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Uniform in Style and Binding with Kyle's "Ear, Nose and Throat." 


By J. F. BIKNIE, A.M., CM. (Aberdeen) 

MP /-/Surgery, /.,.■ .•.*<■ Amrricm* 

SMtgtemi Aitmiittien 


Willi 567 Illustration*, I mmilicr being colored. I2mo; x -f- 655 pages. 
Full Morocco, Gill Edges and Round Corners. Ktt S3. 00, 


B\ A. E. THAYER, M.D. 

Hrtftiurr o; : , 'livrrjiiytj lt.1.11 ; /"• mtrly Amsl.inl IklIi utile in .' ., 

*fy..Corrnit MeiitcaJ S c ktwii 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. 



iMr Chief Httidtnl Pkjrttrtam, /!.-: 

■ [ON 


Aiiiifiin/ Dmumttiqriti, Phllaitiphia ttotfilal; AttiHant Drrmaielogitt, 


; 785 [»gex. l-'ull Morocco. Gill Edges and Round Corners, Net £2.50, 



/.•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*, 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 h um r mn tt ••"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. 






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 




Copyright, 1906, by P. Blakiston's Son & Co. 

run or 

Tiff In Era Pmame Commit, 
Lakastm. Pa 

icAt.'M - Av . ,v V-" 



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 

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. 




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 ** 



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 



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 


Mucous Membrane 38 

Lymphatics 38 



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 



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 



I. The Pharynx 64 

Subdivision <»S 


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 



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 g z 

Natural g 2 

Acquired g 2 

Hyperemia g 2 


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 



Record 100 

Light 100 

McKenzie's Light Condenser 102 

Allison Chair 103 

Nasal Speculum 104 

Tongue Depressor 104 

Rhinoscopic Mirror 104 

Palate Retractor "^S 


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 



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 


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 





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 



Local Anesthetics 156 

General Anesthetics 159 

Post-operative Treatment 163 

Local Depletion 165 

Natural Leech 165 

Artificial Leech \(>(> 


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 



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 


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 



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 



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 



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 



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 



Anemia of the Labyrinth 289 

Hyperemia of the Labyrinth 289 


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 



Injuries of the Mastoid Process 301 

Fracture of the Temporal Bone 301 



Malformation of the Hearing Apparatus 303 

Deaf-mutism 303 

Simulated Deafness 305 

Ear Diseases in Life Insurance 306 



Acute Rhinitis 308 

Simple Chronic Rhinitis 312 

Hypertrophic Rhinitis 314 

Turbinectomy 317 

Turbinotomy 321 

Atrophic Rhinitis 323 

Fibrinous Rhinitis V-S 


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 



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 



Neoplasms 359 

Nasal polypi 355 

Papilloma 362 


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 




Deflection 379 

Abscess 384 

Ulceration 385 

Perforation 386 

Spurs 387 

Dislocation of the Columnar Cartilage 388 

Fracture 389 



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 




Acute Ethmoiditis 405 

Chronic Inflammation of the Ethmoid Cells 407 

Suppuration or Ethmoidal Sinusitis 409 

Neoplasms 418 

Syphilis 419 



Acute Catarrhal Inflammation 421 

Acute Empyema 422 

Chronic Empyema ,. 424 



' Acute Catarrhal Inflammation 428 

Chronic Catarrhal Inflammation 429 

Acute Purulent Inflammation 431 

Chronic Purulent Inflammation 433 

Foreign Bodies 440 

Mucocele 440 

Tumors 440 



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 




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 



Deformities 504 

Acute Uvulitis VA 


I Atrt ilinii* 505 

kUmfcati'M 506 



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 



A< ule Inflammation 526 

Myoerjilania 527 

A t*r*»» 528 

M y«:o»i» 529 

Lingual Varix 529 



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,± 


Papilloma 555 

Fibroma 555 

Cystoma 555 

Angiomata 555 

Myxoma 556 

Enchondroma 556 

Lipoma 556 

Adenoma 556 

Malignant Neoplasms 557 

Carcinoma 558 

Sarcoma 559 




Laryngismus Stridulus 562 

Aphonia Spastica 563 

Laryngeal Chorea 564 

Laryngeal Vertigo 5(4 

Paralysis 564 

Anesthesia 568 

Hyperesthesia 569 

Paresthesia 570 



Tracheotomy 573 

Bronchoscopy 576 

Esophagoscopy 576 



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> 



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 \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 



Fibroma 95. 

Myxoma 97 

Head Mirror and Band 100 

Mi Kenzie's light Condenser and Refleclor 102 

Allison's Treatment Chair 103 

Mykt 1 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.) *^ 


I i I I Ol 'ill 


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 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«*> 


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 


Page 60, top line, instead of ' Nasal ' read nose. 

Page 223, top line, instead of 'Pathology' read Pathology and Symp- 

Page 231, fourteenth line from bottom, instead of 'inflammation ' read 




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 


Reconstruction Off tiik Kmhmvo 2.11 mm. Lone. 

ni, AUaoMia; «. amnion; fl, belly -Ktalk; .-'1. chorion; h, heart: mt, m*io- 
dermic somite; as. 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 



Soulier pouch, 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. 



■ MtucTiox or the Otocyst or a* Ensure or 13,) mm. 

4-*, Cochlei; de, cndolvmihatic duel; K, tctnicircular canal. (After Hit, fr H 
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. 


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 

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 


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 


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. 






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 



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- 


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. 


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 


.•:, 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 



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- 



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- 



gether at the median line separating the mouth from the nasal 

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 


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- 



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 


1,1 fhr ectoderm, Which COmei in contact with the endoderm 
and fori, 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 

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 



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. 



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 



■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. 



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 

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 



;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 



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 


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. 


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. 


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. 






ttrtttd Ar. 



n i 

Sii/la.ii MnnSi' 



r Practl 

Siape tltas 

Facta I 'A'tne 


■ • . 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- 


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 



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. 


1 he Mucous 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 



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- 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 




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 



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 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& 



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 

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 



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 bj r 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 only 1 (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 



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 


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 

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. 



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 



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. 


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 

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. 



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 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\& 



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- 

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. 



"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. 





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 proc e sses 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 



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 



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 



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 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- 

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 

\\ i i 

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 




<)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- 



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- 



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." 



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 



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*. 



: .'. 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 


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 \» 



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. 


Fie. j3 . 
27 20 25 






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. 




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. 


;. Palatine nerves n I '. maxillary sinus: 3. alveolar recess of 

maxillary sinus; 4, floor of nasal cavity: JS. lower margin of inferior 
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. « <-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. 



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 



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. 


Fic. 36. 


^^^^v ^VT^fr*r~l 

1 '*m£ V 

V^3K\tf «• ^B^^^jb 

\ %.'■»■ 

ft! r v TC>fM 

\1\ - * 


\V - -^ 

1 -i_ i- 


agityai. Section m Si Showjxc a F mem ax's Sphenoidal Doucie 



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 


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 


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. 



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- 




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. 


■■■■ ;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 

The average dimensions given by Turner, are: Vertical 



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 




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 

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 

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 

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. 

6 4 


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. 4 1 . 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 

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- 


6 7 

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 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. 



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. 



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 

The Larynx. — Within the region of the laryngo-pharynx 
i« situated the most important organ (if voice and speech, the 

Fie. 43. 



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.) 



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 
; L r ins 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 


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 

7 2 


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 

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 


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 

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 



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 

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 



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. 

7 6 


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. 


— — 


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 


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 



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- 




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 



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 




* Ik 



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. 



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 



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 




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\. 

s 4 


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 


8 5 

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 

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. 



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 

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 



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 

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 



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 

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 con n e c t iv e 
tissue which continues to grow independent of surrounding 
tissue, following, frequently, the course of the blood vessels. 



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 » 



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 

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 



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- 



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. 



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. 



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. 



Flat-celled carcinoma arc 

spoken of as epi- 

thelioma and involve those structure* oa re red with flat or 
squamous dl rated ep ith e lium and occur on the skin or junction 
of the skin and raucous me mbra ne, mouth or air ot the nose, 
pharynx. larynx and auride. 


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 



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. 


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- 

9 6 


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 

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 



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 



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. 



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- 

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 



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. 



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- 




- i Nouvana 

•u NOi-Lvuna 




H : 


a* : J 

E : 

ui ; 

a • 

ac • 

ui . 

o : _ 

k : 

CO : 

< : 



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. 



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 

Electric laryngologtcal lamps can be had through any instru- 
ment bouse. They arc so constructed that reflection of a solid. 


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. 


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 



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 



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 



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 



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 

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 


Throat Mikkokx. 


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. 


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. 


The art of direct examination of the larynx is known as 
autoscopy, first described by Kirstein of Berlin in 1895 (Fig. 

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 


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 ' 6 4- 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. 



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. 


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 


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. 


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 


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 



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 


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. 



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]) 

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 w r ill 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 

\ !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 




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 COm pr es ai OIL 

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 



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. 



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 



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. 




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 


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. 


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 


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 

Aquas, ad q. s. 
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 •) 




\i Tinci. iodi corap., 

4.00 c.c. (5 i) 

Phenol (crypt), 

1.16 Km. (gr, xviii] 


75.00 c.c (J iiss) 

Aq. dot., 

3CMX1 r.c. (5 i) 


B Ichthyol, 

2.00 c.c (5 •») 



120.00 c.c. (5 iv) 

The following antiseptic solutions are often recommended 10 

suppurative inflammation, ma 


growths and fracture of 

the nose. 

B Resorcin, 

.iS c.c. (gr. iii) 


4.00 C.C. (5 i'l 


B Phenol, 

.30 gm. (gt 


4.00 c.c. {Si) 


30.00 c.c. (5 i) 

B Potass, permang.. 

.06 gm. (gr. i) 


30.00 c.c. | 

]i Formalin (40%) 

.30 cc. (gtr. v) 


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) 

Thymol, / 

.60 gm. (gr. x) 


.30 gm. (gr. v) 

Ul. gaultheria-, 

.36 c.c (gtt. vi) 


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- 




(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., 
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 : 


1 rlyeerol tannic, 

4.00 c.c. | 

Aqua:, ad. 

30.00 c.c. fj i) 


Argcnti oitratit, 

.18 gm. (gr. iii) 


30.00 c.c. (5 i) 


Argenti nitram, 

.03 gra. (gr. 'A) 


30.00 c.c. (3 i) 



.60 gm. (gr. x) 

Aq. hamamelU dot., 

8.00 (3 ii) 

Ai|u.t, q, s. ad. 

30.00 c.c. (3 i) 


Zinc sulpli . 

.34 gm. (gr. iv) 


30.00 C.C. (3 ») 


Zinc ptiei]ol.iul|iliunatc, 

.12 gm. (gr. ii) 


30.00 c.c. (3 i) 


loimalin (40/), 

I -SO C.C. (qt. xx) 

A qua:, 

30.00 c.c. (3 i ) 


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 


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. 



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 alteration. 
The following solutions are frequently used in atomizer and 
nebuli/ri : 





.34 Rin. (Rr. iv) 
-i* gm. fgr. iv) 
30.00 e.c (3 i) 


I2 7 



.12 gm. (gr. ij) 


.12 gm. (gr. ij) 


30.00 c.c. (3 j) 




.60 gm. (gr. x) 


1.20 gm. (gr. xx) 


1.20 c.c. (gtt. xx) 

01. cubebae, 

.60 gm. (gtt. x) 


180.00 c.c. (f^vj.-M) 




.42 gm. (gr. viiss) 


4.50 gm. (gr. lxxv) 


4.50 gm. (gr. lxxv) 

01. cinnamon!, 

42 c.c. (gtt. viiss) 

01. petrolina;, 

90.00 c.c. (3 iii) 




.60 c.c. (gr. x) 

Camphor, \ ^ 
Menthol, > 

1.20 c.c. (gr. xx ) 


.30 c.c. (gtt. v) 

Petronol (Lilly), q. 8. 

120.00 c.c. (5 iv) 




0.50 gm. (gr. viii) 

Chloretone cryst., 

0.50 gm. (gr. viii) 

Ol. petrolatum, 

90.00 gm. (3 iii) 


Olive oil, 

8.00 c.c. (3 ii) 


1.20 gm. (gr. xx ) 


u Dissolve, and add to the following: 

Acetoform, • 

.60 gm. (gr. x) 


1.20 gm. (gr. xx) 


1.20 gm. (gr. xx) 


.72 c.c. (min. xii) 


60.00 c.c. (5 '') 


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. 




The following solutions are 

indicated in the treatment of the 

enumerated affections of the upper and lower air passages. 

IJ- Menthol, 

.60 gm. (gr. x) 
60.00 c.e. (3 ij) 


In chronic pharyngitis: 

IJ Menthol, 

Ol. caryoph., 

-35 K m > fS'- vi) 
.67 co (gr. xi) 
30.00 c.e. (5 j) 

( Brown ) 

IJ Thymnl, 
OI. anisi, 

.06 gm. (gr. j) 

.35 gm. (gr. ri) 
8.00 e.c. (5 ij) 
30.00 c.c. (3 j) 


B 01. menth. pip., 

4.65 c.c. (3 jJ4) 
30.00 c.c. (5 j) 

In nasopharyngeal catarrh: 

R Thymol. 
01. cubebje, 

.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 


# Crrawiti, 

Ol. picis. liquidae, 

♦.00 cc (3 j) 
i.aj cc (gtt. xx) 
15.00 cc. (J n) 

In laryngeal tuberculosis: 

8 Camphorse, 

Ol. santali, 

.06 gm. (gi 

.14 gm. (gr. iv) 

-JO «• (*««■ vi 

30.00 cc ( 

In rheumatic pharyngitis: 


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 



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 '}) 


k lodi, 

()!. pick liq.. 


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 

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) 


# 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- 



Magnesii carbonat., 
Aqua; destill., 

2.10 c.c. (gtt. xxxij) 
3.75 gm. (5 j) 
30.00 c.c. (5 j) 


01. cubebas, 
Magnesii carbonat., 
Aqur destill., 

.06 c.c. (gtt. j) 
1.30 gm. (gr. xx) 
30.00 c.c. (3 j) 


Ol. pini sylvestris, 
Magnesii carbonat., 
Aqua; destill., 

2.50 c.c. (gtt. xl) 
3.75 gm. (3 j) 
30.00 c.c. (3 j) 


Spt. camphorx, 
Spt. vini rect, 
Aqua; destill., 

3.75 c.c. (3 j) 
i-95 cc. (gtt. xxx) 
30.00 c.c. (3 j) 



Ferri sulph., 

•97 Rm- (f?r. xv) 
30.00 c.c. (3 j) 


Ferri et ammon. sulph., 

.97 gm. (gr. xv ) 
30.00 c.c. (3 j) 



Potassii iodidi, 


1.92 gm. (gr. xxx) 
.32 gm. (gr. v) 
30.00 c.c. (3 j) 


Acidi hydrocyanic!, 

3-75 gm. (5 j) 
30.00 c.c. (3 j) 

Signa. Teaspoooful of the above formula; to a pint of water. 


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 


Investigations bj Pope, nf San Francisco, with methylene 

blue, mucilage and magnesia, when used as a parglc, shows 
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 
Signa. Antisepiic gargle. 

B Acldi tannic!, > u , ,, 

., 240 gm. (gr. xl) 

Ahimrn, I 

A<|. 1 120.00 c.e. (5 


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 


Signa. Follicular tOQBlls. 

K Zinci phenobulphonatis, .30 gm. (gr. v) 

Gijroerini, 4.00 ■ . i J) 

Aqutaococholi*, 30.00 oc. (\ i) 


Signs. For acute pliarvnuitin. 

Douche. — This form of application of medicated 9 
:ially to the nose, has in recent years been almost relegated 



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 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 

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 



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> 


JWi'tW 1 

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 



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. 


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 



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 

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. 



(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. 



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, 


1$ Balsam peni, 


B. Sol. hydra rp., 
Lanolin i, I -- 

Iodi-glycerini, J 

to per rent. 

10 per rciit_. 

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- 



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 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 . 


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 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 



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 

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 

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. 


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. 



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 

Cautery Snare. — I'scd for the removal of enlarged tonsOi 
or hypertrophies within the nose, care should be taken that the 



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 


' 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. 





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 too , 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 


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 

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 


ing the tympanic ca\ ity, l'olitzer (p. 272) recommends the 

" 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. 


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 

9 Potassii iodidi, .30 gra. (gr. v) 

Aqua;, 30.00 c.c. (.si) 

Signa. Ten to twenty drop* for one injection, combined with 
aiitinypliililii- treatment. 

B 'A per cent, camphor-menthol in albolene. 
Signa. Ten to fifteen drops to b« injected while warm into the 
Eustachian tube and middle ear. 

Fie. 77- 


Indicated in acute and chronic catarrhal inflammation of the 
Eustachian tube. 



I. Sodii bicarhonalis, .60 gm. I gr. x) 

Pilocarpine murialii, .12 gm. ( gr. ii 

Albolini, 30.00 c.c. 

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, / 


lv Menthol, 
Tinct. iodi, 

Q Ol. rucalypinl, \ .- 
Ol. pini, I 

8 01. caryuphylli, 

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 


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. 


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 


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 


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 



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 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. 


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. 



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 

" 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 

The tnjCCtion is made between the third and fourth lumbar 
Vertebra*. The patient is placed in a reclining position with 




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 

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 




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, 
Aqua: (ieslill., q. a 
As a powder. 



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 

(ocainx . ' 

1.0 gm. <«« gtt. xvi 


lv Phenol, 
Coeainac hydrachlon 

which is .in anesthetic and caustic. 

1.0 gtn. (gtt. xt) 
0$ (" gr. viijl 



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, 

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. 

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 



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 emer g ency 
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 



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 



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 
c o mfort a ble 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 

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 

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 

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] 



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 

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. 



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 

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 






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 

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. 



1 66 


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 




,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 



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, 

' 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. 


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. 



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, 

\ must valuable stimulant and "voice lozen 

I '■: Stimulating and antiseptic. 

I'se: Strongly astringent. 
GUJIJC T.IWIS. -Tannin l gr. 



chlorate potassa 2 gr. 


CAPSICUM.— \ gr. 


■iMMuSIA AND GUAIAC—i p.. each. 


i Each 

lozenge contains J4 R r - 

cubebfc) Marked C. B. 

I m: 

\ 1 1 v serviceable in d 


rig cucssive secretions of 

mucue t 

mm pharynx, larynx and trachea. 


( £» li 

lozenge contains 2 gr. 

gii.'iiaiurn resin.) Marked G. 


A specific for arresting excrescent inflammation of the 

tonsils and pharynx. 

Aural Suppositories. — In 


affections of the external 


canal nr middle ear. 

the following: prepared supposi- 

tones arc recommended: 


Bismuth! Milntit., 

.06 gm. <gr. 1) 

Ac. benzoic!, 

.06 gm. (gr. i ! 


Blimutbl subnii., 

.t2 gm. (gr. iji 


.06 gm. (gr. j) 


.06 gm. (gr. j) 

Ac. tanas t, 

.12 gm. (gr. ij) 


Zinci sulphocarb, 

.12 gm. (gr. ij) 

/inn ratph., 

.06 gm. (gr. j) 


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) 


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) 


Ac. Hlicylii i, 

.12 gm. (gr. ij) 

Ac Imrici, 

.06 gm. (gr. j) 

Ac. tannic!, 

.ij gm. (gr. \\\ 



]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 

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 

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., 


.12 gm. (gr. ij) 
-03 gm- (gr- *») 

5 Potassii chlorat.. 

.18 gm. (gr. iii) 
.03 gm. Igr. n) 

B Bismuth, suhnit., 

.06 gm. (gr. )) 
.06 c.c. (in. j 1 


# 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. T V) 

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. T Ju) 

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. %) 



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- 

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 



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} 


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. 



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 



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 


■ 7 S 


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- 



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 

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 


with the drum. Schmeigelow reports a case in which a small 
stone was pushed into the middle ear, through the auditory 

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 



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. 



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 

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 



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]., ' 


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 




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. 



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. 



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 

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. 



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 

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, 
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 



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 

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. 



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 

k Phcaol, 


,. 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. 


Signa- To he applied 



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: 



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 

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 

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 



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- 

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 



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 

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 - 



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 

i 9 4 


disease and failure to respond to other than antisyphiliri« 

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. 


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. 

A W 1Wg W .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- 



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. So meti mes 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 



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 


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 



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- 



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 


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. 


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 


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 



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 



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. 



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. 




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 

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 


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 

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 



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 

Pus QttJ break through in the middle ear, causing acute 



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 


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 



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, 



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- 


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. 



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- 

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. 


2I 4 


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- 



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 

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- 




rinth. If both sides are affected, the bone conduction will 
be more distinct on the side in which the deafness is more 

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. 



(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 






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 



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 



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 

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 



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 


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 



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 



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 
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. 



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 

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. 



Ziiici jiilpliat., 
Acid boracic, 

Aq. desiill., i|. 

s. ad. 

.36 gm. 
.90 gm. 



(5 i> 





. Four or five 



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., to the mouth tti rhr Ku 
Btachian tube once or twice daily. 

I he patent of the tube and middle car is quickly na 



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 



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. 


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\- 



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 


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 



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 
'" with otorrhea chronica as it is in a simple acute in 

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- 

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. 



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- 


and the meatus should be cleansed with absolute alcohol, once 


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. 


\s a piopbylactii t, the patient should be warned 

against exposure to irritations known to have produced the 


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 

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&." 


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 

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 ne gati ve . 
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 



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 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. 




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 

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 

I'ii can he detected upon inspection, which is variable in 
both color and odor. As a rule there is no difficulty in 



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 

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 


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. 



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. 


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 

The patient maj Ik- ordered the Following tor bome treat- 

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*. 

- lini. 
\i| ileMill., q, *. ad. 

J4 gm. (e r it) 

8.00 r.r. (3 H) 
4.00 c.c I 
30.00 c.c. (J i) 



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. 



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 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 


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 
dete c tion 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 
Otitis Media in General Diseases. — The frequency of 
middle-ear complication in general diseases has been mentu. 



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 
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. 



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- 


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 
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- 




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. 



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 extravasa tions 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 

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. 



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 drum v 

-:-| s 


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. 



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 

Trea t ment. — 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 



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- 

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. 



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 
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, 

2 5 2 


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 



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- 




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. 



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). 


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 



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 


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. 


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 



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 
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 ^ 



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. 



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. 


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- 


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 


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 *■ 


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 meinbrmo m 
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 


2 r> 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. 9 2 )- 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. 



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. 



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- 


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. 



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 



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 

-7 2 


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 



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. 




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 

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. 


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 



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 

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 



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 105 . 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 



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- 



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 



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. 


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 



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." 



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 


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 103-104 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 


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. 



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, 


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 



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 patient 5 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- 




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 



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 

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 



of the hearing power for all sounds or for (pacific sounds and 

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 

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. 



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 



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 



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 



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 

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. 



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. 


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 

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- 



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. — 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- 

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 




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. 



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. 




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 

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 



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 

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- 



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 an 1 . 
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 



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. 



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* 




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- 




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 

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, 

i .iniphcirr, 
< 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 


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 : 



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 




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 

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 

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. 



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., 
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 



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 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 

Etiology. — The disease may occur at any age. The cause 



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 

3 i6 


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 

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 


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 

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. 



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 



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 

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 



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- 

The small wire loop of the cold snare can usually be placed 
about tlie over-growth, and by a quick, steady pull, the lissvw. 



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 

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 


3 2 3 

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 



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 

1J Sodii biboratia, i |1; - 
Sodii bicarbonaiis, ' 
Sol. ■ntisepdcl | l.isfer), 
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. 



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 


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 




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 



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 


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 105 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 


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 



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 

co n tract 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 



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 

diseases or Till- NOSE. 


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 

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 




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 

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. 



The local treatment consists in the careful removal of all 
crusts by irrigating twice daily with the following: 

If. Sodii bicarbonati 
Sodii biboratis, 
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 

Potatdl |>errnanganatis, 
Ac. borici, 

A nunc lepicte, 

i-: H m - <K r - '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 



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 | 



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 

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 



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 



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 

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 


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- 

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 



•Aitli antiseptic nose and throat douches and sprays (Lennox 

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 

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. 

34 a 


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 




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 



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. 

34 6 


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 

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 

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 





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). 



Rhinoliths. — Etiology. — The condition is due to a foreign 
body finding lodgment and remaining in the nose for a long 

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 

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 


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. 



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 

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 » 

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 



of the septum, spurs on the septum and sensitive areas of the 

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 N T . 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 



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 
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 




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 



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 



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 

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. 




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 



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 

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. 



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 




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 



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 



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. 



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- 

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 




■ 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 COVCT 1 
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*'. 


(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 

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. 




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 

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. 



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 

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. 



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 

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 



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 



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- 

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 ca 1 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. 


37 1 

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, 



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 


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 



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. 



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 



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. 


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. 



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 

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. 


37 8 


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. 


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 


3 So 


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 



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. 


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 



Fig. 116. 


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 



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 



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 

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 

Diagnosis. — A perforating ulcer is easily detected. If pro- 


3 S6 


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 



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 

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 

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- 



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/ 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 d e st roy e d 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. 


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.) 



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 
cells with retention of air in the cells. The air may be a bsor bed 
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 b r ofew* 
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 



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 

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 

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 



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- 




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 



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 

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 


S9 6 


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 



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 

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. 




"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 

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 



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 

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 

4 oo 


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 i nsp ecte d 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 



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 




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. 



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 

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 



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. 



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- 




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 

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. 




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 

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 

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 



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 

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. 



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 

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- 


4 II 

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 



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 

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 
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 Po s te ri o r 
are involved, pus will be observed draining backward from 
middle meatus over the posterior portion of the middle tur- 



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 

.: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. 


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. St l pe ri w turbinated 


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. 



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- 


4 .S 


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. 




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 


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 


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- p resen ce 

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 p r e d ispo s ing and 

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 



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. 



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«- 



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 

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- 




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 


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. 





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 




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 



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 




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- 

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, 


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 



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 

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 



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, 

' 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- 



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- 

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 



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 45 . 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 


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. 



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 p r ev e n ti on 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 p r eve nti on 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 S tit ches, 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 



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 



;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 

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 

For this operation, the following instruments arc necessary: 


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. 



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 




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 

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 
w r ound 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 


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. 



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 

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 

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 


I>]SI:.-\SI:S (II- rill: N \S( I I'HARVNX. 


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 


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 

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 




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 

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 

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 



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. 

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) 



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 



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. 



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 



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: 



' 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 

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 



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 

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 

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 

45 6 


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. 



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. 


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 

Among those who recommend the removal of adenoids with- 
out narcosis are B. Friinkel, Hartman, Cradle, Cline, Grayson 


45 8 


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 anest h etic 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 


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 




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 

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 



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- 



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 

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: 


4 6 4 


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. 


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 


4 66 


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: 


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. 



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- 

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. ••. 


4 6S 


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 

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 



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 

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 

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, 



.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 



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 





Ol. eassire, 

Ol. eucalypti, 
Ul. gaultherijt, 

.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 (103 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. 

47 2 


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: 


Ac. carbolici, 

.30 cc (git. v) 


.30 gin. (gr. v) 

III. eucalypti, 

ta c-c. (g 


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- 



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 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. 



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 

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 



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: 




.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. 




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 

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. 



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 

'.<• infective .lise.ise. rlioirji such a history is not always 


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 


47 S 


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 

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 fnrmaldr 1 
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 

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 




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- 

exposure to tubercular infection by association with tubercular 


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- 


4 S2 


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 

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 



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. 

4 s 4 


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 

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 

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 86 


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. 


4 S 7 

)t infrequently diagnosed as sarcoma or car- 



Syphilis is not 

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 

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 




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 ob s er v ed 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 ■ 
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 



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 

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 


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 

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. 



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. < n r - 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 

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 



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- 

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. 




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- 

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, 


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 



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 


49 r > 


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 


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- 

Prognosis* — The prognosis must, from necessity, be guarded, 
rrnm general observation, the mortality with antitoxin is 



4 9 S 


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*. 'i rv t 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 1 
theria, the exudation adheres to the mucosa and CtttSCI thr 
surface to bleed upon being detached. 



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. 



1$ Menthol, 10 parts 

Toluol] 26 parts 

Fcrri perehforidi sol. fort., 4 parts 

Alcohol, 100 parts 


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 

Tlic foMowing may be frequently used as a cleansing: spray 
Co the throat: 

\i Boralyptol, 

Banuunelit iic-t , 

Hydrogen pcroxiil. 

I; Sodii, 
Acid carbolic!, 

Aq. destill., ad. 

30.00 c.r. 

.ta gm. [gt. iii 
.06 gm. (gr. i) 

24 E m - (g r - •»■) 
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 


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 



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 

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 




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- 


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* 




the areolar tissue and may be a vaso-niotor disturbance due to 
some toxic disturbance and independent of any local bacterial 

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, 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, 




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' 

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. 


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 

Subsequent treatment consists in cold antiseptic gargles "for 
twenty-four hours, followed by hot antiseptic gargles. 



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 




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- 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 

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 


msn.ASRS OF THE tonsils. 


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 




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 

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 



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 


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 



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: 



Quinin.T bromidi, 

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 



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 

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 


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 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 



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 

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 



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. 



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 


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 


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. 



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 




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 




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 

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. 



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- 



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. 



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 



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 

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 


!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 

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 

B Zinci sul pilaris, 
( ikrrrini, 

.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. 



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 

DISEASES or i'm;: i arvnx 


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 



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; 



Oil of pint, 

; • i.' i- menthol, 
I '!. kiJiililierise. 

.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 



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 
expect o ration 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. 



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 

'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 
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 


voice, the following stimulating solution may be applied once 
daily : 

$ Iodini, 2.00 gm. (gr. xxx) 

Potas. iod., 3.00 gm. (gr. xlv) 

. S"SU M ~— «" 


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 



■ 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 

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 

Treatment. — The treatment is the same SB that in.! 
pharyngitis sicca (see Pharyngitis Sicca). Those remedies 



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, 

.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. 


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 


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. 



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 

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: 

Symptomatohjry.—The sympton 
van In intensity, according to the progress of the disease. How- 



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 

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 

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- 




tricity anil strychnia by the mouth or hypodermatic-ally, are 


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 

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. 



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 • 


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 



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. 




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- 


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* 

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! 


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 : 


.90 gm. 

(gr- xv ) 

01. amygdal. dulc, 

15.00 c.c. 


Vitclli ovarim, 

25.00 c.c. 

(3 vij) 


12.50 gm. 

(3 iij) 

Aquae destill., q. s. ad. 

100.00 c.c. 

(3 Hj) 



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- 

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 



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* 


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 


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 


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 

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. — 



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 

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- 



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 
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. may be sessile or pedunculated. The deep 



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 


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- 


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 



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» 


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