, the nose, naso-pharynx and pharynx
should be thoroughly cleansed bj spraying with a warm anti-
septic, alkaline solution. Following the cleansing of the nose,
a solution of sulphate of zinc, two grants to the ounce, in a
solution of sulphate of silver, one-half grain to the nunre,
should be sprayed intn the nose and naso-pharyngcal spaces.
TJw mucous membrane should then be thoroughly sprayed with
a two per cent, solution of campho-menthol in albolene or accto-
form inhalent.
In addition to the constitutional treatment, a warm alkaline
atld antiseptic solution should be used for home treatment, as
a spnn 01 douche before each meal.
The patient may go out of door* provided the Weather is
damp. A general tonic is frequently Indicated. Enlarged
glands at the angle of the jaw:- m;n accompany and follow
an attack of acute rhinitis.
The prophylactic treatment consists in the careful correc-
tion of any constitutional dyscrasia or gastrointestinal disorder.
Any chronic, nasal catarrh, which is frequently present, should
receive proper attention, personal hygiene should be insisted
upon, cold tub baths upon arising or cold sponge baths are
especially efficacious in stimulating the mucous membranes of
I
3"
DISEASES OF EAR, NOSE AND THROAT.
the body and rendering them resistant to irritants. Nasal
obstructions, post-nasal adenoids and enlarged tonsils or small
tonsils containing cheesy deposits should be removed.
Simple Chronic Rhinitis. — Simple chronic rhinitis is a
chronic inflammation of the entire structure of the mucous
membrane of the nose resulting directly from successive attacks
of acute inflammation of the mucosa.
Etiology. — The disease is more often produced by successive
attacks of acute rhinitis. A lowering of the vitality of the
mucous membrane of the nose may result from age, occupation,
general disease, uric acid diathesis and exposure to unhygienic
surroundings.
Pathology. — The inflammation involves the entire structure
of the mucous membrane. The mucous membrane proper
becomes inflamed and thickened. There is an increase of con-
nective tissue elements and frequently a lessened blood supply
with dilation of blood-vessel wails. There is an abundance of
mucous secretion which is found mixed with desquamative
epithelial cells and leucocytes. The disease is essential ly one
of adult life.
Symptomatology. — The patient complains of a susceptibility
tQ catch cold and more or less stenosis of the nose with a
lenecrtttioil of mucus. The nasal mucosa may become en-
gorged from the slightest irritation, causing sneezing and pro-
lific secretion of mucus. Impetigo and eczematoid dermatitis
frequently accompany the disease. According to Kiesselbach.
chronic rhinitis is one of the frequent causes of eczema of the
nares.
Diagnosis. — Chronic nasal catarrh is observed in adult life.
The mucous membrane over the turbinated bodies appears pale
and somewhat thickened. A thick, grayish, mucopurulent
exudation is observed along the floor of the nose. A chronic
naso-phary [igitis is usually present. The patient's voice becomes
husky upon prolonged use.
Hypertrophic nasal catarrh is differentiated ! ironic
nasal catarrh by the thickened, reddened and boggy condition
of rhc lower turbinate.
DISEASES OF THE NOSE.
3*3
Treatment. — The general treatment is directed, as far as
possible, to the correction of any of the enumerated predisposing
BCS of the disease, thus enabling the vaso-motor system to
regain its normal equilibrium. Some alkaline and antiseptic
solution is recommended for thoroughly cleansing the nose of
ictions. The patient should be given Dobell's solution with
the instructions to use twice daily in Burmingham douche or
spray, preferably before meals.
The office treatment consists in applying Dobell's solution
as a cleansing fluid once daily, followed by the application of
some astringent in varied strength as the symptoms seem to
indicate. The following formula? may be used:
R- Zinci sulpli.,
Glyccrini,
Aquae <le»till.,
R Zinci phenolsulphonafc,
< . Ivccrini,
Aquae dcstill.,
.06 gra. (gr. j)
x.oo c.c (gtt. xv)
30.UO c.c. (5 j)
.06 gm. (gr. i)
1.00 c.c. (gtt- xv )
30.CX) cc (5 i)
This is followed by spray of two per cent, campho-menthol
in albolene. Massage is highly recommended by Braun as a
stimulant to the mucous membrane and is especially efficacious.
is is again followed by an albolene spray. Should the
turbinated bodies fail to react to the treatment, surgical meas-
ures must be instituted (see Turbinotomy).
For the reduction of anterior hypertrophies in chronic nasal
:rh, there is no better method than the galvano-cautery.
In reduction bj this method, the nasal cavity of one side should
be anesthetized with a spray of a four per cent, solution of
cocafn. Following the shrinkage of the turbinate, a four per
cent, solution of coca in should be applied with a cotton-tipped
probe along the line of intended cauterization, After two or
minutes delay, the nasal mucosa is completely anesthetized
and the nasal cavity and post-nasal space cleansed of all debris
with an alkaline, antiseptic spray.
The cautery is tested and graduated to a cherry red. W«.U
.V4
DISEASES OF EAR, XOSE AND THROAT.
the nose speculum in position, the point of the cautci*
ricd to the site of the hypertrophy and the current turned on.
At the bediming of the burning, the point is pressed into the
mucous membrane and drawn gently forward, making an in-
cision on a line parallel w tth the long axis of flic turliu
The depth of the incision varies. It possible, the periosteum
of the bone should not be destroyed. A second application
should be made a week later rather than ovcr-cautcri/ation at
the first application. A slough is formed at the line ot cauter-
ization, which may he blown from the nose a:ur a few days.
As a rule, healing is very rapid and shrinkage <>t hypertrophic
tlSBUe is in proportion to the amount ot tissue destroyed.
Should the periosteum be damaged, more or less severe pain
results, which may continue for two or three days. Mild in-
flammatory reaction may also result, the patient complaining
of symptoms of acute coryza. Cauterization may excite a case
of latent grip into sudden activity.
The nasal cavity should be cleansed three or four times daily
with Dobeli's solution aiier cauterisation, until the wound
is completely healed. Infection is always a possibility I
::/ation anil u.ax r\:rm.| to the siniisrs or middle car.
Due care should be observed against injuring ".lie septum
in applying the cautery to the lower turbinate,
In the absence of the cautery, chromic acid fused upon 3
probe may be used as a substitute. The pain from chromic
anil cauterization is frequently very great.
Posterior hypertrophies should be removed with a cold
or scissors. Hypertrophies of the mucosa of the middle tur-
binate should also be removed with a snare. Following cleans-
ing, the nasal cavity should he dusted with equal parts of ar
and stearate of zinc.
Hypertrophic Rhinitis. — Hypertrophic rhinitis is a chronic
inflammation of the mucosa of the nasal c a it) especially of the
lower turbinated hones, producing more or less stoppage of the
nose.
Etiology. — The disease may occur at any age. The cause
DISEASES OF THE NOSE.
3'5
of hypertrophic rhinitis is usually successive attacks of acute
coryza in which there has been an incomplete return to the
normal. Any local or constitutional irritation, sufficient to
keep the connective tissue of the submucosa distended for any
length of time will bring about the observed overgrowth of tis-
sue. Thus> digestive disturbances, climatic conditions, intem-
perance, sexual excesses, malformation uf the septum, chronic
rhinitis, catarrhal or purulent sinusitis and constitutional dys-
crasias are causative factors.
Pathology, — The entire mucous membrane becomes thick-
ened .'uid swollen from infiltration and increase of connective
tissue clement*. The blond supply is increased to the parts and
the cavernous tissue of the lower turbinates becomes distended
from the venous stasis, which is constantly present in a greater
or less degree. The hypertrophic condition frequently extends
to the lachrymal duct, producing chronic conjunctivitis and
epiphora. The mucous membrane of the Eustachian tube is
frequently involved, producing stenosis of the tube and middle-
ear catarrh. The bony structures of the lower and middle
turbinates tnaj also become hypertropbied from the increase of
osteoblasts, due to the cause producing the change in the
mucous memhrane. The racemose glands are increased in
number from which thick mucus and watery elements arc con-
-i.nitly poured out upon the surface, producing stringy mucus
and thick crusts from evaporation of watery constituents.
The hypertrophic change may be confined to the anterior
or posterior portion or the whole of the lower turbinated body.
A prolonged hypertrophy may change into a hyperplastic or
sclerotic condition.
iptorrntotofy. — The prominent subjective symptoms are
stoppage of one or both sides of the nose, sneezing, constant
blowing of the nose, loss of resonance of the voice and profuse
: -non of sero-mucus. The watery constituents often evap-
orate and leave a thick, tenacious exudation over the surface of
the nasal mucosa and post-nasal space. Olfaction may become
impaired. Objectively, the lower and middle turbinated bodies
3i6
DISEASES OF EAR, NOSE AND THROAT.
are observed to be fearfully distended at their (Ulterior and
middle aspect, pressing against the septum sufficiently to prr-
vent seeing into the nasal fossa.
Nodular masses or irregular swelling of the mucosa Dfl
frequently detected at some portion of the mucosa of the lower
turbinate, and are soft and movable. The swollen miii
membrane perceptibly recedes on the application of cocain.
The color of the mucous surface varies in individuals from a
pale pink to a deep red. The posterior portion of the lour:
turbinates may be found bypertrophied. The latter condition
is sometimes observed when the anterior portion of the tur-
binates in approximately normal in size (see Fig. 27). On ac-
count of the very great blood supply of the posterior turbinates,
they are predisposed to a passive congestion and subsequent
hypertiophy.
Diagnosis. — Upon inspection, the mucous membrane of the
septum and lower turbinate appears reddish or giayish-icd in
color. The lower turbinate sometimes impinges on the septum
and floor of the nose, the point of contact being the anterior
or posterior portion of the turbinated bodies.
Hypertrophy may be differentiated from hyperplasia by the
spongy quality or softness of the mucous membrane and the
tendency to contract under cecain in the former condition.
whereas, in the later, or hyperplasia, the tissue recedes but little
under cocain and is much harder to the touch.
The middle turbinate is susceptible to various changes and
may be swollen and slightly paler than the lower turbinate.
The size and shape of the middle turbinate, which is frequently
seen touching the septum and twisted about at different angles,
vary. With the development of air spaces in the middle tur-
binated bone, complete closure of the nasal fossae may occur.
In rhe posterior hypertrophies, the rhinoscopic mirror may
-how swollen, grayish nodular masses partially filling the post-
Oasa] Spaces. Marked irregularities of the ■- ai f ilugr and bony
septum may be present.
The amount of secretion observed in the nose may vary
e amount ot
tion along the floor of th
bodies. The conjunctiva is more or less reddened and the
patient may complain of epiphora, which is due to hypertrophy
of the mucous membrane of the lachrymal duct, especially about
the nasal opening of the duct.
The ear symptoms arc referred to under Diseases of the
Middle Ear and Eustachian Tube.
Treatment. — Very few cases of hypertrophic rhinitis arc
amenable to simple treatment. Should the hypertrophy be of
a mild character, resort may be had to warm cleansing alkaline
spray, followed by a spray of zinc sulphate, three grains to an
OUno lt and this by camphd-menthol two per cent, in
albolene. By this method, the prolific discharge may fre-
quently be lessened. When the connective tissue deposits arc
the result of years of successive attacks of acute rhinitis, only
radical measures are of value and consist in the application of
chromic acid fused upon a probe, electric cautery, cold snare,
general surgical measures or electrolysis
D. Bradcn Kyle recommends making a V-shapcd incision
along the thickened turbinated hone, which portion is removed
by saw, scissors or sua re loop. A portion of the bone is then
removed by means of strong alligator jaw forceps. The tis-
are then approximated and held in position by splints of
>>n Delavin recommends passing a knife deep into the
Milmuicosa, severing the intercellular tissue with a sweeping
motion, The knife is then withdrawn without enlarging the
openings I he hemorrhage is profuse for a few seconds. Con-
don without reaction takes place and relief is frequently
permanent. Following the operative procedure, the nose should
rested with alkaline and astringent sprays until the abnor-
mal condition of the surface has passed away and the
charge I I- A persistent, chronic nasal discharge is
alw;r live ol involvement of the sinuses.
'!'nrbim(tt,m\\ — Tbtt operation is frequently indicated vft
DISEASES OF EAR, NOSE A\'D THROAT.
hypertrophy and hyperplasia m the turbinated bodies. The
term, turbinecromy. may he applied to the removal of either one
of the turbinated bodies. It must he understood, that, on
account of its anatomical position, it is nearly an impossibility
to completely remove the lower turbinated body. We pro-
pose to use the term " turbinectomy " in a more restricted sense
and apply it t" the removal of the lower or inferior turbinate
(for description of removal of the middle turbinate, see Dis-
eases of Ethmoid Cells).
Indication. — The turbinate bones may partially or completely
obstruct nasal respiration from exostosis or orer-growth of
bone tissue or cysts of the bony structure, independent oi mj
structural change in the mucosa. In addition m tin: hyper-
trophy of the bony Structure, Pi ■<• may have an hypertrophy 01
hyperplasia of the mucosa. The removal of the latter con-
dition, when hone hypertrophy is present, by one of the many
methods, such as snare, cautery, electric cutting instrument and
caustics, is contraindicated for the reason that sufficient breath-
ing space cannot be obtained.
Adhesion of the enlarged lower turbinate to the septum from
ulceration or attempt at palliative measures by some of the
methods enumerated above arc frequently encountered, DO
taring the radical operation.
From congenital or acquired influence, the vomn ma] curve
to the right or left sufficiently to press upon the postertoi por-
tion of the turbinated body. It is sometimes inadvisable t<»
try to remove such deformities, on account of the danger oi
perforating the vomer, and in consequence turbincctoim
indicated.
Malignant growths may be observed growing from the
turbinated bodies which require the radical operation of I
binectoiny or Ho Operation at all.
Many rbinologtsts Oppose the complete removal of the lower
turbinate, believing that the contiguous mucous membrane HBJ
under _'o an atrophic degeneration.
The patient sometimes complains of too much air em.
DISEASES or THB HOSE.
3'9
the nasal passages predisposing ro pharyngeal irritation on ac-
count of being insufficiently warmed and moistened.
Along the line of cicatrix, there is an absence of mucous
glands and therefore crusts may accumulate at this point,
greatly annoying the patient.
It is a question whether the advantages gained by the com-
plete removal of the lower turbinate is greater than those gained
by the partial removal of the body.
Dr. Dudley Reynolds, of Louisville, Kentucky, at a meeting
of the American Academy of Ophthalmology and Oto-Laryn-
gology, reported fifty CBSes showing the turbinates removed in
which no ill results had occurred. Some of the cases had been
under observation for as long a period as fifteen years.
There can he nn great immediate danger of hemorrhage in
turbinectomy or turbinotomy provided the patient is immedi-
ately placed in bed and the nose is frequently sprayed with iced
Dobell's solution one-third and adrenalin chlorid, one-three-
rhousandth. This should be continued at an interval of one
hour for twelve hours.
Method. — The face and vestibules of the nose should be
previousl] d with a hot solution of soap and water,
the itj and post-nasal space thoroughly cleansed with
POOK Dlild alkaline "ash, followed by an irrigation of warm
bichlorid solution, i 5,000,
Adrenalin rhl.uid 1 I.OOO should be applied to the tuisul
mucosa u ith a spray or a cotton-tipped probe. After complete
blanching of the mucous membrane, a five per cent, solution of
cocain should be thoroughly applied to the inferior and superior
portion of the turbinated body. Adhesions of the turbinate
body with the septum aire now broken up with a knife or scissors.
The bone can be quickly severed with a saw propelled by
hand or electric motor, placed beneath the turbinated body near
the articulation with the maxillary bone and directed upward
ami toward the septum of the nose.
The mucosa and connective tissue are cut through with a
strong pair of nasal scissors. The turbinate can afterward be
:.-"
DISEASES Of l:AK, N08E AND THROAT.
removed with a fixation forcep. 1 In- bone may be so large
sometimes as to require a little force in extracting.
Fie. 104.
Ilm.uu'5 Saw*.
Dr. Jackson, of Pittsburg, has devised strong nasal »
which may be used for cutting through the bony stru
There is necessarily more or less splitting of bone in the
use of scissors.
Fie 105.
Jacuob'i Tvmnw$.T* Saw
Following the removal oi tlic turbinated body, small spicula
of bone, shreds of banging mucous membrane and remnants of
adhesion uith tlic septum should be removed with a pair of
scissors.
Adrenalin chlorid is now applied to the surface of the nose
followed by irrigation of a cold solution of bichlorid of
mercury, 1/5,000. The patient is immediately put to
bed for twenty-tour hours. A solution of Dobell's in 1
nrngth of one to three, combined with adrenalin chlorid in
B strength of 1/3,000, should be sprayed ice-cold into the nose
every hall hour for twelve hours, after which the adrenalin
DISEASES OF THE NOSE.
321
chlorid may be suspended and Dobell's solution continued for
twelve hours.
Ice packs of gauze or cotton dipped in ice-water should be
kept upon the nor tor the first twelve hours. Following this
precaution against hemorrhage and infection, the nasal cavity
il dwtcd with a powder of aristol and stearate of zine in equal
parts, twice or three times daily until recovery is comple-te.
The patient may be allowed to go about the roum or ward
after twenty-four hours, but should be instructed to place a
small amount of cotton in the side of the nose operated upon,
in going out into the street, to filter the air and prevent, as far
as possible, any infection being carried to the exposed surface.
Turbinotomy. — By this operation is meant the partial re-
moval of one of the Turbinates or turbinated hodies.
Turbinotomy is indicated in anterior and posterior hyper-
phies an<i in hypertrophy or hyperplasia of the mucous mem-
brane where turhinectomy is contrain.licated. It is also indi-
cated for the removal of malignant growths of the turbinated
bodies, in hypertrophy of the middle turbinates which puss
unduly against the septum and interfere with the function of
the naso-fronral duct or anterior ethmoidal cells and in hyper-
trophies which are too great to try shrinkage by electro-cautery
or escharotics. The operation of turbinotomy or turhinectomy
is always indicated in hyperplasia with obstruction. In hyper-
plasia with little or no cavernous tissue, the cautery or
fscharotics is contrauidicated.
Adhesion which is frequently prone to occur with the septum
after turbinotomy may he prevented by using the hard-rubber
splint devised by Pvnchon.
preparation of the patient for turbinotomy is the same
as for turhinectomy.
For the surgical removal of hypertrophies or hyperplasia,
we may choose scissors, cold snare, biting forceps or electro-
cautery.
The small wire loop of the cold snare can usually be placed
about tlie over-growth, and by a quick, steady pull, the lissvw.
322
DISEASES OF EAR, NOSE AND THROAT.
is quickly removed. The cold snare is especially devised for
the removal of anterior hyperplasia of the middle turbinate,
taking precedence in this location over the hot -
snaring the tissue away, there is always the dangrr of
plete removal of the hypertrophy.
The electro-cautery may be used for the removal of the
anterior or posterior hypertrophies of the lower turbinates with
little or no bleeding. There is always danger in using the
cautery in that we may destroy too much tissue by over-heating
the cautery loop or the current may become interrupted from
some untoward accident which will cause the loop to adhere
to the tissue with so much force as to make its removal difficult
and very embarrassing to the operator.
Of the scissors applicable for this operation, those possessing
the greatest strength are advised. Small, weak, narrow-bladed
us-ors have but little place in nasal surgery.
Jackson's or Knight's scissors are especially recommended.
The nasal cavity is cleansed of all debris following turbin-
otomy. The patient should immediately be placed in bed, the
nasal cavity should be sprayed every hour with a solution of
Dobcll's and adrenalin chlorid 1/3,000. Precautions should be
taken to avoid hemorrhage and infection if the operation «$
performed in the office of the surgeon. Hemorrhage is a belt
nn'tre of nasal surgery, following more often if the patient i*
allowed to be other than perfectly quiet following the opera-
tion. Hemorrhage may not alone follow after the use of cut-
ting instruments, but may be very severe after using the electro-
cautery, frequently coming on a number of hours after the
operation.
It is very difficult to plug the posterior nares, consequently
the patient should be immediately put to brd in all opr-
upon the posterior turbinate. After removal of hypertmpliv
in the anterior nasal cavity, if it is necessary for the patient to
travel a long distance or hemorrhage is anticipated, a small
strip of gauze should be dipped in a two per cent, solution of
camphor and menthol and applied to the cut surface. Strips
DISEASES OK THE NOSE.
323
of antiseptic gauze sufficient to totally plug the anterior nares
should be gently packed over this. The gauze, with the ex-
ception of the small particle of gauze covering the wound, can
be removed the following day without hemorrhage or pain.
The remaining gauze qan usually be removed in forty-eight
hour-, without hemorrhage. Adrenalin chlorid can be pre-
viously applied to the wound, if we suspect hemorrhage. The
nasal cavity should be cleansed twice daily with a warm alkaline
solution until recovery is complete.
Atrophic Rhinitis. — Atrophic rhinitis is a condition of the
mtlCOUB membrane and turbinated bones characterized by
atrophic degeneration of the entire structural elements, often
extending into the pharynx.
Etiology and Pathology. — The etiology and pathology of
atrophic rhinitis is still a disputed question.
Bosworth maintains that atrophic rhinitis results from puru-
lent rhinitis in childhood, which produces suppuration of the
glands and subsequent destruction; Gruenwald, that the dis-
ease is permanently situated in the accessory sinuses; Boyer
and Woakes, that the disease is presumably of a neuropathic
origin; Colowa and Cordes, that the disease begins essentially
in the bnnc and extends to the mucosa of the turbinate. Atrophy
of the bone and absorption takes place from the presence of
osteoclasts. There is a reduction of the blood supply and
consequent lessening of the glandular secretions. The secre-
tion covering the turbinates is, to a great extent, made up of
idering leucocytes and because of the absence of mucus, odor-
producing bacteria find a suitable soil for propagation.
Among the predisposing causes of atrophy are congenital
malformation of the head and nasal passages, especially in flat
type of faces, spurs, deviation of the septum, exanthematous
diseases, syphilN and congenital dyscrasia.
Hajek discovered the bacillus fetidus OZOnae in the secretion
and believed it to be the cause of the disease, but by many the
presence of the bacillus is believed to be accidental.
Symptomatology. — The symptoms are conspicuous dilation
324
DISEASES OF EAR, NOSE AND THROAT.
of the nasal fossa* and partial or complete atrophy of the middle
and lower turbinated bones. Thick mtico-purulent slugs of
tenacious, ill -sine] ling pus may be observed on the lower and
post-nasal space. The characteristic fetor observed in such
cases is due to saprophytic infection. , Two forms of the dis-
ease are observed, those with and those without fetor.
Treatment. — The treatment may extend over many years
and is often very unsatisfactory. The surface is first < Icansed
of the thick tenacious mucus, which is more conspicuous in the
post-nasal space, with a warm alkaline fluid in the post-nasal
douche.
1J Sodii biboratia, i |1;-
Sodii bicarbonaiis, '
Sol. ■ntisepdcl | l.isfer),
Phenol,
ftqUK ilrslill.,
.60 gm. (gr. x)
J-7S ex-
.r.8 c.c. (m iij)
60.00 c.c (J ij)
Resort must be made to probe anil cotton to remove the
secretion when it resists the douche. Alter thorough cleanliness
is secured, it there be any localized pus infection, the surface
can be dusted with powdered ste&rate of sine to which is added
sixty grains of orthoform to the ounce. Brown, Bishop, Braun
and others report flattering results from massage. Douglas
recommends the application of a ten to twenty per cent, m
solution of ichthyol after the surface has been thoroughly
cleansed. Tampons of cotton saturated with ichthyol
ichthargon are allowed to remain in the nose for twenty min-
utes, sufficient time for absorption to take place. This is fol-
lowed by an oil spray. The treatment i> administered every
other day.
Dr. D'Onisio recommends radium. The nine should be
applied to the nasal cavity once weekly. M. Broeckaert rO 1
mends a small quantity of paraffin injected into the turt>">
mucosa. The amount injected vari. hoilU be sufficient
Kore the symmetry of thelowei turbinate.
As a spray to the atrophic mucous membrane, James E.
MSB WES Of Mil: NOSE.
325
Ncwcomb recommends a tablet containing mucin and bicar-
bonate of soda and one grain of menthol, one tablet to be dis-
solved in one-half ounce each of sterile water and sterile lime
water. A fresh solution should be made every two or three
"v p ,.omb reports very good results from the above; spray,
especially in the relief of the odor and dryness of the mucosa.
In involvement of the sinuses, they should be opened and
drained. Constitutional treatment varies necessarily upon the
cause producing the disease.
Fibrinous Rhinitis. — Fibrinous rhinitis is an acute in-
flammation of the mucous membrane of the nose more often
seen in children. It is of a pathogenic origin and is character'
teed by deposits of fibrinous material upon the mucous surface.
Etiology. — The disease may occur from direct infection from
the Klebs-Lofflcr bacillus, the streptococcus or the pneumo-
coccus and may follow cauterization of the turbinates and op-
erations on the septum or turbinated bodies.
Pathology. — As in croupous exudation in 1 lit- larynx or con-
junit:v;(. there is a whitened, glistening, tenacious exudation,
Composed of coagulated fibrin, thrown out upon the surface,
times filling the nose.
Symptomatology. — There may be a history of headache,
slight chills, rise of temperature, general systemic infection
and symptoms of acute coryza. However, the disease may
occur without the above preliminary symptoms other than
stenosis and exudation from the nose. The discharge is
fibrinous or muco purulent and copious in quantity. The dis-
end to the pharynx and tonsils. The area of in
volvemenr may be limited to the anterior nares or may extend
to the pharynx, tonsils and larynx. Taste and smell may be
absent!
Diagrtttsii. — The disease should not be confounded with
>r syphilitic rhinitis. It is best to isolate the pa-
tient, pending bacteriological diagnosis. Upon inspection of the
nose. :» thick grayish exudation is observed covering a part or
the whole of the mucous membrane, especially the respiratory
1
3*6
DISEASES OF EAR, NOSE AND THROAT.
region of the nose. The croupous character of the membrane
is easily demonstrated with a cotton-tipped probe. The lower
turbinated body may appear swollen, impinging upon the
septum. The membrane is removed with difficulty. If mixed
infection occurs, there may be severe hemorrhage from the
nose upon mechanical removal of the exudation. Atresia may
occur from ulceration, especially in individuals past the mid-
dle age.
Prognosis. — The prognosis is favorable regarding life. Ad-
hesions between the turbinates and septum sometimes occur,
irodudng partial atenOHS. The disease in adults runs its
COUTW in from a week to ten days and in infants from four or
five days to four or five weeks.
gtmmt. — The treatment consists in the internal admin-
istration of chlorid of iron in five to fifteen-drop doses. The
swollen turbinated bodies may be reduced by spraying with a
two per cent, solution of cocain followed by a warm alkaline
and antiseptic spray. The bleeding points should be touched
with a ten per cent, solution of nitrate of silver and the :.
dusted with equal parts of stearate of zinc and trypsin. A free
purgative is usually indicated in the beginning of the d
Dry heat should he applied over the nose, three times daily fof
one half hour. Tonics are usually indicated for a few weeks
after the symptoms of the disease have passed away.
Diphtheritic Rhinitis. — Diphtheritic inflammation i
acute inflammation of the mucous membrane of the nasal cavin,
independent of or accompanying faucial involvement ami
to infection from the Klebs-Loffler bacillus.
Etiology. — The causes are both predisposing and e*
Among the predisposing causes arc epidemics of diphtheria
u bjch occur among children between the ages of two and fifteen
years, unhygienic surroundings, lowering of the vitality and thr
acquired disposition of the mucous membrane to infection. I
exciting cause of diphtheria is the Klebs-Loffler bacillus and b
due to direct contagion. The organism may find lodgment
within the nasal cavity during the act of inspiration. The
DISEASES OF THE NOSE.
327
jisease frequently spreads from the ROM i<> die pli.irvn-c 01
from the pharynx to the nose.
Pathology.— The pathology' of nasal diphtheria varies in no
wise from that of pharyngeal diphtheria. There is a necrosis of
fibrinous exudation, which is thrown out upon the surface ex-
Fic. 106.
-
Fkckmah's I'ack Shield.
lending into the epithelium of the mucous membrane covering
the turbinated bodies anil septum. The disease may be localized
or diffused and not infrequently involves the accessory cavities.
There is 3 swelling of the lymphatics as in faucial diphtheria
and nn-ningifis, broncho-pneumonia and local palsies may fol-
low the disease. Pathological changes, the sequela; uf the dis-
ease, vary in no wise from that observed in faucial diphtheria.
Symptomatology. — The symptoms of the disease are a sten-
dJ the nose with a profuse, slightly fetid discharge from
the nose, creamy in color. There is a general debility, enlarged
cervical glands which are usually present though may be
absent, rapid pulse and slight elevation in temperature. The
disease is more often observed In children under seven or eight
32C DISEASES OF EAR, NOSE AND THRO AY.
years of age. The pseudo-membrane adheres to the mucous
surface and \ipon removal leaves bleeding points. The tem-
perature may rise as high as 1050 and is usually greater than
in the faucial form. The Klebs-Loffler bacillus is always p
ent. Albuminuria may also be present. Local palsies BMff
follow as in faucial diphtheria.
Diagnosis. — As a rule, the child first complains of a stoppage
wt \\w DOM and a more or less thickened white nr ycllowbh-
wliitc irritating discharge from the nose. There is slight ele-
vation of temperature with general systemic infection.
Prognosis. — A guarded prognosis should be given for fear of
extension to the larynx and severe general infection.
Treatment. — The local treatment consists in irrigating with
a warm Dobell's solution, followed by dusting with trypsin.
Antitoxin, i/s.fxxi c.c, should be injected, followed by the
administration of chlnrid of iron in fifteen drop doses four
rimes ,].i,[... Purgation should he encouraged by the hourly
administration of calomel in one-tenth grain doses. The pat M
should he isolated.
Specific Rhinitis. — Specific rhinitis is a local manifestatic
of syphilis and may be congenital or acquired.
Congenital Syphilis oj the Nose. — In the congenital
form of the disease, we have the secondary and tertiary mani-
festations. As a rule, a syphilitic mother or father will beaet
syphilitic children. The period of least liability to transmit the
■ lipase is the tertiary stage. It frequently occurs that stroiv.:
and apparently healthy children are born of a father or mOI
Buffering from syphilis.
Colles's law is, that an infant with inherited syphilis will not
infect its mother but will infect its wet-nurse.
L. D. Buckley reports having seen a grandmother with a
chancre within the nostrils followed by the most severe syphilis
h prolonged brain symptoms, who had received the infection
from a syphilitii grandchild, who had died of the diseav.
Symptomatology. — The disease more frequently manifests
lUeli in flic fbrofl of an acute con e* with rwomtions about the
of ult eratniii and necrosis before coming under the observation
of the rhinologtst. The variety of ulcerative conditions pre-
sented are equal to the possibilities. The septum may alone be
destroyed, the vomer, the nasal bones and external nose pro-
ducing a complete collapse of the nose. The illustration (Fig.
107) shows a complete destruction of the columnar cartilage
and septum of the nose. In this case there was partial necrosis
<>| the VOtner. The nasal bones were normal and in consequence
there was no external deformity other than the destruction of
the columnar cartilage and the skin covering the same.
The disease is rapid in its course and shows no tendency
to early recovery. As a further aid to diagnosis, the Justus
hemoglobin test may be made, which consists \n first making
tnoglobiii estimation, followed by an inunction of mercury.
After twenty-four hours, .1 second hemoglobin test is made and
if there is a ten to twenty per cent, reduction of hemoglobin,
syphilis can be expected.
Course and Prognosis. — As a rule, the prognosis is favorable
if thi LI IfestS itself a number of weeks after birth, is
[etected and the child is well nourished. In well-
advanced cases with profound cachexia and anemia, the prog-
1 ni favorable.
Treatment. — The constitutional treatment in the beginning
■ is inunctions of mercury. In the application of
ointment, 20-40 grains of an equal part of mercurial ointment
and lanolin should be rubbed into the skin once daily, beginning
at the inner surface of the right arm, right leg, left arm, left
leg, chest, and abdomen. This form of treatment should he
continued until slight symptoms of salivation are manifest.
Mercury by the mouth usually produces griping and intestinal
1 iers.
Benjamin Brodfe recommends for a child, spreading mercurial
ointment made, in the proportion of one drachm to an ounce of
lanolin over a flannel roller and binding it around the child once
a day. This treatment, according to Hrodie, cures the disease.
Mercury may be given by the mouth. Mercury in the form of
33 2
DISEASES OF EAR, NOSE AND THROAT.
calomel may be given in one-tenth to one-half grain doses three
times daily when the inunction produces irritation. In well-
marked gummata or ulcerations, iodid of potassium in
solution may be combined with the mercury and continued for
a long time after all the symptoms of the disease hare passed
away. There is a syphilitic djKCrasn present in children of
f ic. too.
TrsTiAtr Svrnius of the N
syphilitic parents, which manifests itself in .» tCfldc I
coryza and a general weakness of the mucous membrane and
responds to small doses of mefCltrj and iodid of potassium.
The local treatment consists in cleansing the nasal cavity
with a warm alkaline and antiseptic solution. The I
which form in the nose and about the meatus may be softened
with albolcne. The parts may hr dusted with stearatc o
after cleansing the nasal i tvity. In ulceration i
ii is sometimes advantageous to frequentl) touch the ble
DISEASES OF THE NOSE.
333
surface with a solution of nitrate of stiver, twenty grains to
the ounce of water.
Acquired Syphilis of the Nose. — The primary lesion,
or hard chancre of the nose, is exceedingly rare. Bosworth
In two thousand, two hundred and forty-four cases
observed bj Basserean, Clerg, Lefort, Fournier and Ricard, the
lesion was found in the nose twice. The site of the lesion was
upon the cartilaginous septum. " The chancre of 'the nose
differs but little from the classical chancre.
I he secondary lesion, or mucous patch in the nose, like the
primary lesion, is infrequently found. The location of the
mucous patch is usually at the junction of the skin and the
mucous membrane. The secondary lesion should appear in from
three to six weeks following infection and observable for as
long a period as three years. Superficial abscess of the mucous
membrane may appear at this period of the abscess and in
general appearance is not unlike a diphtheritic patch. Ulcera-
tion may involve both the septum and the turbinated bodies.
Acute anil chronic rhinitis is n frequent complication of secon-
dary syphilis.
Symptomatology. — The symptoms of secondary ulceration
are difficult breathing in one or both sides and a slight watery
and sometimes offensive discharge from the nose.
Diagnosis. — The diagnosis of ulceration without a history of
-yphilis or preliminary administration of the iodids. is very
difficult. Upon inspection, the lower turbinate body is usually
i to be swollen and edematous. A necrotic membrane is
found covering the surface of the ulceration, which causes
bleeding upon being disturbed. The turbinate and septum may
he found agglutinated with the necrotic and granular mass.
When the turbinate and septum are separated with a probe.
bleeding OCCUft. The turbinates are thick and edematous and
contract but dightly under cocain.
Trealmtnt. — The treatment of the secondary lesion is di-
rected to the relief of the constitutional infection by inunctions
of mercury for ten days, followed by proto-iodids of mercury
334
DISEASES OF EAR, NOSE AND THROAT.
one-half to two and one-half grains per day and small doses of
iodid of potassium.
The local treatment consists in breaking up the adhesions
between the septum and the turbinate, cleansing in fifty per cent,
pcroxid of hydrogen once daily, irrigating twice daily
Dobell's solution followed by insufflation of stearatc of zinc.
Tertiary Syphilis. — The tertiary lesions of syphilis of the
nose are," according to Morrow, " gummata, diffuse infiltra-
tion, deep ulceration and fibroid degeneration."
The GUMMA tumor is the first evidence of tertiary lesion.
The site of the gumma is more often in the septum and floor of
the nose. Gumma may be found in the turbinated bodies
posterior nares. The mucous membrane, bone, bony septum,
periosteum or cartilage may be the primary site of the lesion.
Syphilis of the nose manifests a predilection for the cartihi^ n
structures. Ulceration and perforation of the bony septum nm
take place without involvement of the cartilaginous septum.
The ethmoid cells are probably next in frequency of invasion.
Symptomatology of Gummata. — The symptoms of gummata
are indistinct and ill-defined. There is usually nasal obstruction
in one or both sides of the nose and pain of a deep and boring
character. The symptoms of ulceration are bloody discharge
from the nose, accumulation of thick crusts, ozena, foul-smelling
pus in extreme cases, alteration of the voice, and sometimes de-
formity of the no*e. The intcrnasa) form of the disease is
extremely insidious and frequently great destruction of tissue
results before the symptoms arc sufficient to cause the patient
to seek for relief.
Diagnosis of Gummata. — A gumma should be differentiated
from deflected septum, malignant and non-malignant tumors,
chondroma or enchondroma. The tumor is round, and in the
early stages, hard to the touch. The mucous membrane cover-
ing the tumor is usually normal in appearance, dunging « irli
the growth of the tumor ro a pale color. As rhr tumor grows,
disintegration takrs place and is followed by softening and
suppuration.
diseases or Till- NOSE.
335
In the case illustrated, a gumma evidently formed in the
nasal bone, producing necrosis and a fistula, which was closed
externally by surgical measures.
External gummata are frequently encountered and may bring
about destruction of the skin and lateral cartilage and often
extend to the hone, with destruction of the internal nose.
Deep ulceration with destruction of tissue results from
disintegration of the nodules. There is little or no pain in ex-
ternal ulceration. The disease is progressive. The surface is
covered with brownish crusts, formed by the drying mucus and
pus. Ulceration is in progress and pus forms in great quanti-
ties beneath the crusts.
Granulation tissue may spring from a gumma and com-
pletely fill die nasal cavity, and as the tumor bulges from the
nose, it resembles a malignant growth in genefal appearance.
The syphilitic cachexia accompanying this form of inflammation
is veil marked.
Fibroid degeneration of connective tissue, or hyperplasia,
in tertiary syphilis usually involves the turbinated bodies which
are enlarged, hard and whitened in appearance and are, accord-
ing to Morrow, distinct, pedunculated growths, resembling a
polypus.
The hard palate will frequently contain one or more necrotic
ulcers in syphilitic granulations. The granulation may involve
the sinuses, especially the ethmoid. The odor from the nose will
be more or less offensive.
Diagnosis of Tertiary Syphilis. — The diagnosis of tertiary
syphilis of the external nose is comparatively easy. The dis-
ease may rpsemble cancer or septic ulcer. A deep, indolent ulcer
of the external nose, which flues- not quickly respond to local
antiseptic measures, in the absence of a history of syphilis,
should be presumed to he syphilis and treated as such until
the diagnosis is established.
Perforations of the septum arc nor always pathognomonic
signs of syphilis. They may result from trauma, infection from
picking the nose, abscess, chemical irritation, infection from
!
33*
DISEASES OF EAR, NOSE AND THROAT.
diphtheria, small-pox, typhoid fever and tuberculosis. 1'cr:
lions of the septum consequent upon active syphilis are usually
covered, especially on the posterior half, with blood crusts
v. Inch are blown from the nose or detached by a probe, leav-
ing a bleeding surface.
As a rule, saddle nose is due to necrosis of the bony septum.
As long as the necrosis is confined solely to the cartilagin
septum, the nose retains approximately its normal contour, as
shown in figure 108.
The odor of necfoais of eke bone due to syphilis fa variable
•fid is frequently so offensive as to defeat in desctiptivi
the ordinary observer. The odor \g peeuiuurlj Offensive when
the sinuses arc involved and the residual air therein n COBB
pletely saturated with the stench of decomposition. Necrotic
bone in the nose may be detected with a cotton-tipped pr>>
Prognosis of Tertiary Syphilis. — The prognosis, as regards the
removal of gunmiata. is exceeding!) good. Fatty degeneration
and absorption may take place under antisyphQitlC uv.
When the disease has advanced to the stane of deep
tion and necrosis of bone the prognosis is usually unfav
As a rule, spicula of bone are thrown off and healing take*
place with a suspension of all symptoms. Deep ulcerations
without bone involvement heal in a few weeks with formation
of dense cicatricial tissue. As a rule, the odor disappear
the removal of all dead bone.
Treatment of Tertiary Syphilid— -Tin- treatment of gum-
mata and ulceration consists in the administration of the mixed
treatment.
R Kali iodiili,
Hydra rg. hichloridi,
Syr. sarxaparillx,
i. jo gm. (gr. xx)
.004 gn
3.75 c*. (3 j)
Signi. To be adminiistcrcd well diluted.
The iodids must be pushed until the disease responds to the
treatment. After cure of the local condition is accomplished,
we depend upon mercury in some form to eradicate the disease
from the system.
DISEASES OF THE NOSE.
337
The local treatment consists in the careful removal of all
crusts by irrigating twice daily with the following:
If. Sodii bicarbonati
Sodii biboratis,
Phenol,
Glycerin!,
Aqoa <lr>iill.,
'"}
.24 gm. (gr. iv)
.13 gm. (gr. ij)
1.00 c.c. (gr. xvi)
30.00 c.c. (.3 J )
Any necrotic tissue which cannot be removed by irrigation
should be removed by suitable forceps. The disagreeable odor
can be disposed of by irrigating with the following every three
hours:
Potatdl |>errnanganatis,
Ac. borici,
A nunc lepicte,
i-: Hm- <Kr- 'i )
1.20 gm. < er. xx)
30.00 c.c. (3 j)
Alcohol in any form is to be tabooed, nutritious diet is essen-
tial, out-door exercise, frequent haths and warm woolen cloth-
ing are very necessary adjuncts to the building up of the system.
Nasal Hydrorrhea. — Nasal hydrorrhea is, according to
St. Clair Thompson, a profuse, watery discharge from the
nov m»us or remittent, without Ml] visible pathological
change in the nose or any apparent cause.
Etiology and Pathology. — The etiology and pathology is
somewhat obscure. The disease is probably due to some irrita-
tion of the trifacial nerve or vasomotor system, intrinsic or
insic, producing a serous cvnsmosis.
Diagnosis. — It is necessary in diagnosis, to differentiate nasal
hydrorrhea from leakage of cerehro-sptnal fluid.
CoeblTHiptna] fluid is of low specific gravity and may run
tain sugar, is clear and transparent and does not dry quickly.
Upon examination of the nose, there is no apparent ab-
normality or congestion. The patient complains of the sudden
and sometimes continuous watery discharge from the nose and
compares it to the flowing sugar tree. The disease resembles
the sensation that sometimes follows the filling of the frontal
338
DISEASES OF EAR, NOSE AND THROAT.
cells with salt water while in sea bathing, while after an hour
or so a clear fluid suddenly trickles from the nose. The in-
tensity of the disease varies from day to day and the <
frequently recurs at intervals of a few days.
Treatment, — The treatment is directed to the correction of
any dyscrasia that may he present. The nasal cavity should
be sprayed twice daily with Dobell's solution, followed by
syringing with nitrate of silver, one-half grain to the ounce,
followed by a spray of two per cent, camphor and menthol to
albolene. . The following tablet may be given three times daily,
between meals and at bed-time |
B
M.
Atropin uilpli.,
.0002 gm.
(«r. ,i„)
Strychnin sulph.,
.001 gm.
(«r. M
Morphin sulph.,
.003 gm.
(gr. M
For one capsule or tablet.
Ozena.' — Ozena is considered a symptom rather than a
disease, and is characterized by an offensive odor which take>
its origin within the nasal cavity.
Etiology. — The etiology of the condition is somewhat ob-
scure. Ozenic odor may be produced by necrosis, syphil
puration within the accessory cavities, atrophic rhinitis, malig-
nant disease, glanders and according to Abel, the bacillus
mucosus.
On account of the frequency with which the accessory nmM
are involved in infectious diseases of childhood Mich diseases
may be considered extremely important etiological factors in
ozena. The condition may be a tropho-ncurosis. produced by
the ptomains and toxins of microorganisms not yet differen-
tinrrd. The odor k believed by some to result from
of bacteria upon the secretion, and by others to Ih' a pi
chemical substance of the histological structures. Thciscn re-
ports in forty cases of ozena observed, fourteen patients had
pulmonary tuberculosis and believed the ozenic condition to be
a predisposing cause of tubercuh
'See Atrophic Rhinitiv
DISEASES OK THE NOSE.
339
Treatment. — The treatment varies according to the etiology
of the disease. If the affection is due to syphilis, constitutional
treatment and the removal of the necrotic bone within the
nasal cavity is indicated. If atrophic rhinitis is the cause of the
condition, submucous injection of paraffin to restore the normal
size of the lower turbinated bones is indicated, as recommended
by Fliess and others. According to Siziemsky, there is marked
similarity between the toxin of the bacillus of ozena and that
of diphtheria, and in consequence, he recommends injection of
diphtheria antitoxin. Sizfrnislcy's percentage of cases cured or
relieved bf this form of treatment is reported very large.
Where there is necrosis of the sinuses, which, according to
Gruenwald, Herd and Lohnherg, is more frequently the cause
of the disease, the radical operation for the curettement of the
sinuses, which will be outlined in diseases of the accessory
cavities, should be performed. The ozenic odors may first be
detected by the patient. A history of offensive odors from the
nose should be a clue for exploration of the ethmoidal and
sphenoidal sinuses.
Hanine recommends citric acid in full strength or with equal
parts of surai of milk tor the relief of the odor of ozena. The
treatment does not irritate and the effect lasts for a number
of days.
Glanders. — Glanders is an acute or chronic infectious dis-
ease, characterized by the formation of nodules and ulcers in the
mucous membrane or skin of the nose.
Etiohgf. — The disease is due to the presence of the bacillus
mallei. Among the lower animals in which the disease is found
are the horse, mule, ass, sheep, goat, rabbit and dog. The dis-
is more frequently contracted from horses and observed in
men who habitually come in contact with horses. The avenue
of infection may be through a scratch or break in the skin or
brane, from the virus being blown in the face by
the snorting of the horse or carried to the nose by infected
hands. 1 : e may be transmitted from man to man.
Pathoiegf. — Small ulcerations or nodules may form on the
34©
DISEASES OF EAR, NOSE AM) THROAT.
skin or mucous membrane or the juncture of the skin and mu-
cous membrane. The glanderous nodule forms a welt M
papule at the apex oi which a small pustule forms, which later
becomes inliltrartd with blood and may break down and form
an ulcer. The ulcerated condition may extend to the accessor)'
sinuses, pharynx, palate, larynx, middle car and cochlea.
Symptomatology. — The period of incubation is from " three
to eight days." According to Warren, there is " first a dryness
in the nasal mucous membrane, and almost always there is
hemorrhage. This is followed by tension about the root of the
nose and swelling of the mucous membrane. The discharge
is first scanty and is followed by a thick, tenacious, bloody
mucus, which later becomes dirty yellow in color and extremely
foul in odor. Pustules and ulcers may be seen upon the mucous
membrane and perforation of the septum may occur." The
pulse is rapid at first, gradually becoming slower as the gravity
of the disease increases. Coma or tetanic spa&XI may precede
death.
In the chronic form of the disease, there may be a slow-
process of destruction of bone, perforation of the septum, general
infection, mueo-purulent discharge from the nose and a wasting
■way of the body.
In the cutaneous form, ulcers may form, heal and reform.
The pustules fill with pus, subsequently break down and form
ulcere.
Diagnosis, — With a history pointing to infection from
horses, the symptoms as enumerated above and the discovery of
the presence of the bacillus mallei in the secretion, the diagnosis
is clear. The disease may be mistaken for syphilis or tuber-
culosis.
Prognosis. — The acute form of the disease usually termi-
nates fatally in from one to three weeks (Morrow). In the
chronic form of the disease, patients seldom recover, the dis-
ease producing death by a slow process of growth.
Treatment. — The treatment, though practically useless in
the majority of cases, consists in supportive measures together
DISEASES OF THE NOSE.
W
•Aitli antiseptic nose and throat douches and sprays (Lennox
Brown).
Lupus. — Lupus of the nose is essentially a tubercular infh.n
mation of the skin and mucous membrane, characterized by
the formation of minute reddish-brown nodules which may sub-
sequently suppurate and produce destruction of tissue and dense
cicatrix. Two well-known classifications are lupus erythema-
tosus and lupus vulgaris.
Lupus of the nose usually begins as a small macule, situated
in the skin covering the nose, due to tubercle bacillus. The
disease is usually slow in its course and may remain superficial
or extend deeper and involve the bony structure. The affection
may take its origin on the nose and spread to the cheek and
mouth.
Etiology. — The predisposing causes of the disease are the
predisposition to tuberculosis, lowered vitality and local irrita-
tion. The disease often begins in youth and manifests itself
in middle life. The disease may originate primarily in the
mucous membrane, but in the majority of cases involvement
of the mucous membrane is secondary to infection of the ex-
ternal nose. The exciting cause of this morbid condition is the
tubercle bacillus.
Symptomatology. — In the early stages of the disease, the
objective symptoms are the presence of reddish-brown nodules,
somewhat transparent, at the tip or ahc of the nose. The
tissue surrounding the nodules is brownish and discolored,
k, dry scabs are formed during the process of ulceration,
followed by the formation of deep scars. There is usually
a htttOf] of exacerbations of the disease.
The subjective symptoms in involvement of the mucous
membrane of the nose, arc nasal stenosis, slight pain and a sero-
mucous discharge. In involvement of the skin alone, the patient
may complain only of the formation of scabs
Should the disease advance to tin- destructive stage, as shown
in the illustration (Fig. no), there will be total nasal stenosis,
atresia of the mouth, inability to articulate distinctly and take
other than liquid food.
34a
DISEASES OF EAR, NOSE AM) THROAT.
Pathology. — The usual sice of the lesion is in the tip or al;c
of the nose. Lupus is observed to be at first reddish-brown
nodules, somewhat transparent and covered with true skin and
may be single or confluent. In seventy per cent, of cases of
lupus vulgaris treated in Copenhagen by Professor Finsen, the
mucous membranes were involved and not uncommonly, the
nasal mucous membrane was first involved. In structure the
Fi<;. i to.
Lupus op the Nose ani> Moith.
Cltr. arc lliirty live.
lies resemble a submiliary tubercle and contain granul
tissue, giant cells and leucoi
There is a tendency to ulceration, with involvement o:
treat ol surrounding tissue. Perforations of the septum are
sometimes observed. With the exacerbatiocM of the disease,
deep cicatricial tissue is formed. During the process of ulcera-
tion, the surface is covered wuli brownish scabs and the
becomes soft and granular.
Diagnosis. — The disease resembles syphilis and may even be
taken for rhino-scleroma. In the non-ulcerative form of lupus,
small brownish-red tubercular nodules are observed in the skin
or mucous membrane, which may disappear by a process of
absorption and desquamation of the epidermis with formation
of deep channels of cicatricial tissue. Upon detachment of the
brown crusts in the ulcerated form of the disease, there remains
■ soft . granular ulcer covered with mucus. Grasping the tissue
with a fixation forceps, the tissue forming the periphery and
base of the ulcer is found to be soft and is detached as a
granular mass. The sott tissue can be removed with but little
hemorrhage with a curette. The pain from curettement is very
severe. A history of prolonged nasal discharge should suggest
the possibility of lupus.
The disease is differentiated from syphilis by its failure to
respond to antisyphilitic treatment, from epithelioma by micro-
scopical examination.
Treatment. — The treatment is usually curettement in the
■uivc stages and the daily application of the X-ray to-
gether with the correction of any constitutional dyscrasia.
Plastic Operation may be resorted to for the correction of the
nasal deformity.
In the presence of the nodular variety, the X-ray offers the
speediest relief. In the absence of the X-ray, the nodules may
be scraped with the Volkmann spoon, followed by the application
of nitrate of silver in the solid stick. There is frequently a ten-
dency to spontaneous recovery with the formation of a cicatrix.
Compound s> rup of hypophosphate, syrup hydriatic acid or some
preparation of arsenic is usually indicated as a general tonic.
Rhino-Scleroma. — Rhino-scleroma is a chronic and pro-
gressive inflammation of the mucous membrane of the nose,
extending to the external nose, lips, etc., and characterized by
the formation of thick, nodular growths in the tissue.
'"gy. — According to WoJkowrtsch, Chiari, Cornil and
others, the disease is produced by the bacillus rhinn-sclernmatis.
The bacillui grows upon blood serum and is stained with
methyl-violet.
i
344
DISEASES OF EAR, NOSE AND THROAT.
The affection is observed in " eastern Austria and south-
western Russia. Isolated cases have been observed in Silesia.
Italy, Egypt, Belgium, Sweden, Switzerland and Central
America" (Ziegler). According to Dr. A. W. Bray ton, one
case has been observed by him is Indianapolis.
Pathology. — The disease is characterized by the formation of
nodular thickenings on the nose and sometimes on the pharynx
and larynx with ulceration of the mucous membrane. I
growth resembles syphilitic granulation or granulating
and is yellowish or grayish in color. Bacilli are found between
the cells. The infiltrated and ulcerated tissue may change into
dense scar tissue, producing deformity of the organs involved.
Symptomatology. — The symptoms vary with the growth of
the disease. There is little or no pain accompanying the dis-
ease. Nasal breathing may be interfered with as the growth
extends backward into the nasal cavity. In involvement of the
larynx, there is difficulty in swallowing and impaired respiration
from the dense cicatricial formations. In involvement of the
lachrymal duct there is epiphora and conjunctival irritation.
When the mouth is involved there is difficult speech and inter-
ference with ingestion of other than liquid food.
Diagnosis. — The disease is especially one of adult life and is
characterized by the formation of thick nodular masses in the
mucous membrane and skin. Microscopically, the disease re-
sembles a granuloma and between the cells are found the
bacillus, which resembles Friedlander's pneumocou
The disease should be differentiated from tuberculosis, syph-
ilis or epithelioma.
Treatment. — Salicylic acid locally and by the mouth in ten
grain doses is recommended by Lang. Operative treatment is
of little avail as the disease has a tendency to recur. In ob-
Btructioa of the larynx, operative meatuses may be necessary
to prevent total stenosis and death.
Tuberculosis of the Nose. — Tuberculosis of the nose is
characterized by the formation of neoplasms or ulceration of
the mucous membrane and often accompanies a general pulmonic
tuberculosis.
DISEASES OF THE NOSE.
345
Etiology. — The disease is due to local injury of the parts,
followed by infection from the tubercle bacilli from tubercular
foci in some other part of the body.
Pathology. — The disease is due to the presence of tubercle
bacilli, which produce a circumscribed ulceration, more often
on the septum or floor of the nose, or a hyperplasia of the mu-
cous membrane, which may be sessile or pedunculated and pale
gray or slightly yellowish in color. Miliary nodules may some-
times be seen surrounding the ulcerated form. Microscopically
a section of a tubercle neoplasm of the nose resembles the sub-
miliary tubercle.
Symptomatology. — In the ulcerated form there is an accumu-
lation of crusts which are blown from the nose. There may
be more or less stoppage of the nose, perforation of the septum
and nasal catarrh. In the neoplastic form, there is nasal ob-
struction and symptoms of hypertrophic catarrh.
Diagnosis. — With only a few exceptions, there is present a
general or pulmonary tuberculosis. Tubercular ulcers are
at irregular in outline, have a characteristic yellow sur-
face and are surrounded by apparently normal tissue. There
is DO deep necrosis of tissue and suppuration as in syphilitic
ulcer or the ordinary infective ulcer. There is a tendency to
bleed upon irritation with a probe. In the neoplastic form,
small papillomatous growths may be seen attached to the sep-
tum, floor of the nose and turbinated bodies, and upon micro-
scopical examination are found to contain tubercle bacilli. The
location of the ulcer is reported to be more often observed in
the order of their frequency upon the septum, the lower tur-
binate and the middle turbinate.
Prognosis. — On account of the general infection, the prog-
nosis in regard to cure is unfavorable. Deformity following
the disease is comparatively slight, and in consequence, the
removal of the neoplasm and local treatment are favorable for
the amelioration of the local irritation.
Treatment. — In the necrotic form of the disease the nose
should be sprayed twice daily with a mild alkaline spray, fol-
lowed by an oil spray containing acctozonc.
346
DISEASES OF FAR. NOSE AND THROAT.
Small pupt'Ila-lik'c growths may be destroyed with the gal-
\:iiiu -cautery or removed with snare and It is acl-
visable to refrain as far as possible from surgical procedure in
the nasal cavity in a general Tuberculosis.
The general treatment is directed to combating the tuber-
cular infection by tonics, sunshine and out-door life.
Epistaxis, or Hemorrhage from the Nose. — Etiology. —
The causes of nasal hemorrhage are both predisposing and
exciting.
D'Astros considers hereditary syphilis, with or without ul-
cers, as the most frequent cause of hemorrhage of the nose in
children. Additional causes of epistaxis are ulceration of the
mucous membrane from syphilis, tuberculosis, and infection,
carcinoma, purpura hemorrhagica, purpura rheumaiiia. hemor-
rhagic diathesis, vicarious menstruation, plethoric habits, moun-
tain climbing, chronic anemia, cardiac hypertrophy, valvular
disease, Blight's disease, typhoid fever and malarial
Children at puberty frequently suffer from epistaxis. The
condition may also be produced by necrosis of the accessory
cavities, foreign bodies in the nose and the strain of uhoopin
cough.
Among the exciting causes are injury of the epithelium f:
picking the nose, blow, fracture of the nose or fracture of the
base. According to Phelps, in two hundred and eighty-six
tabulated cases, hemorrhage from the nOM OOCtimd in one-
fourth of all the cases of fracture of the base and especial 1> WM
there hemorrhage in fracture of the anterior fossa and l'
of the anterior middle fossa.
Symptomatology and Diagnosis. — Hemorrhage from the
nose may be so profuse and so prolonged as to produce exsan-
guiriation and syncope. The diagnosis of the exact 01
the hemorrhage is sometimes difficult The blood may some-
times be seen spurting from the artery in septal hemorrhage.
The nose should be sprayed or mopped with a four per cent.
solution of cocain. followed by i '1.000 adrenalin s<
Blood clots should be removed by blowing the nose. After free
ping
torn
DISEASES OF THE NOSE.
347
cxpnsurc of the nasal cavity, rhe site of the hemorrhage can be
located. Hemorrhage may be from the lachrymal canal, as re-
ported by Bookwalter, emptying itself into the inferior meatus
and slightly posterior to the anterior tip of the lower turbinate.
Hemorrhages from the anterior septum are easily located. The
site of a hemorrhage originating in the posterior portion of the
nose or accessory cavities is sometimes very difficult to locate.
Treatment. — Rest in bed and spraying the nose with adrena-
lin chlorid will, in the milder form, arrest hemorrhage. If the
hemorrhage is from the exposed vessel on the septum the vessel
should be lightly touched with chromic acid fused upon a probe.
Touching with the galvano-cautery will have a like effect.
When the hemorrhage is from the post nasal space, deep packing
with strips of hichlorid gauze soaked an albolene is indicated.
The nasal gauze packer may be used to advantage in packing
the cavity. Fluid extract of ergot fn twenty drop doses every
hour, with the patient sitting erect with head thrown back, will
arrest hemorrhage in mild forms of epistaxis, supplemented by
ice bags to the nape of the neck. The post-nasal space may be
plugged by means of the Hellocq cannula or soft catheter. The
plug itself should not be left in position longer than forty-
eight hours for fear of septic infection. The plug, which should
be made of sponge, cotton or lint, should be three-quarters of
an inch long and one-half inch wide for adults and should be
tbQfOUgMy sterilized before inserting. The catheter to which
8 strong aseptic string is attached, or the Bellocq cannula is
passed along the floor of the nose into the pharynx, when the
string from the cannula is brought forward through the mouth.
If the movable rod which contains an eyelet in the cannula of
Bellocq protruded into the mouth and can be threaded, the
plug, oiled with rarbol-vaselin, is drawn into position quickly
but not too forcibly, for fear of destroying the normal epi-
thelium. It should not be introduced too tightly for fear of
causing sloughing of the mucous membrane and necrosis of the
boile. \i hemorrhage occurs after removal of the plug, the
nares should be thoroughly cleansed before another is intro-
duced to obviate danger of sepsis (Bryant).
348
DISEASES OF EAR. N'OSK AND THROAT.
Rhinoliths. — Etiology. — The condition is due to a foreign
body finding lodgment and remaining in the nose for a long
time.
Pathology. — As the result of the presence of a foreign body.
the salts of the nasal secretion may collect about the foreign
body as a nucleus. The progress of growth i> nccOMTily very
slmv. The salts that go to make up rhinoliths are sodium
chlorid, calcium phosphate and carbonate, magnesium phos-
phate and organic substances.
In addition to the progressive nasal stenosis, there may be
pain in the nose and a profuse and sometimes offensive mm<>
purulent discharge from the anterior and posterior nares.
Ulceration of the hard palate or septum may occur from
pressure.
Diagnosis. — The nose is first sprayed with a four per cent.
solution of cocain and adrenalin chlorid, 1/5,000, followed by
cleansing with Dobell's solution.
Under good illumination, the calcareous deposit can be de-
tected with a cotton-tipped probe. The condition may be
confounded with necrosis of bone.
Treatment. — The treatment is essentially surgical and 9
directed to the mechanical removal of the foreign body. If
small, the calcareous formation may be removed under local
anesthesia, with a blunt hook or goose-neck forceps. Should
the size of the growth preclude its removal in toto, it should
be crushed with a lithotritc. The subsequent treatment is
directed to keeping the nose clean wirh an alkaline and anti-
septic solution. Ulcerations due to pressure should be touched
at intervals with a ten to twenty per cent, solution of nitrate
of silver and dusted with stearate of zinc.
Foreign Bodies. — Symptoms and Diagnosis. — Foreign bod-
ies may be placed in the nose by young children, insane and
hysterical individuals. The object may sometimes be dot.
in the anterior narrs. There is usually a history of acute sten-
osis and more or less watery discharge from the noie. If the
foreign body is of a character which swells from absorption
DISEASES OF THE NOSE. 349
of moisture, the patient complains of pain in the nose. An un-
detected foreign body in the nasal cavity, especially in young
children, may bring about spasms, cough or purulent sinusitis.
Treatment. — Under good illumination and with a Bosworth
nasal forceps, the foreign body, if situated anteriorly, can usu-
ally be extracted with but little pain. If the foreign body is
situated in the attic or middle portion of the nose, the mu-
cosa should be anesthetized with a four per cent, solution of
cocain, which produces shrinkage of the mucosa and free ex-
posure of the nasal cavity. It is seldom necessary to resort to
chloroform or ether narcosis for the extraction of foreign bodies
from the nose.
CHAPTER XIX.
DISEASES OF THE NOSE (CONTINUED).— NEUROSIS OF
THE NOSE AND NASAL FOSS2E.
Neurosis of the nose and nasal fosse are motor, sensory
and reflex.
Motor Neurosis. — Motor disturbances of the nose are in
frequent. The dilatatores nasi may, from syphilis and weak-
ness due to imperfect breathing due to the presence of a.:.
become partially or completely paralyzed, causing a sudden
collapse of the lateral membranous walls of the nose and inter-
ference with respiration. Twitching of the nose is due to
irritation of the peripheral nerves, especially branches of the
seventh nerve.
Sensory Neurosis. — Sensory disturbances are more often
anosmia, hyperosmia, parosmia, disturbances of ol taction, anes-
thesia, hyperesthesia and paresthesia.
Anosmia. — Anosmia is a condition of complete toss of smell
and may be congenital or acquired. The acquired form may-
be due to disease or injury of the olfactory nerve and may be
central or peripheral. The condition may be associated with
ia, meningitis, tabes, brain tumors and acute or chronic
rhinitis.
llvii.KosMiA. — Hyperosmia is an increased sensilvi
the olfactory nerve. Odors and the ability to detect the samr,
are intensified.
Parosmia. — Parosmia is a perversion of the sense of smell
and may be associated with local or systemu rlisturbani
sanity and hysteria and is classed as an aura of epll.
Disti riianli: of Olfaction. — This is a lessening of the
of smell and may he due to acute coryxa, in flam n
35°
DISEASES OF THE NOSE.
35 »
of the ethmoidal cells, systemic disturbances or operation within
the nasal cavity.
ANESTHESIA. — Anesthesia is due to some irritation, obstruc-
tion or paralysis of the trigeminal nerve. Tactile sense of the
skin and mucous membrane is lost. Irritation, when applied
to the mucous membrane of the nose, does not bring about
sneezing or allied reflex disturbances.
Hyperesthesia. — Hyperesthesia is an over-sensitiveness of
the branches of the trigeminal nerve and may be due to central
or peripheral irritations. It is sometimes a purely psychic con-
dition. The nasal mucosa is found to be over-sensitive to the
slightest irritation.
Paresthesia. — Paresthesia is due to a general neurosis.
The patient imagines the presence of foreign bodies and dis-
eased areas of the nose. Affections of the nasal cavity may
exist. The source of the irritation, however, is placed in some
other portion of the nose.
Reflex Neurosis. — RchVv neUTOOCS arc irritations of the
skin and mucous membrane of the nose, producing local and
general disturbances* The three principal reflex neuroses are
Zttlg and asthma.
Nasal cough is frequently observed in young children and
adults who" have acute or chronic thickening of the nasal
mucos i.
'.rdiu« to Mathcson. stammering is due to diseases of the
nasal cavity, in most cases in early life.
Whether or not hay fever is porch a neurosis of nasal origin,
is yet to be determined.
ii reports a case of epilepsy, which was greatly re-
lieved if not entirely cured by the removal of a large exo |
of the septum.
Hay Fever. — Etiology. — The cause of hay fever is both
predisposing and exciting. The important predisposing cause
of hay fever is idiosyncrasy, which is probably accentuated by
ma I formation of the nose, uric acid diathesis, heredity, climatic
conditions, social environments, enlarged turbinate*, inflection
352
DISEASES OP EAR, NOSE AND THROAT.
of the septum, spurs on the septum and sensitive areas of the
mucosa.
According ro Clias. P. Grayson. " Whatever \vc term this —
lithemia, or the gouty or uric acid diathesis — is immaterial,
the essential 1 that through intestinal toxemia or some
disturbance of normal metabolism, there results a persistent
poisoning of the blood current. At the very moment that con-
tamination of the blood occurs, there is inaugurated an increas-
ing irritation and- a steadily diminishing stability of the rrflcx
nervous centers. The vaso-motor centers arc early affected
and when their loss of equilibrium is perhaps added to a
long precedent nasal lesion that has rendered the pituitary
mucous membrane particularly intolerant to any form of fa
Ution, we have but to wait the floating of some variety of
pollen into the nostrils to witness the speedy evolution of
this disease."
The exciting cause is the pollen of the rag weed and the
goldrnrod, which is found floating in the atmosphere about the
middle of August. This acts as an irritant to the mucosa upon
being inhaled and brings about a condition known as hay fens.
Pathology. — The exact pathology of the disease is still un-
determined. Since Hack proclaimed his theory of nasal reflexes
numerous investigators have come to believe thoroughly in the
neurotic origin of hay fever. The theory of John NT. McKr
is that the disease is a vaso-motor paresis due to some peripheral
irritation. According to Shurley. recurrence of h; ■■
leads to hyperplasia of the turbinated bodies and other portions
■ ■I the lining membrane ol the nasal and tsjui
tutes the effect as well as the cause of the disease.
Sneezing is purely a reflex neurosis, produced by some irrita-
tion upon the anterior sensitive areas of the mucosa.
Symptomatology. — The disease makes its appearance about
the middle of August and in the beginning is characterized bj
symptoms resembling an attack oi acute coryza. The patient
suffers from periodical attacks of sneezing, of the
mucous membrane of the nose, stenosis, prolific mucous discharge
DISEASES OF THE NOSE.
353
from the nose, sometimes photophobia and lachrymation. The
patient frequently suffers from headache, constipation and slight
elevation of temperature. The disease is frequently complicated
With asthma. The disease continues until frost, which occurs
about the middle of September and in northern climates much
earlier. Upon examination, the nasal mucosa during an att.uk
is seen to be very edematous, whitish and covered with clear
glistening mucus. The lower turhinates are frequently hyper-
trophied and impinge upon the septum. During the intervals
of the attack the condition of the mucous membrane of the nose
varies from that observed in chronic hypertrophic catarrh, to
that resembling hyperplasia or sclerosis.
Diagnosis. — The diagnosis of hay fever is comparatively
easy. Rose cold resembles hay fever and is a hyperesthesia of
the mucosa, occurring in the month of June, the exciting canst
of which is odor or dust of roses.
Treatment. — The treatment is both local and constitutional.
The constitutional treatment should be directed to the cor-
rection of irregularities in the habits of the patient, such a-
indiscretions in diet, alcoholic, narcotic and sexual indulgences.
According to the investigations of D. Braden Kyle, local
irritations are due to chronic changes in the constituents of
secretion from the mucous glands and in many cases he found
sulpho-cyanids and ammonium salts in the nasal secretion.
Kyle reports that by rapidly changing the character of the
secretions, either from an acid to an alkaline or from an alkaline
to an acid, neutralizing the secretions, he was enabled to relieve
eighty or ninety per cent, of all the cases treated.
Professor Dunbar, of Hamburg, believes the disease to be
due to a specific poison found in the pollens of rye. barley,
wheat, and other granous substances and with this in mind,
has given to the profession an antitoxin which is presumed
not onlj to Immunise the patient against pollen toxins, but will
palliate the symptoms of the ilisease during its cycle of activity.
The method of immunization consists in using the serum
Wtttbxifl or powdered pollantin after the directions of Professor
34
354
DISEASES OF EAR, NOSE AND THROAT.
Dunbar. The serum antitoxin is obtained by the inoculation
of horses with the toxin obtained from the albumcnoid body
found in the starch particles of pollen granules ami the scrum
from the horse is dispensed in small phials provided with a
dropping pipette. The directions for its use are as follows:
" Bring, by means of the pipette, one drop to the outer angle
of the eye, and, drawing down the lower lid with the finger,
allow the drop to come in contact with the mucous membrane.
A pleasantly cool sensation felt in the eye shows that the
instillation has been properly carried our.
" With the head bent sfmicwhat backward, insert the point
of the pipette about half an inch into each nostril and express
one or two drops of pollantin into each. Care must be taken
to keep the pipette squeezed as long as it is in the nose, other-
wise the pollantin will be drawn back into the pipette again.
After pollantin has been introduced into one nostril, the other
must be krpt dosed, while the serum is sniffed up from the one
treated, tapping the while on the Outside of the nostril, with
rise finger."
The directions for the use of powdered pollantin arc as
fallow •-:
" Fill about one-fourth of the little scoop inserted into the
cork of the serum-containing rube with the powdered pollantin.
Holding this under one nostril sniff the powder up, keeping
the other nostril closed. The powder will l>e better distrili
uted over the interior of the nose it. while sniffing, the our
of the nostril treated he lightly tapped.
" Those patients who wish to use powdered pollantin for thr
Treatment of the eyes should dip the arenmpanving camel -I,
b into the powder and brush it alonj tin oner rurfaci
the lower •-,< lid prei iou Ij drav
The general direction? foi thi use of the pot erum
" Hay fever patients ought to sleep with closed windows
daring the lurj fever sea
" Pollantin should be used, both for eyes and nose, regularly
DISEASES OF THE NOSE.
355
every morning, a few minutes before rising. Should it cause
sneezing or reddening of the mucous membrane of the eye, the
preparation should be again used after a lapse of one or two
minutes, and if the sneezing or the reddening of the eye does
not then disappear the instillation should be repeated a third
or even a fourth time.
liv this morning-rrcatm<-nt the patient will generally find
himself insensitive to the hay fever poison for several hours,
often, indeed, for the whole da\ .
" Those patients who are unable to keep themselves com-
pletely free from attacks — even when they begin the serum
treatment before the commencement of the hay fever season,
always sleep with windows closed, and regularly carry out the
above described morning-treatment — are recommended to carry
pollantin always about them. They should use the scrum dur-
ing the rnursc of the day whenever there is the slightest sign
of irritation, and not wait until a sharp nasal attack sets in,
when the nose becomes so swollen and blocked that pollantin
cannot be efficiently applied, nor probably absorbed from the
altered mucous membrane.
" If the use of pollantin at the correct time, as described,
has been neglected, the scrum may sometimes still be used with
benefit in the early stages of the attack, stopping the burning
in the eves, the excessive flow of tears and sneezing. Should,
In m ever, the hay fever poison have entered the body in such
amounts that the eyes have become strongly inflamed and the
H06C swollen and blocked with secretion, or that asthma have
appeared, then the patient should retire to rooms with doom
and windows closed, and remain there until all these symptoms
have disappeared. By using instillations of pollantin, at first
every ten minutes, and later at longer intervals, this process
can be accelerated. When the patient's condition is once more
restored to the normal he should endeavor to prevent any fur-
ther attack by the careful use of the serum as above described."
In addition, the general local treatment is directed to over-
coming the idiosyncrasies of the disease and special attention Is
356
DISBASB3 OF EAR. NOSE AND THROAT.
directed to the intestinal canal and cmunctorics of the body.
Physical exercise is especially indicated. When uric acid
anemia exists, Bishop recommends carbonate and citrate of
lithium, as well as a preparation of sodium and potassium of
magnesium, 10-15-20 grains of lithium is given in water
morning and evening. Five and ten grains of sodium and
potassium of magnesia arc tu be administered in the- samr » I « ■ - ■
The diet of the patient should consist of milk, fish, white
meats, bacon, cereals, vegetables, etc. Roast beef, coffee, tea,
alcoholic liquors, steaks and all those foods and drinks which
tend to increase the uric acid condition, should be dispensed
with.
The surgical treatment consists in the removal of any spurs
or hypertrophies of the middle or inferior turbinated bones and
the destruction with the calvano-cautcry of any sensitive areas
in the nose. Cauterization of the septum has been highly recom-
mended by a number of writers, followed by dusting the nasal
cavity and the antrum with aristol, through its natural opening
by means of a cannula, as recommended by Fink. The applies
tion is made daily, for three days, after which the arrack be
comes rapidly lessened in intensity.
Change of climate usually brings about the most MtUfflKt
and earliest alleviation of the distressing symptoms of the dis-
ease. Hay fever patients in the United States find speedy relief
from a sojourn in the White Mountains, northern Michigan
or an ocean voyage. The intensity of the disease varies some-
what according to the seasons. Patients who suffer from the
distressing nervous symptoms of the disease should resort to
climatic change before the disease has made its onset. Patients
frequently trust to Providence to relieve them of the harrow-
ing symptoms and in consequence of misplaced confidence, dis-
tressing nervous symptoms often manifest themselves, which
incapacitate the patient for active duties for a very long time
after all the symptoms of the disease have passed away.
Asthma. — Etiology. — The causes of asthma may be con-
genital or acquired, predisposing and exciting.
ory
DISEASES OF THE NOSE.
357
The underlying cause is probably a peculiar irritability of
the mucous membrane and constriction of the muscles of the
bronchi, associated with a like condition of the nervous system.
The disease has been observed in children as young as three
or four months and may be associated with enlarged tonsils
and adenoids. In young children, the disease is sometimes pro-
duced by indigestion and hysteria.
Asthma and hay fever are frequently closely allied and the
same cause may produce the two conditions. The asthmatic
attack may continue only during the course of the hay fever
and remain latent during the remainder of the year. In many
hay fever patients, asthma continues in a mild form during the
whole of the year and is accentuated by climatic conditions,
seasons, emotional excitement, pelvic diseases in women, nasal
irritation from polypi or hypertrophic nasal catarrh.
Pathology. — The pathology of the disease is somewhat ob-
scure. The mucous membrane of the bronchi is swollen and
covered with a mucous exudate. Upon post-mortem examina-
tion in uncomplicated asthma, nothing is discernible to indicate
the morphology of the disease. In chronic asthma the mucous
membrane may be hyperplastic or atrophic and when atrophic,
emphysema may complicate the disease.
Symptomatology. — The disease more often comes on during
the night and less frequently during the day. The symptoms
vary according to the severity of the disease and may come on
suddenly or be preceded by prodromal symptoms. There is
a sensation of restriction of the lungs and inability to breathe,
which ends in profound dyspnea. The patient sits up in bed
or rushes to the window for breath. There is intense nervous
depression, cyanosis, wheezing rales and cold extremities. The
spasm may last for a few minutes to a number of huurs.
Diagnosis. — There is seldom any difficulty in differentiating
From valvular heart disease. If due to irritation of the
Dose, under cocain anesthesia rhe symptoms will be distinctly
ameliorated. If polypi, nasal hypertrophies, sinus disc.
adenoids and hypertrophied tonsils are present, especially to
358
DISEASES OF EAR, NOSE AND THROAT.
children, one is justified in believing them to be contributing
causes. Only by <i process of exclusion can we differentiate
between nervous asthma and asthma from local or systemic
d ist u rbances.
Prognosis. — If due to adenoids or hypertrciphied tonsils in
children, a CUM or distinct relief of all symptoms, speedilj
results from operative measures. If the disease is brought under
treatment early and the predisposing cause is removed, the pa-
tient may go through life with only mild relapses of the dis-
ease. It the CftUtt is located and removed, recovery may be
complete. As a rule, the disease is chronic and susceptible to
frequent accentuations.
Treatment. — Hot applications to the chest and extremities
are indicated. Internally, tincture of lobelia, ten to thirty
inin., or extract grindclia robusta, two to ten min., may be
given.
The nasal cavity should be sprayed with a four per cent.
solution of cocain. In violent spasms, it is neCB give
chloroform, which may be inhaled, or morphia, hypodermatic
ally. Stramonium leaves mixed with saltpetre may be burned
in a plate and the fumes inhaled. lot! id of potassium combined
with bromid of potassium is highly efficacious during the attack
and in the interval of the disease.
Change of climate frequently brings about a quick ameliora-
tion of all the symptoms. If the disease is dependent upon hay
fever the symptoms may pass away with the relief of the nasal
irritation. Suspected irritation of the nose amenable to sur-
gical treatment, adenoids and hypertroph led tonsils, especially
in asthmatic children, should be removed. Gastro-intestinal and
pelvic disorders should be relieved.
According to Bullawa and Kaplan, Montefiore Home, adren-
alin chlorid hypodermatically in from six to ten drop doses
will relieve the asthmatic attacks in the majority of cases.
Smaller doses ma) be given and repeated in a short time if
necessary. In a feu rs maj come on after
the administration of adrenalin chlorid. The drug should be
given hypodermatically and not by the mouth.
CHAPTER XX.
DISEASES OF THE NOSE {CONTINUED).
Myxomata or Nasal Polypi. — Nasal polypi arc peduncu-
lated .in.l jelly-like masses usually springing from sonic localized
area ol necrosis LEI the bony structure of the nose. They may
be sinnlc or multiple in number.
Etiology., — The cause of nasal polypus is somewhat a matter
of dispute. The tun important factor! in the etiology of the
disease are extrinsic irritations or irritations applied to the
mucous membrane, and intrinsic irritation or irritation beneath
the epithelium.
Woakes believed the condition tu he due to a chronic nasal
catarrh with localized caries of bone from which might spring
layers oi connective tissue cells; this distending becomes the
enveloping membrane of the polypus.
The theory of a number of investigators is, that the polypi
are due to some previous inflammation of the mucous membrane
which results in a budding and subsequent infiltration with
n. a liquid like substance.
\lu. mis polypi more often spring from the region of the
middle turbinate (two-thirds, according to Zuckerkandl) and
at a point exposed CO the irritation produced from any fnllani
:i or suppuration in the frontal or ethmoidal cells. Irrita-
tion from chronic inflammation in the ethmoid region must be
id as the important factor in the causation of the disci-1
Pathology. — The condition is probablj one of edema and
Stretching of the mucous membrane from an accumulation
nt a gelatinous intercellular substance, containing mucin, a
substance freel] secreted In the mucous glands of the nose. The
are <•' a mucous polypus varies according to the localized
necrosis and blood stasis in and about the tumor and. www
359
360
DISEASES OF EAR, NOSE ANO THROAT.
contain fibrous connective tissue or broken-down epithelial
cells, debris and pus cells.
Polypi do not change into malignant tumors. Billroth,
however, discovered that a malignant tumor could spring from
a mucous gland of a polypus.
Symptomatology. — The patient complains of frequent attacks
of cold in the head, nasal shortness of breath, sneezing, drop-
pings in the throat, headache, otophonia, loss of smell and
general debility. One or both sides of the nose may be affected.
Polypi may be the exciting cause of frequent attacks of
sneezing, rhinitis, hay fever, bronchitis and asthma.
Malignant growths of the nose and accessory cavities may
be produced by irritation due to the presence of polypi. Fre-
quently malignant tumors of the nose accompany nasal polypi,
independent of the polypi.
Diagnosis. — The presence of polypi in the nose, especially
when located near the anterior middle turbinate, is compara-
tively easy. They appear as pale adenoidal bodies, covered at
times with thick mucus. Following cocaini/.atiou of the nasal
cavity, the tumor can be moved about and is observed to be
pedunculated. Polypi situated posteriorly and in the middle
meatus are sometimes very difficult to discover and are fre-
quently overlooked until the turbinate is removed. Small polypi
may so contract from the application of OQCfUfl as to escape
early detection.
The disease is more often observed in men than in women
and after adult life.
Treatment. — The treatment is essentially surgical and
sists in the complete extirpation of the tumor, and frequently
the removal of the middle turbinate anil 1 UTettemeot of the eth-
moid sinuses. I'm ■ ■ ■•, the Wright'*
snare (Fig. 110) is on< SO be manipulated •
freedom. The nasal cavity should Ik- sprayed with a five per
cent, solution of cocain, followed by the application of adren-
alin 1/5,000. The am 1 ihould be applied as far as
possible about the pedicle of the tumor with a cotton-tipped
MSBASB8 OF THE NOSE.
361
probe under good illumination. After anesthesia is complete,
the nose should be irrigated with a normal salt solution or
Dobell's solution.
The loop of the snare is passed about the tumor and pushed
to its attachment by a rocking motion of the hand. While the
loop is being passed into position, it should be gradually reduced
in size. In a very large polypus, it may be necessary to grasp
Fig. hi.
WtMBV'l Skabe.
the base of the growth u ith a hook or goose-neck forceps pre-
'. luusly passed through the wire loop. With its base in position,
the wire is pushed home. It is frequently impossible, on ac-
count of the hemorrhage, which may obscure the field, exhaust
the patient, etc., to remove all of the growth that may be in the
nose, at one sitting. Hemorrhage following the removal of a
polypus is, as a rule, inconsequential. Following the removal
of polypus, the nasal cavity should be irrigated with a warm
antiseptic and alkaline fluid and dusted with s tea rate of zinc
(sec method of removing the middle turbinate).
:otic areas of bone should be curetted. If there is present
a chronic, purulent ethmoid it is with necrosis of the walls, the
362
DISEASES OF EAR, NOSE AND THROAT.
sinuses should be opened and curetted. The nasal a
should be inspected a few weeks following the removal of all
polypi, for evidence of new growths.
Papilloma. — Papilloma is a wart-like growth springing
the skin or mucous membrane. Those springing from the
mucous membrane are known as soft papilloma, while titOM
from the skin or junction of the skin and (UUCO ianc
about the nasal orifices, are known as hard papilloma.
Etiology. — Syphilis is probably a very important foctOI in
the etiology of the disease. The disease should be attributed to
some torm of irritation, extrinsic or intrinsic.
Pathology. — The disease is probably one oi proliferation and
hypertrophy of the papilla- .it the skin or mucous membrane
(see Pathology of Papilloma).
Diagnosis. — The disease is usually easily diagnosed. The
tumor may appeal somewhat paler than the surrounding tissue
and variable in outline. The wart like condition of the tumor
is detected with a blunt-pointed probe. In (q 'ibsorved
by the author, the tumon WCK more often located on the
anterior septum.
Prognosis. — Provided the growth is all removed, the prog-
nosis is good in regard tO recover}-. It is sometimes difficult
to remove all the growth at one time if the growth is situated
posteriorly along the floor oi the nose. In consequence, a sec-
ond operation is sometimes neceaa
J'nntiihiit.—M large enough, the growth should be snared,
followed by the application of chromic acid. When situated
upon the septum, the growth will be more easily removed with
scissors. Hemorrhage follows the operation and is especially
profuse when the tumor has a broad base.
Adenoma. — Adenoma is a tumor composed of new- formed
gland Tissue, occurring in the skin or mucous membrane cm
ing the nose or nasal orifice.
Etiology and Pathology. — The pathology of adenoma
nose is- the same as that of adenoma of any other portion of
the body, M the breast, kidney an.! liver, and i-
under Pathology of Adenoma.
DISEASES OF THE NOSE.
363
Diagnosis. — The disease may occur at any age and is observed
to be a non-vascular, grayish-white tumor, nodular in char-
acter. Upon microscopical examination, the coils of ducts can
be detected.
Treatment. — The treatment consists in incision under anti-
septic precautions, evacuation and curettement of the sac sur-
rounding the tumor.
Angiomata. — Angiomata arc vascular tumors, which occur
infrequently in the nose.
Etiology and Pathology. — (See Pathology of Angioma.)
Symptomatology, — Angiomata of the nasal cavity may give
rise to nasal obstruction and sensations of fullness in the nose.
They sometimes ulcerate and produce violent hemorrhage.
If the growth is very small, there may be little or no irritation
from its presence. During an attack of acute coryza, the tumor
is inclined to become distended.
Diagnosis. — On account of the structure of angioma, which
is composed largely of dilated blood-vessels, the diagnosis is
comparatively easy. Capillar)' angioma or nevi is usually
congenital or come on soon after birth and is easdy dif-
ferentiated.
Treatment. — Angioma of the skin or mucous membrane
should be removal as soon as detected. If the growth is small
it may he punctured with an electric cautery- If too large to
be destroyed with a cautery, the tumor should be snared and
the nose packed with gauze.
Capillary automata are more easily destroyed with a cautery
or by electrolysis, the negative pole being inserted into the
growth and the positive held in the hand or at the nape of the
neck. The port wine and claret stains are usually too ex-
tensive to be destroyed with local treatment, and excision can-
not be practiced on account of the destruction of tissue and the
marked cicatricial change, which necessarily follows.
Fibromata. — Fibromata are tumors composed of bundles of
fibrinous tissue having their origin in the sub- mucosa. They may
occur at any age, but more often in young adults. They are
I
3*4
DISEASES OF EAR, NOSE AND THROAT.
■ 1'iM-ly allied with sarcoma and sometimes change into sar-
comatous growths. They may also undergo calcareous, cystic
or osseous degeneration.
Dr. Kcenc reports a ease of soft fibroma of the skill COVCT1
ing the nose with a distention of the acini and possibly hyper-
plasia of the sebaceous glands.
Fibromata arc frequently found in the nasal pharynx and
have a large sessile or pedunculated base.
Symptomatology and Diagnosis. — There is usually more or
less obstruction of the nasal passages, and if the growth is
located in the post-nasal space, the patient evinces symptoms
of adenoid growths. There is little or no pain accompanying
the disease. A soft or hard tumor, regular in outline, may
be detected upon inspection, extending from the turbinated
bodies and filling the post-nasal space, attaching itself to the
mucosa covering the sphenoidal hone.
Microscopical examination of a section of the tumor is
necessary for differential diagnosis.
Treatment. — A pedunculated fibroma of the nose and nasal
pharynx may be removed with a snare or curved biting forceps,
which is introduced through the nose or behind the soft
palate. It is sometimes necessary to guide the loop of the snare
into position with the finger passed in behind the soft palate.
Harmon Smith reports the cure of a naso-fibroma by the
injection of three drops of mono-chloracetic acid at an interval
of from two weeks to two months. There was but little
(ion from each injection and the successive sloughs formed,
finally removed the disease.
There is always more or less danger in the removal of a
sessile fibroma from the nose, especial K where rhr growth in-
volves the bony structures and fracture of the ethmoidal and
sphenoidal bone. Hemorrhage, convulsions and death may
follow. Removal with the snare is very unsatisfactory where
the base of the ve-n hroad.
According to Jacobson and Steward, in operations in u
there is involvement oi bone, three methods may be pur*'.
DISEASES OF THE NOSE.
(a) Those in which the attack is made through the mouth.
(A) Those in which the attack is made through the nose.
(c) Those in which the attack is made by removing the
upper jaw, partially or completely, or by resecting this bone
ostcoplastically.
The operation for the removal of naso-pharyngeal fibroma
through the mouth, according to Jacobson and Steward, con-
sists " in splitting the uvula and soft palate exactly in the mid-
dle line from before backward, then prolonging this incision
along the center of the posterior half of the hard palate, going
here down to the bone; from the end of this incision two others
are made slightly obliquely downwards toward the teeth, also
going down to the bone. The Haps, together with the peri-
osteum, are then detached, so as to form nearly rectangular flaps.
Two large holes are next drilled through the hard palate, each
well to one side of the middle line, the intervening bone is cut
away by placing the ends of cutting pliers in each of these holes,
and, by making lateral cuts back to the free border of the hard
palate, a rectangular portion of the posterior half of the bony
vault is removed. The mucous membrane and the periosteum
on the upper surface of the bone, which will now be found
detached, are divided, and, if it be needful to get more room,
more or less of the vomer is cut away. Room being thus ob-
tained, the fibroma is removed and its attachment dealt with.
If all the growth is taken away satisfactorily, the palate flaps
are united in the ordinary way; if further treatment is necessary,
Staphylorrhaphy must be performed later."
Where the operation is made through the nose or naso-
pharynx, one of the classical operations described by Lawrence,
Oilier and Langenbeck. may be used.
The Lawrence operation consists in making a curved in-
cision extending from the inner canthus down to the alse of
the nnsr and upward to the opposite inner canthus. The nasal
bone and the nasal process of the superior maxilla? and nasal
tun are separated with strong scissors. The separated DISSS
irncd upward and the nasal cavity exposed for any further
operative procedure.
I
$66
DISEASES OF BAR, NOSE AND THROAT.
The Oilier method is a reversal of the Lawrence operation;
The nasal bone and nasal process of the superior maxi'l
sawed through in the line of the incision, thus allowing the nose
to turn downward. If it is impossible to saw through the nose
Fie. it j.
c ii i u . -. Operation. (After E ma&tlg, foc*b*on and Sievwd.)
in the line of incision, a small hole may be bored through the
nasal hone and the saw inserted for the completion of the bony
incision.
The Langenbcck operation consists in making an in
through the inner edge of the eyebrow, along rhe bridge of
the nose to the cartilaginous portion (if the nose, when the
incision is curved backward to the junction of the ala? of
the nose and check. The nasal cartilage dissects loose, with
a fine saw inserted at the separation of the cartilage from
the bone, the nasal process is sawed through up to the lachry-
mal sac The incision is carried forward to the bridge of
the nose and is again directed downward through the nasal
bone at the junction of the septum and nasal bone. A mall
particle of bone is easily removed with forceps md scissors.
Removal <>i neoplasms or partial 01 complete removal of the
superior maxillary bone is described under carcinoma of thr
maxillan antrum (page 4.41).
The operation for the complete removal of the maxillary
bone is indicated where the fibrinous growth has become very
extensive and involves the nasal bone and sinuses of one or both
of the head.
DISEASES OF THE NOSE.
367
1 he question of preliminary laryngotomy is one that must
be left to the operator, especially in the removal of the superior
maxillary bone.
Where the operation is performed through the mouth, pre-
liminary laryngotomy is indicated.
In the Lawrence and Oilier operation, the question of pre-
liminary laryngotomy is necessarily dependent upon the size
of the growth to be removed. If the growth does not extend
into the nasal pharynx plugging the post-nasal space may be
performed.
The same rules of operative procedure for the removal of
fibroma may apply to the removal of malignant neoplasms.
Chondromata or Enchondromata. — Chondromata or en-
chondromata are tumors made up of hyaline cartilage or fibro-
cartilage or a combination of the two. Their origin is more
often on the septum of the nose. Tumors of this character
possess an adherent capsule.
Diagnosis, — The size of the chondroma varies and may be
small or of large dimensions, sometimes undergoing cystic
eneratiotL In the early stages of tin- growth of the tumor
it is hard and immovable.
Chondroma may occur at any age and sometimes change
into sarcoma. Unless rlu- growth is entirely removed, recur-
tsktfl place. If the growth cannot be removed through
the nose, the Lawrence or Oilier operation is indicated.
Treatment. — Complete removal of the growth and its cap-
sule by excision is early indicated on account of the tendency
SOge into sarcoma.
Lipomata. Lipoinata involve the tip and '-ides of the now
and are composed of adipose tissue. The) ma.3 be soft or hard,
nodul ir "ed. and may be observed at any age. Like
other hen ths, they rarely produce metastasis.
Diafnotis. — The diagnosis of lipoma is comparatively easy.
peculiar lohulated or nodular structure of the tumor.
which is situated about the orifice of the nose, producing in-
crease in size and marked deformity of the nose, suggests the
diagnosis without the aid of microscopical section.
368
DISEASES OF EAR, NOSE AND THROAT.
Prognosis. — As far as life is concerned, the prog:
favorable. However, the growth may attain quite a lis
interfere with respiration. Degeneration and sloughing of the
tumor may take place.
Treatment, — The treatment is purely surgical and COS
in partial or complete removal of the tumor.
Ostiomata. — Ostiomata are bony tumors which may have
their origin in the bony or cartilaginous portion of the nose
ami may extend into the nasal cavity or backward, producing
deformity.
Tumors of this character may have their origin within
the sinuses or press into the nasal cavity ur outward into the
orbit, displacing the eyeball. The growth is usually self-
limited. 1 he tumor may be cancellous or compacted, and i>
usually fixed by a firm, hanl ki>-.-.
Symptomatology and Diagnosis. — The symptoms are those
of nasal obstruction and painful pressure. The disease USUI
occurs in those past middle age, though it may be observed BI
any age. The disease should not be confined to < •
Treatment. — If the pressure and pain arc very great
the tumor, removal is indicated by means of a chisel, saw Of
bur. It may only be necessary to remove that portion of the
tumor which produces pressure.
Malignant Neoplasms. — Malignant neoplasms of the itfK
(see Pathology", page 89), are divided into carcinoma and sar-
coma. There is a tendency to give off secondary or metastatic
growths and a disposition to recur alter removal. The location
of malignant growths of the nose is extremely variable and may
be the accessory sinuses, bony structure, mucous membrane 01
external nose. They may take their origin within the nose an.i
extend to contiguous parts and involve the nasal cavity as 1
result of metauasis or extension.
Diagnosis. — The disease may be taken for tuberculosis, srpl
ilis, rhino-scleroma or a non-malignant tumor. A microscopic
section should be made of a suspected malignant rumor a< earU
as possible. If there is any reason to presume the presence
DISEASES OF THE NOSE.
369
syphilis, heroic doses of iodid of potassium should be prescribed.
Should the disease react to the iodid of potassium, the diag-
nosis of syphilis is at once manifested.
In carcinoma and sarcoma, there are nasal stenosis and fre-
quent hemorrhages from the nasal cavity. The patient com-
plains of pain, especially in sarcoma, which is of a deep boring
nature. If the malignant growth involves the sinuses, the
pain becomes so severe as to demand hypodermics of morphia
for its alleviation.
Courte and Prognosis. — The course of the disease is usually
very rapid and unless interfered with by operative measures,
as a rule, ends in death in from six months to two years.
The prognosis is variable. If the disease is removed early
and before infiltration of the lymph glands as in carcinoma or
involvement of the sheath of the blood-vessels extending into
contiguous parts as in sarcoma, the disease may be cut short
by operative measures. Unless all the tumor is removed, the
disease will recur. There is always a tendency to metastatic
spread of the disease.
Treatment. — If the tumor is confined to the deeper struc-
tures of the nose, the treatment is surgical and the operation'
of Langenheck, Oilier or Lawrence is indicated for its removal.
Radium is highly recommended for the mitigation of pain.
A small tube containing the radium should be passed into the
nasal cavity and allowed to remain from live to ten minutes,
every two or three days.
Epithelioma of the external nose is frequently relieved an!
sometimes cured by the X-ray. Upon failure of the X-ray to
cure the dttease, the tumor should be incised and the plastic
operation performed for the restoration of the symmetry of
the nose.
Erysipelas. — Etiology. — The predisposing causes of ttf-
sipelas are trauma-producing excoriations or rupture of the cutis
01 miaous membrane and a predisposition of the system to in-
fection. Dr. James C. White, in a discussion before the
American Dcrmatolugical Association, i«jo4, is reported to have
I
37°
DISBASBS OS i:u, \ost and IHRuat.
" referred ru the frequency with which erysipelas lias its origin
in the nasal cavity, bong usually due to the habit of forcibly re-
moving scabs and crusts from the mucous membrane of the nose.
He expressed the opinion that a large number of cases of ery-
sipelas of the face was due to this habit, which aifoi
germs of the disease a ready means of entrance. He audi
recall perhaps twenty instances where persons who had loflg
been subject to recurrent attacks of facial erysipelas, were
permanently relieved by having their attention called to this
habit and refraining hom it In the future."
The exciting cause of the disease is Infection from the
streptococcus of Fehleisen, an organism identic*] with the
streptococcus pyogenes.
Pathology. — The streptococcus of Fehleisen gains entrance
through the cutis or epithelium of the mucosa from some
solution of continuity, producing dilation of the blood- and
lymph-vessels, with a seious exudation, peculiar redness of the
parts and swelling. The disease may invade the deeper stnu-
tures, prod tiring a cellulitis. Toxins are eliminated, which
hrtng about elevation of the temperature and general dis-
turbances.
Symptomatology, — The period of mediation is from three
to eight days. The onset of the disease is usually marked by a
chill or chilly sensation, followed by a rise of temperature and
sometimes vomiting. In the old. there may be general pros-
tration and sometimes delirium.
Soon after the manifestation of the general
small red spot is observed at the gitC tti 'I"" prerious injury,
which may be in the muco-cutaneous juncture, mucous mem-
brane, alie, side or bridge of the nose, which rapidly extends •"
tlic surround ing: cutaneous structures or backward into the
nasal ca1 All the edges of tlu- Inflamed area ire marked
and the pans are red. swollen and infiltrated. In involvement
of the mucous membrane, the redness i-- of a deep hue :•.•
tinct from the Surrounding mucous membrane. The pharvnjra!
wall, soft palate and uvula may be involved at the same time.
DISEASES OF THE NOSE.
371
Diagnosis. — History of injury, sudden onset of the disease,
high fever and circumscribed redness and infiltration of the
mucous or cutaneous structures, with frequently extension to
the eyelids and face, render the diagnosis easy.
Treatment. — The treatment is both local and general. The
general treatment is directed to the gastro-intestinal tract.
Calomel should be given in one-fourth grain doses every three
or four hours, until free purgation of the bowels is secured.
I'orrhlnrid of iron in twenty drop doses or Bland's pills should
be given every three hours. It is better to isolate the patient
with confinement to bed. In the old, especially where there
is great lowering of the vitality and cardiac lesions, strychnia
and whisky are usually indicated.
If there is involvement of the mucous membrane, the local
treatment consists in spraying the nose and throat with warm
Dobcll's solution, every hour. The nose and throat may be
sprayed with a five per cent, solution of coca in for the relief
of the burning and smarting. Upon detection, in phlegmonous
inflammation in the soft palate or uvula,* the same should be
incised and drained. A ten per cent, solution of ichthyol may
be applied to the mucous membrane nf the nose upon a cotton-
tipped probe, three or four times daily. The local treatment in
inflammation of the cutis consists in painting the surface with
pure carbolic acid and neutralizing, after the surface becomes
white, with absolute alcohol. Ichthyol in fifty per cent, solu-
tion is highly recommended as a topical application. This may
be painted over the surface with a camel hair brush or cotton-
tipped probe. Phlegmonous abscesses should be incised An<\
irrigated twice daily with warm lysol solution, one drachm to
the quart of water and dressed with bichlorid or iodoform
gauze. Elevated temperature should be treated by cold sponge
Cold applications are contraindicated.
Furuncle. — Etiology ami Pathology. — The cause of fur-
uncle is some form of traumatism, followed by infection with
the staphylococcus, which enters through the hair follicle.
The predisposing causes of furuncle or boil, are lowered vitality,
372
DISEASES OF EAR, NOSE AND THROAT.
diabetes and picking the nose with infected fingers. 1
ing the infection, a necrotic mass or " core " forms, which is
composed of necrotic connective tissue, leucocytes and the in-
fecting bacteria. Two or more follicles may become affected
or the disease may spread and thus produce a very large area
of necrosis. If superficial and a mild infection only occurs,
a pustule is formed.
Symptomatology and Diagnosis. — A boil is usually located
on the tip of the nose and from the rapid swelling, circumscribed
induration, intense redness, throbbing and beating pain, is
easily differentiated. The disease ends by rupture, by absorp-
tion or by evacuation of the core.
Treatment. — The treatment is prophylactic and curative.
On account of the tendency of the disease to spread and recur,
some form of prophylaxis is indicated and usually consists of
mild purges, tonics and administration of three to six grains of
calcium sulphid, three times daily.
The local treatment consists in frequent applications of
campho-phenique and poultices of antiphlogistin.
If the furuncle is located within the vestibule, the hair of
the affected follicle should be extracted. If located externally,
sometimes freezing for a few seconds with ethyl chlorid will
assist in aborting the disease. Puncturing the follicle with a
sharp bistoury or paracentesis knife sufficiently to cause free
hemorrhage is very efficacious in many cases in relieving pain
and may aid in aborting the attack. After pus is formed, a firr
incision should be made with evacuation of the core, followed
by antiseptic dressing. The patient should avoid picking the
nose for fear of carrying infection to some other section of the
body.
Deformity of the Nose. — Deformity of the nose may he
genital or may result from blow, fall upon the nose, fracture
or ulcer. For cosmetic reasons, some form of operative pro-
cedure is often necessary. In addition to the correction of
- i.i.ii,- in,i pub rmsi In paraffin injection (page |75)i u ■*!
be necessary to employ some form of artificial bridge for the
DISEASES OF THE NOSE.
373
restoration of the nose. The artificial devices designed by
Martin and Weir, known respectively as Martin's saddle and
Weir's platinum bridge may be used. The bridge (Fig. 113)
may be inserted by doing the Rouge operation, which consists
in making an incision in the gingivo-labial fold from the
Fk;, 113.
/"
Martin's Bridge :» Position.
first molar tooth to the first molar tooth on the opposite side,
lifting the lip up and dissecting upward until the nasal passage
is exposed. Holes should be drilled in the upper maxilla for
the implantation of the legs of the bridge. With the bridge in
position, the nose is replaced and the lip stitched into its original
position. The subsequent treatment consists in keeping the
patient quiet for a few days and cold applications to the nose
fog 'ur hours following the operation. The nasal
cavity should be irrigated twice daily with Dobell's solution,
until the exposed surfaces have completely healed.
374
DISEASES OF EAR, NOSE AND THROAT.
Angular deformities or bony humps are more often removed
for cosmetic effects. In the operation designed bj Roc, the
burgeon enters the nose through the meatus and exposes the
nasal bone by making an incision at the junction ot the nasal
bone and lateral cartilages elevating the skin and soft tissues
and chiseling and sawing away of sufficient bone to correct the
deformity. The bony hump may also be removed by making
the incision through the skin of one side of the nose, elevating
the tissue and removing the deformity with chisel and saw.
Fracture. — The bones involved in fracture of the nose are
nasal bones, cartilaginous and osseous septum, nasal process of
the superior maxillary bone, ethmoid and sphenoid bones (see
Fracture of the Base).
Etiology. — Fracture is usually due to WtOlt toTta of trau-
matism and is more often due to a fall upon the face or l>
upon the face or head. Fracture may also he due to gunshot,
contra-coup, and irradiation. Fractures may be depressed,
pie, compound or comminuted.
Fracture of the vomer is a condition which may accompany
fracture of the cartilage and on account of its location, B
overlooked in the greater number of cases.
Symptomatology and Diagnosis. — In fractures of the nasal
hone and septum, there is pain, swelling and deformity. In
fracture of the nasal bone, with gentle movement of the bridge
of the nose, the diagnosis is easily established by crepitation.
Under good illumination, if the septum is involved, it will
be bowed or turned. The usual site of the fracture of the sep-
tum is the anterior portion of the bony septum or the posterior
portion of the cartilaginous septum. In a great many cases
of fracture of the nose, cither simple or compound, infection
may occur, ending in the formation of an abscess and necrosis.
Fracture of the ethmoid bone may follow blow or fall
upon the head and face. Symptoms of fracture of the ethmoid
are profuse bleeding of the nose, loss of smell, pu fitness of the
conjunctiva and pain upon pressure in the inner sockets of the
eye.
I.'IM ASES OF THE NOSE.
375
In fracture of the sphenoidal bone there may be sudden loss
of sight, pressure upon the optfe nerve, paralysis of the motor
oculi, pain in the back of the eyes and hemorrhage from the
nose. The temperature is slightly above normal. Meningitis
may follow fracture of the ethmoid and sphenoid bones.
Treatment. — In fracture of the nasal bone or septum, the
nasal mucosa should be anesthetized with a five per cent, solution
" in, followed by irrigation with s mild antiseptic solution
and examination under good illumination for deviations, for-
eign bodies and spicula of bone.
With a Rose elevator, depressed nasal bones or displaced
septum can be easily pushed into position. In many cases the
Asch or D. Braden Kyle splint can be used to advantage in
holding the septum in place. In the absence of nasal splints,
iodoform or sterilized gauze may be used to hold the fragments
in position. If the mucous membrane is lacerated, the gauze
should be soaked with sterilized albolene beiore being placed
in the nose. The nasal fossa should be dressed every twenty-
four hours to prevent infection. Various deformities or frac-
ture of the external nose should, at the same time, be corrected
by manipulation. The tin or lead splint can be shaped to the
nose and fixed in position by a strip of adhesive plaster.
Cobb's splint is especially recommended when pressure is
only necessary on one side to keep the nose in position. During
the fitSt iu ent v-tuur hours, when it is necessaxy to pack the nose,
the nasal cavity should be sprayed even two hours with iced
Dobejl's solution. Compresses dipped in cold bichlorid solution
should be placed over the bridge of the nose for the first twenty-
four hours following fracture.
Paraffin Prosthesis. — Since the introduction oi the paraffin
injection for the correction of deformity by Gucrsny in iyoo,
injection of paraffin tor the correction of saddle nose has come
into universal use with evidence of lasting satisfactory results.
Some of the untoward sequels that may follow paraffin in-
jection are toxic absorption, continued pain from undue pres-
sure, formation of abscess, air embolism, paraffin embolism and
hyperesthesia of the skin.
,nd
prepared bj
York, with a melting point no" F., as suggested by Dr. Har-
inun Smith, has proved extremely satisfactory to the author.
The syringe used is that designed by Dr. Harmon Smith, and
Can be bought at any instrument house.
The paraffin may be melted in the small test-tube and can
be drawn into the syringe in a liquid form. After cooling,
" so that the paraffin emerges from the needle in a thread like
string," it is ready for injection.
The technique of the operation consists in sterilization of
the instrument and thorough cleansing of the nose over the
site of the intended operation. The nose and face should first
be cleansed with clean soap and water anil alcohol. The
surgeon's hands should be cleansed as for any surgical operation.
The question of preliminary local anesthesia is governed by
the condition of the patient. The operation ha* been performed
at the Bobb's Free Dispensary of the Indiana Medical College
without local anesthesia, the patients making little or no
complaint. However, in nervous individuals, Schleich's solu-
tion or a two per cent, solution of cocain may be injected into
the subcutaneous tissue.
The point of the needle is inserted into the subcutaneous
tissue and passed to the point from which the moulding of the
parts is to begin. By gently twisting the screw of the syringe
and at the same time slowly withdrawing the needle, the
paraffin is forced gently into the tissue and is moulded with thr
thumb and forefinger sufficiently to overcome the deformity.
Two or mnre injections may be necessary to bring about
satisfactory restoration of the parts.
The after-treatment consists in covering the wound produced
by the needle with collodion. Cold pressure should be applied
to the nose for from twelve to fifteen hours.
Intemasal Adhesions. — Fibrous adheakma may be congenital
or acquired. If acquired, they arc due to ulceration of the mu-
cosa from infection, syphilis, nasal diphtheria, purulent rhinitis,
application of the electro-cautery or intcrnasal operation.
DISEASES OF THE NOSE.
377
Bridge-like bands may be situated in any portion of the
r.osc, but more often join t lie lower turbinate with the septum.
They are fibrous in character and may become cartilaginous or
infiltrated with calcareous matter. The size of the band is
variable and may be thread-like or very broad and thick.
Symptomatology and Diagnosis. — There is obstruction to
breathing and frequently accumulation of mucus, which the
p.-itirnr is unable to dislodge by blowing the nose. The patient
may complain of headache, insomnia and general disturbances.
Post-nasal catarrh and Eustachian-tubal catarrh arc frequent
t omplioations of the disease.
Anterior bands are easily detected upon inspection. Pos-
terior adhesions frequently demand shrinkage of the nasal
milCOM and exploration with a cotton-tipped probe, for their
detection.
Treatment. — The treatment is governed by the size of the
band. Small bands may sometimes be destroyed by the appli-
n <>f chromic acid or the electro-cautery. Large fibrous
or cartilaginous bands should be removed with scissors. The
after treatment consists in preventing new formations by strips
of gauze or Pynchon hard-rubber splint. The splint or
gauze should be changed daily, followed by irrigation of the
il cavity with a warm alkaline solution. The treatment
should be continued daily until the cut surfaces are entirely
covered with mucous membrane and all tendency to new ad-
bns has passed away.
Congenital Occlusion of the Nares. — Partial or complete
congenital closure of the nares is infrequently observed. The
situation of the obstruction is more often the post -nares and is
due to an outgrowth from the hard palate. The anterior nares
bo be partially or completely closed. The occlusion is
probably due to faulty development in the mucous membrane
during embryonic life.
■ 'Stomatology. — The patient complains of inability to
breathe properly on one or both sides, more or less loss of smell
and subjective aural symptoms. The subjective symptoms are
usually those of ordinary nasal catarrh.
I
378
DISEASES OF EAR. NOSE AND THROAT.
Diagnosis. — It the web-like deformity is situated anteriorly.
diagnosis is established by inspection. In post-nasal congenita]
atresia, the deformity is detected by passing a probe through the
narcs, when a smooth, hard, membranous obstruction is en-
countered and can be outlined with a cotton-tipped probe. In
the case observed by the author, there was no secretion in
the post- nasal space.
Treatment. — The wisdom of operating depends upon the
amount of discomfort produced by the obstruction. If confined
to one side, the obstruction had better be left alone.- Should
both sides be affected, one or both sides may be opened by borinu
through the osseous web with an electric trephine and formation
<it a window with saw and scissors. The after-treatment con-
sists in rest in bed and frequently spraying the OOSB with a .-»Iu-
tion of Dobell's and adrenalin chlorid 1/3,000, for the first
twenty-four hours. The further treatment consists in daily
irrigation of the post-nasal space until the tendency to accumu-
lation of mucus has passed away.
DISEASES OF THE NOSE (CONTINUED).— DISEASES OF
THE SEPTUM.
Deflection of the Septum. — Etiology. — The cause of devi-
ation of the septum is still a matter of conjecture. In the
eight hundred and fourteen crania of aborigines collected from
the American continent, Freudenthal found deviation of the
septum in two hundred and sixty-four cases. The theory
advanced hy Freudenthal and Chairi is based on the rule that
in most individuals a slight concavity of the septum takes place
on the side of the body more strongly developed. In addition
to heredity as a cause, deflection may be due to a fall upon the
face m infancy, abnormal growth on the turbinate pressing on
the septum of the opposite side, injury of the child during de-
livery and inherited syphilis. The septum may be bowed,
ridged or a sigmoid deflection with exostosis and librous changes
and may be located interiorly or under the flour of the septum.
The stenosis from deflection may be so great as to bring about
a total atresia of one side.
Symptomatology and Diagnosis. — The symptoms are diffi-
cult breathing, frequent attacks of acute coryza and catarrhal
deafness. Pressure from the deflected septum may bring about
severe nervous manifestations and may excite epileptic attacks,
hay fever, headache, and general nervous debility. Under good
illumination, the diagnosis, a comparatively easy. Exostosis
should not be confounded with deflection of the septum. It
frequently occurs that enlarged middle turbinates may press
against the septum, producing a bowed condition. There
sometimes exists a deformity of the external nose as a result of
the septal deflection.
Treatment. — The submucous resections, so-called " window
379
3So
DISEASES OF EAR, NOSE AND THROAT.
resection," advocated first by Ingals and later by Kricg, have
Coma into great favor both in this country and Europe. The
operation consists in removing in part or entirety the deviated
cartilage and allowing the mucous membrane to remain intact.
This operation with modifications is recommended by IngaU
Kricg, Bocnninghaus, Moore, White, Peterson-Hartman, Freer,
llajek, Mcnsel and others, and consists in making an inci'
into the mucosa and through the perichondrium down tn
cartilage and removal of the deviation in a variety of ways
with specially constructed instruments. The operation is per-
formed under cocain anesthesia and with the patient sitting in
an upright position. The method of Ballenger ( The Laryn-
fOfcQfte, June, 1905) is a modification of the In^als and Kricg
operation and is a method which has been successfully used
by the author in a number of cases.
"The technique of the operation," according to Balltfl
" is after the Menzel-Hajek method with the exception of the
removal of the cartilage. In the Menzel-Hajek operation, the
cartilage is removed piece by piece with punch forceps; whereas,
by my method, it is removed in one piece with one cut of the
swivel knife. The time required for the removal of the car-
tilage after the muco-pcrichondrium has been elevated need
Fie. 114.
B»iX«l«o»« S»r. ■ ••
consume but a few seconds; whereas, by the Menzel-Hajek
method, it takes from a few to several minutes for its removal.
1 nog a special knife (Fig. 114), I make a curved incision in
the septal mucosa of about one inch in length, beginning near
the floor of the nose and curving forward ami upward, as high
as I can, through the vestibule of the nose and about one-fourth
inch posterior to the anterior margin of the cartilage. I have
not found it necessary or expedient to make the incision on the
DISEASES OF THE NOSE.
38«
convex side of the septum, as is commonly recommended; but
I find it advisable to make it on the left side of the septum
regardless of whether this is the convex or the concave surface.
I do this because it is convenient to use the knife with the
right hand while the forefinger of the left is inserted into the
right nostril. Having made the curvilinear incision through
the miico-perichondrium on the left side of the septum, I next
Fig. 115.
Hull's MucoriBlClIONDHIAL F.LHVATOB.
resort to the semi-sharp elevator of Hajek (Fig. 115) to elevate
the anterior portion of the muco-perichondrium from the septum
after which Hajck's blunt elevator (Fig. 1 1 5 ) should be used.
The semi-sharp elevator should only be used to start the eleva-
tiun, as to continue its use might result in a perforation of the
mucous membrane, whereas, the dull elevator can be used with
great rapidity without danger of perforation.
" The next step in the operation consists in carrying the an-
terior curvilinear incision of the mucosa through the septal
i.uitlagc tu the perichondrium of the opposite side. This is
done with a small bistoury (see Fig. 114), the forefinger of the
left hand being inserted into the right nostril to detect when
the cartilage is completely incised. After one has had con-
siderable experience in the incision of the cartilage with a
knife, he may not find it necessary ro introduce the finger into
the opposite nostril as he can readily appreciate when he is
rhmugh it by the sense of touch or by the resistance felt with
the hand holding the knife. The semi-sharp elevator of Hajek
may be used to perforate the cartilaginous septum along the
line of the curvilinear incision by rubbing it to and fro in the
I
DISEASES OF EAR, NOSE AND THROAT.
Fig. 116.
VI
miK 't-pcrii -hondrial incision, the index finger of tlie left hand
being inserted in the right nostril to exert counter pressure and
to detect by the tactile sense when it is completely
broken through,
"The incision through the cartilage h.
been made by either of the above methods, the
Mini sharp elevator should be inserted through ii
with the flat side turned so as to lie against the
right side of cartilaginous septum, and, while in
this position it should be moved up and down and
insinuated between the cartilage and the muco-
perichondrium of the right side. To facilitate
this procedure, the tip of the nose should lie
turned toward the patient's right side thus expos-
ing the curvilinear incision through the mucosa
and cartilage, and making it possible to introduce
the semi-sharp elevator on a plane parallel with
the septum. After this tide LI started, the dull
elevator is used to complete the separation. Care
should be taken to lift the muco-perichondrium
from the entire deflected area as to fail to do so
makes it impossible to remove a sufficient amount
of the cartilage.
" The muco-perichondrium on both sides of the
septum ROW being elevated, the prongs of the
swivel fork are introduced through the curvilinear
incision, one prong being on the right til
the septum, and the other on the left. Tl
strument should now be directed backwards par-
allel with the floor of the nose until the posterior
limit of the cartilage is reached, when it should
be directed i and forwards following the
outline of the anterior end of the perpendicular
plate of the ethmoid CO the bridge of the nOJc,
when it should be pulled downward parallel
cavity, the triangular blade resting upon the concavity of the
QaI i RNH ■'<
SwiVB Kjupe.
ilu- ridgC of the nose to the upper extremity of the curvilinear
incision. In this way almost the entire cartilaginous septum,
except the anterior tip which is left to support the tip of the
nose, is removed. The excised cartilage should now be seized
\\ nil a pair of dressing forceps and temoved through the cur-
s i lunar incision. The cartilage thus removed is usually rough-
lv triangular in shape, the acute point of which represents the
posterior end of the cartilage.
" It is obvious that this method of removing the cartilage
is a rational one, as it does it with ease, rapidity and without
traumatism or laceration of the mucous membrane."
For the. removal of a portion of the bony septum, Frcer's
modification of Gfuenwald's punch forceps may be used. With
the instrument, according to Freer, bone one-eighth of an inch
thick can be bitten in two. With this instrument, the l>on\
septum may be removed, piece by piece. After removal of the
CftrtOage, the nasal cavity and wound are cleared of all debris.
The mucous membrane is brought into as near normal apposi-
tion as possible and covered with gauze previously dipped in
alholene. Over this a very light packing of bichlorid gauze is
placed. On the opposite side of the nose, a light packing of
gauze may be placed as n support to the membranous septum.
The dressing on both sides may be dispensed with the follow-
lav. The nose should be cleansed twice daily with Dobe
solution until recovery is complete.
Perforation may recur in this operation as in the Ingals
or Kreig operation. However, with familiarity and skill in
making the incision of the cartilage, perforation of the mucous
membrane on the opposite side may be prevented.
The technique of the Asch operation consists in complete
anesthesia following irrigation of the nasal cavity. The bead
oi thr patient is placed inclining downward over the edge of
the operating table. With a blunt or sharp separator, the ad-
hesion of the septum and the turbinates is first broken up. The
Asch septum scissors arc now quickly passed into the nasal
3«4
DISEASES OK EAR, N'OSE AVI) THROAT.
septum and the straight blade over the convexity. They are
then forcibly closed, making a button-hole incision. They are
now withdrawn and a second incision is made in a vertical
direction over the first incision, which was parallel to the
floor of the nose. With the finger in the nose, the convex
portion is forcibly pushed into line, breaking the segnv
the base. The compression forceps are now introduced furthci
to strengthen the septum. Immediately, the previously sterilized
rubber splints are forced into the nose and held in position by
strips of adhesive plaster, the nose is sprayed with sterilized
iced Dobcll's solution and bichlorid solution. The patient is
instructed to remain in bed for lour days.
The subsequent treatment is spraying with Dobcll's iced
solution every hour for twenty-four hours. Ice compresses
should be kept on the nose for twenty-four hours after the
operation. Cold spray and applications not alone guard against
hemorrhage, but prevent inflammation. After twenty-four
hours the tube on the side of the concavity is removed, the
nasal cav it) cleansed and sterilized and the tube reinserted.
The tube is discarded after forty-eight hours. The tube on
the convex side is removed after forty-eight hours, 8t»
and reinserted. This tube is sterilized dail\ and worn for one
month. As a rule, the results are satisfactory. A few cases of
septic infection following tins Operation have la-en reported.
Abscess. — Abscess of the septum is a circumscribed collec-
tion of pus.
Etiology. — The cause of a localization of pus in the septum
is usually some form of trauma and frequently follows fracture,
especially fracture of the nasal bones. A blow upon the MM
may produce an effusion beneath the perichondrium of one or
both sides or a rupture of the cartilage and effusion, which
may become infected and lead to the formation of pus.
Symptomatology. — There is usually a history of tnram
With pain and swelling of the septum and nasal stenosis. The
patient complains of headacl M of temperature.
Diagnosis. — The septum bulges into the anterior nasal
DISEASES OF THE NOS£.
3S5
cavity, producing partial or complete stenosis. The mucous
membrane is paler than normal and dry and glistening. Upon
palpation, the septum is tender and painful. Fluctuation, in-
dicative of pus, may sometimes be detected. Pus can be dis-
covered by making a free incision unto the septum at the point
of infection.
Treatment. — A free incision is indicated wherever pus is
suspected, and the opening prevented from closing with tam-
pons of bichlorid gauze. The septal abscess should be irrigated
once daily with a weakened normal salt solution, followed by
tamponing. The length of treatment varies and may be con-
tinued for a number of weeks. More or less deformity of the
septum usually follows.
Ulceration. — Ulceration of the septum may be confined to
the mucosa or involve the mucous membrane and cartilage and
b perforating or non-perforating. There is a localized solu-
tion of continuity of tissue without a disposition to heal.
Etiology and Pathology. — The causes arc both predisposing
and exciting. PredispoMiig causes of ulceration are syphilis,
tuberculosis, herpes, varicosities, atheroma, diphtheria, irriga-
tions continuously applied to the mucous membrane, irritating
gases and the habit of picking the nose.
The exciting causes are infection from some pathogenic
in ism, among which are the staphylococcus pyogenes aureus,
streptococcus pyogenes, gonococcus (gonococcus infection would
probably be by metastasis, as only one or two cases of gonococcus
infection of the nose have been reported), actinomycosis, tubercle
bacilli, barillus scleroma, bacillus coli communis and diplococcus
pneumoniae.
Symptomatology. — This condition is usually one of slow
development. There may be little or no pain accompanying
the formation of an ulcer. The patient may complain of fre-
quent attacks of epistaxis and accumulations of crusts in the
nose, which the patient attempts to dislodge by picking the
nose.
Diagnosis. — A perforating ulcer is easily detected. If pro-
I
3S6
DISEASES OF EAR, NOSE AND THROAT.
gressive, the rim of the ulcer will he covered with blood CTUSO
which leave a bleeding surface upon heing removed. A super-
ficial ulcer is grayish in appearance, circumscribed and covered
with mucus or muco-pus. If there is much destruction of
tissue, the cartilage may be exposed.
Treatment. — If the ulceration is due to syphilis, mercury
by inunction and iodid of potassium in large doses are indi-
cated. If the disease is due to tuberculosis or infection from
one of the many causes enumerated, the treatment is more es-
pecially local and consists in frequent irrigations with a warm
alkaline wash, stimulating repair with daily applications of a
solution of nitrate of silver, twenty to thirty grains to the
ounce with a cotton-tipped probe. The patient may be given a
stimulating ointment, compound of the yellow oxid of mercury.
eight grains to the ounce of lanolin, to be applied to the surface
of the ulcer twice daily.
Constitutional treatment is directed to building up the tyj
i rni with tonics and alterative-.
Perforation of the Septum. — Perforation of the septum
may be of the cartilaginous or bony portion. Perforation of the
bony septum probably exists more often than is supposed, but
is overlooked on account of the location.
The cause may be stab, untoward accident from removal of
a spur or deflection, gunshot, abscess, syphilis or tuberculosis.
Syphilis is probably the most important factor in the causation
of perforation of the septum. One should not beguile hiiv
into believing that all perforations of the septum an- pathog-
nomonic signs <>t syphilis. The septum is uonocfinry for the
I'M -crvation of the symmetry of the nose. As long as the
bony structures arc unaffected there is no danger of collapK
of the nose (see Fig. 108).
Treatment. — The treatment varies, and if due to syphilis.
general anrjsyphilitic treatment is necessary to prevent the
spread ot the affection. Perforations from trauma or local in-
fection arc usually small and have no tendency to destroy all the
cartilage. The treatment consists in frequently cleansing the
DISEASES OF THE NOSE.
3«7
nose, applications oJ nitrate of silscr, guctj grains to the ounce,
and the administration of tonics and alteratives.
Spurs on the Septum. — Etiology. — Spurs on the septum
may be located on the cartilaginous or bony portion and may
extend the entire length of the septum. The causes are con-
genital influences, fall upon the nose or inflammation of the
mucous membrane extending down to the perichondrium or
periosteum.
Pathology. — Spurs may be fibrinous, cartilaginous or osseous
and covered with mucous membrane.
Fibrinous or cartilaginous spurs may undergo partial or com-
plete osseous degeneration. The disease is frequently due to
a mild localized perichondritis or periostitis, with subsequent
hypertrophy and hyperplasia.
Symptomatology. — The patient frequently complains of nasal
Stenosis, ringing in the ears and progressive deafness. There
is a disposition to repeated attacks of cold in the head. Spurs
arc presumed to excite reflex disturbances, i. c, hay fever, head-
ache, cough, asthma and prodromes of epilepsy. The position
dJ the spurs is quickly noted upon inspection. The spur may
or may not impinge upon the turbinate. There is always a
question in regard to the possibility of irritation from a small
spur on the septum. Whether or not a small spur with free
breathing space and no catarrhal or inflammatory condition of
the mucosa demands removal must be judged solely by the
physician. In a case with catarrhal inflammation of the nose
with ear complication, the nasal cavity should be restored as far
as possible to a symmetrical and normal condition.
Diagnosis. — From the foregoing enumeration of symptoms,
the diagnosis is easy. The condition should not he confounded
with papilloma, tubercular nodule, abscess of the septum or
osteoma.
The question of the Influence of a spur as a cause of reflex
rbances CM) only be settled by its complete removal.
Treatment. — Spurs on the septum should never be cauterized
for fear of subsequent ulceration and thickening. Their re-
3$8
DISEASES OF EAR, NOSE AND THROAT.
muval should be by knife, saw or bur. Frequently a small
cartilaginous spur may be removed by submucous dissection.
An incision, as for window resection, may be made, the flaps
turned inward and the spur shaved off with a knife and »
The flap is returned to its normal position and gau/r d
applied. Where the growth has undergone an osseous deflJCfl
eration, the saw or bur is necessary. There is more or less
destruction of the mucous membrane with the use of the MW.
It is frequently advisable to shave the spur from the septum
without regard to the preservation of the mucous membrane.
With a sharp knife, the spur may be cut through from abate
downward. If bone is encountered, the incision may be com-
pleted with a saw. As soon as the soft tissue is encountered,
the knife or scissors may be used to completely sever the spur.
The spur is lifted from the nose with a goose-neck forceps.
The after-dressing consists in frequently spraying the nose with
Dobcll's solution and adrenalin chlorid. i/j.ooo. If h
rhagc is anticipated or should occur, the wound should be
covered with a thin strip of oiled gauze over which is packed
strips of gauze, which should be removed the following il;o
The strip of gauze covering the wound may remain from forty-
eight to fifty-two hours, the gauze having been previously
soaked in adrenalin to avoid hemorrhage following its removal,
caused by the fibers adhering to the wound. The mucous mem-
brane quickly re-forms over the wound. Should granula
tions occur at the site of the wound, they may he destroyed IV lb
a strong solution of nitrate of silver or scissors. If there is a
tendency of the lower turbinates to adhere to the septum from
the operation, a Pynrhon hard-rubber splint should be
in the nose for a few days or until the mucous membrane of
the septum is rrccnrr.ited.
Dislocation of the Columnar Cartilage. — The columnu*
is that small, narrow portion of the cartilage supporting the Dp
of the nose and separating the two nostril*. Frequently from
a blow or fall upon the nose, kick of a horse, ulceration or
Injur? during birth, the cartilage may be dislocated. Collapvr
of the nose may accompany dislocation of the cartilage.
DISEASES OF THE NOSE. 389
Treatment. — The operative procedure varies according to
the deformity. If the detached portion stands out into the
vestibule knuckle-shaped, an incision along the junction of the
skin and mucous membrane may enable a submucous resection
of the cartilage and its complete or partial removal. Should
the base of the cartilage be directed to one side, the plastic
operation for its removal should be performed.
Fracture of the Septum. — (See Fracture of the Nose.)
CHAPTER XXII,
DISEASES OF THE ACCESSORY SINOSES OF THE NOSE
Acute Catarrhal Inflammation of the Frontal Cells.—
On account of the position of the nasofrontal duct ami the
tendency to uninterrupted drainage, the frontal cells arc less
liable to inflammation than the sphenoidal or ethmoidal cells,
hut when once diseased arc more difficult to cure. As a result
of the extension of the same kind of epithelium as found in
the nasal cavity, the frontal cells are involved in the majoi
of cases of acute eoryza and exanthematous disease (see Fig. 31 ).
Etiology. — The disease may occur independently of any pre-
vious catarrhal infection of the nasal mucosa or. as a result
of extension, by continuity of tissue. Acute eoryza is probably
the most pronounced factor in the causation of the disease.
addition to acute eoryza, may be mentioned exantheuiatous dis-
eases, typhoid fever and influenza. The predisposing cause*
arc catarrhal diathesis, syphilis, tuberculosis, inflammation of
the anterior ethmoidal cells, malformation of the middle tur-
binate and deflected septum. Edema of the mucous membrane
of the ostium may produce complete closure of the front.il
cells with retention of air in the cells. The air may be absorbed
and predisposes to passive hyperemia with hemorrhagic rxtra-
1 :011s into the mucosa.
Pathology. — There is present a hyperemia and edema of the
epithelial structures with increase of glandular secretion. The
character of the secretion varies ivith th«- I the disease,
and is at first clear mucus and scrum, becoming sligl
bid after a time from exfoliation of epithelium ;*u.l brofew*
down li in hi y lis. With the introduction of infection into the
sinus, the disease rapidly passes into a condition of acute puru-
lent sinusitis.
tnmutulog'j and Diagnosis. — rain, unilateral or bilat-
eral, over the frontal region which is aggravated by assuming
a stooping posture, coughing, blowing the nose, and nasal
tones in speaking are characteristic symproms. The disease
may run its entire course without pain. More or less conges-
tion of the nasal and conjunctival mucosa may be noted. I he
discharge from the cells is at first a thin, stringy mucus, later
becoming mucopurulent. The discharge from the cells is
sometimes very profuse and continues for a number of davs.
UpOO inspection of the nasal cavity, the thick sero-mucus will
be seen draining anteriorly and in the trough formed by the
■eptUOl and bony structure dense mucus can be detected empty-
ing into the middle meatus.
ilmtnt. — Where there is much congestion about the naso-
frontal duct, symptoms of fullness in the attic of the nose can
be relieved for a very long time by causing the patient to lie
prone upon a table or couch with head extending over the edge,
in which position four or five drops of equal parts of adrenalin
chlorid. witch ha/el and camphor water distilled, may be
injected into the anterior attic of the nose with an ordinary
medicine dropper. There will be slight pain following the
injection, which passes away in a very few seconds. After four
or five minutes, a warm oil solution composed of two per cent,
camphor, menthol and cocain in albolene may be Instilled into
the rpgion oi the naso-frontal duct with the patient in the same
position as before. If the physician desires, rlie patient's home
treatment may consist of the same method of treatment or a
frequent spraying of the nose with a warm, mild alkaline solu-
tion, followed by a two per cent, camphn-mcnthnl in oil or
adrenalin m oil. It is better to keep the mucous membrane
retracted by COCain or adrenalin sufficiently long enough to
allow the constrictor fibers of the blood-vessels to retain their
normal tone. Adrenalin in neutral oil may be prescribed as a
substitute for cocain.
Dry heat over the affected part should be ordered for as near
constant use as possible. The pain may often be controlled
3V3
DISEASES OF EAR, NOSE AND THROAT.
by dry heat. Any lithemic condition should be overcome with
the free administration of water.
A warm foot-bath at bed-time with ten grains of Dover's
powders internally for the adult, followed by a saline upon
arising, should be administered when the inflammation is acute.
If the disease persists fox any length of time, the administration
of those drugs which tend to stimulate elimination are iod -
cated, such as benzoate of sodium in ten grain doses three times
daily. Topical applications of warm irrigations and sprays
of hydrocarhons should he frequently used. Tampons of cotton
dipped in fifty per cent, solution argyrol arc efficacious if placed
far up into the nasal cavity. Where there is no chance of ex-
posure, Turkish baths are of great value. Surgical measures
may be subsequently demanded for the removal of hypertrophy
of the middle turbinated bones, deviation of the septum and
polypi.
Chronic Catarrhal Inflammation of the Frontal Cells.
— Etiology. — Chronic catarrhal inflammation of the frontal
cells is due to successive attacks of acute inflammation of the
OIUCOU8 membrane lining the frontal cells, produced by succes-
sive attacks of cold in the head, exanthematous disease, tuber-
cular diathesis, chronic catarrhal inflammation of the ethmoidal
cells, hypertrophy of the middle turbinated bodies, tumors,
foreign bodies and any condition which may produce a chronic
inflammation of the mucous membrane of the naso-frontal duct.
Pathology. — The entire mucous membrane lining the canal
becomes involved with sometimes a slight involvement of bone.
The mucous membrane becomes thickened and hypertrophied.
There is a chronic catarrhal exudation constantly thrown off,
which may be filled with broken down epithelial cells and
leucocytes. Exacerbations of the disease frequently occur at
the end and beginning of winter, when the days are damp and
chilling.
Treatment. — The treatment is primarily directed to the
removal of any internasal obstructions around the naso-frontal
duct and the correction of any local or general catarrhal con
DISEASES OF ACCESSORY SINUSES OF NOSE.
393
dition and Constitutional dyscnisia. If the tip of the middle
turbinated bone impinges upon the lateral wall, preventing free
drainage into the meatus, it should be removed with the Holme's
scissors and snare. Where the condition is due simply to nar-
rowing of the canal from hypertrophy of the mucous membrane,
dilation with a Freeman's frontal duct bougie, is indicated
(R& 79)-
In addition to the tampons of cotton, a fifty per cent, solu-
tion of argyrol may be placed in the infimdibulum once daily
and allowed to remain tor ten minutes. Hot antiseptic or alka-
line solutions should be prescribed as a spray for home use.
If there is very much secretion from the frontal cells, they may
be irrigated through a Hartman cannula with Dobell's solution,
provided the pain is not too great.
The rules of personal hygiene should be rigidly enforced.
The patient should take plenty of out-door exercise and avoid
exposure to irritating gases, tobacco smoke and the over-use
of alcoholic liquors. A general tonic is usually indicated for
the Stimulation of cellular metabolism.
Acute Purulent Inflammation, of the Frontal Cells.—
Acute purulent inflammation of the frontal cells occurs from
an obstruction of the naso-frontal duct, due to acute inflam-
matory swelling of the mucosa. The mucous exudation within
the sinuses becomes infected with pathogenic organisms and
rapidly changes to pus.
Etiology. — The causes of acute purulent inflammation of the
frontal cells are both predisposing and exciting. Among the
predisposing causes are lowering of the tissue resistance of the
mucous membrane lining one or both sinuses, more often uni-
lateral, from acute coryza, la grippe, operations in the nose,
removal of posterior spurs, turbinotomy, exanthematous dis-
eases, lowered vitality from tubercular diathesis, syphilis, ex-
posure to damp and chilling weather and acute or chronic
inflammation of the ethmoidal cells. Hypertrophy of the
middle turbinated body, on account of the possibility of per-
manently or temporarily obstructing free drainage from the in-
"
m
DISEASES OF EAR, NOSE AND THROAT.
fundibiilum, from acute swelling, is a very important factoi
the etiology of the disease.
The exciting causes are more often the presence of some
pathogenic organism, especially the grip bacillus or the staphy-
lococcus pyogenes aureus or albus. The infection may be
mono- bacterial or polj bacterial.
Pathology. — The disease may extend from a like condition
of the mucous membrane or occur as a primary inflammation
of the frontal cells. From the anatomcal Structure, rhr inflam-
mation probably begins as n primary inflammation of the D
frontal duct and is due to some injury of the epithelium fol-
lowed by infection. There is a swelling of all or a portion of
the mucous membrane lining the cavity, follnvu-d by exudation
of serum or fibril] With M exfoliation of epithelial cells and a
leakage of leucocytes. A rapid swelling of the mucous mem-
brane lining the nasn frontal duct may prevent free egress of
air into the cells and in cot^rcpiencc, a SCrOUS congestion may
follow with leakage through the blood-vessel's wall and hemor-
rhagic extravasations. With the presence of pyogenic urgan-
i>ins, the mucous or fibrinous exudation is changed by a process
of peptonization into muco pus and as a result of the chemical
change toxins may be eliminated, which affect the caloric o
Causing a variation in the temperature of the body.
Sytnplntnatnlngy. — The patient ina\ OT ma\ flOt complain of
stoppage of the nose. Pain u\ the frontal region, sometimes
radiating M the temple, car and back of the eye, increasing
in character, is the one symptom complained of most. The
pain necessarily increases as the secretion fills the cells. With
the periodical discharge of the sei retion from the cells, the pain
08 and may even disappear for a short time. The pain
ni,i\ come OTI earlj in the morning with the rising of the
and in consequence, has received the cognomen of sun pain.
However, die pain may make its onset later in the day and
is intensified upon movement, such as walking or stooping.
The conjunctiva of the same side may appear injected and
sometimes edematous. The patient complains of tender
DISFASFS OF ACCESSORY SINUSES OF NOSE.
395
upon percussion and pressure. Frequently there arc marked
systemic disturbances, loss of appetite, elevation of temperature,
a general cachexia and rapid loss of flesh. Upon examination
of the nasal cavity when partial drainage is in progress in the
early stage a thick, tenacious and glairy mucus is detected,
which, with tin: increase of leucocytes, changes into pus or
muco-pus, and may be observed oozing from the juncture
of the anterior tip of the middle turbinate and outer wall
of the nasal cavity. The turbinate may be so swollen that
it is nearly impossible to pass a cotton-tipped probe into the
middle meatus. By watching the point from which any muco-
pus has been removed, a reaccumulation is observed after a
few seconds. A slight necrosis of the epithelium at the site of
the pus may be observed in some cases. If the tissue reacts
to the application of a five per cent, solution of cocain and
adrenalin l/5,000, the positive source of the pus is easily
disclosed.
Diagnosis. — With the foregoing enumeration of symptoms,
the diagnosis is usually very easy. The tuning fork, when
applied to the frontal bone on the affected side, will not be
heard as distinctly as on the unaffected side. When pus is
present, transillumination will show a darkened area in the
affected region. The diagnostic lamp should be placed in the
anulc formed by the nose and eyebrow.
Count and Prognosis. — The course of the affection is ex-
ceedingly variable, the disease usually ending in from one to
two weeks. There is always a tendency to recurrence after a
weeks or during the damp, ooid days of the winter months,
with a lapse into a chronic, purulent, frontal inflammation.
I nder careful treatmenr, however, the disease often ends in
Complete recovery. At the time free drainage has established
itself, the pain ends suddenly and convalescence takes place
very rapidly.
Treatment.— External operative treatment for the relief of
ent inflammation of the frontal cells is seldom, if
nanded.
S96
DISEASES OF EAR, NOSE AND THROAT.
Local treatment consists in the application of a five per
cent, solution of cocain and 1/5,000 adrenalin chlorid to the
region of the infundibulum, followed by a warm alkaline spray.
The cocain and adrenalin should be applied every two hours
to the region of the inflammation, with a cotton -tipped probe
or spray. Warm two per cent, camphor and menthol in albo-
lcne may be dropped into the nose n ith the head thrown far back
as in the treatment of acute or chronic catarrhal inllammatiun
(see page 390). Patients frequently express themselves as being
greatly relieved by the application of this soothing solution.
Dry heat in the form of a Japanese hot box or a hot-water
bottle should be constantly applied over the affected region.
Free purgation should be encouraged by the administrati
calomel in one-tenth grain doses until the free evacuation ot the
bowels is accomplished.
If the pain is very severe, hypodermic injection of inorphin
in one-eighth to one-fourth grain doses may be given. Massage
or gentle friction over the site is often very beneficial.
It is advisable to confine the patients to bed, but in spite of
this advice, they insist upon seeing the physician at his office.
After the active inflammatory stage has passed away, the
sinuses may be flushed with a warm boracic or normal salt
-."lotion once daily. The nose should be sprayed frequently
with a waim alkaline solution. The patient must guard a^;
exposure to cold, damp weather for a feu weeks folio
inflammation. A general tonic treatment is usually indicated
toi a number ut weeks after convalescence has been cstabli •:■
Chronic Purulent Inflammation of the Frontal Cells
or Latent Empyemia. — As the name implies chrome pi
lent inflammation of the frontal cells is a chronic purulent in-
flammation of the mucosa lining the frontal Bunne& < h\c or
both sides may be involved. The two sin; he connected
by a small perforation of the septum, or one sinus only may
exist, as shown by Turner.
Etiology. — The causes arc more often successive ana.
acute purulent inflammation of the frontal cells, in which there
DISEASES OF ACCESSORY SINUSES OF NOSE.
397
is gradual formation of hypertrophies ami myxomatous growths
about the ostium frontalis, which prevent free drainage from
the sinuses and encourage multiplication of infection within
the sinuses. A chronic purulent inflammation of the ethmoidal
cells may produce a like condition of the frontal cells. An
acute empyema of the frontal cells may rupture into the eth-
moid cells or orbital cavity, producing a secondary inflammation.
Symptomatology. — The symptoms are somewhat variable and
arc frequently so obscure as to render the diagnosis often purely
conjectural. The most important symptom is the discharge
of pus from the region of the naso-frontal duct, continuing
over many weeks and months. The character of the pus like-
wise varies and may he nnico-purulent or thick and yellowish.
Fig. 117.
I -,iS-Fkee» TnAr.-5iLi.vMir.AnoN Foa r*osr.u. Sisi's .anh Aktiiiu or
H16HMOM.
Turnrr speaks of Killfan's observation upon the green color
of the pus from the frontal sinuses and says that too much
diagnostic importance must not be attached to any of the
phy 1 ristics of nasal discharge. Small muco-purulcnt
1 ru»tS may farm in the attic of the nose. Tuner mentions as
1I1; DOStlC aid in sinus disease a Condition which has fre-
quently been observed by the author, that the sufferers are
.ious of a fetid odor which an observer is unable to detect.
'
39»
DISEASES OF BAR, NOSE AND THROAT.
"The pain of chronic frontal empyema is somewhat variable
in intensity and sometimes produces night terrors and restless*
ness. Pain at the root of the nose may be Stcd by Hoop-
ing and exposure to damp weather. There may he more
less pain upon pressure, especially in the supraorbital region.
Diagnosis. — In unilateral purulent empyema, the discharge
will be from one side and may be detected making its appear-
ance at the anterior attic of the middle meatus. According to
Grucmvald, Turner and others, pus originating in the frontal
sinuses may, providing the naso-frontal duct is susceptible to
catheterization, be demonstrated by pasting a probe or cannula
into the frontal duct and observing the flow of pus alone the
side of the cannula. Sometimes during the irrigation of the
sinuses, pus may be detected flowing from the region of the
(,stium.
Information gained by transillumination is sometimes very
unsatisfactory ; however, a shadow should be looked for.
Trent me nt. — The treatment in simple, uncomplicated,
chronic, purulent inflammation of the frontal cells witl
involvement of the ethmoidal cells or deformity of the middle
turbinated bone, consists in irrigation of the frontal sinuses
with a mild alkaline solution. Myxomatous growths and
hypertrophies of the middle turbinate should he removed. It is
sometimes only necessary to remove the anterior half in hyper-
trophies of the middle turbinate. Frequentl] the i*>r-
tion of the lower turbinate is so hypertropliied that itispo
of the middle meatus is nearly impossible, Such cond
existing, the anterior portion or all of the lower turbinate should
removed. In suspected involvement of the ethmoidal cells.
the middle turbinate should be removed. It is better to explore
the ethmoidal cells for any suppurative foci. After free drain-
age is established as far as possible and the discharge continues
with the distressing symptoms as enumerated above, the radical
operation is indicated.
In the consideration of external operative measures, it is
hardly necessary to reiterate a proven fact, that nothing but
DISEASES OF ACCESSORY SINUSES OF XOSE.
399
free exposure of the sinus should be undertaken, if the operation
is at ill indicated. There are many methods of external opera-
tive procedures, notable among which are those suggested by
Bryan, H&jek, Killian, Ogston, Luc, Kuhtit and the different
modifications, known as the Ogston-Luc, Hajek-Luc and the
Kulint-Luc.
The teclinique of the different operations are described in
numerous text-books and current literature. All operators
practically advocate the enlargement of the naso-frontal duct
and obliteration of the anterior ethmoidal cells, securing thus
practical permanent drainage. The disposition of the external
wall varies according to the operation. Some operators advo-
cate complete closure of the external wound, others partial
closure, allowing a strip of gauze or drainage tube to pass from
the external surface into the nasal cavity. The deformity
varies and necessarily depends upon the amount of frontal
plates removed, and whether or not primary union of the
cutaneous edges of the wound takes place. In the hope of
preventing deformity, Czerny, Kilter, Latbrop and Others
have recommended an osteo-plastic operation, that is, a flap of
bone i> removed and replaced after curettement of the cells
and establishment of free nasal communication;
A simple operative procedure and one attended by little or
no deformity, described and recommended by many surgeons,
is the following:
I be eyebrow of the affected side is shaved the night before
the operation and the forehead ami face washed with soft soap
and water, followed by washing with pure alcohol. The parts
are dried and covered with gauze and bandages. Before pm-
reeding to the operation, the post-nasal space on the affected
Side is sometimes plugged with gauze With chloroform or
ether anesthesia, the parts being again disinfected, a curved
incision is made from approximate! y the supra-Orbital notch,
along the lowei edge oi the eyebrow, to, or slightly below, the
riM»t of the nose, down to the bone. The periosteum is sep-
arated and pushed back with a periosteum elevator. The
4oo
DISEASES OF EAR, NOSE AKD THROAT.
edges of the wound arc separated with retractors. With ■
small trephine, or preferably, a gouge and mallet, an opening
sufficiently large to expose the cells and permit of exploration
is made on the line of incision and one-thin! the distance from a
median line of the forehead to the supra-orbital notch. The
hemorrhage is quite profuse and is controlled by compression
or ligation of the supra-orbital artery. The bone at this point
is thickest and requires considerable excavation to reach the
muco-periosteal lining of the cells, which is of a dark bluish
cast in counterdisrinction to the white appearance of the dura-
mater. Where the skin incision is insufficient t the
sinus for examination, a second and vertical incision from
the base of the nose as in the Efajec-Luc operation, may be
made and the triangular flap turned upward. The mucous
membrane of the sinus is incised and the cavity explored
with a blunt-poinred, malleable probe. Pus and debris should
be washed away with a warm normal salt solution. Polypi,
hypertrophies and muco-periosteal lining of the cavity should
now be curetted away. The naso-frontal duct should next
be located and enlarged with a curette and the anterior eth-
moid cells broken through so that a free opening exists, as
described by Turner,' large enough to permit the passage of
the little finger. Unless the opening is made as large as
possible, there is no assurance against its early closure. The
sinus is curetted in all its ramifications of all disrased mucous
membrane and swabbed with a one-twentieth carbolic acid
solution or a fifteen per cent, solution of nitrate ot silver. A
drainage tube is now inserted within the sinus and anchored
with | safety pin, the nasal end extending well into the nasal
cavity. The wound is carefully closed up to the drainage
tube. The external wound is covered with iodoform gai
and bandage. The patient is instructed to remain in bed
quietly for four or five days. Tli wound is inspected in
twenty-four hours and the drainage tube sy _hly
with I warm Dobell's solution. The tube should lie ■•
a number of weeks. A new tube may occasionally be inserted
DISEASES OF ACCESSORY SINUSES OF NOSE.
40I
by attaching it to the old one and drawing it into the wound.
After the tube is removed, the wound is allowed to heal.
A modification of the above operation in regard to the final
closure of the wound is that of Luc, in which the sinus is
packed with a strip of gauze, the end protruding from the
nostril and the external wound entirely closed. The gauze
packing is removed through the nose after two or three days.
In severe and complicated cases with entire involvement of
the ethmoidal cells and inability to thoroughly curette the rami-
fications of the sinuses, the operation of Kill inn or the Kuhnt-
Luc operation, i. e., osteoplastic flap in place of chiseling away
the outer tahle, is necessary.
The operation designed by Killian and known to the world
as the Killian operation consists, under chloroform narcosis
and rigid antiseptic precautions, in first making an incision
from the temporal extension of the eyebrows to the middle
of the base of the nose down to and through the periosteum.
The vertical and lateral extension of the sinus is first, however,
determined by a skiagraph. The sinus is perforated with a
chisel, care being taken not to wound the mucous membrane.
Wirh a blunt-curved probe separating the mucosa from the
frontal plate, the vertical extension of the cell is discovered, and
from this point a second incision is made in the median line
down to and joining the primary incision at the base of the nose.
The flap is now dissected upward. The frontal wall as outlined
wirh a blunt-pointed probe is chiseled away, followed by curcttc-
ment of the entire diseased mucosa. The ethmoid and even the
sphenoid cells may now be opened. The floor of the sinus at its
nasal portion is now chiseled away and the nasal cavity entered
with a sharp bistoury: the nasal mucous membrane is brought
forward and stretched to the wound facing the nasal cavir\.
The flap of skin and tissue is now stretched into place.
The patient is instructed not to blow his nose, but to suck
nil the secretion back into the pharynx. The depression pro-
d by the removal of rhe frontal wall, according: to Killian.
is filled up with granulation and hut little scar results. During
I
4-02
DISSASBS OF EAR. VOSE AND THROAT.
the removal of the upper wall of the orbit, there is great danger
of injuring the eye.
Mucocele. — Mucocele is a retention cyst, due to a serous
transudation from the mucous membrane Lining the sinus, which
is prevented from escaping by chronic catarrhal inflammation,
tumors, hypertrophies, etc., of and about the naso-frontal doOt
Etiology. — The disease is often due to chronic catarrhal
inflammation of the mucosa, extending primarily from the
nasal cavity. Polypi, hypertrophies of the middle turbinate,
caries and necrosis of the naso-frontal duct are important I
tors in the etiology of the disease.
Symptomatology. — When the naso-frontal duct is slightly
open, the symptoms are those of a chronic catarrhal inflamma-
tion of the frontal cells. The patient complains of great dis-
tress at the base of the nose and along the frontal prominence.
Where the nasofrontal duct is completely closed, the pain be-
comes very great from distension and pressure. The pressure
may be so great as to cause the tumor to bulge into the nose.
The cyst wall and contents may degenerate with the formation
of straw-colored fluid or pus. The symptoms then become the*
of empyema.
Diagnosis. — Pain in the supra-orbital region and root of
the nose, history of occasional discharge of mucus from the an-
terior narcs. tenderness and swelling at the inner angle of the
Dibit are BlgOS of the disease.
Treatment. — If the cystocelc bulges into the nasal cavity.
it should be opened by incision. Sometimes by the evacuation
of the contents of the cyst the naso-fruntal duct dilates an*
due course of time returns to the normal without further
operative procedure. If there is a retention cyst of the sinus,
the treatment is the same as for empyema of the frontal ccDt
The cells should be opened by one of the more simple opera-
tions and the serous exudation evacuated and the err.
gated with a saline solution. The wound should be prevented
from closure by tamponing with strips of iodoform gauze. The
cavity is irrigated once daily until free and uninterrupted drain-
age is established through the naso-frontal duct.
DISEASES OF ACCESSORY SINUSES OF N'OSE.
403
Foreign Bodies in the Frontal Cells. — Foreign bodies in
the frontal cells may gain entrance through the naso-frontal
duct and BUI) bo maggots, screw-worms and other insects.
Foreign bodies which gain entrance from the exterior are
bullets from gunshot, point of knife blade from stab, and par-
ticles of iron due to explosion.
Symptomatology. — In the consideration of insects in the
frontal cells, Burnett makes special mention of marked de-
pression of the general health, followed by intense frontal
headache, frequent epistaxis. mucopurulent discharge from the
nose, severe swelling of the eyelid, the patient becoming deliri-
ous and frequently developing suicidal mania.
Diagnosis. — The diagnosis of insects in the frontal sinus
is difficult and may only be differentiated when the larva? arc
red escaping from the naso-frontal duct with the nasal
muco-purulent secretion or upon trephining of the cells. The
diagnosis of the presence of inanimate objects is usually by
history' of the case or inspection of the wound.
Treatment. — The treatment for foreign bodies in the frontal
BUtUE is nece^arih surgical and consists in trephining the sinuses
and irrigation. The wound is irrigated with a mild antiseptic
on and tamponed with iodoform gauze. After all dan-
ger of infection is passed, the tampon may be removed and the
wound allowed to close by granulation, which is usually very
rapid.
Fracture of the Outer Plate. — Fracture of the outer plate
may result from a blow or fall upon the forehead. A fracture
may be depressed, compound or comminuted. The outer plate
may be so shattered that there is complete exposure of the
frontal cells, sufficient to allow insertion of the linger.
Treatment. — In simple depressed fractures, the treatment
is rest in hrd and cold applications over the site of the injury
for the first twenty-four hours. Sometimes severe vomiting
and nttfOOS disturbances follow from this injury but are
purely transitory in character. Tn compound comminuted
fractures, small spicula of bone should be removed ; provided
4°4
DISEASES OF EAR. NOSE AND THROAT.
there is no undue pressure on the internal plate, depressed I
may be left alone. The outer fragments may be lifted into
position if there is much deformity. The wound is tamponed
with iodoform gauze for a few days until repair takes place
and all danger of infection has passed away. The parent
should remain quietly in bed fur the first few days and atten
tion should be given to the digestive appaiaius, 06 in air, other
surgical operation. If there is no great swelling, infection or
pain in the wound, the gauze packing should remain in the
wound for four or five days, when it may be removed and the
wound allowed to heal.
Tumors of the Frontal Cells. — Tumors of the frontal
cells may be malignant, benign or mixed and may be of local
origin or due to an extension from contiguous structures. The
malignant tumors which may occur in this region are Mr-
OOflUt, carcinoma and mixed tumors.
Non-malignant tumors may be cyst, osteoma, myxoma a
fibroma. The possibility of syphilis and tuberculosis as a cause
of swelling of the frontal cells, should not be overlooked.
Treatnunt. — The treatment in all cases of tumors depend*
somewhat upon the rapidity of the growth and the character
of the tumor. I m mediate removal of all structures is indicated
En malignant growths. NoR-malfgnani eumon maj he dealt
with according to the exigencies of the occasion. As a n
all tumors of the frontal cells should be removed.
CHAPTER XXIII
DISEASES OF THE ACCESSORY SINUSES OF THE NOSE
(CONTINUED).— ETHMOID CELLS.
Acute Ethmoiditis. — Acute ethmoiditis is an acute in-
flammation of the mucous membrane lining the ethmoid cells.
Etiology ami Pathology. — Acute inflammation of the ethmoid
cells may be a primary or secondary involvement. The secon-
dary form is due to extension of infection from a like condition
of the nasal mucosa. The disease is one of the complications
of measles, scarlet fever, typhoid fever and influenza. Edema
of the nasal mucosa may bring about a closure of one or all of
the ostia of the cells, producing acute retention of secretion.
In acute catarrhal inflammation, the mucous lining of the
; ill-. Iktooio swollen and congested, followed by a profuse
serous exudation, which may become muco-purulent in character.
Symptomatology. — There is present headache, pain about
the orbit, general or acute coryza, pain in the region of the
sinuses when stooping over, slight rise of temperature, with
often mental dullness. When there is marked retention of
moon purulent secretion the pain in the region of the sinuses,
temples and forehead becomes excruciating. The discharge
from the cavities varies in character with the severity of the
disease from a thin mucus to a thick, creamy pus. The dis-
ease may be unilateral or bilateral.
CottTH and Prognosis. — The course of the disease usually
varies in severity and may continue from one to two or three
weeks. The symptoms gradually disappear and the swelling
: ii.! i . ;d obstruction recede, the patency of the ostia is restored
and free drainage is established with the recovery of the patient.
There is always a tendency for the disease to become chronic.
Diagnosis. — The diagnosis usually depends upon the fore-
405
I
406 DISEASES OF EAR, NOSE AND THROAT.
going symptoms. Upon inspection, the nasal cavity is usually
hyperemic. The middle turbinate is swollen nnd impinges upon
the septum, causing stenosis and autophonia.
Upon inspection, a sero-mucous discharge is seen filling the
middle meatus and covering the middle turbinate. The secre-
tion filling the middle meatus or olfactory cleft is a thin glisten-
tag mucus, changing in consistency as the disease advan«.t>.
Fie. 1 1 8.
Kiixian's Nasal SpCCQ
Treatment. — The intra- nasal treatment varies but little
from that of acute inflammation of the frontal cell*. The
swollen and congested condition of the middle turbinate can
best be reduced with ;i two per cent, solution of cocain and
adrenalin 1/3,000, dropped into die attic of the nasal on
while die head is suspended over the end of a couch or table.
This method of treatment should be repeated four or five ti
daily.
Where this plan of treatment is contra- indicated from age or
other contingencies, the treatment consists in spraying the
nose as high up into the attic as possible with a solution of
adrenalin chlorid 1/5,000, followed by a warm alkaline
This should be repeated four or five times daily. In addition.
DISEASES OF ACCESSORY SINUSES OF NOSE.
407
the
patient, if an adult, should be given ten grains of Dover's
powders and one grain of calomel at bed-time, followed by a
Seidlitz powder or Hunyadi water upon arising.
The pain from ethmoid itis depends a great deal upon the
amount of exudation within the cells and the patency of the
ostia. Where the pain becomes very severe, five grains of ace-
tanilid compound and one-fourth grain sulphate of codeine may
be given the patient every three or four hours. Hot applica-
tions in the form of dry heat across the forehead and eyes
will aid in alleviation of the congestion and pain.
On account of the tendency of the disease to recur, the pa-
tient should be warned against over-heating the body and
sudden exposure to cold draughts of air. Hypertrophies of
the middle turbinated body, polypi or any other tntra-nasal
malformation or catarrhal condition of the mucosa should be
removed as soon as active symptoms of the disease have passed
away.
Chronic Inflammation of the Ethmoid Cells. — Chronic
inflammation of the ethmoidal cells is a chronic inflammation
of the mucous membrane lining one or all the ethmoid cells.
Etiology. — The disease is more especially due to recurrent
attacks of acute inflammation of the ethmoid cells and is often
located in the posterior cells. The condition may also be due
to chronic nasal catarrh, polypi, syphilis and tuberculosis. One
of the important factors in the causation of the disease is im-
perfect drainage from hypertrophy of the middle turbinate which
produces a lessened amount of atmospheric pressure in the
attic lit the nose, thus preventing necessary air pressure and free
ventilation of the cells and physiological suction caused by
currents of air passing uninterruptedly through the nose. The
!tM rn.iv sometimes involve the bony structure, according to
Shirley, producing a necrosing clhinoiditis or ethmoiditis
granulosa.
Pathology. — The pathology of the disease varies but slightly
from that of chronic catarrhal rhinitis. There is a thickening
of the whole structure of the mucous membrane with a rapid
-
proliferation of mucus, broken-down epithelial cells and some-
times muco-pus. There is but a step from chronic nmco-puru-
lent inflammation of the ethmoid cells to purulent cthmoi d
Symptomatology. — The patient may complain of tin
stant accumulation of mucus in the posterior attic of the no*e.
necessitating hocking and expectorating. Accumulation of mu-
cus may be from one or both sides of the nasal space. There
is often an accumulation of thick mucus in the anterior auk
of the nose, which, upon being blown from the nose, renders the
attic of the nose patent for a short time.
The constant dropping from the post-nasal cavity is more
often due to a catarrhal inflammation of the ethmoid cells.
This may he especially demonstrated by the removal of the
middle turbinate and the free drainage of the cells. In those
cases in which local treatment had proven of no avail, the
cause of the continual discharge will often be found to be
located in the ethmoid cells. The secretion may flow <!■
from the middle or lower turbinated bodies and from evapora-
tion of watery constituents, form thick crusts in the attic and
along the floor of the meatuses, which predispose to catarrhal
inflammation of the nasal mucosa.
Diagnosis. — With the above enumeration of symptoms, ilr
diagnosis is sumetimes easily established. Where thrre is a
necrosing rrhmoiditis, the same may be disenvrrrd by first
cocainizing the attic of the nose and afterward exploring with
a slightly curved, bhint-pointcd probe.
In posterior rhinoscopic examination, the discharge may some-
times be discovered emerging from the ethmo-sphenoidal recess
and covering the lateral walls at the naso-pharyngcal junction.
On account of the anatomical position of the ethmoid cells it
is frequently an impossibility to detect through the anterior
narcs secretion in the superior meatus. Secretions, however,
from the anterior ethmoidal cells, draining into the middle
meatus may be often accurately differentiated as coining from
the ethmoid cells.
Among the frequent eye complications of chronic ethmoiditis
DISEASES OF ACCESSORY SFNUSES OF NOSE.
409
arc asthenopia and pain behind the eyes, associated with
periodical attacks of frontal headache.
Course and Prognosis. — The course of a chronic inflamma-
tion of the ethmoid cells is usually very slow. The great ma-
jority of these cases go undiagnosed and the patient receives
treatment all the while for a chronic catarrhal inflammation
of the nasal mucosa. The probability of an early cure depends
upon the surgical measures, that is, the removal of the middle
turbinated body, the establishment of a free ventilation of the
attic ui the nose and uninterrupted drainage from the cells.
Treatment. — Local medication consists in spraying the an-
terior nares and irrigating the post-nasal space with a nasal
douche, with Seder's or Dohell's solution, twice daily. In
mild catarrhal inflammation of the anterior ethmoid cells, tam-
pons dipped in fifty per cent, ichthyol and equal parts of gly-
cerin and water may he placed in the attic of the nose for nuc-
hal t huiir daily, followed by a spray of camphor and menthol in
albolene.
In addition, tonics and alteratives are indicated according to
the general condition of the patient.
Anterior hypertrophies of the middle turbinate or polypi
should he removed. The presence of polypi in the superior
meatU vn frequently only discovered by removal of the anterior
halt of the middle turbinated body. After the removal of polypi
From the region of the infundibulum and superior meatus, ne-
CTOtic areas may frequently he discovered, which demand system-
atic curcttement, followed by daily irrigation with a mild alka-
line solution and direct application of fifty per cent, argyrol or
fifty per cent, ichthyol on a cotton-tipped probe. This should
be continued daily until recovery is complete.
Suppuration in the Ethmoidal Cells or Ethmoidal
Sinusitis. — Ethmoidal sinusitis is an acute or chronic puru-
lent inflammation of the mucous membrane lining one or all
of the ethmoidal cells, originating in loco or by extension of
infection from contiguous parts and may be unilateral or bi-
lateral, closed or manifest.
JIO
DISEASES OF EAR, NOSE AND THROAT.
Etiology.— The cause of acute purulent inflammation ot the
ethmoidal ceils is some disturbance of tlie metabolism irom in-
fection from some pathogenic organism. Infection from the
grip bacillus is probably the most trequcnt factor in the causa-
tion of the disease. Infection may be carried into the ethmoidal
cells by irrigation with a douche and as suggested by Luc, may
follow washing of the maxillary sinuses.
Intra-nasal surgery and the application of the galvanocautery
may be followed by infection, ending in acute, purulent sini.
Because of the interference with free ventilation of the attic
of the nose and drainage from the anterior ethmoid cells, hyper-
nnpln of the middle turbinate is one factor in the causation d
the disease.
Purulent inflammation of the frontal 01 sphenoidal cells may
iid to a&d Involve the ethmoidal cells. Infection maj
also follow from fracture or suppuration in the orbit.
The predisposing causes ot the acute form 01 the disease are
the same as for acute, catarrhal inflammation of the ethmoidal
cells (see page 404).
The cause of chronic, purulent inflammation is a failure of
the acute, purulent inflammation to undergo complete resolution
or a gradual change of a chronic, catarrhal inflammation into
a chronic purulent inflammation by the admixture of patho
lismsr
The predisposing causes are a lowering of dlfl Btetabol
the body from inherited or acquired disease, hypertrophy of the
middle and lower turbinates, catarrhal inflammation of the nasal
mucosa and polypi.
Pathology. — The pathology H the MUfle as that of purulent
inflammation of the frontal cells.
Symptomatology. — The symptoms of acute purulent inflam-
mation of the ethmoid cells or closed suppuration arc more pro-
found than symptoms of latent or manifest empyema.
In closed suppuration we have all the sym acute
inflammation with a retention of pus. The pain is severe and
deep-seated and may involve the entire face and is more espe-
DISEASES OF ACCESSORY SINUSES OF NOSE.
4II
dally directed tu the forehead] posterior and inner angles of tlit-
eye. Photophobia may be present. These IS mental dullness,
otophonia, loss of sleep, Constipation and rise of temperature.
1 he \ mptoms continue until spontaneous rupture and free evac-
uation of pus takes place.
The symptoms of latent empyema vary in individuals and
frequently resemble those of acute empyema.
There may be general mental depression, melancholia and a
Sensation of distention in the bridge of the nose. The patient
complains of an offensive and disagreeable odor, which cannot
be detected by the physician. The discharge from the nose is
variable in amount and character and may be muco-purulent
or thick, creamy or yellow pus. There is often an accumulation
lit a niu<;ei-purulent substance in the post-nasal space, nccessi-
tating frequent hocking and expectorating.
Crusts frequently form in the attic or middle meatus of the
nose and arc blown from the nose as thick slugs. Sometimes,
following the removal of the slugs, the patient complains of a
foul odor and taste in the mouth.
Where we have accumulations of slugs of mucus with de-
generation, there is usually loss of appetite, general debility.
headache and insomnia. In the more advanced form of the
disease, the patient may complain of pain in the ears, radiating
to the temples and behind the eyes, especially at night. In
chronic latent or closed empyema, the ethmoid cells may become
extended, protruding into the inner angle of the eye, some-
times rupturing and forming fistulous openings through the
upper or lower lid. At the same time, the cells may extend into
the nasal cavity, completely occluding the naves. Under such
circumstances, the cells periodically rupture and refill again.
During thr process of refilling, the patient suffers all the
SjrtD] 1 usitis. Upon inspection of the anterior
nares in manifest empyema, thick and yellowish pus from the
anterior ethmoidal cells may be detected draining into the
middle nn The drainage may be slow and in consequence,
thick, yellowish crusts are formed. The crusts should be lifted
412
DISEASES OF KAR, NOSE AND THROAT.
genrly with a probe and detached with the hope of detecting the
origin of the pus. Sometimes with a blunt-pointed probe passed
up into the middle meatus, pus may be observed flowing al
the probe. If necrosis of bone is detected in this region, the
diagnosis is positively established of suppuration in the anterior
cells.
It sometimes occurs that the middle turbinate is shrunken
during the day, which permits of some degree oi comfort in nasal
breathing, but at night upon lying down it swells, impinges upon
the septum and produces headache, difficult breathing and ob-
struction to the exit oi pus from the sinuses. As soon as the
patient is up and about, the tissue relaxes and pus begins to I
into the anterior or posterior nares.
Sargent F. Snow makes the assertion that eighty per cent,
of the cases of Tic Douloureux are due to intranasal or sinus
pressure. The number of cases dependent upon ethmoidal af-
fection is of course conjectural, bur is undoubtedly very large.
If the purulent discharge passes into the post-nasal space for
a great length Oi time, infection with swrllin i
rtdfl about the ostium tuba takes place, produi ing chronic
salpingitis and catarrhal deafness. The patient may also 0
plain oi insomnia, indigestion and loss of flesh.
Diagnosis. — The diagnosis oi suppuration of the anterint
and posterior ethmoid cells is not always an easy matter. There
is usually present a catarrhal inflammation of the nasal mucosa
and as enumerated under symptom of the disease, thick crusts
form in the nasal cavity. These crusts are sometimes more
apparent in the postnasal space. Frequently the first evidence
of chronic empyema in the anterior ethmoid cells is the pres-
ence of small polypi an.l granulating tissue springing from the
region of the infundibulum. Upon removal of the polypi or
granulations an.l exploration with a blunt-pointed probe, pus
of a creamy consistency may be detected Rowing from the
anterior Cells. Upon post-rhinoscopy, when- the Posterior 0
are involved, pus will be observed draining backward from
middle meatus over the posterior portion of the middle tur-
DISEASES OF ACCESSORY SINUSES OF NOSE.
4'3
binate and along the lateral walls of the pharynx, sometimes
ring the hood of the ostium Cuba.
It is sometimes only passible to differentiate the disease upon
removal of the middle turbinated bones. By so doing, the
sphenoidal sinuses will be exposed for direct exploration and the
presence and ahsence of pus in this region can he demonstrated.
It is often possible without removing the middle turbinate, as
shown In the illustration, ro pass a curved cannula, shaped after
that of the Eustachian catheter, directly into the sphenoidal
sinuses, thus ascertaining the presence or absence of pus in this
region (see directions for irrigating the sphenoidal colls). With
the cannula in position, fluids 01 pus within the sinuses may be
I H.. t |g,
■
sucked out with 8 Witter bag. Pus ma] he detected by the
character of the secretion in the cannula or by microscopical
examination.
.:mcni. — The treatment of acute purulent Inflammation
of the ethmoidal sinuses is the same as that for acute serous
inflammation in this region. The treatment of chronic empyema
of all the cells is purely surgical and is directed to the estab-
lishment oi free communication of the cells with the nasal cavity
nverting the small cells into one large cavity.
I
n i.*t>.
I. dolmen's «•»*■ "ii few fcmi>v»l of tl»c middle turbinated body;
f, Ijomr turbinated body; ., Middle turbinated body. i. Stlperiw turbinated
body.
DISKASKS OF ACCESSORY SINUSES OF NOSE. 4 1 5
FlC. 121.
r, L11. in portion U - naval of the middle turbinate, after
HI partially ibrouKli with Holmes's Bci&sors: .\ Middle turbinated body;
■
GhUSMWALD Pi •■>n tub Rm <«i or mi Pi>tui"<
I'omiok or nit Su renew Tvmixatb *sx> Pomouoi »
/, Grnenvrald punch forceps; : P \*»*iti
body; j, Shutting the anterior ponton ..f ' ■ mmrrr4, <
poiing the nuo-frenul duct; y, Sphenoidal cell.
DISEASES OF ACCESSORY SINUSES OF NOSE.
417
In involvement of the anterior cells, polypi and necrosis of
bone, the surgical treatment consists in the removal of the
anterior end of the middle turbinate, as shown in the figure,
removal of the polypi and curettement of the cells. If the
disease is confined to this region alone, with the establishment of
free drainage and systemic irrigation, recovery may be com-
plete. If the middle meatus is wide and the middle turbinate
narrow, it may sometimes be unnecessary to remove a portion of
thai uiettement bcinp usually accomplished without in-
jury to the turbinate bone. In involvement of all of the cells,
the middle turbinate is removed under local anesthesia with a
five per cent, solution of cocain and 1/1,000 adrenalin chlorid.
The nasal cavity is previously cleansed as for any internasal
operation. (In referring to Fig. 120, Holmes's scissors are
shown in position.) With the first cut of the scissors, the tur-
binated bone is partially severed from its attachment. The
N i^ors are now withdrawn and a Luc forceps inserted as in
Fig. 12 1, which grasps the turbinate, and by gently twisting the
entire turbinated bone is removed. Following the removal of
the turbinated bone, the area of the operation is rendered free
from hemorrhage with applications of cocain and adrenalin. The
anterior cells are sometimes exposed in the first incision with the
Holmes adssors and if not exposed at this time, they should be
opened with a sharp curette. Following this, the Grucnwald
punch forceps (Fig. 122) may be used for complete obliteration
of the posterior ethmoidal and sphenoidal cell. Following the
breaking down of the cells with a free communication of the
nasal space, the cavity is freed of all myxomatous growths,
hypertrophies. Granulations and necrotic bone by gentle curette-
ment. The exposed cavity is now irrigated with a Dobell's
solution and the patient put to bed with the instructions to
spray the attic of the nose with iced Dobell's solution and
. : enalin chlorid every hour for twelve hours, after
which time the patient may be allowed to go about the room.
After four or five days, the patient may take gentle exercise out
of doors, with the nasal cavity protected with small plugs of cot-
I
4.S
DISEASES OF EAR, NOSE AND THROAT.
ton in the vestibule of the nose. The local treatment con-
spraying the attic of the nose and nasal cavity with a warm Do-
bell's solution and irrigating through the post nasal space with
the same solution. Purulent discharge may continue for some
FlC. 1 2 J.
COAKLKV'a SlMUS ruint'
length of time after operation, though it gradually disappear;
with the healthy regeneration of the mucous membrane lining
the cavity.
Fig. 124.
Mi 1 ia'a Nmai I
Neoplasms of the Ethmoidal Cells.— Neoplasms of the
ethmoidal cells on account of the frequency oi the involvement
of the ethmoidal cells over other accessory cavities, are not in-
frequent!) obsei
Tumors in the ethmoidal cells ma) 1m- malignant, ben
mixed. Syphilitic granuloma are frequently observed invol .
the ethmoidal cells. Mj xomatous growths, as mentioned before.
28
DISEASES OF ACCESSORV SINUSES OF NOSK.
419
are extremely frequent in this region and if not changing into
malignant growths, induce malignancy by irritation.
Treatment. — The treatment of all growths of the ethmoidal
cells is necessarily operative anil consists in following out the
well-known classical operative procedures. The technique dif-
fers but little from that of operations for empyema. In curette-
ment of the ethmoid cells for syphilitic granuloma, general ne-
crosis and tubercular infiltration, great care should he taken
lest the brain cavity be exposed, predisposing to meningitis and
brain abscess.
Syphilis of the Ethmoidal Cells. — Syphilis of the eth-
moidal cells is more often a tertiary lesion and may extend from
an ulceration In contiguous parts or originate primarily in the
ethmoidal cells. On account of the frequency of inflammation
in the ethmoidal cells, metabolism of the parts is reduced, and
in consequence) tertiary lesions in this region are not infrequent.
Symptomatology. — The patient may complain for some time
of nasal stenosis and of the symptoms of acute ethmoiditis.
With the necrosis of bone, there is more or less purulent dis-
charge from the nose and fetid odor which is easily detected.
1 h<- patient may sometimes blow spicula of bone from the
nose. I here is usually present a history of syphilis dating over
a numbei of sears. In young children the disease is usually
purels congenital.
Diagnosis. — The disease is differentiated frcim chronic puru-
lent inflammation of the ethmoidal cells by a histoid (>f syphilis
and general symptoms of syphilis, either inherited or acquired.
There is usually an offensive odor, which is not so conspicuous
in simple, purulent inflammation of the ethmoid cells. With
• tton-tipped prohc passed into the region of the ethmoid cells,
necrotic bone is detected by the peculiar grating sensation im-
parted to the prohc.
Treatment*- In addition to the general anti-syphilitic treat-
ment for necrotic hone, hypertrophies or polypi within the region
es should he removed. If the spicula are too large
removed c| injuring the contiguous pans, the bone
I
Catarrhal Sphenoiditis. — Inflammation of the sphenoidal
cells may be acute or chronic, unilateral or bilateral (see
Fig- 35).
Etiology. — The cause of acute inflammation of the sphen-
oidal cells is often the same as that producing EC like inflammation
of the ethmoidal cells. From an attack of acute rhinitis, the
mucous membrane of the sphenoidal ostium swells, closing the
cavity, which causes a retention of secretion. The cause of
chronic catarrhal inflammation is the same as for a like condi-
tion of the ethmoidal cells. Among the predisposing factors of
the disease are syphilis and tuberculosis.
Pathology. — The pathology varies in no wise from that of
acute or chronic catarrhal inflammation of the ethmoidal cells.
Diagnosis. — The diagnosis of catarrhal sphenoidal inflam-
mation is exceedingly difficult and is frequently overlooked.
In acute catarrhal inflammation with retention of secretion,
there may be pain behind the eyes, radiating to the ears, photo*
phobia and symptoms of a post-nasal catarrh, dropping from the
post-nasal space or from cither the sphenoidal or ethmoidal
cells. Catarrhal exudation from the sphenoidal cells, because
of the anatomical structure and movements of the pharyngeal
muscles in swallowing, flows with greater facility toward the
median line of the pharynx than secretion from the posterior
ethmoidal cells, which more naturally drain along the lateral
walls of the naso-pharynx. The presence of chronic catarrhal
inflammation may sometimes be established by catheterization.
Periodical attacks of headache, deep-seated and reflected
421
to the occiput, with dread of light, is highly suggestive of
retention of secretion in the sphenoidal cells.
Treatment. — The local treatment of acute inflammation is
the same as for acute rhinitis. The region of the sphenoidal
ostia should be sprayed with a five per cent, solution of cocain,
followed by adrenalin chloric!, 1/5,000. Argentina nitrat-
9 strength of from ten to fifteen grains to the ounce or a I
per cent, solution argyrol, should be applied to the mucous
membrane about the ostia with a curved, cotton-tipped piobe.
The post-nasal space should be irrigated twice daily with a
warm Do bell's Eolation in the post-nasal douche.
The general treatment consists in flushing tin- bowel-
Dorsey's mixture or magnesia sulphate, followed bj large doses
of salicylate of soda.
The treatment of chronic' catarrhal inflammation consists
in irrigating with a warm alkaline solution eVerj two or three
days. In case a chronic sphenoidal inflammation is suspected
and the cavity cannot be reached with a cannula, the middle
turbinate should be removed in its entirety, thus permit
direct therapy under the guidance ot flu- ew. I In- presence
of polypi or granulation tissue in toe region of tbe ostium
catee necrosis of the cells and necessitates curettiement,
Acute Empyema. — Etiology. — Acute ci spbe
noidal cells is an acute purulent inflammation <>: the n
periosteal lining of one or both cells and is due to some
pathogenic infection. The causes arc both predisposing and
exciting.
The predisposing causes are syphilitic and tubercular diathesis,
exanthematous diseases, influenza, typhoid fever, acute naso-
pharyngeal catarrh and purulent inflammation of the post'
ethmoid cells.
The exciting cause is some pathogenic microorganism, es-
pecially the pneumococi us.
Ptithotngy. — The pathology is the same as thai fof any other
mucous membrane inflammation. On account of thr complete
aeration of the cells from a compa large ostium and
DISEASES OF ACflSSoR', SINUSES OF NOSE.
423
close apposition of the nasal mucous membrane to the bone,
inflammation of the sphenoidal sinus is less frequent than the
frontal or ethmoidal cells. These ma\ be ;i natural tissue resist-
ance to infection, nature's compensation lnr the anatomical
situation of the sphenoidal ostium.
Symptomatology. — In acute sphenoidal empyema, the patient
may complain of severe coryza, sudden pain in the top of the
head, radiating to the front of the ear and side of the- face 00
one or both tides, dizziness, rise of temperature, constipation
and sometimes nausea, vomiting and delirium. The pain in the
ears may resemble that of acute otitis media or Tic Doulourettitx.
There may be present a dread o1 light and the patient remains
closed in a darkened room. There may be pain of a deep,
boring character in back of the eyes. The symptoms of pain
continue until there is spontaneous rupture into the spheno-
ethmoidal recess and a free Hon of pus.
Diagnosis, — The diagnosis of acute purulent sphenoid:^
depends, to a great extent, upon the above enumeration of
symptoms, which readily suggests the region affected. Acute
inflammation of the ethmoidal cells resembles in symptomatology
sphenoidal inflammation, but can usually be differentiated after
ocular inspection of the nasal cavit\ and shrinkage of any intra-
nasal hypertrophies. Acute retention of pus in one or both
sphenoidal cells is very difficult to detect, unless effort is made
to enter the sinus with a cannula, followed by irrigation. After
Spontaneous rupture and discharge of pus. the same may be
detected u ith rhinoscopic mirror, flowing from the region tA
the spin ■iiii-mstiiim and near the median line. In suspected cases
of sphenoidal involvement, irrigation of the cells should be at-
tempted. With the relief of the symptoms following irrigation,
the diagnosis is established. Frequently the disease may establish
itself at Bhort intervals, demanding a number of irrigations.
Course and Prognosis. — The course of acute, purulent sphen-
oid iris is exceedingly slow on account of the anatomical position
lie ostium and imperfect drainage. The disease has a ten-
dency to become chronic.
4*4
DISEASES OF EAR, NOSE AND THROAT.
Treatment. — The treatment is the same as for acute puru-
lent ethmoiditis. Attention is first directed to securing free
evacuation of the bowels and free aeration of the attic of the
nose by the shrinkage of any enlarged middle and lower tur-
binates. With free ventilation of the nasal cavity, spontaneous
evacuation at the sphenoidal cells is a natural condition.
For the relief of the pain in the region of the sphenoid
and along the course of the tri-facial nerve, codeine in one-
fourth grain doses combined with aspirin in five to ten gram
do*es may be given every three hours. Hot foot-baths should
be given two or three times daily. Warm nasal douche of
Dobell's or Sellers solution should be ordered twice or three
times daily. Once daily, the region of the sphenoidal ostium
should be cocainized and argentum nitrate, twenty grains to
the ounce, applied with a curved cotton-tipped probe passed
through the nasal cavity.
With the dLsiharge of pus and a continuation of pair
sinus should be irrigated through a Freeman cannula, once
daily, with a mild alkaline and antiseptic solution.
Any constitutional cachexia should be corrected by altera-
tives and tonics.
Purulent inflammation of the ethmoidal cells that may be a
contributing factor to the disease should be corrected by the
removal of the middle turbinate, establishment of free drainage
and the removal of any diseased tissue.
Chronic Empyema. — Etiology. — A chronic purulent in-
flammation of the sphenoid cells may be unilateral or bilateral
and is often due to an acute purulent inflammation.
Pathology. — There is a destruction of the muco-periosteal
lining of the cells, either partial or complete with sometimes
the formation of granulation tissue and polypi. With the
destruction of tissue by odor-producing bacteria, a condition
of ozena sphenoidalis is brought nbout. The staphylococcus
and pi: us may also he present.
On account of the slow process of necrosis in the bone, and
thinness of the superior walls of the sinus, then- is a ^r;u«-
DISEASES OF ACCESSORY SINUSES OF XOSE.
425
tendency to the formation of a brain abscess, optic neuritis
or anesthesia due to disease of the spheno-palatine ganglion.
Symptomatology. — Recurrent attacks of the retention of pus
in the sphenoidal cells give rise to the symptoms of exacerbation
of acute purulent sphenoiditis. Exacerbations of attacks of Tic
Douloureux and ozena may frequently be traced to sphenoidal
involvement.
The discharge of pus from the p«st-nasal space resembles
the symptoms of post-nasal catarrh and may, unless a very
careful inspection is made, be mistaken for post-nasal catarrh.
Crusts may form in one or both sides of the nose, high up in
the channel from the accumulation of mucus and pus and the
evaporation of watery contingents.
The character of the pain varies in individuals and may be
that of a dull headache or a sensation of dullness of the head
and intellect. In exacerbations of the disease, the pain may
become harrowing in the extreme. The. location of the pain
may be in the vertex, radiating to the front of the ear and
sometimes along the inferior dental nerve. Pain may also
involve the back of the neck and the general course of the
tri-facial nerve.
Periodical attacks of headache with a naso-pharyngeal
catarrh, in the absence of a cause, should always suggest
sphenoidal sinusitis.
The ocular lesions which may accompany the disease are
osthenopia, ocular headache, retinal hyperesthesia and often
retrobulbus neuritis, followed by partial or complete atrophy.
Suppuration of the sphenoidal cells may bring about necrosis
of the roof of the ceils, producing septic meningitis. In ex-
tension to the sphenoidal fissure, paralysis of the motor-oculi
nerve may occur.
Diagnosis. — The discharge of bright yellow pus into the
post-nasal space and accumulation of scabs in the post-nasal
i- with the enumeration of the above symptoms, are strongly
suggestive of sphenoiditis. Pus due to Thnrnwaldt's disease
can usually be easily differentiated by post-rhinoscopic exami-
I
4*5
DISEASES OF EAR, Noil, AMI THROAT.
nation. The pocket or fistulous opening in the vauh oi
pharynx, described by Thornwaldt, can be detected under good
illumination, with a curved probe passed behind the soft palate.
Direct examination of the contents of the sphenoidal cells may
sometimes be made by cocainizing the nasal cavity with a strong
solution of cocain and adrenalin chlorid, cleansing of all crusts
and exudations and passing a flexible silver cannula approxi-
mately the si/.c of a No. I Eustachian catheter with a
curve necessary for insertion into the frontal cells. With the
mucous membrane thoroughly anesthetized) the oiled cannula
is pasted into the attic of the nose between the middle turbinate
and septum. In this position, it is gradually pressed backward
and downward successively until it is felt to enter the a
When once in position, there is a resistance to further down-
ward movement with I Freedom oi lateral movement. As the
cannula impinges upon the lateial wall, then.- is a sensation
ni striking hare bone. With a compressed Polit/ct bag in the
cavity, pus or the contents of the ERIIUGes ma\ be SUI bed
the cannula. According to Gruenwald, the aver
of the sphenoidal sinus from the entrance of the nose b
female adults, 7.6 cm., males, 8.2 cm.
Count and Progaoair. — The course and prognosis depends
upon the detection of the disease, successful irrigation, 1
the exigency of the case demands, breaking down the anti
wall with the free exposure of the Cells and curettemrnt of
granulations and polypi.
Treatment. — Where irrigation and 1 cation are pos-
sible, relief of all symptoms ma> quickly follow. For the itrr
exposure of the sphenoidal ostium., the entire middle tiuh 1
should be removed, This once done, the irrigation and even
die destruction of the anterior wall is comparative]] veal
easy. For irrigation, a warm DobeU*8 solution is well home.
This should be repeated once daily until pus lias disappeai
Gruenwald's punch forceps may be used tor deatn I the
anterior wall. It the ostium cannot be entered with the upper
jaw of the forceps, a curette may be used for enlarging the
DISEASES OF ACCESSORY SINUSES OF NOSE. 427
opening, which may then be entered with Gruenwald's forceps.
The wound may be packed with iodoform gauze, which is
removed the following day and the wound irrigated with warm
Dobell's solution. Subsequent packing is unnecessary. The
time necessary for complete recovery is variable, usually extend-
ing over a number of weeks. The nasal cavity should be
frequently sprayed with a warm alkaline and antiseptic solution.
Tonics and alteratives are frequently indicated.
CHAPTER XXV.
DISEASES OF THE ACCESSORY SINUSES OF THE NOSE
(CONTINUED).— MAXILLARY ANTRUM OR
ANTRUM OF HIGHMORE.
Acute Catarrhal Inflammation of the Antrum of High-
more. — Acute catarrhal inflammation of the antrum of High-
more is a simple serous inflammation of the muco-periosteum
lining the antrum of Highmore, occurring independently M
coincidently with a general inflammation of the mucous mem-
brane of the nasal cavity, producing closure of the ostia,
imperfect ventilation and drainage (Fig. 36).
Etiology. — The causes are both predisposing and exciting.
The predisposing causes are acute or chronic rhinitis, diphtheria,
scarlet fever, measles and diseases of the teeth, especially those
with the roots in close proximity to the floor of the anr:
The exciting cause is some form of infection, especially the
pip bacillus.
Symptomatology. — There is usually a history of acute rhinitis
and pain in the region of the antrum, extending into the nose
and angle of the jaw. There may be headache and some tender-
ness upon pressure in the canine fossa. The check of the
gfEeCted Bide is frequently swollen. The discharge from this
nasal cavity sometimes produces smarting and burning about
the meatus of the nose. If the affection is due to diseased teeth.
there may he pain and redness in the region of the tooth.
Diagnosis. — With the enumeration of the above symptom*
the 1 is usually simple. There is seldom ani, shadnw
to be detected upon transillumination. The nasal - the
affected side is observed to be congested. The middle turbinated
body is swollen and impinges upon the lateral wall. 'I 1
428
DISEASES OF ACCESSORY SINUSES OF NOSE.
429
usually little or no discharge to be detected coming from the
region of the ostium.
'L'ii- fitment. — The general treatment is directed to the restora-
tion of the general metabolism. In those cases caused by uric
acid diathesis, all meats and alcoholic liquors should be inter-
dicted. The patient should avoid exposure to cold and damp
u-eather and be warned against the general conditions predis-
posing to acute catarrhal inflammation. The bowels should be
Bushed with •« l&line and the patient given salicylate or benzoate
of soda or aspirin in ten grain doses, three times daily.
The local treatment by the physician consists in applying a
five per cent, solution of cocain and 1/5,000 adrenalin solution
to the middle meatus. Following this, the nasal cavity should
be thoroughly cleansed by spraying with a mild alkaline, anti-
septic solution. A fifty per cent, solution of argyrol should
be applied to the region of the ostium with a cotton-tipped
probe. In the absence of argyrol, a solution of nitrate of silver,
ten to fifteen grains to the ounce, should be substituted. The
object of the local treatment is to reduce the engorged condition
of the mucous membrane around the ostium. The nose is
then sprayed with a two per cent, solution of camphor and
menthol in albolene. The patient should be instructed to
cleanse the nose with a Dobell's or Seller's solution, three times
daily, before meals. Hot applications in the form of a hot-water
bag should be applied to the region of the antrum for one-half
hour, morning, noon, night and bed-time.
The disease tends to recovery and seldom becomes chronic.
Where there is very great accumulation of mucus and pain
from pressure, it may be necessary to perform an exploratory
puncture and irrigate the sinuses with warm saturated solution
of boracic acid.
Chronic Catarrhal Inflammation of the antrum of
Highmorc. — Etiology. — The disease is more often due to
successive attacks of acute catarrhal inflammation, typhoid fever,
influenza or a general dyscrasia.
Pathology. — There is a hypertrophy of the muco-periosteal
lining of the antrum with frequent destruction of hone structure
and in consequence, there are frequently observed in the antrum
polypi, cysts, granulation tissue and thick mucus or muco-
purulent exudation.
Symptomatology and Diagnosis. — The patient complains or
periodical attacks of pain in the region of the antrum and u
thick, string}' mucus or muco-purulent discharge irons thr no*
Exposure to damp weather may intensify the local symptoms
The odor from the breath is frequently very- sour and offn
and is due to necrosis of hone and mucous membrane.
There U usually present some ancrobic bacteria which pJ»
duces a condition known as ozena of the antrum. The
ease is more often encountered in patients past the middlo
of life.
Diagnosis. — The diagnosis is by a process of exclusion.
Transillumination may show a darkened area in the region of
the antrum. An exploratory puncture should be made through
the inferior meatus, with a Miles trochar in all suspected cases
of antrum involvement. The lateral wall should br anrv
rhrti/.cd with a ten per cent, solution of enrain, and entire
nasal cavity carefully cleansed by irrigating with Dobell's
solution. Following the introduction of the sterile trocar, thr
cavity should be irrigated with a warm boracic aci.l solution
and the. character of the secretion carefully noted. If pos-
sible, the presence of polypi should early be detected and re
moved because of the tendency to produce some malignant
neoplasm by a process of irritation.
Treatment. — The treatment in chronic catarrhal inflamma-
tion should be, if possible, irrigation through the o t«en-
ing with a warm saturated solution of boracic acid. The instru
mem devised by Vankauer and recommended by Kmil Mayer,
is highly efficacious for irrigating (Fig. I5<*)« Where irrigation
through the natural opening cannot be done, the treatment b
surgical and consists in puncturing the antrum through the
inferior meatus with a large Krause's trocar and irrigating with
a warm Dobell's solution. By using a large trocar, the wound
DISEASES OF ACCESSORY SINUSES OF NOSE.
43'
gtayi open for a longer time and the perforation is sufficiently
long to admit ot eaSJ and painless irrigation. Diseased teeth
in the region of the floor of the antrum should be removed.
The general treatment is directed to the building up of the
system and the correction of any dyscrasia.
Acute Purulent Inflammation of the Antrum of High-
more. — Etiology. — The causes of acuta purulent inflammation
of the antrum of Highmore are both predisposing and exciting.
The predisposing causes are acute coryza, which brings about
edema of the mucous membrane and closure of the ostium
maxilla?, diseases of the teeth, purulent inflammation of the
frontal or ethmoidal sinuses, polypi, exanthematous diseases and
nasal obstruction which may interfere with the free drain-
r in the middle meatus from the antrum.
The exciting cause is infection from some pathogenic organ-
ism, more especially the grip bacillus, which may find entrance
into the antrum by way of the ostium, blond or lymph stream
from suppuration in contiguous parts.
Pathology. — The antrum of Highmore. being covered with
|)scudn st ratilicd columna ciliated epithelium containing goblet
Cell*, with a vascular supply, is predisposed to extension of
infection from the nasal mucosa or the superior maxillary bone.
The secretion following the venous congestion or active inflam-
mation may become inferred by pyogenic organisms, such as
pneumococcus, streptococcus and bacillus of influenza. The
disease may occur at any a
Symptomatology. — The patient complains of pain in the face
in the region of the antrum, extending to the inner angle of the
eye, to the temples ami sometimes involving the whole side of
the face. With the increase of exudation within the antrum,
the pain increases in intensity until free evacuation takes place
spontaneous^ or by operative measures. There is sometimes
a sensation of fullness in the roof of the mouth and tenderness
upon palpation, the sounds produced by palpation being not so
met as upon the well side. The pain may be so great at
night BS to prevent sleeping and in consequence, the general
I
432
DISEASES OF EAR, NOSE AND THROAT.
vitality of the system becomes repidly reduced. The patient's
painful symptoms at night are somewhat relieved by sitting up
or being propped up in bed. The amount of secretion from
the nose is variable, It there is a patency of the ostium.
creamy pus is poured out into the meatus and may be expec-
torated or blown from the nose. The amount of pus blown
"from the nose in the morning exceeds that of any Otbo
of the day. A great deal of pus drains back into the throat
after arising.
The avenue of spontaneous rupture is usually through
natural opening, though the cavity has been known to rupture
through the canine fossa and orbit into the ethmoidal cells and
infiltrate the alveolar process, producing a complete necrosis
of the affected side. During the active stage of inflammation,
there may be a slight rise of temperature and general Lfll
Diagnosis. — Pain in the region of the maxillary antrum with
a discharge of pus from the nose is suggestive of antrum di
Upon palpation, there is a tenderness and the sounds of pal-
pation arc more distinct on the affected side. The tuning fork
Cj uhen applied to the diseased antrum is less distinctly heard
than on the opposite side. There is usually tenderness alone
the alveolar process especially where there is disease ot the
teeth. There may be a history of toothache, the cavity in the
tooth pointing directly to the tooth as an exciting cause of the
inflammation. Previous to examination of the nasal cavity,
the nose should be sprayed with a five per cent, solution of cocain
and adrenalin, i 's,(xx> and cleansed of all secretion and ex-
udation.
Pus from the maxillary antrum is usually pure white or
yellowish-white in appearance and can be detected pouring
out into the middle meatus and is sometimes detected at the
anterior edge of the middle turbinated hone about the median
line, differing in this respect from both the frontal an
moidal cells, which make their appearance in the attic of the
meatus and the juncture of the bone and lateral wall. I'rw-r
wiping the pus away and watching intently for a few seconds,
DISEASES OF ACCESSORY SINUSES OF NOSE. 4.33
fresh pus can be detected pouring out into the region of the
ostium maxillary. Sometimes by closing the anterior nares with
the finger and making deep suction from the nose, great quanti-
ties of pus may be drawn into the middle meatus. Where there
is doubt as to the existence of pus, a Mile's trocar may be used
for puncture and exploration. Pus will sometimes flow from
the trocar, drop by drop. Where the pus is very thick, however,
it is necessary to irrigate the cavity through the trocar. If pus
is present, it will usually be observed flowing from the nose.
Prognosis* — The prognosis of simple uncomplicated purulent
mi-lamination of the antrum is usually very good. As in any
other pus cavity, if the foci of infection can be removed, the
recovery is usually very rapid.
Treatment. — The treatment is both constitutional and local.
The constitutional treatment consists in building up the system
and the correction of any dyscrasia which may be detected.
Any diseased teeth should be removed
The local treatment consists in puncturing the antrum with
a Krauze's trocar high up in the inferior meatus and irrigating
with one-half of one per cent, solution of lysol or warm Do-
bell's solution. The cavity should he irrigated once daily
through a small canula which can he easily passed through
the Opening made by the trocar, into the antrum. This
form of treatment should be continued until all evidence
of pus has passed away. The time of treatment varies from
ten days to two weeks. The symptoms of pain and distress
away immediately upon puncturing and the evacuation of
pus. After the disease is cured, hypertrophies or any obstruc-
tions about the maxillary ostia should he removed. If the
middle turbinated bone is laryc and impinges upon the lateral
wall and septum, it should be removed in its entirety. Subse-
quent treatment consists in treating any catarrhal condition of
the nasal mucosa.
Chronic Purulent Inflammation of the Antrum of
Highmore or Empyema of the Antrum. — Etiology. — The
causes of chronic purulent inflammation of the antrum of
29
•434
DISEASES OF HAR, NOSE AND THROAT.
Highmore arc recurrent attacks of acute inflammation, acute
purulent inflammation which lias tailed to recover, chronic
l itarrhal inflammation of the antrum, chronic catarrhal or
purulent inflammation of the frontal and ethmoidal cells, dis-
eased teeth, hypertrophies of the middle turbinate, deviations
of the septum, producing a purulent periostitis, influenza and
syphilis.
Pathology. — There Is usually more or less destruction of thr
muco-periosteal lining of thr antrum u ifh sometimes invohr
ment of hone with the formation of polypi and cysts. There
in. iv be infection from the aerobic or anaerohic bacteria, D90d
fag a foul odor and pUft, Changes in the bone Structures
consequence of i Long-conruiued discharge, arc HKnewhal
able. I Dc condition of rarefying otitis nun, he brought about.
Sometimes new bone, forming thin plates, described by Bos-
worth, may be thrown out in such a way as to divide thr
antrum into small chambers.
Symptomatology. — The patient complains of a dropping in
the throat, nasal obstruction and ill-smelling discharge trom the
nose. Acute exacerbations of ■ chronic empyema may occur!
producing pain and involvrment in the region of the antrum.
Kou I and offensive discharge is usually greater in thr morning
than at any other rime of the day. There may he present
a history of disease of the proximal teeth. The color of the pis
is usually a creamy white. The character of the pain in chronic
empyema is somewhat variable and may be present in a very
mild form in involvement of the teeth.
Diagnosis. — A chronic purulent discharge from the middle
meatus is usually suggestive of antrum disease. Tta
\cd at the lower or anterior border of the middle
turbinate. With the mucous membrane of the nasal wall
shrunken bv cocain and adrenalin, the pus, when wiped a'-
may be seen to rapidly re-accumulate at this point and with the
■ in holding the head well forward and downwardi In ■>
few seconds the pus is noted t" drain anteriorly. Where the
PUS is retained for any length of time, it may take on the odor
DISEASES OF ACCESSORY SINUSES OF NOSE.
435
or sulphuretted hydrogen. A tuning fork is heard less dis-
ninilv, u pointed out by Kuyk, than on the well side. By
transillumination, a distinct shadow on the affected side is
illy obtainable. By pressing a rubber-hooded lamp over
the maxillary process, a shadow may sometimes be detected
through the open mouth.
The diagnosis may be accurately established by puncturing
with a Mile's or Krause's trocar. 1 believe it better to puncture
with a large trocar, giving the patient the advantage of easy
subsequent irrigations and besides, if it is found necessary to
operate more extensively, dissection of the internasal wall of
the inferior meatus, which is recommended by Holb rook Curtis,
may be readily performed. If either the first or second molar
tooth is diseased;., it Should be extracted and the enviry in-
spected for pus.
Prognosis. — The prognosis is exceedingly variable and de-
pends upon the length of time the disease has existed, the
general necrotic condition of the antrum and the thoroughness
of any operative procedure.
Treatment. — The treatment is both intra- and extra-nasal.
The intra-nasul treatment consists in cither puncturing through
the internal wail of the antrum into the inferior meatus of the
• with a targe Krause's trocar, subsequent daily irrigation
with a lysol solution one-half of one per cent, or a weak solution
of permanganate of potassium. If this procedure is not satis-
factory and the disease is not due to any carious tooth, the
operation, recommended In Hoi brook Curtis, of removing a
button from the internal wall of the antrum in the inferior
meatus and by a previous removal of the anterior portion of the
inferior turbinated bone, curettement and drainage may be
performed (see Fig 12 0.
The technique of the operation, as recommended by Curtis,
Follows:
' The Inferior meatus is packed with a pledeet of absorbent
cotton, saturated with a half-and-half solution of cocain ten
per cent, and adrenalin chlorid solution (r/i,ooo). The in-
43^
DISEASES OF EAR, NOSE AND THROAT.
ferior turbinate is covered externally and internally from its
middle portion anteriorly. It is a good plan to fortify the
patient with an ounce of whisky, 1/25 gr. smchnia sulph. and
l/*5 g*"- digitalin, before operating. After the cotton has
remained in contact with the turbinate and external wall of
Fie. 125-
0 Pi:rf .nvrir.v Cm rums rot Radical Antrim OmATtOH l UUiK**
:,, : l| \| •.. I I I \l', I :■! ■■l.'-r-,.l- ■ ••
tin meatus for ten minutes, we take a 1/8-J/16 in. trephine,
run by an electric motor or dental engine and remove bj a
couple of perforations, followed by the cutting forceps and
snare, the anterior third of the inferior turbinate. In thb
manner, we clear away the body to its line of insertion. The
procedure is almost bloodless. The outer wall of thr meatus
is now hroughr into view. It will be seen that the trephine
DISEASES OF ACCESSORY SINUSES OF NOSE.
437
may be employed to perforate tlie inner wall of the antrum
:ibout a centimeter beyond the anterior point of attachment of
the inferior turbinate just removed, the shaft of the trephine
entering the nostril at an angle of about 450. 1 prefer to
make the perforation at a point a quarter of an inch above
the nasal floor, for the bone is thinner as we ascend the wall.
(faring punctured the antrum, we immediately change the
trephine tor an olivary or barrel burr drill and enlarge the ori-
fice upward, downward and backward. We then stuff into
the orifice some gauze wet with adrenalin solution, 1/5,000,
which quickly stops any bleeding which may occur. By using
properly curved flexible ring curettes, wc are enabled to reach
the walls of the antrum very satisfactorily. The bleeding
dors not annoy the patient as the head is so held that it escapes
anteriorly. Ortlmtnnu or COCain Itwy be used to limit pain,
t»r, if we so decide, the curetting may be postponed until an-
other day " (77/r Lnyngoscofie, October, 19x33).
On account of the inability to reach the cause by intra-
nasal operations, e.xtranasal operations for chronic suppuration
of the antrum of Htghmore are recommended and arc known
as the alveolar, palatal, Kuster, Caldwell-Luc and Jansen
operations.
The first two are the least scientific The alveolar operation
JStS in opening through the root of an extracted tooth
with a dental burr or ordinary hand drill and irrigating daily
with some antiseptic solution. The wound is kept open with
antiseptic gauze or antrum drainage tube. The disadvantages
of opening through the alveolar process are the constant leakage
of pus into the aural cavity, the infection of the gastrointesti-
nal tract and general constitutional disturbances. There is
also a greater danger of bacteria from the mouth reaching the
antrum, bringing about a mixed infection.
The palatal operation consists in opening through the roof
of the mouth into the antrum. On account of the possible
various malformations of the antrum and deviations into the
chambers, the operation, unless there already exists a fistulous
opening, which is indeed a rare condition, is never indicated.
438
DISEASES OF EAR, NOSE AND THROAT.
The Kuster operation consists in making an opening thl
the external wall in the canine fossa large enough to admit the
little finger. The incision is made under chlocrofotlXI narcosis
and antiseptic precautions at the gingivo-labial juncture in the
canine fossa down to the periosteum and the tissues arc rase
back. The mouth is tamponed with gauze for the prevention of
hemorrhage entering the laryn.\. With a gouge, mallet and ron-
geur bone forceps, the outer wall is partially removed. With
the aid of a head mirror, the operation permits the exploration
of the cavity and the removal of areas of granulation tissue,
polypi and necrotic bone by cmvtn-ment. New chambers should
be carefully sought for and removed. The cavity is thoroughly
irrigated with one-half of one per cent, lysol solutioi
and mopped with pure carbolic acid. The Cftvit)
packed with iodoform gauze. The end of the gau/e is alio
BO protrude into the gmgivo-labial incision for the prevention oi
closure of the wound. After five or si\ days, the gauze i»
removed and the cavity cleansed ami repacked. If there is
much secretion at the second dressing, the wound should be
irrigated and repacked dail] until complete recovery ensues.
The Caldwell-Luc operation CO n opening through
the canine fossa as in the Kuster operation with a counter
opening in the inferior meatus of the n09C Alter completion
of the Kuster operation, the anterior two-thirds of the inferior
turbinated body is removed through the nares and the
internal wall of the antrum is removed with the electro-
motor burr and biting forceps. After a portion of the internal
wall is removed, the nose is thoroughly cleansed of all debris
and the antrum cavity again plugged. The an] oi the dressing
protrudes into the nose. The lips of the primary wound in
the gingivo-labial tissue are brought together by Stitches, thus
entirely closing the external wound. All tin robsequcm dress-
ings are thus carried through the antro-nasal wound. The ad-
vantage claimed for this operation is the complete thoroughness
to be obtained by the operation and the lessened i , of
mixed infection. The presence of suppuration following the
DISEASES OK ACCESSOR* SINUSES 01 KOSS.
439
radical operative procedure outlined, is suggestive of ethmoidal.
frontal and sphenoidal involvement.
Jansen claims that u lien one sinus is involved, all the sinuses
on that side are also affected and in consequence, he has devised
and practices the radical operation of opening all the sinuses
at One Operation, Under antiseptic precautions and general
Uiesthesia, the incision is made as in the Kuster or Caldwell-
Luc operation, commencing behind the first molar tooth and
extending afi far as the canine region. The periosteum is ele-
vated and the external wall is removed with chisel and
Rongeur's forceps. The mucn -periosteal lining of the antrum
is entirely freed of all granulations, polypi, etc. The internal
wall is carefully removed and with it the inferior and middle
turbinated bones, leaving the mucous membrane of the nose
intact. A tongue-shaped flap is made in the mucous mem-
brane by an incision from the posterior extremity of the
floor of the antrum forward to the anterior insertion of
the turbinated bone. A second incision is carried from the
beginning of the first incision upward and externally; the
tongue formed is drawn forward into the antrum cavity and
stitched to the buccal membrane at the median extremity of the
giniiivo-lahiul incision. The middle and posterior ethmoidal
cells ami sphenoidal cells of this side are now entirely curetted
away. The entire wound is packed with iodoform gauze. The
gingivo-labial wound may or may not be closed according to the
amount and severity of the suppuration. If the gingivo-labial
incision is allowed to remain open, a strip of gauze protrudes
[ntO the mouth as in the Kuster operation. If the wound is
(1. the gauze extends into the nasal cavity as in the Cald-
well-Luc operation. The packing should remain in the antrum
Uld ethmoidal cells for rive or six days, when it is removed and
replaced with fresh gnu/.c. If there i> some little DUS discharge,
I believe it better t<> moisten the gauze previous to insertion in
the ivOUdd, with peXOXld of hydrogen. The treatment should
be continued until the suppurative condition has completely
passed away.
Foreign Bodies in the Antrum. — Animate or inanimate
objects may be found in the antrum. As in the frontal cells,
insects and their larva may find entrance through the natural
opening into the antrum. Inanimate substances may be <!::
into the antrum by a blow, fall, gunshut wound, dental mut
lation or operative procedure on the antrum. Animate obj
raaj lu- removed by puncturing with a Krause's trocar
irrigating with a warm, mild, antiseptic solution. In case the
insects are not entirely remuved and the purulent discharge
persists, the Kuster operation is indicated. A history of in
and exploration of the wound will lead to detection or any
inanimate substances in the antrum. On account ol thr
stant secretion which takes place in the antrum, foreign bodies
often bring about infection and a chronic purulent inflamma-
tion of the mucous membrane necessitates their early removal.
Mucocele of the Antrum of Highmore. — Mucocele ol
the antrum of Highmore is,- as in mucocele of the frontal
cells, due to serous exudation from the mucous membrane which
is prevented from escaping by closure of the natural opening.
Etiology. — The disease is due to chronic catarrhal inflam-
mation of the mucous membrane of the antrum and is observed
more especially in those past middle age.
Symptomatology. — The symptoms arc those ot acute puru-
lent inflammation of the antrum with a retention of secretion.
Diagnosis. — The patient complains of pain in the region
of the antrum without the characteristic purulent discharge
from the nose as observed in acute empyema. Upon puncturing
with a Kra use's trocar, a straw-colored fluid is washed away.
Treatment. — The wound should be irrigated daily through
the opening made with the trocar, with one-half of one per
cent, solution of Iysol until all symptoms of the disease have
passed away. Where there are diseased teeth or suspected
involvement from diseased teeth, the alveolar operation may
be performed for the removal of the cyst contents and subse-
quent irrigation, rather than the intranasal operation.
Tumors of the Antrum of Highmore. — Tumors of the
JISliASES OF ACCESSORY SINUSES OF NOSE.
IP
;tntiiim of Highmore may be malignant, non-malignant <>i
mixed. Malignant growths of the antrum may be prima t\
or secondary (see Pathology of Malignant Growths). Pri-
mary growths may be due to irritation produced by the pres-
ence of myxomatous growths, granulations, osteoma, trauma,
and predisposition to the disease. Non-malignant growths are
more often due to the irritation of a chronic catarrh of the
mucosa.
Diagnosis. — The presence of a tumor in the maxillary* an-
trum may be suspected whenever there is continued pain. Upon
transillumination, there is a dark area as in retention of pus.
There may also be present myxomatous growths in the nasal
cavity and disease about the natural opening of the antrum.
Where the alveolar process is softened and infiltrated from the
disease, the teeth loosen and are extracted by the patient. The
dUease, whether malignant or non-malignant, must be differ-
entiated from chronic purulent inflammation, neuralgia, cyst
and syphilis.
Treatment. — The treatment may be governed somewhat by
the symptoms of the disease. In suspected tumors, the antrum
should be opened through the canine fossa as in the Kuster
operation and explored. Non-malignant tumors may be cu-
retted or chiseled away and the wound packed with gauze.
The subsequent treatment is the same as for chronic purulent
inflammation. If a malignant growth is diagnosed, micro-
MOfrfeal examination of the tissue removed and total resection
nt the upper jaw of the affected side is indicated.
Epithelfomatous or sarcomatous growths may not alone con-
fine themselves to the antrum, but may involve the ethmoid cells
and alveolar process; in consequence, operative measures must
be the must radical in character and consist in the partial or
complete extirpation of the upper maxilla of the diseased m'.Ic.
This operation, in the nature of things, must enme within thfl
domain of the rhinologist and will therefore be referred to in
derail.
For this operation, the following instruments arc necessary:
DISEASES OF EAR, NOSR AMD THROAT.
scalpel, straight and curved scissors, bone forceps. I ion-jaw
forceps, straight nasal saw, Rongeur forceps, chisel, hammer.
multiple number <>t arte*} Forceps, needle and thread, tn
otomy tube and Paqudins cautery.
Fir,. 126.
Rimovai. or (Ann Jaw. — Early tOgM. (After Jafbum and 5/r-rW>
K. 11. etlofl ••! 1 he Kai> an J Kction of the bones.
Chloroform is usually indicated fol narcosis, P;.
to operation, the patient ially prepared, it a man. b>
1 1 ;i \ mg t he face and net k 1 losety shaved. The mouth and teeth
are cleansed and nasal cavity freed ol .1- much debris as possible
In frequently spraying with Dobell's solution.
On account of the ii Hi ol the accessor; sinusei
whether from necrosis or extension of growth in some cases,
it is quite impossible to secure anything like cleanliness of the
nasal cavity. [1 polypoid grow ths ire present in die nose, care
must Ik* taken to previously remove them with a snare.
In iloing the partial or complete operation, it is necessary
that in addition to tlm nurse and anesthetist, two capable assist*
ants should be present. Hemorrhage, which is always profuse.
will keep the two assistants quite busy at times.
DISPOSES OF ACCESSORY SINUSES OF NOSE.
443
The question of preliminary tracheotomy is one to be settled
by the surgeon. On account of the additional shock from
the operation and the possibility of doing the operation without
the preliminary tracheotomy, the majority of surgeons prefer
to do the operation without this preliminary step. It must
be borne in mind that tracheotomy may be necessary during
this operation and consequently the surgeon should be prepared
for tin's step whenever indicated. The position of the patient
Fio. 127.
RtMoVM. Of tub IJite* Jaw. — Later »Ugc. (After Heath, J&eobson and
SttlVt I I 1 1 1
i.ips arc reflected and held aside. The bones have been divided. The
ii||ii ;.n i> being diiarticulatcd with the lion-jaw forceps while a pair of
eottlng-bonc forcep* complete the division of tlie palatine attachments.
should be with the head slightly lowered and the body slightly
elevated so that gravity will aid in preventing the entrance of
blood into the larynx.
The first incision suggested by Sir W. Ferguson or by
Huguier should extend from a line slightly below the inner
I
444
DISEASES OF EAR, NOSE AND THROAT.
canthus parallel with the nose, round the ahr to near the center
of the lip (Fig. 126), completely severing the lip. An incision
is now made through the skin and the vestibule of the nose,
connecting with the incision in the lip.
If the growth is large and the alveolar process is involved,
a third incision is made from the corner of the mouth backward
and upward sufficient to expose the angle of the jaw. With
all bleeding points secured, a fourth incision is made along the
gingivo-labial border down to the periosteum. The flap of the
fascia is dissected back from the maxillary process until the
entire bone is exposed. The incisor tooth is next extracted.
With a narrow saw in the cavity, the Hour of the nu-.e, ifoeoln
process and hard palate are completely sawed through.
saw is again directed to severing the jaw from its attachment
with the malar bone. The sawing is continued if a complete
removal is desired up to and through the bone forming the floor
of the orbit and last through the nasal process of the maxillary
bone.
If a partial resection only is indicated, the line of the saw
will be below the floor of the orbit, through the superior portion
of the antrum of Highmore. The section of bone is et
removed by a rocking motion with a strong forceps. If
portion of the malignant growth remains, it must be rem Q
with a sharp curette.
Bleeding can usually be controlled by applications of tam-
pons wrung out of hot water. If there be much bleeding, the
wround may be packed with strips of nauze, which should be
removed after twenty-four hours. The flap is carefully sewed
into position, care being Taken that the mucous membrane of
the mouth and soft palate arc brought into apposition as far
as possible. The head is bandaged and the patient put in a
recumbent position. Strychnia. 1, 30 grain, may be adm
tered hypodermatically. if indicated, hot applications applied
to the extremities, and in fact every effort should be made to
avoid shock. Hypodermic injection of morphia should be c
the patient soon after the operation to insure rest. Water jnd
DISEASES OF ACCESSORY SINUSES OF NOSE. 445
liquid food may be given through the mouth with the aid of a
soft tube.
Subsequent dressing consists in the removal of the packing,
spraying with iced Dobell's solution, which, after fifty-eight
hours, may be displaced by warm Dobell's solution for irriga-
tion. It is unnecessary to repack the wound after forty-eight
hours, depending upon the frequent spraying to keep the wound
in a healthy condition.
CHAPTER XXVI.
DISEASES OF THE NASOPHARYNX.
Acute Naso-pharyngitis. — Acute nasopharyngitis is an
acute catarrhal inflammation of the mucous lining of the vault
of the pharynx and is often secondary to a like inflammation of
the nose or oro-pharynx.
Etiology. — The causes are both predisposing and exciting.
The predisposing causes are adenoids, enlarged tonsils, exposal?
to irritating gases and all the predisposing causes of acute
rhinitis.
The exciting cause is the same as for acute rhinitis or KOU
pharyngitis. The disease may be produced from trauma
from digital examination and injudicious use of the posl
spray.
Pathology. — The pathology docs not vary from that of
acute pharyngitis.
Symptomatology, — The general febrile symptoms are the
same as observed in acute rhinitis. The symptoms may. how-
ever, be intensified in children. During the fir>t twent]
hours there is a dry, smarting and burning sensation in the
vault of the pharynx with a sensation of swelling of the mu-
cosa. The condition may extend to the mm Ota membrane lining
the Eustachian tube, producing an active salpingii
The inflammatory condition of the nnso-pharynx seldom ran-
fines itself to that region alone, but extends upward inl
nose or downward into the lower portion of the pharynx. In
the early stage of the disease, there is little ..r m i 1. fol
lowed by a reaction and a rapid accumulation <>t \rllowtth
i :u Bl which fills the naso pharynx and drains downward ovef
the pharyngeal wall. The patients try to dislodge thi
latfbfl bj hawking and expectorating. In those* with an
446
I>]SI:.-\SI:S (II- rill: N \S( I I'HARVNX.
447
sensitive pharynx, gagging and even vomiting may be produced.
The secretion iiu> he ringed with blood.
Diagnosis. — Upon examination, rhinoecopically, the mucous
membiane is red and slightly swollen. There is more or less
accumulation of mucus varying in quantity according to the
stage of the disease. The secretion may be stringy and some-
w bat adherent in the early stage of the disease.
Treatment. — The general treatment is directed to securing
fiee purgation with calomel, followed by some aperient water.
The diet should be regulated and alcoholic liquors and tobacco
temporarily dispensed with.
The nose and naso-pharynx should be frequently irrigated
with a warm Dobell's or Seiler's solution. Chlorid of zinc,
is grain'- to the ounce of water, should he applied with a
I Mttroii-tippcd probe once daily to the vault of the
pharynx,
I WO or three treatments are usually quite sufficient to cure
the disease.
The local treatment should be followed by an oil spray
consisting of aristol, acetoform. camphor and menthol (see
formula?, page 127), or acetozone inhalenr.
The gastro-intcstinal tract should be freed of all accumula-
r on li\ rite administration of calomel followed by a mild ape-
rient u ;iter.
In ven, wiling children, steam inhalation of water and
eucalyptus oil may be used every two or three hours, followed
by an oil spray of acetozone.
Chronic Nasopharyngitis. — Chronic naso-pharyngitis is a
chronic catarrhal inflammation of the entire membrane of the
naso-pharynx.
Etiology, — The exciting causes are more often due to re-
current attacks of acute inflammation of the naso-pharynx,
chronic na- catarrh, hypertrophies of the pharyngeal and
f.iucial tonsils.
The predisposing causes are catarrhal, syphilitic, gout] in
tubercular diathesis, chronic suppuration in the ethmoidal or
I
II-
DISEASES OF EAR, XOSE AND THROAT.
sphenoidal cells, gastro- intestinal disorders, excessive use of
alcoholic liquors and tobacco. The disease is very common
among children and young adults, in which there is present a
lymphatic dyscrasia. The muciparous glands of the pharyngeal
vault are well developed both from the inherited influence and
inflammation.
Pathology. — In addition to the inflammation with:;
structure, there exists an hypertrophy and sometimes an hvper-
pla.ia of the mucous membrane and glandular structure
which is poured out a muco-purulcnt exudation, filled with
desquamated epithelium and debris.
Symptomatology. — The patient complains of a thick muco-
purulent discharge from the vault of the pharynx, which is
difficult to remove. Vomiting and retching may be produced
by the efforts of the patient to remove the secretion by hawk-
ing. Indigestion is frequently one of the accompanying com-
plications of the disease, produced by the infective material
passing into the stomach. The disease predisposes to laryn-
gitis, hoarseness and catarrhal inflammation of the lower air
passages.
Diagnosis. — Upon inspection with a rhinoscopic mirror, the
naso-pharynx is observed to be covered with a thick. string]
mucus, which, upon being detached with a post-nasal spray,
discloses a variety of conditions. In one variety of cases there
is a profuse hyperemia of the vault of the pharynx, in another.
:m irregular and profuse follicular condition. Where thnr
remain well-developed adenoids or Tcmnants of adcno
distinct glandular mass protrudes anteriorly. Another condi-
tion is a dry, glistening and reddened naso-p!
with stringy mucus. The patient complains of excessive drop-
ping In the throat, sometimes headache and indigestion, The
secretion accumulates in large quantities during the night and
is discharged by prolonged hawking and coughing.
Tht i nay be confounded with Thornwaldt's disease
I hornwaldt's Disease), syphilitic ulcer and chronic puru-
lent discharge from the sphenoidal and posterior ethmoidal
DISEASES OF THE NASO-PHARYNX.
449
cells. However, the above diseases may be differentiated from
chronic naso-pharynjjiris l>y carefully cleansing the nose and
nasn-pharynx and inspecting with a rhinoscopic mirror.
Treatment. — The treatment is both local and constitutional.
The local treatment is directed to securing free and uninter-
rupted nasal breathing by the removal of hypertrophies of the
middle and inferior turbinates, spurs, glandular hypertrophies
in the vault of the pharynx and faucial tonsils. It should be
remembered that small tonsils are frequently as great a source
of irritation as large tonsils. They should always be explored
for hidden pockets which contain debris and bacteria and in
consequence, eliminate a toxin particularly irritating to the
mucous membrane of the naso-pharynx. The secretion which
is deposited upon the mucous membrane of the naso-pharynx
can be dislodged by irrigation with a post-nasal douche or
Pynchon post-nasal tip attached to a Davidson spray. Fol-
lowing cleansing, one of the following astringents may be ap-
plied with a curved cotton-tipped probe:
Argyrol in fift\ per cent, solution, nitrate of silver, two
to five per cent, and chlorid of zinc, two to five per cent.
solution.
The following may sometimes be advantageously substituted
for the above and applied with a curved applicator:
V. IiMJiiii,
r.>i.i-.M iodidi,
I , lrrcrini,
.60 gm. (gr. x)
20.00 gm. (gr. xxx )
30.00 c.c. (3 i)
An astringent application may be followed by the following
oil spray to the nose, naso-pharynx and oro-pharynx:
.12 gm. (er. ii>
.30 gm. (gr. v)
.20 cm. (gr. iv)
.12 gm. (gr. ii)
30x10 c.c (3 i)
450
DISEASES OF EAR, NOSE AND THROAT.
The patient should be instructed to use a mild antiscf
and astringent spray in the nose and naso-pharynx twice daily
before meals.
The general treatment is directed to the correction of any
dyscrasia, gastro-intestinal or pelvic disorders.
Change of climate, from a dry to a moist, high to a low alti-
tude and vice vena, is sometimes extremely beneficial.
Naso-pharyngitis Hypertrophica Lateralis. — Naso-
pharyngitis hypcrtrophica lateralis is a chronic hypertrophic
inflammation of the lymphoid structure of the naso-pharyngeal
mucous membrane situated along the lateral walls of the
pharynx. The author has taken the liberty of inserting the
descriptive adjective, naso, to the classical name, pharyn
hypertrophica lateralis, believing it to be etiological!}
rect interpretation.
Etiology. — The disease is due to the causes prodin
chronic naso-pharyngiris. It may or may not be associate*!
with lymphoid infection in other parts of the pli.uwiv.
Pathology- — According to Cordes, the hands are composed
of a fibrinous reticulum, surrounding a collection of lymphoid
follicles and are due primarily tn a peculiar lymphoid diathesis
which exists in many individuals, and secondarily to infection
or prolonged irritation.
Symptomatology. — The patient complains of
catarrhal inflammation of the naso-pharynx. There is usual h
a history of ho;iisrm-s* upon prolonged usr of the voi< r. Women
accustomed to singing .liny aloud are frequently com-
pelled to give this up on account of the irritation. A leflrx
cough frequently takes its origin ham the pharyngeal irrit;-
produced by fibrous bands.
Treatment. — The general treatment it the <^amc as for
chronic post-nasal catarrh. The local treatment is a guarded
application of the galvano-cauter? every week or ten days until
the bands are absorbed. The soft palate should be elevated
for a more thorough application of the cautery. Care must
necessarily be exercised in using the cautery on account of the
DISEASES OF THE NASO-PHARYNX.
451
danger of producing acute inflammation of the middle ear.
The patient should be instructed to douche the nose and throat
with a warm alkaline and antiseptic fluid twice daily. The
excessive use of alcoholic liquors and tobacco is contraindicated.
Chronic Naso-pharyngeal Bursites (Thornwaldt's Dis-
ease).— Chronic naso-pharyngeal bursites was described in
1868 by Luschka and was further elucidated in 1885 by Thorn-
FiC 128.
u-
,
kgixital Cixrr or tbi Pka»ykx om Tjiorswai.dt's Disease. (After
Dunbar /•/
waldt, from whom the disease received its name. It is a
pocket situated in the median line of the vault of the naso-
pharynx, secreting a thick tenacious muco-purulcnt substance.
Etiology and Pathology. — The disease is primarily one of
-152
DISEASES OF EAR, NOSE AND THROAT.
congenital origin and is, according to Schwabach, "the rem-
nant of the middle cleft, the purse or blind pouch being the
posterior cud funned by the partial agglutination of the margin
and that it is but an integral portion of the pharyngeal tonsil
taking part in the disease to which the latter is subject, but not
possessing a pathological character of its own."
Symptomatology. — The symptoms vary in individuals fa
one of the cases observed by the author, there was an entirr
absence of adenoids. However, in this case, the patient had
passed the age in which we might expect absorption of adenoid
tissue to take place.
The patient under observation complains of an active dis-
charge from the naso-phar_vn\. varying somewhat in quantity
from time to time and influenced by the seasons. A thick, globu-
lar mass of mucus maj be discharged from the naso-phaxynx two
or three times daily. The patient complains of a ringing in the
ears and deafness, which is probably a condition of spongifica-
tion of the labyrinth. There is no discharge from the nose and
the patient's general health is good, other than as described abovr.
I'pon inspection, the oropharynx is seen to be covered with a
glistening, mucus-like substance, adherent to the mucosa. Upon
examination with a rhinoscopic mirror, a thick mass, ni
purulent-like, sometimes darkened from dust breathed into the
nose, is observed upon the posterior wall in the median line,
well into the wall of the pharynx. The accumulation
lodged with a post-nasal spray and upon examination, a de-
pression will he observed at the site of the meatus of the
bursa and is sometimes slightl} tinged with blood. L pon
exploration with a probe shaped somewhat after a goose-neck,
a distinct pouch is discernible, extending backward toward
the vertebra?.
With the symptoms in mind, there is no difficulty in differ
cntiating the disease from chronic naso pharyngitis or the chronic
sphenoid itis or chronic posterior ethmoiditis.
Treatment* — Dunbar Roy, in on article on chronic naso-
pharyngeal tonsil itis, read before the American Laryngolo.-
Rhinological and Otological Society, 1901, says:
DISF.ASF.S OF THE NASO-PHARYXW
453
' The best treatment which I found in addition to the
thorough cleansing which the patient accomplished at home,
was an application of a solution of nitrate of stiver, 60 grs.
to the ounce, directly to the sulcus, followed by thorough spray-
in},' of the naso-pharynx with hot, melted vaselin and orthoform.
The curette and electro-cautery point were tried. Thorn waldt
recommends the destruction of the bursa by means of these
latter methods. My own success was not at all gratifying.
Schmiegelow, of Copenhagen, has reported three cases of obsti-
nate post-nasal catarrh cured by cauterizing the bursa. Such
success, however, has not been obtained by many other ob-
servers, and in fact, a majority report a rather small proportion
of cures."
'The prognosis as to ultimate cure in these distinctly char-
acteristic cases is certainly not brilliant, and the laryngologist
will be taxed to his utmost to place the patient in even a
comfortable condition."
In the author's tWO cases, all the above plans of treatment
were instituted from time to time, and in addition, deep incision
d as made from the floor o|- the bursa into the pharynx, followed
by curettcment and cauterization with negative results. The
chances for a complete cure as in the treatment of congenital
fistula.* of the thyro-glossus duct, a somewhat analogous con-
dition, depends upon the complete eradication of the bursal
lining by ourettement.
Hypertrophy of the Pharyngeal Tonsil or Adenoid
Growths. — Histological!}, adenoid growths are a hypertrophy
Hi the normal lymphoid structures, situated in the vault of the
pharynx, and are sometimes designated Luschka's tonsils or
adenoid vegetation.
Etiology^ — Lymphoid tissue within the vault of the pharynx
fa primarily a small histological structure undergoing absorp-
ibout the time of puberty.
. rrig the predisposing causes of hypertrophy of the lymph-
oid tissue are infection soon after birth, recurrent attacks of
acute coryza. eruptive fevers, heredity, lymphatic diathesis, un-
hygienic surroundings and inherited dyscrasia.
From infection at birth or soon after, normal lymphoid fol-
lulr-s assume greater or less proportions, becoming abnormal
Structures.
There is usually associated with the disease, greater or
less hypertrophy of the MMtflfl and hypertrophy of the
discrete lymph follicles of the pharynx. The disease is more
DISEASES OF THE NASO-PHARYNX.
.455
frequently encountered in children, occurring a short time after
birth. Holt and Jarecky mention their presence at birth, which
leads to the conclusion that the condition of hypertrophy may
be congenital.
In adults, the disease differs in structure from that seen
in children. They are more fibrinous in structure and instead
of being soft to the touch and irregular in outline, they are
quite smooth and hard.
Symptomatology. — The most striking symptoms are the open
mouth of the child while at rest and the alteration in the voice.
The facial expression varies according to the size of the growth
and duration of the disease. Sometimes the face becomes dis-
torted from the prolonged mouth breathing. The chin pro-
trudes abnormally, the muscles at the angle of the nose become
drawn and the ala; of the nose depressed.
The child may appear quite stupid from the dullness of
hearing and imperfect Oxygenation of the blood. In typical
cases, the voice has a peculiar dead quality, as described by
Meyer.
The secretion in the nose and naso-pharynx is profuse in
some cases and quite the reverse in others.
In many infants and young children with adenoids, there
is imperfect development of the bod) and progressive inanition.
Deafness, which is frequently the cause of the physician being
consulted, is due to the hyperplastic tissue extending down to
and obstructing the ostium tuba, thus interfering with the
ran- fair ion of the air in the tympanic cavity.
Hans Wilhelm Meyer, in i8f>8, first called the attention of
the medical world to the influence of adenoids in the causation
M
A passive hyperemia and consequent congestion of the mucous
iiK'inlir me of the Eustachian tube, with fibrous exudation and
narrowing of the tube, follows interference with rarefaction of
the Eustachian tube and middle ear. With an alteration in the
atmospheric pressure in the middle ear, the membrana tympani
becomes thickened and slightly retracted. If disease of the
456
DISEASES OF EAR, NOSE AND THROAT.
middle ear is continued for any length of time, the ossicles be-
come agglutinated and deafness results.
Suppuration in the middle ear is a frequent sequela of
adenoids. Many cases of acute and chronic otitis media get
well with no other treatment than the removal of the adenoids
and subsequent irrigation of the nasopharynx with a mild
antiseptic and astringent wash.
In hypertrophy of the pharyngeal tonsils, surticient to obstruct
nasal respiration, there is always a decrease in the hemoglobin
and red corpuscles.
Persistent nasal discharge, cough, spasmodic croup, night ter-
rors, enuresis nocturna, snoring, parching of the mouth and
pharynx and neuralgia are among the many sjmpi
panying the disease. Asthma la reported by Frankcl, Chatcllici
and Bos worth as many times dependent upon adenoid growths.
The author recalls a case of asthma in a child in which there
was immediate relief following adenectomy. Under the continued
use of small doses of iodtd of potassium, this case subsequently
became quite well.
Diagnosis. — The facial expression of the patient, alte
in speech and catarrhal condition of the nose and throat sug-
gest the disease. With a mouth gag or napkin rolled into a
hard knot separating the jaws, the index finger can be easily
passed behind the soft palate into the nasopharynx in all but
very young children. A soft mass may be felt, resembling. as
described by Meyer in his original article, a bunch of earth-
worms and upon extraction of the i will be slightly
tinged with hlood.
Ma>sci recommended a cotton -ripped probe passed into the
ii;iM)-ph:iT\n\ and upon removal the cotton ii named
blood. A slight hemorrhage t<> the Ofo*phaxymt may oo
In children old enough, with the rhinOSCOpic mirror, the vege-
tations may be detected. In exceptional cases, the vegetation
may be seen upon simple inspection extending below the base
line of the uvula. In the adult, when rhinoi
the soft palate retractor may be used after spraying the post-
nasal space with a five per cent, solution of cocain.
• OF THE NASO-PHARYNX.
457
I Jas worth recommends for the detection of adenoids, spray-
ing the nasal cavity with an oil solution. If the nose and naso-
pharynx are clear, this will emerge from the opposite side as
free as upon entrance. If there is an obstruction, the stream
will be feeble or will not emerge at all.
Prognosis. — As far as life is concerned, the prognosis is favor-
ahlc, if proper treatment is instigated. If pronounced, deformi-
ties of the face may never pass away. Care and attention to
their correction by bandages, and instruction and drilling in
propel nasal breathing, will often be very beneficial.
As a rule, deafness, one of the most frequent complications,
is relieved by adenectomy and mild treatment directed to the
middle ear.
Catarrhal deafness in after life is a frequent sequela of
post-nasal adenoids in youth.
Treatment. — Operative interference is the only rational
method in the treatment of adenoids. The removal of adenoids
Under narcosis is worthy of more than passing consideration.
The disease being found particularly in those of a lymphatic
tendency, it is necessary that attention be directed to the
method of operative procedure securing to the patient the least
danger and the greatest amount of good. In the majority of
cases, it is better to sacrifice a certain amount of thoroughness,
which some operators claim cannot be had without oaroo$U,
for safety.
Among the anesthetics frequently used are chloroform, ether,
ethyl bromid, nitrous-oxid gas, chloroform and ether combined,
chloroform and nitrous-oxid gas combined and the A. C. E.
mixture.
Meyer removed adenoids without the use of an anesthetic.
Since Meyer's recommendation, many forms of narcosis have
ie into vogue. At the present time, the pendulum is swing-
ing toward the side of operative procedure without a general
anesthesia.
Among those who recommend the removal of adenoids with-
out narcosis are B. Friinkel, Hartman, Cradle, Cline, Grayson
I
458
DISEASES OF BAR, NOSE AND THROAT.
and Killian. Knight is strongly in favor of nitrous-oxid gas
followed by ether; Kaufeman. Cholcwa and Shurly favor a
general anesthetic; Bishop favors ethyl bromid.
Fig. 13U.
Gottstkis's Adenoid dJBSm
In adults and older children with hypertrophy of the tonsils,
a twenty per cent, solution of cocain will bring about almost
total anesthesia. The hemorrhage following the operation
will be no greater than without local anesthesia.
In operating under anesthesias, some surgeons prefer M
have the child in the Rose position, with the head hanging l
the edge of the operating table. Other opeiatois prefer to have
the child in an upright position in the lap of the nurse, guarded
tor any intubation. In this positinn, with the attendant holding
the head firmly in position, the operation can be completed with-
out general anesthesia.
Ethyl bromid has been more frequently used by the author
and with satisfactory results, though the danger of the anes-
thesia is quite .is great as from, chloroform or ether. The
anesthetic effect of ethyl-hromid is very short and only of
Sufficient length to enable a drxterOUf OperatOI to remove aden-
oids and enlarged tonsils at the same I
In the administration of an anesthetic, it is unnecessary to
carry it to a point of complete narcosis. 'I he presence of ■
cough and retell reflex will aid in expelling blood and particles
of the detached growth.
Personally. 1 prefer a local anesthetic in children and ad
consisting of a ten to twenty per cent, cocain in adrenalin
chlorid, i i ooo, applied to the post-nasal space with a carton-
tipped probe. The pain of adenectonrj in youth is vrrv illgfct
The local anesthesia probably fails to affect the whole lym-
phatic structure. However, it lessens the spasm of the phai
GOTTSTM*'* AOXNOW ClJRKTrKS, SHOWING StJK AMD ShAVI 0» t-l-APZS.
it in position. The confidence of the child, if lost, can he as
readily regained at its next visit, as argued hy Knight.
There is a possibility of some of the growth remaining after
I
460
DISEASES OF EAR, NOSE AND THRU AT.
the operation and also of a turn of the lymphoid hype
as reported by Delavan and Wright
The best surgical results are to be had with the l Sol
curette. This instrument still remains, with its different
(Fig. 131), the most satisfactory curette on the market. The
smaller size can be used in very small children. The instrument
necessary for the operation should be boiled for a period of ten
Fie. 132.
HBMUiuner.'s Apkkoid Fi
minutes in a one-halt per cent, solution of bicarbonate of
With the mouth gag in position, the curette is taken in the
right hand and under good illumination, either natural
artificial, with the left index linger in the mouth acting as a
guide for the curette and as a tongue depressor, the curetting
angle of the forceps pointing slightly downward arid outward
a passed into the pharynx; the instrument is elevated and
rotated on its axis and passed completely up into the posMMBil
space. With the finger still in the mouth to aid in holding
curette in the median line to prevent injury to the ostium tuba
and also to assist in drawing the curette downward if neces-
sary, the adenoids are scraped away. The technique 01 pa-
the biting forceps into the naso-pharynx is the same as for the
curette.
It is sometimes advisable to use the biting forceps
Followed by the curette. If the curette can be n
without meeting an obstruction, the probabilities are that the
entire growth has been removed. As soon as the operation h»
been completed, the mouth gag should be removed and the head
DISEASES OF THE NASO-PHARYNX.
461
inclined forward to allow the blood to freely escape from the
nose and mouth. It often happens that discrete lymph fol-
licles remain on the lateral wall of the pharynx about the Rosen-
mtiller fossa. These can be removed under cocain anesthesia
of the nose and naso-pharynx with a Meyer's curette.
Considerable hemorrhage through the nose or into the naso-
pharynx may follow the operation. Adrenalin chlorid applied
to the naso-pharynx will, in the majority of cases, completely
stop the hemorrhage in a very few minutes. A number of deaths
Fig. 133.
F.A.1MH01 a co. CHr:nm.
\
■ Km 1 PoV INC Eo*CEM.
Mm hemorrhage following ;(<lenectomy are reported. En-
larged tonsils, which may be present, should be removed follow-
ing the adencetniiH.
I he after-treatment consists in keeping the patient quiet for
a few hours with rot in bed. The patient should not be ex-
posed to irritating dusts for fear of infection, for a few days
following the operation. The nose and pharynx should be
frequently sprayed with diluted Dobell's solution (1/3) or
a antiseptic tablet, one tablet dissolved in four table-
spoonfuls of boiled water, continued for a week. Recovery is
Usually uninterrupted.
Under COCain anr-ithrsia and adrenalin, the fiber-like tonsils
in the adult can usually be removed at one sitting. Excep-
CHAPTER XX \ I i
DISEASES OF THE OROPHARYNX.
Acute Pharyngitis. — Acute pharyngitis is an acute inflam-
mation of the mucous membrane of the pharynx and may he
primary or secondary to an acute inflammation of the nose and
naso-phar^
Etiology ami Pathology, — The causes of the disease are both
predisposing and exciting. The predisposing causes are chronic
catarrh, excess of uric acid, gastro-intestinal catarrh, indulgences
in alcoholic liquors and exposure to unhygienic surroundings.
Tlie exciting cause is usually some septic infection which
may gain entrance from the inspired air, food or diseased teeth.
Any condition which may disturb the metabolism of the
pharyngeal mucous membrane will predispose to infection from
Mimr parhogenic organism.
Symptomatology and Treatment. — In children, the disease
may be ushered in with headache and a general malaise lasting
for a few hours, followed by a high fever. In cases of fever
without symptoms pointing to a specific diseasr in small children,
a careful examination of the throat should be made. The fever
and general systemic disturbance in the child as well as the
adult, is often seemingly out of proportion to the local lesion.
Pressnitr.'s bandage may be advantageously used during the
stage of invasion.
Pastilles containing red-^um, potassium chlorid and cocain
are especially recommended for home treatment. Should the
case be seen at its conception, an old remedy which has been
very efficient in aborting the attack should be given, and is
h fellows:
463
464
DISEASES OF EAR, NOSE AND THROAT.
TJ Acctanilidi,
Tr. acimiti,
M. For an adult.
Signa. To he taken at bed-time.
.60 Rin. (gr. x)
.2+ ex. (pi
The patient should be given Dobell's Solution tor a urar^lr
to be diluted one-half and be used every two hours. The pa-
tient must be instructed to close thr nose during the BCf
gargling. The constitutional treatment consists in the ad-
ministration of a saline cathartic. For the slight elevation of
temperature, acctanilid in from one to five grain doses should be
administered ever}- three hours. The throat should be gently
sprayed with iced Do bell's solution, followed by the application
of nitrate of silver in five per cent, solution 01 CDlond <>t zinc.
three per cent, solution, to be repeated every twenty-lour hours-
Spraying the throat with adrenalin chloricl quickly rclievr-
hypercmia. Any lesion of tin- note 01 uastro intestinal tract
which may be a predisposing cause of successive attacks m
in the interim, be removed.
Chronic Pharyngitis. — Chronic pharyngitia is b <
inflammation of the mucous membrane, sub- mucosa and glan-
dular structures of the pharynx.
Etiology. — Among the many predisposing causes of the dis-
ease are successive attacks of acute pharyngitis, nasal obstruc-
tion, indigestion, chronic tonsillitis, rheumatism, excessive use
of the voice, alcoholism, excessive use of tobacco, chronic
bronchitis, tuberculosis of the lungs, and syphilis.
There is observed in the beginning of the disc.i
glistening, swollen mucous membrane, and the patient com-
plains of stiffening of the neck, with tenderness upon external
pressure over the submaxillary region. The uvula may be
hyperemic. The inflammation may extend to the mucosa of
the Eustachian tube, producing partial and tempo 1 "ess.
The patient complains of dryness in the throat and post-nasal
space, and the constant desire to swall
Hoarseness, due to extension of the inflammation of the
larynx, may l>c present, though this is the exception.
DISEASES OF THE ORO-PHARY\'X.
46 =
Following tlic dry, glistening condition which lasts from
five to seven days, we have a relaxation accompanied by more
or less thick, tenacious exudation of mucus, which sometimes
adheres to the surface, though easily detached with a spray.
This condition may continue for three or four days, when
recover] takes place.
Pathology. — The pathology of the disease varies somewhat
according to the chronica ty of the inflammation. There is a
hyperemia and swelling and sometimes hyperplasia of the mu-
cous membrane of the pharynx extending down to and involv-
ing the sub-mucosa. The mucous glands in the early stages of
the i!im;im- secrete an abnormal amount of mucus and later on
become disturbed in their function and in consequence, some
of the glands undergo atrophy and the remaining secrete a
thick, tenacious mucus. Later on, the mucous membrane
may become atrophic and appear smooth and thin as though
tightly stretched across the muscles of the pharynx
Symptomatology. — The patient complains of an accumula-
tion of thick, adherent, tenacious secretion which is found in
the throat, particularly upon awakening, the dislodgment of
which IS vi 1 \ difficult and sometimes produces vomiting. The
• is somewhat husky and chronic laryngitis is frequently
associated with the disease. The tongue is usually heavily
□Dated and the appetite poor. Chronic constipation is frc-
itly present. Upon examination, the pharynx, uvula and
pillars of the fauces are found to be quite hyperemic and the
pharynx is covered with a thick, tenacious secretion. The
faucial tonsils arc often hypertrophied and subject to recurrent
attacks of inflammation. Small varicosities may be seen cover-
ing the surface of the mucosa, which may rupture and produce
I slight hemorrhage, The disease is frequently observed in
those who use alcohol and tobacco to excess, more particularly
ohoL A slight impairment of hearing, due to extension of
infection through the Eustachian tube, is usually associated
h the disease. The inflammation may be confined to the
I
466
DISEASES OF EAR, NOSH (WD THROAT.
mucous membrane of the pharynx without involvement of the
adjoining structures.
Diagnosis. — From the foregoing enumeration of symptoms.
the diagnosis of chronic pharyngitis is comparatively easy. The
influence of chronic hypertrophic pharyngitis upon the diges-
tion and upon the general metabolism should not be overlooked
and likewise the influence of the chronic gastro- intestinal db-
m l< is upon the production of the throat sympti
Prognosis. — The prognosis is somewhat variable and de-
pends to a great extent upon our ability to overcome the gen-
eral constitutional dyscrasias and the correction of the local
cause producing the disease.
Treatment. — The treatment is both genera) and local. The
:1 treatment is necessarily directed to the correct
any habits which are directly OX indirectly irritating to the
mucous membrane of the fauces and upper air passages, gastro-
intestinal disorders, syphilis, rheumatism or tuberculosis. The
general treatment should be particularly directed to the relief
of constipation and disorders of the liver and in consequence
some mild aperient water would be given night and morning
with an occasional dose of calomel and soda.
The local treatment consists in cleansing the nose and tl
with a mild alkaline ami antiseptic spray twice daily. The
additional local treatment consists in the application by the
physician with a cotton-tipped probe, of a solution ot twenty
to thirty grains of nitrate of silver or a twenty to tliirf.
solution of chlorid of zinc, followed by a spray consisting of
the following:
«
lodini,
Camphor, I u
Mcrifhnl, >
1 'I :;iultherie.
Albolctii, c[. ». act.
x* Km. U
.60 c.c. (eit. x)
30.00 c.e. (3 II
Small varicosities on the surface of the pharynx should be
destroyed with the galvano-cautery, under cocain anesthesia.
DISEASES OF THE ORO-PHARYNX.
C'7
Where the chronic inflammation is of a purely lithemic
origin, the treatment consists in the avoidance of all red meats
and alcoholic liquors, free ingestion of distilled water and plenty
of out-door exercise. The patient should be given sodium
salicylate in three to five grain doses every two or three hours
or until the physiological effect of the drug is noticed. Effer-
vescing phosphate and benaoate of soda in heaping teaspoonful
doses may be given upon arising and at bed-time. For the
pain and aching in the throat, orthoform lozenges may be dis-
solved in the mouth every three nr four hours. Hot, moist
applications to the neck for one-half hour followed by massage
i '•• usually very beneficial.
Acute Follicular Pharyngitis. — As the name implies, acute
follicular pharyngitis is an acute inflammation of the mucous
membrane, and more particularly, of one or more discrete
lymph follicles of the pharynx.
Etiology. — The cause is often trauma of the pharynx, ex-
posure to cold, gastro-intcstinal disorders, influenza and sub-
sequent infection.
Pathology. — There is a swelling of the lymph follicles of
the pharynx and a hyperemia and swelling of the mucosa sur-
rounding the follicles. The hyperemia is seldom diffused as
in simple acute pharyngitis.
The infection may travel to the pharynx from the nose or
be absorbed from the pharyngeal mucosa. The disease is essen-
tially an inflammation of the follicles and not of the mucous
membrane. Involvement of the mucous membrane is a secon-
dary process.
Symptomatology. — The symptoms are the same as for acute
pharyngitis with the exception that the patient is conscious of a
localized irritation rather than a sensation of a diffused in-
flammation.
Diagnosis. — The red and swollen follicles arc easily detected
upon inspection, and may be quite small and distinct or welt-
like anil iri npy ;i median or lateral portion on the pharynx.
One or two small, acutely inflamed follicles may produce s. ••.
I
46S
DISEASES OF EAR, NOSE AND THROAT.
subjective symptoms out nt all proportion to the objective
signs of the disc
Treatment. — The local treatment consists in flic treqnrnt
use of a hor saline and antiseptic gargle with the nose tightly
closed. Hot applications externally, antiphlogistin poultice
or Pressnitz bandage to the neck is efficacious. A sixty grain
solution of nitrate of silver should be applied to each fol
and repeated daily One drop doses of aconite may be pre-
scribed for controlling the fever, to be taken every hour until
the symptoms of the physiological effect of the drug arr
observed.
Calomel is usually indicated at night, followed by some
aperient water upon arising.
The severely painful swallowing may be partially alleviated
by menthol, cocain and red-gum pastilles or orthoform lozenges
dissolved in the mouth every two or three hours.
Chronic Follicular Pharyngitis or Clergyman's Sore
Throat. — Chronic follicular pharyngitis is a chronic inflamma-
tion of the mucous membrane of the pharynx, character
by an increase in the size of the lymph follicles.
Etiology. — The disease Frequently develops from an acute
follicular pharyngitis, predisposition to the disease, faulty per-
sonal hygiene, lymphatic diathesis, especially in tin-
chronic nasopharyngeal catarrh, excessive use of the voice.
Indigestion, pelvic disorders in women, tuberculosis of the In:
use of tobacco, alcoholic liquor* and rheumatic diatl
Pathology. — There is a hypertrophy of the mucosa and
•••rplasia of the follicles and mucous glands. Accord in..
Shurly, the secretion is more abundant than normal and con-
tains a large additional proportion of mucin, epithelial debris,
lymphoid cells and mineral ■■:
Symptomatology and Diagnosis. — There is a sense of ever-
present irritation of the throat. The amount of secretion varies
rding to the pathological change and may be profuse, rl
rfacid or scanty. Huskincss of the voice and coughing follow
the prolonged use of the voice in the adult. The quality of the
D1SEAS£S Of THE ORO-PHARYNX.
,,„,
voice is notably impaired. The general appearance ot the
pharynx varies and is that of a venous engorgement, of a
pale pink, resembling the normal. The follicles appear rod
and project above the surface, sometimes surrounded by
varicosities.
The tonsils may be enlarged and cryptic, containing in-
fected cheese-like debris.
Treatment. — The treatment is directed to the correction of
any gasrro-intestinal disorders, injurious habits, rest of the
voice, general tonics and training in the correct use of the
voice.
The local treatment consists in the removal of any nasal
obstructions and cryptic tonsils. The destruction of large
Follicles and varicosities is best done with the galvano-cautery.
Care should be taken in the use of the cautery to avoid too
great destruction of tissue at one time on account of the ten-
dency to prodtice cicatrices which become a permanent source
of irritation. Previous to the use of the cautery, the pharynx
should be sprayed with a five percent, solution of coca in, which
renders the application of the cawte-n pain less.
Applications of the cautery should be made at an interval of
a week. In the absence of the cautery, nitrate of silver in a
strength of sixty to one hundred and twenty grains to the
ounce, should be made to each follicle, care being taken not
to injure the surrounding mucosa with the silver solution.
The following local application may be made by the patient
once daily, by means of a cotton-tipped probe:
9 Iodini,
Fotawii iodidi,
Menthol,
Glycerin!,
.60 gm. (gr. x)
1.20 gm. (gr. xx)
12 gin. (gr. ii)
30.00 c.c. (3 i)
Atrophic Pharyngitis or Pharyngitis Sicca. — Etiology.—
Atrophy of the glandular structures of the mucous membrane
: lie* pharynx may be congenital or acquired and may be an
extension from a like condition of the nose or may occut from
47°
DISEASES OF EAR, NOSE AND THROAT.
a previous hypertrophic or follicular inflammation. All of
the pharynx is usually involved.
Among the predisposing causes arc habits and occupation of
the patient, syphilis and inherited dyscrasia.
From the similarity of the disease to atrophic rhinitis, the
etiology may, advisedly speaking, be considered the same a-
that disease.
Pathology. — There is an atrophy of the entire mucous mem-
brane and glandular structures and diminution in the siic of
the blood-vessels and capillaries. In consequence of the atrophy
of the follicles and mucous glands and a lessened amount of
blood supply, there is a diminution in the secretion and the
surface appears dry and glistening.
Symptomatology, — The patient complains of a dryness and
stiffness of the throat and frequent hawking and efforts to
dislodge a mucus-like substance which adheres to the pharynx.
The symptoms are somewhat variable, changing according to
the stage of the disease and the aching cause. The general
appearance of the entire pharynx is usually dry and glistening
and covered with a tightly adherent, stringy secretion, extend-
ing over the entire pharyngeal wall. The wall of the pharynx
may appear paler than the normal or a motley red. Atrophy
of the nasal mucosa is also frequently present.
Treatment. — The internal administration of those remedies
which stimulate glandular secretions is indicated (■<•<• Treatment
of Atrophic Rhinitis), as iodid of potassium in limited doles
and phosphorus in l/lOO grain doses. The throat should be
sprayed with Dobell's solution. Following this, tincture of
sanguinaria in glycerin is highly recommended. The foil
ing may be used as a spray three or four times daily:
8 Ac. carbdi.i. .65 K»n. (gr. «)
Tinct. iodi. ^
Tim I. ill.*-. • HA .60 C.C. (j 1
Tinct. opii, 1
Glycerin!, • ;■ a ad. 30.00 c.c. (J j)
The following used in a nebulizel is very soothing and
stimulating:
DISEASES OF THE OR.O-PHARYNX.
47'
9
Ol. eassire,
Ol. eucalypti,
Ul. gaultherijt,
Menthol,
Albulene,
.j6 c.c. (gtt. vi)
.72 c.c. (gtt. xij)
.72 c.c. (gtt. xij >
.60 grn. (gr. x)
jo.oo c.c. (5 j)
Any abnormal condition found to exist in the throat and nose
must be corrected. The object of all such cases of atrophic
degeneration is rather to secure relief. The possibility of a
cure is in inverse ratio to the time of existence of the disease.
Acute Infectious Phlegmonous Pharyngitis. — This is an
acute infectious phlegmonous inflammation of the pharynx,
usually originating in one side of the pharynx and extending
to deeper structures, terminating in death.
Etiology. — The disease is usually due to some form of
traumatism, followed by virulent infection with some pus-
producing organism.
Pathology. — There is a rapid swelling of the pharynx and
infiltration of the sub-mucous structures, followed by a speedy
formation of pus, which infiltrates the surrounding tissue, pro-
ducing a general septic infection and ending fatally in from
five to ten days. The organism producing the disease is pre-
sumed to be the staphylococcus, the streptococcus or a combina-
tion of the two.
Symptomatology. — The symptoms characterizing this dis-
ease are sudden soreness of the throat followed by swelling,
difficult deglutition, pain in the throat, rapid rise of tempera-
ture (1030 to 104°). headache with symptoms of general
infection, coldness of the skin, clammy perspiration and dry
tongue, often followed by early collapse and death.
The streptococcus pyogenes aureus is more often found in
the greenish, fetid pus discharged from the diffuse abscess.
The urine contains albumin.
Diagnosis. — From the foregoing enumeration of symptoms,
redness ;\r\A edema of one side of the pharynx, gradually extend-
ing to the opposite side, rapid formation of pus and profound
systemic disturbances, the diagnosis is comparatively easy.
472
DISEASES OF fcAR, N'OSE AND THROAT.
Treatment. — The treatment consists ill placing the patient
in the best possible hygienic surroundings. The tliroat should
be frequently sprayed with Dobcli's solution. Suspected ab-
scess should be incised and drained. With symptoms ol septic
infection, antistreptococcus scrum should be injected. A gai-
gle consisting m the following, used every two hours will give
great relief:
H Sol. antiseptic! (Lister}, 1.80 c.c. (gtt xxm
Ac. carbnlici, .18 c-c. (gl
Glycciini, 1.20 c.c. (git. xx)
Aq. menthol, 30.00 c.c (3 j)
Marked relief may also be experienced by the use of the Press-
nitz bandage. Spraying the throat frequently with the f<
ing acts as a local sedative and antiseptic:
J*
Ac. carbolici,
.30 cc (git. v)
Menthol,
.30 gin. (gr. v)
III. eucalypti,
ta c-c. (g
Albolene,
30.00 cc. (3 j)
After relief of the acute symptoms, the administration
some ferruginous tonic is indicated. Local treatment can be ot
little avail though we may try to relieve all the prominent
symptoms. If asphyxia is imminent, tracheotomy may t*
sorted to, although nothing must be expected from it except
temporary relief (Max Thorner).
The general treatment consists in the hourly injection of
SU)tistreptOOOCCU8 serum and high enemas time ni [our time*
daily of a warm, normal salt solution. Additional treatment
is generally supportive.
Erysipelatous Pharyngitis. — Erysipelatous pharynx
an acute inflammation of the pharyngeal mucosa and is oftrn
due to an extension of the erysipelatous inflammation from
cutaneous structures of the nose or mouth.
Etiology. — The disease is due to an extension oi a ■
flammation from cutaneous structures of the face or may orijji-
niMWNr.S OF nil. OROPHARYNX.
-173
nate in loco and is due to infection with the streptococcus of
I 'Mi/iM-n, gaining entrance through, a solution of continuity
of tissue.
Pathology. — The disease involves the epithelium and upper
layers oi the subnnicosa. The epithelial cells become swollen
and capillaries enlarged and filled with cocci. Vesicles form
on the surface and near the center of the diseased area and are
filled with a serous or sero-p undent fluid. The disease is
considered contagious under favorable circumstances.
Symptomatology. — In the beginning of the disease, there is
usually a marked swelling of the submaxillar and cervical
mis. The patient complains of smarting, dryness and burn-
ing sensation in the throat and difficult swallowing. If the
swelling becomes very great, speech is difficult and dyspnea may
■ iivur. The disease may occur epidemically, as described by
many writers. Such an epidemic occurred in America in 1842,
an.l was known as the " black tongue."
Upon examination, the pharynx is found to be swollen, of a
deep reddish color which is circumscribed or diffused. In the
diffused form of the disease, one or both tonsils and the pillars
of the pharynx may be swollen, with sometimes an extension of
the disease to the nose or Eustachian tube and middle ear.
" Vesicles soon form over the surface of the pharynx, which
rupture and discharge a serous or sero-purulcnt substance,
leaving behind yellowish or white patches, which are easily
removed " (Warren).
The tongue is heavily coated and may become more or less
Swollen- In severe cases, the glottis may become swollen and
the disease is described as extending to the" lungs.
Diagnosis. — Sudden chill, followed by high temperature,
mated tongue, enlargement of the cervical and submaxillary
glands, followed by deep redness with zig-z.ag outline, smarting
and burning of the pharynx independent or accompanying facial
erysipelas, will tuggest the disease.
Phlegmonous erysipelas resembles phlegmonous pharyngitis
so closely that the two cannot be differentiated.
474
DISEASES OF BAR, NOSE AND THROAT.
Course- ami Prognosis. — The disease usually runs its course
in from five to six days and more often terminates in p
In involvement of the middle ear, rupture "i the drum may or
may not follow .
Treatment. — The treatment cunsist* in the internal admin-
istration of iron in large doses, preferably the chlorid. In-
ternally, extract ol suprarenal gland in Me grail) dos
recommended. Local spraying of the throat with adrenalin
chlorid, 1/10,000, or one-half of one per cent, solution of oocain
reduces the hyperemia and lessens the pain. Hot Dobell's
solution should be used as a spray or gargle every hour during
the day and frequently at night. Free purgation is essential
in the very beginning of the disease. The patient should be
isolated.
Scarlatina Angiosa. — Of all the exanthematous diseases.
that of scarlet fever brings about the most varied and far-
reaching destructive, inflammatory changes in the pharynx, ex-
tending often to the middle car and accessory sinuses. In
consequence of the gravity of the SO TSD, >p.t>_r is grWfl
to the treatment of throat affections resulting from the disease.
Diagnosis. — The diagnosis of scarlet fever is, as a rule, de-
pendent upon the preliminary symptoms, i. e.. sudden voirn'
rise of temperature, rapid pulse, straw berry tongue, sore throat
and the appearance upon the neck and chest at the end of the
first or the beginning of the second day, of a scarlet rash, which
spreads over the surface of the body.
Upon inspection of the throat, the pillars of the faucial ton-
sils and the entire pharynx are found to be intensely inflamed
and covered with a catarrhal exudation. The nasal respiration
may be occluded from the swollen mucosa and exudation, com-
pelling the child to breathe through the mouth. The exhalation
from the mouth is very offensive.
The lymph gland* of the neck are greatly swollen from
absorption of toxin- and in extreme cases may suppurat
pur.ifion of the middle ear may occur on account of the vvrrr
infection which is presumed to be of a st reptococcnu* ori
DISEASES OF THE ORO-I'HARYNX.
475
Treatment. — The local treatment consists In cleansing the
nose and naso-pharynx, pharynx and mouth with a warm Do-
bell's solution, diluted with three parts or water. If the child
is old enough, a gargle of one-half per cent, hot Dobell's solu-
tion may be used every hour. If the nasal mucosa is so swollen
as to prevent spraying the nose, a preliminary spraying or drop-
ping into the nose of a solution of adrenalin, 1/5,000, with an
ordinary eye dropper, will so shrink the mucosa as to enable
fluids to pass into the pharynx.
If we are unable to satisfactorily clear the pharynx with the
Dobell's sol ut ton, retort should be made to a gargle or spray
of equal parts of pcroxid of hydrogen and witch hazel. Local
applications may now be made to the pharynx twice daily, con-
sisting of a two per cent, solution of chlorid of zinc or a two
to four per cent, solution of nitrate of silver, followed by a
local application with a cotton-tipped probe or a spray of the
Following every two hours:
U
M.
Menthol,
Crcasoti,
lodini,
Alboleni,
.12 gm. (gr. ii)
.18 gm. (gr. iii)
.16 gm. (gr. i)
30.00 c.c. (j i)
As the inflamed condition passes away the local application
of astringents may be less frequent. The Dobell's solution and
oleaginous spray should be continued at least twice daily until
the patient is quite well.
Gangrenous Pharyngitis. — Etiology find Pathology. —
Gangrenous pharyngitis is a circumscribed necrosis of the mu-
cous membrane and the subcutaneous tissue, and is due to
trauma, scarlet fever, diphtheria or septic embolism. Gan-
grene of the cheek or noma, usually affecting children under
the age of seven or eight years, may have its origin about Sten-
son's duct, perforating the cheek and extending back to the
pharyngeal wall. The disease usually terminates in death.
However, in rare cases the disease ends in recovery, with a
perforation of the cheek and the formation of deep scars.
I
476
DISEASES OF EAR, NOSE AND THRUM.
Symptomatology and Diagnosis. — There ;u<- marked
tutiuriul symptoms with high fever ami sometimes delii
There is a rapid loss of flesh due to inanition Inmi general
systemic poisoning. The diagnosis of necrosis is comparat:
easy. The disease should be differentiated from diphrhen.
scarlet fever. However, in the malignant form of the rwu
diseases, gangrene may ensue.
Treatment. — The treatment is directed to mmbating the
general infection by supporting the strength with nutritious
foody, stimulation by means of whisky and strychnia and con-
trolling the pain by opiates.
The throat should be treated with a spr:i\ .a gargle every
hour with a one per cent, solution of carbolic acid, followed
by peroxid of iron. Orthoform dusted on the surface will act
as a germicide and local anesthesia.
For the mitigation of the odor of decoraposrtuxi m nana.
Graenwald recommends dusting the parts with freshly roasted
and ground coffee.
Hemorrhagic Pharyngitis. — Hemorrhagic pbaryng
an acute or chronic condition of the pharynx, characterized by
the formation of minute or confluent hemorrhagic spots.
Etiology. — The disease is especially observed in those with
a hemorrhagic diathesis and may accompany a follicular pharyn-
gitis. The general health of the individual is often found
greatly impoverished from inherited or acquired disease.
Pathology. — Small hemorrhagic extravasations may a:
the coarse of general diseases and an due to a rupture or leak-
age through the vessel wall into the mucous membrane. In
congenital cases, small, deep reddish, follicular-like extravasa-
tions may be seen on the pharynx, surrounded by varicose
veins. The condition usually accompanies a hemorrhagic
diathesis.
Symptomatology and Diagnosis. — The patieir ptiblr
to recurrent attacks of pharyngitis and frequently. tonsil'
There is usually present a n3so-phnryngraI catarrh and vari-
cosities of the septum. Hemorrhages from the pharynx, char-
acterized by the spitting of blood, is infrequent.
D1SLASES OF THE ORO-PHARYNX.
477
The diagnosis, upon inspection and history of frequent nose
bleed and symptoms of hemophilia, is iinmisTakable.
Treatment. — The treatment consists in the correction of
any constitutional diathesis and the avoidance of tobacco and
alcoholic liquors.
The local treatment consists in the destruction of the varicose
vessels and the deep reddish, follicular-like infiltrations of the
pharynx with the galvano-cautery.
Pharyngitis (Seu Angina) Ulcerosa. — Ulcers of the
pharynx are localized areas of necrosis. Their size and location
vary according to the site of the trauma or inflammation pre-
disposing to the lesion.
Etiology, — Syphilis easily takes precedence as a causative
factor, followed by infection from pathogenic organisms, es-
pecially the staphylococcus aureus or the streptococcus pyogenes,
tuberculosis and cancer following next in frequency.
Trauma of the pharynx or localized disturbances of metab-
,m may be brought about by hot or cold drinks, foreign
dies or constitutional d3'scrasia. Ulcers in this region arc
comparatively infrequent.
Course and Prognosis. — Ulcer of the pharynx is usually slow
in its growth and well developed before observed by the surgeon.
The prognosis is good under favorable treatment, the recovery
being complete.
Diagnosis. — Pain and irritation in the throat, odynphagia,
hn.irsoness and general debility are some of the symptoms sug-
of this disease. There is frequently a history of some
'.<•iirr.il infective .lise.ise. rlioirji such a history is not always
forthcoming.
The patient complains of a loss of flesh, great pain in the
throat, difficult m allowing, frequent regurgitation of fluids
through the nose and partial or complete loss of voice.
Upon observation, a variety of changes may be noted in the
pharynx. The site of the lesion may be noted in the center or
i the pharyix rxtendinu from the naso-pharynx into the
hiryniro -phannx. It may be round or oblong. The borders
I
47S
DISEASES OF EAR, NOSE AN'D THROAT.
are well defined and the edges more or less congested. Necrotic
tissue may fill the ulcer or a comparatively clear-cut floor may
be present. The ulcer may extend over the vertebra?, partially
or completely destroying the pharyngeal muscles.
The diagnosis of an ulcer is easy. It should be borne in
mind that cancer may resemble a syphilitic CM infective ulcer.
1 'In- border in the former may be pair instead of being red and
granular.
The hemoglobin test of Justus may be used in the differ
tion of syphilis. With this test a hemoglobin estimation is made,
followed by a strong mercurial inunction. After M
four hours B second hemoglobin estimation is made and if we
find a ten to twenty per cent, reduction of hemoglobin, we are
comparatively safe in pronouncing the disease syphilis
In addition to this, there remains the old test of heroic do«s
of the iodid of potassium, which, if syphilis, will bring a quick
response in the relief of all symptoms.
Cancer of the pharynx is differentiated by microscopical
section, general cachexia and foul-Miiclling odor, which, as a
rule, accompanies the disorder.
Regardless of the cause of the ulceration, there is present
a mixed infection, due to the ever-present pathogenic organisms
within the oro-phannx.
Treatment. — The treatment resolves itself into both general
and local, the general treatment necessarily depending upon
the cause producing the disorder. If due to syphilis, a satur-
ated solution of iodid of potassium in twenty drop doses should
be given in abundance of water after meals, increasing the dose
daflj nnril the reaction is noted.
If due to any other cause, the iodid of potassium is seldom
indicated and. broadly speaking, a general tonic such as iron,
qtiinin and strychnia, is indicated. The exciting cause, what-
ever it may be. should, as far as possible, be eradicated.
If due to tuberculosis, in addition to the general tonic treat-
ment and open air. curettement and application of fnrmaldr1
i ounce daily, is indicated. For cancerous ulcer, CVFI
mcnt, the X-ray and internal administration of Fowler's solu-
tion, four drops three times daily, should he given.
Infective ulcers are treated like ulcer in any other portion
of the body. The treatment consists in general tonic treatment,
free purgation, cleansing with pemxid of hydrogen in full
strength, followed by tfgefttuffl nitrate, fifteen to thirty per
cent, solution, or trichloracetic acid, fifty per cent, solution.
The ulcer should be treated once daily until recovery is com-
plete. In addition to a hot gargle of Dobell's solution full
strength, orthoform lozenpes may be prescibed for home treat-
ment. The orthoform will act as a sedative and antiseptic
Diabetic Pharyngitis. — Diabetic pharyngitis is a chronic
inflammation of the pharynx, due to interference with the nutri-
tion of the mucous membrane from diabetes.
Symptomatology- The symptoms as described by Vcrdos, are
dryness of the throat, difficult swallowing and tenacious ac-
cumulation of mucus.
Treatment. — The general treatment is that recommended for
diabetes.
The local treatment consists in menthol ized sprays and as-
tringents, such as ioitin, biborate of soda, etc. Frcudenthal
records one case of diabetic ulceration and recommends for
treatment twelve and one-half per cent, orthoform emulsion.
Tuberculosis. — The disease may be primary or secondary
to a pulmonary tuberculosis and is due to infection with the
tubercle bacilli.
Pathology. — The disease may appear as a nodular or ulcer-
ative form of lupus infiltrate. Infection may reach the pharynx
from a tuberculous lung, through food or inspired air, gaining
entrance through some localized solution of continuity. Sub-
mil iary tubercles form in the submucosa and may develop into
nodular infiltrations, which are soft and bleed to the touch.
They may undergo softening, degeneration and formation of
an ulcer. The ulcers are somewhat yellow, with regular, granu-
lar edges, and are covered with thin mucous exudation.
Symptomatology. — There is usually a history of dryness of
I
4&>
DISEASES OP EAR, NOSE AND THROAT.
the throat, huskincss of the voice, sometimes slight bloody
expectoration and a drawing sensation in the throat. On
account of the absence of pain, the disease is usually far ad-
vanced before the physician is consulted.
Diagnosis. — In an ulceration of the throat, accompanied by
a pulmonary tuberculosis, as a rule, the diagnosis is ea:
simple uncomplicated tuberculosis of the pharynx, the diagnosis
is only reached by a process of exclusion. The disease resem-
bles syphilis and in consequence heroic doses of iodid of potas-
sium and inunctions of mercury arc indicated until proof
positive of the absence of the disease is established. Fo!
this, the injection of tuberculin may be tried. The tuberculin
test may give no reaction in a mild case of tuberet:
pharynx. Where there is slow formation of granuloniatiiii-
tissue, in the absence of a positive diagnosis nlis or can-
cer, the disease, advisedly speaking, is tuberculosis. The
tubercle bacilli, which is sometimes found in the granulomatous
mass, renders the diagnosis positive.
Prognosis. — Providing the disease i- pun-Is a ltval one and
all the diseased tissue can he removed by e-un-ttrmrnt, thl
nosis is favorable. Years after the removal of localized infiltra-
tion, many cases develop a pulmonary tuberculosis, due to a
latent pulmonary tuberculosis antedating the pharyngeal in-
fection or synchronous with, or due to, a secondary infection
with the tubercle bacilli from a tubercular tendency.
Treatment. — The treatment is both general and local.
The general treatment consists in giving the patient the
advantage of nutritious diet and plenty of out-door C
free from dust and irritating gases and free ventilation of sleep-
ing apartments.
The local treatment consists in cleansing the nose and throat
frequently with Dobell's solution, curettement of the !■
and ulcerative patches, followed In the application of nitrate
of silver in solid stick. Sometimes the nalvano-cautery may be
applied every week or two. The throat may be sprayed once
daily with a one-twentieth solution of a forty per cent, for-
maldehyd.
exposure to tubercular infection by association with tubercular
patients.
The exciting cause of the disease is the tubercle bacilli.
Pathology, — The lesion is characterized by the format inn.
in the mucous membrane and subcutaneous tissue, of distinct
iyish-red nodules about the size of a sago grain
and may be general or localized. They undergo slow ulcera-
I
4S2
DISEASES OF EAR, NOSE AND THROAT.
tion or absorption with the formation of distinct scan. The
nodules are made up of a small, round-celled infiltration and
typical tubercular giant cells, the nuclei of which point to thr
periphery. Between the cells is a network of fine connective
tissue fibers. The tubercle bacilli are found only in
numbers and with great difficulty.
Symptomatology. — There is frequently I history oi tuber-
culosis in the family. The general condition nt the patient may
be, as far as general appearance is concerned, quite normal. The
patient, on account of the insidious nature of the disease, snrtr:-
but little irritation of the throat until ulceration is far advanced
and contiguous structures are involved.
Diagnosis. — Upon inspection of the fauces in the early I
of the disease, apple-jelly-like nodular growths about th
of a sago grain, separate and distinct, are observed on one or
both sides of the pharynx. With the caseous degeneration,
the nodules appear gray and soon break down and I.
reddish base. The pharyngeal mucosa is hyperemic and some-
times covered with mucus. The disease may Spread
pillars of the fauces, tonsils, soft palate ami larynx. I
ease should be differentiated from syphilis or herpes
pharynx
The tuberculin test should give a positive reaction, that is.
increase of local hyperemia and rise of temperature with a
return to the normal in from twenty-four to thirty >iv hours.
Microscopical examination of the curetted mass should show
i typical arrangement of the giant cells, small, round-crlled
infiltration am! sometimes tubercle bacilli.
Treatment. — The general treatment is directed to tlw
rection of any constitutional dyscrasia and the avi
alcoholic liquors and tobacco.
I he local treatment is frequently disappointing am
in curertement followed bj the application of l
■ lid stick.
H. S. Birkett reports Battering resu ts in the core oi a case
of lupus of thr pharynx, shown in Fig. 134, by the. appl
DISEASES OF THE ORO-PHARYNX.
483
of the Roentgen ray. The tube was placed ten inches from
the patient with ten minutes' exposure. The patient's iace
was protected with a wooden shield painted with eleven coats
of white lead on both sides. Daily applications of the X-ray
should be made unless untoward symptoms arc observed, when
a longer interval of time may be substituted.
Glanders. — Glanders is an acute or chronic purulent inflam-
mation of the pharynx, due to infection from the bacillus Mallei.
Etiology. — The disease is more often observed in those habit-
ually in contact with liorses and from which infection is blown
or carried by the hands of the individual to the face. The
organism producing the disease is known as the bacillus Mallei,
inst discovered by Loftier and Schutz.
Ptitkulngy. — The disease is characterized by the forma turn
nf prmphigus-likc vesicles at the point of infection, which soon
suppurate, producing an ulcer and sometimes gangrene, Mm;i
Static infiltration may occur on the face, trunk and extremities,
which rupture, discharging a purulent secretion and in chronic
cases an ill-smelling pus.
Svtupiom/ilology. — The symptoms of the disease are some-
what variable and may be mild or severe. In the mild form
(it the- disease, we have the formation of vesicles which rupture
with a discharge of pus. The ulcers heal after a short time
without any general symptoms.
In the severe form of the disease, following the period of
inflammation, is observed a marked swelling and inflammation
of the submaxillary and cervical lymphatics, rapid rise of tem-
perature, general prostration, headache, pain upon swallowing,
dryness of the thmat and sometimes hemorrhage and formation
of pustules over the hod}'. The disease rapidly extends to the
snd face. Gastro-intestinal disorders may supervene and
also acute, purulent, septic bronchitis.
The discharge from the thmat and post-nasal space is thick,
foul-smelling, yellowish pus, sometimes streaked with 1111
and blood. The duration of the acute form of the disease in
favorable cases, is usually sixteen days.
4s4
DISEASES OK EAR, NOSE AND THROAT.
In the chronic form of the disease, the course is variable
SUld acute exacerbations frequently occur until the patient
cumbs to the disease.
Diagnosis. — The history of occupation, sodden onst
disease, tin- grave constitutional symptoms/, formation of nml
nplc abscesses over the pharynx, sometimes involving the nasal
cavity, formation of pustules of the skin and discharge 01 a
hud-smelling pus, are diagnostic signs of the disease. In .
tion to the above, discovery ot the presence ot the bad
Mallei in the secretion or by inoculation into guinea
sufficient to differentiate the disease. ( )n blood -erum, the
growth is opaque and of a bright yellowish color.
Prognosis. — The prognosis of the disease is usualh unfavor-
able. The majority of cases both in the acute and chronic
forms terminate fatally; in the acute form in from one
weeks, and in the chronic form in from a few months to a
year.
Treatment, — The treatment consists in the curettement "'
the granulated tissue) spraying with peroxid of hydrogen,
lowed bj the application ol carbolic acid, two per cent
albolene.
The general treatment is directed to flushing the met;>
abscess and combating the systemic infection. Should the casr
terminate favorably, tonic doses of iron, quinin and strychnia
are indicated.
Syphilis. — Syphilis of the pharynx may be prim
dary or tertiary.
Primary Syphilis. — Primary syphilis of the pharj
very infrequent. The position of initial lesion may be on the
tonsils, posterior pillars, pharyngeal wall or about the pharyn-
geal orifice or {Eustachian tube. In the latter region, rhe
infection is more often carried by a Eoatachfag ottb
Secondary SvpHrus. — The mucous patches an o
observed upon the soft palate, pillars of the fauces 01 the
and less frequently on the pharyn
In the congenital and acquired form -<*, the ice-
DISEASES OF ill i- (ikii PHARYNX. 4S5
lesions may manifest themselves in mucous patches,
ulcerations, hyperplasia oi the mucous membrane, hemorrhagic
extravasations and varicosities. According to Morrow, ulcera-
tions are generally found in the median line of the vault and
at the juncture of the palatal process and the superior maxilla.
The areas of destruction on either side are equal and symmetrical.
Tirtiarv Syphilis. — In the tertiary stage of the disease,
there may be gummatous formations, tumors, diffused iniil-
ti at ions and ulcerations.
Congenital tertiary lesions vary but little from those of the
acquired. They usually manifest themselves early in life,
whereas the tertiary lesions of acquired syphilis are usually
observed in those past the eighteenth year.
Symptomatology, — The symptoms of the primary sore or
hard chancre are usually smarting or slight pain in the region
of the chancre and swelling of the submaxillary or cervical
glands. There is an increase of mucus in the pharynx. The
presence of mucous patches usually give rise to the symptoms
hi simple pharyngitis. There is an accumulation of mucus,
luckiness oi the voice upon exercise and exacerbation of any
catarrhal condition of the nose or nasopharynx.
The symptoms of tertiary syphilis vary somewhat according
to the character and stage of the local condition.
The symptoms of tertiary specific pharyngitis, accompanied
bj marked swelling of the mucous membrane are the same as
those for chronic pharyngitis. In the gummatous stage, the
patient may complain of pain in the throat and neck. The
growth usually gives rise to some difficulty in swallowing and
if situated within the region of the nasal pharynx, there is an
impairment of the voice and nasal respiration and sometimes
regurgitation of fluids through the nose. The size of the
gummata is variable and may be very small or quite large.
In the ulcerative stage of the disease, which is usualK . I in-
to the breaking down of the gummata, the patient complains <>t
an irritation in the region of the ulceration, accumulation of
Enuoo-purtilent substances, frequent expectoration, sometimes
4
486
DISKASES OF BAR, NOSE AND THROAT.
regurgitation of Hinds through the nose, huskincss of the
painful and difficult swallowing and loss of flesh.
Diagnosis. — The primary lesion of the pharynx a
overlooked. The location nf the haul chancre, in the author's
experience, has been more often on the tonsil. The
appearance is that of a mild ulceration, covered with white,
glistening mucus. There is usual!) marked enlargement of
the cervical and lymphatic glands.
The skin manifestations ot the disease in suspected rases
render the diagnosis positive.
The mucous patches are observed to be irregular ii
with a distinct, whitish border and are covered with :
exudation. Mucous patches are often Found on the »fi
tonsils and posterior wall and mas • ir in a trv. ui
ni.i\ forrrj Superficial ulcers. A mucOUS patch is so distinctive
that there is little danger <>J error in the dia
good rule to rcniemher in all ulcerative conditions "t the
the ever-present possibility of syphilis.
Tertiary lesions of syphilis rnaj resemble simple ulcer)
chronic pharyngitis, chronic interstitial tonsillitis, lupus, tuher-
culosis, actinomycosis or cancer. Within the tongue may be
one nr more gumniata, which appear above the surtace ■
hard to the touch. The SCftt tissue, which results from the
healing of the deep ulcerations of the pliai ^>ft palate,
resembles the scars from malignant diphtheria, scarlet fever
and lupus.
In doubtful cases of secondary and tertiary syphilis, ibc
diagnosis is usually made clear by inunctions of mercury inJ
foald of potassium, internally.
The author has seen a few cases of tertiary syphilis in the
throat in which there was a history of removal from the lip.
a number of years previously, of a hard nodular growth, pre-
sumably cancer. The immediate results following the aJ-
ministration of iodid of potassium proved conclusively thai the
aid mat ion removed from the lip was not a cancer, as diagnosed
by thr surgeon, but a hard chancre.
DISEASES OF THE ORO-PFIARYNX.
4S7
)t infrequently diagnosed as sarcoma or car-
rest
2
Syphilis is not
cinoma.
Treatment. — The general treatment is so well understood
and outlined in all text-books that repetition is unnecessary.
The local treatment consists in cleansing the pharynx, pillars
and tonsils with a mild alkaline and antiseptic spray. If
the hard chancre, mucous parch or ulceration is present, it
should be gently touched once daily with a fifty per cent, solu-
tion of trichloracetic acid on a cotton-tipped probe. The patient
should be instructed to use a hot antiseptic gargle three or four
times daily and to avoid the use of tobacco and alcohol. The
recovery from secondary or tertiary inflammation of the throat
under the todid of potassium and mercury is usually very rapid
The necessary dose of the iodid of potassium to bring about
resolution, is variable and may range from a few grains, espe-
ly in young children, to from three to four hundred grains
per da;, in adults.
Actinomycosis. — Actinomycosis is an inflammation of the
pharvnx and tonsil, characterized by the formation of an ir-
regular and. bard nodule, which subsequently suppurates and
discbarges pus.
Etiology mill Pathology. — The disease is due to infection
frOBQ the ray fungus which gains entrance to the nose or pharynx
from spores of grain, diseased teeth, inspired air, chewing of
portions of plants, straw or wood containing the ray fundus.
The disease frequently occurs in cattle, horses, dogs and swine
and may be transmitted to man.
The disease may originate primarily in the larynx or nasal
civity.
The pus from discharging nodules contains a typical, yellow,
granular mass, which, upon compression, forms a rosette-like
•structure, opaque or yellowish in color. With Malloiy's stain,
the renter of the rosette stains blue and the club-shaped struc-
ture, red.
Symptomatology. — There is usually a history of slow swell-
ing in the angle of the jaw and difficult swallowing. Upon
I
|S.S
DISBAS A\'D THROAT.
inspection, if suppuration of the mass has not already occurred,
the tumor i> seen to be distinct and rills the angle of the jaw
and palato-gjossa] region, and is firm to the touch, resembling
somewhat the clinical appearance of cancer* The tumor may
Mitten and discharge pus containing yellow granules
Treatment. — The treatment of this particular disease is an*
>a tie factory. Iodid of potassium in large doses is highly recom-
mended by many, Puncturing with the galvano-cautery. open-
tng and cuietting the granulated tissue 01 cauterizing the
w i tli solid stick i»f nitrate ni silver maj be efficacious.
Sawyer reports flattering results from the injection b
tumor ol from fifteen to thirty minims or one per cent, solution
of potassium iodid at an interval of three to tour ds
Heroic surgical measures tor the removal of all affected
is otten oecessary.
Retro-pharyngeal Abscess. — Retropharyngeal abs. .
a circumscribed or diffused formation of pus behind the velum
palari, the deep mediastinal or cervical structures, and has its
origin within the submucoss or Lymphatic strocturea.
Etiology* — The disease is often observed in children and is
due to an infection from the Stn
Symptomatology. — '1 lie disease is USUallj ushered in b)
chill, followed by a high temperature and rapid pulse. 'l"bcrc
is pain and difficult su al lowing, mouth breathing, heada>
restlessness and sometimes delirium.
Diagnosis.— L'pon inspection, there is observed a circum-
scribed swelling with marked redness and rapid bulging of the
inflamed area, if the abscess is high up behind the pa
there maj be profuse redness of the pharynx and soft pa
rhe presence of pus can be d cated by palpation or
i probe.
Treatment. — The treatment is essentially surgical and con-
in opening the abscess under a local anesthesia of from tea
to twenty per cent, solution fit cocain. Complete drainagr ■
tablished.
As soon as the pus begins to Ml-
Following convalescence, a general tonic treatment is in-
iln. .ifed.
Pharyngomycosis. — Pharyngomycosis is a condition of
small wln'tish, horn-like excrescences, appearing sometimes upon
tin- nut'-.ils, pharynx, palate, anterior or posterior pillars, larynx
or lingual tonsils.
Etiology. — The disease is a fungus growth or a keratosis
.springing from the follicle of the pharynx and crypts of the
tonsils and is dm- in leptothrix bacillus or possibly some chemical
tnge in the body, which produces a local irritation ^ i'li the
49°
DISEASES OF EAR, NOS1 WD THROAT.
subsequent formation of horny-like excrescences. The disease
is more often observed in women.
Diagnosis. — Upon inspection of the throat, small horny-like,
white excrescences appear protruding from the surface. Upon
being grasped with fixation forceps, they arc observed to bf
tightly adherent, leaving a bleeding surface upon being detached.
The general appearance of the mucous membrane of the throat
may be quite normal or (he same as thai observed En chronic
pharyngitis,
Treatment. — The treatment is purely local and COOsi
the application oi the electrc-catjtery under i local snestl
of ten per cent, solution oh COCaio. One application to each
excrescence ta usually sufficient to destroy the fungus grov
The treatment should be repeated everj few days until tH
evidences of the disease have passed BV
I.. M. Ilurd reports a case of pfaaryngpmycosis cured after
forty-one treatments of ten minutes each with the X-ray, a
medium tube with a spark gap of about three inches bong used.
Urticaria. — Urticaria of the pharynx ta an inflammation
of the mucous membrane, characterized by the fbn n of
reddish elevations or whorls upon the surface of the pharynx.
The condition is observed in the throat, mouth, larynx and
intestinal mucous membrane.
Etiology. — The disease may occur at any age, more frequently,
however, in early life. The disease may be due to some local
irritation or to some general disorder, mure particularly some
disturbance of the gastro intestinal tract. Many individuals
have a susceptibility to the disease and a predisposition t
the ingestion of certain meats and veg The disease
be associated with diabetes mellitus, albuminuria, small-
pox, malarial and yellow fever, and pulmonary i
Pathology.— Tht disease is probably due to tome disturbance
of the vaso-motor system from toxic infection. The .!
elevation of the mucous membrane is due to a collection tl
serum within the mucous membrane.
Symptomatology. — The patient complains of a smarting and
DISEASES OF THE ORO-PHARYNX. 49 1
burning sensation in the throat and difficult swallowing. The
eruption is somewhat short-! ived, new eruptions taking the place
of the old ones until the disease runs its course, which is usu-
ally from one day to a week.
Diagnosis. — There may be a history of recurrent attacks of
throat affection or eruption of the body from ingestion of cer-
tain foods, medicines and psychic impressions.
A whorl-like formation of the eruption, with smarting, itch-
ing and burning, enables one to readily diagnose the case.
Prognosis. — The prognosis is usually favorable. However,
in m-vc -re cues, in connection with urticaria of the skin, the
disease may sometimes terminate fatally.
Treatment. — The treatment is directed to the relief of the
Eastro-intestinal disorders by the administration of a free purge.
Dorsey's mixture is probably one of the best which can be given.
Effervescent salicylate of soda should be given in heaping tea-
spoonful doses in water, every three hours. The patient should
he Distracted To avoid all those conditions and substances, which,
from experience, have been found to be an irritant to the
nuCOUS membrane.
Hot Dobcll's solution and hot glycothymolin should be used
as a gargle or spray every two or three hours.
Herpes. — Herpes of the pharynx is an acute inflammation
of the mucous membrane, characterized by the formation of
small, whitish, pin-head-like vesicles on the mucous surface.
The disease is presumed to be of a neuropathic origin and
may be associated with gastro- intestinal disturbances. The dis-
may follow from exposure to cold or damp weather or
traumatism.
According to Stelwagen, there is a growing belief that the
disease is sometimes of infectious origin.
Symptomatology. — The disease is characterized by the for-
mation or small, white points, which are clustered over the
pharyngeal mucosa and continue from five to six days.
There is a slight elevation of temperature, difficult degluti-
tion and profuse redness of the mucous membrane, with a
catarrhal exudation.
I
492 DISEASES OP EAR, NOSE AND THROAT.
Treat me nt. — The treatment is both local and constitutional'
The constitutional treatment consists in the administrafioi
quinin and strychnin with nn effervescent salicylate or bro-
zoate of soda.
The local treatment consists in spraying or gargling the
throat frequently with the following tolffl
lv PoUua colorant, 1.30 icm. < nr- xx)
Ac carbolic!, .is c.c. (gft ij)
(Jlycerini. 5.75 im\ (3 J)
A(|ii;r de«till.. id. jo.00 cc. (J jl
M.
Signa. Teavpoonful i" a Wine gla*» "f wafer, to Ix* rrpeiir-'
every two hours.
Local irritation can sometimes be greatly ameliorated with
orthoforro lozenges, one of which ma\ be dissolved in the
mouth every two or three hours.
Pemphigus. — 1'emphigus of the pharynx is an acute Dl
chronic inflammation of the mucous membrane, characterized
l>\ the formation oi small) round or oval blebs, u|xm thr
pharyngeal wall.
Etiology. — So far, no specific organism li
IS a cause uf the disease. The disease 03 .n :><• due to trauma.
gastro -intestinal disorders, irritation of the peripheral nerve*
and diseases of the nervous system, Acute pemphigus
sumed by many writers to be oi a aucrobk origin.
I'tJtholtjgy.— According to OttO, there are tWO
pemphigus of the respiratory tract, vi/... one forming hullr
with lifting up the epithelium, causing adherence. usualU
occurring in the debilitated and situated in the nose, soft palate,
pharynx and conjunctiva: another attacking health] individu
als. situated primarily in the respiratory tract ami consisting oi
a fibrinous exudate.
Symptomatology.- — In the acute stage, we ban
ache, and general malaise with more or less difficult
lowing. On<- characteristic symptom oi dx b the for-
mation of bulls which maj b< observed over the wall
DISI VSI-S OF 'THE ORO I'll \KY\\.
493
pharynx, uvula, check or tonsil. Skin lesions may accompany
the disease. Thr bulla* soon rupture and thus give rise to a
whitish, yellowish or blackish patch (Johnston). With the
formation of ulcers, the soft palate may adhere to the pharynx
and likewise the posterior pillars of the fauces. The disease
run its course in from two to three weeks, and is not presumed
to be contagious. In the chronic form, the only conspicuous
symptom is the recurrent whitish 01 yellowish ulceration over
ilu pharynx or soft palate, without general systemic involve-
ment.
Diagnosis. — Pemphigus may be confounded, in the beginning,
with diphtheria, lupus or syphilis. In the acute stage of the
.;,<•. the course is rapid and does not respond to antisyphilltic
treatment. It may be differentiated from diphtheria by culture
and microscopical examination. The membrane covering the
ulcers is often adherent and like that of diphtheria, causes
bleeding upon detachment.
\n general symptom! aid in the diagnosis in the chronic
form. Recurrent patches of ulceration covering the soft palate
or pharynx may be observed to extend mcr a period of years.
Prognosis. — Unless the ulceration extends to the stomach, the
DOS18 u favorable.
Treatment. — In the ii flte Stage, the treatment is directed
to thorough catharsis by the administration of small doses oi
calomel, followed by a saline cathartic. Hot gargles of Dobell's
solution diluted nne half, may be frequently used.
The headache, fever and general malaise pass away with
the lessening of the infection from the frequent use of hot,
antiseptic gargles,
ink may be prescribed in the form of Fowler's solution,
four drops in water three times daily.
The treatment of the chronic condition is in no wise different
from that of the acute.
Membranous Pharyngitis. — Membranous pharyngitis is
an acute inflammation of the pharynx, characterized hy the
formation of a croupous exudation.
I
494
DISEASES OF EAR, NOSE AND THROAT.
Etiology. — The causes are both predisposing and exciting.
The predisposing causes are the same as for acute catarrhal
inflammation of the upper air passages The exciting cause i>
infection from the streptococcus pyogi
Pathology. — The disease is characterized by the format
a fibrous exudation upon the surface of the pharynx, which has
no tendency to adhere to the surface or to bring about any
structural alterations m the epithelium. The disease is pri-
marily one of streptococcous origin. There is a hyperemia and
swelling of the mucous membrane and epithelium Rod an in-
crease of blood supply to the parts.
Symptomatology. — The disease is sudden in its onset and
may be accompanied by headache, vomiting and rise of tem-
perature.
The symptoms are somewhat variable and may be mild with
little local or general disturbances or quite the reverse.
Treatment. — The treatment consists in frequentlv ..praying
the throat with Dobell's solution or the application <>i Loffler's
solution once daily, followed by a spray of ,'u.etozonc inhalent-
In young children, a Simplex steam inhaler may be used to ad-
vantage. The small sponge may be moistened with one drachm
of the following:
B Menthol,
oil eaccljrptus,
M.
Sign a. To be n»ed i
times daily.
r.90 Km
30.00 ex.
fgr. xv)
inhaler for fifteen or twenty minute* four
The patient should remain quietly in bed until the inflam-
matory symptoms have passed away. Small doses of calomel
are usually indicated early in the disease. The elevation of
temperature can, as a rule, be controlled by cold sponge baths.
The patient's dirt should be carefullv regulated and consist
only of those foods classified as a soft diet.
Diphtheria. — Diphtheria, m a generic sen*e. b an acute in
factious and contagii inflammation of thr murou*
membrane of the throat, due to the Klebs- loftier b
DISEASES OF THE ORO-PHARYNX.
•195
Etiology. — The causes of diphtheria are both predisposing
and exciting.
Among the predisposing causes of diphtheria arc lowering
of the vitality from exposure to cold, adenoids, enlarged tonsils
or some form of dyscrasia.
Children under ten years, of age are more prone to diphtheria
than adults. However, the disease may occur at any age,
Seasons play but little part in predisposing to the disease, hut
the damp, cold days of fall and winter lower the. resistance of
the mucous membrane of the body and favor the disease. Spo-
radic cases may occur the year through.
Children and adults may possess a natural immunity to the
disease. Active immunity from the disease may last for a life-
time or only for a short period. In consequence, individuals
may suffer a second attack. The disease may occur sporadically,
epidemically or cndemically. Unhygienic surroundings, heavy-
rains with Hoods, decaying animal and vegetable matter all aid
m spreading the disease.
The exciting cause of the disease is the Klebs-Lofflcr bacillus,
which (Fig. 46) attacks the mucous membrane. The organ-
ism is long -lived and may be carried from one individual to
another, by cat, dog, cast-off clothing, drinking water, milk
or by direct exposure.
The bacillus of diphtheria may he present in the throat
before any local or general symptoms occur, and in consequence,
easy for one child to spray the organism directly into the
mouth and nose of an associate during conversation and play.
I'/ithnlogy. — Infection with diphtheria bacillus produces a
fibrous exudation which rapidly undergoes a coagulating ne-
t| extending down to the mucous membrane. When the
exudation is nm ihk detai bed, a bleeding surface remains.
The exudation may be diffused or discrete and may extend from
the pharynx to the soft palate, tonsils and nose, or downward
into the larynx and bronchi. The severity of the disease
depends, to a great extent, upon the amount of exudation. The
■ l,c of the disease is often out of all proportion to the
I
49r>
DISEASES OF EAR, NOSE AND THROAT.
severity of the inflammation. At first, rhc exudation is a
or gray, changing Inter to :i yellow ot grayish-green. In typical
cases, the exudation gradually fades away during the process of
recovery.
The Klebs-LofRer bacillus may be found on the surface or
within the exudation. The organism frequently remains in the
pharynx for tweim nine days after all active inflammation h»
passed away.
The disease may spread to the lungs, esophagus, ston
conjunctiva, Eustachian tube, nose and middle ear.
In severe cases, we frequently have a mixed from
the staphylococcus Or streptococcus and soniet imes h
The disease is primarily a local infection, followed I".
temic disturbances due to the absorption into the system ol tbf
toxins ol the bacillus of diphtheria.
True diphtheria differs from the take in that true dipbtherii
is only produced by the Klcbs-Lofflcr bacillus, whereas, in thr
latter, the disease is produced by BOOM other organism, more
especially the pseudo-diphtheria bacillus, streptococcus,
cm. us or :i combination of the last two named. I
conditions can only be differentiated by QUCfOSCOp tOBt
tion. The clinical appearance of the two diseases is qmtr
the same.
Symptomatology. — The general symptom-, vary from tho*r
of mild infection to profuse septicemia.
The temperature varies Erora a few degrees above normal
to 104° F.
I he prodromal symptoms, which continue from two daw
to a week, hut more often two Ot three day*, are yeneril
malaise, headache, loss of appetite anil restlessness. This k
followed In nausea and somd liting, dryness of the
throat, painful swallowing and a rise of temperature. The
tongue be lated, the urine is high fW
ihoWS t Muunin.
It then is in extension to the naso mouth
ithing and an accumulation of purulent catarrh
within the nasal cavity which is sometimes offensive in char-
acter. Should the disease extend to the larynx, there is dry
cough arid hoarseness. With increase of dyspnea, we have
cyanosis and delirium. On the third or fourth day, the exuda-
tion may be coughed up in shreds, or in severe cases, a cast
of the larynx and trachea may be expelled in the act of cough-
ing. This may or may not reform. If two thousand units of
antitoxin are used at once, the possibility of the cast being re-
formed is greatly reduced. In the severe form of the disease,
the pulse is rapid and feeble and the temperature may become
subnormal. However, in severe cases with mixed infection,
the temperature may be very high. A low temperature is more
often observed. The disease may run irs entire course without
.1 rise of temperature.
Course. — The disease usually runs its course in from one
week to ten days. It may end in four or five days in spon-
taneous recovery in mild cases. In severe cases, the disease
reaches a crisis in about four to six days, the recovery being slow.
Since the introduction and the universal use of the antitoxin
of diphtheria, the mortality has been reduced and the course
of the disease much shortened.
With the subsidence of all inflammatory symptoms, mild or
severe cases of palsies frequently occur. The one most fre-
quently observed is paralysis of the soft palate, causing a regur-
gitation of liquids and food particles. Paralysis of the accom-
modation may occur and is shown by the inability of the patient
to read or see objects distinctly, close at band. Paralysis of
the diaphragm and paraplegia of the lower extremities some-
times occur. Myocarditis and atrophy of one or more nerves
of special sense from inflammation or from infection, is fre-
quently observed. Albumin is, as a ride, a transitory- condition
but frequently becomes a serious complication if the patient is
too quick!} exposed to atmospheric changes during the con-
valescence.
Prognosis* — The prognosis must, from necessity, be guarded,
rrnm general observation, the mortality with antitoxin is
31
I
49S
DISEASES OF EAR, NOSE AND THROAT.
about twelve per cent., as against sixty per oent. before the days
of antitoxin. As a rule, the patient recovers from the palsies
in from six to ten weeks. Acute nephritis sometimes occurs.
The earlier the injection of the antitoxin, the more favorable
the prognosis. Kidney complications are presumed by some to
ii a ictM.l rince the use of antitoxin.
Diagnosis, — In the positive diagnosis of diphtheria, wc should
remember thai the clinical symptoms of diphtheria and follicu-
lar pharyngitis are quite the same. Rubens reports one hundred
ii ul seventy-nine cases of suspected diphtheria, in which all the
clinics] symptoms pointed to the disease, but upon micros:
examination, only twenty-six were found to be suffering Irani
diphtheria and one hundred and fifty-three were negativi
due to cocci and psetuio -diphtheria.
The presence oi the Klchs-l.nmVr bacillus may he
by a swab of the throat in the hyperergic sta lie thr
exudation occurs. If there is reason to suspect diphtherial an
early culture should he made.
It is a good role to suspect sunn- throat affection in children
with a rise of temperature.
C ndei good illumination, the throat on th*. 'irvt day of the
inflammation ma] show Ofl« 01 ISOR thin uhiteor bluish-white
spots occupying the crypts of the tonsils or coalescing over thr
whole surface of one or both tonsils. Alter twenty -tour hours.
the exudation will appear a* a heavy yellowish or gre
yellow velvet-like memhranr w irh a liistinct outline. The
surrounding mucous membrane may be sli^htiv or very grearb
indurated. On or about the third day. suppuration I
a muco-purulent discharge. The disease may spread in any
direction: if into the nasal cavity, there is a thick nauoo purulent
discharge from the nose: it to the larynx, there is a dry
cyanosis and difficult breathing,
The odor from a diphtheric throat is very characti
catarrhal exudation differs from a true diphtheria in brine.
thin and glistening and detached from the suit.hr 1
theria, the exudation adheres to the mucosa and CtttSCI thr
surface to bleed upon being detached.
I H SI ASES OF THE ORO- PHARYNX.
m
The bacteriological examination consists in making a swab
i mm tlic inflamed surface and applying it directly To the culture
of blood scrum. After six to twenty-four hours in an incubator,
37' C, a thin, whitish, granular layer forms. A smear on a
cover-glass is now made, dried and stained with Lofflcr's
alkaline methylene-hlue solution. The bacillus does not take
an even stain, and as shown in Fig. 46, the granules appear
more deeply stained than others at the end of the bacillus 01
throughout its length. Differential stain of Nisser may be
sometimes used for staining.
Treatment. — In all suspected cases, according to a great
many Investigators, it is better to give an injection of antitoxin
at once and make the bacteriological examination afterward.
The earlier the Injection oi antitoxin, the greater the pOSSJ
bility of a favorable termination. The antitoxin of diphtheria
has no influence upon infection from any other organisms, and
if the careful rules of antisepsis are carried out in making the
injection, the serum is perfectly harmless. As to the size of the
dose, in a general way it may be stated that the dose for a child
of two years is six hundred to one thousand units, while fifteen
hundred to two thousand units should be given to patients over
years of age. A prophylactic dose is six to eight hundred
units (' llallengcr).
\\ . H. Parks recommends the injection of one thousand units
in mild cases and two to four thousand units in severe cases seen
early the severity of the disease governing the dose. However,
those under one year should not be given more than three
thousand units, and those under six months, not more than two
thousand units.
To follow the antitoxin dose, internally at the onset of the
disease) calomel in one- tenth grain doses should be given even
hour until the bowels are freely moved.
The local treatment consists in the application of LSffler's
solution under good illumination, to the whole of the affected
area two or three times daily.
5<x>
DISEASES OF EAR, NOSE AND THROAT.
1$ Menthol, 10 parts
Toluol] 26 parts
Fcrri perehforidi sol. fort., 4 parts
Alcohol, 100 parts
Signs.
The action of Lottier's solution is to lessen the fibrous exu-
m and act as a mild antiseptic and inesthel
Trypsin dusted directly over the air exudate it highly recom-
mended on account of the property it possesses of di^esl
exudation.
Tlic foMowing may be frequently used as a cleansing: spray
Co the throat:
\i Boralyptol,
Banuunelit iic-t ,
Hydrogen pcroxiil.
I; Sodii bibor.in-,
Menthol,
Acid carbolic!,
trial,
Aq. destill., ad.
30.00 c.r.
.ta gm. [gt. iii
.06 gm. (gr. i)
24 Em- (gr- •»■)
4-00 C-C.
30.00 cc. (J i)
The internal medication is directed to counteracting the
poisonous effect of the toxemia. Weakness in the heart'*
action may be controlled by the admit
two to fifteen drops in combination with tincture of stmphan-
, five drops, three times daily. Apollinaris n 1 ei uted
with distilled watCI should be freely administered foi
the kidneys. In the stage of convalescence, a general tonic maj
be indicated. One of the best tunics is a solution of i
Strychnia and bydrochloric acid.
Pakies, which frequently OCCUT, should be treated by the
internal administration of strychnin and small ■otassium
and the direct application of the constant current, the nc-,- i
pok to the affected parts.
In suspected cases of diphtheria, to prevent the spread oi
the disa me child should be isolated. Children susceptible
to the disease should be injected u ith six to eight hurl
the prophylactii .lose of antitoxin.
solution before removal from the patient's room and the bed
linen and all other clothing should be fumigated with formalde-
Iml during and after convalescence.
Intubation of the Larynx in Diphtheria. — Since the in-
troduction of the antitoxin treatment of diphtheria suggested
by Behring, Intubation is not so frequently practiced. Dyspnea
from diphtheria and causes heretofore enumerated now occa-
sionally demand this procedure.
Instruments and tubes designed by O'Dwyer meet the great-
est number of indications. The set, in a metal case, constttfl
5°2
DISEASES OK J-AR, NOSE AKD THROAT.
of an introducing and extracting instrument, seven tubes vary-
ing in size, a metal finger-stall and a strong mouth gag.
The patient should be held upright, rhe amis confined
sheet over the body, the mouth gag is inserted and the
head steadied by an assistant The run-linger of the left
hand is passed far back into the glottis until the tip of the
epiglottis can be felt. The tube is then inserted in the median
line, the handle of the introducer depressed to the chest oi the
child. Upon the tube reaching the finger, which acts as a
guide, the handle is elevated and drawn forward, the linger
now guiding the tube into the larynx. Previous to insert
the tube, a strong silk thread should be passed through the
shoulder of the tube. This is looped over the little fmga of
the left hand to prevent the rube slipping into the esophl
The thread can be looped over rhe car of the patient for a feu-
hours or withdrawn immediately after the tube is known to
he in position. In removing the thread, the index finger «
introduced and held against the shoulder to prevent the tube
from dropping out of position.
The removal oi the tube is often iar mure difficult than its
insertion. For this, the extracting instrument is used. The
index linger of the left hand is again passed to the tip of the
lottis and acts as a guide for the extractor. As soon is
the closed blades enter the tube they are separated and firmly
held in position while the tnhc is carefully withdrawn.
Neurosis of the Pharynx. — Among the more common
neuroses of the pharynx are anesthesia, hyperesthesia, paresthesia,
neuralgia, spasms and neurosis of motion.
—Anesthesia is s p- lete Iocs o
Mtiorj "i the pharynx and may result from p re bulbar
paralysis, constitutional dyscrasia and general paralysis of the
insane. It may be a frequent accompaniment of hysteria.
The treatment is subjective and depends upon the e\
cause. Galvanic •uncut is usuallj indicated with increai
doses of strychnin internally.
Hyperesthesia is an over-sensitive the pharyngeal
DISEASES OF THE OROPHARYNX.
5°3
mucosa and is usually due to hysteria, excessive use of alcoholic
liquors and tobacco, elongation of the uvula, heredity and acute
or chronic inflammation of the pharynx.
The treatment consists in the administration of large doses
of potassium bromid, followed by the cessation of alcoholic
indulgences and the use of tobacco.
The local treatment is directed to the relief of the catarrhal
condition which is usually present.
Paresthesia is an hysterical manifestation and is a sensa-
tion of some foreign body in the throat. The patient may com-
plain of burning, smarting and itching in the pharynx. There
may be a follicular inflammation of the pharynx and enlarge-
ment of the follicles at the base of the tongue.
The treatment is directed to building up the general nervous
system by the administration of iron, quinin and phosphate
of zinc
Spasm oi the pharyngeal muscles may be due to cerebral
disorders, hysteria and epilepsy. The disease may be of a purely
psychical origin and observed in hysterical individuals.
The treatment is usually the same as for hyperesthesia and
paresthesia. If due to enlarged tonsils, operative measures are
indicated.
NEURALGIA of the pharynx is observed more frequently in
hysterical individuals. It may accompany a uric acid, anemic
or chlorotic diathesis. It may be due to the presence of malig-
nant growths in contiguous structures.
The treatment is directed to the removal of the cause llm
Wtneptic gargles will sometimes give relief.
Neurosis ok Motion may be due to diphtheria, tumors of
the medulla, progressive bulbar paralysis, syphilis of the
pharynx, injury to the facial nerve, etc.
In paralysis following injury oi the facial nerve, diphtheria
or syphilis, the prognosis is usually favorable.
The prognosis in tumor of the brain and progressive bulbar
paralysis is unfavorable. In addition to the general alterative
treatment, strychnin internally with galvanic electricity is
indicated.
<
CHAPTER XXVIII.
DISEASES OF THE DVDLA.
Deformities of the Uvula. — Deformities of the uvula may
be congenital or acquired, two distinct uvulae may be present
or bifurcated, as shown in the illustration ( Pig, i.i7)- Congeni-
tal cleft of the uvula may occur. Cleft palate is a congenital
condition familiar to ever) reader. The entire soft palate and
Ftc. 137-
Bl»:
uvula may be destroyed From disease, especially
tuberculosis and diphtheria. The treatment of all deform
is necessarily surgical and varies according to the symptoms.
Acute Uvulitis. — Acute uvuliris is an acute inflammation
<it tbe mucous membrane and loose areolar tUBUC °f the uvula.
Etiology. — The causes are both local and general. The li*;>
cause is more often traumatism fron
or inflammation of the conl
The general causes may be Rtmosphei I during sleep,
indigestion, alcoholic excesses, nephritis, anemia or lithemia.
Pathology. — Edema of the uvula and a serous exudati*
5«4
DISEASES OF THE ORO-PH ARYNX.
5°5
the areolar tissue and may be a vaso-niotor disturbance due to
some toxic disturbance and independent of any local bacterial
influence.
Acute inflammation is characterized by swelling, redness
and discomfort, in inflammation of the pharynv and tonsils,
there may be an extension of the disease to the uvula by con-
tinuity of tissue.
Symptomatology. — There is a sensation of fullness in the
throat, difficult swallowing, disturbance in the voice and ac-
cumulation of mucus with the frequent desire to swallow. If
the edema is profound, dyspnea may occur. Upon examination,
the uvula is observed to be swollen and translucent or red
and edematous.
Treatment. — If edema is very great, the uvula should be
anesthetized with a ten per cent, solution of cocain and punc-
tured in a number of places with a sharp bistoury, followed by
a hot astringent gargle.
Acute inflammation and edema may frequently be relieved
by an application of a solution of nitrate of silver, one hundred
and twenty grains to the ounce. The throat should be fre-
quently gargled with a hot astringent solution.
A saline cathartic is usually indicated in the treatment of
the disease.
Ulceration of the Uvula. — Ulceration of the uvula is a
unscribed solution of continuity of tissue.
Etiology. — The cause is usually some form of traumatism
followed by infection. Among the general diseases predis-
posing to ulceration of the uvula are syphilis and pulmonary
tuberculosis. Syphilis, lupus and tuberculosis may be pri-
marily situated in the uvula.
Symptomatology. — There is a smarting and burning sensa-
tion in the tliKi.it, sometimes followed by pain upon swallow-
ing cold or hot drinks. Those who smoke may complain of
increased irritation following the use of tobacco.
Diagnosii. — The site of the ulceration is variable and may-
be located anteriorly or posteriorly. If situated posteriorly,
I
=to6
DISEASES OF EAR. NOSE AND THROAT.
the ulcer is only seen with a rhinoscopic mirror or by elevating
the uvula.
Treatment. — The uvula and throat should be cleansed with
a warm alkaline and antiseptic solution, followed by the appli-
cation with a cotton-tipped probe once daily, of a fifty per CMC.
solution of trichloracetic acid or the solid stick of nirrai'
silver.
The general treatment is directed to the relief of any general
dyscrasia. Lupus may be relieved with an application <>•
X-ray. Tubercular ulceration should be curetted and cauter-
ized with a solid stick of nitrate of silver. Swollen and infected
cervical submaxillary lymph glands demand removal.
Elongated Uvula. — Etiology. — Elongated uvula may be an
acute or chronic condition, and is usually due to an acute or
chronic pharyngitis.
Symptomatology. — The symptoms of elongated uvula are
general catarrhal inflammation of the throat, hawking cough
and tickling in the throat. The cough is more distressing at
night while in bed.
Treatment. — If the elongation is very small and quite recent,
the application of a solution of nitrate of silver, one hundred
Fie. i j*.
• t»OML
and twenty grains to the ounce, applied to the uvula i
may reduce the deformity.
DISEASES OF THE ORO-PHARYNX. 507
The treatment is usually surgical and consists in the removal
of the elongation with uvula scissors (Fig. 138), or the removal
of the V section and stitching the lateral halves together. A
ten to twenty per cent, solution of cocain and 1/1,000 solution
of adrenalin, will render the operation both painless and blood-
less. Where the elongation is removed with scissors, the
stump should be painted with a strong solution of nitrate of
silver.
Subsequent treatment consists in cold antiseptic gargles "for
twenty-four hours, followed by hot antiseptic gargles.
CIIAPTKR XXIX.
DISEASES OP THE TONSILS.
Acute Tonsillitis. — Acute tonsillitis a an acute catarrhal
inflammation of one or both tonsils. The u
involve the crypts of the tonsils (lacunar or cryptic tonsill "
the entire mucous membrane (superficial tonsiUi the
mucous membrane and tonsillar tissue (parenchymatous amyg-
dalitis). There is usually more or less general inflammation "t
the faucial mucous membrane.
Etiology. — Among the predisposing causes of acute tun
are a general loss of tissue resistance due to tuic acid condition
of the blood, unhygienic surroundings, exposure t" ii
organism, gastro-intestinal disorders and exposure to cold.
The exciting causes of inflammation of the tonsils are the
streptococcus, staphylococcus and ESberth's typhoid bacillus. The
avenue of infection is through the crypt of the tonsil, the Ivrnph
stream or broken-down epithelium of the tonsil.
Pathology. — With the localization of infection in the super-
lie id form, we have a diffused redness. Swelling and exudation
of the serum, leucocytes and hmken-down epithelium. V
involvement of the crypts which an- lined with the SUM kind
of epithelium as the surface, WC have I fibrinous exudation with
necrosis of tbe epithelium appearing as a yellowish or white
Herniation within tin- cryptS. It cheesy deposits have ex-
isted within the tonsil previous to the acute inflammation, the
secretion removed from the crypts will possess a foul od
The orifices of the crypts are red and swollen in the earl] ie
of the inflammation. The crypts arc primarily the sitf
of the inflammation in the lacunar form. In the parenchym
atoua form, there is a general inflammation ri the glandular
structure following the course ol the blood-TOS
508
DISEASES OF THE TONSILS.
;o<,.
There is a general exudation of leucocytes and scrum into
the tissue. If the infection is too profound, a phlegmonous
abscess may form.
Symptomatology. — The conspicuous symptoms of the dis-
ease in young children may be high temperature, sometimes de-
lirium, restlessness, loss of appetite and constipation. In adults,
therr. is usually high temperature, general malaise, headache,
backache] loss of appetite and painful swallowing. The dis-
ease may sometimes be ushered in with a chill. The amount
of temperature varies in individuals and is governed somewhat
by the character of the infection. The temperature is much
higher in children than in adults.
In the cryptic form, the disrate sometimes simulates dip}]
theria. The absence of the Klebs-LofHer bacillus, high fever
and rapid pulse will enable one to exclude diphtheria. The
marked hyperemia extends high up on the pillars and over the
pharyngeal wall.
In the cryptic hum, the whitish exudation within the crypts
is easily detected. The exudation may be very great or ex-
ceeding!} small. In the latter condition, the inflammation is
wry superficial.
Mycosis Can be differentiated by the history of the rase, ab-
sence of infiltration and adherent fungus growths.
Ulcers of the tonsils resemble in many respects, acute ton-
sillitb. In ulceration, wc detect the well-defined area of neo
either superficial or extending deep into the tonsil.
Mucous patches of the tonsil may sometimes be overlooked
•reatrd for acute tonsillitis.
In inflammation of the tonsil from primary infection of
-vpliils. we have celling of the tonsil, redness, infiltration
of the lymph inlands of the neck, histor> <>\ slow onset of the
disease and i circumscribed area of exudative necrosis and
broken-down epithelium. The glandular tissue is somewhat
hard to the touch. In some cases of hard chancre, we have
temperature, fetid breath and anorexia.
The ■ nptoms continue day aftei da) and do not
I
5>o
i- mi i ,AR, NOSE AND THROAT.
to local treatment. In the secondary stage of syphilis we may
also have a pseudomembrane covering both tonsils, which should
not be mistaken for acute tonsillitis.
Diagnosis. — The disease may be ushered in with a chill, fol-
lowed by fever and burning pain in die region of the i
The local symptoms of distress increase with piility.
There is a dryness of the throat followed b\ an accumulatm:-
of mucus and a desire to swallow.
Course and Prognosis. — Acute tonsillitis usually runs its
course in from four to ten days. The disease is contagious*
and the contagion may he thrown from the throat in ;i line spray
which is emitted from the mouth during speech, or t br-
and exudate, after heinp expelled, maj dry and be diGsenmated
about the room and inhaled h\ other members oi tin- •
The prognosis is tavorahle as tar ;is l:tc a i uiuvncd. The
recovery may he slow, the disease becoming chronic in character
with more or less involvement of the cervical Ivmphatic glands.
Treatment — The treatment varies according to the pa-
thology of the disease. Free purgation with fractional doltt
of calomel, followed bj lOTne aperient water is i
early in the disease. Patients should usually he confined to bed.
Regardless of the form of the tonsillitis, the throat -
be sprayed with a warm Dobell's oj Seller's solutioi
five times daily.
In simple inflammation of the tonsils, i gargle compos
the following should be used every three or four h<>
ft Zinci phenolsulplii"! lib
Boro-xlyceridi,
I .luctini,
Atj. .!<••.< ill., q. *. ad.
I.Jo grn.
30.00 ex. |
15*0 >
Signa. One teaspoonful Iti lie added tn twg table«p<M)aftlli «il
hot water and u*ed a* a Karjilr ever) i«" <>r ilirce hoi
Topical applications once dailj of nitrate of sflvei
of zinc, tv\eii to the ounce, should be made. Aconite.
in one drop doses ever) hour tor the first twelve bo
for the relief of the temperature and as | stimulant .ij the
vaso-constrictur.
msn.ASRS OF THE tonsils.
5'i
For rheumatic or gouty diathesis in the adult, salicylate of
soda or asperin in ten grain doses should be given every three
hours for twenty-four hours.
In the cryptic form of the disease, the patient should he
instructed to use a gargle consisting of peroxid of hydrogen and
extract <>f witch hazel irj equal parts, every three hours. The
Evacuation or a Tonsillar Abscess. (After |
disca- ! crypt on the tonsil should he touched with a fifty per
cent, solution of trichloracetic acid or guaiaeol on a cotton-
tipped probe once daily.
For Interstitial tonsillitis, the treatment consists in a hot
antiseptic gargle, internal administration of salicylate of soda,
relief of any gastro-intestinal disorders, local application to the
tonsil of a solution of nitrate of silver, sixty to one hundred
and twenty grains to the ounce. In the application of a
Strong solution of nitrate of silver to the tonsil, great care
should be taken to apply the solution gently to the tonsil and
avoid contact with the larynx or pharynx. The throat should
he frequently sprayed with acetozone inhalent. If the pain is
I
5'2
DISEASES OF EAR. NOSE AND THROAT.
excessive in interstitial tonsillitis, i deep iiu the totttil,
which may be followed by free hemorrhage, will lessen the
engorgement and predispose to a rapid amelioration of tbe
symptoms. With the formation of pus there is a throbbing,
beating pain and fluctuation upon palpation.
The treatment is necessarily surgical and consists in the
free evacuation of pus with a deep incision of the tonsil inward
and upward, under antiseptic precautions, folic* hot
antiseptic gargles.
Chronic Tonsillitis. — Chronic tonsillitis is a chronic in-
flammation involving the superficial and deeper structure
the tonsils, resulting from recurrent acute attacks of the same
disease in which complete recovery has failed to take place.
Etiology. — Among the important causes of the disease are
gastro-tntestinal disorders, rheumatic diathesis, neglect on the
part of the patient to secure medical attention in acute c«>
tions or to carry out systematic treatment, climatic conditions,
exposure to irritating gases. EobflCCO -linking and a tubercular
diathesis. Within the crypts of the tonsils will frequently be
found plugs of broken-down epithelium and glandular excrr-
tion, containing bacteria. The toxins eliminated are a constant
source of irritation not alone to the tonsils proper, but also to
the pharyngeal and laryngeal mucous membrane.
Course and Prognosis. — The disease may continue as a con-
si ant source of irritation with more or less exacerbations for
months.
The prognosis is verj good as far as recovery is concerned.
Sometimes local and constitutional treatment have but Lb
effect in curing the condition) while the symptoms are quickly
relieved by a change to a dry, warm climate.
The presence of chronically mflame. i tonsils ia ■ constat
menace to the general health, pri ig the patient to ii
mat ism, endocarditis and tuberculosis. It is quite true that
many of the pathogenic or infectious organisms may find lodg-
ment in the tonsils and be taken up by the blood or lymph
DISEASES OF THE TONSILS.
5*3
stream and carried to some other distant organ, where they
multiply and produce inflammation.
I'ltthohgy. — The disease is primarily due to successive at-
tacks of acute inflammation from faulty systemic metabolism
or the presence of attenuated organisms; there is more or less
hype 1 iruplis or hyperplasia of the mucous membrane and gland
structures. The epithelial lining of the small mucous glands
may, from continued irritation, become hypertrophic and finally
atrophic, the normal secreting function being partially or com-
pletely destroyed.
Diagnosis. — There may be little or no enlargement of the
tonsils. The hypercmic discoloration may be confined to the
tonsil or invade the pillars, extending far up toward the median
line of the soft palate. The crypts of the tonsils will be found
full of offensive debris, containing bacteria. By making pres-
on the tonsil or lifting the anterior pillar, offensive plugs
may sometimes be exposed.
There is usually a history of acute exacerbations of the dis-
ease and constant accumulation of mucus in the throat.
The voice may he impaired by the catarrhal inflammation
and chronic enlargement of the tonsils.
Treatment. — The treatment of all chronically inflamed ton-
sils, large or small, is usually surgical and consists in complete
extirpations of the tonsils.
The entire glandular structure, especially that within the
supra-tonsillar fossa?, should be removed. For this we may
choOM the knife, snare, cautery, loop or scissors. It will first
be necessary to dissect the supra-adhesion of the tonsil and only
by so doing can we expect to completely remove the disease
(see operations for removal of tonsils).
When radical measures arc refused, the crypts may be
emptied and destroyed with the galvano-cautery or trichloracetic
acid in full strength. By a slow process of puncturing with
the galvano-cautery, the tonsils may often be substantially rc-
(I in >i/r. Surgical measures for the removal of fibrous
Qs are frequently followed by severe hemorrhage and acute
5 '4
DISEASES OF EAR, NOSI- \NI) THROAT.
inflammation with hemorrhagic extravasation into the sur-
rounding tissue.
The inflammation and pain may continue for four 01
days. The wound should he cleansed twice daily with pet'
of hydrogen and swabbed once daily with a five p<*r cent, solu-
tion of nitrate of silver on a cotton-tipped probe.
Hot Dobell's solution should be used ns a gargle rvcr
hours. The patient should remain in-door* as much as possible
to prevent additional infection.
There is frequently a chronic follicular pharyngitis
varicosities which, should br removed by touching with the
actual cautery. The constitutional treatment U devoted to the
relief of any existing diathesis. Suppurative foci in the nasal
cavity should be removed, decayed teeth must be extracted
01 filled. The local treatment consists of the frequent use of
hot antiseptic gargles and the bi-weekly application to the
sils of a 10-20 per cent, solution of the nitrate of silver on a
cotton-tipped probe.
Membranous Tonsillitis. — The general pathology of mem-
branous tonsillitis is the same as that for acute follicular ton-
sillitis. The exudation is more profuse than in acute follicular
tonsillitis and undergoes a coagulation-necrosis, with etiminai
01 toxins.
Treatment. — The treatment consists in avoiding, as tar «
possible, genera] infection from local conditions by the admin-
istration of calomel in one-tenth grain doses everj bow
purgation results, followed by Spraying the throat with
drogen pcruxid and local application of Ldffli and
the internal administration of iron and quinin in macs.
Rheumatic or Gouty Tonsillitis. — This Es in acute OS
chronic inflammation of the tonsfla resembling acute or chronic
catarrhal tonsillitis, occurring in individuals suffering from l
acid diathesis, with or without local manifestation of the
ease other than in tonsillitis.
Etiology. — According to the investigation and
rs, a lit hemic diathesis may be inherited or acquired sod
the condition results from uastni-mrestinal disorders, over-
indulgence in alcoholic liquors and nitrogenous foods, sedentary
habits and nervous exhaustion. There may be a like inflam-
mation of the pharyngeal mucosa.
Symptomatology. — In the acute form, the disease is sudden
in its onset and frequently subject to nightly exacerbations.
The acute symptoms may entirely pass away during the day
and appear at night. An irritating cough may intervene at
night, interrupting sleep.
In the chronic form of the disease, deposits of sodium urate
may sometimes be observed about the finger joints. Throat
symptoms of the disease may be the preliminary sign of an ap-
proaching arteriosclerosis. The symptoms may continue from
.! few days to a number of weeks.
Diagnosis. — The diagnosis is hy a process of exclusion.
With the history of symptoms enumerated above, diagnosis is
easy- The urine is highly colored and acid. The diagnosis
of rheumatic tonsillitis is based upon symptoms of rheumatism
in other portions of the body and inability to cure the disease
with local medication.
Treatment. — In addition to the local treatment, the atten-
tion should be directed to the removal of the rheumatic diathesis.
This is done by the avoidance of all foods which tend to pro-
duce uric acid, such as meats, coffee, tea, tobacco and alcoholic
liquors. The eliminating organs may be stimulated by hot
bath* Olid light exercise. Distilled or lithia water should be
consumed in great quantities and in addition, granulating phos-
phate of soda in rraspoonful doses in water, should be given
night and morning. Aspirin in ten grain doses is peculiarly
cffii ;: producing free perspiration and the elimination
<>j uric acid.
The local treatment consists in spraying the throat u ith
alkaline antiseptic spray, applications of protargol in twenty per
cent, solution, and gargling with hot milk. Massage acts as
a sedative and stimulant.
Patients of sedentary habits should be encouraged to spend
5>°
DISEASF.S OF FAR, NOSE AND THROAT.
a great deal of time out of doors in mild exercise, golf, horse-
back riding, canoeing, etc.
Herpetic Tonsillitis. — Herpetic tonsillitis is characterised
by the formation of herpetic vesicles over the surface of the
tonsils. Herpes zoster of the face may occur following herpes
of the throat or simple infection of the throat, as ob>
Doplir, who reports an epidemic of herpes zoster of the inferior
maxillary branch of the fifth nerve.
Treatment. — The treatment is directed to the build in
of the general system. Local applications of compound tincture
of benzoin and fifty percent, boro-glycerin (D. Brayden Kyle),
followed by spraying with a two per cent, solution of campho-
menthol in albolene, twice daily, is indicated. For the relief
of headache, fever, etc., the following is recommended:
M.
Signa.
Quinin.T bromidi,
Plienaceciiii,
Crcasoii (beech wood),
Pepsin pune,
To be repealed in four hours.
.18 gm (gr. iij)
.iS K'n. (gr. ii|>
.18 cc. (gtt. ij)
■06 gm. (gr. j)
Actinomycosis of the Tonsils. — Thanks to the investiga-
tions of Jonathan Wright (American Journal of Medical Sti-
en ccs, July, 1904). The Laryugohgist has given an exceptional
description of the pathology of this disease. Literature, possibly
from the rarity of the condition, is barren of more than a
general account of actinomycosis of the tonafla
A great many clinicians have observed the disease infecting
the glands of the neck, but few have reported thr
limited to primary involvement of the tonsils.
Pathology. — The pathology ot actinomycosis of the •
is identical with that <>f actinomycosis of the glands •
neck, the skin, intestinal canal, oophagia or lungs, The en-
trance of the germs into the mouth is through foe- wood
it air. It is presumed that the raj fungi pierce the
epithelium before propagation and therefore, trauma sufficient
DISEASES OF THE TONSILS.
5»7
to interrupt the epithelium is necessary to the infection. De-
cayed teeth may harbor the organism and on account of the
warmth of the tooth cavity and nourishment gained from the
secretion of the mouth, the organism may, after a long time,
liml lodgment within the crypt of the tonsil.
Symptomatology, — The symptom* of the disease are the same
as those of granulating abscess without the pain of abscess and
inflammation and general systemic infection. The abscess-like
condition may involve one or more crypts. Actinomycosis is
usually discovered by accident, as no one conspicuous symptom
causes the individual to consult the laryngologist other than
enlarged tonsils and naso -pharyngeal catarrh, which may be
present.
Diagnosis, — We may or may not have a history of injury
oi the throat from a straw, wood or particles of grain violently
thrown into the throat during threshing, etc. The entrance
hi the ray fungus into the broken-down epithelium brings about
a low form of inflammation characterized by swelling of the
tonsils and the formation of nodules, which, in time, undergo
fatty degeneration and ulceration, with the formation of pus
containing yellow granules. The degenerated foci may be con-
nected by the sinuses and may be discovered by a blunt, curved
probe. Proliferating epithelium or granulating tissue may
line the cavity and may be distinguished by the naked eye. It
fa this process, as observed by Jonathan Wright, " which prob-
uunts for the absence of lymphoid infiltration in id
jacent tissue, which is so frequently observed in other inflam-
matory diseases of the tonsils." Metastatic infiltration may
OOCUr. If so, it is usually from a direct rupture into the blood-
vessel (Zicgler).
Treatment. — The immediate removal of the tonsils is indi-
d, which can be done with a blunt tonsil knife or ton-
nllotoaie. When this cannot be done, the application of the
galvano-cauterj direct to the nodules or ulcerated surface is
the best form of treatment. According to Wright, in the
absence of the galvano-cautery. iodid nj sodium has an inhibiting
<
5 iS
DISEASES OF HAR, NOSH AND THROAT.
influence on the growth of the actinomycosis. Diseased t<
should be removed for fear they may still harbor the organism
and predispose to a second infection.
Cholesteatoma of the Tonsils. — Cholesteatoma of the
tonsils i> I cheesy-like and ill-smelling mass containing choles-
terin within the crypts or pockets tA the tonsil, due to a
process of metaplasia.
Etiology and Pathology. — To Nerval H. Tierce the credit
- due for a complete history of pathological findings and an
nate description of the disea.se. According t< the
condition is more often found in the supiarnnsdlar fbssSS and
is " produced by exfoliations of epithelium, faulty degenail
add finally decomposition of tin* muss."
Symptomatology. — The symptoms vary but little from those
oi chronic tonsillitis. Pierce report) that after the removal of
the tonsils for continued irritation, the patient continue
complain of distress and laryngeal irritation, until the sinus in
the upper portion of the tonsils and between the tonsillar
fossae is cut away.
Treatment. — In addition to the removal of the tonsils, the
treatment consists in the destruction of the crypts oi the to
with the galvauo-tautery.
Peritonsillar Abscess or Quinzy. — A peritonsillar abscw
or quinzy is an acute localized suppurative inflammation within
the tissue surrounding the tonsils. The infection is usoaft)
confined to one side. That portion of the tissue anterior and
above the tonsil is more frequently involved.
Etiology. — The disease occurs more frequent! n than
in women and results from traumatism, exposure to inclement
M Bather and rheumatic diathesis. Adherent tonsils form arti
ficial culture tubes, favorable for the propagation of pathogenic
organisms, which may, tinder favorable conditions, pmrtrate
the surrounding tissue with the fori Ml febscct
Pathology. — A localized abscess in the peritonsillar i
is more frequently dm- to the strq a aurcu*
Oi albus, which find access to the tissue bj 'he lymph stream
DISEASES OK THE TONSILS.
519
miKin-lliil.'it spaces* The severity of the localized necroses
is dependent upon the predisposing cause.
Pus points in the direction of least resistance and ruptures
if left alone. The size or the abscess varies in individuals.
Symptomatology. — In the formation of a peritonsillar ab-
scess, we have all the symptoms of a localized inflammation
in a variable degree, redness, heat, pain, swelling and loss of
(unction.
The disease may be ushered in by a chill followed by fever,
headache, general malaise and great distress in the throat. The
pain and discomfort in the throat increase very rapidly, often be-
coming almost unbearable. The swelling and pain may become
so great as to prevent the patient's mouth being opened for more
than a few millimeters. The area of localized inflammation can
be well observed after twenty-four hours and the tissues are very
dense to the touch. There is a general, catarrhal inflammation of
the fauces with an accumulation of mucus. The tongue appears
thick. and heavily coated, the teeth are covered with dried mucus
gnd the breath is fetid. The temperature may range from
to 105" F.
Diagnosis. — Deep throbbing pain in the region of the tin nut.
difficult swallowing and rapidly increasing symptoms of in-
flammation in adults are suggestive symptoms of peritonsillar
inflammation. With natural sunlight, a head mirror and
tongue depressor, the redness and swelling of the tissues, an-
terior, posterior and above the tonsil, can be detected. It is some-
times very difficult to differentiate a general inflammation of the
tonsils in which the anterior pillar is in close contact with an
enlarged tonsil, from a peritonsillar abscess. The inflammation
illy extends upward, producing marked swelling of the
apprnximal side of the soft palate and edema of the uvula.
The area of infection can be detected by the finger, if the
disease is far advanced. The swelling will be nodulaj before
necrosis has begun. With the formation of pus, the swelling
will become elastic and fluctuating.
tnd Prognosis. — The disease usually runs its ci
520
DISEASES OF EAR, NOSE .AND THROAT.
in from four to eight days. As a rule, there is a complete cessa-
tion of all symptoms and an early recovery upon the evacuation
of pus. A second infection or reinfection sometimes occus
cases in which the pus was not entirely evacuated.
Fie. 140.
Rallehgm's Toxsh. Fcmc«r*.
As far as life is concerned, the prognosis is good. Dj
from obstruction may occur or strangulation or death I
asphyxia from spontaneous rupture into the larynx during sleep,
should the pus gravitate into the deeper tissue of the neck.
Pia 141.
Heck's I'm mi S.immi
Death maj occui unless the area of infection can be located
and removed; if not, a general, spreading infectious inflamnu-
nun more frequentlj supervenes, producing death.
522
SBS OF EAR, t D THROAT.
satisfactory and scientific operation, nine is a discrepancy
of opinion relative to the most efficient tonsil lototne. The
Mafhicvvs and McKenzic are more frequently used. Per-
sonally, the author prefers the McKcn/ir (Fig. 142). In
addition to the tonsil lotomes, there is the punch forceps, recom-
mended by Myles, Rault, Rhodes and others, the scissor by
Robertson (Fig. 144)- the electro-cautery by P\
ecraseur by Ballenger, the wire snare and the elect ro-cautcry.
Quite frequently the pillars of the tonsils are adherent ind
overlapping the tonsil proper, thus preventing an exposure or
the tonsil. For the dissection ol tin- pill.u. the
by Joseph C. Beck (Fig. 141 ), Holmes t hi buial scissors, and the
knife designed by Pynchon (Fig. 142), arc of greai
On account of the submerged condition of the tonsil, a tenacu-
lum or lifting forceps is necessary and the one designed by
Hallenger (Fig. 140), which is slightly curved, is more practical
than s straight forceps.
In the great majority of CJM8, «>me tonn of anesthetic is
necessary and our choice is with cocajn, stovam, chloroform, clhrr
or ethyl bromid. If the individual is of a highly nervous tem-
perament, regardless of the complete an secured by
cocain, results arc frequently unsatisfactory. If more than a
few seconds are required for the dissection of the pillar and
the removal of the adenoid growths, chloroform Bed.
Profound anesthesia is unnecessary. It only a audi
are required fox the operation, Merk's ethyl bromid has proved
an ideal anesthetic with the author (see Anesthesia, p. ifio).
With a Mathiew's ot McKemue'a conaQlotoine, tonsillotomy
consists in first separating the pillars from the : ft a
iroung child, r mouth gag is neces ad grasping th<- mm
with 1 Ballenger forceps, previously passed through the foramen
of the tortsillotome, the tonsil is lifted h bed, the ton-
Mllotome is pressed home and the growth
Its pedicle as possible. The hemorrhage following i* 1
controlled with an iced Dobell's s»_>i ■
acid and water. I he hemorrhage may be prnl rmand
DISEASES OF THE TONSILS. 523
some radical procedure. There is ligation of the external
carotid artery, stitching of the pillars, cautery and tonsillar
hemostat. In severe hemorrhage, the tonsillar hemostat (Fig.
145) is usually sufficient. This should remain in position from
one-half to one hour. In a bleeder with a manifest hemorrhagic
diathesis, the tonsillar hemostat should remain for a longer
time. The hemorrhage occurs more often after the patient has
left the operating room and has made undue movement. Syn-
cope may occur and is nature's method of clogging the vessel.
The diet for the first twenty-four hours should be a cold,
liquid one. Afterward, the ordinary diet may be prescribed.
The local treatment consists in frequently gargling the throat
with iced Dobell's solution. Recovery is usually complete
within a week.
The removal of the tonsils with a cold snare differs in no
way in practical results from the removal with the tonsillotome.
It is argued that hemorrhage is less liable to occur with the
snare. This is quite true in many cases, but severe hemorrhage
following the use of the snare are reported. For the complete
extirpation of the tonsil, the cautery dissection, as performed
by Pynchon, is ideal. In the hands of a novice, the tonsil may
be completely destroyed, but there usually remains a distinct
scar in the pillar, which, to say the least, is unsightly and
unbecoming to behold.
Pynchon's cautery dissection is performed under a twenty
per cent, cbcain anesthesia with a cautery point heated to a
bright cherry red. The tonsil is then grasped with a pair
of tonsil forceps and posterior and anterior portions of the tonsil
are dissected away from the anterior pillar. Following this,
the tonsil is dissected away from the posterior pillar.
In Pynchon's cases, after a few weeks, the pillars are sin-
gularly free from scars and from the general appearance seem
quite normal.
The Robertson scissors resection (Fig. 144) consists in secur-
ing a complete local anesthesia, preferably by injecting into the
tonsils 15-20 drops of 10 per cent, solution of stovain in an
DISEASES OF THE TONSILS. 525
The tonsil punch is especially designed for the removal of
small, cryptic tonsils.
Reduction of the tonsils by the electro-cautery is sometimes
advocated in hemophitic subjects and in those who object to
other operative measures.
The technique of the operation consists in thoroughly cleans-
ing the nose, naso-pharynx and pharynx with some antiseptic
and alkaline solution. The tonsils should be anesthetized with
a twenty per cent, solution of cocain. The cautery point is
heated to a pale cherry red and driven deep into the tonsil or
carried partially through the tonsil. It may be necessary 'to
make more than one puncture and at a week's interval. The
amount of slough and shrinkage correspond to the amount of
tissue destroyed by the cautery. If the tonsil is a hard and
fibrinous one, the pain may be quite severe for a few hours
following the operation.
The after-treatment consists in gargling the throat twice
daily with a hot antiseptic solution.
Barring the time required, the results from tonsil cauteriza-
tion are frequently as satisfactory as by any other method.
CHAPTER XXX.
DISEASES OF THE LINGUAL TONSIL.
Acute Inflammation of the Lingual Tonsil. — Acute
inflammation of the lingual tonsil is an acute inflammation oi
the mucous membrane and glandular structure situated at
the base of the tongue and may be unilateral or bilateral.
Etiology. — The predisposing cause is injury from ctm
substance] foreign body anil constitutional dyscrat
Fie. 146.
HrriirinrHj o» rue Linoual Toks:l. < After CnmwU.)
I exciting cause is some pathogenic organism which mar
be carried to the parts by the foreign body producing the injun
or from contiguous parts.
Pathology. — The pat I the disease Is the same as that
■ ■ utc faudal tonsillitis.
Treatment. — The local treatment n the application
of nitrate of silver, twentj to thirty grains to the ounce, oner
526
DISEASES OF THE UNGUAL TONSIL.
5«7
daily, followed by a spray of a two per cent, solution of
campho-menthnl in al holme. Hot antiseptic gargles should be
prescribed for home use with the instructions to be used every
two" or three hours with the nose tightly closed while gargling.
The constitutional treatment consists to securing free cathar-
sis by the administration of calomel. Benzoate or salicylate
of soda is usually indicated in from ten to fifteen grain doses
three times daily well diluted in water.
Hyperplasia or Hypertrophy of the Lingual Tonsil. —
/>'. — Hyperplasia of the lingual tonsil is due to an in-
herited tendency to the disease, chronic faucial tonsillitis, gastTO-
intestinal disorders, rheumatism, gout, syphilis and excessive
use of tobacco and alcoholic liquors.
Pathology. — There is an increase in the size of the tonsil,
usually bilaterally, which is due to an increase of lymphoid and
connective tissue.
Symptomatology. — The symptoms vary greatly in individu-
als. One of the distressing symptoms frequently produced by
hyperplasia of the lingual tonsil is a constant cough. In addi-
tion to this, the patient may complain of an accumulation of
mucus in the throat, sensation of fullness and constriction about
the Larynx. On account of the pressure upon the epiglottis,
there may be some disturbance in phonation and respiration,
harking cough and the desire to clear the throat.
Hemorrhage from the tonsil may result from rapture of
varicosities due to excessive coughing Ot traumatism.
Diagnotor. — Upon inspection with the laryngoscope with the
tongue turned out as for laryngoscopy examination, the en-
larged lymph glands about the base of the tongue arc easily
detected. In obstinate eases of cough, sensitive areas may some-
!•<• Detected witn > curved, cotton-tipped probe, and when
touched, produce violent spasms of coughing.
Treatment* — The treatment consists in the correction of any
constitutional dyscrasxa and the removal of lymphoid hyper-
trophies by surgical methods or with the calvano -cautery.
For the surgical removal of lymphoid hypertrophies, Roc's
i
5*8
DISEASES OF EAR, NOSE AND THROAT.
lingual-tonsillotome may be used. The technique of the
operation consists in securing local anesthesia with a tu
per cent, solution of cocain or equal pans cocain, menthol
and carbolic acid. Under good illumination, Roe's tonsil-
lotomc caii he passed into the throat, easily engaging ihr
hypertrophy. By a steady pressure upon the blade, at the same
rune making Jinn pressure against the base of the tori:
the instrument, the hypertrophies are easily removed.
The after-treatment consists in cold antiseptic gargles tot
the first twenty-tour hours, followed hy hot antiseptic gargles.
The galvano-cautery is a highly expeditions instrument for tbr
removal of hypertrophic*.
Under good illumination and local anesthesia of twenty per
cent, solution of cocain, the electrode may be passed into the
throat and directly against the lymphoid hypertrophy, when tbc
current is turned on. A number of applications may be made
at one sitting. There is very little or no reaction and the
recovery from the cauterization is usually very rapid.
Abscess of the Lingual Tonsil. — Abscess of the lingual
tonsil is due to traumatism or metastasis followed hy infection
from some pathogenic organism, often the streptococcus or
staphylococcus.
Pathology. — The pathology varies in no wise from retro-
pharyngeal abscess or abscess of the tonsil.
Symptomatology. — The patient complains of swelling at '
base of the tongue, difficult swallowing, rise of temperature,
headache and general malaise. The area of infiltration
easily detected upon inspection. If the swelling becomes
great, protrusion of the tORgUC and examination of the fatten
becomes exceedingly difficult. There is usually redness
the pillars and an accumulation of mucus in the throat The
site of the abscess is usually to the right or left of the median
line and at the base of the tongue. The formation of pus in
the lingual tonsil is usnallv somewhat slower than in the
faucial tonsil. Pain gradually increases in intensity and may
continue from three or four days to a week. The abftcttt
sometimes ruptures spontaneously.
MSI'.ASES OP TICF: UNGUAL TONSIL.
'
Diagnosis. — On account of the swelling at the base of the
tongue and the inability to open the month, it is frequently
impossible to diagnose the presence of pus by palpation. In two
ol abscess <>i the lingual tnnsil treated by the author W ithin
the last year, it was iin possible to locate the pUS 09 account of
the intense swelling, and in consequence, the abscess in both
cases ruptured spontaneously.
li :- necessar) to differentiate the disease from peritonsillar
abscess or abscess of the tonsil. The disease may occur at any
age. but is seen more often in the young.
Treatment. — The treatment is directed to securing a free
evacuation of the bowels by the administration of calomel,
followed by a saline cathartic.
One-fourth grain doses of codein may he given every three
hours for the relief of pain. In addition, ten grains of salicylate
o) soda should be given three times daily.
1 he local treatment consists in hot antiphlogistin measures
externally and hot saline and antiseptic gargles. As soon
BS the pus is detected, it should be incised under twenty pel
cent cocain anesthesia with a curved bistoury. If the swelling
is not too great and the jaws move freely, the knife can be
guided into position with the index linger of the other hand.
Should the abscess rupture spontaneously, the patient should
be instructed to use hot antiseptic gargles until all sensations
of irritation in the throat have passed away.
Mycosis of the Tonsil. — (See Mycosis at the Pharynx.)
Lingual Varix. — Lingual varix is a condition of varicose
veins ot he lingual tonsil.
Etiology. — The disease mav accompany hyperplasia of the
lingual tonsil and is more often observed in rheumatics, typhi*
litns and in those addicted to the excessive use of alcoholic
liquors. I he condition is sometimes observed in individuals
ol i hemorrhagic diathesis.
Pathology. — The pathology is the same as for varicosities
in any other portion of the body.
Spaptomatology. — The symptoms of the disease vary in indi-
53«
DISEASES OF EAR, NOSE AN'D THROAT.
vidusls. Large varicosities may sometimes exist without a
irritation to the patient. In other cases there may be a feeling
of irritation at the base of the tongue, constant cough and at
- a slight hemorrha^p.
Diagnosis, — Upon inspection with the laryngoscopy mirror,
the tortuous and swollen varicosities, extending antero-pos-
teriorly on the lateral halves of the base of the tongue, ate
readily discerned. In mild or severe hemorrhages from the
throat, the possibility of ruptured varicosities at the hasc of the
tongue should always be taken into consideration.
Treatment. — Under an anesthesia of ■ twentj to thirty prr
rent, solution of COCain, or carbolic and, menthol and cocain
in equal parts, the varicosities may be destroyed by the galvano-
cautery. The point of the cautery should be heated 10 a
cherry-red and applied directly to the larger varicosities.
CHAPTER XX&L
DISEASES OF THE LARYNX.
Acute Catarrhal Laryngitis. — Acute catarrhal laryngitis
is an acute inflammation of the superficial layer of the mucous
membrane of the larynx.
Etiology. — The cause is more often some gastro-intestinal
disorder, exposure to cold, excessive use of the voice and indura-
tion from irritating gases. Acute laryngitis may sometimes
accompany scarlet fever, measles, malarial and typhoid fever.
Pathology. — There is a hyperemia and swelling of the mu-
cous membrane and sometimes an edema and round cell infil-
tration. The edema is sometimes greater in children because
of the loose connective tissue in the subglottic region. The
disease is probably a vaso-motor disturbance due to faulty local
nutrition and toxins eliminated from the system.
Symptomatology. — The symptoms vary according to the
degree of inflammation. There is usually hoarseness, sometimes
complete loss of the voice and a dry, hacking cough. Where
the voice is not entirely lost, it is dry and husky and sometimes
reduced to a whisper. Children and the middle-aged are sus-
ceptible to the disease and those residing in a cold, moist climate
are more often affected than residents of a dry, warm climate.
On account of the character of the epithelium lining the larynx,
there is a tendency for the inflammation to remain localized,
but, however, the inflammation sometimes extends to the upper
air passages and into the bronchial mucous membrane.
Diagnosis. — Variety and intensity of coloring will be ob-
served in the mucous membrane and is in proportion to the
edema and the severity of the inflammation. There may be a
slight redness involving the epiglottis and mucosa of the superior
S3»
53- DISEASES OF BAR, MOSS AND THROAT.
ventrical region or a .Jeep redness of the vocal cords and entire
mucosa of the larynx.
Prognosis. — The prognosis of simple, acute, catarrhal laryn-
gitis is usually favorable. The di in from
a few day* r" > week, providing, of COURT, that the patient «*
not successively exposed to the Influence of condition '.'.
produced the disease.
The vocal cords are usually covered with a thick
mucus, which is adherent and can be removed onlj with great
difficulty.
Treatment. — The treatment is both local and general. The
local treatment is directed to the rebel ol local congestion b]
the frequent inhalation oJ hoi steam, medicated with the
following:
!j< Menthol, i.iy urn. (jtr. xx)
Ol. eucalyptus, 30.00 c.c. I
Signa. Ten to fifteen drop* should l>e added to a spongr in the
simplex inhaler.
This treatment should he repeated for a period of I
minutes evrrv two or three hours during the dft]
of hot Dobell's solution every hour w ill lessen the pain and
dryness <<\ the throat and, in the caxij stages of the disease, wS\
:«i<l in the reliei of the congestion, Antiphlogisdn or hot ap-
plications externally will act as a < «>untn-iint;»nt and aid il
lessening congestion. In the adult, it the poultice is rem 1
upon arising, the neck and chest should !*• bathed with cold
water followed by the application or alcohol .mil dried wit]
coarse towel.
In the severe form of the disease, the general treatment con-
sists in confining the patient to a warm room. ( )n «. . ■ ■
the lessened tendency to edema of the larynx in the adult, the
patient may be privileged to go about his busim ded
of course, there is no elevation of temperature and the patient
can refrain from using his voice. In a 'ersl
lent outlined above, the administration of calomel in
onc-tcntli grain doses every hour until free purgation results,
is indicated. The use of the voice should he prohibited for
forty-eight hours, likewise smoking and the use of alcoholic
liquors.
For the relief of the cough, an Hi\ir of turpen-hydrate and
heroin ill one drachm doses should be given every three hours.
If, after a day or two, the secretion adheres to the vocal cords,
muriate of ammonia in three grain doses, should be added to
rhe dose of elixir of turpen-hydrate and heroin.
Uric acid conditions of the system should he relieved by the
free administration of distilled water and henzoatc or sali-
cylate of goda in ten grain doses, three times daily.
The office treatment consists in cleasing the larynx with a
mild alkaline and antiseptic spray. For the cleansing of the
larynx, the De Vilbiss laryngoscopic tube is indicated. Follow-
ing the cleansing, the larynx should again be sprayed with the
following:
B Zinci sul pilaris,
( ikrrrini,
Aqute,
.24 gm, (gr. iv)
1.00 c.e. (gtt. xv )
30,00 c.e. (3 i )
This should he followed hy a bland oil spray. If, after ten to
fifteen days, the congestion of the mucous membrane of the
larynx has not passed away, the parts should be painted with
two to four per cent, solution of nitrate of silver every two or
three days.
Chronic Catarrhal Laryngitis. — Chronic catarrhal laryn-
gitis is a chronic catarrhal inflammation of the entire structure
of the mucous membrane of the larynx and may be circumscribed
or diffused.
Etiology." Successive attacks of acute laryngitis are one of
the prominent factors in the causation of the chronic form of
the disease. With continued irritation from frequent attacks
ot acute laryngitis a general hypertrophic and hyperplastic con
dition results, involving the blood -vessels, glands and mUCQ R,
producing partial or complete alteration of function.
I
534
diseases of ear, nose and throat.
The disease is often slow in its onset, especially if dependent
upon a chltXIIC catarrhal condition of the nose and throat.
Other causes to be especially enumerated are gastric disturb-
ances, bad teeth, mouth breathing, alteration in normal nasal
respiration, sexual excitement, diabetes, rheumatism, chronic
purulent middle ear diseases, chronic, purulent inflammation
of the accessory' sinuses, prolonged exposure to irritating dusts,
alcoholic excesses, inhalation of tobacco smoke, chronic tonsil-
lar affection, uterine and ovarian disorders and tuberculosis.
In the last condition, patients irritate the larynx by continued
coughing and expectorating. Orators and public speakers often
suffer from the disease. Age, heredity, sex and climatic condi-
tions each play a small part in predisposing to the disease. Art
has its influence only to this extent] that systemic oHsturl
are more prone to occur between the ages of thin,
and in consequence, at this period of life, the disease is more
prevalent. Many children suffer from inherited dyscras*
which retards their healthy growth and thus predisposes them
to this disorder. On account of the exposure incident to their
occupations, men suffer more frequently from the disease than
women, especially in damp climates.
Pathology. — On account of the many causes enumerated
above, it can be readily understood that it is possible to so retard
the recovery of ;m acute inflammation or change a hyperemic
condition of long standing of the larynx into a chronic condi-
tion, involving all the structures of the mucosa. On account
of the longevity of the disorder, the blood SUpplj trom altered
vessel walls becomes diminished. Hyprrtiuphy of
rounding tissue may cause an obstruction to thr return of
venous blood, producing a hyperemia. The gi
which supply the lubricating fluid 10 moisten the vocal
often become altered and give rise to a lessened secretion which
causes a dryness of the true and fa! or there may be
just the reverse, a hypersecretion. A variety of hyperplastic
changes is noted in the mucosa and an irregular thickening
described by Virchow as " pachydermia lanngis," is sometimes
•rved.
DISEASES or i'm;: i arvnx
535
Symptomatology, — If the disease is the result of acute
laryngitis, there is a prolonging of the hoarseness, hacking
cough, general sense of irritation in the throat and frequent
expectoration. The voice will be much clearer in the morning,
the hoarseness becoming more pronounced toward evening OX
after using the voice.
The alteration in the voice is sometimes out of proportion
to the visible change in the laryngeal structure. A certain
amount of respiratory effort is required for distinct phonation,
which causes the patient to complain of fatigue in the chest.
Diagnosis. — The diagnosis of chronic catarrhal laryngitis
is comparatively easy. All those conditions which may directly
produce a loss of voice, such as paralysis, tumors, aneurism and
incipient pulmonary tuberculosis should not be overlooked in
reaching a positive diagnosis.
The pillars of the fauces, uvula and tonsils often show a
thickened and chronically inflamed appearance. The pharyn-
geal wall is likewise inflamed and covered with varicosities and
follicles. Kxam ination of the larynx will usually show a gen-
eral hyperemic condition of the mucosa and vocal cords. The
color of the vocal cords varies in individuals from a flesh pink
to a deep red.
The hoarseness is due to a partial loss of function of the
cords or hypertrophy of the muscle assisting in phonation.
A muco-secretion is usually thrown off, which causes fre-
quent hawking and expectoration.
Course and Prognosis. — The course ot the disease is usually
varied. The disease may continue for a very long time, ending
in spontaneous recovery with a removal of the exciting cause.
The voice seldom regains its normal timbre after a prolonged
exposure to a chronic catarrhal inflammation.
The disease is tlO< dangerous to life, only to the extent that
there is a predisposition to laryngeal tuberculosis and morbid
growths of the larynx.
imnit. — The treatment is both local and constitutional.
Before making any local application, the naso-pharynx and
53<S
DISEASES OF EAR, NOSE AND THROAT.
laryngo-pharynx should be freed with laryngeal spray of «q
catarrhal exudation. Local applications arc best made to the
larynx with a curved laryngeal applicator or through the medium
of sprays. In using an aqueous Sprays Che patient should be in-
structed to protrude the tongue and deeply inspire the spray.
Oil spray or nebulizer can be advantageously used. The patient
can draw the nebuli of oil deep into the larynx without bringing
about a spasm of coughing. As an oil spray in chronic catarrhal
laryngitis, then- is nothing better than the following;
Ix
lodi,
Oil of pint,
; • i.' i- menthol,
I '!. kiJiililierise.
Albolene,
.06 k»'- it
.jo ex. iff
40 gM. f^r. xv 1
.jo c& <gr.
KMO r.r. | 3 i )
One tcaspoonful of compound tincture oi benzoin to a pint
of boiling water is highly efficacious l<>r inhalation. The pi
tieiit ran use one of the cheap inhalers DOW on the market.
Local applications should He made for fifteen to twenty minutes,
three times daily, one-half hour before going out of doors.
A- an iqueous spray, some of the milder astringents, such
as tannic acid, sulphate of zinc, phenolsulphonatc of i>per
or hyilrasris in from one to live per tint, solution may he
prest'i ibed.
As a topical application for the treatment of the ch
catarrhal inflammation, a one to five per cent, solu
nitrate of silvei is often used- I ndei good illmninol on I
a head minor, or in main eases under ditxvt sunlight, with
tongue extended exposing the tip of the ep a small
curved, cotton-tipped probe can be passed directly into the
larynx. A spasm of the larynx of B greater or less degree, re-
sults, but is of no consequence. The pat .1 be warned
of this possible condition so that they may not be unduly
htened. Applications of nitri nay be made daily
until the symptoms begin to diminish, when the time ran be
lengthened between the applications. The voio d be
iHSF \SI-S OF THE LARYNX.
537
given all the rest possible. Any possible source of irriration in
the nose and throat should be removed.
The attention in the very beginning is directed to the cor-
rection of any constitutional dyscrasia. A change to a dry,
warm climate may be necessary to induce a cure in obstinate
cases. Rigid rules of personal hygiene should be enforced.
Hypertrophic Laryngitis. — Hypertrophic laryngitis is I
circumscribed or diffused hypertrophy of the vocal cords and
mucosa, due to a chronic inflammation. The circumscribed
form is subdivided into two classes, viz., singer's nodules and
granular laryngitis.
The diffused form may be divided into two forms, viz., the
superioi or general, and the inferior, i. <•., situated beneath the
vocal curds. I he best example of the chronic, diffused form is
pachyderm a laryngitis, as described by Virchow.
Etiology and Cause. — Successive attacks of acute laryivjnl-
are the leading factor in the production of the disease, supple-
mented by continued injudicious use of the voice, unhygienic
surroundings, tobacco and alcoholic excesses, gout, rheumatism
and general debility.
Symptomatology. — The patient complains of continued
hoarseness which is aggravated by any effort at phonation. The
voice may be completely lost. There is a hacking cough with
expectoration of thick, tenacious mucus, suggestive of approach*
n Tili.:i ill..- -. The cough is very often aggravated by using
the voice.
Diagnosis. — With a latyngOSCOpic mirror and under good
illumination, the mucous membrane 01 the larynx may be seen
to be very much thickened with circumscribed or diffused altera-
tions in structure.
Singe: B nodes, or " ckorditit tuberosa" of Tiirke, are small,
white, nodular eruptions, single or double, situated upon the
anterior portion of the free border of the vocal cords. They
an usually observed in singers, orators and artors, though many
nous to the rule are noted.
The granular form is diagnosed by the peculiar diffused.
53*
DISEASES OF EAR, NOSE AND IHRCMT.
granulated appearance of the vocal cords in their anterior aspect.
The granulations are much larger and more numerous than
the nodular form, while in color and arc surrounded i
gested areas.
The diffused variety is recognized by the partial or com-
plete, uneven swelling of the mucous membrane of the ven-
tricular hands and cords. The overgrowth or hyper jd;
condition observed at the posterior commissure, dark grayish
.mil non-vascular in appearance, has been given the nanv
pachy derma laryngitis.
The same grayish overgrowth of tissue may sometimes be
observed beneath the vocal cord>. moving with them arid de-
scribed as chronic larjmptii Itypcrtmphica inferior.
Course anil Prognosis. — The progress of is essen-
tially very slow. As far as complete recovery of the voice H
concerned, a guarded prognosis mast be ^iven. The greater
the amount of hyperplastic change observable, the less possi-
bility of complete recovery and in consequence, a return to thr
normal oJ the pitch ami qualitj of the voice can not be
promised.
'treatment. — The predisposing factors of the disease, su
constitutional dyscrasia, irritating habits, occupation and -
hygienic surroundings, should receivr immediate attention.
Any gastro-intestina] or uric acid condition should be removed-
Attention is directed to the removal of any nasal obstruction.
enlarged tonsils or bad teeth. Public speakers should be
structed how to modulate the voice so as to cause the lent
irritation.
The local treatment as in the acute form c « first
insittg "ith some mild, alkaline solution, followed, it there
ill secretion, by the direct application of some of the
Well-known astringents, such as nitrate .if silver, ten grains to
the ounce ol water, chlorid of zinc, ten •■ thr ounce of
water, sulphate of zinc, ten to twenu ime
ol water.
Where there is a lessened secretion and dry huskiness of the
DISEASES OF THE LARYNX. 539
voice, the following stimulating solution may be applied once
daily :
$ Iodini, 2.00 gm. (gr. xxx)
Potas. iod., 3.00 gm. (gr. xlv)
. S"SUM ~— «"
M.
Signa.
Tobacco and the excessive use of alcohol is interdicted. A
light wine at meal-time may be allowed to those accustomed
to such indulgences.
For home use, the patient should be given ten grains of
benzoate of soda, three times daily to stimulate glandular
elimination. The following may be prescribed to be used in
an inhaler, for the patient to breathe deeply for one-half hour
three times daily:
B Tinct. benzoin, camp., 60.00 c.c. (3 £i)
01. pini, 1.00 c.c. (gr. xv)
Menthol, 2.00 gm. (gr. xxx)
Camphors, 1.00 gm. (gr. xv)
Signa. Add one teaspoonful to one pint of boiling water and
use as directed.
In the nodular and granular forms, complete rest of the voice
in addition to the general treatment as recommended above,
will usually relieve the condition. In a few cases where
hypertrophies or nodules are somewhat pedunculated, laryngeal
biting forceps may be used. Though surgical procedures of
this character are only carried out with difficulty and hardly
within the domain of the general practitioner, the same may be
said of the galvano-cautery. Local applications of iodi-iodin
solution as recommended above, with a cotton-tipped probe
once daily, will usually prove very satisfactory.
Laryngitis Sicca. — Laryngitis sicca is a recognized atrophy
of the laryngeal mucous membrane, characterized by the for-
mation of crusts upon the surface.
Etiology. — The disease is usually an accompanying condition
54°
DlSF.ASKS OF FAR. NOSE AND THROAT.
■ it fetid atrophic rhinitis and is a trophoneurosis, probably re-
sulting from an extension of the nasal trouble by conti
tissue or absorption of toxins from the nasal suppuration.
Inherited tl ysci .1- 1.1. syphilis and tuberculosis probably plav
a very important parr in predisposing 1 In- patient tu the disease.
The structures of the mucous membrane of the larynx differ
slightly from that of the nose, which difference in rhe normal
subject is antagonistic to the extension ut inflammation from
the nose and phar>n\.
Age and sex have but little influence in the production M
the disease. Personal habits which diminish titstn tie resist
are predisposing factors in the causation oi the disease.
SymptomatQlagj. — The patient complains oi a hoaneneai
with a dry. tickling sensation in the throat. Tin- thick d
and shreds which stick tenaciously to the surface of the lai
are often only expelled with great difficulty. Sometimes the
mucus, which is subsequently expectorated, may be stained 9
blood.
The frequent presence of the thick mucus over the I
of the vocal cords produces a cough and dyspnea.
Prognosis. — The recovery oi the disease is dependent upon
the relief of the cause, which, as related, is more often a 1
atrophic rhinitis, and this disease being an obstinate one, a
temporary and palliative measures can be offered the patient.
Diagnosis. — In addition to the nasopharyngeal irr.r
which is usually present, 8 genera] appearance of di
tin cords and mucosa is observed.
The cords and false cords will be seen tu be 1 tth a
tenacious, ^leenish-black secretion. At times, the cords nu>
even appear narrowed, Frequent attacks of acute laryng
which causes the cords to become may accompany
the diseaa
There is always a historj of a lung-continued irritation of the
larynx
Treatment. — The treatment is the same SB that in.!
pharyngitis sicca (see Pharyngitis Sicca). Those remedies
DISEASES OF I KB LARYNX.
54'
which tend to the promotion of glandular secretion should be
administered, such as phosphorus, one one-hundredth grain
doses, or iodid of potassium in three grain doses. Spraying the
throat with Dohell's solution or inhaling steam from boiling
water to which has been added one to three {nuns oi carbolic
acid (D. Brayden Kyle), will aid in the removal of the
sec ret i- hi.
Frequently spraying the throat with the following will
relieve the most distressing symptoms:
l.{ Menthol,
( >]. pini,
All.olenc,
M.
.30 gin. (gr. v)
■ H cm. (gr. iv)
30.00 c.e. (5 j)
One per cent, solution of chlorid ot zinc applied direct, will
have :t stimulating influence.
Membranous Laryngitis. — Etiology. — Membranous laryn-
gitis or croup is more often observed in children than in adults.
The predisposing causes of the disease are a lowering of the
vitality of the parts from unhygienic surrounding,, sudden cli-
matic changes, exposure to cold, intestinal derangement, con-
situtional dyscrasia, inherited predisposition to the disease, en-
larged tonsils, adenoids, chronic nasal catarrh, acute laryngitis,
measles and scarlet fever.
I In- exciting cause is infection from the Klebs-Loffler bacillus,
tbr staphylococcus or the diplocotuts.
Pathology, — There is a rapid swelling of the mucous mem-
Inane of the larynx and the epithelium covering the vocal
cords with a round cell infiltration, followed by fibrinous ex-
udation which coagulates on the surface and forms ■ pseudo
membrane. The duality of the croup and diphtheria is con
. a number oi authorities. In true diphtheria there is
a profound systemic intoxication from the toxins eliminated
by the action ot the Klebs-L riffle r bacillus, whereas, in croup
from infection with the streptococcus or diplococcus, there is
an absence of severe systemic intoxication.
DISEASES OF fcAR, NOSE AND THROAT.
In the majorin ot cases, croup is diphtheritic in nature and
due to the klebs-Lomrr bacillus.
Croupous inflammation is usually confined t<> the
above the vocal cords and may become descending in character.
producing a rracheo-lnryngitis. In young children and r
suffering from pertussis, croup may have its origin in the
trachea and ascend to the laryngeal mucosa.
Symptomatology. — The disease more often comes on during
the night and is sometimes preceded by a cold in the head
with slight fever and vomiting for a few .Ins. The patient
suddenly lioumr- hoarse, followed by a slight cough which i$
rapidly accentuated and becomes a barking or croupy cough.
There is a rise of temperature, headache and redness of the
face. With the increase of swelling and stenosis of the vocal
cords, the patient gasps for breath and presents the picture oJ
alarming eyani
The paroxysms vary in intensity and may last for only a
short time and recur in a few hours. The child may be quits
free from the spasms during the day. only to have them repeated
the following night.
Death may occur from exhaustion, heart failure or asphyxia
In favorable cases, the spasm gradually lessens in frequent
Suddenly completely disappears. The child falls asleep from
exhaustion and the recovery is uninterruped.
Prognosis. — The disease is frequently fatal, the pat
in collapse. The results of tracheotomy and intubation are
more favorable in croup from infection with the streptococcus
or diplocoCCUS than in true diphtheritic infection.
Treatment. — The constitutional treatment consists in the ad-
ministration of one to five thousand units of antitoxin which
may be repeated in twenty-four hours if no marked amelioration
of the symptoms is observed. One-tenth grain doses of calomel
should be administered every hour until free purgation r<^
Emetics are rarely necessary. Leeches are sometimes applied
about the larynx as a quick antiphlogistic measure.
The local treatment consists in moist inhalation from a
DISEASES OF THE LARYNX. 543
lin lamp or simplex inhaler. Cresolin may be used with the
cresolin lamp or simplex inhaler. In the absence of cresolin,
compound tincture of benzoin, one ounce, to which is added
carbolic acid in a strength of five per cent., may be added. The
throat should be frequently sprayed with acetozone and campho-
menthol in albolene. Antiphlogistin as a poultice to the neck
is highly efficacious. The child should be encouraged to freely
drink hot milk or hot malted milk. The child should be iso-
lated and kept in a room at a temperature of 75° F. The room
should be carefully ventilated from time to time and the air
of the room well moistened with steam of a boiling kettle.
When stenosis of the larynx is very great, intubation should
be performed early. The tube is generally worn from one to
seven days, according to the severity of the disease (see Tech-
nique of Intubation).
Edema of the Larynx. — Edema of the larynx is an acute
condition characterized by a serous exudation into the tissue
above the vocal cords.
Etiology. — The causes of the disease are both local and
general. The local causes are traumatism, heat, cold, applica-
tions of the cautery, gunshot wound in the neck, erysipelas,
peritonsillar abscess, lingual abscess, syphilis, tuberculosis and
malignant disease of the larynx.
The general causes are a lowering of the vitality from climatic
conditions, unhygienic surroundings, rheumatism, pulmonary
tuberculosis, valvular heart disease and disease of the kidney.
Pathology. — The disease is probably some vaso-motor dis-
turbance and is characterized by local or diffused serous exuda-
tion in the submucous tissue of the larynx.
Symptomatology. — The disease is sudden in its onset. The
patient is attacked by dyspnea and difficult swallowing. There
is a partial or complete loss of voice due either to edema of the
ary-epiglottic folds, the mucous membrane covering the epi-
glottis, or the mucous membrane covering the true vocal cords,
and in rare cases the subglottic laryngeal mucous membrane.
54-1
HSEASBS OF EAR, NOSE ANO THROAT.
Tin- location of tin- swelling necessarily varies according tn tfcr
traumatism and tissue de resistance.
Diagnosis, — I'pon examination with the laryngoscopy
and with the tongue protruding from the mouth, the cderrunx*
mucous membrane is easily detected. The general appearand'
oi the larynx is the same as that observed in acute edema of tb
uvula. Difficult breathing is a prominent subjective •.\mntoeL
■ tmrnt. — The constitutional treatment should be directo!
as far as possible to the relief of the general causes producing
the disease. Free purgation - usually indicated at once. TV
patient should be confined to a warm room with the atmospberr
moistened with steam from a boiling kettle. Hot applicatwe*
to the throat externally and hot astringent gargles are indicated
early in the disease. Where the edema is well i
bulbar mass should be punctured with a laryngeal cutting for-
ceps under good illumination.
Pilocarpin in one to twenty grain doses, twice daily, will i^
in Stimulating the elimination and absorption uf the edeou
The prophylactic treatment is directed to the correction oi
constitutional dyscrasia and the avoidance of any
known to excite the disease.
Syphilis of the Larynx. — Syp - other
than a fa< tOI in the etiology of chronic laryngitis, is in frequently
observed.
A Primary Lesion, from the anatomical position of tr
larym. i on bird!1, exist. Such a condition may possihb
times and is overlooked.
Si condarv Lesions oi syphilis are characteri
hyperemia and catarrhal inflammation of the larynx Miuuf
ulceration may sometimes occur. John N. McKen/.ie mem
having observed one case of mucous patch oi the larynx
Tertmrv Lesions of syphilis oi fta are mote often
encountered and may be gummnta. fibroid de:
ulceration.
Symptomatohjry.—The sympton
van In intensity, according to the progress of the disease. How-
DISEASES OF THE LARYNX.
545
ever, there are usually sensations of fullness in the throat,
catarrhal laryngitis and partial or complete aphonia. There
IS usually a history of syphilis and subjective symptoms of the
disease.
Diagnosis. — A diagnosis of chronic hypertrophic laryngitis
due to syphilis can only be positive after anti-syphilitic treat-
ment. In the early stages of tuberculosis and some forms of
malignant and non-malignant tumors, the diagnosis can only
he made after the administration of iodtd of potassium.
In the early stages of gummata, the diseased area appears
swollen and slightly red, surrounded sometimes by dilated
blood-vessels. The location of the gummata may be observed
in any portion of" the larynx.
As the name suggests, a fibroid degeneration appears as a
hard and nodular tumor, which steadily encroaches on the lumen
of the glottis, producing deformity. They have a whitish or
anemic appearance and are hard to the touch.
In the ulcerative stage, the ulcers may be single or multiple
and according to McKcnzie, more often appear on the lingual
surface and free edge of the epiglottis. The vocal cords are
less frequently involved than the upper part of the larynx. In
the tertiary ulceration, there is deep destruction of tissue. The
healing takes place from the periphery with the formation of
ant (cicatricial scars and deformity in proportion to the amount
of tissue destroyed.
The disease may be mistaken for tuberculosis or malignant
neoplasms.
Prognosis. — Under active anti-syphilitic treatment, the prog-
nosis is usually favorable. Cicatricial bands may be formed,
interfering with respiration, which demand subsequent removal
with the laryngeal cutting forceps.
Treatment. — The general treatment varies in no wise from
that of syphilis of the nose. The patient should be warned
again-.; the use of tobacco and alcoholic liquors. In paralysis
of the larynx, in addition to the antisyphilitic treatment, elec-
I
546
DISEASES OF EAR, NOSE AND THROAT.
tricity anil strychnia by the mouth or hypodermatic-ally, are
indicated.
Cicatricial bands may be destroyed by the laryngeal «.
forceps. In extensive stenosis, intubation or t rachcotomy may
be necessary to prevent suffocation.
Dilation with Schrottcr's dilators is sometimes valuable in
stricture of the glottis.
Tuberculosis of the Larynx. — Tuberculosis of the larynx
is a primary or secondary infection of the laryngeal mucous
membrane and submucous structures, due to the tubercle ba
Etiology. — The causes are both predisposing and e\
The predisposing causes of the disease are chronic Iaryn,-
exposure to tubercle infection, tubercular diathesis, constitu-
tional syphilis and primary tubercular involvement of the lungs.
The disease is more often observed between the age of twenty
IHd forty years.
According to Scltmaus and Ewing, tuberculosis of the larynx
and trachea occur in about thirty per cent, of the COM
phthisis and in the majority of cases follows infection Iv,
bacilli in the sputum passing over the laryngeal surface. Geo,
L. Richards believes that in ninety five per cent, or more of
cases, the disease coexists S) itli. o» is secondary to, tnbei
ut the lungS.
Infection may also reach the larynx through the lymph
ncls, mouth of the glandular ducts or the blood supply from an
infected lung.
Meyer, F„ Fraenkel and Jonathan Wright believe thr ba-
cillus can enter the structures of the larynx through intact
epithelium.
From the foregoing the conclusion is that but few cases of
piim;in Infection of the larynx exists. Sidney Yanks
I review of the literature of the subject of tuberculosis ol
larynx, reports the casi of 15. I >. Sh« .vhich the
ivolved for nine months and tubercle b
the lungs became affected.
Pathology. — As in tuberculosis of other mucous membranes.
54«
,i:S OF EAR, NOSE AND THROAT.
with the formation of an ulcer and destruction of cartilaginous
Structure. Before caseous degeneration takes place, the tume-
faction in the glottis, aryglottic folds, epiglottis and arytenoid},
may be seen.
The location of the tubercle is often in the arytenoid car-
tilages, liy-epiglorttc fold or vocal cords. The true status of
primary infection of the larynx is open to discission.
J. W. Gleitman believes in the occasional occurrence of
primary tuberculosis of the larynx; Grayson, that the disease
is extremely rare; J. Home, that when the larynx is affe>
there is an already affected atea in the lungs.
Symptomatology. — The majority of cases of tubei
the lungs is preceded by .1 chronic catarrhal laryi iiiiii
is primary or secondary to pulmonary tulx
The patient complains of a dry cough, boai and a sen-
sarion ot a lump in the throat, which may continue tor |
time without any other symptoms other than chronic laryngitis.
The amount of sputum varies according to the lung involve-
ment. As the swelling increases and ulceration takes place.
the voice may become entirely lost and swallowing difficult
and painful.
In the caiU stages «>f the disease, there i> no extern*
dence ot laryngeal irritation until swelling and ulceratioa of
the larynx has taken place. Pressure upon the externa] '
produces pain and the parts are swollen and hard to ihi
In the beginning of the disease, there is icral
malaise, loss of flesh and slight rise of temperature. As the
disease progresses, night sweat- and a general hectic •
supervenes.
In the early stage of the disease, the mucous membrane is
found, upon inspection, to br pale and anemic in appearai
Small areas of red and thickened tissue will be seen within ihr
lield. Sometimes in the early stages of the disease, small.
grayish, pin-point-like be seen beneath the epi-
thelium before the swelling and infiltration have taken place.
In the infiltration stage of the disease, a distinct tumefaction
DISEASKS OF THE LARYNX.
549
observed in the epiglottis ( turban -shaped epiglottis), ary-
tenoids (club-shaped), one or both, or the ary-epiglottic fold,
hater on, the edematous membrane becomes covered with
grayish spots or miliary tubercles which are beneath the stir
face. The miliary tubercles soon break down and converge;
thus distinct anas of ulceration arc easily detected. The ulcer
:.i\ Ish yellow in color and is covered with mucus and pus.
Paralysis of one or both cords may be present. In ulceration
of the vocal cords, the " distinct notches " and " worm-eaten "
appearance is detected.
Diagnosis, — The early diagnosis of the disease is sometimes
difficult. With a dry, hacking cough, periodical attacks of
hoarseness and a tubercular history, the disease should be sus-
pected. With the observation of the above enumeration of
symptoms and discovery of the tubercle bacilli, diagnosis is
usually certain.
The disease may resemble syphilis and possibly carcinoma.
Syphilis will respond quickh lo antisyphilitic treatment and
carcinoma is characterized by great pain. Small tumefactions
(it the arytenoid cartilage on the posterior wall of the larynx,
unilateral congestion of the vocal cords with hoarseness are
early signs of the disease, For the early detection of the dis-
ease, Glletsman recommends Dr. Van Ruck's watery extract
of tubercle bacilli. If there is no general reaction, there will
be observed locally an increase of hyperemia and a visible in-
ise in the siae of the infiltration and nodules.
|r,r the early detection of pulmonary tuberculosis and before
the bacillus is discovered. Rcmouchamps highly recommends a
method of laryngeal crepitus. The patient sits erect with the
mouth open, before the physician, whose right hand rests upon
(he patient's left shoulder and left thumb upon the patient's
chin. With the physician's ear two or three inches from the
patient'-, mouth, a small crepitation can be heard as though
directed from the larynx. The sound is compared to that of a
pin m r.itching the surface of fine paper. The sound is more
distinct during expiration than in inspiration.
i
55°
DISEASES OF EAR, NOSE AM) THROAT.
Prognosis. — Most pregnant women suffering from I:
tuberculosis " die during pregnancy or soon after." In laryn-
geal tuberculosis, provided the lung lesion is not too far ad-
ced and can be cured or brought to a standstill by climatic
conditions or local treatment, the progni favorable in
man} cases.
S. E. Solly says of the cases treated in Colorado: "Taking
the results in laryngeal cases without considering the ultimate
fate of the patient, there was permanent arrest oi the local
disease in uxty-four per cent., temporary arrest in five per cent.
additional eases in which latter the tissues again broke down
shortly before death. Looking at the ulcerated cases alone,
fifty per cent, healed permanently, ten per cent, tempo
Treatment. — The treatment is medical, forgical and radio-
thcrapeuticaJ.
The medical treatment is both general and local.
The general treatment is directed to securing the best h>-
gienic surroundings and preferably in a high and ide.
If such cases ran he confined to a sanitarium li.r the dire
ai the disease in the early Stages, prospects tor the relief of all
the symptoms and the arrest of the disc old be much more
favorable than ..theru ise.
According to Solly | fournal »r LaryagoJogfj June, 1904).
In cases of tubercle infiltration of the larynx without ulcerat
the best treatment is by submucous injection of about twentj
drops of a fifteen per cent, watery solution of lactic acid, pre-
ceded by the injection of cocain and adrenalin, the inje.
being somewhat painful, hut not extremely so. Solly alio
recommends Lugol's solution with an equal solution of alcohol
and glycerin painted lightly over the parts, tWO or three time*
weekly.
During the ulcerative stage of the disease and while the
pain is quite severe, Soil) recommends cocain izat ion oi thr
parts with a ten per cent, solution and touching W ith pure
lactic acid, as recommended by Kra
Gentle curettcment followed by the applies!
DISEASES OF THE LARYNX. 55 1
thirty per cent, solution lactic acid is highly recommended by
Heryng. For the relief of pain during ulceration, Solas Cohen
recommends the following to be insufflated into the larynx:
]* Orthoform, j M ^ gm (3 • >
Anesthcsin, •
Ext. suprarenale, 8.00 gm. (3 ii)
Iodoform!, aa 8.00 gm. (3 ii)
Frudenthal recommends as a local anesthesia the following
emulsion :
Menthol,
.90 gm.
(gr- xv )
01. amygdal. dulc,
15.00 c.c.
(3«)
Vitclli ovarim,
25.00 c.c.
(3 vij)
Orthoform,
12.50 gm.
(3 iij)
Aquae destill., q. s. ad.
100.00 c.c.
(3 Hj)
Emulsionis.
Fiat.
For the relief of cough, codeine sulphate may be given in
one-fourth grain doses and heroin in one-twelfth grain doses.
During the stage of infiltration, Gruenwald and Kronenberg
report favorable results from the application of the galvano-
cautery and insist that this form of treatment is far superior to
chemic agencies. Lockard, of Denver, reports favorable results
from the use of formalin in both the infiltrative and ulcerative
stages of the disease. According to Lockard, after local anes-
thesia by the application of cocain, the parts should be sprayed
with a one-half per cent, solution of formaldehyd, after which
the infiltrated and ulcerated surfaces should be scrubbed each
day with a solution of three to ten per cent, solution of for-
maldehyd according to the susceptibility of the individual.
In addition, the patient is instructed to spray the throat fre-
quently with a one-two-hundred-and-fiftieth solution of for-
malin.
The operative treatment for the cure of tuberculosis of the
larynx is somewhat limited and is especially indicated in tu-
berculous tumors and deep ulcerations of the epiglottis. When
pulmonic symptoms of the disease are well advanced, operative
55*
DISEASES OF EAR. NOSB AND THROAT.
procedures are contraindicatcd. Where the pulmonic symp;
are very mild, operative procedures for the relief ot stenosis
and the removal of tubercular tumors may be advised.
The operative procedures recommended by Lockard are a*
follows:
1. Division of the pOSterioi commissure in the median line,
under cocain anesthesia, with a pair of angular Scissor*. Rectal
feeding for one week, if necessary.
2. Division »r removal "f the epiglottis,
s. Tracheotomy.
4. Laryngo-fissure (for method tee LaTyogO-fJsaure in Car-
cinoma of the Larynx).
Grucnwald reports satisfactory results in the nodular form
of the disease by reflected sunlight. The rays of the sun are
directed into the throat with an ordinary mirror and again
reflected into the larynx by means of the laryngeal mirror.
With the X-ray, Finsen light, ultra-violet ray and actinic
light, results are indefinite.
Epiglottitis. — Epiglottitis maj be acute <>r chronic and is
visually associated with a like condition ot inflammation in the
surrounding tissue.
Etiology. — The disease is more often due to traumatism or
injury from thermic or chemic cause-.. Acute inflammatim
the epiglottis may result from injury in the use of the galvann-
eautery, in or about the larynx. The epiglottis i> frequently
involved in syphilis, tuberculosis, malignant and non-malignant
ills.
Symptomatology and Diagnosis. — 1 lu-n- is usually roc
less distress upon swallowing and pain in the region of the epi-
glottis. Upon inspection, the epiglottis is usuallj seen to be
hyperemia and the mucous membrane sometimes presents an
appearance of general hypertrophy.
The diagnosis is usuallj established with the laryngoscopic
mirror, under good illumination.
Treatment. — The local treatment is the sstOM as thai
acute or chfOBM lai\ ngil
DISEASES OF THE LARYNX. 553
The general treatment is directed to the relief of the consti-
tutional dyscrasia producing the disease.
Chondritis and Perichondritis. — Acute or chronic inflam-
mation of the larynx is usually secondary to an inflammation
of the mucous membrane.
Etiology. — The causes of chondritis or perichondritis are
usually syphilis, tuberculosis, diphtheria, rheumatism, scarlet
fever, typhoid fever, traumatism and exposure to cold. In-
fection from pathogenic organisms is usually a secondary con-
dition and follows a lowering of the metabolism of the car-
tilage and its covering, by the above enumerated causes.
Symptomatology. — There is usually painful swallowing, rise
of temperature and constipation, followed by swelling of the
cartilaginous framework and hyperemia of the mucous mem-
brane. The pain upon pressure over the larynx is usually very
great. The pain in acute perichondritis is usually quite severe
and is aggravated by eating, talking and drinking. Suppura-
tion and destruction of cartilage may take place and are de-
pendent upon the exciting cause of the disease.
In tertiary syphilis, tuberculosis and malignant tumors, there
is usually more or less destruction of the chondrium.
Treatment. — The treatment varies somewhat according to
the etiology of the disease. Cold externally is indicated early
in the disease by means of the Pressnitz bandage, ice bag or
Leiter coil. This is continued for forty-eight hours, after which
dry heat should be instituted. Calomel should be given in
one-half grain doses at bed-time, followed by a brisk saline
cathartic in the morning..
If syphilis, tuberculosis or rheumatism are exciting causes
of the disease, the constitutional treatment is as heretofore
outlined.
The local treatment consists in spraying the throat with
acetozone inhalent and frequently gargling with a warm, anti-
septic and alkaline solution. Steam antiseptic inhalations are fre-
quently very beneficial.
Fracture and Dislocation of the Larynx. — Etiology. —
554
DISEASES OF EAJt, NOSE AND THROAT.
Fracture and dislocation of the larynx may result from a blow,
hanging, gunshot wound ami contusion.
Symptomatology. — The conspicuous symptoms ire great pain
and swelling of the larynx, crepitation, dyspnea, oonyuk
coughing, bloody expectoration and difficult swallowing. Speech
is rendered very difficult or is entirely Lost Marked emphysema
may follow rupture of the mucous membrane. Instantane
death frequently follows dislocation.
Treatment. — The treatment is directed W the correction
of the displacement by passing the linger into the pharynx
making oontra-pressure.
The subsequent treatment is directed to the reduction oi
the swelling by hot. moist applications, rest in bed and rectal
feeding for a short time. If there is increasing dyspnea, trache-
otomy is indicated. Hemorrhage from the mucous membrane
may be controlled by touching the bleeding surface with sponge*
which have been moistened in a hot solution of adrenalin chlo-
rid, 1/5,000.
Non-Malignant Neoplasms of the Larynx. -
nialignant tumors of the larynx, as in an] other portion
body, have 00 tendency to spread by Oft and do nut
recur after complete removal. They are dangerous to
only in that they interfere with deglutition, respiration and
predispose the patient to constitutional disc;:-
Benign Dl in the order of their frequency are papil-
loma, fibroma, cystoma, myxoma, enchondroma, lipoma and
adenoma.
Etiology. — The causes of non-malignant neoplasms are more
often faulty metabolism from constitutional diseases, prolonged
irritation of the larynx from excessive use of the voice, chronic
inflammation, tobacco and alcoholic excesses. The affe> I
is more often observed in men in adult life.
Pathology. — I Sec Pat I Benign Tumors.)
Symptomatology. — The usual symptoms are
sation of a foreign body in the larynx anil symptoms l
chronic catarrhal inflammation. The en-
DISEASES OF THE
555
tircly lost, or may have a peculiar sound as of a foreign body
in the back of the throat. In exercise, stooping and certain
pations, die victim of a neoplasm in the larynx may suffer
from ilyspnr.i and difficult swallowing. Tn advanced cases, the
Pia 14-y.
iv I'll i iim-v in nil Laivnx, (After GrmtnvuU.)
tumor may suddenly completely close the larynx and produce
nation.
PAPILLOMA arc more often observed in young adults. The
tumor takes its origin from the papilla? of the mucosa and may
be single or multiple in number. The tumor is granulated or
Watt-like in appearance, of a pale pink color and is more often
situated on the rocal bands I Ft& 149).
The condition may be mistaken for tuberculosis or syphilis
oi the hn\ 11 \
FjiiRD.M.v is a connective-tissue tumor growth, presenting a
HDOOtb reddened surface. The tumor varies in size and usu-
ally possesses a broad base.
CYSTOMA may occur at any age. The tumor is BSUallj
pedunculated and may he intrinsic or extrinsic. The pedicle
of the extrinsic cystoma is sometimes very difficult to locate.
The tumor appears dark bluish in color and perfectly sym-
metrical. Large tumors of this character are usually extrinsic.
During examination, a large tumor of rhis character may de-
reive the examiner as to its exact origin.
Anv.io.mata may be sessile or pedunculated. The deep
55<S
DISEASES OF EAR. NOSE AND THROAT.
bluish discoloration and tendency to bleed will enable o
diagnose the condition.
MYXOMA usually occurs on the vocal bonds and may be
pedunculated or sessile. The diagnosis is usually by rt
of a small portion oi the growth and microscopical examination.
Enchondroma, or cartilaginous tumor, occurs in some por-
tion of the cartilage of the larynx. It is usually hard to the
touch and extremely slow in growth.
LIPOMA is usually a pedunculated tumor and in the i
Holts, described by Knight, the tumor was pedum (dated having
01 [gin "ii the rim of the glottis
Mi.
Lamraui Fo*cct*.
Adenoma is a tumor originating ui dilated glands.
cording to I Irayson, the location is more often in the epigh"
Generally speaking, non malignant tumors i in their
ih and can be differentiated from cube syphilis
and malignant diseases by these • ulcera-
tion ami systemic disturbano
ttnunt, — Broadly speaking, the treatment -lalig-
DISEASES OF THE LARYNX. 557
nant neoplasms is surgical and consists in their removal, per
via naturales, thyrotomy, tracheotomy and intubation.
Non-malignant growths of the larynx may be destroyed with
the galvano-cautery or chemical caustics. One objectionable
feature in regard to the use of the cautery in the larynx is the
tendency to acute edema. For the removal of papilloma, the
McKenzie cutting forceps (Fig. 150), McKenzie forceps for
evulsion and Schrotter-Turke cannula forceps are indicated.
The operation may be performed under twenty per cent, so-
lution of cocain anesthesia. Kirstine's autoscope may sometimes
be advantageously used for the removal of neoplasms. General
anesthesia is usually indicated in children. The anesthesia
should not be produced to a point of complete narcosis.
Cystoma of the larynx may sometimes be removed with the
snare or twisted from their pedicles.
Fibroma which can not be easily removed through the natural
channel, should be removed by laryngotomy and the same rule
is applicable to enchondroma, and angioma. On account of
the tendency to severe hemorrhage in the removal of the
angiomata, the external operation is usually preferable.
The after-treatment consists in cleansing the nose and throat
with Dobell's solution, followed by an oil spray consisting of
aristol, acetozone, camphor and menthol (see formula, p. 127).
Malignant Neoplasms of the Larynx. — Malignant neo-
plasms of the larynx are carcinoma and sarcoma, which are
classified by Krishaber as intrinsic and extrinsic.
According to De Santi, intrinsic tumors are those which arise
in connection with the vocal cords, ventricles and false vocal
cords, or may be immediately below the true vocal cords. The
term, extrinsic, may be applied to tumors which grow from the
epiglottis, ary-epiglottic folds and intra-arytenoid folds, etc.
According to Krishaber, lymphatics are not involved as long
as the tumor is intrinsic, but as soon as the tumor becomes
extrinsic, the lymphatics are quickly affected.
Etiology. — The etiology of malignant growths of the larynx
is still a matter of conjecture. The predisposing causes are
55S
DISEASES OF EAR. NOSE AND THROAT.
syphilis, cbronk ulceration, age, heredity and prolong i
tation of the htt>n\ t'roni sWcmu dlStUrbai and
alcoholic liquor.
Carcinoma is much more frequent than sarcoma. I
one hundred and three cases ol malignant disease cd the la.
Semon found three cases of sarcoma. Sarcoma, as "i |
portions of the body, occurs at an earlier aye than carcinoma.
According to statistics, carcinoma is mure frequently obsorvel
between the aires of fifty and sixty and sarcoma between rhr
ages of forty and fifty.
Pathology.- — (See Pathology of Malignant Growths. ) 'I Ik
most frequeni form of carcinoma of the larynx is die
theliomatous variety.' The other varieties are excetv
rare. " Spindle cell sarcoma is more frequently observed than
any other form,"
Symptomatology. — The first symptom of intrinsic carcinoma
is hoarseness, followed by pain. Hoarseness is likewise a ,
liminary symptom in sarcoma. The hoarseness in s.i
usually due to pressure, whereas, ui carcinoma, the cotid '■< '
more often d\ic to direct involvement of the true and false
vocal cords. The pain io carcinoma U mOTC intense t
of sarcoma. In both conditions, there is a sensation of fullness
in the throat and as the growth :.i m si/c, there is a
dysphagia and stenosis of the glottis causing d>spnra. The
pam til extrinsic carcinoma >s greatei than that of intrii
De Santi says that in some lttt< carcinoma, no
pain is experienced during the whole course ot the disease.
The pain is aggravated in atl tonus of malignant growths of
the larynx, by swallowing peaking. Pain radiating
the ear is a suggestive sign of malignant tumor of the larynx
Diagnosis, — On accoum ol its insidious nature, a malignant
tumnr is usuall) tar advanced before the physician is con-
sulted, and in consequence a distind pathological chan^
early detected by la nination.
Upon laTMiu'ii.scopic examination in carcinoma of the larynx
there may be detected a crater-like ulceration, a i roi»
DISEASES OF THE LARYNX. 559
or wart-like excrescence, a thick and circumscribed reddish
discoloration or a distinct, irregular tumor springing from some
portion of the larynx, more often on one of the vocal cords.
In the early stages of epithelioma of the vocal cords, the
cord is observed to be red and swollen with a tendency to in-'
crease in size, followed by ulceration and complete destruction.
A more or less distinct tumor is observed in sarcoma of the
larynx. Ulceration in sarcoma is not so manifest as in car-
cinoma. A smooth, irregular tumor, somewhat pale in color,
may lead to the first suspection of sarcoma.
Both sarcoma and carcinoma may resemble a non-malignant
tumor, syphilitic ulceration, syphilitic gummata, tubercular
infiltration or perichondritis.
A small section of the growth should be removed in all
cases of suspected neoplasm of the larynx and subjected to a
careful microscopical examination, for only by this method can
the character of the tumor be differentiated and active measures
instituted for its cure. In addition to the microscopical exami-
nation of the secretion of the tumor removed, John N. Mc-
Kenzie advocates laryngotomy for diagnostic purposes.
Prognosis. — In uncomplicated malignant growths of intrinsic
origin in which surgical measures are early instituted and the
growth entirely removed, the prognosis is favorable. In in-
volvement of the lymphatics, the prognosis is unfavorable. In
malignant, extrinsic tumors of the larynx, on account of the
blood and lymph supply, there is a great tendency to metastasis.
Treatment. — The treatment of both sarcoma and carcinoma
is more especially operative. Iodid of potassium should be
pushed to the limit for diagnostic purposes in all suspected
cases of tumor of the larynx. The steady progress of the
disease and the diagnosis of malignant neoplasms makes palliative
treatment a waste of time, and radical operative measures
imperative.
Dr. Ernesto Botella, of Madrid, in the consideration of the
actual status of the different methods employed in the treatment
of cancer of the larynx, gives the following report of results:
56o
DISEASES OF EAR, NOSE AND THROAT.
KtiJu-laryncral operational 5-7 per cent. loulted in death in»
the operation; 22.8 per cent, in recurred - per cart.
LaiyngDUmj gave 7-S per cent, deaths from the opera-
tion; 4.I.5 per cenr. recurrences; 26.4 per cent, cures; total
extirpation, 34 per cent, deaths from operation; 25.3 per ctaL
recurrence; o. per cent, cures. Hemilaryngectomy gave 1
cenr. deaths from operai 01 ■• ~, pes cent recurrence; u
cent, cures.
Since the death of Frederick die Noble, interlan-ngeal
tiom tor the removal of malignant growths have hern 1
lamented bj the operation of tfrj rota
■-. .1! of !
[que of which can be had from an} text-book on •
rj (Jacobson and Steward] Vol. II.).
The operation of thyrotonty is «s follows:
I In patient is placed upon the opcratinji table in a proof
position and anesthetized with chloroform. I ndci rigid anti-
scptii precautions .mil with the neck the iocs
made through the skin from the one in a median line
down bo near the stt ["he structures are separated down
ro the thyroid cartilage or trachea witl - and blunt end
of a scalpel. The blood-vessels are clamped and the ed
the wound separated with ■ retractor. After the insertion ot
the cannula, the blood-vessels should be ligated. The 1
is now m|m cntnrny and ■ " Halm's com.
d sponge cannula inserted " (De Santi). The operator
rum waits for a period of ten to twelve minutes, until the
sponge swells " from the absorption of the moisture and com
closes the trachea. Beginning at the cricoid cartilage,
the thyroid is split in lian line, .taken
lu.r mi injure the attachment of the epiglottis. Whew Che
cartilage rgone calcification, a strong pair 1
will be necessarj to split the cartilage.
In the method of Butlin, the thyroid cartilage* an
ind held apart by a ^ilk thread passed through the
Lartilane. " I: ire anesthetized with a tweffl
DISEASES OF THE LARYNX. 56 1
solution of cocain," to* prevent spasm of the larynx. Under
good illumination from a Killian lamp or head-mirror, the
larynx is explored and the tumor outlined. The growth should
be completely removed at least one-half inch into the normal
tissue, with a knife or scissors, preferably the scissors. After
the spouting blood-vessels are ligated and the wound thoroughly
dried, the thyroid cartilages are again brought together and
fixed in position with silk or silver sutures. The Hahn tube
is now removed, and according to De Santi, the edges of the
cutaneous wound are brought together and sutured, except at
the lower part, where the tube is inserted. This is left open
to enable blood and secretion to escape from the larynx and the
subcutaneous tissues. The wound is covered with iodoform
gauze, which should be frequently changed. The tendency to
constipation should be relieved with enema. Feeding is usually
through a tube or per rectum, for a few days. It is sometimes
possible for the patient to take liquid food or water with the
head turned far over to the opposite side from that operated
upon. As soon as the patient can do this successfully, all
liquid foods can be taken in this manner through a tube placed
in the angle of the mouth.
The local treatment consists in cleansing the throat and
region of the larynx with a cotton-tipped probe dipped in Do-
bell's solution, after which the wound is dusted with iodoform
or aristol. Exuberant granulations appearing during the
process of healing may be destroyed by touching with a strong
solution of nitrate of silver.
As a substitute for dry insufflation, the following may be
used in a spray, three times daily:
# Olive oil,
60.00 c.c. (fl. 3 i>)
Aristol,
12.00 gm. (grs. cc)
Dissolve and add
Acetoform,
.60 gm. (gr. x)
Camphor,
1.20 gm. (gr. xx )
Menthol,
i. 20 gm. (gr. xx )
Eucalyptol,
.72 c.c. (min. xii)
Albolene,
60.00 c.c. (fl. 3 ii)
Dissolve.
Signa.
37
CHAPTER XXXII.
DISEASES OF THE LARYNX (CONTINUED).— NEUROSIS OP
THE LARYNX.
NEUROSIS of the larynx is an incoordination of motion, due
to some trophic disturbance and is subdivided into two classes.
i. e., motion and sensation. Neurosis of motion is subdivided
into spasms of the laryngeal muscles, laryu
aphonia spastica, laryngeal chorea and laryngeal epilepsy and
paralysis.
Neurosis of sensation may be anesthesia, hyperesthesia and
paresthesia.
Laryngismus Stridulus. — Laryngismus stridulus or spasm
of the glottis is a spasmodic condition of the adductors of the
vocal cords and is more often observed in young ihildrcn.
Etiology. — The disease maj be due to tome oerroua derange-
ment, rachitis as observed of KasSOwitZ, expOStUC to cold J
predisposition to the disease, adenoids or enlarged tonsils.
Symptomatology. — The attack comes on suddenly during the
night without the prodromal symptoms of cold and inflamma-
tion as observed in croup. The spasm may be repeated dui
the day. The parent is usually awakened by the dry, .
like sounds made by the child in an effort at inspiration. The
child is observed to he tossing about the bed from the au-
and distress from difficult breathing. At the height of the
spasm and marked cyanosis, the symptoms suddenly pas* away
as the child takes a deep inspiration, without leaving any in-
flammatory symptoms,
Diagnosis. — The disease differs from croup in that there
is no exudation, swelling of the mucous membrane or inflam-
matory symptoms.
Prognosis. — There is a tendency for the attack to re«
DISEASES OF THE LARYNX. 563
intervals for a period of a week to a number of months. Death
seldom occurs from the disease. In very young children, the
disease sometimes terminates in general eclampsia or convulsions
(Gratzer).
Treatment. — The treatment is directed to the relief of the
spasm produced by an adduction of the vocal cords and consists
in the external application to the larynx and neck, of extreme
cold or heat.
Three drops of 1/1,000 solution of adrenalin chlorid, hypo-
dermatically, will sometimes relieve the spasm.
Other methods for the relief of the spasm are splashing cold
water in the face, patting the child on the back, forcible exten-
sion of the tongue and sneezing produced by the bearded end
of a quill passed into the nose, as recommended by Gratzer.
Prophylactic treatment consists in the administration of
somnos in from one-half to one teaspoonful doses, given four
times daily, or the following:
$ Tinct. belladonna;, .74 (gtt. xij)
Chloralis hydratis, 1.25 (gtt. xx)
Potassii bromidi, 3.90 (3 j)
Syr. pruni vir., 15.00 (3 ss)
Aq. men. pip., 90.00 (5 "j)
Signa. Teaspoonful every hour until relief from the spasm is
produced.
Prophylactic treatment is directed to the removal of adenoids
or enlarged tonsils that may be present and the correction of
any constitutional dyscrasia.
Aphonia Spastica or Spasm of the Tensor of the Vocal
Cords. — This is a condition in which the cords are, as de-
scribed by Gowers, brought together too forcibly.
The patient cannot speak at all, or the voice is found altered
and disappears after a few efforts at phonation. The condition
may come on suddenly in the middle of a sentence and the
speaker may be compelled to desist from further effort. The
patient may suffer pain in the larynx (Jurasz-Gravers). There
is no observable alteration in the vocal cords.
The treatment is directed to re>f oi per-
sonal hygiene and out-door exercise.
Laryngeal Chorea. — Laryngeal chorea is a condition of
lack of coordination of the glottis, characterized by a persistent,
(In. barking cough, which may continue during the day or only
at longer or shorter interval*. There is no hoarseness or per-
iblc change in ty of the voice. The condition oc-
curs more frequently in hysterical females. Upon examination
with the laryngoscope, the cords can be detected during the
beginning of the spasm, to suddenly close with great force.
The cords are again quickly and suddenly separated by an
expiratory effort, \\htch produces the characteristic barking
cough.
Treatment. — The treatment is directed to the buildup up
oi the system with tonics of strychnin, iron, quinin and BOM
pbosphid.
The negative pole of the galvanic current may lie applied
once daily over the larynx and the positive to the nape of the
neck.
Laryngeal Vertigo. — Laryngeal vertigo is a peculiar inco-
m dilution of movement of the vocal cords, producin :
of the glottis, followed by dizziness and loss of i
The attack is ushered in hv :i sudden irritation u\ the lai
and is followed by vertigo and unconsciousness lasting for a
few seconds. The art;i< \- ue on at different intr:
and continue over a number of montl
atment. — The treatment i^ directed t<> the building up "1
the general health, personal
If due to pressure, operative measures should be instituted.
Strychnia. I IS {jr., subcutaheouslj once daily, with the posi-
tive pole of the galvanic current over the course of the nerve.
i-. indicated in adults.
Paralysis of the Crico-thyroid. — There is an unevt
of one or both vocal cords which i< due to inability of rhr mil
to tilt or lower the posterior part of the arytenoid and
bring the cords tense.
DISEASES OF THE LARYNX.
5*5
ie came »» the disease is injury or disease of the superior
laryngeal nerve am! is more often due to the toxins of
diphtheria.
Symptomatology* — The symptoms are hoarseness, pain upon
prolonged use of the voice and as described by Cohen, a lack
of precision in phonatioa, a peculiar dissonant slide occasionally
occurring during conversation.
Treatment- — The treatment is directed to the removal of
the cause and if due to diphtheritic toxins, iodid of potassium
in small doses ami strychnin, one-sixtieth to one fifteenth of a
limes daily, are indicated.
Paralysis of the Thyroarytenoid Muscle. — There is a
partial loss of the voice due to the inability of the vocal cords to
approximate when one or both muscles are paralyzed {Fig.
151). The edges of the cords are concave. The inner fibers,
or internal tensor, are more often affected.
Fig. i jr.
HU.ATUAS. PaIAITSIJ Or HIE ISTtHHAL Til YtfU ARYTENOIDS. (After Knight.)
The cause is acute or chronic laryngitis, syphilis, tuberculosis,
injudicious use of the voice, neoplasms which have affect'
nerve by pressure, diphtheria or hysteria. The voice may be
partially or completely lost.
Treatment. — The treatment is rest of the voice, strychnia
internally and the correction of any constitutional dyscrasia.
Paralysis of the Lateral Crico-arytenoid Muscle (Bi-
lateral or Unilateral Adductor Paralysis). — In paralysis
of the lateral cricoarytenoid muscle, one or both cords being
affected, they are widely separated at their base.
566
DISEASES OF EAR. NOSF. AMD THROAT.
This condition is rarely met and is clue to hysteria and pelvic
disorder* in women. There is a sudden loss of function and
complete aphonia.
Treatment. — The treatment is directed to the resto
of the weakened nervous system and the- correction or nq pelvic
disorders. Static electricity, ur inm .nul -tmlmut, are usually
highly beneficial.
Paralysis of the Arytenoideus.— In paralyse} of the ary-
tenoidcus there is an inabilin to approximate the arytenoid
cartilages and posterioi ends ad the racal cords (Fig> isj).
The cause of the condition is traumatism, svplulis. local or
general tuberculosis, acute pharyngitis, ulceration, tumors be-
tween the cartilages and hystei a.
fat, IS2.
Dl nit \ky
night, i
There is a hoarseness and fatigue "i the voice upon effort*
at pliniiatii.ii. Upon examination, the triangle tunned by the
il cords at the arytenoid attachment is easily discernible
and diagnosed.
Treatment. — The treatment is directed to the removal of
the cause. Tonics and galvanism are usually indicated.
Complete Paralysis. — Etiology. — The cause may be organic
dlKaM of the hrain, the neoplasm pressing upon the laryngeal
nerve or the pneumogastru nerve after its ex be hrain.
aneurism of the right - i Ol innominate artery, aneurism
of the arch of the aorta, locomotor pararj - - and paralysis of the
insane, syphilis, injur) and degeneration of the nerve trunk.
DISEASES OP THE LARYNX.
567
The voice may be impaired, but not lost, in either unilateral or
bilateral paralysis.
Complete paralysis of the recurrent laryngeal nerve may be
detected upon laryngoscopy- examination, by the complete im-
mobility of the vocal cord at a position relatively midway be-
tween the pi .sit ion <>t phonation and deep inspiration.
Fie. 153.
Rccki EtacoHuui i'i»>i\Mi oh Pbohatcox. (After Knighi.)
In unilateral paralysis, the unaffected cord may be observed
approximating the middle line and sometimes crossing the
middle line, the unaffected arytenoid passing in front of *he
paralyzed. There is little loss of voice though dysphonia exists
1 Cohen).
In bilateral paralysis there is a plight dyspnea and nearly
complete aphonia (Fig. 153)-
The cause may be aneurism of the arch of aorta and enlarged
glands >>f the neck, typhoid fever and diphtheria.
1'uialysis of the right side may be due to aneurism of innomi-
nata or subclavian artery and pleuritic adhesion at the apex of
the I ungs.
I he central cause may be cerebral apoplexy, cerebral tumors,
cerebral abscess, embolism and syphilitic degeneration.
The paralysis is governed by the cause and duration of the
condition. If the condition has existed for some time and the
nerve cells have undergone degenerative change, the prognosis
infavorable. If due to local irritation and the cause is
amenable to treatment, the prognosis is favorable. If the ccn-
S6S
dim ssirs nr iar. nose and throat.
rral lesion is due to syphilis, results may be favorable under
antNyphilitic treatment.
Treatment. — The local and general treatment is sub''
and is directed to the removal of the anise. Surgical treat-
ment of cancer ot the esophagus or rumor of the neck pressing
upon the nerve, is early indicated.
Tic:. 154.
F'A«»l»tl5 nr TIIU [KTttMAl TllY»l> ABrtYKOlIM MTD IBIU1
Galvanism is indicated with the negative pole applied with
the McKenzie laryngeal electrode along the course of the nerve,
the positive pole to the nape of the neck. Strychnia should be
given internally in one-sixtieth to one-twentieth grain, three
times daily or one -fiftieth grain to one-turnnVth hypodcr-
matically.
Anesthesia of the Larynx. — Anesthesia of the larynx may
he partial or complete and Is a loss of sensation in the mucouc
membrane, sometimes extending to the epiglottis and trachea.
Etiology. — This condition may result from disease of the
superior laryngeal nerve, the roots of the vagus and degencra-
1 inn in the medulla (Gowers). The condition may result from
the absorption of the toxins of diphtheria, tuberculosis and
pathogenic bacteria. The affection i- sometimes observed as
an accompanying condition of ulceration of the larynx, hysteria
and chronic laryngitis.
Symptomatology and Diacno>is. — With a loss of sensation.
there is an absence of the faculty of reflex H, and in
DISEASES OF THE LARYNX. 569
consequence, foreign bodies may be sucked into the larynx and
trachea producing asphyxiation, septic pneumonia and some-
times death.
Treatment. — In diseases of the medulla, destruction of the
root of the vagus or the superior, recurrent laryngeal nerve
from ulceration, local or general treatment will have no effect.
As a sequela; to diphtheria, or general infection, alteratives,
tonics and faradism with the negative pole to the larynx, re-
sults are favorable.
Chronic catarrhal affections of the larynx should be treated
as described under that affection (see Chronic Laryngitis).
Hyperesthesia of the Larynx. — Hyperesthesia of the
larynx is a condition of hypersensitiveness of the laryngeal mu-
cous membrane.
Etiology. — Many individuals of a nervous temperament suf-
fer from a hyperesthesia of the larynx. Among the causes which
may be classed as both predisposing and exciting, are tuberculosis
of the lungs, syphilis, alcoholism, hysteria, acute or chronic
catarrhal inflammation, sometimes morbid growths of the
larynx, rheumatism, gastro-intestinal disorders, adenoids, en-
larged tonsils, pelvic diseases in women and irritation at the base
of the tongue.
Symptomatology and Diagnosis. — There is usually an annoy-
ing laryngeal cough, expectoration of mucus and at times hoarse-
ness. Pain and inflammation may be due to the catarrhal
cough and effort to dislodge minute accumulations of mucus.
The larynx may be unduly sensitive to irritating gases, atmos-
pheric changes, etc.
Treatment. — The constitutional treatment is subjective and
is directed to the relief of any of the above enumerated con-
tributing factors of the disease.
The local treatment is directed to the relief of any local
irritation by the application of a solution of nitrate of silver,
two to ten grains to the ounce. A Pressnitz bandage can be
worn advantageously for one-half hour daily. Cold plunge
57°
DISBASES OS EAR, NOSE AND THROAT.
baths or cold sponging of the neck and chest is especially
efficacious in the absence of the cold full hath.
Paresthesia of the Larynx. — Paresthesia is a perverted
nr abnormally sensitive condition of the laryngeal mucous
membrane.
Etiology. — The condition is more; freimentlj I ' \\:'-U
hysteria, insanity and highly nervous individuals, who D18J fa
injured the epithelium by some foreign body passing int«.
esophagus. The condition mny he due to a chronic irritation
ol contiguous parts.
Symptomatology and Diagnosis.— The patient frequently
complains of the prcMtice oi a foreign body in thi and
a smarting rod burning sensation, The patient nuq
history of having swallowed BOfflC foreign substance, which
seems to them to have lodged in the larynx, preventing free
phonation and irritation. Upon inspection little or r
tion of the larynx can he detected.
Treatment. — The treatment is directed to building up the
patient's general health and alleviation of the nen lirJOfl
bj the aiiminist ration of hyoscyamus, mm vomica, phosphate
of sine and quinin. The patient should be convinced by the
physician of the complete absence oi any foreign substance, an.i
fot this, a thorough exploration with the \ raj rod Uuryi
scopic mirror should be made. In addition to the above methods
oi exploration, the Kirstine autoscope may he used.
FOREIGN BODIES IN THE TRACHEA AND BRONCHUS.
AmONQ the man) foreign bodies which are sucked into the
trachea and bronchus are pins, small toys, shelled peanuts and
carpet nails. The right bronchus it more frequently affertol
on account of its more direct branching from the trachea.
Diagnosis. — There is usually more or less laryngeal Bpa80S|
COUgh and dyspnea accompanying the introduction of a foreign
body into the trachea or bronchus. The patient may become
cyanotic and die in a short time. By auscultation, one may
i ('times detect the presence of a foreign body by friction
caused by the movement of the body during inspiration and
expiration and by the altered respiration in one or both lungs.
With the ladiisMipc ur by radiography, metallic foreign bodies
can he located. The size of the body governs to a great extent
the respiratory movements of the lung, which can be detected
upon auscultation.
Prognosis. — Broncho-pneumonia, abscess, hemorrhage, tuber-
culosis or gangrene may follow lodgment of foreign bodies in
the bronchus. Unless the foreign body is quickly removed or
expelled, a guarded prognosis should be given. Foreign bodies
have been known to remain in the bronchus for years and after
disintegrating and loosening, be roughed out.
Successive accumulations of pus may take place which will
be expelled from time to time during a spasm of coughing.
Traumatic pneumonia is frequently one of the accompanying
Ptoms. Long pins which may have found lodgment, are
sometimes partially expelled in the act of coughing and can be
seen with the eye. I hey remain in view for only a short time.
when they are again sucked into the trachea, and expelled later.
Children are more prone to meet with this accident than
571
57-
DISEASES OF EAR, NOSE AND THROAT.
adults. The trite saying that while there is lite there is hope, is
quite true or foreign bodies in the trachea and bronchus. -Nj
lure, in the moment ot our despair, may loo 'he
foreign body with the consequent restoration of the child to
health.
Medical literature is replete with illustrations of forf
bodies in the lungs being coughed out after years.
Treatment. — The larynx should he carefully searched for
the presence oi a foreign body in a luspecbsd case 1>
in which the examination is painful or difficult on accoun
the Bpasm oi the pharynx and larynx, tin 'ould be ■
thetized with a four to ten per cent, solution of cocain, applied
with a sponge or cotton-tipped probe The larynx mrj U
amined with the laryngoscope OI knstine'.s aufcOBCOJM in adi
According to Chevalier Jackson, chloroform anesthesia makes
laryogoscop; quite easy in infants. Foreign bodies may some-
he located with the X-ray.
Explorative thyrotomy or tracheotomy is indicated in
where there i* great difficulty in the examinat ■
(see Thyrotomy and Tr;n h.otmm ). On ai count of the da
and difficulty of thyrotomy in poung children, !■
the more frequent operation.
Tin foreign hods ma\ be expelled I".
follow ihl With I run id hook 01 the
foreign substance may Mimi/tiriu.-s he extracted. If this is ac-
complished by thyrotomy, OI Splitting the two lateral hal\>
the cartilage, they should he closed with a cat-gut suture.
In tracheotomy, the wound should be covered with bichlori*!
gauze and allowed to heal bj granulation. It :ln-
cannot be removed following the tracheoto: mint of
the spasm of the larynx, a tube should lx- inserted.
On removal ol the tube tor cleansing, or effort to dkpenv
with it. S spasm of the larynx frequently occurs, demanding tt
quick reinsertion of the tube. The tube should not be allow*
to remain in the tn longer than absolutely necessary.
For the extraction of steel or partially steel foreign bodie
•FOREIGN BODIES IN TRACHEA AND BRONCHUS.
573
after tracheotomy, the Habb giant magnet may be used, as
suggested by Dr. de Roaldes.
Tracheotomy. — Tracheotomy may be indicated in the fol-
lowing cases: croup, diphtheria, foreign bodies in the larynx or
lower air passages, malignant or benign growths of the larynx,
edema of the larynx, fracture of the larynx, syphilitic and tu-
bercular ulceration and spasmodic closure of the larynx.
Fig. 155.
Laryngotomy in the Adult. (After Vcau.)
Vertical incision through crico-thyroid membrane. At its lower end a cross
incision divides the attachment of crico-thyroid ligaments.
The successful termination of the operation depends to a
great extent upon the disease and the early realization of the
indications for its performance. If performed for the relief
of membranous laryngitis in children under two years of age,
the case usually terminates fatally. If the dyspnea is very great
and venous congestion and edema of the lungs in consequence
have been allowed to become profound, accompanied with a
rapidly failing heart, tracheotomy will, as a rule, only hasten
death.
Site of Operation. — Two distinct regions for performing the
operation have given rise to the descriptive terms, high and low
operation.
574
DISr.ASHS OF FAR. nosh axd throat.
The high operation consists in opening the trachea above rhr
thyroid isthmus between the thyroid Ifld cricoid cartilage, in-
cluding in many cases, the cricoid cartilage and first ring ot thr
trachea.
The low operation consists in opening the trachea below the
isthmus, and on account of the greater room for exploration
and the prospect of larger opening into the trachea, n i
often indicated.
The severe venous hemorrhage which often complicatec thr
operation may be due to a plexus oi ram covering the anterior
Fie. i i(>.
! IH TIM la
Between Uie dotted line* lies the istlmiu* <>i tit.-
■ •. Small adventitious arteries may also cover the anterior
surface and cause considerable hemorrhage upon severance.
Mithod of Operation. — The head and neck arr stretched
over a small pillow so as to bring the trachea p
view. The instruments necessary are a small scalpel,
dissector, dissecting forceps, artery clamps, d 'Ik gut
ligature, tube and head mirror. Chloroform b usually indicated
for n
With the left hand of the operatoi steadying the trachea,
an incision sufficiently made through the fckin and
•FOREIGN BODIES IN TRACHEA AND RROVi HI S. 575
superficial fascia. Bleeding points should be at oner secured.
With a blunt retractor, the rings tA the cartilage, if in the
Operation, or the cricoid cartilage, if in the high, are cx-
ed. The white rings should be brought distinctly into view
before making puncture with the knife. The incision 01 the
cartilage should be in the median line. With the severance
of the cartilaginous ring, a distinct blowing and whistling sound
is produced. Previous to the insertion oi the cannula, the wound
should be cleansed of all mucus, blood or other debris, alter
which the cannula is inserted and held in position by ribbon
tape around the neck.
It is well to remember that as soon as the ring of the trachea
tvered, blood, it present, will be sucked into the trachea upon
inhalation and will be thrown out through the wound in great
force, and if infection is present, may expose the operator to
great danger. As a rule, the severance of two rings will be all
that is necessary.
The after-treatment consists in keeping the patient in an
even-tempered room with the atmosphere moistened with steam
from a boiling kettle, covering the opening of the cannula with
a veil of gauze. If the tube should become occluded with
mucus, it should be removed, cleansed and reinserted. The
tube should be disposed of as soon as possible.
If great pain is produced by feeding, a Jaque's catheter tan
be passed through the nose into the esophagus, end liquid food
taken in that way.
In children, after three or four days, the inner tube should
be removed, cleansed and reinserted it necessary. Should the
tube remain in the trachea for too long a time, there is great
danger, as a result of loss of the faculty of breathing naturally,
of the child becoming asphyxiate. I upon its removal.
The wound heals verj rapidly, n s rule, by granulation.
The parts should be brought into apposition hv strips rjl ad-
hesive plaster. Granulations which sometime* form about
the wound, may br removed with a Curette 01 BCieSOtS. The
child should he given a liquid .1 few days following
the operation.
5?8
is (■)[■ i \R. NOSI. .WD THROAT.
is that the operation can be performed in a light room, whereas.
9 itli the Kirstine lamp, a dark room is necessary. The opera-
tion can be done under cocain anesthesia in tlie adult. However,
in the majorin of cases, genera] chloroform i through
the " Rrophv inhaler" will be neo ta in any other
operation about the throat, the time tela ted shi Id be earl'
the morning before breakfast or late in tin- afternoon,
nip mid-da> meal has been Taken.
After anesthesia, the patient's head should be brought to
the edge of the tabic and hung tabic in the Rose po-
Thc bronchoscopes arc to be bad in | number of 1M
which make it possible to use for infants oi adults. The
bronchoscope is oiled with liquid vasclin and the head turned
I ightly to the side the bronchoscope being passed into the
opposite side of the mouth ai i I into the trachea with the
finger, n-- in intubation. The mouth and larynx should be
illuminated with the Kirstinc la ula lamp nuq
be substituted alter the tube IS passed ihl II. The
bronchoscope contains a small perforation at the >ug
ted bj Ingals, tor the passage of air from
m case the tube should pass into the bronchi. Where
there is a great accumulation of mm ic tube, it should
be removed wlr\\ a cotton-ripped) especially •
catOT. As SOOT as the foreign bod] is detected, it may be rr
moved with a different]] devised gral bii ii strument.
For eso] ipy the same technique is indicated. Til
is probablj rite most certain method for the location and
zation of foreign bodies in the eso ' trumeni may
also be used after the detection of ulcrrs. tumors and Stricture
phagu*.
INDEX.
Abscess of brain, 285
cerebellum, 285
extra-dural, 284
lingual tonsil, 528
mastoid, 249
peritonsillar, 518
retro-pharyngeal, 488
septum, 384
tonsil, 508
Acetezone, 130
Achscharumow, 217
Acoumeter, 117
Actinomycosis, otitis media in, 247
pharynx, 487
tonsils, $16, 487
Acustica crista, 35
macula;, 35
Acustico-facial ganglia, 4
Adams apple, 70
Adeno-carcinomata, 95
Adenoids, 65, 453
Adenomata of larynx, 556
nose, 363
Adhesions, mternasal, 376 •
Aditis ad antrum, 9
Adrenal secretions, 84
Adrenalin in hay fever, 358
Aids to hearing, 174
Air filter, 120
superheated, 146
Alt, 134
Ampullae, 4, 31
Amygdalae, 67
Anatomy of auricle, 18
cochlea, 32
ear,_ external, 18
internal, 29
middle, 7
Eustachian tube, 36
nose, 39
pharynx, 64
Andrews, 224
Anemia of labyrinth, 289
Anesthesia of larynx, 568
nose, 351
pharynx, 502
Anesthetic, local, 157
carbolic acid, menthol and cocain
in paracentesis, 226
general, 159
Angiomata, 98
larynx, 555
nose, 364
Anosmia of nose, 350
Antidote for cocain, 157
Antiseptic solutions, 123
Antrum of Highmore, 13
diseases of, 428
foreign bodies in, 440
Aphonia spastica, 565
Appolinaris, 500
Argonin, 167
Argyrol, 168
in acute otitis media, 231
catarrh of middle ear, 22 1
tubal catarrh, 249
Arytenoid cartilage, 17, 70
ridges, 17
Arytenoideus muscle, 73
Asthma, 356
Astringent solutions, 123
Astringents, 167
Atomizer, 118
Atrophy, 88
Attic of ear, irrigation of, 154
Auditory canal, external, 177
bony portions, 18
cartilaginous portion, 18
cholesteatoma of, 196
cilia of, 8
deficiency of secretion, 183
diseases of, 177, 183
disorders of secretion, 181
exostosis. 177
foreign bodies, 179
hyperostosis, 177
injuries of, 177
contusions, 176
gun-shot wounds, 176
incisions, 176
lacerations, 176
mycosis of, 194
Auditory nerve, 4
Aural suppositories, 171
Auricle, anatomy of, 18
burns of, 187
diseases of, 176
dermatitis combustionis, 187
congelation is, 186
erysipelatosa, 185
gangrenosa, 186
phlegmonosa, 185
traumatic, 184
eczema, 187
herpes, 194
hyperemia, 184
keloid, 177
lupus vulgaris, 190
perichondritis, 106
syphilis, acquired, 191
congenital, 192
embryology of, 11
injuries of, 177
tumors of, 178
Auscultation, 112
Autoscope, 108
Kirstine's, 557
Autoscopy, 109
Bacilli in inflammation, 78
579
5 So
IN'DEX.
Bacillus of diphtheria, 80
mallei. 484
bacteriology, 78
bach; 1 1.1 of eat exttt naf, 78
middle, 78
Eustachian tube, 78
mouth, 70
r, -g
teeth, 79
tonsils, 75
Hallciiecr, « 1
Baltengera swivel knife, 381
Hatha, colli, 167
general, 167
Turkish, 167
warm, !<•;■
ltauni, 137
• **7. 3°S
lling test. 1 IJ
Blrkctt, 481, 48*
Blood scrum, diffc 1 ■ ■:', 302
supply of ear, middle, 38
labyrinth. j$
larynx, 74
nasal cavity, 4;
nose, 4 j
pliarynx, 64
tonsils. 67
Bex imltifihnus, 381
IJonain. 158
if middle ear, 76, 38
waller, 347
1 1 1 . 333
rtoiciit
11 ouc heron, 109
lloniric. ij"
electrolytic, 144
in Eustachian tube, m
Freeman's front:il
hard-ruhher filifoim, u, an
nfhenr/idal. 1 53
rt. .m. in :m. gtarib of. \ _
iW «•■.*, 2*5
• 344
nroca, 23
r.rneik.icrt. 134. 324
Bronnei, 148
llronchoscopy. 576
Bronchus, foreign bodies in, 57:
Brown, Gardner, 1 1 }
' I 347
Buckley. 328
• '. 358
Bums of auricle. 187
-. chronic, iisso-ph.itviiseal. ±st
S7«
Caldwell Luc operation. 439
er, 204
Camphorox/tl. 239
■ ' . auditory, 177
ilraris, 32
rcimirnt. 3
Carbolic and. menthol ami •
|>aracen lean. 126
88
definition. 88
''Visions, Ql
Caries of temporal bone. 276
'• '"
columnar, dislocation of. 388
,.;, JO
ol .ternal, 18
labyi intb
Catarrh of D 1 aetata, a»9
■i.i in-, J14
Mian, 111
in-,. 1 tlotl ■ ll
sterilization of, 111
1 iiatioa of auliitm. maxillary.
, ethmoidal,
sphenoidal. 153
Cautery snare, 143
Cells, ethmoidal, alacaatea a( 404
frontal, diseases of, 390
of Hcnsen, 34
sphenoidal, diseases of. 420
'Hum, abscess of. *8$
■ < spinal fluid, differentiation of.
1 y of, 183
imparted, t8:
1 hi, iii, 343, 380
i hilbUin. 186
160
Utalt ex-
tern:'!
diagnosis, 147
symptomatology, 107
treat
mastoid, 374
middle ear, 274
tonsil. 518
Chotidfitu of lar>in, 553
Chondromata. 07
nose, 367
Chorda tympanic nerve, *6
$64
I externa .iiilis. — utr.
, '"7-
•late, embryo
468
514
I 376
to, 157
antidote for. 157
ea, anatomy, jj
embryology, 5
< ■xhlear ducts, embryology, a
Cole. 177
Colowa, 313
Constitutional treatment. 160
Corslet, 3*3
Cornil. 343
■Tgan of. 4. II
Crico-arj musvle.
73
l.ilri ..'iv B1USI Ir, Ja
Cricoid cartih.
-if ear. eslemal. 1*0
llhier, 274
■I , 131
: thyrogloamua durt. it
INDEX.
58l
Cystomata, 98
of larynx, 555
Czerny operation, 400
Day, 244
Deafmutism, 305
diagnosis, 305
etiology, 304
pathology, 304
prognosis, 304
treatment, 305
Deafness, 305
Deficiency 01 cerumen, 183
Deflection of septum, 349
Deformity of ear, 1 1
nose, 380
uvula, 504
Dieter, cells of, 34
Delamere, 46
Delaven, 317, 460
Dench, 149, 150
Depletion, 165
Dermatitis of auricle, 184
combustionis, 187
congelationis, 186
eczematoid, 309
erysipelatosa, 185 ,
gangrenosa, 186
phlegmonosa, 18s
De Roaldes, 573
De Santi, 561
De Vilbiss, 119
Diabetes, otitis media in, 246
Diaphoretics, 166
Dionisi, 137
Diphtheria, 404
bacillus of, 80
of ear, external, 201
intubation in, 511
in otitis media, 242
diagnosis, 242
treatment, 242
Disorders of secretion of external ear,
181
Dobell's solution,' 123
D'Onisio, 323
Doplir, 516
Douche, 132
Douglas, 57
Dry cold, 139
Ducts, cochlear, embryology, 2
Duel, 144
Dunbar, 343
Ear, anatomy, 18
attic of, irrigation, 154
diseases of (see external, middle
and internal ear), 177
life insurance examination in,
306
drum, 17s
examination, 100
external, anatomy of, 18
auditory canal, 18
bony portions, 18
cartilaginous portion, 18
cilia of, 18
cartilage, 18
diseases, 176
croup, 199
Ear, external, diphtheria, 201
furuncle, 197
otitis externa, circumscribed,
acute, 197
course, _ 198
diagnosis, 198
pathology, 197
symptomatol-
ogy, 198
treatment, 198
chronic, 199
treatment, 199
crouposa, 199
diagnosis, 109
symptomatology,
199
treatment, 199
diffusa, 200
course, 200
diagnosis, 200
symptomatology,
200
treatment, 200
diphtheritica, 201
course, 202
diagnosis, 202
treatment, 202
syphilis, 191
disorders of secretion, 181
embryology of, 1 1
foreign bodies, 199
glands, 118
membrana tympani, 20
muscles, 18
skin, 18
tumors, 178
internal, anatomy, 29
membranous portion, 30
osseous, 30
diseases, 289
auditory nerve, neurosis; 291
hyperaudition, 291
hyperesthesia acus-
tica, 291
parcusis, 292
paresis and paral-
ysis, 299
diagnosis, 300
symptomatol-
ogy, 299
treatment, 300
tinnitus aurium, 292
labyrinth, anemia, 289
diagnois, 289
etiology, 289
treatment, 289
hemorrhage into, 290
diagnosis, 290
prognosis, 290
treatment, 290
hyperemia, 289
diagnosis, 289
prognosis, 290
symptomatology, 289
treatment, 200
inflammation (otitis in-
terna), 294
diagnosis, 295
P'oirnosis, 295
symptomatology, 294
treatment, 295
S&2 INDEX.
in. Internal, syphilis oi labyrinth, S9<S In.
11 niriK'I>».
dtici
■i omatology. 2*0
p.ifholopy. 296
merit. »8o
prognosis, ^'>r
necrosis of ossicles, 37a
s> mplomatology, 296
treatment. 371
treatment, .•.;;
paralysis of facial nerve.
ii re's disease, jgo
373
diagnosis •'" 1
uiomatology, 391
rtiolouy. ayj
patholoiry, 374
prognosis
treatment, 291
osteosclerosis, 397
::iOSI3, 299
symptomatology.
etiology, 398
(inlliology, 298
a?3
treatment, 174
treatment, jqi)
i. 370
diagnosis •.
symptomatology, 37 1
rna (aae inflamma-
tion p( labyrinth), 294
panotitis, 395
treatment, 371
thrombosis of lateral si
•nni.-ilfilogy, 395
treatment, 1
rmHtynloity. 1
diagnosis, »fii
lymphatics gj
middle, anatomy, 7
symptomatol-
ogy. 381
blood supply. 38
benea, w, 38
treatment, sfl
■ hian tube, stricture
diseases, 303
of, 331
catarrh, chronic (hypertro-
otitis media, catarrhal, acute.
phic, a 16
209
eonrae, att
t 011 r »■
diagnosis, 316
etiology. -
diagnosis, 3 to
'logy, 309
pathology, soo
prognosis, a 14
■ iin.ilalnny,
prognosis, 310
314
imatolocy.
treatment, ti6
309
hypertrophic (sec chronic
treatment. 210
catarrh), a 16
oiiUs medio, purulent, acute.
complications. 270
337
abscess of brain and cer-
character
ebellum. 285
symptomatology, a8j
control Of pain
treatment, 385
'3'
absccvi, extradural. 384
courv
etiulujty, a84
. lomatology,
af4
diagnosis,
etiology, aaj
inflatinn 01 ,
treatment, 384
<!lr
caries and necrosis of.
temporal bone.
rrmsU'id compli-
,.276 .
cation
diagnosis, 177
prognosis. 378
pathology. 337
prognosis, ajo
symptomatology.
prophylaxis. 231
»?7
treatment. 379
um.
cholesteatoma of middle
and mastoid,
IBM, H »l kw
.."4 ,
33»
diagnosis, 37s
etiology. 275
rymplomatol
23*
treatment, 37$
treatment. 231
granulation* in middle
mica, sj«
car and mastoid.
adenoids in.
■•70
■J7
treatment. 370
color of pus
ngitls, 379
MS
djrtafona, 380
■lest n
purulent. 180
osaick-i
serous, 380
'3*
prognosis, *8o
diagnosis, 296
INDEX.
5S3
Kar, diseases of middle, otitis media,
eburnation in, 234
enlarged tonsils
in, 237
etiology, 233
extension of
suppuration
in, 234
membrana tym-
pani, 234
morbid anat-
omy in, 234
pathology, 233
perforation of
membrana
tympani, 234
prognosis, 236
symptomatol-
ogy, 234
treatment, 237
simple, acute, 222
course, 223
etiology, 222
pathology, 223
prognosis, 223
treatment, 224
suppuration in, 233, 237
tuberculosis, 240
diagnosis, 241
etiology, 240
primary form in children,
241
prognosis, 241
symptoirfatology, 24 1
toxins of bacilli in, 240
treatment, 241
tubercular bacilli in, 240
embryology, 7
mucous membrane, 29
muscles, 29
structure, 26
Ecchymosis of membrana tympani, 205
Eckstein, 134
Ectoderm, embryology, 1
Eczema of auricle, 187
Edema of larynx, 543
Electricity, subdivisions of, 141
high-frequency current, 220
X-Ray, 506
Electrolytic bougie, 144
Elongated uvula, 506
Embryology of antrum, 8
auricle, 1:
cleft palate, 14
cochlea, 2, 5
cochlear ducts, 2
ear, external, 11
internal, 1
middle, 7
ectoderm, 1
endoderm, 1
Eustachian tube, 16
labyrinth, membranous, 4
larynx, 17
membrana tympani, 9
mesoderm, 1
nasal pits, 12
nose, 11
olfactory pits, 13
oral fossa, 1 1
organ of Corti, 41
Embryology of ossicles, 9
otocyst, 2
perilymph, 5
pharynx, is
process globular is, 12
sacculz, 2
scala tympani, 6
vestibuli, 6
semicircular canals, 2
sensory cells, 3
septum, 12
sinuses, ethmoidal, 13
frontal, 13
maxillary, 13
sphenoidal, 13
throat, 11
tongue, 14
tonsils, facial, 16
pharyngeal, 16
turbinated bodies, 13
uvula, 14 _
vocal cords, 17
Emulsion of orthoform, 158
Enchondromata of larynx, 556
nose, 368
Endoderm, embryology of, 1
Epiglottis, 71
Epiglottitis, 552
Epistaxis, 346
Erysipelas of nose, 370
Ksophagoscopy, 576
Ethmoidal bodies, 13
cells, 52
diseases of, 404
embryology, 13
sinus, catheterization of, 153
Ethyl bromid, 160
Eucain, 157
Eustachian catheter, no
tube, anatomy, 36
application of bougie in, 221
definition, 221
diseases of, 247
catarrh, acute, 247
course, 247
diagnosis, 247
etiology, 247
prognosis, 247
symptomatology, 347
treatment, 248
chronic, 248
courses, 248
etiology, 248
pathology, 248
prognosis, 248
treatment, 249
ulceration of orifice, 249
electrolytic bougie in, 221
embryology, 8, 16 '
injuries. 204
medication, 222
mucous membrane, 8
stricture, 221
superheated air in, 221
treatment, 222
Examination of ear, method of, 100
nose, too
throat, 100
Exostosis of auditory canal, 177
auricle, 177
Extra-dural abscess, 284
5«4
INDEX.
I nerve, divisions, 25
57. 3«> .
paralyata of, 273
Ilii imn. 400
position, -.'i
I . uceti pillara ( i
1 laritaway
1 1 ml iiililit-i lilil'.niil bougie, IZ. XZI
I-rhlcisen. streptococcus of. 370
Hirtmnu. tSIi
Peneatra ovalla, 31
1*7
roiun !
Hay fever. 351
1 din in, 358
Hbromaia of larynx.
Head mirror, ica
nose, 364
Bearing, aid
Finsen, J41
appai 11 of, jim
1 i K li L , 145
11 1 nitali i" 1
treatment. 304
1
• ps, Kcrrlson lyinpanic. -•=,■>
1 1. -inc. J63
]''ijrci|{ti bodies, 199
■ | MB "1 Hh I1: 1. ill'. 44.1
ll« iati
llrUniortic. 133
auditory canal, 1 »g
Hemoglobin tc»t. Justua'. 478
bronchus, 571
Hemorrhage, 133. 'i6j, 164
external en
of labyrinth
frontal cell*, 406
nose. 346
nose, 348
Ilcnle, apTni 1
tr.uln.a, 571
1 It oaes, cell* of. 34
1 i.Ktine of larynx, 553
Herpi 1 94
nose, 376
_ pharynx. 401
niecottgBj i'i|
•ii, 389
1 r.inkel. _45?
Pi n iii;iiiV f iiiiil ,il h. ,■ |
High-frequency current. **o
ITigbntere, antrum of. 13
1 ) iL-r, |86, 184
dlteaaea,
Freutfentlial, 157, 380
Foreign bodies, 440
1 ■ 11 . It nberg, 159)
Holme
1 ■ d boogie, $s
unci, I j6
t*J Cells. 4.8
Horn
diseases of, 390
1 r . > 1 -
• bite-. 186
rbca. nasal. 337
furuncle of car. external. 197
1 1> peraudh
nose, 371
xmia, 8 j
Gallon vMstle, 118
( inn) " facial. 4
of auiielr, 184
drum af>i
iwllc, 4
.•89
i.H i
mc-iiili r.Liin ttnipani, wj
1. 100
Hyp 350
tic, 1 3 2
■
It test, 117
of larynx, 569
General am
pll.l :
bath, 367
Hypcrostnia, jao
.itory canal. 177
Gcrrang, 133
Icn of nose, 3j8
Hyperplasia. 87
pharynx. 483
.•1 lingual tonsil, $zy
dl d! IIiivumii, 44, 6z
Hypertrophy. X7
>i1 car, 118
• if lir.jrual tonsil. 453
nasal etxity. 42
pharyngeal ti
pharynx, 6$
■ infirm, 548
I scrum, 87
< llobe neb
Immunity. 16
Impacted cerumen. 1B1
rlottidcan |»ui hi
■ ■ ■ .
Impetigo contagiosa, 190
iwerai sfij
Incus, 8. 38
"'■• 4?7
Inflammation, 83
Grant, i iS
bacilli in. 78
"■13 in mastoid cell
InHji .94
middle ear, i] 1
In'! 1 «j
Crattcr. 563
treatment. 243
>". 35->. 4*7
Grafter, m. u j,
Ineal
Inlul M
litlll!.!
ilnunwald. S»a, 339, s$i
(iruncrt. jj8, J46
Insects in ear.
i-ial car. anatomy, n
Gumma of nose, 344
disejsrv 489
Hack, 35J
embryology, 4
lymphatics. 38
INDEX.
535
Internasal adhesions, 376
Intertympanic irrigation, 154
Intubation in diphtheria, 511
Inunctions, 166
Iritis in syphilis of nose, 328
Irrigation of attic of ear, 154
intertympanic, 154
Jackson, 244
Jansen. 437
J arisen s modification of Staclce's op-
eration, 263
Justus' hemoglobin test, 478
Kaplan, 358
Keene, 365
Keloid of auricle, 177
Kerrison tympanic forceps, 259
Killian, 458
nasal specula, 406
Kirstein, 109
Kirstein s autoscope, 557
Konig's rods, 118
Kretschmann, 263
Kreig, 379, 381
Krenenberg, 551
Kuhnt-Luc operation, 400
Kuster operation, 400, 438
Kyle, D. Braden, 317
Labyrinth, artery supply, 36
blood supply, 3$
diseases (see diseases of internal
ear), 289
divisions, 4
membranous portion, 31
osseous portion, 31
embryology, 4
Lamina cribrosa, 54
Langcnbeck, 366
operation, 367
Laryngeal chorea, 564
tuberculosis, 128
Laryngismus stridulus, 562
Laryngitis, acute catarrhal, 531
chronic catarrhal, 533
hypertrophic, 537
membranous, 541
sicca, 539
Laryngoscope, 107
Larynx, cartilage of, 70
blood supply of, 74
diseases of, 531
chondritis, 553
etiology, S53
symptomatology, 553
treatment, 553
dislocation, 553
edema, 545
diagnosis, 544
etiology, 543
pathology, 543
symptomatology, 543
treatment, 544
epiglottitis, 552
diagnosis, 552
etiology, 552
symptomatology, 552
treatment, 552
fracture, 553
etiology, 553
Larynx, diseases of, fracture symp-
tomatology, SS4
treatment, 554
hemorrhage, 390
laryngitis, catarrhal acute, 531
diagnosis, 531
etiology, 531
pathology, 531
prognosis, 532
symptomatology, 531
treatment, 532
catarrhal, chronic, 533
course, 535
etiology, 533
pathology, 534
prognosis, 535
symptomatology, 535
treatment, 53s
hypertrophic, 537
cause, 537
course, 538
diagnosis, 537
etiology, 537
prognosis, 538
symptomatology, 537
treatment, 538
membranous, 541
etiology, 541
pathology, S41
prognosis, 542
symptomatology, 542
treatment, 542
sicca, 539
diagnosis, 540
etiology, 539
prognosis, 540
symptomatology, 540
treatment, 540
neoplasms, malignant, 557
diagnosis, 558
etiology, 557
pathology, 558
prognosis, 559
symptomatology, 558
treatment, 559
non-malignant, 554
adenomata, 556
angiomata, 555
cystomata, 555
enchondromata, 556
fibromata, 555
lipomata, 556
myxomata, 556
papillomata, 555
etiology, 554
pathology, 554
symptomatology, 554
treatment, 556
neurosis, 562
anesthesia, 568
diagnosis, 568
etiology, 568
symptomatology, 568
treatment, 569
aphonia spastica (spasm of
tensor of vocal cords), S63
hyperesthesia, 569
diagnosis, 569
etiology, 569
symptomatology, 569
treatment, 569
586 IND17X.
Larynx, diseases of, neurosis, laryn-
- . 34>
geal churcji, j«i \
Llchwltt, 133
function, 564
insurance examination ir rat
vertigo, 564
■1. 1 • ■
treatment, 564
inula, 06
laryngismus stridulus, 5<Si
ol larynx. $s6
diactioais, 56a
etiology, 5fii
Lingual tonsils, abscesi of.
,
nosis, 56 a
itcuogjr, jfij
Local anesthetic. 157
ii 1 ■tan mi, tfia
l>:ir;iKii>. Mi adductor, bilat-
'■ 55 1
• -4-"
eral, 565
1 112. 330
unilateral, 565
jr> I uuuiilc- il3 sti(.
1 < . 4T0
" treatment, 566
. 116
Llipna of auricle, 100
erico-tliyri.i.l 1.1 ;
ti.-matology,"
nose, 341
pharynx, 4M:
treatment, 565
vulgaris, too
lateral lofd
ninsrle, 565
in-.it iivi-iu, 460
,. i r.iiij.lcl.-, .■ . e 1
r.uacka lonatl of («-c adm. ■■
Lymphatic* of ear. external.
1 1 -
ataeaet, cut 1
etiology, 50s
middle, 331
treatment, 568
thyroarytenoid muscle.
McJUtuie, 358, 559
Mi K«i Him, aj7
'
Mace wen, 351"
paresthesia. 570
M.I. III. 1 .;. II, |
diagnosis, etiology, 570
utriculi, 4
1 lomalology. 57 1
M.lkjll. JO|
treatment, 570
cerinff, 30 <
1 lacllJtn, 4R4
perichondi Iritis), 553
syphilis, S44
Mtlli tit, 8, »8
diagnosis, J4 4
1 i.sc. J7t
ilivrkiitiik, 54.)
Mat row, lyz. 334
primary lesion, 544
Mart in' t caddie, 37
ici ondarv Ii -.
tertiary lesion, 544
Maaeage, 13$
- in middle ear di«raar.
prognosis, 545
zio
iyroptomatology. 54-4
4S6
treatment, 54s
tuberculosis, 54b
Mastoid process, cliolcctcatoma of.
•3
diagnosis, 54a
etiology, pathology, 546
prognosis, 5 so
.Somatology, $43
1 .ilation* in, J71-1
injuries of, 30
liditia, acute, 149
treatment, Jjo
dislocation of, 553
hrynlnijy of, 17
1 ijntv ijl
l.i .11
.■;. 11, radii al
fracture of. 553
(unction of, 74
tecJininiic of, »5»
intubation In, )oi
primary. 240
mucous membrane. 73
, »ji
muacJee, 7:
HTCOI
! lasms. malignant, 554
symptomatology, a$o
non-maltsnanti hj
atty e supply of, 72
Ma J$a
1 conic, 73
1 iffiuibosi* of, 280
rhai j4
ionise. 1J4
>n, 400
-'5-4
>4
Lawrence. 366
'
1 J54
'"''
In-con, 350
1 ■• OMitia, agl
Maatill ■ 'ihryolocy 0
Left
'4'
IjeuWriuia. otitic media in. 147
Mr. ' iibc. nt
l-CUl«Tt. iJO
Membrana b
Levin, .-jy, 78
ti-nipani. anaton. .
INDEX.
5S7
injuries of, 203
in otitis of influenza, 229
Membrana tympani, color, 21
diseases, 205
ecchymosis, 205
hyperemia, 205
symptomatology, 205
treatment, 205
myringitis, acute, 206
diagnosis, 207
etiology, 206
prognosis, 206
symptomatology, 206
treatment, 207
chronic, 207
diagnosis, 208
prognosis, 208
symptomatology, 207
treatment, 208
division of, 21
embryology, 10
function of, 22
incision of, in acute mastoiditis,
251
of, 203
of influ
layers of, 21
perforation of, in chronic mid-
dle ear disease, 235
size of, 21
trichloracetic acid in perfora-
tion of, 233
vestibularis, 33
Meniere's disease, 290
Meningitis, 279
Mensel, 380
Menthoxal, 239
Mercury, preparation of, 169
Mesoderm, embryology of, 1
Meyer, 455
Middle ear, anatomy of, 7
blood supply of, 28
bones of, 26, 28
cholesteatoma of, 274
diseases of (see ear, middle),
,. 2°3
divisions, 7
granulations, 241
mucous membrane, 29
muscles, 29
stricture, 26
Moestig-Moorhof operation, 267
Moist cold, 139
Moore, 380
Morgagni, 73
Mucocele of the antrum of Highmore,
440
Mucous membrane of ear, middle, 29
Eustachian tube, 8
larynx, 73
pharynx, 65
Muller, 274
Muscle, artenoideus, 73
crico-arytenoideus lateralis, 72
posticus, 72
crico-thyroid, 29
of ear, external, 18
middle, 29
larynx, 72
stapedius, 9
Mycosis of external auditory canal,
194
lingual tonsil, 529
Myles' nasal cutting forceps, 418
specula, 104
Myringitis, acute, 206
chronic, 207
Myxomata, 96
of larynx, 556
nose, 360
Nadoleczny, 223
Narcosis, 160
Nasal cavity, blood vessels of, 45
divisions of, 42
epithelium of, 42
function of, 61
glands, 42
lymphatics of, 46
mucous membrane, 42
nerves of, 43, 45
olfactory nerve, region of, 43
vestibule of, 42
cutting forceps, 418
nerve, branches of, 45
function of, 45
location of, 45
pits, embryology of, 406
specula, Myles', 104
Pynchon's, 104
suppositories, 172
Naso-pliaryngeal catarrh, 128
Nasopharyngitis, acute, 446
chronic, 447
hypertrophica lateralis, 450
Naso-pharynx, diseases of, 446
Nebulizer, globe, 129
Necrosis of temporal bone, 276
ossicles, 272
Nerve, auditory, 4
chorda tympani, 26
facial, divisions, 25
paralysis, 274 ,
position, 25
olfactory, 43
nasal, 45
of nasal cavity, 43, 45
supply of larynx, 72
nose, 41
tonsils, 68
Neuralgia, 503
Neuromata, 98
Neurosis of auditory nerve, 291
larynx, 562
motion, 503
nose, 350
pharynx, 502
Newcomb, 325
Nose, anatomy of, 39
anterior nares, 39
attic of, 41
blood supply of, 43
deformity of, 372
diseases of, 309
congenital occlusion of nares,
,.377
diagnosis, 378
symptomatology, 377
treatment. 378
epistaxis (hemorrhage from
nose), 346
diagnosis, 346
symptomatology, 346
treatment, 347
5S8 i IV.
Nose, diseases of, erysipelas, 369 Note,
diseases of, non-maligr.ant ne«-
diagnosis 370
pathology, 370
symptomatology, 370
plaimt. oilinniai
aHfieata iH
,,logy. 3*8
t realm
treatment, .171
furuncle, 370
papfflwmat 1
diagnosis, 37a
etiology, 371
pathology, 371
symptomatology, 373
diagnosis, 36 a
etiology, 363
pathology, j6a
prognosis 36s
[|< ,:Illi<-nl
treatment, jbj
glanders, ■
■■•. 349
diagnosis. 34c
etiology, 339
pathology, 339
a, 35S
diagnosis, 3S7
'""logy, 356
pathology.
symptomatology, 358
prognosis 340
symptomatology, 340
treat
hemorrhage (set- epfataxh), 34;
1 neiit, 3$7
iiiti-rn.-isnl adhesions. 375
hay fever.
diagnosis
symptomatology, 367
3 S3
etc!
.'5 '
treatment, 3731
lupin 34a
diagnosis .11,1
etiolofy, 341
sy mptomatuiogy , 341
treatment, jjj
motor, 3J0
■ na .1 v. 350
treattn< nt, 34s
anesthesia, 35"
nasal hydrorrhea. 336
EMllftj .13:
anosmia. 350
urbane* of olfaction.
etiology, 357
pathology. 33?
35"
hyperesthesia, 351
liypetouiiia. 350
neoplasms, malignant, 368
paresthesia, 3S»
course, _369
parosmia, 3 So
■li.ij
prognosis, 300
etiology, 33'
j6p
.138
. non malignant, 350
rhinitis, acate, sot
ndenutnala, 31
diagnosis. 31 «
«04J
pathology, 309
diagnosis, 364
etiology, 36*
pathology. j6l
prognosis, 311
symptom) t<
t re at men t, 311
treatment, 364
. 363
diagnosis, 364
ii. ■',.. • ' .
atrophic. 333
etiology, 3*J
pathology, 3.13
symptomatology, 3 13
pathology, 364
treatment, 364
• li.unln.nuta, J67
Irratment. 334
diagnosis, 367
ilieritie, 3a*
iliagiioua, jat
pathology, 311
prtsfosaa, safl
• logy, 3*7
enrhondromata (see
ri.li.Moaia), jr.?
filiromala, 363
diagnosis.
' "logy, 365
treatment.
li|.OI!l..!.l. [,,..
(ijiIm ;
diagnosis
■
treatment, .\<.F
myxomaia (nasal poly] 1 >.
*.3Stt .
diagnons, 300
etUpocy, .jo
pathology, 359
• 3'S
dm. 1
etiology. 315
1 omatology. fit
360
treatment. 36*
treatment.
INDEX.
589
Xose, diseases of, rhinitis, simple
acute, 311
diagnosis, 313
etiology, 313
pathology, 313
symptomatology, 313
treatment, 314
simple chronic, 3 1 1
diagnosis, 313
etiology, 313
pathology, 313
symptomatology, 313
treatment, 314
specific, 327
gumma tumor, 334
diagnosis, 334
symptomatology,
334 . ,
syphilis, acquired, 333
diagnosis, 333
symptomatology,
333
treatment, 333
congenital, 328
course, 331
diagnosis, 329
prognosis, 331
symptomatology,
328
treatment, 331
tertiary, 331
diagnosis, 335
prognosis, 336
treatment, 336
rhinolyths, 347
diagnosis, 348
etiology, 348
pathology, 348
treatment, 348
rhino-scleroma, 342
diagnosis, 344
etiology, 343
pathology, 344
symptomatology, 344
treatment, 344
septum (see diseases of), 379
sinuses, accessory (see diseases
of), 390
syphilis (see specific rhinitis),
328,
iritis in, 329
tuberculosis, 343
diagnosis, etiology, 34 s
pathology, prognosis, 345
symptomatology, 34 s
treatment, 345
embryology, 11
examination, 100
foreign bodies, 348
diagnosis, 348
symptomatology, 348
treatment, 349 •
fracture of, 374
diagnosis, 374
etiology, 374
symptomatology, 374
treatment, 375
mucous membrane of, 41
nerve supply of, 41
septum of, 41
turbinated bodies of, 41
Nose, walls of, 41
Occlusion of nares, 368
O'Dwyer's intubation set, 501
Ogston-Luc operation, 400
Oil sprays, 126
Oleostcarate of zinc, 169
Olfaction, disturbances of, 350
Olfactory nerve, 43
divisions 01, 43
olfactory cells, 44
sustentacular cells, 44
pits, embryology of, 13
region, 43
Oilier, 365
Operations, Caldwell-Luc, 439
Czerny, 400
Hajek-Luc, 400
Jansen's modification of Stacke's,
263
Kuhnt-Luc, 400
Kuster, 400, 438
Langenbeck, 367
I.athrop, 399
Lawrence, 365, 367
mastoid, radical, 263
Moestig-Moorhof plastic, 267
Ogsten-Luc, 400
Panse, plastic, 361
for persistent retro-auricular open-
ing, 267
Stacke, 260
tonsils, removal of, 521
tracheotomy, 521
Troutmann, 269
turbinectomy, 317
turbinotomy, 321
Oral fossa, embryology of, 11
Organ of Corti, embryology of, 1 1
Oro-pharynx, diseases of, 463 -
Orthoform, 157
emulsion of, 158
Os planum, 54
Ossicles. 28
mobility of, 109
necrosis, 272
origin, 8
Osteomata, 98
of nose, 367
Osteosclerosis of labyrinth, 297
mastoid, 255
middle ear, 297
Otic vesicle, 2
Otitis externa, circumscribed, acute,
, '97.
chronic, 199
crouposa, 199
diffusa, 200
diphtheritica, 201
interna, 294
media, catarrhal, acute, 209
in general diseases, 241
actinomycosis, 247
diabetes, 246
diphtheria, 242
diagnosis, 242
treatment, 242
influenza, 243
treatment, 243
leukemia, 247
measles, 242
59°
INDEX.
Otitis media. In general diseases,
per.
acutsr, i(<7
am tnia, ;
\ hronic, 468
pllt'llllii'inia, 3.J5
, 47$
• 476
treatment, 24s
scarlei Fever, 144
membranoug, 494
syphilis. 246
phli 471
treatmniti ?4*>
lunatic, 464
tuberculosis), 244
■Jon
■ iinenl, 345
ulcerosa, jr:
typhoid li"'
PharynfomycoaSa, 489
Phai | na anatomy of. ' 1
symptomatology.
2+4
trcaliiirnl, 344
ii! 1 supply ■>(. 64
punilcnt.i acute, UJ
diseases of, 446
■••nic, jj.i
It * I'll-. --."
■ • :esl, 48K
r^iuptomntoloitT, 4B8
Otoeyst, embryology,- a
( »l.l!l>> l-UM .
COP*. Sleglc' .
treatment. 4I8
1, 404
487
pathology. 487
symptomatology, 487
treatment. 48ft
' ■ BM, 337
Pilate retractor. 105
Panotitis, 105
M plastic operation, ifio,
adenoid growths (ftM hypcr-
trophy of pharyngeal
r.<l>illu<iiflta, 99
of larynx. 55s
1. in. ii... chronic, nawvpli ■
Real (Thornwaldt's
disease), 451
noM
Parai 1- nt*« . ng
carbolic Mia, menthol and •:<
>coin
in, 2*6
picparatiort for, sjyfl
etiology. 4)1
pathology. 451
Paraffin [in 1 ••.. jyj
Parallels of arytenoldcua, 566
treatment
auditory nerve.
■■ - :d idductoi
1I11.I1I
' • 494
ctieo-lli) roi'l, 51. |
diagnosis. 498
etiology, 405
faii.i
larynx, 566
intubation. 501
lateral cr teo-sry tcnoidc 113
495
proa
S^-t
1 rtOtd MUSCICj 564
sj mptomalology. 406
unilateral adductor, 565'
499
Parenchymatous amyilgalilis. 508
glanders, 483
diagnosis, 484
ctioWy. 48.1
Paresis of auditory nerve, .
i ■ m •■'<■ -i 1 of larynx,
no»e. 351
pharym
Parka, 499
: T»malology, 48.J
Parens*!*, 293
trcatam m. 484
Para ■ a, .149
M.ipi-5. 401
les, 78
491
iment. 49*
livjicrlmpliy o( pharyngea
inin, 11
ails (aden
■
diagnosis, 450
tumor*. Ry
ctiolop'. 45J
pathology. 454
prognosis, 457
pbigut, 402
I'erfu septum. 3R5
Perichondritis of Bin
■ S$3
lupus,
!'<■! Iliciriir
in.
diagnosis, 481
481
pathology.
•loay. 4R2
Perai l< il retro-auricular opening.
''■:
ires'
1 'li ir jfngitis, .11 i:l«-. 463
iiaso-phsryngitiv scute, «4-i
stroptni
1 -X, 464
diagnosis. 44 •
etiology. pathology. 446
diabetic. 4TQ
symptomatology. 44(1
i • laioaa, 17-
treatment.
INDEX.
591
Pharynx, diseases of, nasopharyngitis,
chronic, 447
diagnosis, 44S
etiology, 447
pathology, 448
symptomatology, 448
treatment, 449
hypertrophic lateralis, 450
etiology, pathology, 450
symptomatology, 450
treatment, 450
neurosis, 502
anesthesia, 502
hyperesthesia, 502
neuralgia, 503
neurosis 01 motion, 503
paresthesia, 503
spasm, 503
diagnosis, 490
etiology, 489
treatment, 490
pemphigus, 492
pharyngitis, acute, 463
etiology, 463
pathology, 463
symptomatology, 463
treatment, 463
atrophic, 469
etiology, 469
pathology, 470
symptomatology, 470
treatment, 470
chronic, 464
diagnosis, 466
etfology, 464
pathology, 465
prognosis, 466
symptomatology, 465
treatment, 466
diabetic, 479
symptomatology, 479
treatment, 479
erysipelatous, 472
course, 474
diagnosis, 473
etiology, 473
pathology, 473
prognosis, 474
symptomatology, 473
treatment, 474
follicular, acute, 467
diagnosis, 467
etiology, 467
pathology, 467
treatment, 468
follicular, chronic, 468
diagnosis, 468
etiology, 468
pathology, 468
symptomatology, 468
treatment, 469
gangrenous, 475
diagnosis, 476
etiology, 475
pathology, 476
symptomatology, 476
treatment, 476
hemorrhagic, 476
diagnosis, 476
etiology, 476
pathology, 476
l'liarynx, diseases of, hemorrhagic
pharyngitis, symp-
tomatology, 476
treatment, 477
membranous, 463
etiology, 463
pathology, 463
symptomatology, 463
treatment, 463
phlegmonous, acute infec-
tious, 471
diagnosis, 471
etiology, 471
pathology, 471
symptomatology, 471
treatment, 472
sicca (see atrophic pharyn-
gitis), 469
ulcerosa, 477
course, 477
diagnosis, 477
etiologyj 477
prognosis, 477
treatment, 478
pharyngomycosis, 489
diagnosis, 493
etiology, 492
pathology, 492
prognosis, 493
symptomatology, 492
treatment, 493
scarlatina anginosa, 474
diagnosis, 474
treatment, 475
syphilis, 484
diagnosis, 486
primary, 484
secondary, 484 •
symptomatology, 485
tertiary, 485
treatment, 487
tuberculosis, 479
diagnosis, 480
pathology, 479
prognosis, 480
symptomatology, 479
treatment, 480
urticaria, 490
diagnosis, 491
etiology, pathology, 490
prognosis, 491
symptomatology, 490
treatment, 491
divisions, 65
embryology, 15
fossa: of, 65
function of, 64
glands of, 65
mucous membrane of, 65
spasm of, 108
Phlyctenular keratitis in syphilis of
nose, 329
Pierce, 5 18
Pillars of fauces, 66
Pituitary membrane, 42
Plastic operation of Moestig-Moorhof,
267
Panse, 260, 263
Plicotomy, 220
Pneumonia, otitis media in, 245
Pneumococcus, 230
592 INDEX.
Pol i r, -»ri
Septum <lf : ■••
i r hae. 1 1 1
diai .*- ■■•. 1 7>
abucr'
r.iii.ic in in h.iv i. i ■ i . jj4
Polypi of nidoh eai . jo,
1 1<"«-, 3S9
Pontic*, isfl
r..-i operative, ireai i
deflection, jyo
1'iicillici-. c«o
i ' i - 1 36
I'ti; i
Pritcbard, -«04
. 3*6
I'rcm-s tlnlnil.-ir'- i-:iilfi v.iliigy t>f, 12
Protaxwf,
spui ■
.1*7
• ■ 1 ioi 1
patli J
JR7
Pi •iiil.t-Kniisriia
I'yin-iimi, gaj
li.idiiim. 144
Ircuii
1I1 , ■
Randolph. 317, 224
Rrinhart. 263
Reissnei's membrane, 3j
t»5
pathnlo
Kctrn-nharynaeal abscess. 488
Reynolds. 318
Rheumatic pharyngitis. 128
1 1 c .1 1 ■ 1
Rhinitis, acute, 308
dl»l" ''ar cadi
atrophic, .t-'i
l.-||I< of, 1
diphtheritic, 3»s
fibrinous, ,124
ciiilu ok>i if. ix
hypertrophic. 314
Simpli: ihrcin:,:, JI4
fracture of. 389
Sliafcr, jiij
specific, gaj
Shirley. 4^7
RhtnoltrJia, 347
Siebi 11
Rhino-SClfifOaa of nunc, ,ii_>
Rinne teal
'■. Irtotl "1"
Roy, 45s
Rudolph, 227
in tubal catai rl .
• J*o
lena of. **
Siecule, embryology of. ■
ethmoidal ccll«. .
Sbjous, 84
bulla rthtnoidali*. $i
: l$J
uvula scissors.
Sal ammoniac in tuba] catarrh. 249
1
• -»4 7
chronic, 248
diagnosis. 4>vs
Salpingoscopy, 106
rtloJojty. 4m
Santorini) 1
pathology. «<m
Sftlt "1" 1 ilrlillitillll Hi .
rroirni>«(». 4 "4
division?.
celled, q 1
celled, at
|0|
1 celled, ui
inflammation, chronic.
spindle celled, 91
«' f
Sola tympani. .12
of. 6
eours*. 400
diagnosis.
vestibuli, u
pathology. 407
it in a angiosa, 474
Scarlet feva la otitis molls, 242
procnosi-
snnp4QBi4tolo|{y.
Rchadc, soj
408
•■iderian incniliranc, 43
treat mem, 4»o
Schultxe, 771
4 17
Scbwabaeb test, 117
.V-ITCC, 163
Secretions, adrenal. 84
■ nee ••(. in auditory canal, 183
disorder* of. in auditory ...n.iJ, 181
ir, 181
on of, 4«e
1
etiolour. 4I"
aartaiitiaj, in
symptomatology.
Semicircular canals, membranous, em-
9J
osseous, embryology of, jj, 35
Sensory cells, embryology of, 3
410
INDEX.
593
Sinuses, accessory, divisions of, suppu-
ration of ethmoiditis in ethmoid
cells, treatment, 413
syphilis of, 419
diagnosis, 419
symptomatology,
419
treatment, 419
frontal cells, 48, 371
catheterization of, 151
empyema, latent (see
chronic purulent in-
flammation), 396
foreign bodies in, 402
diagnosis, 403
symptomatology, 403
treatment, 403
fracture of outer plate,
403
treatment, 403
inflammation, catarrhal
acute, 389
diagnosis, 391
etiology, 390
pathology, 390
symptomatol-
ogy, 391
treatment, 391
catarrhal, chronic,
3?2
etiology, 392
pathology, 392
treatment, 392
purulent acute, 393
course, 395
diagnosis, 395
etiology, 393
pathology, 394
prognosis, 395
symptomatol-
ogy, 394
treatment, 395
purulent, chronic
(latent em-
pyema), 396
diagnosis, 398
etiology, 396
symptomatol-
ogy, 397
treatment, 398
ostium frontale, 52
tumors, 403
treatment, 404
Highmore, antrum of (see
maxillary antrum), 152
maxillary antrum (antrum of
Highmore), 427, 48, 57
foreign bodies in, 440
inflammation, catarrhal
acute, 428
diagnosis, 428
etiology, 428
symptomatol-
ogy, 428
treatment, 429
catarrhal chronic, 429
diagnosis, 430
etiology, 429
pathology, 432
symptomatol-
ogy. 430
Sinuses, accessory, divisions of, chronic
catarrhal inflammation of, treat-
ment, 430
purulent, 432
diagnosis, 433
etiology, 432
pathology, 532
prognosis, 433
symptomatology,
43 >
treatment, 433
purulent chronic, 433
diagnosis, 434
pathology, 434
prognosis, 435
symptomatol-
ogy, 434
treatment, 43 s
mucocele, 440
diagnosis, 440
etiology, 440
symptomatology, 440
treatment, 440
ostium maxillare, 59
tumors, 440
diagnosis, 441
treatment, 441
sphenoidal cells, 48, 153 _
air cells of sphenoidal
bone, S7
catheterization of, 153
empyema, acute, 521
course, 424
diagnosis, 423
etiology, 422
pathology, 422
prognosis, 423
symptomatology, 423
treatment, 424
chronic, 423
course, _ 425
diagnosis, 424
etiology, 423
pathology, 423
prognosis, 425
symptomatol-
ogy, 424
treatment, 425
ostium sphenoidal is, 5 7
sphenoiditis, catar-
rhal, 420
diagnosis, 420
etiology, 420
pathology, 420
treatment, 420
embryology of, 13
functions of, 48, 61
lateral, accidental opening of, 262
thrombosis of, 280
Smelling salts, 172
Smith, 133, 364
Snow, 412
Solly,_ 550
Solutions, alkaline, 124
antiseptic, 123
astringent, 125, 123
Dobell's 123
fluid, in middle ear catarrh, 219
oil, 126, 128, 129, 130
in middle ear catarrh, 219
Seller's, 124
594 INDEX.
1 • . 'I..I
Thyr.i hyoid lit? 1
tensor i.l vocaJ i>n 'I*, 56s
1 hyi 1 , 711
Spbc del In m lit v., 1 \,
1, Doulonrecu 41*
boigmi i$3
:ius aurium.
Cell* ss
Torn''
diseases of. 420
embryology of, 14
embryology of, 13
Tonvi' . j»8
sinuses. ■ Hon ot, 1 JJ
chronic, it*
Sphciio-iialHiinc artery, 45
-Spine of llenlc. aa
cryptic, 508
BOUty._$l4
herpetic, 510
Splint, Cobb's, 375
Spongitieation of labyrinth, 397
lacunar, jo8
Spray, oil, 13&
mtmbraflona, 514
• on septum. 164
rheumatic 514
-'■.. faiifjil, blood rupply, 67
Stack*
operation. 260
■ li«ra*e« 01, 508
Janecn's modi lie ation of. J63
abscess, peritonsillar (qum-
Stapedectomy, 2x2
l««
Stapedius muscle, 29
course. s»9
nen 1 , >(
diagnosis 519
Stapes, <i< 18
Stein, mo
etiology. s«>
"•'"By, 5'*
Stimulation of throat, ijq
prognosis, ;t 9
I 1. , |||
cymptcnnaintOgT, $19
Strcplcir<n CO! of !'• Ml
actifl ii6
Stricture of ear. midill*
diagnosis.
1
Eustachian tab*
Superlie.iteil air, 14a
in middle ear, an
treatmctii
SuppuntiOTi of mlddla car. sjj, aj?
Syphilis of am Iclc, mi. i<)j
cholcfctcatOMUtj si*
ctiolop-. S'o
pathology, si 8
labyrinth, 596
larynx. 544
symptomatolosor. 518
nose, j»8
treatment
iritis in, j.'ij
phlyctenular keratitis in, 3*9
tonal yB
course, s'o
otitis media in, 246
togy. $08
. $08
I'liMiynx, 484
prognosis.
toroatology. sot)
l-'I'i-l. 1*7
Temporal bone. Wood supply of, 24
treatment. 510
curies of. j;6
chroi
fracture of. 301
course, JIJ
diagnovi-.,
diagnosis. 513
liocr, >u
pathology, 513
prognosis. 5'*
prognosis, joj
•M:il!nrnl, 3''2
inner lurfao
mastoid process. 23
treatment. 513
necrosis of. 17*.
gout' 'nail* ton-
sillitis). J<4
ntrve supply. 14
tquamo-nutatoid suture, 21
herpetic. Jt6
Spine or llenlc, U
treatment. 516
gjrfomatic process of, u
membranous
Tensor tympam muscle, 19
treatment, $14
1..'. King, 117
rheumatic. 514
GtPe, 117
of hearing, tuning fork, 115
diagnosis. PS
'•-'gr. IM
watch, 114
symptomatology. 515
whisocr, 111
Justus' Hemoglobin, 478
treairoent.
embryology of. 16, 67
Thermic agents, 138
f. 68
Thiosinaranin. Ml
if, 68
Thompson, 337
ply of. 68
1 OCT, at 2
Thornwaldfa disease, 451, 448
1
discuses Of. S»6
1. bryology of. 1 1
examination 0?
diacnosis. $28
'
pathology, \n
. ■ iniitology. §48
10-nrytefioidriK externa,
Thyro glowus duel. I|
treatment, 5*9
hyperplasia, jjj
INDEX.
595
Tonsils, lingual, hyperplasia, diag-
nosis, 527
etiology, pathology, 527
symptomatology, 527
treatment, 527
. pertrophy
'sia), 527
hypertrophy (sec hyperpla-
inflammation, acute, 526
etiology, 526
pathology, 526
treatment, 526
lingual varix, 529
diagnosis, 530
etiology, 529
pathology, 529
symptomatology, 529
treatment, 530
mycosis (see mycosis of
pharynx), 529
operation for removal of, 521
pharyngeal, embryology of, 16, 67
hypertrophy of, 453
Trachea and bronchus, foreign bodies
in, 517
diagnosis, 571
prognosis, 571
treatment, 571
Tracheotomy, 573
site of, 573
method of, 573
Trautmann, 269
Trichloracetic acid, 233, 240
Tuberculosis, of ear, middle, 240
laryngeal, 128
larynx, 546
nose, 343
pharynx, 479
Tubcrculum impar, 14
Tumors, anotinic genetic, 89
of auricle, 177
division, 89
etiology, 89
of ear, external, 178
malignant, 88,. 90
carcinoma, 93
adeno-carcinoma. 93
cylindrical celled, 93, 94
flat celled, 93, 94
glandular, 95
solidum, 93
sarcoma, 90
non-malignant, 95, 96
angiomata, 99
chondromata, 97
cystomata, 98
fibromata, 96
lipomata, 96
myxomata, 96
neuromata, 98
ostcomata, 98
Sapillomata, 99
bodies, 54
anatomy of, 41
embryology of, 13
meatuses of, 41
Turbinectomy, 317
indication, 318
method, 319
Turbinotomy, 321
Turkish bath, 167
Turner, 399
Tympanic cavity, embryology, 7
forceps, Kerrison's, 259
Typhoid fever, otitis media in, 243
Ulceration of larynx, 54s, 546
pharyngeal orifice of Eustachian
tube, 249
cause, 249
treatment, 249
pharynx, 477
septum, 385
tonsil, 509
uvula, s°5
I'rbantschitsch, 139
Urticaria, 490
Uvula, deformity of, 504
diseases of, 504
uvulitis, acute, 504
etiology, 504
pathology, 504
symptomatology, 505
treatment, 505
elongation of, 506
symptomatology, 506
treatment, 506
ulceration of, 505
diagnosis, 505
etiology, 505
symptomatology, 505
treatment, 506
embryology, 1 4
scissors, Sajou s, 506
Uvulitis, acute, 504
Vaijor, 150
• in middle car catarrh, 218
Ventricular bands, 73
Vertigo, laryngeal, 567
Vocal cords, anatomy of, 73
embryology, 17
nerve supply, 74
Voice, 74
Vomiting, 163
Waldyer's lymphoid ring, 65
Warm baths, 167
Warren, 339, 473
Watch test, 1 14
Weber, 133
test, 115
Weir's platinum bridge, 374
Whisper test, 113
Whistle, Galton, 118
White, 369, 381
Whiting, 257, 260
Woakes, 322, 258
Wolf, 113
Wolkowitsch, 342
Wright, 517
Wrisbcrg, cartilage of, 71
X-Ray, 506
Zona ossia, 32
membranacea, 32
Zuckerkandl, 57
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