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Dean o( the Metlituil Faculty of (jiiren'H l'nivfr»ity, KingNton, iiml Profeswirof IHacnHCs of the Kye, Ear, Nome and Throat. n ■^ * j^ firs. Gift of Or. N.A/Chldng» Faculty of Nedlclnea Queen's UniTerslty Queens University at Kingston rjR.1 Bracken Library Catalogued in Memory of Warren McDonald Willis beloved Nephew of Dr. Kenneth Axmith (meds '62) and Mrs. Dianne Axmith Queen's University at Kingston DISEASES or TM« EYE, EAR, NOSE AND THROAT 4 A MANUAL f OR UNDCWORADUATB8 J. CAMERON CONNCLL, M.A.. M.D. ^...O- O, OPHTH..-OCOO.. .TC. P^eUCT. O. -.-.C.-.. -U.--. U-.V..«.T» SURMON TO TM« KlN^TO- 0€l4«l.*t MO«mTAL r.ULOW or T«. A««Hie*M LAIIY-.001.001CAL. HHIMOUOOICAL AMD OTOCOWCAt. SOCIITT KINGSTON I902 TMB JACKSON WmM»% PREFACE. This book is published to relieve my students of the labor of taking notes and to save time for practical work. It embodies the theoretical part of lectures delivered annually to undergraduates of the Medical Faculty of Queen's University. The text is to be studied in connection with attendance on clinics, demonstrations, and operations in the Ge ^1 Hospital. J. C. C. Kingston, Nov., 1902. CONTENTS. DISEASES OF THE EYE. CHAPTER I. PAGE Diseases of the Conjunctiva 1-21 CHAPTER II. Diseases of the Eyeliils . 22-3^ CHAPTER III. Diseases of the Lacrj'mal System 35-38 CHAPTKR IV. Diseases of the Cornea . 39-57 CHAPTER V. Diseases of the Liens 58-01 CHAPTER VI. Diseases of the Sflerotie 62 CHAPTER VII. Diseases of the Iris and Ciliarj- Hotly . 03-70 CHAPTKR VIII. Sympathetic Ophthalmia . 71-73 CHAPTER IX. Diseases of the Choroid . 74-75 CHAPTER X. Diseases of the Vitreous . 70-77 CHAPTER XT. (ilaucoma . 78-83 CHAPTER XII. Diseases of the Retina 84-88 CHAPTER XIII. Diseases of the Optie Xerve . . 80-92 CHAPTER XIV. Fnnotional Diseases of the Retina . 93-95 CHAPTER XV. Diseasc^s of the Orbit 96-98 CHAPTER XVI. Disorders of the Ocular Movements . . 99-1 00 CHAPTKR XVII. Abnormal Refraction and Accommmlation , 107 110 VI roXTENTS. OPERATIONS ON THE EYE. CHAPTER I. Operations on the Eyeball CHAPTER II. Operations on the Eyelids PAOB .. 111-129 .. 130-189 DISEASES OF THE EAR. CHAPTER I. The Clinical Examination CHAPTER II. Diseases of the Auricle CHAPTER III. Diseases of the External Meatus CHAPTER IV. Diseases of the Membrana Tynn)ani CHAPTER V. Diseases of the Eustachian Tube . . CHAPTER VI. Otitis Media CHAPTER VII. Diseases of the Perceptive Mechanism .. 140-155 .. 156-1F8 .. 159-173 .. 174-178 .. 179-184 .. 185-221 .. 222-232 DISEASES OF THE NOSE AND THROAT. CHAPTER I. Clinical Examination of the Nose 283-240 CHAPTER II. Functions of the Nose and Subjective Symptoms of Disease 241-250 CHAPTER III. Taking Cold 251-255 CHAPTER IV. General Etiology and Pathology of Diseases of the Nose .. 2.56-258 CONTENTS. CHAPTER V. CHAPTER VI. CHAPTER VII. CHAPTER VIII. CHAPTER IX. CHAPTER X. Acute Rhinitis Hay Fever Chronic Rhinitis Epistaxis . . Foreign Bodies . . Nasal Polypi CHAPTER XI. Diseases of the Accessory Sinuses . . CHAPTER XII. Affection of the Nasal Septum CHAPTER XIII. Anosmia and Parosmia CHAPTER XIV. Nasopharyngitis and Adenoid Vegetations CHAPTER XV. Pharyngitis CHAPTER XVI. Uvulitis and Tonsillitis CHAPTER XVII. Laryngitis CHAPTER XVIII. Haemorrhage, Oedema, Foreign Bodies .. CHAPTER XIX. Tuberculosis of the Larynx CHAPTER XX. Laryngeal Tumors and Neuroses . . CHAPTER XXL Idiopathic Croup CHAPTER XXII. Diphtheria CHAPTER XXIII. Laryngismus Stridulus Vll PAGE .. 359-264 .. 365 368 .. 269-381 .. 883-385 .. 286-288 .. 289-391 .. 293-300 .. 301-303 .. 304-306 : 306-312 .. 313-320 .. 821-828 .. 329-333 .. 333-336 .. 337 340 .. 341-344 .. 345-348 .. 349-360 .. 361-363 DISEASES OF THE EYE. CHAPTER L DISEASES OF THE CONJUrCTlVA. These form about thirty per cent, of all the af- fections of the eye falling under the care of the surgeon. The conjunctiva being a mucus membrane, is subject to the changes to which mucus t-'ssues in general are liable, as well as to some which are peculiar to itself. Through the nasal duct, it may participate by continuity in the inflammatory proces- ses of the nose. It is also implicated, to a greater or less extent, in the inHammations of th«. anterior part of the eyeball, — keratitis, iritis, and cyclitis. It seldom takes part in the affections of the choroid and retina. The only contagious diseases of the eye are some of those affecting the conjunctiva. The most noticable feature in a conjunctiva in a state of inflam- mation ir- a change in the vasculari/^ation. In health the transparency of the membrane is but little affect- ed by the number or size of the vessels, the white 8 DISEASES OF THE EYE. sclera being clearly seen through it. In hyperaemia or congestion the vessels are greatly multiplied, me veins are moi-e tortuous and increased in diameter, and the sclera may be entirely obscured, the white of the eye being of a "bloodshit" appearance. In this conjunctival congestion the vessels are freely movable over the globe, and in this way are to be distinguish- ed from the deeper ciliary congestion, the so-called *'circum-corneal" injection, in which the vessels are fine and straight. In the second stage of the inflam- matory process there is an abnormal amount of secretion. In health the conjunctival glands secrete only enough mucus for the lubrication of the parts and the maintenance of the proper softness and plia- bility of the tissues. In hyperaemia there is often a deficiency of secretion giving rise to a feeling of dry- ness and stiffness in the eyelids. In the acute form of hyperaemia the discharge is almost wholl' watery, due to increased secretion of tears. When the second stage of inflammation sets in, there is a hyperactivity of the glands and the quantity of mucus secreted is greater than normal. When there is no condition leading to pus formation, this secretion is mucus, or catarrhal. When there is formation of pus, the pus cells are found mixed with the mucus, and the discharge is muco-purulent and of a yellow- ish color. In the severer cases pus predominates or constitutes the whole of the secretion. In an uncom- plicated case of conjunctivitis there is little actual pain, because the tissues being lax, there is but slight pressure on the nerve filaments from the in- flammatory exudation. The feeling is more one of annoyance and discomfort, heaviness and heat. HYPKItAKMlA OF THE CONJrNCTIVA. 8 HyI'KRAKMIA Oh' THK CONJUNCTIVA. — This is either active or passive. In the active form it may be the initial stage of a catarrhal or a purulent con- junctivitis. In it the arterial circulation is increased^ as is shown by the large number of small straight vessels running to the cornea. The eye has a suf- fused look, due to more or less increased secretion of tears. In this passive form there is a retarded and sluggish venous return. The veins are incieased in size, are more tortuous, and often stand out promi- nently on the conjunctival surface. It is one of the most common of eye affections, and while net serious, is very annoying and uncomfortable and often renders any regular use of the eyes impossible. There is a sensation of heat, burning, and itching in the eyes, a heaviness of the fids, with a tendency to keep theni closed, especially in artificial light. There may be a feeling of dryness and stiffness in the lids, experienced specially on awaking .^t night. A feeling of sand or grit in the eye is caused by the protrusion of the swollen veins above the level of the conjun- ctival surface, acting as a foreign body. Causes. — The strain of ametropia-, or wearing im- proper glasses, and local irritantS: such as dust, foreign bodies, tobacco smoke, cold winds, are causes. The abuse of alcohol is a common cause. It is often associated with nasal catarrh, lacrymal obstruction, blepharitis, and hay fever. Treatment. — The first step is to remove the cause as far as that can be determined. The ame- tropia is to be corrected. When the sunlight is complained of, smoked glasses may be worn for protection, and a shade may be t'sed to soften * Ji/SKASES OP THE EYE. an artificial light. The nasal mucus membrane must be attended to. Direct medication of the conjunctiva consists in the application of some mild astrmgent. Boracic acid, ten g rain.s to the ounce, can be freely used in the eye three or" four th^^^ day. Biborate of soda,, ten ^rrains to the ounce, will suit many, an alkaline solution being to them more grateful than an acid one. Chlorate of potash may be used in the same way. When a stronger astrin- gent IS needed, the acetate of xinc, one or t wo grains -i2i!ll.£iL2££' ^Mhe sulphate^ol xm c, or sulpH^tTd _co££er IS useful. Equal parts of thi^uITrof opium and water is a good stimulating collvrium. Where the lids are dry. the silver preparations should not be used. Sometimes it is advisable to make a profound impression on the vascular walls, and this is best done with the solid sulphate of copper crysta l. The alum stick is much milder. That which^ives the greatest immediate comfort is the spraying of the lids with cold water, or water and alcohol or cologne, or the simple douching by the hands with water alo'ne. The opening of the eyes under water is not so effi- cient, a..d ma> cause swelling of the epithelium. Catarrhal or Mi copirllkxt Conji .nxtivitis. —This is characterized by congestion of the con- junctiva, some photophobia and blepharospasm, and increased secretion, either mucus or mucopurulent. It IS the condition frequently called "pink eye." The fact that it is epidemic and that it is contagious by the secretion renders the existence of a specific germ certain. This is known as the Weeks' bacillus. CATAIIRHAL CONJVNCTIVITIN. 5 The germ is often found in the healthy lacrymal sac, and becomes virulent only under some change in local conditions. The conditions of hyperaemia and congestion probably furnish a field for the acti- vity of the germ. All the organisms found in pus are, however, not obnoxious to the conjunctiva for the pus from an orbital abscess, from a stye, or from an acute dacryocystitis, does not produce a conjunct- ivitis. Symploms. — In the preliminary stage of hyperae- mia there are the symptoms already described. These may last a few hours or a few days. Then the sec- retion from having been watery becomes mucus, or mucopurulent in character. This will gather as a slightly frothy material at the angles, or when it dries, glue the edges of the lids together. There is a slight swelling ot the lids and a sense of heaviness and discomfort, though not usually any definite pain. There is some photophobia. In the severer cases the conjunctiva is deeply congested and velvety in appearance, and there is chemosis. Vision is im- paired partly from the adhesion of some ot the discharge to the cornea, and partly from the mace- ration of the epithelium of the cornea which takes place only in the severer cases. All ages are liable to it. The course varies from one to two weeks, but complete recovery takes place. Usually both eyes are affected. If neglected it may become very troublesome as in families and institutions it readily becomes epidemic. Z'mj/wt'w/.— Nothing should be applied to the eyes which will prevent the speedy exit of the sec- retion, as the retention of the secretion reacts upon • niSKASES OF THE EYE. the membrane. The eyes should be cleaned fre- quently, from every hour to three times a day, accordinjj to the amount of the secretion. The best solution is that of Iwracic acid, and it may be applied by a mop of absorbent cotton, the eye dropper, or the douche. Cloths wrunjj out of cold water, or saturated with lead water and laudanum, may be laid upon the eyelids for their cooling; and soothinjj pro- perties. For some, the hot applications are better borne. To prevent j,nimming, the lids are to be anointed with vaseline at bed time. When the secreting stage sets in, the use of astringents may be commenced. In addition to those already mentioned, formalin, one to two thousand, every four hours may be used. If there is a decided admixture of jpus. J|>itrateof silver, two to ifive grains to the ounce is to be preferred. If the cornea is nr plicated, atropine is to be used. As the discharge is more or less infectious, care must be taken with the towels, handkerchiefs, and other articles used about the patient's eyes. Smoked glasses n-iy be worn for protection. No poultices or tea-lea^ applications are to be permitted. The latter may produce a conjunctivitis. It may be necessary to give a laxative, and to follow this with a tonic, such as quinine. PuRULKXT CoNjixcTiviTis.— A large percentage of the blindness in the world is due to this disease. From one-third to one-half of the cases is the esti- mate given. It is essentially an infectious disease most frequently produced by the diplococcus of gon- orrhoea. Other micro-organisms may give rise to it. rVK ( LENT COXJUNCTIVIT/S. » The staphylococcus pyojjenes aureus and albus and the streptococcus pyogenes, and the pneumococcus ar'^ causes. In cases of gonorrhoea, infection of the eye may be brought about in a variety of ways, but generally it is by the patient's own hands. After manipulation of the genitalia with the hands, they are used to rub the eye or the face about it, and so the micro-organism finds its way to the conjunctiva. It may just as easily be carried by the handkerchiei, towel or dressings. For this reason physicians, nurses, and attendants should ex- ercise the utmost care in handling eyes in this con- dition, and the patients should be isolated from the other patients in ihe ward. A catarrhal conjunctiv- itis may be aggravated till quite a quantity of pus is discharged, but this is not infective, at least nor to the same degree, nor is it so dangerous to the eye. Only a microscopic examination of the discharge will establish the differential diagnosis. Symptoms. — These first appear in from twelve to forty-eight hours after inoculation, the period of incu- bation varying with the intensity of the poison. The lids become red and swollen and the integument smooth and hard and glistening. There is an abundant discharge of thin fluid, which may contain some flocculent material, and may be reddish in color from the presence of some blood-corpuscles. The eye feels hot and there is some local and general elevation of temperature. If the lids can be separ- ated, the conjunctiva will be seen to be infiltrated with serum, its vascularity increased, and there may be some haemorrhage. This soon gives wg- to the second stage, in which there is a free purulent dis- » ntSKASKS OF THE K) K charge. The pus is thick and creamy, is rapidly formed and constantly oo/es from the palpebral fis'- sure. The hardness of the lids is not so ^reat, but the swellinj^ of the conjunctiva is not diminished. It comes up around the base of the cornea (chemosis) and overlaps its ed^'e, causing' it to appear sunken below the surface of the swollen conjunctiva. The swellinjr of the upper lid is sometimes so ^^reat that it han«:s down like a bag over the lower one, and it IS then impossible to expose any part of the cornea. The «:reat danger is from involvement of the cornea which may come about in one of two wavs, either by direct inoculation of the cornea with the' gonococcus when the epithelial layer becomes macerated anil des- troyed from constant contact with the pus, or the oedema around the base of the cornea mav cause a strangulation of the nutrient vessels and produce a sphacelation of the cornea as a whole. The epithe- lium first becomes steamy and then the corneal tissue seems to melt away. The entire anterior layers are destroyed, leaving the more resistant posterior layer, or Dcsccmet's membrane. The latter may also hi destroyed, allowing the lens to lie expelled, and there may be a panophthalmitis. The substance of the conjunctiva itself is not destroyed or even ulcerated. If left to itself, the inflammation runs its course in from three to six weeks, generally ending in some thickening of the membrane. 7>m/w^«A --Prophylaxis is of the utmost import- ance. The patient should be isolated to some extent at least. When one eye is aflected. the other should be protected by a bandage hermetically sealed, or by some device such as Buller's shield. If there is a pcnvLF.NT voyjvNf'TrriTis. suspicion that some infective material has gotten into an eye it should at once be washed out with an anti- septic fluid, and a few drops of a solution of nitrate of silver, two to ten jjrains to the ounce, instilled. An attempt at aborting an attack in the first stage will be a f lilure and may do harm. Some blood may be drawn from the temple in the case of full blooded patients, but the applications of caustics and scarifi- cation of the membrane will do no goixl. When the stage of secretion has s et in, nitrate of silver is tlmost specific in its action . It destroys the epithc- lal layer of the mucus membrane and with it the germs that are present. The strength of the solution is t o be varied according to the amount of the secre- tion, an d may range from two ^6 forty grai ns to the ounce. When the strong solutions are used they must be followed by salt solution or by ice cold com- presses to diminish the amount of the reaction. In place of nitrate of silver, protargol is coming into use but is not so certain in its action. It must be used in ten times the strength of the silver solu •>n to pro- duce the same effect. Next in importance to the silver application is the proper cleansing ot the eye. The cleansing is done with a saturated boracic acid solution, sublimate solution i to 5,000, or formalin solution I to 2,000. When the lids are greatly swol- len, this is not easily done. The solution may be squeezed from a pledget of cotton or introduced from a dropper, or douche, or Andrews' irrigator may be used. Great care must be taken not to injure the cornea by the manipulation. Cold applications may be used in the first stage with benefit, and some pre- fer to use them throughout the attack. The second 10 DLSflASES OF THE KYK. Stage is, however, better controlled by periodical ap- plications of heat. Hot borated compresses are generally used, but it is best made by immersing the eye in a cup or tumbler filled to the "brim with water as hot as can be borne. The cup is held in the hand and the head bent forward so as to bring the eve and surrounding parts into the water gradually. This is cleanly and convenient. The bath shguld be con- tinued for a few minutes, and repeated every one, two, three, or four hours according to the severity of the symptoms. When the pressure on the cornea becomes dangerous, we may lighten it and at the same time secure the benefit of a bloodletting, by a division of the outer canthus, termed canthotomy. or cantholysis. The incision may be made with a heavy pair of scissors, and should extend through the orbi- cularis muscle. Vaseline is usually put into the eye freely after each dressing. Atropine or eserine may be used when the cornea is threatened. Ophthalmia Nkoxatorim.— A separate con- sideration is necessary for the ophthalmia of the new- born infant. The cause is the introduction into the eye of some infective material from some portion of the genito-urinary tract at the time of, or shortly after birth. The infection usually takes place while the head is in the parturient canal, and is more likely to occur in face presentations. The idea that any severe conjunctivitis can be caused by exposure to bright light, catching cold, or washing with strong soap, cannot now be entertained. Of course every case of ophthalmia neonatorum is not gonorrhital, but the OPHTHALMIA NEON A TOR UM. 11 case should be regarded as such till proved by the microscope to be otherwise. Any discharge from the vagina of the mother may set up a purulent inflam- mation. Symptoms. — It usually begins on the third day, though it may set in as early as twelve hours after birth, or may be delayed for a week or more. The longer after birth the disease commences the less severe is the attack likely to be. There is first a slight redness of the conjunctiva with a trifling dis- charge, succeeded by great cushion-like swelling of the lids, intense chemosisand congestion, severe pain and free discharge. The symptoms increase with great rapidity till there is an almost continuous stream of pus. The surface of the swollen lid is hot, dusky red, and tense, and the upper lid overhangs the lower and can only with difficulty be raised. The risk to the cornea is very great. Treatment. — Prophylaxis is of the greatest im- portance and is very satisfactory in its results. Cau- tious vaginal antisepsis may be secured during labor, but more important than this is Crede's plan of pre- vention, which consists in the use of a few drops o f a two grain solu tion_of mtrate of_ silver immediately after birth. The value of this was first demonstrated by Prof. Crede at Leipsic in 1882. Previous to this the percentage of cases of ophthalmia was as high as 19. In the same lying-in hospitals it had dropped to 0.24 in 1890. Crede recommends that as soon as the head has passed the vulva, the face of the child should be wiped clean, the eyelids opened with the fingers, and a few drops of the solution let fall into the eye from a glass rod. More recently it has been 12 DISEASES OF THE EYE. considered advisable to use a stronger solution, as much as a ten grain solution being preferred by many. For the active treatment of a case the same principles hold as have been detailed for the ordinary purulent conjunctivitis. Cold applications and blood- letting are not suitable for infants. Otherwise the treatment will be the same. Mkmbkaxois CoNjrxcTiviTis. — In this there is the formation of a distinct membrane in which the bacillus of diphtheria is often present. Some des- cribe a croupous form due to some other organism than that of diphtheria. I n either case the symptoms are much the same as in a severe purulent conjuncti- vitis, and the treatment locally is the same. Anti- toxin should be used. Phlvctkmlar CoNjiNXTivrris.— This is also termed Herpes Conjunctivae, Scrofulus, Lymphatic, or Strumous Conjunctivitis. It is not infectious, but the condition of the general system and the state of nutrition are important factors. In a simple typical case there is a little red eminence, of about the size of a millet seed, which develops at some point on the limbus of the cornea. In the beginning it is conical, its apex being covered by the epithelium of the con- junctiva. In a short time the epithelium at the apex of the elevation, or efflorescence, as it is often called, separates, and the tissue that lay beneath it breaks down, so that the cone bears on its top a small gray ulcer which lies above the level of the neighboring PHL YCTENVLAR CONJUXCTIYTTIS. 18 healthy conjunctiva. As the breaking down con- tinues the ulcer sinks to the level of the conjunctiva, then becomes clean and gradually is covered with epithelium. No visible mark is left on the conjunc- tiva. The process is ordinarily completed in eight to fourteen days. While this is going on the adjacent part of the conjunctiva is hyperaemic, the injected vessels being directed from all sides toward the noduie. The remainder of the conjunctiva is perfectly free from congestion. There are many modifications of this simple type, so that cases differ widely from each other. These modifications con- cern — (i). The number of the efflorescences or phly- ctens. It is rare to find but one of these ; generally there are several, and often a good many present at the same time. Then the conjunctiva appears red- dened all over so that the focal nature of the disease is obscured. (2). The site of the phlyctens. They may not be limited to the limbus, but either extc- i^ to it, on the bulbar conjunctiva, or interior to it on the cornea itself. In the latter case the condition is properly termed phlyctenular keratitis. There is usually an abundant lacrymation, but no mucus or muco-purulent secretion. The sub- jective symptoms are photophobia and blepharos- pasm. The intensity of these symptoms bears no relation to the severity of the disease. Children seek the darkest corner of the room, and bury the whole face in a pillow, the least ray of light seeming to cause them agony. These symptoms are worse in the morning than in the afternoon and evening. 14 nrSHASHS OF THE EYE. The appetite is always poor, and very frequently de- praved, there bein^r a craving for indigestible and unwholesome food. The constant wetting of the lids by the tears may lead to blepharitis, to eczema of the skin covering the lids, and in time to ectropion of the lower lid. Treat n en t.—'\\\Q local treatment consists in the application of antiseptic irritants, of which calomel and_Pagenstecher's ointmenr of the yellow oxide of JHercurv, are most in use" The calomel in a fine powder is dusted lightly over the affected area ; the ointment, one to five grains to the ounce, is put inio the conjunctival sac, and is then rubbed about with the lids so as to distribute it over the whole conjun- ctiva. These are to be employed only once a day. They arc contraindicated in recent infiltrates and progressive ulcers ot the cornea. Boracic acid solu- tion may be used freely by the patient himself. Much irritation calls for the use of atropine and cocaine. Bad cases should be cauterized with the ?-tual or the galvano cautery, or with carbolic acid. The general treatment is of great importance. The chikl should never be kept in a dark room. *bIu ^sho u[d_be out in the open air as much as possiTTe. ir spite of any photophobia that may exist. Attention to the diet, to batlimg. and to^^xxT^e is of great importance. The medicinal treatment consists in the use of cod-liver oil, and preparations of iron, arsenic, iodine and quinine. Grami.ar Conjunctivitis. forms of this. The re are two aiiANl'LAIl i'OXJVyvTIVITlS. 15 ( I ). Simple granular or follicular conjunctivitis. (2). Trachoma. In follicular conjunctivitis the surface of the pal- pebral conjunctiva is covered with granules, varying in si/e from a rape seed to the point of a pin, evenly distributed, and usually in rows parallel to the edge of the lid. They are reddish or yellowish in color, and the conjunctiva beneath may be thickened, but is soft and pliable. They are sometimes the result of long-continued, though it may be low and mild, inflammation or simple (.ongestion of the parts. In its simplest form it may be a manifestation of adenoid activity. The symptoms are those of chronic con- gestion. There is a feeling of discomfort about the eyes, especially by artificial light, and the secretion may gum the lids together in the morning. The main part of the treatment is to use the various irri- tant astringents. Sulphate of copper in crystal is the best. Acetate of zinc, one grain to the ounce, is useful. If there is much secretion then the nitrate of silver may be used. The nasal mucus membrane should be examined and any fault found there cor- rected. If there is ametropia, properly fitted glasses must be worn. Trachoma is a much more serious and important condition. It is the most important of the diseases of the conjunctiva, on account of its wide-spread dif- fusion, its chronic course, and serious results. No micro-organism has yet been discovered which is generally accepted as peculiar to it, but the clinical picture, especially in advanced cases is clear and un- mistakable. There is a morbid deposit or change in the tissue which in time causes a destruction of the IS I)ISEASi:s (}F THE RYE. parts surrounding it. The trachoma granule is best seen in the early stages, before the inflammatory changes have set in. It appears as a small, round, greyish elevation, embedded in, but rising above the level of the conjunctiva. These are confined to the palpebral conjunctiva, particularly that of the up- per lid, and to the retro-tarsal fdds. They are usually in irregular masses, not unlike frog-spawn, or grains of sago. Sy III pioms. —The symptoms are those of conjunct- ivitis. The lids are often thickened, and there is a partial ptosis. When the lid is everted, the inside is seen to be roughened or granulated. In the stage of cicatrization the inside of the upper lid assumes a hard, gristly appearance, and there are bands of cicatrization running lengthways. The subjective symptoms are the usual discomfort and inability to use the eyes, especially by artificial light, and the sensations of burning and itching, and heaviness of the lids. Sometimes the disease is far advanced before the subjective symptoms appear. When the cornea becomes involved, there are lachrymation, photophobia and pain of a neuralgic character. The keratitis is a mechanical one, due to constant friction of the rough conjunctiva over the surface of the cornea. This form of keratitis is termed pannus. A serious complication or result of trachoma is the incurving of the tarsus of the upper lid, caused by the contraction of the citatrix. This is known as entropion, and will be discussed under diseases of the lids. One characteristic of the disease is its ten- dency to remissions and exacerbations, and it may continue with periodical attacks from childhood to OEANVLAR CONJVNCTIVITIS. Vt old a^e. It is held by most authorities that the dis- ease is contagious, but there is some difference of opinion on the subject. It has been called a disease of filth, poverty, and overcrowding, and without doubt these conditions hasten its development in those predisposed to it. The predisposition is not confined to individuals, but includes races. The Jews, Irish, and Orientals generally are subject to it, while the negroes of America are exempt. Treatment. — This is medicinal and surgical. The medicinal treatment is limited to the application to the diseased surface of some kind of astrigent or caustic substance which will temporarily increase the hyperaemia of the part and in this way hasten the absorption of the morbid material. Almost every known astringent has been recommended and used at some time as a local application in trachoma, and no doubt all with a show of some success. In th e ordi- nary chronic form the crystal of sulphate of coppe r is the safest and most satisfactory application that can be made. The effect is easily regulated. It can be made light or severe, according as it is applied lightly or heavily and repeatedly. It may be repeat- ed every day, every other day, or once or twice a week. Nitrate of silver may be used if there is much secretion. Boroglyceride antTthe glycerole of tannin are useful in the later stages of the condition. The surgical treatment aims at the removal of the granu- lations in some way. Excision has been practised for a long time, but it removes the normal tissues as well and causes too much retraction of the conjunc- tiva. Expression or squeezing is the treatment in vogue at present. It removes the morbid tissue with 18 nrsHASKs OF the eye. less injury to the normal structures than the ethers, but it is not suitable when there is much thickeninjj of the conjunctiva. It may be combined with scarifi- cation, and requires a special forceps such as that of Knapp or Noyes. For the pannus it is advised to excise a narrow band from around the base of the cornea, this operation bein^^ termed peritomy. A re- medy which is used for the pannus is jequirity, the abnis precatorius, in powder or watery extract. This has the power of exciting^ a violent purulent in- flammation, which as it subsides leaves the pannus either much thinner or completely absent. Inocula- tion with gonorrhoeal matter was also practised for the same end in Belgium some years ago. The general condition of the patient and the hygienic sur- roundings must be attended to. Xkrosis ok thk CoNjixcTiVA.— This is also called Xerophthalmia. It consists of a dry, shrunk- en, and lustreless condition of the conjunctiva and cornea. In all pronounced cases the lacrymal flow- is entirely stopped. The conjunctiva is more or less anaesthetic, and becomes so shruijken that it looks like skin. The disease is one of malnutrition, and the worst cases are seen in marasmic infants. Local- ly, antiseptic emollients are to be used, and generally attention given to the nutrition. PiNGL'icuLA.— This is a small round, yellowish elevation often seen on the nasal side of the conjunc- tiva over the insertion of the rectus internus near the cornea. It is most common in mature persons and PINdVIVVLA. IB in those exposed to influences irritating to the con- junctiva. It does not >jive rise to any trouble, but it may be advisable to remove it when it produces the sensation of a foreign body. PrKRYiiiiM. — This is a peculiar fleshy growth of hypertrophied conjunctiva and subconjunctival tissue, its apex resting on the cornea, its base spreading out over the conjunctiva. It is usually at the nasal side of the cornea, but is sometimes found on the temporal side and rarely on both. The apex may lie on the corneal surface anywhere from the sclero-corneal margin to the centre, beyond which it does not pass. Its growth is usually slow, taking years to reach its maximum size. They are not painful, but they render the eye liable to attacks of conjunctivitis, and they only interfere with vision when the apex comes in front of the pupil. They may possibly produce astigmatism by dragging on the cornea. Removal is the only treatment, and this is to be done by excision. Injlriks to the Conjunctiva.— One of the most common is burns from chemicals or explosives. The most frequent and dangerous of these is from lime. If unslaked, it rapidly absorbs .the water of the tissues and gives out an immense amount of heat, leading to a rapid destruction of the part. The cornea may be involved as well. As both the bulbar and palpebral conjunctiva are affected, there is great danger of union of the two opposing surfaces as they are healing, causing a symblepharon. In u -m- 30 niSHASKS OF rtfK FYK. mediate treatment of a burn from lime it is best to avoid all watery solutions. An oil or fat of some kind, or milk arrests the action of the lime. Usually, however, all the lime has been oxidized by the flow of tears lonj; before the patient js seen by the doctor. Still the oil treatment is the best that can be followed, as it affords jjocd protection to the burned surfaces. Castor oil, on account of its viscidity, makes the best dressing. Cocaine or atropine may be mixed with it. Acids may get into the eye and cause burns of the conjunctiva of greater or less severity according to the strength of the solution. The mineral acids, nitric, sulphuric, and hydrochloric, are the most dangerous. The eye should be washed out with water, or a mild alkaline solution. Burns from car- bolic acid, even when the acid is pure, are not very serious, as only the epithelium is afifected. Hot water, hot ashes, molten metal, and simlar things, sometimes find their way into the eye. The injury is to be treated on general principles. Incised or lacerated wounds do not require much interference. It may be necessary to bring the edges together with fine sutures. FoRKiGN BoniKs in the conjunctiva are very common. Bits of coal cinders, large particles of dust, etc., may find lodgement on the conjunctiva, especially under the lids. In all cases of rather sud- den pain and irritation of the eye, careful exami- nation should be made for a foreign body. This c-'n generally be wiped ofi" with a bit of cotton. Only occasionally it is embedded so deeply as to require digging out with a needle or !,pud. /■'OJtKIOX lUUiJKS. tl Conjunctivitis from strong light is distinguished by swcHing of the lids, hyperaemia of the conjunctiva, and lacrymation, and is attended by a goo I deal of pain. Snow-blindness is of the same nature so lar as the conjunctiva is concerned. In addition to the exhaustion of the retina there is a sunburn of the conjunctiva from the reflected heat of the sun, show- ing as a hyperaemia These are to be treated the same as any other case of hyperaemia. CHAPTER II. diskames of the eyklidh. There are a number of afTeclions of the skin of the eyelids but they do not call for special consider- atjon. These are Krythema, Eczema. Krvsipelas, Herpes Zoster Ophthalmicus. Rhus Poisoning. Chromidrosis, Xanthelasma or Xanthoma, Milium, Malignant Pustule, Cangrenc. Phlebitis, Lupus, Chancre, Kpithelioma or Rodent Ulcer, Vaccinal Eruption, Warts, Horny Growths, Angioma, and several others. m hccusMosis is frequently seen. I'he common cause IS a direct contusion, as in the case of "black eye" from a blow of the fist. Spontaneous ecchym- osis IS often seen, and occurs from weakening of the vessels from old age or other causes, or may l>e in- duced by violent coughing or straining. It is one of the well-known symptoms in scurvy. Emphysema of the lids is produced bv a communi- cation between the subcutaneous tissue and one of neighboring air-cavities, the lacrymal, nasal, frontal, or maxillary. In any case air is forced into the tissues by the expiratory effort in blowing the nose. The avoidance of this is the only treatment. OKPKMA. M Oi:»KM.\ of the lids is a symptom and not a pri- mary condition, but it is so frequent and so conspicu- ous that it may well be considered in detail. It may be either Inf-^n.matory or non-inflammatory. As lon«: as oedema is on the increase, the skin of the lid is tense and smooth ; but as soon as it bcj^nns to de- crease, there are minute wrinkles in the skin of the lid. Oedema often causes more alarm than the lesion which lies at the bottom of it, because the patient cannot open the eye, and so cannot see with it. In every case the lids should be opened, usIh^' Desmar- re's lid elevators if necessary to inspect the eyeball. The affections producing oedema may be classified as follows: (I). Oedema as a superficial condition. 1. Hordeolum. In this there is one spot in the lid of greater induration and painfulness. 2. Dacryocystitis. In this there is tenderness over the inner angle and pus is evacuated from the puncta by pressure, and there is epiphora. 3. Krysipelas. In this the redness and swel- ling are uniform. 4. Furuncle, malignant pustule, and abscess of the lid. There is a circumscribed, in- durated and painful nodule in the skin. 5. Periostitis. The margin of the orbit is thickened, enlarged and tender. 6. Traumatism. This is accompanied by haeniorrhagic effusion into the lid. 7. A non-inflammatory oedema is met with as one of the signs of general oedema, as in heart disease, hydraen.ia, and nephritis. '-'•* l>fS'F.ASES ()J- Tin: F.YK. Sometimes the lid oedema is the first sijrn of the disease. In such cases the oedema of the iai appears under the ^uise of flvin^ oedema (oedema fu^fax) i.e.. it comes sud- denly and disappears a^^ain in a few hours or a few days, only to return after a short time. (2). Oedema due to deeper affections. 1. Conjunctivitis. The purulent, muco-puru- lent. and diphtheritic forms mav produce an oedema. 2. Inflammations of the interior of the eye- ball. Irido-cyclitis. acute -glaucoma, and pan-ophtiialmitis may cause it. 3. Tenonitis, phlegmon of the orbit, and tiirombosis of the cavernous sinus. In these the eyeball itself is normal, but there >s protrusion, immobil.tv and chemosis. In thrombosis there is also oedema behind tlie ear and serious cerebral complications 4. Tumor of the orbit. This is non-inflam- matory. HoRD,.:o..i M OR SrvK.-This is a small furuncle on the mar^^in of the lid and consists of a localized mflammat.on of the connective tissue, or of the gland usually going on to suppuration. It tends to be- come multiple or to recur. A series mav be kept up for months. Certain occupations, driving in the cold working in dust, and the strain of ametropia, predispose to this trouble. Frequent attacks indicate some derangement of health and are often associated with constipation and menstrual disorders. IIOIiTiFJUAM. 25 Treatmen' — Hot fomentations hasten the process of suppi ;iii;iii and rupture. When the swelling points it slu^'jld be piMictured to evacuate the pus. An ointi KMit of mere ry will assist the suppurative process, anu is cil„i' useful in preventinlia, termed madarosis. 3. The lashes become stunted, curled, and mis- placed. Some of them lake a false direction and come in contact with the cornea, and this is termed tricliiasis. 4. The lower lid may become everted. This is ectropion. There is at the same time a displacement of the punctum which produces epiphora. Treatment. — It is of the first importance to remove all sources of irritation. Krrors of refraction should be I orrected, as the proper glasses not only relieve the strain but serve for protection against wind and dust. Close work should be restricted and early hours enjoined. In the local treatment ointments are most useful. The basis of the ointment may be vaseline or cold cream (unguentum aq. rosae, — almond oil, 50 parts, white wax and spermaceti, of each ten parts, rose water, thirty parts). For the additional ingredient, one of the mercurial precipi- tates is usually selected, the white, yellow, or red, from one to five grains to the ounce. The patient applies the ointment by rubbing into the edge of the eyelid at bedtime. All scales and crusts must be removed before this application is made, and to do this without injury to the lid it is often necessary to use an alkaline solution, the best being bicarbonate 38 niSHASKS OF THE EYE. of soda, five {,'rains to the ounce, in warm water. In the ulcerative form, the small abscesses should be opened every day, and the cilia removed, the ulcer- ating surface bein^j touched with nitrate of silver. I^tnas recommends the iodide of mercury in olive oil, two to one thousand. Tkii iiiAsis wn His iKiiiAsis.- Trichiasis is an affection in which the eyelashes are misplaced and turn inward aj^ainst the eyeball so as to be a source ot irritation instead of a protection. In distichiasis there are two distinct rows of cilia, the posterior row bein^ a new growth, and turning in to touch the eye- ball. Some authors deny the existence of distichiasis except as a congenital condition. It is very doubtful if a new growth of cilia can be produced by any dis- ease, though cases are seen where there is an exces- sive growth. The essential in either condition is contact with the eyeball. This produces photopho- bia, lacrymation, and a constant sense of something in the eye. The cornea may suffer great injury. Superficial opacities are developed by a callous thickening of the epithelial layer, and small ulcers of the cornea are also formed. Trachoma is the most common cause, but it also comes from blepharitis, hordeolum, burns, and operations on the border of the lids. Treatment. — If not numerous the lashes may be pulled out, and this repeated as often as they grow. The hair follicle may be destroyed by electrolysis, but this is only suitable where a few large hairs are at fault. If the whole border of the lid is affected ^ 1 KNTnOPlOX. S9 seme operation must be done to change the direction of the whole lid margin. Entroimox. — This is an inversion of the lid. The distinction between entropion and trichiasis is one of degree. In entropion the edge of the lid is rolled in so that it cannot be seen at all from in front. The result is the same in each case. Two forms of entropion are seen, ( i ) spastic entropion, and (2) cicatricial entropion. The spastic form is that which is produced by contraction of the orbicularis. Two conditions are necessary for its development ; defective support of the free border of the lid, and an abundant amount of extensible skin upon the lid. Hence it develops when the eyeball is absent, when it is diminished in size, and when it is situated deeply in the orbit. So it is most frequently seen in old people with flabby lids, and it is favored by blepharospasm, or by the wearing of a bandage. It is sometimes an unpleasant complication during the after treatment of cataract operations. It is almost without exception seen affecting the lower ltd. The cicatricial form is caused by contraction of the conjunctiva drawing the free border of the lid inward. Trachoma is the common cause, but it may follow a diphtheritic conjunctivitis, or a burn. Treatment. — The spastic form may be managed without an operation. If caused by a bandage and we are compelled to continue its use, we place upon the lower lid in the neighborhood of the margin of the orbit a roll of adhesive plaster, which is kept pressed against the lid by the bandage. For the other form some operation is necessary. 30 niSKASKSOF THH HYU KcTROi'ioN.-This is eversion of the lid. usually the lower, and the consequent exposure of the con- junctiva. There are different degrees of ectropion. The lowest is that in which the internal margin stands off a little from the eyeball. Kven tuis tends to increase bv its own condition. The displacement of the punctum produces epiphora and this leads to a contraction of the skin of the lower lid. and hence an increase in the ectropion is produced. Ectropion mav present all degrees up to complete eversion of the entire lid. Redness and thickening of the con- junctiva result from the exposure to the air. Accord- ing to the etiology of ectropion the following classi- • fication is made : ,. Spastic ectropion. If the lid becomes everted from any cause the action of the orbicularis is likely to keep it in that condition. . Paraivtic ectropion. This arises as a result of paralvsis ot the orbicularis, the lid falling away from the evcball bv its own weight. So this affects o. r the lower lid. The palpebral fissure cannot be clos completely, and this is termed lagophthalmos. 3. Senile ectropion is also found only in the lower lid, 'and arises from a relaxed condition of the parts. 4 Cicatricial ectropion. This is the result of the destruction of some part of the skin and its renewal by cicatrices which contract the lid. Injuries, burns, ulcers, the excision of skin in operations and canes of the orbit, are causes. Treatment,— 'YhQ spastic form is usually relieved by replacing the lid and applying a bandage. In the paraivtic form the bandage may be u-^^ed also, but the improvement will depend on the facial paralysis. LA (HJPHTHA LMO.S. 81 The hijjher degrees of ectropion, and all the cicatri- cial cases can only be treated by operation. AxKYi.oBi.Ki'HARON. — This is an adhesion of the borders of the lids. It is either partial or total, and is often combined with symblepharon. As a result of burns or ulcers the edges of the lids become raw at opposed points and so become adherent. Ankyloble- pharon diminishes the size of the palpebral fissure and restricts the movements of the lids. The treat- ment consists in separating the adherent surfaces by an operation, and keeping them apart. Lagoi'HTHAlmos. — This is an inability to close the evelids. In the lesser degrees it is possible to close the fissure by an effort in squeezing the lids together; but in sleep there is no such effort, and these patients sleep with their eyes open. The harm comes from the eyeball being insufficiently covered. The cornea either dries up and becomes ne:rotic, or the epithelium becomes thicker and epidermoid, and of course opaque. In any case vision is in danger. Fipiphora always accompanies the condition. The possible causes are as follows : 1. Shortening of the lids. 2. Ectropion. 3. .Paralysis of the orbicularis. 4. The state occurring in persons who are very ill or who are unconscious, in which the eyes remain open on account of a lessened sensitiveness of the cornea, so that the reflex acts of winking and of shutting the lids are no longer performed. 33 DiyKASKS OF TJIF. KVK. 5. Kniarfjcment or prominence of the eye, such as occurs in staphyloma of the cornea, in Graves' or Hasedows' disease, and in proptosis from orhital tumor. The elevated position of the lid in Hasedows' disease is supposed by some to be due to spasm of Muller's muscle. Treatment. As this is practically a symptom the treatment must depend on the cause. The operation of tarsorrhaphy may be done. Blkimiarospasm. — This is an involuntary con- traction of a part or of the whole of the orbicularis palpebrarum, and is either a clonic or a tonic cramp. A clonic spasm in its mildest form is a twitching of a few fibres of the muscle, most commonly in the lower lid, very annoying to the patient and often the cause of undue alarm. It arises from the strain of uncorrected ametropia, prolonged eye use, and defi- cient amplitude of accommodation. It is often a symptom of hysteria. Children an often affected with it, and in them it may ex^^ond to the other muscles of the face, when it must be regarded as choreic. Many cases are plainly due to reflex irri- tation of the fifth nerve. These are induced by foreign bodies in the cornea or conjunctiva, iritis, cyclitis, and phlyctenular ophthalmia. The most violent cases are met with in association with trifacial neuralgia. There are periods of complete remission, and there is entire cessation during sleep. In some cases the spasm can be arrested by pressure on the supra-orbital, infra-orbital, or temporal nerves. The treatment is the wearing of proper glasses to ■li .. 5? PTOSIS. 88 correct the ametropia, and local and jjeneral tonics. Resection of the fifth nerve and canthoplasty are done in the severe cases. 1 li Ml m Ptosis. -Falling of the upper lid varies in degree from a failure of the lid to follow the motion of the eyeball in looking upward, to complete closure of the eye. It is due to a variety of causes, such as in- creased weight of the lid from inflammatory hyper- trophy, or morbid accumulation of fat, tonic spasm ot the orbicularis, injury of the nerve or muscle, im- perfect development or innervation of the muscle, and paralysis. Paralysis of the levator may be cen- tral or peripheral, and it is sometimes hysterical. A slight drooping noticed only when the eye looks up- ward and the lid fails to follow the motion of the ball, has been attributed to paralysis of Muller's muscle which is described as an organic muscle arising from between the striated fibres of the levator along the under surface of which it runs to the upper margin of the tarsus. Muller's muscle is innervated by the sympathetic. Some similar fibres are found in the lower lid. Paralysis of Muller's muscle causes the condition of the upper lid already mentioned and with it there is found a slight elevation of the lower lid, contraction of the pupil, hypersecretion from the .conjunctiva, increased temperature of the side of the face, and diminished tension of the eyeball, all these being symptoms of disease or injury of the cervical sympathetic. Treatment.— Pios'is of paralytic origin may dis- appear spontaneously, or may be amenable to treat- M DISEASES OF THE EYE. ment without operation. This is true specially of syphilitic and rheumatic cases. Operation should not be done early in the history of the case,— not within several months of the onset. If an operation is done we must he sure that there is no diplopia which may prove to be a greater evil than the ptosis. CHAPTER ra. mSEASEH OF THE LACRYMAL SYSTEM. The diseases which affect the lacrymal gland are rare and only two of them need be mentioned. These are (i) Dacrycadenitis, and (2) Hypertrophy of the lacrymal gland. They are to be treated on the general principles of surgery. The diseases affecting the drainage apparatus are very common. All the parts are liable to pathologi- cal changes. The puncta, the canaliculi. the lacry- mal sac, and the nasal duct are all the scat of disease processes. The puncta are liable to occlusion, or may assume a malposition ; the canaliculi may be closed by strictures, or may be obstructed by the formation of dacryoliths, by the growth of polypi, or by the entrance of foreign bodies ; the sac is subject to acute and chronic inflammation which may lead to the formation ot a fistula ; and the walls of the nasal duct are often the seat of inflammatory processes re- sulting in narrowing of its lumen. All these con- ditions have a common symptom ; the passage of tears from the eye to the nose is interfered with, and in consequence they overflow on the cheek. This is called epiphora, or stillicidia lacrymarum, and this in itself tends to set up a chronic conjunctivitis and an eczematous condition of the face. m 89 />/.SAM.NA*A OF THE EYE. Atrksia of riiK PrNCTi'M. This may l>c cither a conjTcnital or an acquired condition. Complete obliteration does not cccur except from injury, such as laceration, or its destruction with some caustic af^ent. If the canaliculus is intact it will not he a dirticult matter to remedy the atresia, (.icnerally a slight depression marks the position of the punctum, and with a needle or a sharp pointed probe an openinj,' may b- made into the canaliculus, throu}^h which larjjer piobes mr.y then be introduced. When displacement of the punctum is present also, the canaliculus must l)e slit, or no relief will be given to the epiphora. M.\i.iH>smo\ of the puncta gives rise to epiphora. The puncta may be partially or completely everted ; they may be inverted; or, owing to the small size and deeply set position of the eyeball, they may not be in apposition with it. The eflkicnt remedy is the slitting of the canaliculus. nACRYOi-iriis occasionally form in and . bstruct the canaliculi. The mass is a fungus, usually a leptothrix. When the canaliculus is slit their remo- val is easy. Polypi and small foreign bodies are found in the canaliculus. Dacryocystitis.- -This is an inflammation of the lacrymal sac, and is met with in a chronic and an acute form. Primary inflammation of the sac is rare. In most cases it is secondary to and dependent 11 DACItYOrYSTITIS. 87 on disease of the nasal duct, stricture bein^' the con- dition wliich K'ives rise to it. With this as a cause it begins as a mild chronic affection, unattended by pain, but with -piphora and the accumulatioin ot tears and mucus in the sac. Acute exacerbations of the catarrhal cmiJition, with the formation of pus, occur from time to time, and this constitutes the acute dacrvocystiti;-. The cause of this is the en- trance of micro-organisms into the sac, exposure to cold, some constitutional disturbance, or the closure of the cii-.iliculi at the point of entrance to the sac. There is severe pain, with tens- -elling of the sac, marked oedema and redness of i. s, constitutional disturbance such as fever, loss of appetite, insomnia. Thick pus forms in the s ic which after several days tends to point beneath the internal palpebral liga- ment. In a few cases the pus escapes through the canaliculi. As the inflammation subsides, and the discharge lessens, the opening through which the pus has escaped lessens in si/e, and in the course of a few weeks closes. A permanent fistula may, how- ever, develop from the continual discharge of tears through the opening. The treatment is mainly directed to the lacrymal duct, as its stricture is the common cause. In the acute stage a local appli- cation of a lotion of opium and acetate of lead by a pad of gau/e, or blood-letting will relieve. A pur- gative must be given, and an anodyne to subdue the pain. If the lotion does not control the inflammatory action, poultices may be used. As scon as pus has formed it should be evacuated by an incision into the sac. In the acute stage no attempt can be made to open tiie nasal duct. T^Wf' ■s^m.. 88 DISEASES OF THE EYE. Strictirk ok thk Lacrymal Duct.— This is commonly due to partial or complete closure, through nasal disease, of the duct where it enters the nose ; to inflamt . u y swelling of the mucus lining; to fibrous stricture o. .he upper end of the duct ; or to disease of the bony walls surrounding it. The treatment is directed to re-establishing a passage into the nose. In some cases treatment of the nose is of the first importance, as the removal of bands of cicatrices, or hypertrophy of the lower turbinals, will be sufficient. In other cases the cure of the inflammation in the sac by syringing allows the duct to open. For the more serious cases it is necessary to use the probe repeatedly, or to wear a style continuously, till the tendency to re-contraction of the stricture has been fully overcome. The probes should be as large as can readily be passed. Disease of the bony walls requires a radical operation for the removal of the diseased bone. CHAPTER IV. DISEASES OF THE CORNEA. These form from one-fourth to one-third of all the diseases of the eye. The cornea is the most exposed to external injuries of all the portions of the eyeball, and it is not supplied with blood-vessels. The cent- ral zone is quite a distance from the .mtrient vessels, and, as compared with the conjunctiva, it lacks suf- ficient strength to combat the causes of disease. In ordinary traumatic disturbances the regenerative pro- cesses are almost as rapid as those of the conjunctiva, and much more energetic than those of the sclerotic. When the reparative pj*ocesses are complicated by micro-organisms, regeneration is delayed and much inferior to that of the conjunctiva under similar con- ditions. All portions of the cornea are subject to the influences of ordinary pathogenic causes-physical, chemical, and microbic-but they are not equally susceptible to alteration of nutrition in consequence of such noxious influences. Bowman's membrane and the hyaline lamina of the membrane of Descemet are slow to take on pathological processes. The epithelial and the endothelial layers react energeti- cally to pathogenic causes. Keratitis.— Before discussing the varieties of keratitis it will be well to consider the condition generally. 8n 40 niSKASES OF THE EYE. IIP I >. There are three pathognomonic symptoms of keratitis (i) corneal disturbance, (2) inequalities or dulness of the corneal surface, and (3) ciliary injection. 1. Corneal disturbance. — Gray or yellowish dis- coloration may be present in varying degree. When the epithelium alone is affected the discoloration is trifling, and the naked eye cannot discern it. Obli- que, focal, or lateral illumination will decide in difficult cases. The appearance is intensified, or even made quite discernible by coloring matter that penetrates the corneal , tissue through epithelial lesions. A drop ot a two per cent, aqueous solution of fluorescinc gives a greenish yellow color to the substance proper of the cornea, and resorcine, in two per cent, solution, gives it a reddish brown color. In this manner an exact idea of a corneal lesion can be formed. Old corneal spots and maculae are not colored, nor are deep infiltrations, if the epithelium is intact. 2. Dulness or inequalities of the corneal surface. A slight dulness can only be seen with difficulty, by careful examination by reflection and with the ophthalmoscope. 3. Ciliary injection. The superficial and deep pericorneal vessels supply all the nourishment to the cornea. In any marked case of keratitis both sets of vessels are congested, but only the superficial ones are visible. There are three symptoms which indi- cate the gravity of the disease : (i) The congestion of the iris, (2) the intolerance of irritating drugs, and (3) the formation of deeply seated vessels in the cornea. The symptoms of congestion of the iris gy, KERATITIS. 41 will be discussed under hyperaemia of the ins. They consist of contraction of the pupil, sluprgish action of the iris, discoloration, and ciliary pa.n. Remedies suitable for conjunctivitis are sometimes used when the corneal trouble is not recognized, with the result of causing great irritation, the pain and ciliarv injection being much increased. When a keratitis is complicated by vascularization of the cornea, the affection is seen to be deep or superficial by the position of the vessels. Other symptoms are photophobia and blepharos- pasm. Lacrymation accompanies thf^se. There are also visual disturbances. When an eye is first affected with keratitis it easily becomes fatigued. Later, vision is diminished by opacities. General Therapeutics. —On^ of the most import- ant principles in the treatment of diseases of the cornea is not to use any irritant. The next point is the protection of the eye. This is secured by the occlusive and compress bandage, and by dark glasses and shades. The act of winking is a mechanical irritation, and on this account alone it is advisable to bandage the eye. A certain amount of pressure is beneficial, and the dressings should be absorbent to take up all the secretions. At the same time the bandage prevents the entrance into the eye of all dust particles. The third point is as to the use of antiseptics. Most cases of keratitis are infected or are liable to become so. For this reason it is neces- sary to keep thoroughly clean the surface of the cornea, the conjunctival sac, the edges of the eyelids and the surrounding skin. We may use the boracic acid solution, or the bichloride of mercury, i to 48 DISEASES Oh THE EYE, 5,000, or I to 10,000, or biniodide of mercury, i to 20,000. Pyoktanin is also used, i to 1,000 to i to 10,000. The next point is the use of mydriatics. Atropine in four grain solution is of great use in many cases of keratitis, it being indicated in the cases where there is iritis or hyperaemia of that membrane. By dilating the pupil it contracts the vessels of the iris, while ciliary pain subsides as soon as diliation commences. It does not seem to have any direct effect on the cornea, and to produce the indirect benefit the in;tillations must be continued till the pupil is dilated. It is not called for and does not give relief in the superficial form of keratitis which is local and does not cause ciliary neuralgia. In such a case the dilatation increases the photophobia by allowing more light to enter the eye. It is also con- traindicated when dilatation of the pupil is impossible and where there is severe hypopyon and iritis, or in which anterior or posterior synechiae are present. In the latter cases it tends to produce a glaucoma. Miotics may be used to diminish the tension of the eye by contracting the intraocular muscles and freeing the angle of filtration. Eserine is generally used, but pilocarpine is also effective. The contraction of the pupil is useful in ulceration to prevent ectasis or perforation, and in reducing any peripheral prolapse. Cocaine is useful to allay the superficial pains and renders the cornea insensitive ta severe applications such as the thermo-cautery. If used to excess it may lead to exfoliation of the epithelial layer and so aggravate the condition it is intended to benefit. Cauterization is efficacious in the treatment of infiltrations and infected ulcers which are often pro- gressive. I ■HUH! KKRATJTIS. 48 VARIETIES OK KERATITIS. (i). Superficial keratitis. 1. Superficial traumatic keratitis. 2. Phlyctenular keratitis. 3. Granular pannus. 4. Acne of the cornea. 5. Herpes of the cornea. 6. Dendritic keratitis. 7. Filamentary keratitis. 8. Superficial punctate keratitis. 9. Vesicular and bullous keratitis. (2). Deep keratitis. 1. Deep ulcerative and suppurative keratitis. 2. Deep non-suppurative keratitis. ^3). Cicatricial sequelae of keratitis. (4). Corneal tumors. w Mi Si I'FRFiciAL Traumatic Keratitis.-A simple wound of the cornea usually heals in such a way that it cannot be called a keratitis, but the injury may be followed by an infection and this will constitute a keratitis. The infection may come from a blephar- itis, affections of the lacrymal passages and of the nose, or it may be conveyed by the hands or hand- kerchief. The treatment consists in the removal ot the cause if this is determined, the use of antiseptic lotions, the application of the protective bandage, and. in certain cases, the use of the yellow ox.de ointment and the curet. li 44 DISEASES OF THE EiE. Phlyctenllar Kkratitis. — What has already been said about phlyctenular conjunctivitis applies here. The conjunctival condition may precede, ac- company, or follow the corneal phlyctens. The phlyctens usually appear at the corneo - scleral margin. Their tops, at first gray, grow yellow, break down and form superficial ulcers. There is local congestion, increased lacrymation, and photo- phobia. The phlyctenular ulcer has a tendency to creep over the surface of the cornea toward the pupil, taking behind it a leash of blood vessels. When the ulcer heals, the blood vessels disappear but a strip of opacity remains. There is a tendency to recurrence, but in mild cases the result is scarcely noticeable. The treatment is the same as has been already outlined for phlyctenular conjunctivitis. It should be both local and general. Granular Panni's. — This has been mentioned when speaking of trachoma. It is a vascularized granular keratitis, usually involving the upper half of the cornea. It is subdivided into pannus tenuis and pannus crassus. Both t^rms are very per- sistent, may last for years nnu completely destroy vision. In treating the condition it is first necessary to get rid of the trachoma, when the milder forms disappear without further treatment. For the severe cases peritomy is done and the treatment by jequirity may be employed. The latter produces an inflam- matory reaction resembling the purulent form of conjunctivitis. lilii FfL AMENTA R Y KERA TlTIS. 45 ACNK OK THE CoRNEA.— Acnc of the face may be accompanied by eruptions on the cornea which have the ap^^earance of small phlyctenules. They are found only in those who have passed adolescence. They are very difficult to treat and are prone to re- lapse. Calomel, antiseptic lotions and the yellow oxide ointment are used. Herpes ok the Cornea. —The vesicles are transparent, are more or less numerous, arranged in groups, and are not larger than the head of a p.n. It usually appears in the course of febrile or catarrhal troubles, especially with bronchitis, pneumonia and influenza. The vesicle bursts and leaves a small slightly infiltrated ulcer. The treatment is by a bandage, antiseptic lotions, and atropine if necessary. Dendritic Keratitis. —This is also called malarial keratitis. It begins with a circumscribed intense infiltration which penetrates to a certain depth. The infiltration then ulcerates, the borders of the ulcer being perpendicular and infiltrated. The affect- ed area has first the appearance of a comma, but it elongates and becomes arborescent and ramified. When neglected it may suppurate and penetrate. The treatment is the same as for infected ulcers The cautery is of great use. Filamentary Keratitis.— This is a rare con- dition seen in the eyes of old people. With slight pericorneal injection, pain and photophobia, some 46 niS EASES OF THK EYE. liti If small vesicles appear on th "ornea. These are tiny globules attached by a slenuer pedicle. The smallest of these are swept off, the larger become filaments which hang over the surface of the cornea. The affection may continue for months or years. The treatment is to remove the filaments, but subsequent eruptions may occur. Pi'NCTATK Keratitis. — This superficial form of keratitis is also rare. There appear on the cornea small, superficial, yellowish-green spots that are fairly well defined. There may be from five to fifty of these. They last a few days and suddenly disap- pear. No irritant should be used in treating the condition. Vk.sici'lar and Bi llous Keratitis. — These affect only the epithelium. Sometimes they appear in eyes not otherwise diseased, but they are com- monly found in eyes having large corneal opacities or staphylomata, which are often glaucomatous, blind and lost from irido-cyclitis. The removal of the vesicles and of the bullae gives relief. Deep keratitis will be discussed under the two forms of ulcerative or suppurative keratitis and non- suppurative keratitis. The first is caused by ex- ogenous microbic infection, and the second by endogenous, microbic or non-microbic infection. The first is a local disease, the second is usually con- stitutional. : i i riAKliS OF THE VOHNEA. 47 Ulckrs of the Cornea— An ulcer is a loss of tissue which is or has been progressive, -that is, the process has invaded the surrounding t.ssues. 1 he pent of interest in connection with an ulcer is its source of infection. The staphylococci, the pneu- mococcus, the streptococcus, and some undefined bacilli arc found. The following classification may be made : ,. • , 1. Simple ulcer.-This is a small superficial gray lesion either idiopathic or traumatic. 2 Deep or purulent ulcer.-This consists of an area of vellowish purulent infiltration surrounded by a zone' of hazy cornea with a tendency to travel inward and to produce perforation. -, Idolent ulcer.-This depends on some failure in nutrition due to nerve disturbance. The patients are usually anaemic. . . . , a 4 Sloughing ulcer.-These spread widely and easily become complicated with hypopyon and iritis. They are often seen in old people as a result of some trifling injury and they are then styled serpiginous. A slight injury from a chip of stone, a splinter a beard of wheat or the like, which may be an insignifi- cant injury in a young person, produces in the aged this dangerous form of ulcer. c Ulcus rodens.-This also attacks old people, beginning at the margin of the cornea and under- mining the superficial layers. It does not tend to perforate but heals at one side while it progresses at the oth:r till the whole cornea is rendered opaque. 6. Circular ulcer.-This is in the form of a crescentic groove which girdles the cornea. II m mSf.ASKS OF THE EYE. I i ii ^ 7. Dendriform ulcer. —This is the malarial form of keratitis which has already been desi^nbed. The projjression of an ulcer is caused by the ap- pearance of new infiltrations. The floor of an ulcer is often studded with infiltrated areas or necrosing corneal lamellae, that are in the process of being cast off by the inflammatory process. Sometimes the floor is transparent, especially when composed only of the membrane of Descemet. The retrogression of an ulcer. — An ulcer begins to clear up when the resistance of the tissues prevails against the destructive action of the microbes. The shreds of necrosed tissue are thrown off, and the epithelium of the sides extends gradually over the floor or bottom of the afiected areas, which becomes more or less bright or polished in appearance. Vessels may develop in the sides and bottom of large ulcers. The loss of tissue is gradually made good. The tissue used in the process of repair is at first cellular, and is later transformed into fibrillary cicatricial tis- sue, covered by a layer of nearly normal epithelium. Ulcers of long duration, affecting the deeper layers, sometimes do not fill completely, and thus leave a corneal depression. The new connective tissue is always distinguishable under the microscope from normal tissue by the irregular arrangement of its fibrils. The maculae are more or less apparent according to the extent of the ulcer and the length of time it has remained vascular. The membrane of Descemet is distinguished from the rest of the corneal tissue by its greater power of resistance to injurious agencies It is also very elastic so that when the ulceration has destroyed the corneal tissue just in li, mm warn VI.CKRS OF THE CORShA. 40 front of this membrane it yields to the intraocular pressure and bulges forward, remaining tran- narent and becoming only slightly or not at all affected. This is called keratocele and it usually tcrmmales in perforation. An ulcer may perforate without a pre- ceding hernia of the membrane of Pescemet. The actual rupture may take place in consequence of some effort which increases the intra-ocular pressure, such as coughing, snee/ing. or stooping. The patient feels a sudden sharp pain, which is followed by a gush of hot liquid. The aqueous humor runs out, the ins and the lens are brought close to the posterior wall of the cornea, thus abolishing the anterior chamber, and the tension of the eye is very much lowered. After perforation the symptoms of keratitis generally abate, the pain ceases, and the ulcer begins to heal. The opening is closed by the pressure of the ins and lens, and it may be further obstructed by the exten- sion of a plug of fibrin from the iris. The aqueous humor re-accumulates, gradually filling the space between the cornea in front and the iris and lens behind, so that the latter are pressed back to their normal positions. Such a favorable result can only be looked for in small ulcers. Persistent adhesion of the iris to the cicatrix is more common, this being termed ant ,• synechia, in large ulcers a hernia of the iris is likely to take place, the pressure from the aqueous holding the iris in place. As the pro- lapse increases the hernia may rupture. A large central perforation may allow the expulsion of the lens -vhen perforation takes place. An extensive prolapse of the iris may become cicatrized as a thin fibrillary membrane, pigmented posteriorly and AO I US EASES Of THF. EYK. lit N covered with epithelium anteriorly. An ectasis is produccJ hy thf aqueous humor pushing the ci<.atrix forward. ' Uirc of the cornea gives way under the pressure, mU a staphyloma is formed couMsting of the prol i| .>t'J tns, cicatrized on its surface and cover- ed over wiih epitlielium. A staphyiomatou'^ eye soon becomes l.uu 'ritous. Kven when there is staphy- loma, ii" ihe .-.yncchia be large or totii' the i ye will be lost from glaucoma. Traction iwi the iris and deep infection of the eye may lead to irido- cyclitis, phthisis, pjinophthalmitis, or intra-ocular haemorrhage that m.r disorjjanize l!iee\'-. Some- times the perforation will remain .pen for a long time, so as to form a listula oi the cornea. Etiology of Ulceration. — The chief predisposing cause is the absence of Wootlvesse!'^ in the cornea, by which the resistance o\ the tissue to infection is materially lessened. The cxciiinjj causes are trau- matic and microbic. Prognosis.- This is very variable and must be estimated according to the locality, depth, si/^ dnd degree of infection, of the ukor. Treatment. — Causes stumid be searched for nd eliminated as far as possible. Foci of i ert- ion, such as blepharitis, or ->lennorrhoea thae lacrymal sac are to i>e abated ■ destroyed. 1> racic acid lotions should be used fre^uentl\ . Other nti- septic preparations may be used. The bandage to be applied, and atropine 'Tstilfed. A protuse secretion may contraindicate = bandage, «s the e- tained secretion undergoes ompi -iition and so infects the ulcer. Atropine =ys the pain 4^'-^^^ the pupil id so prevents the ki-rmt^n of p jsi ^ luf *9 S/lIPPrttA TIVK A K HA Tin.' 51 syneAiae, na b(«aKS recent adhesion. Atromne is not to )c employcJ when it fails to dil; e the pupil, as it th.n renders the ye glaucomatous. In such a case c-erire or piloca . nc is Inciter. In the more s^^ew «a**^ ' i^ ^sa'"> »« "'^^ ^^ ''""" cptic^ the h.chU>rid. - c .yanide of mercury, or iodoform rtay ' ^d mto the eye, or the cra> >n of poktanmapf: ^^'^ rapid progress .s^ lent Lheinfctic, . sto. used. VVh. Per- fetation seenv ur. is better th.. the owning si uld Ik n *. > the :eon, m a h.althy S^ af th ripi V of the cor. A prolapse of iris s .n .d Ix .Heved by exci-,ion or the cautery. \ :. le should be tapped ir pierced. \n in- dolsat V may be lightly scraped with a cur. t. V i'rahvk KKRATiTis.-This ma -'^ed ve ulcer and abscess of the corn. »s va > the suit of severe microbic infeci ae ui ■■ to the presence of a large number of m^ s, or lo bacteria of great virulence. The resistance of th< cornea mav be lessened by a contusion or as the result of some general dyscrasia. The infection always comes from without but the point of entrance may be verv minute. S^mptoms.^X purulent infiltration with no open- V.g lOT the escape of pus may vary in intensity and size It is distinguished by an intense yellow.sh- xvhite color which diminishes toward the periphery and merges into a slightly congested oedematous zone A deep infiltration usually increases in size before it ulcerates. In most of these cascr. pus 52 DfSKA.'.KS OF THE KYK. m 1 1 1 1 appears in the anterior chamber, and this is termed hypopyon. The pus mixes with the aqueous humor and sinks to the bottom of the anterior chamber, where it forms a yellowish-white collection which is horizontal on top. Often Xht pus is compact and fibrinous ; when it is liquid it readily changes its position as the head is moved from one side to the other. The pus may reach the level of the pupil, or may completely fill the ariterior chamber. It is always a serious complication. A small amount of pus in the anterior chamber may be absorbed and disappear, but a large collection tends to produce ne- crosis of the cornea and destroys the sight. The pus in hypopyon comes from the irido-corneal angle, from the iris, and from the ciliary body. The prognosis in this condition is always serious. The cornea becomes opaque, anterior and posterior synechiae remain and predispose to a secondary glaucoma. The lens may become opaque, and corneal staphyloma are frequently formed. Treat ment. —Th\s is the same as for grave corneal ulcers. When the hypopyon reaches the level of the pupil, it will no longer absorb and must be evacu- ated by a paracentesis. Forceps will usually be necessary to remove the mass, or the anterior chamber may be irrigated with a salt solution. The puncture should be made below the level of the pus, and in a part of the cornea which is still healthy. Atropine is of no use in large collections of pus. During the last few years subconjunctival injections of solutions of the bichloride of mercury have been tried. The results have not been very satisfactory. II i' NEUJfOPABAL YTIC KKKA TITIS. 58 Neuroparalytic Keratitis.— This condition is observed in complete paralysis of .the trigeminus or in one of i- ocular branches, and especially the nasal branch. Under these conditions the reflex actions of winking and of lacrymation do not take place. The eye ordinarily remains open, its surface becoming dry and being exposed to contusions, foreign bodies and dessication from evaporation. When exfoliation takes place infection occurs and infiltration goes on rapidly. Suppuration and hypopyon, perforation, staphyloma, and phthisis buibi complete the case. £/.t;/o^^.— There are various theories to account for the condition : 1. It may be due to trophic changes. It is sup- posed that there are trophic nerve fibres in the trige- minus which control the nutrition of the elements in the cornea. Trophic nerves are still spoken of, but their existence has not yet been clearly demonstrated. 2. It may be due to th ^ lessened power of resist- ance in the cornea to external injuries as a result of the insensibility. 3. It may be due to irritation of the fifth nerve by the lesion. 4. It may be due to micro-organisms. 5. It may be due to increased evaporation from the cornea. _ . The true theory is probably in a combination of these possibilities. ' It occurs in connection with dis- ease of the Gasscrian ganglion, of the nuclei of the fifth pair of nerves, and with periostitis of the orbit, syphilitic deposits, and fracture of the base of the skull. 7-mi//«e«A— niligent and careful treatment may 54 DISEASES OF THE EYE. often save some useful vision. Local measures, based on the traumatic theory, are needed. Antiseptics are necessary, and a bandage to protect the eye, or the lids may be kept closed with adhesive plaster. Dkki', Non-sui'itrativk Kkratitis. — These con- ditions are due to constitutional troubles. The kera- titis begins in the tissue proper of the cornea, and is therefore analogous to diseases if the fibrous tissues in other parts of the body ; and, like them, are of long duration and demand general treatment. They do not suppurate or ulcerate. IN" iCRSTiTiAL Kkratitis. — This is the common form of deep, non-suppurative keratitis. It is also known as interstitial keratitis, and deep diffuse kera- titis. Etiology. — The common cause is inherited syph- ilis. Hutchinson has called attention to the associa- tion of two other symptoms,— deafness and a peculiar conformation of the teeth, with interstitial keratitis, as a result of congenital syphilis. Acquired syphilis very rarely gives rise to interstitial keratitis. It is also attributed to scrofula, malaria, rheumatism and depressed nutrition. It occurs usually at puberty, but may come as early as five and as late as fifteen years. Symptoms. — Points of ciliary congestion appear and then spots of opacity in the lamina propria. Gradually in a few weeks the whole cornea has a steamy, ground-glass appearance, and blood vessels run into the cornea producing the "salmon patch of Hutchinson." Ulceration does not occur. Vision is INlEliSTITIAL KERA TtTIS. 55 greatly diminished, and may be reduced to mere per- ception of light. The disease usually attacks both eyes, either simultaneously or consecutively. After two or three weeks, sometimes after several months time, the condition begins to disappear, starting with the periphery. The clearing process may occupy months or even a whole year. Examination will al- ways show a certain diffuse opaqueness in the centre of the cornea. The subjects of typical forms of the disease present a remarkable combination of physical defects : dwarfed stature, coarse flabby skin, sunke.. nasal bridge, scars at the angle of the mouth, mal- formed permanent teeth, the central incisors being vertically notched; there is deafness, some cicatrices in the pharynx, chronic periostitis of the tibia and hardened glands in the postcervical and epitrochlear '^^'rTeatment.-nWxs must be general as well as local. The first indication in the local treatment is to use atropine to keep the pupil dilated, so as to prevent glaucoma which would be sure to arise from the formation of synechiae. Dark glasses or a shade may be worn for the photophobia. All irritating ap plications are to be used with great care. When the process of resorption begins we may use hot com- presses and the yellow oxide of mercury ointment. Some massage may be employed with the omtment. Subconjunctfval injections of bichloride of mercury have recently been recommended. As to the genera treatment, the syphilitic forms will require toe usual specific treatment, though many of these patients are already debilitated and cannot bear the mercuna s. Inunclion may suit some of them. For feeble infants. I 5« DTSEASES OF THE EYE. (■ ft 5 I the iodides should be combined with codliver oil. For robust young people, hot baths of the entire body, foUoue 1 by sweating in bed, will be found beneficial. SKyUKI.AK OR CONSKOIKNCKS OK KERATITIS. (i). Opacities which are more or less permanent. According to the density of the opacity these are classified as : (i) nebula, (2) macula and (3) leucoma. The term sclerosis is also used for a very dense leucoma. The position of the opacity will determine the interference with vision. The more central the greater the disturbance. Treatment. — A macula may disappear spontane- ously, if it be recent and not too intense. The clear- ing of all kinds of opacities of the cornea is favored by means that are more or less irritating to the eye, such as hot compresses, steam, yellow oxide oint- ment, with massage through the eyelids. Scraping of the cornea or cutting olT the superficial layers has little effect as healing takes place by the formation of new tissue that is not transparent. It has been at- tempted to insert in an opaque cornea a button of glass, of celluloid or other transparent substance, but this is a physiological impossibility. Efiorts have also been made to fill up a gap in a leucomatous cornea with transparent animal cornea the grafts be- coniing attached organically, but the tissue always becomes cloudy and the gain in vision is nothing. (2). Inequalities of the cornea distort the retinal images and produce astigmatism. Nothing can be done for such a condition. SKQ UELA EOF KKltA TITIS. 57 (3). Dense maculae are produced by incrustations of lead from applications to the eye of coUyria made of acetate of lead. The incrustations are usually in Bowman's membrane, are covered by the epithelium and so are permanent. No lead lotion should be used in any ulcer of the cornea. (4). Staphyloma of the cornea. The iris usually forms a sood part of the staphyloma. It is always consecutive to a perforation with more or less destruc- tion of the corneal tissue. The iris adheres to the remnant of the cornea, there being no longer any an- terior chamber. The eye is more or less hard. The sclerotic may take part in the process and the eye is then said to be in the condition known as buphthalmia. The lids will then be unable to cover the protruding mass. Vision is abolished. The vitreous humor becomes softened and reabsorbed. The choroid, retina, and the ciliary body undergo atrophy. Opera- tion is usually necessary. (5). Fistula of the Cornea. —A perforation of the cornea may fail to close for a week or more. A permanent fistula does not occur, some cases the eye must be removed. (6). Malformations of the cornea. -There are three of these : i. Keratectasia is a bulging of the cornea alone, the iris not being involved in it, as in staphy- loma. 2. Keratoglobus. This is the result of infan- tile glaucoma. The whole cornea becomes thin and distended. 3. Keratoconus. In this the centre ot the cornea becomes thin and is pushed forward, so that the cornea is conical but transparent. At first there are symptoms of myopia. It appears between the ages oi fifteen and thirty, but the cause is not known. The treatment is optical and operative. CHAPTER V. DISEASES OF THE LENS. Luxation of thk Lens.^ — This is either traumatic or secondary to some pathological change in the eye. In either case it is rare. Sometimes a rupture of the sclerotic accompanies the condition and the lens will be found under the conjunctiva. It may also take place into Tenon's capsule or into the vitreous, or forward into the anterior chamber. ' '-1 Cataract. — This is an opaque condition of the lens, or of its capsule or of both. VV'e therefore speak of capsular, lenticular, and capsu'o-lenticular cataract. A classification is made into ISF.\ O/ THE KYK. i 11 of the ciliary nerve's, so the pupil is contracted. The reaction of the pupil may be diminished or Uist. 4. An exudation of inflammatory products always takes place. This may be (a) into the tissue of the iris, (h) upon its anterior or posterior surface, (c) in- to the pupillary area, or (e ^S ^716) 288 - 5989 - fax CHAPTER XI. GLAUCOMA. iii This is a condition depending on an excess of pressure in the chambers of the eye. The causes are various, but all culminate in an obstruction to the escape of the intra-ocular fluid. Increased tension is the leading symptom of glaucoma. This was first recognized in 1830 by Mackenzie. Etiology.— The remote causes of glaucoma include constitutioual disease such as rheumatism, gout, syphilis, disorders of the respiratory, vascular and nervous system, injuries of many kinds, morbid growths, congenital imperfections and senile changes. The immediate cause in every case is an obstruc- tion in the path of the intra-ocular fluid. The ob- struction is difterent in different forms of the disease. When the anterior chamber is deepened, the lens and iris being displaced backward, the obstruction lies either in the contents of the chamber or in the tissues of the filtration area. When the iris is bulged for- ward by retention of fluid in the posterior aqueous chamber, the obstruction is primarily at the pupil, secondarily at the periphery of the chamber. When the pupil is open and the anterior chamber shallower, or at least not deeper, than in the healthy eye, we may expect compression of the filtration angle by pressure of the ciliary processes against the base of OLA UrOMA. 79 the iris. The cause of the displacement is sometimes a tumor or an effusion of blood into the vitreous chamber. Primary glaucoma appears to depend en some vascular disturbance which congests the uveal tract, or upon a faulty relation of the lens to the parts around it. In any case the filtration angle is narrowed or closed. Glaucoma is rare before forty years of age. The Jew is specially liable. It may be hereditary. In eyes predisposed to it, it is excited by worry, in- somnia, or any disturbance of the circulation. The use of atropia will bring on an attack in those predis- posed to it. Symptoms. —The objective symptoms are, — i. In- creased intra-ocular tension. Tension is determined as follows: — The patient looks downward without closing the eyes tightly. The observer, standing in front and steadying his hands by resting the outer fingers of each on the patient's forehead, places the tips of the two index fingers on the upper eyelid, and with gentle alternate pressure feels the globe behind the corneal region. He then feels the other eye for comparison. The symbols of Bowman are in con- stant use to record the tension. Tn=tension nor- mal. T+i==slight increase. T + 2=considerable tension. T + 3 = stony hardness. T—i= slight de- crease. 2. The second objective symptom is a change in the size and shape of the pupil, and in the mobility of the iris. The pupil may be round or oval or egg- shaped, semi-dilated and sluggish, or inactive. 3. There is a loss of transparency of the cornea which resembles ground glass. This is due to the oedema. 80 DrSEASES OF THE EYE. 4. There is a change in the depth of the anterior chamber. It is usually lessened, but it may be in- creased. 5. There are changes in the normal appearance of the iris, and turbidity of the aqueous and vitreous. 6. Venous hyperaemia of the conjunctival and episcleral vessels. 7. Excavation of the nerve head or cupping of the disc. It is necessary to distinguish between this and the cupping that occurs physiologically and following atrophy. 8. Pulsation of the blood vessels on the surface of the disc. A venous pulse is often seen in healthy eyes at a knuckle of the veins as they bend over into the excavation. Pulsation of the arteries is to be seen in aortic regurgitation and in glaucoma. It is caused by resistance to the entrance of the blood into the eye. The subjective symptoms are, — 1. Pain. This is severe and neuralgic. In vio- lent cases the pain is intense and is accompanied by depression, pallor of the countenance, nausea anJ vomiting. 2. Diminished sensibility of the cornea. This is the result of pressure on the corneal nerves. 3. Loss of vision. This varies considerably in different cases and in the same case at different times. In each attack of subacute glaucoma the vision fails and gradually returns after the attack passes off, but each recurrence leaves a more permanent impression. In acute glaucoma vision is lost in a few hours. 4. Change in the refraction and accommodation, and in the field of vision. GLA rCOMA. 81 5. Iridescent vision. With this there is also halo-vision, photopsia and chromopsia. Clinical Types of Glaucoma. I. Acute primary glaucoma. This is inflamma- tory or congestive. Two stages are recognized. («) The prodromal or incubation stage in which there is a sudden failure of vision for a few moments or hours at a time with failure of accommodation, attacks of foffSy vision, and halo-vision. These attacks come when the head is congested, after a full meal or dur- ing emotional excitement and with insomnia. This period may last a year or two. (b) The period of at- tack. This may come without warning. There is violent pain in the head, nausea and vomiting, usually coming on during the night. The symptoms come on rapidly. If left to itself it goes into the state of absolute glaucoma. The eyeball is stony hard, the iris atrophic, the lens opaque, the anterior chamber obliterated, and there is general disorgan- ization of the eye. 2. Subacute primary glaucoma. This is charac- terized by its being intermittent. The first few at- tacks may amount to only slight obscuration or rain- bow vision. Gradually the recurrences become more frequent and severe, and the remissions less complete and by degrees a persistent congestive glau- comatous condition is set up. It runs from several months to a year, and leads to total blindness. 3. Chronic primary glaucoma. This is also called simple glaucoma. It begins and progresses slowly, with little tendency to exacerbation or remis- sion. The patient is usually over fifty years of age. There is an absence ot the usual signs of glaucoma hi! f i I m 8S DISEASES OF TJfE EVE. in the anterior aspect of the eye on ordinary inspec- tion, and there is >. ^ pain. Tension is only very slightly increased, and is often doubtful. The diag- nosis is made from the excavation of the disc, and the contraction of the field. It may pass into either of the forms already mentioned. 4. Absolute glaucoma. This is the term used when the stage of blindness is reached. The main symptoms have already been mentioned. Advice is sought for the pain, which may be severe. 5. Haemorrhagic glaucoma. This condition has an important bearing on the operation. 6. Secondary glaucoma. Treatment.— The progress of glaucoma can only be arrested by measures which lower the tension of the eye, and these must be employed early if loss of sight is to be avoided. In the absolute form treat- ment is only for the relief of pain. Eserine and pilocarpine are used to lower the ten- sion by opening the angle of filtration. Morphine internally will sometimes cut short an attack. Aperi- ents are also indicated. Operative treatment is often necessary. Paracen- tesis will relieve the tension temporarily and is often done preliminary to a more extensive operation, to determine the tendency to haemorrhage. Iridectomv^ is the usual operation done to open the angle between the iris and cornea. ^ bout one-fifth of the iris should be removed, and the wound should be in ihe scle- rotic but in front of the iris, and iarge enough to per- mit extensive detachment of th- iris. The knife should be withdrawn slowly to prevent a sudden gush of the aqueous, for too rapid reduction of tension OLAVVOMA. 8g leads to intra-ocular haemorrhage. Care must be taken that no part of the " ^ cmains in the wound. If tension is lowered a favorable result is indicated. Scleral puncture or posterior sclerotomy is also done. It is indicated in advanced cases where the eye is blind and to relieve pain, or as a preliminary operation in cases of suspected hacmorrhagic ten- dency. Sclerotomy is an operation resembling the incision in iridectomy, but leaving the iris intact. CHAPTER XIL DISEASES OF THE RETINA. VAEMIA AND ISCHAEMIA OF TMK RkTINA. — Is- cnaemia of the retina is the name /?iven to the most profound retinal anaemia. It is seen as a symptom in embolism of the central artery, and in compression of that artery by di'-ase or neoplasm. Anaemia is a symptom of local , isure, general anaemia, cerebral anaemia and syncope. It is most often seen as a re- sult of extensive haemorrhage. The fundus-picture shows thin arteries, dark veins, and occasional spon- taneous arterial pulsation. Treatment. ^Nitrite of amyl will restc-e vision for a few minutes in the recent cases. General treat- ment is not of much value. Hyperaemia of the Retina. — This .. cliarac- terized by increased calibre and tortuositj of its ves- sels. This must often be inferred from the appear- ance of the vessels over the optic disc, showing in- creased redness. The condition is (i) active, when increased blood is sent to the retina because the syste- mic tension is increased, e.g:, in the tachycardia with fever or pneumonia ; (2) passive hyperaemia, when the blood is not returned from the eye, as occurs in mitral disease, emphysema, violent cough and con- vulsive seizures. The treatment must have reference to the primary cause. Ametropia is to be corrected. JiKTIXlTJS. 8S Hyi'eraesthesia ok thk Rktina.— This is found in neurotic and hysterical pi.Jents and may or may not be associated with ametropia. It is character- ized by the symptoms which indicate a supersensitive retina, i.e., photophobia, lacrymation, blepharo- spasm, neuralgic pain and imperfect eye-indurance. It is seen with chronic headache, neuralgia, and after prolonged fevers and pulmonary disorders. It may depend on disease in the nose and naso-pharynx. The treatment is to find the cause if possible and eliminate it. General tonics, rest and massage are of use. Retinitis — The general symptoms are as follows : 1. Loss of transparency of the retina. This is the only characteristic ophthalmoscopic symptom. It may be a diffuse haze, a circumscribed opacity and swelling, or streaks of white infiltration. 2. Areas of exudation. This is a more advanced stage. White spots, sometimes discrete, some- times confluent, or patches of bluish-gray, buff or yellow color are seen. 3. Tortuosity of the vessels and change in their size. The veins are darker than normal and wavy in outline. The arteries may not be changed. 4. Haemorrhages. These are either in the fibre layer or in the deeper parts of the retina. They may occur independently of inflammation. In the super- ficial or nerve fibre layer it is flame shaped. When in the deeper layers it is clean cut and more rounded. 5. Changes in the optic disc. There is increased 06 />ASAV1.V/;,V OF TUK KYK. redness and loss Oi the distinct ontline. Atrophy of the disc follows severe retinitis. 6. Pi^'mentation. This is not necessarily a symptom of retinitis. 7. Atrophy of the retina. This is marked hy a permanent white or yellow opacity. 8. Change in the visual acuity. 9. Change in the field of vision. The entire field may be contracted, or scotomata may appear. 10. Distortion of vision. The forms of this are micropsia, macropsia and metamorphopsia. 11. Pain and photophobia are rare. There is usu.Jly a sense of discomfort rather than actual pain. The diagnosis of any case depends on the loss of transparency determined by the ophthalmoscope. The other symptoms make up the characteristics of the various types. Prognosis may be favorable or fatal according to the extent of the inflammation, its situation, and the cause. Treatment. —Rest and blood letting are the local measures. The medicines most likely to be useful are mercury, iodide of potash, bromide of potash, ergot and pilocarpine. The varieties of retinitis are as follows : 1. Pri- mary. 2. Secondary. i. Circumscribed. 2. Dif- fuse. The clinical divisions are i. Syphilitic. 2. Puru- lent or Septic. 3. Haemorrhagic. 4. Albumenuric. 5. Diabetic. 6. Retinitis pigmentosa. Serous retinitis or oedema of the retina is a con- dition in which there is infiltration of the nerve fibre and ganglionic layer causing opacity, oedema and ItHTIS'ITlS. 87 venous hypcracmia. There are no external signs. Vision is (o^^y. The causes are cold and exposure to undue heat and li^jht. No cause can be assigned frequently. F»arcnchymatous retinitis shows in addition to oedema a cellular infiltration and organic change leading to atrophy. The cause of this is various constitutional complaints, disturbance of uterine functions, and intra-cranial diseases. Syphilitic retinitis may occur in both acquired and congenital syphilis. In the acquired form it appears from one to two years after infection. Purulent retinitis is seen in pyaemia, purperal septicaemia, putrid bronchitis, and such pyogenic conditions. Both eyes are affected. Haemorrhagic retinitis may exist without inflammation. The size, number and position of the haemorrhages vary. They are either linear, flame-shaped, or irregular and round. The causes are diseases of the heart and blood vessels, such as hypertrophy, aneurism, and endarteritis ; supl pressed menstruation and the climacteric. ''he haemorrhage is due to the rupture of a small vessel whose coats have degenerated. The haemorrhage may set up a retinitis. The prognosis is usually un- favorable. In albumenuric retinitis variously shaped and placed white spots appear, beginning in or near the macula. These are first small, discrete and sharply separated, and later form a star-shaped figure. Haemorrhages of a flame shape also are seen, but not constantly. They indicate the violence of the disease. The common cause of this is Bright's disease, especially the chronic granular kidney, but it also occurs with the large white kidney and in I 88 msKASKS OF TJIK EYE. I ■ lardaccous disease. It alsa is seen with scarlatinal nephritis and the albumenuria of pregnancy. Three staj^es arc recoiinized. i. I lypcraemia, opacity and haemorrha^je. 2. Fatty degeneration. .3. Retro- grade metamorphosis. Diabetic retinitis occurs in several forms. There arc no pathognomonic signs. In Retinitis Pigmentosa there are no phenomena of inflammation. There is degeneration of nerve tissue associated with great contraction of the blood vessels and the deposition of pigment in the retina. The pigment masses resemble bone corpuscles. Nystagmus is a frequent symptom with it. There is also hemeralopia or night-blindness. Treatment is of no value. Dktachment ok tmk Rktixa.— This is a separa- tion of the retina from the choroid due to serous fluid or blood between these membranes. The normal color of the fundus is lost and appears grey or bluish- grey, and the retina stretches out into the vitreous in folds which oscillate with the movements of the eye. The vessels look like dark tortuous cords. The de- tachment is partial or complete and may occupy any part of the fundus, but is most frequently below. The patient complains of metamorphopsia, floating spots or clouds, and phosphenes. The causes are malignant myopia, traumatism, efi'usion of blood, intra-ocular tumor, tumors and abscess of the orbit, retinitis and irido-cyclitis. Treatment. — This consists of rest in the prone po- sition, a pressure bandage and pilocarpine. Opera- tion may also be of value. CHAPTER Xm. DrSEASE OF THE Cr V C NERVE. Certain conj^enital anc > These are: — I. Opaque nerve uores of the disc. 3. Coloboma of the sheath of the optic disc. are often seen. 2. Irregularities Hypkrakmia ok tiik Disc— The disc is of a dull red or brick-dust hue with slightly blurred edges. The causes are:- i. Errors of refraction, especially hypermetropia and hypermetropic astigmatism. 2. Prolonjjcd exposure to glare and heat. 3. Certain toxic agents. 4. Certain disorders of the brain, of which chro insanity is a common example. Optic Nkuritis.— Inflammation of the optic nervt ;.. ;y affect: — !. The intra-ocular termination of thi nerve. 2. The retro-bulbar portion. 3. The intra-cranial division. IxTRA-ocuLAR Oi'T'c Neuritis.— This is also called Papillitis or Choked Disc. The symptoms are,— I. Changes in the disc. These are increased red- ness and blurring of the borders, swelling of the disc, loss of the light spot, and complete hiding of the margins. liil 90 DISEASES OF THE EYE. 2. Changes in the blood vessels. The arteries are smaller than normal and partly concealed in the swelling-. The veins are dark, distended and tor- tuous. 3- Haemorrhages. These are either in the swollen disc or near it. 4. Vision may not be affected. 5. There are no external changes and no signs of irritation. Diagnosis is possible only with the ophthalmo- scope. The course is very variable. It may come on rapidly or develop gradually for months with pro- gressive failure of vision. As the inflammation and oedema subside the veins are less distended and ves- sels which were obscured reappear. The borders of the disc become visible, beginning usually at the temporal side. Then the disc becomes very white and atrophic. Etiolog)'.^T\\Q most common cause is brain tumor, and it occurs with all types,— fibroma, sarc- oma, carcinoma, solitary tubercle and gummata. It also appears with haematoma of the dura mater and abscess of the brain. Meningitis is next in order of frequency as a cause, especially when located at the base of the brain. Other cranial causes are aneurism cerebritis, haemorrhage, thrombosis of the cavernous sinus, and hydrocephalus. It is also a symptom in the following conditions: 1. Acute febrile affections,— typhus fever, variola, scarlatina, diphtheria. 2. .Syphilis. 3. Toxic agents, like lead. 4. Anaemia. INTRA-OCULAR OPTIC NEURITIS. 91 5. Menstrual disorders. 6. Exposure to cold and rheumatism. 7. Injuries. 8. Diseases of the orbital region, — tumors, caries and periostitis. The treatment will depend on the cause. There is no local treatment. 1 Atrophy ok the Optic Nerve.— The symptoms of this are, — 1. Alteration in the color of the disc, varying from a slight gray to a pure gray, greenish-gray, or pure white. Rarely it is blue. 2. Alteration in the centre of the disc. There is a sinking of the surface in different degrees to form the atrophic cupping. 3. Unusual distinctness of the margin of the disc. 4. Change in the vessels. The arteries are small- er and the veins unchanged usually. 5. Change in vision. This is of all degrees. 6. Loss of color vision. 7- Change in the pupil. It does not react to light, but it may to efforts of convergence. Varieties, — - 1. Primary atrophy. This is also called gray, progressive, spinal or tabetic atrophy. 2. Secondary. 3. Consecutive. The common causes of optic atrophy are locomo- tor ataxia, general paralysis of the insane, insular sclerosis, lateral sclerosis, exposure to cold, imper- fect nutrition, and venereal excess. The condition runs a course extending over months or years. 99 DISEASES OF THE EYE. The treatment is not very satisfactory. Strych- nia, santonin and galvanism are used. Orbital Optic Neuritis is also called retro- bulbar neuritis. In this the inflammation is in the orbital part of the optic nerve. At first there is no change to be seen in the fundus, and only very slight change to be seen at any time, but there is great loss of vision or complete blindness. The causes are toxic agents, such as lead and nicotine, menstrual dis- turbances, rheumatism, measles, diphtheria, scarlet fever, and overwork. The treatment is to remove the supposed cause and to use pilocarpine and later strvchnia. A ' CHAPTER XIV. FUNCTIONAL DISEASES OF THE RETINA. Amblyopia,— partial loss of vision. Amaurosis,— total loss of vision. These terms are used where there is disturbance of vision without ophthalmoscopic changes. Modern methods of ex- amination have greatly reduced the number of cases where these terms are applied. Varieties.~\. Congenital amblyopia. In this there is a lack of development of the nerve elements, 2. Amblyopia ex anopsia. This is from want of use. It may be a congenital condition, or due to corneal opacity, persistent pupillary membrane, con- genital cataract, or squint. 3. Congenital amblyopia for colors. Color blind- ness is present in about three per cent, of men, but only one-fifth of one per cent, of women. Achrom- atopsia and dyschromatopsia are terms used in this connection. 4. Reflex amblyopia. This is seen with para- sites in the intestinal canal and with carious teeth. 5. Traumatic amblyopia. This comes from severe injuries to the head, bruises along the spine and on the brow along the course of the supra-orbital nerve. 6. Uraemic amblyopia. 7. Glycosuric amblyopia. I 94 niSEASKS OF THE EYE. 8. Malarial amblyopia. 9. Amblyopia from loss of blood. 10. Amblyopia from abuse of drugs. Those which may produce amblyopia are lead, tobacco, alcohol, nitrate of silver, mercury, carbon-bisulphide, nitro-benzol, salicylic acid, and quinine. 11. Hysterical amblyopia. 12. Simulated amblyopia. This is diagnosed by the use of prisms (the diplopia test), and by the use of colored lenses and letters or wool. HEMioi'iA.—This is also called Hemianopsia or Hemianopia. In glaucoma, optic atrophy and neu- ritis one-half of the visual field may be wanting, but that must not be confused with this condition which depends on a lesion in the optic chiasma, in the visual tract, or in the visual centre in the occipital lobe. The Visual Tracts. —Tht macular fibres in the retina make a triangular bundle, entering the papilla at the infero-temporal side. In the orbital part of the nerve it runs in the axis, coming to the upper and inner part just before the chiasm. Beyond the chiasm it again finds the axis and follows that to the brain. In the chiasm there is a semi-decussation. The tract winds around the crus cerebri and terminates in two roots,- corpora geniculata, externa and interna, and upon the posterior part of the optic thalamus (pulvi- nar). Fibres go to the anterior part of the corpora quadrigemina which are concerned in the activity of the pupil. These parts are the primary visual ganglia or primary optic centres. From these, fibres HEM ro PI A. ^ radiate through the internal capsule to the cortex winding outside the tip of the lateral ventricle to the lower part of the median surface of the occipital lobe. I. Homonymous He.nianopsia. In this the cor- responding halves of each field is wanting, i.e., either both rights or both lefts. 2. Heteronymous Hen.ianopsia. Of this there are three forms : («). Binasal. The " sion is at the anterior and posterior angles of the chiasm. (A). Bitemporal. The lesion is on both sides of the chiasm. {c). Horizontal. The lesion is above or below the chiasm. In the first form the lesion is on the opposite side to the dark fields. It is caused by a lesion • n ihe occipital lobe, the optic radiations, the internal capsule, the primary optic centres or the optic tract I hese are ai: back of the chiasm. The pupa in Hemianopsia.— \i we reflect the light on the dark field and reaction takes place, the lesk,n is back' of the primary centres. If no reaction takes place, then the lesion is in or in front oi the primary optic ce.. res. This is Wernicke's symptom of hemi- opic pupillary reaction. The condition of hemianopia not be diagnosed by the ophthalmoscope, but oni y the answes of the patient. ^ggM CHAPTER XV. DISEASES OF THE ORBIT. The general symptoms of disease of the orbit are, — 1. Proptosis or exophthalmos. 2. Im?nobility of the eyeball, either complete or partial. The following symptoms are less frequent : 3. Chemosis of the conjunctiva. 4. Redness, swelling and oedema of the lids. 5. Pain, especially on attempted movements of the eye and on pressure. Frontal headache points to involvement of the ftontal sinus. Tenderness on pressure along the margin of the orbit points to periostitis. 6. F"luctuation. 7. Disturbance of vision. This may be absent. When present it is due to interference with the optic nerve producing papillitis, atrophy or haemorrhage. Ckliatlitis. — ^This is an inflammation of the con- nective tissues of the orbit, and may be acute, sub- acute or chronic. It may be monolateral or bilateral and may undergo resolution or terminate in suppu- ration. When mild the symptoms are dull pain, slight swelling of the lids, slight exophthalmos and diplopia, without inflammatory or constitutional CELL ULITIS. „ symptoms. When severe there are chills, fever, deep-seated pain, general headache, limited move- ments of the eye, oedema of the lids and chemosis. V ision ,s not affected unless there is neuritis from extension to the nerve,-then atrophy may result. The abscess may be chronic and much less violent. Etiology. —It may be idiopathic and due to ex- posure to colu. It may follow typhoid or scarlet fever, or may result from meningitis. It occurs with erysipelas. Some cases are netastatic and occur with pyaemia or septicaemia. Prognosis.~\n serious cases there is often a fatal termination from pus finding its way to the brain through the sphenoidal fissure. Treatment.—LocaWy, frequently changed hot compresses and bleeding from the temple are of use. Open if there is any suspicion of pus. The opening IS prcierably made through the conjunctiva. Iron may be given internally. Quinine may not be used on account of the tendency to aggravate a menin- gitis. i Tumors of the Orbit are either simple or ma- lignant. Clinically they are classified according to the structures from which they spring. 1. Tumors of the bony wall. 2. Vascular tumors. Tumors of the connective tissue. Tumors of the optic nerve. Tumors of the lacrymal ^land. Tumors of the orbit do not extend to the eyeball They may ,.stroy vision when they set up inflamma- 3. 5. fl i < 9S DISEASES OF THE EYE. tion. The only exception to this is in the case of a tumor of the optic nerve. If, therefore, a tumor is seen in both the globe and orbit it is safe to infer that it started in the globe. As a tumor of the orbit grows it produces more and more exophthalmos and interferes with the movements of the globe. Vision is most frequently lost by pressure produc- ,g either neuritis or atrophy. Certain tumors fnay extend to the orbit from adjacent parts, — 1. Encephalocele. 2. Nasal polypi. 3. Growths from the accessory cavities of the nose. 4. Tumors of the lids and skin of the face. CHAPTER XVL DISORDERS OP THE OCULAR MOVEMENTS. Movements of the eyeball are required to place the most sensitive part of the retina where it will receive the image of the object especially looked at ; to keep the eye turned in the desired direction during the movements of the head and body that would other- wise displace it ; and to keep the two eyes directed to the same point to secure images which, by fusion, will give binocular vision. There may be inability to execute these movements, or they may be accom- plished by undue eflfort. If an eye is so directed that the image of the point on which attention is fixed falls on the fovea, the eye is said to fix that point. Normally both eyes fix the same point. If one does not fix the point looked at, but has its visual line directed elsewhere, it is said to deviate. Such an eye is called the deviating eye, the other is called the fixing eye. The point fixed is called the point of fixation, the angle between the deviating position of the visual line and its normal direction thiough the point of fixation is the angle or degree of squint. An eye which deviates is said to squint. The devi- ation constitutes a squint or strabismus. The varieties of strabismus are, 1. Strabismus convergens. 2. Strabismus divergens. 3. Strabismus deorsum vergens. 4. Strabismus sursum vergens. 100 DISHASES OF THE KYE. Convcrfjcnt squint.— In this the visual line of one eye is directed to the object fixed v.liile that of the other is deviated inward and intersects that oi tne sound eye at some point nearer than the object fixed. If, for example, the left eye squints the rij^'ht projects images correctly, the left makes a false projection to the left side, or the diplopia is simple or homony- mous. Divergent squint.— Here the visual line of the squinting eye lacks the necessary movement inward to fix the object. The diplopia is crossed or heter- onymous. In vertical squint the diplopia is crossed. Another classification of squint is i. Concomi- tant, and 2, Paralytic. In the concomitant form the angle of the squint is the same in all positions of the eyes. In the para- lytic form it varies. Paralytic strabismus — The general symptoms are, — 1. Loss of binocular vision,— /.('., diplopia. The separation of the images increases as the object is moved to the side of the paralyzed muscle. 2. Strabismus or non-correspondence of the di- rection of the two eyes. This depends on the loss of power in the affected muscle and the unrestricted action of its antagonist. This is not always plainly manifest and may appear only when an attempt is made to move the eye in the direction of the affected muscle. 3. Loss or limitation of movement. This is also called the primary deviation. The limitation is al- ways in the direction of the action of the affected STltAtttSMl'S. ,(j| muscle. Consequently the deviation of the eye is in a direction opposite to the action of the muscle. 4. Deviation of the sound eve when the affected eye hxes. This is the secondary deviation. Dur-ni? the act of fixation by the aflccted eye the same decree of nervous impulse passes from the centre to the muscles of the affected eye and to those of its non- affected associate j the former requires an abnormallv fc^rcat influence to stimulate its movement and hence the latter is over-excited and the resulting movement IS excessive. The secondary deviation, then, is greater than the primary. T^rimary and secondary deviations are in opposite directions. 5. There is fal projection of the field of vision. 1 his depends on an inaccurate estimation of the po- sition of an object situated in such a position that it requires an effort on the part of the affected muscle to turn towards it. 6. Vertigo may be produced by the diplopia and the confusion which arises from trying to distinguish between the true and the false. 7. Altered position of the carriage of the head. This depends on the impulse of the patient to carry his head in that direction in which he is least troubled by double images. Thi? is usually toward the side of the affected muscle. special Symptoms in Paralysis of Individual Muscles.-ln each case suppose the right eye to be affected. i. The external rectus paralyzed. The followinir may be present ; {«) Homonymous diplopia. The images are side by side, parallel, and the distance between them widens as the object is moved to the right. illi^ IM mSEASKS OF THE RYK, (*) Converjjent strabismus with limitation of movement outward. (c) The secondary deviation is inward, the false projection of the field of vision is to the right side, and the face is turned to the rijjiif. 2. The internal rectus paralv/ (fl) Crossed diplopia, the images being side by side and parallel, and the disUnce widening if the object be moved to the left. (*) Divergent strabismus. The secondary devi- ation is outward, the false projection to the left side, and the face is turned to the left. 3. The inferior ohlique paralyzed. (o) Homonymous diplopia in the upper field, the images being one above the other, the image of the affected eye being higher and inclined to the right (to the affected side), the vertical distance between them widening as the test object is moved up and to the left. {b) The affected eye is turned downward and in- ward. The secondary deviation is upward and in- ward, the false image is too far upward and the face is directed upward and to the left. Method of examination and diagnosis of the af- fected eye. — This is not always a simple matter. If the paralysis is complete there is little difficulty. When partial, strabismus and limitation of move- ment are wanting, and the diagnosis must be based on an investigation of the double images. The patient is to be seated with the head and eyes in the primary position ; that is, twenty feet from the ob- ject, in this case a candle flame, and one eye is covered with a red glass to distinguish the images. The following points are then determined : STRAnrSMVS. 108 1. The relation of the double images to each other and whether the images a. . visible in all por- tions of the field or limited to a portion of it. 2. The effect upon the lateral separation, the dif- ference in height and the obliquity of the images when the test object is moved along the horizontal plane, to the right and to the left, and above this plane, upward and outward, and upward and 'n- ward; then below the pbne, downward andoutv*. and downward and inward. 3. The character of the diplopia. If the .uble images are only visible in the upper field tn.n an elevator is involved, i.e., the superior rectus or the inferior oblique ; if only in the lower field, a de- pressor, i.e., the inferior rectus or the superior oblique. In the former case the false image is higher, in the latter it is lower. The Causes of Paralytic Siradismus.—Thesc are either peripheral or central, i . Syphilis. 2. Diph- theria. Th' affects the ciliary mu^^first, and the external muscles later. It comes a month after the attack. 3. Rheumatism. This is a peripheral cause, and usually affects the external rectus. 4. Poisons. Acute and chronic alcoholism, chronic nicotine, chronic lead and fish poisoning, and gelsemium, chloral and carbonic acid. 5. Diseases at the base of the brain. A meningitis, a tumor or an aneurism may press upon the cranial nerves at the base of the brain. 6. Diseases of the spinal cord, e*^; cially locomotor ataxia. In the latter case the i.db si.. , is often temporary and partial and may be iisooiatca with the pupillary changes characteristic f i>?\s af- fection. 7. Injuries. 8. Cppgenital paralv:-is. 104 DISEASES OF THE EYE. The prognosis depends entirely on the cause. The treatment also depends on the cause. The annoyance of the double images may be obviated by a ground glass over the affected eye. In some cases prisms may be worn to fuse the images. .Advance- ment of the muscle may be done. Paralysis of the intra-ocular muscles or cyclo- plegia may or may not be accompanied by dilatation of the pupil. The chief symptom is loss of accommo- dation just as occurs as the result of a mydriatic. This may be complete or partial. It cannot be de- tected after the age of fifty. Concomitant Squint. — In this the squinting eye has the power to follow the movements of the other eye in all directions. It may be periodic or perma- nent, monolateral or alternating. Etiology. — I. Disturbance of the relation between accommodation and convergence by errors of refrac- tion. 2. Disparity in the length and thickness of op- posing muscles. 3. The size and shape of the eyeball and orbit. 4. Amblyopia of one eye, by the loss of the natural stimulus of diplopia to exact convergence. 5. The distance between the pupils. Single Vision in Concomitant 5'^?««/.— Diplopia may be present at first, but does not continue, for the false image being less distinct than the true one is suppressed by the brain centre. Treatment of Concomitant Squint. — i. The spec- tacle treatment. The error of refraction should be determined and the proper glasses worn. In most cases the error is a hypermetropia, often associated with astigmatism. STltAIilSMUS. 105 2. Operative treatment. Tenotomy of one or both recti, with or without advancement of the op- posing muscle. Advancement is also made without tenotomy. S-wanzys simple test for binocular vision.— Wold a pencil midway between the eyes and the page of a book at right angles to the lines of type. If binocu- lar vision is present there is no obstacle to reading ; if not, portions of the page are obscured by the pencil. Latkxt Squint, Insufficiency of thk Ocular Muscles, Muscular Imbalance, Heterophoria. —These terms are used to describe a condition in which the patient has a habitual binocular vision, but maintains it by special exertion, and when one eye is covered deviation is manifest. The terms in common use are, — Heterophoria, a tending of the two visual lines to the same point. Esophoria is a latent con- vergent squint, and is produced by insufficiency of the external recti. Exophoria, a tendency to a divergent squint, is produced by insufficiency of the internal recti. Hyperphoria is a latent vertical squint. Causes. — The causes include some of the causes of actual squint, opposed by a well-developed power of binocular co-ordination and fusion. 5>'w/>/owj.— -Headache and eye ache are the most common symptoms. In severe cases vertigo, a sense of strain, or a feeling of mental confusion are also present. Pain in the occiput is common. It may follow the use of the eyes, or it may be delayed and come on at certain hours of the day or night. Chorea, epilepsy, melancholia, migraine, palpitation i 106 DISEASES OF THE EYE. Of the heart, night terrors, flatulent dyspepsia, and a host of other complaints have been attributed to mus- cular and accommodative asthenopia. No doubt they are often associated, and cure has followed the correction of the ocular difiiculty. but it has been exaggerated as a cure-all. The diagnosis of these conditions is made with t-ie aid of prisms, the Mad- dox rod or double prism, or Stevens' phorometer. Trealment.Sm^n errors are unimportant unless causmg symptoms. The error of refraction must be corrected, and this may be enough. Gymnastic exercises with prisms are of value. Practice is given in fusing the double images produced by pr:,ms Prisms may be ordered for constant wear. If these methods fail a partial tenotomy of the antagonistic muscle or an advancement of the feeble muscle may be done. •' Nystagmus. -Thisisa slight, rapid, involuntary, to-and-fro movement of the eyeballs. It may be from side to side, up and down, or rotary. It is either congenital or acquired. It is usually bilateral. In congenital cases it is seen with defective construction of the eye and in albinism. It may be caused by certain occupations, especially mining, and this form .s commonly called miner's nystagmus. This is the result of working in a poor light for hours with the eyes m a strained position. If high astigmatism is associated with it some improvement may follow the use of proper glasses. Change of occupation will also relieve the miner's cases. CHAPTER XVn. ABNORMAL REFRACTION AND ACCOMMODATION. Normal refraction is termed emmetropia. This is the condition in which parallel rays are focused exactly on the retina, the eye being in a state of rest. Abnormal refraction is termed ametropia, and of this there are three forms : 1. Hypermetropia. 2. Myopia. 3. Astigmatism. Hypermetropia.— In this parallel rays of light come to a focus behind the retina, the eye being in a state of rest. The causes are either an arrest in the development of the eyeball in its antero-posterior axis, the eye being too short from before backwards, or it may depend on deficient refracting power in the media. To correct hypermetropia a convex lens must be pl:i> cd before the eye to supplement its power of refraction. The strongest convex glass with which a hypermetropic eye can sec distant objects most dis- tinctly is the glass which corrects its error of refrac- tion, and is the measure of the hypermetropia. When no glass is used there is an excessive demand upon the accommodation in the effort to see distinctly. The effect of this strain is to produce, — 1. Cramp of the ciliary muscle. 2. Accommodative asthenopia. 3. Convergent concomitant strabismus. iifii i It; 108 hi i ■ nisKASj:s OF the eye. Mvoi'iA.-ln myopia parallel ray's of light come to a focus in front ol the retina, the eye being in a state of rest. In most cases the antero-posterior axis of the eye is too long. The amount of the error may be determined experimentally by trial lenses. Con- cave spherical lenses are used for this purpose, and the weakest lens with which the patient sees perfectly at a distance is the measure of the mvopia. It devnelops from the eighth to the tenth year and is apt to mcrease, specially during the early years of puberty. Its progressive increase is encouraged by much use of the eyes for near work. When myopia IS progressive it may lead to organic disease such as,- 1. Posterior staphyloma. 2. Degeneration of the choroid near the macula lutea. 3. Haemorrhage into the retina. 4. Detachment of the retina. 5. Opacities in the vitreous. It is also common to find insufficiency of the in- ternal recti muscles associated with myopia. Astigmatism. - This is a compound form of ametropia, due to the cornea being more curved in one meridian than in the other. The directions of the greatest and least curvature are always at right angles to each other, and usually fall in the vertical and horizontal meridians. The result is that rays of light entering the eye do not meet at a common focus but form a streak of light. There are various kinds of astigmatism, according to the position of the two principal foci in relation to the retina. ASTIGMATISM. 109 1. Simple hypermetropic astigmatism. In this the eye is emmetropic in one meridian and hyper- metropic in that ai right angles to it. 2. Compound hypermetropic astigmatism. Both meridians arc hypermetropic in this case, hut one more than the other. 3. Simple myopic astigmatism. 4. Compound myopic astigmatism. 5. Mixed astigmatism. In this one focus falls behind the retina and the other in front ; one meridian is hypermetropic and the other is myopic. There is also a condition called irregular astigmat- ism in which the refraction of the eye differs in differ- ent parts of the same meridian. This is due to ir- regularities on the surface of the cornea, the result of ulceration. It cannot be corrected. ANisoMHTROPiA.—This is the term used to denote a difference in the refraction of the two eyes. Presbyopia.— This is a diminution of the power of accommodation, which begins at an early age. and is due to natural changes in the eyes. At the tenth year of life the near point begins to recede. This is due to a progressive change in the crystalline lens, which becomes harder and, therefore, less easily altered in its curvature. In advanced life there is also diminished energy in the ciliary muscle. As the near point recedes from the eye it finally reaches a distance beyond that at which the person usually reads or writes. This cr.mes between the ogcs of i no J) /'S EASES OF THE EYE. forty and forty-five in normal eyes. In hyperme- tropia It is earlier; while in myopia it is postponed, or m the higher degrees does not come at all. Paralysis ok Accommodation. -This is usually combined with mydriasis. It can only be ascertained by examination of the function, and it causes incon- venience according to the state of refraction. It is caused by atropine, paralysis of the third nerve, ex- posure to cold, syphilis and diphtheria. Treatment depends on the cause. OPERATIONS ON THE EYE. CHAPTER L The Practice of Operations on Animals- Eyes.— The frequent practice of operations on the eyes of animals is of the greatest importance to a beginner, as it enables him to become acquainted with the use of the various instruments, to recognise the difference in density of the tissues which have to be cut, to become familiar with the technic of each operation, and to lose a certain amount of the ti- midity which is almost invariably present when be- ginning operative work on the live human eye. A set of instruments should be obtained and used for this purpose alone. The following are all that are required for practising most of the operations on the eyeball and muscles :-An eye speculum, a pair of fixation forceps, an angular keratome, a Graefe cataract knife, a pair of iris forceps, a pair of iris scissors, a cystotome, a scoop (Daviel's), a cataract needle, a strabismus hook, a pair of strabismus scis- sors, a small scalpel and a few curved needles. 119 opj-:iiATroxs oy the eye. P.gs eyes are the most useful for practice, as they more near^^ resemble human eyes in si.e and density of fssue than do the eyes of other animals that a e readny ohta.nable. Sheep's eyes and cows' eves wU do for demonstrafon, but are too dense and too large For operation upon the muscles, the orbits and the hds it is necessary to have the head with the eyes .n posmon. If possible the operations should be practiced also on the head of a cadaver, but it is -fficult to obtain material of this chara..r and en wlien .t ,s at hand the eyes are often so shrunken and collapsed, and have undergone so great changt hat they are not satisfactory. It is advisable to ot tarn some experience also on the eyes of living ant "^als. Dogs, cats and rabbits may be used for this purpose, of course under chloroform. If not convenient to use the dead eves at on.. tace. In the orbital cavities are placed removaM, fecu ell Will. It one does not nossess a mask a very good substitute can be had in a larX ee tacks A still more simple plan is to use a towel in which the eye is wrapped and held in the han" euher one s own or that c: an assistant. This is he best plan m practicing puncture and counter-puncture and the different varieties of corneal section lliinKCTitMY. 118 Iridectomy. -This is the principal operation done on the iris. It consists in an excision of part of that membrane. The indications for it are, 1. In closure or obstruction of the'pupil to make a new openin- for the rays of li^ht. This is termed an artificial pupil. 2. In central opacities of the cornea and lens. 3- In hi^rh degrees of keratoconus. In connec- tion with this the point of the cone is removed by cautery, the knife or a caustic. These three indications are for optical purposes. The operation is also used for therapeutic reasons] and is then termed curative iridectomy. 4. To reduce increased tension of the eyeball. 5. To cure or improve chronic iritis and irido- cyclitis. 7. To remove tumors and foreign bodies in the iris. To ripen immature cataract. As a preliminary step in cataract operation. •9- In removing traumatic or operative prolapse of the iris. The instruments necessary are a lid speculum, a pair of fixing forceps, a bent lance-shaped knife,' a pair of curved iris forceps, a blunt iris hook, a pair of curved iris scissors, a spatula, a blunt pointed probe and a narrow bladed cataract knife. The Execution of the 0/>emfion.-~Th^ patient lies on the bed or table ; his eye is sterilized and cocain- ized. In glaucoma and when the eye is much in- flamed it is necessary to use general anaesthesia. The speculum is introduced, the eye is held by the fixation forceps at a point opposite the point of punc- 8. I ■ 114 oj'KnATroNs ox riff: hyk. ure. The lance-shaped blade is entered at the ^I'Shtl) toward the .r.s. As soon as the point of the kn.fe enters the anterior chamber, the dire tl L chan.^ed so that it is pushed toward the axis^ the eye. and parallel to the surface of the iris. If Zo^ sary to enlar«:e the wound this mav be done when o he . Next the .ns forceps are entered and the ed.^e of the ms cau,.ht near the pupillary margin. The ns .s then w.thdrawn and the protruding. ,^.rt cut off -th the scssors. If the iris maintains its tJn t e orne re,„,„ to their natural position, and tl, pupH has the appearance of a keyhole. If the iris is caught .n the wound it must be freed bv he b lun po.nted probe. The eye is then dressed.' '^ ' " ordinarily not much reaction. Instead of the lance shaped knife, the narrow cataract n.fe maybe used, and it is a decided a„ ta^e.n glaucoma and when the anterior chan.ber is The iridectomy in glaucoma should be large and ■n the penphery. The Graefe knife is keptt^H "„ the sclera border, and as much of t.,c iris removed as poss.ble. The iris is cut first at one margin ^hn .t may be torn from its attachment or it uku b cT and hen a third snip removes the other corner If .t Ks necessary to make a verv small round openmg for optical reasons, we make a small co "al mcs.on a short distance from the limbus In an aphakial eye it is difficult to catch the iris -th forceps so we use a blunt hook for the purpose Accaen^s a,uf Misiakes.^^ When the anter o" ill inrhHcTOMY. ,,5 chamber is very shallow the knife may be advanced only between the layers of the cornea. This position of the knife should be recognized by the absence of the metallic lustre which any knife blade has when in the anterior chamber. If such a mistake happens, the kn.fe should be withdrawn and a new incision made. 2. The knife may en^^a^e the tissue of the iris If It cannot be freed the knife may be withdrawn enlar«:ins the wound at the same time bv cutting from within out. If the wound is still too 'small it may be enlar^-ed with a pair of scissors. 3- The capsule of the lens mav be injured. This will be followed by cataract unless the lens was in this condition before. The injury mav be done by the point of the knife or may be caused by the iris forceps in the attempt to catch the edge of the iris. 4. Haemorrhage into the anterior chamber may be the result of two causes, either a faulty tochnic in the operation or a haemorrhagic predisj osition of the eye. When the whole cavity is filled some of it may at once be removed by the spatula. 6. Prolapse oi the vitreous mav occur. In glau- coma no harm comes from this. ' Some operators consider it rather a favorable condition. 7. Incarceration of the iris. This is one of the most common imperfections of the operation. A second operation may be done to relieve it. Operations on ihk Crystallink Body.— Cata- ract operations are of three kinds : ,, displacement, tin onKiiATroxs ny the hyk. til when the cataract remains within the eve hut is pushed away from the pupil; .. extraction, where i s taken out cf ,he eye ; and ,. discission, where the lens capsule .s divided, and the lens suhstance hrou^rht ,n contact w.th the aqueous humor. I,v which .t .s K-radualiy dissolved and ahsorbcd. This' onera- t.on ,s also called the method by solution. I).s.M..xcKMKxr.-This is now more of historical ttun practical mterest. From antic,uitv down to about ,S3o u was the reco,.ni.ed operation for catl! ract. It was done m two ways : '. By depression. A broad needle was intro- Uuced throu.^h the lower segment of the cornea int the pupdlary space, with the surface of the blade flit pen , he capsule of the lens, then by ..adually ra.^i'; the handle of the needle the lens is pressed down and couched .n the lower anterior part of the vitreous 3. By reclination. The needle is introduced throu.^h the sclerotic some distance bc-hind the cor- ea. t e eye bein,. rotated at the same time in the op|.os,te d.rcvt.on. The needle is thrust oblinul orward to enter the lens which is then torn ^ »rom .ts l„.ament and pressed down into the vitreous' The cataract would often rise a^^ain before t^'^ needle was withdrawn, and the operation had to t repeated. It mostly rose a^^-dn the following, dav o! -some t,me later. It produced irido-choroidi^is lu coma, detachment of the retina, and phthisis b'u.bi" The operation ,s still recommended by a few for ce ta.n cases of shrunken and secondary cataract ExTRACTtON-.-This operation was first done by uav.el m ,745. it was not universally adopted tin almost a hundred years later. The operation is Z KXTItAcriOX. 117 dicatcd in all hard cataracts when the functional ex- amination warrants the possible restoration of vision. There must In; perception of lig^ht from all parts of the field of vision. The age of fifteen years is usually considered the end of discission and the bcKinnin',; of extraction. Old a^re is no contraindication, if the health is jjood. The question is often asked whether we should operate for cataract as lonp as the other eye has ^rood sipht. The answer to this must depend on the con- ditions surrounding each patient. \\c should ope- rate when the chances for success are greatest, ft is never advisable to operate on Ijotli eyes at the same time. The instruments necessary are : A speculum, a fixing forceps, a Graefe's knife, a cystotome. a Daviel's spoon, a wire loop, a spatula and blunt pointed prol>e, and if excision of the iris is necessary, the iris forceps and scissors. The Technic of Extraction.^ 'X\XQ first step is the corneal section. The puncture is made through the limbus of the cornea on the temporal side about one-half to one millimetre above the horizontal me- ridian ; the knife passes straight across the anterior chamber, keeping clear of the iris, and transfixes the limbus of the cornea on the nasal side at a point just opposite to the point of entrance on the temporal side. By backward and forward movements of the knife the section is completed in the limbus, but at the last a small conjunctival flap may be made. The section comprises almost half of the corneal circum- ference, and lies from one end to the other in the same plane. 11« oi'KnArroxs ox 77//.; aia-. eveball bv means o a IW' I ' " ''"' °" "'" . . '"■■""•ol •> l>aviel scoop or a sniiliila If till- lower p:m of the corn,.n .1,. "P-raila at itself in Z'.a^ '^ '"T' "'P '"™"'''' P'^*"^ , '" '"° K^P' "'"I ""Jcr continued pressure it will closed and ailoued to rest L '* • ^'' " "'''' z;;j-Sa^:;.r'f-=--:::: of the eU^csofZ" ;, '^ T,,';'-; T*" ^-P""'"" and the dressings applied '' ""' """^ ■="""■•" anterior e,,an,,,erlt;i::-\,:;tn^::r:,:,'rtt'^ rected. ^^'thdrawn and the trouble cor- up»L''''vrc:d;er:ii;',''^"'r "■■'--"'"« ly forward to avofd i. If '•/"■' ""'"'^ '*'«'"- -ains before t::;:ife;i'Hr-^!:;Vn:;,t;'' I':XTIi'ACTI<)X. 110 T,. The knife may be introduced with the back up instead of the cuttin^r cd^e. This can be remedied by simply turnin^r the knife and continuing the sec on as if nothing had happened. 4. If the knife deviates from th ti le plane of the whicl is section, it w ill make an uneven sui favorable for primary union. 3. In using the cystotome the ligament of the lens may be ruptured. This may not involve any- tiung more than removing the capsule with the lens, or it may necessitate an iridectomy. 6. We may fail to open the capsule. Then the cystotome should he again introduced. 7. The section in the cornea may not be large enough to allow the lens to pass out. In such a case the wound shoul.1 be enlarged with scissors. 8. Prolapse of the vitreous is one of the common accidents, and it may be unavoidable. As a result of disease the ligament may be frail or ruptured, and as soon as pressure is put on the eye vitreous presents. 9. I laemorrhage from the depth of the eye is most serious. This may occur during the operation or soon after. It is generally accompanied by intense pain. DiscissioN.-This is indicated,-!. In cataracts of young people up to the age of fifteen, and some- times up to the age of thirty-five. 2. To ripen cataracts. 3- As a step in the sur-o^ical treatment of high niyopia by extraction of the lens. This is known as tukala's operation. 130 act op/:h\\T/oy,s (KX thf. eyf.. 4. As a frequent operation for secondary catar- The instruments required are, a speculum fix bein.-- sliHuK- ,,Ki; , '"'''^^'"' ^'i^-' puncture -™:r- xr;,- j'i5 ? OPERATI0.\H OX THE COKNEA Cou.NKA.-Jh,s ,s called also abrasio cornea. h 2. In the de^reneration of the corne-,1 .....m ,^ ^^- Which a senp „f,|,e ,i«„e C ^op^ f"" '" fit' 'a^nr °"" " ™"' ^°"- °f- opac : CAVTIUilZATION. jgl Incision, CrRETTiNo, and Disinfection of ClRCLMSCRIBKn INFILTRATIONS OF TIIK CoRNEA.— This IS applicable :— 1. In pustules of the cornea. 2. In marginal infiltrations which produce ores- centic. annular, and progressive ulcers. 3- In irregular, progressive infiltrations, such as accompany dendritic, serpiginous, and malarial kera- titis. A fine sharp spoon is used to scrape awav as much tissue as may be necessarv, and then the 'area .s touched with iodine, nitrate of silver, or bichloride of mercury. Iodine is the best. There is also the method of hyJraulic curetting by means of a fine jet ofantiseptic solution thrown with considerable for'ce from a fine syringe. This operation is facilitated bv the use of fluoresccine. i Cauterization. -The cautery mav be chemical, thermic, or electric, and is used in diseases of the cornea, and conjunctiva, and for certain conditions of the lids and lacrymal apparatus. Nitrate of silver is the chemical caustic most in use. The actual cautery does not require a special instrument, but may be used in the form of a platinum or silver wire heated m ^spirit lamp. The galvano cautery may be used .n the following conditions. ,. In infected corneal ulcers. 2. In keratoconus. 3. In infected wounds after cataract extraction. 4. In trachoma. . To obliterate the lacrymal sac. 6. In small staphyloma ot tile cornea. OPKItATloys ox THE KYE. with^ , . V" "" ^"'^^-^v.-This Is made u.th a .tra.^Hu or bcMU lance or wi.h a narrow or tri- an^rular cataract knife. The indications are - ■• \o evacuate blood from the anterior chamber. 2. ro evacuate pus from the anterior chamber. 3- In intis serosa. 4- In glaucoma. 5. In swelling of the lensafterdiscission or injury. atcd In slowly withdrawing the knife while pressing the posterior lip of the wound, or after the 1< nifeit removed a probe or directo- may be used to keep the wound open. * Kk-'ATfoxs ox Tin: kyk ■i 1 years. The immediate elTect of a tenotomv of the external rectus increases the next three or four davs, then it diminishes very j^radually so tliat the uhimate result may he that the eye is in the satne position as before the operation. In diverj^ent strabismus there is not much danjjer of convertiny^ into a convtrj^^ence. To diminish the effect sutures are apph'ed, either a simple closing; suture, or a restrictive suture, taking a firm hold. To increase the operative effect the wound may be extended up and down, but this must be done with great >.are. If overdone it makes the eyeball protrude and the caruncle sink, ijiving the eye a starinij look. For the same purpose the eyeball may be drawn to the ether side by a suture passed throu.i,^h the super- ficial layers of the sclerotic near the cornea and the corresponding lid commissure. The following accidents and mistakes may happen : — 1. The wrong eye may be operated upon. 2. Haemorrhage may occur into the capsule of Tenon so that d. The advocates of this operation substitute it for enucleation in all cases except intraocular tumors and foreijjjn bodies. I'"visl"i;r.\tu)N with tuk Inskrtion ok a.v AuiiiiciAL ViTRKOLS. — This is known as Mules' operation. After evisceration a bead of glass is in- serted before the wound is stitched. Many of them heal nicely, the artificial eye fits well, and moves perfectly. '\ 5 OPEUATIONS ON THE TEAK PASSAGES. 1. DlLATATrON OK TlIK LacRY.MAL P'NCTA. — This is done with a conical probe, usually as a prep- aration for washing the passages. 2. SurriNi; thk Canaliculis. -A canaliculus knife with a probe point is used for this. 3. SvRiNi;iNG the canaliculi and the other parts of the tear passages. .Anel's or Meyer's syringe is used. The fluid may regurgitate through the same canaliculus, it may escape through the other canali- culus, it may distend the sac, or it may pass through the duct into the nose. pryrTi'Rf-:. i::d 4. F'tNCTiKK OR Pakacknthsis o( the lacrymal NIC is done with a small scalpel or a cataract knife, below the inner canthal li^'ament, throiij,'li skin, muscle, and lateral wall of the 'sac. 5. I'aktiai. Kxcisidn of the sac and extirpation of the sac are extensive operations. They should not be resorted to until other operations have failed. 6. I»Ri>HiNi; the lacrymo-nasiil duct. Bowman's or Theobald's probes are used. CHAPTER II. 'i . » OPERATIONS OX TIIK EYKLIDS. Oi'KRATtON lOR CiiALA/.ioN.— The incision may be made cither throujrh the conjunctiva or the skin. The latter is chosen when the cyst is of larj^e size and is nearer to the skin, and when this is necessary It is advisable to use a general anaesthetic. King forceps or a Snellen clamp is used to give complete control of the lid and to prevent bleeding. The in- cision should be hori/oiual. The sac is then caught with forceps and dissected out with a small knife or small scissors curved on the flat. The cartilage and conjunctiva should l>c spared as far as possible. If the wound is large it may be closed by very small sutures which may be removed in twenty-four or forty-eight hours. \o special dressing is needed. Cold applications will diminish extravasation and oedema. When the incision is made through the conjunctiva local anaesthesia is employed. Tiie clamp must be dispenscJ with on account of the pain. Pressure and a small curet are used to remove the contents of the sac. Ol'KKATIONS lOK TRICHIASIS AND DlSTICJUASIS. —These are directed to repeated removal of the of- fending lashes, correction of their deviated positions, or destruction or excision of their bulbs. Simple extraction of an inverted lash is a palliative measure FOR Tnrrm.ists AND pistk ufAsrs. tsi only, though in rare instances the frequent repetition of this causes the bulb to atrophy and the lash ceases to grow. The epilation is done with cilia forceps. When only one or two lashes are involved, the rest of the lid margin being normal, it mav be well to he content with the relief obtained in this way. Indi- vidual lashes may be gotten rid of by electrolysis By this means the bulb of the lash is destroyed. A constant battery of six or ten cells is used. ' A very hne needle of steel or platinum is attached to the negative pole, then introducet' into the follicle at the side of the lash, and the circuit closed by apply- mg tht . ;e electrode to the temple or hand. A milliamperc meter is necessary also, for not more than five milliamperes should be used for this pur- pose. When the circuit is closed, a slight frothing IS seen around the stem of the needle, caused by the escape of bubbles of gas, and this is the sign for breaking the current. The lash comes awav witb the needle or is withdrawn by very gentle tract'ion, if the application has been successful. There is seme pain in the operation. Where the trichiasis involves a small group of lashes the Gaillard suture is used bv many operators A thread is entered through the ski., at the edge of the lid near the deviated lashes, passed deeply under- neath the muscle, brought out half an inch from the lid margin, and firmly tied. It is left to slough out and so forms a cicatrical band which holds the lashes everted. There is an ancient operation known as "illa- quaetio ciliorum," that is still done to change the di- rection of individual lashes. Celsus rctc'i^s to the Ik' mrM-'r^:^ 132 0/'K/,'AT/(>XS OX Tin-: EYELIDS. I I operation but without approval. "Some allej,^e that 'tis proper to pierce the external part of the eyelid near the eyelashes with a needle which must be passed through with a woman's hair doubled for thread ; and when the needle has gone through, that the offending hair must be taken up into the loop of the woman's hair, and by that drawn upward to the superior part of the lid, and then to be glued down to the flesh, and a medicine applied to close up the orifice thus made." The only difference now is that a thread is used in place of the hair. The trouble with this little operation is that the cilia only live for three or four months and their successors cannot be depended upon to grow in the new direction. Another operation is that of "scalping." The edge of the lid is split and an incision parallel to the lid margin is made through the skin and muscle only. This sepatates a narrow band of tissue con- taining the bulbs of the cilia, which is dissected away. The cut edges of the skin and conjunctiva are united with fine sutures. Care must be taken to remove all the bulbs, and search for them may be made with a lens, the part being kept bloodless by clamp forceps. Oi'KRATiONS FOR ExTRDi'ioN. — The Curability of disease is in inverse proportion to the number of remedies proposed for its cure. If that is true en- tropion is a very difficult condition to treat. In going over the literature on the subject one soon comes to the conclusion that since the time of Celsus every surgeon wiio has treated the eye has devised an FOR ENTltOPION. 133 operation of his own, or at least has modified the operation of some other operator. It would not be profitable to attempt to describe even the modern methods of operating. It will be enough to point out the four classes of operations done. 1. Those that propose to evert the lid margin by the removal of the skin of the lid, or by the contrac- tion resulting from the use of caustics, cauteries or sutures. 2. Those that depend on the tension of the skin caused by uniting it with the orbital margin of the tarsal cartilage. 3. Those based on the transplantation of the bulbs of the cilia. 4. Those in which the tarsal cartilage is incised or grooved on its inner or outer surface. Opkrations for Ectroimon.— Acute swelling of the conjunctiva producing ectropion may be relieved by scarification of the membrane. This is best done by introducing one blade of a pair of sharp-pointed scissors beneath the membrane and slitting it freely throughout its whole length. The operation may be repeated several times if necessary. If the lids are permanently everted by hypertrophy, a portion of the thickened conjunctiva should be excised. This may be done with the sharp pointed scissors, or the lid may be held in the clamp and a fold of the conjuncti- va dissected out with a knife. Such an operation must often be combined with slitting the canaliculus, to provide an exit for the tears. The canaliculus is converted into an open trough. 134 opuhw rroNs on the kyklids. In simple removal of the mar^nn of the lid from the eyeball, due to senile relaxation or partial paraly- sis of the orbicularis, the appearance is much im- proved by narrowing the commissure ; the edges of the lids are freshened and brought together by a suture. This is termed tarsorraphy. Snellen's oper- at.on by ligature will give good results in ectropion of the lower lid without cicatricial contraction and without much elongation of the lid margin. Each end of a thread is attached to a needle, and both needles are entered through the conjunctival fold and brought out through the skin some distance below the margin of the lid. The points of exit should be wider than the points of entrance. Traction is made on the ends of the thread till the lid is replaced, and then they are tied over a piece of adhesive plaster. Two such sutures may be introduced. A compress bandage is applied, and the threads are allowed to remain for four days. Dieffenbach's operation is more certain and per- manent. An incision is made in the skin parallel to the lower margin of the orbit and slightly above it. The wound is made to gape by stretching, and the dissection is continued till the conjunctiva ' ^ached. It is then incised throughout the extent ound, and the anterior edge of this conjunct, . cisioni which is connected with the attached mj..^i„ of the tarsus, is drawn into the wound by hook or forceps and secured there by sutures. When there is con- siderable elongation of the lid margin it is necessary to remove a portion of it, and a number of operations arc practiced for this purpose. Adams' operation removes a wedge shaped piece. FOR KVTltOPION. 185 involving the whole thickness of the lid. This is removed at the middle of the lid margin and the edges of the wound are brought together by small harelip pins. The healing of a wound in this situa- tion is apt to be interfered with by the accumulation of tears, and a puckered, irregular cicatrix in the middle of the lid is a serious deformity. Von Ammon's operation dees away with this ob- jection. The redundant lid is shortened by removing a piece at the outer canthus. When the eversion is due to contraction of the skm, as is the case after burns, some operation must be adopted th t will return the surface of the lid to its normal position at the expense of the skin of the neighboring regions. These are plastic operations, and must usually be devised to suit the case. Opkrations for Ptosis.— In most cases the muscle has lost its power, so that not much can be expected from its adv^ancement. The latter form of operation would only be successful Jn those rare cases where the muscle has been detached from the carti- lage by a wound. In all other cases the object is to promote the supplementary action of the occipito- frontal is. The simplest operation is the removal of an ellip- tical piece of skin from the lid and bringing the edges together with sutures. The result is satisfac- tory when there is only redundancy of the integu- ment, and will answer in the slighter cases from other causes ; but in the higher degrees the effect is insufficient. 130 OPERATIONS ON THE EYELIDS. By Graete's operation the lid is shortened subcu- taneously and the power of the orbicularis is weale adopted for the physical and functional examination. A chn- ical history alone is not sufticient to form an accurate diajjnosis, except in the case of lesions of the auricle. Tin- Phy skill Examination :- This resolves itself into four parts as follows : 1. Inspection hy the naked eye of the auricle and surround in^r parts, and examination by the finger of the parts around the auricle. 2. The use of the speculum to examine the meatus, the membrana tympani, and sometimes the tympanic cavity. 3- The use of rhinoscopy and the finger to exam- ine the nose, nasopharynx and pharynx. 4. Examination of the eustachian tube and tym- panum by inflation and the diagnostic tube. Inspection by the naked eye is made to determine the state of the skin, the presence of eczema, inter- trigo, swelling, inflammation, tumors, boils, mal- formation, facial paralysis and injuries and collapse of the meatus. Inspection is supplemented by pal- pation to discover hard tumors, fluctuation and ten- derness. In regard to tenderness the following rules will usually hold. Tenderness over the tragus indi- cates inflammation of the meatus ; tenderness below the auricle on deep pressure into the glenoid cavity indicates inflammation of the middle ear ; tenderness on pressure over the mastoid denotes mastoid in- flammation. The second part of the examination has to do with the external meatus and the mem- brani tympani. The first essential in making this examination is suitable light, which may be either direct or indirect ; direct when thrown from the ill 149 DISEASES OF THE EAR. source strai^rht into the ear; indirect when it is reflected hy a ..lirror into the ear. The h>;ht may be sunli^'ht. dilTused dayli^'ht or artificial light. The two former show the natural color of the parts seen, but sun- light is not always to be had, and diffuse davlight vanes greatly in intensity and cannot be depended upon. Any form of artificial light will do if suffici- ently intense ; in a darkened room a common candle will do very well, while in the patient's house a kero- sene lamp or the ordinary gas light answers the purpose. In an office it is best to work in a bright room, using the incandescent gas light with a Mac- kenzie condenser. This light is not only the best but the cheapest. The mirror used to reflect the light IS worn on the forehead and the polished sur- face IS concave with a focal distance of from eight to twelve inches. The size of the mirror varies from two and a half to four and a half inches in diameter. The mirror is perforated at the centre and is worn so that the perforation is directly in front o. one eye or the other. The position of the light in relation to the patient and to the examiner is important. The sur- geon should sit directly facing the ear, having the light to the side of and beyond the patient's head and on a level with the ear and his own eve. If the right eye is used the light must stand to 'the right • If the left eye, to the left. It is impossible to vievv the drum membrane with both eyes on account of the small aperture, the length of the canal and the short distance at which it is necessary to work. The eve behind the mirror is used, the other being completelv relaxed. The specula used are either long, short or dilating. The long consists of a long, narrow fun- J'J/rs/rAL HXAMIXATlDN, i^ nel. cither round or oval in section. These may be introduced into the osseous meatus, and are supplied m sets of three or five, bein^r made of silver or vuU can.te. The dilatinjj speculum consists of two blades introduced closed, and then dilated either bv a screw or handle. Sci^le's pneumatic speculum is'a modifi- cation devised to examine the mobilitv of the mem- brane. To mtroduce a speculum it should beheld .jjhtly between the thumb and index fin^^er of the left hand, the auricle grasped firmly at its upper and posterior margin, between the third and fourth fingers of the .san.e hand. As the speculum is intro- duced the auricle is drawn upwards and outwards, and ,t should be of such a size that the walls are simply separated by it and not stretched. Forcible insertion or attempts at dilatation are to be avoided n makmg t.he examination attention must be paid to certain point, regarding the canal. Note whether ,t is free throughout its entire length or partially or completely obstructed. If not free 'the nature of the obstruction should be determined It may be a foreign body, a mass of impacted secretion from the ceruminous glands, or epithelial debris from an infiammatory process or from a parasitic growth or It may he a fluid blood, serum or pus. The canal may be obstructed at only one point, in which case a probe is used (o determine Its densitv whether it is hard or soft, tender or anaesthetic, and whether presenting a denuded surface. The canal may be narrowed uniformly, the densitv of the walls being determined by the probe. The condition of the skin lining the canal must be noted to determine whether it is dry and desquamating or moist and lU !i: nisFASf:y OF Tilt: / i /,•. rcJUcncd. or covered with p uchcs of Jrv cr..v ^oxt the drum membrane .. examined or pa,h> loKMcal changes. A perforation ...n in most . ies uc ea-Iy.nadeout. .tmay. i.owever,bcsosmall.hat of its valvular shape. Infla, h>„ while it is under o},- «.rv..t.on or with the di.,....., ,.h.. ..„ ,,,,,, ^ cxtstenee or pos.t.on. Variations .. ,he lustre .. .h. m.,n^.nef^.rn.sh va|uaMeindicat.on.i. ^ertai. .^ fecnons. In health the .rt. have a pecuhar bri, , •TPc-^ ance wh.ch may be diminished or a.uiL he bttcr cond.tion inJ eating, a I .ss of ,he ^upet' K.al eptthelium. The cone of li^^ht is to be cLre- ullyexam.ned its sha,.-. position and extent, " ^e presence of one or n,orc bri.,'ht points or An reflexes ,n ,.cher parts u^ the membrane all .u. ststance in form.n^ a dia^niosis. The .nomb, . ." v.brans should ^ of uniform t.xture xccn, ,» the per^hcry and u...x> where it is omewhat th.. ...„^ in d,s.aseth.s n,av undergo hypertrophy in i.ce- he aftc. red areas appearing, less translucent rha th surround.. .g portion. The same eOlc is p.oLced by calcareous deposits, which anp,,,: as .m well-dchned. lustreless, white area^ '^ '"'' of the drum may be either o . ^J the bul^riK outward i, excels. th, cation between the canal wall ,d i; literated. Accumulati ns of fluid ii common caus of such displacv deyee they may be produced , .....,,., ,,,^^^^^^ etract.on of .he drum head p. oes pron„„en ^f .he tympamc .n^ and fb-eshorten .g c^ eh . n,a^:^ l>ispiiicemenr i'' tymp, en?s, bu! ■ I, -icmar- ;hi in simple rrl nation. Ik. /'itysi^M. /;.v., i/SATtOX. IT '»anUle. if „o adhesions exist jK-t^vcen it md th . • ivmi>aiH\ wall I . ^*-" "•'"" »ne inner vmpaiHv uall. hen such adhesions do evist ,l, Ppcars a prurn.ne.a r.d^.,. hut is not foreshortened S-ha.onU.aon,sf. ,uently seen in children .h ZZr'tT'- T"^ '^>-^^-^' -f ''^ht is o ^;V '• , '^ ''^V"''"'"""^^' '■■* ^'^ '■'«"^'«-« the h-,.ht •t reach the circ. ference ; when the con- 'S Verv irri.-if if n ^" tl' 'mbo. o, ,.s ost entirely. When the .vl. t"^>-^'-"-P«'-'^>f the inner wall t\mp„ 11 ^-.-in f^, seen. .1- The e.\ .mination of the nni:.. «.. u ~i.:.. -_. , " pertrophic and atro- •v- ,..,.1 .. _ >; and naso-pharynx we :Jrrouths, cic;-i'ices of • hypertrophic and nouth carious teeth phic catarrh. In the look for ^granulations, former ulcers, enlarged atrophic pharyngitis. i should be noticed. otherwise Th ,. ^'^°-^*' P^*^^ n«t iccessible ;n .he ™a.„s of ,h. ^z ant,;:: h::ir.tr:f .he surge... ,„„„„,„ „, ,„^, ,„„^„„;'-.;" f/J "' 14(i niSKASHS OF THE KAIi. by a sudden condensation of the air in the naso- pharynx, which causes a corresponding increase of a.r pressure in the middle ear. provided that the eustachian tube is open. As the tympanum is sepa- rated from the external meatus by only the thin mem- brana tympani the impact of the air upon this deli- cate membrane is readily heard by the diai,^nostic tube I h,s sound of impact under normal conditions 's oi a sharp metallic character, and is due to the stretching' oi the drum head bv condensation of the a.r ,n the middle ear. The sharp metallic click or snap ,s sometimes followed later by a similar sound of lower pitch and less intensity, due to the return of the membrane to a condition of equilibrium. Fa- m.hanty with these sounds in health enables one to 'nterpret the meanin^r ,,i any modification due to pathological conditions. If a perforation of the drum exists a whistle is noticed, while if moist sounds are produced fluid is present. ■ J/.M«/.v of Injla/ion.-^u Valsalva's method. I 1 he patient compresses the alae nasi with the tliumb and fo.elin^.er to close the nostrils ; at the same time the mouth is closed and an attempt made to force the a.r throu-h the nostrils by an expiratory efTort. The result .s to force air up the eustachian tubes into the tympanum. This may be done while the surgeon lias the speculum in position and he can see the ef- tcct on .he drum of increased intra-tvmpanic pressure. 2. \ oht.er's method. This consists in the use of a rubber bag to force air through the eustachian tube. I he extremity of the tube is provided with a nose- p.cce which IS inserted so as to close the nostril. The other nostril is closed by compression, and the rXFLA TrON. 147 Th.. o.f f ,. ^"^ eustachian tubes 1 ne act of swallow nir shuts nff tu, . m.l;.":'„::rre - ■": '^--^ "-- ' '^« or an> sellable i^ontam ntr the K sonml i • r ■he ac, of c,vi„,. p.„duc« s^ffi^:: "!„: '„" Ts! panum of one side or the other by meLns of . an> of the methods detailed or ivh^n »k u ^ Uesires ,„ .„„u.v oarof,,,,, t ^^uT HeaV^T tlia^rnostic tube. In the wav nf tr . ^ ,^1, I t ' ''' treatment t is <»m ployed where it is desired to act ,.n The catheter is of silver vt^I . ^^ '^' °"'>'- f. . Miver, vulcanite or irum-elasrio from s,x ,0 ciKh> Inches Iohr, ben. in L arc of i c.rc,ea,„„ecnd. Tho o.her end is dillVs^aAo 148 liTSKASF.S OF THE EAK. receive the nozxle of the air baj^, and here also is hxed a guide ring to indicate the direction of the curved point after it has been introduced into the nasal passages. The catheters vary from Xos. , to 6 of the French scale. Pure silver or vulcanite i^ to be preferred because the curve of these can be easily changed to suit individual cases. The catheter should bo introduced into the nostril with the curved point downwards. As soon as the point passes the elevated anterior margin of the floor of the nose, the hand IS to be raised so as to bring the straight part of the catheter to the horizontal position. The in- strument IS guided straight backwards until it reaches the posterior wall of the naso-pharynx. Force should never be employed. To bring the catheter from this position into the orifice of the eustachian one of two methods may be employed. It may be drawn for- Avards about H or -, of an inch and then rotated till the guide ring points directly outwards to the side to be mflated. The hand is then elevated a little and carried slightly towards the opposite ear ; this causes the pharyngeal end to descend and press lightly agamst the lateral pharyngeal wall. Then by draw- mg the catheter a little outward the tip can be felt to impinge on the posterior lip of the tube. It is to be drawn over this, the tip being slightly lowere^^ if necessary, avoiding undue force. Then' the catheter -s rotated until the ring points upward and outward towards the ear. while at the same time the outer end of the catheter is pressed against the septum. It ^s now hrmly held in position by the left hand, the nght being free to compress the bulb forcing air through the tube into the middle ear. The second CATjn:T^:,..zzATroy or , r,,cuu.y rcn^. ,„ method is eo have the poim of ,ho cathe.er airain,t vaTrhro'"""-^^'"'''"-^- "- "> --".i o wards the opposite side, then withdraw it ,M ,u curve hooks the septum. While h Mfil l i' tw! pos,t,on rotate asain ,80, the outer end J'' pressed aga.nst the septun,. When the pj „, o^hf catheter ,s ,n the riyht position the Kuide rin , ,L^^ re :i;h:r",:r ''"""- " "■= p-« ^-t'"^ : o . .u ^'f*-^^*^" against the sepfum. If in dnuht as to the position of the end of tho cathete a rhinn SCOP.C examination should be m. le to verify its ho uic air Dag is fixed in its outer extr^m.f,, and air forced throiurh tk- • ""'^r extremity uirougn. 1 his IS at o.ice felf hx, tu patient and heard by the surireon f I amount of obstruction exLs tt "' ^? """"^''^'^ produced by compressi:;^ ^I^ I^^f^.^^ ;-i^ swallows. When one nostril is cios^ed the eath e may be passed through the other ..h/ 1 being lengthened. Thtre is al^o p "' /^' '""^^ to be used through thr::^^ L^pLt^tTir from the use of the catheter are rare C^ Ported^f.ossofconsciousness::d^.^S:::?t;;: 'ng. A more common occurrence is om^h ^^ c s °: ';t'r """ "" "'■'''"' '» '"cxcusawe t catheter. This is dangerous and must be prac lit! ISO ihsi:asi:s hf rm-: kaii. t.sed w.th «:reat caution. Over innation of the jjood ear may be avoiJed hytiltin.^^ the head till the side to be .nfated is uppermost and then having the patient press hrmly into the meatus on the side not aflected so as to support the drum. The sounds heard on auscultating are produced uther ,n the tyn,panu,n. in the eustachian tube or at the pharyngeal orihce. A great deal of practice is U 1 n t e tube .s open a sound from the tympanum s full, clear and unm>.taka!,!e. If the drum is per- n^ated the sound varies with the si.e of the ori^. W hen large the a.r seems to blow right into the sur- .<-^" s ear; ,f small a whistling sound is heard. n.sroRv. -After completion of the physical ex- --"Hfon and before going on with the functional nvest,gat.on it may be well to enter ful.v into story of the case. First the general history and then that of the aural affection ha„i;^„;'-;L"si'K;:,r";:"v""-' "^■""™'°" """ "■= h.K-. r known, particularly the habtts of the patient regarding the use of op-ate ^.nudants and tobacco, or the fact of his go „' hrough any uK-ntal strain or physical exert.on. Tht h.story of any previous illness should be considered • whether ,n childhood he had any of the exanthemata* factor .s the presence of hereditary taint.-- tubcrcu- lous, syph .t,c. gouty or rheumatic, as well as the bcrs of the family. Special attention should also be Pjud as to whether at any time it has been nee I ^ to take continuously large doses of the drugs which have a specie action on the auditor- or.rans The present state of the ..nera. health should be Inded portant si". t '" '''''' '"' ^^^^-^ is i^- portant so also ,s the condition of the pelvic or^rans 1 he cond.fon of the ears in childhood Lou d bt a t certa.ned and the length of time that the prLnt troub e has existed Ti, . o present mtionr I. symptoms upon which the cond,„o„s .hese are mo»e .r„ublc»m., whe he the patient hears better in a noisv „r i„ place, and .-hether the chief UiStv,'e„nZr termincJ,— whether in the moninir or -.f th« a \ power "The- '■-■''•''".■^■^""^- ^ '--? -he hearing pice e^tnination retfuires the'estil'tio^ fl^.hTe" Suahtattve and quantitative condition of Sng! 152 nrSEASES OF THE KAIi. I M There are many patients who consult the surgeon for tmn.tus and whose hearin^^ is distinctly impaired, yet deny any sug^ft^estion of deafness. The fact is that ,n ordinary surroundings the normal ear is rarelv called upon to exert its functions to the fullest extent possible ; and so a considerable degree of deafness the faTt! ' '"^' '^'"■^^^^P*^"^'"^' appreciation of Sound waves may be carried to the sensorium in two ways, — I. By air conduction, and head' '^' *"'"'" ''''"''"''^'''"' ^h'-0"ffh the bones of the There are two practical methods of testing the hearmg power by air conduction ; (,) the watch, and (2) the voice. Folit.er's acoumeter and Xeefs hammer and induction coil arc for theoretical demon- strat.on rather than practical use. For convenience he hearing power .s usually expressed ^ a fraction, he denominator of which represents the distance in tect or inches at which the sound is heard bv the normal ear. and the numerator designates the dis- tance at which the same sound is heard by the affected ear. Thus if a patient hears a watch a three inches which ought to be heard at thirty inches 3-30ths represents the hearing power. Certain prel cautions are necessary in testing with the watch rhe opposite ear should be closed and the watch brought from a distance towards the ear till the tick .s heard, and this repeated several times to be certain the answer is correct. The ideal test is the human voice, since that is the s.und which the patient is most desirous of hearing, and because his own esti- FUNCTIONAL IJXAMINA 770.V isg mate of the progress of his disease is based ov the ease or d.n,cuhy with which he is able to understand the vo.cc m general conversation. The onhnarv conversational voice varies .. -...h in pitch dT^ ":::r^r^^^^'^^''^ -di^tead. ^^ K'vesa fairly constant sta. ... . The patient soon becon^es familiar with set worus and phra'ses u ed in berr:r:"^r"' " '"^ " '^ ^^"^-^ ^^ -"p'«y — bcr. of t.o figures, and to change these constantlv. tions of letters are more easily perceived than others Even when whispered with the same intensity el h letter has a value peculiar to itself, the vowelsLfng heard more easdy than the consonants. This lo^o graph,c value of letters has been worked out by Br." ^. J. Blake for consonants and is as follows •- I being the letter with the greatest intensity of sound ,s valued at ,00. Z-63. C-6.. P^,h, 0^56 B 5.. D -45. S_40, F-35. K-3X. L_L N_ '' As many patients unconsciously acquire the art of l.p-read.ng .t ,s advisable to seat him sideways with the ear to be tested towards the surgeon. I o make an examination of the qualitative con- cl.nonofthe hearing it is necessary to be prov ded v.th some mstrument to produce the lower notes of the mus.cal register and the ven- high notes. The norma, ear can perceive vibrations varying from ,6 to about .3. 500. These are regarded as the iL r and upper l.m.ts of audition. For the lower tones and for the m.ddlo ones a tuning fork is used ; for the extent of the impairment of hearing by these methods. IM nr.sKASKs OF nth: /;.!/,•. if n e .. h' '"'^" ''^" pathological condition m uthcr the conduct.n.^. or the perceivin^r apparatus The mast eonunon test is that of NVeb'r u'o fir ; po.nted out that if the stem of a vibrating tuninl^ fork he paced on the mfddle hne of the skull/ and if on^ ear he closed with the finger, the sound is leard . ^'-ly or onlv on that side. In the same w^ "^ d.sea.ses of the external meatus and middt a'the sound of the vibrating tuning fork is heard bett;r in the obstructed ear. The vibrations are carred b" bone conducfon. and the deduction is readilv ISe that .n cases where hearing is in^pair^d on one side only, or .n which it is impaired on both sidrs to at unequal degree, the perception of the tun ng fo" rom the med.an line of the head is strongest in 1 1 e ear .n wh.ch the pathological condition fn the con- ducfng mechanism is more marked. In other word bone conducfon is better in the poorer ear. ' If the fork is heard better on the non-affected side or on the s,de least affected then the patlX , cond.t.on oi the opposite side is in the pec' pt Jl rather than ,n the conducting mechanism. Th f st does not always prove satisfactory f'"f->^-;-/^-''/'''^v;/. If a vibrating tuning fork be placed on the mastoid process of a health v ear t II t has become .naudible and then held in front of the ^::^: iJcaii jt:;;::: ^^"^^ ^^^^-^ -^^^ ^^^ If this test gives a positive ,it where the hear- ■n,^ .s .mpa.red it justifies a susp , Ion of labyrinthrne clKsease. On the other hand if the bone conduction .s fi^reater than air conduction the inference is tit ' FUNCTTiKSA L EX AM IN A Tloy. xtA the lesion is in the conductinij mechanism. Opinions U.ffer as to the value of these two tests and th e is no doubt the experiments sometimes vield d t y opposae results There are also several other ^t^ to i:?:;l:: " ""'^"^ '-" ''''''' ^ - — ^v In lesions of the conductin^r mechanism.-- '. I here is loss of hearing the lower notes. /> the lower tone limit is raised. 2. Bone conduction increases while air conduction decreases. >«uniuii 3. The highest notes are well heard. In lesions of the perceptive apparatus,- I. I he lower tone limit is unchanged -'. 1 he relation between air and bone conduction i:^rasr^' "^ ''- -'-'-^ ^"-•- ^^ ^oth ■: CHAPTER n. nrsEAHES OF THE AUKICLE. exist alone or Ik- associated with malformations c^ o h r r ,, ,,,, ^^^ ^^,^^^ of development of th ^e or s:de o( the face on the same side There m. 11 sometimes be devised to suit ,h '-"""V "'""' IK- diliicull to Uc-klc whetlicr it isaUvisahl, „ ,, ' .o cs,.,h„s„ „.. .,„.,, u „,. o,,,*:: t" :: ':r there ,s no crtamty of the position of ,l,e mmTlZ iNJ-KiKs re, niK AiH/tLic-These are , >' h cl.a..u>sed and treated on genera. prin^pIeT Thev' a. conU..ons incised wounds, hu^s. c,!;,h,;ins;^U trost b.tcs. I he cartilage should not he included in sutures because of the liability to necrosis Li'TAN-Ko, s DisKASKs of the auricle do not differ oms.mdar conditions on other parts of the bod - Kczema ,s the most common. Others are h ' .ntertri,o. pemphigus, s,phi,i,,:^::r::j:;:;X; rrr.iXKor.i /)/.v/;,i.vbs. ,„ acn,a.on,„ a„ri» i.s „„ ,m,.s,on o, Wo„J , Ir in „ .he s,,,«,a„cc. „r,l,c ca„naKc or l«,»ec„ ,hc' , " " and .he pcndH,„Jri,.n,. This is frcquon.lv , s^ °f .njury bu, i, „,ay occur wi.lu,,,, .,„ch . hi '■„ v (■dH>l^..h,c) 1, is frequently ™c> with in ,hc !„«"' »o rc,„cn,ly ,ha, i, has been .ern,ed -w/JH m ::'rn,r'^rs'''rb,''r''^-*"' pcHchouuHu. J: .*r ,4""^?^,;:^- "■'•■ l^ars as a rule s„me« l,a, suddenlv uZtl" "'" ceded by a feelin, of b n« or pruri s^bL l^^"; here are no prodromal sy™p,„„,s. The ^ffu" o„ ^"^ disappear spontaneously, or i, n,av be evaeu',"ed bv spontaneous t-uptua.. or the contents tuav unpul.,' In any case there is ,„„re or less deformitv at h«' •Suppuration and necrosis of .h.. . .-. .o considerable loss of Su Tn Z y"" T' '""' inflau,n,a,ory reaction IsToV usl:^ -^ClV: ■" ::i.n";f T ''^""•"" """"-"" •>- -tuTcof ' ™ ted to r;' T'"' '"' "-'"""•"" *™W be ^o,int:.;:e:trr;e':,:r:;:^;rr ^e:.r::;:r:r.ensL-ft^^^^^^ ^ssues, evacuation by free incision is adv'^ble The cavty should then be freely curetted tori:': Mi II 11^ iff^ 180 ni.sKASRs OF Tin: kah. all necrotic tissue and to favor a rapid obliteration of the space by granulation and adhesion. The wound •^.- . d be packed firmly with >jau/e and mana^'cd according to the rules of ^jeneral sur^'ery. There is certain to be deformity after such treatment. Mali^rnant growths are sometimes found in the car primarily. Kpithelioma is the common one. CHAFl ER III. DISEASES OF THE EXTEHXAI. MEATUS. C.RC, MSCKIBKI, Ink. AMMAno.V OR FlRrNCLK - ThKs .s a circumscribed inflammation of the skin' or subcutaneous cellular and fibrous tissues o the auU.tory canal, terminating^ i„ a small absc st o boil ::rrr;:^"'"^"^''^^^'^^''-nar.oft,:ea:-:^ canal, in:t beintr must lilrfiv »« -^ „, , . . '- '^' I'Ktly to occur in a part rich in fi^Iands. .t .s apt to be found in the outer par ," "leatus. Hods in the auditory can.-.I may occur n Elioio^y. These boils arc alwavs of artificial -.-MK.n, :a.sed by the introduction of '; i ,:•'';;; -'-'-f the ski. in the act of rubb^; . >ng of these parts. fhe staphylococcus -•> n er through an abn,.,ion .r by way of a hair foluc.c or cerumenou-, .'S.i, i The nr v causes as f-.r I • n .,. I fie predisposincr o diet 1; •^"""" '" '^•'•'''>'' ^•■^''^-'^-^ 'Change o' Uiet and similar conditions Th..*:.. *u c ™us, be :,kc„ into .on ...Mer"- in : " ''"°" I. «.nsli(utional state favorable lo the .rro„,h and Je™op„,en, of the suphyloeoecu.. *•''""' ^- The presence of the staphylocoeeus. .he epiulr "^'"" "' ■'"■^ ".i"o.t«a„i». beneath whit""""'"'-" ""' '■' '"'"'"'■>• " S^""' deal of pain »h.J, may precede the loeal lesion. The pain isT- KSO nr-sKASKs OF the hah. creased on movement of the auricle or |a- and m.v be. .^pi..n,, some genera, e.evition:;;':^^ Tnd f, ■"■ ""'"^■'^'•'^ '"">■ ^ ^'^-^"' at once ad often as one subsides another develops, and th.s ecurrence often extends over weeks or m ,nths The hearmj, is not affected except temporarirf m c^ur^o the meatus .nswenin, or accumu.a^.^r: pus. U hen the furuncle is situated in the osseous part of the me.uus there is sometimes a con^e H^^ the drum ..self wirich subsides onlv uith the is appearance of the fumncle. On inspecting, the ca ai one or more suvlbn^.s will be seen encroachin' '" ^elu,.en^, ,,,,„,, These may not be recS as ho.ls by the .nexperienced l>ecause thev are neither r^ nor acum.natcd as is usual with boils elsewh re The sk.n may not be colored at ail and only Uc severe pa.n on touching, them n.arks them as nfl.m t usua ly result in the evacuation of a sm.I qua.ftyofpusand a central core or slouch T car,.la,.nous meatus is the usual situation, b. smal pustules are sometimes found in the osseous meTtu and ^nve r.se to very severe suffering, because the -.|onconta.ns very little loose tissue and is ^.t rrcun,u',U.^ln the immature s.a^^e „,e best an r^.cat.on ,s a mixture of black wash^ (calom ,4'" par s. rh s softens the inflamed tissue with an anti ^"^lietr"- '^r^^^^^'^'^^^-^f-ton:: : m the Hash every hour or two till pus is formed ' >en the sur^'eon should mop awav w^th a forma ^n solution (I to I oon\ -ill fi, . •" formalin U to I, GOO) all the secretions and especially the open mouth oi the boil r^h»i i Dii-mskKxtkrvai. Otitis —Ac n, . nK.a.u». in „-hic„ ,ho local ™nUm„ . ZJ:^; ">: .1.0 ennrc .anal „, , ,„, ,„ -^ >•. h- ofdv,narca,,c.n iK.uccn nor.nal and aflcCcU a e!s no! beinR clearly marked. The dis,.a„, :, .■ , " ""' consider the chronic process /irsl KCneral lerm applies („ everv (nr,„ "J'"; ~ ^'"■'' chronic innan,n,lr.v condili™ o^ 'di, it cW, "' ;=::trd"::----"^^^"- ^.:.s:rco:-:nrrc^rx:c- The most common cause is inflammation ot^e nnddle ear with a dischar.a- throui^h -. / ! men,brane. Traumatism p av T'lst """''' part in its production. Th: ::;;;. ^^ ^^^^ such as may he produced bv too th-rouih H. of the canal by touel ear snon.r ^'''''^^ cleansing: ) "««-'. tar spon^re or spoon. Wounds Uii niSFASES OF THE EAR. l.'i I.: Of pa.n m the ear or toothaehe and onlv .nve rise to lium. Infection readilv tTk-..« «!. »u ^P'tne- Synip/otux Pain is ii.ii...ii., d't.on u is intended to relieve I W "" Ihis m-.v. K. f "^ ri'itxc. UeaJnessiscommon OTITIS EXTERNA. ,^ ensue; or k may be from obstruction caused by a,r- Kregafons of epithelium from eczema, or by masses of fung,, or sebaceous crusts or by secretion. Tinni- tus ,s produced eitlu-r by the myringitis or by the presence of foreign substances. Certain reflex symptoms are often present. These are severe pain over the distributio of the fifth nerve, headache" autophony and epileptiform attacivs. Coueh is also a sympton:. Indeed it may 1^ for the cough tha^ the patient seeks advice. When the inflammation is severe a discharge appears at the onfice of the meatus- when profuse it is watery in character. Glandula.^ enlargement is not uncommon. Diasnosi. M is necessary to distinguish between this diffuse inflammation of the meatus and deep in- flammation of the mastoid. When the disease is conlmed to the canal, pressure behind the ear di- rected backward and inward, will fail to mveal ten- derness; but if the pressure is exerted so as to move the cartilaginous meatus then it will elicit tenderness So a so pressure from above, below or in front of the canal will produce more pain than if exerted over the mastoid. Kxamination with the speculum in the milder cases of seborHuva. ec.ema and aspergillus will show the walls covered with some foreign sub- stance. In the desquamative form the walls of the canal are moist and sodden, the superficial epithelium Ix-mg easily wiped off by a cotton pledget P^«^««.v/.v. The course o^ the disease varies ac- cording to the cause. The simple forms are not at- tended by serious results, but are obstinate to relieve I he prognosis is grave where the deeper parts are affected, where the disease is of long standing, or h I 1«4 ^^''^^■■i''(J?s'ofrm,^,^^, •'.ere ,„av Ih- exK.::: \/; •^'^^-'-■""■■v. f„„, up in ,IK. .nidi; :»;',"'■ '^"""'^'^ '"»•'■ '« «e' removed hv ,on„ , t . ''"'""" "">■ "' ■" be alK.k.„e or on .;:;, " l'" ;'">; !"-'--Pan„io„ „„h ,, ;"--"e..r.r:4^i\r:'rr' - hydrar^. amm„„i„,. Ui ,„^,j t,,^ "'"■ "' "'^- ""«■■ The pa,ie,„ „„», refrain from ■ ?■''"" "•■'^■''■""■ J^iaaj m„,s, Ih; forbidden .TTif^ "-?" 'i^-^ of the innan,„,a.orv p ^^s "r" """•'"'"■ and eoiton plej„et cir, i, "" , ''> f>'reeps, ciirci ins .he eanll. tta," ,^'"1,' "■'",'" •■'™''' "-'""- --ova,, a., .he v^i^ r-„.mrf'"'r''''"'' "" sensitive. Wlien ',. ,„ 1 '""'"' estrcmeiy ^h,j,,o„:;,Ti"n'^'«';'':;;*-^^^^ .,SJ"5^* -'^. of a?^;^ ^.^^ cotton na n, 1,00k „,u curct ,lus win |^ accomplished Mk.„ o„co cloaneJ ,h. indication is ,0 set rtecni- m-idc bj tlie surgeon himself dailv. If „ecro«i. ad ,hen ,0 manage on general principles. If ,.ra„u. cautery, n.trate ol silver, or chromic acid , ^d ■ranula„ons may develop into polvpoid tnasses 1,^ occurs as an e,acerha.i„no;:;::i:;,:::i,--^^ ^^'tLpJlir^i--;---;^...^ ::^o;:!f:;:-h:ri:':-'"'------ Jifluse inllamntation ' " *•'"" ■■"" '" "" -"'= -of,or::;;„„;r;;::-r-rr"r -surrounJin^r |y,„p|,,Hc ^,,a„js es ' n '^"^ "'" behind and hclou the luric e h " '^"""-y '^'^'^^ J"''^ "ic auricle, become infiltrated and WBsm' 166 nrsKASHs (if Till-: kaii. tender so that any movement of the jaw is painful and the mouth is opened with dillieulty Diagnosis. This condition may be confused with c.rcumscnbed external otitis and with aftections of e middle ear and mastoid. Careful examination with the speculum should prevent anv error W,.v.„/.-^TI,is must he directed towards re- •■ev.n^ the pain and an attempt mav be made to abort the process before pus has formed. To relieve adopted .X orph.a may ho ^iven and some blood dra vn from the temple or from the mastoid region At least two ounces should be drawn and the ice bag or the hot water bottle afld ho, irri^^ation used, [f these means fail then a deep full incision mav l,e made in the canal. ' OTOMVcos.s.-Most text books descril>e this as a special disease. It is properly considered as a form of d.ftuse external otitis. Tiicre is a ^^rowth in the canal of that kind of fundus called AsperKMlUis. the two varieties found are the n.gricans and the ,W»a.. orflavescens The dia.^nosis of the condition as well as the form of fungus must be made bv the micros- cope. If the fungus has been in the ear but a short time a patch of pale yellow pollen-like matter is seen at the fundus of the canal. In most cases the fungus mass looks like a ball or plug of wet blotting paper. ool. I he plug may be mistaken for ear wax ; but the latter looks more solid, is shining and dried and does not excite pain and inflammation to the degree produced by the aspergilhis. OTOMYIOSIS. lOT AV////>/o//7.r. -There is a sense of fulness, slight pain, burning, itching, tinnitus aurium and hardness of hearing. After a feu days a shght serous dis- charge sets in and then the pain usually ceases. Per- loration of the drum head sometimes takes place and the tympanum is invaded. Tn-ahnent. This has already been indicated. There are three points, to remove the parasite, to kill the germs, and to allay the inllammation. The first is accomplished by syringing and wiping out with a cotton swab. Ti> destroy the parasite the powders mentioned are more useful. Chinoline salicylate in boracic acid, one to sixteen, is specially recommended. This not only destroys the asper- g'llus but allays the inflammation it has produced. K(irkk;n HooiKs in imk K.vr. These are either animate or inanimate. The former may be of great surgical importance from the annoyance, inflam- mation, pain and deafness which they are ant to produce. The source of foreign bodies is either from within or without. Under the first class is placed, abnormal col- lections of ear-wax, masses of epithelial scales (the kcratosh obturans oi Wreden). and collections of stiff hairs from the auditory canal and tragus ; also clotted blood, inspissated discharges, and scales of dead bone. Under the second head may be classed all things small enough lo have been placed in, or to have gotten into the canal from without. i IIM niSHASh:s OF tii/-: fa/,: ''^' "ill considLT if V ' "^'^ common that -^■.-u «.™ .: -e" x:'-';,, ■'"••• "— f -- -n :«:fr,/H:''' ■''""" '"•«'■" "•«'■• •»■.. mc,„l,™„;, ,,;;!, " ";; " ■""-■•-■ "'i"i".e^ mouth, the m-,ss .,f . '"^1 hccst towards --- -c:,;i::::;:rr',,r '-« <>• "H- .<.cr„a, n,:; s.'™ ,:"::™"-; '-rani '"»-'■•. small .scra,ol, on ,„.. ^ZT.^"''" ">' -"'" away from ihe mall auditory canal, juM a from tl *■" niomhranc mov '•-'lis. our u pon (|,e « c «:raduallv •s a spot on the ' all of tht 'o matrix towards the Hi ' '.i;or nail move} anotlur lore tory ciinal bv t| .tier end. Tf I" ""-^ movement imparted to th f f tht 'e motion of the jaw icre is aud I- canal preser.ts eert x'e IS tiTc or if ihe orifi (llio junction of tli meatus) contracted, the fc mcnis of the jaw "" anomalies iif LTV nan e cartilat^inou curva- mus .>rcc "^^ or the isth s uith the osseou.v may have tl produced by the m •e reverse effect, so that ove- IMPM'TEh i'lUtlMES: 10!) any body \y\n^ j,, ,he canal th an outward. If a is carried inward rath Hic canal its pre nci^'lihorhood to small mass of cerumen coll se nee stimulates the I'land er ects in an increased secretion \.hil -same time it acts as an obstruc s in tlu at the tion to the outward l^::^..."'' '!'^ '^'•"^'"^^ -f ^'^^ Klands n.rth ;on removal tl,ese masses are fbund to c;;;;;;^'c^: tarn ve,.-tal,le spores. desc,uamated epithelium nd sonKn.mes a forei,. body which ha^ LZ ' ^ e r^ k? T'' '' "" ""^'^ '^ "^ --•^-«» whi h - V"' "^ '" ^'^•''^J"^'"^ative indammation -l..ch may result in dilatation of the osseous cmal or even destruction of the walls and invasio of th pneumafc spaces cf the mastoid. The me.nl r -^ .ympanimaybeper^ratedasaresultof^h:;^::^ Syn,f,ionn. These depend .n the si.c of t " txc.cd. I he hrst s.^n of trouble mav be sudden -payment of hearin, a,,lowin^ ,,e -entrant o^ -ate, .nto the ear. The ear feels su.ffv and full Th,s ,s attributed by the patient ,o the water in tt canal and as he is unable ,o n-lieve hiuKself helk! adv.ce. l<..x.-.mination shows the presence n i t'- nn.st have been there ,W a'^^^^ . " ""^^ si-dden loss .i hearing is probablv du^ to .h^pij^ ment of the pU,, so that it entirely closes the pasvl or comes ,n contact with the drum. More rarelv the pat-ent complains of verv gradual loss of he;; -.nu f'c- lK>K->n.n^. ol subjective noises. If the closer's complete he complains also of autophonv n e pressure may induce severe neuralgia, not in the ear alone b.u m the temporal and supraorbital re« on/ A comn,on roflex disturbance is cou^h. wlWc . h 170 fU.Sl-:ASF:s' OF Tllh FA If. m, spasmiHlic ami may be severe enough to induce a scconUarv a.nj,avstion of tfic larynx. Other reflex symptoms are apro.sexia. vcrtiK and epileptiform sci/iires. If the impiiction occurs in an ear tormerly the scat oi a purulent middle ear inflammation there is serious obstruction to the outflow of the discharge. /)itiff„ox/\. l^bjective exaijiination is necessary to make a postive diagnosis. Tn'tUnun/. Die first indication is to remove the mass. This should In; done at one sitting bv means of syringing, the blunt hook and curet. These in- struments are to be used only with the greatest care and under perfect illumination. SkBOKKHOKA oi- TMK E.XTKkSAI. AiniTOItY Canal.— Usually this affects both ears. The patients complain of having some pain or itching which has led them to make various applications to the affected parts or to scratch the canal. This leads to inflammation and pain. The ears become full of inspissated matter, in crust-like pieces, and in conse- quence there is more or less deafness and tinnitus. On examination the canals will be found filled with gravish-white scales, forming a pellicle, clinging to the wall oi the canal and covering the membrane. It is often mistaken for eczema, but eczema rarely attacks the canal, and when it does it will be found on the auricle as well. Treatment.-- The local treatment of most value is the application oi an ointment of ammoniated mer- cury, -la. lo to the ounce of vaseline. The general health usually needs invigoraling. >te-'' AouK/nx mtniEs. vn FoRKiiJN KoniKs KKini WniiorT.- It sometimes h.sppcns to individuals that an insect citiier flics ^r crawls into the ear. When this conies into contact with the sensitive osseous m-^atus or the drum most alarminjj symptoms may result. Tinnitus, pain and giddiness arc present to a greater or less extent. Where a foetid otorrhoea exists flies may be attracted by the foul odor and enter the meatus and deposit their cpRs. These develop into majjjjots, which at- tach themscives to the drum membrane or enter the middle ear. Great pain accompanies this. More commonly, however, various inanimate Iwdies are found in the ear. A long list might Ik* made of these. They are such things as peas, beans, seed^, cherry pits, nuts, beads, slate pencils, buttons, shells, cotton wool, small stones, sand, bits of glass, pieces of straw, chips of wood, pins, pieces of gum, paper in wads, round tips of pencils and penholders, and many other similar foreign bodies. For practical purposes it is necessary to distinguish bctv.een those which tend to swell by imbibition of moisture, such as peas and beans, and those which do not. Tfeatmenl.-—\i is most important that the surgeon should assure himself of the presence of a foreign body before undertaking its removal. This advice may seem unnecessary, but it is really impossible to take the statements of a patient or his friends with- out verifying them by examination. Often no foreign body will be found when the patient is per- fectly certain that one is present. Removal is to be efTected by the syringe, hook, forceps or curet. If the drum is perforated and the MICROCOPY RESOIUTION TEST CHART (ANSI and ISO TEST CHART No. 2) 1.0 I.I 136 140 2.5 150 "^= 1^ In 1^ 2.0 1.8 A ^PPLED INA^GE inc ^p" ■6'>3 Labt Main -jtfee! r^ Rochestef. Ne* 'o'h 14609 USA ■as 1716) *82 - 0300 - Prone SBS i'7l6) 298 - 5969 ■ Fox .i|r iii^ ¥' 172 niSKASKS OF THE EAR. forc.i,^., body is in the middle ear, water may be thrown through the eustachian tube while .suction externally is employed. If the substance is small and heavy the ear should be syringed with the head down over the end of the table, to get the benefit of the force of gravity. Lowenberg has suggested the apphcat.on oi . small brush dipped in glue', which is allowed to set, so that the foreign body is withdrawn with It \\ hen the meatus is closed or constricted or the foreign hody impacted so that it cannot be -e- moved .n the ordinary way, then an operation must be done. That is, the auricle is detached posteriorlv so that direct access may be had to the osseous por- t.on, followed if necessary by chiselling awav the posterior wall of the canal. Insects in the ear may be killed with a few drops of oil, or by filling the canal with water, and then removed by syringing. Maggots_are to be killed by ^iIl^Hi!iiIiLJi. f«:^v clrops of ether or chlorcloTnT.""^ then removed by aj iook or by syringing. IvAK OK .,„, Xku- Horn C.i.n.^^If the external car and auditory canal of the new born is let alone no trouble will come from retention of the natural secretions. These will be removed by the natural outward growth of the skin of the auditorv meatus. 1 he child IS often the victim of swabbing and wash- ■ng. Ihis may induce infection and inflammation and even lead to perforation. Fu.UTtKK OK ll.K TVM,.AV,C HoxK.-This bone enters largely into the formation of the posterior FJ{A VTVliE OF THE TYMP. \ M( • JioXE. 173 boundary of the glenoid cavity, as well as into the formation of the anterior wall of the osseous auditory canal. Fracture of it may result from falls or blows upon the chin or cheek. The haemorrhajrc from the ear which results has often misled the surjrcon into a dia^rnosis of fracture of the base of the skull. The mistake is all the more likely if the patient is un- conscious when first seen. If conscious he com- plams of pain in the ear, especially on movinj- the jaw. This symptom, with the swollen meatus and the detection of a projection of bone from the anterior wall into the canal completes the diagnosis. Hxcessivc haemorrhage is to be checked in a wav not harmful to the drum. Hence cold water should not be syringed into the ear. Any portion of bone projectmg into the canal, against or through the drum, should be pushed back or removed, if »oose. Bi.KKi).XG ..ROM TMK Mka Tis. -This is not al- ways serious. The traumitism mav produce no fur- ther lesion. A blow on the mastoid has been followed by a sharp haemorrhage and nothing more. In such a case the bleeding is from a fissure in the skin in the osseous meatus. ■IP CHAPTER IV. li m i DIHEAHES OF THE MEMBRANA TYMPANI. TlIK OlTKR Sl'RFvVCK t^K THK MkMBRANA TyM- PAM. — VV^hen the membrana tympani is looked at from without there are several prominent features. 1. Its circular shape and peculiar polish and lustre. 2. Its vertical and horizontal inclination. The handle or manubrium of the malleus. The short process of the malleus. The folds of the membrana tympani. The flaccid portion of the drum head above these folds, the so-called membrana flaccida or Shrap- nell's membrane. 7. The bright triangular reflection of light in the antero-inferior quadrant of the membrane, called the triangle or pyramid of light. 8. The normal membrane is concavo-convex with the centre at the umbo. 3- 4- 5. 6. MvKixorTis. — As an idiopathic disease this is very rare, as a secondary condition very comrhon. Some assert that it never occurs independently, but is always secondary to an inflammation in the middle ear or external meatus. Symptoms. — A typical case is characterized by pain and tinnitus, but there is little disturbance of MYRINGITIS. 175 hearing, at least at first. The membrane is seen to be congested, the degree varying according to the intensity of the condition. The position of the drum is not abnormal, and the wall of the meatus near the drum does not take part in the congestion ; the eustachian tube is free and there is no evidence of fluid in the tympanum. Treatment.— Ury heat will usually control the pain in this condition. It may be necessary to use a local anaesthetic application. Wounds and Injuries of thk Mk.mbrana Tymfani. — The drum membrane may be injured by direct or indirect violence ; direct, when instruments are introduced into the canal ; indirect when the in- jury is caused by the sudden condensation of the air in the meatus, as when a heavy gun is discharged close to the ear. The upper part of the drum is directly continuous with the integument of the upper wall of the meatus, so that traction upon the auricle, especially in children, may tear this part of the mem- brane. If a myringitis becomes intense, tissue necrosis may take place and the drum become per- forated. Perforation of the drum from inflammation within the middle ear is very common but is of secon- dary importance. Injuries by direct violence are usually in the upper and posterior quadrant. When due to sudden condensation of the air in the meatus, either from a blow upon the ear or from an explosion, the rent is also in the postero-superior quadrant because the greatest breadth of the tympa:iic cavity is in this region. Openings through the drum are 17tl />/s/:.iM:.\- or thk ear. Mi in usually sinffle when traumatic. Tliev varv in sJiapc from a simple rent, the edf,res beini,' only sli-htly •separated, to an irregular opening;, such as occurs when the force is considerable or when the membrane is very tense. Rupture followini; severe injurv to the head is usually ^^{ sli-ht importance in compari- son with the fracture of the base of the skull or the cerebral concussion. .SVW//OW.V. The first symptom is severe pain, referred to the deeper part of the car. There is at the same time deafness and 'jud subjective noises. \'ertit;o may be present and is ^\w to sudden increase of labyrinthine pressure. 'j-here soon follows a water\- dischari^e, and the acute pain .gixes way to a dull throbbiiii,' and achin.i,r. I'pon blowing the nose the attention is at once dm \n to the whistling sound pn liiced by the passage of air through the perfor- ation. Didf^nwsis. \ recent rupture is easilv made out on examination. When close to the margin of the drum it may not be recognized. Wounds in Shrap- nell's membrane are less easily seen on account of the natural flaccidity of the parts. Treatment. ^TWxs should be negative as far as possible. Dry the parts very lightly, dust a little boracic acid along the edges of the wound, occlude the meatus with some cotton wool and leave the rest to nature. If infection has taken place the treatment must be the same as for a purulent middle ear inflammation. MkDICO-LkGAI, SlGXIIICANCK OF IxjlTRIKS TO Tin: DiUM Mkmhrank. -After a blow upon the ear, either during a quarrel or in play, an action at law /NJCnrKS TO DIU'M MEMRRANt:. 177 may be taken to recover damages for supposed injury of the drum and consequent loss of hearintj. In such a case the surgeon will be called upon to decide, first, whether there has been an injury done to the drum, and, second, if so, how far will it impair the hearing. In the first consideration he must bear in mind that the drum may have been perforated before the blow was received, though the patient or his friends may or may not have known it. The chronic perforation can easily be distinguished from the acute by its round and cicatrized edges. The acute one is irregular in outline and often has dried blood on its edges. If it is determined that a previously normal drum-head has been ruptured by a blow upon, or a thrust into, the ear, it remains for the surgeon to de- termine whether the hearing has been or will be im- paired by the injury. .\ simple fissure may not in- jure the hearing in the least. If there has been no concussion of the inner ear, and no inflammation set up in the middle ear or in the drum head, the rupture will heal quickly if let alone. Ignorance on this score hay often led to the use of drops of various kinds immediately after the injury, and these have produced trouble in the middle ear where none would have arisen, but the perforation would have healed in a few days of itself. Thus it would appear that the blow caused the bad result when in reality it was due to the meddlesome treatment, [f in a case of asserted violence to the ear, deafness should be dis- covered by the surgeon, it must be determined whe- ther it has been produced by the same blow which ruptured the drum or whether it existed before. A temporary diminution of hearing is very likely to oc- ™fI Hi 178 niSKASKS OF TltK EAR. cur after a blow on the ear, hard enough to rupture the drum, but if great and sudden deafness comes on after a blow on a previously healthy ear, and it re- mains so for several days without signs of improve- ment, it must be judged permanent. ■■ 11 HI CHAPTER V. DISEASES OF THE EUSTACHIAN TUBE. Eustachian Catarrh or Tubal Congkstion. — The most common cause of this condition is acute coryza or acute nasopharyngitis. Rarely it is a primary condition due to exposure to cold. It com- plicates light attacks of the exanthemata in children. It may depend on the entrance of some irritating fluid while bathing or using the nasal spray. The chief predisposing cause is some obstruction in the nose or naso-pharynx. Adenoid vegetations in the vault of the pharyx are a very important factor, as they become engorged with blood, causing venous hj peraemia of the walls of the tube, narrowing or completely closing its lumen. At the same time this g^f .;.;,; ,e affords lodgement to pathogenic bacteria t ■ I ^ring respiration, and from this locality Hi ji'y find their way into the canal. Pathology. — Within the tube the condition is one of simple venous hyperaemia, the mucus membrane becomes swollen and flabby, the walls of the tube lying in contact and adhering closely on account of the viscid secretion. The secretion is at first thin, but when the process is fully developed it becomes thick, tenacious and glairy and may close the tube completely. The cartilaginous part of the tube is most affected. VVHien the eustachian tube is closed for any reason, the air contained in the tympanum 180 lifSllASKS DF T/fK K.l/f. § f .1 1 1 M; nil Ml U.sappcars by ..h .-rption. This produces diminished atmospheric pressure in this cavity and the pressure jmhout beinjj ,he same the drum head is crowded inuard. If ,he canal remams closed lon^^, ^e find the drum membrane displaced or retracted so that it comes m contact with the opposite tv mpanic wall. ^i'w/i/«,„,v. -When this accompanies a cold in the head there is usually a sudden onset of the symptoms. There is a feeling of stuffiness or heavi- ness m the ear as though the external ear were closed by a forei«:n body, and the patient has a desire to insert the fin^^er into the meatus to clear the ear. I hrs fin^rermjr may produce a momentary relief from exhaustion of the air in the meatu as t'he finder is u-.thdrawn suddenly. There may be some slight pain in the upper part of the pharynx or near the tonsil, or ,t may be referred to the larynx or radiate from It toward the ear ; but there is no actual pain m the ear. Hcarin^r is impaired and subjective noises are always present. Among the rarer svm- ptoms are vertigo from sudden increase of labv'rin- thine pressure and mental heaviness and torpidity - the patient says he feels stupid. /J/V/iv/aw:v. ^Inspection shows a retracted drum membrane ; the color and lustre are normal but the .ght reflex IS either absent, displaced or multiple. Owing to the stretching to which the membrane is subjected It may appear thinner than usual. There .s no evidence of congestion. The physical appear- ance IS due entirely to the lessening of the Ttmos- phcric pressure m the tympanum. When the ear is .nflated either by Polit.er's method or by the catheter we hnd that the canal is opened with some difficulty' \ xr.sTAciiiAy iATAiiiiii. m anJ several attempts may \vi made before any air enters the tympanum. Wlien it enters freely! the sudden replacement of the drum to its normal posi- tion is rccoKnized by the sl-arp metallic click as the membrane is forced outward. Upon testing the hearinj,', we find it materially reduced. Hone con- conduction is increased and the tuning fork o i the J^^^^' forehead or teeth is referred to the poorer ear. Pw^Ho.v/.v. -This is ordinarily one of the simplest affections of the ear and an attack passes off, under treatment, in from five to fourteen days. The danger lies in recurrence and neglect. The abnormal posi- tion of the drum head gradually becomes permanent and chronic inflammatory changes are set up in the middle ear. Treatment. —This is directed to the acute attack first of all and then to prophylaxis. The subjective noises, the deafness and the feeling of discomfort are relieved by inflation which restores the membrane to its normal position. Inflation may be accomplished by Politzer's method or the catheter. The relief is instantaneous when the malposition is corrected, and the mental depression is removed at once. Alter the first inflation the retraction, and, of course, the symptoms return in from three to twenty-four hours, and it is well always to prepare the patient for this.' It is unusual that a single inflation will permanently relieve the condition. The abnormal condition of the tube requires some attention. It is usually the cartilaginous portion of the tube that is affected and an application of an astringent to the mouth of the tube will be beneficial. Nitrate of silver, lo to 20 grains to the ounce, is probably the best solution. !H tn />MAM,VA'.V OF THE AM/,'. Prophylactic measures include attention to the mucus membrane of the nose and naso-pharvnx. These patients are always s.ibject to colds in the head or throat. KnlarK^ed tonsils and adenoids must be re- moved. So also any hypertrophy of the turbinated fwdies. or deviation of the septum must l,e radically treated. The general hygiene of the patient must be mvest.jrated. The daily bath, the use of all wool underwear and a regulation of the habits of life will tend to prevent successive attacks. 1= * Tl Bt>-TvM|.AN,e CONliKS riON OK Tl BO.TVM..ANIC CATARRic-ln this condition there are changes in the tympanum in addition to those already mentioned as occurring in the eustachian tube. The congestion m the tympanum depends upon physical changes rather than upon any inflammatory process. The excitmg causes arc usually the same as those of simple tubal catarrh. PcMogy.-W^M in the tympanum a simple engorgement of the vessels supplying the mucus membrane, which may result in one of two con- d.tions ; either a hypersecretion and accumulation of mucus within the tympanum, or a serous exudation. The latter may be determined by the tenuity of the vessel walls.-a constitutional condition not uncom- mon ,n those afflicted with gout, or with cardiac, hepatic or renal disease. This venous congestion can be seen in the tympanic membrane and is great- est along the manubrium mallei, close to the peri- phery and in the upper and posterior segment Sj',nptoms.~Th^ symptoms gi^en for tubal ca- tarrh are modified when the tympanum is involved. Kf'STA VUIA X < A TA liltll. m There is distinct pain and the feeling of heaviness is less marked. Pain is particularly severe when the vault of the cavity is involved. The loss of hearing; is not sudden nor as great. Tinnitus is present and is worse when the patient is lyinjj down. When there is fluid n the tympanum, hearing varies ac- cording to the position of the patient s head. An- other charactcrisii- sympton is the occurrence of a bubbling or snapping sound when the patient blows the nose forcibly or during the act of deglutition. Autophony is also troublesome. Diaj^nosi's.— The apjiearances vary in the dif- ferent cases according to the actual condition pre- sent. The distinctive feature as contrasted wi.h simple tubal stenosis, is in certain changes in the circulation. The drum head, instead of being pearly white, is changed to cither a dull white or is of a slightly pinkish-white tinge. At the periphery and along the handle of the malleus the change oi" color is decidedly more marked and is of a dull red hu These changes indicate a venous congestion and i a true inflammatory action. The collapsr of tl . drum head is not usually so great as in si.npie ob- struction, and if exudation of ser, -< has tal. n olace into the tympanum, the displacen.v.>'t is very flight. Instead of this the lower part of the membrane is slightly yellow, the lustre is diminished and the density is increased. This appearance is due to the fluid, and sometimes we see a sharp line crossing the drum transversely and marking the upper level of the fluid. Movement of the head may cause a change in the direction of this line. When inflation is prac- tised the air bubbles are sometimes visible. Upon * i 184 nrsEASKs OF the kah. ■it -i ■ If exam.n.n^r the hearing we find diminished air con- ducfon both for sharp sounds and for the conversa- .onal vo,ce and for whispered speech. The tunin.. tork- on the m.ddle line is heard better on the affected Pro^^nosfs.^U is the exception for the parts to re- urn to the normal condition without treatment. Lhronic otitis media is Iiii ? ^^ "°'''"'''' may p™,„ce a ..,a.veU drum .ZlZt ZIX wan of .1.0 '4;p:r :;:;x''::ri"« •'-^ ™"-' m A VITJ-J CA TA RRHA L i> TIT IS MEDfA. 189 trlcial contraction, displacing the parts and interfer- ing with their function. Extension to the cranial cavity does not take place when the disease is of the catarrhal type. , Treatment.—lhii first indication is to relieve tl"^ pain. The patiei.t should be put to bed, a saline cathartic given, and an opiate administered suffi- cient to allay the pain. Complete relief from the pam should be secured fo-- some hours during which \ an attempt may be made to abort the inflammation. \ This is to be done by local bloodletting. From tv.o I to four ounces of blood should be drawn from in front of the tragus, or two leeches may be applied in this situation. The application of dry heat is also of jalue to relieve the pain. 'Hmjiiav be secG7eTbr die^ hot water bottle or hot salt ba"^ Coldanpli- iSieasJ^jliim. Irrigation with hot wltoTli'ai^ beneficial as it brings the heat directly to the drum membrane. Oily solutions are of no value. Relief is sometimes given by aqueous solutions of cocaii e, morphia and atropine, and carbolic acid in glycerine (I to 20) is also frequently used. If the attack i^ not aborted by these means then the membrane should be incised. The local depletion is of great lalue and is permanent. When bulging is present the cc.tre ot the incision should be over the most prominent point. If there is nothing to guide us the knife should be entered close to the periphery, just below the posterior fold, and a curved incision made in the clear membrane parallel to the line of insertion and down to the '-nferior quadrant. The membrane of the inner tympanic wai! should be incised at the same time to secure depletion. Before operation IIH) i i-i f^f'^f'-i'SKS' OF TJtK j,,^j^ -emhranehas bee lideU^' V'^l"'''" ^^^^ ''^^ pain and to restore the v iels "' h! '" "''"''^ ''^ I^ur-n^^ the period of discTate ' "''"''' '^''■^'■^• '^Jear and this may be done k ^ '"' """'^ ""' ""^^^ 7ith a .i,d .nti^ic so ut ;^' '^Z'""' '''"''"' depend on the amount of h r I ^^^^"ence must « ^ay may be neceLa.^Vt ^ t"t^^" '"'^ "■-- Prolon^^ed as the dischar J eco^' '7*^"'^' '^'^'"^ cases should be seen daity by ^ '"' '^'^^^^ should cleanse the can.I him ,f '"'■«^^°" ^^^o ■nsufflate a small quanti y ^s ' ' •" ^"^ «"^ '^en sumcient bein.. usL to dus^ oreTtr'"';'^ '""'''^'^ but not packing, the cana so L '"''" "■^^'^'>' drama^re. j^ ^^ as to prevent free openin, should be e^ar^ d^d ^"^ "^"^^ ''^^ cleared out by inflation or hv '^^''y ^^en ^ynn,.e. Tinnitus ZlZJZ^T^ ''' "''^'^'^ -^ the parts appear normaUnd ^h ^ '"'"^ '''""' ^^^r Ultimately the sub|ec" vl 'i r" "^ '^ '■^^'^'■^'^• hromic acid is of ue to allay f "'P^^^' "^''^- this kind. ''"'*>^ ^ persistent tinnitus of otitis media indicatesan infection If?.!''' ^""^ ""'"''^"^ « may follow a catarrha otir [ '"' '^^''y- '^^us the exudation either hi hth"" '^ '"^^^'•°" ^^ throu.,.h the perforation" . '"''^'^'■^" ^"^e or ;;he most common aus s is' '"''"'""^^- ^^ ''^ disease, such as scarlatina m. . '"'"'" '"fectious ACUTE I'VltULEXT OTITIS MEDIA. m meningitis. It often follows the introduction of fluids into the middle ear through the eustachian tube. An external ( itis may pass through the Rivinian segment and set up a purulent condition. Pa//io/o^'.— The four micro-organisms which have been shown to produce a purulent inflammation in the ear have already been mentioned. In addition to these there are three others which have been exceptionally found, (i) the bacillus pyocyaneus {2} the meningococcus intracellularis and (3) the actinomyces. The first stage is a hyperaemia which produces an engorgement of the tympanum. This is followed by a transudation of the fluid element of the blood and a migration of white blood cells. Then local necrosis takes place, the tissue breaking down with the formation of pus. As a res;ilt of the local oedema the blood supply of the ossicular chain is interfered with and bony necrosis may occur quite Cc riy. This usually takes place in the incus first because of its limited blood supply in proportion to its size and the fact that the blood vessels follow such a course that they are subjected to pressure early in the attack The fluid gravitates to the lowest part of tht cavity. Sy,np/oms.~The characteristic symptom is sud- den and severe pain deep in the ear. With this there is elevation of temperature, from loi to 103, severe headache, constipation and marked consti- tutional depression. The hearing is impaired, tin- nitus IS present and sometimes vertigo. In children convulsions may usher in an attack, and in adults delirium may sometimes accompany the elevation of temperature. The pain continues till the pus is fHiJi 1V3 niSKASHS OF THE /-JA/i. llff evacuated and thus may not be for several davs. If he oedema .s considerable, the pain is not entirely removed by the rupture, unless it is lar^^e enough to permu very free draina.^e. Extension to the mas oid ells may occur before perforation or subsec,uent to .t. but m euher event, it is characterised by a Uneral au,.mentat.on of the severity of all the svmptoms Involvement of the structures within th'e cranial cav.ty ,s accompanied by chill or rigor, verv hi^rh temperature, violent delirium, and convulsive' mov^- ments followed by paresis. When the lateral sinus becomes .nvolved, either from the middle ear or from the mast.,d. symptoms of pyaemia appear. Thes^ are a dull or ngor. sudden high temperature with an equally sudden return to the normal or subnormal and profuse sweating. The sudden changes in tern- perature are repeated at intervals varying from a Z hours to one or two days. When the labvrinth is .nvolved there .s vertigo, nausea and either absolute deafness or loss of certain portions of the registe The latter complication is very rare, a fact which -suggests that the vascular connection between the middle ear and the labvrinth is not ve-y close />/./^«am-. -Early inspection of the drum mem- brane shows the upper part or membrana flaccida congested, presenting a dull red color. In this eady stage prompt measures may abort the attack. Later on when engorgement takes place the membrana flaccida IS pushed outward. The entire drum is oil deep red color, oedematous. moist and the normal "stre IS entirely wanting. The short process and the manubrium may not be visible, being obscured by the oedema. The secretion may be confined bv 1; ACITK SrPPrRATJVE OTITIS MEDIA. m the mucus folds in the tympanum so as to present several tumlfied masses in the fundus of the canal c ose to the superior wall. When perforation takes place spontaneously it is usually found in the pos- tenor portion just above the centre and near the peri- phery : but it may be above the posterior fold and entirely within the membrana flaccida. When the fluul .s in the attic, forcing' air into the middle ear before perforation may not show the presence of Hu.d, and after perforation there may be no perfora- tion whistle. Prognosis. -When once pus is formed it must be evacuated. The perforation may then heal and the parts be restored to their normal condition. Very rarely the pus finds its way into the throat through the eustachian tube. Under the most favorable con- ditions there is likely to be .nore or less permanent destruction of an area of the drum, and the ossicular Cham IS usually bound down to the internal tympanic wall at various points by cicatricial bands. The in- terference with hearing depends on the location of these adhesions. In the majoritv of untreated cases a chronic purulent otitis developes. Death may result from direct involvement of the cranial cavity or sub- sequent to mastoid inflammation. Involvement of the labyrinth is the exception. Treatment.- Th^ treatment advised for the cat arrhal form should be used first. If the pain contin- ues then an attempt may be made to abort the attack .Slia^yLQg blood from in front of the tragus The wet cup or the leech can be used. The leech, how- ever, does nothing which the wet cup'"cannot do and much time is saved. If depletion in this way dees fiiii im niSHASKS UF THE HMt. If not j,Mve immediate relief then the drum should be j!HizJi!iL'5£i and the bleeding which f ollows shouid J^j^ncouragedjjvjn^^ wa rm wate r. We do not expect to find pus, but to'prevent its forma- tion, and therefore the jirreatcst care must be taken to keep the field of operation perfectly aseptic. Upon the appearance of discharj^e either by spontaneous rupture or after incision, the canal must be kept free by frequent irri^'ation with a warm antiseptic solution. In all cases the patient should be kept quiet and con- fined to the house. A mild laxative should be given and all stimulants and rich diet forbidden. The action of the skin should be promoted. When the discharge is profuse it may be necessary to douche the ear every hour. The frequency with which this is done must depend on the quantity of the discharge. After the inflammatory symptoms have commenced to subside the dry methou of treatment should be adopted to promote healing. This consists of drying the canal and then with a powder blower introducing a powder such as boracic acid, stearate of zinc with aristol, or dermatol (bismuth • ubgallate). This should be dusted lightly into .iie canal and not packed so as to prevent the exit of the secretions. If the pus does not gradually cease some astringent must be used. Alcohol is probably the best. In all cases ;i -ention must be paid to the nose and naso-pharynx. it : Chronic Cat. rrhal Otitis Mkdia,— This is an affection of the middle ear, characterized by gradual and progressive changes in the structure of the mucus membrane and adjacent connective tissue, rnnoxic cATARitJiM, otitis media, iot these changer takinjj the form of cellular proliferation, orjiTanization of new tissue and hypertrophy, follow- ed by contraction of the new tissue and atrophy. Clinically it may be defined as a chronic non-sup- purative inflammation with progressive deafness, tinnitus and vertigo, the drum membrane being changed in lustre, color, consistence, tension and curvature. "Catarrhal deafness'* is a term frequently applied to these cases and while in a sense it is cor- rect it usually leads to confusion. Many authors describe two distinct forms of this disease ; a chronic exudative or moist catarrh of the ear and a so-called dry form or in other words a hypertrophic and an atrophic or sclerotic otitis. These titles represent differen! pathological conditions but there are so many intermediate forms and the conditions so often succeed each other that their separation as distinct diseases is not possible. More- over the clinical symptoms, subjective and objective, are so often the same that it is impossible to dif- ferentiate between them in this way. A7/o/o^v. The predisposing causes are all cir- cumstances which tend to produce a permanent depression of the vitality of the body. Heredity has been regarded as one of the most potent and frequent factors. Certiin families show a peculiar predis- position to catarrhal otitis. It commonly begins in early life before the age of twenty. Climatic con- ditions have an important bearing. Climate is mainly dependent on three factors,— temperature, humidity and barometic pressure. The disturbing effects of climate are based not so much on the yearly range of the temperature, humidity and pressure as upon \ :« IM nrSKASKS OF the KA/f. the rapidity with which these conditions arc apt to vary at any one time. It is a matter of common experience that chanjreable weather is most favorable to the development of colds; that catarrhal aflections of all sorts are most numerous in autumn and spring' when sudden alternations of heat and cold occur. Systemic depression is caused most often by sudden chilling of the surface of the body when not prepared for the action of cold. This refri,,reration is most often produced by a current of air, and the absolute temperature is not of :so much importance as the relative temperature of the air and body. For ex- ample a comparatively warm bree/e acting upon a skm which is relaxed and perspiring from the elTects of exertion and heat, has a decidedly greater cooling tendency than a cold winter wind striking a non- perspiring bloodless surface. The local impression may be profound or slight, the difference depending upon differences in individual susceptibility, which cause the same degree of exposure to bt followed in the one case by no ill effect whatever, in anotlier by a cold in the iiead. and in a third bv an attack of pneumonia. Unhygienic surroundings and methods of living is another important factor. Among poorer people, overcrowding, bad air and insufficient or improper food produce a great many sickly and anaemic persons who are prone to catarrhal troubles Kxcesiive mental and physical strain lead also to a depreciated system. Chronic diseases such as syphilis and scrofula predispose to these trouble^ also. As to the exciting causes, a chronic aural catarrh may follow an acute tubo-fvmpanitis, or it may be idiopathic. In any case where the disease is s^ r JitiOAK • i.i TA ItnitA A UTITIS MKHIA. lOT chronic from the first it depends on some fault in the manner of living through which the piaticnt becomes susceptible to vascular changes in those portions of the body lined with mucus membrane. Frequent exposure to cold produces repeated attacks of acute rhinitis or acute nasopharyngitis and this leads to congestion in the tympanum. Reflex irr'Ution from .ocal diseases is also an exiting cause. Another important cause is continual exposure to loud noises and repeated concussion ; residents of noisy cities, railroad employees and artisans in noisy manufac- tories furnish many cases. Paf/io/ogy. The changes in this disease are multiform, Init they may be reduced to two sets of phenomena, one comprising the various processes of proliferatini, exudation and overgrowth and the other the processes of contraction and atrophy. The membrana tympani usually takes part to a greater or less extent in the processes going on in the tympanic cavity. The changes produced are hyper- aemia, retraction, thickening and atrophy. The congestion is specially marked along the handle of the malleus. Retraction is caused by the pressure of the external atmosphere, the air in the tympanum becoming rarified by absorption. If this retraction is maintained for a long time it becomes organic, caused by organization and shrinking of the exudates. When extreme, the drum head lies against the inner wall of the tympanum and it may be immovably attached to it by adhesions. Thickening of the drum membrane is a very common feature. Atrophy is less frequent. 198 litsHASKs OF rjfj-: avi//. ¥ if. Ml Symp/o„ix. -^ Deafness is always present and vanes from sii^rht impairment to almost absolute deafness. It is pro^rressive hut usually so slow that the patient is not aware of the advance. Extreme degrees of deafness indicate involvement of the laby- rinth. Moderate degrees are produced bv the changes in the middle ear. Altered tension, retraction and rigidity of the drum, displacement and fixation of the ossicles, contraction of the lumen of the tym- panum, and diminution jf air pressure all interfere with the transmissisn o^ sound waves. Peculiar modifications of hearinf> are frequent in this disease. 1. Autophony. In this the sound of one's own voice IS heard either as if coming through the tissues of the head or as if from some outside source. 2. Dysacousma. This is a sensation of pain or discomfort caused by loud or even moderate noises. I his diflers from hyperaesthesia acustica which signi- fies an excessive sensitiveness of the auditorv centres so that there is an abnormal acuity, the patient hear- ing sounds inaudible to others. 3- Pseudacousma or false hearing in which out- side sounds or one's own voice is heard altered in pitch and quality. This is most likely to be observed in trained musicians and is a serious impediment to the practice ot their profession. 4- ''ara.usis duplicata, in which sounds are doubled so as to be heard twice in the same ear. 5- Paracusis VVillisii. or increased hearing power in a noise. This is quite common and has been usually regarded as pointing to an unfavorable prog- nosis. ^ Tinnitus is the symptom next to deafness in im- CnnONIV (WTAimilAL otitis media. 199 portance. In many cases it is the only symptom of wiiich the patient complains. If it is at all promi- nent it is sure to produce ^reat annoyance and dis- tress. If more intense the disagreeable sensation may amount to actual pain; and very aggravated cases make the patient's life a burden to him. The latter are likely to become melancholic and may go on to actual insanity. Like the deafness it tends to increase as the case advances, but it shows great fluctuation both in intensity and constancy. In- volvement of the labyrinth may increase or decrease it according as the auditory nerve fibres are simply irritated or rendered functionally incompetent. Tinnitus varies not only in intensity and con- stancy, but also in quality, pitch and rhythm. There is scarcely a known sound which has not had its counterpart as a subjective noise in the ear. The patient likens the noise to external sounds, with which he is familiar. The mechanic thinks he hears the sound of escaping steam or the noise of ma- chinery; the farmer says he hears the buzzing of bees or the humming of flies. In hysterical patients the imagination comes so greatly into play as to render their account of the character of the noise quite worth- less. A pulsating, beating or pumping sound, es- pecially if synchronous with the heart beat, is pro- duced by vibration from the passage of blood through the vessels and transmitted to the internal ear, either through the ordinary channel or through the bones of the head. These vascular sounds are increased on stooping, by physical exertion, mental excitement or anything intensifying the circulation in the vessels of the head and neck. Other sounds are synchronous 3(X) DISEASES OF THE EAR. WW If. i> with the movements of respiration, mastication or deglutition. Certain other sounds are produced in the ear itself. These may be due to movements of the ossicles, in which the noises are apt to have a metallic character and to be describee as ticking or grating ; or they may be due to agitation of the dry drum head, and are then spoken of as crackling or crumpling ; or they may be caused by the sudden separation cf agglutinated mucu. surfaces, when the patient says he has the sensation oi opening and shutting the cars. Lastly, the sound may be due to changes in the sound perceiving apparatus when there will be some other evidence of labyrinthine trouble. Patients usually complain that the tinnitus IS more annoying at night, this being due either to the fact that their attention is more directly called to It when everything is quiet or else because of the in- creased congestion of the head in the recumbent po- sition. Auditory hallucinations are a form of tin- nitus, modified by the patient's imagination. Thus the noise of blood pulsating may, to a nervous per- son, be transmuted into the voices of dead friends or of enemies or some supernatural sound. The im- portance of these, apart from the distress thev cause lies in the fact that in persons predisposed to 'insanity they actually induce it. The hearing of voices is al- ways to be regarded seriously. The third leading symptom is vertigo, which when present is com- plained of more than all the others. It occurs in about eight per cent, of all cases, and it may not, in the mind of the patient be associated with the ear trouble. In mild cases it is limited to transient attacks of gid- diness, while those more severely affected are unable CHRONIC CATAllliHAL OTITIS MEDIA. 201 to maintain their balance and fall to the ground un- less supported. This symptom is due either to struc- tural changes transmitted from the tympanum to the internal ear or to simple alteration in the intra- labyrinthine pressure from increased tension of the ossicles transmitted through the fenestra ovalis. The difference between these two varieties is of great im- portance, because while the first cannot be benefitted, the second class may possibly secure some relief. As a matter of fact the removal of the ossicles has been followed by cessation of all vertigo. The dis- crimination is however difficult and sometimes im- possible. It must be remembered, too, that the ver- tigo may be the result of some intercurrent cerebral disease. Vertigo, like tinnitus, varies greatly, being aggravated by any condition which increases the intra-cranial pressure, such as physical exertion, straining, stooping and mental excitement. Sensa- tions of discomfort in the head and ears are very frequent. These are described as a feeling of weight, pressure or fullness. Pain in the ear is very rare in this condition. It should be regarded rather a,; - i intercurrent symptom. Certain general symptoms are often met with. These are mainly the symptoms of the general condition producing the catarrh. In children we find the pale, bloated or sodden skin, in- dicating chronic malnutrition from disease or im- proper hygiene. In adults there are symptoms of nervous exhaustion or depression, such as excita- bility and irritability of temper, a tendency to be- come tired in mind and body after slight exertion, and a predisposition to neuralgia or migrane. !!i 'i 303 niSEASES OF THE EAR. Objective E.xaminafion.—'Vhc diagnosis is effected by three procedures: i. Inspection of the membrana tympani. 2. Testing the function. ^3. By artificial alteration of the conditions of tympanic pressure. The appearance of the drum membrane does not always afford a certain indication of the state of 'the tympanic cavity, but as it is the only part accessible to direct observation we must be prepared to draw from it whatever inferences we can. Hence changes in lustre, curvature, consistency and tension are care- fully scrutinized. The lustre and color may be very nearly normal even when a sclerotic process is far advanced but in most cases the evidence of involve- ment of the drum is very marked. There may be patches of opacity, or the whole membrane mav have lost its iranslucency, the surface being dull and lustreless. The normal pearly hue is converted into a dull muddy hazy gray; sometimes the surface has a greasy, moist look, sometimes it appears dry like paper. The cone of light becomes shortened, broad- ened and irregular, grows duller and finally dis- appears altogether. If the thickening of the tissues goes on all the uistinctions on the surface are obliter- ated and we have simply a porcelain white sheet ; but on the other hand if the case goes on to the atrophic stage, the membrane again becomes lustrous and may be more translucent than usual. The degener- ative processes may also produce clear-cut, chalky white opacities from the deposition of calcareous matter. The second procedure is to test the function. The tuning fork tests are not entirely satisfactory. The third procedure is the use of the pneumatic test, by the artificial alteration of the intra-tym panic pres- !i*' CHIiONK' CATAIfRHAL OTirfS MEDIA. 203 sure, either by rarifyinjr or condensinj^ the air in the external auditory canal or in the tympanum. For this purpose we use Sie^le's otoscope, Politzer's air bag or Valsalva's method. The simplest method is to have the drum under observation when the patient inflates by V^alsalva's method or the diagnostic tube ma\' be used. In this way we ascertain whether the eustachian tube is open, and whether the drum mem- brane moves freely, is rigidly fixed or abnormally flaccid. The hearing should be tested before and after inflation to ascertain how far the deafness is due to eustachian closure. Proffitosis. This depends upon the age of the patient, the state of his general health and the amount of damage which the car has already suflered, as well as the duration o{ the case. It is usually unfavorable. ZV^vz/wt'///. - Unfortunately most of these cases come after the disease has lasted soine years and has done great damage. It is often necessary to express an adverse opinion and to decline to treat the case at all. When a case is undertaken an attempt should be made to get rid of the cause provoking the catarrh. The causes for which treatment may W undertaken, are unfjivorable climatic conditions, unhygienic con- ditions of life, diseases producing debility, and the reflex and exvting causes from other organs. Mu:h may be done by attending to proper ventilation and moisture, and the avoidance of draughts in living and sleeping rooms. So also proper clothing should be worn to protect the body against sudden extreme changes in temperature. The middle ear may also be treated by frequent inflation and the introduction of a vapor to influence the tension of the drum and to m i9 •M4 . [M! m DISEASES OF THE EAR. remove the exudate or to promote its absorption. The use of the Politzer's air nag to keep the eustach- ian tube open and to force the drum head out when it is retracted will sometimes break up adhesions between the drum and the inner wall. The injection of vapors through the eustachian is also beneficial. Free iodine is of the greatest service as it provokes a mild reaction which tends to carry off pathological deposits. This is used by placing in the nose-piece of the Polit/er bag a few drops of a solution of iodoform in chloroform, one dram to the ounce. When the pressure is exerted the diffusion of the gas is so rapid that it is felt at once in the middle ear. Operative measures upon the tympanum and its con- tents have been tried lately but without satisfactory results. These operations include paracentesis of the drum head, tenotomy of the tensor tympani and stapedius and the removal of the drum head and ossicles. Chronic Suim'irativk Ixflammation ok thk MiDDLK Ear.— This is a continuation of an acute otitis media, and therefore the causes need not be discussed again. Middle ear inflammation in measles, scarlet fever and diphtheria is prone to be- come chronic. In tubercular patients the condition may be chronic from the first, that is, it may not be ushered in by the usual pain and general disturbance, but deafness and a discharge of pus are simultaneous. Otitis in diabetic patients also runs a chronic course. Anatomically all cases of chronic suppuration have the following points in common, viz., a perforation CHRONIC ly FLAM MA TION. 20S in the tympanic membrane and more or less purulent secretion thrown off from the mucus lining of the middle ear. There is always more or less deafness, but the degree varies within wide limits. This symp- tom is due to several factors, — three at least, i. The perforation. 2. The swelling of the mucus membrane or the clogging of the ossicles with pus. 3. Destructive changes in the tympanum. A per- foration is not in itself the cause of ver\' marked deafness. In the case of a very large perforation oc- cupying the posterior and upper part, the hearing is often very good, as the sound waves reach the stapes directly. When the perforation is small the secretion tends to accumulate in the tympanum and so inter- feres with the motion of the ossicles. In some cases the ossicles have all been destroyed, and then great deafness is likely to be present. When absolute deafness exists it is due to co-existing disease of the labyrinth. The various forms of perforation are : 1. Pinhole perforation. Usually valve like and hard to see. 2. The typical perforation, which is round or oval and clean cut. 3. Kidney shaped. This is owing to the long handle of the malleus. 4. Healing perforation. There is a margin of injected membrane. 5. Unhealthy perforation. The margin is thick- ened and surrounded by granulations which often give rise to polypi. 6. Dry free perforation. This has healed around the perforation margin and becomes a permanent condition. ifl Hi 1 \\,hi UW. 2m nrsKASHs or the em}. 7. Hry adherent perforation. This is adherent to the inner wail of the tympanum. S. Perforation in the membrana flaccida. This is tlie most serious and danj^erous. Pain is not a symptom of uncomplicated chronic suppuration. Tinnitus is not always present and verti^ro is rare. Discharge of pus' or muco-pus through the perforation is more or less constant. This may be very alnindant so as to flow from the external meatus, or it may be small in amount so that the patient is not aware of it. There is always an intense fetor. That the secretion is irritating is shown by the frequent occurrence of eczema or ul- ceration about the meatus and auricle. The dis- charge may be classified as follows : 1. Healthy or what was formerly called "laud- able " pus. This is thin and not offensive. 2. Ropy. This is seen after recent acute inflam- mation and is on account of its admixture with mucus. 3. Thin and watery. During the healing stage it may become of this character. Also in neglected cases it may become so, but then it is acrid, copious and very irritating. 4. Sanguineous. Hlood denotes a granulating surface or a soft polypus. 5. Foetid. This is always present in neglected cases and when bone is diseased. On inspecting the ear various pictures present themselves ; indeed it may be said that no two cases are exactly similar. The discharge must be removed before the drum membrane can be inspected. The latter or what remains of it is more or less thickened; it may have a fleshy look or contain calcareous de- VHROXIV I NFL A mr A TION. ao7 posits. More than one perforation may be present in the same membrane. /Jid^mosis.- This is simple. Discharge of pus is strong presumptive evidence, while pulsation of the secretion corroborates. The r)erforation is usually visible and when Valsalva's inflation is done, bubbles of air and fluid are seen to pass through it. The same is the case when vSiegle's pneumatic speculum is ised. A perforation in Shrapnell's membrane may not give the perforation whistle, because the upper parts of the tympanum may be shut off from the lower by the inflammatory process. The course of uncomplicated chronic suppuration varies. It may, under treatment, gradually cease and the perfo- ration become cicatrized as a dark colored patch be- coming gradually more transparent. The cicatrix may become adherent and fix the drum to the inner wall. In a certain proportion of cases the discharge ceases, but the perforation remains. Such a con- dition is liable to recurrence^ on account of the ex- posure of the tympanic mucus membrane. In an- other class of cases the discharge continues in spite of treatment. This is more likely to be the case when there is perforation of the membrana flaccida. Prognosis. — This is cf interest in reference to life and hearing. In regard to the danger to life, the freer the drainage the less it is. A history of repeat- ed attacks of pain followed by re-appearance or increase of the discharge is a serious matter. As to the hearing power we cannot speak definitely from the appearance. If the perforation is large we can form some idea from the condition of the mucus membrane in the tympanum whether treatment will lil! 908 nrs EASES uF the ear. 111 be of bencllt. If it is much swollen and seerctinK freely uc may expect to restore some part of the hearing'. If inflation causes distinct improvement some benefit will come from treatment. The prog- nosis in such diseases as phthisis and diabetes is not good. Tnatmcnt. Cleanliness is of the first importance. Ihe patient may be allowed to syringe the ear him- self frequently with an antiseptic solution if no unpleasant sensations such as vertigo result from it. If. however, a chronic case is to be cured the surgeon must undertake the whole thing and treat the ear ii.mself every day. The syr inge may be used first with carbolic or bichloride solution. Then Polit/er's -infladon is done to drive all the secretion out of the middle ear. I!£roxidc.ofJijdrogen may be used on a cotton swab to cleanse the cavity. When once this IS done, medication of the diseased surface is to be considered. ^Alcohol makes tjie very best application -£I2y.!M ihere is no necrosed bone and no great periostitis. Lastly the parts are dusted lightly with ^adry powder, either boraic acid or stearate of zinc jnih„arislol. If no complication existrthi^ealment will mvairably give good results. The artificial drum membrane may he tried in all cases where con- siderable deafness is present, after the discharge has almost or entirely ceased. Vearslev in 1X4, made an artificial drum with cotton wool and this still re- mains the best form. They are also made of rubber and of sized paper which is moistened before being applied. Quite a lucrative trade is carried on by '•-acks in these things, as all sorts of deaf people buy them in the hope of finding something that will im^ rinn)xrc /XFL.iAnrA tiox. 300 bcncJlt them. T is no doubt that all forms are of benefit merel> from the slight pressure exerted. It is impossible to tell except by experiment whether any given case will be benefited by them. It is most useful for cases of large perforation in the posterior superior quadrant exposing the stapes. Some of these patients experience sudden changes in hearing power. Some hear better when some liquid is poured into the meatus or when a drop of glycerine lies on the drum head. If the cotton wot>l pellet improves the hearing the patient can soon lie instructed to apply it himself. Kvery form of artificial drum is a foreign body and liable to cause irritation. It should therefore be worn for a short time each day. If dis- charge reappears or pain occur it must be discontin- ued at least till the ear is better. The complications and sequelae of chronic sup- purative inflammation are o. great interest and importance. They are as follows : - I. 2. 3- 4- 5. 6. I am. Granulation and polypi. Facial paralysis. Exostoses. Malignant disease. Caries and necrosis and loss of the ossicles. 7. Cholesteatoma. 8. Inflammation of the mastoid. 9. Cerebral complications, a. Thrombosis of the cerebral sinuses. b. Meningitis. c. Cerebral or cerebellar abscess. d. Cerebral embolism. 10. Pyaemia. itO msKASKs OF rm: am/.-. ',-1 These will now be discussed. I. Pain. In acute inflammation pain is a usual and comparatively inniKcnt symptom, but in chronic suppuration it is always of serious import. When the patient complains of pain, and at the same lime a previously existing dischar^'e ceases, danger is im- minent. The ear should be carefullv examined and If mspissated pus, foetid crusts or any mechanical obstruction to the rutnow of tlie pus Ik- found, active treatment must be employed without delav. Pain usually means imperfect drainage. The prognosis in rcK'ard to life is always worse when there is a history of rcpiated earache. The treatment is alon^' the line of promotin^r draina^'e. Inspissated pus must be removed completely. A solution of bicarbonate of soda w.ll be of use in di^solvin^r .such a mass, and for the same purpose one of the digestive ferments is sometimes used. A small perforation must Ik- en- larped. If these measures do not speedilv ^ive relief then a more extensive operation is nec-ssarv. 'Ih^ pus cavity may be curetted with a small sharp spoon throujrh the enlar^red perforation. The drum mem- brane may be detached and the ossicles removed as m .Stacke's operation so as to permit direct access to the middle ear cavity and all possible seats of disease 2. Granulations and Polypi. Granulations arc very often seen in middle ear inflammation, and polyp, are to be regarded as enlarged granulations. The latter are sessile, led. uneven-lookin^r ^rrcnvths bleedin^r freely when touched. They spring, from the' walls of the tympanum or margins of a perforation or from the ed^re of a sinus, or from a drum cavitv in which carious bone exists. If jrranulations are prcs- ClfKON/C tXFLAMMA T/OX. fn ent there is more or less blood mixed with the dis- char^rc and this is increased by syrinjjin^'. On examination it is easily made out. If touched by a probe it will In* found to have a broad attachment and to bleed readily. After removal they tend to recur rapidly. Perforations of the membrana flaccida are often associated with granulations which tend to take on a polypoid form. As to treatment no fixed rule can be laid down applicable to all cases. If dead bone be the cause little good can come from simple removal of the ^granulations. A more extensive oper- ation must be done. If suppuration alone is the cause then scraping and the application of caustics will give permanent relief. The curet is first used to remove everything possible. This is followed by alcohol, carbolic acid, chromic acid or the galvano- cautery. For the removal of polypi a fine snare is used. There is usually free haemorrhage but this can always be controlled by plugging the meatus. The pedicle shoiild be destroyed by caustic or the cautery. If the after treatment cannot be supervised by the doctor, some alcohol may be given to the patient to instil once or twice a day. 3. Facial Paralysis. This is not uncommon as a complication of suppuration of the middle ear. Often there are anatomical peculiarities in the middle ear favoring facial paralysis. The paralysis may be caused by inflammation of the neurilemma due to extension from the tympanic cavity, or there may be caries of the Fallopian canal associated with des- truction of the nerve. The prognosis is always doubtful because there is no means of distinguishing the favorable from the unfavorable variety except by It 213 nrsi:ASEs of the far. the course of the affection. The treatment must he directed to securing free drainage and it is desirable to keep up the nutrition of the facial muscles by galvanistn and massage. 4. Exostosis. This sometimes comes from a long continued chronic inflammation. It is of importance so far as the exit of pus may be interfered with, when some operative measure will be necessary to remove it. 5. Malignant disease. Carcinoma is the most common, but even it is extremely rare. Only two cases have occurred in my own' practice, both of these being epithelioma. In sixteen published cases of carcinoma twelve appeared after long standing suppuration. The symptoms are pain, associated with >ert.go, while the discharge is mixed with carious matter. Facial paralysis is usual. On ex- amination the ear is found full of. granulation tissue which bleeds readily and recurs rapidlv after removal. The adjacent lymphatics are not always infiltrated, but late in the disease the mastoid is swollen and may become soft and break down. Extension to the cerebral cavity may occur. Death from exhaustion, meningitis or haemorrhage finallv terminates an ex- istence which has ceased to have anv attractions. Treatment is directed to relieving the pain by cocaine locally and morphia internally. 6. Caries and Necrosis. -Caries and necrosis af- fecting the temporal bone and ossicles arc usually the result of chronic suppurative inflammation, but may occur during the acute stage. Certain forms of inflammation are more prone than others to lead to disease of the bone. In the otitis media of scarlet I! < IfROXIC INPLA.SfMA TION. 213 fever and in the course of diphtheria the ossicles may be swept away during: the acute stage. So also in those afflicted with str.-...a, Jiaix:t^s, phthisis and syphilis the bone is moi\' liable to be affected. The parts of the temporal b(^ it- are attacks d in the follow- ing descending order of •. ,;,.,..„ yr -i. The mastoid process. 2. The roof of the tympanum. 3. The posterior and upper wall of the external meatus. 4. The ossicles. 5. The -nner wall of the tympanum. 6. The groove of the lateral sinus. 7. The floor of the tympanum. 8. The posterior wall of the carotid canal. 9. The labyrinth. 10. The internal auditory meatus. Of the ossicles the malleus and incus are more frequently attacked than the stapes. The foot plate of the stapes is rarely affected. The symptoms differ very much in different cases. In some cases the existence of dead bone is easily detected by ob- jective methods alone, but in others the actual carious area is not detected either by sight or touch. The surgeon muTit then draw his conclusions from the following data : Pain in the ear is usually present. It is not always constant, but recurs from time to time, lasting for days, becoming worse at night and being often associated with diffuse headache. The pain is aggravated by percussion of the bone and by astringent instillations. The pus is watery and is mixed with masses of cheesy consistence. It is very foetid. Spicules of bone may be found mixed with the discharge. The appearance of the meatus is often much narrowed from swelling of the soft parts or hyperostosis. In the deeper part of the canal lux- uriant granulations are seen which bleed readily and grow rapidly after removal. Glandular enlargement 314 DfS/-:.\SKS OF THF. FAR. ll " is frequent and the pus may burrow into the neck. During' the progress of the case portions of the meatus, mastoid cells, tympanum or labyrinth may be thrown off as sequestra. 'I'he pro^^nosis is always doubtful. The dan^rer is from extension to the cranial cavity and from haemorrha^re. rn-a/nien/. -The local treatment must be ener- getic. Antiseptic solutions are to be used freely in cleaning the parts. Nitric acid in % per cent, solu- tion IS recommended to dissolve the spicules of bone. The digestive ferments are also employed for this purpose. Operative interference early in the course of the disease will irjve the most satisfactory results. 7. Cholesteatoma. This is a collection of densely packed laminated epithelial cells, under-oin^r fatty degeneration and intermin^^led with numerous cells of cholesterin. Sometimes these cells are contained m a kind of capsule of connective tissue. According to V^irchow this is a true neopla.m. The mass orig- mates only in cases of perforation, and they may invade the mastoid cells and even lead to'actual distension or perforation of the osseous walls. Ab- sorption or erosion of bone and invasion of the deeper parts of the cranium is the common result. In many mstances the cholesteatomatous masses can be re- moved from the ear by syringing. If very dense they must be softened by instillations of hydrogen peroxide or a mixture of bicarbonate of soda, glvcerine and water, syringing being repeated till the mass is dislodged. Impactions in the mastoid cells can be reached and removed only by a mastoid operation. S. Inflammation of the Mastoid. Some anatomi- cal points are of great clinical importance in con- cirunxfc rxFLA^r^rA tton. 215 nection with this disease. The mastoid process which is situated directly behind the ear, usually consists of pneumatic spaces which communicate with the tympanum. The sp. es present endless vari- ations, sometimes they are all pneumatic, sometimes they are part pneumatic and part contain diploe, sometimes all contain diploe. The air spaces usually communicate with the tympanum through the mastoid antrum. This latter cavity, the mastoid antrum, very seldom varies. It opens into the tympanum at the upper and posterior part. It is present in the new- born, and the air spaces which are formed later, open into it. It is important to bear in mind that the inner surface of the mastoid process contains the groove for the lateral sinus, and sometimes this is well forward. Another important landmark is found on the outer surface of the mastoid at the anterior superior corner. There is an elevation here called the spina supra meatum which seems to be the pos- terior part of the zygomatic line, and immediately below it is a depression. This hollow is usually well marked. This is the point at which the mastoid is opened. It is customary to divide inflammation of the mastoid into superficial mastoiditis or periostitis, and deep mastoiditis or empyema of the cells. Inflammation of the mastoid occurs as a compli- cation of both acute and chronic middle ear suppur- ation, with or without caries, polypi or cholesteatom- ata. In acute inflammation the process extends directly from the tympanum through the antrum to the cells. In chronic inflammation the mastoid com- plication is the result of deficient drainage. The pus finds its way into the antrum and cells and gives rise to caries and necrosis. 216 niSHASES OF THE EAh'. The condition is usually associated with consider- able rise of pulse and temperature. Usually there is ^'reat pain, diffuse headache and photophobia. When it occurs in the course of a chronic suppuration there is a history of dischar^re lessening or ceasing before the onset of the pain. An examination may show some obstruction to the exit of the pus, and the mastoid process is painful and tender to the touch. As the condition develops, the parts behind the ear become red and swollen and the auricle stands out from the head. Subperiosteal abscesses form over the mastoid or in the posterior wall of the meatus. This is often associated with perforation of the bone at a point over the antrum ; or perforation mav take place in the region of the digastric fossa, and so allow pus to burrow into the tissues of the neck. The proK-nosis is always ^rave, except where the periosteum alone is affected. In children extensive death of bone is frequent and the patient dies of marasmus from j^'eneral exhaustion. In adults the chief risk is from cranial affections. The treatment must be conducted alon^r the line of securing free drainage. Polypi and granulations must be re- moved, a small perforation enlarged, the middle ear irrigated, and hard masses of secretions are to be softened and removed. The local measures appli- cable to the mastoid itself are blood-letting, the application of iodine and heat. If these methods fail to relieve the pain an incision should be made over the mastoid down to the bone. This is called Wilde's incision. It relieves pain by lessening ten- sion on the outer surface of the bone, but it does not aid in draining the tympanum. The incision is f I: ! } ('JHiom< ' lyFLA mm a t/ox. an made half an inch behind the auricle, parallel to its attachment and should extend from the tip to near the base of the mastoid. It is usually advised to make the incision from below upward, to avuid any chance of the knife slipping into the tissues of the neck. Opening the mastoid cells has long been re- cognized as a surgical procedure, but the indications for, and the method of opening are those laid down by Schwartzc. The indications are as follows :— 1. Acute inflammation of the mastoid not yielding to other means and threatening cranial symptoms. 2. Recurrent inflammation of the mastoid It there is a fistula or burrowing of pus the indication IS strengthened. .1. When the exterior of the mastoid is healthy but there is evidence of retention of inflammatory products in the middle ear. 4- In intense neuralgia of the mastoid. This is associated Avith a sclerosis of the propess or filling up of the pneumatic spaces with bone. 5. As a prophylactic operation, in order to esta- blish drainage and facilitate cure in cases of chronic suppurative otitis. The operation is not devoid of danger. The lateral sinus may be opened, or the facial nerve be mjured and ^ paralysis result, but the danger is really slight as compared with the risk of deep seated tension. 9. Cranial complications. (1). Meningitis. This may arise from the middle ear or from mastoid involvement. The process may affect the entire surface or be localized It is marked by a high temperature which does not fluc- Mil .4 Ed 218 niSKASES OF THE F.ML \S\\ [HI I f4iU5 tuate much, varyinjr from loi to 105 . There is se- vere headache, photophobia, vomiting and localized or general convulsions. Fhe last symptom is more common when children are affected. Delirium also occurs in young patients. In adults a basilar menin- gitis affects groups of muscles supplied by particular nerves involved at their points of exit from the cranial cavity. Paralysis follows as the disease advances. When the basilar meninges are affected there is seen the peculiar respiration known as the -'Chevne- Stokes," in which there are several short efforts at inspiration followed by a long sighing expiratory effort. The paralyses met with are those involving the third, fourth and sixth nerves. Strabismus is thus produced. When the third nerve is implicated there is first a contraction of the pupil and later a dilatation. Meningitis of this kind is usually fatal, but Maccwen reports six recoveries after operation. The treatment will be secondary to that necessary for the condition of the ear. The application of ice to the head is agreeable and may retard the progress of the inflammation. Large doses of bromide of soda are indicated. Opiates are to be avoided, but may have to be given on account of the intense pain. Free purging should be had. Surgical measures to be effective must be undertaken early. (2). Sinus Thrombosis. The occlusion of one of the large venous sinuses within the cranium by an infectious thrombus is one of the possible compli- cations of acute or chronic suppuration in the tym- panum. The mastoid veins communicate freely between the lateral sinus and the pneumatic spaces covering it, so that the septic material is readily 1.!} :! CIlROXrv TXFLAMMA TTOX. 319 carried from the spaces into the sinus. Not only may this happen but a middle ear inflammation, without involvement of the mastoid cells may cause the condition as well. Here the channel of infection may be the superior petrosal sinus or some of the smaller veins. When such a deposit takes place the first step in the process is the occlusion of the sinus by a Hrm fibrinous clot. The development of pyo^reni- bacteria in this mass leads to general septic infection by the entrance of bacteria into the jrenera! circulation. The thrombus may remain localized in the sinus itself or it may extend to the internal jujrular vein. If life is prolonjjed after the general infection, we find secondary purulent deposits in various parts of the body, the lungs being the favor- ite site. Secondary brain abscess is also met with and secondary thrombosis of some of the other venous sinuses, and sometimes these secondary lesions are on the opposite side of the brain. The symptoms are insidious and may escape notice. The point which is characteristic of the involvement of a large sinus is a sudden rise in temperature followed by a spontaneous fall to normal or nearly normal. This may escape observation unless the temperature is takei; frequently. Then symptoms of general sepsis develop ; asthenia, emaciation and an ashy hue of the skin. The rise of temperature is followed by a profuse perspiration. In uncomplicated cases symptoms such as headache, local or general convul- sions, paralysis, mental dullness or delirium, are absent. In making a diagnosis it is most important that the temperature be taken frequently,— say every two hours. A second symptom of much importance 220 nrSEASKS OF THE KAlt. I J is the development of an asthenic condition without local disturbance to account for its development. A few cases reco\er spontaneously. Death usually occurs from profound systemic infection, from men- ingitis, cerebral abscess or pulmonary involvement. The surgical treatment alone is of use, and it must be undertaken early. Particular attention should be paid to the general nutrition of the patient. {t,). Cerebral and cerebellar abscess. A localized purulent focus within the brain tissue may be either acute or chronic in development. The acute cases are rare and the most common cause is purulent otitis. These abscesses may be single or multiple. They may involve the cortex or deeper regions of the brain and may be limited to one side or met with in both cerebral hemispheres. The common situations are the tempero-sphenoidal lobe and the cerebellum. As a rule they are deeply situated in the cerebral substance and tend to rupture into the lateral ventricles. An abscess may remain latent for years and be excited to renewed activity by the occurrence of an acute inflammation in the region primarily involved. Examination of some of these abscesses shows that the fluid is sterile. Whev. located so that pressure is exerted on the motor tract or upon the motor area in the cortex, localizing symptoms occur. These are at first of a convulsive character if the process is acute. When chronic the increase in pressure is so gradual that the areas are destroyed without a stage of excitement. As the most common site is the tempero-sphenoidal lobe, the characteristic localizing symptoms are only pro- duced when the abscess has attained considerable ClinONK • fNFLA M.\fA TIQN. 321 si/e, in which case it involves the speech area and produces either sensory or motor aphasia. If in the cerebellum, there is unsteadiness of ^raitand vomiting as a result of pressure on the middle lobe. The termination of a case of cerebral abscess is usually sudden, death takinp place from rupture into the ventricles, or from comprei,jion or destruction of vital centres. As to dia^rnosis, complicatin|r lesions may render diagnosis difficult. Examination of the fundus of the eye may show choked disc, but this indicates an intracranial lesion simply and is not characteristic of abscess alone. The examination of the field of vision may also yield some information. Unless surgical methods give relief an abscess in the brain means death. As soon as a diagnosis is made an operation should be Jone to explore the cavity. Localizing symptoms will simplify the oper- ation. CHAPTER VII. hi'! DIHEASKS OF THE PERCKPTTVE MEt'llANIHM. Anakmia ok Till: Labvkintm. — The causes of this condition arc jj^cncral haemorrhage cither from traumatism, rupture of an aneurism or uterine haem- orrhage, and simple or pernicious anaemia. Syniftfoins. Hearing is impaired for sharp sounds and musical notes ^^i a high pitch. When the laby- rinth suffers from malnutrition the patient seems listless and inattenti <\ and it requires an effort on his part to hear w'ih: jaid. The subjective noises are distressing and arc worse on lying down. The noise is usually dull, low-pitched, synchronous with cardiac pulsations, and is apparently identical with the venous bruit heard over the great vessels in the neck in many cases of anaemia. Attacks of vertigo are produced by slight pain or some slight visceral disturbance. The patient is dull, abstracted and inattentive. The pallor of the skin will always attract attention. This variation from the normal standard is frequently better ob- served in the mucus membranes than in the cutaneous surface of the body. The physical examination is negative. The functional examination shows the upper tone limit reduced. Bone conduction is re- duced. As to prognosis, a favorable result may be looked for in cases depending on haemorrhage or ANAKMtA nF THF. LMlYIUSru. '"a simple anaemia. To confirm a Uia^'nosis a few drops of nitrite of amyl should he ^w^n when all the symptoms disappear for a short i,..ie. In hyperaemia of the lahyrinth the same dose a^'jjravates all the symptoms. The specific treatment is to administer trinitriii in doses of i-rcwth of a ^vAm t.i.d. Iron and arsenic may he j,'>ven to improve the quality of the hlood. Cardiac stimulants are also in order. Hyi'erakmia ok TiiK Lahvkin Til.- '1 his may be due either to a venous stasis from mechanical obstruc- tion to the return current, or to an increased quantity of arterial blood bein^r conveyed to the part. This condition is likely to develop in individuals of a full habit and particularly in those who are of a grouty or rheumatic diathesis. Sudden physical exertion, over-indulgence in alcohol, sudden diminution in atmospheric pressure, the prolonged action of one sound, either mechanically or from exhaustion or over-stimulation, as is observed in telephone opera- tives and boiler makers,- all these are causes. Con- densation of the air in the external meatus from a blow on the ear or from an explosion forces the stapes suddenly inward and may cause hyperaemia of the labyrinth. Among the causes which lead to venous statis may be mentioned mechanical obstruction to the return of blood through the veins of the neck, such as pressure from a tumor, severe attacks of coughing, sneezing, or violently blowing the nose, or any similar strain. ^^'w/>/ow.v. -There is a feeling of fullness and dis- tension in the head, slight giddiness or vertigo, and high-pitched subjective noises. Hearing is slightly impaired unless the vessel wails are diseased. In ^ m /»/.SAM.V/;.V (tF TIIH HMi. patient of full hahit these symptoms come on In any slij;ht excitin),' cause, .such as frij^'ht. ra^a\ sudJen exertion, indigestion and too free use of stimulants. In makinj; a diajjfnosis atnyl nitrate may be used as already suj^'j^^ested. Physical examination j^'ives no information. The functional examifiation shows very much the same conditions as are present in anaemia. The upper tone limit is lowered, hone conduction lessened and sharp sounds are painful or not heard at all. As a help to dia>,'nosis the state of the intejjument of the face may be noted. The pro- minence of smaller vessels be iih the skin is a fair index of the condition of the circulation in the laby- rinth. The proj^nosis is not very favorable. If the hearinjr is but slii^htly impaired we may hope to ef- fect absorption and a return to the normal. When of lon^,' standinfT the outlook is unfavorable. Care- ful re^'ulation of the habits of life may do much for same. Treatment. -Local depletion bv blood-letting' from the mastoid is the most important measure. Cieneral blood-letting is pcrmissable when the attack is of unusual severity. Free catharsis and diuresis must be had. Blisters behind the ear may be of some use in chronic cases. Pilocarpine and iodide of potash are useful. Severe and sudden exertion and the use of alcohol should be interdicted. Diet must be reg- ulated so as to diminish the general plethora. Labykixtiiixk Hakmokrmagk.- This is caused by external violence, sue .s a blow on the head, or a fall from a height, or the sudden action of a loud LAllYlilSTIllXH llAHMuinUlAaH. m sound such as an explosion. It mav be caused by en'orts to relieve some middle ear trouble, such as forcible inflation with the catheter or I'olit/er's air bag. \arious conditions of the blood itself predispose to it, for example, the haemorrhagic diathesis, per- nicious anaemia. Icukamia. or fragility of the walls of the vessels in old people who are atheromatous. When the haemorrhage is considerable, complete disorganization of the parts may take place. This is the result of pressure, and a complete return to the normal is impossible even though the blood mav lie absorbed. Where the traumatism is not so great the pressure may be gradsi 'lis- relieved by absorption or organization of the clot and the function is gi i.: , 'v restored. A>///;»/ow.r. -Sudden giddiness, intense nausea, severe tinnitus and great impairment of hearing come without warning. Unconsciousness may occur if the attack is severe. If it follows labyrinthine hyperae- mia there may be premonitory signs such as a fullness in the head and a throbbing in the ears. The treat- ment is much the same as for hyperaemia. We exhaust our remedies when we use local depletion, blisters, purgation, pilocarpine and iodide of potash! SvpiiiLfTic Inh.ammation v)|. thk Labyrinth. —Both acquired and hereditary syphilis affect the labyrnth. In the hereditary cases interstitial kera- titis is very frequently associated with it. In the acquired cases it is a tertiary symptom. The changes are of a chronic inflammatory nature. Sudden and profound deafness and subjective noises in an adult m fit iii Hi 886 DISK ASKS OF THE EAR. apparently in good health without evidence of middle ear disease should always lead to a suspicion of syphilis. The treatment of the acquired cases is satisfactory, but those that are hereditary are not likely to be benefited by any drug. IxiaAMMATiON OF i..K LABYRINTH secondary to chronic suppurative and non-suppurative inflam- mation of the middle ear. Where the tympanic structures have for a long time been subjected to an abnormal pressure from an adhesive process in the middle ear certain changes take place. The terminal filaments of the auditory nerve may be completely destroyed, or the increased tension may prevent the conduction of aerial vibra- tions, and the filaments undergo atrophy from disuse. An inflammatory process in the tympanum may pass by continuity to the adjacent labyrinth. This is true in both catarrhal and suppurative inflammation. If an infection of the labyrinth occurs it results in disintegration. Fortunately this does not often take place because there is no free anastomosis between the vessels of the middle ear and those of the labv- rinth. As to the symptoms of extension it is usually difficult to determine when this takes place. The most constant symptom is the presence of subjective noises. Disturbances of equilibrium are also fre- quently complained of. This points to an invasion of the labyrinth in the neighborhood of the semi- circular canals or involvement of the canals them- selves. Treatment is mainly directed to the condition in the tympanum. rEnEIHtO-SPrNAL MENmoiTTS. 237 The Acute Infectious Diseases and the per- cept..e mechanism. During the course of scarlet fever, measles, diphtheria, mumps, typhus and typhoid fever, variola, influenza and epidemic cere- bro-spmal meningitis, the organ of hearing is often the seat of pathological changes. In scarlet fever measles, diphtheria and influenza the middle ear is the part attacked, extension to the labyrinth being secondary. There are cases, however, where the specific poison exerts a direct influence upon the labynnth the middle ear remaining healthy, or a double infection taking place. The poison is carried to the labyrinth by the blood current and excites an inflammation of the tissues which line its long chan- nels, in some cases causing destruction of the terminal portion of the auditory nerve, while in others there .s an eff-usion of fluid into the labyrinth with increas- ed tension. Pilocarpine and strychnia are said to benefit some cases. Mumps.- Epidemic parotiditis or parotitis is prone to afi^ect the labyrinth rather than the middle ear. The local infection is from the blood current in precisely the same manner as in a complicating orchitis. The eftect is usually very profound and when ,t occurs in eariy life is a frequent cause of deaf-mutism. EiMDKMic Ckrkbro-simxai. Memxgitis.— In all other conditions mentioned the infection is by the blood. In this, the inflammation extends along the lymph channels of the vestibular and cochlear aquc- I ii K ■ I ii-i rap •■> Aim 'lliiil r s; » 11,.: 228 DISEASES OF THE EAR. ducts. If the patient recovers from the meningitis the outlook for hearing is very bad. In severe cases absolute deafness is the result, and in young patients this leads to deaf-mutism, such words as have been learned being forgotten. In older children who are able to read, mutism may not follow, since the as- sociation between written and spoken words is suffici- ent to preserve the power of speech. In acute meningitis of a non-epidemic character the labyrinth may be involved in much the same way. If it is traumatic in origin only one side is affected. Thk Effkct ok Diskask ok the Gknkral Nkr- vous System upon the Perceptive Mechanism. — This has reference to those affections characterized by degenerative changes in the various parts of the brain. These are, cerebral congestion, apoplexy, cerebral embolism, endarteritis, cerebral tumors, dis- seminated sclerosis and tabes dorsalis. From the location ot the cortical centres for hearing and the fact that each auditory centre receives fibres from the labyrinth of either side, any cortical lesion must be bilateral and extensive to produce absolute deafness upon either side. The crossing of the auditory fibres takes place in the medulla in the region of the olivary body. So an intracranial lesion on one side could only produce deafness in one ear when situated be- tween the foramen of exit of the auditory nerve and the corresponding olivary body. A tumor at the base of the skull might possibly produce this effect but neoplasms seldom occur in this region. Cases of haemorrhage and embolism show that in very few EFFECTS OF GENERAL NEUROSES. 329 cases is the organ of hearing affected to a perceptible degree. Even when one side is destroyed its place is supplied by the corresponding area in the opposite hemisphere, and the loss of function is slight. "Word deafness" is the most characteristic symptom of a cortical lesion, i.e., the words are heard but not understood, the patient simply obtaining the general impression of sound without being able to interpret it. There are also in these cases certain complex auditory impressions or hallucinations. The patient seems to hear voices, either directed to him or he may be simply a listener. Among musicians these hallucinations may assume the character of well known musical compositions. These symptoms i..e the same whether the change in the cortex be con- gestive, haemorrhagic, degenerative, sclerotic or neoplastic. As to treatment little can be said. The indica- tions are furnished by the general nervous disease. For the subjective noises, the bromides or hydro- bromic acid will be most useful. Tmk In'fluknck ov Ckrtain Medicinal Sub- ST -s Upon thk Organ of Hearing.— Of these it important is quinine. Salicin, salicylic t ■ id its salts exert a similar effect in a less de- gict. There seems to be a difference of opinion as to whether this is a hyperaemia or an anaemia. When administered for a long time these drugs pro- duce structural changes in the labyrinth which do not disappear even when the drug is stopped. When the ear is normal to begin with, serious injury from 230 DISEASES OF THE EAIi. this source is rare, but where a chronic innammatory process is jjoing on, their use must be guarded against. They should never be given except in an extremitv. HI iiT m DlSTlRBANCKS OK HkARIM; DkI'KNOKNT UpON KiNCTioxAL Nkrvols DisoRnKRs.- Neurasthenia and hysteria are the two common functional nervous diseases which influence the organ of hearing. The manner in which they do is a matter of conjecture. The disturbance probably depends on some pre- existing pathological condition which should ordi- narily pass unnoticed. The lesion may be either in the meatus or tympanic cavity and not be recognised by any examination. In any case the disturbance ot function is not at all in proportion to the pathological condition present. Hypnotic treatment is of more value in these cases than drugs, and should be tried. Dkaf-mitism. -The loss of hearing in early life, or congenital absence of this special sense, invariably leads to deaf-mutism. In many cases it is impossible to tell whether the power of sound perception has been destroyed in infancy or has been absent from birth. Heredity seems to play sone part in the cause as several members of the same family are frequently affected, though the children of deaf-mute parents generally escape. Consanguinitv of parents IS among the most common cause. Defective mental development is not as a rule associated with a con- genital defect in audition, indeed in many of these people the mental faculties are developed bevond the normal standard. Hereditary syphilis is a 'cause in DEAF-Ml'TISM. 231 certain cases. Other causes are injuries to the head during labor or in early infancy, the acute infectious diseases, acute and chronic inflammatory conditions in the cranium, and adenoid vegetations. Symptoms. — In very young children who have never spoken the first symptom noted is usually the failure to acquire the power of speech. In older children there are the usual signs of deafness. Diagnosis.— A.S the age at which children begin to talk and at which they respond to stimulation of the organ of hearing, varies greatly, it may be difficult to say whether a child is deaf or whether the develop- ment of the special sense is only delayed. It is not safe to give a positive opinion in children under eighteen months. In making a test the examination should be carefully conducted. Tuning forks of high and low pitch should be held near the ear when the attention of the child is diverted from the ex- aminer. If the sound is heard, the child will turn towards it or there will be a change in the facial expression. Clapping the hands behind the child's head, snapping the fingers or ringing a bell are also tests that may be used. Parents will volunteer information that certain sounds are heard, but one must not be misled by vibrations such as are pro- duced by the slamming of a door. If nothing can be done by treatment for these children no time should be lost in placing them in the hands of those who make the education of these patients a life study. ii lit Nkurai.gia of thk Ear.— This is not very com- The causes are dental irritation ^nd any debilitating cause such as would produce neuralgia mon. IMI ffflff 888 nrSKASKS OF THE EAR. elsewhere. The symptoms are pain affecting one side and often associated with neuralgia of the face and scalp. It is aggravated by a heated atmosphere and has a tendency to be worse at certain periods of the day or night. There are no inflammatory signs or symptoms and hearing is not affected. The treat- ment should be similar to that for neuralgia else- where. If a decayed tooth is found it should be removed. Quinine and arsenic are the most used remedies. h.AK Coi liii. - It is not unusual to find that a reflex throat irritation and cough are produced simply by touching the skin in the external meatus with a probe. So a foreign body in the meatus may pro- duce syncope, vomiting, giddiness, sneezing and coughmg. The cough is the most common symptom, and many interesting cases are recorded in which after searching vainly elsewhere for the cause of a cough, the attention has been directed to the ear, a foreign body removed and the cough has at once disappeared. Arns TO Hkaring.— One is frequently consulted about some form of instrument which will assist the hearmg. Of course no help can be given where the function of the internal ear or nerve centre is ces- troyed. It may also be laid down as a rule thai no form of invisible instrument is of any use. Of the various forms of trumpets, conversation tubes, audi- phones. car cornets, etc., a selection should always be secured for the patient to trv, as it is impossible to know except by trial what form of instrument will be best. DISEASES OF THE NOSE AND THROAT. CHAPTER U CLINICAL EXAMINATION OF DISEASES OF THE NOSE. The nose may be examined by three methods. 1. Anterior Rhinoscopy.— A speculum is intro- duced into the nares and the anterior part of the cavity can be seen. 2. Median Rhinoscopy.— By means of a small mirror introduced into the nasal cavity, with the re- flecting surface directed obliquely upward, the centra! part of the nose can be inspected. 3. Posterior Rhinoscopy. -The posterior portion of the nose and the posterior nares can be seen with a mirror placed behind the uvula. The first essential in an examination of the nose is suitable light, which may be either director indirect ; m 2*1 IHSKASKS OF THE NOSE A SI) THIidAT. direct when it is tlirown from the source straisln into the nares; indirect when it is reflected by a mirror. The li^rht ,r,;iy be sunlight, diffused' daylight, or artificial light. The two former show . natural color of the parts seen, but sunlight is not always to be had, and diffused daylight varies greatly in intensity and cannot be depended upon. Any form of artificial light will do if sufliciently intense ; in a dark room a common candle light will do, while in the patient's home a kerosene lamp or the ordinary gas light answers the purpose. In the oflice the operator may work in a bright room, using the in- candescent gas light with a Mackenzie condenser. This light is not only tho best, but the cheapest. The electric incandescent lamp of Trouve may be used attached to the forehead in place of the forehead mirror. The mirror which reflects the light is worn on the forehead and the polished surface is concave with a focal distance of eight to twelve inches. The size of the mirror varies from 2% to 4 inches. They are perforated in the centre and are worn so that the perforation is directly in front of one eve or the other. The position of the light in relation to the patient and the examiner should next be considered. The examiner must sit directly facing the patient, having the light to the side of and beyond the pa- tient's head and on a level with the parts to be ex- amined and his own eye. The eye behind the mirror is used, the other being kept open and completelv relaxed. To illuminate the parts thoroughly the nostril must be dilated with a speculum, but' often much can be seen by simply raising the tip of the nose with the linger and directing the light into it. CLrXK 'A A JiXA MfXA TfOX. sgg There are many useful forms of nasal specula, some of them more or less self-retaining. The model of Lennox Browne is the one recommended. For chil- dren the larger sizes of ear specula may be used. It IS well to have several sizes and patterns, as one will not answer for every case. The blades should not be fenestrated, because otherwise the vibrissae in the vestibule obstruct the view. The manner ot holding the Lennox Browne speculum is of some importance, i he blades should be well inserted with the handle upwards towards the forehead. After dilating, it is held between the thumb and forefinger of the left hand, the third and fourth fingers resting on the forehead or over the bridge of the nose where bv gentle pressure the position of the patient's head may be changed as necessary. It is sometimes a decided advantage to have the hand holding the speculum above the nose instead of in front of the mouth as is necessary with certain forms of specula. T/te Siruclures Exposed in A nterior Rhinoscopy. _ The inferior turbinated body is seen occupying about two-thirds of the outer wall. and the middle turbinated which IS smaller, is s^en in the upper part of the cavity, occupying about one quarter of the outer wall and almost touching the septum. The superior can- not usually be seen. The mucus membrane covering the whole cavity is normally smooth and of about the same color as that covering the gums, but often ap- pearing slightly congested. By having the patient move his head to right and left and up and down a complete view can be had of the lateral wall and sep- tum, the floor and inferior meatus, the middle and rarely the superior meatus. The inferior turbinated J 38« DISK ASKS OF THE Nfh\l-: ASH Til II OAT. body contains a plexiform arrangement of venous sinuses similar to the corpora cavernosa of the penis and constitutinj; a true erectile tissue. This tissue is also found to a less extent over the floor of the meatus and the lower part of the septum, and sometimes in the lower part of the middle meatus. The function of these erectile tissues is to regulate the area of mucus membrane over which the air passes in inspiration, to secure proper filtration and to impart sufficient warmth and moisture. According to the degree of turgidity, we can see to a greater or less extent along the inferior meatus. After exposure to cold air, dust, and in acute coryza, the erectile tissues are swollen and darker in color. A probe may be used to exam- ine the inferior turbinated when in a state of turges- cence. On pressure it is very soft and seems to fluctuate. The application of a 4/; solution of cocaine reduces it to its collapsed condition, so that the amount of turgescence or of actual hypertrophy may be exactly estimated. The inferior meatus is that portion of the fossa below the upper border of the inferior turbinated body. Into the anterior part of this opens the lacrymo-nasal duct, but this cannot be seen. The middle meatus lies between the middle and inferior turbinated bodies. Beneath the middle turbinated body a deep furrow, the hiatus semilunaris, extends from the anterior extremity downwards and backward ; this is crescentic in shape, the convexity looking forward. The anterior extremity of the hiatus presents a circular opening which is the orifice of the frontal sinus. Immediately behind this the openings of the ethmoidal cells are to be found, and still farther back is the ostium maxiilare which leads (•/./yfCAL /;.\M.V/AM TfOX. «t into the antrum of Highmore. The superior meatus is not easily seen. Into it opens the sphenoidal sinus. In most individuals there is greater or less deviation of the septum. The most frequent position is at the junction of the vomer with the perpendicular plate of the ethmoid and the triangular cartilage. This increases the difliculty of properly examining the side encroached upon. Median Rhinoscopy. This is only rarely of value. A small laryngeal mirror is introduced along the floor of the cavity with the reflecting surface upward. This method may be sometimes of use to determine the presence of small neoplasms. Posterior Rhinoscopy. - To examine the naso- pharynx and the posterior nares the patient, surgeon and light should be in the respective positions already described. To see the parts the tongue must ht depressed, the soft palate relaxed and a small mirror so placed behind the uvula as to reflect an image of the parts above. Hence in addition to the light and reflector a tongue depressor and a small mirror on a long handle are necessary. There are many forms of tongue depressor, and one is perhaps as good as another ; each has its advocates. It is well, how- ever, to have several of different sizes nnd of a form easily cleaned. The small mirror should be from one-half to three quarters of an inch in diameter and attached to the hapdl- at an angle of from 90 to 130 . Some operaiu.s use a combined depressor and mirror, while some employ only the ordinary mirror handle to hold down the tongue. A great deal depends on how far the patient has his tongue and throat under control. Some are able to keep the illM 38N n/sKAsr:^ or hie sosf. axp rnnnAr. tonjjuc down and x\v parts relaxed so that the mirror may be intn^duccd alone without touching; the tonj^ue, while others require an excessive pressure upon the tonjjue with a depressor. \ patient may l»e educated to hold the depresst r hinsdf. In any case the mir- ror must be j^ently ."nirieJ behind the uvula without touchinj; either it or 'tu p v.crior wall of the pharynx, or else the patient wUI cvilainly j;aj;. Firmness and jjcntleness are abscMiitolv noccssary. and if the parts are sensitive it is we!) to .:ake a numlwr of exami- nations rapidly rather than jtrolonjij a single attempt. When the tonjjue is depressed and the li^'^ht focussed it is necessary to see that the paiate is relaxed. Most individuals when tlie mouth is opt-ii and the lonijue held down, draw up the palate a; J breathe thnmj^'h the mouth. They should Ik* asked to breiUhe thrtiujijh the nose, and thoujjh they may not succeed, the verv effort is often sufficient to produce the ne* -sary relaxation. Sometimes the appiic.«*ion of a s or lo solution of cocaine to the lau cs will ix- of assistance ; althoujjjh it may sometimes agj. avate the reflex retchinj^ and ga^j:^in^. in spite i>f the anaesthesia. Finally if these means fail or the space between the soft palate and the pharynx l>c narrow it wil; tie necesssary to draw the soft palate forward with a palate retractor. When operatiims are to bt performed the palate may be tied forward ith tape, or a soft rubber catheter may !h' passed tlv nigh the nose, brought out through ilie mouth and tied. The catheter should be smeared with steriaized vase- line before being introduced. The rhino-copic mir- ror must first be warmed by holding tli. reflecting' surface over the flame of the tamp ior a ■ omciu to ifli cMNJr.i I, h:\ AMIS i tion. prevcn' (he moislure of the breath from condcnsinj^ on thi glas- ant' so obKcurinj; the view. A; c-r warmmjf, the H vk , ^ mirror should be tried against the hnid so - uiat it is not too hot, Ti.c mirror is to be hcM h>{htly like a pen, ar.1 intrtnUiced with thr reflecting surtac« upward, d wiiliout towchins^ the fauces, tonjftie or uvula, to a point i)e- hlnd the '; ula ar,: neneatli or to * •>; !e c>i it. The viev\ vili tpcn i on the r-^^n m ot the mirror, as, on accaun! i^f its si^^, pw* = s«aH irea is seen at once. - V ole pi nrt nor n res and nasopluirvn b<"n{j nw4v ' rie.s views. -1 • In . ho ntal, so !ic , .It of i Hxster- i .\ »e reflecting hurface is i.rly vertical position tin- poster- ith the septurr. dividing them. N iiom alx^vc downward. On the ach side the turbinated bodic masses. High up is the super ler in color than the others and die rbinatcd is the most easily mir. >r is slightly turned to one sidi the other we see the yellowish openings of the eustachian tubes. The orifice is funnel-like in pro- fife. Uchind .he tuhe and between it and the poster- • *r w.. is a depression known as Rosenmuller's fossa. ,\- 'he h^^^hcsI jHjint in the cavity ihiie may some- times be .n the raised collection of Iymplu>id tissue descrilic^ ha's tonsil and in the centre of this a dopres^ I he normal color of the nasal and nasopharynge.il mucus membrane is not easy to determine as it varies to a considerable degree in The m'r - irs! • as to i: .Ol)| io *aH oM^ phar* br Ui^ht ! 1 ov ior nares are se« The septum n^rrc oatw-*ni wall of app* ts pale p wf turt«fiated. smaller. '' -.Jv seen. VV'l 240 DISEASES OF THE NOSE AND THROAT. different individuals and in the same individual at different times. In front the darkest portion is over the inferior turbinated. Behind, the structures are pale grey; in the naso-pharynx, pinkish grey be- coming darker towards the pharynx. Digital examination of the posterior nares and naso-pharynx is sometimes the only possible means of making a diagnosis. More especially is this the case with children, though it is often of use also in adults. The finger is introduced behind the soft palate to feel the septum, nares, roof and walls. If a tumor is found its consistence, tenderness, mobility, place of attachment and vascularity should be deter- mined. In the case of young children it may be ad- visable to give an anaesthetic. ll ^^i. CHAPTER II. FUNCTIONS OF THE NOSE AND SUBJECTIVE SYMP- TOMS OF DISEASE. Functions of thk Nose.— Respiration. i. Passage way for air in breathing. 2. Warming, moistening and filtering tiie inspired air. Olfaction. — i. Perception of odors in inspiration. 2. Perception of flavors in expiration. Phonation. — ■■ . Resonance. 2. Production of overtones. Protection. — i. By sensation. 2. By olfaction. Ventilation, i. Of the ear. 2. Of the accessory sinuses. Accuracy of diagnosis requires that the subjective symptoms be considered in connection with the phy- sical examination. It is proposed now to review the various subjective symptoms of diseases of the nose and to associate with them the conditions which may explain these symptoms. The order in which these are considered is purely arbitrary. I. Physiognomjy.— This is of some interest and importance in connection with nose disease. Speak- ing generally it may be said that the thin prominent nose has a tendency to suffer from some form of ob- struction, while the small wide upturned nose leads to atrophic rhinitis, pharyngitis sicca and more or less severe laryngitis, the rcsuk of abnormal patency. ill 242 DISEASES OF THE XOSE AND THROAT. The so-called strumous physiognomy is present in a certain proportion of the cases of atrophic rhinitis. There is an unusual width of the bridge, alae and osseous framework of the nose. The point of articu- lation with the frontal bone is depressed, and the nostrils look downward and forward. The nose itself is small and seems to be sunken in tlie face. The lips are thick, everted and without expression. The mouth is generally closed but may be open, from obstruction of the nose with masses of inspissated secretion. Where partial obstruction exists for any length of time a deep furrow is seen running from the ala to the angle of the mouth. This is probably caused by a constant contraction of the levator labii superioris alaeque nasi, which brings the nostrils more nearly on a Kvf^l with the inferior meatus and so facilitates nasal breathing. The deformity known as frog face is usually due to intranasal or naso- pharyngeal tumors though it is produced temporarily by orbital cellulitis and facial erysipelas. The pres- sure from intranasal neoplasms such as polypi, fibromata and sarcomata, tends to absorb and separ- ate the outer walls of the nose and to extend into or obliterate the maxillary antrum. Thus the nose be- comes widened and flattened and the eyes are corres- pondingly apart. If the orbit is invaded the eyes may become prominent and even protrude. Collapse of the bridge of the nose is usually an indication of syphilis. The nose falls in from one of two reasons, either from destruction of the cartilage of the alae or the nasal bones themselves, or from ilestruction of the osseous septum which supports the bridge. When the loss of tissue is accompanied by ulcerating H PHYSIOGNOMY. 348 outgrowths and ulcers, lupus may be the cause and not syphilis. The main point of distinction between lupus and syphilis so affecting the nose is the rapidity of progress. Syphilis will produce a lesion in a few weeks which lupus can develop only in years. The difference in the character of the ulcers and in the tubercular formation is not very marked. It must not be forgotten that syphilis and lupus may co-exist. There is a combination of facial symptoms which in children invariably point to the existence of aden- oids in the post-nasal space. The lower jaw hangs down, the mouth is open and the lips are thick and expressionless. When the nose is examined closely a slight depression on each ala is seen at the angle between the superior and inferior lateral cartilages. Besides the nostrils appear very narrow, while the bulk of the nose is so great that the bridge seems unnatur-illy wide. These chile ren have a particularly stupid appearance, partly from this physiognomy, partly from the deafness which so often is associated with it, and partly from an intellectual dulness or in- aptitude. There is also in many of these cases an enlarged transverse vein at the root of the nose. Where these symptoms are combined with confirmed mouth breathing, post nasal adenoids are certain to be found. Deflections of the septum may cause ex- ternal deformity, the point of the nose being turned to the opposite side to that affected. 2. Na^al obstruction and mouth breathing. — The nose ih > merely the seat of olfaction, but is the natural ^tor. Air in passing through the nose is warmt. , filtered and moistened. However low the atmospheric pressure and temperature, the air is 4 I \ 344 i>TSEASi:S OF THE XdSE AND THROAT. It V ||S> raised almost, if not quite, to the temperature of the blood, while passing through the nose alone, and before reaching the pharynx ; however dry the air may be it is two-thirds saturated with moisture in the nose ; and exchanges t;.ke place in the nose between the gases of the blood and those of the air in direct proportion to the rise in temperature of the air. When any obstruction exists in the nose, mouth breathing is adopted. There are frequent exceptions to this however. In partial or transient nasal ste- nosis the mouth may be kept shut and breathing per- formed through the nosv even until there is evidence of lessened atmospheric pressure in the lungs. In infants the instinct to nasal breathing is remarkably strong. Even when the mouth is open the tongue is closely approximated to the roof of the mouth, and any obstruction in the nose may be the cause of se- vere dyspnoea, especially during sleep. Laryngis- mus may be induced by such obstruction. The nasal passages of infants are very narrow and the swelling from a slight rhinitis may be responsible for setting up serious ailments. The patient, however, does not often seek relief from mere obstruction of the nose, for even when the closure is complete he soon grows accustomed to it and may not realize his dis- tress till his attention is called to it. The statement of a patient that he does breathe through the nose should not be accepted without testing. If the nose is sufiiciently patent he should breathe through it unconsciously, and whether at rest or exerting him- self. If the stenosis is part'al he may be able to breathe through it so long as he fries ; but when in- quiry is made it is found that he snores and wakes in NASAL STENOSIS. 24ri the morning with his mouth open and his tongue parched. Snoring in children is always a sign of nasal obstruction ; but as is well known, adults very frequently snore where there is no nasal stenosis, and they may not do so where a very considerable nasal obstruction exists. Mouth breathing is sometimes a habit, that is, il exists where no mechanical obstruc- tion is found in the nose or behind it. There is little doubt, however, that it is always produced in the first place by a nasal stenosis and may persist after the cause is removed. The various causes of nasal obstruction are as follows : (a) Acute rhinitis. In the second stage of this condition there is a turgescence of the erectile tissue which may completely block the passages. As re- solution takes place, in the later stages, the tenacious or muco-purulent secretion may also interfere with nasal respiration. {b) Hay Fever. The stenosis in this is very dis- tressing. (c) Chronic hypertrophic rhinitis. This is the result of a continual turgescence. It is frequently observed in persons with large prominent noses. [d) Chronic atrophic rhinitis. In this condition the inspissated crusts accumulate until the whole of the cavity is blocked and the patient is forced to breathe through the mouth. (f) Polypi. (/) Granulation tissue at the ostium maxillare in empyema of the antrum or from caries of the ethmoid. {g) Fibromata and malignant tumors. ih) Deflections, ecchondroses, exostoses and abscess of the septum. If 34fi DISEASES OF THE NOSE ANP THROAT. ill lii (/) Foreign bodies and rhinoliths. Obstruction is not often complete but partial from these causes. (_/) Post-nasal adenoids. In this case the ob- struction is not in the nose but behind it, in the naso- pharynx. 3. Discharge. — The discharges from the nose may be from one nostril or both and may take place either anteriorly or posteriorly. They are classified as follows : — (i). Liquid discharges. («) Clear fluid which may come from irritation of the trifacial, or from escape of the cerebro-spinal fluid through a fracture in the cribriform plate of the ethmoid as a result of injury. (A) Turbid fluid which is present at first in acute rhinitis, and may become mucoid or muco-purulent. (f) Purulent. {d) Blood. Epistaxis. (2). Semi-solid. Such secretion mav be taken to indicate a chronic rhinitis. (3). Solid discharges. (rt) Dry crusts from chronic rhinitis (atrophic) which may be foetid and of a green ish-vellow color. {b) Rhinoliths or chalky concretions which are usually accompanied by a sanious, putrid discharge. (c) Diphtheritic membrane. The normal secretion from the nasal glands is regulated by the spheno-palatine ganglion and the fifth pair of nerves. In health the cilia of the mucus membrane carry the secretions backward to the naso- pharynx where they are to some extent, probably, re-absorbed by Luscha's tonsil. When the balance between secretion and its physiological removal back- NASAL niSCJIAHOE. 947 ward is interfered with, as in acute coryza, a running from the nose results. The function of the cilia ceases if they are wanting, as they are in some strum- ous children, or if they are destroyed by improper cauterization or by long-continued inflammation. A thin watery discharge from the nose may be produced by acute rhinitis, hay fever, a foreign body, polypi, and other intra-nasal growths, or the discharge may be the cerebro-spinal fluid escaping from a fracture in the base of the skull. In the latter case there is always the history of a severe accident. A purulent discharge from the nose may be caused by a foreign body, a rhinolith, polypi, caries, necrosis, gonorrhoea, or by empyema of one of the accessory cavities, more especially of the maxillary antrum. It is usually one sided and produces a foetid smell or a nauseous taste. The smell is present only to the patient, or is but very rarely of sufficient intensity to be offensive to his neighbors. The discharge from an empyema of the antrum is frequently intermittent and may flow more freely in one position of the head than another. In some cases it escapes only when the head is held between the knees ; or again, with one patient there is a free discharge only when lying down, while with another the reverse is the case. A purulent discharge from the anterior ethmoidal cells or from the frontal sinus is of the same offensive character, and of the same bright yellow color and appears in the nose in the same place, — under the anterior portion of the middle turbinated. It is however constant rather than intermittent as in empyema of the antrum; but it is only by taking into consideration other symptoms that we can differentiate between these conditions. I i ^1' m iiiiii 248 DISEASES OF THE NOSE ANP THROAT. When the posterior ethmoidal cells or the sphenoidal sinus is the seat of an empyema the pus is discharged into the naso-pharynx. The diagnosis of the latter condition is often extremely difticult. When the discharge of pus into the post-nasal space is associ- ated with exophthalmos, sudden blindness, ptosis and strabismus there is likely to be empyema of one or both of these cavities. 4. Sneesing.--'Yh.\^ is a reflex phenomenon which is usually caused by some irritation of the branches of the fifth nerve distributed to the nasal mucus mem- brane. It may also be produced by irritation of nerves in other parts, as, for example, sneezing caused by exposure to a strong light. As a symptom it indicates intra-nasal irritation. Apart from the application of a direct irritant, such as pepper, it occurs in acute catarrh, in hay fever and in hyper- trophy of the inferior turbinated body. 5. Anosmia. — Loss of the sense of smell and the taste of flavors are of frequent occurrence in disease of the nose. These may occur together or separ- ately. In the latter case it is usually the sense of taste that persists. 6. Pain. — This is not a usual symptom in dis- eases of the nose. A sense of weight in the bridge is often complained of by those suffering from thick- ening of the mucus membrane of the niddle turbi- nated. In empyema of the sinuses pain and weight are felt in the cheek and in the forehead. 7. A sensation of something moiung to and fro in the nose on respiration is sometimes met with. This is produced by a mucus polyp or some pedunculated growth. SYMPTOMS OF XASAL DISEASE. 24U 8. A ffections of the voice, thickness of articulation, undue nasal resonance, inability to pronounce certain consonants and impairment of the high notes of the singing voice are often mentioned by persons who have nasal diseases. 9. Deafness and tinnitus are common indirect consequences of intra-nasal disease. These may arise in two ways, ( 1 ) by extension to the eustachian tube and tympanum, and (2) by interference with proper ventilation of the middle ear, in consequence of nasal obstruction. 10. Reflex Phenomena. — These are classified as. follows: - (i). Serous or mucus discharge from the nose is frequently of a reflex nature and due to nervous influence on the glands of the nasal mucus membrane. (2). Sneezing as already mentioned is reflex. (3). Cough. Sometimes on touching the anterior extremity of the interior turbinated a hacking cough is produced. The conclusion is that in cases of cough not explained by conditions in the throat or chest a very careful examination of the nose should be made. (4). Asthma. — The removal of polypi or the cauterization of swollen turbinated bodies has cured many cases of asthma either temporarily or per- manently. (5). Redness and swelling of the outside of the nose may be due to reflex vessel dilatation, pro- duced by dilatation of the turbinated bodies. (6). Itching of the alae of the nose is frequently associated with intra-nasal irritation. (7). Other reflex phenomena are nightmare, mig- 250 DISEASES OF THE NOSE AND THHOaT. Ith' rane, constant headache, supra-orbital neuralgia, pain in the eyelids, giddiness, epilepsy and chorea. It has not been determined how these originate, or whether in each case a definite part of the mucus membrane is atfected. mm, CHAPTER m. TAKINCJ COLD. Most of the diseases ot the upper air passage are caused more or less directly by what is popularly known as "taking cold," so it will be well to try to understand the meaning of this term before taking up the different diseases. Various theories have been advanced to explain the phenomena, but no one of these seems to be satisfactory in all cases. It is a well known fact that the human organism must be maintained under all circumstances at a temperature equal to 98" F., otherwise disease will result; and that the source of this heat is within the organism, the expenditure of which by radiation we endeavor to minimize by living in houses and by protecting the surface of the body with clothes. Heat is pro- duced in the organism in two ways ; first, by oxida- tion of food, and second, by the conversion of mus- cular movement into heat. How and where the oxi- dation of food takes place we need not discuss here. Muscular exercise produces heut, but the contractile force of the muscles is kept up by part of the food taken into the system. The heat whicli is generated within the body would be lost by radiation if the tem- perature surrounding the body was far below the normal temperature of the system, and therefore the 3.VJ />/.s7vM.va;.v of the sosf, .\sn rn/ftur. loss is minimi/oU by intcrp*vsin); hctuccn the Iwily and the air non-conductors ot heat in ;; .• form of clothinj,', not to keep llie cold oi.i so much as to keep till heat in. The hyjjfrometric condition of the atmospiiere. apart from llie temperature, has a jjreat deal to do with the temperature of the body. We feel more chilly in a damp atmosphere than in a dry one of the satne temperature, and we can endure a jjreater amount of heat when the air is dry than when it is filled with atjueous vapor. This fact has not been satisfactorily explained. As a matter of clinical ob- servation we know that colds occur in the spring and fall months, seasons which are characterized by moderately low temperature, but with ^reat damp- ness of the atmosphere, toj^ether with considerable atmospheric motion or hij^h winds. Mence we re- coyni/e that there are three external factors at least necessary for the production oi a "cold, "--low tem- perature, air in motion, and moisture. It is also necessary as a rule that one or more of these factors should act for some time. The momentary' action of an intense cold or drauj^ht or moist atmosphere does not usually produce any morbid change. Thus amonjjf the familiar causes of cold may be mentioned sitting in a draujjht, wearing insufticient clothing, insufficiently protected feet, going from a warm to a cold room and slight exposure while perspiring. Among the various theories advanced as to what takes place in the organism, that of Rosenthal is perhaps the most frequently accepted or, at least, repeated in the text books. This is, that the imme- diate elTect of cold on the surface of the body is to excite contraction in the peripheral vessels by which TAKING Vnt.D. Mt the blood is driven in from the surface upon the in- ternal orj^ans and acts there as an irritant, exciting inflammation. This does not explain what goes on when membranes near the surface are involved as in coryza and conjunctivitis. .Schcnk arranges ordinary colds into two groups, — those due to bacterial nfection and those that are not. In the former there is a period of incubation, in the latter the disease follows at once after ex- posure. There is ,i class of cases due to bacteria but in which there is no period of incubation or it is very short. Surveyors and prospectors who sleep out of doors durwi^r the whole summer, rolled only in a Hudson Bay blanket, invariably take cold the first night they sleep in a bedroom, due no doubt to the return to civilization and bacteria. Seit's theorv is that disorders resulting '' 5m catchint^ cold are due to th< removal of heat to an w^w w\\ extent fror . the externa or internal surface 01 ..^ hodv ; thiu this causes some functional disturf . ' -h in turn gives rise to certain morbid prcx:e . s >, ne portion of the body perhaps far removed •■ n :he part im- mediately affected by the cold. That the morbid changes are not due to the immediate or direct efifect of the exposure is evident from the fact that, as a rule, some time elapses l>efore the ch? r.-es set in. This theory is not ..mpletc. The true . tion of cold in producing morbid conditions is probably on those nutritive changes tvhich are constantly going on and by which the animal heat is developed. The direct action of cold is on the surface of the bod", but the resultant morbid condition is upon sr le organ remote from the exposed part. The nutritive 'J I aS4 DtSKASKS OF THE NOSE AXf) THROAT. I m« processes going on in the whole economy are governed by the central nervous system and a certain amount of nervous force is expended in the regulation of these nutritive processes. If as a result of ex- posure these processes are arrested in one portion of the body, the same nervous force being sent out from the central system, it will be understood how the local arrest in one portion is attended by a certain amount of increased nutritive activity in another portion. Now increased nutritive activity means in- flammation and this intlammation locates itself at the point of least resistance, that is, where a mild chronic inflammation is going on, this being lighted up into an acute process as a result of a cold. When the body is perspirir.g the loss of heat goes on rapidly, and a slight exposure is liable to result in far more serious consequences than would i .cir if the body were not in an overheated conditio... There may be a difference however ; if the perspiration is the result of violent exercise all the nutritive processes are stimulated to great activity, heat is being rapidly produced and the perspiration . in as a conserva- tive measure to prevent the accumulation of too great heat in the system. If in this condition the body is exposed to cold and the perspiration suddenly check- ed, very seriors results may ensue. Hut on the other hand, a copious peispiration may be induced artificially when the body is quiet, as by a Turkish bath, where the source of heat is outside the body and the heat producing forces are not disturl)ed. So the cold plunge while it suddenly stops perspiration docs not give rise to any bad effect. A swimmer will remain in water at a temperature of 20 or 30 below TAKING COLD. 25fi that of the body for some time, but while in the water he is in a state of constant activity and keeps in play the heat producing processes, but, if the bath is too prolonged, there comes a time when the body is not equal to the task of supplying sufficient animal heat to make good the loss, and the bather succumbs to the direct influence of this tremendous drain upon the system. Here the result is not an inflammatory attack, but there is great prostration, violent cramps, weakened circulation, intense venous congestion and the whole system is robbed of its normal heat. In the course of an ordinary cold the interval between exposure and development may be long or short. In the slighter disorders the interval may be only a few hours; or it may be prolonged two or three days when something more serious may develop. As to the so-called liability to take cold, this is no doubt due to an existing chronic catarrhal inflammation, perhaps of so mild a type as to give rise to very trivial symptoms or to pass unnoticea. The renewed attacks consist in a lighting up of 'nx. are called upon to perform this there is great loss of heat which acts prejudicially on the whole svstem as well as on the immediate parts affected. ' In atrophic rhinitis there is an enlargement of the lumen, jss of the cilia and wasting of the membrane and glands and the physiological functions are not performed. The cold r'-y air impinges directly on the pharynx and produces pharyngitis sicca. Also in time the larynx and bronchi are affected and the eustachian tube and tympanum may be involved. The nasal passages are constantly exposed to changing atmos- pheric conditions of heat and cold, dryness and moisture. The amount of blood suppiv and glandu- lar secretion varies with every fluctuation of the barometer, with every breeze that blows and every change in the atmospheric dust. This requires a sensitive regulating mechanism which exists in con- nection with the spheno-palatine ganglion and the li y« 888 DISEASES OF THE NOSE A Xf) THliOA T. ii ■Pfc il--- fifth pair of nerves. In every ordinary acute catarrh there is a congestion or erection of the vascular portion of the membrane and especially of the so- called turbinated corpora cavernosa. This erection becomes permanent in the state known as hyper- trophic rhinitis as a result of constantly recurring abnormal erections. Changes in temperature, and mechanical irritation as from particles of dust, snuff or pollen of grasses, are among the most common stimuli. The stimulus may be at some other part of the body, e.g., irritation of the sexual organs is a factor. This is explained by reflex action and the bond of union which exists between the erectile tis- sues of the body. There are some patients who always suffer from coryza after a venereal debauch. When the erection of the turbinated structures is carried beyond the physiological limit the normal process becomes a pathological one and there is chronic congestion, general swelling and proliferation of the constitutent elements and this is hypertrophic rhinitis, in time the connective tissue elements in- crease and ultimately these contract and culminate in fibroid shrinking and atrophy of the membrane and bone. This last stage is atrophic rhinitis. The ciliated epithelium is lost, viscid and fatty secretion is not cleared away, and decomposition takes place. This is ozaena. But the hypertrophic stage does not always pass into the atrophic but may stop at any point ; nor conversely, is it a fact that the atrophic form is always preceded by a hypertrophic stage. The atrophy may be the chief factor from the first in strumous subjects. Hypertrophy may also be local- ized and so give rise to distinct neoplasms. This is probably the origin of polypi. CHAPTER V. ACUTE RHINITIS. The predisposing causes are chronic rhinitis, nasal stenosis, struma, tubercle, syphihs, prolonged mental strain, sexual debility, physical fatigue, and adenoid vegetations in children. The disease is, however, very common among people in all states of health, but those who live out of doors and have vigorous muscula- bodies are less liable to this trouble than those who follow indoor occupations and have feeble constitutions. It is not common in old age. The exciting causes are, (i) exposure to cold and wet, (2) mechanical irritation by smoke, dust and irritating fumes, (3) chemical causes. As to the first of these exciting causes, most people con- sider exposure to cold the cause of their malady, though often unable to determine when the exposure took place. Exposure to cold alone is an over-esti- mated source of the disease. Some other exciting cause is present at the same time. In the second class of causes, dust is the most common cause. Certain individuals are susceptible to the dust of cer- tain localities or of certain kinds. To some the limestone dust of Kingston is particularly irritating. 'Ihe dust inhaled on a railway journey will always produce it in others. Coal-dust, wood-dust, flour- dust and tobacco-dust all have their victims. The -fa ai: ! iff :f I iff: 111 ;w 380 DISEASES OF THE XOSE AXD TJHiOAT. well-known rhinitis that follows the taking of potas- sium iodide is a type of the third class. This is supposed to be due to the carbon dioxide acting on the potassium iodide in the nasal secretions setting free the irritant iodine. Ipecac-dust will cause an acute rhinitis on account of the irritating effects of its alkaloid, emetine. Other chemicals capable of pro- ducing coryza by inhalation are chlorine, ammonia, nitric acid, mercury, arsenic, phosphorus, hydro- fluoric acid, the bichromate salts and formalin. Sywphms. — The symptoms vary in individuals and according to the exciting cause. There may be slight prodromal symptoms, headache, fever, vague pains throughout the body, but in a simple cold the local signs are the first noticed. There is a burning, itching sensation that excites sneezing,- -evidence ot hyperaemia. Theie follov.s an excessive flow of ir- ritating serous secretion from the congested mem- brane. Later the secretions become thicker and even purulent. In the second stage the passages become blocked, partly on account of the accumulation of the secretion and partly because of the swelling of the turbinated bodies. The swelling is likely to be in- termittent, with times of almost complete relief. When the nose is blocked the feeling of obstruction produces depression and sometimes a feeling of suffo- cation. Alteration in speech occurs, varying from a slight loss of resonance to complete deadening of the voice, due to nasal obstruction. In these cases ar- ticulation becomes defective. In the severer cases partial deafness, tinnitus, lacrymation and conjunctival redness are present and there are disturbances of smell and taste. The continued mouth breathing .yi'Tt: iiirrxiTis. g^, gives the ton^rne a dry brown coating, and there IS often loss of appetite. The mucus membrane of the nose is usimlly .cd and congested in the severer cases, but m the milder ones there is little or no change to be seen, so that the increased amount of secretion ,s the guide in determining how much trouble IS present. A variety of acute rhinitis is that occurring ,n nursing infants, which mav he either a simple Idiopathic rhinitis or an acute purulent nasal catarrh, or the syphilitic nasal coryza peculiar to in- fants. The simple rhinitis of infants differs from that of adults in that it mav become a serious affec- tion. A little swelling makes it impossible to breathe through the nose, and as the child has not learned to breathe through the mouth, it .,pens this only when dyspnoea forces ,i to do so, and after a hx, gasps closes it again until renewed dvspnwa com- pels It to open k once more. Nursing and nutrition are interfered with and exhaustion and atelectasis of the lungs may supervene. In a purulent rhinitis the secretion is purely pus from the start. The symp- toms are all severe and emaciation is rapid and great The external nose swells, the nostrils are closed by crusts, removal of which shows a nose full of pus either creamy or thin and ichorus. In most of these cases the infection can he traced to a condition of the maternal passages, the disease being communicated at birth. It may be accompanied bv purulent con- junctivitis, suppurating otitis media and enlarged lymphatic glands. Complications of Acute /fhmilis.-T\M^ nasal en- trance and the swollen upper lip are macerated by the constant flow of secretion and may form the starting n . \ I If 3«2 DISKASKS nF TIIK MtSF. ANH TtlKOAT. w :il point for extensive facial eczema in children. Herpes labialis also t«ccurs and facial erysipelas may start from the fissures on the edges of the nostrils. The inflammation may extend by continuity through the iacrymal duct to the conjunctiva, causing slight coniunctiviiis with lacrymation and photophobia. The purulent form may set up suppuration in the Iacrymal cyst and canal. The accessory sinuses may be involved in acute rhinitis, but the nuicu.> mem- brane usually returns to its normal condition when the nasal catarrh subsides. Some involvement of the frontal sinuses is the cause of many of the severe frontal headaches .iccompanying colds in the head, just as the presence of pain and heaviness in the check may mean extension to the antrum of High- more. These conditions of the antrum may suppur- ate and go on indefinitely, more particularly in the rhinitis of influenza. Severe colds and suppurative rhinitis have been known to precede cerebro-spinal meningitis, and it is surprising that this does not occur more frequently considering the direct lym- phatic and venous connection between the nasal cavitv and the subdural and subarachniod spaces. Pain in the forehead and cheek is not always due to sinus disease as infraorbital neuralgias accompany acute rhinitis. This is explained by the fact that the first and second divisions of the fifth pair of cranial nerves supply the nose with sensation, and their terminal fibres on the surface of the nasal mucus membrane are subjected to strong irritation in acute rhinitis. Acute rhinitis may extend to the naso- pharynx and cause enou},'^h swelling of its mucus membrane to mechanically close the orifice of the ACl'Tf: ItHJNlTIS. 2«8 eustachian tube and stop the ventilation of the middle ear. It may also extend directly to the tube and produce an otitis media, either catarrhal or sup- purative. It may occur as an early manifestation of measles or scarlet fever or as part of a general acute disorder. Prognosis — An ordinary attack may last a few days or as many weeks. Recovery ukes place by resolution. The stage of dryness may last only a few hours, that of free discharge several days, while the third period, that of resolution, is of very variable duration. Recurrence after apparent recovery is common. Treatment, The best preventive of acute rhinitis is physical vigor. An out-of-door life, proper at- tention to nutrition, cold baths, sufficient exercise, with the avoidance of excessive clothing and over- heated rooms, all contribute to the prevention of attacks of cold. In spite of the greatest care, how- ever, most people have an occasional cold in the head and individual nredisp.)sition seems to count for more than great vigor. Local prophylaxis includes the removal of such obstructions as adenoid vegetations, polypi and septal deformities. The idiopathi c variety can be.aborted in the fir s t stage b^ a mixture of TFT Opii m. 20, Tr. ttelladolTnrm. 10, Aq. C'amph. t w^ ounc_es. Ihe opium contracts tKe capillaries and the" belladonna inhibits glandular secretions and obviates the constipating effects of the opium. Cocaine solu- tions, snuffs and ointments are useful in the first stage but must be ordered for the patients use with great discretion. For the condition itself there are scores of remedies and new ones are always being i ImU 304 y*y.sAM.vA'.v o/' 77//; A'o.v/; JA7> mint AT. added, but the doctor is not often consulted at the time of an acute cory/a. Of the remedies for internal use, the most valuable are the salicylates, which certainly limit the duration and improve the symptoms of an acute rhinitis. For IiKal application, the most soothing and cleansing solution is one of bicarbj one to remove the tissue iiuickly at one stroke so that the blecdin^j which is very free as sot>n as the first cut is made, does not interfere with tlie com- pletion of the operation. Klectrolysis is another method of dealinj,' with these cases. The great advantage of this is that there is little or no reaction and no bleeding, the objection being the slowness with which results are obtained. If adhesions follow other methods of operating, electrolysis is the best means for iheir removal as the destruction following its use is not accompanied by the formation of any granulations. Care must be taken not to make the nasal fossae too roomy by operative measures, lest one produce conditions similar to thosj of atrophic rhinitis, with nasal passages so large that the air is not suflk'icntly moistened by the diminished mucus surface, and the secr.«tions dry and accumulate. Chronic Atrophic Rhinitis. —This is a disease which has for centuries been the subject of much dis- pute. In ancient times its unfortunate possessor was excluded from the priesthood and in modern days it has sufficed for divorce. It is known under a host of names, such asdysodia, coryza foetida, foetid catarrh, stinknose, rhinitis atrophica and most common of all, ozaena, fiom the Greek word meaning a stench. This is an unfortunate term, for the condition, ozaena, is not a disease but a symptom of a number of pathological states. It occurs in all ulcerative diseases of the nasal mucus membrane whether Irom ciiiioxn' ATunpim mi is it is. S77 syphilis, cancer, rhinoliths, foreign iHHlies, phajje- denic or other ulcers and usually accomfwinies caries and necrosis of the intra-nasiil bony framework. It is a complication of nasal and post-nasal growths, and may be a symptom of simple or purulent inflam- mation of the accessory cavities, and particularly of the antrum of Hij^hmuic. In simple coryza it may {•■•velop from retention and decomposition of tl' secretion. A simple inodorous catarrh may bcco. ^ offensive at the menstrual epoch or an existing odv." be aggmvated at periods corresponding to the men- strual iKnv. So o/aena is entirely a different term to chronic atrophic rhinitis of which it is only a symptom. In chronic atrophic rhinitis the mucus membrane and the bony framework of the nasal cavity atrophies. The cnanges are most marked on the turbinals which shrink away, leaving the fossae abnormally roomy. The secretions become dry and adhere to the mucus surface in the form of crusts. If fhe crusts be lifted off, their under surfaces are four. noist or covered with fluid pus. The crusts may discrete or line the entire nasal cavity like n cast. Etiology. — Tli'S is at \ ';ent the subject of con- troversy. The i i t in disp.ite is whether atrophic rhinitis is the last stage of the hypertrophic variety, or whether it originates in other ways. Probably it may originate in several ways, or is the final stage of more than one morbid process. The majority of the patients are children and young adults. The trouble dates either from an attack of measles, scarlet fever or other exanthemata ; from a single or series of bad colds in the head ; or from a bad blow on the 278 DISEASES OF THE NOSE AND THROAT. nose followed by epistaxis. A certain proportion of the patients present the so-called typical strumous physiognomy. The nose is small, the bridge and alae wide, the point of articulation with the frontal bone depressed and the nostrils look forward and downward. The nose appears sunken in the face. The lips are thick and expressionless, everted and the mouth generally closed, though sometimes it is open, indicating that the ii' e is completely filled with inspissated plugs of secretion. In other cases the:^ is only an unusual width of the alae and osseous framework of the nose. Symptoms. — The general health of the patient is not impaired. The two prominent symptoms are the horrible odor and the tendency to crust formation. The latter is really the characteristic symptom of die disease. The fetor is so peculiar and penetrating that it needs no description ; when once experienced it is not forgotten. The only smell equalling it in intensity is that from syphilitic necrosis in the nose but there is an indescribable distinction. The crusts vary in color from a dirty brownish-gray to greenish- yellow or a pronounced black. They exhibit also various degrees of consistency, from soft, easily friable to tough, leathery masses. They adhere with great tenacity to the mucus membrane and when removed form a complete cast of the region occupied. The senses of smell and of taste are usually impaired and may be entirely lost. On examination the first point that asserts itself is the absence of vibrissae and the next is the abnormal degree of patency in the nasal fossae. So widely separated are the turbinated bodies from the septum that when free from crusts CHRONIC ATROPHIC RHINITIS. 279 we can see the posterior naso-pharyngeal walls, and frequently the movements of the orifice of the eustachian tube during deglutition. The mucus membrane is pale unless eroded and bleeding. When sinus disease exists as a complication or cause, distressing neuralgias and headaches often accom- pany this condition. There are a few cases unaccom- panied by any odor. The odor is the result of putrefactive changes or fermentation. Diagnosis. — This will depend on the exclusion of other affections which cause ozaena. Syphilis of the nose is the condition most likely to be mistaken for ozaena. If the syphilis is active, necrotic bone and ulceration are present. If not active, the defects in the bony septum almost always left by syphilis enable one to make a diagnosis. Prognosis. — If lett to itself it continues for many years, but it does not cause much inconvenience in those over thirty-five. In rare cases the atrophied tissues have been regenerated, but the rule is that the atrophy cannot be remedied. Treatment. — There are three indications, (i) cleanliness, (2) prevention of inspissation of mucus, and (3) to augment the blood supply. To insure cleanliness the nose must be thoroughly and repeat- edly washed by the surgeon himself. This may be done by syringing, by spray or swab of cotton, or by a combination of these. The best solution for cleansing and disinfection is permanganate of potash, from one-twenty-fourth to one-eighth of a grain to the ounce ot water. To prevent inspissation of mucus and the formation of crusts there is nothing so effective as the insertion into the nasal fossae of a ; ! a 1 i 280 DISEASES OF THE NOSE AND THIiOAT. tampon of cotton wool so as to fill completely the widened inferior meatus. This acts best if the wool is non-absorbent and it need not be medicated. It prevents nasal breathing for the time, but that may be beneficial. The tampon should be worn for four hours in one nostril and then for the same time in the other. The blood supply may be augmented in four ways, (i) by artificial stimulation, (2) by the physical method, (3) by electricity, (4) by massage. Artificial stimulation may be obtained by powders, by medicated wools, by fluid sprays and by tampons. The powders most in use are made up with sugar of milk as a base, and whatever is added f-hould not cause the patient discomfort for more than ten minutes. The additions to the base are mercuric chloride from one-tenth to one-fifth per cent. ; iodol, twenty-five per cent. ; boric acid, ten per cent. ; aristol, five to eight per cent. ; benzoin or myrrh, twenty per cent. ; berberine muriate, ten per cent. Wool is usually medicated with chloride of ammonia for this purpose. Of the sprays, Tr. Sanguinaria, five to thirty drops to eight ounces water is one of the best. The physical method of dealing with these cases is one of the most effective, but it requires the co-operation of the patient. The benefit from it de- pends on the fact that diminished barometric pressure in the nasal cavities results in increased blood supply to the walls of the cavities. If the nostrils are partly closed by a plug of cotton wool and the patient per- sists in breathing through the nose in spite of the great difficulty thus produced, the conditions are ful- filled. This forced nasal breathing should be per- sisted in for two or three hours daily. Almost at the P'l CHRONIC ATROPHTC KIUNITIS. 281 outset of this labored breathing the mucus begins to flow freely from the dry mucus membrane. Electricity is used in the form of the constant current and by copper electrolysis. Injections of diphtheria antitoxin have been used for this with temporary benefit. fl CHAPTER Vm. EPISTAXIS. El'ISTAXIS NOSK-BLKKD OR HaEMORRHAGIA Narium. —This is a symptom of very common oc- currence. It means the rupture of a blood vessel, usually a vein, in the nose, the accessory cavities, or the naso-pharynx. It is the result of injuries, local disease of the nose, general diseases, or it may be vicarious in nature. Injuries include blows upon the nose, forcible blowing and sneezing, picking with the finger, the entrance of foreign bodies, frac- tures of the base of the skull, and operations in the nose and naso-pharynx. Local diseases of the nose producing epistaxis are atrophic rhinitis, the various forms of ulceration, fibrous tumors of the naso- pharynx, malignant disease of the nose and throat and exostosis and more rarely polypus and hyper- trophies. The septum, in any case, is the most frequent site of the rupture of a vessel. Next to it we most often find the bleeding point on the inferior turbinated. It is usually the anterior part of the nose that bleeds. The general diseases in which epistaxis is a com- mon symptom are of three kinds: (i) The blood itself may be altered in constitution, (2) the vessels mav be diseased, and (3) there may be obstruction to th.;' circulation through the lungs, liver, kidneys or other organs, causing a sudden tension or strain of the whole system which gives way at the weakest ElISTAXrS. point. This is often in the nose where the vessels are very superficial and ir> places cavernous. Under the first class, or diseases of the blood, the most common cause of epistaxis is haemophilia or the haemorrhagfic diathesis. In plethoric children epis- taxis is often preceded by a sensation of fullness in the head. The connection between the veins of the nose and the sinuses of the dura mater explains the i iief experienced by the bleeding. It also occurs in erup- tive and relapsing fevers, diphtheri:;, scc'uius, purpura, yellow atrophy of the liver and poisoning by phosphorus. In the second class, those due to disease of the blood vessels, are placed the cases of atheromatous degeneration. This is most often met with in elderly people but may be found in tne young as a result of syphilis and chronic alcoholism. Un- der the third class may be placed strain of the vascular system such as produced by lifting heavy weights, violent coughing, vomiting or running or any other excessive exertion. This cause is intensi- fied by any artificial obstruction to the return of the blood from the head, such as njight be produced by tight neck wear or by tumors of the neck. Venous obstruction from engorgement of the right side of the heart, emphysema, severe bronchitis, diseases of the liver, kidney and spleen, are all causes of this character. Strong emotion may also be a cause. Lastly it may occur vicariously, taking the place of the menstrual flow in women, or of some periodical escape of blood from the enlarged veins in the rectum, leg or elsewhere. Symptoms. — In epistaxis from traumatism the blood flows freely from one side of the nose and soon •jUga 884 DISEASES OF THE NOSE AND THliOAT. Stops of its own accord. In other cases the blood iricklcs by drops. When caused by cerebral con- gestion there are premonitory symptoms such as headache, tinnitus aurium and injection of the con- junctiva. When the bleeding is excessive, syncope is liable ;o occur and may prove fatal. Examination of the no.se in ordinary cases when the bleeding has ceased, will show the erosion or bleeding point. In some cases, however, it is impossible to detect any place which might be a likely source of the bleeding. During the bleeding, wiping away the blood with tampons, if it does not flow too freely, will disclose its source. Treatment. —Or Amary attacks need no treatment as they soon cease spontaneously. The upright position is the best. When there is a tendency to syncope have the patient seated or lying down. Often the haemorrhage can be arrested by simply closing tightly the bleeding nostril for a few minutes, as in most instances the blood flows from a small point on the cartilaginous septum. Raising the arms above the head to force the blood io mount against gravity, may assist in the formation of a clot. Hot foot baths and mustard to chest, neck and ankles, have . derivative action. Stimulation of the vaso- motors may be induced by cold applications to the back of the neck, forehead and over the nose. Com- pression of the facial artery is also recommended. One who is familiar with the use of nasal instruments will prefer at once to plug the nares rather than resort to any form of styptic application. The latter may be used in the form of powders or sprays but may not reach the bleeding point at all in a nasal EPISTAXTS. 38S fossa filled with clots of blood. The styptics in use are ice water, or very hot water spray, insufflation of tannic acid or alum, or preparations of iron. Adren- alin is one of the latest and best. If the haemorrhage be arrested by any form of local application there is no certainty that it will not return when the surgeon is far away, while a properly applied tampon insures against return of the bleeding till the removal of the tampon. The best material for plugging is absorbent lint cut into strips one-half an inch vide and from one to three feet long. The strips may be impreg- nated with iodol or bismuth subnitrate, and so be kept aseptic for some days. Absorbent cotton is not a good material for this purpose as it loses its elasti- city and bulk, while the strip of lint swells when it becomes soaked. Pieces of the cotton may be lost in the nasal cavities. In the ordinary case it is only necessary to introduce the tampon as far back as the middle of the inferior tii'-binated, as the biood comes from the anterior part of the septum. In other cases in which the bleeding comes from the posterior part the whole fossa must be filled with the tampon. Posterior plugging may be necessary. Bellocq's canula is an instrument specially adapted for the purpose. A soft rubber catheter, howe\er, is the proper thing to use. It is passed through the nose into the throat and drawn into the mouth with forceps. To this a string with a plug is attached and then drawn through to close the posterior nares. The string should be double, one end through the nose, the other through the mouth to facilitate its removal. Such a plug should not be left in longer than twenty-four hours and should be saturated with some antiseptic before being introduced. ! aiAPTER IX. M' ■ FOREIGN BODIE8. FoRKK.N Bodies in thk Nosk.— These are most often found in children. In addition to the usual way through the nostrils, foreign bodies may enter by way of the naso-pharynx during the act of vomit- ing or when food is coughed out of the larynx where it may have been lodged. The variety of foreign bodies found is endless. 5;i'w/>/o/w.v.— Small, smooth substances of inde- structible material may remain indefinitely in the nose without producing any symptoms. As a rule the symptoms are marked but misunderstood and attributed to nasal catarrh. Foreign bodies of vege- table material swell and even germinate, so that the pressure from the increasing size causes pain and ir- ritation. The nervous symptoms may be severe. Intense headache and pain in the cheek and nose oc- cur, "'he most striking symptoms are unilateral obstruction and discharge of purulent material with an offensive odor. A unilateral purulent offensive discharge in children up to the seventh year almost invariably means a foreign body in the nostril. Treatment.— 'Some foreign bodies may be expelled by blowing air into the unobstructed nostril by Politzer's air bag. It is not safe to use water in this way on account of the risk of its entering the middle ear. Many can be removed by means of a small hook, and the various styles of nasal forceps are also FOREION BOniKS. 887 useful. Some can only be removed by the naso- pharynx. After treatment is not often necessary. Rhinoliths. — These are cretaceous masses which usually owe their origin to the lodgement in the naris of some foreign substance upon which calcium phos- phate, calcium carbonate and other mineral substan- ces are gradually deposited from the secretions. Blood clots may give rise to these masses. They are comparatively rare, but are more serious as re- gards symptoms and difficulty of removal than foreign bodies. They tend to grow to a large size, may occupy both lower and middle meatus, and may perforate the septum. Their shape is usually irregu- larly ovoid while a few are smooth. Their color is grayish brown or yellowish, greenish, dark brown or dark green, and they are often friable or brittle. The symptoms are those of a foreign body, only greatly intensified. Swelling of the nose and cheek on the same side as the rhinolith is sometimes present. Treatment. — It is often necessary to break up the mass before attempting its removal. This can be done with forceps, or a lithotrite may be had for this purpose. Some may be pushed into the naso- pharynx, but if this is done care must be taken that it is not drawn into the larynx. Maggots in the Nosk. — Nasal disease due to the invasion of the nasal cavities by the larvae of certain species of flies, though common in tropical countries, is quite rare in temperate latitudes. There is, however, an extensive literature on the subject. The flies liable to deposit eggs in the human nares belong to the genus oestrus^ or gadfly, and the I II !!Ii- 2m nrsKASKS of the nose and throat. muscidae or house fly. The oestrus larvae live in the human nasal passages without causing any destruc- tion of tissue, but simply irritate the surface of the mucosa. The muscidae, however, cause the most frightful destruction of the nasal interior. Both varieties are likely to enter the noses of sleepers in the open air in the daytime, and more particularly those of persons with offensive discharges. The symptoms rapidly follow the deposit of eggs, as they hatch in a few hours and the larvae rapidly grow to their full si/e. At first there are irritation and tick- ling with slight discharge, hut the tickling increases to unendurable formication, with violent snee/ing. Pain begins when the larvae begin to burrow. Per- sistent headache, rapidly increasing to agonizing intensity, is a prominent symptom. The maggots may even enter the sinuses. The face swells pre- senting the appearance ot erysipelas on one or both sides, while abscesses appear, burst and discharge pus and maggots. Severe and repeated epistaxis marks the course of the trouble and helps to exhaust the patient. Th pain is so great that delirium sets in and some attempt suicide. Meningitis is a fre- quent termination. Sepsis and pyaemia may come in the later stages. The rarity of the affection will lead the doctor to think ot every disease but maggots in the nose till inspection brings the worms to view or some of them are seen in the discharge. Early recognition is of the utmost importance. Treal men/. ^The destruction of the maggots is best accomplished by the use of chloroform vapor, or the solution itself may be syringed into the nasal cavities, in the less severe cases the maggots may be picked out one by one with forceps. CHAPTER X. NAHAL POLYPI. Nasal Mucus Polypi. — These are not myxom- ata, but the word mucus is used to distinguish them from fibrous and malignant growths. They occur often in great numbers in the nasal fossae, and are apt to block the passages completely. They are either pedunculated or sessile and in most cases give rise to a free mucus discharge. Etiology.— It is probable that these growths are the result of an acute or chronic rhinitis, and repre- sent a hyperplasia in a state of oedema. During the progress of the inflammatory condition one point be- comes oedematous, then pedunculated and pendulous. Other cases originate in granulation tissue, the polyp being merely an enlarged granulation. Polypi are found in people of all ages, and may be congeni- tal, but they are rare in childhood and old age. There is a hereditary predisposition. Pathology. — The typical polyp is attached to its base by a slender neck or peduncle, and is of varying shape, but usually pyriform or globular, and varies in size from a small pea to a large walnut. It shows a smooth and glistening surface, and is of jelly-like translucence. Fine blood vessels are seen entering the peduncle and spreading over the surface of the growth. It may be firm and opaque f connective • iii 3tM) DISK ASKS OF TUK NOSE AND TIlliOA T. tissue predominates in its structure. When the epithelium is exposed to the air or to irritation, as when they are located in the nasal vestibule or naso- pharynx, it becomes like epidermis and covers the surface with an opaque white coating. The shape of the larjjer ones is influenced by the nasal passages in which they jjrow. They may be very numerous but the average number is from six to ten. The source of orifjin is usually the lower border of the middle turbinated, but they may jjrow from any part of the mucus surface, even the septum, the lower turbinated and the floor, but these are rare. They are sometimes found attached to the openinjjs of the accessory sin- uses. Nasal mucus polypi are connective tissue growths. In the typical polyp this forms a delioate reticulum of fibres resembling embryonal connective tissue. Symptoms. — They cause no symptoms as long as they are small. As they grow larger they give rise to mechanical irritation and a discharge of a serous or purulent nature. The purulent secretion stimu- lates the mucus surface to the production of more polypi, and in fact the discharge from sinus disease or other nasal suppuration may originate the growths. There is often a perpetual sniffing anl frequent and unsatisfactory attempts at blowing the nose. Anosmia and deafness are common. A sense of pressure and fulness in the nose is often felt, and neuralgic pains radiating into the various branches of the first and second divisions of the fifth cranial nerves are frequent. Reflex asthma is caused by polypi. Damp weather causes them to swell be- cause of their hygroscopic qualities. If after remov- XASAL PnLYI'l, aoi ifiK' a polypus wc weigh it and then immerse it in water for an hour we find it increases its weight by half as much again or more. When examined by anterior rhinoscopy they present themselves as trans- lucent, glistening, greyish bodies of an appearance so characteristic that they form an easy object for diagnosis. Those used to rhinoscopic appearances will hardly mistake polypi for any other condition, but a malignant growth, such as sarcoma or epi- thelioma, has sometimes the appearance of a poly- pus. Ill such a case an attempt to remove the mass will result in free haemorrhage and the structure is found to be friable. Polypi persist for years. They have no tendency to spontaneous recovery. In prog- nosis the most important point is recurrence after operation. Treatment — There are various antiquated meth- ods of removal seldom now adopted. Hippocrates removed these growths by means of a sponge forced through the fossae. The application or injection of the growths by caustics or astringents is one of the older methods but is unsatisfactory. .\ome surgeons still use the polypi forceps. The operation most in favor is removal with the cold wire snare, while a few prefer the galvano-caustic wire. Local anaesthesia IS employed and no after treatment is needed. To prevent recurrence, the pedicle or base may be cauterized or that portion of the bone from which the polyp springs may be entirely removed. A' i I-- i mn CHAPTER XI. m ^\i DISEASES OF THE ACCESSORY SINUSES. Empyema of the Maxillary Antrum. — In- flammation oi the lining of the antrum of Highmore may be acute or chronic. It is accompanied by a discharge of a serous, mucus, muco-purulent or purulent nature often offensive. In some of the acute cases there is no secretion from the lining of the antrum, the symptoms being caused by swelling of the mucus lining. Etiology. — This often accompanies acute rhinitis and influen/a. The acute infectious diseases are fre- quently causes, especially pneumonia, typhoid fever, measles, scarlet fever, diphtheria and small-pox. Inflammatory disturbances in the neighborhood are liable to involve it by extension ; this i? especially the case in disease of the teeth of the upper jaw. Decay opens the pulp cavity, clearing the way for infectious germs to follow the root canals, to the periosteal lining of the socket of the root of the tooth. Here an abscess may form around the root, and if the lamella ot bone separating it from the cavity of the antrum be thin, or, as in some cases, wanting, infectious material finds its way into the antrum and sets up an acute inflammation. The septic material may also find its way through the bone, which becomes inflamed as a sequel to the periostitis. In this way an incisor tooth may be' the cause of an EMPYEMA OF THE MAXILLARY ANTRUM. 298 empyema. Disease of the roots of the first and second molars is most liable to be followed by in- flammation of the antrum. Chronic empyema is found associated with atrophic rhinitis, though in some cases it is to be regarded as a sequel to the empyema. Symptoms.—Th&sQ may be mistaken for those of neuralgia of the superior dental, supra-orbital, or infra- orbital nerves accompanying an acute cold in the head, and it is probable that antrum disease is often not re- cognized because of its obscure symptoms. In the milder cases of the acute inflammation there is very lit- tle distress, but in the severer cases there is moderate fever and perhaps severe pain. The first sensation is of weight and distension in the upper jaw, gradually changing to pain. The discharge may appear at once in the nose or only after several days. When decayed teeth have caused the disease the discharge is very off^ensive from the first. Acute inflammation of the maxillary sinus lasts from one to three weeks, unless it merges into the chronic form. It may involve both antra and one attack may be followed by others. The chronic form of empyema may be latent, the discharge not having noticeable character- istics, while there are no subjective symptoms. In a typical case the chief complaint is of the discharge, generally pus or muco-pus. The position of the outlet of the antrum near the top, makes drainage of the cavity imperfect, so that in the upright position it has to fill to the level of the ostium before discharge of secretion can occur. If a patient lie on the healthy side or invert his head or bend forward, the fluid con- tents of the antrum may for mechanical reasons, I I I I Imii liii 204 DISEASES OF THE NOSE AND THROAT. 4i,.. il'i::: discharge more freely. The discharge may be so free that it comes drop by drop, or so scanty that it dries in crusts. The discharge flows into the middle meatus, and from here may spread forward and downward upon the nasal floor or back into the naso- pharynx. The putrid odor and taste of the secretion are disgusting to the patient, and keep him hawking, spitting and blowing tin' nose, and if swallowed, the pus may nauseate him and cause vomiting. The patient is haunted with the stench, though it is seldom so intense ai> to be offensive to his neighbors. In chronic empyema pain is not a prominent sym- ptom. There may be a local aching and feeling of weight, but usually these are absent, while neuralgic pains are felt in the teeth, temple, eye, forehead or one-half of the head. Reflex eye symptoms also occur— pain in the eyeballs, lachrymation, weakness of accommodation, and diminution of the acuteness of vision. When the suppuration extends to the orbit, great swelling of the lids, chemosis, exoph- thalmos, and partial or complete blindness occur. Diagnosis. — It js sometimes difficult to be positive in diagnosis. We must base an opinion chiefly on the situation of the discharge as it is seen in the nose. When we see an opaque canary-colored, pur- ulent discharge lying in the cavity of the middle turbinated which discharge is renewed at once after being wiped away, we need not hesitate to open the antrum. A valuable aid to diagnosis is transillumin- ation which consists in the insertion of an electric incandescent lamp into the mouth in a darkened room or under a photographer's cloth. A five volt lamp is used. When the lips arc tightly closed a rosy red EMPYEMA OF THE MAXILLARY ANTRUM. 295 light suflFuses the face, the cheeks and lips being the most brilliant. When there is pus or a solid tumor in the antrum that side of the face is less bright than the other. In cystic disease that side is the brighter. This method is not always positive. In atrophic rhinitis and where from any cause there is thickening of the walls of the antrum the cheek may be dark and yet no empyema exist. Other methods of investiga- tion are probing the antrum, insufflation, irrigation and aspiration. To pass a probe through the normal opening of the antrum is possible in a few cases. When the opening is found with the probe, pus will sometimes flow out beside it. A fine silver tube may then be introduced in the same way and connected with an insufflator to blow secretion from the cavity. If this is successful, it may be joined to a syringe and the antrum irrigated to wash out the pus. If the normal opening cannot be found, a sharply curved trochar and canula or a hollow needle may be thrust in through the middle or lower meatus. Treatment. — The antrum offers four points of ap- proach for therapeutic measures : \'\\. natural open- ing or its neighborhood in the middle meatus, the inferior meatus, the socket of a molar tooth, and the anterior wall of the antrum through what is usually called the canine fossa. In recent cases, irrigation through the natural opening or through the artificial one made in the neighborhood may be tried. It is well in any case to clear the natural opening of all obstacles, as, if the opening is made elsewhere, and this is not done, there is a return of the trouble as soon as the artificial opening is allowed to close. Access to the normal opening can be had usually m 206 DISEASES OF THE NOSE AND THROAT. after ;emoval of the anterior end ot the middle tur- binal. This is done by scissors and snare. The same preliminary operation must be done in cases of ethmoid and frontal sinus disease. If it is impossible to irrigate in this way or if the irrigation is not effective, then an opening may be made through the socket of a tooth. If there is a bad tooth it should be drawn as it m :y be the cause of the empyema. The socket of one of the molars or of a bisuspid may be chosen, but in the latter case there may be a diflfi- culty in getting through. The opening is to be made with a drill of any kind, and a drainage tube should be used. The best for this purpose are made of soft rubber with a flange on each end to keep it in place. The radical operation is to open through the anterior wall, where an opening can be made large enough to properly explore and curet the whole cavity. The corner of the mouth is drawn upward by a broad blunt hook and an incision is made through the mucus membrane and periosteum where the cheek joins the upper jaw, in a line above the prominences caused Ly the roots of the teeth, and extending from the canine to the second molar tooth. The soft tis- sues are then pushed up and the bone exposed. The antrum is then opened by a chisel, using one about half an inch wide. The opening may be enlarged by the same chisel or by small bone forceps until the little finger can be passed into the antrum. This may be used to search for foreign bodies, tumors, carious bone, projecting roots of carious teeth, dis- placed wisdom teeth and other causes of suppuration. vSepta should be broken down and granulation tissue and oedeinalous folds of mucus membrane removed INFLAMMATION OF THE FRONTAL SINUS. 897 by a sharp curet. Afterwards the cavity is to be packed lightly with gauze and treated on general surgical principles. Inflammation ok the F'rontal Sinis. — The frontal sinus is in intimate relation with the foremost of the anterior ethmoidal cells, and for this reason an inflammation of the frontal sinus almost invariably involves some of the ethmoidal cells. Etiology. — The common cause is acute coryza and influenza. Chronic inflammation is apt to re- sult from an acute attack. Symptoms. — The most marked symptom is pain, varying from a sense of weight in the region of the sinus to an intense aching, radiating to the eye and other portions of the head. The pain is throbbing and is worse when bending forward and after cough- ing and sneezing. When the outlet of the sinus is closed, absorption of the air in the cavity takes place with the production of negative pressure, or the secretions accumulate until they produce hydrostatic pressure on the mucus surface. The pain is apt to be periodic and worse in the morning. In the chronic form the pain is not so severe, but exists with varying intensity for months or years. Dilatation of the frontal sinus may take place as the result of distension from the retained secretions. Prognosis. — Most of the acute cases recover, a few become chronic, and in very rare instances a septic process extends beyond the sinus leading to serious complications. Treatment. — The acute form usually yields to che measures used for the relief of the coryza producing 396 DISEASES OF THE NOSE AND THROAT. it. The septic form oquires the opening of the sinus from in front. In the treatment of the chronic cases the first aim is to clear the opening in the nose from obstructing hypertrophies and polypi. If the sinus prove to be accessible, irrigation may be enough to cure. Boracic or normal salt solution is to be used. In opening the sinus from without, the incision should be made in the eyebrow along its lower border, and extend from its middle to the centre of the nasal bridge. The sinus should be opened near the angle of the orbit with drill, chisel, trocar or trephine. The opening should be large enough to admit the little finger, and it must be thoroughly cleaned out by curetting if necessary. Communication with the nose is to be re-established. E.MPYKMA OK THK SPHENOIDAL SiNl SKS. — This is rare, or, at least, the diagnosis of the condition is rarely made. Acute inflammation of this cavity is the result of an acute infectious rhinitis. Symptoms. — As in inflammation of the other sin- uses, pain is the most marked symptom of the disease in both the acute and chronic forms. In the acute variety there is a history of a severe cold accompanied by great pain in the forehead, occiput and deep in the skull. A feeling of pressure from behind is felt in one or both eyes. In the chronic form there is an abundant discharge in the nose or naso-pharynx, and it may have a foul odor. Diagnosis.— \n order to make the sinus accessible it is often necessary to remove the anterior end or all of the middle turbinated. If a probe is passed from SlPPCItATlO.y OF THE ETHMOIDAL CELLS. 290 the lower border of the nostril upward and backward across the centre of the middle turbinal parallel to the septum, it will reach the anterior wall of the sinus. When softened by disease, the probe will readily enter the sinus by its normal entrance or by perfor- ating the mucus membrane and softened bone. If the probe enters, the patient should be told to close the opposite nostril and forcibly blow through the one on the affected side, when pus and blood will be aspirated into the naris. This generally gives im- mediate relief. The important object is to get a free opening for drainage. If the probe is passed as described, it should be followed at once by the use of the syringe and curet. Suppuration ok thk Ethmoidal Cklls.— This is in many cases secondary to suppuration of the frontal or maxillary sinus. It may arise from the same causes as produce suppuration in the other sinuses. Symptoms. — The pain is perhaps more intense than that due to disease of the other sinuses. It is felt at the root of the nose, the lower and inner part of the orbit, the upper part of the cheek, and the re- gion of the frontal sinus. When the anterior cells are affected, pus will appear in the middle meatus, coming from the hiatus semi-lunaris. When the posterior cells are diseased the pus appears in the olfactory region between the septum and the middle turbinal, and flows back over the body of the sphen- oid into the naso-pharynx, appearing as flakes and crusts. Prognosis. —A great number of oells form the ethmoidal labyrinth so there may be hidden foci of II ! I 800 DISEASES OF THE NOSE AND THKOAT. suppuration that are badly drained, and the danger- ous region they occupy makes vigorous operation risl/owj.— Atthetimeofthe injury there may be some nose-bleed. The pain soon subsides, and it is only the discomfort of the obstruction that forces the patient to seek advice. Treatment — The proper treatment is by incision, and the opening should be large, as it tends to close quickly. The cavity should be packed with gauze Absckss ok thk Nasal SKPXUM.-This is usually the result of haematoma. Perichondritis is the basis of all abscesses of the septum not traumatic. The difference between haematoma and abscess can only be determined by an exploratory puncture and aspir- ation. Simple abscess does little damage, but those due to syphilis result in very great destruction. The treatment is that for haematoma. CHAPTER Xrn. ANOSMIA AND PAHOHMIA. These are in most cases only synnptoms but they deserve separate consideration. Anosmia is absence, hyposmia is diminution in the sense of smell. Anosmia is divided into respiratory, essenti;»l, and central, according,' to the seat of the lesion. In the respiratory form the olfactory rejjion is intact, but shut off from the air current by obstacles so the odors cannot reach it. If the obstruction is removed the sensation returns. The essential form is due to in- hibition of function, destruction or atrophy of the nerve branches of the olfactory nerves or the olfactory cells. Acute catarrhal inflammations may injure the ciliated ends of the olfactory nerve cells enough to cause temporary anosmia. The function may be temporarily suspended by applications of cocaine, morphine and atropine. Stronji astrinj,'ent applica- tions will create anosmia and are therefore to be avoided. Excessive irritation by stronj^ odors may cause total anosmia. Pus or crusts in the olfactory region will inhibit the sense of smell. It may also follow diphtheria and influenza. The removal of the Gasserian ganj^lion is followed by marked diminution in the sense of smell, the reason for this not being understood. Central anosmia may be caused bv atrophy of the olfactory bulbs or by their injury in A\OS.\//A AXn PAtiOSMtA. n» fractures, such as tho.c of the cribriform plate. Intra- cranial diseases may produce it hy pressure on the olfactory bulbs, and tumors, meningitis, extravasa- tions of blood, or subdural abscesses are causes The treatment must be guided by the cause. In the cen- tral cases the prognosis is bad except they be due to syphilitic gummata. HVPKROSMIA.-There are great variations in the acuteness of the sense of smell in different individuals so that Its intensification can only be considered pathi ological when it becomes an annoyance to the indi- vidual I he condition may be one of increased irntab.l.tyofthe individual rather than of increased acuteness of smell, so that odors which do not disturb and may even please others, arc disagreeable to him. This explains why the basis of hyperosmia is often neurasthenia, hysteria, anaemia and pre^^nancv. loxic hyperosmia is produced by the local annli- cat.on of strychnia to the olfactory mucosa, and may also follow Its general i:se. I>ARO.SMiA.-ln this there is perversion of the sense of smell. Odors are not perceived correctly or else the individual is conscious of an odor which does not exist. Those cases of nervous origin occur in neurasthenic, hysterical or pregnant persons, and often in those mentally diseased. The subjective odors are usually disgusting or disagreeable. It may follow influen/a. Parosmia may be due to dis- ease of the olfactory bulb or tract, the gyrus occipito- temporalis. the gyrus hippocampi, and the pes hippocampi major. CHAPTEK XIV. XAS()PHARYX(HTI8 AM) ADENOID VEGETATIONH. AciTi: Nasoi'hakvncmtis.- -This is a common and an important condition because of the aural com- plications. In many individuals a cold in the head or a sore throat always appears in the nasopharynx. It is probable that exposure to cold merely diminishes the local resistance to infectious .trerms which find the lymphoid tissue of the nasopharynx a favorable place for invasion. In children the condition is likely to confine itself to the post-nasal space, while in older persons it is usual to find an extension by continuity into the nose and into the throat. Symptoms. These are modified by the presence or absence of Luscha's tonsil, and as this is practically a structure o^ childhood, the symptoms in early life are essentially different from those of adults. In the case of children there is fever as in a ^reneral infection. The fever may be continuous and last for a few days or a few weeks. At the same time the child becomes a mouth breather; there is snoring and noisy respirat- ion during sleep, and often a rattling .sound due to the secretion in the nasopharynx mixing with the air current. Otitis media is a very frequent complica- tion. The disease may terminate in permanent enlargement of Luscha's tonsil, or so-called adenoid AccTi-: x.tso/'/f.t n yxarrrs. 807 Ir vegetation.-,. ,„ auuits me condition is a local pro- cess. 1 here :v,y he malaise, lieadache, loss of appe- tite, but r ,ieiy any ..•!,.,, ion of temperature. Swal- lowmg c, uses pain, "he secretion is profuse and sticky an . ,s onlv re. loved with difliculty throu-h the mouth. " r.ec,/,„enL^\n little children local treatment is difficult but somcthins: can be done. The secretions can be removed by droppin^^ into the nose a warm sokition oi bicarbonate of soda, five grains to the ounce, the head being thrown back. The general condition is modified by an antipyretic, such as ammonol. After the secretions are removed some oil may be introduced also through the nose bv means of a dropper. In adults the soda solution may be used or if the discharge is purulent a solution of perman- ganate of potash strong enough to have a light pink color. An oily spray should follow this. Internally salol and soda salicylate are of distinct value. Chro.vic NAsoPHARVNGnis.-This is associated with a similar inflammatory condition in the nose or oropharynx. AV/o/«^'.— This is the condition spoke,: of by the laity as " catarrh " and is much advertised by quacks to terrorize the ignorant. It is so much more frequent in America that Mackenzie called it Ameri- can catarrh. It is common between the ages of twenty and fifty, and probablv originates in repeated attacks of the acute condition. Among the remoter causes of the condition are living in badly ventilated, dusty rooms, breathing an atmosphere of tobacco 308 DTSEASES OF THE NOSE AND THROAT. smoke, and abuse of the voice. It is frequently seen in climates subject to sudden and extreme changes in temperature. Too little moisture in the inspired air produces it by causing a drying of the secretion on the mucus surface which results in a chronic irri- tation. 5)'w//ow.v.— There is a constant feeling of dryness and a raw sensation in the nasopharynx which is intensified by swallowing. The patient complains of a sensation of secretion dropping from the naso- pharynx to the oropharynx, and of a constant desire to hawk and clear the throat. This desire persists even when no secretion is present as the mucus membrane is hyperaesthetic. In Fome cases there is deafness and tinnitus aurium. Inspection of the nasopharynx will show the glue-like secretion flowing down the posterior wall and coating it like a varnish. Prognosis.— Tho. disease may extend over a period of years, but is not dangerous to life, and there ap- pears to be no tendency for it to extend downward or to pass into tuberculosis. When it has lasted many years it is doubtful if it can be cured. Treatment.— \n the local treatment the matter of first importance is the complete removal of secretions and especially crusts. This is best done by post nasal syringe or spray, or an irrigating tube. The solution may be any mild alkaline wash. In addition to cleansing it is usual to make astringent or stimu- lating applications. For excessive secretion terebene, ten minims, in albolene one ounce, sprayed freely is one of the most effective remedies. m\ ' A DJ'lNOin \ 'FMKTA TIONS. 309 Hypkrtrophy ofthk Pharyngeal or Luscha's Tonsil. — This is more commonly termed adenoid vegetations. This condition has a most important bearing on the health of the individual. Etiology. —One or more attacks of nasopharyngitis is the common cause. It is a disease of childhood ; it may occur as early as the first month, but is not common till after the second year and up to the tenth or twelfth. It may persist into adult life, but does not originate after puberty, as the pharyngeal tonsil normally atrophies at that period. In most cases enlargement of the faucial and pharyngeal tonsils co- exist, and it is more usual to find the pharyngeal tonsil enlarged and the faucial ones normal than the reverse. There are certain anatomical conditions which predispose to the condition. These are anter- ior stenosis in the nose with enlargement of the erectile 'issue, a V shaped upper jaw, and deflected septum. The exanthemata are exciting causes. Symptoms. — The most striking symptom is the obstruction to nasal breathing. These growths are by far the most common cause of mouth breathing. In milder cases the mouth breathing occurs only at night during sleep ; in the severer ones the mouth is held open in the daytime, and the child acquires the stupid and listless expression known as the adenoid face. The second important symptom is snoring. This may attract more attention than the mouth breathing and be loud enough to annoy and distress the parents. The oppressed breathing causes night- mare, so that these children are subject to nocturnal terrors. The reason why the cases are worse at night is that the mucus collects in the inferior meatus and II 310 />/.s/:as/:s of the xuse .i\/> ritiUKW. MajiiS 111 there is .sweliin.t: of the posterior ends of the inferior turbinals. Tlie third important symptom is deafness. This is the resuh either of the mechanical obstruction, or of the invasion of the tube and tympanum by the catarrhal process. The pressure of the ijrowth pre- vents the proper ventilation of the middle ear. If there is no air supply, a partial vacuum is scon pro- duced in the tympanum, the drum head is driven in and hearini,' is impaired. Tiic senses of taste and smell are impaired also. Another important symp- tom is chanjje of the voice. This applies to those sounds requiring an open nasal and nasopharyngeal passage, such as m, n, and ng. The adenoid voice has a peculiar, dead non-resonant quality, which is quite different from that due to obstruction of the anterior parts of the nose. Another symptom is aprosexia, or inability to lix the attention or to think clearly, or to comprehend what is read or heard. This is equivalent to mental dullness. The other subjective symptoms are post-nasal catarrh, cough of a dry tickling character, chronic rhinorrhoea anterior, producing excoriation oi the skin around the nose and lips, and disturbances of nutrition. Objective examination of these patients usually begins with the ear. There is always more or less depression of the drum head. It is dull in lustre, and the pyramid of light is shortened from the base upward. This is due to want of ventilation of the middle ear. The oxygen of the air is exchanged for carbonic acid and this is dissolved to some extent in the mucus secretions, and so some of the pressure on the inner surface of the drum is removed. Therefore the external atmos- pheric pressure on the drum drives it inward. Ex- A IH:X<>ri) I KdETA TIOSS. 811 aminalion of the nose results in tindinj^^ the passaj^cs clear thouj^h often narrow and the anterior nares parti}' collapsed. In the throat the faucial tonsils are often but not invariablv enlarji^ed. Prohablv en- larged faucial tonsils never of themselves cause buccal breathing, this being due to the concomitant post- nasal growths. There are two methods of examining the growths themselves; by obtaining an image of them in the post-rhinal mirror, and by digital explor- ation cf the cavity. The usual *.-o!or is a pale pinkish gray duller and less transparent than polypus tissue and lighter in shade than the mucus membrane to which they are attached. Concomitant conditions are enlarged faucial tonsils, chronic pharyngitis and laryngitis, chronic rhinitis and pigeon breast. The latter is due to the disturbed equilibrium between the external and the intra-pulmonary air pressure. Prognosis. - This is satisfactory from the point of view of treatment, and, in a limited sense, in the natural course of their history. That is to say a certain number of cases are attended by no symptoms whatever and as the patient approaches puberty there is a tendency to spontaneous atrophy. However the worst cases present themselves ai'ter puberty. When there are no symptoms and the patient is in good health it is not necessary to operate. If there are definite symptoms, the prognosis depends on the age of the patient and the duration of the symptoms. Thus if there is serious ear trouble, the result cf prolonged presence of adenoids; when there is otor- rhoea or extensive ear disease; when there is chronic pharyngo-laryngitis. then we must give a guarded prognosis. 312 fUSF.ASKS OF THE SOSE ANh THIfnAT. Treatment. The entire removal of the jjrowths is the only proper treatment. For this we may use (i) the x\n^ knives or curets of Gottstein, (2) forceps, (.1) the fin^'er shield or artificial nail, and (4) the finger nail. The curet is the most useful, forceps heing used in older patients where the j.'^rowth lias hecome fibrous. Many operate without even a local anaesthetic, but chloroform anaesthesia in the primary stage is the proper thing for all the younger pat-'ents. The only instruments necessary are the mouth gag, curet and sponge holder, haemorrhage is some- times profuse but not enough to demand the use of styptics. It may rarely be necessary to plug the vault either in the usual way or with a long strip of gauze passed through the nares. This can be satu- rated with adrenalin, pushed through to the pharynx and then packed tightly Avith the finger. No after treatment is necessary in ordinary cases. The snoring may be worse at first from the clots and swelling. The ears may require subsequent treatment. Means may be necessary to promote the habit of nasal breathing, and voice training to overcome the faulty speech. -~"'°""^= CHAPTER XV. i PHARYNGITIS. AcLTK Pharvngitis. As the pharynx has a double function of air and food tube it shares in the afifections of both the digestive and the respiratory tracts. The common cause is exposure to cold and wet or to sudden changes in temperature. It may be epidemic or contagious but is then due to some septic infection. The pharynx is a huge culture tube for all sorts of bacterial growth. More than one hundred different species of the lower organisms have been found. Under normal conditions they are harmless, but lowered vitality from any cause means lessened resistance to germ growth. Many acute febrile diseases, such as scarlet fever, measles, small- pox, erysipelas and typhoid are ushered in or accom- panied by acute sore throat. Other causes are injuries, such as scalding, use of strong acids or alkalies, injestion of highly seasoned food or irritating liquors or vapors; also after the use of certain drugs, such as atropine, antimony, potassium iodide, and mercurials, and after abuse of tobacco and improper use of the voice. The predisposing causes are con- ditions that impair the general health, such as dis- turbances of digestion, assimilation and circulation ; constitutional diseases such as syphilis, rheumatism and tuberculosis ; also the existence of chronic catar- rhal troubles in the nasopharynx, hypertrophy of ;in insi:.\si:s or the xo\/: .ia7> r/wo.t r. H the tonsils and anyiliins,^ that loads 'o mouth hreathinp. There is an inherited tendency to catarrhal affections, and also an increased sensitiveness of the pharyngeal mucus membrane, especially in those of sedentary hahits who take little outdoor exercise and who are prone to chronic constipation, also in those who live in overheated houses and continually breathe a vitiated atmosphere, and in children whose overcareful parents brini; them up like liot-house plants. Symptunts. These depend on the severity and extent of the process. The oropharynx, uvula and soft palate alone may be affected, or the naso-pharynx mav take part. There is a rise of temperature at first, in children often very high. If there is a rheumatic tendency the whole neck is sore, stiff and painful to the touch. The throat is hot, dry and painful, or may be so only on deglutition. Speaking is painful and difficult and the voice is dead. There may be a nasal twang or even regurgitation of fluids through the nose. When the secretion becomes free the pain ceases. The secretion is a greyish viscid mucus and later becomes muco-purulent; either ex- pectorated, discharged through the nose or sua' v wed. By collecting on the pharyngeal wail it causes retching or even vomiting. The breath is offensive. Moarsencss and a hacking cough is frequent. Local- ly on examination the mucus membrane is found deeper in color, frcm a slight flush to a deep scarlet. Jt often becomes rough and velvety and sometimes * superficial erosions are present. The course is usual- ly short, resolution coming in four to eight days. If neglected it may terminate in a subacute or a chronic inflammation. ! ACITK I'JfA II YXOfTIS. 815 Treutment. This may also l)c aborted by tlic draught recommcMided for acute rhinitis. Diaphor- etics are useful in the form of hot baths and hot drinks. Strict attention must be paid to the bowels and the least tendency to constipation checked. The fever docs not require medicine usually, but phenacetine gives great cv;mfort if headache be present. The great dryness of the throat can be relieved bv pilo- carpine, I lo to I i6 by the sublingual method. Acon- ite is valuable for children. A cold pack for the neck, or Leiter's coil, and small pieces of ice in the mouth may give relief. Fomentations and gargling with hot water or hot milk, or hot claret, gargles of soda, borax, chlorate of potash, or tannin. Inhalat- ions of vapors, either steam alone or medicated with benzoin are very grateful. AciiK Fm.KtJMONors Piiaryngitis. — This is the same form just described but with intensified symptoms, great swelling, and general disturbance. The type of inflammation is distinctlv septic. Anuina Ui.ckrosa or ulcerated sore throat. — This is w ithout doubt of bacterial origin. It is found in hospital nurses, in pathologists, and in medical students who spend too much time in the dissecting room. There is an ulceration of the superficial mucus membrane with a fibrinous exudation mixed with pus. The treatment is to remove from such surroundings as might be the cause of it. The in- dications are to give iron, quinine, whiskey and nutritious diet. Locally use disinfectant sprays and gargles. Permanganate of potash makes one cf the best. CuKONic Hypertroj'mic Pharyngitis. — This is 316 />/.S7,.I.S7..V itF run MtSF. AS It TIHiOAT. seen in those who are debilitated or anaemic. Those subject to frequent attaclxs oi acute pharyngitis may finally be left with the hypertrophic form. Improper and excessive use of the voice is a very common cause. The constitutional conditions with which it is most frequently associated are rheumatism, dis- orders of dijTfstion, congestion and cirrhosis of the liver, cardiac hypertrophy, valvular disease of the heart that produces obstruction to the return circula- tion, and those diseases oi the lungs which tend to prolonged and excessive coughing, such as chronic bronchitis, emphysema, asthma and tuberculosis. .Vvw//>/o'«-v. There is a sensation of fulness in the throat, and the presence of a thick tenacious secretion. This accumulates on the posterior wall of the pharynx at night, and . 'he morning is found to adhere so firmly that tl. . efforts of hawking often result in vomiting before the mucus can be dislodged. There are disorders of digestion, the tongue is coated, the appetite is poor, and the acuteness of taste is much 'essened. Chronic laryngitis is frequently associated with it. The speaking voice is hoarse, and the patient usually finds that he is unable to sing. On examin- ation the mucus membrane is seen to be red, swollen, has a velvety appearance, and the blood vessels, specially the veins are distended and tortuous. The thick whitish mucus can be seen over the surface. /'/'cg-/;o.y/>.— The disease is likely to run a rather long and tortuous course. The difficulty is to correct the constitutional conditions and the mode of life. 7Vtoms. -'Y\\c most distressing symptom is a cough and a tickling sensation as of a hair in the throat. This is most marked at night. The cough produces a hoarseness and tends to keep up a chronic congestion of both the pharynx and larynx. Efforts at speaking tire the throat very greatly and singers cannot control the flexibility of the voice, false tones are produced, and the voice breaks. Treatment. — The essential part of the treatment is to destroy the granulations, and this is best done by the galvano cautery. Chronic Atroi'hic Pharyngitis.— ^This con- dition is often called pharyngitis sicca and is a chronic inflammation resulting in atrophy of tlie mucus mem- brane of the pharyiix. It sometimes follows hyper- trophic pharyngitis, but is more frequently the result of a chronic rhinitis. It may occur in persons who are extremely anaemic, without any previous history either of hypertrophy or of atrophy. Pathology. — The formal subepithelial tissues are replaced by connective tissue. Some of the glands :<18 /i/.sA',i.vA'.v OF Tin. \osK Axn ri/ifiur. atrophy aiul Jisappear, while those that persist liavc their (iinetioiis altered, so that they secrete a scanty, thick anJ tenacious mucus. This accumulates in the form of dry crusts. Symfy/onis. There is an irucnse dryness and hurnini; in the throat. 'I'he irritation of the dry mucus produces considerable reflex couj^hinj; to clear the tlirmit. The voice is husky. From the decom- position of the crusts there is a bad odor to the breath. On examination the posterior wall is pale, dry and covered with a thin crust oi mucus, or, in the Iwd cases, with tb , dark brown or blackish crusts. Trent nun f. This is a condition that is practicallv never recovered from. .Ml that can be done is to lessen the discomfort. A spray should be used to soften and loosen the mucus. Chlorate of potash, ten grains to the ounce, is one of the best. To stimulate the >;lanJs to fjreater activity we may use boroj^lyceride, or some prepar.ttion of menthol. RKrRi>iMi \KV\i;i:.\i. Ahsckss. — This is a col- lection of pus in the connective tissue under the mucus membrane of the pharynx. It is a condition frequently overlooked, but should be borne in mind whenever a child is seen sufferinj^ from difliculty in breathinjjf and swailowinjf. It is important because it mav rapidly prove fatal from rupture and aspira- tion of pus into the larynx. Etiohi^v. In most cases it is impossible to trace the cause. It is essentially a disease of childhood, thoufjh a few ca> ■ are reported as occurring in adults. Tubercu). .^is, rickets and inherited syphilis predispose to the disease. Injuries and caries oi the cervical vertebrae are causes. mmmmmmmm m A' HTItOrH. 1 /.• J'A7/ a;. I /. .1 list 'HSS. aiu Patholofry,, In infancy a few lymph j^'lanUs are found beneath the mueus membrane of the pharynx, opposite the second and third cervical vertebra. It is believed that suppuration occurs in these jJi^Jands. S\>nif>t(>ms. In infants there is a sudden refusal of the breast, with a snuftlin^ cry. dysphagia and dyspnoea. In older children there are the usual symptoms of st^re throat with fever, and there is no diOiculty in makinj,' a diaj^nosis by inspection. The danj;er previous to rupture is from oedema o{ tile larynx causin/ij asphyxia. Pulmonary complications may arise, or death may come from septic absorption. Positive diaj^nosis is made by the explorin/^' needle ai.j' syrinj^e to get pus. TrciUimnt. The abscess .' be evacuated. If the cause is necrosis of the veritora an external incision may lx> made. Otherwise, the incision is to be made through the mouth, and should be in the median line as nearly as possible. After the incision is made the child is to be inverted or placed in such a position that the pus will flow into the mouth. M.\K.\ioire or less discolored mucus can be seen adhernj.; 'o the cords. Treatment. i! a stinuilriting .haracter may h> ne- cessary before the uiscasi- v.m Ik cured. CHAPTER XVUI. HAKvK)KHHAaE. O! RMA, F'»RFI(JV BODIEH. ml i AK V .moil BOSiN of Ci- be Seen early HTm > datinjtr arty an\ 'm of spa- ' w I tim icanoits I >KKHAOK — This is not very t I- iiost important to make a diag- idki' 1 when it does occt •. It mav ■r s of l;irynfjitis. ,iy be an >erci sis of the la vnx, ante- jIci ion. It may accompany n. I Mimetimes caused by a pinjij cough. In women it is some- It is observed in those diseases of £i ood in which there is marked alteiation in its c* .»! lents, as in malaria, chlorisis, ' rynra and scnrvy. .S>w/>/f?w/.v, — The amount of bio klom very ■, usually not more than enouj^h -ak the c.\jji;ctc ttion. The only other sympi i tick- Hng in ihe larynx followed by the co If the trynxi m be examined one or more hacmorrhagic areas can be seen. The prognosis, of course, de- pends on the cause. Treatment. ^\Nhtn the amount of the blood is small no treatment '■>> s ceded, as it soon ceases of Its own accord. When profuse the patient should be ' It to bed, and the coughing controlled by morphine a necessary. Cold applications over the larynx will help to control the bleeding. A spray or a direct application of adrenalin is the best local treatment. 884 DISEASES OF THE NOSE AND THItOAT. CEdema ok thk Larynx. — This is also commonly called oedema of the glottis. The local causes of the condition are the application of caustics in the neigh- borhood of the glottis ; the lodging of foreign bodies in the supraglottic region ; swallowing hot liquids or inhaling steam or irritating smoke ; prolonged or excessive use of the voice ; the inflammation of the larynx that accompanies erysipelas, diphtheria, influ- enza, measles, scarlet fever, and whooping cough. The ulcerative processes that are seen in tuberculosis, syphilis, and malignant disease are frequently accom- panied by oedema. Perichondritis of the larynx, abscess of the larynx, and peritonsillar abscess pro- duce it. The constitutional causes are Bright's disease, diabetes, and the cardiac lesions producing general anasarca. The administration of iodide of potash may cause it in those who are susceptible to the drug. Pathology. — The loose areolar tissue in the ary- epiglottic folds, on the ventricular bands, around the epiglottis, and beneath the cords, is infiltrated with a pale, colorless transudation from the blood vessels in the neighborhood. Symptoms. — It usually occurs quite suddenly. The severity of the symptoms depends on the amount of the swelling and the mechanical interference thus produced with the functions of the larynx. Degluti- tion is often diflicult. The dyspnoea may be so great that cyanosis may develop in a few hours, and unless the mechanical obstruction is removed, death comes from asphyxia. The examination will show the large pale swelling's. Treatment. — In cases of moderate severity, suck- FoKKUiN noniEs jy the lahynx. 385 ing and swallowing pieces of ice, and the external application of cold, often afford relief. When the dyspnoea is severe no time should be lost in scarify- ing the oedematous tissue. Applications of cocaine and au-pnalin may be made first. Should the scari- fication not reduce the swelling promptly then in- tubation is to be done. FoRKiGN BoDiKs IN THK Larynx.- A great variety of small substances have been found in the larynx, such as buttons, beans, pins, needles, pieces of wood, particles of food, and coins. The usual method by which these things enter the larynx is tha- they are being held in the mouth, and the patient's attention is suddenly taken by something else, when an inspiration, Mich as precedes coughing, laughing or sneezing, takes place, and the foreign body is drawn into the larynx with the inspired air. Very small bodies may lodge for a time in the larynx and then fall or be pushed into the trachea and drop into the bronchi. Large chunks of food and foreign bod- ies that completely fill the glottis produce asphyxi- ation, and unless removed at once, death takes place in from two to five minutes. The smaller bodies produce only dyspnoea, the amount of this depending on the size of the obstruction. The voice is hoarse and aphonic, but pain is not common. The cough is very severe and annoying, being spasmodic in character and often persisting after the removal of the foreign body. Every one has experienced the sensation produced by a crumb or a drop or two of liquid enter- ing the larynx, and will have noticed the length of 336 DISEASES OF THE NOSE AND THROAT. V 1 time that the cough and irritation lasts after the re- moval of the offending particles. On account of the persistent reflex cough patients often insist for some days that there is something yet remaining in the larynx. If an examination can be made the foreign body can usually be seen. Treat men/. —Some can be gotten rid of by invert- ing the patient and slapping him on the back. If the foreign body can be seen it should be caught with a pair of forceps, though it is often easier to see it than to take hold of it. Tracheotomy may be necessary, and sometimes thyrotomy for removal. ■S CHAPTER XIX. TUBERCULOSIS OF THE LABYNX. Tuberculosis of the Larynx.— This is usually secondary to pulmonary tuberculosis, but a few cases occur where no other lesion can be found. It is common in adults between the ages of twenty and fifty. The tubercle bacilli gain access to the laryn- geal tissues in three ways, (i) through the lym- phatics ; (2) through the entrance of the bacilli into the blood stream and so being deposited in the tis- sues of the larynx; and (3) through an abrasion in the epithelium of the mucus membrane. There must be in addition a peculiar receptivity of the tissues which may result from any one of a large group of factors, including heredity. Pathology.~ThQ pathological process is the same, whether the lesion is primary or secondary. The first effect of the introduction of the tubercle bacilli beneath the mucus membrane of the larynx is the production of a round-cell infiltration and the forma- tion of tubercle and the giant cell. Where the pro- liferation of these cells is very rapid they crowd upon each other, so as to interfere with their nutrition, and cloudy swelling and cheesy degeneration of the cells in the centre of the tubercle take place. The tubercles may be scattered evenly beneath the mucus membrane, or piled on top of one another, so as to 83S DfSEASKS OF THE NOSE AND THROAT. torm a well defined tumor. When pus producing Iwcuria gain access to the degenerated cells, necrosis and suppuration ensue, and the second stage, or that of ulceration, will be found. The first stage may pass unnoticed, and during this time no symptoms are referred to th- larynx. The ulcers are usually superficial, irregular in outline, having a "mouse- nibbled " appearance. Oedema of the arytenoids is very frequently seen. The ulcers may be found on the aryepiglottic folds, the epiglottis, vocal cords, the posterior wall of the larynx between the aryte- noids, and the ventricular bands. Symptoms. — These depend on the stage of the in- volvement, whether that of tubercle or that of ulcer*. In the stage of tubercle the most noticeable symptom is the change in the voice which is hoarse and very variable. A few words may be spoken clearly, then there is a break. After clearing the throat the voice may come back to its normal tone. The changes in the voice may be due to the mechanical interference with the action of the vocal cords ; to the presence of the tumor in the interarytenoid region ; or to the dilTiculty in approximating the cords, owing to the oedema in the aryepiglottic folds ; or tubercle may be found on the vocal cords and prevent their ap- proximation ; or thick, tenacious muco-pus may be deposited on the vocal cords ; or the muscles of the larynx may be infiltrated by the tuberhle, so that their contraction is interfered with ; or paresis of the cords may be the result of pressure on the recurrent laryngeal by pleuritic exudate at the apices of the lungs. Also in advanced lesions of the lungs the volume of air in the thorax may Iw much less than It mamm TrjiERcrLosrs of the la n vxx. 330 normal, and in the weakened condition of the system generally there is not suflicient force given to the blast of expired air to cause the cords to vibrate, so the voice is weak and feeble. Unless the oedema is severe there is no interference with respiration. Cough is always a symptom, but may he due rather to the pulmonary condition, from which also the ex- pectoration comes. In the stage of ulceration there IS an mcreased amount of secretion and a greater tendency to clear the throat. Much of the secretion may come from the ulcer, and it is usual to find it streaked with blood. Deglutition becomes verv pain- ful where the ulcer is on the epiglottis or the epi- glottic fold. The patients will ^ro for twenty-four hours without food rather than bear the great pain caused by swallowing. The voice is worse than in the stage of tubercle. In addition to these there are the general symptoms that occur with tuberculosis in any part of the body -fever, sweats, emaciation, anorexia, rapid pulse and the others. An examina- tion of the larynx in the stage of tubercle will show the mucus membrane to he very pale, with small areas of congestion. Such an appearance always warrants an examination of the sputum for the tubercle bacilli. A pale, pear-shaped swelling of the arytenoids is characteristic. The tubercles may be massed together and often form a warty-like growth. If an ulcer is present it can usually be seen without difficulty. It will be covered with a thin grey or yellow exudation, and surrounded by more or less thickening or oedema. When the cords are ulce- rated they are irregular and serrated. Differential ZJ/i/A'/ioj/ir.— Tuberculosis of the 840 DISEASES OF THE NOS.. AND THROAT. larynx is to be distiiift^uished from syphilis, lupus, and neoplasms, benign and malignant. The finding of the tubercle bacilli is the most important point, though one negative examination should not be held sufficient to exclude tubercle. Prognosis. \<\\QXfi the laryngitis is secondary the prognosis is bad, as the patient may succumb in a few weeks. This is sure to be the case if the pul- monary condition is at all acute. Where the con- dition seems to be primary the average duration of the case is two years. Treatment.— 'The hygienic and constitutional treat- ment is the same as where the larynx is not involved and will not be discussed here. The local treatment is not satisfactory. The infiltrations are best let alone. If large enough to produce dyspncea they may be scarified and curetted. Lactic acid, 25 of the pure acid, is greatly praised by some and yet it has very little effect. VVhen ulceration is present the most that can be done is to make the patient com- fortable, and one often fails to do even that. The remedies for this purpose are cocaine, orthoform, chloretone and morphia. CHAPTER XX. LARYNGEAL TUMORS AND NEUROSES. Tlmors ok the Laryxx.— These are either be- nign or malignant. The varieties of benign growths are papillomata, fibroma, cystoma, myxoma, hpoma, angioma, adenoma, enchondroma, lymphoma. The malignant growths are either sarcoma or carcinoma. In the majority of the cases no cause can be as- signed for such growths. Some seem to be due to strain, others to cold, some follow the eruptive fevers. The symptoms are due to mechanical obstruction' and vary with the size, location, and hardness. It located on one of the cords there is dysphonia or aphonia. Dyspnoea occurs when the growth is large enough to diminish the lumen of the glottis ; dys- phagia, when the tumor interferes with the closure of the epiglottis. Cough is not usually present. It is only m the malignant tumors that any pain is found. I he treatment is to remove the growths by cutting or crushing forceps. Sometimes intubation or trache- otomy has to be done. The internal form of operation IS to be done if possible. Nkikosks of rmc Larynx. -These aflFect sen- sation and motion. The paralyses of sensation are anaesthesia, hyper- aesthesia, paraesthesia and conditions of neuralgia Afmes/Ziexia, or loss of sensation is due to loss of function of ihe superior laryngeal nerve. This may 342 DISK.iXK.S OF THF. XOSK AXD TJf/fOAT. be due to alteration of its structure at its origin, as in bulbar paralysis, or from diffuse cerebral lesions, affections of medulla, locomotor ataxia, or local neuritis from diphtheria. There is danj^er of choking from accumulation of secretion or food as there is loss of the reflex. J/\'f>entextfu'sia may be a symptomatic rather than an independent lesion. It is sometimes due to a catarrh- al state, and is especially common in laryngeal tuber- culosis and in carcinoma. Pamesthesia refers to abnormal sensations in the larynx. The most common are a feeling of a foreign body, tickling, and desire to swallow. Most of these are referable to some lesion above the larynx, that is, higher up in the respiratory tract, the reflex irritation being referred to a lower level. Neuralgia of the larynx may be caused by rheu- matism, gout, anaemia, malaria, and ulcerative pro- cesses. Sometimes no cause is apparent. The agents which are used for neuralgia elsewhere are to be employed. The motor neuroses are either spasmodic or paralytic. The spasmodic form will be discussed in connection with croup. Motor paralysis may be limited to one side of the larynx, unilateral paralysis; or it may involve both sides,— bilateral paralysis. It may also be limited to one muscle or pair of muscles, or involve several at once. The causes may be divided into four clr «:es:— 1. Disease or injury of the brain, invol.; g the cerebral portion of the nerves which supply the lu.ynx. 2. Injury of, or pressure upon these nerves after they have left the cranial cavity. mm NEVltOSKS OF THE LAIIYNX. 843 .3. An abnormal condition of the muscles them- selves preventing contraction. 4. A systemic dyscrasia.tli rough which the laryn- geal muscles are debilitated so as to be unable to respond to the nervous impulses. The causes of laryngeal paralysis of central origin are, syphilis, tumors, apoplexy, multiple sclerosis, and progressive bulbar paralysis. The length of the pneumogastric nerve and its relative position causes it to l)e greatly exposed to pressure as soon as vessels or glands undergo a temporary or permanent increase in si/e. Enlarged cervical glands, tumors, bronchocele, including the nerve in ligature during an operation or cutting it, are causes of laryngeal paralysis. Lesion of the pneumogastric just below the cranium inducing paralysis of both superior and inferior laryngeal nerves, means complete cessation of all motion, and partial loss of sensation on one side of the larynx. If the lesion is below the origin of the superior laryngeal, the paralysis is confined to the muscles supplied by the inferior laryngeal and there is no loss of sensation. The superior laryngeal is seldom affected because of its short length and position. An aneurism of the internal carotid, tumors in the pharynx or enlarged glands may press upon it. Lesion of the superior laryngeal causes partial loss of sensation, and paralysis of ihe thyro-cricoid, thryo-epiglottic, and ary-epiglottic muscles. The epiglottis is only partially closed and extension of the vocal band is prevented. Lesions of the recurrent laryngeal are the most common. Aneurisms are a frequent cause, and on the right side, the proximity of the nerve to \ S« DtSKASKS OF THE NOSE AND THROAT. the apex of the lung, furnishes another source of compression through expansion and thickening of the parenchyma. On the left side the nerve is not so close to the lung, hut it is more likely to suffer from pressure of bronchial glands and other medi- astinal growths. Enlargement of the thyroid glands, or bronchoccle, may produce bilateral paralysis. Paralysis of laryngeal muscles may be brought about by changes in the muscles themselves,— an inflam- matory infiltration. In such cases the voice becomes monotonous in the true sense. •"PTOA-rnj* («f*i*- , CHAPTER XXI. IDKJPATHIC CROUP. Idiopathic Croup.- -This is a pseudivmembran- ous inflammation of the larynx of a non-infectious nature which exhibits local rather than constitutional symptoms. The local signs are to some extent like those of diphtheria. In former days all cases of acute laryngitis associated with dyspnoea were called croup ; more recently the tendency has been to call them all diphtheria, and many authors still deny that there is such a thing as true croup. The bulk of evidence is in favor of the view that there is a simple exudative laryngitis. The exudation is a coagulated fibrin which covers the surface of the mucus mem- brane and is confined most frequently to the larynx. It may be found in the trachea, the bronchi, and rarely in the nose. It may be a primary disease or it may be secondary, produced by intense inflam- matory reaction which destroys the epithelial layer. Thus it appears in various kinds of traumatism, such as occurs ny caustics or the galvano-cautery. It has been produced in animals by a few drops of liq. ammonia in the trachea. Hot steam and irritating gases also produce it. The condition belongs to childhood, being seldom seen before the twelfth month and not often after dentition. It is said to be epidemic or endemic but this iMfl />/vAM.v/;,v ttr run SnsH ax/) tiikoat. is doubtful. I r it he due to a ^jerm it is one of very little vitality and essentially different from the Klebs- Loefflcr bacillus. \Vh. number of cases come toK'cther in the sam^ house or district, an explanation IS afforded by the existence of similar climatic, at- mospheric, and constitutional causes. Svmfitoms. vhan,,'c o^ voice is usually the first symptom. The hoarseness is at first catarrhal, then the voice is raised in pitch and has a metallic sound. Kmbarrassment of respiration is the most serious and distinctive evidence of croup. This may come on in a few hours, or it may not t^me for two or three days. ICach inspiration is attended by a stridor which is shrill, metallic, sibillant and whee/ing. The cou«h is also distinctive in character, being brassy or laryngeal, and once heard is speedily recognized again. I.aryngoscopic examination is rarely possible. As to the general symptoms, the pulse is first qui. k and full, then stron)^ and bound- ing. The temperature is high at first and abates as soon as the exudate is poured out. Thirst is a very common symptom. There is a general dryness of the skin, the face is flushed and swollen, and the conjunctiva is injected. The dyspnoea gradually becomes excessive, the child is restless and excited and makes constant efforts to grasp the throat as if to remove the obstruction. When the paroxysm comes on the head is thrown back, the accessory muscles of respiration are brought into play, and the difficulty of breathing becomeu extreme. Unless relief is given by expulsion of the membrane, the suffering soon becomes continuous, the voice and cough lose all tone, the prolonged inspiratory stridor is followed by inntpATun' viuwi*. %m an equally It>njr expiration ; the dyspnoea i extreme, and cold sweats break out on the hixly and iivid face; cyanosis with coma comes on and the chik. dies un- conscious from sullbcation. If the membrane is ex- pelled and no extension into the trachea and bronchi occurs, the symptoms are all chan^'cd for the better, breathing' is freer, the cou^'h is metallic but gradually becoiiics softer with the expectoration. This disease may end fatally in twenty-four hours or may continue for five or six dijys. Diagnosis. Idiopathic croup may be confounded with diphtheria, spasmodic laryngitis, and laryngis- mus stridulus. The ^'reatest difliculty is in dis- tinjfuishing it from diphtheria. The culture to show the special bacillus is the only absolute te^t. Diph- theria in the larynx is frequently preceded by mem- brane in the pharynx, or accompanied by it. M i.ality fror. -roup isas always been very great. Heath may K he result off ) apnoea, i.e. by con- vulsionsdurir N"«f« ; jyspnoea, (2)asphyxia, (3) deposit o! * tm . • die heart, (4) exhaustion, (5) coma, (6) secci , rv in. jg complications. Treatment — I ..;. should be active U.mx f the ^rastric portion of the vagus may play some part in pre.'isposing to f le croup as it dr-s in false. (2). J. , ., lieves an overloaded stomach, tavors a prompt ah.nc evacuation, brings on dia- phoresis, increases diuresis, and lessens the fever generally. {X). Should m-mbrane be formed an emetic lavors its dctachnjent and expectoration. Ipecac, wine alone one dram. . ipecac gra. 5 with tartar emetic 14 gr. for a child irom two to five years. K ¥ i ■iv. 848 /)LSJ:aSKS of the XihSE AND THROAT. Apomorphia, i 20 to i 10 hypoJermically, and yellow sulphate of mercur)' are highly recommended. Cal- omel has long been used as a specific, and it certainly increases the secretions. Inhalations of steam and vinegar are grateful. Vapor of slaking line is also useful. In doubtful cases antitoxin should be inject- ed. When the dyspnoea is serious intubation or tracheotomy is to be done. CHAPTER XXn. DIPHTHERIA. Diphtheria.— This is an acute infectious and contagious disease, characterized by the exudation of a fibrin on or in mucus membranes, or on the surface of wounds, constituting the so-called pseudomem- branes. The term should be restricted to those cases of sore throat in which a false membrane is found to contain the Klebs-Loeffler bacillus. It was in 1875 that Klebs discovered the bacillus, but not much cre- dence was given to it until it was demonstrated by Loeffler in 1883, Dissemtnation.~\t is usually transmitted from the sick to the well oy the moist or dry discharges fr-.m the nose or throat of the affected. The transmission may be direct or indirect in so many ways that it is not always possible to trace an individual case to its source. The vulnerability of the mucus membrane in children, the frequency of nasal and pharyngeal catarrh, the narrowness of the nose, the large size and softness of the tonsils, the frequent fermentation of food in the mouth, the sucking of the soiled little finge-s, the constant intercourse of children with each other in large families and in densely popu- lated houses and districts, and in schools and on playgrounds, are all predisposing causes. The vi- tality of the germs is persistent and may extend over :S|r m niSEASKS OF THE NOSE AXD THIiOA T. years. They clin«: to solid and semi-solid bodies, are imported in milk, clin^' to walls and floors, to toys, to curtains, towels, clothing and bedding, to carriage cushions and car seats, and there is no doubt that horses, chickens and cows have diphtheria and spread it. The fact is that in an epidemic there is nobody not exposed to it. and everybody is subject to It under favorable circumstances. One in good health may carry about the bacteria in the mouth and throat indefinitely until a slight inflammation or an abrasion provides the suitable soil for its develop- ment. 5:i'/;///ow.9.— These are constitutional and local. The constituional symptoms are due to the absorption of the toxins and the effect that these have in the per- version of the functions of the various organs. The local symptoms are due to inflammation of the various parts of the upper respiratorv tract in which the exudate is found, and to the mechanical obstruction produced by the exudate. We will discuss the pharyngeal, nasal and laryngeal tvpes separately. Tmk Pmarvn,;k.m, Tvpk. In an ordinary case the child IS ailing for a day. being listless, without appetite, and often vomits. On the second dav sore throat IS complained of; temperature is from loi to .o,:? and the pulse rapid. The urine is scanty, high colored, and slightly albumenous. The glands at the angle o^ the jaw are slightlv enlarged. In the severe form the child is suddenly prostrated, and passes into a semi-coinalose condition from which it is aroused with difHculty. If seen earh . an examin- ation of the throat will show a membrane upon some part of the throat, the tonsils, the uvula, the pillars PHAHYNOEAL DIPHTHEIUA. 8Sl of the fauces, or the posterior pharyngeal wall. The membrane may be in spots but these tend to coalesce. It seems to be shghtly elevated above the mucus membrane, and is surrounded b\ a zone of deeply congested mucus membrane. If the membrane is torn away it leaves a bleeding surface and is re-form- ed in a few hours. At the fourth t the tenth day the membrane is seen to melt away, or to become loosen- ed at the edges and curl up and then is detached. Tmk Nasai Tyi'k.- It is unusual to find mem- brane in the nose without at the same time hndmg it in the throat. The symptoms peculiar to the nose are severe. There are recurrent attacks of epistaxis. and a discharge ofmucus that is blood-tinged and excoriates the nostrils and lips over which it flo.vs. There is mouth breathingand a very offensive odor, the glands of the neck are very much enlarged, and earache and suppurative otitis media are common. The examin- ation of the nose shows it to be completel\ filled with a thick grayish membrane covering- the inferior turb- inal and septum. A complete cast of the nasal cavity is often brought away as a recovery is takinir place. The Lanrngeal Typv. This is usually secondary to the pharyngeal form. Membrane is. however, found in the larynx without any appearing above it! The cough is croupy, gradually hoconing tighter. Dyspnoea becomes a seriou.. svmpfom. and unless relieved, cyanosis soon develops. '|-hero is aphonia. There is a sinking in, above and below the clavicles, and above and below the stcrum with each inspira- tion. The child becomes very restless; convulsitins and spasms may come on, and passing into coma the 852 DISEASES OF THE NOSE AND THROAT. little one soon dies. An examination of the larynx cannot he made. Sequelae.- -The common sequelae are otitis media, suppuration of the glands of the neck, acute neph- ritis, and the diphtheritic paralyses. Differential Diafpiosis. — The conditions with which it may be confused are acute tonsillitis, strep- tococcus sore throat, the mucus patches of syphilis, and mycosis of the pharynx. The first of these has already been discussed. The streptococcus mem- brane can only be distinguished by the bacteriological test. The other two conditions will be known by their chronic course at least. Treatment. This is preventive, local and con- stitutional. Immunity is produced by the injection of diphtheria antitoxin in doses varying from 200 to 2000 units according to the age. This immunization does not last for more than a month during which it gradually wears off. The injection may be repeated without any harm. Any diseased condition of the throats of children should be remedied when there is no diphtheria about. Kspecially enlarged tonsils and adenoid hypertrophies should be attended to. Those in attendance on diphtheria cases should use an antiseptic spray or gargle and a wash for the nose, but care must be taken not to irritate the mucus membrane. A mild soda solution for the nose is best, and for the throat, bichloride of mercury, i to 5000, care being taken not to swallow much of it. Isolation, absolute and complete, should be insisted on, and maintained until a bacteriological examin- ation shows that the bacteria are no longer in the mouth and throat. 'Ihe local treatment, in the way DIPHTHERIA. SW of antiseptic sprays or mouth washes should be con- tinued for the same length of time. The regulations of the New York Health Depart- ment, in reference to diphtheria are clear, concise and to the point. *'If possible, one attendant should take the entire care of the sick person, and no one else beside the physician should be allowed to enter the sick room. The attendant should have no communication with the rest of the family. The members of the family should not make or receive visits during the illness. "The discharges from tlu nose and mouth must be received on handkerchiefs or cloths, which should be at once immersed in a carbolic solution (made by dissolving six ounces of pure carbolic acid in one gallon of hot water, which may be diluted with an equal quantity of water). All handkerchiefs, cloths, towels napkins, bed-linen, personal clothing, night clothes, etc., that have come in contact in any way with the sick person, after use should be immediately immersed without removal from the room in the above solution. These should l>e soaked for two or three hours, and then Iwiled in water or soapsuds for an hour. " In diphtheria and scarlet fever great care should be taken in making applications to the threat and nose, that the discharges from them in the act of coughing are not thrown into the- face or on the clothing of the person making the applications, as in this way the disease is likely to be caught. "The hands of the attendant should be always thoroughly disinfected by washing in the carbolic solution, and then in the soapsuds, after making ap- 854 nrSKASHS (tF THK SOSF. .\Sn THIfitAT. plications to the throat and nose, and licfore eatinj;. "Surfaces of any kind soiled by the discharj,'cs should lie immediately flooded with thi- carbolic so- lution. "Plates, cups, j^lasses, knives, forks, spoons, etc.. used by the sick person for eatinj,' and drinkinj^ must be kept for his special use, and under no cir- cumstances removed from the room or mixed with similar utensils used by others, but must he washed in the room in the carlwlic solution and then iti hot srtipsuds. After use the hot soapsuds should In: thrown into the water-closet and the vessel which contained it should be washed in the carlK>lic so- lution. "The room occupied by the sick person should be thoroughly aired several times daily, and swept frequently, after scattering wet newspapers, sawdust. or tea-leaves on the floor to prevent the dust from rising. After sweepinj;. the dust upon the wood- work and furniture should he removed by damp cloths. The sweepings should be burned, and the cloths soaked in carbolic solution. In cold weather the sick person should be protected from draughts of air by a sheet or blanket thrown over the head while the room is being aired. "When the contagious nature of the disease is recognized within a short time after the beginning of the illness, after the approval of the health depart- ment inspector, it is advised that all articles of furni- ture not necessary for the immediate use oi the sick person, especially upholstered furniture, carpets and curtains, should be removed from the sick room. "When the patient has recovered from the disease nrpjtTHF.niA. m the entire body should be bathed and the hair washed with hot soapsuds, and tht patient should be dressed in clean clothes (which have not been in the room durirj^r the sickness) and removed from the room. Then the health department should be immediately notified, and disinfcctors will be sent to disinfect the room, beddin^r, clothing, etc.. and under no con- ditions should it be again entered or occupied until it has been thort>ughly disinfected. Nothing used in the room should l)c removed till this is done. "The attendant, and any one who has assisted in caring for the sick person, should also take a bath, wash the hair, and put on clean clothes, before mingling with the family or other people after the recovery of ihj patient. The clothes worn in the sick room shruld be left there, to lie disinfected with the room anu its contents." Awvi/ Treatmenl. The local treatment employed has been for the purpose of either directly destruviiig the p.seudomembrane. such as nitrate oi silver, car- birfic acid, the actual cautery ; or to dissolve it. such as the alkaline carbonates, the chlorides, steam, and pap.ivotin ; or to act as astringents, such as lime water, and the chloride and sulphate of iron ; or to disinfect, such as potassic chlorate, chloral hydrate, turpentine, carbolic acid, mercury, sulphur, bromine, iodine, iodoform, chlorine water, and peroxide oi hydrogen. Ihe methods of application have been direct local application, gargles, sprays, injections, and inhalations. In mild cases where there is very little secretion a! the back of the throat it is not nec- essary to use aiiv local treatment. Many young children object very strongly to the use of swabs and i¥, «5« nrS EASES OF THE XOSK AXD Tim OAT. sprays, and strujT^Me violently when they are em- ployed. The exhaustion produced and the extra tax- ation of the heart more than counterh.ilance any j^jood accomplished in this way. LcxMflcr's solution is highly thought of hy many. It consists of alcohol 60 parts, toluol .16 parts, tincture of iron sesqui- chloride 4 parts. It is however not any better than others, has a bad taste, is oiijectcd to very strongly, and gives rise to exhausting struggles. The normal salt solution, boracic acid solution, or lime water will do as much as any of the others. When the nose is affected, irrigation may bo practised. To do this properly the child should be wrapped from head to foot in a sheet or blanket, with the arms down at the sides, so that struggling cannot take place. The child should be laid on its side on a table covered with a rubber sheet. A douche bag with a long tube and a glass nozzle, is filled with saline solution, and the nozzle introduced into the upper nostril. The solution is allowed to flow freely to clear out as much oi the membrane as possible. In laryngeal diphtheria the first danger is from suffocation, and as this is easily recognized, the in- dications for the treatment by mechanical means are easily found. From the beginning of dyspnoea steam must be used, and calomel may be sublimed, but as soon as there is any real distress intubation should be practiced at once. Tracheotomy may be done in place of intubation, but the results are not so satis- factory. As to intubation, we may propcrlv discuss it here. The object is to introduce a tube into the larynx, by way of the mouth, the shape and weight of the lube keeping it in place as long as it is nee- .-J ',1 hH'iiriiKiitA. m? t essary to use it, that is until the swelling: subsides or the membrane is thrown off. The tubes are of differ- ent sizes to tit the larynx at different aj^es. The operation iiein^' decided upon the first thin^' to con- cern the operator and the nurse is the preparation of the patient. When a child is first seen in this con- dition it is usual to find the neck and chest covered with several layers of flannel, and perhaps a lar^'e poultice is also over the throat. These should all lie removed so that nothinjr remains but the ni^'ht dress. The child is then pinned in a sheet or blanket, with the arms extended by the sides. There should t>e no folding' of the sheet to make a roll or bunch under the chin. The more care taken in this preparation the easier will Ik- the holding' of the patient and the less likely any delay at a critical moment. To select the proper sized tube it is necessary to know the age of the patient. In each set there are six tubes, and a gaujje to show the proper size for a given age. A piece of strong linen thread is put through the eye in the head of the tulje, and when double should be from ten to eighteen inches in length. It is not usua! or necessary to sterilize the tubes before using them, but, of course, they are very carefully cleaned afterwards. The obturator, introducer, and mouth gag are the other instuments needed. The nurse is expected to hold the patient, and assistance is rendered in holding the head by a second nurse or another doctor. When holding the patient the nurse should be seated on an ordinary backed chair ; the child is firmly grasped by the elbows and brought into such a position that its head is above the left shoulder of the nurse and on the same level as her »M n/\KA.SFS OF Till XOSK ,|.v/, TlinOAT. head. It tlic child is of any size, or say four vears and upwards, its legs must Ik- finnlv held between the k.ues of the nurse. The i>ther assistant stand behind the nurse and patient, and j^rasps the head firmly K-tween the hands, h.ivin^the third and fourth fingers under the jaws. The head must Ik- kept in the middle line and erect, the assistant holding it as though he were stretching the neck. The Iwck of the patients head may In- steadied a.uMinst the assistant's chest to prevent the cluld from throwing itself sud- denly kickward. If no second assistant can Ik- had then the child is to Ik- placed so that the Kick of its head rests upon the left shoulder of the nurse who places her left arm firmly across the chest and the right hand upon the forehead of the child, the legs being held as before. The operation is also some- times done with the p;iticnt in the recumt)cnt position on the table or bed, the reason for this being a weak heart or a moribund condition. The doctor standing in front of the patient introduces the gag between the teeth on the left side. When in place the handles lie against the cheek and the assistant who is holding the iiead should place the left index finger Ijetween the jaws to keep it in position. The operator then inserts the left forefinger into the child's mouth feels for the epiglottis, lifts it up to a vertical position, then passes the tube into the mouth and on until the point of the tube rests on the epiglottis with the finger. The handle of the introducer is raised at the same time the finger is pushed on behind the larynx to steady it while the tube is going through. When the tube is almost in place the finger is raised to the head of the tube and it is pushed home, at the same ^i^(7 ntPHTUKHIA. 80» time the obturator is freed from the lube anU it and the introducer withdrawn. The string is kept in the tube for a few minutes to watch the effect oi the in- tulwtion. When the tube is properly in position, one or two couj^'hs will be jjiven ; the child's respir- ation, which was croupy, becomes quiet; the cyanosis clears up. and the child quickly falls into a quiet sleep. The operation takes a long time to describe, but is done in a few seconds. The nursing and the feeding oi the patient are of the utmost importance. CoHstituiiomtl rnalmeiit.—Tht use of diphtheria antitoxin has become almost universal, and there can be no doubt as to its value. The earlier it is ad- ministered the more valuable it becomes. It may be given no matter how late the case is seen, but the best results may be looked for if it be used before the third day. The dose should Ik- from looo to 3000 units, hypodermically. In severe cases one half the maximum' dose may be repeated in twenty-four hours. A rash often follows its use. but it soon passes off and does no harm. Before antitoxin came into use almost every remedy in the pharmacopoea had its advocate as being most valuable in diphtheria. Only two have survived, ^calomel and tincture of iron. Calomel in one quarter grain tablets should be given at the onset of the attack and continued till the bowels are moved freely. During the course of the disease it is well to repeat this. Sublimation of calomel fifteen grains every twelve hours, is practiced while a tube is being worn. The tincture ferri chlor.. one part; glycerine, four parts ; fifteen drops of which may be given to a child one year old, every two hours, and thirty drops to a child over two years, is an old and really useful MICROCOPY RESOIUTION TEST CHART (ANSI and ISO TEST CHART No 2) 1.0 1.1 36 40 m 2.0 1.8 1.25 1.4 1.6 M APPLIED INA/1GE Inc ^^ Mi^i East Ma.n Street rJZ Hochester, New Yo'k '4609 USA i^S {7)6} 482 - 0300 ■ Phone ^S (716) 288 - 5989 - To. 3(i0 lUSKASES OF THE NOSE AND THROAT. remedy. The condition of the heart must be watch- ed from the first. It is well to give some stimulant from the beginning of the attack, as heart failure may make its appearance early. The treatment of the sequelae need not be discussed here. '.< CHAPTER XXin. SPASMODIC LARYNGITIS. Spasmodic Laryngitis.— This is also called spasmodic croup. It takes an intermediate place be- tween idiopathic croup and laryngismus stridulus. It is a catarrhal laryngitis associated with spasm of the glottis, and almost exclusively affects children. The child goes to bed in good health, or perhaps with a cold in the head or a slight hoarseness. Dur- ing the night the croup-cough is heard, hard, me- tallic and barking. This may be repeated, and with it a certain amount of stridor. This is the single symptom. The child is apparently well in the morning. These attacks may occur for several nights and then disappear. Very simple treatment is necessary. A drink of hot milk may give relief. Small doses of paregoric and ipecac will help the cough and relieve the spasm. LARYXGisMrs Stridulus.— This is also com- monly called spasm of the glottis. It is a spasmodic closure of the glottis due to tonic spasm of the ad- ductor muscles of the larynx. It is strictly a neurosis and may have a central or a peripheral origin. It may be a local convulsive attack. It is an affection of young children, but is sometimes seen in adults. Dentition is a cause, and digestive derangement is often present. It may be due to a foreign body or 802 DISEASES OF THE NOSE AND TlUtOAT. pressure on some motor nerve. The opinion gen- erally held is that it is a reflex irritation of the larynx from some remote disturbance. The symp- toms come on at night suddenly. The clii'd breathes with difficulty and with a peculiar inspiratory stridor. Convulsions or opisthotonos may occur. This passes off in a feu minutes with a loud inspiration, which is the end of the spasm. It may result in asphyxia. Attacks recur at intervals of weeks, months or years. There is no fever or coughing. When the snasm is over the child is perfectly well. The treatment is directed first to arrest the paroxysm, and second . to prevent recurrence. For the first, plenty of fresh air should be admitted to the room, the feet may be plunged into cold water, the clothing loosened, the head lowered, cold compresses to the head, or cold water dashed into the face. Mustard plasters may be applied to the back of the neck, and morphia with atropine, injected. Ammonia and chloroform inhalations will help, if respiration is not completely arrested. Hlmetics are not of much use. Intubation may be done if there is time. Between attacks the system must be built up by hygienic measures, good ventilation, open air, nourishing food, proper clothing and the daily cold bath. If the act of nursing causes a spasm, feeding must be managed with a spoon. As the condition is closely allied to eclampsia, the bromides, chloral hydrate, and antipyrin are suitable remedies. INDEX. . A CNE of cornea, 45 Adenoid vegetatiunH, 809 Advancement operation, 126 Aids to hearing, 383 Amaurosis, 98 Amblyopia, 98 Ametropia, 107 Angina ulcerosa, 815 Anisometropia, 109 Ankyloblepharon, 81, 138 Anosmia, 304 Astigmatism, 107, 108 Atresia of punctum, 86 Atrophy of optic nerve, "1 Auricle, disease of, 156 Autophony, 198 BLEPHARITIS, 25 Blepharospasm, 83 CANTHOPLASTY, 137 Cataract, 58 Cauterization of cornea, 131 Cellulitis of orbit, 96 Chalazion, 35, 180 Cholesteatoma, 214 Choroiditis, 74 Ciliary injection, 40 Conjunctivitis, 1, 21 catarrhal, 4 follicular, 15 granalar, 14 membranous, 13 muco-purulent, 4 phlyctenular, 13 purulent, 6 Crede's prophylaxis, 11 Croup, 345 Curetting cornea, 131 Cyclitis, 68 DACRYOADENITIS, 85 Dacryocystitis, 28, 86 Pacryoliths, 86 Deaf-mutism, 330 Detachment of retina, 88 Diphtheria, 349 Discission, 119 Disinfection of cornea, 131 Displacement of cataract, 116 Distichiasis, 38, 180 Dysacousma, 198 PAR, clinical examination, 140 cough, 383 foreijtn bodies in, 167 functional examination, 151 inflation, 146 neuralgia, 231 physical examination, 141 Ecchj'mosis, 33 Ectropion, 30, 133 Emmetropia, 107 EmphyHema, 33 Empyema ethmoidal, 399 frontal, 297 of max. antrum, 293 sphenoidal, 398 Entropion, 29, 132 Enucleation, 137 Epiphora, 36 Episcleritis, 63 Epistaxis, 283 Eustachian tube catarrh of, 179 catheterization of, 147 Evisceration, 187 External meatus, 159 Extraction of cataract, 116 ulNI INDEX. piHTULA of cornea, 67 Foreign hodi in con- junctiva, 20 Foreitfii liudieH in Inrynx, JlS/i in uoMe, 28tt Furuncie, 1511 QLAUroMA, 7« Clinical typCH, 81 H EMORRHAOE from lar- ynx, :W3 HaeniorrhaKC from pharynx. Hay fever, 2115 Hemiopia, i)4 Herpes of cornea, 45 Heterophorin, 105 HippiiH, TO Hortleolum, 33, 34 Hyalitin, T)' Hyperaemi ; ili.sc, 80 of iri8, 03 of retina, 84 HyperaestheHia of retina, 85 Hypermetropia, 107 HyperoHmia, 3(t5 INCISION of cornea, 131 Injuries to conjunctiva, 1!> to ear, 175 Intubation, 858 Iridectomy, 113 IridodonesJH, 70 Iritis, 03 JEQUIRITY, 15 K ERATECTAHIA, 57 ^ Keratitis, 30 dendritic, 45 filamentarj', 45 granular, 44 interstitial, 53 neurofiaralytic, 53 non-sui)purative, 54 l>hlyctenular, 44 imnctate, 40 sequelae of, 50 superficial, 43 suppurative, 51 therapeutics of, 41 traumatic, 43 vesicular, 40 Kcratoconus, 57 Keratofrlohus, 57 Keratoplasty, 133 LABYRINTH, anaemia of. Labyrinth, haemorrha^'e, 334 hyperaemia of, 333 syphilitic inHam., 335 secondary inHam., 330 Lacrymal flstula, 37 Lagophthalmos, 31 Laryngeal haemorrhage, 3!J8 neuroses, 341 tumors, ;{41 Laryngismus stridulus, 301 Laryngitis, 330 chronic, 331 Latent squint, 105 Leucoma, 50 Lingual tonsil, 33h Luscha's tonsil, 300 Luxation of lens, 58 MACULA, 50 JTaggots in nose, 287 Malposition of punctum, 30 Mastoid inflammation, 214 Maxillf • sic IS, 302 Mup 1.; : 'unce, 105 Mya My( <7 Mj'oiui. I, '08 Myofis, 00 Myringitis, 174 f^AHAL discharge, 347 exostosis, 303 obstructiim, 243 polypi, 380 septum deflection, 301 stenosis, 345 Nasopharyngitis, 30t» chronic, 307 Nebula, 50 Nose, clinical exam., 334 functions of, 241 Nystagmus, 100 lyhK.x. m' .. OEDEMA of eyelids, 33 of larynx. 334 Opacitit'H of vitreouH. 7(1 OiieratiouM on ani..ialH pyoH, 111 Ol>erationf( on cornea, 130 on crystalline l«us, 115 on tear i>assa;;es, t3^* Olihthalniia neonatorum, 10 Optic neuritis, Hi) orbital, 03 Otitis externa, 181 Otitis media, IHS acute catarrhal, IHft acute purulent, IIM) chronic catarrhul, 11)4 chronic suppurative, 304 seciuelae, 200 Otomycosis, l(Mi PANNUS, 44 Papillitis, 80 Paracentesis of cornea, 133 Paracusis duplicata, 1!W Willisii, 108 Paralysis of accommodation, no Parosmia, 305 Peritonsillar abscess, 335 Pharyngitis, 313 atrophic, 317 i;ranular, 317 nvpertroi)hic, 315 phlegmonous, 315 ulcerosa, 315 Physiognomy, 241 Pinguicula, 18 Presbyopia, 109 Pseudaconsma, 198 Pterygium, 19, 123 Ptosis, :«, 135 RETINITIS, 84 pigmentosa, 88 Retropharyngeal, abscess, 318 Rhinitis acute, 359 atrophic, 307 chronic, 208 hyi>ertrophic, 374 intumescent, 372 Rhinoliths, 287 Rhinoscopy, 333 S^JLERITIH. 03 Sclerotomy, 124 Hoborrhoea of ear, 170 •Septum, nasal abscess, 303 haematoma, 303 perforation. 303 Minus thrombosis, 318 Hpasmodic laryngitis, ittll Htaiihyloma, 57 Htiliicidia lucrymarum, 35 Htrabisnuis, 90 concomitant, 104 paralytic, 100 Stricture of Inci ymal duct, ;JN Hymblepharon, 138 Hympathetic ophthalmia, 71 inHanimation, 73 irritation, 72 Hynchisis, 77 Swanzy's test, 105 JAKINO cold, 251 Tarsorrhaphy, 138 Tatooing cornea, 123 Tenotomy, 135 Tinnitus,' 198 Tonsillitis, 333 chronic, 330 Trachoma, 15 Trichiasis, 38, 130 Tuberculosis of larynx, 339 Tubo-tympanie catarrh, 183 Tumors of orbit, 97 Tympanic bone, fracture of, 173 UI-.<;ERS of cornea, 47 Uvnlitis, 321 VISUAL tracts. 94 XER08IS, 18 iniiiHiiiinii 9 MKM oaatMio (^^;5to^