THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT 
 
 Mrs. Henry S. Gradle
 
 DISEASES 
 
 OF THE 
 
 NOSE, PHARYNX, 
 
 AND 
 
 EAR 
 
 BY 
 
 HENRY-CRADLE, M.D. 
 
 Professor of Ophthalmology and Otology in the Northwestern 
 University Medical School, Chicago 
 
 ILLUSTRATED 
 
 PHILADELPHIA AND LONDON 
 
 W. B. SAUNDERS & COMPANY 
 
 J902
 
 Copyright, 1902, by W. B. SAUNDERS & COMPANY. 
 
 Registered at Stationers' Hall, London, England. 
 
 ELECTROTYPED BY DR 
 
 STCOTT * THOMSON. PH.LAOA. w . SAUNDERS & COMPANY .
 
 wv 
 
 PREFACE. 
 
 THIS volume is intended to present disease as the 
 author has seen it during an experience of nearly twenty- 
 five years, while in touch with the work of others. It 
 has been the author's aim to answer in detail those ques- 
 tions regarding the course and outcome of diseases which 
 cause the less experienced observer the most anxiety in 
 an individual case questions to which an answer is not 
 easily obtained from text-books. In order to carry out 
 this plan, the book could not be written with the brevity 
 and sharp subdivision of topics which have made some 
 of the smaller works popular with students. A text- 
 book should present to the student all the facts bearing 
 on the subject, and present them in their logical develop- 
 ment. But, on the other hand, the work is not intended 
 as an encyclopedic treatise, and hence lacks the literary 
 and historical completeness proper to the latter. In the 
 therapeutic part the author has aimed to detail only those 
 procedures which have stood the test of critical experi- 
 ence, and to omit those that have failed under this test, 
 even though sanctioned by the tradition of text-books. 
 
 As a requisite for all surgical work, topographic anat- 
 omy has been given a liberal space. Since anatomic 
 statements are necessarily based upon the labor of pro- 
 fessional anatomists, it has seemed proper to the author 
 to draw, as well, upon the superior illustrations in some 
 of the anatomic works less accessible to the English 
 student. It is especially to the works of Zuckerkandl 
 and of Politzer to which he is indebted for anatomic 
 illustrations. * 
 
 9
 
 CONTENTS. 
 
 BOOK I. 
 
 DISEASES OF THE NASAL PASSAGES AND 
 PHARYNX. 
 
 CHAPTER I. 
 
 PAGE 
 
 Development, General Descriptive Anatomy, and Physiology of the 
 
 Upper Air- Passages 17 
 
 CHAPTER II. 
 
 General Etiology and Hygiene of Nasal and Pharyngeal Diseases ... 40 
 
 CHAPTER III. 
 
 Symptomatology; Methods of Examination and Appearances of Nose and 
 
 Pharynx ; Methods of Treatment in Nasal and Pharyngeal Affections . 51 
 
 CHAPTER IV. 
 Diseases of the Vestibule of the Nose ; Coryza 85 
 
 CHAPTER V. 
 Chronic Nasal Inflammations; "Chronic Catarrh"; Chronic Purulent 
 
 Rhinitis 92 
 
 CHAPTER VI. 
 Diseases of the Nasal Accessory Cavities loo 
 
 CHAPTER VII. 
 Diseases of the Maxillary Sinus 125 
 
 CHAPTER VIII. 
 Diseases of the Frontal Sinus, Ethmoid Cells, and Sphenoid Sinus . . . 137 
 
 CHAPTER IX. 
 
 Ozena (Fetid Atrophic Rhinitis) ; Simple Atrophic Rhinitis 155 
 
 11
 
 1 2 CONTENTS. 
 
 CHAPTER X. 
 
 PAGE 
 
 Anterior Dry Rhinitis ; Perforating Ulcer of the Septum ; Hematoma and 
 
 Abscess of the Septum ; Membranous and Diphtheritic Rhinitis . . 163 
 
 CHAPTER XI. 
 Enlargement of the Cavernous Tissue (Irritable Nose Coryza Vasomo- 
 
 toria) 168 
 
 CHAPTER XII. 
 Retronasal Catarrh 174 
 
 CHAPTER XIII. 
 Simple Chronic Rhinitis; Hypertrophic Rhinitis 177 
 
 CHAPTER XIV. 
 Nasal Polypi ; Papillomatous Tumors 187 
 
 CHAPTER XV. 
 
 Nasal Stenosis ; Collapse of the Sides of the Nose ; Synechiae ; Occlusion 
 
 of the Posterior Choanse .... 194 
 
 CHAPTER XVI. 
 
 Anatomy of the Septum ; Deviation or Deflection of the Septum ; Lateral 
 
 Crests ; Deformity of Septum by Fracture 200 
 
 CHAPTER XVII. 
 Epistaxis ; Hydrorrhrea Nasalis 220 
 
 CHAPTER XVIII. 
 Anatomy of the Tonsils ; Acute Inflammation of the Pharynx and of the 
 
 Tonsils (Angina) 224 
 
 CHAPTER XIX. 
 Peritonsillar Abscess or Quinsy; Retropharyngeal Abscess , 234 
 
 CHAPTER XX. 
 
 Chronic Pharyngitis ; Chronic Tonsillitis (Pharyngomycosis ; Suppurative 
 
 Pharyngitis) 238 
 
 CHAPTER XXI. 
 
 Hypertrophy of the Pharyngeal Tonsil, or Adenoid Vegetations .... 249
 
 CONTENTS. 1 3 
 
 CHAPTER XXII. 
 
 PAGE 
 
 Hypertrophy of the Faucial Tonsils 264 
 
 CHAPTER XXIII. 
 Hay-fever Autumnal Catarrh 272 
 
 CHAPTER XXIV. 
 Diphtheria 279 
 
 CHAPTER XXV. 
 
 Syphilis of the Nose and Pharynx; Tuberculosis; Scrofula; Leprosy; 
 
 Rhinoscleroma 293 
 
 CHAPTER XXVI. 
 Affections of the Upper Air-Passages in the Course of other Diseases . . 308 
 
 CHAPTER XXVII. 
 
 Tumors of the Nose and Pharynx 313 
 
 CHAPTER XXVIII. 
 
 Foreign Bodies in the Upper Air- Passages ; Rhinoliths ; Animal Para- 
 sites ; Surgical Injuries and Fractures ; Cicatricial Contractions in 
 the Pharynx . 322 
 
 CHAPTER XXIX. 
 Influence of Nasal and Pharyngeal Affections upon Other Parts of the 
 
 Organism . . . .- 328 
 
 BOOK II. 
 DISEASES OF THE EAR. 
 
 CHAPTER XXX. 
 
 PAGE 
 
 Anatomy and Physiology of the Ear . . . v 345 
 
 CHAPTER XXXI. 
 General Etiology of Ear Disease 386 
 
 CHAPTER XXXII. 
 Subjective Symptoms and Methods of Examination and Treatment in Ear 
 
 Diseases 394
 
 14 CONTENTS. 
 
 CHAPTER XXXIII. 
 
 PAGE 
 
 Diseases of the External Ear (Othematdma ; Perichondritis; Eczema; 
 Diffuse Otitis Externa; Furuncles; Parasitic Inflammation of the 
 Meatus ; Wax and Epidermis Plugs) 415 
 
 CHAPTER XXXIV. 
 
 Diseases of the External Ear (Foreign Bodies; Operative Detachment 
 of the Auricle ; Tumors ; Stenosis of the Meatus ; Injuries ; Myrin- 
 gitis) 423 
 
 CHAPTER XXXV. 
 
 Diseases of the Middle Ear (Catarrh of the Eustachian Tube; Serous 
 
 Catarrh of the Middle Ear; Syphilitic Catarrh of the Middle Ear) . 429 
 
 CHAPTER XXXVI. 
 Adhesive or Proliferative Inflammation of the Middle Ear 442 
 
 CHAPTER XXXVII. 
 Operations for the Relief of Deafness due to Adhesive Processes in the 
 
 Middle Ear 453 
 
 CHAPTER XXXVIII. 
 
 "Sclerosis of the Middle Ear" (Rarefaction of the Capsule of the Laby- 
 rinth) ; Ankylosis of the Stapes 457 
 
 CHAPTER XXXIX. 
 
 Simple Otitis Media (Purulent Otitis Media without Perforation) .... 461 
 
 CHAPTER XL. 
 Acute Purulent Otitis Media (with Perforation of Drumhead) 465 
 
 CHAPTER XLI. 
 Mastoiditis . 476 
 
 CHAPTER XLII. 
 Chronic Purulent Otitis Media . 488 
 
 CHAPTER XLIII. 
 
 Local Complications of Chronic Purulent Otitis ( Polypi ; Caries and 
 Necrosis of the Bone ; Cholesteatoma ; Paralysis of the Facial 
 Nerve ; Tubercular Otitis) 505 
 
 CHAPTER XLIV. 
 Otalgia 512
 
 CONTENTS. 1 5 
 
 CHAPTER XLV. 
 
 PAGE 
 
 Pyogenic Extension of Otitis (Serous and Purulent Meningitis ; Phlebitis 
 and Thrombosis of the Lateral Sinus with Septicemia or Pyemia; 
 Subdural Abscess; Abscess of the Brain) 514 
 
 CHAPTER XLVI. 
 Diseases of the Internal Ear 526 
 
 CHAPTER XLVII. 
 Diseases of the Auditory Nerve (Anatomy of the Auditory Nerve) ; 
 
 Deaf-Mutism 535 
 
 INDEX. . 541
 
 BOOK I. 
 DISEASES 
 
 OF THE 
 
 NASAL PASSAGES AND PHARYNX. 
 
 CHAPTER I. 
 
 DEVELOPMENT, GENERAL DESCRIPTIVE ANATOMY, 
 AND PHYSIOLOGY OF THE UPPER AIR-PASSAGES. 
 
 i. Development of the Upper Air-passages. The 
 
 upper air-passages from nostril to larynx are developed 
 from three different starting-points during embryonic 
 formation. The nasal or olfactory fossae begin in the form 
 of two pits between and at the level of the embryonic 
 eyes. They are separated from each other by the rela- 
 tively very thick median frontal process, the lower curved 
 end of which becomes transformed into the upper lip. 
 Underneath this area the broad fissure constituting the 
 primitive mouth reaches at first inward only as far as 
 the closed anterior or ventral wall of the esophageal end 
 of the intestinal tract. The intestinal tube itself extends 
 in the form of a blind pouch up to the rear end of the 
 base of the skull. The subsequent coalescence of mouth 
 and esophageal pouch forms the pharynx. Meanwhile 
 the nasal fossae continue to grow inward and to elongate 
 downward. At this period they are but shallow longi- 
 tudinal fissures, opening merely in front. The external 
 nose covering the facial end of the nasal passages is a 
 product of a much later stage of fetal development. 
 The floor that separates the nasal fossae from the mouth 
 the primeval palate is the matrix of the intermaxillary 
 
 2 17
 
 iS THE UPPER AIR-PASSAGES. 
 
 bone, and has nothing to do with the subsequent true 
 palate. 
 
 In the next place the nasal pits perforate into the mouth. 
 For a time the nasal passages, separated from each other by 
 the thick septum, form one continuous space with mouth 
 and pharynx. A relatively rapid growth of the nasal 
 fissures takes place in the direction from the facial orifice 
 to the pharynx, while the median wall between the nasal 
 fissures is being prolonged by a downward growth of a 
 partition from the base of the skull as well as by the 
 elongation of the primitive septum. The final nasal 
 septum is thus formed from an anterior, as well as from 
 an upper rear starting-point. This double development 
 is indicated during subsequent life by separate arterial 
 and nervous supply of the front and posterior areas of the 
 median nasal wall. 
 
 From the matrix of the superior maxillary and palatal 
 bones transverse plates begin to grow, which, by joining 
 finally in the median line, form the palate and thus sep- 
 arate the nasal passages from the mouth. An arrest of 
 development of these plates constitutes the deformity 
 known as cleft palate. The orifices which remain at 
 the rear end of the nasal fissures after the completion 
 of the palate form the posterior choanse. 
 
 2. By the time the palatal plates have united with each 
 other and with the buccal edge of the nasal septum each 
 nasal passage has become surrounded with a cartilaginous 
 capsule, of which the portion common to both sides is 
 formed by the cartilaginous plate in the septum. On the 
 external wall of each nasal passage a series of ridges, 
 usually six in number, but with accessory extensions, 
 now develop in the lining, which is transformed grad- 
 ually into mucous membrane. The ridges, curved with 
 the convexity downward, converge from the front and 
 the roof of the nose toward the posterior choauae. As 
 these ridges change into projecting crests, cartilaginous 
 lamellae, more or less curved, develop in them and form 
 the turbinal processes, or conchse. In man but two of
 
 DEVELOPMENT OF THE UPPER AIR-PASSAGES. 19 
 
 these projecting lamellae retain a pronounced prominence 
 the inferior and the middle turbinal. The others 
 viz., the two below the middle turbinal (the ethmoid 
 bulla and the uiicinate process), as well as all above the 
 middle turbinal (the ethmoturbinals) recede relatively 
 in development, become more or less curved upon them- 
 selves, and coalesce to some extent. The space between 
 the septum and the turbinal processes represents, finally, 
 the olfactory fissure and the nasal passage proper, whereas 
 the spaces included between the coalesced turbinal pro- 
 cesses develop into the accessory cavities or nasal sinuses. 
 The formation of the ethmoid cells is thus a relatively 
 simple inclusion, while the frontal and maxillary si- 
 nuses grow by further extension into the corresponding 
 bones. The sphenoid sinus, however, represents really 
 the posterior (upper) portion of the nasal passage itself, 
 shut off by accessory turbinal partitions. It is only after 
 birth that these temporary walls around the sphenoid 
 sinus atrophy and leave the cavity surrounded by its per- 
 manent bony capsule, formed by the body of the sphenoid 
 bone. 
 
 3. The infantile nasal passage differs from the fully de- 
 veloped cavity not alone in its absolute, but also in its 
 relative, dimensions. The olfactory area, or, more prop- 
 erly defined, the region bounded by the ethmoid bone, is 
 developed during fetal life more fully than the lower or 
 respiratory channel outlined by the maxillary and palatal 
 bones. The subsequent growth in the vertical height 
 of the nose hence depends mostly on the,postnatal elonga- 
 tion of the superior maxilla. The nasal passage of the infant 
 is relatively very narrow, although the extreme width of 
 the fetal septum has become reduced at birth to the pro- 
 portion maintained during adult life. The inferior tur- 
 binal is, however, so close to the floor and relatively so 
 broad that the inferior nasal meatus is scarcely apparent 
 until about the third year; hence inflammatory swelling 
 during acute coryza is more serious in babes than in later 
 life.
 
 2O THE UPPER AIR-PASSAGES. 
 
 Growth also occurs in the sagittal direction. Until 
 the sixth year the transverse plane of the posterior 
 choanse corresponds to the level of the infantile molar 
 tooth (second bicuspid of the adult). In the course of the 
 second dentition the palate, and with it the nasal walls, 
 elongate so that finally the choanae lie in a plane with 
 the third molar teeth. The accessory sinuses are all 
 relatively very small and imperfectly developed at birth. 
 Their growth is slow until after the second dentition. 
 
 The pharynx at birth is about one-half the size of the 
 adult cavity, except in its width, it being rather more 
 than one-half as wide. The growth of the maxilla and 
 the vertical plate of the palatal bones causes a gradual 
 displacement of the pharyngeal orifices of the Eustachian 
 tubes relative to the floor of the nose. These orifices, 
 situated below the palate in the fetus, reach the level of 
 the palate at birth and ascend, until the eighth year, to 
 the height of the rear end of the inferior turbinal. 
 
 4. General Descriptive Anatomy. The Nasal Cav- 
 ity. The gateway to the nasal cavity is the pyriform 
 aperture, bounded above by the nasal bones, on the 
 sides and below by the edge of the superior maxillary 
 bones. The intermaxillary portion of the latter forms 
 a sharp-pointed median crest the anterior nasal spine. 
 The bridge of the nose is built up by the nasal process of 
 the frontal bone, the frontal process of the superior max- 
 illa, and the two nasal bones joined in the median line, 
 while on the internal side of this junction the nasal sep- 
 tum is inserted. . The relative extent of cartilaginous 
 portion of the septum and bony portion (perpendicular 
 plate of the ethmoid) participating in this articulation 
 varies considerably in different subjects. The shape and 
 strength of the bridge of the nose protect the septum 
 against traumatic fracture from a blow unless this be 
 sufficiently intense to fracture the bridge itself. The shape 
 and prominence of the nasal bones are pronounced racial 
 characteristics. By its protruding nasal bridge the Cau- 
 casian skull can be distinguished from that of other races.
 
 GENERAL DESCRIPTIVE ANATOMY. 
 
 21 
 
 Below the nasal bones the external nose has a cartilaei- 
 
 o 
 
 nous framework (Fig. i). The septal or quadrangular 
 cartilage gives off two approxi- 
 mately triangular wings, the tri- 
 angular cartilages, which, forming 
 the - middle part of the side of the 
 nose, adjoin the lower edge of the 
 nasal bones, but overlap them on 
 their internal side. Below this 
 level the cartilaginous septum does 
 not reach to the tip of the nose, 
 the gap in the partition wall being 
 completed by the movable mem- 
 branous septum. The lower part 
 of the nasal side contains the two 
 cartilages of the nasal wing, each 
 a thin plate reaching from the tri- the external nose after re- 
 angular cartilage to the tip and movin s the skin ' showing 
 curved anteriorly so as to insert its 
 ' ' doubled ' ' median border into the 
 membranous septum. In the nasal 
 wing this cartilage is fragmented vertically, thereby 
 
 FIG. I. Front view of 
 
 the nasal bones, quadran- 
 gular and triangular carti- 
 lages (Zuckerkandl). 
 
 FIG. 2. View of the nasal vestibule from below, showing the prominence of 
 the fold (Zuckerkandl). 
 
 giving the nose flexibility. The triangular cartilage 
 overlaps the lower cartilage likewise on the internal side,
 
 22 THE UPPER AIR-PASSAGES. 
 
 and its prominent border appears as a projecting, hori- 
 zontal fold, the plica vestibuli, which may be considered 
 as the threshold of the nasal cavity, the space outside 
 being the vestibule (Fig. 2). 
 
 The external skin lines the vestibule and changes 
 gradually into mucous membrane at about the level of 
 the protruding fold. As far as there is true skin the 
 vestibule is protected against insects by coarse hairs 
 the vibrissas. The external muscles surrounding the 
 sides of the nose dilate the nostrils, while their relaxa- 
 tion results in collapse of the sides of the nose, variable 
 with its degree of flexibility. The muscles are inner- 
 vated by the facial nerve. 
 
 5. The nasal cavities are surrounded entirely by bony 
 walls, but are separated from each other by the septum, 
 which in its front portion remains cartilaginous. The 
 floor of the nose is made up of the palatal process of 
 the superior maxillary and the horizontal plates of the 
 palate bones. It is a level, shallow gutter. The floor is 
 the shortest of all the nasal walls, as the rear edge of the 
 middle wall slopes backward and upward, besides being 
 slightly concave toward the rear. As the free border of 
 the septum determines the plane of the nasal opening 
 into the pharynx, all nasal walls exceed the floor in 
 length. 
 
 The middle wall or septum presents normally a nearly 
 plane surface. The anatomic peculiarities of this wall 
 will be considered in Chapter XVI. 
 
 The roof, completed in front by the awning of the 
 nasal bones, consists of the cribriform plate of the 
 ethmoid bone anteriorly, and of the body of the sphe- 
 noid bone in its posterior half. The ethmoid plate is the 
 weakest part. The anterior surface of the sphenoid 
 body slopes down and backward, while the inferior sur- 
 face of this bone has, likewise, a slight slant toward the 
 rear and down. The nasal space is hence considerably 
 lower in the rear than in front (Fig. 3).
 
 GENERAL DESCRIPTIVE ANATOMY. 23 
 
 The external wall, the most complicated of all, is 
 formed by three bones. The greater area below the 
 floor of the orbit consists of the nasal surface of the 
 superior maxilla, separating the nasal cavity from the 
 maxillary sinus. From this there extends upward the 
 narrow frontal process of the maxillary bone, which 
 articulates posteriorly with the lamina papyracea of the 
 
 FIG. 3. View of the external wall of the right nasal passage, with probes in 
 the sphenoid sinus and in the nasal duct (Mihalkovics). 
 
 ethmoid bone, forming the partition wall between the 
 orbit and the upper part of nose. At its rear edge the 
 lamina papyracea joins the anterior surface of the sphe- 
 noid body, which, by its presence, reduces the height of 
 the nasal passage. Below the sphenoid bone and poste- 
 rior to the superior maxilla the external wall consists of 
 the vertical plate of the palate bone.
 
 2 4 
 
 THE UPPER AIR-PASSAGES. 
 
 The space inclosed by the nasal walls is approximately 
 rectangular, but is encroached upon in such a manner by- 
 accessory bony structures, arising from the external wall, 
 that each nasal cavity proper is reduced to a nearly tri- 
 angular cross-section with a roof only 2 or 3 mm. wide, 
 while near the floor each side is from 12 to 18 mm. wide. 
 
 The bony ledges, which thus reduce the width of the 
 
 FIG. 4. Frontal section through the nasal passages at the level of the 
 orifice of the maxillary sinus. Anterior half seen from the rear : p, p, Uncinate 
 process and, external to it, the hiatus semilunaris ; c, anterior half of maxillary 
 orifice; d, infundibulum ; /, /, lamina papyracea (Zuckerkandl). 
 
 nasal passage, are the turbinate processes or turbinals (or 
 conchae). During embryonic formation there are six 
 main turbinal ledges or projecting lamellae, with a varia- 
 ble number of minor shelves between them. They 
 follow a curve with its convexity downward and forward, 
 and converge toward the posterior choanae. By coales- 
 cence and partial arrest of development the number of 
 turbinal ledges becomes reduced, so that at birth there
 
 GENERAL DESCRIPTIVE ANATOMY. 25 
 
 are but four or five. The inferior turbinal is a separate 
 bone a thin lamina in the form of a curved, overhang- 
 ing ledge, a short distance above the floor, which begins 
 within i cm. behind the pyriform aperture and ends in 
 the plane of the posterior choanae, where its end is 
 slightly rolled upon itself. It articulates with superior 
 maxilla, palate bone, and lamina papyracea of the eth- 
 
 FIG. 5. Frontal section through the rear part of the nasal passages: A, 
 Roof; B, floor; /, external wall of nasal passages; C, C, alveolar process, high 
 and spongy ; a, a, a, the three nasal meati ; b, b, middle turbinal ; c, olfactory 
 fissure; d, respiratory fissure (Zuckerkandl). 
 
 moid. The space underneath it is the lower meatus ; the 
 channel above it, the middle nasal meatus. The other 
 turbinal processes are part of the ethmoid papyraceous 
 plate. Of these, the middle turbinal is the most inde- 
 pendent. It conforms, on the whole, with the shape and 
 inclination of the inferior concha, begins about i cm. 
 posterior to the front end of the latter, ending like the
 
 26 
 
 THE UPPER AIR-PASSAGES. 
 
 latter in the plane of the posterior choanse with a similar 
 rolled end. In the living, no structure above the middle 
 ttirbinal can be recognized. Dissection, however, shows 
 one well-defined, though smaller, turbinal process above 
 the middle concha, and above this usually at least one, 
 sometimes two, smaller bony turbinal folds. All these 
 structures are lined with mucous membrane. 
 
 The narrow chink between the nasal septum and the 
 
 FIG. 6. Frontal section through the rear part of the nnsal passages, show- 
 ing the anterior surface of the sphenoid. Through the posterior choanae a view 
 is had of the nasopharynx : O, Roof; a, anterior surface of the sphenoid bone; 
 
 b, b, depression between the anterior and posterior folds of the upper nasal wall ; 
 
 c, c, anterior fold, d, posterior fold, of the upper nasal wall ; e, spheno-ethmoid 
 recess; yj'orifice of sphenoid sinus; t, Eustachian prominence; p,f, pharyngeal 
 tonsil (Zuckerkandl). 
 
 turbinal surfaces above the middle turbinal is the olfac- 
 tory fissure in which the nerves of smell spread out in 
 the mucous membrane. Between the middle and the 
 upper turbinals and the external wall of the nasal cavity 
 are the ethmoid cells, the spaces confined by the deviated 
 and partially coalesced turbinal processes and accessory 
 septa. These are a series of more or less communicating 
 cells lined by mucous membrane with orifices into the 
 nasal passage (see 1 43). Beneath the front end of the
 
 THE PHARYNX. 2"J 
 
 middle turbinal are the openings leading into the frontal 
 and maxillary sinuses. The sphenoid sinus communi- 
 cates with the nasal space through a slit in the anterior 
 sphenoid wall. The only other channel connected with 
 the nose is the lacrimal duct, which empties under the 
 external side of the inferior turbinal, close to its front 
 end. 
 
 The nasal passages connect with the pharynx through 
 the posterior choanae. These openings, each of oval 
 shape, are separated by the posterior border of the vomer, 
 and are bounded above by the lower surface of the sphe- 
 noid ; externally and below, by the palate bones. Their 
 plane is not quite vertical, but slants slightly downward 
 and forward (Fig. 6). 
 
 6. The pharynx may be described as a somewhat flat- 
 tened tube, increasing in width from above downward, 
 the posterior wall of which curves over to form the half- 
 dome-shaped roof. This roof is level with and contin- 
 uous with the roof of the nasal chambers. The main 
 tunic of the pharynx is a fascia, the shape of which is 
 best described by its attachments. The periosteum lining 
 the inferior surface of the occipital bone is thickened in 
 the form of a firm plate, termed basilar fibrocartilage. 
 From this fibrocartilage, and as a part of it, the pharyn- 
 geal fascia extends downward, being fastened to the 
 slightly protruding body of the atlas, while below the 
 atlas it is separated from the vertebral bodies by loose 
 areolar tissue. Laterally, the curve of the pharyngeal 
 roof extends over to the edge of the inferior surface of 
 the petrous pyramids of the temporal bones, to which 
 the fascia is fastened, and from which it descends. In 
 front the fascia gliding over the short exposed (rear) area 
 of the lower sphenoid surface adheres firmly to the bony 
 rim of the choanae, and thence passes transversely to the 
 inferior maxilla, where it ends anteriorly. The sides 
 and posterior wall of the pharynx are completely sur- 
 rounded by the fascia, which thence continues down- 
 ward as a lamella of the cervical fascia. The pharynx
 
 28 THE UPPER AIR-PASSAGES. 
 
 proper ends at the level between the fifth and the 
 sixth cervical vertebra. The pharyngeal fascia is lined 
 throughout with mucous membrane, and is surrounded 
 below the atlas by the constrictor muscles of the pharynx. 
 
 From the foregoing description it is apparent that the 
 pharynx has no real anterior wall. Below its roof are the 
 nasal openings. Between the nasal passages and the 
 cavity of the mouth is the bony palate, the plane of 
 which is prolonged by the soft palate. The latter is a 
 muscular diaphragm lined by nasal mucous membrane 
 on its upper, and by buccal mucous membrane on its 
 under surface. The muscular fibers converge into the 
 palate from the base of the skull, rim of the choanae, 
 and pharyngeal walls, and end in a tendinous aponeurosis 
 inserted into the rear border of the bony palate. The 
 free posterior border of the soft palate is concave, but 
 with a pendant tongue-shaped prolongation from its 
 center the uvula. Inspection shows that on each side 
 of the uvula there arises a fold or ridge in the mucous 
 membrane of the palate, parallel with the posterior free 
 border, running transversely to the insertion of the palate 
 at the roof of the mouth. There the posterior palatal 
 border continues downward in the form of another fold 
 of mucous membrane running down and somewhat back- 
 ward, the posterior pillar of the fauces, while the 
 aforesaid palatal ridge descends on the side of the mouth 
 as the anterior pillar down to the root of the tongue. By 
 the divergence of the pillars a niche is formed for the 
 tonsil. During the act of swallowing and gagging the 
 faucial pillars protrude in the form of a well-defined 
 septa under the constricting influence of the muscles ex- 
 ternal to the mucous membrane. During such move- 
 ments the palate is stretched tense and maintained in the 
 horizontal plane, so as to separate the nasal from the oral 
 part of the pharynx. When relaxed, however, during 
 rest, the rear part of the palate curves downward. 
 
 In the triangular niche between the faucial pillars, 
 normally quite shallow, lies the tonsil. The normal tonsil
 
 MEMBRANOUS LINING OF THE RESPIRATORY PASSAGE. 29 
 
 is a thin cushion of adenoid tissue in the substance of the 
 mucous membrane. In our climate it is more often seen 
 morbidly enlarged than normal. Across the base of the 
 tongue there stretches a bridge of adenoid tissue from 
 one tonsil to the other the lingual tonsil. The (incom- 
 plete) ring of lymphatic tissue in the pharynx surround- 
 ing the buccal opening is completed by a cushion of 
 adenoid tissue in the mucous membrane at the roof, im- 
 mediately behind the choanse the pharyngeal tonsil. 
 
 The cartilaginous portion of the Eustachian tubes lies 
 underneath the lateral walls of the pharynx, outside of 
 the fascia. As these tubes expand in passing forward, 
 downward, and slightly inward, the side of the pharynx 
 is made to bulge inward in the form of a flattened eleva- 
 tion. In front of this tumefaction, at the level and back 
 of the end of the inferior turbinal, is the Eustachian 
 orifice. By reason of the divergence of the anterior and 
 posterior lips of the Eustachian orifice the pharyngeal 
 end of the tube appears as an irregular triangle of a yel- 
 lowish-white color. The (variable) prominence of the 
 Eustachian tube forms a recess at what might be called 
 the junction of the lateral wall of the pharynx with the 
 superoposterior wall the fossa of Kosenmuller. This re- 
 cess becomes shallower downward and ceases just above 
 the level of the palate. 
 
 The caliber of the pharynx is, of course, influenced by 
 movements of the head. When the head is inclined 
 backward, the distance between the palate and posterior 
 wall is lengthened, whereas by depression of the head it 
 is shortened. When the head is turned to the side by 
 rotation upon the axis (second vertebra), torsion of the 
 pharynx, which is observable through the mouth, results. 
 
 7. The Membranous Lining of the Respiratory Passage. 
 The entire respiratory passage is lined by a continuous 
 mucous membrane, which extends into all communicat- 
 ing passages and sinuses. In the nose it is thickest over 
 the inferior turbinal, becoming thinner in the higher re- 
 gions and still more reduced in the pneumatic cells and
 
 3<D THE UPPER AIR-PASSAGES. 
 
 accessory sinuses. Close examination shows a some- 
 what uneven surface of the nasal mucous membrane, 
 with minute ridges and furrows and miniature wart-like 
 elevations. This unevenness of the surface is often 
 grossly exaggerated in inflammatory hypertrophy. In 
 the pharynx the mucous membrane is smoother but 
 thicker ; it is especially massive, however, where it is in- 
 filtrated with adenoid tissue so as to form the different 
 tonsils. In the nose and accessory cavities the mucous 
 membrane is inseparable from the periosteum. The tran- 
 sition from skin to mucous membrane begins at about 
 the level of the projecting fold in the vestibule. Beyond 
 this threshold, throughout the nose and pharynx, the 
 membrane contains an abundance of branched tubular 
 mucous glands; in the nasal sinuses, however, the glands 
 are few in number. The surface epithelium consists 
 of stratified cylindric cells, of which those on the free 
 surface are ciliated. Interspersed are mucus-forming 
 "beaker cells." In the pharynx, at about the level 
 of the second vertebra, the epithelium changes into 
 stratified pavement epithelium. The epithelial cells in 
 the interior of the mucous glands are cuboid. 
 
 In the upper nasal region, which contains the nerves 
 of smell, the structure of the lining membrane, and also 
 of its epithelium, is peculiar. This area extends over the 
 nasal surfaces above the middle turbinal and anterior to 
 the sphenoid sinus, both on the septum and on the sur- 
 face of the upper turbinal processes. Here the epithelial 
 cells form large cylinders, not ciliated in the ordinary 
 sense, but presenting a few coarse, hair-like "cilia," 
 non-motile, but presumably the specific end-organs of the 
 olfactory nerve. 
 
 Underneath the epithelium there is a well-defined 
 structureless basement membrane, with a multitude of 
 tubular perforations, which are probably the inlets (or 
 outlets?) of the lymphatic system. The substance of the 
 mucous membrane consists of a connective-tissue stroma 
 with elastic fibers. Both connective-tissue and elastic
 
 MEMBRANOUS LINING OF THE RESPIRATORY PASSAGE. 3! 
 
 
 B 
 
 FIG. 7. Histologic structure of the mucous membrane over the inferior 
 turhinal : a, Ciliated cylindric epithelium ; Abasement membrane; c, adenoid 
 layer ; f, follicle ; p, elastic layer of periosteum ; pc, cellular layer of periosteum ; 
 , bone. 
 
 fibers are more or less continuous with the periosteum 
 over the bony walls, with the perichondrmm over the 
 cartilaginous part of the septum, and with the pharyn-
 
 32 THE UPPER AIR-PASSAGES. 
 
 geal fascia. Where the surface is plane in the nose the 
 mucous membrane is easily detached, but wherever there 
 are bony crests or sharp angles it adheres firmly to the 
 underlying structure, as it does also in the entire phar- 
 ynx. Along the turbinals, most noticeably the middle 
 turbinal, the stroma dips into the smaller cellular spaces 
 of the spongy bone and assumes a medullary structure 
 with the presence of fat-cells. All larger bone-cells, how- 
 ever, are lined by very thin mucous membrane and 
 epithelium. 
 
 Underneath the epithelium the stroma presents a uni- 
 form infiltration with lymphoid cells throughout its en- 
 tire extent. These round cells are migratory, and are 
 found penetrating into the epithelial layer. This is par- 
 ticularly the case in the region of the pharyngeal tonsil, 
 where the epithelium is crowded with lymph-cells. The 
 tonsils themselves (pharyngeal, faucial, and lingual) con- 
 sist of lymphoid cells arranged in the form of follicles, 
 with incomplete connective-tissue capsules in the sub- 
 stance of the mucous membrane. 
 
 8. The Vascular Supply of the Upper Respiratory Tract. 
 The whole lining of the respiratory tract is exceedingly 
 vascular. The capillaries are arranged in three layers 
 a deep stratum close t6 the periosteum, a coil of capil- 
 laries around the glands, and an extensive network in 
 the superficial adenoid stratum. Most peculiar, however, 
 is the arrangement of the veins. Throughout the entire 
 mucous membrane there is a dense network of veins with 
 small meshes, the caliber of the vessels increasing in 
 proportion to the distance of the vessels from the surface. 
 The thickness of the mucous membrane depends largely 
 on the development of the venous plexus. In several 
 areas in the nose viz., at the anterior end of the in- 
 ferior turbinal, along the margin of the middle turbinal, 
 at the rear ends of both inferior and middle turbinals, 
 and to a less extent over the tuberctilum of the septum 
 the venous plexus changes into true cavernous tissue. 
 The vessels are relatively large, compared with the inter-
 
 VASCULAR SUPPLY OF THE UPPER RESPIRATORY TRACT. 33 
 
 FIG. 8. Cross-section through the mucous membrane of inferior turbinal 
 (posterior end) (Hartnack Obj. 4, Oc. 2). The glandular vessels in exag- 
 gerated magnification : a, a, Subepithelial layer with cortical vessels ; b, the lacu- 
 nar part of the cavernous body with arteries verging toward the subepithelial 
 layer (Zuckerkandl). 
 
 
 FIG. 9. Cavernous tissue of the inferior 
 turbinal after removing the superficial layer 
 of mucous membrane. The interior of the 
 vessels is shaded (Zuckerkandl). 
 3 
 
 FIG. 10. Cast of the venous 
 plexus over the inferior tur- 
 binal : corrosion specimen 
 (Zuckerkandl).
 
 34 THE UPPER AIR-PASSAGES. 
 
 spaces between them; but, on the other hand, they are 
 individually short, on account of their fusion to form a 
 network, and they present an enormous development of 
 the muscular tunic not found in ordinary veins. When 
 not artificially injected, these veins show an irregular 
 puckered cross-section. The density of the venous net- 
 work can be observed best in a corrosion specimen. 
 These veins are fed only through the capillaries, and do 
 not communicate directly with arteries. The thickness 
 of the mucous membrane changes within wide limits, ac- 
 cording to the degree of turgescence or collapse of the 
 cavernous plexus. 
 
 The efferent veins of the nose are not large, but they 
 are numerous. They emerge partly into the orbit 
 through the ethmoid plate, into the cranial cavity, into 
 the palate, and to some extent into the sides of the phar- 
 ynx. Larger veins form a plexus around the pharynx 
 external to the mucous membrane, and empty into the 
 internal jugular vein. 
 
 The arteries of the nose and pharynx are likewise not 
 large. The sphenopalatiue artery, a branch of the in- 
 ternal maxillary, supplies the nose from the rear, emerg- 
 ing from the sphenopalatine fossa, and sends branches to 
 both external wall and septum. A collateral supply is 
 likewise obtained from the ethmoid and external nasal 
 arteries. 
 
 The pharynx derives its blood supply mainly from the 
 ascending pharyngeal artery, which ascends along, but 
 outside of, the lateral pharyngeal wall, enters at the roof, 
 and sends branches in all directions. There is, besides, 
 free communication with all adjoining arteries. The in- 
 ternal carotid artery and internal jugular vein run par- 
 allel to "the lateral pharyngeal wall, but are separated 
 from the pharyngeal fascia by a layer of loose areolar 
 tissue over a centimeter in width. Hence they are not 
 endangered by ordinary pharyngeal operations. 
 
 The lymph-vessels form a close network in the sub- 
 stance of the mucous membrane, and empty through
 
 PHYSIOLOGY OF THE UPPER RESPIRATORY PASSAGES. 35 
 
 channels in the soft palate and pharyngeal walls into 
 the cervical lymph-passages and glands. In animals a 
 communication has been shown between the subarach- 
 noid spaces and the nasal lymph-channels. In man this 
 connection has not been demonstrated. Injection of the 
 lymph-vessels allows the fluid to escape through the 
 tubular perforations in the basement membrane into the 
 epithelial layer, even up to the free surface. 
 
 9. The Nerve Supply of the Upper Respiratory Tract. 
 The specific nerve of smell is the olfactory nerve, which 
 sends its branches through perforations in the lamina 
 cribrosa in two rows, of which the inner row descends 
 along the septum, whereas the outer spreads over the ex- 
 ternal wall as far as the attachment of the middle tur- 
 binal. The nerves of ordinary sensation of the nose are 
 branches of the fifth nerve. The embryonic formation 
 of the septum and, to a certain extent, of the nasal 
 walls from two distinct areas of development accounts 
 for the peculiar double supply of nerve-fibers. A branch 
 of the first division of the fifth nerve the ethmoid 
 enters the nose through the ethmoid canal and supplies 
 the anterior area of the septum and the external wall. 
 The entire rear region, however, derives its fibers the 
 postnasal nerves from the second division of the tri- 
 geminus. These fibers, coming from Meckel's ganglion, 
 enter above and posteriorly from the sphenopalatine fossa. 
 The pharynx receives its sensory fibers from the pharyn- 
 geal plexus, which is made up of branches from the 
 vagus, spinal accessory, and glossopharyngeal nerves. 
 This plexus supplies also motor nerves to the pharyngeal 
 and palatal muscles, except the tensor palati muscle, 
 which is innervated by the internal pterygoid branch of 
 the trigeminus. The muscles of the external nose, which 
 dilate the nostrils, are tinder the control of the facial 
 nerve. 
 
 10. Physiology of the Upper Respiratory Passages. 
 The nasal passage fulfils a double purpose. It contains 
 the organ of smell, and it serves as the main channel for
 
 36 THE UPPER AIR-PASSAGES. 
 
 the entrance and exit of air in breathing. The olfactory 
 nerve-ends ramify over a much smaller area in man than 
 in most of the lower animals, and the sense of smell is 
 correspondingly less highly developed and of smaller im- 
 portance in man. The olfactory area in the human 
 being is limited to the surface of the septum and the ex- 
 ternal wall, above the middle turbinal and anterior to the 
 sphenoid bone. The current of air bearing odoriferous 
 particles or vapor enters the narrow olfactory chink 
 during ordinary inspiration, but it is directed thither 
 more forcibly during sniffling, short, abruptly ending 
 inspirations, which creates eddies in the intranasal air- 
 current and thus favors diffusion. The expired air does 
 not enter the olfactory fissure on account of the configura- 
 tion of the posterior choanse. For this reason odors 
 arising from the presence of decomposed secretions in the 
 throat and nose are not perceptible to the patient himself. 
 Inflammatory swelling leads readily to occlusion of the 
 olfactory chink, thereby abolishing the sense of smell 
 temporarily. To what extent the nerves of smell and 
 their terminal epithelia suffer permanently in various 
 nasal diseases has never been determined. 
 
 By reason of the shape of the vestibule, the current of 
 air during inspiration is directed somewhat upward, and 
 describes a curved path mainly through the middle 
 meatus to the posterior choanae. Eddies are produced in 
 the air-current on account of the various irregularities of 
 the intranasal surfaces, and this rotary motion favors per- 
 meation of all recesses by the moving air. In its passage 
 through the nose the air undergoes three changes: It is 
 warmed nearly to the body-temperature, is saturated with 
 aqueous vapor, and is partially freed from dust. This in- 
 fluence upon the inspired air is due to the large expanse 
 of nasal surface and its high degree of vascularity. The 
 absolute amount of warmth imparted to the air depends, 
 of course, upon its previous temperature. The quantity 
 of moisture lost by the nose varies likewise with the 
 atmospheric conditions. The saturation of the inspired
 
 PHYSIOLOGY OF THE UPPER RESPIRATORY PASSAGES. 37 
 
 relatively dry air of a winter's day requires about 30 grains 
 of water an hour. This high figure would naturally be 
 much reduced on warm days or in moist weather. The 
 deposition of dust is favored, no doubt, by the vestibular 
 hairs, but depends mostly on the convolutions of the 
 moist surface over which it passes. This clearing of the 
 air is not, however, absolute, and the filtering mechanism 
 proves insufficient when the air is unusually dusty. The 
 deposited dust containing living germs is expelled from 
 the nose by the pushing motion of the epithelial cilia, 
 which wave in the direction toward the anterior nares. 
 Experimentation, has shown that in spite of the micro- 
 scopic dimensions, the energy of the ciliary motion is 
 quite considerable, on account of the rapidity of the 
 vibrations. Various observers have found that the inter- 
 nasal surfaces harbor remarkably few bacteria, although 
 every breath of air deposits its living dust. It has been 
 claimed, but has not been definitely proved, that the 
 nasal mucus possesses some bactericidal properties. The 
 surface, to the depth of the cilia on the epithelial cells, 
 is continuously bathed by a layer of mucus, but during 
 health there is never sufficient secretion to flow along or 
 accumulate on the surface except momentarily in re- 
 sponse to irritation. This statement applies equally to 
 the pharyngeal lining. 
 
 Narrowness of one side of the nose does not interfere 
 with ordinary breathing if compensated for by sufficient 
 width of the other side. It makes the subject, how- 
 ever, short-winded on exertion. But if both nasal pas- 
 sages are insufficient, a reflex mechanism enforces open- 
 ing of the mouth and mouth-breathing results. In its 
 passage through the mouth the air is not warmed, 
 moistened, nor clarified to the same extent as occurs in 
 nasal breathing. Although it cannot be said that cool, 
 relatively dry or dusty air is directly a cause of disease of 
 the lower air-passages, it undoubtedly exercises an un- 
 favorable effect that may aid other disease-producing 
 influences. In nurslings the mechanism of mouth-
 
 3o THE UPPER AIR-PASSAGES. 
 
 breathing is not yet fully established, and hence nasal 
 obstruction is more distressing to them, especially during 
 nursing. 
 
 The soft palate acts, as a triple valve between nose, 
 pharynx, and mouth. When its muscles are at rest there 
 is free communication between these three spaces. 
 During the act of swallowing likewise gagging and 
 retching the nasal part of the pharynx is shut off from 
 the lower region. The palate is stretched horizontally 
 and is tense, the posterior pillars are changed into pro- 
 jecting septa applied against the posterior wall, while 
 the constrictor muscles of the pharynx narrow its caliber 
 and cause its posterior wall to touch the edge of the 
 palate. When this mechanism is viewed from above 
 through the nasal passage, widened by any destructive 
 disease, the pharyngeal wall appears constricted in a 
 ridge meeting the elevated palate. This protrusion, due 
 to the action of the constrictor muscles, is known as 
 Passavant's ridge. Incidentally the levator and tensor 
 palati muscles cause the Eustachian orifice to gape 
 during their contraction in swallowing. When the 
 palatal muscles are paralyzed, as in postdiphtheritic pa- 
 ralysis, the closure of the nasopharynx is incomplete and 
 food and fluids find their way into the nose. If nasal 
 breathing is to continue while the mouth is open, the air 
 is kept out of the mouth by elevation of the base of the 
 tongue, while slight tension of the muscular fibers in the 
 anterior faucial pillars pulls the pendant palate against 
 the tongue. 
 
 During speech the palate is in a variable state of 
 activity. Pure vowels are produced only when the air 
 passes through the mouth and the palate is partially 
 raised. If a part of the air passes into the nose, the 
 vowel has a nasal twang. The most pronounced nasal 
 sound, "ng," occurs during absolute relaxation of 
 the palate. The position of the palate varies with the 
 different consonants. A very sensitive test to detect the 
 passage of air through the nose during intonation is
 
 PHYSIOLOGY OF THE UPPER RESPIRATORY PASSAGES. 39 
 
 furnished by a cold mirror held in front of the nostril, 
 upon which the expired air will deposit its moisture. 
 
 II. The nasal membrane is very sensitive to touch, 
 although deep incisions produce only moderate pain. 
 The nasal sensitiveness resists anesthetics to such an ex- 
 tent that tickling of the inside of the nose with a feather 
 is sometimes of service in impending failure of respiration 
 during narcosis. Nasal irritation, mechanical or chemical, 
 results in sneezing and the free flow of a thin, mucous 
 secretion. The surface of the pharynx is less acutely 
 sensitive than the nasal lining, and its mechanical irrita- 
 tion distresses mainly by reason of the reflex retching 
 movements that it calls forth. Mucous secretion from 
 the pharynx, brought on by irritation, is more viscid 
 than the nasal fluid.
 
 CHAPTER II. 
 
 GENERAL ETIOLOGY AND HYGIENE OF NASAL 
 AND PHARYNGEAL DISEASES. 
 
 12. Origin of Nasal and Pharyngeal Diseases. 
 
 Most nasal and pharyngeal affections are of inflammatory 
 origin, being due either to an acute or a chronic inflam- 
 matory lesion or to its consequences. Acute coryza, 
 either simple or as part of some infection (influenza, 
 measles), and the residual inflammatory processes that 
 may persist afterward, as well as hypertrophies thus pro- 
 duced, the involvement of the accessory cavities in the 
 course of a coryza or as part of some general affection, 
 and the various forms of inflammation and enlargement 
 of the pharyngeal lymphatic tissue are responsible for 
 most of the complaints referred to the nose and throat. 
 The parasites giving rise to these infections have been 
 only partly identified. The microbe of common coryza 
 has as yet escaped detection, although the history of the 
 disease leaves no reasonable doubt that it is of microbic 
 origin, while its frequency indicates the universal distri- 
 bution of the virus. It has, likewise, not been fully es- 
 tablished to what extent secondary infection with the 
 various familiar pathogenic microbes is responsible for 
 the prolongation of a coryza. In affections of the nasal- 
 sinuses the various forms of pyogenic bacteri'a staphy- 
 lococci, streptococci, pneumococci, diphtheria bacilli, coli- 
 bacilli, and others have been found. Tonsillitis is due 
 mostly to streptococci, occasionally to other forms. A 
 limited role is played by specific infection in the nose 
 and pharynx by the diphtheria bacillus, the bacillus tu- 
 berculosis, and the virus of syphilis. 
 
 13. "Colds." Of equal, if not of greater, clinical im- 
 
 40
 
 "COLDS." 41 
 
 portance than the identification of a parasite is the recog- 
 nition of the external and internal conditions which favor 
 or even determine infection. Of all influences, that of 
 "taking cold" is most often accused by the layman to 
 be the cause of nasopharyngeal disorders. Indeed, in 
 the mind of the laity the etiologic aspect has been so con- 
 founded with the pathology that most nasal and throat 
 diseases are commonly called "cold." This universal 
 belief is supported only to a very limited extent by tan- 
 gible evidence. 
 
 It is a matter of frequent observation that individuals 
 who have chronic affections and structural lesions in the 
 upper air-passages experience at times acute aggravations 
 within from twelve to twenty-four hours after a chilling 
 of part or the whole of the surface of the body. In some 
 instances it is prolonged chilling of the feet; in others, 
 the exposure of the head and shoulders to a draft, espe- 
 cially when these parts were previously warm. Some- 
 times, perhaps less often, it is the cooling of the entire 
 skin which apparently leads to an acute intensification 
 or extension of an existing inflammatory process of low 
 grade. The difficulty of investigating these occurrences 
 is very much increased by the fact that such exposure 
 is not always followed, by the same results, and that, on 
 the other hand, the history of exposure does not always 
 precede such exacerbations. Yet the significance of 
 exposiires of this kind is sometimes demonstrated by 
 the success with which patients evade these "colds" 
 after their attention has been called to the necessity for 
 better protection. Strongly suggestive, too, of the reality 
 of " taking cold" is the common experience that these 
 aggravations are least likely to occur under conditions of 
 equable weather for instance, in midsummer. It is not, 
 however, the constant cold of winter that experience has 
 shown to exert the most marked influence, but, rather, 
 the sudden thermometric changes in fall and spring, 
 especially when combined with humidity and chilling 
 winds. In this connection it is of interest to remember
 
 42 NASAL AND PHARYNGEAL DISEASES. 
 
 that various arctic explorers (Nordenskjold and Nansen) 
 have spoken of the noteworthy exemption of their crews 
 from "colds" while wintering in the far north. 
 
 All these observations confirm the view that chilling 
 of the skin can play an important role in intensifying 
 nasal and pharyngeal inflammations and causing their 
 extension at least when combined with other influences 
 the nature of which is as yet unknown. Whether, how- 
 ever, the act of "taking cold" can give rise to an in- 
 flammation in a nose or throat hitherto entirely normal is 
 an undecided problem. In most cases that belong to this 
 category a history of exposure cannot be obtained with 
 the definiteness requisite for scientific reasoning. Yet 
 the seasonable distribution of fresh attacks of coryza and 
 of tonsillitis lends some color to the view that they, too, 
 may result, under some circumstances, from "taking 
 colds." 
 
 It is probable that the mechanism of " taking cold " 
 consists, in part, in circulatory disturbances. In persons 
 in whom previous nasal disease has led to enlargement 
 of the cavernous venous tissue the influence of chilling 
 of the warm skin upon the intranasal circulation can be 
 studied advantageously. Under these circumstances ex- 
 posure immediately gives rise to a turgescence of the 
 nasal mucous membrane, usually with sneezing, and fol- 
 lowed by a watery discharge from the nose. As a rule, 
 these disturbances cease in a short time. It probably 
 requires the conjoint influence of other unknown factors, 
 together with chilling, in order to start or extend infec- 
 tion in the nose. 
 
 The Prevention of " Colds." In giving advice regard- 
 ing protection against "taking cold," it is necessary to 
 individualize. Cast-iron rules concerning clothing are 
 neither supported by experience nor are they likely to be 
 accepted by many patients. The most sensible plan is 
 simply to wear comfortable clothing suitable to the time 
 of the year and to be prepared for sudden changes in the 
 weather.
 
 COLDS. 43 
 
 The amount of clothing requisite for this purpose 
 varies with the vigor and habits of the individual. 
 Most persons are apt to be indifferent regarding chill- 
 ing of the feet; hence advice concerning woolen stock- 
 ings, heavier shoes, overgaiters, or rubbers is often fol- 
 lowed by benefit. 
 
 Cold feet are due, in some instances, to the evaporation 
 of a profuse perspiration. This can be controlled effec- 
 tually and permanently by a single foot-bath of a few 
 minutes' duration in a 5 per cent, solution of chromic 
 acid. On account of the possible poisonous effect of 
 chromic acid upon the kidneys the writer has limited the 
 application to one foot at a time, and has never had any 
 unpleasant results. Formalin in full strength will also 
 control excessive perspiration, but must be used re- 
 peatedly at intervals of weeks. When cold feet are due 
 merely to a poor cutaneous circulation, this can be 
 improved satisfactorily by the use of tincture of capsi- 
 cum as a foot-wash continued for days or weeks. Good 
 results are also obtainable by daily foot-baths, alternating 
 a few times between cold not cool and hot water, and 
 finishing with the latter. 
 
 Temperature of Dwellings. As the temperature of the 
 interior of houses is not much lower in winter than in 
 summer, it is wiser to adapt one's self for the cold out- 
 doors by wearing changeable outer garments rather than 
 by an excessive quantity of underclothing. Muffling of 
 the neck is often found to increase the liability to 
 "colds." 
 
 So far as it is possible, attempts should also be made 
 to regulate the temperature of the interior of dwellings, 
 avoiding both extremes, excessive heat and unpleasantly 
 low temperatures, and giving due regard to ventilation. 
 An unbiased observer can hardly escape the conclusion 
 that the popular fear of drafts does more damage to the 
 general health, by causing people to live and sleep in 
 a vitiated atmosphere, than an indifference to drafts 
 would do, even if it be responsible for an occasional
 
 44 NASAL AND PHARYNGEAL DISEASES. 
 
 "cold." Much of the fear expressed by various writers 
 regarding the dangers due to the dryness of the air 
 caused by artificial heating, especially by steam, in 
 winter, is based on speculative reasoning only. Most 
 of the Western States, especially the mountain regions, 
 have a very low relative humidity, while their climate is 
 universally acknowledged to be very "healthful." The 
 compensatory ability of the organism is such that it can 
 adapt itself to wide variations in the surrounding physi- 
 cal conditions. 
 
 There can be little doubt that the ability to resist 
 unfavorable meteorologic influences depends largely on 
 the individual's habits and training. Restrictive anxiety, 
 especially when it interferes with an outdoor life in the 
 rearing of children, is probably more disastrous than 
 negligence in the other direction. 
 
 Cold baths and cold sponging are recommended highly 
 by text-books as preventives against "colds." A fairly 
 large experience, started originally with some enthusiasm, 
 leads the writer to believe that the efficiency of this 
 measure is somewhat overrated as regards its influence 
 upon the resisting power of the respiratory passages. Yet 
 he would heartily recommend a daily cold plunge for its 
 general tonic effect, provided it be followed by a com- 
 fortable reaction and a feeling of warmth. In anemic 
 and neurasthenic conditions this reaction is sometimes 
 not obtainable. It is more likely to follow a quick cold 
 plunge than a cool bath or the mere sponging of the 
 skin. Diseases and chronic lesions of the upper respira- 
 tory passages need not interfere with baths of any kind. 
 Baelz, with sixteen years' medical experience in Tokio, 
 states that the Japanese take one or more baths daily at 
 from 42 to 44 C., many of them passing at once into 
 the streets, thinly clad, even in cool weather. Experience 
 has not showji that "colds" result from this practice. 
 It is also well known that the change from the hot steam 
 room to the cold plunge in Russian baths is not ordinarily 
 followed by unpleasant consequences.
 
 INFLUENCE OF CLIMATE. 45 
 
 14. The Influence of Climate on Diseases of the 
 Upper Air-passages. Regarding the influence of cli- 
 mate upon affections of the air-passages, there is as yet 
 but little precise knowledge. The best known instance 
 of the influence of climate on disease is shown by the 
 immunity of certain localities to hay-fever. These are 
 partly mountain resorts, partly the shores of various 
 bodies of water. This disease, which is not an inflam- 
 matory process, but essentially a nervous disturbance, is 
 promptly arrested when the sufferer arrives in these 
 exempt localities. Common to them all is the relative 
 absence of dust. Many other dust-free localities do not, 
 however, grant similar immunity. A definite climatic 
 influence can also be observed with regard to the nervous 
 symptoms and disturbances that are often caused by 
 "perennial" turgescence of cavernous tissue in the 
 nose sneezing fits, asthma, headache, etc. They are 
 promptly relieved on reaching moderate altitudes in the 
 mountains, and, as a rule, are permanently benefited by 
 a sojourn in such localities. Apart from these two 
 instances, there is much diversity of opinion regarding 
 the effects of climate upon the nose and throat. The 
 author's impressions, based upon the histories of travel- 
 ing patients or those who have permanently changed 
 their residence, and upon discussion with physicians in 
 different parts of the country, as well as upon some 
 personal traveling experiences, may be stated in this 
 manner: Acute attacks and acute inflammatory exacerba- 
 tions occur most frequently where there are sudden 
 changes in temperature, prolonged spells of wet and cold 
 weather, and irregular winds. On the other hand, they 
 are least likely to occur where the temperature is equable, 
 especially when there are no prolonged spells of high 
 atmospheric humidity, and where the winds, even if 
 intense, occur with a certain regularity. All these hy- 
 gienic conditions exist more on the western than on the 
 eastern side of the Rocky Mountains, and especially in 
 the Southwestern States. Since all chronic lesions in
 
 46 NASAL AND PHARYNGEAL DISEASES. 
 
 the nose and pharynx are, as a rule, aggravated by acute 
 exacerbations, a residence in the Western States, and 
 especially in the southwestern parts (California, Arizona, 
 New Mexico, Southern Utah), is less likely to intensify 
 or maintain nasal disturbances than living in the Middle 
 or Eastern States. Moreover, as irritative symptoms 
 (sneezing, asthma, etc.) are usually promptly relieved by 
 the. western climate, especially at moderate altitudes, 
 excepting in dusty regions, patients often experience 
 much benefit from a trip to these parts of the country. 
 Regarding its influence upon inflamed nasal passages, 
 Colorado is not praised by its own physicians, but, in 
 the author's experience, his patients have usually been 
 benefited by its dryness and sunshine. Regarding the 
 Southern States east of the Rocky Mountains his own 
 impressions have been much less favorable. There 
 are, however, many chronic conditions, such as deep- 
 seated suppurative foci and hypertrophic lesions, that 
 will not disappear under climatic influences alone, 
 although the subjective annoyance produced by them is 
 reduced by favorable climatic environment. 
 
 15. Factors in the Etiology of Diseases of the 
 Upper Respiratory Organs. Of great etiologic impor- 
 tance in the pathology of the upper air-passages are the 
 anatomic configuration and the changes resulting from previous 
 disease. It can be readily observed clinically that both 
 suppurative and hypertrophic processes occur predomi- 
 nantly in narrow nasal passages, narrow either from pro- 
 nounced relative narrowness of the skull or encroachment 
 of the external nasal wall upon the caliber. Wide pass- 
 ages, on the other hand, appear in the minority in nasal 
 affections, except in ozena, to which they predispose. 
 Even more important are circumscribed encroachments 
 upon the caliber of the passages, such as deflections of the 
 septum, crests upon the septum, hypertrophies of mucous 
 membrane, and enlargement of the pharyngeal lymphatic 
 tissue. Hypertrophic processes accompanied by inflam- 
 mation thus tend to perpetuation, by reason of the vicious
 
 FACTORS IN ETIOLOGY. 47 
 
 circle to which they give rise. In one-sided nasal steno- 
 sis it is especially noticeable that any acute and ordinarily 
 transient inflammation is likely to become persistent on 
 the narrower side of the nose, or to extend to the ear of 
 that side. Striking, too, is the diminished liability to 
 acute ' ' colds ' ' after a properly indicated removal of a 
 pharyngeal tonsil, a successful septum operation, or cau- 
 terization of redundant tissue. There are, moreover, some 
 inflammatory processes, which, even though they seem 
 to have healed entirely, as judged by clinical evidence, 
 create a disposition to their own recurrence, such as acute 
 inflammation of the frontal sinus, and especially tonsil- 
 litis. Hence the surgical treatment of existing chronic 
 lesions, even when they cause but little discomfort, plays 
 an important role in the prophylaxis of nasopharyngeal 
 affections. 
 
 The liability to structural changes depends often on 
 hereditary peculiarities. Enlargement of the pharyugeal 
 tonsils is strikingly frequent in some families; in others, 
 it is totally absent. 
 
 16. Although most of the diseases of the nose and 
 pharynx are strictly localized processes, their occurrence 
 and persistence are in some instances more or less de- 
 pendent upon morbid conditions elsewhere in the body. A 
 specialist can never afford to lose his interest in general 
 pathology. 
 
 The liability to "colds" is increased by anemia and 
 other conditions of malnutrition, and diminishes again 
 with returning systemic vigor. Of acute infections of 
 the accessory sinuses, the majority are incident in the 
 course of infectious diseases, as shown by autopsies. While 
 most of the sinus involvements under these circumstances 
 present but few clinical symptoms, yet a small number 
 turn into chronic and persistent forms. In affections of 
 the maxillary sinus the origin must be sought in carious 
 teeth in a moderate proportion of cases. 
 
 Inflammatory processes in nose and throat are also 
 largely influenced by disturbances of the digestive system.
 
 48 NASAL AND PHARYXGEAL DISEASES. 
 
 The various forms of dyspepsia, and especially constipa- 
 tion, are often a serious obstacle in the treatment of dis- 
 eased air-passages, and proper attention to diet and the 
 function of the bowels is not rarely the first step in the 
 road to success. In chronic constipation which does not 
 yield to fruit and exercise, enemata of hot water prove 
 more serviceable in the end than the habitual use of 
 laxatives. 
 
 The discomfort due to a given degree of nasal disease 
 is to some extent an index of the condition of the nervous 
 system. Thus, for instance, chronic suppuration of the 
 accessory cavities need not give rise to much actual suf- 
 fering in subjects with vigorous nervous system, whereas 
 in neurasthenic conditions such processes may cause con- 
 siderable pain in the form of headache and neuralgia. 
 The tone of the nervous system is also indicated strikingly 
 by the vascular irritability in the nose and the so-called 
 reflex disturbances thereby engendered in those cases in 
 which there is enlargement of the cavernous plexus in the 
 nasal lining. Thus it is not uncommon to see these dis- 
 turbances intensified during pregnancy. In such instances 
 more can often be accomplished therapeutically by advice 
 from the standpoint of the neurologist than by treatment 
 limited to the nose, although, of course, both lines of 
 therapeutics should be considered. 
 
 17. From an etiologic point of view the habits of the in- 
 dividual must not be ignored. It can be readily observed 
 that smoking tobacco irritates and increases the secretion 
 in affections of the posterior parts of the nose and of the 
 throat. The difference is promptly noticeable if the 
 patient reduces his allowance of tobacco, especially if 
 this is used in the form of cigarettes. If he can restrict 
 himself within the limits of two or three cigars daily, or 
 their equivalent in the pipe, it is generally unnecessary 
 to insist on total abstinence. There is, however, one 
 form of pharyngeal disease in the etiology of which 
 smoking plays a greater role than in any other affection. 
 It is the diffuse chronic pharyngitis, usually dependent, in
 
 AGE. 49 
 
 the first place, upon nasal stenosis or nasal suppuration, 
 and characterized by thickening and uniform injection of 
 the pharyngeal wall, and especially its adenoid elements, 
 the tonsils and strands of lymphatic tissue behind the 
 posterior pillars. In this form the throat is very sensi- 
 tive to mechanical contact. According to personal expe- 
 rience, this form of pharyngitis occurs mainly though 
 not quite exclusively in smokers, and necessitates total 
 abstinence for relief. Alcoholic excesses, too, may have 
 some share in the etiology of this pharyngitis. The 
 morning vomiting of hard drinkers is often dependent on 
 this diffuse pharyngitis; sometimes, however, it is due to 
 chronic inflammation of the lingual tonsil. Attention 
 has also been called to the injurious influence that the 
 drinking of very hot fluids may exert upon the pharynx. 
 
 Inflammatory disease of the upper air-passages is also 
 engendered and maintained by exposure to irritating dust 
 and acrid gases. Workmen employed in lime, cement, 
 arsenic, and especially chrome works frequently suffer 
 from ulceration of the nasal septum. 
 
 18. Age is an important factor in the predisposition to 
 different ailments of the upper respiratory passages. Al- 
 though all ages are equally liable to acute coryza as well 
 as chronic purulent rhinitis, suppuration of the sinuses is 
 rarely seen clinically in young children, and, indeed, not 
 often under the age of puberty, although anatomically 
 it has been demonstrated frequently in connection with 
 infectious diseases of the upper air-passages. The acces- 
 sory cavities are but poorly developed until after the 
 seventh year. Septum deformities, too, are uncommon 
 in childhood, especially crests and spurs, while deflec- 
 tions may occur before the second dentition, although 
 they are infrequent. Hypertrophies of the nasal mucous 
 membrane, in particular polypi, are rare lesions in child- 
 hood. This is one of the reasons why children are 
 almost exempt from postnasal catarrh. Atrophic rhinitis 
 (ozena), on the contrary, usually begins early in life. 
 
 The lymphatic structures in the pharynx do not grow 
 
 4
 
 5<D NASAL AND PHARYNGEAL DISEASES. 
 
 morbidly after the first three or four years of life, unless 
 hypertrophy had begun previous to that time. After 
 puberty the morbidly enlarged tonsils, especially the 
 pharyngeal tonsil, may recede moderately. When en- 
 larged, they give rise to more annoyance during child- 
 hood than in later life, partly because pharyngeal and 
 tonsillar inflammations are more especially an ailment of 
 childhood and adolescence, and, in part, because the 
 lymphatic structures become more fibrous and less vascu- 
 lar in the course of years. Infectious diseases localized 
 in or involving the upper air-passages, such as diphtheria 
 and the eruptive fevers, become less and less common as 
 early childhood is passed.
 
 CHAPTER III. 
 
 SYMPTOMATOLOGY; METHODS OF EXAMINATION 
 AND APPEARANCES OF NOSE AND PHARYNX; 
 METHODS OF TREATMENT IN NASAL AND PHA- 
 RYNGEAL AFFECTIONS. 
 
 19. Subjective Symptoms. Pain Most nasal dis- 
 eases do not cause pain. Abscess of the septum and 
 gummatous tumors under the periosteum may, however, 
 give rise to severe suffering, the pain not being correctly 
 localized, but described as headache. In neurasthenic 
 persons various nasal diseases may be attended with 
 much discomfort, especially in the form of diffuse head- 
 ache, while neuralgia of the supra-orbital or infra- 
 orbital nerves, sometimes of great severity, can be caused 
 by inflammation of the accessory sinuses. Acute inflam- 
 mation of any of the structures in the pharynx is always 
 painful, particularly during swallowing, and to a degree 
 commensurate with the intensity of the disease. If the 
 upper part of the faucial tonsil or the recess VJehind the 
 posterior pillar of the fauces is involved, the pain is said 
 to shoot into the ear. In chronic pharyngeal inflamma- 
 tions patients describe the sensation less as pain, but 
 rather as an irritation or tickling. 
 
 20. The most common complaint of patients with 
 nasal disease is obstruction of the nasal passage. This may 
 be present at all times if due to a structural narrowing 
 of the nasal caliber or transient, if caused by temporary 
 distention of the vascular plexus in the mucous mem- 
 brane or by the presence of viscid secretion. The stuffy 
 feeling may be limited to one side of the nose or may 
 exist on both, while if due to excessive vascularity, it 
 often passes abruptly from one side to the other. Nasal 
 obstruction is also very characteristic of any encroach- 
 
 51
 
 52 NASAL AND PHARYNGEAL AFFECTIONS. 
 
 ment upon the capacity of the vault of the pharynx by 
 enlargement of the pharyngeal tonsil or by a retropharyn- 
 geal abscess, even if the nasal passages themselves are 
 clear. This obstruction, too, is intensified when the 
 vasctilarity is increased by the reclining position. Hence 
 during sleep mouth-breathing occurs, even if nasal res- 
 piration is possible during waking hours. Whenever 
 the tongue is arched during mouth-breathing so as to 
 leave merely a narrow passage between itself and the 
 soft palate, the current of air starts vibration of the soft 
 palate and causes snoring. 
 
 The patency of the nasal passages can be gauged 
 objectively by the sound produced by breathing. The 
 air passes through a normal nose both during inspiration 
 and expiration without any sound whatever, except when 
 a most forcible effort is made. In proportion to the 
 narrowness of the passage breathing yields a rustling or 
 whistling noise. In order to test one side at a time the 
 other side of the nose must be closed with the thumb 
 without pressure on the flexible septum. 
 
 Interference with nasal respiration is also indicated 
 by the nasal "twang" of the voice. The voice is not 
 affected by a one-sided obstruction if the other side is 
 entirely clear, but whenever both halves of the nose are 
 narrowed, the normal resonance of speech is changed 
 and' the voice sounds "dead." The most characteristic 
 change in the voice is found with enlarged pharyngeal 
 tonsil. 
 
 31. Nasal Secretions. In the normal condition the 
 nasal mucus is never secreted in sufficient quantity to 
 require removal either by blowing the nose or by aspira- 
 tion into the pharynx. Hence whenever there is any 
 discharge from the nose it is an abnormal occurrence. 
 The discharge is glairy, clear mucus if due to mechanical 
 or chemical irritation of a non-inflamed mucous mem- 
 brane, but more or less turbid, or pure pus, if caused by 
 inflammation. The secretion from the rear third of the 
 nasal passage is blown out only with difficulty, but either
 
 METHODS OF EXAMINATION OF THE NOSE. 53 
 
 drops into the pharynx from time to time, or is drawn 
 back by forcible inspiration. Discharge from the nasal 
 sinuses may also drop into the throat under some cir- 
 cumstances, especially in the recumbent position. If 
 scant nasal discharge dries in the form of crusts, the 
 patients will sometimes remove them only at long inter- 
 vals. If inspection does not satisfy the surgeon as to the 
 kind or quantity of discharge, the douche can be used 
 (see T[ 25), whereupon any nasal secretion can be seen 
 floating in the basin. 
 
 Purulent nasal secretion has a pronounced odor only 
 if pent up and decomposed or dried in the form of crusts. 
 The two most characteristic odors are those of ozena and 
 of syphilitic necrosis, which may enable an expert to 
 make a diagnosis. Foul, too, but different is the odor in 
 sinus suppuration with retained pus and in concretions 
 and foreign bodies. In any form of nasal obstruction 
 with secretion the breath through the mouth is likely to 
 be offensive, especially on awakening. 
 
 22. Sneezing is a normal reflex action whenever the 
 nasal lining is irritated. It is a prominent symptom 
 during acute nasal catarrh so long as the nose is not en- 
 tirely occluded. In chronic nasal diseases sneezing, some- 
 times in uncontrollable fits, is an annoying feature in 
 proportion to the "nervous" disposition of the patient. 
 It occurs least whenever the mucous membrane is either 
 much hypertrophied or atrophied. 
 
 Coughing is not, as a rule, produced by nasal disease, 
 but may accompany pharyngeal lesions, especially hyper- 
 trophy of the adenoid tissue at the root of the tongue. 
 The cough of pharyngeal patients is, however, commonly 
 due to extension of the disease into some of the struc- 
 tures of the larynx or to coexisting bronchitis. 
 
 23. Methods of Examination of the Nose. The ob- 
 jective examination begins with the external shape of the 
 nose. A flattened bridge is often seen in patients with 
 ozena. Decided sinking in of the bridge of the nose is 
 due to cicatricial shrinkage of the septum, almost always
 
 54 NASAL AND PHARYNGEAL AFFECTIONS. 
 
 the result of syphilis, either acquired or inherited. De- 
 flection of the nose to one side indicates asymmetry of 
 the septum, caused either by unequal growth or by an 
 injury. On watching the alae nasi during forcible inspi- 
 ration it is to be noted whether they remain normally 
 rigid or collapse and are drawn in with every breath, 
 thereby indicating obstruction. 
 
 In order to see the interior of the nose light must be 
 thrown in. This is done with a concave mirror with a 
 central perforation through which the surgeon looks. 
 The mirror is held in the hand or is attached by means 
 of a ball-and-socket joint to a strap around the forehead 
 or to a metallic spring clasping the head. There are 
 some handles made that may be held between the teeth. 
 The source of light should be the strongest one available. 
 Sunlight can be used advantageously, with a plane mir- * 
 ror in summer to avoid burning. The light from bright 
 white clouds is perhaps the best of any. A blue sky 
 gives an insufficient light. Of all artificial lights the 
 Welsbach incandescent burner is the whitest, but any 
 gas-jet, preferably an Argand burner, or a broad kerosene 
 flame will answer. Of electric lights, one with spirally 
 wound filament is the best. The various forms of con- 
 densers placed in the market offer no practical advantage 
 over the naked flame. If artificial light is used, the eye 
 is more sensitive when daylight is excluded by window- 
 shades. 
 
 A very convenient arrangement is an electric headlight, 
 of which various forms are in the market (Fig. n). A 
 6 or 8 candle-power miniature lamp inclosed within a 
 tube with condenser lens is attached to the forehead just 
 above the eye. This is connected by means of a flexible 
 and easily detachable cord to the source of electricity. 
 A street current of not over no volts is the most con- 
 venient source of energy if its intensity is suitably 
 reduced by a proper resistance in the form of a wall- 
 lamp furnished by the maker. An additional device 
 found by the author to be useful is that of putting a
 
 METHODS OF EXAMINATION OF THE NOSE. 
 
 55 
 
 resistance (a lamp of 210 ohms) into the same circuit as a 
 (parallel) shunt, whereby the shock felt by the hand 
 when the exposed metallic connectors are touched is 
 reduced to a minimum. If no street current is available, 
 resort must be had to a battery or a storage-cell, which 
 requires attention and gives rise to some annoyance. 
 
 FIG. ii. Electric head-light. 
 
 With the electric head-lamp the observer is more at 
 liberty to move his head than when he reflects the light 
 by means of a mirror. 
 
 It is rarely possible to see any distance into a nose 
 without separating the flexible walls of the vestibule by 
 means of a speculum. Additional space is gained by 
 raising the tip of the nose by upward pressure. A bi- 
 valve speculum (Fig. 12) can be handled with the least 
 
 FIG. 12. Pynchon's bivalve nasal speculum. 
 
 annoyance to the patient, and, on account of the broad- 
 ness of its blades and the control that the hand can exert 
 over it, it permits the most satisfactory view. It has the 
 disadvantage, however, of not being self-retaining, a re- 
 quisite in most operations. Of the various spring specula, 
 the author has found Goodwillie's (Fig. 13) and Palmer's
 
 56 NASAL AND PHARYXGEAL AFFECTIONS. 
 
 (Fig. 14) the most convenient. Wire specula do not 
 cover the hairs in the vestibule, which, in some cases, 
 interfere with the view and require clipping. 
 
 In small children the nose can be viewed through an 
 ear-speculum. 
 
 The view into the interior of the nose begins with the 
 vestibule the space within the external part of the nose. 
 The alse nasi are lined by true skin with more or less 
 hairs (vibrissae), whereas on the septum the skin changes 
 into mucous membrane within a few millimeters above 
 its inferior edge and behind its front end. Erosions are 
 sometimes found at the junction of the septum and ex- 
 ternal nose. The septum is normally straight, but may 
 be deviated morbidly more or less to one side. The lower 
 rim of the triangular cartilage of the side of the nose 
 
 FIG. 13. Goodwillie's nasal speculum. FIG. 14. Palmer's self- retaining 
 
 nasal speculum. 
 
 projects into the interior of the vestibule in the form of a 
 skin-covered prominent fold narrowing the entrance into 
 the nasal passage (compare Fig. 2). 
 
 The nasal cavities proper are the irregularly shaped 
 passages between the nasal septum and the external walls. 
 They begin at the pyriform aperture bounded by the 
 sharp edge of the maxillary bones, and end with the pos- 
 terior choanae. Their length varies from 50 to 75 mm. 
 in the adult, the width of the two sides together, meas- 
 ured between the external, walls along the floor, from 29 
 to 42 mm. , the total height from floor to roof, from 38 to 
 50 mm. They are lined by mucous membrane normally 
 of a light grayish-red or pink color. 
 
 Each nasal half is bounded on the median side by the 
 septum. When this is perforated pathologically, the view
 
 METHODS OF EXAMINATION OF THE NOSE. 57 
 
 extends into the other side of the nose. The septum is 
 not, as a rule, an ideal straight wall. In its anterior 
 upper portion the tuberculurn of the septum forms a 
 more or less projecting tumefaction. The examiner must 
 note whether any existing projecting irregularities along 
 the septum encroach sensibly upon the nasal caliber or 
 extend even far enough to touch the lateral wall. The 
 surface of the septum may be smooth, and yet, by the 
 convexity of an asymmetric position, the one half of the 
 nose may be narrowed, the other perhaps widened. By 
 successive examinations of the two sides it is ascertained 
 whether an asymmetric septum is merely curved or bent 
 angularly or is absolutely thickened. When the septum 
 
 FIG. 15. View into the normal right nasal passage through the wire speculum, 
 showing the inferior and the front end of the middle turbinal. 
 
 is straight, the view extends to the rear, so that with 
 sufficient illumination the posterior wall of the upper 
 pharynx can be seen. The view upward is terminated 
 usually by the narrow chink between the middle turbin- 
 ated body and the septum. The upper turbinated process 
 is not visible (Fig. 15). 
 
 The floor of each nasal passage is smooth, without 
 landmarks. The external wall presents the most varied 
 and variable architecture, on account of its horizontal 
 projecting ledges, the turbinated processes or turbinals. 
 On anterior inspection only the inferior and middle tur- 
 binals are visible. The space underneath the former is 
 the inferior meatus ; that between inferior and middle 
 turbinal is called the middle meatus of the nose. The
 
 58 NASAL AND PHARYNGEAL AFFECTIONS. 
 
 inferior turbinated body forms an overhanging cornice 
 reaching nearly to the floor. Any undue obliquity or 
 projection of this ledge narrows the respiratory passage. 
 Even with normal architecture of the bone the inferior 
 turbinal may obstruct the space by reason of distention 
 of its venous plexus or hypertrophy of its mucous mem- 
 brane. The swelling, if due to the former condition, 
 can be indented with the probe, but this is not the case 
 if it is dependent on thickening of the mucous mem- 
 brane. The vascular tumefaction disappears upon the 
 application of cocain, which does not change the appear- 
 ance of the thickened mucous membrane. In atrophic 
 rhinitis the ledge formed by the inferior turbinal is more 
 or less reduced in size. The space between the inferior 
 and middle turbinated bodies is variable in height. 
 
 The middle turbinal is a ledge that, by reason of its 
 curving, hangs down to a variable extent. The distance 
 between the vestibule and the front end of the middle 
 turbinated body is also subject to much variation. Its 
 anterior end is sometimes broadened by expansion of its 
 bony frame. 
 
 The mucous membrane covering the middle turbinal 
 is not freely movable, since there exists no well-defined 
 vascular plexus in it. It is only when it is hypertrophied 
 that it can be moved to and fro by the probe. The im- 
 portant space where the maxillary and frontal sinuses 
 communicate with the nasal cavity through openings in 
 the external wall of the nose is completely hidden from 
 view by the middle turbinal. The rear ends of inferior 
 and middle turbinated bodies can generally not be well 
 defined in the anterior rhinoscopic view. The color of 
 the nasal mucous membrane is a pale pink. A red tint 
 indicates inflammation. 
 
 If, in a nasal examination, the view is obstructed by 
 general congestion of the mucous membrane or by en- 
 gorgement of normal or abnormally situated cavernous 
 tissue, a spray of cocain solution, 2 per cent, to 4 per 
 cent, in strength, or of suprarenal solution will cause
 
 METHODS OF EXAMINATION OF THE PHARYNX. 59 
 
 sufficient contraction of the blood-vessels to permit a 
 subsequent reexamination at better advantage. 
 
 24. Methods of Examination of the Pharynx. 
 While proceeding to the examination of the pharynx the 
 examiner should note the appearance of the mouth. Ca- 
 rious teeth, especially those back of the cuspids, are not 
 a rare cause of suppuration of the maxillary sinus, while 
 sensitive teeth, especially molars or erupting wisdom 
 teeth, may cause neuralgia referred to the ear. Some in- 
 ference may be made relative to the shape of the nasal 
 fossae from the shape of the roof of the mouth. An 
 asymmetric palate implies asymmetry of the nasal sep- 
 tum. A high palatal vault is often, but not always, 
 indicative of stenosis of the nasal passages or obstruction 
 of the upper pharynx. Unusual length of the uvula is 
 of significance only if it causes the uvula to rest upon 
 and thereby irritate the root of the tongue. Slight 
 asymmetry of the uvula may be normal, but its adhesion 
 to one side is due to scars following syphilitic ulceration 
 or diphtheria. 
 
 Coating of the tongue, if not referable to disease of the 
 teeth or of the stomach or to an acute disturbance, sug- 
 gests mouth-breathing. 
 
 The normal tonsils are practically invisible except on 
 '"gagging" or on retraction of the anterior pillar with a 
 blunt hook. They consist of a thin and scarcely project- 
 ing layer of adenoid tissue with minute crypts, between 
 the anterior and posterior pillars of the palate. Every 
 visible prominence of this structure means morbid over- 
 growth Existing inflammation of the tonsillar tissue is 
 shown by any redness differing in hue from that of the 
 adjoining mucous membrane. Within the crypts of the 
 enlarged tonsil there may be concretions that may or may 
 not be visible. If their presence is suspected, they may 
 be squeezed out by pressure with a blunt rod or by insert- 
 ing a blunt hook into the crypts. From one tonsil to the 
 other there extends a bridge of adenoid tissue along the 
 root of the tongue in front of the epiglottis, called the
 
 60 NASAL AND PHARYNGEAL AFFECTIONS. 
 
 fourth or lingual tonsil. It consists of a row of small 
 papules, each about 3 mm. high, with central crypts. 
 The lingual tonsil can be seen only with difficulty by 
 pulling out the tongue, but it can easily be examined by 
 means of the inverted rhinoscopic mirror. 
 
 It is often hypertrophied by reason of chronic inflam- 
 mation, while its pronounced atrophy suggests the exist- 
 ence of old syphilis. 
 
 The pharynx may be compared to a somewhat flattened 
 tube, the upper end of which is closed by a half-dome- 
 shaped roof that slopes gradually into the posterior wall. 
 It ends below at the level of the larynx underneath the 
 root of the tongue. Its anterior side is incomplete. Above 
 the palate this is formed by the plane of the posterior 
 choanse, which plane slopes forward and downward. 
 Underneath the choanse is the soft palate, forming a 
 horizontal diaphragm anteriorly, but which curves pos- 
 teriorly, when relaxed, so as to hang down like a curtain. 
 The posterior surface of the pendant portion of the palate 
 thus forms a part of the anterior boundary of the phar- 
 ynx. Below this is the communication between mouth 
 and pharynx, while the curve of the root of the tongue 
 forms the lowest part of the imaginary anterior wall of 
 the pharynx. 
 
 The posterior wall of the lower pharynx is seen only 
 when the tongue is depressed. If the subject cannot do 
 this naturally, the surgeon must use a tongue depressor. 
 This should be of heavy steel, in order not to be bent by 
 an unruly tongue. The simplest shape, two rigid plates 
 at right angles, of which the one for the tongue is per- 
 forated to increase its hold, is better than a more com- 
 plicated instrument (Fig. 16). The examination can be 
 made in a good, direct light opposite a window, or light 
 may be thrown in with the mirror. The more the lips 
 are retracted, the better the view. Turning of the head 
 to either side may simulate asymmetry of the pharynx. 
 
 If the person gags during the examination, the tonsils 
 are pushed forward and toward the median line by the
 
 METHODS OF EXAMINATION OF THE PHARYNX. 6 1 
 
 action of the constrictor muscles of the pharynx. Dur- 
 ing this movement they encroach upon the cavity much 
 more than when in their normal position, and that part of 
 their mass which is ordinarily hidden by the pillars of the 
 fauces is thereby well shown. 
 
 The normal pharyngeal surface is a pale pink. Ex- 
 treme pallor indicates anemia; lividity, on the other 
 hand, suggests venous stasis, possibly due to heart dis- 
 ease. Enlarged veins are the result of chronic irritation, 
 not uncommonly from smoking. Diffuse redness signi- 
 fies inflammation. In chronic troubles the vascularity 
 may increase during the examination. Red and slightly 
 
 FIG. 1 6. Bos worth's tongue depressor. 
 
 raised follicles of lymphatic tissue are not normal struct- 
 ures, and the same may be said of strands of injected 
 lymphatic tissue at the junction of the posterior and lateral 
 walls of the pharynx. These lateral lymphatic strands 
 are, in rare instances, hypertrophied in the form of pro- 
 jecting wings. The normal pharynx is not covered with 
 secretion. Lumps of mucus or crusts of dried pus are the 
 results of disease, but the lesion is more likely to be in 
 the nasal passage or at the roof of the pharynx than in 
 its lower part. 
 
 In order to view the region above the palate a rhino- 
 scopic mirror must be placed behind the posterior pillars 
 of the fauces at such angles that it gives successively
 
 62 NASAL AND PHARYNGEAL AFFECTIONS. 
 
 images of the upper part of the pharynx and of the poste- 
 rior nasal choanae. The mirror is at once clouded by the 
 moisture of the breath, unless it is either warmed a trifle 
 above the body-temperature or soaped. A film of soap, 
 by itself invisible, remaining after gentle wiping with a 
 cloth, prevents deposition of dew. The mirrors vary in 
 diameter from i to 3 cm., and are fastened on the handle 
 at an angle of 45 degrees. The larger the mirror that can 
 be tolerated, the better will be the illumination and the 
 more extensive the view. But it is not possible to see 
 all structures at a single glance with any mirror, and it 
 requires tilting in various directions and shifting of the 
 examiner's head in order to bring them successively into 
 view. As the light is weakened by its double reflection, 
 the examination is more satisfactory the stronger the 
 illumination. Sunlight is by far the best. It is, of 
 course, necessary to throw the light in the direction of 
 the glance through the central hole in the mirror. 
 
 An expert can make a satisfactory examination with a 
 rhinoscopic mirror in perhaps one-third of all patients at 
 first trial. A few patients can never be examined viz. , 
 those who oppose the surgeon from fear. This applies to 
 adults as well as to children. The younger the child, the 
 more difficult is it to overcome its fear, but sometimes, 
 even in children as young as three years of age, the roof 
 of the pharynx can be seen fairly well. As soon as the 
 patient fears the instrument he gags and thereby brings 
 the soft palate and the pharyngeal walls into contact, 
 thus rendering the examination impossible. Sometimes 
 this is due to actual irritability of the pharyngeal surface, 
 especially in the chronic inflammation of smokers and 
 drinkers. More commonly, however, the pharyngeal move- 
 ments are of psychic origin, and can be seen to begin 
 when the mirror is approached and before it touches 
 the mucous membrane. Many patients can be induced 
 to submit by persuasion. Sometimes it requires a few 
 sittings to train them. When the resistance is due to 
 sensitiveness of the pharynx, a 10 per cent, solution of
 
 METHODS OF EXAMINATION OF THE PHARYNX. 63 
 
 cocain brushed on the pillars, pharynx, and soft palate 
 may render the examination possible. On account of its 
 unpleasant taste this should not be used needlessly. The 
 view is more sweeping if the soft palate is pulled forward 
 with a palate hook (Fig. 17). If the pharynx is nar- 
 row in the anteroposterior direction, the use of the hook 
 may be a necessity. The hook, however, does not reduce 
 the patient's sensitiveness, although it is often as well 
 
 FIG. 17. TornwalcTs palate hook. 
 
 tolerated as the mirror itself. During gagging the hook 
 affords no assistance to the examiner. For operations a 
 self-retaining palate hook is often serviceable (Fig. 18). 
 Just as serviceable as a palate hook, but also equally as dis- 
 agreeable, is the retraction of the palate by means of rub- 
 ber tubing. A drainage-tube 3 or 4 mm. thick and about 
 30 mm. long is pushed through the nostril and seized in the 
 pharynx with forceps, pulled through the mouth, and its 
 
 FIG. 18. Hoffman's self-retaining palate hook. The elastic traction is made 
 by rubber bands. 
 
 ends are tied over the upper lip. Under all circumstances 
 the examination must be made with gentleness, and con- 
 tact with the mirror with the walls is to be avoided. 
 Like all physical examinations, the use of the rhinoscopic 
 mirror requires much practice before the surgeon can 
 have command of it. 
 
 A part of the posterior wall of the nasopharynx and 
 sometimes even its entire extent up to the posterior lip
 
 04 NASAL AND PHARYNGEAL AFFECTIONS. 
 
 of the Eustachian orifice is visible to direct inspection 
 without mirror, when the patient throws the head back, 
 while the palate is pulled forward firmly with a palate 
 hook, provided the patient does not gag. The mouth 
 must be opened as wide as possible to permit the surgeon 
 to look up. 
 
 In the rhinoscopic image the posterior wall of the 
 pharynx can be traced up to its sloping junction with 
 the roof (Fig. 19). The slope varies in different heads. 
 The transverse width of the pharynx is narrowed above 
 the palate by the projecting lips of the Eustachian tubes, 
 
 FIG. 19. Postrhinoscopic view of the septum, choanse, Eustachian tubes, soft 
 palate, and pharynx vault. 
 
 while above and behind them are the recesses known as 
 the fossae of Rosenmuller. The more the elevation of the 
 Eustachian tube projects, the deeper are the fossae. They 
 may be obliterated partly by hypertrophied lymphatic 
 tissue. The vault or roof of the pharynx ends anteriorly 
 at the upper rim of the posterior choanse. The central 
 area of the upper posterior wall is the site of the pharyn- 
 geal tonsil. This cushion of submucous adenoid tissue 
 does not project normally beyond the plane of the sur- 
 rounding surface. Whenever it forms a distinct tume- 
 faction, it must be called hypertrophied. Its normal
 
 METHODS OF EXAMINATION OF THE PHARYNX. 65 
 
 color is slightly redder than that of the posterior wall 
 below it. In children, and somewhat less markedly in 
 normal adults, the pharyngeal tonsil presents from five to 
 seven slightly prominent sagittal ridges. During the 
 earlier stage of morbid hypertrophy this ridged and fur- 
 rowed appearance is exaggerated in the form of cocks- 
 comb-shaped growth. At a later period the enlarged 
 mass becomes smooth in surface. As the normal tonsil is 
 at least from 5 to 8 mm. behind the rim of the choanae, 
 the obliquity of the mirror image gives the appearance 
 as if this clear space were a vertical anterior wall above 
 the choanae, which in reality does not exist. The mor- 
 bidly enlarged tonsil appears in the mirror at least flush 
 with the rim of the choanae, but may even hide a large 
 part of the posterior nasal orifice from view. Near the 
 lower or posterior end of the tonsil and in or near the 
 median line there is sometimes seen a small pit the so- 
 called pharyngeal bursa. 
 
 The dimensions of the pharynx are governed by the 
 variable size of the bony rim of the posterior choanae. 
 Zuckerkandl states this as 
 
 IN THE ADULT. NEW BORN. 
 Maximum width of each opening . . '. . .20 mm. 7 mm. 
 
 Minimum width of each opening 13 " 6 " 
 
 Maximum height 39 " 9 " 
 
 Minimum height 25 " 7 " 
 
 But as the posterior choanal rim, parallel with the edge 
 of the vomer, slopes upward and backward, the actual 
 vertical height of the pharynx is less than the former 
 figure, averaging about 20 mm. in the adult. The 
 anteroposterior depth is least next to the sloping roof, 
 and greatest at the level of the inferior choanal rim. 
 The obliquity of the choanal plane is not recognizable in 
 the mirror image. 
 
 The normal anterior wall of the pharynx shows the 
 sharply defined edge of the nasal septum in the median 
 line. Prominences on either side of the septum are 
 pathologic. The rear ends of the inferior and middle 
 
 5
 
 66 NASAL AND PHARYNGEAL AFFECTIONS. 
 
 turbinals are well seen in the normal image. They 
 appear as pale, scarcely pink, obliquely pendant lobules, 
 the lower even paler than the middle, and are covered 
 with a smooth mucous lining. Normally there is a 
 distinct space between the turbinals and the septum. 
 Morbidly they may be enlarged to a variable extent, even 
 projecting into the nasopharynx, and of a bluish, livid 
 hue. Bach choanal opening is oval, the upper rim being 
 slightly more curved than the lower. Asymmetry of 
 the two choanae is rare and not normal. 
 
 Prominent landmarks on the lateral sides of the upper 
 pharynx are the projecting Eustachian orifices posterior 
 to the inferior turbinals and about on their level. The 
 yellowish-white, funnel-shaped orifice is surrounded by 
 projecting lips, an anterior and a posterior one, which, 
 by diverging downward, give the opening the shape of a 
 triangle with curved outlines. The prominence of the 
 Eustachian tube is subject to variation, and in proportion 
 to its projection varies the depth of the recess above and 
 behind the Eustachian lips the Rosenmiiller fossa. 
 
 When a rhinoscopic view cannot be obtained, exami- 
 nation with the finger can inform the surgeon regarding 
 the size of the pharyngeal tonsil, and any existing 
 hypertrophy of the inferior turbinated or other growths. 
 A practical plan to prevent children from biting during 
 the digital examination is to press in the cheek between 
 the molar teeth with the other hand. 
 
 as. Methods of Treatment in Nasal and Pharyn- 
 geal Affections. Applications in Nose and Pharynx. 
 The nasal douche is used for both diagnostic and therapeu- 
 tic purposes. When we wish to know if there is any se- 
 cretion in the nose, in case it cannot be seen, it will be 
 found in the basin receiving the water with which the 
 nose has been flushed. The douche serves likewise to 
 remove viscid secretion or crusts in order to expose the 
 surface to view. For curative purposes the douche is 
 invaluable in all cases in which the discharge cannot be 
 removed by other means viz., when it is dried in exten-
 
 TREATMENT IN NASAL AND PHARYNGEAL AFFECTIONS. 67 
 
 sive crusts or when it is viscid. The principle of the 
 douche is simply to wash the nasal surfaces with a 
 current of indifferent fluid. Pure water is more irritating 
 than the so-called physiologic salt solution i. e. , common 
 salt in the strength of 0.5 to 0.7 per cent., or the same 
 amount of sodium bicarbonate. The douche should 
 never, however, be given unnecessarily to a patient, since 
 its careless use may involve a grave danger. If the water 
 enters the rear of the nose with pressure, or if the patient 
 swallows during the time and thereby causes gaping of 
 the Eustachian tubes, the water may enter the middle 
 ear. This accident causes, as a rule, suppurative inflam- 
 mation of the middle ear, sometimes of great severity. 
 It is probably not the presence of the water as such in 
 the middle ear that does the mischief, but the water in 
 entering carries with it pathogenic germs that abound in 
 every diseased nose. 
 
 In order to guard against this danger I have learned to 
 use a pointed nozzle that does not occlude the nostril, in 
 preference to the olive-shaped bulb usually fitted to the 
 douche. I likewise find it more convenient to use as 
 syringe a large rubber bulb held in the hand rather than 
 the irrigator ordinarily sold as a nasal douche. The 
 water should be of the temperature of the body, and the 
 patient must not swallow, cough, or spit while the 
 water flows. When the patient leans forward with the 
 mouth open, the palate is raised by reflex action while 
 the water flows through the nose, so that the fluid does 
 not get into the lower pharynx at all or only to a limited 
 extent, but returns through the other side of the nose. 
 If one side of the nose is narrowed, the fluid should 
 always be made to enter through the narrow side, in 
 order not to be under pressure in the upper pharynx. 
 
 With these precautions I have not had a single accident 
 in many thousand applications made by myself. Before 
 I became familiar with all these details I have had 
 patients state a number of times that they felt the water 
 entering one or both ears. In every one of these
 
 68 NASAL AND PHARYNGEAL AFFECTIONS. 
 
 instances I. inflated the middle ear immediately by the 
 Politzer method or with the catheter, and in no case 
 were there any further consequences. The use of the 
 douche in the hands of the patient is necessarily more 
 likely to lead to this accident than when done under the 
 eyes of the surgeon. Hence the douche should never be 
 ordered except when actually required. The various 
 cup- or spoon-shaped vessels sold as nasal douches involve 
 all the dangers of nasal irrigation without its real utility, 
 since their contents do not reach the upper portions of 
 the nasal chamber. 
 
 When we wish to cleanse the nasopharynx more than 
 the nose, the postnasal douche, a long tube with curved 
 beak connected with the douche-syringe, is inserted 
 into the nasopharynx through the mouth, and the fluid is 
 allowed to run off through the nose. The same precau- 
 tions are required as with the ordinary form of nasal 
 douche. 
 
 The object of the douche viz. , the removing of viscid 
 adhering secretion or crusts cannot be attained by snuff- 
 ing up fluids or by pouring them into the nose with a 
 spoon or spoon-shaped vessel. A forcible jet is required 
 for the purpose. Hence atomizers, too, are but an im- 
 perfect substitute for the douche. But as their use 
 involves no danger to the ear, we must often be contented 
 with some form of spray-producing apparatus in the 
 hands of the patient, especially in the case of unruly 
 children. A copious spray, followed by repeated blow- 
 ing of the nose, will remove fluid secretion fairly well, 
 but not adherent crusts. Considerable air-pressure is 
 necessary to produce a good spray. A single rubber bulb 
 is preferable to a double bulb. For office use a tank for 
 compressed air is a great convenience, though not an 
 absolute necessity. About 20 pounds' pressure answers 
 all demands. When the spray is used for cleansing pur- 
 poses, a i per cent, solution of sodium bicarbonate is all 
 that is required. 
 
 Antiseptics of a sufficient strength for actual disinfection
 
 TREATMENT IN NASAL AND PHARYNGEAL AFFECTIONS. 69 
 
 are not tolerated by the mucous membrane. Besides, it 
 has been shown by numerous experiments that mucous 
 membranes cannot be sterilized in the same manner as the 
 skin. The only substances suitable for sprays to which 
 a distinct influence and perhaps a slight antiseptic effect 
 can be ascribed in the treatment of nasal diseases are the 
 essential oils dissolved in water. These solutions are not 
 irritating ; if anything, they are agreeable and clinically 
 superior in their therapeutic effect to indifferent fluids. 
 After many trials the author has found the following 
 preparation the most agreeable : Oil of cloves, 2 per 
 cent.; oil of wintergreen, 0.5 per cent. ; menthol, 0.5 
 per cent., are triturated with magnesia, and the necessary 
 quantity of water, with the addition of i per cent, of 
 sodium bicarbonate, is added and the mixture filtered. 
 Only a part, however, of the essential oils really enters 
 into solution. A favorite solution with many for nasal 
 use is Seiler's antiseptic solution, which contains: 
 
 Sodium bicarbonate 240 grains 
 
 Borax 240 " 
 
 Sodium benzoate 10 " 
 
 Sodium salicylate 10 " 
 
 Eucalyptol 5 minims 
 
 Thymol 5 grains 
 
 Menthol 2^ grains 
 
 Oil of wintergreen 3 drops 
 
 Glycerin 4 ounces 
 
 Alcohol ' I ounce 
 
 Water to make 8 pints. 
 
 The ingredients are also put up in tablets, of which one 
 is intended for a two-ounce solution. For nasal use 
 Dobell's solution, quoted extensively in text-books, con- 
 sists of : 
 
 Borax I dram 
 
 Glycerinated carbolic acid (20 per cent.) . . . 2 drams 
 
 Sodium bicarbonate I dram 
 
 Tepid water pint. 
 
 Neither of these solutions can be said to possess any
 
 7O NASAL AND PHARYNGEAL AFFECTIONS. 
 
 therapeutic influence beyond the mechanical effect they 
 exert as spray or wash. 
 
 An antiseptic fluid of great penetrating power and in- 
 tense germicidal action (within a few seconds) is Loffler s 
 solution, much used in diphtheritic and other infectious 
 forms of pharyngitis. Its formula is 
 
 Menthol 10 
 
 Toluene 36 
 
 Creolin 2 
 
 Tincture of iron chlorid 4 
 
 Alcohol up to 100. 
 
 To be applied undiluted and kept in contact for at least 
 ten seconds (see 1 203). 
 
 Oily solutions made with liquid petroleum or the hydro- 
 carbons, known as albolene, etc., can be diffused well in 
 the form of fine sprays by the class of atomizers known 
 as vaporizers. The author, by unprofitable experience, 
 has become fully satisfied, however, that there is no 
 permanent benefit of any kind to be obtained from oily 
 solutions. Even the striking influence of menthol solu- 
 tions in vaselin is but transient, and gives no satisfactory 
 result in the end. 
 
 Fluids are best applied to small areas of the nasal sur- 
 face on pledgets of cotton wound around wooden tooth- 
 
 FIG. 20. Pharyngeal applicator. 
 
 picks. Applications to the pharynx require the use of 
 long wire applicators, the end of which is bent at a right 
 angle (Fig. 20). Cotton is wrapped around the screw- 
 thread at the end. Brushes and sponges should never be 
 successively used on more than one patient.
 
 ACTION OF DRUGS. . 7! 
 
 Powders are blown into the nose and pharynx by means 
 of insufflators (Fig. 24). Such instruments, with a re- 
 ceiver for holding a store of the powder, have been 
 devised by the author, De Vilbiss, and others. Curved 
 tube attachments permit the blast to be directed upward 
 in the pharynx. An additional tubular nozzle facilitates 
 asepsis of the end of the instrument. 
 
 The lower pharynx is commonly supposed to be reached 
 by gargling. This is not entirely true. During gargling 
 contact between the root of the tongue and the soft pal- 
 
 FlG. 21. Author's powder-blower. 
 
 ate separates the mouth from the pharynx proper, and 
 drops of the solution pass this barrier only by accident. 
 This has been shown by using staining solutions. Hence 
 since the gargling fluid reaches the rear pharyngeal wall 
 but very imperfectly, this mode of application is less 
 efficient than that of brushing or sprays. 
 
 36. Action of Drugs upon the Respiratory Mucous Mem- 
 brane. Cocain constricts the blood-vessels of the surface 
 to which it is applied, and thus shows the difference be- 
 tween their distended and contracted condition. Its 
 effect, hence, permits a better view of the interior of the 
 nose. It gives a subjective feeling of clearing of the 
 nose, which is more marked the greater the previous 
 obstruction caused by vascular distention. A 2 per cent, 
 solution does this fairly well unless the mucous mem- 
 brane is inflamed, when a strength of about i : 20 is 
 required. A spray of this strength is harmless if used
 
 72 . NASAL AND PHARYNGEAL AFFECTIONS. 
 
 sparingly. For anesthesia a solution of at least 5 per 
 cent, strength is necessary. If deep action is desired, 20 
 per cent, and from five to ten minutes' contact are re- 
 quired. The anesthesia lasts from ten to twenty minutes. 
 The author has made use of this strength of cocain solu- 
 tion on pledgets of cotton tightly wrapped around tooth- 
 picks in thousands of instances, and has never seen any 
 alarming effects produced. It is not an uncommon occur- 
 rence, however, for the patient to complain of subjective 
 faintness or "nervousness," due partly to the cocain and 
 partly to the dread of operations, and it is well to be pre- 
 pared to have the patients lie down for a few minutes. 
 When, formerly, the author used cocain on loose pledgets 
 of cotton, he saw these accidents more frequently and 
 twice was embarrassed by acute maniacal attacks lasting 
 a few hours. In children I have occasionally observed 
 embarrassing talkativeness after the pharyngeal use of 
 cocain. Since more serious accidents have been recorded 
 by others, care should be used in the employment of 
 cocain to avoid any dripping of the solution into the 
 lower part of the throat. 
 
 A deep localized anesthesia can be obtained by the 
 submucous injection of weak solutions of cocain (0.5 to 
 i per cent.) or eucain (0.2 percent, in indifferent salt 
 solution (0.6 per cent.) according to the Schleich method 
 of infiltration. This is especially applicable in operations 
 on the septum. An ordinary hypodermic syringe with 
 long needle is required. 
 
 An excellent substitute for cocain for the purpose of 
 local anesthesia is nirvanin. It has been found harmless 
 and not productive of poisonous effects, but it acts only 
 when injected into the tissues, and not on the free sur- 
 face. It may be used in from 3 to 5 per cent, solution in 
 water. 
 
 In order to anesthetize the pharynx the applicator, 
 moistened, but not dripping, with cocain solution (20 
 per cent.), must be held in place for a few minutes. The 
 pharyngeal anesthesia is neither complete nor deep.
 
 ACTION OF DRUGS. 73 
 
 Cocain anesthesia in the nose or pharynx is very much 
 intensified by the anemia caused by a prior employment 
 of suprarenal extract. Under no circumstances should 
 cocain be given into the hands of patients, for fear of 
 inducing the pernicious cocain habit. The relief this 
 drug gives in turgescence of the nasal lining is a great 
 temptation to its continued use. In cases of known 
 idiosyncrasy against cocain eucain /9 may be used in its 
 stead in 5 per cent, solution for purposes of anesthesia, 
 but otherwise it has no advantage over cocain. Bucain 
 does not constrict the blood-vessels. 
 
 Orthoform has no influence upon intact mucous surfaces, 
 but its remarkable anesthetic effect upon exposed tissues 
 can be utilized advantageously by blowing the powder 
 upon painful wounds for instance, after tonsillotomy. 
 Intranasal wounds do not ordinarily require it. 
 
 A solution of the active principle of the suprarenal 
 gland produces an intense anemia upon local application, 
 which continues for one or two hours. On inflamed sur- 
 faces its effect is more difficult to obtain and more tran- 
 sient. Its use renders nasal operation almost bloodless. 
 Its previous application intensifies cocain anesthesia. A 
 5 to 10 per cent, solution suffices. The solution filters 
 very slowly, and hence may be prepared by allowing the 
 dried powder from which it is made to settle by deposi- 
 tion. It putrefies speedily unless preserved sterile'. It is 
 not altered by boiling, but the sterility is lost on opening 
 the flask. The addition of i per cent, chloroform (more 
 than enough to saturate water) preserves it permanently. 
 The chloroform is only very slightly irritant, and may, 
 besides, be driven off by heating. Chloroform is also a 
 useful agent for the preservation of sterility of other solu- 
 tions, kept in bottles repeatedly opened for instance, 
 cocain. As a spray for the temporary reduction of intra- 
 nasal turgescence a solution of cocain (2 per cent.) and 
 suprarenal extract (2 per cent.) is very appropriate in the 
 hands of the surgeon. In rare instances, however, supra- 
 renal solution causes disagreeable sneezing fits coryza
 
 74 NASAL AND PHARVNGEAL AFFECTIONS. 
 
 vasomotoria. Suprarenal solution loses its activity grad- 
 ually. In order to be reliable it should have been pre- 
 pared within less than one week. 
 
 Menthol, too, produces constriction of the venous plexus 
 in the mucous membrane, but less than cocain. The 
 subjective feeling of clearness due to the reduced turges- 
 cence is intensified by the cooling sensation caused by 
 menthol, but it does not anesthetize the surface. A fine 
 spray of menthol dissolved in six parts of fluid vaselin or 
 albolene gives a pleasant relief whenever the nasal pas- 
 sage feels " stuffy," but the effect is transient in propor- 
 tion to the inflammatory condition causing the vascu- 
 larity. Coarse sprays or menthol solution applied directly 
 are irritating. 
 
 37. Surgical Procedures in the Nose and Pharynx In 
 order to avoid repetition it may be convenient to describe 
 certain surgical measures which are employed in various 
 morbid conditions. 
 
 Cauterization. Superficial cauterizations can be made 
 with a bead of silver nitrate melted on a probe without 
 unpleasant reaction. A deeper caustic effect is obtained 
 by chromic acid handled in the same way. The excess 
 should be washed away with sodium bicarbonate solution. 
 Chromic acid burns are often slow in healing. This dis- 
 advantage does not apply to cauterization with trichlor- 
 acetic acid, which causes less inflammatory reaction 
 than the former, while very voluminous eschars indicate 
 its penetrating power. Its hygroscopic nature renders 
 it awkward to manage. Only fresh dry crystals can be 
 melted on a probe, and this with difficulty. The crystals 
 can be held in cup-shaped applicators, or when melted 
 may be absorbed by cotton wound around a probe. The 
 application of the acid should be followed at once by an 
 alkaline wash. The slough produced by chemical or 
 actual cauterization becomes detached within from four 
 to seven days, according to its depth. The wound then 
 heals in from six to fifteen days and requires no treatment 
 except occasional removal of crusts.
 
 SURGICAL PROCEDURES IN THE NOSE AND PHARYNX. 75 
 
 The deepest and most localized caustic effect is obtained 
 by means of galvanocaustic burners shaped according to 
 the locality and object they are intended for (Figs. 22 
 and 23). The handle of the cautery must have a push- 
 
 FIG. 22. Galvanocaustic burners. 
 
 button in order to regulate the duration of the current. 
 By far the most convenient source of electricity is a con- 
 verter attached to a low tension, alternating street current, 
 when accessible, as this requires no care. When only a 
 
 FIG. 23. Handle for galvanocaustic electrodes. 
 
 "constant" street current is available, the problem of 
 getting a current of low voltage (from 6 to 10 volts) and 
 of sufficient intensity (20 to 25 amperes) is more compli- 
 cated. The large rheostats supplied by makers cannot be 
 recommended. They are expensive, absorb very much 
 current, and still give too high a voltage, which, in case 
 of a "leak," may prove at least very unpleasant, if not 
 dangerous. It is preferable to interrupt the current by a 
 motor and then to reduce the voltage by a converter, as 
 sold by the Edison and other companies. A "motor 
 converter" may be used, which, by double winding of 
 the armature, gives a suitable current of low voltage. An 
 excellent one made by the Victor Electric Co., of Chicago, 
 has been used by the author for several years with .satis- 
 faction (Fig. 24). The motor itself, when connected 
 with a "dental arm," is a very convenient source of
 
 76 NASAL AND PHARYNGEAL AFFECTIONS. 
 
 power for operations with drill or trephine. A storage 
 battery of two, or, better still, three, cells of good make 
 and well charged in the first place is the next best source 
 of electricity. It must be kept charged by connection 
 with a lighting current at intervals of some weeks. If 
 allowed to remain inactive too long, "it runs down" 
 by means of internal chemical changes and then re- 
 quires a charging current of several amperes in order to 
 be restored. Constant batteries generally require fre- 
 
 FIG. 24. Victor motor transformer for cautery with attachment for dental 
 cable for operating drills, etc., also an attachment for pump for ear massage. 
 
 quent attention and refilling in order to keep in good 
 condition. The directions are supplied by the manu- 
 facturer. Perhaps the most desirable of all available 
 cells is the Edison Lacland type, largest pattern, of which 
 three in series, or six in two series of three, are necessary. 
 Since both constant batteries and storage-cells lose 
 slightly in the course of time, it is best to have an excess 
 of power in the first place. A small rheostat or the re- 
 sistance of a variable length of thick German-silver wire
 
 SURGICAL PROCEDURES IN THE NOSE AND PHARYNX. 
 
 regulates the strength of current. With a voltage of at 
 least six volts the cords used commercially for electric 
 drop-lights (largest size) are available in preference to the 
 stiffer cords generally sold by the surgical supply houses. 
 
 The object of cauterization is to re- 
 move redundant tissue. If this can be 
 done with scissors or snare, a clean and 
 rapidly healing wound is left, which 
 is much preferable to the slow heal- 
 ing and discomfort of a burnt wound. 
 But cutting instruments are not al- 
 ways applicable, especially in the case 
 of flat tumefactions or enlargement of 
 the submucous venous plexus. The 
 heated burner acts beyond the area of 
 the eschar which it produces, causing 
 thrombosis in the adjacent vessels, with 
 considerable ultimate obliteration. It 
 is an advantage to destroy as little as 
 possible of the mucous surface, which 
 can be done by making multiple deep 
 punctures instead of extensive surface 
 burns. The larger the surface that has 
 been destroyed, the slower the healing 
 and the greater the probability of sec- 
 ondary infection during healing. Be- 
 sides, the resulting scar is liable to 
 be covered with crusts for long periods 
 of time. Attempts have been made at 
 submucous cauterization with needle- 
 shaped burners, but the results do 
 not differ materially from multiple 
 punctures. 
 
 28. An instrument much used for FIG. 2 s.-jarvis' snare, 
 nasal work is the snare (Figs. 25, 26, 27). The most 
 convenient form is that in which the wire is threaded 
 through an eye in a stilet, like Wright's and Krause's. 
 Otherwise much time is wasted in pulling the wire
 
 70 NASAL AND PHARYNGEAL AFFECTIONS. 
 
 through the cannula. Steel piano wire is used, but 
 should not be bought on spools, as such winding curls 
 
 FIG. 26. Wright's snare. 
 
 it too much. The snare loop is slipped around the 
 utmost base of the growth to be removed. When the 
 
 FIG. 27. Krause's nasal snare (with stilet). 
 
 growth is flat and does not project, it can be transfixed 
 with a needle (Fig. 28), over which the loop of wire is 
 
 FIG. 28. Jarvis' transfixion needle. 
 
 slipped. Where hemorrhage is feared on account of 
 vascularity, the cutting should be done very slowly
 
 HEMORRHAGE FROM THE NOSE. 79 
 
 (preferably with a Jarvis snare, the nut of which is 
 turned gradually). 
 
 The hot snare (Fig. 29), an attachment to the galvano- 
 cautery handle, has little advantage over the cold snare. 
 The difference in the amount of bleeding is, as a rule, 
 only slight, whereas the inconvenience of the hot snare 
 to the surgeon is considerable. The same steel wire may 
 be used as in the cold snare, but must be replaced each 
 time. Platinum wire is not much better and very ex- 
 pensive. 
 
 29. Hemorrhage from the nose or that following opera- 
 tions in the pharynx will generally cease spontaneously 
 if not of arterial origin. The patient should keep quiet 
 
 FIG. 29. Galvanocaustic snare-handle (Kuttner's). 
 
 and reduce the blood pressure in the head by standing 
 upright or at least sitting. Tannin and other astringents 
 blown into the nose or pharynx do not stop bleeding. 
 A more definite effect on hemorrhage can be obtained 
 by the use of coarse glutol powder, which probably 
 acts mechanically. If the nasal bleeding is arterial 
 if it spurts and is bright red or even if venous, and 
 does not cease soon or is very copious, the nose must be 
 plugged. A strip of iodoform gauze i to 2 cm. wide and 
 about | m. in length is packed in with the probe. 
 Cotton will answer equally well for the time, but in the 
 case of wounds does not help to keep them aseptic. It 
 is handy to wind the cotton in required thickness upon 
 tooth-picks, using a sterile cloth over the fingers in order
 
 8O NASAL AND PHARYNGEAL AFFECTIONS. 
 
 not to infect the cotton. If the hemorrhage is from the 
 rear end of the turbinal or from the pharyngeal vault, 
 the upper pharynx must be packed. A plug of iodoform 
 gauze or iodoform cotton with a string attached can be 
 pushed up behind the palate through the pharynx by 
 means of curved forceps, if necessary with the aid of a 
 palate retractor. This is difficult on account of the 
 patient's gagging. A neater way is by means of a 
 Belloc's sound (Fig. 30). The slightly curved tube is 
 passed through one nostril. A springy stilet, when 
 pushed through this tube, curves down behind the soft 
 palate, and the cord attached to a gauze plug can then be 
 threaded through the eye of the stilet in the mouth. 
 Upon withdrawal of the Belloc sound this cord can now 
 be pulled at its emergence from the nostril, and the plug 
 
 FIG. 30. Belloc's sound for plugging the postnasal space. 
 
 thus be lifted into place. A second string attached to 
 the plug hangs out of the mouth and is tied over the 
 upper lip to its mate in the nose. 
 
 Packing does not stop the visible hemorrhage instantly : 
 it usually requires a few minutes' waiting. If the 
 hemorrhage persists to an alarming extent after packing, 
 cotton plugs moistened with iron persulphate will control 
 it. On account of the irritation that they produce, how- 
 ever, they should never be used except in case of positive 
 danger. Less disagreeable than the iron solution and 
 nearly as effective is the combination of antipyrin and 
 tannin, which forms a sticky paste. The cotton plug or 
 pledget is brushed with antipyrin solution (10 per cent.), 
 then dusted freely with tannin powder. In persons 
 known to be bleeders it is best to avoid nasal operations,
 
 HEMORRHAGE FROM THE NOSE. 
 
 8l 
 
 if possible. In such subjects even the galvanocaustic 
 burner may lead to embarrassing secondary hemorrhage. 
 Several personal experiences, however, with bleeders 
 terminated well ultimately. 
 
 30. At the present time every surgeon recognizes that 
 it is his duty to have every instrument sterilized before it 
 is brought into contact with a wound or an absorbing sur- 
 
 FIG. 31. Author's sterilizer with removable bottom (B) and cover (C). D is 
 a steam chamber for steam disinfection. 
 
 face. The only method that gives absolute assurance of 
 complete disinfection is three minutes' boiling in i per 
 cent, sodium carbonate solution. In the absence of spores, 
 even one minute suffices to kill germs. On account of 
 the solvent action of hot soda solution upon dirt this ren- 
 ders unnecessary the painstaking scrubbing which must 
 precede immersion in cold antiseptic solutions (5 per 
 
 6
 
 82 NASAL AND PHARYNGEAL AFFECTIONS. 
 
 cent, carbolic acid or o. i per cent, corrosive sublimate). 
 It is advisable to have a sterilizing kettle (Fig. 31) in 
 permanent use next to the instrument table, and to get 
 into the habit of throwing all instruments into it after 
 use. For instruments used merely for examination and 
 not coming into contact with wounds, for instance, the 
 rhinoscopic mirror and the nasal speculum, scrubbing 
 with a brush under running water suffices, whereas the 
 mere dipping into a disinfecting solution is useless, 
 because inefficient. When there is any suspicion, how- 
 ever, of contagious disease, syphilis, tuberculosis, diph- 
 theria, or even acute angina, it is our duty to boil the 
 instruments after use, even if the rhinoscopic mirror does 
 deteriorate gradually. The nozzles of rubber throat- 
 atomizers withstand boiling without damage. Cotton 
 swabs wound on tooth-picks for mopping and for applica- 
 tions can be kept aseptic by handling the cotton with a 
 sterile cloth instead of with the naked fingers. 
 
 It has been claimed by St. Clair Thompson and Hew- 
 lett that the normal nasal lining is generally free from 
 bacteria, and that they are largely deposited in the vesti- 
 bule or expelled from the mucous surface by the move- 
 ments of the epithelial cilia. As all other mucous mem- 
 branes are likely to have germs upon their surfaces, this 
 statement ought not to be accepted fully until it is 
 extensively corroborated. The impossibility of practi- 
 cally sterilizing other even more accessible mucous mem- 
 branes, like those of the conjunctiva or vagina, excludes 
 all hope of successfully sterilizing the surfaces of nose or 
 pharynx by present methods. Since the nasal mucous 
 membrane cannot be made sterile, we cannot guarantee 
 an aseptic course after operations. Attempts to keep the 
 surfaces protected against germs by means of painting 
 with methyl-violet and other antiseptic substances have 
 not proved successful and do not seem rational to the 
 bacteriologist. The only real protection is afforded by 
 iodoform gauze packed closely against a wound, since 
 iodoform in powder form is soon swept away by secretion.
 
 HISTORY AND LITERATURE. 83 
 
 Clinical experience has led me to trust, to some extent, 
 to glutol in coarse powder blown upon the thoroughly 
 clean and dry wound. This substance, by reason of its 
 absorbing power, helps to stop bleeding and forms a well- 
 adhering crust under which wounds in the nose and 
 throat have healed in a very clean and rapid manner. 
 Fortunately, however, wounds in the nose and throat do 
 not often follow an untoward course. Superficial infec- 
 tion is almost inevitable except under iodoform gauze or 
 under a glutol scab, but suppuration of wounds is not 
 common in the nose, although more so in the pharynx. 
 Traumatic erysipelas is very rare. Pyogenic infection 
 of nasal wounds sometimes leads to acute tonsillitis on 
 the same side and perhaps later on the other side or to 
 suppurative inflammation of the middle ear or of the 
 maxillary sinus. Streptococcus infection may manifest 
 itself by the prolonged formation of false membranes 
 with delayed healing, but usually without serious 
 danger. 
 
 History and Literature. The former scanty knowledge con- 
 cerning .surgical diseases of the nose and pharynx (polypi, ma- 
 lignant tumors, empyema of frontal and maxillary sinus, and 
 tonsillar enlargement) can be found in the text-books on surgery 
 of the various times. From a medical point of view, these parts 
 received no attention worth mentioning prior to the introduction 
 of the laryngoscope by Tiirck and Czermak (1858), except in the 
 case of acute infections of the pharynx. In 1859 Czermak applied 
 the inverted laryngoscopic mirror to the postnasal space. Ante- 
 rior nasal inspection through a speculum was employed by Mar- 
 kusovszki, of Pesth, in 1859, but popularized by Thudichum 
 (Duplay, and especially B. Frankel) only after 1868. Thudichum 
 also introduced into therapeutics the nasal douche (1864) pre- 
 viously used for physiologic purposes by Weber. The danger 
 of the douche to the ear was later shown by Roosa. While the 
 knowledge of the various affections of the nose was gradually 
 augmented by laryngologists of all countries, the most important 
 discovery regarding postnasal pathology was the description 
 of the enlarged pharyngeal tonsil (adenoid vegetations) by W. 
 Meyer, whose first report in Danish literature in 1868 was supple- 
 mented by his more accessible German publication in 1873. 
 Medical interest in the nose as a source of wide-spread nervous
 
 84 NASAL AND PHARYXGEAL AFFECTIONS. 
 
 "reflexes" (asthma, headache, etc.) was aroused by Hack's an- 
 nouncements in 1881, continued for several years. The important 
 role played by the accessory cavities in suppuration hitherto con- 
 sidered of intranasal origin was emphasized by Ziem in 1881, and 
 has received extensive attention within the last twelve years. 
 
 Rhinologic study should begin with the fundamental treatise 
 by Zuckerkandl on the anatomy of the nose (magnificently illus- 
 trated), Normale und pathologische Anatomic der Nasenhohle, Bd. 
 i., 1882, and 2. Ed., 1893, Bd. ii., 1892. Nasal pathology is illus- 
 trated by Seifert and Kahn's Atlas der Histopathologie der JVase, 
 Mundrachenhohle, und des Kehlkopfs, 1895. Among general 
 treatises on nose and pharynx B. Frankel's volume in Ziemssen's 
 Handbuch d. spec. Pathologic (1876) was the earliest in date, while 
 among the most comprehensive recent text-books may be men- 
 tioned Burnett's System of Diseases of the Ear, Nose, and Throat, 
 1893, and especially the Handbuch der Laryngologie und Rhinol- 
 ogie, begun in 1896 under the editorship of P. Heyman. Among 
 the landmarks on this subject may be mentioned the Diseases of 
 the Throat and Nasal Passage by J. Solis Cohen, 2 Ed., 1879, an( i 
 The Diseases of Nose and Throat, by Morell Mackenzie, vol. i., 
 1880, and vol. ii., 1884. Much historic information can be found 
 in this work and in J. N. Mackenzie's articles on "Nasal Affec- 
 tions" in Wood's Reference Handbook of the Medical Sciences, 
 vol. viii.
 
 CHAPTER IV. 
 
 DISEASES OF THE VESTIBULE OF THE NOSE. 
 CORYZA. 
 
 DISEASES OF THE VESTIBULE. 
 
 31. The entrance into the nose is not often the prim- 
 ary seat of disease, but suffers frequently in the course of 
 various intranasal affections, especially purulent rhinitis. 
 
 Ecsema occurs sometimes in the acute, more often in 
 the chronic, form. The characteristic vesicles are soon 
 transformed into moist scabs covering an excoriated, 
 bleeding surface. The patch extends usually downward 
 over the upper lip, but is sometimes limited to the floor 
 and sides of the vestibule. Eczema is most commonly 
 seen in scrofulous children. Sometimes it is also a per- 
 sistent annoyance in adults with morbid nasal secretion. 
 When of long duration, it is likely to cause thickening 
 of the upper lip, typically seen in scrofulous children. 
 The eczematous abrasion may permit the entrance of the 
 tubercle bacillus into the lymphatic system, as indicated 
 by permanent enlargement of the anterior cervical lymph- 
 glands. It may likewise prove the starting-point of 
 facial erysipelas. The eczematous crusts should be re- 
 moved, and the surface protected by a zinc oxid lanolin 
 salve (50 per cent.). Rebellious cases are cured in the 
 quickest manner by cauterization with silver nitrate, 
 repeated if necessary. Oil of cade salve (i : 4) and 
 balsam of Peru act more slowly, but are especially useful 
 in preventing relapses. 
 
 An annoying and easily overlooked lesion is a shallow 
 fissure at the junction of the septum and the lateral wall 
 of the external nose. It is more or less painful, always 
 tedious in its course, and likely to recur if partially 
 healed. Sometimes it maintains an embarrassing red- 
 
 85
 
 86 DISEASES OF THE VESTIBULE OF THE NOSE. 
 
 ness of the tip of the nose. Occasionally it is the start- 
 ing-point of spells of sneezing. Its presence favors acute 
 " colds." A fissure causes pain when the nasal speculum 
 is inserted. It can be seen on searching for it. It yields 
 most readily to repeated applications of silver nitrate 
 solution (30 per cent.) on thin cotton applicators. 
 
 Furuncles of the hair-follicles in the vestibule give 
 rise to decided pain and swelling and sometimes to exter- 
 nal redness. A furuncle can be recognized as a small 
 papular swelling on the inner surface of the side of the 
 nose. It should be incised if it has not broken sponta- 
 neously. Relapses are common. The best prevention 
 in my experience is to brush the inside of the side of the 
 vestibule with a weak (4 per cent.) solution of silver ni- 
 trate once in a few days for a number of weeks. 
 
 CORYZA; ACUTE NASAL CATARRH; ACUTE PURULENT 
 RHINITIS (SNUFFLES, IN NURSERY PARLANCE). 
 
 32. Acute nasal catarrh is the most common of all dis- 
 eases. Very few persons pass many years without an 
 attack. The well-formed normal nasal passages of vig- 
 orous individuals may not be invaded for a number of 
 successive years, while poor health and especially de- 
 formed nasal passages and chronic intranasal lesions pre- 
 dispose to repeated attacks within one season. Hered- 
 itary syphilis is a noteworthy predisposing condition in 
 infants. No age is exempt, but coryza occurs less fre- 
 quently after middle age is passed. Least common dur- 
 ing equable weather in summer, or during a uniform dry, 
 cold spell in winter, it is most prevalent after changeable 
 weather in fall and spring. Its geographic distribution, 
 too, corresponds with the peculiarities of the climate. 
 
 The attack begins with sneezing, followed by a feeling 
 of fulness in the nose and head, which culminates after 
 some hours in nearly total occlusion of at least one side 
 of the nose, sometimes of both. At the same time there 
 occurs a watery, acrid discharge, becoming purulent in 
 the course of about twenty-four to thirty-six hours,
 
 CORYZA. S/ 
 
 after which time the secretion is a thick, purulent mucus 
 of yellowish-greenish tinge, sometimes slightly bloody. 
 The full feeling increases during the first day, and is 
 sometimes accompanied by considerable headache. On 
 account of the swelling around the Eustachian orifice the 
 ears may feel "stuffy. " In children, less commonly in 
 adults, a febrile rise of temperature of from i to 3 F. 
 may be noticed. Quite often a general feeling of malaise 
 and lassitude is felt. The tongue becomes coated, the 
 appetite often is impaired, all the more so as the sense of 
 smell may be absent and hence taste interfered with. 
 The smoker refuses his cigar. 
 
 In the typical attack, not modified by preexisting 
 chronic nasal disease, this condition lasts two or three 
 days, and then begins to decline. The nose becomes 
 clearer, at least one side at a time, although the dis- 
 charge is more likely to increase during the first three 
 days. The secretion is likely to cause excoriation of the 
 skin at the entrance of the nose, which in its turn may 
 prolong the annoyance. The discharge changes grad- 
 ually into clearer mucus with purulent flakes. In un- 
 complicated instances, not prolonged by exposure, all 
 symptoms disappear completely in from six to ten days. 
 
 Inspection shows the mucous membrane to be red- 
 dened and thickened. The occlusion of the passage is 
 partly due to turgescence of the submucous venous 
 plexus. This may be overcome transiently by the pres- 
 sure of a probe or by the action of cocain or suprarenal 
 extract. The mucous membrane, however, is, besides, 
 swollen from infiltration with leukocytes and serum. 
 During the receding period the vascularity diminishes 
 and the membrane is sometimes seen to be edematous 
 soggy. Acute rhinitis is a diffuse process involving the 
 entire lining of the nose uniformly. Examination with 
 the postnasal mirror, when feasible, shows that the phar- 
 yngeal tonsil is, as a rule, involved, being reddened and 
 swollen, though to a variable extent in different patients. 
 In some instances the inflammatory redness and swelling
 
 88 DISEASES OF THE NOSE. 
 
 extend visibly along the pharyngeal mucous membrane 
 down below the level of the soft palate. 
 
 Histologically, coryza is a diffuse leukocytic infiltra- 
 tion, with congestion of all vessels, especially the venous 
 plexus, and with partial loss of the ciliated epithelium. 
 
 Deviations from the clinical course, as described, may 
 occur in either direction. In patients with either chronic 
 suppurative or hypertrophic rhinitis acute exacerbations 
 occur with symptoms of a milder character than in the 
 typical attack. The climax, which is not so severe as 
 in a hitherto normal nose, is reached within the first day, 
 and within from three to five days the symptoms subside 
 to the grade they presented prior to the fresh ' ' cold. ' ' 
 Some patients give the history of frequent "colds" 
 lasting only a few hours. These are, however, not in- 
 flammatory attacks at all, but merely spells of turgescence 
 of the cavernous tissue, with sneezing, occlusion of the 
 nose, and a copious water} 7 discharge entirely free from 
 pus. On the other hand, nasal stenosis may cause a pro- 
 longation of the climax for several days and may lead to 
 an indefinite persistence of the symptoms during the 
 declining stage. Delay in the disappearance of an acute 
 coryza may also be caused by exposure to inclement 
 weather and insufficient protection against cold. 
 
 In the light of our present knowledge we cannot but 
 attribute acute purulent rhinitis to the action of some 
 widely distributed parasite. In spite of many attempts 
 the virus ha's not yet been identified. At times coryza 
 attacks a number of persons in a household in succession, 
 so that a suspicion of contagiousness seems warranted. 
 Direct inoculations, however, with the discharge have 
 failed to transfer the disease. The presence of various 
 forms of pyogenic cocci during the declining stage, and 
 especially in protracted nasal suppuration, makes it prob- 
 able that secondary infection often plays a role. Popu- 
 larly, acute catarrh is always ascribed to " taking cold." 
 As stated in Chapter II., there is no reason to doubt that 
 chilling is an important factor in causing chronic cir-
 
 CORYZA. 89 
 
 cu inscribed inflammatory processes to become acute and 
 diffused. The fact, however, that the same chilling of 
 the body does not always or even often lead to the same 
 result signifies that it must coincide with other influ- 
 ences which we do not know. In the acute catarrh of 
 hitherto normal noses the chance of satisfactory inquiry 
 is so rarely afforded to the physician that a definite opin- 
 ion concerning the importance of " taking cold " cannot 
 be given. 
 
 An acute purulent rhinitis is often a part of the clinical 
 picture of influenza, although this disease may also occur 
 without it. In measles there is always an inflammatory 
 condition of the nose, with watery discharge as the first 
 manifestation. In some instances the nasal symptoms 
 subside without suppuration as soon as the cutaneous 
 eruption has appeared; in others they develop into an 
 ordinary coryza which is apt to be prolonged in a sub- 
 acute form. 
 
 Coryza involves no danger to life in the adult. In 
 infancy, when the nasal passages are relatively narrow, it 
 may be accompanied by great swelling (and subsequent 
 hypertrophy of the pharyngeal tonsil), and the inter- 
 ference with nasal respiration, causing dyspnea and rest- 
 lessness, gives the appearance of serious danger. But, 
 after all, fatal issues must be very uncommon, if they 
 ever do occur in uncomplicated cases. A serious danger 
 in infants is the possible complication with bronchitis 
 and bronchopneumonia. Although complete spontaneous 
 recovery is by far the most common result, acute catarrh 
 may change into a persistent chronic inflammation if 
 there is nasal stenosis, if it be prolonged by exposure, or 
 if often recurrent. The acute inflammation may also 
 extend into the accessory cavities. This is probably the 
 case more often than is now taught, especially so far as 
 the ethmoid cells and sphenoid sinus are concerned, and 
 the severe headache sometimes present during a u cold " 
 is probably due to this extension. However, most of the 
 acute inflammations of the sinuses heal spontaneously.
 
 9O DISEASES OF THE NOSE. 
 
 Quite often acute rhinitis is attended with acute con- 
 junctivitis, which can be improved by treatment (zinc 
 sulphate solution, 0.5 per cent., or brushing with silver 
 nitrate solution, i to 2 per cent.), but not entirely cured 
 until the nose has become normal. The greatest danger 
 of the disease is the extension into the ear, as secretory 
 catarrh or acute purulent otitis most likely when there 
 is nasal stenosis. Coryza is rarely followed by tonsillitis, 
 more often by tracheitis and bronchitis. 
 
 The diagnosis depends upon the acute nasal obstruc- 
 tion and purulent discharge. In doubtful cases inspec- 
 tion must not be omitted. A careless observer may 
 make the diagnosis of simple coryza in cases of mem- 
 branous or diphtheritic rhinitis, abscess of the septum, 
 and in diphtheritic and non-diphtheritic inflammation of 
 the pharyngeal tonsil. Genuine coryza must be differ- 
 entiated also from acute but transient non-inflammatory 
 vasomotor disturbances (spells of turgescence) in which 
 there is no purulent discharge, and from the effects of 
 iodism upon the nose. In iodin poisoning there is 
 likewise no purulent, but merely a watery, secretion, 
 although later on a secondary infection may change the 
 character of the fluid. Moreover, the iodin effect ceases 
 speedily on withdrawing the drug. 
 
 There is no treatment that can be considered curative 
 or even permanently palliative. All statements concern- 
 ing therapeutic results are merely copied from one book 
 to another, or bear the stamp of hasty and unfounded 
 generalization, and are found to be untrue when tested 
 clinically. The popular belief in the abortive effect of 
 quinin is a myth. Coryza cannot be aborted any more 
 than any other infectious disease for which we possess no 
 specific treatment. Cocain gives momentary relief, but 
 no permanent benefit. The same is true of the douche. 
 Suprarenal solution as a spray (2 to 5 per cent.) has a 
 more lasting, even if transient, palliative effect, and is 
 less objectionable than cocain. The quickest course is 
 observed if the patient stays in the uniformly warm
 
 COKYZA. 91 
 
 room and avoids physical exertion. The headache of 
 accompanying sinus involvement can be checked by 
 antipyrin in the dose of i gram for an adult. The ex- 
 coriations of the skin under the nose heal under any 
 bland salve (oxid of zinc ointment or cold cream). The 
 treatment of subacute exacerbations and chronic pro- 
 longation will be found in Chapter V.
 
 CHAPTER V. 
 
 CHRONIC NASAL INFLAMMATIONS; "CHRONIC 
 CATARRH"; CHRONIC PURULENT RHINITIS. 
 
 33. Chronic Catarrh. The various forms of chronic 
 nasal disease give rise to very similar symptoms viz., 
 discharge and obstruction. These symptoms were hence 
 referred by the older writers, and are still by the pub- 
 lic, to the existence of a ''chronic catarrh." The so- 
 called "catarrh," however, can be resolved into a num- 
 ber of separate affections and lesions, varying in character 
 and significance. This clinical analysis is made difficult 
 by the frequent coexistence of several lesions in the nose 
 or throat. By selecting from a larger experience those 
 cases in which only single lesions are present, certain 
 types of nasal and nasopharyngeal disease can be estab- 
 lished, which the diagnostician must recognize whether 
 they occur in uncomplicated or in associated forms. The 
 special term "chronic catarrh," if it is to be applied in 
 its conventional sense to a chronic inflammation of a 
 mucous membrane attended with mucous discharge, may 
 be reserved for that form of nasal disease in which there 
 is an excessive production of mucus viz., retronasal 
 catarrh. The ordinary chronic nasal and pharyngeal 
 affections comprised under the generic term "catarrh" 
 can be classified under the following heads : 
 
 With ordinary purulent f Chronic purulent rhinitis, 
 discharge. | Suppuration of the acces- 
 
 sory cavities. 
 
 Suppurative forms , ~. ,, . , , , . , . .. 
 
 vv . f Ozena (fetid atrophic rhinitis; 
 
 With modified purulent I simple atrophic rhinitis ; 
 discharge. anterior " dry " rhinitis 
 
 (round ulcer of septum). 
 Non-suppurative f With mucous dischar e - Retronasal catarrh. 
 
 inflammation. I Without discharge. 
 
 *- Hypertrophic pharyngitis. 
 
 92
 
 CHRONIC PURULENT RHINITIS. 93 
 
 Sequels of inflam- 
 
 Deformities of the septum. 
 
 Enlargement of cavernous tissue. 
 
 Diffuse hypertrophy of mucous membrane. 
 
 Circumscribed hypertrophy of mucous membrane (polypi). 
 Hypertrophies of pharyngeal adenoid tissue. 
 
 It will be most serviceable, however, to describe these 
 affections in an order differing somewhat from the one 
 best adapted for classification. 
 
 34. Chronic Purulent Rhinitis. Symptoms. Puru- 
 lent rhinitis is characterized by the discharge of pus from 
 the nose. As this symptom is common to various diseases, 
 it must be determined in every case whether the pus 
 comes from the nasal cavity itself, the roof of the phar- 
 ynx, or from one or more of the accessory sinuses. Accord- 
 ing to the area involved in the disease the amount may vary 
 from large masses of pus, viscid by reason of the mucin 
 present, to trifling flakes that are easily overlooked. Some 
 text-books speak of the occurrence of a catarrhal dis- 
 charge. This term is likely to lead to error. In 
 many forms of nasal disease the mucous membrane is 
 abnormally irritable and secretes freely in response to 
 irritation by dust or chilling of the body. When abun- 
 dant, this fluid is watery, but when scant, it is very 
 thick and viscid. This transient discharge is either 
 entirely clear, indicating the absence of suppuration, or, 
 when it occurs in connection with any purulent process, 
 it is mixed with streaks of pus. Very scant purulent dis- 
 charge may escape detection until the flakes are looked 
 for in the water after douching the nose. Although the 
 discharge is mostly blown out, it may pass also into the 
 pharynx when formed in the posterior regions, or be 
 guided thence by a stenosis anterior to the secreting 
 region. The swallowing of copious purulent secretion 
 may give rise to stomach disorders. 
 
 The other symptoms of purulent rhinitis, variable in 
 different cases, are transient obstruction from the presence 
 of pus or from vascular turgescence, and irritability, as 
 shown by fits of sneezing and momentary watery, flow.
 
 94 CHRONIC NASAL INFLAMMATIONS. 
 
 Many patients are so little annoyed by the disease that 
 the diagnosis is made only incidentally when ear or 
 throat complications arise. 
 
 Etiology. Chronic nasal suppuration is not a morbid 
 entity, but may depend upon a variety of conditions 
 which require detection in the individual case. Acute 
 purulent rhinitis, especially when it is a manifestation 
 of influenza, is likely to become chronic under certain 
 circumstances. These are sometimes constitutional dis- 
 turbances, chlorosis, malnutrition from other enfeebling 
 diseases, and dyspepsia. Quite often the history is that 
 of recurrent acute attacks, which finally become perma- 
 nent, especially when exposure to u cold," insufficient 
 protection, and longer spells of unfavorable weather have 
 interfered with spontaneous recovery. Most commonly, 
 however, local lesions will be found that account for the 
 persistence of the disease. These are, in general, narrow- 
 ness of the nasal passages, localized stenosis from de- 
 formities of the septum or spurs on its surface, or cir- 
 cumscribed hypertrophies of the mucous membrane in 
 the form of papillomatous tumors upon the inferior 
 turbinal, or polypi from the middle turbinal or external 
 wall. Relatively often nasal suppuration is maintained 
 by the enlarged pharyngeal tonsil in children or young 
 adults. The presence of foreign bodies or of concretions 
 may protract a nasal discharge indefinitely ; in such a 
 case it is most likely to be one-sided. 
 
 Pathology. Examination shows that the purulent in- 
 flammation is rarely an extensive or a diffuse process; more 
 often it is a localized condition, especially in the upper 
 recesses. In the diffuse form the entire mucous mem- 
 brane is reddened, but not much swollen. Even when 
 a localized focus exists, a diffuse redness may be due to 
 the coexistence of a diffuse non-suppurating, but hyper- 
 trophic inflammation, a not infrequent clinical combina- 
 tion. On the other hand, the entire lower intranasal 
 area may appear normal. Sometimes the source of the 
 discharge may be detected in a limited injected part of
 
 CHRONIC PURULENT RHINITIS. 95 
 
 the surface high up, the vulnerability of which is shown 
 by bleeding when touched with the probe, or which 
 is covered with granulations. Exposed bone is never 
 found in simple purulent rhinitis. Its detection signifies 
 syphilis or deep involvement of the ethmoid cells. In 
 every case of nasal suppuration in which the discharge 
 amounts to more than small flakes of pus, repeated efforts 
 must be made to ascertain or exclude involvement of any 
 of the accessory cavities, according to the methods to be 
 described (1 40). 
 
 In a large proportion of cases purulent discharge from 
 the nose comes from one or more of the accessory sinuses. 
 Fetor of the discharge, especially if one-sided, suggests 
 the possibility of a foreign body, particularly in children, 
 or of a concretion (rhinolith). The diagnosis can easily 
 be made with the probe. 
 
 In ordinary cases of uncomplicated purulent rhinitis 
 the discharge is not fetid. Sometimes, however, the 
 discharge is retained by swelling of the mucous mem- 
 brane, due to circumscribed edema or granulating sur- 
 faces. It becomes inspissated, cheesy in appearance, and 
 horribly offensive. This constitutes the rare form de- 
 scribed as rliinitis caseosa. There is usually very much 
 nasal obstruction in this form. By thorough removal of 
 the pent-up secretion by irrigation it is changed into the 
 ordinary purulent rhinitis, which then yields readily to 
 treatment. 
 
 Uncomplicated chronic purulent rhinitis may disap- 
 pear without treatment under improved climatic and 
 hygienic environment. As a rule, however, it does not 
 heal entirely during the warm season, but merely im- 
 proves until unfavorable weather returns. Possible com- 
 plications to which it may lead are chronic conjuncti- 
 vitis, purulent inflammation of the tear-sac, ear disease 
 (usually the secretory catarrh in a persistent form), 
 chronic hypertrophic pharyngitis, and laryngitis or bron- 
 chitis. 
 
 Treatment. The treatment is ordinarily successful if
 
 9 6 
 
 CHRONIC NASAL INFLAMMATIONS. 
 
 properly individualized. It may succeed in a few days or 
 may require many weeks. Faulty habits should be cor- 
 rected, insufficient clothing, exposure to dust and weather, 
 cold feet, constipation, stomach disturbances, or anemia 
 should receive attention (see 1 14 to 1 17). Local treat- 
 ment demands removal of the pus, as this fluid is too 
 viscid to drain off without aid, especially when anatomic 
 configuration favors its confinement. The most efficient 
 measure is the douche, which is to be used daily even 
 several times a day (see f 25). Irrigation through a 
 small cannula (Fig. 32) may prove more satisfactory 
 when hidden recesses are to be reached. A few days' 
 
 . _ ll.crn. _ . 
 
 FIG. 32. Griinwald's irrigating tubes. 
 
 steady use shows either the benefit of irrigation or its 
 inefficiency in a given case. With abundant secretion 
 and fairly wide passages the douche may be intrusted to 
 the patient. In nasal stenosis this would be contra- 
 indicated by the risk to the ear, and we must rely upon 
 the use of a spray. Yet a spray from even a good atom- 
 izer is not an efficient substitute for the douche for the 
 purpose of removing pus, especially if this be dammed up. 
 The addition of medicaments to the spray solution exerts 
 but little influence, as its effect is practically mechanical. 
 A i per cent, solution of sodium bicarbonate or the pleas- 
 ant solution of ethereal oils (1 25) may be used.
 
 SUBACUTE RHINITIS OF SCROFULOUS CHILDREN. 97 
 
 When a circumscribed area of pathologically changed 
 mucous membrane can be detected, it should be treated 
 by direct localized application. Localized surface in- 
 flammation yields to a few brushings with silver nitrate 
 solution (5 to 10 per cent.), while a granulation spot will 
 react well to superficial cauterization with trichloracetic 
 acid. 
 
 Some cases, however, prove rebellious. In most of 
 these the hindrance to a cure will be found in structural 
 configuration, causing either stenosis or local damming 
 up of pus. Some of these lesions should receive surgical 
 attention at once for instance, papillomatous tumors, 
 polypi, and flabby hypertrophies of the {urbinals ; espe- 
 cially, however, any existing hypertrophy of the pharyn- 
 geal tonsil. The same statement applies to deformities 
 of the septum of sufficient degree to cause stenosis ; but 
 in the case of septum deviations or ridges of minor de- 
 gree, an individual study and a proper trial of irrigation 
 should precede the decision to resort to operative meas- 
 ures. 
 
 Besides the atypical form of purulent rhinitis just 
 described, some more definitely characterized varieties 
 may be recognized. 
 
 35. The subacute rhinitis of scrofulous children 
 begins as a mild or subacute, nasal suppuration, and per- 
 sists until mild weather arrives or until it is successfully 
 treated ; often, however, it recurs the next season. The 
 subjects are typically scrofulous young children with 
 tubercular glands in the neck. The discharge is rela- 
 tively thin, mucopurulent, and leads to excoriations and 
 eczema below the nose. There is, as a rule, moderate 
 enlargement of the pharyngeal tonsil ; rarely, excessive 
 nasal obstruction. The disease is often associated with 
 phlyctemilar keratoconjunctivitis, and frequently causes 
 purulent otitis. A cure is sometimes obtained by better 
 protection and healing of the excoriations under the 
 nose by silver nitrate (10 per cent.) applications, followed 
 by a zinc or ichthyol-lanolin salve or oil of cade. Cod- 
 
 7
 
 98 CHRONIC NASAL INFLAMMATIONS. 
 
 liver oil is generally of benefit. The same may be said 
 of all hygienic measures directed against scrofula, such 
 as fresh air, baths, and proper feeding. The douche is 
 very useful, unless a hypertrophic pharyngeal tonsil con- 
 traindicates its use, in which case a spray must take its 
 place. Any enlargement of the pharyngeal tonsil that 
 causes symptoms of obstruction calls for its removal. 
 This does not, however, necessarily cure the rhinitis, 
 although always of beneficial influence. As the children 
 approach puberty the relapses cease. 
 
 36. Another variety has been named ' ' purulent rhi- 
 nitis of children" (Bosworth). It is a typical, but not 
 very common, affection. Its subjects are not necessa- 
 rily scrofulous. It begins early in childhood, and if not 
 checked, persists during adolescence. In a few instances 
 the author has known it to cease spontaneously. The 
 discharge is thick, very profuse, not fetid, and but little 
 influenced by the season. Examination, difficult in chil- 
 dren, does not show the origin of this profuse flow of 
 mucopus. It begins before the accessory cavities are 
 well developed. The nasal lining appears pale. The 
 passages are, as a rule, roomy, especially the pharynx. 
 The pharyngeal tonsil is often normal. When enlarged, 
 its removal, even if otherwise indicated, does not dimin- 
 ish the secretion of pus, at least not for many weeks, 
 perhaps ultimately. Like all purulent nasal affections, 
 it menaces the ear, often leading to purulent otitis with 
 tendency to relapses. A view expressed by Bosworth 
 that this form of purulent rhinitis may be the first stage 
 of ozena has not been confirmed by any one, and was 
 disproved in the author's experience by several observa- 
 tions continued through a number of years. The disease 
 can be cured by the persistent use of the douche for 
 many months. 
 
 37 Nasal suppuration was not distinguished sharply from 
 the non-suppurative forms of rhinitis in former text-books. It is 
 only within the last ten years that it has been shown by Ziem, 
 and later by others, especially Griinwald, that many cases of so-
 
 "PURULENT RHINITIS OF CHILDREN. 99 
 
 called purulent rhinitis are really sinus affections. Perhaps the 
 clearest exposition of suppurative affections of the nose and its 
 adjoining cavities can be found in Griinwald's Lehre von den 
 Naseneiterungen, second edition, 1896 (American edition, Treatise 
 on Nasal Suppuration, 1900). The purulent rhinitis of children 
 was described by Bosworth in his Diseases of the Nose and 
 Throat, 1889. The form I have described as subacute rhinitis of 
 scrofulous children has not been differentiated clearly, except by 
 Klemperer in Heymann's Handbuch der Laryngologie, etc. It is, 
 however, a clinical picture quite familiar to ophthalmologists.
 
 CHAPTER VI. 
 
 DISEASES OF THE NASAL ACCESSORY CAVITIES. 
 
 38. In communication with the nasal passages are the 
 six hollow sinuses or cavities viz., in the superior maxil- 
 lary, the frontal and the sphenoid bones, as well as a series 
 of cellular spaces in the ethmoid bone. They are all lined 
 by a thin mucous membrane continuous with that of the 
 nose and inseparable from the periosteal lining. Nothing 
 is known concerning the utility of these spaces, except 
 that they lessen the weight of the head. While only the 
 severest type of disease of the sinuses was formerly recog- 
 nized as a very rare surgical accident, it has been learned 
 within the past ten years that affections of these spaces 
 are very common. Their remarkable frequency has been 
 shown even more strikingly by autopsies than by clinical 
 experience. Systematic researches have been made on 
 the postmortem table by Harke, E. Frankel, Dmochowski, 
 Wolff, Pierce, and others. It has thus been shown that 
 one or more of the sinuses are found diseased in nearly 
 one-half of unselected subjects dead from different causes. 
 In diseases of the respiratory passages the ratio is even 
 higher, and in infectious diseases, like diphtheria and 
 scarlet fever, involvement of some of the cavities is 
 almost the invariable rule. The sinus involved most 
 commonly is the maxillary antrum; about one-half as 
 often the sphenoid cavity is found diseased, while the 
 frontal sinus suffers relatively rarely. The ethmoid cells 
 have not been examined to the same extent, and there is 
 some discrepancy as regards the frequency of their in- 
 volvement by different authors. They are evidently much 
 less often diseased than the maxillary sinus. Relatively 
 common is multiple disease of several sinuses. 
 
 The lesions found vary from a mild superficial to a 
 100
 
 SYMPTOMS OF SINUS DISEASE. 1OI 
 
 deep-seated inflammation, with more or less loss of epi- 
 thelium and sometimes with membranous formation, 
 while the contents of these spaces may be a turbid 
 serum or pure pus. There is usually much inflamma- 
 tory edema present. 
 
 The involvement of the accessory cavities in severe 
 systemic disease occurs either but shortly before death, 
 or produces so little symptomatic manifestation that it 
 has hitherto been practically overlooked clinically, as 
 acute affections of the sinuses are not often seen clinic- 
 ally, while of the chronic instances only a moderate pro- 
 portion can be traced to some previous general disease. 
 Still, among the patients presenting a purulent discharge 
 from the nose a large number really suffer from disease 
 of one or the other sinus. 
 
 39. Symptoms of Sinus Disease. Prominent among 
 the symptoms of acute sinus disease is pain. This may 
 occur in the form of headache, especially in the case of 
 the sphenoid and ethmoid spaces. Disease of the frontal 
 sinus commonly causes supra-orbital neuralgia or tempo- 
 ral headache one-sided if the lesion is unilateral. In- 
 flammation of the maxillary sinus produces infra-orbital 
 neuralgia and pain in the teeth of the upper jaw. The 
 localization of the pain is, however, not absolutely diag- 
 nostic of the sinus involved. Corresponding to the seat 
 of disease are spots of tenderness during the acute period 
 viz., over and under the brow when the frontal sinus 
 suffers, and under the orbit when the maxillary space is 
 involved. In chronic instances the same forms of head- 
 ache and of neuralgia may be present, especially in neu- 
 rotic subjects, but they are not so constant. Suppuration 
 of the ethmoid and sphenoid cells is at times the source of 
 periodic attacks of migrain. Sometimes chronic sinuitis 
 is not attended by pain, especially when the escape of 
 pus is not obstructed. Patients with sinuitis are often 
 noticeably intolerant to alcohol. Pronounced mental de- 
 pression is not uncommon. 
 
 At its onset acute sinuitis causes the systemic dis-
 
 IO2 DISEASES OF THE NASAL ACCESSORY CAVITIES. 
 
 comforts of infectious disease viz., slight fever, lassitude, 
 and loss of appetite. In chronic cases, too, systemic affec- 
 tion may occur in the form of stomach disturbance, per- 
 haps due to the swallowing of the discharge, as well as 
 loss of vigor and general malnutrition. Continued sup- 
 puration may lead to neurasthenia, especially when pain 
 helps to depress the nervous system. The direct nasal 
 symptoms of sinus disease are more or less obstruction 
 its degree dependent upon the width of the passage and 
 purulent discharge. The latter may be very slight or 
 extremely copious, bland or foul. Some patients pay no 
 attention to the slight discharge; in others it may drop 
 into the pharynx. Not rarely nasal lesions are associated 
 with sinus disease, such as purulent or hypertrophic 
 rhinitis, and especially polypi. These lesions are either 
 the consequence of sinus suppuration, or, if preexistent, 
 are a predisposing condition. The latter statement ap- 
 plies especially to ozena. Often, too, sinus inflammation 
 leads ultimately to disease of the pharynx or larynx or 
 the bronchial tubes. Occasionally inflammation of a 
 cavity, especially the ethmoid cells, is the starting-point 
 of asthma. 
 
 Complications. Among the dangers of all sinus dis- 
 ease are the possible invasion of, or influence upon, ad- 
 joining organs. The ear may suffer from acute puru- 
 lent otitis or serous catarrh. Extension toward the eye 
 may involve the tear-passages in the form of purulent 
 inflammation. Suppuration of either the frontal or the 
 ethmoid cavities may lead to bulging of the orbital wall 
 of these spaces, simulating an orbital abscess. More 
 serious is the actual perforation of this wall, with invasion 
 of the orbit itself, although the true orbital abscess may 
 also follow a benign course. Some of the intra-ocular 
 tissues sometimes suffer in consequence of different forms 
 of sinuitis. In the course of ethmoid or maxillary sup- 
 puration iritis of a very persistent character with great 
 liability to relapse may occur. Atypical forms of cho- 
 rioretinitis and of exudative choroiditis have also been
 
 PATHOLOGY. 1 03 
 
 observed as a complication of these sinus diseases. Sup- 
 puration of the sphenoid space has in rare instances led 
 to inflammatory involvement or to atrophy of the optic 
 nerve, separated from the sinus only by bony walls of 
 variable thinness. Any form of sinus disease may 
 result in irritability of the eyes and obstinate asthe- 
 nopia. 
 
 Deaths have been recorded in moderate number in 
 consequence of extension of sinus disease to the brain. 
 This, however, is not a frequent accident and does not 
 apply to disease of the maxillary sinus. 
 
 Pathology. The lesions in acute sinuitis as observed 
 at autopsies vary from a superficial inflammation to an 
 involvement of the deep periosteal layer, with more or 
 less edema and sometimes ecchymoses. The epithelium 
 may be intact or partially lost. Croupous and pseudo- 
 diphtheritic inflammation is less common. In chronic 
 cases studied during operations the mucous membrane is 
 usually found thickened; occasionally, in a state of cys- 
 toid degeneration; in other instances, tough and sclerosed. 
 Polypi are not often met with. Prolonged deep inflam- 
 mation may lead to roughening of the bone by the forma- 
 tion of osteophytes. Granulation tissue is quite com- 
 monly found. When pus exudes on curetting these 
 granulations, caries of the bony wall exists underneath, 
 but this is a relatively rare lesion. Occasionally necrotic 
 sequestra of bone have been seen. 
 
 Dilatation of a sinus with bulging of one of its walls 
 occurs not very rarely in the case of the frontal and 
 ethmoid cavities, evidently on account of an occluded 
 orifice. Sometimes the contents are turbid or even clear 
 mucus, and the process is due to retention without pyo- 
 genic infection. This condition has been termed hydrops 
 or mucocele. In other instances pyogenic influences 
 complicate and pus is present, usually with decided ten- 
 dency to spontaneous perforation. Hydrops of the 
 maxillary sinus is likewise a not uncommon occurrence, 
 but does not cause bulging of its walls. Indeed, the
 
 IO4 DISEASES OF THE NASAL ACCESSORY CAVITIES. 
 
 only disease that leads to visible distention of the max- 
 illary cavity is the presence of dental cysts in its interior. 
 
 Etiology. Autopsies have shown that the most com- 
 mon causes of sinus disease are severe systemic affections 
 or the terminal ^infections that produce death. Although 
 pathologists state that commonly there are no nasal 
 lesions in such cases, it is more logical to assume that 
 the infection occurs oftener through the nasal orifice of 
 the sinus than by way of the blood current. Fatal diph- 
 theria produces, invariably, fatal influenza, scarlet fever, 
 and measles, quite commonly disease of one or more of 
 the cavities. This involvement is more often due to 
 secondary infections than to the specific parasites of the 
 original disease. 
 
 But of the sinus affections thus produced, relatively few 
 are observed clinically. If the patient does not die, most 
 of these forms of sinus affection get well spontaneously. 
 It is evident clinically that the spontaneous recovery is 
 hindered by any conditions interfering with drainage, 
 such as coexisting intranasal lesions. The larger pro- 
 portion of the clinical cases of sinus disease can be traced 
 to the time of a severe nasal inflammation, either simple 
 coryza or more often the nasal affection during the course 
 of an influenza, pneumonia, typhoid fever, scarlet fever, 
 or measles. Less commonly syphilitic nasal disease is 
 the original cause. Relatively often the cavities become 
 involved in the course of ozena. Disease of the higher 
 sinuses may spread into the maxillary cavity secondarily. 
 Traumatism plays a minor role. Intranasal cauterization 
 occasionally causes maxillary or frontal involvement. A 
 large minority of the maxillary cases can be traced to 
 defective teeth. 
 
 The parasites found and presumably the cause of sinus 
 disease are pneumococci, staphylococci (different va- 
 rieties), streptococci, pseudodiphtheria bacilli, coli bacilli, 
 and the bacillus mucosus capsulatus (ozena), often in com- 
 bination. In influenza the influenza bacillus has been 
 found less often than other parasites. Diphtheria of the
 
 DIAGNOSIS TREATMENT. 10$ 
 
 nose causes always diphtheritic infection of some sinuses 
 (in fatal cases), whereas diphtheria of the throat leads to 
 sinus disease, but not necessarily to diphtheritic infection 
 of the sinus. There is good reason to believe that the 
 long-continued contagiousness of convalescent diphtheria 
 patients is partly due to the persistence of the germs in 
 one or the other sinus. 
 
 40. Diagnosis. The diagnosis of any sinus suppura- 
 tion depends upon the demonstration of the discharge. 
 It is sometimes very difficult to trace the pus to its source. 
 The frontal and the maxillary sinus and the anterior 
 ethmoid cells empty their morbid contents underneath 
 the middle turbinal near its anterior end. The posterior 
 ethmoid cells and the sphenoid sinus discharge through 
 the space between the middle turbinal and septum. 
 When the nose is filled with pus, this must be partly 
 removed by mopping before the path of entrance can be 
 traced. If no secretion can be seen, the douche will 
 bring out any discharge, which must be sought in the 
 basin. In doubtful cases tampons may be left in the 
 middle meatus or between the middle turbinal and the 
 septum for a short time and then examined. Probing 
 through the natural orifices is difficult, but generally 
 possible in the case of the sphenoid sinus; less successful 
 in the case of the frontal sinus, but very uncertain so far 
 as the other cavities are concerned. Attempts may be 
 made to dislodge pus by directing a stream through a 
 narrow cannula toward the natural orifice of the sus- 
 pected space. Maxillary suppuration can usually be 
 demonstrated by translumination (see ^[ 49). In doubt- 
 ful instances the diagnosis can be made certain only by 
 an exploratory puncture. 
 
 41. Treatment. The treatment of acute cases may 
 be expectant unless urgent symptoms indicate immediate 
 operation. Probably most acute cases heal spontaneously. 
 The healing is favored by all measures that facilitate 
 drainage, such as the use of the douche and frequent 
 spraying by the patient, as well as applications of cocain
 
 IO6 DISEASES OF THE NASAL ACCESSORY CAVITIES. 
 
 or suprarenal solution, while obstructive lesions should 
 receive due and, if necessary, surgical attention. The 
 acute pain can generally be checked by antipyrin. Neu- 
 ralgic pains, if not permanently controlled by antipyrin, 
 are often cured by the use of quinin in large doses (0.4 to 
 0.6 twice a day). All chronic cases, however, in which 
 a purulent discharge has persisted for many weeks 
 require operative interference. 
 
 While the special operations required for the different 
 sinuses will be described in connection with each, a pro- 
 cedure applicable in disease of the anterior ethmoid cells, 
 the frontal and the maxillary sinus, can be detailed at 
 
 FIG. 33. Griinwald's cutting forceps for operation on the middle turbinal. 
 
 present. It is resection of the front end of the middle 
 turbinal, as advocated by Griinwald. By the removal of 
 this overhanging ledge the nasal side of the orifice of the 
 spaces is made accessible. The middle turbinal can- 
 not always be grasped sufficiently by the wire loop of the 
 snare to be removed satisfactorily. Hence Griinwald cuts 
 the front part of its lateral attachment with a specially 
 designed forceps (Fig. 33). Any cutting forceps, how- 
 ever, of such shape as to reach this locality can be sub- 
 stituted. The snare loop can now be slid through the 
 gap, and the front end of the bony lamella may thus be 
 snared off. When the lateral insertion cannot be reached
 
 ANATOMY OF THE NASAL ACCESSORY CAVITIES. IO/ 
 
 easily by forceps on account of its height, the author 
 has cut a vertical gap through the middle turbinal, i to 
 2 cm. behind its front end, and then grasped the anterior 
 extremity with the snare through this gap, thus letting 
 the wire cut horizontally instead of vertically, as Griin- 
 wald advocates. 
 
 History and Literature. Prior to 1880 the literature of sinus 
 affections consisted mainly in the reports of isolated cases of suffi- 
 cient severity to make the diagnosis a simple matter. The fre- 
 quency of empyema of the maxillary sinus, foreshadowed in 
 dental literature, was emphasized by Ziem, a personal sufferer 
 from that disease, in many reports since 1880. Attention was 
 called to ethmoid disease by Woakes, the value of whose clinical 
 observations was impaired by false pathologic notions concerning 
 ' ' necrosing ethmoiditis. ' ' Numerous reports scattered throughout 
 periodic literature gradually helped to establish the clinical pic- 
 ture of sinuitis. Disease of the frontal sinus was well described 
 and appropriately treated in Kuhnt's treatise ( Ueber die entzund- 
 lichen ErkrankungenderStirnhohlen undihre Folgezustande, 1895). 
 Extensive autopsy reports began with Weichselbaum, but espe- 
 cially Harke (Beitrdge zu Pathologic der oberen Athmungswege, 
 1895), and were extended by E. Frankel and others. The most com- 
 plete reviews of the entire subject are found in Griinwald's Treat- 
 ise on Nasal Suppuration, Killian's articles in Heyman's Hand- 
 buck der Laryngologie, etc., but especially to be recommended is 
 Hajek's Pathologie und Therapie der Nebenhbhlen der Nase (1899). 
 The last-named treatise and Zuckerkandl's Anatomic der Nasen- 
 hbhle are the best sources of anatomic information. 
 
 ANATOMY OF THE NASAL ACCESSORY CAVITIES AND 
 THEIR TOPOGRAPHIC RELATION TO THE NASAL PAS- 
 SAGES. 
 
 42. The pneumatic spaces known as the nasal sinuses 
 surround the external wall and partly the roof of the 
 nasal cavity. The roof begins with the awning-shaped 
 covering of the vestibule formed by the nasal bones. 
 The nasal cavity proper is closed above by the ethmoid 
 bone anteriorly, and by the body of the sphenoid bone 
 posteriorly. The distance from the floor to the roof 
 underneath the horizontal plate of the ethmoid is from 
 38 to O mm. Posterior to the ethmoid the front surface
 
 IO8 DISEASES OF THE NASAL ACCESSORY CAVITIES. 
 
 of the sphenoid body falls off vertically, with a back- 
 ward slant, and thus shortens the nasal height about 
 15 mm., while, by reason of the downward slope of the 
 lower surface of the sphenoid, the vertical diameter of 
 the nose continues to diminish toward the posterior 
 choanae. Of that part of the roof formed by the hori- 
 zontal or cribriform plate of the ethmoid only about 2 to 
 3 mm. are accessible on each side of the septum, as the 
 various ethmoid lamelle that form the labyrinth reduce 
 the width of the olfactory fissure to that extent. Under- 
 neath the sphenoid the width of the roof is determined 
 by the breadth of the inferior surface of the sphenoid 
 bone. The variable thinness of the ethmoid roof that 
 separates the nose from the intracranial cavity enjoins 
 the utmost caution in operations near the roof. 
 
 The external wall of the nasal passage is formed in its 
 anterior two-thirds by the nasal surface of the superior 
 maxillary below and by the lamina papyracea of the eth- 
 moid bone above, while the posterior third is made up of 
 the vertical plate of the palate bone. The nasal width 
 between the external walls diminishes upward, but the 
 nasal passage itself is very much narrowed by the turbi- 
 nated processes. The turbinated bone (inferior turbinal) 
 runs as a ledge from about i cm. behind the nasal aper- 
 ture to the posterior choanae. By its external articulation 
 it is attached to the maxillary as well as the palate bones. 
 This thin curved and partly rolled lamina presents its 
 convexity upward and inward. Its posterior end appears 
 broadened by reason of its ciirve. The delicacy of this 
 bony ledge is hidden by the thick and turgescent mucous 
 membrane covering it. Nearly parallel with and above 
 the inferior turbinal is the middle turbinal, beginning 
 anteriorly about i cm. behind the lower one, which it 
 resembles in shape. The middle turbinal, however, 
 originates from the lamina papyracea of the ethmoid, but 
 extends beyond that bone posteriorly to the posterior 
 choanse. Between it and the external wall are other 
 bony processes of the ethmoid, to be described later
 
 ETHMOID CELLS. 
 
 ICQ 
 
 Above it, too, are additional laminae from the ethmoid 
 bone projecting like the middle turbinal inward and 
 downward. All of these offshoots of the ethmoid narrow 
 
 FIG. 34. Frontal section through the rear part of the nasal passages : A, 
 Roof; , floor; b, external wall of nasal passages; C, alveolar process, high 
 and spongy ; a, a, a, the three nasal meati ; b, middle turbinal ; c, olfactory 
 fissure; d, respiratory fissure (Zuckerkandl). 
 
 the upper part of the nasal passage to the width of the 
 olfactory fissure (Fig. 34). 
 
 ETHMOID CELLS. 
 
 43. The key to the complicated architecture of the 
 nasal cavity and its sinuses is furnished by the anatomy 
 of the ethmoid bone (Fig. 35). Its horizontal or cribriform 
 plate (lamina cribrosa) separates the nasal from the intra- 
 cranial cavity. Its width corresponds to the space be- 
 tween the internal boundaries of the orbits. From this 
 plate descends centrally and vertically the perpendicular
 
 HO ANATOMY OF THE NASAL ACCESSORY CAVITIES. 
 
 lamina, which, by articulating with the nasal bones in 
 front and with the anterior surface of the sphenoid body 
 behind, forms the upper part of the nasal septum. 
 
 Above the cribriform plate the prolongation of the 
 perpendicular lamella extends into the cranial cavity as 
 a short sharp ridge the crista galli. The lateral surface 
 of the ethmoid bone is formed by the thin, nearly vertical 
 lamina papyracea, which constitutes the internal wall of 
 
 |--Sph.C. 
 
 JHK/J^ftMdff' 
 
 Lf.- --> 
 
 p.p. i M ' e Mt 
 
 up. 
 
 FIG. 35. Ethmoid bone seen from the left side : /, /, The orbital surface of 
 the lamina papyracea; C. g, crista galli; F. c, frontal cellules; C. c, lacrimal 
 cellules ; Z. /, perpendicular plate ; u. /, uncinate process ; M. c, maxillary 
 cellules; M. t, middle turbinal process ; S. t, superior turbinal process ; Sph. C, 
 sphenoid cellules. 
 
 the orbit This plate does not join the lamina cribrosa. 
 Instead of a sharp edge, which would be formed by the 
 junction of upper and external sides, the ethmoid bone 
 presents here a series of pneumatic cells (foveolse eth- 
 moidales) open in the macerated specimen, but closed in 
 situ by articulation with the correspondingly hollowed 
 margin of the orbital plate of the frontal bone (Fig. 36). 
 Downward the lamina papyracea extends to the (nasal) 
 border of the orbital process of the superior maxilla.
 
 ETHMOID CELLS. 
 
 Ill 
 
 The two laminae papyracea diverge slightly downward 
 and backward. 
 
 From the internal face of the lamina papyracea arise a 
 series of more or less concentric, shelf-like lamellae, the 
 ethmotnrbinal processes. Their attachment to the lam- 
 ina papyracea describes a slight curve with its convexity 
 downward from the anterior upper end to the inferior 
 lower termination. In transverse (frontal) section all 
 these processes appear curving downward so as to form 
 overhanging ledges. The three lowest processes viz., 
 
 FIG. 36. View of the frontal hone from the pyriform incisure, showing the 
 pneumatic spaces which form part of the upper ethmoid cells (Hajek). 
 
 the uncinate process, ethmoid bulla, and middle turbinal 
 extend downward below the inferior margin of the lam- 
 ina papyracea, so as to cover a part of the gap in the 
 nasal surface of the superior maxilla. 
 
 The lowest ethmoturbinal lamella is the uncinate 
 process (Fig. 37). This delicate broad-sword or sickle- 
 shaped bony lamina does not arise from the lamina 
 papyracea itself, but from the anterior expansion of the 
 middle turbinal process, where the latter articulates with 
 the frontal process of the superior maxillary bone.
 
 112 
 
 ANATOMY OF THE NASAL ACCESSORY CAVITIES. 
 
 It proceeds backward and somewhat downward in a 
 plane not quite vertical, as its upper concave edge points 
 toward the maxillary sinus. Near its rear end this 
 process is attached by delicate prolongations to an upward 
 extension of the inferior turbinal bone and to the roof of 
 the maxillary sinus. The internal or nasal wall of the 
 maxillary sinus has a large aperture in its upper part in 
 the skeleton. The space between the lower border of the 
 
 FIG. 37. External wall of the right nasal passage : B, Bulla ethmoidalis ; 
 /, uncinate process; H, hiatus semilunaris ; S, sinus within the bulla ethmoid 
 alis (Zuckerkandl). 
 
 uncinate process and the lower rim of this bony aperture 
 in the maxillary wall is closed by the junction of the 
 mucous membrane of the nose and of the maxillary 
 sinus, which two linings are here inseparable. This mem- 
 branous wall, containing some vertical bridges formed 
 by slender spicules of bone, is termed the nasal fontanel. 
 Above (and behind) the uncinate process there springs 
 from the lamina papyracea a thicker but hollow bony 
 ledge, likewise slightly slanting inward from the vertical
 
 ETHMOID CELLS. 113 
 
 plane the bulla ethmoidalis. Its interior cavity has an 
 opening behind. Between the uncinate process and the 
 bulla there is a curved cleft the hiatus semilunaris. 
 This -cleft is the entrance into a funnel-shaped space of a 
 depth variable up to i cm., the infundibulum, at the 
 bottom (external side) of which are the orifices of the 
 frontal and the maxillary sinus. This space, as well as 
 all the recesses to be described, is 'lined by the nasal 
 mucous membrane, which passes uninterruptedly through 
 the orifices into the different sinuses, but in these spaces 
 does not retain the thickness and the venous plexus 
 which it possesses in the nasal cavity. 
 
 Above the bulla another ledge springs from the lamina 
 papyracea the middle turbinal. This passes inward and 
 then curves downward like a cornice, so as to cover com- 
 pletely the hiatus semilunaris. The middle turbinal ex- 
 tends beyond the lamina papyracea backward and some- 
 what downward, reaching thus underneath the inferior 
 surface of the sphenoid body up to the rear end of the 
 nasal passage. 
 
 The spaces between the uncinate process and bulla and 
 middle turbinal form the anterior ethmoid cells. These 
 recesses open thus into the middle meatus of the nose 
 underneath and external to the middle turbinal. 
 
 Above the middle turbinal, and somewhat back of it, 
 another ledge arises from the lamina papyracea, the 
 superior turbinal, while finally and uppermost another 
 bony lamella springs from the horizontal plate of the 
 ethmoid the supreme tnrbinal. These thin bony ledges 
 all curve downward with edges more or less rolled, form- 
 ing the upper ethmoturbinal processes. The spaces 
 inclosed between them are the posterior ethmoid cells, 
 which open into the olfactory fissure between the middle 
 turbinal and septum (Fig. 38). 
 
 The architecture of the ethmoid cells is complicated 
 by the variable curvature and irregular shape of the 
 turbinal ledges, but especially by incomplete bony or 
 membranous septa subdividing these longitudinal pass-
 
 I 14 ANATOMY OF THE NASAL ACCESSORY CAVITIES. 
 
 ages into a series of communicating cells of variable size 
 and number. These cells constitute the ethmoid laby- 
 rinth. All these spaces are lined with a continuation of 
 the nasal mucous membrane. The bony frame of the 
 
 , -si 
 
 asph. 
 
 FIG. 38. Ethmoid labyrinth from the nasal side, with demonstration of the 
 main lamellae: s.f, Frontal sinus; s. sfh, sphenoid sinus; Z 1 , the first lamella, 
 the uncinate process; Z 2 , the second lamella, the bulba ethmoidalis; h. s, 
 hiatus semilunaris ; Z 3 , the third lamella, the main lamella of the middle tur- 
 binal ; s. e. a, anterior ethmoid cell ; Z 4 , the fourth lamella, the main lamella 
 of the superior concha; s. e.p, posterior ethmoid cells (Hajek). 
 
 middle turbinal broadens in its anterior part by becoming 
 cancellated. The deeper (periosteal) layer of the mucous 
 membrane dips into the spaces between the bone-plates 
 and assumes a medullary structure rich in fat-cells. In
 
 ETHMOID CELLS. 115 
 
 some instances pneumatic cells extend into the middle 
 turbinal process. 
 
 The number and, conversely, the size of the indi- 
 vidual ethmoid cells vary considerably. In rare in- 
 stances there are only a few large spaces. The relation 
 in size of anterior to posterior cells is also variable and 
 depends on the site of the middle turbinal, which divides 
 the two sets of cells from each other. The ethmoid 
 
 c.e.a 
 
 ee.p 
 
 FIG. 39. Large frontal sinus ; the ethmoid labyrinth exposed through the 
 lamina papyracea : s. f, Frontal sinus ; f. I, lachrymal fossa; s. m, maxillary 
 sinus; c. e. a, anterior ethmoid cells (4); c. e.p, posterior ethmoid cells (4); 
 d. e, nasal orifices of ethmoid cells (Hajek). 
 
 bulla is occasionally enlarged and expanded, sometimes 
 to an extent to become visible on anterior inspection. Its 
 enlargement is apt to cause one or more of the foremost 
 cellular spaces to intrude into the frontal sinus. On the 
 other hand, the rear cell of the posterior set may also 
 intrude into the sphenoid sinus (Fig. 39). 
 
 The orifices of the anterior ethmoid cells, variable in 
 number on account of the variability in the size and
 
 ANATOMY OF THE NASAL ACCESSORY CAVITIES. 
 
 intercommunications of the cells, open usually between 
 bulla and middle turbinal. The posterior cells present 
 small openings along the external wall of the superior 
 
 nasal meatus. 
 
 FRONTAL SINUS. 
 
 44. The frontal sinus is an irregularly shaped cavity 
 in the frontal bone above and between the orbits. It is 
 variable in size and extent, usually larger in the male 
 than in the female (Figs. 40 and 41). Scarcely developed 
 at birth, it grows slowly until puberty, when it is only 
 about the size of a pea, after which period it rapidly gains 
 
 FIG. 40. Frontal bone, the external plate removed to show the frontal 
 sinus: u, Lower wall, h, posterior wall, of frontal sinus; s, frontal septum; 
 o.f, frontal orifice; B, bulba frontalis (Zuckerkandl). 
 
 its full development. The two sinuses are separated by a 
 median partition occasionally curved and asymmetric. 
 The vertical height close to the septum is between 28 
 and 40 mm. The anteroposterior depth is determined to 
 some extent by the prominence of the brow. It may ex- 
 tend backward as far as the middle of the orbit or even 
 beyond. More variable even is the transverse width of 
 the two spaces, which oscillates between 20 and 75 mm. 
 Sometimes one or both cavities are rudimentary or even 
 obliterated. The anterior wall is generally quite thick. 
 The floor formed by the upper, and to some extent by
 
 SPHENOID SINUS. 
 
 117 
 
 the inner, orbital wall is the thinnest boundary. Occa- 
 sionally a sinus is incompletely subdivided by bony par- 
 titions. At the lowest part of the floor is the orifice 
 of the nasofrontal duct, a short, funnel-shaped opening. 
 The distance between the orifices of the two frontal si- 
 nuses is determined by the width of the ethmoid bone. 
 
 FIG. 41. Sagittal section through frontal sinus : S, Frontal sinus ; b, frontal 
 bulla; s, sinus within frontal bulla; B, bulla ethmoidalis; P, uncinate process > 
 H, sinus between anterior insertion of the middle turbinal and the uncinate 
 process (Zuckerkandl). 
 
 The nasal entrance is usually at the anterior end of the 
 hiatus semilunaris, between the uncinate process and 
 bulla of the ethmoid, sometimes, however, anterior to it, 
 but always underneath and hidden by the front end of 
 the middle turbinal. Occasionally an anterior ethmoid 
 cell protrudes into a frontal sinus. 
 
 SPHENOID SINUS. 
 
 45. The sphenoid sinus is the cavity in the interior of 
 the body of the sphenoid bone, separated by a median and
 
 n8 
 
 ANATOMY OF THE NASAL ACCESSORY CAVITIES. 
 
 not always symmetric wall into two non-communicating 
 spaces (Fig. 42). This sinus varies in height from 13 to 
 27 mm. ; in length, from 10 to 28 mm. ; and in width, 
 each from 10 to over 25 mm. (by extension into the lesser 
 wing of the sphenoid bone). It is rudimentary during 
 early childhood. Bony partitions sometimes subdivide 
 
 FIG. 42. External wall of left nasal passage : b, Bulla ethmoidalis ; /, unci- 
 nate process ; t, lachrymal bone ; IV, superior vault of the hiatus projecting 
 toward the frontal sinus; O, nasal orifice of frontal sinus; O.f, passage into 
 frontal sinus partially opened; m, middle turbinal; m', middle ethmoturbinal ; 
 O, superior ethmoturbinal ; a, fissure between bulla ethmoidalis and middle tur- 
 binal leading info a sinus of the orbital part of the frontal bone ; a', cell between 
 the middle turbinal and the anterior sphenoid surface, without partition between 
 the two spaces (Zuckerkandl). 
 
 it into several spaces. The superior wall, usually solid, 
 is sometimes imperfect, which may bring its mucous 
 lining in contiguity with the dura mater, thus en- 
 dangering the optic nerves above it in case of disease. 
 The lateral walls are largely within the intracranial 
 cavity. Adjoining them (above) are the internal carotid 
 artery and the cavernous sinus. The inferior (nasal wall)
 
 SPHENOID SINUS. 
 
 is the thinnest. The orifice of each sinus is situated in its 
 anterior wall near the roof, in the space between the sep- 
 tum and the nasal surface of the ethmoid labyrinth. 
 This opening, of good size in the skeleton, is narrowed 
 by the mucous membrane and is sometimes reduced to a 
 mere slit. It can be reached directly by a slender iustru- 
 
 s.r 
 
 FIG. 43. Horizontal section through the human frontal, ethmoid, and 
 sphenoid bones : S.f, Frontal sinus ; L. c, lamina cribrosa; C, ethmoid cells; 
 O. sph, sphenoid orifice ; S. sph, sphenoid sinus (Zuckerkandl). 
 
 ment inserted through the olfactory fissure. The dis- 
 tance from this orifice to the pyriform aperture of the 
 nose has been found to vary from 60 mm. to 82 mm. in 
 the living (Fig. 43). 
 
 Embryologically the sphenoid sinus is originally the 
 upper rear portion of the olfactory fissure. The upper
 
 12O ANATOMY OF THE NASAL ACCESSORY CAVITIES. 
 
 rear ethmoturbinal (cartilaginous) lamella of each side 
 changes during its ossification into a closed bony capsule, 
 the sphenoid concha or ossicle of Bertinus. The inclosed 
 space is the sphenoid sinus, which is thus separated from 
 the nasal chamber at birth, though as yet very small. 
 The body of the sphenoid bone behind it is small and 
 solid. The sphenoid rostrum, however, is an extended 
 partition and separates the capsules of the two sinuses. 
 
 About the fourth year the ossicles of Bertinus begin to 
 atrophy, and the anterior surface of the sphenoid body 
 curves around them by its growth on all sides except 
 the median. About the tenth to the twelfth year the 
 sphenoid conchse have dwindled down to small triangu- 
 lar plates which, by their coalescence with the growing 
 sphenoid walls, now form part of the anterior wall of the 
 sinus, while all the other sides are now supplied by the 
 sphenoid body itself. The rostrum has become the par- 
 tition wall between the two sinuses. From this time 
 until puberty the sinus completes its growth at a more 
 rapid rate. 
 
 MAXILLARY SINUS. 
 
 46. The maxillary sinus or antrum of High more is an 
 irregularly shaped cavity in the interior of the superior 
 maxillary bone, which can be approximately compared 
 to a three-sided pyramid with base upward (the orbital 
 floor), an external or facial, an internal or nasal, and a 
 posterior side (Fig. 44). It is scarcely developed at 
 birth, and does not reach its final size until after the 
 second dentition. When well formed in the adult, its 
 different dimensions range between 20 and 35 mm. But 
 this cavity is not rarely diminished in size in one or the 
 other direction by absorption of the cancellated bone 
 tissue in the alveolar process or by the sinking-in of the 
 facial wall, or at least its thinnest part, the canine fossa, 
 or by the bulging of the nasal wall toward the sinus. 
 All these conditions may coexist and, if combined with 
 diffuse thickening of the bony walls, may in rare
 
 MAXILLARY SINUS. 
 
 121 
 
 instances almost obliterate the sinus. The encroachment 
 upon the cavity by any considerable depression of the 
 facial wall reveals itself in the architecture of the face, 
 while unusual width of a nasal ineatus also suggests 
 stenosis of the maxillary sinus. The two cavities are 
 not rarely asymmetric (Fig. 45). On the other hand, 
 
 FIG. 44. Right superior maxilla ; antrum opened from the external side : 
 O. m (large), maxillary orifice; O. m. a, accessory maxillary orifice; , unci- 
 nate process (Zuckerkandl). 
 
 the space is often enlarged by the formation of niches or 
 recesses in the solid bone, leading to the formation of an 
 alveolar palatal infra-orbital or molar sinus, while in 
 other instances the cell in the orbital process of the 
 palate bone may constitute a posterior niche connected 
 with the maxillary sinus. These recesses are sometimes 
 spaced off by incomplete bony partitions. Occasionally
 
 122 
 
 ANATOMY OF THE NASAL ACCESSORY CAVITIES. 
 
 more or less complete bony septa, vertical or horizontal, 
 divide the entire sinus into two separate chambers, each 
 communicating with the nose. 
 
 The floor of the antrum, formed by the junction of the 
 external and posterior walls, varies in width in different 
 subjects, and is often reticulated by the prominences cor- 
 responding to the teeth beneath the floor. According to 
 the degree of absorption of the cancellated tissue, the 
 
 FlG. 45. Asymmetry of the two maxillary sinuses. On the right side, at a, 
 a deep alveolar recess, while on the left side the alveolar process, b, extends 
 upward (Zuckerkandl). 
 
 roots of the teeth may project into the cavity or be 
 separated from it by a thick alveolar process. The 
 number of teeth below (or in) the floor of the antrum 
 varies with the development of the alveolar and palatal 
 niches. Zuckerkandl found in 26 skulls that the sinus 
 reached from the last molar to the first molar 6 times, to 
 the second bicuspid 3 times, to the first bicuspid 13 
 times, to the canine teeth 4 times. The infra-orbital 
 canal, containing the infra-orbital nerve, which passes 
 along the roof of the antrum, is partly deficient in some 
 subjects, leaving the nerve exposed.
 
 MAXILLARY SINUS. 
 
 123 
 
 The opening between the nose and sinus is in the 
 upper part of the nasal wall of the antrum, close to the 
 roof or orbital wall of the sinus (see Fig. 37). It is 
 usually oblong, its height ranging between 2 and 5 mm., 
 and its length between 3 and 10 mm. But this opening 
 leads only indirectly into the nose through the space 
 called the infundibulum. The large aperture found in 
 the upper half of the nasal wall of the macerated max- 
 
 P.e 
 
 r.i. 
 
 T.m 
 
 FIG. 46. R, Superior maxilla, nasal surface, the inferior concha partly re-' 
 sected in order to show the maxillary process : P. m, Maxillary process of the 
 turbinated bone ; P. e, ethmoid process of the turbinated bone ; P. I, lachrymal 
 process of the turbinated bone ; C, f, turbinal crest of the palate bone ; C. e, 
 ethmoid crest of the palate bone ; C. e' ', ethmoid crest .of the maxillary bone 
 (Zuckerkandl). 
 
 illary bone is narrowed by the articulation below with 
 the maxillary process of the inferior turbinated and the 
 uncinate process, posteriorly with the vertical lamella of 
 the palatal bone, and above with the hollow process of 
 the ethmoid the bulla ethmoidalis (Fig. 46). The latter 
 forms a cornice slanting backward and somewhat down- 
 ward on the nasal side of the sinus wall. The uncinate 
 process of the ethmoid bone, shaped like a sickle, begins
 
 124 ANATOMY OF THE NASAL ACCESSORY CAVITIES. 
 
 in front and below the bulla, and, passing backward and 
 somewhat downward, crosses the bony aperture and 
 divides this opening into an anterior (lower) and a pos- 
 terior (upper) half. The spaces between the uncinate 
 process and the rim of the bony opening are closed by 
 mucous membrane and constitute the nasal fontanels 
 of the antrum, usually containing a few delicate bony 
 bridges. Near the center of the upper or posterior fon- 
 tanel, between the uncinate process and bulla, is the 
 orifice of the maxillary sinus. The cornice-like project- 
 ing bulla and the uncinate process inclose between them 
 a semiltmar slit, a curved recess slanting backward and 
 downward like the processes which surround it of a 
 width of from 2 to 6 mm. and a length of from 20 to 30 
 mm. This slit, the hiatus semilunaris, is the nasal gate- 
 way into the space between the bulla and uncinate proc- 
 ess, the infundibulum, in the external wall of which 
 the actual opening into the sinus is found. In the wider 
 anterior portion of the infundibulum there is usually the 
 orifice of the frontal sinus ; sometimes, however, it is an- 
 terior to it. The aperture of the maxillary sinus is thus 
 situated unfavorably for the escape of secretions, and 
 every slight swelling of the mucous lining of the semi- 
 lunar hiatus or of the infundibulum may shut off the 
 communication between the nose and sinus. As the 
 semilunar slit is completely covered by the middle tur- 
 binal, it is invisible during life. It is hence difficult and 
 often impossible to enter it with instruments. A second 
 accessory maxillary aperture is found in about 10- per 
 cent, of subjects in either the upper or the lower fonta- 
 nel, but is iisually smaller than the principal orifice.
 
 CHAPTER VII. 
 DISEASES OF THE MAXILLARY SINUS. 
 
 ACUTE MAXILLARY SINUITIS. 
 
 47. Acute inflammation of the maxillary sinus is clin- 
 ically an occurrence of but moderate frequency, and not 
 nearly so common as the findings of fresh lesions at 
 autopsies. The clinical picture is, however, well defined 
 and not difficult to recognize. It occurs either as the 
 sequel of an acute nasal catarrh or an influenza rhinitis, 
 or sometimes apparently primarily. In other less com- 
 mon instances the infection proceeds from diseased teeth. 
 In rare instances the disease is brought about by intra- 
 nasal operations, especially cauterization. Acute onset 
 of moderate fever, with general malaise for a few days, 
 disturbed appetite, and bad taste usher it in. As a rule, 
 there is considerable infra-orbital pain, sometimes shoot- 
 ing into the teeth, and often supra-orbital pain and 
 tenderness, suggesting involvement of the frontal sinus, 
 which is not present. The cheek is tender to touch, 
 sometimes slightly edematous. 
 
 The acute disease is usually one-sided. Free discharge 
 of pus from one side of the nose occurs within the second 
 day. Sometimes this is offensive from the start. Even 
 if the pus is bland, the patient usually complains of a 
 subjective bad smell. 
 
 The acute symptoms begin to subside in the course of 
 about a week. In favorable cases the disease heals spon- 
 taneously in from three to six weeks. It is doubtful 
 whether a spontaneous cure ever occurs in cases of den- 
 tal origin. The liability to become chronic is increased 
 by the coincidence of intranasal lesions causing stenosis. 
 
 The diagnosis, which is strongly suggested by the sub- 
 
 125
 
 126 DISEASES OF THE MAXILLARY SINUS. 
 
 jective symptoms, is confirmed by the appearance of pus 
 issuing from the middle nasal meatus. It may be verified 
 by translumination (see Tf 49). An exploratory puncture 
 is scarcely ever needed for diagnostic purposes. 
 
 The treatment demands physical rest during the acute 
 stage. Neuralgic pain can be suppressed by antipyrin or 
 phenacetin, and, if these fail to give permanent relief, 
 quinin, 0.4 to 0.6 gm. , taken once or twice daily, in 
 soft capsules, will usually succeed. The cure is facili- 
 tated by all measures favoring drainage, such as the 
 douche, the use of sprays, and applications of cocain or 
 suprarenal solution in the middle nasal meatus. As 
 soon as the nasal tenderness has subsided an attempt 
 may be made to inject salt solution through the natural 
 maxillary opening (see 1" 49). If this is successful, an 
 exploratory puncture may be deferred as long as there is 
 a history of steady improvement under the less active 
 treatment. If, however, a series of days brings no decided 
 improvement, irrigation may be practised through an 
 exploratory puncture, and, if necessary, repeated a few 
 times. Chronicity is sometimes due to irritation by 
 inspissated pus, which can be removed by a single wash- 
 ing out. The details of the surgical technic will be 
 described under the head of Chronic Inflammation. In 
 cases of dental origin it is always necessary to extract 
 the offending tooth, and generally best to puncture 
 through the socket, with subsequent irrigation. 
 
 CHRONIC INFLAMMATION OF THE MAXILLARY SINUS. 
 
 48. Symptoms. Chronic suppuration of the maxillary 
 sinus (empyema of the antrum of Highmore) is the most 
 frequent cause of one-sided purulent discharge from the 
 nose. In a small proportion of cases the disease is bilateral. 
 The history is often vague. A few cases begin acutely, 
 especially those due to carious teeth. But even the dental 
 cases may be of insidious onset. While most acute in- 
 flammations, except those of dental origin, heal spon- 
 taneously, chronicity may be due to preexisting nasal
 
 CHRONIC INFLAMMATION OF THE MAXILLARY SINUS. \2*J 
 
 stenosis, to imperfect drainage on account of a small or 
 swollen orifice, or to poor health in general. In many 
 instances no acute history can be ascertained, and the 
 lesion probably started in a subacute manner during the 
 course of some infectious disease. Traumatism plays a 
 very small role. Occasionally foreign bodies (snuff, vom- 
 ited material) enter through the natural opening. More 
 often foreign bodies get in through the surgeon's fault 
 in the extraction of teeth or through exploratory open- 
 ings made for acute disease and not properly guarded. 
 Sometimes infection results from an intranasal opera- 
 tion, especially cauterization. 
 
 Chronic maxillary disease may remain latent for an 
 indefinite period of time in some instances. Its only 
 constant symptom is purulent discharge. This is some- 
 times so slight as to escape the patient's attention, or, 
 guided by the shape of the nasal wall, it may flow into 
 the pharynx. As a rule, however, it is the pus which 
 annoys the patient. Sometimes the discharge is very 
 profuse. It is more often foul than bland. Occasionally 
 the discharge is but moderately offensive, while at the 
 operation inspissated pus of intense fetor is met with. 
 Either through absorption of toxins or by the swallowing 
 of the pus, stomach disturbances and interference with 
 nutrition may result. A bad taste, especially in the 
 morning, is common. 
 
 Nasal obstruction by reason of turgescence becomes 
 annoying in proportion to the narrowness of the nose. 
 Even in the one-sided disease the stuffiness is more or 
 less bilateral, but, of course, most marked on the narrow 
 side. Sometimes there is pronounced nasal irritability, 
 with sneezing fits. Asthma is an uncommon complica- 
 tion. 
 
 The occurrence of pain seems to depend on two factors 
 viz., interference with drainage by reason of hyper- 
 trophy around the hiatus semilunaris, and a neuropathic 
 tendency. There may be headache, but more often infra- 
 orbital neuralgia or pain shooting into the teeth is com-
 
 128 DISEASES OF THE MAXILLARY SINUS. 
 
 plained of, sometimes in periodically recurring attacks. 
 One-sided disease produces one-sided pain. Tenderness 
 of the cheek is not always marked. 
 
 While the disease may be combined accidentally with 
 any form of nasal lesion, the intranasal affection most 
 likely to be associated with it is polypoid hypertrophy 
 around the hiatus semilunaris. This may not be visible 
 until the front end of the middle turbinal is amputated. 
 It can, however, be felt by the probe. Persistent profuse 
 discharge generally leads to chronic rhinitis and pharyn- 
 gitis, sometimes laryngitis. While the ear is menaced 
 only indirectly by secondary nasal lesions, empyema of 
 the maxillary sinus occasionally leads to eye complica- 
 tions, such as affections of the tear-passages, persistent 
 and recurring iritis, and circumscribed forms of chorio- 
 retinitis. 
 
 Suppurative disease of the maxillary sinus causes no 
 external signs, especially no distention of the sinus walls. 
 When the latter occurs, it is always due to the presence 
 of cysts. 
 
 The lesions, as observed at autopsies and after opera- 
 tions, are variable. During acute sinuitis inflammatory 
 edema is commonly found. In chronic cases this may 
 also persist, but oftener an actual hypertrophy of the 
 mucous lining is found, characterized either by intense 
 round-cell infiltration or later on by fibrillary sclerosis. 
 The epithelium is mostly intact, but the surface is uneven, 
 often warty. Polypi are not often seen. Pigmentary 
 accumulations are common as the result of hemorrhages. 
 Cysts due to dilatation of glands or to circumscribed inter- 
 stitial edema are quite common. There may be granula- 
 tion tissue in spots devoid of epithelium, usually indi- 
 cative of lesions in the bony wall. 
 
 As the deeper layer of the mucous membrane consti- 
 tutes the periosteum, the bony walls are apt to become 
 involved in severe instances. The most frequent lesions 
 are osteophytes like stalactites on the wall, sometimes 
 even detached and loose. Much less common, but more
 
 CHRONIC INFLAMMATION OF THE MAXILLARY SINUS. 1 2Q 
 
 serious, is caries of the bone, which in rare instances may 
 lead to perforation. Caries cannot be recognized with 
 certainty by the use of the probe alone, on account of the 
 roughness of the osteophytic surface. 
 
 49. The diagnosis is not always easy and may require 
 repeated examinations. If pus is seen issuing from un- 
 derneath the middle turbinal, it should be removed by 
 mopping. A rapid reappearance of pus indicates that it 
 comes from some reservoir opening in that region, which 
 may be either the frontal sinus, the anterior ethmoid cells, 
 or. the maxillary sinus. The latter is the most frequent 
 source. On account of the location of its orifice next to 
 its roof, its contents do not escape during the erect posture 
 except by overflow. If the head be turned so as to bring 
 the orifice to the lowest level, a more rapid escape takes 
 place, unless the fluid is very viscid or has been emptied 
 just previously. Exploration of the orifice with a probe 
 is possible only in a minority of instances. The probe 
 should be bent at nearly right angles about 5 mm. from 
 the tip. The middle meatus is cocainized, and by very 
 gentle manipulation the probe is pushed through the 
 opening in the hiatus semilunaris, or, to better advantage 
 even, through the accessory orifice, if one is found poste- 
 rior and a little below the hiatus. If pus is present, it 
 will be found on the probe and along its track. If the 
 probe can enter the orifice, an attempt may be made to 
 irrigate through the same channel with a slender silver 
 or rubber cannula shaped like the probe. Before this is 
 done the nose must be cleansed completely by means of 
 the douche. When irrigation through the orifice brings 
 forth pus, the diagnosis is definite. The finding of pus 
 in the antrum does not exclude purulent disease of the 
 ethmoid cells, which may or may not be present as a 
 complication. 
 
 Translumination is a valuable but not infallible diagnos- 
 tic method. A miniature electric lamp of from 4 to 8 
 candle-power, mounted in a metal or rubber hood open 
 on one side, is placed in the mouth, and the lips are 
 
 9
 
 I3O DISEASES OF THE MAXILLARY SINUS. 
 
 firmly closed. Any dental plate worn by the patient 
 must previously be removed. The room must be abso- 
 lutely dark, or a hood of opaque cloth may be placed 
 over the heads of patient and examiner. When the cur- 
 rent is turned on, a red glow is seen through the normal 
 cheek and extending laterally in 1 the shape of a butterfly's 
 wing underneath the lower rim of the orbit. The two 
 normal sides are generally symmetric. If, however, the 
 maxillary sinus of one side is rudimentary and the cheek 
 bone indented, the corresponding side may be darker 
 than the other. When pus is present, the darkness of 
 the affected side is unmistakable. Decided absence of 
 translucency is a positive indication of maxillary disease. 
 Either one-sided or double-sided sinuitis will rarely es- 
 cape detection, but a moderate darkening may simply be 
 due to denser structure of the bony walls. A diseased 
 antrum, containing at the time but little pus or only a 
 thin secretion, may give a doubtful indication. The 
 diminished translucency in antrum diseases is, however, 
 not due merely to the presence of pus, but also to changes 
 in the mucous membrane for, in pronounced instances, 
 the red glow does not return at once after evacuation of 
 the antrum. 
 
 When all other indications fail, the diagnosis can be 
 established by an exploratory puncture. After cleansing 
 the nose with a douche, a stout hollow needle is thrust 
 through the external nasal wall into the sinus, a. to 
 3 cm. behind the front end of the inferior turbinal. 
 Above the inferior turbinal the nasal wall is membranous 
 or contains but a thin lamella of bone. It is hence 
 easily perforated ; but if the nasal passage is very wide 
 and the antrum small, care must be taken not to pene- 
 trate through the cavity into the orbital wall of the 
 sinus. On the other hand, below the inferior turbinal 
 the bony wall is so thick that much force is required, an'd 
 some pain may be felt in spite of cocain. There is, 
 however, scarcely any possibility of not striking the 
 antrum if the needle is held as nearly transversely as the
 
 CHRONIC INFLAMMATION OF THE MAXILLARY SINUS. 13! 
 
 space permits and is pointed upward. If it enters the 
 nasal wall too far in front, it may penetrate through the 
 anterior maxillary wall, and the subsequent injection 
 may cause swelling and possibly infection of the cheek. 
 When the socket of the second bicuspid or first or second 
 molar tooth is available, the antrum can easily be reached 
 by means of a small drill. An effort should first be made 
 to blow out the secretion by means of an air-bulb, since 
 a serous fluid would escape detection when mixed with 
 water. Subsequently a stream of tepid sterile salt solu- 
 tion may be forced through the needle, and the escaping 
 fluid caught as it flows from the nose. 
 
 50. Treatment. It is doubtful whether a chronic maxil- 
 lary empyema ever heals without evacuation even under 
 favorable circumstances. The treatment, therefore, con- 
 sists in the evacuation of the fluid. This may be at- 
 tempted by irrigation through the natural or accessory 
 orifice by means of a slender silver or rubber cannula bent 
 near its tip. This procedure, only occasionally possible, 
 is unreliable as to permanent effect. It is facilitated by 
 the removal of the front end of the middle turbinal in 
 case this operation is indicated by reason of hypertrophies 
 in the middle meatus. If any of the upper teeth back of 
 the incisors are diseased at their roots, tender to pressure 
 or to heat or cold, their extraction is indispensable. 
 
 The easiest operation for draining the antrum is 
 through the socket of an extracted tooth, preferably the 
 first molar, or, if need be, the second molar or second 
 bicuspid. It is rarely desirable to sacrifice a healthy 
 tooth. A narrow orifice can be drilled on the internal 
 side, between the two molars or first molar and bicuspid, 
 but this opening has its drawbacks and is usually too 
 small. The drilling can best be done with a drill 
 attached to a dental motor. A conic hand drill can be 
 used (Fig. 47) instead, but is more awkward where the 
 alveolar process is thick. The hole should be at least 5 
 mm. wide. Cocain or nirvanin injected under the gums 
 secures painlessness. The thickness of bone varies from
 
 132 DISEASES OF THE MAXILLARY SINUS. 
 
 perhaps 2 to 8 or 10 mm. When the facial wall of the 
 sinus is deeply sunken in, there is a small possibility of 
 drilling from the alveolar socket through the canine fossa 
 into the cheek. Perforating into the nose can happen 
 only when the instrument is held too slanting and when 
 the nasal meatus is excessively wide at the expense of 
 the sinus. After irrigation the hole may be plugged 
 with iodofonn gauze for a day or two. Later a rubber 
 plug or cannula should be fitted by a dentist. This must 
 be guarded from slipping in by a thickened inferior edge, 
 and will readily stay in place if slightly club-shaped at 
 its upper end. If the plug is hollow, irrigation can be 
 practised through it without the necessity of removing it 
 every time. Food does not enter through a small open- 
 ing. Without plug the fistula would close rapidly by 
 
 FIG. 47. Hand drill for the maxillary antrum. 
 
 granulations. The patient learns easily to irrigate through 
 the opening, using warm sterile salt or boric acid solution 
 in a rubber bulb syringe with pointed nozzle. There is 
 no natural drainage through the opening, as the fluid is 
 too viscid, and the opening is not necessarily at the low- 
 est point of the sinus. 
 
 The puncture through the alveolar process, known as 
 Cowper's operation, gives immediate relief from all 
 symptoms, but cures only a fair minority of cases, espe- 
 cially those of dental origin. If the secretion does not 
 diminish steadily in the course of weeks, and has not 
 ceased entirely after the lapse of from three to four 
 months, no further improvement can be expected, ex- 
 cept from a more radical operation. Comfort, however, 
 can be secured as long as the opening is patent and irri-
 
 CHRONIC INFLAMMATION OF THE MAXILLARY SINUS. 133 
 
 gation is practised. When no more secretion is found, 
 the opening should be maintained about two weeks for a 
 further test before the plug or cannula is withdrawn per- 
 manently. If a scanty secretion still persists, it will 
 become noticeable again during a week or two of inter- 
 mission. Upon withdrawing the rubber plug the open- 
 ing shrinks within about one week to a fine fistula, which 
 then closes more slowly. If a foreign body gets into the 
 sinus through the opening, the suppuration continues 
 until it is removed. 
 
 51. Drainage into the inferior meatus of the nose is 
 preferred by some operators to Cowper's operation. In 
 several recent reports by German and American observers 
 this operation has been highly praised, although most 
 rhinologists have formerly found it objectionable. A 
 stout curved trocar (Fig. 48) is thrust through the thick 
 
 FIG. 48. Curved trocar for perforating the maxillary sinus through the nose. 
 
 nasal wall of the sinus underneath the inferior turbinal, 
 and nearly 3 cm. behind its front end, the instrument 
 pointing slightly upward. In spite of cocain this is apt 
 to be painful. The opening has not so much tendency 
 to shrink as the puncture through the alveolar socket. 
 On the other hand, it is practically impossible to fit a 
 cannula into it. It is more difficult for the patient and 
 often more painful to learn to wash out the sinus through 
 this opening. But it has been claimed recently that 
 many cases heal even without irrigation, except during 
 the first few days, if the opening is only kept patent. 
 Insufflations of boric acid or iodoform have been prac- 
 tised with good results. 
 
 52. The obstacle to a permanent cure of maxillary em- 
 pyema may be the existence of polypi or granulations in 
 the sinus, or, less commonly, caries of its walls. Cases
 
 134 DISEASES OF THE MAXILLARY SINUS. 
 
 not cured by irrigation through a small orifice require 
 removal of the anterior wall. This procedure, known 
 as Kiister's operation, can be tolerated under cocain or 
 nirvanin injection, but may require narcosis in the case 
 of a timid person. A horizontal incision is made down 
 to the bone below the canine fossa from the canine tooth 
 to the second molar. At its front and rear ends the 
 incision is curved upward in order to form a flap. The 
 periosteum is detached upward, and the thin anterior 
 wall of the sinus perforated either with a large trephine 
 run by a motor or with a chisel. The opening is enlarged 
 with bone nippers until a fair view can be had of the 
 interior of the sinus. If the probe or inspection reveals 
 no extensive changes in the interior, the operation may 
 be considered finished. The view at the time is, however, 
 often hindered by bleeding. A tampon of iodoform gauze 
 is then inserted for a couple of days. After that time the 
 interior can be inspected, and polypi and patches of gran- 
 ulations can be removed under cocain anesthesia. A rub- 
 ber obturator plate is then to be fitted by a dentist. The 
 patient irrigates several times daily, and the cavity is in- 
 spected from time to time in order to treat surgically 
 any hypertrophy of the mucous membrane or patches 
 of granulation. The healing always requires a number 
 of months. A large opening will persist without harm 
 for a long period or indefinitely. 
 
 When inspection shows extensive changes in the 
 cavity at the time of the operation, or when such changes 
 can be assumed on account of rebelliousness to previous 
 treatment through a former opening, a more radical 
 operation is to be performed. The entire anterior bony 
 wall is then to be resected, and, after thorough curetting 
 of the interior, the anterior flap of periosteum and mucous 
 membrane is pushed into the cavity after loosening it by 
 two lateral vertical incisions. It is then made to cover 
 the denuded walls by tamponing. In extreme instances 
 Boenninghaus has added to this operation the removal of 
 the nasal wall of the sinus bv careful chiseling from the
 
 CYSTS IN THE MAXILLARY SINUS. 135 
 
 side of the antrum. He thereupon pushes the mucous 
 membrane into the sinus from the nose, and thus practi- 
 cally covers what is left of the sinus walls with healthy 
 mucous lining from the nose and from the gum. As 
 cicatrization proceeds very slowly over the denuded sinus 
 walls, the transplantation of Thiersch grafts has been 
 practised to advantage. The healing requires many 
 months, but ultimately an entire cessation of secretion 
 can be obtained. 
 
 A similar but less radical operation has been practised 
 by Caldwell and is warmly indorsed by Luc. The an- 
 terior bony wall is lifted up in the form of a flap with 
 base up by chiseling and finally breaking the bone. The 
 cavity is inspected and treated, and a counteropening is 
 made into the nose. The diseased lining of the sinus 
 is thoroughly destroyed by swabbing with a saturated 
 chlorid of zinc solution. After a gauze drain has been 
 placed through the nasal opening, the anterior flap is 
 replaced and sutured. 
 
 CYSTS IN THE MAXILLARY SINUS. 
 
 53. Autopsies and surgical explorations have shown 
 the frequent occurrence of cysts in the maxillary sinus, 
 sometimes with very little / concomitant disease of the 
 mucous membrane. They are either retention cysts, 
 originating from the mucous glands, or edematous accu- 
 mulations in the interior of polypoid hypertrophies. The- 
 contents are usually a clear, yellowish, viscid fluid which 
 coagulates spontaneously. Glandular cysts may also have 
 purulent contents due to secondary infection. The symp- 
 toms due to cysts are vague. Probably no annoyance is 
 caused in many instances. In others they may induce 
 nasal irritability. Local discomfort, headaches, and ill- 
 defined neuralgic pains are sometimes produced by them, 
 and are relieved by treatment. If not accompanied by 
 empyema or not purulent in themselves, these cysts 
 cannot be recognized with certainty. Translumination 
 usually shows a suspicious reduction of translucency, but
 
 136 DISEASES OF THE MAXILLARY SINUS. 
 
 not always. On puncturing and aspirating, the charac- 
 teristic clotting fluid is obtained. If cholesterin crystals 
 are found, it indicates a retention cyst. Evacuation re- 
 lieves the symptoms, sometimes permanently, sometimes 
 transiently. When the contents are purulent, a rapid 
 but only apparent cure results from a single irrigation, 
 but a permanent result can be obtained only by evulsion 
 of the cyst-wall through a sufficiently large opening. 
 
 Of an entirely different nature are dental or follicular 
 cysts. They are made up of a thin bony capsule, often 
 containing an included tooth. The fluid is turbid and 
 viscid or even purulent. They are of slow growth, but 
 ultimately lead to distention of the antrum and bulging 
 of one or more of its walls. Follicular dental cysts and 
 tumors are the only lesions which are positively known 
 to cause distention of the antrum walls. The other 
 symptoms are usually vague. The treatment consists in 
 removal of the entire capsule with chisel and bone for- 
 ceps through an opening in the canine fossa.
 
 CHAPTER VIII. 
 
 DISEASES OF THE FRONTAL SINUS, ETHMOID 
 CELLS, AND SPHENOID SINUS. 
 
 INFLAMMATION OF THE FRONTAL SINUS. 
 
 54. Acute inflammation of the frontal sinus, less 
 common than acute disease of the maxillary cavity, is a 
 well-defined clinical occurrence. During a coryza or after 
 an influenza or some general systemic infectious disease 
 (typhoid fever or erysipelas) it starts with slight fever 
 and pain over the brow, the latter sometimes very severe. 
 There may be more or less continuous dull browache, 
 with spells of sharp, supra-orbital neuralgia. Often 
 there is transient edema of the upper eyelid. There is 
 always tenderness to touch over the brow and on the 
 upper wall of the orbit. The disease is mostly one- 
 sided. Hither at once or within a few days there occurs 
 a profuse purulent discharge from that side of the nose, 
 sometimes with relief of the pain. Of course, there is 
 some nasal stuffiness, especially if there is a complicat- 
 ing diffuse nasal catarrh. Acute frontal sinuitis heals in 
 most instances within from two to three weeks, but 
 without adequate treatment an unknown proportion of 
 cases become chronic. Even after apparent cure, occa- 
 sional later relapses are not uncommon. The diagnosis, 
 complications, and treatment can be discussed under one 
 heading for acute and chronic disease. 
 
 55. Chronic inflammation of the frontal sinus is 
 usually the prolongation of an acute attack. In other 
 instances it begins insidiously. Its occurrence is favored 
 by septum deflection and hypertrophies in the middle nasal 
 meatus, the latter themselves often a result of sinuitis. 
 The disease is sometimes wholly latent, and indicated only 
 
 137
 
 138 DISEASES OF THE FRONTAL SINUS. 
 
 by purulent discharge. Usually subjective symptoms are 
 added whenever an acute coryza occurs. In most in- 
 stances more or less suffering is constantly present. This 
 may be dull or sharp frontal headache, usually but not in- 
 variably one-sided, when the sinuitis is one-sided, which 
 is the more common occurrence. More characteristic 
 is supra-orbital pain in attacks, sometimes of remarkably 
 punctual periodicity. Mental irritability, depression, in- 
 ability to concentrate the attention, more rarely dizzi- 
 ness, may be complained of. There is commonly tender- 
 ness over the brow and along the upper wall of the orbit. 
 Occasionally puffiness of the upper eyelid is seen. 
 
 The discharge is variable in amount, and is sometimes 
 retained for a few days on account of swelling in the in- 
 fundibulum. When temporarily confined, it may or may 
 not cause suffering, which may be suddenly relieved by 
 the reappearance of the flow. When profuse, the flow is 
 fairly continuous during the erect posture. The pus is 
 not always fetid, rather less often than in the case of 
 maxillary empyema. The mucous membrane around 
 the infundibulum underneath the middle turbinal is 
 mostly swollen. During acute sinuitis this swelling is 
 due to edema. Later on polypoid hypertrophy of the 
 edges of the hiatus semilunaris is common. When there 
 is much discharge, chronic rhinopharyngitis usually 
 results. The effects of pus-formation and swallowing 
 of pus upon digestion and nutrition are sometimes seen 
 when the suppuration is profuse. 
 
 56. Distention of the walls of the sinus, especially 
 bulging of the thin roof of the orbit, is an occasional 
 symptom. This may occur very slowly, but sometimes 
 increases rather suddenly. The contents in this case are 
 either a viscid, slightly turbid mucus, or a mucopurulent 
 fluid, but usually not pure pus. In some instances they 
 have been found bacteriologically sterile. While it has 
 been usually assumed that the accumulation of contents 
 and the resulting distention depended on occlusion of the 
 frontal duct, it has been shown recently (A veil is) that at
 
 INFLAMMATION OF THE FRONTAL SINUS. 139 
 
 least in some of these cases the lesion is not at all primary 
 disease of the frontal sinus, but a closed mucocele or 
 empyema of an ethmoid cell intruded into the frontal 
 sinus. After a slow growth for a long time, such a 
 mucocele may finally perforate into the orbit. 
 
 The severest cases are those in which caries of the 
 bony walls leads to perforation. This happens rarely in 
 the first acute attack, more commonly during a later 
 acute exacerbation. The least serious, but also the least 
 frequent, perforation is through the anterior wall, causing 
 an external fistula. More common and more important 
 is the breaking-down of the orbital wall. The escape of 
 pus into the orbit may lead to diffuse phlegmonous in- 
 flammation and may even cause extension into the cranial 
 cavity, with fatal results. In more fortunate cases a cir- 
 cumscribed orbital abscess results, which may open at 
 the upper inner angle of the orbit. A most serious but 
 relatively rare accident is caries of the posterior wall of 
 the sinus, resulting in intracranial disease in the form 
 of a subdural or cerebral abscess or a diffuse meningitis or 
 thrombosis of the longitudinal sinus. Further diagnostic 
 references regarding pyogenic intracranial affections can 
 be found in the chapter on Intracranial Complications 
 of Middle-Ear Disease. 
 
 Frontal sinuitis causes ocular disturbances quite fre- 
 quently. Asthenopic discomfort from the use of the eyes 
 and insufficiency of convergence are frequent functional 
 disturbances. Constriction of the visual field has been 
 observed. When distention of the orbital wall occurs, 
 the eyeball is displaced laterally and its mobility may be 
 interfered with. The most serious consequences may 
 ensue in case of perforation into the orbit. Thrombosis 
 of the retinal vein, optic neuritis, and, later on, atrophy 
 have been observed, although such complications are 
 rare. 
 
 57. The lesions in the frontal sinus are principally in- 
 flammatory edema during the acute stage. The chronic 
 form depends mostly on hypertrophy of the mucous
 
 I4O DISEASES OF .THE FRONTAL SINUS. 
 
 membrane. In more serious cases the bony walls become 
 involved, at first by the formation of osteophytes, but in 
 severe infections later on by caries. Perforation seems 
 to occur especially along the channels of exit of the sinus 
 veins, which become thrombosed. When the walls are 
 gradually distended, the process is one of bony absorption 
 on the inner side, with deposition of fresh bony lamellae 
 under the external periosteum. The passage-way from 
 the frontal sinus to the infundibulum is probably never 
 or rarely closed permanently, but sometimes temporarily 
 occluded at its nasal end by swelling or hypertrophy of 
 the mucous membrane. In many instances inflammation 
 of the frontal sinus is complicated by suppuration of one 
 or more of the most anterior of the ethmoid cells, which 
 may communicate with the frontal sinus or intrude into it. 
 The diagnosis of frontal sinuitis is suggested by the 
 external signs, when present viz., supra-orbital neuralgia, 
 tenderness, especially along the inner upper wall of the 
 orbit, edema of the lid or bulging of the sinus wall. 
 Pain and tenderness without other symptoms are not 
 sufficient to establish the diagnosis. They may be due 
 to true supra-orbital neuralgia or to hysteria with some 
 form of asthenopia. Mucocele without discharge can be 
 recognized only when bulging occurs. The discharge of 
 frontal sinuitis is found issuing underneath the middle 
 turbinal. It may be difficult to distinguish between in- 
 flammation of the frontal sinus, the ethmoid cells, and 
 maxillary ant rum by means of the nasal symptoms. 
 Maxillary disease must first be excluded by translumi- 
 nation or exploratory puncture. An effort should be 
 made to pass a probe through the frontal opening. A 
 flexible silver probe is bent at an obtuse angle about 3 
 cm. from its end, and the intranasal part may be slightly 
 curved, with convexity toward the external side. After 
 cocainization the probe is to search underneath the front 
 end of the middle turbinal until it finds a passage leading 
 upward and forward. When it has been pushed in by 
 gentle manipulation to the extent of 3 cm., it is either in
 
 INFLAMMATION OF THE FRONTAL SINUS. 14! 
 
 the frontal sinus or in an anterior ethmoid cell intruded 
 into the sinus, which cannot be distinguished from the 
 sinus. Probing is successful only in a minority of cases. 
 When the removal of the probe is followed by a flow of 
 pus, a diagnosis is established. In doubtful cases syring- 
 ing in the direction of the probe by means of a thin 
 cannula may bring forth the pus. These manipulations 
 are much easier after the front end of the middle tur- 
 binal has been snared off. Repeated examinations may 
 be necessary to make a diagnosis. It is sometimes pos- 
 . sible to force out the pus by air pressure according to the 
 Politzer method of inflation viz., by blowing into the 
 nose with a rubber bag during the act of swallowing, 
 while the other nostril is firmly closed with the finger. 
 Translumination has been practised by means of two 
 small hooded lamps pressed against the upper inner 
 recess of the two orbits. In the absolutely dark room or 
 under a hood a red glow is seen over the area of the 
 normal frontal sinus. As this is not necessarily sym- 
 metric on both sides, translumination has not been found 
 trustworthy by most observers. 
 
 58. The treatment of acute disease requires rest and 
 reduction of the swelling of the nasal mucous membrane. 
 Cocain, suprarenal solution, the douche (in case of diffuse 
 nasal suppuration), or sprays favor drainage from the 
 frontal sinus. The neuralgia can be checked by anti- 
 pyrin or quinin in acute, but rarely permanently in 
 chronic, cases. Pain of any kind is relieved by drainage 
 of the pus. This may be attempted by irrigation through 
 the natural orifice if feasible. Decided relief can some- 
 times be obtained by forcible inflation of air by the 
 Politzer method. When, in chronic cases, hypertrophies 
 are found underneath the middle turbinal, it is best to 
 snare off the front end of that bony process. Polypoid 
 growths may be removed by the snare or sometimes even 
 better by means of a curet. The burner should never be 
 used in this locality for fear of obliterating any of the 
 orifices of the different sinuses. If irrigation of the
 
 142 DISEASES OF THE FRONTAL SINUS. 
 
 sinus is possible, its efficacy may be increased by using 
 solutions of silver nitrate, 2 to 5 per cent in strength, 
 after the pus has changed into a mucous secretion. So 
 long as the fluid is thick and yellow, there seems to be 
 no advantage in using anything but salt or boric acid 
 solution. Intranasal methods of treatment usually suf- 
 fice, even when there is some distention of the sinus 
 walls. A number of weeks or even some months may 
 be required, however. When the persistence of thick 
 and yellow pus indicates graver changes in the mucous 
 membrane or the bony walls of the sinus, or when alarm- 
 ing symptoms in the form of uncontrollable pain or 
 cerebral irritation suggest the possibility of perforation, 
 an external operation becomes necessary. 
 
 As a substitute for an external opening SchaefFer and 
 others have penetrated into the frontal sinus from the nose 
 by boring upward with a scoop, either between the middle 
 turbinal and roof of the nose, or along the natural chan- 
 nel from the sinus to the infundibulum. These attempts 
 have been justly abandoned by most surgeons, as they 
 involve the risk of penetrating into the cranial cavity. 
 
 59. Of all external surgical procedures, Kuhnt's opera- 
 tion has received the most extensive trial and has given 
 satisfactory results. An incision is made down to the 
 bone in the hairy part of the brow, through two-thirds 
 of its length, beginning at the nasal end. The brow 
 hides the resulting scar, and as the hairs can be satis- 
 factorily sterilized, it is best not to shave them off. A 
 vertical incision about 3 cm. long is then extended 
 upward in the crease made by the corrugator muscle. 
 The periosteum is detached from the bone, which some- 
 times is difficult to do, and a triangular flap is lifted 
 upward and outward. The front wall of the sinus is 
 entered either by a trephine run by a motor or by means 
 of a chisel, and if the sinus is found filled with granula- 
 tions, the entire anterior wall is resected. The entire 
 mucous membrane is removed by curetting, with pains 
 to enter every recess, including the sinus end of the
 
 INFLAMMATION OF THE FRONTAL SINUS. 143 
 
 frontal duct: The duct is thoroughly cleared or enlarged 
 down to the nose, and the wound is thereupon sutured, 
 leaving only a small gap for a gauze drain at the median 
 end. The posterior wall is closely inspected and probed 
 if there is any suspicion of extension to the cranial cavity. 
 In case a cerebral abscess is suspected, it can be sought 
 and opened after cautious resection of the posterior sinus 
 wall. Under daily irrigations through the wound a cure 
 is usually attained inside of six weeks. The sinus 
 becomes obliterated, and the skin-flap sinks in, but the 
 resulting disfigurement is not very conspicuous. The 
 only objection against the operation is that in case of 
 multiple disease of the frontal sinus and the ethmoid 
 cells the latter cannot be easily reached through the 
 wound. 
 
 It is needless to specify all the various modifications of 
 this operation which have been devised, but not exten- 
 sively tried. Jansen resects the inferior (orbital) wall of the 
 sinus and thereby gains easier access to the ethmoid. cells 
 if required. His results are good, but are attended with 
 considerable disfigurement. An osteoplastic operation 
 with the immediate replacement of the bony flap has 
 been practised by Czerny, Killian, and others. Goluvin 
 has performed the same operation with a device to pre- 
 vent disfigurement. His incision is like that of Kuhnt. 
 Upon raising the skin-flap, without periosteum, he 
 chisels a flap through bone and periosteum, with con- 
 vexity upward, and hinges it forward by breaking it at 
 its inferior base. The sinus is then curetted, thorough 
 connection established with the nose, the bony flap re- 
 placed, and the skin sutured completely. The subse- 
 quent treatment is entirely carried out through the nose. 
 The same author has also reported a series of cases in 
 which good, quick, and permanent results were obtained 
 by making merely a small trephine opening and destroy- 
 ing the diseased lining of the sinus by means of steam. 
 The steam is conducted from a small boiler through rub- 
 ber tubing and a rubber cannula into the opening made
 
 144 DISEASES OF THE ETHMOID CELLS. 
 
 by the trephine, and allowed to act for from one-quarter 
 to one-half of a minute. The result is obliteration of the 
 sinus by ossification. The wound should be kept open 
 and drained until dry. 
 
 SUPPURATION OF THE ETHMOID CELLS. 
 
 60. The ethmoid cells have not received as much atten- 
 tion at autopsies as the other accessory cavities, and hence 
 we possess less accurate information regarding the fre- 
 quency of their involvement in disease. Clinically, ethmoid 
 suppuration is nearly, if not quite, as frequent as disease 
 of the maxillary sinus, but it is probably not recognized 
 as often. It takes its start from an ordinary coryza, an 
 influenza-rhinitis, or more insidiously from some sys- 
 temic infection. Very little is known clinically about 
 the acute stage of ethmoiditis. It is ordinarily observed 
 in its chronic form. There may not be any but nasal 
 symptoms. A number of patients, however, complain 
 of more or less severe, though not characteristic, head- 
 aches, without definite localization; sometimes of peri- 
 odic attacks of migrain. There is sometimes tenderness 
 to pressure over the bridge of the nose. Mental irri- 
 tability, depression, less commonly vertigo, may or may 
 not be present. Long-continued suppuration may itself 
 be the starting-point of severe neurasthenia. The inten- 
 sity of suffering depends somewhat on the neuropathic 
 disposition of the patient. Intolerance to alcohol has 
 been often observed. 
 
 But in other patients there may be none but nasal 
 symptoms, and possibly these even of moderate degree. 
 Except in very wide passages there is always more or 
 less obstruction. This is partly due to transient venous 
 turgescence. In many instances, however, the obstruc- 
 tion depends upon the presence of polypi. Of all the 
 various forms of sinus disease, none are more frequently 
 productive of polypi than suppuration of the ethmoid 
 cells. But this coincidence is not invariable, and, on the 
 other hand, polypi may occur without ethmoid suppura-
 
 SUPPURATION OF THE ETHMOID CELLS. 145 
 
 tion. Yet the presence of polypi with purulent discharge 
 should always raise a strong suspicion of ethmoid disease. 
 The disease is perhaps as often bilateral as one-sided. 
 
 In a certain number of instances ethmoid suppuration 
 is either accompanied by ozena or produces the entire 
 train of symptoms which we term ozena. The discharge 
 may dry in the form of adherent crusts of characteristic 
 foul odor, with the appearance of atrophy of the inferior 
 turbinal. It is at present impossible to state definitely 
 the relationship between ozena and suppuration of the 
 ethmoid or other accessory cavities. There is every reason 
 to believe that ozena can exist as a diffuse disease of the 
 nasal lining, without involvement of any of the sinuses. 
 Sinus disease, however, is at least a frequent complication 
 of ozena, and, on the other hand, there are some instances 
 in which the entire clinical picture of ozena ceases after 
 the cure of a suppurating sinus or ethmoid cell. 
 
 61. Apart from the cases presenting the appearance of 
 ozena, the discharge is a creamy pus or purulent mucus, 
 sometimes bland, sometimes fetid in odor. Its apparent 
 origin varies according to whether the anterior or the 
 posterior ethmoid cells are diseased. In involvement of 
 the anterior ethmoid cells the pus issues underneath the 
 middle turbinal near its front end. As a rule, it flows 
 toward the anterior nares, but occasionally through the 
 middle meatus to the posterior choanse, thence dropping 
 into the throat. Its path can then be seen in the post- 
 rhinoscopic mirror. Suppuration of the anterior ethmoid 
 cells can be assumed whenever pus in any quantity flows 
 into the middle meatus, and disease of the maxillary and 
 frontal sinuses can be excluded. In multiple empyema, 
 in which the ethmoid cells participate as well as one or 
 the other of the other accessory cavities, or both, the 
 diagnosis of ethmoiditis can be made gradually only 
 after emptying the other sinuses, and still finding pus 
 issuing forth. It is sometimes necessary to tampon the 
 middle meatus with bits of cotton temporarily in order 
 to demonstrate the source of the pus. Probing of the 
 10
 
 146 DISEASES OF THE ETHMOID CELLS. 
 
 anterior ethmoid cells is very uncertain and not definitely 
 indicative of their disease. The probe can be passed 
 into one or more orifices upward and slightly outward 
 underneath the middle turbinal. If pus can be removed 
 by irrigation through a slender cannula introduced into 
 these spaces, the diagnosis is more definite. These 
 measures are all facilitated by the removal of the front 
 end of the middle turbinal. 
 
 The secretion from the posterior ethmoid cells issues 
 through orifices above the middle turbinal into the supe- 
 rior meatus of the nose. When the olfactory fissure is 
 seen filled with pus, this fluid comes either from the 
 posterior ethmoid cells or from the sphenoid sinus. The 
 distinction is neither easy nor always possible. The 
 diagnosis is largely based upon exclusion of sphenoid 
 disease, according to the methods given in Tf 66. 
 
 The recognition of disease of the posterior ethmoid 
 cells may be more definite after space has been gained by 
 removal of the middle turbinal. This can usually be 
 done only gradually by snaring off the front end and 
 subsequently the rear end, and finishing with cutting 
 forceps. The pus from the posterior ethmoid cells is as 
 likely to flow into the pharynx as into the anterior uares. 
 Not rarely it forms adherent crusts at the roof of the 
 pharynx. 
 
 Besides empyema of the ethmoid cells with escape of 
 pus into the nose, we must recognize a form of eth- 
 moiditis with confined secretion (mucocele). The fluid 
 is more likely to be mucous or mucopurulent than pure 
 pus in these cases. Its accumulation causes distention 
 of the cell in which it is found. This may be a cell 
 intruded into the front end of the middle turbinal, or it 
 may be the ethmoid bulla underneath the middle tur- 
 binal, which, when enlarged, appears as a reduplication 
 of the turbinated process. Confined secretion reveals 
 itself in these instances by nasal irritation, stuffiness, or 
 headaches. On inspection a distended, bony tumor is 
 seen protruding into the nose. Confinement of secretion
 
 SUPPURATION OF THE ETHMOID CELLS. 147 
 
 \yith distention may also occur in the cells adjoining the 
 lamina papyracea. In that case a bulging appears at the 
 inner wall of the orbit. Perforation may take place into 
 the orbit with results similar to those caused by perfora- 
 tion of the frontal sinus. Encroachment upon the orbital 
 space starts from ethmoid cells oftener than from the 
 frontal sinus, and the site of the tumefaction is below the 
 inferior wall of the frontal sinus. Pressure upon such 
 orbital tumefaction gives to the finger the same sensation 
 of yielding as when the thin cover of a tin can is pressed 
 upon. 
 
 63. Apart from the orbital symptoms produced by the 
 bulging of the lamina papyracea or its perforation, eth- 
 moid disease may lead to various ocular disturbances. 
 Asthenopia is not uncommon. Recurrent iritis is some- 
 times observed. The writer has seen repeatedly a peri- 
 pheral palsy of ocular muscles, the coincidence of which 
 with an exacerbation of one-sided ethmoid disease was a 
 strong reason for suspecting the latter as the etiologic 
 starting-point. There are on record a moderate number 
 of well-authenticated instances of fatal meningitis re- 
 sulting from suppuration of the ethmoid cells. Eth- 
 moid empyema, like other forms of nasal suppuration, 
 is likely to induce secondary hypertrophic changes in the 
 nose and pharynx, with occasional extension into the 
 larynx or even further down. 
 
 63. The lesion in suppuration of the ethmoid cells is at 
 first inflammation of the mucous membrane. It is charac- 
 teristic of the lining of these spaces that it swells readily 
 in response to irritation. Acute inflammation may cause 
 edema, which makes the mucous membrane protrude 
 wherever it is not confined. After amputation of the 
 front end of the turbinal the lining membrane underneath 
 will often appear swollen and polypoid shortly after 
 exposure. This acute condition may subside completely. 
 But in the course of more persistent inflammation, hyper- 
 trophy of a permanent character takes place. Hence 
 ethmoid suppuration is often accompanied by hypertro-
 
 148 DISEASES OF THE ETHMOID CELLS. 
 
 phies of the mucous membrane and true polypi. In the 
 course of time the thin bony lamellae become involved, as 
 the mucous membrane and periosteum are practically 
 continuous. The bony lesions are partly those of a rare- 
 fying ostitis with partial absorption, partly thickening of 
 the bony plates secondary to proliferative periostitis. In 
 rare cases the disease may be limited to but one or a few 
 cells. More commonly suppuration extends through an 
 entire series of ethmoid cells, anterior or posterior, or 
 sometimes both. 
 
 Woakes, who first drew attention to the frequency of ethmoid 
 suppuration, vitiated his clinical observations by false pathologic 
 notions. He described, as the basis of the disease, necrosis of 
 the bone, " necrosing ethmoiditis." His theory, accepted to some 
 extent by clinicists, has been entirely refuted by anatomic re- 
 search. Necrosis and caries of the bony walls play a very small 
 role in ordinary forms of suppuration of the ethmoid cells. De- 
 struction of bone may be a secondary complication in very severe 
 disease. But, on the whole, it is not common, except as the 
 result of syphilis, or, less frequently, tuberculosis. 
 
 64. The treatment of ethmoid disease requires, in the 
 first place, the removal of all polypi and hypertrophies of 
 the nasal lining. If these are difficult of access, it is best 
 to snare off the middle turbinal at its front or even at its 
 rear end. Under the use of the douche, or, still better, 
 irrigation through a slender cannula brought close to the 
 ethmoid orifices, a small number of cases will heal in the 
 course of weeks. The larger proportion are only bene- 
 fited, but not cured, by this treatment. A more radical 
 measure is the exposure of the suppurating cells, usually 
 after resection of the middle turbinal. The safest and 
 most satisfactory instrument is the sharp nasal hook, 
 suggested by Hajek (Fig. 49). This is not likely to do 
 accidental damage, which must be feared when drills ate 
 employed. The hook follows the path previously ex- 
 plored by the probe when searching for the origin of the 
 pus. The suspected orifices under the insertion of the 
 middle turbinal are entered and torn open. As a rule,
 
 SUPPURATION OF THE ETHMOID CELLS. 149 
 
 the slender hook suffices; if necessary, the heavier model 
 is employed. Each suspected cell is torn open, and the 
 shreds of the mucous membrane and bone are clipped off 
 with cutting forceps. There is generally enough bleed- 
 ing to necessitate the gradual performance of the opera- 
 tion at successive times. In searching for the posterior 
 cells, the hook passes into the olfactory fissure above the 
 middle turbinal. As long as the nasal roof is avoided 
 there is no risk in these manipulations. As soon as a 
 suppurating cell is thus completely exposed and drained, 
 the symptoms caused by it, especially the headache, 
 cease promptly. As long, however, as symptoms con- 
 tinue, the surgeon must try to follow the channels of 
 suppuration by opening other cells or breaking down the 
 
 FIG. 49. Hajek's hooks. They fit into the usual nasal handle at an obtuse 
 
 angle. 
 
 thin partitions between them by means of curets. The 
 treatment, therefore, is very apt to be tedious, but it is 
 sure to give relief. Still only a small proportion of 
 patients are completely cured. In the majority the dis- 
 tressing symptoms are relieved, but the secretion is not 
 entirely stopped. 
 
 The treatment is simple and quite efficacious in case 
 of secretion pent up in one or a few ethmoid cells the 
 so-called ethmoid mucocele. It suffices to expose these 
 cells thoroughly by removal of the bony wall. Accord- 
 ing to the location and prominence of the distended cell, 
 this can be done either with a snare or the hook, or a 
 hand-drill, and finished with a curet or cutting forceps. 
 
 In exceptional cases of alarming severity, and espe-
 
 I5O DISEASES OF THE SPHENOID SINUS. 
 
 cially in instances of multiple empyema, it may prove 
 necessary to perform an operation from the outside, with 
 complete exposure of all the ethmoid cells. This opera- 
 tion will be referred to under the head of Multiple 
 Empyema. 
 
 INFLAMMATION OF THE SPHENOID SINUS. 
 
 65. The sphenoid cavity is frequently found diseased 
 in autopsies. But clinically affections of this space are 
 not observed so commonly, probably because they are 
 often overlooked. The symptoms are not definite. We 
 do not know how many cases run a latent course, the 
 disease causing merely nasal suppuration and obstruction. 
 The pus is observed in the olfactory fissure, between 
 middle turbinal and septum, more often one-sided than 
 bilateral. It is as likely to flow through the posterior 
 choanse as into the anterior nares. In some instances 
 sphenoid suppuration produces the symptoms of ozena 
 viz., fetid, adherent crusts, with tendency to atrophy of 
 the inferior turbinal. Probably, many of the instances of 
 crust formation at the roof of the pharynx are due really 
 to sphenoid suppuration. The nasal obstruction which 
 may result from sphenoid affections is due mainly to 
 turgescence of the rear ends of the turbinal. In fact, 
 every periodic engorgement of the cavernous tissue at the 
 level of the posterior choanae should direct suspicion 
 toward the sphenoid sinus. 
 
 When headache is present, it is generally of a severe 
 type and not definitely localized. It seems to be a fairly 
 frequent symptom. The disease starts sometimes in an 
 acute manner for instance, after influenza. In other 
 cases its origin cannot be. traced. Eye symptoms in the 
 form of asthenopia are not uncommon. Extension of 
 the disease through the upper wall has in some instances 
 caused optic neuritis, in others atrophy of the optic 
 nerves. Caries of the sphenoid walls, though probably not 
 common, has been observed. It has caused fatal hemor- 
 rhage by erosion of the carotid artery. Thrombosis of
 
 INFLAMMATION OF THE SPHENOID SINUS. [51 
 
 the cavernous sinus is likewise a possible consequence, as 
 well as fatal meningitis. 
 
 66. The diagnosis depends upon exploration of the 
 sphenoid sinus through its orifice. If the probe slants 
 sufficiently backward and upward, it is bound to touch 
 the anterior surface of the sphenoid body. By holding it 
 nearly vertical and probing too near the front end of the 
 middle turbinal its tip reaches the dangerous nasal roof. 
 But by crossing the middle turbinal behind its center this 
 danger is avoided. The sphenoid orifice is situated close 
 to the roof of the nose and nearer to the lateral wall than 
 to the septum. By bending the tip of the probe a trifle 
 upward, it is quite often possible to enter the sphenoid 
 orifice. The distance from the inferior rim of the pyriform 
 aperture to the sphenoid opening varies from 6 to 8 cm. 
 in the adult. After entering the orifice the probe can then 
 slip into the sinus to the extent of i to 2,\ cm. When 
 pus issues next to the probe or adheres to the probe, the 
 diagnosis is established. If this test fails, a slender 
 cannula can be substituted for the probe, and an attempt 
 made to dislodge the sphenoid secretion by warm salt 
 solution. It is often difficult, sometimes impossible, to 
 distinguish between suppuration of the posterior ethmoid 
 cells and of the sphenoid sinus until the middle turbinal 
 has been nearly entirely removed. 
 
 67. Treatment. When the inflammatory process in the 
 sphenoid is of a superficial character, a few irrigations 
 through the natural orifice will sometimes terminate the 
 disease. In instances attended with suffering, the first 
 successful irrigation gives relief. If irrigation through the 
 natural opening proves impossible or insufficient, the ante- 
 rior wall of the sinus can be opened in the safest manner 
 by means of Hajek's hook. Traction with a hook does not 
 involve the risk of slipping that attends the use of a drill 
 or a perforating curet. The opening of the sinus suffices 
 for a gradual cure, except when its interior lining is per- 
 manently hypertrophied. In such instances the mucous 
 membrane has been successfully removed by means of
 
 152 MULTIPLE EMPYEMA OF SEVERAL ACCESSORY CAVITIES. 
 
 the curet or the introduction of a pledget of cotton on a 
 probe moistened with chlorid of zinc solution. This 
 should be introduced through a tube in order to protect 
 the nasal lining. On account of the possible thinness of 
 the upper wall of the sinus, Hajek advises as the safer 
 method the evulsion of the thickened mucous membrane 
 with forceps rather than with a curet working in the con- 
 fined space. The use of the curet on the inferior wall 
 involves no risk. In the majority of instances, suppura- 
 tion of the sphenoid sinus can be controlled by treatment 
 with more certainty than extensive disease of the ethmoid 
 cells. 
 
 MULTIPLE EMPYEMA OF SEVERAL ACCESSORY CAVI= 
 
 TIES. 
 
 68. Although sinuitis is mostly limited to one cavity, 
 multiple disease of several spaces is not uncommon. Such 
 instances may be one-sided or bilateral, in the latter cases 
 perhaps most frequently with symmetric involvement 
 on both sides. In the case of the frontal sinus bilateral 
 disease is sometimes due to a defect or morbid perforation 
 of the median partition wall. The spaces which partici- 
 pate the oftenest in multiple empyema are the ethmoid 
 cells, the anterior in connection with maxillary or frontal 
 sinus disease, the posterior with sphenoid suppuration. 
 Occasionally all cavities are found diseased on one or 
 even both sides. 
 
 As in the case of disease of a single sinus, the symp- 
 toms may vary greatly. On the one hand, a few 
 patients complain of nothing but a very profuse discharge. 
 It is remarkable how little disturbance of health there 
 may be in such exceptional cases. On the other hand, 
 there may be, besides the local discomfort and the nasal 
 secondary disturbances, headaches of great severity, 
 general malnutrition, and neurasthenia, until the patient 
 becomes a physical wreck. 
 
 The diagnosis can be made only gradually, as the in- 
 volvement of one cavity after another is being recognized.
 
 TREATMENT. 153 
 
 Efforts must be made to trace the origin of the pus ac- 
 cording to the indications discussed previously. 
 
 69. In instances in which no severe or dangerous 
 symptoms are present, the attempt may be made to expose 
 the suppurating spaces by the same intranasal operations 
 which apply in disease of each individual sinus. But 
 whenever urgency is called for, a more radical method is 
 the free opening of the accessory spaces from the outside. 
 A number of different modifications of osteoplastic opera- 
 tions have been devised by Gussenbauer, Wiukler, and 
 Killian. All of them give fairly satisfactory results; 
 none of them have received extensive trial. The prin- 
 ciple of such an operation for one side at a time is the 
 following: 
 
 General narcosis, tamponing of the nasopharynx, in- 
 cision down to the bone in the median line from the 
 upper level of the frontal sinus along the bridge of the 
 nose down to beyond the lower border of the nasal bone, 
 pushing back the periosteum sufficiently for separation 
 of the nasal bones at the nasofrontal suture. Sub- 
 periosteal resection at the same level through frontal 
 process of superior maxilla with a fine saw or chisel, 
 opening the bony frame of the external nose through the 
 suture between the two nasal bones, and pushing outward 
 the external wall of the nose (nasal bone and frontal 
 process of submaxilla), if necessary after grooving along 
 its nasal surface in case it offers too much resistance. 
 The ethmoid cells can now be entered from the front, 
 and by breaking down all cross partitions and septa with 
 forceps, they can be changed into a single continuous 
 space from lamina papyracea to middle turbinal, opening 
 freely into the nose. The operation can be extended to 
 the anterior sphenoid wall, and the sphenoid sinus ex- 
 posed. In case of frontal empyema a horizontal incision 
 is extended through the brow, a portion of the anterior 
 wall of the sinus is resected, the duct identified by a 
 probe introduced into it, and the floor of the sinus chiseled 
 away as far as it is accessible from the nose. Gauze tarn-
 
 154 MULTIPLE EMPYEMA OF SEVERAL ACCESSORY CAVITIES. 
 
 pons leading into the nose, replacing of bone flaps, 
 primary or early secondary suture. After-treatment 
 through the nose. 
 
 In Gussenbauer's operation for bilateral disease the cu- 
 taneous incision begins near the middle of each eyebrow, 
 runs down vertically (about 5 mm. beyond the internal 
 canthus) along the sides of the nose, and connects across 
 the nose at the lower border of the nasal bones. A single 
 bony flap is made of all the nasal walls circumscribed by 
 the incision, including the lachrymal bone and a slice of 
 the lamina papyracea, as well as the perpendicular plate 
 of the ethmoid. After sawing and chiseling through all 
 connections, the flap is reflected upward and access ob- 
 tained to the upper part of the interior of the nose and 
 the entire ethmoid labyrinth on both sides. After the 
 complete exenteration of all diseased spaces the flap is 
 replaced.
 
 CHAPTER IX. 
 
 OZENA (FETID ATROPHIC RHINITIS) SIMPLE 
 ATROPHIC RHINITIS. 
 
 70. Symptoms and Course. Atrophic rhinitis is char- 
 acterized by a purulent secretion, drying in the form of 
 adherent crusts, and accompanied by progressive atrophy 
 of the nasal mucous lining and of the turbinated bones. 
 In the " simple" form the crusts are nearly odorless; in 
 the fetid form the more common variety the crusts 
 have a very strong offensive and characteristic smell. 
 As the fetid form can be changed by treatment into the 
 odorless simple form, the two varieties of the disease 
 similar in course may be considered under one head. 
 
 The beginning of the disease has been but little de- 
 scribed and is probably not seen often. In some personal 
 observations it began as a minimal localized focus of 
 characteristic suppuration on the middle turbinal, with 
 crust-formation gradually extending in area. The sub- 
 jective annoyance is but moderate. There is some 
 transient obstruction when large scabs form, which 
 diminishes, however, as the atrophy proceeds. The 
 crusts cause the patient to blow forcibly in order to expel 
 them, as there is but little fluid discharge. In neurotic 
 subjects severe headaches, both more or less irregularly 
 continuous pain, as well as periodic attacks of migrain, 
 are not uncommon. The patients have occasional fresh 
 "colds," with increased discharge, but these attacks are 
 both less severe and less common in atrophic rhinitis than 
 in other chronic forms of nasal disease. They cease 
 almost entirely when the atrophy has advanced far. The 
 most distressing symptom, present only in the fetid form, 
 is the foul odor noticeable sometimes across the room, 
 but not perceptible to the patient. The patient's sense 
 
 155
 
 156 OZENA. SIMPLE ATROPHIC RHINITIS. 
 
 of smell is often reduced, especially when there is abun- 
 dant scab-formation. 
 
 The discharge is viscid greenish-yellow, and so tena- 
 cious that it does not flow along the mucous surface, but 
 adheres and dries superficially, forming scabs with some 
 thick fluid underneath. It is formed mainly around and 
 opposite the middle turbinal, but is, of course, gradually 
 pushed down by further flow from above. A large part 
 of the nasal walls may thus be lined with crusts. The 
 amount of crust-formation varies. In many cases casts 
 are found at the roof of the pharynx. Occasionally the 
 disease seems to be limited to this locality alone. When 
 the disease improves under treatment, the pus becomes 
 more fluid, less greenish, and changes finally into a 
 slightly purulent mucus. The odor in the fetid variety 
 is so characteristic that an experienced diagnostician can 
 distinguish it at once from the smell of either syphilitic 
 necrosis or of suppurative sinuitis with retention. But 
 the odor is not inherent in the fresh discharge: it is the 
 result of secondary changes. When the crusts have been 
 thoroughly removed and are not allowed to form again by 
 proper tamponage of the nose, the pus upon the tampon 
 has merely a slightly mawkish odor, as in the simple, 
 non-fetid variety. The fetid form can thus be transformed 
 into the non-fetid variety, but usually changes back in 
 the course of weeks when the treatment ceases. Whether 
 the non-fetid form occurring spontaneously acquires the 
 odor in the course of time is not known. But while the 
 odor is thus a secondary feature, it is one of great impor- 
 tance, for not only is it the main annoyance to the patient, 
 but the changes which cause the odor are, by themselves, 
 a significant factor in the course of the disease. The sim- 
 ple non-fetid atrophic rhinitis much less common than 
 the typical form of ozena shows neither as much dis- 
 charge nor as much atrophy as is usually found in ad- 
 vanced cases of fetid ozena. 
 
 71. The atrophy of this disease is a gradually increasing 
 process. Scarcely recognizable at first, it continues until
 
 PATHOLOGY. 157 
 
 the passages have become abnormally wide and the 
 complex architecture of the turbinals is reduced to rudi- 
 mentary ledges. When ozena occurs in a nose with 
 strongly deflected septum, the atrophic process is always 
 much less pronounced on the side narrowed by the con- 
 vexity of the septum. In extreme cases of this kind the 
 disease seems to be almost wholly one-sided, while ordi- 
 narily it is symmetric. The atrophy involves the entire 
 mucous membrane. The venous plexus shrinks likewise, 
 and turgescence becomes finally impossible. Even in 
 the living it is evident that the atrophy involves also 
 the bony structure of the turbinals and leads to their 
 reduction in size and partial absorption. Ulceration and 
 caries of bone are, however, never found in-ozena. Oc- 
 casionally a circumscribed hypertrophy of the mucous 
 membrane over a part of a turbinal probably antedating 
 the ozena persists for a while. Hypertrophy of the 
 pharyngeal tonsil is conspicuously absent. Moderate 
 enlargement of the faucial tonsil is sometimes met with. 
 
 Ozena begins mostly in childhood after about the 
 sixth to the eighth year, less commonly in adolescence. 
 The fetid variety is much more common than the disease 
 without odor. The female sex preponderates markedly. 
 The disease continues an indefinite period, but probably 
 ceases in some instances spontaneously in middle or ad- 
 vanced life. The atrophy, however, remains. 
 
 Ozena does not often lead to complications. Ulcerative 
 blepharitis of a severe type, purulent dacryocystitis, less 
 frequently persistent secretory catarrh of the middle ear, 
 are its possible consequences. 
 
 73. Pathology. Atrophic rhinitis is an inflammatory 
 disease. As long as the atrophy is not complete, the 
 mucous membrane is found infiltrated with round cells, 
 both in a continual subepithelial layer, as well as around 
 arterioles and glands. The cylindric ciliated epithelium 
 is changed into non-ciliated cuboid pavement cells. The 
 surface epithelium, as well as the gland-cells, shows fatty 
 infiltration. From the start the atrophic changes are
 
 158 OZENA. SIMPLE ATROPHIC RHINITIS. 
 
 unmistakable. The mucous membrane becomes grad- 
 ually thinner, the glands shrink and finally disappear 
 largely, while arteries, and still more the venous plexus, 
 atrophy proportionately. The bony skeleton of the tur- 
 binals shrinks in all directions and becomes fragile, show- 
 ing a histologic picture of bone absorption (osteoclasts). 
 The atrophic process is a diffuse one, although not always 
 uniformly extensive. 
 
 It has been shown clinically by Griinwald, and con- 
 firmed by Hajek and others, that ozena is often associated 
 with suppurative inflammation of one or more accessory 
 cavities, especially the sphenoid sinus. The extreme 
 view, however, which considers ozena simply and in- 
 variably a manifestation of sinus disease, is not tenable. 
 A number of autopsies have shown that ozena can exist 
 without involvement of any sinus. Clinically, too, cases 
 are occasionally observed in which the curative influence 
 of douches and tampons permits us to exclude sinus dis- 
 ease, which would not yield to these measures alone. On 
 the other hand, the majority of unquestionable instances 
 of suppuration of the various sinuses do not present the 
 characteristic clinical picture of ozena viz., the typical 
 greenish adherent crusts and the progressive atrophy. 
 The odor of foul pus from a sinus is also not identical 
 with that of ozena at least, as a rule. 
 
 There can be no doubt, however, that suppuration of 
 one or more sinuses is an important and frequent, though 
 probably a secondary, lesion in ozena, and that this associa- 
 tion explains in many instances the inefficiency of treat- 
 ment. It may even be stated that there are occasional 
 instances of apparently typical ozena, usually not far 
 advanced, in which the cure of suppuration from the 
 sphenoid sinus or the ethmoid cells puts an end to all 
 manifestations of ozena. The atrophy, however, remains, 
 but this has generally not advanced far in cases of this 
 description. 
 
 73- As the cause of atrophic rhinitis, a microbe has 
 been described by Lowenberg in the shape of a coccus.
 
 CAUSE. 159 
 
 But the same germ was subsequently identified by Abel 
 (Paulsen and others) as a short bacillus the bacillus mu- 
 cosus capsulatus. l It has been invariably found, although 
 in scant number, in the fresh discharge in this disease, 
 whether odor was present or not. This microbe does not 
 give rise to the characteristic odor in cultures. It has 
 been seen occasionally in the discharge in other nasal 
 diseases. This latter fact would not overthrow its etio- 
 logic significance, as it is well known that different 
 unquestionably virulent microbes (diphtheria, cholera, 
 and tubercle bacilli) can occur at times on mucous 
 surfaces without leading to infection. But since this 
 bacillus is not found in the interior of the tissues, and 
 since no conclusive inoculations have been reported, its 
 importance cannot be said to have been fully established. 
 Still, infection by some specific form of microbe is the 
 most plausible explanation of the peculiarities of this 
 disease. Coexisting inflammation of different sinuses 
 may, however, be a secondary or mixed infection with 
 other pyogenic micro-organisms. The secretion started 
 by this specific infection differs, at least quantitatively, 
 in its composition from the pus of other diseases, for in 
 other nasal affections we do not find such crusts unless 
 there is ulceration present, as in syphilis and infected 
 wounds, and in these cases the crusts have not the charac- 
 teristic odor. Yet the odor is not directly due to the 
 presumable parasite of ozena, since, as stated before, the 
 smell can be abolished by preventing retention and dry- 
 ing of the discharge, while in the simple form of atrophic 
 rhinitis there is no odor at all. Hence it is probable that 
 
 1 A bacillus about 1.25 fj, thick, of variable length sometimes so short as 
 to look like a coccus. Often in chains. Surrounded by a distinct capsule. The 
 bacillus is easily stained, but loses its color by the Gram method. Aerobic. 
 Grows on gelatin, forming thick white colonies of fluid but viscid consistency, 
 without diffuse liquefaction of soil. On potato a creamy rich growth of color of 
 soil. Retains its life in culture indefinitely. Pathogenic to white mice, pro- 
 ducing a local exudate and septicemia. Much less virulent to other animals. 
 While this bacillus belongs to the same group as the pneumobacillus of Fried- 
 lander, it is distinguishable from it by its cultural peculiarities.
 
 l6o OZENA. SIMPLE ATROPHIC RHINITIS. 
 
 the characteristic smell is produced by secondary decom- 
 position of the pus by other bacteria, which find a favor- 
 able soil in the pus peculiar to the " fetid " form of this 
 disease, but which in certain other cases the simple 
 form are resisted by (unknown) influences unfavorable 
 to them. These secondary decompositions undoubtedly 
 are an additional pathogenic factor in the disease, since 
 any tendency toward improvement is observed only when 
 the retention and decomposition of the discharge are pre- 
 vented artificially. Besides the bacillus mucosus cap- 
 sulatus, other bacteria are always in abundance in the 
 crusts. There is no clinical evidence that ozena is con- 
 tagious. Its rare occurrence in several members of one 
 family is more likely due to congenital anatomic predis- 
 position. 
 
 It is noticeable that atrophic rhinitis occurs usually in 
 relatively spacious nasal passages. Measurements by 
 Hopman have shown that there is usually a relative 
 shortness of the nasal septum as compared with the 
 depth of the postnasal space. Atrophic rhinitis is a 
 purely local disease, not related to other disturbances of 
 health. 
 
 Of the numerous speculative views regarding the etiology of 
 ozena, only two need to be mentioned and to be refuted. Frankel 
 claimed that ozena is the terminal stage of hypertrophic rhi- 
 nitis. No one has ever seen this transition conclusively, and 
 the mere presence of a hypertrophic spot in ozena is insufficient 
 evidence. Moreover, ozena begins usually in childhood, before 
 hypertrophic rhinitis is at all common. Bosworth has suggested 
 that his " purulent rhinitis of children " might be the beginning 
 of atrophic disease, but has also failed to furnish positive proofs. 
 According to personal experience, the peculiarities of the purulent 
 rhinitis of children persist so long as the disease lasts and do not 
 change into those of ozena, while it is generally recognized that 
 the characteristics of ozena are present from the start. 
 
 74. The treatment demands the removal of the tena- 
 cious pus and the prevention of its desiccation. If the 
 douche used with considerable force does not detach the 
 crusts, they must be picked off with forceps and probe.
 
 TREATMENT. l6l 
 
 The douche should be continued until the water comes 
 out clear. In a few hours the crusts form again. But 
 on irrigating twice a day properly, the secretion soon 
 diminishes, becomes clearer and less tenacious, and crusts 
 can be prevented. An important addition, and to some 
 extent a substitute for the douche, is the tampon intro- 
 duced by Gottstein. A pledget of cotton of the size of a 
 little finger is pushed up into the nose and replaced in 
 the course of hours as soon as it feels wet. It may be 
 wound on a probe with a screw-thread, which is then 
 withdrawn by rotation, or it may be rolled permanently 
 on a wooden tooth-pick. Its application must be learned 
 by the patient. As long as the surgeon applies the tam- 
 pon himself, packing with gauze is, if anything, more 
 agreeable to the patient than cotton. If possible without 
 interference with nasal breathing, the tampon may be 
 worn on both sides continuously, otherwise alternately. 
 Its use during the night depends on the patient's toler- 
 ance. The tampon starts a more abundant but thinner 
 flow of mucus, which diminishes in the course of some 
 days. The tenacious pus is thus removed more com- 
 pletely by absorption by the cotton plug, while desic- 
 cation becomes impossible. If properly applied after a 
 thorough cleansing, the tampon removes all odor within 
 a few days. On stopping the treatment, the odor returns 
 after a time, varying in duration according to the pre- 
 vious improvement. By the use of the douche and the 
 tampon, every case of ozena can be made comfortable 
 and improved up to a variable limit. A small number, 
 perhaps 10 per cent., are completely cured in the course 
 of many weeks. The possibility of cure depends less on 
 the degree of atrophy than the absence of suppuration of 
 accessory cavities. 
 
 Griinwald has shown that ozena rebellious to all other 
 treatment can be cured by opening up all foci of sup- 
 puration in the different sinuses which may be involved. 
 Quite often the sinuitis is multiple, and may hence 
 require multiple operations. The difficulties of recog- 
 11
 
 1 62 OZENA. SIMPLE ATROPHIC RHINITIS. 
 
 nizing and curing affections of the accessory cavities 
 (compare Chapters VI. to VIII.) are at present so great 
 that but few reports have appeared confirming or limiting 
 Griinwald's claims. The writer's personal observations 
 are favorable to them, but he can neither share his radi- 
 cal views concerning the all-importance of sinuitis, nor 
 his sanguine statements regarding their speedy surgical 
 cure. 
 
 Many other methods of treatment have been recommended, 
 but none have obtained general indorsement. Medicinal applica- 
 tions of methyl-blue, ichthyol, oil sprays, mild caustics, and a 
 host of other measures have found but little favor on tests made 
 by others than their first originators. Electrolysis carried out by 
 means of a copper probe used as negative electrode with a current 
 of from 15 to 25 milliamperes for a few minutes has also been 
 found uncertain, although at first highly praised. Massage by 
 means of vibratory movements with a cotton-wound probe, or 
 with an electromagnetic vibrator, seems to have given satisfaction, 
 but definite reports regarding permanent cures are still to appear. 
 Injection of diphtheria antitoxin, a procedure without any theo- 
 retic foundation, has been reported curative, but the unfounded 
 and arbitrary reason for this procedure has not attracted much 
 confirmation.
 
 CHAPTER X. 
 
 ANTERIOR DRY RHINITIS. PERFORATING ULCER 
 
 OF THE SEPTUM HEMATOMA AND ABSCESS 
 
 OF THE SEPTUM. MEMBRANOUS AND DIPH- 
 THERITIC RHINITIS. 
 
 ANTERIOR DRY RHINITIS (RHINITIS ANTERIOR SICCA). 
 PERFORATING ULCER OF THE SEPTUM. 
 
 75. Anterior dry rhinitis is the term applied recently 
 by Siebenman to a frequent nasal affection which had 
 previously been ignored, perhaps by reason of its seeming 
 innocuousness. It is an inflammation of the lower part of 
 the cartilaginous septum, with formation of adherent 
 crusts and tendency to ulceration. On the surface of the 
 cartilaginous septum, barely behind the vestibule and 
 just above the floor of the nose, adherent thin scabs are 
 found on one side, as a rule. They are not purulent, 
 and look like dry scales of varnish. When detached 
 (with difficulty), the surface underneath is found exco- 
 riated and liable to bleed. L/ater on deeper ulceration may 
 be seen. The disease remains limited to a small area. 
 It has little tendency to heal spontaneously, arid may last 
 long periods of time, leading in many instances finally to 
 a perforating ulcer of the septum. As the disease ad- 
 vances the mucous membrane is destroyed, and the cartil- 
 age is seen exposed. The ulceration extends through the 
 center of this denuded area, and then spreads centri- 
 fugally until a perforation approximately circular and 
 rarely over 2 cm. in diameter results. The disease never 
 extends beyond this stage, but the edge of the perforation 
 may remain excoriated for a long time. Finally this heals 
 too, and nothing but a hole with smooth undeformed edge 
 remains. 
 
 During its entire course the disease causes very little
 
 164 ANTERIOR DRY RHINITIS. 
 
 disturbance. The patient complains of slight annoyance 
 from the crusts and is apt to pick at them. Occasionally 
 persistent and repeated bleeding occurs, especially after 
 enfeebling diseases, like typhoid fever. There is no 
 liability to acute inflammation or other complications, 
 but the disease may sometimes be associated with a puru- 
 lent rhinitis. 
 
 76. The cause of dry rhinitis is not known. 1 The dis- 
 ease is not ordinarily seen in children. Fragments of 
 excised mucous membrane show round-cell infiltration, 
 especially along the course of the blood-vessels, some 
 hyaline degeneration of the mucous membrane, and 
 the presence of plasma-cells. Hemorrhages occur into 
 the tissue, and leave evidence of their presence in the 
 form of yellowish pigment granules, which give the 
 surface a yellowish appearance. Such discolored areas 
 have been described by Zuckerkandl under the name 
 xanthosis. The cylindric epithelium changes into flat 
 cells with keratous degeneration. Later on the epithelium 
 is, of course, lost. The progressiveness is apparently due 
 to changes in the blood-vessels. When it comes to actual 
 ulceration, the diseased area is found infiltrated with 
 cocci, to the presence of which the destruction must be 
 ascribed. The adherent scabs consist of dry mucoserous 
 secretion with very few round cells. Similar adherent and 
 persisting crusts are sometimes seen after surgical wounds 
 in the cartilaginous part of the septum, but in these in- 
 stances no tendency to progressive ulceration is observed. 
 
 77. The disease is but imperfectly controlled by treat- 
 ment, perhaps for the reason that patients lack the neces- 
 sary endurance, in view of the slight annoyance which it 
 causes them. Nitrate of silver applications, 5 to 20 per 
 cent, in strength, exert a distinct, but not always per- 
 manent, influence. The crust-formation is controlled 
 by cotton tampons as long as the patient is willing 
 to wear them. Treatment is likewise inefficient after 
 
 1 Workmen handling chrome or arsenical salts or those manufacturing 
 cements frequently suffer from ulceration of the septum.
 
 HEMATOMA AND ABSCESS OF THE SEPTUM. 165 
 
 the ulcer has perforated. Here, too, nitrate of silver 
 applied to the edges is of some benefit. Stronger caus- 
 tics or the galvanocaustic burner give no satisfactory 
 results. But while we may not be able to check the 
 ulceration, we can be certain of its benign and ultimately 
 limited course. 
 
 78. It is very important to distinguish between this 
 benign perforation of the septum and syphilitic ulcera- 
 tion. The former produces little disturbance, never ex- 
 tends beyond an area of about a five-cent piece in size, 
 is approximately round, and its edges are not thickened 
 or deformed and are covered only with thin crusts. It 
 never extends beyond the cartilaginous septum, and 
 when the edges heal, the crust-formation ceases. Syphi- 
 litic ulcers, on the other hand, the result of either a cir- 
 cumscribed gumma or diffuse gummatous involvement of 
 the blood-vessels, cause decided disturbance, at first in 
 the form of pain, and later on by reason of the copious 
 secretion and the thick purulent crusts. The edges of 
 syphilitic ulcers are always thickened, infiltrated, and 
 more or less deformed, and the ulceration, if not checked, 
 extends beyond the cartilage into the bony septum. If 
 not controlled, it may cause extensive loss of substance 
 down to the floor of the nose and high up in the bony 
 septum. Such extensive ulcers cause later on sinking-ill 
 of the bridge of the nose, which never follows non- 
 syphilitic ulceration. On the other hand, syphilitic 
 ulceration is rapidly controlled by thorough specific and 
 proper local treatment. (Compare Figs, i and 2, Plate I.) 
 
 HEMATOMA AND ABSCESS OF THE SEPTUM. 
 
 79- A very rare occurrence, almost invariably of 
 traumatic origin, hematoma, is an effusion of blood 
 under the perichondrium of the cartilaginous septum. 
 It occludes the nose and appears as a soft swelling on the 
 septum. It rarely undergoes absorption. As a rule, it 
 lasts a number of days and then changes into an abscess 
 which may bulge on either side or on both sides of the sep-
 
 1 66 MEMBRANOUS ANE DIPHTHERITIC RHINITIS. 
 
 turn. This usually causes some pain and headache. It 
 is very slow to open spontaneously. When opened widely 
 with the knife, it heals uneventfully. Even if the cartil- 
 age has been perforated by the suppurative inflammation, 
 no unpleasant results are apt to follow after the healing. 
 
 MEMBRANOUS RHINITIS. DIPHTHERITIC RHINITIS. 
 
 80. Inflammation of the nasal mucous lining, with 
 formation of false membranes, occurs under various con- 
 ditions and from different causes. It is occasionally 
 observed after extensive cauterization, especially surface 
 cauterizations, and in such cases is a strictly localized 
 process. There is but little annoyance beyond slight 
 soreness and obstruction and perhaps moderate bleeding. 
 The grayish membranes are not detached easily, and 
 when removed, leave a denuded surface on which they 
 form again within some hours. It is due to infection by 
 the streptococcus, rarely the staphylococcus, but always 
 follows a benign course, although it may last two to 
 three weeks. 
 
 A more diffuse, and hence more annoying, membranous 
 rhinitis occurs, rarely spontaneously, not uncommonly, 
 however, after scarlet fever. This, too, is due to the 
 streptococcus, yet it is only of local importance and 
 causes no systemic disturbance. Like all nasal inflam- 
 mations, it threatens the ear. 
 
 81. Indistinguishable in its appearance from strepto- 
 coccus infection is true diphtheritic rhinitis. It causes 
 similar grayish false membranes on a denuded bleeding 
 surface, with rapid regeneration of the membranes after 
 their detachment. The process is sometimes so super- 
 ficial that it may be termed croupous, while in other 
 cases it involves the depth of the mucous lining, as in 
 typical diphtheria. Yet the disease is of a benign nature 
 as long as it is limited to the nose, and it causes no 
 systemic infection or sequels. The diagnosis of its diph- 
 theritic nature must be based upon finding the bacillus 
 of diphtheria by the microscope or by culture. Its grave
 
 TREATMENT. 167 
 
 importance is its contagiousness, all the more so as the 
 patient is scarcely sick. Even after the membranous 
 formation has ceased the diphtheria bacilli persist in the 
 nose for weeks. Some of the accessory cavities are prob- 
 ably always involved in the process, harboring the specific 
 bacteria, even if there be no membranous inflammation 
 in the sinus. It is not known why diphtheria limited to 
 the nasal lining has none of the malignancy character- 
 istic of that disease in other localities. 
 
 82. The treatment of membranous rhinitis must de- 
 pend upon the diagnosis of the parasite causing it. 
 Diphtheria patients must be isolated, even for some time 
 after recovery. Antitoxin should be invariably employed 
 within the first three or four days of the disease. If of 
 longer duration, it is doubtful whether the specific treat- 
 ment has any influence upon it. In either diphtheritic or 
 streptococcus rhinitis the membrane should be detached 
 gently with forceps as far as it can be done without 
 causing bleeding. No one has recorded a sufficient ex- 
 perience to formulate any rules for medicinal treatment. 
 It is desirable to check secondary bacterial decomposi- 
 tion, but active germicides are not tolerated well by the 
 nasal lining. Sprays of essential oils in watery solution 
 (1 25) are of some service if used at very short intervals. 
 Loffler's solution (compare f 25), while momentarily very 
 irritant, can be used (after cocain spray), but its efficacy 
 has not been sufficiently tested. 
 
 Much more serious is nasal diphtheria when com- 
 plicating and secondary to diphtheria of the pharynx. 
 Under these circumstances it constitutes one of the most 
 serious manifestations of diphtheria, a great menace to 
 life and always a danger to the ear. Yet it is amenable 
 to the specific antitoxin treatment if resorted to at once. 
 It is, however, mostly in neglected cases of throat diph- 
 theria that the extension into the nose occurs. This 
 complication always involves a very long course up to 
 many weeks if not treated specifically at the beginning. 
 Further details will be given in Chapter XXIV.
 
 CHAPTER XI. 
 
 ENLARGEMENT OF THE CAVERNOUS TISSUE. 
 (IRRITABLE NOSE CORYZA VASOMOTORIA.) 
 
 83. Enlargement of the venous plexus, with increased 
 vascular irritability, is a lesion associated with various 
 nasal affections, but one which may also occur as a 
 sequel without persisting coexistence of other nasal dis- 
 ease. As certain characteristic nasal symptoms depend 
 directly upon this condition, it deserves special descrip- 
 tion. 
 
 The entire nasopharyngeal mucous membrane is highly 
 vascular, with a decided preponderance of veins in the 
 deeper layer. Around the anterior end of the inferior 
 turbinal, and to a less extent around the posterior ends of 
 both inferior and middle turbinals, the venous plexus in 
 the mucous membrane is massed so as to form a distinct 
 vascular cushion capable of turgescence (see Figs. 8, 
 9, and 10). Normally, the mucous membrane ap- 
 pears slightly compressible over these areas, showing 
 the normal distention of the vessels by blood. Un- 
 doubtedly moderate variations in the vascularity occur 
 during the normal condition, but are not so demonstrable 
 as when the cavernous tissue is increased. Even in a 
 normal nose a visible vascular constriction is produced 
 in these localities by the application of cocain or supra- 
 renal solution. But when the cavernous tissue is mor- 
 bidly augmented, the changes in its turgescence are very 
 striking. Under the influence of fright or syncope, or 
 upon the application of cocain, the previously swollen 
 mucous membrane shrinks visibly though without 
 change of color until it lines the bony contour accu- 
 rately. As the result of various modes of irritation the 
 vascular swelling may, on the other hand, become so ex- 
 
 168
 
 ENLARGEMENT OF THE CAVERNOUS TISSUE. 169 
 
 tensive as to occlude the passages entirely. The course 
 of the nerves presumably both vasoconstrictor and vaso- 
 dilator fibers which control these blood-vessels is not 
 known. 
 
 The turgescent area at the front part of the inferior 
 turbinal slopes so gradually toward the rear that its limits 
 cannot be defined, especially as the vascular network 
 throughout the entire mucous membrane over the turbi- 
 nals differs from pronounced cavernous tissue only in 
 degree. The cavernous cushions on the posterior ends 
 of inferior and middle turbinals are more circumscribed. 
 Their normal pale yellowish-pink color changes into a 
 violet-pink hue when their turgescence makes them 
 appear as globular tumors occluding the posterior choanse 
 in the postrhinoscopic image. As the result of disease, 
 vascular cushions are sometimes Developed in localities 
 where there is normally no cavernous tissue viz., ante- 
 riorly over the tuberculum septi, sometimes on the floor 
 of the inferior meatus, or as part of a hypertrophic pro- 
 tuberance on the septum next to its posterior edge. 
 
 Every acute inflammatory attack is accompanied by 
 engorgement of the cavernous plexus. While a single 
 transient coryza leaves no gross change, repeated or pro- 
 longed attacks may lead to permanent enlargement of the 
 cavernous tissue. Whether this hypertrophy differs from 
 the original normal structure histologically has not been 
 studied fully. A condition which is of marked deter- 
 mining influence by favoring the augmentation of the 
 vascular structure is the existence of septum irregu- 
 larities. It is, however, not the extensive deflections or 
 thick prominences causing continuous stenosis which 
 lead to vascular hypertrophy, but rather small spurs and 
 crests which do not perceptibly narrow the passage except 
 while there is vascular engorgement. The larger septum 
 irregularities in connection with any persistent inflam- 
 mation favor hypertrophy of the entire mucous mem- 
 brane, which becomes most redundant on the (roomier) 
 side of the septum concavity.
 
 I/O ENLARGEMENT OF THE CAVERNOUS TISSUE. 
 
 Purely vascular enlargement is readily distinguished 
 from hyperplasia of the entire membrane. In the former 
 case the swelling can be indented with the probe and 
 disappears completely when cocainized. An excised bit 
 of mucous membrane shows normal thickness. In the 
 latter case the probe recognizes the excessive thickness 
 of the lining membrane, which an excision confirms, 
 while after cocain the membrane covering the bone, 
 although somewhat reduced, still shows a distinct aug- 
 mentation of volume as compared with the normal. 
 Vascular enlargement and actual hyperplasia may be 
 combined to a moderate extent, but any extensive hyper- 
 trophy of the mucous membrane as a whole excludes 
 overdevelopment of the venous plexus. 
 
 84. In subjects giving the history of frequent, though 
 transient, attacks of coryza and presenting some slight 
 surface irregularity of the septum, permanent enlarge- 
 ment of the cavernous tissue without any coexisting 
 inflammatory lesion is occasionally observed. Women 
 are more liable to it than men. It is not common in 
 children. Closer inquiry always reveals in these patients 
 a neurotic condition, sometimes neurasthenia, often 
 hysteria, sometimes mere u nervousness, " but always 
 exalted excitability of the nervous system. Quite often, 
 too, the history proves that intestinal disturbances, 
 especially constipation, have been of etiologic influence. 
 
 More frequently than as an isolated condition vascular 
 overdevelopment is found in association with other irri- 
 tative nasal diseases, such as suppuration of the nasal 
 passages or accessory cavities, polypi, or hypertrophic 
 rhinitis in its earlier stages. Under these circumstances, 
 too, the vascular irritability is a mirror of the instability 
 of the nervous system of the individual. Female patients 
 preponderate decidedly. Massive diffuse hypertrophy of 
 the mucous membrane, on the other hand, limits the 
 development of cavernous tissue; advanced atrophic rhi- 
 nitis excludes it. 
 
 85. The complaints are partly mechanical, partly
 
 SYMPTOMS. I/I 
 
 nervous symptoms. In spite of considerable enlarge- 
 ment of cavernous tissue the passages may be clear a 
 variable part of the time. But in the recumbent posi- 
 tion, especially during sleep, engorgement occurs in the 
 nostril on the lower side of the head, causing occlusion 
 of the passage. The slight difference in the venous 
 blood pressure produced by turning the head on the other 
 side suffices to transfer the engorgement to the other side, 
 allowing the first affected nostril to clear in the course 
 of a few minutes. Very striking is the alternating uni- 
 laterality of the turgescence. Except during acute in- 
 flammation or in very irritable subjects with one-sided 
 stenosis, cne side of the nose is, as a rule, clear. The 
 same one-sided engorgement can occur in consequence of 
 drafts, dust, or irritating gases and smells. The occlud- 
 ing vascular turgescence is seen on inspection anteriorly. 
 In some instances a similar but more localized engorge- 
 ment is found at the posterior end of one or both turbinals 
 on examination. The swelling may subside in a short 
 time, or under conditions of irritation may alternate be- 
 tween the two sides for a longer period. Cocain or supra- 
 renal solution reduces it at once. (Comp. Fig. 3, Plate I.) 
 
 86. In nervous subjects the vascular dilatation may 
 lead to other symptoms. A sneezing fit, sometimes 
 lasting to a distressing extent, with watery secretion, 
 tearing and redness of the eyes, and finally total nasal 
 occlusion, at least one-sided, constitute the attacks of 
 so-called vasomotor coryza or irritable nose. Their fre- 
 quency depends very much on the nervous condition of 
 the patient and on the opportunities for irritation. 
 
 Some patients possess an idiosyncrasy in regard to 
 certain odors or irritants which give them always a 
 severe fit of vasomotor coryza. Such irritants are ipecac, 
 the odor of roses, and perhaps more frequently the smell 
 of horses. The attacks may pass off in a fraction of an 
 hour, or, when severe, may last many hours. These 
 fugitive attacks, resembling a true coryza in their sub- 
 jective symptoms, have led to much confusion in litera-
 
 ENLARGEMENT OF THE CAVERNOUS TISSUE. 
 
 ture, and account for the many erroneous reports con- 
 cerning the abortive treatment of " colds." It is singular 
 that the sneezing fits and attacks of vasomotor coryza 
 cease entirely during the course of any severe general 
 disease. The astute observer, Jonathan Hutchinson, has 
 asked pointedly, "Who has ever heard a sick man 
 sneeze?" In markedly neurotic subjects these spells 
 may be followed occasionally by fugitive edema (urtica- 
 ria) of the eyelids, conjunctiva of the eyeball, or skin of 
 the face next to the nose. Attacks of vasomotor coryza 
 may likewise lead to scotoma scintillans with headache, 
 dizziness, or more generally a feeling of confusion or an 
 attack of asthma, sometimes a prolonged fit of coughing 
 (compare Chapter XXIX.). The results of local treat- 
 ment show that these nervous phenomena depend on the 
 turgescence in the anterior parts, rather than on the en- 
 gorgement of the rear end of the turbinals. 
 
 87. Treatment must begin with the search for any local 
 irritative lesions. The removal of a small hidden poly- 
 pus may end all trouble. Proper cauterization of an 
 inflamed or granulating area, successful drainage of a 
 suppurating sinus or a cyst in the maxillary sinus, may 
 effect a cure. Very rarely a fissure in the vestibule keeps 
 the nose irritable. The removal of spurs and ledges on 
 the septum (see Chapter XVI.) is often an indispensable 
 step for success, but may not be followed by a speedy 
 cessation of the irritability indeed, may prove insuffi- 
 cient, if not accompanied by cauterization of the cavern- 
 ous tissue. If removal of the presumable irritative lesion 
 fails to cure the irritability, or in case no other lesion can 
 be found, the vascular engorgement and irritability can 
 be permanently stopped by thorough destruction of the 
 cavernous tissue. When there is only vascular enlarge- 
 ment without hypertrophy of the mucous membrane, the 
 swelling cannot be thoroughly taken away with the 
 snare. Cauterization with trichloracetic acid or superfi- 
 cial cauterization with the galvanocautery gives relief, 
 but no permanent results. The only radical way is deep
 
 TREATMENT. 173 
 
 cauterization by multiple punctures (1 27), one side at a 
 time, followed two to three weeks later by the same 
 operation on the other side. The case should then remain 
 under observation for many weeks, and whenever return- 
 ing symptoms and repeated examination show the vascu- 
 lar areas still capable of engorgement, these should be suc- 
 cessively destroyed. It is very rarely necessary to operate 
 on the posterior ends of the turbinals. By these means, 
 persistently pursued, a permanent cure can be obtained. 
 Cases complaining only of mechanical obstruction are 
 much more readily controlled than the nervous phe- 
 nomena of neurotic patients. The relief from insufficient 
 operations may gradually disappear, and a relapse may 
 occur, since the remnants of cavernous tissue regenerate 
 readily under the stimulus of acute inflammations or per- 
 sistent irritation. 
 
 Cauterization can be dispensed with or deferred in 
 those patients whose complaints depend on some nervous 
 condition of transient or controllable nature. The nervous 
 nasal symptoms are, for instance, apt to be exaggerated 
 during a pregnancy, to subside again later on. As there 
 are some instances of miscarriage on record, attributable 
 to cauterization, discretion should be exercised. A pa- 
 tient run down by overwork, anxiety, or loss of sleep 
 may become comfortable by proper hygienic management 
 without local treatment. The injurious influence of 
 digestive disturbances upon the nose must not be over- 
 looked. Relief may be obtained by avoiding hitherto 
 disregarded exposure to dust. A trip to the mountains 
 or to any dustless locality with mild climate is apt to 
 give at least temporary benefit.
 
 CHAPTER XII. 
 
 RETRONASAL CATARRH. 
 
 88. Retronasal catarrh is characterized by a mucous 
 secretion in the posterior part of the nose, with absence 
 of all gross lesions. The disease the most frequent 
 of all nasal affections in the United States is not cor- 
 rectly described in most text-books, and is generally 
 confused more or less with hypertrophic rhinitis. While, 
 indeed, it is often associated with other forms of nasal 
 disease, it occurs in the uncomplicated form sufficiently 
 often to justify its recognition as a disease entity. 
 
 The only symptom is the secretion of mucus dropping 
 into the pharynx. The mucus is thick, usually some- 
 what inspissated, foamy from air-bubbles, and in cities is 
 stained grayish dark by soot and dust. While containing 
 a few round cells microscopically, it is not at all purulent. 
 From the posterior parts of the nose it flows into the 
 pharynx, to be swallowed or spat out. When very viscid, 
 it adheres to the posterior surface of the soft palate and is 
 removed by the familiar guttural gurgling sound of hawk- 
 ing, which throws the palate into vibration. When very 
 abundant, the patient occasionally draws it into the 
 pharynx by a strong nasal inspiration, as he cannot 
 expel it forward. The discharge is not identical with 
 pus formed at the roof of the pharynx in inflammation 
 localized at that spot. In a normal nose there is no 
 secretion whatsoever, sufficient to flow or to collect, 
 except momentarily in consequence of external irrita- 
 tion. 
 
 89. In uncomplicated retronasal catarrh no gross lesions 
 whatsoever can be detected in the nose or nasopharynx. 
 Such uncomplicated cases are more common among fe- 
 males than males. More frequently, however, retronasal 
 
 174
 
 RETRONASAL CATARRH. 175 
 
 catarrh is associated with hypertrophic rhinitis, some- 
 times with other nasal lesions. We may thus find sep- 
 tum deformities and thickening, diffuse localized hyper- 
 trophy of mucous membrane on the turbinals, enlargement 
 of cavernous tissue, and hyperplasia of the various areas 
 of pharyngeal adenoid tissue. But none of the lesions 
 are constant or essential. The amount and viscidity of 
 secretion are, however, very much influenced by any 
 interference with the patency of the nasal passages. The 
 disease is relatively rare in subjects with wide passages, 
 while the annoyance from the "sticky" discharge in- 
 creases with the degree of nasal stenosis. Any obstructing 
 lesion, even transient enlargement of the cavernous tis- 
 sue, is thus an aggravating factor in the disease. 
 
 90. The disease, almost unknown under the age of 
 puberty, is common only after adolescence, being more 
 frequent at least in its associated form in the male. 
 Every-day observation shows its extreme distribution, 
 as judged by the characteristic hawking noise wherever 
 people meet. On account of the slight annoyance and 
 the absence of sequels, patients with the pure type of the 
 disease do not commonly seek treatment. The disease 
 usually lasts indefinitely, improving in mild weather, 
 but rarely disappearing entirely, except under improved 
 climatic environment. 
 
 It is of inflammatory origin, as can be learned in those 
 rare cases which seek advice at the beginning. It is 
 temporarily aggravated by every fresh coryza. In ' the 
 absence of lesions visible during life and in default of 
 autopsies we can only infer that it consists in a low grade 
 of superficial inflammation localized in the posterior 
 region of the nose. 
 
 91. There is no treatment known which can directly 
 cure a retronasal catarrh and stop the dropping of mucus. 
 In the rare instances of retronasal catarrh with normal 
 caliber of passage, which we do not see often, since such 
 patients are so little annoyed, local applications of any 
 kind have proved useless. I base this opinion fully as
 
 1/6 RETRONASAL CATARRH. 
 
 much on the history of patients treated by others as on 
 my own negative results. At the most we can give some 
 palliating advice regarding moderation in smoking, 
 proper diet, if required, and attention to the state of the 
 bowels. But in the majority of cases which call for treat- 
 ment, complicating and prejudicial lesions are found 
 that can be removed with decided improvement in the 
 patient's comfort, though without curing the retronasal 
 hypersecretion in the strict sense of the word. Operations 
 upon existing septum deformities, the snaring of mucous 
 tissue hypertrophies, the cauterization of excessive cavern- 
 ous tissue, if judiciously, done, usually give the patient 
 subjective satisfaction.
 
 CHAPTER XIII. 
 
 SIMPLE CHRONIC RHINITIS HYPERTROPHIC 
 RHINITIS. 
 
 92. Next to retronasal catarrh, chronic or hypertrophic 
 rhinitis is the most common nasal disease in our climate. 
 It is a chronic, more or less diffuse, inflammation of 
 the nasal mucous membrane, which ultimately leads to 
 generalized or circumscribed hypertrophy. There is, 
 hence, no sharp distinction between simple chronic and 
 hypertrophic rhinitis. The symptoms are those common 
 to all chronic nasal affections and are not characteristic of 
 it. Indeed, there may be total absence of all symptoms. 
 It is always associated with some enlargement of the cav- 
 ernous tissue during its earlier stage. Hence a variable 
 amount of intranasal turgescence is one of its features. 
 Later on, however, when the stage of massive hypertro- 
 phy of mucous membrane has been reached, the vascular 
 enlargement and its variable engorgement become of 
 minor importance. The amount of nasal obstruction 
 caused by the cavernous engorgement, and later on by 
 the permanent thickening of the mucous lining, depends 
 upon the original width of the nasal passage. The nar- 
 rower the passage, or the more encroachment by any cir- 
 cumscribed hypertrophy, the more distressing becomes 
 the interference with nasal breathing. In extreme in- 
 stances both sides may be permanently insufficient for 
 the passage of air. Such excessive nasal obstruction 
 gives rise often to a feeling of oppression in the head, 
 and may cause irregular dull headache in neurotic sub- 
 jects. Insufficient nasal caliber necessarily causes mouth- 
 breathing. 
 
 There is no discharge peculiar to hypertrophic rhinitis. 
 When not associated with other lesions, especially retro- 
 
 12 177
 
 1/8 SIMPLE CHRONIC RHINITIS HYPERTROPHIC RHINITIS. 
 
 nasal catarrh, there is no discharge whatsoever. Usually 
 the mucous membrane is irritable and starts a watery 
 flow upon irritation by dust or from turgescence due to 
 drafts. When a purulent rhinitis coexists with it, the 
 pus present is due to that complication. When there is 
 much diffuse hypertrophy, the sense of smell is often 
 interfered with. 
 
 Chronic rhinitis does not pursue a uniform course, but 
 is intensified by every acute attack, and may become 
 nearly latent under favorable surroundings. It rarely 
 ceases permanently in our climate. It may come to a 
 standstill in more favorable localities. Any existing 
 hypertrophies, however, persist. 
 
 93- While this disease may present few or no symptoms, 
 its importance depends on its possible complications. 
 These are stricture of the lachrymal duct, chronic con- 
 junctivitis, occasionally marked irritability of the eyes, 
 causing asthenopia, hypertrophy of the various pharyngeal 
 structures, among which chronic disease of the lingual 
 tonsil is the most distressing. The disease, furthermore, 
 predisposes to laryngitis and to bronchitis. Its most 
 serious aspect, however, is the liability to extend through 
 the Eustachian tube, causing a hyperplastic process in 
 that passage and in the middle ear. 
 
 94. On inspection the mucous membrane is found 
 more or less injected. This morbid redness may dimin- 
 ish under favorable influences until the normal pallor is 
 attained. With every acute coryza, however, the injec- 
 tion returns and persists for a while. After the disease 
 has led to hypertrophy of the lining membrane, the 
 acute inflammatory attacks are apt to be milder and of 
 more transient character than in normal nasal passages, 
 but, on the other hand, they occur oftener and always 
 prove more persistent in the end. 
 
 Diffuse hypertrophy of the mucous membrane is recog- 
 nizable only when it has reached a high degree, and can 
 be best observed where the lining passes over some promi- 
 nence of the bony or cartilaginous frame. The thickened
 
 SYMPTOMS. 
 
 179 
 
 membrane is often roughened or corrugated. On the 
 surface of the septum the normally minute ridges are 
 exaggerated. The inferior turbinal often presents papil- 
 lary elevations, especially in the middle and rear regions. 
 Even when the thickening is not apparent to the eye, 
 the microscope shows in excised fragments inflammatory 
 round-cell infiltration with some increase of connective 
 
 FIG. 50. Polypoid degeneration of the mucous membrane over the inferior 
 turbinal (Zuckerkandl). 
 
 tissue. The ciliated epithelium is partly changed into 
 cuboid cells and often increased in thickness. 
 
 Circumscribed hypertrophies can be more easily recog- 
 nized. They may be limited to but a single locality, or 
 may occur in combination. Occasionally every one of 
 the types to be described is found present. On the in- 
 ferior turbinal the mucous membrane is distinctly thick- 
 ened, sometimes forming a flabby, pendant overgrowth. 
 Unlike the pure hypertrophy of the venous plexus this
 
 ISO SIMPLE CHRONIC RHINITIS HYPERTROPHIC RHINITIS. 
 
 mucous membrane hypertrophy does not shrink much 
 under the influence of cocain or suprarenal solution. 
 When the veins have retracted under the influence of 
 these agents, the thickened mucous membrane can still 
 be lifted at the free border of the turbinal by the probe. 
 This thickening may be limited to the anterior end or 
 may extend over the entire length of the inferior turbinal 
 (Fig. 50). A well-defined hypertrophy is always found 
 at the front end of the inferior turbinal on the concave 
 (roomy) side of the nose in case of any marked septum 
 deflection. A similar lesion is . found less often at the 
 front end of the middle turbinal. Here the redundant 
 
 FIG. 51. Postrhinoscopic view of hypertrophy of inferior and middle turbinals. 
 
 mucous membrane may hang down so as to resemble a 
 polypus. True polypi, however, have a distinctly con- 
 stricted pedicle. Circumscribed hypertrophies may be 
 found at the rear ends of inferior and middle turbinals. 
 In the postrhinoscopic mirror they are seen in the form 
 of semiglobular tumors filling and even occluding the 
 posterior choanae. Their surface is sometimes smooth, 
 more often wart-like (Fig. 51). When these growths 
 consist of cavernous tissue exclusively, they are of pur- 
 plish hue and disappear entirely when cocainized. But 
 the more hypertrophic mucous membrane they contain, 
 the more gelatinous and grayish is their appearance, and 
 such overgrowths retract onlv to a slight extent under
 
 SYMPTOMS. I 8 1 
 
 cocain. These lesions can, of course, be observed in the 
 living only by means of the postrhinoscopic mirror. 
 (Compare Figs. 3 and 4, Plate I.) 
 
 Deviation of the septum from the median line is an 
 important predisposing condition, and hence often found 
 in hypertrophic rhinitis. The disease itself, however, 
 leads to deformity of the septum by producing lateral 
 crests, ridges, and spurs. The detailed description of 
 these hypertrophic lesions of the septum will be given 
 in Chapter XVI. 
 
 A septum .lesion peculiar to hypertrophic rhinitis is 
 the cushion-like prominence seen occasionally in the post- 
 rhinoscopic image on one or both sides of the septum, ad- 
 joining its rear edge. This is a hypertrophy of the mucous 
 membrane, with more or less cavernous tissue, situated 
 
 FIG. 52. View of the posterior choanse in the cadaver from the rear, showing 
 polypoid hypertrophies on both sides of the septum (Zuckericandl). 
 
 often, but not always, over a spur on the septum. It 
 appears as a grayish protuberance when seen from the 
 rear, and is somewhat reducible by cocain (Fig. 52). 
 
 The clinical history of hypertrophic rhinitis is not 
 complete withoiit reference to the various hypertrophies 
 of the pharyngeal adenoid tissue (tonsils) which com- 
 monly occur in connection with it, but which will be 
 separately described in Chapters XX., XXI., and XXII. 
 In fact, in most cases the disease might be called rhino- 
 pharyngitis, since the inflammatory and proliferative 
 process extends throughout the entire lining of nasal 
 passages and pharynx. 
 
 95. Chronic rhinitis results from the prolongation of 
 acute coryza, especially when this occurs in frequent
 
 1 82 SIMPLE CHRONIC RHINITIS HYPERTROPHIC RHINITIS. 
 
 attacks. It is aggravated by every fresh coryza. A per- 
 sistence of the inflammation seems to depend largely on 
 any structural peculiarities narrowing the nasal passage. 
 While localized projections which dam up pus help to 
 perpetuate a chronic purulent rhinitis, any diffuse form 
 of stenosis, on the other hand, favors the occurrence of 
 hypertrophic rhinitis. As the disease itself leads to further 
 hypertrophies, its tendency to perpetuation explains itself. 
 It is uncommon in wide passages, and much less common 
 in childhood than after adolescence. Its occurrence in 
 children is favored by hypertrophy of the pharyngeal ton- 
 sil. Unfavorable hygienic factors, exposure to drafts and 
 insufficient protection, a poor cutaneous circulation, cold 
 feet, and bowel disturbances predispose to it. There is 
 no reason to doubt that, like most forms of inflammation, 
 it is directly or indirectly dependent on parasitic in- 
 fluences. But no definite form of bacteria has as yet 
 been found associated with it in. various researches. The 
 tendency to hypertrophy is evidently an individual pe- 
 culiarity of which we do not know the conditions. The 
 disease may last long periods of time with scarcely any 
 hypertrophy in some patients, while in others it rapidly 
 leads to the lesions described. 
 
 96. The treatment of hypertrophic rhinitis aims to arrest 
 the disease and to remove surgically any enlargements 
 which exert an unfavorable influence. Since the chronic 
 rhinitis is the outcome and perpetuation of acute inflam- 
 mation and becomes intensified by every acute attack, the 
 hygienic management must attempt to prevent acute and 
 subacute exacerbations. Attention must be paid to the 
 general health, the digestion, the state of the bowels, 
 the peripheral circulation (cold feet), and the habits 
 of the patient (compare 1 16 and 1 17). The inflamma- 
 tion itself may be reduced by daily treatment with the 
 spray of essential oils in watery solution (compare 1 25). 
 Its influence is augmented by previously reducing the 
 nasal turgescence by means of suprarenal solution in the 
 form of a spray, preferably with the addition of cocain.
 
 TREATMENT. 183 
 
 Under no circumstances, however, should cocain be given 
 to the patient for habitual use. The douche is entirely 
 uncalled for unless the disease is associated with purulent 
 rhinitis. Localized areas of injected mucous membrane 
 may be brushed with nitrate of silver solution (5 to 10 
 per cent.), but diffuse applications of this agent, as well 
 as of other so-called astringents, tannin, iodin solutions, 
 and so on, have generally no appreciable influence. In 
 fact, it is quite questionable whether the disease can be 
 influenced to any marked extent by medicinal applica- 
 tions of any kind, except during periods of subacute 
 intensification. 
 
 Decided benefit can be expected from surgical pro- 
 cedures directed against any hypertrophies of sufficient 
 extent to encroach upon the caliber of the passage. As 
 the disease itself is perpetuated by any interference with 
 the nasal caliber, such surgical procedures influence not 
 merely the spot against which they are directed, but the 
 entire disease. Hence, by properly restoring the patency 
 of the nose, we can practically cure all manifestations of 
 the disease in many instances. Relapses, however, must 
 be expected under unfavorable environments. 
 
 97. Hypertrophies of the mucous membrane over the 
 anterior end of the inferior turbinal are removed best by 
 means of the cold snare. If not of such shape that they 
 can be grasped securely by the loop, they are first to be 
 transfixed with a needle, over which the loop is then 
 placed. There is but slight bleeding at the time, but often 
 enough later on to require a tampon for the first twenty- 
 four hours. When the enlargement consists of relatively 
 much cavernous tissue with but little hypertrophy of mu- 
 cous membrane, the snare cannot grasp enough after the 
 action of cocain. Bucain /?, which does not constrict 
 the blood-vessels, is more applicable in such a case. 
 When snaring is not feasible, the hypertrophy may be 
 reduced by the galvanocautery, preferably in the form of 
 multiple punctures without needless sacrifice of surface. 
 A burned wound, however, is always more unpleasant
 
 184 SIMPLE CHRONIC RHINITIS HYPERTROPHIC RHINITIS. 
 
 and requires a longer time to heal than a clean cut. In 
 the case of extensive diffuse hypertrophy of the entire 
 mucous membrane over the inferior turbinated bone in a 
 narrow nasal passage, the most satisfactory operation is 
 partial removal of this process, including the bone. This 
 operation, called turbinectomy, lately much favored in 
 England, is quite useful when properly indicated in 
 other words, when stenosis is due to the prominence of a 
 projecting hypertrophied inferior turbinated bone. In 
 any other case it is a needless mutilation. The projecting 
 part of the process can be cut off by suitable slender cut- 
 ting forceps, or even by the wire snare after notching 
 the free border toward the rear with the galvanocaustic 
 burner, in order to insert the snare. It may be also am- 
 putated easily by means of a small sharp saw. 
 
 Overgrowth of the mucous membrane at the front end 
 of the middle turbinal requires removal by snaring only 
 when sufficiently pendant to be easily grasped by the 
 snare. 
 
 Hypertrophies of the rear ends of inferior and middle 
 turbinals require removal whenever they can be seen in 
 the postnasal mirror as distinct encroachments upon the 
 space. These are, however, difficult operations. The 
 most satisfactory instrument is the cold snare. When 
 the operator feels that the loop inserted through the ante- 
 rior nares has grasped a resisting projection, its position 
 should be verified by the use of the postnasal mirror, or 
 by the finger in the pharynx. The loop may have to be 
 variously shaped and bent before it will catch. On ac- 
 count of the probability of bleeding, it is best to tighten 
 the wire very slowly, and even then the operator must be 
 prepared to plug the postnasal space (compare 1 29) if 
 tampons wound on tooth-picks do not control the bleed- 
 ing. When the wire loop cannot be applied successfully, 
 it will sometimes slip easier into grooves burned into the 
 turbinals. For this purpose a suitably shaped bent 
 burner can be inserted through the nose, while its posi- 
 tion is watched in the postnasal mirror. Usually retrac-
 
 TREATMENT. 185 
 
 tion of the soft palate by the hook or rubber band is 
 required for this purpose. After the burner has been 
 suitably placed, the mirror may be withdrawn and the 
 cautery handle is now brought into contact with the 
 burner meanwhile held by the finger. With a slight 
 withdrawing movement a groove can thus be burned. In 
 the case of very vascular tumefactions which retract under 
 cocain or even in consequence of the patient's anxiety, so 
 that they elude the snare, their obliteration can be ac- 
 complished only by the galvanocaustic burner under the 
 guidance of the mirror. Very suitable double-jointed 
 scissors have lately been devised by Fein (Fig. 53). As 
 they are sure to catch the projecting hypertrophy, it can 
 
 FIG. 53. Fein's scissors for the removal of the posterior ends of the inferior 
 
 turbinal. 
 
 be cut off promptly. A free hemorrhage, however, is 
 apt to follow. 
 
 The cushions of hypertrophied mucous membrane 
 found on the side of the septum near its posterior edge 
 cannot well be reached by any instrument except a flat 
 burner under the guidance of the mirror. By these 
 means they can be easily removed. If, however, they 
 are seated over a projecting spur of bone, they can be 
 better dealt with by any of the operations applicable to 
 septum deformities (compare 1 123), especially the spoke- 
 shave. 
 
 98. A relatively rare, but not unimportant, complica- 
 tion of hypertrophic rhinitis is edematous occlusion of 
 the nasal passages. This occurrence, which the writer
 
 1 86 SIMPLE CHRONIC RHINITIS HYPERTROPHIC RHINITIS. 
 
 has not found described in literature, has been observed 
 a few times as a sequel to an acute inflammatory attack 
 usually an attack of influenza in patients previously 
 subject to hypertrophic rhinitis. Both sides of the nose 
 were occluded for weeks by edematous infiltration of the 
 entire mucous membrane. The lining appeared grayish 
 pale and distinctly soggy. There was slight turgescence 
 of the cavernous tissue. The reduction of the turgescence 
 by cocain restored transiently very imperfect nasal per- 
 meability. There was no secretion and no lesions were 
 found, except those of hypertrophic rhinitis. The edema 
 was removed, and nasal permeability gradually restored 
 by the use of dilating tampons moistened with cocain 
 solution. As soon as the nasal caliber had been partially 
 reestablished, the existing hypertrophies were removed 
 and the cure thus completed.
 
 CHAPTER XIV. 
 
 NASAL POLYPI. PAPILLOMATOUS TUMORS. 
 POLYPI OF THE NASAL PASSAGES. 
 
 99. Although but a form of circumscribed hypertrophy 
 of the mucous membrane, nasal polypi present pecu- 
 liarities which require a separate description. The term 
 polypus is applied to any tumor springing from a free 
 surface by a constricted pedicle. Nasal polypi appear 
 as elongated tumors, usually pendant and freely movable. 
 They are either of a " fleshy " appearance, slightly more 
 reddish than the normal mucous membrane, and of solid 
 consistency, or more generally they are soft and grayish 
 translucent by reason of edema. They vary in size from 
 that of a small pea to the largest masses which can be 
 accommodated by a nasal passage. They are more often 
 multiple than single, more often bilateral than one-sided. 
 Their most frequent points of origin are the free border 
 and external surface of the middle turbinal and the 
 region of the hiatus semilunaris. Smaller ones are often 
 hidden underneath the middle turbinal, springing from 
 the smaller ledges of the ethmoid or from the vicinity of 
 the infundibulum. In rare instances a polypus from the 
 upper part of the maxillary sinus protrudes through the 
 hiatus into the nose. Much less common is their origin 
 from the upper ethmoid structures. Very rarely a polypus 
 is attached to the upper part of the septum. Different, 
 however, from the ordinary polypus is a polypoid bleed- 
 ing tumor occasionally seen on the septum the bleeding 
 polypus of the septum (T[ 237). Characteristic polypi do 
 not grow from the inferior turbinal, although sometimes 
 a cavernous hypertrophy may assume a polypoid shape 
 ( Fi gs. 54 and 55). 
 
 187
 
 188 
 
 NASAL POLYPI. PAPILLOMATOUS TUMORS. 
 
 Polypi are rare in childhood, very common only after 
 adolescence. Ztickerkandl found polypi in over 10 per 
 cent, of unselected subjects in the dead-room. 
 
 100. The symptoms of polypi are nasal obstruction, 
 more or less proportionate to their size. Patients often 
 feel the moving of the pendulous masses during forcible 
 breathing. When small tumors do not occlude the pas- 
 
 FlG. 54. External wall of the right nasal passage, with polypi in the mid- 
 dle and the superior meatus and on the inferior ethmoturbinal : b, Polypus 
 originating from the middle turbinal ; c, polypus in the inferior ethmoidal 
 fissure; J, dilated infundibulum harboring a polypus (Zuckerkandl). 
 
 sage mechanically, they are apt to cause transient ob- 
 struction by turgescence. In such cases there is usually 
 much nasal irritability, and sneezing fits, transient watery 
 discharge, and distant nervous symptoms are quite com- 
 mon. The most frequent distant disturbance caused by 
 polypi is asthma. In most instances polypi are associated 
 with purulent rhinitis or suppuration of accessory cavi-
 
 PATHOLOGY. 
 
 189 
 
 ties, especially the anterior ethmoid cells. There are, 
 however, cases in which there is no discharge. Bleeding 
 is not caused by typical polypi. Occasionally polypi are 
 partly angiomatous in structure, in which case free 
 hemorrhages may occur. 
 
 101. Histologically, polypi present the structure of 
 mucous membrane with inflammatory round-cell infiltra- 
 tion (Fig. 56). The term myxomatous tumor, formerly 
 
 
 FIG. 55- Lateral wall of the right nasal chamber, with two large polypi : 
 b, Infundibulum ; c, cyst of the mucous membrane ; a, accessory maxillary 
 orifice (Zuckerkandl). 
 
 applied to them, is hence quite incorrect, as they are 
 neither tumors in a pathologic sense nor do they consist 
 of the embryonal connective tissue which makes up a 
 myxoma. The gelatinous appearance of many polypi is 
 due to edema. This edema is shown by the enormous 
 shrinkage which such polypi undergo upon drying. 
 Under the microscope it reveals itself by infiltration of 
 the tissue with serum, which coagulates when placed in
 
 igO NASAL POLYPI. PAPILLOMATOUS TUMORS. 
 
 alcohol. The serous infiltration may distend the meshes 
 of the connective tissue to such an extent as to give 
 some polypi a cystic appearance. True cysts, however, 
 lined by epithelium occur only to a small extent in 
 polypi. The growths are covered by the normal nasal 
 epithelium. Polypi are generally not very vascular, and 
 possess but few nerves. The number of glands found in 
 
 FIG. 56. Histologic structure of a nasal polypus. The normal stratified 
 cylindric epithelium changes toward the right side to a less regular stratified 
 series of flattened pavement cells. In the areolar tissue are meshes of variable 
 size, filled with serum. There is not much more than the normal amount of 
 cellular (leukocytic) infiltration except around the blood-vessels. 
 
 them varies with the area of mucous membrane from 
 which they spring. 
 
 The inflammatory origin of these growths is shown by 
 clinical observation. They occur mainly in connection 
 with suppurative disease of the nasal passages or of the 
 accessory cavities. Well-ascertained histories often teach 
 that polypi are started by prior suppurative disease, which 
 their presence then serves to perpetuate. The finding 
 of the polypus should always direct a search for suppura- 
 tion of accessory cavities, especially the ethmoid cells 
 and the maxillary sinus, for the recurrence of extirpated
 
 TREATMENT. 19! 
 
 polypi may be expected sooner or later if the primary 
 suppuration is not removed. Yet there are instances in 
 which polypi are not accompanied by any form of in- 
 tranasal or adjoining suppuration. Another condition 
 which is often found clinically as a predisposition to 
 polypus formation is the narrowing of one nasal passage 
 from septum thickening or from deviation. In such cases, 
 however, polypi are usually found on both sides of the 
 nose. Polypi cannot be considered analogous to other 
 hypertrophies of the mucous membrane ; for the over- 
 growth constituting the polypus is not diffuse, but is 
 strictly localized in a small area which continues to grow 
 after it has separated itself from its source by a pedicle. 
 The constriction of the pedicle implies that the growing 
 process takes place only in the body of the polypus. 
 There must hence be some strictly localized stimulus 
 causing this growth. All research for bacteria has 
 hitherto been negative. 
 
 102. A polypus incompletely removed undergoes rapid 
 regeneration, but complete abscission at the base of the 
 pedicle eradicates it. The removal of a polypus often 
 permits small ones hitherto concealed by it to grow at a 
 more rapid rate, but when the polypi have been com- 
 pletely taken away, their reappearance need not be exr 
 pected unless some suppurative process persists. 
 
 103. The removal of a polypus is easily accomplished 
 by placing the snare loop around its pedicle at its base- 
 and cutting through. Under the proper use of cocain 
 this is painless and generally not very bloody. If the 
 loop cannot be pushed up to the very base of the pedicle, 
 it is better to tear off the polypus after tightening the 
 wire, rather than to cut it off incompletely. As a rule, 
 some of the mucous membrane from which it springs is 
 thus torn away with it, and the removal is complete. 
 The method of the older surgeons to seize polypi 
 with forceps, especially without the use of the mirror, 
 can only be condemned as inefficient and barbarous. 
 When the polypus is not accessible to the wire loop, its
 
 192 
 
 NASAL POLYPI. PAPILLOMATOUS TUMORS. 
 
 base may be cut away with a sharp curet. The hot 
 snare has no advantage over the cold wire. The use of 
 the galvanocaustic burner involves the risk of obliter- 
 ating the orifices of accessory cavities. In the case of 
 narrow nasal passages various accessory operations may 
 be necessary for the complete eradication of polypi. 
 When they are multiple on or underneath the middle 
 turbinal, it is often best to amputate the front end of 
 
 FIG. 57. Papilloma on the inferior turbinal (Zuckerkandl). 
 
 that process. When a thickening of the septum inter- 
 feres with the accessibility of the growth, some form of 
 operation on the septum may be necessary before the 
 nose can be entirely cleared. After the removal of 
 polypi all hidden foci of suppuration must be sought and 
 cured in order to prevent subsequent growth. 
 
 104. Papillomatous tumors are localized overgrowths 
 found, as a rule, mainly on the inferior turbinal. In 
 their clinical significance they are analogous to polypi,
 
 PAPILLOMATOUS TUMORS. 1 93 
 
 differing from them only by reason of the different area 
 of mucous membrane from which they spring. They are 
 much less common than polypi. Their structure is that 
 of the mucous membrane covering the inferior turbinal 
 with inflammatory round-cell infiltration. These growths 
 occur either as hard or as soft papillomata, the difference 
 being due to the preponderance of fibrillary connective 
 tissue in the former, while in the latter the abundant 
 presence of round cells gives them almost the structure 
 of granulation tissue. The name of papilloma is given 
 to these growths on account of their minutely lobulated 
 surface, which thus resembles the papillary structure of 
 the skin. In appearance they may be aptly compared to a 
 raspberry, which they also resemble in color. They occur 
 most frequently in connection with chronic purulent 
 rhinitis, and their presence helps to perpetuate the sup- 
 puration. They can be easily and permanently removed 
 by snaring (Fig. 57). 
 
 13
 
 CHAPTER XV. 
 
 NASAL STENOSIS COLLAPSE OF THE SIDES OF 
 THE NOSE. SYNECHI/C. OCCLUSION OF THE 
 POSTERIOR CHOAN/E. 
 
 NASAL STENOSIS. 
 
 105. While the width of the nasal passages varies in 
 different subjects with the width of the skull, the normal 
 nose offers no appreciable resistance to the current of air 
 during quiet or even during forcible respiration. Any 
 narrowing or encroachment upon the caliber of sufficient 
 extent to impede the respiratory current is termed ste- 
 nosis. In default of more accurate physical methods of 
 measurement we can gauge the normal or diminished 
 permeability of the nasal passage by auscultation. When 
 the caliber is sufficient, the ingoing or outgoing air pro- 
 duces no sound, even while breathing forcibly. Any 
 interference, however, with the respiratory capacity of 
 the nose causes a sound varying from a gentle rustling 
 noise to a sharp hiss. The more forcible the breathing, 
 the more distinct is the sound. Either side must be 
 tested while the other is closed by the thumb. In a nose 
 otherwise not diseased stenosis or even occlusion of one 
 side causes no annoyance ordinarily as long as it is com- 
 pensated by full width of the other. For the animal 
 system has in most of its functions an excess of capacity, 
 and hence some physiologic latitude. But when the 
 breathing is deepened in consequence of severe exertion, 
 the nasal passages of less than average capacity become 
 insufficient, and the individual is "short-winded." If, 
 however, both nostrils are narrowed, a condition which 
 occurs only in consequence of disease and not merely as 
 a structural anomaly, the subject feels the difficulty of 
 breathing, and upon the least exertion is forced to breathe 
 
 194
 
 NASAL STENOSIS. 1 95 
 
 through the mouth. Especially is this the case in the 
 recumbent position (during sleep), when the increased 
 venous blood pressure in the low-lying head causes ad- 
 ditional nasal obstruction by turgescence. As the path of 
 the air through the mouth is cut off whenever the tongue 
 arches upward so as to touch the soft palate, which move- 
 ment often takes place while the mouth is open, the 
 sleep is apt to be interrupted or troubled by momentary 
 dyspnea. 
 
 Mouth-breathing, furthermore, subjects the throat and 
 lower air-passages to abnormal and irritating conditions. 
 The inspired air is both warmed and nearly saturated 
 with moisture in passing over the convoluted surface of 
 the normal nasal passage, while the dust it contains is 
 almost wholly deposited there. None of these conditions 
 are fulfilled during mouth-breathing. The cool, rela- 
 tively dry, and possibly dusty air reaching the pharynx 
 and lower air-passages acts as an irritant. While this 
 irritation by itself is not sufficient to cause local disease, 
 it aids other pathogenic influences, such as infection, in 
 overcoming the resistance of the tissues. 
 
 106. Nasal stenosis is an important determining condi- 
 tion in the persistence and chronicity of all forms of nasal 
 inflammation. It favors the prolongation of a coryza in 
 the form of a chronic purulent or simple rhinitis. It 
 predisposes in the latter case to the occurrence of hyper- 
 trophies, even of polypi. It hinders the free drainage in 
 acute suppuration of the accessory cavities, and thus aids 
 in changing these into chronic affections. Last, but not 
 least, all forms of stenosis exert the most pernicious in- 
 fluence by favoring the extension of inflammatory disease 
 through the Eustachian tubes into the ear. Of all nasal 
 diseases, ozena is the only one the predisposition to 
 which is not augmented by stenosis. 
 
 When a one-sided nasal stenosis has become compli- 
 cated by actual nasal disease, stenotic annoyance is felt by 
 the patient on both sides on account of the variable 
 turgescence of the cavernous tissue, which causes tran-
 
 196 
 
 NASAL STENOSIS. 
 
 sient occlusion of one or the other side alternately. The 
 patient may then be at a loss to state which seems to him 
 the narrower side. Nasal stenosis depends principally on 
 the deformities of the septum, which will be considered 
 in the next chapter. But besides the septum irregu- 
 larities, other structural anomalies may require con- 
 sideration. Even a considerable degree of deflection of 
 the septum may lead to no morbid results in the case of 
 a naturally wide nasal passage, while in a narrow nose, 
 a relatively slight convexity or ridge on the surface of 
 the septum may cause disastrous consequences. A physio- 
 logic septum irregularity which originally caused no 
 stenosis may do so after hypertrophy of the lining of the 
 inferior turbinal has further narrowed the nasal passage. 
 Hence, even when the septum is partly at fault, opera- 
 tions on the inferior turbinal, such as the galvanocaustic 
 destruction of cavernous dilatation, the snaring of hyper- 
 trophied mucous membrane, or complete removal of the 
 
 turbinal process in case of 
 abnormal projection of this 
 ledge or diffuse papilloma- 
 tous degeneration of its lin- 
 ing are sometimes indicated 
 if the mechanical conditions 
 are not favorable for opera- 
 tions on the septum. 
 
 107. A minor condition, 
 but one sometimes deserving 
 attention, is the inspiratory 
 collapse of the sides of the 
 nose (alse nasi). Although 
 itself the consequence of 
 FIG. 58. Schmidt's dilator for col- sorne intranasal anomaly 
 
 lapseof the external nares, the upper ^^j ste nosis, it hltensi- 
 
 sketch showing it in position. It is . 
 
 made in various sizes. fies the latter - Wlth everv 
 
 inspiration the sides of the 
 
 external nose sink in, thereby slightly narrowing the 
 vestibule. It occurs in connection with long-standing
 
 NASAL SYNECHIjE. 197 
 
 intranasal stenotic lesions, and only in subjects whose 
 alae nasi are very thin and flexible. It probably de- 
 pends on insufficient activity of the dilating muscular 
 fibers. The want of breath which the patient feels 
 is relieved at once by keeping the nostrils open for 
 instance, by the speculum. Temporary relief may be 
 obtained by the use of the wire dilator devised by M. 
 Schmidt and constructed by Feldbausch. Its application 
 is shown in Fig. 58, and may be varied slightly by bend- 
 ing the wire frame. It is made in three sizes. Occa- 
 sionally its temporary use is followed by permanent relief. 
 By other surgeons silver tubes have been used for the 
 same purpose, but these are often not so well tolerated as 
 a wire dilator which does not touch the septum. 
 
 NASAL SYNECHI/E. 
 
 108. Connecting bridges between the septum and the 
 opposite external wall are formed under various condi- 
 tions. Their most frequent cause is insufficient care after 
 operations, bloody or caustic, in narrow passages, when 
 two denuded opposing surfaces are not prevented from 
 
 FIG. 59. Luer forceps (especially adapted for the removal of intranasal 
 
 synechise). 
 
 growing together. A lateral crest on a convex septum 
 may touch the inferior or middle turbinal and consolidate 
 with it when the points of contact are involved tran- 
 siently in an acute inflammation. Broad or multiple syne- 
 chise are very often due to nasal syphilis. In some cases 
 synechise are of congenital origin. They are mostly
 
 198 NASAL 
 
 membranous, but occasionally bony. Sometimes irrele- 
 vant, they may in other instances cause stenosis or dam 
 up secretions. Again, they may be the starting-point of 
 nervous, so-called reflex, disturbances. They are easily 
 removed by any form of broad rongeur forceps (Fig. 59), 
 which exsects the whole bridge. If curvature of the 
 septum renders them less accessible, they may be cut 
 through at one side and then snared off, or removed 
 with the spoke shave. The broad synechise of syph- 
 ilis may, however, tax the surgeon's ingenuity to the 
 utmost. 
 
 109. Total occlusion of one nostril at its anterior 
 vestibular entrance has been observed a few times in 
 consequence of destructive processes (syphilis, lupus, 
 small-pox, and rhinoscleroma). 
 
 no. Total occlusion of the posterior choanse, 
 while not a frequent occurrence, is on record in more 
 instances than anterior closure of the nose. It is always 
 congenital, and may be one-sided or bilateral. The one- 
 sided closure causes scarcely any annoyance so long as the 
 nose is otherwise healthy; only the sense of smell is 
 abolished on that side. Any form of inflammation, how- 
 ever, leads to the retention of secretion and subsequent 
 annoyance. The closure is membranous in some cases. 
 In others it consists of bony plates springing from the 
 palatal bone. 
 
 The diagnosis of choanal closure must be confirmed 
 by the use of the postrhinoscopic mirror, which shows a 
 diaphragm across the choanse. If this is membranous, 
 it can be easily cut through. Should it not be possible 
 to exsect it sufficiently, the galvanocaustic burner may 
 be used. Operations on bony plates closing the choanae 
 are more difficult. They are painful and bloody. The 
 posterior wall of the pharynx must be guarded by the 
 surgeon's finger, or, still better, by a suitable bent plate 
 introduced through the mouth. The diaphragm can be 
 pierced by a stilet, and the opening enlarged by the saw 
 or chisel. It is much better to make a large opening at
 
 TOTAL OCCLUSION OF THE POSTERIOR CHOAN^E. 199 
 
 once than to attempt to enlarge it subsequently by any 
 mechanical means. Sometimes a tube must be worn for 
 weeks. Among the recorded operations, some of them 
 of recent date, there have been various accidents, such 
 as middle-ear infection and even an occasional death.
 
 CHAPTER XVI. 
 
 ANATOMY OF THE SEPTUM. DEVIATION OR 
 
 DEFLECTION OF THE SEPTUM. LATERAL 
 
 CRESTS. DEFORMITY OF SEPTUM 
 
 BY FRACTURE. 
 
 in. The two nasal passages are separated by a 
 median wall common to both the septum. This is 
 made up in front and below of the quadrangular carti- 
 lage, in its upper portion of the vertical plate of the 
 ethmoid bone, while its inferior posterior part is the 
 vomer. The extreme anterior tip is membranous and 
 consists of skin. A dense perichondral membrane covers 
 the cartilage underneath the mucous membrane, while 
 the bony plates have a periosteal lining. In its upper 
 anterior region the mucous membrane is thickened into 
 a tumefaction the tuberculum of the septum rich in 
 glands and veins. Some distance above the floor the 
 mucous membrane forms a series of shallow ridges dur- 
 ing development, which usually dwindle later on, but 
 sometimes enlarge in hypertrophic rhinitis (Fig. 60). 
 
 During its early fetal formation the septum is a single 
 plate of cartilage reaching from floor to roof. About the 
 second month the vomer becomes differentiated in the 
 form of two ossifying parallel plates, joined in front, 
 below, and behind, but including between them the 
 original cartilaginous layer. Toward birth these two 
 bony plates coalesce, with disappearance of the included 
 cartilaginous plate. At the upper border, however, the 
 bony plates are still separated by a groove in which a 
 strip of cartilage persists. By this time the vertical 
 plate of the ethmoid, too, has ossified from above down- 
 ward, and now joins the upper border of the vomer, 
 leaving still the strip of cartilage now incased by bony 
 200
 
 ANATOMY OF THE SEPTUM. 
 
 201 
 
 walls. This condition may change to complete ossifica- 
 tion during adult life, or may persist indefinitely. 
 
 US. The developed vomer represents a stout bony 
 lamella, the height of which increases from before back- 
 ward, by reason of the slope of its upper or anterior 
 border. Its inferior border articulates with a narrow 
 ridge at the median junction of the two superior max- 
 
 FIG. 60. Nasal septum after detachment of its mucous lining : Z, Perpen- 
 dicular plate of the ethmoid; V, V, vomer; Q, quadrangular cartilage; S t 
 nasal spine of the frontal bone; C, nasal crest of the palate bone (Zuckerkandl). 
 
 illary and the two palatal bones, reaching thus from the 
 front to the rear end of the floor of the nose. The slop- 
 ing anterior border connects partly with the quadrangular 
 cartilage, and back of it with the vertical plate of the 
 ethmoid. It runs up to the rostrum or spine on the 
 inferior surface of the sphenoid, where it turns to form 
 the short (superior) border articulating with the rostrum. 
 The posterior free edge of the vomer slants upward and 
 backward and is concave. 
 
 The quadrangular cartilage articulating in front and 
 above with the nasal bones forms the median wall of the
 
 2O2 DEVIATION OR DEFLECTION OF THE SEPTUM. 
 
 external nose. The triangular cartilaginous plates of the 
 sides of the nose are joined to it. Its inferior anterior 
 rounded corner is framed by the short, thick, membran- 
 dus septum, which thus completes the middle wall of the 
 external nose. The inferior border of this cartilage rests 
 on the anterior half of the vomer. At this contact the 
 edges of cartilage and bone are sometimes square ; more 
 often, however, the cartilaginous edge is bent toward one 
 side and overlaps the bony junction, or is split overriding 
 the bone on both sides, while the vomer may or may not 
 have its groove obliterated. These irregularities of the 
 junction are the starting-point of morbid crests. 
 
 The vertical plate of the ethmoid completes the gap 
 between the roof of the nose, the anterior surface of the 
 sphenoid bone, the upper border of the vomer, and the 
 cartilaginous septum. The ossification of this bony 
 lamella proceeds from above downward and extends 
 forward to a variable extent, so that while the bridge 
 of the nose is mostly supported by this bony plate, it 
 rests occasionally only on the cartilaginous septum. 
 The ossification is completed by the sixth year, at the 
 latest about the ninth year of life. But, as before de- 
 scribed, a strip of cartilage usually remains after this 
 period, for a variable length of time, incased by bony 
 walls viz., by the inferior edge of the vertical ethmoid 
 plate and the trough formed by the upper border of the 
 vomer. The lateral crests so often found in the nose are 
 due to hypertrophy of this cartilaginous remnant, with 
 secondary bulging of the sides of the bony troiigh. 
 
 113. The normal septum is not always an ideal 
 straight wall. Asymmetry due to curvature is found in 
 more than one-half of all skulls of the white races. In 
 uncivilized tribes septum deviations occur only to the 
 extent of about 25 per cent. The deflection pertains 
 principally to the cartilaginous portion, but may involve, 
 to a variable extent, the perpendicular part of the eth- 
 moid plate. The deflected septum is convex and bulging 
 toward one side and correspondingly concave on the
 
 "CAUSES. 203 
 
 other. The curvature is usually more marked in the 
 vertical than in the horizontal plane. The convexity 
 may be scarcely noticeable, or may, on the other hand, 
 occlude practically the one nasal passage. Sometimes a 
 double S-shaped bend is met with, reducing the patency 
 of both sides. When the asymmetry extends to the front 
 portion of the septum, the external nose is deflected to 
 one side. Occasionally, but not often, the free anterior 
 end of the cartilage is deflected and then usually thick- 
 ened, so as to occlude partly one side of the vestibule 
 (Fig. 61). The architecture of an asymmetric septum 
 is very often complicated by the existence of lateral 
 
 FIG. 6l. Stenosis of the right nostril by thickening and deflection of the 
 anterior end of the septal cartilage. The membranous septum is displaced to 
 the left, and thereby narrows the left nostril. 
 
 crests on one or even both sides, which thicken it and 
 augment its injurious mechanical influence. 
 
 Regarding the causes of asymmetry of the septum, 
 many unfounded hypotheses have been recorded. But 
 nothing more positive can be stated than that it is the 
 result of a disproportionate growth of the septum as 
 compared with that of the rigid bony frame within 
 which it is contained. In very pronounced cases of 
 curvature it is sometimes apparent that the concavity 
 of the septum corresponds to the smaller maxillary bone, 
 which has not attained the growth of its mate, giving 
 the entire face an asymmetric expression. Pronounced 
 asymmetry is rarely observed before the second dentition. 
 The influence of traumatism, so often quoted, has been 
 much overrated. It does seem in some instances to lead
 
 204 
 
 LATERAL CRESTS. 
 
 to an exaggeration of a preexisting asymmetry, but it is 
 scarcely probable that it can cause a deflection without 
 fracture of a previous straight septum. 
 
 114. Less frequent, but clinically more important, 
 than deviations of the septum are the lateral crests, also 
 called spurs and septal ridges or spines. They occur in 
 about every third skull and are often associated with 
 some deflection. The lateral crests are protuberances on 
 
 FIG. 62. Frontal section through the nose, showing a large crest on the left 
 side of the septum : a, a, Septum ; b, crest (Zuckerkandl). 
 
 the side of the septum in the form of ledges running 
 backward and somewhat upward. They begin usually 
 in the cartilaginous portion, but sometimes only at the 
 bony part, and may or may not extend up to the sphe- 
 noid bone. In the cartilaginous portion they may or 
 may not be double-sided. In the bony part they are, as 
 a rule, one-sided, and if bilateral, one is much more 
 prominent than the other. These protuberances may be
 
 MODE OF ORIGIN. 2O5 
 
 scarcely prominent, or may extend laterally far enough 
 to touch the inferior and toward the rear partly the 
 middle turbinal (Fig. 62). The rear end of a lateral 
 crest is sometimes covered by hypertrophic and turges- 
 cent mucous membrane in the form of the gelatinous 
 cushion described in ^[ 94. In some instances sharp, 
 cornice-like projections, the lateral crests are in others 
 diffuse flat tumefactions. Their location is at the side of 
 the anterior sloping border of the vomer, anywhere from 
 its front to its rear end, but their parallelism with this 
 border may be masked by their variable and irregular 
 height. By the older writers the spines on the septum 
 have been incorrectly termed ecchondroses and exostoses. 
 These terms are not applicable, as they refer to localized 
 tumors of progressive tendency, and of a structure which 
 the lateral crests do not possess. 
 
 The mode of origin of lateral crests has been defi- 
 nitely established by Zuckerkandl. In the anterior part 
 of the septum the lateral spurs or prominences are due to 
 the lateral overriding of the edge of the cartilaginous plate 
 over the edge of the vomer, with more or less hypertrophy 
 of the displaced cartilaginous edge. Further back, where 
 the vomer and the vertical plate of the ethmoid meet, 
 the lateral crest is due to hypertrophy of the strip of 
 cartilage, which persists in the interior of this articula- 
 tion, incased within the trough-like border of the vomer. 
 This hypertrophy causes bulging of the bony shell 
 which covers it ; hence the outer wall, at least, of the 
 lateral crest is bony ; indeed, sometimes a very solid 
 bony plate. Quite often, however, the hypertrophied 
 cartilaginous strip itself undergoes later on ossification, 
 in which case the lateral crest is bony throughout. The 
 cause of this hypertrophy has not been fully ascertained. 
 Clinical experience points to an inflammatory origin, 
 for it can often be learned that in noses which had pre- 
 viously presented no lateral crest, such a prominence has 
 gradually developed during the course of repeated acute 
 attacks of inflammation. The side toward which the
 
 2O6 
 
 DEFORMITY OF SEPTUM BY FRACTURE. 
 
 bulging of the enlarged cartilage occurs is partly deter- 
 mined by the previous shape of the septum. When this 
 is deflected, the crest is, as a rule, on the convex side. 
 The presence of the crest seems to increase the septum 
 deformity, and in such cases the concavity on the opposite 
 side of the septum is often very deep. Within the carti- 
 laginous portion lateral ridges may occur on both sides, 
 even in a deflected septum. Traumatism may play a 
 slight role occasionally in exaggerating the growth of 
 lateral crests, but careful criticism does not lead to the 
 belief that it is a common or essential condition. 
 
 115. Deformity of the septum as the result of a frac- 
 
 V 
 
 FIG. 63. Old fracture of nasal 
 bones. The cartilaginous septum is 
 bent to a high degree, and on the 
 left side touches the external wall in 
 front (Zuckerkandl). 
 
 FIG. 64. Old fracture of the nasal 
 bones. Dislocation of the cartilag- 
 inous septum at its articulation with 
 the vomer (Zuckerkandl). 
 
 ture is much less common than the previously described 
 asymmetries. According to Zuckerkandl' s numerous 
 dissections and experimental tests, fracture of the septum 
 can occur only in connection with fracture and disloca- 
 tion of the nasal bones. As this accident, unless 
 promptly treated, always leads to lasting deformity of
 
 CLINICAL SIGNIFICANCE OF SEPTUM DEFORMITIES. 2O/ 
 
 the bridge of the nose, the presence or absence of the 
 latter can guide the diagnosis. Fractures of the septum 
 pertain essentially to the cartilaginous plate ; much less 
 so to the vertical plate of the ethmoid. The vomer 
 seems to be protected by its strength and its deep situa- 
 tion. The fractures are usually horizontal ; much less 
 often, vertical. The fractured ends overlap and often 
 become thickened. Within the cartilaginous portion 
 they are reunited by connective tissue. In the bony 
 portion only a thin callus is formed. The deformity 
 resulting from fracture is a sharp, angular bend, usually 
 with very great thickening of the mucous membrane on 
 the concave side. A traumatism sufficient to break the 
 nasal bones may also dislocate the cartilaginous plate 
 over the vomer edge, causing 
 thus an excessive thickening in 
 front, near the floor of the nose 
 (Figs. 63, 64, 65). 
 
 116. Another tumefaction on 
 the septum, while not uncom- 
 mon, but of relatively little clin- 
 ical importance, is the hyper- 
 trophy of the cushion of mucous 
 membrane in the anterior tipper 
 part, known as tuberculum of the 
 septum. This may be thickened 
 by hypertrophy of the mucous 
 membrane, with more or less over- 
 development of the venous plex- 
 us. Even when very thick it 
 does not interfere with the cur- 
 rent of air, but it may interfere 
 with the drainage of secretions 
 to a sufficient extent to justify 
 
 its reduction by the galvanocautery or its abscission with 
 a knife. 
 
 117. Clinical Significance of Septum Deformities. The 
 disturbances due to irregularities of the septum de- 
 
 FIG. 65. Fracture of the 
 cartilaginous septum with ob- 
 struction of the anterior ends 
 of the nasal passages.
 
 2O8 CLINICAL SIGNIFICANCE OF SEPTUM DEFORMITIES. 
 
 pend upon their mechanical influence. Deviation of 
 the septum is in no sense of the word a disease, merely 
 an unfavorable structural anomaly. Lateral crests, 
 while really a morbid overgrowth, are likewise of sig- 
 nificance only if they interfere with the permeability 
 of the nasal passage. The most important effect of 
 septum deformities is the stenosis which they, may pro- 
 duce, and this depends upon their prominence, as well 
 as upon the natural width of the nasal passage. If no 
 stenosis sound is heard during examination, it must not 
 be concluded that the septum prominence is harmless, 
 for it may lead to partial occlusion whenever the venous 
 plexus is turgescent, and certainly will do so during in- 
 flammatory attacks. A one-sided stenosis, if compen- 
 sated by full width of the other passage, does not neces- 
 sarily lead to annoyance nor to disastrous results, so long 
 as the nasal mucous membrane is healthy ; it merely 
 makes the patient short-winded on exertion. But it is 
 an important condition favoring the persistence of any 
 inflammation. Hence repeated or severe attacks of 
 coryza are very apt to lead to hypertrophic rhinitis under 
 these circumstances. Clinical observation shows also the 
 importance of septum irregularities in the maintenance 
 of suppurative rhinitis or suppuration of the accessory 
 cavities, the occurrence of polypi, and in the extension 
 of nasal disease to the pharynx, larynx, and bronchial 
 tubes. The most striking observations are those which 
 show the influence of one-sided stenosis together with 
 inflammatory nasal disease in the production of ear dis- 
 ease. This may be either acute or it may be a chronic 
 adhesive process extending through the Eustachian tube 
 in the middle ear. In the case of one-sided nasal steno- 
 sis a one-sided ear affection occurs almost invariably on 
 the narrow side, very rarely on the other side. In 
 bilateral ear disease the side most severely involved 
 corresponds in the overwhelming majority to the nar- 
 rower side of the nose. Quite often, too, ear affections
 
 DIAGNOSIS OF SEPTUM DEFORMITIES. 209 
 
 persist in spite of all treatment of trie ear until the nasal 
 stenosis has been successfully relieved by operation. 
 
 The pernicious influence of nasal stenosis has been 
 ascribed to rarefaction of the air behind the narrowed 
 part of the passage during every inspiration. It has 
 been assumed that in consequence of this increased nega- 
 tive pressure, a permanent congestion of the mucous 
 membrane occurs. This hypothetic, but plausible, view 
 does not fully explain all the injurious effects resulting 
 from stenosis. It is very noticeable that in deflection 
 of the septum the inferior turbinal shows, as a rule, pro- 
 nounced hypertrophy of the mucous membrane on the 
 concave, roomy side of the nose. 
 
 A septum irregularity which does not sensibly interfere 
 with the passage of air may interfere with the escape of 
 morbid secretions to such an extent as to favor the per- 
 sistence of suppurative processes. Hence, the operative 
 removal of spurs and ledges often permits the cure of 
 previously unyielding nasal suppuration. 
 
 Lateral crests may also be the source of nervous dis- 
 turbances in irritable noses. In the majority of cases of 
 vasomotor irritability lateral prominences are found on 
 the septum. It is especially those with a sharp edge 
 which seem to irritate most. Even greater importance 
 can be attributed to lateral crests which extend far 
 enough laterally to touch the inferior or middle turbinal, 
 be it permanently or only during periods of turgescence. 
 Some of the most satisfactory cures of nasal irritability 
 can be obtained by the removal of such ledges, even 
 when they do not cause the auscultation sound of stenosis. 
 A crest which extends far enough to touch a turbinal 
 process may become united to it by a bridge of mucous 
 membrane, causing a nasal synechia. This junction 
 seems to augment sometimes the pernicious influence of 
 the crest. On the other hand, very prominent crests 
 may cause localized atrophy of the turbinal process 
 where they come in contact with it. 
 
 118. The diagnosis of septum irregularities is self-evi- 
 
 14
 
 2 1C SEPTUM DEFORMITIES. 
 
 dent from their description. When the anterior region 
 of the nose is narrow, it is necessary to explore the deeper 
 part thoroughly with the probe under good illumination, 
 in order to get a clear picture of the extent of the septum 
 irregularity. The indications for operative interference 
 are very plain, and the results eminently satisfactory in 
 all high degrees of septum irregularities. But in minor 
 degrees of septum asymmetry and thickening the me- 
 chanical chances for success are not so favorable. Hence 
 in such cases it must be carefully considered whether the 
 disturbances observed are principally due to the encroach- 
 ment of the septum deformity upon the nasal caliber, or 
 whether they are due to any coexisting hypertrophies on 
 the external nasal wall, as the latter are more easily 
 removed by operation. Small and insufficient operations 
 on the septum are, as a rule, to be deprecated as useless. 
 An incompletely removed lateral crest is very likely to 
 continue its growth; for if we remove only the bony 
 shell covering the hypertrophied cartilage nucleus, the 
 latter will grow again later on. 
 
 Many surgeons, including the writer, have been tempted 
 to obtain straightening of a deflected septum or atrophy of 
 a lateral crest by some form of continuously applied pres- 
 sure. But hitherto all these attempts have proved failures. 
 Pressure by tampons, tubes, or metallic springs leads to 
 ulceration of the septum if kept up, and if discontinued, 
 its effect is soon lost. Successful operations upon septum 
 deformities have been extensively practised only within 
 the past fifteen years. The operative attempts of the 
 older surgeons, tried merely in extreme cases, were mostly 
 failures. In the present treatise only those operations 
 generally recognized can be considered. 
 
 119. The simplest and most satisfactory correction of 
 a deviated septum is the operation devised by M. J. Asch, 
 which can be done in a few minutes. Its object is to 
 fracture the cartilaginous septum and to let it heal in a 
 straight position. General narcosis is usually employed, 
 with the head hanging over the edge of the table on ac-
 
 OPERATIONS UPON THE SEPTUM. 
 
 211 
 
 count of the sharp bleeding. A tolerant patient, how- 
 ever, can bear it under cocain, especially when injected 
 into the mucous membrane. The nose should first be 
 explored for adhesions between septum and external wall, 
 and if found, they should be cut with cutting forceps or 
 a concave gouge. The straight Asch forceps are then 
 introduced horizontally, with the narrow blunt blade on 
 
 FIG. 66. Asch's instruments : A, Straight scissors ; B, angular scissors ; C, 
 compressing forceps. 
 
 the narrow side (Fig. 66). The cartilage is cut through, 
 exactly over the apex of its convexity. The scissors are 
 then inserted as nearly vertical as possible, so as to make 
 a crucial incision, splitting the cartilage into four flaps. 
 When the straight scissors cannot be well inserted for 
 the vertical cut, the more cumbersome bent scissors may 
 be employed. The finger is now put into the narrower 
 side, and the fragments are crowded over to the other.
 
 212 CORRECTION OF SEPTUM DEFORMITIES. 
 
 The cartilaginous flaps should be fractured at their base. 
 The Asch compressor is then inserted, and the fracture 
 completed with the intention to render the septum as 
 nearly straight as possible. Asch does not advise frac- 
 turing the bone, even if the latter be deflected. The 
 sharp hemorrhage can be controlled quickly by an iced 
 spray or temporary tampons. As soon as this is checked, 
 the Asch or (improved) Mayer tubes are inserted. They 
 are made of rubber, perforated, and somewhat curved 
 (Fig. 67), oval in cross-section, and in six sizes. They 
 bear sterilizing by boiling. The largest one possible is 
 inserted on the formerly convex side until concealed 
 within the vestibule. Its object is to keep the septum 
 straight while healing. The smaller one is put into the 
 other side for the first twelve hours, in order to guard 
 
 FIG. 67. Mayer's hollow nasal splints. 
 
 against bleeding, and is then omitted permanently. The 
 tube on the formerly convex side is removed once daily 
 for cleansing, and the nasal secretion is cleared away by 
 a spray. The removal and reinsertion should be painless. 
 The patient can learn to do it himself after a few days. 
 The healing is completed in three and one-half to four 
 weeks, when the tube can be left out. The fractured 
 fragments overlap on the formerly concave side, and 
 their edges sometimes thicken later on. Occasionally 
 this requires shaving off with the scalpel, or slight 
 touching with a burner. 
 
 The operation gives ideal results in the case of a curved, 
 bent, but not thickened septum, with plenty of room on 
 the concave side. When a moderate-sized lateral crest 
 complicates the septum deflection, it may be removed
 
 OPERATIONS UPON THE SEPTUM. 213 
 
 (1 122) just before the septum is fractured. With very 
 diffuse thickening, however, or stenosis on the concave 
 side the Asch operation is not applicable. 
 
 ISO. For extreme cases of septum curvature, even if 
 complicated by lateral crests, a more radical operation 
 has been devised by Krieg and cultivated especially by 
 Boenninghaus. It is the resection of the deflected cartil- 
 age. On account of its tediousness the German surgeons 
 usually operate under cocain and without narcosis. With- 
 out speculum two incisions are made at the beginning of 
 the curvature on the convex side, one parallel to the floor, 
 the other parallel to the bridge of the nose. The incisions 
 go through the mucous membrane only and are not quite 
 i cm. long, on account of the free hemorrhage following, 
 which jnust now be stopped. Suprarenal solution aids 
 more than mere tamponing. The triangular flap-mem- 
 brane thus outlined is then pushed back with a large 
 blunt periosteum scraper. Hereupon the incisions can 
 be extended gradually as far as necessary, until the entire 
 curved part of the septum is exposed. The detached 
 mucous membrane is temporarily pushed out of place 
 by crowding it upward and back. In the next place the 
 incision is extended through the cartilage itself, with 
 care not to wound the mucous lining on the concave side. 
 This may be guarded against by putting the finger into 
 the concave side. This step can also be facilitated by 
 lifting up the mucous membrane on the concave side by 
 means of submucous injection of fluid (with cocain). Per- 
 forations are not always avoidable. The incision through 
 the cartilage is extended by means of scissors, always 
 with the same care to spare the mucous membrane on 
 the other side. The liberated cartilaginous triangle now 
 shows the tension under which it was restrained, and 
 bends further toward the external wall. It is seized with 
 stout rongeur forceps and broken off piecemeal. This 
 gradual removal of the deflected plate must extend to 
 the bone if necessary. At the same time lateral crests 
 are taken away in the same manner, so as to clear the
 
 214 CORRECTION OF SEPTUM DEFORMITIES. 
 
 nose entirely. There is very little hemorrhage during 
 the work upon the cartilage. The bleeding comes mainly 
 from the cuts in the mucous membrane. After a sufficient 
 extent of the deflected septum has been removed, the 
 operation is finished. The wall between the two nasal 
 cavities now consists only of the intact mucous membrane 
 on the concave side. Krieg and Boenninghaus do not 
 attempt to preserve the lining on the convex side, as they 
 claim that it rolls up and cannot be stitched in place. 
 (But by much care it can be preserved, at least partially, 
 and the time of healing shortened by the temporary use 
 of carefully inserted tampons which retain it in place.) 
 The great advantage of this operation is the fact that 
 practically no after-treatment is necessary. The wound 
 heals in seven to eight weeks, but requires no special 
 care. The result is a perfectly straight septum. No 
 sinking in of the bridge of the nose has been observed or 
 needs to be feared. 
 
 Partial resection of the cartilage has been practised by 
 the writer in deflection occurring at the extreme front end 
 of the septum, especially when the free border adjoining 
 the membranous septum is bent and at the same time 
 thickened. In cases of this kind the obstruction is com- 
 paratively within the vestibule (see Fig. 61). No typical 
 operation is suitable for all cases, but by cutting upward 
 or downward with a knife the cartilaginous projection is 
 abscised flush with the normal plane of the septum. It 
 is sometimes possible to save part of the mucous mem- 
 brane by detaching a flap, as in the Krieg operation. 
 
 I2i. Lateral crests of the septum can be removed 
 easily by the saw, according to the method of Bosworth. 
 A thin saw, mounted on a shank bent at an obtuse angle, 
 is introduced in the plane of the septum, and with a 
 steady to-and-fro movement the entire ledge is sawed off. 
 Usually the teeth of the saw are underneath, but some- 
 times it is more convenient to use it reversed and saw up- 
 ward (Fig. 68). It is sometimes difficult to detach com- 
 pletely the sawed-off crest, in which case its rear attach-
 
 OPERATIONS UPON THE SEPTUM. 215 
 
 ment is separated either by use of the snare or by scissors. 
 The use of suprarenal solution facilitates the work by 
 making it almost bloodless. It aids, besides, the action 
 of cocain, so that a pledget wet with 20 per cent, solution 
 will give perfect painlessness after five minutes' applica- 
 tion. Subsequent hemorrhage may render temporary 
 tamponing desirable. The wound heals smoothly in 
 
 FIG. 68. Nasal saw. 
 
 from one to two and one-half weeks, according to its 
 size; more slowly, however, if it be ragged or irregular. 
 The results are perfectly satisfactory if a sufficiently large 
 piece has been removed. When the sides of the crest 
 slope very gradually, it is difficult to use the saw prop- 
 erly. This is also the case when the ledge extends up to 
 the sphenoid surface. 
 
 Some surgeons like M. Black claim to facilitate the 
 operation by using a saw driven mechanically by the 
 
 FIG. 69. Author's nasal chisel (two-thirds size). 
 
 rapid rotation of the hand-piece of a dental motor. 
 Others prefer the use of a chisel and mallet, which is a 
 matter of individual preference or skill. There are cases 
 where there is so much slope on the upper and lower 
 sides of the crest, with a relatively square front surface, 
 that the chisel is more applicable. The writer has 
 devised a hollow chisel of elliptic cross-section, of which
 
 2l6 CORRECTION OF SEPTUM DEFORMITIES. 
 
 only one-half has a cutting-edge (Fig. 69). This instru- 
 ment, pressing itself against the external wall, cannot 
 slip like a plane chisel, and is bound to gouge out the 
 projecting ledge. It is of service in the case of very 
 broad diffuse tumefaction, especially when situated on 
 the convex side of a nearly plane septum. It is, how- 
 ever, apt to cause perforation, which, in the writer's 
 experience, has not proved a serious objection. 
 
 12,2,. In the case of crests difficult to saw by reason of 
 their sloping surface a very serviceable instrument is the 
 trephine run by a motor with a dental handpiece. As it 
 is difficult to hold this instrument steady, the writer uses 
 it under the guidance of a sheath into which it fits closely 
 (Fig. 70). This cylindric sheath has one half of its 
 
 '^^^^^^^B^^M^^/ 
 
 FIG. 70. Nasal trephine, with author's guarding sheath (two-thirds size). 
 
 periphery removed, so as to hug the ledge upon which 
 the trephine is to act. When the crest consists of 
 such hard bone that the trephine gets caught, a smaller 
 one is first used within the same guard to perforate 
 the crest longitudinally and weaken it thereby, where- 
 upon the larger trephine easily cuts it away. Work 
 with the trephine is much quicker than with the saw. It 
 can be used, too, to good advantage in order to reach up 
 to the rear end of crests extending up to the sphenoid 
 surface. As the entire width of the trephine is 'only 8 
 mm., it can merely cut a groove with a radius of about 
 4 mm. In the case of broad ledges the guard is with- 
 drawn after the first cut and reapplied slightly turned, 
 so as to inclose now the balance of the tumefaction, 
 which a second action of the trephine thereupon re-
 
 OPERATIONS UPON THE SEPTUM. 
 
 217 
 
 moves satisfactorily. The only objection to the tre- 
 phine is that the wound made by it is concave, and its 
 healing is more likely to be delayed by crust- formation 
 than the plane wound made by the saw. 
 
 Lateral ledges and spurs limited to the cartilaginous 
 portion can be cut off smoothly with a sharp knife. 
 
 When the contour of a crest has so gradual a slope 
 for instance, on the convexity of a curved septum 
 that it is difficult to apply the knife properly, the spoke- 
 shave which cuts backward can often be substituted 
 advantageously (Fig. 71). The instrument is pushed in 
 until its cutting-edge surrounds the spur from the rear. 
 
 FIG. 71. The spokeshave in two sizes. The third knife, in the shape of an 
 incomplete ring, is used when a total stenosis hinders the introduction of the 
 other forms. Universal handle for nasal instruments (one-half size). 
 
 On pulling it out with the necessary strength while keep- 
 ing it pressed against the septum even hard bony crests 
 can be abscised thoroughly in one sweep without danger 
 of accidental injury. The same instrument may be used 
 to smoothen uneven wounds made by any other mode of 
 operation. 
 
 123. The wounds made by these various modes of 
 operation heal kindly, as a rule. The hemorrhage may 
 persist for hours, but is not serious. An aseptic healing 
 cannot be guaranteed, but is usually obtained, especially 
 as -long as the passage is evenly packed with iodoform 
 gauze. Where the patient had previously not been able 
 to breathe through that side of the nose, this packing is
 
 2l8 CORRECTION OF SEPTUM DEFORMITIES. 
 
 not complained of. But most patients without previous 
 complete stenosis prefer the slower healing with unob- 
 structed passage to the advantages gained by a gauze 
 tampon. The best but still not absolutely reliable sub- 
 stitute for iodoform gauze the writer has found in glutol, 
 which adheres quite well to the wound. Other powders, 
 like iodoform or any of its substitutes, do not stay in 
 place at all, but are washed away by the watery secretion 
 of the wound. With open treatment surgical wounds of 
 the septum do not usually suppurate, and practically 
 never ulcerate. The healing, especially if the wound is 
 not even, is apt to be delayed, however, by the formation 
 of crusts. As long as no infection has occurred these 
 wounds are painless. When they become inflamed, dull 
 pain is sometimes referred to the teeth, or described as a 
 diffuse headache. Slight fever may be observed in such 
 instances for a few days, but the wound, as a rule, does 
 not show the infection by any altered appearance except 
 slight swelling of its edges. Occasionally infection leads 
 to tonsillitis on the same side, which may later on pass 
 to the other tonsil. 
 
 124. As a substitute for bloody operations electrolysis 
 of cartilaginous ledges has been recommended by vari- 
 ous writers. Two needles connected with insulated 
 conducting cords are inserted into the septum promi- 
 nence, and an electric current up to the strength of about 
 25 milliamperes is gradually turned on. This current, 
 requiring a battery of 20 to 30 cells, is continued for five 
 to ten minutes, and then is again gradually turned off. 
 Any sudden increase or diminution in the strength of the 
 current causes a very painful shock. As the negative 
 pole is the active one, the positive pole may be used in 
 the form of a large external sponge instead of a needle in 
 the septum. This procedure has no influence upon bony 
 crests, but it does caiise a gradual shrinkage of cartil- 
 aginous prominences. If the effect is insufficient, it may 
 be used repeatedly at intervals of about two weeks. It 
 is, however, painful, and the inflammatory reaction fol-
 
 OPERATIONS UPON THE SEPTUM. 219 
 
 lowing it always lasts several weeks, and sometimes leads 
 to localized necrosis of the cartilage with perforation. 
 Moreover, it is not always efficient. Its indication is 
 hence to be restricted to the case of flat, diffuse tumefac- 
 tions in very narrow noses in which surgical instruments 
 cannot be used satisfactorily. It is certainly not a desirable 
 substitute for any other feasible operation. 
 
 The galvanocaustic burner can be recommended as a 
 more satisfactory measure for the reduction of smaller 
 prominences -on the cartilaginous septum. It is not a 
 substitute for a clean cutting operation when the latter is 
 mechanically feasible. But narrow crests which encroach 
 sensibly upon the caliber because they happen to be 
 situated on the convex side of a moderately bent septum 
 can be completely removed by a number of multiple 
 punctures or a few linear incisions with a knife-shaped 
 white-hot burner. The wounds heal in two to three 
 weeks without unpleasant reaction, and the cicatrization 
 causes enough shrinkage to clear the passage.
 
 CHAPTER XVII. 
 EPISTAXIS HYDRORRHOEA NASALIS. 
 
 EPISTAXIS NOSEBLEED. 
 
 Bleeding from the nose may depend on various 
 intranasal lesions or different systemic disturbances. As 
 a matter of convenient reference it is well to summarize 
 these different conditions under one head. The loss of 
 blood from the nose may vary from a mere trifle to a 
 flow alarming by its persistence. Yet there are probably 
 no immediate fatal results on record, as the hemorrhage 
 usually stops in the end by reason of fainting. The 
 frequent recurrence of bleeding may, however, cause 
 serious anemia and lessen the resisting power to other 
 diseases. 
 
 The most common lesion causing nosebleed is ulcera- 
 tioh of the septum in the anterior inferior region imme- 
 diately behind the pyriform aperture, the ulceration 
 being the intermediate stage between anterior dry rhini- 
 tis and perforating ulcer (1 75). If the health is other- 
 wise good, the bleeding from this lesion is generally not 
 copious. When the bleeding spot can be seen, the hem- 
 orrhage can be checked by cauterization with a bead of 
 nitrate of silver or a cotton pledget containing (melted) 
 trichloracetic acid. The galvanocautery presents no ad- 
 vantage over chemical cauterization. Either measure may 
 fail for the time being and packing may prove necessary. 
 
 A comparatively rare lesion, but one which bleeds 
 freely, is the "bleeding polypus of the septum " (1 237). 
 Its site is above the usual location of the septum ulcer. 
 It appears as a small, red polypoid tumor, bleeding freely 
 on touch. If well accessible, it should be snared radi- 
 cally, otherwise its base should be completely cut through 
 with the galvanocaustic burner. 
 220
 
 EPISTAXIS NOSEBLEED. 221 
 
 Very copious bleeding can be caused by intranasal 
 tumors which are partly made up of cavernous tissue. 
 This applies to benign polypi, suspicious adenomatous 
 tumors, as well as to malignant cancers. Excessive hem- 
 orrhage may also be due to an unmixed angiomatous 
 growth. Postnasal fibromata are likewise very prone to 
 bleed freely, more, however, into the pharynx than 
 through the nose. Slight nosebleed occurs to some 
 extent in children with enlarged pharyngeal tonsil. 
 
 Transient bleeding may be caused by a blow, usually 
 without lasting lesion. Any nasal operation may be 
 followed by secondary bleeding within the first few 
 days. Sudden diminution of air pressure in ascending 
 high mountains starts bleeding from the nose in many 
 persons. 
 
 Nosebleed with or without visible septal lesion may 
 depend on various systemic conditions. After typhoid 
 fever, in the course of grave anemia, but especially in 
 any form of pernicious anemia, as well as in leukocythe- 
 mia, it may prove difficult to manage. In scurvy and 
 hemophilia it is more li'kely trivial if spontaneous, but 
 if traumatic in a bleeder, it gives cause for anxiety. 
 Nosebleed is an early symptom in typhoid fever, less so 
 in measles and scarlatina, in which latter case it is said 
 to be indicative of severe infection. 
 
 In middle or advanced life epistaxis may indicate 
 arteriosclerosis and thus prove a forerunner of cerebral 
 softening. The nosebleed referable to the climacteric 
 period in women is probably also dependent on some 
 change in the blood-vessels. Hemorrhage from the nose, 
 vicarious for suppressed menstruation, is occasionally 
 observed, but its frequency has been exaggerated. 
 
 If epistaxis occurs with symptoms of nasal inflamma- 
 tion, fibrinous rhinitis or nasal diphtheria should be 
 thought of. 
 
 136. In any ordinary case of nosebleed the patient 
 should be instructed to sit up, or, better still, stand up, in 
 order to lower the blood pressure and to plug the nostrils
 
 222 EPISTAXIS HYDRORRHCEA NASAL1S. 
 
 with cotton. Wiping and other useless meddling merely 
 protracts the bleeding. The popular practice of placing 
 anything cold (for instance, a key) on the nape of the neck 
 probably causes reflex action of the vasomotor nerves and 
 is not without some utility. Severe bleeding requires 
 surgical plugging with gauze (or cotton in case of emer- 
 gency). Slight bleeding is easily controlled by the use 
 of suprarenal solution on cotton. But there has not been 
 enough experience with this agent to state definitely 
 whether it can be relied upon in grave cases and whether 
 it checks hemorrhage permanently. Pledgets wet with 
 antipyrin solution (10 per cent.) often act quicker than 
 mere mechanical plugging, especially if the pledgets are 
 dusted with tannin powder. The latter alone, however, 
 is not of much use. In dangerous cases Monsell's solu- 
 tion of iron is certain in its action, but very disagreeable 
 by reason of the firm clot which it produces. Whenever 
 the blood flows into the pharynx in spite of nasal plug- 
 ging, a tampon must be placed in the nasopharynx by 
 means of Belloc's sound (or by aid of a rubber drainage- 
 tube pushed through the nose) (1 29). In all instances 
 the lesion causing the bleeding should be looked for as 
 soon as practicable and treated. 
 
 137. Nasal hydrorrhea (or rhinorrhea). a discharge 
 of a clear watery fluid from the nose, is a symptom of 
 variable significance. It is most frequently seen in con- 
 nection with sneezing fits in nasal irritability. This may 
 depend in some instances on abnormal turgescence of 
 cavernous tissue in neurotic subjects (vasomotor coryza), 
 while in others it is due to the presence of polypi. In 
 cases of this nature the hydrorrhea occurs as a spell 
 of short duration. In less common instances the watery 
 discharge lasts longer and is very profuse. Within 
 less than an hour many handkerchiefs may be satu- 
 rated. Much less common is a continuous discharge 
 lasting day and night. Its cause can usually not be 
 determined. A few times it has been seen in connection 
 with disease of the fifth nerve, either neuralgia or paraly-
 
 HYDRORRHCEA NASALIS. 223 
 
 sis. In some instances the internal use of atropin has 
 proved of service. In other instances the fluid dropping 
 from the nose is cerebrospinal fluid. This diagnosis is 
 favored by finding in it chemically a substance reducing 
 Fehling's (copper sulphate) solution like sugar. An 
 escape of cerebrospinal fluid may occur as the result of 
 a fracture of the base of the skull. A few fatal cases 
 have been .reported in which a continuous flow of clear 
 fluid from the nose accompanied atrophy of the optic 
 nerves with pronounced contraction of the visual fields 
 and with the presence of other cerebral symptoms (head- 
 ache and vertigo). The autopsies showed a perforation 
 of the roof of the sphenoid sinus due to tumors of the 
 hypophysis cerebri or other basal tumors or hydro- 
 cephalus.
 
 CHAPTER XVIII. 
 
 ANATOMY OF THE TONSILS. ACUTE INFLAMMA- 
 TION OF THE PHARYNX AND OF THE TONSILS 
 
 (ANGINA). 
 
 128. Anatomy of the Adenoid Tissue and Tonsils. 
 
 The shape and topographic anatomy of the pharynx 
 have been described in Chap. I., 1 6, and Chap. III., 
 1 24, the structure of its lining membrane in Chap. I., 
 Tf 7. For a study of the diseases of this region some 
 further details concerning the adenoid tissue are neces- 
 sary. The entire mucous membrane of the pharynx is 
 normally infiltrated with lymphoid cells, but a special 
 localized development of lymphoid tissue surrounds the 
 anterior entrances into the pharynx in the form of a 
 u lymphatic ring," as termed by Waldeyer. This is 
 constituted by the two faucial tonsils, the bridge of ade- 
 noid tissue stretched across the base of the tongue (the 
 lingual tonsil), and the pharyngeal tonsil at the roof of 
 the pharynx. Under morbid circumstances lymphatic 
 tissue may also develop in visible masses in the form of 
 follicles on the posterior wall of the pharynx, and espe- 
 cially in the form of the (hypertrophied) lateral cords of 
 the pharynx. 
 
 The faucial tonsils form a slightly prominent cushion 
 in the space bounded by the anterior and posterior pillars. 
 The pillars themselves are projecting folds of mucous 
 membrane, practically the downward prolongation of the 
 free border of the soft palate extending down to the 
 tongue. Above each tonsil and underneath the superior 
 junction of the two pillars is a recess, sometimes a deep 
 pocket the supratonsillar sinus. The tonsil itself is a 
 thickening of the mucous membrane due to the develop- 
 
 224
 
 ANATOMY OF THE TONSILS. 
 
 225 
 
 ment of lymph-follicles within a delicate capsule (Fig. 
 72). The tonsil is marked by about one dozen pits lined 
 by mucous membrane (and pavement epithelium) the 
 lacunae or crypts. Any distinct prominence of the ton- 
 sillar tissue must be considered a morbid enlargement. 
 
 Across the base of the tongue there extends a bridge of 
 lymphoid tissue the lingual tonsil. Besides the diffuse 
 development of lymph-follicles, this area presents a trans- 
 
 FIG. 72. Histologic structure of the hypertrophied faucial tonsil. Soft 
 (cellular) form of childhood. The normal pavement epithelium is penetrated 
 by leukocytes to such an extent normally that the appearance of stratification is 
 partly effaced. The epithelium sends offshoots into the underlying adenoid 
 tissue. The lymphatic structure does not differ essentially from a normal speci- 
 men. The blood-vessels are larger and more numerous than in the normal 
 tonsil. 
 
 verse row of larger lymphatic nodules, each from i to 4 
 mm. wide, containing a central crypt. 
 
 The pharyngeal tonsil consists of a cushion of mucous 
 membrane thickened by the development of follicles so as 
 to project in the form of shallow sagittal ridges, six or 
 seven in number, which coalesce in front and behind. 
 It begins at the roof of the pharynx, about 5 mm. be- 
 hind the upper rim of the choanae, and has a length of 
 about 2 cm. Transversely it does not extend into the 
 fossae of Rosenmiiller. The recess between the central 
 ridges is sometimes developed into a deeper pit, the 
 pharyngeal bursa. This is not always present. Like in 
 
 15
 
 226 ANATOMY OF THE TONSILS. 
 
 the faucial tonsil, the mucous membrane dips into shal- 
 low pockets termed crypts. The epithelium covering the 
 pharyngeal tonsil is ciliated cylindric, while that over 
 the faucial and lingual tonsils is stratified pavement, the 
 same as throughout the lower pharynx. 
 
 The adenoid tissue of all the tonsils consists of minute 
 lymph-nodules surrounded by a fibrillar stroma and filled 
 with lymph-cells. 
 
 From all the tonsillar structures there occurs normally 
 an outpour of leukocytes, which can be seen in microscopic 
 sections between the cells and on the surface of the epi- 
 thelium, making it, indeed, difficult to define the outline 
 of the epithelial layer. The object of this egress of 
 wandering corpuscles is not known. In fact, it cannot 
 be said that we know anything definite about the physi- 
 ology of the tonsils. They are capable of very active 
 absorption of minute solid particles, like pigment gran- 
 ules. 
 
 ACUTE TONSILLITIS. 1 
 
 129. Diffuse or Catarrhal Tonsillitis Follicular 
 or J^acunar Tonsillitis. Acute tonsillitis is a com- 
 mon, typical infectious disease of self-limited duration. 
 Two varieties are described viz., the diffuse catarrhal 
 or erythematous tonsillitis, in which the tonsil appears 
 diffusely reddened, and the follicular or lacunar form, in 
 which small white exudates protrude from the orifices of 
 the crypts. There seems to be no essential difference 
 between these two varieties, excepting the more active 
 participation of the lining of the crypts in the follicular 
 form. Diffuse tonsillitis without lacunar involvement 
 is much less common than the other variety. Tonsillitis 
 begins with chilliness, fever, headache, and diffuse pains 
 through the muscles and general malaise and lassitude. 
 The temperature may reach 104 F. in children, 102 to 
 103 in adults. The systemic disturbances cease promptly 
 within two to three days in most instances. They are pro- 
 
 1 Tonsillitis and all forms of pharyngeal inflammation are often termed 
 angina by continental authors.
 
 ACUTE TONSILLITIS. 22/ 
 
 longed if the disease begins in one tonsil and then spreads 
 to the other, while more commonly both tonsils suffer 
 alike from the start. There are some forms of tonsillitis 
 in which the systemic disturbance may last four or five 
 days, on account of a bacterial infection different from 
 that of the ordinary form of the disease. The lymph- 
 glands of the neck are usually enlarged, sometimes tender. 
 Occasionally splenic tumefaction is demonstrable. From 
 the start the throat is sore, especially on swallowing, but 
 the pain is only moderate. On inspection the tonsils are 
 found enlarged and red. The degree of enlargement de- 
 pends somewhat on the previous size of the tonsil, but even 
 tonsils of normal size may swell enormously and some- 
 times recede again perfectly on recovery. In the so-called 
 diffuse form there is uniform redness of the surface. The 
 redness extends always beyond the pillars, in the form of 
 collateral hyperemia. In the follicular variety the white 
 spots protruding from the crypts give a characteristic 
 appearance. The surface redness is not always very pro- 
 nounced in this form. The small .white plugs consist of 
 detached epithelium interspersed with bacteria, especially 
 cocci. Sometimes the follicular exudate extends in the 
 form of separate bits of false membrane suggesting the 
 possibility of diphtheria.. There are even instances where 
 the entire tonsil is covered by a distinct coherent mem- 
 brane, in which the diagnosis of diphtheria can be ex- 
 cluded only by the absence of the diphtheria bacillus. 
 The clinical course of these (less common) forms of mem- 
 branous tonsillitis, although a little more severe than that 
 of the ordinary variety, is still that of a tonsillitis, and 
 not that of true diphtheria. The final criterion is the 
 absence of postdiphtheritic sequels and the inability to 
 transmit diphtheria to others. 
 
 The local appearances in tonsillitis persist a few days 
 after the systemic disturbances are over. When the upper 
 respiratory passages had previously been healthy, com- 
 plete recovery takes place inside of a week from the 
 beginning. In the case of a previously diseased nose or
 
 228 ACUTE TONSILLITIS. 
 
 throat the local recovery is somewhat delayed, or tonsil- 
 litis may even persist for a time in a subacute form. The 
 membranous variety lasts a few days longer than the 
 simple form. 
 
 130. In rare instances follicular tonsillitis is limited to 
 a small part of one or both tonsils. In such cases the 
 systemic disturbance is nearly as pronounced as in the 
 ordinary form, but the local lesion may scarcely be felt 
 by the patient and can easily be overlooked. 
 
 131. Complications. While tonsillitis follows usually an 
 uncomplicated course, complications and sequels are not 
 rare. The most frequent danger is to the ear, in the form 
 of acute suppurative otitis. In a certain proportion of 
 cases not fully estimated numerically tonsillitis is fol- 
 lowed by acute articular rheumatism, especially in adults. 
 It seems as if the cause of rheumatism, not yet identified, 
 entered through the tonsils in such instances. Much less 
 frequently there are observed apparently pyemic acci- 
 dents, metastatic phlegmons, localized inflammations, 
 and even endocarditis. The swollen cervical glands 
 occasionally, but rarely, suppurate. 
 
 132. Etiology. Tonsillitis is most common in child- 
 hood, not rare in middle life, but not often seen after this 
 period. In some subjects it is frequently recurrent, some- 
 times repeatedly in one season. These recurrences dimin- 
 ish after the growth of the body is completed. Chronic 
 inflammation of the tonsils, especially when in connec- 
 tion with nasal suppuration, predisposes to acute attacks 
 of tonsillitis. Occasionally the disease attacks appar- 
 ently normal and not enlarged tonsils. Tonsillitis spreads 
 so often throughout the household that the contagious- 
 ness, of some forms at least, cannot be doubted. While 
 the disease is commonly attributed to a cold, "such an 
 etiology can be but rarely demonstrated." The influence 
 of exposure is, however, suggested by the preponder- 
 ance of tonsillitis during periods of inclement weather. 
 Typical tonsillitis is sometimes seen after nasal opera- 
 tions followed by slight local infection. Its origin from
 
 DIAGNOSIS. 229 
 
 the wound is shown by the limitation to the tonsil of 
 the corresponding side, although the second tonsil may 
 become involved subsequently. 
 
 The disease has been attributed to infection by the 
 streptococcus, which is nearly always demonstrable on 
 the surface and in the exudate. Still, as this is a fre- 
 quent inhabitant of the normal mouth, its presence on 
 the surface does not establish its role absolutely. Of 
 more importance is its demonstration in the interior of 
 (amputated) acutely inflamed tonsils (Frankel), and in 
 the fluid drawn from the interior of the tonsil (Lemoine). 
 French observers have described other forms of tonsil- 
 litis dependent upon the presence of staphylococci, 
 pneumococci, the pneumobacillus of Friedlander, and 
 the coli bacillus, but without specifying the clinical 
 peculiarities of these forms. It must be emphasized 
 that the diphtheria bacillus can give rise to a simple 
 tonsillitis in rare instances which does not differ in 
 appearance from the non-diphtheritic form. 
 
 133. While inspection establishes at once the patho- 
 logic diagnosis of tonsillitis, the etiologic significance of 
 an inflamed tonsil may deserve serious attention for the 
 purpose of a differential diagnosis. In the first place 
 diphtheria must be thought of. A non-membranous 
 tonsillitis is rarely of diphtheritic origin, but still such a 
 suspicion is justified especially when exposure to diph- 
 theria has occurred. The systemic disturbances of 
 diphtheritic tonsillitis without membrane-formation are 
 usually not so pronounced as in the ordinary non-diph- 
 theritic form. But a positive diagnosis can be made only 
 by finding the diphtheria bacillus microscopically or in 
 culture. A membranous tonsillitis, on the other hand, 
 may or may not be of diphtheritic origin. The more 
 acute the onset, the less likely is the diphtheritic nature, 
 but here, too, the decision is given only by the presence 
 of the specific bacillus. Scarlet fever may begin as a 
 typical tonsillitis before the rash comes out, or may con- 
 tinue as such even without rash. It should be suspected
 
 23O ACUTE TONSILLITIS. 
 
 when there is a diffuse deep redness of the soft palate and 
 uvula, and when vomiting occurs. Syphilis, too, pro- 
 duces occasionally a typical picture of follicular tonsilli- 
 tis, but the clinical course is different in this case. The 
 disease is not of sudden onset, does not produce the 
 intense systemic involvement, and lasts many days un- 
 changed, but accompanied by a low fever. 
 
 134. Under the head of treatment text-books present 
 a formidable and suspiciously long array of drugs for 
 both internal and local use in acute tonsillitis, and each 
 author lauds his own method. An unbiased discoverer 
 can draw one inference only from the comparison of 
 different text-books. We possess at present no method 
 of treatment which can shorten the typical course of any 
 infectious disease, except the so-called specific medication 
 viz., the artificial employment in an intensified form of 
 those means by which the organism rids itself of the 
 disease during natural recovery. Such, for instance, is 
 the treatment of diphtheria by antitoxic serum. There 
 is neither any logical reason nor any definite experience 
 to warrant the belief that we can abort an attack of 
 tonsillitis. All claims to this effect are based either on 
 the want of recognition of the self-limitation of the 
 disease, or on the confusion of acute tonsillitis with sub- 
 acute aggravations of chronic pharyngeal trouble. We 
 can minister only to the comfort of the patient, and by 
 combating the liability to complications, obtain the 
 shortest possible course of tonsillitis. The febrile dis- 
 comfort may be lessened by the use of alcoholic drinks. 
 Headache and bone-ache can be allayed by antipyrin. 
 Sleep may be enforced by chloral or even morphin if the 
 patient's condition demands it. Any gargle which tends 
 to check secondary decomposition in the mouth is agree- 
 able and apparently useful, even though it does not reach 
 the tonsillar surface to any extent. The writer has been 
 pleased with the clinical effects of a combination which 
 certainly lessens the odor of the breath and adds to the 
 patient's local comfort. It is :
 
 ACUTE INFLAMMATION OF THE LINGUAL TONSIL. 23 1 
 
 Thymol I 
 
 Ol. gaultherise 0.5 
 
 Ol. cassise 0.5 
 
 Chloroform 5 
 
 Alcohol 25 
 
 To be mixed with one quart of water (or two teaspoons to the glass of water) 
 for gargling. 
 
 It must be used at very short intervals in order to obtain 
 any lasting effect. Chlorate of potassium in saturated 
 solution has enjoyed much popularity as a gargle, but on 
 doubtful grounds. The dangerously poisonous nature of 
 the drug, which has caused many deaths, should curtail 
 its use, especially in children. There is not much more 
 to be gained by using any so-called antiseptic sprays. 
 The liability to persistence of tonsillitis in a subacute 
 form after the acute symptoms have subsided can be 
 effectually checked by various topical applications, such 
 as nitrate of silver (10 to 15 per cent.) or tincture of iron. 
 The writer has seen the best effects, however, from the 
 use of Loffler's solution (compare 1 25). 
 
 Much can be done to guard against the habitual re- 
 currence of tonsillitis. Our action must depend upon 
 the previous history of the patient. Enlarged tonsils 
 liable to become inflamed should be abscised. Smaller, 
 irregularly shaped, but chronically inflamed tonsils which 
 cannot be removed satisfactorily may be rendered harm- 
 less by cauterization with the galvanic burner. A pointed 
 burner bent like a hook should be introduced into every 
 visible crypt, whereby the crypts become obliterated 
 (compare ^ 151). 
 
 135. Acute inflammation of the lingual tonsil is a 
 rare occurrence which manifests itself by the same sys- 
 temic disturbance as ordinary tonsillitis. The pain is 
 rather more acute, especially during swallowing, and is 
 referred to the base of the tongue. On searching with 
 the mirror the lingual tonsil is found swollen, red, and 
 often marked with specks of lacunar exudation. What- 
 ever has been said of the course of treatment of faucial 
 tonsillitis applies equally to the present form of disease.
 
 232 ACUTE TONSILLITIS AND PHARYNGITIS. 
 
 136. Acute inflammation of the pharyngeal tonsil 
 
 is a subject scarcely mentioned in literature until recently, 
 though it forms part of most cases of severe coryza. 
 The only additional symptoms to which it gives rise, 
 besides those directly due to the nasal inflammation, are 
 purulent discharge in the throat and very slight soreness 
 on swallowing. Collateral hyperemia may extend down 
 into the oral part of the pharynx. Postrhinoscopic in- 
 spection shows acute inflammation at the roof of the 
 pharynx. 
 
 Acute tonsillitis of the pharyngeal tonsil may also 
 occur in rare instances as an independent affection. The 
 writer has seen about half a dozen instances, mostly in 
 children. It begins like tonsillitis, but lasts usually 
 somewhat longer, up to six or nine days. In all instances 
 there had previously been unimpeded nasal permeability 
 until within some hours after the fever began. The nose 
 was more or less blocked, especially during sleep, and 
 the voice acquired the nasal twang characteristic of en- 
 largement of the pharyngeal tonsil. There was, how- 
 ever, no coryza with, it, but moderate mucopurulent 
 secretion in the throat. Pain was not mentioned. The 
 mirror inspection, often unsatisfactory in children, showed 
 redness in the upper part of the pharynx, while the 
 finger could detect a swelling and some tenderness of the 
 pharyngeal tonsil. In all instances the pharyngeal ton- 
 sil regained its normal size, and, after recovery, perfect 
 nasal respiration became reestablished. In some of the 
 later instances the writer made applications of Loffler's 
 solution during the latter part of the disease, apparently 
 with beneficial results. The intense irritation due to 
 LofHer's solution did not last long. No complications 
 were observed. 
 
 ACUTE PHARYNGITIS. 
 
 137. Acute diffuse inflammation of the entire pharyn- 
 geal lining is not so common a disease as tonsillitis. It 
 occurs mostly in children. It begins like tonsillitis and
 
 ACUTE PHARYNGITIS. 233 
 
 has about the same duration, sometimes lasting a few 
 days longer. There is rather more pain on swallowing 
 than in tonsillitis. There is, besides, some mucopuru- 
 lent secretion coming from the roof of the pharynx. The 
 entire pharyngeal lining appears diffusely red. Occa- 
 sionally a few white lacunar specks are seen in the center 
 of follicles on the posterior wall. Such follicles, how- 
 ever, had existed before the disease. In many instances 
 pharyngitis is combined with tonsillitis. Pure pharyn- 
 gitis has not the liability to recurrence characteristic of 
 inflammation of the tonsil. Its course, causes, complica- 
 tions, and treatment are the same as in tonsillitis. 
 
 138. A rare occurrence which the patient is apt to 
 consider as an acute inflammation in the throat is edema 
 of the uvula. It begins suddenly, with some soreness, 
 usually without recognizable cause, and gives rise to a 
 feeling of foreign body, which the patient is tempted 
 to swallow. The discomfort may increase to intense 
 anguish. On inspection the uvula is seen to be swol- 
 len, sometimes enormously, but pale and evidently 
 edematous. In the course of hours the edema subsides. 
 Scarification is recommended. The writer has been able 
 to relieve the few instances seen by him by long-continued 
 massage of the sides of the neck. Suprarenal solution 
 might deserve a trial.
 
 CHAPTER XIX. 
 
 PERITONSILLAR ABSCESS OR QUINSY. RETRO- 
 PHARYNGEAL ABSCESS. 
 
 139. Peritonsillar abscess, also known as quinsy, or 
 deep or phlegmonous tonsillitis, begins like ordinary 
 acute tonsillitis, with or without lacunar exudation. On 
 the first day no distinction can be made between it and 
 acute tonsillitis in many cases. In some, however, the 
 systemic disturbances begin with less abruptness than in 
 simple tonsillitis. The fever may decline within a day 
 or two, but does not disappear until the abscess opens. 
 The local discomfort increases steadily. After one or 
 two days the patient has a constant feeling of fulness in 
 the throat, with a sense of oppression, embarrassing the 
 breathing subjectively. This distress interferes with 
 sleep. There may or may not be visible dyspnea. The 
 moderate pain becomes intense upon swallowing and pre- 
 vents eating. Characteristic is an enormous secretion of 
 clear mucus in the pharynx. The voice is peculiarly 
 " thick" and somewhat nasal, but not so "dead" as in 
 blockage of the nasopharynx. The tonsillar swelling 
 shows on the outside of the neck. The cervical glands 
 are usually palpable. 
 
 Quinsy is more often one-sided than bilateral. On in- 
 spection the reddened and enlarged tonsil is seen pro- 
 jecting toward the middle line or even beyond. There is 
 distinct swelling in front of the anterior pillar and in the 
 soft palate above the tonsil. After the lapse of five to nine 
 days a spontaneous perforation occurs, usually through 
 the soft palate, about i cm. above and inward from the 
 tonsil. The symptoms now subside, and within half to 
 one day complete relief is obtained. About three days 
 later the disease is ended. 
 
 234
 
 PERITONSILLAR ABSCESS OR QUINSY. 235 
 
 Quinsy, much less common than tonsillitis, may occur 
 at any age, but least often in childhood. It is clearly a 
 pyogenic infection, evidently entering through the tonsil. 
 It is doubtful whether it ever occurs except in subjects 
 with some tonsillar hypertrophy. Its determining con- 
 ditions are unknown. Recurrences in subsequent years 
 are not uncommon. The exact seat of the abscess has 
 not been determined by autopsies. It is not within the 
 tissue of the tonsil, but external to it. 
 
 Notwithstanding the severity of its symptoms quinsy is 
 scarcely ever followed by complications, even on the part 
 of the ear. In enfeebled, decrepit subjects the abscess may 
 extend and perforate into the external meatus of the ear. 
 Under such circumstances death may occur from pyemia 
 or septicemia, especially on extension into the mediasti- 
 ual space. 
 
 The rational treatment is the evacuation of the pus. 
 No other measures give any relief, but until distinct 
 pointing of the abscess is visible the surgeon can never 
 be sure of striking the pus. Yet the attempt must be 
 made even with the chances against its success. The 
 surface can be anesthetized by the prolonged application 
 of a pledget wet with cocain solution (20 per cent). 
 Sometimes a blunt probe thrust into the supratonsillar 
 fossa will reach the abscess. If this fails, a knife may 
 be thrust into the most prominent part of the soft palate, 
 directed outward and backward. The anatomy of the 
 large vessels must be remembered, but they would only 
 be endangered by carelessness or unnecessarily deep in- 
 cisions. Incisions through the tonsils generally fail to 
 reach the pus. If the operator does not succeed, he may 
 try again daily until the pus can escape. No further 
 treatment is required. After recovery a painstaking ab- 
 scission of the tonsil should be made, to guard against 
 future recurrences of peritonsillitis. 
 
 140. Phlegmonous inflammation underneath the 
 lingual tonsil has been reported by several observers, 
 evidently a rare occurrence. In connection with the
 
 236 RETROPHARYNGEAL ABSCESS. 
 
 systemic effects of pyogenic infection a painful swelling 
 develops in the region of the lingual tonsil, with intense 
 distress. The choking feeling is so intense that trache- 
 otomy has been found necessary in rare instances. Re- 
 lief is at once obtained upon spontaneous escape of the 
 pus or incision. 
 
 141. Retropharyngeal Abscess. Purulent exuda- 
 tion or infiltration into the loose areolar tissue behind 
 the pharynx is a disease moderately common in infancy 
 and early childhood, but quite infrequent in later life. 
 There are two forms, different in significance and in 
 treatment. The acute abscess is a pyogenic infection of 
 self-limited duration, and serious only by its possible 
 sequels, while the chronic or cold abscess is the conse- 
 quence of and indicates tuberculosis of the cervical 
 vertebrae. 
 
 The acute abscess, it is claimed, starts from infection 
 of the retropharyngeal lymph-glands situated between 
 the pharynx and the spinal column. Some suppurative 
 process in the nose or upper pharynx, idiopathic or part 
 of an eruptive fever, furnishes the virus. The retro- 
 pharyngeal inflammation begins sometimes suddenly 
 with acute fever ; more often it is of gradual onset. 
 When the abscess is situated above the level of the 
 palate, it interferes with nasal respiration in the same 
 manner as swelling of the pharyngeal tonsil. When 
 located lower, it may not block nasal breathing, but it 
 produces dyspnea, especially intense if low enough to 
 press against the larynx. The lower the swelling, the 
 greater is the obstacle to swallowing and the pain pro- 
 duced thereby. Stiffness of the neck is common and 
 due to muscular rigidity. After the lapse of four to 
 eight days spontaneous perforation occurs, which usually 
 results in recovery. In debilitated infants the infection 
 may spread into the posterior mediastinal space and 
 cause fatal septicemia. Pneumonia, perhaps due to 
 aspiration of escaping pus, has also been observed. 
 
 The abscess can be seen as a more or less circumscribed
 
 TREATMENT. 237 
 
 swelling on the posterior wall of the pharynx, usually 
 one-sided, and hence asymmetric. Only in exceptional 
 instances does the diagnosis require palpation of the 
 space above the palate by the ringer. 
 
 The treatment consists in an incision. In most in- 
 stances this can be done satisfactorily by cutting into the 
 swelling on the posterior pharyngeal wall with a knife 
 with a short blade. Surgeons of a former generation 
 used the finger-nail. Too small an opening may have to 
 be reopened. In extensive retropharyngeal phlegmons 
 some surgeons practise an opening from the outside 
 behind the sternomastoid muscle, of course, under general 
 anesthesia. 
 
 142. The tubercular retropharyngeal abscess is of slow 
 development and indefinite duration. It is not certain 
 whether it is ever due to tuberculosis of the retropharyn- 
 geal lymph-glands without disease of the vertebrae. In 
 its symptoms it resembles the acute abscess, but lacks the 
 acuity of the latter. A large exudate may ultimately 
 break spontaneously, sometimes with recovery, more 
 often, however, ending in secondary infection. The 
 ultimate prognosis depends on the course of the verte- 
 bral disease. The most .successful treatment is aspiration 
 through a thick needle and injection of iodoform glycerin 
 emulsion. This should be repeated as soon as the abscess 
 refills.
 
 CHAPTER XX. 
 
 CHRONIC PHARYNGITIS. CHRONIC TONSILLITIS 
 (PHARYNGOMYCOSIS) (SUPPURATIVE PHARYNGITIS). 
 
 143. The description of chronic pharyngitis is beset 
 with difficulties on account of the variety of clinical 
 pictures which this disease may present in different sub- 
 jects. There is much confusion both in the nomencla- 
 ture and classification given by text-books. Some pre- 
 sent the subject under a number of subheads, giving the 
 impression of separate disease types, which in reality do 
 not conform with actual experience. Practically, chronic 
 pharyngitis must be considered as an extension of, or the 
 pharyngeal equivalent of, chronic rhinitis. As a rule, it 
 is associated with simple, hypertrophic, or purulent nasal 
 inflammation. Occasionally it is observed without co- 
 existing nasal disease, because the latter has ended in 
 recovery. In such instances the lesions are limited to 
 the faucial or lingual tonsil. As in hypertrophic rhini- 
 tis, we must distinguish between the inflammation of the 
 lining membrane and its hypertrophy. Either lesion 
 may exist alone, especially in the case of the tonsils, but, 
 as a rule, both are combined. Morbid appearances may 
 be limited to the tonsillar surface or other small areas, or 
 may be diffuse, extending throughout the entire pharynx. 
 The intensity of the visible inflammation also varies con- 
 siderably in different instances. 
 
 144. Chronic tonsillitis shows itself by a redness of 
 the tonsillar surface extending always over the anterior 
 pillars. The amount of tonsillar swelling is very varia- 
 ble. The tonsils may be nearly of normal size or enor- 
 mously hypertrophied. Mere hypertrophy, however, 
 although the sequel of inflammation, is not active in- 
 flammation, and an enlarged tonsil may be perfectly pale 
 
 238
 
 CHRONIC PHARYNGITIS. CHRONIC TONSILLITIS. 239 
 
 and present no evidence of irritation. Tonsils in a state 
 of chronic inflammation often present a very ragged 
 appearance. 
 
 Inflamed tonsils frequently show characteristic whitish- 
 yellow specks or plugs retained in the crypts. Some- 
 times these specks are visible on inspection ; in other 
 instances they must be sought with the probe. After 
 attaining a certain size (3 to 5 mm.) they usually pop out 
 spontaneously. They are of very offensive odor, of 
 which the patient sometimes complains, and their pres- 
 ence may taint the breath. They consist of masses of 
 bacilli, apparently a pure culture of an unidentified 
 species. Small hard concretions of phosphate of lime 
 are found in the tonsil in rare instances. Not so uncom- 
 mon are yellowish submucous spots, minute abscesses in 
 tonsillar follicles, without any tendency to extension. 
 
 145. The lingual tonsil is often the seat of persistent 
 inflammation, but only after the period of adolescence. It 
 appears reddened and swollen, and the individual nodules 
 are sometimes much enlarged, resembling a cauliflower 
 growth. There may be a continuous bridge of hyper- 
 trophied adenoid tissue from one tonsil to the other 
 across the base of the tongue. 
 
 146. In chronic pharyngitis enlarged follicles of lym- 
 phatic tissue are often seen on the posterior wall in the 
 form of red prominences of the size of a pea. This ap- 
 pearance has been termed granular pharyngitis, but all 
 forms of transition occur between this and other varieties. 
 
 147. A very striking and usually very annoying form 
 of hypertrophied adenoid tissue may occur in the form 
 of folds of mucous membrane on the lateral wall of the 
 pharynx back of the posterior pillars. In extreme cases 
 they appear as vertical reddish, wing-shaped ledges, pro- 
 jecting from the sides of the pharynx and receding 
 toward the roof. 
 
 148. Chronic inflammation of the pharyngeal mucous 
 membrane is not always accompanied by much redness. 
 The surface may appear of normal color, but when the
 
 24O CHRONIC PHARYNGITIS. CHRONIC TONSILLITIS. 
 
 membrane is thrown into folds during the act of gagging, 
 its thickening is apparent. Intense vascularity of the 
 posterior wall associated with great irritability is some- 
 times seen in patients with nasal stenosis or nasal sup- 
 puration. The most pronounced instances are found 
 only in habitual smokers and drinkers, scarcely ever in 
 women. In this, as well as in other forms of chronic 
 pharyngitis, dilated veins may be observed. Varicose 
 veins, too, are sometimes seen on the tongue, in the 
 region of the lingual tonsil. Even circumscribed varices 
 of the size of a pin-head may be found. These are at 
 times the source of bleeding, which may raise a wrong 
 suspicion of pulmonary disease. In chronic pharyngitis 
 the uvula is occasionally elongated. There has been too 
 much importance attached to this by various writers. It 
 has been claimed that the elongated uvula touches the 
 tongue while the mouth is closed and causes mechanical 
 irritation. This is true only in extreme instances. In 
 moderate elongation of the uvula nothing is gained by 
 its amputation. 
 
 149. The complaints in chronic pharyngitis are as 
 variable as the clinical appearances. They depend some- 
 what on the individual, as well as on the character of 
 the lesions. Often there are no subjective annoyances. 
 Many patients, especially men, are annoyed most by the 
 viscid mucous secretion dropping into the throat. This 
 is due to the coexisting retronasal catarrh which usually 
 complicates the different manifestations of pharyngitis. 
 It is, hence, really a concomitant symptom of nasal 
 origin. Viscid mucous secretion is also produced in the 
 region of the pharyngeal tonsil, but neither on the sur- 
 face of the lower part of the pharynx nor by the mucous 
 lining over the faucial tonsils. Some mucus, however, 
 may be secreted in the region of the lingual tonsil, and 
 the presence of this gives rise to hawking and clearing 
 of the throat. 
 
 The voice suffers commonly in consequence of pharyn- 
 gitis. There is, at least, quick fatigue on attempting to
 
 SYMPTOMS. 241 
 
 sing. Moreover, the larynx becomes involved so fre- 
 quently in slight chronic inflammation in consequence 
 of pharyngitis that the singing ability may be consider- 
 ably impaired. The vocal cords are very often found 
 permanently congested. Still, noticeable exceptions may 
 be observed. 
 
 Chronic pharyngitis by itself produces no pain. There 
 are, however, frequent subacute exacerbations of inflam- 
 mation lasting a few days, during which there may be 
 more or less soreness. Apart from these subacute attacks, 
 patients complain frequently of an uncomfortable tired, irri- 
 tated, "raw" feeling. Considerable tickling may be felt, 
 especially when the lingual tonsil is involved. A very 
 distressing feature in chronic pharyngitis are occasionally 
 sensations of psychic origin. There is sometimes a dis- 
 tinct pain started during a subacute exacerbation, or in 
 consequence of traumatism, for instance, on swallowing 
 a fish-bone, and this pain will apparently persist after its 
 original cause has ceased. In others the sensation is de- 
 scribed as an irritation or oppression rather than as a pain. 
 The most striking example of these sensations of psychic 
 origin is the globus hystericus a feeling of a lump rising 
 in the throat and threatening choking. The subjects of 
 these fictitious sensations are not always hysteric patients: 
 they may be persons with normal nervous system, but of 
 emotional and self-observing disposition. These fictitious 
 sensations probably always have a material origin at the 
 start, but are kept up by undue attention even after the 
 lesion producing them has long been healed. They 
 cannot be influenced by any form of treatment except 
 suggestion. Sensible people may be cured by being 
 assured of the harmlessness of these fictitious sensations. 
 Undue attention given by overanxious physicians may 
 prove a serious obstacle to their cure. 
 
 150. The various lesions of chronic pharyngitis give 
 rise at times to distressing reflexes. The most common 
 of these is cough. This may be due to a concomitant 
 bronchitis or laryngitis, or it may depend entirely on 
 
 16
 
 242 CHRONIC PHARYNGITIS. CHRONIC TONSILLITIS. 
 
 the sensitiveness of the inflamed areas in the upper 
 throat, and disappear with their successful treatment. It 
 is common in hypertrophy of the lingual tonsil. The 
 pharyngeal irritability may lead to retching or even 
 vomiting. This is particularly started from the inflamed 
 lingual tonsil or the congested posterior wall. The morn- 
 ing vomiting of drinkers depends in part upon the pharyn- 
 geal irritability. 
 
 Chronic pharyngitis has an indefinite duration. Like 
 chronic rhinitis, it is subject to fluctuations dependent 
 partly on exposure to inclement weather. Subacute ex- 
 acerbations are quite common. Under favorable hygienic 
 surroundings the disease may cease to annoy the patient, 
 but rarely disappears entirely, except upon radical change 
 of climate. 
 
 Ear complications are very common in chronic pharyn- 
 gitis, and probably depend more upon the condition of 
 the nose than upon that of the pharynx. Such, at least, 
 seems the conclusion based upon the results of treatment. 
 Extension to the larynx is also very common. 
 
 151. The treatment of chronic pharyngitis must begin 
 with a cure of the nasal' condition present, even if the 
 patient is not annoyed by his rhinitis. As long as the 
 nasal passage remains diseased, only a very imperfect 
 and transient improvement can be obtained by pharyngeal 
 treatment. The removal of a nasal stenosis or suppura- 
 tion, together with hygienic management, often suffices 
 to restore the patient's comfort. Smoking and drinking 
 must be restricted or even forbidden when the character- 
 istic congestion of the mucous membrane indicates its 
 harm fulness. The stomach, bowels, and cutaneous circu- 
 lation must receive attention (compare 1 14 to T[ 17). 
 
 Although gargling reaches the pharynx but to a very 
 limited extent, the writer cannot but admit the utility of 
 gargling with a sulphate of zinc solution (0.5 per cent), 
 as judged by its effects upon the vascularity and the irri- 
 tability of the pharyngeal membrane. The use of sprays 
 of this solution as well as of other agents has, on the whole,
 
 TREATMENT. 243 
 
 proved disappointing. When there is much vascularity, 
 considerable improvement may be obtained by brushing 
 the inflamed surfaces of the tonsillar region or the poste- 
 rior wall with Loffler's solution (T[ 25). In spite of the 
 temporary irritation produced thereby, many patients 
 recognize subjectively its beneficial influence. It may be 
 continued as a daily application for several weeks. Ni- 
 trate of silver solutions (10 per cent.), formerly much in 
 vogue, have not proven so satisfactory in the writer's 
 experience, except when applied to the lingual tonsil. 
 From the various other astringents recommended in text- 
 books the writer has seen less decided effect than from 
 the use of Loffler's solution. 
 
 When there is much hypertrophy of adenoid tissue, 
 surgical measures are necessary. Large tonsils should 
 be removed. A description of the technic will be found in 
 1 182. For the cure of the offensive concretions in the 
 tonsillar crypts slitting of these pockets has been recom- 
 mended. A blunt hook is inserted and pulled through. 
 The author' has not seen as good a result from mere slit- 
 ting as from obliteration of the crypts by means of a 
 hook-shaped galvanocaustic burner. The burning, if 
 limited to a few lacunae at a time, causes very little in- 
 flammatory reaction. In order to attain success, the bur- 
 ner must be inserted into the bottom of the pocket. 
 
 When the lingual tonsil is much hypertrophied, me- 
 dicinal applications are not equal to surgical removal, 
 even though they give transient benefit. Prominent 
 lymphatic nodules on the tongue can be snared off or de- 
 stroyed with a burner. Very large prominences may be 
 removed with a curved guillotine-shaped knife (Fig. 73). 
 
 The enlarged lymph-follicles on the posterior wall of 
 the pharynx have formerly received more attention than 
 they deserved. As a rule, their persistence does not 
 interfere with comfort after the causative nasal lesions 
 have been eliminated. When very large or persistently 
 inflamed, the follicles may be destroyed by inserting a 
 pointed burner into the central crypt. An awkward and
 
 244 CHRONIC PHARYNGITIS. CHRONIC TONSILLITIS. 
 
 rebellious lesion is the hypertrophy of the lateral strands 
 of adenoid tissue, the lateral cords of the pharynx. While 
 they do not shrink much upon the application of Loffler's 
 solution or other astringents, the irritation caused by 
 them may subside. When prominent, they are too large 
 to be influenced by superficial burning, while snaring is 
 usually impossible on account of their shape. In extreme 
 cases they may be amputated by means of cutting forceps, 
 which, however, leaves a painful, slowly healing wound. 
 Amputation of the elongated uvula is of much less ser- 
 vice than would appear from the teaching of some text- 
 books. It is useful only when the uvula exceeds a length 
 of 2^ cm. While it can be done in a simple manner 
 with scissors, the resulting wound is quite painful for a 
 number of days, as the stump heals by granulation and 
 
 FIG. 73. Myles' lingual tonsillotome. 
 
 moves with every motion of the palate. A few instances 
 of disagreeable hemorrhage have been described in con- 
 sequence of this operation. 
 
 153. Pharyngomycosis is a relatively rare disease, 
 characterized by the presence of small white spots on 
 the pharyngeal lining without surrounding inflammation. 
 The spots, from the size of a pin-head to that of a grain, 
 appear as white tufts on apparently normal mucous mem- 
 brane. They are most frequently seen in crypts of the 
 tonsils, less often on the follicles on the posterior wall or 
 in the crypts of the lingual tonsil. There may be a few 
 or many of these spots. The white projecting tufts are 
 very firm and cannot be completely removed with forceps. 
 Microscopically, they consist of interlaced, branching 
 filaments of leptotrix, a fungus normally found in the
 
 SUPPURATIVE PHARYNGITIS. 245 
 
 mouth, especially on the teeth, and usually classified, 
 although with questionable propriety, among the bacte- 
 ria. But, as Heryng has shown, the parasitic invasion 
 is really a secondary phenomenon, while the primary 
 lesion is proliferation and keratous degeneration of the 
 epithelium of the crypts from unknown causes. The 
 disease has hence also been termed hyperkeratosis lacu- 
 naris. 
 
 The disease often causes no symptoms, merely frighten- 
 ing the patient by the appearance. Sometimes moderate 
 local irritation is produced by it. As a rule, it disappears 
 spontaneously in the course of months or a few years. 
 The spots can be removed with a certainty only by deep 
 punctiform burns with the galvanocaustic burner. If no 
 symptoms are produced, there is no reason for any thera- 
 peutic interference. 
 
 SUPPURATIVE PHARYNGITIS. 
 
 153. Pathologic and therapeutic considerations de- 
 mand that suppurative pharyngitis should be considered 
 apart from the other forms of pharyngeal inflammation, 
 although it may be associated with hypertrophic lesions. 
 The only pharyngeal area from which pus is secreted is 
 the region of the pharyngeal tonsil at the roof of the 
 pharynx. Purulent secretion is not observed clinically 
 from any other part of the pharyngeal lining. The 
 presence of pus in the lower pharynx does not establish 
 the diagnosis of suppurative pharyngitis, as the secretion 
 originates much oftener from within the nose than from 
 the pharyngeal roof. The diagnosis can be made only 
 by seeing the pus at the vault of the pharynx in the mir- 
 ror. Even in the latter case the pus may come from the 
 sphenoid sinus or posterior ethmoid cells. Suppurative 
 pharyngitis is, besides, often associated with some form 
 of purulent rhinitis. 
 
 Purulent secretion may be found in connection with 
 moderate hypertrophy of the pharyngeal tonsil in children. 
 Although of a chronic nature, there may be complete
 
 246 SUPPURATIVE PHARYNGITIS. 
 
 intermissions in the course of this form of suppurative 
 pharyngitis during mild weather. When the enlarged 
 pharyngeal tonsil persists after puberty, it undergoes a 
 sclerotic change, and is then much less likely to form 
 pus. Hence in adults suppurative pharyngitis is more 
 commonly observed without enlargement of the pharyn- 
 geal tonsil. In the class of cases mentioned the secretion 
 is that of thick, yellowish green, but fluid pus. In 
 another variety of the disease the secretion is more scant 
 and dries in the form of adherent crusts dislodged with 
 some difficulty. The surface underneath is found red- 
 dened and often slightly excoriated; rarely, thickened. 
 This variety of disease, not very common in general, is 
 extremely rare in childhood. It resembles ozena in the 
 character of the secretion. The comparison is also borne 
 out by the spaciousness of the pharynx often observed. 
 The mucous membrane may even present an atrophic 
 appearance, as judged by the naked eye. But the specific 
 odor of ozena is lacking except when this form of pharyn- 
 gitis is combined with true nasal ozena. 
 
 The complaints refer, in the first place, to the secretion. 
 It is especially when dry crusts form that patients are 
 irritated by their presence and make forcible efforts to 
 dislodge them, sometimes finishing by retching. The 
 crusts seem to form only once in from one to three days. 
 Their presence may cause reflex symptoms, such as 
 coughing and headache referred to the occipital region. 
 
 154. Pharyngeal suppuration is usually due to a dif- 
 fuse inflammation of the mucous membrane in the area 
 of the pharyngeal tonsil. When the tonsil is enlarged 
 enough to be prominent, there is no method of perma- 
 nently arresting the process, except by the operative 
 removal of the adenoid tissue. But as seen in adults 
 without thickening of the pharyngeal lymphatic tissue, 
 the suppuration may be stopped by other means. Quite 
 often the persistent removal of the secretion by the post- 
 nasal douche will lead to a cure in the course of some 
 weeks. An atomizer with curved pharyngeal tip may
 
 TREATMENT. 247 
 
 prove equally efficient if properly used. When these 
 means do not suffice, the writer has succeeded at times, 
 but not invariably, by brushing the pharyngeal vault 
 with nitrate of silver solutions (20 to 30 per cent.) or 
 Loffler's solution. Due care must be used not to spread 
 these irritant fluids over the adjacent surface, for which 
 purpose the palate may be held by means of a broad re- 
 tractor. When the pharyngeal disease accompanies puru- 
 lent rhinitis or suppuration of a sinus, the nasal lesion 
 must be cured before the pharyngitis will yield to treat- 
 ment. 
 
 155. A peculiar pathologic basis has been claimed by 
 Tornwaldt for many cases of suppurative pharyngitis, 
 especially those in which crusts are observed. He at- 
 tributes the disease to an inflammation localized in the 
 pharyngeal bursa, which, he claims, is a deep persisting 
 recess of embryologic significance. Neither his anatomic 
 notions nor his clinical data have received full confirma- 
 tion by other observers. The bursa is not a constant, 
 and rarely a deep, sinus, and others who have sought for 
 this localized inflammation have not found it so typical a 
 disease as Tornwaldt asserted. It must be admitted, how- 
 ever, that the clefts, and especially the central cleft be- 
 tween the ridges of the pharyngeal tonsil, may be the seat 
 of a persistent suppuration, and that occasionally types 
 of pharyngeal disease are found which correspond to Torn- 
 waldt' s description. Tornwaldt claims to have cured his 
 patients by cauterization of the diseased recess with a 
 bead of nitrate of silver or by the insertion of tire galvano- 
 caustic burner. In those cases where pus can be seen to 
 issue from clefts in the pharyngeal tonsil, I have occa- 
 sionally found this mode of treatment successful. 
 
 156. A lesion not rarely found in the pharyngeal ton- 
 sil are cysts with' purulent contents, the result of suppu- 
 ration confined to a lymph-follicle. They may be of the 
 size of a pea or larger, and produce symptoms of pharyn- 
 geal irritation. They are removed by abscission of the 
 tonsil (1 174).
 
 248 PHARYNGITIS SICCA. 
 
 157. A form of pharyngeal disturbance formerly de- 
 scribed as "pharyngitis sicca," or " atrophic pharyngitis," 
 must be mentioned, although it is not a real pharyngitis. 
 The mucous membrane looks pale, dry, apparently 
 atrophic, and is covered with a varnish-like clear secretion 
 dried on the surface. The appearance results from puru- 
 lent rhinitis or sinuitis, and with the cure of the nasal 
 suppuration the pharyngeal lining recovers its normal 
 condition.
 
 CHAPTER XXI. 
 
 HYPERTROPHY OF THE PHARYNGEAL TONSIL OR 
 ADENOID VEGETATIONS. 
 
 158. The frequent occurrence of hypertrophic lym- 
 phatic tissue at the vault of the pharynx had been 
 entirely overlooked until W. Meyer described this im- 
 portant condition in 1869. Yet it is a very frequent and 
 very noticeable disturbance. In various school examina- 
 tions it has been found to exist in from 5 to 9 per cent, 
 of all children. No race and no country seem to be 
 exempt. Its existence since historic times has been 
 made probable by Meyer by finding the characteristic 
 facial expression indicative of it in various portraits from 
 the middle ages and even in some statues of antiquity. 
 
 The direct consequence of enlargement of the pharyn- 
 geal tonsil is obstruction of nasal breathing to an extent 
 proportionate to the space occupied by the new growth 
 and hence inversely proportionate to the dimensions of 
 the pharynx. On account of the vascularity of the 
 lymphatic tissue its size is subject to fluctuations. While 
 a moderate enlargement may be inappreciable during 
 erect posture, the increased blood supply during the 
 reclining posture may entirely prevent nasal breathing. 
 The obstruction is also increased during sleep by the 
 accompanying turgescence of the posterior ends of the 
 turbinals. Still more noticeable is the obstruction when 
 an acute coryza increases the congestion. The patient 
 hence sleeps with the mouth open, and snores whenever 
 he lies on his back, although while awake he may be 
 able to breathe through his nose (except in high degrees 
 of hypertrophy). When there is secretion, which often 
 occurs in this trouble, the child cannot blow his nose, 
 
 249
 
 250 HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
 
 but draws the pus back into the pharynx. Enlargement 
 of the pharyngeal tonsil also betrays itself by its influ- 
 ence on the voice, which becomes " dead " and loses its 
 resonance. The nasal sounds "in" and "n" are espe- 
 cially interfered with ; the former (" m ") sounding like 
 " b," the latter (" n ") like " d." An excellent descrip- 
 tion of the speech in high degrees of adenoid vegetation 
 is given by Dickens in his character Barney, in Oliver 
 Twist. It is only in complete obstruction of the nose by 
 a severe coryza or polypi that the same mode of speech 
 is heard. 
 
 159. The interference with nasal breathing results in 
 the course of time in thickening of the lips and sink- 
 ing in of the sides of the nostrils. These peculiarities, 
 together with the open mouth, give these children a 
 very characteristic "stupid" expression, accentuated by 
 a "dreamy" look due to vascular fulness of the lower 
 eyelid, whereby the lid-space is reduced in aperture. In 
 well-marked instances the expression, as well as the 
 voice, suggests a positive diagnosis. The characteris- 
 tic appearance has been termed the "adenoid habitus." 
 In many cases the obstruction of the nasopharyngeal 
 space is accompanied by changes in the shape of 
 the hard palate, which at first becomes merely arched 
 to an abnormal degree. After the second dentition, 
 however, its form often changes to a V-shaped or 
 Gothic arch, while the lateral teeth, especially cuspids 
 and bicuspids, may incline inward instead of pointing 
 straight downward. The changes in the palate and 
 alveolar process are, however, not absolutely character- 
 istic of enlarged pharyngeal tonsil. Children with en- 
 larged pharyngeal tonsils are very prone to "take cold." 
 They get fresh nasal catarrh from slight exposure, and it 
 often remains chronic during the inclement season or 
 even longer. Purulent secretion, however, when pres- 
 ent, is always due to a complicating inflammation of 
 the nose or of the pharyngeal tonsil itself often very 
 persistent, but it is not a symptom resulting from mere
 
 SYMPTOMS. 25 I 
 
 hypertrophy of this structure. In typical instances it 
 may be entirely absent. In the less pronounced forms 
 of hypertrophy of the pharyngeal tonsil there is often 
 the copious mucopurulent discharge described in T[ 35 as 
 the "scrofulous" form of purulent rhinitis. 
 
 If the adenoid vegetations are not removed, a hyper- 
 trophic condition of the turbinals, especially the posterior 
 ends, as well as septal overgrowth, are very often found 
 in older children. Hypertrophy of the pharyngeal tonsil 
 is often accompanied by enlargement of the faucial 
 tonsils. They are generally deep seated between the 
 pharyngeal pillars, and hence do not apparently project 
 far into the mouth as compared with their actual size. 
 
 160. The ears suffer in a large proportion of cases of 
 adenoid vegetations. The most common condition is that 
 of catarrh limited to the Eustachian tube, which form gives 
 the least unfavorable prognosis. More serious are attacks 
 of purulent inflammation. Serous catarrh of the middle 
 ear is not common in younger children, but not so rare 
 in the period preceding and following puberty. As a 
 rule, the ears are involved in consequence of some tran- 
 sient acute or subacute inflammation, and not merely on 
 account of the mechanical presence of the enlarged ton- 
 sil. The tonsillar hypertrophy, however, is the import- 
 ant determining condition, without which the temporary 
 coryza or pharyngitis would scarcely endanger the ear. 
 While the ear affections yield to the usual local treat- 
 ment, relapses are almost sure to occur unless the hyper- 
 trophied tonsil is removed. Hence with neglect the 
 hearing may become permanently damaged, 
 
 A common complaint of children with adenoid vegeta- 
 tion is cough. Generally this is due to frequent and 
 often persistent attacks of bronchitis following acute 
 nasopharyngeal inflammation. In other instances it 
 seems to be a reflex disturbance without lesions in the 
 lower respiratory passages. 
 
 161. Children with marked pharyngeal obstruction 
 not merely look stupid, but often are so. They find it
 
 252 HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
 
 difficult to concentrate their attention. This mental 
 sluggishness has been termed aprosexia. Headaches 
 referred to the back of the head are not uncommon 
 during inflammatory exacerbations. Asthenopic com- 
 plaints, difficulty in the use of the eyes, fatigue, and 
 strain are sometimes complained of. I have seen a fair 
 number of instances in which low degrees of far-sighted- 
 ness or astigmatism annoyed the children sufficiently to 
 necessitate glasses, which could be discarded after the 
 pharyugeal operation which, of course, does not change 
 the structure of the eye itself. The interference with 
 nasal respiration disturbs sleep. Such children are often 
 restless at night, toss about or wake with nightmare or 
 frightening dreams. Nocturnal incontinence of urine is 
 also not uncommon. Groenbeck observed it 26 times in 
 198 cases. In about one-half of the instances this 
 annoyance ceases at once after the operation. In most 
 of the others it improves gradually. The cervical lymph- 
 glands are frequently enlarged. How large a proportion 
 of such indurated glands is tubercular has not been 
 determined. In high degrees of pharyugeal obstruction 
 the children may present a stunted growth and marked 
 insufficiency of weight. The dependence of this im- 
 paired nutrition upon the blockage of the pharyngeal 
 space is often shown by the satisfactory increase in the 
 rate of growth following operation. 
 
 162. Attention has also been directed, especially by 
 earlier French surgeons (Dupuytren, Chassaignac) to de- 
 formities of the chest observed in children having large 
 tonsils. It is partly a constriction of the lower part of 
 the chest as compared with the dimension of the upper 
 part, partly a flattening of the thorax in the lateral 
 diameter, with undue prominence of the sternum the 
 so-called pigeon -breast. Whether these conditions are 
 not dependent on the coexistence of rickets is perhaps 
 an open question. Undoubtedly, however, the interfer- 
 ence with breathing and the resulting violent exertion 
 of the diaphragm, together with undue pressure of the
 
 SYMPTOMS. 253 
 
 external air upon the yielding infantile thorax during in- 
 spiration, account for the occurrence of these deformi- 
 ties. The respiratory obstacle is, however, not so much 
 due to the enlarged faucial tonsils, as was formerly be- 
 lieved, as to the blockage of the pharynx by the adenoid 
 vegetations, which the earlier observers had not recog- 
 nized. Among my patients in this country, where rickets 
 is not a frequent disease, I have seen but little of these 
 chest deformities, and never in a very pronounced degree. 
 Although most of the disturbances due to enlargement of 
 pharyngeal tonsil are of mechanical origin and are hence 
 pronounced in proportion to the degree of enlargement or 
 its relative bulk compared with the (variable) size of the 
 pharynx, still at times even very moderate growths will 
 give rise to much interference with nutrition (Harrison 
 Allen). I have sometimes seen improvement in the 
 general health of children that seemed out of proportion 
 to the small amount of adenoid tissue shown by the ope- 
 rative removal. 
 
 The pernicious influence of adenoid vegetations upon 
 the blood (anemia) shows itself by a poverty in red glob- 
 ules and hemoglobin, with absolute increase of mononu- 
 clear and eosinophile leukocytes and lymphocytes, while 
 after the operation there is a gradual return to the nor- 
 mal condition of the blood (Lichtwitz and Sabrazes). 
 
 163. While the enlargement of the pharyngeal tonsil 
 is an affection of childhood, it does not necessarily dis- 
 appear at puberty. Sometimes the respiratory obstacle, 
 with all its resulting disturbances, lasts during middle 
 life. As a rule, however, the pharyngeal space grows 
 during the second decade of life at a faster rate than its 
 adenoid tissue, and the latter often undergoes partial 
 involution. This is evident by the rotundity which the 
 surface of the enlarged gland presents in adults, compared 
 with the coxcomb-shaped irregularities of the surface in 
 earlier childhood. Hence, after adolescence the mechani- 
 cal interference with breathing subsides somewhat as a 
 rule. Yet secondary hypertrophic changes in the nasal
 
 254 HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
 
 walls and Eustachian tubes, and hence liability to fre- 
 quent inflammatory attacks of nose, ears, or bronchial 
 tubes, are apt to persist after adolescence as the sequel 
 of juvenile adenoids. 
 
 164. The diagnosis of enlarged pharyngeal tonsils 
 can be made with much certainty in more pronounced 
 cases on noting the facial expression and the character- 
 istic speech. If inspection shows no obstruction in the 
 nose itself, the cause of the respiratory interference must 
 be in the upper pharynx. With the exception of rare 
 cases of excessive enlargement of the posterior ends of 
 the turbinal, or the still rarer occurrence of fibroid tumors 
 in the pharynx, the lesion will be found to be enlarge- 
 ment of the pharyngeal tonsil. The diagnosis is con- 
 firmed by examination with the finger. The surgeon 
 presses the cheek between the teeth, so as to keep the 
 mouth open and prevent the child from biting, and there- 
 upon inserts the finger through the mouth into the upper 
 pharynx by sliding in behind the palate, and observes 
 the resistance met with in feeling for the upper rim of 
 the nasal passage. In normal instances the relatively 
 resisting posterior wall and roof are recognizable by touch, 
 and the space will be found clear. When the adenoid 
 tissue is enlarged, a soft cushion can be felt lining the 
 pharynx and encroaching upon its caliber. As a rule, 
 too, the finger gets bloody. The surgeon may be misled 
 as to the amount of adenoid hypertrophy in case the body 
 of the first cervical vertebra is exceptionally prominent in 
 the pharynx. 
 
 The digital examination is very disagreeable to the 
 patient. In the case of tolerant children a mirror ex- 
 amination may be attempted instead of palpation. Im- 
 practicable under the fourth year, it is quite feasible in 
 many older children, especially after they have passed 
 the seventh year. A partial view may also be obtained 
 by direct inspection on retracting the palate with a hook 
 and throwing the head back to the utmost extent. In 
 younger children the surface of the enlarged gland is
 
 DIAGNOSIS. 255 
 
 irregular. There are coxcomb-shaped ridges running 
 anteroposteriorly, usually six in number, sometimes more 
 by reason of branching or less by coalescence of the 
 ridges. Most of the illustrations in text-books showing 
 tufts and cauliflower-shaped projections are fanciful and 
 do not correspond to what is actually seen. As pu- 
 berty is approached the involution of the adenoid tissue 
 smoothens the surface and the growth is more likely to 
 appear as a semiglobular cushion relatively hard. The 
 pharyngeal tonsil is to be considered pathologically large 
 whenever its outlines are recognizable as an elevation 
 above the level of the surface, since when perfectly nor- 
 mal, the edge of the adenoid area slopes so gradually as 
 to be distinguishable from the rest of the mucous surface 
 
 a b c 
 
 FIG. 74. Enlarged pharyngeal tonsils removed in one piece by the author's 
 adenotome (actual size) : a, From a child four years old; b, from a child eight 
 years old ; c, from a young man twenty years of age. 
 
 only by its slightly darker tint and ridged and furrowed 
 surface. Normally there appears a clear space of a few 
 millimeters between the front end of the adenoid cushion 
 and the upper rim of the choanse. The more the tonsil 
 is enlarged, the more does it project over the upper rim 
 of the bony frame of the nose, while in pronounced cases 
 it covers the entire posterior choanse in the postrhino- 
 scopic image. The enlarged gland can sometimes be 
 seen by direct inspection on retracting the palate forcibly 
 with a hook, while the head is thrown backward. 
 
 165. The structure of the enlarged pharyngeal tonsil is 
 that of the normal gland with all its elements uniformly 
 increased. In earlier childhood the tissue is soft, due to
 
 256 HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
 
 a preponderance of lymph-cells. As involution progresses 
 the growth becomes harder, as felt by the knife in cutting 
 it. This depends on the gradual increase of the fibrillar 
 elements, with corresponding reduction in the number 
 of lymph-cells. Not uncommonly some of the follicles 
 undergo suppuration and change into miniature abscesses. 
 The size of the growth may in extreme cases amount to 
 about 6 to 8 c.cm., attaining the bulk of a walnut. Its 
 attachment is always central, and does not extend laterally 
 into the fossae of Rosenmuller (Fig. 74). 
 
 166. Etiology. Enlargement of the pharyngeal tonsil is 
 the consequence of acute coryza in childhood. Whenever 
 a continuous observation is possible, it can be learned 
 that the respiratory interference begins with an attack 
 of coryza, and persists after the nasal inflammation has 
 ceased. Successive inflammatory attacks gradually lead 
 to the full morbid development of the adenoid tissue. 
 This usually begins during the first years of life, rarely, 
 if ever, after the third, but may continue to increase dur- 
 ing subsequent attacks of rhinitis until the period before 
 puberty. The possibility of adenoid hypertrophy depends 
 on a predisposition, the nature of which is not understood. 
 It is often a family trait, conspicuously present in some 
 families, markedly absent in others. It is favored by 
 small dimensions of the nose and pharynx, but is 
 strikingly absent in the spacious passages of subjects 
 suffering from ozena. 
 
 There has been some confusion created by descriptions 
 correlating adenoid vegetations with scrofula. It is now 
 admitted that the term scrofula is often used in a vague, 
 not well-defined, sense. Some of the characteristics for- 
 merly referred to scroftilosis are the direct consequence 
 of hypertrophy of the pharyngeal tonsil viz., the thick 
 lips, the -attacks of subacute purulent rhinitis, and the 
 liability to purulent otitis. All this may occur in chil- 
 dren in whom no other evidences of scrofula are present, 
 and hence the diagnosis scrofula may be incorrectly made, 
 merely on account of the presence of adenoid vegetations.
 
 ETIOLOGY. 257 
 
 On the other hand, the pharyngeal hypertrophy is often 
 associated with true scrofula, as shown by the presence 
 of palpable tubercular lymph-glands. 
 
 167. It has been claimed that there is some relation- 
 ship between adenoid vegetations and tuberculosis. The 
 most positive assertion is attributed to Koch by Traut- 
 mann, to the effect that children with this disease react 
 to diagnostic tuberculin injection. No one else besides 
 Koch (and Petruschky) has made this test on a sufficiently 
 large scale. In the writer's experience of more than 
 twenty years a large number of subjects with adenoid 
 vegetations during childhood have not presented any 
 evidence of tuberculosis during many subsequent years 
 of observation. 
 
 Various recent researches have shown that about 5 per 
 cent, of enlarged pharyngeal tonsils contain tubercles 
 with tubercle bacilli. These tonsils differ in no wise 
 from the appearance of non-tubercular hypertrophies. 
 The tubercular disease is and remains entirely latent. 
 The diagnosis can be made only by the subsequent micro- 
 scopic examination, which shows the presence of typical 
 tubercles scattered throughout the adenoid tissue. In 
 most cases the tubercular infection is a secondary occur- 
 rence, as shown by the existence of tubercular foci in 
 other parts of the body. Indeed, it has been found that 
 in tuberculous cadavers even the not enlarged normal 
 pharyngeal tonsil may be the seat of miliary tubercles. 
 It is to-day an open question whether a primary tuber- 
 culosis of the pharyngeal gland does occur at all. Yet 
 while the disease follows a latent course without leading 
 to further changes in the adenoid tissue, the subsequent 
 tubercular infection of the lymph-glands may help to 
 spread the mischief. All these statements concerning 
 the occurrence presumably secondary of latent tuber- 
 culosis and its numerical frequency apply to the faucial 
 tonsils to the same extent as to the pharyngeal tonsil. 
 The results of operations are just as satisfactory in the 
 case of tonsils subsequently found to be tubercular, as 
 
 17
 
 2$8 HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
 
 when we deal with simple enlargement without tuber- 
 culosis. 
 
 168. Treatment. Every enlarged pharyngeal tonsil 
 which causes any symptoms whatsoever should be re- 
 moved by operation. It is only when the enlargement is 
 discovered accidentally and has hitherto caused no mani- 
 festations that the question of operation may be left for a 
 future time. The operation may be said to be free from 
 risk. There are about half a dozen cases of fatal bleeding 
 on record, either in bleeders or in poorly nourished sub- 
 jects, not watched sufficiently after the operation. In the 
 case of a bleeder operated by myself, an annoying hemor- 
 rhage persisted for thirty-six hours without leading to 
 bad results. The hemorrhage is always profuse momen- 
 tarily, amounting in exceptional cases up to 50 to 100 
 cm., but rarely persists long. Its persistence is generally 
 due to shreds incompletely detached, and may be stopped 
 by removing these shreds. Plugging of the postnasal 
 space is very rarely required. 
 
 Beyond a slight fever, apt to occur within the next 
 twenty-four hours, it is quite uncommon to see any 
 annoyance from the operation. Soreness is never pro- 
 nounced, often absent. The wound heals in about a 
 week, during which period there is sometimes some sup- 
 purative discharge. There is no after-treatment required 
 or of any service. 
 
 169. Abscission of the hypertrophied pharyngeal ton- 
 sil removes promptly all the symptoms caused mechani- 
 cally by its presence, while the remote consequences dis- 
 appear gradually. Even an incomplete removal may give 
 temporarily very satisfactory results. The less thorough 
 the operation and the younger the child, the greater the 
 liability to subsequent growth; hence apparent relapses 
 are sometimes observed which may necessitate a second 
 operation. A complete removal precludes relapses. In 
 cases complicated, however, by intranasal anomalies, 
 stenosis, purulent rhinitis, or sinus affections the benefit
 
 TREATMENT. 259 
 
 of the operation may be masked by the persisting nasal 
 disease. 
 
 170. It has been much debated whether the operation 
 should be done with or without narcosis. The writer's 
 experience has led him to condemn narcosis as unneces- 
 sary in most instances. Hinkel has collected 18 deaths 
 from American and English sources alone from 1892 to 
 1898 from operations on the pharyngeal tonsil done under 
 narcosis. This is an appalling mortality in an operation 
 otherwise devoid of risk. Hinkel suggests that the de- 
 velopment of the adenoid tissue coexists often with per- 
 sistence of the fetal state of the thymus gland, the con- 
 dition termed status lymphaticus which predisposes to 
 sudden death from trivial causes. Bromid of ethyl has 
 been lauded as a convenient substitute for chloroform or 
 ether for this operation, on account of its quick and tran- 
 sient anesthesia. But statistics have shown that for 
 other purposes this agent is not safer than other anes- 
 thetics. 
 
 Narcosis makes the operation more formidable and 
 necessitates more assistance. It does not in any way 
 permit a more thorough operation, as most of the relapses 
 which the writer has seen had been operated previously 
 by others, or by himself under anesthesia. The pain in 
 well-arranged operations is not sufficient to necessitate 
 the superfluous risk of an anesthetic. It is only in the 
 case of unruly children from whom active resistance 
 must be expected that narcosis becomes necessary. Nar- 
 cosis is also preferable when the faucial tonsils are to be 
 excised at the same sitting, as this triple operation is 
 usually too severe a tax on a child's tolerance. With 
 narcosis the head must be pendant over the edge of the 
 table, or the body turned to one side. With this pre- 
 caution there is no risk of blood entering the lower 
 air-passages. 
 
 Without the narcosis the child is firmly held in the lap 
 with its body tilted forward and the head thrown back, 
 as this position is the most favorable. The pain is very
 
 2(5O HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
 
 much reduced by the use of a cotton pledget moistened 
 with 20 per cent, solution of cocaiu, held in place for 
 some two to three minutes. It has seemed to the writer 
 that cocain anesthesia is enhanced by the previous use 
 of suprarenal solution, as well as the hemorrhage some- 
 what reduced, but some pain must be expected. 
 
 171. The easiest, quickest, and most thorough mode 
 of operation is by means of the curved guillotine devised 
 by Schiitz. The writer had been experimenting along 
 the same line, and devised a similar instrument with a 
 more favorable form of handle (Fig. 75). The pharyn- 
 
 FlG. 75. Author's adenotome. 
 
 geal end of the guillotine is 20 mm. wide, the sweep of 
 the knife about 22 mm. in length, and the curve is 
 adapted to hug the entire roof and upper posterior 
 pharyngeal wall. The instrument is slid up behind the 
 palate, pushed upward and backward with considerable 
 force, and in one sweep the knife removes the entire 
 adenoid growth. By inadvertence this may be swallowed 
 without harm. By extensive comparative trials the 
 writer has found no other mode of operation so thorough, 
 so quick, so painless, and followed by so little hemor- 
 rhage as by means of this instrument. The ordinary 
 size of the instrument will fit any child over three to four
 
 TREATMENT. 
 
 26l 
 
 years of age. A smaller size can also be had. L,arge 
 faucial tonsils are no real obstacle to its introduction. 
 173. A very popular instrument is the Gottstein knife, 
 which should be well sharpened (Fig. 76). It is intended 
 to slide in place along the posterior edge of the vomer, 
 
 FIG. 76. Gottstein's adenoid knife. 
 
 whereupon it is forcibly pushed backward and downward. 
 Soft adenoids are easily removed in one sweep. But in 
 case of harder structures of older children, the knife is 
 more apt to slip than the guarded blade of a guillotine. 
 It may have to be inserted repeatedly until the finger 
 finds the space clear. 
 
 FIG. 77. Trautmann's sharp spoon. 
 
 The Trautmann sharp spoons or curets (Fig. 77), made 
 in three sizes, although very efficient, have been super- 
 seded by the broader Gottstein knife. They often fail to 
 remove the entire gland, while causing considerable 
 hemorrhage. 
 
 173. A postnasal cutting forceps for the adenoid opera- 
 
 FIG. 78. Author's adenoid forceps. 
 
 tions was originally devised by Loewenberg. As his 
 model was too clumsy and withal its blade too small, 
 the writer constructed a forceps of sufficient size to 
 grasp the entire tonsil (Fig. 78). The upturned part is 
 17 mm. high, and the curved cutting blade extending
 
 262 
 
 HYPERTROPHY OF THE PHARYNGEAL TONSIL. 
 
 through the arc of a circle has a total length of 15 mm. 
 Yet it will rarely remove the entire gland in one piece, 
 although three or four successive cuts can clear the space 
 very perfectly. The lateral spring-guards originally in- 
 tended to prevent the pieces from falling into the larynx 
 have been found unnecessary. In my former experience 
 I found it advantageous to supplement the work of this 
 form of forceps by the subsequent introduction of another 
 forceps cutting transversely, so as to reach the extreme 
 lateral end of the growth (Fig. 79). 
 
 -S^s 
 
 FIG. 79. Adenoid forceps cutting in the anteroposterior direction. 
 
 174. Some surgeons use the cold snare through the 
 mouth either with a straight or a slightly curved cannula. 
 This causes relatively little bleeding, but must be re- 
 applied quite often, in order to remove the entire tonsil. 
 At the best, it is an uncertain and tedious mode of operat- 
 ing, although not very painful. The writer can rec- 
 ommend it only for small remnants left by previous 
 incomplete operations, especially in older subjects who 
 can tolerate the pharyngeal mirror. 
 
 The snare put through the nose is even more uncertain 
 in its action and very disagreeable. The operation was 
 done originally by Meyer by means of a ring-shaped 
 curet put through the nose vertically and then turned 
 horizontally. This method has been entirely abandoned.
 
 TREATMENT. 263 
 
 The so-called simple method of scratching off the vege- 
 tations by means of the finger-nail is still occasionally 
 mentioned by writers. It is thoroughly unsurgical and 
 entirely inefficient when the tonsil is of firm structure. 
 The use of a sharp steel shield over the end of the fin- 
 ger the artificial nail can likewise not compete with 
 the use of properly designed instruments. 
 
 175. In any form of operation except by means of the 
 curved guillotine used with sufficient pressure there is a 
 possibility that some fragments may be left. If these 
 are of 'any size, a recurrence of the growth is possible in 
 younger children. Partially detached shreds may cause 
 a persistent hemorrhage. Unless examination of the 
 excised tonsil or its fragments gives assurance that the 
 operation has been thoroughly done, the pharynx should 
 be explored by the thoroughly sterilized finger. It is, 
 however, difficult to recognize small remnants of the 
 gland immediately after the operation. During the 
 following five to seven days any remaining bits of ade- 
 noid tissue are swollen by reason of traumatic inflamma- 
 tion, and bleed freely when disturbed. If any remnants 
 of the tonsil are detected after the lapse of a week, they 
 should be removed by the use of cutting forceps or the 
 cold snare. 
 
 No medicinal treatment has any influence upon an 
 enlarged pharyngeal tonsil. Cauterization chemical or 
 thermic is inefficient and dangerous to the ear.
 
 CHAPTER XXII. 
 
 HYPERTROPHY OF THE FAUCI AL TONSILS. 
 
 176. Enlargement of the faucial tonsils is even more 
 common than excessive growth of the pharyngeal tonsil. 
 It begins in early childhood, rarely later than about the 
 tenth year of life, and remains unchanged during subse- 
 quent development The protrusion of the enlarged 
 tonsil is either inward or outward. In the former case 
 the tonsil protrudes into the fauces as a more or less 
 globular body. In the latter case the adenoid cushion 
 spreads out, but remains more or less hidden between the 
 pillars, and finds room for its overgrowth by crowding 
 the tissues outward and somewhat upward. In extreme 
 instances of this type the tonsil may scarcely protrude 
 while the palatal muscles are at rest. But its large size 
 is shown by corresponding prominence during the act of 
 gagging. Most commonly the tonsil grows both inward 
 and outward. The projection of the hypertrophied tonsil 
 may be very unequal on the two sides, but when an out- 
 ward growth occurs, it involves usually the two tonsils to 
 a symmetric extent. The enlarged tonsil, when not in- 
 flamed, is pale. The orifices of its crypts are very dis- 
 tinct. Large tonsils are, however, often in a state of 
 chronic inflammation, especially during childhood, and 
 present a redness which extends over the adjoining part 
 of the palate and anterior pillar. 
 
 177. Hypertrophy does not change the typical struc- 
 ture of the tonsil. All its constituent elements are 
 uniformly involved. During the earlier period the en- 
 larged tonsil is soft and quite vascular. Upon the appli- 
 cation of cocain such a tonsil shrinks very decidedly in 
 size. Later on many enlarged tonsils undergo a fibrous 
 change and become harder, with a predominance of the 
 
 264
 
 HYPERTROPHY OF THE FAUCIAL TONSILS. 265 
 
 connective tissue and stroma over the lymphoid cells. 
 Although these harder tonsils are less vascular, the fibril- 
 lar sclerosis involving the arterial walls may lead to trou- 
 blesome hemorrhage during operations on account of 
 imperfect retraction of the vessels. 
 
 178. The morbid enlargement of the faucial tonsils is 
 produced by the same causes which lead to hypertrophy 
 of the pharyngeal tonsil viz., repeated attacks of coryza 
 during early childhood. Hence enlargement of the fau- 
 cial tonsils is often, though not invariably, associated 
 with enlargement of the pharyngeal tonsil. On the other 
 hand, it is rare to find adenoid vegetations without at 
 least some overgrowth of the faucial tonsils. L,arge 
 tonsils are often found without any history of previous 
 throat inflammations. But the occurrence of tonsillitis 
 is an additional factor often leading to further growth. 
 Nasal stenosis of any kind seems also a potent etiologic 
 factor. 
 
 A small proportion of enlarged tonsils contains tu- 
 bercles without any characteristic or distinctive appear- 
 ance during life. This latent tuberculosis does not reveal 
 itself in any way except by the induration of the cervical 
 lymph-glands, which is not characteristic. The state- 
 ments made in 1 167 concerning tuberculosis of the 
 pharyngeal tonsil apply equally to the faucial tonsils. 
 Here, too, tubercular infection is mostly, if not always, 
 secondary to some other focus of the disease somewhere 
 else in the body. Infection results most likely from 
 tubercular sputum, but may perhaps be primary in some 
 cases from the use of tubercular milk. 
 
 179. Enlarged tonsils, when not inflamed, need not 
 cause any symptoms or disturbances. This is especially 
 true of tonsils which have grown into the faucial space, 
 and which many a patient retains to old age without 
 suffering therefrom. Those glands, however, which, by 
 their growth, have pushed the tissues outward and up- 
 ward and are concealed between the pillars, may produce 
 mischief by their mechanical presence. They may cause
 
 266 HYPERTROPHY OF THE FAUCIAL TONSILS. 
 
 engorgement of the posterior ends of the turbinals suffi- 
 ciently to necessitate mouth-breathing with accompany- 
 ing restlessness during sleep. They may simulate the 
 presence of an enlarged pharyngeal tonsil. Yet in the 
 majority of cases, when symptoms of mechanical origin 
 are referred to the faucial tonsils, they are really caused 
 by the coexisting enlargement of the pharyngeal tonsil. 
 More potent for mischief are large tonsils in a state of 
 chronic inflammation, when distinctly and permanently 
 reddened. In this condition they may constitute the 
 essential lesion of so-called chronic pharyngitis and 
 account for all the symptoms present viz., uncomfort- 
 able sensations, throat irritation, and cough. Persistently 
 reddened tonsils are often subject to periodic attacks of 
 acute or subacute inflammation. The history of many 
 patients teaches that recurrences of acute tonsillitis are 
 common until the tonsils are removed. Chronically in- 
 flamed tonsils may also help to maintain chronic disease 
 of the Eustachian tube, even though they represent but 
 one of the factors involved. It is current belief, though 
 not definitely proven, that large tonsils increase the 
 liability to and the danger of diphtheria and scarlet 
 fever. 
 
 180. Treatment. The description of the disturbances 
 produced by enlarged tonsils indicates what may be gained 
 by their operative removal. Tonsils that have caused no 
 symptoms may be let alone, but whenever any constant 
 or periodic disturbance can be referred to their presence, 
 the tonsil should be removed as thoroughly as possible. 
 Abscission of a superficial slice is of very little value. 
 The operation is practically free from serious risk. Per- 
 haps a few dozen cases of fatal hemorrhage are on record 
 in bleeders or from neglect. Annoying hemorrhage is 
 not uncommon, especially in adults with hard tonsils ; 
 less so, in children. Primary hemorrhage may be avoided 
 by the use of the hot snare. But even in this case a 
 secondary hemorrhage, though very rare, is possible after 
 detachment of the eschar. There are no large bleeding
 
 TREATMENT. 267 
 
 vessels, but free oozing may occur, especially in hard 
 tonsils, and is sometimes difficult to control. Gargling 
 with tannic or gallic acid as recommended in text-books 
 does not check it. Pellets of ice are sometimes of benefit. 
 More positive is a tampon steeped in antipyrin solution 
 (10 per cent.), dusted with tannin, and held firmly in 
 place. A tampon wet with Monsell's solution of iron is 
 equally effective, but forms a disagreeable, voluminous 
 clot. Steady compression by means of a plain tampon 
 held by forceps will often suffice. Patience is a neces- 
 sary virtue. Various clamps have been devised to be left 
 in place for hours. In very rare extreme cases it has 
 been found necessary to tie the external carotid artery. 
 
 181. Tonsillar wounds become covered with a whitish- 
 gray coating which may resemble diphtheria. Super- 
 ficial infection is probably inevitable in every case, but it 
 is not common to see any deeper or more serious evidence 
 of infection. Even when such unpleasant reaction does 
 occur, it causes only transient annoyance and no real 
 danger. Tonsillotome wounds heal in from five to ten 
 days, according to their size. It is not possible to main- 
 tain a tonsillar wound aseptic. The nearest approach to 
 it the writer has found in the free and repeated insuffla- 
 tion of glutol, which, however, adheres but incompletely, 
 lodoform does not adhere at all. So-called antiseptic 
 mouth-washes (compare H" 134) add to the patient's com- 
 fort during the healing and control the odor of the breath, 
 but do not influence the wound to any extent. Tonsillar 
 wounds always pain more or less, but this pain can be 
 entirely controlled by the insufflation of orthoform a few 
 times a day. 
 
 Tonsil operations require anesthesia only when active 
 resistance on the part of the patient is to be expected. 
 The pain is considerably reduced, but not entirely 
 avoided, by free brushing with 20 per cent, solution of 
 cocain. 
 
 182. The simplest mode of operating is by means of 
 the guillotine, of which there are various patterns (Fig.
 
 268 
 
 HYPERTROPHY OF THE FAUCIAL TONSILS. 
 
 80). In all of them a gliding spear drags the tonsil 
 inward while the knife cuts. The guillotine must be 
 forcibly pressed against the pillars in order to grasp 
 enough of the tonsil. This operation is efficient when 
 a globular mass projects into the faucial space, but it is 
 
 FIG. 80. Mathieu's tonsillotome. 
 
 insufficient when dealing with a broad, flattened tonsil 
 hidden between the pillars. When remnants are left 
 after the use of the tonsillotome, they may be seized with 
 forceps and snipped off with long scissors or a blunt- 
 pointed bistoury. Indeed, it is not difficult to amputate 
 a projecting tonsil simply by the use of the bistoury and 
 
 FIG. 8l. Author's hot snare for tonsillotomy. 
 
 traction forceps, but the operation cannot be done as 
 quickly as with a tonsillotome. 
 
 183. In the case of hard fibrous tonsils in which hemor- 
 rhage is feared (especially in adults), or when the shape of 
 the gland does not permit complete removal by the ton- 
 sillotome, the hot snare can be used to advantage. As 
 most of the galvanocaustic snares in the market are too
 
 TREATMENT. 269 
 
 fragile, the writer has designed a stronger instrument for 
 the removal of the tonsil (Fig. 81). The tonsil is seized 
 with a double hook or a vulsella forceps, over which the 
 snare is slipped until it grasps the tonsil as near as pos- 
 sible to its base. The wire is drawn tight while cold, and 
 heated to a bright-red glow only when resistance is felt to 
 its further constriction. The resulting wound heals nearly 
 as quickly as a cut with a knife. No bleeding whatsoever 
 occurs. If necessary, the snare may be reapplied until no 
 projecting remnants are left. When the shape of the tonsil 
 does not permit the snare to be applied, the adhesions of 
 the adenoid tissue to the pillars may first be separated by 
 the use of a hook or a blunt-pointed knife. The grasp of 
 the snare may then be facilitated by burning a shallow 
 groove into part of the periphery of the tonsil with a 
 
 FIG. 82. Ingals' tonsil forceps. 
 
 galvanocaustic burner. The wire loop can now be easily 
 slipped into this groove. Special grasping forceps are 
 sometimes useful (Fig. 82). 
 
 The cold snare is a less cumbersome instrument than 
 the galvanocaustic snare. It is slightly more painful, 
 however, and unless a strong instrument is used, the wire 
 may not cut through, but pull out of the instrument, 
 causing embarrassment. A strong and apparently effi- 
 cient snare has been devised by Peters (Fig. 83). The 
 cold snare does not prevent hemorrhage with so much 
 certainty as the hot wire. Some surgeons have suggested 
 dissecting out the entire tonsil by means of a galvano- 
 caustic knife-shaped burner. This is an uncalled-for 
 mutilation, leaves a large painful wound, often resulting 
 in irritating scars, and may give rise to serious secondary 
 hemorrhage.
 
 2/O HYPERTROPHY OF THE FAUCIAL TONSILS. 
 
 184. It is often a serious question how to deal with large, 
 deep-seated, and not projecting tonsils which cannot be 
 reached well by any instrument. In the case of very 
 young children, discretion is sometimes the better part 
 of valor. Inasmuch as such tonsils do not ordinarily 
 cause any serious damage and usually shrink somewhat 
 in the course of time, it is at times the wiser plan to let 
 them alone. If an operation is, however, clearly indi- 
 cated, it can be made more thorough by removing the 
 deeper portion of the tonsil piecemeal with any kind of 
 punch-forceps for instance, my postnasal forceps (Fig. 79). 
 
 Considerable reduction in the size of tonsils may be 
 
 FIG. 83. Peters' tonsil snare. 
 
 obtained by inserting a pointed burner into the crypts 
 and obliterating them gradually. The result is ultimate 
 shrinkage. If only a few crypts are burned at one sitting, 
 there is but very little inflammatory reaction. Yet the 
 result in the end is never so satisfactory as that of a clean 
 amputation if the latter is feasible or accepted by the 
 patient. 
 
 Hypertrophied tonsils cannot be reduced in size by 
 medicinal treatment. The swelling due to chronic inflam- 
 mation, however, may be influenced somewhat by the use 
 of Loffler's solution. Its employment for some weeks will 
 sometimes render an operation unnecessary. A marked
 
 TREATMENT. 2/ 1 
 
 influence upon the size of chronically inflamed tonsils is 
 also exerted by the removal of the hypertrophied pharyn- 
 geal tonsil. Faucial tonsils which seem to indicate 
 operation will often become quiescent and harmless after 
 the successful removal of adenoid vegetations.
 
 CHAPTER XXIII. 
 
 HAY FEVER AUTUMNAL CATARRH. 
 
 185. Hay fever is an affection characterized by severe 
 nasal irritation, usually extending to neighboring organs 
 and occurring only during a part of the warm season, but 
 recurring annually. It may be compared to a severe 
 coryza vasomotoria produced by certain unknown condi- 
 tions existing only during the summer. The attack 
 begins with itching of the nose, which extends to the 
 eyes and often the ears. The nose soon becomes ob- 
 structed, a part of the time wholly occluded. Periodic 
 sneezing fits occur, followed by profuse watery discharge. 
 The nasal symptoms, as well as the complaints referable 
 to adjoining organs, fluctuate during different times of the 
 day and on different days. They are usually made worse 
 by hot, dry weather, moderated by rains and cooler spells. 
 A high degree of nasal occlusion causes a feeling of pres- 
 sure in the head, sometimes headache. The eyes become 
 suffused with tears, blood-shot, and the lids show venous 
 congestion, which may finally give them a dusky hue. 
 The ears often become stuffy, but no permanent ear 
 lesions are produced by hay fever. The throat feels 
 irritated, and more or less severe coughing may follow. 
 The most distressing symptom is difficult breathing, 
 which increases to periodic spells of asthma, especially 
 at night. 
 
 On examination the nose presents no appearances char- 
 acteristic of this disease except edema of the mucous 
 membrane, especially over the turbinals during the height 
 of the attack. The nasal lining is not injected except 
 when previously in a condition of hypertrophic rhinitis. 
 There is, however, excessive turgescence of all cavernous 
 tissue. The surface is very sensitive to contact of the 
 
 272
 
 HAY FEVER AUTUMNAL CATARRH. 2/3 
 
 probe. Mechanical irritation intensifies the attack and 
 starts the secretion. The discharge in typical cases is 
 a clear serum. Occasionally, but rarely, the disease is 
 combined with a true inflammatory coryza with purulent 
 discharge. Whatever other lesions or anomalies may be 
 found are not due to hay fever, but existed previously 
 and constitute a favorable predisposing condition for this 
 disease. It is quite common to meet with septum de- 
 formities, sharp lateral crests, and circumscribed hyper- 
 trophies of the mucous membrane or enlargement of the 
 pharyngeal tonsil, but all preexisting before the attack 
 came on. 
 
 After hay fever has ceased with the end of the warm 
 season, the patient has no further nasal symptoms ex- 
 cept those due to any existing lesions and anomalies 
 independent of hay fever. The disease returns annually, 
 with an occasional exception. After many seasons it 
 sometimes stops spontaneously, especially on permanent 
 change of residence to a more favorable locality. Most 
 patients, however, do not lose their annual affliction. 
 In our climate typical cases begin toward the end of 
 July or middle of August, and often on the same day 
 each succeeding year. The affection stops at the latest 
 with the first frost, in some people indeed with the begin- 
 ning of cooler weather. In less typical instances it may 
 start earlier in the season, even in June, or whenever the 
 weather gets warm. In these cases it is likely to fluctu- 
 ate considerably with the weather, or even to intermit 
 temporarily. The less typical cases present all gradations 
 from genuine hay fever limited to the "summer months to 
 irregular spells of vasomotor coryza brought on by various 
 other modes of irritation, as well as by warm weather. 
 This atypical form is known as "rose-cold." In Eng- 
 land and on the Continent hay fever begins and ends 
 earlier than in America. The disease seems most preva- 
 lent among the English and Americans. It has scarcely 
 been observed in the north and south of Europe. But 
 reports are multiplying concerning its occurrence in 
 
 18
 
 274 HAY FEVER AUTUMNAL CATARRH. 
 
 Germany and France. The same statement really applies 
 to our country as well, and it is an open question whether 
 the disease is on the increase, or whether physicians give 
 it more attention than formerly. 
 
 186. The disease ceases within a few hours, or at the 
 latest within a day, on going to certain localities known 
 to be immune against hay fever. Some parts of the 
 White Mountains, especially the village of Bethlehem, 
 and the open sea afford relief to all sufferers. Many 
 other localities give immunity to most patients, but not 
 to all. Strange to say, some people may suffer in one 
 place and find relief in the other, while to others this 
 boon is reversed. These favored spots are the larger 
 lakes, the upper Michigan shore of Lake Michigan, most 
 of the shore of Lake Superior, the woods of Northern 
 Michigan, and many of the higher localities in the 
 Rocky Mountains. The peculiar seasonal and geographic 
 distribution of hay fever has led to the view that it 
 is produced by the inhalation of the pollen of grasses 
 floating in the air. In our climate the pollen of the 
 universally distributed ragweed is especially suspected. 
 The principal basis for this view has been furnished by 
 the researches by Blackley, himself a sufferer from the 
 disease. By means of a device resembling a rain gauge 
 he collected and counted the number 'of pollens on 
 microscopic slides exposed for a definite length of time. 
 He found thus that the beginning of the attack coincided 
 with a certain increase in the number of particles floating 
 in the air, while the remissions during cooler or moist 
 weather coincided* with diminished prevalence of the 
 pollen. As we do not know any other form of irritant 
 the seasonal and geographic variations of which explain 
 the etiology of hay fever, the pollen theory is at present 
 a plausible working hypothesis. But it cannot be said to 
 be established definitely. Blackley contracted an attack 
 of hay fever while on the ocean by opening a package of 
 pollen, and thus apparently showed that these vegetable 
 particles can bring on the attack, yet this isolated case is
 
 ETIOLOGY. 275 
 
 scarcely convincing on account of the psychic factor in- 
 volved. The fact that sufferers may get the disease in 
 cities far distant from fields is consistent with our knowl- 
 edge of the wafting of dust over large distances. But there 
 are a few instances on record of attacks persisting on sea- 
 board on the ocean at distances over which the land dust 
 is not carried. Perhaps the most difficult problem not 
 answered by the pollen theory is the immunity enjoyed 
 by small areas, for instance, the village of Bethlehem 
 in the White Mountains, while neighboring regions, 
 apparently under similar conditions, do not protect 
 against the disease. All the favored localities are rela- 
 tively dust free, but mere absence of dust does not neces- 
 sarily protect. 
 
 187. All observers agree that some form of predisposi- 
 tion is necessary in order to contract the disease. It is 
 rare in very young children, but often begins after about 
 the tenth year. It does not often begin after the fourth 
 decade of life, but even old age is not entirely exempt. 
 It is more common in men than in women. It is a 
 disease almost limited to the refined classes, and is hardly 
 ever observed in people below a certain social status. A 
 person who is poor and uneducated is practically proof 
 against this disease. This peculiarity, as well as the 
 recurrence in many on the same day of every year, 
 points to the importance of psychic factors, the full role 
 of which we cannot yet analyze. Many patients present 
 a distinct neuropathic taint, although pronounced neu- 
 rasthenia and hysteria are not markedly predisposing. 
 While the bulk of the sufferers are otherwise in good 
 health, anemia and convalescence from enfeebling dis- 
 eases often coincide with the first attack of hay fever. 
 Those in whom no personal nervous history can be 
 elicited give usually evidence of nervous instability in 
 the family history. The disease involves not rarely 
 several members of a family. Basing himself on exten- 
 sive statistic inquiry, Beard has termed hay fever a func- 
 tional neurosis. If we understand by the term neurosis a
 
 2/6 HAY FEVER AUTUMNAL CATARRH. 
 
 nervous disturbance not dependent upon demonstrable 
 change in the nervous system, and not the necessary con- 
 sequence of some peripheral lesion, this name is applic- 
 able. We may thus call hay fever a neurosis due to a 
 certain irritation of the respiratory mucous membrane by 
 an unknown irritant in predisposed subjects. 
 
 The predisposition depends partly upon the existence 
 of other nasal anomalies. This is shown by their fre- 
 quent coexistence, as well as by the beneficial influence 
 of their elimination. The successful removal of septum 
 deformities, of circumscribed hypertrophies of mucous 
 membrane, and enlargement of the pharyngeal and fau- 
 cial tonsils or of foci of suppuration relieves some patients 
 markedly and occasionally cures one completely. 
 
 188. Hay fever victims escape the disease by spending 
 the fatal season in an immune locality. Some stand the 
 distress as long as possible until the increasing heat forces 
 them to flee for relief. The sufferers have formed a hay- 
 fever association with headquarters at Bethlehem, which, 
 while it serves to spread useful information, exerts, on 
 the other hand, a bad psychic influence. 
 
 Most writers speak of the valuable influence of nerve 
 tonics, arsenic, zinc phosphid, or valerianate strychnin, 
 etc., upon the disease, but I cannot find a single record 
 of any permanent cure obtained thereby. The latest re- 
 ports of the Hay Fever Association claim emphatically 
 that there are no cures on record. On the other hand, 
 more can be expected of intranasal surgery upon proper 
 indications. The full restoration of nasal patency relieves 
 the suffering to a great extent, even if it does not prevent 
 the attack. In medical literature a number of apparent 
 cures are on record, but they have mostly not been fol- 
 lowed for a sufficient number of successive seasons to be 
 fully convincing. I may say the same of several instances 
 in my own limited experience with this disease. Some 
 years ago galvanocaustic destruction of the turgescent 
 cavernous tissue was extensively practised, apparently 
 with some relief during the following season. But the
 
 TREATMENT. 2/7 
 
 records of the Hay Fever Association disclaim any per- 
 manent cures obtained thereby. During the attack itself 
 any operative treatment, except a clean incision resulting 
 in free patency of the nose, gives rise to very unpleasant 
 reaction. 
 
 Decided temporary relief is obtained by the use of a spray 
 of suprarenal solution. This agent has also been recom- 
 mended for internal use, but on questionable theoretic 
 grounds and with very questionable results. In several 
 instances in which hay fever coexisted with and seemed 
 dependent upon purulent rhinitis I have obtained an ap- 
 parent cure for the season by the use of this spray, fol- 
 lowed by the douche, and the spray of watery solutions 
 of the essential oils (T[ 25). The use of cocain is too 
 transient to be serviceable, and the danger of cocain habit 
 too great to sanction its employment by patients. The 
 asthmatic attacks can sometimes be greatly relieved by 
 antipyrin internally. 
 
 189. It is instructive to compare the pathology of hay 
 fever with that of another disease of similar seasonal and 
 geographic distribution viz., spring catarrh of the 
 conjunctiva of the eye. This affection is not directly 
 related to hay fever. In about 15 instances of it which I 
 have seen I have known only one patient to suffer at the 
 same time from hay fever. Its lesions are the striking 
 but not constant grayish tumefactions of the ocular con- 
 junctiva around the cornea, while absolutely constant, 
 but less noticeable, are the lesions of the conjunctiva of 
 the upper lid. The disease begins during the warm sea- 
 son and ends with frost, but returns annually. Its symp- 
 toms are irritation of the eyes, watering, sensitiveness to 
 light, and discomfort on use. The symptoms cease during 
 the cold season at first, but in some patients persist in a 
 very mild degree during winter after a duration of many 
 years. The first summer the conjunctiva of the upper 
 lid shows merely a mild degree of catarrhal inflammation 
 with stringy mucous secretion. The second season the 
 surface is slightly follicular. Later on the follicles en-
 
 2/8 HAY FEVER AUTUMNAL CATARRH. 
 
 large and assume the appearance of papillae. During 
 winter the conjunctiva is again normal, but after a num- 
 ber of years the lesions diminish, but do not disappear 
 entirely during cold weather, producing, however, very 
 little annoyance. Like hay fever, spring catarrh returns 
 with fatal regularity every year. As the writer was the 
 first to point out, a sufferer gets absolute relief by going 
 to a locality immune against hay fever. The resemblance 
 to hay fever is, unfortunately, completed by the rebel- 
 liousness of the disease to all treatment.
 
 CHAPTER XXIV. 
 DIPHTHERIA. 1 
 
 190. Diphtheria may be defined clinically as an inflam- 
 mation with the formation of false membranes, and etio- 
 logically as the reaction of the tissues to infection by the 
 diphtheria bacillus. These two definitions do not coincide 
 fully. A pseudomembranous inflammation is sometimes 
 caused by other germs, while the reaction to the diph- 
 theria bacillus may be limited to a superficial inflamma- 
 tion without membranes. Diphtheria is essentially a dis- 
 ease of childhood. Uncommon within the first few months 
 of life, its maximum frequency and mortality occur in the 
 first five to seven years of infancy, becoming less frequent 
 and less fatal after that period. It is not frequently seen 
 after adolescence and very rarely after middle life. 
 
 The disease begins with fever, usually increasing for a 
 day and of variable height, rarely excessive, sometimes 
 remittent or even absent. The fever lasts usually as long 
 as the local lesion. With it there are marked general 
 disturbance, lassitude, malaise, want of appetite, furred 
 tongue, and often more or less albuminuria. The cer- 
 vical glands are generally swollen, and remain so until 
 after recovery. From the start there is pain on swal- 
 lowing and sore throat. The affection begins most often 
 on the tonsils, generally on both sides, sometimes on the 
 posterior pharyngeal wall, rarely on the soft palate. The 
 invaded spots show a whitish coating, in the form of a 
 membrane, which from the start cannot be detached with- 
 out leaving a bleeding abraded surface. In severe cases 
 
 1 It is not within the province of this work to include a complete descrip- 
 tion of diphtheria, as this disease is fully treated in all text-books on general 
 medicine. Hence details will only be given regarding its localization in the 
 upper air-passages. 
 
 279
 
 28O DIPHTHERIA. 
 
 the color of the membrane may turn to a dark brown, 
 being stained by blood extravasation. Around the mem- 
 brane is an area of considerable redness and swelling. 
 When the tonsils are involved, they swell. Except in 
 mild or in properly treated cases the membranous inflam- 
 mation extends so as to involve the larger part of the vis- 
 ible throat. It may spread upward into the nasopharynx, 
 which is rare, or even into the nasal passages. Much 
 more common is the involvement of the larynx in the 
 form of croup. The extension may continue from two to 
 five or seven days, rarely longer. After this period the 
 membranes gradually detach themselves, and the abraded 
 surfaces heal. When the membranes are detached arti- 
 ficially, they form again in a few hours. Occasionally a 
 relapse or rather an exacerbation occurs when the disease 
 seems nearly ended. In exceptional cases the persistence 
 of the disease for a number of weeks has been observed. 
 In rare instances deep ulceration may follow after detach- 
 ment of the membrane and cause cicatricial shrinkage 
 and adhesions in the pharynx. 
 
 191. The disease varies in severity with the epidemic 
 and with the individual. We can distinguish between 
 abortive, mild, average, and severe or septic cases, but 
 with transitions between these forms. The systemic dis- 
 turbances are more or less pronounced, somewhat in pro- 
 portion to the intensity of the local process. But sequels, 
 especially the different forms of paralysis, are nearly as 
 apt to occur in the mildest cases as in the severe. The 
 contagiousness, also, does not depend on the severity of 
 the case. In abortive cases nothing is seen beyond an 
 apparently slight pharyngitis or tonsillitis. The diagno- 
 sis suggested by known exposure can be verified only by 
 the bacteriologic test or the subsequent occurrence of 
 paralysis. In mild cases the typical membranes are seen, 
 but they do not spread in extent after the first or the 
 second day. In the severe or septic form, the severity of 
 which depends perhaps on concomitant infection by 
 other germs, especially streptococci, or on want of re-
 
 COMPLICATIONS. 28 1 
 
 sisting power of the victim, the prostration and fever 
 reach a high degree from the start. The membranes 
 spread rapidly and extensively and are of more than 
 ordinary thickness, while the septic complication is 
 shown by the intense foulness of the breath and the 
 systemic prostration. Hemorrhages into the mucous 
 membrane stain the membranes a dark brown. In such 
 severe instances the disease lasts longer and is followed 
 by a more tedious convalescence. 
 
 192. The mortality of diphtheria varies considerably 
 in different years and with the class and age of patients. 
 Before the antitoxin treatment was introduced the aver- 
 age death-rate in hospitals was from 30 to 35 per cent. , 
 this figure being much surpassed in children under five 
 years, while adults gave a more favorable prognosis. In 
 private practice the death-rate did not generally exceed 
 about one-half of this figure, but fluctuated in different 
 years. The most common cause of death is extension 
 into the larynx, resulting in suffocation. In the second 
 place, general sepsis due to streptococcus complication is 
 to be feared. Bronchopneumonia carries off a large pro- 
 portion, especially in hospitals. A small number die 
 from sudden heart failure. 
 
 T 93 The recovery is complicated in a large percentage 
 of cases by transient paralysis of the soft palate. This 
 occurs about two to three weeks after the start and lasts 
 two to three weeks, always terminating favorably. It 
 shows itself by the passage of fluids or even solid food 
 into the posterior choanse during swallowing, and by the 
 changed and diminished resonance of the voice. On 
 inspection, the palate is seen to hang flaccid and immov- 
 able during intonation. Somewhat less common is paral- 
 ysis of the ciliary muscle of the eye, with complete 
 suspension of accommodation, but without involvement 
 of the iris movements always bilateral. Except in the 
 case of myopia it causes inability to read, while hyper- 
 metropes who require their accommodation for the dis- 
 tance see blurred even in the distance. Like paralysis
 
 282 DIPHTHERIA. 
 
 of the palate, it always ends in spontaneous recovery in 
 the course of two to three weeks. The percentage of 
 these postdiphtheritic paralyses has risen since the intro- 
 duction of antitoxin treatment, on account of the greater 
 number of patients surviving under this treatment. 
 More serious than these localized affections is the diffuse 
 involvement of motor and sensory nerves throughout the 
 body, of which cases a small proportion end fatally. 
 Diphtheria of the pharynx and nose leads to suppurative 
 otitis in a moderate proportion of cases. 
 
 194. The clinical description of nasal diphtheria as an 
 extension from the pharynx has been given in ^[ 82. 
 While this must be considered as a very grave complica- 
 tion, primary diphtheria of the nose as described in ^[ 81 
 is a remarkably mild disease, often entirely afebrile and 
 rarely leading to any complications. It is, however, just 
 as contagious as other forms. 
 
 In a small number of instances diphtheria ascends into 
 the upper pharynx above the palate, probably always as 
 a secondary extension from below. It may prove rather 
 persistent in this locality, causing mild systemic disturb- 
 ances, with nasal obstruction and sniffling due to post- 
 nasal secretion. When the postnasal mirror cannot be 
 used, the diagnosis is based on obtaining fragments of 
 membranes on exploring the region with a cotton-appli- 
 cator or on the bacteriologic test. 
 
 According to postmortem findings, some of the nasal 
 accessory cavities are commonly infected during ordinary 
 diphtheria. The infection is due to the bacillus of diph- 
 theria in nasal diphtheria, although even then the in- 
 flammation is not necessarily pseudomembranous. When 
 the process has not reached the nose, the sinuses are 
 transiently inflamed, with or without secretion, by reason 
 of the entrance of some of the ordinary pyogenic 
 microbes. 
 
 Recovery is followed by immunity lasting many 
 months, and often a lifetime. Yet recurrences after the 
 lapse of a year are sometimes met with.
 
 PATHOLOGY. 283 
 
 195. Pathology. The diphtheritic process consists of a 
 necrosis of at least the epithelium, or even of part of the 
 mucous membrane, to a variable depth, with inflammatory 
 reaction in the mucous membrane underneath. The ne- 
 crotic tissue still in contiguity with living tissue becomes 
 imbued with coagulating fibrin. Its detachment by 
 sloughing occurs subsequently after the destructive action 
 of the microbes upon the living tissue has come to a 
 standstill by the resisting power of the latter. Patholo- 
 gists distinguish between croupous and so-called true 
 diphtheritic inflammation. In the former case only the 
 epithelium is involved, and a firm, easily detached mem- 
 brane results. In the latter type the process is deeper 
 seated and the necrosis affects the mucous membrane 
 underneath the epithelium. Both forms of inflammation 
 are caused by the same parasite, the process depending 
 somewhat on the resisting power of the tissues and more 
 so on the locality affected. In the larynx it is superficial 
 croup, as a rule ; in the nasal passage it may be croupous 
 or deeper diphtheritic inflammation ; in the pharynx, it 
 is generally true diphtheritic inflammation. 
 
 196. Etiology. Diphtheria is the result of infection by 
 a specific microbe, known as the Klebs-LofHer bacillus. 
 Its precise description and cultural peculiarities can be 
 found in all bacteriologic works. 1 It has been found and 
 
 1 A short straight or slightly curved bacillus, variable in size, averaging 
 about 0.5 to 0.8 fi in length by ^ p width. Non-motile. Many irregular club- 
 shaped forms mixed with typical rods. Stains fairly readily, especially with 
 alkaline methylene-blue. Takes Gram stain. Staining shows polar differentia- 
 tion, the ends being more colored than the center. Neisser's stain applied to 
 fresh culture of diphtheria bacilli shows granules at or near the end of each rod 
 stained blue in an isolated manner. A culture kept at 35 C. for ten to twenty 
 hours is used. After fixation by heat the cover-slip is stained one to three 
 seconds with 
 
 Methylene-blue (Gruebler) I 
 
 Alcohol (96 per cent.) 20 
 
 Distilled water . 950 
 
 Glacial acetic acid 50 
 
 well washed in water and counterstained three to five seconds in veuvin solu- 
 tion (1:500 boiling water). The diphtheria bacillus grows readily in most
 
 284 DIPHTHERIA. 
 
 identified by observers in diphtheria throughout the whole 
 world. About one-fifth to one- fourth of the throat diseases 
 which suggest the clinical diagnosis diphtheria are really 
 due to other germs, mostly the streptococcus. In these 
 cases the specific bacillus is, of course, not found. How- 
 ever much the appearances may temporarily resemble true 
 'diphtheria in these instances, the clinical course is, as a 
 rule, not quite the same. They are milder (except in 
 connection with scarlet fever), are less likely to extend 
 in area, have a small or no mortality (again excepting 
 scarlatinous angina), and are never followed by paralytic 
 sequels. Clinically, however, it is often impossible to 
 distinguish, at the beginning, between a membranous 
 angina due to other germs and a mild diphtheria. The 
 diphtheritic bacillus is also not found in true diphtheria 
 if the examination in a septic case is made at a late 
 period, when other coexisting parasites have crowded out 
 
 media and does not liquefy gelatin. Thrives especially well in Loffler's solid 
 serum (3 parts blood-serum with i part bouillon containing I per cent, peptone, 
 I per cent, grape-sugar, and 0.5 per cent. salt). On this serum other microbes 
 do not grow as rapidly as the bacillus diphtheria?, which shows, in the incubator, 
 round, moist, grayish-white colonies within twenty-four hours, while within 
 eight to ten hours the colonies, too small to be seen by the eye, may be exam- 
 ined microscopically on transferring them to a cover-slip. Grows readily in 
 milk without changing the appearance of the fluid. Cultures and dried bacilli 
 remain alive for long periods of time. Killed by water of 60 C. inside of 
 half an hour, and practically instantaneously by boiling soda solution. 
 
 Much confusion has arisen from the existence of another bacillus, the 
 pseudo-diphtheria bacillus of von Hoffmann, which resembles the true diph- 
 theria bacillus closely in morphology and cultural peculiarities. A distinction 
 between the two is certain only by reason of the absolute harmlessness of the 
 pseudo diphtheria bacterium to animals, and very probable on careful comparison 
 of cultures in various media. According to most observers, the pseudo-diph- 
 theria bacillus does not show the characteristic polar granules with Neisser's 
 stain applied to young cultures. 
 
 The pseudo-diphtheria bacillus is found relatively often in the normal throat, 
 and to some extent, too, in non-diphtheritic disease of the pharynx, but not 
 usually in large number. On the other hand, in true diphtheria the pseudo- 
 bacillus does not multiply, as a rule, and whenever tests on animals have been 
 employed, it was found that all the bacilli in real diphtheria were pathogenic. 
 Hence when a micro-organism resembling the diphtheria bacillus is found in 
 abundance in any throat lesion, the diagnosis of diphtheria can be made with 
 very little chance of error.
 
 ETIOLOGY. 285 
 
 the specific germ. Cultural search for the diphtheria 
 bacillus will also fail if antiseptics have previously been 
 applied to the throat. But apart from these apparent 
 exceptions the Klebs-Loffler bacillus is always found in 
 genuine diphtheria, and its presence or absence decides 
 the diagnosis. Since the successful treatment of diph- 
 theria is absolutely specific, a bacteriologic search should 
 be made in every case. 
 
 In stained cover-slip preparations made by wiping the 
 membranous spot with a sterile rod the bacillus can be 
 detected in a sufficiently characteristic form for diagnostic 
 purposes in more than 50 per cent. In case of doubt a 
 culture is made from the membrane by wiping it with a 
 sterile rod, with care to prevent contamination. On the 
 surface of the serum recommended by Loffler the diph- 
 theria bacillus grows more readily than most bacteria 
 likely to be found in the throat, so that its characteristic 
 colonies can be detected with the microscope and identi- 
 fied after the lapse of eight to ten hours (in the incubator 
 or any warm place of about 100 F.). A very convenient 
 culture-dish is the flat covered _tin box suggested by 
 Jaques, its advantage being the small bulk, its protection 
 against contamination, and its low cost. 
 
 197. The diphtheria bacillus has been found by culture 
 a number of times in the normal throat of persons known 
 to have been exposed to the disease. In the case of sus- 
 ceptible subjects, especially children, its presence may 
 finally result in delayed infection. But undoubtedly 
 many individuals, particularly those beyond early child- 
 hood, are more or less proof against the disease, and the 
 bacillus may exist in such throats transiently as a surface 
 parasite, harmless to the bearer, but a source of danger to 
 others. In other instances the germ causes a superficial 
 or very mild inflammation without the formation of mem- 
 branes the abortive cases. 
 
 198. In microscopic sections of the diseased pharyngeal 
 mucous membrane the bacillus is found only in and im- 
 mediately underneath the false membrane. The appear-
 
 286 DIPHTHERIA. 
 
 ances show positively that the tissue necrosis extends as 
 deep as the bacillary invasion. By culture a few isolated 
 germs are sometimes found in the viscera in fatal cases. 
 
 The proof that this parasite is the cause of diphtheria 
 has been completed by the demonstration of its pathogenic 
 power in animals, as well as by the study of the poison it 
 produces and of the physiologic antidote formed in the 
 animal body against this poison. Inoculation of mucous 
 membranes in animals (especially young animals) with 
 the isolated germ produces diphtheritic inflammation, 
 however, without the marked tendency to extend as it 
 does in man. But the reaction to most pathogenic germs 
 is by no means identical in different species of animals. 
 
 The etiologic significance of the diphtheria bacillus is 
 supported by a study of the effects of its poisons. When 
 the culture fluid deprived of living germs is injected into 
 animals, the characteristic prostration is obtained, ending 
 fatally in case of a sufficiently large dose and causing a 
 lingering cachexia in smaller quantities. In many in- 
 stances characteristic paralyses follow. A fatal dose of 
 poison is contained in a small fraction of a drop of the 
 culture fluid. Injected under the skin, it produces in- 
 flammatory swelling and even necrosis. But the charac- 
 teristic diphtheritic inflammation is not produced by any 
 soluble poison. By the repeated injection, at intervals, of 
 non-fatal doses of diphtheria toxin animals become immu- 
 nized to enormous quantities of poison, and are likewise 
 rendered germ-proof thereby. The immune animal has 
 developed a remarkable new property in its blood-serum. 
 The immune serum is an antidote against the diphtheria 
 poison, and the intensity of this antidotal action is pro- 
 portionate to the degree of immunity. The quantity of 
 antidote which will neutralize an amount of poison repre- 
 senting a ten-fold fatal dose for a guinea-pig is termed 
 an antitoxin unit. By suitable immunization of horses 
 during the course of a number of months a serum can be 
 obtained containing as an extreme about 500 units per 
 cubic centimeter. The neutralization of diphtheria toxin
 
 CONTAGIOUSNESS. 287 
 
 by immune serum takes place if the two are mixed before 
 injection, or if either be injected a short time before the 
 other. But if many hours are allowed to elapse between 
 the injection of the poison and its antidote, the requisite 
 number of antidotal units must be enormously increased. 
 The longer the animal has been under the influence of 
 the poison, the more antitoxin does it take to undo the 
 effect of the poison, until the recovery of the animal 
 becomes at last impossible. Antitoxic serum has no 
 direct effect upon the diphtheria bacillus. It does not 
 influence its life in any way. But by protecting the 
 organism against the deleterious effects of the poisons 
 which this germ generates, it enables the system to treat 
 the diphtheria bacillus as a harmless parasite. The ani- 
 mal organism has the ability to rid itself of all microbic 
 parasites which do not overwhelm the resisting power of 
 the system. 
 
 199. Diphtheria, as seen clinically, is usually a mixed 
 infection, or at least becomes so in the course of the dis- 
 ease. Streptococci or staphylococci, or both, as well as 
 various other forms of microbes, are found to a variable 
 extent associated with the diphtheria bacillus and often 
 replace it later on. The gravity of the disease is ap- 
 parently much enhanced by this mixed infection, which 
 is more pronounced the more severe or septic the form of 
 the disease. On the other hand, the diphtheria invasion 
 may be secondary to some prior lesion of mucous mem- 
 branes. Thus we may have a secondary diphtheria as a 
 sequel to the sore throat of scarlet fever, measles, or 
 syphilis. When ulcerations due to any other affection 
 become diphtheritic in appearance, the diphtheria bacil- 
 lus is, as a rule, found to be the cause. A diphtheritic 
 appearance, however, may also be due to streptococcic 
 infection. 
 
 200. Diphtheria is eminently contagious. Coughing, 
 spitting, and even speaking disseminate through the air 
 microscopic droplets of fluid containing the living germs. 
 Physical considerations make it likely that this mode of
 
 288 DIPHTHERIA. 
 
 infection can spread only through a small area. There 
 is more danger from kissing and the handling of toys and 
 soiled utensils. Sputum dried on the handkerchief may 
 scatter the germs as dust. According to clinical expe- 
 rience the dissemination of the germ through attendants 
 and clothing does not occur to any great extent, and the 
 greatest danger is from direct contact. It has often been 
 claimed, but never absolutely proven, that the virus may 
 be disseminated through milk. The danger of the diph- 
 theria patient to others persists for at least a number of 
 weeks, sometimes over two months, after perfect recov- 
 ery; for during this period of time living virulent germs 
 can be detected in the throat and often, too, in the nose. 
 
 The disease is most likely to become epidemic during 
 the cold season and in crowded localities, evidently on 
 account of the greater facilities for its dissemination. Its 
 incubation is two to three days, but as infection does not 
 necessarily follow at once upon introduction of the germ 
 into the mouth, a week or even more may elapse before 
 the disease breaks out after exposure. 
 
 2Oi. Since the treatment of diphtheria is absolutely 
 specific, the diagnosis should be established by bacterio- 
 logic test. But it would not be wise to wait half a day or 
 longer until the test has been made or reported upon by 
 some expert. Time is of the utmost importance in the 
 use of antitoxin. It should, therefore, be injected at once 
 upon clinical indications, and deferred only until the end 
 of the bacteriologic test in cases when the clinical diag- 
 nosis is in doubt. The best results are obtained by in- 
 jecting at once a large number of units not less than 3000, 
 and 4000 or more whenever the symptoms are pronounced 
 or the case has advanced beyond the first half day. When 
 extension threatens, the dose may be repeated several 
 times if needed, at intervals of twelve hours. As a rule, 
 this is not necessary. The hypodermic injection should 
 be made with full aseptic precautions to guard against 
 the possibility of abscesses. The antitoxic serum itself
 
 TREATMENT. 289 
 
 is put up sterile and usually preserved by the addition of 
 trikresol (0.5 per cent.). 
 
 As the result of this treatment the fever disappears in 
 from one to three times twenty-four hours, but the symp- 
 toms of systemic disturbance cease sooner, so that the 
 child, hitherto sick, begins to play. There is no apparent 
 influence upon the membrane, but almost invariably fur- 
 ther extension of the diphtheritic inflammation ceases 
 at once. When the larynx is still intact at the time of 
 injection, croup formerly so much dreaded scarcely 
 ever appears. There is, accordingly, too, but little to 
 fear of other sequels like bronchopneumonia. 
 
 It is difficult to state in an individual case that the 
 recovery is due to the treatment, as the disease in favor- 
 able cases heals spontaneously in the same way. But the 
 influence of the specific treatment upon the mortality is 
 now universally admitted. The few voices raised against 
 antitoxin on the part of writers not open to conviction 
 have now practically ceased. Statistics from the entire 
 civilized world have shown that the mortality has, on an 
 average, been at least cut in two, while individual ob- 
 servations under favorable circumstances with sufficiently 
 large dosage and early employment of antitoxin have 
 yielded results even much more favorable. The crucial 
 test, indicating the value of the specific treatment of 
 diphtheria, is the mortality-rate arranged according to 
 the date of employment of antitoxin. Within the first 
 twenty-four hours the death-rate has been below 5 per 
 cent., and in many small series has been nearly zero. 
 When employed after the first day, the antitoxin has less 
 decisive control over the disease until the influence is 
 nearly lost, apparently, by delaying the injection until 
 the fourth or fifth day of the disease. No other treat- 
 ment in this or any other disease has been tested in this 
 crucial manner in so many thousands of instances and 
 with such incontrovertible results. Even though sta- 
 tistics do not show a reduction of the death-rate when 
 the treatment is delayed until the fifth day, it must not 
 
 19
 
 290 DIPHTHERIA. 
 
 be forgotten that these delayed and hence selected cases 
 represent a series of more than average severity, and hence 
 ordinarily of more than average mortality. For other- 
 wise there would be no need of beginning the injections 
 at this late time. Deaths occurring within twelve hours 
 after the injection simply show that the treatment was 
 begun too late and had not had time to exert its effect. 
 
 202. There are no contraindications against the use of 
 antitoxin. In about 10 per cent, of cases the injection 
 gives rise to disagreeable, but not serious, consequences. 
 Within one or a few days it may be followed by a rash 
 resembling either measles or scarlet fever, but lasting 
 only a day or two, with moderate fever, occasionally 
 nettle-rash, and in rare instances inflammatory swelling 
 around some joints, which subsides within a few days. 
 The few deaths which have occurred shortly after in- 
 jections were due partly to the severity of the disease, 
 partly to other sometimes unaccountable influences, like 
 habitus lymphaticus. It is well known that any trivial 
 operation may sometimes be followed by immediate un- 
 accountable death. Very few minor operations have been 
 practised on so enormous a scale as antitoxin injections. 
 
 203. It is very questionable whether we possess any 
 means of treatment to influence diphtheria except anti- 
 toxic serum. A comparison of the enormous array of 
 drugs recommended formerly by every writer, with 
 strong individual preferences not shared by any other 
 writer, leaves but little doubt that the treatment was 
 more suggested by humane intentions than by positive 
 knowledge. None of the means of local applications 
 have ever been tested statistically according to the day 
 of their employment. They are all being gradually dis- 
 carded. Lofrler, the discoverer of the diphtheria bacillus, 
 tested the ability of antiseptics to kill the bacillus im- 
 mediately and to penetrate at the same time through 
 thick layers of a culture. His most satisfactory results 
 were obtained with a fluid known as the Lofrler mix- 
 ture viz. :
 
 TREATMENT. 29 1 
 
 Toluol 10 
 
 Menthol 2 
 
 Tincture of chlorid of iron 4 
 
 Alcohol up to loo. 
 
 This has been tried on a limited scale for the local treat- 
 ment of diphtheria, and while moderately praised, has 
 not found universal recognition. It undoubtedly does 
 penetrate deeply, killing both the diphtheria bacillus as 
 well as other germs present as far as it reaches. But, 
 after all, those in the depth of the false membranes escape 
 largely. Yet, judged by clinical evidence in individual 
 cases, its use, when brushed upon the affected spots once 
 in four to eight hours, is not without some benefit. It 
 certainly has a very decided and lasting effect upon the 
 foulness of the breath. The offensiveness of the breath 
 is also controlled to some extent by mouth-washes and 
 gargles of the less irritating antiseptics and aromatics, 
 as, for instance 
 
 Thymol 2 
 
 Oil of cloves I 
 
 Oil of cassia 0.5 
 
 Chloroform 5 
 
 Alcohol 25 
 
 of which one teaspoonful is dissolved in a glass of water 
 (8 oz.). 
 
 The constitutional treatment of diphtheria and the 
 methods of quarantine and disinfection can be found in 
 all text-books on general medicine. The indications and 
 surgery of intubation and tracheotomy are likewise out- 
 side of the scope of the present work. 
 
 304. Individuals exposed to the disease are protected 
 against it almost infallibly by a prophylactic injection of 
 at least 150 units of antitoxin, if given within twenty- 
 four hours after exposure. Two or three days after ex- 
 posure a larger dose (600 units) is required, and even this 
 may not protect absolutely, but infallibly reduces the dis- 
 ease to a very mild type. The passive immunity pro-
 
 DIPHTHERIA. 
 
 duced by antitoxin injection lasts a number of weeks, 
 not exceeding about six. 
 
 205. A singular and exceptional form of chronic disease appa- 
 rently due to the diphtheria bacillus has recently been reported 
 (Neisser and Kahnert). Five instances were observed, all in 
 young women. For years they had complained of dryness in the 
 throat, discomfort, even some pain, and viscid secretion, but prac- 
 tically only during the cold season, with apparent intermission 
 during summer. Purulent crusts without fetor were found in the 
 nose and entire pharynx down to the larynx. The mucous mem- 
 brane appeared atrophic, somewhat vulnerable, partially con- 
 gested. The symptoms resembled those of non-fetid atrophic 
 rhinitis, but with extension through the pharynx. The only 
 micro-organism found absolutely constant was the typical genuine 
 diphtheria bacillus, but devoid of pathogenic property in some of 
 the cases. In one instance only the disease dated from a former 
 attack of diphtheria. The serum of several patients had antitoxic 
 efficiency. Injections of antitoxin did not influence the disease.
 
 CHAPTER XXV. 
 
 SYPHILIS OF THE NOSE AND PHARYNX TUBER- 
 CULOSIS SCROFULA LEPROSY 
 
 RHINOSCLEROMA. 
 
 SYPHILIS OF THE UPPER AIR-PASSAGES. 
 
 206. In the course of syphilis the pharynx is involved, 
 as a rule, during the early period of secondary manifesta- 
 tions. But this form of lesion is not often seen by the 
 rhinologist. Yet syphilitic manifestations in general are 
 so common in the nose and throat that they constitute at 
 least 2 per cent, of average practice in this field. 
 
 The primary sore, very exceptionally found in the 
 nasal vestibule or near the front end of the septum, is 
 not so rare in the mouth and pharynx. In statistics of 
 over 10,000 cases of extragenital chancres compiled by 
 Bulkley, and continued by Miinchheimer, .5 per cent, 
 were observed in the tonsils and nearly 3 per cent, in 
 other parts of the pharynx. The infection was conveyed 
 partly by lascivious modes of kissing and sexual aberra- 
 tion, partly by utensils and tools for instance, the blow- 
 pipe of glass- workers. More than 50 pharyngeal chancres 
 have been reported from the use of infected Eustachian 
 catheters. Infants acquire the disease by nursing. The 
 sore appears as a sharply cut ulcer with unclean surface, 
 surrounded by an edematous and reddened areola, of 
 indolent course, lasting weeks, even up to two months. 
 Usually but not always the base becomes indurated. Adja- 
 cent lymph-glands become inflamed and palpable. The 
 diagnosis cannot be made absolute unless the history of 
 exposure is certain, or until secondary symptoms appear. 
 Yet the only ulcers for which it might be mistaken 
 after an existence of two weeks or more are secondary 
 
 293
 
 294 SYPHILIS OF THE NOSE AND PHARYNX. 
 
 syphilitic ulceration, tubercular ulcers, and ulcerating 
 carcinoma. 
 
 Until the diagnosis is beyond the possibility of doubt 
 it is not to the interest of the patient to use specific 
 medication. If a sore disappears under specific treatment 
 before its nature is certain, the diagnosis of syphilis may 
 be left in uncertainty for months and years. The ulcer 
 heals in the end without treatment, but its cure can be 
 hastened by nitrate of silver, tincture of iodin, or 
 Loffler's solution, and its discomfort lessened by ortho- 
 form insufflations. 
 
 207. During the early secondary stage the throat, as a 
 rule, is affected by syphilis. But as these lesions are rela- 
 tively mild and their cause is usually known to the patient, 
 they are but seldom seen in special rhinologic practice. 
 Syphilitic erythema, common on the palate, less so on 
 the posterior pharyngeal wall, appears in the form of red, 
 well-circumscribed spots, often symmetric. It causes 
 slight soreness and is transient. It may persist, however, 
 as a deeper type of inflammation in the form of a tonsil- 
 litis, presenting sometimes the typical appearance of 
 follicular tonsillitis. Whenever this lasts more than 
 about a week, with steady but moderate soreness and 
 without acute onset, it can be safely referred to syphilis. 
 
 Mucous patches are among the most frequent and per- 
 sistent of the early syphilitic manifestations, with dis- 
 tressing liability to recurrence. They occur anywhere 
 in the mouth on the tongue, or at its base, along the 
 pillars, on the tonsils, or less commonly the posterior 
 wall of the pharynx. At first resembling spots produced 
 by cauterization with nitrate of silver, they are oval or 
 irregular, slightly raised, grayish-white patches of varia- 
 ble size, surrounded by a slightly reddened areola, the 
 color of which is most saturated (by contrast) at the 
 edge of the gray patch. In mild or well-treated instances 
 they may disappear in the course of one to two weeks. 
 But, as a rule, they undergo further changes. The epi- 
 thelium becomes macerated and gradually detached, and
 
 SVi.HIUS OF THE UPPER AIR-PASSAGES. 295 
 
 a slightly bleeding sore surface remains. This may pro- 
 ceed to deeper ulceration if not treated, especially on the 
 tonsils. By the coalescence of several elliptic ulcers a 
 characteristic " serpiginous " appearance is often pro- 
 duced. The ulcers may become complicated by second- 
 ary infection, mainly with streptococci, but even occa- 
 sionally with the diphtheria bacillus. 
 
 In the nose early secondary manifestations are said to 
 be rare or at least give rise to so little disturbance that 
 they are not recognized. The writer, however, has a few 
 times seen very persistent superficial ulcerations on the 
 septum, serpiginous in appearance, but without tendency 
 to extend in depth. They were probably the outcome of 
 mucous patches, and when recognized after a duration of 
 months, yielded quite promptly to specific treatment. 
 
 208. The later or so-called tertiary forms of syphilitic 
 localization in the nose and throat are not rare. They 
 may appear within one year after infection, but are much 
 more common at later periods, even twenty years or more 
 after the beginning of the disease. In the pharynx the 
 lesion is a gummatous infiltration. It is either relatively 
 diffuse and superficial, being in the mucous membrane 
 itself, or it may be a more circumscribed nodule in the 
 underlying tissues. Its preferred site is the soft palate, 
 less often the pillars, but it may occur on the posterior 
 wall or the lingual tonsil, or be hidden in the naso- 
 pharyngeal space. It causes but little disturbance until 
 it ulcerates, which happens in the course of one to two 
 weeks, unless energetically treated from the start. When 
 the gumma breaks down, a small, well-defined, often 
 crater-shaped opening is found, from which a thin puru- 
 lent secretion issues. If healing is not brought about 
 by prompt treatment, further extension of ulceration fol- 
 lows, probably dependent on secondary infection with 
 other microbes. In the soft palate a gumma usually 
 opens on both surfaces, and causes thus a permanent per- 
 foration. If situated on the posterior wall or the pillars, 
 the ulceratioii is likely to lead to extensive shrinkage and
 
 296 SYPHILIS OF THE NOSE AND PHARYNX. 
 
 adhesions after healing. Very serious mechanical dis- 
 turbances may result therefrom. In some instances gum- 
 matous ulceration of the throat has given rise to serious, 
 even fatal, hemorrhages. In the nasopharynx syphilitic 
 ulceration causes severe headache and profuse secretion. 
 Postnasal examination with the mirror should not be 
 neglected in syphilitic patients with symptoms of disease 
 above the palate. 
 
 Within the nose, syphilis can produce a number of 
 well-defined lesions which can be distinguished as 
 
 Gummatous infiltration. 
 
 Ulceration of the septum. 
 
 Necrosis of bony wall. 
 
 Diffuse hypertrophic rhinitis. 
 
 Syphilomatous tumors. 
 
 Ultimate atrophy of the mucous membrane. 
 
 209. Gummatous infiltration appears as a more or less 
 circumscribed tumefaction mostly on the septum, in its 
 upper and anterior area, to a less extent along the floor or 
 on the inferior turbinal. In other localities it is quite 
 uncommon. During the formation of the gumma it 
 may cause considerable aching pain or headache, espe- 
 cially if on the septum. Otherwise no symptoms are 
 produced except slight stuffiness, but breaking down of 
 the gumma is sure to follow unless it is promptly treated. 
 A crater-shaped fistula results, leading into considerable 
 depth. The purulent secretion issuing is likely to dry in 
 the form of crusts. From this time on there may or may 
 not be associated with the localized gumma a diffuse 
 rhinitis with profuse discharge of pus. The ulceration 
 of the gumma shows no tendency to extend in area 
 except when situated on the septum. 
 
 210. Late syphilis leads often to characteristic perfora- 
 tion and destruction of the septum. It is not definitely 
 known whether this ulceration always starts from a dis- 
 tinctly localized gumma or not. It begins usually in the 
 cartilaginous portion, often but not always quite high up,
 
 SYPHILIS OF THE UPPER AIR-PASSAGES. 297 
 
 but is sure to extend to the bony septum unless checked. 
 It is a typical progressive caries. If not checked, it will 
 destroy a large part of the septum in the course of months 
 or years. The perforation is rarely seen when very small, 
 as probably a fairly large area sloughs away at once. It 
 has not the typical round form of the non-syphilitic 
 perforating ulcer. Its edges are thickened and often de- 
 formed. The ulcerated edge secretes a thick pus, which 
 dries in adherent, yellowish-green crusts. Quite com- 
 monly there is, besides, free purulent secretion from the 
 entire nasal surface. (Compare Fig. 2, Plate I.) 
 
 In the course of time caries of the septum is followed 
 by deformity of the external nose, sometimes with pitiful 
 disfiguration. Of course, all possible degrees of deformity 
 may be seen, from slight sinking in of the bridge to a 
 typical saddle-shaped nose, or a retraction of the entire 
 external organ, leaving two up-turned apertures. Even 
 these may be disfigured or narrowed if gummatous infil- 
 tration of the alae nasi has been allowed to do its ravages 
 without check. The sinking in of the nose is not due to 
 the mere defect of the septum. Even a very large per- 
 foration leaves the septum strong enough to support the 
 bridge. Indeed, the latter is practically self-supported 
 by the architecture of the nasal bones. Moreover, the 
 sinking in does not occur during the time the perforation 
 extends, but usually follows it at a later period. The re- 
 traction is due to cicatricial shrinkage of the septum, and 
 is rarely seen in patients who have been properly treated, 
 even though they have a large hole in the septum. 
 
 2ii. Essentially different from the caries of the septum 
 is syphilitic necrosis of the bony walls. This is not a 
 progressive lesion. It is practically never seen at its 
 beginning when the patient merely complains of some 
 stuffiness. It probably begins as a syphilitic disease of 
 the arteries of a small area, leading to their obliteration 
 and to the death of a circumscribed sequestrum of bone. 
 The piece of dead bone varies in size as much as ordinary 
 coins do. It is more often a fragment of two adjoining
 
 298 SYPHILIS OF THE NOSE AND PHARYNX. 
 
 walls than a single plane lamella of bone. Its most fre- 
 quent location is at the rear area of the junction of the 
 horizontal plate of the palate bone and the vomer, but it 
 may occur almost anywhere. Perforations of the hard 
 palate with opening between mouth and nose are com- 
 mon and characteristic. As a rule, they are small on 
 account of the integrity of the lining membrane of the 
 mouth. The maxillary sinus may be opened by necrosis. 
 A portion of the ethmoid labyrinth may come away. 
 In one case on record the sphenoid body was thrown off. 
 The symptoms which compel the patient to seek advice 
 are the offensive discharge and the horrible stench. The 
 latter is absolutely characteristic of syphilitic necrosis. It 
 cannot be influenced in any way whatsoever until the piece 
 of dead bone is removed. No matter how accessible the 
 sequestrum may seem, deodorizing substances will not 
 conquer the smell. By the use of douches with perman- 
 ganate of potassium and sprays of essential oils the patient 
 can merely make his presence tolerated until the dead 
 bone is removed. The sequestrum can be felt by the 
 probe. On account of the intricate anatomy of the nose 
 it would usually require a formidable operation to remove 
 the sequestrum. It is hence the wiser plan to wait until 
 it is nearly detached, when it can be seized with forceps 
 and extracted. This may take from three to six weeks 
 or even longer. By breaking off a portion of the seques- 
 trum and leaving a part in place, nothing is gained. 
 Within a few days after the dead bone is cast off the odor 
 ceases. The necrosis is not progressive, and hence as 
 such is not influenced by specific treatment. But it is 
 commonly associated with a purulent rhinitis, which is 
 of specific origin and which yields to internal medication 
 as soon as the necrotic. piece of bone has been expelled. 
 
 213. In connection with the various lesions described 
 there is, as a rule, a diffuse purulent rhinitis with moder- 
 ate diffuse swelling of the nasal mucous membrane. This 
 form of syphilitic rhinitis is characterized by a profuse, 
 thick, greenish-yellow discharge tending to dry in the
 
 SYPHILIS OF THE UPPER AIR-PASSAGES. 299 
 
 form of adherent crusts. If there is no bony necrosis, no 
 odor is present at first. But by reason of neglect second- 
 ary decomposition may take place and give rise to a foul 
 smell. Characteristic of the disease is its tendency to 
 form broad adhesions. Synechiae, especially when multi- 
 ple, between the septum and the turbinal processes are 
 almost diagnostic of syphilis, unless clearly due to im- 
 properly done operations or cauterization. This purulent 
 rhinitis, unlike most syphilitic lesions, is not self-limited 
 if not specifically treated. During its earlier period it 
 yields to internal medication, aided by local measures, 
 though not always promptly. If it has been allowed to 
 turn into atrophy of the mucous membrane, it is almost 
 incurable. 
 
 213. A special form of localized nasal hypertrophy of 
 syphilitic origin is the syphiloma, a tumor of granulation 
 tissue. The tumor, sometimes multiple and variable in 
 size, is soft and friable and easily broken down by manipu- 
 lation. In color it is grayish pink. It may spring from 
 the septum or from a turbinal. It is often, but not always, 
 associated with gummatous infiltration or some destruc- 
 tive process adjacent to it. Besides local stuffiness and 
 discharge, it may give rise to distant symptoms like 
 headache. It is a rare lesion, and may create diffi- 
 culty in diagnosis. Histologically, it cannot be readily 
 distinguished from tubercular tumors and soft sarcomata. 
 It consists of mucous membrane infiltrated with round 
 cells, so as to give it the structure of granulation tissue, 
 often containing some giant cells. Its arteries are char- 
 acteristically thickened by round-cell infiltration. The 
 best plan is to remove it at once by the use of the snare. 
 A relapse, however, must be expected unless specific 
 treatment is pursued. 
 
 214. When syphilitic rhinitis is not checked in the 
 beginning by specific treatment, it proceeds to the stage 
 of atrophy of the entire nasal mucous membrane. The 
 clinical appearance is now strikingly like that of ad- 
 vanced ozena viz., large spacious passages with rudi-
 
 300 
 
 SYPHILIS OF THE NOSE AND PHARYNX. 
 
 mentary appearance or nearly complete absence of the 
 turbinals, and thin, dry, cicatricial looking mucous mem- 
 brane lined with adherent greenish crusts (Fig. 84). The 
 presence of any ulceration or perforation of the septum 
 distinguishes it absolutely from non-syphilitic ozena. 
 
 FIG. 84. Syphilis of the nose ; external nose sunken in ; alveolar process 
 defective, and communication between nose and mouth ; septum almost entirely 
 destroyed, except at its rear end. The alse nasi are enormously thickened, and 
 the mucous membrane is mostly hypertrophic. Inferior turbinal atrophied, espe- 
 cially in front ; middle turbinal atrophied in front, enlarged toward the rear ; 
 hiatus semilunaris exposed by reason of atrophy of its bony boundaries while 
 the surrounding mucous membrane is considerably hypertrophied (Zuckerkandl). 
 
 The odor, too, is not quite that of ozena, though it may 
 resemble it closely. In some instances there is no odor. 
 At this stage the disease is practically incurable. The 
 annoyance may be lessened by the continued use of 
 douches and Gottstein's tampons. Specific treatment 
 has no influence upon it.
 
 TREATMENT. 3<DI 
 
 315. All specific lesions in the nose and throat are 
 very readily controlled by internal treatment if begun 
 early. The earlier or secondary manifestations require 
 mercury. Its effect is the same whether given internally, 
 by hypodermic injection, or by inunction. The latter 
 mode is regarded as the most thorough and permanent 
 in its effects. It is not necessary, and, indeed, very un- 
 desirable, to induce salivation or disease of the gums. 
 This should be guarded against by thorough attention to 
 the teeth by removing tartar and by mechanical cleansing. 
 Thorough dental cleanliness should be enforced. The 
 gums may be hardened by using finely powdered salt 
 upon the tooth-brush. Care must be taken not to per- 
 mit the presence of decomposing food between the 
 teeth, and any cavities should receive the attention of a 
 dentist. The slightest salivation or tenderness or bleed- 
 ing of the gums should cause a temporary intermission 
 in treatment. If the gums become affected, they may 
 be brushed with diluted tincture of myrrh (i : 20), and 
 a mouth- wash of thymol solution and oil of cloves (^ 134) 
 may be used at short intervals. Chlorate of potash tab- 
 lets kept between gums and cheek seem also to be of 
 some service. 
 
 lodid of potassium has a less pronounced influence on 
 the early specific lesions, unless they assume a gummatous 
 appearance independent of their recent date. In later 
 manifestations iodid is the sovereign remedy. Its dosage 
 must be increased rapidly until an effect is obtained, 
 which should be apparent in four or five days. It is best 
 to begin with 15 drops of the saturated solution in order 
 to guard against unpleasant effects, which may exception- 
 ally occur in case of idiosyncrasy. The dose should be 
 increased by 5 drops each .successive time (three times 
 daily) until an effect is obtained or up to the limit of 
 tolerance. In exceptional cases as much as 8 to 10 grams 
 per dose may be required usually one-third of this suf- 
 fices. It is tolerated best when given after meals in 
 several glasses of fluid, preferably milk. A slight degree
 
 3O2 SYPHILIS OF THE NOSE AND PHARYNX. 
 
 of iodism need not interrupt its administration, as these 
 untoward symptoms may disappear in spite of its con- 
 tinued use. 
 
 Local treatment is often required in addition on account 
 of the complication by secondary infections. Ulcerated 
 surfaces are benefited by nitrate of silver application (20 
 to 30 per cent.) or Loffler's solution. The pain of ulcers 
 in the pharynx is alleviated by orthoform. Nasal sup- 
 puration requires removal of discharge by the douche or 
 at least the frequent cleansing with liberally used sprays. 
 When the nasal secretion dries in the form of crusts in 
 spite of these measures, this occurrence can be prevented 
 by tampons of cotton or gauze. When applied to raw 
 surfaces, iodoform gauze for the tampon is a distinct ad- 
 vantage, but not if in contact with intact mucous mem- 
 brane. The patient must, of course, be consulted whether 
 he will permit the iodoform odor. 
 
 2i6. Inherited syphilis can produce the same lesions in 
 the nose and throat as the acquired disease. This may 
 occur at any time from earliest childhood to adolescence 
 or beyond. The sunken-in nose is, unfortunately, a fre- 
 quent stigma of hereditary syphilis. Many authors refer 
 to the frequency of diffuse purulent rhinitis (snuffles) in 
 syphilitic infants. The writer has not been convinced, 
 either by personal experience or from any definite state- 
 ments in literature, that the often reiterated statement 
 that severe coryza in a nursling is strongly suggestive or 
 even indicative of syphilis is based on careful observa- 
 tion. Various syphilitic lesions, some of them compli- 
 cated with the above-described specific purulent rhinitis, 
 may occur even at the earliest period of life. But, on 
 the other hand, the majority of instances of coryza in 
 syphilitic infants are probably not specific in origin, 
 but are merely acute nasal inflammation complicated 
 by hypertrophy of the pharyngeal tonsil. As soon as 
 the diagnosis of a nasal specific lesion can be made, the 
 infant should, of course, receive specific treatment. 
 
 The writer has not attempted to give more than a mere
 
 TUBERCULOSIS; 303 
 
 outline of the treatment of syphilis, since fuller details 
 can be found in any special work on syphilis. 
 
 TUBERCULOSIS. 
 
 5517. Tuberculosis does not often cause clinical mani- 
 festations in the nose or pharynx. In most instances the 
 tubercular lesions are secondary to other foci of the dis- 
 ease in the body. Yet occasionally primary infection is 
 encountered. The disease begins as a superficial infiltra- 
 tion of the mucous membrane with miliary tubercles 
 in a small area. The spot appears unevenly swollen and 
 congested and is easily eroded. It changes soon into an 
 ulcer with ill-defined edges, grayish-yellowish surface, 
 and surrounded by flabby, bleeding granulations. Ad- 
 joining the ulcer, but sometimes, too, without ulceration, 
 the disease produces, in rare instances, tumors of granu- 
 lation tissue of pinkish-gray appearance and spongy con- 
 sistency tuberculoma, which may puzzle the diagnos- 
 tician. 
 
 In the nose tubercular disease affects the septum more 
 frequently than other parts of the wall. At the entrance 
 of the nose tuberculosis of the mucous membrane is some- 
 times evidently due to extension of lupus of the adjacent 
 skin. In the pharynx its site by preference is the soft 
 palate. When the uvula is involved in infiltration, it is 
 characteristically changed into a thick, misshapen stump. 
 When not involved, it appears unproportionately thin. 
 Less often than on the soft palate tuberculosis may invade 
 other parts of the postnasal space or pharynx. 
 
 In the nose it causes but moderate disturbance, stuffi- 
 ness, seropurulent, fetid discharge, not rarely, however, 
 headache and feeling of heaviness. In the lower pharynx 
 tubercular ulceration causes great pain during swallow- 
 ing, and if not relieved, may lead to starvation. It gives 
 a very foul breath, probably from secondary invasion 
 by concomitant bacteria. In the nasopharynx tubercular 
 ulceration may run an almost latent course. Wherever
 
 304 TUBERCULOSIS OF THE NOSE AND PHARYNX. 
 
 situated, tuberculosis pursues a slow but steady progress 
 unless checked therapeutically. 
 
 The diagnosis is usually not very difficult. The pres- 
 ence of cutaneous lupus or the appearance of yellowish 
 miliary tubercles at the edge of the spot confirms the sus- 
 picion raised by the above-described appearances. The 
 histologic structure of tubercles in excised fragments or 
 the demonstration of the tubercle bacillus renders the 
 diagnosis absolute. In case of doubt certainty can be 
 obtained from a diagnostic injection of tuberculin. 
 
 218. The treatment is essentially surgical. The tuber- 
 cular tumor is snared off. The ulcer is curetted and 
 cauterized. Opinions are divided as to the preference for 
 the galvanocautery or the application of lactic acid (the 
 latter on a pledget of cotton). A fair minority of per- 
 manent cures have been reported. As a rule, the disease 
 cannot be completely eradicated, especially when com- 
 plicated by tuberculosis of other organs. The patient 
 should receive all possible benefits in the way of hygienic 
 management and climatic environment that can be given 
 him. Tuberculin has received scarcely a fair trial in this 
 disease, as the lesions are usually seen at an advanced 
 period beyond the power of this specific agent. The 
 pain of pharyngeal ulceration can be well controlled by 
 orthoform. 
 
 219. Much discussion has taken place within the past 
 few years as to what extent the tubercular virus enters 
 the system through the upper air-passages. It was start- 
 ling news to learn that among the healthy attendants in 
 the tubercular wards of hospitals a large number show 
 the presence of tubercle bacilli on the surface of the 
 intact nasal lining. In all probability the presence of 
 the normal mucus and the movement of the epithelial 
 cilia ordinarily prevent infection. Further research has 
 shown, however, that tubercles are not uncommon 
 in the hypertrophied pharyngeal and faucial tonsil. 
 Various observers have found miliary tubercles with 
 characteristic bacilli in sections of excised tonsils, in
 
 SCROFULOSIS. 3O5 
 
 some instances as often as one out of every six. A 
 larger number of observations has shown an average 
 of about 5 per cent. This form of tuberculosis is en- 
 tirely latent, and such tubercular tonsils cannot be 
 distinguished from ordinary hypertrophy. The signifi- 
 cance of this frequent tubercular infection is somewhat 
 reduced by the fact that it is almost invariably secondary 
 to tubercular disease of other organs, especially the lungs. 
 It is, indeed, not proven that it does ever occur as a pri- 
 mary invasion. On the other hand, it has been shown 
 that in autopsies of subjects dead of tuberculosis tubercles 
 are found very commonly in faucial tonsils, perhaps a 
 little less often in the pharyngeal tonsil. This is true 
 even when the tonsil is not morbidly enlarged. Although 
 clinically latent, tuberculosis of the adenoid structures is 
 not harmless, as it leads to descending tuberculosis of the 
 cervical lymph-glands and may thus help to disseminate 
 the disease through the body. The excision of tubercular 
 tonsils causes no reaction different from that in ordinary 
 cases. 
 
 22O. Scroftilosis has often an important relation to 
 the upper air-passages. At present it is almost generally 
 admitted that this disease is really but a form of tuber- 
 culosis, the reaction of the juvenile organism to poisons 
 generated in some tubercular focus, usually in a lymph- 
 gland. The lesions produced by scrofulosis in the nose 
 and pharynx are not in themselves tubercular. The 
 most characteristic manifestation is the subacute sero- 
 purulent rhinitis of scrofulous children, described in ^[ 35. 
 A thin discharge, variable with the season, frequently 
 relapsing, and often associated with eczema below the 
 nose, produces a typical picture. This rhinitis is the fre- 
 quent precursor of phlyctenular keratitis, a character- 
 istically scrofulous affection. Scrofulous children are 
 commonly subject to enlargement of the pharyngeal ton- 
 sil in connection with the rhinitis described. There is, 
 as a rule, but a -minor degree of adenoid hypertrophy. It 
 is, however, rare to find a scrofulous child without some 
 
 20
 
 306 LEPROSY. 
 
 adenoid enlargement. On the other hand, it cannot be 
 said conversely that enlargement of the pharyngeal tonsil 
 is necessarily indicative of scrofula. But some of the 
 symptoms formerly referred to scrofula are largely de- 
 pendent upon the hypertrophy of the tonsil. The fre- 
 quent attacks of nasal catarrh, the thick lips, the liability 
 to purulent otitis, all formerly considered manifestations 
 of scrofula, are the direct results of the pharyngeal hyper* 
 
 trophy. 
 
 LEPROSY. 
 
 221. Although this disease is but a rare curiosity in 
 our part of the country, it invades the upper air-passages 
 so often that a few diagnostic comments seem proper. It 
 has been claimed recently by Sticker that lepra begins, 
 as a rule, in the nose in the form of septum ulceration, 
 and that this is one of its most persistent manifestations, 
 all the more important because the nasal discharge con- 
 tains the specific germs in abundance. The lesions in 
 the nose and pharynx consist of follicles which coalesce 
 and ulcerate. In the course of time a spontaneous heal- 
 ing takes place, resulting in smooth but extensive scars, 
 sometimes with a good deal of shrinkage. The diagnosis 
 is said to be fairly definite from local appearances, but 
 depends mainly on the detection of the systemic disease. 
 
 222. Rhinoscleroma, or scleroma of the upper air- 
 passages, is a disease which requires description in con- 
 nection with the diagnosis of syphilitic and tubercular 
 lesions. It is very rarely seen in this country, and only 
 in emigrants, but is quite common among the poor in 
 Poland and the eastern and southern provinces of Aus- 
 tria. It is a chronic, slowly progressive, incurable dis- 
 ease, which may not destroy life iintil at a very late period. 
 The lesion consists of nodular infiltration, sometimes 
 diffuse, sometimes circumscribed, often multiple. The 
 nodule, of hard and variable size, sometimes as large as a 
 bean, begins often in the skin of the external nose, and 
 may extend through the upper lip. In other instances it 
 commences in the pharynx. Gradually the process ex-
 
 RHINOSCLEROMA. 307 
 
 tends throughout the entire air-passages, including the 
 larynx and trachea. There is not much ulceration, but 
 rather a superficial erosion, with very profuse purulent 
 discharge, drying in the form of crusts. The disease is 
 identical with the blennorrhea of the air-passages de- 
 scribed by Stoerck. In the course of time the infil- 
 trated mucous membrane shrinks, and the resulting exten- 
 sive scars often lead to narrowing of the pharynx or 
 larynx. Tracheotomy may become necessary in order to 
 prolong life. 
 
 When the diagnosis cannot be made from the appear- 
 ance, an excised fragment can be examined microscopi- 
 cally. It shows granulation tissue, with some typical 
 large oval cells. In the tissues short bacilli are found in 
 great abundance, which resemble closely the pneumo- 
 bacillus of Friedlander or the bacillus mucosus of ozena. 
 They are justly regarded as the cause of the disease. 
 Scleroma cannot be influenced by any treatment.
 
 CHAPTER XXVI. 
 
 AFFECTIONS OF THE UPPER AIR-PASSAGES IN 
 THE COURSE OF OTHER DISEASES. 
 
 223. Measles. This disease is characterized by con- 
 gestion and irritation of the conjunctiva and the mucous 
 membrane of the entire upper air-passages from the start 
 before the cutaneous eruption appears. With good illu- 
 mination miliary red spots can often be seen on the first 
 or second day on the nasal mucous membrane, and still 
 more distinctly on the soft palate and tonsils, as well as 
 on the inside of the cheek. The diagnosis can thereby 
 be made before the rash appears on the skin. In the 
 milder cases the nasal and the throat lesions pass over 
 without further complication. In cases of moderate 
 severity a secondary coryza sets in, sometimes quite per- 
 sistent. Tonsillitis is a relatively rare complication, but 
 any exposure to diphtheria is very likely to lead to in- 
 fection as a sequel to measles. Nasal hemorrhages are 
 not uncommon before the rash appears. The nasal 
 sinuses are probably involved often, but it is very rare 
 that their affection is clinically evident. 
 
 224. Scarlet Fever. It is very rare and seems to 
 occur only in the mildest cases that scarlet fever is not 
 ushered in by an eruption in the throat, especially on 
 the soft palate. This is usually the first localized symp- 
 tom of the disease. It consists of dusky red, more or 
 less coalescing spots, the injection usually spreading 
 over the tonsils, and to some extent over the posterior 
 wall of the pharynx. Occasionally scarlatina begins 
 with a distinct tonsillitis. In cases of moderate sever- 
 ity the eruption fades as the cutaneous rash disappears. 
 In a large proportion of average and severe cases, how- 
 
 308
 
 SCARLET FEVER. TYPHOID FEVER. 309 
 
 ever, there is a secondary throat affection varying from 
 superficial inflammation to formation of diphtheritic 
 false membranes or even gangrenous sloughing. The 
 corresponding lymph-glands are always swollen and 
 tender. These throat lesions are mostly due to infection 
 by streptococci. Scarlatinous diphtheria, however, is in 
 some cases the result of secondary infection by the diph- 
 theria bacillus. The diphtheritic affection, due to the 
 streptococcus, does not show the tendency to extension 
 found in true diphtheria. Extension to the larynx is not 
 frequent. But from the start the more severe forms of 
 throat affection, even those without false membranes, 
 show a septic character and septic and pyemic sequels are 
 not uncommon. Purulent involvement of the ear is like- 
 wise a very frequent sequel. The throat affection, if of 
 any severity, may last two to three weeks. Treatment 
 has but a moderate influence. Antiseptic gargles and 
 sprays (thymol or the essential oil solution (see If 25 and 
 1 134) ) are of some service. The most active but dis- 
 agreeable local application is Loffler's solution (1" 25). 
 
 The nose is not involved as often in scarlet fever as the 
 throat. The initial rash is said to be visible on the 
 nasal mucous membrane in many instances. In a small 
 proportion of the more severe cases a purulent, some- 
 times a membranous, rhinitis occurs as a sequel. Autop- 
 sies show that in fatal cases disease of the nasal accessory 
 cavities is quite common, but clinically this is usually 
 not recognizable. 
 
 225. Small-pox is sometimes ushered in by nasal 
 hemorrhages. They are said to be of more serious prog- 
 nostic significance in adults than in children. It is stated 
 that, as a rule, characteristic papules appear on the palate 
 and tonsils even earlier than on the skin, and that these 
 follow the usual course and change into pustules. 
 
 226. Typhoid fever is attended by hemorrhage from 
 the nose in nearly one-half the cases, especially in young 
 people. Occasionally the bleeding is alarming. During 
 the later stage pharyngitis is not uncommon and some-
 
 3IO UPPER AIR-PASSAGES DURING OTHER DISEASES. 
 
 times small oval ulcers of some persistence are seen, but 
 with little liability to extend. 
 
 227. In leukocythemia nasal hemorrhages occur in 
 perhaps half the cases at different times. 
 
 228. Influenza. This disease has changed its char- 
 acter considerably in different years since its extension 
 throughout the world in the form of an epidemic in 1889. 
 In some years nasal affections seem quite uncommon ; in 
 others they are frequent. Autopsies have shown the 
 frequent involvement of one or more nasal sinuses. Prob- 
 ably many of these instances escape clinical detection. 
 In others the usual symptoms of sinuitis, especially of 
 the ethmoid cells and of the sphenoid sinus, are present. 
 The sinus affections are more often due to secondary 
 infection by streptococci and other germs than to the 
 influenza bacillus itself. Some of the influenza epidemics 
 are complicated in many instances by severe purulent 
 rhinitis, very liable to become subacute or chronic and 
 often leading to early, sometimes to late, involvement of 
 the ears. The throat suffers only exceptionally in this 
 disease. 
 
 229. Herpes. Herpes febrilis, the familiar "cold 
 sore," occasionally involves the pharynx. This occur- 
 rence is very uncommon in this part of the country. The 
 pharyngeal affection may occur in connection with herpes 
 of the lips or sometimes without the latter. It begins 
 with a sharp fever lasting not over a day. The herpes 
 vesicles in the pharynx may be few in number or very 
 numerous. The amount of congestion corresponds to 
 their number. Sometimes they heal within a few days; 
 more often each vesicle changes to a superficial ulcer 
 with yellowish deposit. Occasionally several coalesce 
 and form a diphtheritic-looking membrane. This may 
 protract the disease and confuse the diagnostician. 
 Herpes is said to attack some persons in frequent relapses 
 during the whole life. If the vesicles do not heal spon- 
 taneously within a few days, the ulcers may be touched 
 with nitrate of silver with advantage.
 
 DIABETES MELL1TUS. RHEUMATISM. 31 I 
 
 230. A few instances of herpes poster of the pharynx 
 have been recorded. The vesicles are larger than in 
 febrile herpes, and lead to deeper and more lasting 
 ulceration. As a rule, the spots are one-sided. There is 
 considerable pain, sometimes of a neuralgic order, and 
 its presence and persistence suggest the diagnosis. 
 
 331. Diabetes mellitus is said to reveal itself often 
 by persistent dryness of the pharynx. The writer has 
 never observed this symptom in diabetes. Recently 
 ulceration of the pharynx has been described as a compli- 
 cation of diabetes (Freudenthal). The ulcers on the ton- 
 sil, pillar, posterior wall, or base of the tongue may be 
 superficial or may extend deeper. They resemble tuber- 
 cular ulcers, but bacilli cannot be found, and, unlike 
 tubercular disease, they can be readily cured. The pain 
 which they cause interferes considerably with nutrition. 
 
 332. Rheumatism. Rheumatism has no relation to 
 any nasal lesion, but it is very frequently referred to by 
 authors as an etiologic factor in tonsillitis. This is 
 partly due to a misconception as to cause and effect. A 
 number of observers have noted that rheumatism may 
 follow acute tonsillitis. Indeed, tonsillitis is a frequent 
 antecedent in attacks of acute rheumatism, so much so 
 that the latter must be regarded in many instances as the 
 consequence of an inflammation of the tonsil. It is, how- 
 ever, an open question whether this is ordinary tonsillitis 
 or an inflammation due to the invasion by the specific, as 
 yet not identified, virus of rheumatism. The tonsillar 
 origin of rheumatism has been stated as high as 80 per 
 cent. (Fowler). But most observers give very much 
 lower figures (5 to 20 per cent). It has also been noted 
 that patients with the history of former rheumatism are 
 prone to attacks of acute tonsillitis. But the frequency 
 of this factor in the etiology of tonsillitis is, after all, a 
 very small one when compared with the prevalence of 
 tonsillitis, especially in children. Even in distinctly 
 rheumatic subjects acute tonsillitis follows its ordinary
 
 312 UPPER AIR-PASSAGES DURING OTHER DISEASES. 
 
 rapid course and is not influenced to any demonstrable 
 extent by antirheumatic treatment. 
 
 Some forms of chronic tonsillitis have been ascribed to 
 a rheumatic basis. The descriptions of different authors 
 are, however, so discordant, and their criteria of rheu- 
 matic origin so indefinite, that no positive conclusions 
 can be stated. The writer's personal experience has 
 made him familiar with a form of sore throat of indefinite 
 duration, fairly frequent, which in most cases can be 
 influenced promptly by the liberal use of salicylate of 
 sodium. The patient complains of pain in swallowing, 
 which he cannot localize. Inspection shows some diffuse 
 redness, but no localized inflammation of the mucous 
 membrane. The lesion is in all probability a rheumatic 
 inflammation of the fibrous fascia of the pharynx, and 
 not an affection of the mucous membrane. 
 
 233. lodism. The internal use of salts of iodin pro- 
 duces, in some persons, symptoms of nasal irritation. 
 The patient feels "dumpish," the head is "stuffy," the 
 nose full and obstructed, like in a fresh "cold," and 
 secretes an abundant thin mucus, but no pus. This may 
 or may not be associated with other evidences of iodin 
 poisoning, such as acne pustules, foul breath, and dis- 
 ordered stomach. Inspection shows turgescence of the 
 nasal lining, but not necessarily any hyperemia. As a 
 rule, the nasal irritation subsides within a day on with- 
 drawing the drug, or it may even cease in spite of its 
 continuance in larger doses. Very rarely it changes to a 
 purulent rhinitis. lodic irritation of the nose is due to 
 the "idiosyncrasy" of some patients, and may come on 
 even after small doses. Unless severe or persistent, it 
 need not prevent the continued administration in in- 
 creasing doses.
 
 CHAPTER XXVII. 
 
 TUMORS OF THE NOSE AND PHARYNX. 
 
 234. Neoplasms within the nasal cavity are of un- 
 common occurrence aside from the inflammatory hy- 
 pertrophies viz., polypi and papillomata. Polypi are 
 found clinically in about 2 per cent, of nasal patients, 
 but in dissections of unselected subjects Zuckerkandl 
 saw polypi present in about 10 per cent. Papillomata 
 are considerably less frequent. These overgrowths of 
 inflammatory origin have been described in 1 99 to 1 104. 
 In the present place it is necessary to refer to them 
 simply from a diagnostic point of view, and in order to 
 point out their relation to other growths. A variety of 
 nasal tumors, both benign and malignant, can assume 
 a polypoid shape, and may hence be mistaken for mu- 
 cous polypi. Such polypoid shape may be assumed by 
 a hard fibroid, an angioma, sarcoma, adenoma, car- 
 cinoma, and syphilitic or tubercular granulomatous 
 tumors. From all these the true mucous polypus can be 
 distinguished by its smooth, glistening surface, its rela- 
 tive softness without tendency to bleeding, and in most 
 instances its edematous condition, while its color varies 
 from that of the normal mucous membrane slightly in- 
 jected to a yellowish-gray gelatinous appearance when 
 markedly edematous. Polypi may, however, be asso- 
 ciated with other tumors, especially angiomata, so that 
 in complicated cases the diagnosis is not always simple. 
 Polypi grow mainly from the middle turbinal and the 
 various ethmoid lamellae. They have been very rarely 
 seen attached to the septum. 
 
 235. Next in order of frequency are the papillomata. 
 In well-marked instances these wart-like tumors are of 
 raspberry or mulberry shape, of reddish or violet hue, 
 
 313
 
 314 TUMORS OF THE NOSE AND PHARYNX. 
 
 sometimes single, sometimes multiple. From the typical 
 papillomata as large as a cherry there are all gradations 
 down to the most insignificant, scarcely circumscribed, 
 hypertrophic elevation of the mucous membrane. This 
 tumor, like the polypus, is of inflammatory origin, and 
 usually associated with purulent rhinitis. Its favorite 
 site is somewhere on the inferior turbinal, less often on 
 the nasal floor. It is not frequently met with on the 
 septum. When found at the front of the septum the 
 papilloma resembles the cutaneous wart by its decided 
 cauliflower appearance, due to indentation by its pro- 
 liferated epithelium. These hard septal papillomata 
 are regarded with distrust on account of their possible 
 transformation into malignant epithelioma, especially in 
 elderly people. 
 
 236. Nasal tumors produce at first very little dis- 
 turbance. The obstruction to breathing is not pro- 
 nounced until at a late stage, and is often ignored by the 
 patient. It is hence quite rare that tumors are seen at an 
 early period. The one symptom which leads most fre- 
 quently to their early detection is bleeding from the nose. 
 
 237* The tumor which more than any other reveals 
 itself by bleeding is the "bleeding polypus of the septum." 
 It is a single polypoid excrescence on the septum, of the 
 size of a shot to that of a pea, bleeding freely on touch. 
 It is always one-sided. It is rarely found in men, mostly 
 in adult women. In structure it is either granulation 
 tissue with dilated vessels, or a pure angioma or a mixed 
 fibro-angioma. Its only significance is its liability to 
 bleed and its recurrence after incomplete operation. It 
 should be radically removed by the snare (and curet) or 
 the galvanocaustic burner. 
 
 238. Another form of bleeding tumor is the pure or 
 mixed angioma in other sites. Although not frequent, 
 these growths are of considerable importance, on account 
 of the very free bleeding to which they may give rise. 
 This vascular tumor appears of the color of the normal 
 mucous membrane, is soft, even flabby, and bleeds upon
 
 HARD FIBROMA. CYSTS. 315 
 
 the slightest touch. It springs mainly from the external 
 wall in the form of a diffuse tumefaction, sometimes 
 lobulated enough to be polypoid in shape. It is made up 
 of cavernous tissue, dilated venous channels with thin 
 walls. On account of the prevalence of cavernous tissue 
 throughout the nose, different nasal tumors, such as sar- 
 comata, adenomata, and at times even harmless mucous 
 polypi are apt to be in part of angiomatous structure, 
 which point must be remembered in the diagnosis. The 
 unmixed angiomata may extend into adjoining spaces 
 like the orbit, and may thus prove quite annoying, 
 although not at all malignant. Vascular tumors can be 
 safely removed with a cold snare, provided they can be 
 thoroughly grasped. It is necessary to use a snare with 
 screw-nut, which can be drawn home very slowly in 
 order to avoid hemorrhage. When the snare cannot be 
 satisfactorily used, the attachment of the growth may be 
 cut through with the knife-shaped burner in a series of 
 sittings. The surgeon must be prepared, however, for 
 very copious hemorrhage. Electrolysis by means of 
 needles inserted near the base of the tumor is lauded by 
 some, condemned by others. It requires a current of 10 
 to 25 or even more milliamperes for five to ten minutes 
 at a time, with many repetitions at intervals of a few 
 days. 
 
 239. The hard fibroma is a rare form of nasal growth, 
 which may become serious by pressure, on account of its 
 continually increasing size. It is a firm fibrous structure 
 with broad pedicle. When detected early, it can be 
 removed with a snare. But after it has filled the nasal 
 cavity or extended beyond its confines, it may require 
 a major external operation in order to gain access to it. 
 
 240. Cysts are a frequent occurrence in the maxillary 
 and frontal sinuses, but very uncommon in the nasal 
 cavity. In rare instances a glandular retention cyst is 
 found on the floor or on the external wall. Even less 
 common is the development of a cyst in the septum 
 secondary to a hematoma which has not gone to sup-
 
 316 TUMORS OF THE NOSE AND PHARYNX. 
 
 puration. The diagnosis of the cystic nature of the soft 
 globular tumor can be established by puncture with a 
 hollow needle. A radical cure requires either removal 
 of the greater part of the cyst-wall or obliteration by 
 injection of tincture of iodin, which is not always suc- 
 cessful. 
 
 341. Osteoma is a rare form of nasal tumor springing 
 from the floor or external wall, or originating in one of 
 the accessory cavities. Its nature is recognized by its 
 hardness. Its seriousness depends on its rate of growth 
 and the displacement of tissue and organs to which it 
 ultimately leads. If accessible by the intrarjisal method,' 
 it can be removed without much danger, bn . its hardness 
 is such that it is necessary to chisel thiough the healthy 
 bone from which it springs. If too large to be accessible 
 from the nose, it may require a formidable operation in 
 order to be removed. Even less common are cartilagin- 
 ous tumors, chondromata, originating from the septum 
 or sometimes from the ethmoid bone. These growths 
 are apt to become detached from their matrix, being con- 
 nected in that case only by means of a bridge of mucous 
 membrane. When seen at this stage, their removal is 
 very easy. 
 
 242. Spurs and ridges on the septum which are some- 
 times referred to as exostoses and ecchondroses should 
 not be classified among tumors for reasons given in 1 114 
 and 1 115. The beginner should also be cautioned 
 against the mistake of taking an expanded middle tur- 
 binal for a true tumor. 
 
 Reference must again be made to the occasional, though 
 rare, occurrence of granulomatous tumors due either to 
 tuberculosis or even more rarely to syphilis. Either 
 tumor appears as a fleshy growth, readily bleeding on 
 touch, the tuberculoma being the least firm of the two. 
 The site is preferably on the septum, less commonly on 
 the floor or external wall. Both of these forms of morbid 
 growth are attended with seropurulent discharge, which 
 in tubercular disease is usually very fetid. These tumors
 
 OSTEOMA. 317 
 
 may prove puzzles to the diagnostician. Microscopically 
 they consist of rather firm granulation tissue, in part 
 even fibrous. Tubercles may not be found except in 
 some parts. Giant cells are met with both in syphilis 
 and in tuberculosis. Tubercle bacilli, if present at all, 
 are scant in number. In the syphilitic tumors the arte- 
 rial walls are found thickened and infiltrated. If the 
 history or concomitant lesions or the microscopic ex- 
 amination does not clear the diagnosis, it may have to be 
 based upon the result of a diagnostic tuberculin injection 
 or a week's employment of iodid of potassium in large 
 doses. 
 
 243. Of malignant tumors, sarcoma is more frequent 
 in the nose than true cancer. Both, however, are very 
 rare. The former is more likely to grow rapidly, dis- 
 placing the nasal walls, but less likely to ulcerate early, 
 and hence to bleed, than carcinoma. The latter is also 
 more apt to be painful. Sarcoma is essentially a disease 
 of youth; carcinoma, of more advanced age. Either 
 tumor presents itself as a firm reddish mass, often with 
 eroded or ulcerated surface, and liable to bleed, especially 
 when mixed with overgrown cavernous tissue. The 
 sarcoma is sometimes pigmented. Such a melanosarcoma 
 is not always as malignant in the nose as it is in other 
 localities. The diagnosis cannot generally be made until 
 after microscopic examination of a fragment, and even 
 this may prove indecisive. Unless radically removed, 
 these malignant tumors give a bad prognosis. Their 
 removal is generally a quite formidable operation. Ma- 
 lignant tumors may escape detection until a late period 
 if they originate in the maxillary or frontal sinus. 
 
 244. A tumor formed by the proliferation of the mucous 
 glands, the so-called adenoma, is intermediate between 
 benign and malignant tumors. The pure adenoma is 
 probably extremely rare. Most of these growths are 
 more of the nature of a true cancer. Relatively often it 
 is a mixed type adenoma with angioma. The writer's 
 experience has probably been exceptional in observing a
 
 3l8 TUMORS OF THE NOSE AND PHARYNX. 
 
 radical cure for at least three years after the intranasal 
 removal of a pure adenoma in an old man. 
 
 245. In the pharynx tumors, in the proper sense of the 
 word, are likewise not common. Hypertrophy of the 
 pharyngeal tonsil cannot be called a true neoplasm. In 
 examining the upper pharynx, especially when exploring 
 with the finger, the beginner should not be misled by an 
 exceptional prominence of the first cervical vertebra, 
 which may simulate a morbid swelling. Edematous 
 polypi, which are sometimes found in the nasal pharynx, 
 are, as a rule, of nasal origin, having grown beyond the 
 posterior choanae. The appearance of such a growth 
 when seen in the mirror is like that of the ordinary 
 nasal polypus. Its removal by the nasal or curved post- 
 nasal snare may be quite difficult. Lange has suggested 
 the use of a small stout blunt hook, introduced through 
 the nose, by means of which the growth, supported as it 
 is by the bony rim of the choanae, can be torn from its 
 attachment. 
 
 246. The most common, though by no means a fre- 
 quent, neoplasm in the nasal pharynx is the hard fibroid. 
 It occurs almost exclusively in boys, and if not previously 
 fatal, it is said to disappear spontaneously about the 
 twenty-fifth year of life. It is a firm fleshy tumor spring- 
 ing from the roof of the pharynx or the bony rim of the 
 choanse by a broad or often a multiple pedicle. It is apt 
 to become eroded or ulcerated, and may then attach itself 
 by adhesion to other surfaces. Felt at first only as a 
 foreign body, the presence of which affects the voice and 
 excites efforts at hawking, it becomes formidable as it 
 continues to grow. Although not very vascular, it bleeds 
 in many instances, often to an extent creating extreme 
 anemia. Drowsiness is often noted as its symptom. 
 The ulceration of its surface may cause sepsis, sometimes 
 fatal. When allowed to grow, it fills the entire upper 
 pharynx and occludes it absolutely. It may extend to 
 the nasal chambers and expand the lateral walls, causing 
 the disfiguring flattening of the face known as frog face.
 
 POSTNASAL FIBROIDS. 319 
 
 Exceptionally it grows through the roof of the pharynx or 
 nose, enters the cranial cavity, and kills by some cranial 
 complication. 
 
 247. The removal of a postnasal fibroma may prove 
 very difficult. The cold snare can generally not cut 
 through its firm base. When the attachment is well 
 accessible, the hot snare may answer. Considerable 
 hemorrhage may be expected. Electrolysis has been 
 employed with fair success. It requires, however, many 
 sittings, sometimes months, until the detachments have 
 either shrunk sufficiently or sloughed so as to permit 
 complete removal. A current of more than 20 or 25 
 milliamperes cannot be tolerated without narcosis. With 
 anesthesia, currents of two to three times that strength 
 have been employed. But even in that case many repe- 
 titions are necessary. When no urgent symptoms are 
 present, electrolysis may be considered the safest mode 
 of operating, and its tediousness may be shortened by 
 finishing with a hot snare as soon as feasible. When 
 these measures prove inapplicable, or when rapid removal 
 is indicated, access to the postnasal space must be gained 
 by some preliminary operation. The least formidable 
 one is the splitting of the soft palate in the median line 
 (leaving the uvula on one side). When fully accessible, 
 the growth is dissected out, hemorrhage controlled by a 
 tampon, and the palate sutured. In the case of large 
 growths this method is rarely sufficient, and more exten- 
 sive operations are required, either by a temporary re- 
 section of the superior maxilla or by entering through 
 the side of the pharynx. The operation becomes one of 
 considerable magnitude and danger. 
 
 Fibrous tumors are found in the lower part of the 
 pharynx to a much less extent. Being easily accessi- 
 ble, they can be recognized earlier and removed without 
 much difficulty. 
 
 348. The most common of all pharyngeal neoplasms 
 are papillomata. In this locality their surface is always 
 more or less cleft, like cauliflower, and the relatively
 
 32O TUMORS OF THE NOSE AND PHARYNX. 
 
 thick epithelium gives them a firm consistency. They 
 are found mostly on the pillars or the uvula, sometimes 
 hanging by a long thin pedicle. 
 
 249. Vascular tumors have been met with in the phar- 
 ynx, especially on the tonsils. They vary from a superficial, 
 nevus-like spot of vascularity to a tumor-shaped angioma. 
 In the former case the condition is harmless and usually 
 stationary, and requires, as a rule, no treatment. In the 
 latter case the presence of the protruding tumefaction, 
 the liability to further growth, and especially to bleeding, 
 render operation necessary. The snare, hot or cold, 
 should be used only if it can be applied to the base of the 
 growth beyond the area of dilated vessels, otherwise an 
 uncontrollable hemorrhage may result. If the shape of 
 the growth does not permit the use of the snare, it may 
 be dissected out with the knife-shaped burner, preferably 
 in one sitting. Under some conditions of inaccessibility 
 the better plan is to puncture the base of the growth with 
 the pointed galvanocaustic burner, and thus induce gra- 
 dual shrinkage and formation of an artificial pedicle, per- 
 mitting subsequently an easier removal. In this case it 
 is usually safer to puncture into healthy tissue beyond 
 the growth. Electrolysis has also been utilized in this 
 condition. It is easily manageable and fairly safe, but 
 its extreme tediousness is an objection. 
 
 250. Some peculiarities are presented by tumors grow- 
 ing in the soft palate between its buccal and nasal sur- 
 faces. They have been termed intramural tumors. The 
 majority of them are benign a fibroma or rarely a cyst 
 or a lipoma, but occasionally an adenoma or a malignant 
 sarcoma. In either case the tumor is encapsulated and not 
 difficult to dissect out from the buccal side. The diagnosis 
 of the nature of the tumor cannot generally be made 
 until after its removal. 
 
 251. Malignant tumors in the pharynx are not much 
 less frequent than benign growths. Of these, cancer is 
 rather more often seen than sarcoma, the former espe- 
 cially in advanced life, the latter in youth. The symp-
 
 MALIGNANT TUMORS. 321 
 
 toms may remain trivial for some months. Gradual 
 interference with speech and deglutition, pharyngeal 
 irritation, and secretion lead to their detection. Carci- 
 noma is, as a rule, painful in its late stages. Either 
 tumor may finally cause starvation on account of the 
 difficulty in swallowing. The main sites are the tonsil, 
 the lingual tonsil, and the palate. The posterior wall is 
 least often affected, and if at all, more likely secondary to 
 a laryngeal growth. Sarcoma is rather a more distinctly 
 circumscribed tumor than carcinoma, which appears and 
 spreads usually as a diffused infiltration with early ulcera- 
 tion. In sarcoma ulceration occurs later, if at all. The 
 breaking down of the growth gives rise to awful fetor of 
 the breath. Cachexia becomes marked by this time, and 
 may become complicated by sepsis. Subacute inflam- 
 matory attacks frequently start from the growth, and some- 
 times cause much inflammatory edema. Corrosion of large 
 arterial twigs, occasionally with fatal hemorrhage, has been 
 observed. Unless a radical operation is feasible, death is 
 only a question of time. In the diagnosis of malignant 
 growths, especially of carcinoma, all obtainable evidence 
 must be carefully weighed in order to decide between 
 this process, syphilitic chancre, gumma, and tuberculosis. 
 The cervical lymph-glands are enlarged early in can- 
 cer and primary syphilitic sores; often, but not always, 
 in tuberculosis, and, as a rule, not at all in sarcoma and 
 gumma. 
 21
 
 CHAPTER XXVIII. 
 
 FOREIGN BODIES IN THE UPPER AIR-PASSAGES. 
 RHINOLITHS. ANIMAL PARA5ITES. SURGICAL 
 INJURIES AND FRACTURES. CICATRICIAL CON- 
 TRACTIONS IN THE PHARYNX. 
 
 253. Foreign bodies get into the nose principally in 
 consequence of mischievous pranks of children. Beads, 
 beans and peas, seeds and kernels, small buttons, paper 
 wads, and similar articles are the most likely objects. 
 Bullets and fragments resulting from an explosion occa- 
 sionally remain lodged in the nose after perforating the 
 facial bones or migrating with suppurative inflammation. 
 Rarely do solid pieces of food, bits of bone, etc., enter 
 the posterior choanae by reason of coughing while swal- 
 lowing or during vomiting. Equivalent to foreign 
 bodies are concretions formed in place, the rhinoliths. 
 They are hard bodies, consisting principally of phosphate 
 of calcium. As a rule, they form around a foreign parti- 
 cle as a nucleus, sometimes around a bit of inspissated 
 pus. They occur especially in workmen in cement fac- 
 tories and lime-works. In other instances their origin 
 is obscure. They may be of any size up to that of a 
 plum-kernel or even larger, sometimes smooth and oval, 
 or again of irregular shape and rough. Their color is 
 quite variable. 
 
 Foreign bodies are lodged mostly in the inferior nasal 
 meatus, but may be impacted anywhere. Unless smooth 
 and bland, they are rarely tolerated long without causing 
 inflammation, with purulent or seropurulent discharge, 
 sometimes bloody, almost always offensive, and, of course, 
 ordinarily one-sided. Such a discharge should raise a 
 suspicion of foreign body, especially in young children, 
 
 322
 
 FOREIGN BODIES. - ANIMAL PARASITES. 323 
 
 in whom stippurative sinuitis is very rare. Granulations 
 are apt to form around the offending substance and may 
 hide it from view. Ulceration, even perforation of the 
 septum, can be caused by sharp-cornered bodies, especially 
 rhinoliths. Under these circumstances distant distur- 
 bances, headache, especially one-sided, and even asthma 
 are not uncommon. Nevertheless, foreign bodies have 
 sometimes been endured by patients for years and es- 
 caped detection. 
 
 The diagnosis depends upon feeling the foreign body 
 with the probe. Its removal may require tact, especially 
 when dealing with a child. When recently introduced and 
 not impacted, a foreign body like a button can often be 
 blown out by forcing air through the other nostril, ac- 
 cording to Politzer's method of inflation of the ear. If 
 forced back by blowing into the involved side, the sub- 
 stance enters the pharynx and may be swallowed. When 
 this method fails, the simplest way is to grasp the body 
 with stout forceps with scoop-shaped or large perforated 
 blades and to extract it. An unruly child requires nar- 
 cosis. Good illumination is indispensable. In the case 
 of round, smooth substances, especially when far back in 
 the nose, a spoon-shaped curet is often better than forceps. 
 If the purulent rhinitis does not subside within a few days 
 after extraction, it should be treated according to 1 34. 
 
 253- A special form of foreign bodies, found a number 
 of times in the nose, are animal parasites the maggots of 
 various species of flies, and particularly the screw-worn. 
 They may be present in large numbers and extend into 
 the maxillary and frontal sinuses, causing violent sup- 
 purative sinuitis. Their presence causes always much 
 inflammatory reaction and often extensive ulceration. 
 Death from cranial involvement or sepsis has occurred in 
 a noticeable proportion of reported cases. The diagnosis 
 is evident when maggots or worms are found on searching 
 with forceps. It has not always been found possible to 
 remove all parasites mechanically. Probably the least 
 objectionable antiparasitic poison is chloroform vapor
 
 324 INJURIES OF THE UPPER AIR-PASSAGES. 
 
 blown through the nostrils, while the patient breathes 
 through the open mouth. 
 
 As an exceptional occurrence the intestinal parasitic 
 worms, ascaris or oxyuris, have been found in the nasal 
 cavity and the maxillary sinus. 
 
 254. Foreign bodies may get into the maxillary sinus 
 through an artificial opening, especially when in the 
 alveolar process. Fragments of surgical instruments, 
 metal cannulae, remnants of gauze, etc., may maintain 
 suppurative inflammation until removed. If not felt by 
 the probe, when suspected they may be demonstrated by 
 an X-ray photograph, if of a material opaque to those 
 rays. 
 
 255. In the pharynx sharp foreign bodies get caught 
 when accidentally swallowed or aspirated. Fish-bones 
 and pins are the commonest objects, and they are usually 
 found in the tonsil or impacted in the pyriform sinus 
 between tongue and epiglottis. It is sometimes difficult 
 to see them. When found, they can be grasped by any 
 forceps with broad ends. 
 
 256. With the exception of fractures of the external 
 nose surgical injuries extend very rarely into the nose or 
 the pharynx. Although traumatism accounts for a mod- 
 erate number of septum deformities, its frequency has 
 been much overrated in some books. It is true that 
 violence to the external nose is very common in children, 
 but it cannot break the septum unless it smashes or dis- 
 locates the bridge of the nose. This statement is based 
 upon tests on the noses of cadavers by Zuckerkandl, as 
 well as upon his dissections of (united) fractures of the 
 septum. The history of a blow some time ago in the 
 case of a septum deformity is not proof that the latter 
 resulted therefrom, unless the nasal obstruction appeared 
 at once after the accident. Traumatic bleeding from the 
 nose occurs so readily that a fracture cannot be inferred 
 merely on account of epistaxis. Fracture with or with- 
 out dislocation of the nasal bones can be easily detected 
 soon after the accident, but within a few hours the swell-
 
 FRACTURES OF THE EXTERNAL NOSE. 325 
 
 ing may be so intense that nothing can be made out. Of 
 course, such extreme swelling is by itself highly sus- 
 picious of fracture of the bridge of the nose. If the 
 fracture is complicated by tearing of the mucous surface, 
 gaseous distention emphysema of the face may happen 
 when the patient sneezes. The interior of the nose should 
 be promptly examined whenever the bridge is broken. 
 A fracture of the septum involves always the cartilagin- 
 ous part. The ethmoid perpendicular plate will break 
 only from intense violence; the vomer, never. The line 
 of fracture is usually nearly horizontal, rarely vertical, 
 sometimes multiple. As a rule, the fracture is a simple 
 one with intact mucous membrane. The fragments of 
 the septum may override more or less. There may also 
 be dislocation and lateral displacement of the cartilagin- 
 ous plate at its junction with the vomer. Occasionally 
 a fracture of the nasal bones causes only bending, but no 
 fracture of the septum. In the bony septum the reunion 
 is ultimately due to callus, while the cartilaginous frag- 
 ments are merely joined by connective tissue. Unless a 
 broken septum heals with accurate adaptation of the frag- 
 ments, there will always remain more or less nasal ob- 
 struction. Fracture of the nasal bones leaves flattening 
 of the bridge of the nose proportionate to the dislocation 
 of the fragments. Not infrequently disfiguring asymmetry 
 of the external nose results from a break of the bridge 
 and septum. 
 
 When the patient is seen before firm union of the 
 fractured bones has taken place, every effort should be 
 made to restore the plane of the septum and the shape of 
 the external nose. Immediate firm tamponing of the 
 nasal passages with gauze has, on the whole, given the 
 best results. The bridge should be lifted from the inte- 
 rior with the largest rod or thickest probes, which can be 
 introduced and the septum straightened in the same man- 
 ner. Broad forceps, especially the Asch pattern, used in 
 the operation for deflected septum (Fig. 66), may aid in 
 reducing the dislocation of the septal fragments. Narco-
 
 INJURIES OF THE UPPER AIR-PASSAGES. 
 
 sis should be used if necessary. The nasal passages should 
 then be firmly packed with gauze on both sides, necessi- 
 tating, of course, mouth-breathing. After a few days the 
 Asch or Meyer rubber tube (1 119) may be substituted 
 for the gauze in the lower part of the passage. If the 
 comminution and impaction of the bridge of the nose are 
 such that the normal shape cannot be restored by manipu- 
 lation, the tendency of modern surgery is to reach the 
 fragments by an external incision of course, under 
 asepsis and to retain them in place, if necessary by 
 wiring. In the interior no incisions are ever required. 
 When a faulty union has begun, it is better to await the 
 final (partial) absorption of the callus than to refracture 
 at the time. The later appearances of a fractured septum 
 have been described in 1 116. 
 
 257. Cicatricial changes after ulceration may interfere 
 with the function of the pharynx to a variable, sometimes 
 an extreme extent. The most common lesion is adhe- 
 sion of one or even both posterior pillars to the posterior 
 wall, possibly to an extent separating practically the 
 nasopharynx from the oral pharynx. In other instances 
 the anterior pillars may be so contracted that the 
 palate cannot reach the posterior wall. Scars in the 
 region of the lingual tonsil may narrow the fauces. A 
 variable part of the palate may, besides, have been lost, 
 which, however, is not so common as a mere perforation. 
 Narrowing of the pharynx by cicatricial changes in the 
 posterior wall is less common. In the nasopharynx there 
 may be adhesions between the Hustachian prominence 
 and the posterior wall, bridging over or obliterating the 
 fossa of Rosenmuller. The two Eustachian orifices have 
 been seen united by a transverse bridge. 
 
 The most frequent cause of pharyngeal shrinkage is 
 said to be scleroma in those countries where it is preva- 
 lent, especially Poland. With us, tertiary syphilis 
 ranks first. Tuberculosis is rare and heals even less fre- 
 quently. Diphtheria can do much damage in exceptional 
 instances of deep ulceration. Shrinkage from swallowing
 
 CICATRICIAL CHANGES IN THE PHARYNX. ,. 327 
 
 caustics is very uncommon. -The disturbances may be 
 insignificant in case of moderate deformity, especially 
 after the patient has become accustomed to the annoy- 
 ance, or they may be extreme and of vital importance. 
 Partial or total shutting-offof the nasopharynx gives the 
 voice a nasal twang and enforces mouth-breathing. If 
 suppuration is started, it persists practically incurable 
 until the patency of the postnasal space is restored. The 
 ears may suffer from persistent exudative catarrh or sup- 
 purative otitis. Swallowing is made difficult by any 
 constriction of the fauces or pharynx. In extreme cases 
 starvation threatens. Even breathing may be interfered 
 with to an extent requiring tracheotomy, although this is 
 very exceptional unless the cicatricial shrinkage involves 
 the larynx. 
 
 Cicatricial adhesions cannot be prevented during the 
 healing of ulcers spreading over opposed surfaces. It is, 
 of course, worse in neglected cases on account of the ex- 
 tent of the ulceration. The treatment which gives the 
 most and immediate relief is the division of any folds of 
 mucous membrane for instance, the pillars, which are 
 made tense by the shrinkage without being involved in 
 the cicatrix. When space can be gained by such liber- 
 ating incisions in healthy tissue, the problem is an easy 
 one. In all other cases treatment is tedious and often 
 unsatisfactory. The division of adhering surfaces does 
 not prevent their ultimate reunion. Plastic operations are 
 rarely possible. Partial success can generally be obtained 
 by persistent dilatation, at first with sponge-tents, later 
 on by means of hard-rubber appliances, sometimes fast- 
 ened to the teeth according to dental methods. Fuller 
 details can be found in the larger treatises on diseases of 
 the larynx.
 
 CHAPTER XXIX. 
 
 INFLUENCE OF NASAL AND PHARYNQEAL AFFEC- 
 TIONS UPON OTHER PARTS OF THE ORGANISM. 
 
 258. Affections of the nose and pharynx are not rarely 
 the starting-point of disturbances in adjacent organs, or 
 even distant parts of the body. The majority of cases 
 of disease of the middle ear, various ocular troubles, 
 some systemic disturbances, rare instances of pyogenic 
 affections of the brain or its membranes, and quite often 
 certain functional nervous derangements, can be traced 
 etiologically to the upper air-passages. The routes 
 through which nasal or pharyngeal anomalies may in- 
 volve other organs can be summarized as 
 
 Extension of tumors; 
 
 Extension of infection; 
 
 Absorption of poisonous products; 
 
 Mechanical influences partly exerted through the blood 
 and lymph circulation, partly through impeded breath- 
 ing; 
 
 Nervous or so-called reflex disturbances. 
 
 In some of the cases of distant disturbances the exact 
 mode of origin is not entirely clear ; in some others nasal 
 anomalies exert their influence through several of the 
 above-mentioned routes. For most purposes, however, 
 this analysis of morbid influences suffices for an under- 
 standing of the pathogenesis. 
 
 259- Tumors originating in the nasal passages or ac- 
 cessory sinuses may invade the orbits or extend through 
 the ethmoid or sphenoid bone into the cranial cavity. 
 This is true as well of malignant carcinoma and sarcoma 
 as of benign but encroaching vascular tumors and fibro- 
 mata. There is, however, not a large number of such 
 occurrences on record. 
 
 328
 
 INFLUENCE OF NASAL AND PHARYNGEAL AFFECTIONS. 329 
 
 360. The most frequent mode in which nasal affections 
 involve other organs is by extension of infection. This 
 is quite rare in an ordinary uncomplicated coryza, rather 
 more likely in the acute rhinitis of influenza or measles, 
 but especially so when a purulent process occurs in nos- 
 trils previously stenotic. L/ess of a menace to the ear, 
 but more so to the orbit and brain, are affections of the 
 sinuses. It is not so much the continued chronic condi- 
 tion which is liable to extend as the subacute exacer- 
 bation when a fresh coryza is added. The organ most 
 likely to suffer by extension of nasopharyngeal dis- 
 ease is the ear, in the form of purulent otitis or serous 
 catarrh. The ear is endangered as much by pharyngeal 
 inflammations, even though not suppurative, such as 
 tonsillitis, pharyngitis, or diphtheria, as by purulent 
 processes in the nose itself. Pharyngeal affections are all 
 the more dangerous to the ear if the pharyngeal or 
 faucial tonsils are permanently enlarged. Whether the 
 common plastic form of middle-ear disease (dry catarrh) 
 comes under the head of infection is not known. Acute 
 inflammatory processes in the nose and pharynx are 
 likely to extend likewise into the larynx and bronchial 
 tubes, and if the disease becomes chronic in the upper 
 air-passages, it is also likely to persist in the lower. It 
 is not positively known, however, that disease of the 
 nose may directly lead to involvement of the lungs them- 
 selves, and various statements to this effect have not been 
 adequately supported by proof. An occasional complica- 
 tion of chronic purulent disease of the nose is facial 
 erysipelas, sometimes in recurring attacks. 
 
 Affections of the tear-passages are, as a rule, due to 
 extension of nasal disease. This is true of hyper- 
 trophic inflammation causing stricture, as well as of 
 purulent involvement of the tear-sac. Disease of the 
 frontal sinus and of the ethmoid cells may invade the 
 orbit, causing either a circumscribed abscess or a diffused 
 phlegmon. The eye itself may suffer in the course of 
 purulent rhinitis or affections of the sinuses. Acute
 
 33O INFLUENCE OF NASAL AND PHARYNGEAL AFFECTIONS. 
 
 nasal catarrh is often accompanied by an acnte conjunc- 
 tivitis. In what way the deeper structures of the eye 
 may become involved is not clear, but the coincidence 
 of eye disease with purulent nasal affections is often 
 striking, and their relationship apparently confirmed by 
 the results of treatment. Tedious forms of iritis, exuda- 
 tive choroiditis, and atypical subacute chorioretinitis have 
 been seen by the writer, as well as by others in connec- 
 tion with purulent sinus affections on the same side. 
 The writer, too, has seen peripheral palsies of the ex- 
 ternal ocular muscles occur during exacerbations of 
 purulent nasal conditions (on the same side), and cannot 
 but believe that they were dependent upon the latter. 
 How the infectious material is transported in these ob- 
 scure instances is not known. In rare cases on record 
 the optic nerves have suffered in the form of neuritis or 
 pressure atrophy in consequence of the upward extension 
 of sphenoid suppuration beyond its confines. Intra- 
 cranial infections in the form of meningitis and brain 
 abscess have been seen as the consequence of purulent 
 affections of the frontal and sphenoid sinuses and ethmoid 
 cells, very rarely in acute, mostly in chronic, cases. 
 This extension cannot be called a frequent one, although 
 probably many such instances are not correctly inter- 
 preted by the general practitioners. 
 
 Sinus suppuration leads in rare instances to pyemia or 
 metastatic inflammations in distant parts. This is true 
 also of ordinary tonsillitis. Endocarditis, joint affec- 
 tions, visceral abscesses, have been observed under such 
 circumstances. The relationship of tonsillitis to rheu- 
 matism has been discussed in f 232. To what extent 
 tuberculosis of the tonsils faucial or pharyngeal, cer- 
 tainly not a rare affection endangers the system by 
 extension is at present an open question. 
 
 261. Suppurative processes in the nose and accessory 
 cavities may undermine the health by the absorption of 
 toxins. The systemic poisoning reveals itself in some 
 instances by a loss of strength and appetite and increas-
 
 MECHANICAL INFLUENCE. 331 
 
 ing anemia. It is not improbable that the continued 
 absorption of poisons may account, for the neurasthenia 
 often observed in such patients. The swallowing of 
 pus is probably also not wholly indifferent, as the puru- 
 lent masses are not digested by the action of gastric juice 
 and pass through the stomach with their load of patho- 
 genic or fermentative bacteria. There may be some re- 
 lation between the dyspepsia often complained of and the 
 swallowing of nasal secretion. 
 
 Under the head of absorption of poisonous products 
 may also be included the various forms of toxic palsies 
 occurring subsequent to diphtheria. Statements as to 
 the possibility of such degenerative changes following a 
 simple tonsillitis have in no case been supported by a 
 sufficiently thorough bacteriologic examination of the 
 throat disease. 
 
 262. A mechanical influence upon the system may 
 result from nasal stenosis by reason of the increased 
 positive expiratory and negative inspiratory pressure 
 behind the narrowed region. As an instance of this 
 effect Freudenthal has claimed the frequent coexistence 
 of nasal obstructive lesions with hernia. Mechanical, 
 too, is the production of chest deformities in rickety 
 children in consequence of blockage by postnasal vege- 
 tations. A more frequent occurrence is the influence 
 exerted by obstructive, together with acute inflamma- 
 tory, nasal lesions upon the circulation in adjacent re- 
 gions. Bilateral nasal obstruction, especially when due 
 to the enlarged pharyngeal tonsil, is often accompanied 
 by mental apathy, inattention, and listlessness, a condi- 
 tion which has been termed aprosexia. It is probable 
 that this depends on circulatory disturbances within the 
 cranial cavity. This may be also the origin of some dull 
 headaches observed under such circumstances. Conges- 
 tion of the conjunctiva of the eyelids is a very common 
 incident in nasal disease, and in its turn predisposes to 
 secondary local affections like .blepharitis. Circulatory 
 disturbances are often revealed by a dusky hued turges-
 
 332 INFLUENCE OF NASAL AND PHARYNGEAL AFFECTIONS. 
 
 cence of the eyelids for instance, in hay fever. Con- 
 gestion and edema of the Eustachian orifices are common 
 conditions in nasal disease favoring morbid involvement 
 of these passages and of the middle ear. 
 
 A variety of disturbances may occur in connection with 
 impeded nasal respiration, such as restlessness during 
 sleep, increasing up to night-terror and nocturnal incon- 
 tinence of urine. These disturbances depend probably 
 on temporarily insufficient aeration of the blood. They 
 are observed often in children with adenoid vegetations, 
 but occasionally, too, in high degrees of nasal stenosis 
 due to other lesions. Anemia is not rarely dependent on 
 insufficient nasal breathing from adenoids or extreme 
 septum deformities, and improves after a successful 
 operation. In what manner the general malnutrition 
 so often found in children with adenoids is brought about 
 is not entirely clear. 
 
 363. Certain sequels of nasal and pharyngeal affections 
 which have attracted much attention are the nervous or 
 so-called reflex disturbances. The term "reflex" is not 
 an appropriate one, for in physiology it signifies the re- 
 action of a nerve center to an impulse reaching it through 
 a sensory nerve, the response being in the form of activity 
 of some centrifugal nerve. Of course, this definition is 
 inapplicable to sensory disturbances, and not quite appro- 
 priate to most of the motor phenomena which come under 
 this head, as these are but exceptionally the exaggeration 
 of a normal reflex act. Most of the so-called motor re- 
 flexes are really due to a state of morbid excitability 
 induced in the nerve centers by the peripheral stimulus. 
 The author, hence, prefers to call these nervous dis- 
 turbances (sensory, motor, or vasomotor) "neuroses of 
 peripheral origin" i. e., of nasal, ocular, etc., origin, 
 as the case may be. 
 
 The dependence of a neurosis upon a suspected periph- 
 eral lesion can only be proved definitely by a successful 
 therapeutic test. A commonly observed coexistence of 
 peripheral lesion and neurosis may suggest a relationship.
 
 NASAL " REFLEXES." 333 
 
 This suspicion may be confirmed by a time relation for 
 instance, when the nervous disturbances increase when- 
 ever the nasal symptoms become more pronounced. The 
 etiologic hypothesis is also favored when the nervous 
 symptoms are one-sided and on the side of the nasal 
 affection. But a definite proof is only furnished when 
 the neurosis ceases promptly after the elimination of the 
 peripheral lesion. Of course, the possibility of an in- 
 fluence by mental suggestion must be taken into account 
 in the case of transitory nervous phenomena. The etio- 
 logic proof is all the more positive, however, in those 
 cases in which the cure has been an incomplete one, and 
 in which a relapse of the neurosis coincides with the re- 
 turn of the peripheral affection. 
 
 Since these neuroses occur but in small proportion of 
 patients with nasal disease, it is necessary to assume that 
 other factors besides the peripheral lesion are requisite 
 for their production. We must infer an increased sensi- 
 tiveness or diminished resisting power of the nerve- 
 centers. The nasal lesions may have existed for a long 
 time without nervous disturbances, the latter appearing 
 only after other predisposing conditions had come into 
 play. In some cases this nervous instability is clearly 
 suggested by the patient's previous personal or family 
 history, as a hereditary liability to functional nervous 
 disease can often be elicited. In other cases previous en- 
 feebling influences, sedentary habits, and want of out- 
 door exercise, long interference with sleep, anxiety, 
 sometimes pregnancy, convalescence from infectious dis- 
 eases, and especially anemia play an etiologic role. But 
 neuroses of peripheral origin may also occur in persons 
 of apparently good health, in whom we must assume an 
 instability of the nervous system without being able to 
 prove it. These disturbances have but a remote con- 
 nection with hysteria. They may occur in hysteric sub- 
 jects, but are not particularly frequently observed in 
 them. On the other hand, they may be much exaggerated 
 and diversified by the coexistence of hysteria.
 
 334 INFLUENCE OF NASAL AND PHARYNGEAL AFFECTIONS. 
 
 Neuroses of nasal origin are favored by existing dis- 
 turbances of the stomach and intestines. Not merely are 
 these two conditions often associated, but it can be learned 
 in many instances that aggravation of the intestinal con- 
 dition increases both the nasal discomfort and the nervous 
 phenomena, while the successful management of dyspep- 
 sia or constipation may for the time reduce, or even 
 remove, the neurosis. 
 
 Nasal neuroses may be brought on by various nasal 
 lesions. Of the sensory neuroses, especially those of a 
 relatively constant character, the larger part is due to 
 affections of nasal sinuses. In the case of acute severe 
 sinuitis, headaches and neuralgic pains are so constant a 
 phenomenon that they must be considered a direct symp- 
 tom rather than a superadded rfeurosis. With sufficient 
 intensity of sinus inflammation every subject will get the 
 same pains, whether he be neurotic or not. But in the 
 case of chronic affections the condition of the nervous 
 system determines the amount and extent of suffering. 
 While in some a chronic sinuitis may cause no pain what- 
 soever, others of a more neurasthenic type complain at 
 least of periodic attacks, sometimes even of more or less 
 constant spells of neuralgic pains. An important deter- 
 mining factor is. the pressure of the pus in the sinus. 
 With retention there is much greater probability of pain 
 than when the flow through the natural orifice is unim- 
 peded. 
 
 Most motor neuroses and some sensory disturbances, 
 especially those of periodic type, are due to a different 
 form of nasal disease. They are observed mainly in pa- 
 tients with nasal irritability associated with turgescence 
 of the cavernous tissue. As stated in f 86, the liability 
 to turgescence of the nasal lining is in some instances due 
 to the presence of irritating lesions viz., small polypi, 
 papillomata, sharp-edged crests on the septum, or foci of 
 suppuration. Quite often there are septum deformities. 
 In such cases any existing reflex nervous disturbances 
 will generally cease after these primary lesions have been
 
 NEUROSES OF NASAL ORIGIN. 335 
 
 eliminated. But there are many instances in which nasal 
 irritability and vascular turgescence are observed without 
 any other coexisting intranasal anomaly. The condition 
 seems to be the result of previous acute nasal inflam- 
 mations in persons of a neurotic disposition. This nasal 
 irritability without coexisting other lesions is not rarely 
 the starting-point of neuroses. Their occurrence depends 
 in many such cases on the periodic turgescence of the 
 cavernous tissue, and if this be thoroughly destroyed, the 
 neurosis will cease. Since the galvanocaustic destruc- 
 tion of the enlarged cavernous tissue can put an end to a 
 neurosis, even without the removal of coexisting irritating 
 lesions, Hack, the pioneer in this field, formulated the 
 theory that nasal neuroses depended upon the turgescence 
 of enlarged cavernous tissue. This view has not been 
 upheld in its entire extent by subsequent experience. 
 But it is nevertheless true that neuroses of nasal origin, 
 especially motor neuroses and those of a periodic type, 
 rarely occur except in connection with periodic turges- 
 cence of the venous plexus. Neither diffuse hypertrophy 
 of the mucous membrane with relative contraction of the 
 veins nor atrophic processes of the nasal lining lead to 
 neuroses of this type. It is sometimes possible to induce 
 experimentally a transient attack of a neurosis, for in- 
 stance, headache or asthma by irritation of the mucous 
 membrane with a probe or with chemical irritants. It 
 can be seen in such cases that the intranasal turgescence 
 precedes the nervous disturbances. 
 
 264. The various forms of neuroses of nasal origin may 
 be summarized under the following heads : 
 
 The most typical reflex is sneezing, sometimes occur- 
 ring in fits of distressing duration and accompanied by 
 one-sided, later on even by bilateral, vascular occlusion 
 with serous discharge. The occurrence of this reflex 
 varies considerably with the nervous instability of the 
 patient at different times, and depends, of course, on the 
 occasions for direct provocation, such as drafts, dust, 
 irritant fumes, sometimes idiosyncratic smells. When a
 
 336 INFLUENCE OF NASAL AND PHARYNGEAL AFFECTIONS. 
 
 distinct morbid lesion can be found as the starting-point 
 of the irritation, a polypus or a septum crest with sharp 
 edge, sometimes even a fissure in the vestibule, the re- 
 moval of the lesion often stops the attacks permanently. 
 In other instances the reflex is only relieved, but not 
 entirely controlled, until the overdeveloped cavernous 
 tissue is destroyed by one or more thorough applications 
 of the galvanocaustic burner. Where no irritant lesion 
 can be found, the destruction of the excessive cavernous 
 tissue is the only therapeutic resource. There are, how- 
 ever, rare instances in which this nasal irritability occurs 
 without much accompanying vascular turgescence and 
 without any occlusion, and in such cases no local meas- 
 ures are applicable. The only way of benefiting these 
 patients is by judicious attention to the nervous system or 
 improved climatic environment. 
 
 265. Spasmodic cough is rarely due to nasal lesions, but 
 is not infrequently of pharyngeal origin. It has been 
 observed in connection with hypertrophies in the poste- 
 rior parts of the nasal passages, especially, however, as a 
 neurosis complicating enlargement of lymphatic tissue, 
 either of the pharyngeal tonsil or of follicles on the poste- 
 rior walls. Sometimes relatively small, though hyper- 
 trophied, faucial tonsils, especially when chronically in- 
 flamed, are the starting-point of coughing spells, as can 
 be shown by irritation with the probe. In most of these 
 instances, but by no means in all, the cough is, at least 
 in part, accounted for by a complicating inflammation in 
 the larynx or bronchial tubes. In others the cough is 
 purely a reflex from morbid spots above the larynx. 
 Proper local, especially surgical, measures can remove 
 the cough permanently. 
 
 266. Asthma is in certain instances a neurosis of nasal 
 origin. The frequency of this etiologic relationship has 
 been much overrated by some rhinologists since the 
 days of Hack, but underrated or too often ignored by 
 writers on internal medicine. It must be clearly under- 
 stood that asthma depends often on pulmonary lesions
 
 ASTHMA. 337 
 
 (emphysema), cardiac or renal disease, and is in no way 
 connected with the nose. But it is equally positive that 
 there are instances of typical asthmatic attacks which 
 result from nasal anomalies and are permanently cured 
 by their removal. The most frequent and the most 
 definite instances of this kind are those due to nasal 
 polypi. Here a complete removal of the growth stops 
 the attacks, while a return of the polypi brings back the 
 spells of asthma. In other cases the cause is suppurative 
 disease, sometimes of the maxillary sinus, more often of 
 the ethmoid cells. These affections are not cured so 
 quickly, and especially ethmoid disease may prove very 
 rebellious, with corresponding persistence of the asthma. 
 Repeatedly I have seen asthma dependent on spurs on 
 the septum, especially those which touch the middle tur- 
 binal toward the rear. Occasionally no structural nasal 
 lesion can be found except enlargement of the cavernous 
 tissue. A cure in such instances depends on the thor- 
 oughness with which the enlarged vascular tissue is 
 destroyed. The writer has observed a striking instance 
 of this kind in the person of a physician, a sufferer 
 from periodic asthma since childhood, who submitted to 
 a galvanocaustic burning in 1883. The first operation 
 gave him decided relief as to the frequency and average 
 intensity of the spells. But a continuation of galvano- 
 caustic treatment did not stop the attacks completely for 
 a long while. Fully impressed by the views stated at 
 that time by Hack, the patient submitted in the course 
 of a year to fourteen caustic operations, until the sub- 
 jective feeling of periodic nasal turgescence had ceased 
 completely, even on exposure. to dust and other irritations. 
 Since that time, a period of over fifteen years, the gentle- 
 man has been entirely free from asthma. 
 
 Hay fever is accompanied very commonly by asthmatic 
 breathing. Properly applied surgical measures often 
 relieve this asthmatic feature markedly, even if they do 
 not prevent hay fever. 
 
 The diagnosis of the nasal origin of asthma cannot 
 22
 
 338 INFLUENCE OF NASAL AND PHARYNGEAL AFFECTIONS. 
 
 always be made with certainty. It is probable when 
 nasal symptoms like occlusion and less often sneezing 
 fits directly precede the asthmatic attack. It is made 
 positive when the patient can check the spell by using 
 cocain or suprarenal solution in the nose at the beginning 
 of the attack. But failure of this test does not disprove a 
 nasal origin. There are, indeed, instances in which the 
 nasal symptoms are scarcely noticed by the patient. On 
 the other hand, the rhiuologist will meet occasionally 
 with therapeutic failures where there are remediable 
 nasal lesions, especially in cases of long duration. These 
 cases, probably at first a purely nasal neurosis, have 
 become complicated in the course of time by either 
 secondary changes in the nervous system or peripheral 
 lesions like emphysema, which remain after the nasal 
 anomaly is removed. 
 
 267. The characteristic symptom of the asthmatic 
 attack is difficult inspiration. This is attended by a 
 wheezing sound, audible even at a short distance. There 
 is a feeling of intense oppression over the chest. Ex- 
 piration, though not normal, is less labored. If not 
 aborted, the attack usually lasts hours. As a rule, the 
 patient has normal breathing between the asthmatic at- 
 tacks. In severe cases there may be labored breathing 
 continuously for long periods of time, intensified, how- 
 ever, to an agonizing extent during the typical attacks. 
 The spells recur in a very irregular manner. For a time 
 they may return every night. But, as a rule, asthma of 
 nasal origin does not occur so frequently or persistently. 
 Under favorable climatic influences or change of residence 
 it may stay away indefinitely. A mere change from one 
 street to another may have an influence. On the other 
 hand, dust and irritating gases or " idiosyncratic" smells 
 may bring on an attack. 
 
 The conditions upon which the impediment to breath- 
 ing depends have not been definitely demonstrated. 
 Tonic contraction of the diaphragm, spasm of the un- 
 striated muscular fibers in the bronchial walls, conges-
 
 NAUSEA VOMITING. 339 
 
 tion of the mucous membrane in the smaller bronchial 
 tubes, have been accused by different writers as the 
 lesions underlying the attack. The writer is inclined to 
 believe that in severe attacks edema of the bronchial 
 tubes probably plays a role, since an edematous condition 
 of the nasal mucous membrane can sometimes be demon- 
 strated in such patients. 
 
 The treatment of asthma will be discussed with refer- 
 ence to the cases of nasal origin only. Where no de- 
 monstrable intranasal lesions can be found, and where 
 close questioning elicits no history of nasal turgescence, 
 the case does not come under the care of the rhinologist. 
 In doubtful instances the patient may make the attempt 
 to abort the attack at the beginning by inserting pledgets 
 of cotton with 5 per cent, cocain solution, with or with- 
 out the addition of suprarenal extract. For permanent 
 purposes cocain should never be given. 
 
 For curative purposes the nasal lesion suspected as the 
 starting-point of asthma should be removed surgically. 
 Pronounced septum deflection should be straightened. 
 Lateral crests, especially those which touch the external 
 wall, should be cut off by the use of the saw, trephine, 
 or spoke-shave. Polypi should be removed and suppura- 
 tive foci properly treated. Where excessive cavernous 
 tissue plays a role, it must be destroyed completely by 
 the galvanocautery. Temporary relief may be obtained 
 by inhaling fumes of burning stramonium leaves, espe- 
 cially in the form of the so-called Kidder's pastilles (or 
 Schiffman's powder). Until the cure is completed a 
 change of residence may prove palliative. A trip to the 
 mountains gives immediate relief, sometimes lasting for 
 quite a while. 
 
 268. Nausea and efforts at vomiting are occasionally 
 caused by pharyngeal disease, especially by hypertrophy 
 and chronic inflammation of the lingual tonsil. These 
 disturbances are common, too, in connection with the 
 diffuse hypertrophic pharyngitis seen in smokers and 
 drinkers. In the latter cases the irritated condition of
 
 34O INFLUENCE OF NASAL AND PHARYNGEAL AFFECTIONS. 
 
 the lining of the stomach is probably also a determin- 
 ing condition. Nevertheless, local pharyngeal treatment 
 may prove satisfactory, but bad habits must, of course, 
 be corrected. 
 
 Cardiac disturbances, sometimes irregularities and inter- 
 mittence of the pulse, more often palpitation (tachycar- 
 dia), have been observed as the result of hypertrophies 
 of the posterior ends of the turbinals, and have been 
 checked by proper local treatment. 
 
 269. There are on record a few observations of exoph- 
 thalmic goiter (Graves' or Based ow's disease) which are 
 said to have been cured by the cauterization of intra- 
 nasal cavernous tissue. These cases were all reported 
 when the first enthusiasm concerning nasal reflexes pre- 
 vailed, and none have been described since that time. 
 
 Epileptic convulsions have been referred to a nasal origin 
 in a small number of instances. Many of these cases 
 have been reported after too short a period of time to be 
 considered as satisfactory demonstrations, yet there are a 
 few on record in which a nasal origin seems fairly well 
 established by the permanent cessation of the attacks 
 after nasal treatment. Reflex epileptoid spasm is prob- 
 ably a very rare, though possible, neurosis of nasal 
 origin. The writer has seen an instance of petit mal 
 with laryngeal spasm in an infant, apparently due to a 
 chronic pharyngitis which ceased permanently after the 
 successful treatment of the inflammation by nitrate of 
 silver. 
 
 Chorea has also been described as an occasional neurosis 
 of nasal or pharyngeal origin. The evidence, however, 
 is not satisfactory. It is entirely improbable that a 
 general chorea should be started in this manner, but it 
 is not unlikely that choreiform twitchings of the eyelids 
 and facial muscles may in some cases depend upon nasal 
 or pharyngeal irritation. While such cases may be 
 benefited gradually by proper local treatment, the thera- 
 peutic results are, as a rule, not sufficiently prompt to 
 prove the relationship.
 
 NEUROSES OF NASAL ORIGIN. 34! 
 
 There are on record a few instances of clonic spasm 
 of the facial nerve cured by intranasal cauterization. 
 
 270. Numerous sensory disturbances have been de- 
 scribed as reflex neuroses of nasal origin. In the case of 
 severe and constant headache and neuralgic pains accom- 
 panying the inflammatory lesions, especially acute sup- 
 puration of the sinuses, it seems more logical to classify 
 the pain as a symptom due to radiation of the sensation 
 rather than as a complicating neurosis. Periodic attacks, 
 however, of either headache or of neuralgic pains, can 
 be more properly interpreted as neuroses of nasal origin. 
 In the first publications on this topic, fifteen to eighteen 
 years ago, many instances of such pains were referred to 
 turgescence of the nasal cavernous tissue and apparently 
 cured by its destruction. More recent experience, how- 
 ever, has taught that, as a rule, demonstrable and struc- 
 tural lesions are present in these cases viz., sinus dis- 
 ease, polypi, or other tumors or septum crests. Thorough 
 search for intranasal lesions and judicious treatment lead 
 to many satisfactory results in obscure forms of headaches 
 and neuralgic pains. The writer's experience has shown 
 him that in some such instances the cause may be found 
 in suppuration at the roof of the pharynx, as well as in 
 the purely nasal lesions. 
 
 A form of sensory disturbances, very common in nasal 
 disease, especially in pronounced hypertrophic rhinitis 
 and septum deformities, is asthenopia, the inability to use 
 the eyes without itching, burning, smarting, and other 
 uncomfortable or painful sensations. It is doubtful 
 whether this is a purely nervous influence or whether 
 it does not depend in part upon a circulatory disturbance 
 within the eyes. In well-selected cases the therapeutic 
 results of nasal treatment are very satisfactory. 
 
 A few extremists have occasionally reported neuras- 
 thenia as a nasal reflex. This cannot but be considered a 
 misinterpretation. Neurasthenia can undoubtedly be 
 engendered in the long run in predisposed subjects by 
 long-continued suppuration of the nasal accessory cavi-
 
 342 INFLUENCE OF NASAL AND PHARYNGEAL AFFECTIONS. 
 
 ties. But this is a toxic rather than a nervous influence. 
 A neurasthenic patient can, moreover, be made worse by 
 any frequently recurring headache due to nasal disease. 
 In such instances nasal treatment may give relief by 
 abolishing the pain and permitting the depressed nervous 
 system to recover, but the alleged direct dependence of 
 neurasthenia upon peripheral irritation is not in accord 
 with any judicious views regarding the nature of neuras- 
 thenia. 
 
 Although a few reliable cures of asthma by the removal of 
 nasal polypi had previously been reported, the subject of " nasal 
 reflexes" received but little attention until Hack proved its im- 
 portance. In numerous publications from 1881 up to his death in 
 1887 he showed the frequency of a variety of neuroses of nasal 
 origin. The fullest details are found in his work, Ueber die op. 
 Radicalbehandlung bestimmter Formen von Migraine, Asthma, 
 Heufieber, etc. , W. Hack, 1884. At the same time Roe and Daly in 
 this country suggested the nasal origin of hay fever. A flood of 
 publications followed, many of them of uncritical character. Some 
 of the earlier crude ideas and exaggerations have since been re- 
 futed, while the better-founded claims have been extensively 
 confirmed. The attention given to nasal reflexes led also to the 
 recognition of the influence of nasal and pharyngeal diseases 
 upon the general health through other routes besides the nervous 
 system.
 
 I 
 
 
 ' 
 

 
 PLATE I. 
 
 FIG. I. Perforating (benign) ulcer of the nasal septum, its edge almost 
 entirely healed. 
 
 FlG. 2. Syphilitic ulceration of the nasal septum, extending toward the 
 rear further than the view ; the lower edge of the ulcer is covered with crusts ; 
 pus and crusts above the ulcer on the left side (reversed) ; a broad adhesion 
 between the right middle turbinal and the septum. 
 
 FlG. 3. Turgescence of the cavernous tissue of the rear ends of the (left) 
 inferior and middle turbinals, occluding a nasal passage otherwise structurally 
 normal ; the right side is represented after all engorgement has been removed 
 by a cocain spray. 
 
 FIG. 4. Hypertrophy of the mucous membrane of the inferior turbinals as 
 seen in the postnasal mirror. On the right side of the septum there is a poly- 
 poid cushion of hypertrophied mucous membrane ; the pharyngeal tonsil is 
 enlarged moderately and is not undergoing any marked involution. (From a 
 young man. )
 
 PLATE I. 
 
 FIG. 2.
 
 BOOK II. 
 DISEASES OF THE EAR.
 
 BOOK II. 
 DISEASES OF THE EAR. 
 
 CHAPTER XXX. 
 
 ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 271. General Anatomy and Development. The 
 
 auditory organ is divided into the interior, middle, and 
 external ear. The interior ear consists of the termina- 
 tions of the auditory nerve in the interior of chambers 
 hollowed out in the depth of the petrous bone. This, 
 the apparatus for the perception of sound, is the first part 
 of the ear developed in the embryo and the only part 
 found in the lower vertebrates, especially the fishes. It 
 develops at the side of the hind-brain vesicle in the form 
 of a pit in the epiblast, which, as it sinks in deeper, 
 changes into a vesicle detached from the surface. The 
 auditory nerve, growing out from the brain, enters this 
 vesicle. The latter elongates and divides into two por- 
 tions the upper becoming the utriculus, the lower, the 
 sacculus. From the upper extrude hollow ridges which 
 change into the semicircular canals. The lower cavity 
 sends forth a tubular extension, the cochlea. This tube 
 coils in a spiral manner in higher animals, reaching 2\ 
 turns in man. The semicircular canals, of which it is 
 doubtful whether they serve for hearing, exist in all ver- 
 tebrates, although the lowest fishes have but two. The 
 cochlea, the organ of sound perception, is developed 
 progressively in the animal scale beyond fishes. Semi- 
 circular canals and cochlea constitute the labyrinth con- 
 tained in tunneled-out spaces in the petrous bone. In 
 
 345
 
 346 ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 the course of embryonic growth these epithelial structures 
 become surrounded' by a cartilaginous capsule, which 
 ultimately changes into a thin compact bony shell of 
 characteristic shape imbedded in the cancellated bony 
 tissue of the petrous pyramid. Between the capsule and 
 its epithelial contents a layer of gelatinous embryonic 
 (mesodermal) tissue furnishes the membranous tunics of 
 the labyrinth, while its partial rarefaction leads to the 
 formation of the subsequent lymph-spaces filled with 
 fluid. The acoustic communication between labyrinth 
 and surrounding medium takes place through a mem- 
 branous window. It is remarkable how very little the 
 interior ear especially the semicircular canals varies 
 with the size of the animal. 
 
 A middle ear or drum cavity is found in nearly all ver- 
 tebrates living on land. It consists of an air-space within 
 bony walls separated from the external air by the thin 
 tympanic membrane. The sound vibrations taken up by 
 this membrane are conveyed by a rod of bone or a set of 
 ossicles to the membrane of the labyrinth. The drum 
 cavity communicates with the atmosphere through the 
 Eustachian tube, reaching from tympanum to pharynx. 
 The drum cavity is formed by a recess on the external 
 surface of the petrous part of the temporal bone, which is 
 completed as a closed cavity by articulation with the 
 squamous and tympanic portions of that bone. It de- 
 velops as a recess from the upper part of the first visceral 
 cleft of the embryo at the same time with the Eustachian 
 passage, which latter from the start communicates with 
 the pharynx. During its formation the tympanic cavity 
 is filled with gelatinous embryonal tissue. The ossicles 
 of the middle ear develop outside and underneath the 
 embryonic drum cavity, as shown in Fig. 85. The ham- 
 mer and anvil and the bony frame of the drumhead 
 the annulus tympanicus are derived from the cartilage 
 formed in the first visceral arch, while that of the second 
 visceral arch furnishes the material for the stapes. These 
 ossicles thus started outside of the skull gradually enter
 
 SURGICAL ANATOMY. 347 
 
 the tympanic cavity from underneath as its embryonal 
 connective-tissue contents become absorbed. 
 
 The external ear consists of the conduit tube lead- 
 ing to the drumhead the external auditory ineatus. 
 The bony part of this passage forms only after birth. In 
 the new-born the external ear consists but of a cartilagin- 
 ous tube (the external meatus) and its expansion in the 
 form of the auricle. In lower mammals the auricle is 
 
 ST 
 
 FIG. 85. Head and neck of a human embryo of eighteen weeks. The vis- 
 ceral skeleton exposed by dissection (Kolliker). The lower jaw is displaced 
 forward in order to show Meckel's cartilage, which can be followed up to the 
 malleus. The drumhead has been removed, and the annul us tympanicus is 
 exposed to view : h. , Malleus ; M. k, Meckel's cartilage ; u. k, lower jaw ; 
 am, anvil ; st, stapes ; pr, annulus tympanicus ; grf, styloid process. 
 
 practically a segment of a funnel for catching sound. In 
 man and the higher apes this function is lessened by rea- 
 son of its less favorable shape. 
 
 272. Surgical Anatomy. The auricle is made up of 
 a slightly curved plate of reti ciliated cartilage, convex on 
 its inner side, its outer surface being convoluted by the 
 ridges and furrows visible externally. The most periph- 
 eral posterior ridge is the helix. Inward from it and ap-
 
 348 ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 proximately parallel with it is the antihelix. The pro- 
 jection in front which represents the outer end of the 
 cartilaginous meatus is the tragus, and opposite to it is 
 the antitragus. The expansion of the meatus between 
 tragus and antitragus is termed the concha. The cartil- 
 age is covered by a perichondral membrane. In the 
 pendant lobule of the ear there is no cartilage, the space 
 between the two layers of the skin being filled with fat. 
 The skin is more adherent on the concave side of the 
 auricle than on the convex surface. It contains numerous 
 sebaceous glands, and at the entrance of the auricle are 
 more or less fine or in elderly men coarse hairs. Be- 
 tween the cartilaginous ridges there are several small 
 strands of muscular fibers of no significance. The flat 
 muscles which move the auricle in animals are, with rare 
 exceptions, not under the influence of the will in man. 
 They radiate from the junction of auricle and meatus 
 upward and backward and insert themselves partly into 
 the adjoining bony surfaces and partly into the fasciae. 
 Underneath these muscles the fascia surrounds the junc- 
 tion of auricle and meatus. The principal anchorage of 
 the auricle is, however, maintained by the cartilaginous 
 meatus the inward prolongation of the auricular cartil- 
 age. 
 
 273. The external auditory meatus consists of a car- 
 tilaginous tube set into a bony, funnel-shaped conduit 
 (Fig. 86). The entire passage is lined by thin skin, the 
 deeper layer of which serves as periosteum. The car- 
 tilaginous portion is not a complete tube, but a thick, 
 tapering gutter open at the upper and posterior side, 
 which gap widens inwardly so that the cartilage tapers at 
 its inner end with a blunt apex at the anterior side. The 
 gap is closed by connective tissue, which becomes con- 
 tinuous with the deeper layer of the skin and the 
 periosteum of the bony part of the channel. The car- 
 tilaginous tube is broken into three fragments of nearly 
 equal length by two transverse gaps (incisurse San tori ni), 
 across which there is a membranous junction. This
 
 EXTERNAL AUDITORY MEATUS. 349 
 
 segmentation permits a moderate displacement when the 
 auricle is pulled upward and backward, and when the 
 articulation of the lower jaw presses against the cartilage 
 on closing the mouth. The cartilaginous portion is 
 about one-third the total length of the meatus. It can be 
 readily separated from the bony canal by dissection, which 
 hence permits in the living a close approach to the drum- 
 head. 
 
 In the bony canal we can distinguish four walls con- 
 tinuous with one another. The upper wall is formed by 
 
 m 
 
 s 
 
 tr 
 
 FIG. 86. Horizontal section through the external meatus ; left ear : C, 
 Concha ; tr, tragus ; i, junction of cartilaginous and bony meatus ; m, mastoid 
 process ; V, anterior wall of meatus ; S, sinus-like pouch adjoining the drum- 
 head ; t, membrana tympani ; T, tympanic cavity (Politzer). 
 
 the squamous portion of the temporal bone. This con- 
 sists of two firm plates, of which the upper is the inner 
 surface of the cranial cavity and forms in part the roof of 
 the tympanic cavity. The lower plate separated from 
 the upper by a variable thickness up to 8 mm. of can- 
 cellated bone extends up to the bony frame, across which 
 the drumhead is stretched external to the drum cavity. 
 The posterior wall separates the meatus from the cells 
 and the antrum of the mastoid process. Superior and 
 posterior walls present a slight concavity. The inferior
 
 35O ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 wall is moderately thick 'and compact. The anterior 
 wall, a thin plate of bone, separates the meatus from 
 the articulation of the jaw with the glenoid cavity 
 (Figs. 87 and 88). The anterior and, more so, the 
 inferior wall are distinctly convex. The lower wall, in- 
 deed, descends next to the drumhead to such an extent 
 
 FIG. 87. Left temporal bone (adult) : frontal section through bony meatus and 
 tympanic cavity; posterior half (Zuckerkandl). 
 
 FIG. 88. Left temporal bone at birth. In the infantile bone the squamous 
 plate is nearly vertical, the petrososquamous fissure is still open, and the attic 
 is more developed than the rest of the tympanic cavity (Zuckerkandl). 
 
 that a dilatation of the meatus, called the sinus, is formed, 
 in which foreign bodies may lodge. 
 
 In the thin skin lining the meatus the sweat-glands are 
 slightly modified and yield a thick, oily secretion, the 
 ear-wax or cerumen. These glands, the orifices of which 
 can be seen by the naked eye, extend throughout the 
 cartilaginous portion, but in the bony part occupy only a 
 narrow sector at the upper posterior wall, reaching nearly 
 to the drumhead.
 
 EXTERNAL AUDITORY MEATUS. 
 
 351 
 
 The meatus is approximately elliptic in cross-section, 
 with its long axis oblique (pointing upward and forward). 
 About 8 to 10 mm. in average diameter, it narrows at the 
 point of greatest convexity 
 of the lower wall near the 
 drumhead, sometimes to 
 about 5 mm. (transversely), 
 but dilates again before it 
 reaches the membrana tym- 
 pani. Along its length it is 
 slightly curved, with con- 
 vexity upward and backward. 
 This curve is nearly obliter- 
 ated by forcibly pulling the 
 auricle upward and back- 
 ward. The average length 
 is about 24 mm., but the 
 anterior and inferior walls 
 exceed the posterior and su- 
 perior walls by about 5 to 6 mm. in length, so that the 
 plane of the drumhead is quite oblique. 
 
 274. The anatomy of the meatus differs considerably 
 at birth from its fully developed condition. The bony 
 meatus is so flattened from above downward that there is 
 scarcely any caliber. There is no bony meatus at the 
 time of birth. The obliquity of the drumhead is much 
 greater than later on. Indeed, the membrane is almost 
 
 FIG. 89. Left temporal bone ; 
 horizontal section through the bony 
 meatus; upper half (Zuckerkandl). 
 
 FlG. 90. External aspect of the annulus tympanicus ; left ear at birth : a, 
 tuberculum tympanicum anterior;/, tuberculum tympanicum posterior (Zucker- 
 kandl). 
 
 horizontal and nearly at the base of the skull. Dissection 
 shows that at birth the membrana tympani is attached to 
 a bony frame in the form of an incomplete ring, the
 
 352 ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 annulus tympanicus, of which an upper segment is 
 wanting (Fig. 90). This bony ring is grooved on 
 its interior, and into this groove the membrane is 
 set. In the new-born the squamous portion of the 
 temporal bone is merely a vertical plate, to the lower 
 edge of which the annulns is attached (Fig. 91). The 
 mastoid process is as yet undeveloped, not projecting and 
 not cancellated. The tympanic bone (annulus) now 
 grows until it constitutes a bony gutter, which ultimately 
 forms the anterior, inferior, and posterior walls of the 
 
 \ 
 r 
 
 
 
 FIG. 91. Left temporal bone of the new-born : S, Squamous portion ; , its 
 lower part with malar ridge ; a, annulus tympanicus ; n, n, suture between 
 squamous portion and mastoid extending to f, the stylomastoid foramen ; o, 
 oval window ; r, round window (Politzer). 
 
 meatus. The posterior wall coalesces with the develop- 
 ing mastoid process. The upper wall of the meatus is 
 gradually formed by the growth of the squamous portion 
 in the form of the horizontal plate extending inward 
 from the outer surface of the skull, and in the course of 
 this growth the horizontal position of the drumhead 
 changes ultimately to its more erect plane. About the 
 fourth year of life the ultimate shape of the bony meatus 
 is perfected, and its growth now continues at a diminished 
 rate until a few years after puberty.
 
 TYMPANIC CAVITY. 
 
 353 
 
 275. The auricle is supplied by a number of small 
 arterial twigs radiating toward it from the arteries in the 
 neighborhood. Some of these twigs enter the meatus. 
 The venous supply is similar. The muscles of the ex- 
 ternal ear are supplied by the facial nerve. The sensory 
 nerves are twigs from the auriculotemporal branch of the 
 fifth nerve and the auricularis magnus of the cervical 
 
 1. Jc. tii.f. 
 
 FIG. 92. Frontal section through the meatus, tympanic membrane, and 
 cavity ; right ear : o, Pneumatic spaces in the superior wall of the meatus con- 
 necting with the middle ear ; d, roof of the drum cavity ; u, inferior wall ; 
 t, drum cavity ; h, head of malleus ; g, manubrium ; a, anvil ; s, stapes ; c, 
 cross-section of Fallopian canal ; f, jugular fossa ; k, posterior wall of bony 
 meatus ; /, inferior wall of meatus ; dr, glandular openings in the external 
 meatus ( Politzer) . 
 
 plexus. Besides these a branch from the pneumogastric 
 nerve supplies the meatus as far as the drumhead. 
 
 276. The tympanic cavity is formed by a niche on the 
 external surface of the petrous bone. It is completed as 
 a closed chamber by the articulation with the squamous 
 part of the temporal bone at the upper external border, 
 with the annulus tympanicus all around, and with the 
 
 23
 
 354 ANATOMY AND PHYSIOLOGY OF THE EAR 
 
 mastoid process posteriorly. It is an irregular-shaped 
 cavity, flattened in the transverse direction (Fig. 92). 
 The external wall is formed largely by the membrana 
 tympani and its bony frame. This thin membrane (o. i 
 mm. thick) is stretched across the annulus tympanicus, 
 being fastened in the groove on its concavity. About one- 
 seventh part of this bony ring is absent at the upper 
 periphery, and here the drumhead is attached to the mar- 
 gin of a crescentic gap in the squamous portion Rivini's 
 incisure. This extra-annular area of the drumhead is 
 called the flaccid portion, or Shrapnel!' s membrane. The 
 drumhead consists of thin true skin on its outer side, 
 delicate mucous membrane on the tympanic side, with a 
 double layer of connective-tissue fibers between. The 
 fibers are arranged radially in the external layer and in 
 concentric circles in the inner layer. This fibrous layer, 
 to which the membrane owes its firmness, is wanting in 
 the flaccid portion. At its insertion in the groove of the 
 bony ring the fibrous layer is thickened in the form of a 
 tendinous ring (Fig. 92). The membrane is grayish and 
 translucent. 
 
 The plane of the drumhead is not vertical, but slants 
 downward and inward and forward and inward. In an 
 imperfect view through the meatus it seems to be nearly 
 the continuation of the posterior upper wall of the meatus. 
 The membrane, however, does not lie in a single plane, 
 but has a peculiar curvature which can be artificially 
 imitated in the following way : If a flexible but plastic 
 membrane (moist bladder) is stretched across the wide 
 mouth of a bottle and pressed down in its center by an im- 
 pinging rod, the membrane becomes conic, with its apex 
 toward the interior, while each radius from periphery to 
 center assumes a curve with convexity outward. This 
 shape has been proved, both by trial as well as mathemat- 
 ically, to be the most favorable for the reception of sound- 
 waves. The shape of the drumhead is even more com- 
 plicated, because the traction is not merely exerted at its 
 center, but from the center to nearly the upper periphery
 
 TYMPANIC CAVITY. 355 
 
 by the linear attachment of the handle of the hammer. 
 The handle of the hammer is oblique with reference to 
 all axes of the head, its lower end pointing inward at an 
 angle of 35 degrees, and also slightly backward as com- 
 
 FlG. 93. Normal membrana tympani (left), enlarged. 
 
 pared with its upper end. The tympanic cavity is nar- 
 rowed to about 2.5 mm. at the level of the center of the 
 drumhead, by reason of this inward depression. 
 
 The attachment of the hammer divides the drumhead 
 
 U-- 
 
 FIG. 94. Inner surface of the left membrana tympani enlarged : h, Head 
 of malleus ; ha, neck of malleus ; mf, tendon of the tensor tympani muscle 
 and anterior fold of the drumhead ; u, inferior end of the manubrium ; v, an- 
 terior half of the drumhead ; hd, posterior fold of the drumhead and chorda 
 tympani nerve ; a, anvil ; K, its short process ; /, its long process (Politzer). 
 
 into an (smaller) anterior and (larger) posterior half. The 
 prominence of the upper end of the handle (or short 
 process) causes the appearance of an anterior and a poste- 
 rior fold radiating peripherally from this sharp point.
 
 ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 These " creases " are exaggerated when the membrane is 
 morbidly retracted. On the internal surface of the mem- 
 brana tympani the handle of the hammer is seen attached 
 along its entire length from its projecting neck to its 
 flattened lower end (Fig. 94). At the lever of its upper 
 insertion into the drumhead the mucous membrane is 
 raised in the form of two folds or ridges the more promi- 
 nent posterior and the lesser developed anterior fold ex- 
 tending to the bony margin. They correspond nearly 
 in site with the projecting creases marked on the external 
 surface. These duplicatures of mucous membrane form 
 pockets with the flaccid portion of the membrane. The 
 chorda tympani nerve, which leaves the facial nerve at 
 the upper end of the Fallopian canal, passes across the 
 membrana tympani along this fold or ridge to the Glase- 
 rian fissure in front and above, where it emerges from the 
 drum cavity. 
 
 The area of the membrana tympani is an ellipse, with 
 its long axis tilted slightly forward, the long diameter 
 being about 10 mm., the short diameter about 9 mm. 
 At the upper margin the flaccid portion extends slightly 
 beyond the elliptic outline. 
 
 277. The floor of the tympanic cavity is 2 to 3 mm. 
 below the level of the inferior margin of the membrane. 
 Above the upper margin of the drumhead the cavity ex- 
 tends upward 5 to 6 mm., being slightly higher behind 
 than in front. This upper space is known as the attic (Fig. 
 95). The external wall of the attic is furnished by the 
 up-turned lower plate of the squamous part of the tem- 
 poral bone. The upper or cerebral plate of its hori- 
 zontal portion projects slightly inward and helps to form 
 the roof of the drum cavity, being overlapped by a 
 lamella from the petrous bone. Through the suture 
 between the squamous and petrous parts there extends a 
 vascular process from the dura mater in childhood, which 
 obliterates later on. At the upper front corner of the 
 suture between petrous and tympanic portion a chink is 
 left in the bone, the Glaserian fissure, through which
 
 TYMPANIC CAVITY. 
 
 357 
 
 the chorda tympani nerve leaves the drum cavity. The 
 narrow roof of the drum cavity slants downward and 
 forward. It consists usually of cancellated bone 2 to 3 
 mm. thick, but may be reduced to a thin plate, which 
 is sometimes defective, permitting contact between the 
 dura and tympanic mucous membrane. 
 
 u. 
 
 FIG. 95. Eustachian tube and tympanic cavity in connection : t, Mem- 
 brana tympani ; h, head of malleus ; u, lower end of the handle of the ham- 
 mer ; a, body of the incus ; K, short process of the incus ; m, tensor tympani 
 muscle ; o, pharyngeal end of the Eustachian tube ; i, isthmus of the Eusta- 
 chian tube ; of, tympanic opening of the Eustachian tube; right ear (Politzer). 
 
 The posterior wall is represented below by a narrow 
 curved gutter formed by the junction of external and 
 internal walls. It widens upward, and, at the level of 
 the upper margin of the drumhead, an opening leads into 
 the mastoid antrum. This the aditus is of triangular 
 shape, with base upward. Underneath it is a conic pro-
 
 ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 jection, the eminentia pyramidalis. In a tunnel in its 
 interior the short pear-shaped stapedius muscle is attached 
 and hidden, only its tendon emerging from the hole at 
 the apex. The inferior wall, narrower than the superior, 
 presents a roughened surface. Underneath it is the bulb 
 of the jugular vein. This wall is of variable thickness, 
 sometimes partially defective. The anterior boundary 
 of the tympanic cavity is formed by the forward slant of 
 the internal wall. Outside of it (anteriorly) is the canal 
 of the carotid artery. Below the level of the upper part 
 of the membrana tympani is the opening into the Eusta- 
 chian tube, of funnel shape and without sharp boundary 
 between drum cavity and tube. It is about 3.5 mm. 
 wide and 4.5 rnm. high. Above the Eustachian tube 
 and parallel with it is a narrow bony canal for the tensor 
 'tympani muscle. 
 
 The internal wall, a thin but firm plate of bone, sepa- 
 rates the drum cavity from the labyrinth. Its center is 
 marked by a prominence the promontory formed by the 
 projection of the first turn of the cochlea. Above and 
 behind the promontory is the oval window, 4 mm. in its 
 transverse, 1.5 mm. in its vertical, diameter. It is the 
 opening into the vestibule and is closed by the foot-plate 
 of the stapes. The plane of this window slants downward 
 and inward. It is set deeply in a niche into which the 
 foot-plate of the stirrup fits. About 3 to 4 mm. below 
 the oval window, and hence below and behind the prom- 
 ontory, is the smaller round or triangular window 
 which leads into the cochlea. It is closed by a mem- 
 brane, the membrana secundaria. The facial nerve 
 coming from the interior passes in a curve over the 
 vestibule and thence runs in the slightly projecting Fal- 
 lopian canal (sometimes a mere groove), with a concave 
 turn above and behind the oval window. The canal 
 pursues its visible course downward at the junction of 
 internal and posterior wall, and through it the facial 
 nerve reaches its exit through the stylomastoid foramen 
 (Fig. 96).
 
 TYMPANIC CAVITY. 
 
 359 
 
 278. The tympanic cavity is lined by a delicate 
 mucous membrane containing few mucous glands. The 
 epithelium is ciliated, cylindric in the lower, but flattened 
 in the upper, areas. The deeper layer of mucous mem- 
 brane serves as periosteum. The membrane follows the 
 surface accurately, but is raised in the form of the re- 
 duplications or folds across the upper part of the drum- 
 head, while several inconstant folds are usually found 
 between the walls and the upper part of the ossicles. 
 The mucous membrane lines the ossicles as well as their 
 
 FIG. 96. Sagittal section through the entire middle ear of the adult, inner 
 half of left ear : op, Pharyngeal end of Eustachian tube ; of, tympanic opening 
 of Eustachian tube; te, Eustachian tube ; tp, tensor tympani muscle ; f, prom- 
 ontory with Jacobson's nerve across it ; u, inferior tympanic wall ; sf, stapes ; 
 sp, stapedius muscle ; /, facial nerve ; an, mastoid antrum ; w, w', mastoid 
 cells (Politzer). 
 
 various ligaments. It is continuous with the lining of 
 the mastoid antrum and that of the Eustachian tube. 
 
 The ossicles, three in number, form a bony chain from 
 drumhead to oval window. The hammer or malleus has 
 a club-shaped head with an articulating surface for the 
 anvil. The tapering neck has a projecting knob, the 
 short process, inserted at the upper end of the drumhead, 
 from which the handle or manubrium descends at an 
 obtuse angle, terminating in a flattened end. The point 
 of attachment of this end near the middle of the drum-
 
 360 
 
 ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 head is termed the umbo. From the neck of the 
 hammer a slender bony process the long process ex- 
 
 1 2 3 
 
 FIG. 97. The ossicles of the middle ear: I, The malleus: k, head; h, 
 neck ; gr, manubrium ; /, long process ; g, articular surface. 2, The incus : 
 k, body ; o, short process ; /, long process ; g, articular surface ; s, cog beneath 
 the articulation. 3, The stapes : k, articulating head ; S, crus stapedii ; /, 
 foot-plate (Politzer). 
 
 tends forward to the Glaserian fissure (Fig. 97). The 
 anvil or incus resembles in shape a molar tooth with two 
 
 roots. Its articulating sur- 
 face, like that of the ham- 
 mer, is saddle-shaped. The 
 long process descends slant- 
 ingly inward and somewhat 
 posteriorly, and is attached 
 to the stapes. The hori- 
 zontal short process points 
 into the mastoid aditus. 
 The stirrup or stapes has 
 the exact shape indicated 
 by its name. Its head, a 
 detached button of bone, 
 articulates with the long 
 process of the anvil, while 
 the foot-plate fits into the 
 oval window. Between 
 head and foot-plate are the 
 two crura. The articula- 
 
 FlG. 98. Tympanic cavity exposed 
 by removal of the roof, showing the liga- 
 ments of the ossicles : h,h, Head of the 
 malleus ; La, ligament, mallei ant. ; 
 Le, ligament, mallei ext.; K, project- 
 ing spina tymp. post. ; a, mastoid antrum 
 
 (Politzer). 
 
 tions between hammer and 
 
 anvil and anvil and stirrup are true joints with minute 
 plates of cartilage and capsular ligaments. . The foot- 
 plate of the stirrup is attached to the margin of the oval 
 window by an encompassing annular ligament. While
 
 TYMPANIC CAVITY. 
 
 the chain of ossicles is held in place by the attachment to 
 the drumhead and oval window, the ossicles are steadied 
 besides by additional ligaments. 
 A short superior ligament sus- 
 pends the head of the hammer 
 from the roof. A fan-shaped 
 band springing from the neck of 
 the hammer inserts itself into the 
 margin of the incisure of Rivini 
 (Fig. 98). A similar narrow one 
 attaches itself forward along the 
 upper anterior corner of the drum 
 cavity. This anterior ligament, 
 together with the extreme poste- 
 rior portion of the external liga- 
 ment, forms the axial cord around 
 which the hammer can vibrate. 
 The short process of the anvil is 
 also steadied by a small ligament 
 coming from the upper posterior 
 tympanic wall. The tensor tym- 
 pani muscle, a thin slender mus- 
 cle, originates from the walls of 
 the narrow canal in the bone, 
 above and parallel to the Eusta- 
 chian tube. Its tendon, travers- 
 ing the upper part of the tympanic 
 cavity from the anterior internal 
 corner to the hammer, attaches 
 itself at the junction of neck and 
 handle. It pulls the handle in- 
 ward. The stapedius muscle 
 originates and is concealed in the 
 tunnel in the eminentia pyrami- 
 dalis at the lower internal portion of the posterior wall. 
 Its tendon issues through the minute hole in the emi- 
 nentia, and reaches the head of the stapes, which it can 
 deflect slightly backward and downward. 
 
 FIG. 99. Microscopic 
 section through hammer, 
 drumhead, and external part 
 of the attic : h, Head of the 
 hammer; te, tendinous inser- 
 tion of the membrana tym- 
 pani ; b, short process of the 
 hammer ; u, umbo ; /, trans- 
 verse section of chorda tym- 
 pani nerve; e, external liga- 
 ment of hammer; /, superior 
 ligament ; s, Shrapnell's mem- 
 brane ; ae, external attic ; /, 
 Prussak's space ; c, a vascu- 
 lar channel between attic and 
 bony meatus (Politzer).
 
 362 ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 279. The ligaments of the ossicles, together with some 
 irregular and inconstant bridges of mucous membrane, 
 subdivide the attic into a series of minute chambers (Fig. 
 99). The most constant of these are Prussak's space, 
 between Shrapnell's membrane, short process of hammer 
 and external ligament, and the external part of the attic 
 between the external wall above the drumhead and the 
 head of the hammer. All these spaces communicate nor- 
 mally with the tympanic cavity through minute orifices. 
 It is easy to see how readily inflammatory action may 
 lead to occlusion of these spaces and retention of secre- 
 tion. The irregular and inconstant arrangement of 
 bridges of mucous membrane from the walls of the attic 
 to the heads of the ossicles has an embryologic reason. 
 Until shortly before birth the drum cavity is filled with 
 embryonic connective tissue, which then undergoes ab- 
 sorption and transformation into thin mucous membrane 
 lining all the contents of the cavity. 
 
 280. It is important for surgical purposes to be able to 
 locate the tympanic contents with reference to the mem- 
 brana tympani. It must be remembered that the plane 
 of the drumhead slants obliquely forward and inward 
 as well as downward and inward. On account of the 
 curvature of the membrane the area above the umbo and 
 the handle of the hammer is at an angle of about 35 
 degrees with the vertical, while the inferior part of the 
 drumhead is more nearly vertical. By the imaginary 
 downward prolongation of the handle of the malleus and 
 an imaginary horizontal line through the umbo the mem- 
 brane is divided into four quadrants. In the case of large 
 perforation or total loss of the membrane various parts of 
 the tympanic cavity can be seen during life, although the 
 visible field depends considerably on the varying size and 
 curvature of the meatus (Fig. 100). The anterior upper 
 quadrant does not quite permit a view of the Eustachian 
 orifice. The tendon of the tensor tympani muscle, 
 barely visible, is, however, accessible to the knife. 
 Through the posterior inferior quadrant the promontory
 
 TYMPANIC CAVITY. 363 
 
 and often the round window are visible. The posterior 
 upper fourth of the membrane, if absent, permits a view 
 of the long process of the anvil, its articulation with the 
 head of the stapes, the posterior crus of the stapes, and 
 the tendon of the stapedius muscle. The chorda tympani, 
 sometimes visible at the upper margin of the membrane 
 as a transverse filament, can be reached and injured by 
 instruments. The facial nerve in its canal is not en- 
 dangered by the ordinary intratympanic manipulations, 
 but must be carefully avoided in resection of the poste- 
 rior wall of the meatus. 
 
 281. The Eustachian tube, about 3.5 cm. long, passes 
 
 FIG. loo. Topographic relation of drumhead to the internal tympanic 
 wall (schematic): vo, Anterior upper quadrant; vu, anterior lower quadrant; 
 ho, posterior upper quadrant; hu, posterior lower quadrant; as, articulation of 
 anvil and stapes; r, round window; s, Shrapnell's membrane (Politzer). 
 
 obliquely downward, forward, and inward from the upper 
 part of the anterior wall of the tympanic cavity to the 
 side of the pharynx (compare Figs. 95 and 96). Its upper 
 third is formed by the incomplete bony canal in the 
 petrous bone, completed partly by the tympanic portion 
 externally and the sphenoid wing in front and above. 
 There is a gradual transition from tympanic cavity to the 
 Eustachian canal. Thence on the bony passage narrows 
 until near its end the so-called isthmus it is but 2 mm. 
 high and i mm. wide. The lower two-thirds of the 
 tube the cartilaginous portion expands in the opposite 
 direction up to the pharyngeal orifice, which shows a 
 height of 9 mm. by a width of 5 mm. The principal
 
 364 
 
 ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 structure of its wall is the triangular plate of cartilage 
 which forms the median wall. By curving at its upper 
 border in the form of a hook it forms also the roof of the 
 tube (Fig. 101). The external wall and floor of the tube 
 are membranous. The Eustachian cartilage is about 12 
 mm. high and 5 mm. thick at its pharyngeal end. In 
 its length of 25 mm. it tapers toward the rear to a height 
 of 7 mm. and a thickness of about 2 mm. The bony 
 
 Itrat 
 
 FIG. 101. Vertical section through the middle third of the Eustachian tube, 
 showing the tubopalatal muscles (Randall). 
 
 canal expands again beyond the isthmus (inward) and 
 the cartilaginous plate is set into this opening. Its upper 
 border is fastened in a groove between petrous bone and 
 sphenoid wing. It is, furthermore, strengthened by a 
 lamella from the basilar fibrocartilage. The projection 
 of the Eustachian cartilage into the pharynx forms the 
 prominent posterior lip of the Eustachian orifice the 
 Eustachian tumefaction the mucous membrane over
 
 TYMPANIC CAVITY. 365 
 
 which is thickened by an adenoid cushion. The orifice 
 itself is a funnel-shaped niche surrounded by a triangular 
 or oval frame, formed by folds of mucous membrane (Fig. 
 102). Posterior to it and above it is the fossa of Rosen- 
 muller. The pharyngeal mucous membrane is contin- 
 uous with that of the tube, in which channel, however, 
 it is puckered in the form of longitudinal folds. The 
 
 FIG. IO2. Sagittal section of frozen head ; left head ; exact representation of 
 Eustachian orifice and surroundings (Zuckerkandl). 
 
 outer wall of the tube is formed only by mucous mem- 
 brane strengthened by fibrous tissue and thickened 
 toward its upper end by a cushion of fat. The mucous 
 membrane continues throughout the bony part as a more 
 delicate lining, and is continuous with that of the drum 
 cavity. The pharyngeal orifice in the adult is at the 
 level of the posterior end of the inferior turbinal. At 
 birth its level is scarcely above that of the palate, while
 
 366 ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 the entire tube at that time is relatively much shorter 
 than later in life. 
 
 The caliber of the Eustachian tube forms a somewhat 
 S-shaped slit throughout the cartilaginous portion, the 
 walls of which are in actual contact. In the bony por- 
 tion the caliber, though much smaller, is patent. Gaping 
 of the passage occurs only during the act of swallowing, 
 and in some persons while yawning. The dilatation of 
 the tube is due to the action of two muscles, the levator 
 palati and the tensor palati. The former arises from the 
 petrous bone and runs parallel to and underneath the 
 floor of the Eustachian tube to the soft palate. During 
 its contraction its thickening raises the floor of the tube. 
 The tensor palati muscle is attached to the inferior sur- 
 face of the sphenoid wing to the lower lateral end of the 
 hook-shaped cartilaginous roof of the tube, as well as to 
 its external membranous wall. Descending obliquely it 
 winds itself around the pterygoid hamulus and inserts 
 itself into the fibrous expansion of the hard palate. By 
 its action it unrolls the curved roof and pulls outward 
 the external wall of the Eustachian tube, thereby per- 
 mitting its gaping. It has hence been termed the abduc- 
 tor or dilator tubcz. 
 
 382. The tympanic cavity communicates toward the 
 rear with the cavity in the mastoid process the mastoid 
 antrum and the adjoining cells. In the upper part of 
 the posterior wall there is a triangular opening, with base 
 up, the aditus, through which the tympanic attic is 
 continuous with the mastoid antrum. The latter, an 
 irregular shaped cavity of variable size, at the level of 
 the attic and behind the tympanic cavity, is surrounded 
 by smaller air-cells in the mastoid process and often com- 
 municates with air-spaces in the petrous bone ; some- 
 times even with recesses in the occipital bone. The ex- 
 tent of these pneumatic spaces is especially well seen in 
 casts made by corrosion (Fig. 103). 
 
 The mastoid process, essentially a part of the petrous 
 portion, is covered in front and to some extent externally
 
 MASTOID PROCESS. 367 
 
 by the squamous part of the temporal bone, which also 
 forms in part the roof of the antrum. Between squamous 
 and petrous portions is the mastoid fissure, which oblit- 
 erates gradually during childhood. The anterior bound- 
 ary is the posterior wall of the meatus. Externally it is 
 covered by thick, tough skin firmly united with the 
 aponeurosis and the periosteum. At its lower tip the 
 surface is roughened for the attachment of the sterno- 
 
 FlG. 103. Cast of the Eustachian tube, tympanic cavity, mastoid antrum, 
 and some mastoid cells posterior to the antrum, viewed from the external side : 
 I, Incomplete cast of a cell between tube and anterior tympanic cavity; 2, cel- 
 lular dilatation in the tympanic roof; 3, transverse incisure anterior to the 
 aditus ; 4, cavity in which the heads of hammer and anvil were lodged; 5> 
 site of short process of anvil ; 6, rear end of antrum ; 7, transitional cell ; 8, 
 terminal cell (Bezold). 
 
 cleidomastoid muscle. In its interior the mastoid pro- 
 cess is made up either of large pneumatic cells (about 
 one-third of all instances) or of firm cancellated bone 
 (about one-fifth of all subjects), or both types of bony 
 structure are represented to a variable extent. The 
 larger cells are continuous with the antrum through 
 narrow orifices and are lined by thin mucous membrane. 
 Smaller cells are not pneumatic, but contain medullary
 
 368 
 
 ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 FIG. 104. Mastoid process 
 opened, with large pneumatic 
 spaces (Politzer). 
 
 FIG. 105. Mastoid process 
 consisting of dense bone ( Polit- 
 er). 
 
 contents. In less common instances, but especially in 
 pathologic cases, the bony shell may be quite hard, even 
 
 FIG. 106. Horizontal section through mastoid process with large pneu- 
 matic cells (seen from above) : t, Tympanic cavity ; g, posterior wall of mea- 
 tus; a, mastoid antrum; S, lateral sinus; w, it/, external field of operation in 
 opening into the mastoid antrum (Politzer). 
 
 sclerotic (Figs. 104 and 105). The roof of the antrum is 
 usually but a thin plate of bone, sometimes partially de-
 
 MASTOID PROCESS. 369 
 
 ficient. Of great surgical importance is the relation of 
 the antrum to the lateral venous (or transverse) sinus. 
 This venous channel runs in a groove (sigraoid fossa) in 
 the bone, passing downward and forward along the in- 
 ternal surface of the squamous portion, and then, with a 
 sharp bend behind and partly above the antrum, it turns 
 forward and inward along the posterior surface of the 
 petrous pyramid to reach the jugular foramen. The 
 bony groove in the cerebral plate projects into the antrum 
 at its upper posterior corner the variable extent of 
 which cannot be predicted from external inspection 
 
 FIG. 107. Horizontal section (seen from above) through the temporal 
 bone ; mastoid process of relatively dense bone : t, Tympanic cavity ; u, in- 
 ferior wall of external meatus; s, groove for lateral sinus; w, external surface 
 of the mastoid process (Politzer). . 
 
 (Figs. 106 and 107). It is generally a little lower on the 
 right side than on the left. It is more apt to encroach 
 upon the antrum when the bone is diploetic than when 
 it is pneumatic. In operating upon the mastoid the sur- 
 geon must, hence, be prepared to encounter and to avoid 
 the lateral sinus. Suppurative inflammation of the mas- 
 toid antrum can readily involve the lateral sinus or 
 extend through the thin roof into the cranial cavity. 
 The distance of the antrum from the external surface of 
 the bone is about 12 to 14 mm. A direct route to it is 
 obtained by drilling immediately behind the auditory 
 meatus parallel with its posterior upper wall. 
 
 24
 
 37O ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 283. The mastoid process is but a flat, undeveloped, 
 and hence scarcely prominent plate at birth. The cavity 
 of the antrum is present, but is covered merely by a thin 
 shell of bone without pneumatic spaces. It is hence 
 easily reached by operation. The roof, on the other 
 hand, is relatively thick, so that during early infancy 
 there is less liability to cerebral extension of mastoid 
 disease. 
 
 384. The middle ear is well supplied with numerous 
 small arteries and veins entering from various directions. 
 None of them are of sufficient size to require detailed 
 description for surgical purposes. Through Shrapnell's 
 membrane the tympanic vessels anastomose with those 
 of the meatus, while connecting branches between drum 
 cavity and the internal ear penetrate through the laby- 
 rinthine wall. The membrana tympani has a small 
 artery with a vein descending along the handle of the 
 hammer. Between these vessels and the periphery there 
 exist branches running radially. The cutaneous and 
 the mucous layers of the drumhead have each a separate 
 set of vessels, which, however, anastomose. The sensory 
 nerves of the drum cavity are derived partly from the 
 trigeminus, mainly from the glossopharyngeus. There 
 are also fibers from the sympathetic nerves. The largest 
 nerve-branches are found on the internal wall of the 
 cavity. The facial nerve gives off two branches in the 
 Fallopian canal viz., one for the stapedius muscle and 
 the chorda tympani, which ascends along the posterior 
 wall and then traverses the drum between the neck of 
 the hammer and the anvil along the folds on the inner 
 surface of the drumhead. 
 
 385. The internal ear or labyrinth is situated in passages 
 tunneled out in the interior of the petrous bone. In the 
 adult the surrounding bony substance differs so little in 
 consistency from the capsule of the labyrinth that its 
 demonstration by dissection is very difficult. But in the 
 new-born the spongy bone substance can be removed 
 more easily, leaving the bony labyrinth. This consists
 
 INTERNAL EAR OR LABYRINTH. 
 
 371 
 
 of vestibule, cochlea, and semicircular canals. The 
 vestibule is an irregular elliptic cavity, inward from the 
 tympanum, with which it connects through the oval 
 window (closed by the stapes). A vertical crest on its 
 
 Can-aitt. 
 
 cW.T 
 
 Carup- 
 
 FIG. 108. Left bony labyrinth seen from the external side and somewhat 
 from below (enlarged) : Can. F, Fallopian canal ; C, cochlea; Ca, cupola; Pr, 
 promontory; Fen. r, round window; fen.o, oval window (Gegenbaur). 
 
 internal wall divides the vestibule into an anterior spheric 
 and the posterior elliptic recess (Fig. 108). Downward 
 and forward it is prolonged into the cochlea, a slightly 
 tapering tube coiled upon itself like a snail, with 2| 
 
 Se.v. 
 
 FIG. 109. Section through the cochlea (enlarged) : H, Hamulus ; Sc.v, 
 scala vestibuli ; Sc.t, scala tympani ; L.o, lamina spiralis ossea; M.i, internal 
 auditory meatus (Gegenbaur). 
 
 turns, the terminal coil or cupola being in front. The 
 beginning of the cochlea causes the bulging of the 
 internal tympanic wall, known as the promontory. In 
 the axis of the cochlea bony trabeculse form the spindle
 
 3/2 ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 or modiolus, a conic axis with a screw-shaped lamina 
 projecting into the coils and reaching half-way across 
 them. This osseous lamina spiralis is completed by a 
 membranous extension across the cochlear passage which 
 divides the channel into an upper half, the scala vestibuli, 
 and the inferior half, the scala tympani (Fig. 109). This 
 partition does not quite reach to the end of the cupola, 
 where the two scalae communicate. The scala vestibuli 
 is continuous with the interior of the vestibule. The 
 scala tympani, however, is closed at its vestibular end by 
 the spiral partition wall. Through the round or triangu- 
 lar window it is in communication with the drum cavity. 
 The membranous partition in the cochlear passage con- 
 sists, however, of two layers, between which a third 
 channel, the cochlear duct, is left, which follows the 
 convolution of the bony tube from vestibule to cupola. 
 
 On the posterior side of the vestibule the three semi- 
 circular canals constitute three tunnels in the bone, 
 lying in three planes all vertical to each other. Their 
 planes do not strictly coincide with any normal plane of 
 the head. The anterior or superior semicircular canal lies 
 nearly in the frontal plane. The internal or posterior or 
 inferior vertical semicircular, the longest and narrowest 
 of the three, lies approximately in the sagittal plane, 
 while the external semicircular canal, the shortest and 
 thickest, is about horizontal, with its vertex toward the 
 rear. It projects slightly into the drum cavity behind 
 the Fallopian canal. The external ends of the semi- 
 circular canals expand in the form of the ampullae, while 
 the insertion of their other end into the vestibule has 
 the same caliber as the canal itself. The superior and 
 the posterior semicircular canal unite with each other at 
 their junction with the vestibule. 
 
 386. The auditory and facial nerves enter the petrous 
 pyramid near the middle of its posterior surface, through 
 the internal auditory meatus. This short canal, passing 
 outward and somewhat backward, enlarges into a pouch 
 inward from the vestibule. Here the facial nerve sepa-
 
 INTERNAL AUDITORY MEATUS. 373 
 
 rates and enters the Fallopian canal, passing over the 
 vestibule in the form of a sharp bend, whence it pursues 
 its curved course toward the rear and downward. The 
 auditory nerve, however, divides into its branches, two 
 to the vestibule and one to the cochlea, which latter 
 enters partly direct at the vestibular end, partly gradually 
 through the spindle, in which it pursues a spiral course. 
 In this spiral passage the nerve becomes gangliform by 
 the addition of nerve-cells. Its fibers pass in a comb- 
 shaped fashion through fine perforations in the lamina 
 spiral is into the cochlear duct. 
 
 287. The membranous labyrinth is in the interior of the 
 bony chambers. While its shape resembles that of the bony 
 labyrinth, it does not form an accurate lining for the lat- 
 ter. Between the bony walls and the membranous laby- 
 rinth there is a lymph-space filled with a fluid, known as 
 the perilymph. The bony labyrinth is lined by a delicate 
 periosteum with endothelial cells. The interior of the 
 membranous labyrinth is also filled with a fluid the 
 endolymph. The perilymphatic space communicates 
 with the subarachnoid space of the brain through the 
 cochlear aqueduct. The latter, a fine membranous tube, 
 passes from the closed end of the scala tympani through 
 the petrous pyramid to its lower posterior margin, where 
 it becomes continuous with the meninges. A similar 
 passage, the vestibular aqueduct, puts the endolymph 
 into communication with the cerebral lymph-spaces. It 
 begins in the form of two minute passages from the 
 membranous sacs in the vestibule, one from the utricu- 
 lus, the other from the sacculus, which unite, pass 
 through the pyramid, and empty into the cistern on the 
 middle of its posterior surface. This latter small closed 
 bag communicates probably through microscopic chan- 
 nels with the subdural space (Fig. no). 
 
 388. The interior of the vestibule contains two mem- 
 branous pouches, the utriculus and the sacculus, which 
 communicate with each other only through the branches 
 of the forked vestibular aqueduct. The posterior of
 
 374 ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 these bags, the utricle, much smaller than the vestibule, 
 is attached to its internal surface. It is continuous with 
 the membranous semicircular canals. These tubes line 
 the bony ampullae, but contract in the bony semicircular 
 canals to the tubules much smaller than the bony tunnels. 
 They are fastened along the convex wall and steadied by 
 transverse bands. All these membranous passages are 
 lined by flat epithelium. In the utricles and in the 
 ampullae the wall is thickened in spots, termed maculae, 
 where the epithelium changes into cylindric cells with 
 long cilia. These hair-like processes are covered with a 
 sticky, jelly-like substance, in which crystals or carbonate 
 
 FIG. no. Rear view of the bony labyrinth at birth (enlarged): co, 
 Cochlea ; mi, internal meatus auditorius ; ac, aquasductus cochleae ; av, aquse- 
 ductus vestibuli (Politzer). 
 
 of lime the otoliths are suspended. As these ciliated 
 cells are supplied by nerve-fibers they are considered the 
 sensory terminations of the nerve. 
 
 The sacculus, the smaller and anterior of the vestibular 
 poucrues, is fastened likewise to the internal wall of the 
 vestibule. Its structure and interior are similar to those 
 of the utricle. Through a very fine tubule it com- 
 municates with the cochlear duct, which latter apparently 
 terminates at the cochlear end of the vestibule in a blind 
 cul-de-sac. 
 
 289. The cochlear duct is the most complicated of all 
 labyrinthine structures (Figs, in and 112). This spirally
 
 INTERNAL AUDITORY MEATUS. 
 
 375 
 
 wound passage is triangular in cross-section. Its wall 
 next to the scala tympani the inferior lamella of the 
 
 FlG. III. Enlarged section of the cochlea of the new-born: Sc. v, Scala 
 vestibuli ; Sc. t, scala tympani ; K, lamina spiralis ossea ; b, lamina basilaris ; 
 /, triangular ligament; If, Reissner's membrane; Cc, cochlear canal; o, organ 
 of Corti ; m, Corti's membrane; n, fasciculus of cochlear nerve-fibers; g, spiral 
 ganglion (Politzer). 
 
 lamina spiralis is known as the basilar membrane. This 
 increases in width from the cochlear end to the cupola. 
 
 FIG. 112. Terminal apparatus of the cochlear nerves in the organ of Corti 
 of man (enlarged) : o, Lamina spiralis ossea with cochlear nerve-fibers; /-/, 
 lamina spiralis membranacea ; H, Huschke's cog, or crista spiralis ; c, inner 
 column of Corti ; ^, outer column of Corti ; r, lamina reticularis ; Z, cells of 
 Corti ; D, Deiters' cells ; i/i, inner ciliated cell ; ah, four outer ciliated cells ; 
 e, radiating cochlear nerve-fibers passing to Corti's cells ; K, cells of the sulcus 
 spiralis internus ; Cl, Hensen's supporting cells ; Cm, Corti's membrane ; Vs, 
 vas spirale (Retzius). 
 
 It is made up of transverse fibers capable of vibrating 
 individually. The superior plate of the lamina spiralis
 
 3/6 PHYSIOLOGY OF THE EAR. 
 
 separating the cochlear duct from the vestibular scala is 
 known as Reissner's membrane. The external wall next 
 to the bony capsule is highly vascular and is termed the 
 stria vascularis. The flat epithelium which lines the 
 cochlear duct changes into cylindric cells with long 
 cilia on the surface of the basilar membrane next to the 
 osseous lamina. These constitute the organ of Corti, the 
 presumptive sensory termination of the auditory nerve 
 (compare Fig. 112). Near the center of this epithelial 
 prominence is a longitudinal tunnel lined on both sides 
 by a row of lengthened (non-ciliated) epithelial cells, the 
 columns of Corti, which, by inclining, meet at the top 
 and inclose this tunnel. The nerve fibrils coming through 
 the osseous lamina spiralis terminate in the ciliated cells. 
 The cilia are covered by a cuticular plate, the membrana 
 tectoria, which arises from the apex of the triangular 
 cochlear duct. 
 
 PHYSIOLOGY OF THE EAR. 
 
 290. Sound is perceived when the ear is reached by 
 aerial vibrations ranging in frequency from about 16 to 
 50,000 a second. But it is only between the range of 40 
 and 4000 vibrations a second that sounds can be employed 
 for pleasurable musical purposes. The theoretically sim- 
 plest form of vibration is that described by a swinging 
 pendulum, and is termed mathematically a sinus wave. 
 Such sinus waves produce simple tones. They can be 
 obtained by means of some forms of open organ-pipes or 
 from tuning-forks mounted on resounding boxes. Almost 
 all tones produced by other means are complicated, con- 
 sisting of a fundamental note with a variable number of 
 overtones. Their graphic representation is hence entirely 
 different from that of a sinus wave. The number and 
 height of overtones, combined with the fundamental note, 
 give each sound the characteristic termed musically the 
 timber, or quality. The trained ear can detect these 
 overtones within certain limits. By means of so-called 
 resonators their existence can be demonstrated physically
 
 SOUND. 377 
 
 (Fig. 113). Noises differ from tones, first, by having a 
 large number of discordant overtones, and, secondly, by 
 the irregularity of their duration. 
 
 The funnel-shaped and movable auricle of animals aids 
 in locating sounds, as the sound is loudest when the 
 auricle points in its direction. In man this function is 
 lost, and the auricle is of but little use in intensifying 
 sound-waves by reflection. 
 
 The membrane of the drum is remarkably sensitive to 
 sound-waves, both on account of its thinness and espe- 
 cially by reason of its curvature. It is set into vibration 
 by any sound-waves entering the meatus. By reason of 
 the curvature of its radial fibers the low energy of sound- 
 
 FlG. 113. Helmholtz's resonator. 
 
 waves suffices to produce a sufficient mechanical effect 
 upon the handle of the hammer to cause it to vibrate. 
 The hammer is thus made to swing around an axis formed 
 by the ligaments attached to its neck. This vibration is 
 transmitted through the articulation to the head of the 
 anvil, and through the long process of the latter to the 
 stapes. With sufficiently intense tones visible vibrations of 
 the drum membrane and ossicles may be obtained. Under 
 ordinary circumstances, however, their extent of move- 
 ment is of microscopic dimension. When the membrana 
 tympani is pressed inward, the pressure is transmitted 
 through the stapes to the perilymph of the labyrinth, 
 and the membrane of the round window can be made to 
 bulge visibly. Sound-waves thus travel through the 
 perilymphatic space of the vestibule and the vestibular 
 scala of the cochlea, returning from the end of the latter
 
 3/8 PHYSIOLOGY OF THE EAR. 
 
 by way of the scala tympani' to the round window. 
 Through the thin membranous walls of the cochlear 
 duct the vibrations are communicated to the endolymph. 
 According to the theory of Helmholtz, there are in the 
 cochlear duct structures tuned to resound with all notes, 
 and these are presumably the fibers of the basilar mem- 
 brane. How these sympathetic vibrations are trans- 
 formed into activity of the individual nerve-fibers is as 
 yet beyond our comprehension. 
 
 The inward movement of the hammer is accurately 
 followed by the corresponding motion of the anvil by 
 reason of minute cogs on both ossicles underneath the 
 articulation, which interlock during inward movement. 
 But when any traction pulls the manubrium outward, 
 the anvil does not follow beyond the slight limit set by 
 the elasticity of its ligaments. 
 
 There is not much known about the functions of the 
 muscles of the ossicles. It has been shown in animals 
 that the tensor tympani pulls the hammer inward at the 
 beginning of every loud sound. This is a momentary, 
 not a continuous, muscle-jerk of reflex nature. Some 
 persons can contract the tensor tympani voluntarily in 
 connection with yawning movements, and during this 
 period they hear a low humming sound and are less 
 sensitive to external sounds. The tensor tympani muscle 
 is under the control of motor fibers of the fifth nerve, while 
 the stapedius muscle is innervated by the facial nerve. 
 
 291. The sensitiveness of the membrana tympani to 
 sound-waves is greatest when the air-pressure is equal on 
 its two sides. This equilibrium is maintained by periodic 
 ventilation of the drum cavity through the Eustachian 
 tube. The walls of the cartilaginous part of the tube 
 are in actual contact, but this contact is overcome easily 
 by any increased air-pressure in the pharynx. Hence on 
 closing the nostrils and mouth and raising the pharyn- 
 geal air-pressure by an expiratory effort air can be forced 
 through the tube into the middle ear (Valsalva's experi- 
 ment). The diminution of the pharyngeal air-pressure
 
 SOUND-WAVES. 379 
 
 during an inspiration with closed nostrils and mouth is 
 not sufficient to open the tubal walls. But if a swallow- 
 ing movement be performed while the nostrils are held 
 closed, the air is sucked out of the tube and middle ear 
 (Valsalva's negative experiment). The Eustachiati tube 
 gapes normally during the act of swallowing, by reason 
 of the combined action of the tensor and levator palati 
 muscles. During this momentary dilatation of the tubal 
 caliber the normal ventilation of the middle ear takes 
 place. In some persons the tube also opens during 
 yawning. The gaping of the Bustachian tube during 
 swallowing can be shown by holding a sounding tuning- 
 fork in front of the nostrils. The sound, ordinarily in- 
 audible, is heard during the act of swallowing. When 
 the tube is obstructed morbidly, the air in the middle ear 
 is gradually absorbed by the blood in the capillaries, and 
 its tension is lowered below that of the external atmos- 
 phere. The external air then presses the membrana 
 tympani inward, thereby producing a feeling of fulness 
 and a diminished sensitiveness to sounds. 
 
 292. The admission of sound-waves to the drumhead 
 is interfered with by any occlusion of the meatus. But 
 when there is still a narrow path left, sounds are only 
 moderately enfeebled. Small holes in the membrana 
 tympani do not interfere much with its normal function. 
 Larger defects reduce its action upon the hammer in 
 proportion to their extent. Even in total absence of the 
 membrana tympani and ossicles the hearing power may 
 be still practically useful, though much enfeebled. Any 
 morbid process, however, which interferes with the 
 mobility of the ossicles, such as contact with the swollen 
 mucous membrane or rigidity of the articulations, re- 
 duces the transmission of sound to the oval window to a 
 large extent. Of all obstacles to sound-conduction none 
 are more damaging than ankylosis of the foot-plate of 
 the stirrup in the oval window. But even in this condi- 
 tion sound-waves reaching the drumhead are still faintly 
 perceived.
 
 380 PHYSIOLOGY OF THE EAR. 
 
 293. Sound-waves can reach the labyrinth through 
 another route besides the conduction from the drumhead 
 through the ossicles to the oval window. When waves 
 are made to pass through the bones of the skull, they 
 reach the labyrinth and cause the sensation of sound. 
 This is termed bone-conduction. Sound-waves in the 
 air, however, do not cause perceptible vibration of the 
 skull bones, except in the case of very high notes. Such 
 high tones, produced, for instance, by the Galton whistle 
 or by the chirping of insects, are perceived nearly as 
 well when the meatus is occluded. All sound-waves, 
 however, can be passed through the cranial bones by 
 placing the latter in contact with the vibrating solid 
 for instance, the stem of a tuning-fork. Aerial waves can 
 be conducted into the skull by a thin elastic plate of 
 rubber (the audiphone) held between the teeth. But 
 their intensity is far below that obtained by conduction 
 through the normal drumhead and ossicles. 
 
 When sound-waves reach the two healthy labyrinths 
 by bone-conduction, the sensation is not referred to 
 either ear, but simply to the head. But if an obstacle 
 exists to sound-conduction either in the meatus or in the 
 chain of ossicles, the sound perceived through bone-con- 
 duction is heard loudest in the ear thus impaired. If, 
 for instance, a tuning-fork be placed against the teeth or 
 the forehead, it is heard loudest in the ear the meatus of 
 which is occluded. This is known as Weber's test. 
 
 The binaural perception of aerial sound-waves enables 
 us to detect the direction from which the sound comes. 
 When both ears are normal and alike, the observer re- 
 cognizes the greater loudness in the ear turned toward 
 the source of sound, and by gradual movements of the 
 head is able to locate it. 
 
 294. The internal ear serves as the organ of another 
 sense besides that of hearing. For want of a better term 
 this has been called the static sense, or, less appropriately, 
 the sense of equilibrium. The semicircular canals en- 
 able vertebrate animals to estimate the motion of their
 
 THE STATIC SENSE. 381 
 
 bodies relative to the surrounding space as well as their 
 position with reference to the action of gravity. As these 
 sensations do not ordinarily enter the domain of conscious- 
 ness with the vividness characteristic of the activity 
 of the other senses, the static sense is not recognizable 
 by self-observation, except under selected experimental 
 conditions. The static sense can be demonstrated sub- 
 jectively by rotating the observer while seated on a 
 whirling platform. With closed eyes one perceives un- 
 mistakably the direction and the rapidity of the rotation, 
 until this becomes uniform in speed. For it is only the 
 acceleration, or negatively the retardation, which is per- 
 ceived, not the uniform motion. The arrest of motion is 
 again felt and is followed by a transient subjective feeling 
 of rotation in the opposite direction, a negative static after- 
 image, so to speak, of fictitious nature. If the head is 
 maintained in any inclined position, the direction of the 
 rotation is referred subjectively to the axes of the head, 
 irrespective of the motion of the body, and the reversed 
 after-sensation is likewise referred to the axes of .the head 
 and moves with the latter when the position of the head 
 is voluntarily changed. An objective evidence of these 
 static sensations are certain reflex movements of the eyes. 
 When the eyes are not intentionally controlled by the sub- 
 ject, they are rotated in a direction opposed to that of the 
 whirling table with a speed equal to that of the mechani- 
 cal rotation. After extreme version they return with a 
 sudden jerk to nearly their initial position, from which 
 the contrary rotation is again assumed. These move- 
 ments can also be felt by the finger placed on the closed 
 lids. These ocular movements enable us to estimate the 
 relation of the body to external space and to conform the 
 visual sensations with those furnished by the static sense. 
 If for any reason the eyes do not move at the same speed 
 as the whirling table, the images of external objects 
 wander over the retina and the sensation resulting there- 
 from is incorrectly interpreted as indicating motion of 
 external objects. The eye movements may hence be
 
 382 PHYSIOLOGY OF THE EAR. 
 
 called compensatory. The static sensations as well as 
 the compensatory movements of the eyes are absent in a 
 large proportion of deaf-mutes when tested by whirling 
 (James). This fact supports the view that both the sen- 
 sations and the ocular movements are started from the 
 semicircular canals, as this part of the external ear is 
 found destroyed in many, though not in all, deaf-mutes. 
 
 In birds passive rotation results in a swinging motion 
 of the mobile neck and head comparable to the com- 
 pensatory eye movements of mammals. This reflex move- 
 ment is prevented by extirpation of both entire labyrinths, 
 provided the eyes are kept covered, as otherwise the move- 
 ments are started in a reflex manner by visual sensations. 
 
 In birds, especially pigeons, the large semicircular 
 canals are freely accessible and have hence been experi- 
 mented upon extensively. The most decisive observation 
 made in this manner refers to the occurrence of swinging 
 motions of the mobile neck in the plane of the one canal, 
 which has been either divided or plugged. When the 
 entire labyrinth is destroyed, the animal suffers from ex- 
 treme incoordination of movements, from which it recovers 
 largely in the course of time. From a most painstaking 
 and varied series of experiments Ewald has come to the 
 conclusion that the labyrinth exerts a reflex tonus upon 
 the entire muscular system, and that any movements of 
 the body in any one plane become incoordinate if not con- 
 trolled by the intact semicircular canal of that plane. 
 After destruction of the labyrinth the animal gradually 
 learns to regulate the extent of its movements by the 
 sensations furnished by the other senses. 
 
 A physical explanation of the functions of the semi- 
 circular canals has been suggested by Mach, Breuer, and 
 by Crum Brown, which seems to harmonize with all the 
 facts. Each semicircular canal, with its ampulla and the 
 utricle, forms a complete hollow ring with fluid contents 
 the endolymph. The three semicircular canals are 
 strictly at right angles to each other and hence correspond 
 to the three planes of space. The semicircular canals of
 
 SEMICIRCULAR CANALS. 383 
 
 one ear are so mated to those of the other side that rota- 
 tion of the head in any possible plane involves rotation of 
 at least one pair of semicircular canals around its axis. 
 On account of the bilateral symmetry of the two laby- 
 rinths the direction from ampulla to semicircular canal is 
 the opposite in one ear from what it is in the other. On 
 account of the inertia and the mobility of the endolymph 
 this fluid lags behind in any rotation of a semicircular 
 canal until wall and fluid contents have acquired a 
 uniform velocity. If, hence, a semicircular canal is ro- 
 tated, for instance, with its ampulla in advance, there 
 results either a motion of the fluid in the center of the 
 caliber in the opposite direction, or at least an increase 
 of pressure in the ampulla on account of the hindrance 
 of the flow in the extremely narrow semicircular canal. 
 These movements or changes in the pressure of the endo- 
 lymph excite the nerves terminating in the cilia of the 
 maculae. Within a short time after rotation has begun 
 the endolymph moves with the same velocity as its wall, 
 and now the rotation is no longer perceived if the eyes 
 are closed. When, on the other hand, the rotation of the 
 head is stopped, the inertia of the endolymph starts again 
 a current in the opposite direction, and the nerves of the 
 opposite ear are thrown into activity hence the after- 
 sensation of (fictitious) negative motion. 
 
 It is not merely the acceleration or retardation of a 
 rotary movement which we can perceive, but also any 
 change of speed in horizontal or vertical translation. Of 
 this we can assure ourselves by observations, with closed 
 eyes, in elevators and smooth-running railroad cars. It 
 is not quite .so clear how the semicircular canals are in- 
 fluenced by movements not rotary in character, but in all 
 probability similar changes of intra-ampullary pressure 
 are thus created, due to the fact that each ampulla is 
 continuous on the one side with the very much narrower 
 canal, and in the other direction with the much wider 
 utriculus. 
 
 295. The movements of the labyrinthine endolymph
 
 384 ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 started by rotations produce the feeling of dizziness, but 
 the vehemence necessary for this sensation varies enor- 
 mously in different persons, so that some are easily made 
 dizzy, others only by extreme rotations. Morbid irrita- 
 tion of the semicircular canals for instance, when due 
 to caries is hence accompanied by characteristic vertigo. 
 The connection with the semicircular canals explains the 
 frequent occurrence of dizziness in the course of various 
 forms of ear disease. Lesions of the labyrinth are espe- 
 cially characterized by vertigo and unsteadiness, which 
 persist until the patient has learned to depend entirely on 
 the evidence of his other senses. In deaf-mutes with 
 destroyed semicircular canals dizziness can no longer be 
 produced by rotation. These patients have, on the other 
 hand, the disadvantage that they cannot learn to perform 
 bodily movements requiring an accurate sense of equi- 
 librium, especially while closing their eyes. 
 
 296. The ordinary sensibility of the ear is very acute. 
 Even the most delicate touch of the skin of the meattis, 
 the drumhead, or the exposed tympanic walls with a 
 blunt probe is painful. Mechanical irritation of the 
 lining of the meatus is apt to cause a characteristic 
 reflex viz., fits of coughing. 
 
 The gross anatomy of the ear was mainly developed by the 
 great anatomists of the sixteenth centurj% Vesalius, Eustachius, 
 and Fallopia. At the end of the seventeenth century Valsalva 
 added many details. Since that time the anatomy of the ear has 
 been completed gradually by numerous contributors. Good de- 
 tailed accounts can be found in all larger treatises on systematic 
 anatomy. In otologic literature the fullest descriptions are in 
 Schwartze's Handbuch der Ohrenheilkun.de, 1892, and in Politzer's 
 Ohrenheilkunde, fourth edition, 1901 (English translation by 
 Dodd, 1892). 
 
 Politzer has also written an indispensable guide for the dis- 
 section of the ear, Zergliederung des menschlichen Gehbrorgans, 
 1889. The physiology of hearing was almost wholly the work of 
 Helmholtz, and is detailed in his Lehre von den Tonempfindun- 
 gen, 1870 (English translation by Ellis, Sensation ojf Tone, etc., 
 second edition, 1885). 
 
 The semicircular canals have been extensively experimented
 
 PHYSIOLOGY OF THE EAR. 38$ 
 
 upon since the days of Flourens. Goltz was the first to charac- 
 terize them as the organ of a special sense of equilibrium. The 
 most extensive researches on the subject are those by Ewald in 
 his Phys. Untersuchungen uber d. Endorgan des Nervus Octavus, 
 1892. The observations on man made on the whirling table by 
 Mach, Breuer, and by Crum Brown are excellently described by 
 the latter in a lecture in Nature, June 20, 1895. 
 25
 
 CHAPTER XXXI. 
 
 GENERAL ETIOLOGY OF EAR DISEASE. 
 
 297. Notwithstanding the deep protected location of 
 the organ of hearing, it is very frequently affected by 
 disease. According to various statistics, the external ear 
 is involved in 25 per cent, the middle ear in 70 per cent, 
 and the internal ear and nerve in about 5 per cent, of all 
 ear patients. Traumatism plays but a small role in the 
 production of ear disease. Blows may lead to bloody 
 effusions in the auricle with subsequent deformity or to 
 rupture of the drum-head. Foreign bodies in the meatus, 
 a frequent accident in childhood, cause serious mischief 
 only if violence for instance, during attempts at extrac- 
 tion wounds the meatus or drumhead and opens the 
 gate to infection. Slight traumatism combined with 
 subsequent infection is a common result of scratching the 
 meatus with pins, hair-pins, and other articles. The 
 thin skin is very easily abraded, and, being covered 
 with dust containing living germs, furuncles, diffuse 
 inflammation of the meatus, and even extension to the 
 middle ear are not an uncommon penalty for this habit. 
 Diving under water accounts for some ear disease, 
 especially when certain unfavorable conditions preexist. 
 Wax present in excess will swell when wetted and may 
 now occlude the meatus. A former cured suppuration 
 may be rekindled if a perforation of the drumhead 
 permits the water to reach the middle ear. Cold water 
 pressing against the intact membrana tympani some- 
 times, though rarely, starts the extension of a catarrhal 
 process from the pharynx to the ear. All this can be 
 guarded against by a plug of ordinary non-absorbing 
 cotton in the ear while bathing. 
 
 386
 
 GENERAL ETIOLOGY OF EAR DISEASE. 387 
 
 Less common, but more serious, is acute otitis media 
 due to the entrance of water through the Eustachiau 
 tubes as the result of swallowing- under water. 
 
 298. The majority of affections of the middle ear, 
 excepting tubercular otitis media and sclerosis, originate 
 from extension of disease in the nose or pharynx. In a 
 broad way it may be stated that all cases of catarrhal or 
 purulent middle-ear disease are preceded by nasopharyn- 
 geal lesions, except that some of the eruptive fevers 
 (measles and scarlatina) may involve the mucous mem- 
 brane of the middle ear and of the nasopharynx at the 
 same time. In all the various forms of inflammation of 
 the middle ear nasopharyngeal lesions are either present 
 or were present at the start. In some instances of pro- 
 liferative and of serous catarrh of the middle ear the 
 dependence on the lesions in the air-passages can be 
 shown by the successful results of nasopharyngeal treat- 
 ment. This success is, however, not always obtained. 
 Suppuration of the middle ear, on the other hand, after 
 it is once started, continues independently of the condi- 
 tion in the nasopharynx, and is hence not cured by their 
 successful removal. But when the history shows fre- 
 quent recurrences of otitic suppuration after natural or 
 surgical cure, the benefit of proper nasopharyngeal treat- 
 ment is easily demonstrable. The nasopharyngeal origin 
 of ear disease is often plainly suggested in one-sided 
 affections by the limitation of the ear disease to the side 
 of the nasal stenosis. 
 
 The etiologic relation of the different forms of nasal 
 and pharyngeal disease to aural affections can be sum- 
 marized as follows : Ordinary acute coryza and pharyn- 
 gitis or tonsillitis do not often cause ear trouble if the 
 respiratory passages had hitherto been structurally nor- 
 mal. The liability to involvement of the ear increases, 
 however, with the degree of previous structural anomaly, 
 especially if of an obstructive character. In children 
 the most important predisposing lesion is enlargement of 
 the pharyngeal tonsil and, to a much less extent, hyper-
 
 388 GENERAL ETIOLOGY OF EAR DISEASE. 
 
 trophy of the faucial tonsils. In adults the adenoid 
 overgrowth plays a minor role in frequency and import- 
 ance, while any form of nasal stenosis is an important 
 pathogenic factor. As long as the obstructive lesions are 
 not accompanied by acute or subacute inflammation they 
 do not lead to any acute ear disease. But it is their 
 presence which renders any complicating acute nasal or 
 pharyngeal inflammation a menace to the ear. The form 
 of ear disease resulting from these conditions are reten- 
 tion of wax in the meatus, purulent otitis, or serous 
 catarrh of the middle ear. In children the acute ear 
 involvement is usually the purulent form. After the age 
 of puberty serous catarrh is more likely to occur than 
 purulent otitis. In cases of one-sided nasal stenosis the 
 ear of the same side is much more likely to suffer than 
 its mate. The danger of nasopharyngeal inflammation 
 as regards the ear is much greater when the respiratory 
 lesions are part of some general disease, as measles, 
 scarlet fever, and especially influenza, than in affections 
 purely localized in the nose and throat. The danger 
 from diphtheria is about the same as from ordinary 
 pharyngitis, at least numerically, although the ear dis- 
 ease when it does follow diphtheria is likely to be more 
 severe. 
 
 Subacute inflammatory processes in the nasopharynx 
 of children with enlarged pharyngeal tonsil result in 
 catarrh of the Eustachian tube, an affection which may 
 be said to have a subacute course. 
 
 Purely chronic inflammatory conditions in the nose 
 and throat lead to the adhesive form of middle-ear 
 catarrh, especially when the nasopharyngeal condition 
 tends toward hypertrophy. A material determining 
 factor in the extension of the hyperplastic process to the 
 ear is the narrowing of the nasal passage by septum ir- 
 regularities. The influence of nasal stenosis is generally 
 upon the ear of the same side, but in the chronic and 
 insidious form of disease there are occasional exceptions 
 to the rule. Acute or subacute catarrh al exacerbations
 
 GENERAL ETIOLOGY OF EAR DISEASE. 389 
 
 in the course of hypertrophic rhinitis usually intensify 
 the middle-ear affection by corresponding exacerbations 
 of the ear disease. 
 
 Diseases of the middle ear are thus not only an exten- 
 sion of nasopharyngeal processes, but, on the whole, also 
 a copy of the type of the disease in the air-passages. 
 The ear disease may, however, persist after the original 
 disturbance in the nose or pharynx has ceased. More- 
 over, the course of the ear disease may become com- 
 plicated by secondary changes, such as adhesions in 
 catarrhal otitis and bone affections in the purulent form. 
 
 299. The microbes causing purulent inflammation of 
 the middle ear have been identified as the pneumococcus, 
 streptococcus, staphylococcus, bacillus pneumoniae (Fried- 
 lander), bacillus pyocyaueus, and exceptionally a few 
 others, sometimes in combination. In serous catarrh of 
 the ear the same bacteria have been found in a small num- 
 ber of observations. Whether the etiologic difference 
 between purulent and serous otitis depends on a difference 
 in the number of microbes or on a different mode of re- 
 action of the tissues in different subjects is unknown. 
 Clinically the two diseases are separate and distinct, and 
 the occurrence of one renders the future appearance of 
 the other very unlikely, even in the ear of the other 
 side. 
 
 Pathogenic microbes can reach the middle ear through 
 the Eustachian tube for instance, during violent efforts 
 of coughing or blowing the nose. The most striking 
 demonstration of this mode of pyogenic infection is the 
 otitis following within eight to twenty-four hours after 
 the entrance of water from a nasal douche into the tube. 
 In most cases, however, it is probably less a transport of 
 infectious material through the Eustachian passage than 
 a growth of the parasite in the mucous membrane or the 
 lymph-channels of the tube which leads to otitic infec- 
 tion. Yet the pharyngeal end of the tube is not rarely 
 normal during life or at the autopsy in acute suppurative 
 otitis.
 
 390 GENERAL ETIOLOGY OF EAR DISEASE. 
 
 Whether the plastic or hypertrophic form of disease 
 depends on the presence of parasites is not known, either 
 in the case of the ear or of the respiratory lining. The 
 process in these cases is a continuous one from the pharynx 
 through the tube to the tympanic cavity. 
 
 300. "Taking cold" is an important factor in the 
 causation and perpetuation of middle-ear disease, espe- 
 cially in serous catarrh and exacerbations in the course of 
 hypertrophic otitis media. The mechanism of u taking 
 cold " and the known facts concerning it have been dis- 
 cussed in the chapter on Etiology of Nasal Diseases (f 13). 
 The doubt whether chilling of the body can start an in- 
 flammatory process in a hitherto normal structure does 
 not apply in the case of the ear, since its involvement 
 under such circumstances means only the extension of 
 preexisting nasopharyngeal disease. A clear history of 
 "cold " as an etiologic factor can be obtained only in a 
 small number of instances, but in some of them its in- 
 fluence seems well supported by the evidence. There 
 certainly can be no doubt that careless exposure and 
 insufficient protection exert an unfavorable effect upon 
 the course of any inflammatory affection of the middle 
 ear. Habitually cold feet should receive attention in 
 connection with any ear disease (compare ^[ 13). 
 
 301. The eruptive fevers are responsible for a large 
 proportion of ear diseases. In measles an inflammatory 
 lesion with exudation has been found in every fatal case 
 examined, while in scarlet fever we know at least clini- 
 cally that involvement of the ear is very common. The 
 first lesion in eruptive fevers is probably the specific 
 exanthema in the mucous membrane of the Eustachian 
 tube and middle ear, coincident with the eruption in the 
 pharynx and perhaps prior to the cutaneous manifesta- 
 tion. But this specific lesion follows a benign course 
 and is not revealed clinically at all, unless complicated 
 by secondary infection with pyogenic microbes. The 
 probability of this complication increases with the degree 
 of previous structural anomaly in the nose and pharynx
 
 GENERAL ETIOLOGY OF EAR DISEASE. 39! 
 
 and the intensity of their involvement by the eruptive 
 fever. Diphtheria does not extend to the ear often, but 
 when it does, the disease is of a severe type, though 
 rarely due to the bacillus of diphtheria itself. Influenza 
 may cause a primary otitis media, of a hemorrhagic, but 
 generally not purulent, character. Within the past few 
 years this form of influenza otitis has become less com- 
 mon, while the ordinary purulent otitis secondary to a 
 purulent influenza rhinitis is seen oftener. A large 
 number of children with purulent otitis are scrofulous. 
 Whether this disease itself viz., the poisoning of the 
 system from some minute tubercular focus in lymph- 
 glands reduces the resisting power to pyogenic infection 
 is not definitely proven, though probable. The direct 
 cause, however, of the purulent otitis is the enlargement 
 of the pharyngeal tonsil, together with the frequent 
 spells of acute and subacute nasal inflammation common 
 in scrofulous children. Eczema of the face or scalp is 
 likewise a frequent manifestation in scrofula, and its ex- 
 tension to the auricle is, therefore, not uncommon. 
 
 Extension of pyogenic infection from the middle ear 
 into the mastoid process or into the bone in general is 
 favored by any impoverished state of nutrition for in- 
 stance, diabetes. 
 
 Non-suppurative ear disease, especially the proliferative 
 form, is not a rare sequel to typhoid fever. Relatively 
 often I have seen post-typhoid trouble in the form of 
 plastic middle-ear disease, often one-sided, of rapid prog- 
 ress for a number of months, but afterward permanently 
 stationary. Diseases of the middle ear, while not directly 
 caused, are usually unfavorably influenced by any mal- 
 nutrition, as anemia and digestive disturbances, exactly 
 like the nasal and pharyngeal affections starting them 
 (compare If 16 and 1 17). 
 
 302. Morbid change in the internal ear and nerve-ends 
 may result from various intracranial diseases, first among 
 which ranks cerebrospinal meningitis. Atrophic proc- 
 esses in the auditory nerve occur in the course of tabes.
 
 392 GENERAL ETIOLOGY OF EAR DISEASE. 
 
 Severe affections of the internal ear are also due in limited 
 number to scarlet fever, mumps, typhoid fever, syphilis, 
 especially the inherited form. Sometimes they coincide 
 with severe forms of digestive disturbances. Nerve- 
 deafness occurs in a small but noticeable proportion of 
 patients with pigment degeneration of the retina. A 
 curious observation, repeatedly noted, is that among 
 albinotic (white) cats there are very many deaf-mutes. 
 
 Direct injury to the labyrinth has been observed after 
 large doses of quinin and in few very rare instances from 
 salicylate of sodium. Affections of the teeth may in- 
 fluence the ear. A mild purulent otitis apparently trace- 
 able to a coryza coincides quite often with teething in 
 children. Caries of any of the rear teeth or even the 
 normal eruption of wisdom-teeth is sometimes attended 
 by neuralgic pains referred to the ear, the origin of which 
 is found only after a definite search. 
 
 303. The surroundings and occupation may have an 
 influence upon the ears. Continuous loud noises, like 
 heavy hammering, impair the hearing gradually by set- 
 ting up a sclerotic process in the internal ear. Boiler- 
 makers, workmen in machine shops, and, to a less extent, 
 railroad engineers and firemen, show a large percentage 
 of cases of progressive nervous deafness. The danger is 
 greater to those who enter such employment with some 
 previous anomaly in the middle ear. Artillery men are 
 somewhat subject to the same danger, besides suffering 
 at times from rupture of the drumhead in consequence of 
 detonations. Opening the mouth to facilitate equalization 
 of air-pressure through the Eustachian tubes and wearing 
 cotton plugs in the ear are well-known protective meas- 
 ures among the artillery. Whether the cotton plug 
 would also protect boilermakers and others exposed to 
 loud din is probable, but has not been tested sufficiently. 
 Mechanical accidents to the drumhead may occur too in 
 workmen working in pneumatic caissons in compressed 
 air under water, as in bridge-building. It is not the ab- 
 normal air-pressure by itself, but rather a too sudden
 
 GENERAL ETIOLOGY OF EAR DISEASE. 393 
 
 change in the pressure, which, when not quickly com- 
 pensated through Eustachian ventilation, may cause 
 rupture. Too sudden a diminution of such extreme air- 
 pressure leads to liberation of air-bubbles in the capil- 
 laries, often with minute hemorrhages, and this accident 
 has occurred as well as in the labyrinth of the ear as in 
 the central nervous system. 
 
 304. Heredity is an important factor in the predis- 
 position to ear disease. The liability to aural affections 
 is decidedly increased by the history of disease in the 
 parents or near relatives. While plastic and sclerotic 
 middle-ear processes are the commonest forms observed 
 in predisposed families, still the individual under the 
 influence of a bad heredity may acquire any type of ear 
 disease. The intermarriage of deaf-mutes leads to a 
 large proportion of deaf-mutes in the offspring, but still 
 with a preponderance of normal children.
 
 CHAPTER XXXII. 
 
 SUBJECTIVE SYMPTOMS AND METHODS OF EX- 
 AMINATION AND TREATMENT IN EAR DISEASES. 
 
 305. Pain in the form of more or less severe earacne is 
 produced by acute inflammation in either the meatus or 
 the middle ear, and especially in the mastoid bone. Its 
 severity and duration are proportionate to the intensity 
 of the inflammatory processes. Chronic disease does not 
 cause pain. Subacute catarrh of the Eustachian tube 
 is sometimes productive of earache in children. Acute 
 pharyngeal lesions near the Eustachian orifice, such as 
 ulcers near the lateral recesses of the pharynx and wounds 
 of the upper part of the tonsil, give rise to sharp pain 
 referred to the ear. Erupting wisdom-teeth and disease 
 of any tooth back of the bicuspids can induce otalgia 
 neuralgic pains in the ear. 
 
 Itching in the ears is at times a source of great distress 
 to nervous people. It may be due to an easily overlooked 
 area of slight eczema in the meatus, or, on the other 
 hand, to venous congestion around the Eustachian orifice 
 in neurasthenics with irritable nose. It is often very 
 annoying in hay fever. 
 
 A full or " stopped-up " feeling in the ears results from 
 occlusion of the meatus by wax, especially if the latter 
 presses on the drumhead. Furuncles and diffuse inflam- 
 mation of the meatus cause stuffiness in proportion to 
 the swelling present. Stuffiness is characteristic, too, of 
 serous catarrh, while in the plastic form of middle-ear 
 disease it is a less constant or prominent symptom. It is, 
 of course, present during the acute stage of purulent 
 otitis. 
 
 In connection with the "stuffy" feeling patients 
 mention the subjective want of resonance of their own 
 
 394
 
 VERTIGO. 395 
 
 voice. It sounds muffled to the patient, even though his 
 hearing for external sounds may not have suffered ap- 
 preciably. A similar muffling of the sound is often 
 noticed, especially in one-sided disease, when a noise is 
 produced by scratching the region around the ear. Quite 
 different from this subjective muffling of the voice is 
 the excessive resonance, which has been termed "au- 
 tophony." It is complained of by patients without ear 
 disease, but whose Eustachian tubes presumably gape to 
 an abnormal extent on account of inflammatory rigidity 
 of their walls or perhaps from wasting of the cushion of 
 fat in the external wall of the tube. 
 
 Vertigo varying from momentary slight dizziness to a 
 more or less continuous feeling of insecurity may result 
 from various ear affections. Pressure of wax against the 
 drumhead, syringing with cold water or with too much 
 force, especially when there is disease of the attic, can 
 cause it. Persistent dizziness is a grave symptom in 
 suppuration of the middle ear. Disease limited to the 
 tympanic cavity without retention of pus in the attic 
 does not provoke vertigo unless there is caries of the 
 labyrinth. This symptom, however, is characteristic of 
 any involvement of the semicircular canals, whether the 
 disease be primarily labyrinthine or due to extension to 
 the internal ear. Severe ear vertigo leads to nausea and 
 vomiting, staggering, or even the inability to rise from 
 the recumbent position. 
 
 306. Noises and ringing in the ear, technically termed 
 tinnitus, are a serioiis annoyance to many ear patients. 
 Some neurasthenics have been driven by it to suicide. 
 Wax in the meatus may cause a roaring sound. In sup- 
 pnrative otitis tinnitus is usually absent, sometimes, how- 
 ever, following later by reason of intratympanic adhesions. 
 In serous catarrh it is a minor symptom. But the hyper- 
 trophic form of middle-ear disease and to a much less 
 frequent extent sclerosis is characterized by subjective 
 noises, sometimes as the earliest symptom. Disease of 
 the internal ear is not always accompanied by subjective
 
 396 SUBJECTIVE SYMPTOMS IX EAR DISEASES. 
 
 sounds, though mostly so. The aura of epilepsy is some- 
 times an auditory illusion. Tinnitus may sound like 
 roaring, singing of birds, ringing of bells, whistling, or 
 hissing of escaping steam. Quite often it is a pulsating 
 noise, sometimes a musical sound or a changing din. It 
 may be heard only in the stillness of the night, or it may 
 be so loud as to drown continuously all external sounds. 
 Neither the anatomic lesions causing tinnitus nor its 
 physiologic mechanism are fully understood. It must, 
 of course, be due to irritation of the intralabyrinthine 
 nerve-ends. Pulsating sounds are due to the pulsation 
 of the arterioles somewhere in the ear, and are often con- 
 trolled by absolute rest, or transiently by compression of 
 the carotid artery, but are aggravated by any exertion or 
 excitement. In very rare instances pulsating noises have 
 been caused by an aneurysm of smaller intracranial or 
 other adjoining blood-vessels. Snapping sounds which 
 are really objective and can be heard by auscultation 
 through a tube from the meatus to the listener's ear are 
 occasionally due to spasms of the tensor tympani muscle; 
 oftener, however, to contraction of the tensor palati mus- 
 cle, which some people can control voluntarily. Instances 
 have been known in which a nocturnal ticking was com- 
 plained of, due to the watch under the pillow. Diplacusis 
 is the term applied to the wrong "tuning" of one ear, 
 occasionally observed by musical patients in the course of 
 a mild middle-ear catarrh with secretion. All notes sound 
 a trifle, perhaps half a tone, too high or too low as com- 
 pared with the normal ear. It depends probably on some 
 circulatory disturbance or slight effusion in the cochlea. 
 
 307. The hearing acuity is reduced more or less by all 
 diseases of the ear except minor affections of the meatus, 
 like small furuncles or slight eczema. Yet this may not 
 be the patient's reason for seeking advice, either because 
 the deafness is scarcely noticeable in the beginning of an 
 affection or because it has been stationary so long that he is 
 accustomed to it, or because it is overshadowed by other 
 symptoms. In most instances of disease of the sound-
 
 THE HEARING ACUITY IN EAR DISEASES. 397 
 
 conducting parts the hearing is noticeably improved by 
 external noises, like the rattling of railroad cars, which 
 deafen normal persons. In disease of the labyrinth, on 
 the other hand, noisy surroundings reduce the patient's 
 hearing power. 
 
 The hearing acuity cannot be measured at present with 
 any scientific accuracy. We would require for this pur- 
 pose a device furnishing pure tones without overtones 
 throughout the entire auditory range, the intensity of 
 which could be measured and regulated with mechanical 
 precision. Despite numerous efforts to utilize tuning- 
 forks, electric mechanisms, telephone, or phonograph for 
 this purpose, no measuring contrivance has been devised, 
 the utility of which is at all proportionate to its compli- 
 cated mechanism or cost. It is very easy to obtain a 
 single tone of fairly constant or measurable intensity, but 
 the requisite multiplication of notes, especially of pure 
 tones without overtones, makes any such device im- 
 practicable. Tuning-forks or steel rods struck by a spring 
 hammer of constant force (Politzer's acumeter) serve very 
 well as a source of a single tone of constant pitch and 
 intensity, the audibility of which depends on the distance 
 from the ear. But they have no advantage over the tick- 
 ing of a watch. If the distance at which the individual 
 watch is heard by the normal ear is stated as the denomi- 
 nator (d), and the distance at which the patient's ear 
 
 hears it as the numerator (n), the resulting fraction T is a 
 
 convenient though not physically accurate expression 
 of the patient's hearing ability. But this measurement 
 refers only to the high tones of the watch and is not indi- 
 cative of the hearing ability for other tones. Since the 
 hearing power may suffer unequally for different parts of 
 the scale, it would be desirable to have some instrument 
 which could supply tones throughout the entire range of 
 audition. Still the watch gives a serviceable method of 
 measuring the effect of treatment upon the hearing power. 
 The hearing distance should be noted while approaching,
 
 398 SUBJECTIVE SYMPTOMS IN EAR DISEASES. 
 
 rather than while receding from the watch, since in the 
 latter case it is more difficult to state when the audible 
 tick ceases. Young children do not, as a rule, give 
 trustworthy answers when tested with the watch. 
 
 The most serviceable method of measuring the hearing 
 acuity for practical purposes is the voice. Monosyllables 
 are repeated louder or nearer until the patient repeats the 
 word correctly. In order to avoid guess-work, the patient 
 must not watch the lips, and single syllables should be 
 pronounced without prearranged order. Different con- 
 sonants offer variable difficulty of perception, especially 
 in ankylosis of the foot-plate of the stirrup and in affec- 
 tions of the internal ear. Striking confusion in the re- 
 peated words raises hence the suspicion of such lesions. 
 The examiner must learn to speak with approximately con- 
 stant louduess of voice (either whisper or ordinary tone), 
 and test the hearing power by changing his distance from 
 the ear. The range of the voice-test can be increased 
 for instance, in small rooms by learning to modulate 
 the voice with constancy, thus speaking first in a faint 
 whisper, then in a medium loud whisper, and finally a 
 loud whisper, and if this does not suffice, repeating in 
 ordinary voice faintly, in average tone, or loudly. One 
 should, of course, be familiar with the normal hearing 
 distance in a given room and under given surroundings 
 (street noise). A fairly accurate record of a patient's 
 hearing power can thus be kept and changes noted. But 
 a comparison of the records of different examiners in 
 regard to changes in the hearing acuity is scarcely as 
 accurate as an intelligent patient's personal opinion, on 
 account of the difference in voices. 
 
 308. The range of audition can be tested by means of 
 Bezold's continuous tone-series. It consists of a series of 
 tuning-forks, each of which can change its pitch within 
 the limits of nearly one octave by the shifting of movable 
 clamps. The middle register is tested with two organ- 
 pipes with movable stops, while the upper end of the 
 scale is furnished by the Galton whistle. Researches with
 
 THE HEARING ACUITY IN EAR DISEASES. 399 
 
 the continuous tone-series have shown that the remnant 
 of hearing power in affections of the internal ear is some- 
 times represented by a small "island" in the middle of 
 the scale or may comprise a fair part of the lower end of 
 the scale, with gaps for certain tones. 
 
 For most clinical purposes it suffices to test the hearing 
 power for the lower tones by means of a heavy tuning- 
 fork and for the upper end of the scale by the Galton 
 whistle. A large tuning-fork with a movable clamp, 
 giving from 64 to 128 vibrations a second (C-c), is com- 
 monly used. In affections of the sound-conducting ap- 
 paratus (membrana tympani and chain of ossicles) this is 
 not so readily heard through the air as higher tones, 
 while its perception by bone-conduction is normal or 
 
 FIG. 114. Gallon's whistle with rubber bulb. The pipe below the opening 
 is filled by a plunger advanced or withdrawn by a screw, each turn being shown 
 by the scale upon the enlarged tube, and its tenths by that on the revolving 
 collar. It gives an audible sound from 0.5 (theoretically, 84,000 v. s.) to 10 or 
 12 (4200 or 3500). 
 
 slightly intensified. The Galton whistle, a miniature 
 stopped organ-pipe, varies its pitch by sliding the stop 
 (Fig. 114). Its range is from 6000 to nearly 50,000 vibra- 
 tions a second. On some of the more recent patterns the 
 pitch is approximately marked, but this is not absolutely 
 necessary if the whistle is tested by comparison with a nor- 
 mal ear. The perception of the highest notes is not 
 affected by any lesion interfering with sound-conduction, 
 but markedly so by disease of the labyrinth. The shrill 
 tone of the Galton whistle is conducted so much more 
 readily through the cranial bones than through the air 
 that stoppage of the ear by a plug scarcely interferes 
 with its perception. It cannot, hence, detect one-sided 
 disease with certainty.
 
 4OO 
 
 SUBJECTIVE SYMPTOMS IN EAR DISEASES. 
 
 309. The precise site of lesions in the ear is determined 
 by certain differences between the air-conduction (A. C.) 
 and the bone-conduction (B. C.) of sounds in different 
 forms of disease (compare T[ 293). The tests are made 
 with tuning-forks, mainly the c 2 , of 512 vibrations a 
 second, and the c of 128 vibrations (Fig. 115). In Rinne's 
 test the fork, while sounding, is held near the meatus, 
 and its loudness is compared with the tone the patient 
 hears on placing the stem firmly upon the mastoid bone. 
 Normally this sound is much louder by air-conduction, 
 and hence heard longer than when conducted through the 
 
 FIG. 115. Tuning-forks. 
 
 mastoid bone, and Rinne's test is called positive (Rinne +). 
 All lesions which interfere with the conveyance of sound 
 through the drumhead and ossicles diminish the sub- 
 jective loudness in the case of A. C. , and hence shorten 
 the time during which the tone of the subsiding tuning- 
 fork is heard. Bone-conduction is not thereby diminished, 
 sometimes even moderately intensified. This is especially 
 true of the lower tones. Hence the test with the forks 
 C or c is the most definite. After the time of perception 
 by A. C. and by B. C. or at least their ratio has been 
 determined with a watch, it is easy to tell whether the
 
 SUBJECTIVE SYMPTOMS IN EAR DISEASES. 40! 
 
 period of A. C. is shortened in the Rinne test. In ex- 
 treme cases the result is reversed the fork is heard longer 
 and louder through the bone than through the air (Rinne 
 negative or ). In the latter case the patient can 
 state readily that he hears the fork louder when placed 
 upon the bone than through the air. When the disease 
 is localized in the sound-perceiving parts without lesion 
 in the middle ear, the normal ratio of Rinne' s test is not 
 changed (A. C. > B. C.), but the loudness is diminished 
 both ways. In lesions affecting both the middle and 
 internal ear the test is often indecisive. 
 
 In Weber's test a tuning-fork is placed in the median 
 line on the forehead or against the teeth. It is then 
 heard equally loud in both ears if normal or if symmetri- 
 cally diseased. Any one-sided interference with sound- 
 conduction intensifies the loudness on that side, and in 
 pronounced instances the patient locates the sound 
 entirely in the affected ear. This can be imitated by 
 stopping the healthy ear of one side with a plug. If both 
 drums are diseased, the sound is referred to the ear most 
 affected. On the other hand, any disease in the sound- 
 perceiving apparatus reduces the perception on the 
 affected side. In complicated lesions Weber's test, too, 
 is not conclusive. 
 
 Schwabach's test consists in measuring the time of per- 
 ception in seconds when the fork struck with uniform 
 force is set upon the vertex of the head. Any pronounced 
 shortening of the time the tone is heard by bone-con- 
 duction argues in favor of a lesion in the sound-perceiving 
 organ. 
 
 Gelle^s test is intended to demonstrate fixation of the 
 foot-plate of the stirrup (ankylosis). A rubber tube is 
 put air-tight into the meatus, and the air in it is com- 
 pressed by means of a bulb. During the time the pres- 
 sure acts upon the drumhead a sounding tuning-fork set 
 on the tube is heard enfeebled if the stapes is movable 
 (normal), while the intensity of the sound is not altered 
 in case of immobility of this ossicle. 
 
 26
 
 4O2 SUBJECTIVE SYMPTOMS IN EAR DISEASES. 
 
 The various tuning-fork tests may all prove more or 
 less inconclusive in doubtful cases. When the results 
 positive or negative are well pronounced and the differ- 
 ent tests agree, the site of a lesion can be correctly local- 
 ized on the basis of functional tests. This is true in the 
 majority of clinical cases. There are, however, not rare 
 exceptions in which the different tests do not agree and 
 in which our conclusions drawn from these tests must be 
 guarded. 
 
 310. Inspection of the meatus and drumhead requires 
 the use of a perforated mirror, since otherwise the ex- 
 aminer would cut off his own light. The methods of 
 illumination have been discussed in Chapter III., 1 23. 
 The view is hindered by the tortuosity of the meatus and 
 the hairs in it. The meatus is straightened by pulling the 
 auricle upward and backward. The hairs are crowded 
 aside by a speculum. This may be metal or hard rubber. 
 It should be cylindric as far as it enters the meatus, while 
 its outer end flares in order to admit more light. All 
 other shapes are not so advantageous. The diameter 
 varies from 3 to 7 mm., according to the size of the 
 meatus, the larger size permitting the best view (Fig. 
 116). 
 
 If the view is obstructed by the presence of wax, epi- 
 dermis scales, or pus, the meatus should be cleansed by 
 syringing. The water must be warm, as cold water as 
 well as warm water with undue force causes discomfort 
 and dizziness. While sterility is theoretically desirable, 
 no harm can be traced to ordinary clean water. In acute 
 suppurative inflammation, however, routine syringing 
 should be omitted. A rubber-bulb syringe of ^ to ^ 
 pint capacity is rather more convenient than a piston 
 syringe. Small syringes are not advantageous. The noz- 
 zle should be thin enough to enter the meatus. If neces- 
 sary to insert the nozzle deeply, for instance, when 
 thick pus is present, it is best to protect it by slipping 
 over its tapering end a bit of soft drainage-tubing (about
 
 THE NORMAL DRUMHEAD. 403 
 
 3 mm. thick). This soft extension of the nozzle saves 
 unnecessary pain on contact. 
 
 The normal membrana tympani appears as a grayish, 
 translucent membrane closing the meatus (Fig. 117) 
 (comp. Fig. i, Plate II.). It is slightly elliptic rather 
 than circular in outline, and its long axis deviates up- 
 ward and forward about 10 to 15 degrees from the vertical. 
 Through the pellucid membrane the handle of the ham- 
 mer can be seen attached to it on its internal side in the 
 line of its long axis and reaching from just below its center 
 to nearly its upper periphery. At the upper end of the 
 handle the neck of the hammer is seen as an apparently 
 prominent point. From the point two streaks radiate 
 toward the periphery, the anterior and posterior folds, 
 which separate the membrana tympani proper or tense 
 
 O o o 
 
 FIG. 116. Ear speculum : Toynbee's (in FIG. 117. Normal membrana 
 metal) ; Politzer's (in hard rubber). tympani (left). 
 
 portion of the drumhead from its flaccid upper extension, 
 or Shrapnell's membrane. The latter is not so translu- 
 cent as the tense portion. It can be seen well only in a 
 roomy meatus. The handle of the hammer slants inward 
 and downward about 35 degrees from the vertical. Hence, 
 on the whole, the drumhead is somewhat funnel-shaped, 
 the sides of the funnel being, moreover, slightly convex 
 toward the examiner. Besides the whole membrane, or, 
 more accurately speaking, a plane laid through its rim, 
 slants downward and inward and forward and inward. 
 The inferior and anterior sides of the meatus are thus 
 longer than the other sides. On account of its shape 
 the drumhead presents to the examiner a bright light 
 reflection next to the lower end of the handle of the 
 hammer, the triangular spot or light-reflex.
 
 404 SUBJECTIVE SYMPTOMS IN EAR DISEASES. 
 
 311. Important changes are noted in the appearance of 
 the drumhead in disease. Serous catarrh, when acute, may 
 give rise to red vascular streaks parallel to the manubriurn. 
 In acute otitis media the entire membrane is uniformly 
 red on account of its vascularity. Chronic catarrh changes 
 the pellucid appearance into a dull gray color with cloudi- 
 ness ultimately effacing the light-reflex. In the course 
 of long-standing catarrh partial calcification of the drum- 
 head may occur in the form of whitish chalky spots. 
 
 Whenever obstruction of the Eustachian tube confines 
 the air in the middle ear, it is partially absorbed and 
 its tension sinks below the pressure exerted by the atmos- 
 phere upon the external side of the membrana tympani. 
 The latter is hence pressed inward, its funnel-shaped 
 indentation is exaggerated, and the inward slant of the 
 manubrium is increased. On account of being more 
 nearly horizontal than normally, the handle of the ham- 
 mer is seen foreshortened under the circumstances. Both 
 the bony manubrium, as well as the anterior and poste- 
 rior folds between the tense and flaccid portion of the 
 drumhead, appear strikingly prominent, while the light- 
 reflex is somewhat enlarged. These appearances indicate 
 Eustachian obstruction and are common to all forms of 
 catarrh of the middle ear. 
 
 Morbid effusions of fluid in the middle ear can be seen 
 through the tympanic membrane if the latter is neither 
 thickened and cloudy nor congested to an extent to render 
 it opaque. The lower part of the drumhead appears yel- 
 lowish or greenish, and a horizontal black line shows the 
 upper level of the fluid. If air be blown in through the 
 Eustachian tube, air-bubbles can sometimes be seen in 
 the fluid present. When there is much effusion, the 
 drumhead bulges and the light-reflex is effaced. More 
 often, however, the membrane is drawn inward by reason 
 of the diminished intratympanic pressure, even when 
 there is moderate effusion. 
 
 In acute purulent otitis media a protruding pouch is 
 in rare instances seen in the upper rear part of the
 
 THE MEMBRANA TYMPANI IN EAR DISEASES. 405 
 
 drumhead, formed by a hernia of the mucous layer 
 through the deficient or atrophic middle lamina. Inter- 
 stitial abscesses have been seen in the membrana tym- 
 pani. Serous blisters occur on its external surface in 
 myringitis. In this inflammation, localized in the drum- 
 head, but also in influenza otitis, minute hemorrhages 
 are found in its substance. They may also be produced 
 by traumatism. In chronic myringitis the membrane is 
 sometimes studded with small papillary growths. 
 
 Traumatic ruptures of the drumhead from foreign 
 bodies or concussions are mostly linear, with edges suf- 
 fused by blood. The tympanic membrane is normally 
 air-tight, and any perforation in it is indicative of injury 
 or present or former disease. 
 
 312. Perforations the result of suppuration of the 
 middle ear may be of pin-point size in a mild acute 
 case, or may include the entire drumhead in a more de- 
 structive type of disease. A very small hole is sometimes 
 difficult to see if covered by loose epidermis scales or 
 dried secretion, or if hidden by the prominence of the 
 wall of the meatus. In shape perforations may be round, 
 oval, or bean-shaped. They may occur in any part of 
 the membrane. It is important to note whether they are 
 in the tense or flaccid portions of the drumhead. Small 
 perforations in Shrapnell's membrane lead into the attic 
 and do not always communicate with the tympanic cavity. 
 Not rarely perforations of Shrapnell's membrane are com- 
 plicated by defects at the upper periphery of the bony 
 rim, and a fissure may thus be found leading into the 
 attic. Where a large area of the drumhead has been de- 
 stroyed, a part or even the whole of the hammer and 
 anvil may be also lost. 
 
 When a suppurative otitis has passed its acute stage, 
 regenerative changes begin at the edge of the perforation. 
 Provided the defect is not very large, it usually closes as 
 soon as all secretion has ceased. But if the secretion 
 continues after the acute stage, in other words, in all 
 protracted inflammations, the edge of the defect becomes
 
 406 SUBJECTIVE SYMPTOMS IN EAR DISEASES. 
 
 covered with epithelium and the perforation cannot close 
 and remains permanently open. On the other hand, all 
 holes made by the surgeon close with remarkable pre- 
 cision. Even when the entire drumhead has been excised 
 a regeneration usually follows. 
 
 Through the hole in the drumhead if not too small 
 the mucous membrane of the tympanic cavity is seen, 
 pale when healthy, more or less reddened and thickened 
 when inflamed. 
 
 In case of doubt about the existence of a perforation a 
 communication with the drum cavity can be shown in 
 various ways. On inspection through a Siegle speculum 
 (see below) the drumhead will not be seen to move to and 
 fro with changing air-pressure. Auscultation gives a 
 perforation noise when air is forced through the Eusta- 
 chian tube. If the ear be filled with water, air forced 
 through the tube bubbles out of the meatus. These tests 
 fail if the hole (in Shrapnell' s membrane) leads only into 
 the attic and not into the drum cavity proper. 
 
 Healed perforations if larger than a pin-point are 
 closed by a cicatricial membrane more translucent and 
 more yielding than the membrana tympani on account of 
 the absence of the tense middle layer. Large cicatrices 
 are often flaccid and of abnormal mobility. 
 
 313. Of limited utility is the examination of the drum- 
 head through the Siegle or pneumatic speculum (Fig. 
 118). It is a speculum fitting air-tight into the meatus by 
 means of a soft-rubber tube slipped over it with its external 
 end closed by a magnifying lens. Through a lateral tube 
 the air can be exhausted or compressed. The extent of 
 movement of the handle of the hammer under varying 
 air-pressure indicates the mobility, or, vice versa", the 
 rigidity, of the malleo-incudal articulation. The pneu- 
 matic speculum may be used for massage of the drum- 
 head. Alternate rarefaction and compression of air at 
 the rate of two or three times a second can be practised 
 with the mouth or by means of a small rubber bulb 
 (without valve). Elaborate miniature pumps run by
 
 PATENCY OF THE EUSTACHIAN TUBE. 407 
 
 compressed air or electricity have been devised for the 
 same purpose and make an impressive piece of office 
 furniture, but accomplish not much more than simpler 
 apparatus. While vibrating massage of the drumhead is 
 of some slight but unquestionable efficacy in the treat- 
 ment of chronic middle-ear disease, its utility has been 
 much exaggerated. As it requires a long continuance, it is 
 simplest to teach the patient to do it himself twice daily 
 for one to two minutes, by means of a rubber tube led 
 from his mouth to his ear. Practically the same influence 
 can be obtained by inserting the forefinger into the meatus, 
 grasping the lobule with the thumb, and making rhythmic 
 
 FIG. 1 1 8. Siegle's pneumatic ear speculum. 
 
 movements to and fro. The finger acts upon the air in 
 the meatus like the piston of a syringe. 
 
 314. In all diseases of the middle ear it is important to 
 determine the degree of patency of the Eustachian tube. 
 There is no convenient method of ascertaining the degree 
 of patency in absolute measure for instance, with refer- 
 ence to the air-pressure necessary for inflation. But in- 
 formation sufficiently accurate for clinical purposes can 
 be easily obtained. Normally an expiratory effort made 
 while mouth and nostrils are held closed will at once 
 force open the tubes, and the subject feels the ear filling 
 with air under pressure (Valsalva's experiment). The 
 full feeling is instantly relieved by swallowing, which 
 act, by causing gaping of the Eustachian lips, permits 
 equalization of air-pressure in the drum cavity and the 
 throat. The more obstructed the Eustachian channels 
 by either swelling or sclerosis of the mucous membrane,
 
 408 SUBJECTIVE SYMPTOMS IN EAR DISEASES. 
 
 the more difficult is Valsalva's experiment. The patient 
 can thus indicate very accurately any difference between 
 the two sides. When the Eustachian obstruction is con- 
 siderable, inflation by the Valsalva method becomes im- 
 possible. Politzer inflates the middle ear by vigorous 
 compression of a large rubber bag while swallowing water 
 held in the mouth. The bag should have at least 300 c.c. 
 (10 oz.) capacity (Fig. 119). Its nozzle should have 
 a wide caliber, and should be connected by means of a 
 short, soft-rubber tube with a large glass ball fitting air- 
 tight into the nostril. During swallowing the palate 
 closes the pharynx, and the air, forced into the nostril 
 and thus confined, forces its way through the Eustachian 
 tube while the latter gapes. The greater the Eustachian 
 obstruction, the more pressure is required to force in the 
 
 FIG. 119. Politzer air-bag. 
 
 air, until, in extreme instances, the Politzer inflation 
 becomes impossible. By bending the head forcibly 
 toward one shoulder the gaping of the Eustachian orifice 
 is interfered with on the flexed side, and the procedure 
 can thus be partially limited to one ear. If the com- 
 pression of the bag does not coincide with swallowing, 
 the air gets into the esophagus and produces discomfort. 
 In very rare instances the Politzer inflation has caused 
 the rupture of cicatrices (of perforations) in the drum- 
 head, but without doing any permanent harm. Gruber 
 has substituted the forcible intonation of a harsh guttural 
 u k " or the syllable " hock " for the act of swallowing. 
 The palate is closed, but the Eustachian mouth does 
 not gape during the articulation of "hock," and hence 
 Gruber may fail, where Politzer succeeds.
 
 EUSTACHIAN CATHETERIZATION. 409 
 
 315. For most diagnostic and therapeutic purposes in- 
 flation by means of the Eustachian catheter is the most 
 satisfactory procedure (Fig. 120). With the catheter well 
 introduced into the Eustachian orifice air can be forced 
 easily through a passage so swollen that inflation by 
 other methods is impossible. Besides, we can gauge its 
 result objectively by listening through a tube connecting 
 the ear of the patient with that of the surgeon (Fig. 121). 
 The introduction of the catheter should not be painful, 
 although always disagreeable. When the nasal passage 
 is inflamed, sensitive, or narrowed, a cocain spray may 
 be used, especially in timid children. Metal catheters 
 are preferable to rubber, as they keep their shape on 
 boiling. Since syphilis has been transmitted through 
 
 FIG. 1 20. Eustachian catheter. 
 
 FIG. 121. Auscultation tube. 
 
 the use of the catheter, thorough cleanliness, if not abso- 
 lute disinfection by boiling soda solution, is imperative. 
 Flexibility of the instrument is no object, since when it 
 has a proper curve we can very rarely improve the latter 
 by bending it. Its end should be rounded, and the 
 catheter must not be needlessly long not more than 15 
 cm. Many in the shops are of improper length. The 
 instrument is introduced by gliding it along the floor of 
 the nose until its tip touches the pharyngeal wall, where- 
 upon it is turned toward the ear so that its curve lies in a 
 plane about horizontal or slightly tilted upward and out- 
 ward. It is then withdrawn 1.5 to 2 cm. (in the adult), 
 and, as a rule, it can now be felt that the tip glides over 
 the prominence of the Eustachian lip into its orifice.
 
 4IO SUBJECTIVE SYMPTOMS IN EAR DISEASES. 
 
 Upon blowing through the tube the air is heard entering 
 the middle ear. If stenosis of the nasal passage prevents 
 the regular mode of seeking the Eustachian mouth, the 
 catheter must be manipulated by gentle rotation in dif- 
 ferent directions. A very thin, flexible, hard-rubber 
 tube has the advantage over a stiff catheter in this case. 
 If the obstacle in the nose cannot be overcome, the 
 catheter should be inserted through the nostril of the 
 other side and turned toward the desired ear after its 
 beak has passed the nasal septum. By forcing the outer 
 end of the catheter away from the septum it is generally 
 possible to inflate the opposite ear. Inflation is done 
 with a single (not double) rubber hand-bulb (with air- 
 valve), connected by means of soft-rubber tubing with a 
 tip to fit into the end of the catheter. The listener hears 
 a faint, clear, blowing sound when the air enters a nor- 
 mal Bustachian tube. Constriction or swelling of the 
 tube gives the sound a hissing quality. Mucus in the 
 tube or fluid in the middle ear produces a bubbling rale. 
 
 Of great prognostic significance is the degree of sub- 
 jective improvement in hearing or the lessening of tin- 
 nitus and fulness obtained by inflation with any method. 
 
 The only possible accident from the use of the catheter 
 is emphysema of the pharynx and side of the neck. If 
 the tip, especially if rough, happens to scratch the mucous 
 membrane, the air may enter the wound and distend the 
 interstitial lymph-spaces. An immediate tumefaction 
 occurs, with feeling of oppression. The swelling is soft, 
 elastic, and can be deeply indented by the finger. It dis- 
 appears in a few hours without harm. 
 
 In order to blow the vapor of chloroform into the mid- 
 dle ear, the rubber tip of the air-bag fitting into the 
 catheter can be dipped into this fluid, or a drop of it may 
 be dropped into a Politzer bag. The vapor of iodin or 
 of turpentine can be used for Eustachian inflation by 
 placing the material (tincture of iodin or turpentine) on 
 cotton in a capsule between the rubber bag and the noz- 
 zle. A similar metallic capsule can be used to heat the
 
 INFLATION IN EAR DISEASES. 4! I 
 
 air by holding it over a flame. Finely divided chlorid 
 of ammonium may be generated for inflation by letting 
 the air pass through a branched tube over NH 3 and HC1 
 solution contained in separate bottles. As the separate 
 currents of air laden with the fumes join in a third recep- 
 tacle, the NH 4 C1 is formed as a finely suspended cloud 
 (Fig. 122). 
 
 Probing of the Eustachian tube can be practised with 
 a flexible celluloid or rubber probe or a stiff" catgut (violin 
 
 FIG. 122. Apparatus for developing chlorid of ammonium in a state of 
 fine subdivision. A current of air is blown in the direction of the arrow through 
 the two bottles on the right, one containing hydrochloric acid, the other a solu- 
 tion of ammonia. When the two vapors meet in the bottle on the left, which 
 contains water, chlorid of ammonium is formed, while any excess of either acid 
 or ammonia fumes is absorbed by the water. The tube on the left side connects 
 with the catheter. 
 
 D-string) introduced through the catheter. Normally a 
 probe suitably marked to indicate its length within the 
 catheter can be pushed about 25 mm. into the tube 
 without meeting with an obstacle. It is, however, diffi- 
 cult and painful to carry the probe beyond the isthmus 
 of the tube. A uniform swelling, as well as a circum- 
 scribed constriction, can be recognized by opposing the 
 introduction. The utility of the probe for either diag- 
 nostic or therapeutic purposes is not generally admitted.
 
 412 SUBJECTIVE SYMPTOMS IN EAR DISEASES. 
 
 The diagnosis of middle-ear disease is completed by 
 full examination of nose and pharynx. 
 
 All ear instruments should be scrupulously cleaned 
 after use, and all those coming into contact with dis- 
 eased surfaces should be sterilized. For this purpose 
 nothing is so satisfactory as boiling soda solution (see 
 1 30, Chap. III.). 
 
 316. Paracentesis (operative perforation) of the drum- 
 head is often done for therapeutic, rarely for diagnostic 
 purposes. The meatus is syringed to remove wax and 
 scales and sterilized by a bath of at least three minutes' 
 duration with a reliable disinfectant (3 per cent, solution 
 of carbolic acid or carbolic acid in glycerin 12 per cent). 
 A needle or knife mounted on a shank at an angle of 140 
 
 FIG. 123. Paracentesis needle and knife for operation on drumhead, with 
 universal handle for ear instruments ; also two forms of curets for middle-ear 
 surgery. 
 
 degrees(Fig. 123) is thrust through the drumhead, making 
 a long vertical slit, of course under good illumination and 
 through a wide speculum. The incision is preferably 
 made where the membrane bulges most. Paracentesis 
 causes a momentary sharp pain, especially when the 
 drumhead is inflamed. It is not possible to produce 
 local anesthesia by means of a watery solution of cocain, 
 since this is not absorbed through the skin. Cocain dis- 
 solved in anilin oil (Gray) has likewise proved inefficient. 
 A solution consisting of equal parts of cocain, menthol, 
 and carbolic acid (Bonain) gives a partial and not always 
 reliable anesthesia. As this mixture is slightly caustic, 
 it should be applied cautiously on a minute pledget of 
 cotton on a probe to the area to be incised. 
 
 A paracentesis properly done, and with aseptic pre-
 
 EAR-TRUMPETS. 
 
 413 
 
 cautions, is practically free from danger. There are on 
 record a few instances in which the bulb of the jugular 
 vein protruding through a defective floor into the tym- 
 panic cavity was wounded. The alarming hemorrhage 
 
 FIG. 124. Conversation tube. 
 
 was controlled by a tampon in most instances. It is 
 hence best not to cut down to the inferior rim of the 
 drumhead. After paracentesis the syringe should not be 
 used. 
 
 317* Defective hearing can be assisted by intensifica- 
 tion of sounds by means of 
 speaking-tubes or ear-trump- 
 ets (Figs. 124 and 125). 
 Their underlying principle is 
 the concentration of sound- 
 waves in a funnel-shaped re- 
 ceiver. A simple hollow 
 hard-rubber cone with soft- 
 rubber tube leading into the 
 ear is usually the most satis- 
 factory pattern for listening 
 to individual conversation. 
 It is not possible to advise a 
 patient which model he should 
 select for general purposes. 
 It is better to let him choose by actual trial of different 
 patterns. As a rule, the larger, and hence the more 
 undesirable, the trumpet, the more it collects the sound. 
 Some patterns modify the timber unpleasantly. Small 
 
 FIG. 125. London hearing horn.
 
 SUBJECTIVE SYMPTOMS IN EAR DISEASES. 
 
 contrivances are generally useless. The audiphone of 
 Rhodes, a slightly curved fan of hard rubber held 
 against the teeth as a resounding board, is a very con- 
 venient instrument, but is generally not found quite so 
 useful as a trumpet. 
 
 All patients with progressive impairment of hearing 
 should be advised to learn to "read" speech by watch- 
 ing the lips of the speaker. By proper and long-con- 
 tinued attention, begun while they can still hear fairly 
 well, they will ultimately be able to compensate in part 
 their deficient hearing by interpretation of the lip-move- 
 ments.
 
 CHAPTER XXXIII. 
 DISEASES OF THE EXTERNAL EAR. 
 
 OTHEMATOMA. PERICHONDRITIS. ECZEMA. DIFFUSE 
 OTITIS EXTERNA. FURUNCLES. PARASITIC INFLAM- 
 MATION OF THE MEATUS.-WAX AND EPIDERMIS 
 PLUGS. 
 
 318. Othematoma is a localized swelling in the auricle 
 due to extravasation of blood under the perichondrium. 
 It forms a soft tumor of variable size, with some discolora- 
 tion of the skin, usually in the upper part of the auricle, 
 never in the lobule. It causes but little annoyance, but 
 is sometimes tender to touch. It is, as a rule, due to 
 blows upon the ear, hence seen mostly in pugilists. It 
 was evidently more common among the fighters of classic 
 antiquity, whose writers mention it and some of whose 
 statues show the deformity which othematoma sometimes 
 leaves. It is of remarkable frequency (about i per cent.) 
 among the insane, in whom probably preceding degenera- 
 tion of the cartilage predisposes to effusions of blood, 
 perhaps even without trauma. 
 
 The effusion is underneath the perichondrium. It 
 usually clots and sometimes becomes encysted. The 
 smaller accumulations of blood are apt to disappear spon- 
 taneously in the course of many weeks. They may, 
 however, leave some shrinkage and deformity of the 
 cartilage, especially after recurrent attacks. The ab- 
 sorption can be favored by daily massage. When no 
 favorable change is seen after the lapse of three or four 
 weeks, an incision may be made into the cyst. But since 
 reaccumulation is apt to take place, the cavity should be 
 cleansed as far as is necessary with a sharp scoop and the 
 wound packed with iodoform gauze. 
 
 415
 
 41 6 DISEASES OF THE EXTERNAL EAR. 
 
 319. Perichondritis of the auricle is very rare. It 
 shows its inflammatory nature by diffuse doughy swelling, 
 redness, tenderness, sometimes with considerable pain. 
 The course is very tedious and lasts many weeks. The 
 inflammation may disappear, or it may lead to abscess 
 and phlegmonous sloughing. Its cause is usually not 
 known, but it has been ascribed to syphilis in some 
 instances. As long as there is no suppuration tincture 
 of iodin and ichthyol may be applied locally. As soon 
 as pus is suspected, it rnust be treated surgically. 
 
 320. Eczema is a frequent skin affection and the 
 only common one involving the auricle and meatus. 
 It begins in the form of minute vesicles, which spread at 
 first rapidly and soon change into moist scabs covering 
 an excoriated surface. It is usually seen in its chronic 
 form and may persist indefinitely. The subjective annoy- 
 ances are burning and itching. When seen in children, 
 it raises the suspicion of scrofula, but it does occur as 
 well in apparently perfect health, both in children and in 
 adults. In the writer's experience the only prompt treat- 
 ment has been the free use of nitrate of silver in strong 
 solution 30 per cent, or the solid stick to the excori- 
 ated surface after complete detachment of all crusts. 
 The pain can be relieved by the previous application of 
 cocain. The abraded surface becomes covered with a 
 thin eschar, which blackens when exposed to light, and 
 underneath this film regeneration of the epithelium takes 
 place. Sometimes one application suffices to check 
 the secretion, but mostly a few repetitions are needed. 
 Wherever moisture is seen, the eschar should be de- 
 tached daily and the surface brushed again until per- 
 manently dry. The persisting dry dermatitis and the 
 liability to immediate relapses are effectually checked by 
 the use of a salve of oil of cade (i in 4 of lanolin stiffened 
 by oxid of zinc). If objections are raised to the pain and 
 blackening produced by the nitrate of silver, Peruvian 
 balsam may be applied instead, but with less prompt 
 effect. The various dusting-powders used for eczema
 
 DIFFUSE INFLAMMATION OF THE EXTERNAL MEATUS. 417 
 
 in other localities do not prove very serviceable on the 
 auricle. 
 
 Eczema in the squamous form is sometimes limited to 
 the interior of the meatus, producing distressing itching. 
 With good illumination the skin is seen scaly, like dan- 
 druff on the scalp. There may be a trifling serous exuda- 
 tion which is apt to be fetid. Without careful inspection 
 this skin disease is easily overlooked. In this form it 
 yields very promptly to a salve containing 3 to 5 per cent, 
 each of resorcin and precipitated sulphur. The relief of 
 the intolerable itching is generally very gratefully ac- 
 knowledged. 
 
 Itching in the meatus the pruritus of some writers 
 may, however, be due to other conditions as well as 
 eczema. It is sometimes dependent on vascular turges- 
 cence of the pharyngeal end of the Bustachian tube, and 
 in such cases is more or less relieved by Eustachian in- 
 flation. Severe itching not due to eczema of the meatus 
 indicates, as a rule, a neurotic disposition and may prove 
 a serious puzzle to the therapeutist. 
 
 321. Diffuse inflammation of the external meatus 
 (diffuse otitis externa) is recognizable by more or less 
 swelling of the walls of the meatus, even to the point 
 of complete occlusion, with variable and, indeed, some- 
 times very severe pain. There may be slight serous or 
 seropurulent discharge, or none at all. The disease is 
 not always the same etiologically. It is, of course, an 
 inflammation of the skin, generally also of the deeper 
 tissues of the meatus, due to the invasion by pyogenic 
 microbes. In some cases it is the consequence of eczema; 
 in others it results from scratching of the delicate skin of 
 the meatus. Patients cannot be warned too emphatically 
 against using hairpins and similar implements to relieve 
 itching. Sometimes the apparently diffuse inflammation is 
 really due to multiple but small furuncles. Again, it may 
 result from irritating chemicals injudiciously dropped into 
 the meatus. Sometimes a desquamative inflammation of 
 the skin, with retention and secondary decomposition of 
 
 27
 
 41 8 DISEASES OF THE EXTERNAL EAR. 
 
 moist scales, starts the process, but in all instances care 
 must be taken to determine the presence or absence of 
 inflammation of the middle ear when the meatus is found 
 swollen. When the swelling does not permit a view of 
 the drumhead, this diagnostic question may have to be 
 left in suspense. 
 
 The walls of the meatus are seen swollen, sometimes in 
 actual contact, but are very little reddened. The greater 
 the swelling, the more severe the pain and the more the 
 patient complains of a fulness in the ear, with transient 
 deafness. With cotton wound on a tooth-pick search is 
 made for secretion. When the latter is purulent and 
 thick, there is reason to suspect involvement of the mid- 
 dle ear. A thin but fetid discharge may come from the 
 meatus itself. Minute coherent plugs of thick pus indi- 
 cate furuncles. 
 
 In non-suppurative instances the writer has found no 
 application equal to carbolated glycerin (10 per cent.) 
 dropped into the meatus with a drop-tube and retained by 
 a plug of cotton. The inflammation, which might other- 
 wise last weeks, may thus yield in a few days. When 
 the excoriated surface secretes fluid it should be syringed 
 with sterile water through a fine cannula. If scales of 
 skin cannot be dislodged by the current, they should be 
 scooped out. After filling the meatus with carbolated 
 glycerin a gauze drain should be introduced beyond the 
 swelling to permit drainage. The aseptic drainage is 
 especially important when suppurative inflammation of 
 the middle ear is suspected. When the walls of the 
 meatus secrete fluid the disease is likely to last at least a 
 week under treatment. 
 
 322. Furuncles in the meatus, or circumscribed 
 otitis externa, consist of minute cutaneous abscesses 
 with a central slough. The affection is very painful. 
 The furuncles are more often single than multiple. When 
 healed, they are apt to recur unless guarded against. 
 Sometimes a recurrence takes place after many weeks' 
 interval. As a rule, no constitutional cause can be
 
 FURUNCLES IN THE MEATUS. 419 
 
 learned. They may be due, however, to local traumatism 
 by scratching. As the meatus contains atmospheric dust 
 and probably always living germs, lesions of its delicate 
 skin are apt to cause infection, especially by staphy- 
 lococci. 
 
 The furuncle can be seen as a small, not well-defined 
 swelling, exquisitely tender to touch, in the cartilaginous 
 meatus. After a day or two it shows a small "head," 
 which then breaks with some relief. The ear itself feels 
 stuffy. The great pain which sometimes radiates over 
 the entire side of the head may raise the (unfounded) sus- 
 picion of mastoid disease. Such a wrong diagnosis is 
 in rare instances suggested by a puffy swelling behind the 
 ear, due to a small abscess started by the furuncle. The 
 correct diagnosis should be guided in these deceptive 
 cases by the brief duration and the negative history (no 
 previous middle-ear disease). Such a furuncular abscess 
 may produce a febrile rise of several degrees. 
 
 As soon as the purulent contents can be recognized, the 
 furuncle should be incised deeply with a sharp small 
 bistoury. The incision is very painful, and no local 
 application can prevent the pain. If the cut is made 
 before the contents are soft, the throbbing pain of the 
 furuncle is not relieved at once, although its course is 
 shortened. Some relief can be obtained subsequently by 
 filling the meatus with carbolated glycerin. It should 
 then be packed lightly with a sterile gauze drain. It 
 has been claimed that firm packing of the meatus with a 
 thick tampon will, after a while, relieve the suffering 
 during the early stage, but the writer cannot corroborate 
 this. Recurrence of furuncles can be surely guarded 
 against by filling the meatus once in a day or two with 
 carbolic acid solution either 3 per cent, watery or 10 
 per cent, glycerin solution. This should be kept up for 
 several weeks. 
 
 323. Parasitic otitis externa or mycosis of the 
 meatus is a rather rare occurrence, which is seldom ob- 
 served in this country. It is due to the invasion of the
 
 42O DISEASES OF THE EXTERNAL EAR. 
 
 meatus by a mould fungus, usually a variety of aspergillus. 
 It may cause no symptoms at all or more or less fulness and 
 discomfort. The skin scales in flakes, sometimes forming 
 casts on which greenish or black spots occur. These are 
 recognized as a fungus upon microscopic examination. 
 The disease is checked by a few instillations of alcohol 
 containing 2 per cent, of salicylic acid. 
 
 324. Impacted Cerumen. Ear wax, a yellowish, 
 thick, oily substance, is secreted by the glands in the 
 skin of the cartilaginous meatus and of a narrow zone 
 along the upper wall of the bony part of the canal. Nor- 
 mally it dries in the form of soft but crumbling scales, 
 which are gradually carried outward by the normal out- 
 ward growth of the epithelium. The process can be 
 shown by making a stain in the depth of the meatus with 
 an anilin dye or nitrate of silver. It can then be seen travel- 
 ing outward slowly in the course of weeks. The expul- 
 sion of the wax is also favored by the movement of the 
 joint of the inferior maxilla communicated to the car- 
 tilaginous meatus. Under unknown circumstances the 
 escape of wax is hindered and perhaps its rate of secre- 
 tion increased. A necessary condition seems to be naso- 
 pharyngeal disease, either in the form of acute attacks or 
 persistent chronic lesions. The wax accumulates without 
 causing any annoyance as long as a narrow channel is still 
 left. When this is filled up by further secretion or by 
 swelling of the plug from water, the patient complains of 
 fulness, impaired hearing, noises, and sometimes dizzi- 
 ness. Inspection shows the meatus filled with a formless 
 mass of a color varying from light brown to black. The 
 condition persists indefinitely, although sometimes the 
 plug dries and falls out after a long period of time. A 
 long persistence of impacted wax damages the ear per- 
 manently, though but to a slight extent. It probably 
 leads to slight hypertrophic changes in the drum cavity. 
 Wax plugs occur much oftener in both ears than in one 
 alone. They are almost sure to recur in the course of 
 months or years, but the presence of excessive wax seems
 
 EPIDERMIS PLUGS. 421 
 
 to be an assurance against the occurrence of any form of 
 progressive deafness. On the other hand, absence of wax 
 indicates always serious nutritive disturbances in the mid- 
 dle ear. 
 
 Wax plugs should not be removed with instruments, 
 since traumatism, even with sterile instruments, may 
 cause infection. Syringing is always sufficient. A large 
 syringe, either a rubber bulb or a piston syringe, with 
 thin but blunt nozzle, and sufficient patience are required. 
 Coolness of the water or too much force may cause pain, 
 dizziness, or even fainting. When the plug is difficult to 
 dislodge, it can be softened by a strong solution of bicar- 
 bonate of sodium. Either a few repeated instillations 
 each with an action of some five minutes may be em- 
 ployed, or the fluid may be left in the ear for hours after 
 plugging with cotton. By the aid of its solvent action 
 the wax plug can always be removed without injury. 
 Any persisting feeling of fulness after removal is relieved 
 at once by Bustachian inflation. 
 
 325. Epidermis plugs must be distinguished from 
 wax plugs, both on account of their significance and the 
 difficulty of their removal. They occur as often one- 
 sided as double-sided. They consist of scales of de- 
 tached epidermis and are distinctly laminated. They are 
 often covered or interspersed with wax. The exfoliation 
 is the result of a desquamative inflammation of the skin, 
 which, by itself, may cause no unpleasant sensations. 
 The presence of epidermis plugs may lead to infection of 
 the walls of the meatus or middle-ear disease, and even 
 to carious destruction of the bony walls of the meatus. 
 Quite often the macerated scales contain germs causing 
 decomposition and fetid odor. When epidermis scales 
 are found in the external meatus, middle-ear disease 
 should be thought of as a possible complication. Choles- 
 teatoma of the middle ear sometimes extrudes into the 
 meatus and may simulate or complicate the affection of 
 the meatus. Epidermis plugs cannot always be removed 
 by syringing alone, although this should be tried first.
 
 422 DISEASES OF THE EXTERNAL EAR. 
 
 They can be softened better by means of glycerin than by 
 bicarbonate of sodium solution. When difficult to detach 
 and requiring the use of instruments, it is well to fill 
 the ear with carbolated glycerin, both for maceration 
 and protection against infection. A tooth-pick dipped 
 into a concentrated solution of caustic potash may be 
 thrust carefully into the center of the plug in order to 
 macerate and soften it. By the use of a blunt ear spatula, 
 blunt broad forceps, bhint, sometimes even sharp, scoops, 
 these plugs can be gradually picked out in the course of a 
 few days if necessary. If the skin of the meatus appears 
 macerated or inflamed after removal of the plug, it should 
 be brushed with nitrate of silver solution (10 per cent.) 
 until healthy. When this is done, epidermis plugs are 
 not so likely to recur as wax plugs.
 
 CHAPTER XXXIV. 
 DISEASES OF THE EXTERNAL EAR. 
 
 FOREIGN BODIES. OPERATIVE DETACHMENT OF THE 
 AURICLE. TUMORS. STENOSIS OF THE MEATUS. 
 INJURIES. MYRINGITIS. 
 
 336. Foreign bodies, such as beads, peas, wads of 
 paper, and the like, get into the external meatus mainly 
 through the pranks of children. Cotton and gauze are 
 sometimes forgotten and left. A variety of small objects, 
 sticks of wood, and so on get in by accident, and insects 
 for instance, bedbugs and the larvae of flies have been 
 found at times. As long as the foreign body is not sharp 
 its mere presence causes no annoyance beyond, perhaps, 
 a feeling of fulness, and it leaves no consequences. It is 
 the traumatism, especially from unskilful attempts at 
 extraction, which is to be feared. The inexperienced 
 physician cannot be warned too emphatically that it is 
 safer to leave a foreign body in the meatus for the time 
 being than to take the chances of wounding the walls or 
 the drumhead. No attempt to remove a foreign body 
 should be made unless the latter is seen. If it be covered 
 by wax, the removal of the wax is in order. If it is so 
 small as to be hidden in the deep sinus of the meatus next 
 to the membrana tympani, it will probably drop out when 
 the head is turned to the side. Hence leisurely inspection 
 through the speculum with a good light should establish 
 the diagnosis before any therapeutic action is attempted. 
 Prompt action is only required if traumatism, either in- 
 cidental or due to former attempts at extraction, has led 
 to complications. These may be diffuse inflammation of 
 the walls of the meatus or inflammatory involvement of 
 the middle ear. In the latter case extensive traumatism 
 involves the risk of extension to the brain. 
 
 423
 
 424 DISEASES OF THE EXTERNAL EAR. 
 
 The safest way to remove a foreign body is by patient 
 syringing with warm water. In the case of peas or beans, 
 which swell when moistened with water, oil or alcohol 
 may be used for syringing, unless they are freely mobile 
 and can be made to drop out by turning the head. Live 
 insects may be dislodged by tobacco smoke or chloroform 
 vapor. Impacted objects which do not budge on syring- 
 ing should be seized with the utmost care with a small 
 sharp hook or a flat curet, with its blunt edge turned 
 toward the wall, or the snare. The surgeon should 
 always remember not to push the object deeper into the 
 canal. Forceps of any kind are apt to do this. Good 
 illumination is indispensable. In the case of an unruly 
 child anesthesia may prove necessary. If the attempted 
 extraction fails, it is sometimes better to desist for the 
 time as long as there are no urgent symptoms. Under 
 the use of carbolated glycerin moderate swelling of the 
 meatus may recede sufficiently to permit an easier ex- 
 traction a day or two later. 
 
 327. When other methods fail and urgent symptoms 
 indicate prompt interference, the auricle and cartilaginous 
 meatus .are to be detached from the osseous canal in order 
 to gain access to its depth. The typical operation is done 
 as follows: 
 
 Vertical (slightly curved) incision down to the bone, 5 
 mm. behind the auricle from the tip of the helix to nearly 
 the tip of the mastoid process. Compression or torsion 
 of bleeding vessels. Detachment (by means of an ele- 
 vator) of the periosteum and of the cartilaginous meatus 
 from the bone. Transverse (vertical) section through 
 the posterior cutaneous wall of the osseous meatus with 
 the tenotome. By pulling the auricle forward, the car- 
 tilaginous meatus is almost entirely lifted out of the 
 osseous canal, which is now accessible. Good illumina- 
 tion without reflecting mirror is all that is required. If 
 the foreign body cannot be removed by reason of impac- 
 -tion, the osseous meatus is now enlarged by chiseling 
 away its posterior wall with small concave gouges. After
 
 TUMORS. 425 
 
 completion the cartilaginous meatus and auricle are re- 
 placed and the external wound is sutured. If the poste- 
 rior wall has been chiseled, the integument of the meatus 
 is slit longitudinally for the purpose of better coaptation. 
 The meatus is then packed with iodoform gauze. The 
 operation is rarely required, except in the case of com- 
 plicating inflammation of the middle ear or shot wounds. 
 
 328. Tumors of the external ear or of any part of the 
 ear are not common. The most frequent growth of the 
 auricle is the fibroma or keloid, sometimes the consequence 
 of irritation by an ear-ring. Keloids are more often seen 
 in negroes. Sebaceous cysts occur mainly on the concave 
 side of the auricle. Cancer and lupus are rarely seen here. 
 All these morbid processes present no peculiarities dif- 
 ferent from those in other localities. 
 
 In the meatus polypi are often seen, but they rarely 
 spring from the walls of the meatus, mostly from the mid- 
 dle ear, and will be treated in connection with chronic 
 suppurative otitis. The few polypi which originate from 
 the walls of the meatus must be considered in the same 
 manner as those extruding from the middle ear. The 
 most frequent neoplasms of the meatus are exostoses. 
 They may grow sufficiently to occlude the canal. Some- 
 times they are multiple. They are of ivory hardness, 
 and must be removed by chiseling through the healthy 
 bone around them. Their discussion can be combined 
 with that of stenosis or atresia of the external meatus. 
 
 329. Narrowing or occlusion of the canal may be 
 due to various lesions. Besides circumscribed exostoses, 
 a diffuse hyperostosis of the osseous wall or at least of a 
 part of it is sometimes seen, especially in connection with 
 old chronic suppuration of the middle ear. Cicatricial 
 contraction may follow an ulcerative process, such as 
 corrosion by chemicals or burns or lupus, or, very rarely, 
 diphtheritic inflammation of the meatus. It may also 
 follow faulty healing after a radical mastoid operation 
 with partial removal of the posterior wall of the meatus. 
 Total occlusion of the canal is sometimes seen as a con-
 
 426 DISEASES OF THE EXTERNAL EAR. 
 
 genital condition, either in the form of a membranous 
 diaphragm, or as total obliteration of the caliber. The 
 former condition is recognizable by the yielding to the 
 probe, while hardness of the obstruction shows it to be 
 bony. 
 
 Narrowing of the meatus requires surgical attention if 
 it either interferes with hearing or with the escape of the 
 secretion of a diseased middle ear. The latter indication 
 is imperative. Otherwise it may not be necessary to 
 interfere. Mechanical dilatation and small operations 
 are useless. Drilling by means of hand drills or burrs 
 run by a dental motor or chiseling is permissible only 
 on the anterior wall and only within the length of the 
 meatus. Any encroachment toward the drumhead in- 
 volves risk. In the case of exostosis or diffuse hypertrophy 
 of the posterior wall the proper method is chiseling after 
 detachment of the auricle. The hard growths can be 
 shelled out by gouging through the normal bone. When 
 working on the posterior wall it must be remembered 
 that in the vicinity of the drumhead there is danger to 
 the facial nerve and semicircular canals. Congenital 
 occlusions are easily dissected out if membranous. In 
 the case of total obliteration of the canal an operation is 
 risky and of questionable utility. It should not even be 
 considered unless tests with tuning-forks establish the 
 integrity of the internal ear on that side beyond ques- 
 tion. 
 
 330. Under the head of accidents to the ear frost-bites 
 must be mentioned as the most common. Congelation 
 of the helix or of the lobule causes a blanching, followed 
 by persistent lividity. The popular practice of rubbing 
 frozen ears with snow in order to thaw them gradually is 
 probably founded on experience. The congestive reaction 
 after a frost-bite may last a long time and is apt to return 
 upon slight exposure. Nothing can be done for it beyond 
 protection in cold weather. 
 
 331. The most frequent injury to the ear is that result- 
 ing from a blow. It may lead to ringing and slight deaf-
 
 MYKINGITIS. 427 
 
 ness, without visible lesion of the drumhead. This may 
 be due to a hemorrhage or merely a concussion of the 
 labyrinth. The effects pass off in a few days at the most, 
 unless the ear was previously the seat of a catarrhal 
 process which is sometimes considerably aggravated. A 
 blow may also cause a rupture of the drumhead. The 
 same lesion is sometimes the result of explosions, and 
 necessarily follows any direct traumatism by pointed 
 implements. Traumatic ruptures of the membrana 
 tympani are linear and show bloody suffusion of the 
 edges. The hearing is temporarily impaired. They 
 usually heal without reaction if not irritated or infected 
 by injudicious treatment. Nothing beyond rest of the 
 parts is called for. Syringing and applications are at 
 least useless, if not injurious. 
 
 More serious is any traumatism of the drumhead which 
 leads to bruising as well as to rupture. This may hap- 
 pen from the entrance of tree twigs or stalks or from 
 unskilful manipulations in the meatus. The damaged 
 drumhead often sloughs for a number of days with gradual 
 enlargement of the perforation, and, of course, with sup- 
 puration of the middle ear. The treatment in such cases 
 should be that of acute otitis (T[ 360). 
 
 When violence causes a fracture at the base of the skull it 
 is apt to rupture the drumhead as well. . The diagnostic 
 sign of this accident is the discharge of cerebrospinal 
 fluid, more or less bloody, through the meatus. If the 
 patient survives, severe suppurative middle-ear disease is 
 apt to follow. It should be guarded against in such cases 
 by immediate asepsis of the meatus with carbolic acid 
 solution and the introduction of sterile gauze drains as 
 in the treatment of purulent otitis. 
 
 332. Myringitis, inflammation limited to the mem- 
 brana tympani, is a rare occurrence which the writer has 
 never seen in the acute form unless of traumatic origin. 
 It is described by Politzer as a formation of small circum- 
 scribed blood blisters, serous vesicles, or even minute 
 abscesses on the cutaneous side of the drumhead. It
 
 428 DISEASES OF THE EXTERNAL EAR. 
 
 causes more or less shooting pain, with scarcely any im- 
 pairment of hearing, and heals, as a rule, within a few 
 days. The vesicles may be pricked with a needle and 
 the membrane dusted with boric acid. 
 
 Chronic inflammation limited to the drumhead is 
 not quite so rare as acute myringitis, but is, as a rule, a 
 secondary affection resulting from eczema or a desquama- 
 tive dermatitis of the meatus, or is a sequel to suppurative 
 inflammation of the middle ear. The drumhead appears 
 cloudy, and its surface macerated and sometimes covered 
 with moist scales. Politzer describes a papillary form in 
 which the membrane is partly covered with minute granu- 
 lations. The disease produces very little disturbance 
 beyond slight discomfort and itching. After cleansing, 
 boric acid powder may be blown in. If this produces a 
 temporary watery discharge or if no improvement follows 
 within a few days, a 10 per cent, solution of nitrate of 
 silver can be tried. For the papillary form Politzer 
 recommends brushing with tincture of chlorid of iron.
 
 CHAPTER XXXV. 
 DISEASES OF THE MIDDLE EAR. 
 
 CATARRH OF THE EUSTACHIAN TUBE.-SEROUS 
 CATARRH OF THE MIDDLE EAR. 
 
 333. Diseases of the middle ear are divided into 
 affections (a) without and (b) with suppuration. The 
 division is justified by the difference in the prognosis and 
 therapeutic indication of the two groups. The non-sup- 
 purative group includes 
 
 Catarrh of the Eustachian tube ; 
 
 Serous or exudative catarrh of the middle ear ; 
 
 Plastic or adhesive inflammation of the middle ear ; 
 
 Sclerosis. 
 
 CATARRH OF THE EUSTACHIAN TUBE. 
 
 Inflammatory obstruction of the Eustachian tube ac- 
 companies all inflammatory affections of the middle ear. 
 But as a lesion limited to the tube, without primary dis- 
 ease of the middle ear, it is not commonly seen in adults, 
 though very common in childhood. It is due in most 
 instances to the presence of an enlarged pharyngeal ton- 
 sil (adenoid vegetations) and occurs in the course of sub- 
 acute inflammatory processes involving the nasopharynx. 
 In rare instances it is the result of an acute nasal catarrh 
 without permanent enlargement of the pharyngeal tonsil, 
 and under these conditions it is sometimes seen during 
 adolescence. Any systemic disease accompanied by nasal 
 or pharyngeal inflammation may be the remote cause of 
 Eustachian occlusion. 
 
 The only manifest symptom of Eustachian obstruction 
 in children is reduced hearing acuity. The impairment 
 begins either acutely or, as a rule, more gradually, accord- 
 
 4?9
 
 43O DISEASES OF THE MIDDLE EAR. 
 
 ing to the intensity of the nasopharyngeal inflammation. 
 It remains more or less stationary for a variable or even 
 indefinite period of time, and does not usually reach any 
 high degree. Hypertrophy of the pharyngeal tonsil pre- 
 vents, as a rule, complete spontaneous recovery, or leads 
 to frequent relapses if the hearing has been restored tem- 
 porarily. When the pharynx becomes normal after a 
 transient catarrh, the Eustachian affection disappears 
 entirely. The impairment of hearing is sometimes so 
 slight that it is detected only by the child's inattention. 
 Tests show that there is reduction of air-conduction only, 
 not of bone-conduction. Both ears are always involved, 
 though not necessarily alike. 
 
 Adults complain of a sense of fulness in the ears. Young 
 children either do not feel or do not notice this sensation. 
 
 FIG. 126. Retracted membrana tympani in Eustachian catarrh, with serous 
 fluid in the middle ear. The level of the fluid is marked by a straight line. 
 
 Sometimes they admit it after being relieved by inflation. 
 Occasionally sharp earache especially one-sided is com- 
 plained of, most likely during the night. Although the 
 cases with this pain follow the same course and yield 
 equally rapidly to treatment as typical painless Eusta- 
 chian catarrh, the pain is probably due to some slight 
 lesion in the middle ear. This view is supported by the 
 presence of vascular streaks congested vessels along 
 the handle of the hammer, which are not seen in ordinary 
 Eustachian catarrh. 
 
 The drumhead is normal in color and luster, but is 
 distinctly drawn in. The handle of the hammer hence 
 appears foreshortened (compare Fig. 2, Plate II.). In 
 some instances, but not as a rule, an effusion of clear 
 serum can be seen through the drumhead (Fig. 126).
 
 CATARRH OF THE EUSTACHIAN TUBE. 43 1 
 
 334. A single successful inflation of the middle ear by 
 Politzer's method or by means of the catheter removes 
 all results of the Eustachian obstruction, except in long- 
 standing disease with secondary lesions. The hearing 
 becomes normal at once or in a few minutes; the fulness, 
 if felt before, disappears, and the drumhead regains its 
 normal position. If fluid is visible through the mem- 
 brane, it is apt to be churned into foam, and air-bubbles 
 can now be seen. The fluid disappears gradually by 
 absorption. 
 
 Although there is but little opportunity to study the 
 pathology of simple Eustachian catarrh in the dead-room, 
 its nature and mechanism are clearly understood. Indeed, 
 this knowledge is the key to our understanding and treat- 
 ment of all the diseases of the middle ear which are com- 
 plicated by Eustachian obstruction. The obstruction is 
 due to swelling and venous engorgement of the mucous 
 membrane at the pharyngeal end of the Eustachian tube. 
 The immediate and often permanent results of infla- 
 tion leave no doubt that the swelling depends mainly 
 on serous infiltration inflammatory edema of the Eu- 
 stachian lining. The imperfect postrhinoscopic view, 
 which, as a rule, is all that can be obtained in children 
 with adenoids, shows no gross change at the Eustachian 
 orifice. The inflammatory process itself does not always 
 extend into the tube. The assumption of some writers 
 that adenoid vegetations can block the tube mechanically 
 is not supported by actual examination of the naso- 
 pharynx in the living or dead. When the Eustachian 
 channel remains closed without periodic ventilation of 
 the drum cavity, the air confined in the middle ear is 
 gradually absorbed by the circulating blood in the vessels. 
 The tension of the air in the drum cavity hence falls below 
 the pressure of the external atmosphere. As a result, the 
 greater pressure on the external surface of the membrana 
 tympani forces this membrane inward. This faulty posi- 
 tion of the drumhead is recognizable by the obliquity of 
 the manubrium and the elongation of the triangular light
 
 432 DISEASES OF THE MIDDLE EAR. 
 
 spot. This pressure upon the membrane is transmitted 
 through the ossicles and oval window to the contents of 
 the labyrinth, as can be shown by experimentation with 
 a fresh specimen. 1 
 
 The reduction of hearing is accounted for partly by 
 the increased labyrinthine pressure, partly by the press- 
 ure exerted upon the chain of ossicles, which impairs 
 their ability to conduct sound-waves. The diminished 
 air-pressure in the tympanic cavity permits abnormal 
 engorgement of the blood-vessels, which presumably ex- 
 tends into the Eustachian tube and exerts an unfavor- 
 able influence upon the morbid condition at its pharyn- 
 geal end. High degrees of this circulatory disturbance 
 lead finally to an effusion of serum into the drum cavity. 
 This is not an inflammatory exudate, but merely a trans- 
 udate of the fluid of the blood. When tested after aspi- 
 ration through a puncture of the drumhead, it has been 
 found free from micro-organisms. It is evident that a 
 single inflation of the middle ear will repair all the 
 functional disturbances caused by Eustachian obstruction, 
 as long as there are no structural changes present in the 
 middle ear. When, however, the retraction of the drum- 
 head has continued for long periods of time, variable 
 with the individual, secondary changes do occur. The 
 joint between hammer and anvil becomes fixed by the 
 long-continued retraction of the handle, the faulty posi- 
 tion of membrana tympani and ossicles becomes perma- 
 nent, and some impairment of sound-conduction remains, 
 with irreparable damage to the hearing. 
 
 The treatment of Eustachian " catarrh " by a single in- 
 flation results in a permanent cure in those instances in 
 which the inflammatory process in the nasopharynx has 
 subsided without leaving permanent lesions. The infla- 
 tion anticipates the natural cure. When the Politzer 
 method fails on account of the valve-like action of the 
 u soggy" Eustachian mucous membrane, it is best to 
 
 1 By putting a capillary tube into a semicircular canal and observing the 
 rise of fluid in it upon pressing the drumhead inward.
 
 SEROUS OR EXUDATIVE CATARRH OF THE MIDDLE EAR. 433 
 
 inflate by means of the catheter. Sometimes a few 
 repetitions are necessary in the course of a few days. 
 But whenever structural changes of a permanent nature 
 exist in the nasopharynx, such as hypertrophy of the 
 pharyngeal tonsil, enlargement with chronic inflamma- 
 tion of the faucial tonsils or purulent rhinitis, the infla- 
 tion gives relief only for a variable but short period, with 
 certainty of relapse. A radical cure in such instances is 
 obtained only after proper treatment of the pharyngeal 
 or nasal affection. 
 
 SEROUS OR EXUDATIVE CATARRH OF THE MIDDLE EAR. 
 
 335- Catarrh of the middle ear with effusion of fluid 
 is found in nearly 10 per cent, of ear patients. It is 
 much more common after puberty than in childhood. 
 In young children predisposed to ear disease by an en- 
 larged pharyngeal tonsil or other nasopharyngeal lesions 
 low grades of inflammation do not usually extend far 
 beyond the Eustachian orifice, while severer forms of 
 disease lead to purulent otitis. Catarrhal otitis is double- 
 sided in nearly three instances out of four, but quite 
 often one ear suffers so little that the patient complains 
 only of the other. 
 
 The disease begins acutely with a "full" feeling in 
 the ear or through the head. The patient says the ear 
 is "closed." In children earache may be present; in 
 adults it is neither common nor severe if present. There 
 may, however, be some pain on swallowing. Almost 
 from the start deafness is complained of. But, as a rule, 
 this is not so excessive on actual test as the patient 
 claims. He is apt to be misled as to his hearing ability 
 by the stuffy feeling. Tests show great differences in 
 the reduction of hearing in different cases, from barely 
 perceptible impairment to difficulty in understanding 
 loud speech close to the ear. Bone-conduction is always 
 intact. The patient's own voice sounds muffled to him. 
 Noises in the ear may accompany serous catarrh, but do 
 
 28
 
 434 DISEASES OF THE MIDDLE EAR. 
 
 not usually cause much annoyance, especially in the 
 beginning. 
 
 Since the objective disturbances are in part due to the 
 presence of fluid in the middle ear, the shifting of the 
 level of the fluid on changing the position of the head 
 may make a marked change in the discomfort, sometimes 
 for the better, sometimes for the worse. 
 
 Dizziness is occasionally a distressing complaint. There 
 are some exceptional instances on record in which grave 
 cerebral disease was simulated by acute catarrh of the 
 middle ear, especially in infants. Different otologists 
 have seen a condition of coma or stupor, sometimes with 
 convulsions, promptly relieved by the treatment of an 
 acute catarrhal otitis. It is, therefore, sound practice to 
 examine the ears in every case of obscure brain symp- 
 toms, especially in children. 
 
 The course of catarrhal otitis is variable and depends 
 a good deal, but not exclusively, on the condition of the 
 nose and pharynx. Very mild cases without permanent 
 nasopharyngeal lesions recover spontaneously in two to 
 three weeks. In more severe instances complete recov- 
 ery is exceptional unless as the result of treatment. 
 Without sufficient treatment the more acute symptoms 
 may diminish, but complete recovery does not take place. 
 Either some exudate remains in the drum cavity and the 
 disease becomes subacute, with occasional acute relapses, 
 or the changes in the mucous membrane assume a plastic 
 character and the affection changes gradually to the type 
 of chronic adhesive middle-ear disease. The former 
 class of cases offer a much better prognosis in case of 
 late treatment than the latter. A serious obstacle to 
 recovery are permanent nasopharyngeal lesions, espe- 
 cially nasal stenosis. 
 
 336. The lesions found in accidental autopsies of ca- 
 tarrhal otitis are congestion and inflammatory swelling of 
 the mucous membrane, with fluid exudation. The swell- 
 ing may either be trivial or may be so intense as to obliter- 
 ate part of the drum cavity. It may be confined to small
 
 SEROUS OR EXUDATIVE CATARRH OF THE MIDDLE EAR. 435 
 
 areas, especially on the internal wall or around the artic- 
 ulation of the ossicles, or it may be diffuse and even 
 extend into the mastoid antrum, the lining of which is 
 at least congested. The membrana tympani is, as a 
 rule, but little altered. The swelling is due to infiltra- 
 tion of the mucous membrane with serum and round 
 cells. The epithelium may be partly defective. Where 
 the tumefaction of the mucous membrane brings differ- 
 ent parts of its surface in contact with each other, adhe- 
 sions may form which persist after the swelling has sub- 
 sided. The movements of the ossicles may thus become 
 permanently hampered. The swelling extends into the 
 Eustachian tube, but not necessarily far beyond its tym- 
 panic end. Quite often the middle or even the greater 
 portion of the Eustachian channel shows normal lining 
 and structure. The pharyngeal end, however, is fre- 
 quently found in a state of inflammatory swelling. Yet 
 this condition is generally not recognizable on postnasal 
 examination during life. The fluid in the drum cavity, 
 variable in amount, is a more or less viscid, even slightly 
 purulent, mucus. On opening the cavity it is sometimes 
 seen to adhere very firmly to the walls. It may be so 
 scant in amount as not to extend above the inferior rim 
 of the membrana tympani, and hence may not be visible 
 through the membrane. Upon withdrawal of the exu- 
 date by paracentesis it has been found to contain staphy- 
 lococci and streptococci. The same microbes are also 
 found in part of the cases of purulent otitis. Why they 
 should lead to a superficial catarrhal inflammation in one 
 case and to a suppurative process with tendency to in- 
 volve the deeper tissues in another is not definitely 
 known. 
 
 Catarrh of the middle ear is probably always secondary 
 to an inflammation in the nose or pharynx. The primary 
 trouble may have ceased by the time the ear is examined. 
 Although the ear may become involved in the course 
 of an uncomplicated coryza of sufficient intensity, the 
 majority of cases present more permanent structural
 
 436 DISEASES OF THE MIDDLE EAR. 
 
 changes in the nose or pharynx, which must be con- 
 sidered important determining conditions in extension 
 of disease to the ear. In children the most important of 
 these is hypertrophy of the pharyngeal tonsil. After 
 adolescence this lesion, even when it does not recede, 
 becomes less of a menace to the ear. In adults stenosis 
 of the nose deserves especial attention as a factor in the 
 production, as well as in the perpetuation, of aural 
 catarrh. Subacute exacerbation of a diffuse purulent 
 rhinitis in the course of chronic rhinitis or sinuitis is 
 oftener the starting-point than uncomplicated primary 
 coryza. Ozena is not a common, but sometimes an im- 
 portant, primary affection. Occasionally large tonsils 
 seem to be of influence. 
 
 Exudative catarrh occurs not only in the typical un- 
 complicated form, but also in subacute spells of exacer- 
 bation in the course of chronic adhesive otitis. Details 
 regarding this form of disease will be found in the de- 
 scription of adhesive otitis. 
 
 337. The diagnosis of exudative catarrh of the middle 
 ear, suggested by the sudden impairment of hearing with 
 feeling of obstruction, is based on the evidences of intra- 
 tympanic exudate with swelling of the mucous lining of 
 the drum cavity. The membrana tympani may show 
 but little anomaly at first. Some vascular streaks may 
 run parallel to the handle of the hammer, but a diffuse 
 redness is foreign to this disease. The Eustachian 
 obstruction, which is rarely absent, causes within a short 
 time typical sinking in or retraction of the drumhead, as 
 described under the head of Eustachian catarrh. The 
 handle of the hammer appears foreshortened, on account 
 of increased obliquity, the triangular light spot elongated. 
 The luster of the membrane is apt to become dimmed in 
 the course of the disease. In case of long duration the 
 translucency of the drumhead diminishes. Exudation in 
 the middle ear can be seen through the drumhead when- 
 ever it reaches appreciably above its inferior rim. Very 
 often this is not the case. It requires strong illumination
 
 SEROUS OR EXUDATIVE CATARRH OF THE MIDDLE EAR. 437 
 
 in order to see it. The level of the fluid is marked by a 
 line across the drumhead, usually dark ; sometimes, how- 
 ever, a bright reflection (compare Fig. 3, Plate II.). The 
 line may be low down or high up. On account of the 
 irregular shape of the membrane the line indicating the 
 level of the fluid does not necessarily appear straight, as it 
 really is, but may seem curved or bent. Below the level 
 of the fluid the membrana tympani is darker, yellowish 
 green or yellowish red. When the fluid can be recog- 
 nized, the level is seen to shift with inclination of the 
 head, while slowness of this motion indicates the vis- 
 cidity of the exudation. 
 
 The Eustachian obstruction is apparent in the Valsalva 
 experiment, but is not always revealed by inflation 
 according to Politzer or by the catheter. On auscultation 
 during the entrance of air a bubbling sound indicates 
 the presence of mucus in the tube or fluid in the drum 
 cavity. The sound varies from a coarse to a very fine 
 rale. Its quality can be learned only by practice and not 
 by description. Eustachian narrowness is revealed by a 
 change from the normal faint clear blowing sound to a 
 hiss or even a squeak. As a rule, the sound heard signi- 
 fies but moderately impeded entrance of air, except in 
 some protracted forms verging toward chronicity. 
 
 Of much diagnostic and prognostic importance is the 
 subjective effect of inflation. In catarrh of the middle 
 ear inflation improves the hearing and reduces the fulness 
 invariably, but to a very variable extent in different cases. 
 For the conditions described in the chapter on Eustachian 
 catarrh (^[ 334) are always present viz., diminished 
 patency of the Eustachian passage, hence less regular or 
 even abolished ventilation of the drum cavity, reduction 
 of intratympanic air-tension by absorption, unbalanced 
 pressure of the external atmosphere upon the membrane 
 transmitted through the ossicles to the labyrinth, and 
 congestion of the intratympanic blood-vessels. While 
 all these mechanical disturbances yield to inflation, there 
 exists, besides, inflammatory swelling of the tympanic
 
 DISEASES OF THE MIDDLE EAR. 
 
 lining, causing more or less rigidity of the ossicular artic- 
 ulations, as well as a variable amount of fluid exudate. 
 These latter changes are not influenced immediately by 
 inflation. Hence the degree of immediate improvement 
 resulting from artificial ventilation through the tube is 
 inversely proportionate to the extent of the morbid 
 changes in the drum. In some instances inflation is 
 followed only gradually by an increasing improvement in 
 hearing and comfort until the full benefit is obtained some 
 hours later. The effect of Eustachiaii ventilation is not 
 limited to the prompt relief of the mechanical anomaly. 
 For by restoring the normal air-pressure in the drum an 
 important factor in the maintenance of vascular engorge- 
 ment is eliminated. There is every reason to assume that 
 in the ear, as elsewhere, vascular congestion of mechani- 
 cal origin interferes with the normal resolution of an 
 inflammatory process. While in Eustachian catarrh a 
 single inflation ends all disease manifestations, the effect 
 of an inflation is only temporary when there is disease in 
 the middle ear itself. The greater the immediate effect, 
 the longer it will persist and the less complete will be the 
 return of the previous symptoms. But in any case the 
 effect of inflation begins to decline in the course of a 
 day. 
 
 338. The treatment hence consists in the repetition of 
 inflations at least once a day. In the mildest case com- 
 plete recovery can thus be obtained in about eight to ten 
 days. Inflation is often more efficient by means of the 
 catheter than by the Politzer method, as judged by the 
 immediate result. The Politzer bag may, however, be 
 intrusted to the patient's hands, if necessary, though, as 
 a rule, it is not to the patient's benefit to expect him to 
 carry out any part of the treatment to which the surgeon 
 ought to attend. Eustachian inflation generally stops 
 promptly any earache in the earlier course of middle-ear 
 catarrh. The pain can also be controlled by antipyrin. 
 
 In the less favorable instances the benefit of inflation 
 is nearly or wholly lost within twenty-four hours. There
 
 SEROUS OR EXUDATIVE CATARRH OF THE MIDDLE EAR. 439 
 
 may even be occasional exacerbations in spite of treat- 
 ment. In such cases it is best to advise the patient to 
 use the Politzer bag several times daily. Extensive 
 trials have been made to increase the effect of inflation 
 upon the absorption of the inflammatory swelling and of 
 the exudate by adding the vapor of iodin, chloroform, or 
 oil of turpentine, or finely divided chlorid of ammonium, 
 or hot air (1 315). It is very difficult to judge the efficacy 
 of these measures in a given case, or even in a series of 
 cases, on account of the positive, but somewhat variable, 
 influence of the inflation itself, particularly, however, on 
 account of the impossibility of foretelling accurately the 
 course of an individual case. It cannot be said of any 
 one form of vapor application that it has received decided 
 praise by many except the original author. While it 
 would be unjust to deny the utility of vapor inflations 
 entirely or to refuse them some trial, it cannot be said 
 that by their employment results can be obtained which 
 are not possible without them. Chlorid of ammonium 
 deserves perhaps trial more than any other substance. 
 
 The injection of a few drops of fluid into the tube 
 through the catheter must be spoken of with less reserve 
 (nitrate of silver solution 2 per cent, or zinc sulphate 
 solution 0.5 to i per cent). Its benefits are, at the best, 
 doubtful. A few drops blown in do not penetrate beyond 
 the tube, which is usually not diseased throughout its 
 middle half. A larger quantity may cause and has 
 caused suppurative otitis. 
 
 When fluid exudate persists in the drum without 
 being absorbed and the disease is thus prolonged, it 
 may be removed by a paracentesis (1 316). It is only 
 in a small minority of cases of exudative catarrh that 
 paracentesis is indicated, but when called for it is of 
 decided benefit. When done aseptically, it causes no 
 unpleasant consequences. After making a free inci- 
 sion the exudate is blown out by a Politzer inflation. 
 If viscid, it may be seen adhering to the wound. 
 Boric acid is insufflated lightly, and a piece of ab-
 
 44O DISEASES OF THE MIDDLE EAR. 
 
 sorbent gauze is left in the meatus to absorb the fluid. 
 Syringing must be strictly omitted after paracentesis. 
 On account of the high position of the tympanic open- 
 ing of the Eustachian tube fluids in the drum do not 
 escape through the tube, except as the result of overflow. 
 Suction through a flexible tube pushed in through the 
 catheter is hence irrational. Exudates disappear by 
 absorption when the tympanic mucous membrane is not 
 too much diseased. But the presence of the exudate 
 itself keeps up the inflammation of the mucous mem- 
 brane. 
 
 The only other direct mode of treatment which can 
 exert an unmistakable though feeble influence upon aural 
 catarrh is pneumatic massage (T 313). It is of most ser- 
 vice after the acuteness of the process begins to decline. 
 
 The persistence of catarrhal otitis in spite of local treat- 
 ment is due in many cases to the persistence of the nasal 
 or pharyngeal condition which started it. It must be 
 remembered that the direct cause of extension to the ear 
 is the nasopharyngeal inflammatory process. If this has 
 subsided spontaneously, no nasal treatment is called for. 
 But if the inflammation of the upper air-passages remains, 
 its treatment produces a beneficial effect upon the ear 
 proportionate to its influence upon the nose or throat. 
 In proportion as we succeed in reducing purulent secre- 
 tion and turgescence of the nasal cavernous tissue we will 
 find an improvement in the ear. If the disease in the 
 nose and pharynx can be made to yield to sprays, the 
 douche, and medicinal applications, the aural lesion im- 
 proves correspondingly. But if the persistence of the 
 nasopharyngeal inflammation depends on the presence of 
 permanent structural changes, such as stenosis due to sep- 
 tum irregularities, or hypertrophy of mucous membrane 
 or of cavernous tissue, or pharyngeal adenoids, operative 
 treatment is required in order to stop the morbid process 
 both in the respiratory passages and in the ear. It does 
 happen at times that 'the nasopharyngeal inflammation 
 recovers completely in spite of a stenosis, and in such a
 
 SYPHILITIC CATARRH OF THE MIDDLE EAR. 44! 
 
 case the ear will also recover without nasal operation, but 
 relapses are to be feared. On the other hand, our present 
 means of treatment of nasal and pharyngeal diseases are 
 not infallible, and hence a catarrhal otitis may drag on in 
 spite of nasal treatment. 
 
 Aural catarrh will occasionally prove obstinate, even 
 after disappearance of the nasopharyngeal affection. Re- 
 covery depends on the normal resisting power of the 
 tissues. This may be enfeebled by a variety of other dis- 
 turbances of the system for instance, anemia, intestinal 
 derangement, etc. Hence proper hygienic management 
 must not be overlooked. 
 
 339 Syphilitic Catarrh of the Middle Bar. Vari- 
 ous observers have described occasional instances of 
 severe middle-ear affections apparently due to syphilis, but 
 neither their discordant reports nor a few scant autopsies 
 suffice to establish a definite clinical type. I have per- 
 sonally seen some instances of a form of middle-ear affec- 
 tion which seemed to me peculiar to syphilitic patients. 
 It was apparently a severe catarrhal inflammation of 
 moderately acute onset, bilateral, with considerable im- 
 pairment of hearing, much noise and fulness, and some 
 dizziness. The impairment referred to air-conduction, 
 not to bone-conduction. The drumhead was cloudy and 
 sometimes slightly injected. Eustachian inflation showed 
 diminished patency and the presence of a very scant 
 exudate. Inflation, however, did not improve subjec- 
 tively or objectively. Specific treatment likewise pro- 
 duced no noticeable benefit inside of two to three weeks. 
 Unfortunately, none of the patients were observed for 
 any great length of time.
 
 CHAPTER XXXVI. 
 
 ADHESIVE OR PROLIFERATIVE INFLAMMATION 
 OF THE MIDDLE EAR. 
 
 340. The names "adhesive, proliferative, plastic, or 
 hypertrophic " otitis, or "dry catarrh " of the middle ear, 
 refer to an affection of the middle ear which must be 
 considered the analogue and extension of hypertrophic 
 rhinitis. Very rare in early childhood, it cannot be 
 called common until after growth is finished, from which 
 time on its frequency increases until every third or cer- 
 tainly every fourth individual in advanced age presents 
 some evidence of this disease. The disease is rarely 
 one-sided mostly bilateral. But quite often one ear 
 is less affected than the other, sometimes so little that 
 the patient calls his disease one-sided. The progress of 
 the disease is not necessarily parallel in the two ears. 
 
 In typical cases it begins so gradually that its exact 
 date of origin can often not be stated. Ringing in the 
 ear, perhaps only occasional at first, may be ignored for 
 a long time until it becomes annoying. Later on it may 
 become the main complaint, more serious to the patient 
 even than the deafness. In neurasthenics tinnitus can 
 cause much suffering and unhappiness. " Stuffy " sensa- 
 tions are usually not present to any distressing extent 
 except in complicated cases. Dizziness is likewise not 
 a strictly "normal" symptom of adhesive otitis, but it 
 does occur in a small proportion of cases on account of 
 some special localization of the lesion or as a complica- 
 tion, and it may prove very distressing. The hearing 
 becomes affected gradually. Sometimes the patient is 
 not conscious of any impairment for many months; in 
 other cases he is annoyed from the start. The impair- 
 ment is, of course, most perceptible when listening to 
 
 442
 
 ADHESIVE INFLAMMATION OF THE MIDDLE EAR. 443 
 
 faint sounds for instance, in the telephone. The dis- 
 ease never ends in absolute deafness. Except in case of 
 ankylosis of the stapes, loud speech can always be under- 
 stood close to the ear. It may take years before the per- 
 ception of ordinary conversation becomes embarrassing; 
 but in those instances in which ankylosis between the 
 foot-plate of the stirrup and the oval window takes place, 
 the hearing is much more seriously compromised. This 
 is, on the whole, not a frequent occurrence in adhesive 
 otitis. It may begin early or late in the course, and 
 when begun, it may reach its completion within weeks 
 or within several years. When complete, it practically 
 bars hearing of the voice, except through a speaking 
 tube. It is a common observation in hypertrophic otitis 
 that conversation is better understood in noisy surround- 
 ings, like railroad cars, etc., than where silence prevails. 
 
 Tests show that a faint whisper is not heard normally 
 even at a time when the patient claims normal hearing. 
 As a rule, the perception of the watch is more impaired 
 in this disease than that of the voice. Tuning-fork tests 
 show air-conduction diminished, especially for low tones, 
 for which bone-conduction is normal, or later on even 
 increased. In Weber's test the sound is localized in 
 the more affected ear, except in cases complicated with 
 lesions in the internal ear. Rinne's test shows impaired 
 air-conduction ; later on its normal formula becomes re- 
 versed, especially for low tones (Rinne negative). 
 
 The course of proliferative otitis is variable. It is only 
 a small minority of cases that continue to get worse 
 steadily. This severe course is favored by pronounced 
 hypertrophic rhinitis with nasal stenosis; but it may 
 happen, too, even without nasal obstruction. On the 
 other hand, a fair majority of patients lose their noises 
 and feeling of stuffiness and retain their hearing for a 
 time without further continuous impairment. The dis- 
 ease has apparently come to a stand-still. The damage 
 done to the hearing is usually permanent, as a rule, even 
 under treatment. This apparent arrest of the disease is
 
 444 ADHESIVE INFLAMMATION OF THE MIDDLE EAR. 
 
 in most cases not permanent. With a fresh "cold" in 
 the nose the symptoms return to a variable degree. 
 Whether or not the loss of hearing power is steadily pro- 
 gressive can be judged only by the history during a 
 period of at least some months. But the presence of 
 other symptoms, tinnitus, fulness, or discomfort of any 
 kind, is evidence of the progressive character of the dis- 
 ease. Yet a permanent arrest of the disease is not so very 
 rare. It can be expected only if the irritative symptoms 
 are either of recent origin, or if of longer duration, have 
 not been continuous. The younger the patient when the 
 disease began, the less probable is a favorable termination. 
 
 341. The clinical course of proliferative otitis is com- 
 plicated in some instances by a slight degree of exudative 
 catarrh. A small number of cases of exudative catarrh 
 change gradually into the plastic form, and thenceforth 
 present the combined lesions of hypertrophy with mu- 
 cous secretion into the drum cavity. Others do not give 
 the history of acute onset, but pursue a mild, subacute 
 course from the beginning, with considerable variation in 
 the degree of exudative inflammation in consequence of 
 changed environment or as the result of treatment. This 
 "mixed" type of middle-ear disease is aggravated by 
 every fresh "cold" in the nose more so than the purely 
 proliferative form without secretion. But, on the other 
 hand, it is also more readily influenced favorably by treat- 
 ment. In adhesive otitis, but especially when some exu- 
 dation is present, the patients claim to hear worse in bad 
 weather. The complaint is not always corroborated by 
 actual test. The patient is at times deceived as to his 
 hearing power by the subjective feeling of fulness or the 
 tinnitus which may be increased by unfavorable weather. 
 
 342. The morbid changes in plastic otitis consist of 
 inflammatory swelling, hypertrophy, fibrillary sclerosis, 
 and adhesions of the mucous membrane. In the pure 
 type of proliferative inflammation the lesions are often 
 localized, especially around the articulation of hammer 
 and anvil. When exudation is present, the process is
 
 MORBID CHANGES. 445 
 
 more likely to be diffuse. The exudate, if present, is 
 scant mucus, sometimes very viscid. Diffuse inflamma- 
 tory swelling occurs probably only during subacute exacer- 
 bations, or in the case of exudative catarrh gradually 
 changing into a plastic otitis. Ordinarily more or less 
 circumscribed hypertrophy of the lining is found, the 
 surface being uneven, sometimes with papillary or villous 
 prominences. The articulations may be imbedded in 
 hypertrophied mucous membrane. As a result of much 
 thickening, the protruding prominences of the lining 
 come into contact and form adhesions, especially between 
 the joint of hammer and anvil and the opposite walls. 
 In other instances the membrane is not hypertrophied, 
 but transformed into relatively rigid fibrous tissue. It 
 has no longer its normal delicacy and pliancy, but binds 
 down the mobile parts which it envelops. Instead of 
 broad adhesions of mucous membrane, narrow rigid ad- 
 ventitious bands are found bridging from one surface to 
 another. There is no good reason to consider this fibril- 
 lary sclerosis as the later transformation of hypertrophy 
 of the mucous membrane. It is more likely the result 
 of imperfect involution of inflammation under unknown 
 conditions. The mobility of the hammer is reduced, and 
 its normal position changed into one of increased obli- 
 quity, which is maintained partly by adhesions, partly by 
 contraction of the ligaments and of the tensor tympani 
 muscle. The latter may be shortened by fibrillary trans- 
 formation or bound down by adhesions. The prolifera- 
 tive changes may extend to the round window, thicken- 
 ing its diaphragm. When the disease attacks the vicinity 
 of the oval window, it leads to ankylosis of the foot-plate 
 of the stirrup, the most serious lesion possible in the 
 middle ear so far as sound-conduction is concerned. Even 
 a partial involvement of the articulation by fibrillary 
 transformation of the tissues damages its function. In 
 complete ankylosis the foot-plate is bound down by rigid 
 fibrous tissue, sometimes with interstitial deposition of 
 lime-salts. Bony ankylosis does not often take place in
 
 446 ADHESIVE INFLAMMATION OF THE MIDDLE EAR. 
 
 proliferative otitis ; more so, however, in disease of the 
 bony capsule of the vestibule (see ^[ 350). 
 
 The Eustachian tube is involved in this disease, at 
 least at its tympanic end. In all probability the Eusta- 
 chian lesion is the primary one in plastic otitis. Morbid 
 changes are found, as a rule, in the bony (tympanic) por- 
 tion of the canal, while the cartilaginous part of the tube 
 internal to the isthmus is mostly normal. The lesions 
 correspond to those in the middle ear viz., diffuse thick- 
 ening of the mucous lining, or fibrillary sclerosis with 
 concentric narrowing, sometimes adhesions, often valve- 
 like overlapping of the tympanic opening by a fold of 
 mucous membrane. Circumscribed cicatricial strictures 
 like those found in the urethra do not seem to occur in 
 the tube. The pharyngeal portion of the Eustachian 
 lining shows more or less inflammatory swelling (leuko- 
 cytic infiltration) or permanent hypertrophy, according 
 to the character of the primary nasopharyngeal lesions. 
 
 343. Etiology. Proliferative otitis is the extension of 
 chronic nasal inflammation into the middle ear. It is 
 never observed when seen at the start, except in connec- 
 tion with chronic nasal disease. If the latter heals as the 
 result of changed environment or treatment, the lesions 
 of adhesive otitis may persist in the ear apparently inde- 
 pendently ; but the loss of hearing is, as a rule, not pro- 
 gressive. The nasal etiology is illustrated strikingly by 
 the coincidence of the first or more affected ear with the 
 narrower side of the nose in the case of one-sided sten- 
 osis. There are, however, some rare exceptions to this 
 rule. Fluctuations in the degree of nasal inflammation 
 are usually accompanied by similar variations of the 
 condition of the ear, especially when we review longer 
 periods in the patient's history. The dependence of the 
 ear disease upon chronic rhinitis is demonstrable in some 
 instances by the arrest of the former by nasal treatment. 
 There are, however, various reasons why this therapeutic 
 test is not always successful. Nasal treatment, even 
 operative, however successful it may be, does not, as a
 
 DIAGNOSIS. 447 
 
 rule, eradicate all chronic inflammation of the nasal 
 mucous membrane. It only removes the annoyance 
 caused by the rhinitis, but the diseased membrane still 
 remains in a state of slight chronic inflammation. More- 
 over, an actual hypertrophy of mucous membrane once 
 produced is a permanent lesion. It is only the inflamtna- 
 tory swelling which is transient ; the thickening of the 
 mucous membrane not due to round-cell infiltration, but 
 to real hyperplasia does not disappear spontaneously 
 or in consequence of treatment. It can hence not be 
 expected that any changes in the middle ear beyond 
 those of inflammatory swelling should disappear, even 
 after the influences which brought them on have ceased. 
 Besides, when permanent changes in the Eustachian 
 tube have reduced its patency, either by relative stenosis 
 or by rigidity of its mobile portion, the deleterious con- 
 sequences of reduced intratympanic air-pressure persist 
 even though the nasal lining were again made normal. 
 If, at the same time, the tympanic mucous membrane 
 has begun shrinking by fibrous transformation, further 
 reduction of the mobility of the ossicles and fixation in 
 a faulty position are inevitable. 
 
 While a simple chronic rhinitis without coarse struc- 
 tural changes or stenosis is sufficient to start plastic otitis 
 media, the course of the latter is apt to be hastened and 
 intensified by nasal stenosis or circumscribed hyper- 
 trophies. This view, suggested by the observation of 
 any large series of patients with a variety of nasal lesions, 
 is often confirmed by the beneficial results of nasal opera- 
 tions when done at an early stage of the ear disease. 
 
 344. The diagnosis of proliferative otitis is based (a) 
 on the results of the functional tests showing reduced 
 air-conduction, with normal or exaggerated bone-con- 
 duction; (&) on the' appearances of the drumhead; and 
 (c) on the evidence furnished by inflation. The mem- 
 brana tympani, normal at first, gets dull and opaque in 
 most instances. Its luster becomes dimmed. Chalky 
 white spots of calcification are not rare, but these
 
 448 
 
 ADHESIVE INFLAMMATION OF THE MIDDLE EAR. 
 
 changes in the membrane, although indicative of plas- 
 tic inflammation, do not permit any conclusions as to 
 the hearing or the progress of the disease (Figs. 127- 
 129 ; compare also Fig. 4, Plate II.). They may co- 
 incide with normal hearing and arrested disease, while, 
 on the other hand, in an unfavorable case the drum- 
 head is sometimes not altered structurally at all. In 
 
 FIG. 127. Pronounced retraction of drumhead in chronic hypertrophic 
 middle-ear catarrh with Eustachian stenosis. The membrane has nearly its 
 normal luster, but is discolored and less translucent than normally. Instead of 
 the normal triangular spot there is a crescentic reflex figure. 
 
 subacute exacerbation there may be a vascular streak 
 parallel to the hammer, but ordinarily the membrane is 
 pale. Of decisive importance is the change in the shape 
 of the membrane. Retraction of the drumhead with 
 obliquity of the handle of the hammer characterizes 
 the majority of instances. It is indicative of impaired 
 
 FIG. 128. Drumhead cloudy, dis- 
 colored (thickened), and moderately 
 retracted in long-standing chronic 
 proliferative middle-ear disease. 
 
 FIG. 129. Cloudy and thick- 
 ened membrana tympani with spots 
 of calcification in chronic prolifer- 
 ative catarrh of the middle ear. 
 
 Eustachian patency, which is always incident to the 
 course of the disease. There are exceptional cases in 
 which the Eustachian patency is not demonstrably 
 diminished in the earlier period, and the drumhead 
 may then have its normal position. But if the tube is 
 found normal after a history of active disease for months,
 
 DIAGNOSIS. 449 
 
 this fact would change the diagnosis for that of "scle- 
 rosis. ' ' 
 
 Inflation by Valsalva or Politzer shows diminished 
 patency of the Eustachian tube in this disease, when 
 it affects the two ears unequally. When symmetric on 
 both sides, the obstruction is not noticeable in this man- 
 ner until quite pronounced. The catheter, too, gives a 
 sound, usually from the very beginning, indicating nar- 
 rowed caliber, of course, most appreciable on comparing 
 two sides not equally affected. The Eustachian ob- 
 struction is never sufficient to prevent inflation by the 
 catheter, but it may finally make the Politzer method 
 inefficient. The diagnosis of slight secretion as a com- 
 plication must be based entirely on the auscultation sound 
 on inflating, as there is no other evidence of it. 
 
 The effect of inflation varies according to the pre- 
 dominance of Eustachian obstruction or of plastic changes 
 in the drum. The latter are not influenced, while the 
 mechanical disturbances of tubal closure are temporarily 
 relieved. There may thus be a fair subjective improve- 
 ment of more or less duration, but never so striking as 
 in exudative catarrh. On the other hand, inflation may 
 have no effect whatsoever. The result of the first inflation 
 determines the prognosis. The greater the subjective im- 
 provement, the more reason to assume that the changes 
 in the tube and drum are still capable of resolution. The 
 prognosis, however, depends even more on the duration 
 of the benefits of Eustachian inflation than on their im- 
 mediate degree. 
 
 Inflation does not always clear the ears at once: some 
 patients feel the subjective improvement only after the 
 lapse of some hours. The immediate results of infla- 
 tions cannot be gauged merely by the improvement in 
 the hearing. This is never so marked as in exudative 
 catarrh ; indeed, mostly not very striking at all, often not 
 measurable objectively. But the effect on the tinnitus 
 and on any fulness felt in the ear is the test of its bene- 
 ficial influence. When thorough inflation through the 
 
 29
 
 45O ADHESIVE INFLAMMATION OF THE MIDDLE EAR. 
 
 catheter gives no subjective relief, either at once or in 
 the course of some hours, there is nothing to be gained 
 by its repetition. 
 
 345. For the purpose of treatment inflation should be 
 practised daily as long as it influences the hearing or the 
 discomfort of the patient. Longer intervals in the treat- 
 ment mean a waste of time. As soon as inflation fails 
 to improve the condition for at least a few hours, it is 
 useless to continue it. Sometimes its period of useful- 
 ness is over after a few weeks of treatment; in other in- 
 stances it is of some benefit in staying the disease during 
 months. The fluctuations of proliferative otitis may 
 demand a repetition of inflation when the disease gets a 
 fresh start. While it will generally be found that cathe- 
 terization is more effective than the Politzer inflation, yet 
 the latter may be left to the patient as an additional help. 
 Many persons can learn to catheterize themselves, if re- 
 quired. The final results of a course of inflation are very 
 variable, depending largely on the transient or permanent 
 character of the constricting lesion in the Eustachian 
 tube, and of the changes in the drum cavity. They can 
 be predicted with moderate certainty from the effect (and 
 especially its duration) after the first inflation. The 
 utility of vapors turpentine, iodin, chloroform, or finely 
 divided powders (freshly formed chlorid of ammonium) 
 injected through the catheter has been discussed in 
 1 338. As a rule, critical comparison does not show any 
 pronounced advantage over simple inflation, and even in 
 the apparently favorable instances a true appreciation of 
 the value of these agents is very difficult. Dilatation of 
 the Eustachian tube by sounds introduced through the 
 catheter has not been found useful by many observers, 
 although recommended by some. It is painful to reach 
 the osseous portion, which is usually the part involved. 
 Moreover, there is no reason to expect a permanent 
 benefit from the transient pressure by the probe. 1 
 
 1 Recently electrolysis of the Eustachian tube hns been highly indorsed for 
 the cure of inflammatory narrowing (Duel, Kenefick). Through a well-fitting
 
 TREATMENT. 45 1 
 
 Pneumomassage (*|[ 306) of the drumhead and ossicles 
 is, as a rule, subjective!)' agreeable. Its long continu- 
 ance, about one to two minutes, twice daily, is often of 
 some little influence upon the hearing and the noises. 
 Yet its value is enormously overrated in some reports. 
 If a few tests do not show very decided benefit, it is more 
 appropriate to let the patient keep up the exercise at 
 home for months than to force him to come to the sur- 
 geon's office. 
 
 How much benefit may be expected from nasal treat- 
 ment in hypertrophic otitis can be inferred from the 
 etiologic discussion in T[ 343. In instances of relatively 
 short duration, months, and especially in those charac- 
 terized by rapid course and fluctuations in the severity of 
 the aural symptoms, a decided improvement will often 
 follow the successful operation of nasal lesions. Re- 
 moval of septum deformities, snaring of hypertrophies 
 of the inferior turbinal, cauterization of excessive cavern- 
 ous tissue, either anterior or posterior, and especially 
 galvanocaustic destruction of vascular prominences at 
 the rear of the septum (1 94 and 1 97) give at times very 
 satisfactory results, both as regards improvement of hear- 
 ing and disappearance of tinnitus and fulness. But such 
 fortunate instances constitute only a small minority and 
 
 Eustachian metal catheter insulated on its external surface by means of rubber 
 an olive-tipped gold wire, I mm. wide at its bulbous end, is pushed into the 
 tube until it enters nearly or quite up to the middle ear (about 35 mm. beyond 
 the end of the catheter). As soon as resistance is encountered, the gold wire 
 is made the negative pole of a battery current of \ to not over 4 milliamperes in 
 strength. The positive pole may be a sponge or a bowl of salt water into 
 which the patient dips his hand gradually in order to avoid a shock. This cur- 
 rent is employed for a few minutes. During its action the probe glides easier 
 through the narrowed Eustachian passage than previously. Inflation must not 
 be practised for at least a day for fear of causing emphysema. It has been 
 claimed that in many instances decided relief from the tinnitus and fulness fol- 
 lows the first application, and the hearing may improve correspondingly. A 
 few repetitions in intervals of some weeks are said to have given permanent 
 results in many instances. The method has not yet been tried sufficiently by 
 others to test its value. Personal trial has shown me that in spite of care and 
 antiseptic precautions a mild grade of suppurative otitis may be caused by it.
 
 452 ADHESIVE INFLAMMATION OF THE MIDDLE EAR. 
 
 cannot be foretold with certainty. Of most cases, how- 
 ever, it can be said that nasal treatment will tend to 
 arrest the ear disease in proportion to its result upon 
 the nasal disease. It must again be emphasized that 
 in hypertrophic rhinitis operations which relieve the pa- 
 tient subjectively do not necessarily restore the normal 
 state of the nasal mucous membrane, and that, indeed, 
 our therapeutic control over this disease is limited. But, 
 on the whole, all measures benefiting the nasal affection 
 give the ear the best chances possible for the arrest of the 
 disease. This applies not only to operations and medi- 
 cinal treatment, but equally to all hygienic measures 
 referred to in ^[ 14 to ^[ 17. But in spite of all care, the 
 prognosis is doubtful in many instances, even at the 
 beginning, and bad in most advanced cases. The his- 
 tory of steadily progressive deafness with tinnitus not 
 controllable by inflation, the demonstration of Eustachian 
 stenosis, and the absence of gross lesions in the nose give 
 the therapeutist little chance for successful intervention.
 
 CHAPTER XXXVII. 
 
 OPERATIONS FOR THE RELIEF OF DEAFNESS DUE 
 TO ADHESIVE PROCESSES IN THE MIDDLE EAR. 
 
 346. The uncertainty of treatment in hypertropliic 
 disease of the middle ear has led to various operative 
 attempts. 
 
 A striking observation is the exemption of those ears 
 from any form of progressive deafness in which there is 
 a permanent perforation of the drumhead. When this 
 is one-sided, the ear does not even participate if the 
 other ear with intact drumhead becomes gradually deaf 
 from plastic inflammation. In view of the frequency of 
 hypertrophic middle-ear disease this exemption is quite 
 remarkable. As long as a middle ear with perforated 
 drumhead still continues to suppurate the hearing is 
 occasionally further damaged by subacute exacerbations. 
 But after the suppuration has ceased, the hearing of such 
 an ear remains stationary. It is self-evident that a per- 
 foration in the drumhead prevents all the pernicious con- 
 sequences of Eustachian obstruction. Observations on 
 ears with healed suppuration but persisting defect in the 
 membrane suggest, moreover, that even those intratym- 
 panic changes which so often occur in connection with 
 but moderate impairment of the Eustachian patency are 
 secondary to the latter. It would hence be a perfectly 
 justifiable operation to make a permanent fistula in the 
 drumhead in all cases of beginning middle-ear catarrh, 
 if we only knew of any method to maintain a perma- 
 nent perforation. It sounds paradox that we cannot 
 imitate nature in the example she sets in every chronic 
 purulent otitis. In the latter case the edges of the per- 
 foration are cicatrized and covered with epithelium, and 
 
 453
 
 454 RELIEF OF DEAFNESS DUE TO ADHESIVE PROCESSES. 
 
 the hole is permanent and can be closed only artificially. 
 On the other hand, every attempt to maintain a perma- 
 nent perforation by exsecting a piece of or even the 
 whole drumhead or by inserting a cuff-button-shaped 
 cannula or clamping a U-shaped perforated tube around 
 the manubrium mallei has proved a failure. When the 
 tendinous insertion of the membrane in its bony frame 
 is chiseled away, regeneration is often, but even then not 
 always prevented. The preventive operative treatment 
 of chronic middle-ear catarrh is hence a matter of the 
 future. There is no good reason, however, to believe 
 that a permanent perforation would necessarily prevent 
 the continuance of adhesive and ankylotic processes in 
 the middle ear after they have been well started. In 
 advanced cases of middle- ear catarrh some temporary 
 relief is sometimes, but not always, obtained by punctur- 
 ing the drumhead. 
 
 A different procedure was suggested by observations in 
 chronic purulent otitis rebellious to conservative treat- 
 ment. It has been found that the removal of the ossicles, 
 together with the drumhead, does not often damage the 
 impaired hearing, but, on the contrary, is quite apt to 
 improve it, sometimes to a striking extent. In favorable 
 instances ordinary conversation can be well heard in the 
 absence of the drumhead, the hammer, and the anvil, 
 although, of course, the hearing is far from being perfect. 
 Attempts have, therefore, been made by many surgeons 
 to remove these parts in progressive deafness due to 
 plastic processes without suppuration. The operation, 
 moderately painful, can be tolerated without general nar- 
 cosis only by a courageous individual. Cocain is of ser- 
 vice only after the drumhead has been opened, not before. 
 Suprarenal solution is of considerable help in suppress- 
 ing troublesome hemorrhage. The operation through 
 the meatus is feasible only when the latter is normally 
 wide. Otherwise preliminary detachment of the cartila- 
 ginous meatus would be necessary (T 327). The most 
 advantageous illumination is that by an electric lamp on
 
 OPERATIONS. 45 5 
 
 the forehead. The drumhead is detached from its inser- 
 tion by a curved peripheral anterior and a similar pos- 
 terior incision from above downward. A fine bent knife 
 then severs the tensor tympani tendon and the joint 
 between the long processes of the anvil and the head of 
 the stapes. A delicate snare is pushed up until it grasps 
 the head of the hammer, and with cautious prying move- 
 ments the latter is taken out. If the anvil does not 
 follow, it may then be searched for with the snare, or 
 with small, variously bent hooks. The removal of the 
 anvil is not easy, and sometimes impossible. Under 
 absolute asepsis and the avoidance of syringing there is 
 very little reaction and no suppuration. The after-treat- 
 ment consists only in placing a sterile gauze tampon into 
 the meatus. With thorough knowledge of the anatomy 
 the only accident to be feared and that not a common 
 one is injury to the stapes. In the latter case severe 
 dizziness may ensue for days. Severe purulent otitis 
 may occur in case of imperfect asepsis. Through care- 
 lessness the facial nerve may be wounded. 
 
 347. There is no doubt that the operation has in- 
 fluenced the hearing favorably in a small proportion of 
 cases. In a larger number of instances the distressing 
 noises have been permanently benefited. It cannot be 
 learned with certainty from published reports whether 
 the hearing remained stationary in any large number of 
 instances after this operation. Very few cases seem to 
 have been watched for a sufficiently long time. On the 
 other hand, in a minority of instances the tinnitus was not 
 benefited, and in a large majority no gain accrued to the 
 hearing power, while not rarely the latter was seriously 
 damaged. The operation has been abandoned by many 
 former enthusiasts ; still, it does not deserve to be unre- 
 servedly condemned, but it should be understood that its 
 prognosis is absolutely uncertain. In a number of in- 
 stances the moderate benefit temporarily obtained was 
 lost after the membrane became regenerated. 
 
 348. Tenotomy of the tensor tympani muscle has been
 
 456 RELIEF OF DEAFNESS DUE TO ADHESIVE PROCESSES. 
 
 practised considerably in former years, sometimes with 
 some temporary benefit, but has now been abandoned as 
 inefficient. 
 
 The removal of the ankylosed stapes has been done 
 quite a number of times, especially by Blake and Jack. 
 The hammer and anvil need not necessarily be removed 
 in this operation, but, of course, the drumhead must be 
 partially detached. As a rule, there is severe reaction in 
 the form of dizziness, if the foot-plate of the stirrup is 
 really removed by the operation. Although some benefit 
 has been claimed, this delicate operation has not gained 
 favor among otologists. 
 
 In relatively rare instances an adhesion of the drum- 
 head or even of the manubrium to the internal tympanic 
 wall results from a destructive purulent otitis. In such 
 cases a moderate benefit to the hearing, but especially a 
 relief of tinnitus, may be obtained by dividing the adhe- 
 sions with a minute knife bent on the flat. 
 
 349. Abnormal relaxation, with flaccidity of the mem- 
 brana tympani, is sometimes met with from unknown 
 causes, perhaps at times from imprudent repetitions of 
 Valsalva inflation by the patient. Occasionally, too, 
 large cicatrices of the drumhead are seen to be flaccid 
 and possess abnormal mobility when tested with the 
 Siegle pneumatic speculum. This condition reduces the 
 hearing without other symptoms. In such rare instances 
 an improvement in the hearing can be obtained by render- 
 ing the drumhead more tense by a coating of collodion. 
 Whenever the condition returns by reason of the collo- 
 dion peeling off, the membrana tyrnpani may be brushed 
 again with the solution.
 
 CHAPTER XXXVIII. 
 
 "SCLEROSIS OF THE MIDDLE EAR" (RAREFACTION 
 
 OF THE CAPSULE OF THE LABYRINTH). 
 
 ANKYLOSIS OF THE STAPES. 
 
 350. It had been noticed by even the earlier otologists 
 that there is a certain type of progressive deafness which, 
 while it resembles "dry catarrh" of the middle ear, 
 differs from it sufficiently to be distinguishable clinically. 
 On account of false pathologic ideas this disease has been 
 termed sclerosis of the middle ear. Its true pathology 
 has now been so completely demonstrated (by Politzer, 
 Siebenman, and others) that an accurate differentiation 
 is possible. Although an affection of the sound-conduct- 
 ing parts, it is really not a disease of the mucous mem- 
 brane of the middle ear. 
 
 The disease begins usually between the fifteenth and 
 twentieth years of life, less often later on, predominantly 
 in females. It occurs in rather less than 5 per cent, of 
 ear patients. It is always double-sided, and, as a rule, 
 without much difference between the two ears. A 
 hereditary tendency to ear disease is often found in the 
 family. The hearing becomes gradually dulled, with 
 very little other annoyance. No fulness, no stuffiness, 
 no dizziness. Tinnitus is sometimes complained of to a 
 moderate extent ; it is neither constant nor steady. In 
 the course of some years it becomes difficult to follow a 
 conversation. In some the deafness does not proceed 
 beyond considerable embarrassment in ordinary speech. 
 In others it is steadily progressive, and after many years 
 practically bars the patient from social intercourse. 
 
 These patients have no catarrhal history. During their 
 younger years they are conspicuously free from nasal and 
 pharyngeal disturbances, and their rare attacks of coryza 
 
 457
 
 458 "SCLEROSIS OF THE MIDDLE EAR." 
 
 heal promptly. Later in life slight chronic changes may 
 occur in the upper respiratory passages in unfavorable 
 climates. The drumhead is normal at first. It may 
 become slightly retracted, but not necessarily so. It 
 often looks atrophic by reason of the special prominence 
 of the neck of the hammer. The luster is normal. A 
 pinkish hue due to congestion of the promontory is often 
 noticeable through the translucent membrane, and is of 
 inauspicious significance. The Eustachian tube is normal. 
 Functional tests show reduced air-conduction, the result 
 of fixation of the foot-plate of the stapes. Rinne's test 
 soon becomes negative. The tuning-fork on the vertex 
 is heard abnormally long. The main distinction between 
 this form of disease and proliferative middle-ear disease 
 is the pronounced deafness for the lowest tones of the 
 scale when heard through the air. The range of audition 
 is shortened by one to even three octaves at the lower 
 end. In the course of years these tests become less deci- 
 sive as the disease is likely to become complicated by 
 involvement of the auditory nerve-ends. This is then 
 indicated by shortening of the upper end of the auditory 
 range on testing with the Galton whistle. 
 
 Sooner or later the disease ends in complete ankylosis 
 of the stirrup bony union of the foot-plate of the stapes 
 to the walls of the niche in which the oval window is 
 located. It is not yet certain whether this condition can 
 be invariably recognized by means of Gelle's test (1 309). 
 When the bony ankylosis is complete, the deafness 
 usually ceases to increase. In some instances, however, 
 the hearing continues to suffer even beyond this period, 
 and the functional tests then indicate involvement of the 
 nerve-ends in the labyrinth. 
 
 351. It was formerly supposed that this type of disease 
 was due to fibrillary degeneration of the tympanic mucous 
 membrane hence the name, sclerosis. This supposition 
 was entirely wrong. The tympanic mucous membrane 
 is normal in this disease. The real lesion is disseminated 
 rarefaction of the bony wall of the labyrinth. Separate
 
 ANKYLOSIS OF THE STAPES. 459 
 
 small yellowish foci are found, especially in the neighbor- 
 hood of the oval window. In these spots the compact 
 bony substance is changed into the cancellated type. 
 The rarefaction is indicated by the presence of lacunae 
 and of osteoclasts. Enlarged and newly formed vessels 
 render these foci abnormally vascular. Later on minute 
 osteophytes form both on the tympanic and on the intra- 
 labyrinthine surfaces. This secondary proliferative proc- 
 ess culminates in bony ankylosis of the foot-plate of the 
 stirrup. It is doubtful whether the process can be called 
 inflammatory. It is a return to the embryonic condition 
 of the bone from unknown causes. We know nothing 
 of the etiology beyond the frequent family predisposi- 
 tion. 
 
 So-called sclerosis cannot be influenced therapeutically 
 by any known means. Eustachian inflation is sometimes 
 agreeable subjectively, but has no permanent influence 
 and is even accused of being harmful in the end. The 
 same may be said of massage. Excision of the ossicles 
 or operative manipulation of the stapes only can be con- 
 demned on the basis of experience. No internal medica- 
 tion tried up to the present time iodids, thyroid gland, 
 phosphorus has given any decisive results. It is gen- 
 erally believed, perhaps on doubtful evidence, that the 
 disease is least likely to progress rapidly when the 
 health is maintained at par. 
 
 353. Ankylosis of the stapes is a not infrequent 
 lesion in proliferative middle-ear catarrh, as well as in so- 
 called sclerosis, in which it is a constant terminal feature. 
 In the former disease it is usually not a bony union. 
 There may be true sclerosis of the deeper periosteal layer 
 of the mucous membrane, causing fibrous rigidity, and 
 this may be complicated by more or less calcification or 
 even partial ossification. The lesion necessarily causes 
 a high degree of deafness. It is indicated by the rever- 
 sion of Rhine's test, by exaggerated bone-conduction and 
 total deafness for aerial sound-waves of low frequency. 
 When in Gelle's test increased air-pressure in the meatus
 
 460 ANKYLOSIS OF THE STAPES. 
 
 does not reduce the perception of aerial sound-waves, the 
 diagnosis may be considered assured. 
 
 In most instances of stapes ankylosis due to prolifera- 
 tive catarrh of the middle ear the diagnosis of the catar- 
 rhal origin can be easily made. There are exceptional 
 instances in which the functional tests indicate stapes 
 rigidity at a very early period, while the other symptoms 
 do not as yet point to any extensive proliferative changes 
 in the middle ear. Such cases are sometimes difficult to 
 distinguish from so-called sclerosis. The latter, however, 
 is always bilateral, while in the former type of disease it 
 is not uncommon to find one-sided instances with very 
 little involvement of the other ear. 
 
 Ankylosis of the stapes may also be the consequence of 
 a purulent otitis. If the latter has healed without leav- 
 ing visible evidences in the membrana tympani, as some- 
 times happens in childhood, the diagnosis of the origin 
 of the ankylosis may prove puzzling.
 
 CHAPTER XXXIX. 
 
 SIMPLE OTITIS MEDIA (PURULENT OTITIS MEDIA 
 WITHOUT PERFORATION). 
 
 353* Suppurative inflammation of the middle ear is 
 distinguished from catarrh by the greater depth of the 
 inflammatory infiltration, which may even extend into 
 the bone, and by the nature of the exudation. The lat- 
 ter varies from clear serum to pure pus, but is not the 
 more or less turbid mucus of catarrh. Purulent otitis 
 has hitherto been identified with a clinical picture begin- 
 ning with well-defined pain and leading to a perforation 
 in the drumhead, with subsequent discharge through it. 
 But while this is the predominating type of the disease, 
 there are other forms which have as yet received less 
 attention. 
 
 It has been shown that a purulent inflammation of the 
 middle ear is found at autopsies in about four-fifths of 
 all dead nurslings. There is in this case the same dis- 
 crepancy between the frequency of the lesions found in 
 the dead-room and the scantiness of clinical observation 
 which has been noticed in diseases of the nasal accessory 
 cavities. Kutscharianz, Kossel, Ponfick, and others have 
 shown this remarkable liability to purulent otitis in in- 
 fants during their last days of life, apparently independent 
 of the cause of death. The exudate has been found to 
 contain the familiar pyogenic microbes, streptococci, 
 staphylococci, and pneumococci, as well as in some 
 instances the influenza bacillus. While all evidence 
 points to invasion through the Eustachian tube, which 
 at this age is relatively wide and short, the nose and 
 pharynx were found normal in many instances. 
 
 In nurslings dying shortly after birth Aschoff found 
 frequently lanugo hairs and vernix caseosa in the drum 
 
 461
 
 462 SIMPLE OTITIS MEDIA. 
 
 cavity, presumably through the entrance of amniotic 
 fluid into the Eustachian tube during swallowing move- 
 ments of the fetus. On the basis of this observation he 
 considers at least some of the instances of infantile otitis 
 as an inflammatory reaction, due to the presence of for- 
 eign bodies in the middle ear. 
 
 This otitis, complicating so many of the diseases of 
 early infancy, is clinically latent when the child is very 
 sick and apathetic. In other instances it is suggested by 
 restlessness and tossing of the head. A sudden rise of 
 temperature may be due to it, as it has been shown that 
 puncture of the drumhead may lower the fever during 
 the course of other ailments complicated by concomitant 
 otitis. It has also been pointed out (Ponfick-Barth) that 
 this purulent otitis with escape of pus through the 
 Eustachian tube can account for intestinal disturbances 
 observed in such children. 
 
 It is not easy to diagnose this inflammation of the ear 
 in the infant. The small meatus permits only the use of 
 the smallest speculum. Very strong light is hence re- 
 quired. The meatus is apt to be filled by epidermis 
 scales, which it is better to scoop out gently than to 
 remove by syringing. The drumhead, very oblique at 
 this age, is not easily distinguished from the posterior 
 upper wall of the meatus. It is relatively little con- 
 gested, but more turbid on account of the exudate than 
 normally. It is yet to be determined by future observa- 
 tions how much this concomitant otitis, with its nearly 
 latent course, adds to the danger of the disease which it 
 complicates. Whether or not to puncture the drumhead 
 is also an open question. There certainly should be 
 more systematic attention paid to the ear of all sick 
 babies. 
 
 Entirely different from this almost latent form of con- 
 comitant otitis is the ordinary purulent otitis, with per- 
 foration, which can occur in infants at the earliest age, 
 and which presents the pronounced symptoms to be 
 described in 1 356.
 
 SIMPLE OTITIS MEDIA. 463 
 
 354. A latent form of purulent otitis seems to be the 
 invariable rule in all cases of measles even when no pro- 
 nounced aural symptoms are observed. In every fatal 
 case of that disease examined by Bezold and his assist- 
 ants the middle ear and mastoid pneumatic spaces were 
 found filled with pus. Yet the great majority of patients 
 with measles present no clinical symptoms of ear disease. 
 In scarlet fever various observations on a more limited 
 scale have also shown at least a frequent coincidence of a 
 clinically latent purulent effusion into the middle ear. 
 The same statement applies in diphtheria. 
 
 355- True pyogenic inflammation of the middle ear, 
 which, however, does not lead to perforation of the drum- 
 head, is observed at times in children and somewhat less 
 frequently in adults. It begins with slight fever and sharp 
 pain. The pain, however, is not continuous, but inter- 
 mittent, generally worse at night. Fulness and deafness 
 increase gradually during a few days, and when the cli- 
 max has been reached, the pain subsides. The drum- 
 head is either uniformly reddened or at least congested 
 in its upper posterior portion (compare Fig. 5, Plate II. ). 
 Auscultation during inflation shows the presence of fluid 
 in the middle ear. During healing this fluid becomes 
 absorbed. 
 
 This form of otitis without perforation (which is not 
 generally recognized) has been described by Politzer as a 
 type of disease not identical with the ordinary perforating 
 form of otitis. According to my experience, it is really 
 but a milder type of the same disease which usually 
 causes the drumhead to give way, but perhaps with a dif- 
 ferent localization. It occurs mainly in connection with 
 the milder forms of nasal or pharyngeal disturbances. 
 Coryza or tonsillitis, especially in the presence of ade- 
 noids, may lead to involvement of one or both ears. It 
 may last from one to more than two weeks. The dis- 
 tinction between this form and purulent otitis tending to 
 perforation is based at first upon the intermittent charac- 
 ter of the pain. The distinction is not a difficult one
 
 464 SIMPLE OTITIS MEDIA. 
 
 when the drumhead is only partially injected, but un- 
 certain when it is diffusely vascularized. Subsequently 
 the diagnosis is established by the subsidence of the 
 symptoms without perforation of the drumhead. The 
 disease differs from exudative catarrh by the more pro- 
 nounced inflammatory symptoms at the onset. After 
 these have subsided the difference between this form 
 and acute catarrh is not so pronounced. The exudate, 
 however, usually scant, is never as tenacious as the 
 catarrhal secretion. 
 
 The tendency to recovery is decidedly aided by rest 
 and protection and Eustachian inflation. The symp- 
 toms may, indeed, subside as promptly after a single 
 inflation as they often do in exudative catarrh, but like 
 in the latter instance, they increase again until the next 
 treatment. Inflation stops the sharp pain at once. In- 
 stillation of carbolated glycerin (10 per cent.) seems to 
 help in shortening the duration. After a few days of 
 treatment inflation sometimes seems without further in- 
 fluence. Pneumomassage, while less effective in its im- 
 mediate influence, is, however, of some benefit until 
 the hearing becomes normal. Politzer warns against 
 paracentesis of the drumhead. This, indeed, is usually un- 
 necessary. But with the more recent methods of guard- 
 ing against secondary infection through the meatus by 
 absolute asepsis and gauze drainage paracentesis does 
 not involve the risk of protracted suppuration, which 
 Politzer cautions against as the danger attending punc- 
 ture of the drumhead in this disease. The operation 
 may hence be done when the case does not show a 
 steady improvement tinder treatment by inflation, pro- 
 vided inflammatory symptoms or intratympanic exuda- 
 tion persist.
 
 CHAPTER XL. 
 
 ACUTE PURULENT OTITIS MEDIA (WITH PERFORA- 
 TION OF DRUMHEAD). 
 
 356. Acute suppurative inflammation of the middle 
 ear is a disease prevalent at all ages, but most common 
 in childhood on account of the predominance of its 
 causes during that period. As the course of the disease 
 is quite variable according to its etiologic conditions, it 
 is best to begin with a review of its causes. 
 
 The disease is caused by the invasion of the middle 
 ear by pyogenic microbes. In more than one-half the 
 cases it is the pneumococcus, next to it, the streptococcus, 
 less often, the staphylococcus, occasionally, the pneumo- 
 bacillus (Friedlarider), the colon bacillus, or the bacillus 
 pyocyaneus. As a rule, only one variety of germs is 
 present originally, but in neglected cases streptococci 
 and staphylococci may come in as secondary infection. 
 The invasion takes place mostly from the nasopharynx 
 through the tube. Much less common is the infection 
 from the external meatus in consequence of traumatism, 
 such as careless removal of foreign bodies or plugs of 
 wax, or as the result of extension of eczema. Cold 
 water entering through a previous perforation of the 
 drumhead may also rekindle an otitis. The most fre- 
 quent starting-point of the disease is acute nasal catarrh. 
 It is popularly believed, and not improbable, that the 
 extension through the tube may be due to "taking 
 cold." But simple uncomplicated coryza does not often: 
 infect the ear unless aided by other conditions. In 
 nurslings this may be teething. In older children the 
 presence of an enlarged pharyngeal gland is the predomi- 
 nating factor more than any other. Later in life nasal 
 
 30 465
 
 466 ACUTE PURULENT OTITIS MEDIA. 
 
 stenosis favors the spreading of suppurative rhinitis to 
 the ear of the same side. These predisposing conditions 
 play the same role in connection with the nasal inflam- 
 mation accompanying eruptive fevers. One of the most 
 frequent underlying conditions is scrofula, but its in- 
 fluence depends largely on the existence of the enlarged 
 pharyngeal tonsil so common in this affection. Suppura- 
 tive otitis, often quite severe, may result from the entrance 
 of water through the tube while using the nasal douche 
 or while diving. Acute tonsillitis is not a rare cause. 
 Diphtheria leads to clinically manifest otitis only in a 
 small proportion of cases, but when it does occur, it is 
 of a severe type. It is more often the streptococcus 
 than the diphtheria bacillus which reaches the ear in 
 diphtheria. Scarlet fever infects the ear often, and, 
 as a rule, severely; measles much less frequently, at 
 least clinically manifest, and generally not so severely. 
 Rhinitis during small-pox, typhoid fever, or pneumonia 
 may likewise extend to the ear. Influenza produces 
 relatively often ear trouble, either a streptococcus 
 otitis or a special form of influenza otitis, which will 
 be described separately. Nasopharyngeal inflammation 
 does not always extend along the lining membrane of 
 the tube to reach the ear. In some cases the infection 
 travels through the lymph-spaces. If purulent otitis 
 does ever occur through direct infection of the middle 
 ear "by way of the blood-current, it is certainly not 
 common. 
 
 Of the various causes of otitis, simple nasopharyngeal 
 inflammation leads, as a rule, to the mildest type, espe- 
 cially in young children. The ear disease following 
 scarlet fever and diphtheria represents, on the other 
 hand, the most severe and destructive form. Of the 
 various causative germs, the streptococcus produces the 
 most severe infection. 
 
 357. The morbid changes are those of purulent in- 
 flammation in general viz., inflammatory swelling of 
 the mucous membrane, with partial destruction of the
 
 MORBID CHANGES. 467 
 
 epithelium and with abundant secretion of serum, sero- 
 purulent fluid, or thick pus. The most purulent form 
 of discharge is usually due to streptococcus infection. 
 The process may be very superficial or may extend into 
 the periosteal layer. In the latter case secondary caries 
 or necrosis of the bony walls or of the ossicles may 
 follow in severe instances. In all but the mildest cases 
 the inflammation extends into the mastoid antrum, and, 
 as a rule, the same discharge is found in this cavity as in 
 the tympanum. The attic is probably but little involved 
 in the case of mild superficial lesions, while in unfavor- 
 able instances it may be the principal, or at least the 
 most persisting, seat of the disease. 
 
 358. Acute purulent otitis begins with sudden fever, 
 the height of which is variable, depending somewhat on 
 the preexisting local or systemic disturbance which caused 
 the otitis. The fever does not, as a rule, last long, espe- 
 cially in adults. A subsequent sudden rise of tempera- 
 ture, however, indicates some new extension for in- 
 stance, the deeper involvement of the mastoid process. 
 The accompanying febrile disturbances, malaise, loss of 
 appetite and so forth are somewhat variable, but gener- 
 ally not severe. 
 
 In very rare instances severe symptoms may occur 
 which simulate brain disease, especially in children. 
 Stupor, delirium, even convulsions are sometimes due to 
 otitis without cranial complication, and cease as soon as 
 the drumhead is perforated. Examination of the ear 
 should be imperative in all obscure instances of apparent 
 brain disease, especially in children who cannot tell of 
 their earache. 
 
 The predominating symptom is pain, earache, often 
 very severe and radiating, generally with more or less 
 headache (one-sided). There is tenderness around and 
 behind the ear, extending underneath the jaw, and 
 often pain on swallowing. The pain lasts until the dis- 
 charge finds its way through the drumhead. In severe 
 cases, however, pain may persist for hours or even days
 
 468 ACUTE PURULENT OTITIS MEDIA. 
 
 after perforation. The persistence of pain with tender- 
 ness over the mastoid region should arouse the suspicion 
 of mastoiditis. In the most destructive instances of 
 otitis during scarlet fever pain is sometimes conspicuously 
 absent, or at least not mentioned by an apathetic child, 
 which important fact should not be forgotten by the gen- 
 eral practitioner. Pain is likewise absent, as a rule, in 
 relapses of suppurative otitis in ears with a persisting 
 perforation in the drumhead. The ear feels full and 
 stuffy until well along in the course of recovery. There 
 is rarely any tinnitus, but this sometimes follows for a 
 while after the cessation of discharge. The hearing may 
 be but little affected during the first day or two. Subse- 
 quently it becomes dull in proportion to the severity of 
 the disease. There is but little improvement in the 
 hearing by the time the discharge has ceased. But it 
 can be safely predicted that normal hearing will return 
 in the course of weeks, perhaps as late as six weeks after 
 the attack, except in the case of extensive destruction 
 or neglected treatment. 
 
 Perforation of the drumhead with the appearance of 
 discharge gives relief to the pain, as a rule, but not in- 
 variably. Perforation rarely occurs in less than thirty- 
 six to forty-eight hours; exceptionally as late as the 
 fourth or fifth day. It cannot be too strongly emphasized 
 that the discharge is in most instances serous at first. If 
 not properly drained, it is apt to become purulent after a 
 few days in all but the mildest cases. This change is 
 partly due to insufficient drainage, as it can be prevented 
 by a properly maintained gauze drain. Later on the 
 purulency is often the result of secondary infection by 
 other bacteria invading the fluid in the meatus. It is 
 possible and it should be the aim of the surgeon to keep 
 the serous discharge serous and not to let it get purulent. 
 In many severe instances, however, especially those due 
 to streptococci, the discharge is purulent when it first 
 breaks through the drumhead, or even when a relatively 
 early paracentesis is performed. Still, in even such
 
 SYMPTOMS. 469 
 
 instances it is an open question whether opening the 
 drumhead at the very start would not have shown a 
 serous effusion. The discharge may be very profuse as 
 much as several ounces in twenty-four hours. After two 
 to three days it begins to diminish gradually in quantity. 
 The drumhead is uniformly and deeply injected from 
 the start (compare Fig. 7, Plate II.). All details of 
 structure are effaced; the inanubrium is generally not 
 distinct. Sometimes circumscribed purulent pouches 
 appear (Fig. 130). The spontaneous perforation is gen- 
 erally not larger than a pinhole, and occurs mostly be- 
 hind the umbo, often quite high up. In inflammation 
 localized principally in the attic the perforation occurs 
 in the flaccid portion or Shrapnell' s membrane, and 
 
 FIG. 130. Acute otitis; membrana tympani congested, especially in upper 
 posterior quadrant, serous infiltration almost effacing all landmarks. Circum- 
 scribed bulging in upper posterior quadrant. 
 
 this region may remain reddened longer than the rest of 
 the drumhead in such cases. In the destructive forms due 
 to scarlet fever or diphtheria and those following trauma- 
 tism the hole in the membrana tympani is apt to grow 
 by sloughing of its edges. In other forms this is rarely 
 the case. The drop of fluid seen in the perforation pul- 
 sates. When the discharge is thick, a view of the per- 
 forated drumhead can be obtained only after cleansing 
 by syringing or mopping with cotton. In the course 
 of recovery the drumhead gets pale, but often remains 
 thickened and cloudy (compare Figs. 8 and 6, Plate II.). 
 Small perforations close almost invariably if the disease 
 does not become chronic; even large holes do so very 
 often. Drainage through the perforation is in rare in- 
 stances interfered with by a 'singular unfavorable change
 
 47 ACUTE PURULENT OTITIS MEDIA. 
 
 viz., a nipple-like prominence of granulation tissue, 
 with a narrow fistula in it which projects from the hole 
 in the membrana tympani. This occurs often in disease 
 of the attic with perforation through Shrapnel 1's mem- 
 brane. It is best to remove this nipple by means of the 
 snare, or even a small galvanocaustic burner (Fig. 131). 
 
 The duration of the disease varies with the etiology, 
 severity, and to some extent with the age of the patient, 
 and especially with the treatment. In a teething baby the 
 earache of one night may be followed by three days of 
 discharge and recovery. An attack of moderate severity 
 in a grown-up child or adult rarely lasts less than ten to 
 fifteen days, and often three to four weeks if the discharge 
 is allowed to become purulent. Indefinite perpetuation 
 
 FIG. 131. Membrana tympani in acute purulent otitis after a spontaneous 
 perforation has become obstructed by granulations in the form of a pouting nipple. 
 This projection is hollow, and there is a drop of pus at its orifice. The membrana 
 tympani is cloudy and thickened, but its congestion is beginning to subside. 
 
 of the disease in the chronic form may happen in almost 
 any case. It is least likely in very young children; most 
 likely in adults. Mild cases are, as a rule, self-limited, 
 but when the disease is due to scrofula, measles, scarlet 
 fever, diphtheria, or influenza, or when the patient is ill- 
 nourished or anemic, spontaneous termination is much 
 less likely. Adenoid vegetations and nasal stenosis, as 
 well as chronic nasal suppuration, favor persistence and 
 relapses. Suppuration of the attic is especially liable to 
 become chronic. Chronicity can in every case be pre- 
 vented by appropriate treatment, which may in some 
 few instances include a mastoid operation. 
 
 359. Of complications of purulent otitis, acute mas- 
 toiditis is the most common: All but the mildest forms
 
 TREATMENT. 47 I 
 
 of inflammation of the middle ear are accompanied by 
 some inflammation of the mucous membrane of the mas- 
 toid antrum. This condition may be clinically latent, or 
 if more severe, may reveal itself by more or less tender- 
 ness over the mastoid region. In favorable cases this 
 subsides gradually, but in some it may increase until 
 finally the indications of disease of the mastoid bone 
 appear in the form of pain, tenderness, redness, and ex- 
 ternal swelling. The detailed description will be given 
 in the chapter on Mastoiditis. Paralysis of the facial 
 nerve is a very infrequent complication, but is sometimes 
 due to a destructive lesion in the bone. The facial palsy 
 ends in recovery after the lapse of a number of weeks, or 
 even some months. Intracranial complications are much 
 less common in acute than in chronic purulent otitis. 
 The small fatality of acute purulent otitis, probably 
 much less than 0.5 per cent., is mainly due to menin- 
 gitis. The symptoms of meningitis may exception- 
 ally, however, be simulated by the ear disease itself, 
 and disappear when the pus escapes. Cerebral ab- 
 scess is even less frequent than meningitis. Throm- 
 bosis of the lateral sinus with pyemia is likewise a 
 remote possibility, not nearly so common as in the 
 course of chronic ear disease. Yet, however unlikely 
 these complications are, they add some gravity to the 
 prognosis of any individual case. The symptoms of 
 these complications will be found in Chapter XL/V. 
 
 360. The treatment of acute purulent otitis is efficient 
 only if based on the surgical principles applicable in the 
 management of suppuration in general viz., drainage 
 and prevention of secondary infection. All other forms 
 of treatment are to be condemned as inferior. The pa- 
 tient should be put at rest during the acuteness of the 
 symptoms. After they have moderated and drainage 
 has begun, there is no further advantage in complete 
 quietude. The pain ceases mostly as soon as the dis- 
 charge can escape, though it sometimes persists for a 
 while after perforation. The pain may require palliative
 
 472 ACUTE PURULENT OTITIS MEDIA. 
 
 treatment. Its radiation and the accompanying headache 
 can usually be controlled by antipyrin. Severe earache 
 itself may necessitate morphin or opium. Hot applica- 
 tions (the hot-water bag or the Japanese stove) often give 
 some relief. The only local application which some- 
 times mitigates the pain before perforation is carbolated 
 glycerin (10 per cent, solution). In mild cases of otitis 
 permanent relief is sometimes seen after the use of this 
 fluid in the form of a prolonged ear-bath. But this is 
 true only of those instances which do not end in per- 
 foration of the drumhead. Whether the use of carbolated 
 glycerin can mitigate the disease so as to avert perfora- 
 tion is an open question. All popular ear drops, cam- 
 phorated oil, laudanum, and the like, are entirely useless 
 and delay necessary intervention. Eustachian inflation 
 may give momentary relief, but is never of any perma- 
 nent benefit. It has been severely condemned perhaps 
 unnecessarily so by many recent observers as dangerous 
 on the ground that it may carry the infected material 
 into hitherto healthy spaces. 
 
 Paracentesis should be performed at once as soon as all 
 hope must be abandoned of regarding the case as one of 
 non-perforating otitis. When severe pain has lasted with- 
 out intermission for more than about eight hours and the 
 diagnosis is apparent by the uniform redness of the drum- 
 head, it is the safest and wisest plan to puncture imme- 
 diately. The operation is free from danger, requires no 
 special skill, gives quick relief, and assures the shortest 
 possible course. It should be done with the broad 
 paracentesis needle or bistoury (Fig. 123) in the most 
 prominent part of the membrane or in the inferior 
 posterior region. When the disease is limited to "the 
 attic, as shown by the localized vascularity, Shrap- 
 nell's membrane should be divided horizontally. Too 
 large an incision is better than too small a cut. There 
 is a momentary sharp pain, which cannot be prevented 
 by anything except general narcosis, which, as a rule, is 
 superfluous. The bleeding is insignificant. Before
 
 TREATMENT. 473 
 
 the paracentesis the meatus should be cleansed of wax 
 and dust by syringing, and thereupon sterilized by 
 filling it and the concha for at least three minutes with a 
 solution of carbolic acid in water (3 per cent.) or in gly- 
 cerin (10 per cent.). After paracentesis the meatus should 
 be packed with a strip of sterile gauze about i cm. wide 
 and 10 to 15 cm. long, pushed through the (sterilized) 
 speculum gently with a flat probe. The entrance to the 
 meatus and the grooves in the auricle are then loosely 
 filled with strips of gauze until enough of a pad has been 
 formed to absorb the most copious discharge for at least 
 half a day. If necessary, this is held in place by a nar- 
 row strip of adhesive plaster across the auricle. As often 
 as the external pad of gauze gets moist it should be re- 
 placed, which the patient can do himself. The strip in 
 the meatus should be replaced only by the surgeon at in- 
 tervals of one or two days. As it is impossible to assure 
 asepsis by means of sterile gauze alone, various antiseptic 
 additions have been tried, which, however, must be non- 
 irritating. Chinolin-naphthol gauze is lauded by some. 
 The writer has been well satisfied with a powder of boric 
 acid mixed with one-sixth of salicylic acid dusted freely 
 into the meshes of the gauze. A freely absorbing gauze 
 must be selected, since the object of the dressing is to 
 remove the discharge as fast as it forms. When the fluid 
 is serous, this is easily accomplished. A change of serous 
 discharge into pus indicates inefficiency of the surgeon's 
 antiseptic precautions and means a serious prolongation 
 of the disease. When the fluid is purulent from the 
 start, the strip of gauze in the meatus must be changed 
 oftener, in order to maintain a continuous flow from the 
 middle ear to the surface of the absorbing pad. Syring- 
 ing is of no benefit whatsoever in this disease. If done 
 with ordinary water, it may even cause secondary infec- 
 tion. Syringing with sterile water or salt solution is less 
 harmful and may sometimes be called for when thick dis- 
 charge has not been properly absorbed by the dressing. 
 In the case of purulent discharge maceration of the skin
 
 474 ACUTE PURULENT OTITIS MEDIA. 
 
 of the meatus is at times annoying. The skin should be 
 cleansed by mopping with wet and subsequently with dry 
 sterile cotton and brushed with a 2 or 4 per cent, solution 
 of nitrate of silver. Anointing the wall of the meatus 
 with a thick zinc oxid ointment is also of service. The 
 regular dressing should thereupon be replaced in the 
 usual way. As the discharge diminishes, the amount of 
 gauze may be lessened and the intervals of dressing 
 lengthened. By the time the fluid has become scant, 
 its secretion usually ceases abruptly. In cases properly 
 treated according to this method from the start relapses 
 of the disease are almost unknown and complications quite 
 infrequent. When the discharge has ceased, the hearing 
 is, as a rule, still very much impaired. Spontaneous 
 recovery follows, however, in the course of weeks without 
 further treatment. After closure of the perforation Eu- 
 stachian inflation and pneumomassage are sometimes of 
 some service. 
 
 When spontaneous perforation has occurred, the mildest 
 and shortest possible course can be expected only if the 
 same mode of dressing is begun while the discharge is 
 still serous. If it has changed into pus, either from the 
 continued influence of the original germ or by secondary 
 infection after other germs have entered through the 
 meatus, a more prolonged course must be expected and 
 complications are more to be feared. As soon as the 
 patient is seen after the spontaneous perforation, the 
 meatus should be cleansed by aseptic syringing and an 
 effort may be made to combat secondary infection by a 
 prolonged ear-bath with carbolated glycerin. The pre- 
 viously described dressing should then be applied, and 
 the case managed as detailed in the preceding paragraph. 
 Any deviation from these rules will only result in a less 
 favorable course. 
 
 After spontaneous perforation and occasionally after a 
 paracentesis made too small or narrowed by a nipple of 
 granulation tissue, the acute symptoms will, in excep- 
 tional instances, persist or return until a larger puncture
 
 INFLUENZA OTITIS. 4/5 
 
 is made in the drumhead. When this treatment, properly 
 carried out, does not result in the steady subjective im- 
 provement and diminution of discharge in the course of 
 about two weeks, it is safe to assume that there is destruc- 
 tion going on within the mastoid cavity, even if there 
 are no external symptoms of mastoiditis. This arbitrary 
 period of about two weeks does not refer to the length of 
 the disease or to its original date, but only to the time 
 during which its symptoms are absolutely stationary 
 under treatment. In such cases no cure can be obtained 
 until the mastoid antrum is opened. 
 
 361. Influenza Otitis. During the extensive epi- 
 demics of influenza for some years before and after 1890 
 a peculiar form of middle-ear inflammation was often met 
 with early in the course of that disease. It was due to 
 the invasion of the tympanic cavity by the influenza 
 bacillus. It began with intense pain, often radiating in 
 the form of a diffuse neuralgia, and with much fulness 
 and often dizziness. Objectively it was characterized by 
 hemorrhages in the drumhead and presumably the tym- 
 panic mucous membrane. Spontaneous perforation of 
 the membrane did not always occur. When it did per- 
 forate or when it was tapped, the discharge was a bloody 
 serum. In spite of its apparent severity this form of 
 influenza otitis usually ended favorably in about two 
 weeks or less if not interfered with by any active treat- 
 ment. Paracentesis was generally not necessary or bene- 
 ficial. Of late years this form of disease has become 
 uncommon. It is well known that the entire clinical his- 
 tory of influenza is changing, either on account of altered 
 virulence of the bacillus or on account of partial im- 
 munity of the population. Nowadays the usual form of 
 influenza otitis is a late severe streptococcus infection of 
 the middle ear, with the ordinary clinical course of an 
 intense otitis.
 
 CHAPTER XLI. 
 MASTOIDITIS. 
 
 362. The mastoid antrum participates in all severe 
 forms of purulent inflammation of the middle ear. This 
 has been shown by autopsies, and is strongly suggested 
 as well by the copious secretion found in many forms of 
 purulent otitis, too copious indeed to be furnished by the 
 small area of the tympanic cavity. This inflammation 
 of the mastoid mucous membrane may not reveal itself 
 at all clinically, or it may be indicated by pain and ten- 
 derness over the mastoid process. This superficial inflam- 
 mation, however, limited to the mucous membrane, is 
 not the pathologic basis of what is ordinarily called 
 mastoiditis. Whenever symptoms occur which the 
 clinicist interprets as mastoiditis, they are due to an 
 extension of pyogenic inflammation into the bony sub- 
 stance of the mastoid process, complicated often, but by 
 no means always, with caries or necrosis of the bone. 
 In very rare instances an abscess is limited to some of 
 the cells underneath the antrum and does not extend into 
 the latter. 
 
 Primary mastoiditis is very rare and is probably an 
 osteomyelitis of the mastoid bone. As a rule, mastoiditis 
 is secondary to purulent otitis media. In rare instances 
 it follows that disease after an interval of many weeks 
 after apparent cure of the otitis. As a rule, it is a com- 
 plication during the continuance of an acute otitis with 
 purulent discharge, sometimes beginning suddenly with 
 a chill, more often developing gradually. In a small 
 number of instances of severe otitis, especially the strep- 
 tococcus variety, mastoiditis pursues an insidious course, 
 with gradual abatement of its acute symptoms, continu- 
 ing in a chronic, but none the less dangerous, form. 
 
 476
 
 SYMPTOMS COURSE. 477 
 
 This almost latent form sometimes changes into a more 
 acute disease. Mastoiditis is apt to be very destructive 
 in diabetic patients. 
 
 Clinically manifest mastoiditis complicates but a small 
 percentage of cases of acute otitis probably considerably 
 under 5 per cent. It is not quite so frequent in children 
 as in young adults. It is noticeably infrequent among 
 negroes. The direct cause is not clear. It is not usually 
 due to occlusion of the aditus, for this is quite commonly 
 found patent during operation. A large antrum seems 
 of predisposing influence. The germs found in the pus 
 are the same as those in acute otitis (^ 356). 
 
 363. Mastoiditis rarely begins with a chill and a rise 
 of temperature during the subsiding fever of otitis. As 
 a rule, it simply prolongs the otitic fever in an atypical 
 manner. Quite often it causes no rise of temperature. 
 The characteristic symptoms are pain over the mastoid 
 region and tenderness. The former, variable in degree, 
 is rarely absent, but may subside while the destructive 
 process continues in the mastoid. The tenderness is 
 more constant. One-sided headache is rarely absent. 
 As the inflammatory process extends through the bone 
 toward its surface, edematous swelling and, later on, 
 congestion and inflammatory edema of the soft parts 
 behind the ear become pronounced. Of great signifi- 
 cance, too, is the steady continuance of the discharge 
 from the ear, without diminution, even if the other 
 symptoms should be less marked or receding. An in- 
 fallible, but not constant, sign is the bulging of the 
 posterior upper wall of the meatus, sometimes with 
 marked redness. 
 
 In its course mastoiditis may present the following 
 possibilities: 
 
 1. It may end in recovery without perforation of the 
 bone. 
 
 2. It may lead to a subperiosteal abscess. 
 
 3. It may perforate through the bone (a) on the ex- 
 ternal surface ; (fr) on the anterior surface (posterior wall
 
 4/8 MASTOID1TIS. 
 
 of the meatus) ; (r) on the internal surface of the tip, or 
 (d) the inflammation may extend through the bone to 
 the cranial contents. 
 
 4. It may become chronic. 
 
 364. Recovery without perforation is probably the 
 most common termination in all those instances of 
 mastoiditis in which there is no destruction of bone. 
 This fortunate turn becomes less and less probable when 
 pain and tenderness have continued about a week. It 
 may be excluded after pronounced inflammatory edema 
 of the soft parts has lasted for more than a day or two. 
 Edema without congestion does not preclude it. Distinct 
 bulging of the posterior upper wall of the meatus is a 
 sure sign that such recovery is impossible. 
 
 365. A subperiosteal abscess as a sequel of mastoiditis 
 is sometimes seen in children ; less often in adolescence. 
 The pyogenic infection extends outward from the antrum 
 through the squamomastoid fissure, which closes later in 
 life, or perhaps through vascular channels. The abscess 
 does not communicate with the mastoid antrum. As a 
 rule, the symptoms of mastoiditis are very mild in such 
 cases. The primary otitis may even have ceased when a 
 subperiosteal inflammatory swelling appears over the 
 mastoid process, generally some distance behind the ear. 
 When this is properly opened, it heals kindly. In cor- 
 rectly diagnosticated cases the opening of the mastoid 
 bone is entirely uncalled for. It is, however, sometimes 
 impossible to distinguish between these comparatively 
 innocent abscesses and the more serious spontaneous 
 perforation through the bone. When distinct and pro- 
 tracted symptoms of mastoiditis have preceded the 
 accumulation of pus under the soft tissues, it is well to 
 make the incision large enough to search for a fistula in 
 the bone. In early childhood and in those instances in 
 which an early perforation indicates a thin bony wall of 
 the antrum the patient may do quite well after a simple 
 incision down to, but not into, the bone. But in older 
 patients and in the case of narrow long fistulse the heal-
 
 PERFORATION IN MASTOID1TIS. 479 
 
 ing is more protracted and the course not so free from 
 danger as after a proper opening into the bone. 
 
 366. Impending perforation is indicated by inflamma- 
 tory swelling of the soft parts behind the ear. They 
 may be thickened to three or four times the normal 
 extent. The ear may stand out nearly at a right angle 
 to its normal plane. By carious corrosion of the bony 
 wall the pus finds its way from the antrum to the 
 exterior of the bone, raises the periosteum, and after the 
 lapse of a good many days breaks through the skin. 
 There is in such cases at least a carious fistula leading 
 into the antrum. There may be necrosis of a small or 
 large area of the external plate, or there may even be a 
 sequestrum in the antrum. The latter is usually filled 
 with spongy granulations which bleed freely on touch. 
 The pus found in the cavity is thick and creamy. It 
 may be scant, but more often a large or morbidly en- 
 larged antrum contains it in abundance. In severe 
 instances the destructive inflammation extends through- 
 out all the pneumatic spaces of the entire bone. In rare 
 cases the antrum itself is not involved, the disease being 
 limited to some cells in the mastoid process below the 
 antrum. When perforation has taken place through a 
 narrow fistula without free drainage, the dangers of 
 mastoiditis are merely lessened, but not removed. 
 
 Perforation through the anterior wall into the meatus 
 does not take place often, even where bulging of the 
 wall of the meatus shows the action of pent-up pus. 
 When an opening occurs through the anterior boundary 
 of the mastoid antrum, the pus is more. apt to burrow 
 underneath the cartilaginous meatus to the exterior than 
 to appear in the meatus itself. 
 
 In the case of a markedly pneumatic mastoid process 
 the inflammation may extend throughout all the cells to 
 the tip, and if the inferior inner wall is thin, perforation 
 can occur here underneath the sternomastoid and scale- 
 nus muscles. This relatively infrequent occurrence is 
 known as Bezold's perforation. The pus burrows under-
 
 480 MASTOIDIT1S. 
 
 neath the muscles and cervical fascia, forming a deep 
 abscess. If this does not open spontaneously or is re- 
 lieved by the knife, it may extend into the anterior or 
 posterior mediastinal space, with fatal result. With deep 
 incision and good drainage the prognosis is otherwise not 
 bad, provided the mastoid process be well opened. 
 
 367. The greatest danger of mastoiditis is the exten- 
 sion of pyogenic infection upward. This may occur 
 even after spontaneous perforation outward if the pus 
 does not find free exit. Sometimes a carious spot is 
 formed in the roof of the antrum. In other cases the 
 inflammation extends through the thin or even normally 
 defective plate of bone, separating the antrum from the 
 posterior cranial fossa. The possible consequences are 
 phlebitis with bland or purulent thrombosis of the lateral 
 sinus, serous or purulent meningitis, subdural (epidural) 
 abscess, or intracerebral abscess. The description of 
 these diseases will be found in Chapter XL/V. In chil- 
 dren the thicker antral roof makes the upward extension 
 much less common than in adults. 
 
 368. In a small number of instances the acute symp- 
 toms of a mastoiditis subside wholly or in part without 
 recovery, and the inflammation continues in a chronic 
 form. There may or may not be some pain left. The 
 tenderness, however, disappears. The only symptom is 
 the persistence of the discharge from the ear, which resists 
 all forms of treatment except opening of the mastoid 
 process. This chronic condition may continue indefi- 
 nitely as a form of chronic purulent otitis, but is apt to 
 exacerbate at times in a subacute form. In these cases 
 the mastoid process is often found sclerotic, probably in 
 consequence of the long-continued inflammation. 
 
 369. The treatment should be, in the first place, pre- 
 ventive. The liability to mastoiditis is least when a 
 purulent otitis receives proper attention and drainage 
 from the start. In my own experience clinically mani- 
 fest mastoiditis has never occurred as long as the dis- 
 charge from the middle ear remained serous. But it
 
 TREATMENT. 48 1 
 
 is not correct to state that mastoiditis can always be 
 prevented, for in some instances, especially of strepto- 
 coccus otitis, the discharge is purulent when first seen. 
 At the onset of the disease rest and free action of the 
 bowels are desirable. Some authors recommend cold 
 applications; others insist on heat. In all probability 
 neither application has any influence upon the disease, 
 but heat is often subjectively agreeable. It may be ap- 
 plied in the form of a hot-water bag or the Japanese 
 stove. The latter, a small tin box heated with charcoal 
 cartridges and sold in Chinese stores, is a very pleasant 
 way of making warm applications lasting about two 
 hours. The value of any counterirritants applied to the 
 skin is less than problematic. Subperiosteal abscesses 
 are to be opened by a deep and sufficiently long incision 
 through the bulging area. This may be done even with- 
 out narcosis or after freezing with ethyl chlorid. This 
 cut, known as Wilde's incision, is all that is required, 
 provided the wound be properly kept open. Wilde's 
 incision is, however, not the proper treatment for a col- 
 lection of pus due to perforation of the bone. It may 
 answer in a child, but where a narrow long fistula ex- 
 ists, the latter should be enlarged by gouging. Wilde's 
 incision has also been recommended as an abortive 
 measure when the first external signs of mastoiditis 
 appear. On account of the uncertain prognosis of the 
 disease at that time it is difficult to estimate the efficacy 
 of this procedure. If it is done for this purpose, it should 
 be made close to the auricle, so that it can be utilized for 
 a subsequent bone operation if required. In such a case 
 it is absolutely necessary to keep the wound aseptic. 
 
 Whenever the pain and tenderness of mastoiditis have 
 lasted without cessation over a week; whenever inflam- 
 matory swelling of the soft parts has persisted for more 
 than two days, or when, under proper treatment, the dis- 
 charge of acute purulent otitis has not diminished for 
 about ten days with more or less vague manifestations of 
 mastoiditis, recovery without artificial opening of the 
 
 31
 
 482 
 
 MASTOIDITIS. 
 
 bone cannot be expected. It requires good judgment to 
 guard, on the one hand, against an unnecessary opera- 
 tion, with some, though a small, fatality, and, on the 
 other hand, not to defer surgical interference, which may 
 save the life. When the symptoms of mastoiditis in- 
 crease steadily for two or three days, or when any 
 urgent signs of cerebral irritation have made their ap- 
 pearance, an operation should be done at once. 
 
 370. The opening into the mastoid, usiially known as 
 Schwartze's chisel operation, is intended to reach the 
 
 Li 
 
 FIG. 132. Chisels for opening the mastoid. 
 
 antrum by the shortest possible route. It consists in 
 cutting a passage through the bone more or less parallel 
 to the posterior wall of the meatus, and much nearer to 
 the superior than to the inferior wall. Experience has 
 shown that the safest tool is the chisel, of which the 
 wider ones (10 to 12 mm.) are used externally, while in 
 the depth the narrowest ones (3 to 5 mm.) are employed 
 (Fig. 132). The mallet is filled with lead. The hole in 
 the bone is made funnel-shaped, but the wider this fun- 
 nel is made externally, and hence the shallower its depth, 
 the less the danger of accidental injuries. The hole in
 
 MASTOID OPERATION. 483 
 
 the bone should begin with a width of about 1.5 to 2 cm., 
 but this aperture may be widened if it is necessary to 
 enter very deeply. The external opening should be im- 
 mediately behind, and its center 2 or 3 mm. below the 
 level of the upper wall of the meatus. The upper border 
 must be below the linea temporalis. The anatomic 
 anomalies to be feared are protrusion of the sigmoid fossa 
 (lateral sinus) toward the antrum or low level of the mid- 
 dle cerebral fossa. The lateral sinus, generally a trifle 
 lower on the right than on the left side, is usually fully 
 i cm. behind and slightly above the posterior upper wall 
 of the meatus. The more pneumatic the bone structure, 
 the greater the probability of a normal distance between 
 meatus and sinus; the more compact the bone, the more 
 likely is a dangerous proximity of the sinus to the meatus 
 (see Figs. 87, 89, 104 to 107). In extreme cases there 
 may only be a distance of 5 mm. or even a trifle less 
 separating the two. The exposed sinus, if normal, ap- 
 pears as a bluish-gray vessel, the walls of which can be 
 easily indented by the probe. The danger of wounding 
 the lateral sinus is least if the chisel is only directed 
 downward and (alternatingly) forward after the first few 
 external strokes. The shallowness of the wound is 
 favored by resecting the external portion of the posterior 
 wall of the bony meatus by chiseling in a forward direc- 
 tion. It should be the aim to enter the antrum at its 
 lowest level. As soon as the antrum is exposed, any in- 
 tervening spongy bony substance can be more safely 
 scooped out with a curet. But if the apex of the conic 
 hole is lower than the center of the meatus, the antrum 
 will generally be missed. In young children the first 
 few strokes of the chisel suffice to break down the thin 
 external wall. In adults 12 to 15 mm. is the average 
 depth of the requisite hole in the bone as measured from 
 the spina siipra meatum, a short spur at the upper poste- 
 rior angle of the entrance of the exposed bony meatus, a 
 landmark present in about three- fourths of all subjects. 
 Measured from the external surface of the mastoid bone
 
 4 8 4 
 
 MASTOID1TIS. 
 
 itself, the distance is more variable. As soon as this 
 distance is exceeded, the utmost caution is required in 
 order not to wound the facial nerve or the external semi- 
 circular canal. When the antrum is not reached at this 
 depth, careful measurements should be made of the depth 
 of the meatus up to the membrana tympani, and if at 
 
 FIG. 133. Operative exposure of the mastoid antrum in a moderately pneu- 
 matic process. Appearance after completed operation and before closure of the 
 wound. 
 
 the corresponding distance from the surface of the mas- 
 toid the antral cavity is not found, the operation should 
 be abandoned. It is a singular and not yet explained 
 fact that a number of cases with urgent symptoms have 
 done well after such incomplete operations in which the 
 diseased cavity was not reached (Fig. 133).
 
 MASTOID OPERATION. 485 
 
 The bleeding on cutting the soft parts varies with their 
 congestion, as also does the bleeding from the bone. 
 When the antrum is filled with granulations, these bleed 
 very profusely until thoroughly scooped out. When the 
 sinus is accidentally wounded, a big gush of venous 
 hemorrhage occurs, which can be controlled by pres- 
 sure with gauze. This accident has usually proved 
 harmless in the end, but it may necessitate tempo- 
 rary abandoning of the operation until a firm clot has 
 formed after a few days. Very few deaths have ever oc- 
 curred from the entrance of air into the opened sinus. 
 Should the cerebral plate be damaged and the dura ex- 
 posed, no evil consequences result, as a rule, if the opera- 
 tion is done aseptically and all sharp spiculse 'of bone 
 are carefully removed. As in all major operations, all 
 details regarding asepsis of instruments, the hands of the 
 surgeon, and of the field of operation should be rigidly 
 carried out. The hair should be shaved far beyond the 
 wound, and the head inclosed in sterile towels or a rub- 
 ber cap. The instruments required are scalpels, scissors, 
 several forceps, needles, and ligature threads, two retrac- 
 tors, a periosteum elevator, a set of chisels, a hammer, 
 two sizes of sharp curets, and a few artery forceps. The 
 several steps may be summarized as follows: 
 
 General anesthesia; incision down to the bone, i cm. be- 
 hind and parallel to the auricle, from its tip to the end of 
 the mastoid process. If this is insufficient, a short poste- 
 rior transverse cut is made above the middle of the wound. 
 Arrest of bleeding by compression, artery forceps, torsion, 
 and occasionally a ligature. Blunt detachment of the 
 periosteum, both forward and backward. Chiseling of 
 the bone with successively smaller chisels, at first from 
 the entire periphery toward the center of the wound, but 
 subsequently only in the forward and downward direction, 
 and merely upward from the lower edge with care. The 
 chiseling should extend through the posterior wall of the 
 meatus, at least in the external half. If a carious fistula 
 shows the way, this path should be followed by goug-
 
 486 MASTOID1TIS. 
 
 ing. As soon as the antrum is reached, the granula- 
 tions usually present are scraped out with the curet, and 
 the bony channel is smoothened with the same tool. 
 The purulent infiltration must be followed as far as it 
 extends. In some instances it is necessary to gouge out 
 the contents of the entire mastoid process through the 
 pneumatic cells to the tip. It is best to remove any 
 overhanging thin cortical shell of bone. The bleeding 
 stops soon after emptying the antrum. In recent cases 
 syringing is uncalled for. When there is retained and 
 foul pus, it is better to irrigate with sterile salt solution. 
 There may be or may not be at the time communication 
 between the antrum and the tympanic cavity, with escape 
 of the fluid through the meatus. Packing of the wound 
 in the bone with iodoform gauze. Suture of the soft parts 
 above and sometimes below the drain. A large gauze 
 pad is put over the wound. Meanwhile the ear has been 
 rilled with a fresh sterile gauze drain, whereupon the 
 dressing is completed. 
 
 When a carious spot is found leading into some cells 
 below the antrum, and on scooping them out nothing 
 points to involvement of the antrum itself, the operation 
 may be finished at this point, provided the clinical signs 
 did not clearly indicate empyema of the antrum. 
 
 37 1 - The first dressing may be left as long as five days 
 if neither pain, rise of temperature, nor excessive dis- 
 charge calls for its removal. The subsequent dressings 
 should also be changed only at the longest intervals 
 proper. The patient is kept in bed for a few days until 
 comfortable. When afebrile from the start, the operation 
 should cause either no rise of temperature or only a tran- 
 sient mild aseptic fever. After a properly done operation 
 the discharge from the ear ceases very speedily. The 
 discharge from the wound rarely disappears in less than 
 two to three weeks, and sometimes as much as six or 
 eight weeks are required, if the wound is not wide enough 
 externally. It is often difficult to keep the wound open, 
 and the gauze drain should not be dispensed with until
 
 MASTOID OPERATION. 487 
 
 the wound is dry. When the discharge remains offensive, 
 which is very rare, it is better to depend on accurate tam- 
 poning than on syringing. Attempts have been made to 
 close the wound by a complete suture and to let it heal 
 under a blood-scab. Although this may often be success- 
 ful in the hands of a thoroughly competent surgeon, it in- 
 volves considerable risk. It is proper, however, in the 
 case of an incomplete operation in which the antrum is 
 not reached. When the diminished discharge does not re- 
 quire a voluminous dressing, a serviceable form of band- 
 
 FIG. 134. Author's bandage for mastoid operations after the discharge has 
 become less profuse. 
 
 age is the one shown in Fig. 134, which is kept from 
 becoming distorted by the insertion of whalebone at its 
 two edges, while the bands of tape prevent it from slip- 
 ping. 
 
 The mortality of mastoid operations is below 8 per cent, 
 in recent years ; in some published series of cases even 
 very far below this figure or nearly zero. The majority 
 of deaths are due to the extension of neglected disease, 
 and only a small proportion of the accidents can be as- 
 cribed to the operation. The mortality of mastoiditis 
 without operation is not known, but must be very high.
 
 CHAPTER XLII. 
 
 CHRONIC PURULENT OTITIS MEDIA. 
 
 372. Chronic suppuration of the middle ear is the se- 
 quel of acute inflammation. When the acute symptoms 
 the pain and the feeling of stuffiness have subsided, 
 and when the amount of discharge has become about 
 uniform for a number of weeks, the disease can be called 
 chronic and no spontaneous change in the condition can 
 then be expected except in the course of long periods of 
 time. The main symptom is the discharge. This is 
 rarely profuse, generally scant, and sometimes so minimal 
 that it dries in the form of crusts which the patient mis- 
 takes for wax. It is always purulent, but when copious, 
 it is apt to be mucopurulent. With rare exceptions the 
 discharge is offensive in smell characteristically fetid. 
 The rare exceptions are, on the one hand, occasional in- 
 stances of copious thin mucopurulent fluid ; on the other 
 hand, a very scant discharge which dries in the form of 
 minute crusts. The odor of the discharge should always 
 be noted by mopping the meatus with a small pledget 
 of cotton, as its persistence or yielding under treatment 
 indicates the type of the disease and determines the prog- 
 nosis. When the discharge is so scant that it cannot be 
 seen in the meatus, it should be looked for by mopping 
 with cotton. Even if this test fails, suppurative otitis 
 should not be excluded in suspected cases until the search 
 for small flakes of pus is negative in the water with 
 which the ear has been syringed. 
 
 The impairment of the hearing is very variable and 
 depends principally on the destructiveness of the inflam- 
 mation during the acute period. The deafness may be so 
 slight that the patient is not aware of it. On the other 
 
 488
 
 CHRONIC PURULENT OTITIS MEDIA. 489 
 
 hand, the ear may be deaf for all practical purposes. 
 The deafness does not depend so much on the perforation 
 of the membrana tympani as on the adhesions in the 
 attic, or between membrana tympani or ossicles and the 
 internal tympanic wall. Noises and stuffiness are rarely 
 mentioned. Dizziness is not common, but when present 
 indicates active disease, usually in the attic (or, in severe 
 instances, caries of the labyrinth). 
 
 373. Chronic purulent otitis may remain absolutely 
 stationary, or may spontaneously heal temporarily or 
 permanently or may present transient subacute exacerba- 
 tions. 
 
 In the course of time and under favorable environment 
 an otitis which has remained chronic for a long period 
 may finally heal without intervention. But this is not 
 common. The vicious advice so often given by physi- 
 cians of a former period to let an otorrhea alone was not 
 founded on correct observations. When a chronic puru- 
 lent otitis has healed, either spontaneously or in conse- 
 quence of treatment, relapses may be expected under cer- 
 tain conditions. These are mainly the persistence of naso- 
 pharyngeal lesions which caused the disease in the first 
 place, especially adenoid vegetations, and less frequently 
 the purulent rhinitis of children. Occasional instances 
 are observed in which a discharge from the ear is started 
 with every severe cold, subsiding afterward even without 
 aid. Independently of nasopharyngeal lesions relapses 
 occur, besides, in a noticeable proportion of patients 
 apparently cured of ear suppuration complicated with 
 cholesteatoma or caries of bone. Whenever a purulent 
 otitis has healed, leaving a permanent perforation of the 
 drumhead, a subsequent attack of purulent infection of 
 that ear begins always in a mild subacute manner and 
 rarely with any intense acute symptoms. 
 
 The most serious cases of chronic purulent otitis are 
 those occasionally subject to subacute exacerbations. 
 These are mainly the class which I shall describe as 
 the type of purulent otitis with retention of pus. The
 
 CHRONIC PURULENT OTITIS MEDIA. 
 
 aggravations vary very much in severity and danger. 
 On the whole, however, their danger to life is much 
 greater than that of primary acute inflammations of a 
 hitherto normal ear. The majority of instances of pye- 
 inia and of intracerebral complications due to otitis occur 
 in the course of subacute exacerbations of the chronic 
 disease. Various estimates have shown that about ^ to 
 YZ per cent, of all deaths are due to ear disease, mainly 
 in the chronic form (in European statistics). These sta- 
 tistics, however, are not absolutely trustworthy. It is 
 worth noting that many life-insurance companies refuse 
 applicants with chronic purulent otitis. 
 
 374. The liability of an acute suppurative otitis to 
 become chronic depends on the severity of the infection 
 and on the age of the patient. In very young children 
 it is only the severe otitis of scarlet fever or diphtheria 
 which is likely to become chronic, or perhaps a fre- 
 quently recurrent inflammation due to adenoids. In 
 adults, on the other hand, the healing of an otitis with- 
 out medical aid occurs only in the mildest forms of in- 
 flammation. The direct cause of chronicity is mainly 
 the stagnation of pus with secondary infection from the 
 meatus. In the discharge of the chronic disease the 
 original parasites are not necessarily present. The pneu- 
 mococcus has, as a rule, disappeared, and has been re- 
 placed by streptococci and staphylococci. The fetid 
 odor is due to the coexistence of putrefactive bacilli. 
 The change of an acute otitis into the chronic form indi- 
 cates inefficient treatment. I am pleased to have noted 
 the gradual diminution in the proportion of chronic puru- 
 lent otitis presenting itself for treatment in the course of 
 my practice, undoubtedly due to the better training of 
 physicians in otology. It must be admitted, however, 
 that some cases cannot be prevented from becoming 
 chronic, except by opening the mastoid. 
 
 375. Instead of an unsystematized description of the 
 appearances and lesions in chronic purulent otitis the 
 author prefers to classify the disease under several heads,
 
 TYPES OF CHRONIC PURULENT OTITIS. 
 
 4 9 I 
 
 with details regarding pathology and treatment sub- 
 divided correspondingly. 
 
 We can distinguish clinically between 
 
 A. Simple chronic purulent otitis; 
 
 B. Purulent otitis with retention of pus (with or 
 
 without complications). 
 
 In the first type of the disease the suppurating areas are 
 accessible, and the fetor of the discharge is readily re- 
 moved by cleanliness. In the second type there is reten- 
 tion of pus coming from inaccessible spaces, and the sec- 
 ondary infection which has caused the odor cannot be 
 controlled by syringing. The distinction is based on 
 pathologic grounds, but it can in some instances be rec- 
 ognized only by the therapeutic test. In describing chronic 
 purulent otitis we must furthermore take into account the 
 absence or the presence of complications viz., polypi, 
 bone disease, and cholesteatoma. 
 
 376. In simple uncomplicated chronic suppurative otitis 
 the perforation of the drumhead seen after cleansing is 
 usually of moderate size, sometimes round, sometimes 
 
 FIG. 135. Large kidney-shaped 
 perforation in membrana tympani in 
 chronic purulent otitis ; drumhead 
 thickened, cloudy, and retracted ; 
 manubrium only partly visible; tym- 
 panic mucous membrane congested. 
 
 FIG. 136. Perforation in lower 
 part of membrana tympani in chronic 
 purulent otitis ; membrana tympani 
 is thickened and opaque ; the mu- 
 cous membrane of the inner tym- 
 panic wall appears dark red through 
 the perforation. 
 
 oval, sometimes bean-shaped, and anywhere in the 
 membrana proper (Figs. 135 and 136 compare Figs. 
 10 and n, Plate II.). It is not common to see the 
 small, pin-hole-shaped perforations found early during 
 acute suppuration. On the other hand, the total drum-
 
 492 CHRONIC PURULENT OTITIS. 
 
 head and even the ossicles may have been destroyed by 
 the primary disease. Perforations in Shrapnell's mem- 
 brane usually indicate the type of otitis with retention. 
 The perforation is a stationary condition, not changing 
 in spite of the persistence of suppuration. Through the 
 hole the tympanic mucous membrane is visible, being 
 usually reddened while the discharge lasts. 
 
 In default of postmortem information we must assume 
 the lesion in this type of disease to be a superficial in- 
 flammation of the tympanic lining membrane. The 
 thickening of the mucous membrane sometimes seen 
 through large perforations can only be due to inflam- 
 matory infiltration. No other lesions could disappear 
 as rapidly under treatment. 
 
 377. Both as a diagnostic test and as a therapeutic meas- 
 ure the ear should be syringed very thoroughly at the first 
 examination. Accidental observations have shown me 
 that syringing alone can cure some instances. The 
 water should be pure and uncontaminated. Sterility, 
 while theoretically desirable, does not seem to be of 
 practical importance. There is no object in adding anti- 
 septics to the water. The time of their action is too 
 short for efficiency. In case of strong fetor it is practi- 
 cal, however, to add some deodorizing substance like 
 permanganate of potassium (i : 1000) or formalin (i : 300), 
 in order to prevent the stench from clinging to the basin 
 and utensils. Peroxid of hydrogen, a fluid often recom- 
 mended, possesses no advantage over any other deodor- 
 izer. Its alleged power to dislodge pus by the bub- 
 bles of liberated oxygen is a myth. After syringing, 
 boric acid powder is blown in in a thin layer with 
 an insufflator (Fig. 21). The effect of this treatment 
 is complete removal or considerable diminution of 
 the odor within the next twenty-four hours. If two, 
 or, at the most, three repetitions of this treatment at 
 intervals of twenty-four hours do not remove the odor 
 absolutely, the case is not one of simple suppuration 
 without retention, and the further continuance of this
 
 TREATMENT. 493 
 
 form of treatment is totally useless. In rare cases a 
 single thorough application stops the discharge per- 
 manently. More commonly from one to two and a half 
 weeks are required for a complete cure. The discharge 
 gets less copious and thinner gradually. If the treat- 
 ment ceases while there is slight discharge left, a relapse 
 is very probable. If the intervals between treatments 
 have been too long, the time required for a cure is un- 
 necessarily extended. There should be some powder 
 from the previous application found in the meatus at 
 each dressing. Numerous indorsements of substitutes 
 for boric acid have generally been due to poor observa- 
 tion or poor reasoning. In those instances where there 
 is no retention of pus the healing under boric acid is as 
 rapid as the nature of the lesions permits. Boric acid 
 is said to cause eczema of the meatus in rare instances. 
 This I have never seen. There are some cases, however, 
 in which it starts a profuse watery discharge, and these 
 patients progress more rapidly when nothing is put in 
 the meatus after syringing except a sufficiently large 
 gauze drain. In exceptional instances a tedious muco- 
 purulent but not fetid discharge persists long in spite of 
 treatment probably coming from the Eustachian tube. 
 The most efficient measure I have found in such cases 
 to be the instillation of tannin dissolved in glycerin (i : 4). 
 
 378. After the cure of otitic suppuration the hearing 
 improves, as a rule, but the degree of improvement 
 cannot be predicted. The hearing can be noticeably 
 augmented in some patients and by the so-called artifi- 
 cial ear-drum. This acts simply as a support for the 
 hammer, and is of use only in some instances with 
 moderate-sized or large perforation. A pellet of cotton 
 or a strip of gauze fulfills the same purpose. When the 
 ear has become permanently dry, the Toynbee artificial 
 drum of rubber, mounted on a wire, can be used by the 
 patient on trial (Fig. 138). But, after all, the artificial 
 drum is less often useful than the public believes. 
 
 The perforation itself persists after the suppuration
 
 494 
 
 CHRONIC PURULENT OTITIS. 
 
 has ceased. An effort may now be made to close the 
 hole, according to the method of Okuneff. The edges 
 of the hole are touched gently with trichloracetic acid, 
 by saturating a thin coating of cotton around a probe 
 with the deliquesced acid. There is usually very slight 
 
 FIG. 137. Cicatrix in the puckered and thickened membrana tympani after 
 the closure of a perforation due to a severe purulent otitis. The cicatrix appears 
 dark while sunken in ; on inflation it becomes more prominent and brighter. 
 
 reaction ; sometimes, however, a trifling suppuration. 
 After all reaction has ceased, another application may be 
 made if the hole has not closed entirely. The perfora- 
 tion should not be closed if there is any reason to fear 
 relapses. 
 
 379- Chronic suppurative otitis with retention of PUS 
 
 m 
 
 FIG. 138. Toynbee's artificial 
 drum membrane, consisting of a 
 round sheet of soft rubber with a 
 wire handle. 
 
 FIG. 139. Perforation in Shrap- 
 nell's membrane in chronic suppura- 
 tion of the attic. The rest of the 
 membrane is slightly cloudy. 
 
 may present the same appearances as the simple type of the 
 disease and can then be distinguished only by the failure 
 of the therapeutic test. Generally, however, the appear- 
 ances are different and indicate involvement of the attic. 
 There are cases in which the membrana proper is intact,
 
 PURULENT OTIT1S WITH RETENTION OF PUS. 
 
 495 
 
 and where there is only a small perforation in Shrapnel!' s 
 membrane. In others Shrapnel 1's membrane is largely 
 destroyed and there may even be a fissure or gap in 
 the bone around Rivini's incisure, so that the attic 
 is partly exposed to view (Figs. 139, 140 compare also 
 Figs. 9 and 12, Plate II.). Again, the upper part of 
 the membrane may be intact, but there is a large hole 
 or even total deficiency of the entire lower part, with 
 absence of the handle of the malleus or oblique displace- 
 ment of its stump (Fig. 141). Less commonly there are 
 two perforations, one of them leading into the attic. 
 
 FIG. 140. Chronic suppuration 
 from the attic with cholesteatoma ; 
 destruction of Shrapnell's membrane 
 and of the superior wall of the mea- 
 tus (anterior wall of the attic), form- 
 ing a fissure into the attic in 
 which a cholesteatomatous globule is 
 lodged. The membrana tympani 
 proper is nearly normal and only 
 slightly opaque. 
 
 FIG. 141. Chronic purulent otitis 
 with granulations on the internal 
 tympanic wall. Only a small (upper) 
 rim of the drumhead is still present. 
 The handle of the hammer is partly 
 destroyed, and the remaining stump 
 is adherent to the inner wall of the 
 tympanic cavity. 
 
 The criterion, however, is not so much the appearances 
 as the inability to deodorize the discharge. When two, 
 or, at the most, three thorough efforts at syringing, 
 followed by boric acid insufflation, have failed to re- 
 move the odor, incomplete drainage of the pus must be 
 assumed, even though the discharge may have been 
 somewhat lessened by the treatment. The continuance 
 of this treatment will then prove useless. In these cases 
 pus is formed in some inaccessible pocket or recess in the 
 attic, and in quite a number of instances there is also 
 suppuration from the mastoid antrum. There may or
 
 CHRONIC PURULENT OTITIS MEDIA. 
 
 may not be complications in the way of caries of the 
 osseous walls or of the ossicles. 
 
 380. In order to dislodge the pus from its source intra- 
 tympanic syringing should be attempted by means of a 
 fine cannula introduced into the tympanic cavity. The 
 Hartmann cannula of hard rubber found in the shops is 
 too thick. The author uses a thin metallic tube closed 
 at the end with a lateral eye (Fig. 142). The stream is 
 directed at haphazard toward the attic and toward the 
 mastoid aditus. The tip of the tube follows any pre- 
 existing fistulous passage. It requires a steady hand if 
 the tube is attached to a piston syringe, and some pain is 
 inevitable. It may, however, be attached by means of a 
 
 FIG. 142. Blake's syringe for the middle ear. 
 
 flexible tube to a. syringe which an assistant manipulates. 
 Sometimes the immediate success of .this mode of syring- 
 ing is assured by the appearance of lumps of inspissated 
 pus of foul odor. Another mode of intratympanic syr- 
 inging recommended by German surgeons (Schwartze) is 
 through the Eustachian tube by means of the catheter. 
 This is difficult and not always feasible. It is easy, how- 
 ever, in the case of double-sided disease to force salt 
 solution through the Eustachian tubes by means of a 
 Politzer bag filled with the fluid. During swallowing 
 efforts a lively stream of water comes from the ears. I 
 have not found this mode of syringing efficient as often 
 as by means of the intratympanic cannula.
 
 PERSISTENT ODOR OF DISCHARGE. 497. 
 
 When these measures fail to deodorize, success can 
 sometimes be obtained by rilling the ears with a fluid of 
 less surface tension than water. A mixture of alcohol 
 and ether may penetrate into crevices inaccessible to the 
 syringe. It is especially when this alcoholic instillation 
 is followed by an ear bath with carbolated glycerin that 
 an occasional success is obtained in deodorizing the dis- 
 charge. As soon as the odor has been removed, the case 
 may then be regarded as one of the simple type, without 
 retention, and will, as a rule, heal under the previously 
 described treatment. The healing, however, is apt to 
 require more time. 
 
 When all these attempts have failed to remove the 
 fetor, the author can recommend one other measure 
 previous to surgical intervention. This is the drainage 
 of the secretion by capillary absorption through a gauze 
 drain. The meatus is packed with a sterile strip of 
 gauze placed in contact with the drumhead, or even the 
 tympanic lining, and replaced by another before it has 
 become completely soaked by the discharge. This 
 method introduced in the treatment of chronic purulent 
 otitis by N. Pierce proves successful in the end in a 
 number of instances which would otherwise be incurable 
 except by a radical operation. The action of the gauze 
 drain is peculiar. The discharge is often increased 
 slightly at first. It then diminishes gradually without 
 losing its offensive odor until the gauze remains dry. 
 This may take from two to four weeks, or longer if the 
 treatment has not been carried out properly. If a relapse 
 occurs after the odor has once disappeared, the pus is 
 odorless. The various measures may all be combined in 
 the interest of the patient. There is no objection to- 
 beginning with gauze drainage at the first treatment. 
 Every effort possible, however, should be made to dis- 
 lodge pent-up pus from the beginning. For as soon as 
 deodorization of the discharge shows success, precious 
 time has been gained, while if this has failed, the gauze 
 drain has in the meantime begun its influence. Even 
 
 32
 
 498 CHRONIC PURULENT OTITIS MEDIA. 
 
 after the stagnation of pus has been obviated these cases 
 may prove very slow in healing. But, on the other 
 hand, it is no great hardship to a patient to come once in 
 four or six days for a fresh packing, even though some 
 months be required. When the gauze is left in the 
 meatus for many days it should be kept aseptic by 
 powdering it freely with a mixture of boric and salicylic 
 acids. The longer the time required for the cure of the 
 suppuration, the greater the probability of a relapse at 
 some future time. But even by means of a radical 
 operation we cannot give these patients absolute exemp- 
 tion from relapses, and in the meantime we can at least 
 assure them that they are free from danger as long as the 
 ear stays dry, and practically so if they submit to treat- 
 ment at once in case of relapse. 
 
 381. When it proves impossible to remove the odor, or 
 even when the odorless discharge does not yield, which 
 is very exceptional, we must decide whether (a) to 
 desist and wait, (ft) remove the ossicles, (c) open the 
 antrum, or (d] perform a radical operation. To desist 
 from further treatment means to keep the patient in 
 constant jeopardy as long as the fetor shows stagnation 
 of pus. If, however, efficient drainage is proven by the 
 absence of odor, the danger of waiting indefinitely while 
 packing the ear aseptically is probably no greater than 
 that of any operation. With aseptic packing such cases 
 will generally heal in the end. 
 
 The removal of the ossicles (see 1 346) cures those 
 instances in which pus stagnates in the pockets and 
 recesses of the attic, and especially those in which the 
 ossicles themselves are carious (1 385). A small perfora- 
 tion in Shrapnell's membrane is strongly suggestive, 
 though not proof positive, of caries of the anvil or 
 hammer or both. A larger destruction of the flaccid 
 membrane, especially if it extends to the periphery, 
 points to caries of the walls of the attic. We cannot 
 foretell, however, in any such case whether the mastoid 
 antrum is involved or not, and hence ossiculectomy,
 
 RADICAL OPERATION. 499 
 
 while usually beneficial, is not always curative. When 
 the pus is abundant we can almost surely expect disease 
 of the antrum. The operation of ossiculectomy is free 
 from serious danger in the hands of the expert. If the 
 stapes is accidentally dislocated, distressing dizziness may 
 follow for many days. Ossiculectomy rarely injures the 
 remaining hearing power, but often improves it to a 
 moderate extent. The operation is usually too painful 
 without general narcosis in purulent cases. In the case 
 of a narrow meatus it cannot be done without temporary 
 resectioji of the cartilaginous portion. This makes a 
 larger operation, and in such cases it is better to do the 
 radical operation at once. 
 
 382. Opening the mastoid (1 370) cures the majority 
 of cases of otherwise incurable suppuration of the attic 
 and antrum. In these chronic instances, however, the 
 after-treatment is sometimes very tedious and protracted 
 through months. It should be the preferred operation 
 in those instances in which the persistence of good hear- 
 ing makes it desirable to save the ossicles. It may also 
 be done when the ossicles have been entirely destroyed 
 previously by disease. Simply opening the mastoid is, 
 however, not so sure of success as the radical operation, 
 but, on the other hand, easier and perhaps a trifle safer. 
 After establishing a large opening into the antrum, both 
 this artificial canal and the meatus should be kept packed 
 until all discharge has ceased. This may take from one 
 to four months. In old chronic purulent otitis the mas- 
 toid is often found sclerotic, probably as the consequence 
 of long-continued suppuration. It is hence usually more 
 difficult to chisel into the antrum than in the case of 
 fresh disease. 
 
 383. The radical operation is intended to convert the 
 tympanic cavity, the attic, and the mastoid antrum into 
 one large continuous cavity with unobstructed outlet. It 
 should be done in all cases of inaccessible cholesteatoma 
 or of chronic fetid suppuration otherwise incurable, espe- 
 cially, however, when urgent danger symptoms are pres-
 
 500 
 
 CHRONIC PURULENT OTITIS MEDIA. 
 
 ent. Of the various modifications of the radical opera- 
 tion, I will describe the one suggested by Zaufal as the 
 easiest (compare mastoid operation, 1 370). 
 
 General narcosis. Detachment of the auricle and of 
 the cartilaginous part of the meatus by a long, slightly 
 
 FIG. 143. The radical operation completed. Antrum and attic fully ex- 
 posed and the two ossicles removed. Of the internal portion of the posterior 
 wall of the meatus a slanting ridge is left intact in order to protect the canal 
 of the facial nerve. 
 
 curved incision down to the bone from above the upper 
 rim of the auricle to a point below the tip of the lobule, 
 I cm. behind the insertion of the auricle. Elevation of 
 the periosteum backward and forward from the incision
 
 RADICAL OPERATION. 5<DI 
 
 up to. the cartilaginous meatus. Detachment of the lat- 
 ter from the rear, and transverse (vertical) incision with 
 a tenotome through the posterior upper cutaneous wall 
 of the bony meatus as far inward as possible. The par- 
 tially detached cartilaginous meatus is pulled forward 
 by the steady action of a small retractor placed in the 
 meatus. The mastoid surface is now attacked by the 
 chisel in the usual place viz., immediately behind the 
 meatus and a trifle above its center. But instead of 
 merely making a funnel-shaped hole in the mastoid 
 process, the chisel is directed against the meatus so that 
 its upper posterior wall is gradually removed. The 
 wound in the bone assumes thus the shape of a broad 
 crater, the inferior and anterior boundaries of which are 
 the normal inferior and anterior walls of the meatus. As 
 soon as the antrum is reached any bleeding granulations 
 are curetted. 
 
 While at the external orifice of the wound in the 
 bone the posterior wall of the meatus should be en- 
 tirely removed, the lower part of the posterior wall 
 must be scrupulously avoided as the surgeon approaches 
 the tympanic cavity (Fig. 143), for otherwise the facial 
 nerve and possibly the external semicircular canal would 
 be wounded. The internal portion of the posterior wall 
 of the meatus hence forms a slanting ridge along the 
 floor of the cavity thus created. After the antrum is 
 reached, small chisels are carefully used to cut away the 
 external wall of the tympanic attic (upper wall of the 
 meatus), so as to gain access to the entire tympanic space, 
 until a curved probe meets with no obstacle in gliding 
 outward from the roof of the attic along the upper (partly 
 resected) wall of the meatus. During this part of the 
 operation Stacke's guard (Fig. 144) may be used to pro- 
 tect the internal wall of the drum cavity (labyrinth and 
 facial nerve) against accidental slipping of the chisel. 
 The guard is held by an assistant after introduction into 
 the drum cavity. The patient's face should be watched 
 continuously by the assistant, in order to call attention
 
 5O2 
 
 CHRONIC PURULENT OTITIS MEDIA. 
 
 to any twitching of the facial muscles indicative of irri- 
 tation of the facial nerve. Whenever feasible, delicate 
 bone nippers may be used from the antrum forward to 
 remove the bone in fragments. Finally the entire tym- 
 panic space, including its attic, becomes accessible, and 
 on account of the previous removal of the cartilaginous 
 meatus it can be well inspected with good illumination 
 without head mirror. The two ossicles are now removed 
 with forceps after severing their adhesions with small 
 knives. Wherever granulations are found they are 
 curetted off under the guidance of the eye from within 
 outward. Curetting blindly is too dangerous. The 
 stapes should not be touched unless found denuded. 
 
 FIG. 144. Stacke's guard for the protection of the facial canal and labyrinthine 
 wall in the radical operation. 
 
 After the removal of all diseased tissue the posterior 
 membranous wall of the meatus is slit longitudinally 
 from without inward, so that the two flaps can apply 
 themselves to the posterior upper bony surface of the 
 surgical channel. 
 
 In case of cholesteatoma, or when it has been found 
 impossible to remove all diseased tissue with certainty, 
 or in case of dangerous symptoms, the retro-auricular 
 opening is left open and drained. Otherwise it may 
 be closed by sutures and the after-treatment carried 
 out through the meatus. Very careful packing with 
 gauze is essential. The directions for changing the 
 gauze are the same as in the case of the ordinary 
 mastoid operation. During subsequent dressings any
 
 RADICAL OPERATION. 503 
 
 adhesion of the gauze strips in the depth of the 
 wound can be overcome in the gentlest manner by in- 
 stilling peroxid of hydrogen solution. The cicatriza- 
 tion of the extensive cavity may be materially hastened 
 by placing Thiersch grafts upon the exposed bone, either 
 at the end of the operation or as soon as satisfactory 
 cicatrization is in progress. Still it never takes less 
 than three to four weeks, and not rarely as many months, 
 before cicatrization is complete and all discharge has 
 ceased. Considerable care is required during the after- 
 treatment. Excessive granulations must be curetted or 
 touched with nitrate of silver. Careful packing is in- 
 dispensable up to the end. After the discharge has 
 ceased the patient should stay under observation for 
 many weeks with periodic inflations of boric acid. 
 
 A properly done radical operation is absolutely cura- 
 tive, but it is not always possible to remove all diseased 
 bone at once. The loss of the odor indicates whether the 
 operation has been thorough or not. Even when some 
 odor persists it will now yield gradually to packing. No 
 radical operation, however, can give an absolute guar- 
 antee against a future relapse of suppuration. But with 
 all obstacles to drainage removed, and nothing left but a 
 clear space, such relapses are not likely to prove serious 
 or rebellious to very simple treatment. The radical 
 operation does not often injure what hearing there is left, 
 and, indeed, may improve it moderately. Injury to the 
 facial nerve, a deplorable accident, has happened occa- 
 sionally in operations done by expert surgeons. 
 
 The form of radical operation described above is the one sug- 
 gested by Zaufal, which I personally consider the easiest and 
 safest for the less experienced operator. Nearly at the same 
 time Kuester, Zaufal, and Stacke (1889 to 1890) advocated a more 
 radical operation than the mere opening of the mastoid in chronic 
 cases, by removing at the same time the posterior wall of the 
 meatus and the external wall of the attic. Stacke's operation is 
 primarily intended for the removal of the ossicles.. The auricle 
 and cartilaginous meatus are detached, and the superior wall of 
 the meatus is chiseled off until no barrier is left in front of the
 
 504 CHRONIC PURULENT OTITIS MEDIA. 
 
 attic. After cleaning the attic the mastoid cavity is explored 
 through its aditus, and if found diseased is opened by chiseling 
 away the posterior wall of the meatus. Most surgeons, especially 
 in this country, prefer to remove the ossicles through the intact 
 meatus when the anatomic conditions are favorable. Hence 
 Stacke's operation, as mostly done, is really a radical operation 
 with slightly modified technic. 
 
 A number of modifications have been devised in the 
 plastic part of the operation, in order to cover the exposed 
 bony surface. Among the most serviceable plans is that 
 of Siebenmann. He does not keep the retro-auricular 
 opening patent as such, but combines its orifice with the 
 meatus by using the skin of the concha as a lining. The 
 detached meatus is slit longitudinally in the center of its 
 posterior wall, and from the external end of this slit a cut 
 is made downward and another upward through the 
 concha, so that the entire incision has the shape of a hori- 
 zontal Y. The cartilage is thereupon resected from the 
 posterior surface of these flaps, so that they can be com- 
 pletely adapted to the exposed bony surface of the wound, 
 being held in place by tamponing. 
 
 As far as the bony surface is surely healthy it may be 
 covered with Thiersch grafts at the time of the operation, 
 which are kept in place by the tampon. In the deeper 
 parts of the wound grafts should be used only after longer 
 observation has shown normal healing without the pres- 
 ence of any bone disease or focus of suppuration.
 
 CHAPTER XLIII. 
 
 LOCAL COMPLICATIONS OF CHRONIC PURULENT 
 
 OTITIS. 
 
 POLYPI. CARIES AND NECROSIS OF THE BONE. CHO- 
 LESTEATOMA. PARALYSIS OF THE FACIAL NERVE 
 TUBERCULAR OTITIS. 
 
 384. Polypi are a frequent occurrence in chronic otitic 
 suppuration. Granulation tissue in the form of red, ele- 
 vated, easily bleeding patches is often seen in the tym- 
 panic cavity through perforations. When this occurs in 
 the form of a tumor with a constricted pedicle, it forms a 
 polypus. Polypi are made up of granulation tissue origi- 
 nally, but many in the course of time assume a firmer 
 consistency by fibrillary transformation. They are lined 
 with epithelium and are quite vascular. They may 
 resemble minute beads, being sometimes multiple, or may 
 grow until a large reddish mass fills the whole meatus 
 
 FIG. 145. A tabulated polypus springing from the upper part of the tym- 
 panic cavity and protruding through a large perforation in the upper posterior 
 quadrant of the drumhead. The membrana tympani is thickened so that the 
 manubrium is not visible. 
 
 (Fig. 145). They originate mostly from the attic ; rarely 
 from a carious spot in the wall of the meatus. They are 
 often, but perhaps not always, indicative of caries under- 
 neath. When cut off incompletely, they are apt to grow 
 again. Their removal should hence be thorough. Co- 
 cain and suprarenal solution make general anesthesia 
 
 505
 
 506 LOCAL COMPLICATIONS OF CHRONIC PURULENT OT1TIS. 
 
 superfluous. The most satisfactory instrument is a deli- 
 cate snare (Fig. 146), the loop of which grasps the growth 
 next to its base. The best wire is the thin flexible iron 
 wire used by florists. The base should then be curetted. 
 Cauterization is generally superfluous, except when the 
 base is inaccessible to the curet in the attic. A suitably 
 bent probe upon which a bead of chromic acid has 
 been melted can then follow the path of the polypus 
 to its base. The excess of the acid is removed by a solu- 
 
 FIG. 146. Blake's polypus snare. 
 
 tion of bicarbonate of sodium. It is worth remembering 
 that small polypi may disappear without operation under 
 boric acid insufflation, provided there is no stagnation 
 of pus. 
 
 385. Bone disease is a frequent complication and 
 often the cause of the persistence of chronic otitis, espe- 
 cially in poorly nourished subjects. Relatively rare in the 
 simple form, Jt is very common when there is stagnation 
 of pus. The more usual form of the disease is caries, while 
 the necrotic separation of a sequestrum is much less 
 common. The most frequent seat of caries is in the 
 ossicles, especially the long process of the anvil ; less fre- 
 quently the head of the anvil or the head of the hammer. 
 The destruction of bone is not a passive corrosion by pus, 
 but a true ostitic ulceration. Caries of the head of the 
 hammer is indicated iisually by a fistula in Shrapnell's 
 membrane. Destruction of the anvil may be suspected 
 when the greater part of the membrana tympani is de- 
 stroyed, or in case of perforation at its upper rear border. 
 Less commonly than in the ossicles caries is found in 
 some area of the tympanic wall ; sometimes even in the
 
 BONE DISEASE. 5O/ 
 
 meatus. A noticeable seat of the disease is the bony mar- 
 gin around Shrapnell' s membrane, where large bony 
 defects are not infrequently met with. There are no 
 symptoms attributable to caries in these localities beyond 
 the persistence of the discharge. Whether the fetor of 
 the discharge can be abolished or not depends on the con- 
 ditions for drainage and not on the presence of the bone 
 disease. The diagnosis can be assured only by feeling 
 the exposed bone with a delicate probe. Granulation 
 tissue and polypi render the existence of caries underneath 
 probable. 
 
 The treatment in these instances is that of the chronic 
 otitis. After drainage has been established as indicated 
 by the absence of fetor, carious spots will generally heal. 
 When an odorless slight discharge proves rebellious to 
 treatment, various devices may be used with more or less 
 uncertain result. Instillations of a 4 per cent, solution 
 of hydrochloric acid left in for some fifteen minutes or 
 kept in for a day on a pledget of cotton, can dissolve dead 
 bone and facilitate cicatrization, but the effect is uncer- 
 tain. A solution of iodoform in alcohol and ether has 
 proved a little more definite in its action. A few times 
 I have seen unquestionable results from the use of balsam 
 of Peru, followed by the ordinary aseptic packing. 
 
 Caries in the mastoid antrum is incurable as far as we 
 know, except by proper opening of the antrum. In the 
 antrum necrotic sequestra are found oftener than in other 
 parts of the ear. 
 
 When progressive caries extends inward into the 
 petrous bone, it may lead to serious symptoms. Carious 
 spots have been found relatively often in the bony walls 
 of the semicircular canals, especially the horizontal canal. 
 This localization is characteristically indicated by persis- 
 tent dizziness. Headache and local pain mayor may not 
 be present. When present, however, these sensory symp- 
 toms constitute an important warning. A small number 
 of instances have been observed in which necrosis ex- 
 tended into the petrous pyramid and the entire cochlea
 
 5O8 LOCAL COMPLICATIONS OF CHRONIC PURULENT OTITIS. 
 
 has been extruded by spontaneous demarcation a number 
 of times with ultimate recovery. Whenever urgent 
 symptoms dizziness, pain, headache, especially with 
 fetor of the discharge indicate progressive caries, noth- 
 ing can be considered except a radical operation. In all 
 instances of caries the general health should receive due 
 attention, and no details of hygienic management fresh 
 air, exercise or therapeutic indications iron, cod-liver 
 oil, or whatever may be required should be overlooked. 
 
 386. Cholesteatoma is the most serious of all local 
 complications of chronic otitis. This name is given to 
 concretions of exfoliated epidermis gathering in the 
 aural spaces during or after a chronic suppurative proc- 
 ess. The desquamative inflammation limited to the 
 meatus has been described under the head of epidermis 
 plugs (T[ 325). Oftener than in the meatus it is found in 
 the attic of the middle ear and in the mastoid antrum. 
 The masses are white or yellowish, distinctly laminated, 
 sometimes of firm consistency, and rounded like a pearl; 
 at other times more friable and conform with the shape 
 of the space. The masses consist of epidermis scales 
 with cholesterin crystals and more or less inspissated pus. 
 When there is suppuration, there is always decomposition 
 of fluids around and in the cholesteatoma. But after the 
 suppuration has ceased there may be no fetor whatsoever. 
 Even bland, odorless cholesteatomata may continue to 
 grow and enlarge the bony space in which they are 
 confined. The formation of these masses is due to des- 
 quamation of cutaneous epithelium derived from the 
 meatus, which has grown through a peripheral perfora- 
 tion in the drumhead into the middle ear or attic, or even 
 into the mastoid antrum. This comprehensive statement 
 defines the conditions under which cholesteatomatous con- 
 cretions grow. Why this desquamation takes place is 
 not fully known. It may continue to take place even 
 after suppuration has ceased. 
 
 The diagnosis of cholesteatoma is obvious when the 
 mass is seen either limited to the meatus, or protruding
 
 CHOLESTEATOMA. $09 
 
 into the same, or when visible in the attic on account of 
 the existence of a defect in the bone at the upper margin 
 of the drumhead. (Comp. Fig. 12, Plate II.) When the 
 cholesteatoma is not visible, its presence may be inferred 
 by the persistent appearance of epidermis scales in the 
 fluid on irrigating the middle ear. Inspection must 
 decide, however, whether these scales are not simply 
 derived from the macerated walls of the meatus. Choles- 
 teatoma confined to the antrum may not make its pres- 
 ence known until the cavity is opened by an operation. 
 
 When a cholesteatomatous formation coexists with 
 fetid suppuration, the latter cannot be influenced until 
 the epidermis masses are removed. This is possible only 
 if they are accessible to the eye or to the intratympanic 
 cannula, but not if they extend into the antrum. When 
 the otitic suppuration has been cured, the masses may 
 form again in the course of months without producing 
 symptoms. Sooner or later relapse of suppuration will 
 follow. As a rule, this can again be cured by the com- 
 plete removal of the cholesteatoma. In those instances 
 in which past experience has shown that the suppuration 
 can be easily deodorized and controlled the patient is 
 in no greater danger when treated conservatively and 
 watched than when subjected to the radical operation, 
 especially as the latter, too, gives no absolute guarantee 
 against relapse. If, however, the discharge cannot be 
 deodorized, a cholesteatoma demands radical operation 
 without question. There are obscure cases in which 
 cholesteatoma of the mastoid antrum without suppura- 
 tion causes persistent dull feeling, discomfort, pain, and 
 threatens life by the possibility of pyogenic complication 
 with extension. A presumptive diagnosis of such cases 
 is based on the history of former long-continued suppura- 
 tion and the existence of peripheral defects in the drum- 
 head. 
 
 387. Since the facial nerve is separated from the tym- 
 panic cavity only by the thin walls of the Fallopian 
 canal, which may even be defective, it is evident that
 
 5IO LOCAL COMPLICATIONS OF CHRONIC PURULENT OTITIS. 
 
 facial paralysis may occur in consequence of middle-ear 
 disease. This is rare in the course of an acute catarrhal 
 otitis, and not common in acute suppurative inflamma- 
 tion, but by no means rare when persisting suppuration 
 has led to caries. Facial paralysis is more often due, 
 however, to traumatism, rarely from the simple mastoid 
 operation, oftener from a radical operation even by an 
 experienced surgeon. It may likewise result from 
 violence in the extraction of a foreign body. The symp- 
 toms are the well-known palsy of the facial muscles on 
 the same side. In the case of a paralysis due to an 
 inflammatory process recovery may follow in three to six 
 weeks. Severe traumatism may protract the regeneration 
 until after the lapse of four months or may make it im- 
 possible. It is an open question among neurologists 
 whether the local use of electricity in any form has a 
 permanent influence. When the paralysis is due to an 
 inflammatory process, improved drainage, if necessary by 
 means of a mastoid operation, is indicated. In all opera- 
 tions involving the posterior wall of the meatus the part 
 adjoining the drumhead should be scrupulously avoided 
 on account of its proximity to the Fallopian canal. The 
 latter is not endangered by the removal of the upper 
 wall of the meatus. The chorda tympani nerve is easily 
 wounded by intratympanic manipulations ; necessarily 
 so during removal of the ossicles. Its division causes 
 loss of taste in the tip of the tongue with a numb 
 feeling. 
 
 388. Tuberculosis of the middle ear is not a frequent 
 disease, but common enough to deserve attention. It is 
 probably always secondary and usually occurs only in 
 pronouncedly tubercular subjects. The process may 
 begin in the tympanic mucous membrane, but is almost 
 sure to invade the bone sooner or later. Tubercular 
 otitis is characterized by the absence of acute symptoms, 
 even if of acute onset. Pain is conspicuously absent. 
 There may be a feeling of fulness for a few days, where- 
 upon perforation occurs and a seropurulent discharge
 
 TUBERCULOSIS. 5 1 1 
 
 begins. In some instances tuberculosis of the middle 
 ear leads to abundant granulations filling the entire cav- 
 ity. In others a fibrinous pseudomembrane adheres to 
 the diseased surface. In either case there is remarkably 
 little irritation. In advanced tuberculosis of the system 
 the drumhead and bony walls may break down very 
 rapidly with scarcely any granulation tissue. The diag- 
 nosis suggested by the tubercular history and the peculiar 
 onset should be verified by searching for the tubercle 
 bacillus in the discharge by means of the usual staining 
 methods. The bacilli are sometimes scant in number, 
 and may be found only after repeated examination. 
 
 Under favorable environment and proper local treat- 
 ment the disease may come to a stand-still or even end in 
 recovery. The local treatment is the same as in other 
 forms of otitic suppuration. When destruction of bone 
 has occurred, a radical operation should be performed if 
 the general health warrants it. In properly selected 
 cases it arrests the local disease permanently. Of course, 
 all hygienic measures proper in tuberculosis should be 
 carried out.
 
 CHAPTER XLIV. 
 OTALQIA. 
 
 389. The name otalgia is given to the various forms 
 of pain referred to the ear which cannot be traced 
 directly to some aural lesion. Ii is hence the generic 
 name of pain which may vary much in character and 
 duration. The complaint may be a trivial one; or, in 
 other cases, it may incapacitate the sufferer. It is mostly 
 one-sided. 
 
 Some instances of otalgia can be definitely traced to a 
 dental origin sometimes the eruption of a wisdom- 
 tooth, oftener caries of a molar tooth, either upper or 
 lower. In the former case the pain ceases when the 
 tooth has made its appearance, unless some soreness of 
 the gum persists. In the case of a carious tooth the pain 
 may persist until the origin is recognized and remedied. 
 There may not be any toothache whatsoever. Some- 
 times the pain is intermittent. In an extreme instance 
 observed by myself a young child had had daily attacks 
 of earache for some months. After passing through the 
 hands of half a dozen physicians without relief, the child 
 had become accustomed to daily injections of morphin. 
 The attacks ceased at once after extracting a carious 
 tooth. 
 
 In other instances the pain referred to the ear is of 
 pharyngeal origin. Acute inflammations in the lateral 
 angle of the pharynx, ulcerations of any kind, tonsillar 
 wounds, carcinoma of the faucial or lingual tonsil, are 
 all apt to be accompanied by more or le.ss earache. But 
 when such lesions can be demonstrated, the term otalgia 
 is superfluous. In hysteric subjects painful affections of 
 the throat sometimes leave behind a psychic remembrance 
 of the pain referred to the ear, even long after the heal- 
 
 512
 
 OTALGIA. 5 1 3 
 
 ing of the original lesion. It is very difficult to relieve 
 such patients. Their pain usually yields to nothing but 
 time, or some strongly impressive suggestive treatment. 
 The use of electricity may come under this head. Severe 
 pain, constant or intermittent, referred to the mastoid 
 region without evidence of existing ear disease, is in rare 
 cases due to a growing cholesteatoma without suppura- 
 tion, or may even indicate a subdural abscess. The 
 diagnosis is suggested in such cases by the former his- 
 tory of otitic suppuration. There are on record some 
 instances in which persistent pain, uncontrollable by 
 other means, led to an attempt at mastoid operation. 
 The bone was found sclerotic. The antrum was either 
 not reached or found intact, and still the operation, ap- 
 parently uncalled for, resulted in a permanent cure. 
 
 In the majority of cases of so-called otalgia no local cause 
 can be found. Sometimes the attacks are typically neural- 
 gic and may yield to antipyrin, quinin, or arsenic. Regu- 
 lar periodicity of the pain has in a few instances been 
 traced to malarial influence and cured by quinin. In 
 other cases again the pain is not typical of neuralgia. 
 It may depend on anemia, and in such instances is 
 benefited by iron. If it is in any way related to rheu- 
 matism, large doses of salicylate of sodium may some- 
 times prove of benefit. One of the rarest forms of 
 otalgia, usually bilateral, is periodic migraine localized 
 in and limited to the region of the ear. Its diagnosis is 
 made by its irregular periodicity and its accompanying 
 symptoms for instance, the more characteristic sick 
 headache or nausea. 
 
 33
 
 CHAPTER XLV. 
 PYOQENIC EXTENSION OF OTITIS. 
 
 SEROUS AND PURULENT MENINGITIS PHLEBITIS AND 
 THROMBOSIS OF THE LATERAL SINUS WITH SEPTI- 
 CEMIA OR PYEMIA. SUBDURAL ABSCESS. ABSCESS 
 OF THE BRAIN. 
 
 390. The greatest danger of otitic suppuration, acute 
 or chronic, is the possibility of its extension into the cra- 
 nial cavity. This may take place through the intact roof 
 of the middle ear or of the mastoid antrum, when the plate 
 of bone is thin or even partially deficient. In children the 
 relatively thick roof of the mastoid antrum diminishes the 
 danger from this locality. Oftener, however, carious spots 
 and fistulae are found in the roof of tympanum or antrum. 
 In the antrum the inflammatory process may extend 
 through connecting pneumatic cells to the cranial sur- 
 face. L/ess common is suppurative extension into the 
 labyrinth, whence it can reach the cranial cavity either 
 through the aqueducts or along the course of the audi- 
 tory nerve. Quite rare is the propagation of the disease 
 through a thin anterior wall of the tympanic cavity to the 
 carotid canal and thence upward. 
 
 The diagnosis of intracranial complications may be 
 quite difficult, especially the differential diagnosis be- 
 tween the different lesions. With the exception of 
 meningitis the other complications may sometimes de- 
 velop so gradually as to mislead any one not thoroughly 
 familiar with the symptomatology of inflammatory ear 
 disease. On the other hand, an otitis may itself provoke 
 symptoms which suggest a cerebral complication. As 
 pointed out in If 358, acute otitis produces occasionally 
 in children very rarely in adults symptoms which 
 simulate brain disease viz., headache, stupor, delirium, 
 
 514
 
 SEROUS AND PURULENT MENINGITIS. 515 
 
 or convulsions. The dependence of these symptoms on 
 the inflammation of the middle ear may be shown by 
 their prompt cessation after paracentesis of the drum- 
 head, but such observations are very rare. The per- 
 sistence of such symptoms, except headache, after free 
 drainage has been established would positively indicate 
 extension beyond the tympanic cavity. 
 
 In chronic cases with cholesteatoma or caries it may 
 also be difficult to recognize intracranial complications 
 at the beginning. One-sided headache, dizziness, nausea, 
 and vomiting may depend merely on extension of the 
 disease into the labyrinth, or may signal the beginning 
 of an intracranial accident. Fever is a more significant 
 symptom. It is only moderate and transient in uncom- 
 plicated acute otitis, except in children. If, therefore, a 
 high fever persists during acute aural disease, or still 
 more significantly, if fever develops in the course of a 
 chronic otitis, it means either meningitis or thrombosis 
 of the lateral sinus. In the former case the fever is more 
 continuous, and chills are not common, while sinus dis- 
 ease is characterized by sharp thermometric fluctuations, 
 often with chills. Yet this rule is not absolute. Ab- 
 scess, either subdural or intracranial, has but little, if 
 any, fever. When distinctly cerebral symptoms occur, 
 viz., mental alterations, coma, delirium, pareses (more 
 than merely facial), intracerebral disease is evident, but 
 even then a differential diagnosis may be difficult. In- 
 flammation of the optic nerve (optic neuritis or choked 
 disc) is rather exceptional in all these affections, but when 
 present, is very significant. All cerebral complications 
 are apt to produce the systemic disturbance common to 
 pyogenic infection viz., derangement of the appetite 
 and digestion, furred tongue, constipation, and lack of 
 vigor. 
 
 An important diagnostic method in obscure cases is 
 lumbar puncture the tapping of the spinal canal below 
 the spinal cord. As the question has lately been raised 
 regarding the absolute safety of this procedure, it is best
 
 516 PYOGENIC EXTENSION OF OTITIS. 
 
 to limit its use to those instances in which no diagnosis 
 can be made without it. The technical details of this 
 operation do not require discussion in this place. The 
 information gained by lumbar puncture is positive as 
 to the existence of meningitis, negative regarding the 
 other complications. When the cerebrospinal fluid 
 escapes under abnormal high pressure, but is either 
 perfectly clear or contains only microscopically leuko- 
 cytes, a serous meningitis is proved. When the fluid, 
 however, is turbid and the microscope reveals the pres- 
 ence of pus-cells as well as bacteria, especially strepto- 
 cocci, it is proof positive of a purulent meningitis. In 
 abscesses within the skull and in sinus phlebitis the evi- 
 dence by lumbar puncture is negative. 
 
 The otitic intracranial complications are most common 
 in late childhood and early middle life, are decidedly 
 more frequent in the male than in the female, and occur 
 oftener on the right than on the left side. Of all the 
 lesions, the extradural abscess is the most frequent and 
 often the intermediate step between ear disease and the 
 other complications. In the case of acute otitis the 
 cerebral sequels may not become manifest until quite a 
 time even weeks has elapsed after the apparent cure 
 of the ear disease. The liability to cerebral complica- 
 tions is very small in those cases of chronic purulent 
 otitis in which free drainage is indicated by an absence 
 of fetor. The greatest danger is in the cases with stag- 
 nation of fetid pus, especially in the course of subacute 
 exacerbations, particularly when caries or cholesteatoma 
 exist. 
 
 It is sometimes not possible to recognize with certainty 
 the existence of an intracerebral complication or to diag- 
 nose the exact lesion prior to the operative dissection. 
 If in the course of an operation carious fistulae or paths 
 of granulations are found, they are to be followed up to 
 wherever they lead. As with rare exceptions these 
 patients are sure to die if not treated surgically, the 
 operation must not stop short of the utmost obtainable
 
 EXTRADURAL OR SUBDURAL ABSCESS. 5 I/ 
 
 limit. To refuse an operation means sure death. In 
 every case the suppurative focus in the temporal bone 
 should be completely eliminated. This, indeed, may be 
 sufficient for recovery from beginning sinus thrombosis, 
 serous meningitis, possibly even circumscribed purulent 
 meningitis. It is prudent for the aurist of limited ex- 
 perience to employ trained surgical assistance. 
 
 The importance of the subject demands a detailed dis- 
 cussion of each lesion, while on account of the rarity of 
 these complications this will be made very brief. 
 
 391. Bxtradural or subdural abscess occurs between 
 the bone and the external layer of dura mater, which 
 serves as periosteum. It begins always oil the temporal 
 bone, rather oftener in the posterior than in the middle 
 cerebral fossa. Exceptionally it may be situated deeply 
 near the apex of the petrous pyramid. Its size varies 
 from that of a small to a large nut. In the cases due to 
 acute otitis the dura is usually covered with granulations, 
 and the pus is odorless, containing the pneumococcus 
 perhaps oftener than any other microbe. In chronic 
 cases there is apt to be sloughing of the membranes, and 
 the pus is often fetid. If let alone, the abscess will in 
 rare instances break through the tympanic roof, or even 
 through the squamous plate of the temporal bone. As a 
 rule, however, it proves fatal by leading to meningitis or 
 to sinus thrombosis with pyemia after the lapse of weeks 
 or months. 
 
 The diagnosis of extradural abscess is very obscure. 
 There may be scarcely any distinctive symptoms. Head- 
 ache, especially when localized, tenderness, sometimes 
 indicated by rigidity of the neck, are its most frequent 
 manifestations. As a rule, there is no fever at all ; some- 
 times a slightly abnormal evening temperature. But 
 slight systemic and stomach disturbance, and especially 
 constipation, is often noted. Vertigo, nystagmus, nau- 
 sea, and vomiting may be present, but are perhaps of 
 otitic origin. Distinctive cerebral symptoms are excep- 
 tional and rather suggestive of other complications. The
 
 5l8 PYOGENIC EXTENSION OF OTITIS. 
 
 most positive but infrequent evidence is circumscribed 
 tenderness with edema or even a subperiosteal abscess 
 behind and above the ear, due to pyogenic penetration 
 along a venous channel in the skull. In many instances 
 the diagnosis can be made only by finding and following 
 carious tracks or cellular paths filled with granulations 
 during a mastoid operation demanded by the aural con- 
 dition. 
 
 If such carious or granulation paths are seen, they will 
 be found to lead to the abscess on persisting in the 
 judicious use of chisel and rongeur forceps until the 
 dura is exposed over a sufficiently large area. The dura 
 should not be opened or curetted even if covered with 
 granulations, in order not to excite a meningitis. If 
 symptoms suggesting a subdural abscess persist after a 
 properly performed mastoid or radical operation in which 
 the cranial cavity was not opened, a secondary operation 
 should be made. If no local indications are found along 
 which the opening should be extended, the skull may 
 be trephined through the squamous portion. The extra- 
 dural exploration should be followed up, if necessary, to 
 the apex of the petrous pyramid. A simple after-treat- 
 ment is carried out along the usual lines of modern 
 surgery with an iodoform gauze drain. The mortality in 
 early operations of uncomplicated subdural abscess is 
 very small, but increases materially when other compli- 
 cations have occurred. 
 
 392. The intracerebral abscess, more common in 
 chronic than in acute cases, is sometimes, but not as a 
 rule, secondary to a subdural abscess. The exciting 
 microbes may spread along the course of small arteries, 
 veins, cerebral nerves, or strands of connective tissue. 
 It is always on the same side of the ear, more often in 
 the temporal lobe of the cerebrum than in the cerebellum, 
 rare in the basal parts or in the occipital lobe. The otitic 
 abscess is single. If multiple, it may be of pyemic 
 origin. 
 
 R. Miiller has lately tried to distinguish between inter-
 
 INTRACEREBRAL ABSCESS. 519 
 
 stitial and parenchymatous brain abscess. In the former 
 case the pyogenic microbes, usually streptococci, travel 
 along a connective- tissue septum and produce a true 
 abscess with an abscess wall. These pus accumulations 
 are likely to cause pressure symptoms. The parenchy- 
 matous abscess, on the other hand, is due to the invasion 
 of the brain substance by destructive bacteria. It is often 
 due to a mixed infection and contains fetid pus, with 
 sloughing of the brain substance, but with little inflam- 
 mation. It is more apt to cause symptoms resulting 
 from destruction than those due to pressure. Miiller 
 admits, however, that the majority of abscesses are of a 
 mixed type. 
 
 The beginning of brain abscess may or may not be 
 indicated by vague symptoms, general disturbance, head- 
 ache, nausea, vomiting, and perhaps slight fever. As a 
 rule, the abscess then follows a latent course for weeks or 
 months. When its presence finally becomes manifest, 
 we can distinguish between diffuse and focal symptoms. 
 The former are general malaise, sometimes constipation, 
 headache, more or less severe and not necessarily localized, 
 tenderness of the scalp, slowness of the pulse, dizziness, 
 mental alterations, insomnia, delirium, and coma. These 
 symptoms are present to a very variable extent. Optic 
 neuritis is not common, but if present is significant. The 
 focal symptoms are of greater importance for diagnosis, 
 but may be late or even absent. Abscess of the tem- 
 poral lobe may cause deafness of the other ear, word- 
 deafness, disturbance of speech and some form of aphasia, 
 especially if left-sided in a right-handed subject, or vice 
 versa. If it extends toward the internal capsule, it may 
 cause hemi-anesthesia or hemianopsia and crossed paraly- 
 sis of the facial nerve and arm or leg ; rarely, spasms. In 
 the cerebellum the abscess is likely to reveal itself by 
 localized occipital headache, rigidity of the neck, ataxia, 
 staggering, vertigo, and vomiting. An abscess in any 
 locality may raise the intracranial tension sufficiently to 
 cause palsy of the various ocular muscles.
 
 52O PYOGENIC EXTENSION OF OTITIS. 
 
 In the diagnosis of brain abscess special care must be 
 taken to distinguish it from brain tumor and tubercular 
 meningitis. 
 
 Without treatment abscess of the brain is invariably 
 fatal, mostly by breaking into the ventricle and causing 
 meningitis. By operation, however, over 50 per cent. 
 of cases are permanently cured. The abscess may be 
 searched for from the extension of the wound made in a 
 mastoid or radical operation, if the latter is indicated. 
 Otherwise it is preferable to open the skull with a tre- 
 phine or by means of an osteoplastic resection above the 
 auricle. 
 
 A crucial incision is made into the dura. Sometimes 
 the brain substance will protrude if the abscess is in the 
 proximity. No definite conclusion can be drawn from 
 the presence or absence of brain pulsation. It is more 
 certain, and not any more dangerous, to explore the brain 
 with a knife thrust in the suspected direction than with a 
 needle. Four centimeters is the limit of safety, for be- 
 yond this distance the ventricle might be tapped. When 
 the pus is found, the intracerebral incision is dilated by 
 means of forceps and a large gauze drain is put in. The 
 after-treatment is according to ordinary surgical princi- 
 ples. 
 
 393. Meningitis is, of all complications, the one most 
 feared. Purulent meningitis was until lately considered 
 fatal and a positive contraindication to operations on the 
 skull. Yet a few recoveries have lately been recorded 
 after radical operations. The gloomy prognosis when 
 the diagnosis meningitis is first made is, moreover, some- 
 what relieved by the possibility that instead of a purulent 
 process it may be the so-called serous meningitis, which 
 ends in the recovery after elimination of the suppurating 
 focus. A serous meningitis cannot be distinguished at 
 first from the purulent inflammation of the membranes, 
 but, unlike the latter, it tends to recovery after a radical 
 operation. In serous meningitis the brain membranes as 
 well as the brain substance appear edematous when ex-
 
 MENINGITIS. 521 
 
 posed, and upon incision a copious flow of clear fluid 
 ensues. This discharge may last several days. In puru- 
 lent meningitis the purulent inflammation of the arach- 
 noid space is at first limited to the region of the disease 
 in the temporal bone. It may remain thus localized by 
 reason of adhesions, and perhaps occasionally heal. But 
 usually it spreads and reaches other distant areas of the 
 cerebral surface. Sometimes a meningitis of a very acute 
 character is due to the perforation of an abscess into the 
 ventricle. 
 
 As a rule, meningitis begins with fever, which is apt 
 to be continuous and high. Rarely is fever absent most 
 likely perhaps in localized meningitis or in the serous 
 variety. Diffuse severe headache is a prominent symp- 
 tom, with rigidity and often forcible backward retraction 
 of the neck. The head is very tender on motion. Dizzi- 
 ness and vomiting are common. Soon other cerebral 
 symptoms follow, such as various pareses of eye muscles, 
 eyelids, or muscles of the extremities. None of the eye 
 symptoms are absolutely diagnostic either way. The often 
 mentioned boat-shaped retraction of the abdominal mus- 
 cles is also not constant. The mind may stay clear, but, 
 as a rule, becomes obscured several days before death. 
 Somnolence or delirium may occur. When the menin- 
 gitis extends down the spinal cord, the accompanying 
 pain indicates this involvement, and corresponding pareses 
 of the limbs, as well as of the sphincter muscles, may 
 ensue. 
 
 A serous meningitis which simulates purulent inflam- 
 mation may disappear within a few days or a week after 
 thorough removal of all diseased bone and the opening of 
 any abscess. Purulent meningitis,, when well pronounced, 
 is probably always fatal within a period of a few days to 
 three weeks at the latest, usually inside of the first week. 
 No treatment can be advised directly against the purulent 
 form of the disease. Indeed, until recently most sur- 
 geons abstained from any operation when the diagnosis 
 of purulent meningitis was made.
 
 522 PYOGENIC EXTENSION OF OTITIS. 
 
 394. Next to extradural abscess phlebitis with throm- 
 bosis of the lateral sinus is the most frequent conse- 
 quence of ear disease, especially in chronic cases. It is 
 often, but not always, the result of an extradural abscess 
 around the sinus the so-called perisinuous abscess. In 
 other instances no distinct abscess is found but merely 
 continuity of pyogenic infection through the walls of the 
 antrum, as indicated by caries or granulation tissue. The 
 inflammatory process may lead to circumscribed phlebitis 
 and thickening of the sinus walls, without thrombosis. 
 On the other hand, a thrombosis may begin without 
 much visible change in the appearance of the venous 
 wall. The thrombus is at first small and parietal i. e., 
 adherent to the wall, without complete obstruction of the 
 venous channel. It may or may not finally occlude the 
 caliber. The thrombus may or may not remain firm and 
 bland, the bland thrombus being probably due to the 
 action of absorbed toxins, without invasion of the clot 
 by living bacteria. But if not interfered with surgically, 
 the thrombus is sure to become septic at last. On open- 
 ing the sinus it will then be found filled with pus or 
 chocolate-colored decomposed blood. Occasionally the 
 wall remains apparently sound, merely thickened. Often, 
 however, in septic cases the venous wall is discolored 
 grayish or greenish and becomes perforated or even gan- 
 grenous. The thrombus may extend backward to the 
 torcular and centrally to the jugular bulb, or even far into 
 the internal jugular vein. From the jugular bulb retro- 
 grade thrombosis may enter the petrosal and even the 
 cavernous sinus. 
 
 Systemic infection is sure to follow if the changes in 
 the sinus are not arrested by operation at an early period, 
 for even in the case of a clot solid at both ends liquefac- 
 tion and entrance of microbes into the circulation will 
 ultimately take place. The absorption of toxins reveals 
 itself by fever and general systemic disturbances, while 
 the detachment of particles of the clot laden with bacteria
 
 THROMBOSIS OF THE LATERAL SINUS. 523 
 
 causes pyemic metastases, especially in the joints and 
 lungs ; less often in other viscera. 
 
 395. At the beginning the symptoms of sinus throm- 
 bosis are not very distinct. They are merely the exag- 
 geration of the disturbances produced by a severe mastoid 
 process. Headache is rarely absent, and especially prom- 
 inent when the thrombosis is started by a subdural ab- 
 scess. Malaise and gastric disturbances may be due to 
 the mastoid disease alone. The characteristic symptom, 
 however, is fever. Whenever the fever of an acute otitis 
 does not cease within a few days, except in children ; 
 whenever it increases suddenly or steadily ; and espe- 
 cially when fever sets in in chronic afebrile cases, sinus 
 thrombosis should be at once suspected. Chills alternat- 
 ing with extensive fluctuations in temperature establish 
 the diagnosis ; yet there are occasionally rare exceptions 
 to this rule. Tenderness, edema, or inflammatory swell- 
 ing over the site of the sinus are not constant, but very 
 suggestive symptoms. 
 
 If the thrombosis extends into the jugular vein, this is 
 often indicated by perceptible hardness and tenderness 
 of the vein, sometimes with inflammatory edema of 
 the tissues of the neck. This condition must not be con- 
 fused with perforation of a mastoid abscess through the 
 internal surface of the tip. 
 
 The absorption of septic poisons is indicated only by 
 the general systemic disturbances, including enlargement 
 of the spleen and sometimes jaundice. Pyemic metas- 
 tases, however, produce unmistakable symptoms. If 
 they occur in the joints, the latter become tender and 
 swollen. In the lungs the pyemic emboli are revealed 
 by the occurrence of sudden irritation and cough, and if 
 superficial enough, they can be detected by dulness and 
 r&les. The clinical picture may be complicated by the 
 coexistence of a serous meningitis with the symptoms 
 peculiar to it. 
 
 With rare exceptions sinus thrombosis is fatal unless 
 treated surgically. The earlier the operation, the greater
 
 524 PYOGENIC EXTENSION OF OTITIS. 
 
 the chances of recovery. Even in imselected cases the 
 mortality is not over 50 per cent, and very much smaller 
 when all unnecessary delay is avoided. If only inetastases 
 into the joint have occurred, the prognosis is still fair ; 
 more serious, however, in the case of pulmonary embol- 
 ism. In any case operation should be attempted. 
 
 396. According to the existing indications, the opera- 
 tion should either be the simple chiseling into the 
 mastoid or the radical clearing of mastoid antrum and 
 tympanic attic. The sinus is then to be laid bare by 
 working upward and backward from the antrum, using 
 small rongeur forceps as much as possible in preference to 
 the chisel. When the indications are clear for incision 
 into the sinus, the latter should be exposed to the utmost 
 extent 3 to 4 cm. or even a trifle more. Whether the 
 operation should include opening of the sinus or not 
 must be judged by the following criteria: If the symp- 
 toms are relatively mild and the sinus wall is not dis- 
 colored, and the sinus is still felt by the p % robe to be a 
 channel containing fluid blood, it may be let alone after 
 completely removing all diseased bone and exposing the 
 sinus wall. The incision into the sinus may not add to 
 the danger of the operation, but, on account of hemor- 
 rhage, it complicates the after-management. If the sep- 
 ticemic symptoms do not abate in the course of one to 
 two days, the sinus may be opened at the next dressing 
 without the necessity of narcosis. But in the case of 
 pronounced pyemic symptoms or even in the absence of 
 the latter when the sinus is discolored or gangrenous it 
 should be included in the operation. Even when the 
 venous wall shows little change, it may be found that 
 the severe systemic symptoms present are due to the 
 septic breaking down of the clot. The puncture of the 
 sinus by means of a hollow needle is not a reliable diag- 
 nostic method, as it neither reveals a small parietal clot 
 nor any small accumulation of pus which it does not 
 happen to strike, while it does involve the danger of in- 
 fection of the dura if the needle happens to perforate the
 
 THROMBOSIS OF THE LATERAL SINUS. 525 
 
 inner sinus wall. The opening of a sinus begun with 
 scissors may be finished with a bistoury on the grooved 
 director. The broken-down clot should be scooped out 
 until a solid thrombus is reached, and toward the rear 
 even until the blood begins to flow. It is best to excise 
 the infected part of the sinus wall. Before the sinus is 
 opened the operation on the bone or on any existing sub- 
 dural abscess should be completed, because hemorrhage 
 may enforce a rapid interruption of further operation. 
 It can, however, be always checked by compression with 
 gauze. 
 
 Opinions are divided as to the advisability of ligating 
 the jugular vein. Its exposure adds to the shock of an 
 otherwise necessarily long operation (one to two hours). 
 It is also said that ligation of the vein is neither an abso- 
 lute preventive of pyemia nor necessary in every instance 
 of jugular thrombosis. Yet experience has shown that 
 the danger of pyemia is certainly diminished by elimi- 
 nating a menacing clot in the jugular vein. When 
 jugular phlebitis can be recognized, it is best to begin 
 the operation by an extensive exposure of that vein in 
 the neck. It should then be ligated below in the appar- 
 ently healthy part, and upward as close as possible to the 
 jugular bulb, and the intervening portion excised, with 
 ligation of the internal facial vein. If the exposure of 
 the lateral and sigmoid sinus shows thrombosis extend- 
 ing to the jugular bulb, many good operators deem it 
 best to ligate the jugular vein in the neck before pro- 
 ceeding to clear out the sinus.
 
 CHAPTER XLVI. 
 
 DISEASES OF THE INTERNAL EAR. 
 
 397. The labyrinth is found diseased in about 5 to 8 
 per cent, of ear patients. The differential diagnosis 
 between lesions of the labyrinth and those of the middle 
 ear can usually be made with certainty, but it is often 
 impossible to distinguish between affections of the inter- 
 nal ear and those of the auditory nerve, except by the 
 history and other concomitant symptoms. Since the 
 labyrinth is the organ of both the sense of hearing and 
 of the static sense, its disease may cause symptoms 
 referable to either or both. On account of their vehe- 
 mence the disturbances of the static sense are apt to 
 predominate in the clinical scene. Dizziness may vary 
 from a mere sense of unsteadiness to a feeling of passive 
 rotation or falling. It is relieved by rest in bed, but 
 may even then be distressing. When severe, the diz- 
 ziness is apt to lead to nausea and to vomiting. It may 
 also reveal itself by nystagmus-like swinging movements 
 of the eyes, generally of slow rhythm. Vertigo neces- 
 sarily interferes with steady gait. There may be inco- 
 ordination of movements. In pronounced instances the 
 sufferer steadies his walk by spreading the legs. The 
 dizziness is apt to last as long as the lesion in the semi- 
 circular canals is of an irritative character. When it 
 begins to decline, it is apt to fluctuate in severity with 
 periodic intensification. In most instances the dizziness 
 ceases ultimately. The patient learns to control his 
 movements with the correlated aid of the other senses, 
 so that finally he gets along fairly well under ordinary 
 circumstances. But when the eyes are closed, the un- 
 steadiness reappears. After extensive disease of the 
 semicircular canals all unusual movements requiring 
 
 526
 
 DISEASES OF THE INTERNAL EAR. 527 
 
 fine coordination for instance, standing on one leg or 
 balancing become difficult or impossible. 
 
 398. The hearing may be but moderately damaged, 
 or it may be entirely abolished. Absolute deafness is 
 a positive proof of labyrinthine disease, except when 
 due to destruction of the auditory nerve. It is charac- 
 teristic of labyrinthine lesions that the perception of high 
 tones is lost first. The failure to hear the highest notes 
 of the Galton whistle proves disease of the internal ear. 
 If the deafness is not absolute, it may be often found 
 that there are small "islands" in the auditory range 
 for which perception is still retained, with a defect for the 
 greater part of the scale. Tuning-fork tests show that 
 bone-conduction is reduced to the same extent as air- 
 conduction. The Rinne" test is always positive, never 
 negative. The time of perception of the tuning-fork 
 placed on the skull is reduced in proportion to the deaf- 
 ness. In Weber's test the sound of the tuning-fork is 
 referred to the better ear if the affection is not symmetric. 
 When labyrinthine disease is complicated by middle-ear 
 lesions, all tuning-fork tests become indecisive. In such 
 cases dependence must be placed mainly on the loss of 
 the high tones and on the history. 
 
 Another symptom of cochlear involvement is dipla- 
 cusis. A musically trained ear hears certain or even 
 all tones accompanied by another note one-half to one 
 tone higher or lower in pitch. As a rule, diplacusis is 
 due to hearing the " false " note in the affected ear, with 
 normal perception in the other, but it may also be due 
 to "double" hearing in the diseased ear. Still dipla- 
 cusis is very rare in purely labyrinthine affections. This 
 symptom, infrequent at best, is oftener met with in slight 
 exudative catarrh of the middle ear, denoting, never- 
 theless, a labyrinthine complication, usually of a very 
 transient character. Tinnitus is complained of in all 
 affections of the internal ear, except when the auditory 
 nerve-ends are totally destroyed. There is nothing about 
 the noises which distinguishes them from those heard in
 
 528 DISEASES OF THE INTERNAL EAR. 
 
 diseases of the middle ear. They are apt to vary in in- 
 tensity with the nervous condition of the patient. 
 
 Affections of the labyrinth are either complications in 
 the course of middle-ear disease or due to descending 
 processes from the cranial cavity, or, in a minority of 
 cases, strictly primary. Even of the primary labyrinth- 
 ine lesions many are the result of some previous systemic 
 disease. As the most striking type of an affection of the 
 internal ear it is best to begin with the description of 
 
 LABYRINTHINE APOPLEXY, OR MENIERE'S DISEASE. 
 
 399. Intralabyrinthine apoplexy begins in the form 
 of a sudden spell. The patient is seized by intense 
 dizziness and falls, usually remaining conscious, but in 
 some instances becoming even unconscious for a short 
 time. Nausea and vomiting soon follow. When the 
 sufferer regains his self-control, he notices intense noises, 
 sometimes hissing, sometimes roaring or rumbling sounds, 
 and discovers that he is partially or totally deaf, at least 
 in one ear, sometimes in both. The spell usually begins 
 without warning. Occasionally it is preceded by hours 
 of prodromal symptoms of similar nature as the spell 
 itself, though much less severe. At the beginning of 
 the attack headache is sometimes present. The dizziness 
 is apt to enforce rest in bed for days, or even longer. The 
 attempt at walking results in staggering or falling. The 
 ataxia may betray itself even in the handwriting of the 
 patient. In the course of time he regains control over 
 his movements, though his unsteadiness is likely to per- 
 sist indefinitely, getting worse on excitement. The tin- 
 nitus is often a source of great distress. The impairment 
 of hearing is permanent, but, as a rule, stationary and 
 not progressive. In some instances, especially those of 
 a milder type, the spells of labyrinthine apoplexy recur 
 at long intervals. A few times the two ears have been 
 successively attacked in separate spells. 
 
 400. The well-defined clinical picture sketched in the 
 preceding paragraph constitutes what may with propriety
 
 LABYRINTHINE APOPLEXY, OK MENIERE's DISEASE. 529 
 
 be called Meniere's disease. It is of comparatively rare 
 occurrence. Common enough, however, are cases which 
 present more or less of the preceding symptoms, but 
 without the clinical history and typical beginning char- 
 acteristic of Meniere's disease. These less well-defined 
 forms of labyrinthine disease may be said to present 
 Meniere's symptoms. They occur more or less pro- 
 nounced in all affections of the internal ear, no matter 
 what their etiology and what their mode of onset. The 
 synonym, labyrinthine apoplexy, is justified by the result 
 of at least one autopsy by Meniere, in which a bloody 
 exudate was found in the semicircular canals. As the 
 disease is by itself not fatal, there are scarcely any other 
 satisfactory postmortem records. 
 
 401. The treatment of Meniere's disease is very un- 
 satisfactory, lodids have been tried and found useless. 
 Pilocarpin has received the credit for an occasional mod- 
 erate improvement, but with doubtful propriety. It is 
 injected subcutaneously in doses of 6 to 15 milligrams. 
 Others have injected it through the Eustachian catheter. 
 It is not at all certain but what it may be administered 
 just as well by the mouth. Charcot has suggested the 
 use of quinin in single daily doses of 0.5 to i. for some 
 six weeks, principally for the purpose of relieving the 
 distressing tinnitus and dizziness. He had observed that 
 as the remnant of hearing disappears the noises cease 
 likewise, and claimed that this could be hastened by the 
 steady use of quinin. This claim has been confirmed 
 only to a moderate extent. Quinin should be restricted 
 to those instances in which the hearing power of the 
 affected ear has been damaged enough to make it useless. 
 
 402. Meniere's disease is in some instances mimicked 
 by spells due to functional nervous disease. Hysteric 
 spells, attacks of epileptic equivalents, and even migrain 
 have been known to cause vertigo, nausea and vomiting, 
 as well as tinnitus, for hours. The transient nature of 
 these symptoms and the absence of permanent impair- 
 ment of hearing exclude actual labyrinthine disease. 
 
 34
 
 53O DISEASES OF THE INTERNAL EAK. 
 
 Meniere's symptoms without the typical onset of laby- 
 rinthine apoplexy occur under a variety of conditions, 
 occasionally as complications of middle-ear disease. It 
 will be most convenient to describe these various affec- 
 tions according to an etiologic classification. 
 
 403. In the course of non-suppurative affections of 
 the middle ear the labyrinth is occasionally, but not 
 often, involved. Whenever there occurs ankylosis of 
 the stapes or ossification of the round window, a gradual 
 atrophy of Corti's organ may follow, which can be de- 
 tected by the loss of perception of the highest notes of 
 the Galton whistle and the impairment of bone-conduc- 
 tion. The form of disease described in Chapter XXXVIII. 
 as sclerosis or rarefaction of the bony capsule of the 
 labyrinth impairs hearing at first only by reason of the 
 rigidity of the oval window, and is not, hence, primarily 
 a disease of the membranous labyrinth. After years, 
 however, it is likely to end in partial atrophy of the 
 nerve terminations. A rare complication of catarrh of 
 the middle ear is a partial and incomplete attack of 
 labyrinthine vertigo a rudimentary form, so to speak, 
 of Meniere's disease. Purulent otitis complicated by 
 caries may invade the labyrinth, especially in poorly 
 nourished individuals. The most frequent lesion found 
 in radical operations is a carious spot in the walls of the 
 horizontal, less often the posterior semicircular canal or 
 in the vestibule. It reveals itself by incessant vertigo, 
 sometimes with vomiting fits, and often with nystagmus. 
 Jansen, the only one who has published any experience, 
 does not hesitate to scoop out the carious spot with very 
 small drills or curets, in order to allow the intralabyrin- 
 thihe pus to escape. In order to avoid the facial nerve 
 this operation must be made either several millimeters 
 behind the Fallopian canal or anterior to it in the region 
 of the promontory. He has obtained a satisfactory per- 
 centage of cures. The purulent otitis media of scarlet 
 fever and measles is sometimes complicated by purulent 
 destruction of the entire labyrinth with Meniere's symp-
 
 TRAUMATISM. 531 
 
 toms and total deafness. In some instances the whole 
 cochlea becomes uecrotic and may be expelled by suppura- 
 tion. 
 
 404. Traumatism by means of sharp utensils may 
 reach the labyrinth through the meatus and drumhead 
 and bring on the characteristic symptoms. The internal 
 ear may also become involved in fractures of the tem- 
 poral bone at the base of the skull. There may thus 
 occur a traumatic form of typical labyrinthine apoplexy. 
 Violent disturbances of equilibrium and vertigo have 
 occurred a number of times in consequence of accidental 
 or intentional exarticulations of the stapes in the 
 course of operations upon the ossicles. The symptoms 
 have sometimes been mild and transient, but have in 
 other cases necessitated rest in bed for weeks, and even 
 left some permanent impairment. Evidences of laby- 
 rinthine involvement possibly slight hemorrhage are 
 sometimes observed after violent blows upon the ear, 
 occasionally with long persistence of symptoms. 
 
 Another external influence which has produced a num- 
 ber of instances of labyrinthine disease with Meniere's 
 symptoms of variable severity is the sojourn in com- 
 pressed-air caissons used in submarine work and 
 bridge-building. The attack comes on when the work- 
 man leaves the compressed-air chamber. It is presum- 
 ably due to the liberation of the absorbed gases in the 
 capillaries of the labyrinth when the external pressure is 
 removed too suddenly. The damage is usually of a 
 permanent character in these cases. 
 
 405. Unusually loud sounds, especially explosions, 
 are likewise an occasional cause of labyrinthine symptoms, 
 mainly in the form of tinnitus or partial loss of hearing. 
 As a rule, the damage .is transient. More permanent is 
 the influence of persistent din, to which some trades, 
 especially that of boilermakers, are subject. Of me- 
 chanics working under such extremely noisy surround- 
 ings a large proportion find the hearing gradually im- 
 paired in the course of years. Middle-ear affections
 
 532 DISEASES OF THE INTERNAL EAR. 
 
 seem to predispose to some extent to this so-called boiler- 
 makers' disease of the labyrinth. But, on the other 
 hand, it has been noticed that whenever more advanced, 
 one-sided middle-ear lesions interfere with sound-conduc- 
 tion, the ear of that side does not suffer so much in the 
 end as its mate. The labyrinth is shown to be the seat 
 of boilermakers' deafness by the loss along the upper 
 end of the auditory scale and the impaired bone-conduc- 
 tion. Tinnitus and vertigo are not usually complained 
 of. It is not quite settled whether the use of firm cotton 
 plugs in the ear affords protection against the influence 
 of such loud dins. 
 
 406. Drug" action has in rare instances injured the 
 labyrinth. Large doses of quinin produce a characteristic 
 roaring, which ordinarily ceases within less than twenty- 
 four hours. There are on record, however, a number of 
 instances of more or less complete permanent deafness, 
 always bilateral, traceable to excessive quantities of 
 quinin. Experiments on animals have shown that poi- 
 sonous doses may cause effusion of blood into the laby- 
 rinth. The same has been found true of salicylate of 
 sodium. Clinically, however, the latter has very rarely 
 done any permanent damage to the hearing. Yet in 
 rare instances patients claim that a moderate tinnitus, 
 due to middle-ear disease, has been permanently intensi- 
 fied by large doses of salicylate of sodium. 
 
 407. Labyrinthine involvement, mainly confined to 
 the auditory nerve-ends (partial deafness and tinnitus), is 
 observed in rare instances in the course of various infec- 
 tious diseases, such as typhoid, typhus, pernicious ane- 
 mia, etc. There are, however, some forms of systemic 
 disease in which the labyrinth suffers with greater fre- 
 quency. In leukocythemia complete or incomplete 
 attacks of Menire's disease have been observed re- 
 peatedly. Mumps is known to localize itself at times 
 in the internal ear, resulting in complete deafness, from 
 which very few recoveries have been recorded. This 
 metastasis, one-sided oftener than bilateral, occurs rarely
 
 SYPHILIS. 
 
 533 
 
 at the beginning, oftener during the course or after the 
 termination of mumps. There may be with it some 
 pain and considerable tinnitus. 
 
 408. Syphilis is accused often as a cause of labyrinth- 
 ine disease, but according to personal experience, as well 
 as published reports in literature, the localization in the 
 labyrinth is really very rare in the acquired form of the 
 disease. It is apparently more frequent in congenital 
 syphilis, occurring in females more than in males, and 
 usually between the ages of eight to twenty years. Con- 
 genital syphilis localizing itself in the labyrinth coin- 
 cides often with or follows syphilitic keratitis, and the 
 subjects generally show the malformation of the upper 
 incisor teeth known as Hutchinson's teeth. In the ac- 
 quired form a few casual observations have shown the 
 labyrinth filled with an inflammatory non-purulent exu- 
 date, presumably preceded by syphilitic disease of the 
 blood-vessels. Autopsies at a later stage have shown 
 osseous transformation of the labyrinth with disappear- 
 ance of the nerve-fibers. The labyrinthine affection in 
 both the acquired and the congenital forms may assume 
 the apoplectic type, or may in an acute manner destroy 
 rapidly the hearing without vertigo. In other instances 
 the affection has been of a slower character and some- 
 times did not proceed to complete deafness. As a rule, 
 it is double-sided. Specific treatment has had no posi- 
 tive effect in most instances. In the slower forms it is 
 not even possible to arrest the disease with certainty. 
 Sometimes, however, moderate recovery has been ob- 
 served, which by some surgeons has been attributed to 
 the use of pilocarpin in addition to specific treatment. 
 
 409. A typical labyrinthine affection is a frequent un- 
 fortunate outcome of cerebrospinal meningitis. Its 
 percentage varies somewhat with the type of the disease. 
 After severe epidemics of cerebrospinal meningitis its 
 victims constitute a large part of the deaf-mutes of the 
 locality. The disease, as well as its labyrinthine com- 
 plication, occurs principally in children. Its beginning
 
 534 DISEASES OF THE INTERNAL EAR. 
 
 is usually overlooked on account of the severity of the 
 primary disease and the somnolence or coma so fre- 
 quently present. As the patient recovers, he finds 
 himself completely deaf and generally distressingly 
 dizzy. The vertigo improves, the staggering gait be- 
 comes steadier, after a while incoordination occurs only 
 under trying circumstances, but the deafness remains. 
 Postmortems have shown the lesion to be a suppurative 
 inflammation extending along the auditory nerve into 
 the labyrinth and destroying both the trunk of the 
 nerve and its ends. 
 
 A primary inflammation of the labyrinth with fever, 
 headache, dizziness, and deafness has been described by 
 Voltolini in children. This affection, however, is now 
 generally believed to be an abortive form of cerebro- 
 spiual meningitis.
 
 CHAPTER XLVII. 
 
 DISEASES OF THE AUDITORY NERVE. DEAF- 
 MUTISM. 
 
 410. Anatomy of the Auditory Nerve. The eighth 
 cranial nerve pursues a short course from its emergence 
 at the side of the medulla oblongata underneath the pons 
 to the internal meatus in the middle of the posterior sur- 
 face of the petrous pyramid. It is joined by the seventh 
 or facial nerve in its course, which leaves it in the depth 
 of the internal meatus to pass over the vestibule into the 
 Fallopian canal. The auditory nerve consists of two 
 branches really representing separate nerves, the cochlear 
 branch or posterior lateral root, and the vestibular nerve, 
 or anterior median root. The independence of these two 
 branches is shown both by their separate peripheral dis- 
 tribution and their separate central course. Besides, the 
 vestibular nerve receives its medullary investment earlier 
 during embryonic life than the cochlear nerve. The 
 cochlear nerve-fibers pass through the spiral ganglion in 
 the interior of the modiolus. The first neuron of this 
 nerve consists of the fibers in the lamina spiralis, periph- 
 eral to the spiral ganglion. The second neuron begins 
 in the latter and terminates in the anterior or ventral 
 and posterior or dorsal auditory nuclei in the medulla. 
 Thence the further path is by means of fibers in the 
 trapezoid body and striae acusticae, which, decussating, 
 pass forward in the lateral inferior fillet (lemniscus) to 
 the posterior corpora quadrigemina. Through the sub- 
 thalamic region and posterior part of the internal cap- 
 sule they finally reach the cortex of the temporal lobe, 
 in which they terminate. The vestibular nerve is inter- 
 rupted by a ganglion in the internal meatus, whence its 
 fibers enter the vestibule and ampullae. The nerve ends 
 
 535
 
 536 DISEASES OF THE AUDITORY NERVE. DEAF-MUTISM. 
 
 in a dorsal nucleus in the floor of the fourth ventricle. 
 Its subsequent connections have been traced into the cere- 
 bellum, but are not yet completely known. 
 
 411. Affections of the auditory nerve central to the 
 labyrinth are quite rare and are oftener seen by neurolo- 
 gists than by otologists. As in labyrinthine disease, the 
 deafness is characterized by impairment of bone-conduc- 
 tion as well as air-conduction, but, unlike the latter, it 
 is stated that the perception of the highest notes does 
 not suffer first. Tinnitus is, as a rule, not so pronounced 
 as in labyrinthine disease or is even absent. The deaf- 
 ness, too, is not necessarily indeed, rarely associated 
 with vertigo. The diagnosis, however, must be based 
 largely on other concomitant nervous symptoms. 
 
 The auditory nerve trunk suffers from degeneration in 
 a small proportion of patients with tabes. The atrophy 
 is of the same character as the lesion of the optic nerve, 
 which latter, however, is much more common. It is not 
 certain whether there ever occurs a true neuritis of the 
 auditory nerve, except as a complication of adjoining 
 inflammatory processes. Deafness, sometimes one-sided, 
 does occur when basilar disease, localized meningitis, or 
 especially syphilitic disease involves the auditory nerve, 
 but all this is very rare. The intracerebral nerve path may 
 suffer from hemorrhagic effusions, tumors, and abscesses. 
 On the basis of the involvement of the auditory nerve, a 
 localizing diagnosis cannot be made, since its symptoms 
 have been observed in consequence of disease of the 
 cerebellum, as well as of the corpora quadrigemina, sub- 
 thalamic region, internal capsule, and temporal lobe. 
 When the process is distinctly one-sided, it is the oppo- 
 site ear which becomes deaf. This has a special bearing 
 in the case of abscesses of otitic origin situated in the 
 temporal lobe. 
 
 Besides actual deafness disease of the temporal lobe 
 may result in what has been termed word -deafness, or 
 amnesic aphasia. The patient hears, but does not under- 
 stand the significance of the words. He can repeat the
 
 DEAF-MUTISM. 537 
 
 words mentioned, but he cannot recall the words for inde- 
 pendent speech. This mental deafness is observed only 
 when the left temporal lobe is diseased in right-handed 
 subjects, or vice versa. 
 
 412. Purely functional deafness occurs at times in 
 hysteria. Neurologists often find that in hysteric sub- 
 jects unilateral anesthesia extends into the meatus up to 
 the drumhead and is accompanied by a one-sided reduc- 
 tion of hearing, of which the patient is not conscious. 
 The hearing can be restored by suggestive influences, 
 such as electricity or metallotherapy. More striking, 
 however, is the occasional occurrence of sudden absolute 
 bilateral deafness in hysteric subjects, usually due to emo- 
 tions or viciously concentrated attention and sometimes 
 accompanied by speechlessness. The absence of vertigo, 
 of nausea, and of subjective noises distinguishes the hys- 
 teric deafness from Menieire's disease. Under suggestive 
 influences hysteric deafness may disappear as suddenly 
 as it occurred, while otherwise it may last indefinitely. 
 
 DEAF-MUTISM. 
 
 413. Since speech is normally dependent upon the re- 
 tention and repetitions of auditory impressions, a child 
 born deaf cannot learn to speak in the normal way. 
 Bven after speech has been learned it is again forgotten 
 if deafness supervenes before a certain age. This age- 
 limit is about the seventh year, being somewhat variable 
 with the intelligence of the child. It is only after the 
 auditory centers have become fully developed that the 
 impressions once stored up in them remain permanent 
 without fresh additions. 
 
 Deaf-mutes are either born deaf or have become so dur- 
 ing early childhood. Both classes are about equal in 
 number. The proportion of deaf-mutes to the total popu- 
 lation is 66 in 100,000 in this country, and varies in 
 Europe from 43 in Holland to 245 in 100,000 in Switzer- 
 land. Males predominate slightly over females. Among 
 the determining conditions heredity is to be mentioned
 
 DEAF-MUTISM. 
 
 in the first place. Among the descendants of deaf-mutes 
 the defect occurs in every eleventh instance according to 
 statistics, while parents with normal hearing have but one 
 deaf child in every 10,000. Statistics further show that 
 the hereditary influence is not merely a matter of direct 
 transmission, but that the chances of deaf progeny are 
 very much increased by the occurrence of the same 
 anomaly among the brothers and sisters of the parents, 
 even if the latter be normal. The family influence is often 
 revealed by the multiple occurrence of deaf-mutism 
 among many or all the children of one family. It has 
 also been shown that the first child runs greater chances 
 of deafness than the subsequent offspring. Consanguinity 
 of the parents seems a predisposing factor ; more so, how- 
 ever, by the cumulative effect of unfavorable family 
 influences than merely by inbreeding. Other instances 
 of degeneration, idiocy, epilepsy, and retinitis pigmen- 
 tosa appear often in the family history. 
 
 The direct cause of congenital deafness is mainly an 
 inflammatory affection of the labyrinth, sometimes local- 
 ized more in the semicircular canals, sometimes more in 
 the cochlea. The inflammatory lesions are seen only in 
 early autopsies. In later examinations the labyrinth is 
 fcmnd ossified and sometimes apparently absent. Mal- 
 formations of the petrous bone, suggested by narrowness 
 or even obliteration of the internal meattis and a rudi- 
 mentary condition of the tympanic cavity, are not often 
 observed and may be secondary to a fetal labyrinthine 
 inflammation. In some instances the third frontal con- 
 volution of the left side of the cerebrum and the adjoin- 
 ing part of the island of Reil have been found atrophied, 
 evidently because the speech center has never become 
 developed. 
 
 Acquired deaf-mutism is the result of the various laby- 
 rinthine affections described in the previous chapter. In 
 most statistics cerebrospinal meningitis occupies the first 
 place in etiology. Next to it come scarlet fever, diph- 
 theria, measles, and syphilis. The other infectious dis-
 
 DEAF-MUTISM. 539 
 
 eases and brain diseases like internal hydrocephalus are 
 less frequent causes. 
 
 414. In acquired deaf-mutism the hearing is almost 
 always totally destroyed. In the congenital form, how- 
 ever, it is not uncommon to find remnants of auditory 
 perception comprising a small range of tones in different 
 parts of the scale. In the acquired form dizziness may 
 persist to a variable extent for many months after the 
 beginning, but it always ceases in the end. Most deaf- 
 mutes, however, do not possess perfect coordination, at 
 least in difficult movements. Feats of balancing, for 
 instance, are learned only with difficulty and depend 
 mainly on the control by sight On the other hand, the 
 majority of deaf-mutes are not made dizzy by whirling 
 on account of the destruction of the semicircular canals. 
 The intelligence of deaf-mutes is usually not impaired; 
 they are often very bright and observant. It is notice- 
 able, however, that they are apt to be emotional and lack 
 self-control, which may be partly the result of insufficient 
 training, partly the expression of a degenerative ten- 
 dency. A striking fact is the frequent occurrence of an 
 enlarged pharyngeal tonsil at least in one- third, and 
 according to some authors in two-thirds of all deaf- 
 mutes. However important the removal of this anomaly 
 may be, it must not be expected to benefit the hearing. 
 
 Unless specially trained, deaf-mutes utter no sounds 
 except a few inarticulate tones of emotional origin. 
 Their natural mode of communication is by gestures. 
 As a rule, they learn reading and writing very easily 
 under competent teachers. Formerly the letters were 
 taught them by sign language or by movements of the 
 fingers and hands. Their sphere of utility is, however, 
 much enlarged by learning to speak and to read language 
 by watching the lips. The younger the training is begun 
 the easier it is for a child to acquire this skill, and the 
 more nearly perfect will be his enunciation. The speech 
 of a deaf-mute will always betray him to an experienced 
 observer, but in many instances he can get along ex-
 
 54-O DEAF-MUTISM. 
 
 cellently for an active business career. Good teachers 
 prefer to begin instruction before the fourth year of life. 
 When there is any remnant of hearing left, its methodic 
 exercise enlarges the mental horizon and improves the 
 enunciation. The exercise is carried on by speaking into 
 an ear trumpet. 
 
 415. Deaf-mutism is in rare instances simulated by a 
 peculiar form of mental disturbance in children. This 
 was first described by Wilde, but has received very little 
 attention in otologic literature. Recently some cases 
 were reported by Moyer, and the writer has personally 
 seen 3 instances. These children do not acquire speech 
 and apparently do not understand words addressed to 
 them. Some of them are quite apathetic as regards 
 noises of any kind or as regards speech. Yet in several 
 instances closer tests showed that words spoken in only 
 moderately loud tones were distinctly heard when the 
 child's attention was enforced. The words could be cor- 
 rectly repeated, and when the child was willing, it could 
 follow commands which it evidently understood. There 
 was hence no complete deafness, though undoubtedly 
 some defect of hearing. Neither was there entire in- 
 activity of the sensory or motor parts of the speech 
 center. The defect is evidently one of mental origin, 
 and can probably be partially or wholly overcome by 
 persistent patient training.

 
 PLATE II. 
 
 FIG. I. Normal membrana tympani (left ear adult). 
 
 FIG. 2. Retracted drumhead; boy with adenoids and neglected Eusta 
 chian catarrh (right ear). 
 
 FIG. 3. Yellowish exudate within the tympanic cavity, seen through a 
 slightly cloudy drumhead in a middle-aged man who had had several previous 
 attacks of serous catarrh (right ear). 
 
 FIG. 4. Cloudy and slightly retracted membrane; elderly woman with 
 adhesive middle ear disease of long duration (right ear). 
 
 FIG. 5. Right drumhead in acute otitis which healed ultimately without 
 perforation (girl of eighteen years). 
 
 FIG. 6. An old healed scar in the (left) membrane after purulent otitis. 
 Hearing slightly impaired. 
 
 FIG. 7. Acute otitis media on the second day (right ear). 
 
 FIG. 8. The drumhead of Fig. 7 two days later, after paracentesis had 
 been done and gauze drainage maintained. 
 
 FIG. 9. Old case of suppuration of the attic with perforation in Shrap- 
 nell's membrane, through which the injected mucous membrane is visible ; the 
 (right) drumhead slightly cloudy and retracted ; fair hearing. 
 
 FIG. 10. Chronic purulent otitis dating back to scarlet fever, with large 
 perforation, through which the mucous membrane of the internal tympanic 
 wall is seen swollen and granulated (left ear). 
 
 FIG. II. The drumhead of Fig. 10 three weeks later, after the disease 
 had been healed by boric acid insufflations ; the tympanic lining is now pale 
 and smooth ; the handle of the hammer is adherent to the inner tympanic wall 
 (young girl). 
 
 FIG. 12. Defect caused by former caries in the bony margin around 
 Shrapnell's membrane; a cholesteatomatous collection in the attic protrudes 
 through the gap ; no discharge at the time ; fair hearing, although the drum- 
 head is thickened.
 
 PLATE II.
 
 NDEX. 
 
 A. 
 
 Abscess of brain, 518 
 
 mastoid, 479 
 
 subperiosleal, 478, 481 
 
 of nasal septum, 165 
 
 peritonsillar, 234 
 
 retropharyngeal, 236 
 
 subdural or extradural, 517 
 Accessory nasal cavities, 369. See 
 
 Sinus. 
 Adenoid vegetations, 249 
 
 operations of, 258 
 Adenoma of nose, 317 
 Age, influence of, in diseases of 
 
 nose and throat, 49 
 Air-conduction of sounds, 379, 400 
 Air-passages, development of, 17 
 
 mucous membrane of, 29 
 
 syphilis of, 293 
 
 vascular supply of, 32 
 Alas nasi, collapse of, 196 
 Alcohol, influence upon throat, 49, 
 
 239 
 
 Angina, 226 
 
 Angiomatous tumors of nose, 314 
 Annulus tympanicus, 351 
 Antisepsis of nasal wounds, 83 
 Antrum of Highmore, 120. See 
 
 Maxillary sinus. 
 Anvil, 360 
 Aprosexia, 252 
 
 Aqueducts of internal ear, 373 
 Asch operation, 210 
 Asthenopia of nasal origin, 341 
 Asthma, 336 
 Attic of middle ear, 354, 362 
 
 exposure by radical opera- 
 tion, 499 
 
 inflammation of, 469 
 
 Audiphone, 414 
 
 Auditory nerve, anatomy of, 535 
 
 diseases of, 536 
 Auricle, diseases of, 415 
 Autumnal catarrh, 272 
 
 B. 
 
 Bathing, injuries to ear in, 386 
 
 Baths, influence of, upon respira- 
 tory passages, 44 
 
 Belloc's sound, 80 
 
 Boiler-maker's deafness, 531 
 
 Bone-conduction of sounds, 380, 
 400 
 
 Brain, abscess of, 518 
 
 Bulla ethmoidalis, 113 
 
 Bursa, pharyngeal, 246 
 
 c. 
 
 Caisson disease, 531 
 Cancer of nose, 317 
 
 of pharynx, 320 
 
 Caries in middle-ear disease, 506 
 Catarrh, autumnal, 272 
 
 chronic nasal, classification of, 
 92 
 
 Eustachian, 429 
 
 proliferative, of middle ear, 442 
 
 retronasal, 174 
 
 serous, of middle ear, 433 
 
 syphilitic, of middle ear, 442 
 Cauterization in the nose, 74 
 Cavernous tissue in nose, 33 
 
 enlargement of, 168 
 Cerebrospinal meningitis, 533 
 Cerumen glands, 350 
 
 plugs of, 420 
 Cholesteatoma, 508 
 
 541
 
 542 
 
 INDEX. 
 
 Chondroma of nose, 316 
 Chorda tympani nerve, 354 
 
 division of, 510 
 Chorea, reflex nasal, 340 
 Chromic acid, cauterization with, 
 
 74 
 Cicatrices in drumhead, 406 
 
 in pharynx, 326 
 Climate, influence of, 45 
 Cocain, 71 
 Cochlea, 371 
 Cochlear duct, 374 
 Cold feet, influence of, 43 
 
 prevention of, 42 
 
 taking, 40 
 
 Collapse of alae nasi, 196 
 Concretions, tonsillar, 238 
 Coryza, 86 
 
 complications of, 89 
 
 diagnosis of, 90 
 
 treatment of, 90 
 
 vasomotoria, 171 
 Cough, reflex, 336 
 Crests on septum, 204 
 
 operation upon, 214 
 Cysts in maxillary sinus, 135 
 
 of nose, 315 
 
 D. 
 
 Deaf-mutism, 537 
 
 of mental origin, 540 
 Deafness, boilermaker's, 531 
 
 hysterical, 537 
 Development of air-passages, 17 
 
 of ear, 345 
 Diabetes, 311 
 Diphtheria, 279 
 
 bacillus of, 283 
 
 influence of, upon ear, 390, 
 466 
 
 nasal, 167, 282 
 Diplacusis, 396, 527 
 Drumhead, 354. See Membrana 
 tympani. 
 
 artificial, 494 
 
 cicatrices in, 406 
 
 paracentesis of, 412 
 Duct, cochlear, 374 
 
 E. 
 
 Ear, anatomy of, 347 
 development of. 345 
 diseases, etiology of, 386 
 microbic parasites of, 389 
 symptoms of, 394 
 foreign bodies in, 423 
 frost-bites of, 426 
 hemorrhage from, 427 
 inflation of, 408 
 injuries of, 427 
 internal, 370 
 
 syphilis of, 533 
 middle, 353 
 syphilis of, 441 
 tuberculosis of, 510 
 physiology of, 376 
 speculum, 403 
 trumpets, 413 
 tumors of, 425 
 
 Earache, 394. See also Otalgia. 
 Eczema of auricle of ear, 416 
 
 of nasal vestibule, 85 
 Edema of nasal mucous mem- 
 brane, 185 
 of uvula, 223 
 Electrolysis of Eustachian tube, 
 
 450 
 
 of septum hypertrophies, 125 
 Embryologic formation of nose, 
 
 17, 18 
 
 of palate, 18 
 
 Empyema, multiple, of sinuses, 152 
 of frontal sinus, 137 
 of maxillary sinus, 126 
 of ethmoid cells, 144 
 Epilepsy, reflex nasal, 340 
 Epistaxis, 220 
 Equilibrium, sense of, 380 
 Ethmoid bone, anatomy of, 109 
 cells, 113 
 
 operation upon, 148, 153 
 suppuration of, 144 
 Ethmoiditis, necrosing, 148 
 Ethmoturbinal lamellae, 19, in, 
 
 112 
 Etiology of ear disease, 386 
 
 of nasal and pharyngeal diseases, 
 40
 
 INDEX. 
 
 543 
 
 Eustachian tube, anatomy of, 363 
 
 catarrh of, 429 
 
 catheter, 409 
 
 electrolysis of, 450 
 
 inflation of, 408 
 
 patency of, 407 
 
 stenosis of, 446 
 
 Exophthalmic goiter, reflex nasal, 
 340 
 
 F. 
 
 Facial paralysis in ear disease, 
 
 510 
 Fibroma of nose, 315 
 
 of pharynx, 318 
 Fissures in nasal vestibule, 85 
 Foreign bodies in ear, 423 
 
 in nose, 322 
 
 Fossa, Rosenmuller's, 29 
 Fractures at the base of skull, 427 
 of external nose, 324 
 of septum, 206, 324 
 Frontal sinus, 1 16 
 
 acute inflammation of, 137 
 chronic inflammation of, 137 
 operations upon, 142, 153 
 Frost-bites of ear, 426 
 Furuncles in meatus of ear, 418 
 in nasal vestibule, 86 
 
 G. 
 
 Gallon whistle, 400 
 Galvanocaustic apparatus, 75, 76 
 Gelle's test, 401 
 Globus hystericus, 240 
 Goiter, exophthalmic, reflex nasal, 
 340 
 
 H. 
 
 Habits, influence of, on nasal and 
 
 pharyngeal diseases, 48 
 Hammer, 360 
 Hay-fever, 272 
 Hearing, acuity of, 396 
 
 tests, 398 
 Hemorrhage from the ear, 427 
 
 from the nose, 79, 220 
 Heredity, influence of, upon ear 
 diseases, 393 
 
 in nasal diseases, 47 
 
 Herpes of pharynx, 310 
 
 zoster, 311 
 Hysterical deafness, 537 
 
 mimicry of Meniere's disease, 
 529 
 
 I. 
 
 Illumination of ear, 403 
 
 of nose and throat, 54 
 Influenza, 310 
 
 otitis, 475 
 Injuries of ear, 427 
 
 of nose, 324 
 
 Instruments, sterilization of, 81 
 Internal ear, anatomy of, 370 
 
 diseases of, 526 
 lodism, 312 
 
 J. 
 
 Jugular vein, phlebitis of, 523, 525 
 
 L. 
 
 Labyrinth, 370. See also Internal 
 
 ear. 
 
 ethmoid, no 
 of ear, 370 
 
 apoplexy of, 528 
 rarefaction of capsule of, 457 
 Lateral sinus, 369 
 
 thrombosis of, 522 
 Leprosy, 306 
 Leukocythemia, 310 
 Lingual tonsil, 225. See Tonsil, 
 
 lingual. 
 
 Loffler's solution, 70, 291 
 Lumbar puncture, diagnostic, 515 
 Luschka's tonsil, 225. See Tonsil, 
 pharyngeal. 
 
 M. 
 
 Maggots in nose, 323 
 Malleus, 360 
 Massage in ozena, 162 
 
 pneumatic, of ear, 406 
 Mastoid abscess, 478, 479, 481 
 
 antrum, 366 
 
 operation, 481, 499 
 
 subperiosteal abscess, 478, 481
 
 544 
 
 INDEX. 
 
 Mastoiditis, 476 
 results of, 477 
 Maxillary sinus, 120 
 
 acute inflammation of, 125 
 chronic inflammation of, 126 
 cysts of, 135 
 operations upon, 131 
 translumination of, 129 
 Measles, 308 
 
 influence upon ear, 390, 462, 466 
 Meatus, external, of ear, anatomy 
 
 of, 348 
 at birth, 351 
 
 diffuse inflammation of, 417 
 foreign bodies in, 423 
 furuncles of, 418 
 mycosis of, 419 
 occlusion of, 425 
 operative detachment of, 424 
 internal, 372 
 Membrana tympani, anatomy of, 
 
 354 
 
 morbid appearance of, 404 
 normal appearance of, 402 
 paracentesis of, 412, 453 
 perforations in, 405 
 ruptures of, 427 
 Meniere's disease, 528 
 
 symptoms, 529 
 
 Meningitis, cerebrospinal, 533 
 of otitic origin, 514, 520 
 serous, 521 
 Menthol, 74 
 Middle ear, adhesive inflammation 
 
 of, 442 
 
 operations on, 453 
 sclerosis of, 457 
 serous or exudative catarrh of, 
 
 441 
 
 syphilitic catarrh of, 441 
 turbinal, resection of, 106 
 Mouth-breathing, 52, 195 
 Mucocele, 100. See Sinuitis. 
 Mumps, 532 
 Myringitis, 427 
 
 N. 
 
 Nasal douche, 66 
 danger of, 67 
 
 Nasal hemorrhage, 220 
 
 hydrorrhea, 222 
 
 mucous membrane, 30, 31 
 
 papillomata, 192 
 
 passages, anatomy of, 20-26 
 cavernous tissue in, 32, 33 
 development of, 17, 1 8 
 disease, influence of, upon ear, 
 
 387 
 
 external wall of, 23 
 infantile, 19 
 nerves of, 35 
 obstruction of, 51 
 occlusion of, 198 
 physiology of, 36, 37 
 polypi, 187 
 secretions, 52 
 stenosis, 194 
 synechiae, 197 
 wounds, antisepsis of, 83 
 Necrosis of bone in middle ear, 506 
 
 syphilitic, of nose, 297 
 Neuroses, nasal, 332 
 Nirvanin, 72 
 Nose, adenoma of, 317 
 bridge of, 20 
 cancer of, 317 
 chondroma of, 316 
 cysts of, 315 
 fibroma of, 315 
 foreign bodies in, 322 
 fractures of, 324 
 hemorrhage from, 79, 220 
 injuries of, 324 
 irritable, 1 68, 171 
 maggots in, 323. 
 necrosis of, syphilitic, 297 
 normal appearances in, 57, 58 
 osteoma of, 316 
 redness of, 86 
 tuberculosis of, 303 
 tumors of, 314 
 
 o. 
 
 Obstruction of nasal passages, 51, 
 
 52 
 
 Occlusion of meatus of ear, 425 
 of nasal passages, 198 
 by edema, 185
 
 INDEX. 
 
 545 
 
 Odor in chronic purulent otitis, 488, 
 
 491 
 
 of nasal secretions, 53 
 Olfactory nerve, distribution of, 35 
 Orthoform, 77 
 Ossicles of drum, 359 
 
 removal of, 454 
 Ossiculectomy, 454 
 Osteoma in chronic purulent otitis, 
 
 498 
 
 of nose, 316 
 Otalgia, 512 
 
 Otitis media, acute purulent, 465 
 chronic purulent, 488 
 
 with retention of pus, 491 
 of influenza, 475 
 of nurslings, 461 
 simple, 461, 463 
 Otomycosis, 419 
 Ozena, 155 
 
 simulated by ethmoid suppura- 
 tion, 145 
 syphilitic, 300 
 treatment of, 160 
 
 P. 
 
 Papillomata in pharynx, 319 
 
 nasal, 192, 313 
 
 Paralysis, facial, in ear disease, 510 
 Parasites, animal, in nose, 323 
 Perichondritis of auricle, 416 
 Pharyngeal bursa, 246 
 
 tonsil, 225. See Tonsil, pharyn- 
 
 geal. 
 Pharyngitis, acute, 232 
 
 chronic, 238 
 
 granular, 238 
 
 sicca, 247 
 
 suppurative, 244 
 Pharyngomycosis, 243 
 Pharynx, anatomy of, 27, 28, 29 
 
 at birth, 20 
 
 blood-vessels of, 33 
 
 cancer of, 320 
 
 cicatrices in, 326 
 
 development of, 18 
 
 fibroma of, 318 
 
 herpes of, 310 
 
 mucous membrane of, 30 
 35 
 
 Pharynx, nerves of, 35 
 
 normal appearances in, 59-66 
 
 physiology of, 38, 39 
 
 tuberculosis of, 303 
 
 tumors of, 318 
 
 Phlebitis of lateral sinus, 514, 522 
 Physiology of hearing, 376 
 
 of semicircular canals, 380 
 Plugs, cerumen, in ear, 420 
 
 epidermis, in ear, 421 
 Pneumatic massage of ear, 406 
 Politzer's inflation of ear, 408 
 Polypi in ear, 505 
 
 nasal, 187, 313 
 
 Polypus, bleeding, of septum, 314 
 Promontory of drum cavity, 358 
 Prussak's space, 362 
 Pyemia of otitic origin, 522 
 
 Q. 
 
 Quinin, influence of, upon ear, 532 
 Quinsy, 234 
 
 R. 
 
 Radical (mastoid) operation, 499 
 Rarefaction of capsule of laby- 
 rinth, 457 
 
 Reflex neuroses, 332 
 Retropharyngeal abscess, 236 
 Rheumatic sore throat, 312 
 Rheumatism, 311 
 Rhinitis, acute purulent, 86 
 
 caseosa, 95 
 
 chronic, 93 
 
 diphtheritic, 167 
 
 dry anterior, 163 
 
 hypertrophic, 177 
 treatment of, 182 
 
 membranous, 166 
 
 purulent, of children, 98 
 
 simple chronic, 177 
 
 subacute, of scrofulous children, 
 
 98 
 
 Rhinoscleroma, 306 
 Rhinoscopy, anterior, 56 
 
 posterior, 64 
 Rinne's test, 400 
 Rose-cold, 273 
 Rosenmiiller's fossa, 29
 
 546 
 
 INDEX. 
 
 s. 
 
 Sacculus, 373 
 
 Salicylates, influence of, upon ear, 
 
 532 
 Scarlet fever, 308 
 
 influence of, upon ear, 390, 462, 
 
 466 
 
 Sclerosis of middle ear, 457 
 Scrofulosis, 305 
 
 and enlarged pharyngeal tonsil, 
 
 256 
 
 Secretions, nasal, 52 
 Septicemia of otitic origin, 522 
 Septum, nasal, 200 
 abscess of, 165 
 anatomy of, 200 
 asymmetry of, 202 
 crests upon, 204 
 deformities of, 208 
 fracture of, 206, 324 
 hematoma of, 165 
 hypertrophies on, 181 
 operations upon, 210-219 
 polypus of, 314 
 resection of, 213 
 ulcer of, 164 
 
 Sinuitis, complications of, 102 
 diagnosis of, 105 
 ethmoid, 144 
 etiology of, 104 
 frontal, 116 
 in general, 101 
 maxillary, 125 
 
 treatment of, 106 
 pathology of, 103 
 sphenoid, 150 
 Sinus, frontal, 116 
 
 inflammation of, 137 
 operations upon, 142, 153 
 lateral, 369 
 
 thrombosis of, 522 
 maxillary, 120 
 sigmoid, 369 
 thrombosis, 522 
 Skull, fracture at base of, 427 
 Small-pox, 309 
 Snare for the ear, 306 
 galvanocaustic, 79 
 nasal, 77, 78 
 
 Sneezing, 53 
 
 fits, 171, 335 
 Sound, Belloc's, 80 
 Sounds, conduction of, 379, 400 
 Specula, nasal, 55, 56 
 Speculum, aural, 403 
 
 Siegle's, 406 
 Sphenoid sinus, 117 
 
 inflammation of, 150 
 operation upon, 151 
 Sprays, 68, 69 
 Stapes, 360 
 
 ankylosis of, 459 
 Static sense, 38 
 Stenosis, nasal, 194 
 
 of Eustachian tube, 446 
 
 of meatus of ear, 425 
 Sterilization of cotton swabs, 82 
 
 of instruments, 81 
 Sterilizer, 81 
 Suprarenal solution, 73 
 Synechiae in nose, 197 
 Syphilis of air-passages, 293 
 
 of internal ear, 533 
 
 of middle ear, 441 
 
 T. 
 
 Tabes, ear affections in, 536 
 Teeth, influence of, upon ear, 392 
 Tensor tympani muscle, 353. See 
 
 Tympanic cavity. 
 tenotomy of, 455 
 Throat, rheumatic sore, 312 
 Thrombosis of lateral sinus, 522 
 Tinnitus; 395 
 Tobacco, influence of, upon throat, 
 
 47. 239 
 Tone-series, Bezold's continuous, 
 
 398 
 
 Tonsil, faucial, anatomy of, 224 
 hypertrophy of, 264 
 inflammation of, acute, 226 
 
 chronic, 238 
 lingual, 225 
 
 inflammation of, 231 
 phlegmonous inflammation of, 
 
 235 
 pharyngeal, 225
 
 INDEX. 
 
 547 
 
 Tonsil, pharyngeal, hypertrophy of, 
 
 249 
 
 inflammation of, 232 
 operations upon, 259 
 Tonsillar concretions, 238 
 Tonsillitis, acute, 226 
 
 chronic, 238 
 Translumination of maxillary sinus, 
 
 129 
 Trichloracetic acid, cauterization 
 
 with, 74 
 Tuberculosis of middle ear, 510 
 
 of nose and pharynx, 303 
 Tumors of ear, 425 
 of nose, 313 
 of pharynx, 318 
 Turbinated process, anatomy of, 
 
 24, 58, 108, 113 
 Turbinectomy, 184 
 Tympanic cavity, anatomy of, 
 
 353 
 Typhoid fever, 309 
 
 as cause of ear disease, 391 
 
 U. 
 
 Umbo, 360 
 
 Uncinate process, in 
 Utriculus, 373 
 Uvula, 28 
 edema of, 223 
 
 V. 
 
 Valsalva's experiment, 379 
 Varicose veins in pharynx, 239 
 Vegetations, adenoid, 249, 258 
 Vein, jugular, phlebitis of, 523, 525 
 Vertigo from ear disease, 395 
 
 from semicircular canals, 384 
 Vestibule of internal ear, 37 
 
 nasal diseases of, 85 
 Voice in adenoid vegetations, 250 
 
 W. 
 
 Weber's test, 401 
 Whistle, Gallon's, 400 
 Wilde's incision, 481
 
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 M. D., Professor of Ophthalmology, Jefferson Medical College, Phila- 
 delphia. With 152 colored figures and 82 pages of text. Cloth, $3.00 
 net. 
 
 ADDITIONAL VOLUMES IN PREPARATION. 
 18
 
 Saunders' Medical Hand-Atlases. 
 
 VOLUMES JUST ISSUED. 
 
 Atlas and Epitome of Bacteriology. 
 
 Including a Hand-Book of Special Bacteriologic Diagnosis. By PROF. 
 -DR. K. jd. LEHMANN and DR. R. O. NEUMANN, of Wurzburg. From 
 the Second Enlarged and Revised German Edition. Edited, with addi- 
 tions, by G. H. WEAVER, M. D., Assistant Professor of Pathology and 
 Bacteriology, Rush Medical College, Chicago. In Two Parts. Part I., 
 consisting of 632 colored illustrations on 69 lithographic plates. Part II., 
 consisting of 511 pages of text, illustrated. Per part: Cloth, $2.50 net. 
 
 Atlas and Epitome of Otology. 
 
 By DR. GUSTAV BRUHL, of Berlin, with the collaboration of PROF. DR. 
 A. POLITZER, of Vienna. Edited, with additions, by S. -MAcCuEN 
 SMITH, M. D., Clinical Professor of Otology, Jefferson Medical College, 
 Philadelphia. 244 colored figures on 39 plates, 99 text-cuts, and 292 
 pages of text. Cloth, $3.00 net. 
 
 Atlas and Epitome of Abdominal Hernias. 
 
 By PRIVATDOCENT DR. GEORG SULTAN, of Gottingen. Edited, with 
 additions, by WILLIAM B. COLEY, Clinical Lecturer on Surgery, Colum- 
 bia University (College of Physicians and Surgeons), New York ; Sur- 
 geon to the General Memorial Hospital, New York. With 43 colored 
 figures, on 36 plates, 100 text-cuts, and 250 pages of text. In Press. 
 
 Atlas and Epitome of Fractures and Luxations. 
 
 By PROF. DR. H. HELFERICH, of Greifswald. Edited, with additions, by 
 JOSEPH C. BLOODGOOD, Associate in Surgery, Johns Hopkins University, 
 Baltimore. With 215 colored figures on 72 plates, 144 text-cuts, 42 
 skiagraphs, and over 300 pages of text. In Press. 
 
 Atlas and Epitome of Diseases of Mouth, Throat, and 
 Nose. 
 
 By DR. L. GRUNWALD, of Munich. From the Second Revised and 
 Enlarged German Edition. Edited, with additions, by JAMES E. NEW- 
 COMB, M. D., Clinical Instructor in Laryngology, Cornell University 
 Medical School. With 42 colored figures, 39 text-cuts, and 225 pages 
 of text. In Press. 
 
 Atlas and Epitome of Normal Histology. 
 
 By PRIVATDOCENT DR. J. SOBOTTA, of Wurzburg. Edited, with addi- 
 tions, by G. CARL HUBER, M. D., Junior Professor of Anatomy and 
 Director of the Histological Laboratory, University of Michigan. With 
 80 colored figures and 68 text-cuts from the original of W. Freytag, and 
 2 75 pages of text. 
 
 Atlas and Epitome of Operative Gynecology. 
 
 By DR. OSKAR SCHAEFFER, Privatdocent at the University of Heidel- 
 berg. With 42 colored figures and 21 text-cuts from the original of A. 
 Schmitson, and 1 25 pages of text. 
 
 ADDITIONAL VOLUMES IN PREPARATION. 
 19
 
 NOTHNAGEL'S ENCYCLOPEDIA 
 
 OF 
 
 PRACTICAL MEDICINE 
 
 AMERICAN EDITION 
 
 Edited by ALFRED STENGEL, M. D. 
 
 Professor of Clinical Medicine in the University of Pennsylvania; Visiting 
 Physician to the Pennsylvania Hospital 
 
 ris universally acknowledged that the Germans lead the world in Internal 
 Medicine ; and of all the German works on this subject, NothnagePs " Speci- 
 
 elle Pathologic und Therapie " is conceded by scholars to be without question 
 the best System of Medicine in existence. So necessary is this book in the study 
 of Internal Medicine that it comes largely to this country in the original German. 
 In view of these facts, Messrs. W. B. Saunders & Company have arranged with 
 the publishers to issue at once an authorized American edition of this great ency- 
 clopedia of medicine. 
 
 For the present a set of ten volumes, representing the most practical part 
 of this excellent encyclopedia, and selected with especial thought of the needs 
 of the practical physician, will be published. These volumes will contain the 
 real essence of the entire work, and the purchaser will therefore obtain at less 
 than half the cost the cream of the original. Later the special and more strictly 
 scientific volumes will be offered from time to time. 
 
 The work will be translated by men possessing thorough knowledge of both 
 English and German, and each volume will be edited by a prominent specialist 
 on the subject to which it is devoted. It will thus be brought thoroughly up to 
 date, and the American edition will be more than a mere translation of the Ger- 
 man ; for, in addition to the matter contained in the original, it will represent the 
 very latest views of the leading American and English specialists in the various 
 departments of Internal Medicine. The whole System will be under the edi- 
 torial supervision of Dr. Alfred Stengel, who will select the subjects for the 
 American edition, and arrange for the editing of the different volumes. 
 
 Unlike most encyclopedias, the publication of this work will not be extended 
 over a number of years, but five or six volumes will be issued during the coming 
 year, and the remainder of the series at the same rate. Moreover, each volume 
 will be revised to the date cf its publication by the eminent editor. This will 
 obviate the objection that has heretofore existed to systems published in a number 
 of volumes, since the subscriber will receive the completed work while the earlier 
 volumes are still fresh. 
 
 The usual method of publishers, when issuing a work of this kind, has been 
 to compel physicians to take the entire System. This seems to us in many cases 
 to be undesirable. Therefore, in purchasing this encyclopedia, physicians will be 
 given the opportunity of subscribing for the entire System at one time ; but any 
 single volume or any number of volumes may be obtained by those who do not 
 desire the complete series. This latter method, while not so profitable to the pub- 
 lisher, offers to the purchaser many advantages which will be appreciated by those 
 who do not care to subscribe for the entire work at one time. 
 
 This American edition of Nothnagel's Encyclopedia will, without question, 
 form the greatest System of Medicine ever produced, and the publishers are con- 
 fident that it will meet with general favor in the medical profession. 
 
 20
 
 NOTHNAGEL'S 
 ENCYCLOPEDIA OF PRACTICAL MEDICINE. 
 
 AMERICAN EDITION. 
 
 VOLUMES JUST ISSUED AND IN PRESS. 
 
 TYPHOID AND TYPHUS FEVERS. By DR. H. CURSCHMANN, of Leipsic. 
 
 Editor, William Osier, M.D., F.R.C.P., Professor of the Principles and Practice of 
 Medicine in Johns Hopkins University, Baltimore. Handsome octavo, 646 pages, 
 72 valuable text illustrations, and two lithographic plates. Cloth, $5.00 net; Half 
 Morocco, $6.00 net. Just Ready. 
 
 VARIOLA (including VACCINATION). By DR. H. IMMERMANN, of Basle. VARI- 
 CELLA. By DR. TH. VON JURGENSEN, of Tubingen. CHOLERA ASIATICA 
 and CHOLERA NOSTRAS. By DR. C. LIEBERMEISTKR, of Tubingen. ERY- 
 SIPELAS and ERYSIPELOID. By DR. H. LENHARTZ, of Hamburg. PER- 
 TUSSIS and HAY-FEVER. By DR. G. STICKER, of Giessen. 
 Editor, Sir J. W. Moore, B.A., M.D., F.R.C.P.I., Professor of the Practice of Medi- 
 cine, Royal College of Surgeons, Ireland. Handsome octavo of 682 pages, illustrated. 
 Cloth, $5.00 net; Half Morocco, $6.00 net. Just Ready. 
 
 DIPHTHERIA. An original article by WILLIAM P. NORTHRUP, M.D., of New York. 
 Measles, Scarlet Fever, Rotheln. By DR. TH. VON JORGENSEN, of Tubingen. 
 Editor, William P. Northrup, M. D., Professor of Pediatrics, University and Bellevue 
 Medical College, N. Y. Handsome octavo, 672 pages, illustrated, including 24 full- 
 page plates, 3 in colors. Cloth, $5- co net > Half Morocco, $6.00 net. Just Ready. 
 
 DISEASES OF THE BRONCHI. By DR. F. A. HOFFMANN, of Leipsic. DIS- 
 EASES OF THE PLEURA. By DR. O. ROSENBAUM, of Berlin. PNEUMONIA. 
 By DR. E. AUFRECHT, of Magdeburg. 
 
 Editor, John H. Musser, M. D., Professor of Clinical Medicine, University of Pennsyl- 
 vania. Handsome octavo, 700 pages, 7 full-page lithographs in colors. Cloth, $5.00 
 net ; Half Morocco, $6.00 net. just Ready. 
 
 DISEASES OF THE LIVER. By DRS. H. QUINCKE and G. HOPPE-SEYLER, of Kiel. 
 DISEASES OF THE PANCREAS. By DR. L. OSER, of Vienna. DISEASES 
 OF THE SUPRARENALS. By DR. E. NEUSSER, of Vienna. 
 
 Editors, Frederick A. Packard, M.D., Physician to the Penna. and the Children's 
 Hospitals, Phila. ; and Reginald H. Fitz, A. M., M. D., Hersey Prof, of the Theory 
 and Practice of Physic, Harvard Univ. Handsome octavo of 75 P a g es > illustrated. 
 Cloth, $5.00 net ; Half Morocco, $6.00 net. Just Ready. 
 
 INFLUENZA AND DENGUE. By DR. O. LEICHTENSTERN, of Cologne. MALA- 
 RIAL DISEASES. By DR. J. MANNABERG, of Vienna. 
 
 Editor, Ronald Ross, F.R.C.S., Eng., D.P.H., F.R.S., Major, Indian Medical 
 Service, retired ; Walter Myers, Lecturer, Liverpool School of Tropical Medicine, 
 Liverpool. Handsome octavo, 700 pages, 7 full-page lithographs in colors. 
 
 ANEMIA, LEUKEMIA, PSEUDOLEUKEMIA, HEMOGLOBINEMIA. By DR. P. 
 
 EHRLICH, of Frankfort-on-the-Main, DR. A. LAZARUS, of Chailcttenburg, and DR. 
 FELIX PINKUS, of Berlin. CHLOROSIS. By DR. K. VON NOORDEN, of Frank- 
 fort-on-the-Main. 
 
 Editor, Alfred Stengel, M.D., Professor of Clinical Medicine, University of Pennsyl- 
 vania. Handsome octavo, 750 pages, 5 full-page lithographs in colors. 
 
 TUBERCULOSIS AND ACUTE GENERAL MILIARY TUBERCULOSIS. By 
 
 DR. G. CORNET, of Berlin. 
 
 Editor to be announced later. Handsome octavo, 700 pages. 
 
 DISEASES OF THE STOMACH. By DR. F. RIEGEL, of Giessen. 
 
 Editor, Charles G. Stockton, M.D., Professor of Medicine, University of Buffalo. 
 Handsome octavo, 800 pnges, with 29 text-cuts and 6 full-page plates. 
 
 DISEASES OF THE INTESTINES AND PERITONEUM. By DR. HERMANN 
 NOTHNAGKL, of Vienna. 
 
 Editor, Humphry D. Rolleston. M.D., F.R.C.P., Physician to and Lecturer on Pathol- 
 ogy at St. George's Hospital, London. Handsome octavo, 800 pages, finely illustrated. 
 
 21
 
 CLASSIFIED LIST 
 
 OF THE 
 
 MEDICAL PUBLICATIONS 
 
 OF 
 
 W. B. SAUNDERS O COMPANY 
 
 ANATOMY, EMBRYOLOGY, 
 
 HISTOLOGY. 
 
 Bbhm, Davidoff, and Huber Histology, . 4 
 
 Clarkson A Text-Book of Histology, . . 5 
 
 Haynes A Manual of Anatomy, .... 8 
 
 Heisler A Text-Book of Embryology, . . 8 
 
 Leroy Essentials of Histology, 16 
 
 McClellan Art Anatomy 10 
 
 McClellan Regional Anatomy, 16 
 
 Nancrede Essentials of Anatomy, . . . . 16 
 Nancrede Essentials of Anatomy and 
 
 Manual of Practical Dissection, . . . . n 
 
 Sobotta Atlas of Normal Histology, . . 19 
 
 BACTERIOLOGY. 
 
 Ball Essentials of Bacteriology 16 
 
 Eyre Bacteriologic Technique 7 
 
 Frothingham Laboratory Guide 7 
 
 Qorham Laboratory Bacteriology, ... 7 
 Lehmann and Neumann Atlas of Bacte- 
 riology 19 
 
 Levy and Klemperer's Clinical Bacteri- 
 ology 10 
 
 Mallory and Wright Pathological Tech- 
 nique 10 
 
 McFarland Pathogenic Bacteria n 
 
 CHARTS, DIET-LISTS, ETC 
 
 Griffith Infant's Weight Chart, 8 
 
 Keen Operation Blank 9 
 
 Laine Temperature Chart 10 
 
 Meigs Feeding in Early Infancy n 
 
 Starr Diets for Infants and Children, . . 13 
 
 Thomas Diet-Lists 14 
 
 CHEMISTRY AND PHYSICS. 
 
 Brockway Essentials of Medical Physics, 
 Jelliffe and Diekman Chemistry, . . . 
 
 Wolf Urine Examination, 
 
 Wolff Essentials of Medical Chemistry, . 
 
 CHILDREN. 
 American Text-Book Dis. of Children, . . 
 
 Griffith Care of the Baby 
 
 Griffith Infant's Weight Chart, 
 
 Meigs Feeding in Early Infancy 
 
 Powell Essentials of Diseases of Children, 
 Starr Diets for Infants and Children, . . 
 
 DIAGNOSIS. 
 
 Cohen and Eshner Essentials of Diag- 
 nosis 
 
 Corwln Physical Diagnosis, 
 
 Vierordt Medical Diagnosis, 
 
 DICTIONARIES. 
 
 The American Illustrated Medical Dic- 
 tionary, 
 
 The American Pocket Medical Dictionary, 
 Morten Nurses' Dictionary 
 
 EYE, EAR, NOSE, AND THROAT. 
 
 An American Text-Book of Diseases of 
 
 the Eve, Ear, Nose, and Throat i 
 
 Briihl and Politzer Atlas of otology, . 19 
 TJeSchweinitz Diseases of the Eye, . . 6 
 Friedrich and Curtis Rhinology, Laryn- 
 gology and Otology 7 
 
 Gleason Essentials of Diseases of the Ear, 16 
 
 Gleason Ess. of Dis. of Nose and Throat, 16 
 
 Gradle Ear, Nose, and Throat, 7 
 
 Grant Surgery of Face, Mouth, and Jaws, 8 
 Griinwald Atlas of Mouth, Throat, and 
 
 Nose . . 19 
 
 Griinwald Atlas of Diseases of the 
 
 Larynx 17 
 
 Haab Atlas of External Diseases of the 
 
 Eye, 17 
 
 Haab Atlas of Ophthalmoscopy 18 
 
 Jackson Manual of Diseases of the Eye, 9 
 
 Jackson Essentials of Diseases of Eye, 16 
 
 Kyle Diseases of the Nose and Throat, . 9 
 
 GENITO-URINARY. 
 
 An American Text-Book of Gem to- 1 Jri- 
 naryand Skin Diseases, 2 
 
 Hyde and Montgomery Syphilis and the 
 Venereal Diseases 8 
 
 Martin Essentials of Minor Surgery, 
 Bandaging, and Venereal Diseases, . . 16 
 
 Mracek Atlas of Syphilis and the Vene- 
 real Diseases I 7 
 
 Saundby Renal and Urinary Diseases, . . 12 
 
 Senn Genito-Urinary Tuberculosis, ... 13 
 
 Vecki Sexual Impotence 15 
 
 GYNECOLOGY. 
 
 American Text-Book of Gynecology, . . 2 
 
 Cragin Essentials of Gynecology, . . . . 16 
 
 Garrigues Diseases of Women 7 
 
 Long Syllabus of Gynecology, i 
 
 Penrose Diseasesof Women, . ..'... n 
 
 Schaeffer Atlas of Operative Gynecology, 19 
 
 Sclaaeffer Atlas of Gynecology 18 
 
 HYGIENE. 
 
 Abbott Hygiene of Transmissible Diseases 4 
 
 Bergey Principles of Hygiene 4 
 
 Pyle Personal Hygiene, 12 
 
 MATERIA MEDICA, PHARMACOL- 
 OGY, AND THERAPEUTICS. 
 
 American Text-Book of Therapeutics, . . i 
 Butler Text-Book of Materia Medica, 
 
 Therapeutics, and Pharmacology, ... 5 
 
 Morris Ess. of M. M. and Therapeutics, 16 
 
 Saunders' Pocket Medical Formulary, . . 12 
 
 Sayre Essentials of Pharmacy, 16 
 
 Sollmann Text- Book of Pharmacology, . 13 
 
 Stevens Manual of Therapeutics, ... 14 
 
 Stoney Materia Medica for Nurses, . . 14 
 
 Thornton Prescription-Writing 15 
 
 22
 
 MEDICAL PUBLICATIONS OF W. B. SAUNDERS & CO. 23 
 
 MEDICAL JURISPRUDENCE AND 
 TOXICOLOGY. 
 
 Chapman M e d i c a 1 J urisprudence and 
 
 Toxicology 5 
 
 Crothers Morphinism 6 
 
 Golebiewski Atlas of Diseases Caused by 
 
 Accidents, 18 
 
 Hofmann Atlas of Legal Medicine, ... 17 
 
 NERVOUS AND MENTAL 
 DISEASES, ETC. 
 
 Brower Manual of Insanity 5 
 
 Chapin Compendium of Insanity, ... 5 
 Church and Peterson Nervous and Men- 
 tal Diseases 5 
 
 Jakob -Atlas of Nervous System, . . . 18 
 Shaw Essentials of Nervous Diseases and 
 
 Insanity 16 
 
 NURSING. 
 
 Davis Obstetric and Gynecologic Nursing, 6 
 
 Griffith The Care of the Baby 8 
 
 Meigs Feeding in Early Infancy n 
 
 Morten Nurses' Dictionary n 
 
 Stoney Materia Medica for Nurses, . . 14 
 
 Stoney Practical Points in Nursing, . . 14 
 
 Stoney Surgical Technic for Nurses, . . 14 
 
 Watson Handbook for Nurses, 15 
 
 OBSTETRICS. 
 
 An American Text-Book of Obstetrics, . 2 
 
 Ashton Essentials of Obstetrics 16 
 
 Boisliniere Obstetric Accidents 4 
 
 Borland Modern Obstetrics 6 
 
 Bint Text-Book of Obstetrics 8 
 
 Norris Syllabus of Obstetrics, n 
 
 Schaeffer Atlas of Labor and Operative 
 
 Obstetrics . . 18 
 
 Schaeffer Atlas of Obstetrical Diagnosis 
 
 and Treatment, 18 
 
 PATHOLOGY. 
 
 An American Text-Book of Pathology, . 2 
 Diirck Atlas of Pathologic Histology, . . 17 
 Kalteyer Essentials of Pathology, . . . 16 
 Mallory and Wright Pathological Tech- 
 nique 10 
 
 Senn Pathology and Surgical Treatment 
 
 of Tumors 13 
 
 Stengel Text-Book of Pathology, . . 14 
 
 Stengel and White Blood 14 
 
 Warren Surgical Pathology and Thera- 
 peutics 15 
 
 PHYSIOLOGY. 
 
 An American Text-Book of Physiology, 2 
 
 Budgett Essentials of Physiology, . . . 16 
 
 Raymond Human Physiology 12 
 
 Stewart Manual of Physiology, .... 14 
 
 PRACTICE OF MEDICINE. 
 
 An American Year-Book of Med. & Surg., 3 
 
 An American Text-Book of Theo. & Prac., 3 
 
 Anders Practice of Medicine 4 
 
 Eichhorst Practice of Medicine 6 
 
 Lockwood Manual of the Practice of 
 
 Medicine, 10 
 
 Morris Ess. of Practice of Medicine, . . 16 
 
 Nothnagel's Encyclopedia 20, 21 
 
 Salinger and Kalteyer Mod. Medicine, 12 
 
 Stevens Manual of Practice of Medicine, 14 
 
 SKIN AND VENEREAL. 
 
 An American Text-Book of Genito- 
 Urinary and Skin Diseases 2 
 
 Hyde and Montgomery Syphilis and the 
 
 Venereal Diseases, 8 
 
 Martin Essentials of Minor Surgery, 
 
 Bandaging, and Venereal Diseases, . . 16 
 
 Mracek Atlas of Diseases of the Skin, . 17 
 
 Stelwagon Diseases of Skin 13 
 
 Stelwagon Ess. of Diseases of the Skin, 16 
 
 SURGERY. 
 
 An American Text-Book of Surgery, . . 2 
 An American Year-Book of Medicine and 
 
 Surgery 3 
 
 Beck Fractures 4 
 
 Beck -Manual of Surgical Asepsis, ... 4 
 
 DaCosta Manual of Surgery 6 
 
 Helferich Atlas of Fractures 19 
 
 International Text-Book of Surgery, . . 9 
 
 Keen Operation Blank 9 
 
 Keen The Surgical Complications and 
 
 Sequels of Typhoid Fever, 9 
 
 Macdonald Surgical Diagnosis and Treat- 
 ment 10 
 
 Martin Essentials of Minor Surgery, 
 
 Bandaging, and Venereal Diseases, . . 16 
 
 Martin Essentials of Surgery 16 
 
 Moore Orthopedic Surgery n 
 
 Nancrede Principles of Surgery n 
 
 Pye Bandaging and Surgical Dressing, . 12 
 
 Scudder Treatment of Fractures, ... 13 
 
 Senn Genito-Urinary Tuberculosis, ... 13 
 
 Senn Practical Surgery 13 
 
 Senn Syllabus of Surgery 13 
 
 Senn Tumors, 13 
 
 Sultan Atlas of Abdominal Hernia, . . 19 
 Warren Surgical Pathology and Thera- 
 peutics 15 
 
 Zuckerkandl Atlas of Operative Surgery, 17 
 
 URINE AND URINARY DISEASES. 
 
 Ogden Clinical Examination of the Urine, n 
 
 Saundby Renal and Urinary Diseases, . 12 
 
 Wolf Urine Examination, 15 
 
 Wolff Essentials of Examination of Urine, 16 
 
 MISCELLANEOUS. 
 
 Bastin Laboratory Exercises in Botany, . 4 
 Galbraith Four Epochs of Woman's 
 
 Life, 7 
 
 Golebiewski Atlas of Diseases Caused 
 
 by Accidents 18 
 
 Gould and Pyle Anomalies and Curiosi- 
 ties of Medicine 7 
 
 Grafstrom Massage 8 
 
 Keating Examination for Life Insurance, 9 
 Robson and Moynihan Diseases of the 
 
 Pancreas, 12 
 
 Saunders' Medical Hand-Atlases, . 17, 18, 19 
 
 Saunders' Pocket Medical Formulary, . . 12 
 
 Saunders' Question-Compends 16 
 
 Stewart and Lawrance Essentials of 
 
 Medical Electricity, 16 
 
 Thornton Dose-Book and Manual of 
 
 Prescription-Writing 15 
 
 Warwick and Tunstall First Aid to the 
 
 Injured and Sick 15
 
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