^,
IMAGE EVALUATrON
TEST TARGET (MT-3)
k
A
.< w#
■^
1.0 ;^K£ 1^
1^
11.25
U4
m
U 11.6
Hiotographic
Sciences
Corporation
V
iV
a>^
:\
\
rv
cS^
^-^ W?ST MA!N STRUT
WEB»r*'x, N.Y. US80
(716) •72-4S03
Q" -^ "^^ ">>
CIHM/ICMH
Microfiche
Series.
CmM/ICMH
Collection de
microfiches.
Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques
Tdchnical and Bibliographic Notas/Notes tachniquas at bibiiographiquas
Tha Instituta has attamptad to obtain tha baat
original copy availabia for filming. Faaturas of this
copy which may ba bibliographically uniqua,
which may altar any of tha imagas in tha
raproduction, or which may significantly changa
tha usual mathod of filming, ara chackad balow.
D
D
D
n
n
Coloured covars/
Couverture da coulaur
I I Covers damaged/
Couverture endommagie
Covtirs restored and/or laminated/
Couverture restai/'6e et/ou pellicul6e
I I Cover title missing/
Le titre da couverture manque
I I Coloured maps/
Cartes g^ographiquas en couleur
Coloured ink (i.e. other than blue or black)/
Encre de coulaur (i.e. autre que bleue'ou noire)
I 71 Coloured plates and/or illustrations/
Planches et/ou illustrations en couleur
Bound with other material/
Reli6 avec d'autres documents
Tight binding may cause shadows or distortion
along interior margin/
La reliure serr^e peut causer de I'ombre ou de la
distortion le long de la marge intirieure
Blank leaves added during restoration may
appear within the text. Whenever possible, these
have been omitted from filming/
n se peut que certaines pages blanches ajouttas
lors dune restauration apparaissent dans la taxte,
mais, lorsque cela 6tait possible, ces pages n'ont
pas M film^es.
Additional comments:/
Commentaires suppl^mentaires;
Tha
toti
L'Institut a microfilm* le meilleur exemplaira
qu'il lui a iti possible de se procurer. Les details
da cat axamplaira qui sont peut-Atre uniques du
point de vue bibliographiqua, qui peuvent modifier
una image raproduite, ou qui peuvent exiger une
modification dans la mithoda normale de filmage
sont indiquAs ci-dessous.
r~~| Coloured pages/
Pages de couleur
Pages damaged/
Pages endommag^as
□ Pages restored and/or laminated/
Pages restaurias et/ou pellicul6es
Tha
poai
of tl
film
Orifl
bag!
th«
aion
oth<
first
aion
oril
V
D
Pages discoloured, stained or foxed/
Pages d^colories, tachat^es ou piqudes
I I Pages detached/
Pages ditachdes
Showthrough/
Transparence
Quality of prir
Quality in^gale de I'impression
Includes supplementary materia
Comprend du material suppl^mentaire
Only edition available/
Seule Edition disponible
r~/| Showthrough/
I I Quality of print varies/
I I Includes supplementary material/
I I Only edition available/
Tha
shal
TINI
whi(
Mar
diffi
antii
bagi
righ
raqu
mati
Pages wholly or partially obscured by errata
slips, tissues, etc., have been refilmed to
ensure the best possible image/
Les pages totalement ou partiellement
obscurcies par un feuillet d'errata, une pelure,
etc., ont 6ti filmies A nouveau de fapon d
obtenir la maillaure image possible.
This item is filmed at the reduction ratio checked below/
Ce document est film* au taux de reduction indiquA ci-dassous.
10X 14X 18X 22X
/
12X
16X
20X
26X
30X
n
24X
28X
32X
Tha copy fiimad h«r« ha* b—n r«produc«d thanks
to tha ganarosity of:
University of British Columbia Library
L'axamplaira film* fut raproduit grica i la
gAnArotitA da:
University of British Cc<umbia Library
Tha imagae appaaring hara ara tha bast quality
poasibla consldaring tha condition and lagibility
of tha original copy and in kaaping with tha
filming contract spacifications.
Original copiaa in printad papar covara ara filmad
baginning with tha front covar and anding on
tha last paga -.vith a printad or illuttratad impras-
sion, or tha back covar whan appropriata. All
othar original copiaa ara filmad baginning on tha
first paga with a printad or illustratad impraa-
sion, and anding on tha last paga with a printad
or illustratad imprassion.
Tha last racordad frama on aach microficha
shall contain tha symbol •-^- (maaning "CON-
TINUED"), or the symbol Y (maaning "END"),
whichaver applias.
Las imagas suivantas ont AtA raproduitas avac la
plus grand soin. compta tanu da la condition at
da la nattatA da l'axamplaira film*, at an
conformiti avac las conditions du contrat da
fllmaga.
Las axamplairas originaux dont la couvartura an
papiar ast imprimia sont filmAs an commandant
par la pramiar plat at an tarminant soit par la
darnlAra paga qui comporta una amprainta
d'imprassion ou d'illustration. soit par la second
plat, salon la cas. Tous las autras axamplairas
originaux sont filmAs 9n commandant par la
pramiAra page qui comporte une empreinte
d'impression ou d'illustration at en terminant par
la derniAre page qui comporte une tella
empreinte.
Un des symboles suivants apparaltra sur la
darnlAre image de cheque microfiche, seion le
CBs: le symbole — ^ signifie "A SUIVRE", le
symbols V signifie "FIN".
Maps, plates, cherts, etc., may be filmed at
different reduction ratios. Those too large to be
entirely included in one exposure ere filmed
beginning in the upper left hand corner, left to
right and top to bottom, as many frames es
required. The following diagramit illustrate the
method:
Les cartes, planches, tableaux, etc., peuvent Atre
filmAs A des taux de reduction diffArents.
Lorsque le document est trop grand pour Atre
reproduit en un seui clichA, il est film* A partir
de Tangle supArieur geuche, de gauche k droite,
et de haut en bas, en prenant le nombre
d'images nAcessaire. Las diagrammes suivants
iiiustrent la mAthode.
1
2
3
1
2
3
4
5
6
DISEASES
OK I UK
Nose ^.nd Throat
\
J. I'KICK-iJROW.X, M.B., IJ<.(MM:.
«iMi> llo.iir*,,. Laim.%.;oi.o.;i.t to tmk l'i„>,KsT<.vr Oki-iiaxV ir„M, Kki i..w <„ ruy
A-KH.,..v I,...v.s,..„...„„.. «„,>„. .„,. ,M. .,r.,...H...., S,.,, V. M. *.
".' T.I,: l.,.,T„„ Mkdmm, A.,».ur,.,N. t.,k I-.x-Amk,,,, „ M,...,-.,
(.■.>.m:kk,^, tmk <'*.v*i.riM MKi.ir,,,. a»»hi..ii.,.>, riiK
D.NTllUi. MKI.1. «l ASSCK lATKlS. KTl'.. KTI
Illustrated with .59 Engravings. !ncludlng 6 Full-page
Color-plates and q Color-cuts in the Text,
many of them Original
3ir
'^iiii..-
i'Hir..\r)Kr,nri\. \k\\ v..i;k, dit. A(i..
TlIK K A. DAVIS COMPANY. PriUJSHEKS
19(K)
CUPVKIUIIT, I90U.
BY
THE V. A. DAVIS COMPANY.
I Kegi>'t«reil iit Stntloiiers Hall. I^>nili>ii, Kii;
l*liiliidel|ihia, P«.. V. S. A. :
The Medital Bulletin PrititiiiK-liniise,
1111 1-IC Chun-) Street.
V'S\
IN l.'KCOdMTloN OF HIS UNTIKINci KNi:i{(iV IN TM|.:
INVMSTKiATIOX OF SCUFNTIFIC TIM Til
HIS FMINFNT SKKVICKS IN TIIK \l>\ ANCF.M FN I OF
LARYNGOLOGY AND RHINOI.OGY
THIS VOLUMH
n
Al'KKi TI(»N.\TKI.Y DkiHi a IKIi
TO
PROF. E. L SHURLY, M.D.,
■ir
Ills SINCKliF FiilFNK:
THH AUTHOR.
ri{Ki-Aci<:.
In Jildiiij,' (iiif iiMMv |i. the Inii^r 1,^1 ,,1 u.uk.-, llial liiiM' Ix.'uii j)ulj-
li.-litd iiiM.ii iliscascs nl" Hi,, nose iiiid tlin.at tlu' iiiithor is iiwHrc that lie
iias iiiKlcrtakcn iicillior a li^^lil ikh- aii irri'sponsihlt' task; and wcro it
not Jur llic fact that tlu-nj is a ])i»)l" siuiml field in a hir-;c mcasiirt' still
linon ii)Hc<| lie would not have vciiliind to present to the mtdiiii! piililic;
lUiotluT Noiiiiiii' upon this suhjccl.
■*.^ ii pnicliiioiicr ulio foi' nearly iwenty \r,ir> was eiii^aired in ^'eii-
<'ral 1)111(1 ICC, an<l who for the last ten _veai> ha- devoted hiin>elf ex-
••lusncly lo nose-and-tliroat work, he ha.- fre(iiieiill_v been struck witli
the small aiiKUinl of knowledjie possoMd \,\ the jirid'ession at largo
upon tli( diseases of these iiiijiortant or-ans. Tatients are sent to the
speeiali-l n|' acknowledged skill, hy i)hysieian- of towns and cities far
renioi.. in, in iIk residence of the speeiali>t himself. I'.iit these patients
are the Inriiiiiale few: those who have coiiifortahle lioines with all that
gooil lo(d. kind friends, and liygieiiie surroundings can do to re.-tore
them tn health, a> well as means i.. pay the sjieeialist whose serviiT.s
Ihey re(piirc. What ahoiit the larger nunihery the imju'cunious? the
}K)or? Iho.-e who might pay a small fee for relief from constant siill'er-
ing, hut who are iimihle to make hmg journeys, and to meet the obliga-
tions rtupiircd hy staying in the city and remunerating the laryn-
gologist for liis work? It is for physicians and surgeons who so fre-
quently iiiict patients of this class and for students preparing for the
regular practice of their prcd'ession that this hook is written.
In this rushing age, when a thousand and one things demand the
attention of the Inisy praelitioiu-r, any work of this kind to he of real
nise must he terse and to the poiid. At the Siime lime, when the j)ro-
fcssion is overcrowded, and the ]diysician's fees often small and dilli-
cult to eollect. a large jiricc for a hook is often out of the question.
'lo meet these re«iuirenients in a reasonahle ami candid way lias heen
the author's aim.
Jn order to do this he has left out certain subjects which are n.su-
ally considered to belong to this specialty. For this, however, there ia
ample reason, as some of these are dealt with in works on general medi-
cine, and others in works on ophthalmology and otology. This may
be said of descriptive anatomy of the nose and throat, which is touched
(V)
VI
I'liKT \ri:.
ll|Mi|l ii|||\ .11 liir i|> ll I'clilli'. In llli |i|';li'l Kill I ri'ilt IIK'lll n|' illsriisc: ,,\'
tllCSC nririlMS. I>i>('l|srs ul' lllr Ircillljll >lllll> ilinl lllr liHI \ lllill filllill,
idlllllli: ll>-llilll\ limlrl' the iliiliiiliti III llli' (irllli>t. Ilil\(' IkiII left rlllil'i'lv
lo iiit) cart'. Siill t'liitlirr. (Ii«fii>(« ol' ihr car iirc im! >|ii.k.'ii dt', r\((|it
to Uic cxlcnl lliiit iinsii-|ilijir\ iiirtal (liM ii-t - iillVci ihr hlii^tiiiliiini tulic.
Astliiim. too, is (lixiissnl irmri' cxlinii.-l i\r|\ m wi'll-irrn^'nizi'il wnrks
(III •rcllcral llli'iiirilK' tllilll it cnllld lie within the lilllil> of tln'M' |l.'i;.r('>.
iiml ciillMilMCIll ly llll> iml licrll tlrillid nl. Ill OIK citlur poilll it l.«
Ii(»|mmI tlic |in)r»'-sii)ii will iijircc willi llii' iiiitlmr. aiiil tliiit is in tlif
(VcliiMiiii (if ili|ilitlii'riii rrniii tlii> voIiiiih'. 'I'Ih' iin'iliciil litcriitiirr i<\'
llic (liiv i> lull of till' >ulij((i. j'',\( ry nicdicjil joi.ritnl ol' iiiiy >liiiiiliiiu
(llli tell till' liitrsi with rciranl to this iliscasr. Toxins iiml iiiitiloxin>
iiioiii'|inli/c the iittciition ol' tlir iiicdiciil world, and yet tlic rviict ^^hihis
id' oiir ami of ihr ollirr in rr^anl to thr |iro|)ajrat ion and picvriiii.iii
of disrasf it may take another lialf-( mt iiry to fiillv and ali-ojulcly
dclitic.
It IS not thr authoiV de-ire |o *|ieak in any \\a\ »li^hli!i;^ly of the
iiii|iortaii(e and interest i>\' lliese siil«Jee|-, or of the aii.«o|iite necessity
fd' iiivcsiiiMl in;; to the ulniost all that «<iei)ce can advance in nd'eronco
to th.
:'se.
What
lie wishes lo sav i- that, after takiiii: all the cir-
ciinisl into coiisidera ion, he ha.- acted ailxiscilly in not idaciiiji
(liplil'.cna upon the list of suhjeets treated of.
Another reason for liiiiitiiiLT thi< work strictly within certain lines
\\a> the de.-ire to enter as fully as s|tiice would |icriiiit into the many
subjects within its ran.iie, iiiid to do so in accordance with the results
of the most recent scientific invosti.iiatioiis. Iiriii<:in,ir the recoril (d' the
art ami science of laryri^cdojry and rliino|o;,fy down to llie iiiiiiieilinto
iresent
Another ih'partiirc from tlie ordinary rule in works cd' this kind
has hcen luade. It is one, however, for which, in the minds of most
thinkers, tlie time has arrived. 'I'liis is the snhstitntion throuuMioiit
the work of the metrical system of weights ami niea.-iirc.- for the (dd
Koinan, which is gradually losing its grasp among the civilized nations
of the world.
in one otlicr point luis lie straycfl from the idd and well-heaten
way, and that is by <>ntirely leaving out the eniinieration of synonyms.
In carefully s(decting in eacdi case the title tliat lie deemcHl most ap-
propriate, ho trusts that lio has made a selection thiit will l>e sufli-
ciontly distinguishing, and at the same tiiiu' fully aece])tah]o to the
r(
ador.
1
rKKFACK.
Vll
In «nti(lnsion, tlic nudior. with imuli <lilli<l,.|ur, oWrva his ooni-
plmi.'iii.s to ihr pnilV-sioii, .111,1 lu< trusts tlnit. in ilicir criticism of his
work, tluy will ...vlriMl |„ hi,,, that forhcannur aii.l kin.liv i„t,.,-,.st to
which honest hihoi-. however laiiH y. always looks for its reward.
.'17 ( Art! ION S, ,(|.:n,.
'JOIIONIO. jlll IMIIlvK, IHIHI.
ACKNOWJ.KlHiMKN'l.
In pivpiirinjx this work for j)ul)liiati()n the author foeU that he in
iiikUt (h'«'|t ohli^'ation to vi-ry many. Having' jfathcrod much of liis
material from hooks aiul journals' of recent <hitf. he extends to their
writers his thanks for the valualile aid with whirii he lias thus l)een
favoreil. In this he feels that lie is })artieularly indehted to Dr. Jios-
worth for ,i,Mantinj,' so freely tiie use of pictures and plates from his
most recent work. To Mr. licniio-x lirowne, also, the author is under
the highest oldi^ation, as his kindness ha.-- eiialiled him to place ii\ the
j)resenl work a lonjr series (»f illustrations taken throughout from i..en-
nox lirow lie's lifih edition unon "' ..-.ease of Tliroat and Xose," i.ssued
so recently.
Among otlier autliors whose writings he lins so freely <.'onsulted
li(> might mention particuhirly llishop, ('a.sselherry, l)ehivan, l''raenkel,
(ileitsmann, (Jrant, (iriinwald. ileiyng, Ingals, .lonathan Wriglit,
Knight, Kyle, Lake, Max 'I'horner, Myles, Morell Mackenzie, Noland
Mackenzie, l{oe, Sajous, Semon, Shurly, Wagner, and Zuckerkandl.
In his own city of Toronto he is umh'r ohligation to Professor
Primrose fnr ihr serie> of frozen sections which he kindly permitted
him to ohtain from the Museum of the Anatomical Department of the
I'niversity of Toronto; and to Mr. Arthur Bensley, also of the nni-
versily, for pictures of patliological sections furnislied hy the author.
Ife would also acknowledge his indehtedncss to Jliss Wrinch for
the care and skill with which she prepared many colori>d and Tndian-
ink illustrations.
Drs. Aniyot, Sweetnam, Caven, Carveth, and Wilson also cordially
oontrihutcd a share to the pathological work required.
To the F. A. Davis Co. the aiitlmr owes much for the unfailing
promptitude and kindness with which he has always heen treated; and
for the suggestion^ and e(>-()]K'ration which they have ever heen willing
to grant.
(viii)
MKTinCAl- WKKiins AM) MKAM R|;s
A\ri riiK.ijt
K\(ir,IS|l IK^nVALKNTS.
1 ^riiii.iiir iiiiirkcd tliii.< I nuiiil.- l."..i;i;
1 tfiiti>;riiMiinc luarkt'd tini.s. . (il (t|ii;il« ' ,, (,,
I millignimiiic inaikcl thus.. jOOl ».(|i!;il, ,il„Mii
I •••■nti^'iaimiio is '/,„„ part of j. ^r,j,,nnw.
1 iiiilli'M-jii
yiiiins.
1
;:rain.
L'raiii.
i^M-ainuiu is V,o„„ pari <if a ;rrain
1 litri' tMnials ;{:..:>r5.| fliiidoiinccs.
1 niftri' ('(jijals 3!>.;{7!t:!» inches.
I c'lihic (cntiiMotrc, marked 1 c.
inc
In d
li(iuids. as weil
:■., cqiiai^ I
ispcnsin^', n(>oordin/,' fo the m.ti
iniiiirib
a I
as so
lid.'
"Vstciii. ill
terms ;:ramn:o, eeiiti^'rammo, and mill
are snppo.<ed to l.c wei<;hed. and tl
le
to pla
I'd faeililale writin*; prescrij)ti<)n.s it
i^raniiiK onlv are ii-
decimal th
CO a perpendicular line hetween Ih
IS more cdnvenient
c irramtne and tlie
fract
ional part
m the ordinary plan of placin- a d..t t., indie:,!,. (|
le
!i
%.
fix)
CONTENTS.
'I'llI.K
I)KI)I( A IKtN
I'ltKl'A* K
A('K.\()\vi.i;i)(imi;n I
AlK'iiK Ai. \\i;i(iiirs AM) Mkasiuk
Taiii.!-: ok ( (i\ti:\ is
I.IM ol ll.l I sriiA IIONS
TACK
i
iii
\'
viii
i.v
X
. xvii
si:( 'iioN
DISKASKS OK IllK NASAL l'ASSA( . KS,
('iiai'Ii;k I. A.NAioMv ()(■ iiii: Mxikknai. Nusi:, Nasai I'assauks,
AM) AccKSSOUY SlMsKS
Exloriiiil iinsc. :i: iiiisiil I'lissic. .'i : frontal sinus, (i; s|ili(>iiiii(l. 7:
t'llliniiitl cells. 7; iiiaxilliUX' sinus. S ; ncrxcs. 11: liluod vessels.
11; f,'lan(ls. 11.
CllAl'TKlt II. i'llVSIOI.()(a Ol 1111, .NdsK AM) .\( CKSSOKV Sl.MSK.S
Sense of smell. I'J: llii' nose in plioi ation. I'J: the nose in respira-
tion. i:i.
( iiAiTKi! III. — Instiu mi:n rs Iskd loit iiii-; F.xamina iion and TiiKM
Mi:\T OK DtSKASKS OK TIIK Nosi; AM) 'I'mioAr
I'",leetrie lani|i. 1."): lieadiuiirois. 1(1: .Mackenzie eoni-cntiator. 17:
nasal s]ieculum. 17: Kosw ortli'-. IS: Slmrly's. IS; ( loodw illie's,
IS; Myles"s. IS: Sincrock"s. IS; jiost rliinal mirror. I'.l; self-
retaininir jialali' retriictor. 1!': roiioii a|i|iliciitors. 2(1; tonjiue-
(le])ressoi"s 'Jl : atomi/e|s. -Ji' : insullialor-i. 'I'.l: jiost-nasal
syriiifjfcs. 2.'!; coin|ire<>c(l air apparatiw. 'J.'i : uasiil ^aws, 21;
<'liisels, 2"); iliills. 2('); cold w ire snares. 2(i: j.m1\ aiiocaufery
siiiires, 27: spokcsliaves. 2S ; |iunclies. 2S: curelles, curved
sci-sois. nasal hiiri*. etc.. 2S ; antciior rliinoscn|iy. 2!!; ))osteri(>r
lliilloseo|iy. ;!(t.
l)isKAsi:s Ol- IIII' NdsK.
ClIAl-lKl! I\'. .VciTK IJlllMTlS
I'alliolofry. ■i'2: cliolo^iN. .{2; syin|ptoniiilolo>,'y. .",2: dia^ruosis. '.V.\:
|)roji;nosis. ;!;! : |)ro|iliyla\is. ;{,'! : treatment. .'!t.
ClIAlTKIt \'. ClIliONK HlIIMIlS
I'atliolofT.v. ;i7 : etiolojiy, ;f7 ; syiu|)tomatoloi.'y. .'(7; diafrnosis. 3S ;
)irojj;iiosis. ;{S; treatment. .'^S.
( IIAI-IKU \l. I'lItCI.KNl KlllNiriS OK ( 11 1 1.DliKN
I'atlioliifjy. 41; etiolofry. 42; symptomatoloe-y. 12; diajruosis, 42:
[iroefnosis. (ili: treatment. 43.
( uvri Kii \'II. II vi'Kitritoriiic KiiiM ris
I'at lioloify. 4,"): etiolofjy. 47; syni|itomatol()f>y. 4!t; dii\;rnosis. ")();
profrnosis. ft\ : treatment. 51; ojieration by eliromic acid. 52;
i>|)eralion liy fralMinoeaiitery-knife, 52: ^'alvanoeaulerv snare,
51: operation l)y electrolysis. 55; turhineetoiny. 5(i: olectro-
eauterv ]iiinctiire. 57; snhmucous knife incision. 57.
(X)
12
32
37
41
45
(ON I lA IS.
M
12
i:>
.^2
37
n
»,")
t'HAPTEK VIII ATUOI'HK KlIIMTIS
l*ath(>liij,'y, r»H: t'tiiiloj,'.v, riil; syinptiniialolu;,'^ till; (liii;:iiii>i->. (il ;
luujriiuMs, »i2: trratnu'iit. tl2: use <if the pont nasal syriii}."'. (i.l;
(;(>lt>tfiirs |(lii;is, t;J: tn-almt'iit h\ u\A<-i;{<:i\ M.
CllArTKIl l\. (KdIMAKH S l!lll.MTI^*.
I'A(.K.
."iS
t'llAl'TKH X. I'lUUINDl s KlIlM I l>
Ndii ili|ilitliriiiic. T'l: tiaiiitialic iiifiiiliiiiinni-. iliiiiii i-;. 72: t|ii(-<
'lion III' iili'iility of liliriiioiis i'liiniti-< with ili|>litlii ria. Tii.
(.HAiTii! XI. l)i:i oKMiriKs ()!• iiii': N'asai. Ski- mm
I'lcxaltiiic of -ciital (Icfni nlilit■•^ anmn;: rivili/id ra<i'-.. 74: rarity
III ili'forinitirs aniini;: almii^nnal rarcs, '■\; cxaniiiiat inn nf Indian
skulls. 74: cla-^ilicalion of (lc\ iat inns. ;.'i: t'tiolniry. 7."); views
of /iirkcrkantll. l!o<'. 'ricndficiilinrir. .Mayo ColliiT. upon laiisa-
tion, 7ii; >y niptoinatolo^'y, SI: (lia^'no>is. SI; |.!otrno>is, S2 ;
Irciilincnl. s-J : liy us*- of saws, s;{ : knixt's. S;{; liuns. s;i ;
ln;;al>'s incllioil. S;i ; LoolTs indlioil. s;{ : liy i lc<)rolysis. S4 : liy
n-c of sihcr tnla's, H't; liy Watson's nictliod. St!; hy usi- of
inliltcr splints. SS.
CiiArri'.u Ml. DisToimoN oi riii: Coii mnak (aim ii ai.i:
CiiArir.n XIII. I'i:iti iiitATiiiN oi- nii: Scrii m
Kliolo>:y. Ill : tifatnicnt. ill. .Mis.c-^ of the M'plnni. !I2. I'lci ra-
tion of tlic septum. '.12.
• >7
70
CiiAi'TKU Xl\. II. XV l"i:\ i:ii. (lit \ .< sdNKmiu ItniMiis
I'at lioloj.ry. li.'t: ctioldi.'y. !I4; alinonnally sennit i\i' nci\ i' rcni ii'^.
!I4; liy|i('iii'>tlu"»ia of tlic pt'iiplirral tciniini. '.14: |irt's»uri' of an
irrita* injr aircnl . '.i.'i: tlic polirn IIh'oi'v, H."); llic uric acitl theory,
!lti: syniptonia1olo<ry. !itl; diaf.'nosi-i, !IS: |iriiirnosis. !IS; juc-
vcntivc mca-iiic<. '.IS; .natnicnt. ii'.l; constitutional ticatincnt.
!lil; t i<'at niciit of the di^ea^cd condition of the na-al passiiy;es.
1(111; treatment of the spa-niodic .iltack. Itid. Na-al hvdior
rh.ea. lii:!.
< iiAi"ii:i! X\'. .\N(ismi.\: r.MiosMiA: I'l in \( i i.osis
.\nosniia. liM: paio>inia. 1(15; fnnini ulosi-.. Id,").
CiiAi'i iii X\l. I'.nsi .WIS
I'atholo<,'y, 1(1(1; etioloi.'y. l(l(i: syniploiiial(Ooi;y. HKi; diai:iio--is,
107: jiroijiiosis. |II7: treatment. Iti7.
C'lIAI'Ill! X\II. li'lllNninils: I'ditl.It.N r.oliIIS: I ' \I!.\Si 1 i:s
IJIiiiioliths. llii; >ym|itomatoloi_ry. IK): diaj.'nosis. 111; prot;no>is,
111; treatment. 111. l'orei;;n liodie-. 1 12; syniptoinatoloiry. ||2:
dia;.'-|i"sis, 112: treatment. II.'!. .trasiics. li:t; Miiscii innii-
tiiiiii. riiiniisiiiiniiii iinifti Ihirin. Ill: symptomatology. 111:
I reatment , 1 1,').
CiiM'iKii Will. Nasai, I'm vim
I'alholo^'y. 11(1: site of attaelimeiil . 117: eiinloMy. IIS; v\m|ii(im
atolooy. 1111; dia;,'iiosi<. pJl; proe;Mo-i<, 121; treatment. 122;
li.\ snares. l-_'2; liy the use of foicep-. i2."i: liy clectroh si<. |_'."(.
('HAi'lllt XIN. r.\l'Il.l()M.\
Sit
',11
'.i;!
1()»
Hill
I'atholojL'V. 12(1; treatment. 127. Ililateral tumors of tli
l.xMiphoid \:
■rci't 1
\ariei\. 1:
'pi iim.
treatment ,
CllAI'lKIt .\X. I'lltlidMA
I'atholoe-y, 12S: eliolocry, IJS; syinptomatolojry. 12S: dia>riiosi
I2!l: piojriiosis. 12!».; treatment. I2!l. History of a case, Kid.
12S
xn
CONTKNTS.
PAOE
ClIAI'TKK XXI. ADKNOMA: AsiiHiMA KVi
Adciioniii, l.'12; an^rinniii. I.'t.'j.
ClIAI'TKK XXn. -CY^ST()MA Ol Till-: NosK 134
ClIAl'TKU XXIII. ('MO.N'DIiOMA : ( )sTi;().\l A 130
C'lioiidroiiia. \'Mi. (Islcnina, l.'{(»; patliolciifv. l.'JT: cliolngy, l-'?7:
Kyiii|il()inat<)I()}fy, l,')"; f rcatniciil, ]'M.
ClIAI'TKK X.\l\'. SaU( .>.MA 13»
l'atli<il(ijry. l.'tS: of idlofry. |:iS: -y iiiptiiiiiiitul(i;ry. |;{!i; diagiioHi'^,
l;f!l; |Hii<,nio«is, l.'5'.t: treat rnciit , l.'C.t
ClIAI'TKK X.W. (AKriNOMA 141
I'atlidldfry, 141; clidliifry. 141; s\ iii|it(iiiiiiliil(iffy. 141; ilia^iiU'^is,
I4"2; ]iro;;n()sis, 142; Ircatiiiciil . \ i'2.
Chai'tkk XW'I. 'rniKKcri.osis 143
Talliolo^ry, 143; cliold^iy, 144; sympt(Hiiati>!o;.'v. 144: diaj^iiosis,
144; profjiiosis, 144; Iroatinciit. 14").
ClIAI'TKK XXVII. 1,1 IT.'^; (Jl.ANDKKS 14(>
l,ll|ilis, 14ti: iialliolofty, I4('>; ct inl(i!,'y. 14ti: sy ni])lomati)lny;y,
14tl; (liajfiiiisis, 147; prognosi's. 147; trratinciit. 147. ( ihindcrs,
I4S.
ClIAPTEK XX\I!I. - l{lllNOS(I.KKOMA 149
CiiAPTKK XXIN. SYriiii.i.>< 151
Muc()\H patch. I.'il ; siipt'i'lk'ial iik-cr, ir>I ; bony iiporosis, ir)l ;
patli(>liiy:y, ir)2; symptoiiiatolofry. \'>'l: diafriKPsis, 153; proj^
iKisis, 153; trt'atiiicnt, 153.
ClIAI'TKK XXX. roNCKMTAI. SY1'IIII.I.>< 155
Sviiipt<)inatol()fj;v. 155; diagnosis, 155; i)ro<;iio«is. |.")(i: tifalinoiit.
■l5(;.
DiSKASKS OK ACCESSOKY Sl.MSKS Ol TilK No.SK.
CHAI'TKK XXXI. ACITK SlMSITIS 1 i")9
Ktiolofry. I5!»; syinptoniatolofiy, Kid; tnatnicnt. Mil.
ClIAI'TKK XXXIl. ClIKOMC DiSKASK OK TIIK AXTKIM OK Ill< IIMOKK lti2
Patliolofjy, Itlli; ctiolofry. I(i5; syiuptoniatolopy. lt»5; diafiiiosis.
1(1(1; pidjriiosis, l(i!); trcatinciit. Id!); first, by direct irrijiiitimi
thioii>rli the ostiimi. 1(!!»; second, by o|ipiiin(j (hroiiffh (ho in-
ferior meatus. Kilt; tliiid, by removini; a tooth and washing
tliiongh (he alve(dus. 170; fourth, by opening (ho canine fossa,
170; tiftli, bv the condiined method. 171. ('\st of (he antrum,
174. ■
CllAI'TKI! XXXIII. IvrilMOll) DiSKASE 175
I'adiology, 175; eliology. 17(i; syuiploniatology. 177; diagnosis,
77: ]>rognosis. 177; (rendiient, 17!^.
ClIAI'TEK XXXIV. Sl'IlK.NOin DISKASK 180
Frontal-sinns disease. IS I.
SKCTION II. DISKASKS OK rilK I'llAKVNX.
ClIAI'TKK XXXV. .\NATOMY OK TIIK PlIAKYNX 185
Houndaries, 1H5; openings in(o (ho jiharynx. IS5; mucous mom-
hraiio, IH!); jdiaryngeal glands, l!t(l; arteries. IJtfl; veins, 100;
nerves, 1!(0; naso pharynv, l!tO; faucial tonsils, 101; lingii.nl
tonsils, 101.
^
Itl
coNrKNTs. xi'i
l»AOE
('IIA|-Ii:it XXWl PllYSl()l.()(iY Ol TUK I'lIAItYNX Ut.'J
Division into niiso pharynx and oropharynx. 1!>.'{; the soft pahito,
Mt.'i; lissnos of (he oro-pliarynx. 1!)3; (h'fjlutit ion. 1!>3: physio-
h)^nral fnnctioim of the tfinsils, H14.
DlSKASKS OK Tin: \AS0 I'HAHYNX,
ClIAI'TKK WWII. NaSO lMIAUYN<ii:AI. (AiAnnii 1!>5
Pathology, lO'i: otiolofjv. |!MI; syni|iloni:ilnlofr\ . ijiS; diaHiui.sis,
l!t!t; I'lroffnosis, 1<I!»; "trcatnionl". !!•!•.
Cmai'tkk .X.X.W'in. .\i)i:.\()ii) (liiowi lis Ol riii; Naso i-iiakynx 204
l'atIioloj,ry. •2(M: ctiolofry. 2<M!: syinptoin.itohifry, 'H*7 : ^rcnorai
symptoms, 2(IS; cxtfrnal (icftirmitics of nose and chest due to
tiie disease, 20!): dia},'nosis. lild; proffiKisis, 210; treatment, 211 ;
{reiicral ana'sthesia durint.' operative treatment advisat le witli
ehildren, 212; relative merits of ether, bromide, of ethyl, nitrous
oxi(h'. and ehloroform. 21.'i: operations by galvanoeau'tt'ry, 214;
snares, 214; i)ost-iiharynpeaI forceps. 214; curettes. 215.'
CiiAiTKu XXXIX.- MYXoiinno.\fA of tuf. .Naso imiary.nx 217
I'atholopy, 217; etiolofry, 218; symptomatolofry. 218; diaf,'nosis,
21!»; prognosis, 2 lit; treatment ,' 2I!t; report of cases. 220, 221.
C'JiAi'TEU XL. Fiukoma ok nn; \as'> i'hauynx 223
Patholon-y, 22.3; etiology. 223; symptomatology. 224: diagnosis,
224; prognosis, 224: treatindit, 224.
CiiAi'TEU XI.I.-Mai.ki.nant Diskasks (11 Tin: .Va.so i-iiauynx 227
Sarcoma, 227; jiathology. 227; etiology. 227; syinptomatologv,
227; diagnosis. 227: prognosis, 228;' treatment, 228. Carci-
noma. 220. ( hondroniii of tho nasopharynx, 2.30. Foreign
bodies. 2.30.
l)isi:ASi:s OK TiiK Oho riiAHYNX.
CHAI'TKK XIJI. .\( ITI- rilAIlYXOITIS 231
rathr)logy. 231; etiology, 231; symptomatology, 2.32; (iiagno.sis,
233: jirognosis. 2.33; treatment". 233: comparison of the values
of eoeaine and eueaine. 233.
CiiAPTKif XI, III. CiiHoxic riiAinX(;iTis 237
Pathology. 237: etiology, 237: symptomatologv. 2.3.S : diairnosis,
238; prognosis, 238; treatment! 23!t.
TiiAi'TKi! XI. I\'. ToMK iT.Ai! I'll A H Y .\(irns 240
Pathology. 240; etiology, 240; symptomatologv. 241: diagnosis,
242; prognosis. 243: treatment, 243.
CiiAi'TKit XLV. .VciTi: 'roNsii.i.rn.s. or (^iinsv 24.5
Pjithology. 24;"); site of abscess. 24t!: etiology. 247: svmittom-
atology, 247: di.ignosis. 248; prognosis. 24!'t; treatment. 240.
(Question of the time the abscess should be incised. 2.')0.
Chapter XLVI.— Diseases ok the Cvi i a; (Kdema; Ki.onoation. 252
(Kdema. 252; etiology. 2.V2: symptomatologv. 2.")2 ; jirognosis, 252;
treatment. 2.52. Klongatinn" of (he uvula." 253; patholngv,' 253;
e(iology. 253; symptomatology. 2,")4 : diagnosis. 2.54; prognosis',
254: treatment, 255.
Chatter XL\'ir.- Rethopiiaryxoeai, Ans( kss 258
Pathology. 258; etiology, 2.58; symptomatologv, 2.50: diagnosis,
2.50: prognosis, 200; treatment". 200.
1
XIV
(II A I
ClIAl
(11 A I
(11 A I
(11 A I
(HA I
ClIAl
( IIAl
ClIAl
C'lAI
ClIAl
ClIAl
CONTKNTS.
PA (IE
IKK XI.Nlll. lIvrKiM lioi'iiv ()!■ nil-: FAitiAi Tonsils •2(i2
l'iillit>lnj,'y. 2(i2: ct ioliifry, 2(14; syiii|it4iiiial<>l«i;x\ . 2(i4 : (liiif;iiii.-iiH,
'M't'y. ]niij;m>sis. 2(l(i; t icat miciiI. liliT : iiit'dical. 2(17: ^ur^'iciil,
2(17; toiisillotoiiiy. 2ti7 : sccniiilarv liii'imii rlia;.'i' at'tcr tonsil
lotoiiiy, 2(>!l; (>|i<'i'ati()ii liv colilw ire snare. 27(1; sci.-sors. 270;
caiitciy, 271.
TKK XLIX. — LAtlNAll 'r<).\sii.i.iTis 272
l'atlii)l<)<.jy, 272; t'Molofry, 27:i: syni|>t()iiiati>|iiu:y. 27;{: (lia>;iir.,is,
274; ]ir<i<,'n()sis. 27r>; IrcatiiH'iit, 27').
ii:ij L. I'liAUVNCiKAi, .My( osis 277
J'afli;>l<)<ry, 277; cliolopy, 27!l; syni|)t()nia((il<ifr\ . 2S|; iliaiiiici^is,
2S2; proffiiosift. 2H2; trcatincnt. 2.S2.
TI 1! 1,1. Ihl'I'IlTlirHMlY (H- Till-; r.I.NMil Al ToNsii 2S4
I'atlinjdf.'y, 21S4. <'|i()lnfry. 2sr); syinptoiiialolnfiy. 2S(!: diaf^iiosis,
2S7; ]iri)<rn()sis, 2S7 ; licatiiK'nt . 2S7 : i)|i('raMi)n l)y <.'nlvani>-
cault'ry, 2S8; by liii<;nal tonsillotonic. 2HS: 1)\- hot or fold siiaio.
288.
TKU lAl. — HK.NKiN Tr.MOHS Ol' TIIK IMlAUYNX 2!H)
l*a|>iIloiiia. 2!M1; iiliroiiia. 2!t(): oju'iativc (rcalniciit. 2!il. .Vdcnoiua,
2!)l. Dermoid Imiiors. 2!t2.
•ii:k I,1II.--Ti iii;i{< ri.osis oi- riiK I'iiauv.nx 293
I'alliolo<,'y, 2!t;{; etiolo{;y, 2!>.'{; syin|i1oinalolo<,'y. 2!14: (lia<;iiosis,
2!t4; profTiiosis, 2itr); treatment, 2!tr».
TICK 1,1V. l.iiMs or Tin: I'iiaiiynx 297
Patliolojry, 2!I7: et ioloiry. 2!IS ; syinplomatolojry. 2!t8 ; diaj^nosis,
2!>!>: ilrof;>-osis. :{(l(»: 'treat iiiciit'. :{(»().
1 Kit l,V. Syimums ok nil': I'hauynx .'?0I
I'atliolojfy. .'{(tl ; primary, secondary, and tertiary lesions. :!()l: e(i-
olo<ry. .'(02; symptomalolojjy. .■{(12; diajjnosis. ;{()4: elianerc.
sy|)liilitie erytlii'ina. miie<ins ]iateli, j:\ininiy tuinois. deep ulcers.
I'ieatrieial tissues, ;{((4. .'id.'); prof^nosis. ."ill."); Ireatnicnt. 'M)■^.
.Xctinomycosis. 30(i,
TKI! I,\l. SaI!< OMA OI lUV. Ka ICK.s .'{07
I'atlioloNy. .■!()7: et iolojr.v. .■!(t7: syniptoinaf oloir.v. oOS; diajfnosi-.
;)(I8; jirojriiosis. .'td'.l: t reat nK'iit'. :i(Mt. Leukoplakia palali. .TKi.
ri;i! l,\ll. Caiscinoma oi' riii-; I'.mcks :?11
I'atlioli'jiy. :{|1: etiolo|.'y. I!l.'t: -.ymploiuatidoLry. .'!l,'{; diagnosis.
.'il4; ]iro<,'iiosis. :il.'i: ticatmeiit. :{|.i.
nii l,\'lll. Ni:riiosi:s ok riiK Kaicks 318
Nciirose-i of sensation. .'ilS; liypcra'stlicsia. jiara'stlifl-iia. ;ilS:
neuralfjia. ,'ilS. Nenrosc-i of motion. ;jl!t: spasm of tlio ]iliaryn\.
,'!l!): paralysis of the ]iharvnx. 31!); myopathic jiaralysis. 31!t:
]ialato <rliisso ])har\ii<rcal paralvsis. ,321); acute hnlhar paralysis.
.•i2(».
TKU I.IX. 'roNsii.i rnis. l"oi!Ki<i\ Hodiks in i iik Faicks .321
Tonsillitlis. 321. Foreijfii iMidies. 322; svniptoms. 322; ]>rof5nosis.
323: treatment. 323.
I
SK( T|()\ 111. I)|SK.\SKS OK riiK i,.\i;ynx.
ClIAl .'{ 1,X. .Anatomy ok tiik Fakynx 327
Anatomy of the eiieoid. 327; the thyroid, 328; the arvtonoids,
320; the epifrloUis. 3,30; the lifrinnents. 331: (he articulations.
3,34; the muscles. 3,3.'); (ho arteries. .33,"); the lyuipludics. 33');
the ni'rve-i. ;i3,") : (he mucoui mcmhranc. ,3.3,">.
(()Nri:M>. XV
r.xf.i:
ClIAriKK LXI. I'lIVSlOl.iX.Y OK TllK I-AKY X .'!.'17
iMHictioiis of llio liirvnx. .'f.'!7 : ic«i|iiratiiiii. ;i;!7 ; )iliiiiial inn. ;f:fS;
pitch, :VM: intensity. :i:i!i: ciu:ility, :!.{!•.
C'iiAiTKii LXIF. LAUV\(ios( oi-v ;j4it
The use of tlic tliroat-niinor. :{KI; t'xainiiiation of tin- laryn\. .'ftii;
lioldinfif the tonf^iH", ;{4<i; view of the v >i'al conls. :\\2: po^ilioii
of the ('[liirlottis. :iA2: piclnrc of tiic larynx. .'U:!: po-iiion of pa-
tient in laryiif;oiiiffieal examination. ."{44.
<'iiAi>Ti:u lAili. AfKiscoi'Y :il.')
Chai'iku I.XIW Inti iiation :!.")(•
< IIAl'IKK lAV. — 'JllA( 111:0 If)MY: TllYKoroMY ;!.")!
Instruments re(|uire(l. ;i.")4: iliseases for wliieh tlic operation may
l)f' re(|uireil. .'{.")4: nci'essity for anii'stlii"»ia. ;!.").">; eiioice of allies-
tlK'tics. ;!.").■); tlie use iif eoeaiiie. 'iM; the hiirh op<'iation. :!.")7 :
tlie low operation. .'!.")S ; thyrotomy, .'!.")S.
( llAl'TKI! I.XVf." ACI TK l,AltYX(UTIS I'.CrJ
I'atholoMfv. ;{()2: etiolo}.'y. 'M'fl: symptomatohi;;y, :!();{; diagnosis.
."Ui.'J; ])ro<rnosis. ;itl4; treatment. :{ti4.
C'liArTi'.u LX\II. .\( 1 11; r.AltY\<HTIS oi' ('iiii.i>1!i:n :!(i7
l'atliohi<,'y. ;i(i7; etiolojr.v. •i<i7 : symptomatolo;;y. :>liS: liiaj^iiosis,
.'{(iS: I'lrojrnosis. .'!()!»: "treatment", .'iti'.t.
<'iiAi'Ti;i{ i.XVIII. — .\( iTK (Kdkmatois Lahymutis .{71
I'atliolofry. 1^71; etiolojry. .'i7l; symptoma1ol(ij;y. :','-2; cliaj;iiosis,
'M'2: ]ir(i^nosis. .'i7."{: treatment, .■{7."i.
f'llAlTEU I, NIX. ."^IMlM.l. (Kni.MA OI- Till'. l.AHY.NN ^^7't
I'atliolo^'y, .'?7"): etiohijry. •■!7"): symptoniatoloMy. .'!7">: <Iiagno-i<,
.'i7(>; jirojfiiosis. ,'i7(l: tieatnieiil . .■!7t>.
CiiAiTKi! lA'X.- ( iiitoMc LAiiYNciiris ;!77
l'allioh]<ry. .■J77: etiolofry. .^77: syniptomato]ci<ry. "S ; (lia;jno-i-.
:i7'); ]iidijrn(isis. ;{7!t : treatment, HSd.
CiiAi'TKi! I.XXi. -AritoiMiic LAHY\(;n i.-< :!s4
J'atliohifry, .'?S4 : svmptomatolojfv, .'>S4 ; iliaj;nosis, ;i,s."> ; jiro^fiio-is.
.^S-); treatment.' 38,").
CiiAiTri! lA'Xir. l'A(iiYi)i:nMiA I,auyn(;is :!S7
I'atholooy. .'!S7: etiolojry. .'t.S7 : symi>toinalolofry. 3,SS: (]ia;.'nosis.
."iS.S: pi«i<rnosis. :i,SS: treadnenl. .^S!!: |iaeliy(h'rmia consiripta.
.3.S!l: pachx cleniiiii (iilliisa. :!S<l. Sul'jrloHie cliroiiic hirvni'itis
C'liAi'TEi! I.XaIII. l'si:ri)()\ir.Mi!i!ANors I,auyn<.ii!s :!iii
CiiAi-rr-H i.XXi\'. I.AiiYNcKAi. l'i;i!iriio\i)itiTis ;{!».!
]*atiio|.j<ry, :{!i;!; etiolojry. .'5!l.T; symptomatoloiry. :{<);{: (lia;.'no-is,
.1!t4; hi-tory of a ease. .W."i ; 'pro^rnosis. ,n;t,")': treatmenr. .T.tli.
AU'eetimis of (lie erieoarytenoid artieiilal ion, .'100.
f'liAi'TKij I.XXV. Ti lir.ucii.o.sis or thk I.ai:-^ \\ 3!is
I'atliohifry, :!nS: etiolonry, ;{!i!l ; syinptomaloloj,ry, :<!»!»: dia^rnusis.
40(1; pri'i.Miosi<. 401: (reatment. 4(t-2: intrahuynr;eal siirj,'ienl
treatnieiil, 4(».'i: eiind tement.. 4(U: eonda-indicat ion« of cmetle-
inont. 403: traclieotomy and larynfrotomy. 40:!.
i'li.M'iru LXX\r.- T.TIMS or tiik T^auynx 401;
I'atliolofry and otinhicry. 4()(;: symplom.ttcdojry. 407: diaiinosi*.
407: prognosis, 408; treatment. 40S.
XVI
CONTENTS.
CiiAPTKK LXXVIf.— I.ki'Hosy oi tiik Aiu i'AssA(ii;s 410
Leprosy of tlie nose. 411. Leprosy of the mouth and pharynx. 41;?.
Leprosy of the laryn.x, 412; treatment, 414.
CiiAi'TKK LXXVIIL— Syimiii.is oi thk Lary.nx 415
Palholofjy. 41"); etiolojjy. 41(1; syni|)lomatiilo<ry. 417; diaj^nosi^,
417; prof^nosis, 418; treatment, 418; snrf^ical (icatinent, 41S.
('on<(eni(al sypliilis of the laryn.x, 420.
Cjiai'TEU LX.XIX.- .\i:ri{()si;.s ok riiK Lauynx 421
Nenro.ses of sensation. 421. Anu'stliesia, liypenesthesia. para's-
thesia, iieural<:ii, 421; treatment, 421. Nervnus aplionia, 422;
sympt.oni:itol(i<ry. 422; treatment. 422. Neuro>es of motion, 42.S.
Spasm of the ghjttis, 42H ; i'liolofjrv, 423; symplomatolofry, 42.'V;
(liatrnosis, 424; prognosis. 424; treatment. 425. I'aralysis of the
laryn.x, 420. Alidiutor par;ilysis. 42t). Hilateral |iaraly«is, 427;
treatment, 428.
ClIAl'TKK LXXX. — XO.NMAI.ICNANT TlMOHS OI- 1 HE LaUYNX 429
I'aftilloma, 429; fibroma. 429; cystoma. 430; lipoma, 4;>it; an
gionia. 430; sym])tomatology, 430; diagnosis. 431; prognosis,
432; treatment. 432. Knehondroma, 433; midtiple papillomata
of children, 434; treatment by trucheotomy, 434.
CiiAi'TEU T>XXX[. — Mai Ki.NANT Tr.Mo»8 ok the Larynx 436
J'athology, 437; symptomatology, 437; diagnosis. 438; jirognosis,
438; treatment, 438; endolaryngeal ojK'ration, 439; hnyngec-
tomy by Solis-Cohcn o|K-rntion, 440; l)ehivan"s rules for gniil-
ance, 440; Middiemas Hunt's case, 441.
Ciiai TER LXXXIL — Foreign Hodies in the Laisynx 442
Svmplomatologv, 443; diagnosis. 443 ; pi'ogno>is, 444; treatment.
■ 445.
Chapter LXXXIIL- Hoentoen Kays in Larynoeai, Sltroeuy 447
Chapter LXXXIV.- Operations for Nasai, Deformities 449
Annandale's operation. 450; Ellet's operation, 450; Roe's subcuta-
neous operations, 451.
Chapter IAXXV. -(H'krations for Ci.eft Palate 454
Stapliylorrhaphy. 455; MacDonald's opc'ration. 455. rrano])la8ty,
450; Ferguson's opei-ation, 450; Mason Warren's method, 450;
lirophy's mctiiod. 457; before operation. 457; operation, 458;
aft«r oj)oration. 45S: Owen^'s opinion. 459.
Index to Literary Kei krinc ks 461
General Index 464
I-IST OF IIJ.rSTKATlONS.
11(1.
I.
s.
it.
Id,
II.
12.
13.
14.
15.
Hi.
17.
IS.
IS).
20.
21.
22.
23!
24.
25.
2fi.
2fiff.
27.
28.
28«.
28h.
28r.
29.
.•to.
31.
32.
33.
34.
35.
3().
37.
38.
39.
40.
41.
Ciirtiliifjci of tlu' iiosc xM'ii ill |iri)lili'
Sagittal section of skull, just lo the ri;,'lit of the septum, show int;
ii;,'lit nasal fossa ^
Anterior section of the nostrils
The ]>osterior rhiiiosco|iie iiiia<;e
Frozen section of head of adult 1 color <-ut )
IMiillips's <>Iectric |ihoto|ilii.ne, willi adjusliiiciil for focusin<{ light..
Head iiiiiro.r '.
ll( ad-mirror in posit ion
Laryngoscope, gas stand, mirror, condenser. ;iiid liihiiig
liosworlli's hirge and small nasal <<|(ecnla
<!o<i(lu illie's nasal speculum
M ylcs's nasal speculum
Sincroek's nasal s])eculuni
Sincrock's nasal speculum, with handle
l^usworth's nasal speculum, with sjiicld for (autcry work
Shurly's nasal speculum '
Post-rhimil mirror
Post-rhinal mirror
White's fielf-retaiiiing ])alate retractor
Applicators
Tongue-de|)ressor
Tongue-depressor
Tongue-depressor
Sass's tongue-depressor
Tiirek's tongue-(lei>ressor
Davidson's atomizers, to he useti liy eoni|u-essed air or hand-bull). . . .
Hurgcsa's nielaltulie atomizers: straight, up, and down
Mosworth's atomizer
Compressed-air apparatus
Powder-hlowor with mouth-jtieee and tube
Powder-blower w ith bulb
Powder-blower with tubing and bulb
Powder-blower with scoop
IJosworth's nasal saws
Mial's reversible saw
Hartmann's nasal chisels
Freeman's drill
Hosworth's nasal polypus-siuire
Sajous's nasal polypus-snare
Hall's nasal i)olypus-siiare
Deneh's nasal polypus-snare
Universal cautery and snare-handle, with cannula and snare
Cautery-electrodes
Nasal burrs
Nasal trepliines
Beren'a and Nichols's spokeshaves
(xvii)
I'A<IK
I)
15
10
10
17
18
18
18
18
18
19
19
19
19
19
20
20
21
21
21
22
22
22
23
23
24
24
24
24
25
25
25
26
20
20
27
27
27
27
28
28
28
will
M>l' 111 II.M>II! \ll(tNS.
no. r.\(iK
•lii. Aiitciiiir iliiiiii^<ii|i\ , |iii«iti<>ii ni' the IkmiI I'm iii-ptii iti;,' tlic wnll nf
llic |iliiii viix lliniii;:li the iiiwal iPiixwiijri's 29
■4.'!. I'ltstt'iidr rliimisrii|iic iiiiii;."' 'M)
44. Jl v|i('ili<>|iliy nf mi. Idle :iii(| iiifi'iinr t iiiiiiiiiil« 45
4r>. Si'fliiJii nf iiUVriiir tinliiiiiilccl {■!'> iliiiiiicl(i-.i 40
4<1. I,!ir;fi' iiiii^scs nf liy|M'it ni|iliii'(l iiH'iiiliiiuic nil llic |)()>ti'riiir tcniiinii-
tinll (if (he liivvcr t iirltilUltcil Ikhics, iikiic (if less coiiiiilcUly
lillin;,' tin- |iii-i«ii(ir iiiiic-; 47
■l(i»/. Aiilci inr |iiirliiin nf iiifciinr tiiiliiiial ('/..iiuli nliiccliNci 48
4(i/». l'(i>l('iior iiititidii (if iiiiVriiii- linliiiial (l-iiicli (iLJcctiN ci 4H
47. lialluiil },'al\aniu-aiit('ry lialh ry. with fiml. liamlli', and knife 53
4K. Knif>lit'N n!i>ial scissms fiCi
4!». Sliiirly's nasal forcc|i« 57
51). I'ost na-al --yrin;.'!' (i;{
5((</. J'lwl nasal syiiii;;r ((3
5i. Fm/cn section nf the head <if a iliild a<jed 5 years i (dlnr cut ) 77
5|(/. I'ldzen seelinn nf ^aiiii' eliild. taken twi eentimelres anterior in |''ii^,
51 leolor-eUt I ~',)
52. Seetidii of cart ila;.'iniiiis -yuv fnmi tlie na-al septnin (25 diaineters) . 84
5.'{. Silver tnlies for se]ital defniMiity 85
54. Silver tnlies for sejital deforniity .• 85
55. I!ell<i( (|'s cannula 108
5(!. Kliinolitli reninved from the left nasal jiassa^'c of a lady, ayed 2S,
nineteen years after the Insertion of the Imlton intti the nostril. Ill
57. S|ioiin 113
58. Hoswiirth's nasal forceps 113
5!». Allij;ator for.'cps 113
fiO. liartniiinn's foii-ep-. 114
til. Nasal polypi IKi
(12. ^Microscopical section of na-al polypu- i2(il( diameters) 118
(i3. !Miei()sco|iieal section of nasal polypus from a child 7 years old.... 120
04. r.lake's ear iiolypu- snare ' " 122
65. ("aseous mass washed out of antrum thron;_'li ostium maxillare 102
00. Lateral frozen section throufrli the middle rejrion of the nose (color-
eut.) 103
67. I'ileclrie illuminator with llcxihle shank and cords 1()7
68. (jironal section of the maxillary sinus, the suhject of cystic disease. 173
Oft. Inlhunniation of the ethmoid cells, show iiii; jj^lands to ri;i;ht (|uite
normal and those to lower left hand more or less altered 170
7(1. Sectional \iew of the ]iharynx 180
71. Frozen secliim. Side-view of nose, pharynx, and larynx of child,
afzed .'t years (color-cut ! 187
72. The muscles of the soft ]ialate and pliar\n\: the pharvnx laid open
from hehind .' ' 18!)
73. Infantile ademiids 204
73«. Infantile adenoids (represents a ".nnwth i|uite common) 204
74. Stalactite forms 205
75. Micrnsco]iical section of hypertrophied ]iharynf.'eal tonsil with lym-
jilioid intiltration (2(i diameteria) 20(5
70. Adenoid forcejis 213
77. Adenoid curettes 215
78. Dr. (iranfs ease of ]iost nasal jmlypus 217
70. Uvula-seissors 255
80. Excision of uvula 250
81. Simple livpertrophv of faneial tonsil (57 dianieters) 203
82. Mathieu's tonsillot'omes 208
53. PliarynfroTuyeosis (polor-eut) 277
84. Loptothrix. Adventitious folliele to left side (color-eut) 278
LIIST OK ILI.OI li ATIONS.
XIX
Fli.. VM.y.
S'>. I,t|il<illiri.\ I// ■•>■///( r , illi ll iilijccl ixc; ccilul- cut I i'S
Hti. Kfiiilosis of tnii-^il «illi liptdt liiix ('/,;iiicli (it)j('clivi': ((iliirciit i . . 27!>
k7. llypt rlmiiliy "t tlif Nil liii;iiiiil tonsil 2M
H'a. I'.ilatciiil li\ |ititroi)liy of liiiyfiinl Inn-il , . .• 284
HH. I.iii^iiial \;iii\ (lolo'r-rut ) 285
8!t. .Mil ros('o|)i(al section of iolif of lin^niiil tonsil 280
!)(). Itoc's lin;;iiiil ton>illoti.nH' 288
!•!. I.nims. I'alntiil a|i|icaiancc 2f)7
\t± l.n|iiis of linjrinl tonsil ('/.riiidi olijcdivc; Klirlich-lUondi stain:
color-cut ) -Jiis
'Xi. Lupus of lin^'ual ton-il (' iiidi olijiiiivc; I'lirlicli lUonili ^-tain;
color. Ml I •-'!"•»
!tt. Malijiuanl i iiitliclionia, cxtcnilinj; fn ui rij,'lit tonsil to liasc of
1oii;.'U(' . . •'Ml
!»"). Stialilii (1 c|iitliclioiiia of lon-ils (''.-inch ohjcclivci ,\\'l
!)')(/. Kpitliclionia show inj; cell iicsts ('/..-incli olijcctixc i :i\'A
(tli. ]{()l)crt son's calculus fimn ri^zlil ton-il .'!'J"J
!•?. 1 lu' laifilafiinous frame of iIk' larynx, with the hyoiti Imne ami
li^'amcntous atlachiiients .'t2S
ftS. 'I'he crii'oid, seen anteriorly .■{2i»
fli>. The cricoid, u]i|ier surfiiee .T2!l
KM). The cricothyroid niuscle, \ic\\ed anteriorly 'V,W
lOtV/. 'J'he \<ii(c hox. or larynx, seen from liciiiiid X\\
1(11)6. ^'ie\\ of the \di<-e lioN, or laiynx, cut open from liehind UHl
101. 'J"hc arytenoid and posterior cricoarytenoid )nuscles 'i'.i2
102. Side-view of tne larynx. -ho\\in;r the interior, the ri^rht plate of the
thyroid lieinif removi'd 'Mi
lO;?. The lar\ Uiioscopic inia;.'e diiiin;: respiration 338
104. The laiyn;roscopic imajre duiiiiLr phonatioii 338
10.'). l,ai-yn;,'eal and posl-rhinoscopic nnrrors ;!ti»
lot). The hirvnf;eal mirror in |iosiiion (Cohen) when held liv tin; left,
haiid ■ 341
107. Position for aiitoseopy 345
105. .\ulovcope w ith jihite instead of hood 34(5
100. .\ntoscopie o|icration 347
110. Tonj,'Ui'-(lepre-sor for ]pharynj:oscopy and dircit iarynf;otracheo>copv. 'MS
111. O'Duyer's int nhal ion-set '. ." " " . 350
112. Instruments for intwliation 351
113. Plated iraeheotoiiiy-tnlK" 354
114. Hard rnldier tracheotomytulie 355
115. Klsl)er<ir's t lacheotomy-tulie 355
W'lit. Hank's tracheotomy tnhe 35(i
1 Hi. Low traeheotomv (color-cnf > 350
'J'lnrotomv (eolor-cnt i 350
I'.
I,
1.
iiryufroscopK' appearance
123. l.upns of the opifflottis (Vn-i'H'h objective; Khrlidi-Hiondi stai
eoloi- cut )
400
407
124. I.upus of the epijjlottis ('/.-inch ohjective; Khrlicli-Miondi slain:
ef)Ior-eut.) 408
125. l.ejirosy of the tonijue and epiglottis 413
12(!. Destnietion (,f cpifrlottis from s\philitie ulceration 415
41(1
410
127. ( ieatricial stenosis of larynx, tlie result, of syiihilitie idceratic
128. Lennox Browne's hollow larviiwal dilator with enttiiifr-tjlade
129. P«i)illonui of cord during rps))iration 420
XX
LIST (»K Il.I.USTHATlONS.
no.
130.
131.
132.
133.
134.
135.
130.
137.
138.
139,
140.
141.
142.
143.
144.
Sumc during plionalitui
Fibroma situatt-d hcncutli tlie rifjiil vonil lord
Chondroma of Mip epiglottis
Angioma of the left arjepiglottic fold
Kxtirimtion instruments
Sarcoma of tlie larynx, as seen from heliiiid
Tooth-jihite in glottis
Tooth-iilate removed ; ; / ; •
Laryngeal polypus forci-ps, Maeken/.ie'.-,, revolving, with three altaeli-
ments
r.aryngeal polypus forceps, \\ axliam's
Laryngeal polvpus forcc)s, I'raeiikcrs, culling jaw
Laryngeal polypusforcf ps, Mackcii/.ic's, articulated
Load iilate for nasal uveli
Steel pill for nasal transfixion
Nasal ajiplianie in i"Hit ion
'.VOB
429
43U
431
431
433
43(i
442
443
444
444
44r)
445
449
449
451
r.voK
421)
. 4ao
. 4:u
. 4:u
. 4:j:»
. 431)
. 44-2
. 4»;j
444
. 444
445
. 445
44»
, 44i>
. 451
S1{(TI{)N I,
Diseases of the Nasal Passams.
f
I llAITKIf I.
ANATOMY OF TlIK KXTKKVAl. NOSH, NASAI. PASSAGES,
AM) A( ( KSSOIiY SINLSKS.
TilK outer iKxi' ('(insi.-ls nf ilic \i«ililc jinriiim nT that organ,
t'omposed of lioiu's, cartilajics, lilmtii.-; tissue, umsck's, integument,
and mucous inemhraiu". It contains, within, the two vestihulae, sepa-
rated from eaeh other perpentlieularly hy tlie anterior portion of tlie
trianguhir cartihige (Fig. 1) and tlie iiiti'rnal union of tlie h>wer lateral
cartilages.
The lateral wall.s are Torined liy tin' nasal hones, and the nasal
processes of the superior ma.xillary Ixmes, together with the upper
and lower lateral and sesamoid cartilages.
The septum dividing the two nas^al cavities from each other is
formed directly helow the triangular cartilag<\ already mentioned, hy
an additional narrow slip of cartilage at the entrance of the nostrils,
termed the "columnar cartilage."
The openings of the anterior nares are usually on a lower level
than the floor of the nosi"; and they are also ]»rotectod hy a " "her
of stilf hairs, or vil)rissa>, which line the nostrils and the vesihuio.
The various muscles of the nose are attached to the external walls
and are for the i)urpo.>o of dilation and contraction of the nostrils
and for the elevation and depression of the orjran.
The nasal fossa3 are two cavities ahout equal in size, extending
from the nostrils, or anterior nares, directly hackward to the naso-
pharynx, and entering it hy the posterior nares, or choanas, as they are
sometimes called. These cavities vary very much in size, the average
depth from heforc hackward in the adult heing ahout 5 centimetres,
and the height 3.5 centimetres in the centre of the fossie. The sum-
mit of the vault on each side is only a narrow chink, arching from
the front to the hack; while the floor runs almost horizontally hack-
ward, with a surface varying hetween 1 and 1 Vj centimetres in width.
The external walls of the passages slant irregularly outward and
downward (Fig. 2).
(3)
4
i)isi;.\si;s OK jin: ^.\^Al. tassagls.
Tlio si']iliiiii divides the fossji' fi'oiii caoli other from front to
back. ]{ is fiiniicil of ilic Iriaii.uuhu' cartila.L; ■ in front, the pcrpen-
dicidar ]ihitc of the I'thiiuiiil in ihc nppi'r portion behind, with tlie
vomer inuiicdiately heiicatii it. In eaily lilV the septum usually oc-
cujiies its natural eeniral jiosilion; diii'iiii;- youth and eonimeneing
Jiiaturity it very fre(iuently heeonies delleeted in some part of its course.
Fig. 1. — (■utiliiLic^ 111 I III' iiiiM', x'cii ill ]ircililL' (Ijapin'yj. 1, Right
lateral cartilage, li, Its aiiterim- lionler. ."i, .\n aecofsory cartilaginous
nucleus attadied t<i the iiilVrinr JKirilcr "f the same eartilago. 4, Anterior
accessory eartilages reiiiarkalile fcir their nvnidal form anil tlic constancy
of tlicir existence. 5. lv\teriial Inaiieh of the alar cartilage. (I. Union of
this branch with the infernal liraneh. 7, S, f), Seeonilary rartilaginous
branches added to the external braiieh of the alar cartilage. 10, .\cccssory
cartilage not constantly found. (.Vfter Bosworth.)
•'i
The onter walls of tin- nasal fossa' are formed from before back-
ward by the nasal, the siijierior ma.xillary, the laerymal, the ethmoid,
the palate, and the iiilernal ptery,<:oid plate of the sphenoid. At-
tached horizontally to this bony wall, arranged from above downward,
are tliree scroll-like bones: the superior, the middle, and the in-
I
t
AS \H)\\\ <ii 1 III: N(i-i;. 6
IVrinr turbinatt'ds. Tlie sii|n'riiir lurliiiialnl, dcsi'dnliiii,' vertically
from the cribriform plato ol' the cthninid, is imly nidiinontary in form.
The middle turbinated is hirircr, and lias its (iri.uin in the lateral mass
of the ethmoid. 'I'he inferior turliiiialrd. iiiiicii larger llian the middle
I
- /-^W/Vf^flBj I
8 :.^rSi^^ra!fflE^ySS!Mttiii:r":^" '^
I'i.ir. 2.— SM^riltii] s.Tiidii III ~kiill. JihI m ihc liijiit „f tlio sciitiiin.
showiiif,' riglit imsMl fcis>ii. I. Iiui-dv cidinl. i?, limd palate. :t, 4, Parts
of median cnis of thr caiiila^r,. ,,f tlic a]iiitiiiv. .">. Aiitciidi- part of tlio
same eartilaf;,-. (I, Caiiila^.'c <>i the sc|itiiin. 7. (iniuvc 'cadin;,' to niidilio
meatus. 8, Aa-;y,T nasi. !i. |-nni(ai sinus. 10, Inferior etlmioid eomlKi.
11, Superior etlunoiil eonelm. 1',/^ Snperinr meatus or etlimoid fissure. 12,
Recess of uiner meatus. i;{. Vjitranee t<> spliemiid sinus. 14, Pituitary
fos.sii. 15, Sphenoid sinus, id. inferior turliinal (nnixilhiry eoneha). 17,
Rod passed into Kustaeliian tube. IS, Salpinj.'o-])lnuyn-roal fold. 10, Soft
palate. 20, Ivulji. 21, Tonjiue. (.\fl.r henm.x Hrow tie, IS't!).)
6
])isi;.\si;.s oi' thk nasal passaciks.
one. extends right through tlio nasal cavity from front to back along
the hony wall, and is attached to tlie othiiioid, the superior maxillary,
the lacrymal. and the j)alate hones. The s])ace between the sujierior
turbinated and the middle one is called the sujterior meatus; tliat be-
twci'U the luiddle and iul'crior tuiliiuateils. the uiiddie meatus; and the
lloor of the passage behiw the inferior turbinated, the inferior meatus.
Tlie roof is formed by the up))cr portion of the nasal bones in front, and
the cribriform plate of the cthmoii! behind: the lloor by the liori-
12 —
Fifj. 3. — Anterior scctidii nt' tlic iiostiils ( Liisi'hka). 1, Septum of llie
narcs iit position of tut)er(le. li. Micklli' luibinatcd l)0(ly. ',i, Inferior t ,-
binated l)0(ly. 4, Suiicrior turl)iiiat('<l lindy. fi. Superior meatus. G, Middle
meatus. 7, Inferior meatus. S. Itespiratory jiortion of tlu> nares. 9, Olfac-
tory portion. 10, Floor of the nares. 11, Cavity of right antrum. 12,
Opening from antrum to nostril. i;{, Kthnioid eells. 14, Hoof of the nasal
f()Msa>. If). Floor of the nnsal fossa'. 10. Cavity of oibil. (After Lennox
l^rowne, 18(10.)
zontal processes of the suj»erior maxillary aiul [)alate bones (Figs.
3 and 4).
The. accessory cavities or sinuses are the frontal sinuses, the
sphenoid sinus, the ethmoid cells, and the antra of Highmorc, all
opening into the nasal cavities.
I'.acu frontal sinus opens into the corresponding middle meatus
by a luirrow canal called the infundibulum.
I
ANATOMY OF THE NOSli. 7
The sphenoid sinus is divided into two irregularl} -snaped cavities,
situated in the body of the splienoid; Ihoy are separated from each
other by a tliin septum of bone. The canal into each communicates
with tlic superior meatus of the corresjuuidinir side. Tlie opening is
usually not more than a millimetre in diameter; and the roof, sepa-
rating the sinus from the brain, nut mure than two millimetres in
thickness (Fig. 5).
This sinus stands alone; and, while it is more difficult to reach,
its isolation, fortunately, renders it less liable tu disease. The two
divisions of the sinus are rarely equal in size; and the septum is
frequently to one side of the centre. The ostium on each side is
high, although less elevated relatively than the ostium maxillare.
An important feature to remember about the sphenoid sinus is
'n
the
all
Fig. 4. — The posterior rliinoscopic iiiiayc. i, St'pluni. 2, Middle tur-
binated bone. 3, Inferior turbinuted bone. 4, Superior turbinated bone.
5, Superior meatus. G, Middle meatus. 7, Inferior meatus. 8, Main
passage of nostrils. 9, Vault of pharynx and pharyngeal tonsil. 10,
Cushion of soft palate. II, Posterior surface of uvula. 12, Jtidgc formed
by levator palati. 13, Salpingopharyngeal fold. 14, Salpingopalatine fold.
15, Eustachian pioniineiice or cushion. 1(1, Fossa of Rosenmiiller. 17,
Eustachian orifice. (After Lennox IJrosMU', 18!)!>.)
its near rel-ation to the cavernous sinus and nerves i)assing into the
orbit.
The ethmoid cells, situated in the lateral ma.<s of the ethmoid,
are irregularly divided into the anterior and jiosterior, the former
opening by minute orifices in the neighborhood of the hiatus semi-
lunaris and the latter into the back part of the sujieriur meatus.
These delicate bony cells, strung together like a chain, are distin-
guished by t!;eir thin, ])aper-like walls, which become more attenu-
8
DISK ASKS OF THE NASAL PASSAGES.
IP
aled with advancing years. Tliov form a s])ocies of labyrinth, and
are almost in direct communication with the orbit, the partition being
sometimes perforated from incomplete ossification. The lining mem-
brane is exceedingly tliin and practically free from glands (Fig. 3).
The inaxillanj sinus, or antrum of Ilighinore, is situated in the
body of the superior maxillary bone. It is pyramidal in shape and
the largest of the accessoiy cavities— often large enough to hold
many grammes of fluid. Kach antrum has one opening, situated on
the upper portion of the internal or nasal wall, called the ostium
maxillarc, and located in the middle meatus (Figs. 3 and 5).
This sinus is lined throughout with mucous membrane, closely
adherent to the periosteum. This is of the columnar ciliated and
chalice epithelium type. Although the antral mucosa is about twice
the thickness of that in the other sinuses, yet, like them, it is almost
free from glands. What there are, histological examination has proved
to be of the tubular variety. The two antra frequently differ in size.
Zuckerkandl has found supernumerary apertures in a number of antra;
but these are too small to be of physiological importance.
The maxillary antrum differs from the other sinuses in several
impoi'tant particulars: 1. It is very much larger in size. 3. The
only opening into it is in the upper portion of the sinus, whereas
in the other sinuses the openings arc always upon a lower level. 3.
It is more prone to early disease, owing to the frequent encroach-
mrtit of dental caries and also to the absence of dependent drainage.
The lacrymal duet opens ijito the inferior meatus below the front
end of the inferior turbinateil.
The mucous membrane .f the nasal cavities is continuous with
that of the pharynx and the Flustachian tubes, and extends, in turn,
to all the accessory sinuses. It is formed in three layers: First, the
surface-epithelium, comjiosed of ciiithelial cells of the columnar
variety, extending over tlu' u]i]ier half of the septum, and the supe-
rior turbinated and pnit of the midille turbiiuited bones; and of
ciliated cells over the lower part of the septu!n and tile remainder
of the turbinal surfaces. Second, the true mucous membrane, com-
posed of white, fibrous, elastic, connective tissue, inclosing within it
blood-vessels, smooth muscular fibres, serous and mucous glands, with
tubular orifices opening upon the epithelial surface. Third, a sub-
mucous layiT of connective tissue, very loose in form, and lying
directly upon the periosteum and perichondrium of the nasal frame-
work. It is composed largely of venous sinuses studded with tu-
Ki^. ."). I'|(i/cll -eel inn nl |i(M(| i(|' ildllll. I. Iliijlil and Icl'l optic
niTvi-;. li. S|ilicMcMil sinii^ Willi ]i(isl('ri(ir wall icninvcd ;!. S|iliiiiiiid -inn-*
with j>i>«tcri<ir uiilj in |iii-iiiiin. 4. I.dt nii-:ii l(i--ii. ,■"), \a-:il -cptiini. li.
Ilitilil iiil'crini- iinlnnaicil l)(inr. i I'rmn I'l iniid-c'^ An.ildiniial .Mn-iiini.
I niMi^itv 111' Inicinlu.i
I i
ANATOMY OF TlIK NOSK.
11
biilar niiiooiis gland:^, and lias it.s liighest (levolopiuL'iit ov{;r the tur-
binated bones, particularly upon the middle and posterior portions
of them — forming, with the middle layer, the so-called corpora
cavernosa nasi. The mucous memi)rane of the middle and inferior
turbinatods dilTers from the remaining surfaces in this respect: the
rich endowment of blood-vessels and muciparous glands enabling
tliem to perform so freely their physiological function. The color
of the columnar epithelium, in the mucous membrane of the npper
portion of the nose, is yellowish pink; that of the lower, or ciliated,
region, from its richer blood-supp'y, is reddish pink; while the pos-
terior ends of the inferior [urbinatcds, [larlieularly when much
swelled, are of a whitish or ])urplish hue.
The Nerves. — The innervation of the nose is of a dni'ble char-
acter: the one consisting of the special sense of smell, the other of
ordinary sensibility. The former is supplied by the olfactory nerve,
which i)asses by many minute filaments through the cribriform plate
of the ethmoid, and is distrilnited ovei* the upper third of the septum,
the superior turbinated, and the upper half of the middle turbinated,
terminating in the rod. or olfactory, cells of Scluiltze, which arc con-
sidered to be the special terminals of the olfactory nerve-fibres. The
latter is abundantly supplied by superior nuixillary braiu^hes of the
trigeminus and the nasal l)ranch of the ophthalmic and some fila-
ments from Meckel's ganglion.
lilood-vcssrls. — The vascular supply to the frontal sinuses, eth-
moid cells, and roof of the nose is derived from the anterior and
posterior ethmoidal l)ranches of the ophthalmic. The sphcno-palatine
branch of tlie internal maxillary artery supi)lies the mucous mem-
brane of the turbinateds and septum, while the alveolar branch of
the internal maxillary sup])lics the antrum.
(IJainls. — The upper, or olfactory, area of the nose is said to he
relatively more richly glandular than the lower, or respiratory, area;
and one function of the exosmosis being merely to keep the sensory
nerve-filaments in a constantly moist condition, these glands are almost
solely of a serous character.
CIIArTKU Jl.
niYSIOLOGY OF THE NOSE AM) ACCESSORY SINUSES.
Within the last liair-coiitiiry it. was the general impression, even
among medical men, that the nose had only one important funetion
to perform, and that was to preside over the sense of smell. Now
it is kn(jwn to perform tliree important fuiictinns. dl' which olfaction
is, perhajis, llie least. 'J'hc otiiers are to give heauty and resonance
to the voice and to perform a comjilex duty in I'cfcience to respira-
tion.
Tiih Sknsk of S.micll.
Tlie sense of smell is produced hy infinitesimal particles of
odorous hodies being drawn into ihc nasal cavities during insj)iration.
They arc there dissolved by the nasal mucus and, coming in con-
tact with the terminal filaments of the olfactory lUM'ves, a sense of
their presence is at once transmitted to the nerve-centre and their
odorous qualities recognized. Dry particles on dry membrane are not
])erceived by the nerve. ]Icnec the importance of the nasal mucosa
being in a healthy moist condition. In the same way the presence
of crusts or tumors or foreign bodies within tlie nasal cavities, by
preventing the contact of odorous particles with the sensitive mucosa,
mars the full observance of this iinjjortant function. In order to
insure a perfect sense of smell, the nerve itself must be in a healthy
condition.
Frecjuently in prolonged and chronic nasal disease the terminal
filaments lose their normal sensibility, and this loss of functional
power affects, to a marked degree, the sense of taste, as well.
Tun; Nose in Piionatiox.
This organ, in conjunction with the nas()-i)liarynx, has a very
important influence upon the formation of the voice, ('ombinedly
they act as a resonance-chamber in which ihe voice, after passing
through the vocal cords, receives its final tone. All vocal sound is
(12)
PHYSIOLOGY OF THE NOSE.
18
])rocliuc(l by vibrations of a euluran of air issuing thiougli the glottis.
Tlie pitch of tone is regulated by the tension uf the cords; the volume,
by the force with which the column of air i.> driven tlirough them;
wliile the cliaracter or individuality of the voice itself is dependent
largely upon the mouth, pharynx, and the formation of the nasal
ciuunbers.
Tlie soft palate has a great deal to do with correct phonation,
and, to perform its duties well, should be perfectly free from ob-
structive lesions, either in tlie naso-pharynx above or the tonsillar
region beneatli.
TlIH XOSE IX IJESl'inATIOX.
is
Tile triple function of saturating, cleansing, and heating the
uir of respiration, as it passes through the nasal fossic to the throat,
is probably the most important of all the duties which Nature has
assigned to this organ. It luis been i)roved by experiment, over
and over again, that ordinary dry air, containing only a minimum
of moisture, becomes saturated as it passes through the nose during
inspiration. This added moisture is olitained from the serous exuda-
tion of the mucous membrane of the turbinateds. This fluid exudes
from the cavernous sinuses, caused by the stimulation of the air as
it ])asses over them, and is sliglitly diluted by the mucus from the
tubular glands. These venous jilexuses, which perform so important
a function, are named by Zuckerkandl Scliicellkorper, or swell bodies.
In a healthy condition they are fully surcharged with blood, and the
serum passes out by transudation, to be absorbed by the air during
inspiration.
The amount of moisture thus given of! by the healthy nose in
twenty-four hours is estimated at about one-third of a litre and, as
can readily be seen, plays an important part in the ])henomcna of
normal breathing. To in,sure this supply of serum, the sinuses of
the turbinateds are always filled with blood, yet this hypera?mic con-
dition, normally, is not sulTicient to produce stenosis of any part.
Kverywhere throughout the nose, however tortuous, these narrow
passages are open; and the air of respiration becomes saturated while
]iassing through them.
At t'.'" same time the air becomes elevated in temperature by
contact wiui the hot, moist walls, being many degrees nearer blood-
heat by the time it reaches the pharynx than it was on entering the
anterior nares.
n
DISEASES OF Tllli NASAl. I'ASSAtiKS.
Tlien, also, tlie air is inirificd as it passes throu]ij:]i the nasal
})a?sagc>. Insects, heavy dust, and minute foreign hodics are hirgcly
kept out by the fringe of vibrissa', wliieh stands guard over tlic en-
trance to eacli nostril. It is, however, the moist nasal mucosa which
does the chief part of tiie cleansing, the myriads of leucocytes and
mucous cells acting as phagocytes and destroying the invading hosts
of noxious germs as they advance backward from the vestibule. U. L.
AVagner says: "The action of these leucocytes docs not consist in
their total destruction, but in greatly diminishing their activity."
Whether the normal mucous secretion is a germ-destroyer or not is
still, in some degrees, an open question, pathologists differing upon
the sul)ject. Still, one thing is certain, that, whereas the mucus of
the vestibule is always loaded with microscopical germs, that in tlio
back ])arts of the normal nasal passages is almost, if not entirely, free
from them. It is possible that a great deal of the cleansing process
is (Inc. however, to the oft-repeated etTorts of Xalurc to eject, by
forcible exjtulsion, anything that irritates the nasal passages.
The special function of tlu' large antra of Ilighmore is probably
one of jilionation. Filled, as they are. by air when in a healthy con-
dition, with free openings into the na«al chambers, they may give
additional vibration and tone to the voice, whether in vocal exercise
or ordinarv use.
■:*
CHAl'TKK IIJ.
INSTRUMENTS USKI) FOR JllK KXA.M I NATION AND TKi: \T-
iAIKNT OF Dl.SEASFS OF TlIK NOSE
AND TIIHOAT,
Fou tlie successful examination and treatment of nasal iliseascs
we require the aid of arfiflcial light, either reflected from an electric
lamp i)laced on the forehead of the surgeon (Fig. 0) or from hricrht
Fig. C.-Phillips's electric pl.otophone, with adjustment fm-
focusing liglit.
"light of some kind placed on either side of the patient and relh^.ted,
from the head-mirror of the operator, upon the part to he examined
(tigs. 7 and 7a).
The ordinary plan, and the one largely adoj.ted hy specialist^
Jip the present date, is the latter one. The light should he on a
level with the patient's nose, and on a plane a little posterior to it
Ihe surgeon sits immediately in front of the patient, and hy adjust-
(15)
1
IG
DISKASKS OF TllK NASAL I'ASSAdKS.
Fi". 7. lli'iid niirrcr.
i 1
Fig. 7«. — Ilead-niirror in position.
ing the head-mirror the fociis of light is thrown directly upon the
spot to be observed. The advantage of this arrangement is that, by
INSTIMMIAIS AM) TIIICIK ISi:!*.
17
looking' with oiie I'Vc lhroii;rh the hole in tiic mirror and with tlic
otluT past its odjic, lie ciitiri'Iy escapes any direct rays of the lij^ht
from falHn^ upon his own retina. The eiiaracter of the lif^dit used
is of some ini]»ortan('o. An inclosed li^dit in a dark corner of tlic
room is host. The li<,dit itself shoidd he hri<:ht, clear, and steady,
placed, if possihle, in a MacKeiizie concentrator or one of the more
modern forms (Kijr. >^). It may he hy electricity, gas, or nil. I'lven a
Fig. 8. — Laryngoscope, gas-stand, mirror, condcnsiT, and tubing.
(After MacKenzie.)
tallow candle, if notliin;;- l)etter can be obtained, may be of good
sen-ice.
For anterior rhinoscopy tlic nasal speculum is rccjuired, the ol)-
ject being to open the nostril painlessly to its widest capacity for
the admittance of light. Of this instrument there arc many varieties,
of Avhicb Figs. 9 to 13 are samples. Each surgeon must make his own
choice. I have found those of an ovoid, cylindrical form much the
most convenient, protecting the nostril and admitting abundance of
18
DISEASES OF THE XASAE PASSAGES.
liglit. Some like a spring-wire instrument. Shurly considers a spe-
cial protection to the nasal wall opposite to the side operated on to
Fi<ir. 9.— I'osworth's huge and small nasal specula.
Fiy. 10. — tJoodw illio's nasal speculum. Fig. 11. — Myles's nasal sjjoculum.
^
'K
.•:!,.
Fig. 12.— Siniitick's nasal speculum.
^^f
Fig. 13. — Sincrock's nasal speculum, with handle.
be an essential, and has devised the instrument shown in Fig. 15 for
this purpose. Bosworth's Fig. 11 is formed in a somewhat similar
manner.
I
INSTRUMENTS AND THEIR USES.
Fig. 14.-Bosworth's nasal speculun,, with shield
for cautery-work.
■-•^lii^j^
Fig. 15.— Shurl.v's nasal speculum.
19
Fig. io-Po3t-rhinal niirn
or.
Fig. 17.-Post-rhinal
mirror.
Fig. 18.-VVhite'8 self-retaining palate
retractor.
I
20
DISEASES OF THE NASAL PASSAGES.
For posterior rhinoscopy posterior rliiiial mirrors of small sizes
are required (Figs. 16 and 17), and, to facilitate post-pharyngeal ex-
amination, various palate-retractors have also been introduced (Fig.
Fig. 19. — Applicators.
18). The latter arc rarely nccespary, as l)y a little practice on the
part of the operator and training on the part of the patient nios!:
pharyngeal and {)o.st-r]unal cavities can be examined without tiioir
aid.
To these might he added o()l(on-aii[)li('ators or prol)os for tlic
; t
'I
■^
Fig. 20. — Tongue-depressor.
application of solutions and cleansing of the passages (Fig. 19), anci
tongue-depressors to facilitate examination of the post-nasal region
(Figs. 20 to 24).
IX.STRa.MENTS AND TIIKIR USKS gj
1. Atomizers to throw sprav wifhin iU , "•
'P''i> witliui the nasal cavities, anteriorly
Fig. 21.--Tongiie-(lci)
J)i-c.ssor.
Fig. 22. '
rongne-depiosaor.
Fig. 23.-Sass'.s tonguo-doprcssor.
'■" H.o purpose (Fis. Jy'"'''"'''"'^ «"■ f™m f=nl-s specially devised
t;
1 1
i 1'
22
DISKASKS or TIIK NASAL I'ASSAGES.
■ I
Fig. 24- Tiirck's tongue-depressor.
Kig. 25.^ — Davidson's atomizers, to be used l)y compressed air
or hand-bulb.
Fig. 26. — Burgess's metal-tube atomizers: straight, up, and down.
IN'STRt'MRN'TS AVP THKIK fSKS.
'2-3
Fig. 2r)«.- liosworth'a afomizor.
Comprpssod-air iipparatus.
2. Insufflators, or powder-blowers, of wliicli also there are uiany
in the market (FigfJ. ^8, 2S«, 281), and 2Hr). 'I'he name is indicative
of their utility. Also post-nasal 8yrinp;es.
I " .;m
24
DISEASES OF THF NASAL PASSAGES.
i
H"!
^'^'
Fig. 28. — Powder-blower with inoutli-piece and lube.
Fig. 28«. — Powder-blower with bulb.
Fig. 28ft. — Powder-blower with tubing and bulb.
Fig. 28('. — Powder-blower with scoop.
3. Nasal saws, of wliicli l?os\vorth's is the model upon which
most of the others are founded (Figs. 2J> and 30). They are used
INSTRUMENTS AND TIIKIU USES. gg
to remove segments or sections from tlie nas-,1 senfnm t? » •
Fig. 29.^-]5os\vortl,'8 nasal sau..
Fig. SO.-Alials reversible saw.
Fig. 31.— Hartniann's nasal chisels
!|J;
ill
2G
DISEASES OF THE NASAL PASSAGES.
Fig. 32.— Freeman's drill.
Fig. 33. — Bosworth's niisal polypus-snare.
Fig. 34. — Snjoiis's nasal polypus-snare.
5. Cold-wire snares of many varieties are exceedingly valuable
for removal of polypi, as well as other growths within the nasal
cavities (Figs. 33 to 36).
INSTRUSfENTS AXD TIIKIR USES.
27
Fig. 35.-nall's luisal polj
pus snare.
Fig. 36.-Doneh's na.sal polypua-snar
Fig. 37.-UniversaI cautery and snare-handle, ^^i
th cannula and snare.
:%
ii
ble
isal
Fig. 38.— Cautory-eleetrodoa.
6. The galvanoca-utery-siiare is also receivofl ulH, u
Quartpf'? ^FJfr •?7\ +1 i , ittcnoa with iavor in some
i'j
V'S
DISKASKS Ol' TIIH NASAf, I'ASSA(iKS.
l-'or the latter, ("annaiilt Jones's spokesliavc, with various mollifica-
tions of it, has hocn received with marked favor in iMiglaiid, wliile
on this continent it has nsuallv not Ix'cn Vidiicd so IiiLxhlv (I'Il:. II).
E D
m
B
l-'ig. 31). — Xa*il huiTH.
Q
I'ig. 40. -Nusal tn'pliiiK'ss. (Cuiiisa.)
]''i;^. 41.- Hcri'iTs (1) ami XicliolsV cii sjidkcsliavi s.
'J'o the above might be added punches and curettes, curved scis-
sors and knives, forceps and clamp.s, a? well as other instruments spe-
AMKUIOlt UlllNOSCOI'V
'J!»
ciiiDy (lovi.-('(l I'or uso in partiiiilnr cnscs. Nasal burrs for antral as
well as sL']ital uuil: tiiav also he inciilioiicd ( l'"i>.'. <V,i).
Am icitiou J»iHN()sc(H'Y.
The view oliiaiiit'd liy means of the I'tiinoscnjio, inehulin^' as it
lines, tlu' liead-niiri'or iVl'^. T). llie relleeted liiilil, and lln' nasal >|ieiu-
liiiii ( Fi,u'. 1'.') i- iiniy liniiled, when eonlined to one pnsilion; init l)y
niiivinix tlie iiead in dilfeieut direelions, a ,ixreater part (d' tlit.' na.-al
(•avity can l)e Krought siiceessively into view. 15y lool<in^ directly
in. tlie iloiii' nf tlie nn^e ;ind the infei'ior turbinated, as well as the
Kifr. 42.- Anlcrior rliinoseoiiy, ]Misitio!i of the licad for inspoctinrr tlie wiill
of the pliarynx tlu'ou<,'h the nasal iiassagcs. (After Bosworlh.)
■if.
ICIS-
pe-
liiwer ]iart of the M'ptnni, can he seen. The septum is very rarely
perfectly central in ]iosition, being deiiected to one side cv the other.
In these cases the whole length of the inferior turbinated can fre-
(juently be seen, as well as the post-])haryngeal wall, tlirough the
wider passage: and if the ])erson e.xaniined he reciuested to count
], 2, 3, the movements (d' the palate can also ])0 distinctly observed
through the inferior meatus (Fig. 4'^).
When,, owing to the turgid condition of the mucous membrane
the passages are too narrow to admit of examination, this can always
be aided ])y spraying the nasal fossa^ with a l-])er-cent. solution of
cocaine. In a few imunents its astringent ell'ect upon the mucous
30
DISEASES OP THE NASAL PASSAGES.
membrane drives away the blood, and, shrinking the tissues, a better
view can be obtained.
In the normal state the middle and inferior turbinateds and
septum are of a pinkish Inie, while the roof of the nose and the
superior turbinateds are yellowish pink.
Fi{r. 4.3. " rosUMior rliinosropie imaj^e. (After Bishop.)
POSTEUIOU KlIINOSCOl'Y.
To accomplish this, the head-mirror, rcllccted light, tongue-de-
pressor, and post-rhinal mirror are always required; and sometimes
the palate-retractor also (Fig. 18). Fig. 43 illustrates the method of
taking a view. Before entering the throat-mirror it is first gently
heated to a blood-temperature over a gass-jet or spirit-lamp, to avoid
the condensation of moisture upon its surface. Care should be taken.
rOSTKUIOU IMIINOSCOl'Y.
31
after clcpixvssing tlie toiiyiu', not to touch the soil partrf while passing
in the instrument.
'J'o ohtain a good view of the ])ostcrior naros and vault of the
])harynx it is always nooossary that the jialatc .-Imulil hang straight
down. Jiy a little training this can usually l)c iiccnniplislied, alliiough
on first ell'orts the patient is very lii<ely to relraet the palate against
the post-pharyngeal wall, thus circctually cutiiiig oil' all view of the
vault ahove. liy directing the patient to hreathe through his nose
the desired result may sometimes he ohtained. (Jf course, when the
mouth is opened and the tongue held down liy a depressor, it is im-
j)ossihle to l)reathe alone through the nose; but the attempt drops
the palate and gives the reijuired view.
This method failing, a solution of cocaine applied to the palate
may remove irritation and produce the desired result. At all events,
it will enable a retractor to be applied, and, the velum being drawn
forward, a vision is obtained.
In the little post-rhinal mirror we first have the upper surface
of the soft palate, then the posterior nares, with the dividing septum;
to the two sides, the mouths of the Kustacliian tubes and the lateral
walls of the naso-pharynx; above the vault, and behind the post-
pharyngeal wall, over the two latter we may have the pharyngeal ton-
sil, or, as it is usually called when in an hypertrophied condition, the
adenoids. Between the post-])haryngcal wall, on each side, and the
mouth of the Eustachian tube, is the fossa of Rosenmiiller.
All these parts cannot be seen at once; and it will require a
little care and patience, both on the part of the observer and the
observed, with different adjustments of the instrument, to obtain an
entire view. The color of the vault is often a dark pink, witii lighter
hue at the sides and lower portions, while the posterior nares are
inclined to be a yellowish pink.
li
DJSKASKS OF TUP] NOSK.
CilAlTIlK 1\'.
ACUTE RHINITIS.
'I'liis is ;iii iU lite iiitliiiiiiualion ol' llic iiiuimjUs iiuMuhrimo ol' the
iiiisal |ia??n2foy. It usually allV't'ts both sides aliko and is attoiidod 1)V
i>oiTza or dist'liarizc Froquontly the iuilaiuniatnry aclidii extends to
the jiharynx: and soineiiines. thouiih unt very ol'teu. to the var
lOU?:
accessory vi\\ liie:
and
lu' lacrvnial (
Uiet.
Pathology. — The coninieiuenient of the disease is the period of
con,i:!'estion, with arrest (>•' secretion, and is common, during the lirst
stau'c. til all inllanimalions of nnicous mcnihrane. This is followed
hv transu(hition from the uorsied venous sinuses and increased seere-
lidii of mucus from the glandular structures,
Tl
lesc
her urae
on the exfoliative processes of the niGmhrane, and leucocytes, as widl
as epithelial cells, are thi'own off in vast numhers. ju'oducing niuio-
lundent discharae durimi' t
le la
iter staii'c of the disease
Etiology. — The most common cause i-; exposiire to cold. This
is particularly the lase with susceptible ])ersons. In these the su(hlen
impression of a fall in temperature seems to paralyze the vasonuitcn*
lu'rves of the naso-mueosa: and, the control of the capillary circula-
tion beiuLT lost, the nu'ndtranes become congc-^ted. The extent to
which this congestion occurs before the inhibilnry power is restored
wiiuld imlicate the severity of the disease, in some casi'-: acute rhinitis
is caused by exposure to acrid vapors and irritants of one form or
another; while in not a few instances it is primarily due to the pr^-
existcMice of chronic rhinal disease. It is also one of the early indica-
tions of certain of the exanthemata, particularly in the case of measlo?.
Acute rhinitis is more prevalent among children than nnumg adults.
Wagner believes that it is often produced by migraiions of micro-
organisms from diseased tonsils into the nasal cavities.
Syinptoiiiatology. — 'i'lie first symiiiom is nsually that of dryness
ACU'"1-: HHINITIS.
X\
of the nostril?, at'cumpauiod liy iiioie or loss frontal '■ pi\ision and
sneezing. There may he ehilliness, lassitude, and slight I '/file action.
The tingling si'nsation within the nostrils is (jnickly followed hy sero-
mucous discharge. The llux may he serous at lirst, then sero-mucous,
and finally muco-pus hefore the discharge ceases. Tsually a certain
amount of febrile action takes place.
If the frontal sinuses are affected, frontal oppression and head-
ache are the result, wliile the extension to the luistachian tubes and
pharynx render syinpt(uns in connection with these organs apparent.
Irritation of the coiijiiiuiiva, with discharge of tears over the cheek,
would indicate that tlu' hurymal duct was sutl'cring from tein[)orary
occlusion.
Sometimes the nasal stenosis is very distressing, necessitating
oral breathing. I'Lxcoriations of the lips and al.T, by the discharge of
acrid secretions, are likewise often jiroductive of much discomfort.
The sense of snu'll may also be alVeeted during the severity of
the attack.
Diagnosis. — Tiie group of sym])toms descril)ed are so character-
istic llial diagnosis should l)e easy. The mucous meml)rane is at first
>\vellcd ami red; then bathed in serum; and gradually, as tlie color
becomes lighter, muco-pus takes its place. 'I'be jwistcrinr clioana^,
examined by the rliinoscnpe. reveal the niidille and inferior tnr-
binateds swelleil, l>athcd in disciiarge, and lu-aclically tilling up the
nares. Other mucous membranes involved in tlie intlammalory action
all jiresent a similar pink and swelled condition.
Prognosis.- — Kavoralile in a large majority of cases. It involves
no danger to life, and usually disaj^pears in about a week. '^Fhe real
danger lies in allowing colds to f(dlnw each other in such quick suc-
crssicm as to prevent the nasal mucosa from resuming its normal
'one. IVrmewan and Carter have also reci'utly drawn attention to
the possibility of severe systemic' infection neiuLT induced liy ibis
disease, cases being rcporteil in which |)i'(d(>i \L;ed illtn.-s and continued
fever, otherwise unaccountable, were entirely removed by antiseptic
intranasal treaiment.
Prophylaxis. — To tb.ose inclined to the disease regular habits of
life are impiu-tanf. Daily cold bathing either by plunge or sponge,
when followed by promiit reaction, is an important ]>reventive.
Clothing shoidd be comfortable and equally dividcfl over the body.
Heavy neck wrappings are always ol)jectionable. Heavy furs
worn bv the ladies while callimr and left on in hot rooms often have
:■!
u
34
DISEASES OF TUE NASAL PASSAGES
the effect of producing cold on returning to the street. Wearing of
wet garments, which tlie exigencies of weather or occupation so fre-
quently render necessary for the time, will rarely during active exer-
cise produce injurious effects, but it is the continued wearing after
the exercise is over that does the harm. In short, if people would
systematically use good common sense in their daily walk of life, the
colds from which so many people suffer would be very much rarer
than they are.
Treatment. — ISTothing seems to check the general feeling of
malaise, attendant upon acute rhinitis, so quickly as quinine in ^7^-
gramme doses. 1 prefer to give it in capsule form, repeating the dose
each morning while the disease lasts. In strong vigorous adults a
gramme might bo given to commence with, taking the smaller amount
after the first day or two. In young children Y^ or ^/g gramme, ac-
cording to age and bodily habits.
A saline cathartic is al.-;o beneficial; and the feet put in hot water
at bed-time, followed by a stimulating drink of ginger-tea or hot
lemonade. The object aimed at is diaphoresis and restoration of the
nf.tural equilibrium of the whole body. If there is unrest and wake-
fulness, with flushed face, acetanilid in V^-gramme dcses might be
repeated once or twice during the night-time. For the same purpose
minute doses of morphia and atropia in tal)let form arj often given;
the combination has the advantage of the astringent effect of the
atropia upon the mucous membrane: —
1. R Atropia aulph |0013
ilorph. sulph |0(i5
M. Fiat in pil. x dividenda.
Sig. : One to be taken every four or six hours if required.
For Local 'Treatment. —
2. 1} Menthol |0
Alholonc 001
M. Sig. : To be used with an atomizer to tlie nostrils several
times a day.
1. H Atropia sulph gr. Vbo.
Morphia sulph R"". j.
AT. Fiat in ])\\. x dividenda.
2. 1\ Menthol gr. x.
Albolene Sij.
M.
ACUTE RUINITIS. 33
Or
1. H Thymol 1 12
Menthol \:i
Albolene tio'j
M. Sig. : To be used with an atomizer to the mintrils several
times a day.
Eitlier of these will be found an excellent remedy in this disease.
Bishop, in his recent work on "Kar, Nose, and Throat," strongly
recommends 3 per cent, of camphor-menthol in lavolin as a spray
in acute rhinitis. It has a similar action upon the inilamed mucosa
to the ones just referred to.
Lennox Browne, in the new edition of his valuable book on
"Diseases of tlie Xose and Throat," speaks emphatically of the value
of menthol in the treatment of diseases of these organs. Speaking
of this "remarkable drug," he says: "1. It stimulates to contraction
the capillary blood-vessels of the passages of the nose and throat,
always dilated in the early stages of the head-cold and influenza. 2.
It arrests sneezing and rhinal How. 3. It relieves pain and fullness
of the head by its pain-killing properties. 4. It is powerfully germi-
cide and antiseptic."
All these statements, with the exception of the one referring to
sneezing, I have agreed with for years. The sternutatory effort is
frequently produced by the first api)lici ns of the menthol-spray
to the nose; but the mucous membrane soon becomes accustomed to
the slight irritation, and subsequent applications will be borne with-
out difficulty.
When the symptoms show tardiness in abating, recovery may
often be hastened by using stronger solutions of the stearoptenc-! in
the hydrocarbon menstruum. For instance, the menthol mnv be
doubled or tripled to the same ijuaiitity of albolene, mid the ame
may be said of thymol. In this case, however, they sliould be inhaled
directly into the mouth from the atomizer, and, the mouth being
dosed, exhaled through the nofic.
When there is much nasal stenosis, there is sninetinies a teiii|iia-
tion to use cocaine, owing to its ])o\ver as an astringent in producing
immediate relief. It is unwise, however, ever to place this remedy
1. IJ Thymol pr. ij.
I\Ien1 liol trr. v.
Albolene 5ij.
M.
3
36
DISEASES OF THE XASAL I'ASSAfiES.
in the paliont's hands. The relief it afrords is only temporary, and
the more frequently it is used, tlie more rapidly does reaction take
jilace, with return of the swelling. The danger of forming the co-
caine-hahit makes it imperative to confine the use of this drug to the
doctor's olTice.
After the vascular ])letliora has passed away and the exudation
diminished Bosworth rccummends tlie application of chromic acid
to the still swelled memliraiie. After coeainization he apjilios minute
crystals of tlie acid to the promiiuuit portions of the inferior turbi-
nateds, with the view of pinning down tiie parts and so securing con-
traction. AVherever I have fouiul cautery treatment necessary, it
has always been in ca>es in which some previously existing hyper-
trophy denunuled the operative treatnu-nt.
Dry lieat api)licd to the forehead is sometimes of benefit in the
later stages, relieving tlie frontal headache ami taking away the full-
ness wliicli so often is feU over the root of the nose.
ClIAPTKK V.
(TrHOXFr HinxiTis.
'J' 1 1
IS i> a chrniiic intljiinination (>( the na>al imicnsa licarinir a
direct, relation to the aeiite disease. Some oliservers lielieve it to he
the cause of the oft-repeated occurrenee.s of the hitter, while others
look upon it as the elTect. The last mentioned is prohal)ly nearer the
truth. The entire mucous membrane nuiy he involved, and tlie dis-
ease may extend to the iMistaehian tul)es, the lacrymal ducts, and, as
in the acute ilisease, to the accessory sinuses.
Pathology. — The mucous memhrane is thickened and puffy,
while tiie venous sinuses are chronically relaxed. Interstitial infil-
tration is the result, hut of a changeahlc character. Freciuently will
one nasal fossa he affected, closin<^- it sulhciently hy cedema to pro-
duce complete nasal stenosis, while fin- the time the other is free
enou<rh to carry on respiration. Lyiug for a short period on the
open side will reverse the condition, simply hy hydrostatic ijravita-
tion. Hydrorrhnea from the veiuius sinuses, together with the dis-
charge of leucocytes and pus-cells from the chronically-irritated
glands, becomes a leading feature.
Etiology. — Ciiiiliniied exposuic to inclemencies of the weather
— with insudicieiit clolhiug. wet feet, etc., ])roducing oft-repeated
colds— is a frei|Ui'iit cause. Inhalation of irritating dust and gases,
during ordinary occupation, when prolonged, will induce the disease.
The presence of a strumous diathesis may be a predisposing cause;
as also may be lh(> jircsence of slriictnral lesions and hy[)ertrophies.
Symptomatology. — The most prominent symptom is a constant
nasal discharge, chiefly of a muco-jiurulent character, whicli induces
oft-repeated efforts at blowing and hawking. In aggravated cases the
nares are filled with a pasty, yellow matter; and the constant efforts
to void the discharg(\, in some cases, produce swelling and redness of
the nose, as well as eczema or ulceration of the anterior nares. Owing
to the limited proportion of serum exuded, the secretion often be-
comes dry, resulting in crust-fornuition about the nostrils. To
liberate thi.s, j)icking is resorted to, with gradual destruction of the
(37)
illi
38
DISEASKS OF THE NASAL I'ASSAUES.
il
I "^
1§
mucous nionibrane; and, in some cases, the septal cartilage eventu-
ally becomes perforated by this digital irritation. The disease occurs
most frequently between childhood and early maturity.
Diagnosis. — There is sometimes a nice distinction to be made be-
tween chronic rhinitis and Jiosworth's purulent rhinitis of children.
In the former the disease may occur any time after early childhood,
but rarely during that period, while in the latter it always occurs
during early life. In the former there is less purulent discharge
than in the latter, while, owing to the shorter period of its exist-
ence, there is less likelihood of its culminating in atrophy. The
diagnosis between this and hypertrophic rhinitis is more easily made.
The application of a 4-per-cent. solution of cocaine for the time
will shrink away the infiltration of chronic disease, which it cannot
do with the enlargements arising from hypertrophy. On the other
hand, when of long duration, it may resemble and even be the
initiatory stage of atrophic rhinitis.
Prognosis. — In the region of the great lakes of this continent
chronic rhinitis is very prevalent, owing to the humidity of the at-
mosphere and the variability of temperature. As these cannot be
avoided, the prognosis as to permanent result is not very encouraging.
If proper means are adopted, however, a cure can be accomplished,
though the tendency to return may still exist. When long continued,
the disease is likely to culminate in clironic hypertrophic rhinitis.
Consequently a guarded prognosis as to ultimate results should always
be given.
Treatment. — Regulation of the pmnce vice and toning up the
general system are in many cases necessary and can be done on the
principles of general medicine.
Locally, the nasal ])assages will require systematic cleansing. For
tliis, alkaline sprays will be required; and, of these, what is called
Dobell's may be considered the best type. All modern English
writers on disease of nose and throat acknowledge the utility of
DobcU's solution, and give credit to Dobell for introducing it to the
world, yet scarcely two of them agree upon its formula. I have be-
fore me the most recent works of Sajous, Bosworth, and Bishop;
and in giving ihe formula of Dobell's solution, while they all agree
as to ingredients, they all differ as to quantities. Here, I think, lies
the intrinsic value of the preparation as a type, the combination re-
maining intact, while the proportions are varied, according to the
judgment of the physician in charge.
CHRONIC RHINITIS.
39
(or
sh
of
Ihe
lee
les
je-
ll e
My own rendering of Dobell's solution is the following: —
1. R Sodii bicaili 21
I
Sodii bibor 2
Aeidi earbol 1
Cilyei'iin 15
Aquuiii ad 250
;M. Sig.: To be used with llif atoinizpr to thr iioso, as re-
quired, several times a day.
The advantage of this and similar preparations, used freely as
sprays to the nose, is that they are l)oth alkaline and disinfectant,
acting as solvents to the muco-purulent secretions, which require to
be removed.
After clean.sing, oleaginous sprays are indicated for their sooth-
ing, protective influence upon the mucous nu>ml)rane. The oil used
as a menstruum slimild be one of the recently-discovered hydrocarbons,
as from their mineral origin and chemical composition they can never
become foul or rancid. It matters not whether it be liquid vaselin,
lavolin, glycolin, albolene, or any other of the many that are in the
market, so long as it is pure, colorless, inodorous, aiul unirritating;
but these requirements arc essential. The one I have generally used
is albolene. The medicament dissolved in the oil should be of a
slightly stimulating and antiseptic character. For instance, 1 to 2
per cent, of menthol in albolene, ^/^-peT-ccni. thymol in alliolene, 1
to 2 per cent, of eucalyptol in albolene, 1 per cent, of crcasote in
albolene, or 1 to 2 ])er cent, of camphor-inonthol in alljolcne. The
first and second of these I have used moro extensively than tiie others,
the treatments being repeated from one to three times a day.
The treatment of atrophic rhinitis by massage, introduced several
years ago ])y Braun, of Italy, induced me to try it also in simple
chronic rhinitis. He used probes with olive-shaped tips; and. passing
one into the nostril, guided by iiead-mirmr aiul nasal speculum,
would, by tremulous pressure of the hand, ]U'odiico vibration over the
diseased tissue. The method T have followed, though copied from
Braun, has been of a simpler nature, and would be practiced on each
visit of the patient for treatment.
R Sodii bicarb frr. xxx.
Sodii bibor ,!-'r. xxx.
Aeidi earbol ptt. xv.
Cilycerin 3iv.
Aqiiani ad Jviij.
M.
m
10
])lSi;.\SKS OF THE NASAL PASSAOKS.
Tlic end of an ordinary nasal cotton-carrier would l)e wrapped
firmly with a small })ledget of cotton, the thickness of the temporary
tij) beintf made to accord with the width of the crevice in the nasal
])assa<j:c to which it was to he applied. Then the tip would lie dipped
in alholene, and. after insertion into the nostril, manij)ulated in
accordance wilii Hraun's nicthod. \>\ })roper care, coml)ined with
gentleness of touch, massage of the whole mucous membrane can he
done without the use of cocaine, and with very little discomfort to the
patient. With eacli ajiplicalion the used pledget is stripped olf and a
new one aj)j)lied almost in a moment — three or four being required
for each nostril at one sitting. After massage a spray of alholene or
sinular oil is all that is needed.
]n a large uumber of cases this treatment has been attended with
very satisfactory results. The usual ollice-forraula has been: 1.
Cleansing the nasal fossiu by a free spray of DobelTs solution. 3.
Massage of both jiassages. '•>. Application of a spray of alljolene to
each, for iHUiie-trcatment the patient has been instructeil lo use
simple ch'ansing sprays, as required, between the visits to the ollice
for massage — the latter being re])eateil every second or third day, a
few treatments oidy being required.
Of the two methods, 1 have looked upon the massage treatment
as more elfectual than that of simple medication.
In the posterior thickening of the septum, which so frequently
occurs in the chronic rhinitis of adult life, we have a combination of
oedema with epithelial cell-proliferation. It is usually bilateral, ami
exists in the form of a perpendicular ridge, a little in front and on
each side of the posterior edge of the vomer. The hypertro])liy is,
in some cases, so great as to seriously interfere with the nasal breath-
ing and to necessitate operative treatment. This is best done l)y the
galvanocautery. After cocainization the l)lade is passed into the nostril
and, guided by the post-rhinoscopic mirror, the membrane is freely
singed. No special after-treatment is needed; and after a week or
so, by which time the surface will have healed, the operation can
be re])eated if required.
CIIAITKU VI.
PURULENT KIILNITIS 01" ( HILDREX.
lioswORTii was the first to clearly and di'Cmitcly outline i)iiruleiit
rliinitis and to place it on the list of representative nasal diseases.
Other writers had spoken of it before, jtarticidarly MacKenzie,
Stoerck, Fraenkel, and Cohen, but it remained for ]>oswor(h to recog-
nize its lull importance and to intimate the position which he believed
it to occupy in the etiology of atrophic rhinitis.
Pathology. — As described by him, it is a disease peculiar to the
earlier years of childhood, its prominent feature being tiie chronic
discharge of purulent nuilter from the anterior nares. This discharge
is purely local, and not dependent on constitutional diathesis. In the
earlier stages there is increased secretion of mucus, with ra|)iii ^\c!^-
(piamation of epithelial cells. The discharge gradually assumes a pu-
rulent form, and after lasting a nuiidicr of years results in the shrink-
age of the turbinated bodies and the development of atrojiiiic disease.
In support of this theory J3oswortli says: "That in youth the epi-
thelial structures are especially liable to become the seat of diseased
action, whereas in adult life this tendency seems to disappear, and in
place of it there obtains a tendency to the involvement of the con-
nective-tissue structures. Thus, in the earlier years of life we notice
this tendency in the development of enlarged tonsils and follicular
disease of the upper air-tract, as well as in the vulnerability of the
lymphatic glands, wliei'i>as, in adult life, inflammatory changes in the
mucous membranes result in true connective-tissue hypertrophy."
Wagner also expresses the same opinion when he says: "During
childhood the skin and mucous membranes are more excitable; more
prone to disorders of the circulation. The function of the lymjihatic
glands is prominent in childhood; the cpiantity of lym])h is increased;
the lymphatic glands at this time have their greatest development."
Hence the tendency during childhood would appear to be toward
the abnormal development of glandular, adenoid, and lymphatic tis-
sues in the throat and naso-pharynx, and to proliferation and des-
quamation of epithelial cells in the nose itself.
(11)
n
48
DISEASKS OF TlIK NASAL PA88AOKS.
Etiology. — Tlie literature regarding the etiology is very scant;
but, as it occurb in otlicrwise iicaltliy and rugged children, struma
and hereditary syphilis are not considered potent factors in its pro-
duction. Bosworth ascrihcs taking cold from unhygienic conditions,
and also neglect of the ordinary rules of health, as the only assignable
causes.
From my own experience, I believe we frequently have more direct
causes, and that the pathological tendencies already referred to as
incidental to childhood are suflicient to produce the disease. In many
cases th*at I have seen the purulent rhinitis has been associated with
hypertrophy of the faiicial and pharyngeal tonsils. These bodies
have been so large as to interfere seriously with nasal respiration.
In these cases the adenoid enlargement and the epithelial desquama-
tion ran side by side; but, owing to tlie stenosis, it was impossible for
the purulent discharge to make its escape. Like a ilowing well, it
ebbed out and over the surface, while the retained discharges produced
irritation and continued development, as a consequence. That the
adenoid enlargement was the real cause of the purulent rhinitis
seemed verified by the fact that the removal of the tonsils and ade-
noids would be followed by cessation of nasal discharge and restora-
tion of normal breathing. Some cases undoubtedly do occur with-
out the co-existence of tonsillar hypertrophy, but the majority that
I have seen have, at least, been associated with adenoids. This view
is borne out by the experience of Lennox Browne upon the same
subject.
Symptomatology. — The chief symptom is the continued discharge
of yellow muco-pus from both nostrils. During the night-time con-
siderable quantities flow out aiid are deposited upon the pillow. On
examining the pharynx, the V.'ce discharge, perhaps slightly grayer in
color, may frequently be seen trickling down behind the soft ]ialato,
the yellower color as it exudes from the anterior nares being due to
freer oxidation. The blocking of the nostrils necessitates mouth-
breathing, which is still further aggravated when adenoids are present.
Fcetor is of rare occurrence, except late in the disease, when it is
gradually assuming the atrophic form.
Diagnosis. — The continued presence of the anterior nasal dis-
charge is a strong point in diagnosis. Another one is that it is bi-
lateral and odorless. In scrofula and syphilis the discharges are
offensive in odor and often are bloody, and accompanied by systemic
manifestations indicative of the disease. The presence of a foreign
IMUll.KN T IIIIIMTIS OF CHII-DUEN.
43
body or rhinolitli would 1)o dit^tinfruiplied hy being unilateral and the
discharge accompanied by malodor. Sometimes ]iurulent nasal dis-
charges accompany the develojimont of exantheniatous diseases; but
in these cases the history proves the relationship, and the unpleasant
symptoms are short lived.
Rhinoscopic examination anteriorly, after the removal of the dis-
charge, will reveal a slightly swelled and reddish condition of the
turbinateds and septum, but without ulceration; while, posteriorly,
grayish or yellowish-green mucus will be observed in the naso-pharynx.
Prognosis. — Without appropriate treatment tlie prognosis is bad.
There is no danger to life, and it is a self-limited disease; but the
limit extends over so many years that serious results of a permanent
character follow, unless the limit be l)roken. When adenoids co-
exist, they naturally comnumce to shrink away about the tenth or
twelfth year; and with the shrinkage comes freer nasal breathing
and drying of the mucosa. r>ut during the years of the purulent
rhinitis the epithelial layer has slowly wasted away, and the follicles
and mucous glands and venous sinuses have all been involved in the
shrinkage, while the relief from the adenoid absorption has come too
late to prevent the occurrence of the dreaded atrophy.
In the early stages, however, before the vitality of the mucous
membrane has become exhausted, a hopeful prognosis may be given,
provided proper treatment is instituted and carried out.
Treatment.— The first step in treatment is to ascertain whether
adenoids are present or not. If present, even if not very large, they
should be at once removed; as a limited ])ost-nasal swelling, coupled
with the purulent inflammatory cfuidition, will ])roduce severe steno-
sis. The removal of these growths lias a double cirect: First, by
direct depletion of the parts by the liaMuorrhage resulting from the
operation, and, second, by the permanent removal of the obstruction;
both of which have the effect of checking the purulent inflammation.
Consequently the su])sequent treatment which I have found most
effective has been of the mildest character, sprays of albolene alone,
or of 1 per cent, of menthol in albolene, or Vj P^i' cent, of thymol
in albolene, two or three times a day, for a short while, to the
nostrils, being all that has been required to effect a cure.
In cases where it is inopportune to operate, or in which an
operation is not required, the nostrils should be thoroughly cleansed
by the use of a good atomizer several times a day, using either a mild
saline or alkaline solution. Dobell's solution to which has been added
44 MISKASKS OK llli; NASA I, I'ASS \(i KS.
V4 pci' cent, of tliyiiiol is an I'll't'ctivc! cloniLsiT. Of others. 1 per cent.
of chloride' of sodiiiiii in water, or 1 per cent, of chlorate oi iiota.ssa
in water, will either of them do ^.'ood service, a few drops of ^.dycerin
being aiUlcd to give softness to tiie soliilidM.
Tlie spraying of the nose siionld each time he followed hy forcible
blowinir to remove the pus. After this IJosworth I'ecommends spray-
ing witi: mild astringent solutions for the purpose of controlling cell-
I)roliferations, and he iu.-luuces the following nuuuig others: —
1. It (llycciol laiiiiiii 4'
Aquiim ad UUi
M.
2. U Arj,'ciil. iiilnit 12
Aiiuiiiii ad ;((»[
M.
3. U Alnniiii-. |((o
A(iuam ad .'idi
M.
Altlu)Ugli I have often tried them, 1 have never heer favnrahly
impressed by the \i>o of a(|ueous sprays in this disease, ^'oung chil-
dren are exceedingly averse to the irritation jtrodnccil hy tluMu. The
objection is frei[uently so greai that to secure tlu' successful use of
tlie atomizer tbe pbysician is obliged to apply it himself, wbicli is
usually impracticable, when it reiiuircs to he \\>r(\ more than once
a day.
The sprays of bydrocarbons, on tbe other hand, arc so line and
imirrilating that they can be borne by tbe child with impunity, and
the parents or guardians can ajtply them without any ditViculty. They
possess this advantage, too, that a single preparation will answer all
purposes, thus simjdifying the treatment. In some cases sprays of
albolene or glycolin alone, repeated several times a day, have been
sufTicient, while in others 1 to 2 ))cr cent, of menthol in the bydro-
o;irbon and ^/., to 1 per cent, of thymol in the like menstruum have
been required. Other drugs as well — as eucalyptol, oil of caraway,
creasote, etc., in small quantities in tbe neighborhood of 1 ]ier cent.
— could also be used to advantage in these only ajiparently intractable
cases. The use of these preparations, however, do not detract from
the importance of the removal of obstructive lesions when they exist.
1. B Glycerole of tannin 3i to Jj.
2. R Ardent, nitrat. t;r. iii to ,?j.
•'). B Aluininis trr. \ to Sj.
,;! "
{•ii.\rri:i{ vii.
iivrKUTiioi'inc miiMTis.
This is a rlironic iiilliiiimiiitinii of tin- iiiiicnii.^ mombrano of the
uusal passii^ii's all'cctiiiji ihii'tly tliu turltiiiatL'il Ijodics ami ueeurriiig
most i'l'L-iiiU'iitly during tlu' early years of maturity.
Pathology. — 'l"lic iiiiicou> nii'iiilniiiit' of the miiMle ami inferior
turbinatods, particularly tlic latter, is tbiekeued and eorniyated (Fig.
44). The snrfafe-epitlicliiiin is hypcrtropliicd, sninetiiiies extt'iiding
ii
IH
Fiff. 44. ilv|icrtin|iliy nf iniiliilc mikI inferior tnihinals.
i.\l't<'i- l!iis\\(i)tli. I
in a .stratiiied form into the eoimcctivc-tissiu' layiT lieiicatli. Tbis
secoml biyer is lil\e\\i>e eiilargt'd, owing to ])roliferation of new tis-
snc-elements, wbieb freipieiitly become fibrous in character. The
cavernous sinuses below, together with all the Idood-vessi^ls of the
miicnsa, may bcciune permanently ililated. the glandular elements
likewise being affected, the racemose glamls having increased in num-
bers. With all tliis coud)ined bypertropby. there is little epithelial
desquamation. In advanced stage~ <d' the disease new connective
(4.5)
II
46
DISKASlCiS OK TlIK NASAl. I'ASSAtlKS.
tissue is formed hy proliferation from the old c >nnective cells, produc-
ing the want of tendency of these hypertrophies to undergo spon-
Fig. 4r).— Section of inf.rior (iirliiiialid iLT) diainetiMs). o, Stratified
ciliated opitlielium. b, (Jlitnds of siil)imi(osa. c. Sinus of erectile tiaauo.
d, irter\. t', Vtlii. f. ]|y|icitrc])liie(l (nil)iiintt'(l Imne. fAnthor'a speci-
men by Ik'nsley.)
llYrKIlTROPHlO imiNITIS.
47
taneous resolution. In some cases the hypertrophy involves the tur-
binal bone also, as shown in microscopical section (Fig. 45),
Of the inferior turbinatcds, all parts are about equally liable to
enlargement, with possibly a predominance of tendency in the pos-
terior end (Fig. 46), while in the middle turbinated it is the anterior
end that is usually involved. The Figs. 4Ga and 4G& give histological
sections of portions of tlie anterior and posterior ends of the inferior
turbinated.
Etiology. — Anything which will produce continuous partial ste-
nosis in the anterior end of one nostril has a tendency to produce
m
Fig. 40. — Large niassos of hypertrophied niembnane on the posterior
termination of the lower turbinated bones, more or less completely filling
the posterior narcs. (After Uosworth.)
turbinai li\])ertrophy on the same side. A little consideration will
make the I'cnson of tliis iilaiu. Inspiration of air ihroiiiih the nar-
rowed inlet iiiiMiediately produces rarefaction Ixliiud the obstruction,
owing to the forcible manner ii! wliich the air i.s drawn through the
passage. This rarefaftiou means diminished atniospher.c pressure,
repeated with each inspiration, and, acting on the soft tissues of the
turbinatcds, it produces a tendency to abnonnal congestion.
Consequently any malfmination of tlie front end of the septum,
whether of traumatic origin or not, wbich has the olTect of making
one nasal passage materially narrowc than the other, is likely to
cause a gradual, but pernumenl, enlargement of the turbinai tissues
behind it. If, on the other band, the closure of the passage from septal
48
DISKASKS OF line ^■A^.V^ PASSAIiKS.
deformity is so complctL' ii.< to jirodiice actuiil stonosis, there can be no
hypertrophy on tlic iilTectcd side; but tliere may l)e on the opposite
one, owing to tlio extra lalior ot inspiration through the single channel.
]''ig. 4G</. — Aiitciior pditidii of inferior tiirliiiial ('/;.-inch objective).
(After T.ciinox Brow no.)
Fig. 4G6. — Poshrior |iorlion of inferior turbinal ( I-incli objective).
(After Lennox Browne.)
Narrowing of the anterior nares by displacement of the columnar
cartilage may also produce turbinal hypertrophy in the same way.
llVl'KHTKOrillC RHINITIS.
•I!)
There is iinotlici' CfUisc of Wua (lii^ease which I have not seen
mentioned hy any iuilhoi' upon the suhject, Ijiit whicli I hclievt' is not
by any means infrequent, and that is the ]ial)it which many a molluT
has of always hiying lior eliihl on the same side while sloei)ing. It is
a well-known fact, which any observer can verify for himself, that
lyinji' oil one side will, in a very few minutes, produce turi^escence of
the turl)inat('ds of tiuit side, accom|)anied l»y comparative ana'iuia of
those in the upper nasal cavity. This is simply the result of gravita-
tion. The turbinal tissues are naturally so lax that the dependent
ones, other things being equal, are always congested at the expense of
tliose fluit ai'e above. l>y closing the lower nostril the upper one
will be found to be doing nearly all the breathing, while closiin' of
the upper oiii' will reveal the fact that little air passes through the
one beneath. Ifeversing the position to the oi)])osite side will further
substantiate the same law.
The conse(juence is that, l)y persistently placing tlie child on the
one side while sleeping, t!'e mother is continually pi'oducing con-
gestion of the same set of turbinateds, forcing the infant to do the
greater part of its respiration through tlie upper nostril. It is only
reasonable^ to conclude that, in a healthy, rapidly-growing child, con-
tinual hypera'mia of one set of turlnnateds would lead to their hyper-
trophy. l)Ut this is not all; the rarefaction nf the air upon the lower
side of the soft cartilagiiu)us septum of the infant, with the full
pressure of fifteen pounds to the inch on the upper side, will have a
tendency to slowly, but surely, dellect it toward the least resistance,
thus jK'rnianently narrowing the nostril and tending to hypertrophic
onlargenient.
(}uite fre(|UenlIy, liyperl rophic rhinivis owes its origin to other
jauses. Strumous habit may ]iro(luc(^ it. particularly when attended
by injudicious exjiosure. Sudden changes of temperature oft re-
peated, particularly when the patient is unwisely or inedlciently
clothed, nuiy also give rise to it. Tiong-continued chronic rhinitis may
also, in certain cases, culminate in hypertrophic disease.
Symptomatology. — The most ludniimuit symptom in hyper-
troidiic rhinitis is the olistnu^tion to nasal resjiiration ])roduced by
the enlarged turbinal tissues. Together with this, there will be a
change in the normal secretion and its reti'iition to a more or less
extent within the nasal cavity. The discharges are thicker and
more opiupii'. owing to lessened exwdation of serum and increased
seereticu of innco-pus. The ditliculty in luisal respiration and the
50
DISEASES OF THE NASAL I'ASSAOKS.
amount of discliarge are both variable, being controlleil, to a certain
extent, by the temperature and humidity of tlie atmodpliere. In warm
dry weather the nasal passages are freer, with less abnormal secretion,
while in damp and cold seasons of the year there is greater swelling,
increased stenosis, and more profuse muco-purulent discharge. When
tins occurs, the pharynx also becomes involved, becoming dry and
irritable, on account of the oral breathing which has become necessary.
Crusts do not form in this disease, except occasionally around the
anterior nares and the front ends of the inferior turbinateds. When
they do occur, it is due to the drying effect of the atmosphere, com-
bined with deficient serous effusion from the affected membrane.
There is rarely any odor with this disease. When, however, the
dense secretion is retained among the deep crevices for an unusual
length of time, mild putrefaction may set in; but the odor is very
different from the more offensive one of atrophic rhinitis.
The sense of smell is often notably impaired, owing to occlusion
of the nasal chambers. The voice becomes thickened and nasal, while
impaired hearing and occlusion of the lacrymal duct may occur as
results of the disease.
Headaches may arise from hypertrophy of the middle turbinateds,
and in these cases the enlargement is likely to press upon the se])tum.
ITay fever and asthma are also, in some cases, attributed to it.
Diagnosis. — For this, rliinoscopic examination is necessary.
Symptoms may indicate in a general way, but they cannot alone give
a ]>ositive diagnosis. On examination, the turbinateds will l)e found
to be more or loss swelled, and the mucous membrane covering them
of a bright-roddish color. A certain amount of muco-pus will always
be present. The lower turbiiuited is usually the most swelled, some-
times almost filling the inferior meatus. The anterior end is the
reddest, the color gradually assuming a grayer hue toward the middle
and ])osteri()r end of the bo.ly. Tlie enlargement of the turl)inateds
is Uf^ually somewhat irregular, nodules often standing out jiromi-
ncntly in dilTcrent parts. Occasioiuilly the hypertrophic masses have
become united lo the septum by bridges or syuecliiie of fibrous tissue.
This is more likely to occur in hypertrophy of the middle turbinated
than of the inferior, owing to its closer proximity to the septum and
the greater tendency to enlargement of the anterior end.
The nasal speculum, aided by reflected light and the use of
the head-mirror, is always essential lo examination. In posterior
hypertrophies the post-rhinal mirror reveals the condition, the end
uyi'Ektkoi'Hic uiiimtis. 51
of the inferior turl)inated assuming a corrugated, swcllctl appearance,
almost like a wliitc strawberry, and in some cases entirely tilling the
posterior clioana (I'ig. -KJ).
In a few instances the posterior liypertrojiliy lias a reddish hue.
Sometimes an (edematous congestion, as in rhinitis auleniatosa,
might he mistaken for a true hypertrophy; hut the application of a
r)-j»er-cent. solution of cocaine will soon remove the (loul)t. In either
ease the swelling will be reduced; but in true hypertrophy the re-
♦luction will be limited, the abnormal librous tissue of the body still
leaving it in a swelled condition, while, in the other, the cocaine will
soon shrink the (edematous tissue down to even a subnormal state.
Prognosis. — Under pro])er surgical treatment, wlien the disease is
• me ol' simple hypertrophy, the prognosis is always favorable. Without
surgical treatment it is a prolonged disease, the ultimate result in
many ca.<es being exceedingly unsatisfactory. Not a few writers believe
that it is the forerunner of atrophic rhinitis, laying the majority of
cases that occur at the door of uncured liypertrophy.
Bishop says that: "After middle age the hypertrophies generally
are absorbed aiul disappear, when this form often becomes merged
into atrojihic catarrh."'
I seriously doul)t the correctness of this statement, ]mrticularly
with regard to age, as the large majority of cases of atrophic disease
that have come uiuler my observation have been many years under
the period of middle age. It is also generally accepted by rhiuologists
that atrophic rhinitis has reached its term by middle life, and from
that time gradually disappears, or, at least, the dislres-iiig symptoms
])ass away.
Treatment.— 'J' he kind of treatment reijuired deijeiids largely
upon the extent and severity of the disease. If the liypertrophy be of
a mild character, producing only slight stenosis, alkaline spray.s, fol-
lowed by mild astringents, may be all that shall be reipiired. The
solutions referred to in the treatment of purulent rhinitis wnuld also
lie suitaiile. to wbiih list miLrbt be adiled: —
1. U Zinci siiliiliiit 2
Glvccriiii 21
Aquaiii iul 301
H.
1. B Zinci sulphat gr. iij.
Glyccrini wxxx.
Aquaiii aJ 5j-
*
k:
it
o2 DISKASKS OF TlMv NASAL I'ASSAfiKS.
1. It (.'anii)hoi-incnthol 1
Alboleiie SO
Tlic mmilxT of ciisi'.s. liowcvcr, in wliicli r^iiiiplc spniy-tioatment
will elTect a cure is very limitod. I'liticnts usually delay seeking
advice \intil pernianont hypertrophy has taken jilace, to remove which
operative treatment of one kind or another is required.
For this, two methods of operating are largely in vogue. One
is l)y the application of chi'omic acid; tlu; other by lh(! use of the gal-
vanocauteiT. 'I"he first has the advantage of cheapness and simplicity
of management. The nasal fossa is first sprayed with a 2-per-cent. so-
lution of cocaine. This, in three or four minutes, will produce general
shrinkage of the mucous nuMnhrane, with the result of widening the
fossa. Then a stronger solution — .«ay. S to 10 per cent. — may be
apjilied to the turbinated, on a cotton-holder, to remove the remain-
ing sensibility. To apply the chromic acid, first dip the end of a
slender bent probe into mucilage; then pick up with it two or three
crystals of chromic acid, and hold them in tiie tlame of a gas-jet,
until they fuse into a head on the end of the probe. This cools in a
moment and can be apjilicd to the hypertrophic tissue. A small
eschar is formed, which in a few days separates, reducing the swelling.
The ojieration can be rcjicated several times, at intervals, until the
re(iuired amount of reduction has l)ecn accomplished. The chief
thing to guard against in using the chi'omic acid is the possibility
of touching other jiarts while carrying it to and from the diseased
tissue. Care in application should ])revent any accident of this kind.
The second method, by the use of the galvanocautery. is mucli
more generally followed, particularly by specialists. The chief diffi-
culty is the cost of expensive apparatus; l)ut the advantage lies in
the thoroughness of treatment and the ni<'ety and precision with
which the operative woi'k can l)e (bme. For this ])urpose the various
forms of sforage-batteries are usually employed. These can be
charged with electricity, at any works where electric light is manu-
faciurcd. as fre(|uently as the expenditure of the current may require.
T?i towns and cities lit iiy electricity, transformers can be constnu'ted
in c(mnectiou with the ])lant. and. when furnished with the reipiisite
re>^istance-coil. are always ready for use. In urlian sections, where
storage-l)atteries cannot be regularly charged, the plunge-batteries
1. R ('aniiilior-incnthol gr. xv.
Alholono 3j.
IlYl'KHTHOI'llK' HIIINITIS.
53
answer a very ji;oo<l purpose. 1 have latterly u^■e<l a lautery-trans-
former connected with the alternating current I'rum the city electric
works. It docs excellent service, heing constantly controllable as well
as easily regulated.
In Fig. 47 is shown a Ballanl, l-volt, two-celled storage-battery
that I used for years. On the top the metal l)ars comprise the adjust-
able volt-selector, by which the current may be made of 2- or 4-volt
power. For cautery-work only 2 volts are recpiired; for electric light
4 volts are needed. I ii front of the battery is seen t he rheostat by which
the cautery can be regulated froni a dull-red to a white heat. I'^ig. 4T
Fig. 47.--I5iillai(l yalvanocautt ly-liatti ly, with cord,
handle, and knife.
also gives a galvanoeautery-liandle wiih knife and also shows electric
cord. In this case the two cords, for convenience sake, after separate
coating, are wrapped together in a single wel). As will be noticed,
the two ends for attachment to the cautery-handle are separately
covered with rubber tubing. This is to positively prevent their touch-
ing each other when attached to the battery in circuit, as, should
this occur, the instrument might be destroyed i)y short circuit.
To operate with the cautery-knife successfully requires both care
and skill on the part of the operator. The ]iarts should first be
thoroughly cocainized and the nostril opened and protected by a
£ If
If
tic
m
i
i
54
DLSKASKS Of TllK NASAI, I'ASSACilCS.
largo-sized speculum (Fig. 13). Shurly's, with its ivory septal pro-
ad i
ibk
th
V
)tliei
tcctor, is
like the ovoid the best, a» tiiey slip into the nostril and j)rotect the
vhole circimirereiice. The speculum in jxisitioii, tlie cautery-knife
'i!^ l)assed into the naris and directly back to the posterior end of
the enlargement to be operated upon. 'J'lic current i.> then turned
on at a bright-red heat and an incision made into it from behind
forward. When the turbinal hypertroi)liy is very large, jiresenting a
round j)rojecling surface, J have usually applied the ilat side of the
instrument, cutting in jiretty deeply. 1 know this is contrary to the
ordinary teaching, but I have found, after the slough has separated,
tliat there has still been abundance of my.xomatous tissue and epi-
thelial coating to heal perfectly, without leaving a scar. In doing
this care must be taken not to have too wide a blade, and to confine
the application to the one width of the llattened surface of the elec-
trode.
On the other hand, when the hypertrophy is less prominent and
less enlarged, a slight knife-edge cauterization will produce the best
result. It is well in either case not to operate too extensively at one
sitting; and we should always be as conservative in our operations as
the nature of tlie case will allow. After operation the passage should
lie s[)rayed out with albolcne or glycolin, fur its cleansing and pro-
tective effect; and a tampon dipped in the same hydrocarl)on should
be inserted between the cauterized surface and the sei)tum. This will
prevent any possibility of adhesion, and it should be left /'/( .s(7« for
thirty-six to forty-eight hours.
The best iiu'thod (if (ipeiatiiig upon large hypertrophy of the
posterior end of the inferior turbinated is sometimes a vexed cpieslion.
Many authorities advise removing the hypertrophy with the cold
snare. This done by the slow turning of a Jarvis snare is a tedious
and painful process, even after free cocainization, ])articularly as it
may take from half an hour to an hour to separate the mass. Any
severe traction or ])ulling upon the jiarts is likely to do serious harm,
as, if resorted to, it may loosen the attachment ox the turbinated bone
itself.
Other authorities advise the galvanocautery-snare as being speedy
and cflfectual. The olrjection may lie nrgcd that the large surface
exposed during the operation to the action of the heated wire contains
a considerable element of danger, particularly when we remember the
close proximity of the growth to the Eustachian tube. When resorted
llYl'KHTUOriUC imiMTis.
to, tlie lingor should invariably be passed behind tiio i)alat(', to adjust
the wire and insure the safety of the tube itself.
In my own experience, I have had better results in the treat-
ment of ordinary posterior turbinal hypertropliies by operation witli
the tliit electrode than by any other niclhod. After ai)plying a 10-
or lo-jicr-ccnt. solution of cocaine freely, I have jiasscd the electrode
back through the nostril to the growth, guiding the application of
the cautery liy the post-rhiiial mirror. 'J'his sometimes r('(|uir('d a
little training of the patient; but I would not venture to o])erate
without I could see the point of the instrument clearly rellecled in
the glass. This being recngtiized, a lirm hand, guided by a knowledge
of tlic anatomy of the part*, -should ])erl'orm the operatimi without
risk. The growtli is large and vascular, and, pressing the electrode
flatly upon the centre of its inner side, you can burn dnwii ih'eply
into it without producing pain. The one cauterization is all that
should be done at one sitting. In this case tamponage is not neces-
sary. It may be followed by swelling, but scarcely enough to touch
the septum; and a daily sjiray of weak solution of cocaine, followed
by albolene, will help to kct'p it open. In three or four (lay< the
mass will slough away, aiul the o])eration can be repeated carefully at
intervals until the turbinated returns to its normal ;■!/(•: l)ut one or
two rc'jietitions are all that arc ever required, and in >onie cases a
second burning is not needed.
I have never known niiddle-ear disease to arise from tbif method
of treatment, but 1 have seen several instances in which tinnitus
aurium and slight deafness have been removed l)y it.
Of course, tliis nH.'thod of reducing the hy[)ertropliy shoidd not
be attempted by the inexperienced operator. ^Vilat may he one man's
food may be another man's liane, and any individual, by constant
])ractice, may liecome so skillful in the use of a sinu'le instrument as
to prefer it to all others in the performance of certain operations.
Ifelot, of l?ouen, recommends the use of electrolysis by the bi-
polar method for the treatment of posterior hypertrophy. The parts
are first cocainized, and then the electrodes are passed through the
anterior naris and inserted side by side into the enlargement. 'l"he
si'dinrs last five minutes or more, and are repeated at intervals of
several days until the hy]iertrophic tissue shrinks away.
During the last two years a new method of treating severe cases
of this disease has been discussed and practiced by many l-'nglish and
I'hiropean rhinologists. On this side of the oc(>an the ])lan, although
m
50
DlSKA^^Kt* ()!• Till-; NASAI. I'AISSACKS.
iiccoptod ill a iiiodilicd di-gn'o, luis not been j)ructice(l in its entirety
to any great exleiil. This is o])eration by tiirbineetoniy, or removal
of the tiirl)inate(l body. The term "turbinotomy"' has also been ap-
jilied indiseriniinatt'ly to tliis operation; but as this term, from its
derivation, really mean.- simple incision ol' tlie Uultiiiated, its ase is
searcely appi'opi'iate, and i'onse(|iiently should not be applie(l to the
operation at all.
Tiirbineeltiiiiy may lie partial "or eomplele, and it is the latter
that has been so strongly ai' oeated in certain cases by Carnialt Jones,
Dundas (iranl, Jiaber, and bers. For this a sjieeial instrument has
been made: L'arnialt Jones's spokeshave, modilieations of wliieb are
re])resented in Fig. II. After cocainization the entire turbinated can
be removed by it. its n>e i> only adNocated in <'.\trciiK. cases, where
milder opei'ative measures have failed to give the nninired relief.
This .severe and I'lidical operation is opposi^l by many surgeon.-, par-
l''iji. 48. — Kiii;;lifs nasal si'issiois.
tieiilarly in .\nierie-a. on aceount of the imimrtant posilinii which the
inferior turbinattd occupies in normal respiialion.
!Modilletl turbinectomy, on the oilier band, is accepted by all
rhinologists. and, in ajipi'ojiriate eases, is constantly being done. F^re-
(piently the anterior cud of the middle turbinated, bulging and press-
ing n]ion tlu' .-cptum, can be better excised than binned away. And
can be removed ell'edually by means ol' serrated scissors (Fig. 48).
The anteriiu" end of the inferior turbinated, likewise curled upon itself
and filling the whole of tlie inferior meatus, can often be best removed
by cutting instruments; and partial turl)inectoniy in either case would
be unattended by the intlaniniatory swelling which might be expected
from extensive cautery operation. The same applies, tliough in a
modified degree, to the posterior end of tlie infeiior turbinated. Fig.
id shows forceps specially designed for nasal work tlie spring closing
the instrument, and pressure opening it.
MYl'KinilOI'llK KIllNII IS.
• )«
Tlio.se vjuidu.s uji(.'iiilii)ii» can bo |K.'rl'i)riiii(l iiiulor cociiiiic iiiia'.—
tliL'^^ia by jiicans of various iiistruiiu'iils, such as curvrd .scissors,
knives, ])uneli-l'oi<e|)s, (Iriiiiwald's typical uiciliod, (ir I'vni .-aws
properly guarded. 1 ba\c liciiufiilly used the last-named instrument
in excising the niiich-ciirved anterior end ol the interior turl)iiialetl.
In (Iriinwald's operation a not<'li is cut in the neck n\' the middle tur-
binated, or near the central part id' the lower turliinated, and the
part thus marked oil' is reinosed by hoi or cidd snare.
llowevei' well complete or e.vteiisive turbineciomy may sinl the
moist and saline atinosidiere of CJreat JJritain. in the drier climate i>\'
the I'nited Stales and Canada it can rarely, ii' ever, be rei|uired. It
is quite jiossible thai entire removal wouhl leave >iich an atrophic
condition thai ihe cure would be worse than the disease.
A method (d' trt'atmcnl has been advanced by j,eiuii)\ Umu ne
diirini;' ;he last year which is wni'thy uf 11111113 c\tcn>i\e trial. It is
]'ijr- ^!'- ^llUllv"s Ilil-ill fci|rc|i-..
by clectroeantery-i)uneture <d" the liypertroi)hic tissues. After co-
cainization a sharp needle is jiassed deejily into the enlargement,
[taralhd with the wall of the fossa. Il is left in sihi at a red heat
for a few nunnent-^ and then removed. Uy this means, while the
mucous membrane is .^avi'd. the hypertroithie tissue shrinks. The
method 1 would consider jiarticularly ap[ilical)le to postciiui- hyper-
trophies, special care being taken not to puncture the Eustachian tulie.
Still another method of ireatnu'iit has been pi'oposed by Uryson
Dclavan, somewhat similar to the lasi inenfioued. the dill'ercnce being
that, instead of cautery-puncture, we have submucous knife-incision.
After cocainization a small Idaded ophthalmic knife is passed into
the hypertrophic tissue without perforating the opposite side. A
slight sweeping movi'iuent is made as the knife is brought out of the
same opening. Kelief is usually pr(im]it and fnlldwcd by no un-
pleasant results.
iff
■II.)!
ClIAlTKll VIII.
ATHOI'llIC lailNlTlS.
This discas-c lias lictii kmiwii I'or ^'onorations liy tlio nanio ol'
calarrli, liciiig considered a.s si^iiilicant of nasal discharge accom-
panied hy fold odor. Catarrh, however, is not a disease. Init a symp-
tom, and as a symptom it dilfers widely, both in character and degree,
according to the pathological conditions t<i which it owes its origin.
Among the many detlnitions of atrophic rhinitis given hy lead-
ing anthoi's, I know of none more terse and comprehensive than that
of Wyatt Wingrave, who says: "It may be delined as a progressive
and persistent form of dry rhinitis, characterized hy a shriidvage of
the mucous mend)rane, which tends to invade; contiguous chand)ers,
and is accompanied by the formation of crusts, with more or less
ffctor of a special character."
Pathology. — In the atrophic slate the normal cdia lining the
mucous mcmbi'ane (d' the lower half ol' the nasal foss;e are gradually
destroyed. In severe cases this loss of the ciliated epithelium becomes
complete and permanent, their place l)eing taken by r layer of ilat,
squamous, epithelial cells in a state of constant desiiuiunation. ]>elow
this the cuboidal ejiitheliuni, the adenoid or hyaloid layer, the acinus
glands, the blood-vessels, and eavenious sinuses, all gradually shrink
away, losing their power of physiological engorgement and collapse,
so essential to the proper performance of the respiratory functions.
This atrophy of all the special tissues of the mucous meml)ranc is ac-
companied by formation of abnormal connective tissue, though in a
minor degree than when the result of hypertrophic disease.
Notwithstanding the shrinkage of the turbinated tissues, Win-
grave, on microscopical examination, fouiul imbedded in the inter-
lobular tissues of the glands, in the lymphoid tissues, and sometimes
in the stratified epithelium, small, round, refractive cells \vhicl' he
called hyaloid bodies. They varied in size from one-eightieth to
one-thirtieth of a millimetre. Those bodies increase in numbers as
the disease advances. Finally they break up into minute refractive
bodies, resemhling spores. The question of the nature of these bodies
(58)
ATROPHIC imiNITIS.
8»
is still undecided. Some biologists believe Ibem to be the bacteria of
atrophic rhinitis.
Klebs-Loefller l)ueilli iiiid also staphylococci have been found in
large numbers in certain cases of atrophic rhinitis without develop-
ing either diphtheria or general suppuration.
Microscopically, multinucleated lymjihocytes arc found in the
atrophic discharges as well as the bacillus fu'tidus and bacillus of
Friedliinder. Aecfirding to Tjcnmix iJrowne, tlio crusts consist of
mucin, cell-globidin, and serum-albumin, with traces of suli)hur and
l»hosphorus.
l-'raenkel and Loewenburg have discovered a diplococcus which
they claim In have an induciicc in (he etiology of the disease.
Xolanil Mackenzie maintains that atrophic rhinitis is a sclerosis
— a chronic intlammation in which there is an atrophy of specialized
tissue, accompanied by mild liypertropby of cfninective tissue; that
this eonditidii is present in hypertrophic as well as atrophic disease;
that the two (lill'er not in kind l)uf in degree, the one being hyper-
trophic sclerosis, llie other atro])hic sclerosis.
v.. T-. Shurly believes tlie disease to be a pure neurosis of central
origin.
Incidental jialhological changes occur in a majority of cases.
Out of (»(» recorded, the ]iliaryngeal and fnucial tonsils had entirely
disappeared in 50; while in the remaining 4 they were small, thiis
indicating a direct relationship between the surrounding lymphoid
structures ami the atroiiiiic disease.
Perforation of the cartilaginous septum is of frequent occurrence.
It is, however, geiu'rally Ix'lieved to he. not so much the direct result
of the disease itself, as of digital picking. Tn my own experience, I
do not remember a case of jierforated septum co-existent with atrophic
rhinitis in which I could not trace the origin of perforation to the
period of childhood. When it comes under the notice of the physician,
the margin of the perforation will usually be found coated with
tenacious mucus, overlying a layer ol' ju-oliferated epithelium. The
whole history of these cases of ])erforation would appear to support
Bosworth's theory, that purulent rhinitis in children was the fore-
runner of the subsecjuent atrophic disease.
Etiology. — Perhaps there are few subjects in medical science
upon which there exist so many dilFerenccs of opinion as upon the
origin of atrophic rhinitis. Fraenkel was the originator of the idea
that it was a sequel of hypertrophic rhinitis, and a large number of
1 II
Si
■4
m
till
DISKASKS (M' Tin: NASAI. I'ASSACi KS.
(ilwcrvLTs art' still of tlu' same oj)iiiic)ii. Scilur says tliat, wiiili! il may
l)e till' result (if liyjxMti'ophy, it may also be atrophy from the start.
J)rakt' claiiiis dn'oiiii- |iiiiiik'iit iiillaiuiiiatioii ol' the accessory sinuses
as the cause, (lottsteiii holds that (lei'eetive development of the tur-
liinated hollies may be responsible for the disease. ]\layo Collier has
thrown out the suggestion that it may yc: he diseovered that the
initial (li>ease was degeneration df the lU'i'vo-ganglion and nerve-ilhres
supplying the pai'ls. !•]. L. Shiirly soiiu'what I'avors Collier's idea, for
he has long been of the opinion that it was essentially a tro])hic
neurosis of central origin. r>osworth, on the other hand, in his recent
i>sue of liSiKI, expresses as em]ihatically as ev ■]■ the belief that the
disease is the result of a previous attack of infa. .ile purulent rhinitis.
(ielli als,) favors Ibis theory.
Personally J have seen a great many case> in young ])eople which
could I'e 1 ! iced back direcily to jmrulent rhinilis of childhooil. In
examining these cases there was no history whatever of previous
hyjiertrop e disease: but there was the history of chronic ])urulent
discharge, dating hack as far as ineinoi'v could reach. 1 helicve, loo.
thai it i^ ]H)s.-ible for atrophy to \)v a seiiuel to hypei'trojtby, for I
have seen cases in whicii the relationship ap])eared to exist; b\it 1 do
not bcli(>vo that i' is. hy any means, the rule.
\\'c rircly meet with bypc'trophy of the turhinaieils during
childhood: as a I'ule, it is a disease of early adult life; and il is
'Veil to icniemher that llie majoiily of eases o\' atrophic distvise like-
wise otcni' in young men and women. Jt would seem impossihlc for
a slow liypei'ti'oj)hi(' process to have time for development, and that
to oe followed by suilicieiit shrinkage to jiroduce afro])hy at the lime
of life when ue ai'i' usually called in to treat these cases.
(^hiili' fi'iMpienlly alro|ibic rhinitis is unilati'ral. intirely conllned
to the one nasal cavity, and that one the widest, with a curved .-ep-
tum, the convex surface within the narrow nostril. There may lia\e
been no prcvicuis purulent disease; and lln.' c(Miclusion seems reasmi-
ahle that the great width of the fossa had allowed free breathing.
whil(> pcrmiiliiig the retention of di>cliai'ge. 'The retained secre-
tions would, in time, become iiuiulcnt. Criist-fin'malion would fol-
low, Mhieli eventually, hy it> repeated presence and ])ressure, would
produce greater slirinkage (d' ti.<sue.
Symptomatology. — The -ymiitonis are eharae eristic and too well
known to reipnre a careful delineation. They consist of dryiu ss of
nose and throat, the latier in consequence of the former, accompanied
ATllUI'lIlf ItlllMlh
61
1
liy lOi'iiiatioii I'!' crusts within tln' nasal cavities. 'I'iic-i are nl'tcii
tliiliciilt to blow uul; and. as the disjcase advances, it heconies im-
possible, by Nature's elToii alone, to thonniiihly remove them.
On rliino.-copie examination the fossa' will i)rove t<> I'C ciihirized
to a greater or less extent, acc'ordin>i' to the severity nl' tlic disease.
the enlargement being due to the shi'ink.ige nf the middle and in-
fei'ior turbiiiate(l bodies, (ireeiiisii-vellow eiiisi-. \\iih a eliai'aeter- •
istic. oU'ensive ud(ir, will partially hll the |ia.-sage>; and mi the I'e-
niii\al of the.-e llu' ;niiei)us mendiraiie. although nnlu'oken by uleei'a-
lioii. will jiresL'iil an unwontedly sep.nken and pallid appearance.
.in this disease the nnrmal >ei'(ius discharge iiec(inie> limited, and
iiually almost ceases, having the air diy and I'nul by the time it
reaches the thi'oat. With diuiiiiutioii nf seiniis thud theri' i> iii<Tea,-e(l
exiolialion of epithelial and pu.— cell>. These tngelher iiieru-t ai. 1
(leg up tiie pas.-ages. In Imig-slanding ease- anosmia i^ <>[' Ireqiieiit
oei-urreiice. while in many the seii.-e of ta,-te i.- like\\i>e impaireil.
I>i'yness id' throat, or phaiyngiti.- >ieca. i- alway.- a ic-ult in ad-
sarii'ul eases; ami. as C(dlateral events, the I'aucial and pharyngeal
Icuisils n.-ually ln'c(une atrnphie; ihe eontigiMUs siiiu>e> mil inlVe-
([Uently beeonu' involved, and the Mu-tacdiian tidies ni;iy also be
all'eotcd.
A\'liile the oll'ensi\e l\elor pi-culiar to .Urophic rliinili.- is usually
lielieved to ari-e from putitd'action of the retained sei-reii(ms. '\"in-
gra\e has advanei'd a new and somewhat jilausible theory: lie ,-ays
that, as the mueous membrane i> a tran^foi'med epidermal -iruitiire,
having with its glands a common origin with the skin; so iii this dis-
ease we have a structural rever;-ion, in the .-iratilication of ihe siii-face
epitlioliiim. to the pi'imiti\c type: and in the glands there i- estab-
lished a perverted function, the miicou- membrane being convertt'd
into cutaneous structure, .villi a cori'e-poiiding change in s.^crelion.
F<illowing out this line of argunieiit, he speak< of the various odors
produced by dillV'reiit ]Mn'tions of the skin, smdi as the feet, the
axilla', the pi'epuce. etc.. and (dainis thai the odor of atrophic rhinitis
has a direct kinship with these.
Diagnosis.- -I'Accpt in its earliest stage, a cand'id and thiu'oimh
examination should, with little dilliculty, ex(dude cvt'iy other disease.
'{'here is one remarkable fad. that, after the crusts have been caicfully
and thoroughly removed, no matter how attenuated the turbinated
tissues may have become, ulceration will always be an ab<enl (jiian-
lity. Of course, where sejital perfoi'ation exists, there may be ubera-
iH
6«
DISKASKS Ol- Tin; NA^Al, I'AS^AtiKS.
tion around its maigin; but the perioration dates hack to an earlier
date than the atrophic disease. Syphilis, on the other hand, is often
the cause of oxtonsive ulceration of the hone as well as soft tissues;
hut the odor of atrophic rhinitis, while disgusting enough, is still
distinct from that of syjihilitic iK'crosi«.
Prognosis. — ^Vithont ireiitnicnt, prognosis is liad. With treat-
ment, relief can be ol)tainod. and the conditinn very much improved,
and in a few casos cured. Hut this ; an only lie accoiupli>li('d by care-
ful and thorough treatment, carried out for years in many cases.
Fracnkel, of Berlin, says,, referring to atiopliic rhinitis: "A cured
case of oza'iia is unkiu)wn to me." liosworlh, in bis la.-t edition, says:
"In the early stages of the disease, before the ftttid symptoms set in.
T have seen cases recover. In the advanced stages characterized by
fo'tor, and in wliieh the turbinated boues have ahnost entirely disap-
jieared, I have not seen a case cured. :'' ''y cur(,' is meant a conilition
secured in which there remains no neci'ssity t'oi' any measure of local
treatment." Sajous says: "Atrophic rhinitis is, perhaps, the most un-
satisfactory of the na.-al alfectious to treat .-ut-cessfuUy."'
All, however, agree that much can lie done In amcliorair the
symptoms and make life comfortalile
Treatment. — The ini.ial step is always to tlnuouglily cleanse the
uasal and naso-pharyngca.' cavities, rcnuiving completi'ly all incrusta-
tions wlicrever located. This is best accomplished i»y the use of
aqueous alkaline s))rays, such as Dobell's .-dluiinu. to iln^ anterini-
nares; and the i;se of the post-nasal spray-syringe, by which water
at the temjjcrature of 100° V. can be thrown forcibly through the
nostrils from behind. For the latter purpose a Davidson syringe
with a curved spray-tube attached is an admirable instrument. Tlie
tube l)eing jias.-ed up behind the palate and the patient's head tii)ped
well forward over a receiving-bowl, a constant stream id' a piiit (U*
more may lie readily thrown througli. This not ludy loosens the
concretions witliiu the nasal passages, but also those beliind the
])alate; and. even if it does not bring them all away, it materially
softens them and facilitates their removal. Other iii-t ■timcnts ( l''igs.
.')() and od*;) act upon the same principle, although le-s ell'cctively.
The method of using the nasal douche, and instructing tlu' pa-
tient to pass 1 or 3 (piarts of hot, medicaleil thiid daily through the
nose, up one nostril and down tlu' other, wliich is often recommended,
only accomplishes jiart cd' tlie object in view. It Hoods the nasal
passages. l)ut not the na-o-pharyn\; ami in this disease it is as im-
I
ATKOPIllC lUIIMTIS.
03
portant to cloan.se the uno as the other. If the iio.-e during the douch-
ing is elevated enougli to allow the tluid to pass beyond the soft
palate, there is serious risk of flooding the Miistachian tul)es, an
accident involving much danger to the inner car. Tlic use of the
post-nasal syringe, carefully adjusted well up beliind the soft palate,
with the head tipped forward, is dcvuid of this danger, while, as
Hi
Fig. 50. — Post-nasiil syringe.
already stated, it cleanses the combined nasal and post-nasal region,
and conse(iucn(ly is preferable to the former method. It also simpli-
fies the treatment, as ])aticnts cnn be taught to i)ractice tlie one as
readily as the other.
The anterior na.'-al spray from a good atomizer is a good adjunct
to the post-nasal treatment. Still, when tlie disease is severe, the two
.^ffi"
^
(*W«LL SU" -w»t .0
Fip. iV-W. — Postnasal syringe.
together will not elTectually cleanse the jarts from crusts. Tn com-
plete the removal, the nasal cotton-carrier by the anterior nar.'S, and
the curved cotton-carrier by tlie nnso-pharynx. will 1)oth l»t' required
In first treatments especially tiiis should i)e done in a painstaking
and thorough manner, and always by the aid of anterior and posterior
rhinoscopy with a good refiected light
-■ ■,<),. J
i i
i< . ,1
y
64
i)i>i;Asi;s OK riii: nasai, passack.s.
This stcj) liiniiiL;- liccn ;u(()iii]»lislR'(l, it is; generally coiioodod
tliiit till' next one i< tn siiniuliite tlie atrophic inenil)rane to a bettor
])erfonnance of its natnral riiiiciinn df secretion. To this end (iott-
stein reeonmiends jihiggiiiii the mi^li'ils Inr twcnty-rour lionrs witli
cotton tani|HMis. When ihcv me iciniivcd a How of mucus Inllows the
siiinuhiliim. A\'heii the llnw -iih-ide-. tlic cavities ar,' cleansed a.^rain
and l'f( sli tainjiniiv inxitcd 'I lie whole procedure is I'epeaii'd as i'rc-
(jUenilv and for as Ion,::' a |ieriod a.> recpiired.
A\'oakes uses (iott^tein".- |)lni:s foi' tin' pni'pose of applyinu' pow-
ders of a .-tininlatinu' cliaracler to liie uiseaseil niendirane. Sajons
advises the n.-i' of tlie iialvanocjinlery passed rapidly over the snrfaces,
and T>enno.\ lirowiie favors the .-aine plan with snhseipient insnillation
of iodol or iodohu'n). Shindy and ISryson l)(devan reeoniniend the
galvanic enrri'iit. tlie jiositive eh'ctrode being ])laced on the napo of
the iieek. and the negative, wrapped in alisorbent eotlon. to the in-
t( rior of the no-e. Hidevaii uses fr(nn l to 7 niillianiperes with a
duration of from -even to lifteeii minutes at eaidi sitting, until serous
discharge occur>.
Other method- of tri'atment are the n>e of stimulating s[irays
after the clean.-iiig. -iicli as -(dntions of thynio]. creasote, argent
niti'ate. etc., of varying strengths; but these are of donbtfiil value.
Another method of treatment originated by IJraun, of Trieste.
several yeai's ago. and which from its enthusiast ii' acceptance by his
cotuitrynieii. might lie calleil the Italian method, is that of vibratory
massage of the miicou- membrane. Outside of Italy either in Kurope
or Amei'ica it lias not lieen received with any marked favor; but I
am glad to -ee that r>isho|i. ir, his recent work, speaks faviu'ably of
]iiassage. i'er.-onally. from my own expi'rienee. I indorse his views,
though each of ns has niodilied bis practice to suit his own individual
eases. As reeoinnieuded by Ib'anu. an olivo-poi]ited probe is passed
within the nostril. It is held b(>tween thumb and linger like a pen,
aud the vibrations are in-odiiced by the clonic rhythmical niovemeiits
of the hand and forearm of the opcM'ator as he ])rosses the olive jioint
against the uiucous niembraue. i>y practiic these contractions are
said to mimber aliout fmir hundred per minute.
The mucous membrane <d' each nasal fossa covers between thirty
and fiu'ty stpiari^ ceulimelres. and the siiaee operated on will bt' about
one sipiare centimetre at a time. T'.raun says he makes the time of
each vibratory apjilication about five minutes to each nostril. lie also
precedes the treatment liy the application of cocaine.
ATKOPHIC RHINITIS.
(55
To relieve the fatigue of tlic oiieralor, as well as to make the
vibrations more rapid and nniform, electromotor instruments have
been made, from wliich their originators claim to have produced even
better results than hy maimal vihralidii.
])ishop's modification is by using an ordinary cottnii-holder, or
probe, lie wraps the end with a lonsf wad of cojoii. and. passing it
into the nostrih hv hand-vihration cnnilmn'- the dm
Ihic
iinrpo;
=0 of
cleansing and massage.
My own incthnd. and frdin wjiii-h 1 \\;\\v. seen excclh'nt results,
is sninewhat dilTerciit. i have practii-etl it now fur several year-.
After tiioroughly cleansing the fossa. I wrap a jdedget of absorljent
cotton firmly and closely round th(> end of ilie liolder, in the form
of an olive-siiapcd lip. 'i'liis is dipped in aJlHilene and \\<vi\ hy hand-
vibration according to i'>raun"s inetliod. A tier each viltratory move-
ment the cotton is .~lippeil olf: and with a fi'W twii'ls lietween tluimli
and finger anotiu'r one applied. One advantage cd' tiiis nu'tliod is
that the firm cotton tip can he made of any simpe aud sizi> to suit
the various crevices within the nasal cavity. I may also add that,
for nuissage so applied, 1 never tind ii necessary to us(> cocaine.
Sometimes after removing the ineiii.-taf ion- a- tiioroughly as
possilde. even with the after-i reatmeid of massage, a thick layer id'
tenaciniis e)iitheliiiin. ]ii'ojecting from llie lower border of the middle
or inferior tui'liinatc(ls, will still <]:(}■ nil clVorts at cleansing. To
remove this tlii' application of a Iti-per-t cut. soluti(Ui of nitrate of
silver ti» the spot will sonu'timt'S he suiluient: hut 1 have usually oli-
taincd the best results hy singeing the proliferation with the galvano-
cautery. This should never he carried to the extent of destruction
of the whole epithelial coaling. As a result, the pale, bloodless, striivjy
membrane would give place to a pinkish one of more healthy color.
One pecidiarity of formation I have observed in several instances.
In each case it was confined to the side alfectcd by the more marked
atrojdiy. This was the attachnuMit. by a cicatricial liand. of ])art of
the inferior border of tlu^ middle turbinated, either to the upper
part of the lower one or to the external wall of the middle meatus.
These special instances seemed to owe their origin to a ]n'e\iiiu-
hypertrophic condition. Tn treating thon. affer ajiplying cocaiu(\ I
liavc separated the attachment by the galvanocautery with advantage
to the ])rogress of the case. One thing more T may add: that for
years now, after cleansing and massage, instead of com]deting each
treatment by the use of some stimulating spray, I have obtained the
1 f t
is t
I,.
(JG
DISEASES 01' THE NASAL I'ASSAGES.
most satisfactory results to my patients by simply fini.shing with a
spray of one of tlie hydrocarbons. As said before, these bland, in-
odorous, aseptic j)reparations are soothing and grateful to tlie patient,
and act as protectives to the whole lining of the mucosa.
For home-treatment the patients are directed to U:^i^ the post-
nasal .syringe first, at least once a day; and follow this up with sprays
of albdlene or glycolin at intervals of several hour:;, until they return
to the ofTico again for more thorough treatment.
The solutions nsed in the post-nasal syringe may consist of 1 per
cent, of any of the folhiwing, in water at a temperature of 100
degrees: —
]\luriate of anunonia.
Chlorate of potassa.
( hloride of sodium.
Boric acid.
IJesorcin.
Oi' '.' per cent, of
JUborate of soda or
Bicarl)onate of soda.
Or a -"i-jier-cciit. solution of jxToxidf of hydrogen.
Those answer very well for a time, until the patients have be-
come familiar with the jio.st-nasal method of treatment. 1 have sub-
secpiently obtained ])etter results l)y having them nse simple clear
water at as high a temperature as they could comftji'tably bear.
ClIAl'TKK iX.
(EDEMATOUS KIIINITIS.
1
i
, 1
■' u!
1
Tiiic earliest mention I can iiml of iliis ili.sea.«e is jn the report
of the American .Laryngologieal Association for 181J;). Jn his jjaper
J. C. Mulhall dcscrihes it as a serous inlilti'atioii of the middle or in-
ferior turhiiiateds. It is remittent in eliaraeler am! may ije unilateral
or iiilateral. It may aho be migratory and either acute or chronic.
When punctured, serum slowly exndes. lie says cocaine has little or
no influence over it. It may be associated with broncliial asthma,
but only in a minority of cases. It is considered to bo a neurotic
aireciioii, yet distinct from tlie neurotic diseases which are caused by
extrinsic excitants.
In treatment ]\lulhall says that sprays are contra-indicated, and
that the best results are obtained by scarification. If nasal deformi-
ties are present they should be removed. In treatment the alimentary
canal and the general system should be carefully attended to.
This is a rare disease, and I have only seen one well-marked case.
The ])atient is a young man, aged 2(i years, of sedentary occupation.
A number of vears aao I removed a larue spur for him, and also
cleared the naso-pharynx of adenoids, to remove the stenosis from
which he was suifering. For a couple of years lie was free from any
difliciilty in nasal respiration. Tlu'ii the stenosis commenced to recur
again, sometimes very suddoily. Previous to the attack tin septum
and turbinateds would appear perfectly normal, and there would be
no dilVicuUy whatever in breatliing through either side. Then from
cold taken from exposure, or su(Men dropping of oIlicc-tcmpiTalure,
one nostril, within an hour oi' so, would bn-nine completely blocked.
I'xamination wonld ri'veal one fossa (juite (bar, ili>' oilier absolutely
closed, a pale, serous-looking onlenia distcmling the mucosa of both
the s( ptum and inferior turbinated of the alfected side, and the parts
bathed in muco-serum. On examining the throat, the posterior rhino-
scofte would reveal the corresjionding choana tilled by the gray,
swollen, inferior tur])inated body.
m
HCH
68 i)isi:.\si:s or riiic nasal tassacucs.
Unlike Miilliall, I found the niiplicalidii nf a l-per-cent. solution
of cofjiinc, passed slowly ilir<niL,di the nostril upon a cotton-rarrior
and applied freely to the whole length ol' the luri)iiiatpd. would, on
eacli ooeasion. give speedy relief. The charging of a good-sized
pledget would he all that would he reipiired, and iu live luinutes
resj)iration through the passage would he restored. I found, also,
after rejx'aleil trials, that the relief ohiained woidd ho very much
prolonged and in some cases would continue for days, if the cocaine
trcatiuent was su])j)leiuented, as soon as the passage hccanic clear, by
a spray of thyiuo-meulhol of the following strength: — -
1. n Tliyiiiol |13
J^rcnthol 1|
Albolciu! 30|
M.
The preparation appeared to prolong the astringent elTect of the
cocaine and to stimulate the tissues to moi'e elTectual control of the
vasomotor vessels.
Quite frequently the (cdema, after occurring for two or three suc-
cessive days on one side, woidd suddenly cease and appear again in
the adjoining cavity in just as severe a form, disappearing for the day,
after treatment, to occur again perhaps twenty-four hours later.
In this case there was no hypertrophy whatever, either of septum
or turhiuateds, and, when the attack ])assed otf, the parts seemed to
be in a ])erfectly normal condition. Sonu^times months would pass
without an^' trouble. In every otlu'r way the young nuin was in a
strong, healthy condition.
During the fall and winter, however, ho has for years had a num-
ber of seizures; and the ])resent year the symptoms, partieularly
on the left side, with ])articidarly severe, threatening to remain
throughout the sunuucr mouths as well. CousiMpuMilly T decided to
make a deep galvauocauti ry incision along the full length of the
lower turhiiuited on that side. Vor a day or two there were no signs
of haunorrhage. Then it eanu; on profusely, ami plugging with kite-
tail tampons had to he re.<^orted to. They were worn nearly a week
and then extracted piecemeal for several days longer, the fossa being
washed daily by sprays of 2-per-cent. cocaine and V„ per cent, of
rj 'riiynidl pr. ij.
Mcntliol pr. XV.
Albolene 5j-
M.
(KDHMATOIS HIIINITIS,
C!)
h}mol ,„ .lyn-lin. The tissues seem to he a^ain un,l.r control, and
lor weeks now tiio ..dcMnn has coa.scd to occur. Whether the advent
of he changeable autun.nal season will hrin^^ it hack again ronu.in.s
to be seen. '
I.
i,;
ill!
I'll
-■ r-
I'llAl'TKU X.
FUJKINOUS RHINITIS.
qf'
'I'll IS is nn acuU' iiithiiniiiatiim ul' the iiiucoiis iiioiiiliiaiie of the
nasal passajffs. attciKU'il by a di'j)Oi-it of fibrinous exudation upon its
surfaces. Il jiiisi'nts tlic patiioloi.Mfal fraturi'.s of false iiRinbraiie
inipoi-ed upon tlic epitlu'lium witlioul invol\iny llie deepei- tissues.
As most of tin; eases of membranous rliinitis that have occurred
and been examined have been simply an extension of diplitheria de-
posit upward into the nasal cavities, many observers still Ijelieve that
it is always of diphtheritic origin and the result of the presence of llie
Klebs-Loolller bacillus.
IJecent experiences aeconi]!anied by careful clinical and [)atho-
logical examinations have proved, however, that this is not the case.
Fibrinous exudate within the nasal passages of non-diphtheritic origin
does sometimes oecur, and it is of this I nnw speak.
In 18!)3 tile ''Transact ions of the I'aliudngieal Society of Lon-
don" contained ,"n exhaustive article upon the subject. In it Abbott.
while leaning toward the idea that all iase> were of a niildly-
<liphtheritic characler, states positively that: '"It cannot lie too often
insisted upon that the true nature df all membranous do})osits upon
the mucous membrane of the aii-pas-ages (referrijig to tlie nose) cai\
only be definitely I'evealed by bnet( I'iologieal research": a tacit ad-
mission that non-diphtheritic mendorane might exist.
In \>^\i[ Ih'un .Murdoch, at the laryngological section of the
British ^ledical Association, reported a case of recurrent nunnbranous
rhinitis wliich dccurred in a female aged ,'5o years. During a little
more than a year she suffered from six different attacks without any
indications of true diphtheria. A number of bacteriological exami-
nations of the false membrane were made; but all failed to show any
Klebs-Loenier bacilli, although a number of micrococci of no special
'moment were ])vesent.
The symptoms weie at lirst those of slight head-cold, rapidly
getting worse and continuing for several days, with complete occlu-
sion of nostrils. Abmit the fifth day white membrane would appear
in the anterior iiares. This would scale off, leaving the parts some-
(70)
IIHUIMM h ItlllMTlS.
71
wlial raw and tlic iinsc swollen, 'riu'ix' was no rise of ti in|>(,'raUnx'.
but sovort' sneezing. Tiic wliole attack would last al)out a I'ortnighl.
Jlot bathing, iodolVtrni, menthol in iluid vasclin, cocaine, I'lc,
only sliglitly relievtd the syiii|itoMis. .\t diu' time i^'aUanocjiiitcrv-
singeing produced partial relict.
In the same year Si-hillVr read hd'orc tlie Uclgiaii Socii'ly ol'
Otology and i.iiryngology a papi'r on the "Pathogenesis (d' N'on-in-
fectiotis Croup (d' the Nasal Mucous Mend)ranc,"' with lin' histoiy id' a
case. 'J'he mcndtranc was ciinlincd to llic nasal cavitic?-. The general
symptoms were slight, save for the iiiisal mendiranous ohstrnetioii.
!Microscoj)i(al examination pioved the ahseiu^e of the Klei)s-L(i(dller
liacilliis. 'I'Ik le was no si^n id' the disease lieiivi infection-;.
In 18!ts Middlemas Hunt, in a paper nn "''I'lie lielatioii of l'il)ri-
nous TJhinitis in r)iphtheria,"' reported four cases <d' lii)rinous rhiniti>.
In two of tliese ther,' were no indications of Klebs-Locdiler liacilli. in
the other two, although none was discovei'cd at the time, diphtheria
followed in the one ])aticnt two weeks later, and in the i'amily id' the
other after a similar interval. In cdiieludiiiL:' his artiide ilnni uses
tliese words: "T am afraid there are no elinieal characters on which we
can rely in distinguishing the two diseases, and our one method i.- to
turn for help to tiie skilled bacteriologist."
Richard Lake, of still later date, gives ihe history (d' a case of
clironic pseudomcndn'anous rhinitis, occurring on the right ^ide. in a
man aged 5-1. He was a hay-fever subject. Treatment had only a
temporary otf'ect: and when he returned for examination, ten months
later, the membranous disease had increased in severity. Microscnjiical
examination revealed the staphylococcus pyogenes aureus in abun-
dance, but no Klebs-Loefller bacilli.
In March, 1S!)S, I reported an idiopathic case of membranous
rliinitis to the Toronto ^ledical Society. It occurred in a young lady,
aged IT years, an abstract account of which appeared in the Journal
of Lari/Hffdhifjj/. May, 1899. This was unilateral. alTecting and closing,
for the time, the left nasal fossa. Tlic membrane was whitish-} ellow
and inodorous throughout. It extended to the jiosterior naris, l)ut
not into the ii.iso-pbarynx. The treatment consisted of applications
of cocaii. e, sol'itions of nitrate of silver, and albolene. There was
no fever. Microscopical examination discovered no Klebs-Ijocdller
bacilli, but a large and jntre culture of staphylococci was made from
the membrane. The cure was completed in about three weeks of
regular treatment.
\m
f
IMAGE EVALUATION
TEST TARGET (MT-S)
/>
1.0
I.I
11.25
l^|2£ |2.5
|io "^" SiflH
U£ 1^ |2.2
U 11.6
£f liii
£ us
— 6"
Photographic
Sciences
Corporation
33 WEST MAIN STREET
WEBSTER, N.Y. UiSO
(716) 873-4503
37
\^
iV
:\
\
rv
6^
«■
■<<^;*
#
'.«^
^
%^
<S^
^
n
UlfSKASKls Ol' Tlili NASAL I'ASSAliES.
With it'l't'ic'iu'f to tliu statement that a simihir false meinhrane is
always produced by the appliiation of the galvunocautery to the nui-
coiis surface, it must be remembered that tlie ])rotective covering is
only formed upon the sjjots cauterized, whereas, in fibrinous rhinitis,
the whole mucous lining may be aU'ectcd. Sometimes, however, the
cllVct of cautt'rization is not so limited, and the burning of a single
spot within the iia'^al cavity may induce the formation of false mcin-
biiine throughout the fossa. Although this fact is well known, the
literature upon the subject is so meagre that the rcjxirt of a case nuiy
not be without interest.
In September, 1895, a young lady, aged Ji5, a farmer's daughter,
came to me for tieatmcnt for hay fever. On examination there was
nothing unusual in the appearance except that the inferior tur-
binateds were very inuch enlarged. Otherwise they had the ordinary
pale hue usually present when hay feA'cr exists. Under cocaine, 1
burned both the iiilerinr liodies througli the ceiitrt' froiu behind for-
ward. Twenty iiours later, on her return for irealment. both nares
were slenosed and the whole lining mucosa of each passage, so far as
it could be seen, was covered with falst' membrane. All that I
could do for her relief was the application of cocaine followed by
vaselin. Tiu' mcmlu'ane Ixcame thicker, but retained its clear, white
color willioul odor. In two days it commenced to loosen, and I re-
moved it gently in large Hakes with the forceps. The recovery was
rapid and the relief of the hay fever complete.
Two years later, in September, 18!)T, she returned again for
treatment for hay fever. She said she had noiu' the previous year.
On examiiuitiiiu. the inferior turbinateds were all right, but the middle
ones were eniaiged aiul pressing on each side against the septum.
These 1 also cauterized, though much less extensively than the in-
ferior ones (in llie furmer occasion. 1 also took the precaution to in-
sert a small pledget of cuttcin on each sidi' between the septum and
lb»> middle bodv.
When she returned to the ollice on the following dav the old con-
dition was repeated. The whole mucous membrane on each side was
coated with white, fibrinous nu-mbiane. and the treatment and history
was but a repetition of what occurred two years before. On both
occasions it was undoubtedly traumatic pscudonu'mbranous rhinitis,
but it was unaccompanied by fever. 1 regret tha. lu. bacteriological
e.\aniinatit)n was made on either occasion. Other writers have re-
])orted similar ca.scs resulting from cautery-work.
HCTff-
1 I
FIBIUNOUS RIllMTIiS.
73
In dosuv^r this chapttT I inny, perhaps, vfiiturf to draw the follow-
ing conciiihions: —
1. That non-(li|ihthcritif i)scMi(loiiu'iiihranous rhinitis doi's soino-
tiiiK's occur, and, thoii^i^^h a very rare discas... it is probably as frequent
as primarif nasal diphtheria.
2. That on clinical grounds alojio it is possible, in a niajoritv of
cases, to distinguish it from genuine diphtheritic disease.
3. 'J'hat, owing to a possible mi.<take in diagnosis, isolation in all
cases should be imperative, until a reliable bactcrioh.gical examination
can be made.
Since writing the above an aide i;rticle has app.'ared upon
"Fibrinous Khinitis" from the pen of (JiM, Wishart, in the Septmi-
l<er issue of the Lun/n,jos(ope. In it h- gives the history uf sev«'n
cases, two of which were benign, wlnle live exhibited th.; Klel)s-
J-oetller bacillus. Jle also sums up all the ca>es of which he can find
a record, totalling 98: (JU with Klebs-Loelller bacilli and l>!» without.
In conclusion, while he recognizes that many observers consider
fdn-inous rhinitis a distinct disease, he believes that the accumulated
evidence proves the following points: —
1. Fibrinous rhinitis and dii.hlheria are not distinct diseases.
y. All cases of fibrinous rhinitis need the same preciiutions as
to isolation that diphtheria requires.
* f.
11
II
iti
\1'
M.
i'
DKroliMITIKS OF TIIK NAS.M. SKITI.M
In adult lil'f ^('|ilal ilcfdrmit ics arc tlic iiih>i rrr(|iii'iit caii-r, ii'U
only "if calanliiil aUV'ctions ol' tlic; nasal passajrcs, but also of (k'fcftivc
and iunt|iial nasal lircatliinLT. What seems .eti'an;j;e is that these
deviations from the normal in symmetry should ho conlincd so largely
to the civilized raees of mon. This is borne out by examinations of
the skulls of civilized and aboriginal races. In the museum of the
lioval College of Surgeons, I^ondon, out of '-.Mo".' skulls, it is reported,
on reliable authority, that over TO per cent, have irregularities of the
se|»tuni. ( ►n the other hand. Sir Morel Mackenzie and Zuckerkandl,
after carefully examining a large luunber of the skulls of the
al)origines of America, Africa, and Australia, found only •?<• per
cent, of the nasal cavities presenting osseous abnormalities. Allen
examined the skulls of !•!} negroes, and found dcthntions and irregu-
larities iji only I'l per cent.
liecenily, in Toronto, at the Arclutological Museum of Ontario,
whicli eontains the most ' \haustivc collection in Canada, I examined
220 Indian >kulls. by far the largest number of tiu'm being llurons
and Irf)(|uois. One hundred and eight were all in wiiich the septa
were sutliciently well marked to base a judgment upon. The result,
however, was diil'erent to that of the observers already mentioned.
Of the lOS, 51 had deviated septa and 51 had straight ones, or 50 ])cr
cent, of each. Of the number I were Flatheads from British Colum-
bia; 2 had deviated septa, 2 had straight. Two others were Mound-
builders from .Arkansas, of ]>re-Columbian history. 1 liad deviated
septum and 1 straight.
I miglit add, as a curiosity, that, among a number of skulls of
Egyptian mummies, only one was suHiciently unwrajjped to admit of
examination. In this the septum was straight; but the left inferior
turbinated was wedged against the j)osterior end of the vomer. This
archaeological specimen, three tliousand years old, was an exlremi'
exception to the general rule; for almost invariably when the septum
was straight and centrally situated there was nothing abnormal in
the condition of the turbinated bones.
(M)
iii;i i»i{Mri'ii:s or iiii: nasai, skitim.
«t>
'(
To iiini ill tlic cdndilions in iicliuil life, ('nlli<'r ri'|)orts that, out
(if ](•*)() iuliilt |iiitifiits cMiMiiiicd iii(lisci'iiiiiiiitlt'ly at tlic Xortliwcsi-
Loiidoii lldsiiital, only lid, or alioiit 1(1 per cent., had iiorniai nnso.
a lariro propoilion licitiLr aircclcd hy pi^pial doviatimis. In cliildron np
to the aizf ol" ('ii:li( (ir ten years tlic scpla as well as t iirltiiiatods wcit
generally normal or ahnost so- any olistriiriioii nt that early aire hein^
usually eansei y lesions other than bony. Fijrs. 51 and i)\(K taken
from a fro/en seetiim cd' a eliilil a,;:e(l .") years, is a striking e.\eo|»tiiin
to this rnle, the deviation and the spur to the left heing stron,i:ly
marked.
in the nni'iiial nnse tin- -eptiim is .-imply a hony and eartikminoii.-.
Willi, dividing,' it e(|nally into two symmetrieal fos-sa*. In all tin' lower
animals, in ynnnir children, and in the lower untutored races of men.
this is still, in larj'e measure, the ease. I'ul. !is you a]tproaeli aduli
life amotiH- the eivili/ed races, septal deformities appear in lari^e iium-
hers, until, as repoi'ted hy so many oh-ervers. the percenla<r(! of these
iiU'(|inilities heeomes e.vceedinjrly ^n'cat.
A |iro])er classification of these deviation.* would he diirniilt to
make. (>nile freipiently the septum is not thiekciu'd. Init the car-
tila.irinous portion makes a full convex curve into one or other na-al
fossa. In other cases witli the curve there will also he a nuirked
jjrojection or spur (Ui the convex side. Ajrain. spurs or conical
projections nniy ajipcar on (/ite or hotli si(h's of the lower end of the
triaiiLMdar cartila^a' without an; curvature of the ujiper septal wall.
In other instances a longitudinal ridi:e will appear in oiu^ fossa, ox-
teinling backward along the hase of the cartilage and involving also
the lower jiart of the vonuT. while the upper part of the septum
retains its integral position. Sonu' septa ' i.v" a douhle curvature, or
ccHwavo-convex form, from before hackwanl; iind still others have a
sharp longitudinal notch on one side, like the i ieho of an open book,
with a })rojocting pcriiendicular ridge on tin, ojiposite si(h' of the sep-
tum. Synechia\ or brid^'.s connecting the bony septum with the
middle or lower turjiijuited of the sanw siih", are jiot infretpuuit.
There is often, too, a combination of several irregularities in the one
nose; while last, but not least, almost any deformity on the one sidi
of the septum is atl(>iuh'd by sonu' deviation from the normal on the
other.
Etiologfy. — This is a niany-si(h'd (piestion. and many diverse
views are held upon it. Some authorities, I»os\vorth among the num-
ber, bcdieve that the large majority of cases owe their origin to trau-
f
h'
ll
l)l
IJISKASKS OK TIIK NAS.vl. TASSAiiKS.
Iliati>lll.
Ins iiiillior
"}••
'I'l
II- |M)iiit (in wliic'li
\ny
■ pec
ial
(■iii])li;isis is tliiit tlic (Icforinily i?; [iriiiiarily tlic result ol' tniimiatism,
and. sccdndarily, of a slnw inllaniniatdry proci's.s which results thore-
rnini."" /uckcikandl lias jioiiitcd out tliat in many instances a narri)w
.-triji of cai'tila^^e lies between the iirrpendienlar plate of the ethmoid
and the vomer, due to defective ossili/ation, and in eases of -eptal
injniv this mi,iihl readily ^i\e ri,-e 'm lid.ijes fdiiml in this I'eninu.
Iloe draws attention to the fact that in early 'ife the vomer is
divided into two lamina', separated from each other hy a thin layer
of eartilaL^i', which is prolonjred forward to form the cartila^'inous por-
tion of the septum. Ossilieation hejiins in the second week of infantile
life in each plate, hut i> not eiunplete ui
111
luhert V.
About tl
I bird year union eomnieuees beiween the plates frum behind forward.
in this ease, too, it is not complete until adidt life, and sometimes
never. lliMiee many (d' the deformities may arise from overirrowth
(d" the anterior or free portions of the plates. This would also account
for the rarity with which we meet this deformity of the |)ostcrior end.
Trcndeletd»urj; bidieves that many cases arise from llu' upward
pressure of a hi^bly-arclu'd jialate. Other writers believe that the
deformity is produced hy overj;rowth of the septum in a confined
spai'C. iJarvis ailirins that many cases owe their origin to heredity.
and reports four cases (tccurrini: in one family in support of liis
view. It is easy to believe heri'dity to he an important factor in
producing intrana.sal deformity, just as it is a ])olent element in pro-
ilucing ty|H's of feature and id' form. As an instance, I might men-
tion that one of my patients, a boy of lU years, has developriig a
curvature of the septum to the left. His father had a curvature to
the ieft. also, large enough to jiroduce almost complete stenosis on
that side. On further ini|uiry, 1 was informed that the grandfather
had been a great snulT-taker, but that he always took it through the
one uosfril. The conclusion is obvious: the grandfather had trans-
mitted the tendency to the son and grandson.
With all this mxdtiplicity of views as to causation, it is possible
that ^Fayo Collier's researches, founded upon Zeim's experiments on
young animals, may have struck the kt-y-note. He claims that these
deformities are largely due to tit the elTects of atmospheric ])ressure,
badly eiiualized wilhin the nasal cavities. In his investigations
Zeim would completely block one nostril of a young animal with
some soft substance, efTectually stopj)ing the respiration on that side.
This would be left in for a long time. The result in everv instance.
1 -.,
2 .
a
t —
4-
5
9
4
J
G
hi,:;. .■)!. I'm/iii -iilimi ,,f iMr Inad i>l ii iliiM ,i^ci| :i \i-ir~, I. Sn--
lioii ili:nii:,'li liii.k |iiiil (>l i-\r. _'. l'(.-icTii.i •iliiiioiil cclN. li. Siipciinr lur-
iMliiiIrd Imiiic. 4. Miildlc liirliiiMl( (I Ipniif, .".. .\m1iiiiii n\ lli;;liin(nv, ti, Sep-
tiiiii ciirxril III ilic liii, 7, Inriiiiii I iirliiiiiiiiil. s, Sii|H'iiiir iiumIii-. !I.
.Miildlf iiiciilii-.. Ml. Iiiini ,,|||~. .(■■rniii l'iiini.i-i'> Aimimnii mI
.Mnsciini. I 'iii\ci-.ii \ ni ruiiiiiin. i
" III
Ml
Fig. .">!<(. I'lip/i'ii -I'ciidii (if «iiiiir child, liikfii two rent iiiii'l ri'> an
U-rior t<» Vifi. T)!. I. Anifii ir ctliiiioiil cclU. 2. Miiidic tiirhitiatcii lionc
;{. Scptmn curved In (he h'ft. \. Inl'crior tniliiiiiilcd lioiic. .">. Aiilriiiii nf
lii^'hiriiirc (>. Hard pahitc. 7. Niiiilt nt' inoiiih. i l''i'iiiii l*riiiii'<Kf°s An-
atomical Mn^i'iiMi. 1 iiix cr»it \ of 'Idroiiici.)
I.'l
i.r
DKKOIIMITIKS OK TIIK NANAI. SKI'TIM.
81
and lu' trit'd it in a jrrcat many, \\a> the ainsi of tln' (li'Vi'lippnicnl
(Ml that side, with delU'i'tinn nl' the SL'iitinn, the |iiilati'. the intci'inaxil-
larv and fmntal hones, all toward the IdocktMl cavity. At the same
time, tile nnolistructed cavity wonld lie lamer than natural ami more
fully develo|ied. 'Die reason i^ the rarrl'aelinii dt tlie air in the closed
nostril during inspiration, caused hy the ru-li nl' air throu<^h the open
one. with the conse(|U('nt atmospiicrie j.re,--iirt iipnn all .-idcs of I lie
closed cavity.
Collier applies the same jiriiiciple in unilateral na.-al ohsl ruction
oceiirrinj,' in men as Zeini docs in hi> cxpciiniiiits on aninuils. Of
<'oiirse, hid'ore the cirects of rarei'actidn cniild dccur, iliere must arise
i'l-Din sdiiie cause partial stenosis of mic nasal fn.-sa. 'riien, in due
time, tliou<ili it ini^dit take years to develop, ihe ic.-ulis indicated
\V(udd he likely to follow. In children, and many of the cases have
their oriiLMii in early life, tlu' oli-^triiction iniLdil arise from nej^lectcd
colds, particularly when the child was allowed to lie too consecutively
on one side.
Symptomatology. — The principal syni|)toni is that of nunv or less
unilateral nasal sti'uosis. The secondary ell'eet is a ehaii^icd condi-
tion of the mucous memhrane, which usually culminates in a chronic
nasal catarrh. It is often the eiitarrhal condition, with its attendant
throat-dropj)inji-, which chietly altracls ihe patient's attention; and
ho will frequently present himself for treatment without any per-
sonal knowledge of the existence of ihe stenosis, owing to its very
gradual development.
St'ptal deformity will freipiintly give rise to epistaxis. The pro-
jecting surfaces are exjiosed to the dust with which the air of n'spira-
tion is often loaded; and the contact of tlie^e particles tui the walls
of the capillaries ])roduee minute lacerations and conscijuent ha'inor-
rhage. And it must he ri'inemhered that it is from the septum that
the nose nsnally hleeds.
'JMio voice also heconies affected, ]iartieularly when the ileformity
is very marked; hut this symptom is I'oiumon to nasal olpstructioii
from any cause.
Dullness of hearing is not an infrequent symptom, arising from
the extension of the catarrhal condition to the Mustaehian tuhe. In
these cases straightening the septum may he expecteil to he followed
\)\ imj)roveinent in h* iring.
Diagnosis. — This can only he made positive by direct examina-
tion, for which reflected light, head-mirror, nasal speculum, and post-
1^. ill'
s;
i
m
lil^
8V
IIISKAHKB OF TIIK NASA I, l'A!St>Atli:s.
I'liMiiil iiiirrnr niiiy nil \>v n'muifil. A [iraitiinl kn<»\vlf(l<.'t! of tlic
|iarl.« shdiilil then remove all (luiilit. Soinclimcs a mistake may be
iiiadc liv llii' aiilcrior I'lul dl the iiiidiilt' tiirliinatcd heiiii.' on a line
witli llie s('|i|iiin. At this spni
;rni
i|i III' |iroje('tiri|r ji;lamls may liiih
the point of scparalion. Cre.-Wfll liakci' call.- this spnt '•tuliiMVuliiiii
scjiii.'' Carel'iil e.xaniiMatinn. li(o\c\cr. will ca.-ily rrmovc llie doiilit.
Nasal po|\|iiir; ami lilnonia i<\' tlio .-('pliiiii ar*' hotli m>ivaiil(\ while
llic sepliini is not. 'Tlie rnrnicr. too, is lijilitif in cnlnr .md sdl'tcr.
while the latter i- darker and . .dijrct to lia'inoiiliai:e nn the .-li;:hte>t
ftHlcli.
Prognosis. 1,
It to itself, ni
•plal de\ ialinn or dri'orniity wil
inipiiAf, and the symptoms produced hy it arc likely (o remain un-
relieved.
Jn eases wli'.ic ilic .-yiiipiuin> arc nci-ily ealarrhal. wilh partial
stenosis on the allVcted si<li in ii(i\;d n\' iho nlistrneti(»n should he
attended hy ^ood re.-nlts. In ear di>ea-e, tuo. ari.-in^- from this cause,
hcnelit may he expected, fnun -imilar tieatnient. Tharyn^'eal catarrh
is also ^really hcnedled hy rci-ioralion (d' normal hreathin<;. In hay
i'ev( r and asthma, these disease- lieinj,' so frctpienlly I'cilcx in origin,
improvement will often fnlhiw operatinii. thoiiirh the proj.Miosis should
always he iruarded.
Treatment. — The removal of the stenosis produced hy the de-
formity is the mr-st essential IV-ature of treatment, and the methnd.<i
to aecomplish this vary materially, accordini: to the eharaeter of the
lesion.
Althoii<;h fractures and displacements of the ,-eptum arc of fre-
<pient occurrence, they are unfortunately rarely jiresented for treat-
ment until after irrejrular union and lualimj; has occurred, and the
aftcr-elTeets noticed. When, however, the fracture is fresh, the fra^r-
ments can he jiressed hack into position, and retained in jdaee 1»y
suitable ruhher or cork splints, i iit to the retjuired shape and placed
within the nasal ])assa^M's. It lias heen said that splints are not re-
((uirod in these cases, as there is no muscular action to displace the
structures, oiice placed in position. This is a mistaken conclusion.
.After fracture there is always swelling or o'dema, and this itself may
M'parate the newly-adjusted parts. Blowing, to free the nose frinn
discharges, may also interfere with the ])ro|)er union. On the other
hand, a carefully-adjusted splint inserted on the side of depression
will support the fragments without ]>roducing distress; and n week
or ten davs" immohilitv will <ut!ice to elTect the d(>sired union. Thick
i)i;i'uiiMriii:s of tiik nas.m, skittm.
83
riibliiT splints III' iiK'diuiii sdl'tni'sti, carcl'iill} adjii.-ttil to -iiil tlu' oi/c
jiikI (•(imlitiuii of the pints, arc also in many cases of ruivatun' of (lie
fciO|iliiin t'.\c;('i'(lin;.'ly n.-cful. If \\<)ni for a niiinlitr of \U'tks, llic coii-
stanl .*u|i|K)rl tlifV cllcc t will restore tli<' |ias>a^'e to an alnio.-t n'T-
innl eontJition. Tlieir usefniness is Iiiirhly ajipreeiated iiy Lalie ami
oilier writers.
Consolidiil.d (Icformit'i s of the .-epiiini are treatid in \ar;on.s
ways liv (liil'erent aiiliu.i.-. \\ here projeetiii!' .^j'tirs ami n(l>;es pro-
duce .ilistriiction, idl a;?ree that tlie exostoses and liyperelmndria
slioiild lie removed. Many believe, witli Mosworlli. thai tiioy -honld
he excised hy means of saws. 'l"i intention is to lca\e a smooth,
))lano .snrfaee over which mueoiis ni inhrano will ijniekly form with
little or no cicatrix.
W hen tl'.e distortion propciil.s its'M' in the form of an hyper-
frophied rid;.'e or spur npon tlie eartilnir.iii.iis portion of the septum,
this can freqiionlly lie removed hy means of a sharp, iiarrow-hladed
knif''. leavin.ir. as a r<'snlt, a smooth surface and ;in opi n pa>.-aLre. A
reeoatinu' I'f new mueons memliraiie (|uiekly foilnw-:. The aeconi-
Ijanyinj: microscopical section was t;iken from n -pur iinuned in this
way from a irentleman, ajred TiS, who had lieeu siill'crin<j; from na-al
Oijstrnction for thirty years. Calcilieation had ciijnmenced in the
liy])ertrophied cartilaue (Fig. •'"•■^/.
Other operatiirs advocate the use of luirrs operated h} a denial
engine or clectrninotor. lloHunok Cuiti.'.- has invented a series of
.«mall iK'phincs adapted for the loinoval of this se|)tal outgrowtli.
These are ingenions, Imt unless very skillfully used they may fail to
leave the perfectly smooth surface which is so dcsirahle and which
can he .-ciiired hy the use <if the saw. The latter instrument is
usually operated hy hand, hut can also lie attached to an electromotor
machine.
To save the mucous memhrane, Fletcher Ingals make.-, an in-
cisiiui aloiijr the lower maririn of the spur, dissects np the mucosa,
and, retracting it to free operation, excises the pri\jeclinLr carlilage.
The mucf)us memhrane is then drawn down and sninred to its foinier
attachment. Hy this means the original mucosa is retained in it.s
entirety. Kyle follows a similar plan in curvature of the se|)lum.
Loch advocates the use of sharp, highly-tempered curettes, par-
ticularly in cases where saws cannot he used.
Cheval, liallinger, Casselherry, and other recent writers havt;
used electrolvsis with good results in removing cartilaginous spurs.
84
DISKASKS OK Tin; NASAL I'ASSAUKS.
T)io latter I'ound clcttrdiiiotor force of 11 to 14 volts necessary, with
a current-strength of rrnni 1") to 40 niilliamperes, according to tlie
amount of resistance found in the spur operated upon. The time
for each sitting was from live to eight minutes, to he repeated two
or three times at inttTViil.^ (if x-vcral days.
Jn some cases al'tt r I'diioving a spur or ridge, at the hase of a
Fig. 52. — Section of ciiililiiginons spur from the nasal septum (25
diameters), a. Stratified eiliated epitlieli\im. I), Stratified squammis 0|)i-
tlu'liiini. r. (ilandsi. rf. Connective-tissue layer, r, Cartilaginous ai)ur. the
lower, shaded portion undergoing calcifieation. (Author's specimen by
Bensley.)
convex curvature. I liave corrected the curve above by the use of a
silver tube. If the instrument is worn for a few weeks or months,
the cartilage, being pressed by it into the normal position, will re-
main so with but little subsequent deflection, the adjustment being
DDIOUMITIES OF TUE NASAL SEI'Tl M.
^.)
reiKlci('(l cai^y by tlie ciitiing awiiy of the :=i)iir or ridgo base. The
advantage oi' silver tubori lies in their lightne&s, aseptie cliaraetcr,
smooth surface inside and out, and the fact that a silversmith can
form one to suit each special case. Tiie open tulie enables the patient
to breathe through it. A small bulge jiliui'd cm tiie outer wall will
secure its retention, and tln! patient can soon learn to remove it daily
for cleansing ])urposes and return it to its position (I'igs. i'ui and 51).
Tubes of this kind are also uselul in cases of severe traunuition.
in which either of the antciior nasal pa^snges has been destroyed.
In one case which I reported to the laryngological section of the
American Medical Association at San Francisco several years ago, the
'!■■
Latciiil view.
isrcll fldlll al)OVl\
Viff. ry.i
II
Liitoral view. Seen frmn aliovc.
Fig. .'54.
Silver tubos for septal deformity.
mucous membrane of the car+'^-'ginous portion of the left nasal pas-
sage bad been entirely destroyed, the anterior ends of the middle and
inferior turbinaleds being firmly united to the se|)tum. 1 cut a new
openinir throuirh the fibrous cicatricial tissue and bad the tube (I'ig.
T),?) made to be passed into it. Tlie front end was half a centimetre
from the anterior naris and invisible. The arch being upward pre-
vented mucus from gravitating into the tid>e, and it enabled the
patient to breathe freely through it. The bulge kept it in position.
The wearer takes it out every morning as a matter of toilet, and at
once returns it. He has worn it now for five years. Since the opera-
tion he has resumed his position as leading tenor in a large church.
m
Hi
■f.v
8()
UlSKASKS OF Tllli NASAL TASSAGEH.
^W^
III''
ill'
which he had been compelled previously to resign, on account of
j)ost-nasal catan-h caused by the unilateral stenosis. 1 expect in time
the artificial opening will remain permanent, without the use of the
instrument.
In a somewhat similar case, in which traumatic adiiesions had
formed from the lioor to the middle meatus, Myles succeeded in a
(liU'orcnt way. Ifc trephined along the iloor of the nose, and then
iii.-ertcd a rubber tube. This was retained until a new passage had
formed. The subsequent operation was the removal of the cicatricial
tissues l)ctw('('n the superior meatus and the new opening.
When till' enlargement would iudicati' increa>:cd Ictigtli or height
of septum, Arthur Watson advocates removing an elliptical or wedge-
shaped portion, as the ca?e might requiix', cutting through the se])-
tuni, but leaving the mucous meinlirane on the opposite side entire.
Cutting forceps could be used if retpiiicd. The piiit- iirc then |>ressed
into position and held by pins, the ends of {Uc pins liciiig piidiled to
lU'cvi'iit ulcirjition. 'J'hey may
in position fur three weeks,
when union uili Ite aeconi|ilislied witii cure of the deformity. The
sp(d<i'sliave is also used f(jr the rciuovai of ])rojecting nodules and
sj)urs upon the septum, giving, in many instances, a satisfactory re-
sult.
.\s a rule. I tbiidv the most widely useful of all is the saw opera-
lion, it will fulfill the requirenu'ids of the majority of ciiMs. In the
first place, a ">i- or 4-per-cent. sidulion of cocaine should be thrown
into the nostril by an atomizer. Then a stronger solution, of 10 or
15 per (lilt. -Iioiild he iipjilicd by a curved cotton-ludder to the sep-
tum. This iniiy be re|teated two nv three times. In live to eight
minutes the parts are ready for operation. Two saws are required;
one with teeth on the upper i'^lixc. the otlier with teeth on the lower.
It is always better also to have the handle of the saw at an angle of
forty-live degrei's to tlie central line of the shaft, 'i'he lower lilade
is insei'tid first and ttie cutting is always done parallel to the axis
(d" the cpfiiiii. Then the cut downward with the upper sa.v is made
to mi'i't exactly with the inferior incision. 'i\) ]H'rform the opera-
tion reipiires a good s])ecidnin and a good reflected light. The word-
ing of the operation is sim]de. but. to do it successfully, care and
])atience are reijuired. When the exostosis is large and bard, the
operation nuiy be tedious, necessitating several stop]iages before com-
pletion, in order to arrest or remove the blood. There is also danger
from fainlncss, diuj to the action of the cocaine conddned witli tlie
DKKOaMlTlKS or THE NASAL SEl'JTM.
87
shock of the ojRTiition. 'J'hcTc is likewise diuij^or of flitting throiigli
tliu tfcptimi, ami, althuuirh this was tiio approved ineliiotl of ti'cat-
niont at oiio time for tlie relief of one-sided stenosis, it is something
which the can'ful surgeon wi.-hes to avoid imw . With judicious
management, it is an accident of e;.eeedingly rare occurrence.
J.ittle after-lieatment is necessary. Jf liieinorrhage arising from
the operation does imt at on^e sui-side, it is better to pack the blecd-
ing-sjiot with cotton tampons. These may he left in for one, two,
or evi'u three days witiiout producing any evil elfect. They may
be renewed entindy or in [)art at any time, as llie tendency to bleed-
ing may direct. One uf the main objects after operation is to pre-
vent the anterior part of the cut surface from beconung dry, as any
liard crust forming upon it would retard the proces.', of healing.
'J'o avoid this the patient should ))e directed to aj)ply vasclin to the
septum several times a day. This should be done particularly before
retiring for the night.
In the majority of ca?es a few weeks will sullice to recoat the
raw surface with mucous membrane. It gradually forms from the
border-line, usually covering the wound without leaving any cicatrix
to nuirk the site of the operation.
Occasionally unpleasant sequels follow operations upon the nasal
septum: such as severe luemorrhage, which may recur at intervals
for several days before it entirely ceases; formation of synechia;
between the septum and the inferior turbinated; and tlie production
of excessive granulations. Careful treatment will avoid or at least
overcome all these dilhculties. ^"ery rarely even a septal abscess has
been the result of septal operation. Ledernuui recently reported a
case of this kind. It occurred in a young woman aged 22. Ordi-
nary antisejitic precautions were taken. The first saw operation upon
an extcTisive ecchondrosis gave some relief and healed well in two
weeks. A second operation to complete tlie removal of a remaining
exostosis was tlien done. In four days an abscess of the septum com-
menced to form and had to be lanced several times iK'fore it entirely
healed.
In dealing with these cases it is not tlu> operative, but the post-
operative, treatment that I have usually found the most troublesome.
By saw or knife, drill or scissoi-s, or curette, single or combined, the
projecting spur or ridge might be removed; synechia' connecting the
turbinated with the septum could be excised; or a partial turbincctomy
when necessary might be performed; but to procure smooth equal)le
in
88
i)isi:asi;s ok thk xasal I'assaoes.
M
support for tlu' iiuisud tissues duriiij: tln' procop? of hcalin^r has been
a mucli harflor matter.
1 think tliat ruhher splints, niaih' as Lake advises, from thick
rubber sheetinjr, do bettor work than anylliing else we have at our com-
mand for many of tliosc cases. Their surfaces are smootli. C'om|)res.^ible,
and ehistic; tliey can be readily cut to the required shape, and they can
be obtained of any thickness we desire.
.\rter cncaini/.ini: the ]iarts and coating the plug with va.selin it
can readily be placed in position. Once in, it will not only retain its
])la(e. but l>y elastic pressure give a smooth and even fjupjxirt to the
raw surface to which it is applied, as well as prevent that profuse
granulation which otherwise would sometimes occur. At the same
tiuie it does not retard the gradiuil exteii-ion of the im'vv mucous mem-
l)rane, while it molds the tissues into a smooth and regular form.
The stiir plial)le ruhlier, although TU)t so hard on the surface, nor
possessing the j)oIisli of the vulcanite, is proliablv Just as imperviouh
to bacterial invasion. Souu'tinus, however, after prolonired u-^e it will
accpiire a peculiar, unpleasant odor, in part arisiug- from the rubber
itself. In these cases new splints or tajupons should be substituted for
the old (Uies.
The lenglli ('!' time during wliicli the splint will rcipiirc to be
worn will depend upiui the particular condition of each case. On
])lacing it in ]iosition it may usually be allowed to remain in from two
or three days to a week witliout removal. The chink above the splint
can be washed out each day with a weak sju-ay of cocaine, followed
by one of albolene; so that there is no danger of retention of septic
secretions. Quite frequently, too, when once removed, there will be
no necessity for a replacemenl of the tampon.
t
CHAPTER XIT.
DISTORTION' OF THE COLl'.MNAl! CAKTILAGE.
'
BoswouTH was (lie firt^t to draw attention io the dislocation of
this hddy. Tn hoth the ease:? of which he iravc a detailed report the
disjilaceiiienl was cxtrciiic. >eriMii>ly iiiii il'crir.u' "ill) respiration
thi'niiu;h the e()rresp()iulin<; naris; ami in each, iii (Hilcr id i^ive ade-
([iiate relief, conijdete removal ni' the lartilaue hecaiiie necessary. A
small incision was made alnng the axis of the cartilage and the car-
tilage itself removed through the opening. Then the redundant por-
tion of the nuicons niemln'aiie was excised and the edges united with
fine sutures. The result was satisfactory in each case.
Although extreme caM's are rare, dis]ilacement of the columnar
cartilage, to a more or less degree, is not hy any means infrequent.
'J'he columnar cartilage is a little column of cartilage placed
directly anterior and inferior to the triangular cartilage of the sep-
tum, it is loosely attached to it hy connective tissue in the centre
and mucous memhrane on the two sides, a is very movahlo, covered
hy integument, and foiin~ the septal division of the two anterior
nares.
The anterior end, placed just hcneath the tiji of the nose, is
almost invariahly in position. It is the lower, or ]iosterior, end that
so fretpiently hecomes distorted; and, heing displaced to one side,
may have the efTect of almost comi)letely closing that nostril.
The cause of the distortion is somewhat ohscure; as displace-
ment of the septum in infancy is almost unknown, displacement of
the cartilage at that early age would he even more rare. The proh-
ability is that the distortion is in every instance acquired. It may
owe its origin to i)icking the opposite nostril or placing the finger
in the wider cavity, to which some children are addicted. From
personal observation I believe, too, that it sometimes arises from the
habit, acquired during childhood and practiced on through life, of
invariably twisting the nose over to one side when using the pocket-
liandkerchief.
One of my earliest cases was a gentleman of 40 years. He had
(89)
90
DISKASKS OF TJIK NASAL I'ASSAUKS.
a good (leal of septal deformity, but the columnar eaitila<;f wa.s the
worst of all. It was doubled on itself and almost filled the right
naris. I observed his use of tiie Inndkerchief, and he informed me
that he had always pulled the nose over to the right wlieii wiping
that organ.
Treatment.— Ill cxlrcme cases IJosworth's method would prob-
ably be the best tiiat could be followed. In milder cases, however,
the treatment might be materially modified, and, allhougb. I have
operated on a number of cases, I have never found entire rennival
of the cartilage necessary.
The treatment consisted, first, in producing local anaesthesia by
injecting a few drops of r)-per-cent. solution of cocaine beneath the
cuticle of the septum, followed by the local apjilication of a stronger
solution to the mucous menil>rane. Then, by ])rcssing the skin of
the septum toward the opposite nostril the cuticle of the cartilage
was put on the stretch. Thereupon, with a sharp, nari'ow-bladed
knife, the prominent portion, membrane and cartilage together, was
split off from end to end. By this means a ])ortion of the cartilage
was in each case saved. There was no redundant mucous membrane
left, and that jjortion which had been pressed f)n the stretch over to
the opposite nostril slipped back, in great measure, over the raw
surface and covered it. Sutures were not required, and in a few
days by simple vaselin dressing tlie wound healed, leaving the nos-
tril patulous and the naris almost in a normal condition.
II '
1
'I
CIIAPTKH XIIT.
rEiiror.ATJONS of thk s^ki'tum.
This usually occurs throui^h the triangular curlilaj^c; sometimes,
though rari'iy, tlirnujjh the vomer. When in the latter situation, it
is believed to l)c the result of syjiliilis, serol'ula. or nialijrnant disease,
or else of traumation. Perforations of liie cartilage are u.-ualiy of
local origin; and, as the majority of cases occur during the hiter
years of cliildhood, they are probably the result of digital erosions,
made during that period, when purulent rhinitis is being gradually
transformed into atrophic disease. 1 look u])on this as probal)le from
the fact that the nuijority of cases that have come under my obser-
vation have been atrophic cases, and yet in wliich the patients could
not tell when the perforation had taken jdace.
Another cause in the scrofulous subject is the projection of the
triangular cartilage into one nostril. In this case dust-laden air re-
peatedly inhaled im])inges upon the prominent spot, gradually pro-
ducing erosion of the mucous membrane and cartilage. r)y and by
crusts form; and the removal of these crusts leaves an ulcerated sur-
face which continues to develop until perforation is the result.
Bosworth looks upon the erosion and ])erforation as an efTect of
Nature to remove the obstructive lesion, and the result as beneficial
rather than injurious to the health of the patient.
Treatment. — In this matter very little is required. The main
point is to keep the perforation free from accumulation of secretions,
and not to allow crusts to form upon its margins. If the outline is
irregular and jagged, this can be trimmed to produce an even sur-
face, and, as l^ishop says, if the perforation produces a whistling
sound in breathing, the shape can be altered to allow the air to
pass through the opening less noisily. Sometimes the posterior half
of the opening will become thick and granular, rendering that part
of the septum unusually thick and with a tendency to bleed ujion
pressure. In this case the parts can be reduced by knife or cautery
operation to the respiratory advantage of the patiiuit.
Accidental perforation of the bony septum during operation for
the removal of spurs, etc., will sometimes produce severe shock; but
(91)
fl
i: tk
• i\ ■iml
II I
1)2
DISKASKS Ol- TUK NASAI. I'ASSAUKS.
I lit' iiflcr-i'tlVits iiiv not vt'i'v sLTiouri. Still, it is tlic tluty of every sur-
f,'con to do all that he car. lo avoid an accident of this kind. French
perforates the sei)tuni to improve the breathin^^-spaee when necessary.
Wright insists upon proper antiseptic treatment before and after all
operative work ii|)on the nose, with which all surgeons, no doubt,
agree.
Abscess of the septum is an exicedingly rare disease, but wiicn
il does occur it is usually the result of traunuilism, and should bo
treated upon ordinary, antiseptic, surgical principles.
riceration of ihe sejitum. a])art from its occurrence as a i)relude
to jierforation, is also a vi ly rare disease. Still, in scrofulous and syj)!)-
ilitic subjects il docs sometimes occur. Likewise in young children,
victims of Ascaris rcniiicularis, itt-hing of the nose may be produced
by reflex irritation, leading to picking and scratching of that organ
until septal ulceration is the result. In all these cases systemic as well
jis local treatment may be icijuired to cure the disi'ase.
li
! ;
It'
'1
I
.1
:.
i
1
.,
il
f<
i ■
C'llAlTK't XIV.
HAY FKVKU, OU VASUMUTOK lailMllS.
JiosTOCK, of Luiulon, in ]81!) was tlu; liol amoiiy uiodtini writcis
In dniw attention to tliis disease, alllii>u<f|i it iiad heen reeoi^iiized in
an indefinite manner by iihysieian.s U>v the previous two centiirie,*.
It was observed by liim to occur during tiie summer months ,iion;i
persons worlcing in Die vicinity of jiew-mown hay. l''rom iliis Imt
it derived the name which it still t)ears. That there are two varieties
of this disease, one occurrin<; in June ami the other in .\uuust, and
that till' symptoms may be provoked by emanations from a multitude
of substances, have not militated against the title, inasmuch as the
symptoms are in all cases alike.-
J lay fever may be defined as a periodic disea.se occurring an-
nually at a fixed period of the year, an I attended by intense liyper-
sensitiveness and hypersecretion from the mucous membrane of the
nose, eyes, and throat.
Pathology. — The pathological changes occurring in this disease
have long been the subject of careful investigation. During the
most aggravated exacerbation there is little, if any, rise in tempera-
ture. There is no jirevious chill. There is no febrile action, and yet
the wliole system is affected by the violence and suddenness of the
explosion. Suddenly, and without warning, a vasomotor i)aresis is
induced. The blood-vessels and venous sinu.^es of the turbinateds
become relaxed and surcharged with blood. There is complete pa-
ralysis of the nerves which control exosmosis, and the serum is tran-
suded freely from all the pores of the mucosa.
The length of time during which the veins remain in this state
of dilatation depends, according to some writers, upon the ([uantity
of irritant present within the nasal passages. The exciting raii.se being
over, the ve.-j.sels contract, the exudation ceases, and the parts return
to their normal ((111(1111011, the nnieo.-a relainiiig only an ana'tnic
apjiea ranee.
It is generally believed now that this disease is essentially a neu-
rosis. It affects chiefly jiersons of a nervou.- temperament. The
y
': !(
,m
■>',
i::i
III!
!)l
i»isi:.\si;s ni iiii; s.\s\t, I'assaoks.
luTvo iiirciiiil iirc llic >viii|i;iilici ic iiiid liii:t'iiiiiiii>. which idiiiiol the
VllSdiiinlnr .sVsli 111 (if the lliisc. .Idhll .Mili'Kcll/.ii' lirlirvcs it to he: "'A
(lisdiilricd rimctiniial iittivitv nl' tlic nervous ccntn's"; .loiil, l.flhiivo.
ami
i( r.« that it i- a irih'v neurosis; Dehivaii that unilerlviii'' tliat
iieiii(i.-i> ihi ]•(• are ''eiieral or diatlietic coiulilioi
IS Wll
ich leliil to ih
prndiii tioii of the disease. Hence it is jjn'tty fieiierally looked upon
as a timet ioiial neurosis, l)Ut, like other functional neuroses, it never
destroys lite, and the neuropath(do,i.'ist in eonseiinenee is d(^i)rivi'd of
the opportunity of iiost-iiiorteni iiivestijiation.
Etiology. — Misliop presents the following' as a summary of our
present knowlcd.ire ni)on this ])ranch of the subject: "Tlius, it ap-
pears, from the manner in whicli paroxysms of hay fev{>r arc started
and developed, that there are three ecuiditions njion which the ex-
istence of the disease depend.-: 1. Alinornially-suseeptihlo nerve-
centres, l*. Hypor.Tsthcsia of the peripheral termini of the sensory
nerves. 3. The presence of one of a larire variety of irritating ajxents.
Kxcludc one of these conditions, and the paroxysms are prevented.
Allay the susee])til)ility of the nervous centres l)y certain central
sedatives and an attack is averted or arrested, ana'sthetize t'u^ nerv-
ous supply of the oversensitive areas and the result is the same. He-
move the patient beyond the reach of exciting causes and he is as
comfortable as any mortal."'
Bosworth also gives three conditions as essential to the produc-
tion of an attack of hay fever, l)ut they differ somewhat from
Bishop's, and they are given in an inverse order. They are: "1. The
presence of pollen in the air. 2. A neurotic habit. 3. .\ morbid con-
dition of the nasal mucous membrane."
1. "Abnormally-susceptible nerve-centres" and the "neurotic
habit" may be taken as essentially the same thing, and is probably
the primary cause of the disease. Witliout its presence, to cominenco
with, hay fever would be an impossible thing. What the essential
pathological condition is that we term the neurotic element would
be difficult to ox])lain. Still, it is well known from extensive clinical
examination of hay-fever subjects that the family history, in a
majority of instances, justifies the opinion of the presence of ab-
normally-sensitive nerve-centres in other members of the family like-
wise, though it may not liave been manifested in the same way.
2. ITy])er{rsthesia of the jieripheral termini of the sensory nerves
may arise from dilTerent causes: such as a morbid condition of cer-
tain parts of the nasal mucosa, hypersensitive areas, obstructive
1
V
WAV i"i;vi:i(, Oil vasomotor hiiinitis.
95
lofinns of tlio sopttim or turltiiiiitfflH, or llio pressure of overgrowth
upon adjoiTiinj^ lissiic-j.
',h The presence of nii irritiitinj,' ngent will include Hosworlh's
first ciius(>: the pollen-in-thc-;iir theory, \r,\<v(\ ou iilacklev's investi-
gations. 'I'liis <ientlonian was himself the subject of hay fever,
usually coinin.u; on in Juno. With the idea that pollm, lloating in
the atmosphere, mi;,dit he the cause of it, he undertook a series of
experiments to asceiiain the truth of his theory. His most success-
ful experiments were hy the \\<t' of a small disk of iilass, coated with
glycerin and suspended in the air. He found tluit in twenty-four
hours, in the hciiinning of June, hut a small numlier of grains of
pollen would heconie attached to the disk. I>y about the tenth they
would have increased ahout tcnf(dd, and the hay fever wnidd have
eoniincTU-ed. Inside the next three weeks the grains of pollen would
agaiti he tripled, with niaiknl iiurease in ilie severity of the symp-
toms, from this time forward tlie pollen, and with it the hay fever,
W(udd -uliside. until hy .\ugust Isj imth would disappear. If h(>avy
rains occurred during the prevalence (d' pollen, they would tempo-
rarily dimiiiisli in nuudier. aiul the symptoms for tlie time l)eing
would also suhside. while hoth would return as soon as there was a
chance for the grains to rise acain iji the air.
Isxperience. liowevcr, does not condne the local irritant by any
means to pollen. AVe tind many of our cases residents of our large
cities, where little pollen can be possible in the air of respiration; no
doubt the coincidence of the prevalence of hay fever at the period of
the year when the atmosphere is most loaded with it would indicate
a causative relatioji as existing between the two. But there are many
irritants, ])hysical and even mental, which may induce an attack.
The presence of feathers, odor of aninmls, ])erfumes; hot, impure air;
sudden change of temjierature, mental worry, even exposure of the
spinal column to the air have all induced exacerbations of the dis-
ease. So true is this that a violent attack has been known to be in-
duced in an old hay-fever patient by merely gazing upon a })icture of
a field of new-mown hay.
Although we can understand the jircsence of an irritant to l)o
the original exciting cause of the first attack, yet it is diHicult to bc-
]i':'ve that each exacerbation is dependent upon the same exciting
cause. For instance, a patient, after a paroxysm of sneezing, and
profuse flow of serum from +he nostrils, and profound tickling irri-
tation of the palate, will retire to hed under a sense of complete relief.
iii
1}
if
I
r' :w\
(■■J .ft
ih' fit
"1
Im; |)|si;.\si:s or riii; n asai, I'assa(ik.s.
Kv(i>tliiii;,' is (liiiic h) Miiihr lliu air ol' tiiu rnom pini' imd t'icf I'min
irritiitil>. 'I'lic iii;;lil is hot ami he can hrar iiothiii;^ but a .sheet over
him. 1 am s|ieal\iii;; ol' a east; wilh uliicli I am perfeetly i'amihar.
'I'iiat |ialiiiit kiiowfi by e.vperieiiee thai il' he lies perfeetly still ii|»on
his hack, wilii all his body, hands, and I'eet covered with the' sheet.
he will he able to lie for hours, and even tu sleep, btd'ore another e.\-
aeerbalioM will appear. Iiut. warm as it is, if hi; e.\pose.s a foot or
a hand fnmi beneath the co\eiiii^'. he knows that another attack
of biioezinj? will come on at once, and lli.it he will saturate two or
three more handkerehii'fs before it subsides.
What has pollen, or dusi, or foul air. or feathers, or animal o(h»r
lo do with this?
J know a case, alu, of a ^^'nileman who has a periodic attack
of hay fever for a month every year, eonimencin;,' near the end of
Au^usl. Ili.s worst exacerbations occur durin;^ the iii«rht-time; but
he can j;(i daily and sit to ri'ad in a larjre |)nblic garden, (illcd with
llower-bed,-> and exotics, without feeling any inconvenience from the
jiolleu rising from them.
I do not wish in any way to dei)recate the importance of poUon
or any other irritant us e.xeiting eause.s of this disease, but 1 do wish
to emphasize the fact, that there must be something inherent in the
system, when the disea.se has once developed, which itself j)roduees
these periodic explosions, from which hay-fever patients so severely
siifTer.
Shaw Tyrrell, of Toronto, and IJisliop, of Chicago, have for
years, independently of each other, been advoraliiig a new theory as
to the cause of hay fever. They believe that to some extent it is
caused by the presence of an abnormal amount of uric acid in the
blood. According to this theory, the fonnation and retention of uric
acid in the tissues docs not produce hay fever, but the presence of
uric acid in the blood does.
'J"he majority of cases of this di';ea.se occur between, the ages of
ten and forty years, and, in accordance with Bosworth's statistics, the
majority, in the ratio of two to one, are nuiles.
Another important point, u]ion which all writers agree, is that it
is a disea.se incident to the educated cla.sses and sedentary life. This
is what we might expect when we remember that hay fever is so
largely a neurosis.
Symptomatology. — Slight premonitory symptoms in the form of
tingling or itcdiing of the eyelids, nasal passages, or soft palate may
IIAV IK.VKH, n|{ VASO.VtOIOK l(IIIMII>.
n;
|tros('iil tliciiisclvo f(ir tliiv.- licfurc tlu' iliscjisc fully ilfVi-lops. 'riicn
hpiisiiHidic riilliit'Sn dl' tlic nose will occur, -ncc/in}; will coiiir on, iiml
the c<)n{,'csti<iii will Iiml rclicl' in |»i(»riist; wntcry diMliar^c. 'i'lio c.vi'-
lids and cyclmlls liccniiic cnii;;c.-il('d, and cuiiiniis lacrymatiDii adds In
the j,aiicral di,«lics,-. 'I'lic dixhar^fcs arc oltcii |ii'(il'ii.-c and liic .■.ncc/-
ing very violent and ( imtiMiinus. Anotlicr ,'yiM|>t(ini. nlii n |irr,-( nt.
Ih an intense tickling irritatidii <il' the snii palalc, iMdium^' an irre-
fii-tihle desire tti scralch it uilh the ton;,Mie, r\iii wli.n ihc |iaticni
knows from c\|ierien<'e that the very friction of the tMn;^iic on the
t^uft palate will inci.a-e the rapidity > f the sneezni;:.
'J'lie hydrostatic eondilion of tlic iiirhinated> i- partiiMilai ly mani-
fest (hiring an atlari\ of hay I'eNcr, the par^-is h,i\iiiL: deprived tln'
tissues of their normal power of resistance. \a\ the |iali(iit lie on
one side, in a very few moment> the ( nrre^pondin;: iio.-tril will lie
coiiiplclely stenosed. Let him turn to the othei'. and the condition
will he at onct! reversed. Let him lie on his liack. and I lie posterior
onds of the two inferior tiirhiiiateds will liecoine ^o -uolleu iLat iliey
will iili hotli p(jsterior choana', and hreathiiiL; thioiieh tlie no.-c will
he an impossihility.
Many eases of hay fever, after the lirst few year.-, al-o taki' on
the element of asthma, to increase the sidlerer's mi.-eiy. This comes
on two or three weeks after the (■ommeiiceiiicnt of the symploms; and
iji some cases will last for weeks after the hay fever proper has
Ml lis i (led.
It is a question whether the a.-lhma owes its origin to hay fever,
or whether they are not hoth the products of the one cause, pro-
ducing vasomotor rhinitis in the upjicr ri'^ioii and vasonintur hnm-
C'hitis in the lower.
One remarkahle peculiarity of hay fever is its exact periodicity.
Quite frecpiently it will come on year after year almost to the very day,
usually ahout the '^Oth of August, and last for four or six weeks, or
nntil the advtnt of cold weather, and then di>appear aliiio.-l a> sml-
denly as it came.
K.xamination of the nasal passages during an attack reveals the
turljinated bodies swollen and water-soaked and of a grav or pur-
plish hue. The mucous memhrane is painful and sensitive, while
the necessity, which so often exists, of sleeping with the mouth ojien
renders the throat dry and i)arched.
Througliont the Ignited States and Canada the usual period of
attack is during the latter half of .\ugust; hut with some people,
r:
M
fii
»!»*;
!i.s
iii>i;asi.s ui I mi; n asm, r.\s>Atir>
i
^>'
\\\o\\ixh tilt y arc {greatly in tlic iniiioiily, tlu' attack (•(uncs oii in June-
licnriiiLT IIk- iiimic nl' "rdsc-cditK" t'rnm tlif I'licl of r
uses iiKKiininir al
lliat tiiiic
111 nllicr iiisliiiiccs, tiKMiL'li llicsc ii
(•nines (111 sciiii aiiniiiillv
I. likewise I'iire. Ilie nlliick
li.-ive (Hie liidv pill lent wIid Iui' years !i:i(l ii
liiilit attack in Miircli, to lie rollowed iiy a severe one in Ahl'IisI. 'The
latter still coiiliiuies, t'ollowed or accoiiiiiiiiiieil liv a-llini.i, wliilc the
rorincr lias diiriiiLT receiil years d
:sa|i|ieared
Willi regard In f;coL:ra|ihi(al area, il is I'diiiid on lliis conliiicnt
oxeraliiiosl all parts (d' the I'nilcd Slates and ('aiiada. 'I'lierc are cer-
tain rei^ioiis, liowcver. said to lie excnipl, siicli as the While Moiinl-
aiiis, the Adirondaeks, Maniloidin Island, jiarls (d' Miiskoka, lli(>
vicinity (d' (j)iielicc, etc. I'liil il is said, also, thai, as iirhan life cn-
lends into tlii'sc regions, their loinier iiiiinnnily may madiially pass
away.
Diagnosis. J'tM-haps aciile rliiniiis is llie niily disease thai it is
likely to he niistaken for. in this, howoer, the chances of error
are slii^ht. In iiciitc rhinitis the niiicoiis meinhraiic is hriglit and rod,
with no great ainoiinl of swelling, in hay fever the color is a grayish
or purplish red, and the swt lling a leading feature. The discharge in
aeiit(> rhinitis is iiiuco pus (d' a yellowish color; in hay fever it is
liltl(> hut ('(dorless seriini.
Prognosis. Hay fever rarely, if ever, produces a fatal result.
Still, while it lasts it causes iiuicli intense sulTcring. In some cases
(luring the process of years the attacks of themselves hecoine gradually
ligliUM" and iinally disappear; hut in the majority, if uurelieve'l hy
ireatniiMit, llicy culminate in asthma .d a severe and ('(nitinued form.
'I'lie disease is, however, more or less amenahle to treatment, and a
large jiercentage of cases have Ikhmi reported cured.
Preventive Measures. -.\s a preventive ineasurt\ nothing occu-
pies .so |)roniiiiciit a position as the removal fr(Uii home-surroiindiiigs
to a locality where hay fever is said not to exist. Of such regions
those already named hear a high repulalimi. particularly tlio While
.M(nintains. l>etlileliem seems to he a favored spot in these nuniut-
aiiis. The cle\;iti(Hi is less than *.'(l(t(> feel, hut large niiinhers (d"
people annually spend the wlude of the hay-fever season there, and
claim, during their sojourn, almost complete immunity.
The Muskoka islands and lakes hav(> also during recent yoar.'? re-
ceived a good deal of attention as a !iay-f(n-(>r resort. The elevation
of 1000 fopf above the sea. the purity of the waters, the rooky and
.
II. \v i'i;vi;if, ou \ ASdMoTou itiiiNiris.
;»:*
)
siiiid}' liiiliii'c (if llic soil, lli(> iiliiiiulaiicc nf Wdiidhind, iitid liic l(!Utii~
iii^ varii'l}' III' llu' iMiniiiH'i'.'dili' i>liiiids liavr all liclpcd to iiiakc it an
ideal r(';;ioii I'nr llic iiicvciil inn, ;is udl as t irai inr'il , dl' this di.-i'aM'.
Till' ti|p|irr \\alri'.-> 111' llir Sa;4iitiia_\ . iIhmil'Ii Iduci' in clrNalinn,
is also ;;aiiiiiiu iii rrpiilal mii, |iail iiidai ly ai'mn;; .-iilVrrns dirrrlly
Id t III' Miiil li i.r I lii> ii una 111 II' ir;;iiiii ; as aUn i~ (lcurL'i;i ii liav, Willi ils
jiiu'c, (lr\ al iii(i |i|ii-ii', ami I lhiii,-aiiil> nf rnck\ i-|;iiiil,.
'I'lir iiiii.-l iinpnrhiiit I'mcI to lie ciuiMilriTil, in iiiinii rl kui willi
lliis \ir\\ III' |ii i'\ I III iiiii. IS llir ad\ isaliilil y nl' iiihn in;.'; I" iIh' iIhl^i'Ii
s|iiil lii'l'dTc Ihc rdimiu'iu'riiiriil id' llic animal allaik. 'I'lir oiiji'cl is
1(1 ^rl llic ciilii-c licndil 111" the rliiiialic rlian,L:c; In |iri'\cnl the dis-
ease I'liini dc\clii|iiMji;, muI to hi'cak il ii)! aflcr it has made its appear-
ance. Annlller pnilll wllicll cannnl lir Inn st l'nM;dy em [lliasi/.i'd : if
llic palicnl Udcs hy railmad to tlic ravdicd rcsni'l, livfurc tin- time nl"
llie annual attack, even if that pciind i.- nidy a Few day-^, tlu' syiiiplnins
will not, dc\el(ij) dnrin;;' llic jonriiey; hut it' the lii|i is made (ij'lar
the hay-fever symptoms have commeneed, they will he nialerially
agf^ravalcd hy the time he reaches his destination.
'The rcsnits arising from this inclhdd of prcvcnliiin ditl'cr ma-
terially. In some cases the occurrence of the disease for I he season
is lirokcn entirely; in dthers the severity is weakened and tlu! period
of the attack shnrlcncd; while in others lilfh; or no salutary etreet,
is produced. They may i^o the round of all the resorts lliey can hear
(if, and yet tlu! liay fever will e.xhihil itself with its (dd-time foreo
and duration.
Treatment. — 'I'liis will frciiuenlly require to Ik; of a threefold
eharaeler. 1. ( 'onslit utioiial Ireatmeid, for tin; correction of the ikmi-
rotie liahil. ^1. Treatment of the diseased condition of the nasal pas-
sages. ;{. 'I'reatnient of the spasmodic attack.
1. Coiistitulional treatment. In this, rcfrulatinii of the ali-
irienlary eamd and the urinary system may he of prime iniportanc(!,
and should he followed hy Ihc administration of nerve and syslenne
Ionics, such as iron, (pnnino, stryehnino, arsonie, and |ihosphide of
zinc, ('old hathing |tractiee(l daily is an excellent adjuvant, as is
also sysloniatized exorcise.
liishop, basing his eoiicliisions upon liis own theory of the pres-
ence of uric acid in tlu; Mood as tin; real eanse of the disen.so, ad-
ministers systctnie treatment liiider the title of ))reventive treatment.
In the first place, he reduces as raueh as possible the supply of foods
that increase the formation of uric acid, such as meats, sugar, beer.
, Jc
' if
100
|)|si;.\m:s or tiik nasai. I'AssAtJKs.
wine, etc.: nJid limits the did larirdy to rriiits, vogclablop, milk. I'iits.
ol(\; 1111(1 ill tho siuiu' tiitu' iKlmiiiislcrs salicylatci' for several weeks
]iri(ir io the onset of the dij-ease. in order to diminish the iirie aeid
as it forms.
Tlie moment. ho\\e\ci-. ihal ^\ni|tlonis of hay I'ever show Iheni-
selvrs, he drops the salicxlalis and r(>\erls lo acid treatment, .\fter
numenms evperiments. he |iitfers llorsl'ord's aeid phosphates, which
he i;i\es in l-uiamnie dosis two im' three times a day. lie claims
that this prexeiits lhi> solntion of uric aeid in tln^ hlood. and at (Mice
checks the di><'ase. while, on the other hand, if alkaline treatment
wei'c re>ort(Hl to at this time it wonld produce iiricaciihemia ami pre-
cipitate an attack of the lr(ndde he is trying lo prevent.
".*. Treat nuMit of the discasi'd condition of the nasal passages, in
many cases the hypera'sthetie eondition (d' the mncosa depends upon
intranasal lesions of one torm i>r another. It is self-evident that this
discasi'd (dmlilion slnndd he removed and the passages rendci'cd nor-
mal if possiidc. neilcctions o\' the septum, hypertrophic rhinitis,
nasal pidypi. ])rcssnr(> of the niiddl(> fnrhinated npon the se|)lnm may
any of tlnnn re(piire o]ieralive interference: and the trealinent should
he dire(t(>d toward the riMiioval of these ediiditiinis when present, ac-
('(M'ding to tlie methods already indicated in prcviims chaplers.
.\s regards the period l)est suited \i\ operatimi. it wonld, without
donht, he hetter to remove all ohslruetive lesions pri(M' \o the annual
onsi>t of llu^ disease. .\s a ruK'. however, the patient docs not prcsi ut
liimsidf for trc.-itmcnl until the se\(M'it_\ (d' the exaccrhations impid
him \o s(M'k r(di(d'. ^^ hen he (hies cimie. his case should he i>\amined
into tlKM'iMighly, with lhi> aid id" the neee-^sary rliim^scopic instrii-
iiienls. This can always he accomplished, even in the most sensitive
eases, after ajiplying a ■I-p(>r-eenl. siduti(ni of cocaine. The essentia!
th'Mn-y is, {\y<{. to remh-r ea(di nasal passage fre(> enough to allow of
normal re>pirati(ni through it. and. second, to nunove any pressure
upon the septum arising fioni turhinal hypiM'trophy. .\t the same
time it is always well to he guarded against too extensive operative
interference, and, except in extreme eases, it would he heller not to
o))(>rale during the actual presence of this periodic disease.
Sajoiis and ^racKenzie Ixdieve that there are sensitive areas, in-
dependent of hy])ertrophy. and that slight galvanoeautery operations
upon thorn will destroy llio terminal filaments of tho nerves for tho
timo being and thus cheek the exaeerhations.
'A. 'I'roatmont of the spasmodic attack. No troatnieiit while the
!
I,
\
':
HAY I'KVKIt, OK VASOMOTOR lllllMrif-. 10 1
oxnccrbiitioii is acliuilly nii will ^ivc siuii j mmpt relief as i\ spray of
a sdliilioii of I'ocjiine. At the same time im driiir is more (latif^erous
to liie palieitt, if lie Iteeomes aililiileil |o its iiidiserimiiiate use.
\Vherever tliere is vascular tiir^esceiue of the iKt>al iiiiicosa, from any
cause, the appli<'at ion of w solution of cdiaine will ai once remove
it; ami in hay fever the ailemlant symptiuu> arc. for the tiuu", re-
lieved likewise. In nmst cases the followinj: pre-^cri|ili(Ui will he ijuite
stroiiji: on()n;ih: -
1. U (''xniiii' li\ (Imclildr !M
.Anuiioii. cliliniil l.'l
A.iiiu :i(t|
M. Si^',: S|ir;iy imiIi iii'^llil willi :i >iiki1I .|ii;oilil\ .\\\i\ iilln.v
i) 111 lie rcliiiiii'il. Any <,'oiiil iidiiiii/cr im-; V\\i^. -•"•,
l!(i, iiiid L'7) wimld iuiswcr I'nr ^juiiy I iciil mint.
OiH' dinicul'.y, apail from the ilani;cr of actpiiriuLj the cocuine
Iiahit. which can oidy he slii;ht in the use nf <o weak a solution, is
Ihe fact that its action is only temporary, and, after Iiein;: used n
nnmher id' limes in succession, the reaction from the condition of
the vessels prodiiccil liy it liecomc> rapid and iioticcaiilc. That is, the
tisstics swell up aiiaiii even more ipiickly than they did hcfoi'c ils w^v.
Here, a,L;ain, to prohmi; the ellicacy of the cocjiinc. i,rood results can
he olitaincd from a 'v*-per-cent. solution of menthol in alholcne.
thrown up the nostrils hy a second atiuni/cr, a- .-ooti as the cocaine
has heen ahsorlicd.
There is another method of IrentmenI I have found very salis-
faclory, in which cocaine has not heen use(| at all, except for the
purposes of examination. 'I'his is hy usimr a much stroii^rer solution
(d" menthol in adiolene as sjiiay to the Ihroat only — inhalin;:f it
forcihly diiriui;' a full ins]»iration, and then elosimr the mouth and
lireatliinir out fhrouuh Ihe nose. This is repeated over and over aLrain
until relief is ohtained. 'IMio stremrfli id' Ihe sidution mi^ht he :5,
■1, or "t |)er cent, as the ease miii'lit rcipiire, repeated, irrespective of
time, ni^ht or day, upon tlie approach of each threatened o.xaeer-
hation.
Tliere are a niiinher of mentliol-inlialers in Ihe market, hut
usually the n.«o nf tlie spray is nttonded hy hetter results.
Bishop advocates the n.'^e of a 1-per-cent. solution of eamphor-
1. rt Cocniiic livdroclilor pr. v.
Anunoii. clilorid pr. ij.
Aqua Sj.
M.
imw
■■»-i
102 DISKASKS OK THE NASAL I'ASSACJKS.
menthol in lavoliii as a sjumv to thu iU)so in tliis disease, gradually
increasing the strength to ;5 ])er cent, it' retjuired. lie claims it to be
blander and more sootiiing tiian menthol ahjiie. 1 have used it on
many oeiasions, but still jirel'er the menthol ami ihyniol-nienthol
prejiarations. Of the latter the following is a good fornuila: —
1. U 'lliyiiiol 15
Mclltliol 15
All.oU'lU! 30|
This should be used as a spray {o the throat and dinunished to
one-half strength when iist'd to the nose.
Lennox Urowne has moie failh in ilie local a|i|ilieation of men-
thol than of any other iliiiu' in the relief of this disease.
K. li. Sluirly lias found .-nulT of datnrine in >tarch a very etli-
cie.'U remedy; while Fletcher Ingals. after eautei ization. adnnnisters
tonics, together with the loral a|i|ilieation of eoeaine, to relieve the
exacerbations.
In severe cases, when, from liusiness engagements or other cir-
cumstances, it is im]iossible to use spray-treatment of any kind to
relieve the exacerbations, minute crystals of menthol dissolved in the
mouth will elVieicntly keep the sym]itoms under control.
As direct sedatives to the nuifuns mend)rane administered in-
ternally ]ierha]is none are better than a eond)inatioii of atmpia and
morphia in minute doses. They have a ([uieting elTect upon the nerv-
ous -ystcin. as well as an astringent etfect ujion the mucou> membranes.
The fcdidwing is a good formula: —
2. H Atrojiiii siilph (ii:{
M(>r|)liia sulpli ,05
M. Miikc into 100 taliK-ts.
Sig. : One to be taken every two, three, four, or six hours ag
required.
Still, as with all narcotic sedatives, cocaine included, considering
the danger that is always present of forming a habit, the less of
these medicines tiiat are given to the jiatient. the better. When
1. B Til yniol pr. ij.
Menthol pr. xxij.
Alholene 5j.
M.
2. It Atropia stilpli gr. %',.
^I<iri)h. sulpli gr. x.
M. Make into 100 tablets.
HAY I'EVKIi, OK A'ASOMOTDH HIUMI'IS.
lo:?
ahsoliitciv lU'ri'SMiry tlu' dniLT sIkiuM liu p re pared in ilif doilor's
otlice, and not in tin' way ol! ])roscri[»tion.
Solis-Cnhcii and Waiiiifr speak lii;:lily of suprarenal-caiisule ex-
traet in the treatnunl dt' liiis di.-ease. Sulis-Colien administers the ex-
traet in ."i-granime (h)ses live times a day. insuriiii,'^ tliereliy a "sneeze-
less, eiiryzaless" niiilit. Warner I'avors its local applieatinn in Iho
lurbinal tissnes. with nr \\itli(Uil eoeaine. nl)taininir excellent results.
I
5
Xasai. HvDiioitKiKi: a.
'J'liis is an atl'eetion somewhat resendilin^ij hay i'ever. particularly
in the abundance of the serous discliarge. It i.s very rare and oceurrf
at irreguhir intervals, the name indicates the nature and symptoms
of the disease. The discharjics, however, are more id' a passive char-
acter than in hay fever, and unaccompanied hy the severe sneezing
and palate-irritation which attend that disease. It seems to arise froni
idiosyncrasy of constitution. Sometimes it is a forerunner of nasal
polypi. How far it may stand in a causative relation to it at i)resent
it is impossible to say. Treatment similar to that id' hay fever is
called for; electrolysis under cocaine anaesthesia may i»e u.seful, and
operative treatment for removal of ohstrnctions may sometimes be
required.
A case of "vasomotor rhinitis"" reported by Howard Straight,
although accompanied by severe sneezing, 1 think should really come
nnder this head. The attacks were sin\ilar to those of hay fever
only for the facts that they come on move freiiuently durinir wet
weather than dry. and. lasting a day or two. occurred about every
two weeks all the year round. .V nundier of liandkerchiel's wo\dd be
saturate(l with each attack, and all (H'dinary treatment failed to give
ndief. Finally the doctor, linding the entire nasal ]iassage, tur-
binateds included, in a normal condition when the attack was olf,
singed the inferior turliinatcds lightly with the llat galvanocaulery
electrode. The re>ult was a great improvement of the I'oniliiion, with
almost com])lete >uli>idcnce of the attacks.
St. Clair 'i'hom>oii has very recent Iv di-awn attention (n jht^ pos-
sibility of mi-taking escape of cerein'o-spinal tliiid for nasal hydror-
rlnea. the s\mptoins being somewhat alike. A number of cases are
recorded in which, in otherwise pei'lVctly healthy sultjects. cerebro-
spinal fluid W(ndil escape almost continuously from the one nostril, the
intermissions being rare. ]n trui' nasal hydidrrlnea the discharge* is
more irrc<ridar and at the same time bilateral.
m
■ f
,; I ■
■i '
' ii n
CIIAl'TKU XV
ANOSMIA; PAROS.MIA; FUIIUXCULOSIS.
Anosmia.
hi
I -! ft
I "
Tins (li?easo, iiidiciitiiiir li»ss oL' tlio 8L'iise of Pimll, may owe its
origin to either eeiitral or |teri}ilieral Ic.-^ioiis or to mere I'unelional
distiirhaiiec of the nerve-eeiitres. Wlien of central origin it may arise
from the pressure of a tnmor on the douljle nerve-centre, or upon the
Ui'rves tliemselvi's. as in liodcr's case, in whicli tlie pressure arose from
scirrhus of the j)ituitary hody. Appei't's case also arose from press-
ure U|)on the olfactory nerves liy abscess of the pituitary. Bonet's
case was caused liy pus-formation within the olfactory bulbs. Jt may
arise also from atrophy of the l)ull) or trunk of tlie nerve as a func-
tional result of insanity and as the result of U'sinn caused liy fracture
of tlu^ bono of tlie Inisc of tlie skull.
r)y far the hirger number of cases arise from peripheral com-
pression or lesion, or from causes that will prevent the contact of
odoriferous particles witli tlie olfactory area of the nose. The causa-
tive eifect of lesion of the terminal ncrve-fllaments is well illustrated
in cases of atro])hic rhinitis and malignant disease. Here the nerve-
endings are destroyed, in the one case by atrophy, in the other by the
substitution of neoplasm. In all cases of anosmia the sense of taste is
likely to be impaired. Excessive tobacco-smoking will sometimes im-
pair the sense of smell. The pressure of nasal polypi not infreipiently
will destroy the sense also.
"When the anosmia is the result of atrophic rhinitis, a thorough
and sy-stematic treatment of the latter is not infrequently followed in
the end by restoration of the olfactory sense. Joal records two cases
as cured by douches of carbonic acid. ITe applied it through a caout-
chouc tube, the effect being first, irritant and then resolvent.
"When the cause is central, there is little hope of cure. Still, the
galvanic current may be useful and also courses of treatment by
nerve-tonics such as strychnine, arsenic, iron, and phosphorus.
In cases associated with liysteria and insanity the affection is of
(104)
I
i
I'AUOSMIA. riKUXCULOSIS.
1U5
minor moment, and, as a neurosis, may disappear with tlie restoration
of the mind to a normal condition.
r.VKOSMIA.
Tliis disease, althonirli very rare, may manife. I. itself in various
ways. One of ihe most eommon is that of hypera^sthesia of the olfac-
tory nerve, hy which the palieiit ]iei((ives natural ndors with exaii-
gerated inteiisity. This oeeiii's chiclly in hysteric. il >iihjeets. Aii-
othei' Wiiy is liy perversion of the natural function. The olfactory
impi'is.-ions iii iMses of tiiis kind arc usually of an unpleasant char-
acter. The odors complained of ai'c disaiirecnhlc. .-ucli as carrion,
kerosene, fi'reasy raid's, etc. It is >aiil that this perverted olt'actory
function is )iot infre(|uently fiiuud .■iuioml;' epileptics and the insane.
Treatment. — This .^IkiuM he dii -iniilar lines to those recpiired
in the treatment of anosmia. Still, as its oi'igin is move likely to he
central, the jiroLinosis is not so favorahle.
Is
l'"ri;r\rri.(isis.
Small hoils within, the anteiim' nares arc nni hy any means in-
freipient. 'i'licy ju'oduce sor<'ness, redness, and swellim:' of the !nd
of the nose. 'J'hcy occur most fretpiently at ihe outer mar^iin of the
vestihnle or the inner side of the ala, havin.ir their (n'igin in disea.-ed
hair-follicles. The nmst notahle sym])tom is general soreness of the
part, with sharp jiain produced hy Idowing or handling the nostril.
Treatment. — Systemic and local treatment, hased on general
principles, is recommended. .\ local application of a '-iO-jjer-cent.
solution of camphor-menthol in lavolin is recommended hy Hishop;
also a 12-por-ccnt. solution of carholic acid in glycerin. When pus
is found, he recommends evacuation, followed hy a])plieation of
yellow-oxide-of-mercury ointment.
I have found a simpler treatnuMit speedily ethcacious. When
the little hoil, or furuncle, is fm'ming. Iiefore pus can have developed
at all, a sharji needle should ])0 pressed deeply into its centre. This
can he done hy the patient without the aid of the surgeon. Tlien,
by vigorously blowing, blood is freely evacuated. This blowing
should ho repeated a lunnber of times in (piick succession. If blood
does Tiot appear, the little operation should he repeated until it does.
The evacuation will have relieved the congestion, and healing takes
place at once without after-treatment.
I t
CIIAITKIJ XVl.
.
Kl'lSTAXlS,
i
'Tills term is ii|)|)li('(l to iiU cases ol' luisiil liii'iiiorrhiijii! wliatovcr
the origin iiiny lie. It is ol' rrt'cuu'iit oc-ciirrrncc in childhood; I)ut
imich rarer in ndiilt life.
Pathology. — The hh'cdin.u nsually arises from erosion or rupture
of tlic minute blood-vessels, and in the majority id' cases comes from
the lower ]iortion of the cartilaginous septum. Cliiari believes the
majority of cases, particularly in adult life, are tubercular, lie gives
a record of si.x, in all of which the niicroscope proved the lul)ercular
nature (d' the disi'ase. Hard granulations or tumors had formed on
the septum and from these the bleeding had occuri'i'd. In malignant
disease luvmorrhage may be severe, from any part of tlu> neo])lasm,
and the same is true of fibroma, only that in the latter spontaneous
haMuorrhage is more rare, owing to the deii.-ity of tiie fibrous tissue.
I'ndoubtedly many lasi's occur without the system in any way being
involved.
Etiology. — In cbildren the most fretpient I'auses are falls and
blows ujioii the nost'. Ticking the nose and the insei'tion of foreign
))odies also give rise to if. In deviaticm of the septum the erosi(m
of the prominent point of tlu' cartilage by particles of dust may
proiliicc bleeding, as also may fi'acliii'cs of the nose m the base of
the skidl.
Sometimes the hjcuKU'rhage may lie vicarious in plaee n\' su<-
peniled intMistruation. W'licn occurring after th<^ nieiinpaii-e. it may
lie considerc(l an elVort to !'clie\i' the di-teiided biddd-vc.-.-els.
At other times il may aii-e from const il ut i(Uial cachexia, .-iicli
as pei'iiicious aiia'iiiia or pui'pnra lia'inoi'i'hagica. or again fiom organic
<lisease id' the heart or kidneys, as a iircmonifory sign id' typhoid, and,
as alreaily said, as the r(\-;ult (d' septal fuberi'iilosis.
Symptomatology. — It often occurs withoiif premoidtory -ymp-
toms. In other cases prodromic symptoms of vertigo, headache,
throbbing of the temples, etc.. ])recede the vnous discharge. Pro-
fuse arterial ideeding rarely occurs, except from malignant disease,
(100)
Kl'lSTAMS.
\o:
fihi'oinii, nr iriiiiiiiMliiiii. As m riilr. tlic luriiuirrliiiiif ncnirs diilv rroiii
oil'' iidsinl
Diagnosis.
II llli> llli'l'c >l|nlllil lie 111) (lillicllll y
h
11 lllc hli'C(M!|i|
ncclllS while Ihr |illllt'lll 1- 111 ;l CollscKUIS I'nIHill Kill. I' l('( | llcllt Iv.
Iiiiw cvt'i'. >li,L;lil liu'iiinirliiiuc \\in ncciir in ilic iii^iht. If llir |i;iti('t'i
is ;i>l('('|i ill the ,-ii|iiiii' |i()silii)ii iin diM-liMrui' iiiiiy r.-cii|i(' Iroiii ilic
jinlcrinr iiiiic.-. I'd-trrior rliiiiiis((i|iy cscii in llicsc ca-r^ slioiiM H'-
IllOVC t 111' lidlllll.
Prognosis.^ In inillnr lilcnlill^- lIlc |l|nnni]<is i.~ ;ilu;i_vs |■;l^ .irillilc
in (li|iliili('ria hihI ihr laltcr .-la,L;rs o\' i\|i|ii)i(| ii is iini -o lidpcl'iiK
while liaMiKirrlia^e (iccui riiiu' in iiiali.uiiaiil ili>ease ami |iiir|iiiia may
he (■n|i>i(|ere(| ii~ II |l j'a \Oialile i 111 I ical idllS.
Treatment. If the altack is mild. siniiiL: i|iiielly in a chair with
the lu'.iii tilteil .-liuhlly liarkwanl will nl'leii arre,-l the hleediiiLi-. If
tlie jialieiii heiids his head fnrward tn elean.-e tlie iin^lriN id' the
eliilled lilnnd. lia'imirrhaLJe will eiimmellee auaiii: lint, let him iilnw
(lilt the ai i'nMinlatinii> and at miee roiime the fdrimi {i(i>itinii, it
will lie likely tn sdon eeax'.
I 'dill Id the .■•|iine. Iidt a|i|ilieal idii- tn ihe eMeriial iid.-e, Imt-
waler ddiiehes In the lid.-tlil, |i|edn(.is df cdttdii snaked ill i;lyeern-
laiiiiin iir tincture n\' inm ha.ve all lieeii recninniended. It is I'arc,
liowt'Vcr. that activt' treatiiieiit will he necessary.
When hIeediiiL;- threatens tn he severe, il i- Well liy meaii» (if
the nasal <|iecnliiiii and rellected lii:ht tn search fnr the lileediii,i:-
Jinint and tn |iack the >|ini lirmly with cnlldii |i|edL;'ets ahme or
saturated with astriiiLi'enls ali'cady iiienliniied. In these cases kite-
tailed tiiin])()ns answer an excellent |iiir])nse. Small )iieces i)\' aseplie
nlisnrbeiit cntdni are tied inn;ether hy a striiia' at inti'i'vals nf one inch
and a half frnin each nther. 'They are all then, after cncaini/.in^ the
imicniis ineniiirane. packed mie after aiidtlier intn the hleedint: nnstril
liy means nf enllnn-hnliler nr small curved fiirceps. until liy pressure
the Inemorrhaiie ceases. 'I'lie pliiu' is lelaineil fnr tweiity-fniir nr
fnrty-eiii-ht hniirs. .\fter thai the wlmle nr part nf the pieces may he
withdrawn hy t:-entle tractinii. a pnitidii liciii^ retained tn the third
day if the return nf ha'innrrhaii'e appeared tn lie pi'dliahlc.
In anlicipatinii nf the latter. In^als siiLiui'^t- the u~e nf a strip nf
'"odofnrni izaiize as less likely tn heenme oll'eiisive dnrinu' a prnlniiLred
retention.
Vnr deep packing (ileasnn also iis(>k a lon^' strip nf iraii/e. snaked
in one of the hydrocarbon oils and packed, fold after fold, hack as
II
■!■'.:«
»»^WJ.-g<»^;«'<M918W<B
108
DISKASKS OK I'lll-; NASA I. I'ASSAdKS.
fiir as the jKi-^tcriiir clioaiia'. AmUlu'r iiK'tlmd. which lie roiisich'is
c(|iiiilly t'tliciicii'iis. ill the (lu'ckin^' of (li'cp ha'iiiiiri'hii,ur. is to sunk
a loosi' pit'io (il ahsiirlit'iil colioii in a l.'j-vohiiiu' solutinii of pcioxiilo
ol' livilniucii, and lo ]>Yv>-i it ahmi;' the iiilViior nu'atns to the pos-
terior iiaiis, as in tlic lirsl iiicthutl. llo ehiiins tliat l)y tliis moans
posterior |iaekin,:i can Ik- avoided.
In po<t-rhiiial ha'iiiorrhai:e from inali^naiit or lihroid diseases
these methods may all fail: then rn-ljoeii's eaiiiiiihi (l''i,u'. o')) will do
exeelleitl sei\ iee. 'I'he olijeetioii to this inst riiiiieiit wlii'ii first intro-
diR'od was on aeeoiiiit of the curve in the tuhe. That, however, has
vanislied, as the in-triinieiit now in use is almost straii:ht. The oh-
jeet aiiiu'(| at i.- to pliiLi' the postiTiiu' miris of the hleetlin^ side lirst
and the anterior iiaris afti'rward. The •.•a:Jiuila is tlireadcd with a
stroiiiT eon! throiiirh tlu' eve of the spriiii;'. The thumli-serew is next
J'ij;. .")."). I!t'ili)((i"s cannula.
adjusted so that it will retain the spring within the cannula. 'I'lien
the instrument i- passed aloiij: the lloor of the inferior meatus until
the end projects heyoiid the vidnm. The spring is now touched and
the cord is at once seen witliin the mouth. 'I'o tliis eord is fastened a
jiledget of wool large enough to lit tlu' ])ostei'ior naris. Then the
cannula is withdrawn, the wool pulled through the nosti'il iiiln posi-
tion, and cut loose. In drawing tin- cotton through the naso-pharynx
it can lie guide(l in its course hy the ling' r of the left hand of the
operator.
It is claimed that the cotton plug should he large enough to liU
both jiosierior nares, as otherwise the ha'inorrhago might continue
from the free side. This looks like false logic, as there is no natural
communication hetween the two j)assage8.
In a ease of a severe liaMnorrhage from nasal fibroma, the only
occasion in which T have ever rccpiirod to nse this instrument, I
Ml
I'
Kl'lSTAXlS.
I''"--'''' ""■ "'!'' >i'l'' «'i,!y. r„!|nur.| |,v
iiii'iiiorrliii^rc.
'AlKitlirr |il;m of Ifcjlli
109
ii'i"i'''liiitr (TssiilinM ,,]■ the
;;;.;;;:;':::;;;:;::;;::r,^:::j:';;:-::
■ 4 1
CIIAI'TKR Wll.
luiiNoi.iriiS; i()i;i;i(..\ uodiks; i'akasitks.
TilllNOI.IIIIS.
A i!ii iNni.iiii i- a iiii>al (alculii-. It is rorincd l)_v tlic u'i'ailiial
(Ifjiosit (if till' iniiicial cdiistil iiciils nf llic iioriiial iuimiI socrclioiis
U|)(iii the >iii-|'aii' (if sniiic lorci::!! Iiody, li)cnti'il witliin tlio nose iiiid
lu'tiii.ir ;i> a nucleus.
'I'lic rarlir-i rccdiil tpf (Uic liciiiu' I'l'inovrd \\a> n'|Mi|-t('tl liv (Jardi
ill 1A(i".'. It \\a- indcliiiiudy dc-ciilii'd a- liciii^' a- lar,m' as a lii'-coiu'.
Dui'iiij.' the Iniir cciiturii'- li'iuii ilicii until lunv uuut than a humlrud
liavc 1u'cn ilii'niiirlcd. SiiU. rliinolitlis arc of rare occurrcMcc and
tlu\v nccni' so inri(M|Ucnlly that each individual i^ase is usuallv coa-
sidorod Wdrlhy dl' a ri'cni'd hy itself.
In the mailer id' hi-tury, ihey I'nlldw the same law that jxtiverns
tile I'dMuatinn nf calculi in the hladder and olhcr orirans of the hody,
and in most instances snnie trace of iiucleiis can he round. It usually
tiikos many years from the insertion of the oriirinal I'oreijxn hody in
the nasal cavity to the full development of tlio rhinolith, as seen
when the patient applie- to ihe siiruciin for relief.
Symptomatology.- Someiimes from their size and position they
'/wo rise to great deformity. In llendloy's case the nose was swollen
and there was an external >inu>. Iroiii which jius exnded; in UovilTs
case facial ]iaialysis ami destruction of the hard palate. In Ilill'.?
case the rhinolith wa- veiy larLie and had caused extensive rhinitis
caseosa. In .Mar.-ITs case there was marked deviation of the septal
cartila.u'c to the left, heliind which the calculus lay concealed. One
of ihe writer's ca.-e-. a </\v\ (d' 1!' years, was similarly all'ected, hut in
her case it was on the riirlit side. On rcniovinir a portion o\' the
hypertrophied and deviatetl cartilage the stone was discovered he-
hind. It was liroken in i'rairinents and removed. The nucleus had
lieen a cherry-stone pushed into the nose when the patient was six
years of age. In ihe other case of which an illustration of fragments
of exact size is given (Fig. ."if)) the stone was exceedingly large. It
(110)
\
iiiiiMH.n ii>.
1 1
filled llir wlinlt' III ilic iiili'iiiii' lui'iitii^ iiml iiail li> ln' lii'ukt'ii ii|i liit'ort'
it foiiM III' rciiinvnl. 'I'lic initlcii> \\;i> II liiiitiiii, US .-littwii in tlu' iipjifi*
rif^lit ciiil III' ilii' lii:iii('.
One |)I'iillli||rlll .-yill|itiilll illtrllllin.L:' nil cm-.'- nf Inllif -tlllnlillU'
is a siininiis. iiiiico-ituiiilfiil ili-ili;ir::r n| |ir(iiliiiil\ iin|i|('n«iuil ihIhi-.
It is aliiiDst cliariirtcrislic nl' tlir ili^'ii-r iiml (jiiiir ilill'i'iTiii rniiii
tiiat |irniliiici| liy ntrojiliir iliiiiili-.
Diagnosis. A- ilir ilr\r|ii|inii'iii nf ilnniilitli- i- a -Inw iiniccss.
tlicv I'jii'rly iMiiiic iiinlci' iiliM'i'\aI lull iiiilil ;iiiiill lilr. I'.y lliis liiiH',
I'i'iiiii llirir ^izi'. till' >yiii|itiiin~ Kriniiii -iM IT. In iliilillimul iiiiv liaiil
siilisiaiicr I'liiiiiil within llir nn-i' i- likrly tn ln' a I'nrcii^ii luuly,
witlinnt ilic calcafrniis ilr|iii«it. altlnMi^li Imtli (.'lark ami Jtabur rcpDfl
ca.scs oi-i-urrinu' in rhiMiTn.
In (liiTci r.Viiniinatinn tli'' urilly -riisniinn lU'ndniril liy tlir tmi'-li
(if tlu' |ii'(i!ir i> inilii-at i\i' III' raliiilu-. Wlim ciiivat ur<' ni ilir M'ptiiiii.
as ill tlic IW'i ca:-!'-- rrlalcil. Iiiilr~ tlir -tiuir rrniii iiii-irvat inn, the illi-
i i
; '1
!
YiiS. .")(!. liliiiiojilh rciiiii\ cil irmii the Ift't iia-iij |i:i--ii^'i' ui' a laily, ajri'd -^.
niiictcrn M'ais afli r (lie in-crliiin nf tlii' Iniltiiii iiitn the iiii<|iil.
podimoTit may rci|iiir(' to lie rcrmivi'il licfnn' the (liai:iin-is can lie niadi'
sni'c.
Prognosis.- -Til (• I'ldar-vd (■alciilns can never lie reimived e\ce|it
])y o)H>rat ion. Siiri:ical relief liy one means or dtlier i- always ])os>il)|c.
Treatment. — This is simply the removal of the ihiiioliih like any
other forei,<.ni lindy. 'i'his can rarely he acc(mi])li.-lied without thi>
enisliiiiji' or hreakinu'-np process. l-'ortiinately they are not often
dense enonuh to resist the force of com|iressinn-l'orceps. and wlu'ii
that ilensity (\n^^> exist small lithofriies may he \\<fi\ instead.
Some opci'aloi's have found it ni'ce--;iry to enlar,LM' the nasal ori-
fice by incision. Others have cut thrniit^h the snfi palate or perforated
the hard palate to facilitate removal. iWit these cases occurred in
earlier years; and, \viili the improved facilities of cocainizaiion. ox-
.imination. and puraical treatment of the pr(\scnt time, the .surtreon
should not reiinire to resort to any elTorts save prr rias vahirahs.
After removal of the rhimdith there nuiv he MHiie ha-morrhaffe
• , I
■ \l i
113
DISKASKS OF THE NASAL I'ASSACKS.
)^!C
Hi I'
ii^
caused by contusion of the soft tissues, but liealing is always rapid.
Odor entirely disapjjcars and the catarrh almost at once ceases.
FORKIGX ])0T)1ES.
Foreign bodies are ])ut in the nose l)y children, sometimes by
hysterical fcinaK'S, and occasionally by insane persons. They have
been known also to enter the nose dui'ing sudden insjjiration, and to
have got there by accident of one form or another. In tlie act of
vomiting masses of undigested food have been thrown u[) behind the
pafate and into the nasal foss;e. Bosworth lelates an instance in
which he removed a deciduous tooth from a gentleman's nose, which
had loosened and been swallowed when a lad. It had probably been
vomited and thrown into the naris, causing purulent rhinitis for
twenty-live years before the coctor was called to remove it. Lowndes
tells of a ring l)eing ini[)acte(l in the jju^terior Jiares of a child of
IT) months. It was too large to have got there through the nostril.
Cotton tamjions have been renu)ved after remaining in the nose for
years. Young children frequently put buttons, peas, pebbles, etc.,
into the nose.
Sometimes if they give little trouble nothing is said about them.
If discovered within a year or two they may be found unchanged.
But, as is mentioned in the first jart of this chapter, if retained, they,
in course of time, become the nuclei of rhinoliths.
Symptomatology. — Profuse tero-mucous discharge accompanied
by sneezing are the earliest symptoms. Tlicrc may also be pain, par-
ticularly if the object is rough, ajigular, or large. Subsequently the
discharge from ])ressure nuiy liecomc muco-])urulent and of oll'ensive
odor. Obstruction is also a prominent symptom, arising partly from
the pressure of the foreign body and partly from swelling produced
by the irritation. Toleration, however, in many instances soon occurs,
as the body usually lodges in the inferior, or largest, meatus — a region
less liable to irritation than the olfactory areas aljove. The seui-e of
smell is rarely affected.
Diagnosis. — This can only be jnadc by direct inspection wdien
the patient is either ignorant of the fact or unwilling to tell what he
knows. Cocaine should always be used during examination, as it jjcr-
forms the double duty of shrinking tlie tissues and at the same time
relieving their sensibility. AVith the use of a ])robc aided by re-
flected light and nasal si)eculum, there should not be much dilliculty
fP-
rOliKlGN liODlKs. I'AUASriES.
113
in diagnosis. In young children a gonoral aiiii'stliolic might be re-
quired. The touch of the prolie should distinguish it from calculus,
Mhile thorough o.xaniinalion should rcuiove all neojjlasms by exclusion.
Treatment. — An auivsthelic will he re(|uire(l dui'ing renu)Yal in
iMtr.
1)1 . — .>|I(HI|1.
J
most cases occurring in young childrfU, but in some complete aniws-
thosia may not be necessary. The ajijilicalion of a drop or two of
.solution of cocaine to the mucous memhrane will shrink the tissues
and facilitate i'.\tra;lii)n.
Fig. 58.- -I'osw drill's ua^a' fureeps.
A nasal spoon (Fig. 51) in ilie majority of instances will readily
remove the object, ■ hough sometimes mouse-toothed or curved nasal
forcejis may bo re^'.'ircil (Figs. oS to (iO). When these fail a snare
may possibly be slipped ovi'r some projecting point, and render the
extraction easier than by any otlu^r method.
r.vn vsiTi:.'^.
The presence of extraneous or jiarasitic life within the nasal
cavities is very rare in temjierate climate?, so rare that many rhinolo-
K
114
DISEASES OF THK XASAL PASSAOKS.
I'll
gists linvc iiovor scon a riisc, wliile in trnjiical countries it is compara-
tively fro(iucnt. In Jndia alone Laliory collated 91 cases, 2 of which
were fatal. Jn ("hxinet's case, a man, after slee])ing in an open field,
was seized with severe pains in the foreliead and with swellino; of the
face. He was taken to a hospital. Worms commenced to crawl about
his nostrils and ears; and on lancing the swollen tissues several
platefiils are said to liave been taken away (l'»osworth). The i)atient
recovered Mith tlie loss of his eyes.
Fraenkel says that in teni])erat(! climates the presence of ozainn
is favorable to the gnnvlli of parasites, ami that the most active enti-
ties in producing tiie malady are the Mitsca romiloria, the Muf^ra
carnaria, and the gadfly.
fjoldstcin, in tiie Laryngnscope lor December, 1897, graphicabv
Fig. GO.— Hiirtniann's foitciis.
!:lr::
( .'1
introdnci's a new insect to tlie notice of his professional brethren.
This is tiie Cotupsoniijia macceUaria, or Texas screwwo:;u-fly. Pro-
fessor Williston. of Yale, says that it prevails everywhere from Canada
to I'atagonia.
Til is ]Hst n>nally confim^s its ravages to cattle, b\it sometimes it
invades the nasal passages of human beings. Several deaths have
been recorded from its effects. In all the known instances, bow-
ever, in wliich the (>ggs of the screwworm have l)een dejiosited in tin;
nose or ear there has been either ]U'c-existing oza^na or otorrhn^a.
Tlie lly deposits its eggs upon decaying anhual or vegetable matter,
and upon this tlie lly feeds voraciously.
Symptomatology, — The symptoms in all cases are pretty nearly
alike. These are excessive irritation, excruciating pains, formication,
and the ajipcarance of the maggots craMling within the nasal cavities.
PARASITES.
115
Tlicy arc very tenacious of life, and wil! stick to tlie walls of the
passages with great tenacity. Muco-i)uriilent and bloody discliarges
soon follow, accompanied by headache, fever, and other constitutional
symptoms. When death occurs it is probably due to the supervention
of cerebral meningitis, possibly aided by the development of septi-
ca'mia, from the extensive supi)urations which sometimes occur.
Treatment. — -'J'he best treat n'.eut is to curette and pick out the
larva". The scrttwworm i.s said to be so tenacious of life that it will
live for several minutes in pure carbolic acid. The vapor of chloro-
form, if conconlrated, will kill them; but care would be required lost
in zeal to destroy the parasite the patient shoidd be sacrificed. Ordi-
nary washes and s])rays are useless. Rigid watchfulness, with oft-
repeated extractions of the gnd)s, aided by cocaine and retlected light,
would appear to be the best treatment.
Scbappegrell advises the use of warm oil. He says it destroys
the larvse by occluding their respiratory organs. He ])laces the i)a-
tient in the horizontal position, and fills the nostril with the lluid:
olive-oil, albolene, glycolin, etc., and claims to eradicate the worm
by careful and painstaking use of this means.
'Mr 'J
i 1
!( .M
it. t
m
pi
Ml!
■J
WW 11
1 1 I i'-
('IIArTKJi XVII I.
NASAL roLYI'I.
TiiKSE arc tiiinur= nf ihe 7iii^e, luescnting several marked char-
acteristics. Tlu'V liavc smooth surfaces, arc lobiilatetl, but usually
are rcirujar in form, each hcini: attached by its own Itmad or narrow
])cdicle. The color is jirayish hluc, sometimes slightly jiink. They
are tense .id elastic to the touch, and arc of jelly-like consistency.
i. ^
•: t '
i^
Fig. 01. — Xasal polypi. (After 15osworth.)
They rarely appear simultaneously for the first time in both nasal
fossa\ but attack one nostril first. Sometimes, through a long course
of years, the other one is never invaded. In other instances the de-
velopment of polypi on one side is quickly followed by their forma-
tion on the other (Fig. ('•>]).
Pathology. — This is a subject in which there exists, particularly
among recent writers, a considerable difTerence of opinion.
Biibroth classes nasal polypi with the adenomata; Bosworth,
(lUi)
XAiiAL roLYri.
ii:
Kri(li.>-rii, and Hiitlcr consider tlu'm to be nivxoma; wliilo J. X. ^lae
tliat the cli
til
)t
i.s 1101 iiiyxomatous, hut
that of simple inllanunation. He says that the ordinary mucous poly-
pus is an (edematous fihroma, not a myxoma. Jonathan Wright also,
al'ter extensive niieroscopieni exaiiiiniitions, has arrived at the eon-
cdusion that true myxomata are never found within tlx! nasal eiiam-
bers, and that the growths usually called t)y this name are simply
the results of chronic intlammation. lie finds that, in addition to
the degeneration of the stroma and tlii> ledumatous iMiiltralion so
generally ])reseiit in nasal ]iolypi. there are also occasionally hyaline
bodies (U* berries. They are conlimd ;dmo>t entirely to the struma,
and vai'y in sixe from that of a round, white blood-cell to three or
four limes thiU dianiclci'. "'riii-c liodirs are ilivide(l symmetrically
by sulri, wiiicli I'clracicd the light strongly into lobules. comiM'essed
into polygonal shapes. a]i|iarently liy a limiting membrane"" (donatlian
Wright)?'
Swain has proved histologically that ]tolypi having surface cor-
rugations contained a lari:-e amount of fibrous tissue, and that, whether
in their origin they had a purulent basic foumlatioTi or not, no bacilli,
cocci, or jiarasitic bodies seemeil to be present in their tis-ue. Swain's
observations seem 1o have brought out an addifiomil fad: that tiie
histological character of the polyp beais a direct relation to the
density of the tissue upon which it grows, lie also believes their
origin to be inflammatory, invohing the pre -existence of an hyper-
trophic condition of the mucous membrane.
Xotwithsfaiiding dilferences of opinion upon fundamental ])rin-
ciplcs, there are certain pathological comlitifuis in which all agree.
The external surface of the polypus is composed of an epithelial layer
similar to that of the ordinary mucosa; it may b(,' mixe(l in character,
or either s((uamons or ciliated, according to circumstances ami situa-
tion. Within this there is hypertrophy of the stnu'tuial elements
of the mucous mem!)rane and connective tissue, giving a fine reticular
frame-work, the me.<lies of which are filled with semifluid mucin
and leucocytes. Cilandular tissue may be present, but there is usually
a minimum of vascular eh nients (l-'ig. (!'?).
The site of attachment is usu.illy the internal surface of the
middle turbinated. It may be around the margin of the ostium
maxillaro or along the whole of the lower border of the bone. Some-
times they are attached to the inferior turbinated and occasionally to
the septum; but these instances are rare.
Mi
i
tl
1
-
1
: i
i
W:
■i
!
■
i
'i
.i
1-
I
n
1 : f
118
]>isi:.\si;> Ob' Tin; nasal passaciks.
Etiology.— Altlioii'ili tliis sulijoft lias engaged tlio atteiiliou of
so many keen ()l)servers, as has already been said, they do not all
agree. The probability is tliat there are many causes which may lead
to tlic develoinnciit oi' this disease'. 'I'he fact tliat tiie mucous mem-
Fi}T. 02. — ]\Iici'os(.M)]ue-iil scctiuii of iitusal iiolypus ("ilMI (lianiptors).
a, Stratified ciliated I'liitlicliiini. h. I'cticular fraino-work. c, rolyiiuclear
leiic'Ot'ylo. (/, Yascular iciitic. c, liadiaUiig blood-vessels. (Aulliov'a
speeiiDcn by ]?ensley.)
brane of tlie middle turbinated is of softer and more delicate con-
sistency than that of the lower, and composed of a liner reticular tis-
sue, may make it more liable to this so-called myxomatous hyper-
trophy. In a normal condition the tissues of the middle turbinateds
NASAL rOLYl'l.
Hit
are in constant condition of scroud oxo.sniosis. The inenibrano in
some cases may be easily overdistended, and, if from any cause in-
liibition is lost at a given ])oinl, ibere is notiiin^if to prevent tlie dis-
tension increasinf?, with proliferation of cell-elem(>nts.
Woakes believes the large majority of cases to be tlie result of
necrosing etlimoiditis, while (iriinwald considers the formation of
polypi to be secondary to enij)yema of tiio accessory cavities, ^fc-
]Jride considers tbcm to be simply (edematous iiljromaia, to be dis-
tinguished from papillonnita by their density, color, and site of origin,
but to \)e the same in character and cause. Zuckerkandl suggests that
they originate as adenomata, but that during development some of
the ducts become occluded, resulting in myxomatous (le_ luM'ation of
glandular tissue. Somewliat in opposition to all these views, Jonathan
Wright and Swain, of this continent, nuiintain that the disease is, in
all cases, a result of chronic inllammation of the mucous membrane.
]My own conviction, based on i)ersonal clinical experience, is that
the etiology cannot be contined to any one cause. In the large ma-
jority of cases that I have seen, where the polypi were large and
numerous, there was no sinous disease. On the other hand, cases of
antral disease that 1 have attended were usually alfected also with
polypi of tlie adjoining middle turbinated; but these polypi were
always small, and after the healing of the sinus the poly])i ceased to
return. Hence they were ]mrely secondary results, quite dilferent
from mulliple myomatous disease.
Nasal ])olypi are ^^nid to occur more frequently among males tiuin
females. Tliey rarely occur in early life, although one of the most
severe cases 1 ever saw occurred in a little girl aged 7 years, from
whom 1 removed about twenty from the two nostrils; Fig. 03 gives
a microsco])ical section. Her mother stated that she had been
troubled with them from the age of two and a half years; and that
for more than a year after that she was un(h'r the constant care of
a specialist, who reniovt'd tiiem as rapidly as they apjieared. This
case, I think, was undoubtedly congenital. The rarity of these cases
is evident from ]\lour(!'s statistics, for, out of 10,5'v'O cases of na.-^al
polypi, only o occurred among children. This is strikingly brought
out by Dtmbar Roy in an aide article reporting a case.
Symptomatology. — Two noted authors give directly opposite
statements as to tirst sym})toms. iiosworth says: "The first and
earliest symptom is tense irritation in the u])per air-passages of the
cavity, manifesting itself in more or less violent attacks of sneezing.
r.'d
l)isi;.\si:s OF TilK N.\s,\[. i'.\s>.\(ii:s.
'I
li i
:■!
ili!^
:! t i,|
{U'((iiii|iiiiiic'il uitli wiitciy (liscliiirirc."' liCimnx Urdwiic says: '"Sucoz-
in<^' is seldom cxhiljitcd, imiiiuiiity irom tliis tlisajii't'cnlili' symptom
licinir (loiihrk'ss due In a liluiitiiii,' ol' the sciisiliility of tlii.' iktvc-
c'iidiii<rs."
I 111 ink till' fact is tiiat wo so rarely see cases of nasal polypi
when tlicy cdinmence to lonn tliat wo cannot tell wi\ellier they are
accniiipanied liy sneezin.ti' or net. When tiie jtatietit first presents
liiiiisclf for treatii'.ent, it is usually for the relief of nnilateral catarrh,
associated witli more or less nasal stenosis and frontal coniprossion.
Jn some instances we are asidnislied at the small amonnt of apparent
Fig. 0.3.^ — Microscojiical sfclioii of iia.sal polypus from ii cliild 7 yo.iis old.
(Aullior"s sppciinen by Beiislcy.)
distress which larfre masses of polypi will produce. The reason of
this is obvious: they always form in the middle tur1)inated region
and by their presence and pressure expand the upjier ])ortions of the
nasal fossa\ By this means the lower tnrhinal region is also ex-
l)andcd, giving com])ensatory siiace; and it is not imtil tliey are
large enough to drop dcwvnward that breathing is interfered with.
The sense of smell is likewise seriously affected in the majority
of cases.
Xot infrequently nasal polypi give rise to reflex disturbances.
This is particularly the case with hay fever and asthma; and the
truth of the statement is proved by the history of numerous cases
NASA I, I'oi.vrr.
rn
of
on
he
'X-
irc
[ty
Ics.
Ihe
pes
in wliici) tlici-c ;ill'i'(ti(iiis luivc liccii rclicvccl liy tlic removal ot' IIr'
oH'cndiiiii- canst'. Ain'iiscxia. or hick of |iii\vcr nl' coiicciili'atidii, is also
sonu'tinu's a roiilt.
'I'lic (icuiar and aural (lisliirlianfos imltifcd liy the prossuro of
nasal |i(ily|ii arc not m) iiuicli ul" a rcllcx character as (luiii^ to direct
])rL'ssiire ii])on couti.uuous structures in the ease of the eye and inter-
ference with the noi'nial cdiidition id' the luistachian tniu! in thai of
the car.
Diagnosis. --This can only lie made hy direct inspeclion; and,
no matter how easily seen the growth may he, it is hetter to make a
thoroiiiih examination by rellected liiiht. 'I'o the exjierienced ohservei'
scarcely anythiuii' else can In- mistaken I'm' polypus. To the inexperi-
enced it is widely dill'ereni. Sometimes the polypi aie deeply seated
and may he hidden liy a derornud septum, t>v the inlerior turhinated
may lie so enlai',L!t'(l as to hide them friun view. The application ol' a
solution of cocaine will, in a few nnnutes, i-cmovc thoe dilliculties
and facilitate examination. The liluish-^'i'ay color and shiniuLr sur-
faces of the polypi slmuld easily lie recoL;uized. Then hy u-in.Li' the
probe they can readily he moved and thcii' >ui'l'aces indeiiled. When
tlie p(dypi extend baekward into the posteiior choana", they can always
be examined by aid of the ])ost-rhinal mirror. Ifero. on aecount of tho
color of tho two heing nearly tin' same, liyportrophy of the posterior
( iid of the inferior turbinated might be mistaken foi' poly]ius: the
corrngated surface of the former, however, as compared with the
smooth shining surfaces of tlu; latter, should make the diagno.sis
certain.
Prognosis. — Xa.sal polypi involve Init little danger to life. They
proflnoe, however, a great deal of physical distress, while thoy ex-
liibit little, if any, tendency toward spontaneous arrest of develojunent.
While a catarrhal condition (d' the mucous mendiranes is ]H'oduced
liy their presence, the most serious n^sidts that may be expected ai'c
the development (d' hay fever and asthma by rellex iu>rvous action.
To these might be added destruction of the sense of smtdl. and, also.
what is more serious, impairment of hearing caused by pressure of the
post-]iharyngeal ]iolypi on the Kustachian tubes.
The longer the disease is neglected, tho larger, tho more numer-
ous, and the more ]irolific do the growths become. It is also a disease
which ha.- a strong tendency to return. T.et the ]ioly])i be removed
as perfectly as seems possible, and in many instances a few months
will snflfico to have a now crop appear, like young grapes in an old
I
HI'
1)|si:a-i:s ov i ii
\ \- \ I. i'.\>sA(ii;s.
III-'.'
viiii'vanl. Tlic niily \vi>c pljiii i,- In ki'i'p ihc^c (•;!<('> iimli'i' cnii.-tiint
nlisi'l Vill iiill. iMliI liV (iircllll Opl'lill l\i' I l-i'ill llli'lll In r(|llil\(' the |l(i|v|IS
as I'iisi as llicv 1(11111. In llii.s way iiiaiiy (.iin* in ilic end ran lie
iK'COUiplisllL'd.
Treatment. — C'nmiilctc rcmo\al of liio neoplasms is the only
])ro|u'r Ileal iiK'iit. wlicllu'r accomplishod by alilation or (Tostniction,
or both, {''niiiicrly tlic application of n>ti-in<xt'iil-: in the 1'onn of
powders and sjirays to iIk' siiriacrs of llic polypi was jar^rly prat'-
liced, tnit, beiiii; jtractically nsoless, it lias been aliandoncd.
Removal by cold snare or forceps, and to destroy thciii by gal-
vatincantery or electrolysis are the methods now in use. Of these the
cold snare has in every way the preference. Tt is more widely used
than any other instrument, and it iiroduees tlu' best and most lasting;
results; it is indorsed by such men as ]\Ioure, lieiinox Browne, l^os-
worth, Sliurly, Delavan, Sehech, MaeKeiizie. and a host of others
<Fi,!,rs. ;?;i, -aV, I]'}, ;'.(;)
Kijr. (!4. Hliikf's I'lU' pciJN jius siiiiii'.
Jarvis was the liist to introduce ablation by this instrument.
Since then the sieel-wire snare has underiione many nio(li(icati(nis,
and at the i)resent time there are many varieties in the market.
The simpler the instrument is. the shorter its shaft and handle,
and the more easily it can be manipulated, the better. The chief
points in selection are io have the instrument light and strouix; with
the handle jilaced at an angle with th(^ shaft, so as not to oiiscurc
the vision of the jiarts while operatinsx; and to have it so hung that
in the large majority of cases it can be manipulated for the removal
•of the polypus entirely by the one hand.
Personally 1 liav(! in my armamentarium a number of expensive
instruments highly recommended. They are haiulsomc. highly
polished, and indir'ative of scientific knowledge and skill on the part
of their inventors. But I rarely use them. I have iried them over
and over again on ditferent occasions; but they are all so cumbersome
f.nd unsatisfactory that they lie in the case, simply to be looked at;
H
NAS.M, rOI.Yl'l.
133
1111(1 1 lilt all my work now with two or tlirt'c eiir-|toly|ui.- .-nan'-; of
almost till! siuno pattern. I liml tln'iii iiuitr rapaltli' of gras^ping and
rrnioving tlit' lai'gr>t iimmiI pol\'pii.s cvrii when lilliiii: the postcrioi'
clioana. Tlicy arc almost identical in form ami -i/.c with IMakc's
cai'-|io!y|iii> .-11,11'c (Fig. <> I ).
Ill opcrntiiig cocaine should always l)c used, iiot only to aiia'S-
thetize the parts fully, hut al.«o to .-liriiik the tissues and render the
vision of the fossa as perfect as po.-silde. it is lust to throw in a
■l-per-ccnt. solution first, and llicn apiijy a lii- lU' lo-pcr-ceiit. solulion
liy means of a cotton-liolder.
fn adjusting the snare ca''" should lie taken not to have the
loop much larger than the circumference of the polyp to he inclosed,
'riicii, as the attachment is always on the external, and not in the
septal, side, the lower rim of the loop should he dulward as it is
passed into the nasal rw ity aiul slipped under the lower margin of
tile ])oly]uis. r.y a gei'.le hack-and-l'orward movement and gradual
tightening of the loop, it can usually he slipped up to the neck of
the polyims: then the wire is drawn home and hy traction the hody
removod.
This is only a general rule id' operation, and must he modiiiud in
detail according to the numiier and jiosilions of the dill'erent ])<dy|)i
and the e.\])erieiice of the operator. After cleansing the fossa of dis-
charges that may occur, the routine may he repeated over and over
again at the one sitting, until all that are visihle are removed, or until
it seems advisahle to postpone the conclusion of the work. As a
rule, the liivmorhage is slight, hut occasionally it may he more severe;
and in some cases tampons might retpiire to he inserted to hasten
its control. 1 have never, however, seen a case where this was neces-
sary.
ITow thoroughly the removal of the visilde polypi j'roni one or
hotli nostrils at the one. sitting may he acco. »!ished depends a good
deal on the ahility of the patient to stand the combined eifects id' the
cocaine and the ojierative treatment. In any ease I believe it is
better to have the patient return at intervals of two or three day.s regu-
larly until all the poly])i are extracted. T have freipiently seen case.s
where I liav(,' taken away all that 1 could see on the one day, and on
the reappearance of the ])atient, forty-eight hours later, another si?ries
were visible in the lower part of the middle meatus. These were
not of new formation; hut liad merely availed them.selves of tlie open
Sjiace produced by the ju'evious evulsion and by gravitation and ])re.'!s-
If;
l-.'l
msKAsi'.s oi' iiii: NASAi. i'AssAt;i;s.
I:
I!,
lire 11(1111 ;il)n\c luiil iiiiuli' llu'iii.-rlvt.'s visil)lf. Some jiiillmritics advise
to \v;iit ii week liclnrr ((ptTiitiii;,' tlxi sfcoiul liiiir. Wliv .^lioiild tliis
he ddiif!"' 'I'lic |)iiti('nl (ilicii cniiit'S lifiy or one hundred niile.> to lie
relieved (d' liis n.i.-iil lidnlde. 'I'iine is prei ions to iiiin; iind it would
seem to lie our duly lo relieve liiin iis llioroiijiiily as |tossil)le during;
the liniiti'd period at his disposal; and we may he ahle to do this by
operalinji: on alteinate days until the work he a('e()m])lished. provided
tlial the reaction I'loni eaeh operation has sid)>i(h'(l hel'ore' tlu' next
one is done, hiii'in;^' the intervals hetween (tperations 1 have ioiind
my patients rendered niueh nior" eomt'orlahle liy the repeated use of
a spray (d' simple allxdeiie.
When tlu' nostrils aic pretty thoroughly cleansed id' p* lypi, it
is advisahle to aiiain iipply cocaine: and, n])on dryin^f the parts, little
rrajrineiits and slumps oi' polypi may still he vi>ihle. 'i'lu'se should
he tou(dii(l with ilic uahaiuicaulery: ami it can he done with l»ut
sliijht injury to the siirroiiuding mucosa. Tlu' healiim' is rapid ami
attended by little or no discomfort.
Bosw'orth says that: '"If we tiHU'ou<;hly extirpate the grc
they do not recur." '{"his is contrary to my own experience aiiu lU
that (d' a lar;;'e numln'i' of rliin(do,irists. Sonu' operators are more
skillful and more successful than ollu'r>: hut, as a ride, you may re-
move eveiy ve.-li^e id' polypus that can he found, you may ahlate
completely ami watch the case for weeks or months withiuil the
sliiihtest apparent return, hut let two or three years pa>s hy. particu-
larly in youu^ people, withoid any treatment, and in a lai'uc numher
(d' cases, upon examination, you will tind a reforuuilion of the
lirowths. 'i'his may not lie on account of iiicomi)lete extirpation:
hut from the fact that, although you can ei'adieate the disease, you
may not lie aide to erailicati' the innate Icndency to its development.
Casselherry strongly favius removal of the anti'fior I'lul of the
middle tiirhinated l»y scissors, foiceps. and curette, when the polypi
form, as they friMpiently do. directly ai'ound the hiatus semilunaris.
I'his uives much iireater freeilom of access to the bases of the [lolypi.
and periiiil> of nioi'e Ihorouiih eradication.
1 do not uieaii to say that this disease cannot be curetl. for F
believe it can: hut that, to thoroughly destroy the tendency, each
case slioidd he seen often eiiou>;li to ni|) the buds as they form, and
by this nu'aiis eventually to hreak up the habit.
The dilliculty is that patients experience such complete and
trrafifyini; reliid' after thorough operative treatment that they do not
I
IP
NAS.M, l■(l|.^ I'l.
1 •.'.".
tiikc (,'();fnizaiii'i' ui' the .-lnw rctiiin. ami Irciiui'iilly jmU oil' lln' \i.'>it
t<t the siir^'cnii iiiiiil :i liir.i^c iiiiiiilirr of pulvpi have a;.faiii (lt'Vfln|ici|.
Tilt' stH-'ond iiii'llinil (iT ii'cal inciit, ilial <i|' rviiUinn liy l'iiicc|is, i-
tlic oldest iiicthod oT opciativi' ]irucc(liiic. and is still lar^ifly iirac-
liccd. Many rmiiis ol' tliis iii>tnmi('iil have liccii devised, 'i'lie lilades
should he narrow and stronLT. as well as -Jcrrated. ny tnoihcd. and set
at a similar an;:le to the na-al saw and |inly|in>-»iiare and I'lii' the
same reasons. Seller'^ t nhe-toree|is are aUu »aid in --erxe a ;^niu\ piir-
posf.
The chief ohji'ction to the I'oreeps o|ieratiiiii is the injury .-o likely
to he inilieted upon the mueoiis nieudiraiie hy its um'I a consider-
ation so lar,i;('ly ahsent in the carerul u.«e of the -naie. If the suri^eon
decido to operate with the fnrccp.-, it hcc(imc« hi« imperati\e duty
to e\crci>e the ^'reatest care in nrder to produce a minimum of injury.
in operating;', after cocaini/alion. aich'd hy -pcculum ami mirror,
the forccjis should he closed and ,u'ently in-erled until the neck of
the polypii.- i.« reai'hcil ami carefully seized. Then hy a tui-tin;:' rotary
inotioM it is detacheil and withdrawn. 'I'he M|ieratioii is to he re-
peated until all the polypi ai'c removed. There is nuu'e tearinji in
(his operation than with the snare and conseqiuMitly more hleedin;.;'.
So that, as a rule, a smaller iiumher can he removed at one .sitlinu'.
The <;alvanoeaulery-.-iiare had nuuieriuis ailvoeates anioiii; the
earlier writei's for the elVeetiial removal of nasal polypi. NOItoliui,
^liehel. liriin.-. and others heiuii' earnest advocates (d' the method.
Later writers, however, do not approve of it. the chi(d' ohjectimi heinu-
the <lilllcnlty of adjustinu' the soft ami |)liahle platiiinm wire to the
iieek of the polypus. In place of it the cla>tic spring of the cold-steel
wire has found almost univeisal faviu'.
One other method of treatment mu>t he ineiil'oncd which ha~
heeii received with some favoi' hy seveial recent writers; this is treat-
ment hy electrolysis. Two methods of applieatio:; are advocated: one
is to attach till' po.-iti\c pole of the hattei'y lo a neeille to he in-erted
into the polypus, wliile the nciiiilivc pole with ^ponu'c electrode is
])laced over the nose; the other is to pa-s hoih needles into ilie poly-
]ms side hy side. The current in each ca-c shoidd lie coiitiniied foi'
ten or lifteeii iniiuites at each sittine-. 'I'he proeos is a \ciy tedious
one. and for this diseasi' of douhtful utility.
I
:
I
Jl
1
-■ -■--
— -.,. ..
li
; . : i
i: ■?
CIIAI'TKli XIX.
papillo:ma.
As ALRi-APY staled ill the prooodiiig chaptor,^ the palli(ilo,<iical
dill'creiu'o \n tlio rnnstnu'tion of na.'^al jmlypus and nasal papilh)nia
is very sli<;ht. The elementary tissues are the same in each, the dif-
ference, accord iiiii' to ]\Icr>ride, lieiiiir dependent very nuich iijion
density of construction and site of attachment, their microscopical
characters heina' very much alike. The pa])illoma is the result of pro-
liferation of epithelial and connective-tissue elements. When found
near the entrance of the nn,«tril, the growth is firm and dense in
structure and cinered with sipiamous epithelial cells. When deeper
within the cavity, tlie covering is of columnar C(dls and the papilloma
is of softer texture (nopmann).
The usual site is the anterior jiortion of the nostril, either upon
the inferior turbinated, the septum, or the floor of the nose. Tliey
are supposed to be caused by irritation of one form or another. Still,
as they resemble cutaneous warts in method of growth, as well as
structure, it is dillicult to trace the etiology.
They are not of fre(pient occurreiu j, although much has been
written about them. Their growth is slow and painless, and fre-
([uently the only knowledge the patient has of their existence is
from digital examination, 'i'lie annoyance which the discovery has
produced may induce the patient to have them removed. Sometimes,
like their congcmers, warts on the hands or face, they may appear in
numbers; and produce a certain amount of stenosis, with local irrita-
tion and muco-purulent discharge.
In regard to prognosis, operation is said to liave been followed
by death in two cases. In Ward's cas(^ the patient died of pneumonia
twelve days later, though what connection existed between the two
])henomena we are left to conjecture. In A'crneuiTs case death
seemed to have resulted from an extension -f the tumor. With these
exceptions, the results of ojierative treatment have apparently always
ho'Ti successful.
Treatment. — This is simply removal of the growth, either by
I'Al'IM.OMA.
V27
snare, scissors, or knil'c. The iiiiiin olijc i- o ri'innve the neoplasm
in its entirety and with as little irritation '■., the surrounding mucosa
as possible. In the majority ol' instances this can be act oniplished by
means of the cold-wire snare. As a rule, no after-treatment is re-
(luired. If, alter ablation, any prominent tissue is left or the removal
is incomplete, the base should be touched with the galvanoeaufery.
When near the margin of the nostril, it would l)e well to apply vaselin
occasionally for a day or two to allay irritation.
In my own practice I have seen but one case. This occurred in
a lady aged ."i.") years. It was located on the lloor of the right inferior
meatus, and would occasionally bleed, ll was cliiiped oif with scis-
soi's and wilhoul u>ing cocaine, and healed without furllier treatment.
In the majority ol cases it would be iietter to use a local aiues-
thetic l)erore o]ierating.
1)11. \ii;i! At. TiMoL's {)[■■ nil, Si;i'HM.
I'eglcr {■/ (lit null of Ldri/iiiitiliKiii. riJilnoloijij, and Ololiiiji/, October,
1S!)S) divides these growths into two varieties: the lymphoid and the
erectile. 'I'lieif eliiei' interest lies in tlieir etiological relationship to
nasal obstruction, paresis of the soft palate, and sininalic dyslalia, or
affections of speech.
Of the lymphoid variety the aiitlun' report- one case. This con-
sisted of a growth on each side of the septum, a!i<uit three millimetres
from the posterior border. The fniuors wen^ attached by a broad,
tough pedicle, and projected into the naso-pbaryn.v. They were o\al
in shape, pale in color, and mammillated on the surface. Microscop-
ically they con.sisted solely of lymphoid tissue, iiuapsuled by ciliated
epithelium. There were no adenoids, but large hypertrophies of the
ndddle and inferior tnrbinateds were ])resent.
1"he (M'cclile \ariety appearc] as parallel longitudinal ridges, ex-
lending along the se|)lum from before backward at the level of the
tubercle. "^Ibey, too, are br>'ad-based, pink in color, and sometimes
lobulated. .Microscoj)ically they are composed of erectile tissue, min-
gled with masses of lymphoid cells.
The treatment o\' the lymphoid (iimors was removal by cold snare
and spokeshave, aided l)y the linger in the naso-pharyn.x. 'J'he erectile
growths were excised by means of a curved, probe-jiointed tonsil-knife,
the snare being us(>d to engage what had escaped abscission.
I i.i
" m\
m
Iljrt
I'Wk
CHAPTKU XX.
FIBUOAIA.
'll'l
I:
The nifijority of cases of fibroma alTcctiiig the air-passages are
to be found in the naso-pharynx. iStill, an examination of tlie liter-
ature upon the suljjecl will prove tluit it sometimes does oecur
witliin the nasal cavities, and the reports of something like fifty cases
have been published.
Pathology. — Fibroma, wherever found, presents the same essen-
tial ])atliologieal features. Its chief constituents consist of close-
grained fibrous tissue, witli stellate cells scattered between the bundles.
The fibrous tissue is chiefly wliite, with yellow, elastic fibres inter-
lacing through it. l>ilbroth has shown that the starting-point of
development is in the nerve-sheaths and walls of the small arteries.
As the growth develo])s, the nerves shrink ; way, while the arteries
become enlarged. This will account for the (omparative insensibility
of nasal fibroma, together with its tendency t.) re[)ealed Imenijrrhages.
Sometimes myxofibroma appears from the first, and the excessive
arterial supply may. in others, lead to formation of angiofibroma.
Etiology. — 'i'iie rich supply of nerves aiul blood-vessels within
the nose may have a causative relation in the etiology of this disease,
particularly as it is in the nerve-sheaths and advcntifia of fhe arteries
that it makes its first manifestation. Traumatism is, in some case.s,
the exciting cause. It occurs more fre(]uently among males than
lemales, and it is most prevalent during the earlier years of life, —
say, between the ages of 15 and 4(i years. — though no period of life
is exempt. In Jol)son Home's case tlie patient was a woman aged
TO years, while Sikkel's ca<e was congenital, lieiiig pi'cscnt at the birth
of the child.
Symptomatology. — The chief symjitoms are gradually-increasing
stenosis of one nasal fossa, atteiuled l)y frequent luT'morrhages. and
occurring during the earlier years of life. The closure of fhe nasal
cavity increases as a result of the growth of the neoplasm. The
attacks of bleeding are sometimes very frequent as well as persistent.
The sliglitest touch U]ion the tumor may give rise to it.
Other symptoms, the result of ])ressure. are observed as fhe dis-
FIHHOMA.
l-.*!»
<'asi' iulvanccr;. Such a.- aiio^min. I'loiii coinprt^sioii nf the oll'actni'y
iK'i'vt'-filamcnts; dcafiicfs, Iroiii closiuv nt' tlu' Kiistacliiaii luhi'; or
c']ii|ili()ra, iroiii pros.siirt' ii]Mm the lacnnial duct. Facial ami [lalaial
<lct'(irniity arc also frc(|iU'iUiy ])rc>cnt from the same caii.-c.
Diagnosis. — M.xaiiiiiialion with the nasal spcciihuii should reveal
tliu front siirfacc of the tumor. Application of cocaine will shrink
the surrounding tissues, and after removal of secretions hy the cotlon-
lioidcr a g(M)d vision should he ohtaineil. 'j'he color should he a pale-
rcddi.-li ]md<, some parts hrighter in color and ready lo hnrsl with
the contain(!d hlooci. When in a slate of (piiescence and unirritatcd.
the white, fibrous tissue may, in some cases, he seen bi'nealli the
glistening surface. M'he growth is u.-nally -nuioih. Inlndated, and
irregular in forir. its limits well delined. and its attachment sessiU'.
'i'he body ol the growth is tirm and not easily moved, though touch-
ing by ih(! jirobe may not infrecpiently ])roducc luemorrliage. The
postcricn' side of the tumor can usually l)e e.xamiiu'd by aid ol' the
rhinoscopic mirror, when displacemenl ol' the normal tissue^ ma\
be obseiveil, as a result of the enlargement of the neoplasm.
The relentless growth of (Ibroma is one of its characteristics,
iind in this it resembles sarcoma, i'lic more iiiegular contoui', with
the presence of greater pain and a larger amount of surface-sloughing,
should di>tinguisli the lattc but it will reijuii'e microscopiral I'Muui-
nation to complete the dia,i:i' isiw.
Prognosis. — Without suci-essful operation the rosidt \\ dl always
be unfavorable. The steady advancement •■'' tin' gr<»u - upon all tiie
surrounding tissues, muscles, cartilages, and bunes. ano il- nearness
to the vital points, — arti-i'ies, nerve,-, and bi'aiii,— I'cndcr ,. laial re-
.^ult iiu'vitablc.
With operative treatment iriany cases have jM^rinanenlly recov-
ered; and when the tibroma lan be entirely removed the |)rognosis
is hopeful. The ojieration itself, however, is iu)t witl ut danger.
A nundier ot case< are rei-oi'ded in which dealb directlv the
result, and in most (d ihem from the ha'nioi'rhage ii-rli. iil the limi
of the operation.
Treatment. — Local treatment by \\;iy of >prays and powders is
useless in this disease. Klectndysis. howevei'. a- reportei] of one ease
by Tngals and another by the writer. lia> been u>i'i\ with advantage in
reducing the size of the growth and in facilitating nitu'c radical meas-
ures. Whether or not it can be made availalde for complete removal
rcmaiir-
to 1
)e seen.
J «;.
130
DISEASES OF TUK XASAF. PASSAOKS.
Wlieii tlic tumor ciiii lie (.'iiibraCLMl hy a Cdlil-wirc snare or tl\o
galvanocaiitery-ecrasoiir (Fiji. 37), there are no better moan- ot' oper-
ating at our di?p<jsal. Of the two, as in the cas^e of nas^al polypi,
the i^teel wire is more readily adjusted than the jtliahle )>latinuin, and
iu the use of the one or tiie other each case must be judged upon its
merits. The slow compression of the steel wire will probably do
more for the prevention of hamiorrhage thaii the more rapid adjust-
ment of the cautery-snare, allliough the latter might have a better
efl'ect in destroying the base of tlie tumor.
Owing to the broad, sessile base which so often oi( urs, Cassel-
bcrry's device, of notching the base of the fibroma at each side by
the galvanocantery-knii'e (Fig. 3(S), and then adjusting the steel
snare into the notches and round the growth, may suit some of these
cases.
Tn some cases the neoplasms have liocn so large and ditlicidt to
reach that the surgeon has resorted to direct dissection by operating
upon the nose or througii the jialate in order to reach the seat of the
disease.
Still, in all cases, nn matter how operated on, the great danger
of lia-morrhage at the lime has to be met. In CJerdy"s case and in
Seiler's both died on the table from tiiis cause.
Ill ii case the history i)f wliich I read hcfurc tlie hiryngoliijjrical M-ctiou
(if tlic AiiuTican Medical Assnoiaticm at HaltiiiKiic. in ISito. the j)atient alnu>st
bled to death in my ollice at the eoiiiniencenient of fiiK-raticin from palvano-
eanl^ry iiicisioii into llie irrowth. Tlio man. ajjcd '22, had been treated t)y a
surjienti fur a i)h'ediii;r ".Mowth in his nose five years previously. Sevetal at-
leiiil»ts were made at tliat time to remove it. but each time there was ex<f'ssive
hfeniorrha<,'e. folh)\ved l)y rapid jxrowth of the tumor. A section «as removed
for microseopieal examination and it was pronouneed sareonia. Sul)seqiiently
he went to a liospifal in one of the \Mantie v-^ities to have it removed. This
would appeal- to have been successful'y ac('om)ilisi."d. for it did not recur again
until about a year Ix'fore he eamo *.o me for treatment.
On examination I f<nind the posterior half of the right na-al fo.isa tilled
with a grayish-red growth. In front of it was a wide cavity with completi;
ai)sence of inferior turbinated bone: probably removed at the former ojxTa-
tion. 'Die attachment was widely sessile, extending over the upper part of
septum, vault above, and middle turbinated. Posteriorly it pressed the palate
downward, the septum to tlie left, and the Kustachian tube liaekward.
As it was impossible to snare it, owing to its wide attachment. I con-
cluded to try successive operations with the galvai. ^cautery. Tlie first opera-
tion was at the lower sept^il attachment, indsing upward. There was little
bleeding. Two days later the ojieration was rejicated at the outer margin.
This time the bleeding was severe, and I inserted kite-tailed tampons to control
FIBROMA.
i;n
it. One week liiti-r 1 iiifiscd the I'Ciitral iioitioii bctwci'ii tlic two fovincr cuts.
In 11 iVw Ht'coiuls, while tlii' instriiiticiit, was still in position, aiti'iiiil blood
oonniicnicil to jt't vij,'(!ioiisly from tlio nose; kite-tailed tanijioiis weic resoited
to a<;ain. witlmnt avail. Dr. I'eeve kindly eanic to my assistance and we
jilugycd the nostril from liehind with l!ello((j's cannula (Kif.?. ").">). I'lie patient
was in a eollapsed condition, and was confined to lied for seveial days, at the
♦■nd of which time 1 removed the plnj.'-s and coiiimeiiccd the use of hipolar
electrolysis. The needles were inserted a (piartcr of an inch ajiart thron;^!! tiie
anterior naris into the growth. This was repcatcil at several sittings, produc-
ing ])allor of the growth and slight shrinkage. Then the current was changeil,
one straight lU'cdlc iiciiig inserted tiirough the anterior naris into the growth
anif a curved neidle passed Ijcliind the palate and into the tumor from hehiiul.
The uniurc in each case was from tliree to five minut<'s, all the patient could
endure, although 2U-per-cent. solution of cocaine had licen apjilicd.
I then returned to the use of the galvanocautery-knife, and little hy little
destroyed the whole of the growth witinnit further accident. There were six-
teen oi.ierations ill all. covering a jjcriod of two nmntlis. One half the o]icra-
tions were through the anterior naris; the other half, though jierforined
through the anterior naris, were guiih'd hy light retlectcd from the post riiinal
mirror.
Twice over microscopical sections were made, and they proved the growth
to be a fclose-grained fibroma.
This is now four years after the operation, and there has been no return.
It is l)tit liircly that filiroiiia of the nose is quite pure in its for-
mation. I'rciiiiciitly there is a eoinhination witli iny.xoma, sarcoma,
or angioiiia, or else the so-caTied soft iil)roina of Stoker or Victor
Laiiii'e. coniixised of vasciihir |ia]iil]ary growths of the niiddK; and
inferior tin liiiiatt'(ls.
I'rohalijy uiic of thi' iiio;-! cliaracteristii^ cases of pure (ibroina
that has oeetirred was the one reported hy Cliark's Knight. It was
composed of dense iiI)rons tissne. with colh'clions of small, rotind
cells of inllammatory origin near certain points of its surface, and
it was noted hy its absence of vascularity. It was pediiiiciilated and
its removal easily accomplished hy cold-wire snare. Tiierc was no
recnrrence.
|!«t
iM'ii
m ^1
s
vr
,M.
hh
("IIArTKU XXI.
A I ) 1-; N 0^\ A _; A N (J 1 0.M A.
Ai»i:\(»M A.
Auknoma of tlic iia.-iil imssiincs is so (■.xcccdiDnly Viirc jliiii ajiy-
tli'm^iT iiini'i' tliiin iui iillurion to it will not lie iicco^iuv iicii'. 'I'iio
iiiinie indiciiti's that it is a growth of Lrlamlular cliaracte'i'; ami, as
tlio ji'lnnds within the nasal ("'avity arc few in nnnihci' and only limited
in action, it can readily lie seen that tnniors of a jilaiidular nature in
ihi> reuidii must of a nece.-sity lie infi'c((uent.
Still, thill they do occur is verified hy several instances that
have heeii rceoi'ded: and a> or.e rt'jiortcd hy (ios>elin irivcs th(> his-
tory, pathology, and treatment of the case, 1 will repeat it as de-
scribed liy him:^ —
"A man, a^^ed I.'), presented with the following history: I'^arly
in ISoT he developed iiasal stenosis, for which ho sought iclici; at
the hospital, early in the April I'ollowinir. when a numbci' of polypi
weie removed. A scecmd operation of tiie same character was done
in October. In Februai'y, ISoS. he was seen hy Gosselin, who found
the light nasal jiassage comph'tely closed by a tumor which presented
at the nostril and also projected into the })harynx. It was of iiim
( onsistency and grayish in colur, the surface being soft and pul-
laceous. Tt was attached in front and above. An operation being
decided upon, access to the cavity was obtained by external incision,
and the giowih extracted by means of forcc[is and manipulation.
The o])eration was attended by but slight hioniorriiage. ]\Iicroscop-
ical examination showed the growth to be composed of 'abundant
epitlielial cells with glandular ntl-dc-saci^,' on wliich the diagnosis
of a glandular tumor was based. The operation was successful and
the oaticnt left the ]ios])ital apjiarently cured."
AxcroMA.
AVhen we consider the exceedingly vascular nature of the nasal
mucosa, we would naturally be of the opinion that it would be prone
to the development of angiomatous tumors. Still, very few cases have
.\MilOMA.
VM
been vceordcd, proljubly not iiioru than 20 in all. Aindiiu' the most
recent is the one reported to the Larynirological Society of liondon
in March, 181)(), by St. Clair Thonl^^oll. Jl was removed I'rom the
riglit middle meatus of a man aged 29. The growth was the size of
a liazel-nut, irregidarly ovoid, and lobr'ated. It was attached by a
hluisli ])edicle to the right cartilaginous '.ptum and removed by snare.
'L'here was free; lueniorrliage, checked by the galvanocautery. Ueciir-
rence took ])lace. This was also reieovcd. .Mieroscoj)ical sections
were made, proving the tumor to ho ait angioma.
Pathologically these section,- were almn>i completely surrounded
by ncu'mal columnar epillielium. in some parts innnediately beneath
the e])ithelium thei'c was loose connective atul myxomatous tissue;
while in other parts the epitlielinm lay directly on tlu' new growth,
'i'his was compose<l almost cnlii'cly ol' hlood-vox'ls of very dilTcrcnt
sizes whose walls were formed of cells, and did not contain either elastic
or mu.-cniar tissue, '['he stroma between the vessels consi.-ted of loose
fibrous tissue, willi oval and spindle cell-, which weic of uniform char-
acter thronghonl. and arranged around the \<'ssels. among which was a
good deal of e\t I'avasated l)io()(l.
This account of the histological conditions of Thomson's case
does not dilfcr materially from the jtathology of the <lisease described
by Ijosworth years ago.
The etiologv is doubtful, it being dillicnll to assign a definite
cause, cithei' active or ])redisposing. iioswoi'th suggests that it nuiy
arise from disturbed nutrition of the vascular walls. It occurs during
all ages of life.
The symptoms are similar to those attending iiasal fibroma, ex-
ce])t that the softer character of the growth will ])revent nasal de-
formity by pressure. Angioma diifers also from lUiroma in not being
dangerous to life and in being more readily anu'nablc (o treatnu'iil.
Treatment. — About the only treatment recommended is removal
either by the steel wire or galvanocaiitery-snare. Tlu; former is con-
sidered the l)est, as by slowly tightening the wire hannorrhage may
be avoided, darvis's snare, with its nut-screw, is believed to be the
best adapted to the Irealmcut of these cases, placing the wire as high
as ])ossible upon the jiedicle.
11 HI
i m
4r'
ii!
i^'i
CIlAlTKIf \.\ll.
CVSroMA Ol' TIIK NOSK.
|f'«;
Dki.avan ro])Oi'U'il in IS!*,") iIhto cases of this soiiiowhat lari;
atl't'itinii. ^riicy \VL>rc all lasi'.s which had hecn i'or yt-'iti'^ all'i'ctcd with
nasal polypi and in which, after rcpcatcil opi'ralioiis for their rc-
iMiival. cystoma had eventually di'veloped. in one case the u'lMwth
hiinif ont of. the nasal fossa into the posl-pharyniical space, it was
rdund, and ahoiit an inch in diameter, ami was renioved hy Jarvis's
snare. In llie other two cases all elforis to remove them were iin-
axailinji until the growtiis had heeii punctured. 'Then a ];\vgv amount
of tluid drained away and, the walls collapsing, they were removed
hy snare or poIypu.s-l"orcc])s. Microscopical examination of the rem-
nants, niade in each case hy Dr. llodenpyl, jn'oved them to bo com-
posed of columnar and ciliated epithelium, glandular matter. fil»rin,
and cell ilclriliis, diagnosing each case as loose iihroma. The fact
that eacli of them contained ciliated epithelium would prove their
origin from the middle or lower tui'l)inalcds.
The cases of Johnson, Watson, and J^'U'ei'ts. as reported hy I'ms-
worth, were also of iniddle-turhinal origin (Fig. 01).
Urown Kelly {Joiinuil of Jjari/nj/oltuju, lijiinolotjii, ainl Oliihujij,
June, ISihs) gives a report of an entirely different series of cas^s of
cystoma of the nose. The situation of developnu'iit is the lloor of
tho fossa; and as no full account has heretofore been ])ublished,
together with the history of his cases, ho gives a sketch of tlie diseasi-.
Jt always occurs in females. .\t any rate, the twelve cases, up to
the ]ireient lime !'ep(>rte(l. have all appeared in wnnien. the ages
being l)elween nineteiii and lifty-eight years. The site of formation,
likewise, is always the same, ht'ing the outer lloor of the nostril,
anterior to the inferior turbinated body, and just behind the union
of the skin w ith the nasal mucous meml)rane. The appearaiu^'s within
the nose vary only in dogre(>. When the cyst is small, it forms a gray-
ish hemispherical eminence, about the middle or outer half of the
floor. As the sac enlarges, it extends t)ackward, aiul also downward
into the incisor fossa, hut verv rarelv toward the septum.
(134)
CYSTOMA OF TJIK NOSE.
135
would '
mm tho^i^ringivo-lal.iiil fold
two of the cases report od
- -'- '".■«"■ ' M;::;r:r;::,',,.;;;':;;2
^£:L«';K-*:™-:s.i:;~i:;"r,K;;i
i! U
'
#
f
k'-
mu
<
Im
•«■■»
¥
CHAPTER XX 111.
ClION IJRO.M A ; OSTEOMA.
Mi
in :
C'lIONDUOMA.
Most of tlio cases ot ciirtilaginoiis onlargcincnt within the nose
that C'onu; imdiT observation are merely hypertrophies of tiie cartilag-
inniis septum, and cannot be placed under this head. The term
"('hoiidroma"' is confined to those cases of round nodulated tumor
occasiojially met witli wJiicli niacroscopically resemble fibroma, but
which on closer examination are found to consist of cartilage. They
are usually found at the anterior, inferior angle of the cartilaginous
septum.
The etiology of these growths is still unknown. The period of
their dcvelojinient is during the adolescent years of life. The symj)-
toms are sim.ilar to those produced l)y benign neoplasms. They differ,
however, from fibroma and angioma hy being unattended by ha;mor-
rhage and by their yellowish color. To touch they are liard and
cartilaginous, hut the pressure of a needle will distinguish them from
the still greater hardness of osteoma. In structure they are com-
posed of hyaline cartilage, combined with white librous and yellow
elastic tissue.
Simple surgical treatment is required, the object being removal
of the growth. U'hethcr this is done by snare, scissors, curette, gouge,
or knife is immaterial, so long as the tumor is completely excised.
There appears after successful operation to be no tendency to return.
Osteoma.
Osteoma requires to be distinguished from exostosis, as the latter
term ajjplies to bony outgrowths of the septum, at the sutural junct-
ure of the vomer with the perpendicular plate of the ethmoid, or
the palate, or maxillary bones, wliile the former is restricted to osseous
neoplasms, having their origin independent of sutura^ union. They
are usually located in the upper portion of the nose, having their
origin in the bones of one or other of the accessory sinuses.
(13fi)
(
I
OSTEOMA.
i;57
Pathology. — In soiin' t'ascs tlio osteoma is D.adc up oiilirely of
liani, c'uiiipat't tissue. In otlitrs tiie body of tlio hone is cancellous
ami covered with a close and compact layer. In Adenot's case the
tumor was an osteogenic exostosis, with a ehondromatous envelojje.
In Coakley's it was exceedingly hard. s[iringing from the inferior
turhiiiated, and of tertiary syphilitic formation.
Etiology. — The etiology is unknown. rossil)ly it may arise from
some constitutional dyscrasia. The period of it;', greatest freciuency
is eaily life. The niaj(nity of cases are said to occur in males.
Symptomatology.— Mxterna I defoiinity is one of the earliest
synipt(iM)s. This is owing to the situatiim nf the growth, hcing in the
upper part of the nose. ll(>nce, stenosis, one of the earliest symptoms
produced hy the majority of benign nasal neoplasms, may be late in
appearing. Pain is likely to occur, owing to jjressure upon the nerve-
iiliiments. In Adenot's case, epileptic seizures, produeeil by rcllex
aelion of tumor, wcr(> relieved, after veitieal osteotomy had been per-
formed, l'!pistaxis ami nasal di.-charge are neither of them likely
to be troublesonu'. The jioinl (d' origin is fret|uently in the neigh-
borhood of the ethmoid (H'lls, and may be fr(Mu little islands of car-
tilage or l)one in the mucous membrane.
Osteonuita are usually irregularly lobulated an<1 covered with
mucous membrane. When the growth has s|)aee enough to develop
itself v.ithout infringing upon surroniuling bony structures, it will
remain free and rounded. It is when its development becomes im-
peded by osseous resistance that it becomes lobulated or tlattened.
If from any cause its attachment 1)ecoines fractured, it may remain
within the nasal cavity as a foreign body.
Treatment. — Osteomala difl'er from other nasal neoplasms in the
fact that they usually rc(piire external operations to accomplish their
removal. This is owing to the density and size of the growth and
the dillicnlty in reaching the site of attachnu>nt. The surgical oper-
ation required to reach the growth is sometimes more dillicult than
the excision itself. This must be conducted upon ordinary surgical
]irinciples. When the tumor is reached, the chisel, saw, or forceps,
may readily separate the neck from its attachment, Ifa'morrhage,
which is sometimes severe, requires to be guarded against.
li!
I
ll
( IIAI''1'K1{ X.\l\.
SAUCOMA.
FoiM TNA'iKi.Y this iiiiilijii:.'nt cUsfii.-o nirt'lv occiir-s williiii thf
iiiisnl I'ossn. Altli(Uifj;li tlie iiinjorily of enscs occur in niatiiro lil'o, the
aviTii^e iij;e of piiticiils iilllictod with it is less tluui in carcinoma,
while tho yoiiii^'cr the patient, the greater tlie nuiliffniincy and the
quicker the fatal result. The usual site is the septum, but it may
arise from the turi)iiiate(lp or any other portion of the nasal cavity.
Pathology. — Tlie pathological hi.3tory of sarcoma of the nose does
not diil'er from that of otlier regions of tho body. It originates from
tile meshes of connective tissue and is fdled with round, ovoid, and
fusiform cells, the round often prevailing. Myeloid and large granu-
lar cells are often jirescnt in large numbers. When the granular
structures of the mucous membrane have undergone proliferation in
connection with the development of round- or spindle- celled elements,
adenosarcoma may result. In other instances, proliferation of the
stellate mucous cells, together with the sarcomatous elements, would
indicate myxosarcoma; while in cases where the ordinary blood-
vessels are lost, and vascular spaces are foiind instead, in connection
with the sarcomatous develojmient, angiosarcoma is the result.
Etiology. — The history of the forty-one cases collected by Bos-
worth, and another dozen that have been recorded since then, throw
little light upon the subject. Some were preceded by nasal polypi,
which might bear a causative relation to the development of the
malignant disease; but a very large number arose de novo, and with-
out assignable cause. Some writers believe that surgical traumatism,
in the way of galvanocautery and forceps operations, is, in some in-
stances, a cause. As an objection to this idea, it may be argued that
a large number of the severest cases of sarcoma occur in the earlier
years of life, when prior nasal operations have not been thought of.
Personally I have never seen a case of malignant disease of any kind
which could in any way be traced back to operative treatment.
Symptomatology. — The first and most prominent symptom is ob-
(138)
I •
1 1
SARCOMA.
1311
striu'tioii to M;i.-.il liroathinj:. This is soon I'ollowod or aicnmjiiiniod
l)_v ii I'd'tid mucous ilis(liar<,^'. Tlir color is often ^Tocnisli anil luciiior-
rlia|,'e I'roqiicntly occurs. This ()(h)r arises in part from (h'coiiiposcd
rctainod secretions, i'ain, ahhongh not necessarily severe, is of fri'-
iiueiit occurrence and is due to pressnrc. When h)eated in the an-
terior region of the nose, there may ho great deformity. \Vh( n in
tile posterior, deafness and dysphagia may result. W Inn in the upper
and middle tiirliinal region, destruction of ihe crihrifcu'ni plate id'
the t'thnioid and extension id' the disease to the luaiii may had to a
fatal issue.
Sarcomata Idecd ea.-ily when touched with a prohe. 'I'licv have
no ic~iliency, and li.-ivc ;i reddish color, freijucntly a"UminL:' a hluish
or violet tinge. Thev occur sinulv and may ho either iieduuculated
or have a liroad or sessile hasc.
Diagnosis. —The malignancy of the growth can scarcely I'scapi
recognition after careful rhinoscopie e.xannnation. The soft ])ulla-
ceons tissues, with reddish-gray surfaces, foul odor, and olTensive di.--
oliargc will, in many instances, at once ,-tamp the nature of tlu' dis-
ease. l)ut, wiien occurring in mature years, nothing hut microscop-
ical examination will ])ositively distinguish it from carcinoma.
Prognosis. — It is a hopeless disease save for the relief that may
he ohtained from operative treatment. Wlien taken early and thor-
oughly removed liy operati'Ui, there is a fair prospect of recovi ly.
One-half the cases reported up to the present time are said to have
been cured. ^IMiis statement must he accepted with much reservation,
as many of the reports were ohtained hut a short time after operation
and l)efore there could well he a recurrence of the disease.
Treatment. — Complete extirpation when the disease is not too
far advanced for operation is the only correct method of treatment.
"Without there is good prospect of this l)eing accomplished, it should
not he attempted at all. With regard to the nature of the operation.
each case must he a rule for itself.
When the removal can he made through the anterior nares, with-
out facial operation, it is much the better ])lan to follow, taking the
neoplasm away by smire, curette, spoon, cautery, etc., or all cond)ined.
as tlie case may require, always guarding against the possil)ility of
excessive Invmorrluige. This method can only be available in the
very earliest stages of the disease, the parts being antcsthetized by a
strong solution of cocaine.
In other instances, however, primary surgical operations tlirough
1 'ii
JV i
I',; "
140
DISEASES OF JlIE NASAL PASSAGES.
tlic nose or soft palate will be reqiiiietl before the base of the growth
can be reachod. Having eradicated the tumor, the parts are replaced
by regular surgical methods and the internal wound treated as tlio
conditions of the parts may rcipiire.
liil
ClIAPTKK XXV.
CARCINOMA.
IvAKE as is sarcoma wilhiii the iiasal cavity, .^till more rare is tlie
more malignant disease eareinoma. Tlie average age of persons
afllicted witli it is also somewliat greater, althoiigli, as in sarcoma, tlie
period oi' cliildliood is not entirely exempt. The thirty cases carefully
collected liy J5os\vortli were all of primary origin, and the same may
1)0 said of the cases of llindc. 'Mas Tliorner, llaton, Dreyfuss, Fliitan,
Domoe, Sync, lloj)kins. and Lennox Urowne which have occurred
.siiu'c tlic issue of iJosworth's woi'k. That is to say, in each of these
cases the epithelioma made its appearance lirst within the nasal cavity.
In all these cases tlie oidy elaboration of the carcinoma was by
extension, and not hy formation of new foci in distant regions. As
secondary carcinoma of tlic n«ise, I have so far not been able to find
a case on record, although extension to the nose from tlie neighboring
organs might possibly occur.
Fc*;hology. — As in sarcoma, the path(ih)gy of carcinoma is the
same wherever found. When near the cutaneous surface, the cancer
Tiiay be ;; squamous epithelioma (\'erncuil). Dee]ier within the cavity
the a(hiio-('pilhelial type may he devchipcd. as in the i-ase recently
reported by Ma.x Thorncr. 'J'liroughout the growth an enormous
mass of tubuli or alveoli will be found surroundt'd by connective and
epithelial tissue and filled with colloid substance.
Etiology. — Hereditary inlluence is probaldy the most potent
jiriinary cause in the develojimcnt of cancer, (jiraniing this, we know
that physical injury is frequently the exciting cause for its develop-
ment in other jiarls of the body. Possibly the reason of its extreme
rarity in the nose is the infrecjuency of s>vcre traumatism in that
region. It is a disease which rarely occurs until after middle life.
The possibility, h wever, (d" the development of malignant disease
from eiiner myxoma or iibroma of the nose is now an acknowledged
fact.
Symptomatology. — The .^ymjitoms are almost identical with
those produced by sarcoma of the nasal passages. Tiie submaxillary
glands are more likely to be involved, the cachexia t© be more
(111)
immmmmtm
U2
niSKASKS OF THE NASAL I'ASSACSKS.
!■
M
marked, nnd the progress of the disease more rapid, wliile the average
ago of the ]iationt is greater. But the stenosis, the oltcnsivo and foul
discharges, tlio deforniity, and the internal appearance of tlie growth
arc very mneh alike in hoth diseases.
Diagnosis. — Tlic diagnosis must depend materially on microscop-
ical examination, the resemblance to sarcoma being so great that the
distinctive cancer-cells would need to be discovered to insure a posi-
tive opinion. From tuberculosis and syphilis the clinical history
should be suificiently jiositive to make the diagnosis certain, par-
ticularly with microscopical aid.
Prognosis. — The prognosis is the worst that can l)e ex])ected,
except in exceedingly rare cases where the disease has been recognized
and promptly removed upoii its earliest manifestations. Even in
these cases sj)eedy recurrence is more than a possibility.
Treatment. — The majority of cases do not come under observa-
tion until after the disease has become thoroughly seated and the
deep-lying tissues involved. In such cases operation would be useless,
and would only induce more rapid development. All that could be
done reasonably would be in the way of soothing antiseptic applica-
tions, such as cocaine, aristol, iodoform, iodol, etc., together with
systemic support.
In early cases, when there is freedom from glandular enlarge-
ment and a fair prospect of complete cradlcaiion, it would be the duty
of the surgeon to extir{)ate at once, and by the most available means,
as already described in dealing with sarcoma, the main features of
the operation being to avoid undue injury to surrounding parts, bear-
ing in mind the possible evils of traumatism upon already-weakened
tissues. A large number of these cases occur in the ethmoid region,
and one can see how hopeless radical o])eral:ion wotdd be even in
the most initiatory stages. In very few instances has operation been
successful even in giving temporary relief, while in not a few it has
hastened the final issue.
CHAl'TEll XX Vi.
TUBERCULOSIS.
As AN indioatiou of the rarity witli which tuhorculosi.s attacks
tlic nasal passaizes, Willigk, out of 42G autopsies upon tlie bodies of
persons who had died of tuhoreuh)sis, found only 1 case in which the
disease had alfccted the iu)sc: and Weichsel!)aum, out of 1«!1 similar
autopsies, found only '2. On the other hand, rare as iho disease is in
this region, J^eidel reported 2 cases in which primary tuberculosis of
the septum existi'd lor years, without tlie liinus being in any way
alfected by the disease; and William J I ill in ]8!)(i reported 1 of
tuberculosis of the inferior Uirbinated in whicli disease of the lung
was so slight fhat he mistook the nasal disease to be nuilignant, and
performed turbiiu'ctomy. The patient did well, although subse(]ueMt
microscopical examination proved it to ijc a case of tuberculosis.
Symonds, Watson, Williams, and riaeh have all reported cases of
primary septal origin.
Pathology. — The exhaustive investigations of recent patholo-
gists, particularly of such men as St. Clair Thomson and Hewlett,
have thrown new light upon the subject of nasal pathology. These
gentlemen jiroved that about 500 litres of air, containing, on the
average, inoo bacteria, are inspired every hour by each person. Thir-
teen healthy individuals were examined. As the vestibule of the nose
contains vibrissio and is line(l by membiane, partly integumentary
and partly mucous, they made one series of cultures and cover-glass
preparations from the vestibule and another series taken from the
mucous nuunbrane deeper within the fossa. The result was that, while
in the first series they fouiul a large uund)er of micro-organisms, in
the second they found very fow, 80 per cent, of them Ijcing sterile,
having no micro-oi'ganisms at all. The natural conclusion is that
the comparative immunity of the nose from such diseases as tuber-
culosis, cancer, sarcoma, syphilis, etc., is due in some measure to the
bactericidal properties possessed liy the jihagocytes of the nasal
mucosa.
There arc two forms in which tuberculosis of the mucous mem-
brane of the nose may ]iresent themselves. In the one ulceration
(14.3)
■MvM
L' IF
I'i ^i
]<m
H[r;
\ !•!
'■ !" ' ^
;tii-
^1
i i
III
lj
■ V
"I 1
14-i
DISEASES OF THE NASAL PASSAOKS.
i1
may take ])laco, either on tlie septum or on the floor of the inferior
meatus. In tiie otlier, hyperplasia, witli a sessile hase, may appear
upon the septum, the inferior turbinated, or the outer wall. Ulcer-
ation fdllows, surrounded by pale granulations. There is usually
more or less round-celled infiltration, together with nucleated epi-
thelial cells. Tubercle bacilli are frequently few in number.
Etiology. — Tlie disease usually occurs as a secondary deposit,
following j)ulnionary tuberculosis. In some cases the method of at-
tack is said to be by autoinfection, from contact of the sputum during
coughing with an excoriated septum. In others it occurs through
tlie lym])hatics. One case is reported by Chiari to have been caused
])V infection from the antrum of Ilighmore. In some cases the germs
must have come from without, dust, laden with bacilli, being de-
j)osited upon abraded mucous membrane near the anterior nares.
Symptomatology. — When hyperplasia has taken place, it is of a
grayish-red color, soft and protruding, bleeding easily, and of irregu-
lar outline. It is often covered with mucus or crusts, with a tend-
ency to ulceration. When ulceration takes place, crust-formation is
likely to be tr..ublesome. Stenosis is (?ften present, but there is no
pain. The usual discharge is that of grayish mucus, the amount
depending on the severity of the ulceration.
Diagnosis. — Tuberculous ulcers wherever found always present
similar appearances. The color is usually whitish gray. There is
little loss of tissue, the centre being only slightly depressed. The
border is irregular in outline. There is never any areola round the
ulcer, and the bluish-red tinge gradually blends imperceptibly with
the surrounding mucosa. The irregular crusting and bleeding of the
nose are produced by the drying and irritating effects of respiration.
Tlie neoplastic form of tubercular disease, usually found in the in-
ferior turljinated, presents an appearance of little, grayish-red warts,
and must be distinguished from papilloma by being smaller, flatter,
and softer. ^Microscopical examination will usually discover tubercle
bacilli, though in small numbers.
Prognosis. — In a large majority of cases this is purely a second-
ary matter, depending upon the progress of the primary pulmonary
lesion. It is usually slow of development, and may continue for years
without serious results, the comparative fatality of pulmonary, laryn-
geal, and ])haryngeal tuberculosis not applying to the protected cham-
bers of the nose. The local lesion can frequently be readily removed,
but is apt to return.
TUBERCULOSIS.
145
aiipporting measures arc also raiuiml 'l'l,„ „! , ,,,
^=..pplyas)arKcnnamo,„,t„f„,Uri„ent „ ,' , ,'°"'"' '" '°
forees .-„„UI l.nve power a^t^^.^ '1™ "^
iron, and sh,el,„:„e'are .1, us ,■ ," i Zvf:!^ 'TT'i
creasote is the bc«t fm- ifc e,- f • ! ^ "-'"''''■ ' °^ '»'•' carbonate of
tains 90 per o of c4 sot '"l' T' "'^'^^-■1-*- ^^-ts. It eon-
irritant, an b ta 1 Iv tal 1 "t> ' "f ''"'""^^ '''"'"'''''' '^'^ --
The dose is 1 toT "'n! ^ ■^'" J"""' ^'''"-^ ^'1' ''""^ ^'^ «'^«"^'J^^'^-
takenread y n Jaror :" r ""./'''•^^V''"" ^ ^^•^^- ^^ -" '-
of the lattei codbver-o,l, „, doses of 10 or 15 grammes
i.'i
i
m
CJlAFTKll XXVII.
LUPUS; GLANDERS.
n
Lui'us.
Sometimes, tliougli rarely, lupus raay occur primarily within
the iia.«al l'os?a; but u.sually the cxtornal nose or the palate is affectccl
first, and the disease extends backward or forward into the nasal
cavity.
Pathology. — Tbe essential pathological change in this disease is
the deposit of round cells of granulation-tissue in the meshes of the
mucous membrane. This deposit, or infiltration, is gathered in little
nuisses or nodules, and seems to follow, in a measure, the course of
the blood-vessels. In addilion to the characteristic round corpuscles
of lupus giant corpuscles also occur. As tbe nodules rise above the
surface they ulcerate; but the nodular reproduction beneath is more
rapid than the siirface-desiiuamalinn; consequently, unless the dis-
ease is cheeked by medical or surgical treatment, the proliferation
of the neoplasm is in excess, and the nasal passages become blocked
by the development of the disease. Schiiller has found irregular
chains nf micrococci among the granular cells and extending into
the surrounding connective tissue. Neisse was the first to demon-
strate the presence of tubercle bacilli; and. as more recent investi-
gations have frequently discovered their presence, the theory that
lupus is a species of tuberculosis has been established.
Etiology. — There is no doubt that tlie disease arises from the
deposit of a specific virus which produces changes of an inflammatory
and ulcerative character in the mcmljrane affected, and that a stru-
mous diathesis is a prominent factor in preparing the soil for the
germ. The majority of cases occur in the early years of maturity,
but quite a nundjcr even in youth. One is reported at the age of
six months, while Eeed. Shurly, and Tresilian record cases at the
fourteenth year. !Most nasal cases attack the cutaneous surface first,
and the mucous membrane afterward.
Symptomatology. — A certain amount of nasal stenosis is always
present. After idceration brownish or greenish-brown crusts form,
accompanied by sanious discharges from beneath their edges. On
(14(1)
LUPUS.
117
lifting tlio crusts, Ijlood will oxiule from the central parts nf IJio
nodules. Odor is not marked, but. when it does not occur from reten-
tion of the scabs, it is of a musty ciiaracter. Pain is not a ])romi-
nent symptom, nor is the physical system materially atfected.
Diagnosis. — The peculiar reildish, nodulatid appearance of the
external m)se, with the greenish-brown crusts and eharacteristic dis-
charge, should remove all ditliciilty in diagnosis wlu'ii the external
organ is aU'ecled. Any intranasal lesion will only be an extension
of the external disease, the cartilages usually succumbing to its on-
ward march. When, lK)wever, the mucosa is the only part aU'ected,
considerable dilliculty may attend the diagnosis, and the truth may
only be readied by a process of exclusion. One point should be
remembered, however, aul that is the peculiar softness of the lupoid
growth. It can be easily removed by the si)oon and indented or
])enet rated bv the probe.
From syphilis it can be distinguished by constitutional treat-
ment, and from tuberculosis and malignant disease by the history of
the case and the general coiulition of the system.
Prognosis. — in all cases it is a slowly progressive disease, and in
a large measure amenable to treatment when taken early. Very
few cases confined entirely to the mucous mendirane have been
reported as incurable, and they often heal without leaving a scar.
This is not so when the cuticle is the s( at of the disease, as in these
cases cicatrices always are left after the healing process is over.
When the lesions arc extensive, the ])rognosis is not so favorable, the
development being indicated liy the growth of new nodules, in con-
tinuous succession into the surrounding tissue.
Treatment. — Among local applications lactic acid is received
with favor. The parts should be first cocainized, and then freely
rul)bed with a 50-per-cent. solution. This can be gradually increased
to 75 or 100 ]ier cent. Care should lie taken to apply it to every
])art thoroughly, the applications l)eing repeated every second or
third day. In some cases this is said to destroy the growth.
Lake has had good results from the administration of thyroid
extract in doses of a little over 1 gramme per diem, the disease
almost disappearing under its use.
For years, too, tuberculin has been used with more or loss favor
by a number of European writers.
Of directly surgical treatment, evulsion by Volkmann's spoon
or a sharp curette has many advocates — dusting the surfaces after-
■■' i
MiflL
:;i:
1
u
.: ■
M
ji
i
n
1
1^
f ;
i r
:|
118
UISEASKS or TIIIC NASA I, I'ASSACiKS.
ward will) iodoform or brushing tiioiii with lactic acid. Burning the
nodules down with the giilvano-eautery is advocated by liresgen.
Tresilian successfully treated a case recently by scraping with a sharp
spoon, subsequently burning it with galvanocautery, and tlien brush-
ing with 50-per-cent. solution of lactic acid. Dundas Grant also, in
one of his latest cases, was eiiually successful by a similar line of
treatment.
Glandeks.
This is a communicable disease, peculiar to higher animals, par-
ticularly horses, and liable to spread to man upon exposure to infec-
tion. It is also contagious among men. In its acute form it is very
virulent and uniformly fatal. When chronic tliere is a little more
hope of rccoveiy. The usual site oi' attack is the mucous membrane
of the nose, from which it may spread to both pliarynx and larynx.
The incubation-jieriod is fioni three to six days.
Pathologically there is a low-grade inflammation, resulting in
formation of granulation-tissue containing large numbers of bacilli.
The characteristic germ of glanders is the bacillus Mallei. IJapidly-
spreading suppuration and ulceration follow along the line of the
lymphatics. Glands become swollen. Pya?mia, necrosis of bone and
cartilage, deep abscesses among the tissues, all follow. The discharges
arc also profu.se and oil'cnsive. The chronic form dilTers only from
the acute in being somewhat milder. (Kyle.)
Constitutionally there is marked fever and prostration. The dis-
ease may last from fifteen to twenty days, death taking place by coma
and collapse, '^rrcatment, although practically useless in the majority
of cases, consists of supporting measures, together with antiseptic nose
and throat douches and sprays. (Lennox Browne.)
CHAl'TKJt XXVIll.
RIIINOSCLKROMA.
This (lii^cal=o occurs but rarely. It i.s characterized !iy the (U'-
posit in all the layers of the i^kln or nuicnu> membraue of dense, hard
nodes, or ])lates. The first deposits are usually in the neiyhhorhood
of the nostrils, gradually extending into the fossa). The ])rogress,
from all records of the disease, a[)])cars to bo steady, irresistible, and
almost, if not entirely, uninlhienced by treatment.
Jt is believed to owe its ori,<jiii {<) the rhinoscleroma bacillus which
has been extracted and cultivated by I'awlowsky and Freudenthal.
The latter gives a coniplete history of a ease treated by him in
189G. It occurred in a (ialician Jew aged 45. The nose was of
immense size. The right side ])resented a lunior as larg(! as a hen's
egg. It was dark-bluish red. with a few vessels coursing over it and
of ivory hardness. There was a separate nodule in the U])per li|).
The right inferior turbinated was involved in its whole extent,
completely occluding the i)assage. The pharynx was a nuiss of scar-
tissue, the uvula destroyed, and the naso-j)harynx and the glottis
almost entirely shut olf, so that a tracheotomy-tube had to be inserted
to permit of respiration.
There is little, if any, pain in this disease, except when the
extension of the growth is very great. Then the ])hysical obstruction
to mouth and nose may produce great distress. There is no tendency
at any time to ulceration or softening of the tissues.
In Pean's case the nose was surrounded by dense lardaceous
neoplasm. The upper lip had degenerated and the rhinoscleroma
had extended through the maxillary and ethmoid sinuses.
The pathological condition is believed to be one of infiltration
into the afTected tissue of masses of small, round cells. These cells
are gradually transformed into spindle cells, and then into dense
fibrous connective tissue. Corneil found a small, rod-like bacillus
inclosed in a hyaline capsule, the same that is spoken of by Freuden-
thal and Pawlowsky.
Treatment. — It is usually regarded as entirely incurable. Oper-
(Mil)
IP
:i;i
150
DISKASKS Ol' TlllO NAh.VI. J'ASSAUKS.
It
4
■n
ativc trcaliiii'iil lias so little circct that it is considered useless, except
when reiiuired to restore the possihility of rcsi)irati<m. Internal medi-
cation is also useless. Xotwithstanding this, Dontrelcpont reports a
cure from the application dI' a J-pcr-ient.-corrosive-suhliniate oint-
ment twice a day J'or three and one-hall' ninnths. As Hoswoith
remarks: '^May this not have ln'cn a syphilitic <ase cured hy mer-
curial inunction?''
I'awlowsky treated two cases hy hypodci'niic injections of rhino-
sclerin, or the ihcinical I'stract of ciillnrc- of rhinoseleronia. The
injection of the extract in a jiaticiil IS years old produced feverish
reaction and swcllin<;' of llie alVected nose. A month later, after
1") injections, the phK/iirs were softened and tluic were si^^nis (jf acute
intlammation. lie treated this case for a year, aiul duriuff that time
th.e disease had not advanced. In a second case treated t!ie same
way, although it was not cured, there v/as during six months no
increased development, llcnce the author helieves, from the history
of these two cases, that he has focd in rhinoselerin a diagnostic
and therapeutic agent for this disea.-i .
Tean tried surgical treatment in the case of a woman aged 20.
ViV extensive operation he removed the nose and all the upper lip
and the turhinatcd hodies, resecting the ascending part of the maxil-
lary hone and curetting the antrum, lie approxinuited the cutaneous
flaps. All that was left was a large hole in the middle of the face.
Subsequently cauterization of suspicious parts was jjcrformed with
Cancpioin's paste. How long the ])atient lived we arc not informed.
('ii.\i''n;i; xxix.
SVI'IIII.I>.
'I'liK iiidiciitiiitis ul' sy|iliili.- in the nasal [nv-sa^fs arc identical
with llicir local nianil'cslatidn.- in the Ktlicr or;^aii» nf the ImkIv, ami
iK'cd not lie cntcicd into uiinnicly licrc. '["he primary lesion, or
hard clianci'c, i^ one of the rarest ol' intraiia>al lcsion>. Siill. eases
are rccoidcd of it> occuri'ence. Its hi.-tory and apiH^arancc. aided hy
til. process oj' excliisii)n, shnnld render its reco^iiiitioii ca>y.
The nuicous patch, allhnn^^li rare, is one oi the most lrc(|nenl
iiiaiiiJ'ostatioiis ol' early syphilis in ilii> reL;ion. 'I'ho tendency of the
disoiisc to tievehtp at the nuico-cutaneon- horder-lines of the lip and
iiii.^tril exists here, as at the anus and vuUa, although in the former
rc<;ioii the cases arc very infieijucnt. hivasse and Devillc, in re-
porting' iSd females siilVerini;' froni mucous patch, onlv found S in
which the patch all'ecled the nose.
'J'he superfiiial (deer i,- iielieved liy many to occur (Uily in the
secondary sta,i;e, \\\<< or thicc years after ilu' primary sore, and to
he caused hy the softening- ami l)reakin;^' down of a inm-ous patch.
IJosworth l)elieves that it helon^s to a later dale of the di-^ease, and
is the re.-nli of softening and erosion of su|)erficial jiiimmatou.* de-
posit; particulai'ly as the latl' r j^ivi's so little indication of its \)vv>'
eiice that it may he ovi'i'looki'd until the attention is drawn to the
more notahle features of the i'ully-developed idcci'. The site of >uper-
licial ulcer is usually the septum or the llooi' of the nose: hut this
is not invariahly the case. At the ju'cscnt time I have a patient, a
niarrie(l man, who has superlicial uIcim' of the left miildle tui'hinated
and also of the po>t-pharyn,L;'eal wall'.
liony necrosis is a residt of e\ten>ion of deep ulceration, throiijih
gummy dejiosit, and hence is of a ti'rtiary nature. Amonii Kuropean
races it occurs ten or lifteeii years after tlu' primary disease. Amon<,f
some of the earlier races, particularly the Chinese. Aral)s. and Mexi-
cans, the disease is more virulent ami runs a more rapid course.
Most of these hony lesions occur u])(Ui the septum, the tnrbinateds
comin<; ne.xt; that is. when the muio-cutaneoiis surfaces are not
invaded first.
1" ( 1 :. 1 )
168
i)isi;.\si;s oi' Tin: nasai- i'AssA(ii:H.
Pathology. — Syphilitic lesions, ulicrcvci' foiiml, nic nil nl' nii iii-
flinniniitory (•luii'iictcr, and the iiasnl piissii^jt's nro im cxci'ptinii to ilio
rule. In primary lesion of tiic nnsal imieoiis nieniliranc tlie t'el)rilo
action rnns liijih, and tho nicer may present n lariro (granular mass,
filling np the nostril and eaiisinj;; deformity, while the sli;;litest press-
nic may |ir()diic(! hloedinj,'. Tho mucous ])atch and the siiperlieial
ulcer will (lill'er little from their appearance in other reuMons. 'There
need lie no j;reat thickeiiiiiix without the ulceration arises from an
Pidarired ;;umma, the chief stenosis hein^' caused by the ahnndance of
miico-pus constantly secreted.
When the <:ummy tumor forms, it iiulieatcs an active condition
of the tertiary slaij,i'. Tliei'c may he lar;;'e deposit of ;:,ununatous
nuiterial with infiltration or tumefa(;tion of the mendiraiu". Xo part
of the nasal cavity may escape tlie deposit. 'J'he ulcerative ])rocess
early invades the gumma, and bone as well as cartilage nuiy soon ho
involvi'd.
Sometimes surface-ulceration ends in resolulinn and culminates
in cicatrization; hut in the majority of eases the underlying peri-
chondrium or periosteum ])nrtakes in the ulcei'ation. and necrosis of
lione or cartilairc f(dlows.
Symptomatology. — When the disease is jirimary — that is, the re-
sult of direct contagion — the ordinary syiujitoms of chancre may he
expected, oidy in an aggravated degree. There will he intlammatory
swelling, pain, diilieult nasal breathing, discharge, and considerable
fever.
In tho secondary stages, a.s variously manifested, there will bo
coiyza from mild to purulent. The mucous membrane will b(^ luifTy,
red. and congested, (ireenish-yollow pus will exude from the nos-
trils, and. after thorough cleansing, ashy-gray patches nuiy sometimes
be seen.
In tl;e tertiary type ulceration is deep and formidable, heing snr-
roiimled by ragged oi\^j:v< and an angry-hiokinu: areola. The cartilages
and bones being involved, foul, offensive ]nis, with shreds of necrosed
cartilaginous and os-((iu> tissue, come away, until eventually both
oaitilage and bdiie may lie destroyed, leaving unsightly facial de-
formity. In the sevei'est cases the triangular cartilage, ]U'ri)endieular
plate of the ethmoid, vonu'r. and even the turl'inateds are all in-
volved in the ruin, nothing bnt Chinese '■nose-holes'" being left —
more apertures in front of an irregularly-flattened face.
In one case that came under my observation the whole of the
sv I'll I LIS. |."i;!
iiitonial ii;i-iil stnictnroa had l)oc(niio ilctiiclu'd from tlii-ir HtirroiiiKl-
iii;:s, and rormrd iiiln a Ihiltc, I'li'tiil, iuovmIiIc iiias.-;. 'I'liis oiciinril
it! ii iiiiirricd woiiiiiii ii^^t'd iiliniit .'!(» vtiii-;. 'I'lic cutidil imi, I \\a>
iiironiH'd, Iiad cxisliMl lor a miiiilit'r nf years ami slic was iml rcfcrrnl
for spt'ciiil ti'calmtiil until a small |i('ii'nratiiui thiiiii^li the haul
palato liad rormcd, allnwiiiu' the iu'tiil secretions to tiiekle tliroui;li
into the mouth. The Ireatmeiit ennsisled of lueakiii^' up the mass.
CN tract in.!.,' the I'raLiineuts throuj:h the anterinr narcs. and wasliin;;' out
the ca\iiy. Internally the syru]i of the indidr of iron was adminis-
tered.
Diagnosis.- When all other diseases have hcen put aside by a
procc.s.s of exclusion, a n^sort to conslitiit ional treatment my help In
remove nil I'eiuiiinin,!:' doidd as to the true nature of the disease.
Prognosis.-— 'I'll is (h^pends lar;;-ely upon the i'.\tent and severity
of ihe loioiis. If the ,i:enei'al health ha.- imi materially .-ull'ereih ami
tile lesions aic of a superlicial character, treatment slmuld he fol-
lowed liy the hes; results. I'lven when houe and cartihijie have he-
roine inv(dved, when this destruction i.s nn'rely local it may l)e
possihle to arrest it in its pioyress. And, even in the wor>t case-^,
.■-ome little <itnn] may he expected from judieioiis ami careful treat-
ment.
Treatment. — This is one of the few Tiasal alTcctions in which
systemic medication is ahsohilely essential to eU'ect coniplete rescdii-
tion. Specific treatment, aided hy soothiiiL;' and cIcausiiiL:' lavaire of
the nasal fossa', will in many cases ell'ecl a cure. 'I'lic main thiii^
is to commence the internal treatiiicnt at once. Tluii the local treat-
iiiciit, to he uuideil liv Ihe reipiireuients of the case, after wasliiii;^
out the nasal cavity with a solution of Koric acid, hy means of an
atomizer:- -
1. 11 .\ci(l. I.mic !«
A(|ua 'Mil
Arislol oi' ioilo] miuht he thi'own into the fossa> hy insuniators,
or the parts miuht he touched with tincture of iodine. Nitrate of
silv(M' fused on the end of an aluminum ajiplicator will fr'Mpieiitly
control ulcerative acti<m. rtalvanocauterization is I'arcly ne<'essary
1. R Aokl. borip pr. x.
Aqua 5j.
M.
m
• ii
I
ir; n
ioi
niSKASKS ;H' ■lUK NASAI. I'ASSACKS.
ill this ili.-i'ti.-''. Ill .-oiiir i-asr- of t'Xtcn.-ivc uli (.'lalidii liizlil .-iiiiiciny;
(if tlu' ])iirls exercises a {■onli'dlliiii;' iiilliieiiee.
As til iiilenial iiiediealiim. Sajous I't'coiiuiieiiils red iodide of nwv-
ciiry ill doses of I iiidli,i;rah;iiies three times a ihiv. parlieiilarly in
.^ecfindary all'eeti(iii>. After |ityar,.-iii ha.~ oeeiirred. he substitutes
iodide id' |)iita.->a for llie |iiir|)oi' of I'liiiiinatioii. In the tertiary
form niereiiry is le.-.- ell'eelive tliaii the iodide, whirh shiudd he uiveii
in full doses to produci' tlie ih'sii'ed result.
When merenrials are reijuired. it matters little what ,-i)eeial form
is used. The main features are to choose the |ire])arati(>n least oh-
jeetionalile to the stomach, to ,i:ivi' d in minute doses, and to watch
its ellVet. kee|iin,a- its inlliieiice iij i the systi'iii tlioroiiidily under
control.
Wliou osseous or cartilaginous necrosis takes place the hreaili
becomes horri^ \y oll'ensivi', and ojierative jirocedure may become
necessary to save the patient from absori)tion (d' necrotic material.
The sharp spoon or curette in these casi's will do the liest service,
billowed by thorougli antise]ilic and ase|)ti<' Ireatmi'iit.
Suiiporting measures in the way of tonics, codliver-oil. good
diet, daily baths, warm (dotliing, abundance of jinre air. and thor-
ouglily hygienic surroundings are all of essential benefit.
(HAITI-; 11 \,\.\.
(()N(;i:\iT.\i. svriiii.is.
I'!!
T is .-till iiii imx'ltird (|iif.-iinii u hcilii'i' ;i >y|iliilinr lallic!' ciiii
triiii>i.iil the disciix' III hi- rliilil wiUidiii alirctiDL; t!ic iiit'ihcr at Ilir
sail. I' nine
It
!i'V('(l
iMiwcvci', llial if iMlhcr iiarciil i- a
liVctrd
iiv the (lisca~c al lln liiiic nf iiii|ii'c,i:nal inn. ilic unrnininalc nlV.-pi'iiii:'
will, as a rf,i;-c(|llc|ici', he the .-iillVrcr.
Symptomatology, ('nrvza. inuciiHT wiih sniiic (lill'n^c U>v\\\ d
(•iilani(iii> i'rii|il iui). is ii-iially llic carlicsl .-yiii)i|oin. The cnryza. a-
a rule. i> watcrv .al liisl.
"here is also -wrlliiiL: "\' t ln' iia^al i
lHirii>a.
pullicii'iit lu iiii|u'(lr ur |ir('\cnt iia-al rc-piral inn. (iradiially the di--
•liar*
,e Itcfdiiics imic()-|>nnil('iit, |ir(idii(inL; irnialinii id' llic ikisIimI
iutd ii))]i('i' lip. will) ( rii>t-l'()i'inati(in. 'Plic di-(liai^;(' i> ir.orc irrilat Iiil:
than llial |irndii(i'd liy an nnliiiiirv cold. Syphilitic cliildrcii arc .ipl
til lie pale .■mil cadavcrmis InnkiiiL:', and may liaNc the wilhered Innk
of a^>i' e\('ii diirin^' I lie lirsl year. 'Tin- inav lie partly due In iiialiilily
to take a jirnper ainnnnl nf nnnrislinient. t'l'mn the Inn-id'len careless
iiiotlier, iiwiiiu- to nasal -tcnn>i< pnidiu
Iiv iI
le ijl-casc
( 'iiii,u'enilal syphilis ol' the nns
e iisnallv run- ;, rapKl cmirse
many ca>es ulcci'aiKin nl the ,-cptiiin ;ind nasil carlila^'es (niickly
follow the ciiryxa. r>iine is laid hare. .-loii;:hiii,i; id' I issuer and nc-
cfosis of lione niav i'nlliiw. with I'lclid catari'h and dcd'oriiiiiv as direct
results
of ti
le dcl'iirmitv of >addle-liaek iin-c. lu'oduced liv destniclion
le septum and -inking' in of the ti.-sues. fi'cipicntly has its o:'i;;in
111 inlu'rited t(
VI lai'v disease of childhi
iiirse of the disea-t
is more rapid in infantili' than in adult life, owinu' in ihe lessened
power of i-e-i,-i,ince which cxi-is in ynniiii' children. .\mon,L: ihc
(■ui'ions results nf tiiis di>case is one reported hv (iilili W'isharl. in
wliieli. toiicthei' with ureat dot met imi nf the hoin frainc-wnrk of
the nose, there is alxi Ihe dcvelopnicnl of a lonih within ihe iia-al
fossa.
Diagnosis. -In the otlierwi,-e-heallhy child, oidinary aciiti' ca-
tarrh of ihe nasal passa,i.;'es speedily uiuleffroes resnluiion. Syphiliiie
rhinitis of childhood, on tlic otiu'r hand, is noted fnr its continuity
and the severity of its symptoms: also for tlii> iinhcallhy cachexia of
(I.'.:.)
i:
I i
IjG
DISK.VSKS Ol' I'lIK NASAI. I'ASSAC KS.
its victim.-. Tile diiiLMiu.^i.s irniii nrdinary purulent i-hinilis of cliild-
liood .should lint lie dillieult, as syijhilitic I'liinitis will be iiiauii'e.^t
duriiii,'' eailv inlancy. whereas purulent ihinitis d()e> not usually ap-
])ear before the third year. The syijhilitic eaehexia, and the ehar-
aoteriitic cutaneous erujition, absn, do not ])resent theni.^elves in the
milder disease.
Prognosis.-— The eailiei' the po.-itive symptoms appear in the life
(d' the infant, the niori' severe the disease and the less the prospect of
recovery. When tlu' symptoms are nuniifcst at first nasal stenosis is
nsually so great as to inierfere with nursing. ^lalnutrition i- the
result, with eonse(pient decay in vitality. The nasal septum sonn
idccrates away, and falling in of the bridge may be the result, if the
little ])aiient survives long enough to experience the deformity.
On the other liand, if the diseaso is lighter, the s}mptoms ap-
pearing later, the nasal tissues may not be destroyed, and uiuler
proper treatment there is hope of cure.
Treatment. — Cleansing and soothing treatment of the irritated
and intlamed nuicons niemljrane is very important. To shrink the
swollen tissue, by diminishing turgescence, and at 'he same time to
lessen the sensibility id' the nerve-filaments, the use (d" a weak solu-
tion of cocai.ie is advisable. In making the snliition, however, it
should be retuembered that muriate of coeaine and biborate of soda
are incompatible, an insoluble borate of cocaine being at once formed,
iiicarbonate of soda and muriate of cocaine are also incom])atibIe, the
cocaine alkaloid being de])osited, and chloride of sodium being left
in solution.
EitluM' of the I'nlldwing ]irescriptions would, however, answer
the ])urpose:—
1. Ft Cocaine liyiiriirliiiii-
Acid. I)(iiic
.\(|uam iul 30
W.
Iiut
Mithei' (d' these nnght be used as a spray to the nares
))etter plan, according to my experience with young children, would
be to apply it Iiy means of a pledget of w>:o| upon a cotton-holder.
Witli the child in the recundx'id po>tui'e, it can be placed uitliin
the nostril mnic elfeelually and will be received with less opposition.
1. H ('oi'iiiiic liydidihlor <sr. iij.
.\ci(I. Iioric <.'r, vi j.
.\(|\iioii ad 5i.
M.
COXOKNITAL SVl'llU-iS.
IT)?
Or
1. IJ Cocaine liydidclili))' 12
Amnion, liydrcx-hlor 3
Aciiiaiii iid ;il)|
M.
!iii,i;lit ])(' used in the saiiic wwy.
TluMi, afU'i" tin.' slii'iiikage of llic nasiil iiiiico^a which a t'ow
iiiimiU's^' iictii)!) (if the (•ocainc woiihl ]in)du(M\ tlie following or some
similar prt'iiaralioii ii)i_i:ht be applied in the same way: —
2. H Tliyni.il '13
Mciitliol J3
Albolcne :W
Tile parts hy tliis lime hriii^' amestlieli/.ed. the child will proh-
jihly submit to I ho use of the spray, if not, the cotton-holder can
be used with this solution as before, pressing it gently through the
nostril to better cleanse the passage. If sneezing is })rodueed by it,
a good pur])ose will have been accomplished, as the sternutatory etforts
will involuntarily clear the nostrils of sectrctions.
As a local application to the u]iper lip and intlamed anterior
nares, the following has a soothing ell'ect, applied as ..ften as re-
quired :• — ■
3. R Unp. zinci nxidi HI
Vasclin allia H;
M.
For ulcerative action wiiliin the Ud.-trds ai'i>l(i|, iodol. lodnform,
etc.. may any of them be npcd by insufllation after cleansing.
This trcn'meiit. while lienefieial to the local manifistation of
the ditieasf', can do nothing Inward eradicating it from the system.
■'la
iill
m
UVil
m
:W}: |l
1. R Co^ aino hydrochlur pr. iij.
AniTTKin. li.\ driM-liIdr jrr. v.
A<4i«iiin ad ,^j.
M.
2. It Tliyimd yr. ij.
Mfntliol jTf V,
A Ibolciif fi;
3. I{ I r,ff. ziiici oxidi
N'.iHolin all)a . . . .
M.
Sij.
!li
lofS
l)isi:.\si;s OK iiii: nasal passages.
This citii Hilly 111' acroiii]ilislie(l liv constitutional iiu-ans. and tlio best
111' tliL'sc is tlif iiitcniiil iidiiiinistration of inc'i'onry. This can usually
)L' acfoniplislic
\>\ the stomaeli. Minute doses of anv of the uu.t-
curioals iiiav lie irivcii. aovcrnt'd l»v the lixnl nilt'S which jruide tlic
ad
ministration df these driius. li' tlie stomach is disturbed liy tin
mercury, inunction may possibly yield better results.
(icncral rules with reuard to food ano hygiene .-hould. of cour.so,
ho enforced.
i:;!;!
DISKASKS OF 'I'll!': ACCKSSOiJ V SINTSKS OK 'nil': N(»SK
(•IIAI''l'Ki; XXXI.
A( ITK SINrsiTIS.
T IS ii'ciu'i'iillv (•(iinciii'il, wi'ii i'ci:;inl In chi'iiiuc inllniiiinntinn
of (lill'i'i'ciit rt'uidiis (if ilii' iKiX' iiiul Uu'diit.
;is Well ;is iiUlfr oruMlls nl
th
c liodv, that thcv iiiu~l nf iicii'ssitv nc priccdcd liv iiciiti- inliiiiii-
iiiatorv actioi
1 (11 iiiic tni'iii di' aimthcr.
W
IV diseases of the aiit fiini.
ethmoid
cells, and s|ilu'ii()id .-inns slniuld lie i'\cc|itii)ns to this rnlc
it is dillicult to say.
As. Lennox lirowiie teisily says, •'.Vcute sinusitis is fri'qiii'iil."
altliongli the I'aer, for which ahnndant proof has hcen liiven, is not
as yet generally admitted.
Weichselhanni, of \'ienna. perfoi'med autopsies upon tlu' imdies
of a large nuniher of patii'nls who hail <lied id' inlluenza. In Hit
per cent, of these he I'ound evidences id' intlanunation of oiu' iw
other of the ae<'essorv sinuses.
Friinl<
el, ot
llai
nionrg. likewise perlorineil antop-ies iipiui the
bodies of Mii pativ'nts. followed liy t)acteriological examinations i\\'
the contents of the sinuses. 'I'iiey were fonnd to he all suhjects of
sinusitis withont one of them heing diseoM'icd during life.
J>acteriologieal I'xaminiUions have proved that nunier<in,- hacilli
enter into the development of acute .«inous disease. .Among these are
the diplococcns laneeolatus in the pnciinioinc torin (d' antral disease.
Streptococcns is sometimes found in pure culture. Staphylococcn-
is nsnally associated with the other mganisms. Ilacillus pyogene-
ftetidns, hacteriuin coli. and . I. v/^c /•'//'//»>■ finiiujiilii^ have all hcen dis-
covered in some eases.
Etiology. — .\cute eiidorhinit
IS, or. a> It IS u.-uallv e
aciiti
rliinitis, is the most rrc(|uent canso of sinoiis disease. Next to thi-
may he considered the infections diseases: scarlet fever, measles,
tyjihoid fever, and small-po\. .\nother cause not >u(heiently appre-
ciated liy the professicm is the presence (d' lampons (d' ali>orhent
cotton within tli(> nasal cavities, placed there hy the surgeon, either
to check lu'emorrhage or as an after-treatipent following operation.
(l.-)!M
I'
IGO
DISK.VSKS OI- TllH NASAL TASSACKS.
ni^i
\Ut
9 I
A si'Vcit' ciisc (if acute |iiiriilciit .-iiui>ilit;, iirisiiiu' from the liist-
montioncd oauso. canio rocciitly iimlcr iiiv ohscrvatioii. Jt occuriL'd
in a ])Iiysieiaii a^ed 40. Tlio syinptoins wx'vv rulliic'ss and lu'avino.-.s
in the ro^don of tlie antrum, with coj)ious discliarge llirou.iih tlio
ostium, ))articularly upon Ijcnding forward. The antrum healed up
in a sliort time without any special Iroatnienl oihi-r than that re-
quired for an ordinary eohl.
The maxilhiry anti'um is the sinus usually all'ccted in this dis-
ease, though sometimes the ethmoid eells may be the primary seat
of lesion. Sometimes the inllammation may atlaek the two success-
ively.
Symptomatology. — The subjective symptoms are tisually those of
acute nasal catarrh, atfecting llie one side ])articularly. There may
he neuralgia in the region of the orliit, with photophobia and lacry-
mation, together with a general fejling of malaise. These symp-
toms appear to he amenable to treatment.
Physical examination without first applying cocaine to shrink
the tissues will usually be without avail, owing to the swollen con-
ilition of the mucous membrane. .M'ter the shi'iid<a'ie, however, if
suppuration has occurred, the middle turbinated of the all'ected side
will be seen more or less bathed in pus. There will likewise he
tenderness on pressure uj)on the all'ected side.
The majority of cases of acute sinusitis get well without treat-
ment, for the simple reason that they jjass away without ever being
discovered. Still, it is very ])robable that a large number of cases
of chronic sinusitis have originated in the acute form, which by
timely treatment might have been arrested.
.'\s Lermoyez has well said, acute sinusitis is almost invariably
amenal)le to cure without operation, ^\■hile in chronic sinusitis no
I'cmedics are available except the surgical.
Acute sinusitis is supposed to last about eight days, subacute is
(>.xtended to two or three weeks, while a longer existence merges it
into the chronic disease.
The ])roportionate danger arising from acute inflammation of
the antrum, ethmoid cells, and sphenoid sinus is in the invi'rse ratio
to their fre(iuency. Acute disease of the antrum, although the most
frequent, is the nuldest i ^ 'ype, owing to its greater distance from
the meningeal nii'nibranes. The ethiuoiditis is more severe on ac-
' onnt id' danger of inducing basic meniugitis and orbilal (oMiplicn-
tions, while acute inllamnuition of the s])henoid sinus, although so
ACUTE SINL'SITIS.
1(11
I'are as to be almost unknown, is supposed to l)e the gravest of all
when it does occur, owing to the pnssibility of inducing cavernous
tjirombosis.
Treatment. — This should lie along tlie lines alreadv iiKlicated
for the trratmcnt of acute rliiniiis. Mild catharsis in the coninicnce-
iticnt of tiu' di-ease, followed by V '.,-graniiii(' doses of (piiiiinc two
or three times a day, together with tablets for the night-time, com-
posed each of y, centigramme of morphia and '/,„ milligramme of
atropia, rej)eated every two or three hours until sleep is induced,
may be considered an advisable course of systemic treat uieid. When
fever is ])resent droj)-doses of tincture of aconite eveiy hour has a
good effect.
Local treatment by •■3-])cr-cent. spray of cocaine will relieve the
intraiuisal congestion, the astringent t-lfect of which may be prolonged
})y following it with sj)ray of 2 ]jer cent, of menthol in alboleiu'. This,
repeated as often as required, will bivor free(loin of discliarge and
hasten the liealing process as the slight fever al)ates.
Ill
m
( IIAI''I'KK XXXII.
( lli;n.\|c DISKASK oi' 'IIIK A\l Itl'.M OK II l(;il.M( tl!K
'I'lii-; aiili'iini dl' 1 1 i^lmini-c. lifiiiii," llii' liiru'c-^l nl llic nasal
accc:
sory siniisfH, and the mic iimst IVci|U('titly ail't'clcd with ])iinili'iil dis-
ciisc. is worthy of ilic most carct'iil ciinsidcial i(m (l'"i,L;'. •!''). 'I'ln' term
indicalcs a chriiiiic iiillaimiiatdiy cuiidiiiiin id' tlic iiiiicniis niciiihranc
lining: the -ii|H'i'i()i' iiia.xillaty sinus, attciidi'd Iiy llic roi'inalioii nj' |iiis.
'I'liis irradiially lills the cavity, and. liavint;' no otlici' outlet, when
the |iurnlcnt matter I'eaelies the iiei^iit ol.' the ostium maxiUare it
tri(d\k's over into the ini(hlle meatus, heiieath tlio middh' tnrhinated
body, and is dischar,ii('(l Ky the anterior and [toslerior iiares.
Pathology. — .\l tlie comineiicement (d' the disea>e the mueons
mendirant' id' the anli'uni is sli,Lilitly swollen ami hypeiu'nuc. Some-
l'"i.<.'. (i."). ('ii-i'(nw mass wiislii'd eut of aiitnini tludii^'li
(istiiiiii iiiaxillariv
times the hlood-vessels lupture in dilVerent ))laces. caiisinii' little spots
of eccdiyinosis. .\s the disi'ase advances. tli(> meiid)rai)e ihitdveiis,
ill some cases hocomiiiu' infiltrated and in others covered with granu-
lations. Xot inl're(iueiitly (edematous nodules form, which in tinu'
take on the myxomatous aspect, until clusters of small polypi may
he found lian.uin<: round the internal horder id' the ostium. Kantliack
records a case (d' polypoid growth within the anti'um. Synionds
found several in one antrum varying hetween one and two centi-
metres in length. i\oth says antral polypi are scarce. In the Ainnils-
of ()j)]ilJi(ilni(ili>iiii (Hill Oliihiijii for lS!>ti 1 repoHcd a ca>e in which
what seemed to he s(d't p'>lypi were washed out thrfuigh a large
hiatus semilunaris, the nozzle of the syringe being placed in one end
of the passage. The accompanyini: cut (fig. ().")) gives the exait size
of the largest, after being in alcohol over two years ^licroseopical
(l(;v?)
il; ^i,, i!
I-'Il;'. lili. Liitciiii liii/cii -cciidii iIii<ium1i tlii' iiiiildic rruiinn nl' tlir iiu-r.
I. Klliiiidiil fell-. \i. Su|iirini- t nrliiiiiitnl. :;, Mi, Idle i inliiiniird. 1.
Aiitnmi lit lliiiliniiiic. ."i. I nidii, (n ^viiriliiii. Iiriwci'ii -i'|ituni :n\i\ inlciiiN'
1 iirliiiKilfil. ti. liitViiiir I in liiinitcd Imni'. 7. Il.iid pnlaii'. s. Toii;.'iir. ;i.
Middle incatiis. Id. Inlriiin nuiiiii-. 'I'luiii I'riiiiiu-r', .\ii;it(iiiiii;il
-Mii-cmn. I 'iii\( i-ii \ ot rniniilc. i
§
i'
ill:
I-
M^ ■;*:
t'liKoNK i)isi:\>i: ()!• Tin; anitm \i ov iiinininKi:
|ti..
Ill' nil.-- Mccdiiic.-. aiisnrhcd nnd the crili
('\;linilllllii)ll of tln' .-illlir ill lllc pl'i'-rllt tiliif |il'ii\c> il t(i lie llolliill;,'
liiit ;i iiiji.-.- (if rascdiis iiiallir, coihimim'iI oT cell di'lriln^ ainl p"ly-
iiiiclfiir li'iicncylfs. C.-iM's occii.-idiiiilly (U'ciir in uliirli ihc lliiid nf
iliir clciiH'iit- iiiiilrri.fi) lally
(l(',t;t'iU'ratioii. 'I'his is llic casi'oiis lonii of the iliscasc. and it is ai'-
cniiipaiiicil liy niiiiu'riiiis liactci'ia. -iicli as .-laphylocucciis iiyouciii-'
iiiul soiiH't iiiii's Asiirriiilliis fuiiiinnl iix.
Siiiiictiini'.- ill ailvaiiccd ca.-cs the |icri(isl('iiiii liccniiu's uiiiisiially
jn-tivi", and little jiittin.iis and >|M(iil;r of lunic will m'nw ami prnjccl
out into the aiitnd cavity, rvni in rare casos hridjiiiii;- it aiToss and
\)\ riiniuilioii (d' tlii'ir laniclla' ilividinjj; it into scdidiis. In raii'
cjisi's. also, cysts J'orni hy (lislcnsion nj' lynipli-spaccs or ducts williin
the antniiii ( l''i,i;'. liS).
Etiology. — The iiid tradition liandcd down fur jicncral ii)ii>, that
decayed tcetli were the u>ual cause of antral einpyeina. is advocated
liy Moldeiiliaur. I''racnkei, IJeverly lioi)iiis()ii, and others, while Ziicker-
]\aiidi, Chatellier, Demochowski, ScliiU'ers, etc., helieve in it- intra-
nasal oriffin in a lartre majority of cases; and this accords lar;rely
with my own t'.\|)erience. iJosworth doubts the prohahility (d' actual
extension of tlie disease from the nasal fossa into the maxillary sinus,
but is of the o])inion that the majority of cases arise (1) from
closure of the ostium from pressure (d' nasal ])oly])i, ('I) from pressure
of cnlarjzed middle turbinateds, and (;5) from extension of disease
from I'arious teeth; while N'yles is of the opinion that the iio~c and
teeth are abont eijual as causal factors in ,i,Mave forms of the disease.
M. Saint llilaire reports two cases (■lininuil nf fjirjituidlniiji,
Auiiust, LSitS) of enii)yenia of the antrum (d' Iliiihmore cau.-ed by
plu^'irinii' (he nasal fossa'. One occurred in a lady, au'ed .")'.', who had
l)eeii sulferini;' from alliumiiiuria for two years. To check a severe
attack (d' epistaxis liello((|'s cannula was nsed, jiluir^inj: the anterior
and posterior ends (d' the pa.-sa,i:e. In two days severe pain occurred
ill the suborbital region. The anterior pliii:' was removed and two
days later the posterior one also, hut the aiitnim was full id' pus.
And three months later operation for its relitd' wa- performed.
The other was in a woman of ;!!•. The iiost
I'll wa.-
l)luj:<i'ed to
cluck violent cjiistaxis. This, owini: to similar pain as that of the
first .-ase, was removed two days later. Pain and (edema disajjpeared,
but in a few days the antrum filled with pus, which conld be seen
in the middle meatus.
Symptomatology. — Tf tlie disease is caused by inflammatory ac-
m
IH
IMAGE EVALUATION
TEST TARGET (MT-3)
J
1.0
I.I
11.25
UilU |2.S
Ui "^
X' Ki 12.2
S Hi ""^
u
6"
Photographic
Sciences
Corporation
23 WEST MAIN STREET
WEBSTER, N.Y. 14580
(716) 872-4S03
\
iV
ip
i\
[V
\
C>
•«^
^"15 "
.^^
4>#
^
IGG
l)isi;.\si;s (IF Tin; \.\s.\[, i'.\ss.\(ii;s.
iioii ;iii(l x'tTclioii (if jnis iiidiicifl liv clnsiirc nf tlio ostium, the cavity
will in time Ix'i'oiiiL' i'lill, and pain from tlie prossurc of retained
secretions will resull. WIk n it arises from caries of the teetli, i\w
ostiiNii not liciriLi closed, the dischar.L'e c.-ca|ies tliron;_'h the outlet
and piiin docs tupI Ikiiuiic .-d curly or |iii>ininiiit a ^\nl|•tom. In
either case, however, tlie Jaw may he tender on pressure, and the
teeth on the all'eeted side may have a fullness and soreness on
closinjr. Sooner or later fietid. creamy-C(dored disehar;:e makes its
escape, and flows from the no.-lril. The odor, oiie-sidednoss, and
r(dor are chari.i Icri-t ic <d' >inu< disea>e. 'Ihc jidjnt i- to asceiMain
positively the source of its origin.
Diagnosis. — The dia.irtm^is of antral disease is fre<iuenlly oI)scnre,
aiul conseiitu'ntly a po.-ilive ci>iicIu-ion can randy he arrived at upon
the lirst examination. The pnxnce in (uie nasal cavity of pus of a
creamy color, and posses-ini:' an unpleasaidly aromatic odor, while
the other nasal cavity is free, is always suilicicnt to indieat(! tluit
suppurati\c discas(> exists in otic or other of the accessory siinises.
'I'he (lUistion is whrlher the disease is frontal, ethmoidal, antral,
or sphenoidal":' Sometimes, too. the muco-purulent dischar;ie pro-
duced hy the picsciice of tia^jd polypi, associated with alro|ihic dis-
ease, simulates thi' pu* of :inlral -uppuration. l''oreii^ii i)odies aiul
rliinoliths may also ;:ive ri-e to a sonu'what similar discliarL'e.
Alter cleaiHiiii: the nostril the application of cocaine to the
mucous niendirane should malerially aid iti diatrnosis.
Its astrin<j;ent action upon the tissues will make the presence or
nhsonce of polypi (citain. The same may he said of forei,<rn hodies.
These heintr excluded, ihe next (piotion is: which sinus is atrected?
After thorou^ih clvausin^^ and shrinka,i;e, the presence of a drop of
creamy ]>us in the middle meatus, just exiermd to the lower border
nf the middle turhinalid. is jilnio>( of diaj.Mie.stic value, if the pus
is farther hack and vi>ihle in the posterior nares. it may have e()Mie
from the diseased sphenoid sinus. If farther forward in the vicinity
of the infundihulum. from the ethmoid cells or frontal sinus; hut
in both the latter the tissues of the orbit would be likely to be
alfected. This rar( ly occurs in simple antral disease. When the
(pinntity of pus is hirne. even after (leansinir, whatever its ori^nn, it
may extciul to all these locations, and the diai:nosis becomes more
dinicidt. S(unetinHN by bcndinj.' Ihc^ head forward, the exit of the
pus from the ostium niny bo verilied by examination with the nasal
speculum inmu'diately afterward.
CIIUOMt' ItlSKASi: ()!■■ Illi: ANIlil \I OK 11 ICll Molil
Hi:
Tlio iit'iiriil;:iiis wliidi nriM' I'rniii siiiii.-iti>. uliiMx-vcr luciititl. arc
not of imicli (liiiiiiio^li \jiliir. Si ill. tlicrc is nil iiiironit'nrtjil)l(! fi'ol-
injz. ii <(ii>itivciirss (111 prcssiiif. iiml ;i liiHliiiir-» nf \\\i- ull'cctt'il jaw
ill clo.-iiiLr the ti'i'lli, any (if wliicli iii.iy lie (aiii-cd Ky aiilial disease,
but imt l»y sii|t|nii'ati(m of iIk' dllicr .-iiiiisi's.
Mdicaii lli'dwii izixcs line .-iun in (l;;iuii(i-i- wliidi in my cNperi-
eiuc ha> liccii (if liltlc value lie >ay- llial after elean-iii;: llie pus
away liy a |ile(l;:ei df enMnii. |ire«siire iipdii llic f;iii;il Willi (if tlie
niaxillary siiiiN will pi'd.liiee its reiipiieiirniiee. 'I'iic iiiii\illary Iioiie
seemed lo lie Ulli llll llelleed liy .-Iliy preS-Ulc which il 'I'cmed safe to
make
1 iriijatidM i- aNd I'eedmineiidi d ;i- nii ;iid Id (li;i'_'iidsis. 'I'liaf i.-.
liy jiassiiitr the pdinl (if a l\iisiaehiaii ealhet( r atlaelied to a svriii,L:i'
ilitd the (i^lium and w;i-hiiiLr dUt llie (:i\ilv with unrm w;iter; the
M
1"\<S. ti7. I'lliil lie illiiiiiiliiitiiv with llivililc -liiiiil< :iiiil ( nrd-;.
pus disciiarLicd wmild iiidieale the presence df the diseii.-e. It may,
liowever, lio remarked that when the [lassa^fo is suiriciently upcn Id
admit tlie ininidiiction of tlie catheter th(> pus can usmilly lie seen
issuing' frdiii the ostium without the use of the iiislrumeiit.
I'lxpldratdiy puncture as ji mithid of dini^uo-is lias alwavs re-
ceived a certain amount df favor. It i- made either throuirli the in-
ferior meatus, the canine fo><a. or the oral (a\ity. hciween the second
l)iciis|iid and tli;' first molai' teeth, and iniernal to tin in. With at!
the pre-cut iuean> of exploi'Mt idii at cdiiimaud. it isdoulilfnl whether
puncture will ever he freipieiiily re(|iiire(i in the future, ('hiari, in
givinj: tli(> history of mu' hundred cases, says that the rhimiscopie
(wamination ,i;ave ^uch e\eelleiit diaLrimstic results that lio nnlv rc-
(piired to piincturo fiuirtccn times throiifih the inferior meatus, to
iIl^urc a correct dia,LMinsis.
Of all the aids to diagnosis, prohahly transillumination, hy
'iff
'! !
108
m^i. \-i> (ir riii; \ \> \i, r \>> \<;i>.
!(
plilcillLl il ^llilldnl rlccll'lc hiMI|) ill the liiuk |iilll (il lllr i|(i-ril llliilllh.
illl I(Pi|llc( (I li_V \'n|tti|illi, >t;lllil- the lil>l (l''i;^. (11). A 1 1 lu Ulu II nl IIM-
<l(iiilili'il Viiliic. llic ,'iiiii'iini <i|' \v('iL:lil iitlai'lird |n ii li\ ililVcrciii
rliiii(i|iii:i>i.- \iirir- ,cr\ i:ir,iil\. (;niiL;iii nhciiii >ii\- ilini i iiiii-;lliiiiii-
ri;i!ii(n i« (ificii i'iiili;iriii->iiiL:. <>n ii.«iiiLf it lie luis rmiinl \\ rll-iiiiiikid
>iilHirliiiiil iiiiilii'ii. imliial iiiL: \n\-. iiml ii|>i>n n|ii'iiiii,u tlir aiilniin I'hiiikI
liiinc — llif iliirkciiinL: ln'iiiu raii-cil liv a tliickciii'd iiiih o-a. tiiaiil.
"Ill ilic nilicr liaiid. think- it iiiav iil'tfii lie ii-criil in a iic,uati\(' wav.
Ill .-f\cral >ii>|ii(inii> cax'-, uhcrc piN ua.- Iifluvi'il to lie |irfsciit. In-
I'niinil Kii t rair-illiiiiiiiiat inii tlir lian-liH'ciii'V mi clrar that ciiiiivciiia
dl' the >imi,- ((Uild he |iii-il i\cly (Acliiih'd,
These are iiiily e\ee|p|i(m^. hnwcver; as a rule, the ii.-c n\' ilie
eleelrie hiiiiji ill the iiKUith will |ir(>diiee an iiiiilira. nl' nmre ur less
ileM>it_v heiieatli tlu' jnwcr eyelid in each ease (d antral disease.
Milli^an tells ns he use.- NdllnliniV lain|i in every sir-peeted ease: and
wherever it Tailed to iinidiiee a li.izht z<ine lieiieath the eytdid. and u
led and liiiniiKiii.- |iii|iil. on ii|ienin,u the aiilnini pus had hi'en loiind.
(Ireville Maediinald lay.- ;:reat stress cm the iael that where we
have -ii|t|iiirati()ii with ;.M'aiiiilatinn-ii.-siie ur |>idy|ii in llie middle
meatus, we can stddnm Ite sure id' the extent or severity nl' the disease.
He says he lia> Ireiplelltly seen ease- when the siippiiratinn nl' the
antrum was siippd.-ed in Ke the whole tmnlile. Iiiit in wliicii it was
afterward proved that the Imnial sinus ami etlinmid cells were Jiisl
as seri()n>ly involved, while, on the other hand, eases which had lonji
lieeii treated lor so-called neerosiii":' ethmoiditis turned o\il to he
overlooked cases of profuse antral siippuration.
My own iiio.-t recent ea,-e was u[' this doiilile nature. I at first
took it 1o he pure ethmoid di-ease. as there was piofu-e granulation
and snppiiratioii of the po>terior ethmoid cells, accompanied hy deep-
.-eated pain in the eye of thai <ide. (iahaiiocaiitery operation of the
hyperplasia and ciirettajre of the cell- failed to check the discharire.
'riien I discovered that the correspoiidim: antrum was involved.
l{eino\al of a molar tooth, perforation of the aheidus. and daily wasli-
iiijrout with hot hoileil water in a few weeks, toiicther with the previous
treatment, reinoxcil the whole of the do'dile disease.
For several years I have u>i'i\ transillumination l»y the electric
lamp in all cases where I su.-|»ected antral suppuration; hut I cannot
say that the result has lieeii suMiciently marki'd to make the diaij;nosis
jiositivc liy it alone in a sinjrle ease. I have not opened an antrum
without findin<r pus: Imt still the umhra from illumination was not
CIIHONIC IMSKASK (»l' llli; ANIIUM (»!' II K; llMOlii:.
HI!)
«li'cicli'(l I'lioiij;!). even with tlic (liirkciicd |iii|)il iidilcil. to justify iiii
<>|H'nili<iii uitluiiit llic iMfsciicc nl' dllicr ciiinilly ]Mi.--itivo si^ns.
Prognosis. 'I ln>c ciiscs iiivolvf iilllc iliin.^cr to lilV; vet s|)nti-
laiK'dii.- ic((i\ory Jinm cliroiiic sii|'|iiirati(iii of the iuitniin rarely, if
<'ver. ocfii'-s. I>y (arcliil ami |)ci'.-i.-iriit in-ai iiniil, liowcvfr, all cast-s
■ :iii |pc i('li('\('(l. ami many nl tliciii ciirrd.
Treatmen'. r.n-uorili icll- n.-: ••'I'lir (■>-(iilial rcaliiir nl' tin-
trcatiiit'iit (if a ca.-i' nf >ii|i|iiiialivc di^ra-r of the aiitiiiiii cmisists in
(i|iciiiii^' (lie lavity fur jpihimi- di'aiiiauc, ami -iili-ti|iiriiily its thiiinii,i,'h
<li'aiisiii<r and disinlVciidii."
In ill'' lalit-r clan-c all rliimi|n::i.<is ai^rrc 'I'liry aurt'c also in
llic foriiicr. while tliey dill'i r w idrly in ilicir methods of |iroeeduri'.
Still, they iiniliilly aeee|il a- im|'erali\e the k nio\al of any polypi,
^liiannlal ion-I i.-:-iie. ni h_\ |icrl io|i|i\ nf the middlr 1 iirhinated which
jniiiht he oli-l lUel in:: the o-nnni mavillaie.
The diri'il inalmiiii d iIh' -ii|ipiiralion may he <ondneted in
one or other of the fojlouin.u way.-: —
1. \'t\ direct iniLialion ihion^h the ostium. (Ja\il. of Lyons, is
the v:vv:\t apo.-lle n\' \\\\< incthod ttf treatment, lie claims that it
lan he aecompli>hed in a laiLic majority of cases, and that the anirnm
can he washed onl icniilarly and ((iinpletely without any arlilieial
opening;' \\liate\er. nui of II caM'.- he >iiceeedeil hy tlii- method in
t.'^. or (>'■'' '/., pel' cent.; and "iil id' lhe.«e had to I'esorl to other treat-
ment in only (i la-i .-. 'The larger niimher were cured in a ,>hori time.
The thiid iwed \\a.- u.-ually a warm >M|uliim (d' horic acid. The in-
."-trumcnl \\>rt\ was a I leryuL; catheler, lll^e|■tl•d. willi tin point turned
downward, hetueeii the middle tnrhinatrd and the mit-ide wall.
l'a.->iiiL'' the in^Irunieiit upward to a positi'^ ai'o\c the ostium, he
turns tlii^ ]ioiiit outward and ;;ently cn^aLics it ii the uiMiitli of ilu!
cavity. This icipiire- careful manijiulalion, as \\ ■ pmnl of tiie in-
stnnnent is in clo.-^e jiioximilv to the orhit.
At the llr-t washiiiL: tlu' li.-chap^e is puiuieiil. fcetid. and sonie-
tinu'S ciiseons: hut htdiuc the irrii;ation is over the lliiid returns from
the naris jierfectly clear. On each HUcceediii;^- wa>hinu' the pus dc-
ci'easos in quantity. After a few washinirs notliini: comes away hut
a mass nf ffclatinon.s innco-)ui>, the water itself lieini^ (piile clear.
At caoli gittini,' llio mass dischar^^ed liecimies smaller and finally
ceasi's, tlic patient hcin^ cured.
2. By openin,!,' throuLdi the inferior meatus, or Jourdain's
method. Of this plan Oundas tjrant is a vimt stronu' supporter. Mo
K(»
J»lSi;.\>l> »tl llli; NASA I, I'ASSAOKS.
clllilllS lluit il- lllf lllltllllll rnliillUlllicilto willl the I't'Spi niloIV I'ilS"
sii;T(.fi^ jiimI Hot tlic (lijjTstivc, llic more iiiilunil (iiK'niiij^ will ho liy thu
iiiisc. A Iter Mpplviiij,' a l.">-|i('r-cciil. MiliiliiPii nf curniiic Id tin' iiiiicniis
riiciiiliriiiir. he uses J\riUiM'"s truiiir ,iml ciiniiiil;!. )i('iu'tnitin<( llu;
Jiritriiiii tlifoii^li the wiiil ol' tlii' iiilVrinr iiifiitiis. \Villi(liinvin^f lli<'
trocar and Iraviiiir tiic (imimla in kIIii. lie attailics it to the |i(iiiit ..|'
till,' >viiii,ii('. ami waslirs oul llir cavity wiili warm solution nf l)oric
acid, llic lliiiil c>ca|piii,L; lliroiit;li tli'' natural opening. After cacli
'rcalnicnt llic cannula i^ rcnio\cd. At the uoxt sitting' (•oeaiiit! is
a<:aiii a|)]dicd, the cannula rcin>crtcd, aiul the trcatiiienl repealed,
(irant claims that, althonjih the treatiiu'iit is somewhat diiliciilt,
Vet the nunilicr of irrij^atimis rcipiirid. hein^ los than l»y other
meth'ids, will justify it.- ii.-e.
/('im, of haiit/.ic, criticizes this nicllmd .-e\crrly. 'I'lic dilTioiilty
of operatin;^ in this re-fion, the tliicknc.-- of the naso-antral wall in
many cases, inellicieney in diaina^ic. ami the impossihility of personal
irri^Mtioii Ky the patient are amoiijr the points which he emjiluisizes;
and to these miLilit he added the evil ciVccts of successive a])plications
of cocaine.
;{. i'>y removing' a nudar tooth aiul openin.ir the antrum tlirouiih
the alvc(du.~. This is ('oo|ier's wcll-kiuiwn method, and is warndy
supported hy Zeim, Harrison, .Milli<:an, and Hoswortli.
When the teeth are sound, Zeim condemns renuival, and sii<igesls
porforatin^'^ the antrum throufrh the roof of the mouth in rlo.se prox-
imity to the teeth, cither hetween the second hiciispid and tlic first
molar or hetween the lir.-t and secoml molars, 'i'he fact that tin'
opening: into the alveolus, or floor of the antrum, and the ostium
ma.xillare are at opposite etui- (d' the same cavity, must l)e conceded as
an advantafio in irripition. while the facility it alFords for personal
treatment is also in its favor.
To kee|i the artificial openinj: clear, various silver and gold tubes
have h;M'n devised for permanent insertion, during the period re-
quired for treatment. Tli(> tnhes are attached hy silver wire to the-
adjacent teeth, and plugged to prevent the entrance of food.
Tn many instances, however, when the treatment rc(|uircd is of
limited duration, these tidies can he entirely dispensed with, as, with
ordinary care, there is little if any danger of the food passing through
the opening into the antrum.
4. Desault's plan of opening the canine fossa appears to bo
steadily gaining ground. Tt is claimed that tlio patient can treat
<iii{(iMc him'.am; m' iiii: \\ii;i\i ni iikmimoi;!
1:1
liiiiiM'lr rtpiallv ucll in tin.- Wiiv a.- llirmi::!! llic iil\ culii-. an.l ilial it
will frctjiu'iitly |iic\riii the sacrilicf dj' n -muikI inotli. A tiilic with
11 phitc attached tn lit airniii-t tin' jaw can lie iriaiind, cvi'ii licttrr
tliiiii ill till' alvcnlu-. and witlmiit uirin;,'. l'liij:^in,u tlic tiilx' i.s nn-
ii(H'c.->a!'V, as lliric i- pract iiallv \\n (lan;:iT id' I' 1 ('iitri'iii;^ tlir
uiitniiM.
Sonio (tpcraturs liavf invadid lln' lanino I'ns-a \ri\ cxtciirivclv;
and witliniit lu'^ilatiiMi cliisrlcd away iiioii^^li id' tlic iMrnial aiitial
wall to adinit nf digital rxploriiliuii >>( thf caviiy. Tin' aiitniin is
tlu'ii ciirrtti'd and uaslivd out iind |».i('ki'd with indnl'min nanzc 'I'his
is cliaiiircd i'('i;iilarly, lln' cavity lirini; krjit ii|ii'ii nntil llinmimli Inal-
iiifi takes place. Altlnmirli rcvivrd nirnily, llii- plan id' trcatnicnl i-
lint iirw, I'nr wc read of la Mmicr as early as IT'in treatini; a i a.-e
i«iicccssriilly in tins way.
."). The Ifoliertsoii method of cnmltiniiif; the chii-elinir of the
canine fossa with the jierforation of the inferior meatus, in mie or two
places, has also a niimhcr of supporters. Scaiies Spicer favors this
plan (d' tre.'itment, as the mily mie -eciirini; thoioimh and ell'eiinal
tlraiiiiiffo in many of the mo-t dilliciill cases. lie makes a lariic o|icn-
iiiLT in hotli the anterior and internal sides of the aiitriim. These
o|)enin;;s lire intended to he permanent. He then irriir.ite- tlioron;:hly
with lioric solution, and follows this hy paid<in^' the cavity liirlitly
with creolin j^^auze. This is left in for forty-ei<r|it hours and I lien
removed. Xo form of tuhiijie or mechanical drainaLre is used, hut the
cavity is syringed out daily with a similar waiin solntidn. '{'he
patient is directed 10 hlow out the cavity fretpiciitly. from the iiu-r
to the month, and also from the mouth to the nose, lie claims rapid
Iioaling, and, although the perforations contract, tlu'y usually remain
permanently open to some slijrlit extent, without inconvenience to
the patient.
This multitude of methiMls all jiractitM'd to-day hy leadiiiii
rliinolo<:ists. oaeli preferring his own s])ecial plan as the hest, hut
ntilizin<i somi' other method in exceptional cases, seems to prove that
the results are not, on the whole, as satisfactory as wc would like them
to 1)0. A few eases are cured (piickly. Others take a lontrer time.
All are relieved; Init in many cases the treat ment re(inires to he
carefully, systematically, and persistently followed out, and tliat for
a considerahle time in order to pecure a perfect cure.
Tt is nndonhtodly true that manv cases of antral disease come
under the domain of the dentist for treatment, and manv dentists
.■■ 1:
^<>'l
If '
172
DISKASKS OF THK NASAL TASSACIKS.
cliiim to Im' piirticiiliirly sii'ci'ssrul in (li'iiliiifj witli tlit'so rn?o>. ]\\\t
lliis is lint ti) i)f woiidtTi'd ill Tlie cases tiiut ((iiiic iiaturallv iindi'r
their chiir^M' arc tlmsc of denial ()ri;;in, the reginn id' the osiium not
hciiig at all alVcctcd. And wIkh the carious tontli is rciiiovc(l. iho
imtnini luTloralcd thron^rli \\< alveolus, and the cavity antiseptically
washed out i'or a I'cw times, it is natural I'or the linini: nicnihrano to
heal. An entirely dill'erent state of tliinirs e.\i-i- when the I'liotogy
is nasal: ami il is this class id' cases thai ii.-iially Fall into the hands
of the iliinoldiii.-t to deal with.
In my own |ira(iice the lar^e majniity ef my cases ha\e heeii
treated through the aKcnjiis. .\illi(PUL;h in >e\eral t>\' \ hese it [in)k many
months of treatment, yet they were all e\eiiliially cured. In one
case the treatment wa- (niilineil to wa-liin.Lr out the nntiiim thr(iu<rh
the o>liiim maxillare with a waiiii suliilinn (d' resorciii This ca,-e
healed rapiilly ami without return. in tliice I tried perforation
ihror.gh the canine fossa with insertion of a silver tuhe and follnwed
i)y reirular iri'iual inn. In the first of llie-e it was siicces^fid. In the
second it failecl. lur tliiee years the patient peisnnaily cariicd nn the
cleaiisinii' treatment. Imt declined to lia\(' any other operative treat-
ment than the renewal of the tulic as frei|Ucntly as the njd one wni'e
away, in the third, after trial for weeks, there was im pro.-pect of
healing in the antrum, so a tooth was extracted, and a week or two
of reiiular iri'iijat inu with Imt hdiled watei' eirected a ciire.
'I'iic sci'otiil III' tlicsc (■;iM> is wurtiiy of fiiitiiiT ((iii^iiji'nil imi. 'I'ln- ]iiiti(iil
Wiis (if a I iiluii iil:ii- liiTnily. lliifc liiii|liii» and his innthii liaxiii^r diid nf jiiil
inoiiiiry t iiIm rciiln-is, .\ few iriuiillis •.\<^i>, a- tiicir scciiii'ii In In' im |iiiilialiility
(if ccssal idli (if aiitial (li--iiiarj.'('. lie linally ( (iiisciitcd td iIk' cNtrad ion (if tlio
lirst. iiiiilar Innlli. and jici furat imi ilnniiuli tiic ahcdjiis.
liisti'iid (if littiii^f a >i!\(r tulii' to llie (i|i(iiiiijr. as I liad dinii' in liis case
ill till- caiiiiic fossa. ! in-tnich d liiiii to iiial<i' a liardv-.ood |ilu^' to lit tlic jiassif^e,
tlic lower end liciiii.'- larirc ciHniLrli lo iircxiiit ils s1i|i|iiiii,' w Imlly into llic
aiitrmii. 'i'liis |iian I liad followed mi |iic\ioiis occasions in tlic trcatinciit of
other cases with iiniforinly ;.''ood icsiilts. Ilic |ilnijr Iniiiu' rcinoMi! each lime
irritfiilidii was rc(|nir! d. and rc|ilaciil ininicdialcly atlcrward. .Vt'lcr a few days.
as tlio jiaticiit inana^'id the local Ircatineiit cjlicicntly. the anionnl of ims at
ilic same time i;radually diininishiiif,' in i|iianlity, I told him that he need not
return to I he oHicc au'ain for a iiunilicr of days, lie ict iinicd. Iiovv ex cr. sooner
lliaii cxiKM-tcd and, with a distr»ssnl c\|ii-cssi()ii fif face infoiincd me that the
last and laifjest pliiij he liad used had (.'one up into the imtnini, and he was
afraid that the jiivvious eiie had slipped in also. It ajipeared that two nights
|irevi(iusly he had fitted the ]diifr into the alveolus on jroinjj to lied. When he
involve in tlie moniiiifj it was (,'one. lie ]iasscd a pr.ilie into the hole, liut could
not feel it. Thiiikin}.f tliat jiossilily he iiiiyht have swallowed it, ho made a
i
ciiuoMc MisKAsi; or mi; vsritrM >>v iiKiiiMoHi:.
it:}
lai'P'i' iiiir iiiul |iusli<'il it in ti;.'lill,\. jftiT wathin^ cuil tlic aiilrniii. 'I'lit- iit'Xt
I'Vciiiii)^' it wiiM till ri;.'lit. Imt w In i> lir iiwnkt' in llic nimiiin^' lir could juHt
rcacli it with liis tniij^Mii', and an lii>ni' latfr it had cnlinly di«a|)|M iirrd.
On ('.\aniiniiii; tin* antiiini tlinin;;li lli<- ojirnin^s with the |irnl)t' I Kiiihl
nut liinl cither ni' the fnii'i;.'n lii>dic>(. There ■«cein<'i| ti> In- an almiidanre ol
space, ami, wj-hiii;.' lhiiin;.'li the .aixenhis, the llnid e<ia|ie(| freely fn'in (he
1'^
If
l-'ig. tiS. CdlDlial nceliiill lit the niJ\illai\ -iini>, the -.nlijeel of ey-<tie
disease, a, (';;nee!!n||s ^|lael•s in liniiy \\;\\\. I), I'ejriiin (if (lie crirttil tiir
liiiiali<. i\ (ilands .if na«al |o»sa. '/. <;laiiiU nf the niaxillaiy sinus, r. l)e-
fjenefatinj,' ^'land ii>sue. The wavy lines aii.und iiKJiiate the eapsule of the
cyst. (From Lennox Jtrowne, IS'.iU.)
nose throiif^li the o-iinni niasillare. t hi lije patient'- a~-nranie that at li'a>l
one of the ]iln;,'s was in the antrum 1 had an ana-thetie ailniini-.t(red. aiid.
after dissecting hack the tissues, with liaininer and ehisij .■nlai;.'eil the opening
in the canine fossa (o Hie dianaler of a cent iinidre. I'ihIci- the impression that
-.
Kt
i»i-«i. \»i.> Ml I III. N \> \i, r.\>.-« \(.i>.
Ilif lor<'i;;ll ImiiUi"*, il' tln'lr. wkiiIiI III' nil I lie tliior of tlir ililtllllll. I is|>l"iii|
■ lull. ri';;ii>n lii-l, luit roiijij imi liiitl iiii\ lliiii;,'. 'riicii I |iM«-^nl lln Imi.].
IcWiinl III)' <i>>liiiiii williniii .11111-'- Al'li'i' liiii|i|iiii'.' out the riixily willi ali
t«oi'lM'iil coltoti I ii^iiiii |iii>-ii| till' tiiii'i|i>< n|iv\iiri| and IkkKw mil. 'I'lii- liiiii'
fldtiiclliin^' \\ii.'« ■M'i/t'il. till! il ii'i|iiiiri| ,1 ^'ooil ili'iil i>l' liMitjoii Ik ili'ioil;^!' il,
wlii'ii oiil. riiiiii' II |oiiM iiinl tliiik |ihi;:. \iiolliri' iilii'iii|i| \va> iiiailc in llir miimi'
li';,'io||. lojjowtil li\ till' lAll.litioll o| i\ .lill i.llMri' I, lie. | h|||i|>ii.|' IIi.iI ilflt'l'
Hicy \\rli' rii;.M;.;i il uillilli I In iii\il\, wiiiili wa- llirirc. I lir loiii iil' y la V ilMl imi.
uiiili* l\ in;; on llic liaik. to^ritliii willi ilic iti-|>iriiioi y lone in lii''.il hiii;;
tliloii^'li till- o..liiiiii, ii.iii ilia.vn ill) 111 ll|nMll'il ullil liai kw iil'il In III)' l'< vi"*l **l
wliiili llii'\ hail 111 I oiiM' iiii|iai II il. TId' »iiiall)-l iilii;; «a> luo iiiil iiini n « in
l)'n;:lli ami hall a ii'iil inal n- in )liaiii)'l)'i', iId' lai;,'i'i mii' >iiiii)'u hal thiikii. and
hall' a iriiiiinilD' lon;:i'i . 'I'Id'v wcri' liolli )if tliciii witlinnt i he Imlj;)' on ihi'
I'tlil thai I had olijilrd
Cyst (i|- ihi; Amim m.
'I'\\<» yiiils jiuii (liiiilo II. iMiiylil wmt)' a coiiiiiri'lii'ii-^ivo review
111" wliiit wii'- tlieii kiinun III ilii-i rare di-ea.-ii'. elosiiiL: willi the ln.»tniy
(if il la-e. Hi.- |ialielll oillljilaineil kI' no S_VIII|it(illl.- e\ee|>t tile <|e-
rnnnilv III ill)' Irii iiiaiai' i'e::iiiii ami KJnoivu-laliia! I'dM caiL-eil \i\ ilie
|ire.».-iire nf the Iniie'r. On iiiei-iiiL;- Irei'lv iiitn the eaiiiiie I'li'-a the
liiiliy uall was I'diiiDl tn he aliiii)>t e(im|iletelv ah-oihcd. Si\ty
;.'raiiiiiie.< nf thin, liiiliiil lliiiil were drained away: ihi' liiiinir iiiem-
hraiU' uiidI tn he i-l)i>ely ailhereiil (i> the Imiie. hiirital I'xaiiii-
nalin i(iS)'d iintliiiiL;' ahiioniial. Al'ler wa-hiiiL: niii ihi' lavity
and |i,iikiiiL: it I'nr three da_\< with iiidnrdnii uaiize llie reeii\eiy and
In'aliii;: wer)' iiiieviiit I'nl. A year later there wa> no reliirii of the ey.«t.
l,eiiiio\ liiowiie .-ay.- thai: "Cy-tie >iiiii,-ili.< may oriKiniite in two
wa\>: r>y ili-teii-ion (II <d' l\ iii|ph--|iaee>. c.') <d' thi' i:iaml- aeiiii or
duets. V\'j:. (IS. iiiiiii a pii'iiarat ion hy Alexander, of Uerlin, )'N-
i'in|ililies a eomlition due lo the lii -t-iiaini'd eaii-e. It i.- charaeter-
izi'd hy e\ei'->i\e laiiei'liatioii uT the lione. hy di-ienih'd KJand-duet.-i.
siiliie palehes id' rnuiid-eill iiililt rat ioii. and a ey-t-lik)' iiielii^ion of a
mass of ili-itsed tdands and Idoml-vi-M I-."'
.■t
^4
( i!.\i''n:ij x.wiii
i;illM<»||) IHSKASK.
< ' A I AI.'lillAI. illT''cti(iIl> III' llir clllllliiiil lr;.'iii|i.- ;nr imt of illfli'-
i|ii('iil iirciinciici': iiml in iuiilr i km-, vsIu n ili> iii||;iimi'iI tells iirr imt
(idliiiliil liv till' >uclliiii: 111' tlif -liirniiinliiiu lui-al iiiiiiDsi. tlic tli»-
i;i>r in;iy «llli.»iilf iim! (li>;l|i|Hiir Ultll lllr i:rlirl:ll llrrllllt,' III' lllr
ratiinlllll rnilililimi. W llcll lllc (ills lu'niiiii' lilnrkcd \i\ |i|i'»-urr
I'liilll witlliUlt or rinlii rlllilliZiMHiit 111' lllr miiMIc llllliilllllcd Ii.m|\,
lllf illllilllH'ij ciillililidll.- lililV IiiIm' nil >ll|i|ilir;ltiV(' llrtioli. I'VcIl IC-llh-
iiii: in iHTiiistfiil iilrrnu imi iiml flliiiiniil in'rro^is.
Pathology.- -'I'll Nnliinil Miiikrii/ir lu'lnn-- ihr limiiir nl' lil'iiiiu'
lllc \fil tllilt SI) lIcllM'lv (ili-(Ulri| nlir klMW Iriluc ii|' lllr )iilt lli*|i i^'V
111' llii> n\i:inii. r.v Jill cMi'li-iM' .-crirs dl' iiivc-t ii;;il imi- lir li;!- ;ini\ril
ill the (•(iMcliisioii thill tlif Mi-nillcd iiiVMUiiiitinis (li';.MiU'r;iiii)ii ol' llir
ctliiiiniil is imt (III*' to niiicoiis cliiiiiLri' III iill, liiit to siMi|i|i' iiilliiiii-
matoiy aclimi. In tlii.- \ii\v In' i< .-irnniily .-ii|i|iiirtfil liv .Imiiit lian
\Vri,:;lil. Ill' liclicxrs tliiil iill llic ( liiini^i - rniiinl in ihr iilmioiil crll-
ii'|irc-('iil iiicri'ly siic((s>ivi' .-liii^rs ol' tin' ,-aini' all'i'ct imr, iiinl thai
tilt' re lore divisions and .-iilMlivisions ol' clliiiioidilis tend In intrndiirr
ill) clcnu'iit of ciiiirii-iiin into our |)iilliiilo;jiraI ronci'iitinii nf tlu' di>-
oaso ( l""i;;. li!')-
In o|i[)iisitioii to ^\'llilk^^"s idcii tlnil all t! hiiioiditis is of tlir
iialiiic of ncci'osi.-. Miickcnzii' .-ijilo |)ii>ili\rly. and in this he i-
>ii|i|iorit'(l liy ll;ij(.'k. I hilt |iiiiiilriit ct liiiioidit i,- may ciiduir for Vfurs,
without iModiiciiii:' any lionc-lcsidn. iiiiil that, ihcrcfori'. llic |iro|>o«i-
lion that all cllinioidilis Inids towiird and usually dcvclojjs into niTfo-
sis has no I'oiindalioii in |iiitliii|oL:ical fact. That it diic> so occa.-ioii-
idly. however, he freely admits.
Two other I'iicts he dwell- upon; the niic. that the ethmoid
re<rion iilFords ji most excellent place for the study of the ori^riii of
the so-cidled nasiil jiolypi; the other, the very ^trikin^' similarity tluit*
exists lietween the yminji' ;:ranulation-ti-siie found in the ethmoid
rejrion iind the structure o round-cell siinoma. iiiid hence the possi-
Iiilitv of error in din^jnnsis.
iij
..(*]
176
lUHKASKs (ii iiii: \.\>\t, r.\ssA(ii:s.
MylcH nccfiitiiatcH tun iitii> utant facts in iln {intliulu^v nf ctli-
inoiil tliscnsc.
1. Ill cxtrctiH' pnlypnid cast's tlic ctlimnid is rather linttlc, iitnl
parts laii ca>il_v !»■ iciiinMil.
'J. 'i'lic liniic i.s aliiKot lliiitv liai'il in sii|i|)iinitiv(.> cases.
'riic )iatliol(ij.'y of ctlimoid iiiid aiilral disease reseiiiMes each
other 111 the existence of sii|i|Mirative |irn((«s iiiid in the sij.'iiiltcaiicc
<»f pro-lire in the iiri;.'iii id' em h.
Etiology. 'I'he uri;:!!! i>i the disease is rret|Ueiiily nl)«(iire.
I''!;;, 111'. I Mlhniiiii:il ion "i llir (thiiniiil rclK, >liiiv\ in;; ;;l;iiiil- tu i i;,'lit
(luitr Tinrinnl and tlici>c tu lower Irt't liaml intuc or Icsh iiltci'i'il. In tli<'
cxlirinc lower left the tini'ly tilpiillatcd ti>siie i.s a t'aUe iminlpiani' eoin|io-iei|
of liyaiiiH' tilirin willi a few pus eelln. ^.\fter.l. .Nolaml .Maikeii/ie. i
Xo<:h'cted catiiii'Ii;il iivoccs-cs iiiiiy pniiliice pcniiaiieiit hyper.eniia,
risultitiL' ill retained secretiniis. witli liiial sii|ipiiraiive actidii. It may
SiIm> arise I'rnin pressure of nasal pnlyjii, tlimioh liy many writers siiji-
purafion of the etlimoid cells is hclieved to he the cause of polypoid
disease. Not ini'reiiiicnt ly the cause is an extension of the .snppiira-
ti\c action from the other acces-^ory cavities. Accordinj^ to Mylcs.
l\vo-(liirds (d' the eases are due (o tlii' presence of polypi in the region
i:i iiMciin iiisi;.\fK.
i:r
i<{ iIk' ctliinoid iciU. vnIiiIi' id ntlu r iiiMiiix • s ntropliic rhinitiH is
-fniit'lijiifs llu' iiui.«f.
< '(*ii«iitiitiiiiiiil (U'liililv iii'i.-iii;: li'diii tiilicK r.lnsi-, iiiiili|iniiiit (lis-
t ii'i'. or »\|iliili- iiiny iiIj^o lut n- ii pirdispoHiii;: iiui^c
Symptomatology.- rain nt iln- nmi kI ilic imsr aixl iti llic
iirliiliil iiml ttiiiporjil rf;ii<iiis i« mir n| ihr rnrln'cl symptniiis. TIiIh
IS ii»i'(iait(| ii«iially wiili ili.-cliar^'r nt ni iiiii-fnlorfd \\\\<, uf a iiuto
iir l(■^^ I'liiitl iiilnr. lriiiii till' iiJiii- In -miH' t a.»r«. tiii'ir is prnnii-
liciici' i>v liiil^'iiij: al till' "iflc <i| till iMiii nf ill. iiM-f. 'I'liis, liowovtT,
is not frii|iii nt • \rt pt a.- a it^mIi ni prosiiir truin p"l>pi assncinti'd
Willi llif riliiiiKjii ili»(ii»f, \\ lim tlif antfiinr cclN. wliiili aif twn "r
tliiti in nnnilMr ami >iliiatril cxli'irial In llic antiiinr tnil nl' tlif
mikIiIIc liirliinali'il, air atl'Mtiil. I'Mipjii' ilnna inav Kr pri'scnt from
prcsfiirc npon tlir wall nt iln oiIhi m ij |ni>-inli!tration may ocrnr.
tlirollL'll pi'li'niatioli.. nj' till dllut;'! platr of lllr (' ll IIH ii<l. With tilt'
|iii-t(iinr cell., wliicli an ilu -.,ni. m iii.,!ilii r. tlionL'li Ioniser, llif
pain i- iini .piitf >o scvtTi'.
Diagnosis. .M'tcr rlcan-iHL' tin iia-al pas<a^-c liv the nM' of an
alkaline >pra_v. am! ^Iirinkiiij.' tin' tif;«-Me- \>\ the application of cocaine,
all niher (liscjiscs Iml tlin>.r uf the aices.-oiT sinuses slioiiM he easily
•xeliidefl. In ili^tiiiL'iii^hiiiv elnniohl finin antral <li»ea-< ihe tliiont-
lamp shonlil he of ;:reat >ei\ice. a.- there i- lanly. if ever, an ninhra
in purely ethmoid all'eetions, w lierea> in siippnraiion of the antrum
it is n-iially one of the distin^ruishin;; features. Inirals points out
that, after thorough clran-iiiLr. pus from the antrum may he imted
trickling' down over the middle of the inf.rior tnrhiiiatcd, while in
issnin;: from the ethmoid (dls it llows over the posti'rior end. 'I'Iil'
deep-seated pain produced hy ethmoid disease is also of diagiiostie
\iilue. ili>tinL'ni>hiiii: ii fnnn antral, in which this symptom is usually
wanting;. 'J'he l)nl;:in^f of the I'Vo forwanl iloes not occur as a result
of ( ither antral or -plunoid di<:easp.
Prognosis.- -Simple catarrhal ethnioiditi-: under^rnes re^cduiion in
unison with tlu^ acute rhinitis to which it owes its ori.L'in. Woakes's
necrosin<r elhnioidiii>. in wliieli varies of the hone exists, is a much
more -erious alVair. and little likely lo re-iilt in ahsohite euro. Sup-
piiiative ethmoiditis, occupyiiii: a niedmni position hetwcen the two,
.-hoiild he ameiiahle to treatment, and ic-uli in enre in the majority
of instanees.
The disease is imt daiit'erous to life unless it extends to the
(M'anial onvity. More fre(|ueiitly. owinj: to the thinness nf the walls
•Ii '^
;■■• 'it
1T8
DISKASKS OF THE NASA I, PASSAGKS.
and its i)r().\iiiiit}' to the ove, the (irbil hfcoines atri'cted, soiuetiiiios
resulting in ahocess. Operative treatment, combined with thorough
(•leansing and drainage, is often prnduelive oi' godd icsults.
Treatment, — In mild cases, unattended hy hyiiertrophy, shrink-
ing the jiarts with cocaine, and J'oUowing this with sprays ol' solu-
tions of either l.")-volume j)eroxide of liydrogen, boric acid, or resor-
< in, should relieve the disease and (juickly result in cure.
Any of the al'ove miLrht be used as follow-: —
I. H reroxiilc 111
In III ii<'cii ( |o
:\(liiiuii ml .SOI
^r.
■J. H Acid, h.irir 2
(ilyccriiii 4
AfiUiiiii at ."U)
.\r.
:!. H Itc-inciii 1
Ainiaiii ad 30
In severe eases wlu re suppuration exists without nccrosi.-, oper-
ative treatment will be necessary. Polyj)!, if present, should be re-
moved. Also any granulation-tissue that may apjjcar in the neighl)or-
hood of the cells. This may bo done by curetting or cauterization,
and will clear the way for the antiseptic treatment already referred to.
Direct opening of the ethmoid cells above the middle turbinated is
a diilieult operation. V>y removing the anterior end of this body it
ean be better aeeomplished and the anterior ethmoid cells more easily
reached. This can be done by the use of tlie cold snare, curved scis-
sors, gouge, cutting-forceps, or (Iriinwald's fnrceps. The cells can
be reached by gonge and curette. '^I'he main features after operaMon
are antiseiitic treatment and free drainage. The ajiplication of lactic
acid is sometimes followed by the best residts. (Jleitsmann favors
the application of strong solutions of nitrate of silver in many of
1. R rcroxiJe of liydinfri'ii 3ij.
Aqiuim ad .^j.
•2. B Acid, boric prr. xxx.
(Myccrini Sj.
Aquam ad .^j.
.'). It TJcsorcin Rr. xv.
Aquam ail 5j.
M.
KTIl.M(HI) I»1M;a.-.K.
ITii
tlii'M. CM,., a cue luMii- ol.fainc.l l.y the combined siiru-i,,,! aiul lo.al
iroatment m some iiistaiuos in one or two months. Jle al-o 1 ,v<
stivss on the importance of alhnvin- the reaction of one curett..mcnt
to inu<s ofT before another i.s accompli.she,] in cases \Nh..ie this „|,er-
iitioii is necessary.
:^lvles drills or gouges an opening tliroii-h the lloors of \\w an-
I"''""" ""'^ !'"-^l^'nor cells, and then uith the antero-po>terior and
lateral clippers cuts away as much of thr lloors as he con^ider^ nece-
^ary. All his patients treated l.y ,1,1^ nntlmd were relieved an,i ...me
cured
ill
i 'I
( IIAPTKR XXXI v.
Sl'HKNOIl) DISKASK.
SiMi'i.i: ciitiirrlial di.-iiix' dl' I lie splionoid sinuses is proiiahly, like
the siiiiilar disease ol' tlic etiiuinicl ci'lls, of frequent occurrence. Tiic
syiiiploius, however, are so masked hy tlie associated diseases of the
rhinal i'ossa' that they are unol»sfrved, and tiie course and recovery
hccome essentially uiieveiitful. Tlie situation of th(; sphenoid sinus
i< seen in Fin. 5.
Su])puration of (lie sphenoid sinus, on the other hand, althoujrh
still very ohscurc, is a much more scrinus afVeetion, and may lead to
dangerous results. The symptoms, unfortunately, are not by any
means distinctive, and it is dilVicult to diagnose it with any degree
of certainty from the ethmoid disease. The etiological and patho-
logical conditions are nnich the same; and the deep-seated pain of
the j)ost-cthmoid cells is dilTicult to distinguish from the deep-soated
jiain of the sphenoid. 'I'lie discharge, similar to that from tlie other
accessory cavities, flows more naturally down the post-pliarynx, though
a certain amount linds it way over the turbinated bodies. The eye
symptoms are also similar, inasmuch as a larger ])lane of the sphenoid
enters into the formation of the orbital cavity than can be said of
the etiimoid, although bulging of tht; eyeball is usually an absent
(juantily.
In some cases after shrinkage by cocaine the jirobe can be passed
gently upward and backward over the lower part of the middle tur-
binated, between it and the septum into the s[)lienoid sinus, and.
after drying tlie passage, a small pledget of cotton ])assed in on a
holder would indicate whether pus was in the sinus or not.
J'latean reports, in the Joiirndl of fjariinfiolofiii, etc., for IS!)").
having treated 2(i cases of empyema of the sphenoid. Only once ha<l
he seen it in connection with oza-na; ])oly]»i were rarely present, ex-
cept in cases in which the ethmoid and s|)henoid disease were asso-
ciated with each other, 'i'he most comnuui conijdication fouiul in
this large r.uniber wa< with disease of the ethmoid cells. Tn many
cases the etiology was d(Uilitfiil. but in other eases it foUoweil as a
secpiel of exantheniatons disea.ses. In treatment he found that per-
foration into the sinus, with subse(|uenl cleansing and free discharge,
was necessary, llolbrook Ciirti'^^ has devised an instrument for
(1S(»)
I
bl'IIKNOili I)ISI:ASI:. IltONT.VI, diskask.
isi
iiTi<j;ating the siiuis after trephining, tlie ])atient being able tti intro-
<iiice the tube of tlie irrigator into the sinus withnut dilliculty.
Ilajek'e liook is said to l)e tlie best instrument lov curetting the;
eavity.
IJosenburg luis lurnishcd some iu'eresting facts al)()Ul lliis nl}-
scure disease wliich are worthy of mention, lie says tliat tiie age
of jtatients vary fi'iun ]1» to :>."> yi'arr:. and th:.t ii never arises as the
residt of syj)liilis or serofida. The distance from the spina nasalis
anterior to tlie anterior wall of the sphenoid sinus i< from (> to 7..'
centimetres, averaging ('>.S centimetres; and to the posterior wall nf
the same from 7 to 10 ccntimi'tres, averaging 8.5. The amniinl of
space in the twc nasal fuss;e varies so mucli in certain cases that the
twisted se])tum will allow a probe lo be passed through the one nasal
fossa into the siiiu- on the opposite side. He deseriix'S the sidijeetive
symptoms to be: burning in the iu)se; pain at the root of the nose,
over the eye, and in the tcm]ioral region; shooling pains in the head,
and a feeling of stulViness. In one of his cases, attendci by severe
pain in the head, no pus could be seen, but, after the re uoval of the
hypertrophied middle turbinated, ])us ilowed down from the sinus
and the pain immediately disajipeared.
In dealing witli (his subject, in a recent able article, .Myles says:
''The sphenoid cells are not so dilficult to open as some are inclined
to think, in cases where the septa are moderately straight and where
the jiosterior end of the middle turbinated bone has been removed,
the oozing pus can be easily delected at the point of the natural open-
ing, high up ami near the septum. The probe will often enter after
caieful use; a small, sharp, linn curette passed in and Ihen pulled
outward will often tear away the sidt's of the ojiening sulliciently for
good drainage. T ilo not consider it safe to curette the upper and
external walls of these sinuses. Cart'fid scraping of the anterior wall
ami the floor often produces decidedly beneficial results."
I'ifON r AI.-SlMS DlSKASK.
Disease of Hie reiiuiiiiiug aci'cssory cavity, the fi(Uita! sinus, is a
very wide subject, and an exceedingly important nn(>. It falls natu-
rally, however, under the domain of the oculist, ami hence is usually
treated by him. 'i'his vohune is a treatise upon the nose and throat
(Uily, and, conseipiently, can leave fronlal-sinu-; disease, without ju'cju-
dice, within (he limits of its own ))roper sphere (Fig. 2).
' -l H
f
!
!i
m
ll
If.
£
SECTION II.
Diseases of th(> Pharynx.
li
if
■fa
"1^ .
m
n
.1
\
i 1 '
( llAiTKU XXXV.
ANATOMY OK TlIK IMIAKW-X.
Till; jiliiiryiix is a iiiusrulo-iiH'iiiliiiiiiPU.s .-;k-, lying 'irlwci'ii tlu'
hack of the noso ami tlic (I'sopliagus. Thr base is iipwaid Ix'iuMlli I he
base i)i the skuU, and llie apex downward trniiiiiatiiig in the (I'soph-
agus, and on a li'vcl with tlic crii'oid carlihigv' and lilth ciTviial
vertehra. It is .-iliiatcd hchind the no-c, nioulh, anti hiryiix. In
length il is Ix'twi.en tm and eleven i-eiii iimtres. and it is limader
laterally than iielore haikwanl. lis greatest hicadlh is midway lie-
tween tlie jialate' and the (e.-(i|)hagus, and its nai'r()we.-l at the lesipph-
ageal termination (I'igs. TO and 71).
The houndaries oi' the ]>haryn\ are, as I'dol'. the liasilar pr(pee>s of
the oeeiitil.d lioiie; and, as lloor, the entrance to the (esophagus, the
right and left sinn.- pyrifoiinis, and the aryteimid cartilages and I'om-
inissnre of the larynx, rn-teiiorly it is separated from the iipjier
four cervical vertebra' in the lentre and the reeti capitis antici ami
Iniigi cdlli inuscdes at the sides by loose areolar tissue. The promi-
nence of the arch id' t1ie alias may oi'leii be recognized near the upper
cMreinity of this .--uil'aiH'. Tiic iiiiterior hiuindaiy i-; f(Uincd by toe
posterior nares. Mjiarated by the \(inier. the internal pterygoid plates,
the soft ]ialatc, the t(Uigue when the mouth is closed, the hyoid bone,
iind the epiglottis. Mach lateral wall is marked at its uppiT eml by
the pharyngeal (U-ilice cd' the l'".u?taehian tube ami the I'os.-a of K'om'U-
uiiiller. ami is connected with the >lyloid processes and Ihi'ir muscles.
This wall is also in I'ontact with the common and internal carotid
arteries and internal jugular veins and with the eightli. ninth, ami
symjiathetie nerves.
There are seven openings into tlu' pharynx: the two piistcrior
nares, the two iMistaeliian tubes, the UKUitli, the larynx, and the
(esophagus. As described in dealing with the tuiM'. the |io>terior
nares are the oval openings which enter the |iharyux on the anterior
wall almost on a level with the vault. The two j-liistachian tubes
opi'U one on each side of the pharynx, almost directly behind the in-
ferior meatus. The miuiili.- (d' these lubes are ovoid, or funnel-
sliai)ed; Ifoosa describes them as ■"trumpet-shaped orifices, nine milli-
metres high and five millimetres broad."' The opening of the tul)e
(185)
I'll
•I :■•!
il If
T
r
1 '';■
■
1
1
i
!
1
!
1
!
18(5
DISKASKS UK niK I'HAHYN.X.
is ]i,'irlly .-iirioiiiuk'd by a cartiliiginous ring, which in iiior^t jjromiiu'nt
jiostorinrly iind ahovo, lifrhtcr in front, and aliscnt lioncath. liohind
the I'liistaehian orifice, and hclwcfn it and the posterior wall of the
pharynx its an eimiixati'd (h'prcssion: the I'ossa of Hosenniiiller. While
at rest the Kustaohian orifice in closed; hnt in the various motions of
H'
Nasopharynx. <
Oro-pliarynx. ^
Laryiif^o-iihaiynx.
rif^. 70.- Si'ctioiuil \ i«'w of tlie pliurynx. 1. Left Eustachian tube.
2, I.oft fossa of Kosonniiillrr. 3, Palate and uvula. 4, Tongue. 5, Left
tonsil. 6, 0, Upper and lower houndary of larynx (epiglottis and cricoid
rartiliige). 7, Cavity of narcs. 8, Cavity of mouth. (After Lennox
Browne.)
>»i:
the fauces it is frequently opened hy the contraction of the tensor-
palati muscles.
Directly l)e]iind and below the posterior narcs lies the superior
surface of tlie soft palate, with the uvula in its centre. Below that the
mouth, then the l)ase of the tongue, epiglottis, and larynx. The
oesophageal opening is the apex of the pharyngeal cavity.
il:K
IP
r-
l'"ii.'. 71. l-'ni/t'ii ~i'(linii. Siiic \ic\\ nt' ii"-i'. |iliaiyii\. iiinl hirviix of
iliild. iijicd :> \ciir-. I. I'mdv (il •i|p|iciinicl. 1. I'll liiiKiid cells :itid -ii]>i'ricii-
llK'iltUs. :!. Middli' llii liiiiiilcd l"iiic. 4. Midillf iiiralii-. .">. Iiifciior liir
liiiiat('<l liniit'. 11. XCstilndc uf llic nose. 7. Sii|n'ii(ir iiiiixillaiy liniic. s.
Soft palatf. !•. TciiiiiiK'. Id. Na-i()|iliar.\ ii\. II. I'!|ii,i;lnt( is. |-J. |,aryn\.
I l''r(iiii I'liiiirusc"-. .\iia1iiiiii(al Miisiimi. I'liix crsilv <it 'riirniitd. i
I
:
ANAIOMV UK Tin: I'll \ltVN\.
isn
'I'lit' |ili;irviix is fuiiipnM'd ui tlirci' ((iiil*: ii iiiiunii.- ciiat, a Uliruu.s
cnjit. iiiul a niiiscuhir layor hi'iu'iitli. 'I'lu' iiiiisciilar cnat {•()iisi.>ts of
the .-uinridr, iiiiildlc. and iiifcridi- coii.-t riilnr.-; tin- Icvaturcs palati,
mid the ti'iisorcs palati. to^itlur uiili the >t_\ lt>-pliai_viii:<'i and |ialato-
jilianiiLTfi ami |ialat<>-^i()>..i iniisclfs, a I'ldlcr acciniiit nl' uliidi wdl
1)0 I'uiiiid in the standard wniks dii atiatnniy (Ki;,'. t'-i).
Tlic (ilinuis coat is sitiiatol lictwci'ii tin' iiiiisciilar and iniicnn-;
layers; and is termed tlie |iliaryn;:i'al a|iiineiir(isis. It i» thick ai)ove.
'*
('(•l)lialo-
or Naso |iliiiryn\. '
Ilyo- (ir
(Mil jiliaryiiN. <
F.iiryti>,'o-
|iliiiiyii\. '
]"ip. 7'2. 7 ho niusclcs of ttip soft juilato and pliaryiix: tlie pliarynx
laid open frotn t)rJiind (niodilitd from (Jiay). 1, 1, Lcvutorcs pahiti, the
loft lioitifj out short noar to its oriijiii. 2, 12, Toiisoros palati, tho loft siiow -
inj; its rofloctocl tondon and relation to tho hainular process {a). ,3, .'t.
I'alato plossi (.antorior pillars of tho fanoos). 4, 4, Palato-pharynfjoi (pos-
terior pillars of the faiicos). 5, 5, Tonsils. 0, A/y};ns tivnltv. 7, Uvula.
S, 8, Eustaohian tubes. 9, 0, Inferior constrietors (larynfjo-pharynfjoi).
10, 10, ^liddle eonstrietors (hyo- or oro- pharyn<;ei). 11, 11, Superior
oonstrietors (ccphalo- or naso- |)harj'nfTei). 12, 12, Epiglottis and laryn.x
not laid open. f.Vftor Lennox Browne).
I i
I I
IDII
DISKASMS OK TIIK I'HAUYNX.
Ilcn- tlic niu>('iilar lilms arc iiiisciii ami llic lilinni.'* cual i> altadicd
lirnily tn llir li.i>ilar pi'iH'cSii; of llu- iM'ri|iiial ami ilic |i*'irniis |)nrtiiiii
of I lie tcm|ii'i-,i! liiiiH'. As ii (IcMcml.-, it licinMics ^rradiially li»t in
llic Hue iiiiL-ciiLii' cital lii'iiciitli it.
Till' iiiiicdii- liiviT is iiiiitimiiiii.« with that ul' ihr iiair-., Mii-
slachian tiilirs, iin<iilh. iiiid lai'Viix. 'I'Ih' ii|i|m'|' .^iirlaii' i>|' thf Mij't
palati', with (he \aiill ul' the |>liai'vii\ dnw n as lnu as llir llo ir of llir
iiai'i's, is I'oNi'i'id uitii (iijiiiiiiiai' cdiatcil I'lnthciiiiiiu while in thr oral
part of till' pliar\>i\. IhIow ihc palalf. ihi' cpiiiii liiim is of the
siinaiiioiis variciv ,
'I'lic iiioxciiicMl- of ihr soft palaii' aic lonliojlcd liv ihr Icvator-
palati. palato-|»hai\vii.L;ti. ami a/\\i;o«-ii\ ida' iiiii-clcs. of which this
llr\ili|c piece of me(haili»lll i- (•o||ipo>ed. Se\e|al of ihe-e !llll>il('»
have al.-o a direct relation to the I'.ii-lai liiaii tnhe> hy opciiiiiLr theiii
wlieti Tieces>ary to admit the i iitraiice of air.
'I he pharvii'jial i:laiiil> are of two kiml.«: lln follicular, -iiiiple
and compniind. -caller( d t hi'oiiiiliniii the pliar_\n\ lieiiealh llie iiincoii-
iiicnihrane; and llie racciii<i-e. in the upper |iliar_vn\ helwccii ihe
I'liislachiaii |iilie~.
'i'lic arterie- are >iippli(d frmn the a-cendiiiLr pharyii.LTeal. the
jialatal hraneh of the facial. toL'cthcr with hraiicho.s of the internal
maxillary.
The \cins Ciller inlo the inlcrnal jnL.Milar.
'i'he iier\cs are derived from the second and lliinl divi-ion- of
the tiflh, to^-cihcr with hram-hes from the e|i)>.;,i-|i|iiii viiLTcal and llie
vaiTiis.
ic pharynv. owinu' to its rclalinn In the nose at the oiu' end,
and the lar\n\ and (e,-npliai:iis at (he other, (oi:ether wilh the fact
that its posti'rioi' wall i.- an nninterrupled siiid'ace. may he considered
as a single division (d' the respiratory tiact. For physioloudcal as
Mcll as palh(dou;ieal rcaMiiis, however, it is u>ually considered to \)v
divided into two sections hy ihe soft Malato, known a^ the nasn-
pharynx ami the oro-pharynx.
in the nasii-pliarynx, the tissue or plu.i'yiiLreal tonsil >ituatcd on
the hack wail and upon the hase (d' the occipital hone, and known
by the older anatomists as tlu' racemose irlaiids, frcipicntly nnderjrocs
oiiorinoiis development (Fij:s. T;> am' Tl). In its natural state it pre-
Fcnts a .«oft, cnsliion-like surface. It is sometimes covered with
rounded elevations. At otliers divided hy deeji fissures, runninij; chiefly
in a per])endicnlar or lonuitudinal direction. This mass of ijlamls is
! I
;l( t
on
All
rt'-
th
"lly
is
ANATOMY <»K Till: I'llAHYNX.
191
cnllcil tln' |ili!ir\ ii^riil tiin:'il, (T I-ii-clika's tnnsil. in liMimr ul tlif iniiii
uIki liist l:ii\'' ii lull imntiiiuiciil <l('Sfripti<iti of it. In llir jnut r |i;iri n|"
til*' tiiii..il III ill*' iiii'ijiiil line is smiirtiiiu's loiind a siiuill uiicniiii: li'iiiliii.i;
into tlic >i\f. ciillfd till' Itiirsa itliarvii^rca. 'I'liis sac iiiav lif I'nun niu*
III Iwn tflllilllrtrrs liillL.' ilinl Irolll tlllCc In si\ III ill llllcl fi- \U(I». Ill
till' iiaiiiiiil -lalc till- |iliaiviiui al cii-liiun ^Imiilil iirMi' in aiiv pail
nt' it lie iiiMji' than I'nur t<i .-iv iniHlnirtrt'.-. in lliickiu',--. ^'railiially
lliiniiiiiL' away Inuaiil il- miti i' inaiLini-.
'I'll r I' \i I I \ I 'ruNsii.s.
'I'llf^f \\\<t lOlind nV alll|n|l(|-.-|iapl(| linilir« (1(1 IKit llcldllL' I" IlK'
|i!iai\n\ |irii|i('r. Inn arc -cparalcd iidiii il (Hi cadi -idc \>\ (iic palalo-
pliai\ iit:cii« iiiii-( Ic. Till y lie liciwccn ihc antciidr ami pd-tcrjor pil-
lai> (if the I'aiicc*. and diii(tl\ ain'Vc the Ka-c nf the Idicjuc. 'I'licir
direct anat'iinical rclalidii.- arc ihn- (lc-cril(((| hy l>clavan: "The rc-
latinii> d!" Ihc Idii-ij 'ii the inleiiial carnlid artciv arc iidt so intiinatc
as cdiiiiiidnly -nppdscd, I'dr hel\\(cii the laleial uall dl the pharynx,
the inlcnial plci'vuniii. and ihc upper cervical vcrlchia' there is a
s|»aee (illcd with cdliihir ti.-siic. the pliaryiiird-maxillaiy inlerspace.
ill the pd-li iidr pari i>( uhii h arc locfited the lar^c vc>scN and nerves,
and which lies alnid^t dircdly hackuard I'rdiii ihc pharynnd-palatine
arch, 'i'lie tdii>i| Cdric-pdiid- to llic aiilciidr pari dl' lhi» interspace.
.-(> that lidtli eai'dlids arc hchiiid it. -the iiiicrnal cardlid dUc and
live-tciiths ceiiliinct res. the cMeriial cardlid lud cent iiiicl res. distant
Troiii its lateral peri|ihery."
The t'Uisil may iie dcserilied as cdinpd-cd (d' lyniphnid li>>uc. It
presents nii its (inter -iirl'aee a nuiiilier id' orifices varyiiiLi' I'min five
or six to a dozen in niimhcr. leading;' ddun td the deep crvpt- of ilic
tonsil, licsides tlii>e. fidiii tlic rc>earclic« id' His. and iliiriii;^' the past
year of 1>. X. I'atcrsnn. \\e have had diauii to mir notice the evistciieo
ill tlio upper part of the inn-il id' an anatoiiiical space called the
-npratonsillar fo>sa. In the majdriiy nf instances careful examina-
lioit will reveal a >mall recess in this sitnatidii, clusc In the anterior
palatal arch, liavini: a diU'ereiit fdldiii'i and hein,::' mucli lai'L'er in
every way than an ordinary crypt.
In youiii;' sidijects. particularly, a wch nf ineiiilnane is frciiiicntly
attached to the hdi'dcr of the anterior pillar, cxfeiidinu' downward
and hack ward over ihc toii-il. It is called I he plica trianirularis: and
it is hetweon this ]dica and the ii]iper portion of the tmisil that tlio
snpratonsillar fossa is foniid.
III
in;
DISEASES or THE PHARYNX.
Tho lyni])lioid tissue consists of two kinds: lympli-piilp and
lyinpli-nodules. Tlio pulp constitutes tliu greater part of the tonsil.
The nodules form ten or twelve oval or round masses, immediately
below the walls of the erypts, and situated within the lymph-pulp.
They dilfer from, while in some respects they rcsciid)lc, tlie Mal-
pi;fhiaii hudit's nf ihe spleen. Tliey are surrounded hy a dark zone of
reticular tissue.
The lyini)li-pul|) consists (>f lymphocytes inclosed in a delicate
reticulum. The cells are lar;:t'r and the reticulum coarser than in
tho nodules. The reticulum is fornu'd of elonpded cells inclosinL:j
lymiih-spaees through wlmse walls lymph and migratory corpu.^les
readily pass from the capillaries. (Lennn.v IJi'owne.)
Thi; LiNciAi. Tonsils.
At the hase df the tonuue on either side of the ,<:losso-epiji;lotlic
lold are situated two irrcizular nodular masses, varyin^tx widely in
degree of developnu'iit and of form. These are known as (he lingual
tonsils, llisfdiiigieally they ai'e identical with the i'aucial tonsils.
The crypts are sometimes, however, lined witli ciliad'd epilludium,
and the cellular tissue is mine dense than in (he i'aucial region.
Another important point in regard to them: they freiinently do not
commence to develop until adult life, — the ]ieriod when the faucial
tonsils have commenced to disappear.
lii
fiiAi''ii:u xxxvi.
PiiYSioi.ocv OF III!-; i'iiAi;v\x.
Till-; ])hysiulnifical fiiiictit)iis of the iiaM)-|)liiirviii:\'al iiml (uo-
l)liaryng(.'al divi.^idiis of the plinryiix an.' in .-oiiio rcspucls very <lis-
tinet from each other.
The foriiicr ha- hirgely respiralni'v fiiiictii)n.s to perforin, and.
like tile li;\ver half of the nasal pa.ssages, is .-npplied wiih cohinuiar
ciliated epithelinni. lo aid in keejting the ])as.saue free from any
secretions which might im])ede normal respiration. The naso-pharynx
is also richly endowed with the glands (d' the pliaryiigeal tonsil, whose
s])eeial function api)ears to he to secrete clear, C(dorlcss nuu^ns for
the purpose of moistening and keeping pliahle the surrounding tis-
sues and to help to lubricate the food ere it leaves the ()ro-])harynx
for the lower alimentary canal.
The sid't palate, or velum peiidnlnni palati, hanging m mid-
position in the ])harynx, has several functional duties to perform.
Hy ])ressing tightly the ]io>t-phai'yngeal wall diiriii'i the act of
swallowing, it completely divides the pharynx into two jiarts, and
etfeclually iircvents food whether solid or lluid from entering llu'
naso-pharynx. At the same tinw. hy its jiressure u|iward ami back-
\vard, it forces down into the oial cavity the nnicons secretion already
spoken of. ll also ])lays a very important pai't in the fuiu-tion of
voiee-production, which will he spoken of mon' fully when dt'aling
with the larynx.
The tissues of the oro-pharynx are of harder and denser texture
Than those (d' the naso-pharynx. Tiiis enables it to perform the
duties of deglutition without injury to its llexible surface. It has
fewer glands than the naso-pharynx, and depends largely for the
moisture and lubi'ication it reipnres upon the salivary glands and the
mucous discharge from the jiharyngeal tonsil.
Deglutition is a complex movement. After mastication the food
is forced backward by the t'muue pressing gradually fr(uu the lip
to the base against the hard ))alate. As it reaches the pharynx, the
faucial muscles come into play, forcing it still farther backward and
downward, while the i)alato-i)haryngei and levator-palati muscles pre-
(193)
il«
11 i
394
niSKASKS OF THK IMIAUYNX.
vent its pjissii^fc into tlic ii|»|)ur pharynx. At tlic moment tliat tin*
fancial muscles eoiilraet, tlie miHcles of the liyoid bone draw up the
larynx Itehind the base oJ' tli<' ton;.aie. l>y means of tliis comph'X move-
ment tlie epi^hittis is tilted l)aek\\!ird, and the whole of tlie oro-
pliarvnx is transformed into a funnel, down which the food is forced
hy muscular action into the tcsophaj^us.
'J'he pliysioio^ical fuiutions (d' the tonsils liav(^ h)njj; l)een an
oljject of investi,iration. Formerly it was the prevailing impression
that they were secret iiiLi' bodies, the object (d' the secretion hein^ to
prepare the food for dcLilutition. At a latter (hiy it was claimed that,
like lymphatic structures generally, iheir nussion was the production
of white eor|)US(des of the l)lood. Jlingston Fox and Seanes Spicer
lield this view, while the former gave them another mission: ihat
of reahsorption of the salivary secretions after defrlutition had been
accomjilished. Swain suggests that tiieir real function may lie ti>
destroy jiathogeuic germs entering the mouth with the food; thu.-.
the lymphatic cells or leucocytes of tlu.' tonsils would do the work of
scavengers or phagocytes. J'osworth believes that, whatever tlu'ii'
function, they are really absorbent organs, and that yet the crypts and
tubular glands of the tonsil would iTidicafe a secretory power, how-
ever limited. Bruschke is of tlu; opinion thai the tonsil, without
being ulcerated or inllanu'd, may be the |)oint of entrance for pyo-
genic micro-organisms. Semon also found evidence that the infect-
ing micro-organisms in septic inllammalion of the pharynx gain
entrance through the tonsillar crypts: and Wagner, of San Francisco.
has shown that rheumatism may be due to migration (d' germs from
the tonsillar tissiu'. lie has fouiul the same micro-organisms in the
synovial fluid of the knee-joint in two instances, and in the urine of
nearly all his eases, as existed in their diseased tonsils, of which the
clinical history proved they were (piite free, [irior to the attack of
tonsillar disease.
These opinions would seem to be ai variance with the somewhat
prevalent one, of ili(> existence of ])hysiological. tonsillar pliagocytosis.
DISKASKS OK 'I'll I". XASO-I'HAK VN X.
ClIArTKH XXX VII.
N'Aso i'iiai;v\(;i:ai. cataimiii.
'rjii> disease niiiy iipiHiir in an aciHi' or c-hronic I'lU'iii. Ii is
sdiiicwiiat rare. liowi'Ver. I'm' it to fall intn tln' liamls nf the iihysician
ill I he acute slajre. When it (1(H's, it is usually an (•\ti'n>ion of or
accniiipaiiiiiiciif to acute rliiiiiti-. as the ili.-ca-i' i- iiKirc likely to cx-
tfiid from liefni'c backward than fri)tn the lower pharynx to the
vault above. When ft)rtunately treated as an acute disease, it is at-
ten<led by similar sym[)toms to those of acute rhiniti-, and, lieini;'
associated with it, is amenable to similar treatment.
Tlu' subacute, or chronic, bu'in. however. re([ui!'e> distinct con-
sideration.
Pathology. — In this disease thei'e is thickeneil na.-o-pharynucal
mucosa alTeetini: particularly the muciparous Lrlands of the pharyn-
geal tonsil. Wiiercver these irlamls are clustered to.trethei' in large
uumbcrs, there is a preclisposition to chronic inllammatory disease
and cell-des(|uamation. This is particularly so in ihe |iharynfreal
vault; and, whenever a proximate cause exists, a muco-iiurulent dis-
charge from the evenly-distributed mass of glandular structures may
be tlic result. This chronic inllammatory action is usually attendeil
liy more or less hyperplasia. liosworth believes that the sac or cavity
called Luschka's or Tcu'nwaldt's bursa is not a natural condition, but
the result of inllammatory action. I'y it. the iwn lateral lobe-, into
which the pharyngeal tcmsil is sometimes divided, ai'c swollen ami
crowded together, and the superficial layer (d" epithelium on the (uie
side unites with the epithtdial layer on the other, the intei'ior being
left open, thus forming the so-called luirsa.
in th(>se cases, as well as those in which the hyperplasia is more
uniform ami unattended l)y bursal dovelopnu'nt, the surface nuiy
assume a mamnullated or raspberry-like contour. This lymph-tissuo
(IDa)
111
W
m
d(
iii
; I- I
i'JO
DISKASKS Ol' JlIi; I'llAUYNX.
I
is well supplied with blood-vessels, but with few acinous glands, and
hence is dilVerently formed than ordiiuiry gland-tissue. It is supposed
that tiie increased secreli(jii, not liaving an aciiu)us origin, must be
formed in the sulci or fissures which separate the hypertrophied lobules
from each other. When Tdi'uwaldt's bursa exists, its lining mem-
brane may also proihu'e much of the discharge which occurs in this
disease.
Etiology. — Meteorological changes in atmospheric conditions are
fre(juenfly the exciting cause of this disease, particularly on the lower
levels and along the uatei'-ways. Throughout the extensive lake-
region of North America this disease is very common. The cold, damp
winds that prevail so extensively along the laki's iluring the change-
able seasojis of fall and spring, cliilling the cutaneous surfaces, pro-
duce congestion of the naso-pharyiigeal mucosa and lead to the chronic
inflammation which exists so widely during these seasons of the year.
Iidialed dust may also be a factor in some cases. l)ut can only lie of
moment wlicii tlic situation is di'v and elevated and away from the
hike-region.
In mountainous districts. Imwcvcr, and on the extensive iidand
prairies there may mii be sullicicut natural cxosmnsis from the tur-
biiialt'ds to saturate the air as it is ins[)ir(Ml. In ihese cases dry, dusty
air may pass through the nares aiul strike against the post-iihniynu-eal
wall, inducing chronic iiiliammation and catarrh.
The conse(iuence is that these two causes alone, from theii- varied
features of humidity and altitude, may produce two entirely dilVen'ut
varieties of post-nasal catai'rh: the luie hypertrophic, the other atro-
jjhic. Or, in other words, the "moist" catarrh prevails with the lake-
<lwellers, while the "dry" catarrl holds sway upon the elevated plains.
The tendency among chih.ren to disease of lym])hatic tissues
would lead us to look for nar.)-])haryngi'al catarrh most freipu'iilly in
early life; ^louri .says tliat it is even common among infants.
We ai'c not sufhciently cognizant of the fact that une([ual nasal
hreathing beai's, in many instances, a direct relation to it also. In a
large munber of instances the eomjiarative respiratory freedom of the
two nostrils bears the relation of one to two or one to three. What-
ever produces freedom of res])iration In one nostril at the expense of
the other tends to accumulation of secretion behind tlu' stenosed re-
gion, and that accumulation results in disorganization of tissue and
catarrhal disi'ase.
Charles Knight has shown conclusively that exostosis of the sep-
N'ASO-l'HARYNGEAL CATAUIUI.
1!»1
luiii is a fi'LHjiiL'iu causo of chroiiio iiaso-plianni^tal dirioaso. Tlu'
l/oiiy projt'otioii is usually in the i'unu of a souunvliat irrogular ridm'
niniiin<,^ froui before backward alonj,' the osseous sepluin. parallel with
the lluor of the iio.-r. Soinetiiues it is even adherent to the infeiiof
(iiriiiiiated. l)i>ehar;:('s are retained liehind the obstruetiou, oti'a-
sioiiiuLT ]iutrefaetioii ami conseipieiit iuereased irritation. Wliile eon-
(k'luiiinii' nllicious operative^ treatment in all cases, the indieations are
elear to remove the ohstrnetive lesion and hv this means to produce
etlicient diainaLic.
]n atr()|)liie rhinitis naso-pharyn^n'al catarrh is always tlie result,
'i'he vault of the pharynx is in no way supplied with the ven'ous sinuses
of the turhinateds; so when the air, nn account of turhiual atrophy,
fails to reach the ])oint of saluiation in passiiiL:' thr<iunh the nasal
])a>>ai;es. it (piiekly dries u]) the seaidy secretion of the phai'yn-''eal
vault, Icavinii- hei'e the inspissated mucus, which it is so often dillicull
to remo\c.
This disease is said to he more prevalent in America than in Ku-
ropc.
Another cause, parliculai'iy in oui' iai'^e cities, owes its orijiin to
our suj)posed advaiucd civilizalion. Naso-pharyn.ii'eal catarih anion,:^'
the ahoriyiiU'S of the various continents is almost an unknown ([uaii-
tity; hut in our fnrnacedu'ated homes, with tlic intciisi; dryne^s of
the air, it is anioULT the commoiu'st of catarrhal atl'eclioi'.s.
Let a man wearing;' speciades enter a house in tlie wiider-lime
comfcu'tahly heated by >toves oi' lire-])laces, and immediately ilie nioi.-t-
ure of the atmo.-phere will condense upon the j,dasses, and make vision
throu.trh them impossible; and without he dries them, it will take sev-
eral miindes helore the ^la.-> will acijuire the teiuju'ratiin of the room,
and pernut of dryiui;- by evap(ualion. l>ct the same man, on the othei'
hand, enter a house heated by a hot-air furnace, and the ylass will re-
main iterfectly dry, inasnnich as the air contains too little moisture to
))ei'mit of condensation.
The rcas(ui of this is that furmic(! manul'actui'eis hav(.' too little
knowledge of pneumatics and hydrostatics to build furnaces correctly.
A water-])an for evaporation i> supplied with each liirnace; but il is
usually altogether too small ami too remote from the lire to he of
material l)ene(lt. My own furnace is a case in poiid. It was consti-
tided on tlu; regular ortluxhtx ]ilan ami the water-pan evaporated a
pailful of water per day. Ihit the air was so dry as to he distressing
to the nuicous mendu'anes. Thi- hnted oiu' winter. The second season
M
iliill
!■ i
nil
iil
11»8
Dlt^KASKS Ol'" Tin; I'llAUV.NN.
tfl''
ilf
I liiid tlio huildcr piil in a liirjrc rxini wati-r-piui, rijrlit in tlio I'lirnaco-
wall aiul alxivc tlic coal sliiitf. Tliis cvaporatctl nearly three times
as mueli water jter day as did the first mie; and the two toiffther
made the h(iii>e a i^i'eat deal ukhc eoinl'nrlalde. Of enur>e, eare had
te. he taken aijainsl too alii'ii|it ehanufes t^i tem|iei'at lire in liunishiiiu
llie \alei'-su|t|ily.
Symptomatology. The eailie>t symplnm nf iias(i-|)haryML;-eaI
catarrh is ihe |ire>enee of >nnielliiiiL:- in ihe ii|i|ier narl nl' the iliioal.
accnm|.aiiied liy a (h'<ire or im|iiilse le n move it 'I'hi' di-ehai\i^'e w liidi
ha\\l\iiiL;' hrin_;> aua\ is dl' a mere or le>> miicd-puriilenl character.
vcllew in cnliir, and tcnaeiniis in cnn^i.-lciK
leh liV the IKlllelit
to he huiu-cd hcliind llie ])alatc; ami. wlien tlie disease is n|' hm^' sland-
in_L:\ (|nitc i're(|iienlly the im>st |iersi<lent ell'nrts will tail to ell'ect a
complete i'enio\al.
(hie el' liie eomiiioii symptoms is ilic sn-callid ■"diiippiiiL:"' which
flic patient feels ill the throat. Of course, the term "droppim^"" is
lai^Li'i'ly a misnomer. The dischar,i;(' is often too thick and tcnacion>
to di'op. Another thinu'. it is n(M located so niiich upon the palate
as oti the posl-pharynii'cal wall : and it is the constant desire to -wallow,
which its presence prodiici's, that irives ri>e to the mistaken idea.
In tiiis distant' the throat is easily fatii;aied. .\ feeling' of con-
striction and e\en of achinir is e\pericm-ed. The discharge varies
nuich in den>ity. Sometimes it consist.- almost fiitirely of sero-pns
and trickles (low n over the pharynx and olT the palate easily. In others
it is so ti'iiacions that it canmit even he washed away, hiit rctpiire.- tlie
manipnlal ion of a cottoiidiolder to remove it.
AlthoiiLiii the (liscliarL;'e may lie constant, day and ni^hl. the move-
ments of the pharynx, tou'ctlicr with elTorls to tdcanse the throat, may
keep the parts free hy day-time: hut diirini;' the loiiii- hours of sleep
tlie <leposii aecumulatcs, to lie removed with iliniciilty in the momiiiL:.
Sometimes the l-"iistachian cartilaucs are swollen ami I'cd, and the
(H'ifiees (d' the tiiiics hlocked hy secret iiui. If this extends deepiv into
th(» tuhes. catarrh id' the middle cai' and dcafm^ss may result.
In children. iidlammatiUT thickcidnu' td' the iilands may indiioe
adenoid disease, with moidh-hreatliing and all the other symptoms
produced hy nasal stenosis.
I'erhaps no class of people feel the etVects id' this disease so se-
verely as voice-users; and of these prohahly cler,<rymen are the most
mimerons. as they s|)eak for loni,' jieriods at a stretch more n^unlarly
than any other class of speakers.
N.\S(i-l'll.\KVN(ii;.\l, I'A rAIilUI.
lit!)
1
Diagnosis. Altlioiijiii thcrt' is little diiliriilty in tliscovcriiii,' tlu'
|ir('si'iiii' of ii |)(i>l-ilimiil (lisi'liiir;;i', citlici' in llic (ir()-|ilijirvn.\ nr n;isn-
I'liiiniix, vet liicic luiiy lie considcriililc (lilliciilty in diiii^niosinu tlic
( iui,-c nl' its (iccniTi'inc. 'I'll lie sure tliiit it is imicly n;i-(i-|ili;ii\ iii;i'iil.
I 111' i'\(lii.-i(in (if ji ii;i>al vau-v will \>v nccrssary. Many inso of pliaryn-
".fal ilisciiar^i' aii>f fi'oni na.-al olistrnction or Ic-ion, cvm ulu'n tin'
I liaryn^i'al l()n>il i.- liy|icilio|iliic; and. when alro|iliir I'iiinitis exists,
llio throat all't'ctioii is, in ncai'ly all ca.-fs, MTondary. Ww sanii' may
III' said of nasal |iiily|ius.
If. hnwi'MT. \vi' can rxilmlr tlic \arions aiVrrtion.- of the no.-c. and
lind till' ulandnlai' ti>~n(' in the llii'oat cnatrd with scc'Tt imi. instead
iif lu'in.u' clear, nioi-i, and of it- natural pinkish-i-cd color, the ca.-e i-
clearly one of |diai'ynu. .li oi'i.irin. When Luschka".-. or, a.- it is sonic-
linies called, 'roiiiwaldl 's, lmi>iti~ lias oci nrred. liic dischai'L;e will he
more [inrulent than in othei' varii lies of ihe di-ejise; and in the centre
<'( the \aidl. alio\e the |ii'oiniiience of the atla-. will he Men tlu' pro-
jecl in,li' '^''f-
'The possihility of niislakini;- syphili> (d' the na>o-pharyn\ should
he avoided hy exclusion. In douhtful ea.-es a course ol s|)ccitic trcat-
luent should he ti'ied.
Prognosis. When taken early and clii-onicitv ha.- not liad time
to he thorou^^'hly estahlished. it is usually anienahle to ireatnicut; hut
it is not. a disease that has any tendency toward .-poniaiieous cni'c.
W hen it has heen lon.i;' in existence, and lias heconie e>-ent tally chronic,
althoiiLih much can he done t'or it. positive and pi'rmaiient cui'c need
not he expected. In cases. howe\ei'. when it i- pui'el\ a sceoiidaiy
nll'ei't ion, the removal of ihc pi'ini.-iry cause should always he followed
iiy cure.
One tlilliculty the phy.-uian has to contend with in dealiuL;' with
these cases is the ,i,^'iieral nnw illimiiiess of patient- to >uhiuit t^ a
hui;.^' coiii'se of treatment fm- what they often con-ider a eompaiat i\ dy
ninmpoitant disease.
Treatment.- Whatever may havt^ heen the origin of the all\'clion.
or the prcdisposiiiy- cause which tended toward its development, it is
essentially local in its manifotat ions. Ilciiee the lii'.-t ohjecl of treat-
ment should he to -ecure peifeet (deaiiliness (d' the part-; all'ccteil. This
can usually hi' accoin])lislied hy the use of certain alkaline waslies
The leniiieralure of tlic solution should always he ahoiit 1(10° l'\
In order of merit the i'ollowini: will serve as illiistrations:--
S
'4^)0 i»isr,.\si;s (»i- Tin: I'JIahvw.
1. li S.ul. l.icarh 8
Sod. bibor 8
Acid, ciirl.dl 2
(ilscciiii 15
.\(|iiimi ad ;tOO
M.
2. li Snd. fhlnii,! 8
.\i|uaiii iid ;t(10l
M.
;!. li .\cidi iMiiici 12:
(ilyci'riii 8
A(|iiiiiii iui ;joo.
. 8
. ;ioo
I. li I'dt. flil'ir
A(|iiani bullifiit
M.
Tlic best iiicllidd (if applyirifj the i^oliitioii is by thi' use of a post-
nasal spray-syrinue (Fiir. •"><')• I'l usinif the iiistniniont, after insert-
ing tlie hard-rubber end l)eliin(l the palate, the head shoiikl be bent
forward over a bowl. Then tlie llnid is foreed tliroiigh the naso-
jiharynx and the nasal passatrcs, coming out, in great measure, through
the anterior narcs. By this metliod both the vault and the nasal
fossae are elTeotually cleansed. The position of the head referred to is
important, when a continuous stream is thrown through the passages,
as otherwise part of th(^ fluid would find its way into the laryn.v. When,
however, the interrujited flow is used, the bulb being filled separately
each time, this precaution is not necessary.
This method of treatment should be followed twice a day at first.
When improvement has become marked, the interval between treat-
Ti Slid, liiciuli 3ij.
S(><1. bibov 3i.j.
Ac. carbnl 3sa.
(Jlyreriii 3iv.
Aquam lid Jx.
Sod. r]il(iri<l 3ij.
Aiiuaiu ad 3\-
Acidi borici 3iij.
(ilyccrin 3ij.
Aquam ad Jx.
Tot. chlor 3ij.
Aquam bullicut Sx.
M.
n
II
M.
R
M.
Kr''
li
NASU-l'ilAUYNUEAL CATAIIHII,
'-iOl
niciits iiKiy l)t' li nu'tliciicd tn suit tln' r('([iiir('iiit'nts of ciich ciisc. If
from acuto Fonsitivcti' -- ol' tlio parts llic Hiiid used slioiiM prove to
lie too irritating', it ruiild l)i' wciikcm'd In linli'-strciiLTth or even loss.
In sonu' cases diiriiii,^ early treatmeiils a weak soliitimi id' eoi-aiiie mi'^dit
require to he applied, lnit oiiiy under l!ie doetorV siipervi.-inii.
Soiiu'tiiiies even this vij^orous treatment may not cUVetually re-
move the tenacious eoatiii<:; and a curved cotton-lioldei'. jiassed up
lichind the ])alate, guided by the post-rhi:ial mirror, may lie reiiuired
to moj> it away.
Ilaviiiir thoroiiLihly cleansed the naso-pliarynx, stiinuhitinu' and
astringent treatment of tlie diseased miK'osa is tlieii re(|uiri'd, ami
probahly for this purpose no application is sn useful as that of l(i-
per-cent. solution of nitrate <if silver. It shoidd he applied by means
of a curved cotton-holder. It has an astriiiiieut elTeet updU the dis-
eased surface-epithelium, and at the same time appears to check pus-
cell ])roliferation.
The following tannin pigment lias also a good efTect applied in
the same way: —
1. R Afidi taniiici 1|5
Glycerin 31
A(iuam ad .'30|
M.
Of sprays, after ollicc-treatment, to be used by the patient, I have
found nothing better than the following applied by atomizer through
the nose, and in suitable cases into the post-nasal pharynx, by means
of the curved tip, two or three times a day: — •
i-i
i V] i
111
2. R Tliymol
Mentliol
Albolene CO
M.
.•\nv of the following would also answer:—
1. It Aridi tannici {rr. xxij.
Glvf'orin wixlv.
Aqiiaiii ad 5j.
M.
2. IJ Thymol pr. iij.
Mpiitliol frr. X.
Albolene S'j,
M.
'■ ' 1
1
■ : ■ i
H: 1
j
1
1
11
,\-<
fiii
205J iJlSKASKS OF TlllO I'llAIlYNX.
1 . H Kiicalypt 1)1 21
Mfiitliul 15
All)olcllr (i()
M.
2. H Crcasolc lO
Ol. iiii'iitli. pip lU
.\ll)(il<'iic tiOl
M.
.'i. U I'nrimiliii 41
.\i|iiniii ad 00;
M.
4. H Ilydni^fcii iicioxiilc 12|
.\i|Uaiii a>l (ill'
M.
^\ livii llii' nns()-pli;ii\ ii;it'iil ,L;liin<l.- nvr liiliii'ucd, and cdiitiiiin'
^;l't•^('tln,li■ pus with liltic ])i'ii>|n'cl nl' iiiiiiroNriiicin, the rnnoxal or dc-
stniction (iT .iiliiiid-tissiio Ix'coiiu'S lU'ccssaiT. 'I o a((niii|i|ish Uiis vari-
ous Mutliods lia\(' laH'ii devised. Auioiil;' the niiinla'i' is the use nt the
galvaiuK'auh TV. 'This can lif done, alter apiilvini: a l--)-pei-eeiit. solu-
tion ol' cocaine, li_v pas-inir the electrode directiv hackwai'd tlu'onL;li
the nose, the (jperation hein.ii' .yiiided hy the post-rhinal minor, it
can also he accomplished hy the curved post-ihinal oloolrode, passed
throuuh the mouth and up behind the palate. i;uidcd. as Ijcfore, hy
the u.-e (d' the mirror, in the latlei' meihod the proteelioii of the soft
])alati' is an iinpuManl cnnsidei'alion.
'I'hi- can he acconiplishe<l in two ways: either liy the use of a well-
chosen palate-rctractipr or hy the u>v of ruiiher cords passed throu.uh
tlie narcs and out thrcuiLih the niouth. the two ends hein^' lied on cacli
side over the lip.
("ascs occur in which it is impossihic even to examine the post-
1 . R Fdcal ypl ol Sss.
Menthol jrr. viij.
Ailiiilt'iic ,^ij.
\\.
2. \i. Cicasofo mx.
(>| inciitli. ]ii]> iiiK.
.Ml)()l('in' ,^ij.
M
.'?. H I'onnalin Sj.
.\(|iiam ad Ji j.
4. IJ lIy<lro<;i'n peroxide 3iij.
.\(iuaiii ad Sij.
M.
i
NA>t>-niAitVN(;i;Ai. ( \ i akuii.
.'U3
|iliiinii\ williiiiit llic ii.-c 1)1' ii iiiilali'-rftiactiir; Iml. riuliiiiiiti'ly, tliu
iiiiijority (if |iiiti('iil> ciiii lie triiiiicd t(i (•niili<i| the piihiti-iiiiisclos 8iit'-
liciciit tor this |iiir|i()st'.
I liclicNC. however, tliat the ln.-i nuthoil nl' ii'iiioN iii^ iht'-.c post-
toi:>illai' ciihir.^ciiiciil,^ i> li_v the ii.-r ol' ( Jn| t>l(iirs ciiictlc-. \\\ two
or thrcr sutTps of thr in^liuiiinit the (li>ca^('(l ti.->ih' ran Ik' iTiimvi'd
and a smooth surface left in it.- placi'.
Sometiiiics ehroiiiie aeid i- n>e(l a- a eaiistie instead of the Ltalvano-
eantery. Imt. like this inst riinuiit. it i- lii<el_v to injni-e lualtliy tis^Me,
except under the iHost cai'eful manipulation. I'.oth. too. are tedious,
reipiirin^' a se|-ie.- of operation.-, to cllVct the de-ii'ed result.
As a distinct variety of iia>o-pliar\ n,L;eal eatai'rh. the atrophic
type miu'lit lie mcnlioiU'd. Jt is d(Uilitful, howevci'. if ii ever occurs
except as a re-ult and continuation of at I'ophic rhiniii.-. It i> produced
hy the ^-anie cause, and lias e»entially the same patliolo:^y. dia.irnosis,
and pi'oiriiosis. Left to itself, it is ju-t a.- hopele.-- of amelinration or
euro, while it demands, ami i> ecjually anu'iiahlc to. a similar line of
troatnieiit — a speedy oi' ])0<itive cure heinij impos.-ihle, while ameliora-
tion of symptoms and a fair deixrei' (d' comfort can alway.- I htaincd.
When Toniwaldt's disea.-e or inllammation of the .-o-callcd pharyn-
.^eal bursa exists, free incision, with suiiseipieni anti-eplic treatment,
will often be followed by a jjood result.
Hi
ai
■ !'
," i i
CIIAT'IKU XX.W 111.
ADKNoll) (;|;n\\ll|S OF 'l ||K NASO I'll \l;VN\.
I
l'(»>r-i'ii \ i;v\(;i: Ai. adt iiui(I> nir n\ci l:iw\mIi- ni' alitioniial ilovel-
(i|itii('iits (if llic l\ Miplhiid tissiKs which cxi-t iiatiiinliy during enrly
life ill ihi' naxi-pharviiv. Wilhrjin Meyer ua.- the tiisl to study tlu'
lii>tory of these vcLidat inns lh<ii'(Ui<4lily; and he ha>ed iiis coiKdusioii:*
upon the jieisoiinl mid ciiiLdtil invcstiLriitidii (d' nver one Inindrcd cases.
iS'unu'i'ous writers have written extensively upon the suhjt'et since
Jfeyer's first ])aper appenred, hut tliey liave added, comparatively
speaking, little tn wjiat he had already given us ([•'igs. fA and ?3«).
l''i;r. T.'i. liifniitJc aclciieid^. V'v^. T.'f" icincscnN a irrnwlh
i|iiit(' ciiiiiiiioii. (After SclKullf. )
t .
i
u\h
Adenoid growths are found i'l tlie upper and back part of the
naso-pharynx. on the site of the piiaryngeal, or FiUsclika's, tonsil. The
situation is hetween the orifices of the Eustacliian tiihes. hut behind
and ahove them. Tn some cases they grow so large as to press upon
these tubes, even overla]iping their orifices, and preventing the proper
action of the tubal muscles (l''ig. 71).
Pathology. — Between infantile and adult life, the pathological
conditions of adenoid disease vary very much. Tn the former the sur-
face of the adenoid enlarixenicnt presents a convoluted appearance, of
(204)
SASU-I'll \liV\\. AliKSulliS.
•.'iir,
titraw lifiiT-likc ("iiitiiiir, the iini|ii|r> .■-IjiiiiliiiL:' mit n\(i- tlic wlmlc siir-
fiici', cxcciil wlicii l.ii»clil\ir.s file is |iri'-('nl; llidi the (ciitriil poitioii
will ('xliil)it a iiiarkiil pinjtctinii, In ilir lalirr tlir l\ in|iliatic ct'll-
I'lciiicnts lia\i' uiMii platr, in soiiir iiifa^iin', \i> I'limirctivr-tissiU' rnriua-
tion, iuul a dciiMr jiml ^tiinoilirr (lc\i'lu|iiii(iit iMciipir* the pdsitinii u|'
the (iri;:iiial ailiiiniil .-inul iiif. In ihr iransitinii-pcridd k\' life tlir
l()ii>illai' li\ pelt injiliy will alMi indicalc a lilrinlinu >>\ the iwn types.
Itl ynlin^cllililicn In t III' Idllrll II I- alnici«l like t hr -dfl nc.-s n|' rcITlll'al
(is-iic.
MiiTd'^cMpirally llii' -nifacr i- cdvcnil wiih tnlnnmar ciliatt'd cpi-
tlicliiiin, Init llic cilia arr iVcipicnl ly lirnktn and linii and in sonic in-
stiUK'cs ali>cni. I'lcm^alh lliis \\c lia,\i' tlic niy\dniat(iiis niucnsa llllcil
with lynipli-ciiijin,-clc< iind tlic idiiuil lynipli-luliiclc^. separated froni
■r\
II
Fig. 74. Stiiliulitt' forms. (Alter Sdiaillc)
the
Tlio
lind
lion
pper
Ilea
piir-
of
cacli otiicr liy inlci-rolliciilar iract,- (I-'i'j. '•'>). It is essentially a lym-
phoid stnicturi', copiously sujiplied with lilood-vessels, (he wh<de boiiiii'
arranged in the form of lobule.s (and secret injjr mucus ny lymph from
the crypts 1)etween the follicles). As the aileiioiil hccomes old with
increasinir years, tli'^ lyinpli-tis>ui's hccome ahsdriied. often slii'inkin.i,^
away hy the (Ifteeiilh (u- the twentieth year. In other instanc(>s hyper-
plasia takes tlie jilace of alisorptitm, and fibrons connective tissue de-
velops arnonif tlie follicles and lohules of the adenoid.
'rii(> .ireneral im])r<v-ion. founded on clinical experience, is that
the rd)rous, connective-tissue element vai'ics in dii'cct ratii> with the
aae of the ])aticnt. ^Icliride, in his recent W(uk, takes issu(^ with this
idea. Fonndinij liis opinion upon tlie examination of six hnndrju
eases of adenoid disease, he savs: "Tliat wliile in manv cases there is
) ■
■
t
i
20G
DISKASIJS OF THE I'HAUYNX.
a tondoiicv to iiicica.-i' ol' tlif (ihroiis oloment at tlie oxpen^^e of the
cellular, yet it is a iiiistakrii idea to bolic've that it tfiids to eoiiie on
ni any ^nveii a^o, and that it is mori! (-'0111111011 in the very younii' eliild
than in the adult."
Together with adenoid development, there are often, |)roliai)ly as
an ell'ort ol' extension, chains or clusters ol' enlaryed follicles extend-
ing- down the sides of the oro-pharynx, and situated behind the poste-
I
Fig. 75. — Microsc()])itiil section of hypertrophiod jiluiryngeal tonsil
with lynii)hoid infiltration (20 diainoters). fl, Lymphoid follicle, h, Strati-
fied squamous epithelium of tonsillar cryjit, infiltrated with lymphoid cells.
c, Cavity of crypt filled with secretion and lymphoid cells. (Author's
specimen by Bensley.)
ill
Tior pillars of the fauces, while sinj^fle ones may be scattered here and
there over the post-pharyiifjeal wall.
Etiology. — Thi.s is not believed to be a disease of early infantile
life. Very few cases occur during the first two years. The exanthem-
ata usually attack cliildren after that age has been reached, and it
is to the effects of those diseases that many cases can be traced. Bar-
;
Li-
ps,
r'a
land
Itilo
3Tn-
it
NASO-PHAUYNX. ADEXOIDS.
•.'o;
rctt and Wi'hstcr, of .Mclljoiinic, hclic'vo tliat scarlot IVvcr, mcaslos.
di|)litliiTin. and \\iiiMi|)ini,'--c()iii,di haxr a directly-causal relation to
adenoid development. Iiasinir their theory upon the natural tendency
to lymphoid development manil'i'sled iiy children ahoul the period ol'
the ~ei'oiiil ileiitition.
'I'hc lar^c-t |iei'centaL;'e of i^ases occur hetween the aires of five and
fifteen years.
(ii'c\ille .Macdonald's iilni that one prominent cause in youm;"
chililii'n is the procnee of anterior na^al >teno>i.--. the cH'cct heini;-
to lowci' iiai'oniel ric pre>>ui'e in ilie na>o-;)haiyu\ and to pi-oducc hy-
j)era'niia Ihere. appeai> in .Vmei'ica to he nntenalile. in my own e\-
])eri<'nce. I haxc found nasal stenosis in yonnu' children /h'i' si' e\cee<l-
ingly laiH'. Where I have seen it the cause has almost invariahly i)een
Iranmatic. Kveii whei'e the nostril- have heen lilocked with niucus.
adenoids iieimi' present, clearinti' the pas>a,;;es has reveale(l patt'Ut nos-
trils: (piite sullicienllx' open, after the adetioids hail heen I'cmoved. to
permit of noiinal respii'at i(Ui. Instead of ol)stru(tion and disease of
the nasal passa.ii'e- iieinii' the cause of a(h'noi(l enlaru'cment in yoiin^"
cliildreii. 1 helieve the I'cvei'se to he the case, and that not infre(iiiently
hoth ]iuru!ent and atrojihic I'hinitis owe their oi'iiz'in (hrectly to the
enlaiLienieiit of the so-called Luschka tonsil.
Jleredity is not without its inlluence in etioloLiy. for fretpu'ntly
several mendiers of the sann' fannly will successively apply for treat-
ment for the same diseaM'.
The compai'ativc frecpieiicy in males and female-; varies little.
It is fre(piently associateil with the presence of hypertrophied
1'atu-ial tonsils. ])rohahly indicatin.u' the existence of a strumous diathe-
sis, with a tendency to .duiormal lymphoid (h'velopment.
Symptomatology. — The symptinns may he divided into aural and
gi'iieral. Of the two classes, the aui'al are the most important. Thi-
importance lies in the fact that when auial symptoms do appeal' they
indicate no little dan,ii'er to a very important ori;an. In the Iani;'ua,i:'e
of Pymhon. "Deaf-nudism is prohahly more often due to ailenoid
hypertrophy tlian to any other siuLiie caus(\ the hypertropliy havin,ir
occurred Ixdore the child has learned to speak."
The lirsl >ympt(un of ear irouhle is the presence of nu>re cu' less
deafness, caused hy the closure or ohstriiction of the I'histaehian tube
This may he followed hy tinnitus aurinm. otitis meilia, and abscess,
residtinjj' in perfoiali<ui. Ilealinc: may then lake place; l)ut freiinently
ehronjp otitis media puruleida nMnains foi' weeks or months and < von
1
I
I
:!|
i
m
1 1
; I
>? |.
i! I
■' r
208
DISEASES OF THE ]'1IAI{YNX.
'«'■
years without iK'aliii,!;', ii' the adcnoitls, the cause of the abscess, arc not
removed. When liealing of the otitis does oeeur witlioiit acU'imid op-
eration, tlie continuance of pressure and the extension of catarrli to
tlie ]uistac]iian tul)e, ])rodiiced 1)V tlie evcr-))rcsent liypertr(i])hy, may
lead to renewal of the inlhimmalory attack at any lime.
If the dcveh)pnient of the adenoids is uneven, tiic growth licing
in juxtaposition with (me tuhe and not tlie other, it is (jiiile ])o,-sihle
for one-sided deafness to exist for years, and the liearing |)ower to liave
diminished one-lialf, witliout having l)een discovered. 'J'he evil ed'ect
of tiic ])rescnce of adenoids upon hearing is chielly ])roduced in early
life, although the stenosis and general shrinkage which occur in ma-
turity may lemoxe all intt'i'fci'i'nce with the Eustachian tid)es; yet the
evil may already have heeii accomplished, and the sense of liearing may
have become permanently impaired. Still, many cases do occur in
which ear-symptoms arc never develo])ed.
General )S!/iii/iloiiis.- — Jn young children the most pronoui;c d
symptom is continuous nmuth-breathing, with discharge (d' yellowisi;
muco-pus from both anterior and ])osterior nares, the source of the
secretion being chielly the cry[)ts and follicles of the hypcrtrophied
adenoid tissue. The presence of the growth, together with the accu-
mulated secretion, seriously interferes with nasal respiration. 'i"he
child has neithei' the kuowh'dge nor the ahility to tlii'ow olf the dis-
charge, and it simply trickles away. When the ])hai'yngt'al tonsil is
only moderately enlarged there is still room for nasal breathing during
the day. 'I'he anteri(n' nares nuiy be free from secretion: but the ro))y
nuicus still ]U'esents it>elf in the thi'oat, and on going to sleep the
nunitli drojis open. The night pa-ses with stertorous, disturbed breath-
ing, accompanied by ti^etrulness and dreaming, and in the morning the
little patient wakes nj) tired and uni'cfi'eslied.
One symptom which is always pre~eut. when stenosis occurs as a
result of the obstruction, i- what .Meyer calls '■(he ilead voice."' The
lone undeigoes a change. The r( sunance of the voice is d. ii'o\ed, bv
licing cut olV trnm the resonating chainlicr. Iii>tead of what is com-
moidy called the "nasal twang" being produced, it is abolished. The
vocal wave> are inti'rl'ered with, and the pro))er voice is, in a sense,
smothered, thc' power of correct singing being entirely destroyed.
When the nasal pasMiges are free and t)u^ breathing nornud. mas-
tication and deglutition do not inlerl'ere in any way with respiration;
l)ul, when the naso-phai'yngeal stenrwis is severe, the act of eating be-
comes a ili>tressiui;' thiuu' foi' the little sull'erer.
■<ij
lis a
lu;
l.v
un-
lie
use,
IlilS-
|()ir,
1.0-
.NASO-l'lIAlfV.NX. ADKNOli)?^.
■J<);»
Kxteriial ilrroniiitii's of tlic face and clicsl arv also the result of
j)ri)|(iii^e(l adciidiil ili>('as('. ( ilcitsiiianii lias [.dinted out the inlluriiee
of aci'MKiids u\>i\]] the dcvi'ldpinciit ami (•(inli;^iiiatinn of the nasal sep-
tum and upper maxilla. Many facial defminities. he .-ay.-, aic produced
hy their iuteiiVreiuc \\ilii nasal I'espii'atitui, sueh a.~ hiiih-arched palate,
^'-sllape(l upper maxilla, with the latei'al teeth tiii'iied inwai'dly. and
the molars out\var<lly. As a loult. the upper jaw. heim;- llatteiied,
projects ))ointedly forwaid.
De Havilland Hall lay^ emphasis nprni the amount of ehcst-de-
I'onnity produced hy (h'fective nasal respiral inn. This in early life,
ho says, is alnu)>t alway> (lecasioneil hy the pri'seiice of adenoid ve,i;eia-
tions.
The reflex inlluenees of adcunid enlarucmi'iits olVer a wide held
for investigation, l^ven over the voluntary movements of the young
child their eil'ects have been notieeil. Leiiiiox IJrowne and Uiwson
Delavan have each of them I'elated the hi.-ioiy of a ease of masturhation
in a young child troubled with adenoid disease; and in each case re-
moval of tho growth was followed, without any further interference,
by cessation of tho habit.
Headache is oftert the result of adenoid picssure: and instances
of asthma, lai'yngeal c(Uigh. and hay fever havi' all been relieve<l by the
removal of tho growth.
Otto gives the histiuT of a remarkable case of a young lady, aged
is. who was completely <iii'ed (d' enuresis noctnina by extirpation of
a mass of adenoids located in her miso-pharynx.
One other point in reference to symptonis should be uu'Utioned
here. In the most sevei'e cases of adenoid cidarg( uieul a ciuidition
termed aprosexia is freijuently developed. In other words, the dull-
ness ami menial apathy indicated by the open nuuith and \innatural
expression of featui'cs has its countei'pai't in the nu'Utal e<indition (d"
the jiatienl. 'I'his is evideiu'cd by iri'itabilily of tempei'. incapacity of
concentration, and deiicieucy of memory. That the lueutal power of
the brain is not itself injured, except by temporary suspension, is
])roved by the complete change of both facial expression and mental
activity which follows the removal of the gi'owihs. The sulky and
cross child with opi'U moulh will he Iran-formed into a brigbl aiul
cheery one with closed lips aiul an aptitude bir .-tudy pre\iou>ly un-
known to it. 'J'he cause of this lack of mental grip is ascribed to the
condition of lyin|)hatic stagnali(m at the bast' id' the brain, t^uail'e
draws attention to the inuiu'rous nnmde foramimi communicating be-
•* :S
!^ n
4;
■ 1 ,
'; r
ji
s:
h
2M)
i)isi;.\si:s OK ttik nrAHYNX.
twot'ii the iiasiil |)iissii,i:'<'s iind the cniiiiiil cavily, and that a similar nioii-
tal condilion is stuiR'tiiiK's round in sevfre cases ol' nasal ])olypns.
Diagnosis. — 'J'lic faucial symptoms, nasal stenosis, open inoutli,
flatness ol' voiee. toifc'tlior with the eai'ly life of the patient are usually
sullicient to ])roduce a correct dia<iiiosis without a rhinosco|)ic or digital
examination, 'i'he use ol' the jiost-nasal mirror is often impossible in
children; hut examination of the pharynx hy either suidiyht or re-
flected li,i:ht will often revt'al a fullness of the ])alale or the reuion
])e1iind it diaLinoslic of the cause of ohstniction. Digital examination
behind the ])alate, however, will at ont'c render the diaji'nosis possible.
'J'lie s(dt. corrupited. brain-liki' tis.-ue will be felt to present itself on
the postei'ioi' and upper wail of (he naso-pharynx: a condition which
in early life ' nld he ])roduccd by no other abiKirnial iirowth. Some-
times they THiv descend into the oio-plinrynx and lie visible to
direct exaniinati'
When it is ])os.-ible to obtain a post-rhiiial \ iew, a r(Uinded (U'
stalactite or llattened nodular tumor will be ^(H^n luin,iiiii,u' down froiu
the rooi' of the vault and |)rojecting forward from its posterior surface
(Fij;. 7'^). Sometimes it hauii's directly downward, hidiuii' the upper
\r,\r{ of the posterior nares from vii'W ( l''i,g. Tl). When very larii'e. the
whole of the choanal may be covered.
In adult life, when the growth is present, it will have lost its
nianunillated ajipearance, — at least, in a majority of instances. It is
then more hyi)erplastic in character, the fibrous, connective-tissue ele-
ments having, in large measure, taken the ])lace of the lymphoid and
glandular. The consecpience is that the tonsil is denser and firmer,
with a smoother surface and containing fewer crevices and indentures.
Prognosis. — in mild cases, insufficient to ])roduce na<al stenosis
and Kustachian obstruction, the prognosis even witliout treatnu'iit is
favorable, as Nature favors absorption of the tonsillar hypertrophy,
when puberty and adult life are reached.
In many cases reipiiring operative treatment the proguosis after
removal is cijnally good, provided ear-lesions have not alreaily oc-
curred. Even when serious ear-com])lications do exist in young chil-
dren, hope may be expressed of arresting the progressive deafness, to-
gether with expectation of a certain amount of im]n'ovement. When
lict
)sis, we mav satelv pre(
the ear disease has stopped short of necn
the arrest of chronic otitis media, both catarrhal and su^jpuralive, at
least in a majority of cases.
I?
ecurrence (
if adenoids after removal rarelv occurs. The text-
NASO-rilARYNX. A DKNOIUS.
211
)
books speak very li.ii:lilly upon tlic subject. Some even afTirni that after
tbor()U<fh al)Iati()ii thev never return. .Mthouirb this is tbe rule, still
many in-iauees liave occurred in wliich, after thorou^^h extirpation,
there has beeu a re(Icvi'b)pinent ot the jfrowtli. Dehivan, Wriylit,
lUitts. Meyer, and (itiicrs have rec(U(h'd cases; and Hopkins aives the
liistory of three in wliich, after couiph'tr reumval. a<ieuiiids developed
ajfain. 1 have pi'i'sonally atteiuh'd two cases in which reciirreuce took
place after what 1 believed to be IIhu'oiiuIi removal.
Alth(ni<rh the operations for the removal of adenoids are usually
attended with little dan^iicr. and at the same time productive id' the
best results, yet in some instances a fatal i.-sne has followed the opera-
tion. Sandford reports the death of a child six hours afterward from
convulsions; ^Fayo Collier reports a similar case. Tn both eoeaine was
the local anavlhetie used. Death was attributed in each ease to nerv-
(Uis explosion.
Treatment. — (Jeneral treatnu'nl. mi far as the reirulation of the
alinu'ntary canal and the tonin,u" up of the system are coneerni'd, is
always advisable. At the same time it can have but little elTeet in eon-
trolling the development of the aih'iioid disease. Sj)rays and washes
are also of little etiicaey in severe eases, and tluMr use is likewise usu-
ally resisted by the little sutl'erer. When the hypertrophy is not large,
but just sullicient to produce a certain amount o\' catarrhal discharge,
without nnicli stenosis, this may be nnnedied by a slightly stimulating
or astringent spray, of which tbe following is a good exami)le. Tt
should be thrown u[) iiehind the jialate once or twice a day by an
atomizer: —
k il
ler
M'-
il-
|o-
'11
let
lat
t-
1. B Acid, laiiiiic 1
Sod. l)il)(ii ]
Carbolic ucid
filyocriii
.\()u;nn lul (ifl
M.
The formula on llu' following page is another excellent spray for
ilie same ])urpose. being antiseptic and slightly stimulating.
One ])art of this alcoholic solution should l)e a(l<h'd to 7 parts of an
1. B Acid, liiiuiic }jr. XV.
Sod. liitxir K'"- >^v.
( 'arliolic aiiil iiiv.
( Jlyccrin 3iss.
Atpiain ad Jij.
At.
f
!
w^
M::i
Hi
212 DISKASKS OF Till-: I'llA I! YN X.
nqiit'oiis ^-])ci-((iit. solution of Ijorie acid, and used with an atomizer
to the iiojo and throat.
]. U Kiicalyi.tol |25
()1. fiiUlltll.T i2
AIciiUkiI ,1
'i'\\\ llKll 13
Alcoiioi ivct ;«>.
When Iroiii our caiisc or another an atoini/.cr cannot he u.~cd, the
prt'jjaration already mentioned, of J-per-cent. tJoliition of menthol in
al1)olene, could be i^nulTed uj) the nostril.
Any of these could he ust'd two or three time.- a ilay.
When the adenoids are lai',i;'e. I'cmoval hy sur;rical operation be-
comes necessary. 'J'his may be done hy the use id' hot or cold snares,
galvanocautery-knii'e, cutting i'orcejis. or curettes. It is impossible to
com])letely destroy the sensibility of the paits by application of a local
antvsthetic; but after cliildhood and during' adult life it will rarely
be necessary to administer a general anaesthetic, a lo- or 20-per-cent.
solution of cocaine, applied by means of a cotton-hohlei', being all tliat
shoidd be reqnired.
During infancy and early childhood the case is ditrerent; and my
own impression is that an amvsthetic should always be administered.
If the adenoids alone require to be rem<ived, it need not 1)e given to
the extent of complete ana?sthes;a; but the o|)eration can be performed
so much more easily, rai)idly, and paiidessly under its inlluenee that
the advisability of its use can scarcely be ([ueslioned. The choice of
the anesthetic, however, is an exceedingly important matter, the safety
of the patient being always of the liighest consideration. Owing to the
wide i)reference for ether, which has been displayed by surgeons for so
many years for general sui'gical work, many are tempted to use it for
throat-\vork also. There are serious objections to it, however. Xot
01 ]y is it believed to ])roduee nmre bronchial congestion and ]iliaryn-
geal hypersecretion than chloroform, and also, according to Linde-
mann, acnte pidmonary (cdema during or after the narcosis; but what
is perhaps equally important is the fact tluU the vapor of ether is in-
1. R Eucalyptol viiv.
01. fraulllicr '"iij.
]\I('iitli(il ^i'. iss.
'J'liymel jrr. v.
Alt'olinl icct Sj.
M
.\A^()-J'11.\KV.\\. ADK.Ndll).-.
:.'K5
lliiiiiiiial)lc, iind lliiit it wdiilil lie (liinncrmi.- \o ux' ;i ciiutciT in any
J'orm to tlio no?e or tliruat whik' lusing (.'lliur as an aiia'sthelif.
l>roiiii(le (if ethyl has rct'ciitly hcfii I'fci'ivcil with i^rcat l'a\(ir lor
thi'sc ojicratidiis. J>i.-liii|i (■()n.-;i(li'r> it I'.ii' ana'slhi'iic jatr e.rrellcncr lor
ihriiat-wdi'k in ihililrcn. 'J'hc litlh' patient is jihieed in a silting- ]in>t-
ui'e on the assi.stantV lap. an onnee iiihe i<\' hrmuiih' ef ethyl is einptieil
into the air-ti.<;ht inhaler ami atlininistered. alhiwiiiLi' no air to enter.
Ana'stlu'sia is indneed in ahoiit (me luinule and lasts ahoiit ilvo. Ahmit
one-halt' the hionude is taken and ennseionsness (|niekly relnrns.
Mitrotis oxide aUn dnrinu' recent years has ui'own ra))idly in favor as a
i-afe ana'slhetii. V^v >hnrt (ipei'atiuns it i- adinirahlv suited, and its
1 !
rii'l
■in W
Fig. "()."" (il('il>niaiiii's ioj ami J.i'iwciitirin's i^i iiiliiinid t'lUi
oU'eot can he prolon^iicd hy eondiinini;' it with nxyocn. l.eiinnx IW'nwne
stronsrly favors its use.
The chdiee woidd ^eein \n lir hctwccn iii'diiiide of ethyl and
iiiti'()ns oxide. The cutnparat i\e safety of the two it i> too early to
positively deei(h'. One advanta.u'e of hoth of them, if advantaji'o it is.
lies in the fact that they ean he administered in a sitting posture. As
regards siin])lieity of nianagenient. however, chloroform would seem
to have the advantage. A clean, coarse towel is all the instrument re-
(jTiired, and the drug >hoidd always he given j>cr iinlhiliiii. Often a
very little is needed and in a I'vw moments the operation i- all over.
A few deaths liavc been recorded froie its n-e in throat-work, out of
the tens of thousands of time.s in wliicii it has Ihhmi given; hut many
! !
■ !
'41
*tv
2U
ItlSKASKS OK llli; I'llAliVNN.
Hi'
'!
of tlioc could lie iiiiccd to (iii'i'lrs- iuliiiiiiist lilt ioi) : iiiid we nrc not
sure of tlic pci'Tc'ct salVtv ol' aiiv iiiia^tlictic tliiit luis ever lii'cii UM'd.
'i'hc ^^iilviiiiociiiitcry opcrntion would lie iicrl'oniicd as already do-
ficribod in tlir e-liaptcr on '■Naso-pliarynucal Catarrli." tlio nioiitli-<:a,<r
bcin;:' inserted and the palate I'eli'aeted liel'ore the eleelrode is passed
into the naso-phai'vn\. The child should lie recuiiilieiit. with the head
Ihrown hack, the lace heinji liirned towanl tlu' opi'raI<u' and with snn-
li^lit playin<i' upon the open jiharvnx. The position >lioul(l he the
same no matter what instrnnu'iit i.- w^^'^l in the ojieration. parlieiilarly
if chlorid'orni is the aiia'sthetic elio>eii. lu ii-iiin' the caiiteiT the sense
of touch should he a sullicient .u'uide f(U' the iii>tiiiiiic!it.
Snari's, altliim<iii u<('i\ hy some siir^'eoiis, are not generally con-
sidered satisfactory instruments for the removal of adenoids. When
tliey are nsed, whether hot or cold, the snare may lie ])assed throiiirli
tlie Jiosti'il (W up hehiiid the ])alate, but it should be adju.-ted to the
growth by the forelinjicr of the left liand ( l'"i,u's. lit to '-u).
Many o])eralors use ])ost-|iliaiyn,<real euttin,<: forceps, sucb as tliose
of liiiwenberg or (Jleitsmann (l'"ij:\ ll! a. h). taking- the adenoids away
piece by piece. In some eases the whole operation is completed at one
time. In others several operations are required before the adenoiils
can b(> entirely removed.
Tlie most satisfactcu'y instrunu'nt, bowever. and tlio one most
extensively used by tlie profession at the present time, is OottsteinV
curette. Of this there are various sizes and several modifications since
(lottstein introduced tlie orijjfinal design. It is a ring-instrument witb
tlio cutting edge >-o placed that in the downward movement it will lie
in contact with the post-pbaryngeal wall, excising completely all witbin
its grasp (Kig. 77 n, h, r. d). Jn using it. altbougb the moutb-gag is
rc(juired, tlie palate-retractor is not. .After amvstbesia in the nprigbt
posture — in the case of bromide of ethyl or nitrous oxide and in the
recumbent in that of cbloroform — the instrument is slip{)ed u]) bebind
tbo jialate, to the front of the adenoid growth. It is then jiressed
against tbe vault, and brougbt down with a sharp swei'p, tlie sliaft of
the instrument being elevated toward the nose as tbo blade descend^;
along tli(> |)ost-pliaryngeal wall, tbe central ])art of tbo adenoid being
swept away. It may be at once reinserted, first for one lateral jiortion
and tben for tbe other. 'To complete tbe operation and to avoid leav-
ing any loose fragments of tissue, it is ht'tter to pass up the sterilized
forefinger of one band afterward and scrape tbe surface .clean witb
tbe flnuer-nail.
i 'i
NASO-I'IIAUVNX. ADKNOIDS.
lo
III iildtT piitit'iits tlic ciirottaj'O can l)c doin' in the (i|iri'atini,^-cliair
iindor cocaine aiucsthc^ia, and witliout the use oT tlic mmitli-.Lraj;.
In my own cxjx'ricnco, the hirj^c majority of my patients have
heen eliihlren l)et\vi'en tlie a^i,^'S of -1 and Id or I".' years, and I liave
niadi' it a nde to operate with the patient lyinu on the hack with the
liead h)W, and iii\arial)ly to liave the ana'sthetic adniinistii'ed hy a
ciualiiied practitioner. In this (dass of cases I always optTate dii;itally,
iisinir tile nail of the foreiiii^cr of either 1iand, whichever at tho time
I I
i
I'M
(b)
Fig. 77. — Adfiioid curt'ttes: ((/) (iottstciii's; {h} Hoswoitii's, rigid
shank; (c) rayne's; (*/) Mungi'i's,
is tlie mo.'it convenient to use. Tlie soft l)idpy lymplioid tissue ran
easily be stripjied olf at a 8in<:;le operation; and llu; educated di<,nt can
apply itself more tlioroufjlily and ellieiently to tho lateral resfions, be-
tween the Eustachian tubes and the sides of the central ])romontory,
than it would be possible to do at one sitting with the curette alone.
When the tissue is too dense to lie removed by the finger, the curette
can be used to complete tho operation.
The objection sometimes made to this nietliod of operating, that
!
-nr,
Dl.^KASKS (If rilK I'llAliVNX.
piii'tiilcs of adt'iioid tis>iK' aro likely td drop into the liiiynx. is, I hc-
litvc, jjntimdlt'ss. Tlic rfcuiMljciit jiosHiru with tlif liciul on tlie siinio
level with the liody, iuid with it turned soniewlial townrd the oporator
and tliidwii hack diiriiiL;' the o])eratioii. and the nuiek feveisal to the
side posilimi to iaeililate the luenmri'liaj^e throiiL;li the na>al [lassages
into the howl, will m-iit ralix.e this tendency; and 1 ha\e imt seen a
sin<;-le instance in which ! had the sliu'litcst rea-nii to sus])cct its oc-
cliri'enee.
In oldef ydUtli- and adidts, a- .-aid lietnt'e. the nperation is ])er-
iornied under cocaine anu'sthesia and in the oiieratinj^chair, the in-
strmncnt used heing one form or other (d' (JottslcinV curettes. Jt has
usually in these eases reipiired two or three operations to secure a per-
fectly satisfactory residt. My use (d' post-nasal forceps lias never heen
a success, although I have tried them variously modified in a nuudicr
of instances.
The o])eration is always nmre or less paiid'id. the cocaine never
producing complete ana'sthesia of the parts. Still, there is no douht
that it materially niodilie-^ the sensihility. Cleansing sprays for a few
days after the ( |)i'iation are .idvisahle; hut they should not he com-
menced until thirty-six or forty-eight hours after tlie removal of the
growth. The hydrocarlM^.i oils coidaiiung V^ to 1 per cent, of thymol
or menthol are among the hest for tlds purpose.
Sometimes, though rarely, severe Iwmorrliagc will follow the op-
eratio. for the removal of the adenoids. In Jidy of the present year
^lartin, of San Francisco, reported three cases of severe hnGmorrhagc
after op(M'ation. though fiu'tunately none of them were followed hy
death. Schmiegelow, one year ago, gave the history of a case by which
the o]>eration was followed immediately hy a gush of arterial blood
from the mouth ami nose; and in a few minutes the boy was dead.
Post-mortem exanunation proved that the internal carotid artery had
been puslu'd out of ])osition by swollen glands, and was opened by the
curette. Several years earlier Newcombc reported two or three other
cases, including oiu> of his own, in which death occurred from general
luvmorrhage from the vault. Fortunately these cases arc very rare,
though not infreiptently severe bleeding will occur without resrdting
in a fatal issue.
rii.\rri:i: x.wix.
MYXOFll'.i;(i.M.\ <•!• nil-; NASd l'IIAI!^■ NX.
' ■ i
M vxoiMiiiiOMA. or |i()lv]iii>. III' till' iiiiso-plianiix is of compara-
tively rare occiirrciKi'. Il i- !•■-< inwnmatous in cliaractcr than wIrmi
within the noso, and contain-; innvc lilirnii- cnnncotivo tis-uc. llcnco
it must 1)0 considcrod a distimt variety nl' ilie disease. The surface is
di'cply c'onirostod, in oontradi>iineiiiin in the blue-gray of the nasal
■r
.^i;' 4 '!«
■^ ''■'*>'" v"- *
I I
Fifj. "S. — Dr. Crniifa ciisr' of justiiMSiil jmlyp-is.
polypus, whilo its freednm truni |ire--m'e within the naso-pharynx
enahles it to attain a muoh larper size (Fiir. TS).
Pathology. — 1'he site of oriirin of polypus influences its patho-
loo'lcal character. The onlinnry iuueon< ]iiilypus ii,,.- its orisrin usually
along the summit of the middle uieatiis hetween th(> middle turbi-
nated and the external wall, from n juire mucous membrane. .As the
mucosa descends downward over the Imdy of the inferior turbinated
and toward the post-rliinal choana. the fibrous, connective-tissue ele-
ments within it become more numerous. 7r(Mice, the polypus spring-
ing from the upper portion of one of the posterior nares, or the
(217)
•» 1 V
/vlO
DISIiASIOS OF Tin: I'MAUYNX.
Ill
jiinctidii (if llic nose aiul I lie iiii.s(i-|iliiiryiix, is (•onipnpod of a com-
liiontion of Ixjtli flciiiciils, the liliroii> [ircpoiKlcratiil^' over the
imu(jiis. I. ike iiiisiil i)(»l_v|iiis, tlic histolojfical (k'Hiiiiioii is tiiat of
loose lli)roiiui, tin; fxlcnial wall hciiijr of denser tcxliiri! and more
lild'i'ally sii|)i)lit'(l with hliKxI-vcssels. 'I'hcv i\n not always arise from
till' eliiiaiia', however. Sictlioll' re|)orts a ease in which (he tiiiimr filled
the whole <)[ the post-nasal >|Mee, and the site (d' the atlachnieiit wad
the |ii)>terior end of tiie middle Uirl)inated hody. Miiroseo|tieally
it \\a.> an adenoid, eonneclivi'-tissne <j:rowtli, covered with stratilled
and ciliated e|iilheliiini. IJ. A. h'ceve, of 'I'oronto, also icports a
jieenliar ca-e occnrriim in a man ai;cd •JO, The growth wa- lonir imd
eveidy thick thronuhoiit, visihle in the pharynx helow the soft palate
and attached to the summit of the vault. It was of a grayish-red
eohn'. 'I'entat ively iodid. |iot. was j^iven in lai'ne doses for a week.
\\\ this time it had diminished in size; so that the drn^ was (in-
tinned \ulhonl opei'ation, and in a few weeks complete aii.-or|ition had
taken place.
Etiology. — This is still, in a measure, an unknown (piantity. Jt
cannot he allirmed positively what the cause may he; hut as the
post-nasal poly|)Us heai's some relation to the ordinary myxoma of the
nose, not infre(pieiitly occuri'intr in the same individual, the causes
may he identical. They are said to oct'ur more fre(piently in females
than males, and hetwccn the iifteeiith and thirtieth years. They are
usually siniile.
Symptomatology. — The ])rincipal symptoms are those caused hy
physical intcrl'orcnce with res})iration, voeali/iation, and dcfrlutition.
As it lianfjs down from one posterior naris, it occludes the passage
on that side; and, the enlarjicment continuinif, soon lias the ell'ect,
by its ])ressure, of closing the other. Consequently respiration, of
necessity, becomes oral, Avhile vocal resonance incident to a normal
condition of the nasal chambers is destroyed by the ])resence of the
growth. Deglutition is interfered with, just to the extent that the
movements of the palate arc linuted by the pressure of the polypus.
Although there may be progressive discomfort, there is little pain.
As the growth increases in size it may project below the palate and
be visible in the pharynx. Like other nasal ncoplasnis, it occasion-
ally ])roduces reflex symptoms. ]>osworth reports a case in his own
practice in which spasmodic asthma was caused by the pressure of a
post-nasal myxofibroma, and in which removal was followed by com-
plete relief.
NASU-I'llAUVW.
MVXOKIIIUOMA.
•.'!'.•
Diagnosis.— lV)stcrif)r rliino.scopic cxaiiuiiatinii slioiilil iiiiikc ilif
round, sinoctli, ]tiiil\i>li tiiiiiDr visihlc l''ri)in inli'iinifl-i it \< dis-
tin^Miislic(l liy its sito of ori;,Mii, li^hliT folor, ami |h,ii-,--Ii.i|m'(1 a[i-
[icarance; J'loiii liliroiiia, liy more regularity of oiilliiH'. k'ss rciliioss,
and no tendency to liiPUiorrliage on lieing toiiclicil I'ost-tuiiiinal
liyj)erlropliy lia.s a nioro (.'orriigaled .surface, dots noi project far into
(lie posl-rliinal cavily and is alway.s ]iale in eolnr. Animm the .-irik-
ing characteristics (d' po.st-na.sal jiidypiis are the facts that it is ea^jily
niov.dde; and docs not produce liaMiiorrhage, erosion, oi' facial de-
formity; nor does it pos,->ess that tendency to maliLMiniit di\e|(i|)inent
which true fibroma is supposed to do.
Prognosis. — While there is no prohahility of the luninr leailiiii;
to a fatal issue, its renu)val by slougliinij; or al)Sorption are not very
])romising. After complete rcmo\aI, however, hy operative measuri'S
tlu'y rarely recur.
Treatment.- -f!vul,-ion by sironu; serrated fnreeps thr(iui;ii the
mouth, when the tumor is sullicienlly lar>:e to be ^M'a-jied witiiiu the
naso-]iliarynx, i> one of tlic best nuMhods n[' operation. .\ l.")-per-cent.
solution of cocaine should (irst be a])p! i-d freely to the >;ro\\th throiiudi
the nose. Tliis can lie done hy means of a cotton-carrier. Then, l)y
grasping the tumor with the instrunu'id, aided, if lu'cessary. hy the
post-rhinal mii'i'or, it can be drawn down to obtain fi'eedom of motion,
and twisted olT its pedicle, care being taken not to x]:^^^ too nnieli
force in extraction.
In other case?, the nasal ]iassages having been cleared and the
ti.«sues slirunken Ijy cocaine, a siuire may lie passed through the nasyl
fossa and the wirt' adjusted to the ])edicle liy a linger passed within
the naso-pharynx. 'J'his is a safe and in many cases an excellent
method of extraction, ])articularly when the polypus is not very large,
and may he done hy eitlu'r the cold-wire snare or galvanocautery-snare.
Tlie sjiring of the former, however, renders it much more adjustable,
and, hence, it has a distinct preference over the pliahle platinum wire.
When the cold wire is used, the hase of the growth should he cauter-
ized afterward, and the ?ame may be said after the forceps operation.
In using the cauiery-snarc the I'histachian tube shoidd be properly
guarded.
Some writers recommend, in certain cases, incision into the soft
palate, to increase the space and facilitate removal. With modern
appliances for intranasal work, this should rarely, if ever, be neces-
sary for removal of simple myxofibroma, however large. Under co-
ri
1' .■
14
ni:
220
DISEASES OF THE rnAUY> >:.
w
{■aiiio the .i^rowlli ciiii be taken away IlirniiLrli tlie nasn-ii'iarviix with-
out resorting to eutting operation:? iiild the normal ti.^sue. Later ex-
porienee lias proved tliat in many eases the eohl-wire snare passed up
beliind the palate is the best method (if removal.
I have seen three eases. The (irst was a child aiied •") vi ais. The
pinkish, soft growth was visible lianging down behind I he palate.
Under chloroform I attempted to remove it with post-ii;)sal i'orcc^ps;
but the atlaehment would slip from the grasp ol' the instrmni'nt.
raili:.g this, I serajied it from the child's left posterior ehoana with
the nail of the riuht I'oretinger. This oeeurred four years ai^^o and
there has been no return.
The secnnil w;!s in a man jiasl middle life. 'I"he ginwth had
formed from a large sessile base, an«l was attached to the upper part
and on both sides of the posterior end of the septum. It partly filled
both posterior nasal fossa% and lay up(jii the upper surface of the soft
palate. I found it impossi1)le to pass the snare around it. 'I'ho
surface was suiooth and glistening, and of a grayish-])ink eoloi'. With
the posterior rhinoscope slipped behind tlu; growth, the base eoidd ])e
seen attached to the central part of both ch()ana\ With posterior
nasal force])s part of it was removed. The galvanocautery-knife was
then passed through the anterior nares, first on one side and then
on the other, an incision being made in i ;ieh ease through the at-
tachment close to the septum. Several days later, the attachment
having loosened, the l)ulk of the growth was removed by the forceps
from behind. The extended base was then singed by a curved elec-
trode })a.ssed tlirough the nares. Spray-treatment for cleansing pur-
poses was subse(iuently used. Three yea/s later, at the ago of 60,
there wa^ no return.
1\. A. JJeeve, of Toronto, has reported another case of myxo-
fd)roma of the naso-pharynx. Unlike the one already referred to, this
one had reached an imnuMisc size. It occurred in a woman iiLfed
49. On examining tlic nose anteriorly something resembling myx-
omatous tissue seemed to fill the lower portion of both nasal fos.^ac.
Q^he masses, however, were not attached to the turl)inateds as they
usually are in ordinary cases of nasal polypi. On examining the
throat the growth was found to fdl the whole naso-pliarynx. Tn
order to remove it, a vidsellum-forceps was bent to a suitable angle
and the tec th blunted. The instrument was carefully passed up be-
hind the palate and the body of the growh seized near its attach-
ment to one of the posterior ehoana}. With comparatively slight
I
liev
the
In
i)c-
ich-
XAso-ru A i; vn x. m yxofibuo.m a .
/» V 1
1^
ht
Iriulidii the wliolo innss was removed in one piece '''he projocting
teiUaclcs lying in the inferior nienti were hut overL:. »\ths of a huge
polypu-:, and slipped backward and out withoi'*" severing their con-
neclion. Oil cxaiiiiiiatinii the altachiucnl pnuMl I ■ he by a eoiiipara-
tively small pe(li( h'. which was scvrrcd hy the trai-tion of the \iilsi'l-
hnn. As a I'esiih, the jiatient received eiilire and permanent relief.
Since writing tlie ahove the following ca-c> have heen recorded: —
Weil (Wrincr ineilirinisrhc ]Vorliensclirifl, Jaiiiiarv. lS!)i)) reports
one case. It wa- atlachc(| all along the posterior v{\'j^^' of the vomer.
Two hemispherical ])rocesses filled the naso-pliarynx and caused com-
plete nasal ohstniclion. One largi' hraiich of the polypus lilleil the
right nasal cavity as far as the anterior naris, while a pear-shaped por-
tion, whose lower extremity could only he seen l>y strongly depressing
the tongue, covered the whole post-pharyiigi al wall. Weil removed
it throuiih the po~t-pharynx in one jiiece. lis weight was forty-live
gramiiKs.
]\rax Thorner (Lnnjiiijoafopr, .\[)i'il. iSliii) reports another, which
wa-^ even larger. Ifearing was much dimini-hed. there was complete
na^al stenosis, and the voice had the characteristic nasal twang. The
left nasal fossa was free, hut the right one, posteriorly, was filled with
the mass. The attachment was at the posterior portion of the right
nasal fossa. It was removed rn itimi^o hy means of a cold-wire snare
passed np l)chind the palate and around the growth. It was composed
of many large and small nodules, some of them of the size of a small
hen's v'^i:. 'I'he jiedicle was slendi'r. not larger than a lead-pencil.
'I'he wt'ight was fifty grammes. The ]iatient was a man aged 30 years.
The author might likewise ri'fer lo one which he removed from
the naso-pharynx of a woman aged lit. on .\pril "M, 1S!I!). 'I'he phy-
sician who hronght this case for trcalment had already removed a
jiolypus fr(Uii the left nostril. The jirnlniliiljly, however, is that this
was only a ju'ojection forward of the oi'iginal growth into the naris
from the naso-pharynx. On th(> left side there was complete stenosis.
I'ost-nasal examination revealed a li.i^e lohulate(l. nrm. and pinkish
tumor, filling the jiost-nasal pharynx. .\ cold snare was passed u|)
behind the soft ])alate. and was ad.iiisted over the growth by the index
(Inger of the left hand. The wliole was removed in one mass. Al-
though much smaller than the two already recorde(l, its weight was
sixteen gramme-^.
The author would also like to make one remark, which so far ho
has not observed in reading np the literature upon this subject, and
i;l
■
II
ilh
ii
222
DISEASES OF THE PHARYNX.
lU
that is: wlionevor a true fibroma (Kdematosa, or naso-pliaryiigoal
polypus, is successfully removed, it is iisually taken away in a single
])iece. It is dillieult enough, and requires care and patience to adjust
the snare well up around the body of the tumor; but it is next to
ini])(issible to press the wire closely npon all sides of the mass so as
to gras]) oidy the pedicle. 8li!I, when the snare is tiglitened, it docs
not sever a piece, l)ut reuKives the whole. The reason is oi)vious on
examining the structure of the polypus. The body has often been
years in growing, and is dense and fibrous and innssivc in character,
while the pedicle is formed largely of blood-vessels and mucous mem-
brane, and contains comparatively little fdjrous tissue; and henco
yields more readily to the traction ]ihu'ed upon it than does tlie body
of the tumor.
I
■al
to
as
ocs
on
icn
[er,
■ni-
ne
ixlv
1
CHAPTlvU XL.
FIBROMA OF THK NASOl'lIAHVNX.
This disease clifl'ers materially from the one rccnr<lc(l in the pre-
vious chapter, hein^ composed almost entirely of (ihrous tissue and
having its origin, many authorities say, from the base of the occipital
bone, near its junction with the sphenoid, insiead of in the choanal
region. It dilVers, too, in its slow, steady, and relentless growth,
crowding its way onward irrespective of the natnic of the invaded
tissue, and ])roducing absorption of bono as well as (ithci' tissues if
its way is impeded. With regard to origin, however, ('apart says that
in history of fifty eases he has usually found the tunu)r to arise from
the internal surface and base of the pterygoid apophy>ii.«, and always
on the right side.
Pathology. — 'I'liese tumors always oeeur singly. The attaelnnent
is by a broad surface or pedicle, and sometimes the surfaee-attach-
nient expands with the growth of the neoplasm. In color they are
a dark red, though sometimes of a brighter or ]iinkish hue. They
have a hard or dense texture, and at first ,i I'ounded form and smooth
surface. 'J'he latter changes, and irret,niiarily oeeuis as the disease
advances. 'J'hey ar(^ formed of ise-grained. white, fibrous ti-sue
])lentifully supplied with blood-vi '-. Scattered through the lihrcs.
which often interlace, are found the arteries and veins, and around
these arc numbers of fusiform cells. The >« ho1(> tumor is inclosed
in a capsule derived from the mucous mendnane. In addition to the
vessels that permeate the growth, there are nunieroiis i»lood-spaf'e.<j,
some of them lying directly lielow the outside coating of the fibrous
neoplasm.
Etiology. — In lUsbop's ])ithy words: '"'i'lieir cause remains in
obscurity." This is true in regard In many diseases. Xotwitlistand-
ing the rapid progress medical seiene(> has made during recent years,
we arc still, in refereiu'e try etiology, gro))ing in the dari-. .,nd how
far bacteriological research will, in the near future, enable us to jilace
this division of the science ujion a sound basis yet remains to be seen.
The majority of cases oeeur in males, and during the years of early
maturity, the disease rarely enmnuMieing after the age of twenty-five
mil)
! '!
$
S. ' '
224:
DISKASES OF THE I'HAKYKX.
il
years. Tlio surface blood-vessels of tlie growth are larger than those
of the interidr; hence tlie tendency to ha;niorrliage from mere sur-
facc-ahrasinii.
Symptomatology. — 'Die must prominent symptom, apart from
those of nasal stenosis, wjiich have already been more than once de-
scribed, is that of fre<jnently-recurring ejtista.xis arising from the
bursting of some of the numerous venous sjiaces on the surface. This
is possibly caused by friction with the soft palate. Tlie amount of
bleeding dilVers from a few drops to copious and even dangerous
Invmorrhago. As the growtli increases in size it will i)ress the palate
downward, often causing serious dcrniniity. In the same May it may
extend anterio"ly into the nasal fossa'. dis})lacing the nasal bones and
producing deformity even of the face itself. There is usually con-
siderahh? muco-puruk'iit or niucd-sanguincous discliarge. 'i'he intcr-
ferciu'c with nasal respiration and the pressure of the palate down-
ward will alfect deglutition and induce pharyngeal and laryngeal com-
plications. The stenosis priMluced by naso-pliaryngcal fibroma, al-
though unilateral at lirst, soon becomes bilateral, gradually fUling u])
tiic whole post-nasal cavity.
Diagnosis. — I'ost-rliinal examination sliould distingui>h it from
any other disca>e. evtii at an early dale. Xaso-]iharyngeal fil)roma is
less regular in nuiline tlian myxolibroma and of a redder hue. Tlie
former is hard, the latter soft: it will also bleed on touching, ^hile
the naso-jiliaryngeal polyjuis will udt. lieneath the reddish-])ink sur-
face of tlie filiroma the white llbrous tissue may sometimes be seen.
While the tumor is hard to toiuli, it can easily be distinguished from
the still-liarder texture of osteoma. One other characteristic wliich
distinguishes it from all other neoplasms, except those of a malignant
character, is the teiideuey to oft-re])eated lumnorrhage.
The ])()ints of dilference between fibroma and the malignant dis-
eases, sarcoma and carcinoma, will be dwelt upon when dealing with
these subjects.
Prognosis. — If unnmovMl by .ipcrativc measures the tendency
is toward a fatal result, ])artly owing to the repeated lucmorrhages
which so frequently occur. These growths, however, rarely develoj)
after puberty; and, that age lieing reached without a fatal issue,
development may sometimes be arrested and giadnal shrinkage of
the tumor ens\ie. Several cases have been recorded in which this has
occunvd. Still, it is not wise to postpone treatment with the hope
of such an issue, for. if unarrested, the surromiding structures, no
'1
[lo])
lias
lope
no
NASO-rilAUYXX. I'lHHOMA. •.'•-.'•)
matter liow vital their cliaractcr, are likely to be invadud l)y tlie
disease.
Treatment. — These growtlis should invariably be roniovod, if
there is any ju'ospect of tliis being aeconi])lished without ineurring
risk of life. When at all possiblo, too, tlie operation should be per-
formed per lias natiiralcs. There are few instances requiring the
radical method, projjosed by some writers, of removing the upper
maxilla. If necessary, it woidd be better to divide the soft palate in
order to reach the base of the growth. Tlie ])a]ale is not alTeeted
except by pressure, having no allachnu'iit to the tumur itself.
Operation by galvanoeaulery-eeraseur is considered one of the
best methods now adapted, as Ijy tin; slow action of the cautery
haemorrhage may be prevented. After ))assing the snare through the
nasal fossa the platinum wire is adjusted to the l)ase of the growth in
the vault by the finger. Then the wire is drawn so as to grasp the
tissue, and the electric current turned on at a red heat, and slowly
tightened until the growth is excised. Tliis operation is easy to
describe, but difficult to accompli.sh, especially with the instruments
that are now in use. The platinum wire, wbcn drawn tightly, will
often break, particularly when at a dull-red lieat, and the y)art to
which it has to be adjusted is difficult to manipulate with so soft a
wire.
Still, 14 cases arc reported liv Linenln as treated in tliis way.
Of these. 11 were cured, wliile in the dIIkt :> I'eeiii'rence took place;
whereas in iJS operations in wliieli the superior maxilla was resected
10 were cured, 8 died from the operation, 11 recurred, and 9 were
incomplete. In 7 operated on through the jialate 2 recovered. 2 re-
curred, 1 died, and 2 were incomplete.
In some cases, where the galvano-eeraseiir i^ unavailable or does
the work incompletely, the galvanocautery-knife may do better serv-
ice. It will require great care in manipulation to jirevent lui'mor-
rhage.
Operations by cutting forceps and the curettes in the early stages
have been tried, but the same care against excessive bleeding requires
to be taken.
Bosworth ])refers the cold steel-wire snare, applied in the same
way, the instrument being a stronger one than those ordinarily in
use and made of the Jarvis type, with a bar to tighten the screw in-
stead of a wheel.
Capart and Ingals favor electrolysis in the ti'eatnient of this dis-
^nt
!i
iJxJG
DISEASES OF THE PHARYNX.
i;!
eai-c. It has the advantage over all others of being unattended by
iiffiinorrhage, and when the parts are freely cocainized it is not very
painful. It may be j)racticcd cither by the bipolar or monopolar
method. In ihe former the po.sitive and negative nt'cdlcs, properly
protected, are pa.ssed side by side directly into ihe tumor at the dis-
tance of half a centimetre from each other. Tlii.>; can l)c done eitlu^r
through the cocainized na^^al fo<sa or by curved needles into the
growth from bcliind the palate. Tlie current should be between 15
and "2') milliani]:iere.s and l!ic time at cacli sitting ten to twenty min-
ule.<. By the monopolar method, the right pole might be a large flat
electrode applied to tlie cervical s|)iiu', and the left ]iolc a needle in-
serted into the tissue a.s before. 'J'hc number of trc;itmcnts required
woukl vary materially, sonu' re(]uiriiig a large number and others
comparatively few. WJien the electrolysis is not destructive of the
tumor, it may have a contracting ell'ect upon the calibre of the blood-
vessels, thus limiting the arterial supply and rendering subsequent
radical operation less dangerous. The frequency of treatment would
be every two or three days.
Whatever jtlan is followed, the parts can be kept as aseptic as
possible by the use of cleansing, antiseptic sprays.
^1
\U 6
ClIAPTFJl XLi.
MALIGNANT DISEASES OF THE XASOPllARYXX:
SARCOMA AND ( AIMIXOMA.
Sarcoma.
ArALlGX.WT (lisc'ii^os of tlii> n\ui(ui nrc \ti\v rare, luil of ihe two
— siircoina ami cai'C'iiioiiia — sarcoma is iiiiii-li more i'r(M|iirtit.
Pathology.— Tlie oriji;iu of sarcoma of the nasii-pharvnx, like
fibroma, is usually from the iieiLrliborliood of the union of the basilar
process of the occipital bone with the sphenoid. The tiuiior is more
sessile in its attachment than iil)roma. It starts in the deeper layers
of the mucosa, and, while the liase is expanding, the growth dc\elops
downward, with a lobular surface, rapidly lilling the post-jiharynx,
and sometimes extending forward through the post-nares into the
nasal cavitic«. Histologically it jiresents the usual characteristic feat-
ures of sarcoma, with large and small round cells and dense fdjrous
connective tissue. The growths are of softer texture than fibroma,
and, hence, are less likely to displace the dense osseous tissues.
Etiology. — The bacillus of sarcoma has so far not been dis-
covered, but it is more than probable that it is, in all cases, of bacil-
lary origin. It usually occurs in early life, in this way differing from
the rarer diseas'\ carcinoma. Still, it does occur occasionally even
in extreme age. It is more fretiuent iit males than I'etnales.
Symptomatology. — In tlie early stages the symptoms do not dilTer
materially from those of the diseases already described which impede
nasal breathing. There is, however, somewliat early in its history a
characteristic discharge of od'ensive malodorous sero-pus. IIa;mor-
rhage sometimes occurs, though less frcdiirntly and less severely than
in the milder disease, filiroma. The general health likewise^ suffers.
A\'hen the sarconui grows large, it interferes with the normal condi-
tion of the adjacent organs, pressure on the Kustachian tulx's pro-
ducing deafness to a more or less degree, and invasion of the pharynx
inducing ditRcult deglutition and vocalization. Shooting pains to the
cars sometimes occur.
Diagnosis. — Sarcoma of the naso-pharynx is to be distinguished
from carcinoma, fil)roma, tuberculosis, and tertiary syphilis. Its soft,
grayish, ])ultaceous appearance should distinguish it from the harder
(2ar)
)i'iS
niSKASES OF TIIK rirAUVNX.
m
Pi
I i"
s i.
11:
1 '
niid pinker liliroiiiii. From carcinoma, llie age of the ])atient sliould
lu'lp in the (liii;:no»i.s. Tlic cxcci'ding rarity of carcinoma, also, to-
gether witli its more mai'ked cachexia and greater tench'ney to be
associated witii ghmdular enlargemenl, sliouhl lielp in tliis matter.
As to tul)ereulosis and sypliilis, the general constitutional symptoms
and perM)nal history should nialerially aiti in forming a correct con-
clusion.
Prognosis. — The younger tlu' patient, the more ra])id the ])rogrcss
of the dist'ase. This is never toward resolution, but always toward a
fatal issue. Small-celled sarcoma is said to be mon; rapidly fatal tlian
the large round-celled or the spindle-celled varieties. Fibrosarcoma,
wliicii is merely a combination of the fibrous witii the malignant dis-
ea.«e, is slower in development, although more likely to be attended
during its course by attacks of severe luemorrhagc. l^ven after suc-
cessful removal by operations, in the majority of instances, recurrence
takes ]»lace, a very small ]ierccntagc of recoveries having been
reeoi'ded, wliile a large number of patients have died on the ()])erating-
table.
Treatment. — As a rule, jialliative nu-asures, with mild cleansing
wa.-hes to tlie parts alfected, are the only justifiable means of treat-
ment. The general system should be supported by tonics and good
digestilde food, wliile hygienic conditions should he carefully at-
tended to.
The results of operative treatment are usually very unfavor-
able. The old method of sjilitting the palate and dissecting out the
grDwth; and tiie larger one, of icnioving a porti(Ui of tlie upper
maxilla, to get at the pedicle of the disease, have hi'en attended almost
uniformly by a fatal result. IJryson Delavi!n. however, reports a case
wliich sei'ins to be an exception. After the sarcoma had developed,
until it partly idled the naso-})harynx, and almost entirely the left
nasal cavity, electrolysis was resorted to and carried on for a year.
I'nder its ufic, haemorrhage ceased, the growth shiank. and health
improved. J>y that time it lost its ellicacy, and operation was ])er-
fornu'd, removing the growth as thoroughly as ]jossiblc. l^ecurrenee
was soon very marked, and o])eration was again performed. This
time the njipcr jiart of the left superior maxilla was removed, and
the growth found to be attaehed to the sphenoid sinus. It was ex-
cised thoroughly. An o]iening was left in the hard jialate by which
the site could be watched. It recurred slightly several times and was
each time burned awav with galvanoeauterv. On recording this case
NASO-1'IIAUYNX. CAHCINOMA.
four months had eUipsod without any rutuni, and the youtli, aged
17, was well.
liosworth reports a case cured in a gentleman aged 42. This was
done by repeated snaring nf small pDrtioiis of the growth, carried on
daily for several weeks, and follnwed hy a series of galvanoeautery
operations, conducted in like manner. After a time the sarniiiia was
entirely removed, and seven years later there had been no return.
Logan, in ISIM, rejiorted a somewhat similar case. In this a num-
ber of smire operations had been performed, but all were followed liy
rapid recurrence of the disease. Finally the case fell into his Jiands.
lie tied the jtalate forward an<l found the growth attached to the riH)f
of the naso-pharynx. Jle divided the growth into several sections
and removed each section by a galvanoeautery operation. Si.x years
later the sarconui had not returned and the man was in perfi'ct health.
In all these cases microscopical examinations proved the correct-
ness of the diagnosis.
In Bosworth's case as well as Logan's it will be noticed that the
linal successful work was done by the galvanoeautery: a clear indica-
tion of the value of this instrument in dealing with malignant disease.
If the tumor is taken early, and can l)e removed piece by })iece
by means of the galvanocauteiy, which can be so controlled as to
occasion but little luBmorrhage, we are certainly justified in making
the attempt. By this means we also save the jiossibility of autoinfec-
tion, which might occur througli knife operation upon unafl'ceted
tissues.
1
Cakcin'oma.
The literature u]ion this subject is confined to the liistory of a
few reported cases. The disease ri'sembles sarc(nna in many ways, and
is so invariably fatal that little need be said of it here, liare as is
sarcoma, carcinoma, the more malignant of the two, is still more rare.
A few important ])oints are woitby of notii-e. however: It is a ilis-
ease that almost always occurs late in life. I'nlike sarcoma, it is also
attended by profuse glandular enlargcnu'ut and a general ap])oaranco
of malignant cachexia. ]\Iicrosco])ically the presence of epithelial
cells distinguish it from sarcoma.
The prognosis is nniforndy unfavorable. Operative treatment is
useless, mild cleansing and supporting measures being all that can be
of any avail. Opiates internally and the local ap])lication of cocaine
may, in the latter stages, afford a certain measure of relief.
' I ti
2;{()
DISEASES OF THE I'lIARYNX.
Chondroma of the Naso-piiarynx.
This non-malignant disease is so exceedingly rare that only mere
mention of it will be necessary. The symptoms are those of ordinary
stenosis. There may alno lie occasional attacks of headache and also
of syncope. Post-nasal examination reveals the presence of a hard,
dense, whitish growth. Microscopical examination of segments show
tlio cartilaginous character of the neoplasm. There is no tendency
to malignancy. Surgical operation will he reiiuired for removal.
There should he no return of tlie disease.
lM)lii:i(iN' r.ODIKS.
Somciimcs, lliougli rarely, foreign bodies become lodged in the
naso-jiliarynx. Although they ju'oduce symptoms, they may remain
for years before they are discovered. The two following are interesting
cases and worthy of note: —
\l. I'atterson {Jatirnal of Litriititjnior/!/, 'May, 189!)) reports a for-
eign hody impacted in the naso-pharynx for four years. This was a
mt'fal regulator of an infant's feeding-bottle. Tt was removed from a
child, aged years, suffering from otorrhtfa of the left side, with foetid
discharge from left nostril. There was also complete nasal stenosis,
and something could be distinguished in the ])ost-pharynx on looking
through the left nasal passage. Tnder anivsthesia a hard mass was
discovei'ed and removed from the naso-pharynx, and was found to be
the body mentioned, thickly coated with phosphates.
The history obtained was that, when the child was fifteen months
old, while playing with a regulator it suddenly showed difTicnlty of
breathing. This was relieved by suspending the head downward.
From that time nasal breathing became obstructed, and the child's
health suffered. At various times subsequently bougies had been
passed into the o'so])hagu.-' by medical men, to prove to the parents
that the foreign body was not still in the throat.
TI. S. liirkett {Monrrcal Mcdiral Journal, June. 1S99) reports a
foreign liody in the naso-pharynx for eighteen years and gives the his-
tory of this peculiar case. It occtirred in a woman aged ^3 years. She
had had profuse muco-purulerit discharge from 1)oth nnstrils foi' many
years. The odor was characteristic of a foreign body.
When five years old she accidentally slipped a thimble into her
throat. This was followed by a violent fit of coughing, which suddenly
ceased upon her being thumped upon the back.
hi
DisKASKs or Tiir; ()i;()-i'ii.\i;v.\x.
(•ii.\rri;i; xi.ii.
ACUTK I'llAKVNCII IS.
AcuTK sore llirnat, llic cniiiiniiii naiin' ol' lliis (li.-casc, is of I'rc-
(|ii(iit occiirrt'licc. ]t airc'Cts the whdlr I'niirial rcLiimi, iiicliiilin^ tlia
H)l'l iKilati'. wiih i!ic uvnla, I'aiirial pillars, ami tnn-ils. 'J'lic spi)!. first
attacked, ami ri'(iiii wiiieli it spreail^ to tlie sui'rniiiKliii'j iis.-iies, varies
ill (litrereiit eases. Jn ])ers()iis sulijeet to the disiiise. llie |ilan ol' attack
and e.\ien.-ioii often i'oliows an almo.-l invai'ial)le coiii>e.
One ])atient will always I'eol at the misct an iiiicdiiiroi'taldc prick-
in.LT soreness in the one tnn.-il. from wliirh it will cxtiinl to the wlmle
]ihaivnt:eal ea\ity. Another will jjcrceive tin' lir-l .--ynipti-m> on the
hack wall of the ])liaryn\', while a third will declare thai the primary
irritation is always fell in the hack part of the nn>irils or the post-
nasal spaei;. Slill another will state po.-itivcly that, while the acute
colli will always commence in the tliMUt, il invaiiahly extends npward
to the nose hefore it (lisap|)cars.
Pathology. — The nuicons meinhrane of the fauces is hut scantily
snp])lied with glands. Consequently in the liist stage of acute inllam-
niation the S(juanious e|)ithelial lining slmus maiked hyperaunia, ac-
companied with arrest of secretion and drvness of the .-urfae(
The
condition may last twenty-four hours or so, and is followed hy ex-
osniosis of serum and intermixture of nuico-jnis and epithelial cells.
Micrococci are present in large numhers, of -which stre[)tococci in
many cases predominate.
Etiology. — While sudden exposure to a greatly lowered tempera-
ture, ])articnlarly when that exposure is conlimd to certain ])arts of
the body, will often he the immediate cause, yet it is ])retty generally
conceded that this rarely occurs without the jiresence of a ])rior or
latent cause for the production of the disease. So many people are
exposed in a similar manner without acfjuiring acute pharyngitis that
we are forced to believe in a special tendency toward its development
in tlie case of those who habitually become victims.
Whether that tendency is produced hy the constant presence of
■(^^
1- ^
• 1 1
232
DISKASKS Ol' Tin; I'llAICi NX.
iJr
» '
chronic liiiiciiil (li.-i';i>t', tnii-illai' li\ pcr|ilii^iii. iiiiso-jiliiii'Vii,!:'!'!!! .-((iin-
sifi, goucial (lysci'aKiii, ov ild'aii^rcil diuc-i idii ur not. nnc ol' tlu'sc, at all
t'Vi'iits, hccoiiics in many in.-lanco a |iiilcnl Iik tur in the otiol();.ry, anil
if possible should he rcnioMil.
'J'lic altiick may he iironjjlil on hy cxpo^iiic of tlic liaik ol' tin,'
neck or chest to a cold wind, |iait icidarly when ihc system is ovei'-
Iieated or |icrs|iii'in;:. In ilw >ame way, .-iidden chan'ies of nndei-
garnicnts li'om hi'avy lo liuht. without i\\\i' rcLiaid lo almospherie
temperaluic, may eldll llie snrtace and increa.-e the hUiod-pre^sui'c in
a weakened pliarynjieal inueou- meinhi'anc. Tlie disease is ol'icn
caused hy a vilialeil almos[ihei'c. iidialcd hy pei'-on> employed in over-
heated, ill-veiililated rooms. Tiic-i' iinfoilnnates I'reipicntly hecome
tile victims.
It is more apt to oceiii' in adult lii ihan amonn- cliildrcii, as in
the hit lei' the lyni|iliatie and ;:landiilar eleiiiciits are more prone to
iiillainmatory aclioii than ai'e the conneetive-t issue slrut-lures.
Symptomatolog'y. - -Slitiht i-hilline.~- and Licneial malaise, accom-
panied by a sense ol' discomfort and soreness id' throat, are usually
the first symptoms. The rise in temperature is sli<,dit, rarely more
than one or two degrees. Frontal headache is sometimes present, and
when the inllammation t-xtends to the Mustachiau thOes, producing
temporary stenosis, there may he ringing or deafness.
For the first hours the throat will feel dry and irritable, and on
inspection will reveal an hyperannic condition, with ditl'used redness
pervading all the visible parts of the jdiarynx. After this the blood-
vessels and small glands commence to relieve themselves, hy ])ouring
out upon the surface a copious elfusion of sero-mucus ; pus-corpuscles
may also develop, and the inllamed ])horynx, coated with secretion,
nuiy in some places ])c almost hidden from view, particularly when
the vanlt is involved.
In some cases consi(h'rahh> o'denia of the soft palate takes ])lace,
and the mucons memhrane of the mouth and tongue i)ecome llahhy
and heavily coated and the breath itself unpleasant. When the inflam-
matory condition extends downward to the larynx, an irritable cough
is induced. This, although it occurs comj)aratively early in the dis-
ease, rarely extends to the bronchial tubes.
The duration of acute pharyngitis may he from two or three
days to a week. By ])rompt treatment it can often be shortened and
the temperature reduced to the normal, followed by rapid disappear-
ance of symptoms.
()1{U-1'1IAUVN\. ACrii: I'll VKVSdl I IS.
•y.VA
,.
Diagnosis. Snic tliioat,- (uriir in coimcctinii with , Niiiitliciiiatniw
(liscii.-cs. ,'iihI in these ciists thi' (liiijiiiDsis nmv lu'i he ccrtiiin until thr
hnrfiicc ciiiiitiiin apiicars. Slill. <•!((.■-(■ cxaininaliiin >liunhl (li.-tin,Lj,iiish
tlio even h_v|icra'niia <>{' sini)i|c .^nic ihi'nat I'rniii ihc -iihnniiiiii< I'lHoroi:-
ecncw (if llic ciiiiitivr r vcr.-. In ciininii'iicinj; t(»nsillitis the pain (if
tlio tnn^il aH'cdi'd is nimc scmii' than in siinjilc acute pliann^iti.-
while the redness of the suri'du'iHlinij: niuen.^a is h'ss evenly distrihnteil.
Jn rlienuialie Mire tliinat tiiere is u.-iially h's- ledenia than in the
second .-laue nj' tjii- disease^ wjiik' tlie t'aueial mnscK'S are nmre pain-
ful.
Prognosis. — rnle>s the inlhiininatmy adidn extends [n the
larynx, it usually snhsides within a week. Siuur wiiteis have re[i(»rted
cases |nll(i\.ed l)y .systemic paialy>is, luil it i» dniditl'ul wludhiM' the
toxic eireet iif the ili>caM' cuuld Ih' SeVele ellnllLlh li' pi'nduce pai'csis.
Other writers helievu that these must ha\e heen casesj ol' masked
diphtheria, in which the Klelis-Ldelller haiillus, althnnii'h lu'csent,
could nut he t'dund.
Treatment. — Uefore cnicrini:- upon the treatment <d' acute iihar-
yni^itis a wnrd i<v twd mii^ht lie >aid here in refercnee to euraiiie.
intrndnced a cnnple u\' years a,i:i) as a enHatei'al dru;_r which nii,L;ht
ill some cases take the jilace ot' cocaine in tlie treatment (d' iinx'
and throat diseases. 1 have lud spoken ol' eucaino before, because
from the writini;s of authors and my own porsnnal oxporience I did
not think it cnnid be \\>v(] with advaiitauf in nasal work, and in this
field would be i'ar inlVrinr in idility to cocaine as a local amrstbotic.
In the pharynx, wbero we have ample sjiace for vision, and do not
re([uiro to contract the tissues in order to obtain a view, the case
may l)o dilferent, and I will bore pive the views of several leading
writers upon tlio comparative merits of the two drugs.
Soniers {Thcmpeulic Gazelle) says cocaine produces local anirs-
tlicsia in from .'? to 5 minutes, lasting from 20 to 30 minutes; eucaino
produces local ana>stbesia in from S to 10 ininufcs lasting only 20
minutes. Cocaine produces ana-niia of iniicous membrane. Kucaine
produces hypera'inia. This action of eucaine, he says, strongly mili-
tates against its use in operations upon byperlropbie tissues. The
advantages, however, wbicb it lias over cocaine are the following:
It produces less pbaryngeal disturbance, is less harmful to tlie system,
keeps better in solution, and tlie efTlciency of tlie drug is not injured
by boiling.
Poucbet (La Semaine Medicale), reporting to tbe Societe Tbera-
I'd
i '
23i
UlSKASES OF THE rUAliVNX.
})eutiquc, said that lie liatl investigated tlie physiological action of
oucaine. He found the toxic equivalent almost equal to that of co-
caine, lie sa3s eucaine may produce toxic ell'ccls, whicli may even
])rove fatal witliout any prodromie stage. Its action on the heart is
as intense as that of cocaine. Eucaine must therefore be looked upon
as a dangerous drug.
Keclus (lirilish Medical Journal J'JpiloDw) says that in equal doses
its anitsthetic ]io\vcr is less than that of cocaine. He thinks, there-
fore, that it i^liould not be used in serious oj)orations.
J. S. (iihl) {Philadelphia Poh/clinic) has used eucaine in diseases
of nose and lliroat, and sums up as follows: L Kucaine is ecjually
elliciont witli cocaine a- an anaesthetic in ordinary examinations. 2.
It possesses e(iual ana}stlielic power with cocaine aiul hence is as use-
ful in o])erations on nose, throat, and laiyiix. .'!. luicaine is nearly
if not quite as effective as cocaine in reducing the engorged turbinated
bodies. 4. Kucaine is su]ierior to t-ocaine, in thai it is less likely to
produce toxic symptoms and also unpleasant subjective symptoms,
particularly as regards the pharynx.
f.asily, Jobson Home and MacLeod Yi'arsly [JiritisJi Medical
Journal), 'fler a long article u])on the subject, close with the follow-
ing sti lenient: "Several points I'cniain for furtlicr experience to
decide, out ws consider lliat our results, so far, justify us in con-
tinuing the investigation. luicaine cannot, however, wholly replace
cocaine, since the eU'eet of the latter, in reducing the size of the tur-
binated bodies, gives it a value as an aid to diagnosis which eucaine
does not appear to possess."
These combined remarks seemingly would justify our exclusion
of eucaine in dealing witli diseases of the noK^; while they indicate
a probable utility in regard to the treatment of pharyngeal disease.
To return to the treatment of acute pharyngitis. ^I'.ch can be
done in the way of aljortive treatment in tbe ]ihysician's ofllce. It
can fre(|ncntly be arrested by prompt local treatment. First, cleanse
the ]>]iarynx with a spray of Hobell's solution. Then spray it at once
with a Iv-pcr-cent. solution of cocaine. Pos>il)ly a similar solution of
eucaine would answer equally as weP.. This will, in a few moments,
deaden the terminal ner.'c-filaments and prepare the mucous mem-
brane for the im.|)ortant jiait of the treatment, which is simply to
brush the pharynx with a 5-per-cent. solution of nitrate of silver,
applying the pigment most thoroughly upon the parts afTected. The
treatment is to be repeated in twenty-four hours if required. In the
OKO-1'HAUYNX.
ACUTE l'liAHYN(iniS.
nieantiinCj and subsequent to the brusliin<3% oitlier of the I'oUowing
solutions, applied with an atomizer every three or four hours, will
act as an antiseptic to the throat and aid in keeping it clear of
catarrhal secret iojis: —
i :
1. It Ixi'sortin 112
Glycerin Gl
Aqiiam iid GOI
M.
2. IJ Tliyinol 1005
Boric acid 2!
Glyicrin 15
Aquani ad GO
M.
Although by tnis method slightly increa.-^ed tenderness of the
throat may be experienced, as soon as the eil'ect of the cocaine or
eucaine has ])assed away, yet the course of the disease will be short-
ened. In a day or two the increased redness of the mucous membrane
will have disapyicarcd, and, instead of the pultaceous inliltration and
muco-purulent discliarge that sometimes occurs, it will have resumed
an almost normal appearance.
To accomplish the same object in a dilTei'ent way JMshop advises
tlie administration of pelk'ts each containing ^/„ milligramme^ of
atr(i])ia and 8 milligrammes'' of morphia, repeated every few hours
as required, to act by their combined anodyne and drying efTect uptm
the mucous membrane.
Quinine might be administered in either ease and a brisk cathar-
tic if required.
Amniig the older methods of treatment, one that has often been
very ell'ectivc in checking the disease is the giving of drop doses of
tincture of aconite every hour until the throat symptoms commence
to abate, after wliich the interval should be lengthened. This would
1. B Krsnrcin ffr. xviij.
(ilyccriu 3iss.
A(iuaiii ad .'^ij.
2. R Thyiiiol !-'r. j.
Horic acid ;;r. xx.x.
• .lyccrin Hixlv.
Aiiiiiiiii ad Sij.
M.
' V(M grain. • '/« grain.
IS
I -',*:.
I ': .ft- i
III
! ly-
^3
li:
23G DISKASICS 01'' TIIK IMiAUYNX.
usually occur before the first tweut^'-l'our doses luul been given.
Tincture of belladonna might be prescribed in the same way, in ;?-
drop doses every two hours. Jiotli are arterial sedatives, with an
astringent cfl'ect upon the fauces.
(iarglcs of alkaline solulir.ns. such as Diiliell's, chlorate nf potassa,
etc., have long been advised in tin' ircatment of this disease, (largles
are, however, as a rule, only iinpcrft'ctly applied, the solution not
being allowed to enter the lower {)haryn\ at all. ('onseipiently, even
when using the same solution, a good atomizer is much to ho pre-
ferred.
]f the ini])rovciucnt seems tardy, the alkaline spray niighi be fol-
lowed by an astringent, my own preference being for the liydi'ocarbon
C'ompnnnd, used, of course, with an atomizer.
1. IJ .Acid, taiiiiie 2|
(Jlyccriii 31
A(piiuii ad GOI
At. '
2. H ThyiiKil |]3
Moiithol 113
.•Vlbolcnc OOJ
M.
As regards external applications to I he nock, 1 do not believe
they are of much value. Sometimes a enld wei flaniu'l applied to the
front of the throat, and kept in position by a rubber bandage around
the neck, wdl reduce the irritation by its sedative elTect. When
counter-irritation is needed. ei|ual parts of spirit of iuriicntine and
sweet oil form a good application, the throat being covered witli a
layer of cotton-wool.
As said before, persons subject to this di.sease arc frequently
sufferers from some obstructive lesion, which is the primary cause.
Ifence, after recovery, it is the duty of the jdiyt'cian to see to it that
the lesion if present be removed, and that the entire naso-pharyngeal
mucosa be ])laced in as souiul a condition as possible.
1. It Acid. t;iiiiiif pr. XXX.
(Glycerin »/ixlv.
A<ni;iiii ad ,^ij.
'2. It 'riiyitiol gr. ij.
Mciiduil pr. XX.
.Mliolcnc 3ij.
]M.
CllAi'TKll XLlll.
ciiiioxic I'liAiivxcnis.
J
This (lisca-^L' is coiiiincd lai\i:cly in tin: pharviiiifal iiiiicoiis nieni-
braiie, the .-ol'l ))alatt' aiul tlic uvula In'iiig rarely alVectcd, oxt-cpt in
cast's wliicli have a nasal oriuiu. As it (ncurs cliiclly in adult life,
the j^landular systcMn is lint. littU' ad'cctcd. The tonsils, however, if
in an liyper^jlastie condition, not infrequently hcconie atl'ected l)y the
disease.
Pathology. — Successive I'ejiet it inn of ailaek- of soi'e throat, from
whatever cause, is likely to produce peimauent hypera'niia and relaxa-
tion of the hlood-vossels. A species of pliarytiLreal paresis takes phice
—the cnntinned coni^-estinn rcsnltincj; in surfaee-intiltratinn and struct-
ural thickening'' of the mucosa. The lymph-follicles and muciparous
glands arc also alVecled, sometimes hciug marked hy distinct hy[)er-
tro])hy in the lines (if the salpinu^o-pharyngeal folds.
Etiology. — There are many canses for this disease, and writers
in tracing out the etioloiry are ai)t to be indneiiced !)y special features
coming imder their ])ersonal ohservatiou. in my own experience,
chronic nasal disease, d(>viations of the septum, the presence of neo-
plasms, or post-nasal adenoids have heen the ])i'evailiu'^- causes. The
result of any of these would he oral Itrcathinir, particularly at ni.^ht,
and the direct contact, repealed every ni<:ht for a prolonjied period,
of dry air upon the post-pharynx, for reasons already explained,
would he suHicient to induce the ilisease.
Home writers believe that the nuist comnuui cause is the occui-
renco of the ofl-repeat(>d attacks of acute pharyii'iit is, while otheis
as«ert that tliis is never the cause, hut that the chronic disease is the
etiolo,<,ncal factor of the acuje.
liosworth traces tlie disease to chrnnie ^lastrilis of one form or
another, hasin;^'- the he]ief on the theory that the lu-o-pharynx i- a part
of the food-tract, and conse(|uently nmre in sympathy, physioloirically
and patholoirically. with the diixesiive than the respiratory organs.
Castric disturliances of a chronic cliaracter almost invariably atVect
the pharynx, possil)ly by retlcx influence. This is particularly th(>
case in chronic alcoholism. The tobacco habit, too, is not unattended
If
ill'
238
DISEASES OF TJIE TJIAUYNX.
by evil results, though whetlier they arise from nicotine ahsori)tion
or the direct efl'eet of tlie hot, dry air upon the throat is still an
undecided question. Persons wliose oecujiations keep tlieni exposed
to constant respiration of foul air or irritating gases are also subject
to the disease. Jt is also frequently caused by improper or prolonged
use of the voice.
Symptomatology. — A sensation of iluoat discomfort, accom-
panied by a desire to swallow, in (jrder to relieve the parts of sup-
posed accumulations, is one of llie coiumonest symptom.-, particularly
when the disease has a nasal origin. When it arises from chronic
gastric disturbance, tiie throat is more irritable, and on examination
with the tongue-depressor retelling may be produced, while the raw,
inflamed condition of the lower jiharynx will ))e ol)sorvcd. The
voice, too, is often altcri'd in Iniic. 'I'licrc may he a ras[)ing screatus
to clear the lower ])liaiyn\. and a jfrky hnarseness, sometimes lapsing
momentarily into aphonia. A voluntary cough to free the arytenoids
from mucus may l)e jircsent. In certain cases the palate becomes
relaxed, hanging down like a llabby curtain, ami even the uvula may
become o'dejnatous and elongated, though these conditions can only
occur, I Ijclieve, when the primaiy cause lies in the upper air-passages.
Diagnosis. — The symjjtoms described, together with the sensa-
tions experienced Ijy the ])atient, should easily distinguish this from
any other disease. The chief dilliculty in diagnosis sboidd not be as
to existence of chronic pliaryngitis, but as to the catise which pro-
duced it, whellicr it arose fiiun gastric or nasal disturbance or from
some purely external source. One broad distinction lies between the
first two. In tlu! former the lower throat will be deeply congested and
the tongue will be irritable, with red ]iapilla3 stamling over its base,
ibe jialate being 1)iit slightly all'ected. In the latter the redness and
irritahilily will he slighter, the post-])haiTnx l>e more deeply coated,
and the ]ialate alTected more or less by the disease. When both
these causes can be excluded, the history of the case per se may
indicate the origin.
Prognosis. — This i- not an alarming disease; but, as the cause
])roducing it is usually of a chronic character, both chronic condi-
tions rccpiire to be removed, and it may take careful treatment for
a long time to accomplish the end in view. Still, much relief even
from the commencement can be given, and it is worth the patient's
while to submit to the necessary treatment.
Treatment. — When the disease is secondary it becomes important,
()I{()-l'IIAIiVN\. fltKONIC I'llAUYNdll I>.
^39
if possililc. 111 rciiKivc the jiriiiuirv ciiusi', wlidlici' thai lie \i\ >iii'^ical
removal of ol)sti'iictivc lesions of nose or iiaso-jiliaiTiix or systrinic
treatment of clironie gastric disease. It may lie necessary \n lurak
or check the liquor hahit or to interdict the use of tohaceo. DilVnult
as either of the latter may seem to be, llie patient who appreciates
the throat all'ccjion sullicicntly to seek professional relief will usually
do his liest to carry nut the physician's advice.
Direct trcalnient to (he throat will also he reijuired. The r!r,>t
should he ihorouiih cleansiufr with alkaline sprays. If there is much
fhickeninp- and infiltration of the mucosa, this should he followed liy
the application of a 10-per-cent. s(dution of nitrate of silver. The
best way of a])plying it is by means of a cotton-holder. Sometimes
the throat is so iriitalile that the pressure' of the tongiu'-depres-or
upon the hack of the tongue will immediately produce contraction
of the pillars, shutting off almost the whole of the post-pharyngeal
wall from view. To obviate this a weak sulution (if cocaine, 1 or 2
per cent., nuiy be applied to the fauci's. Then, in applying the silver
solution, the eiul of the holder, aftrr b!'u>liing th<' part of the })ost-
pharynx in view, sluuild he lient to an aiigh' of loO degrees or so, and
slipped behind the posterior pillar on one side, and glided up aiul
down to the full depth of the fold, the other side being treated in
the same way. This treatment need not be repeated oftciu'r than
once or twice a week at the physician's nllice.
Other astringents — such as sulphate of cojiper. chlnride of zinc,
glycero-tannin, etc. — might be used instead, but for directly removing
the ontside coating of the mucous membran(\ and stimulating normal
action of the capillaries, no application ap[)ears to act as ethciently as
nitrate of silver.
For luuuc-lreatment the patient should spray the throat freely
twice a day with an alkaline solution, and follow this each time by one
of the hydrocarbon preparations already mentioned, «uch as: —
3-per-cent. camphor-menthol in albnlene.
o-per-cent. eucalyptol in albolene.
3-per-ccnt. menthol in alboleiu3, etc.
The general system should also be regulated, the alimentary canal
attended to, and apjiropriate tonics prescribed if necessary.
; .]
' ] i
I !• :i!
t 1.
! n
i liii
CHAPTEK XLIV.
FOLLICULAR PHARYNGITIS.
! ;
ili
This disease, as its name implies, is confined to tlio follicles of
tlie pharynx, particularly to those of the post-pharyiigeal wall. Tlie
inllammatory process, without extending to the wliole mucous surface,
scattered over the
cted follicles vary-
oduces hyperj)lasia in a number of isolated spots
and location of the affe
luces
membrane.
th
le abundance
ing in dill'erent cases.
Pathology. — The lymph-follicles involved in this disease are en-
larged and stand out prouiinently above the surrounding mucosa.
While the mucii)arous glands are few upon the pharyngeal wall and
tlic lymph-follicles widely scattered, yet it api)ears to be those situ-
ated in the immediate vicinity of tlic glands that have tlie greatest
tendency to hypertrophy. Tiie morbid process consists of abnormal
deposits of lyin])h-clenK'nts accompanied by epithelial growth. In
the exudative form, instead of tlie latter develo))nient, the follicular
tul)ules are distended by a cheesy secretion, which exudes, and may
crust upon the surface. In some cases the inflammation becomes
more diffuse. A niinibcr of follicles will be united by connecting
submucous hyperplasia, and plaques are found varying in size rising
above the niueuus mcml)raiu'. "When the disease occurs in early life,
tlie granulations are soft and sometimes large; but as they rarely
disappear of themselves, they undergo a change as the patient gets
older, becoming smaller and more dense in texture. Sometimes the
hypertrophy of the follicle is associated with atrophy of the surround-
ing mucosa. In others there are not only the isolated granulations of
the central wall, but also strings of thickly-studded lateral granula-
tions extending upwaid into the naso-pharynx. behind the posterior
jiillars of the fauces.
Etiology. — I'lxcept in the two extremes of life, during which
l)eriods the disease is almost unknown, age has little influence in pro-
ducing it. It occurs from childhood all the way up to middle age.
In early life wlien adenoids are present we would naturally expect
these granulations to oecur in conjunction with them, the adenoids
being the cause, not by dirt'ct extension, but hy pro(lueing throat
(•MU)
ORO-PIIAKYNX. I'OI.LICILAU I'M AUYNdlTIS.
•^11
irritation consequent to oral breathing. The rorniation di' adenoiils
and follicular disease are both influenced in many cases by the pres-
ence oi' scrofulous diatliesis. In adult life it frequently occurs as a
result or coni])lication of previously-existing nasal disease.
It is said to occur more frequently among wniucn than men,
probably owing to the more sedentary occupations oi' the former, and
the consequent greater tendency to the dcvelDpmciit of disease of the
mucous membrane. We should remend^er, also, how much the phar-
yngeal mucosa is inlluenced by the gynjecological condition of the sex.
Granting a tendency toward the disease, breaihing a dusty at-
mosphere, excessive use of the voice, continued nasal ol)struflion, the
occurrence of acute or chronic pharyiigitis, or any other comlitions
which may imluce continuous throat iiritution may irsull in the
development of pliaryngcal granulations.
Symptomatologfy. — When occurring in children, the symptoms
are rarely noticeable, being thrown entirely into the shade by the
existing primary disease. In adult life this is dilferent. The suii-
jectivc sensations are more intelligently realized. Tlie nasal stenosis
or post pharyngeal discomfort may have been relieved, but the dry-
ness and pricking sensations, and hacking cough ])roduced by the
presence of the granulations are still there, producing annoyance and
discomfort to the patient. The voice loses its full aiul rounded tone
and is easily fatigued.
^\'hen the disease is associated witii post-nasal catarrh, the pos-
terior wall of the pharynx may l)e covered with a grayish, stringy
coating of mucus-pus, often hiding the granulations from view until
it is removed. Then the surface will he seen more or less covered
with promineiit little hypertrophies. They vary from one to live
millimetres in diameter, and, when phniiies are present, they some-
times cover from one-half to one s(|uaro centimetre in area.
Although strings of granulations may sometimes l)e observed
running upward behind the pillars into the naso-])harynx, it is com-
paratively rare to find the posteiior pillars affected. When they do
form on the pillars or the margin of the velum or uvtda, the granu-
lations arc very small and hard, like little, red seeds, standing out
upon the mucous mend)rane.
Stiffness of the throat, painful deglutition, aiul sori'iu'ss after
prolonged speaking are freciucnt symptoms, and have given I'ise to the
term "clergyman's sore throat" which has often been applied to it.
The application seems to be an unfortunate one. a-; the sore throat
! Ui
ifi
M
2[\
DISEASES OF THE PKARYNX.
I r
by which so many clergymen arc affected is almost always due to other
cau?es. This was particularly exemplified in a paper which I read
before the Canadian Medical Association ir M(mtrcal in August, 189G,
giving the history of 10 cases of so-called clergyman's sore throat.
Allhougli it is a slight digres<;ion, yet it has a bearing upon tiio
subject, and the quotation of the last few sentences will not be out
of place: — -
"In conclusion, according to old ])arlancc, the 10 cases I have
reported niii;lit all be called 'clcigvuiiui's sore thrnnt.' wliil(> in
reality only 2 had follicular pliaryiigilis. All had soi'cness and hoarse-
ness in a more or less degree; hut these sym])toms arose from widely
differeiil causes, and in several instances hypertrophies of different
kinds wore found to exist in the one case.
"Jirielly to epitomize: —
In 1 there was a large nasal y)olypus.
In 1 a dislocated columnar cartilage.
In 1 hypertropliy ol' the faucial tonsils.
In 1 ulceration of the hyoid fossa.
In 2 there were septal ridges.
In 2 septal s]uirs.
In 2 cntarrhiil li\'pci'lro|ihi('< of the i)ost-seplum.
in 2 clongalion of the uvula.
In 2 |iharviigcal granulalious.
In .") turhiual h_vperiro])hi('S.
"While in only oni'.' and that the most serious case of all, was
there uneoni|dieated laryngeal disease."
Whether a name which will cover sueli a variety of diseases, merely
because one or two symptoms may be present in all, is worthy of a
place in medical literature is at least doubtful.
Diagnosis. — Carefid exaniiiuition by means of the head-mirror
and relleci(v] light should at once exclude every other disease. The
little, round, red or grayish-red spots, shining brightly upon a ]ialer
background, could not he mistaken for anything else. When the sur-
face is coati'd from post-pharyngeal catarrh the spots may be hid,
but clearing tliis away by the use of an alkaline spray will soon render
them visible, together with any plaques or lateral granidalions that
may be present.
Prognosis. — This is usually a chronic disease, and rarely subject
' Eijilitccii iiKiiillis later lliis gentleiuan died of malignant disease of the
larviix.
OHO-rilAUYNX. I'Ol.l.ICI l.AU I'llA H VMUTIS.
•v'4;5
to spontaiu'ous cure, cxicj)! as iiicideiitiil to llie lyni|iliati(' atrophy,
coninion in old aj,fe. Be:>idcs the annoyance it causes, in persons wlio
do not rc([uirc to use the voice unusually, its presence may be of littli!
moment. In voice-users, liowever, whether public speakers or sin<;ers,
the presence of l'(jllicnlar pharynLritis becomes a serious matter, as
it interferes with the tone and ([uality, as well as tlie endurance, of
the voice itself. Fortunately, however, it is amenable to treatment
in a liii'.ire majority of cases.
Treatment. — This consists, after cleansing the pharyn.v of all se-
cretions by the free nse of ?prt.ys, in destruction of the hypertrophic,*
follicles one by one. For this purpose many methods have been ad-
vised, the object being to destroy the overgrowth without injuring
the surrounding healthy tissue. London paste and diroinic acid are
both used for this purpose. The chief objection to each is the possi-
bility of the extension of the effects of the agent to the adjoining
mucous membrane. The galvanoeautery-puint carefully used is en-
tirely free from this objectionable tendency.
Although the operations are slight, and the pain of burning re-
duced to a minimnm, it is always Ijetter to precede the operation by
the application of a solution of cocaine to the ])harynx. Some oper-
ators consider this unnecessary. Still, the fact that the deadening of
the pharyngeal wall prevents the reflex contraction of the posterior
pillars during the operation makes it almost im])erative to use it. At
the first sitting three or four or half a dozen granules may be touched.
The operations should be repeated at intervals of three or four days
until all have been removed. A mild spray of V„-pcr-cent. solution
of thymol in albolene iised several times a day by the patient will
have a soothing influence during the course of treatment. If ca-
tarrhal secretions interfere, they can be removed by an alkaline spray
instead. The kind of electric point used should depend on the size
and shape of the granulations, and the heat should not be so great
as to produce luvmorrhage. The small-pointed hypertro|)hies would
require the needle-pointed electrode, the larger ones a thicker ti]i,
and the plaqiics may be incised at a dull heat from side to side with
]iarallel cuts — the whole surface not being destroyed at one time.
There is alwa^'s more or less inflammatory action afterward, and it is
always better so to operate as to keep reaction at a minimum point.
If the granulations are very numerous the treatment should be
prolonged and sometimes intervals of weeks might be allowed to pass
between the cauterizations.
■■ ■
: 1 .
illt
iii:
in
I
844
DrSEASKS OF THE I'HAKVNX.
Of coiirso, if the disease owes its orij^Mn to nt'()|iliisiiis or ovor-
growtlis ill (Ik; upper ri.'S])iratory passages, these should ho removed
heforo the patient is dismissed from treatment. Any deran;.fement
of the system should also Ik; reetilied iiy judicious medication, to-
gether with attention to diet and hygiene.
CIIAPTKR XI, V.
ACITK TONSlLl.mS, OH QL IN-SV.
:*■
^1 !i
The close observation with which this iliseasc has been observed
<Iurin<f recent years lias e.'^lablir^lied the fact tiiat although tlie tonsil
j)artakes in the acute inllaniniation which is developed, in a large
proportion of cases the di.-case originates, not in the tonsil itself, but
in the areolar tissue surrounding it. Still ilicie can be little (Iduhi
that many cases occur in which the inllanimaiory action, if nut
virtually confined to the tonsil, at least has its origin there.
JJosworth believes that all cases of quinsy are |)eritonsillar inthiui-
nuitions of areolar tissue; Cassellierry cipially I'a.ors this view. 'I'iu'
older writers, and ]>ishop among the new ones, claim the condiliou
as one of amygdalitis, or abscess of the tonsil itself, and an_\ peri-
tonsillar extension to be of a secondary character. In Lennox
Browne's experience oo per cent, of cases occur in the lacun;e of the
tonsil, 28 ])er cent, in the ])areiichynui, and only i:') per cent, in the
peritonsillar tissue.
From my own experience, I believe the (U'igin may he cither
cxtratonsillar or intratonsillar. '^rii(> deep i)hlcgmonous abscess, in-
volving all the peritonsillar tis>ues, with the whole lateral wall stand-
ing out, and pressing the tonsil itself directly across the i'aucil cavity,
may in every instance be peritonsillar in its oi'igin; but others, which
are oft-recurring, definitely localized, and arutely painful, in which
the most marked ocular signs are in the tonsils themst'lves. are likely
to be tonsillar in their origin, any extension into the siiriounding
tissues being of a secondary character.
If not. it might be asked, how is it lliat in the latter class of
cases the tonsils themselves steadily increase in size. l)ecoming larger
and larger with each successive attack, while, so far as can be seen,
the Pin-rounding tissues remain unchanged!-' And how is it, also, that
the removal of a large segment of the hypertro[)hie(l tonsil will, in
most cases, effectually check the recurrence of (piiusy?
Pathology. — Although acute tonsillitis, as a rule, results in s>ip-
puration, yet in some instances it extends no farther than acute in-
flammation, becoming red and shiny: according to Leland. the jiaren-
m
24(1
DISKASKS OF rilK I'lIAIlYNX.
cliynuitous variety, 'riicro iiiiiy he inliltratioii witli incroased cell and
lyjiiplioid dcvc'lo]iin('iit, tojri'tlicr witli tlu; proscneo of pathnlojiical
goriiis within the crypts of the tonsil. Stroplooocous jjynLronc.s and
|)nciunoco('ci may he prosoiit; hut i^o h)nji as they arc ail on the sur-
face or witliin the crypt.s oidy, and not uitliin tin; drcpcr tonsillar
or areolar tissues, ]»h]e<;nionoiis aliscess docs not occur. In a lai'tjc
proportion (tf cases, however, the infectious ])rocoss doi's not stop here.
The IncnnjG of the tonsils niny heconie blocked. l*atho,i,'enic f^erni.s
nuiy already have found an ci)ti'anc(\ and. the eiypls licin;,' (dosed.
exposure to the surface cold uiny produce hypei'a'Uiia of a rhcuniatie
throat, iind inllainniatory action he developed in all its intensity. In
a rheumatic diathesis the peritonsillar tissue, particularly when pressed
by a liard, liypcrtropl\i(Ml tonsil, will he prone to intlammatory action,
and havijig commenced may soon spi'cail In the suiTonndim: tis-ue
and the tonsil itsidf. I'us-corpuselcs are formed, a phleuiiKuious
abscess results, and streptococci pyo<ren(\s may be found in larire num-
bers. Sonu'tinies pneumococci and stapliylocoeci will also be present.
The site of the abscess varies greatly, sometimes it is in front
of the juncture of the anterior and posterior pillars. .\( others deeply
seated behind the lower part of the anterior f(dd, pressing the tonsil
inward almost to the opposite wall of the pharynx. .Again, it may be
at the ])osterior side of the tonsil, deeply engaging the soft palate
and uvula in inllammatory infiltration, while not infre(|nently the
whole body of the tonsil itself may be the subject of phlegmonous
enlargement.
When the pus forms, the soft character of the surrounding tis-
sues do not tend to limitation. Fortunately it spreads e(|ually in all
directions, and, there being no dense membrane between it and the
surface, spontaneous evacuation usually soon occurs. When the sup-
puration is decjdy seated, behind a dense hyperplastic tonsil, ])rogress
toward the mucous surface is more tardy and the pus may burrow
extensively into the surrounding tissues. Velpeau reports a case in
which the pus made its way into the cellular tissues of the neck as
low down as tlie clavicle. L*cid reports another in which the ])ns
burrowed along the course of the great vessels into the ]deural cavity,
resulting in death from empyema.
Tn some cases the tonsillitis is confined cntirtdy fo the tonsil, and
is deeply ulcerative in character. Lake reports a case of this nature.
The ulcer was as large as a shilling and covered with a tenacious
gray slough, lie removed the tonsil and in five days the young man
ond-i'ii \i;VN\. griNsY. V 1 1
\Vll!i Well. 'I'llf llllr|n.-( i)|i(' IcVcillrd lill';;*' lllil.-.-L'» ol' lirildctl hiliilli oil
tlio advaiiei'd nl'^a ol' llio tfluiigli.
J';du'> H'poits tiircc cfiscs ol' lU'uU' tuiif:illiti> in wliii'li the tnii-
fil.s tilt iii.-t'l\t's wcro tlic .«(':il of till' dist'iisc, huiiig in ciU'li liisc rrd
and swollen. On nii('rosco|iii;d cxiiininalioii of the lilood-M rum ;i
|uire cultnrt' of {'"ricdliindcr's liacilliis was found in lacli, in one of
tlimi lii'inu !is.-ociatrd wilh sta|iiiyl()c()ccns auicii*.
Etiology.- 'i'lii' ]»ciiod of life duiiiiL;- uiiicli this iliscasc is most
|)n'vali'nt is hului'un llio ages of lo and 10 }'tars, tlu' largci' luuidxT
bi'ing near thu ixMilio uH that period. Slill, s(jiiic oeciii' even in ehild-
hood, while a very few aii' reported among the liflies and sixtie.s.
The rheuiiiatie diathesis is a predisposing cause, and in many casis
aoiite rheiiinatism of the joints is a pri'lude to rheumatic tonsillitis,
while in othef instances the tiuinsy precedes liie gem'ral rheunuiti.-tn.
Siu'cessive atl icks td' tonsillitis lend to prodtiee liyperlrophy (d' the
tonsil, while the increasing hypertrophy jironioles .susceptihility to
intlaniniatoiy action. The disease occurs more frequently aiiumg
males tlian ft'.males, owing to the greater exposure as well as climatic
])rivatioiis to which men are suhjecl. There is also in scuno cases a
marked hereditary teiulency. This ocurs chielly in strumous eases,
liyperlrophied tonsils being a prominent feature of development. One
fact is readily observed, that ijuinsy rarely occurs when the tonsils are
of normal size.
'J'lie usual exciting ean-e is sudden and unei[ual exposure of the
body to cold. The chilling > f the surface, and the consequent con-
gestion of any weak internal organ, will in many instances tesid to
the development id' the disease. 'I'liere is aimther point, whieli 1 do
not reineinbi'r lo have seen referred to. but which I have ol)~erved
in practice, and that is that the majority of eases of quinsy occur in
mouth-l.M'cathers. The constant oral respiration exposes the throat
to a variety of changes, both of leinperalurc and purity of air, wliicli
the normal bi'i'ather escapes.
Symptomatology, — The dejnTssing cll'eet whicli tliis disease lias
upon the nervous .•system is indicated by the feeling of weariness ac-
companied by chilliness and exhaustion, with which it is often ush-
ered in. For the first day or two general febrile action takes place,
risinir to lo'i'" or lo.'5°, in some cases even higher.
These symptoms are accompanied by ])ain in the affected tonsil,
swelling soon takes place, and in two or three days it may become
so great as to materially interfere with deslntition. When the disease
ij'i
It
' V
Ifl.
'f j!
248
1)1si;asi:s oi- 'in-; I'Hakvnx.
is pcritonsilliir tlie ti>>\ic< 1)ltoiiu' voiy l)ra\vny and jiainfiil, the
muscles swollen, and the iiidvenients ol' the inferior maxilhi are ma-
terially interJ'ered with. The ell'orts to swallow even Jluids are some-
times almost unavailing, and, ouiiiL lo the imperfect action of the
swollen jialate, they may escapi' thi'( ii.iili the nose mi the ell'ort of
swallowiii::-. 'I'iie voice becomes mu!lle(i and indi-tinct, and sleep al-
most im])os;-ible. At first the pain i- ^harp and lancinating. Later
on swelling occ^irs, and the pain I.ecMines nf an oppressive, aching
character. As the swelliuL:' in the ihi'oai lieconio greater, s;diva
drihhU's from llw moiuh and llie jaw> heconie almost immnvahli.'.
'J'he temperature goes i|ov\ii. ihe hoily may he hathiMl in c(jld swci.ts,
and even respiration may he si('rloi'(nis a^ impcdeil. I.itth; or no
nourishment can he laki'n. and llu' recumhcni jtosturc heconu's almost
impopsihle. This cniulition may continue sevei'al days without relief
is given liy surgical : '"ans. i-'inally tlie pu-^, aiming at some point
within the ]iliai'ynx or hack part of the mouth, gradually softens the
surface meml)i'aiu'; the mucMisa gives way, ami, the pus lieing dis-
charged freely, the jiatient obtains imnu'diate relief.
When the disease attacks both tonsils, it is rarely exactly at the
same tinu', hut in (piick succcssiim. the one being invailcd within
two or tliree days of the other. They then run their course almost
together, the main dill'cri'uce between single aiul double tonsillitis
being iti severity of .-symptoms.
Diagnosis. — The acuieness id' the iidlammatiuu. with its rapid
development, ai.d high fever, should distinguish it in all cases from
syphilis, tuberculosis, (U' maligTuint disease. With reference to other
acute afTections, the characteristic symptoms o" quinsy should render
the diagnosis plain. Th(> sudden onset of high fever, accompanied by
sharp unilateral jiain in the tonsil, bright redness and swelling in
one side of the throat, the ditllculty in swal owing, the immobility of
the jaws, the dilTIculty of bending the neck, aiul Ihe peculiar dis-
tressing look of the face point to this disease in contradistinction to
all others. When the disease is double, th.e intensity of Ihe symptoms
shotdd retider the diagnosis more certain. l'r(un ]ihleguinnous abscess
of the post-pharynx it must be distinguished by the position of the
enlargenuuit. and the greater impediment to respiration which the
disease induces. Talpation is always a nuitorial aid in diagnosis. In
the early stages the brawny feeling of the abscess, wherever located,
may he outlined, and, as the suppuration advances, the point of soften-
ing can be readily discovered.
OKO-1'llAUVXX. QIINSV.
2\\)
lu tlu' coniineiiceniont Uicre is a possibility of confounding this
disease with (liplitlieria and acntc lacunar tonsillitis, hut attentive
ol)servati()n should remove all ditliculty. Tlio onset is more sthenic
than ill diplithiTiii. hut there is less eiilarti'einent df the viands, no
albuminuria, no development of false nieinlirane. As to lacunar ton-
sillitis, the jiresence of tonsillar exudalioii, unaccompanied by much
eidar^'ement or by deep-seateil pain<. should dislini,niish it at onie from
the more scritur; malady of tonsillar abscess.
Prognosis, — Acute, painful, and excei'dinuly distressinir, as the
disease always is, it very rare'*' |ud\rs fatal per sc. When it does do so,
it occurs either from (cdeina of the air-passages or extension cd' the
abscess into the surrounding tissues. It is a self-limited disease, and
runs its course in from oiuj to two weeks. Afler free evacuation of
the pus-cavity, wbellier by necrosis of the surl'ace-tissiie or by surgical
operation, recovery is ii-iuilly very rapid.
The possilhlity and e\en prolndiility of the recurrence of the
disease should always be borne in niind.
Treatment. — CnforfuiiaJcly in this, as in many other alTcctions,
the patient, as a rule, does not seek treatment until the disease is well
established; and by that time it is too late to aliort it. Prompt treat-
ment on the 'irst appearance of the throat .-symptoms would in many
instances check its progress. For this object a saline cathartic, such
as sul])hate of magnesia or Eoeludle salts, may be given, followed at
once by a dose of \/._, to 1 gramme of (piinine. I'rompt treatment
of the tliroat, also, should be attended to. First wash it horoughly
with a sjiray of DobelPs soliiiiiui. Then api)ly a 10-pcr-cent. solu-
tion of cocaine freely to the affected tonsil, and follow this ity brush-
ing it with a lO-pei'-cent. solution of nitrate of silver. The cocaine
tem])orarily drives away the blood frcmi the congested tissues, while
the cathartic is attempting to prove its elliciency. The astringent
and autiscjitie eflVct of the silver will remove a good deal of the super-
ficial iri'ifation, as well as destroy the surface and lacunar bacteria,
th
lus ])roduciuu' a trene
ral sedative elfect uiion the intlamcd gland.
Other astriuLTciits- — such as solutions of siiliihatt' of coi
pe
r, alum.
or tannic acid — might he tried, but they lack the elTectivencss of llie
sil' er nitrate.
If the tonsillitis is of rheumatic origin, full doses of salicylates
should he given.
Failing the abortive treatment, other measures will be required.
As the disease advances, it becomes very diHicult to open the month;
p
250
DISEASES OF THE I'HARYNX.
and, while examinations may \)g necessary, in order to keep cognizant
of the location and ])rogresa of the disease, freqnent digital exami-
Jiations are inadvisable. The touch of the linger in the early Ijrawny
(!ondition may help to clear up the diagnosis; but even tlien it is
scarcely necessary. Subsequent to that, the touch of the (Mjiton-
holder with its thin, tirni stem and little pledget of cotton-wool on
the end, aided by reflected light, should be sullicient to indicate the
condition of the parts.
When pointing is indicated, from the grayish color and softened
condition of any spot, it is best to open the abscess freely at once
and liberate the contained pus. The question often arises: Should
we lance the inllamed tissues earlier, or before we are absolutely sure
of the presence of purulent matter? In many instances I believe we
should. 1 have seen instances where a dee|) incision into the tonsil
itself, producing free venous haemorrhage, without the nutlet of pus
at all, has been followed at once liy relief of the most urgent sym[)-
toms and gradually recession of the disease. Another instance I can
well rememljer, in the case of a rheumatic patient, in which the
])harynx was almost filled with an intensely-painful riglit-sided phleg-
mon. The teeth could not be opened more than 1ml f an inch; but,
inserting a tongue-depressor, a deep and long incision was made
])arallel with the edge of the anterior pillar. Bleeding was very free,
but there was no pus. IJelief from the severe tension was marked,
and twelve hours later pus commenced to flow from the wound.
While incisions to give relief re(piire to bo free, tlie ])roximiIy
of important vessels should always be borne in mind. The intonu'l
carotid artery is in near proximity to the posterior and external
border of tlie tonsil, and if wounded death might result before the
vessel could be cut down upon ami ti('(l. As a rule, however, it is
better not to lance until we are morally certain of tlie formation of
pus; and, without the o]ierator is perfectly sure of his bearings, this
should be tlu- law in all cases. Sometimes the jjus-cavity is not a
single sac, and several ojienings nu\y require to be made before all
the pus can be discharged.
Frequent gargling of the throat with hot waler, before and after
operation, will usually have a grateful elTect upon the patient; and
the sanu' may be said of steaming the pharynx by means of a rubber
tube attached to a kettle of hot water.
With regard to external applications, many believe in hot poul-
tices to the neck; while others recommend the application of crushed
I
OUO-PirAIiYXX. ycixsv. ggj
ieo in the sa.no way. In my own c.xp.ri..,,,-. a nn,,,!.. nuahu,! Ins
sufi-cod, g.v,n, e.,nal c.nlort with l... ,n.nl,l.. Wann .pint of t
po^^.no and ohve-oil ,„ „,„,, ,„,„ ,,„,, ,,„,,,„„, ,,„„,^. ,_^^ / J
of he tonsds and tl.en a tlu.k narrow lay.r ol' .u;,oon: al. C
cot on was appli.nVon, side to side and ,a>,.„..d r;. ,,,,;,,,;
mn^ an a,e TJus was repeated twice a day. se.unnl a .en.at o
01 warinth and support.
Dm-in^ the progress of tl.o disease, lid,, and no„,i.lnn. diet will
'T lu.deuey in r..,-,uTe,Ke. Tlw onln.arv ruh. reonlatin.
c^iet, c.lotlnng, and hy.iene d„u,ld. of , .., ,.„ ,;,,,„,,„,. ;[,';;
^-..however of. dl,,UH.r.u,., .,vnn.e...^
h3porp]as,an ,lH.,on<dswlneh .ill ,..v.„,Uu. n.nrn ;',•,!,.. ,,in.v
islhe reinnval of ll,e diseased nl,,,,,!... '
;i
i!.1)
CIIAPTKli Xi.Vl.
iJJSKAbKS UF TllK L \ LLA : iKlJli.MA; ELUMiATlOX.
(Kdema.
'i'iii> i> a .-iiii|i|i' scTdiis cxuiliitidii ii)tt) the ilccjn r layt'i'.s of the
Tiiiii'ou.- iiu'iiiiiiaiii'. W lull .-I'Vt'i'i' ami lu'nldiiucil. liio (ilircs of the
azygov uvula' iiiav he iiivuhed, also the soft ]ialate an<! jiillars of the
faiiec's. Ii i> llie stToiiil sta--e of iiillaiiiinaton' r.otion in the softeiieil
ami iclaxid ii.-,-iie>.
Etiology.-- -t I'Jii'ina of the inula is almost always of a seeoiulavy
iialur(\ liaviiiii' its origin iii aciile or ehnuiie inllammaticii of souk;
porlinii of the nose or na-o-)ihai'yii\. Occasionally it is a rellex
Iraumatisiii from surgical ofieratioii upon the lurhinaleils or faucial
tonsils. SonietiiiH's it is idiopathic.
in one patient I was struck \v h the peculiar fact that on several
occa>ions the ajiplicalinu ni iii-|i(.i'-ccnl. snlntion of cocaine to tlie
nasal cavity preparatory to operati'iii was followed, in les- Ihan half
an luuir. hy (edema of the uvula, which in a ciiu|ile of hours spou-
tanemisly siihsided.
It may. in a W'W cases, he the resnit of pharyngeal tuberculosis
and nisii of general ana-area.
Symptomatolog'y.-- A tickling sensation in the middle of the
throat, with a feeling cf fullness as if from the presence of a foreign
body, accoinpanicd by c(Ui-lant elVorls to clear the pharynx by hawk-
ing and swallowing, ai'e the leading .-^ympicnus. I'hysieal examination
will at onec reveal the ciuidition. The jialate will be relaxed and the
nvnia-clongated. thickiiied. and baggy — will have hist its normal
]iinl\ hue. and assumed ihal (d' a transparent bag of serum.
Prognosis.- -When it ;iii-es fi'(uii traumatism, the subsidence will
be spontaneous, usually within a few hours. When fioni acute or
chronic disease, the swelling may not so soon abnl(\ l'"acli case, even
without treatment, sluiuld, in time, .>-iib-ide, unless it owes its origin
to general dropsical ttVusion. \'o fatal case has lieon rocorded.
Treatment. — .\s a rule. tli(> treatment for the renuival of the
primary cause is all tluit will ho required. When 'he symptom.? are
(552)
OKO-rilAKVXX. KLONGATIOX OL' TIIH UVfl.A.
^J3
very distrossiiijr, astringent gargles of tannic acid, subacetate of lead,
alum, ete., might be used. In otiiers the .-iirface of the uvula might
be brushed with a solution of cocairu''. and then tlie mucous mendiranc
could be jiuiu'tui'cd in a niiinbcr (d' |ilai-cs with the; |<(iint of a lance,
to alliiw tiiL! cll'n.~i(iii to escape. Sulisci|Uciitly the throat coubl be
.-tt-anicd, or a.-iringciit gargles usi-d.
iM.ONiiAridN oi' I in: I vri.\.
Tliis i^ ri'djiiriitlv assuciiitcd wiili h v|n'il mpliv oi' ihi' (irgaii.
Xormally the ii\ida -hmild h;iii^r dnu ii fr.'i'ly within ihc taiircs. uilii-
out touching the t mguc, and (d' a hiigth vai'ving from eight [n iwclvi;
milliiiu'lrcs. The muc(ui~ ini'inhi'mic >hniild |ii (•h)S('ly to the niii>clc
hcncalh, and the surface shmdd lie liini iiiiil t>\' a clear, piid; enh)i'.
When elongation takes |ilaee. the leiiulii may he even ihree centi-
metres or more, and uider-s ihi' iiicrca.-e in length aiises nui'ely rmm
(I'dematuus llii(d>;cning o\' the mncMus niendirane there is u-ually
present hypertrophy likewise.
Pathology. — As a I'ulc, the eomlitidn nf clircnic irrilatinii which
eventuates in eloiigatiitn (•imlines ii-elf in piddiieing hy|ier|i|;isia id"
the nuiciuis inendii-ane. the while lihi'niis and clastic tissue (d' the
muscle remaiiung unaU'ectcd. ConseiiiU'iitly ihe . hmgatitut is purely
beh)w the azygn.-. Still, c.ises iKcur in which the whoh' organ is of
abnormal thickne.-s as well as length; nf a I'eil, deeply-eongested
coloi'; and in which even the free applicaiion of ln-|H'r-t'ent. solution
of cocaine will produce very liiniied ,-hrinkage. In liicso cases the
azygos mnselo extends down deculeijly below ihi' centimetredinc. and,
the whole organ has the a[i]iearani'e of a lai'ge tleshy mass, d'hc
permanent congestion seems to result in grannlar hyperplasia of the
lihrousdissuc elements, situated below the true mucosa.
Etiology. — l-'longation of the uvnla is so fi'eiiucnl an attendant
upon chronic nasa.1 and naso-pliaryngeal disease that it wmdd seem, in
the majority of ca-es, to owe its origi?! to their prcst'ucc. The jiei-
p(dnnl movement- of the palate to clr.ar the itaso-pharynv keep it in
a stale of constant ii-rilalion. resulting successively in relavMioii.
I'lotigation. and hypertropliy. A weakened conditimi o\' the > -'.ni
oi- l()ss (d' mnscnlar tone may accentuale the ironbic, allowing;- a I'e-
laxcd palate to diop I he nvnla upon the toiie-ne. 'I'he conslaid elfort
of the patient to dislodge lU' swallow th(> seeming foreign body has
the cfToct of keeping the uvula in a congested and irritable condition.
In some instances the chnigation is congenital. In these cases,
t^
')i
J.^51
I)Isi;asi:s ok jiik i-iiakynx.
Aviici'c there i- iiii iiiiso-|ili;nTii,i;ciil ii'ritiitinn to ii^'u'i'iivate the iroublo,
tluTL' is lillle likeliliiHid (if livperlnipliie (level(i|iiiieiit. llie siiiijilo
('U)ll,t:;lleii, leilellialnlis ll\lll;l lieillt:' il 1 1 tlllil i> likely ti) oeelir.
Symptomatology. The -yiniildin,- emue (ni .-n .i;r,-i(lu,illy nml
|iiiiiik'-.-ly ihiil ejiiiii^iiiidii I re.|iieiitly i,~ imi I'eedi^iii/eil iiiijil invosti-
Llillinll I'm' Mime iither (li-eii~e reVejll.- ils |ire.-eliee. 'I'lie .-y lll|ii(iIIIS 11 11'
ihiisL' (if iiiiiin.'iiy ihniiii iri'iliil inn -iiiiiliii' in tli(i>e nf (edema (if tlio
ll\ll]ll. hill dl' millnl' (IcLlli'e.
I )e,iiliit il idii is mil much iiilerrere(l wiih. hut iihdii at jdn. wlieii
ihei'e is hy|ieiMi'd|iliy a- well a> ehm.i^at i<iii, i.- IVei|iieiitly all'eeteil.
This is partieiilailv ihe ease with [iiihn_c_sjj(/ajitxs_ iiiHl siii^'i;.<. Id
these it_jnv(s_the voice a 2!J"lJi':iJ.. thidaly eharae tei', as if tlio iiiidiia-
t idii issue d li oiii the jiha iviix witluiia the clear control of the iiuisc-les
id^jjhe^ljingiie and iiioiitl|.
'J'he eoiitih in'odiieed liy ehinualioii df the ii\iila is of an ii'i'itahle,
nervous eharaetei' and iinaeedm|ianied hy e.\|ieelo!'at ion. sa\'e that
which can he hawked up from an ordinarily catai'rhal |iha!'yii.v.
When the iivnla is very Ihiil:'. iIk.' >iipine position will cause ii to lie
dii the po>t-pliaryn.uial wall. While llie uprisjhl po>ilioii. if the
larynx is silualed hiuh in ihe ihroat, aill make ii loiieli tin.' e|ii-
ulottis, in t'ilher ca.-e prodiieini;' lemporary irrilalioii and cdiiLih.
A.-tlima is recorded as one nf ii- relle\ results.
Diagnosis. --'I'll i< can only he a mailer of simple examiiialioii.
Wliellier thick or thin, if Ioiil: and pendulous, and accomjiaiiied hv
ihroai catarrh and iicivou- cnuiih. ii may he cdiieliided that the con-
dition of t his oi'uan is aluiormal.
Prognosis.- -'I'o life it invokes no (lauLrer. To ^cncfal health
\ci'y lillle. 'i'o the .-pcakcr or sin_i;i'r llui presence of the elonixalion
i- not a [S I nineii. as. without operation, the dillienltv i- likelv to
he permaiiciil. lleiice ill thest' casi's, and in all where il i- accom-
p;inied hy llii'oal irritation, the proLinii>is sliould |)oinl lo a Mat i on
of a jiortion df the otl'endin,i:" nieinlier.
Treatment. -In mild ea.-es dev(ud of aiinoyiiiL; .-vmptiun- the use
of astrinu-enl ,i;ari;ie< may he df lieiicllt. j'erhap.- the lie~i of these
\Miiild he Lilyecro-iannic nr sulphate of irdii. Tdiichiiii: Mie end df
the nviila al-o wiili a ln-|i(.|--ccnt. .-dluiioii id' nilrale df -iUer miiiht
he of service. When the clom-'atioll i- produced entirelv hv livper-
tropliy df ihe miieii-a. hru-hini; \miIi liiicinre df indine niav he
iltlended h\ L'ond iv-iill-.
In iiid-l (ii-e-. Iid\\e\er. a -li:jht opeialion will he found neees-
; I
n|{()-|-|l \1!VN.\. Kl.ONCA THIN (tK llli; I \l l.\. V.).)
sary, tlu' ri'diiiHlaiil [un'lioii nl' ilic uvula n'(iuiriii^' to \)v rciiinvril.
In (loiiiff lliis there i.< always daiiffor of cuttiu'' olT too larw a iiurlidii.
If we (k'sire to (sfaMisli a siiii|ik! rule thai iniulit ,u(iv<'rii all cases
ill uhicli operations was alisoliitoly nMiuire(|, i, iiiiulit he iliis: -V('''o'
Id cut off liioir ',l:<in mn'-lKtlf j'roDi llic h'lnjlii nf llir iiniln.
As in(1ieat<"l, IroMi whal lias already heeii ,-aiil, the excision
sliDiihl only he ;lial ol the hy |iert rophieil niiH'oiis iiieiiihiaiie al the
eiul nf ilie u\iila. in ea-''- una! leiideil hy niii-eiilai' hyiieil rnphy.
'There ari' -eveiai nietliod- ]i\ wliieh ihe lillle operation ean lie
perfiiriiied, ea(di iiiethnd re(|iiiriiiLi' dilTereiit in.-l riiuieiii -. .Maeken_-
zie",- llVlllotollie llliiihl lie luellliolled. eiiH.-lrihli'il nil llu' principle of
the faticia! toii.-illninnii'. Ilo-woriirs >erraieil ^eissln■s is al-o prai-ed
iis a u'ood in-l ninieut. ina>iiiiieh a- the .-errateil idadi- prevent any
possihiliiy of -lippin_t; (I'i.i:'. 'i-M- Jlc IjIoIb's galvaiioeaiiterv-Liiiillo-
tiiie is an iiiLieiiioii- in-trunieiif. preventiiiL;' any lueinnnham' al the
I'l-x. Til. I 'villa seissiiis. f.Vflrr I'losw ml li.)
liine of operaliiin. Kyle uses a >liaip hi-lmiry. eiiltiiiL:- out a wediic-
sliaped pi<'ee from the einl (d' the iiiiila and thii> avoidin;^' a eliih-
sliaped >tiiiiip.
^^y own pV(d'erenee lies with the lollii' and eur\cil sei>sor.~ to-
.Uelher with lollii-. inolise-toiit lied foicep^.
Ill opcratiii"' 1 invariahly secure the pali<'iit'- a^-i-laiiec. (I have
only seen one ease in childhood, and in this ihe iisula was removed
under 'dilorofiprin. ) A In-prr-cenf . -idutinu id' eoeaiiie i- lirst, applied
on a plcd^ict. of eonon to ilir n\iila. 1'lie palieiM ili.'ii hold- thr
toiiLiiie down with a toiiL:Ue-depre>sor. With the left hand llm oper-
ator seizes the inida Hear llie ivxtremilv with the foi'ccp-. and draw-
it p'ciitly forward without piiilini;' it on the stretfdi: and with tlie
vi.Lilit applies the Mi-.-nrs, leaniii'^' upward ,ind haekwaid. so a- to cut
the u\ula with an aeule aiiuh' to the front. Ily ihi< iiieaiH the heal-
iiiii' is mostly nn the posterior surface, the anterior niueiMi- meinhrane
lieiiin- hd't almost entire tl''ii:. SO).
;J:i :
i:
2')(\
])isi:.\si:s ov nii: rnAifVNX.
I' I
■H
Xo furtlic' Irciitniciil is nM|iiirc(l except to iiisist upon light ^ soft
^^t^)f ti CHHiiMeinpi'RUure lur a day orjwu. No coiidiiiionls or hot
iluids or irritants of any kind sliould he tai\cn duiing that period,
on accdunt dl' the anilc pain they might proihicc.
Sevt-rc hiiMnnii'lingc al'tfi' iivnhitdiny i.- t\c(M'din,::ly rare. One or
two deaths have iie<'ii icported i'ollowiiig the operation. Imi it is
(h)ubtl'ul if Ihi' dcatli really oceiirred as a residt. A i'vw eases of
severe hannorrhage after the operation, some of them dillieult to con-
trol, have also l)een re(iirdc(L In a iiumher of these many lionrs
elapsed liefni'e the hiecdiiig eniild \h' stopjied; and in lialf of ihem
,^^:«
I'iti. SO. I'".\tisi()ii of iiMilii. lAftiT liosw ortli.)
the whole organ had been removed. If the uvula itself was liyper-
tro))hied as well as elongated, and the large fleshy mass was e.\eised
entirely on a lin(> with the arches of the soft ])alate, one would not
wonder at lueniorrhage l)eing severe. If. on the other hand, it was
accepted as a fixed prinei])le never to remove more than one-half the
length of the organ, the ha-mni'i-hage should always he easily con-
trollah](\ I never saw a ease wliich hied severely, and invariably what
little bleeding did occur was over in a few minutes.
If cocaine has been freely applied before operating, there will
rarely be any bleeding ai all for several seconds after the piece is
OUO-l'IIARYNX. KLONOATIOX Ol- THE I VLM.A.
ft
Miipped oir, uwiii- tn ih- hIn.Ml beiii- driven out hv the astriiinvnt
netion of the cocaine; then .-li-ht Llce(lin;L,' only will occur.
I have not .^cen a case recorded of return of abnormal growth of
llie uvula after it had l,een once e.xci.^ed. Sonic vars auojiowever,
a clergyman, aged oK, came to me for treatment". J found that he
had Jiasal j.olyjiu.s relaxed palate, and a very long uvula, the central
muscular portion extending almost to the end of the organ. He in-
formed me that a ihrr.at si,eciali.st had performed uvulotoniy several
years before, luit that it had grown again and he desired to have it
removed. This time J reduced it to the length of ah-mt one centi-
metre. Jt Jia.» given no further trouble.
Occasionally we meet with c-a.^^es of congenital bifurcation of the
uvula. One branch is usually smaller than the other and planted to
one side. If no symptoms arise as a cnnse^nienee, tliev shnuld n.,t be
interfered with. Sometimes for aesthetic purposes tiie smaller may
bo removed. Wben tlie bifurcation is even, extendinir into the palate
the edges should be pared and the cleft closed hv fine sutiuvs
:ii
'•ill
rilAl'TKi: WMl.
i!i"i i;(iiMiAi;\ NcKAi. .\r.s( Ks>
'riii> ilJM'ii.-c n'sniiMr- imi-illai' iili.-(;fss, fXccpi ili;ii in.-i
ClKI Ml
I .:/:
oc(.'iirrin,L;' iii llic tdii.-illiir I'c^inii n. Ii;is its oriLiiii m ilii' i>'i<t-))hiir_\ ii-
gciil Willi. (.)irH(' ]i(issiMy ;iL:-L:i'ii\ak'il ciisc.-; ol' [)crit(iii>illar iilis(;c>.<
niiiilit cMcimI liy >iiliimic(iiis iiijilti'aiinii intn tin; iIccimt |iliarynui'Ml
liji.--ii('S and i'('>ult ill ('MciisivL' jm^-.-ac rnniiatKui.
Pathology. — '\'hv patliolno-icaj loiiiiitinii of it'i!'n|i|iarviiiiral ali-
scoj-s oci-iiniiiL;' in chilillHHMl ililVci- Irniii that nrciii'rini;' in inatiii'i'
year.-. Jn early lil'c tlu' lyin|iliatii' ti.-.-ucs arc in a >tatc nl' active
(Icvclopjncnt, ami in tlicir iniiiuiture condition arc niofc prone to di--
('a?c, Mliorcas, wlicn maturity i.s reached, thi.-; development has lieeii
completed : permanent ^lirinka.iie ha.- already coniincneed. and there
i.s little tendency to .-nppnrative action in them. In adult life it is
the ei'Unlar lis.-iics rather than the lymphatic that arc lialilc to in-
llaininatory action: Imt there i- jtrohahly no irreater tendency to
al)Sce.-.--devclop!nent at thi> ]ici'io(l in the throat than in other regions
of the liody.
The development of alisce,-s in c> 'hilar ti.-snc i.- ii^nally rapid;
and. just as t|ninsy will run it- coiir,-c in a vci'y few days. >o will
i-ctropliai'ynj^'eal ahseos.s in the ailiilt re.-iilt in pus-formation ami ex-
tension into the snrroundini:- tissues in a .-imilar leiiL'^th of time.
in childhood, howevi-r. the sni)puration takes jdace in striimou.s
lymphatic glands which have ]iri'vionsly heen swollen, and the de-
vcdopnient of \\\c disease is a slow and tedious ]»roc'oss.
Etiology. — As in the |iatli(dogy. so in llu^ etiolocry. the disease
diU'ers accdi'diim^ to the period nf life in which it occurs. In childhood
the presence (d' the lymphatic diathesis renders (he tissues of tlu' post-
idiarynx more ready to take nii -iippurative actimi. The con-ei|iicnce
is that diirin.L;' this jieriod ihc primary cause in a majority of cases
is the same: the ]n'esencc nf a ^trunioii- liahit. In these eases any
cause which may excite glandular intlammation im either side of the
]iost-]tharyn,i;-cai \\all may re-iilt in suppuration.
In older persons the can.-c.- are nioi'c idiopatiiic in their character.
!i)il
oiio-i'iiAitvNX. i!i;ri;oni \i{\ m.kai, ahm i;ss.
*i5})
C'dcli iiidividiiiil ciiso liciiij; (It'iifiuli'iit ii|iiiii somo piircinl cause <>( ]\^
own. Sonic cases arise from caries of llie vcrtelira'. altliouj,'li the |iei-
centa^fc is verv small: Mime a> -e(|Ue|;e nf e\anl liemalii. pai't ii iilail\
M-arialina. e(|nall_v small in nnmlur; ami iii(ii>iimally nnc fi'om liau-
niaii,-m. I'eilia|i> cnld. aeiint: u|inn a ~rn-itive llirual, llie pliy-ical
iicallli liein,ii' at llie time lielnw par, may in ailnll lile lie \\\r me-i
fri'ipicnt caHM'. Sc\ ha.- no -|iicial inlhience. in nid a::e ii rarely.
if e\el', oeenr-.
Symptomatology. In children ijn- -\ni|iiiMn> are iIkim' altendinL;'
the ,-lnu -ii|i|iiiral inn nf ihe |ym|iha!ie L;lands. 'I'here i~ rarely any
chill. Inn llie feeliiiu' of malaise. III-.- (if a|i|ieiite. and laiiuimr. 'I'ln'
fe\cr i- very sliiiiii and aeeom|ianie(l liy ;:railnal In-- n( Ih.-h. I lay-
may elapse hefure alieiiiiiin i- di-aun In the ihmat. 1 >ei:lin il inn
e'radiially lieenmc- dilliciili. and may llnally lici-nmc i ni|iii--ihle. while
the voice a.->iinie- a |ii'ciiliar (jiiackiiii;' Inne.
On e.xaminalinii al' ihe ihi'nal the |in-i-pliaiyn\ uill he fniind tn
he -wnjlcii a- if hy o'dema, pan iciilarly nii nnc -ide. lillint:' up ihe
]ihai'yn\ and pre--inLi' iipnn the toni^iic, My-pmea al-o hccnme-. in
many ca,-es, a sci'ioii- .-yniplnni. nwin;^- in iJic pres-iire nf ihe plile;:-
innnniis sac iipmi ihe larynx, prndiicin^- defective ai'ralinn of hlond
and more nv Ic,-.- cyaiio-i-. The child"- head may hecoine llxcd: henl
forward slijzlitly if llie discasi' is hilatcial and toward the iinalVeefed
side if unilateral.
In adults there are no liini:-cnnt iniied pi'einnniinry -yniplnm-.
'Inhere is no ulandiilar all'e(-tion: hiit cmnini: on -nddenly are the
direct .-yinptimi> of severe faucial le-inii. This is in the fnrm of
acnte inthiinmation in a localized spot, rc.-ultin^ in early suppuration.
with rapid extension i)itn tli(> surroundiiiLT tissues.
There is pain in the pharyn.x frnm the tirst, a,ir,i,'ravated hy any
atlcinpt at de.iiliitil imi. The disease is >ilienie. ii-iially ushered in
hy a chill, and marked hy a ri>e of .-everal dcLM'ecs in temperature:
whereas in children the fever is of a low asthenic type.
Another nnlahjc diiVercnce is that in adult life, while dcHliiti-
lion may he exceed in,::ly painful and almn>t impn-sihlc. dy.-pmea
rarely occurs.
Diagnosis.-- On examination the ]iost-iiIiarynx will he dark and
iSwoihii. 'lid in due tiiiu' the j)oint of nearest a]iproach of pii- id ihe
sui face Will he noted hy its <rrayish. dead appearance. These, with
the „feue.al plileuinomnis ooudition. eitiier across the whole nf the
poslerinr wall or limiled pai'tially tn mic .-ide. .-Innild indicate pretty
r!/l
'(I
■I':
IMAGE EVALUATION
TEST TARGET (MT-3)
fe
//
^0
.v«
^^^
A
:/.
V
#
1.0
I.I
11.25
1^ 1^
us 12.0
U IIIIII.6
Photographic
Sciences
Corporation
iV
•1>^
A
\
^\
6^
23 Vt>(:i>r ^ M'j STNilT
WEBSTER, N.y. MSBO
(716) 873-4503
,.<fc
\
o^
<^
"I
ill
III
•J GO
DISKASES OK IIIK I'll A li V N X.
wi'Il tlic imluiT' of the disoaso. Piiljintioii would indiciitc the i)n'S('iico
1)1' |)iis or llu! brawny condition pri'dMliiiL;- it. 'J'lic same nii^lit liu
.<ai(i ol' the ciircfiil nsc (if tl)o cotton-liolilrr. the clastic sensation at
I lie |ioiiii ul' snlicniit^' iicin;,' iccoiiMi/alile \>\ citlicr means.
Ill I lie astiieinc ahsee.-s o
'iiildhood ther
e I.- le;
loeallXeij in-
llaniKiatoi y action, and ]ierli;i|i'- iikhi' ol' an o'deniatoiis a|i|ieai'an( e.
'I'lie disease is also more likely lo lie unilateral. Hence, from tlio
(inc-hided fullness, toiictlier with llie indications from toiiili. tic diai,'-
nosis slionld imt l>e dillieiill
iliroillell V III (
liild-life -lioiild not
lie forjidttcii. In al' eases, liotli in cliildrrn and ailiills. tbe |ieiiiliar
eliaractcr of voice, lixation of tlic head, aliseiiee of coii'd), and freedom
irom tonsillar comjilication should help to exclude all other disea>es.
'J'lie possibility of niislakiiifj; aneurism for post-pharyn^rcal altscess
sec'in.s almost incrcdilde. The stron.Lr regular pulsation of the one.
free from all inllamiiiMlory aeiion, should, liy sii;ht as well as touch,
distinjniish it positively from abscess of the pharynx.
Prognosis. — The plilej^monous abscess of adult life runs it- course
ill somethiiifjf like a weid\. Then, in favorable cases it will open
spontaneously, and in a few days heal. When lanced earlier, the
conrse is shorter. It is rarely a dan^'eroiis disease, even if let to llnd
its own o'.illet, althouj;li both painful and dislressiiii:.
In childhood it.s course is much more |ir<d(mired, exiendin;.; over a
miinber of v cks. and not unattended liy danirer. rn-uceessful dia;x-
nosis niny prolong; the disease anil ciulan^rer life from siiirocation,
riiiitiire of al).«eess into the air-passa,i:es. or proloni:ed ana'inia and de-
bility. (Kdeina, also, miirhl lead to stenosis and death.
When the disease arises from spinal carie< the proiriiosis is not
Xood, inasmucli as the cause cannot be removed.
In very severe cases, wlien unrelieved by surjrical interfcrenee.
tlicrc is serious dan.irer of general -epiii;emia, to be followed by a
fatal issue.
Treatment.- -In adults the treatment is almost identical with
that of (juinsy. The abscess should be opened as soon as the presence
of ])ns becomes certain, and the swollen and inllaincd li.>isues may be
scarified even before the existence of pus is discovereil.
In yonn;^ children, considering: tlm; the phliiiinonous inflam-
matory condition is absent, scariliealion would be contra-indicated,
but openiii>: of the abscess as soon as discover(>d should certainly he
done. As a rule, the opening should be made in the most dependent
part of the abscess, and into the pharynx. Cases, however, do occur
u ;
<>it<.-i-iiAiiVNx. i!i:Ti!nniM!VN.,i;.M, AitscKss. ;;'.;i
i'l "lixli .■in vuvviui] u.-isinn is \hv lavt; hut this ran only he when
Ihv Mi|,,u.ratjv.. Ivniphmic :h.n.ls r-.m hvA he ivachcl in that way
I'onltiun- in this .lis.as,. ,,,1, I f Ijule avail. In juv.M.ihs tl,e
<•on.ht.on IS loo asfhcnir t.. iv.,,„.v ihcir a|.|.li,ation. In a.luU.s they
;"">'"t 'vad. the aireete.! parts. an,l h,,,.-,. are nseless. If applications
to the neek are re.|uire.l at all. the warm e..tton-woul n.IIs already
iH<rre(l to m tnafin- nf .piinsy are all that ^^nuh] hv rcp.ircd In
chihlren alt.r rxa.ualion the application of tineturo of iodine to the
swollen ^rlan.ls nii-ht h.. pro,|ii,.|ivc of -.„„|.
Snj.portin- nica.Mnvs and noun.hini: dirf in children are always
"1 I'lnee, an.l n-uh.tion ni ,hr prlw^r viv i„ a,lidl~. uiih antiperiodio
treatment, niiMhi h,. ,,f s.'rvic.'.
A.rri: ixn:. thus nii.i:.;MuN ot tmi: ni miynx is an •■xeeedin-ly
rnre and fatal dis.-ase. It is speeiflr ,n .hararl.r and differs from
••Hropharyn.uval al.srrss in h.-in^r mo,-,. vi,„!..„t. hut nm unattended
hy drvrlopnirni „f p„s-sa<s. Treatment i. -aid to W support,...' hut
uiuivadiii'r.
m
M
I ii.\i''i"i:i{ MAiii.
lIVI'Kiniv'ol'IIV OK TIIK I \r( l.\L T(i\SII.S,
l\ ciirlv lilr till- ili^cil.-f 1> o.-cll
tiall
y Mil cllllll lii'lllcllt 111' |i!'(i-
11
lil'tTiitinii (iT ilic Iviiiiiliiiiii' tis-iio of wliirli ilir ii'ii-iniil t'lnsil i- cdm-
All
lie (Iclllrllt.- n( lllc Inll<il lire ('ll:^il!.''i'(| ill tilt' |'r(i(T>.-, lull
it i- lllc lyiii|iliiilic (■tll-(Ji'V(lii)iiii('nt wliicli is iliiclly >tiiiiiil;ilr(l.
ill iidiilt lil'c Jiiiy liy]icrti'(i|iliy oiciirriiitr in tlic lnii<il n-nally
iiic.-iiis liypcrt rnjiliy .il' ilic cniinttl i vc-t i--iir clcinciit-. iiml imt --o iinuli
III' iIm' iulciHiiil, |pr(i(|iiiiiiL: piiiiiiiiiciil thickciiiiiL:' <<( the lilmnis and
liarriicliynialiiii- li-.-iic ut tin' tnn>il. lifiicc arisrs the hard, smontli
liyitfrplasia so (d'tcii seen in iiini ami wnmrii in cimi radistiiiclion to
tlic snl't, lyniplioid liyiicrtropliy ol' iliildliiMid. 'I'Ihti' is also tlit»
huiinai' variety, not iiilriMHiciitly nirt with, in .vliich tln' lacuna*
hccoiiic lii'cally distended with ca^c(lll^ iiiatlcr. niakin.ij: clefts and
sinuous iia.-sau('> in the imisil, ultimately invuhinu' lln' |iaroncliynia.
'riieie i- likeui-e what I'ynehon lias recently descrihed as the
"Suhniei^icd 'ron>il." heiim a condition in which, not witlislandinir a
^feiieral I'lilliic.-- i>\' the tliroal. no distinct tonsillar ciilar;j:enu'iit can at
llr-t lie >een. Chi-er iii-|iection. hnucvc:'. will rc\tal the true eomli-
lieii. In -oine ea-e> the I'aiicial pillais are urcatly etilai'LTcd. caiisinji^
an e\eii lateral l'ulliie-> with the tonsillar thickenin<:'. In others the
cidariicd ton>il i.- hidden liy the plica trian^rnliiris. already descrihed.
V hich soinetimes extends downward and haekward Ironi tlie inar;(in of
lllc anterior pillar.
Pathology.- In early life there is in the toii.«il- an active pro-
liferation iif lyiiiphiiid cleiiieiil-. 'I'he crypts are widened and can he
seen stiiddiiiL; the siirfaic. The ciilarLicd tonsil tills in the cavity
hetwi'cn the anterior and po-terior |iillar-- on each -ide. standing,' t.ui
promimnlly and projeeiiiiir toward the illegal line. 'The mucous
iiieiiihrane i- niicliaiiLied. dippinLi' dnwii within the fold- uf the crypts
niiicli as in health. The papilla' arc ciilariii'd and llatlciicil hy the
(lislension of the or;:an. 'I'he lymphatic liodies are nofahly enlarged
and the hlood-vesscls increased in siz(> ami niimher. while the con-
nective-tissue lihres. even in (hildhood. may he increased, interlacing
mil liindini;' toLi'eiher the lymph-hodies as a whole {\'\is. Si).
oito-i'iiAKYNX. in ri:i{i lioi'ii V ui- riiK iunsii.s.
•H\:\
' I
111 adult life tlif iiiiliiral tcmlfiicv l..nanl >liriiikaL,'<' "f tln' l_vm|ili-
tisstics is usually apparent, tvcii in ra.-.(- <■[' cxlrii^isi' livpcrtropliy.
Tlif'sc hollies may have lieen ciihirL'ed. Iml they are ImmiikI (\n\\\\
liy the e(i|ll,eetive-!i.-Slie ;:lnu ih. I 'ruli t'rl ;it n Ul enlitilllles; tile crypts
llieiiiM'lve^ are ii)\aile(l niilil ihey aic nh-i ni( ted ; ami. in-tead nt ihe
(•pen i'.dlleies wlliell "re jnliiid in t!ie miimal nv I'Ven ill tile liypef-
tniphieil tnn>il. tlie .■-...ixiili. fniindid. liyperplaslie siiil'aee is lei't in
its place. 'I'liis h\ pi'iplastie tun^il thiw ennsists of hiiiidles ol' vi>\\-
M-
? I
■'"\.i^f::.r>::
-f
I'i^'. >^l. Siiri|i|i- li\ |iiil rii|ili\ 111' l.iiiii.ij |iiii-il i .">7 il niirlfr^i. (/.
Strut ifii'd -i|iiMiiiiiii- i'|iitli('liiiiii. I>. ( niiini ii\( t j--U( \:;.,-- i niMiiinititr
lil<Ki(l-vc»ils. I. M lie II- •^I'cri'l in;; ;:iiiiic|-. '/, l.\ iii|iliiiiil li--iii' inniainini,'
fiii;r iiiiiliilc«. I. i;|iii licliimi iif I r\ |it /. (.i\ii\ iii'ii\|ii. i .\iil hen > ^inci
incll li\ l'.rll-li'\ . I
.' 1
nect i\('-tissiie elements, eiiiitaiiiiiii iiludd-v e-~e]s. nerve-, and -hfiinki'ii
lymplialic hodiiv-. In this j'ni'm. I'foni the -iipply nf hhind heini:
limited, the surface is snnielimes n\' a paler line than natural. Winn
the lacuna' have heeoinc ilisternhd iiy the -iiietinn nf ea-eoii- niatter.
this ran lio sijueozed out readily hy prc-siire.
In other instances, the hypertrophic foi'm of ehildhoocl doe- imt
niateriallv (haime as mature var- are reached, aiiv enniiective-tissiio
-' t
Mil
I)ItiKASi:S 01 Tin; rilAKVNX.
(IcVfllipllKIlt cilllv illi icil^illi: the L'flHI'ill Clllill'ircllR'nl Ol' lllO Iliafl.S. 1 •(?
Siiiioni ^pcjiks iif ilic ilivcln|iiii('iii (if vOi^ctalilo jianisitof, or hlas-
Iniiiyccii «. ii> nil iiiliiot 111:,' liist<iliii,'ii al Teat HIT associated with clirnnir
tnlisilllti.- ill lllr IlLlllt (it flinldirv.
As a lull'. wliati'MT tlif tnrin nf liNpiTtrojiliy, it is IiilatLTal,
tliiiii;^li il i.- I'arc llial tlif lun >iil('s arc I'ljiially ciilarLM.'d. 'I'lu' l»i-
liilcial <iiii(litinii is cdiHidi'icd in hr an iiidicatinii id' the diatlu'ti(r
iiiitiirc lit (lie di-ca>c. 'I'lii,-. 1
inUrVc!-. dncs lint did lllTc; liill, \*!l('ri
We liavc dniilili' liin.-illar h_v|iiTl ni|jliy. ihcii' is usually eiilaru'riin'iit
(d' tl.i- |iliaryii::i al tniisd likewise.
Etiology. -Tliis iini iiiriei|iiinlly is a ciuiueiiilal CDinlilidii, llie
eiilar,L'eiiMiil liaviiiir ciiiiiiiieiii i d piinr lo liirtli. as a iiiaiiifestatinii of
■1 l_\ iii|iliatie nr .-Iriiiniiiis diallir»is. .\< a rule, the hy |iertrii|iliy cnm-
liielKes diiriiiLT ehildlindd. a lar;ie perci'lita^e of thi' eases heiui:' de-
\e|ii|i(d eiulicr tliiiu tlie telllll ;e;ir. r.isllo|l phU'lIS tllO hu'^'est IlUUl-
lier (if ea.«es hetweeii the tenth and twentieth years. Prohahjy all
( ii.M- iiceiirrini,' al'tt r tlu- latter a^e are (d' cither hypcriilasiio or lacunar
l'(irni.
The diallietie liahit wiiiild ualiirally invnlvc the hereditary in-
llneiice, and. Liiveii this tendency. trc(|ueiil exposures to cold wniild
kccj) the throat cdnstanfly lialde to attacks of inllaniinatory di-ea«.',
while each attack would lia\e additional enlargoincnt.
In the same way the exaiitheni.itiuis diseases — scarlet fever,
measles. di|ihthcria. etc.- all of them fre'juenily leave in their trail
the conimeneeineiit (if (let |i-.-eated tonsillar hypertrophies. Conjii'iiital
syphilis, too, is said to he a pnlerit (dement in tiie production of this
disease, while tlie rh(Mimalic hahit. leadiiii: so frocjucntly to pliaryn-
iri'al rheiiiiiaii-ni in adiill life, is the direct cause of many cases of
severe hyperpla-ia.
Symptomatolog'y. In (hildhond the external appearance of the
face, without examination of the throat at all, is almost siinicieiit to
indicate the presence of the di^tase. at least sutVicient to divide the
cause with adenoid ciilarL'ciiient. 1'lie facial symptoms are those
spoken of in connection with that di-ease. altluuiLdi they are prohahly
exa;i'frei'al( d more in pharyii;.:('al than in faiicial hypertrophy. When
the ton-ils alone or in comhiiiation with adenoid enlarirement are
sidViciently liy|»ertrophicd to prodiu-e nasal stenosis, the facial symp-
toms heconie vr-ry apparent. The vacant look, the open mouth, the
pinrlied nostrils, the oral llreatllillL^ may all lie present: while ster-
torous respiration and restlessness are regular, nocturnal .symptoms.
ui!<)-ni.\i!'i NX. 11 vri;i(ri;nniv (»r nii: rovsii.s
xm;..
'riicso syiii|il<itiis iU'i' all nl' a inccliaiiiial cliaiadrr. Tlio (nii-il-
nct like IniciLMi Imilics olislnictiiiLr lln' tliniat atul iiasd-pliarvnx ami
prcvt'iil iiil;' nnniuil na-al lircatliiiiLT. 'I'liis lurciil juiil iniiliiuicil sii>-
jii'iisiipii 111 iiatuiiil ii .-iiiralinii inuls lo iirmlm r jiliaiv iiL;ial cniiu''""-
linii. rr-iiliiiiL: III i!i(i'i'ii-( (I h\ pell in|i|iv Willi ijicli 1 1 1 lla iiiiiia t > pit attack.
I!iiiipariii>-((1 ri'>|iiiiiliMii i- niiniliM !'r>iili uliiili nrim ucciir.-,
|iart iciilaiiv in early lilV. ami in lailillir ov .•.crdfiilnii.- -iilijccts is likt l_v
tci lie I'dijiiunl I'V clii'-i-dcl'iirniily. The vnicc aUii ln'cnmo alVi'cti'il.
ndt niily with ilic -i)-rallc'il na>al tuan.::. I'lii al-.i I'lnm a tliiik. inutlliil
tunc. I'c.-iillin::' fi'niii iiniialiiial [iliaryiiLifal fullness.
I 'I'L^lniiiinn i- iiwl iiiihii inii rliTid with, f.\c('|it in ydiinu infant-,
wliiii. a.- in the (iiM' (if aili'imiiN. llii' inijins^iiiiliiy of munial iia.-al
lircai liMi.u' |ir«'vcnts ihc child frmii nur-iiiLr \\iili any mnilnii.
it is (|(iniitfiil whcthci' ciilai'ucnicn! of the fam-ial tnii^il- has the
(•i''ict upiiii the i'ii-;acliian liihcs n-iially a-^iirmil tn it. There ai'i'
III! 'nilitiMlly many cases of deiifiiess .md chronic i:\v disease a>Mi-
cial. ! with tdii-illar liy perl mphy ; Ini! it nin-t he cuiiceded that,
aliiiii-i iiuaiiaidy, iiDtaMe hyperlnijihy nj' the faiuial tnnsil- is aei-nm-
paiiiid iiy eidarL;cnieiit >'\' the pharynuial |nii~il; and iliat it is to the
lallci' that tho pros-nre upon the Mii-lacliian tiilie is due.
|-;xccssive tonsillar st i n linn is imt a characlerislic (if this disease.
Chee-y conci' ■! iii!i>. hiiU(\(r, aic depcsited in sdiiie ca-e- within the
laciiiiM'. pi'ddiiciii:: -ofcnc-- hy their pfe^cm-e and an (iir( ii-i\c imIhi-
frmii lull::- icieniinii.
Diagnosis. - 'riiiifiaiuh exaniinalimi with m- witlidiit rcllocted
liu'lil -hduld in all ca^'S '•(■ siillicieiit to estai'li-h a correct diai;mi-i-.
To in>iiro this flu,' toii-il -li"iild he examined in two position.-: 1.
Willi the po>tcri(ir faiicial pillais in their iialnral relaxc(l po-ithm;
that is when the iiKUitli is wide open, the anterim' and posterior pil-
lars standing;' parallel with each (oilier. 'I'liis can ii>iially he accoin-
plislie(l liy ^(Mitly depressina' the toni:ue. If eii!ar;.:(d. the tonsils will
stand out prominently hcyoml the pillar- projectiiiLi toward the medial
line. '.'. ^\'ifll the pn.stcrior pillars drawn tiLdilly and tlie toiiLiiie well
depressed. I>y this nienns the toii-iis are thrown fare fiu'waid and all
the iiie([nalities and irreiiularilies n\' outline iKcnine dislim tly \i.-ihlc.
They arc not only tiirneil fiuward. Inil. in a mea-nre, iii-ide cut a-^
well, the deep snlci and wide clefts which so often occur, and whi( h
remain unnoticed in the mirinal positiini. liein^' hroiiLdit into view.
It is said that there is sonietimos danLrer of niistakinLT an enlar;:ed
tonsil for a tonsillar ahsccss. The latter is attemle(l hy fever, pain.
I
•.'(!•»
iii>i; \>i;s oi' I in; ni \it\ w.
jiiid pcritnii-illjir t'iilliii,->. wliicli n-c nil iili»riit in tlif Iniiiicr cDiidi-
tioii. I>i;:iiiil ('MiiiiiMiilinii ^limild rt'iimvi' iitiv rciiiiiiiiiiiL' ilniilit.
Ill iil'lri-lilc iiiiiliitiTiil (•iiliir;jt'iin'iit licluicii llic pilliiis iniglit
;iri.-c t'l'i.m iiiiiliL'iiiiiit (lisr;i«('. Init the (listiii'_'iii-liiiiLr Iriitiin'S of
(■;l(lic\i;l. IKllli' |i:lill. liml l;i|M(l (iiljilLirMiciit . Ultll icilninii-. il i-i|iar<£e
\\lii(li (li-I iiii:ni-li ciiiirrr. wniiM [ircvciii a wrimi;- (liiii:ii(i-is.
I liiui' >ri'ii niii' cii-c ulinc Irli iiiitsiiliir lilinniiii (Irvt'lojicil in a
lilUVcl'. ilLIl'il I*. Mijllr lilllc IlI'ltT illl llV|>cr|)li|>iic tn|l<il ll;|(l lici'M
ri'iiiovcd. hill till' u hie
I'.'icl ii iiiiL;lit liinc licrii 1
iKrll jiir ;| -IIIIIIH'
|oll>ill;ir cllliir^jclllrlll. il u;i- ill-n 1 1 i-t i IILI II i-lli'il I 'V ils wllilc lilirnIM
cliiii'iirlci' ;iih1 ihi' .-lidntiiiL: piiiiK uliiili |i;i>»i'(l in (lijl'crciil ilirn i ions
Irniii il. Ii was ,-('<>ilc mill |ii'(iiiiinriil and initircrcil with tlic use
111' the \(pi(r. Il was rriiinMil liy rc|icalcil uahaiiuraiilcrv n|iri'alii)ns
and did imt rtliirn.
( >(iii-iiiiiall V a liiii-illil II. liiirird wiihin ihr ;:l;:nil. will cause in-
1 nin ciiiriirf hv its >'\/.c aiid iiiav lir iiii-takcii I'm' ~iiii|ili' liy|pcrl rophic
Irsinii.
Prognosis. Tlif naimal iciidcncy is lor tlir tonsils, wlini not
M'rioii«|\ riilarLii'd. In -lirink awav irradiiallv ami lir alisorlicd during'
till' (•arlirr year- id' inatnriiy. .-o that a iihti' sciiililaiK-i' of tin' tonsil-
lar li^-iic rciiiaiii-. And uhcii licariiii; i- iiiialTi'i-tid. wlnii respiration
is normal, and ilicrc is no tendency to -oi'enes> oi' the throat, even
if the (oii^ils are liyperti'opliie. Nature ~h(nil(l he allowed lo do her
own prc>criliiiiLr. Jind the toii>ils left >e\erely alone.
• til I he oil II r ham!, w hen they are -erioii-ly eiilar-ed. oral hiealh-
iiie' heiiiL; one of the result-, there is >eri(ni.- ri-k to ihe health of the
patient in ,-e\eral ways. Not only doe- the iiii-al -teiio-is deprive tlie
air ( f re.-piration of the ndvaiitai;i'> of -aliiration. elenn-ini:. ami lieat-
ini:. wliieli nasal hreathine- pi'ovidrs. Imt the open mouth makes tlio
eiilai'Lied lon-il-- -till more -u-cepi iMc lo irrilalion. 'I'he ;:erms of
disea.-e llMatiii:: in l!ie air liml ii ready imhis fur de\e|opment in the
open -lllei of llie toll-il-. 'I'lli -e lai'l^e Imdie- are partiriilarly .-U--
eeptihle to infection, and il i- ue|| known llial children haviiiir ton-
>illar liy perl ropliie- are more prone to the di-eaM'- id' eliililliood than
tho-e v\ho do not po--e-s them. I lypcil rophied ton-ils are al-o liahle
to attack- of ipiiii-y: ami when children 'jiow up to adult aL;e. with
hvperlrophv LiiviiiL^ way to liypcrpla-ia. the periodic attack- nf ipiin-y
often continue for year-, eon-lanlly iiicrca-iiii;' ihe comiecl i ve-tis-iio
development .
Treatment. Medical ircaliiicni for eiilarucd lon^iU. Imtli inter-
oijiii'ii Mivw. II vi'i;i!i liurin or mi: inN>ii.s
!i;il iiiiil Infill, liiis so frc'(|iiciitly lictii liirtl. nml uith siicli iiiiit'ormly
iiii.siiti.-fiutoiy rc.-iilis. tli;it il i- iiliiin«i ii^( It -. til ^pciik (if it licfi'. It
is pos.-'iMi lliiit ill iiiilil (ii^i> llii liiiiil ;i|i|ilniiliiiii 111' iiidiiii'. Ill', wlicic
tlici'c i- iilniiv (if ,-_v-lciii. tlu' ;iiliiiiiii>i nil Mill df imlidc (if inui inirr-
llilliv lllllV lie (if .--'line llM'. Sil ill.-ii il.-llillL'i lit .Liiir.ulfS n( llllrturc III'
11(111 111 Miliilidii, (If llic liic.il ii|i|i|i(aliiiii 111' iiilralc ol' silver, iiiiiihl he
tried III cases in uliicli I'nr variniis realms ii|ieiali\e trealiiieiil wmild
ite iiia|i|iliealile; liiil. uleii .-t ridiis >_viiiiiiiiiii> aii-e I'lmii the luc-eiice
id' tlic li_V|ui'ti'ii|iliie(| iiia.-ses. eNtiipalinii i.« liie niily rea.-niialile treal-
iiieiil.
Of course, liefnre ii[iei'atiii,i,', it i- always iii>( to .xciire the coii-
.-I'lil iif the piltieli!, or. ill the ca>u of ehihlicii. the coli-eiil of lilt'
;,MliU'(liaii ill ( haiue.
'The various method.- of operalion, hy iMi.-iiin with cuiAed scis-
sors, histoiiry. ,i:alvai!ocaiitery-kiiife, cold-uuc -nare. ualvaiim-aiitery-
Miiirc. 'ir hy llu' various toii.-illotoiiies, all have ilieir advocates. Uiil
the la>l iiielliod, ill all cases where the loii.-illolniiie or ^'uiHotiiie can
he iiseil. i~ ilic one liiost L'ciierally ado|iied | I'lir. .s".').
Ill all ca-es. htd'ore ojieratiiiL; the throat -lioiiM he thoroiii.flily
(•leaiir-ed hy the ii,-c of an alkaline .-pray or di-iiih'cl,iiit ihroat-wa-h.
And it is he.-t. when a Liciieral aiia'sihelic is imi u-id. lo paint the
tonsils freely with a I'l-pcr-ceiit. .-oliition of (niajne or i ucaiiie. I
sec no reason fnr iiidiicinL: iinnceo.-ary p.iin in any |iaticnl, and. as
ihc diiiL' i.- ciiiinly under the cniiliol nf ilic opiraiinu' .-nrL''eon, iherc
need he no ri.-k whatever of forinini: the narcctic hahii. hy its judi-
cious application. The iDcainc may not make the ii.-c of iii.-iruinenls
entirely painless, hut it will jiiatcrially l(\-;scn the sulVerinir.
As the majority of patieiiis re(piiiinj: tonsillotomy are children,
1 ha\c, as a riih'. found it the he-t plan lo adinini-ler a Lieiieral
anie.-lheiie to lluiu. W'iiile it may he ipiite po-sih|c to adjust the
instrnmcnl to the iir.-t tonsil without cxcitinjj; the ehildV alarm, the
-eooiid adjii.-tnienl \Mii,ld lie iiupos>ihIe without piovokiii:: terror as
well as resi.-tance. I'.\ iwiiii.: an aiuc-thc! ie hoih of the>e are avoi(h'd.
I'dr performiiiL^ tonsillotomy many varieties of iMiL-iildtomc arc
in the market. 1 think, mi the whole, however, that Mathieu's is
to he preferred, particnhii'ly with its ino.-t recent niodilication; that
is, with smooth spcijr-points. the harhs near the ends heini.' ronuivcd.
Tlioy iirc iiiteii(h'(| to hold the tonsil for extraction, after it has hcen
excised. This would seem to ho nnnecessary : as in iisim: the ncwnr
instnimeiit. the tonsil, in my experience, ha> always remained iipotj
IT
;
m
M
i f -
VtiN
nisi;\>l> n|- I hi; I'HAUYNX.
tlif jMiints iIiiniiLr rxttiHticiii. iintwiiliMjiii.liiiir tlic alisi'iice of tin-
lijirlis; find cuiilil I,.. .|i|i|if(| nil' more ivji.lily .il'tiTWiird. One liciiutv
of |lll> idslllllll.lll is the liMUCr nf ;i(Iill>till;r d,,. ,.x.,ct iUIKUint of
Iriictiiiii Villi di'sirc lo niiikc iiiinn the tdii.-il l.y inrinis n\' the siTtnv
in the s|.riir-lil;Mlr. Tlif nnlv niiilt witli ili(' instriimciit is the fiict
I'i-,'. S2.— Mad'.ii u's tonsillotomcp.
lliaf it i.s oomposcd of distinct segments, and rp-piircs to 1)e taken io
piocTS to l)c disinfootod and cleansed, after earh operation. Still,
tliis only takes a minute or two. and ean he attonded to eaf^'ly I'V
any nurse or assistant.
In applying' the tonsillotomo, the patient holding the tongue
iiu=
(tKo-i'iiAitvN\. II vn:i!i liuni Y ni I mi: iun^ii^
•Jtl'.t
•IdWii ;it till' liiiif wiiii the i|i pressor, it is im|p"rljiiit to pii.-s ilic iii-
>tniiiii'iil Will iiVft- tlir lowi'i' |iiirt of the tnM.sil, ji" this iiortmii is ortcii
pciiiliildiis, ami, Ix'iiiL' situated lnw ilnwii iii tlu' |iliai\vn\. iiiav rscapr
<»l)M'r\ati(iii. iiiili.'S (liif rare is taken. 'I'lic ri^'Iit liaml \\\\\ hold the
in.-tiiiiiiriii. w liielifvcr >idi' is dpeialed iipdii; aii'l the tnii^ij ran he
held liiinlv III lnuanl ihe pliaiviix li_\ niii^idc |iic..«iire nl' the lell
hand. There i- thus, iiudir ((.laiiie ana-lhe-ia. im iiet-e.«.«ity t'nr tin
pre.-( lice (>{ ail a.'.-i.-iant.
Allhiiiieh the tniisils can nficii he reninvid wiilidiit ihe aid nl
rt'llceti'd li,L'hl. Vet uheii it i- a\ailalile it i- al\\a\,« helter lo use it.
'I'lie iijieralnr. >ciii((l dnccilv in I'lnin nt' the jialieiil. can hy it-
relleitinii mc the pail- innch iiinrc elcailv and adjii-t hi-^ iii-l riiiiient
with more picci>ioii than he diherwise eoiild.
In caseo aiiioiii;- children, in which ^( inial ana'^'he-ia i,> ie(|iiiici!.
(■thvl-luoiiiidc or nilioiis oxide may he ailministi'reil m the inclhod
already nieniinncd. And in \iew of ihe expcncmr nl' other men, and
ill llic li;jlit of hi.-loiy, I raiiie-ily re(()iiinieiid oiic nf the-e drtiL:> \"
he ll-cd.
Still, ill my own piiuiuc I have herelofdre ii>e(| chlornl'iii'm iii
tlu'so cases, th iiu'thod hciim •" havi> it administered jnr ijutlitliiH.
and not to i:i\c sulVhient to produce vciy profound ana'-lli<'>ia.
'I'he child, when ready, is turned o\cr mi it- .-ide, with it.- face
toward a piod lii:!it and the tonsils reiiio\rd in ipiick .-ucec,--ioii. 'The
hudy i~ then rolled to ncmly a prone po-ition, the In ad iieiiiir held
over the side of the coiuh to allow for the e,-capc of hlood into the
howl hcitealh. In defence of in\ po-iiioii I may -ay that in a pio-
I'l'ssional cxpcriciici' uj' thiiiy \c,ii-, and covrniii; ihoii-and.i of ca-e.-
iii which liciicial ana^tln-ia ha- hecii icpiiird, for one opeiatiuii or
another. 1 have iml ,-ccii a ihalli occur from it- ii-e. either in my o\mi
practice or in that n| jnv of my pi'o|'c--ional lucthri n.
lUoedinjx after ton>illo!oiny. altliou;:h u-iially free, is rarely
scvcri'. lastiiiir only a few iiiinu;i,- and 'jiadually cea.-iiiL;. .A uood
many ca.*cs, 1io\m'\ it, have hei n ii > oiilnl m w liirli the Ikciiioii ha^e was
alarmiii!.:'. This has alnio-i invariahl'. occiirred in adult-. ()ut of 'h
recorded cases only 1 or o wcie youn;;! r lliaii I') years. With some
exceptions, the idecdiniT oceiiired imimdiafely after or within a few
Inuirs of the operation. Two df the former were in my own practice.
One. a slmn^f, jilethoiic, medieal tiidciit. ua- attacked hy -ecoiidary
ha'morrha''(' on the liftli dav, after o\er'\eriion. The other was the
:i- f
i
v- ■
I;
Iii tie a-vear-old
n of a |ihy-ieiaii. In hi> ca-e the hloediiii,^ came
I
a7o
i»i>i;a.»i:> hi i iik ni \io n \.
fill wllilr -IlTjiillL' ill tlic i;lllv lllnfllillL'. I"""!!!' illlil . inc-llillf (lny-i illlir
()|H'nitinii. Ill lidlli ciiM'S the lii-'iiiiii rliiiy;t; Wii-^ .-Iniiitcd willi littli'
ililliciiltv.
It is I'dTl iiiiiilc lliiit, \utli :ill ;lii\.c cii-c- nf Ml cdiiiL:. I li;i\(' so fill'
III I 11 iinalilr III liml ii r.'isc rnnnliil in wliiili li;i'iiinrrli;ivi' Irnin tnii-il-
llilnlllV IlilS lUllMMJ lUtill.
Kx.'i^
imi liV llirilll- 111 ( lir\ri| Mi».nrs (IP li,.Iii|irV i- llli|ilir;llilr !■
lITi ;:lllilll\ --illl|n i| |ii|l-iK. Siilllr (ipiTnlnrs <j,) -n t'lir il- In ri'ciillllllrinl
till' llirtlliiil Jul' ;ill
ril-r
A I'irr rm irii/;lt lull.
Ilr liilmllr jirjll'' ili'
|irr-M'il. Ilir ti'll-ll I-
•i/i'il liv ii \ iil-illiiiii 111' Iim.iIhiI l'iircc|w. iiiul
aiilcil li_v nllrctril lii:lit tlir lthw lli is cut aw.iv. 'I'lli- initiinil is Ilinsl
siiiliililc til cii-cs iiiTM'iitiiiL: inciiiiliir |i|iijrctiiiii-. in uliiiji llir tmi-il
jotiillM' riillM lint III' il|i|iliril.
Tlic iiM' III' llic riilil-uiir -niiic' mill aUn I'n' i;al\aniMaiii('i v-siiair
lia\r cai-li liail llirir ail\niatr>. part iiiilai ly nii llir i^rniitiil llial liv
this iiicaiis liM'iiiiiriha.i:r wmilil lir av..'i .il. Wlirlln r nii arrniiiit nl'
till' ililliciilly in a|i|ilyiii^ ilir wnr. tli.' |ia;ii nf tiir njiriatinii ilsilt',
111' llir (iiiiiral sliiiii|i tlic 'i|i( rat inn i- apt tn |ca\c, uv all cnniiiincij.
tlii,- iiictlinil lia- imi liccii rcicivcil with uciicral t'avnr.
Oiii' nllicr iiicllinil. n|icratinii liv ;:a I \ a iinca 11 ' ii'\ k 111 I'c. remain-
tn lie coii>ii|crcil. In -iiitaltli rases, |irn|>eilv ,-elciicil. im nilirr iii-
striiiiieiit that I kimu nl' can iln as cH'cieiit wmk. It i- parlicularly
siiiteil tn tlinse irrcLMihiiiy-i |n\ cii tnii«iU which \\c nl'icii meci with.
Kmil .-ecret inii>. jnailcil with pal lin;:enic Lii'iin-, I'nrin williin llic cleft-;
iiiiil nti-repeateil attack- nf -lire ihmai. ri-iili in liv pi riinphy nl'
irrcLiular. parciicliyiiiatnii- iiia--e,-. In the hanl. hypcrpla>iic imisils
ol' ailiilt lite the ;:al\aiincaiitciy t rcat iiiciil can al-n lie n-cil In ail-
vantaiie. ('Iicc>y masses arc cnii-taiiily rnrmiiiir within the ilccp ami
iiarri.w ciypts. lU llicir pn -ciicc they pnnliicc a iinnil ileal nl irrita-
tinii; ami liny lan niil\ he reimiveil hy ilirect p|•c-^llrc. .Neither nl'
t!ic.-c varieties are nf a rnrm tn ho seize. 1 ciVeetiially hy the inn-illo-
tniiic. They ai'e |irnliahly al-n inn hard nr Inn lilimii- in yield readily
to citlltM* hislnliry nr >cis-nis.
The nrdiiiary mcihnd adviMil in ^iich caM'S. when the i^ahano-
caiitery is cnn-ideicd In he ihc pmpcr iiisi rnniciit. is to make a iiuiii-
licr nl' jiiiiictiires with the caiitcry-iiccdlc iiitn llic face i)\' the Imisil,
iiml after an interval of several days in repeal tin' npciatinn. When
tlio trrowths arc very larirc. this methnd is said tn take almiit twenty
operations to ell'ei t a cure: no dnuhi a tcdinii- and |iaiiiful process
to the jintieiit.
I
ui!ti-i'ii.\ii\ NX. in ri.i;i liiifin <ii iiii. iiin^ii.>. v , I
[f wniild MTiii nii.-iiniililf III limit miitfriiilly iIm iiiiimIhi nf uptr-
jitiiiiis iiiiil hImi llif tiiiK' ii'iniiicil lui' ihr wmk. All' r tliiiriiiii:li m-
niilli/lltiiill Cilcll lillir tllr rilllti rv-lsiufi' ill»trili! nf ll'i'llf Illli;lll lu'
ll-(i|. Tlie li|i lirillL' lii'Ill III li,L'llI illlLjIi- III till' iilililr, Jllnl lili'll ( ilM'-
liiliv ii\iiiilitiL: till' iiilliir* iiml lliiir iinn'ii :it tlu' ii|ini'i' ;iiii:li'. the
isllilV is ji;l->ril ,'lt 11 lili;.'llt-lril (if wllili' lliilt trulll In|i til !iii||(i|ll III'
till' .-iriictiirc to 111' I'ciii'ivcil. Tliis i^ rr|iiiiiii| «i A.ral Iiiih'-. iiiiiKiiii:
Iiarallrl iiK-i.-imi* as widely aiul (l<'('|ily a« tlu' (i|ii'ratiir iii hi- jiiiL'-
imiit liclicvfs aihi^alili' fur iln- niu' npr-al imi. it i-- In -I in r\i'i\ lasc
Inr thr -liruciill nnarrll-liiMlril til tlli- IIKlliml III 1 aillil'l/al iiill In r"II\-
iMciu r I aiitioii.-lv until cxiifru'iK T lirciiim » hi <"iiilr. It i- iint iii'irs-
sai'V, liiiwcvir. to limit tlic tirst ii]M'i'aliiiii In niir >ii>il. linlli ran Itr
Ircjitnl .It rarli -iiliiii^-. I'hi' several (lay- iiiilil -prays ami liirlil diet
will lie I'l'ijiiireil, The 11 I he ii|ii I'al inii laii 1 < re|ieii;iil. ami -n nil illll il
llie Uiil'k i- iliHle. A.- a Illle. ihlee iiT fnhl' ii|ieiatliili will -llllice fur
eii|ii|il 'te reiiiDVal nf the nil'emliiiL: ti'-iie. 'The [iilhu's (if tile fame-
iiMiM remain imiii jiireil. ami a -iimntli tnii.-illai' .-lump lie left mi radi
-nle as a le-iilt. In ihe -iilniieriied imi-il a Mniilar methml mav lie
I'dllowed. The pliia trianunlaii^ lan alsn ninic readily he ieiiin\id li\
elect fiiiaiitery than hy aii\ nther niethml: and it i- aiKmated -tiniejlv
liy i'ynelinii. with the cinr additinii: that he draw- mil the nll'iiidini;
ti,->lle with a teliaellllllll eaell lime lielnre npij'at i II'J'.
in pi'ifiirniiiii;- nece--ary nperalinn- iipnii eithif im-r nr thniat.
it sliniild never lie the aim merely In i:i\e relief. While this i- un-
dnllhtrdly ille llln-! illl|inl1ant nliiect. the enrini'tie eil'eil -hnllld alsn
lie kept i'eliuii'ii-l\ ill View. W'heii Nature ill her liiL'he^t and iim-t
nnrmal develiiiiment leaves a -ymniel rieal -iirfaie. the -iirucnu -h.uild
endeavnr tn (In sn lilscwi-e. and the lleafi I' we call fi-tnfe the varinu-
iir,L'Jins we have tn inat in the iinriiial fniin and I'liiiditinu, the inortr
Slirelv We have lielfnl'mnl nlll' dlltV tn nlir patiellt.
'
d- 1
. , 1. ,
>! i i '
( IIAI'TKU WAX.
i..\( r.\.\i; inNsii.i.ii i>.
n
Tins ili.L'asi', ii.- ils iiaiiic Jiiijilii.-, i> ;iii iniiic inlliimiiiatioii of
ilii' hiciiiur. or cnpl^, nl' the Idii.-il.-. jillcinli'd liv tin.' tlL'pii>il of
u hit i.-li-_vcll()W cxiidiitf ;it tlicif iifiliccs.
Pathology. -'I'Ik.' iinirMil Ic-ion cnii.-i-is of a i-aliii liiiil iiillaiuma-
tioii ol' the |iai'riicli_viiKi nf the l(iii.-il, accdin |iaiiir(l li_v a lilifiiioii.- (.'.Mi-
ilation Jidiii tlic liiiiiij; iiieiiilnaiic nl' iho laciiiiu'. lilliiiir tliciii with
litth", ]i('iifly-\vhitc iiias.-cs {•()|ii|hisci| <<( li'iicocytcs. lihriiicii.-. Iil)i'il!;e
(Siiki'low-ki ), ami cjiitlu'lial ft'lls, which apinar \isiMt' at the n|iriiiii,i,fri
111' tlu' cfviils. As Ihcv iiicfcaso in .-i/.c tlirv >pft'a(l mil (i\rr tho
iiiiK oil' im'iiil)i'aii(', siMToiiiKliiiL: thr nicniiii.- nl' ilu- laciiiia'. ami. hciiii,"
Milt and frialik', arc t'asily hiiishcd auav.
Iii'^ai'diiii: till' ]in.--;iliilit_v nt' iiiistaUiiiu tliis disfa.-c I'm' di|ihtln'i'ia,
Sciidziak ill IMh; invcstii^atcil llic siihjccl mtv fully. In thirty ca.-fH
uliicli wcrt' hi.-;lii|i!^ically cxaiiiiiKd, all wric fduiid Uw fri.ni Klchs-
Ldi'lllcr iiacilli: four had Lnrlllrr'> p.-ciiddiliphtlHTia liaiilli. Inil tlu'y
ucfi! nii.xcd with dtlirr |iatli(i,i:eiiic iicrni.-: while all hail .-laiihyhn'OL-ci,
slfcptociicci, or |iiu'iiiii(H(>r(i, cither siniilc or eoiiihined. sia|iliyloc()cci
hciii.ii' usually in excess. His concliidiiii: wdrds are: -
"IJelyiiiL;' on the clinical |iicliii'c nf the di.-ca~c. and the rc-iilts
ohtaiiied hy liaclcrinlnuical im c.-ti;_Mt ions in my thirty ca-cs. 1 main-
tain that the so-called follicular aii;::iiia. or. hetlei". lacunar tonsillilis,
is elinically and hi-lojouically an indc|iciidcnt ]iatlioloiiical iirncess,
liavinj: nothiiiL: in cnmnioii with true diphihcria. It is no diuilil in-
fectious, hut We tinfort uiialely dn ni.t know its >peeilic \iius.""
The coinnmn title, "follii.'iilar tonsillitis," iismilly applied to this
disease is not only discarded hy Seiid/.iak, hut also hy W'olfendeii,
Lennox Tn'owne, and others. Wolh'iiden say>: '"'I'lic \(iy term •fol-
licular" is really erroiieoiis, since it is not the fojli. h> of llic tuiisils
wlii(di are aU'ectcd, e\i-ept in a very secondary I'laiiiier and in a ir\v
ca^os. It is the ton.-illar crypts, or laciime. which aie the chief seal of
the disca.-e."
As a mil', liotii tonsils are atl'eeicd >iiiiulianeoiisly. The calar-
riial aireetion extends to the pillars, palate, and pharynx also, and no-
(»i!(i-riiAi!VN \. i.AcrsArt rossit i.i ris.
':;<
Ins
',,1-
lils
lot'
l"~
lu'-
casionally spots df cxiKlatitiii (uriir nii ilic.-c pari-. 'I'lir ctrvical
{rlands liKi'wi.-i' liccdinc sensitive ami in mimic cases eiilar.ireil.
Etiology. It is litiierally lidievcd to I'c a speeilic disease, de-
peiulciu upon the access of iiiiero-org'aiiisiii- to the toiisiN in certain
condition- o]' the sv.-tcni. \\ liMc in <oine I'c-pccts it rcscndilc- the ex-
antlicinala. it dilVci- fi'iini ihciii m lieiiii: in no \\;\\ ]irolccti\c uiiainst
th(> po>-ihilit_v ol' I'iiiui'c attacks.
Allhonjih the irciin itsdf and its oriirin art .-till unknown, it is
lielievi'd rrcipiciitlv to ai'ise I'l'imi the cU'incnts o** putrefaction m de-
fecli\e scwcis 'I'hi- idi a ha- oriLiiiialcd fidin ilic fact <d' it- preva-
h'liee in old houses where drainaiic has hcen ilcfcetive.
Scn.-itive inllanied throats with ciilarLied tonsils arc fit sidijects
for inl'eetion. 'I'lie spoiiLiy ti->uc with open civpts olVer frei; lodL^inetit
for llie invadinir hacteria; and. as a similar tonsillar hypertrophy fre-
(piently all'ei-t- all lh(> children (d' ;; family, all may he alTccted sue-
<-essively hy the endemic infection.
Altl'oni:li more pre\aleid in ehildhiMiil than in maturcr yiar-.
it frequently occurs durim^ ih" latter pci'jnd. Sex lias no sjjec ial in-
tluence over it. .\- miL:ht lie I'xpccted. ji is more prevalent in the
spriiiiT and fall than dnrinir other seasons (d' the year.
One pcciiliar fcalui'e that las hcen (ihscrve(l hy rhinoloL,dsts is
the developincid of lacunar tonsilliti- in fi'oin twcnty-fnur to forty-
eij:lit hours after nasal operation, particularly when jterformed hy
<ralvanocautery. The tluMiry has been ailvanied that the absorption
of the ".'erni iniirht take plaeo Ihrnnufh the nasal wound, and the near
proxinnty {>•> the tonsils would facilitate its tran-itioii and the de-
velopinoTit of lacun.'ir di-( a-c.
If the disease occurred cipially after knife and saw n])('rafions, llic
theory woidd ser'ni more t'ea>ihh'. .\s ihe L'alvano<aidery. when it
docs not produce ha'morrhai:e. hcrmeiical seals the wound, may it
lud arise from the i'aet that Lrahaiiocautei'y o|ierations u[)on the nose
are ti'mporarily fidhuved hy ledi nia and more or les.s stenniais, resulf-
inir in Tnoutli-lireathin;:? The impact of the ,i:erins npon the crypts
durini: ihe depressed vitality rcsultinir from the shock of op(Talion
would I'aturally tend to inflammatory action in the nriran so affected.
Symptomatology. — The onset of the disease^ is luded hy a irem ral
fe(din,ir of chilliness, which may last for several Imurs, to he followed
by fcbriie action, the temperature in smne cases risin.cf as mii(di as
thrcn or four de^'reos. Tain in the back usually accompanies the
dcvc'lopihcnt of fever. ']'o<rether with the fever and \K\\n. the throat
¥
: ii
DISK \>i:s (»|- iiii; niAHYNX.
-yiiijilniiis luiiiiil'i'st tliciii~( Ives. 'I'lii'ic i-
li'Viicss iiiiil irritntiiiii. ful-
II' . !
li)\\i'(l hy the rnriiiiit idii 111' ihc lacimai' ili-pn.-ii, acroiiiiniiiii'il liv |iiiin.
upon iiiovciiiciil ul llic iDiisils. pjirtu'iihirly in doulntilidii. In yniuiji
I'liiMicn tlir sv.-tcinic disiuiliancc i.- soniclinic* vitv severe, the leni-
lei'aliire n.-mii'. even tliiiiiL:li rai'elv, a.- Iii'jh a.-
in;
ami u-hei'eii m
IV eiin\ ul-iiiii.-
Wilh the
1i1l:Ii teni|iii-al lll'e tllel'e will lie aceelel'a I ion
nf |piil~e and al.-n III' re-|iir;uiiin.
r>y the .-eennd or third (hiy the I'elnih' syniptoni.- .-uliside, an
inii'.-iie a veiv inndilied enui'.-e iinlii the ilisea-e ihsapipea
r~. hetweeii
II K' lil t li iind M'veiilh (hi v.- I'lnni il> eoninieU'enient . The i hfnal .-\ n!]i-
Iunl^ |iei'si.-t until near ihi ejnse oT the ailaek, uide» nioditied hy
t real nienl.
In .~e\eie ease-: idliuiui u u fill i> luiI hv ally ineaii- a liiie -ymp-
luin. rnrnieily ihi' presence i>\' thi- eoiiiplieiilioii, in e\udali\e throiil
dis(■a^e ol' any l\iiiil, \va> enii.-uh fed a po.-itive iiidieatinn that the
diseaM' was diphtheril le. 'riii> idea is imw discarded, and. ahhuuu'h
alhiiiniiini ia is ninre prevah'iit in diphtheria, the mily pn-ilixc e\i-
ileiice niiw ackimw h'diied 111 I'aNnr ol' that di>caM' is llic presence of
the l\h'h,«-Li)elller hacillir-. In regard In allinniinuria, W'nlt'enden
.-late.- positively: '"That it i< rarely ali-eip in ca.-e> ol' acute |on-
silliti.-."
I'lieuinonia and ncphiiti> have .-npi r\incd in rare instances,
while orchitis and ciilar.ued >pleen are oecnrrciicc- widch have heeii
known lo iniincdiately follow the tonsillar disease.
Diagnosis. -The only other di.-easo it is liktdy lo he confounded
wilh is diphtheiia. Siuiic ea>es may .-o re-einhle mild diphi lierit ie
di.-easc thai in -iiiiple clinical e.\aiiiiniU ion an ciini' in diauiiosi- miiilil
occur, and. in fad. has freipieiitly lieen made.
To examine the faiice- i horiuiiihly. lellciicd li.uht. head-mirror,
and loiiuiie-depressor are all nccc--ary. In lacunar tonsillitis the
::land i> red and swollen, while, ai the mniilli.- u\' ihe lacuna', clear,
white, pearly spots will he seen, adliei'in.t;' closely to tlie miii'ous nicin-
ipiMiie heiieath 'J'hese spots, as they (K'Velop. u'l'ow smiiewhat larizer
and extend outwardly around the iiioutlis of the crypts, and can lie
hnislu'd oil" with the cotton-holder without injuriiiii- the surface.
They always retain their original cohu' id' hlui.-h or yellowish white
and are non-odorous.
In diphllioria the tonsil, alflnnmh siunewliat swollen, instead of
beinir hri^zlit n^l is id' a bluish, tur.udd color. The exudation fonn.s
an even Hake, varvinir in tliiekiu'ss ami covorin<i the tonsil. In color
It
nli(»-|'ll AliVNX. I.AClNAIi I'ONSI 1,1.1 )!>.
1 .»
I'liir.
rlir,
'111-
IICI'.
lit.;
|ins
llor
it is yellow nr ".cllnw i>li i;ray, juhI ciiiiiiot In- lini-linl nil' uiiliniu
Iciivinir a raw >iiriii((' liciuiiili. (>ii tlic sccmid or ihiid ilny iii-tcaij of
I'ftaiiiiiii:' its color, ihc iiiari:iii> a--iiiiic a j.Tayi-li-iilack tiiii:<'. aiui
iiiiilodor i> (li>tiiictly |M'rcciiiilili\
<liic other |ioiiil ill eliiiieal lii>tory is of eoiisideralile iiiiportaiiee:
Aeiile lacunar tonsillitis is a sllieiiic diseiist- with lii<:li ''elirile action,
w liena- diplu licria. the iiiavr di.-ea>e of the two. i- asthenic and
marked liy i lower teiiiiicral lire. Ilotli are infection.-. Init di|ililhci'ia
is the more virulent id' the two. Still, in all ea^cs. where there is tlie
siij,dite>t dmiht ill dia-^iiosi^ it i> hetter to -uhiiiil the exude to iniero-
seopieal evamiiiatioii. The hi-Ioiy of the ca>e slnuild di.-tiii,LMii>li it
from the throat crn|itioii of the exantheiiiatoiis (lisea>.'s. also fniiii
cancer and ,-yphilis.
Prognosis. Thi^ is usually favoralde. The di-eaM' runs a re'_Milar
(oiirse of four oi' ti\e ilay> ny a week. and. altlnuiLdi it may he attended
hy considerahle pain and fever, it is not likely to leave any -crioii-
cDniplicalion altci' it -uhsides. The alhiiniiiinria which occurs :>;
usually mild and of >lioil duration, i'araly.-i- (d' the pah.li' ha- in a
few instances fidlowcd the disease. Ia>tint;' at the |oni;cst only a few
wi'cks. (,)uin.-y has ,d^o heen developed as a re>i;lt of the tonsillar
irritation.
Treatment, .\ticiition to hyiiieiiie rules, aluindaiice (d' liuhi did.
and regulation of the alimentary canal are all that seem to he re-
t|nired in many of lhe,-e cases. While the fever i- hiuh and the tiowcls
eoiisti|iated. >aliiie e.itliartics ai'c indicated. I'pon the hot and irri-
taiile throat alkaline spiays hav(^ a LM'atcful elVecl. .\moni: the in-
ternal rein('<lies none liaxc a hetter repiita'ion than tr. fi'r. iiiur., ".'n
per cent, ill iilycerin. in doses (d' I to '■.' Lirammes every one or two
hours. It is liivcn iimliluted. it- cllicacy as a sv-temic tonic heiiii:
allied hy the direct contact of the iron upon the ton-illar exudation.
In my own ca-es I have not admini-lered the iron in this wav. Init
ha\i' diliiti'd it Very freely, in ordei' lo a\oid any injurioii- ell'cci the
clihu'ic acid iniLiht ha\e upon the teeth id' the patient. To free the
tonsils the ferric ;^lyiei-ide was applied twice a day to thciii hy nnaii-
of a cotton-holder.
In many of tlie-c ca-es I ha\e <cen ailvanta;.''e from the -edative
and a-trim.:ent ell'ect of nitrate of silver, applied in the oarlv >taL'e of
eMidatioii. The tonsil- were lii-t hrii-hcd with a l-per-ceiit. solution
of cocaine, followcil in three or four minutes hy the application of a
10-per-ceiit. -olulioii of the nitrate, l-'or the liist lioiii' the patient
1T.(
i::|: •,
'wr-
\ 1
1.
2?6
iiisi:asi:s ok iiii; i'Iiauvnx.
wciiili] sc'irccly iHTccivc iiiiy clVi'd I'nuii llii.' ;iit|iliiMliiiii. 'I'licii llic
scii.-alioii III' .-(irfiii.-s uoiild luilv \)v ?li:.'lil. I'>_v llu' fnllowiiiL; day llio
flopu.^il WdiiM lie more tliaii hall' ol' it ynm; ami a .-cioiid similar
iri'aliiiciil would t;()ii)|)lc'li' llif rctiinval. 'i'lic diliucd iruii soliilion
wuuld lie I'ciiiilarly adiiiiiii.-l»'n'd iiitciiially, during' tlic wIkiU' pi-riotl
ol' trt'atinciit ; and, liy the (•(Hidiiiicd inctliods, t!ir tiuir.-L' oi' tln' dis-
mast' Wduld. ill mail) iti>laii( t'.-, lie iiialcrially .-Imrlfiicd.
1 liavi' I'liiiiid till' iiiiralc ol' .-ilver particularly u-i'l'iil ii; lliat
traumatic class of cases, the result of nasal (i|iciatiou>, already re-
ferred to, tjiiite frequently only a siii;:le bru^hiii;! willi tlu' silver iieiiiL'
required.
When there i> much headache and iii-nmnia ' ^- to ', _,-gramnie
doses of iiheiietidin or acetanilid, ,i;ivcii at lied-tinie, will often secure
ijuiet and refreshing rest for the night; ,-nialler doses to ho given to
children in proportion to age. id' this as well as any other medicines
rctjiiired.
If there IS much diprc>-ion alter the lir>t two or three dayr-,
iiuinine may hi' reMUled lo. in ' \,-graiumc doses once or twice a day.
The (|iiestion of iMilalion in lacunar ion,-illitis is one of no little
iiinnient. \Vlicue\er there i.- the ,-lmhler-l dniilil a~ to the ideiiiity of
the disease, there >hould he no hesitation upon ihc matter, and Mic
patient should at oiicc he placed out of re;ich of alfeciing oilier,-.
When .sure that \\ e have iioi diiiliiheiia to contend with, we mav
'Oinowhat relax our viiiils. while care is taken l^
I kee|i the |iaiient
aloof from tlmse who would he most susi-eptihic to tli
inji tlia! the chief daiii:er is from its ei
c ili-ca.-e. Know-
idemie eliaiacler. and m t I I'om
IO,-lI
the slighlly-infectious nature of the e\udation-de]
In Ireatnieiit of aciile lacunar tonsillitis I do not think the lance
oan evir he iei|uircd. .\ftcr the subsidence ni the disi'ase, however.
if the loii.-ils are hy|uil lophiid, ionsilloioniy should hi' perfoiiued.
This, in a large measure, would pri'Veiit the recurrence of the disease.
As an external applicaticui, camplioiateil oil. or a (N>ml)ination
of spirit itf lurpeiiline and olive-oil. rulihed over the region of the
tonsils, and the surface eover^'d at once with a layer of absorbent
eottnn, alwavs aiHwers a Li'ood iiurpose.
I iiArri.i; i,
I'll \i;NN(ii;.\i. .\!V( (ISIS.
M^|(l-!v I'liiii^niilcs, a ciiiiii.iirnl i\ I'lv rare di.-ca.-r, \\ii(ii ii dncs
(icciir ii.-iiallv iilVrc!.- Miiiit. |Hii'tiiiii nf \\\f j'aiii-f.-. It is Irriiicd ■"myco-
cis iiliaiviiLicii-." ■■in_vc(i-is ti'ii>illai'is," "iiivcu.-is liiiiriiiilis,"" cic. ac-
ciii'iliii::' til ilir iiiiiiiiiis iiicmliniiic alTidtil. lint iis it cnIi'IuN. in iiidsI
instance-. t(i all iIm-c localities, liciiiix raifly coiifimMl exdusivrlv tn
diU' ^itl'. tlio title iit the head t'l' tlii> < halter may he ccn-idered ;he
hc'^t (Fii:. S:^).
*■ -1; L\
laiH-e
,ever.
llied.
-e:\se.
lation
tlio
Irltcnt
l-'iir. ^'i. IMkii \ iiLr"iii\ cnsis. lAutiinr'^ -pciinu'n li\ W'lincli.i
Pathology. -The lorni mycosis. I'mni the (ireek wmd iivx-r-. i-\g-
nifyiiiiT I'lmiiii,-. indicates the character of the plant. This is a ])ara-
sitic disease, c(iin|iii-.ed oi small. '.\ hili.-h-ycllnw liniuihs. dense in
.strucMire. and pnijcciiiiLr aliove the ninciMis niemhrane upnn which
they have urnwn. It helon^'s to the schiznniyccles ::i(iiip of t'un;:i: and
the species i.- called leptothrix, from the cyliiidrii'al. or throml-liko,
shn[H' (d" the cells. 'I'hc term is aiijilicd to a variety (d" veirctahle
(tr<:anisms I'onnd in drains. :.Mrl)a<re, Imtrs, etc. Thev mav also he
found in milk. mine, and fold watery solutions, after proloiijjed ex-
posure to the air. The inicmscope reveals the thread, ov ro(ldikc.
cells (if the lepidihriv indieddcd in anMi-phnu- Lrrannles. streptococci.
t' f I
•i
i
-~*t
278
DISKASKS or Tin: niAItVNX.
etc. (Fijrs. Ml iiml N")). If trciilcd uitli liii<:(»rs solution, these Itodie?
assume ii liliii>li tiii<:i', iiidieatiiii: tlie presence of >tiir<'li. Tlie cell-
1 : I.
i ,1
V\<^. S4. I.«'|)l(itlirix. Advfiititiuus follicle to left «itli'
( Author"-; siiccimcii liy IJt'iislcy.i
I !
i
t *
1
Fig. 8,"). l.('|itolliri\ /;( xlin i' , iiicli nliicctivci.
(After I^cniiox lirownci
I
vary in form iieeoi-dinix to tlie iiiiatoniical reirion from wliicli tliey are
removed. When the fiin!.nis aiipears on the surface (d' tlie mucous
arc
»i
OUO-I'IIAUVNX. I'llAItVNdKAI. MY(()SIS.
-.';!•
iiu'iiiliriiiic. it iiiiiv he |uirfly >ii|i('iliciiil. or lir iiisritcd in a wcil;.'!'-
flui|U'(| iiiaiiiiiT ill the parciHliviiia. In llic (Uir it i- r-iinply attaclMMl
/■;/ iinixsi' tn tile llatlciicd cpit licliiiin. and i- Iiii|ii<il;i'iiciiii-1_v slriatcd
in a|i|it'araiur ( Uosudrtli ). In the dlliiT, when ii iiiiicii'alcs dci'|ily
into tlu' I'liitlii'liiiiii, tilt' ;,fni\vtli is dciistT and iiinic ;:ranular, ;iiid
till' iiiicroscn|ii' MiinctiiiU'S fails to dciiiiiii.--trati' the iMd-likc I'dls.
Ilt'rvii>i- liflicvc- that this nlditfinl inn i> caii-fd hy the |iic.->i:r('.
Wlu'ii the iiiycd.-is ciitfrs still dt'(|irr inln the (ry|it.-. the latter lic-
coiiu' dilated and Idled with l'iiii^n)ii> LMowtli, deireiierated epilheliiiin,
and aiii(ir|)li(iii> matter. Sninetiine,- ;i horny hypertrophy of the ejii-
\
V\)l. SCi Kfiiild
111 toii-ij with |(|piiitliri\ i' .iiuli nliji'ii i\ r i .
(Alter l.ciinnx Itriiwiit'.)
tlieliMl celU. instead of -iiiiple catarrh of ihe irypi-. aet^ a~ a liase for
the leptotlii'ix. foriiiiii;:' a keratosis of the loii-d ( l-'iu. •'^I')-
Etiology. — The oi'i.iiinal >oiiree of ihe fiiimii- i< -till a matter
of (|iiestion. The miei'o.-copieal examination- of Toepliiz. W'auner.
I hiniaseliino. Colin, and others have proved, hdwcvri'. that the li'|i|o-
(hrix is frecpieiilly found in the month, ahidiiiu there, like man\
other licrms, iiin(uiioii>ly. hut that a eoiidiliim of impaii'ed heaitli.
t()j;i'tlier with idin>ynerasy (d' const itiit ion. W(mld appear to he le-
i|tiired to sectiro the attachment and niowth ol the fimuus within
the pharynx. Tiic peculiar featiii'c i.- that, althoiii^h the hacteria may
he present in such laru-e iinmhers uiihin the iumI cavity, they should
.so rarely liiid a nidus fo|- dcvelopmciii then', and -hould prefer the
:||
■
w
■\\
\
M
I
K'
; r ; t
j,i n
*1
Sfhd
nisi;.\si;s (U i in; ni \ i:v\\.
.i>:
li
{ 1
:
tf-^iN
li I
iM
fiiiiciiil ii';:i(in. I'i'i li;i|i.- tlic inlciiM' inii-culiir ;iiii\ily nf iIh' mMiiili
il.-r|r iiiny ad as a ildi'iii'in to Icjildlhrix aUachiiicnt. Sex ha-; liltlr.
if anv. inlliii'iirc. It rai'civ dcciir- licruro early iiialiiiitx. and imt
vci'V nfifii ill did aL;c. ('nliii .-ays tin' prridd dI' lil'i' lia!>lr Id allack-;
is liciurcii ilif aiics (d' tjii and lid year-.
Sicliriiiiiaiiii (Aniiir fiir Ldri/iiiiiiliniir nihl l!liini)i()(jii\ \^\)'i) lia-
a IdiiL:' ariirjc iijiiiii tliis viilijcci. ( hi !ii>ld|d-ifal LiTdiiiiil- lir >trdimly
comhats llu' tlicdiy ijiai )iliaryiiL:di!iycdsis nwc- iis drii.fiti id ihc pres-
ence (d' the leptdl liriv. Ill' (Ir-I de.-erilies the iiiieidscdpical appearaiiee
df a siiiL^le (|iiil| of ilie di-ea-e and llieii a -I'didH (d' the tdii-i| with
(|iiill (// silii. 'Ihr eMiniinatidii >h<iu> the ina.~- Id he made up of a
eysl, (ir saek, cdinpdMil d|' a central nai'mw liiinen .-iirrdiii ded h\' an
epithelial wall, lie c(nii|iai(> it wiili the hiinian hair in ~iriieliire.
'Che wall (d' the i|iiill is partially Cdnipd>ed d| haiihued iinniieleated
epitlndi.il cell-, and partially id' hdnid,t:'eiiedii> lidinv >iih>taiiee. 'The
central Iniiien i- naridw and lilled with drlriliis. haeieria. and iniieu>.
'{"he iiiiler siirfaee <d' the (jiiili as it (U'djeets i'mni the erypi i-; ed\ered
willi hiiiulles id' leplnlhrix. lie >ay.- that in the iieiLihlidrhddd id' the
ery])i lh('r(> is no evidence of inllannnatidii. siudi a.- hypeiti'dphy of cuii-
iicetive tissne and small, nnind-eidled inliltratidn.
As the resnil id' his invest iu'at ions he cdiuliide- that the pmees^
is an iinnsnally intense ciirnilieatidii ni' the lacunar epithelium, ternii-
naliii.ii' in ipiill-I'drmatidn. lie alsn says that l<crald>i- nf the tiuisil-
cryjils in a mild fniin is not an nncdinnidii cdiidilidii. and that the
pri'scnce id' the leptnthrix is pnndy incidental, and hear.- mi relatinii ti>
the dis( ase a- a eansat i ve factiir.
'I'lie I .('jil'illi ri.r hiiniilis is a ^apniphyte. nr I'linuiis. I'liuiul in almd>t
every nidiith- -the nidic richly where the epilhelial cells are lliicke-.t.
liasini:' this theory on the ahstdiite deimmstration of llie ejiithelia!
rofmatidii of the iniills. with the manifestation of the leptdtlirix-s])ores
only on the outer surfaces. Siehenmann considors 1ii> case dearly dem-
onstrated, and desires the name of the condition to he diaiiLicd to that
of ''Hyperkeratosis I aciinaiia."
K'icliardsoii. of W'a-hinirtoii. from iiatliolo.i^ical examinalion and
I linica] experience. alMi stronirly favors Sielienniann"s \ iew.
The a^es of all the ease? 1 have seen arc the fidhiwiii;:-: IT, ii>.
'■i'2, 2n. '^>8, :!(), 40, T)."). and (iO years. The la.-t two occurred in the
same acntlcman, with an interval of lictweeii four and five years of
(Mitirc freedom from the disease. The second ca-e was that of a
<rirl \vnrl<!nir in a hrush fadorv. She stated that the dust from a cer-
II'
i
1>I
oKM-rii AUVNX. i'ii.\i;v.Nt;i;.\i- mV(()si>.
•J SI
fain kind of hristlfs ahvavs produced sori'Jic>:.>J of the tliroal. wliii li
eVL'nuiaiiy di'Vclojiod into this disease. Tlie sixiii ia>e is also uorlliy
(d' incMliiiii. 'I'lie patient was a yonni; farmer. Two _\ears Ixl'ore I
saw iiiiii with tile ni_vci)-;i.H lie came from a dislaiit tnwii to lie irt'Utid
I'nr aiilial dJM'ase. Alter .xuiic weeks" ireainient a r(iiii|iletc riiic was
accompli.-lieii and lie retiirmd lionn'. "nc yiai' and a halt lairr he
.-|)cnt the winter polisIiin,ir cow-horns, during' which time his ilu'iat
hecame sm'e. in the spring' he came ajiain for trcatniint. ^Ui c.aiiii-
natiiiii I found the whole of the tonsils, lower pharvnjjeal wall, and
hase of the tongue cdvercd witii ihe leptntlirix fiin,i:i. There was no
return whatever (d' the antral disease. Jn llio tiftli case the lii-t indi-
cations oecnrred duriiii,'' the fnurtli we('k of an attai k of tvplmid
fever.
Symptomatology.- When .-iluated in any pi>riioii of the i'aiices,
mycosis presents very few .'-uhjective symjitoms. It pinduces no in-
llammatory action, and is cau.-ative of slilfne.-s nmre than xireiicss.
W lien the eruption is very abundant, a feelinji of irritation may. how-
ever be developed. As the ]tlants increase in niimlier, and liecomo
scattci'ed over a laiger area, the movements (d" the iliarynx become
somewhat restrained, and the muscles sli^ditly .-lilfencd, partial
dyspliauia beinj: the result. Occasionally, too, a >li,<;hl irritable cdiiuli
may be jiniiluced; l)ut these pynijitoms are never marked.
The miifit frc(|ueid .-ite. and where it present.- llw lariic-t de-
\elnpiiiciit, is in and hetweeri the crypts of the faucial ton-ils. next
or, the liiieiial tonsil, on the walls of the phaiyiix. and last upon ihe
pharyngeal tojisil itself. Siebeiimann and Schubert both recite <a.-es
in the latter reiiion; but the rrrowlli in these was aspcririllus instcail
of IcjUothrix. I have only seen one ca>e of (b'velojmient in the naso-
pharynx, and that was an exteii.-ion upward fn.'m the faucial region.
^Mycosis, when examined, presents small, milk-white opatjue
nia.«ses ])rojeeting above the mucins membrane. They are soft and
moist in appearance, but are not easily moveil. Colin describes three
forms of develo]iment : 1. Small isolated s|iots. '<i. Larger spots like
a cock's cond). 'A. ."^mall. smoiith, yellow-white jilivjucft. Whatever
form they take or wherever they are loeateil. |iarticiilarly in the kera-
tosic variety, they vvill stand a large amount of friction withont sepa-
rating their attachment. I'snally a large nnniber of the plant.s are
scattered over the area affected, varying in .size from a millet-seed
to a shelled cat-seed or larger. Sometimes they exist for years, pre-
senting few symptnins of a distressing character.
U:
:i- ! I
li: ; !
,!l!
ti : it;
>'MV
DisKAsr.s (»i iiii: niAiivvN.
J'
I
nil
Diagnosis. On ii i'ii>iiiil iiis|ii'i limi u iniL'lit |M>>-ilily lir inistiikoii
fill' ili|ililli( ria: Itiil a ciU'criil cMiiiiiiiiilinn -liniilil at nncr rciiuivc
ilmilii ill )lii.> (lin'('tii)ii.
Till' (inly disease In wliiiji |iliarviiL!( al iiiyci-ir hears any rcxiii-
lilaiire i< laciiiiai' |nii>illilis. imt in <li»l iiejni-lnni: it tlierc ^liniiM lie
iMi ililliciilty. 'I'lie (iiic i- a silieiiic inllaniiiialniy ili-ea>e <il' liniited
(liiralinii: the ntlier. iiiin-inllaniiiiatnry. a-tlienic and e.».-eiilially
chronic. In the (Uie the cryptal de|io>it is sdl'i and |iiiltaeeiiii.« and
easily reiiuiveil. In the other the (inn le|itiitlirix deve|ii|iiiient adliere-
teiiaciMii.-ly to any |iarl (if the |nii>i| nr |iliaiyii\ ii|iiin wliieli it iii.iy
have uiduii.
I'd.-silily. tun. that clifonic eonditinn n|' the tiin>il in which
cheoy de|in>its jdiin williiii the laciiiKc and |iriitriide almve llie sur-
face nii;:lit he mistaken Inr inycnsis. Here Imtli the diseases are
chniiiic and niin-inillaniniatniy ; hut tliechei^y iiias-e> only apiiear at
the iiKiiith (if the cry|its. never anywhere (d>e: and they are easily
pressed niit, while the inycosis is scattered in every directidii and (an-
llot lie sd easily iiKived.
Prognosis. — In |iliaryii,i:cal niycdsi,- there i- iidthiiiL,' (iaiiiicrdiis to
life: and a niinilicr (if cases, after existiiiL' f'lr year>. have heeii known
to disappear spontaneoii.-ly. without trcatnient. It is only in excep-
tional ca-t> that the disease is very distre.-sinj.'; still, as a rule, it is
interininalile in cdntiiiiiity, and if left td itself nii.Ldit last thfoiiLdiout
a life-time. 'I'liis Ion;,'' i-onliniiaiicc nndoiihtcdly has a depressing;
elVect upon the vital fdrces, and tuay render the .-iilijcct more -ns-
ceptihle td the inlliiciice of other disi'ases.
Treatment. — The trcatnient coiisi>ts in the -eradication of the
plant. In a few recorded cases this has heen done witli facility; hut.
in the majority, careful, viirorotis, and persistent treatment has heen
rcijiiircd for a proloiiL^'d period lud'ore cdinplcte cure has lieeii oh-
tained. Tiiicliire (d' iddine. tannic acid, nitiaie (d' silver, solution of
hiclijdride. calomel in>iiniatidiis, have all lic( n iixmI with mure nr less
cllicacy. ( 'hrdiiiic-acid cautcrizatidii ha- its advocates, and al~d ciiret-
taii'c.
Iiiit. df all meihd(1s, the Lialvaiii cautery needle, carcfiiUy in-
serted directly into each fiiiiLi'oid dcpo-it, is t:cncr,il!v ackiidwlcdiied
to he more positive in its results than any of the dther methods of
treatment. This will prohahly necessitate a hiri.M' niimlicr of
sittin<2s, the use of cocaine or cucaine liein<x in each rc(piirod. Like
all other methods of treatment, the cure will he tedious: lint it has the
oiiu-rii.\i{YN\. I'liAiu N<ii:\i, xmusi^.
.'«;{
m1
■of
nf
<(^
lie
udvaiitajif (if jn rniiiiifiHV in results. A cure citii he aeeomplished,
and, (due cured, llie disi'iise riirely returns. During' tlie intervals hi'-
tween operatidiis the thrdiit shmihl he treated liy aiitise|ttic sprays,
twii or three times !i day. Of all lliiit I have liird. nothing; seems to
liave so elVective an intlueiiee in c<uitrollin|,' the dc\clupmeiit of the
new spores as a .solution of izal. This is a enal-produet, one of the new
hydrocarhons. and said to he much stronirer than earholie acid in its
^'erm-de-;troyiiii: iiitluence. '{"he preparation 1 have used is a l<)-per-
cent. acjut'ous soiiilion.
18
I
'M
('iiAi"n:i{ i-i.
iivi'Kiri imi'iiv nr iiii; i.iscr.M. tonsil.
Jl Y^l•;l!■|■|;ll^ll^ of the 1\ mpliiilic ti-.-iic. «ilii;itril al the lia>c of ilio
lon<iii(', ill the i:ln.-Mi-('|Mt:li)il ic I'n.-Mi. i- iini ul' iiilrcijiiciit oci'iirroiice.
This iiiiis.s 111' iiiiicipiiiiiii-; lilaiiil.-, (ailed tlif liii'jiial tnii>il from its
l'"i^'. ST. lly|ifi trii|'liy ui Iri't liiij,'ii:il tonsil.
(.Vftcr l-('iiiin\ jtrDwiic.i
siiiiihirilv in stnictiu'c to tlio liuaial and pharyngeal toii.sils, is in
many iii.-^tancfs alniormally di'vcldiicd. yivin;; ri.<i' to a ninrbid fullness
and irriiation, which are hoth distrossinir and .soinowhat |iainfiil to the
lii:
it
t ■
1- ifi'. x'li. T?iliitti:il liyjifi lrii]iliy of liii;,Miul Inii.sil
( .\llt Imr"-; .-|icriii;cii. i
patient. The condition may be ciliicr unilateral or bilateral (Figs.
ST and STrt)-
Pathology. — This mass of glands extends from the cireumvallato
pa))illae to the epiglottis. It is divided into two halves by the medio-
()H(t-i'ii \in N N. in I'll; I i.'nnn <ir im; mmm w. iknsii.. •,'>•'»
gl()ssii-('|ii;:l()ttii.' li;.Miiiriit. \\ li.n m n -tnic <i| liv|iri irn|iii_v. ilio
^liimls iiiav LTiiw *o ill) I'lioniiiiii, -i/c, niid lu'cnmi' piickod rlosclv to-
^(I'tlH r frniM fide to t^idc. oxer the li;i-i' id tln' tniitriic. 'I'licy iii'i' Irf-
»|ll('lltly .•ircdlllpilllil'd li_V the di'\rlii|illlilll nf liW'^c VcillS, (■(ilH>ill^ lic-
tWfiii till' l_\ iii|>li(>id ti>.-ii(' iiiid llii' |i;i|iill;i', t'ni'iiiiii;^' llii' liiii;ii,-il viiiix.
Sillijcrs illr -nliicU lull >l|lijr(| In (his dl-Cil-r, UiiIMill Mil II ii H l;l llv
(I'i- N>l.
'I'lic iiiiiiii dill'irtiKc lictuccii Ii\ |)crlrn[diy i>\' the lingual l(in>!l
iiiiil of tliox' alii'iidy iiiiini.iii((l is ilijii, while ilir hitlor uri' lar^'ciy
{[i!|
Fi-rs
luate
•dio-
^KrTT\^rM
l'"iy. f^''^- l.iiii;iiiil \iiri\. 1 Aiilhi.is "inciiiicii liy Wiiiicl
I.I
iiu idriitiil |o (■liihlliniiil. ilic cnlai^ii'iiiciil nf ilic I'nniuT I'ai'cly dr-
vciops heJ'oro niaiurity. 'I'lic umwih i> in tin' forin of a Ijroad layer
of cvypts or follicles oviT the ha^e of tht} toM,Lnie: l)t'neath and lie-
tween \h('<Q laruo liliiid lymphatic hcdies are developed, iiielo.-ed in
lilu'oiis capsule.* (Fig. l^!*). 'I'ho eomhined tis.-uis cidariio until the
sulcus helwccn the tongue and the epiiiloliis i>. in some instances,
completely filled.
Etiology. -This hypertrojihic condition oecuis more rroqucntly
in females than males: the reverse of the historv of faiicial tonsillar
^ 1 ,
m
rlESf :
ysG
ItlSKASK.s ol- IIIK I'llAltVNX.
liVjuTtropliv. rxiswdrth siijr<rcsls (Iml it ut'ciir.^ iiiiicli iiioru fivciiu'iilly
in young cliildrcii than i.- generally >-ii|)j)().se(1, not lioiii,!'- ri'cogiii/od
iVdiii the fact n\' tli(' coiiipaiativc iiiscnsitivi'iicss ol (lie tlimat (lur-
ing early life. ('(Uistitiitinnal (lys<iii,--ia may in iliis, as m dlhor
]iyiXM'trM])lii(.s, lijivc mud, lo do wjtii its primary dcvi'lopnumt. Not
jnim[ucntly it occurs as a sc(|Ufl to diplitlicria. scarlet tVvcr. etc.
Pooplo addicted to tln' e\i(»i\c use of spices, coiidiuieuls. alcohol,
etc.. are also ])roiie to the disia.-e, owing to tlie hypcra'mia produied
by their irritative action upon the post-lingual region. Accordini,Mo
K'ay. the disease is of lii'ijueiit occurrence anunig singer.s.
Symptomatology. -- Lennox IWouiie descrihes three forms of
chronic inllammalory disease of tin; tonsils: 1. As .-imple lym])lioid
or catarrhal inllammat imi. '.', I,acunar intlammation. ;!. j'ari'nchy-
Vi<r. Sii. Mi(i()S(.(i|iii ul M'ctinii of lulic nf liiii,Mud Imisii.
I Aiit lii;r'^ -!r<'(iinrii. i
malou.- inllaiiimation. .-oinciinio ending in ahscess, hut usually in
liypei'lrophy.
\\'hatever the form may lie. the disease is almost invarialdy
chronic, and of a secondary chaiacter.
Not i)ifre(pient]y clironi<- hypertrophy and lingual vari.\ are asso-
ciated together, whili' in not a te\\ \ai'ie(we veins will bo |iresent,
without lymphoid cidai'gemeut. 'I'he prominent >vmptoms are ihe
sensation of a foreign body in the thi'oat. nni'elieved ]\\ swallowing,
and. when the gi'owth is large, acccnnpanied hy a feeling of constric-
tion (d' the lowt'r pharynx. 'I'heri' is (dten a rellex irritahle cough,
a constant eiuleavoi' to clear the throat, laiyngeal fatigue, and also
occasional hoarseiuv-s. in speakers and singers the voice soon tires
and lose- Volume. In many instances tlu> lingual is associated with
ti
)ti.«
l"i\'(liu'iilly
lllnat tliii--
s ill oilier
nont. Not
I'cvi'r, etc.
Is, ak'oliol,
a |ir(i(liu'ecl
(■(■ordiiiii to
' t'onns of
V. lyiiii)lioi(l
. I'ari'iiihv-
\isiially in
mvariiilily
i\ arc a-so-
if |ir('~t'iil.
lis arc lilt'
;\vallo\vin^',
if const ric-
lili' couirh,
'. and !il-o
pnon tire.''
fi;ito«l with
(ii((i-rii.\i; VN \. 11 vi'i'iM K'unn mi im; i.im.i \i, ru\>ii.. '.'sT
faiiciai liyjicrlroiiliy. W lirii varico-r vi'iii> an' |iri'-i'iit ha'iiinn l:au;i' i-
ofirii a |iroiiiiii('iit syiniuoiii. (nciirriiii:' u-iially in the ninrniiii:.
Diagnosis. —So many ihiDai ilisca-r- jirnijiu-c syni|iloins similar
to tlio>f of hypertrophy of llio liiijziial tonsil that to in~iiic a corrci-l
ilia;:iiosis a thoroiiLili throat cxamiiiiition ^iioujil always he mailr. In
>oiiic cases this can he aceompli>heil hy the use of the toiiiiiie-ih'pre--
.-•or wiihniit further aiil. Hut these ea.-es are ran', relleeled liiiiit iiiiil
ihinat-iiiirror Keiiii:'. in iiin-^t iii.-taiiee-;, rei|nii'i'il.
.\ mass of iiiainmillate<l tis-iie will lie seen mi the base of the
tongue, strcleliiiiL;' from >i(le to -ide and divided in the ci'iilro l)y a
loii;:iiiidiiial depression, indieaiiiiL;' the position n't the Ldosso-c|ii,Ldot-
tic li;ianieiil. SoinetiiiU's thi' hypertniphy nf ii~-ne is so Lircat that
it (ills in the ulo.-.-o-epiu'lotl ie Iioteh eomplelely. e\en nverlappinir the
epiLihdiis ii-elf. when ill the uprii:lil pnsitidii I P'ius. s^ and ST'/).
Prognosis,- -This (li-ea>e in\n|\e~ im daiiiivr to life and hut little
lo the eeiieral health. Still, haviiiL;' oiiee di'Vejdped, there i- little
lil\(dihood of aiiHdiiu'ation of -yinptom-, a~ the growth i- >lo\\ ly
projrressivc, remaining;' for years withnui any leiideiiey to shrinka^ic
or (diane'c. In t!ie case id' varix, the e.indjtion i< nmre -erioiis, as the
fre(|uent liuMiiorrhaiit's which are occasidned hy it are dehiJiiaiiiiLr to
the cnnstilnlion.
Treatment.- - T'lpical applicaiiiiii.~ n\' indine. lilycerii-indide, soln-
tioii (d' acetic acid, chromic acid. etc.. have all heeii iimm] with more
nr less elVect. .Still, ii mu-1 he remenihered that the ,::rowili is e.--;i n-
tially one (d' mature years, and the nriiine>s (d' it.- texinre renders it
litth^ anieiiah'c to mild method- df treatment.
The ohject aiinc(l at should he reiiinval nf the hyperi ropliied
lis-uc, wheilier l\inphiiid nr \arii-e-e ur huth, 'rhi> can he ddiie in
\arioii- wa_\s. Sdiiie authorities ad\i~e excisicm h\ ciirvcil scis.-ors or
hi-tnnry. Others hy the ,L;alvaniicanier\-i''cra-em ui' the cold-wire
>nare. The operation, howi'Vcr. which ha.> heen recei\cd with the
,i;'reale t fa\or arid is the iiio-i l.iruely practiced, i- hy the ,i;ahaiii>-
canteryds7iife or elect rocauteryds idle.
In any ca.-e, (he pari- slmidd he i hdrdUiihly cocainized, ami the
dpcraliot, sllnldd he pcrfolllled hv aid i'|' I'etlected liullt. Tile ohjec-
licn lo cither of the ciittiii,ir operations i- ihe pn~>ihility of indiiciiitr
severe lia'iiiorrhaLi'e and the dilliiiilty n\' i-oiitmnini;' it in such an
iihscure .situation. When the ^niui'oii decide- to ii|ierate hv either
histoury nr <cis-ors, it is hetter In coniim nee leinai ively. and not to
<'Xpose too lari:(' a -nrl'ace (d' raw ti--ne at nue nperalimi.
■,]\'
.*'i.
~T-i •iiM-nraMM
288
i)isi;.\si:s VI riii; rii \i;vn\'.
Olieratioii li_\ llic imt plat iiiiiiii ^llal■l' I liavt.' had im t'Xpci'ii'nfM^
witli, hilt would cxiiccl the same (liHiiiiliy in a]i])lyiii,i:' it to Ihe hroail
hase of iho ;:ri)\\lh in this as in nlhrr sitiiatinns. I liavo \\<L'i\ tho
eold-wire siiarc on two occasions only, U>y removal of liyiiertrophied
lintrnal tonsil. In (hr (list llie opciatioii and result wore hoth satis-
factory. Ill the >ccniid. the patient was a youiii: man ajzed 30. 'riic
L;rowth hail hccn <lc\clnpin,L:' fnr a ui"id many years: a fact thai I
did not know iinlil the .-nare was ti.Liiitly drawn arnimd it. Then the
(•l(i.sest tractimi I could put upon the wire faileil to sever the tonsil.
Fortunately for the patient the part.s were well cocainized. After
trying incllVctnally for a ipiarter of an hour to tighten the wire
\i.'
"\<s. no. IIoc's liiiguiil tonsillotoinc.
enough to cut thi'ou,t:h the tissue. T was <ihliged to sever it heucath
the .-iiare-rini;- hy means of ciirxcd scissor-, 'riii- is a dilliciiltv in
ii.-ing the cold >nare whiidi, ]ierhaps. is not sulUciently reali/.ed. As
in the nose, so in the throat, we sluuild make sure that we do not
gi'a>p in the giiillot ine any tissue, liouy or li! irons, that tiie wire cannot
readily sever.
'{"lie galvaiioeaulery operation, for both operator and patient. T
have found in many cast's to he the hest. 'IMie electrode should ho
eiiiM'd to escape t<uiching the body of the tongue, and. the ]iarts
having heen eoeainized. a inimher of the larger nodules may be
touched freely at the lirst sitting, the patient grn>ping his tongue and
I
mil
".—i.A.v.sx. Hv,.,:„T„„n,v ,„■■ -,.„k us.,., ,„,„, .,,,
place Ihero . „o iuvn-onh.,. The snnVnn, . n ^s^ ■ , t
a U.lo, a very U■^y iw.iUuvui, will .„lli..,. to nKror. ."'"-'""'"'^
«!••' "„.„. 1-^KHl .IHU.M I.,. hLuH^u 1^1 ' 'r ' "
^■n.ten.I. :uu\ uuUl ,ui\^,utw .,ll-.,li„ ' ''^■"'"'^•'-■"ts n.v
proe..s of heali,,.. /'" ^^"' ■'""'""■ ^l"'^'^-'- -""nn^ nurin^ ,1,.
Sun,,, years a^o ]{„., „[ JJ,„.|...,.,. ,„,„„,.,, ^„^ j,,,,,.,,,,,^ , ^,,^,
and s.iicc tluMi various inodificai in- - ' ■ ■• - >'i,_, .oj.
I'l-nii.-lif oiil l,y (liir,,,.,.,,! writor.
""^ "I lii:^ nri-inal .Irsii:,, have Wn
;]!
i !-
( !
i
r- "
If
> ' 1
,!;
i i, j !
1
CIIAl'TKU LII.
I'.KNKiN riM(»i;s III' IIIK I'll.\i;\ NX.
1' ATI I.I.UMA.
X Koi'i, \>M> (if ^cMial kiiiil.- ('(■(■ii.-iiiiijilly iill'cci tlic dilTcrt'iil pm'-
tidii.s of the |iliiirvii\. Stiil, ilicy arc all ciiinparat i\ cly rai'c. I'rol)-
ahly ])a))illiiinaia aic i^'i the iiio.-t lrc(|iiciil (Mciirrciicc. The usual
r^ite is oil sdiiic pail cT llu- ^dl't palate, pariiciilarly tin' uvula.
Occjipinnally tlicy may Ik- fduinl on oik.' of tlii' pillar- nj' ihc I'aiicis.
hut rarely mi the pharyn.t.M'al wall.-.
They arc little, tiriii. warty iriowth.-. SmiU't imes. ihnuiili rarely,
they (levclnp to the flianicter nf a ceiitiiiii't I'c. ami pl•e^ellt a eaulillower
or niaiiimillated .'-uri'ace. Tiny are wliiti.-h ami L;li>tciiiii<:' in color,
and iiiicror-eopically c\hiiiit the u.-iial characlcri-ties. Tli(>y arc cnin-
p(i.-ed (if colllicet i Vc tis-lle. each [)n|tilla heiu^f >upplied with its uWll
hl(ind-vc>sel and coated o\cr with epithelium.
Xo special syiiipt(im< are pr<i(|ueed hy llieiii. 'I'hev are alwa\>
painless and randy t^ive any discoinlort. When V( ry lai\irc, particu-
larly if attached to the ii\ula. they may prnduee ci>ul;Ii and irritation
to some ,s|ii:lit extent. Siill. ihey are rarely hmkcd for, and almost
invariahly are diseovci'cd hy aecideiii.
Treatment is ,-imple. It i> merely in ,-ni|i them olT close to the
surface by scissors or to seize them h; the fori'cps and cut them oir
at the base by a -mall, shai'p-pninted liisioury. When propicrlv re-
moved tbev evince no tendeiicv to return.
i'mitoM A.
Fibroma of the pharynx is iiiiuli rarer than papilloma. Occa-
sionally tins LM'owtli may develop on the soft palate or tonsils. It
consists of similar fibrous tissue to libroma in other ]iarts. and fol-
lows a similar history in development. The disease occurs most fre-
(lut'iitly in the tonsil.
Fibrous neoplasms usually occ-ur in adult life. They ijive rise to
few symptoms, the main features being those attendinji obstruction,
(2 DO)
ic\l-
illll
()>t
;lu'
(.ir
rc-
It
Ifol-
IflV-
to
lion.
OKO-PIIARYNX. FII5U0MA. •31)1
when tlic ^i:r()\vth Inifi attained any largo sizo. Not iiifrc(iufntly ihe
disc'ovory of the fibroid liunor lias been accidental, the use of the
throat-mirror, when applied for some other pnrpose, rendering its
presence apparent. The pinkisli-white color, ronnded or nodulated
form, and rlonse resisting consistency are prominent features, and
should render the diagnosis certain. 'J'hey are also less liable to be
attended by ha'morrhage than fibromata of the naso-|)liarynx.
()l)erative treatment is the only metiiod worth sjieaking of. If
the growth is once thoroughly eradicated, it is not likely to return.
If it is not removed, it will go on growiiig, displacing surrounding
ti.ssues and promoting their absorption; and there is possibility of its
ultimately degenerating into malignant disease.
Treatment should be by evulsion. Sometimes the guillotine may
be passed round its base; and, as tibrous tumors are liable to be
jittended ])y hirmorrhage, this is an excellent jilan of removal, when
])ossible. In others, the tumor may be seized by tenaculum or for-
ceps, and, having been drawn out to the tension-])oint, the attach-
ment may lie severed by scissors or bistoury.
I liavc seen one case only. Tlie patient was a barrister 48 years
of age. The growth was sessile and located in the left tonsil. It was
whitish pink in color and accompanied ])y occasional sliooting pains
up to the car and down to the larynx. It gradually increased in
size and commenced to interfere with speech, causing weariness and
]tain after a long address. In this case I removed it by repeated
galvanocauterizations. The treatment was completed three years ago,
and there has been no return.
Besides pure fibroma, other varieties of neoplasms of a combined
character are sometimes found in the pharynx. Such as fibrolipoma.
a combination of fibrous and fatty tissue; til)rochondronia, a union
of fibrous and cartilaginous; tibrolymphadenoma, containing the
fibrous and lymitbatic elements combined. lUit they are all exceed-
ingly rare, and their history and treatment dilfers little from that of
fibroma in its simjde form.
]\rention should also bo made of adenoma of the palate, whiih
somewhat resembles fil)roma in history and apjiearance, though niiicb
slower in development; and also of angioma, which in rare instances
lias been known to alTect the jtalate as well as the base of the tongue.
In tlie latter rem<ival may be by the means already menfiiuied, the
chief danger in operation being from hirmorrhage. 1'his may be con-
trolled by galvanocauterizati(m at a dull-red heat.
Hi;,
i:ii
m
li .1!
ii: ■
I. 1
I)1m:asks ()1- WW. riiAKVNX.
l»i;i!Moii) TrMoiis.
One (illiiT varii'lv nf iiiiihus. tln' (Icriiio'ul, is (Kcasioiiiilly foiind
in till' |ili: rvn\. 'I'ln'v iiic the rciiiains nl' (Icfcctivf or siipcrlhioiis de-
vi'ln|)iiiciit in iMiiiiniiiiii- liti'. Arnold lias jiatlicrcd a list (d' tiiirty-
ciiflit dcriiio il Illinois nf the raiiccs. Scvciitct'ii of llic^-c i.ccnrrcd in
|picinaturc -iijl-liorii infant-, wliilc a lai'yi' propoi i ion of llic rciiiain-
inii' "lie- died wilinii a day or two of hirlli. Slid, a ihhuIm r of cases
have li('<'n n(ordc(l in wincli children have lived for a l(Mi,utli of tinic
with the deiMuoid ii>-nc still present, and 80vt'nil have arrived at adidt
a<:e withnnt lia\ \\\'j. it renioveil.
The tnnioi- i< formed of oidinary inteiiiinient. i~ atlaehei] hy
])ediele, and eoniains >\\cai and sehaeeons tilands. a- well as liaii'-
lollicles. In it there i- nothing' dan.ucroiis to life; and the laruc nmr-
talitv ineideid to it- developineid lias heen due to vital insiilliciency
indepeiideid of the growth. (Inly nieehanieal syni|itoins are produced
by it. The >iirfaee is -(dt and white. Sometimes hail' is visible, and
the ap]iearanee i> tliat of nrdinary >kin moistened by the secretions of
tlie throat.
The treatment i- -iinple iiinoval liy scissors or whatever other
insti'iimenl appears mot -iiitable for the case. There is no tendency
to reformation after cdinplcte excision.
ft'
!. (.
ClIArTKi: UN
Triu:i!( ri.(»>is ok iiik i'iiai;^ n\
i I H
<)\- all forms of iniliiny tiiliciclc. iliat nf the pliarviix i> the rarol.
While (iiic-scvcnlli of the |io|iiilaI inn wf civiliziMl iniiiit I'io die of |iul-
iiioitarv tiilicrciilosis, it is miiuhly oliiiialfd iliat not nmri' than 1
[)('i- cent, of thc>e ai'e ever alVeetcil liv pliai'v n^eal I nherciilar disease.
One nolieealile feature ahoiit it. however, is it- peeuliai' \irulenev
when developed ill the faiuial region. When in the pharviix. al-
though usually considered an a.-lheiiie di-ea-c, ii i-, in the inajorily
of instaiHi-, >tlienic. >evere, and rapidly fatal.
Pathology. — Wliether in tlie larynx or phaiynx, the patholoi^ieal
clinng'c's very iiundi reseinhle each other. .\t the eninineiicement and
tiirougiioiit till' di.-ease there i- a peculiar pallor i.f tlie >iii'fai-i'. The
lii'st deposit of i^ray nodnle> i- ii.-iially in llh' -oti palate, upon an a^i-
noriiially-^ray niiicosa. With this there iiia\ he inlill I'at ion and ilie
preseiK-e of tuhercle liac-illi. I'.y and hy the nodule- hirak down, and
shallow. irre;.;iilar ulceration-, witli ra,::.:ed ediic-. take place, which
may coalesce and form e\leii,-i\c -iirfaccs nl i iilirniilar di-ea-e. Tlic
tonsils are more rarely alVectcil. 'I'he larynx i- ii-ually iii\aded alniosl
.syiichronoiisly with the pharynx.
Etiologj'. — I'harynueal t uherciilo-i.- i> very rarely a primary ili.—
ease. .\t all events, it is i'ecoL;nized. a> a rule, to he a .-ccoinlary de-
\elopnienl. lollowiiii:- the mani fe-^iatioii of t nlicrciilosi^ in -onie other
orii'iin (U' oi'j^aii- I'ldike ihe di-ea-e in ihe lunus. or I'xm in tlie
larynx, it l- a--Ulllril li\ i|> pre-cHre to illduate llu' exi.-trllcc iif ^-eii-
eral lulu i'culo>i> in oilier origans nf the hodv. It,- rapid clinical lii>-
lory Would seem to liear oiii tlii> view. .\- a rule, it i> a secondary
d('\(dopmeiii to piilmojiiiry ili>ea-e. .Mirrcroinhie and (ice reported
(■uses following' tiihercular ciiteril-: ami. r\r\\ i1iciul:1i not primarily
iccng'ni/.ed in othei' oi',i;ai!>. it is douliifnl if ii i- mu pre-ciil. tlioiiLih in
a latent form. Still, there appears to he no rea-on wliv a primarv dc-
po.-it of tiihercli' is not possihle ill ihe faiiei-. a< wtdl a- in any other
reunion (d' the Imdy. and a iiumher of cax- ha\e lieeii recoi'iied in
which thi-^ seem- in have heeii the ca>e. Li'iiiiox lii'ow lie ha- reported
(■.".1:1 1
\ ,
! '
liJ
J
'■ vji» »» m ii H ii
:.'!tl
iti^i \si;s OF riiK riiAiONX.
.1^
III
h i
two cases in wliitli the moiilli and J'aiico.s were all't'ctt'd willi luhcrcii-
losis between iwo and three years bel'ore there was any nianifestatioii
in llie luii^s.
Symptomatology. -A pa it I'rdin tlio general eonstitntidiial d_v.--
crasia, which wouhl indicate tlie presence of tiiberenhisis, perhaps the
first directly-pliarynj:eal symptom wliich would be noticed would be
pain in the act of swallowin,if or speaking;-. This is of a sharp, lan-
cinating character, and is accompani(>d by chilliness and iiicreaseil
temperature, often rising to 103° and ](tt°. The (edematous condi-
tion of the palate interferes seriously with deglutition. Food will pass
up into the nose, and secretions will accumulate within the ])harynx.
owing to the stiffness and incompetence of the i)alatal muscles.
Cough is always feeble and accumulations diflicult to void. The
voice, although mullled. does not lo.«e its tone, unless the tongue is
atfected: a condition which frccjuently takes place. DifTicidty and
pain in deglutition materially interfere with the proper nourislunent
of the body. Ivxamination of the throat reveals the pallid condition
of the surfaces, and the presence of granulation, infiltration, or ulcer-
ation variously combined, according to the condition of the parts
atfected.
Diagnosis.— This should not admit of any great dilliculty. There
are two well-recognized stages in the history of faucial tuberculosis.
In the first the mucous membrane is unbroken, Init beneath its sur-
face, on close inspection, minute grayish-white spots may be observed.
'J'hey are about the size of mustard-seed, and may be scattered pretty
extensively over the parts affected. There is also slight infiltration
as well as anaemia of the mucosa. The spots are greenish or muddy
colored, (juife difl'erent from the clear, white spots of lacunar tonsil-
litis. In the second these nodular spots of tubercular dei)osit in a
very few days break down into true ulceration, of the type ])eciiliarly
cliaracteristic of tuberculosis.
There is probably only one disease with which tuberculosis of the
pharynx is likely to be confounded, and that is the ulceration of
syphilis. Still, the local conditions manifested by the two diseases
are strikingly different. In syphilis the ulcers are clear cut, deeply
excavated, with bright-red irritable areola, and bathed copiously in
yellow pus. Tn tuberculosis the ulcers are shallow without any well-
defined margins, without areola, slowly progressive, and with limited
discharge of grayish mucus. In syphilitic ulceration there is no fever;
in tubercidnr ulceration fever is well marked. Tuberculous "ranula-
ni{(i-i'ii \i;vN\. I riii'iifii.osis.
•.'!).">
lol" tho
Ion of
isoasos
jlt'cply
^Iv in
\vcll-
imitcd
If ever;
nnula-
tioiis iire iiidnlcnt anil [lalliil. \\liile ;-ypliilitic jxraiiulatioii- ai'c laruiT
anil inllainiiialni'v.
l-npns, heinjDT essentially a ihronic, non-felnili' ili.-caM'. ciiiijil
scarcely be mistaken for tuberculosis. It is also more nmlular. Irss
painl'iil. and <;iven to vij;(irous cicatrization, to which tuberculosis is
nnkiiiiu II.
Bowlby relates a case of (>xtensive jiluirynLri'al lubmulosis in
which the membrane was so e.xtensive and thick and .ijray as in -ii,::-
gest the possibility of diphtheria, while Walton reports one in whiili
tlie hard ])alate was perforated into the antrum of IIi;.diinore, render-
ing a pnpsil)ility of mistaking it for malignant disease.
Prognosis. — This might be jironounccd a hopeless disease werv it
not for the fact that a very few recoveries under favorable circum-
stances have been reported. It is one of the most acute of all tid>cr-
cular afrcction.«, usually ternunating in a fatal result in a compara-
tively short space of time. As it rarely occurs except as secondary
to extensive tubercidar disease elsewhere, it oidy adds fuel to the
existing fire. Still, when the nodules were limited to a small area, or
a small ulceration existed without surrounding nodular deposit, cases
have occurred in wdiich prompt treatment has removed the local dis-
ease and healing has taken place. These patients might ultimately
die of tnberenlosis, but they were cured of the ])liaryngeal disease.
Treatment. — On general principles, it is better to keep the part;^
free from discharges by the use of cleansing sprays. These should be
of a mild character to prevent irritation: "JO-iJcr-cent. solution of
peroxide of hydrogen answers this |)nr])ose vi'ry well. As does also
a 5-per-cent. solution of resorcin. Dobell's solution answers a good
purpose likewise, without possessing as much antiseptic power as
those already named. After cleansing, cocaine might be applied, and
the ulcers rubbed with a 50-per-cent. solution of lactic acid. This
is after Krause's method of treatment of laryngeal tuberculosis. The
application may be repeated at intervals of two or three days, iuid
may be carried out in buccal as well as pharyngi'al tidierculosis. In
regard to the latter, I have seen excellent results in a case of extensive
sublingual tubercular ulceration. This nccurred in a man, aged ;>.">,
sulTering from severe a[)i(al disease. The treatment extended over six
months and ♦he idceration healed, leaving the tongue somewhat
limited in projectile movement. The pulmonary tuberculosis steadily
advanced, resulting fatally the following year.
Of newer remedies, the application of guaiacf)l to the ulcerations
fi
ill
n : i|'
•.".Mi
IMSI-; \>i> or riii: ni \ l,■^ \ \.
Il'l^ 'n'''ll |ilni||l(Il\|. ,,r Mnnd IVMlll-. The -alllr IllilV lie Slid (if -lll|il|(i-
'■ii'illillc of lihrlK.I. |i;ll;lcll|(i|n|i||rni.|. ;|llil cll/Vlllnl. 'I'lic \a\\cV \~
rccniiiliirliilcil \,y .Miiiiiiv ;i- iiclili- ill likr iiiiiiiii.T Willi luetic iieid.
A ."•- Ill |ll-|ie|-ee|||. -|i|;l\ nf |lie!l|||n| in i||i)n|e||e. t,\- il -llniliir
|'i'''|'iii'iili"ii ii-eil li_v nil nid-inlialer. HdiiM juive il ^iiotliiiiL;- ami eienii.-
illi:' ellVel ll|i<in the ili-ea-eil li-^iie-.
Aiiulher inelliiMl nf iivaiiiieiit III' pilars iiireal I iilierrii|()>i,- i> l.v
'■iii'''"''iiiciit anil laelie-aeid ireaiiiieiii enniliined. a- advoealcd iiv
llrniiii. If lli( [iliysieal -M-eii-lii i<\' llie palieiit i- imt too iiiiieli iiii-
piiii'cd, dcsjiiiel ioii id llie iileeralive ii-Mie> liy i^jilvaiineaiiU'CV inav.
ill -nine ea.-e-. elll'ck llie [iniiire-. (if the dl-ea>e.
Aller eleaiisiiii:- iir <i|i( ral mn freijiieiit diNiiiii;- li_v iiid.ifnrin lia<
al-n lii'i'll fiilllld of liellejil.
Iiitenial iiiedieaiiiiii may al-n lie of lieiietii \'nv the ui'iieral tiilicr-
euliiii- (•(indiiinii. l-'iir ilii~ nn remedy at llie pre-enl lime juisses-es
a lii.-lier re|iiila|inii than eiva.-iile and it- dei'i\ative.-. Of ihe hil'.er.
rai'liiiiiale nf erea--i)te. or ereiisntal. |iiolialily lake- the liiM place, iii-
•'■-iii'i'li iis it can he taken in larger dn-e^ ihaii anv id' the others
withiiiit injiiiy I,, the dii^estive tract: do-e- of 1 or "J ^■raimiie> can
readily he taken two or three time- a day. eilher in codliver-ojl or on
>ii,Liar. ( dlier sy-teiiiic ionic- and fernininoii- niediciiio mav al-u lie
pn-crihed in -iiitahlc cases, while the dietetic, hygienic climatic, and
"'li''i' ciindiiion- of the patient are cand'iillv atleiiilcd lo.
(iiAi'i'Ki; i,i\.
1,1 ris ni Tin: ni \in w.
Li I'I > n|' I 111- rcL;iiiii. ii- \\v\\ a- lu|iii- nf i he skin, imsc, nv hiiN ii\.
is ;i \cr_v clii'imii- ili-c:i-c. It i- ,i liiri' ili-ciisc. sldwlv pniurrssivc in
clijii'iK tcr, iiihI uiiirkiil liv iiiHliihir (lc\ i'lH|iiiirni iinil iiilill liil inii. Al-
tli(in<;li in llic I;ii'^t lUiiJnriiv df in-l;in("-. Iu|iii~ ;iil;i(k> the >kiii in
lil'drrcncc In ihr inui'Dn- nicniliinnc. lii-i- iln miiii', iHi:i-inniill\ . in
wllicll the lilltcr i- thr |prinilllV M'MI nl' the (li-r;l-c.
Pathology. Ln|ni- dillVi- uiilrlv Imlli in dinic:!! irL-tmy uml
ii|i|iriii'Mncc I'lnin Inciil i u I iiTcn |u>i> ; \t\ ilic prc-fnci- nf ilw I nl)i'icli'
liiicilli in ciicli jil'ovcs llnil :i dn-c ickit iiin~lii|) exists lictwccM tluMU.
iiiid ii cliisi' invcstiiiiil inn will rc\ciil thf I'iiit n\' ;\ tulicrcnlons cnn-
,
I-'i^'. !M. I.ii|iii-. I'alMtiil ii|i|i(;ir;nicc. i After Lciiimx lirnvMif.i
ncctidti in llic niMJnriiy nf caM-. 'I'lic -nit imlalr or niic nf lite raiicial
iiillafs IS iisiia
llv the |iai1 alVi'cttd lir-i: at
III I'inlil llii- it '*-i,,\\ Iv
S|if('ai|s In the sni'l li->ilr.- n
r till' niiafviiLical walls ( \'\ix. !M ), T
(l('vdn|iin('nl is lliat nf imdnlai' t liickcniiiL;'. iicc(mii>;mic(| liy -Inw
iiicci'iitinii, the pcciiliaf IValiifc nf tlic iilcci'iilini) licin:^' that, while
there i> (Je-tnidinn n|' nininal ti--ue. ihei'e is little diiiniii' of enlnr
mil hut seaiilv ijiscliaiuc nl pus ami ihiiri
hi I.
'he process nf iileer;il inn i- aci-nnipaiiieil hy the eniupensatnrv
fdi Miiit inn of cicjit riciiil tissue, whieh. when devdnped. twists and inn-
tnrts the pliiirynx nut i^{ its natural .-liape.
This (lisciisc is randy -yinniettieal. the lesions lieinjx more cx-
(onsivc oil Olio side nf the pharynx than the other; and the nodular
infiltnition ;ihv;iys presents a ehar;U'leri-tie. viiseiihir. kiiol)l)ed, and
-«:a
•-^98
DISKASES OF THE I-II.\1{VNX.
irrc<;iiliir apiiciiniiicc. 'I'li()ii;;li snmctiincs nsMitiaird willi tiilicriiilar
(license in tlic other (ir^iiii- of tlic! Ixxly. it most rriMniciitly occurs as
iiii iiulcpciKlctit piitliolofriciil cnTidilidii ( l-'i^s. !••.' iiiid !>;}).
Etiology.- It (Mciirs iiku'c l'rc(jiiciitly in IctMiilfs tliiin in iniilos.
Wiiy tliis is the casi; is (lilli( iilt to undiTstiind -tlic icvcisi' licin^' tlic
case in tubcrcnlosis, its kindred diseiise. 'I'lic period ot' life most
subject to it is between tlie n<:es of ten and tliirty years.
A susceptibility to tuberculous invasion may possii)ly be one
cau^'c why tlic deposit of tlie liacilhw tnliereido-i> witliin the pha.'vnx
y
Fig. 92.— Lupus of lingual tonsil ('/.i-incli oJ)jt'cUve; Khrlich-Biondi
stain), (.\ftcr Lennox l!ro\.iu'.)
may lead to its proliferation there as lupus, but why it should take
on that form instead of that of the more prevalent disease, tuberculo-
sis, is the question.
What special conditions are causative of its development in any
given case are still unknown.
Symptomatology. — It is rare for lupus of the ])harynx to be recojT.
nized in the initiatory sta<j;e. as it always develops slowly and almost
without symptoms. Semon recently reported a case of extensive
lupus of the pharynx and larynx in which there had never been the
slightest pain, although the voice had been destroyed for months.
()l!0-ril.\UVN.\. 1,1 ITS.
yu'.j
SlitViicfs (if ilic thrniit iitid slu^'iiisli iiidtinii 'if tlu' |iiirts are aiiioiiL,'
the ciirlicst syiii|iln!iis. I.iittT mi iilcmitinii develops, to.^etlier witli
iiodiiliir ('iiliU'^cnuiil mid ciciitiiziition. Dc^lutilioii ami plionatinn
may Imlh ]»• interfered uitli. Wln'ii the |ial;ite i-i seriously iiivdhed.
fodd can pii-s into the naso-|iliaryiix and tlic nost' during the elVoit
of swallow in l:. Still, with iiainstakinu; ell'mt, suHicierit food ean
always he taken to sustain life.
I'niike syphilis, wlu'ii the palate is aiVecled, the hnecal instead
of the pharyniieid surface is usually the seat of the lesion when lirsL
ohserved. The a|ipearanee of lupus of the uvula is also peculiar. .\s
i.i
.A-'
lake
lulo-
lany
I'ocr.
kost
five
it he
Ihs.
I'ij.'. W.i. I.iii'us of liiif.'u;il tonsil ('/..■incli objective; Ehrlieh-Hiondi
stain). (.After I.eiiiio.'v I'.rowne.)
Lennox llrowne di'scrihos it. the end of tlie oruan is sw(dlen, with
solid infiltration, and cluh-shaped in ai)pearaii(M>.
Diagnosis. — One of the notahle features of this disease is its pro-
lonijed, chronic, non-fohrile character: tlic direct antithesis of it~ fel-
low, tuherciilar jiharyntritis. The deposit is in the form of .-mail
nodules irrcLiularly distrihnted. desfroyinLr the smooth rcjiiilarity of
the niucous nieinhrane. AVhen ulceration commences, it is always
limited and accompanied hy little dischnrire. The surface of the
nodules, as well as the ulcerations, is of a red color. As the destruc-
tive process advances, cicatricial hands form, which are readily seen
upon examination.
The pale-pray color of tuherculons ulceration should not he con-
19
A-
'Hi
ii
Hi
1- i
4.i
m
M
\irr^'-'
W-':ii
•Pi
m
ll
;?(M)
i»isi;.\si;s oi- riii; piiaiivw.
I'ouiiilcd will) lu|iii.-. 'I'lic ((iliir iiiid olijcclivc form of llir two diseases
iii'c riilircly dis>iiiiiliii', while the teiiiieious imico-]uis of the tidiei'eidar
jiroeess is (|iiile di>tiiicl fi'oiii the s<-iireely-iiuliceal)le (lisehartic of
liip'is. The eaehexiii and fevef of the one is also in strikiiit:' contrast
fo the non-fehi'ih'. noii-eaehecl ic conditioM of the other.
From fertiarv syphilis, with its hroad. deep idcei', shaip oiitliiu's,
and copious pnrnh'iit ili-char.uc, it should readily lie distinLiuislu'd.
With nia'.iLinaiil disea.-c likewise it has little in coninion. 'I'he
|iak\ tiioltlcd sui'face of canci r. with its net-i'osis of tissue, frequent
liinnoi'rlia<i'es. oll'ensi\(' disi-liar,i:('s, etc., are characlei'islic of nialiu-
nanl. lm( not (d' lupoid. di.-ca~c.
Prognosis.-- Serious and unfavoralde as thi- disea.-c always is. it
is rarely of itself fatal. It i~ u>ually. however, oidy a complication n['
lupus of the head ov face, and is siunclimcs only a pi'clude to the more
x'l'ious alVection of hipu< (d the laryuN. Still, in all ca,-es life may
he prolonged indtdinitely without appart-nt ahl)re\ iati<iii hy its
presence.
Spontaneiuis cui'o rarely, if cvci'. oceui'. ^'cI there are somc-
tiiiies. under favoralde cirenm.-laiu-cs. (pncsceni pci'iods in which for
years little proi;iess will he made, and in which ihci'e may he some
iinprovcment in symptom^, to lie lolhiwed hy a I'cturn of the onward
march of the di.-case.
Treatment.- -.\.- ihci'c i.- liltle >ccrelioii and likewi>e liiile pidn,
Jieitlu'r (dean-iiii; inu' anodyne treatment i-^ rctpni'cd in the majority
of cases. The only treatment id' any use is radical, either to remove
it altojrethcr or at least to check it.- progress.
The plan usually adopted is to scrape away as much of the dis-
eased tissue a> po,~<iliIe with a sharp spoon or curette, and then to
lirusli the lia>ic >urface fi'ecly with lactic acid, the operation or hrush-
lUil', or lioth. to he I'cpcatcd at intervals of several days while required.
.\nother method of ti'eatmcnt which has heeii ri'ccived witli a '^Doi]
deal of favor is liy the use of the Lzalvanoiaiitcry. Ivxcision, too, is
luit without its advocates. l'"i'ec cocaiiuzat ion in any case would he
necessary prior to oiieraiion.
Internal treatment hv arM'tiic. codlivi'i'-nil, iron. etc.. is als) a
iisefid adiuiiei to t
U' (iperaln e proeeilure
]|y|)oderniic injections of Koch's lymph have frecpiently heen
tried, ami the r(-ult- I'ceeivt'd with more or less enthusiasm, in the
history of many case.-: ihouuli whether permanently <joo(l results have
heen accompMshed in anv ol tiu'i
n is a mattiM' of uraw dotd)t.
I I
) a
ho
liavo
svniii.is OF riiK l'lIAl;^■^•\.
S^ I'll I Ms III' the pliiiiviiN i- mil Ky any iin'an- an iiil'rcijuciit, evciU,
and (icciirs (hiring: soiiic |iiirtinn nl' ilic lii.-imv of ihc majm'ity of casis
(if >y|iliiliiic (liM'a.-c. In rare instances it is priinai'y, in a vci'v lari;r
iiiiiiihcr sccdDilary, and in a rcrtaiii pi'iipoi'lion of ca.-cs il dcciii'- in
till' tertiary I'nrni.
Pathology. - l.e>iiin>, whether >ii|iei-ricial nr ih'e|i, are all i'\' an
inllaininatnry eharaeter, and pafiake laiLt'ely nl' the nature nf ilni.-e
that nceiir (111 the luneniis nieinliraiii' of the genital nruans, nindilied
(inly liy the -trneture and l'nnrli(in> nf the .-peeial ti~>iie n|inn uhiidi
they neelir.
When the primary di-ea.~e. m- hard cliamre, a|;iiear> in the
|iha!yii\. its usual site i.- in the |(in>il, |pre>i'nlinii' similar |iathn|iiL;;(al
lesions to those nianire-ted when il appears mi the peiii-, only thai
they ai'e of an aui^'cavated eharaeter.
'The seeondai'y tnanifestations id' >ypliilis whi(di appear in the
pharynx m.iy he id' ilill'creiit forms: I. Mryihenia or passive hyper-
icmia. 'i'hi- is of venous ehafaeler. as if the parts were eoiiiic-ted hy
(lark, s!n,L;i:i>h hlood. It does not oeeiir until two or three months
after the primary lesion. ".'. Miieoiis patehe». 'riie-e are the ino-t
fre([iieiit of the sei-onilary le-mn.-: and appeal' ahoiit the ^amc period
affcr the initial di-ra-e. In the miieons pafelie- Ihei'e is dilalalioii
of the hlood-ve>sels u\er - vm met iie;i | are;i> npuii e;ieh side (d' the -oft
palate, with elViision of serum and einhryonic cells. There is inerciM'
of cel|-prolil'(M'al ion, with exiidalion upon the -nrface, tiiviiiLi' ihe
peculiar whitish appearance which is so noticealde a I'ealnre of the
imicniis palidi .">. 'I'lie siiperlicial iih-er. This i- another ,-ccoiidary
niaiiircslation nf the pre-ciice of -yphilis; Imf, as if is frei|nenily the
result (d' iiecro-is of miicou.-- patch, it i^ not always a distinct maiii-
fcsfatioii.
'I'lie ferliary period (d' >ypliilis is marked hy \\\o development of
.iiiimmata, which rarely appear lad'oic the fourth or fifth and some-
tinu'is as liiic even as the twentieth year of the di.-ca-t'. When they
(.".1)1 )
m\
ii.
.■:i,:
i
A
•.m
DISICASKS (M- TIIK J'lIAIiVNX.
«ii
o(( ur ill till' jiliiiniix tlic dceiicr tissue's l)cci)iiic involved. 'Die jj^rowtli
forms rapiilly, iiml, liaviii^- liniitiMl vilalily, liicaks down ((iiickly.
I'atliologically it rcsenibk'S guiiuna wlierevor found, but, lieiiig situ-
ated in soft tissues, necrosis occurs earlier than when it is situated on
cutaneous surfaces. Soi'tening quickly and involving the di'eper tis-
sues, it forms the deep ulcer of tertiary disease, the deptli of ulcera-
tion being always limited by the extent of the pre-existing guniiny
deposit.
The only other pathological conditions which need be mentioned
here are those produced by cicatrization of the superlicial and dt'e|>
ulcers of syphilis. Jn tiie superlicial the cicatrici's are small, but
cliaracli'iistie, being stellate in outline, the fibres radiating from a
central mass.
In the deep the cicatrices ])r()duce extensive deformity. Tliey
are formed of dense, inelastic bands of tibroiis connective tissue.
These l)aiids undergo continual contraction, as tliougli Xatiue were
trying to draw the distant normal surfaces together. .\ot only do
cicatrices form across the lields of iilceratidii, but abi'ailcd surfaces,
as between the iialale and |u)st-]iharynx or betwei'ii the uvula and one
of the faucial pillais. will come in contact and unite, resulting in per-
manent destriK'tion of mucous inenibraiie and more or less stenosis of
the naso-pharynx.
Etiology. — Syphilis of the pharynx may arise from direct cmi-
tamination, or as the residt of secondary or tei'tiary disease in the
system. It may occur as a iirimary lesion from direct contact of an
infect(Ml siibject by kissing or Ititing; from using towels, utensils, etc.,
infected by a syphilitic ]iers(in: or from certain loathsome practices.
Max Thoriier recently reported a case of this nature, occiii'ring in a
marrieil woman, the inf"ction being direcily pi'uduced by hei' wretch
of a husband.
Secondary syj)hilis of the tlimat (H-cnr~ in the majdi'ily nf cases
i)f Cdustitntional -syphilis, folbiwing the general trend nf dcvelnpnient
of ..lis disease in the marginal mucous mcinbiaiu's. oi' niend)ranes
near the ])hysical outlets.
Tertiary lesions are ])roduecd by the constitutional disease. Tliey
are of freciuent occurrence in long-standing cases and iray arise from
live to twenty years after the original primar\ disease. Secondary and
tertiary lesions may also l)e liereilitary.
Symptomatology. — The symptoms vary materially according to
the ^taure of t!ii> disease in which tliev are manifested.
I llfV
from
and
()I{(»-I'lIAItVNX. SVl'llll.IS. 3U3
In tlie priinarv the (•]ianci(^ appears \un>\. I'rotpu'ntly ii|ioii tlio
t()ii>il. It is usually uiiilatoral, l)iit .-omotinifs may occur on Ixitii
>i(lf.-. J allien reports a ri'ceiit lase in which hilalcral chancres of tlif
tonsil occurred in a ^rirl aged H. They were caused from sueking
the nipples of a ,-yphilitic parent, ret'ently ilelivercd. The s])onjj:y,
iipeii condition of the lai'unu' of the tonsils may he the reason for the
more ready deposit of the virus in this region, hut other parts of the
mouth, the under surface of the tongue and the lip, sometimes hecome
tlie site of the disease.
The lirst symptoms are those of severe sovi' throat, with jiaiii in
swallow iiig. The tonsil heeomes swollen and I'ed. and a white ahrasion
forms, with slightly-elevatiMl eilges. Jn a I'ew ihiys the gland- <d' the
throat swell and become painful.
Seeondarv lesions, whether as ervthema or mucous naleh, are
u.-nally symmetrical. Hoth eruptions conhne themselves to the soft
palate and pillar.-, and both show a sharp line of demarkatiiui. Iti
holh there is slilVness of the throat and soreness. When the mucous
patch is |iresent there is acute sensihility, particularly in swallowing,
(.nndiments, acids, and hot ilriid<s ])rodiice sharply-distressing jiain.
Tertiary lesion.-. The symptoms attending the development of
gumma in the ])haryn\ are lai'gely mechanical, owing to interfei'ence
in deglutition and ]ili(ination. .Mihoiigh the pain may he sevi^re. it is
not sc lancinating a> in certain hivms of secondary disease. It is un-
like the socomlaiy, lno, in being unilateral at its coMimencenient.
usually attacking (Uie tnn-il with the adjacent ]iiHai's or inie .-ide id'
ihi' post-]iharyngeal wall. I»eep ulceratiDii ipiickly follows the de-
■ elopment of the gumma. It is speedy and extensive in its desirnctive
.:clion. jircsenting piiimiiKMit and ragged edges around the margin of
iic idcer.
When it remain- unarrc>ted, the destruction may be very ex-
tensive, involving the intei:riiy nf the ]ialate and destroying ''e
power of normal deglin ilion. fnnd nnd drink iinding an entrance into
the n.i.-al passage- as a consetpuMicc. 1 hemorrhage (d' a seveic (har-
acter rarely occur-. Terforatimi fn^pienlly takes i)lace.
The symptiini- ari-ing fi'nni cicatricial deformity are almost
jiUK ly (d' a mechanical chaiactcr. Xa-al sb'tmsis. from (dosnre of the
faucial isthmu- nr adhe>i(in of the palate to the pnst-pharyngeal wall,
.- nietinics occurs. Cases arc on record in which the cicatricial con-
tractions were so severe that Hie naso-pharynx was entirely cut ofF
from the (tro-pharynx, and dlheis in whiih the jialate from side to
i-:
I
ri
I*-
I', .
I I
t
t1
: J
j
H;
;5(i4
iiisi;.\si;s ()|- iiii: ni.\ uvw.
1^ 5,
side l)(Maiiir a'.liiclifd t<i the |i(i.-t-|iliiii'_vnu('iil wall. In (illicr instances
til*' palate itsflf lias lieeii Inst, irivinj;' the I'dud an e(|nal (t'lideney to
pass iiUo the iias()-j)liannx as the (esophajius. .Most of tliese del'i)rnii-
ties are irregular and of a one-sided eharaeter. 'I'hey rarely affect the
respiration when conlincd to the pharynx; hut tre(|uentiy tiie voice is
clianired iVoni the nnimal.
Diagnosis. — Chancre of the tiiii>il prc>cnt.~ the oi'dinai'y appcai'-
aiice (d' chanci'e of the pcni>. with the exception that il co\-ers a wider
area. invoUini:' the wliole of the >ni'face of the ton-il. 'I'he margin
id' the ulcer i- indurated and the .-idmiaxillary and cervical ulands
of the all'ccIcMl >ide hccoine enlai':;i'd and lender to pi'cs-ni'c. 'i'ho
.-uri'ace of the uh-ci' is j;rs" '•■" , ,i;ray. and coated with mucus. Some-
times, thonuli rai'cly. the . is small: it may then resemlde more
fully an ordinary chancre. ., dill'cr- from i:iininiat(nis ulceration in
not heiiiL;- excavated.
In syphilitii- I'rythcma the chief dia,mu)>t ic marks arc the .-;harp
line of separation from the healthy tissue, and the dark. dilTused con-
gestion (d' the mucous nu'inhranc atVeitcd hy the disease. 'I'he <oft
jialate and the faucial pillais are the part> ir-ually inv(dved. the po>t-
l)liarynx not hciiiii' touclici! hy the lcsi(m.
The muc(Mis patch is of a hlidsh-w lute c(dor. scaltercil evenly over
tile riu'lif and left sidc> of the jialate and faucial pillar-. Its line of
doniarkation is as closely drawn as that of erythema, and is one of th(>
leading diagiio-tic features. The thickening at lirsi is very slight:
])iit, if the di.-ea.-e remains long without contrid. the patch licconu's
raised ahove the -urface. the cidor more even and opaijue. ami the
margin develops a ring of hypciiemia not Ixd'ore noiiccd. In soiii(>
cases it hecomcs li>>ured. -caly. and ha'iiioi liiagic. rcsuliiuL^' in suimm'-
(icial ulceration. Superlicial ulcers are. as the name implies, shallow.
They are Usually ovoiil in form, arc -harpiv detincd. ami ha\i' little
tendency to extend.
(inmmy tunmrs are hard and id'tcn lai'Lic They are paler than
the surrounding mucosa and not very painful. The diagnosis is often
very dillicult, as they may lie ndslakeii foi' llhromatous or malignant
neoplasms. In these i-ases spccillc medication >hould etl'ectunlly
estahlisli the diagnosis.
Peep nleers of syphili- are much more readily recognized than
guniniata. The eilgcs arc sharply cut. the ulcers deep and depressed,
sometimes undercutting the snrronnding mucoiK memhrane. The
marginal aicohi is very distinct. I'ns i- profusely discharucd, aiu]
11 ' I
<)1!()-I'I1.\ KYNX. SYl'lIll.lS.
305
|llT
'H
hi
Iv
necroses (if the iilceiiiti'd ti^^^u■s is a prdiiiiiieiil feature. A> in siiper-
licial ulcer, there is little tendency to spreading- lieyoiul deline(l limits,
while at the same lime, except under specilic treatment, i-epair is
excecdiniziy slow.
'The cicatricial tissues aic rc<'();:nized i)y tlie -tellate and -np.cr-
tieial character of the roriner. and the irregular. e\ten>ive, and deoj)-
scated pharynii'ciil defoi'iuities jiroduced hy the latter.
Prognosis. — So far as life i.- concerned, it i- only in the tertiary
foitn that there is any tendency toward a fatal issue. It is. however,
one id' the most loathsome diseases and also one of the mo~t cou-
taL,^(•ll^^. :iud. if not I'clieved. productive of almo.-t life-lom;' mi-ery of
one foiiii or another. 'I"he liahility of tlu' developnu'iit of iiummata
;ind deep idci'rative pi'ocesses throULihout the dilVerent li~-ue- of the
iiody should lu'ver lie lost siuiit "f.
Treatment. — Constiluiioiuil treatment is an impoitaut factor in
dealiii.i: with this disease. aii<l slundd he carcdnlly canied out in deal-
ing' with its various forms, particularly the two later ones.
In local treatment, whether primary, -ecimdary. or ti'iiiary.
tluuoULih iiiid systematic cleansiii^' is of ihi' ureatot value. Thi- can
lie doiU' hy alkaline .frm'frles oi' spi'ays. The lattei' when applied are
the moi'c etfectual. When chancre n\' the tiii'oat e\i.~t-. dilVercnt \]}\i'H
id' treatment are recommeiii!e(| hy dill'ei'cnt author-. suh-ei|Ucnt to the
regular thi'oat-wa.-li. hut thcii' main ohjects ai'c alike. Solutions of
permanjxaiiate (d' jioiash. niti'atc of >ilver. acetate of hail, chhu'ide (d'
zini' may any of them he applied to the ulcer hy means of the cotton-
holder: or the vari(Uis form- if ioiliiu' powd(>rs — such a- iodid'orm,
iodol. aristol, etc. — may he dusted on the surface.
'I'he (piestion of reiiunal n{' the chanci'c hy cxci-i(Ui. lU' of the
liypei'trophied tonsil up(m which it may he located, i- lai'cly scrimisly
thought of miw. The virus is alieady in the >ystem when the chanci'c
is found, and the production of a larijfc raw .-ui'faci^ in the -yphilitic
throat woitld prodiu'c -ei'ious daiiL^cr of autoinfectimi.
M iicdiis I'lihli. — In tins it is hi'.:!dy impoiiani to treat nio-t
t!ior(Uii;iily. the ohject hein.i;' to desti'uy the muciui- inlill I'at ion as iMrlv
as possihie. While the ]irimary chancre is a ^eif-limited disease, tin'
mucous ]ialch. unless removed, will uo on indefinitely and may pro-
duce chrcunc throat-lesion. l"or this ther(> is no hetter remedy than
t he application of niti'ate (d' silver in strong;" s(dution. rejieated on alter-
nate days its hmo' as the ilisease lasts, cleansinj,'- sprays heiiiLi' used
during' the intervals. Of other reme(lies that nnu'ht he trieil. iodoform
m
y 1
1-^
;50(i
lUSKASKS OF Tin: I'llAKVNX.
I ■ . :«. ';
i !
m
iiiu! j:l_Vf('ri)-taiiiiiii li;i\f luith dniic irodi! (Muk. ;il~n tiiut. fcr. niiir. in
;.4yceriii, 1 ])<irl to -I. iiiiiiitt'd on the surl'iicc time times a day.
In the uh/i'i'utions, s-upeiliciiil and deep, a.- well as the gnniniy
tumor, Ijcsidcs tlie local clcansiiitf and the aiipliiatinn of tlie iodine*
compounds, already mentionetl, tlie main lliinj,'^ is to get the system
under eonslitutinnal control as ([uickly as possililo, by the admiiii —
tfaliou nf tlie iodides. Tliis treatment sluiuld lie pnrsned with zeal.
in every instance where a gnmma is discovered, with the object of its
resolntion, before ulceration- with all its destructive results — cati taki>
place.
The successful treatment o{ deformities of the pharynx arising
from tertiary syphilis is a very dillicult matter. The most CdUimon de-
formity is adhesion, all or in ]iart, of the soft ]>alate to the post-
pharyngeal wall. -Mthough tiiese adhesions may lie severed, they are
followed by renewal of the cicatrix, without special means are devised
to keep the parts open by the use of siiitalile dilators; and, as the
cases all dilTer from each otiu'r, each one must lie jiulged and treated
upon its own merits. A\'hcn extensive perforations of the palate have
taken place, obturators have sometimes been used to prevent the
passage of food into the nose or naso-pharynx.
.VCI'INOMYCOSIS.
This disease, like glanders, is peculiar td the liiglier animals; but,
instead of selecting the horse as itt; haliitat, it has chosen the bovine
race. Like glanders, too, it is communicable to man. In cattle the dis-
ea.'se is known as '*lumpy-jaw." and owes its origin to the ''ray-fungus."
it may be transmitted to man liy enntagion through an abradecl sur-
face, and from then* tarrieil by the lymph-vessels to the pharynx and
tonsils.
The implantation of the ray-fungus leads to dcvehipnient of
granulation-tunuirs, which result in inflammation, chronic suppura-
tion, and fornuition of ill-conditioned sinuses. The symptoms are thos(*
of local tumefaction and persistent purulent discharge. Tain is vari-
able and is of a heavy, aching character. Sometimes th(> disease might
be mistaken for sarcoma. 'J'he jirognosis is bad, althotigh early treat-
ment might be of some avail. Large doses of iodide of potassium are
said to have cured some cases. Nitrate of silver given internally has
also been attended with good results. In suitable cases extirpation
of diseased tissue should be ac(-omplished. (Kyle.)
\
!■ I
CJIAPTKli LVI.
SARCOMA f)F THE FAUCES.
i.' I
' ■ ■ . ' ;
1 . ' :
)Ut,
iiio
-iir-
Ulll
of
ii'ii-
ari-
-liit
^at-
arr
Tias
lion
This is a (.onipaiatively rare disease. It occurs more freiiuenlly
in the tuiLsil than in the soft palate or [lost-pliaryngeal wall, riilly ono-
liali' ol' tlie cases I'epurted liaviiii: oceiiired in tin; tonsillar region.
Pathology. — Sareouia dillVrs little in physical characteristics
wherever found. ]t has a greater tendency to localize itself than car-
cinoma, and when it develo{)s in the tonsil it grows more rapidly than
in the ]ialate or ])Ost-pharynx. When located in the ]nilato it extends
somewhat slowly and, as a rule, in a liaekward direction. In the
tonsil the spongy nature of the lymjiliatic tissues favors more rapid
growth. Infiltration becomes extensive and the disease jn'ogresses
toward the oro-jjharynx and into the deejier tissues of the neck. Be-
sides the greater rapidity of its development, in one other feature
does sarcoma of the tonsil dilfer from sarconui commencing in the
faucial regions, iind that is in it.- ("iideiicy to exti-nd through the neck
to the outside. There is no iixel rule of development, however,
wherever the disease may he located. Chiari points out that frequently
large tumors are formed in tlie pharynx, mouth, aiul upper jaw, and
the malignant growth may even extend to the larynx, orbit, and
cranial cavity, accompanied by deep and wide-spread ulceration.
Several varieties of this growth occur in the pharynx and soft
palate, though ])erha]is the most fre([uent art; what are called the
round- and s])iiulle- celled sarcomas. ('a<es of myxosarcoma, adeno-
sarcoma, lymphosarcoma, fibrosarconui, and giant-ccllcd saicoma are
also reported.
It is the small, round-celled sarcoma which occurs most fre-
(picntly in the tonsil. The cells are similar to those of the lym])hatic
glands, but their nuclei, while round, are larger. The spindle-celled
sarcomas occur very rarely in tlie tonsil, and the large, round-celled
rarely, if ever.
Etiology. — There is no definite cause known, up to the ]irescn(,
for the development of this disease, no nu'thod of ascertaining before-
hand wliy it should arise in one person and not in another, no means
W
i'i!.
30.S
DISKASKS (tl- Tin: IMIAItYNX.
Hi
ul' aiiiilvxint; ilii' s|i('ciiil cniidit ions fs.-cntial to its ronnalinii, ami
pniiilicsviiiu' (Iclinitcly \\\v (•(uiiinj: rcsiill;. Certain [prciniscs. arc. how-
over, known. l'"or instance, it occurs much more t're(|ueiitly in men
than wimirn. I'nlike careinoma it I'reiiuently alVects ehildliooil. while
it is known to occur durinir all the a.ues of mainri'd life. If there is
any preference in this matter, sarcoma of the tonsil e\hil)its a iirt'atcr
Iciidciicy to dc\clo|i dnriiiu' ihc i .\ii cMi'emes: childhood and oh! a^i'.
Symptomatology. The dcvel()|iment of sarcouia varies ^rrcatly
aceordiiiir to the situation and viruleiux^ of the disoase. in the jialalc
it may come on insidiously, and give little indication id' its presence,
until de<,dutiti(ui and phonation is interfered with. There may he
little cachexia and no Ldaiidular enlargement; hut, when the growth
is attached hy ])edicle, the mechanical presence of the dep(>nd(Mit lioily
may give rise to laryngeal symptoms.
In the tonsil the symptoms may eomc on more rapi<lly and 1)(>
earlier felt. .\t lirst it might he taken for (piinsy, hut the latter is
moi'e rapid and accompanied hy fehrilc action. As ulceration de-
velops, luvmorrhage not infrequently occurs, accompanied hy olfensive
discharges of pus and dfhris. Jn tonsillar sarconui the deep extension
nuiy pass quickly through to the outer wall of the neck, whei'e it ho.-
comes hard and nodular. Swelling of the neighhoring glands occurs,
and the cachexia of malignant disease is more readily noticeahle.
Sarcoma of the pharyngeal walls, like sarcoma of th(> palate,
seems to have less malignancy in detail than that of the tonsils,
'{'here may be less jiain, less haunorrliage, and slower develo|)nuMit.
The glands are less involved and the cachexia less marked. Still, the
geiuTal symptoms are present in ail. and each case, no matter ■nlien-
situateil, is IkudhI hy no fast rules of clinical history.
Diagnosis. — The (hief diseases from which sare(una of the fauces
has to he distinguished are adenoma, fihronia, and carcinoma. In the.
palate sarcoma has a light-reddish c(dor and is rounded or no.lnlated
in form. Jn the tonsil it may he o\' a darker red. while in the pharvnx
it may he of a still m(U'(> purplish hue and mottled in ontline. l-'rom
carcinonui it is distinguished hy the harder, almost-cartilaginous oul-
Hnes. as well as lighter color, of the more malignant disease. The
latter also spreads with greater facility, and is accom]ianied hy more
extensive glandular enlargenuuit. Sarcoma extends backward and
outward in its growth, while carcinoma usually has a forward develop-
ment.
Fibronui of the pharynx is a very rare disease, slower in develop-
I. I
(>U()-1'1IAI!YN.\. SAlii DM A.
;50i)
,ilc.
Iriils.
Mlt.
the
KTr
IICOS
iiteil
VlIX
rmn
(Htl-
hr
Kirc
laiul
|l()p-
lop-
iniMit, :iii(l uiiaiicnilnl li_v Lilaiidular -yiiipatli} . AiK'nmiia, tuo, is
-IdWiT in Ini'iiialioii ami Ic.-s likrly to iilcciati'.
'j'lii' |ins.-il)ilit_v (i| mirtakiiii:- at lirst ~i,L;lil .-arcoiiia nf tho ti>ii>il
I'or (juiiisy has alriatlv \>vvn ii'lVrrod Id, but tho lad that tho latter is
an aciito iiilhiniinatdrv discasi'. with tho attoiulinii' sviiiiitunis so i-asv
to I'ccou'iiizo, shouM at once I't'Miove all doubt.
The liacitliis ol' >aii-niiia ha- so far imt been di.-cdVcrcd ; but in
laih case, if ]K).-sibh\ a ini(!'(iM(i|iical rxauiinat inn df n minutt' si'dimi
nf tlic ueoplasin should be made, to dcuhuistiati' the prcsciue of liu'
crlN indicative of the disease.
Prognosis. — Allhouiih a very iirave di.-easc. it apjtears to bf much
111 ' auK'iiabU' t(i ii'cal incnt. whm .-ituatcd in the ]ialate or nharvnx
than when located in the tonsil. In any ■situation there is no tendency
to sjioiitaneous cure, but in tiic two I'oiincr siicccsslnl removal has
been accomplished more tfeiiui'Utly ihan in the latter, with a certain
arnonnl of immunity from future return. In the pharyn.v the lirowlh
is often pedunculated and lemovalde. in ihe tonsil the allachnient
is broad and ileep, owiiii: to the niixeil character of the tissue in-
volved. The lym]»haties cd' the ton>il li,i\e also intimate connection
with tin underlying lymphatics of the neck; this may possi!)ly ac-
count ior the ,i:reater inaliiiiiaiiey \\hen situateil in this reL:i("in.
in the palate enucleation fi.ini the >iirroundinu- tis.-ues has in a
numbei- of in>taiu-es been attended with the best residts. The dura-
tion of the disease may be bi-iwcen ,-i\ months and two or three years.
Treatment. — This uiay be divided into palliative and operative.
Of the former, cleansin.i:' washc- of an unirritatinL; and a>cp;ie char-
actc'r may be reipiir(>d to kei'p the part- free fiom nuiideiit >eci'etions.
This wiiii .-npportin,^' nu'asures is all that can lie done. (>f internal
ronu'dies, he adnnni^tration of arsenic seem- to be hehl in the higliesi
favor.
Of operative treatment, there is 110 livid inh' for the liiiidanco of
the sui\i:('oii. except the uecessity for the removal nf the I'litirc m-o-
plasm when at all possible, if the iirowth i.- pedunculated, ablation
by the snare is the best method at our command. This may be either
by the cold wire or the iralvanocautery-ecraseui'. and particularly ap-
plicable when the disease occupies the ijluirynm-al wall. A\'hen ses,-ile
lU" nucleated, excision may be necessary. It is always better to operate
directly through the moi Mi when jmssible. At otlu'r times, when the
external wall is afl'eeted. the tonsil being deeply involvt'd, lati'ral
])haryngotomy may require to b(> resortecl to. 'i'he main thing in all
It'
iil
!
\k
'< .
^;!ii
;n(i
1»I>>EASKS or Till-; |-]I.\UVN.\.
cjiiit'S is til niiikt; the dia^irno^ii jiositivo a-; early n^ pos.^ililo; and then,
if there is any i)robability of a good result, to njitrate as ilionniifhly
ns possible and without delay. As to the inetliod required, or tln'
instruments to be used, each I'ase must bo carefully considered iiiion
its own merits. 'I'lie operator should be guided l»y the liest jud:,Miu'nt,
either siii,t:ly or in eonsultalion, always remembfrim: the ii(i.-.-il)ilily of
severe hivmorrhagc, which operations in this locality are liable to
pro
ducc
Lkckoit.akia r.\i. a n.
Ibis IS a conditidii which sonictim(>s, ihuiiLrli rarely, aliects the
anterior border (d' the S(d't palate. Althouah not i arc inomato\is, it is
said to bear an intimate relation to cancerous ilisease; and. if not re-
nuncd, des(|iiamation -nay sot in, with the linal result id' the dev<'lo])-
mi']it of nialii;'nancy. .\s its name implies, it is distiniruisbed by the
development of little, white plmjiirs. v:v\'/]u;j from one or two milli-
metres to a eeiitimetii' ill iliaiueter. diH^ ;o tally dcLreneratioii of the
siii'facc-epitlieliiim.
'i'l'eatiiieiu >hoiild !:■■ local a|)plica{i<)ns rf nitrate of silver, ehromie
acid, or electrociiutery. to,<rether with the us ■ (d' mild antiseptic sprays.
Systemic tre-tment should be of a supportiiii: character.
..jl,
1
ClIArTKi; I.\ II.
( AlK INO.MA ol' 'IIIK KAICKS.
ial!
Silt MoiiiJ.r, M.\rKi:N/i i; (Iciliuil eiiri'iiioiua iti tliis rogidii as
"priiTiarv iiiali_i:na!it disease of the jjharvnx, generally oaiisin^ death
by stai'vation. Imt sdiiirtiiues iiv lia'iiKU'rhaire"' (I'ijr. !*l). At the
present time, while this dctinilitm iniLihl he ruLsidcri'd lari^ely enr-
vcet, a good deal of wi'i^ht wmiM he jilaced upon the inlltu-iiee r)l' the
toxin?, evolved from cnnemms growth, in hastening the fatal resnlt.
■^^-v...
Fip. 04- Miilifiiiant I'liitliclionia, cxtfinliiii: frdin liytit tcii-il to Imsc
of tonfTUO. (Aftfr LriuidX Urowiici
Pathology. — 'i'he ]>re\;iiling i\|ie of canecr nf the fauces, whether
in the tonsils, soft ]ialate. or jiharyngeal walls, is epithelioma. When
located in the soft palate, the history of the eases reported seems to
indicate a temleney not to spread very widely heyond the muscles of
that organ. Whatever extension does occur is usually toward the
pillars and tongue, rather than the pharyngeal tissues as in sarcoma.
Tt has been noticed, in refei'ince to this disease, that when it com-
mences in muscular structure-; it apjiears to avoid lymphatic tissues
('"11)
I
m
iiil
M
in.
..I".' DISKASKS OK TllK l'll\l!\N\.
Ill il> I'Mciii-ioii, whcrciis when il lia.- its oriiriii in lviii|ilialiL' hndics,
as ill Ihc iipii^il, It ,>|iit'a(ls iti(lisi'rimii)ati'ly to llu; surroiuuliiig tis-siios,
III! iiiatlcr wliat their ,-1 iiicliirf may lii'.
()|iiiiiniis arc (li\iilc(l as to llic i(iiii|iarativo frcciiicncy of sarcmiia
ainl carcinoiiia of tlic fauces, reiliaps the wciLrht of opiiiioii is willi
(he latlt'f. There is this diU'eieiKc, howcNci', that, while .-arcoiiia of
the throat occur- frc(|ueiitl_v duriii;;' caiiv life, careiiioina )trevail>
ihiriiij; the iiiiihlh' and hiler periods, huriii,^' iiialiire year.- the lyni-
phatii' structures of tlie tliroat undeiLiit shriukajjfe and diuiinishi'd
aetivitv, wliile the eiiithelial and eMnnrriive-ti«-n(' elenieiils retain
lij,'. fK"). .^liatilicd ('iiitlieliiJiiia di' inn-iU i _ iiK li ul)JL'c'ti\e) .
(AfttT I.cmiiix llrDwiie.)
1 '1
their aptitude for inereased dovelo|)iiieiit. If from any cause this epi-
thelial proliferation heconies siiinulatcd to an ahiioimal deijree, avc
have a condition favoi'ahle to the formation of cancerous tissue, which,
forming first superlicially, ])enclrates deeper, displacing and invading
minnal tissue as the ci)itlielial deposit increases.
Ill all parts of the fauces the development of cancer f(dlo\\s the
ordinai'y couive: rapid formation of the tumor, followed by peripheral
•ulceration and hannorrhagic discharges. When located in the lower
jiharynx, the tendency of the disease is to spread downward, involving
the (esophagus and larynx: when in the tonsil, outward ami forward
as well as toward the pillars: whili'. as said Ixd'ore, its fust develop-
(•|;n-ni \K^ V \. ( AIMINOMA.
;!i;;
llicnt iilnnii;,' the iiiiimI(> oI' llic Mill |iii!iilt' is fullnw't d liy a li'iiilfiicy
to yclf-liTiiitiition.
ilistnldiiiciilly {'pitliclin'iia (if llic jdii-ils n|i|i(ar< in twn forms:
1. 'I'liat of >li'alili('il ('|iitli(liiiiiia willi liniliriatcd proocsscs (l'"i,i:. !•")).
''. Tliat (if (•(■ll-iicst (l('Vi'l(i|iiii(nt aldii.i: the Iraik (if (lie lym|i!i-V('Ssols
Etiology. — The avcraLic aire nf pci'-mi- alllictcd \iitli carciiKUiia
(if the )iliannx is sdiiicwliat almvc llfty yi'ai->. 'This in males ami
fcniiiU's is about alike; luit hdc curidiis fact is iKiticoaUle rolativc to
the cases so far rcrorded, and thai is: while twiee as many males
have cancer of the palate and |(in.»ils as females, the reverse holds
Fip. O'la. I'^iiitluiidina slidwiiif; (('ll-ncsts ('/Vini'h (ibjectivc) .
(After I.ciiiKix l?ni\vii('.)
M
f ii
01)1-
\ve
ueli,
liny
the
leral
|)\ver
i-in<r
lard
lop-
<;ood in reference tn cancer of the lower pharynx.— nidre than two-
thirds of the cases repdrted have dccuri'ed in wcinen.
Of the various rcirions of the throat, it neciiis most fre(piently in
the tonsils, the lar;:-esl nundier oceurrin;: hetween tln^ a,ircs of forty and
fifty years.
' Ueredifary tcjidency has somethinii In do with it> developnumt.
Init how much, it is dillicult to -.ly. Ivxposnre to vicissitudes of out-
door life is also said to he a cause, as also the c.xccs.sive use of alcohol
and tobacco.
Symptomatology. — When confined to the palate, and also when it
has its origin in the jduirynjieal wall, the early symptoms are chiefly
;, .1
I
III
I i
311
DISKASKS ()|- IllK I'llAltVNX.
tlioso ol' ii iiiccliaiiiciil rliaracli r. TIiltc; may \)v ililliciilty uf .swallow-
in;: and al.-() inullled voice; hut ihcro is no level', no liyi)erseerolion
of mucus, and but little pain. On tlie other liand, when t'<e toiLsil.s
arc the seat of the disea>e, .-iiarj) and lancinalin,ij; pains aie among
tlic earliest .«}'niptoin.<. 'J'hese are felt ehielly in deL^lutitioh, and as
the disea.-e advances iiicieasi' in severity, 'i'hey I'adiate in dilVereiit
directions from tlie part airecled, hut chietly toward the ear. As the
tumor develop.- eithei- in ihe pahite or tlie pharynx, the paiii.s also
become more severe, ihoiiuh they are jimhably never so e-\erueiating
a.s ill tonsillar carcinoma. I h-eialion is usually a comparativ^dy
early symplom, and in the tniisils as well as the ])liaryn\ is mure
likely to he foUowi'd l»y iKenmri'liage than in the jialalal disease.
Increased ilow of saliva is also an early sym|iioni, the salivary
glands being stimulated to hyperseci'etion; iiein-e di'uling is often
present.
'J'lic cei\ica] glands hecnine enlarged, pai'licularly in tonsillar or
pharyngeal disease, and the early development of cancerous cachexia
is of frequent iiccui'i-cnrc,
A\'hen the tlisease is situated in the lower pharynx, its extension
lo the (esophagus and larynx interfere decidedly with b.ilh deglutition
and ])lionation, and alsn, as the disease beconies more severe, with
normal breathing.
Diagnosis. — The disea'^es of ;lie I'ances from which carcinoma
]• st be distinguished are ehielly those of saii-oma and fibi'uma. The
lailer is more rare in this r^'ginii than carcinoma. 1' is slower in
growtli, is nnattciiiliMJ by coi-slitui innaj cachexia, is pi'ddndivc of less
]iain, and is usually peilnncuhueil and t'linseipieiitly mnvabli'. On
the tirst ajipearaiice of the neoplasm, liowever, before serimis symp-
toms have had time lo (leveb']i. there may in some eases be room for
doubt; but these will soon vanish by a careful obser\ance of the
])rogress of the disease.
l'"roin sarcoma the distingni.-hing lines ai'c less clearly drawn, ex-
cept in typical cases; and it shonbl be n'lnembcred that in many
cases the imlications (»f the two diseases so overlap each (4her tiiat
withont microscoiiical examination it is almost iuipossible to arrive
at a positive conclusion.
The typical sarcoma is a soft, red, tleshy tumor, not -nueh given
to ulceration and slow in f(vming, while typical carcinoiua is harder
even than fibroma, cartilaginous to the touch, and of a Mhiti.sh-red
color and riodnlated. 'i'he cervical glands become involved early in
Il'l."
ci;i
ith
ih;i
\w
in
On
iip-
for
'X-
liiy
liat
YO
|(MI
lin
\
t)H()-l'll.\i: V.W. ( Al;i INd.MA.
ciirciiKimii. while in sarcniiia they are laic in hcciuninii .:•■'• ,c(l. In
the saiiic way the inalijiiiaiil cachi'xia is imich more early in il.s maiii-
I'estations in the Inrnier ihaii the latter.
( 'areini'iiia nt Ihe Intisil. uhiih i- ii-ii:ill\' scii'i'hn-. i~ haiihr.
w liiler, ami di
n-er Ihan -^aiciima, much mmc jiai
nl III. ninre uim'Ii 1m
(h'cn niccijil inn. nnd nmre likclv lo cxlcml. a- il lu'diiresses lowanl a
alai roiilt. inlo 1 he mill iciiinn.
hiith arc liKch'
t<i he attended iiv
a'liKM rhaLic: Im
I llial fitim >arcmna i> sn|ici1icial. while the bleedini
from carcinmna i> iiku'c lil<clv li
I lie iirtcnal.
Carcinoma of the walls of liie pharynx dill'crs I'r
oni sai'coma, even
iiioro dehnitelv than in the nliici' reiiions ol' the throat. The former
has the ordinary appeai'ance ol epithelium
1. with hmad, llattencd.
prayish, hai'd inliltration; the latter, (
lark red or i)iir|)li.-;h and
pi ilunciilated, as we
11 as sofi. 'I'
icii wjicn iik'cratKin commciiees.
which it (\in'< ipiiie early in the disease, the appearance is almost
dia,i,Miosiic. The centre id' the ,uray, elevated mass is depressed and
covered with yellowish-red seium.
i-'i'oiii adenoma, angioma, etc., Iheie ,-hould he little didiculty
in
the matter of diaLinosis, as, hesides the dill'ci'ence in clinical symp-
tom- and appearances, these diseases arc free from nicei'ation and
the general caelie.xia indicative of the graver alVeclion.
The use of the niicroscojie slio\ild in any event render the diag-
nosis inore ceiiain. Ki'(">nlein, in a hi.-tory of sixty-one cases, says
that they wei'e all tlat-celled epitheliomata, and. fd" these, fifty-six
occurred in men and only live in women. Xo hacillus of cancer lia~
.so far hccn discovered.
Prognosis.— This is always unfavorahlc in cai'dimmatous disea>i>
of tl e throat, whetlier situated in the palate, tonsil-, or pharyngeal
wall-, it is, in fact, a uniformly-fatal disease. The length of time
the |iatient may live will vary fr<ini a few m.inlh- u) (Hie or two years.
In a few eases if operated on eaily the neoplasm may he removed and
temimi'ary relief secured for the patient; hui recurrence almost in-
vnriahly takes place, and sooner or later the result will he fatal.
Treatment. --i'alliative treatment is ahnut all that is advi-ahlc
in these cases: mild washes to th(,' throat and tlie application id'
spray,'^ of cocaine to relieve tlie pain of swallowing. The spray of
menthol in alholene. '.' to 5 per cent , will also produce a grateful and
soothiuL' etTect upon tln^ pharynx and help to relieve the excruciating
pain which siumMimes attends the disease. This is |)ar(iciilarlv the
case if the menthol-spray is applied directly after the cocaine sohi-
20
i
1
>
:ll
i
;.' 1
'■■ \
i
m
w
^f -il
;n»j
niSEASKS Ol- rilK I'llAKYXX.
i' !
tion. It scorns to have tlio ciroct cf prolonging tlic action of the
hitter, and at the .-anie lime of pn'veiiiing the (le[)rcssing ell'eet whicli
the cocaine somotinies prodnces. Supporting measures in the most
palalahle form are also reipiired, for tlu,' ihiy.s of the [lalient frequently
(h'|ii'nil upon the hiiu'li: n| limr ihiriuLi' which lie i-au parial^c n\' fdml
sulliciciit to sustain life.
With I'cgard to ()pciali\e treatment, fd he efl'ecUial at all it must
he radical a- \\(ll a~ carl\ : and many eases, even if taken at the
very cunimcnceiucnt. wduld not he lit >ul)ieets for o|)eraticin. 'I'hc
(pie.-ii(in of excision in any case is a sei-inus one, and upon it the sni'-
gi'on must nse his wisest judgment. Still, cases are nn I'ecoid in
wdiieh the cancerous growth has hecn euliiily i'emii\e(l, the wound
ha< healed, ;ind fur a pi'njiinged |iei'iod tliei'c has hecn no return.
Micknlicz's case, a woman, aged (iTi. who had lieeii .-ulfeiMUg for six-
teen months, was operateil on successfully hy an external lalerid
operation; two and a half years later there was no relui'ii. Dupage,
fdllowing Mickulic/V mellmd of lateral phaiwugntomy, operated suc-
i-essfully upon ihi'ee ca>e>. whicli ai'e all .-aid tn have he;ii cured.
allluuiLih the intervals Itetwcen the operations niid the re[>oit are n(u
gi\en. In {''errai'dV case, aged Tl, the gi'owtli was i'emovt<l from the
palate hy knife operation, and fi\(> years laler there had heeii no re-
tlll'll. 'I'lioe are execpticill.- to the LlCllcral |-llle.
It may he laid down a- a reasonahlc c(uielu>i(ni that in all cases
wliei'e the cancei'im> cacliex^ i ha> hecnme develop( d, radical oper-
ations should not lie undertaken. Cases may occur, however, in wdiich,
although a speedily fatal result is ceitr.iii, the malignant mass may so
ohstruct respiration or (h'glulition that a removal of part of it may
gi\'e temporally ea-e. Menzes, of .\msterdaiii. repents a case of this
kind. .\ l.o .;(' (•ancerou> mas< w as gi'ow ing from the I'iiiiit pharyngeal
wall, prodiicim: (<miplete nasal stenosis. lie removed if hy (Jott-
stein's curette, alldi'ding, for a time, con.plite relief to the patient.
In cases of this kind itperatieni would he hoih jusiillahle and laudahde.
When, on ihc other hand, caclie\ia is not noticeahle, the growth
is acces^ihle, ami there is a fair pro>[iect id' eradicating the tumor in
its entirety, it is usually advisalde to operate. The method must he
governed hy the cin iim.-tances of the case, together with the apti-
tude and experience of the operator.
If the intrapharyngeal o])eratioii can lie accomplished snccess-
fnlly, either hy snare, galvanocautery. or knife, it is to be preferrerl
to the larger operation hy external excision. Still, each case must
ORO-r II AK V N X . ( A]{C IN OM A .
3ir
I may
thiV
Ltt-
licnt.
Ible.
bwth
Ir in
t 1)0
lipti-
poss-
Irrccl
luist
be judged on its own merits, tlie wurk l)eing aceoinjili.-!ied in aceord-
ancc witli tlic \v('ll-('>liil)li>lied rules of surgical procedure.
K\l('. (uir niii.-i riniii millKU'ity. in hi- work ju>t published dwells
U])iin the diircrentiiition w!;ich exists in iliis r;irc disease. Tie say.-:
"If tile earcinoiua be of the epit h''lial variety, the i;i'n\\th is soft, ami
spoiii^y in eliaraeter; or, if of tlie seirrhus variety, it begins as a liard
irregnhuiy-nut lined nuiss. Tn oitlier form, early in the gruwili tin;
nnieous-membrane surface is fairly inirmal in appeaiance; but with
idecijitinn this is entirely lost. The cei'vical gland- are invulve'l, niid
in the seirrhus xai'iety this involvement t.akes place early. It' the
growth occurs low down in the pharynx and is limited to the posterior
surl'a'c it is more often of the fungoid chaiaeter. it is very irregular
in outline, and the surrounding structures are -udllen almost to the
point of being (r'demalniis. In huv involvenuMii of the pharynx there
is not such marked imjilieation of the cervical irlands.""
I
CIIAI'TI-.K LVIll.
NKl KO.SKS OF IIIE TAUCKS.
l)rsoiii)i:i;i:n >on.-iliility nT ;lic ti'iiuinal liliiiiK'nts of the nerves
of tlu! [iliaryiix are imt nl' inrici[iionl (iccurreiir-e. 'J'licy may be
divideil iiilo neiim-i.- of ^L'li.-alinii and iicurnsis (if nidtioii.
Ill;
1 ;
I' i
N i:i iio'-i;- i»i' Si:\<Ariii\.
Xi'iini.-i- iif .-('iisaliitii may he jtre.-eiil in the t'orin (d' aiia'^llie^ia,
hyll^^a^-lhe^ia. ni' para-t hc-ia. ami (K-ca.-innaily a> iieiiral.iiia. 'I'he lir.<t
is (d' \\\\\^' mnmciit. wilhnin ii i> a.-sucaaied with paraly.-is, oT which it
may he a sym|iliiiii. W hcii (McinTiiii;- alone it I'aicly calls U>v Ireat-
inont'. I'os.-ihiy the administratinii df -li-ycliniiie and tlii' apjjiicaiion
of ji'alvanisni may lie nf hcndit.
ITy|)cra'.*thf~ia and ]iaiwsllKvsia (d' tlie jihai'ynx are practically
synonymnns trrm>. and indicate over-ensitiveness of the miici)ns ineni-
hrane, tlioniih tlic Ihihk ]■ i> ii>iially ajiplied to touch, and the latter
to the fcclinti' (d' prickini:- and irritation which .sometimes exists with-
out aj)parently adequate cause. This is ])articularly liable to occur
in liystci'ical wnmcn. .\> a rule, the palate i- more .sensitive than any
other part nf the ihrnat. 1 have nm- male ))atient. however, aged 35,
who has |'(ir years bei'n under treatini'Ut. u(]' and (ui. for atropliic
rhiniti.*: but in his case the sensitive i>art is the base of the tongue.
He cannot bear the slightest jiressuic upon it, without producing
retching, although any dthei' part of the ihrual can bo touclied with
impnnily. l-"ven the application id' ei laine i- without coiUroUing
etl'ect; the e(jnsequenee is that in his caie the use nf a tongue-
depressor is always (mt of the ipiestion. Tn tlic majority of instances
pharyngeal hypera'sthesia nwes its origin to some local lesion the
removal of which woidil relieve the annoying symijloms.
Neuralgia of (he idiarynx i- usually unilateral and may owe iis
origin either to a local nuu'bid condition or to sonu' form of an;x'mia.
Tt is not, as a rule, associated with hysteria. IJemoval of any exist-
ing local lesion or tonsillar conendion, together with the adminis-
tration of systeune tonics, such as ipiinine, iron, arsenic, or -trychnine,
would seem to be the best treatment.
jilfifii
• I';
OKO-rjIAKYN \'. I'AHAl.VSIS OF llli; FAICIIS.
lilt)
S|ia.-iii (iT the |)liiii'3ii.\ i^ nut n\' iiiriLH|iitiii m (•nirciie.'. IL iiuiy
ari.-o I'lciii (.'Iniiiiiuiuii or (I'lluma nf ilic uvulii. aruii' iiliarviiLi'iti-^. ap-
plicalion of local ii'vitaiiis, ( ic. ( 'hiu'iiii/hi ainl Mai^iiau relate cases
arising rroin labcs, wliicli wore al nice cured liy .-riispensioii. 'i'licy
l)olievo that tlie i)!iarynL:eal ^pa^^lll:^ are inlliieiuetl by central or pc-
riplieral lesion.-. Spasm of tlie piiarynx is [uoduced I>y liydropliohia
and also by tetanus, lieini;' in eacli ca^c a -yniptuni of sy.-temic disea.-o.
The pai'l usually alTectcd i.s the sufl palate, the levalm' palati heinu'
the nin.sclc ordinarily insolved in eaj-es oi' chnrea alTectcd liy ])haryn-
gcal spasm. In snnie ca^es the con.-lrictur mu-chs ai'c all eqnaliy
involved.
HSMM
le.
UK
le-
•es
le
PAUATA'SIS OF 'IHi; FAUCES.
One of the most conimnn t'orins df throat; paralysis is that iii
which it occnrs as a sequel to diphtheria. It ha- he. w known al.-o
to follow acute lacunar !on-illitis. In these" cases ihci'e is little doidit
that the disease is of central origin, arisin^i' from the cU'ects nf the
toxins of diphtheria upon the nerve-centre-, in tin's aU'ection the
voice a-sunies a quackinu' oi- nasal iwani:'. ii liecduies impo-sihlc in
some oases to render tense the levatni' palati niu-clcs so a- to close tiio
nasd-pharynx fi'mn llu' Driiqiharynx. ('(iiise(|iicnt ly. in aUemptin;:" to
swalhiw, ilie fciiiil will frri|iiriil ly ]ia>s into the vault almve. In other
instances, the pharynu'i'al enn.-trictors liavinu' hi>| their )>ower of eon-
traetion, ordinary deulnlition becomes imjiossibh', and the patient is
obliLi'cd to force the food downward oiit of the oroqiharynx by iillinij,'
bis mouth with llnid and then aidinir the proci><- by the compression
of the oral muscles.
In th(v-e cases, -innlar treatment to that ]M-eseribed for ana's-
thesia of the ]iharynx. the u-e of nerve-tonics, and tlu; application of
elect ricity may be tried; but they are often nnavailiiiLT. Weeks jtas.s
avay witliont apparent improvement; then the recuperative power
of Nature slowly asserts itself, and the normal function is Liradually
restored.
Sometime- paralysis of the palate accompanies facial paralysis.
It is then nnilateral. Xo special treatment i.-; required.
!Myo])athic paralysis occurs in some morbid condition^ of the
mu.=cnlar fibres. Whether tliis is really the -(\Tt of the lesion, or
whether tlu' ]iaralysis of eerfain muscles ari-^e- from an abnormal
1|,; 11
ir !
I
I : ^f
1]2{J
DISKASKiS Ol' TIIK I'llAHYNX.
'■ M ■
condition of llie pnuillor ncrve!« or nervc-lilanicnts. is still a matter of
([Ui'Ftion. Soniotinics ouu gronj) of niu.-^i'lcs niiiy bo aireetod, sonie-
timos another; tlio allVction may be cillier unilateral or bilateral.
]'alato-glo8so-pharynj.'eal jiaralysis is one (if the symptoms of
])rogressiv(! l)ulbar paralysis. Jt arises from an anivmie condition of
the mednlla. it is rarely met with hefore the age of forty years. All
the nerves su].']ilying the muscles of deglutition and artieidation may
he involved. The gl(issi)-]iharyngeal, hyi)oglossal, facial, spimil ac-
cessory, and trigeminus, all having their origin in the medulla, may
be alfectcd in this disease. As a rule, tlie mahuly alfocts the t(Uigm;
first, then the lips, palate, and pharynx.
As its name iuiplics. it is progressive, slowly but steadily ad-
vancing toward a fatal issui'. Marly in the disease there is indistinct-
iH'SS of s])eeeli: dyspliagia also is an early symptom. These steadily
advance until articulation becomes unintelligible ajid deglutition im-
])ossil»le. AN'asting and misery beconu' extrenu^ and the patient suc-
cund)s.
Acute bulbar ]iaralysis nuiy also occur. It is exceedingly rare,
and dill'ers little from the ]ireceding, except in the rapidity of the
progress of the symptom? and the speedy termination of life.
In trcatmcni of either little can be done; and that little is con-
fined to tlu' relief of concurrent symptoms, based on the general
{U'inciples of tliera|ieuiics.
CllAPTKR LIX.
FOHKHiN liODIKS IN TIIK FAUCKS.
ONSII.l.l IMS.
In (•onncclioii with this suhji'd a wni'd ini^lit he said ahmit the
eoncrt'tions or calnireoiis deposits which arc snuictiiiics i'oi'iiicd within
the laeniiai, or crypts, of tlic tonsils. In certain inilaniniatory condi-
tifiup, Avliicli dnriiiij middU* aire tend to in'odiicc cdnncctive-tissiic
liyporphisia. the mouths of tlic eryiJls niay hcconic ch)scd, and the re-
tained secretion iii-pissated, until in time calcidus is lornied. It is
(loubli'ul. however, whether this can occur without tlie pi'evious do-
])osit within the crypt of sonic sniall loi-ciun hody. wliich. as in the
ease of the rliinolith, liecouies tlie nuch'us ai'ound which the con-
cretion gradually forms. 'J'hese ealeuli were at one tinu' cousidered
to arise from a gonly ad'eetion of the pharynx. This theory has
latterly l)cen discarded, as repealed e.xainiiuitioiis of the tonsillar cal-
culi have alway.s ])ro\cd them to consist of ])liosphate and ear])onate
of lime instead (d' urates. The symptom- are similai' to those of coni-
nu'iicing ([uin.^y. Sometimes the diagnosis is a little dillicult, owing
to the conlpletenes^: with which the foreign Imdy is cuvcred. }'a]pa-
tion and probe exannnation should rcnmve iiU douht. Still, instances
have occurred in which the coiu'retion wa> not su.-pecteil. until it
was grasped liy the tonsillotomi'. 'I'reatnu'iit consists in I'cinoving
tlie calculus hy means of the forceps, or. when nece>-aiy. incision
with bistoury in order to make extracti(Hi po^siiile. ami then I'cuioval
with forceps oi' spoon. The use of a cleansing wa>h would he all the
after-treatment rei|nired.
In the issue for dannary T. ISIM). id' the lirilisli Mnliral .luiininl,
Aitchison TJohertson gives the history (d' the largi-st tonsillar ealcnin.s
on record. It was shaped somewhat like an egg. Its greatest leniith
was 4.4 centimetres ami greatest breadth ;>.S cent imetics. The weisrht
was 2(5.8 yrainmes. The age of the ]iatient was .")i» years, ami its
]iresence was never discovered until it wa- expelU'd by violent cough-
ing during a snlTocative attack which occurred about the middle of
i.Hiiii
i
1
3-^;
i>i.-i:.\m:.s of iiii; i-iiakynx.
lU-
i,
till' iii.Lilit. It caiiu: I'l'Diii tlic liulil tiiD-il. 'I'liero wa.- no liaMnnrilin;ie,
lii:| a lai-c cavily iiiarkid ilic >iU' dt iis I'oniiatioii. It was pale yul-
]u\v ill ciiloi'. hail a wonn-fati'ii a|)[a'araiico. and while fresh hail a
>I li'li'j' (uliir I I'i;^. !H1).
]''uifi;ii;N' i'oniKs.
I''iiri'ii:ii linilio ai'r ntlrii Imli^rij ill the iiliai'viix rrniii witlinni.
Tlivy are vriy ilivir.M' in rharaclcr, cnnsi.>tinij; of siwh siiljstancrs as
pieces (if iiH'af. t'rau'im'iit^ ni' lidno, false teelli. liiiltnns. coins, pins,
iieedli"^. etc. Small, jmintcd l)ndies are apt to heeonic fixed in the
lonsils or pli;iryni:eal walls or about tlu' top of tlu? larynx. Larixer
liodies. riiiinil or sipiare in mil line, arc more likely to he Iodised in
the lo\v(-r pharynx or in one of the i>yrifonn sinuses or hetween the
tongue and epi,L:lottis. Occa.-ionally the ell'ect of Xature to expel the
foreii^ii hody hy spasmodic (laiuhing results in throwing it forcildy
into the naso-ohaiviix, where ii mav either remain lodircd or he airain
cxpell(>d.
11,
I'ig. 'JO.— i;iilKHsiiir~ (■aliulus iVoiii iij,'lit tonsil; weight,
2G.JS i^raimiics. Ailnal si/c.
h : !
Tin; sympionis produced hy i'orei,i.;n bodies in the pharynx arc
freipiciiily di>ire.->in,L:-. I (e.ulutitinn may he seriously interfered with
or e\en suspended. Sc\cral years a,i:o 1 removed a needle from the
lower part of a woman's pharynx which had heen lodiii'd there trans-
versely for twelve hours, during which tinn? she had heen entirely
nnahle to swallow anything, not even fluids. There is no douht in
this ease that the inability was partly voluntary, owing to the pain
which the en'ort ju'oiliieed. Hard substances may loilge in the pyri-
oiiM-i'ii A i!VN \. iiM;i;iti.\ r.itiUKS
•3-r>
I'niiii siiiii.-, ami [irodiici' piiiii in tin' hileral regions of the lower
plKsrynv, as well as inleilere with .-wallowing.
W'Ih 11 the foreign body is located in the oro-pharynx, it may he
oliserved in many eases l>y dinet light; hut, in the majority of in-
stances, the use of rcllected light and a throat-mirror will he reciuired.
In all doubtful cases the exannnation slunild bo as thorough as |ios-
sil)le, and, if the mirror fail.- to rcvi-al anything, digital p.\[)loration
may he resorted to. to make iIk; diagnosis ceilain.
The liistory of the case, togulher with tlo' syin|itnnis niul tlioroiigh
inspection, will usually make the nature and position of the object
clear. When still in doiibi. ilic ii.-c nf thf sciagraph should remove
all remaining um riiainl \ . It niu.-t br miieiiibered, huwever, that
not oidy iiiay the pri'-eiicc of a foreign Imdy in the pharynx be im-
aginary, but also that e\rn iIp- ri'mo\iil or expulsion ol' the foreign
liody ina\' be followe(| lu|- wiik- or even nioiith- afterward with the
iiiipir-.-i(in in the mind of tlic patient thai it is -^till in the old posi-
tion. 'This is part ieiilarly likely to oiciir wlun the subjects are
by-lerical wonieii.
Prognosis,- "This varies according to the nature and position of
the object. Sharp pieces of metal or bono may (hi =erious harm.
They have been known to peiielrate the blood-vessels of the neck
and produce death by ha'inorrliage. In otli(>r in-tantes they have fre-
quently fouml their way into the tissues of tln' neck, and been ex-
tracted from situations far removed from the point of entry. Tvarge
bodies have become impacted, and have prodneed a fatal result, by
ulcerating through the ])haryngeal walls and iiidiieing pyannia.
In the majority of case-, however, tliev mav lie removed with
more or less facility, and
pharyngeal walls.
\\ \\ hoiii !eii\ iii'j an\ -<
rioii- ell'eet ii|)on the
Treatment. — This consists simply in removing the foreign body
as gently as ]iossil)le, and with a minimum of injury to the surround-
ing tissues. To accompli-h this, as a rule, we need a good reflected
light, the throat-mirror, and forceps to suit the position and nature
of the object. The finirer, in exploration as well as removal, is often
of groat assistance. Some objects, such as pins, may ho grasped be-
tween the finger and the miil. in not a few instances, and their removal
eifected. In some cases the curette will be of service, and in others
the snare; while in still anoflu'r class the careful insertion of the
coin-catcher or the umbrella-bougie into the upper part of the oesoph-
agus will result in lifting the olij(>ci directly into the outer air.
ill.!
■ 'i
■ U
. I
1 (,-
Ml
«
1
;}2-i
DISKASKS OF 'I UK I'lIAKYN X.
After the removal no otlier tn'iitiiu'iit i.s recjuireil, except tlie
wariiiiii,' to tlie patient that lor sninr time the impression may remain
that the foreign body is still wiliiin the pharynx.
Wlien tlie obstruetion seriously interfi-res with respiration, and
eannot at the time Ix' remnved. traeliedtniny may he called for, resort
being made to further ed'orts after the artificial breathing has been
established.
•r
SHfTION III.
Diseases of the Larynx.
hi
■ I If
.1^
I
1
u
i!
i
i i,|ji
M
i'i
m
\\'
11
IIIAITKK LX,
AN'AI'OMV <•!•■ TlIK I.MiVNX,
I'ol! till' iiiiiiiiU' aiialdiiiv ol' tlio larynx llif nailti iiiii-i ho le-
rern.'d to tlie doscriptioiis ol" iiiiiix' t'lal)oralt' tuxl-lxinks. liiioii';!!,
liowi'Scr, (if the ;,M'nci.il aiKilinny may l»c !;i\rii lu iiidirati' iiii|HirtaiU
points, \vitli(jut till' l\ii(iu Ifd^i' 1)1' uliiili It uiiiilil Itc iiu|)()ssilili' In in'al
clVt'ftiially (lioeatios ol' this oriraii.
Thi.s cniiipjicatod or;;aii may ho ooiisidcrod as an c'.\|iaii.-ioii of
the trachea. It lii's hoiwccii the hyoid hoiio ahove and tln' liaclica
below. The lowtT phaiynx and the cntiancc to the (osopliauus lie
behind it, and the skin and superlic-ial ti.ssuos cover it in front. On
each si(K' aic the j^rcat vessels and nerves and it is eonneeted with
the adjacent i)arts by nniscles and ligaments.
15eliind tlie laryn.v, from the tip (d' the ei)i<,dottis to tlie lower bor-
der of the cricoid, lie the third, fourth, fifth, and sometimes the sixtli
cervical vertebnx); that is, when the organ is in a stationary position.
During phonation and deglutition, particularly the latter, it makes
notable excursions in au upward direction.
The larynx is the entrance-door to the lungs, and allows the freest
passage of air during the acts of in>piration ami expiration. 'The other
chief function of the larynx is that of phonation.
'J'he larynx is composed of five jirincijjal cartilages: the thyroid,
the cricoid, the epiglottis, and the two arytenoids. There are also four
sup])lementary cartilages: the two of Santorini and the two of Wris-
berg (Fig. <J7).
The cricoid, or ring, cartilage is the foundation of tlie larynx.
It rests directly upon the trachea. It is formed like a seal ring, the
small, rounded, curved portion being in front, and the enlarged, thick-
ened, seal division being beliind. On tlu' upper surface of the back
])art are two large facets for articulation with the arytenoids, and on
the outer portions of the same surface two smaller depressions for
articulation with the inferior corTiua of the thyroid cartilage (Figs.
98 and 1)9).
The nnder surface is attached by rd)rous tissue to the upper ring
of the trachea.
(327)
328
DISKASKS (>|- TIIK I.AUY.VX.
T]iG thyroid cartilage is sliiold-i^liapcd, and fo.ms the hirgest por-
tion of the laryngeal friiiiie-work. ft i.s composed of two .=ynimc(rical,
_ .-.■'.ii*
Fig. OT.—TIic cjirliliicriiio-.is friiinc nf Mic luiyiix, willi tlie liyoid l)oiio
and ligaiiiontous aitacliiiiciits (liroca). .(, llynid bone, li, It, 'I'lio grcalcr
coiiiua of tho hyoid. C. r. 'llic lesser coriiiia of the liyoid. /), Kpiglotlis.
/'-', Tliyroid eartilago. /•', /•'. 'Iii<. superior cdrnua of (ho thyroid. (/, 'I he
lesser cornu of Ihe (liyroid. //. ("ricoid cartilafre. 1. Thyro epi;,rl,itlie ]ign-
nicr . 2, iryo-epifrlotUc ligament. ;!. I.atx'ral thyrohyoid ligament. 4,
Median cricothyroid ligament. 5. Lateral crico*liyn>i''. ligament. (After
riosworth.)
ANA roM^ .
32!)
l'oiir-?i(k'(l [ilates, miitod togcllicr in front, at an aiig'lo of about ninety
(Icfrrccs (V\ix. ]ii(i). 'I'licy form the front and lateral walls of the
hirvnx. and, o\\ inu' to their staliility. arc a diiot protection to the deli-
c-!ite >liiiilin(^ eoiilaincil within tlir (W^aii. 'I he union of the two
|ilatrs sei'ves for the attaciinirni d' thr i-i'icnthyi'nid nimdiranc at iIh'
KiiT. !'^. Ill" riiii'iil. -(Ml inilii lolly ilii'dcn). 1, Aiilcrior porlion,
2, I'ostcridi' pditimi. 3, lii(ciii;il -mliui', 1, Sii]i('i inr circuniferetiii'. a, lii-
t'ciinr bonier. (Al'ftT liosw intli. i
lower iiiarLiin. At the ii|i|i(i' inai-in nl iiiuon there is a deep aeute
an.ii'le. railed the thyroid notch, into which is attaclicd the petiolns of
the epiijlottis. I'rojeef i,<r ]h rpendic iilarly from the ])osterior mnrnin
<d' eacli ])late. one dnwnwnrd and the other upward, are two horns, or
l''ig, !l!l.- Tlic cricdid, U|iiiti- .^uila.". 1, I. Avticiihir facets fot tlic
iU'ytoiuiid ciirtiiiipc fi. (Alter lie^wdrtli.)
coi'iiiia, the npjier one on each side heiiiL;' attaclicd to the hyoid hone,
and the lower one o.i each side to tin' cricoid eartilaiie.
The arytenoids are little, eone-shaped. movahle liodies. standinj.;
ereet upon the lateral facets of the erie .id already described. I'lieir
internal faces arc nearly paralhd willi eaeli other. At their sumnuls
are attached the two little eartihures df Santorini. External to and
330
DISICASKS Of I'lIK J.AltYNX.
ill Front of the Juttoi, and situated at the eoiiimenefmont of the ary-
i']ii.i;loUic fold are the little, >-teni-like earlihiges of Wrisherg (Figs.
JnOtt and lOOi).
Tlie epiglultis is a fihrocartihigi' and said lo he simped like a leaf.
\h'
fl-..^^
Fii^. 1(10. - 'I'lii' < ri(<)tli\ idid iiiu--ili'. Nicwcd Miitrridily ^l?^oca). A,
llyoid 1)0110. yy, 'I li\ idid ciu 1 il!i<.'('. ('. riiynili\ (jid iiiciiibriUio. /), Cricoid
carlilajjc. JJ, (licotlix roid ni'inlnaiir. /'. 'IiucIkii. I, 1, Cricothyroid
muscle. 2, 2. Origin of tlii> musrlc fruiii llic anterior portion and side of
the cricoid. .'?, .T. Tii-ritioii into ijic lower hordci of (he thyroid. (After
Jioswortii.)
ANATOMY.
'6'3\
■y-
It varich iiinrc in I'miii than any uiIkt nr^an nl' the \>in\\\ iml cvni
C'xchi(lin<r tlif nll^(^ h slainis iinniciliatcly aliovc the tliyroiil, with
its (ipcii i'acc hackwaril. ami is atladn'il hy ii> pedicle m- petioliis t(i
the snperiur nntch of the thyroid.
As !i ride, the e|iiL;|niti- ((eenpies nmie (ir less of ii vertical po.-i-
lion. The anterioj- -nil'ac!.' i> e(in\e\. oi' somewhat sadille-sliapod I'roin
side to side, and eoiieave j'l'oni aliose ihiwnwai'd. These outline- vary
in ditiei'ent (■ase>. -ind in extienie (•a>e.- may even he the re\er-e ,,f i\\,-
ordinary rnje. The tio-ieiior >nil'aee i> >liL;hllv concave from side to
i<'. IIM)(/.
I'ii:. Inn').
Fif,'. lOlla. Till' \(iirfli(i\, <ir lMr_\ti\, -^rcii iiiim lirhiiiil. 1, li, Itin^'
<':utilii'.'('. ."i, 4, I'viiiinid imum Ic .'> mik! (i. shield. 7 ami S, 'riiii^^uc'-ljoiic.
1) ,111(1 \'l. ( art 11 ;i ;,'('« of Santoilni. lo and I.'!, t artilaL'is of W'l i>l)cr<.'. II.
14, 1;'), l.id. I(i, WiiKlpipi'. 17, ( ii>liioii of \\\r lid. IS and lit, Hack riiif,'
jyyriiinid nnwclc--. 20, 21 and 22, 2:{, ( cinst i ii lurs (jf the vcstilmli'. (Alter
I.cniio.v l!i(i\\n('.i
V\^. 10U6. — N'ii'w of the voicchox, or larynx, cut o|]cii from hcliiiid.
1, 2, \Uurr cartilafic ■"{, 4, I'yrainid muscle. ,') and (i, X'ocal li^^ameiil^.
5, (J, 7, 8, EntraiK'ca to the pockets. 7 and 8, Poiket lij;aiiients. !), 10,
Cartilapes of Sautoriiii. 11 and 12, ('artilajres of W'rislieifj. 11, 12 and
1.'}, 14. Ary(']ii<;lottiL' foULs. 15, l.id. 10, Windpipe. 17, Cushion of the
lid. IS and Id. I'rop curtilajres. (After Lennox Hrowiie.)
31 A.
I 1
m^
;53-.'
IHSKASKS or Tin; LAUYNX.
side, iiml in sdinc instnnccs deeply (■diiciive. like tlie loim diiiiiieter of
llie hidt'-sectioii of 11 lljittciicd (ul)c. lictwccn tlic^e two every variety
(if rmiiiiition may he IoiiikI. the two sides in each ease lieiii;:-. id' course,
syimnetrieal ( l-'iir. l(»l ).
The e|ii,ul(ptlis is atlaehed to the inner ^ur^aee (d' the iKiteli of the
¥]<:. lol. '] lie iir_\ teiKiiil Mill] ]iesttii<ii- rri< ii;nyt('iiiM<l imiaclos
iBrocal. .1. Ilyoid Imiic. /}. /{, I'ostcrinr Ixmlcr of llic thyroid. ('. Vo>i-
tcri<ir fiKL' of cricoid. /). />. I'oxli rjor ImikIci- of the iirvtc old. /■;. Kpi-
^'lotti>. /•'. /■', Arycpiylottic folds, tl. Trachea. 1. .Arytenoid nmscle. 2, 3,
Oblique films of same. 4. 4. Cricoarytenoid posterior muscles. T), 5, Their
insertion in the outer aiifjle of the lias<. of the arytenoid cartilage. (After
JJoswortli.)
ANATOMY.
3;?;?
thyroid l)y a firm hand oi' (.'iastic tissue; ulicii iinniiincnt. it is cnhcd
the cushion of tho epiglottis. 'I'hc upper margin (d' this organ rises
al)Ove the liase of the tongue, to which it is attaclied in the Iroiit and
the two sides hy the gh)sso-e])ighitlie UAt\< nf mucous jueudiraiu'.
In structure the thyroid, cricoid, and aryti'ni)i<i caitihiges are
liyaiiiu', and in ohl age liave a tench'ucy tn cahil'y. 'i'lte o|iigh)ttis and
tlie cartihigcs ol' Siinlorini and Wrisherg are I'drmed ot llhrocarlilage,
ami show no ieii(h'iic\ to calcilicatidii.
The ligaments n{' the larynx are (I) cxtrin-ic-. (".') iiiti'in-ic. (;>)
mixed. There ni'e llii'ee ihyrdhyoid ligament>: the mc<liiiii and the
two lateral. The median one i~ a memiii'ane (if ela-tic tis-ue, attached
to the posteriiir Imi'dcr nf the hyoid hone ahove anil the upper margin
of the thyroid cartilage iielow. The two lateral thyrohyoid ligaments
are cylindi'ical masses of lihro-clast ic tis>uc. couuccting the superior
(■(U'lina of the ihyi'oid cartilage with the grcatci' corniia of the hyoid
hone, r.etwcen these ligaments and the central mcudu-ane theie is a
thin layer of (ihroiis tissue. The cricotracheal liganu'Ut is a liand i>\'
tilii-o-elastic tissue connecting the lowci- hordei' of the cricoid to tho
upper ring of the trachea.
The intrinsic ligaments arc the cricothyroid, the cricoarytenoid,
the su])eri(ir thyroaryteuoi<l, and the inferior thyidarytenoid oi- vocal
cords.
'J"he cricothyroid is a hand of elastic menduane i-oni\ccting the
two cartilages at the cricothyroid notch, and can lie felt in front (d'
the neck just helow tho prominence known as Adam's apple.
Tho cricoarytenoid ligaments are capsular, ^utfounding the crico-
arytenoid joints (Ui eith(>r side.
The superior thyroarytenoid liganu'iits form the \entric iilar hands,
or false cords. •
The infei'iiu' thyroarytenoid liganu'Uts. or tnu' vocal conls. are
tho most essential and important structures of the larynx. They are
formed of strong hands of ycdlow. elastic tis-ue. They extend \'vou\
the inner surface (d' the thyroid angle directly hackward to the )H'o-
cessus vocalis. oi' the projc(tinir angles i\\' the arytenoid.-, flach vocal
cord is insertetl as a single haml at it- anterim' c\irenuty. This splits
up into three hands as it extends hackward. Tlu' first is inserted into
the vocal proc(>ss of the arytenoid, the second is iuM'ited iido the ante-
rior face of the «ame lartilagc as higii uj) as the ventricular hand, and
the third is inserted into the cricoarytenoid capsular ligament. A
cross-section of the vocal cord shows that it is trianiridar. the api^x, or
;{l^^
m
^
331
DISKASKS DK I'lIK l.AUV.NX.
Iponlcr-lijie, lu.'iiig tunii'd toward its I'ellow of tlie opposite side (Fig.
In \ho adult male the vocal i'()rd has an average length nf '^ ', '„
con timet res and in thea<lull female 1 ■\\ oentimetres. The vocal cords
are covered with iniicoua jnenibrane, and the lihres ot the thyro-
arytenoid mns( Ic unite with their onter margins, making a large ])or-
tion of their >uli-liince.
'I'lie (iiily luixed ligament is (he epiglnttic. ((insisting of two ])()r-
tions, the outer and the inner, 'i'he onter connects the epiglottis with
the root of the tongue and the hyoid hone. The inner, or thyroe]ii-
r I:
Fig. 102.— Side-view (it the hii\ii\, sIkjw iiij,' Uie IiUeridr. tlie ri^'lil
plato of llie tlyi'did lieiii^f 'I'eiiKived. 1. 2, Ai\ U iKiid eiiitihijfcs. ;{, ■'!,
ri(H'e.s.si Vdeale;^ of tlie arytenoids. 4, rroce.ssus iinisiuliis of tlie right aryl-
onoid. i"). Ipiier liorder of eiicoid. ;i, .'!, 0, \'oeal ci/iib. 7, Faeel for
artieuhitioii of the tliyroid v\itii the ciieoid. S, Left plato of ilie thyroid.
!), J.efL siii)eri(ir cormi of thyroid. lU, Cricoid cartilage. 11, Trachea.
(After Lennox Hrowne.)
glottic, ligament connccls the lower end of the epiglottis witli tlic
thyroid.
Between tlie cartilages and the nnicons mendjrane there is a con-
tinuous layer of elastic tissue, giving resiliency as well as smoothness
to the motions of the various parts.
The articnlations of the larvnx are the cricothyroid, cricoarvto-
Ir ? I:
I' ;
ANAIOMV.
n
ho
1)11-
Ite-
iKiid, iiiid tile Saiildrini nrvti'iioiil. 'I'lioc jninl- arf |iiii\ idcd with
articular (■artihijros. syiiovial mciiiliifiiics, and cajtsiihir ligaments, and
the iiiDvc'Uiciit.s pri'^cnt arc tliusc n|' tlcxion and cxloiisioii.
'I'lie larvnx is supplied witii tlin'c sets ol' iniisclcs. 1. 'I'lic crim-
tlivididci in ri'oiil. (■oniicctini;' lln' Idwci' Ijoi'dcr of tln' thyroid with tlic
cricoid. '2. '\'\\v (■i'icoai'vl('iioi(h'i ])ostici, or alMhuiors of the vocal
cords. .'). The cricoaryteiioidei laterales. or addiictois of the cords. —
tlie thyroarytennidci and the nrytenoidcus. Of the latter yroiip the
cricoaryteiioidei laterales and the arytenoidcits arc the adductors. 'I'he
cricothyroidei make teii^e and elongate the vocal cords, while the thyro-
arytenoidei relax and shoiieit them. ISesidcs these, there arc a num-
ber of smaller museh's which help tt) adjust the glottis to the vari(Uis
positions ret[uircd in the ad of vocalization (Kig. KM).
.\l)ove and external to the trui^ vocal cords and hctwceii tlicm
and the ventricular hands there is situated lui each >idc an elliptical
fossa, or fissure, extending nearly the w Imlc Icngt h of t fie cords, 'i'hese
are called the ventricles of the larynx, m ventricles of ^rorgagni, after
tlieir discoverer. In the anterior end of cadi there i< found a little
pouch-liko cavity, called the saceulus laryiigis.
The arteries of the larynx are dcriveil froni hranches of the supe-
rior and inferior thyroid arteries. These laryngeal hranches are diviih'd
into two sets, the anterior and the ])osteri(U', the former consisting of
hranches from the thyroiil ojily. The vein- are similar in their ar-
rangement to the arteries. They anastomose with tlic veins of the thy-
roid, the tongue, and the trachea, and they lermiuate in the inlerual
jugular.
The lymphatics .(re supjilicd aluindantly to the uuicou-; nieiii-
hrane. arranged as a thick net-work. The lymphatic capillaries unite
to form trunks on eitlier side of the larynx: two ahove the ventricular
hands and two helow the cricoiil. At the interarytenoid commissure
tlie lymphatics are so ahundant as to form a distinct tliiekening, called
the laryngeal tonsil, .\lthouuh the lymphatic supply to the iiim-ous
memlirane oi' the larynx is so ahundant, the cartilages, muscles, and
ligaments arc said to he entirely without lymiihatie vesscN.
The nervous supply is diTived fnmi the superior and inferior, or
recurrent laryngeal nerves, 'i'lie former is the sen-ory nerve of the
larynx, derived from the pniMimogastic, the lattiM' is exclu.-ively motor.
The mucous menihraiie of the larynx is supplied with both tes-
sellated and ciliated epithelium. It is contiiUKUi-; with the ]tliarynx
above and the trachea helow. The lower larynx up to thi' ventricular
I ' -■ i
n3()
DISEASKS <)1' TIIK l.AItVW.
Iiiiiuls. uitli tlif except idii (if the voeiil cords, is covered with cnliimiiar
<iliiited epitheliiiiu. 'I'his extends upward over tlie iiitenirvteiioid coiii-
iiiisstire. and also ovei- tiie lower iiall' of the jntsterior siii'face (d' the
o])i^loltis. All the rest of the larviiu^'al inucoiis iiieiiihiiiiic is supplied
with tesse!late<l or S(|uaiiious epithelium.
'I'he liiiiui;' uieinhiaue is also richlv supplied with nniriparous
•ilands, |iartieularly the posterior surface (d' the epi;:lottis and the arv-
epiiilottie folds.
The inner larvux is sometimes divideil into three -ection-: the
upper, or tuhulai', from the epii^lottis to the veiiti'icidar hau(l>; the
<'enlial, hounded hy the veuti'icular hands al)ove and the vocal cords
helnw: ami the infci'ior laryuiical. fidui the cords to the lower mar^irin
lo t he ci'icoid.
n
iti
CilAl'I'KK I.Xl.
1'HVsi()I.(h;v hi- iiik i.ai;vnx.
'J'liK liirviix |i(i.->(,>s(.'s twii liiiu-ti(iii>: nnr in ri'>|iiriitinu; (lie oiIht
in ])li(iniiti(iii.
The riiiictiiiii dl' llic liiiviix ill n-piriit inii i> to permit tlie free
jiassajrc iil' iiir iiilo lln' liiims diiriiiL;' iii-|Mriil imi. 'I'lic I licmy iiciu'rallv
jH'cc'plcd has liccii that, diirinu' t'\|iiratiiiii, the air |)a»iii,u Diit throtiixh
thi' jihittis lorccs the vocal curds dpcii uithdiit any iiiiix-iilar cllnrt nf
tlio hirvnx Ix'iiij^' rcqiiiri'd, hiil that. (liiiiiiL: iii>pirat inii. the vdcal cdi'ds
act like a valve and wniild chi-e Init im- the pu-ierinr ericdarvlennid
muscles- -the ah(liiet(ir,-. which npen thi' Liateway ami permit the air
to (.'liter. 'I'lie (•()iise(|iieiice is tiiat the pdsitiiiii i<\' the cdi'd^ ill expira-
tion is simply passive, while in iiispiratidn it i> active, heiie.:' cdiilrdlled
liy an impul-e I'l'diii the rc-piratory centre, the chink diiriiii:- the latter
act hein^' always the wider nf the two.
Iiccciit t'xteiisive iiivcstiualidn-. \,\ Sir l-'eli\ Seiiidn lime thrown
doiilit upon tlio correctne>s <d' this theory, lie claim.- that, in a lar.^e
nil in her of personal examinat ions of laryiiLics diniiiu' the act id' hreath-
ini:'. lit' has rdiiiid ahsdiiitely im chani^e in the pd>itidii of the coriU
dtirinii^ that act. lie allirms that they ~impl\ dcciipy the position id'
com|)lete miisciilar rest, the width of the chink of the larynx heint,^
prccist'ly the same diirinii' insjiiratioii a,- expiration.
My own oxaininations of larynu■(•^ made .-iiice Semon so clearly
ex|)ri'ssc'<l his views have vindicated hi> position, and I lielieve that the
eomdnsion he arrived at is physioloLjically correct. The dilliciilly i-
that almost any one. while haviiiL; hi.~ larynx examined, will iiiicoii-
scioiisly use iindiie etl'ort dnrin,ii- the ait of in-piration. r.ul let the
observer Avait until rcsjjiratioii has heconie pa.-.~ive. and he will liml
tliat tilt- vocal {■nvi]< remain niotionles> dnriiiir hoth in.-pirat ion and
expiration. 'I'lie sliiihtest inspiratory elloit. however, will piddnec con-
traction of the ahtliictor muscles, and. in my experience, the uieatcr
the ell'ort, invariahly. the wider will liecome the chink.
If tliis is the true condition, the val\e-tlieoiy of the position of
the vocal eords during- inspiration iiuist he erroneous, while the seem-
(■>•> " )
! J
:iM,s
IHsi-; \>i;s or i m; i.au^ v\.
in;:!) iimrr rcjiMniiililc (,i\r. that tlir iHP>iiinri of iIk-c hodics (liiritif
ins|iiiiilinii iis well jis cxiiiiiitinii i> of a purely iiiissivc cliiiractcr, is
|ii'ol)alil\ cdiTcci ( l-'in-. I (i;; I,
111'' |'M'|icf |i( I Inlliiailrc (,r till' fllllclioll of tllf liiiviix (liiriii;;
|'li"ii:ii""i ili|i(ii(U (III the lAiciit jiikI iifciiriicy of tin' vnhiiitiirv ci.n-
•'■"I "!' 'Ii'' \'"iii (Old- (liiriii- ('Xiiiratioii. Th. -c or-aii.- iirc driiuti
I'll" iho |io>itioii of a iiarrou- iliiiik hy the addii.ip.r and llic tensor
III"-''!' ~-- iiiid llieii throw n into soiioroii^ viliialioii.- \>\ forciiiii- the air
"•'' ''Npiialioii ihroii-li th(iii. It i< thu.- >eeii llial the function of
re.-|iiration is really one of in-|.iialioii, while jihonalion is purely one
(d' expiration ( Iml:'. I'i I ).
As said hefore. the only ahdndor mu-ile- ,,{ the lar\i!\. or tliosi>
\\hi(di expand the i:lolti>. are the po>terioi' eric arx letmid.
Fir;-. l(i:!. 'llie linyiifrescoi.ic im- Fij:. KM.- Th,. l;n-vn<;(i-i (i).ic im-
ajre (liniiifr rcspiiiilioii. i .Mter Hes- :il'c (liiriii<r plieiMt i-m. i.XtOr lids-
"orlli.) Weltll.l
"'I ill*' iilher hand, ilie niii--ile> w ho>e >peeial dntv it i< to addiict
llie vocal cords, or dose the j:lottis for ,uir|)oscs of ]ilionali(Ui. are the
lateral cricoarytenoid and the iiiteraryteiioid. The former pulls foi'-
ward (he outer aiiiile of the Ikhc of ilie arytenoid carlila-e. rolatin--
inward the vocal [irocess to which the vocal cord is atta( lied, while the
interarytciioidcus pulls into apposition the arvteiioid cartilaLics. l''or
finer adjustnieut (d' the cords, the thyroarytenoid, heini: attached as it
is to tlie whole length (d'the outer l)order of the cord, hv its hodily pres-
ence -rives firmness as well as increased tension, the latter hciiiir aided
hv the action of the cricothvroid.
i'il\ >it)i,()(;Y.
3:u>
[let
he
hi'-
111 ;i-
he
|or
it
In the Inwcr tdiics llif Inn ii\ iiuivi's downwaifl to n Imvrr lovcl in
llio tliniiit. and in the hi;.dit'r tones tn a lii;,'l>(M' \v\f\.
'I'lic atli'iliiitos of the voice arc pitcli, intensity, and ([uality.
'Pile jtitcli depends upon the nniiiiier of vilnalion- of I lie viual
cords, dnrlni; a .iii\cn liiiu'. in pioduciiiir i||,. (mK , 'I'lio tii^hter the
tension, tlie f^reater the niiinlicr of \ ibral ions and the higher tlie pili li.
'I'he intensity depend- upon t!n> force of the expiratory elTorl.
'I'hc (|nality dc|ieiids u]»on tlie cninhincd inlliicnces of llic whole
vocal apparatus, ineliHlinir larynx, pharynx, nose, and accessory sinnsey.
l'"or a further account of the |)liysioh\i;y of the larynx, particnlarly
in rcf^artl to phonal ion and vocalization, the reader i- airain referred to
niore elidxirate works upon the suliject.
'i\i perform these functions noririall\ the \ocal cords, as well a.-
the nuiscles. niiL-i he in a healthy condition. Mvon sliiflit congestion
of tlie mucous nieinhranc. particularly of the cords, may impair their
vihration and pindiice weakness as well hoarsem^ss oi the voice. When
the symjitoms are more severe, the cause, of necessity, must bo more
serious, and, wlnMi neoplasms occur, respiration may he \ery seriously
interferid with, and the voice in many instances destroyed.
i
('ii.\i"ii:i{ i.xii.
l,.\l!^ \(i(»s( (\\'\.
'I'lii-; |iriin'i|)l('- (iT liir\ ii,L;nscii|iic rxiiiiiiiiiitioii ;iir the -iiiiic ;i- llm^c
of cMiiiiiiiiilidii of llic |)(>>i -)iliarvii.\. 'I'lif uses of llic ln'iid-iiiii ini- ami
rt'llcclcil li^lil iii'c till' >iiiin', wliilc llic (liU'i'ii'iicc ill llic 1 lirniil-iiiiri'iii'
is iiK'i'cly (llic III' (liaiiicliT. llic ciii-iihir face (if llic lar\ ii.L;cal iiiirrdr
Itciiii;' niiicli larger than llic niic ic(|iiii'c(| |'(ir |)(i>l-rliiiial c\aiiiiiiati<iiis
(l'"i;:-. in.')). 'I'lic rcllcclcd |in|ii .-.IkhiIiI lie placed in a daik (.Hinicr, with
as little a> |Mis>ili|c (if the (irdiiiarv -miliulil |irc-ciil.
ill c\aiiiiiiiiii^' the larviix. after waiiiiiiiL; llie iiiiri'di' tn a Id i-
tciii|ierat lire in the iiiaiiiier and fdi' the rea^dns already dcHurilx'd, the
|ialieiil i.- directed Id take lidid df the tdiiu'iie with a iia|ikin and draw
l''ij,'. 1(1"). I.ai \ iij;ciil Miicl |in»i I iiiii(;-.in|iic i.iiniii-.
I •
i:i<H.
it ii'cnlly (int. 'I"hc inirrdf is |ilace(| a,L;aiii>l the xift palate pro-iiiL;'
iho n\iila lii^hlly in an upward and liaekward directidii. and. other
thiti.iis heiiiii c(jnal. the vision of the laiviix i< a( once dhtaiiied ( I'iu.
Jim;).
.\lthdiiL;'h tlic directions arc sinipic, it usually re(|uire> a little
practice, as well as trainiiii;- of the patient td the ii-c df tlic in-tniniciit
to accdinplish the end in view.
I'"irsi witli rcLzard to liohiinu- the foii;inc. It is usnally tau^^Iit tliat
the hiryn^dhiiiist shoidd liold it himself with his left hand, while lie
liolds the mirror liu'litly lielwccii the liniicrs of his riiiht. Init that in
some eases tlie patient may lie allowed to hold it himself. Peixmally.
I believe the ojiposito slioiild he the rule. I'ractically. I never liold
tlie ]iatieiit"s tonsriie, l)ut invariably diicct the patient to do it. lie can
do it just as well as tlie operator, who then alwavs has bis other band
(3-JO)
l..\U\ StiOX Dl'V,
;!»i
lit liltcrtv; lit till' siiiiu' tiiiir it iiiemi^o the cniiliilcncc nl' llie piitii'iit,
who IVt'ls tliiit lio liiiii.-cll' is lu'lpiii^f In <!<> the \\«>ik
Soiiictiiiu'-. lidwcvcr. iiotwithsliiiiiliii^ iIk' tramiii^ \m' '/\\r llu'
piitifiit. till' liiill nl' the liin^iiii' riM',- so lii;:ii llmt it (lirfctl\ iiitci \riU'S
l''i^. |(Hi. 'I'lic liirv njifiil iiiirnir in iMi>ili(m (( uliciii when lii'lil li>
lilt Icl'l liaiid. I Kidiii ){ii>\v(irlli.i
iiml jircvciits a )ii'ii|ht visimi df tliv laiviix. In tlioc (iiM's. while tlic
patient ^tusiis the tdiiuuc, thr cxaiiiiiiiT can hnhl it ihuvn with thf
(U'pres-sor lirjil in ttnv iiaiid. wliilc he n>c> thr tliriiat-niirrni' wilii the
other.
Xot iiil'riHini'iitl.v tlic ]ialali' is si-nsitivi' to pn'ssurc. and rotcliin.i;
;M'J
lil^-KAhKS OF I'lIK I.AIiVNX.
iircui- cM aiicinpt iiiL;' I" iisf (lie luirroi'. I'liiiriit pcr.-cvci'iiiicc will
iisiiiilly ii\('ic(]|iic this. If imi. ;i soliitiuii of cdcairic or I'liciiinr iipplicv]
t(i ihc I'iiiici.- will (ii'tcii ailiiy the liypiTfiL'ii.si' iveiK'.-is of tlit' ])aris.
r>y iii-t lui-linu:" tin; [tnticiil lo hold the lioiiil Iia.-kwiu'd iUiil lo
ln'ciillu' i|iii('ily, the vocal cords will he >ccii ii:; Iway liclwccii aiidiic-
lioii and addiici imi. Ilclow ihc i^loltis the i'iiiL;'s oi' the ti'i'.clu'a cAii he
observed, and, in Mime instances, the whole !eii<:lh of ilie anterior wall '
of the wind-pipe, down to the hirnreatiiui of the hi'dticiiial tidies, is
brou,<;ht. into view.
{•"of tlu' oh>ei'\er lo soe (he vocal cord~ distiiicily. and to hrini;-
thcMi in line parallel with eaeli otlicr. the patient -' >uld -lowly sound
the won! '"all." To ohtaiii a ^till better view, the lone "ee," having
a higbei' pitch, shoidd be attcnipteil. Tin' ejiii:lott is will then be more
erect, as the larvn.x lias attained by the elVort a sliglitly-bigher po.si-
tidii: hnt. 111 ibis instance, as the hasi' (d' Ilie tontine rises with it. the
use (d' the tonuiie-depi'cssor. a.- well as traction, may |io-sibly be rc-
(plired.
The p(i>iiion of the epiirlottis sometimes serimi-ly interferes with
a good view of the larynv. Instead of standing:' erect, it iiiav lean per-
niaiieiitiy backward, oii-t riietiim' the vision, or it may lie curled tijion
itself >o as to prevent dii'cci light froui being thrown upon tiie vocal
eords. l-"\(n tlicM' dilliciilties may in most instanees be overcome bv
the conibine(i elVoris (d' throwing:' the head back, using a very high tone
of "c ," drawing out the tiuiLiiic. and at the same time depressing it.
Iii>lrumeiits have been devi-ed to draw fiu'ward the epiglottis in
e.xlrenie cases, hut they will very rarely be reipiired.
In one extreme case' I found the epiglottis long and narrow, pro-
jecting hofixoiitally iia>k\vai'il and ]ires>ing against the post-])harynx,
the jiaticiit breathing up through the narrow slits at the sides. To
relieve the catarrhal and hoarse condition it produeed, I. removed a
(liiarlcr df an imdi fr(un the end of the organ and so left a permanent
chink. Mveii then, however, the \(.cal c(U'd~ could not be distinctly
seen.
When the toii-ils are very large vision may be obstructed; but
the use of a small mirror may still reinh'r the larynx visilde. An
elongated uvula, while it may seriously interfere wiih the jtost-nasat
examination, does not alTeet examinatidii (d' the larviiv.
On examining tin larynx with the larvngeal nii.'ror. the picture
' Transactidns of (lie Tati Aniciicaii ^rciliial ( '(nifrM s«, Washington, ISO."?.
Section i^f I.arvnirfildcv .
;' i
i'iS ■■
f 1
1 i
LAl{VNti(»S(()l>V
Ki
will natiinilly lie in a ri'versfd position; that i.-. lln' loimur will lie in
a posterior ])ortion of the miii'oi-. and the posterior wall of the pharynx
in the anterior. The ri^ht and left >idi> will aUo be reversed. i'>e-
^rinniny, then, at. the upper mai'^in (d' the iniaizc. the fir.-t thin,L' .-^een
is tlie liase of the ton^ne. ami in t'roiil of it the nnich which separale.-
it from the epiulotti.-. 'I'his oi'L^an eonie> ne\l, ai'ehed in nio>l ea<es
like a how, with the eoiieaviiv in front. (>ii either side (d' it are the
j)har_vni;'o-epi^lollie ''ohls. 'I he color of the epiglottis i~ yellowisli
pink. I'siially blood-vessels may I- ecu seail 'ittl ovei- it. iieiu'alh
tlio eonoavo snrl'aee of the oriian, it ihe vocal cord.- are open, will be
seen a trianu'iilai' openini; wi'h ils apex under the epi^lotti- and ils
base toward the front, of ])ink lolor. wilh wliili,~h ci'o-— liai's. This is
tilt! internal >uilace id' the trachea, alivady nu'nlioned, |)ircctly t i
tlie I'i.ulit and h'ft, fm'ndu.L'- the aims of th<' triani^le, are the luoad,
white vocal bands fornnni^' the i^loitis. When the \ocal coi'd- are
(dosed the trachea will not lie seen, but tlie two white coids w ill ^iretcii
fi'oin fi'oiit to back parallel with caidi ■ithei-. Ivxtcrnal to the li'Ui! eord>
are two trian.ii'ular surfaces (d' a muidi darkci' hue, their ba,-e- beneath
the epiglottis and thei'- apiiH'S stretehinu" to the fi'onl almost the full
len,irth of the vocal cords. 'I'hesc are the vcnii'icular liaud- Tluy oc-
cupy a bi,t;her plane than the vocal coi'd,-, lieinu' dii'cctly above and ex-
tei'iial to tlu'in. Hetween the two on eaidi .-ide lie- the \eniricli' of
Mori^a^iii. Still i'arther to the riuht and left, ami 1ia\inu- their oriLrin
at llu' linut.s of tlie epiirlotlis. we have the ri.ulit and Icfi aryepii^h ttic
folds, eonneetin.tf the eiii.iidott is with tlie ai'ytenoid carl ilaucs. As they
approaidi the latter they eonvcr,L:e and near tln'ir cxti'emilic- are en-
larged by two little, round, projectinu' biilu'c-. The lir-t i- the carti-
lage id' Wrisberg, the second the capiliiliiiii Sanlormi. .\cro-s the
anterior side of tlir- laryngeal mirror, conneciing the two aryepiglottic
folds, is the intorarytenoid ccuumissui'c, thus completing the circle of
the internal larynx. Outside the aryepigloti ic bild- are two pyramidal
cavities, called the pyriform sinuses, while si ill furl her in the front
part of llie image is the compressed opening to the le-ophagus, lying
slightly to tlie r'ght side of the pictuie, meaidng iiidi\ idiially to the
left. Tills is liidden nujstly by th(> extensive folds of the po.-t-pharyn-
gea! wall.
Returning to the interior of the larynx, in certain positions, ami
in some larynges nun h nuu'c clearly than in others, directly Ixdow the
epiglottis and above the aiiLrle of the vocal cords, we find the cushion
of tlie ej)iglottis.
:iii
m^i: Asi:- (i|- i in; i.Ain w.
'I'lic iiiiiciui- nifiiilM'iliii' i\\' the liiryiix, as dhscrvcil liv aid nf llic
laryni:(i-(ii|ii'. i> df a li'jlit-|iiiik cdlnr. 'I'licrc slmuld he \\n acciiniiila-
iioM (if niiiiii> aiiyw lii'if. ami in \ ncalizal inn thr xnciil curd-; .-hduld
cdiiK' freely tii^cl liei'. willidiit any iiilerrerenee fi'nni a tliiekeiieij
niiied-a iict uccii I he aryiciinids.
W illi I'l'L^ard In the |Hi>itinii nf ihc |iali('iil fni' lai'ynuiijooiraj e\-
ainiiiatidn. it i> udl fm' the n|icrat(ii' In accii>tiini hini-clf In \\\v w-v liy
I he pal ii'Ut n|' any >lnn| nr cliail' W llii ll at t lie time happens to he enll-
Nellielit. Slill. in hi- nun <illiee it i- lietlel' In lia\f an npiTat i llLI'-elia i f
specially -nited fdr \\\r irealinent nf the majnrii\ df In- eases.
In lafynu'dldiiieal Wdi'k the patient >hdidd sit eitluT pei'feetlx n|i-
fiiilit "V leaniiiLi' fdi'waid in ni'def td hriim' his head w-.w \n that df
the dpeialdf, and in the line (d' jieidVet virion.
In dfdei' Id aeenmplish this. I had my nperat iim-ehaii' made with
a -trai^^iit hack and li'anin.ti' .-li^ht ly fdi'\var<l. The hack ilself feaelies
ahdve the liead df the tallest patient, and has down it> eenii-e a deep
and wide ui'd(}ve. td lit tin- haek df the head df aii\ patient, ydiiiii;' df
did. 'I'liis pi'e\ents any hackwai'd jerkiiii:' when the head is rested
airaiiist it. 'I'he cdmaxe -nchn <■ likewise militato ai^ainst any side-
ward iiiiivemeiii. while it eiialde- tile patient td slide the liead ripward
iir downward, and to adjust a \ iew (d' the parts to tlu' re([niri'inents ol"
tile operator.
( ii,\i'ii:i; I. Mil.
AiTosi Mr^
V:
l\ l>!i-">. AHrcil Kii^lciii. Ill i'li-rlin, in' I'lMJitcn! to \\\r jiiciliciii
il'nri--!(il) ;l lieu llirtll(i(l <>( (A;! Ill i II I IIU t llr lilTVlIX iiml triH-ll.';! wllifll
II' -lylcil ■■iniln-.(()|i\ .'■ r>y llii- he iiUMiil ilirrct limar i]i>|pi'i-linii
lirmiijli the inniiili i<i ijic Inwcr plMi'viix. I;irvn\. iiiid tnu-hi'ii \\illiiiui
lie iiiil nf a iaiyiiLiial imiinr. in llic rullnwiuu year. Max 'I'linmiT.
>l' ( 'iiiciiinati, ya\r an rxccljcnl t ran>lal imi inin liic l';n::li-Ii laii;^uat:e
l-"ii;. liiT. r<i-iiniii \u\- :i iiin-, ,,|i\ . I'lij^ |ili(aiijr|:i|,|| wic^ takt'ti from
:l |i:ii 1 1\ >l ri|i| ( il |i;(tir]it in ni'lir to -liiw di^liiiitly tlic jin-ition <:!' head
anil lick diiriiiL.' csaiiiiiiiit iuii. 'Al'hr Kii >li in 'I'liniiK i . i
1)1' Kirstc'iu's iiioiKiirraiili, with adilcl iiiiprnviriH'iit-^ a- llic iiu'tlio'l
Ix'cauR' inoro coniiilctc.
'i'lio necessary i(iii(liti(iii> lA' a (•(iiii|)|c|i' linear iii>|ir(tiiiii are: —
1. "'I'lie liddy iimst lie |ilace(l in >;iili a |in,-'tinn tlial an iinaL'inary
eoiitiniiat inn n\' iln' larynirn-t ladical liilie wdiild fall williin the npcn-
iriL'' of the inmilh (Kiir. ]()?).
•^'. "'I'liis iniajiiiiary straisflit line must ho eleared of those partf
of (lie liod (epiirloltis and tlic; base of the tongue) wiiich o])struct it."
(;n:.)
oKJ
i)isi;.\>i:s oj' Tin: i.akvnx.
'\'\]r (ir.it c'undilinii, il i~ said, will lie ohlaijicd liy ,i,M'iilly tilting
tlic head backward so that tlic axis of vision, instead of being at an
a null' of ninety degrees to lln' axis of the ti'iink, will he at an angle of
about inw hundred and thirty-live degrees.
'i'lie iseeond condition can only l>e oijtaincd by drawing the base
(if the tongue forward and downward. 'I'o secure ibis position a spe-
cial tongue-depressor is i'e(jnired, wiiicli must be slipped directly over
the cii'eunnallale papilla' [a the ront df the tongue. Pressure foi'ward
now upon that organ will remove it out of the way of vi.-ion, and at
the >auie time, by compic-.-iug the median giosso-epiglotlic ligament,
ele\ale ibe epigliill i.- and -o di.-pose of the I'emainiiig olisl ruetioii to the
view. Jn some cases it may be neecs.-ai'y to slip the in>ti'umeiil nxrv
the epiglottis itself, and draw it forward, bebue the reipiii'cd view can
be obtained; in these the use of cocaine will be rei|uiied.
Fiiif. jus. Auliisiopc V. itli jilatf (/') iiisti'iitl ot IhhuI.
( A f, ir K irslt'i n-'rii( iiiuT. )
Owing to the position which ', e examiner has (o assume in prac-
ticing autosco]>y, .the ordinary stationary light required for laryn-
goscopy is useless, and lie must cither have an electric lamp fastened
to liis own forehead or, what Kirstein considers better, a species of
electroscopo attached to his special tongue-de])ressor. This transmits
the light along the groove of the spatula, into ihe larynx <d' the ]ia-
tient. wiihout its origin being seen by the operator (Fig. 108).
The autoscope c(msisls of three ]iarts: a spadila. a hood, and a
handle.
The spatula for aibdls is 1 I centimetres huig; I' centimeiies wide
at the tip. which is thickened and i-ouiub'd lo avoid injury to mucous
membranes, and notched to receive the nu'dian glosso-epigloUidean
ligament; ami 1 '/. centimetres wide where it jiasses over the convex-
ity of the tongue; this portion should be grooved longitudinally, lo
Al T()S((>I'\
34T
! i
fit into tlic iiiitunil groove which the tmiiiui' (wliiliit.- on (■(.■iitral do-
jMc^sidii. 'i'he ti]) (if the spaliihi is Ix'iit (low iiwaril. 1 coniiinelro lower
than the onliiiarv uroovcd portion; so that it lan |iif.--s upon the base
of ijic toiiLiuc. ami liv this iiican~ laisc the cpi^jlott i<. 'Hn' in-t riMuent,
is made of itiekel-plali\
The lu)od, whieli is uiaile ol' the >ainr niatri-ial, i~. for the adull,
li i-cntiiiieli'ts Ioiil;' and :) ceJitinietres wide It Ills iipnii \\\r I'ront end
<>( the -paiida, and si rvi'- to keep the pa.->a'^i' cltai' for li,L;ht and vision.
.It is inserted witliin iln' mouth, and i> adjii-la^M. . prevent iiii;' oh-true-
Fig. toil.- Au1i)S((j]iic iijicrutiiin. i.\ttcr Kii>tciii 'riimru'r.)
tion from the np])er teeth, npjiev lip. or mnstaelie. 'j'hc medium
lieiirht of Kii'stein's standard hood is almnt '! millimetres, the slit beins:
imply wide for examination purposes,
le used the hood slioni
W
■n instruments require to
III' of greater liciLiht. I'hc handle i.s ,<cl at
riirht an,!J:les to the sjiatula, and to it is attached h\' .-peeial contrivance,
the electroscope.
Kirstein says: ''Autoscopy is a (U/Jlcnll act, until one has aecpdrcd
a certain hard-to-defino knack in introducing the simtula." The pa-
tient shoidd bend the upper jiart of his body slightly forward, as in
23
:ms
DISKASKS Ol' rilh; I.AltVNN.
l''i^s. 111') iiiid |ii!t, niakiiiL; tlir iiii-|i;is-;iL;(' in ;i -oiiH'wIial diicci line.
'I'liis .i,M\('> llii' iidilil iniiiil iiil\iiiihiL;c nf rclavini;' tlir iiiii>cl('< (t{ tlic
neck.
W'liilc iuit(i.-((i|i\ li.is ihc isvt'ixi advantiiL;!' (if dinct vi-inii, it is
accoiiipaiiii'd liy scNcial iiicnmciiii'Mccs. 'I'lic cliicd' nin's arc: 1. 'I'lif
(■.\|icns(' (pf till' i-('(|iiii'i'd ai'iiiaiiiciitai'iiiiii, I'nr (i|)riMt i\c iiist iiiim'iii>
woidd ic(|iiii'c In lie .'-iii'cialh' siiiird I'm- aiilnscopic uoik. 'J. 'I'lir
IfDiililc (d' ac(iiiiriii;i; the l('cliiii<|ii('. .'!. 'I'lic cIum' proximity of the -iir-
ircnii III llir direr! Iircalh nf llir |ialiriil, willi all lliat tlii> iiivnlvcs.
Still, in llir wiird^ nl' Kirslnii: •■i''ni' llir piirpuscs of sririililic
dciiiniisl rat inn anlnsmpy i' jiisl llir lliiii.u; a riiiiiiiirr ■<( spnialnr.-, can
ln(d\. ntlc al'irr ailnlllcr, llimilLlll iIh' ailln-mpr and llnic llir ciindi-
II
i-'ii:. i 1*1. I onj^uc (|( )in ^^111 llir phai vii;;oMii|iy and ijiicct iai\ii;;ii
t raclini^i ii|i\ . Side \ icw and surl'air view of I hi' aiilcrior portion. In ^oiiic
{■MM's an insli iiniriit with a laiiriT curve of the anterior |)orl ion i., more
prael iealile. (.M'ler Kii -tein 'I'liornev.)
linns. In pcrsniis wi'll adaplcd In anlnsrnpy it i> i'a>v In di'iiiniistrad*
In any layman tlir ninvriiu'iils nf t lie vnrai riud, llir |iliy.-^inlni,Mcal |)iilsa-
linn (if the wall nf llir iraclira. llic >yslnlic liralinu' <'( llic hifnrraliun-
spnr, and i|iiit(' a> easily a eareinoma nf llie larynx."
In many eases llie llimat is <<) furnied that even llie .-killed e\-
iiminer can derive nn ad\antaL!'e fmm the use nf liic aidn^enpe; htit
the Iriiiinpli o\' antnsenpy lie- in llie iiienmparalile view witieli it uives,
in many nllicrs. nf tlie pnsterinr wall nf the larynx and lite i mire inner
siirfaee nf llie Iraellea e\en In the etltra.ae nf the litniirhi.
A« aiiinseiipy ran he praelieed willi faeilily uhile the patient is
under llie inlliieiiie nf all ana"-tliet ie. il is prnlialile that it wiM lie re-
ceived willi miicli fiivnr for the examinatinti nf yninii,' ehildreti. with
whom Iai'\ nonsenpy is itsiiiilly '^neh a diniciill matter.
I i
A i; TOSCO I 'V.
'k' iii>lriiiiifnts for iiiihiscdni,
.•illi
iIMT;iti..ii> aic .-Ii,i|„m1 Ilk,, nii.sil
n.s.unn.nls,u„l, l,„„,,-sl,,.,ns. TImv >l M .....asur. .ImhU .'.. .•,.., (,-
, , , , , - I'liil, auioxdiiic
"''•■''""'"■^^'""''•' l'"":iS.,.Mh,.M, l:MV,mnM.„p,r on,.. (|.',. ,„.,,
Sin... inlro,!,,,.,,,^ ihis nrw n,ril„H| „r ,.x;,nnM,,m'~t |„. larv,,..,.;,!
'■"vily. Kirsl.M.., loronlinarv pur,,,.,.., l.. ...n.uhat sMMpl,li,.,rins
''■•■'''"'I'"'- ^'''"^- ''"-^ '"-'"• ". ^vh.-i, (|„. I I ,. „„,,.,.....,rv ami
'"^vh„.|,,|,,.„.oov..,.anl,k..u,s,. I„.,|,.p,.„.,.,i,,„|, | f ,„ ,., |,„„:. , |„.
^''';' ''' ''"^"" '""-'■'•'•Nn.., uhil,. Ii„. ^,„!,|. ivMun,. ,|,r .„„.. ■,.
;" 'V"'",'""' ''"l""^-"' "'V. 110). In.„.a.l oni,,. „|.,„,,.,„,„,.„„^
'''■''7/ '•' '^' '^l'''''''^'- 'I- l--l-'''l-l'uli- nf Ih.. ,,,,,.,.al,,,Mv,,Ml,l auMw.r
('(jiiiillv \\,||.
^;;'\;'-"'''l-"i"|'niMwalap,,li,.aliononi,,. ,n,l of op„,,_
'""•^'^'^ """•'"■'•''^'^•■•■|""-"-''M.a:-.. ,n wl,„.|, i„. n.,Mo.,.,lap„.'.,.,;r
'•'""■ '-"■ '■'•'Mi.M..nv. lon,^, from th.. supra,loMi,. p„,,ion of tl,..
,'•;""' ='.V"""^n,ana^..,|-il. T p,.,.al,on ua. ,ion. hv thr ai.l
"',"'"■•'."""'"'"' ^^i'l""" "'•■us.. or..o,.an,.Ml„. ,in„. n.,pnn.,| !„ in.r
only a lew s..<-,,n,|>, ' '^
!!«! i
' \
I !
IF^
ClIAI'TKi; 1-.\1\
INTUr.ATIOX.
Tins iii('tliii(! (if rclicviiiL:' huTiiircal sU'iiii>i.- lins lnll^r been ii
Uicorv, cniilc iii.-truiiiciits Ikmiil: iisnl to ol)tiiiii the object in view.
Tliev were not ol' iinicli Viiliie, however, and it remained fur O'Dwyer
to introduce to llie ])rofession (lie nielliod itself, with a I'lill set of in-
slnunents eaiiahle ot aceojnpli.sliing intul)ation. Ui.s own record in
Fin-. 11 1.— ()'I)« vcr's iiitiiliiitidti set.
the nse of tliese insi runieiits lias been brilliant indeed, the regret-
table feature lieint: tliat, at the moment when O'Dwyer's tubes had
obtained a world-wide reputation, and the advantages wliich his re-
searches had given to seit'iue were being fully realized, lie should be
calle(l j'nun his labors and the glory whieh was the product of hi-
genius. The .saddest feature of all is that, notwithstanding this crown-
ing effort for the good of Itumanity, he died a poor man.
(350)
IMl HAl ION.
351
()"J)\vyL'i'> lubes consist of ;i .>-iri(s nf in.-tnimcuts nl' ditlVrciil
lengths iuul sizes, to .-iiit the vniinus ;\-j:v> nf piitieiits. liesides tlie>e,
tliere is an introducer iind an extractm' thai will lit all the tiii)Os. Add
1(1 the>e a iiioni li-iiaL; and a .-eale tu rriiidatr the siz(> (d' ihe tulie in
aeeerdaiiee w ith 1 Ih' ai^e of the pat ielit. and the mitfit is eomiilete ( l''igs.
Ill and \A->).
Tile liilie is a llallened eylinder Ind.Liiim lnwanl ihe emlre, 'I'lie
head is roiindeil and llan^rinj:. id re>t mi the ventrioidar l)and>. and
thiMiiiih eiie >ide nf tlir head is a [K'rfnratinn fnr iln' in-ertinii nf a
cord.
■i<:. 112. IiwtriiiiKiit- for iiituli;i1 imi : iin iiii rudiiri'i-; il)\ tul
((•; .scale; !'/) c.xtiiictiir: C'l iiiniith j^ii^-.
;ret-
had
ro-
l)e
hi^
Wll-
Tlie iiitrndiiccr (•(insi>ts nf a -Ifuder md lilted \\ ith a liandle. On
it is a slidinu- tniie. .\t the dista! end nf the iiitrn(lii(ir i> tlie nliluratof,
a thin, jninted jiiece nf indal which i- -crcwcd nii tn the iiil rodiir-er
at riplit anL;h's. 'I'his passes iliruiiLili the juhe.
'\']\o t'xti'actnr i- fnr the )nir|io-;e of reninviiiLi' tin' luhe when de-
sired. It is shaped with a rii^lit an^de soniewliat like the iidrndiicei'.
'I'hi^ ninuth-ii'ai:- i- tn keeji ilie jaw- apait diiriuL:' the nperatinn.
To ]ierfonn intnhatinn diiriiiu' infancy nr cliildhood. the jnitiont
-hnidd lie wrapped in a slieej fmni the neck downward, so as to se-
ciiroly liold the arms and hands. Tfe slmuld then he hehl fmni In'hind
in tlie upri'jlit imsiiion either in tlie lap of a niir-e or -fandinir on a
I)Isi;asi> or tiik i.akynx.
( liiiir, 'i'lic iissistiii- siir:;c(iii slumld lioM the jSiXji, placed in iK Id't
side of I lie iiiniitli of the iialiciit. taking care to jifcss the liandlcs ligiitly
iiu^aiiist tln' chi'clv. to )ii-('\i'iit the .-lippiii'; ol' the instrument.
TIic ojiciiitor >tiniils iniineiliately in front. 'I'lie introdiu'er is
held in ilic rijilit iuind. The h ft foicljnjrfr, disinfeeli'd ami oileil, is
ihii) )ja.->eil into till' |ihai\n\. tin' e]ii^dotlis i'onnd, and, .•^lippin,^' the
(inLicr ovei- it, the ea\itv iietweeii it and liir aivtilioids is di'teeted.
Imniidiatelv the end n{' the tnlir attached to the introdui ri', and aimed
with a sti'oii;^' thread, i> pa.s.'^cd along the palmar surface of the linger
already toiiehing the larvnx. and. guidi'd I'V it. is slipped over the
I'piglolti^. The handle of the introducer i» now raisi'd so as to direct
the tiji (d' the in-t iiiineiit direellv into the laivnx. If this is not done,
the tiilie slips o\cr the lonimissiire into the (esophagus.
The tiihe having eiitcfed the larvnx. of which the operator may
lie sure hy feeling the soft tissue all around the liihe, the thunih is
pressed on the hiitton of the slide and the tidie sep;iraied. in remov-
ing the intiodiieer the left foiellnger slionld be kept on toj) of the tniie
to secure it> releiiljoii.
.\ lingei-giiard is recommended by some operators. Tt is a cnm-
liersome eont ri\ani-c, and in yonng children there is little enough space
for the linger alone. 1 have never nsed oiu-. and, although 1 have had
the linger hit ten once or twice, in each case it has been caused hy de-
feet ivi' holding id' the mouth-gag: something which could always he
avoided.
If failure of insertion occur on the first attempt, the cliild should
\n' allowed to rot a few minutes before a .second attempl is niadi".
When the tiiiie heconu'^- t)loekecl by false membrane, dnring or
immediately after its introduction, so as to jirodnce threatened sulfoca-
lioii, it should at once he removcfl: and after a little while anotlier
trial made, in ease o\' failure id' elfecting ininl)ation, tiacluoi nnv may
in some cases be required in the attemjit to save life.
In adults, and youths |)o.sscssed of sntlieieiit self-control, intuba-
tion may n ailily be accomplished without the u>e of the left forefinger,
iuit l)y means of (he laryngeal mirror.
'1 he thread should not lie removed until we are snre that the tube
is not only in position. Iiut also that there is no danger of its being
occlmbd liy memlnanr. Then it ean be slipped out, care being taken
not to remo\e the Ildie while (biillg so.
To reiiuue the tiilie. the patient is airain placed in the attitude
rei|iiired for it- ini riHluetimi. The extractoj- i- earried down along the
IN I I HA I ION.
left index fin;:cr a> in the itriinnrv (tpcriitinii. 'I'lic inoiitli <il' the tiilx'
is A'll liolow tlio t'pij;l()ttih imd llic clu.-nl tips of the cNtnu'tor inscrtril
into the ojx'li tlllic. \\\ pressing:- the spriiii;' tiic lihidcs jiii' njicncd, iilid.
,Lrrii>]iiii,L: tlif iii.-idc \\all> <il' tln' tuiic iIliIiiIv, tlic liittcr i- ;ii (HH'c willi-
dr;c,\ii. 'I'lu' ri'iii(i\al i> (dlfti a iimrf ditliciili npcialhiii than the inli'n-
diictidii: and to render tlii> part dl' the wdi'k la-ier. .Ma\ '! Iinriier. n\'
Cincinnaii. lirou,i:lit hei'ore Uie pinle^imi. u the |a-t ineetiiii: ol' ihe
Aincrican Larviii:o|oi;ieal. TiliiiiolniiicaL and Oldleoujil Sdeiety, a de-
sitrn helicM'd ti> he an iinprn\ einent upmi (»'ii«ver"> extractor and
tnhe. 'I'hi' rorinalmn of the tnlie i- the >anie. with llie exception thai
the liead i> more wiihiy and ninic (h'cply ccmcave: ,-o lh:U when the
extractDr touches tiie cavity it will ulide inoie ri'iidily into it. 'I'ln' ex-
tractor itseir is likewix' >iin]ilcr in I'orin, and serves the donhie purpose
of int I'ndncer a.- well as cxt lactnr.
Sunietinics the lidie i- cdii'jiied mit and will re(piiic I'ein.-cii inn.
One (if the main dillicidtio in cniinectinn witli inlubaiion i> the
dilliculty in de,L;lntil ion which allend> it. particnlarly in rcd'ei'ence to
llnids. S(d'l foods can n.-nally he swalhiwed if t:iven slowly and with
care: hnt tlni(].-~ ai'c likely to i^ct thi'on^h the tnhe intn the larynx and
trachea. Wy ailoptinu' Cary".- inelliod (d' placinu' the ]>aticnt (ui his
hack with the hip> well elevaled swallowini:' is said to lie ea>ier; and
in some cases small (piantitn-.-. e\in. of linid can lie iriven in tlii> way.
In any ca.'^c llind nonrishnii'iit can alwavs he adnunisteicd liy eneniata.
the chief part of it heini: readily alwui'lieil.
Intnhatidii i- lare'cly n>ed in case,- (if lai'ynu'eal diphtheria dccnr-
rinii' ir cliihlreii ; and -ince the int I'ddiicl ion df antitoxin inlc i he t reat-
nicnt of this di>ease. the fatal i-.-nes. when the two arc cdndiineij, have
ureatly dimiiiisln'<l in ninnhcr-. while tlu'rc i- nn dnnii! w haie\ci'. even
wlieii nse(l aldiie. thai it ha> saved many live.-. The fad df iidnhalioii
heiiie' accdinplishcd v\ithdwl the n.-e of the knife ha- can-cd if to he
received with mncli favoi' hy parents and fi'icnd- of nalienl- I'eipni'ini;'
o|)eration; and foi' this i-caxm it i- fre.pieniiv preferred id ihe seeni-
iiiffly iiidi'c <eri(ius dpci'atidn (if trachcdldmy. ( 'a>M'|licM'y relates tlie
history of foni' cases also, dccni'rinu in adidt-. in which inlnhation re-
sulted in tie t lii' of this di-ease.
( >"1 >wy( r ha-^ lonnd intnhatidn -crvicealilc in a niimhei' df cases df
slrictnrc froin PiliaiT sypliilis in the adidt. Other ohsei'vcr^, ton, fol-
lowinir liis example. Inive attained a measnic df .-ucce>> in the same
way. De^rlntitidii in these cases i> said in he cumparativ cly ea>y. after
the fir-t dav di' i v\ d.
I I
IMAGE EVALUATION
TEST TARGET (MT-S)
A
V^^
7.
1.0
I.I
1.25
1^ |££
i^ 12.2
1^
^ ^ IlilM
1.4
1.6
m
%p
/a
^h
/A
Hiotographic
Sciences
Corporation
23 WEST MAIN STREET
WEBSTER, NY. M5S0
(716) 873-4503
\
iV
■^
\\
o^
^
"
6^
^
! i
clIAI'IKIf lAV.
TUAriii;(»T(»MV. Tiivi;(»i().\n
'Tit \( iii:<)To\iv.
I I' li> llif liiiu' dl' n'huvcr".- (Ii.»(()\('iy nl iiit ulml inn lliis was (lie
'•Illy oj)enitioii knnwii fur ilic relict' of sull'dcntioii arifsiiitf from luryn-
;:ciil stenosis. Sinco tln'n intiilnition lins in iHiUiy instancrs taken its
place. With the irencral pnlilic tliis lias also liccn received with more
favor, inasiniicli as it is a Itloodless operation. Still, there are many
occasions in wliii li f laclieotomv stands ainne in it< ntilitv an<l iii which
till
I
l'i]L: ll'! I'liilcd 1 liulicoloiiiv liilic.
intuhaliim would l)c wmse tlian nseless, while there iire nthers in which
the choice of operation inu>t tiepend npon the siir<ieon"s judunn'nt of
the eatie |irescntcd lo liini fnr relief. I'nrtlier than this, numerous
cases Iiave oecurrcd in which intuhatiun, ha\inir lieen ]>erformed with
unsnccessful results. trach(><itiiMiy as a 'hriiin- nssart has heen re(|uired.
The diseases for which ihi' (iperalmn may lie retpiired are leih'ma
nf tlu' larynv, ahseess of tin larynx; syphilitic, t iihenuh ms, or malij^-
naiit laryn.uitis; the presence nf nenpla-ni- or fiu'ciirn Imdies. paralysis,
pseudomend)ran(nis larynLMt i-. etc.
Instruments riMiniied arc si'alpel. rctract«>i>, tenaculum, grooved
riiAt iii:»ir(»\i V. ;>.».►
dirccldi', itniiiilt-furccps, cf' , bcsidis tlic iiccrssiiry iriiclu'uioiny-tulx:
siiitalilf Id till' n;;»^ ol" the pationt (Vinf. 11.}, Ill, 11."), W'ta). Also,
to iiiiikr tlio oiitlit complclc. should he aiMcd ncodles, ligatures, tapi's,
:ciss(ii>. iiiid ar(('rv-(laiii]is.
.\< ii I'lilc. an ana'stlictic slnudd ln' u.-cd. <ithfr jronoral or local.
I'i;.'. 111. ll;oil miIiIht triicliciitdiiiy liiln'.
I 'mil ncciill} llu' loriiicr \\a> always adiiiiiiisterod, cillur I'tluT or
chlorol'onii. In cliildliood this is an iiiipoiMnt inattcr. as il is dillicult
to hold the child .>-till inoULdi to pfrl'orni ilif operation when at all
sciisiMo to pain. In cases where liic ilaiiLier \i> lilV hy dehiy is iiu-
iich
of
•ons
•ilh
red.
Ilia
l-'i;:. Iiri, KNlicrg's traclict t<ini_\ tulif.
ininciit or wlim. ow iii!.! to cailionii' aspliyxiaiion. tho scnsiljility to pain
is materially diininislied. the operation may he donr ai onco, without
attcmjtlintr aiiivsthosia. Tn children of larirer trrowtli and in adult-,
hyiiodeniiic injection id' a -olntion of cncaine in the reLMon of the larynx
• !(. ?
:ir)(i
IMSEASKS OK Till-: I.AUVNX.
or iiji|i(>r tniclica will answer an good a piirixiso us the administration of
ii ^M'licral anirslli('tic.
Ill tiic llr.rlincr k'Uiiisrlic W'ocltnisrkifl of Juno, ISHS, Friunkfl
sptiiks str()ii;ily in fuvor of lociil iinastlicsia in tlicsi' (a.-rs. lie lia^
|ifrfonii('d trai'licoloiiiy tweiity-tlircc times diirin^f liie last liirei- years,
(he patients in every instance litiiiL,' iiiKJer eoeaine anu'slhcsia. Many
<i\' tinse operation.-- would have liccii (hiii;;»'i(Hi< under a i;eiieral ana;>-
tlietie. lli.s plan is to inject liypudcMiiieally a few drops of a *^'<l-
per-cenl. solution in two ])lace.- near the site (d' operation, or of a
lO-per-cent. solution in four places. In children he alway> use> the
lO-pcr-ceiit. solution. In adults the anioiiiit injected is ahoiii I
cenli>rraninies of cocaine, lie >ays that the patients dreatl llu' cocaine
less than the ehlorofonn. One of the advantaires (d' ojieratioii under
lociil ana'sthesia is the reiiio\al of ;ill nccc.^sitv n\' undue ha<te, \o
l''!";. lliV/. IliOik's 1rii<'iit'ii|iiiii\ till)!'.
1 '
niatter how ana'.-the.-iii i- |(rodueed, it i,> ahvay^- better to liave o-ie t>v
more assistants, to aid in the \ariiuis diilii'.- n\' the operation.
'i"raehe()toniy may he I'iihcr hiLiii or low. In ]iii:li traelieolomy
the incision into the trachea is aipo\e the isthmus n\' the tliymid; in
low it is helow the i,'>tliiiiiis.
'The former is the one usually pei l'(Uiued. iiiasmuch as it involves
fewer hlood-vc.ssels, aod, heiiiL: nearer the external surface, it is easier
of accomjilishmenl.
In prt>paration for tlie operation, tlie patient is placed upon the
liai l\ with the head tilted haekward hy means of a roller or hard pillow
placed heneath the neck, the ohject heinjr to place the trachea and
larynx in a jiromineiit position. 'The iieek is then thoronirhly and
t|iii('kly washed with a -oliition of cuiro^ive sid liniale. carlmlic acid, or
other disiiifertaiit.
TIlArilKoiuMY.
For till' lli^fll (iptTiltioll llir ilUl^imi li\ ihr «(ill)Hl >linlll(l lie llDIll
lour to :«ix continii'tn's loii^f. iiiid diri'itly in the mcilijin liiif, rMciid-
ing from tlu' oppnsilr i rici.tli\ roiil niciiiluiiiic ilircctly dow luvjiid. Tlu'
two i'mU of tlic incision ^llould lie iirvdcd ^iradujdly in I'mni llu' cx-
icriiiil surliicc at fitlnT end. milking' tin' loii^rcsl part of tlic cut tlu-
external one. Al'trr tlic lir>t or .-km cul. toiictlicr with tliat td' tlu'
>upi'r(icial fascia lias 1. \ uiatlc, tlir di-scctioii inuiird >lioMld lie carc-
liilly done liy iii('an> of the scalpol-haiidlc, nmic than the Idadc.
'I'lic stcrntdiyoid nui.-clcs arc now Itronulit into view. 'I'lie areolar
tissue is pushed a.-idc hy the liandle of the Malpcl, and tlie nui.scles arc
held apart on cither side hy relraelor-;. 'I'lie-e can he held hy an as-
sistant. 'I'iic deep I'a-eia i- iiow ill view, with the thyroid isthiinis at
llic lower end (d' the cut. The part- are cleared of areolar ti>siie. e\-
posin.if the two lavcis (d' l'a>eia. one extendinu: in front of the i-ihmns.
the other hidiind it. The istliiniis ii.-elf is a liltle pink liod\ nwv the
second mid thiid riii;;.- of the traehen.
if on cxaniinalion there -eeiiis tn he roniii enough tn in.-eii llii-
mhc ahove the i>|liliiii>. the deep f,i.-eia i- iiiei-ed fnim the eiicnid
dowjiward and drawn a-ide hy reirailo"-. If the >pace iippeai- to he
too ^iiiall. a traii>vei.-e cut is made throii;;li the deep fascia over tlic
<iicoid cartila^i'. It jiiiist he hum' enoiit:!! tn admit the scalpeldiandle
or grooved director, which is al once iii-eriei| and >lid down hctweeii
ihe deep fascia and the trachea, and tilted up -n as to e\|ii)sr ihc two
upper tracheal rings. In cither case 'lu' ti-sue- arc drawn a>ide iiy
ritractors, the trachea >cized hy a teiiaeiduiii. and the lir.-l twn m three
lings cut in the mc(lial line, care hemg taken not to iiici>e the po>ierior
wall of the traidiea. The linal cut into the trachea should tie. hr made
until the lueniorrhagc fr(Uii the luevioii- iiici-ioii> have alialed i>\- I u
cnntroUcd. lvx|)ul>ive cougliing usually fnllnw- alier the tiaehca ha-
liccn opened, relieving the passage of any sreietinn- or alsc nieiiihiaiie
iliat may ho loose, in diphthcrilic ca.-e- the suigion .-hmild prote<-l
himself, as in iiituliation, from iK ■ contagion <d' particlo of mcmlirane
expelled.
As soon as respiration i- frer through the ailidiial opcniiiLT. as
large a tlihc as will freely i nler >li(udd 1m' inserted. This -hniild lie
wat( lied for a few niiniile.-. and when eoiiLihing is nver. and iircathing
ihidugh it has liee(une natural, the tape-. wlii( h had I ii previon-jv
attaclu'd to the rings, should he fasteiii'd round the neck tn hold it in
position, A thin piece of aiili.-eptic ah.-orlieut cotton sluuild lie placed
around the instiiimeiit heiwccn the -hiejd and the -kin id' the patient.
y.
I'fi
I.,.!j|t
l"'1
I
.•{.•JeS
iiim;.\>i;s (»i iiii; i.akvns.
'I'lic low (i|i( rntinii is pel rniiiicil ill ii .-.iiiiiliir iiiiiiiiitT to the Iii^'h
oiir. The c'littiiiL' is iiccis.-iirily (Icciht, and ( oii>ci[u<'ntly \\]v incision
should 1)0 l()n;,r,.|-^ cMfiidiiiL; I'idiii tlu' ci'iroid alinosl to (lie stt'iiniiu.
'I'lic iiiiisclcs to he held n>id" iiy I't'traclors aro tlu- stc'rnotli\ roid, in-
stead (d' llif stcriKdiyoid. 'I'licix' is niorc (lany;(,'r of liii'Mionlia;:t', as
the |)l('.\iis of vi'ins over tlic trachea is larijcr ami more c()))ioiisly siiji-
[ilicd with hlood. ( Ircatcr care is nectled in dissection; and soincliines
the tliyi'oid artery, extendinir to the mesial line of the trachea, scri-
oic ly iiilcifcics with the operation. When the neck of th" paticMit is
sliorl and thii-k. the operation is iiiiich iiioi'c ditViciilt. 'I'his, however,
is. in some case-. coiiiiterl)alaiiced hy the fact thai llu' lower operation
places a ^^realer distance lictwcen the wound itself and the laryn;real
disease tiian is jiossililc in the hi.i,di operation, and. other thini^s heiiii;
e(|iiai. would L^ivc the paliiMt a ,i:reatcr chance for life (i'"i;i. llii).
With rcfciciicc to Mftei'-treatinciil. it i< essential, in either cade,
that the tiihe ,-hould he (artd'iilly watched. .\ny ohsf ruction that miglit
occur in it shouhl he at once removed, either Ity forceps or cotton-
holder, or hy takiiiL; out ihe inside tidie. clean^ini:'. and retnrniiif^ it.
riie iiKUith of the t lacheoidiiiy-t iilic should he covi'ied with loose moist
antiseptic naii/c. 'I'lns should he chainzcd repeatedly and re^idarly.
'Tho air of the room slioiijd have a nniforni icmperalure ami humidity,
heinjx constantly charireil with tnoistnro in order to make the air (d"
respiration as nearly the saturation point as possihle.
The length <d' time the tnho is worn will dill'cr in each case, ac-
conlino' to I he circumstances relatinj; to it ami the nature of Ihe dis-
ease for the relief id' which it was inserted. 'I'he idiarijo (d' the case
^honld always he placcci in the hands of a rompctent nnrsc. and directly
under the snr^'eon's or pliysiciaiTs contnd.
IIVUOKIMV
Ii I
I'ii: 1 1 " repres( Ills iIk completed opciation for ihyrotoiny. (akim.
loi^cllicr with l'"iir. 1 Hi. hy pi rmi-sioii. from jio-worth's recent work.
The opciation rcsinilijcs somewhat that of tiarheotomy. Th(> incisimi
is made lhroUi.di the iiite,L:iiment aloii:; the mesial line, exiendiiiL;'
from aiiove the thyroid notch to the ciicuid rinir. The inti',i;umenr
iieini: retracted, the areolar tissue is prcsseil aside liy the handle of the
scalpel, revealim;- the thyroid carlilajic: and tlicn with a stronu sharp
knife an incision is made in tlic mesial line from top to bottom, 'i'his
incision shmild he LM'aduall\ and carefully deepened hy suecessivr cuts
;lll)-
4
: \
--*3I»
.j"4;Sf
ffc •• ;v>
i
<§P-
.>?>
•I^r,
•I^'
! ' ■•
ill. lii
sr!
iX:
(1;
, i tit.
i
it
h ,
i!
riiviioroM V.
;;»ll
until Ihf iiiiudus iiicniliiiiiR' is iciii'lirtl. In later ailiilt lilr liu- lliyroid
(•artila^'e is frcijiifiitlv llir >i-.\[ >>{ calcilicati.m and will ri,|uiiv tlio ii.-r
(•!' till' saw or ciittinii-rnici'iis in sc|iaial(' il into s.'^MU'nt>.
Jl is important tn sever (Ik- (■artila.>:c ami al-o to ennti'ui ihe Iki'Iii-
«>rrlia>rc lu'rnrc iienetratin,!.'- the iniienus nieMiliraiie; otiierwise a Iroiilile-
stiinc ciijeh niav riinlei' the eiP!ii|ilet inn dl' the (i|ieiatinii niorr dilliciilt.
Ill (ilder In have ihe npeialit exactly ill the eelitlV. aiul at the
satiic time tn >a\e the vnral cnriU frnin iiijurv, il i> well tn incise the
iiiiicniis iiieiniiraiie frniii lielnw iipwanl. the se\(n'(| earlihii^cs hc'in>;
held apart, while the pn>itinti nf the enrds is e\pn>e(| |n \ ii'w. I>v this
means they heenme a ,^llide tn the cninpletinll >>( the nperalinll.
It i> alway.- lie.-t, if pnssiiile. tn leave a >mall pnilinii i>i the earti-
la.irc directly hem^ath ihe iintch iinsevcrcd. 'i"hi> will prn\iiii' I'nr nmre
perfect iiiii(rii diirinn (he pi.icos i>{' healiiii,'. In nperatin-. the pnsi-
linii nf the cricnt hy rnid arlery ern>sin.Lr the erienihvmid mciidiram'
should li!;ewise he reinemhered.
W hell tile thyroid cartila.Lre ha> thus heeit opened, il i- (d'tcn dhli-
eiilt In distin.irnish correctly the tissues within the lai'ynx. t'arefiil
ohserxation nf the expo.seil arytenoids, howe\er. in their tn and fid
liiovt'iiieiits, will snuietinK"^ reinnve the dillicullv.
After ivmnval of ihr ^i^owth. for which the preliminary thvrotomv
lias heeii perrormed. ami iKemorrha'je has hoeii eniilroncd, ilu> cartj-
laircs are hroii^ht lni;ctlier a-aiii in as perfect appo^iiinn as po.-.-iidc
and secured hy sutures. In a child these should he of ,-ilk-worin ,i,nit
and loll in sihi. The skin i> then .-nliired in the ordinary wav. ( I'.ns-
worlli.)
The question of ju'eliininary tracheotomy and when it slmuld he
dniic iiinst he decided in each case upon ils own indi\idiial merits.
i%
'j
-I
( ii.\i"ii:i: i-.w I.
M I TK l..\i;VN(irilS.
'I'llis is a ciiiiiiiiiiii. lull nni n (hiimcroii-. di-cii-r. Ii i- uiiatlriKlcd
liv .sin<fiiiii('(iii.s inliliratitiii. tin iiilliiiniiialcrv |ir<i(i-,« liciii^ cuiiliiu'd to
iIk' iruicdiis iiifiiiliiaiic witlidiil iiniil\iii<i (lie dti'iicr ti>-iH's. Its chii'l'
iiitcicst lirs ill the iiii|iairiiuiit nr cvcii Idss of voice wliiili ii>iially at-
tt mis its (l(\i'l(i|i!ii(iit.
Pathology, 'i'lic (irst (•iiaiiiro aif tin' ainiipiinal dilatat inn i<( the
la i_v lineal III I-Vfss('ls. willi anc-t ul i:laiiiliilar sctictinn. 'I'iii^ is
i|iii('l\ly I'ollmvcd hy cMidalKni nl -iiiini and ictiiin of iiuicoiis mttc-
tion. 'riic loose I'olds (d' iiMUoii^ nitnilirain' lM'<oinc rii^orifcd witli
liloo(l, as wt'll as liatlicd in x ro-iiuicoii.- di-(l:ar,L:<', Tlic parts most
alVt'clcd arc wliiTe these foMs are aliundaiil a- well as loosely attached,
a> ill the arytenoid coiiiini.--iirc and vcnliinihir hands. As the vocal
cords are ' 'i|i|ilie(| with tiinei|iai'ou^ ulaiid-. their li|ood-ve,-scls
hccoiiie dil- • itlnuit dix har;:e (d' iiineii«. 'Ihe inllaniiiiatory action
rarely exie .ii.- helow the vocal idid.-. and the e|)i<f|ottis is liki'\vis(!
rarely a participant in the di.-ea-e.
Etiology. — Without the e\i>lellee (d' >oiU" pledi-posillL' caiHC,
acute laryii.uitis docs not (dteii oe( nr. 'I'his ll^llally tak<'s tlic I'oriii of
olisfriictive interference with normal re-piration. cither from intra-
nasal lesion fir post-pliaryiiLri'al disease. What lliese palholoLrieal eoii-
ditions are have already iiccn dwelt upon. It will siillice (o say that
hy])ertrophie conditions (d the upper hreathiifj-passaires. wlien siilVi-
cieiit to j)rodiiec oral rcs|iira;i<in. may heconie a predisposiiiLC cause.
The same may he said of ciironic catarrh of the pharynx, and also of
atrophic rliinitis, imismiicli as it deprives the ;iir of rojiiralion of its
necessary moisture.
'riie immediate cause of tin disease is freipieiitly exposure to cold,
.i,'ettin!i the feci wet, siiddeii chanires id' lempeiatiire. too hasty coojiii;;
of the liody duriiiir jierspiratioii, etc.
It ooeiirs at any aire of life. Init in men more than women, owin^j;
to the greater exposure incidental to their lives.
Inhalation of irritating vapors, such as chlorine, ammonia, etc., or
excessive smoking may give rise to it. The internal administration of
(362)
ACITK I,AUVNUIT1S.
yoij
ind. [int. ill liir^'c (|n^(•s Will iil«i' ill (• I'taiii (Msrs |»r(Mlu(t' IiirvM^ral in
tlainiiiatioii.
Amitlicr caiisi' (Hiitc rimirunii aiiKUii,' vnicc-Uifcrs is overstrain nf
tilt' \ni(f ill siniriiiir. [nililic :-|H'akiii,ir, «'ti'.
Symptomatology. Tin' ninst imtii raiilc <yin|.tiini is liciarscnos in
various dc^rrccs. It is nuc. Iinui'vc', \ <v cniniilt Ir a|iliiiiiia tn ociiir.
for till' siinplc rraMiii ilmi it ici|iii!cs iimic or li>s inliltriilicui nf tlif
arvlcmiiils or vocal cords to |iiddii(c alisoliitc loss ol' voice; and tlli^
woiiM place it under tlie licaditii,' of larvii^'itis i^n'avior instead cd' larvii-
irilis niitior. or simple larynjilis. Willioin indltralion rially exist-,
the \iiiee ciiii alwav- lie sipiiiidcd liy inakiiiix extra ciToit. <a\e in those
cases where ilie iierviJiis eleim ni ha» entered lar<re|y into the history,
and in these the iim' (d' the laiyiiu'o>cope should nialeiially aid in the
diai,niosis.
hiseoiiifoil i> ii-iially in the rnini of sdiciK s< rather than pain, and
partak(s <d' the dry and -li'^ht ly-lmi niiiLf chaiin I. r. '["here is no diHi-
eiilty ill re>piratinn. hiil frei|iii inly a har-h. irritatiiit: thioal-coiiudi in-
creases the ;,fencral nialaise. 'i he coii'^li. too. is out ni piopoition to
the sniall anioiint id' expeetoral inn which is at first discharL'ed from
the inllained throat. This secret imi increases somewhat as the disease
advances, 'riieic may he .>-liL;ht diHiciiliy in swallowin,:,' solid food,
while hiand diet will slip down withciiit ell'url.
Of lever there is tint little. No distress id' the <,'eneral system aiid
practically the disease re.-olves itself into tiniporary hoarseness ae<'om-
paiiicfl hy more or less irritation.
Diagnosis.- I'' reijiii 111 ly the aluiipt on>et of the disease, with the
charaeteristic voice, is (|iiile siillicieiit to eslahlish the diaLnmsis. Still.
there are many tliiii;/s wlii( h may jimdiiec hoarseness, and it is lietter
when possihle to nial<e the opiiiinii sure hy the use of the laryn'_ro.'cope.
The chief aim in iisitiLT it should he to examine the vocal cords. If
they are smooth. allhoiiLili reddened, opcnin.: and (dosin'j evenly, and
are without thiekcnini^s nr indcntatimi.- iipi n their horders. (he diai:-
nosis may ho tolerahly sure. The hlood-vesscN upon (heir siirfiices may
he liiirliei t'olored and more prominent than usual, with the cord- ."^till
white and jrlistenini:; or the whole surface- of (he cords in a'^i^'ravated
cases may he hypcra'mie. .\i the same time, the mucous linin>,' of the
laryn.x will have a hright, con'iested line, which in some eases may
culminate in thickcninj? of the intorarytonoid commissure, preventing
entire closure of the cords.
A red or pink color of the vocal cords, however, is not always a
Hi.-
.{»; I
iii>i: \-<i:^ or i in. i,.\in n\.
%! i
iliugiin>iic iiidiiiiliuii 111 liii\ ii;;iti.«, imr I'lllur i> a iMiirlv-wliilc coiidi-
tiun a sure si^n of a tiniinal larynx.
'I'liis was hrniij^lii nui jirumiiiciitly \>\ llcniif,' at the nrcnt Med-
ical ('(•ii;:if>.-^ a( War.-aw. lit' ,<ai<i llial not iiirri'i|iH'ntly tlic pearly
wliiti'iics.s was fati.-t'd li\ iavors ol' lliickciird ('|iillirliiiiii, and lliat
owiii'is (d' Miral (iiiil,- nf tins ciilnr would ('(uih' Io the larvn^f<)lni,'ist I'^r
IrcatiiKiit I'nr Mical iriiiddi-. ulidf. dii llir ullirr hand, xnwf (d' tin:
l>est sin;:('r.'« had I'ld, ratarrhal-lnokini
tioloi.st.s III' knew (d' had sliiihllv-r
ciiid
»»nc (d the liiu'st ladv
('(I ciuil- hcluic Miiinni', and very ro(
1
oiU'S al'ti'i'. In tlu'Si' cases all llie syiii|ilniii- and ^i,^'ns availalile ninst
add the lai) n::n|ii;,d.-t in aniMiiv .il a cnirni dia^no.^i.-.
In ciiniiiariiiL: hdai-eiiev- li'iin ihi> di>(a>e with that piodneed liy
iillicr llndal all'eetinn> il -hnuld he rennni'ieied lliat the h<)ar>ene.--s
(if lar\ni;eal lidiereuhisis i.- Mill anil v.eak, and that (d' s\|)hilis i.s harsh
and '.^latinL:. whdi' thai lr<ini aeiiie i ..unination is even and firm, al-
thonijli il may he ra^pin^ in inne. In IkiiIi the I'liriner. as well as in
niali,uiiaiil di.-ease, and when nenpa-ins aie present, the Imarsoness
eiiiiies mi ::radiially i<iid .-lowly, wilhoiil leiideiiey to inipniv enicin,
while the disease under eoii>ideration is .-ell-liniited in history.
Prognosis.- -I I is imi din,i:erons to lil'e, and it runs a conrse vary-
ing' lidin a lew days tn a eoiiple of weeks. 'The inipairineiit id' the
fiuu'tioii <d" voiee-proiliiciiiiii. pail iiiilarly in ^iIll;l r- and jmldic speak-
ers, is till.' nm.-t iniporlaiil i nii>ideratioii in le^Mrd lo it: another point
is the prohahilily id' it^ reiuiiinee. owinu in the presence of the pre-
dispo-iiiL,'' causes already iianud. .\ny tiinlency to extension (d' the
disiase down into the trachea or hroneliial tiilu's ninst akso owe it.s
ori^dii to the impaired naso-pharynireal respiration rather than to laryn-
geal inllammation. The-e .-hoiild all pnini to ihe importiiiicc id' re-
moving' any stenosis that may oeeur iii any part of the upper re^pira-
tory pa.--aL:e>.
Treatment.- As tlii> is a local ilisiase. attended hy so little fehiile
(hstuihance. 1 helieve larjiicly in relyiiitr upon local treatment. This
should not, however, he conlimd to the larynx, hut slioiilil eonimence
with the none and nasd-pharyiix. W'hatcvci' is the immediate cause of
the disease, examination, as a ride, will find more or less nasal steno.si.s
in one or hoth pa.ssa^'cs. In these, if treateil at his oHice hy the .sur-
geon, a l-jjer-cent. solution of cocaine should he thrown np each nostril
by an atomi/er. .\ small ([uantity will sulliee; and in two or three
minntes tlie astringent elfect of the cocaine will bo noticeahle. The
patnlous condition of tlie jvassages will he increased and the ])atient
.\ri ii; i,\i{VN<iM i>.
:{i:r>
iiilc
Ilia
■nee
-(> of
lusis
;iir-
<tnl
iroe
The
lent
• Jill lildw out I'lVfly iuiy acciiiimlatioiis wliicli liy|)t'rlro|iliic rii;iorg«'-
iiu'iit iiiiiy liavc iiilowi'd to HjitliiT. An iiiipottaiit dul imw to lir aiiiii'<l
at is to kiTj) tln' passa^ri's ()|k'I1 a.s lon;^ us possiltic, lliiis ifstoriii;,' nor-
mal i('.«|iiratioii and I'afililalin^r lai'vn;iial rccovcrv. Spcakinu' J'liliroly
from my oun cxprririicc. i would ajiaiii rclVr to the cjliciciiiy in jiro-
l()ii;.niiLr tilt' astrin;,'t'iit alVccl of cofaiiii'. wliii li 1 Iimm' imiiid tlic ap-
plicaliiiii iif l-per-cfiit. xdiitioii of iiifiitliol m alliolriic to ponsoss.
Wlirii tliiowii into tliL' nasal pussajit's liy an iitoiui/ii' iiiinirdi.iicly after
the aiisorpiioii of ilio cocaine, it not ttnly -l miiihiti's tiic .-nreiing cells,
tlnis relii'\ iii,^' the eiiL:or;:emeiit, hut al.-o coiiiit»'iacts the depressing
i'lrccl which the cocaine itself produces.
.\c\t, the pharynx ^Imuld he spra\(d niil I ii i ly with an alkaline
solution. >ii(li a- linlielTs. This will relieve hi. ill |)liaivn\ and larynx
of any hypeisec reiioii that may he preseiil If the iniyiu is found to
i)e \cry niiieh con.L'este(l, a 1-per-ceiit. solution of ccuniie should also
he thrown into it tliroiij,di the down tip of the atonii/.er. The coii;,resled
condition in a \ery few iiinuK nts is Mimcv hal iidieved. The treat-
ment immediately following this depend- ii|inii the h ii;:ili ni' time dur-
ing whii-li the disease has heeii in e.\i>tei)ic. If aihice is sou;;!it near
the onset of the symptom.- a similar l-nci'-ccnl. solution of monthol
in alholene as that alreadv appliecl to the nose will have a good elFoct,
jind a spray of: —
I. Ii Tliymol ,
Mcntliol
AlbuJL'iiu
M.
.00
iipplied hy the jiaii' nt to the laiyiiv every twn nr ihree hniir.- until he
again retiuires to see the phy-iiian, may he |neMrihed.
If tlio inllammalory Cdiidilion is of loiiLter stamliiig and well
estahlished. the cocaiiK' sidulioii may Ik; thrown into the laryn.x a lit-
tle more freely, and followed immediately hy the ap|tlicati(m of a v-per-
cent. snliitinii of niliiite of silver hy iiicans of the liirvii::eal cottoii-
hohler. .\ similar solution id' the nitrate loiild he ap|iliiil hy atomizer,
and liosworth recommends it in this way. After the application of
the silver the jiatient >lioiild carry out the liome-tri'atmeiil as already
<lescrihed, returning evi'ry second day to have the ajiplication renewed.
In cases in which Ujion examination we find some hypertropliic
1. 3 Thymol f?r- "j-
Menthol >?r. x.
Aibolene 5ij-
f
it
M.
M
36G
iiisi:am:s ui iiik i.ahvnx.
Ijj' i!
it
liiisiil .>|- |iliiii\ iil;i';iI 1i>>iic (M(ii|iviiii;- a |iriiii,iiv ciiUMitivc icliilioii to
the liirviiiiitis. till' i|ii('^tioii (iT ii(l\ isiiliilit y nl' (i|H'r;it inn iiri-cs. Some
liirvii^ioldiii.-ls liclic\c ill \vititiii'4 until llir hii yniriiil ilillicnily has siili-
sidcd licrurc (i|icriil iii^. Ollicis liclirM' in ii|i(ial iiiu' ii- snnii as tin!
loKni i.- (ili.-ci'\('il. lii'lii'V iit.Li 1 1 I.I I till- ilx'ir will |ii<iiliiic a cnic. In my
(iwii niiinl. it' llific i> liill*' nr im |r\ir in cnii-riinciicc nl' llic laryii-
^iti.-. the lallcr i> the plan llial 1 iiidrr in lnllnw ; and I have never
KiKiwii II In lie |irndiiel i\(' nf e\ il re~iill- Si.nie iia-al and |iliaryiii,'eiil
<i|)erat inn- are allended li\ nmre nr Ic-- lilicdini;; aii<l il is well In
ri'iii.iidier ilial tin- lia'iunii lia^e nia\ have a sidati\e ell'ecl ii|inn the
iiillaiiied lai\ n\. Winn, lin\\e\ er. | Ik ic i- niiieli filn ili' act inn nr the
larvnmli- i> -e\ei'e. Il I- al.\a\- lielliT In |in>i|Miiie n|M'ralive iiieasiires
until alialeiiieiit ha- lak( ii plaie. In llie .-aiiie \\ ay ,i;al\anneaiilcry
n|ie|'at in||> Wllllin the nn-e -hnllld lie | in- 1 | in lied , nil aeecnilll < d' til"
(rdeina and -lenn,~i~ wIikIi lhe\ -nineiinn- Ic in|iin'anly ]iindiiee.
When the inllaniiiialni v aclmn i> allended li\ niiieh re\er. and
the lai\ ii,i;eal ii rilai mn i- \ ei v lt. al . a < lire can he evpediied hy .-teaiii-
inlialatinii riei|nenllv re|iei:ted. ur h\ eniiliniiit.' the jialieiit In a warm
rninn. -iiieharLied with inni>tiiie e\a|)nra|ed \yntt\ aiit:se|ilie snlntinti-
(if nne Inriii nr aiinther. W nil llii> the ailiiiiiii-1 lai mil n[' lineliire nf
acnnile. I drn|) per Imiir. i- >till a lavnrile leniedv with iiiaii)'.
When enllllnenienl III the hnll>e JMcnnie.- Ilece-vaiy. I prefer llle
ilpplieat inn In the lleik nf ('i|nal part> nl' iili \ edil and nil nl' I lllpelll ine.
with an niilside wrappiii;^ cd' alisnrheiil entlnii. In the (ddd'ashiniied
inethnd nf pi Ml 1 1 lei 111;'. ( 'nid paekill;.; tn I lie lleek is alsn prndllelive nl
a sedative ell'eil iipnii lln inllained lai\n\.
It i< dnidili'id ir heiielii can he deri\'ed I'min the ii-e nf <iidinarv
ast rill^U'ellt |nZellL:e> in ihi'M' ea-e-. 'rhr\ ilii linl en|ne in eiilltael "vitll
the interlar\ iiL;'eal niiienii~ nn mhrane. and Imw a >liuhll\ a-l rinu'eiil
ell'eet llpnll llle pliai\n\ call iiillelil the runner !.- dnlihirnl. W'liell the
eliii'l' inL[iedienl (d' the |n/.eiiiie i- (if a vnhitile iiatiire tile ease is dil'-
I'erellt. 'rhi> may he -aid id' niellthnl !n/ell'je-. 'I'liey tint nldv InM.!
a Ineal inlliieiiee llpnll the pliary iiu'eal wall-, hiii tie' \apnr nl' the men-
tlinl is emit innally hrmiLihl in cniilai't with the lunenii- inemhrane (d'
(lie lar\n\', prndiieiiiL:' a e<inlin.r. ii- well a- a-l riiiiieiit. eU'eii.
One impnrtanl pnini dnriiej treatmeiil i- In in-i-| npnii a- little
use (d' the vniee as pn»ihle. The /iriiiiii' rid' slimild also he rcLiuliitcd,
ami judicious cITorts made in avoid any repetilimi (d' evposiire to cold.
'Pile ini|)ortiuU'i' of iilisoliite and eniitiiiued nasal respiration should
likewise he impressed upon (lie mind rd' Ilie pidient.
[■ !'
(■ii.\i'i'i;i; i.wii
M \ w: \..\\[\\c,\\\> ni' ( iiii.i)i;i;\.
I\ cillK lll'i' llclllr l;ll\ IlLilM- I- llhUi' llrcjiM Ml lliilM dlirillL; ;|(|lllt
V<'lll>. nwillL: t'l IIk' 'jrlHTilllv |(mi-c ,i1 I Milnilrll t iil' lllr lllllrdll- IIHIII-
lilillH' .-IIhI 111 it- lllir<M-ci| \;l~clll;inl \ . 'I'lli' lllll;illllll;lt HM. ulllrli i<
rit'(|iiiiil l\ phiii \ iii;i>;il III il~ iiiiLiiii. iii;i\ cAlrinl incrciv in llic ii|i|icr
|icirliciii nf ilic l:ir\ii\ iir iii;i\ ]i.i-~ ilnw nw ;iril. ;ilTi( i iirj iIh' iiil i;il;IiiI l ir
rc^inll. 'Ihr |(i(i-c illlilihllji'lll (i| ihc 11111(11-, 1 |ir||||ll.- ol' ,\ (crlillll
illlHUinl 'i| inlill nil mil Ullllnlll |irl|i't ml inu ilrc[i!\ inln \\\r -.IllllllllinU^
I i,--l|i'. I illl.-lllL; till' ill III I II ill- -\ III I I'll II I- W hirll -II I ill III I ice Ml' 111 VdllllL;
cliililrni 'I'lic ca-i- iliMVr in -i\ii'il\, llir iiiiMiT mir- liriiu ili-liii-
^t;lli>llr ' llliTrK li\ ;l ll;ir-Il riillLlll. lilf IIHU'i' -r\i'lr ii||i'- liV M sIlllli'Mt
S|tll.-llliMllr I -Id- 1 ire 111' I 111' -lilt ' I- 1 1 III- ill;; I Ih' ;lit- nf i i iIIl: ll 1 11 '^ II ml lili'lll ll-
Iiil:'.
Patholog'y. In lln- ili-cn^c uc Ikim' In |iri;iiina nf llir liir\ iilk iil
iiiiicii-ii. till niinnlr \i--rl- Ih'iiil:' l^iuliciI with IjIihuI uml the lun-cIv
illt;icll(i| inrllllillllli' liclll;j -Witllill In II llinri' iir li'-- rNliIlt li\ I \ 111 | illlll ir
prcs-lllc. W'lli'll riilllillril In lllr - II | ) I'll L' |i ill Ir |liirlliii|. llli' 1 1 1 llll ■ I'llrt H 1 1 1
is illlliti'il; wllrll inriil'^liil t K It llliiy lie -r\i'|r 11- Ucll ;l- cVtrll-iM',
iiliiinsi rliisiiit; llif Iniiini nf iIh' irirmij rrL;iiMi uml iirmimiiri -cmtc
liir\ llliiili <lrl|ii>i-. Till' -\wlliiu; nf lllr |)lllt- I- :lluil\- I(I|||1iimI In till'
ir.iiciiii- iiii'iiilirniic il-fll'. iiml ilnrs iml iinnKr llir -iiliiniicnii- li-.-iir iis
ill iiciitr ii'ili'inn. ;iml i- |iriili;ilil\ ilnr in ilir jirf-cin c nf llir l\iii|iliiit H'
\C'>-M'I-. wllicll ill r;ill\ \i;ir- In', If- -i i 1 111 | mil ;l li t ;i |i;llt l|| lllr ;l!mln||lV
III thr tlll'nill.
Etiology. 'I'll:' |lli-rmr nl 1 1 \ | ii ■ I I I 1 1 1 il I \ n| lllr I \ 11 1 1 1 1 111 I ir ll--nr-
dl' t l,r I lirmit i- l'rci|i;ciit l\ ii |ircili-|in-iii;^ niii-r, mil (inl\ rmui I Ih' Icm!-
(>lll'\' In l\ m|ill;ll il' inlllllllllllll mil imiili'lltili in niris Illr. luit ;ll-n I'i'nill
lllr nil-ill sli'iiii'-i- uliii'li I'liliirLii'i! rniiiiiil nr |iliiii\ iiunil |(iii-il> -n i'rc-
i|ii('iil iy ciiiisi'. 'I'lic iimiil II -liri'iil liiiiL' \\ Il llll I'lillnw - iiiil- in |)riii|iii-iiiL:'
Iiii\ iiuciil iiriliit ii'ii.
'I'lii' iliscii-i' i- |ir(ili;ili|y iimir iniiiinnn nnmiiL; i||-iiniiri>|ii'(|,
ricjjicclcil. ilj-cloliinl ciiiMicii. Still, it rn'(|iiriit ly ncciiiv ill Mppiir-
ciilly s(r(>n<j iiml xiuornii-; ones. I'mlmlily in tlirsc ;i ciirfriil (•Xiiiiiiiin-
(icm would rcvcnl ii lyiiipli;itic tciKlciicy imt at lli-t iiuticcd.
'M',H
1)Isi:asi:s ok tiik i.akvnx.
'J'lie oxi'iliiiLr ciuiiio is usually idM tir I'xpuj^urt' to ohiin,ijc'al)lo and
uneven teni])eratures. Childri'n often ^,^'1 overheateil while playinj^
and will sit ilown. cooliiii: the body unequally uliilc the skin is still
])ei's))irin;f. 'I'lie eonse(|ii('iuc is ;hat the Mood is driviii I'lnm the sur-
face to the internal tir^aiis. iiml the throat, liahlc as it is to catarrhal
aU'eclidMs, is tlu' or^aii iiil.-i likely lo he alTected.
I'xiys siill'cr more J're»[U('nt]y linni this dism^r than uiils. jirnh-
alilv nwiiiL,'' to ,i;icatei' exposure.
Symptomatology. The niihhr tonus of ;iiuic laiyn,:;itis in chil-
dren usually ((Uiiniciii (• m luiite rhiiiiti-, the inlianiinatory action cx-
tcndin<i down to the pharynx and ihr ^up^al:lllllic■ jjortimi (d' the
larynx. There will he druu'ss ;ind ii'iilatinii of ihe throai. with sli.iiht
hoiirseness and >li'ididiuis couixh. 'I'lic more si\ci'i' ca-c-. ihose to
which the term spa>inodic cidup is >(i ccimmoidy applied, are more
likely to arise in cases of tonsillni' enlaru'emenl. the larynu'eal symp-
toms arisint,^ I'ldm direct irritation. 'I'lie constitulioiiid di>turl)ance
is jjreater in the latter than in the former: and the fexcr, whitdi is
sliglit wlu'U the upper larynx is aiVeeli'd. is likely to iiecome severe
when the suhLdidlic reixion is the seat of the disease. It is only in the
latter that laryn.ircal stenosis is likely to be at all severe, lloarseiu'ss
will be of a shrill, metallic character at lirsl. <,n'adually a>snining a
liarsber tout' and in sonu' instances endinjr in aphonia. C'ouirh attends
this disease from the first and is stridulous ainl croupy. with nocturnal
exacerbations. 'J'he attack usually ctmics on in the nii^ht-tinic, and the
child may coui^h for a ([uarter of an hour before it can obtain relief
by the expectoration of a little mucu-. Sometimes the exacerbations
are re])oated seveial times durini.'' the niiiht.
The disease is more |irevaleid duriuir the cold and dam]) months
of the year, and, haviuLT once oi'curred in any child, is liable to recur
again, uidess the obstructive lesions, which may have triven rise to the
first attack, have been removed.
Diagn* is. - - l.arynnoscopical examinatitin in youni,^ children is
usually very dilbcult. Still, in some instances it can lie accomplisluMl,
and will reveal the liyperaMiiic and infiltrated eomlition of the inntu-
larynx. In these cases Kirstein's antosco])e in skillful hands should do
good service, and under chloroform should be particularly easy. Ac-
cording to Kirstein, it can be done without the use of the anivsthetic.
but is necessarily diilicidt and somewhat dangerous, owing to the
struggles of the child.
When visual examination of the larynx cannot be made by either
Arm: i,.\KY\(ii lis OK ciiii-nitKN. :!•!!>
inctliod, it makes tlic diiii^ninsi? iikiM' ilillicult, as lli<' unliiiaiy syiiipldiiis
bear soiiH' rc>('iiil)lanc(' to those of ineiiihraiioiis ernup or laryni,'eal
iliplithei'ia. Si ill, the severer diseax' is attemlnl liy imieh si'veier
symiitniiis, such as hijilier tonipcrature, more eomplele aphonia, more
noiseless eonuh. and irreater phy^^ieal ])rostrMt inr. Mn-t writers, at the
present time. ai;r<'e with lh(> idea ol" the iilenlity nt' p-eudmnendirannus
croup with laiTnLiea! diphtheria; and it mr.-'i lie reiiiemliered, in the
way of iliajrnosis. that in the latter the exudative disease is striitly
proirrt'Si-ive, while in the so-called spasmodic (•r(Mip the iincturnal e\-
aoerhatinn> are the most important feature.
Prognosis. — 'Ihis diseast> is not usually dan^^ernus to life, 'i'he
nocturnal exaeerliatioiis aie the only indications which >h(udd tause
alarm. I'sually they increase in severity for two or thiec niirh.t.*.
Then they ahate ami soon disappear, the hai'shness of tiMie and throat-
irritation j^radually passin;-' away. The disease may l)e e.xtendi'd out to
two or three weeks, hut usually it is of .shorter duration. Occasionally,
thou^di rarely, death may ri'snlt froni the suliiilottic ledenia.
Treatment. — .\s soon as the decided hoarseness ov croupy i.iu^h
occurs in a child. iiulieatinLi' the presence of acute laryngitis, he should
he placed and kept c(Uitinually in a temperature ol ainuit T<i'' !•". it
would he advi.-ahle to have moisture continually evaporateil in the
room. The bowels should be moved l)y a laxative, ami mild soft nour-
iplinunt -hould be yiven.
For internal admini-itration minute doses of aconite, with car-
bonate or muriate of ammonia, do excellent service, as they relax the
pores of the skin and stimulate the tbro.it to mild secreti(Ui. The I'ol-
lowin<r are suitable |M'eparations: either of these mij^ht answer for a
child four or llv(> year- old: —
1. II Mur. aiuninii ,">
i'v. ai'oiiitf 2.')
(ilyc'criii 4
.XiiUiOii ad aO:
i
-M. Sip.; Olio teaspoon fill every "lie or two liours.
1. li Mur. iiminoii ;,m-. \ iij.
'I'r. lU'onito ;;l t . iv.
(ilyeeriii .ij.
.\ilMani iiil ,^j.
*
:ii
ri
I: .),
IU(» |)I>i:asi;.'«. oi- mi; i.auynx.
1. B Carbon, iiinmnn 14
'I'r. iifonilc 12.')
(ilvccriii 4
.\(|Uillll iltl ."{0!
M. Si;;,: One lt'ns)i<i<iiil'iil cvciy "iif »ir two li<>iir«.
I'"t)r t'Xtcriiiil ticiiliiiciii 1 like iidlliiiii; lu'ltrr iliiui ii stiimiliitin^'
ciMdllii'iit ii;i|ili('iili(iii to tile neck nl ciiiiiplKii' liiiiiiu'iit mihI olivr-oil,
('(jiiiil |tiirls, (»r nil III' tiirpciiliin' :iiiil olive-oil in like proiiortioiis. 'This
.-lidiiid be ;i|)|ili('(| uilli llic Wiinii liiiml to llif iH'ck. llicii ;i smij: l.ivcr
ol' iihs(irl)('Hl ciilldii w iii|i|)i'il i<\cv it iroiii cai' tn car. \\\ its wiii'iiitli
il |iripiii(it('s senile |i('i>|iirati<iii, and lliii> drplftcs Irdin tlic pai't. wliilr
it all'oid.s ca.-f anil ciiinrnrt to the iiillaiiicd tlirnal. 'I'lic iKntiiriial at-
tack,>^ may he rdii'vcd liy a Imt >t('am-inlialat ion. and. when tiiis Tails,
the inluilatimi n{ a IVw di'ii|>> nl' (liloi-nroi-m will soiud iiiics clicck tlic
f.xacfiliatioii.
.\< I 111' (I did ill 1 1 HUM'.-, tlic tliickiics- III t lie til mat drc-.-iiiu sin mid
lie made L:iadiially le>>. and care slinidd In taken aiiain-t Inn eaih an
e\|in<iii'e to cnld.
W'licii ill M'\ere case.- all ntlicr measures Tail tn t;ive relied' tn the
little [lalient. resort may lie had to intuhatinii. l'rnloii,::'ed use of tlie
tulie will not lie rcijiiircd. a> il i> so ri'ei|Ueiit ly in eases nT diplit lieria.
the insertion of the tidic fur a few liiiur>. nr a day nr twn in extreme
casos, Iti'iiij,' all that would he needed. In mi mild a di-ea.-c intiihation
is nndouhtedly |ir(deralile to the more serinii.- operatinn of tracheotomy.
.\fter the recovery of the child, wlieii the disea>e owes its primary
<iri,iiiti to lymphalie hypertrophy, tlii.- should he treated aeeordinu: to
rides already laid dnw n. and iiy thi> mean- an end put tn any tendency
t(> feeurrciiec.
I. II (iOllllll. Mlllinilll xry, vj.
'I'r. aiiiiiitc ;;ll. iv.
( ilytTiiii ,1).
.\i|iiMiii ml .^j.
.M.
.1!
cjiAi''ii:i{ i.wiii.
;|:
ALTTK (KDKMA'iOrs I.AUVNCUTIS.
Aci'ir: iiilhiiiiiiiiitidn of tlic liii'viix. iitlcinlrd liv irdcniii. iin- Inm^r
\)Ovn (IfSfiilicd liy writers uiidci' a diversity nf iiiiiiu -. 'I'lic U\r\> iliiil
it is ail ('Xr('c(liii;il_v acute iiillaiiiinalinii. lliat the iiitlaiiiinal imi ,i;<ies
(lecper than tlie iiuieoiis iiieiMliiaiie. and lliat it i> attciideil hy ~\\\>-
iiuicoiis iiililtratioii arc suHiciciit to make the ahoxc tith'. cho-cn mit
of tlie many it hears, (inc lliat at h'ast is applicalile to the disca-i'.
Pathology.-— The m(ni)id ehaii;:cs are indicative (d' acute \aMidar
tnrjiesccnee. more rapid in luiinalion than in simph' acute laivni;itis,
ami attended hy extension to the >uhniuc()ii> ti>-ue>. with almn.-l im-
mediate serous iiililtratioii. 'I'his occurs most exteiisi\clv where the
mucous inemhrane is loos(dy atta(li:'d. as in the re;iion of the \cii-
tricular hands, the arye|H,u'loltic folds, and the |io>tcrior surface of the
epi^dottis. 'I'lie arytenoids are almost as readily >wol|cn. whilr the
vocal cords and the infra^lottic re^iioii. with a imu'c closcl\ attached
mucosa, are less liahle to the disease.
As a rule, the aireclion is hilateral. and. if iiiu' • keil. -laplivjo-
c'oeci. streptococci, and other oroauism- make their appearance in the
indltration-lliiid. and the disease may pa>s thidULih from the -cidii-;
sla^'o into the purulent. 'I'liese chan.ii-es occur more rapidly when the
disease is unilateral. The cmidilioii in any ca.-e is one of acute cellu-
litis.
Etiology. — Sudden and uneipui! c\po>ure id' llie liodv; In cold is
the a|iparent cause of a majority <d' ca>es. It i- liciirrallv lielie\cd,
liowever, to owe its origin to micro-oiL;aui>ms: and I hat the une(pial
temperature to which the p.aticnt uiitili! he c\po>ei|. i> onl\ ihe malih
vliicli kindles the lire, the find foi' which ha> already heeii prepared
i'or i<;-nition. What would seem to "ive cidnr to this helief i> the fad
that, wliile exposure in one case may produce >imple ai-ute lai\ ii^ilis.
in another similar exposure may residt in inteii.-c n'dcmatou- di>ease.
decent ohservers, as Levi and Lanieres, hclicvc the o'dema to he
of infectious ori.nin. while Liaras helicves that it may he even a trau-
matic (cdema, immediately dependent upon local vasomotor disturli-
ance the result of voU].
(;;:i)
ii
E'k
■672
inii^E.\i<liii OF THE LAKVNX.
!■ (
It orcMn> lunif fiv(jiu'i)tly in iiialcs tliiiu fciiialcs. and in early adult
lii\' than in Inter or earlier years. It i>; a rare disease, synipathctie
tedeina of tlie larynx beinir nnieli more frecjuent in occurrence.
N'oice-strainini,' has heeii an appa'^ent cause in some cases, and
facial erysiprlas has soniftinn- heen rollowcfl inmiediately hy (cdema
of the laryn.v. which, in all jtrohahility, \va> an e.xtension, if not a
metastasis, ol' the erysi])elas itsell'.
'rrauniatic causes will produce acute (udcnia, as from iidialation
of hot steam or swallowinj: of boiling water, etc. As a secondary atfec-
tion, it may ari<e as a conii)lication of the various exanthemata, though
the cases are exceedingly rare.
Symptomatology. — The throat .symptoms occur so ijuickly and are
of such distressing character that the ordinary premonitory symptoms
of chilliness and fever arc sometimes overlooked, althougli they may
be jireseiit in every case. In the most severe one that I have ever
seen no premonitory symptoms oi any kind were observed, save a slight
feeling of weariness. Without warning, the ])atient, a strong young
man of '2'), was seized with dyspniea, and in six hours it became so
severe that respiration liecame stertorous and the face cyanotic.
The voice Mion becomes lost in a soft hoarsenes-. Inspiration and
expiration Itotli become lal)orcd. \{ first the face is flushed, and, as
diniculty in Imathing increases, the purplish Inu' of cyanosis takes its
place.
'i'hese symptom^ nuiy l)ccome fully developed in from ten to
twenty-four hours, or. as in the case referred to, in a shorter period.
In severe cases the result will lie fatal in from one to three days, with-
out surgical relief of one lorm or another is secured. In milder forms
of (rdematous laryngitis tlie course may result in spontaneous resolu-
tion or the development of abscess in some particular spot, with abate-
ment of the general ilisease.
in the severer forms, if the jiatient does not succumb (|uickly to
the progressive stenosis, abscess may become ditfused. speedily bringing
about a fatal issue.
Diagnosis. — Many things will jiroducc laryngeal dyspmea; and
to distinguish acute u'denialous laryngitis from all of these a careful
laryngoscopie examination is absolutely nece.s.eary. Digital examina-
tion may he of some value, revealing the soft tumefaction of the epi-
glottis and aryepiglottic folds, but it must he remembered that, with-
out the explorer is familiar with the touch of the laryngeal region, it
cannot he of much service. On the other hand, in this ])rogre.ssive age
A( TTK (I:I»1;M.\T()IS I.AKYNCniS.
373
it sliould 1)1' the diiiv ol' I'very pliysician to I'aiiiiliarizc hinibrlf with all
tho methods usod in the cxploradon of the afrcctod parts.
Hy the use of the larynjjjoscopo the mucous momhrane of the
larynx will he seen greatly distended. The epiglottis will he thick-
ened, partieidarly upon its horder and posterior surface. The lateral
folds of the inner larynx will be rolled out hehind and to the sides of
the ejjiglottis, the three forming a triangidar chink in the glottic re-
gion.
Although the color is that of iiiereased redness, there is a watery
and transparent cast to the tumefaction, the extent of which depends
upon the severity of the disease. When ])u< has commenced to form,
the spot of its develojimeiit will he marked liy increased swelling or
pointing, as well as the assumption ol' a lighter color.
J'i^t. IIS. lin-\MiMir> liir\ iif.'(nl kiiivi'f*.
Prognosis.' — This is always exei'cdingly grave. In some ca>e«:,
without surgical treatment, a rapidly fatal result may be expected,
arising from serous stenosis, before the disease has existed long enough
to give rise to the development of pus. bidder cases may undergo reso-
lution without j)us-formation, but usually they end in localized devel-
opment of absce,«s, with discharge and recovery. The danger lies in
siifTocation; hence the cases should be watched with the greatest care.
Treatment. — Mere local applications of any kind may be consid-
ered as useless in promoting the main object of treatment: the reduc-
tion of swelling. This can be accomplished, howcvi'r. by free scarifica-
tion of the inflamed and infdtrated tissues with a curved laryngeal
knife, such as Bosworth's or Tol)old's, guided by the laryngeal mirror
(Fig. 118). Free exudation of sero-sanguineous fluid follows. This can
i
< i\
• I I i
DISK ASKS OK I'lIK I. A I! V NX.
I, K
lie iiiilfd liy lint stt'iiin-iiiliiiliit inn.-, wliicli. while proniDtiiiL;' (lisclinriic,
liiivr ii ;,Miilcriil I'llVct ii|Miii tlif iiitliiiiH'(| tissms. 'I'lif scai'iiitiitiiiii miiy
lie i'f|it';iti'(l CM iv Ifw li(iiii> until tlic nr;;('nt >\ni|itnnis aliiilc. In tiic
fjisc iilrciidy iclVrrrd In. tliis |il,in oT ircnt niml was rrwanlcd liv a >ii(-
ccssriil i>snc.
I*i\(ir i('|iniis a <-a»(' cuiimI Ity cNtfiiial Ici'diin,!:. aidcil liy hot I'odl-
lialli- and hot It'nionatlc Levi alxi rt'iiori- one (iircd liy apjilyiiiu six
leeches III the la IT 1 1. ilea I rcLiinii. r»(itli wcic cyaiictic: the stress was
laid nil the iiict that scariticatinn was in the.-c case> nniicccssary.
'I'iariis in I Sil"; ciind a c;i-c liy reinii\ iim a |iiccc nl' the inlill rated inein-
hranc hy |)nncli-r(iice|i-. thus pi'dnuitin^' inr secretion.
In cases where snlTnciit inn liecnnies iininineiit. any nl' llie,-e ineaiis
caniint he relied nil. and 1 rachentnmy will require tn he dniie. 'There
is no dnnht that tin- n|ieiatinii i> |M'(d'eraide to iniiiliatinii in tlii.- di>-
ease. as the laryiiui'al swelling is usually mi a lii.<:iicr plane than the cap
nf the iiitnhatinii-luhc. when placed within the larynx. ( 'onsetiuen'tly.
it' it were inserted, tiie o'deina iiiinht cniitinue to produce stenosis, not-
with-landiiii;' tlu' presence of the tuhe. When ahscessi's pnint, no
matter where located, they slnuild lie pinmptly npened.
Siippoi linu' measures diiriiiL; treatment are reiniired; ami care
shniild always he e.xcrcisi'd against av<iidalile changes nf tcnnicrat lire.
i a
\i
1
1
1 .
5
■ '
t
■ '
lliii.
!
CIIAl'iKK I.XIX,
SlMl'I.K (KOKMA OK TIIK I.AItVNX.
I
SiMi'i.i; uMlfiiiii (if the larviix. iiiicoiiiii'clcd uilli aiiv iiilliiiiiinatnrv
condition of thai orLTaii, not iiil'ni|ii('Mliv mciiis. It i> laii'lv. Iiov,-
I'Vcr, (if iiKTcIv liical iiii,L;in, Iml is a n^iilt of .-cmmc sy>l('iiiic disease
and is df a sccnndai'v iialiirc ll uceiirs diiriii;:' all |ii'rind.-. nf life,
hut rarely in extreiiu' aiic The inajoiily (if (;!-(■> dcciir in iiialo.
Pathology. — In this disease theic is siiiiply ell'iisidii nj .-criim into
the lodsely-altaehed sidnmiei/Us li-siies df the larynx, the iiililt ralidiis
heiii^' lar<:t'st in the aryepiuldtt ie fdlds and the pdsieridr >iiiface df the
cpigldttis. Still, all parts are liahlc td tdiiiefaet idii, and in sdine eases
the veidrieidar l)and> have heen the only parts all'ecled. The vdeal
cords and suliuldttic iciiidii are not dften invdived. Whenevei' dh-
stniction to the Idodd-eiirrent is an element of the ni-ease. the slijfhl
resistance uliieii the larynx dll'eis td inliltratmn lenders it nidic lialile
than other re^idn.- to ininiediale dropsical el1'n>i(in.
Etiology, — As It is a secondary disease, tin' cause must he l(idke(l
for in ii'eiieral alTections of the system which have a (leterioratinii' in-
lluenee upon the vital powers. Any systemic disea.-e which may pro-
duce dropsy in other parts of the hody. other things heiui: e(|nal, may
iiive rise to it here. I>ri,iiiit"s disca.M'. i uiierculosis. -iy|ihilis, and car-
cinoma are amonii' its causes.' ( )l)sli'U(iidn df vemiu.- circulation fi'om
the head, as hy jiressure fi'om thoracic or amtic aneurism, may al-o he
a cause.
Symptomatology.- -The on>ei oi the attack may he -udden. hut
usually it comes (Ui liiadually. Instead of luiarseuos there is very sddu
t-omplete aphonia. i)yspu(ea is the prominent symptom. Inspiration
lieeonies exceediuuly dillicult dvviu^' to the swdllen aiyepi,^lottic folds
rolling' in and cldsin^- the .yldttis. I''.xpiration. on the other hand, is
not so clillieult, as the swollen liodies hy the elVorl roll out ai:ain. Still.
tlie cords are kept so wide apart hy the tumefaction that vocalization
often becomes impossihle. Cyanosis soon occui's. with all the other
.s_vnip(onis of impendin^i' suil'ocation.
Diagnosis. — Tliis is best made hy the u>e of the laryn^dx-dpe.
(.m'i)
' W:
i}H.
i i
r.\i
-'.i-:..;'.uiawE:^'r
I
1 '1
it
Ul
37G
I)ISEA8i:S OF Till-: I-AUVN.\.
The existence of larvn^'oal Htonosis is so selt'-cvidfiit from the syinp-
toniii that the only (lilliciilty is to ho sure of the variety of tlio hiryn-
geal disease. The aiitoscopc. too, particularly in yoini;^ sulijt'cts, shoulil
serve nn excellent pnr|)ose in ,<,Mvin<:f direct vision of the infiltrated tis-
Bues. The resenihhiiiic to phle<(M)onoiis disease; may in some eases he
striking. Still, the swelling in o'denia is likely to he more dill'iised
and the color of tin; mucous mtnihranc paler, while the presence of
systemic disease as the direct cause should rule out the phlegmonoUH
or acute (edematous Iaryngiti>. The shining, grayish-white, trans-
lucent appearance of the swollen masses in the larynx should distin-
guisli the tedema from any other lesion.
Frog;nosis. — As an indication of serious organic disease, tlie pres-
ence of (cdema of the larynx is of the greatest importance, and is usu-
ally the prelude to speedy dissolution; and, although the ]>rimary dis-
ease may he necessarily fatal, the laryngeal stenosis itself, if not re-
lieved, may terminate the case in a few hours.
Treatment. — If the (edema is severe, with threatened stenosis,
the tlr^t elfort should he to n^lieve the swelling hy free scarification.
The room should he warm and the atmosphere charged with moisture
from an evajjorating-kettle. When it arises from tuherculosis or
malignant disease this treatment will often be of service for tlie time
being, even when constituti(mal treatment can he of no avail. In
.syphilis the local scarification may reliev(; the breathing while mer-
curials and iodides are producing a systemic eifect. When general
anasarca exists from heart or kidney disease or cirrhosis of the liver,
heart-tonics and drastic cathartics would seem to be indicated in addi-
tion to the surgical treatment of the larynx, though the relief at best
could only be of a very temporary character.
In malignant disease tracheotomy nuiy be retpiireil. Intubation,
owing to the chief efTusion being su|)raglottic. wnuld in most if not
all cases be practically useless.
i^iliilfi
(■i!,\i''ii:i{ i.w.
( IIHONK I..M;^M;^l'ls.
Tills is a clirniiic iiillaiimiatinii ol' ilic nuirniis nicmluaiic ol' llir
lar}ii.\. It is usually sii|ira,i;l()ttic, Itiit may oxti'inl llirdii^li tlu' Vdial
rords to tlic iiit'ra.i^liitlic I'c^ioii. It is always of a catari'lial (■liaiactii'.
ami (loos lint ipcliidc all'cft idiis of llic larynx aii>in,i; from tulicriMilosis.
syi)]iilis, or mali^Miaiit ilisraso.
Pathology. — 'riicrc is tliickciiiiii;- of ihc mmosii, with liyprru'inia.
tliL' hlood-vcssols hoiii^ |K'rmaiit'iitly dilated; also (■cll-prolifciatioii.
with increased socrt'tion. Winn the disease is td' loiii^' standing thcp-
is increase of lymphoid tissue as well as of the surfacc-cpitliclium and
luljidar irlands. The whole of the lininj^ membrane (d' the larynx may
he allVctcd. or the disease may he eonlincd larirt'ly to tlii' a^ytenoill^.
interarytenoid comniissuri'. and tlic ventricular Iiamls. Sometimes the
vocal cords are involved in the inllammatnry action. I'inally, the con-
dition may extend dt)wn\vard. jirodueing eell-|iroliferation and dis-
charj^e from the infraglottie rei,non and the trachea itself. In simplt!
chronic larynj,fitis erosions an; rarely jtresent. When they do occur,
they arise from the breaking of the epithelial coating from the pressure
of the thickened connective tissue beneath, and can only be found in
cases of long standing.
Etiologfy. — The usual cause is some diseased condition of the nose
01 naso-])harynx producing nasal stenosis, .\nylhing .lat will ))roduce
chronic naso-pharyngeal catarrh has a tendency to induce a sinular
condition in the larynx. Whether this arises from direct continuity
of the diseased mucous membrane, or from irritation caused by tlie
presence of catarrhal secretion in the region of the epiglottis and aryte-
noids, opinions are divided; but where the condition exists, in many
instances, chronic hiryngitis is the result. In other individuals, nasid
stenosis, accompanied by catarrhal pharyngitis, will directly induce
chronic laryngitis by enforcing the inspiration of nnwarmed, nnfdtered,
unsaturated air, the constant breathing of whicli will have an irritating
effect upon the laryngeal mucous membrane.
Atrophic rhinitis is also a frequent cause, particularly in cases
(377)
ft:
»1 ■ f '■■
'' '4
w
11
Wi
fr»^-.
3T.S
l>l>-l ASKS Ml' llli: l.MIVW.
ti i
\\licic il liii> iilit;i(l\ [iKiiliiicd |iliiii'yii;.'itis <iccji. In llicsi' in-tiiiicrs
till' tiiiliiiiiili lis liinc iiliTiidy l<ist the frmctioii of tnuisudnlion, iind
till' iiir piisx's over llicrii t<» flic |jirvii\ iiiiiiKiistciicil niul loiiilcil with
|iiitn's(('iil cminifitidiis. Crusts iiiid fmd liitiiirhid ^/r/in'v (d'tcii iii)|)('di'
I lie I'll! r;i lice In t h( liiivii:^r;d i ii\ il v. iiiid cv civ I hiiii;- diiccllv hi Mils tlu;
(lr\(|n|i|lir|ll n| ;t (I I Idll ic Clllll irhid ci Wld it inll.
Ill iiiiiiiy in-liiiHts. |iiirti(Hl;irl\ in vuict'-iiMTs. Ihc tiiisn-pliiirvil-
^(•!ll cniidilinii i>. not >nirn iciil /"/• S' in illdllic (he di»('ilSi', Init iiicrrlv
iicis iis il |n'cdi>|nisiiiL:' ciiii-r: iind iinv cvccs^ivc striiin, I'ithcr in <\wi-
iiii;' III' >|i('iikiiiL:. piirt il iihiily uhcii lrri|iiciit ly if|uiilril, will ii'-nll in
llic d('\ clniiiih nl III I III' ilix iisc,
Miiiiy spriikri- uliM lirciitlir ((nrccily when in a piissivc conilitinii
entirely i;:iinic coirecl re<|i;riit inn while speiikiiiL:-, W'lijit is eiilled the
"reeii\eiy"' in iii>|Mriil inn is niiide hy llieiii thrniiirh the inniith. iind
iml ihlniiLill the iiip-e. 'This is u fiiiill uhieh. if jirnperly Mlteiided In.
enllld. il> Il rule, he iivnided. iltlil. if the ||a-lll recnscry \\;|< ill-i-led ll|i(i||
hy the --iicnker. il uniijd nn| niily iii-iiic the sat iiriit imi lA' the rc^pini-
Inry iiir. hiii wniild al.-n make the ntleraiiees ninre leisurely, iind hy
this nil an- -a\e I he vnicr I'nr siiiifi rs In ins|iiie nii! ii rally while eiirry-
iiiL' ell their Mieiilioii i- iiiiK II nmre di!liiiill. Il '- well In renieinher.
hnwever. lliiil iheie i- seine eniii|ieii-;it inn fnc iIh' hiss nf tiirhiiial .-eere-
limi in these cii^es ill llie |irnfiise salivalinii wliieli vniee-iisiniT prndilees.
I'llniiuated ii\ iila iiiid hypeil rnpliie tniisils iiiiiy iilsn. hy the pharyii-
,i:eiil irrilalinii they |irni|iice, |e;iil to chronie luryiiLTial disease.
Miili- iire iimre siihjeel In chrnnic laryii'iitis than females, owiiii^
tc the iiinrc fre(|iiiiit expe-uic. ;mil. in piililic speakers, to iiini'e ev-
eessive li>e nf the Xdiee.
'I'he disease neeiir- iiinst frecnieiitlx diiriii^ I'iirly iidiilt iind iniddlo
life.
Symptomatology. Sjinht irritatinn nf ihe larynx, with tendency
t(i repeated hawkiii;;'. are aninii'.,^ the earliest syiiiptmns. Sninetiines
there is ii sense nf dryness, aeeninpaiiied hy spasiiindie ell'nrts to ehiir
the throat. 'These syniptoiiis iire. however, nf a minor idiiiractcr, and
arc marked, in ii meiisiirc, hy the LTadiial development of lioarsonoss.
This may not he imtieeil nuiili diirin; ordinary cnnversation, Init in
sin^nni:- or puhlie speakinu'- hecomes iinnoyinir hotli to speaker and
hearer. .\iiy c.xtra exertion of llu' voice in cither of thcst> ways may
produce hiirninu JUid tieklin,<r sensations in the larynx, with tlio ofTect
of prodiiciiii: a dry. spasmodic coii<rh.
Tlie use of tlic voice by persons airoctcd by chronic laryns^itis is
m
( lllt(»M< I.AIIN \(;l IIS.
I'm!!
iniilill
I'nlldUfil liV (lill'i'irllt |r-||lt« III 1 1 1 ll'i'I'iMt |lil-ii|l«. Ill Miinc lni-kill<s«
will (|(\('l(i|i illlu liniir^rtios. illlil. il till' voice ciilltillllc* t(i lie Used,
illtii c'llhlilclr il|illii|iiil. wllilc. ill nllur,-. r\cll llnjUM'llt'ss will j:ni<lii;illv
(lisii|)|M'iir lis the >|i('iikiii;.' m >iiii:iii;^ nmiiiiiic*. ninl the vnice lu'i'dinr
clfiir lidnrc (lie ctid is rcnclicil. In tlir lii»l ilic hiiv iiu'cul i:liiii(liiliir
-.(•ilTl it'll IniiillM - (Allilll^tcil. while ill llle ,-ee(i||il tile .-eel'eli il'V r<illie|e-
llil\e lelililled llieir |pnUer. Ilinl. lieillL' >t i lllll lilt eil tn eVtlll -eeletimi liV
tlie lletiiiii 111' llie hllV II jeill llHI-i le-. Iia\e 1 111 irieil I ei I |||e \ncil| enlcl-
iiml ellilliled tliejii [it |peir(iriil llieir illereil>ed dlltV.
'I he dls(hiir,u(> I'lniii the l;ir\ ii\ iii'e ii-iiiilly dT ii jfniyi«li enjnr mid
SCllllty. Witlli'lll the illlhllllllliltnl \ iletinll eVtelld- |o llle i II fnililiiU ic
I'CLrinM. 'I'liell lliev liecnine inure ei)|iiim> mid n\' n yelliiwi>ll culnr. the
voice liecoinillli' more Cii^ily I'ntitilied.
Diagnosis. -The 'dt-iciie.itcd ell'mt- in chiir the ihlont. with the
lioiir^ciie>s iipdii ii>iiiL:' the voice, indiciile, to -onie extent, the liiltiire
of t lie di-cii-ie. 'I hi- hom-eiie-- i- li|.:e|y lo incie;i-c n- ihc dny iid\ nil' ■('•;.
mid is ojicii rclie\(d hy ;i niuhlV >lcc|i. St ill. 1 lieic me oi her l;iryiii,'ciil
tioiilile< which will |irodiicc >iiiiiliir >yii! |i|i.ni-. mid the ii-i' of the
liiryiit:{iSCo|ie i- rci|llil'cd to in.ikc the (liii;;lio.-i- -lire.
\\\ its ii-c the iiiucoii- iiiciiilirniie (d' ihc larvnx will in'cseiii the
ordiiiiiry ii|i[ieiirmi( c of i hnurc iiillaiiiniat ion. 'I'lic arytenoid- and
vcniriiiilar IhiihIs will he sliuhtly -wolleii and li\ |h raiiiic. 'I'lic vocal
coriU may he somewhat e(;n;.:c-ted. hut there will he no ;:rcat swelliiij^'
or I iiiiKd'iicI ion. no iircL;idirit v of moiion. little or no sin race-|e-ion ;
lint there may he sliiilil halhinu' (d' the |iart< in iniico-|iiis. Soinetiines
the iiiiniile liiryiiLreiil \es-el- may he swullcn and tortiion-, part iciilmly
(.n the posterior siirlaee id' the epiL:'lotti~; and, in <c\cre ca-e<. they
may he distinctly >een on the \ocal cord> .Minnie uiannlation- iniiv
also appear on tin' vocal coi'il- and int ralaryicical walU.
Prognosis. — .\s thi- disca>e so lrc(|iicnt ly owes its oriLriii In le-ions
ill the upper !iir-pii>-ii,i!es. the prot^no-i- i^ n-nallv ;:ood, when these
are removed: when the cause is chielly voice-ahiise, lei thi: cea-e ami
the disease will likewi>e. .\ larue niiniiicr id' ca<es, howeu'r. aie of a
very chronie (haracler. when thi'y conic under the physician's iioiiee.
The hirynu'ciil mucosa is thickened; the -ecret ioii-, altlion,i;li not
eojiioiis. have heeome hnhitiial: mid cure can oiilv he accoiiip|i,-hcd hy
slow ])rneess. When tlio voice is not an important ractm' in the voca-
tion of the iiatient, the disoaso may remiiiii stationary in many eases
without producing .«erions harm. Still, the fact that every frosh eoM
niav result in an acute or suliaciite attack of larvn'iitis in tho alrt'adv
m
m
lA
'^-^"^-'^rajMiSB
:^so
DISEASKS OF I III'; I.AUVNX.
l\!
i
«liscas('(l orgiUi, would iiuliciiU' llial aiiii'lioratidii .^lioulii hi' aimed at
in all rases.
Treatment.- As clirdnic lai'vnuilis ociurs, as a rule, in persons
ollu'rwise eiijovin,:^' i(il)iisl licallli, lillle is retjuired in the wav of svs-
teniie treatnieiit. II' ihe liver is torpid a diolauogue nuiy lie f^iven, anil
saline calliai'tio niav l)e adiniiiistored wlien the pletliora ol' tln' system
demaiuls il.
Ill ease.- wlicii' iiaso-pliarviii;eal le.-ioiis have |iiddurcd stenosis or
catarrhal disease in the uppei' air-ti'aii il hecomcs the iin|)erative duty
of llie medical alteiuhnil to aim al llieii- removal. 'I'he only ipiestioii
is: Should this he aecomplished at the lime when the laryiiii'eal symp-
toms are most nii^ent or al a later datcy The aii-wcr to that depemls
upo!i whether we are callcil to ti'eal Ihe larynx in its chronic coiidilioii
or ill one of the acule cxacerhations with w Inch il is so oftiMi altaeke(l.
In the former, operation ii|)()n the turhinaleds. se])tum, nasal polypi,
adenoids, or tonsils, when rcipiired. >hi)uld lie done at once. In the
hitter, wliile we may alleviate the steiiotie symptoms hy hivaf^e, etc.,
it shoiihl he the aim to reduce the acute larynu't'al condition hofore
eonipletin<i the naso-pharynjj;eal treatment.
I'"i)r local treatment id' ihe larynx I helieve lliere is no inslrunient
so ^'enerally useful as the atomizer. When properly eonstrueted and
carefully used, the lluid contained in il can l)e ajiplied thoroughly to
tlu' intrieale foldin.i^s of the larynx. To aeeoniplisli this ohjeet the
atomizer sliould have a curved lip ai right angles to the sliaft of the
instrument. M'hen using it the tongue of the patient should h(> iiro-
iruded to its full extent, and, if lU'cessary, held in position hy the pa-
tient grasping it. lightly in the fold.- of a doilet. If we desire the
a[)plieation to reach the infraglottic regiiui. the |)alient should he in-
structed to inhale steadily and I'orcildy while the spray is thrown in.
If the soluli(Ui is intended to eonie in contact with the entire upper
surfaces of the vocal cords, or to wash out the ventricles of Morgagui,
or holh of these, the ]iatient should articulate the sound "ah," prolong-
ing out the note while the spray is thrown in.
As there is always nmrc or less mucous or muco-puriileni secre-
tion in the pharynx as well as the larynx, the first solution used hy
the atomizer should he one of the alkaline preparations already men-
tioned. AVith this the throat should he thoroughly washed. Then,
if the condition is temporarily of an acute character, a 1-per-cent. solu-
tion of cocaine may follow. This will relieve the immediate tender-
ness and enahle an astringent spray to be used without producing sore-
^H I
1(1 \n- aiiiiod at
lie, ill pi'I'SOTlii
he Wily of sys-
\- lie j^nvon, and
I of llic system
(■('(1 stenosis or
iiporativc duty
only (|iR'sti<)n
iryn,i;('iil synip-
) that dt'penils
nnic condition
»rt(Mi attackcil.
, nasal poly|)i,
onci'. In the
ly lavage, etc.,
ndition liofoie
no instrnnu'iit
instrurtod and
thoroughly to
his oltjoot till'
shaft ol' the
Oiould 1)0 pro-
ion by the pa-
wc desire the
slundd he in-
is thrown in.
' entire npper
: of Morgagni,
"all," prolong-
uriilent secre-
ution used by
already nu'ii-
ished. Then,
per-eonl. solu-
ediate tender-
rod ucing sore-
ciiiioMc LAUY.\(ii US. agj.
ne.^s. ir it is siMii)ly the ehronic condition that re(iiiires to be treated,
the cocaine may be omittetl.
Of the astringents now to bi' applied, the following may bo con-
sidered in ortler of merit: —
Argent, nit. in solution, 1 to ;! jier cent.
/inci chloridi in solution, '/. to I per cmt.
Cupri sulj)has in solution, J to .') per eeiii.
Tannic acid, .-.' to T) per cent., with glycerin, lo per cent., in water.
•Any of these may be thrown into the laryn.x; and retained as long
as possible, the patient returning daily to the ollice for treatment, or
at h)iiger interval.-, as may seem advi.sible.
I'or the interim treatment to be carried on at the palieiifs home,
i have always obtained better results fn.m I he stearoptcue preparations
dissolved in one of ihe hydrocari^ons than from the use of aiiiieous
solutions. Among the advantages of the nil s|>rays o\cr the water om;s
are the (iiieiie.'-^s of atomization, the softness of the touch upon lii<> in-
llamed tissues, and the consequent great<-r ])enctrability within iho
folds of the (irgan. owing to the absence of the resistance which the
ctiai'>er sju'ay produces.
'J'he jneparalions are much the same as these already mentioned
in sjioaking of the treatment of jdiaryiigeal disease, but to save the
trouble of reference may be spoken of again here. .Mbolene is only
taken as a good c.xamjdc of the hydrocarbons.
Mentliol in alboleiie, 1 to .'> per eeiiL.
'I'hymol in alboleiie. ' '., to I per cent.
1. IJ M.ntii,.! j3r,
Ol. ciuydiili \qi
Alliolfiic ;}o|
2. IJ 'J'llVIlloI !()(jy
]\lc!ltll(li !;J5
"1- ■"o>i iG7
Alhiilcili' ;j()i
1. H Mtiuliol ^ ,,p ^.
< il. cMryi.iili ^l,^
.Mlidli'iic »j
Af. •'■
2. R Thynidl „r. j.
Moiltliol rir V
(M. iUllSl ,1,^
Alholi'iie fi
M. ^^"
34
n
1 .'I
M
m
383
DISEASES OF THE LARYNX.
l''(>r liiicr atomizatioii to the lliri)at, stron;;or Holmions can be \\mh\
by means either of the nebulizer '/. tlie eiumninutor. 'i'lie Ainoriean
iH'l)iilizer is well athipled for bome-'.se l)y the initient. As seen in V\'^.
I III, the lieavier nil-<,dohiih's are thrown afainsl tlie wall of the bottle,
and flow back into the lliiid, whili' oidy the vaporous particles ])ass out
of (he mouth of the tnb(> in a nii>i. to be iiibah'd by tlie ])atient.
Tile iiiulliple coniininutor is a niorr cjiiliorate development of tlie
same priiK-iplf. Ily its um' several vapiu's cjin be coniliined at one time
for inhalalion. if considered desirable. Its use is specially desifjncd bir
tlie ])liysician's otiice (KiJ,^ I'^O).
Any of these can be used by the patient to the throat with a good
atomizer or mluilizcr two or three times a dav. 'To have the licst
'?!
t '
E
!..|
Fif^. 119. — Aiiu'rifiui iicljuli/.rr.
efTect he should be instnicled to inhale deejily while upinf^ the instru-
ment. In any case the oil solution should not be too strong at first,
the ])roportion of (li«> drug within the inenstriiiiin being easily increased
to suit the susceptibility of the pati(>nt, and also the kind of instrument
by which it is to be ap[)lied.
Any of these preparations have the additional advantages of being
antise|)tie and cooling, as well as astringent.
Tn using nitrate of silver I prefer to apjily it with the laryngeal
cotton-holder after cocainization, guiding it to the part to wdiich it
is applied by the use of the throat-mirror, and using care to avoid
abrasion of the surface by the manipulation. The use of the laryngeal
brush in these cases, while more easily applied, is always more diffuse
in its application.
CIIHONir I,AI(YN'(iITIS.
383
Sonic (iju'iiitors advise tho apjilicatioii of astriii^ciits in a dry form
by moans of insulllators, but tlio motliod is fxcnt'ially ('oiicodod not to
be as otiicacioiis as tiic ono already rcfcrrcil to.
C'ountcr-irritatioii over the larvnx niav also Ik- of ix'iiciit; also
Fif^. I'JO.- ,Multii)le comniinutor.
painting' the .-uifacc with iodine. In some cases, wliere there is actual
doubt in dia<inosis, tlic administration of iodide of potassium may help
to clear up the ditlieulty.
Care in the use of the voice is imperative.
\n
'ii
CllAFTKlJ l.XXl.
U
li
ATUUl'llIC LAKYNCilTlS.
This is a variety oi' chrdiiic larynj^ilis occasionally mot with.
Lilvc ordinary clironic ]aryngiti^, it is a seiiucl or result of disease of
the upper air-passages. As also chronic laryngitis is usually the thick-
ening of the nnu'osa of the larynx, resulting indirectly from thicken-
ing or ]iypertro])liy of the na.-al and pharyngeal tissues, so. likewise,
atroj)hic laryngitis, like pharyngitis sicca, is an indirect result, if not
extension, of a similar disease from the n(i>e and naso-pharynx.
Like atrophic ihinitis, it is characterized by diminished secretions
and crust-formation over the surfaces of the laryngeal mucous mem-
brane. There is also jiallor and shrinkage cd' the normal tissues of the
parts a (reeled.
I'atliologii'ally it is identical with the disease of the nose from
which it originated, and is accompanied by similar pathological
changes. Loewenherg's oza'iui diplococcus lias also been found within
the crusts of the larynx: and, if the microbic origin of the disease may
be granted, the like spori's will be ])resent wherever the disease may be
located.
Symptomatology. — ('ni,>l-foiiiuuion is much more severe during
the night-time than the day. o\'\ng to the cpuetudo of the larynx dur-
ing the hours of sleep, in the morning, particularly, there is a sense
of harshness in the larynx, with considerable didiculty of clearing away
the aecinnidated discharges. The masses expecloraled come directly
from (he lai'ynx, and are usually of a greenish color, and possess, though
in a niiimr degree, the heavy earthy odor characteristic of atro])hic
rhinal disease. On examinatidU i.f the laryngeal mucosa the surfaces
may be found abraded or even idcerated and the exi)ectoration may be
tinged with blood. It is not unusual in atrophic laiyngitis for ulcera-
tions to he extensive, ]tarticidarly when the disease has extended to
the infraglottic region. In this respect atro])hic disease of the larynx
dilfcrs materially from atrophic rhinitis, in which tdceration so rarely
occurs; this is, probably, due to the greater mobility, thinner tissue-
covering, and less vascularity of the larynx itself. I have soon one
(,)84)
I
ATUOI'HIC LAKYNOITIS.
385
t I
(1
(hiring
■nx (lur-
a sense
ig away
case in wiiirii the Iruiit purtions of several of the iijijier rings of the
trachea were coinph'tely dest roved hy the erosion, only minute side-
fragments of tiie rings being lei't. When the vocal cords become in-
volved in tlio disease, or when ernsis I'orm over the interarytenoid re-
gion, the voice is not only hoarse, but often a|)hoiiic.
Diagnosis shonld Tiot be dil1i<nlt. Presence of atrophic rhinitis
and pharyngitis sicca would lead to tln^ impression that any serions
hiryngcal trouble partook of tlit; same nature. When. ad(h'd to these,
are foul, oral breathing, irritation of lower throat, sensitive hyoid,
cough with expectoration of gri'i'nish crusts, hoar>cness, and great dif-
ficulty in clearing the laryngeal cavity, there is little likelihood of
mistaken diagno.-is. Kxamination with the laryngoscope sboidd re-
move any remaining doubt. I'liless there has been thorotiuh cleans-
ing of tlie larynx, immediately before examination, the peculiar green-
ish crusts of the disease will be seen in posifi(Ui, above or below the
glottis, or both. If th(\v have already been reuio\ed, the llattened and
shrunken and ))erhaps ideerated mucosa will l»e seen, generally pallid
in color, and perha])s streak(>d with blood, if haunorrhage has taken
place. When the disease is (>xtcnsive, the crusts adhere to the infra-
glottic region more tenaciously than the snprai;loltie. owing to the
more abimdant supply of glandidar secretions above the vocal cords.
Prognosis. — If taken early in its history, cure may he possible;
but it must be remembered that it owes it.s origin to long-standing
nasal disease, which may he incurable hy the time tliiit the laryngeal
atrophy has developed. In tlu'se cas(>s amelioriition is all that can be
expected. If, on the other hand, the atrophic rhinal condition can l)e
removed hy treatment, the laryngitis sicca shoidd likewise, its a conse-
quence, he arrested. There is another tiling to be ri'meudiercd: that
as atrophic rhinitis under proper care ceases to ])resent seven' symp-
toms in old age. the like result miiy be expected in the hi-t(jry of tlu;
laryngeal disease.
Treatment. — Tlu' lir<t and most im])(U'tanl element in trcatuu'ut
is to ])lace tiie nose and naso-])harynx in as healthy a comlition as pos-
sible; the treatment re(|uii'ed has idieady been described when dealing
with these organs. This haviiiu- been done at each -iiting first, the
like procedure shoidd at once he applied to the larynx iis well.
For first cleansing nothing is better thiin a free spray of DobeU's
solution, thrown forcibly into the larynx with the down tip (U' the
atomizer. If the crusts are dinictdt to remove, the coarser vpray of a
curved laryngeal syringe? may accomplish their loosening more effect-
M
fjijUnHTT^ ' '
1
hm
I
?
»kk\m,-0im»iii\t »m
386
DISEASES OF THE I.AKYW.
nally. With tin- ai<l ol' coiiijjivssi'il air and a DavidsDii alomizcr. tlicre
should never be any ilitruulty.
In rare cases the use of the hiryngeal brush or eotton-lioltler may
be re(iuired to detach \]\(? crusts. 1 never .-aw a case, iiowever, in whicli
tiiis was .leeessary.
As second treatment to be applied each tinu' after the use of the
cleansing spray, the application of the various nu'tallic solutions are
recommended. From my own exi)eriencc. I again ]»refer, for their
mild protective inllueiu'c, the use of the various hydrocarbons: al-
bolene, glyeolin, etc. With the oil nuiy be combined from ', ^ to 1
]ier cent, of carbolic acid, creasote, or thymol. 'I'liis should be used
several times a day l)y the patient, with iiistnution- to inhale deeply
while using the atomizer.
When the case is .severe, the home use of the steam-inhaler con-
taining a weak solution of any of the drugs mentioned will have a
beneficial elTect.
b
ri
CIIAITKU LXXII.
I'.U'HYDKllMIA LAUYNGIS.
This i^: a (lisc'a>o uliifli may ocoiir: (1) in tlu' n'gion of tlu' vocal
procoi^K's of the cords; (•^) over the internal t;urface of the interarytc-
iioid comniissure. 'ilie first is t!;c verrucous form of ])achydermia;
the second the ditVusc. ]ioth indicate a tliickening of tissue: the
former circumscrihcd. the lattt'r irregnlarly hypertrophic.
Pathology. — Histological sections taken from the vocal jjvocesses
arc oval in form, grayish in color, and. according to Damieno. are com-
posed of jiavement-epithclium, heing cliaiigcd into epidcrmoidal layers
of ilattencd cells without nucleus, the mucous membrane at the ])oint
all'eetcd heing apparently transformed into tissue resembling strati-
lied skin. In this variety the epithelial ti.ssues laicken at the expense
of the submucous connective tissue, which in some cases is alnuKst
absent.
In the interarytenoid pachydermia there seems to be a local over-
growth of all the tissues, the connective tissnc as well as the epithelial
elements being alTected. The overgrowth is usually fissured deeply
from above downward.
AVhile the one class of cases lias its origin in the pavement-epithe-
lium of the cords, the other arises from the ciliated epithelium of the
commissure.
Etiology. — 'i'he cause is supposed to be the ])r(sence of chronic
laryngitis, whether occurring upnii the cdrds or between the arytenoids.
In singers and speakers overuse of the voice umlouhtedly has an in-
lluence in the development: uaso-phaiyngeal liypertrophy is also in
some cases a factor in the ctiolngy of the disease. One wtdl-marked
case of interarytenoid pachydermia, eciurriiig in a lady-voealist. T
traced to the preseiue of adenoid vegetation, ami aiu)ther in a gentle-
man to throat catarrh occasioned by the total removal' of the uvula.
In the former, ablation of tiie adenoids, together with brushing the
])achydermia with solution of nitrate of silver, resulted in complete
cure without return. In the latter a change tn a more ccpiable climate
had a favorable result.
(■■iST)
\l
t. .!
388
Dlt^KASKS (»l- nil; I.AliYNX.
If
III,
;
■ '1
II
III;
:( i 7
Symptomatology. — When tlio nodes oeeiir ujmn the cords, gononil
syiii|itoins are very nlightly developed. 'I'liore may he weakness of tho
voiee, however, attended l)y huskiness or hoarseness, owiiiLj to tlie pro-
jeetion of the hypertropliied nodules from the margin of tho cords;
lint there is little, if any, soreness and no coughing or expectoration.
When the dilfuse condition exists, there is more secretion, more
soreness, and laryngeal distress, owing to tlie fact that the projecting
growth lietween the arytenoids may prevent the complete closure of
the cords; the voice hecomes all'ccted, and the patients c(imi)Iain of
aching and general fatigue of the larynx.
Diagnosis.-- -.\s pachydermia of the cords is largely an c])ithelial
develojnnent, there is some danger of mistaking it for epithelioma;
and in some instances it ha.s been asserted that the pachydermia really
devclo[)ed into cancer. Damieno declares that these were cases in
which the epithelioma really existed prior to or in cond)ination with
tho pachydermia, not as a result. The essential dilTerence between
the two diseases exists in the fact that in cancer tliere is true prolifera-
tion of epithelial cells, the cellular nuclei being most active, and the
epithelial iirodiicis penetrating everywhere among the lymj)]iatics and
blood-vessels, while in ]iachydermia there is no true proliferation, but
liyjiertrophy of the e])ithelium as it takes place in a corn, the cellular
nuclei becoming afro))hied and disappearing.
In difTuse pacliydermia there is danger of its l)eing confounded
Avitli laryngeal tuberculosis in the stage of bypertrn]ihy and infiltra-
tion, ]irior to ulc(>ration. The genei'al condition and absenci^ of other
tul)ercular symptoms, together with microscopical examination of the
secretions from the larynx, however, should render the diagnosis
tolerably certain.
Verriu^ous pachydermia, or ])achydermia conscripta, as it is some-
times called, is in the form of liltle. hard nodules situated on or near
the vocal ])rocesses. In rare instances they are fcuind at the junction
of the anterior and middle tliirds of the (,'ord. They are white or
slightly pink in color and about a ])in's head in size, in the tyjjical
form the noduli' may be single. During vocal ell'ort it comes in con-
tact with the opposite cord. This at first ])roduccs an indentation,
which by and by gives way to proliferation and the development of
another node. Tlu'n the two, coming in contact, prevent proper clos-
ing during vocal effort.
Prognosis. — Nodes of the vocal cords of speakers and singers
would frequently disappear of themselves, if prolonged and complete
!i
I'At 1 1 Y I)i:i( M I A I, A It V XUIS.
:?8D
singers
rest of tlie voice wtTo ])riU'tit('(l. It is rare, however, tluit this can ho
accoinplii^hod. 'rrcatmeiit alone, without rest, is of Uttle avail, hut
the two comhined shoiihl in all cases produce a ;^ood result.
in the ditl"us(! iiitriarvtenoid ))acliyderuiia, lissurcd thickening'
liavinif occurred, spontaneous ahsorption is oxeeodinirly rare.
Treatment, — In (h(> pachydertuia conseri])ta, as said hel'ore, some
cases will <i<^i well of themselves if tlu' \(iic(> is s^iveii sullicienl rest.
In mild cases, where Ihe nodules ai'c suivll. lu'ushinLr with "J.")- to oO-
per-cent. solutions of lactic acid or iii-|U'r-(cul. solutimi ol' nitrate of
silver will result in their removal, ileforc the hrushin.u a spray of 1-
por-oent. solution of cocaine would l)e reijuircd, to still the larynx, so
as to enal)le the a|)plication to he conllned as much as possihle to tho
diseased ])arts. Tlu! treatment may he repeated at intervals of one or
two days while re([uircd.
In severe cases autluus diU'cr greatly in tho treatment they advise.
Professor Chiari recommeiuls tlu* use of electrolysis. Ileryng, when
the nodes are any size, advocates thorough cocainization and then the
snipping olf of the ])rojecting nodules. Some recommend the use of
a fine snare, and (Jottstcin advises the use of tho galvanocautery point.
In dilfnse i)achydermia, consisting of so much hypertrophic tis-
sue, the treatnu'ut may reipiire to he more vigorous to eil'ecl a removal.
Under cocaine a r)0-per-cent. solution of lactic acid, applied by means
of a laryngeal cotton-holder at intt'rvals of two or three days, will in
some cases promoto ahsorption, while in others a 1/)- or 20-per-cent.
solution of nitrate of silver used in a similar way will effect a like re-
sult. It usually takes weeks or months of careful treatment to accom-
plish this.
In severe cases scraping the liy])ertropliic tissue with Krause's
curette, as in tho treatment of tubercular iiililtration. has been found
of Svrrvice. This is done after thorough cocainization, and is followed
up by ndjbing the raw surface freely wiili tlu' lactic-acid solution, the
operation to be repeated if required.
PersomUly I have seen four cases of the dilfused variety {Urilish
Medical Journal, November, 1897). Two were treated l)y brushing
with solution of nitrate of silver and two liy brushing witli solution
of lactic a--"d. All recovered, althougli one required treatuu'iit f<u' a
year and a '.<tlf. Another had threatened return a« the fall of the year
approached, and was obliged to seek residence in a milder clime.
One case of node of right cord, occurring in a minister, finally
disappeared under repeated sprays of 4-per-cent. of menthol in al-
3)
J!
l!l
390
DISKASKS OK TIIK I.AUVNX.
bolcnc, tof^ctlior willi comjilcto ri'st of the voiio tor n miinbor ot' wi'oks.
In a second ciisc, the ])atieiit hein^ a lectui'cr, applications ol' solution
of nitrate of silver after coca inizat ion. to^'ctiicr with spray treatment,
resulted in cure
Si'iua.oTTic ciiifOMc i.\i!YN'(irns. which Cehrardt terms ''chor-
ditis inferior hypertrophica," owiny lo tiie fact that it is attended witli
local suh^dotlic hypertrophies, sometimes occurs, and is likely to he
prtiductive ol" a serious de<free of laryn^^cal stenosis. The '"chronic;
blennorrluea of Stoerck" likewise produces hypertrophies and cica-
trices, but on the vocal cords, instead of hetween them. Klebs says
that histolo-xically the eli'iuents in hleunorrluea rrsi'uilih' those of rl)i-
noscleroma. It is a (juestion whether both conditions are not of the
luiturc of pachydermia. (Lennox Browne.)
Treatment would consist of dilatation, with or without trache-
otomy, as the indications of each case miji'ht call for.
I i;
( I
CIIAITKU I.. Will.
rSKU l)( )MKM nUANOL S l.AllY N(i ITIS.
As TltiK or ]isiHi(l()iiitinlir;uious croup is Iji-licvi'd by tlic iiiiijority
of pliysiuiiiDs to 1)(' liirynucal dijihtlu'iia. it will not lie treated of in tiiis
voluiiio, iiiiipimich as it is fidly discussed in works upon general inedi-
<ine.
There are eases, however, of traiunalie pseudomenihraiioiis laryn-
;;itis to which a brief reference niighl be made. It is reasonable to
siijtjiose, also, that if pseiidonieinbranous rhinitis does occasionally
occnr, of a purely idio])athic character, with the total absence of the
Klebs-Loedler bacillus, so also mi^lit a similar disease occur in the
hirynx under favorable conditions.
Of tranmatic origin. 1 have had one case which occurred in Au-
gust, IS!)"^, thai of a young lady aged v-'i. (ialvanocautery operation
upon the tonsils was f(dlowed three days later Ity iiitralaryngeal mem-
branous laryngitis. In this there was no continuation of nu'ml)rane
from the tonsillar operation. The epiglottis was unalTected and the
membrane was fornu'd upon the ventricular bands down to the vocal
cords, the latter bi'ing sliglitly involved in the coating. There was
some laryngeal stenosis and complete ajihonia. with temperature of
100°. Treatment was by stcam-iidialatioii and iron and glycerin in-
ti'rnally. In four or five days the iucml)rane had gradually <lisa])-
jiearcd. There was no recurreiU'c. The case had no connection what-
ever with diphtheria, as tluTc were no eases either before or afterward
in that ni'ighborliood. The probability is that it was a pure tibrinous
deposit of staphylococcic origin.
At the Laryngological Society of Paris, January. IS'.U, Courlade
reported a case of ■•recurrent sultglottie pseudomembranous laryngitis"'
in a female aged ','.■) years, \-\n- eight days the ])atient had sulTocative
attacks after meals and at night. Two years before she had a similar
illness lasting fifteen days. Laryngoscopie examination revealed a
whitish-gray plaque beneath the cords. Antispasmodic remedies re-
lieved the symptoms, and coughing expelled four grayLsh flakes the
size of the little finger-nail and the tliickness of a ten-cent piece. The
cm)
If
If:
U.Ji
41
i; \
\\l
n.
1
•
^li
1
11
1^
'
\l
'
,
j •
^M
/(
J
f
— _— ■ ■ynriTHIlMIIII
tfl
'
1 1'
i
1
1, ';
;. . 1
!: : 1
i
i' 1 1 1
i
ii;li
msKASKS (»K Tin: I.AUVNX.
nplionic voice then liccjiiiic ikhmiiiI. ;iiiil liiiTiiirip>((iiiic cxniiiiiialinii re-
vealed the iniicdus iiicinliriiiic ol' tlif sent i iciiliir liiiiiil«. llic nrvlciiniils,
nnd till' siil)fjl(ilt ic rci^idii nf a (Iccp-rt'il inlor. Itiii willinin trace of v\-
iiilatidi).
At the l-aiTii,un|(iL;ical Scciimi of the ! iilcniat ioiial Mnlical Cmi-
^ress licid in .Nfoscow, in IMK. Kosenlierji rc]iiiitc(l a case of larvnj,Mtis
fil)rinosa in a man aLfetl (i*. N'o infection enidd l)e traced. The dis-
enso lasted ei;:lit days, and \\a< marked liy patelies of meml)iane upon
the epiLiIoltis and inner walls ol' the larvnv. the zones siirrnnndim:- the
alTeeted sj)ots hein^;' >|uite red and inllame<l. Tlic miii'oii> memhrano
nnd pldtnirs were examined mi(T(iseo|iieally. No di|ilitheria haeilli
wej'e found, liiit staphylneocei and streptococci were, ami the false
niend)rane was lihrinous.
Middlenias Hunt also rejiorts a ease (d' reenrreni mendnaiions
larvn^dtis which had existed olV and on, in a nnddle-a^red lady, for 1!>
years. The ni(>nd)rane would form, accompanied by acute sore throat.
and would last for a week or two. and then disappear for a similar
period, to he followed hy another attack. It was always located to the
left side. Sta])hyloeocci and stn^ptocneei woidd he f(nind, hut m>
Klehs-Loefller haeilli.
CIIAI'TKR LXXIV.
I,AUVN(ii:AI, PKKUlinNDKlTIS.
Tills iri a rare discaf^c, occurring soiiu'limcs as a rcsiili of t^ypliilis,
tuberculosis, or tancor of the larynx. Jii a iVw iiistancop, as in the cases
of Xewuian and .lurasz, il di'veUjps an an acute idiopathic airoction;
i.ccasionaily it occurs as a sciiuciu:c lo one ol' tlu' cxanthcuuita. It
comes on very siuhlenly, is al tended hy the grave.-l syinpioins, and is
sometimes so obscure in its uiaiiil'estations that a pusiiive diagnosis
iieconies exceedingly dinicult.
Pathology. — There is at iirsi increased vascularity in the jji-ri-
chondriuiu of the cartiln'^e. 'i'iiis gradually exiends lo tlu; cartilage
itself, with increased cell-i'orinati(m and swi'lliug This nmy be fol-
lowed by formation of ])us Ijcnratli ttie pcricluuulriuin. separating it
from the choiulrium and involving the latter in nccmsis. or, l>y slower
])roccss, cell-organization and hypertrophy may take place.
Of all the cartilages the cricoid is most freiiueiitly all'ected in the
acute idio])alhic disease, and, as a rule, the inllammatioii confines itself
to the cartilage primarily involved. In tuberculous cases the aryte-
noids are the most freiiucnt scat, and in these the inllammatory action
usually extends also to the cricoid. As regards frequency of develop-
ment, ]}osworth, out of ',V,i cases collateil, found that ^3 involved the
cricoid, 3 the thyroid, -1 the arytenoid, 1 the cricoid and thyroid, and
in 2 cases all the cartilages were involved. Luning, out of 55 cases
collated, found disease of the cricoid in 22, of the cricoid and arytenoid
in 14, of arytenoid in 9, of thyroid and cricoid in 5, of thyroid, cricoid,
and arytenoid in 3, and of thyroid in 2.
Etiology. — As a single causc^ perhaps ex|)osiire to cold may claim
the gi'catcst numl)er. It is likely, however, that some acquired or in-
herited weakness of constitution has in each case been a predisposing
factor. Typhoid fever, scarlatina, diphtheria, tuberculosis, syphilis,
etc., are also exciting causes, as also is Iranmatism. The majority of
cases occur in males, and the period is during adult life.
Symptomatology. — In very acute cases the disease is likely to be
ushered in by a well-marked chill and localized pain. As a rule, how-
ever, as there has been some previous indisposition, the chilliness may
be mild or even absent. Fever follows of two or three degrees, with
(3!)3)
I !
It
'rH
J"
f
■ !
i 'i!
: k m
If ^M
. '
* ft
li
1
'■'.'
t '
>
'i
;
f'
!l
3'Jl
DISEASES t»l' illi; I.AliV.W.
]tiiiii in till.' hones iind ^Tncriil (listrc-« of the syi^toni. arisiiii,' from ilic
approach inif (lilliculty of respiration and di'u'hitition.
When the cricoid is aflVcted. tlic swclliii.LT on tlic inner sui face of
the cartihiii'e seriously interferes willi hrealhiuL'. l»otli inspiration and
expiration heinfjj prohmired and dillicnll. 'I'hc tnniefaetion and sore-
ness will also ii\tor!'ere witli de^lntilion. When the arytenoids are in-
volved, the (losing of tlie glottis cannot he conipleted, and hreathini;-
may he easier than with cricoid steiio-is, while ()dynj)!ia;4ia and dys-
phajria will l)olh lie more severe. IN richomhitis of tlie thyroid carti-
lage is nsually on the inner surface and unilateral. In this case the
voice, altiu)uuh hoarse, may not he entirely lost; when 1)ilatoral it
nsually is. The epiglottis l)eing comjiosed of fihrocaililagc instead of
simple cartilage, jiosse^^ses nKU'c power of resistance, and is rarely, if
over, attacked hy idio]iathic disease.
In acute cases (he syni])toms may reach tlieir utmost s(>verity in
a very few days, while in chronic ones they may exist a muidi louLicr
time without ])rodiieing severe stenosis.
Diagnosis. — 'J'ho sudilenncss of the attack, accompanied hy steno-
sis and fever, with the ahsenec of diplitheritie symptoms, may give;
some idea of the nature of the disease. Still, it may not he easy to
arrive at a correct conclusion, even with the aid of the laryngoscope.
With the development of ahscess, there is more or less ledema; and,
although the attending fever may distinguish it from simple (cdema,
yet the laryngeal images of the two are soint'tiines so much alike that
doubt may be occasioned. When the swelling is not great enough to
obliterate the view of the infraglottie region, the unilateral charact(>r
of the perichondritis, with the swelling on the one side and the couse-
<[uent visible distortion of the laryn\, will aid in diagnosis. This is
particularly the case with the supraglottic cartilages, but with the
cricoid, the disease l)eing almost centrally situated and the swelling
widely diffused, it is often imjiossilde for the laryngosco])e to reveal
anything but general ledcjua of the parts.
'J'his was particularly the case in a man, aged od, wliont 1 saw
in consultation sotue years ago. Acute laryngitis of some sort, ac-
companied by dillicult respiration, came on suddenly. In forty-eight
hours from the sup|)osed commencement (d' the attack I was sum-
moned. The man was amemic; breathing was stertorous, inspiration
was more diflicult than ex])iration. Tie had no pains and could walk
about with ease; temperature. 10(1°. By the laryngoscope the larynx-
was found to be (edematous. Pioth arytenoids and epiglottis wcr<>
ac-
h'i.iiiit.
suni-
iitioii
walk
iryiix
wore
I.AUYNtiKAI, I'KIUCnONDIUTIS.
3!ta
8\vull('ii. \ (H ill (iikIs vuuh\ iidt lie -ffii. r>y ii>iii,i; s|iray of cofaiiu;
and menthol in solution lip'atliini; hccanic >li,iiiitly easier. It did not
seem advisalile to [tert'onn ti'aclii'oioniy iinine(liately. iiarticidarly as
the patient \vanle(l any opei'atioii jmstponi'd a- Idii.ir as jxissihlo. 1 did
not see liini apiin alive, as the lollowinir chiy he was thoULdit to l)e
easier. The .-ueeeedin^- night the steitor heeanie more severe. The
doctor was snninioue(l, A\'hen he arri\e(l half an Imur later the pa-
tient was dead.
.■\t the [)ost-inortein we discovered an i'\leii~i\e pcriehondrial all-
seeds. exteniliiiL; more tlian hall'-way round the inner surface of the
i-ricoid. .V portion was to the riui'hl siih', hut. after extending: over tlie
anterior surfac(> of the iio-lcrioi' half of ihe riui;'. it laruelv tilled in the
Kij;. I'il. .Mix-OS (if i-iiitiiil. Liirviix oiitiicd fidiii tK'hind. 'I'lic (larl<
s[i(it ticlow tli(> cciitic Miiil to tilt' left side iiuliciitis flic lai},'('i' opeiiiiig; the
lij;ti(cr >|i<it til llic liu'lit. the siiiallcr (inc.
left side, the caitilag'e itself heini: denuded and tlisortfanized. The
other cartilages were in no way alVecied ( l'"ig. l^M).
I was informed hy a meinher of tlu' family that a hrotlier of llie
deceased died <d' the saiiie troiihle se\eral years previously.
Prognosis. -- The immediate danger is from laryngeal stenosis.
Tn chronic ease,'~ this comes on so gradually that there is lime for con-
sideration hefore operation is re(|uired. .\s disease of the ciicoid |)ro-
d-u;es the most extensive swelling, it is usually attended hy the most
danger. When several cartilages are inv(dved. the prognosis is most
nnfavoral)lc. In neaily all ca.ses. however, life might lie prolonged if
traclieotomy were peiformed comparatively early in the disoa.se. The
presence of the purulent sac within the larynx would jH'cclude tlie
a(lvisn1)ilitv of intnhation.
n
11
it
: !.
HI
^1
1
J ■
1
39C
D1SKASK6 OF TUK LAUVNX.
\h i
ii^ m
' n
Treatment. — Wlu'ii the progivs.s of iho di&oasc is ^luw onougli to
iillow of systemic troatmeiit, tliis may he tried in the way of antiphlo-
gistic and diuretic measures. In eases in wliieh the (vdema is not too
great to permit of laryngeal ohservalion, the point of protrusion may
he freely opened hy the laryngeal lancet, after which inlialations of
steam will favor a free diseliarge. Wlien i)ointing externally, it should
he opened early and discharge encouraged.
Jn cases of severe stenosis, however, whether from the cedema of
the parts or the pressure of the })us-sai'. trat'heotomy is always advis-
ahle. Artificial respiration once estahlished, ell'orts can be made to
more llioroughly treat the jieriehontirial inllammation. and when re-
quired it is possible that the diseased cartilage itself niight be removed,
in the absence of systemic disease.
Supporting treafment, when there i< any prospect of prolonging
life, is always called for. and, owing to dilliculty in deglutition, recourse
may be had to enemata.
'J'he case 1 referred to is one in which 1 lielieve tracheotomy should
have been done at the time of my firsl and only visit. There is little
doubt but tliat it would have prolonued the patient's life; and 1 have
often regrt'tled since that 1 did not insist at the time upon giving him
the required relief.
AFFKOriON.S OF TllK ClUCOA K V PHNOID AkTICI'I.A I'lON .
'1^
l)e la Sota was the first to describi! luinuiry inflammation of this
Joint due to exposure to cold, and Debrousses, in J 8(11, was the first to
express tlie opinion thai such a trouble might l)e rheumatic in char-
acter.
AVhen it is remembered that the cricoarytenoid articulation is -up-
plied, like the other joints of the body, with capside and ligaments and
a true synovial niem])rane, besides possessing slight rotatory and lateral
iiiovcnu'nts, it is but natural to believe that it nuiy be subject to the
tisual run of joint diseases. The investigations of more recent observ-
I'rs have borne out this idea.
In 1880 Archambault wrote that acute laryngeal manifestations
of rheumatism were more common than was generally supposed, and
that one of its manifestations was in the arficulati(uis.
In 1887 George W. Major, of Mojitreal, drew attention to several
affections by which the cricoarytenoid articulation was sometimes in-
vaded. These were sprain, dislocation, direct local injury, acute ,(R-
kliS'll I
AFFECTIONS OF TUB CRICOARYTENOID ARTICULATION.
397
llamiiiiilioii, and ankylosis. Of these, he gave instances, ankylosis of
the joint being the most common. The chief causes meniioned are
jierichondritis, rheumatism, gout, the exantliems, and catarrhal aircc-
tions; the chief of these is rheumatic intlainiuation of tlu' joint.
The leading symptom is embarrassed breathing. The voice is not
much interfered witii and swallowing, as a rule, is not dilVicult. ¥.n-
largement of the joint may be present, but there may be, in advanced
cases, atrophy instead. Other symptoms aie external tenderness and
friction-sounds on manipulation.
Six years later, in an elaborate and valuable paper, bearing the
title of "Arthritis DL'formans of the Larynx,'' Casselberry gave the his-
tory of an exceedingly interesting case. 'J'his occurred in a lady aged
.58. She was a subject of general arthritis deforninns, the joints of
both sides of the body being all'ccted alike. The hands and wrists
were distorted, the fingers and thumbs dislocated, and the feet and
ankles siniilarlv aU'ected, though in a minor degree.
The cricoarytenoid joints were also ankylosed on each side alike.
The vocal processes of Die arytenoids were similarly alfected, the swell-
ing extending to the cords themselves. The poslt'rior I'uds of the cords
were both thickened, ])rojecting downward and upward and beyond the
natural line of the rima glottidis. The abductor muscles were so lim-
ited in their action as to prevent material opening of the glottis.
The history of this case ))roved thai it was in no sense one of
paralysis, and, strange to say, neither did it seem to be one of gout or
rheumatism. This lady had never sulfered from ])ain in any of the
•uints during the develoi)ment of the disease, and, what is more, medi-
c. .OS administered for tlie relief of gout or rheumati>m had not had
: 'ic slightest ed'eet in arrt'sting the progressive deformity, ^\'hile un-
der Casselberry "s care sprays and inhalents ail'ordi'd temporary relief.
Xewcomb has also written upoji the '"laryngeal manifestations of
rheum iIimh," dwelling particularly u])on its develojimenl in the crico-
arytenoid joint, the symptoms being similar to those described by
Major, lie s])eaks also of the dcper congi'stion wliieli (ucurs along
the line of eoiitaet between ihe ai'tieular surfaces of the cartilages
alfected.
Concerning treatment of the rheumatoid condition, nothing has
yet licen found to take the place of the salicylates. Salol, or salicylate
of phenol, is a good addition to the group. IngaLs has found much
relief in these cases from a combination of salol and extract of Phyto-
lacca in V^-gramme doses of each. Guaiac is also sometimes useful..
25
^i
'a, 1
I
I I
.; \
I :
^ -iieemsaaa iai tstasis ^sa s s si
i:
ClIAPTEK LXXV.
tubkik;ui.osis of tiik i.arynx.
ii
M
This (lii^case is said to occur in from 10 lo 20 per cent, of all' cases
of piilnionary tnbercolnsis. in a large majority of cases it is secondary
to that alfeetion, alti, i ' ' i a certain proportion of cases it exists as
a primary disease. lio a tal^es tlie ground that the tubercular
process has added virulence as it occuis nearer the outer world, while
at the same time it occurs with less fretpiency, the ratio l)eing inverted.
That is to say, that, while pharyngeal tuberculosis is the rarest of tuber-
cular manifestations, it is the most ra])idly fatal. And laryngeal tuber-
culosis, occupying a medium position between the pharyn.x and lungs,
also occupies a median position, both with regard to severity and fre-
(piency of the disease. Hence it is less frequent, but more rapidly
fatal, than simple pulmonary tuberculosis.
Pathology. — 'J'he morbid process of tuberculosis is essentially the
same, whatever part of the body it occurs in, being based upon the
presence of the tubercle bacilli in the affected tissue. In the large ma-
jority of eases the fornuition of tubercle witliin the larynx is secondary
to prinuiry pulmonary disease, in rare instances it may arise in the
larynx dc iioro.
In the earliest stages of laryngeal tuberculosis there is infdtration
of the mucous membrane of the parts affected, with multiplication of
round embryonic cells, lymphocytes, and leucocytes. In the central
portion of the periphery these small cells may aggregate more densely,
resulting in necrosis and ulceration of fh(> part, with de]iosit of cheesy
matter in the submucous layer. Quite frequently, although the tuber-
cle bacillus is considcreil the primary agent, it may be dilTicult to dis-
cover it microscopically. I'sually the nodular or tubercular deposit is
at first subepithelial, gradually working toward the surface, and re-
sulting in ulceration. In lu'arly all eases the disease is progressive, the
spots of disintegration mulfiplying as the tuberculosis extends.
The amount of infiltration varies in different cases. In some it
is very superficial, and, according to Clifford lieale, this class of cases
is very much more amenable to treatment than when the disease ex-
tends to the submucous layer.
(398)
TUIiEUCULOSlS.
399
When or recent dovolopnient, the iihers arc tjluiUow and super-
ficial, with jagged edges, tlie base being gray and smootli. On tlie
other hand, old ulcers are irregular, studded with ludlows and small
cavities, around which the tissues are sclerosed.
"J'he most frequent site is said to be the arytenoid comnii.-sure,
next the arytenoids, ventricular bands and cords, and perhajjs last the
epiglottis, although authorities dill'er as to the l're(|uen('y with wliicii
the last mentioned is affected.
In some eases, although the arytenoids, commissure, and ven-
tricular bands may be involved, the cartilages being ulcerated and
eroded, the vocal cords may remain intact even to the last. In other
eases they are the chief seat of the disease, one or both being thick-
ened and jagged for the whole length of the border. When the ])eri-
chondrium is seriously invaded by necrosis, extensive (cdema of the
.submucous tissues is likely to ensue.
Etiology. — Tuberculosis of the larynx is usually a hual inani Testa-
tion of a systemic disease. It is rarely primary in origin, but dependent
upon a pulmonary tuberculosis already present. Granting, however,
a constitutional weakness, abrasion or relaxation of the laryngeal
mucosa may, in some cases, ])erniit the invasion of the liiicillus and
the primary development of the disease within the larynx.
Hereditary tendency has an undoui)ted influence in tbc etiology
of this disease. Catarrhal pharyngitis and laryngitis, as well as con-
tinued exposure to cold and wet, may also be classed as predisposing
causes.
As tidjerculosis usually occurs in the lungs first, autoinfeetii)n is
believed by many to be the chief cause of its occurrence in the larynx,
any abrasion of the mucous membrane of that organ givinij: ready lodi,''-
ment to the tul)ercle bacilli, on tluir way outwaid in the act of cough-
ing; or invasion may occur through the medium of the lympliatic ves-
sels with which the larynx is so freely endowed.
Tubercidar laryngitis occurs more freiiuently in males than
females. It is also a disease of adult life, by far the lai'gest iuind)er
of cases occurring between the ages of twi'iily and foiiy years.
The jiereenlage of eases of judmoiuiry tubfrcidosis whicli are fol-
lowed by tuberculosis of the larynx is variously estimated by different
writers, the figures being between 10 and .")0 ]wt cent. Terliaps the
medium of 20 will be the nearest to the trtdh.
Symptomatology.- — Impairment or softening of the voice is one of
the earliest symj)toms. This is to be distinguished from the harsh
if
,
•
':{ !
■i.' ?
1 ; i
a
5
i^
\ i
M'
,1
ii'
-J
400
DISKASKS OF TUK LAUVNX.
\ii
:i'l
.'.!
if:
voice, with lowered pitch, rcsiiltiiif^ from simple chronic laryni^itis.
In this (lisense the muscles of the larynx are weakened and relaxed,
while the infiltration, which so freiiuently occurs at the arytenoid com-
missure, ])revents the proper vocal adjustment of the cords, with con-
seqnent loss of voice even to the extent of a])honia, as the disease
progresses.
Wlien the disease is unilateral and situated entirely ahove the
vocal cords, or located in the epiglottis to the exclusion of other points,
impairment of voice may not he present.
Pain is a frequent symptom, especially during deglutition. When
the upper portions of the larynx, such as the arytenoids and epiglottis
are affected, the pain is usually more acute, and after ulceration has
commenced may be very severe.
Cough is pro])ably present in all cases, the pulmonary cough being
notably increased by the laryngeal irritation.
There is also, particularly when oedema exists, a feeding of fullness
in the region of the larynx, which is very distressing to the patient.
The expectoration in the early stage as coming from the larynx
is limited. As the disease advances the secretion becomes more abun-
dant, and consists of gray, ropy mucus, as distinguished from the heavy,
muco-purulent matter, the product of pulmonary disease.
The ordinary systemic symptoms of tuberculosis will more rapidly
assume an aggravated form upon the addition of the laryngeal disease.
Emaciation comes on more quickly, mental anxiety is greater, and the
pain sustained liy the patient is more severe than when jjulmonary
tuberculosis exists alone.
Diagnosis. — When the examination of the lungs indicates tul)er-
culosi>, ]iarti('ularly if microscopical examination of the sputum dis-
covers: the presence of tuberch} bacilli, any decided softening of the
voice, together with laryngeal pain, will render the diagnosis of laryn-
geal tuberculosis almost certain. Laryngoscopic examination, how-
ever, will always be necessary to make positive the location and extent
of the disease. In cases, too. where the lungs are affected to only a
limited extent or not at all, the only certain way of arriving at the
truth may be by the use of the laryngoscope.
In this disease the mucous mendirane of the larynx and even the
pharynx will have lost to a large extent its accustomed pink color and
be more pallid in appearance. This will distinguish the tuberculosis
from the hypera;mia of syphilitic and malignant disease.
'I'his pallor, with swelling or infiltration, is the earliest local sign
! ! »
TUBERCULOSIS.
401
revcnled by the laryngoscope. I'lio swelling is confined to the s])ot
involved in the disease, the pallor being diirused over tlic surrounding
tissues. The infiltration is at first unilah.'ral, but may soon extend to
the opposite side, assuming, in the case of the arytenoids, the elub-
shape, and, in the epiglotlis, the turban form.
Prior to ulceration the membrane of the swollen tissues is of a
dull-gray-yellowish tinge, smooth and moist, Itut without the semi-
transparent appearance of licalthy mucous meml)rane. As the disease
advances, minute yellow spots of tubercle may be seen ilotling the in-
filtrated tissue. They form on the mucosa beneath the epil helium.
As they enlarge, they project a little above the surface, and, gradually
breaking down, leave an ulcerated surface. These ulcerations are
shallow and differ little in color from the surrounding tissue. As they
extend, the surface assumes an irregular worm-eaten appearance, and,
although there is consc(pient loss of tissue, this is less apparent, owing
to infiltralion which prevails beneath and around the ulcer. Any
granulations that occur are usually of a pale-pink color.
When the epiglottis is the seat of the disease, loss of tissue fr(>-
qucntly extends rapidly, the greater part or even the whole of the
organ being gradually eaten away by the ulceration. The pallor of the
tissues, the shallowness of ulceration, the results of microscopical anal-
ysis, together with the local and sysJemic symptoms, should render the
diagnosis certain.
Prognosis. — This is exceedingly grave. The large majority of
cases die, and, as it is u-ually a secondary manifestation, its presence
only adds s])eed to the coming fatal i-sue. Still, cases do recover, and
a number are on record in which the laryngeal tuberculosis has been
completely removed, although the j)atient has ultimately died of orig-
inal pulmonary disease.
After extensive personal ol)servation, as well as investigation of
records, llosworth has arrived at the conclusion that the average dura-
tion of life in ])ulmonary tui)erculosis uncomplicated is three yeai's;
complicated with laryngeal disease, two years; and duration of life
after larynx has become involved, one and one-halt years.
Although pulmonary consumption is, in snni(> instances, a curable
disease, the records of post-mortems proving that many people die nf
diseases other than tubercular, although exhibiting cicatrices within
the lung-tissue arising from healed vomicie, yet, when complicated
with laryngeal tuberculosis, the former always eventually proves fatal.
Of late years, however, the cure of the laryngeal tuberculosis itself.
■ i
IP
; i
I I ^li
■ Vl
t
I -i
]
I'
i
1
i ,
i
1
1
I ■
1
'
mvM
^^fmm
A02
DISKASKS Ol' TIIK I.AItYNX.
It 1 1
ii
1,1' :
ill, ''
if taken early, is by ninny laryngoloffists believed to be possible, at
least in innnl)ers of eases, tlie life of ilie sulVerer bein,<,' tliereby pro-
longed.
Treatment. — For general oonstilutional treaUnent, the demands
made in behalf oi laryngeal tubcreulosis do not differ from those re-
t|uired when the disease is located in otlii r organs of the ])ody. Our
province here, however, refers to the diree: treatmcnl of the local dis-
ease. In the early history of cases, and before operative nicasnres can
lie deemed adviifaljle, probably no nietiiod of treatment is of e([nal value
to lliat of sprays, thrown by the atoiniz(!r directly into the larynx. Of
all the medicaments that can be applied in this manner, I have found
none so useful as different percentages of menthol in albolene. This
nuiy vary from 2 to 10 or even 20 jicr cent, of the stearo])tene in the
oil, commeiu'ing with the lower numl)er, and gradually making the
l)roportion stronger as the patient is able to bear the application. Mven
after ulceration has commenced and the tis.-ues of the larynx are grad-
ually becoming disintegrated, tlie cleansing and soothing ell'ects of the
drug thus a])plied are always grateful to the patient, Uishop jn^'fers
camphor-menthol for this purpose, wliile otliers advise insulllations of
iodoform, iodol, aristol, etc. When the jtain is severe, occurring so fre-
quently as it does in the advanced stages of the disease, solutions of
cocaine are recommended for local ap])lication, on account of the tem-
})orary relief which they insure. In the,>e cases, intrinsically lio])eless,
it is undoubtedly our duty to do all that is possible for the comfort and
physical relief of the patient. Lennox Browne, Charles Knight, and
nuiny others believe that much can be accomplished by spray-treat-
ment, and nu'nthol in various proportions appears to be the drug that
they rely most upon in these cases, (juaiacol in albolene or olive-oil
ill 30- to GO-per-cent. solution acts in a similar manner to the menthol
and is worthy of trial.
Of direct local applications to be a]i])lit'd by means of the laryn-
geal cotton-holder, the one that is believed to be; the most useful, and
receives the widest professional support at the present time, is lactic
acid. It was introduced in 18S5 by Krause, and is used in various
strengths from 25- to lOO-per-cent. solution. It may be applied to the
<liseased tissue by brush or cotton-hohb'r.
Parachlorphenol, 5 to 20 jier cent., in glycerin is another remedy
recently advocated by Simonowsky, a))])liod as a pigment, and enzymol
is spoken of by Murray as a most valual)le adjunct to other treatment.
Intralaryngeal surgical treatment is the most modern and radical
TI'BKRCI'I.OSIS.
l(i;{
roinedy
Mizymol
atmeiit.
1 radical
means advocated fdi' tlic relief and cure of this disease. I)iirerei)t lines
of procedure liave been followed with more or less siiecoss.
First and most jirominent is cun'ttennnl. 'Vhm follow sulnmi-
cons injections, eh'ctrolvsis. and ^alvaiincaiilcry o|)eralions. Toirether
with tliese methods, the reiridar throat treatment liy hietie acid, hriish-
ing, etc.. may be associated, aceordinir to tlie jnd<.nncnt nf the operator.
As ])ointc(l out by (lleitsmanti. liftccn nieml)irs of the iiaryn,u;eal
Section of the International Coni^ress at l\ome advocated curettemenl
in snitably-siliiatcd cases, 'i'his is particidarly applicable to the aryte-
noid and commissural region-, in advocating this m(>asnre he diics so
nnder the following conditions: —
1. In cases of j)rimary tulierculons aU'eetions witlioiii pidmonary
complication.
2. In cases with eirciimserilied ulcerations and infiltratinns.
3. In cases with dense, hard infiltrations of the arytenoid region,
the ventricular bands, and tnl)erculous tumors of the epiglottis.
4. In the incipient stage of pulmonary disease, with but little
fever and no hectic symptoms.
5. Tn advanced pulmonaiy disease with distressing dysphagia, re-
enlting from infiltration of arytenoids, as the quickest means to give
relief.
Gleitsmann gives the following as centra-indications of curetto-
ment: — •
1. Advanced ])ulmonary disease and hectic.
2. Disseminated tuberculosis of larynx.
3. Extensive infiltration, producing severe stenosis, when trache-
otomy is indicated or laryjigotomy can be taken into consideration.
The operation should be done under the free use of cocaine, and
by means of Heryng's double curette.
Submucous injection of lactic acid has also its advocates. This
is introduced into tlie afTected tissue by an appropriate curved syringe.
Creasote in the same manner is likewise advocated strongly by Chapelle.
Treatment by electrolysis, as taught by Scheppegrell, is too recent
to be worthy of strong advocacy yet. Halvanocautery operations have,
however, been used to advantage, with or Avithout tlie addition of
curettement.
Tracheotomy and laryngotomy can only he considered advisable
as last resorts, indicated to relieve extreme stenosis and dyspnrea.
As said before, general constitutional treatment is alike whether
the disease be located in the larynx, lungs, or both, and should, mc-
't I
!
d
\
r
■i i
I
8
1
1
■
3
I
^ i
1
i
1
.iiimiimiimaMMBta
404
DISEASES OF THE LARYNX.
(licinally and diotetically, be, in the highest degree, of a supporting
cliaracter. Codliver-oil, wlicn jiurified and deodorized, is by no means
an iiiiftalatable agent; and is still largely and wisely used. Creasote has
long been a favorite remedy in doses of V4 cubic centimetre two or
three times a day variously modified. J..atterly, however, creosotal,
or, more correctly, carbonate of creasote, has largely taken its place,
inasmuch as doses containing several times this amount of creasote
can in many cases be taken without in any way injuring the digestive
system.
A very eligible way of administering the creosotal is in combina-
lion with purified codliver-oil, as: —
1. IJ Creasote carbonato GO
01. monli. oiit ;}G0
M. Sig. : I'.iprht to sixtecr. graiinnes tliri'O tiims a day aiter
iiict Is.
;!i
!f^
ri
With the best of treatment and care this class of cases, as already
stated, cannot, on the whole, be considered hopeful; yet much can be
done to 1 licve the sulferings, prolong the life, and in some '..ay benefit
the iinhappy victims of this disease. Guaiacol is sometimes of l)enefit.
Small doses of morjihine and codeine may also be of advantage in allay-
ing distressing symptoms.
li. Lake (Journal of Lariingohgi/, Uhinohgij, and Ololoij!/, Feb-
ruary, 18!)!)) says that, while ''general treatment is useless, one must
not lose sight of the enormous aid one derives from increasing the
powers of resistance in the body, and by increasing the numbers and
energy of phagocytes and white cor])uscles.'' Local measures he divides
into surgical and non-surgical. The former consist in removing dis-
eased portions, curetting ulcers, and depleting (vdematous tissues by
puncture, etc. The latter consist of insuillation of powders, painting
on or rubbing in of solutions, the injection into the tissues of hypo-
dermic remedies, and the injection into the trachea of oily solutions
by syringes and atomizers, in using any "paint" to the larynx a brush
should never be used, but always a cotton-wool mop, for the two reasons
of cleanliness and cniciency. J5risk and firm friction are required, and
all solutions should be as strong as possible. When injections are given
the temperature should be about 80° ¥., the j)atient being instructed
1. B Creasoto carbonate ,^i j.
01. morrh. ojit ,?xi j.
M. Sig. : Two to four teaspoonfuls three times a day after meals.
Tt'UKIU'l'I.OSIS.
406
to .nl.ale do.ply, l.ol.l his l.roath imnuHliatdy after thr ,n,\rtion and
"ot to mu.h. The n.n.liti<,n. att,.idin,^ h,ryn<,..,l tuhm.uh.si.l aro
;I.VHle,l ,M(o s,x Hiniral head.: 1. (Iran.dar eondi.ion .d" voeal cnr.ls
^. Miperdnal exvnnatinT. nr ,dceiati..n. ;{, (K,h,„.,. 4. <I-:dema and
superlieialnleeratinn. r,. I .eep uleeralin,,. (1. Mixed ...de.na and deep
"'^•^■••'•"on- 1" N"s. 1 ..nd •> „n .nelhnd of freatn.ent has he.^n so olli-
c'anous as infratraeheal injeelinn. 1„ Xos. li and I sn.-ieal treatment
IS re.inired a. well as the appli,.ali„n of paints. ('n(tinur-r,„,-eps do the
most elleetive work. Forn.ie al.K.hyde nr laei,. aeidshouhl be nsed
after every mtralaryn.^enl n,K.ratio„ on a tiduMvula:' suh,Vet, no matt..-
Low small the operation. In Xos. 5 and .; iVietions and' operath.ns are
i.s(dess as well as inloh.ranl to the patient. In su.!, eases insulTlations
of iodoform and orthoforn, will have a wonderfnllv soothing? effect nar-
t.cularly the latter, whieh ,s noted for it. p^olon^ed aeth.n ll I a
iion-toMc anodyne, produeino- anaesthesia of the parts for nearly twenty-
fonr hours. The pro-^nosis. nnder judic.ions treatment, is -.."od nnd"er
he hrsttwo divisions, fairly oood in some of the third and f.nirlh varie-
ties, and universally had in the other two.
■2r,n
f
i
i
^ ,
f
ni\
C'llArTKll JAXVl.
W !
LUl'US OF Till-: LAUYNX.
I'himary lupus ul' Iho liirynx is nut .so nuv as priiiiiiry tuhcrcii-
losis of the larynx, althou>jli Ixitli are believed to owe tlieir orij^in to
the presence of ttihorele bacilli. As a ruli'. lioweve;-, it is secondary
in ils origin, l)cin,ii' derived from lupus ol the jiharynx. which itself
liad been an oH'shoot of lupus of the skin. In this, too, it dill'ers from
tuberculosis of the larynx in beiii,<r sequel to an external disease instead
of nn internal one (Fig. 1 w"-2).
To the comparatively long list of cases of primary origin already
published, Mayer, of Xcw York, has recently added two more. On
i
i I
Fig. 122. — Lupus. Laryiiiidst'opie appearance.
(After Lennox 15ro\\ne.)
in^
•
'i :
!
1' i
i.
1
i'
I
j|::
i.:
1
i
1
M.
examination of the report in the Journal of Laryngology in 1897,
however, only one of these could be called purely laryngeal, and the
other was a long-standing case under the care of ^Morris J. Asch, and
was more pharyngeal than laryngeal. In this cast' the skin was for
years unaffected, and the patient lived for eighteen years, finally dying
of apical tubercidosis.
For the pathology and etiology of laryngeal lupus, reference to
its history as occurring in the ])hnrynx will cover the points of chief
interest. The only jioint that need be further mentioned here is the
one brought out by Lcfferts many years ago, that the first pathological
element of this disease is essential hypertrophy of tissue. This is fol-
lowed by slow, but destructive, ulceration, to be succeeded by dense,
(406)
LUPUS OP TlIK I.AUYNX.
407
I'cncc to
oi chief
ro is the
loloojical
is is fol-
y dense,
hard cicatrices AH thieo Cdiulition;^ iiiny exist in the one hirynx at
the panic time
Symptomatology.— Primary luiuis of tlie laryiiv may exist fur a
long time before developing symptom?. Like its eoiigeiiers in the face
and pliarynx, it may exist almost indefinitely without piodiieing pain.
After awhile tliero may be slight hiisldness, dyspmea, and sorenes.s.
The secondary disease resend)les the primary, but it is more readily
discovered, owing to the primary indications. Iluskinoss may arise
from involvement of the cords and commissure, and stenosis from the
intralaryngcal development of the disease. Cicatrization occurs after
\
e e
\^
A*0
fa, r
Fig. Vli. — Lupus of the epiglottis ('/o'lch objectivo; Ktirlich-Biondi
stain). (After Lennox Browne.)
destruction of tissue, and this may lead to laryngeal strict arc. Tlu.
epiglottis is usually the part first affected (Figs. l'.^3 and VH).
Diagnosis. — A laryngeal examination will always ho necessary for
correct diagnosis. It needs to he distinguished from tuljereulosis,
syphilis, carcinoma, and leprosy. The surface is pale and slightly
(lidemaious. TTlcerations form, but, unlike tuberculosis, tlu^y are fol-
lowed by cicatrization and consequent distortion with marginal thick-
enings. Another peculiarity noted by Lennox llrowne is that in lupus
of the epiglottis the infiltrations are sometimes so heavy that they make
that organ overhang and almost hide the inner larynx. There are no
systemic symptoms as in tuberculosis or cancer, and there is no foul
secretion as in syphilitic disease. In eastern countries it might be con-
i
1'
3
I
I
408
DISEASES OF THE LAHYNX.
founded with leprosy. It resembles it iiu)st in insensitiveness of tissue,
but leprosy never occurs in tlie larynx alone. 'J'he aljseiU'C of systemic
symptoms slioiild make llie diagnosis comparatively certain.
Prognosis. — This in many instances is good, so far as temporary
recovery is concerned. Tlie ))rogress of the disease is slow. Sometimes
it may be arrested for awhile, and recur at a later date at the old cica-
trix. It IS nut often dangerous to life, but, being a manifestation of
the presence of tubercle hacilli, tuberculosis of tiie lungs may super-
vene to carry off the patient. In some instances tlie disease itself has
been known to ])rodii(e fatal stenosis.
l""ig. 121. — l.ujni.s <if tlio I'piglotliH ('/..-inch ubjcctivc; J'lliiliuh-liiondi
stiiiiO. (Aftor I.L'iinox ISiowiic.)
:i|
I' I
li|
Treatment. — 'I'liis does not materially ilill'er from that of laryn-
g<'al tuberculosis. Supporting measures to the system are required,
though not so loudly called for as in the sister-disease. Curettage,
owing to I lie hardness of the nodules, lu'eds to he done more vigorously
than in tiiherculosis, but is followed by bette." results. Local treat-
ment by applications of lactic acid, menthol, and creasote are of the
liighest importance. By the use of one or other of these or all in suc-
cession the disease may freciuently be arrested, gi'ing the patient
months or even years of relief. When operation becomes nece.-.siry it
is more V»opeful than in tul)erculous disease. Schroetter's bougies may
dilate the stenosed larvnx in some cases. Tracheotoniv will always
I.l'T'L'S.
09
aii'ord relief when life is cudangerocl from stenosis. Wlicn s v^ro con-
striction occurs in the glottic region, intuhation may he r^ .^uired,
thoiigli some authorities claim lliat the irritation produced hy the
pressure of the tuhe will only accerituate the growth of the disease.
i
i I
If
I Ik
I
Mr
CHAPTER LXXVll.
LEPROSY OF THE AIK-PASSAGES.
The Intoriiational Conforcuce on Leprosy licld in Berlin in
October, 1897, gave to the general profes>ion almost the first light
they have liad upon this obscure subject. Cliick, of Sarajevo, made a
report upon 37 cases airecting the air-passages, all taken from the one
leprous district; Jeanselme and Laurens, of Paris, based their state-
ment upon 20 cases of general leprosj^, 60 per cent, of which had lep-
rosy of the moutli, nose, or throat.
The disease always affects the mouth or nose before invading the
pharyn.x or larynx. According to Gliick's experience, the np.sal cavity
was affected in 90 per cent, of his cases, the larynx in 70 )-,er cent., and
the mouth and tongue in 50 per cent. In the large mijority of in-
stances the skin is attacked much earlier than the mucous membrane.
In some cases, however, it is reported to have commenced within the
nose.
One of the leading features of leprosy is to attack (1) the epidermal
structures, and (2) the mucous membranes l)ordering upon them, the
two surface epithelial coverings being always atfected before the under-
lying tissues.
There are two varieties of leprosy: the nodular and the ana\-thetic.
*'T1 microscopical changes diU'er somewhat in the two varieties.
Those of the nodular, or tuberculous class, commence as an accumula-
tion of lymphocytes in the perivascular lymph-spaces, forming a net-
work of indllration-strands which, increasing in thickness, appear un-
der a low ])ower as solid cylinders invading and absorbing the inter-
vening tissues. In section under high power these strands a[)pear like
nodules with giant cells, and if stained by the Ziehl-Neelsen or Gram's
method are seen to contain bacilli.
"In the anaesthetic form bacilli are not easily demonstrated; they
can, however, be seen in the iTiflammatory cell-tissue growing along
the ])erineural lympli-spaces.
"The specific bacillus of leprosy, or Hansen's bacillus, has certain
peculiarities which distinguish it from bacillus of tubercle. They are
(410)
LKPROSY OP THE NOSK.
411
alonfj:
from 5 to 6 microns in longili and 0.35 to 0.50 micron in tliickncss.
'J'he rods are said by Babos to be interrupted by non-.«taining, clear
spaces, representing doubtful spores. They are, as a rule, readily
siained in silii, as may easily be demonstrated by the trituration
method, aided Ijv boiling and digesting.'' (Lennox Browne.)
Lei'Rosy in tuk Xosk.
The first symptoms are those of persistent cory/.a accompanied by
formation of crusts. The discharges contain Hansen's bacillus, and
are consequently contagious. This is tlie more dangerous in cases in
which the- nasal disease is primary, as the le])er is conseiiuenlly not
immediately aware of the nature of the disease. Ejiistaxis is also an
early symptom. The bridge of the nose 1)ecomes broader and the
cuticle thicker, while the organ shortens in length, tlie anterior nares
assuming an almost vertical plane. The disease is usually uf the
nodular type.
Soon the cartilaginous septum softens and gives way, the bridge
<lroi)S, and the nose flattens with the rest of the vi.sige, as in the case
of septal destruction from tertiary syphilis.
In the early stages the mucous membrane is reddened, swollen,
and liable to bleed when touched. In tl :att r ones, brown crusts,
erosions, and muco-pns are present. The iiictive lesinus are the
whitish- or pinkLsh- gray, leprous nodules, contracting foreilily with
the deep red of the rest of the membrane. As the noduic-s beconu; con
fluent, they may close up the nares, producing complete lenosis.
When septal perforations take jtlace, it is by resorption and with-
out sloughing or discharge. As the disease advances, ])ronouiiccd
amesthesia occurs. The sense of smell is retained, although jiallor and
atrophy mark the climax of the disease.
Lupus and syphilis are the only diseases for which leprosy of the
nose might l)e mistaken. Lupus-nodules are firmer. In lupus, al.-n,
the nostrils nuiy be eaten away, the !;cptum renuiining sullicientl
tact to support the nose, and always being the last to succumb, while
in leprosy it is almost the first to yield. Leprosy also has more an;es-
thcsia during its progress, and, as tlu' disease advaiu'cs, in\ari;il}]y
all'ects the cuticle to a greater extent than does the lupus. 'I'hc twd
latter symptoms also distinguish this disease from .syphilis, the gciu'ral
history of which, with its unilateral development in the nose, should
be sulhcient to render diagnosis certain.
M
it
li
;
t
'
1
1
,1
4
t
1
:}
i
1
i
412
DISEASES OF THE LAUYXX.
1 .
LEl'JiOSY OF THE MOUTH AXD rilAlCYNX.
In these regions siiioolli patches are first formed, tu l)e .sueceed(>il
hy prominent nodules. 'J'he median i'urrnw of tlie tongue is said to he
greatly exaggerated. Aniestliesia and infiltration of' irregular patches
take place, while the sense dl' faste, like the sen-e of snu'll. is usually
retained. Aloi'ell Mackenzie, in taliulatiiig the history of i weiity-fivi^
cases, only re[»orted dysphagia as present in one. Jt is fortunate that,
so terrihle and loathsome a disease should entail so little physical suf-
fering.
The ])haryn.\ is always more or less iiillauicd. JIypertro])hy of the
tonsils aiul other tissues soon follows, to be succeeded at a later stage
by atrophy.
Jlcariug is also likely to he iuipaired, through extension of the
disease to the Eustachian tubes.
The diagnosis from syphilis and lupu.- must be made on .similar
lines to those already refernd to. l''rom tidn'rculosis of the ])harynx,
which it somewhat resembles; the intense pain attending the fornu-r,
with its characteristic high febrile action, should readily l)e distin-
guished from the anivsthesia and low temperature always found in the
leprous iliroat.
LErilOSY OF TlIK I.AUYNX.
'J'he first appearances of this disease in the larynx are usually in
the form of little, gray, sensitive nodules on the posterior side of the
e])iglottis. At first, as they produce no irritation, they are nnnofieed
by the patient. Later on, as the disease spreads all over the epiglottis
and to the arytenoids and aryepiglottic folds, forming a gray, hanl-
cned mass, respiration as mcII as vocalizatic ii may be 'nterfenMl with.
The interarytenoid commissure, at first appearing like a soft cushion,
at a later period becomes crusted and hardened, a general pachydermia
of ihe larynx having taken place. As the disease advances, it is usu-
ally impossible to examine witli the laryngoscope the lower ])onions
of the larynx," on account of the extensive thickening and fixation of
the ey)iglottis itself (Fig. 125).
When this organ is eaten awa}', as in ^laekenzie's case, the dis-
torted intralarynx may sometimes be examined.
According to liergengriin, the implication of the vocal cords does
not eome on until late in the disease, and sometimes not at all.
The experience of Lennox Browne, from whose book this chapter
J,i:i'ltO,sV Ol' TIIK I.AKVNX.
413
is liir^a-lv laki'ii, br.ii>; (Hit tlial ol' iitliii' obsorvrrs, that the cliaiigL'S
Miiicli ru'!«t occur in liic larvux are thosi! ot gc'iieral tliickeiiing and less
nodular tluin wlien found on the pahite, and thai tlie destruetion of
the I'.alural tissues, as tlie disease advances, is al\va_v< more of tlie nalnro
oi' alisoi'jition than of nh-eration.
W'bih' the funi'li(jns (if plumat inn. respiratimi. and (h'glutilinn
Fiir. ]'l't. I.f'jirosy ol' tlie luiiguc mid ('iiij^luitis.
(l'"ioin Lennox l^rowiie, IS!)!).)
I I
niav be iuteifered with to a \\\<n\' lU' Ic-s extent, tlie ])alient siilfci's
little, if any, pain in this disease. Stnii'iural changes, also, appear to
affect the vocal cords last (d' all. 'I'he voice at first is but slightly
altered. Then the higher tones may he broken, hoarseness and aphonia
coming on at a later ])eriod in many cases.
Deglutition is sometimes ditlicult, hut rarely painful.
Respiration is always interfered with to a more or less extent, and
20
414
DISKA^KS (l|- TlIK I.AKVW.
wlicn till' vociil cords arc atl'ootcd may be; very ditlicult, produciiijj!-
stenosis and nocossitating tracheotomy to prolong the life of the i)a-
tient. ])r. Abraham lias reported a ease in wliich the glottis was re-
duced to the size of a goosc-qnill. I )eatli sometimes oeenrs from (edema
of the glottis the result of the disease.
Treatment. — .No treatment is curative. Palliation is all that ('an
be acconi|ilisli(>d. De la Sota reports beneficial results from ap})lying
resorcin ami iod(d'iirm in ether. JTygienic and dietetic measiires should
be attended to. Lennox I'.rowne suggests tlie advisability of trying
serum-therapy.
i -'
ClIAl'TKlf LXXVIII.
SVrilll.IS OK TllK I.AKVNX.
I'liiMAHV sviiliilis of ilic liirviix i> sn v.wc as to he alinnst unkiiDW ii.
JUKI, iis ii scroiKliirv lesion, il i>
>f'l(loiii met will). '['
ic (■liict iiiani-
iVstaiioii ol' tilt' disease is in the so-ealleil tertiary period, oecurrinix
many years after the development of the pi'imai'v lesion. Congenital
syphilis of the larynx is a rare all'eetion.
Pathology. — 'I'ln pathological conditions pro<liiced liy syphilis of
1"\<X. liiC). — Hotniilion of i'|ii^'lin(is from sy[iliilii ic iih ri;iiioii.
(From Hoswcirth.)
tlif larynx are as variahle as those found in the upper portion of the
respiratory tract, Avith the oxceiition of the extreme rarity ol' the pri-
mary stage.
Tn secondary syphilis theri^ may he tlto deep congestion of tlie
mncotis memhrane, aeeompanied liy dryness, l-'ollowing this may
come infiltration, the swollen memhrane (piickly heeoming tlie seat of
numerous sluillow ulcerations, resembling the mucous patclies observed
in the pharynx, Ijut (listri])uted witli less regularity. These occur from
six montlis to two years after the development of the primary sore in
sonu' other part of the hodv, and are onlv found in the vocal cords.
(41,-i)
H
Ii
" '1
410
DISKASKS Di-
ll i: I.AUY.NX.
Ij^ I
'I'ho ulceratiolis occurring in tiiirf ^[hjxv arc ^iniy in color, siirroimdcd
l)y an hypcr.Tinic red zone. Secondary sypliilis rarely occurs in the
larynx until several weeks or iiionllis alter tiie apjiearance of the
cutaneous cru])tion.
The tertiary sta.uc is also marked by hypera'inia. This may ho
followed by deep and rapid ulceration, destroyin,^ cartihiLic and sur-
rounding tissue. J-'lVorts to repair hy Nature produce severe contrar-
lion from cicatrization, impeding respiration and jn'oducing stenosis.
The extensive destruction of the epiglottis and other cartilages of th(>
larynx, arising from tertiary disease, may end in gross del'orniity as
well (l''ig. l-.'d).
<uiiniiiy luuioi's are jirohaldy th(> iiin-t fro(iuent pathological for-
M
\hi
i !
94
Fig. I'll.- (-iiutricial stenosis of larynx, liic result of sypliilitic
iilcciation. iKroin I'.oswuitii.)
malion found in the larynx during the course of this disease. They
<lo not occur, iiowever, until years after the ])rimary infection. The
interval may he over one and even two decades, the larynx during all
this long interval being practically free from disease. Sometimes the
gummatous tumor involving one of the vocal cords may break down
by ulceration, with extensive destructiofi of the tissues. In others it
may continue as a dark, nodular enlaigement impeding the functions
of deglutition and respiration. The process of cure after destruction
of cartilage is aided by formation of connective tissue; but this rapidly
contracts, resulting in the deformities of cicatrization already referred
to (Fig. 127).
Etiology. — Syphilis of the larynx is usually a tertiary, sometimes
SM'IIII.IS.
-ur
a secoiuliirv. niiuiil'cstiitidn of ii(i|iiiiiMl disease. As a priniarv atroction,
the ea-ic rt'jiortod l)y .Miniro, u! raris, in 1S!>0, appears to he the only
oiu,' un record. The eaiise may be liereditary as well as accpnred. Syph-
ilis of the larynx occurs more fre(iuenlly in men than in uomeii.
Symptomatology. — In secondary syphilis nf tin- laiyn\ the symp-
toms ol' the llrst sta;;e resenilih' those of siiiiph' a( iitc larynj,ntis. There
will he soreness and hoarscnes-, and laryn>,fosc(ipic examination will
reveal the congested condition. Soon the rosy ap|)earance becomes
mottled. Certain ])arts assnme a raised posit inn and sn|)eificial ulcera-
tion follows. The voice changes early and the pitch is lowered. Odyn-
phagia, as well as hacking cough with expecioral inn of muco-pus. is
also usually present. When mucons [)atches are pri'scnt they may be
roniul most fre(picntly upon the vocal cords, then upon the inter-
arytcnoid space. th<' ventricular hamls, and the epiglottis. Cnndylo-
mata soniciiuics occur in this stage. They are u>ually al)sorl)ed. and,
like the ulcerations, are only <d' a few weeks' duration.
In the tertiary stage the deep ulcerations usually alVect the epi-
glottis first, the oral surface on the edge being the lii'.-t to sulTer; ne.xt
the intralaryngcal cavity and infraglotti<' region. It is d\ii'im: this
stage that guuimata are likely to develop. They consist of infiltration
of the dee]ier layer of the laryngeal tissues, sometimes extending to
the perichfnidrium. ^^'hen the cartilages are aU'ected the jiain is more
severe than when the gummatcuis deposit is confined to the epiglottic
folds and ventricular bands. When the tumor develops within the
respiratory tract, dyspmea may follow as an eHV'ct of stenosis, while
impairment of voice will result from the disease alfccting the cords.
Apart from the stenosis produccil by gummatous enlargement, it
arises much more fre(piently from the vigorous cicatrization following
the ulcerative process. S(uuctimc.-- this is so severe as to threaten im-
nu'diate sufTocation. N'ot infi'iMpu ni ly a cieiit ricial wcb foi'ms, uniting
the antei'ior ends id' the vocal CMU'ds logcihci-; and. the slow chronic
inllammation of the mucous nuMubrane continuing, the lunu'n of the
glottis may eventually be almost entirely closed. Pain in these cases
is much less severe than would be expected, from the severity and
extent of the diseased condition.
Diagnosis. — Tn the eai'ly stages it has to b(> distinguished frmn
a simi)lc catarrhal laryngitis. This, however, never extends to ulcera-
tion, and is easily removed by simple treatment, while the syphilitic
lesion only yields to specific treatment. When the mucous patch has
formed, it lia^ the like distinguishing features of mucous patch in the
I
m
118
DISKASKS or TIIK I.AliYNX.
% j!f ' i^^
!*
'!'
phaynx. Tlu' j;iiiiiiiiy tiiiiior. ;is si'i'ii in tin- Inryiix. is a smooth,
roimdi'd tiiiiicliutioii o|' liypcrii'iiiif apiicaiaiicc. and. imU'ss destroyed
liy Ircatiiit'iit or ulceration, likely to reniaiii fur some tiiiio. It is this
inaiiit't'station oi' the disease wliieli mi^lit he iiiislakeii tor tul)ereulosis
or camel'. The diajiiiosis. however, is not always easily made, in
tnhereulosis the iidiltration may l)e extensive as well as aiiaMiiic, in-
stead ol' hy|iera'nne and circumscrihed. in tlu' one yon have more
local ])ain and I'ehrile action. t(!getlu'r with ])nlmonary lesion and
emaciation. In the other these symptoms may all he ahsent, save the
tlilliculty ot dciilntition and ])rohahle stenosis. From malignant dis-
ease it is distinguished hy the history of the case; the ahst'iice ot can-
cerous cai'hexia. exuheranci' ot j^rowth and ha'm(urha,i;'e >hould help
to make the dia^iiosis certain, in all donhtlul cases administration
of antisyphilitic renu'dies should help to clear away the mystery.
Prognosis. -I' nder pro|)er tri'atment this should always he t'avor-
ahle, except in cases in which desti'uctive action has already eom-
meiu'ccl. In even the.-e it may he arrested. When, howi'ver, deep
ulceration ha> followed the uiimmy deposit, cicatrization is houiul to
take ])huH', the only hope lu'inu' to prtuuote altsorptitui and arrest
further ulccrat ion.
Treatment. — 'The local treatnu'ut of secondary symptoms consists
of frcciueni sprays n\' a mild, alkaline character, the main ohject hein;;
to keep iln' miiciuis niemhrane a,~ fri'c as possihlo from all irritalinj,^
or I'oid secretions. If the ulcei'ations or mucous ])atches persist in
devol(^j)meid. a nitrate-of-siUcr ])i,ii'nu'nt of ID ]ier cent.. ap])lied on
a eotttm-hohh'r, will do li'ood sei'vice. tlu' parts liavin;,'' heen previou-ly
(leadened \ty a solution of cncaiiu'. lodofoini or iodol in ])owder hy
insnfllatiiin, or weak s(iluti"n n\' emT(isi\e -uhlimate hy alomizi'r. is
also applied in these ea^es. ('leausiiiL; and disinfectant treatment of
the larynx is always in order in teniaiy as well as secondary disease.
The main reliam-e, liowe\ei'. mu^i lie placed on systemic treat-
ment, in the earlier siaL^'es of syphilitic laryngitis mercurials arc in-
dicated, just as when it occurs in other pai'ls of the hody. while in ter-
tiary disease the iodides arc lU'cded in full and i'eij,ular doses. Some-
times a ((Unhination of the two is attended hy the hest results.
Sui'iz'ical treatment is not reiiuired i'Xee]it in eases in which strict-
ure has hcoome so severe as to ])roduce serious laryngeal stenosis. In
these cases various nu'thods of treatment may he called for. It is not
often that mendn'anous tissue can he icmoved without danger of in-
ducinir still nmre sei'ious strictui'e. Still, in sonu^ eas(>s adventitious
1 1
■ ■ (
i'
SVl'llll.lS.
419
liiiiids iiiiiy l)t' incised or snippi'il iiwiiy. As a rule, wlu'ii stenosis is
.se\('re, laniiiieiil ililiitois arc I'alleil lor. Of the many that have l)een
nsed, Schi'oetler's. Na\ ratil's. and Macl<en/ie",- are anionu tiie hest. Tho
oliject in all is the <iradiial dilatation of the stricture, the instrument
l)eiu<? ])assod into the hiiyiix and retained as Ion;;' as |)ossihlo. The
treatment should he repeated at intervals oi' a day or two and eon-
tinned for months or nntil permanent advantage is secured.
Other means I'ailin.i;- to produce tlie reipiisite amonnt ol' relief, in-
tid)ation possesses, in some I'cspects. a (k'cided advanlajfe over trache-
otomy, inasmuch as it iloi's away with any cnttiui; operation. It can
also he ])racticed hy mcatis (d' reflected liulit, and the tuix' worn or
removed at pleasure, 'i'he chiel' disadvaiitaiic of a prolonired use oj" tlie
. PI
l''i;;. 1:2s. l.ciiiuix I'.niwiit's liollnw lar\ nj^cMl dilatur willi tultiiiy;-
liliulc I ' .. iiicasiiri'iiit'iit 1 .
instrument may he the dei'ei'live deululdion which its insei'tion in a
distorted laryn.x may produce.
Several years aad .1. Miuiiit IMeyer read an exceedingly interest-
ing report to tlie Ameiican Medical .\ssociation, giving the hist(n'y
of tlie snccessful treatment of eiglil casi-s oC syphilitic laryngeal steno-
sis. In all these he comhincd I he use of Lennox I^rowne's cutting
dilator with t1ie after-inseriion of ()"l)wyer"s tuhes (l-'ig. 1"2S). The
tliroat is first spr.iyed with a ■'"-pcr-eeiit. solution of cocaine, 'i'hen
the cntting dilator is inserted, a large-sized throat-mii'ror heing nsed
in order to give snnicii'nt rellected liglit. l-'or the moment hreatliing
is interfered with, lint the incision of the cicatrix is (piickly made.
Sliglit bleeding follows. A few minutes later a large-sized hard-rul)her
intnbation-tn])c is introduced and worn for two weeks. It can be re-
moved once or twice during that period, if re(iiiired, for cleansing pur-
'I
420
iiim;.\si;s ok iiii: i.Aitvw".
poses. In every instimec there was grcally-iinprovod brciithing-Rpnoc.
Tlie st.'vcral innririns of eiifli cicatrix iicalcd without miiiui, leaving
an ahiiost normal chink.
lUeycr ch)ses liis artiele with the following conclusions: —
'*]. Jn the first place, the destruction of the cicatricial web, by
means of the knife, is pri'feraiile in every way to the older operation
(d' simple dilation.
"Vf. Jt is a more radical procedure, and the obstructing tissue is
destroyed (piiekly, instead of being puslied aside and thus allowed to
slough.
";5. 'l"ho operafidii saves time, n lurc Ix'ing cfTccied with less
cliMnoe of a recurrence of the diiliculty. without iiicicasing the risks
of (iperatidti, than by mean-; of simple tli'ali m."
Jn some cases of sy[)hilitie stenosi> iraclieotnuiy may be reipiired.
t.!i
II i :
( ■
! ■'
;1(
! !
Con<;i:ni lAL SYt'iiii.is oi' I'lii': Lakvnx.
J. X. Mackenzie was auiimg the lirst to draw attention to this ex-
ceedingly-rare manifestation of sy]ihilitic disease. lie says that "laryn-
geal lesions have not been found nu)re fre(|ueidly, simply because they
have not been sought. Laryngeal disease is not rare in congenital syjdi-
ilis. It is one of the most constant and charactei'istic of the patludogical
phenomena; and we may hxik fiU' invasion of the larynx with as much
confidence in the congenital a.- in the acquired form of the disease."
Two-thirds of the cases so far reported have occurred during the first
year. The younger the ])aiient, the more rapidly fatal the malady.
'J"he chief symptoms are impairment of voice, catarrhal cough, em-
barrassed breathing, painful and dillicult deglutition, freqticnt laryn-
gismus, and general wasting cachexia. l">equently the only positive
diagnosis can be made by anlisyphilitic treatment by mercurials or
iodides, or both cond)ined. When adenoids block up the respiratory
passages, they should be removed while systemic treatment is in prog-
ress. In some cases res])iration may be so impeded that tracheotomy
and even intubation may be required to relieve and possibly save the
life of the little patient.
ClIAPTKi; 1,\.\1.\,
NKlltOSKS (iK TIIK I.AIIVW.
This ^ulijrcl iiiav vny well he (li\i(l(<! iiiln: "N'ciirdM's dl' Seu-
silitm" iiiid "Nciird^o (if Miiiinii." the hiiw r liciiig siilijcct to a t'lirthor
ilivi^idii: (if ■•s|iiisin" (if tlit; larviix, (ir uvcnictix ity, and "|)aralysi.>" of
the larynx, nr diiniiii.-lu'd activity.
Ni;i ifosKs or Sknsaiion.
N'ai'ions ((inditidiis df the larynx .-udi n.< auiUathci-ia, liyponi'.s-
thcsiti, iiaiirstlicfia. and ncui'al;iia — may be gi'dniicd tdUfthor iindor
this liead. Thi'V all indicate dcpaituic from llu' nuiina!. liie form of
development being the n-sult nf pcr-onal tendency in each individnal
case.
'I'here is no special pathologieal condition indicated; hypera'mia
may or may not be ]ircsent, Imt there is nsually a neurotic eondilidn
df the system.
The cau.ses wliich give vise to tliese conditions are numerous.
Excessive smoking, alcoholic indulgence, nnsanitary conditions, in-
ordinate use of the voice, and liyperlrophicr cdiiditidiis df the nose or
naso-pliarynx may be mentioned as the most cdinindii. Of lU'uralgia,
a rheiinuitic or uric-acid diathesis is a fr('(|ucnt cau>c.
The symptoms are those of lai'yngeal irritation of
duc idrm or
an
other, often accompanied by dryness df the thmat and a teiuleucy
to cough, .\nfesthesia may be an exceptiiin in this rule. ina:>much as
laryngeal accumulations occur almost to the extent of obstruction
without their presence being noticed by the patient.
Treatment. — Kxcc])t in tlie hitter instance, this slionid be of a
will soothe tlie irrita'ile larynx,
witluiut injurv to the general svstem. will be of benelit. Tal)lets of
palliative character. Anything that
chlorate of potassa or muriate of ammonia dissolved ii
1 the 1
nouth are
often useful. Menthol lozenges containing V'4 to '/. per cent, of men-
thol are likewise soothing to the irritated parts.
In the ana>stlietic larynx stimulating the laryngeal nerves by elec-
tricity may be of benefit, together with the administration of strych-
nine, arsenic, or phosphide of zinc.
(421)
ii
I
422
])isK.\si:s ut" Tin; i.akvnx.
Ill the ii('iii'al,i,n(' larynx tlu' cause si. mild Itc invostigatt'd and ro-
movod. 'I'lcatnii'iit hy llie galvanic current, the inU'alaryngeal elec-
trode heing used, in .sometimes bendicial in these cases. In rheumatic
or uric-acid ease- the saiicvlates iiiav \)v of aihantaire.
I-
I
NEUVOI S Al'llOXlA.
Xervdus, or liyslerical. ajihonia is a I'liiictioiial alVectinn of the
adductor nuiseles, giving rise, for the time being, to complete loss of
voice. In it there is no patliological lesion. 'J'he vocal cords are still
controlled by muscles and nerves, anatomically ami pl.ysiologically in
a normal state; hut, owing to the hysterical condition of the patient,
the psychical power oi co-ordination i^ lost, and no amount ut' effort
on the ])art of the patient can juoduce the natural voice.
It seems to he a functional bilateral paresis of the lateral crico-
arytenoid and the thyroarytenoid muscles: the adductojs nl the larynx.
It is a disease jteculiar to women of nervous temperament, and is one
of the not infre(i'"nt manifestations (»f a highly-hysterical condition.
While it lasts, the voice is reduced to a whisper.
Symptomacolog'y. — 'i"he attack is always stuldeii. I^'roin ]ierft'ct
vocalization, the change to complete aphonia may be instantaneou.-.
At the same time the ])0wer of audible laughing or coughing, being to
a large di'gree involuntary, may be retaiiu'd. The paroxysm nuiy cease
as suddenly as it cominenced. To ])ersons subject to the aM;''k..e\-
]iosiire to cold may induce a paroxysm. So may fright oi' intcii-e nerv-
ous excitement.
f-aryngeal examination will revt al the true condition of the Vdc.il
cords. Allhiumh otherwise healthy and normal in apjtearaiiec. ihey
cniinnt be evnily and completely adducleil. often exhibiting a trem-
ulous outline.
The prognosis in these cases is favorable, though even after cure
a temporary i'l'tuni at any time is possible.
Treatment. -Men I'll impression ,vill sn;, letinies i'e<tnre the vnici'.
The int I'oiluetinii n\' a lliroal -iiiirror or the spraying of the larynx with
a slini'ihiling dilution nuiv either of ihein so di,-lodge the aphonic ini-
piressimi as to restore liie power of speech. In oilu'r cases prolonged
treatineiil may be reipiired. ('leansin'.i' and stimulating spray- to the
throat, a|i])lication of the elei-tric current, tonini;' the system bv tlie
af ninistr-'dioii of stryclipir.e oi' valerianate (d' zinc sustaining diet.
and change id' air aii'' scene may all be reip-'red befoic n >ncces>fiil
result can b(> accomplislied.
SJ'As.M Ol- TUK t..l.UlTlS.
Xki'kosks oi' Motion.
4:23
• 1 1 ro
lici'.
with
iiii-
tlio
tlio
li.'U
spASNf OF Tin; (II. orris.
As Sir .Mdi'cII Mncknizic i-ciiiiii'krd, it i> iiiipoitiiiil to licar in iiiiinl
lliiil this i.< iKit ill il^cll' a di^ra.-c. Inil a syiiiptoiii of (lisca.sc. its usual
iiiaiiii'cstation Ix'iu','' in tlio I'onu ol! sjiasiu of tlu^ glottis, or laryii-
i,nsnuis stridulus. 'J'lic uatuic of lliis atVeclioii is varioiislv estimated
by different authors. !Many believe that it is of refle.x nervous origin,
resulting in spasmodic eontraetioii of the adductors of the vocal cw'ds,
the dilliciilt hreatliing and harking cough licing the result of the con-
,«equei)t steiiosi>.
I am afraid we have not got much beyond .Marshall iialTs teach-
ing of sixty years ago, that it was always produced by rcllex action froni
iioiiie region remote from the lai'viix itself. According to this \icw. it
oriirinates "in the trifacial in teething, in the pnenmogastric in iniprop-
<'rly-fe(l childi'eii. and in the spinal nerve- in constipati(Ui. iiile-tinal
disorder, or catharsis."" Some believe that the pathological lesion is
disturbance within the cereiiral nerve-centres. Iliighlings-.Taekson has
pointed out that the nervc-cenires may not be knit m) closely toLiethcr
41S ill the adult, and that a partial cnnviilsioii. ,-iich a- occurs in laryn-
gismus, point.- to the ■uiperfect union of the dilVereiil secti(Uis of the
nervous system. The carpopcdal conirattioiis in children are ex))laiiied
in the .<ame way. 'I'lie nerve-centres not being fully (h'veloped, spasms
of muscles or of gmnps of muscle.-, and c\cn general cuiu ul.-ituis, occur
more readily and fi'e(piently than they du in adulls.
Etiology, — This is a disea-e es.-eni iaih' ]iertainiiig to child-life.
It usually occurs between the ages of tlii'ee niontli^ and three \car-.
About t>»ice as many boys are ail'ecled as gii'l-.
Physical orii'anizalion. whieh i- f!'e(pienlly a I'c-iilt of .-ocial con-
dition, has a ih'cidcd inlluence a- an ctinlogical factnr. Ill-nouri-hed
children, living (Ui pnni' \tu>i\ and in ill-\('ni ilatc(i hou^i's. are particu-
larly liable to ciuitract il. In tl.:' dcn.-ely-popidated cent 'e- of large
cities it is more ]U'i'\alcnt than in nthcr rciiion-. When bad hygienic
<Minditions and '"nsiinicient noiii'i-lnncin are constart. the dll'spring (d'
the ])cople have a tciidi mcv tn rachil ic di-ca>e. .\s a result a large pro-
portion (d' the cbiliireii who iiave -pa.-mndic ci-unn are like\\i-c \ictiin-
(if rickets.
Symptomatology, The first atta k of spasm or closure of the
glottis usually occur.- al nighl-timc. The child is taken with siuhlen
convulsive aeti<ui cd' the adiliictors of the glottis. l'"or toe time being,
H
it
424
1)Isi:.\m;s ok ihi: i.auvnx.
^
r('s|iir;iti(in is iirrcatiil. niort! or loss coiiiiilotcly. Tlie hands and foot
arc clindicd, the licad tliinwn liack, and. if loiii,' conlinncd, the face;
may hcconic cyanotic, lii a U:\\ seconds, or mijiules at the longest, tlie
adductor nmsch's ol' the Jarynx yield, llie aluluctors come again into
action, and respiration returns, sometimes gradually, with long, crow-
ing i)r('alliing, and sometimes sudck'iily.
These attacks vary in dui'alidii and also in rretpiency. When the
spasm is jmri'ly neurotic, relief may l)e c()m})lete tor a time, occurring
again at irregular intervals cd' hours or days. When the stridulous
hreathnig arises from suhglottic inflammation, the stenosis will ho less
compk'te, and at tlie same time more pi'olonged. never leaving entirely
imtil the inflammatory cause is removed.
Laryngeal spasm, although rarely so, is sometimes fatal. C. If.
Hunter (Ih-itish Medical Journal. .April. 1SJ>8) gives the history of
two remarkahle cases. These occurred in hrother and sister. Both
were perfectly well up to a few ndnutes hefore death, and they died
within two days of (>ach oIIut. The mother took the 1)oy, aged 1!)
months, up to wash him. in a lit (d' passion he threw h.i- head hack
and hecame livid and rigid. Jle wa> put in a hot hath at (incc l)ut it
was of no avail. Two days later tlie sister, aged 7 months, suddenly
hecame rigid and hlue in the face, and died like her hrother. withotit
utti'ring a .cound. In hoth there wci'c well-marked carpopedal con-
tractions, l)ut no genei'al convulsions. I'osl-mortem examination^ were
held, hut all the organs were found healthy, 'i'here were no lai'yngeal
ohstruclion-. hut in hoth were indications of rickets. Trederic Taylor
says that rickets occur in 7,") per cent, of all cases of laryngismus strid-
ulus.
Diagnosis.— When ihc .-|ia>m is purely neurotic the diagnosis is
not dillicult, as the exaeerhation- are. a.- a lule, follow* d liy perfect re-
lief. Thei'e is no fclu'ile action and no changx' in voice.
Paralysis of the ahdiuMius might jirodiuc similar crowing symp-
toms, hut in this case tliere woidd he no exacerl)alions. Stenosis would
he continuous witluuit fever ;iiid without vocal change. P'rom the
stenosis ]M'o(lueed hy the jji'eseiu'c of laiyiigeal papillomala. the gen-
eral histoiy. together with laiyngeal examination, wiudd I'cnder the
diagnosis jdain.
Prognosis.-- lii ke ihe eron)iy symploms ai'ising from sidjgloltic
inflammation, this is u-ually favorahle. .\ large majority of cases get
well. When the spasmodic action of the adductors is compleii\ as well
as prolongeil, the result may he at once fatal, as in the cases referre(l
; I
STASM Ul' JllK (JLOTTls.
426
to. This rarely ofciirs. Tlie .spasms, altliuugli repeated several liiues,
usually disappear even without treatment. The i'riends of the little
patient, however, become alarmed, medical advice is obtained, and the
cure hastened.
Treatment.- -d"(U' piii'c nervous spasm of the <>-lotlis. imiiiediale
inhalation of a few drops of amyl-nitrate or chloroform may he li'ied.
Of cour>e. this wnuhl haxc no eflVct if the glottis were coni|)letely
closed. A (luiek ship on the l)ack. dashing cohl water in the face,
jdunging llie lilth' ]iaticnt into a hot hath, may all lie tried. Hypo-
dermic injection f)i minute doses of aporaorphia. a milligramme for a
child of ihi'cc years, may also ])i'oduce diaphoresis and vomiting.
.\-. however, the spasmodic closure of the larynx is only a symp-
tom of cetitral or ])cripheral disturbance of the nervous system, mere
treatment of this symptom should not stillice. An attempt should be
made to ascertain the real seat f)f the evil, and, liy n'moviuL:' il. pi'cvent
the recuiTcnce of the attack,
i-luslaee Smith in the London Laiiccl for Maich I'.i, lS!tS, gives
the history of a case of constant laryngeal stridor in an infant, caused
by the presence of adenoid vegetations. l''rom the age of (Uie month
to four months the strid(U' had been constant day and Jiight. Much
of this tinu' was spent in the hospital, but no relief from the conlinued
croaking breathing could be obtained. Then the adenoids, whitdi were
not large, were removed. At once the night attacks of acuie dyspno'a,
which for thr(>e months had constantly occurred, ceased, and the child
sle])t undisturbed, in a fortnight the croaking during the day-time
eotdd not be heard in ordinary breathing, and in a few nmre days the
child was discharged cured. The history of this case is given as a rare
and peculiar instance of constanl reflex spasm of the glottis.
Spasm of the larynx not infreiiuently occurs in adults It is usu-
ally |)ro(luced by direet ii'ritation ui some portion of the lining mem-
brane (d' the hii'ynx itself. 'J'lie ent I'anec of some ■ light poll ion of food,
drink, or any foi'eign suhstaiU'C will induce a?i attack. On two occa-
sions I have seen seven.' laryngeal spasm occur in elderly men from
sepai'atiotr of a drop ol fluid from a colton-holder. while it was being
]ia.«sed into the naso-pbai'ynx. The drop in eai-h case fell directly into
the open laiwnx. and by rcllex action pioduce(l. for a great many sec-
onds, complete closure of the glottis. I mention this from my own
])racti(e as much in the way of warning as anything else. Whenever
application is made through the ortil cavity into the miso-pharynx, all
redundant moisture should be pressed out of the pledget Ixjforo at-
tempting its insertion.
il
426
DISEASES OF Till-; LARYNX.
«;!■
-i
PAKAFA'SIS (»1- TllK LAUYNX.
I'|( to rt'ci'iU years it was bt'licvod that the abdiicttir or adductor
inusck's iiiijrlit citlicr ol' tlicm be atl'eeted from lesion of th(! nerve-suii-
ph', to tlie exclusion of the ojiposite group. .\lso, that, in otlier cases,
the central lesion nii.Liht be so general as to aH'cct all the motor nerves
of the larynx, inducing paresis (d' both abductors and adductors at the
same time.
Since that period o])inions, based upon extensive clinical research,
have nndergone a material change. Now it is known that, in jiaralysis
of tlie larynx, the abduct(U' muscle, the jiosterior cricoarytenoid, is al-
ways tlie one first afTected and that the term paralysis ol' the larynx,
as u>ually applied, signifies jiaralysis ol' one or both of the abductor
juuscles. Further, wlu'ii paralysis of the adductor does occur, ii is
always secondary to ]iriinary paralysis of the abductor, exce])t in cases
where the lesion is complete at once, as in section of the recurrent
nerve.
Sir l'"clix Si'iuon suii..,iarizi'S this conclusion as follows: '"While
there is not a single authenticated case on record in which it has been
shown by post-morlem examination that in a slowly-progressive or-
ganic lesion of the motor nerves (d' the larynx the adductors had been
])rimarily or exchisively aiVcctcd. we are now in possession of (juite a
number of well-observed case^ demonstrating the opposite order of
events." That is. in whiih the abductors had been primarily or ex-
clusively all'ected.
Semou adduces another curious fact, that, although in general
paralysis (d' the lai-ynx the ai)ductors are always affected first, when
recovery occui's the adductors lead the way. The reason assigned is
that. fr(uu stunc cause still unknown, the abductors arc much more
vulnera1)le to nervons inlhi. ncc than the adductors.
The recent physiological investigations of Kisieii Hussel have
proved that, while the recurrent laryngeal nerve is the motor nerve
par r.vccUi'nrc- of the larynx, it can be split for its entin^ leimlh into
three dilTeicut itundlcs (d' librcs. one of which supplies the abductors,
another the adductors, while the third is without motor influence.
The fibres which supply the abductors of the vocal cords, being situ-
ated on the inner side of the nerve, an thus coin[)letely dilTerentiatcd
from those supplying the adductor muscles.
In the large majority of instances paralysis of the vocal cords is
at first unilaieial. and fi'(uu its pathological condition would produce
rAHAl.YSlS OF Till-; AHDrCTOU MI'SCI.KS.
■i'i:
no >yiii|)t(iii/s wliich would be likely to lead to imniodiutc discovery.
Nothing" short ot laryngol(\ii,i(al (•xaiiiiiiatioii coidd make [Kwitivc its
t'xistciK't.'.
In the first t-taijc of paralysis the cord, which at rest would he in
the cadaveric jiot-ilion, leavinjj abundance of room for ri'S])iratioii,
woiihl bo drawn to the mesial line by the adductors in phonation.
Later on, if tlie adductor muscle remained unalVecied. tin- constant
tension, unopposed Ity the abductor, woidil lead to peruiniicnt reten-
tion of tlie atfected c«u'd in the mesial line. N'ocalization wduld still
be perfect, while rcs])ii'ation would only he slii^ditly atfected. the o[)en-
U)ii made in the jilottis. by the unall'ected aliductor of the opposite
siih'. still bein.i,' sullicient for i)reathin^' purposes.
^Vhen paralysis of the abductor is followed by extension of the
lesion to the adductor muscles, the cadaveric position on that side bo-
comes ]iermanenl. This, of course, would lea\e the hreathinu' s[)ace
unatfected. and would alVect the voice but little, a- the unalVected cord
iliiriiiii' ]ihoiiation would sweej) across the mesial line, to adjust itself
to its paralyzed fellow. I!en<e. even in this extreme case, (udinary
symptoms Avould not indicate the true condiliiui nf the vocal cords.
In case- where the ]»aralysis is bilateial. but in the primary stajxe,
alfcetin<r only the posterior cricoarytenoid or alidudor mu-eles. vocal-
ization will still be little interfered with, as the c<uils are adducted to
the position re(|uired for tlio productiiui of sound. l\espiiali(-n. how-
ever, is seriously obstructed. 'I'he bi'eathiiiL; is lalxu'cd. even to the
extent of impemlinu' sulVocatiou. Wlu'ii to this is added adihictor
paralysis, the breathing" may be soinnvhat easier, as iioth coi-ds are
immovably tixed in the cadaveric position: l)Ut with the chan-c the
voice is completely lost.
Laryui^-oscopic examination >honld in all cases be mailc when
there is reason to suspect tlu^ ])resence of jiaraly-^is; and by it the
extent of loss of powi'r shmdd lie at once ascertained, if an\ really
exists.
'^Phe causes of paralysis are numerous. In bilateral, the lesion is
usually central and may arise from th(> jiresence of <;iimmata, sclero.'^ip,
tumors, proirrcssive inilhar paraly-i-. elTnsions at the nerve-origin, etc.
Diplitheria is not infrequently the cause.
In unilateral paralysis the cause is rmu'c freiiuentlv pressure upon
some part of the course of the nerve itself, as from aneurism id' the
arch of the a(u1a. hypertrophied irhinds in malijrnant disease, tuber-
eulo.sis, etc.
r
Ifi
428
DISEASKS OF TllK LAltYNX.
I 111
il
i
':
'i
r 1
: 1
i
'.riie prognosiri in jiaralysis of the larynx, wliolhcr uiiilatoral or
bilateral, is not usually favorable. As a rule, it is but an indication of
the preseiu-'e of some central or peripheral lesion that is itself incurabk'.
When the paralysis is but the sequel of diphtheria or one of the other
exanlheniatous diseases, tlie outlook is more liopeful; also when arising
from the presence of gummata.
Treatment.- -When aiising from ])ressure upon tlu! rcciirrenl
laryngeal nerve, the removal of the ])ressure either by excision of tumor
or absorption of gummatous deposit should restore to the posterior
cricoarytenoid its normal m/rvous sujijily. For the latter iodide of
polassa should be freely given. Jii di[)iitheritic cases strychnia in sus-
tained doses will have a good eU'eet, and, in both, electrical treatment
should aid in restoration of muscular power. The i'aradic current to
the interior of the larynx, anicslhetized hy cocaiiu', will be followed by
good results in nuiny cases of functional origin, tlie negative pole being
applied to the paralyzed muscles within the larynx, by aid of the laryn-
goscojje, aiul tlie ])ositive pole with a large tlat electrode to the external
larynx.
Systemic means to restore the general health are also required in
these cases.
For ancurismal and tubereular cases, as well as those arising from
central lesion.s, little can lie done save of a geiu-ral ebaracter for re-
cuperative treatment.
George V. Hoss. of Montreal, has recently reported a case of bi-
lateral, abductor. laiTJigeal paralysis in a nuin, aged 50, arising from
chronic alcoholism of long '^taiuling. 'I'lie treatment consisted of
full diet, together with sedatives and tonics. The local treatment was
by galvanism and faradism. 'J'ho result was very satisfactory, as the
chink widened materially under treatment, freeing the patient from
his suffocative attacks.
n
1 s
ji
U
1
11
1 : !
1
tmd
CllAi'THlJ LXXX.
N(l.VM.\I.[(i\.\NT TlMOltS OF TlIK I.AIIVW.
Sri;('iMKNS of nearly all llic varieties ni' l)eiii,L:ii Iiiiiinrs have been
found within the larynx. 'J"he niajniity of these, however, are excoed-
in,i,dy rare. Papillomata are the most fre([nent in oceiirrenee, with
iihroniata ]irol>al)ly as seeoiul, while eases of cystoma, myxoma, lipoma,
c'iK'lioiulroma, and aniifionia are amom;' the rarest of laryngeal all'ee-
tions. I'atholoii'ieally thi'se various neoplasms are the same as when
I'onnd in the nose or naso-jiliai'ynx. the diU'erence in condition heing
one of site, and not of history.
I'aiiilloniata may occnr at any pei'iod of life. 'They occnr most
ii
Pig. 121).- I'iipilloiiia of (111(1 I'io. i;i(i. Smiiic (lining [ilio-
duriiiji!- rcspiinlioii. iiiitioii.
I'iiticiil iiiiilt', agp(l 55. Entirely iciiiovi'd liy lucal a|ii>li('ati(iii of
astringents. L'nder treatment one year. No veeiiirenee. (Author's case.)
t 1
frequently dui'ini;' ehildliood and mature years. Tlieir site is usually
the vocal cords, and they may be single oi' niulti|)le. They dilVer in
color also, from pink or ligld red to gray. Tn early life they are ordi-
narily of a bright -ri'ddish color, and may exist in largo numbers. Al-
though usually sessile, with a warty appearaiu'C. they are sometimes
pedunculated. In adult life they oftt'U occur singly, being attached to
the margin of one of thi> vocal cords (Figs. rj!> and bid).
In childhood I'eeuri'ence after removal is fic(pieid. while in adidt
life it is rare.
Fibromata, although occurring with mucli less frequency than
papillomata, are also usually attaehed to tlu^ vocal cords. They never
(429)
27
'
luO
i)i>i:\>i> (»i' riii; i.akvnx.
occur in cliiUIhood. 'I'licy iirc linrd in (cxlurc, <.'mv or (loop red in
color, and inav bo attiuliod oilhor by ii broad pedicle or a wide, sessile
ba>c. After complete removal tlioy seldom rocnr (Kif,'. 131).
Of tlic otlior varietie? of boni,i,ni tumors, the cysldina. while e\-
cecdin<f|y rare, occurs with e(iual fre<[nciuy \\]u\u the epinlotlis and
the vocal cords. In Chark's Kni^iit's case it (iccurrcd in a colored man
aged 1(1 years. The cyst was pnle in color, with a number of large
blood-vessels on its surface. It was round in form, aliout the size of
a hick(U'y-nut, and attaclied to the left side of the epiglottis. The
Iiiinor wa- reailily removi'd by means of a cold-wii'c snare without
liiomorrhage and without pain, the throat having- been previously
sprayed with a 10-per-cent. solution of cocaine. Myxoma or polypus
when present usually a])pcars on the cord, an<l the same may be said
of anirionia. Kuclioiididuia has been observed on a number of occa-
l"i,Lr- liil. I'ilniuiia >itualt(l licuciitli llic riglil vocal cord, occuniiifi
in a man. a<;c 40, and removed iiy frctiuciit ainilicalions of galvaiioeautcry-
jioint. alter Inn^liinj.'' caeli time with 1.") |iei-cont. solution of cocaine.
(,\iitiior's case, i
M
■ l' r ,
^iniis (l-'ig. ]'.V!). 'I"he usual site has bei ii the inner aspect of the
eficiiid cartihige. The growtli is sessile and hard, iiifrinufing by it-
eoiitinue(| (levelo])ment upon the l)reathin'i' sjiace. Lipoma has its
favorite seat upon the aryepigloltic folds. .\s it eidargcs. it falls over
into the hyoi<l fossa or toso])hagus. and. attaining groat size, threatens
i-iilTocation of the patient, .\ngioma also siunctimes occurs (l''ig. 133).
Symptomatology. — Xcnu? of these growths are likely to be at-
leiided by much jiain. The main symptoms are those arising from
obstruction of res]iiration and phonatioii. In certain cases de<rliitition
may be affected, but only Avhcn the growth within the larynx is large,
oi' else, as in lipoma, when the (esophagus or hyoid is int''uded U])on.
Cough is also pri'sent in mtiny of the cases.
In papillonuitons disease the voice is usually severely afTectod, as
the nco])lasm is located on the margin of the cord. When the papillo-
N(tN-M.\I.I(iN.\Nl' Tl MOliS.
•i;!i
inata arc iiinnciDUs, the voice may lie completoly iiplidiiir and the
respiration interfered with.
\\ lien tlie ^n'owth is situated entirely free from the voeal eords.
tlie voiee may not he impaired, although the ohstruetin^' neophism
may h(! hirge enoujfli to jirodiiee dyspncea.
Diag^nosis. — This will depend almost entirely upon lai'ynj^osco])ie
examination, whieh should reveal the size, coh)r, and hication of the
j^rowtli. When the dia.unosis is still uncertain, a small piece should
be snipped (jif the neoplasm to be submitted to hisiolojfical examina-
tion.
The main distinctive features which I he larvniroscopc reveals are
II the
y it-
s its
over
atcus
VVA).
c at-
froni
ition
u'ge,
uiion.
(1^
tlic ('iii<,''lc>tt is. (After I'o-^-
\\ (irtli, I
\'\'j:. l;{;!. Aiiuidiiia of the Icfl
:il\ rpi^'lottic fold. (After Jios-
uortli.)
as follow: A papillonui is >oft and ninvidilc by in-piialion and expira-
tion. When siniilc, it is a <;ray or pink, and, as a rule, situati'd u|nin
the anterior half of the vocal cord. It is usually sessile, ahliniinji ilu.
base is not very brf)nd. When ninltipli'. as in childi'cn. llic iilllc. ^n['\
nuisscs may have a bi'iuliicr line, and tln' whole Icnu'th of the eords
may be studded witli iluin. I haso seen the latter condition in a jrirl
of ci,iihi('cn years.
.\ fibroma a])pears as a hard. rounde(l mass in -onie cases: it is
multilo])ular in form in othci's. U is usually sessile and may vary in
size from a irrain of wlieat to a couple of centimetres in dianu'ter. The
mucous mend)rane covering it is ricldy supplied with vessels, which
heiglitens tlie color of the tumor.
It
43a
JJISEAS1> UV TllK l.AliVNX.
m
A ('Iioiidroinn. as said bcJ'oro, lies, in tlio majority of cast's, bohiw
tlu' vocal cord,-. It also is round, rcsistinir, mid nodulated, but is
lighter in color than cither ])a|)illouia or libronia. l''roin its color and
appearance il nii^fht possil)ly be mistaken I'or carcinoma, but t'oi' its
occurrence in I'arly lii'e, while mali<,Muint disease of the larynx occurs
only in later years.
A cystoma usually presents itself as a jxMlnnculated cyst, cnni-
prcssible iind soft, and of a pinkish-,<,'ray color.
An<iioma has a red and slrawlxMiy-likc siiifaci'. while myxmiia
looks Wkr a iia-al polypus ti'ansfi'rred to the laryii,i:cal cavity, but tinned
with a hi;.;her shade of color.
Prognosis. — \on-mali,unant tumors involve litiU' danncr to life.
<'xcept when they assume such proportions as to threaten suiTocation.
Ill cliihlreii papillomata are sometimes produced in alai'uiinu' iiiimher>.
One unfortunate ft'ature of their (le\elopnici - that after removal
they have a stroiiu tendency to rcjiroduction. In adults they can usu-
ally be removed, iind, if the vocal cords remaiii uuiiijuied, the voice.
when aH'ccted, soon re.iiains its normal tone.
Treatment. — ^lany iiisti'iimeiits have been (levise(l for opei'ation
upon these beniiiii neoplasms when necessary, but ihcy are all intended
to be used intralaryn<ieally. .\ uood laiyn^'oscopic view of tin' larynx
having; been obtained, the iiisti'uiiient and method must be chosen to
suit the case in hand, care beijig taken to avoid all undue injury to the
healthy soft parts surrounding the diseased tissue.
Jn ])a])illomata after free cocaini/.al ion astringent and stimulating
sprays have sometimes been found benclicial. |)articularly in the iniilti-
])le variety. Of these, ])erhaps. pure alcohol has the liighc<t reputation,
'rouching the single growths with lliiid extract of thuja occidentali^.
20-per-cent. solution <if tannic acid, '>- to J(l-pcr-eent. solution of
nitrate of silver, "'- to .-»-])er-cent. solution of sulphate of copjier. or '2-
to o-per-cent. solution of chhu'ide of /iiic might be nuMitioned, and.
as a caustic, chromic acid melted mi the end oi' Ihe applicator is ad-
vocated by some writers.
IV) eradicate the growths, however, more elTectual measures are
required. Before o])erating a *3()-per-ccnt. solution <d' cocaine should
he freely applied to the inner larynx. Cutting l"orcc|)s (i'lg. l.'?i) of
different kinds to suit each case, for the renuval of pa|)illoiiiata and
fibromata, are the most favored instruments. W1<en the growth is
distinctly pedunculated, the snare carefully adjusted is probably even
more ofTectivo, care being taken to sever the attachment by the wire
'Lii '
NdN-MAl.KiNANI' I'l M()l!>.
4:53
lifforc tiiu iiiiuli t ruction is iiindt'. \'vv\ >iiiiill .-i/rd |ia[>illitmiit!i may
be L'xlrai'ti'tl l»y tlic use of Sclirocitci's tiiiic-rorfciis; Itiit, I'or larj,a'r
growth •. ToboldV. l'"aiiviTs, or .Mackcn/iiV loiccps arc itiTlVrrcd.
I''(ir cvsloiiia. fvaiiiatidM liv the kiiilV. and >m1)si'(|ii('IiI loial [wni-
iiR'iit iiy timtiirc of indinc or nitrate of siUcr. arc ad\i>alilc.
l''(pi' cncliniidi'dnia I he ;:'alvan(icatitery ha> lieen nscd. a> it i- al-n
ill some cases id' lihroma. Myxoinata may he snared or picked oil' by
laryn<j-eal rorce|is, and suhse(|ucidly the site of attachnicid tonched by
Fiir. l;!!. I'lxliriiiilioii iiislnnnciits. i\i;m-
<■ > >ct lit ID. ill
imivcisal liaiidlc
tile ,<ialvanocautcry. Aiii^ionia also iniirht he H'eati-d wiili tlie same
iiistrnmont at a dnil-red lieat.
Kach iiidividnal case shoidd lie ^i\en the nio-i (jn'el'iil coii-iihia-
tion liy the operator; and be treated, not accordini; to ride, inn liy tlie
liglit of e\j)crieiice and npoii its ow n merits. It should ever be I'l'mem-
bered tliat some of these lienijiii u'l'owths. if hd't to themselves, will
eventually disa])])ear or at all eveiit< become innoenon-. |iariicnlarly in
cases wlierc the free use of the vo
ce is not ol vital imporianci
hiTf
is also the possibility of stimtdatin.u reproduction of the neopla>m liy
operative treatment; and. still fnrther. of inducing' the devidoimient
oi' malignant disease by oflicious operative int(;rference. This, at all
events, is the view of manv ahle'writers. among whom Lennox Urowiie
! :;i
434
DlSKASliS (»l' Till'; l.AUVNX.
i: 'i!
I- Ih ■111
Cm I I
.-liiiids iiroiiiiiiciitly I'nrwiird. Ndt tluit these operations srslioiiM In'
eseliewed iillo;^'el liei', lillt tllilt ii wise jlldi^liieiil siioldd i)e exercised ;d-
Wiivs ill deMliiiir iiidividiiidly with these cases.
Ill iiiiilti|ih' |iii|)illitmata of chihlreii treatiiii'iit hy t riiehi'otoiiiy lias
recently heeii received with favor. Iiailton, in the llrillsh Medical
'limrnal, l'"ehriiary. Is'.is. irjvcs the history (d' two little i,Mrls ai^ed,
res|)ectively, ;! and I years, treated siiecessi'idly in this way. One re-
(juired to wear the tiihe I'orty-tive months helore the <,'rowtlis were all
absorhed; the other for twenty-hse inoiilh>. In each the child made
a ;^()od recovi'ry evenlnally, without return (d' t!ie pajiilloniata. Al
lirst silver tidies were worn, then sol't-ridiher one.-. The latter were
reiiewid three times a week K'ailtoii attributes the sjioiilaneoiis atro-
jihy of tlie ffrowths to the removal of the irritation of res|)iration and
coughing. Of course, the jieriod of euro was prolonged, but it must
Iio renienibered that, in cases where laryngotoiny has been performed
to I'aciJilate icinoval. the growths have .-.iil)sei|iiently in many instances
recurred.
in some cases it is possiiilc that piidoiiged intubation might have
the eU'ect of promoting alisorption by the constant jiressure it pro-
duced. Still, the dilliculty of deglutition wdiild lie a hinderance. Tni-
loiiged wearing of laryngeal lubes of any kind has also the possibility
of inducing granulations and p(dypoid growths 'o form round the mar-
gins of the instriinieiit.
Thyrotoniy has frequently been iierforined for this class of cases
in children, but the results have never been bi'illiaiit.
G. llunter Mackenzie (llrilish Mrilicdl .loiintdl. May. IMi'.i). in
Ills rcinarks on laryngeal growths in young children, advocates traidic-
otoiny as the treatment, of all others, most satisaietory in tliis condi-
tion. He lays it down as an axiom, that tlie two methods, so fre([iiently
advocated, — removal per ria inili(riilis and by tliyrotoiny. — are both
inadmissible, the reason given being that direct interference with, or
irritation of, the growths is almost always followed by rapid recur-
rence. Tlie endolaiyngeal method of removal involves a prolonged
series of operations, which are usually followed by recurrences, while
thyrotoniy, when tiied. has sometimes required to be repeated three or
four times within a year, ri'siilling in more or less ])crmanent impair-
ment of the voice, as well as stenosis of the larynx.
Intubation is olqectionable in these casi-s on account of the irrita-
tion it jirodiices. It is also freiiuently dilliciilt to retain the tube in
position.
NON-MAI.IliNANT Tl MOKS.
i;i:.
The iK)iiit tliiit lliinlcr Miickcnzir insists upon is that trachcMiiiiiiy
in this disease is not only a paUiativi', hut alsu a eurative, operation.
Tiu' order ol' invents lie descrihes as j'oliows: First, tlie lireathiui,^
is reUeved. Second, the -jrowths, iieiiit: freed from the irritation of
e()U;.diin;: and phoii.ition, uradtiailv lo>e ihcir vitality and heconie de-
tached from the vocal cords, willidiit any tendency to lecnr. if the
expectoration ;ind secretion from ihc windpipe, as taken from I lie
throat of the jiatient or from tlu' tracheal wound when cleansin- the
tulie. he examined, the growths will he found to come awav in picc.'s.
(Iraduully, in peri<ids varying;- from one nmnlh to .-ix months oi' a year,
the papiHomala shrivel away and linally dL-ajipear.
'i'lu; tuhe should not he i)ermanently removed until the growtli-
are all away. I'his removal of the tracheotomy-tuhe is always ohjeeted
to hy the child, as at first normal hreathini,' is more dillieiilt than the
artificial. Consequently, one or two sIkhi reinsertioiis mav ho neces-
sary. In a short lime, however, hreathinir heconies natural and the
voice is i^i'aduallv restored.
ii
li
tt i
('I[Ai''I'!:r i.xxxr.
MALUiXANT Tl'MOIiS OK TllK L\KVN\.
<>i- these, tl)(>ro are two vmieties: careinoiiia and sarcoma. 'I'lic
lattii- is rarer. oeeurriii<:- in alioiit (Uie-tliird of tlic eases. The growth
of sareoina is the more rapiil ( f the two, ami it mav occur earlier in
i"]'^. I.'l.'). SiUiuiiiji (It the larviix. as seen Ircuii licliiiMl.
(After Leiiiiox liroune.)
life, while the general -\in|it(iiii- and hi.-ioiv resemhlo those of cai'-
i-iiioma, with the exception tliat it develops less syst( inic cachexia and
less inv<dveiiient of the cervical .inlands {Vi[x. i;',")).
Tlistolon-ieal examination alone can make the diagnosis jKisitive
hetween the two: and tin prognosis in each case is ciinally unfavorahle.
Carcinoma of the laivnx. aithiniL:h if oecnrs more frequently tlian
finn)
lAKl l.NO.MA. SAIICd.MA.
437
ill the iidsf. niiMi-|)liiU'VM.\. iiml |iliiirviix ciimliiiird. \v;i>. accord iiijj to
(iiirlt. (Hily rnimd (iij time- in 11. UU ca>i> (d' ciirciiuimiu (ir 1 in ITti,
showing that its IriMjiiciicy is eoiiiparativcly small, in comiiarison with
its occurrence in other organs ol' (lie hody.
Pathology. — The histology oL' ihc-e two diMii-.s is tlie same as
when i'ouiid in other regions.
in the larynx ihe varit'ty. in a hirge majority of in.-taiices. is epi-
thtdioma. 'i'lu' r.iost lre(iiieiit site is the \entriciihir hands. [)roliai>ly
one-hair the cases oecnrring in t'!'- region, the other hall' heing fiiund,
without any ]irecisc order, upon tin' vocal cords, epiglottis, cmnmissure,
arycpiglottic folds, cic. '!"hc variety of cancer foi'iucrly found in the
larynx and called " eiU'ej)haloi<r" would now answer to the title "Vinall-
cc'lled sarcoma": while the '■scirrhus"" of the larynx whiili h'-to'y
speaks of would agree with our jireseiit den>e, ■■>|)indle-cel|e(^ sir-
c(una"" ( Lennox lii'ownc). Ucsides these, two other varietio -chondro-
sarcoma and luyxosai'coma — are hoth somclimo. lIuuiLih rarely, pro-
cm.
Of epithelid cancer two types are met with in thi' larynx: the
si|uamous and tlic alveolar. The first is what is called the nested
variety, the epithelial elements forming solid cylindci- in the snh-
Jaceiit ti.«sue. Tiie second, nr alvcoiar. \ariety is very rare. Its name
implies its character, and it (U'iginate< in glan<l-ti>siic, while the
siinamons develops in -ti'atilied epithelium.
Primary carciiicuna. while cotilined to the inner lavity <>[' the
laiTiix, shows little tendency 1o invohc the glands (d' the neck. This
well-known fad only r<dales to cancel' well wiihiii the laiyiiv.- -foi' in-
stance, the veiilricuiar hands and vocal cords. — and dnes not apply
to the ilisease occurring on the epiglottis, arycpiglottic folds, or aryte-
noids. When the can ci- is located in these regions the surrounding
gland.-: jii'e i[iiiekly aUVcied.
.\s i'losworth has idi'cady shown. Sappy's anatoniieal investigations
<d' the lymphatic snpjdy to the larynx W(udd <ecm to give the rea.'^on.
\\'liile tlie epiglottis and the arye])iglolt ic fold- are ri(dil\' supplied with
lymphatic vessels. the<e hecoiiie attciiuale<i toward the \cntricular
hands and vocal cords, the sup|ily of lymph lo these heing \cry limited,
the atteiinatioii incriMsiiig with years. ('(Ui-eipU'iilly eaucer of the
inner larynx has less power (d' coinmnnicating itself to the gland-
cdemcnts than when it occurs in thi' nnu'c richly-supplied region ahove.
Symptomatology. --The early symptoms o\' carcinoina and sar-
ciuna do not dill'er widclv fi'oni those atlcndinu' the formation cd' noii-
XL-
I lis
i)i.-^i;.\si> di' III I, I. \in \ \.
lllilllL'li;llll L!ln\Ull-, Till' rllV( I ll|i(ill llli- \ii|ii' Will (lr|ii'lli| li|h<n llli'
Mliiiiliiiii 111' llir liiinnr. Sn |nii'.; ;i> lln' miimI conl- arc iiiuiII'itIimI, aii.|
ran cliisi' III )iliiiiial hill, llir \^^\i.v may lie clear; Iml in iiilriii,-ic (•aiucr
ll -iinli licciiiiic- in\ii|\ci|. clllicr li\ illl'cil cMi'll-mil 111 (lisca>c In ihc
c(iril> I liciii-ch cs III- liv (ili.-l iiicliiiii In aiMiHl mil iVmn llic presence uf
I lie ei'ou I h.
Ah iiilill ral mil c\lcnil,-, il\.-|iniea lnllnw.-. likcwiM^ ^jlamhilar en
iar;;'enielll . A leu nimilll.-- rmin llie ciillllliellceliieni nl llie i||sea-e
llleeial mil lie;:ins. In lie rnllnweil. in lliail\ lll^-lailce-. I iV lia'limlllia je
and lliaikeil cancernlls cac|le\ia. 'I'lie lirealll liccii||ie> fii'lKi ami llie
ili.-charee I'niil ami aluimlanl. aeenm|iaiiieil li\ nmie m- le-s salualmn.
I'ain, Inn, I- alnm>I i ii\ analil \ |ire-ciil. nlieii in an iiicrea iIil;
ralm, .-Imniim; up In ilie ear>. and acin>> the pliar\n\. 1 tc'^liil il mii.
Inn, lieeiilile.- pa 1 11 1 11 1 aild dlllii llli.
Diag'llOSiS. 'I'n aeenmplldl llli.- al a.- earl\ l dale a> pns.-ilile i.-
iinpeial i\ e. I .a r\ iiLjnxnpic cxaminal mri i.s e.-seiit lal in all eases in dia^-
imsis. I'«y llie ii.-e nf llie ilimal miimr ihe ^mwlli can lie seen, lliiek-
emd. imdnlar, ami li\ pcra^mie m ihe early slaue-, iilceraled .md en\-
Cl'cd Willi I'll lie nil! erii\\ I ll> la I er nil. 'llie lar\ n\ lieeniiles dislnrled and
Idled willi fnlll and I'lelid -ecrelmn,-. wllicli are nl lliem-el\e> i^i diai;-
llnsl ic impnrlailee
r>\ nplical e\aiiiinalinn alniie a diaeim.-i> lielweeii sai'cnma and
<'arciimma eaniml pn>iii\e|\ lie mad". i'mlialilN in carciimma lliere
iiia\' lie nmie nlceralinii, and al llie same time le-s rapid i:rn«lh than
sarcdiiia: Iml I licsc are nid\ iiial lei> nf (leeree. and iipnii miernsenpieal
e\ainiiialmn llie diaL^imsi- realK depends. I'ns-ilil\. nf llie i \\n, -ai-
ciiiiia iiia\ lie I he |e . pain I nl.
Pl'O^'llOSlS. \\ liere\er i| in;i\ lie Inealed. lancer Is niie 111' llm iim-t
painful a- uell as nm-i j'alal nf diseases, ll- nccnrreiiee in llie lar\ii\
Is tin (Aceplinll In llie i:e|leral rille, W'illmill npelalmil ihere Is lln
Impe w liale\ er ^\{ reen\er\ . W il li npeial mil. all ImiiLili llie nmrlalil \ is
slill \ei\ larije. ea-es lia\e I ii kimuii til ii\e fnr vear- wiilmiil any
letnril y''\ the disease. 'I'lle I 111 pnu elllen I 111 I ech ll lij ,ii> which is imw
piacliced li\' the skill!', ll nperatiif i;ives llie palieiil slill iimri' rea-nii
fnr linpe; aiid the peieentaL'c nl' ieen\ene-. alier la r\ iiL!i'el nni \' lias
liecll pelf. Ilied, IS larger , at ihe pre-eni time lliall e\er hefnle in Ihe
hisldiv y^'i tills di-l ressiii:.: inalaih, alllmuidi slill it is small.
Treatment. 'The ipie-imn y\{ relief m all ca-es is an impnrtaiil
nlie. I lll'iirtllliatel\' il i- the llln-l We can e\pei t In aeennipllsll ill Ihc
majdrily y\\ cases. I.ifi' \\\.\\ he prnlmmeil and made nmie cnml'nrtahlc.
I A i;t I NOJI A. > \ I'liiM \.
I all
-IIkI lillcf I'lnlM |i,iin ll-i'lf. uhlili l-iilli'li ,l'_;i)|||/.ll|H, -limiM ;ll\\,l\- lir
.l^l\ III if ill illl |iii>-lli|r.
A I li r w ;i>liiii^ uiii till- I lima 1 w n h ,\ ('Iimh-iii'^ -|ii:i\ , I lir iiaiii iiia\
III' li'llrM'il li\ 1 liriiW IIIL^ in a Ueak -uillllull III' rnraill''. Till,-' nia\ 1)1'
liilliiWril III llki' llianiliM' li\' a >|ira\ nl ' . nr ' .-jhT i rll! -iilllllnll .i|'
|iiTiiiaiiL';iiiali' of |ii)la.-li. Sniiu' aiil lim il n- |inl'ir ihr iii-iilllal imi uf
|iii\mIiI III inilnl, ailSlnl. nl' |i h In I < ijin. .\ll\ n( lili.-r -IliillM 1 1 1 III I II l^l I
llii' aiiMiiuil III' pliaryiiLiii lai\ literal I'li.vi- and lr--rii ihr i| i-cliaiL;i'.
'I III' nil III liiil, iliviiml, ami raniplinr iiiriil linl .-nhi! inii- aii'i'ail', allmlcil
III li;ni ihi' aililil i.iiial rll'cil uj' iiiiilin'.; ihr iiillanii'il !ai\ii\.
Ill iniiliiil (lie lar\ii:.:('al pain, wiiirli i- .il'lni jhi'm nl in an iii-
M'ra-iiiL' laliu a.- (hi' ilisi'a-r aihaiins, i-nraiiir i~ |priilialil \ ili. Iir>|
M'liii'ilv. It ran ill' I'liniini'iircil l!\' lliti' al nnii/.al mn nl' a I m' '.' [iit-
ii'nl. -nliilKni, lliiiiun iiiiu ijh' tiiiiial, L;iail;iall \ iiiri'ra-iiiL' lln' |iri'
<i'nl:iL'i' (if llii' rnraiiH' a- tin' !i'i|iiiriiiii'nl> uf ilir .a-i' iiia\ ilriiiaiiil.
Winn lir kiiiiu- llial llir i->iH' \ull iiii'\iialp|\ In' l'al;il, il uuiilij itiii
I" III' Mil' >nr:jiMiii > iliil\ In rrinli'i' ilir mlhaiia-ia a- I'm' Irnin {laiii
ami a^ i niiilnrlalili' a- i'ii'riiiii--iami'- will allnw
W lull' ml iilial mn, linni I lir mil iii.' n| I In' ili>i'aM'. wniiM lie u ImlJv
n-rii"-, I iai'ili'ii|n|||\ . Ii\ |il'i'\rlll inu im|li'Mi|inL' -UlTniallnll. will -nlMi'-
liincs lir III' llii' m'l'ali'^l M'r\nr, li nul iifiiiiiL; mil ihr lil'r n|' llir pa
I ii'i.' al li'a>l I'll!' mniil li-.
Iiinin\al nl' maliLMianl urnwili hv i'MilnlarviiL':i'al npi'ialmii ha- I'lr-
• piriilly lii'cii al li'inplril. Sn lar lln- rrpml- lia\r. mi lln \\ hnir, lie, n
r\> ri'ilinijly iin.-al i-rar|ni'y. 'lln' maii-,-! in a prilnl niri' ilial I lia\i'
^•'1 lar M'i'ii ii'pnrlril i- nm- hy Jura-,';, n|' llriilrlln'i'j, Il appraii'il in
I III' ■lniini'il i>/' l.'iri/iiiiiiliKii/, Oi'lnlirr, IM's, In I'li I'lnlifi', IS'.K, hr
i'i'niii\ril rmin ,i wninaii. a^^cil II, iiiiiIit Imal an.-n.-l lir-ia I In' ri;;lit
\iiial rnid I'l'mii llii' anlri'mr cninmi^surt' In ihc pmci-.-^n- vncah-; alsn
pai'l^ nf llir I. I'l \nial nii'il ami aiili'rinr rimimi.-in'i' al a ilill'iTriil sit-
IlIlL''. All Wrl'i' prn\ril li\ III irj'i l.-rnpi. a I iXalllinallnll In lie all'i'ili'll
N^illi ipil lii'lmma. 'I'Ih' iii~I rniin'iil ii-rd wa- mii' spn iall\ i|i'\l~ii1 I'ni'
I III' pnr|in<c. A I I III' 111 I' willing'. I I'll innlll II,- lalrr. linn hail hrrli
lln rrliiin. deal rnial iiirinlnaiir- Inn! rninir'i in llm plan' nl' ihr \nral
<•ll^||^. ami llic paliml rniilil -prak Willi a Inar-i' vniir.
.Inia>/ is III' Mm opiiiin'i Mial Inrah/nl ranrrr ni' ihr mnrr lai'viix
<aii hr rniiiiM'il a- I liiii'nii;:hl\ hv i'niln!ai\ m/ral npi'ialmn a- h\' lai'\ii-
;ir(|nmv. 'I'lii- npinmn, Imwi'MT, apprar- In hr ha-nl iipnn Mir niir
Mici r-^-inl npi'I'al inn
\\ 111 n Mil' caiirrr hail hmi I'liiiliiinl In ihr iiiiiri' larviix. ami Im.s
i
i
>
'■■
Iv ^j
'■
MO
DISKASHS 01' TIIK l.AKYNX.
(•()iisc(|iuiitly liccn Ircr Ironi glandiiliU' coiiiplicatioii. liiryngectoniy lias,
ill a iiiiiiilicr (if instaneos. boon succi'ssl'ul. lVi']uii»s the most rcinaik-
ablc cast", as it was tlic first of its kind, was tlie ono opcratod on oariy
in l«!»:i 1)}" J. Solis-C.'olicn. Tt was a c-asc of cpitholioina of the larynx
in a man abont 40. 'I'lic entire larynx was removed, and the severed
trachea was stitched to the skin, thus slintting oil' entirely the respira-
tory ])assage from the iiuuith. After recoAery the iinin was able to
articnlatc in a loud whisper. It was supposed that the air taken into
the pharynx tilled a sort of pouch in the low r part of it, and then by
miiseiilar contraction was forced through the tightened fauciai mus-
cles in imitation of the vocal cords. Five years later this man traveled
over America and Europe, exhibiting liini-cU' before the various ineil-
ical societies. There had been no return whatever of the malignant
disease.
The !Solis-('(dien o|)eratioii has been performed a number of times
since then. The last case lecoided is i)y Depage in SociHe Beige de
Cliiniriiiv, -lanuary. l.S!»8. The operation was ])erforiiied eight months
previously. .Ml eoinniuiiicatifui between the lungs jiiid mouth was cut
otf, the trachea l)eiiig attached, as in Solis-CohenV ease, to the skin.
He can speak in a whisiier and there is no recurrence.
Judications are beginning to .show that the future of patients suf-
fering from this disease, when eonlined to the inner larynx, is not ([uite
so dark as was until recently believed, liryson Delavan, in a recent
issue of the 'f hern pen lie (latcltr. speaks squarely upon this matter. He
believes the subject should ii'ceive the most careful eonsideratimi.
Thrc^ groups of operations are olTered; Thyrot(tmy with or without
pai'tial laryngecloiiiy: eomplete laryngectomy liy the Solis-Cohen
operation: and complete laryngectomy in cases of extensive laryngeal
disease with glandular involvement.
])elava]i also lays down rules for guidance in selecting cases for
o])eratioii: — •
I. I'lvery malignanl growl ii of the larynx o| intrin.-ic ori'iin.
which can be dealt with, should be treated liy an operation in the ab-
sence cd' a decided indication to the contrary; and the operation should
lie performed with the least possible dcday.
•J. Every tumor of the larynx >us]tected to lie iiiiilignant, of in-
trinsic origin, of limited extent, and a)iparently within reach of free
removal Justifies an exploratory ihyrotomy in a suitalde patient, in
the absence of infiltration k\' the -urroundiii'i -Irnctures and id' af-
fection of the lymphatic inlands.
CAUCINOMA.
AUfOMA.
Ul
3. The method ol o])eriUino' as pursued b}' JWitliii and Semuu is
recommended.
in the ease operated upon l)y J. Solis-Cohen xhv severed end (d'
tlie trachea was l)rouglit to the external edges <iJ' tlie vertical incision
and there retained, thus cutting olt' communication between tbe
pharynx and the lungs. The advantages oi' tl is proci-durt' are very
evident: the danger from inspiration ])neumo;iia is greatly lessened,
swallowing is easily accomi)lishcd, the power of [)hnnation can be ac-
quired (as shown in the cases operated on in this manner), and tlu'
patient's comfort is gri'ally increased, as the weaiing of an arlifieial
larynx is not necessary.
Several years ago a method of treatment nf cam-er was devised by
Coley which seemed to 1)0 ellicacious in eeHiiiii cases of one class (d'
the malignant disease, namely: sarcoma. This wa> by inoeidaiions of
erysi])elas in a jialient sulTering from ino]ier;il)h' sarcoma. Tlie maliu'-
]iant tumor would j)artially shrink away, and remain without I'cgrowtli
for a prolonged ])eriod. .\s little has been heard. liowevtM-. of the
further advance of this method since Coley"s report was lii-st issued, it
is doubtful whether the results have realized the e.vpeelalion^ of the
writer.
I\Iiddlcmas Hunt, in the -lournal of JAirt/ni/oloii!/, UhinohKjij. niid
OUilogij for October, 189S. reports an exceedingly interesting case of
successful operation for llic removal of intrin,~ie eaiicer. the chief in-
terest being in the great age of the patient, which was SO year,-. On
exannnation the anterior jiart of the glof.is was fnund to lie Idled with
a pinkish-white growth, which had begun to break dov\ ii and ulcerate.
Jt sprang from the anterior part of the upper surface of the left vocal
cord.
Owing to the great age of the ])atient, the operation was divided
into two stages: the first, tracheotomy; and, live days later, the secnnd.
thyrotomy, removing the growths and surrounding s(d't parts.
Although attended by the development of pneumonia dining the
second week after ojicration. the man made a good I'eeoveiv. Xiic
months later he was still doing well, with steady iiuprovcnieid of the
voice. Microscopical examination verifieil the ca-e to be one of e])i-
thelioma.
1 1
I UAiTKli J.XXXll.
FOHKKIN liODIKS IN IIIK LARYNX.
l'"()Ui;iiiN liodics of (Uic I'dnii (If aiKitluM' rr('(|U('iitIy Iiccouk' lud^id
within lilt' lai'vii,L;<'iil cavity. 'I'iiis may oi'dir I'rdiii tlic I'dfcilili- iii-
.-jiiiat idii dl' any -iilislaiicc that may iic in iIh' mdntli or |iliurynx ihii-
\])i: laui^hlcr. nv iVniii cari'lessnos in tl.c ad of ^wallitwinir anil in
sniiic cases even in ordiiuii'v inspifalion. 'I'lu' names 'if rorciiiii Imdics
that Inivc ohlaincd an oitrancc into tlic hirynu'cal ca\ily ami hidcjriMJ
thci'c are legidii: hfislles. (Ish-jidnes, needh's. pins, coins, Iniltuns, ])ai'-
lial plates (d' false teeth, ele.. as deserilied In Roe's eatalii,i:'iie, have
all id' them iieen extracted I'l'mn the larynx, and some of them ipiili!
I''i,!,'. I'i'i. i iinl leiijalf ill ujiiltis. lAnrr l.riiiinx HiDwiic.)
fi'('([iiently. Sometimes the iidroduclinn id' the foreitrn hidy has lieeii
from within. i'"iir instame, liindiricoides ha\e found thrir way into
the larynx I'lMm tlie ii'xiphau'u^. and a nnndier (d' installers have hecii
recorded which emlfd fatally, [''oiid has also hei n vomited up. to lie
thmun liy in.-pii'at imi into tin- lai'ynx. the ■e-nll hcimi I'alal. ('hil-
dren wlm have fnrmed the iiaiiit id' carryin'i I'lii'eii^ii liodics in their
ninnihs are particularly iiahle to the aceid^nt. Wdiile ash'cp the nerv-
ous sensiliilily of the pharynx and hu >n\ are in a i|uiesceni >taie. and
the nhjiii slips into the larvux withnut warniiiL:. Wniiieii. who rarry
pins and nredles in their nuiulh-. are liable, diiriuL;' the acts nf ciumli-
iii;^' or sMcc/'inLf, In snddtnlv lintl the liltle instniiiient IndLi'i'il in the
cavity of tlie larynx, l-'ii/s. j.'if! and 1)^7 re})resent a remarkahle ease
(■1!'.')
FOHKKiN liOlUKS.
44a
n'jH)i'ti'(.l by LfiiiKix Jii'iiwiic. Tlu,' tuoth-])liitc liiiil rciuaint'd in posi-
tidii in 11k' larynx lor two years and ci^dit monllis willidiit its prcst'iicc
bt'iii,ir !>iis|)CC'lo<l, I 111' patient Ix'inLT under tlie inijjrt'Sssion tliat she was
sull'ei-ini;- from either ti herudosis or cancer. 'I'lie jxisitioii left a space
for hrealhiim in I'roiit and dso lieliind the t'creiuni liody. l'"ii^. 13T
exliiliils ihc lai'L^e >ize of liu phlte after its ienioval.
Symptomatology. — CmiuiiinLV iri'ilation more or less, and a sense
of strantjuhilion are tlie ordinary syniplonis. Tlioso vary in decree
and chai'acter aeeoi'dinL;- to tlie size and form of the foi'eiuii hody.
inodiiied also by the amouni td' nervous excitability possessed by the
patient. When the l)ody is lar,i:e and soft, lilliicj- up tlie larynx, ini-
niediate snll'ocation is Wkvh to be the I'oult. unles> relief can be at
once obtained. Angular bodies, even when laruc are not so (Uii( kly
fatal, as respiration to a eeriain exieni is practicable past the irrej^idar
■11
to
I'i.ir. \'U. I'lMii li jilalr niiiii\(((l. lAilii Liiiikix liiow iic i
side-;. Iioiiub bddies are likely to produce intl.iniinai ion. Pointed ones
like spiciila' (d' boiie, needles, etc.. while tliey do not int( rfere with
resjn'ration, on the sliulitest motion jirofhiee pain, and from Ibis cause
(d'tcii render dei;-|util ion impossible.
Diagnosis. — (,)uitc freiiuciitly this may be positive from the pcr-
sfiiial experience of the patient, lie know> the nature of the object,
and how it found its way into the larynx. 'I'lii.- can be \erilied by the
use (d' the laryn,i:oseope. In other instances the larynud.-cope alom will
have to he depended n[.on. Sdnietimc- in children neiiher of t'u'se
met bods are of any avail, ixirstein's autosi ope. when it can be a]i-
plied, should reveal the condition of the larynx and the presence of
the forei«i:n body. Digital exploration, also, the (iiiLrer bein;i,' passed
candidly into the larynx, while the orpin is held in position by the
fiiifjers of the left hand, may load to the discovery of the foreif;fn body;
bid, when tliis is of a metallic character, nothing' will reveal its form
Is.
•Ill
i)isi:.\si:s OK Tin; i.auv.w.
1111(1 Idciiticiii Ml |i(isili\cly a- I'Xiiniiiiiitiim liy tlir Kocnliitii \-riivs. so
rcc'cnily iiddcd to our |i>t of inctliods of iiivcstifratioii.
Prognosis. — 'I'lir aciiilt'iital ciitraiicc (d' a foiTiizii liodv iiitd the
larviix may al\vay> hr cniisidcrcd a iiiatltT of xt'ioih iiioinciit. It may
i'"ig. l:'iS.- Liiryiigfiil |mi1\ [iii-i'oiiciis, .Mack('iizii'"s, icxoh iiig,
willi tliri'f altacliiiii'iit;.
])o8sil)ly caiisi' iniiiH'diatcly a fatal roidl. or lead t<p it hy eoiitiiiiied
(distniction and iiillainiiiatoi'y action, 'riicrc i.- al.-o in many iiisiancos
lilt' jiossibility of llic liody .-I'ttling still fartluT down into tlio nar-
Fiir. I'i'i. l.io \ ii;j('m1 |i()l\|iiis-f(iiccps. WaxliiOiTs.
rower passaize id' the trachea. Still, in a larij:e niimher of instanees,
when the hody is eompact in shape and without projecting angles, it
has heen eonghed out without surgical interference. Sharply-angular
l)odies are not likely to he expelled by NTatnre's effort, and will require
r
r 1
i I
1
s. so
iiiiiy
I'orfKKiX ItODiKs.
•u;
;:::;l^::i:::;t;-::r':;;;;l;::;::■-:;:;';,;;■;::^:- -
!
'
■
I'-i^. 140.-- I.a,vn«..al pulvpus-f,,...!., rnu.nk.rs, cul . in. jau .
into iJ.e hronH.u.! .,,1,... .......pletdv olMn,..,in. .vspinuinn ui tho
Fij:. 141.- ).,
'n-iio:Pal pdlypus foic.ps, ^[a,k
nidd
I'll C'.\
piratidu, may possibly cxprl it. I
upward, ma3' dislodge a heavy body. Forcible cou-'i
1'lieso methods failing, laryngeal (•
•■nzH's, aiticiilatod.
levcrsiiig the patient, heel.'-
mirror may etlVct a renmvnl. Of in.trun...nts. Maek
iiig may also aid.
oreep,^ guided by tJie tliroat-
enzic'.s Waxham's,
l\
44G
DISEASES (»1- rilH I.AKVNX.
I'Viifiikcr.s (l""i<:s. i:')S 1(1 111), or any ntlicr jjjood form inny ho used.
.Soinctimos a snare carefully applied would lift out an angular body.
When the ohjoet is below the vocal cords tracheotomy may be rc-
((uired, and in cases where it is lodged within tlu; larynx it can l)e best
removed through tlie tracheal opening. In others it might be pressed
up through llie larynx I'rom tlie trachea.
"\ol infre((uently alter tracheotomy the body, if located below,
may l)e expelled througli the arlilieial opening, or may l)e forced up
so that it can be gras|)e(i iind removed. Should this not occur, the;
patient's body should be shaken or the inverted position assumed, witli
tlu' iio])o of bringiug the oll'ending substance within reach of instru-
mentation, if it be impossil)le at the time oC oj)eration to locate the
body, tlie edges of the trachea may be stitclied to tlie integument and
the wound left open for furl her search. The introduction of a small
uiirrfu- may assist in locating tlie ])ody. Blowing strongly into the
trachea may assist in expulsion by tlie reactionary expiration, or the
aiiilicial ])rodiiction of cough by a feallier may be also of use in dis-
lodgment." (Kyle.)
rJIAl'TKIi' J.XXXIII.
UOKX'KiKN KAVS IN J.AHVNdKAI. SIKCKKY,
Tins WHS tlu' til Ir nl' a iircliiiiiiinrv nnic liy Joliii Miiclntyrc. iiKUi;
tliiiM two years ii^io, upon wluit is nckimw Icdircd now to ln' a very ini-
portaiil siil)joct. Tlic (iiicstion he then iiskcd — "Will tlii> imporliint
discovery of tlic lio('nltj:t'n rays l)c of u<{' in the (Icpnrtniciil
gol
ol liirvii-
oirv
has hccn answcrcil over iind over
liii liv ai
nial
I'l'SUl
111
the alliiinative.
Since that time the nielhod id' utiliziiii;- the Crookes tuhi'>; has
heen greatly improved. The shadows of the skeleton of tlie living hody
can be so clearly delined tiiat every hone ean l)e distinguisiifd in |)6si-
tion from the siirroiindin'; softer tissin
Sill
avs of liirht nass
through even the osseous frame-work, so that any imi)enetral)le metallic
siihstanee, situated in the nose, larynx, or (esophagus can he distinctly
seen by the x-rays.
Still further, the outlines of the skeleton can he so clearly de-
lineated that any destruction of osseons tissue hy malignant, syphilitic,
or tuberculous ulceration can also he discovered, as wdl a- fractures
and malposition of bojies in the dilferent ngions of the body.
Hence it can readily be seen that the discovery (d' the I'oenlgen
rays was no light addition to the armamentaiiiiin of llie tliroat-s[)e-
cialist.
Over and over ai^ain have foreign bodies in the larvnx and
o'^onn-
agus been located by the sciagra])h, thus materially facilitating their
removal. One remarkable thing is the clearness with which thin ob-
jects, such as needles and pins, can be di.'fined while completely buried
in
the soft tissues of the bodv,
^J
W'« I
n-tances of this nature wei-e recentiv reported bv A\'alker
Down.e in a:' October issue of the Jirillsh Mnlintl Journal.
In ilii' f.rst, D. (J., aged ID, put a pin in his mouth while a-leep.
The next n'.orning the first mouthful of breakfast cau>ed a >harp. lanc-
ing pa
in in the tliroat on swallowinir. This was followed I
ly pain on
right side of neck close to the thyroid cartilage. Careful examination
with the laryngoscope revealed nolhin-j:. Two months later a satisfac-
(147)
tl
r'
I
v.
V
T
*>,
.^^^
^» ^."^^^5^
IMAGE EVALUATION
TEST TARGET (MT-3)
/.
^/.
r/.
V
1.0
I.I
11.25
■JO "^^ MIH
Ui 1^ |2.2
-1-120
[; mWM.
<p>
<%>' A
/
^^■
■^
Photographic
Sderices
Corporation
^
«
a>^
f\
^\
v\
23 WEST M .*. STRUT
WnSTIR.N.Y. Msao
(71*) S73-4903
'^
o^
1 i : -'
%
I «■•!
i( :i
Jilli
I
448
U(>i;nt(!i;\ it.ws iv i..\i[YNtii:.\i. siioiKuv.
t'Mv liitcntl \i('\\ of ihc |niits \\ii> olitiiiiifd hv a Cmoko tiilif, ainl llio
|)in (li.scovcri'd in In- located in lln' (•ciilrc n{ the tliyidid cartila;.'*'.
( lilnrol'onii was adiiiiiii>Icr('d and llic cartilajif laid liaic in the iiuddk'
liiif. On (lilting llir(iii<:ii tlic |icri(liiindriiiin. the pnint n\' \hv knilV'
tiiuclicil ttif li('a<l (d the pin. I)nrin;r tlic two ninntlis wliiih time it
had liei'n in tlie laivnx the pin lia<l niceiated ihrunirh the (•artihi;:e.
It was readily e.xtraeted and proved in he liciit upon itself.
The otliei' ca.-e neenrri'd in a ^nrl a.ii'ed IS. She aeeidenlally
(iiUfihed with a pin between her teeth. As a result, the pin i-lippod
dnwn her throat. She thon<,dit .-lu' had swallowed it. and liir sevenil
days thei'e was no pain. l''onr day> latei' she IuiikmI sick al'tci' eating
and vomited. While in the act she leli a sharp pain in the I'i^ht <ide
of the tliroat. close to the thyroid cartilai;e. On heini: examined witli
the laryn^'oscopc nothing"' whatever conld he M'i'u of the forei^rn hody.
.\ -cia;,M'aph. hovTcver. taken at once rcvealcil ii> situation. The ni'Xt
flay the laiynx \\a- ana-lheti/ed with cocaine. an<l cnrve(| forceps were
pa.s.sed lirndy and deeply iido the hyoid fossa. 'I'lic head of the jiin
was touched and Liraspcd and the pin was withdrawn.
.\ niimher nf instances lia\e also heeii recorded in which sciairraphs
liave heeii taken (d' loins locateil in the (eso|»ha,Lnis, the view hy the
.x-ray- hem;: the ^uiile li\ which successful removal was accomplisliod.
I
niAI'TKIf I.WXIW
nl'KHATIoNS KOR NASAL DKI-OKMlTl |;s.
WliKN tliesc (Rorniitii's -.ul.v fin,,, in;illnrm;,ii,.n. ,I..|,.rtivi. .1.-
N'l..l,im.nt, or pnt!i..|o^n,,,i i,.,i„„ „,■ ,,„, ,„,,,,.,,,,, ^^^^^^,^ ^j^^^. ^j^^^^^^^j
rightly he consiili.ml i,> hclnn-i,,- tu tl,,. \r'^\ihun\r (ir|,| „r' tl„, ,hi-
i<"ln-i>t. W hrn. l„.«,.v..r. tli.-y o«.> tlirir nri-in tn vxu-nv.i\ injui v .,r
Kil!. Mli. l..il.I phlt,. ,ur |iil>Ml ;l|cl
I'i;:. I l.f. sic.. I J, ill f.ii- |ii,«;il llMll^li io .
.liM'i.M.. thry wnuM .,...,,, ,„.uv niitiiiallv (o \nUv^ f„ tl.,' .ln„Kim „f
tile irciHTiil siinrcdii.
It is of 1
"■ l'"iiiirr (hiss that thi- ihniilrr
of that unsi^'litly (h'tnii„ity (•o„iiii..nly .iilhd -suidl
iU'iso from a varioly (.f caiiscs. hut it coi
"'<'iii>. iiii'l |)iirti(iihiily
'■-nose. 'ihi^ nuiv
i>ists. as a nih'. (if
of \hv l.rid.iTo. owiiiir io the dc- (ni.lidii „f the cartihi,!:
a si II km;: in
inoiis sept mil.
(II!M
450
Ol'KHATIONS rou NASAL i)i;i'OU.M IIIKS.
Ill^
I- 1
l'rof('s»ur AiiiiaiKliilc (lirilisli Mcdiail Jaiirndl, Noveiiilicr. IS'.tT)
lias tlirowii out sdiiio valiialilf sii<r<,'i'«tii)iis lor tin- tiratiiK'Ht of this
class of casus. l"'ui' lil'toi'ii years he has practicctl wiiat ho (.-alls "sliiiir-
ing"' of tlic (IcprosiMl tissues up into their luitural i)osition, whether
bony or otherwise.
The appliances used (•oiisist )(: 1. A jjieee t)f sheet-h'ad (Fig.
1A2) fornuMl into an areh with a ledge on each side to rest on eaeh
ehoei<. The areh should he slightly higher than the nasal bones when
in their normal position. On eaeh side of the arch. oj)posite tlie Itridgc
of the nose, a slit is made from the cheek-ledge ii]) toward the siimmil
of the arch. ".'. A steel [tin (Fig. J Ui) about live centimetres long with
a point at one end and a cap at the other — the whole central part iieing
a screw with a nut to be ap])lied to the point.
To raise the depressed bone the pin is jtassed deeply through the
nose from side to side o])i)osite the bridge or more dejires.'Jed portion.
The nose is then gi-ntly lifted up by means of the pin. and the leaden
arch slij)))ed over it, tlu' two ends projecting out through the notches.
'I'he nut is then screwed on to give lateral support and iirmness, and
silver wire pas:-e(| in lignre-(d'-eight around the ends of the needle and
over the iirdi. to ]iut slight traction upon the raised tissues. A cap is
also fitted ti> the needle-point to j)revenl injury 1o the cheek. The
apparatus reiniires to lie carefully watched to secure good results, 'i'he
time retjuired for ticatment varies, the object lieing to retain llie a|t-
])aratns until the lissiu>s have been solidified and accustomed to their
new ]iositi()u. Fig. Ml represents the apjiliance iu position.
K. ('. Filet (Mv HI jilt is Medical Munllili/, September. 18i)7) reports
i\ case of successful treatment of .siddle-iuise by surgical operation. In
his ca.se the cartilaginous se|)tum had beeu destroyed by erysipelatous
absces.s, resulting in severe de])ression of the bridge.
'J'he operation ))racticed b)r the i'emo\al of the deformity {(in-
sisted, first, in an incision twenty-five millimetres long, down the
medial line of the nose, extending above and below the depression.
The tissues were then dissected back freely on each side. After cheek-
ing the hivmorrbage with hot comijressos an oval ]tlatinum plate was
inserted over the dejjressed dorsum. This plate had an area of twenty
by fifteen millimetres, was curved from side to side to conform to the
natural shape of the nose, and was ])erforated to allow of more perfect
retention and fixation during the process of healing. Before insertion
the plate had been l)oiled in soda solution, was preserved in alcohol,
and la-tly immersed in bichloride solution. After putting the plate
> 1
t
1
1
i
Ii
t,
sfitciT ANKois (>i'i:i{ \ rioNs.
451
in phuT thr flaps were diawn toirotli.T and siiiuiv.l „v.r it. tli.' wound
being d(.>cd ascptically. Al'liT healiii.ir tli." \vli,.|.. nuso was s-.lid. The
tk'forniit.v had also been successfullv niiidvrd.
l{ot', ui' i{()clicster, has also writH'ii >nnic\vlial extmsivdv lately
upon ihe -correelioj' of nasal (hdnriniti.'s by snlxMitai ii> oixTati.ui."
and the following is ...i abstra<t o( his paper (Hrlli.^h M,;lintl .Journal.
November, 189T) upon th,- sui.j...t. irad at ihr M,,nlnal uw.xuv. „|'
the associatiiin: —
Kig. Ht.—Xasal ai-pliance in position. iAittr Aimaniialo.
"Dr. Koe pointed out that the early advaiita-.. „f siilHuianeou^
operations was the exelusion ..f air from the w.miid. therebv av.)i.lin.'
the subsequent inlla.nniation that followed the exposure of the w.uind
to the air, but that at the present time the only advantage of perform-
ing operations subcutaneously was the avoidanee of a wound nf the
skin on any of the exposed portions of th.' body. The iniportanee ..f
correeting nasal deformities on aeeount of the pmniin.'nce ,d' the nose,
45a
ul'Kli Al ln.\> luK .\.\>.\l, l)i;i'nl(.Mrj|i;s.
k
I' r'
1 1
in:
u
iiiid tln' (Miiisfiiuis cITcct of siiili (Icroniiitics in iiiducncing tlu' lial)iis,
t li(iiii,flils. iind social lil'c nl' a ixm^-oii were then pniiitcd out. ami also
tilt' iiii|Mirtaii(t' of i-orri'ctiiiir tlicsf (Icfonnitii's without woiindiiiy the
skill, so as to Iciivc as few ti'aci's as possihlc of the ]ii'('\i(Mi> disli^niic-
iiiiiit. Nasal dcfoniiitics were usually ili\id('d into two inaiii classes:
idio|iathic, or coii>rciiital, aiul traumatic, or actiuircd: luit, from the
sur;:ical staiid-poiiit, l{oc classilicd them into the deformities which
atVccted the hoiiy portion of the nose and tiie (leformitie> which all'ected
the cartila,i:■inoll^ |iortioii.
"1 >eformitics of the lioiiy |)orlioii iiiiLiht lie suhdividcd into {)i)
vertical — that is. those which distorteil the prolile, in which the dorsal
lino was too coiiv(>x or too con<'ave; and (h) lateral — that is, those
which, when viewed from t'ae front, [iresentcd unusual deviations from
the normal contour, wherehy tlic Iiouy portion mi^zht lie either s])atu-
latOfl or dellected.
"heformities of the cartilaginous jiortion uiiirht ho sulidividod
into (n) those which alTcctcd the tip of th(! nose, whether excessive or
defective in the amount of tissue or distorted from its normal direc-
tion, and {b) those which all'ected the winirs of the nose, which might
he either collapseil or almormally expanded.
"This classilication of nasal ileformities. liowever. did not a|)p!y
to or iiu-lude those deformities resulting from extensive destruction of
the hard or soft parts iiy syphilis, lupu,;, or other diseases, or liy acci-
dents in which metallic or other artificial suj)porfs or jilastio ojM'rations
involving the integument were required for their correction.
"l{oc then descrihed Ihe dilVerent deformities as they were found,
and the oti(dogical relations which they sustained to local causes and
various systemic conditions.
"In the trealmeut of nasal defoiinitii's he jiointed out that the
licaiity of the nose depcnde(l almost entirely upon its symmetry, so
long as the disproportionate relation helwccu the si/e of the nose and
the size of the face was not too great: therefore, in correcting the de-
formities of the nose it was necessary to study the symmetrical rela-
tions of th(> diil'eront ])arts of the nose to one another, rather tliau its
]irop(M'tionate relations to the face, lie also pointed out that, owing
to llic gi'cat variety of causes and conditions of the deformities of the
nose, the ojtorations ro(|uired for (he c(U'rection of these deformities
must ho o(iual1y varied.
'■'Ihere were, howm'or. geiu'ral underlying principles governing
the dilTcront operations which must he ohserved in order to aecotu-
1^
sriu r r AN 1:01 > oi'kka iioss.
•1:.;;
\\\\>\\ till' (l(sirc(l i(>iilt.-. 'rim-, ill (■oiimk vcrtitiil (Irl'nriiiitios of the
lidiiy |i(prtiiiii i>r tilt' HUM', or cxct .-sivc dcVfUtpnit'iit nf tlic ti.-siic of the
ti|» of tlif noM'. tlu' r\cc-sivf or rcdiiiiihiiit ti»iit' iiiiist he rcinovi'd;
wlicrciis, in \Uv coiuavr si-rliinl (Icl'oriiiil v of tlic Itony iiortioti of tln'
nose, or the defect ivc develo|iiiieiit of the iiid of the iio>e. the hoUow
|iorlion iiiiisl lie tilled ill with tissue taken from somr ntlur |iortioii of
the nose where it eoiild he spiired, and the elevated portions rrdiieed,
so iis to make the iio-e symmetrieal. In the ease <d" injiirv to tlu' Tiose,
in wliieli there was displaeeinent rather than destiiution of the tis-
sues, the operation eoii>isted in plaiinj: the tis>nes in tlieir ori>:inal
po.-itioii. or so adapting them as to render the contour ^^i the nose sym-
metrical. In cM'iy instance, however, the operation was to he per-
formed .".iihciitam'oii.-ly from the interior of the nose.
"The writer then deserihed a nuniher of cases, illuslratinix the
I luiner in which the various operations were perfornie(l. and exhihited
enlarired photo^irapliie illustrations of ]iatient> Itefore and after oj)era-
tions. lie also stated that there were three conditions vlii< h must he
ohserxcd in order to insure success in these operations: —
"1. The first was tlioroufrli antiseptic precautions, for, if suppura-
tion in the wound should take place. in;.;rafted tis-iies Wdiild hi' de-
stroye<l. and not oiilv tiie oiijecf of the tiperation lie defeated, hut the
ileforniity of the nose wduld lie iiicrea-ed thereby.
•■'v'. In the next place, the plan of the operation mii-t he cand'ully
studied, in order that all the ti»ues at disjjosal mi.iiht lie utilized to
'.he hest advanta^'e.
'■."». In the third place, ureal care and atti'iuioii. >ulise(|Ueni lo
operation, were as important as the operation itM'lf. for. 110 matter how
well directed the operation iiiii:ht lie. the ohject couhl not he attained
unless scrii|inlous atteidiim was jiaid to the liealin;: process. The |iarts
must not only he held in place hy retentive appliniU'cs, hut the shape
of these ajipliances and the drcs-inir must often he chaniiod from day
to day, as the swelliiii:' siili>ided and the niiioii of tlu' parts took ))lnce.
"|-"re(pienliy the principal or miiin operation mii-t he siipple-
mcjited hy minor operations for the correction of sliirht defects. An
unduly prominent portion inidit reipiire lowcrinir and a <1epressed part
raisin*;, and so on until the work was completed."
i
1 1 :-i
M
I!
! ii
if
i'j^
CIIAI'TKU LXXXV.
OI'KltATlONS RUl Cl.KlT I'AI.A'I'I-:.
It is widrlv comcciIimI tluit ti|M'rations for clcrt piilntf iiro iiiad-
visal)le hoforc tin.' iiid til' llic x-cond vcnr. I'iist operations should l»t'
|irrroriiie<I, if possible, alpoiit that period, and secondarv oporatioiis hy
tilt' fourth or lilth vciir wlicu iifcfssarv. .Still furtlKT, linal operations
upon the hard palate, oi' to eoiiijiletelv close opening's still left in tlio
Boft pahite, should al\\ay> he done hv the trutJi ur twelfth Year at the
latest, .\fter this age. the availai)le ti^^ues are too seanty, and the |)0S-
sihility of inijiroviuf.' the voice loo limited, to render operation justi-
liahle. and the most that can he (h)ne is in the way of li.xation <d' oh-
tnrators, to overcome to some extent the nattiral del'ormity.
Careful ohservations made hy many experienced surgeons have
also hrought out a nuiiilpcr (d' important facts, uhic li help as irnides
in the treatment of this defect in (h'velopnieiit. Wln'n there is hare-
lip logelhcr with cleft palate it is advi^ahle. according: to sume autliori-
tics, to operate vu the lip even in early infancy, in urder to insure
eilicieid nnrsinfT, while the oj)eration in the palati' is deferred lo a
later date. The chief oiijection to surgical inli'rferenee with the hard
or soft palate during the first two years of hi'e is the extreme delicacy
of the tissues alVeeted. with their liahility to teai' upon the slightest
traction.
Tlio liealthier and iielter tempcre<l the child, the les?; voracious
I he api)etite: and. the smaller the chd't. the earlier may the operation
he performed.
Th(> higher the vault of the hard palatt'. the more likely is the
operation to ho successful, as there is a l)ctter suj)ply of soft tissu(^ from
whidi to constriu't tlie necessary Haps.
The longer the ])alate, also, from hefore haekward, tlie more ho])e-
fid th.e prognosis after treatment, as the traction toward the centre
has always a tendency to shorten the antero-postorior diameter of the
palate.
In reply tt> anxious friends who are naturally alarmed at the dif-
(leulty in nursing produced hy the presence of cleft palate, they can
(ir.i)
STAl'IlYI-OHHIlArHY.
4:>5
be asfiiind tliiit tliie can bo aceoniiiiij-litd icaiiily l)y tbe use of n iiiii.--
ing-l)()ttli' willi ii Imij,^ iii|i|ilc witli tin- tiju'iiinir "H the lower sidf ni-
with a projtctini,' lljip «m iho ii|ii(rr nin-. I'.y inittiiiii t-ilhtT nf tlii'>i'
well into tlu' iiiotith, the t)|K'niii<: iii tlic |iiilatc will, tn a laiL't' t-xtfiit.
be closed, 'i'lic chiltl can thus, hy liciii;; better iibie to swalioM, attain
the strength an<l ajrc necessary i'nr succesr>ful treatment.
Sta|)liyl<irrlia|thy i> the name .i,i|ilieil tn operatinji lur the i h)>uii'
of the clel't in the solt palati'. This is an oM (»|>erali<»n. an<l has lie( ii
|)eriornie(l lor more than a century. There are many inetiioils by whii ii
it may l»e done. I'erhaps the simplest is the one ;.'eiierally adopted and
described so clearly by .1. \V. .MacDonald in hi> work upon "SiiruKal
l)ia^'no.«is ami Treatment." I,si»,s. 'J'hc position he chooses i.- lor the
pati»'nt to lie on a hii:h talde with the bead turned to the rijrhl ."-ide.
-o that the blood will not ;rravilate into the pharynx Clinrchili's
position would sctin to be superior to thi>. lie places th>' patient upon
his back with the head at riirht aiiiile-. to the s.pine, hapi,'ini: over iIm'
end of the table and .-u|»ported by an assistant. In tlii- po.-ition tin'
blood will drain into the iia<o-pliaiyn\ an<l conid readily be -ipoiiL;! d
away.
The sta;res of the operation are tin' follitwin;:: —
]. .\fter ana'stheti/.inji with chlorob>rm or .\. ('. V. . a iiioiith-<j;a.u:
is in.serted ami the throat i.'^ reiidereil as aseptic as possiide. The end
of one side of the cleft is then held ten<e by a tenaculum foicep^ and
a narrow strip cut oil' from the ed^re of tbe deft, from the free marLnn
lo the aiiirlt'. This may be done by a thin-bladed knife m- a «baip. nar-
row, aniiular scissors. In tbi- preparatory staire both sides are treal(d
alike, the object beiiiLT to make char-cut. raw edi.'rs throULilioiit.
'i. The sutures may be (d' .-iUci' wire, ehromicized catu'nt. or >ilk.
tile last nientioiied beiiii.;' as j^ood a> any. Ot needle-;. allhoULdi many
kimis are used, the liMlf-ciirve llaL'edorn in a iHidle-bolder i^ ircnm-
metided by Mac Donahl a- i,re!ierally applicable. Tb.' Ili-i in idle -linuld
lie in.-erteil about (i millinieircs from the iiiar;rin on .iin- -idr an>l aliuut
I'.' niillimetre- fi'im (lie an.Lde. and parsed din-etly throu,i:li that pni--
tion of the velum. It should then bi' reinsert<-d from behind forward
on the other siile of the cleft at similar distance.-, thf -ilk thread caie-
fnlly drawn throiii:b by means of forceps, and the needle withdrawn.
< >ther needles .-hould be -imilaiiy plai«'d at distance-, .if about TJ milli-
metres in a similar way until the posterior end of the cleft is reached.
3. If the cleft can now be closed without too much tension the
sntiires mav at once be carefnllv tied and the thread-; cut nlT Tf. iiow-
•I.'.d
on l; \ I ln\- I Hi; (I 1,1 I I- \|. \ IK.
m;
I '
;■ !
\ ■■'."
iiiiP
'
.iii'
^ IlBil
:
»'|
k
VWr, llic .-Uillll 1« li'M ::l(ill. lllf IiII-cM- |iilliltl lllll-clr-. imi-t lir i lll lir-
foro closiii},' the (Id I. Till- ciiii lie ilniic liy inn kin;,' nii iiici-inn miu ihc
Sdl't |i!iliil(' iiiiiiirdiiili Iv iiitiriiiil to the liiiiiiiihii' |iriir('-> iiml iiiii
ll|)\Viinl until the IIHIm l(> air X'M'IiiI. 'I'llis slioujll ll<' ilnllc cili III
side. iUnI then tllr -IIIIIIO llniWII tniii'lJltT iiml tlrd. 'I'lli-r -llolllil II
IM;
I'll
he I'rliiiiM'd iiii
til tl
IC M'VClllll or ClLlilt ll llil\ ,
'rill'(ill;.'ll>>lll tile <i|M'lil| mil llir IiIitiI Mli: -ll<i|||i| lie riinlrnjlnl liv
cjllct'lll |pn'>>lll(' ll|iiill llir iilicdllli: -put.- Witll .-lllilll idcdLTi't.- ot' llllll-
scptic iilit^ftrlifiit ({ittnii. ( iiic liiiiiu liikni lu ;i\<iid iill wniii'tcs-iny dis-
Inrliiiiu*' id' I he niw -in liu
lid I
Will 11 lllr n|irrilt inn ]> iiXtT till' |i;llt.-
I III
sliDiild lie li^ditly dueled uilli iiidiiliinn mid ihr inci-inii piiintrd with
iddnf'onni/.t'd collddion.
Uranoplasty.- 'I'hc nimc diiliiuli iiml .-(■iinii> npcriitutn nf rlii>iii;;'
fis>iiif (d' till' liiiid piiliitc is iisiiiilly |u'rri>rnit'd al'icr Sir Williiiiii l-cr-
^Mis.'^nnV |iliiii. r"ii>t the cdifc- id' tin- clt'l't slionld he piircd ii- in the
ii]K'r;itinn I'nr sl;i|di\ l('rrli;i|iliy. Tin' >ulnn's also iuMTlcd, i>iit ji't'l un-
tied iinil held iisidc liy an assistant. Then midway hctwccn tlir dfl't
and the i:!\t'iilnr nini'Liin an iiici-inii i- inadi' dnwii In the Imni'. the
incision heinj: of ('t|iiai Ifiiirth willi the clcrt in ihr liiird |»alat('. Tiit»
lionc is iircriilly cut throimli with tlic ihisci and I'orccd over
toward ■ ,sial line The siitiiit'> arc tlim lied and tlic lateral in-
cisions packed witll lodol'oini ;;an/.c.
ir the iipcratimi i> >ni(e-sliil, the lis-nies close up liy new Ipuiie-
rorinatioii. and a coniplete hard palate is evcntiially lornicd.
MaMin Warren, of lio-ton. was anion;; the iirsi to i-losc the hard
palate without cutting the lione. His plan was to detach tla|i- of eniii-
lii)icd |K'riost('Uin and iniicoiis nicnihiaiie from tiie hard palate hy means
of a pcriioleal elevator, taking: care not to tear the arteries of the ante-
rior and po.-lerior palat iiie canals. The soft jiidale was also separated on
each side frmii the horizontal plates i>\' the two palatc-liones. IJefore
tyiii^' the suture^, eiits were made, if n'i|uired. midway lietween the
lissiirc and the alveolar margin on eaeli ^ide,
'I'lie after-treatment in all operations is an important malter.
WM
antiseptic irrigation is always needed, ll i- lietter al^-o to apply
the. iodofoinii/cd collodion no inatler what o|)eralion is perfoinied.
The food should he of Iliiid form for a iiiiinher of davs and the sutures
if
.should never he ri'inoved in.-idc ol a week. 1 he hands of the ( hih
wlicn necessary sliould he coni rolled, and a careful watch niaintainod,
until all daii.iifr of injury to the tissues he over.
Will n i-olatcd -lints fail tn uiiiic. ihcv inav sometimes he encoiir-
I II \Miri, \>i V
457
jii^cil to cliiM- li\ y;riiMiilal mil. llic |iiiit- In iii:^ Imic hnl li\ niinili' nf
>il\tr or sin;i«'(| Itv jriilviiiiiMiiiitriv.
Willi till' tilijcct of iiii|iro\iim \Mi<('-|»ro<Iu(lioM nl n- curly iin iii;*'
il-; I HI.-.- 1 1 ill'. r>|o|i|iy. of ('|iirii;ro. Iins riMciil Iv ilcvisrtl iiliij |iril(t it< i|
MU'Ci'>>|ii||\ il sprciiil incllioil of tri'litlin'lil wliicll lir roiisidcrs ;i|i|t|l-
(lllllf rVlll III fillly ilirniuy. I'>V ll lie I l.lllll> tlllll t'lc IMII«(I(". lll-lrinl
oT I If I 111: II I low (I I Id ill ro|i|iy. lire il('Vt'|o|ic(l linin t he lii-I. iiinl I In' iiii>;il
lolll' rilllMll liV lIlC |iri'SCll(C o|' tllf clcl't is llcMT lorilinl.
A Iter \ ivil'yiii;: tlic I i.-.-iics ol' llw Milt di'll I if triiii' t lif lioiiy fili,'f s
of tllf hiiiil fiffl. tliii> fiivoiiiiir tlifir union uhfn liroiiirlit into fon-
tiift. 'I'lifii lif |iiis.-f- ji (loiiiilf >il\fr uiif -iiliiif lliroii'^li lln |iiililtiil
|ir(Kf>s of tllf |iiil;itf-liolif iiliil iiliollifr |Iiio||h1i tlif |iiil;il;il |i|offS- of
tilt' !»ii|ii'rior iii:i\illiii\ . 'I lll^ i- ijoiif Mil fUf ll sjilf , Lfixl liiilioii> iiiiKJr
to suit tllf |iiiit< iiml |ifrfoi;itf(| for tlic wires fiif llifii |iliiffil in |tosi-
tioii. oiif on fiifli siilf. iinil the \virf> nrf |iii>.»fil tliroii::li ilnin. 'I'o
;i|i|ir(i\iiiialf the liony clfft. tlif ii;:lit iiihI li'fl wiif- lifiirf>l llif ;i|if\
jii'f t\vi.-tf(l loLiftlifr. |iiiltiii:: lfn>ioii ii|ioii the |iiirl'. liif Miiiif to lie
ilmif with tllf iiiilfiio!' jiiiir. If r-iilVif If III tfii^ioii liiii lif «iiffl\ |iiit
ll|ioll tllflll to illilW tllf two >iv|fS of tllf fiffi lo^ftllfl'. IIlfl>|o||> will
not lif nfffssjiiv. If iioi. ilifii llif liiinl imlfitf on fiuli side liftwccii
tllf fifft iiml tllf jilvfohir i- to lif lui -iiiic iiiiinfou-|\ , tlm- jillowiiij^
of {,'!'( 'iitcr If lis ion. 'I'lif I III I tons ciin l In- n lif ilr.iw n c lo.-c r toLictlif r liv
t wist iiij: tllf wirf >iit iircs iiiid lifM in |iosiiioii until union takf- |iliiff.
Tilt' purls should now lif tlioroii;rlily drifd. and wlifiif\fr nfff>saiy
liiU' siitiii'fs lif |iiit in to liriii;: tlif tissiifs into |ifi'ffft a|i|iositioii.
('oiii|ilftf fontrol of tllf fliild i.~ always rft|nirfd for .-onif days
after o|ifratioii. .\iitisf|itif trfatiiifiit of tlif i ith >li(iiild al-o lif
attfiidfd to and only .-oft. Ii(|iiid food adniinislf red.
.\s tllf opfiativf tifatiiifiit |iraftif(M| hy j'ldniiind (>ufii. and ile-
>erilif<l liy liini al tlic la>t annual iiifftin^rof the I'liiiisli .Mfdifal .\sso-
eialioii. diil'fi'.- sonifwliat from any of the fo!-f;.ioiiii: iiiftliod>. and sus-
tains sonif |ioiiit.- that are new, ihi- ( ha|itf|- will lie ( lo-ed with a lirief
description of the ihrcf staircs which he dfliiien: —
1. Iicfore operation, ll is iinperalive that the child -hoiild hi;
]iiit in a LTood >tate of health The chronic dys|icp>ia from which many
children liaviii;; clefl palate siiU'cr >lioiild he removed. l'"or I his. tin- ad-
iiiinistratioii of a rliiiharh-and-so !a mi.Miirc is an excellent tliiiii,'. .\ll
carious teeth should he removed or < lcane<l ami lilicd. .\deiioids and
cnhirfrcd tonsils, if present, should also he taken away licfoie opcratiiijr
upon the cleft, and the parts '/\\vu time to heal.
45H
OI'KIIATIONS Foil ( I.Kll I'M. A IK.
! ij
'.'. npcriitinii. lie \isri* n r.iii(li(i((l Smitli ^ra'' nrnvtl witli stotit
siiikcs. wliii li lit into llic crcvict's ol' the ti-ctli ov into tlii' >,Mmis, as he
siiys "liiirml('>s|\ ." Init iiisiiriii;; ii;:iiins( nn.v slippinjr (if tin- iiislru-
iiK'iit iliiriiiL: lln' ii|it riilinii. Tlie iiiiii'stlictic need is tlilororonn.
Allcr iiiiii'stlH-Hi)! is prodiiicfl ii >trnii!,' -iitmc i- pa<s('i| tlirini;fl)
the tip (if tlic (oiiiriii . ami tlir niLraii <lrawii well forwanl licrmi' IIh-
vajr i^i iliMTtcd. 'I'lic ( liihl i> thru lirnn;.'lit In tin' nid nl" tlic tahlc with
the head liani;iim Dvcr to kcrp the h! mk! out <d' the larynx, iiuuh as in
( hlllrlilirs pii>lti<i|l.
Allrr dcmidiii;: llif cd^ri's of tlir cleft a- in the nrdiiiarv niflliod
lir niako a Ion;.' incision on the inner side (d" each alveolar pnx-ess.
'I'hese incisions arc nsnally very fre«', traversin',' lli»' attachment (d tin;
levator and tensor palati muscles as well as the pala(o-pliaryn;,'eus.
'I'Ih II the rnspat(U'y is intridiiccd am' the miico-periosteal thips are
raised. The attachment also id* tin .ipom'iirosis of the velum to tin;
posterior liorder of the hard I'.-.iate is divided with curved scissors. As
these incisions produce a ^'ood deal of lia'inorrhaiie, this is cheeked hy
lirm pressure with sponires hel'ore the sutures are inserted.
(•wen pilfers silver-wire sutures to any others, lie uses a modi-
I'lcatioii (d' Smith's needle, and when the citd't is complete ti'U or twelve
sutures may reijuire to he inserted.
One important ])o' it that he insi.-ts upon is that there should he
no tension whatever ujion the Haps. The incisions at the sides, al-
thou^rh alinort as wide as the orij^inal deft, usually heal without dif-
licnlty.
'!. .\fter operali«>n. .\s anaesthesia passes idl". Hie child may vomit,
hut unless this is very ])rolonj;ed it will not interfere in any way with
the sutures. In order to favor mouth-drainaire, the child should ho so
pla. cd upon the pillow that the blood will (low out upon alisorbont
cotton arranged for tlu' purpose.
Tiio hest food to jjive is liome-nnide heef-jelly, as it slips down
vvithont elfort.
.\s soon as possihle after operation the child may he taken out of
lied, and even out of the house, to secure tlie benefit of inhalin.i,' the
pure, fresh air.
Washinir the month with solution of lioric acid or other antiseptic
should not he insisted on, nnless the child itself is willing, as the struij-
<rle of opposition could do more harm than tlie vvasliin<j would do fjood.
If septic infection takes place we must await the result. The
wcmnd may bo opened by staphylococcic invasion; but after a time,
I'HANOPLASTY.
i:.!»
with proper cnrc. the fovor will siil)si(l(>, mikI the sunderc] aii-l swollni
('<1kos of 111.' ficft will look l)ri;,'lit mid cli-iiri apiiii. and tlim tli,. up<Ma-
(inii may In- ropoafcd, tlioii^'h in n minor d.-uMc.-. and with < vcrv ]m>U-
ahility of bcin;; successful.
Dr. Owen i.s of tli(> oj)inion that, while imthinu i> so prejudicial t(.
pn.nipt union after staphvinrrhapliy as septic itifeetion. vil. havin-r
onee rceovered from the septicirmia. a complete imiminity is for a time
anpiired as a result, and further operation may he at once performed
with the prospcvt of a jrood iiiiinii.
SMfi
1. 1*
I
li i
llli i^
i til
Mi
INDl.X TO Ll'IKIfAKV l!i:i"i:i{KN( KS.
.\lil>.>tt. 711,
AlKiciiiiiiliic. -'.'•!.
Alniiliiiiii. 114.
Aili'iiot. I:i7.
Ali'xiiiidii'. 174.
AmiiiiKiiilc. 4.")(>,
Apiicit. KM.
.\rcli;iiiiti:uilt. lOil.
.\r:i<.l(l. -Jli^.
.\s(li. KMi.
Hnlicr. r.(i. 111.
I'.ahrs. 111.
liiikfr. sj.
I'.iilliii.L'cr. s:t.
IJiinctt. -IW,.
Hciilc. rlilV.inl. :i!N.
r,i'll(!ii|. ItiS.
i!cil,'t'm;i ii'i. 4Ui.
Uill'.rnl'li. 110, 1-JS.
lUikctt. rM.
HislHip. :«), ■■).'•. :!><. '■'!• '■'•"'■ !'*• '"•■
1(11, 'l\:i. 24."). 4t'-2.
Klackli'V. !ir..
UlaU.'. 12:i.
Uoiict. 104.
Hostock, !i:i.
Hoswmth. IS. \i\. :'.o. :;s. 41. 44,
02, 7'). s:;. Sit. '.10. 01, o.'i, 1 12.
nit. 122. 124. i;!s. 141. i.vt. lo"),
1711. lit*. 10.'). 21s. 22!t. 2:!7, 2.')r), :
2S(i, .'ill. ;i.">s. :!o.'j. ;j'.t;!, 401. 4:17.
Huviii. no.
l!(.\\liiv. 20').
Uiiuiii'. :!0. 04. 0.").
hri'sfri'ii, 14S,
Urtipliy. 4r)7.
15ro\vii, MoiciHi, 107.
lirowiir, l.fiiiin\, :i."., .")7, ■")'•', 04.
120. 12.!. 141. lis. 150, 174. 1O2.
2i:i. 2Si'.. 200. ;i!t(t. 402, 41t7. 412.
4:!4. 4'.7. 44:{.
Hii'iis. !2.').
linisrhk.'. 104.
lint 111-. II').
lUills. 211.
('atKHii>it\. 130.
r;ii)art. 22:{. 22;').
Cartel-. 'M.
("ai-v. ;!."):(.
(•aHs.'ll)c-irv. 83, 124, 130, 245. .307.
00.
00.
1 1 .■).
100.
270.
102.
•201 1.
414.
10:!, tia, 111
( lia|iiil.-. lit:;.
t halclliir, 10.').
( hfval. s;!. 10(1. i(;7. 307.
( liiaii. lU. 4.-)S.
( liiiiiliill. 4.").">. l.">-^.
( lark, 111.
( ilHlllct. 1 14.
( oakli'.v. 137.
( dIk'Ii. 4. Solis .
Colcv, 441.
( oliii. 270. 2S(t.
(oilier. 00. 7.'), SI, 211.
(■()()])er. 170.
Conieil. 140.
( DMriiioiit , 310.
Col ilade. 301.
( rodkes. 447, 44,S.
( intiss. llolOniiik. S3. ISd.
1 taiiiasriiiiio. 270.
Itailiiellii. 3S7. 3SS.
Davidson. 02.
l)e llloi.s, 2.").").
|)el)ioiisr<es. 30(1.
I)e la Sola. :iO(). 414.
Itelavail. I'.fvsoii. .")7. 04. 01, IJ2. 1.34,
101, -200. 211. 22s, 440.
I teliuicliow ski. 1('5,
llellioe, 141.
jlcsault. 170.
I !<■ Siiiioiii, 204.
Ilevassc, l;")!,
lleville, 151.
lloOell, .3S.
|lolltrele|i(iilt, 1511
llowiiie. Waikci-, H7,
Drake. '!"
Drcyfib 447.
I )ii]iaj,'c, 310.
i;iiet. ;•:. r.. 4.50.
I'.iiclisin. 1 15.
1m'1-{X11soii. Sir \\ '.. I5(),
Ferrard. 310.
l-'lalaii. 141.
l-'latean. ISIt.
Kox. lliit-rsloii. 104.
Fraenk(d. 41. 50, 02. 150, U'), .35(;.
FveiK-li. 02.
Kniideiiltial, 140.
Friedliiiider. M).
(-H51)
•n;-j
IM>r,X TO MTKItAHV HKKKUKNCKS.
iidi. III),
ivcl. IC.it.
If, 2!t:i.
.■Iinndt, .?!«).
.kIv. i:ili.
il)l.'. .1. S.. 'JIU.
Icji^im. li'T.
leit-^iiNimi. ITS, :2t)H. 214. ln.'i.
liick. 11(1.
<>M-l>'iii. lit.
osscliii, l.^■i.
oltsl( in. CiO. (11. 21). .'tS'l.
<m;:u('iiliciiii, 1(!S.
rani. Dniulii^. r.fi, I )S. Ids. l(;;i. 170.
liiiiuaUI. ;")?. 1 IH, ITS.
iiilt. i:iT.
Il.ill. (Ic liiivilland. 2()<>,
Hall. .Maisliiill. 42;}.
Ilaj
!(;>,
isl.
lliiiiscn. 410. 411.
Harrison. ITO.
Ilaton, 141.
UcIot. 55.
Ilrndlcv. 11(1.
Ilcrynfr. Kill. 2"!), 29(1. 3(54. 3S0.
IlcwlcK. H.-?.
llilairo. 1(15.
Hill, 110. 143.
His, 101.
Ilodonpyl. 134.
Hopkins, 141.
Ildpniann, 12(>.
Home, .IdW'pli, 128, 234.
Hunt, Middlcnias, 71, 302, 441.
Hiinfcr, 424.
Injrals, Mctchrr, 83. 102, 107. 177. 225.
3!>7.
Jackson. Hnslilinfis , 423.
.Fnrvis. 54, 7(1. 122.
.Ifansoliuo. 410.
.I(Mil, 04. 104.
.lohnson, ■^4.
.fdni's, f'arniault, 28, 5(5.
doiivdain. 100.
Jiillion, 303.
Jurasz, 431).
Knnthack, 102.
Krllv. l?ro\vii. 1.34.
Kirstoin. 345, 34(1, 347, 340. 3(58, 443.
Klol)."*. 300.
KniRht, ('. 11., 131, 174, IflO, 402. 430.
Koch. 300.
K rails.'. 170. 205, 402.
Kriiuli'in. 315.
Kvic, S3, 14S,
:!(M5. 31
l.aliovv. 114.
Lake. '7 1. 83. 8S. J Id, 404.
I.aincros. .'17 I .
I.an;ri', \'ict(ir. s7,
I.anrcns, 4 in.
I.I dcrniaiin. s7.
l.cllVits. 134. Iiid.
I.cllaivc. 04.
I.cI.mk!. 245.
Lcrnidxc/., IfiO.
I-.vi. :i7l. 374.
I.iaias. 371 .
l.incdln. 225.
l.iiKlcniiinn. 212.
Lodcr, 104.
I.ojraii. 220.
l.ouciilicri.'. .50. 214, 3H4.
l.owndcs. 1 12.
l-UfT'il. 27s.
l.uniiij,', ."i'.i;!.
I.nsclika. 101. 203.
MacDdnald. ( iicvill.-. 1(18,
Ma.l)<inald. .(. \V., 455.
2(17
4(7.
lliinfcr. 434. 435.
.1. \dland, 50, 04, 100, 115.
41. 74. 122,
Maclnix re.
Mackcn/if.
Maikcnzii',
175, 420.
Mackenzie, Sir Moroll, 17
2.M. 311. 412. 410. 423.
Mciiridc, 110. 12(1, 205.
Mafiiiani. .310.
^fajdi-, 3;id, 307.
Maisli, 110.
Martin. 21(1.
Mathicu. 2(17, 2(18.
Mayer, 40tl.
Ari'iizcs. 31(1.
Mover. Wilholni, 204. 208, 211.
Mioliel, 125.
Miekulic/. 31(1.
:^Iilli,i,'an, 1(18, 170.
Moldenliaiir, Id5.
!Mdrier, 171.
]\Idnnt lilcver, 410.
M<inn\ no. 10(1. 417.
Ahilliall. «7. (!8.
^hirdoeli. 70.
Murray. 20(5. 402.
My lea.' 8(1. 17(i, 170, 181.
Xavratil. 410.
Neisse, 14(5.
Neweonibo, 210, 307.
Xvk's, 1(55.
INDEX TO I.ITKHAKY HKFKKKNCKS.
•U)3
O'Dwvpr. 350, 351, 353, 254.
Otto, 20!).
Owen, 457, 459.
Pakfs, 247.
Paterson, 191.
rattcrsoii, 230.
Pawlouskv, 140, 150.
Pt'an, 140."
Poglcr, 127.
Poiiiiewaii. 33.
Poiahpt, 233.
Piimio.se. 9, 79.
Pivor, 374.
Pynclion. 207, 2()2, 271.
Kailtoii. 434.
Kedus, 234.
Keed, ]4(i.
Reeve. H. A., 218, 220.
Kfid, 24<i.
Keidcl. 143.
Riehaidson. 280.
Robertson, 171, 321.
Robinson, IJeverlv, 105.
Roe, 25, 70, 289, 451, 452.
Roentgen, 447, 448.
RooHa. 185.
Rosenberg, 181. 392.
Rosenniiiller, 31.
Ros8, G. F., 428.
Roy, 119.
Sacli, 143.
Saint-llilaire, l(i5.
Sajons, 38, (i2, 04, 100, 154.
Sandfoid, 211.
Sappy, 437.
8chedi, 122.
Schep])e}i;rell, 115, 403.
Schiil'er, 71. 1()5.
Schubert, 281.
Sehiilier, 14(J.
SeluiKze. 11.
Seller. fiO. 125, 130.
Senioii, Sir Felix. 194, 120.
Sendziak. 272.
Shurlv, 18, 54, 59, GO, 04, 102. 122, 140.
Siebenniann, 280, 281.
Sicthoir, 218.
Sikkel, 128.
Simonowsky, 402.
Sinilii, lui.stjicc, 425.
Sok(d<)\vski, 272.
Soniers, 2;{3.
Spieer, Scaiies. I 14. 171.
St(i,.nk. 391).
Sto'.-.er, 131.
Straifjlit, l!<-\viird. 103.
Kwain. 117, 119, i;M.
Synionds, 143.
Syne. 141.
Tavlor, Frederic, 424.
Tiroiii:<oM, St. (lair, I(t3, 1.J3. 143.
Thorner. .Max, 141, 221, 3(i2. 345, ;M9,
353, 374.
Tiartis, 374.
Toeiilitz. 279.
Torn wa hit. 203.
Trendeleniinrir. 70.
Trehilian, 140, 148.
Tyrrell, Shawe, 'M).
V'elpeau, 240.
X'erneuil, 120, 141.
Volkmann, 147.
Voltolini, 125.
Wajriier. 14. 41, 103, 194. 279.
Walton. 29;).
Ward. 120.
Warren, 450.
Watson, .\rthur. S(i, 134. 1 13.
Webster. 200.
Weiriiselbuuni. 14:i, 1.".9.
Weil, 221.
Williams. 143.
Willif;k, 143.
Williston, 1 14.
Wiiiirrave. Wvatt. 58, 01.
Wishart, r3. i55.
Woakes, 119. 17.').
Wolfenden, 272, 274.
Wrijihl, .lonaliian, !12, 1 l."). ll'.t. 175,
211.
^■^arsh'y, 234.
Zeim, 70, 81, 170.
/uckcrkaiiill, 13, 74, 70. 119, 105,
(iK\i;i{.\L INDKX.
SkcIKiN I. -DiSKASKS OK TIIK VosK.
m
M
if! I
Acccssorv cdvilics. iUiiUuniy nl. 7.
(Iis('iis<'-i of. l.")!l.
Acute sinusitis. I.")!>.
('ti(iliif,'\. I.">'.>.
syinptiiniatoldijy, ItiO.
tri'iitmcnt, Uil.
Adciioiiiii <if tlic nasiil passiifrc^. l.'ij
.Aiiiitoniy of tlio <'.\t('inal nose. .'{.
acccssorv siiiuscs. 7.
ct iimoid cells, 7.
frontal sinus, ti.
niaxillaiy sinns. S.
nasal fossa'. .'!. 4.
septum. 4. '
sphenoid sinus. 7.
tiirliinateil liones, .'>.
Anjfionia of the |ia-i>aj.'es. rt2.
treatment. I. '{.'{.
Anosmia, 1(14.
Antrum, cyst of. 174.
.\ntiiim of llijjtlimore. 8.
Ajjiosexia, 121.
Asthma, lellex, 120.
Atro|iliic rhinitis, 5S.
l!ell()e(]"s cannula in nasal lia'Uior
riiajre. lOS.
I51aekh'y"s invest i^^'at ions. 0").
Hlood-vessels of tlie nose. 11.
Hone, superior turhinated. ."i.
middle turliinaled. ">.
inferior t uriiinated. (1.
Carcinoma of the nasal ]ias-.a;.'es. 141.
dia^fnosis. 142.
eti(do^'y. 141.
patholojry, 141.
jirofinosis. 142.
sNtnptomatolofrv. 141.
treatment.
11 of
Momlrom
!'■
(hronie disease of antrum of Hi",
more. 1(!2.
diajinosis. Ititl.
e\ 'oratory puncture. lilT.
ti silluinatioii. Iti.S.
etiolofT.v. 1 (!.").
iiat hoi
"srv,
102.
irotrnosis, l()!t.
svuiptomatJilojiv. Hi.'i.
'(ICI)
(hronie disease of antrum of Hi;;li-
niore. treat irieiit. Mi!),
coinliincd operation, 171.
direct irri<,'at ion, Kii).
opcnin;; of inferior mealirs. 1(10,
I7(".
alveolus. 170.
canine fossa. 170.
Colunniar cartilafie. distortion of, S!i,
!l(t.
jierforatioiis of, !tl.
f'onjj;enital syphilis, l.">."i.
( ysi of the antrum. 174.
Cystoma ot the nose, l:{ I.
Dex'ialions of nasal scjitum. 74.
Disease of the frontal sinus, ISl.
Disease of the splienoid sinus. ISO.
l)is"ases of the accessory sinuses, l.V.t.
Diseases of the elhinnid cells, 175.
iliajinosis. 177.
etiolo^'V. 170.
palliolo<ry. 17.").
pro^'uosis. 177.
s\niptomatol(p;ry. 177.
ti'eatment. 17S.
Klcctr<icautery puncture in hyper-
trophic rhinitis. ,").').
Kleclrolysis in septal dcfornn'.y, S4.
Ispislaxis, 10(i.
diairnosis, 1(17.
ctiolo-iy, KHi.
patholojiy. lOO.
profrntisis. 107.
syin)pl(niiatolo;,'y, 10(1.
treatment. 107.
I'lthmoid cells, 7.
disease of. 17.").
Piliroma of the nasal passages, 12S.
diagnosis. 120.
•tiol(
128.
pathology, 128.
]ild;;nosis, 120.
svmptomatoloftv. 128.
treatment. 120."
Foreiifii bodies in the nose, 112.
di
lU
sym])tomatolof;y, 1 12.
treatment. ll.'J,
<ii:\i:i;vi, imii;\.
It;.-,
Km
IIIU lllii^i-. Ml.").
<ial\iiii(ujuilci V li:ill< r\-. ,).'!.
fihiMdcrs, lis.'
<iliin(ls .if the iiiKc. II.
' inK^tciii'^ jiliii:-, <il.
liiiiinMild'^ (i|M'iii1i(iii. .">7.
Ilii.v fcvci'. (ir \ii^.iiiii,|.,r ihiniii-. ;i:;.
iliiifjnosis, iis.
• Iiiriilioii (if, !I7. !)s.
'I i(i|<i</y, !I4.
;.'iiijria|iliiinl area. !IM.
|iatlKil(i<ry. !i;i.
IK'iiodiciiy (if. !17.
|ii('\cnti\c iiicasiiic-;. !»S.
|ii(if;ii(isi>^. !)S.
'<yiii|itoiiia((il(i<.'\ , !»(;.
trcalinciit. !i!l.
(•<(tisli)iiii()ii;il ticatniciit. <t!l.
ticatiiiciit (if nasal jiassatrcs. |(in.
If.vdnurlid'a. nasal, l(i;{.
Ny|i<T(i(i|,|iic rhinitis. ■).-).
Fnncivalion nf (lie n(isc, I j.
In-tninicnts nscil in ncisc mt,
I.-..
• icclric ]iliii1ii|i|i(ini'. I.").
laryn^dscdpc, 17.
nasal s]i('cnla. IS.
liowdcr-lilowcis. 24.
saws, etc., ^'t.
snares, etc.. 27.
s|i(ikcslia\ cs. ,.((... -js.
I.acnnial canal. 7.
I.M|ins of tlic ndsc. 14(1.
(liafrnosis, 147.
(•(idldiry. 14(1.
Jiatlldldory. 14(1.
|iro<rndsis. 147.
s.\in|itdniatdldjrv. 14(1.
Ii II lilt .
tri'alniciif. 147
Mas
-Mcnlli
saf'c m
liliii- iliiiiiljs. Cil.
Kil III diseases dt jid.;,. ;,,|,i tin-dill
35.
Xasal lidncs, :).
Xnsal (Icfdniiiti
Xasal liydrdiiliii'a. lo:!.
Xasal iidlypi. 1 HI.
dia;;ndsis. 121.
<'tidld;iry, 1 IS.
|iatll(lld<ry. 11(1.
|ii(ii,''ii(isis. 121.
rcllcN distnrlianics.
sex. Il!».
I's. djicralidii-. fur. 44!t.
120.
.Na-il |iii|\|ii. .\iii|,| alii|d;.'y. 1 1!».
Inatiiicnt. 122.
Iiy clfcliiily^is. 12.'>.
Iiy fiirci'iis. 12."i.
Iiy snares. 122. 12.'!.
\a~al septiiiii. defininil ies. 74.
dia^Midsis, SI.
etidldi_fy. 7.">.
|iiii;,'lid>is. S2.
-ei|nehe allel' dpeial inn. S7.
-yiiiptdni:iidliij^-\ . SI.
Ireatiiienl. s;!.
elec1riily~is. SI.
ineflidds Iiy I'.dsudrtli, s;i
nietlidds Iiy (iissellierry, H4.
Illellidds |,y ( iiili»s. K.'i.
nieihdds liy In^'als. S;!.
luellidds liy Kyle, 8:t.
nietlidds liy Lake. S8.
inetlidds liy Wafsdii. SC).
riililier >plint~. ss.
sihci- inlies, s."i.
Nasal sepiiini. defdiiniiies of. 74.
ediidiliini^ in actual life. 7,5.
-kiills df aliiii i</ines. 74.
df civilized races. 74.
Ndse in plidiiatidii. 12.
Ndsc in rcspiratidii. |;{.
Olfactdiy area (if the nose. 12.
Operiitidiis f(ir nasal defdrniitios. 44!).
.Xnnandale's inethdd. 4r)0.
Kllet's met! 1 4.5(t.
Roe's nietiidd. 451.
Osteoma nf the nose. |:?(;.
etidldfry. 1.^7.
pat lidldj.'y. i;)7.
syniptdniatdl(i<.'y. |;{7.
treatniciil. I.')7.
I'apilldnia nf the iids
tic.ilnienl. 12(i.
Parasites, iiasul. | |:!.
12(1
-yillpttillial(il(i;;y. 1 1 t.
"exas sereww dill
14.
'I
tieatnienf. 1 1.").
rani'inia. l(l."i.
I'll\ ^idliij.;y nf nn-e ;iud Uri-t"
IMI^c-. 12.
iiii-c ill phiiiuil inn, 12.
in respiiiitinn. 1:1,
-elise (if -nicli. 12.
Tdsti
ernir ihiiid^cdpic iina''e, ;{(l.
::i.
site (if attnehnii'iit. 120.
Iiinitis. acute
diauiidsis
eliiildo-y, ;[^
pathdldiry. ;!2
liriifriidsis, ;}.■{.
^l'
ict;
<.i:m:kai, indkx.
m
■■■' s
'.. m
lit
- q;r
i; :
Rliinilis, acute. ])ri(i)livlii\i-. .!.■;.
syiii|ilniiiiit<il(i;>y, ."{.'1.
Ircatiiiciil, .'{4.
Khinitis, alniitliic, r>8.
Uiii^'iiiisis, (il.
I'liolofiy, ')!!.
]in thole Iffy. TiS.
])r()f^ii()sis, (iii.
sym|it<)matol(]<ry, (io.
troatiiH-nt. (i2.
l)y (iottstciii's ]>lii.£!^, 04.
l)y inassajjc, (14.
Kliiuitis, clironii-, '.\~.
diagnosis, IW.
ctiolofiy, r!7.
patliology, .'57.
lirof^nosis, .'{8.
syni|(loiiialoIojifv, 37.
troaliiifiit, .^8. '
inassafic ;{!(.
Rhinitis fihiinosu. 70.
casps by I?rnn .Murdocli. 70.
rasps by ^liddlcnins Hunt, 71.
casps by ]{i(hard Lako, 71.
cases by SeliilTpr. 71.
Khinitis, hypprtrophic, 45.
dififjnosis, ">().
etiolofjy. 47.
])atholojiy, 4.").
profrnosis, 51.
syni|)toinatolo{ify, 40.
treat niput, 51.
by electrolysis. 55.
by turbinectoniy, 5ti.
Ehinitis, nMlematosa, 07.
treatment. (18.
lihinitis jiurulentia of children, 41
diaffiiosis, 42.
etiology, 42.
pathology, 41.
prognosis. 43.
syni])toinatolotry, 42.
treat nipiit. l:!.
lUiinoliths. 110.
<liagnosis, 111.
])rognosis. 111.
symptomatology, 1 10.
Irpnimciit. 111.
Jlhino.acleronia, 140.
troatment. 140.
Sarcoma of the nasal passugi's, VXA.
diagnosis. l.'tO.
etiology. i;{8.
jiathology, l;t8.
]n'ogno>is. i:!!i.
symptomatology. 130.
treatment. 1.30."
.Sense of -imcll, 12.
Sensitive areas, 04.
Se])tum. anatomy, 3.
abscess of. 02.
bilateral tumor-; of. 127.
jK-rforation of. !tl.
treatment of, IM.
ulceration of. }I2.
Sinus, frontal. 7.
nia.xillary. 8.
s])henoid. C
Soft palate. 13.
.Syphilis, 151.
diagnosis, 153.
])athology. 152.
])rognosis. 154.
sym])tomatol((gy, 152.
]>rimary, 152.
secondary, 152,
tertiary, 152.
treatment. 154.
Syphilis, congenital. 155.
diagnosis. 155.
etiology, 155.
])atllology. 155.
])rognosi>^. 15().
symptomat(d(igy, 155
treatment. 15(i.
'I'uberculosis of nasal passages, 143.
diagno>is. 144.
etiology. 144.
])athology. 143.
jirognosis. 144.
symptomatology. 144.
treatment. 145.
Turbimited bones, anatomy of, 5.
Turbinectomy. 5(i.
Vasomotor rhinitis, 03.
N'omer, 4.
Zeim's exppriment< on aninuils, 76.
lifit
Skciion II. -1)isi;.\si:s ok tiik V
Abscess of the post-pharynx, 258.
tonsils, 244.
Actinomycosis, 300.
Acute bulbar paralysis, 320.
Acute infectious phlegmon of
jiliarynx, 2(U.
til
llAliVNX.
J3l.
.Vcnte jjliaryngitis.
diagnosis, 233.
etiologv, 231.
pathology, 231,
prognosis, 233.
symptomatology
232
<;k\ki{al indicx.
467
A<ul(' |iliiuviif,'iti>. Inaliiiciil. SM.
Acute tonsillitis. 24.").
Adenoid 1,'rnwtlw in nii-((> |)liaryn\, u'04.
diiifrnosis, 210.
etidjdfry, 2llti.
patliolnn-y^ 204.
]ir<if.'n()sis, 210.
W,\MI|)t(iniJlt<ll(m\ , 207.
f.'enenil syniii'toMis. 20s.
treatiiicnt. 211.
'i|ieratiiin l)y eiuclle, 214.
fdrccps, 21 I.
fralvanncantery. 21:?.
Adcnnma of the iialale'. 2il|.
Ad\isal.ili|y ,,| j;,.,„.ni! aiui'st liesJM
212.
Anie.'.lliesia of iiliaiyn.x. 212.
Ana slhetic.-, elidiee "df, 212.
I Iddrotdini, 21:!.
ether. 212.
ethyl l)rdniide. 21.'!.
nitrous o.xide. 21.'!.
Anatomy of pliaivn.x, l.s.l.
iirteries. 1!)0, '
faucial tonsils. |!i|.
linpual tonsils, l!)2.
ni'i\es, 1!»0.
<>|K'nin<,'s into pliarviix. is:..
pharyngeal fjlands,' I'tO.
pharyn-real tonsil, ]!(0.
Aprwsexia, 20!t.
Beniffn tumors of pliarvn.v, 2!tO.
dermoid growths, 202.
fibroehondroma, 291.
fihroliponia, 291.
tibrolympliadenonia. 291.
fibroma, 290.
treatment of, 291.
l)ajiilloma. 290.
treatment of, 290.
Cnreinonia of the fauees, ;5II.
diagnosis, .114.
etiology, .'il."?.
patholopy, .-Jll.
profjnosis, SIS. •
symptomatolofry. .■•,1;?. ;
treatment. :]](>.'
e.xternal o|)eration, .SHI. '
internal ojjeration. 'Mn. '
Carcinoma of the nasopharynx. 229.
Catarrh of the na.so-pharvn.x, I9r>.
Chondroma of naso-pharvnx, 2.30.
Chronie pharyngitis, 237.*
Clpft palate, "oporations for, 454. j
Heplutition. 193. •
Perinoid tumoi-H of the pharynx, 202.
Diseases of till' u\ ula. 2.')2.
o'dema of the uvula, 2r)2.
it ioldjry, 2.")2.
pldjrUdsis, 2.'i2.
s.\ liiptoiiialdldir : , 2.")2.
Ir<al III! lit. ■J.'>2.
I lonL'aiioii di I he uvula. 2."):!,
elioldiry. 2.").'!
patiidlo^.y, 2.");;.
I'ni^riii.sis. 2.".4.
-.\ lll|l|dllialdl(Jjry, ■_>.-,}
t'ealriieiit. 2.').'i.
I'llirdina di iiasd piiai-, ii\, 22.'!.
di:ii.'iid*is. 221.
(I lll|(l!.r^- 22.'i.
palhdld^rv. 22;!.
pn j;iidsi.l. 221.
•^.\ nipldm;itdldir\-. 22'l.
Iiealiiieiil. 221,
eokl wire -narc. 22.').
elect ii, lysis. 22(1.
.iralvanoeautery ecrasenr, 22.")
I'ibionii' of phaiynv'. 291.
■•'olliclllar phaiyii^ritis. 240.
I'dii'ifju bd.licsMi the fauces, .'{21
prd;.rnd>is. .'!2.'{.
iieatiiient, .'!2.'t.
Iliemorrha-e follouinj; toiisillotoniv
2(!!».
Hypertrophy of linpual tonsil, 2S4
di.ij.niosis. 2S7.
etidldijy. 2S.").
patholo^ry. 2.>^4.
Jirdf^nosis, 2S7.
syniptoniatol(ip\-, 2S().
treatment. 2.S7.'
"perative, 2.S,S.
Lacunar tonsillitis. 272.
Leukoplakia palati. ;!lo.
r.inpual tonsil, hypertrophv of, 284
I. opus of pharynx, 297.
diafrnosis, 29S.
etioloiry. 297.
|iath(plo;ry. 297.
proirnosis. .'{00.
syiiiptomat(doj,'y, 297.
treatment. .'{(10."
.Malijjnant diseases of nasopharynx
227. • ■ '
carcinoma of naso jjliarviix, 229.
symptomat(dopv, 229."
treatment. 2:{0."
sarcoma, 227.
diagnosis. 227.
Ki.s
• IIAKHAI. IMiKX.
:il
I
V<!;
yi
. ..I.
Malignant ili^fU'.c'. of un-n pliiirviiN.
'^iHi'iiiiiii. I'l ii)l<ij'\ , 2'J7.
|ial liiiluj;\ . 'J-JT.
|piiiMriii«is. -Jjs.
■.\ lll|ilii|ii,itci|ii;,'\ , 1227.
riTiitiiiinl. J_'H.'
Iiv ^iiilviiiioiiuilri \ . .1J.U.
Iliiswiirt li'- I'iisc. 22'.l.
DcliiVitii's CUM'. li-JH.
I.Kjfiiirs ciisi'. l!-J!»,
Mitli^iiiiiil, di-t'!!*!'^ (i| iii'ii |i1kii \ii\.
.•!(I7.
("llcillOlllil. .'ill.
siiicoiiiii. I!(t7.
IMycnsis. |iliiM \ ii;,'r;il. :i77.
ilia,i;iiii-i>. '1X1.
el i(p|(ij.'y. 27'.!.
|iiil lin](i;,'y. '277.
|iriiL.'iiii..is, 'JS'J.
>\ lll|)limiM|nj(i<|\ . jsl .
lll'iltllK'Ill. ISl.
Myiipiitliic piiiiily^is of fauif>, .'Mil.
Myxotilprdina nf iia<ii |iliaryii\. 'J 1 7.
clia^'ncisi-i. 1\'.).
(•ti(il(i;,'y. -ils.
|)atli(i|u!.'y. -217.
|ii(itrii' i-^. -If-
-yili|ilii|iia1(ilii<i;y. 1 IS.
ticaliiiciit. •Jj'.l.'
umisiial (ascs. -Jiil.
Naf*ti-|)liaiyiij;<'al calaiili, l'-i.">.
ilia<;iii)-^is. I!t!l.
el i<)](>;_'y. MMi.
;ia).li(il(ij:y. I!l">.
|ii();;M<isis. I'.HI.
syiii]i1()iiialiiliii;y. I'.IS.
rn'atmciit. i'.t'.l."
Ni'\iri)scs uf llic taiiic-, .'!IS.
iMy<i)iatlii(' ]iaralysis. .'j1!>.
iiiiiral^'ia of I lie jiliaryiix. ;ils.
iiciiriisis of iiiotioii. ;il!t.
of 'iciisation. .'US.
])aralysis of the fauces. I5I'.».
OptM'atioiis for cleft palale. i't\.
I'alato - f,'losso - iiliar\ iiL'eal |iaral\^i-.
.•{•2(t.
I'liaiyufioal inyeosis, 277.
IMiaryiiireal ))a])ilioinata, I'Ml
I'tiaryiifreal iiilperciilosi-^, I'X'i.
IMiaryiifritis. acute. 2.'! I.
IMiaryiifiitis. elirouic, •j:!7.
(liafrnoHis. 2.'i8.
etiolofry. 237.
patliolofry. 2117.
is. 2:51
pr<'K«
:;{H.
l'liar\ ii;.'it i-. cliroiiic. ircatuieiii. 2.'{:t.
riiar> ii;.'ili-. tolli. ulai. 2 HI.
ilia;;iiosi>*. 212.
etio|o;^y, 24(1.
|iatliolo^'y. 2411.
|pro^iio>i>. 212.
wyill|iloiiiatolo;.>y. 21 1 .
tieatuielit. 2l.'<.
I'ljarynv, aiii.toinr of. Is.").
Iiouiiilaiics of. |S.">.
H|ieliili;r^ into. |S."i.
riiy-iolniry of |iliaryii\. 111.'!,
-'oft |ialate. I!i:t. '
loti-iU. 1!U.
<.'Miii«y oi acute tiiii-illil i>. 24.">.
iliaLrMo>i>. 2 IS.
ctiolojry. 2>7.
|iallioloi:y. 21.").
|iro;;nosis. 2l!».
>yiii|itonialo|(];iy. 217.
trealiMcnt. 2l'.t.'
lictio|ihaiy M;:cal al)-le^^s, 2.">S.
ilia;iiior,is, 2.")!l.
etiology, 2')S.
pal lio|o;:y. 2.")S.
|iliiL'tlo>i-;. 2l((t.
*\ IU|ltolMato|ofry. 2.")!l.
licalMiclit. 2IHI.
Sareoiiia of the fauces. ."117.
(Iiaj.Miosis. .'!((S.
ctiolo;,'y. .'1(17.
]iat liolo;jy. .'ilt7.
pro^riiosi-^. ;i(t|l.
syiu|)l<)inatolo;,'y. .'{I}S.
tiealliiellt. MW.'
Sta|iliyloirlia|iliy. 4.").').
Syphilis of the pharynx, .'iitl.
(liafiMosis, ,'5(14.
efiolo;.'v. 3(»2.
patholofJT.v. 301.
))idf,niosis. ,'!()").
syniptoniatolotjy. 3((2.
ininiaiy. 'MVA.
secondaix'. 3(1.'!.
l4'itiaiy.'3()3.
treatment. .3(l.").
ileforniities of pharyii.v, 3()(!.
inucoiH patch. 3<t.'>.
ulceration. 3(l(i.
Tonsillillis. 321.
Tonsillitis, ,321.
Tonsillitis, laetiiiar. 272.
K
syinptoiuatolofry, 23S.
diafinosiS, 274
I'tiologv. 27.3.
\^:h
7!
fiRKKKAI, INIiKX.
1X1.
\. :?ot'..
'^'""Mllilis. iM.Miur. i,all,u|.,.rv ■•:•'
I'lo^nosis. 27 r>. "
••<yiii|)t()iiiiit()|(ijry_ 27;{.
• I'iitiiicnt, 27.')' '
T...iHil|„to„iy I..V tonsillotonM.. o.j;
'•<'l<l-v.iii. ,iiaic, 270.
itii\<(l s(i>siirs. 270.
feMlvnii«ii:ml.T\ kiiitV, "70
loustls. fiiiicijil. nil
liiij.'iiiil, I!»2.
J'li.ilyiijj:(iil. I'M)
i'o'isil,, l.y|M.itn.,,|,v u{, •',;■>
<ii;i;.'ri(isi.s. 2(m.
fliill. )<ry, 2(14.
patliolo.rv, 202
!(;;»
*yil||l|l)|||i,I,,|,,,rv. 204
trcjitiiniit. 207" ' "
r«'inual,|f, ,li«..a„.. 2o;{
IuImiviiI,,,,. ni pliarvMN. 2W
<iia;.'ri<i»i.. -lui,
<'li<l|<)jr\ . 2!>.'{.
I>al)|<l|ii^r\. -t'Xl.
jiri>jriii,*i,. -ji)-,
!'yill|)|.l||l.||ll|.,;..V. 2ii4.
trfatirifiii. 2!»,") "
I'laiioj.la^iy. j.m;
I vula. .luii^Mi,,,,, „,• ^,-.j
"'di'iiia .if, 2.V2.
•^l^'Tlo.N 111. I,,.
;!!i,-,
.•!o;!.
:niH.
''"■yiifjiUs, 371.
-\lw..,s of tl..' larviix
Aeiitc laiyiicrjiis. •{(j.j
(liajriicisis. .'iO.'J.
t'lioldjry. ;j(i2.
I>atil(.I(,(ry^ ;((;._)
profrriosiis. ;{(i4.
^viiiiitoinaluldgv
''■•'iifiiicnl. ;i(i4.'
A.ul.. huynfritis of cliihlivn
Oiafjiiosis. ;{t;,s.
Pti()l(j<ry, ;{(J7
J)at.h()loory^ ;j(;7
Jin.^rno.si.s. .•{09.
syniptoiiiatdlofrv
tivadiiciii, .soy"
AcuU- a'dciiiatoiis I
fliiipKisis. .■!72.
Pti.llofry. ,<}7]
I'iitfiology. ;j7i
I'fofrrio.sis. .■J7;{.
•"yinptoiiiatolopy. :i:->
fnatiiicnt. .•i74
Affcction.s of tho cri<.oarv(
. <iciiIa(ion, ;5!Mi '
Anicncaii iicljulizcr •.iH->
Anafoiny of (|ic laiviix";!';
arteries. .'i.-J.").
Jirvteiioids, ;{2!>.
eriioid eartilat^e .'{'7
nii^'Iodis, ,330"
lifraiiients. 3;{;{.
Jyinphaties, 33").
miieous iiipiiibrane 33",
Jnu.sc'Ics, 3.35. '
nfTve.s of larynx, 3.J,-)
thyroid cartilago, 3'^8
vocal cord,9, 333.
Artfiritio deformities of the
mi.
iioid
ar
laryn.v,
KASNS (,|- 11,,: l,ui\\\,
I Mnijiliic laiyii;,.iij.. .•{,S4.
(Iia;r||n<j. ;;s.-,
, lialliulojry. .3s4.
liru<;n.i-i>. :ts.-).
syiii|.|.,|„ai.ii,,;rv. 3s4
tieatiiienl. 3>..v'
J .\llt<iscoj)v. .•J.|.-,
: -<-"-.M, f,„ autoUpi'"-.,.,,.
j '^''?;'.''"': "•";:Me-depres,or. 345
' P<'S.llo„ ,„ antosenpy, 345.
"•'"iff" '^rn, ,i,. .,f li.e I;uynN. 420.
< ar.JMoiMa of the larxnv 4.30
'lia,!.'ii,,si,. 4;!.s. ■
; |iatll(dojry j;>7
profriioiii^. 4;{s_
Mlllptnui.it.ilnjjv .|;j-
li<a(rneiit. 4;5<)]' '
-ndol.-uynfjeal operation .j;{.,
"""■"'•"i"" h- .-rvsipela.. 441
larynj,'e,ton.y, 44(1.
Sojis CoImii-^ operation 44(i
>ordM,. infenor ,,y,;,Hn;, L^'^oo
.;-.;.. Mennorrh...a' of Stink: S)
< iironic laryngitis. 377.
diarrnosi*. '37!t.
} etiology. 377
pathology. .'{77
Iirognosi.-. 379.
^vnipioniatologv. 37,S
♦ itatinent. .380"
'left palate, operation for. 420
stajiliylorrhapliv. 455
uranoplasty, 4.-;o.
omniinutor for inhalations 383
< "ng.-n,tal -ypl.ilis of laryi'x. 420.
4TU
• ■KMiiAi, rMii;\.
I?
% ^
I
IM
■ l
1
- ': ■
i
III
Dilliciillics in laix n;.'i;il i \;iiiiiii:ui" ii.
JlilFiiHO piiclivdcnniii. ;iSfl.
J)is('u^<'s (if liirvMN, ,'(2').
Filial s|)ii-m of till' liiiyiiN. ■\.1\.
J''il)i(p|iint!i of tlic liir\ii'x, 42!'.
loiii;;!! Iicidiiw ill till' liiiynx. H.'
(liajxiKi-i-i, ti.'f.
|iro;;ll(i>i>i, H I.
-\ lll|ilci|lialo|oj;\ , ll.'t.
tiiat iiii'iil, I |."i.
Ili>>loiy <if a i-A-f of laiyii^rial |i(ii-'
chniiili iii^, ;i!t|.
Iiihilial inn, ,'!.'il).
infulialioii liilif. iiiiiini\ cd. .'irili.
ill ili|ilil liiria. it.'i.'t.
ill lar_\ ii^'cal si rid me. .■!.'i;t.
0'l)\\y<i""s 1 lilies. .•),")!.
o|i('iatioii diiiiii;; iiifaiuy. ,'I."p1. .'ire'.
dmiii;,' adult life. ;{."il'.
iciiiovai of tiif tiiiic, ;{.■).•;.
Kiist
(■ill's aiitosco|i('. ;J4.").
toiij,Mi<'-d('|iicssiir, :{4ti.
Laryiij:('al nianifcstatioiis of i lie
tisiii. ;i!)7.
I.aryii<.'cal )iciicli(Hidritia. 30.1.
diii'MKisis, .'i!l4.
Ulna-
['tiol(
tliol
."5!>:t.
la
"J-'V.
;<»3.
pi-of'liosis, ;?!».■).
syjiiiitoniatdlnpy, D'l.!.
ticatiiiciit. .■)!•(!,"
F-ary Ileitis liliiinosa. 3!t2.
l.arynf,'i(is. aciilc, .'iU2.
of cliildrcii. .'tfi".
atid|iliic. .■{S4.
clirdiiic. .'!77.
(I'dciiiafon.s. .')7I.
tiiliciculav. ;!!IS.
I.aryii{j(isco|iy. ;?4n.
aiitlior'fi opcratiiifr (hair. 344.
difliciiltii's of cxainiiiafioii. ;i4'2.
Iiosilion of ttic ]iaticiit. ;?44.
I,('pi-osy (if tlip air-]iassaj:cs, 4 Id.
aiia'stlictii^ fiiini. 410.
nodular form. 410.
T.cprosv of tho nose. 411.
larynx. 412.
nioiitli and pliarynx. 412.
troatincnt. of, 414. '
T.upiis of llio larynx, 40(i.
diapnnsis, 407.
jirofrnosis, 40S.
I.ii|iii^ of till' laixiiA. '■v iiiptoiiialolopv,
4t"7.
Iiiatiiiiiil. in.H.
.Malignant tumor., of tlic laiMix. 4:ifi.
lii»to!ci;.'i(al ('\aiiiination, 4;{(i.
.Multiple I'oiiiminiitor. 120.
.Multiple papilloiiiala of eliildicn. 4.'!).
1 iial mint hy traiiieotoiiiy, 434.
iiil iilial ion. t.'ll.
N( iMiii- ajdioliia. 122.
».\ iiiptomat(dot;\ . 122.
I real mi lit, 422.
Neurosis of larynx. 421.
sensation. 421.
trealinent, 421.
.Venidses of motion. -12.1.
diaLriio-is, 424.
etiojoijy, 42.3.
|,r.,jr||,,si<. -pjl.
-pa«m of ^^loltis. 423.
-,v niptomato|ii;fy, 423.
Ileatlliellt. 42.">.
N'on nialipnant tumors of the larvnx,
4211.
i\~(omata. 4.'f(i
eneliondidinata. 4.30.
liliromatji. 42i>.
lipnm.ila, 430.
diafiiiosis. 431.
pro^'iiosis. 432.
sym|itomatiil(ipy, 430.
treatment. 4.32."
]iapill(iniata. 42!).
flperation> for nasal deforniities, 44!).
.•\nnaiidale"s 450.
Kllefs. 4.")0.
J{(
4:-)l.
I'acliydermia laryiij;is. 387.
diafrnosis. 38S.
did'usa. 3S7.
eliolojiy. 387.
]iaf li(il(i<;y, 387.
projriiosis. 388.
svniptomatolopv. 388.
treatment, .38!t."
M'rrueoiis. 387.
I'apillomala. 42!t.
Paralysis of the larynx, 420.
otiolopv. 427.
treatment. 428.
Plivsioloirv of the larvnx. 337.
■ attrilnites of the' 33S).
funetion of phonation, 338.
funetion of respiration, 337.
Senion"s theory, 337.
/
OENKUAL INnilX.
4ri
I'MiiidipnicinliriMniuH laryngitis, 31)1.
riiurniit, ."(iH.
tiiniiiiatic, :(JM.
KcniDvnl of forci^fii bodies from
ci'Sn|)|iiif,'lls, 148.
l.iryn\, 4 !.'>.
Kociitffcn's rays in iaryiifrcai siirfjcry.
447.
('Mioki'.i tiilics. 417.
siiayruph, 447.
Siiiiplr o'dcina of (he laryn.x. ;t7>">.
diaf.'nosis. :i7(!.
('(i(il(i;;y. '.U'l,
|iallio|(ij,'y, :i~'i,
liroynosiH. .'t7(;.
syiiititoiiialoloiry, ;!7,",.
trraiincnl. .■i7ti."
Sulijflolti,. cliionif laryiiifitis, ;1!»m.
.Sypliiiis of llii- larynx, 4iri.
diagnosis, 417."
otidlopy, 410.
patiiolopy, 41.').
prognosis, 418.
syniptoniatologv, 4)7.
Syphilid of III,' lai_\h\. in.ii im m. 418.
Syphililic l,irMi;.'ial stenosis. 4i!».
Syphilis, eon;.', nil a I. of the liirxrix.
4-J(i.
'rhyroloniy, .'1,'iH.
'Iiacl loiny. .•f."i(.
general niia'sihi -i;,. ii.-,.,.
high operation. '.Wu.
instriiMii'iit^ n«ed. .'I.M.
hieal aiia-thi'sia. ."I."!!;,
low opeiMlioii. ;i,")h.
'rniiereiilosis of the JMi V ,i\. .'lilS.
diau'iio^i.-., liin.
etiology, ."KtS.
patlMi|(i;.'y. Hits.
pro;,riiosi-. 1(»|.
•<.\ ni|itoinMto|o;;y. ;!<)!».
IrealiMenl. |nj."
loiiira • indiealion-i of i incKe-
ineiif. 40;t.
cliretteliient. 4l).{.
suinnneoiis iiiieetiini in treat,
iiient. in.!.'
lraelieo(<iMiv and larvngectoni v
4():!.
(reatnienl l,y electrolysis, 4(i.'{.
V'errneoiis paehydermia. ;{,S7.