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\>J
HANDBOOK
DIAGNOSIS AND TREATMENT
DISEASES
THROAT, NOSE  AND  NASO-PHARYNX.
                  BY

        CAEL SEILER,  M.D.,
INSTRUCTOR IX LARYNOOLOGY AND LECTURER ON DISEASES OF THE UPPER AIR
 PASSAGES IN THE UNIVERSITY OF PENNSYLVANIA ; CHIEF OF THE THROAT
   DISPENSARY AT THE UNIVERSITY HOSPITAL; PHYSICIAN-IN-CHIEF
           OF THE UNION DISPENSARY, ETC.

         THIRD EDITION,
^.j.iOUGHLY REVISED AND GREATLY ENLARGED.
.LLUSTRATED WITH TWO LITHOGRAPHIC PLATES CONTAINING TEN FIGURES,
       AND ONE HUNDRED AND ONE WOOD ENGRAVINGS.
        PHILADELPHIA:
LEA BROTHERS & CO
             1889.
,7 V*
Zf*f€Z

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                        W V
                        S4fe\V»

t'ilm  v1C!.  \ofof-n,  i  J«w\  £
 Entered according to the Act of Congress in the year 1889, by

          LEA BROTHERS & CO.,

In the Office of the Librarian of Congress.  All rights r<\-serv
DORNAN, PRINTER, 
    PREFACE  TO  THIRD EDITION.


   The favorable reception  accorded to the first and
second editions of this work has  been exceedingly
gratifying, and has encouraged me in the endeavor
to make the third edition even  more worthy of the
commendation of the profession.
   Numerous additions will  be found throughout the
book, among which may be mentioned an entirely
new chapter on the  physiology of the voice and
articulate  speech, and also  a new chapter on vaso-
motor  coryza  and hay fever.  On the other hand,
follicular  and  granular  pharyngitis as well as pha-
ryngitis sicca, have been omitted  from the  chapter
on chronic pharyngitis for  reasons  given  in the
text.
   The  number of illustrations  has  been increased
by the  addition of twenty-four  original engravings
on  wood,  and by two  carefully-executed  colored
plates,  which I trust will prove  of assistance  to the
student and practitioner. 
vi       PREFACE TO THIRD  EDITION.
  I take this opportunity of expressing my grati-
tude to my friend, Dr. John Madison Taylor, and
to his  accomplished wife, who  have greatly aided
me by making  the original drawings for  most of
the new  illustrations.
                             CARL SEILER, M.D.
  1346 Spruce Street,
    January, 1889. 
     PREFACE TO FIRST EDITION.


   This little volume is intended to serve as a guide
 to  students of laryngoscopy in acquiring the skill
 requisite to the successful diagnosis  and treatment
 of  diseases of the larynx and naso-pharynx.  All
 purely  theoretical  considerations have  therefore
 been  omitted, and  only points of  practical  im-
 portance have been  discussed as concisely as pos-
 sible,  so that  the work  may  be used  as a  ready
 book  of  reference  on the  subjects  of which  it
 treats.
  Several  affections,  which  are  classed  among
 systemic diseases, and  merely exhibit severe laryn-
 geal  symptoms,  such as scarlet fever,  diphtheria,
 etc., have  been omitted,  since they do  not strictly
 belong to  maladies of the throat.  The tables  of
 symptoms  to  be  found at the end  of the volume
 are   based upon  carefully kept  records  of  over
one  thousand  cases  treated  by  the  author  in
private practice,  and  at  the  Dispensary  of the 
viii       PREFACE TO FIRST EDITION.
University Hospital,  as well  as  in the  German
Throat Infirmary of Philadelphia.
  I take  this  opportunity  to  express  my thanks
to Dr. J. Solis-Cohen for  his  aid, and for kindly
permitting  me  to  use some  of  the illustrations
which embellish his book  on Throat Diseases.
                            CARL  SEILER, M.D.
Philadelphia, May, 1879. 
CONTENTS.
                      CHAPTER  I.

                   THE LARYNGOSCOPE.
                                                      PAGE
History—The  laryngeal mirror—Illumination—Reflector
  —Source of  light.......13-34


                      CHAPTER  II.

               THE ART OF LARYNGOSCOPY.

Optical principle involved—Position of patient and ob-
  server—Introduction of  laryngeal mirror—Obstacles to
  laryngoscopy—Auto-laryngoscopy—Infra-glottic  laryn-
  goscopy—Rhinoscopy—Posterior rhinoscopy  .    .  34-64


                     CHAPTER III.

ANATOMY AND THE NORMAL LARYNGEAL AND RHINOSCOPIC
                         IMAGES.

Anatomy of the larynx—Thyroid cartilage—Cricoid carti-
  lage— Arytenoid  cartilages — Epiglottis — Ligaments—
  Muscles — Topographical anatomy—Nerve  and blood
  supply—Thyroid  gland — The laryngeal image — Ana-
  tomy of  the nasal  cavities—The rhinoscopic image—
  Case record-sheet.......65-100 
X                    CONTENTS.
                     CHAPTER IV.
         PHYSIOLOGY OF THE LARYNX AND  NOSE.
                                                     PAGE
Physiology of the larynx—Acoustics—Voice production-
  Articulation—Vowels—Consonants—Physiology of the
  nasal cavities........101-133

                     CHAPTER V.
  INSTRUMENTS ACCESSORY TO LARYNGOSCOPY AND THE
          TREATMENT OF LARYNGEAL DISEASES.

The laryngeal sound—Sponge-holder—Cotton applicator—
  —The brush—The atomizer—Air-pump—Vapor inhala-
  tions—Insufflator—The caustic-holder .    .   .  134-153

                     CHAPTER VI.

    CATCHING COLD, PATHOLOGY  OF MUCOUS  MEMBRANE,
                     THERAPEUTICS.

Catching cold — Pathology  of the mucous membrane —
  Therapeutics—Modes of administering remedies .  153-170


                    CHAPTER VII.
                   ACUTE  LARYNGITIS.

Varieties,  cause, symptoms,  duration,  and treatment —
  CEdema of the larynx:  treatment—Subacute  laryngitis:
  symptoms, treatment, and  diet    ....  171-181

                    CHAPTER VIII.
                  CHRONIC LARYNGITIS.

Simple chronic laryngitis:  symptoms, causes,  and treat-
  ment—Laryngitis phthisica: symptoms and treatment
  —Syphilitic laryngitis: symptoms and treatment—Trau-
  matic chronic  laryngitis:   symptoms  and treatment—
  Stenosis of the larynx......181-202 
CONTENTS.
XI
                     CHAPTER IX.
         FUNCTIONAL DISORDERS OF THE  LARYNX.
                                                     PAGE
Aphonia: causes—Aphonia due  to cicatricial adhesion:
  patholygy and treatment—Aphonia due to paralysis:
  pathology and symptoms—Unilateral paralysis: causes
  and treatment—Aphonia due to the presence of foreign
  bodies—Laryngeal forceps.....202-22U

                     CHAPTER X.

         NEOPLASMS OF THE LARYNGEAL CAVITY.
Use of instruments—Neoplasms:  symptoms and diagnosis
  — Classification of tumors  in the larynx—Treatment—
  Prognosis........221-230

                     CHAPTER XL

                      PHARYNGITIS.
Acute pharyngitis:  symptoms,  duration, and  treatment—
  Traumatic  acute  pharyngitis — Chronic  pharyngitis:
  symptoms, cause,  and treatment—Specific chronic phar-
  yngitis: symptoms, treatment—Traumatic chronic phar-
  yngitis   .........  230-239

                     CHAPTER XII.

   ELONGATED UVULA AND HYPERTROPHY  OF TONSILS,
Elongated uvula: causes, symptoms, and treatment—Uvu-
  latomes—Hypertrophy of tonsils: symptoms and treat-
  ment— Tonsillotomies   .    .    .     .    .    .  239-25]

                    CHAPTER XIII.

  DISEASES OF THE NASAL CAVITIES AND NASOPHARYNX.
Pathology — Coryza: symptoms,  cause,  and treatment—
  Nasal douche—Precautions in the use of the nasal douche
                                                 251-273 
Xll
CONTENTS.
                    CHAPTER  XIV.

               chronic nasal  catarrh.
                                                    PAGE
Simple chronic catarrh—Hypertrophic catarrh: first stage,
  symptoms;  second  stage, symptoms;  causes, treatment
  — Hypertrophies — Galvano-cautery battery — Adenoid
  growths—Deviation of the septum—Bony obstructions
                                                273-326

                    CHAPTER  XV.

   HAY FEVER OR CORYZA VASO-MOTORIUS  PERIODICA.

History—Varieties — Symptoms — Etiology — Treatment
                                                326-336

                   CHAPTER  XVI.

               ATROPHIC NASAL  CATARRH.

Atrophic nasal catarrh: cause and treatment—Syphilitic
  catarrh—Lupus—Tumors in the nasal cavities ; pathol-
  ogy, symptoms, and treatment—Galvano-puncture   337-354


                   CHAPTER XVII.

Tables of symptoms of the diseases of the larynx
  and naso-pharynx......354-359 
 
Plate I.
Fig.!
Pig.2.
it\
Fig.3
Fig.4.
Fig. 5.
Fi(S 6 
EXPLANATION  OF PLATES.
                        PLATE I.

Fig. 1. Laryngeal image from a case of phthisis, showing the
         pyriform swelling of the arytenoid cartilages.
Fig. 2. Tubercular ulceration of the epiglottis and tubercular
         nodules on the aryepiglottic folds.
Fig. 3. Syphilitic ulceration of the vocal cords and of the inter-
         arytenoid space.
Fig. 4. Fibro-cellular tumor on the right vocal cord.
Fig. 5. A large papillomatous tumor springing from the right
         ventricular band.
Fig. 6. A  pin imbedded in the posterior portion of the right
         vocal cord. 
 
 
      EXPLANATION  OF  PLATES.


                       PLATE II.
Fig. 1. Fauces and pharyngeal wall in phthisis.
Fig. 2. Acute pharyngitis and tonsillitis with oedema of the
         uvula.
Fig. 3. Chronic pharyngitis with bifid uvula.
Fig. 4. Syphilitic pharyngitis with symmetrical ulcers on the
         surface of the palate. 
Plate II.
 
 
DISEASES
                  OF THE

THROAT, NOSE,  AND NASO-PHARYNX.
                CHAPTER I.

            THE LARYNGOSCOPE.

  The laryngoscope is a combination of two mirrors
so arranged as to enable the observer to see the
interior  of the larynx.  The smaller of the two  is
plane, and  is introduced  into the back part of the
mouth in such a manner as to be directly above the
opening of the glottis, while the  larger and usually
concave mirror serves to reflect a strong light into
the mouth  and  upon  the small mirror.  The  latter
in turn  reflects the light downward, and thus illu-
minates the interior of the larynx so that its image
can be seen on its surface.
  History of the Laryngoscope.—In medical literature
before the middle of the eighteenth century no men-
tion is made of an instrument or apparatus resem-
bling the laryngoscope, but recent excavations  at
Pompeii have brought to  light small polished  metal
mirrors  attached to slender handles which are sup-
posed to have been used to inspect  the cavities  of
                       2 
14
THE LARYNGOSCOPE.
the human body.  The first  authenticated attempt
at laryngoscopy and  rhinoscopy  was made by the
distinguished French accoucheur M. Levret in the
year 1743, who  invented, among   other  surgical
instruments, an apparatus by means  of which poly-
poid growths in the cavities of the nose, throat, ear,
etc., could be seen, and a ligature be passed around
them for their removal.1  This apparatus consisted
mainly of a polished metal  mirror which " reflected
the luminous rays in the direction  of the tumor,"
and on whose surface the image of  the growth was
seen to be reflected.   The  great value of this appa-
ratus for the diagnosis and treatment of nasal and
laryngeal diseases was, however, not recognized, and
it shared the fate of many other valuable discoveries
which  were made before  the  world was  ready  to
receive them: it was  forgotten.
  In 1807 a certain Dr. Bozzini, living in Frankfort
on-the-Main, published a work  describing an  appa-
ratus which he had invented for the illumination and
examination of  the  cavities  of the  human  body.2
This apparatus consisted of a peculiarly shaped lamp
and of a number of metal tubes, polished on their
inner surface, of various shapes  and sizes adapted
for the  different  cavities  of the body.   The one
intended for the examination of the larynx was bent
near its end at a right angle, and had  a mirror placed
at the bend, which served  to  throw the light down-
ward toward the opening of the larnyx when the

  1 Mercure de France, 1 793, p. 24^4.
  2"Der Liehtleiter," Philipp Bozzini, Med. und Chir. Dr., Weimar,
1807. 
      HISTORY  OF THE  LARYNGOSCOPE.    15

tube was inserted into the mouth.   When reflected
light was  to be  used, the interior  of the  tube or
speculum was divided into two portions by a longi-
tudinal  septum, and two mirrors were inserted at
the bend—one for the reflection of the light  down-
ward,  and  the other for receiving  the reflected
image.  This invention of Bozzini was treated, how-
ever, with derision by the medical  profession, pro-
bably on  account of  the extravagant descriptions
given of it  in  the papers, which  were not verified
by its performances.
  In  1825,  Cagniard de Latour, an investigator of
the physiology of the voice, made some unsuccessful
attempts to  examine the living larynx.1
  Senn, of  Geneva, in 1827  endeavored to  examine
the larynx of a little girl suffering from an  affection
of the throat by means  of a small mirror which he
had made and which he inserted  into the phranyx ;
but he failed  to  see the  glottis, because,  as he says,
the  mirror   was too small, and  because  he used
neither direct nor reflected  light to illuminate the
cavity below the mirror.2
  In  the year  1829, Benjamin Guy  Babington pub-
lished3 an account of what he called the glottiscope,
an apparatus which consisted mainly of two mirrors.
One of these was small and attached to a slender
stem, and was used  to receive the image, while the
other, an  ordinary hand-glass, was used to  reflect
the  rays of the sun or ordinary daylight upon the

      1 Physiologie de la Voix, par Ed. Tournie, Paris, 1865.
      2 Journal de Progrcs des Sciences, etc., 1829.
      » Loud. Med. Gazette, 1829, vol. iii. 
16
THE LARYNGOSCOPE.
smaller mirror in the fauces.   This combination was
essentially the same as is used at the present  day in
the laryngoscope, with the difference that we now
use artificial light in most instances, and a concave
mirror instead of a plane one for reflecting the light.
  While Babington was still  engaged in perfecting
his instruments,  a mechanic  named Selligue, who
suffered  from an affection of the  throat,  in 1832
invented a  speculum for his  physician, Bennati, of
Paris, with which the latter was able, as he asserted,1
to see the vocal cords.  This instrument was similar
to the  one invented by Bozzini,  and consisted of a
double speculum bent at right angles and carrying
two  mirrors—one for illuminating the  cavity, and
the  other for reflecting the  image.  Selligue was
rewarded for his efforts by  complete cure  of his
affection.
   A number of others worked in  the same direction,
and  endeavored to see the  interior of the larynx in
the living subject by employing  different apparatus
and  methods of illumination. Thus, in 1838,Baumes,
of Lyons, described a mirror the size of a two-franc
piece (1^ inches in diameter) as useful in examining
the  larynx  and  posterior nares.2   Then  Liston in
1840 used a dentist's mirror,3 and Warden, of Edin-
burgh, employed a prism of flint glass attached to a
long stem as a laryngeal mirror.4   In the latter part
of the  same  year Avery, of London,  employed a

  1 Recherches  sur le MScanisme de la Voix humane.
  2 Compte Rendu des Travaux  de la Societe  de Medecine  de Lyonn,
1836-38.
  3 Practical Surgery, 1840.
  4 Loud. Med. Gazette, vol. xxiv. p. 250, 
      HISTORY  OF THE LARYNGOSCOPE.    17

speculum with a mirror in its end for examining the
larynx, using as  an  illuminator a concave  reflector
with a central  opening, which was supported by a
frame to  be worn on the head of the operator.1
  Up to this  time all efforts at laryngoscopy had
been made with  a view to diagnose diseases  of the
larynx, with the exception of those made by Latour.
In the year 1854, however, Signor  Manuel Garcia,
of London, without any  knowledge of  previous
efforts, conceived the idea of studying the changes
in the larynx during phonation  in his own throat.
For this  purpose he  placed a small dentist's mirror
against the uvula and reflected the rays of the sun
into his mouth  and upon the small mirror by means
of a hand-glass held in the other hand.  By arrang-
ing his  position  in  relation  to  the sun in such a
manner that he could see the reflected image of the
small mirror in his throat in the hand-glass, and in
it the illuminated image of his  larynx, after a few
ineffectual attempts  his efforts at auto-laryngoscopy
were  crowned  with  such  success  that  he  was
enabled to study  the movements of the vocal cords
during phonation, and accurately describe the reg-
isters of the voice in a paper read before the Royal
Society   of London  in  1855.2   Although Garcia
was  the  first who practised  laryngoscopy success-
fully, his  communication  to the Royal  Society
attracted little attention, and would have  been for-
gotten if it had not been that,  in 1857,  Turk, of
Vienna,  having heard of Garcia's  paper, began to

      1 Med. Circ, June,  1802.
      2 Proc. Royal Society of London, vol. vii. No. 13, 1855.
                        2* 
18
THE LARYNGOSCOPE.
use the laryngeal mirror on the patients in the K. K.
Allgem. Krankenhaus for diagnostic purposes.  At
first he was not very successful  in  his attempts, and
began to experiment with  laryngeal mirrors of dif-
ferent sizes and  shapes.    While  thus  engaged
Czermak borrowed  Turk's mirrors,  and  modified
them until he succeeded in the greater number of
cases in seeing the vocal  cords,  using artificial light
for illuminating the larynx.   Meanwhile, Tiirk con-
tinued his experiments, and also succeeded in almost
all cases of throat disease which came to his depart-
ment of the hospital in  seeing  the interior of the
larynx and in treating the lesions.   Both Tiirk and
Czermak improved their apparatus, and especially
the latter,  who  by substituting artificial  light  for
sunlight, and by  inventing a number  of  different
illuminating apparatuses, has given us the  laryngo-
scope in the form in which  it is used at the present
day.   It is  but  natural that  Tiirk   should  have
claimed priority in the successful  use of this instru-
ment, and in consequence of this claim a controversy
was carried on for a number of  years in the medical
press between him and  Czermak, which  at times
became quite spirited, but which left Czermak mas-
ter of the field.  In  the winter of 1858-59, Madam
E. Seller, having  heard of Czermak's  experiments,
had  a laryngeal mirror  constructed  from  his de-
scription,  and  practised  laryngoscopy  successfully
on herself and others, among them the writer, with
a view to  study the  physiology of the voice.  Her
efforts being crowned with success, she was  able not
only to verify Garcia's observations in regard to the 
          THE LARYNGEAL MIRROR.        19

registers,  but also discovered the  so-called  head
register of the female voice, as well as two small
cartilages in the vocal cords.
  The  Laryngeal  Mirror.
—The  laryngeal  mirror
(Fig. 1) as  it is used now
consists of a small  piece of
silvered glass mounted in
a metal frame,and attached
to a wire stem at an angle
of not less than 120°. This
stem, about four inches in
length and about one-tenth
of an  inch in thickness,
should be soldered to the
back of the mirror in such
a way  that the rim of the
frame forms the angle with
the stem,  and should not
be below it, as this would
increase  the  diameter of
the instrument without in-
creasing its reflecting sur-
face.   The stem  is made
to slide into a hollow han-
dle either of wood, ivory,
or of vulcanite rubber, and
is clamped at any desired
length  by a set screw. This
arrangement is preferable      Laryngeal mirror.
to  a   fixed handle, inas-
much as the stem can be  pushed entirely into the
handle, thus  economizing space and rendering the
 
20
THE LARYNGOSCOPE.
 instrument more portable.   The handle should be a
 little more than three inches long and  about one-
 third of an inch in thickness.
   Laryngeal  mirrors of different  shapes, square,
 oval, lozenge-shaped, etc., have been used by differ-
 ent observers, but it has been found that the circular
 form is the most easily borne by the patient, and can
 be used in the greatest number of cases.   However,
 when  hypertrophy  of the  tonsils  exists, an  oval
 mirror  can be  introduced  between  the  protruding
 glands more easily than a round one.
   Mirrors of polished  steel, although  they have  a
 better reflecting surface than glass mirrors, are not
 to be recommended, because they  are  easily tar-
 nished by the secretions of the mouth and  pharynx,
 and are scratched in  wiping them.
   Sir Morell Mackenzie has also used total reflecting
 prisms mounted on handles like a laryngeal mirror,
 but  has not  found them to possess any advantage
 over glass mirrors.
   The round  glass mirrors vary in size from half an
 inch to an inch and a half in diameter, and are num-
 bered by the  instrument  makers No. 1, 2, 3, 4, and
 so on.  The  size IsTo.  3, a  little more than three-
 quarters of an inch in diameter, is  most serviceable
in the greatest number of cases, but in  examining
patients it is advisable to have at least three differ-
 ent sizes at hand, say Eos. 1, 3, and 4.
   Illumination.—In order  to be able to see the laryn-
geal  image in  the small plane mirror, the larynx
must be illuminated.  This may be effected by throw-
ing upon  the laryngeal mirror when in  position  a
strong light,  which will be reflected downward into 
REFLECTOR.
21
the laryngeal cavity.  For this purpose either direct
or reflected artificial light or  sunlight may be used.
Direct illumination, by  allowing a strong artificial
light  or sunlight to  fall into the patient's mouth,
although it is used  b}' several  of the eminent laryn-
gologists of Europe, is both inconvenient and unsat-
isfactory, because the observer must either place his
head in the path of the  light  in order to be able to
see the surface of  the  laryngeal mirror, as in the
case when sunlight is  used, or he must place the
lamp, candle, or other source  of light between  him-
self and the patient, which  materially interferes with
the freedom of  his  motions.  For these  reasons
reflected light  is now  almost universally employed
in laryngoscopy.
   Reflected light may  be obtained by throwing the
light  of a lamp, candle, gas-jet, or ordinary daylight
into the mouth of the patient, by means of a cir-
cular, concave  glass reflector.
   Reflector.—This concave mirror should be from 3
to 4 inches in  diameter, and should have a focus of
from  10 to 14 inches; it should be silvered and not
backed with amalgam.   The  metal  frame in which
it is set is attached,  by means of  a ball-and-socket
joint, to some  contrivance by which it  can be sup-
ported  on the observer's head, or be attached to the
source  of illumination if artifical light be used.
   Semeleder recommends  for this purpose  a  spec-
tacle-frame  to  which the reflector is fastened.  By
means of the ball-and-socket joint the concave mirror
can be  brought before  either  eye, or can be fixed in
the middle of the forehead between the eyes.  This
arrangement, however, will be found not only iuse- 
22
THE LARYNGOSCOPE.
cure, but  also very tiresome if the reflector has to
be supported on the  bridge of the  nose  for  any
length of  time.  A much better support  for the re-
flector is  the frontal band  introduced by  Cramer.
This consists of a broad strap of some strong  ma-
terial,  which  passes around the head of  the  ob-
server, and is fastened  at  the back  by a  buckle.
                      Fig. 2.
Head-reflector.
To  the part  of the band resting on the forehead  is
attached a padded plate, to which  the reflector  is
fastened with its ball-and-socket joint.  (Fig.  2.)
Lately Mr. Ivan Fox, of Philadelphia, has introduced
a head-mirror or reflector, which is very convenient
on account of its portability.  It consists of a jointed 
REFLECTOR.
23
steel band, which passes over the head  from the
forehead to the occiput, and which carries  the reflec-
tor, mounted on a ball-and-socket joint, at  its frontal
end.  This apparatus is,  however, not as secure and
comfortable  as the  Cramer head-mirror, and  is
therefore not adapted for long-continued use.   If
a condensing apparatus is used for concentration of
light, the reflector is attached to it by a jointed arm.
  The reflector usually either has a small hole  in
the centre, or a small space in the centre  is left un-
silvered.  This opening  is intended to be brought
before the pupil of one  or the other eye  of the ob-
server in such manner that  the  line of vision and
that of light have  exactly the
same direction.   Using the re-
flector in this way like the re-
flector of the ophthalmoscope,
it is easier to obtain an  image
of the larynx well illuminated,
but  with the  great  disadvan-
tage of monocular vision, which
makes all objects appear on the
same plane, and prevents  a cor-
rect interpretation of distances
— a very  important point  in
laryngoscopy.  It will therefore
be found more  advantageous  to
place the reflector on the fore- Head-reiie<-t,.r in position.
head, and from thence to reflect
the light into the patient's larynx (Fig. 3).  Both eyes
may thus be employed   in viewing the  laryngeal
image, and a correct idea of the relation of parts in
regard to distances may be formed. The line drawn
 
24           THE LARYNGOSCOPE.
from the pupil of the  eye  to the laryngeal mirror,
and a  line from the reflector upon the forehead to
the mirror, do not form an angle sufficient to make
any very great difference in the reflection of the light
downward, and very little  difficulty will be experi-
enced in obtaining the desired image.  The  head-
reflector should be concave when artificial light or
ordinary daylight is used, but should be plane when

                      Fit;.  4.
Tobold's illuminating apparatus.
direct sunlight is employed, for the concentration of
the sun's  rays by  a concave reflector produces so
much heat as to  become painful to the patient.
  Source of Light—As an  artificial source of light a
candle, coal-oil  lamp, incandescent electric lamp, or
gas flame suffices  for ordinary purposes.   But fre-
quently it is desirable to have a much stronger light 
              [source  of light.             25

than can  be obtained in this manner, and several
forms of apparatus for concentrating artificial light
have been constructed and are in use.
  The simplest of these is the so-called " Schuster
Kugel," first recommended by Tiirk, and used espe-
cially for  clinical purposes by Stork and others.  It
consists of a large spherical flask  of glass filled with
pure water, which is suspended in front of a lamp or
gas-jet, and  which concentrates  the light very power-
fully.  The concentrated beam of light is then re-
flected from the head-reflector into the mouth of the
patient.
  Tobold, of Berlin, constructed a more elegant light-
concentrator for  the  laryngoscope, which is known
as " Tobold's lamp."   It consists  of a brass tube con-
taining several lenses, which are  placed, one before
the other, at such distances as to give the greatest
possible amount of concentration of light.  The back
part of the  tube  is closed, while near the end two
large holes are cut in its sides opposite to each other,
through which the chimney of a lamp projects.   The
whole  is fastened, by means  of clamps, to a stand,
to which is  also attached a jointed arm bearing the
reflector   (Fig.  4).    This  apparatus  is  especially
adapted for use in the office, where, unless disturbed,
it can remain in the same place when not in use.
  Dr.  J.  Solis Cohen  has modified  Tobold's  ap-
paratus by employing gas, and  by inserting the rod
which carries the concentrator and reflectorin a metal
stand, so that the light can be raised and lowered
more easily to suit the different heights of patients.
(Fig. 5.)
  Sir Morell Mackenzie, of London, makes use of
                        3 
26
THE LARYNGOSCOPE.
an adjustable  gas fixture,  which is secured to  the
wall like an ordinary bracket-light.   For a number
of years I have used in  my office a bracket similar

                      Fig.  5.
Cohen's modification of Tobold's lamp.
to Mackenzie's, made  by the  Harm, Brannen &
Forsyth Manufacturing Company of Philadelphia,
upon which the light-concentrator and reflector are
mounted.  (Fig. 6.)   It  has the  advantage of  being 
               SOURCE  OF LIGHT.             27

easily moved with one hand  into the proper  posi-
tion, and at the same time its joints are stiff enough

                       Fig. 6.
Seiler's gas bracket with Mackenzie's concentrator.
to support the weight of the light-concentrator and
hold the  bracket in any position without the use of
a ratchet such as is used in Mackenzie's  bracket,
and  which  necessitates the use of both  hands in
changing its  position.  Mackenzie's  light-concen-
trator—less  complicated,  more  portable,  and yet
quite as efficient as Tobold's—consists of a  cylinder
of sheet iron, about 6 inches long by 2| in diameter.
Near one end a hole is cut in the side of this cylinder,
and a short piece of tube holding a condensing lens
is attached to the edge of the hole.  This lens, which
is  plano-convex, with  a spherical curve, and of 2|
inches diameter, is placed with the plane side toward
the light.   The height of the cylinder is to be so
adjusted as to bring the centre of the  lens  opposite
the centre of the flame. (See Fig. 6.)
  This concentrator is intended to be  slipped over
the chimney of an Argand burner, but it can also be
used in connection  with a candle, lamp, or ordinary 
28
THE LARYNGOSCOPE.
gas flame, to which it  can be fastened by spring
clamps  attached to the lower end of the cylinder.
The  concentrated  light thus  obtained  is then re-
flected from the  head-mirror, and  can be thrown
in any desired direction.   The so-called lime-light,
with its powerful and white illumination, can  with
advantage be used for laryngoscopy, and a number
of laryngologists so employ it; but it requires some
skill and  experience to keep the light  steady, and
unless a large number of patients are to be examined
in succession it will prove too expensive  a luxury.
The same holds good of the old electric-arc light in
which the source  of electricity was  a battery, re-
quiring constant  attention,  and the lamp with  its
carbon points was  not only very expensive, but also
was liable to get out of order.  The best light,  how-
ever,  when the examinations are conducted in the
office of the physician, is  the  electric incandescent
light, which presents numerous advantages over the
gas or oil lamp.  It is more brilliant and whiter than
any other suitable artificial light, giving off neither
gases nor heat, nor does it consume the oxygen in
the room; and since the introduction and perfection
of dynamo-electric machines and of storage batteries
it has become available and convenient for use in
private  houses.  Numerous experiments which the
author has carried on for  some  time  have resulted
in the application  of this form of light for laryngo-
scopy in two ways which are both very satisfactory.
The incandescent  lamp is  mounted upon the uni-
versal gas-bracket in place of the Argand  burner,
and   either the  Tobold lamp or Mackenzie's  light-
concentrator is  slipped over  it, so that it comes 
SOURCE OF LIGHT.
29
opposite the centre of the lens.  In fact, the electric
lamp is substituted for the gas-burner, and the whole
apparatus is used as described above.
  The second  method is to mount the electric lamp
on the head-mirror in  such a way that it projects a
little from the  surface  and is a little to one side of

                       Fig. 7.
The Author's electric illuminator for the laryngoscope.
the centre of  the  reflector. (Fig. 7.)  The light is
then thrown forward in a cone, and can  be directed
with great ease into the mouth of the patient.  Since
the source of light moves  with the mirror, the  ob-
server can follow the  motions of the patient more
easily ;  and if, in the first place, an easy position of
                         3* 
30
THE LARYNGOSCOPE.
the head has been assumed when adjusting the light,
much less  fatigue is experienced by the examiner
with this apparatus than when the light is  reflected
from  a stationary source.  Still another  mode  of
using the incandescent lamp, which was suggested
by Trouve, is to mount the lamp within a  tube one
end of which is closed by a plano-convex lens, while
the other end is covered by a metal cap carrying in
its centre a ball-and-socket joint, by means of which
it is fastened to the frontal plate of the head-band.
In this way the light with its condensing apparatus
is carried on  the forehead like the head-mirror.
           The S. S. White electric laryngoscope.

  Still another mode of using the electric light for
laryngoscopy was first suggested by Edison, and
later, carried out and  perfected by the S. S. White
Dental Co. (Fig. 8.)  It consists in attaching a very
small incandescent lamp close to the laryngeal mir- 
SOURCE OF LIGHT.            31
ror, mounted on a rather thick  hollow stem which
carries in its interior the conducting wires for the
electric current which is supplied by a small battery
carried in the pocket, and has on its surface a small
button which when  pressed down closes the circuit
and lights the lamp.   This apparatus is certainly very
convenient if an examination of the throat is to be
made at the patient's house and  constitutes the ideal
laryngoscope inasmuch as it combines  the mirror
and  illuminator in  one  small instrument.  Unfor-
tunately, however, the light  from the incandescent
lamp besides being thrown downward into the laryn-
geal cavity is at the same  time thrown  into the
observer's eye, thus preventing him  from clearly
seeing the reflected image, and the stem of the mir-
ror must  necessarily be so thick as to obstruct the
view very materially.   These defects make the instru-
ment less useful in practice  than it appears to be in
theory.
  Dr. Wm. C. Jarvis, of New York, devised an elec-
tric laryngoscope in which these objections are over-
come in a great measure.  It consists in a handle of
wood or ebonite at one end of which a small incan-
descent lamp is mounted in such  a manner that all the
light from it is thrown forward  while  the laryngeal
mirror is at some distance from the lamp, its  stem
being slipped into a hole in the lamp handle. (Fig. 9.)
In this way the light is thrown upon the mirror and
from it down into the larynx, while the lamp remains
outside of the mouth of the patient; thus the  heat
developed by the light does not incovenience either
the examiner or the patient, but  there is still some
of the light  which falls  directly into the observer's 
32           THE  LARYNGOSCOPE.

eye and thus interferes with clear vision.  Dr. Jarvis
also uses an electric  head-mirror  similar to the  one
devised by the Author.

                      Fig. 9.
Jarvis's electric laryngoscope.
  Sunlight is  certainly the best source of light for
the illumination of the interior of the larynx and
nasal cavities; but, unfortunately,  it is not available
at all times and in all localities.  When  it can  be
obtained, however, the student should not neglect the
opportunity, and should not be deterred from using
it for examination by the little extra apparatus and
trouble necessary.
  The most convenient plan is to place a small plane
mirror, such as a small toilet  glass, mounted upon a
stand in such a  manner  that it can be  turned  in
any  direction  in the  direct rays of the sun corning
through a southern window.   Then turn the mirror
until the reflection falls upon a second plane mirror
supported by a jointed arm and placed in a distant
corner of the  room, and in front  of the chair upon
which the patient is seated with his back toward the
first mirror.   The light  from the second mirror is
then thrown into the patient's mouth  in the same
manner as when a light-concentrator is  used.   In
fact, the concave reflector of a Tobold's  apparatus
may be removed  and a plane  mirror substituted for 
SOURCE  OF LIGHT.             33
it.  The second mirror may also be mounted on the
head-band and used as a head-reflector, but this latter
plan is not as satisfactory, because the reflected light
from  the first mirror is apt to strike the observer's
eye and temporarily blind him.
  Sunlight, as well  as the light of the oxy-hydrogen
and electric-arc lamps, is white, and therefore shows
us the  parts  in  their  natural  coloring, which  is
claimed as a  very  great advantage over all  other
sources of light.
  It is true that the yellow rays which are predomi-
nant  in all other artificial lights make the mucous
membrane appear  redder than it really is, and the
observer may be led to believe that  a congestion
exists if the patient be examined by white light first
and then by yellow  light on different occasions.  But
as all our knowledge and appreciation of shades of
color depend  upon comparison with  a standard, it
makes no difference whether this standard, as in the
case  before us, be  a littler redder when viewed by
yellow  light  or not so  red  when viewed  by white
light.   This advantage of the white light is, there-
fore,  not of much  practical  value, and the expense
and   difficulties connected  with  the  use  of  oxy-
hydrogen or electric-arc  light for laryngoscopy fully
outweigh any advantage which can be claimed for it.
  Czermak suggested another mode of illumination
of the larynx, which he called " illumination by trans-
parency."  It consists  in concentrating strong sun-
light upon the outside of the neck, thus filtering the
light, so to speak, through the tissues until it reaches
the interior of the larynx;  but even under favorable
circumstances, as when  the neck of the patient is 
34      THE  ART  OF  LARYNGOSCOPY.

thin and emaciated, only a very dimly lighted image
of the larynx can be obtained  by this means.  And
even if  sufficient light could be passed through the
tissues of the neck, the image would  still be  in-
distinct, because there would be no shadows.  The
light  being filtered  through the tissues emanates
from all portions of  the larynx, and  the outlines of
the different parts of the image would be swallowed
up in the flood of red light, in the same manner as
the outlines  of  the bones of  the fingers  are  in-
visible if the hand  be held between the eye and a
strong light.
                CHAPTER  II.

        THE  ART OF  LARYNGOSCOPY.

  Before entering upon a description of the details
of laryngoscopic examinations it will be necessary to
understand the optical principle involved in the pro-
cess.  This  principle  is the law, that the angle of re-
flection is equal to the angle of incidence.  Applying this
law to our case we find  that, in order to illuminate
the interior of the  larynx, we must place a reflecting
surface above and  behind the opening of the larynx
at such an angle that  the light received on this sur-
face shall be reflected  downward. (Fig. 10.) The rays
forming the laryngeal image will then return in the
usual way;  that is, will be reflected from the same
mirror to the eye of the  observer.  From this it will
be seen that the nearer the head-reflector is placed 
         THE ART OF LARYNGOSCOPY.       35

to the eye of the observer the  better and the more
easily will the image be seen.
  It should always be borne in mind that the image
seen in the mirror is a reflected one, like the image

                      Fig. 10.
Diagram of section of head, showing the position of laryngeal mirror
                   in the pharynx.
of one's self seen in a looking-glass.  On account of
the difference in height of the different parts form-
ing the image, and because  the mirror must be
placed above and behind the opening of the larynx, 
36       THE  ART OF LARYNGOSCOPY.
it appears reversed in an antero-posterior direction.
Parts  that  are  in front appear  in  the image to be
behind, and vice  versa.  (Fig. 11.)  The same holds
good when looking at a drawing of a laryngoscopic
image.
                       Fig. 11.
        g tsr   ho  n   q 771  It  I   i
                       c  d  a               '
Laryngeal  opening and back of tongue as  seen  from above in a
           transverse section of the head.  (Turk.)

  Position of Patient and Observer.—The relative posi-
tions of  the observer, the patient, and  the source of 
  POSITION OF PATIENT  AND OBSERVER.   37

light are of very great importance, especially for the
beginner.  The observer and  patient should sit op-
posite each other, so  that the eye of the former is
about a foot from, and on a level with, the mouth of
the latter, whose  head should be slightly  raised and
inclined backward.  In order to be in a comfortable
position when near enough  to the  patient's mouth,
the observer should either bring his knees to the left
of the patient's, or else place one knee on either side.
The latter plan is in many cases preferable, especially
with children, because the practitioner can, to a cer-
tain extent, control  the mo-
tions of his struggling patient
by holding him with his knees.
For office work it is most con-
venient  to  use  piano-stools,
which can be raised or lowered,
for the seats both of the patient
and the examiner, so that the
difference in the height of dif-
ferent patients can be compen-
sated for. The lamp or source
of light should be placed to the
right of and a little behind the
patient, the centre of the flame
being on a level  with the pa-
tient's eye. (See Fig. 4.) When
the laryngoscope is frequently
USed at  the Office of the praC-    Chair with head-rest.
titioner it is of great advantage
to have a head-rest, such as photographers  use, at-
tached to the chair occupied  by the patient, so as to
prevent any change of position of his head (Fig. 12).
                        4
 
38       THE ART  OF LARYNGOSCOPY.

When a piano-stool  is used for the patient to sit on,
the  most  comfortable and  useful  head-rest  is an
upholstered frame with an oval depression in its
centre.   This frame is hung  on the  wall  against
which the piano-stool is placed, at such a height that
the back of the head of an ordinary sized individual
sitting on  the stool fits into the central portion of
the oval depression.
  The positions having been taken, the observer, by
means of the  reflector, then throws the  light upon
the  patient's  mouth, so that the circle  of  light is
bounded above by the tip of the nose and below by
the chin.   If a reflector is used, which is attached to
a light-concentrator (Fig. 6) by  means of a jointed
arm, no  difficulty will be experienced in throwing
the light in the  desired direction.  If,  on  the  other
hand, the head-reflector is employed, it is advisable
to obtain an easy position for the head and then to move
the reflector  on  its  universal joint until  the circle of light
falls upon the patient's mouth, when the joint  may be
tightened,  thus securing the reflector in the proper
position.   After this  has been  accomplished,  the
observer cannot turn his head without moving  the
light from  the proper direction; but having first
secured  an easy and  comfortable position  for his
head, he can  readily assume it  again, after having
moved, and throw the light in the proper direction.
If, on the  other  hand, the position of his head is a
constrained one, it will be difficult, if not impossible,
again to reflect the  light into the patient's mouth.
I should, therefore, advise all beginners  to  practise
with the head-mirror until they are able  quickly to
reflect the light in any  desired direction, as, for 
 INTRODUCTION OF LARYNGEAL  MIRROR.   39

instance, upon a spot on the wall, before attempting
to examine  a  patient.   They will thus save much
annoyance to themselves, as well as to their patients,
and will much more readily overcome the difficul-
ties experienced by all beginners in laryngoscopy.
  When the reflector has been properly adjusted, the
patient  is required  to open his mouth as wide as
possible, still inclining the  head  backward, so that
the centre of the disk of light falls upon the base of
the uvula, thus illuminating all  surrounding parts.
  Before introducing the laryngeal mirror, a careful
inspection should be made of  the parts displayed,
and if the tongue should obstruct the view, by rising
at its root, the patient  should  be required  to pro-
nounce  the  vowel sound  of " Eh," which causes a
rise of the velum palati and allows a view  of the
pharynx.  In  some  cases  it becomes  necessary to
depress  the tongue  by  means  of  an  instrument
called the tongue-depressor, which will be described
further  on.
  Introduction of the Laryngeal Mirror.—The pillars,
tonsils,  uvula,  and  pharyngeal  walls  having been
examined, the laryngeal mirror,  after  having been
warmed to prevent the condensation  of moisture on
its reflecting surface, is  introduced in the following
manner :
  The handle is held between the thumb  and fore-
finger of the right hand like a  penholder, with the
reflecting surface of the mirror  looking downward.
The hand is slightly flexed backward upon the wrist
and is held a little below the mouth of the patient
while the elbow is also flexed (Fig. 13).   By  a sim-
ultaneous unflexing of both the  elbow and hand, and 
40       THE ART  OF LARYNGOSCOPY.

a slight  raising of the arm, the mirror  is quickly
carried into the mouth of the patient in a curved
line, so that during this motion the reflecting surface
of the mirror always remains parallel to  the upper
surface of the  tongue without touching it or the
palate, until its back touches or raises  the uvula.
Meanwhile, the left hand of the observer has grasped
the end of the protruded tongue of the patient, and

                      Fig. 13.
Position of the hand and arm when introducing the laryngeal mirror.

holds it by means of a soft towel or  napkin to pre-
vent its slipping through the fingers.   This holding
of the tongue is necessary in order to increase the 
 INTRODUCTION OF  LARYNGEAL  MIRROR.  41

space in  the  pharnyx, and also to raise the larynx
and  bring its  opening nearer  to the mirror.  Care
should be taken not  to allow  the  frsenum of  the
tongue to come in contact with the edge of  the
lower teeth, aiid thus  injuring  it, as the patient will
at once  remonstrate  against  the  holding of  the
tongue on  account of the  pain it  produces.  This
can be avoided in the following  manner: The napkin
or towel should be laid over the outstretched thumb
and index finger of the left  hand, and a deep fold be
pressed  between them.  The  index finger, is then
laid  with its back  against the lower teeth of the
patient,  so that its  upper surface is higher than  the
edge  of  the  teeth  and  the tip of the  protruded
tongue dips into the fold of the napkin.  The mid-
dle finger is then placed  under the chin and  the
thumb on the  tip of  the  tongue, thus holding it
firmly between the index  finger and the thumb.
Finally the hand is slightly rotated  away from the
patient.   The  index  finger which  lies under  the
tongue acts as a roller upon which the tongue glides,
and while the middle finger acts as the fulcrum for
the lever which pulls  upon the tongue, at the same
time it prevents the head of the patient from com-
ing too far forward.   When holding the  tongue in
this  way the observer has perfect control over  the
head of  the patient, for any involuntary movement
in any direction can be prevented.
  In cases where it is  necessary to make applications
to the throat, the operator needs both his hands,  and
the patient should therefore be taught to make trac-
tion  upon his tongue himself.
  In  the act of introducing the mirror great care
                       4* 
42       THE ART  OF  LARYNGOSCOPY.

should be  taken not to touch the tongue or palate,
as this not only  injures  the reflecting surface of the
Laryngeal mirror in position, displaying the laryngeal image. (Cohen.)

mirror for the|time, but also produces gagging, especi-
ally in persons not accustomed to laryngoscopic ex-
aminations.  Greater immunity from this inconven- 
 INTRODUCTION OF LARYNGEAL MIRROR.  43

ience is obtained by carrying the instrument quickly
and steadily back until the desired point is reached.
  The handle of the  mirror is then brought to one
side  until  it lies in  the  angle of the mouth; this
movement  brings the hand out of the line of vision.

                      Fig. 15.
Faulty position of laryngeal mirror with resultant laryngeal image.

In this position it is advisable to steady  the hand by
resting  one or two fingers against the cheek of the
patient.  If the mirror, lifting the uvula and resting
with its lower rim against the posterior wall of the
pharynx, is allowed to tremble, gagging or retching 
44       THE ART OF LARYNGOSCOPY.

immediately results, and prevents any further exam-
ination at that time.
  When in  position the mirror is slowly but steadily
turned until the image of the larynx appears on its
surface and  can be examined (Fig. 14).   The patient
is required to say "Eh," in order to cause a rising of
the epiglottis and to enable us to see the vocal cords
in motion.  The position of the  mirror in the phar-
yngeal cavity is  of the greatest importance,  and
unless its reflecting surface is placed at the proper
angle only a portion of the  laryngeal opening can
be brought into  view.   If, for instance, the back of
the mirror is placed against the velum so as to allow
the uvula to protrude  below the lower rim only the
uvula itself, the  back of the tongue, and the upper
margin of the  epiglottis are seen  in  the image.
Again, if the mirror is simply placed with its lower
margin against the wall of the pharynx carrying the
uvula on  its back, at a point level  with the  upper
surface of the tongue (Fig. 15), only the back of the
tongue, the  epiglottis, and the arytenoid cartilages
are brought into view.   Only when  the back of the
mirror pushes the velum and uvula  as  high as pos-
sible into the upper portion of the pharyngeal cavity,
can we expect to obtain a perfect image of all the
details of  the opening of the larynx (Fig.  16).   As
soon as there is any indication of gagging, the mirror
should quickly be withdrawn, for if  this is not done
retching  will follow, and not  only cause  a  slight
hyperemia of the mucous membrane, but also make
the throat so sensitive  that a further  examination
becomes impossible.  It is always better to introduce
the mirror frequently and leave it in position but a
short time than  to  wait until gagging  sets in.  It 
 INTRODUCTION OF  LARYNGEAL MIRROR.   45

is better in all cases to leave the mirror in the mouth
but a short time and to introduce it frequently, thus
studying the different parts of the image one after
the other, than to attempt to see  everything at once.
In laryngoscopy, as  in many other arts, not only the

                      Fig. 16.
 Correct position of laryngeal mirror with resultant laryngeal image.

hand, but also the eye, must be educated to appre-
ciate  all  the  details and the  variations from the
normal.   The throat, however, soon becomes very
tolerant to the presence of the mirror when it is held
still, and then the examination of the larynx can be 
46       THE  ART OF  LARYNGOSCOPY.

prolonged  for  a  considerable time, and is  often
terminated only by the  mirror becoming cool and
moisture condensing on its  surface.   In order  to
obviate  this difficulty,  Dr. Henry  Wright  recom-
mended, and  actually  employed a very ingenious
plan for keeping the mirror at  a  uniform tempera-
ture.  He  attached  to  the  back of the mirror an
insulated spiral  of thin platinum wire, which was
connected  with  a small battery by means of  thin
copper wires running along the handle of the mirror.
When  the  current is   established, the electricity
becomes concentrated in the spiral, and elevates its
temperature and also that of the laryngeal mirror.
It has recently been recommended to coat the mirror
with glycerine, which would absorb the moisture;
but  this procedure  materially interferes with the
definition of the image,  and has to be renewed every
time the mirror is introduced.  For all purposes it
is best to warm  the  mirror slightly over the lamp,
with the glass next to the flame so as not to  injure
the  silver  or  amalgam backing  by over-heating.
Before  introduction, the mirror  should be placed
against  the back of the hand of the observer,  in
order to test its  temperature, and prevent its being
placed in position while too hot.   Many laryngolo-
gists are in the habit of testing the temperature of
the mirror by placing it  against the cheek.  This is,
however, a dangerous practice, for a slight abrasion
of the skiu of  the cheek escapes notice, and may be
inoculated  with  syphilitic  poison  from a primary
sore or  mucous  patch  in the  pharynx which  has
been  touched  with the  mirror, while  a scratch  on
the hand is seldom, if  ever,  overlooked, and  thus 
       OBSTACLES  TO  LARYNGOSCOPY.      47

the danger of inoculation may be avoided.  I am in
the habit, before examining a contagious case, to hold
my hands over a little dish containing a few drops
of strong aqua ammonia in order to find whether
there are any abrasions  or cuts of the skin, for the
ammonia vapor soon produces a smarting sensation
wherever the skin is  broken or abraded.  I am thus
enabled to find and  protect such otherwise unper-
ceived vulnerable spots.
   Obstacles to Laryngoscopy.—The difficulties  attend
ing laryngoscopy, and the obstacles which prevent a
good view of the larynx, must be considered under
two heads: 1st. Those that are produced  by  the
examiner himself, which have already been  alluded
to.  They consist principally in  a faulty position of
the mirror in the pharyngeal  cavity, an irritation of
the fauces due to the trembling of the mirror when
in position, the touching of the  back of  the tongue
or palate while introducing the mirror, pulling the
tongue out too forcibly so as to give rise to  pain,
and, finally, the want  of proper adjustment of the
light, without which the larynx cannot be illumi-
nated, even though the laryngeal mirror is in  the
proper position.
   2d. Obstacles  presented by  the  patient.   They
are dependent upon undue irritability or peculiar
formation of certain  parts of the throat.
   Undue irritability  of the fauces is of rare occur-
rence and  is usually confined to the posterior  wall
of the pharynx.  In most cases want of steadiness
of  the mirror is the exciting  cause.  It may be
overcome by  holding  the mirror so  that its lower
rim does not touch the  pharynx;  by letting  the 
48       TEtE  ART OF LARYNGOSCOPY".

patient  drink  a glass of ice-water  immediately be-
fore the mirror is introduced,  the  cold producing
local  anaesthesia for a short time;  or by emplo}T-
ing some anaesthetic, such as a four per cent, solution
of cocaine, ether,  or chloroform, thrown  into  the
fauces by means  of an  atomizer.    Painting  the
fauces with a strong solution of potassium bromide
has been recommended, but I have not found it as
reliable  as I was led to believe.  The surest means
of overcoming this irritability is practice on the part
of the  patient, thus causing  the parts to  become
accustomed to the presence of a foreign body.  This
consists in frequent introductions of the mirror, even
without the anticipation of seeing  anything on the
part of observer, or  by directing the patient to intro-
duce  a  teaspoon as far  back into  his  throat  as
possible.  If the patient is willing to do this before
a looking-glass three or four times a day, he will in
a very short time  be able to  bear  the mirror for a
considerable time  when held firmly without trem-
bling.   The greatest difficulty, however, experienced
by the beginner, is caused by a rising of the back of
the tongue at the approach of the mirror, in spite of
the traction made at its  tip.   In such cases, which
are rather frequent, the tongue should be depressed
with the tongue-depressor, not forcibly, but by slight
long-continued pressure, which tires the muscles of
the tongue and causes the  organ to subside to a level
with the lower teeth.   If force be used, the tongue
will slip from  under the  blade of  the instrument
and rise higher than before.   This may recur re-
peatedly, until  both the patient and the hand of the
observer are tired out by futile efforts. 
           THE  TONGUE-DEPRESSOR.         49

  The tongue-depressor in the simplest form in which
it is daily used by the general practitioner for ex-
amining the  fauces is the  handle of a spoon. For
laryngoscopic purposes, the spoon  is, however, not
to be  recommended,  because the hand  holding  it
must be on a level with the mouth, thus obstructing
the view and light.   An  instrument therefore has
been constructed which obviates  this difficulty.   It
consists of  a  leaf-shaped blade of silver or German
silver,  bent at right angles and inserted into a flat
wooden handle.   The lower surface of the blade is
slightly concave, and  ribbed  so as  to take a better
hold of the  slippery  back of the tongue, and from
the bend is about three inches in length.   It is intro-
duced  into the mouth as far back  as possible, and
pressed upon the back of the  tongue, while the
hand  of the  examiner is  below  the  chin  of the
patient.  For the sake of convenience in carrying
the instrument, the blade has been so hinged to the
handle that it will fold  up against the  latter, and
will open at a right angle with it.   A more elegant
and lighter instrument of the same  description has
lately been introduced in which  the handle is also
made of metal, and, like the blade, is heavily nickel
plated, and which, when folded, can be carried in a
pocket-case (Fig. 17).  Soon, however,  the metal
tongue-depressor becomes tarnished by the secretions
of the  mouth or by the substances used for applica-
tions to the throat, and then presents an appearance
disgusting  to  many patients, who will not, on that
account, submit to its use,   For the sake of greater
cleanliness, Dr.  J.  Solis Cohen  devised a tongue-
depressor made of hard  rubber;  this is known  as
                       5 
50       THE  ART OF LARYNGOSCOPY.
Cohen's tongue-depressor (Fig. 18).   It consists of a
piece of ebonite bent upon itself, either end being a
Fig. 17.                      Fig. 18.
Folding tongue-depressor.         Cohen's tongue-depressor.
little over three inches long.   The bend being more
than at right angles, the hand holding the instru-
ment rests underneath the chin of the patient;  but,
if a  different curve be desired  for  any particular
case, it can easily be obtained by placing the instru-
ment for a little while in hot  water.  When soft it
can be  bent into any  shape,  which it will  retain
when cooled by immersion in cold water.
  Enlarged tonsils sometimes prevent the  introduc-
tion  of a round  mirror into  the fauces,  while an
oval  one  may be  slipped between  the projecting
glands.
  The most serious obstacle  is a too  large or a pen-
dent epiglottis, which completely shuts out the view
of the interior of the larynx.   By letting the patient
sing  in  a  very high key, or making him laugh, we 
THE TONGUE-DEPRESSOR.         51
Fig. 19.
can frequently get a glimpse  of his glottis.   There
are cases,  however, fortunately not  very common,
where this is of no avail.  Several observers have
devised instruments for the pur-
pose  of holding the epiglottis
forward while  the mirror is in
position. They are long, slender,
slightly bent forceps, the shanks
of  which  are crossed  so that
the ends are  closed, instead of
opened,  by the springs,   The
ends  are furnished with  sharp
points, which, when the forceps
is applied, penetrate the mucous
membrane, and thus  prevent
slipping (Fig. 19).  This  is un-
necessary,  since forceps whose
spring is sufficiently strong, and
whose ends are well roughened,
will hold the epiglottis without
slipping.   Several  German la-
ryngoscopists,  in operations at
the anterior angle  of the glot-
tis, have drawn  a silk thread
through the  body  of  the epi-
glottis and held it  up by pull-
ing upon the  ends hanging out
of the mouth.   They assert that
no evil consequences have  fol-
lowed this  procedure, and that
the amount of pain caused by
transfixing  the  epiglottis  is
scarcely worth mentioning.  A better plan, however,
is to  attach to the epiglottis a so-called  bull-nosed
Elsberg's sponge-holder
 and epiglottis forceps. 
 52      THE ART OF LARYNGOSCOPY.

 forceps,  such as is used  for  the compression  of
 arteries in surgical operations, with a  string and
 small weight tied to it.   The weight hanging out of
 the mouth of the patient makes traction upon  the
 string and forceps, thus elevating the epiglottis.  In
 most cases, at least the arytenoid cartilages can be
 seen without artificially elevating the epiglottis, and
 from them a great deal of  information as to  the
 movements of the  cords and the condition of  the
 mucous membrane  can be obtained.
   Auto-laryngoscopy.—The first successful  attempts at
 laryngoscopy were made by Garcia on himself.   He
 observed  the action of his own larynx in singing.
 Since then auto-laryngoscopy has been  frequently
 resorted  to in order to obtain the necessary skill for
 manipulations  necessary in  laryngoscopy,  for the
 hand is guided not only by the  eye of the observer
 but also  by the sense  of touch  in his throat, thus
 enabling him to detect and  correct  a false motion
 much more quickly.
   The instruments  needed for this method of ex-
 amining the larynx  are the same as are used for the
 examination of the  larynx in others,  with the addi-
 tion  of a  plane mirror, in  which the image of the
 larynx reflected from  the laryngeal mirror  is seen.
A short  description of the procedure and of the
position of the instruments will  enable any one to
practise auto-laryngoscopy.
   The observer, having  seated himself in a chair,
with or without a head-rest, places in  front of him-
self a lamp, at such a height  that  the centre of the
flame is on a  level with his mouth when the head is
slightly raised and inclined backward,  Immediately 
AUTO-LARYNGOSCOPY.
53
below the flame  a  small  plane  mirror, about four
inches square, is fastened to the lamp, or, better still,
is  mounted  on a separate stand and placed to the
right of and a little above the flame.  If a concave
reflector  is to be used to throw the light into the
throat, the lamp is placed a little behind and on the
right side of the observer's head, so that the light
does not  shine directly into his eyes and thus inter-
fere  with distinct vision.   The  reflector,  mounted
on a stand high enough  to be  on a level with the
mouth and movable in all directions, is placed in
front of the  observer, and alongside of it the plane
mirror.   If sunlight can  be obtained, the  reflector
can be dispensed with, and the plane mirror used to
throw the light into the fauces, the observer seating
himself with his back to a southern window and
allowing  the sun to shine on the  plane mirror.
  When  all  is ready, the laryngeal  mirror having
been warmed, the observer opens  his mouth, pulls
out  his tongue  with his  left hand  protected by a
towel or  napkin, and introduces the mirror quickly
into  the  fauces, observing and guiding his motions
by the image reflected from the plane mirror.  Upon
emitting  a sound, and at the same time rotating the
mirror in the fauces until the laryngeal image appears
on its  reflecting  surface,  he can study the motions
of his  own  larynx during vocalization,  or quiet
breathing, by the reflection of its image in the plane
mirror before him.
  The same  precautions to prevent gagging have to
be observed in auto-laryngoscopy as are necessary in
examining a patient, and for this  reason the beginner
should commence by examining  his own larynx, for
                       5* 
54      THE  ART  OF LARYNGOSCOPY.

then he will learn by his own and often painful ex-
perience  how  to  overcome the obstacles  to  laryn-
goscopy much sooner than he would by practising
first on others.
  Infra-glottic Laryngoscopy.—In some cases  where
tracheotomy has been performed, and the canula is
fenestrated, the larynx can be seen from below  by
introducing  a  very small mirror through the tube
with  its reflecting surface  turned upward.   Of
course, the image obtained in  this way is an entirely
different one from the ordinary image of the larynx
as seen from above, and hardly anything else than
the vocal cords, which on their under side are red-
dish and not pearl-white  as on their upper surface,
is noticed.
  Only in cases where the larynx cannot be seen
from above, on account of cicatrization of the epi-
glottis tying this organ down, or in cases of tumors
extending below  the glottis,  is this method,  which
was called by Mackenzie  "infra-glottic  laryngos-
copy," of any diagnostic value.

                   Rhinoscopy.

  Rhinoscopy  is  the  art of inspecting  the nasal
cavities, and may be divided into anterior rhinoscopy
or the examination of the anterior nares through
the nostrils, and  into  posterior rhinoscopy or the
inspection of the  vault of the pharynx and the pos-
terior nares from  behind.
  The anterior  nares  may in many cases be  ex-
amined in the  following~manner with a simple bent
probe.   A  strong  light  being thrown  upon the
patient's face, and the head inclined backward until 
RHINOSCOPY.
55
the nose is  on a level with the examiner's eye, the
latter rests  the fingers of one hand upon  the fore-
head  of the  patient, and  elevates  the  tip of  the
nose with his thumb.  With the probe introduced
into the nostril he separates the ala from the septum
with  the other hand, thus opening  the nostril suffi-
ciently  to  illuminate the anterior  nasal cavity on
that side up  to  a  considerable distance, and to ex-
amine the condition of its lining mucous membrane.
Fig. 20.                    Fig. 21.
 Bosworth's nasal dilator.   Jarvis's self-retaining nasal dilator.

The opening of the nostril may, however, be effected
more thoroughly by means of an instrument called
a nasal dilator, of which  there  is an endless variety
in the market, and among them I have  found Bos-
worth's and Jarvis's self-retaining dilators (Figs. 20 
56      THE  ART OF  LARYNGOSCOPY.

and 21) to  be  the most satisfactory.   The blades of
these  instruments are introduced into the  nostril
and being separated by the spring, dilate the nostril
sufficiently to  allow the  inspection of the anterior
nasal  cavity,  and to  make room for  the intro-
duction of instruments high up into the nose.  This
forcible separation of the soft parts from the septum,
which  is effected by these instruments, is, however,
a great disadvantage for diagnostic purposes, because
by it the parts are distorted and  disturbed in their
relation to each other, so that it is impossible to form
a correct estimate of the condition of the parts, as
regards proximity to each other when the nostril is
not dilated.  If for instance an obstruction, caused
by hypertrophy or swelling of the tissue at the ante-
rior extremity of the lower turbinated bone, exists,
as is  so frequently the  case in  nasal catarrh, this
will escape  notice, because  the -obstruction is tem-
porarily removed through the forcible separation of
the parts by the blades of the dilator.
  For  this  reason and  for  others which  will  be
apparent later on, I prefer a rubber nasal speculum,
for examining the anterior nasal cavities, which
closely resembles the ear-speculum in common use,
except that it  is somewhat larger and  has  an  oval
opening instead of a round one  at the narrow end
(Fig. 22).   Three sizes  fitting into each other, and
forming what  is called a nest, are manufactured and
are all that is necessary for most cases.  They should
be made of hard rubber and their inner surface  not
very highly polished, while  the  edge  of the smaller
opening should be rounded off so  as to  prevent
injury  to the mucous membrane.  The metal specula 
RHINOSCOPY.
57
with a highly polished or white inner surface, which
are sold by instrument makers, are  not  satisfactory
because they are more disagreeable to the patient,
are apt to become tarnished by the secretions or the
solutions  used  in  treating  nasal  diseases,  and the
internal reflection  from the inner bright surface  by
dazzling the eye materially interferes with distinct
vision of details in the cavity beyond.

                      Fig. 22.
Nest of rubber nasal specula.
  In making an examination  the speculum is intro-
duced with a slight rotatory motion into  the nostril
until its end has passed the margin of the vestibule,
the ridge or constriction  in  the nostril  where the
skin joins the mucous membrane.   Care should be
taken not to scratch the mucous membrane of the
septum  with the edge  of the speculum, as this not
only gives rise to pain but also frequently to hemor-
rhage which  makes a  further  inspection  of the
anterior nasal cavity  impossible for the time being.
It is, therefore, best to direct  the narrow end of the
speculum toward the ala of the nose while introducing
it until the edge of the vestibule is  passed, when the
instrument can be brought into the  straight position.
A strong light from the stationary or head-reflector 
58      THE  ART  OF LARYNGOSCOPY.

is then thrown through the speculum into the cavity,
when, by moving the speculum  up and  down, the
different portions of the  cavity may readily be ex-
amined in succession.  The head of the patient also
should be moved while inspecting  his anterior nasal
cavities, so that the light can be thrown up when
the head is inclined backward, or down  along  the
floor of the nose when  inclined forward.   When
accumulations  of secretion  obstruct the view, they
should be removed  by washing out the cavity with
an alkaline  solution thrown in with  an  atomizer,
and any changes in the bulk of the different portions
should be examined as to their consistency by touch-
ing them with a probe bent at an angle to the handle,
and introduced through the speculum.
 Posterior Rhinoscopy.—Posterior rhinoscopy is much
more difficult than laryngoscopy or anterior rhinos-
copy, and  requires more  patience and dexterity on
the part of the examiner  than either of the former,
because but very few persons have control over the
movements of the velum palati, and in  most of these
the upper portion of the pharyngeal wall is so sen-
sitive  that  the slightest touch with an instrument
gives rise to reflex cough  and to gagging.   In many
cases, however, with  patience and  skill  the naso-
pharyngeal cavity and the  posterior portion of the
nasal  cavities  can  be illuminated  and  inspected.
This is accomplished by the same instruments and
appliances  used  in  laryngoscopy,  namely,  a small
plane  mirror,  and  a strong light thrown into  the
fauces by means of a reflector.
  Unlike as in laryngoscopy, the head  of the patient
should not be inclined backward, the tongue should
remain passively on the floor of the mouth, and be 
           POSTERIOR RHINOSCOPY.         59

held down with a tongue-depressor, so as to increase
the space in the  fauces as much as possible.   With

                      Fig. 23.
Diagram showing rhinoscopic mirror in position. (Bosworth.)
children the author has found the forefinger of the
left hand to  be the best means of depressing the
tongue, for the little patients, as a rule, have a horror
of the formidable-looking instrument.  The  mirror
having been  warmed,  is then  introduced into the
36378� 
60      THE  ART  OF LARYNGOSCOPY.

pharyngeal cavity behind the velum palati with its
reflecting  surface turned  upward, and by  manipu-
lating, it  is  caused to reflect the light from the
reflector  upward and forward so  as  to  illuminate
the vault  of  the pharynx and the posterior nares
(Fig. 23).   An experienced  manipulator  can use a
mirror of  considerable  size,  and  the larger  the
better; but a beginner should  not attempt  to intro-
duce a mirror larger than one-half inch in diameter.
The stem of the mirror should be  slightly curved,
with the convexity of the curve pointing upward, as
this facilitates  the introduction  of the mirror, and
enables the observer to obtain the proper angle for
the mirror more easily.  In laryngoscopy it is neces-
sary that the mirror should be attached .to the stem at
a fixed angle (120 degrees),  but in posterior rhinos-
copy the angle should be different in different cases,
because of the individual differences found in the
distance from  the vault of the pharynx to  the base
of the tongue, and  from the posterior walls of the
pharynx to the posterior  nares.  It is therefore of
great advantage to  be able to change the  angle of
the mirror, and thus adapt it to the requirements of
the case.   This may be  done with Jarvis's rhinos-
copic mirror and tongue-depressor (Fig. 24) as modi-
fied by myself.  The  instrument  consists of a stout
wire which, after having been forked or divided at
some  distance from its  insertion into the handle,
forms the loop for the tongue-depressor.  The  two
branches then cross each  other, and are bent to form
another loop  at an  angle to  the larger one.   The
ends of the wire are somewhat flattened and press
against each other, thus closing the smaller  loop and
forming a sort of pincette, which  can  be opened by 
           POSTERIOR  RHINOSCOPY.         61

pressing the sides  of the larger loop toward each
other.   The ends of the pincette are perforated by a

                      Fig. 24.
  Seiler's modified Jarvis's rhinoscopic mirror and tongue-depressor.

small hole which receives a  pin  attached at right
angles to the short shaft of a small mirror,  thus
forming a hinge so that the mirror can  be placed at
any  desired  angle  with the handle  or stem.  The
spring of the pincette cannot, however, be made
strong enough to prevent a change of the angle of
the mirror by coming in contact with the pharyn-
geal wall, and I therefore had a ratchet placed at
the shaft of the mirror where it is  hinged to the
ends of the pincette, and a small steel spring coming
from one of the branches of wire where they cross
each other to form the small loop, by  engaging in
the teeth of the ratchet, holds  the mirror at the
angle given to it before introducing.  The large loop
acts as a tongue-depressor, so that with this admira-
ble instrument  the examination  of  the  post-nasal
cavity can be made with one hand, leaving the other
free for the manipulation of other instruments.   In
order to be  able to exert more  pressure upon the
tongue and to bring  the  hand  out  of the  line of
vision, the handle may be attached to the stem at an
angle like the one- in the folding tongue-depressor.
                        (3 
 62       THE ART OF LARYNGOSCOPY.

  Having introduced the mirror  into the pharynx
 behind the velum, it will be  found  that in most cases
 the palate will rise forcibly, thus completely obstruct-
 ing the view and preventing the introduction of the
 mirror into the pharyngeal cavity.   This  difficulty
 can  be obviated by telling the patient  to breathe
 through  his nose,  at  the  same time keeping  the
 mouth open.  After a little  practice he will learn to
 do so,  when the velum will drop and the mirror  can
 be brought  behind  it, illuminating the vault of  the
 pharynx and the posterior, nares.  Under no circum-
 stances should  the  rim of the  mirror touch  the
 posterior  wall  of the  pharynx,  as  otherwise  the
 palate  will  at once rise and obstruct the view.  In
 order  to prevent this  great and  chief  obstacle to
 posterior rhinoscopy, a number of  instruments have
 been devised to hold the velum forward and out of
 the way, but none of these so-called palate retractors
 has proved advantageous in my hands, and I have
 found  that practice on the part of the patient, and
 a diminution of the irritability of the parts by local
 applications, will accomplish the purpose much bet-
 ter than any instrument could do.
  In the case of operations  in the  post-nasal cavity,
 however, it is not only desirable but often absolutely
 necessary that the operator should be able to watch
 his  instrument in the  rhinoscopic mirror;  then it
 becomes necessary  to  prevent a rising  of the soft
 palate  by mechanical  means.  This may be accom-
 plished by inserting a blunt  hook behind the velum
 and drawing it  forward, so  as to increase the naso-
pharyngeal  space.  A  hook of this  kind may be
improvised,  but it has the disadvantage of not being
self-retaining,  and must be held  by an assistant. 
           POSTERIOR RHINOSCOPY.         63

Dr. Porcher, of Charleston, has devised an admirable
instrument for this  purpose, which  meets  all the
requirements in most cases (Fig. 25).  It consists

                      Fig. 25.
of an ordinary palate hook upon the stem of which
a slide attachment has been added.  From the front
of this slide project two arms, which  end in two
medium-sized rings, and at  its rear is an automatic
spring-catch, which 'penetrates the perforated stems
at short intervals.  When in  position the two rings
of the  arms rest on either side of the nose, just
above the alveolar processes, and are easily retained
there by the counter-pressure of the retracted palate.
In some cases this instrument  is, however, not suffi-
cient to keep the palate out  of the way, and then
the method devised by Dr. Jarvis must be employed.
This is as follows:
  An Eustachian catheter is first introduced along
the floor of the nose until its curved end has passed
into  the pharyngeal cavity.   Through  this  a  piece
of catgut  of  about the  thickness of a  "D" string
used on violins is passed until its end appears in
the pharynx below the margin of the palate, where
it is grasped by  a pair of  forceps and drawn out
through the mouth,  the other  end of the string still
projecting from the nostril.   The catheter  is then
 
 64      THE ART  OF LARYNGOSCOPY.

 withdrawn and a piece of narrow elastic tape, such
 as is found in every trimming store, is tied to  the
 end of the string projecting from the mouth, and is
 drawn into the pharynx and out of the nose by  the
 withdrawal  of the catgut string, so that one  of its
 ends projects  from the mouth and the other from
 the nose, thus making  a loop around the soft palate.
 Another piece of elastic tape is  then, in  the  same
 manner, passed through the other nostril  and  the
 end  secured by Jarvis's tape-holder.  These are two
 small V-shaped  spring clips so arranged  that  the
 tape passing through apertures is caught by a tooth-
 like projection and  firmly held.   Pressure on  the
 blades of the  clip releases the catch and  sets  the
 tape free.
   The end of the tape projecting from the mouth
 of the patient  is passed through the slit of the  blade
 of the tape-holder to  which  the  cross-bar  or  catch
 is fastened, and knotted  to  prevent its  slipping
 out.   The other  end is passed through the slit of
 the  other blade  and also  through the slit of  the
 catch, which  can readily be  clone by slightly com-
 pressing the blades of  the tape-holder until the two
 openings come opposite to each other.  The pressure
 being taken off, the  cross-bar draws the tape down
 upon the  blade of the  instrument and firmly holds
 it there, thus preventing its slipping when sufficient
 traction has been made to draw the palate  forward.
 The  strain of the two tapes passing around the velum
 can  be conveniently  regulated and nicely balanced,
thus making  their presence  tolerable, and should
efforts at  gagging or  vomiting  show themselves,
the elastic tapes can quickly be relaxed, giving  the
velum free play. 
ANATOMY OF THE LARYNX.        65
                CHAPTER  III.

  ANATOMY AND  THE NORMAL LARYNGEAL
         AND RHINOSCOPIC  IMAGES.

  Although the scope of this little  manual is not
sufficiently extended to enter at length into the con-
sideration of the anatomy  of the larynx and the
pharyngeal and  nasal  cavities, yet it will be conve-
nient, in a  few  words, to  describe the anatomical
relation of those parts to each other which form the
laryngeal and the rhinoscopic images, before describ-
ing these latter when seen on the  reflecting surface
of the mirror.
  The anatomy of  the larynx and trachea, as well
as of the nasal  cavities, is  so well understood and
described  by authors  of  text-books on general
anatomy and physiology, that a  very few sentences
will suffice to refresh the reader's memory.

            Anatomy of  the Larynx.

  The larynx is a funnel-shaped expansion of the
trachea situated  at the upper part of the air-passages.
Its lower narrow part is circular, while its upper ex-
pansion presents a  triangular appearance.  It con-
sists mainly of  nine  cartilages—three  single  and
three in pairs—which are held together by ligaments,
and are moved upon each other by numerous small
muscles.   The interior of this cartilaginous tube is
lined with mucous membrane, which is thrown into
                       o* 
66        ANATOMY  OF THE LARYNX.
two pairs of folds and is covered with ciliated epi-
thelium, except at the lower folds, the vocal cords,
which are  covered with  tessellated epithelium.  In
examining the cartilaginous skeleton of the  larynx
(Fig. 26) the first object which attracts our attention
Fig. 26.
        Hyoid bone and the laryngeal cartilages.  (Ellis.)
  g. Body of the hyoid bone. h. Large cornu. j. Small cornu. a. Epi-
glottis,  b. Thyroid cartilage,  c.  Arytenoid cartilage,  d. Cricoid car-
tilage, e. Upper cornu, and f. Lower cornu of the thyroid cartilage.

is a  large and  peculiarly  shaped cartilage—the  thy-
roid cartilage.
  The  thyroid cartilage,  so  called  from  its  resem-
blance  to an old Etruscan shield {&vpe6q\ is composed 
THYROID CARTILAGE.
67
of three  pieces—two  lateral wings  or alse, and a
centre-piece.   Each wing is quadrilateral in shape,
and  is united to its fellow by the centre-piece at an
acute angle, which, being covered only by skin, forms
the  projection in the anterior  portion of the  neck
called the pomum Adami; more prominent in the
male than  in  the female on account of the  greater
amount of  adipose tissue overlying it as well as on
account of the fact that the angle  formed by the
junction  of the two lateral wings of the thyroid is
less acute in the female than in  the male.
  The upper margin of the wings is deeply notched
immediately above  the  greatest anterior projection
of the pomum Adami, rising and falling as we trace
it  from  before backward, so  that it presents an
S-shaped outline.   The lower margin is less  compli-
cated, having  for  its outline a simple curve from
before backward.
  The posterior  border  being rather  thick  and
rounded, presents a wavy outline in a perpendicular
direction, and terminates above  in the superior cornu
and  below  in the  inferior cornu of the  thyroid
cartilage.
  The outer surface of the alee presents a roughened
oblique ridge, which passes downward and forward,
originating in a tubercular projection at the root of
the  superior  cornu.  The inner surface is  smooth
and is covered by mucous membrane.
  The centre-piece, which  was first described by
Luschka, can only be seen by removing the perichon-
drium covering the cartilage.  Its shape is that of a
bottle, or pyramid, with  its base downward.  It is
situated at the junction of the wings and forms the
keystone to  the  arch of the whole  cartilage.   Its 
 68       ANATOMY OF THE  LARYNX.

 color is slightly different from that of the two wings,
 being a shade more yellow, and  a microscopic ex-
 amination reveals  the  fact  that  it is composed of
fibrous cartilage, while the wings and other cartilages
 of the larynx are of the hyaline type.
   Cricoid Cartilage.—The thyroid cartilage is mounted
 upon the cricoid cartilage, which latter forms the lower
 expansion  of the  larynx.   It has received its name
 from its striking  resemblance  to  an old-fashioned
 signet-ring (kp'ikoc), the  posterior part  being broad
 and  thick forms the  crest-plate, while  the  anterior
 part is thin  and narrow and forms  the  ring  part.
 On the posterior  plate we observe a  ridge in the
 median line,  which serves for the attachment of the
 crico-arytenoideus posticus muscle.
   The  superior border of the cricoid cartilage is
 directed upward and backward, owing to the great
 width of the  posterior plate.  It has  a smooth  and
 very  slightly  wavy outline, and is notched  at  the
 middle of the plate.  On either side of  this notch
 we observe a smooth oval surface  which serves for
 the articulation with the arytenoid cartilages.  The
 lower  border is horizontal and also wavy, and  is
 connected with the first  ring of the trachea.
   The Arytenoid Cartilages,  so called from   the re-
 semblance  they bear  when  approximated  to  the
 mouth of a pitcher (apvTaiva), are two small, irregular,
pyramidal  cartilages, which  are mounted upon and
articulated with the upper posterior margin of the
cricoid cartilage.  The  posterior surface  is smooth,
triangular, and is  bent  backward.  The anterior
surface is  convex  and  roughened, and  to it  the
thyro-arytenoid muscle is attached.   The  internal
surface is smooth and  very narrow,  concave,  and 
LIGAMENTS                 69
 covered with mucous  membrane.  The base is con-
 cave and smooth, articulated with the cricoid carti-
 lage, and presents two projections or processes in its
 margin.  The anterior process serves for the attach-
 ment of the vocal cords, and is called the vocal pro-
 cess, to  which in the female larynx is attached a
 small elongated piece of fibrous cartilage embedded
 in the  cord, called  the cartilage of Seiler,  while the
 external process, which is shorter and more rounded
 than the vocal  process, serves for the attachment of
 several muscles, and is called the muscular process.
   The apex of the arytenoid cartilage  is  elongated
 and  curved backward and inward.  It is surmounted
 by a small nodule of cartilage, the cartilage of San-
 torini.   Two small  elongated  cartilages  are  also
 placed in the ary-epiglottic fold.
   Beside the cartilage already described,  we find a
 thin  lamella of fibrous cartilage  inserted  into the
 angle of the thyroid cartilage.  This  thin  spoon-
 shaped cartilage,  the  epiglottis, serves  to  close the
 opening of the air-passages in deglutition.   It is
 broad on its free end and  narrow at the point of
 insertion, concave  in its laryngeal surface and convex
 in its glossal surface.
  The  hyoid bone, although  intimately connected
 with  the larynx, does not belong to its cartilaginous
 skeleton.
  Ligaments.—The cartilages of the larynx are  con-
 nected  by ligaments among themselves (intrinsic)
and to other structures (extrinsic). (Fig.  27.)
  The largest of these is  the thyro-hyoid membrane,
a broad fibro-elastic membrane attached  below  to
the upper border of  the thyroid cartilage, and above
to the upper margin of the posterior surface  of the 
70        ANATOMY OF THE LARYNX.
hyoid bone,  being  separated  from the  latter  by a
synovial  bursa.   It  is somewhat  thicker  in the
middle than at  either side, and  is  penetrated by
both  vessels and nerves.

                        Fig. 27.
   Vocal apparatus, on a vertical section of the larynx.  (Ellis.)
  a. Ventricle of the larynx,  b. Vocal cord.  c. Ventricular band.
d. Sacculus  laryngis.  e. Arytenoid cartilage.  f.  Cricoid  cartilage.
g. Thyroid  cartilage,  h. Epiglottis,  k. Crico-thyroid ligament.  l.
Thyro-hyoid ligament.

  Between the greater  cornua  of  the hyoid  bone
and  the superior cornua of the thyroid  cartilage we
find  two round  elastic  cords,  strengthened  by  a 
EPIGLOTTIC  LIGAMENTS.
71
small cartilaginous nodule, which are  called  the
lateral thyro-hyoid ligaments.
  Connecting the cricoid and thyroid cartilages is a
triangular membrane of yellow elastic tissue.  It is
thick in  front, where it connects the upper border
of the cricoid  cartilage to the lower margin of the
thyroid,  and  thin  on either side, where it has  its
upper insertion on the  inner surface of the thyroid
cartilage below the true vocal cords.
  The articulation  of  the  inferior  cornua of  the
thyroid cartilage with the cricoid is enclosed in two
capsular  ligaments  lined with  synovial membrane.
This articulation is a hinge-like joint which  allows
of a  rocking  motion of the thyroid cartilage upon
the cricoid.  The articulation of the arytenoid car-
tilage with the  cricoid is also enclosed by capsular
ligaments, lined  with synovial membrane, and is of
a ball-and-socket-joint character, allowing a rotatory
motion of the  arytenoid cartilage  upon the cricoid,
and also a sliding motion  in a lateral direction and
backward, as well as a rocking forward.
  Epiglottic Ligaments.—The epiglottis is  connected
with  the adjacent parts by several ligaments and
folds.
  1. By the  hyo-epiglottic  ligament  to  the  hyoid
bone.  This ligament extends from the anterior sur-
face of the epiglottis near its apex, to the posterior
surface of the  hyoid bone.
  2. By the  thyro-epiglottic  ligament,  a  narrow
elastic band, to  the  thyroid cartilage, where it is
inserted in the angle of the cartilage just above the
middle piece.
  3. By the three glosso-epiglottic folds of mucous 
72       ANATOMY OF THE LARYNX.
membrane by which the epiglottis is attached to the
sides and base of the tongue, thus forming two large
fossae between them.
  4. By the aryteno-epiglottidean or ary-epiglottic
folds, which  run from  the sides of the epiglottis to
the apex of the  arytenoid cartilages and contain the
cartilages of Wrisberg  and of  Santorini.
  Muscles.—The muscles  of the larynx proper are
divided into two classes: those which act in moving
the vocal cords, and those which are connected in
the movements of the epiglottis.  The muscles of the
first class are again subdivided into muscles which
stretch the vocal cords and approach them, and those
which relax and separate them.
  The  crico-thyroid (Fig. 28) is the first to attract our
attention by its size.  It is triangular in shape, over-
lies the anterior and lateral portion of the cricoid
cartilage, and has its  origin below in the front and
side of the cricoid cartilage. Its fibres pass obliquely
upward, and are inserted  into  the lower and  inner
borders of the thyroid cartilage.  When this muscle
contracts it draws the anterior portion of the thyroid
cartilage over the cricoid cartilage, thus lengthening
and stretching the vocal cords.
  The  crico-arytenoideus lateralis, which  arises  from
the upper border of the side of the cricoid cartilage,
and is inserted in the muscular process  at  the  base
of the arytenoid cartilage, revolves the arytenoid car-
tilage upon  its  base, thus approaching the  vocal
processes together with the vocal cords.
  The  thyro-arytenoid  muscle, a  muscle  prismatic in
its transverse section, which lies along  the base of
the cords, arises from the base of the middle piece 
ARYTENOID MUSCLE.             73
of the thyroid cartilage, and by a few fibres, which
become gradually shorter from the inner side of the
                         Fig. 28.
       View of the internal muscles of the larynx.  (Ellis.)
  1. Crico-thyroideus detached. 2. Crico-arytenoideus posticus. 3. Crico-
arytenoideus lateralis.  4. Thyro arytenoideus, superficial part.  5. De-
pressor of the epiglottis. 6. Thyro-hyoideus, cut.  8. Deep or trans-
verse part of thyro-arytenoideus.

wings of this cartilage, is  inserted into the base and
anterior surface of the arytenoid cartilage.
   Arytenoid muscle.  The arytenoid muscle (Fig. 29),
a single muscle, occupies the  cavity formed by the 
74        ANATOMY  OF  THE LARYNX.
posterior surfaces  of the two  arytenoid  cartilages.
It arises from the posterior surface and outer border
of one  arytenoid cartilage, and is inserted in the
corresponding parts of the other cartilage.   It con-
Fig. 29.
            Posterior view of the larynx.  (Ellis )
   a. Superficial part of the arytenoideus muscle,  b. Deep part of
        the arytenoideus.  c. Crico-arytenoideus posticus.

sists of three sets of fibres,  two  oblique and one
transverse.   The  oblique and superficial  sets  pass
from the base  of one cartilage  to the apex  of the
other, while the transverse fibres which lie  below
pass directly across.
  This muscle,  together  with the  preceding one, is
regarded by Luschka as  forming a sphincter or con-
strictor of the glottis.  The thyro-arytenoid or vocal
muscle, when acting alone, will  draw, however, the 
CRICO-ARYTENOID  muscle.        75
vocal cords asunder near  their anterior  insertion ;
while  the  arytenoid,  if acting  alone, will simply
rotate  the  arytenoid cartilages outwardly, and thus
separate the local processes.  But both muscles act-
ing together will narrow the glottis  by approaching
the cords.
  The  crico-arytenoid,  a large  fan-chaped  muscle
which  occupies the depressions on either side of the
median line of the posterior surface of the cricoid
cartilage, arises from  this  surface.  Its fibres, run-
ning obliquely upward, are collected  into a short
tendon, which is inserted into the posterior  margin
of the vocal process.
  This muscle, when contracting, separates the vocal
processes of the arytenoid cartilage by rotating them
outwardly, and at the  same time pulls the arytenoid
cartilage downward.   The action of these  can be
better  understood  by  consulting  what  might  be
termed a mechanical diagram (Fig. 30).
  A diagram of this kind is easily made  in the fol-
lowing  manner and fully  repays for the  trouble of
making it by greatly facilitating the comprehension
of the  rather intricate  action of these muscles.   Let
the reader take a piece of cardboard and cut narrow
slits into  it of the shape,  size,  and at the position
indicated by the dotted line in  the diagram.  Next
cut out of another  piece of cardboard an arch, like
the  one marked T, representing a section of the
thyroid cartilage and two smaller pieces like the ones
marked A,  representing the arytenoid  cartilages.
Then pass a pin through the points marked on the
diagram P, and insert them into the slits  cut into
the larger piece of cardboard.  Let him then paste 
76       ANATOMY OF THE  LARYNX.
two  narrow strips  of white paper, with their ends
close together, on  the centre of the  arch  and each
end to the point of the arytenoid  cartilages in such

                      Fig. 30.
Mechanical diagram of the action of the intrinsic muscles of the larynx.

a wTay  that  when  the arch  is drawn away from the
lower portion of the  diagram as much as the pins  in
the slit will allow, the strips of paper representing
the vocal cords  lay flat.  A  small  square piece  of
59999991 
EPIGLOTTIS.
77
pasteboard should then be passed over the point  of
each pin  projecting on the under side of the large
piece of cardboard as a washer, so as to prevent the
pieces from dropping off, and  the pin points may be
bent over  so that the model  can be laid flat on a
table.
  The muscles  are  then  represented by strings at-
tached to. the movable parts at the points indicated,
and are passed through holes  in the  base cardboard
at points also shown in the diagram, so that when
pulled upon from behind they will make traction
upon the movable parts in the line of force in which
the muscles act in the living larynx.
  Thus, the  string marked 1  represents the crico-
thyroid muscle  and increases  the distance  between
the vocal  processes of the arytenoid cartilages and
the anterior angle of the thyroid,  thus  stretching
the vocal  cords.  The string  2 represents  the  pos-
terior crico-arytenoids, string 4 the lateral crico-ary-
tenoids, string 3 the arytenoid muscle, strings 5 and
6 the different fibre layers of the thyro-arytenoid,
and  each one when pulled upon  from behind  will
cause a movement of the vocal cords corresponding
with the  action of  the  muscles represented.  For
class demonstrations such a model is invaluable and
should for that purpose be made of wood, but on a
much larger scale.
  The muscles  of the epiglottis are three  in num-
ber :
  1.  Thyro-epiglottideus, which arises from the inner
surface of  the thyroid cartilage, passes upward, and
is partly lost in  the ary-epiglottic fold, and partly
                        7* 
 78       ANATOMY  OF THE  LARYNX.

 inserted in the margin of the epiglottis.  It acts as
 a depressor of the epiglottis.
   2. Aryteno-epiglottideus superioris,  a small slender
 muscle consisting of only a few bundles of muscular
 fibre, arises from the apex of the arytenoid cartilage,
 and is lost in  the ary-epiglottic  fold.
   3. Ary-epiglottideus inferioris, arises from  the ante-
 rior surface of the arytenoid cartilage.  Its  fibres
 pass upward and are inserted into the margin of the
 epiglottis.
   The mucous membrane by which the interior of
 the larynx is lined  is thrown into folds, and, cover-
 ing the cartilaginous projections and depressions of
 the  skeleton, presents  a surface of peculiar shape
 and form for examination.
   We notice,  first, the  superior  aperture of  the
 larynx, a large triangular  opening leading to  the
 cavity proper of the larynx.   It is bounded in front
 by the epiglottis, behind by the apices of the aryte-
 noid cartilages, and laterally by the ary-epiglottic
 folds.
   The cavity proper of the  larynx  (see Fig. 35)  ex-
 tends from this aperture to the lower  edge of  the
 cricoid  cartilage.   It is divided into two  parts by
 the projections formed, inwardly, of the vocal cords,
 the upper and  larger part being elliptical, while  the
 lower and smaller is circular.
  The vocal cords are two prismatic  bands composed
 chiefly of the aryteno-thyroid muscle, and a layer of
fibres at its free edge,  composed of white fibrous
tissue with a few fibres^ of yellow elastic tissue inter-
 mingled.
  These bands present in cross-section the shape of 
THE VOCAL CORDS.
79
a triangle, the upper side of which is concave, while
the inner side is convex, with a small notch below
the inner angle.1 This notch is produced by a folding
inward  of the mucous membrane below  the inner
edge of the  vocal  cord, and is seen  throughout its
entire length.   The greater portion of the section is
made up of muscular fibres,  while  only  the inner
angle is composed  of white fibrous tissue containing
a few fibres  of yellow elastic tissue.
  They extend from  the vocal process of  the aryte-
noid cartilage to the  angle of the thyroid cartilage,
where they  are attached  to  the middle piece of the
thyroid cartilage.   The lower portion of the vocal
bands  is lost  in the  crico-thyroid membrane,  with
which they are continuous.   In phonation these
bands approach each other with their free edges, and
form  a narrow chink or slit  between them, called
the rima glottidis.  In ordinary breathing this opening
becomes large  and triangular in shape, the  base of
the triangle  being formed by the upper margin of
the posterior plate of the cricoid cartilages, and its
sides by the edges of  the vocal cords.  The  mucous
membrane covering these cords  is of a pearl-white
hue, and devoid of ciliated epithelium.
  At the base of  the vocal  cords the mucous mem-
brane  is again supplied with the ciliated   variety
of epithelium, and runs  upward  and backward for
a considerable distance, to be  reflected and to come
down again to almost the place whence  it  started,
thus forming a deep pouch;  it is again reflected and

  i The designations of the direction are in regard to the larynx, not
to the triangle. 
80       ANATOMY  OF THE  LARYNX

runs upward, covering the epiglottis.   This duplica-
ture of mucous  membrane thus formed, which lies
above the vocal cords and runs parallel with them, is
called  the ventricular band.  The pouch spoken of,
which  is of variable size, and situated between the
ventricular bands and the inner side  of the thyroid
cartilage, is  named the sacculus laryngis, while its
elongated, elliptical opening is termed the ventricle.
In the  submucous  tissue of this  pouch numerous
glands are situated, which open  into the sacculus,
and  whose secretion  is  intended  to lubricate the
vocal cords.  The mucous membrane of the  laryn-
geal surface  of  the epiglottis  is  also  the seat of
numerous glands, whose openings may frequently
be seen by the naked eye.
  The larynx is supplied with arterial blood by three
arteries, viz.: the superior  laryngeal, which usually
springs from the superior  thyroid, but occasionally
is derived from the internal carotid, and supplies the
muscle and mucous membrane of the upper portion
of the larynx; the middle laryngeal or crico-thyroid
artery  arises  from  the superior  thyroid  near the
upper   margin  of  the  thyroid  cartilages,  passes
downward and divides into two branches, entering
the laryngeal cavity  at  the lower  margin of the
thyroid cartilage, and supplies  the vocal cords and
the mucous membrane  below  them;  and, finally,
the inferior  or posterior laryngeal artery, which is
derived from a branch of the inferior thyroid, runs
upward  and  divides  into two  branches near the
lower  edge  of the  thyroid cartilage, one of which
joins a  branch of the superior  laryngeal, while the
other supplies the posterior crico-arytenoid muscle. 
THYROID  GLAND.
81
The veins  empty  into the superior,  inferior, and
middle thyroid veins.
  The nervous  force  is supplied by  the superior
laryngeal and the inferior recurrent laryngeal branch
of the pneumogastric, and  also by a  few fibres of
the sympathetic and spinal accessory.
  The superior laryngeal nerve is  in the main  a
sensory nerve and gives sensation to  the laryngeal
mucous  membrane, but it  also  contains  a motor
branch  which  supplies the crico-thyroid  muscles,
while the inferior laryngeal is exclusively a motor
nerve and  innervates  the other laryngeal muscles.
The arytenoid  receives filaments  from  both  the
superior and inferior nerves. The recurrent branches
of the pneumogastric are  united  by a chiasm, which
fact, before surmised,  was established by experi-
ments made on the body of a criminal by Dr. W. W.
Keen and myself.
  Besides the muscles  described as belonging to the
larynx proper, there  are other  muscles  which by
their action determine the position of  the larynx in
the throat.   These are the  so-called extrinsic mus-
cles of the  larynx, and comprise the sterno-thyroid,
the  thyro-hyoid,  the  omo-hyoid, and the sterno-
cleido-mastoid.
   Thyroid Gland.—The thyroid gland, a large duct-
less gland,  divided into two lobes by the isthmus, is
situated  in the anterior part of the neck, overlying
the trachea below the cricoid cartilage.  Occasionally
a third lobe of this gland  is met  with, which, when
it  is present, overlies the trachea extending for
some distance above and below the isthmus.   This 
82         THE LARYNGEAL  IMAGE.
anomaly of  the  thyroid gland  should not be  lost
sight of in the operation for tracheotomy.

              The Laryngeal Image.
  Supposing  that  the  mirror,  after  having  been
introduced, displays a complete image of the laryn-
geal opening, such as is seen in Figs. 31 and 32, we
         Fig.  31.                      Fig. 32.
 Laryngeal image during res-      Laryngeal image during pho-
         piration.                      nation.
observe  a reddish-yellow arch, sometimes  notched
in the centre, with a roundish protuberance in front
of it, of the same  color, but not so well illuminated.
  This arch is the upper margin of the epiglottis, and
the backward bend of the  organ i.ear  its insertion
into the  angle of the thyroid cartilage.   In front of
this protuberance, extending across the  surface  of
the mirror, are  seen two pairs of  bands, the outer
reddish, and  the  inner pearl-white when  normal.
These are the ventricular bands and vocal cords.  In
quiet breathing a triangular space is noticed between
the inner bands, with its apex posterior, and usually
hidden by the arch of the epiglottis.  In  phonation
this space is narrowed  down to a slit, and  is desig-
nated by the name glottis}

  1 The name glottis  is frequently applied to the whole opening of the
larynx, and in many books a very vague idea is given of its extent.
By common consent, the term is applied to the space between the
edges of the cords only.
 
THE LARYNGEAL IMAGE.         83
  In  front, at  the  termination  of  the  vocal cords,
we notice two roundish prominences, with a depres-
sion between them when  the patient is breathing,
but closely applied to each other in vocalization.
These are  the arytenoid cartilages as seen from
above.   On either side a curved band, with its con-
cavity inward, extends backward to join the arch of
the epiglottis.  Along the course of these bands,
'which are the ary-epiglottic folds, we see two small
nodules, the cartilages of Wrisberg and of Santorini.
   In the female larynx we see, along the inner edges
of  the  vocal  cords,  two  yellowish  stripes,  very
narrow and tapering toward their ends.  These are
the cartilages of Seiler, which are only rudimentary
in  the male larynx.
   Behind and above the arch of the epiglottis, two
dark oval spaces, separated by a light band running
backward, are observed.   These are the depressions
on either side of the glosso-epiglottic fold, while the
light band separating them is  the fold itself (Figs.
33 and 34).
   By directing the reflected light a little forward,
we see back of these depressions  a surface studded
with round eminences—the back of the tongue, with
its papillae.
   Through the  glottis when fully  opened we can
see into the inferior cavity of the larynx  below the
vocal cords, where a  broad yellow band, the cricoid,
cartilage,  appears, and  below  it the rings of the
trachea  elevating the mucous membrane. Not in-
frequently, two dark  circles separated  by a bright
line may be seen in the depths  of  the trachea, indi-
cating the openings of the bronchi, and the bifurca-
tion of the trachea.  In very rare  instances a beam 
84           THE  LARYNGEAL  IMAGE.
of light can be thrown into  the  right bronchus, but
very little  can be seen  under  such circumstances, as

                            Fig. 33.
                             coin
  Laryngoscopic diagram showing the vocal cords widely drawn apart,
and the position of the various parts above and below the glottis during
quiet breathing. ' (From Mackenzie.)
  g. e. Glosso-epiglottic fold s.  u. Upper surface of epiglottis.  I. Lip
or arch  of  epiglottis,  c. Protuberance  of epiglottis,   v. Ventricle of
the larynx,  a. e. Ary-epiglottic fold. c. W. Cartilage of Wrisberg.  c. S.
Cartilage of Santorini. com. Arytenoid commissure,  v. c. Vocal cord.
v. b. Ventricular band. p. v.  Processus vocalis.   c. r. Cricoid cartilage.
t. Rings of trachea.
                           Fig. 34.
                       co  ci   com  n
  Laryngoscopic diagram showing the approximation of the vocal cords
and arytenoid cartilages, and the position of the various parts during
vocalization.  (From Mackenzie.)
  f.i. Fossa innominata. h.f. Hyoid fossa, c.h.  Cornu of hyoid bone.
c. W.  Cartilage of Wrisberg.  c. S. Cartilage of Santorini.  a. Arytenoid
cartilages,  com.  Arytenoid  commissure,  p. v. Processus vocalis and
cartilages of Seiler.

everything is  very  indistinct  and differences of color
cannot be determined. 
THE LARYNGEAL IMAGE.         85
  The normal  color of the mucous membrane is a
pinkish-red, varying in shade in different localities.
Thus, the epiglottis is usually of  a yellowish tint,
caused  by the shining, through  the  thin layer  of
mucous  membraue,  of the cartilage.   The  pearly
white of the vocal cords, which has already been men-
tioned, serves as a landmark to the beginner in laryn-
goscopy.   There  may be,  however,  considerable
variation of color in the mucous membrane within
the limits of health, in different  individuals, and
even in the same individual under different circum-
stances, as, for  instance, after a  meal the  mucous
membrane is  darker than before meals, and when
viewed   by a white light,  as  already  mentioned, it
appears lighter than when a yellow light is used for
illumination.
  The shape of  the  different parts also  may vary
considerably without being  abnormal, and  this  is
especially the  case  in  the  shape of the epiglottis,
which may be  curled upon itself or be  flat, may
have a notch in the middle of the upper margin,  or
may, instead of it, be pointed, etc.
  The arytenoid cartilages also vary considerably
in size  and shape, and even in  their movements
during  phonation, for I have frequently seen cases
in which the arytenoid  cartilages, instead of simply
being pressed against each other in phonation, par-
tially passed each other, so that  the vocal processes
seemed to lap without in the least interfering with
the function of the vocal cords.
8 
86   anatomy of  the  nasal cavities.


        Anatomy of the  Nasal  Cavities.

  The nasal cavities,  which are wedged-shaped, with
a narrow arched roof,  extend from  the nostrils to
the  upper  portion of  the vault  of  the  pharynx
(Fig. 35).   Their outer walls are formed in front by
the  nasal process of the superior maxillary and lach-
rymal bones, in the middle by the ethmoid and inner
surface of the  superior maxillary bones, behind by
the  vertical plate of the palate bone, and the internal
pterygoid process of the  sphenoid and turbinated
bones.   These  latter run from  before backward,
three on each side,  and are  designated as the in-
ferior,  middle, and  superior,  the latter being the
smallest of the three.   The superior turbinated bone
is, however, usually  only rudimentary in the adult
nose, and is even not infrequently altogether absent.
In the foetus and in  early childhood it is generally
large and often divided into two unequal portions by
a cleft running parallel with its longitudinal diam-
eter.  The spaces  or sinuses between  these  turbi-
nated bones are called meatuses, so that the space
between the floor of the nose  and the lower turbi-
nated bone is  called the  inferior meatus, the  one
between the lower and the middle turbinated bone
is the middle meatus,  and the  one between the
middle and superior  turbinated bones is the superior
meatus.
  The nasal cavities are separated from each  other
by  a septum or division-wall,  composed of the per-
pendicular plate of the ethmoid bone and the vomer
posteriorly and the cartilaginous septum anteriorly, 
ANATOMY  OF  THE  NASAL  CAVITIES.    87


                        Fig 35.
Vertical section of head ;  slightly diagrammatic.
  1. Superior turbinated bone.  2. Middle turbinated bone.  3.  Lower
turbinated bone.  4.  Floor  of nasal cavity.  5.  Vestibule.  6. Section
of hyoid bone,   7. Ventricular band.  8.  Vocal cord.  9 and 23. Section
of thyroid cartilage.  10 and 24.  Section of cricoid cartilage.  11. Sec-
tion of first tracheal ring.  12. Frontal sinus.  13  Sphenoidal cells. 14.
Pharyngeal  opening of Eustachian tube.  15. Rosenmiiller's groove.
16. Velum  palati.  77. Tonsil. 18. Epiglottis.  19. Adipose tissue behind
tongue.  20. Arytenoid cartilage.  21. Tubercle of epiglottis.   22. Section
of arytenoid muscle. 
88   ANATOMY  OF  THE NASAL CAVITIES.

thus presenting a smooth surface  as  the  inner wall
of each cavity.
  The floor is formed by the palatine process of the
superior maxillary bone and by the palate bone, and
runs in a slanting, downward direction from before
backward.  The roof is formed by the nasal bones and
nasal spine of the frontal in front, in the middle by
the cribriform plate of the ethmoid, and  posteriorly

                      Fig 36.
Transverse vertical (i. e. coronal) section of the nasal fossie at the plane
   of the second molar teeth, seen from  behind.  (Hieschfeld.)
by the under surface of the body of the sphenoid bone.
Directly communicating with the nasal  cavities  by
narrow channels are other cavities, situated in the
bones of the skull, the lining mucous membrane of
which, no doubt, is sometimes affected by the patho- 
     ANATOMY OF THE NASAL CAVITIES.   89

logical processes in nasal diseases.  These  are the
antra of Highmore—large triangular cavities situ-
ated in the body  of the superior  maxillary bone,
and  communicating with the nasal  cavities by an
irregularly shaped opening in  the middle meatus;
which, according to John N. Mackenzie, is partly
covered with a fold or projection of the nasal erectile
tissue; then the frontal sinuses—two irregular cavi-
ties  situated between the two tables of the frontal
bone.  The communication between them  and the
nasal cavities is established by the infuudibulum—a
round opening in the middle meatus—and finally the
spheniod cells or sinuses found  in the  body of the
sphenoid bone, communicating with the nasal cavi-
ties by small openings in the  superior meatus.
   That portion of the nasal cavities which projects
beyond the end of the nasal bone is surrounded by
cartilages,  forming the alse of  the nose.
   In the cartilaginous septum of the lower  animals
we find a small cavity lined with mucous membrane,
called,  after its discoverer, Jacobson's organ, the
minute anatomy of which has lately been described
by Kline.   This  organ  in man  is, however,  only
rudimentary.
   The nasal cavities are lined with  mucous mem-
brane, which  varies greatly in thickness in different
localities, and which materially decreases  the size of
the cavities in the living subject from  that seen  in
the denuded skull.  This mucous  membrane is cov-
ered  by ciliated epithelium in man, with  the excep-
tion of that portion which lines  the vestibule, i. e.,
that portion of the cavities of the nose surrounded
by cartilage only, which is  covered by pavement
                        8* 
 90   ANATOMY OF  THE NASAL CAVITIES.

 epithelium.  In the lower animals we find that in
 the olfactory region the ciliated epithelium is either
 absent, or that ciliated and non-ciliated epithelium
 alternate in patches.  (Henle.)  I have not been able
 to find a statement in the literature on the subject
 as to the kind of epithelium found in the accessory
 cavities  in  man, but it is  very probable that the
 mucous  membrane of the frontal sinuses and the
 antra of  Highmore is covered with ciliated epithe-
 lium, otherwise it would be difficult, if not impossible,
 for the secretions of that mucous membrane to pass
 through the narrow channels into the nasal cavities.
 To the naked eye, however, the  membrane lining
 the antra appears, according to John N. Mackenzie,
 thin, loose, and serous-looking, and seems to have a
 great power of absorbing liquids.
   The color of the normal nasal mucous membrane
 is of  a  light-pink shade  in  what  is termed  the
 respiratory portion, while it is of a yellowish hue in
 the  olfactory  region, that portion of  the mucous
 membrane which covers  the roof and  outer wall of
 the nasal cavities down to the  upper margin of the
 middle turbinated  bone, and the septum down to
 about the same level.  It is in this  region that the
 nerve-ends  of the  olfactory  nerve are distributed.
 Immediately beneath the mucous membrane, and
 between it  and  the periosteum of the bony walls
 and  the perichondrium of the cartilaginous portion
 of the septum, we find a tissue which  bears a strik-
 ing resemblance to the erectile tissue of the genital
 organs.   It is a  network  of  fibrous  tissue,  the
 trabecular of which contain a few organic muscular
fibres. Its meshes, of various sizes and shapes, are 
     ANATOMY OF  THE NASAL CAVITIES.   91

occupied by venous sinuses lined with endothelium.
These are supplied with blood by small arterioles
and  capillaries, which are quite  numerous in the
fibrous tissue and can readily be demonstrated under
the microscope.  In this arrangement of elements
of the nasal mucous membrane we find  a ready
explanation of the fact  that liquids of greater or
less  density than  the  serum  of  the blood, when
introduced into the nasal cavities, produce pain, for
we have  here the  most favorable  conditions  for
osmosis, which will  cause either a contraction or a
distention of the sinuses.  In the larger masses of
fibrous tissue between  the  sinuses or caverns  we
find embedded the glands, with their ducts opening
out between the epithelial cells of the mucous mem-
brane.  There are two kinds of glands in this region,
which have been described by Kline, viz., serous and
mucous glands.
   This cavernous erectile tissue is most abundant at
the lower portion of the septum and the lower tur-
binated bone, and although  it has been recognized
and  described as true erectile tissue  by Ilenle, Vir-
chow, and others, yet to Prof. Bigelow, of Boston,
belongs the honor of having first  called attention to
the part which this tissue plays in nasal disease.   He
gave to it the name " turbinated corpora cavernosa."
   The naso-pharynx, into which  the nasal  cavities
open  by the  posterior  nares, coutains the openings
to the Eustachian tubes on  either side,  and the
pharyngeal tonsil, a  mass of glands  situated below
the mucous membrane and opening  into a number
of follicles, some  of  which are  quite  large  and
readily seen in the rhinoscopic mirror. 
92   ANATOMY  OF  THE NASAL  CAVITIES.

  Nerves.—The nerves of the nose are of two kinds,
viz.: those of special and those of general sensation.
The former consists of filaments from the olfactory
bulb, which are distributed upon  the superior turbi-
nated bone, the anterior upper third of the middle
turbinated bone, and upon the adjacent  portion of
the septum, and are only concerned with the special
sense of smell.
                      Fig. 37.
     Distribution of nerves in the nasal passages.  (Dalton.)
 1. Olfactory bulb, with its nerves. 2. Nasal branch of the fifth pair.
               3. Spheno-palatine ganglion.

  The nerves of general  sense are the nasal  nerve,
a branch of the ophthalmic division of the trifacial
nerve, which  ramifies upon the upper and  anterior
portion of the  septum, and  upper portion of the
external nasal wall.  The spheno-palatine branch of
the second division of the fifth, which is distributed
over the upper posterior portion of the septum and
the superior turbinated bones. 
            THE RHINOSCOPIC  IMAGE.         93

  The Vidian, which has a similar distribution to the
spheno-palatine branches.

                        Fig. 38.
         Olfactory ganglion and nerves.  (Hirschfeld.)
  1. Olfactory ganglion and nerves.  2. Branch of the nasal nerve.  3.
Spheno-palatine ganglion.  4, 7. Branches of the great palatine nerve.
5. Posterior palatine nerve. 6. Middle palatine nerve. • 8, 9. Branches
from the spheno-palatine  ganglion.  10, 11, 12. Vidian nerve and its
branches.  13.  External carotid branch, from the  superior  cervical
ganglion.
  The naso-palatine, which supplies the middle part
of the septum, and the anterior palatine nerve, which
supplies the middle  and inferior turbinated  bones.
Some  filaments  of  the sympathetic can also  be
traced in  the nasal  mucous membrane.   (Figs.  37
and 38.)
              The Rhinoscopic Image.

  On  account  of the  velum palati and the  uvula
covering the greater part of the reflecting surface of
the mirror in rhinoscopy, a complete image can only 
94
THE  RHINOSCOPIC  IMAGE.
be obtained in cases of cleft palate; but, by observ-
ing the different parts of the posterior nares in turn,
a diagrammatic image can be constructed,  which is,
perhaps, for study, even better than one drawn from
nature.  Such a drawing is seen in Fig. 39.
  We see in the middle of the drawing a triangular
plate with its apex downward; this is the  posterior
margin of the vomer or nasal septum.  On either
side  we notice curtain-like  folds  projecting toward
the septum ; these  are the  posterior aspects of the
            Fig. 39.
11
  1. Vomer or nasal septum. 2. Floor of nose.  3. Superior meatus.
4. Middle meatus.  5. Superior turbinated bone.  6. Middle turbinated
bone.  7. Inferior turbinated bone. 8. Pharyngeal orifice of Eustachian
tube.  9. Upper portion of Rosenmuller's groove.  11. Glandular tissue
at the anterior portion of vault of pharynx. 12. Posterior surface of
velum.
turbinated  bones.  On either side of these and on
the margin of the drawing we notice pointed eleva-
tions projecting toward the  interior of the cavity,
with a crater-like depression  on their apices; these
are the lateral pharyngeal walls, with the orifices of 
THE RHINOSCOPIC IMAGE.         95
the Eustachian tubes.   Above  we see the vault  of
the pharynx, and below the posterior surface of the
velum palati with the uvula.
  The obstacles which have  to  be  overcome  in
obtaining a view of the posterior nares are, first, the
elevation  of the back of the tongue, which, as we
have  seen,  can  be surmounted by gentle pressure
with the tongue-depressor; and, second, the elevation
of the soft  palate.   This latter, however, does not,
as a general rule, prevent an inspection of the nasal
cavity ; for the velum drops in  the act of inspiration
through the nose,  even if only  for a short time.
   If  the uvula is elongated or  very large, it is diffi-
cult to obtain  a satisfactory view of  the posterior
nares, and it becomes  necessary to  move it out of
the  way.   This may be  done in  many cases  by
passing another small rhinoscopic mirror behind the
uvula and  velum, with the glass  side toward the
posterior  upper surface of the  palate.   In this way
the swollen uvula may be  lifted up, and by gentle
pressure  the velum  drawn  forward, thus  increasing
the space in the pharynx, and removing the obstacles
to rhinoscopy.  If, however, the patient, as is often
the  case, cannot  bear  this, a  silk  suture  may  be
looped around  the  base of the uvula,  and gentle
traction having been  made, the ends of the thread
are secured between  the teeth of  the patient, thus
drawing  the uvula  forward and  out of the way.
This, however, is but rarely  necessary, except in
cases of  operation in  the  naso-pharynx, and  then
Jarvis's method of securing  the soft palate, already
described, is preferable.
   Although apparently simple and easy, the art of 
96        THE RHINOSCOPIC IMAGE.
laryngoscopy and rhinoscopy is a difficult one, and
requires  careful training  of the  hand and eye to
become proficient in it.  For this reason the student
should not become discouraged if, after a few trials,
he is not able to see the vocal cords or the posterior
nares in the  mirror, but should keep on undaunted
until he has  attained the necessary skill in placing
the mirror in the  right position, and throwing the
light from the head-reflector in the right direction,
when without difficulty he will be able to obtain the
laryngeal or  rhinoscopic image.   But  in a large
number of cases, unaccustomed to the presence of
the mirror in the fauces, he will be able to see this
image for a moment only before gagging sets in, and
the mirror has to be removed.   The mirror may be
introduced again  and again,  and thus a series of
momentary pictures  may be obtained, which must
be  combined in the  mind of the observer to form
the permanent mental impression of the pathological
changes which may exist in a given case.   In order
to facilitate this  mental process, and  to educate the
eye so that many, if not all, the details forming the
image may be taken in and recognized at a momen-
tary glance, it is best that the student should adopt
a system of  examination, to be followed in every
instance, by which one detail after another forms
the centre of observation.   The following outline of
a system will make my meaning clear.
  First examine the tongue: whether there are any
ulcerations or  mucous patches, whether coated or
clean, pale and  flabby, or  of  a natural  color  and
resistance.   Then, after having depressed the tongue,
observe the palate and uvula, the anterior pillars, 
THE RHINOSCOPIC  IMAGE.        97
the tonsils, and posterior pillars, and  the  posterior
wall of the pharynx, and note any changes in color
of the mucous membrane  and condition of  its sur-
face, enlargement of the parts, as, for instance, hyper-
trophy of tonsils, elongation of uvula, enlargement
of follicles in pharynx, etc. ;# the presence or absence
of foreign bodies, hardened  secretion, abrasions  or
ulcerations of  the  mucous membrane; and  finally,
mobility and functional disturbances of the  parts.
The laryngeal mirror may then be introduced and
the details of the image examined,  always  retaining
the order in which the physical and functional con-
ditions of the parts are to be observed, viz., 1. Color
and condition of surface of the mucous  membrane.
2. Size and  shape.  3. Loss of substance  (ulcers,
abrasions, etc.).  4. Presence of foreign bodies  or
accumulation of secretion; and 5. Mobility of parts
and functional disturbances.  Thus it will be found
convenient first to examine the epiglottis and its ap-
pendages, the glosso-epiglottic and the ary-epiglottic
folds, then the arytenoid cartilages, next the ventric-
ular bands, and finally the vocal cords.  If possible,
also the trachea as far as it can be  seen.  In the
same manner should the rhinoscopic image be viewed,
taking note first of the condition of the pharyngeal
tonsil and the roof of the  naso-pharyngeal  cavity,
next of the openings of the Eustachian tube and the
lateral walls of the cavity, and finally of the posterior
aspects of the turbinated bones and of the  vomer.
  The inspection  of the anterior  nares  should  be
conducted in the same systematic manner, using the
probe  to  test the  consistency of the  parts  by the
sense of touch.
                        9 
Name, etc., of patient..............

Previous and  family history

Subjective symptoms................
 Tongue,

 Velum,

 Uvula,

 Pillars,

 Tonsils,

 Wall of Pharynx,

' Epiglottis,

 Ary-epiglottic Folds,

 ArytenoidCartilagcs,

 Ventricular Bands,

 Vocal Cords,

 Trachea,
 Color  i
 and    Secretion.
Surface
Position ;        | Foreign Boihu
 and    Mobility.      and
 Shape.  !           Neoplasms. 
X
fc   Vomer,



<   Turbinated Bones,
S  J
Ph  S
6   Eustachian Tubes,
05


^h   Pharyngeal Tonsils,
w

H
M

!>


O




CD
Turbinated Bones,


Septum,


Floor of Nose,


Meatuses.
I 
100     '  THE  RHINOSCOPIC IMAGE.

  An  examination of the upper  air-passages con-
ducted  on this plan  will  enable the observer to
arrive at a definite conclusion in regard to diagnosis
more quickly and with less annoyance to the patient,
than if he should attempt to take in all the details
at a  glance.  As the  examination  progresses,  the
result of the observations can  be jotted down  on
paper,  and thus a very complete record of the case
will  be obtained,  especially  if any  deviations in
shape or size of the parts, or the presence of foreign
bodies  or  neoplasms, be sketched on the margin of
the sheet,  which will be valuable not only for future
reference, but also  in  watching the progress of the
case.   The  subjective  symptoms,  such as  cough,
pain, etc.,  should of course be  added, as well as the
salient points of the previous  and family history of
the patient.
  A record sheet of this kind  on which the head-
ings  are printed and the outlines of the parts added,
will serve  as an illustration, and it will  be seen that
a very full history, with a  minimum of trouble and
expenditure of time, can  be obtained  by filling in
the blanks. 
CHAPTER  IV.
  PHYSIOLOGY OF THE  LARYNX AND NOSE.

   A thorough knowledge  of the physiological func-
tions of the  upper air-passages is as necessary  for
the student of laryngology and rhinology, as is  the
knowledge of the anatomy,  and for this  reason a
chapter on the functions of the larynx, pharynx, and
nose, will not be out of place in this  volume.  There
are many cases in  which functional  disturbances of
these organs  are present, the recognition of which
materially aids in the diagnosis of the case, and fre-
quently the seat of the disease  can be located, even
without  examination,  by  studying the changes  in
the voice and in  articulation.   At  the same time
many of  the  remote symptoms so  frequently seen
in nasal diseases,  and generally ascribed to reflex
nervous influences, will be found to  be due directly
to disturbances of  the function  of the nose.

           Physiology of  the Larynx.
   The function of the larynx is a  three-fold one,
namely:
   First. The  regulation of  respiration, which   is
effected by the  vocal cords opening and closing so
as to let more or less air pass through the glottis to
and from the lungs.  This motion of the cords can
be readily studied in the laryngeal  mirror during
quiet respiration, and it enables us to prevent a too
                       9* 
102     PHYSIOLOGY  OF THE  LARYNX.

rapid outflow of the breath in  singing  or speaking.
If no such regulation existed, it would be impossible
for us to sing a phrase  or  speak  a sentence without
interrupting the flow of sound  by frequent respira-
tory movements, or as  is  the  case in the so-called
laryngeal stammering,  in  which  affection  the first
word of  the sentence  after inspiration is spoken
with  all the usual expiratory  air, while the other
words must  be pressed out with  the residual air in
the lungs, giving a peculiar character to the voice of
the speaker.
   Second.   The protection of the  laryngeal cavity
and trachea from the introduction of foreign bodies
during the act of deglutition.  This is effected partly
by the  epiglottis bending backward and  covering
the laryngeal opening, and  partly by  the ventric-
ular bands  being  tightly pressed  together during
the passage  of  food from the  pharynx  into  the
oesophagus.   The ventricular bands alone  are suffi-
cient thus to exclude foreign bodies from the larynx,
as is easily seen in cases of partial or complete de-
struction of the epiglottis by ulceration.
   Third. Voice-production on  vocalization.   This
important function, the  study of which  gave rise to
the invention of the laryngoscope, is  even at the
present day  but little  understood by most of those
who,  by their  calling,  should  be better informed,
and it will  perhaps be well to consider it more in
detail than  seems  necessary for  the scope of  this
volume.  But before entering upon  voice-production
as we find it in  man, as  vocalization or sino-ino- with-
out words, and articulation or speech, we must con-
sider a few of the acoustic laws which underlie this
function of the larynx. 
ACOUSTICS.
103
  Acoustics.—Sound is a  vibratory motion  of the
air producing waves,  or a sequence of condensation
and rarefaction of the air, which  on striking  upon
the tympanic membrane of the ear gives rise to the
sensation called sound.  This vibration is produced
in turn by any body which executes a rapid to-and-
fro motion;  in other words, which vibrates.  Sounds
differ from each other—1st, in pitch, or the position
of the tone in the musical scale, which depends upon
the rapidity of the vibration  and  is determined by
the length of the wave;  2d, in loudness, which de-
pends upon  the largeness or amplitude of the vibra-
tion and air-wave; and 3d, in quality or character,
which  depends upon  the form of the  vibration or
wave.
  No sound which we  hear, except the  sound of a
tuning-fork, is simple, but all  single sounds are com-
posed of a fundamental tone  which determines the
pitch, and of a greater or less number of overtones,
which  by the unaided ear are not audible as  such,
but which in mingling with the fundamental tone
change the form of the wave  and thus influence the
character of the sound.
  The  original  vibrations producing  the  sound-
waves  may  be produced  by  any  body  which pos-
sesses elasticity,  such as a steel rod, or to which
elasticity has been imparted by  stretching, as is the
case with  strings.  Even a column of air confined
by resisting walls, but  communicating with the  outer
air,  may  under  certain circumstances   become  a
vibrating body.   Since strings or string-like bodies
and  a  column of air are the vibrating bodies in 
104     PHYSIOLOGY  OF THE LARYNX.

voice-production, wTe will inquire a little more closely
into the acoustic laws governing them.
  A string in order to be able to vibrate and to give
forth sound must be stretched between two resting
points, and must be set in vibration  by some force
external to it.  The longer the string is, the lower
will be the pitch of the tone, and this pitch can be
raised by  shortening the  string.  The greater  the
power  by which the string is stretched, the higher
will  be the  pitch; and,  finally, the thicker  and
heavier  the string, all  other conditions being  the
same, the lower will be the pitch.
  A column of air or gas being, to all intents and
purposes, a string  of a  lighter material, obeys  the
game laws, with  the exception that, being elastic, it
need not be stretched nor can the pitch be changed
by stretching.  This  is compensated for, however,
by the fact that the pitch of a column of air may be
changed by altering the  size of the opening by which
it communicates with the outer air;  and it is a law
that the larger the opening the higher the pitch, and
the smaller the outlet the lower will be the pitch.
  The sound of  an elastic body, such as a string or
membrane, when vibrated in close proximity  to  a
cavity filled with  air, causes the air to vibrate, and
the amplitude of the wave being  thus increased the
sound is made louder.  This is called " resonance,"
and its best effect—viz., the greatest volume of sound
—is obtained when the column of air is made to
vibrate  with the  same velocity as  the string; in
other words, when  the string and air-column  are
tuned alike.  The effect of resonance upon the char-
acter or quality of the sound is very noticeable, and 
VOICE-PRODUCTION.
105
depends upon the fact  that through changes in the
form and shape of the air-column some of the over-
tones can be strengthened or favored, while others
are weakened or extinguished altogether, thus chang-
ing the shape or form of the wave.

   Voice-production.—Having  thus briefly reviewed
the acoustic laws involved, we are now prepared to
enter into a consideration of voice-production as it
goes on in man.
   The first  step is the inhalation of air into  the
lungs, or inspiration.   This air is  then  allowed to
flow gently  through the bronchial tubes  into  the
trachea by a mild expiratory effort until it reaches
the vocal cords.  These during respiration are held
asunder, so  that  they  allow  the air  to flow freely
through  the large  triangular space  between their
free edges, which is called the  glottis; but as soon
as vocalization is attempted they are approximated
until  the glottis is  reduced to a narrow chink;  and
this is effected  by the approximation and inward
rotation  of  the  arytenoid cartilages, to which  the
vocal cords  are  attached.  The narrowing of the
glottis presents  au obstacle to  the  outflowing  air-
current, and since  the vocal cords are also slightly
stretched  and thus  made elastic, they are bulged
upward by the pressure from below until their elas-
ticity overcomes the pressure, when they fly back to
their normal position.   This  motion  is repeated in
rapid succession, and thus the vocal cords are set in
vibration; which can readily be seen in the laryn-
goscopic mirror, by means of which all the changes
that take place in the vocal  cords  during vocaliza-
tion have  been observed.  Drs. T.  R.  French, of 
106     PHYSIOLOGY OF  THE  LARYNX.

Brooklyn, and Lenox Browne, of London, by means
of their ingenious apparatus for photographing the
interior of the larynx, have produced some excellent
pictures  of  the vocal cords during  vocalization,
which verify the observations made  by the laryngo-
scope, and which show the different positions taken
by the cords in the different  registers of the voice,
as described farther  on.
  The vibration of the vocal cords alone gives but a
very feeble  and  disagreeable sound, as has  been
clearly demonstrated by experiments on the larynx
removed from  the  body and  in cases of wounds of
the neck  exposing  the vocal cords and separating
them  from  the resonant cavities above.  What is
more, the compass of the voice—i. e., the number of
tones  of different pitch—is very limited,  comprising
but a  few tones of the musical  scale.  The  sounds
produced by the vocal cords  alone are very  similar
in character  and variety, as  well as in  number, to
those  produced by the double reed of a bassoon or
hautboy when it is vibrated alone and detached from
the instrument.  As soon, however, as a column of
air is brought in contact with it, this latter becomes
a  self-sounding body, and  not only  increases the
volume and number of the tones, but also changes
their  character or  quality.  The  same is the case
with the vocal cords, which,  in causing  the column
of air contained in the pharyngeal and oral cavities
to vibrate, make it  a self-sounding  body, and thus
volume and  character are added to the sound.  This
is still more increased by  the vibration of  the air
contained in the cavities of  the naso-pharynx and
nose, which, although separated from  the direct in- 
VOICE-PRODUCTION.
107
fluence  of the vibrations of the vocal cords by the
adaptation of the soft palate to the pharyngeal wall,
or rather  to the ridge  produced by the lower con-
strictor  muscle of the pharynx,  still partakes of the
vibratory  motion, and  adds volume and quality to
the sound, just as the air contained in the body of a
violin adds greatly to the tone of the instrument.
  The pharyngeal cavity can be changed in size by
the rising and falling of the larynx in the throat,
and the oral cavity can also be changed in its dimen-
sions  by  the action of the  tongue, the  cheeks, and
the lower jaw; and these cavities can thus be attuned
to the pitch of the sound produced by the vibration
of the vocal cords, whereby, as was shown above,
the best effect of tone is obtained.
  But the oral cavity can also be tuned to a definite
pitch by the changeable opening of the lips, as well
as by the motion of  the tongue and cheeks, and thus
still another means is provided for this  purpose.
This adjunct is of great importance, not only in
articulation,  as  will be seen later on,  but also in
vocalization ; for in order to produce a low pitch the
cavity of the mouth would have to be made as large
as possible, which can  be  done only by depressing
the tongue to its utmost, thus pushing the root down
upon the larynx and encroaching upon  the pharyn-
geal cavity, which would not only materially inter-
fere with the activity of the laryngeal muscles, but
would also hinder the free vibration of the column of
air.  But  since  a cavity of air can be tuned lower by
making the opening by which it communicates with
the outer  air smaller, and vice versa, the  cavities can
be tuned  to even the  lowest tone of the voice  by 
108     PHYSIOLOGY  OF THE  LARYNX.

slightly closing the lips  and making the cavities as
voluminous as possible without interfering with the
free motion of the air contained in them.
  This attuning of the  resonant  cavities above the
vocal cords, although natural to man, requires con-
siderable practice for its full development, and it is
the quickness and precision with which  the different
movements are executed  in  these cavities which
make what is called a " trained voice."  It naturally
follows that a voice weak in volume and deficient in
quality  can be made to sound stronger and more
agreeable by such training.   On  the other hand, a
naturally good and strong voice may materially be
altered  for the worse  by interfering with the oral
resonance, be it by the use of too much breath, or by
a faulty attuning of  the resonant cavity, or, finally,
by permanent alteration of this cavity  by  growths,
paralysis  of the  soft  palate,  or a  faulty artificial
denture.
  There are in every voice, both male  and  female,
certain  divisions which can  be differentiated  from
each other both by  the volume  and quality of the
individual  tones within  the limit of the division, and
these have been termed  " registers" of the voice.
They are variously designated by singers and teach-
ers of  vocal music according to their fancy;  but we
will, for the sake  of simplicity, accept  those terms
which  are  most generally  used.   Thus,  the voice is
divided into—1, the lower chest register; 2, the upper
chest;  3, the falsetto;  and in the female  voice  we
find also a second falsetto, and finally a head register.
These  names are derived  from the feelings which  a
singer experiences during the act of vocalization in 
VOICE-PRODUCTION.
109
the different registers.   Thus he feels as though the
voice came from the lower part of the chest in the
lower division; a  little higher up, in the'second;
from the throat in the falsetto, which is therefore
also frequently called the throat register; or from
the top  of the head in  the head register.
  Let us now examine the movements of the  vocal
cords more closely during the act of vocalization,
particularly when the subject  of our examination
sings up the scale, commencing with the lowest note
of his voice, and we will see  that  these divisions  of
the voice are not merely based  upon  the subjective
impressions received by the ear of the listener, but
are dependent upon  important  changes which  take
place in the position and  movements of the  vocal
cords themselves.
  As we  have already  seen, the vocal cords are
stretched between their attachments, and are brought
together by the approximation and inward rotation
of the arytenoid cartilages as soon as an  attempt  at
vocalization is made.    If now the  singer,  whose
larynx we observe with the laryngeal mirror, sings
the lowest tone of his voice, the first tone of the chest
register, we see that the glottis, or  chink between
the free edges of the vocal cords, has the shape of an
ellipse, and  that  the cords vibrate slowly in their
entire length  and width;  in fact, the walls of the
larynx itself participate in the vibratory motion. As
soon as the next tone in the scale is attempted, the
arytenoid cartilages, with a quick motion, fly asunder
and come together again, but a little closer than be-
fore, making the glottis slightly narrower, and the
cords are at the same time stretched a little more.
                        10 
110     PHYSIOLOGY  OF  THE LARYNX.

This is repeated with every successive tone in the
scale until the limit of the register is reached, when
at the next tone, the first in the higher division, the
arytenoid cartilages remain closed, and the partici-
pation of the laryngeal walls in the vibratory move-
ment ceases.  The vibration of the cords  is also less
apparent, because quicker and less violent, but  still
they vibrate in their whole length and width.
  At the end  of this   register  a very  noticeable
change  takes place, for  with the first tone of the
falsetto  or throat register, the glottis, which hitherto
was  comparatively wide, is  reduced to a mere  slit,
and  only the narrow edges of  the  cords vibrate,
which seem  quite thin and sharp.   This is produced
by the unfolding of  the  fold below the edge of the
cord which was described above, and by the contrac-
tion of the muscular fibres forming its body.  As in
the lower chest register, the arytenoid cartilages
again fly  asunder, but the  motion is performed so
quickly as to escape  notice  in many cases.   In the
female voice—and but rarely in the male—a second
falsetto  is noticed,  which, like  the  second chest
register, differs from the first falsetto merely in the
fact that the arytenoids remain in close juxtaposition,
while the cords are stretched  tighter with every
successive tone.
  Finally, the head register is  reached, which  is
peculiar to  the  female voice, and, with its flute-like
tones, is due to  the posterior portion of  the glottis
being completely  closed by the  apposition of the
cartilages of Seiler,  while only the anterior portion
of the  cords vibrates,  thus making  the vibrating
cords shorter and increasing the pitch of the tone. 
ARTICULATION.
Ill
With every successive tone this  shortening process
progresses, until at  the  highest  tone of the female
voice only a small elliptical opening at  the  anterior
portion of the glottis, the  edges of which vibrate,
allows the air to pass through.
   In the so-called whispering voice, the  action of the
vocal cords, according to Rossbach and other investi-
gators, is different from loud vocalization, and  by the
laryngoscope it is observed that the anterior portion
of the vocal cords is approximated until they over-
lap, while the posterior portion of the glottis,  which
is bounded by the vocal processes of the arytenoid
cartilage, is open, and allows the air to pass, setting
its rigid edges into irregular vibrations, much in the
same manner as the lips are vibrated  in soundless
whistling. As a matter of course, no sound, as such,
is produced by the vocal cords, and any changes in
the pitch  and quality of the whispering noise  which
can be observed, are  imparted to it by changes in the
resonant  cavities above  the vocal cords.  Thus  the
whispering voice, or the noise produced by the rush
of air through the triangular opening of the glottis,
may be utilized with  advantage in studying  the
changes in the resonant cavities, and in  determining
the pitch to  which  they are tuned in  some of  the
sounds of articulate speech.
   Articulation.—In the preceding  pages we have con-
sidered vocalization, or voice-production,  without
words, and it now remains to  describe the method
by which the various sounds are produced which,
when  uttered,  consecutively, in a certain  order,
produce what is termed "articulate speech."   Since 
112     PHYSIOLOGY OF THE LARYNX.

this volume is written in the English language, and
will  be read mostly by  English-speaking readers,
all those sounds which enter into the composition of
other languages and are foreign to English, will be
omitted.
  But in order properly to understand a subject, and
particularly one which, like articulate  speech, is so
well  known to every one, and at the same time thor-
oughly understood by so few, it seems to us  proper
to give a definition  of  our  subject before we enter
upon a detailed  description  of it, and  we,  there-
fore, will endeavor to define Language, Dialect, and
Accent.
  Language, as used by man, is  the  arbitrary but
constant sequence of articulate sounds, forming what
are termed words,  and expressing, as  such, simple
ideas, and  the arbitrary  but constant sequence of
words termed sentences, expressing compound ideas.
The difference between different languages consists
in the fact that the same simple idea is expressed
by different but constant combinations of articulate
sounds, and that the compound ideas  are expressed
by different but constant  sequences of words.   In
languages which are related  to each other a simi-
larity both in  the words and sentences can be ob-
served, but in  those not so related a great dissimi-
larity in words and sentences exists.
  Dialect is the substitution of other articulate sounds
for those which are correct in  the language, without,
however,entirely destroying the characteristic sound
of the word expressing the simple idea, and  the in-
troduction into the  sentences  of words foreign to it, 
ACCENT.
113
or of a change in the sequence of the words of the
sentence without destroying its characteristics. Thus
a dialect is only a variety of the language, and  is
limited  to  people living in  a particular locality, or
who belong to different nationalities or races, all,
however, speaking the  same language.
  Accent, by which is understood the peculiarity of
speech characterizing foreigners speaking a language
different from  their-mother  tongue, and which  is
perceptible, even if the language is spoken correctly,
in regard  to pronunciation, grammar,  syntax, and
even colloquialisms, consists in  the peculiar  inflec-
tion of  the voice  in speaking, or, as it  may be ex-
pressed, in the peculiar  melody of speech.   Every
language possesses this characteristic melody, which
is independent of the accentuation of the individual
words and of the inflection of the voice demanded
by the sense of the sentence; and so definite is this,
that a language can be recognized even if the speak-
ers are  too far removed from the listener for the
latter to hear and  recognize the  individual  words
and sentences.   And,  further, we find a great simi-
larity in the melody  of the languages  which are
related  to  each other,  so that it is difficult to dis-
tinguish German  from  Swedish and Italian from
Spanish without hearing and understanding  the in-
dividual words, while there is no difficulty in  appre-
ciating  the difference between English and French,
even if the listener should not know anything  of
either  language.   This melody of the languages
becomes so impressed  upon the mind when  a lan-
guage is acquired in childhood and spoken for years,
that the impression is never entirely erased,  and  is
                       10* 
114     PHYSIOLOGY OF  THE  LARYNX.

transferred to any new language which may be ac-
quired in later years.  As  the  pronunciation  and
composition of a language  are altered by different
localities or nations  or  races, so also is this melody
slightly changed in the same manner, without, how-
ever, losing  its general character; and thus we find
that  in English there are different accents, such as
the Southern, the New England, the English, the
Scotch, and  so-forth.
  From time immemorial grammarians have divided
the sounds  of articulate speech  into two classes—
viz., vowels  and consonants; and  this division will
be retained for the sake of simplicity and conveni-
ence in the following description; but be it under-
stood that in reality there is no such class  distinction
in speech.  Startling as this may seem, yet  this
statement is true,  and borne out by experiments and
close  observation  ; for if we listen to a speaker we
do not hear him  pronounce vowels and consonants
separately, but we hear separate sounds forming the
syllables, which consist of the vowel sounds  altered
in quality by noises  or  in duration by the more or
less sudden  cessation of the sound.  Several years
ago the author verified this observation  by experi-
ments carried on  by  means of one of Edison's loud-
speaking telephone-receivers in the following man-
ner :  In the centre  of the mica diaphragm  was
fastened  a delicate  stylus, made of the end of a
swan's feather, the tip  of which  rested upon the
surface  of a cylinder covered with smoked  paper.
This cylinder, being  revolved, travelled at the same
time from right to left, so that the stylus when at
rest would draw a continuous line in the form of a 
ACCENT.
115
spiral upon the paper. An assistant at the other end
of the telephone line, several  hundred feet away,
would then speak into  a transmitter in connection
with the receiver, thus causing  the mica diaphragm
to vibrate and agitate the stylus, which latter drew
a series of curves instead of a straight line upon the
smoked paper.   In the course of the  experiment  it
was  found  that  each of the five elementary vowels
gave  a distinct  curve, which,  although  altered by
the admixture of the consonants in the pronuncia-
tion of a syllable, still  retained its  characteristics.
In those syllables  in which the consonant  noise is
sounded either before or after  the vowel sound, as
in "as" and "saw," the  irregular s curve was seen
to merge into and  mingle with  the regular curve of
"ah," either at its beginning or end, thus giving the
vowel sound its peculiar character as heard when
these syllables are  pronounced.
   Recently, Dr.  Harrison Allen has made some ex-
periments to determine the action of the  soft palate
in articulate speech, and has by  an ingenious  method
succeeded in obtaining tracings of the motion of this
organ.   The curves which  he  obtained, and which
are produced by the vibration of the velum trans-
mitted to a long lever, one end of which rests upon
the upper surface of the palate, while the other end
projects from the  nostril and  touches the  smoked
paper, give onl}T the upward motion  of  the organ,
and are therefore incomplete; yet they also show to
some extent  this admixture  of consonant and vowel
sounds with the  preservation of the vowel character-
istics.   And, finally, Prof.  E.  W. Blake obtained
similar curves, showing  the composite character of 
116     PHYSIOLOGY OF THE LARYNX.

the sounds of articulate  speech by photographing
the vibrations of the telephone diaphragm by means
of an  ingenious method which he  describes  in
Silliman's Journal for July, 1878.
   The  Vowels.—The vowel sounds are those sounds
of articulate speech which are  primarily produced by
the vibration of the vocal cords, the character of the
sound  being modified in a definite  manner by the
resonant cavities.   Thus, the vowel sound  Ah, as
in "father," is produced  by the sound of the vocal
cords,  and  this sound is  modified by the peculiar
position of  the different parts forming the resonant
cavities, in such a manner that the ear of the listener
recognizes  the  sound as the  vowel Ah, no matter
whether the pitch  of the  sound of the vocal cords
changes from high to low, or remains stationary.  It
is not  the  position of the sound of the vocal cords
in the  musical scale which distinguishes one vowel
from another, but the peculiar quality given to it by
the resonant cavities.  That this is so, is proved  by
the investigations  of Donders, Helmholtz, Wolff',
Seiler,  and others, who all agree that in the pro-
duction of  vowel sounds  the resonant cavity of the
mouth  and pharynx is tuned  to a definite pitch,
which  never varies more  than a fraction of a tone
for the same vowel.  And it has also been found
that no matter whether the vowel is pronounced by
a full-grown man,  a child, or a woman, or even  by
members of different nations, the pitch of the reson-
ant cavity is the same in all  instances, provided, of
course, that the  vowel sound is the same.  The dis-
crepancy in the size of  the  cavity in the  several
instances is equalized by the greater or less degree of 
THE VOWELS.
117
the opening of the mouth, so that the small oral cavity
of the child can be tuned to the same pitch as that of
the larger one of the man. The reader can verify this
by experiment in the  following manner:  Let  him
pronounce in a whisper the vowel sound of 00, and
while doing so, let him tap his cheek with  a lead-
pencil ; he will then obtain the pitch of the resonant
cavity.  Let him now change the pitch of this cavity
by opening or closing the lips, and  then whisper
again,  and he will at once  find  the character of
the vowel to be  changed so  as to approach that of
another vowel.
   This tuning of the resonant cavity to a definite
pitch determines the  character of the vowel sound
by favoring the  development  of some of the over-
tones of the vocal  sound, while it makes the sound-
ing of other overtones  impossible; and,  as  it has
been shown above that the character of the sound de-
pends upon the shape of the wave which is produced
by the addition of  the overtones to the fundamental
tone, it follows  that if  only  certain  overtones are
added, to the  exclusion  of all others, the resulting
wave will  have  always the   same shape, and the
sound  always  the  same character.
   The fact, as shown by the experiment, that a
change in the tuning of the resonant cavity changes
the character of the vowel sound  so as to approach
to that of another vowel, leads us  to  think that all
the vowels  are but modifications of one elementary
vowel.  The elder Du Bois-Raymond  already recog-
nized this fact, and determined upon  the Ah as the
elementary vowel, from which all  other vowels are
derived.   He  took this vowel sound  as the founda- 
118     PHYSIOLOGY OF  THE LARYNX.

tion, because it is the natural result of the vibration
of the vocal cords in  connection with a  resonant
cavity, in which there are no obstacles to the even
outflow of  the sound.   In other words, the parts of
the resonant cavity remain in a quiescent state, as in
normal respiration, and the lips are widely separated,
so that a funnel-shaped tube, extending from  the
glottis to the lips,  is thereby established.
                      Fig. 40.
Diagram of vocal apparatus during the pronunciation of the vowel Ah.
  In referring to Fig. 40, which is a  diagrammatic
outline of the resonant  cavities, and  of the  larynx
in section, it will be seen that in the  pronunciation
of the vowel Ah the tongue lies flat on the floor of
the mouth, the teeth and lips are parted, the velum
palati, with its uvula, touches the projection  in the
pharynx formed by the pharyngeal constrictor mus- 
THE VOWELS.
119
cles, and thereby closes the opening leading to the
nasal cavities,  and the larynx is  slightly raised in
the throat.  The pitch of the resonant cavity stands
at about the middle between the other simple vowel
sounds, and is the dp2 of the musical scale.1
   The vowel sound 0 is produced by approximation
of the lip3, so  that the  opening between them be-
comes smaller than in the pronunciation of the Ah,
and at the same time is circular.  The tongue rises at
its root, and its tip is retracted from the teeth, so as to
make the anterior portion of the oral cavity as roomy
as possible.  These changes would indicate that the
pitch of the resonant cavity is lower than in Ah, and
by experiment is found to be for 0 at1.
   The pitch is still lower  in the vowel 00, because
in the formation of this sound the lips are  brought
together so as  almost  to touch each other, and are
slightly  protruded, thus   forming a narrow  oval
opening to the  oral cavity,  the  tongue remaining
in nearly the same  position which  it took in  the
formation of the 0 sound, so that the  lowering of
the pitch is produced solely by the diminution in the
opening formed by the  lips.  The pitch of the reso-
nant cavity in the pronunciation of this vowel is/.
   These three vowel  sounds—viz., Ah, 0, 00—are
called the dark vowels, and the consonant c is in
most  languages  pronounced  as  k when  either  of
them  follows it in a word or syllable.
   Starting again from  the Ah as the normal vowel,
we find that when the lips and  teeth  are brought

   1 The figures above and below the letters denoting the tones in the
musical scale indicate  the octave on the piano in which the tone is
found, so that the middle C is written c, while the octave above is writ-
ten c1. The lower octaves are written with capital letters, thus, Q, C2, Cs 
120     PHYSIOLOGY OF THE LARYNX.

somewhat closer together, and the sides of the tongue
rise until they come in contact with the roof of the
mouth,  the  vowel sound  A, as in "scale," is the
result, and that the pitch  of the resonant cavity is
raised to 6b;2.
  The vowel sound of E is formed by a slightly
greater  approximation of the  teeth and lips, the
corners of the mouth being at the same time drawn
slightly downward, while the tongue rises still more
at its  edges, touching the palate to such an extent at
either side as to leave but a narrow gutter in the
middle, by which the anterior and posterior portion
of the resonant cavity can communicate.   The pitch
of this vowel sound corresponds to the B23 of the
musical  scale, and  is the highest of all these vowel
sounds.   The  velum palati is  in contact  with the
ridge  formed by the constrictor of the pharynx, and
thus closes the posterior opening of the nasal cavity
in the formation of these vowel sounds.
  The A and E sounds are termed the light vowels,
and before them the c is pronounced as s.
  The relation which these sounds bear to  each
other  can be illustrated by a diagram  in  the form
of a  wedge, thus:
00 
THE CONSONANTS.
121
 The Ah sound forms the centre or angle, and as the
 normal vowel is the starting-point, the light vowels,
 being of higher pitch, rise above it  on the upward
 plane, while  the dark vowels, being of lower pitch,
 are placed on the downward plane.   The 00 and E
 sounds are the termini, while the A and  0 sounds
 stand  between them and the Ah  sound. It  can
 readily be seen, however, that  the qualities of these
 elementary vowel sounds can be  combined,  thus
 forming  a new  sound, which  is called the double
 vowel, or "diphthong," which  is so  largely used in
 the Germanic languages.  But other  combinations
 may also be formed, in which the characteristics of
 the component sounds are not equal, and the one or
 the other is  predominating, as is the case  with  the
 Ah sound in many  English words, so that  some
 grammarians describe as many as twenty vowel
 sounds in the English language.  They can, how-
 ever, all  be reduced  to the  five elementary vowels
 described above,  and need not here be considered
 in detail.
   The  Consonants.—As has already  been indicated,
 the consonants are the more or less distinct noises
 which, in articulate  speech, accompany the vowel
 sounds, and with  them make up the syllables and
 words. Grammarians have classified  them generally
 according to the anatomical  parts of the organs of
 speech by means of  which the noise  is produced,
 as, for  instance,  into  labials, dentals,  Unguals, and
so-forth;  but it  seems more logical to follow  the
classification proposed by Dr. Wolff—viz.:
  1.  Simple self-sounding  consonants, which can be
sounded and  heard without the aid of the vowels
                       11 
 122     PHYSIOLOGY OF THE LARYNX.

 making an audible noise.  These are  the C, K, and
 G, P and B, D and T, F and  V, 8,  J, R, and the
 Th sounds.
  2. Compound self-sounding consonants, as the Sh
 and X.
  3. The  simple tone-borrowing consonants, which
 borrow their sound from the vowel, and are audible
 only in connection with a vowel sound, as H, L, M, N.
  4.  The  compound  tone-borrowing consonants,
 which class contains  only  two—the  W and  the
 Ng  sounds.
  These noises  are produced by a more or less com-
 plete  obstruction to  the outflowing current of air,
 which obstruction  takes place in the  oral cavity in
 three  principal  places: First,  by the  application of
 the tip of  the tongue to the upper incisors;  second,
 by the application of the back of the tongue against
the  velum palati; and, third, by the closure of the
lips.
  These methods are illustrated by the diagrams in

                     Fig.  41.
 
THE  CONSONANTS.

        Fig. 42.
123
Fig. 4::.
Diagrams of the method of producing obstruction to the air current in
              the pronunciation of consonants.

Figs. 41, 42, and  43.  It will be  seen  that the oral
cavity still  retains  its  resonant  quality; in  other
words, sufficient room is left either before or behind
the obstruction in the oral cavity  for a  considerable
quantity of air, which, by being thrown into vibra-
tions, gives the consonant a pitch which is indepen-
dent of the pitch of the vowel  and  the vocal cords, 
124     PHYSIOLOGY OF THE LARYNX.

and which never varies in the same  consonant.   In
fact, in  the self-sounding consonants, in which  the
noise is quite loud, this pitch can readily be deter-
mined  by the unaided  ear when  the  consonant is
whispered.
  The  mechanism of the production of these conso-
nant sounds is quite complicated, and it will  be
necessary to describe it for each sound in detail.
  1. The simple self-sounding consonants.  The P and
B sound is formed  by the outflowing current of  air
meeting with an  obstacle presented by the closed
lips.  The teeth  are slightly separated, the tongue
lies  quiescent in the floor of the  mouth,  and  the
velum  palati  is  applied against  the  wall of  the
pharynx, thus  closing the nasal  cavity.   The  air-
current, being  confined  under pressure in the oral
cavity, will give rise to  the explosive sound of the
consonant  when  the lips are suddenly parted, or if
the consonant occurs at the end of a syllable or word
when the lips are  suddenly closed.  The  difference
between the P and the  B sound consists in greater.
air-pressure and more sudden  opening or closing of
the  lips in the formation  of the P than when B is
pronounced.   This  also gives rise to a slight varia-
tion in the pitch of the tone to which  the cavity of
the mouth is tuned, so that the pitch for P is/=346
vibrations  in the second,  and that  of B is e =320
vibrations.
  In the K and  G1 sounds  the closure of the  oral
cavity is produced by the back of the tongue, which

  1 The ^ is the co-called " hard g," as it is pronounced before the dark
vowels, a, o, u. 
   SIMPLE  SELF-SOUNDING  CONSONANTS.   125

 rises until it comes in contact with the velum palati;
 which latter is in contact with the pharyngeal wall.
 Both the teeth and lips are slightly parted, and  the
 explosive sound is produced  by the more  or  less
 sudden application of the tongue to the velum.   In
 the  pronunciation  of the  G the tongue  touches a
 larger area  of the velum than is the case in the  for-
 mation of the K sound.   At the same time, the  air-
 pressure in  the G is not  as great, nor the impact of
 the back of the tongue against the top of  the palate
 as sudden, as it is in the K sound.   This, as in  the
 case of the  P and B, produces  a slight difference in
 the  pitch of the sounds, which  for  the  G  comes
 close to a'2=582 vibrations; while that of the ^T lies
 nearest to ^=6141 vibrations.
   The third method of producing an  obstruction in
 the  oral  cavity  to the  outflowing  air-current is
 utilized in  the formation  of the T and D sounds,
 where the tip of the tongue, as well as its edges,  are
 applied closely to the alveolar  border of the upper
jaw, and somewhat beyond  it  against  the hard
 palate.  The lips and teeth  are again slightly parted,
 and  the air-current is more or less suddenly inter-
 rupted, which, as in the  case of the foregoing con-
 sonant sounds, produces  the difference between  the
 two sounds.  The pitch of the D sound lies nearest
 to/#2= 726 vibrations; while the Tsound approaches
the tone g2=776 vibrations.   Here, again,  we notice
the difference in the pitch of the proper tone  of  the
consonants produced by the greater or less air-pres-
sure.
  In the formation of the F and V sounds the under
lip is  gently laid  against  the edge of the  upper
                        11* 
126     PHYSIOLOGY OF  THE LARYNX.

incisors, the tip  of the tongue pressed  against the
inner surface of the lower incisors, and the middle
portion of its edges is applied  to the posterior por-
tion of the alveolar border of the upper jaw, while
the velum, as  in the foregoing sounds, closes the
posterior nasal orifice by pressing  against the wall
of the pharynx.   By this arrangement of the parts
a gutter is produced  for the flow of the  air-current,
which is thereby directed  toward the closure pro-
duced by the  under  lip  and  upper incisors.  This
closure being,  however, capable of but  little resist-
ance, the  air forces  its  way  through, and sets the
edges into irregular  vibrations, and thus produces
the blowing sound of F.  The proper tone or pitch
of this sound is very close to <z2=864 vibrations.  A
more gentle flow of the air-current through the
gutter  and  past  the obstruction  produces the  V
sound the proper pitch of  which cannot be accurately
determined, owing to the want of loudness of the
tone and presence of many of the higher overtones;
but, judging from analogy, its pitch should be about
a half tone lower than that of the F.
  Similar to the F, the S sound is formed by a con-
tinuous flow of breath past an incomplete obstruc-
tion, the edges of which are  set in vibration.   So
we find that in the pronunciation of the S the teeth
are brought almost in contact with each other, leav-
ing a narrow slit  between them ; the lips are slightly
parted, the tip of the tongue rests against the inner
surface  of the lower incisors,  and its edges are
pressed against the whole length of the dental arch
of the  upper jaw, thus forming again a gutter be-
tween its middle and the palate.  The velum closes 
   SIMPLE SELF-SOUNDING  CONSONANTS.  127

the posterior nasal orifice to prevent the escape of
the breath  through  the  nose.  The pitch of this
sound, on account of the  small  space of air  in the
oral cavity, is very high, corresponding to 6£=3666
vibrations per second.  The description  of the for-
mation of the S sound comprises in itself, as a matter
of course, the Zand the C when placed  before the
light vowels E and I, which differ from  the  S only
in the greater or less force of the outflowing breath.
   The J sound also comprises several consonants—
viz. the  Ch and  G sound when placed  before the
light vowels—and differs from it only in the greater
or  less force with which  the  air-current is driven
past the obstruction.  The J\s formed by the ante-
rior portion and the edges of the tongue being laid
gently against the palate and the alveolar borders of
the upper jaw; the lips  are  parted, the teeth are
slightly  separated, and the velum pressed against
the pharyngeal wall.  In this way, again, a gutter is
formed for the breath to  flow through, which ends
on a line slightly back of  the  cuspid teeth, and the
air has to force its way between  the palate and the
anterior  portion  of the tongue.  The  pitch  of the
proper tone of this sound  is, as in the S sound, very
high and approaches closely to d4=2328 vibrations.
   Closely resembling the  8 sound  in many ways is
the Th sound, which  is formed  by the tip  of the
tongue being pushed out between  the incisor teeth,
while its edges are applied to the alveolar borders of
the upper jaw, forming again the channel for  the
direction of the air-current, which is prevented from
escaping  through the  nose by  the  velum   being
pressed against  the  pharynx.   The  lips are  parted 
128     PHYSILOOGY OF  THE LARYNX.

to give free egress  to the air after it has passed the
obstruction presented by the tip of the tongue and
the  upper incisors.  The breath as it passes this
obstruction causes a slight irregular vibration of the
edges of the teeth,  which gives rise to the blowing
sound which is so difficult for foreigners to acquire.
The  pitch of the proper tone of the  Th sound is
about a tone lower than that of J, and corresponds
to the c4=2112 vibrations per second.
  The last of this class of consonants is the R sound,
which, however, differs  from all  other consonants,
inasmuch  as it  can  be  produced  in  two different
ways.  Almost  all English-speaking  people pro-
nounce this consonant with the back of the tongue,
but so indistinctly that it is barely  audible, while
the r in most other languages is made with the tip of
the  tongue and  is quite audible as a self-sounding
consonant.  The first is called the " guttural r," while
the  other, the  correct sound, is  termed  the  "lin-
gual r."
  The "guttural r" is produced by the back of the
tongue being placed gently against the velum in the
same place as in the G.   The posterior nasal orifice
is closed by the velum, and the uvula is allowed to
hang down and  lie on the  tongue.  The current of
air  is then forced  past the incomplete obstruction,
and in doing so the uvula is thrown into slow, irreg-
ular vibrations, which produce the peculiar  flutter-
ing sound.  The pitch  of  the  proper tone  of this
sound is near the (73=16J vibrations, the lowest tone
which the ear  is capable of distinguishing as such.
  The "lingual r," on the  other hand, is produced
by the tip of the tongue  being  brought close to the 
COMPOUND SELF-SOUNDING  CONSONANTS.  129

anterior  portion of  the  palate, without,  however,
quite touching it, while its edges are applied against
the alveolar borders of the upper jaw.  Thus a gutter
is  formed, as in some of the foregoing consonant
sounds, and the air-current, being directed against
the tip of the tongue, throws it  into slow vibrations,
whereby the "rolling" sound of the "lingual r "  is
produced.   The pitch of the proper tone of this con-
sonant is near to C2=33  vibrations; i. e. one octave
higher than the "guttural r."
   2. The compound  self-sounding  consonants.   This
class comprises  the  consonants which really are a
combination of two  of the sounds belonging to the
first class,  and in the English language  but two
sounds are comprised in  it—viz., the Sh and the X.
   In the Sh two obstructions  are in the oral cavity,
through which the air-current has to pass.   The one
is  produced by the tongue being almost in contact
with the  middle of the  palate, as in  the J sound,
while its edges are firmly pressed against the alveo-
lar borders of the  upper jaw; and the other by the
teeth being brought closely together, leaving but a
narrow slit between them, as in the 8.  In this way
the  two  compound  sounds are  merged into  one,
modifying each other so  as to  result  in the " rush-
ing" sound of the Sh.  On account of the combination
of these two sounds, there are noticed two proper
tones in this sound, the one produced by the vibra-
tion of the air contained  in the  cavity  of the mouth,
and the  other by the vibration of the edges of the
teeth.  To a trained ear  a third tone  is also appre-
ciable, which is the so-called "resultant" tone, pro- 
130     PHYSIOLOGY OF THE  LARYNX.

duced by  the combination of  the two first tones.1
The pitch  of  the first of these  tones  is nearest the
d4=2328  vibrations;  of  the  second,  nearest  the
&(2;4=3666;  and of  the  resultant  tone, nearest the
/3=1378 vibrations.
   The X is a  combination of the S and the K sounds,
and  is formed like these, the tongue pressing against
the velum palati with its  back, forming the gutter
with its middle, and directing the air-current through
the narrow slit between  the teeth.  The proper tones
also are double, as  in the Sh sound, but a resultant
tone cannot be heard.  Their pitch is that of the K
nearest the fj22==614|, and that  of the S, nearest the
c|^4=3666 vibrations.
   3. The  simple tone-borrowing consonants.   The con-
sonants belonging  to this class  can be heard only in
connection with a  vowel, and  because in their for-
mation an obstruction to the  outflowing air-current
does not take place, and the breath is emitted noise-
lessly and without  effort.   For this  reason also no
proper tone, the pitch of which could be determined,
is heard.
   The first of these consonants is the H, an aspirate,
which in some languages is not  even accorded a place
among the letters of the alphabet, but is designated
by a  sign;  as, for instance, in  the  Greek.   This
consonant consists  in the somewhat forcible exha-
lation of  the breath  through  the perfectly  unob-
structed oral  cavity, which assumes the shape of the

  1 An explanation of the combination and resultant tones would lead
us too far into the science of acoustics,  and the reader is referred
to any of the text-books on physics for a detailed description of this
phenomenon. 
SIMPLE  TONE-BORROWING  CONSONANTS.   131

vowel in connection with which the if is pronounced,
or, if whispered, the cavity has the shape which it
assumes in the  formation of  the  vowel  Ah.  The
posterior nasal orifice is, of course, closed, to allow
the air to flow through the mouth.
  The L is formed by the tip  of the  tongue being
placed against the anterior portion  of the  palate and
the internal surface of the upper incisor teeth, while
its edges lie flat within the body or the floor of the
mouth.  The teeth  and  lips are parted and the
velum palati applied to the pharyngeal wall.  This
arrangement allows the breath to flow gently through
the two large openings left between the edges of the
tongue and the upper teeth on either side of its tip.
In the whispered L no proper tone is  heard, but as
soon as a vowel  is sounded after it, a  tone is heard
which  comes close to that of the vowel  E, and for
this reason the L is considered in some languages as
a semi-vowel, and is frequently interchanged with
the E sound  in the Romanic  languages;  as, for
instance, in the  Latin word flos, which is changed
into fiore in Italian.
  In the M the organs of articulation  are in  a  posi-
tion of absolute rest; that is, the tongue, lips, teeth,
and velum are in the position which they  assume in
ordinary breathing through  the  nose.   In  conse-
quence, no sound is  heard when it is attempted to
whisper; the consonant  and its characteristics are
only brought out when a vowel sound accompanies
it; and even then the vowel sound must be  made with
the lips closed and the posterior nasal orifice opened,
letting the sound escape through the nose before or
after the vowel  itself is pronounced, according to 
132     PHYSIOLOGY OF  THE LARYNX.

the position of  the  M either  before  or after the
vowel.
  The formation of the JVis, in all respects but one,
identical with that of the M, and the difference be-
tween the two consonants  consists in  the fact that
in the M the oral cavity is closed by  pressing the
lips together, while in the N the closure is made by
the tip and edges of the tongue being applied to the
alveolar border of the entire upper dental arch and
the enlarged area of the palate.
  4.  The compound  tone-borrowing  consonants.   This
last class of consonants contains but two sounds, the
Ng and W, which are in reality combinations of two
consonants.  Thus, the Ng is a combination of the
N and  the  G, inasmuch as the oral cavity is closed
by the back of the tongue  being  applied to the
velum palati, as in the G;  and the air is allowed to
escape through the nose, as in the N,  the posterior
nasal orifice being  left open for that  purpose.  As
in the iVT, no sound, except  perhaps the  forcible ex-
piration through the nostrils, is heard  when the Ng
is whispered, and it can only assert itself in connec-
tion with a vowel.
   The same is true of the W, which is  a combination
of the iland the V, and differs in its formation from
the H only in the lips being brought closer together
and allowing the breath to escape through a slit-like
opening  between  them.   As in  the  H, the nasal
cavity  is separated from  the rest of the  resonant
 cavity  by  the  velum  palati  being  again pressed
 against the ridge formed by the  constrictor  of the
 pharynx. 
 physiology  of the  nasal  cavities.   133

     The Physiology of the  Nasal Cavities.

  Like the larynx, so also do we find that the  nose
performs the functions which  are of very great im-
portance, and which should be thoroughly under-
stood by the student of rhinology.   For it is the
disturbances  of these functions which give rise to
the many,  and  often obscure, symptoms which we
notice in connection with the diseases of the upper
air-passages.
  The  first of these functions is to give the  most
advantageous position for the terminal  fibres of the
olfactory nerves in the upper portion of the anterior
nasal chambers, where a portion of the expired air
has access  to them, and where they can  be excited
by the minute odoriferous particles floating in the
air.  Inasmuch as the sense of smell is not so much
one of gratification, but one of protection, by means
of which deleterious substances or dangerous gases
may be perceived, and  thus avoided, the entrance
to the air passages is certainly the most advantageous
place in which to  place the sentry who is to give the
alarm.   Besides being the seat of the sense of smell,
the nose, by its second  function, aids materially in
voice-production  and articulation,  which function
has, however, already  been described  in the  fore-
going pages, and  it is, therefore, not necessary again
to consider it in detail.  Suffice it to  say that the
reader can readily satisfy himself of the importance of
the nose in speaking, if he will close both nostrils
while articulating, and observe the effect upon his
voice;  or, if he possesses  sufficient power over the
movements of his soft palate, let it hang down so as to
                         12 
 134  PHYSIOLOGY  OF THE  NASAL  CAVITIES.

 allow the air to pass through the nose while speaking.
 In both cases, a so-called nasal voice will be the re-
 sult,  which is due to  the absence of nasal resonance.
   The third function, perhaps the most important of
 all, is the preparation of the air prior to its intro-
 duction into the larynx, trachea, and lungs during
 the  act of inspiration.  By the bristle-like  hairs
 called vibrissa?  which are  situated in the vestibule,
 all the coarser particles of dust floating in the air
 are  arrested, while  the finer  particles which  pass
 through this sieve are caught by the glutinous mu-
 cous  secretion  covering the normal nasal mucous
 membrane, so that in its passage through  the nose
 the air is purified from all  foreign bodies.  Further,
 the anatomical  relation  of the turbinated bones to
 each  other and to the septum  presents a very  large
 surface over which the air must  pass in nasal respi-
 ration, and  on account of the erectile tissue overly-
 ing the turbinated bones the warm arterial blood is
 brought very  close to this  large surface.   In conse-
 quence, some of the heat  from the arterial blood  is
 radiated from the mucous membrane and  the  in-
 spired air is raised in temperature.  This tempera-
 ture difference has been estimated to average 2° F.,
 but much depends upon  the temperature of the ex-
 ternal air, for the colder it  is the greater will be the
 amount of heat absorbed  by it in its passage through
 the nose, while in summer hardly any difference in
the external and internal temperature of the  in-
spired air is noticeable.
  And finally, in consequence  of the watery secre-
tion of the serous glands, and also through the out-
pouring of serous fluid into the nasal cavities by the
osmotic action of the  lining mucous membrane, the 
 PHYSIOLOGY  OF  THE  NASAL  CAVITIES.  135

amount of which  is estimated by Bosworth to be
from  fourteen to sixteen ounces in the twenty-four
hours, the  inspired air  is moistened  almost  to the
dew-point, so that, in its passage through the larynx,
it  does not dry up the mucous membrane.   The
surplus of  this large quantity of fluid which is not
taken  up  by the air, passes imperceptibly down
through the pharynx into the oesophagus and stomach
in man, but in most animals, particularly in the ox
and  the dog, it runs out  of the  nostrils, where it
evaporates and produces the proverbial coldness  of
the nose when the animal is in good health.
   It will thus be seen, that the main function of the
nose is to aid in respiration, and that  it is an impor-
tant respiratory  organ, for, as will be described later
on, any interference with  the proper  preparation of
the air for its introduction into the respiratory tract
gives  rise  to  disturbances  throughout this whole
tract.  It will also be seen that, although the mouth
may supply, to some extent, the place of the nose  as
the respiratory orifice, yet it cannot do so perfectly,
and the pharynx, larynx, and trachea soon become
irritated by the  passage of the dry, cool, and dust-
laden air and the inspirations become  more shallow,
showing also irritation  of the bronchi and bron-
chioles.  A very few words will suffice for a descrip-
tion of the functions of the pharynx, that interme-
diate cavity, or rather tube, between the nose and the
larynx and oesophagus.   It is simply  a passage-way
to conduct the  air  from the  nose  to the larynx
during respiration,  and guides the  food into the
oesophagus during deglutition.  In its character as a
portion of  the resonance apparatus in phonation, it
has already been considered, 
CHAPTER  V.
 INSTRUMENTS  ACCESSORY  TO  LARYNGOSCOPY AND THE
        TREATMENT OF LARYNGEAL DISEASES.

   Having  described the laryngoscope, the different
 modes of using it, and the appearances of the nor-
 mal laryngeal and rhinoscopic images, it remains to
 describe some instruments  which, in connection
 with the laryngoscope, are used  for making further
 exploration of the parts  by the sense of touch and
 for making application to the diseased mucous  mem-
 brane  of the throat and  nose.   The instruments
 used for the  extraction  of  foreign bodies and the
 removal of neoplasms, as well as for the performance
 of other operations within the cavities of the throat
 and nose, will be treated of under their respective
 heads.
   The  Laryngeal Sound.—The eye  is frequently  un-
 able to  determine certain  conditions seen in  the
 laryngoscopic  mirror, and others seen without it in
 the pharyngeal and nasal cavities.   Hence the sense
 of touch aiding that of sight is frequently  necessary
 in order to form a correct opinion as to the  condition
 of the  parts.   For this purpose in  laryngoscopy, as
in surgery,  a sound is employed.
  The  laryngeal sound consists of a piece of  silver
wire rounded  off at the end, and  held in a mirror
handle.  It should be  flexible, so  that any  desired 
THE SEPTOMETER.
137
curve can be given to it, but should be stiff enough
to resist  a considerable amount of pressure before
yielding, and it should be long enough to reach to
the anterior angle  of the glottis without bringing
the fingers holding the handle into the mouth of the
patient, and thus obstructing the view.  By means
of the sound, attachments of tumors, depths of ulcers,
etc., are determined.
   The Septometer.—It is often difficult, if not impos-
sible, to  determine with the  eye or sound  alone,
whether  a bulging of the nasal  septum to one side

                      Fig. 44.
Septometer for measuring thickness of nasal septum.
or the other is due to a bend or deviation from the
normal position, or whether it is due  to  localized
thickening of the plate.  This may be ascertained
by means of the author's septometer, an instrument
similar to the one used  by mechanics to determine
the diameter of a piece of wood or iron being turned
in the lathe  (Fig. 44).  In using it the long straight
shanks are introduced, one in each nostril, and being
closed upon the septum the rounded points are gently
moved  up and  down, and  backward and forward
over the bulging portion of the septum.  The motion
of the  index attached  to the curved shanks of the
                       12* 
138       AUXILIARY INSTRUMENTS.
 instrument accurately indicates the relative thickness
 of tissue grasped  between the points in the nose.
 By means of this instrument we can thus ascertain
 whether we have to deal with a deviation or a local-
 ized thickening of the septum, for if it is a devia-
 tion the index will  move but  slightly, while it will
 travel a considerable distance when the points  pass
 over a thickened portion.
   Sponge-holder.—Most remedies employed as appli-
 cations to the mucous membrane of the throat and
 nasal cavities are used in solution.  They may be
 applied  either with a sponge, a tuft  of  cotton, a
 brush, or as a finely subdivided spray.
   A small piece  of  fine sponge tied securely to the
 end of a bent silver wire or sound, and dipped  into
 the solution to be used, can be carried to any desired
 spot in the larynx, pharynx, or nasal cavities.  This
 constitutes what is called a sponge-holder.   As it is
 necessary to renew  the piece of sponge with every
 application, it is more convenient to employ an in-
 strument made for the purpose, to which the piece
 of  sponge can be   quickly and securely  fastened.
 The  already-described  epiglottis forceps may with
 advantage be employed for  this purpose.  A piece
 of  wire bent to the proper  curve, split at the end,
 and secured  in a wooden handle, is, however, gen-
 erally used  as a sponge-holder.   A   sliding ring
 slipped over the split end serves to approximate the
 two halves, thus securely holding a piece of sponge
 between  them (Fig.  45).   The sponge should be
 small, only large enough to  cover the ulcer or abra-
 sion, to which alone  it is  to be applied.  The old-
fashioned whalebone probang, with a large piece of 
COTTON APPLICATOR.
139
rough sponge tied to the end, is altogether unfit for
any application to the delicate mucous membrane of
the throat.
                     Fig. 45.
                             -----QEiiaBFffTgi
                   Sponge-holder.

   Cotton Applicator.—When applications of liquid are
to be made  to lesions in the pharynx or the nasal
cavities, it will  be  found that a tuft of absorbent
cotten attached  to the roughened end of a silver or
aluminium probe is often preferable to the sponge,
because the closer  texture of the  cotton holds the
liquid better,  and  there is less danger of a drop
becoming detached during the application and run-
ning down, causing irritation.   The  cotton should
be wound around the end of the probe in such a
manner, that by a little twist of the fingers it can
be detached after the application  has been  made.
If, however, it adheres so tightly to  the  probe that
it cannot be easily pushed off, the simplest way to get
rid of it is to burn  it off by holding  the end  of the
probe carrying the cotton over the lamp, and  allow-
ing it to become charred, when it can  readily be
wiped off.  For  applications to the  anterior  nasal
cavities I am  in the habit of using  the  ordinary
wooden toothpick as cotton carriers, and throwing
them  away after having made  the application, thus
saving time and  trouble.
   The Brush.—In   many cases a soft camel's-hair
brush, securely fastened to a stiff, curved stem, may
 
 140       AUXILIARY  INSTRUMENTS.

 be advantageously employed for touching ulcers  or
 abrasions in the pharynx and larynx.   The brushes
 should be mounted in a cap of hard  rubber, which
 can be screwed  to  the  end of a  silver laryngeal
 probe.  Frequently, brushes are sold mounted  in
 brass caps; these are not  to be recommended,  as
 the reagents used for applications  attack the brass
 and loosen the hair, so that single hairs, and even
 large tufts of hair, come out of the brush, and are
 apt to remain in the throat of the  patient, causing
 very unpleasant symptoms.
   Another  kind  of  brush  is sold as a laryngeal
 brush, which is tied  to a slender wire, having  loops
 at the end for a handle.   This kind is very unsatis-
 factory, inasmuch as the stem is too thin and elastic,
 and consequently it is very difficult,  or  almost im-
 possible, to touch any desired spot in the larynx or
 pharynx with the point of the brush.
   The Atomizer.—In  most forms of throat and nasal
 disease the application of solutions in the form of a
 spray is extremely  useful,  not only with a view to
 cleanse the mucous  membrane of secretions before
 making applications with  the  sponge,  brush,  or
 cotton pledget,  but also as a means of spreading
 medicated  solutions over a larger  surface, and of
 gaining access to parts which can in no other way
 be  reached.  This spray is produced by means of
 an  atomizer, of which a large variety, of different
 degrees of  usefulness, may be obtained from the
instrument-makers.   The best of these are  the so-
called Sass' atomizing tubes (Fig. 46) made of  glass
or rubber,  and  throwing an extremely fine spray,
either  straight  forward,  upward,  or  downward. 
THE ATOMIZER.
141
They work on  what may be called the exhaust
principle,  in  which  a current  of  air being forced
through a tube, on passing out from the small open-
ing at the end, rushes past the opening of another
tube, the end of which is  below the surface of the
liquid to  be  nebulized.  In doing so, the current
exhausts the air in the second  tube, thus causing a
rise  of the liquid  until it  appears at the opening,
when it is carried along with the current of air in a
finely subdivided state.

                      Fig. 46.
Sass' atomizing tubes.
   The current of air may be obtained by means of
the  well-known  rubber-ball pump  (see  Fig.  47),
which, by  being  compressed in the hand, forces a
puff of air through the tube.  If a continuous spray
is desired (which  is the case in most  instances), a
second rubber ball is connected with  the pump ball, 
142       AUXILIARY INSTRUMENTS.

which, acting  as  a reservoir,  stores the air under
pressure, thus producing a continuous stream,
  Another very good  instrument, especially useful
for cleansing and  medicating the nasal cavities is the
toilet or perfume atomizer.   This works  on what
may  be  termed  the  principle  of  compression, in
which the air from the rubber bulb enters the bottle
containing the liquid, and by its  pressure on the sur-
face forces the solution to ascend through  the  fine
tube until it reaches the contracted opening, where,
by the friction, it is broken up into a spray.   The
most commonly used  atomizer  of  this class is the
so-called "Magic" atomizer, which answers the pur-
pose admirably, but has  the disadvantage that the

                      Fig. 47.
The Burges' atomizer.
cement  with which the cap is fastened to  the neck
of the bottle very easily becomes loose, and further
that  the small  inner  tube being fastened  near the 
THE ATOMIZER.             143
end of the larger tube, is easily detached, rendering
the instrument useless.   These defects have led to
the construction of the Burges' atomizer, made by
Shaw & Geary, of Philadelphia, in which the cap of
hard metal is screwed to the neck of the bottle, the
small tube is  securely fastened and the end of the
large tube is  detachable, affording  easy  access to
both  tubes, for  the  purpose of removing obstruc-
tions.  Three different kinds of atomizers, of this pat-
tern, are in the market, one straight, one for throw-
ing the spray downward into  the larynx, and one
for spraying upward into the naso-pharyngeal space.
Only one bulb  is  needed to produce a continuous
spray, owing to the perfectly air-tight closure of the
bottle and  the  improved  rubber  bulb (Fig.  47).
Although useful in many instances, this atomizer
has its disadvantages.  In the first place, the stream
is  much coarser than  that obtained from the Sass
tubes, and, secondly, being made of metal, solutions
containing salts of  iron, copper, or silver, or acids,
cannot  be  used  with it, as they would  corrode the
tube and close its fine opening.  Atomizers working
on the  same principle, made  of hard rubber, and
with  movable tips, enabling the operator to throw
the stream in an}7 direction, thus avoiding the objec-
tions to the perfume atomizer, may be obtained, but
they are so large and clumsy as to be almost useless.
  For office  use, where the spray  is used largely,
the working of the hand-ball pump is not only very
tedious, but also has the great  objection of occupy-
ing both hands of the operator, one in holding the
atomizer and  the  other in  working  the  ball,  and
thus it  becomes necessary to  have a supply of air 
144       AUXILIARY INSTRUMENTS.

under pressure which can be used at any moment.
For this purpose  the  Burges' blowpipe, to which a
large  reservoir  with  pressure-gauge  is  attached,
forms a very  convenient  and cheap apparatus (Fig.
48).  It is  composed  of  a small  air-pump, worked
by the foot,  forcing air  into the reservoir, which,
Fig. 48.
Burges' air-compressor.
when the desired pressure (ten to fifteen pounds, as
indicated by the guage) is obtained, should be  shut
off from the pump by a stop-cock, to prevent leak-
age through the valve.  To another stop-cock at the
top of the reservoir is attached a long flexible rub-
ber tube, the end  of which  is slipped over the end
of the air-tube of the atomizer.  The stop-cock being
opened,  the air  rushes  through the tube and  pro-
duces the spray, which can be instantly  stopped by 
THE ATOATIZER.
145
bending and pressing the rubber hose against  the
opening of the air-tube with the hand  holding  the
atomizer,  and without the necessity of closing  the
stop-cock  in the  reservoir.   Thus the operator  has

                      Fig. 49.
Water air-pump.
perfect control over the instrument with one haud,
and is free  to hold  the tongue of the patient  or
manipulate the nasal speculum with the other.  The
air used  from the reservoir must be replenished by
pumping as the  pressure diminishes.   By means of
a very ingenious air-pump (Fig. 49), worked by a
stream of water  this inconvenience is obviated, for
the apparatus always keeps a certain pressure in the
receiver.  A regulator  which is attached to it en-
ables  the operator  to  set the pump  so that  there
are always,  say,  fifteen pounds  of pressure in the
receiver,  and when  this  has  been  obtained the
                        13 
146       AUXILIARY INSTRUMENTS.

pump automatically stops work, to begin  again im-
mediately as soon as the pressure has diminished  in
the reservoir.  It can be attached  to any stationary
washstand, and will give as a maximum the pressure
of the water in  the  hydrant  pipe, which  is usually
from fifteen to twenty pounds.  Of course, any kind
of air-pump and reservoir  will answer  the purpose
as long as the necessary air-pressure can be obtained
and controlled at the will of  the operator (Fig. 50).

                      Fig. 50.
Double-acting air pump.
In the office the physician will find it most conven-
ient to attach the hose conducting the air from the
condenser, attached to a  metal  tube, in which are
inserted a number of small stop-cocks, to which,  in
turn, are attached flexible rubber tubes leading  to
the atomizers which are  placed on  a shelf near  at
hand.  If a pressure of not more than fifteen pounds
is  used  in the  reservoir, and the rubber tube is of
good  natural  black  rubber,  the pressure  of the
thumb against the nipple of the atomizer is suffi-
cient to control and cut-off the air supply, and as, in
most cases, a greater pressure than fifteen pounds is 
THE ATOMIZER.
147
rather harmful, this  natural  thumb  cut-off is  the
most convenient and satisfactory.  When, however,
more  pressure  is required, and when the tubes are
of stiff' white rubber, a mechanical cut-off is needed
for regulating and cutting off the  air supply.  These
cut-offs are nothing more than a valve made in such
a shape as to be convenient for the hand, and they
have  the advantage that no air enters the atomizer
unless pressure is made upon  the thumb-piece, thus
allowing greater freedom  of  manipulation  than is
possible when  only the natural  thumb  cut-off is
used.
   When  the spray application is to be made fre-
quently at the  house of the patient, and  especially
when it is to be long  continued, the steam atomizer
(Fig.  51) is the  most serviceable instrument  for  the
Fig. 51.
Steam atomizer.
purpose.  It, like  the  Sass' tubes, acts on  the  ex-
haust principle, but instead of using a current of
air to nebulize the liquid, steam from a small boiler, 
148       AUXILIARY INSTRUMENTS.

to which the air-tube is attached, supplies the neces-
sary force.  The stream of atomized liquid cannot,
however, be directed to any particular part, and the
patient must draw it into his larynx during the act
of inspiration.  In  order to protect  his face from
the moisture the spray is directed  through a sort of
funnel, the narrow  end of which  the patient holds
in his mouth.
  Liquids containing gums or resins cannot be used
in atomizers, because  they clog  the  fine opening of
the tube.   As  they are mostly volatile in a greater
or less degree, they may be employed to advantage
for inhalations in a  different way.
   Vapor Inhalations.—The simplest, but nevertheless
a very effective, method  of using resinous  liquids
containing volatile ingredients is to mix them with
hot water in a tumbler or cup, over which the wide
end of a funnel or  paper cone is  placed,  while  the
vapor rising from the mixture  is  inhaled by deep
inspirations  from  the narrow end  of the  funnel or
cone.  Another convenient  method for hot inhala-
tions, is  to place  the mixture of hot water and
resinous liquid in a  small earthen teapot so that  the
level of the liquid  is  below the natural opening of
the spout.  The lid of the teapot is replaced and the
vapor inhaled with  deep inspirations, by taking  the
end of the spout in  the mouth.
  A more convenient instrument for such inhala-
tions is the so-called inhaling bottle, a wide-mouthed
vial holding from four to six fluidounces.   Its  air-
tight-fitting  stopper of cork or rubber is perforated
by two holes, each  admitting a glass  tube,  one of
which is straight, and long  enough to reach from 
VAPOR INHALATIONS.
149
the top of the stopper to within a fraction of an
inch of the bottom of the bottle;  the  other tube is
slightly bent, and  is pushed  through the  stopper
until  its lower end just protrudes  below the under
surface,  the  other end projecting several inches
above the upper surface of the stopper.   When it is
to be used, the bottle is half  filled with hot water,
and a little of the resinous liquid is added  to it.   The
stopper with the tubes is then replaced, and a deep
inspiration is drawn  through the bent tube.  This
causes a tendency to a vacuum in the  bottle above
the surface of the  liquid, and  a consequent  rush  of
air through  the  straight tube, which, on reaching
the bottom of  the vial, bubbles up  through the
liquid  and becomes impregnated with the  volatile
substances.
   By inserting  a  small homoeopathic vial in the
stopper,  and bending the upper  end of the long
tube in the form of a hook, so that the opening  of
the tube fits over the opening of the small vial, the
bottle  can  also  be used for the inhalation of the
fumes of muriate of ammonium.   In order to obtain
the latter,  the  large bottle  is half filled with  cold
water, to which a few drops of strong aqua ammonia
are added.   The small vial is half filled with chemi-
cally pure  hydrochloric  acid.   By exhausting the
air in  the  bottle,  the atmospheric  pressure causes
the fumes of  the acid to pass down the tube and up
through the ammoniated water. Combining with the
ammonia the acid  forms the muriate of ammonium
in the state of dense white vapor.  In many instances
where  hot water is not easily procured, it is of ad-
vantage to have an apparatus for hot inhalations, in
                       13* 
150       AUXILIARY INSTRUMENTS.
Fig. 52.
which  the water  can be heated on a gas  flame  or
spirit lamp.  For this purpose the author, several
years ago, devised an'inhaler composed of a small tin
can, the lid of which is conical, in the  shape of a
funnel,  and  has  inserted in the rim  a  tin  tube
reaching to the bottom of the  can.  The opening
in the funnel-shaped lid ends in a short tube, over
which is slipped a short piece of rubber tubing, with
a mouth-piece attached to its free end.  In principle,
                    it is  the same as the inhaling
                    bottle, but is less easily broken,
                    and has the advantage that it
                    may also be used for dry inha-
                    lations (Fig. 52).
                     In certain cases of spasmodic
                    affections of the larynx, the in-
                    halation of the vapors of nitrate
                    of  potash  is  used  with  very
                    good results.  Such vapors may
                    be  obtained  by burning  in  a
                 I*  large jar, over which  a  funnel
                    is placed,  or in the  author's
                    universal inhaler,  a  piece  of
                    paper which has been soaked in
                    a saturated solution of  nitrate
of potassa, or other  antispasmodics, and  then dried.
  Insufflator.—Remedies are often applied  to the
throat in the form of an impalpable powder, and
for this purpose an instrument  called an insufflator
is used (Fig. 53).
  It consists of a tube of hard rubber or metal  curved
at one end, and connected with a soft-rubber ball at
the other.   Near the ball an elongated opening  is
The Author's universal
      inhaler. 
INSUFFLATOR.             151
cut into the side of the tube, which may be closed
by sliding over it a short piece of another tube.   In
the improved  insufflator now commonly in use, the
tube is made in  two pieces, which fit into  each
other,  thus forming a continuous tube.   The end
piece is shaped  so that,  at  the  place where it fits
into  the shorter ball  piece, it forms a scoop,  with

                     Fig. 53.
which the powder is taken out of the box or bottle,
and in which it remains until forced out  by the air
current.   When the instrument is to  be used, the
powder is placed in the tube, and  the  ball  is com-
pressed suddenly, thus causing a puff of air, which
carries the powder with it.
  For  office use I have devised a reservoir  insuf-
flator, which  I  have found very convenient.   This
instrument consists of a small  hard-rubber  or glass
vessel with a stopper containing two holes, one of
which admits the tube leading from the ball or air
receiver, while in the other is inserted the longer tube
intended  to emit the powder.  The air-tube reaches
down to within a short distance of the bottom of the
vessel, and is bent at a right angle  as it  leaves the
stopper.  To it is attached  a rubber ball containing a
valve or the rubber tube from the air receiver.  The 
152       AUXILIARY INSTRUMENTS.

other tube, also bent at right angles just above the
stopper, reaches down but a short  distance into the
vessel. The portion outside is bent in the curve seen
in the ordinary insufflator, when it is to be used to
throw powder into the larynx;  or  it is straight and
drawn to a point  when it is  to be employed for the
anterior nares.  The tubes being pushed into the hole
of the vessel,  one  can be substituted for the other as

                      Fig. 54.
DAVIDSON RUBBER CO.
                 Reservoir insufflator.

the case may require.  The advantages of this form of
insufflator are that as the current of air passes into
the reservoir containing the powder it stirs it up and
passing out by the  other tube, carries with it only
the finer particles, while the coarser and heavier ones
which  might give rise to irritation,  remain in the
reservoir.   It also obviates the difficulty of loading
the instrument every time it is to be used.  A similar
instrument (Fig. 54), perhaps more elegant than the
author's, has  lately  been  put in the market, which,
in principle, is, however, the same.  Instead of hav-
ing the reservoir at right angles, it is placed in the
shape of a glass tube in a line with the  rubber ball
and the tube, which  latter  is  made  to revolve, so
that the instrument can be folded up, so to speak.
  An insufflator may be improvised by using a piece
of glass tube or a piece of stiff writing paper  rolled 
CATCHING  COLD.
153
over a lead pencil, into which the powder is intro-
duced and blown out by the breath of the physician.
  The Caustic-holder.—Nitrate of silver, when it is to
be applied to ulcers in  the larynx or pharynx, in  the
solid form, should be fused on to the roughened end
of a silver probe by holding both the end of the stick
of nitrate of  silver and of the  probe over a lamp,
and causing the caustic to melt, when it will adhere
to the probe in the form of a drop, which retains its
shape on cooling. This method  is much safer and
more economical  than the use of solid  nitrate of
silver by the porte-caustique; because  in  the latter
instrument the piece of caustic is apt to break, and
the detached  particle  to  drop into  the  larynx  or
trachea.  Besides, in order to destroy any infectious
material from a specific ulcer, the stick of nitrate of
silver has to be washed, whereby  a great deal of its
substance is dissolved and lost.   The probe, on  the
other hand, has but a thin coating of silver upon its
end, which cannot easily break off, and  can  be
readily remelted over the lamp, thereby  destroying
all infectious  material that might cling to  it.
               CHAPTER VI.

 catching cold, pathology  of mucous membrane,
                  therapeutics.

                 Catching  Cold.

  As most of the diseases of the  upper air-passages
are  caused more or less directly by what is popularly
known as catching cold, I will here in a few words 
154
CATCHING COLD.
endeavor to explain the meaning of this term before
entering upon  the  consideration of the  general
pathology of the mucous membrane.
  It is a well-known  fact that the human organism
must  be maintained under  all  circumstances  at  a
temperature equal to 98° Fahr., otherwise disease
will result, and that the source of this heat is within
the organism, the expenditure of which by radia-
tion we endeavor to minimize  by living in houses
and by protecting  the surface  of  the body  with
clothes.
  The first part  of this proposition is  an accepted
fact and self-evident, while the second needs some
further  explanation.
  Heat  is produced  in  the animal organism in two
ways: first, by oxidation of food, and  second, by
the conversion  of muscular  movement into heat,
according to  the now  well-established  law of the
correlation of forces.   How and  where this oxida-
tion of food takes place  I will not here enter into,
but will state that  certain articles of  food yield  a
larger amount of heat than  others.   Thus animal
food,  and especially  animal fats  and oils, produce
more  heat when introduced  into the  system  than
farinaceous food  and fruits do.  This we find exem-
plified in contrasting the mode of living of the Esqui-
maux and other inhabitants of the north with those
dwelling in the tropics.
  The Esquimau lives almost exclusively on  animal
food and fish  oil, while the South-sea Islander, who
lives most of the time in an atmosphere the tempera-
ture of  which is  higher  than the normal tempera-
ture of  his body, eats  chiefly fruits and vegetables. 
CATCHING COLD
155
And even in temperate climates, where man lives
both on  vegetable  and animal food, more of the
former is consumed  during the warm season, while
the latter is in preponderance during the cold winter
months.   The  Catholic  church long ago recog-
nized this fact, and has introduced the lenten sea-
son, a period of abstinence from animal food, at a
time of the year when the seasons change from the
cold to the warm, for  if more heat-producing food
is  taken  into the system  than is required to keep
the body  at the normal temperature, the digestive
system is taxed  beyond  its capacity, the  blood  is
overcharged with effete material, which is not elim-
inated quickly enough, and, as a result, we feel out
of health, which,  when it  occurs during  the first
warm days  of spring,  we  call spring  fever.  The
same effect is produced when  we change our abode
from  the  North  to the  South during the winter
months, and persist  in the  same mode of living, and
take the same amount of animal food; and if wTe
continue to  live  this way for a length of time, the
result is congestion, and may be abscess of the liver.
This is exemplified  by the fate of so many  English-
men who go to India, where  they eat their  roast
beef and drink their heavy ales, as they have done
in England, but who in a few years have to return
with a diseased liver, blaming the climate when they
should blame themselves.
  In order  to  oxidize the food, oxygen  must be
introduced into the system in  sufficient quantity,
through the lungs, otherwise part of the food only is
burnt up and produces heat, while the rest is thrown
out again as waste material, and  by its presence 
156
CATCHING  COLD.
materially interferes with the normal action of the
different organs.
  Muscular exercise, as is well known, produces heat
within the system by  a  conversion of motion into
heat,  but this  motion  depends  for  its sustenance
upon  the contractile force of the muscles, which is
kept  up  by part of the food taken into the system.
If this contractile force of the muscles is  not  exer-
cised, it  needs not as  much nourishment, and the
surplus is deposited as fat  within and around the
different organs.   This is exemplified by the fact
that, in order to fatten an animal, it is kept confined
within a narrow space and is overfed.
  There  can  be no doubt  that sunlight  plays an
important part in  the  oxidation of food within the
system, and this is  probably one reason why night
air is  generally supposed  to be injurious to delicate
constitutions.
  This heat which is generated within the body by
the oxidation of food and by muscular movement,
would be lost by radiation if the temperature of the
atmosphere surrounding the  body was far below the
normal  temperature of the  system, and, therefore,
this loss must be minimized  by interposing between
the integuments of the body and the air non-con-
ductors of heat, in the shape  of clothing, not to keep
the cold out but to keep the heat in.  The face, part
of the neck, and the hands are,  however, generally
exposed,  and thereby the  epidermis  becomes  hard
and horny, thus becoming a  bad  conductor of heat,
and very little of the  systemic  warmth is lost by
radiation from these parts.
  The hygrometric  condition of the  atmosphere, 
CATCHING  COLD
157
irrespective of temperature, has a great deal  to do
with the temperature of the bod}-, at least as far as
individual  sensation is concerned.   We feel  more
chilly in a  cold, damp atmosphere than in a dry one
of the  same temperature, and we cau endure a
greater amount  of heat  when the air  is dry than
when it is filled  with  aqueous vapor.   As far as I
know, this fact has  not,  as yet, been  satisfactorily
explained, and I would suggest, as a reason, that the
moisture is absorbed by the skin, thus  making it a
better conductor of heat  and facilitating the ingress
and egress of heat through it.
  We also minimize the expenditure of animal heat
by living the greater part of our  time  (in cities, at
least) in houses  and apartments  from which the
outer air is excluded as  much as  possible, and the
atmosphere of  which, during the cold season, is
artificially  heated.
  The maintenance  of the normal temperature of
the body, therefore, depends  upon the production
of heat by oxidation of food within the system, by
muscular exercise, and upon  the prevention, or, at
least,  reduction, of the radiation, and a lowering of
this temperature, especially if it be sudden, causes
contraction of the  capillaries in the outer integu-
ments, a disturbance of  the  heart's action, and a
congestion of some of  the  internal  organs,  and
particularly of the mucous membrane of the respira-
tory tract,
  Taking it for granted  that, at a given moment
there  is  a  certain quantity of blood in the  body
which is distributed throughout the vascular system,
a greater  amount  of blood  than  is  normal  will
                       14 
158
CATCHING  COLD.
 accumulate in some portion  of the  system when a
 contraction of the capillaries  in an area of the sur-
 face takes place.   Such an accumulation causes an
 over-distention of the  capillaries, and consequently
 a congestion of the  part.  As examples of this may
 be cited,  the  facts  that deep-seated  inflammations,
 or congestions, are relieved by  counter-irritation of
 the skin,  and  it is by no means necessary to apply
 the counter-irritant directly over the organ affected
 to obtain  the desired result; and also, that frequently
 inflammation, and even ulceration, of the Jbowels is
 a result of  extensive burns and scalds of  the skin
 of the  chest  or  abdomen.  In  this  latter case the
 capillaries of  the skin are violently contracted and
 the blood driven  to other parts of  the  body, and
 especially to the  intestines, causing  a congestion,
 followed  by inflammation  of their  mucous mem-
 brane.
  In  connection  with,  and  perhaps caused by, this
 contraction  of the  capillaries of the  skin  by cold
 there is always an irritation of the distal nerve ends,
 which, by reflex action, produces a change of the
 heart's action, which, in turn, becomes a factor in
 the production of the congestion in  other portions
 of the body.
  The blush of shame is produced by  reflex nervous
 action, the cause of  which,  however, is central and
 not peripheral, and  not unfrequently congestion of
 the lungs  is produced by violent or long-continued
 emotional  disturbances.    The  reason  why  the
mucous membrane of the respiratory tract is more
liable to  be  the  seat of  this  congestion than any
other  portion of the body, must be looked for in the 
CATCHING  COLD.
159
fact that it, among civilized nations, is hardly ever
free from irritation in one or the other  portion of
its extent.   We constantly inhale particles of vege-
table  aud mineral substances in the shape of dust,
which, by engaging the cilia of the epithelium, act
as irritants.   This, together with  the impure air
surcharged  with carbonic acid which we breathe
in the confined atmosphere  of our dwellings and
public halls, produces a want of  tone in the mucous
membrane of the respiratory tract and its capillaries,
thus predisposing it to congestion.  For, as all fluids,
so will the blood in the body when pressed upon at
any particular point, seek an outlet at the  point of
least  resistance—in this  instance, the capillaries of
the mucous membrane of the nose, pharynx, trachea,
and lungs.  Catching cold may then be  defined as
a momentary  lowering of the temperature of the
body  by  external  influences,  which  causes  both
directly and indirectly an uneven distribution  of
the blood, and thereby a congestion or inflammation
of internal organs.
  Here the question may be raised:  Why is it that
some  persons are more  liable to catch  cold  than
others, who, perhaps,  are more  exposed to cold and
the inclemency of the weather ?
  In order to answer  this question I must state that
the power of producing heat in the system may be
weakened  by  a number of causes, and  that when
thus weakened  it is  not able to produce an extra
amount of  heat when demand for it is made  by
exposure to a lower temperature. Thus we find that
a person  who  leads  a sedentary life and  confines
himself in an atmosphere artificially heated to from
75° to 80° Fahr., accustoms his system habitually to 
160   PATHOLOGY OF  MUCOUS MEMBRANE.

produce  little heat, because little demand is made
for it; or one  whose digestive  apparatus is out of
order will not properly digest his food, and cannot,
therefore, produce sufficient  heat by  oxidation  of
the food; or one who  is  deprived, voluntarily  or
involuntarily, of  the necessary amount of oxygen,
be it by being confined in close rooms or on account
of disease of the lungs;  or finally one who does not
take exercise, and  so  does  not produce  heat  by
muscular motion, will  easily take  cold  from the
slightest  exposure.   While on  the  other hand, a
person who  lives an out-of-door life, and thus ex-
ercises his heat-producing  faculty,  takes  cold  but
rarely, even  though much exposed,
  To prevent taking cold, therefore, a person should
take outdoor exercise at all seasons and in all kinds
of weather, should not dress too warmly, should have
plenty of fresh air in his house, and  especially in his
bedrooms, and should not heat the air  in his rooms
above 68° or 70° Fahr.

      Pathology  of  the Mucous Membrane.
  This subject, if entered into  extensively, would
carry  us  far beyond the limits of a hand-book such
as this, and I will therefore confine myself to a few
generalities, referring the  reader to text-books  on
pathology, and  to the chapters on the different dis-
eases of the  upper air-passages in this volume, for a
more  detailed account of the morbid  changes met
with in the  mucous membrane  of the throat, nose,
and naso-pharynx.
  The mucous membrane lining  the throat and
nasal  cavities is exceedingly liable  to diseases   of 
   pathology of mucous membrane.   161

an inflammatory character, which exhibit the same
phenomena  that are noticed  in  other parts  of the
body.  Such inflammations, accompanied by pain,
redness, and swelling, are  sometimes traumatic,  as
when caused by the introduction of foreign bodies,
the swallowing of corrosive substances, and the in-
halation of irritating vapors;  or they are idiopathic
inflammations.   Diseases of the throat and nose may
also be results or symptoms of a systemic affection,
s-uch as tuberculosis, syphilis, cancer, scarlatina, etc.
Finally, they may be of a nervous character, such  as
the various stages of paralysis of  the different parts,
and the  laryngeal  symptoms of hysteria.  Then,
again, we find the products and consequences  of
chronic inflammation in the throat as we do in other
parts  of the body, such as glandular enlargement,
catarrhal  ulcerations, and  neoplasms,  in different
shapes and  locations.
  In most diseases of the larynx, pharynx, and nose
the secretions  from  the mucous  membrane are
altered in quantity and character.   They are either
increased or decreased in quantity, and  either flood
the parts or  leave them unnaturally dry.
  The natural  secretion  of the mucous  membrane
being a watery exudation, keeping the parts moist
without being visible as a substance, may in disease
become thick and  slimy, running together in semi-
transparent drops, to be collected into larger accumu-
lations and expectorated as mucus.  This thickening
of the secretions is believed  to  be  due to the ad-
mixture of new and old  epithelial cells which have
undergone a retrograde  metamorphosis  instead  of
covering the mucous  membrane.  Thus  the lining
                       14* 
162             therapeutics.
of the larynx, pharynx, and nose becomes in places
denuded of its epithelial covering; such places are
called abrasions.   They  are seen  to be of a darker
color  than  the surrounding mucous membrane, and
appear slightly depressed below the general surface.
Such an abrasion will in time develop into an ulcer
covered with pus, and presenting a whitish appear-
ance,  depressed  in  the  centre and showing raised
edges.
  From this description it will be seen that a simple
inflammation may develop shallow ulcers which are
catarrhal in their character, and are not necessarily
due exclusively to a specific disease of the general
system, such as syphilis or tuberculosis, as is taught
in most text-books.

                 Therapeutics.

  All remedies employed  for the cure of  affections
of the upper air-passages should act first by protect-
ing the parts  from the influence of the air, and,
secondly, by stimulating the mucous membrane and
its secreting glands to a healthy action.  Among
these  remedies, nitrate  of silver  stands in the first
place  as a stimulant and protecting agent.  In the
latter capacity it acts first by coagulating  the albu-
men contained in the  secretions, and, secondly, by
being partly converted into insoluble salts of silver,
the chloride, albuminate, and mucinate, by combin-
ing with the chloride of sodium, the albumen, and
the mucine of the secretion.  In order to obtain the
stimulating effect of this remedy, it is necessary to
make the solution strong enough to have  a surplus 
THERAPEUTICS.
163
of nitrate of silver, which is  not immediately con-
verted into a chloride, used in the formation of an
albuminate, or mucinate of silver.
  Almost all the astringents, such as sulphate of
copper, sulphate of zinc,  tannic acid,  alum,  and
others,  are  used with advantage, both in  solutions
applied with the brush, sponge, or cotton applicator,
or by means of the  atomizer, and in the form of
powder blown into the larynx by means of the insuf-
flator.   They all act  more or  less as  stimulants to
the mucous membrane.  The vapors of ethereal oils,
such  as are contained in  tar, cubebs, tolu, benzoic
acid, carbolic acid, benzole, etc., inhaled from vapor-
inhalers, are employed for the same purposes.
  Alteratives acting  upon the  secretions of  the
mucous membrane, and  in absorbing swellings, are
given internally to aid the topical applications,  and
are also locally applied.
  Modes of Administering Remedies.—Nitrate of silver
in solution is applied to the ulcers,  abrasions, or
centres  of inflammation, by means of  a soft camel's-
hair brush, mounted on a stiff bent wire, held in  a
mirror-handle,  or  by means  of a small  piece of
sponge or tuft of cotton held in the  sponge-holder
or applicator.  It should never be applied all over
the mucous membrane,  as   is  done by  the  old-
fashioned probang.  Solutions of not less than forty
grains to the ounce should be employed, and  fre-
quently the  strength  can with  advantage  be in-
creased  to sixty, eighty, and even one  hundred  and
twenty grains to the  ounce of water, or water  and
glycerine.   Glycerine alone should never be used as 
164             THERAPEUTICS.
a solvent for the silver salt, as its great affinity for
water leaves the mucous membrane unpleasantly dry,
and causes a severe burning pain in many persons.
  As has already been stated, this drug is a powerful
stimulant to the mucous membrane.   But besides
being this, it acts also as a local anaesthetic and an
astringent, and should therefore be used with great
discretion.   It is beneficial when used in the first
stages  of  an acute inflammation, as,  for  instance,
in tonsillitis, where it allays the pain by its an-
aesthetic action,  contracts the capillaries  by its as-
tringent  action, and protects  the surface of  the
mucous membrane by the formation  of  a film  of
albuminate, mucinate, and chloride of silver.  Its
stimulating action comes into play in the atrophic
conditions of the mucous membrane and its glands.
In the subacute and chronic inflammations attended
with hypertrophic conditions of the glandular and
submucous tissue, nitrate of silver is harmful.
  Solutions of this  salt under no circumstances act
as an escharotic or caustic; that is, they do not de-
vitalize the cells composing  the tissue with which
they come  in contact, which statement can readily
be substantiated by microscopical observations.  The
formation of the flakes of albuminate, mucinate, and
chloride of silver, being mistaken for sloughs, has
given  rise to the misconception that solutions of
nitrate of silver act as a caustic.
  Nitrate  of silver  in  the  solid form  is applicable
only to deep specific ulcerations, and for the corro-
sion  of neoplasms too  small for operative interfer-
ence, or for cauterizing the wound after extraction of
a neoplasm, with a view  to prevent its return.  It is 
THERAPEUTICS.
165
best used by fusing a small  piece to the roughened
end of a bent  silver probe  mounted  in a mirror-
handle.   After use, the lunar caustic coating should
be remelted by holding  the end of the  probe over
the lamp, so as to destroy  all  infectious material
clinging to it.
  Nitrate of silver is also often advantageously used
as an inhalation from the atomizer, either the  steam
or  hand apparatus.   When so used,  the solution
should not be stronger than ten grains to the  ounce
of equal parts of glycerine and water.
  Iodine dissolved in glycerine, locally applied, is an
admirable remedy in the hypertrophic  conditions of
the upper  pharynx  and  nasal cavities, acting as an
alterative and  promoting absorption of the hyper-
trophied tissue.  It is, however, not  applicable  to the
larynx, as it  often  produces violent spasms of the
glottis.
  Iodoform, acting like  iodine as an alterative, has
the advantage of being a local anaesthetic, but  it also
has the great disadvantage of its peculiar, penetrat-
ing and lasting odor, which is very difficult to dis-
guise or  prevent.   I have,  however,  found that
vaniline, in the proportion  of  ten grains to  5j of
iodoform, will to a very great extent, if not entirely,
disguise the odor of the  drug.  It  may be used in
the form of a  fine powder with the insufflator, and
is especially applicable for  dusting the ulcerations
in syphilis and phthisis; or it may be dissolved in
ether and used with the spray, the ether heightening
the anaesthetic  effect of the  drug.
   The other astringents  enumerated maybe applied
in the form of  powder, mixed with sugar of milk in 
166             THERAPEUTICS.

various  proportions, by  means of  the  insufflator.
When so  used, they should  be rubbed down to an
impalpable powder and kept dry.   Large particles
of the remedies, if introduced into the throat, act as
foreign bodies, and  produce  more irritation than is
desirable.   Or they may be  applied in solution  by
the brush, sponge, or atomizer.
  Volatile substances are best used for  inhalation
from the vapor-inhalers.
  The touching of ulcers or abrasions in the cavity
of the larynx or posterior nares is rather a difficult
operation.   It requires considerable practice for its
successful performance, and is to  be  done in the
following  way :
  After the  mirror has  been introduced by one
hand, the  patient himself holding his  tongue with
his fingers, protected by a napkin, and  the image of
the larynx is in full view, the sponge or brush is
introduced with the other hand into the mouth of
the patient, until its point nearly touches the image
of the ulcer or  abrasion in the mirror.  The hand
is then  elevated, thereby carrying the  brush down-
ward, but always  keeping the image of the  ulcer
and that of the sponge or brush in a line until the
desired  spot is reached.  After touching the ulcer
once or twice lightly, the brush or sponge  must be
quickly withdrawn, without coming in contact with
either  the posterior wall of the  pharynx or  the
epiglottis  and tongue.   If a  slight spasm of choking
follows, it is easily counteracted by the patient swal-
lowing a  draught of cold water.
   These local remedies, in the form of powder, may
often with advantage be combined with  each  other, 
THERAPEUTICS.
167
or substances may be added  to them for the pur-
pose of dilution, or to  prevent their being washed
away by the secretions, immediately after they have
been  applied.  So, for instance, may iodoform  be
combined with  morphia and  gum acacia,  with a
view  to lessen pain by the morphia, and to cause
the powder to remain  longer in  contact with  the
surface by the gum acacia, which, forming  a paste
with  the secretions, cannot  easily  be   dislodged.
Solutions used in the spray can also be combined,
and the practitioner must use his judgment in select-
ing the proper combinations.
  Ointments also are frequently of use, especially for
application to erosions on the septum, the posterior
walls of the pharynx, and in the vestibule  of the nose.
Among these, the most useful are the ung. by drag.
flav.,  with morphia, as made by Mr. Llewellyn, of
Philadelphia,  and  largely used by oculists  in  the
treatment of chronic conjunctival inflammations, and
a mixture of oxide of zinc ointment with calomel
(gr. x to §j).
  As caustics for the removal of hypertrophic tissue
or small  neoplasms, and  the touching of  ulcers,
chromic acid, acetic acid, lactic acid, and a solution
of acid nitrate of mercury are used, but, above all,
the galvanic cautery.
  For a local anaesthetic, solutions of cocaine hydro-
chlorate in the strength of from 4 per cent, to 20 per
cent., are employed either by  instillation  with a
dropper  into  the anterior  nasal  chambers, or  by
saturating pledgets of  cotton  and  placing them
against the spot to be  made  insensible, or with  the
atomizer, or,  finally, in the  shape of lozenges, for 
108             THERAPEUTICS.
the purpose of overcoming the pain during degluti-
tion in some of the laryngeal affections.
  Local applications should never be made without
having first thoroughly cleansed the mucous mem-
brane.  This is best  done by an alkaline solution,
thrown  into the cavities by  means of the spray.
An excellent solution for this purpose  is Dobell's
solution, composed of

             rj*.—Sodaa bibor.
                 Sodse bicarb,  aa 3).
                 Acid, carbol.    gr. xxx.
                 Glycerinse,      nSJ-
                 Aquae font.      Oij.—M.

which is not only cleansing, but produces a pleasant
sensation in the nasal and laryngeal cavities.  Within
the last two years I employ instead  a solution com-
posed of the following ingredients :
■Sodii bicarb.	3viiJ-
Sodii bibor.	3viiJ-
Sodii benzoas,	
Sodii salicylas,	aa gr. xx.
Eucalyptol,	
Thymol,	aa gr. x.
Menthol,	gr. v.
01. gaultheria,	gtt. vj.
Glycerine,	§ viijss.
Alcoholis,	gy-
Aquae,	q. s. 16 pints
  This formula gives a solution which is sufficiently
alkaline to dissolve the thickened secretion adhering
to the nasal mucous membrane, and as it is of the
proper density, it is bland and unirritating, leaving
a pleasant feeling in the nose.  At the same time it 
THERAPEUTICS.             169
is  antiseptic and acts as a deodorizer, being in this
respect far superior to Dobell's solution, or any other
non-irritating  deodorizer and antiseptic.   As it  is,
however,  inconvenient  for  many patients to have so
large a quantity of solution on  hand, Mr. Frederick
Brown, one of our Philadelphia druggists, made the
solid ingredients into  a compressed tablet, so that
one, when dissolved in two ounces of water, will
make a solution  identical in  its  effects  with  the
solution  made after the above formula,  and most
patients prefer the tablets to the solution.
   If the  secretions have become  inspissated, as is
frequently the case in the  nasal cavities, the crusts
should first be softened with the alkaline solution,
and  then removed by a copious stream of salt and
water from the anterior nasal douche, or, if still
adherent, should be loosened by instrumental inter-
ference.
   Remedies are also frequently used in the form of
lozenges—that is, they are combined with a fruit
paste, generally currant paste,  which is pressed into
small round or  oval cakes.  These lozenges are to
be slowly dissolved in the mouth, thus impregnating
the saliva with  the medicine.   By swallowing this
saliva, it comes in contact with the posterior wall of
the pharynx and also enters the larynx, acting upon
the mucous membrane.
   Among the  alteratives which taken internally act
more especially upon the mucous membrane  of  the
larynx, pharynx, and  upon  the Schneiderian mem-
brane,  are iodide  of potassium, bromide of potas-
sium, calomel, cubebs in the form of the resin  oil,
or the cold fluid extract, crude  petroleum, and other
                       15 
170             THERAPEUTICS.
substances which  might  be named.  The iodide,
bromide,  and calomel  should be  given in  small
doses; and I have found that a combination of the
former two is preferable, and  can  be borne  much
longer by the patient than either alone.
  Acute  as well  as  chronic inflammations of  the
larynx and naso-pharynx  are greatly influenced by
counter-irritation,  such as  is used  in  deep-seated
inflammations in other parts of the  body.  Among
them may be named external application of iodine,
mustard, croton oil, and fly blisters.  In  some severe
cases, especially of oedema of the glottis and epiglottis,
leeches applied to the  neck are  recommended by
high authorities, and are  often of the greatest ad-
vantage in promptly relieving the  tension of  the
parts, and consequent stenosis of the larynx.
  Inhalations of ether, chloroform, nitrite of  amyl,
and other powerful sedatives are employed in nervous
affections of the larynx.   In chronic tonsillitis local
applications of  tr. iodinii, tr. ferri  chlor., concen-
trated solution  of tannic  acid, and  solid nitrate of
silver are used, but  with  doubtful  results.  Lately
the injection of iodine solution into the substance of
the tonsil has been  recommended, but my experi-
ence shows that very little if anything is gained in
this way.
  Many  other remedial agencies are employed by
a variety of methods  in treating   diseases  of the
throat; they will suggest  themselves to the intelli-
gent observer in special cases. 
ACUTE  LARYNGITIS.
171
               CHAPTER VII.

              ACUTE LARYNGITIS.

  The affections of the throat are  divided into two
distinct classes, which are distinguished by location
and anatomical relation of the parts affected.  Thus
we must consider the diseases of the larynx proper
under one head, while the affections of the pharynx,
anterior nasal cavities, and the naso-pharynx are to
be considered under another.   The different mem-
bers of these two classes, however, intermingle with
each other very frequently, and  it often becomes
difficult to determine to which of the two divisions
an affection belongs.   But this difficulty is purely
theoretical, and does not in the least affect the treat-
ment or prognosis.
  For instance, a chronic laryngitis is almost always
associated with a chronic inflammation of the mucous
membrane of  the pharynx and  naso-pharyngeal
cavity, and only by careful examination into the
history of the affection can we determine whether
to call  it a laryngitis or  a  pharyngitis.   To elude
this difficulty, some authors have adopted compound
names,  such  as  laryngo-pharyngitis, or  pharyngo-
laryngitis; but  these appellations have  not  been
generally accepted, and  I shall therefore not use
them in this volune.
  By far  the  most common of all throat diseases
which come under our notice is the acute laryngitis 
172
ACUTE LARYNGITIS.
so frequently occurring in childhood and early adult
life.   It consists in a more or less extended inflam-
mation of the mucous membrane lining  the larynx,
attended by  heat, pain, and swelling, and by general
febrile symptoms, such as acceleration of the pulse,
increase of bodily temperature, dryness of the  skin,
loss of appetite, etc.
   Varieties.—Two varieties of this affection are rec-
ognized, which differ from each other  more in the
severity  of  the  symptoms than  in the causation.
These are the  ordinary  mild acute  laryngitis," and
the  grave acute  laryngitis,  sometimes  called  cede-
matous  laryngitis,  because  oedema is  a frequent
complication.
   Cause.—This affection may be of traumatic origin,
or may be purely idiopathic.
   If traumatic, it may be caused by the  presence  of
a foreign body in the larynx, such as a fish-bone, pin,
button, etc., swallowed, or rather inhaled accident-
tally, or by  the swallowing  of corrosive substances
accidentally, or with  suicidal intent,1 or by  the in-
halation of  acrid vapors or dust.  If idiopathic, it is
caused by a sudden  chilling of the mucous mem-
brane, or  is dependent  upon and a symptom  of a
general  disorder of  the  system, such  as scarlatina,
measles, diphtheria, etc., or, finally, it may be caused
by external  injuries to the neck.

  1 Primary acute  laryngitis is, however, but rarely the result of
intentionally swallowing corrosive substances, because the suicide
expects to be burned by the liquid, and swallows it quickly; while
the person swallowing a corrosive  substance accidentally is surprised
or startled, and takes an inspiration, thus introducing some of the fluid
into the larynx, 
SYMPTOMS.
173
  Symptoms.—In  traumatic  acute  laryngitis,  the
symptoms  show themselves  immediately after the
introduction of the irritating substance, and last for
some time after the removal of the  foreign body, if
such be the cause, or, in the case of corrosive sub-
stances having been swallowed, until the destruction
of tissue has been arrested, and the process of repair
is completed.
  In idiopathic acute laryngitis, on the other hand,
the symptoms are  not  developed until some time
after the exciting cause has made its impression.
  The symptoms in both varieties of the disease are
pain about the  throat,  a feeling  of  constriction,
hoarseness  sometimes amounting to aphonia, diffi-
cult and painful deglutition,  dry  and hard metallic
cough.  Respiration is, however, not usually affected.
Later on the cough becomes loose and expectoration
appears, which is at first of a yellowish-green color
and very thick, becoming gradually more limpid
and lighter in color.   On laryngoscopic examination
we  find  the mucous membrane of a uniform intense
red, and somewhat swollen.   The pillars and tonsils,
as well as the uvula  and soft palate, participate in
the general hyperaemia.
  The epiglottis is generally erect  and thickened,
and the ventricular bands are so swollen as some-
times to obscure the view of the vocal cords.
  The vocal cords are reddened, but are generally of
a lighter color than  the mucous membrane in their
vicinity, so that they can be distinguished  from the
ventricular bands.   The arytenoid cartilages are red
and swollen, and appear like  balls.
  In the graver and more rare form of acute laryn-
                       15* 
174
ACUTE LARYNGITIS.
gitis these symptoms appear very  rapidly, and the
swelling of the mucous membrane becomes so great
by  oedematous  infiltration, especially  on the  epi-
glottis, ventricular bands, or walls  of the  sub-glottic
cavity, as to interfere with respiration, and give rise
to very  grave  symptoms  of asphyxia,  which  may
result in death if not speedily removed.
  Duration.—The duration of idiopathic  acute laryn-
gitis is  usually a week  or ten  days from the first
appearance of the symptoms to perfect restoration
of health in  the  parts, but it may frequently be cut
short by active treatment, or may extend over  two
weeks in debilitated subjects.  The  duration of trau-
matic acute  laryngitis cannot  be determined, as it
depends upon the extent and severity of the injury
received.
  Treatment.—The ordinary  slight form  of  acute
laryngitis without the complication of oedema readily
yields to the  topical application  of astringents  by
means of the atomizer.  Of these, a ten-grain solution
of alum, to which is added a drop of the dilute carbolic
acid, is perhaps the most satisfactory in  its results.
  Hot vapor inhalations of tincture of benzoin or
balsam of tolu afford relief by loosening the cough.
  Internally, saline purgatives, and a combination of
iron, chlorate of  potassa, and bromide of potassium,
should be given.    This  latter I am in  the habit of
prescribing in a form such as this:
               R .—Tr. ferri chlor.  fl 3 ij.
                   Potass, chlor.     gij.
                   Potass, brom.    3'ij-
                   Ext. glycyrrh.    3J.
                   Aquae dest. q. s. fl^vj.
  Sig. A dessertspoonful in water every 3 or 4 hours.  Gargle and
swallow. 
TREATMENT.
175
Or in the form of lozenges, which are more easily
taken by children, and are fully as effective, if not
more so than the liquid mixture.   The following is
the formula:
          ft .—Potass, chlor.
             Potass, bromid.
             Pulv. ext. glvcyrrhizae, aa gr. iij.
             Tinct. ferri chlor.       TTL U-
             Sugar, etc., q. s. to make one lozenge.

   It has the effect of allaying the irritability of the
mucous membrane, and especially of reducing the
swelling of the palate and epiglottis, thus diminish-
ing the dysphagia,
   Counter-irritation, by means of iodine or mustard
applied to the skin over the larynx, should always
be resorted to,  and very often alone leads to a speedy
termination of the affection.  The application of cold
to the neck by  means of an ice bag or a soft rubber
tube wound loosely around the neck three  or four
times, through  which ice water is caused to flow, aids
materially in reducing  the inflammation and gives
great comfort to the patient.  Cloths dipped in ice
water are, however, not to be recommended, as they
keep the  skin  wet, and  must be renewed very fre-
quently to do any good.
   In the graver form, complicated by oedema of the
larynx, or with consequent stenosis and embarrass-
ment of respiration, there is, as a general rule,  no
time to wait for the slow action of saline purgatives,
counter-irritation, leeches  applied  to the neck, or
venesection, to prevent death from suffocation.  A
more speedy and  efficient method of disgorging the
parts of their blood and serous exudation has to be 
176           ACUTE LARYNGITIS.

resorted to.   This consists  in  freely scarifying the
mucous membrane by means of a small  knife-blade

                       Fig 55.
             Tobolt's concealed laryngeal lancet.

attached to  a  curved  handle  and  guided  by the
laryngeal mirror (Fig. 55).   A more detailed  de- 
CEDEMA  OF THE LARYNX.        177
scription of this instrument will  be found further
on.
  By this means the alarming symptoms of suffoca-
tion are arrested, and time is gained for  the action
of astringents, counter-irritation, etc., to effect reso-
lution.  If, however, circumstances will not permit
of this  method being  employed, tracheotomy,  or
intubation, should be at once resorted to, so as to
insure perfect  oxygenation  of  the  blood.  If  left
until everything else has failed, and the toxic effects
of carbonic acid in the blood have progressed too far,
a sudden and even complete oxygenation of the blood
will not restore the normal condition, and the patient
will succumb to the poison, and will be asphyxiated
with his lungs full of fresh air.
   Ulcers are rarely if ever formed in acute idiopathic
laryngitis, while suppuration and the  formation of
abscesses are often met with.  The latter are treated
as if situated on the surface of the body.   In  open-
ing them the knife, which should be a guarded one,
is guided by the laryngeal mirror.
   Should the inflammation be confined to the mucous
membrane of limited parts of the larynx, the affec-
tion  is  designated as epiglottidis if the epiglottis is
the seat of the inflammation, " corditis vocalis'' if the
vocal cords  are affected, and so on.

             (Edema of the Larynx.

   As has already been  mentioned, it happens  some-
times that a serous effusion is thrown  out  into the
submucous tissue of the larynx, thus causing a very
great swelling  of the parts affected.   It  may occur 
178       cedema of the larynx.
independently of any disease of the larynx; or as a
sequel or complication in systemic diseases, such as
smallpox, typhoid  fever, scarlet fever, phthisis, and
syphilis, and rarely in chronic nephritis;  or as a com-
plication of laryngitis, acute or chronic pharyngitis,
acute or chronic tonsillitis, malignant disease of the
tongue, epiglottis,  etc.
  The  effusion, which may be of a bloody, serous, or
purulent nature, is usually found  in  the submucous
tissue of the ary-epiglottic folds, at their inner sur-
face, swelling them and  the ventricular  bands until
they touch  each  other.   Next in  frequency  it  is
observed in the epiglottis, then in the vocal cords
themselves, and rarely  in  the mucous  membrane
lining the subglottic cavity.
  The  symptoms of swelling and stenosis generally
appear  very  rapidly, and if the progress of the
effusion is not  promptly arrested by scarification of
the parts, or the lungs not supplied with fresh air by
an external opening in the trachea, or by the inser-
tion of a tube into the laryngeal opening, according
to O'Dwyer's method, a  fatal issue of the disease
speedily sets in.
  (Edema of the larynx or parts of the larynx occurs
most frequently in middle-aged persons, although it
has been observed in newborn children and  in ex-
treme old age.   Patients suffering from phthisis or
syphilis are more frequently affected; one attack is
often followed by another, so much so that Dr.Fauvel,
of Paris, is in  the habit of supplying patients who
have had one  attack of cedema of the larynx with
tracheotomy instruments, so that  in  case  of  an
emergency they may be at hand.   In  many  cases, 
TREATMENT.
179
however, the swelling does not completely close the
opening of the larynx and trachea, even at the height
of the affection, and  consequently  the  dangerous
symptoms are less marked.   The patient generally
complains of a feeling of oppression, pain, and  ful-
ness of the throat;  and frequently a barking cough
of a peculiar character  is observed—probably  due
to the swollen parts acting like foreign bodies, and
causing the irritation  and excitation to cous:h.   If
the epiglottis or ary-epiglottic folds  are  the seat of
the swelling, extreme dysphagia is often experienced
by the patient.
  On examination with the laryngoscope the mucous
membrane is usually found to be  hyperaemic, and of
a uniform red, which is increased to scarlet or even
purple over  the  swollen parts.  These  are always
more or less pear-shaped, because the serous effusion
gravitates toward the interior of the  larynx, and
bulges the  mucous membrane  more  below  than
above.  If oedema complicates other  throat  affec-
tions, the characteristics of these will be seen beside
the oedematous swellings.
   Treatment.—The treatment must  be  directed to
the speedy absorption or evacuation of the serous
effusion  by  scarification in  severe cases,  as  has
already been described  under the head of acute
laryngitis, and by counter-irritation, bleeding, and
local  astringent applications.  Among the counter-
irritants, mustard-plasters and fly-blisters act more
promptly than iodine  and croton oil when applied
to the neck.   Bleeding should be accomplished by
leeches or cupping, and the general health should
be taken into consideration in regard to the amount 
180        subacute, laryngitis.
of blood to be taken.   The astringents should be in
the form of finely nebulized solutions introduced
into the larynx  by means of  the  atomizer, and
among  them  a  strong solution (fifteen to  twenty
grains to the ounce) of alum acts in most cases with
great promptness in  reducing the  swelling; but
solutions of tannic acid,  chlorate  of potash, iron,
and others may  be used in the same manner with
very good results.  Nitrate of silver or other caustic
applications should not be used, as the spasm  follow-
ing their introduction into the larynx, which under
ordinary circumstances is very slight when only a
small ulcer or abrasion is to be touched, becomes
severe when a larger surface has to  be brushed over.
The blood already not being  fully  aerated  because
of the obstruction  to  respiration,  if suddenly de-
prived of a fresh supply of oxygen,  even for a few
seconds  only,  becomes surcharged  with  carbonic
acid.  A reaction is prevented, and  the patient is
asphyxiated.
              Subacute Laryngitis.

  When an acute  inflammation of  the larynx is
subsiding, or when the inflammatory action  of the
mucous membrane has been from the  besrinnino; but
slight, we noticed what is termed a, subacute laryngitis,
which exhibits the following symptoms :
  Symptoms.—The patient  complains  of little or no
pain, slight dysphagia, little cough, more marked in
the mornings, with a yellow tenacious  expectoration,
and slight  hoarseness  of  the  voice.   On  laryngo-
scopic examination the mucous membrane is seen to
be redder than normal, with here and there spots of 
        SIMPLE CHRONIC  LARYNGITIS.     181

a deeper red; the vessels appear injected, and can
be traced for a  considerable distance, especially on
the free margin and glossal surface of the epiglottis.
The pharynx and velum palati are almost always
implicated in the general hyperaemia.
   Treatment.—This stage of inflammation  usually
disappears in a few days under  the treatment which
has been adopted for the acute form, and recovery
is frequently  hastened very much by topical applica-
tions, by means of  the  brush, of solutions of sul-
phate of  copper, sulphate of zinc,  and especially
nitrate of silver, to the brighter spots.
   Diet,—In all cases of acute and subacute inflamma-
tions of the  larynx, and especially when dysphagia
is present, soft food, such as gruels, mush, milk, and
beef-tea, and  cold drinks should  be given.   With
children, iced milk sweetened with a little sugar is
often the only food which can be taken.  When the
difficulty of  swallowing is very great, liquids can
often be taken more easily through a glass tube or
straw, and soft food can be swallowed by the patient
bending the  upper part of the body and the head
forward.
              CHAPTER VIII.

             chronic  laryngitis.

           Simple Chronic Laryngitis.
  In some cases, especially when the system is below
par, and when the acute stage, being very mild, has
not been treated, the acute and  subacute  laryngitis
                       16 
182         CHRONIC LARYNGITIS.
will  pass  into the chronic stage of  inflammation.
In phthisis,  tuberculosis,  cancerous  disease, and
during  the  convalescence  from  continued  fevers,
when the system is so low as not to react by an acute
inflammation, we observe a  subacute  and then
chronic form of the disease.  As  chronic  laryngitis
is due to a variety of causes,  and  as there are slight
differences in the symptoms and laryngoscopic ap-
pearances  of the disease excited by these  causes,
several  forms of  chronic laryngitis must be recog-
nized, and these  will be treated  of under different
heads.
  Symptoms.—The  symptoms  of  simple  chronic
laryngitis  resemble those of the subacute  form of
inflammation  in  many  points.   The patient com-
plains of a sense  of constriction of the throat,  but
of no difficulty of deglutition, a  feeling of dryness
of the mucous membrane, and a dry and hacking
cough, with white stringy expectoration resembling
boiled starch.  The voice is usually hoarse, faltering,
and easily fatigued, while there exists no embarrass-
ment to respiration.  On laryngoscopic examination,
we  find the  mucous membrane  to  be in a state of
hyperaemia with spots of heightened color, the vessels
injected, the glands  enlarged, and  abrasions  fre-
quently in the inter-arytenoid space.
  This  form following  acute laryngitis, and caused
by a want of tone in the system, is  looked upon by
some writers as very rare. Its peculiarity consists in
the fact that true ulcerations are very rarely found,
but that abrasions are frequent.
  Another very  frequent cause  of  simple chronic
laryngitis  is the so-called mouth-breathing, produced 
        SIMPLE  chronic laryngitis.     183

by nasal  obstruction; for it is a  well-established
fact, that  the air  as  it passes through the tortuous
nasal chambers is  raised two degrees in temperature,
is filtered  of its dust, and is saturated with moisture
by the secretion of the serous glands, embedded in
the  nasal  mucous  membrane.  If now, the  nasal
passages are obstructed, no matter from what cause,
this  dry, cold, and dust-laden air directly impinges
upon the mucous membrane of the larynx, and, cou-
tinuall}' irritating it, causes a chronic inflammation.
And, finally, abuse  or the faulty  use of the  voice
both in speaking  and singing is a frequent cause of
simple chronic laryngitis in speakers and singers.
   Treatment.—The treatment to be adopted in this
form of chronic laryngitis should be, first of all, the
removal of the cause  by removal of the nasal ob-
structions, rest of the voice, and then by local treat-
ment directed to  the laryngeal mucous membrane as
well as general tonic treatment.  The local treatment
consists of stimulation of the mucous membrane by
vapor inhalations of tolu, or of tincture of benzoin,
or by astringents in solution introduced by means
of  the  atomizer.   The   most  important  feature,
however,  is the topical application of a forty to sixty
grain solution of nitrate of silver  to  the  abrasions.
These applications should be made to the sores only
after the secretion has been washed off by an  alkaline
antiseptic solution thrown into the larynx  with an
atomizer, by means  of a piece of sponge held in the
sponge-holder, or better  with the brush, and should
be repeated every other day if possible, so as to keep
the raw surfaces  covered, and allow the new cells to
form under the artificial  scab. 
184         CHRONIC LARYNGITIS.
  The application should  not be made  with the
cotton-applicator, as there is danger of  a  small
thread becoming detached and giving rise to irrita-
tion and consequent often distressing cough.  After
the abrasions have healed the silver solution should
be  discontinued, and  in  its  stead  an  astringent
powder should  be thrown  into the larynx with the
insufflator.  For this purpose, sulphate of zinc and
sugar of milk in equal parts, with the addition of a
little gum arabic powder, will  be found the most
serviceable application.  The  powder should, how-
ever, be very fine, and care should be taken  not to
blow any lumps into the  larynx.
  In this form of laryngeal  disease, lozenges are
frequently the  best form in which to exhibit such
remedies  as are intended to act both locally and by
absorption, for  it has been proved beyond a  doubt,
that a portion of the saliva, as well as the secretion
from the mucous  membrane of the pharynx, finds
its  way  into the  larynx, and  especially  comes in
contact with the mucous  membrane covering the
inter-arytenoid  space.  Therefore, if we impregnate
the saliva with  some mild  astringent substance, we
will obtain a direct local action  upon the laryngeal
mucous membrane, which, being long continued by
the slowly dissolving lozenge, is  very beneficial.
  The persistent and often spasmodic cough being
the most distressing symptom, we must direct our
attention to its  alleviation.  This laryngeal cough is
always due to  irritation  of the laryngeal mucous
membrane, and especially of the mucous membrane
lining  the inter-arytenoid space, and not to conges-
tion of the bronchial or tracheal mucous membrane, 
        SIMPLE CHRONIC LARYNGITIS.     185

Expectorants  and  cough  mixtures will,  therefore,
not be as serviceable as topical applications.  The
laryngeal irritation, however, often  produces what
might be termed a reflex  irritation, lower down in
the respiratory tract, and, if such be the case, anodyne
expectorants will be found  of great service.  Under
no  circumstances, however, should  syrups be use'd,
as they invariably derange  the digestive system, and
thereby interfere with proper nutrition of the system
at large. The following formula I found very service-
able in allaying this  most distressing  symptom of
chronic laryngitis:
         R.—Potass, bromide,       ^ss.
            Potass, cyanide,        gr. iij.
            Ext. prun. virg.       n^ss-
            Ext. grindelia robusta,  fl^iij.
            Mucil. acacise,
            , Aquae dest.     aaq. s. flgiv.—M. Ft. S.
  Sig.  Teaspoonful in water 4 times a day.

   Tonics, and  especially iron, are of great  service in
building up the system, thus aiding in the  restora-
tion  of  health to the  mucous membrane  of the
larynx.   A faradic   current of electricity  applied
externally, the poles  being placed one on either side
of  the neck, acts as  a  local tonic, and is of great
benefit.
   Mild  alcoholic stimulants are also indicated in
many cases, and particularly the heavier still wines,
such as Burgundy, Sherry, and, above all, the Hun-
garian  wines—Buday  and  Tokay.  These  latter
wines, when pure, possess intoxicating  qualities in
but a slight degree, in spite of the  fact  that  they
contain a considerable amount of alcohol;  and it has
                        16* 
186
CHRONIC LARYNGITIS.
been the experience of the author that a moderate
quantity of them taken as a tonic does not affect the
head.  Mr.  Lorenz  Reich, of New York,  imports
these wines for medicinal  use only, and it is owing
to him that this admirable tonic is obtainable in this
country in its original  purity.  The Tokay should
be given in  doses of a  sherry glassful  three or four
times a day, and Buday is best taken at meal times,
a wineglassful at a time.
  As a summer resort for such cases, the sea-shore
should be avoided, as the dampness of the atmos-
phere is very apt to increase the swelling of the
mucous membrane;  in  fact, we can observe always
an increase  in the  symptoms during easterly winds,
even when the patient remains in the house.  Plenty
of fresh air, and especially mountain air, on the other
hand, is  of the greatest benefit, and  will, together
with good nourishing food, often  alone be sufficient
to remove all trouble in the throat.
  Another very frequent form of  chronic laryngitis
is the so-called  clergyman's  sore  throat, or  the
laryngitis of singers and speakers.  In its symptoms
it is  identical with the  ordinary  simple  chronic
laryngitis, but its causation is  widely different.
   Cause.—Its cause lies in a faulty use of the voice,
or in abuse of it;  but in order to comprehend how
such  a factor can produce such results we must look
into the mechanism of  the production of the voice.1
   We found that  the voice is divided into what are
called registers, which divisions  are produced  by
alterations  in the vocal cords themselves,  so  as  to

  1 See "Voice in Singing," by E. Seiler; J. B. Lippincott & Co., 1875. 
        clergyman's sore throat.      187

relieve the pressure brought to bear upon them, both
by the muscular contraction stretching them, and by
the force of the  current of air from the  lungs.  If
we examine a larynx in the act of phonation, and
ask the patient to  raise the pitch of his voice  until
one of the  limits of the register is reached, we will
see a slight redness or congestion of the cords if the
same position and  tension of the cords are persisted
in, and if the same amount of vibrating surface is
exposed to the air-current.  This congestion of the
cords becomes more and more extended the higher
the patient sings with the same register mechanism.
The cords are thereby much more tightly stretched,
and by the influx of blood are made heavier, requir-
ing a greater amount of air force to set  them into
vibrations.   As soon, however, as the unnatural and
excessive tension is removed, the congestion disap-
pears, and  the cords resume their pearl-white color.
If this transgression  of the natural limits of the
registers  is  frequently repeated, the congestion of
the cords does not  disappear, but  becomes  chronic,
and spreads to the  neighboring  mucous membrane,
while the undue force of the air-current,  striking
the parts above when in their peculiar  positions for
articulation, produces an irritation  and congestion
of the pharyngeal  mucous membrane.
  Men speak in  the two chest-registers, constantly
using either, the upper or lower according to the
requirements of  proper  intonation.   Women speak
in the falsetto, but laugh and  scream in the  head
register.  Public speakers, in order  to make them-
selves heard in a large hall, often strain their voices,
that is, they force  an extra amount of air  through 
188         CHRONIC  LARYNGITIS.

the rima glottidis, and in doing so contract the large
muscles of the neck—the sterno-cleido-mastoid, the
sterno-thyroid, and thyrohyoid.
  The contraction of these muscles fixes the larynx,
and prevents its participation in the vibration of the
column  of air above and below it, and also interferes
with the free action of the muscles of the larynx
proper.   This gives rise  to an extra expenditure of
muscular force,  and a  constant feeling of fatigue
after a few minutes of speaking or reading aloud.
  The unnatural intonation  used  by public speak-
ers, and  especially by  preachers, which consists in
drawing the vocal tone of the vowels over a consid-
erable part of the scale, thereby transgressing the
natural  limits of the registers, adds not only to the
expenditure of muscular force, and  is a consequent
source of  fatigue,  but  also increases  the  already
existing  congestion  of the  cords  and neighboring
mucous membrane.' If then, after such abuse of
the vocal organs  for a time, the preacher or public
speaker exposes himself  to sudden  changes of  tem-
perature, the congestion is very apt  to  turn  into
inflammation, which speedily becomes chronic, and
the patient attributes his affection  to this exposure
after use of the voice.
  Treatment.—The treatment as  regards remedial
agents is the same as in ordinary chronic  laryngitis
and pharyngitis,  and will  effect a cure of the dis-
order provided the  patient does not  use his voice
more  than absolutely necessary for ordinary conver-
sation.   As soon, however, as he resumes his work
as preacher or lecturer, the symptoms return speedily,
and in a short time  his throat  feels as sore as  ever. 
         clergymen's  sore  throat.      189

We  must, therefore, in  treating such  cases,  add
another factor to  our treatment, viz., training  and
cultivation of the voice in speaking.
  In  order  to  do  this,  the  patient must first be
taught to  sing up and down the scale, so as to learn
to recognize  the limits of the  natural registers,  and
learn not  to transgress them in singing or in speak-
ing.   He  then must be taught  to  pronounce  the
sounds  of articulate  speech with the proper posi-
tion  of the organs, the larynx, soft palate, lips,  and
tongue, using as little breath  as possible.   He must
further be instructed not to change the pitch of his
voice on any one syllable, but in order to produce a
rise  and fall in the voice, to  make  the change on
different  syllables—that is, not to draw the vocal
tone over.
  It will  be  found that  the  patient, when he  has
acquired  the natural  way  of speaking, can fill a
larger hall  or church  with less exertion, and  can
speak  for any length of time without feeling
fatigued,  except from  his mental  effort and from
standing  for an hour or so.  A more definite de-
scription of this portion of the treatment cannot be
given, because every case requires a careful study of
its own peculiarities, which suggest different expe-
dients to attain the desired result, to be chosen with
regard to  the mental capacity of the patient, and to
be under  the direction of an intimate knowledge of
the mechanism, both of the production of the voice
alone and of articulation.1

  1 See " Voice in Speaking," by E. Seiler.  J. B. Lippincott & Co.,
1875. 
190        LARYNGITIS PHTHISICA.

  The practice should be repeated as often  as possi-
ble, and  should  not be extended over a period of
more  than fifteen minutes at one time in order not
to fatigue the patient.

             Laryngitis Phthisica.

  Another form of chronic  laryngitis  is found in
phthisis  and  tuberculosis, and as it presents  some
peculiarities it may be considered under a separate
head.
  Symptoms.—In laryngitis  phthisica or tubercular
laryngitis we find that the respiration is always more
or less  hurried, and becomes embarrassed in the
later  stages.  The patient complains principally of
a dry,  hacking, and  painful cough, which   later
becomes looser  and  more  frequent,  accompanied
with copious expectoration of greenish or yellowish
phlegm.  Swallowing is difficult in the earlier stages,
and   subsequently  becomes   painful.   Whenever
there is extensive ulceration of the epiglottis or ary-
epiglottic folds, the  pain  in  deglutition is felt as a
sharp, lancinating pain in the ear on that side  most
affected in the larynx.   The  pain is  considered by
some authors as pathognomonic of cancerous disease
of the larynx, but I  have found  it to be very  com-
mon in  cases of tubercular or syphilitic ulcerations,
and it is a source of great suffering to  the  patient.
The voice is always more or less  hoarse and of a
peculiar character,  and  aphonia  usually  sets in
later.  On laryngoscopic examination  we find the
mucous  membrane in a state of hyperaemia, which
culminates in certain places  to form shallow ulcers, 
SYMPTOMS.
191
especially in the inter-arytenoid space.   Frequently
we see also papillomatous excrescences  in the inter-
arytenoid space which give rise to a great deal of
irritation  and  cough.  The color of  the  mucous
membrane of the larynx as well as of  the pharynx
and the velum with its pillars  is of a peculiar ashy-
red, very  difficult to describe, but never to be for-
gotten when once seen (Plate II., Fig. 1).  The epi-
glottis is usually  thickened,  and  often  presents
abrasions or shallow ulcers on its free margin.  The
ventricular bands and the vocal cords are more or
less  swollen and reddened, causing  the peculiar
character of the voice which  we  notice in patients
suffering  from phthisis (Plate I., Fig. 1).
  The most  characteristic peculiarity  of laryngitis
phthisica  is  an abnormal pyriform swelling of the
arytenoid cartilages;  this is frequently seen in the
laryngeal mirror before a physical examination re-
veals  lung  implication.   The  arytenoid cartilages
appear very  large  and rounded at their inner  sur-
faces, tapering  gradually toward  the  side  of the
larynx until the}7 are lost in  the ary-epiglottic fold,
their apices entirely disappearing.  Often  only one
of the cartilages  is  thus tumefied, and it  is then
generally found that the lung on the same side is
affected, while the other lung is still healthy.   Occa-
sionally we find cases in which the reverse is true.
Less  frequently we  find a  iurban-Yike swelling of
the crest of the epiglottis, which at the same time
assumes  a horseshoe  bend.  These two conditions
have been observed to stand in a certain relation to
the disease of the lungs,  so  that in the cases where
we observe the pyriform swelling of the arytenoid 
192        LARYNGITIS PHTHISICA.
cartilages,  the  lung tissue has not as yet begun  to
break down, but as soon as the breaking down takes
place in the lung the epiglottis begins to be affected.
In the literature of the subject  I find that but few
authors make  mention of these facts, while others
either do not refer to them at all or merely hint  at
them by speaking of the phthisical  cedema of the
larynx.
  In the laryngeal mirror  these swellings do not
give to the observer the impression of simple cede-
matous tumefaction,  and free  scarification  of the
parts does  not relieve the symptoms—aphonia and
dysphagia—caused by them.
  Microscopical examination of a number of larynxes
showing these  swellings reveals the fact  that the
loose submucous tissue is largely infiltrated by a
small-celled infiltration, with a tendency to the for-
mation of depots with cheesy centres, and, what is
rather  remarkable, hypertrophy of the  glands and
follicles, so as to amount almost to an adenomatous
growth.  There is  also a certain amount of serous
infiltration  into the network of the submucous tis-
sue, which  only tends to increase the  swelling.
  In the advanced stages of tuberculosis we  find
tubercular  deposits in the mucous membrane of the
larynx, appearing as  numerous  small round eleva-
tions  similar to  the  enlarged  follicles  which we
observe in  follicular pharyngitis.   (Plate I., Fig. 2.)
The  swelling and ulceration of the  epiglottis and
inter-arytenoid  space cause painful deglutition, and,
the irritation   being  transmitted  to the  salivary
glands, an increased flow of saliva is observed.  The
ulceration  in the inter-arytenoid  space,  as well  as 
TREATMENT.
193
on the vocal cords themselves, often  causes painful
phonation, and the patient  frequently complains of
the air inhaled feeling hot, which sensation is due to
the irritating action  of the  air on the raw surfaces.
   Treatment.—The treatment of this throat affection
consists, besides the administration of tonics, cod-
liver oil, and alcoholic stimulants, mainly in reduc-
ing the irritability of the larynx  by painting  the
ulcerated surfaces with strong solutions of nitrate
of silver (60 to  120 grains  to the  ounce), covering
them with iodoform and tannin with the insufflator,
or with a powder compounded as follows :
-Bismuth subnit.	3'j-
Gum acacise,	3jj-
Iodoformis,	3ss.
Morphia sulph.	gr. xx.
Acid. tan.	gr. xxx.
Vaniline,	gr. xv.— M. Ft. Pulv.
spraying the  larynx with a  saturated solution of
iodoform in  ether, etc., and in stimulating vapor-
inhalations.  Lately lactic acid solutions have  been
recommended for the topical treatment of phthisical
ulcerations of the  larynx, but my experience has
shown that they cannot be relied on, and give the
patient so much pain as to be objectionable on that ac-
count. The bromide salts, and especially the bromide
of sodium and ammonium in five- or ten-grain doses
given internally, have a very good effect in loosening
the cough and in reducing the tenacity of the expec-
toration.   In the  later  stages,  when deglutition
becomes so painful  as to interfere  with the proper
nourishment of the  system, a spray  of a 10  per cent.
solution of cocaine thrown  into the  larynx a few
                        17 
194        SYPHILITIC  LARYNGITIS.

minutes before eating, or a lozenge of gelatine con-
taining  one-half grain  of cocaine  dissolved in the
mouth, will in many cases enable the patient to eat
an adequate amount of food, which otherwise would
be impossible.  Moderate daily exercise in the open
air is, of course, essential in staying the progress of
the disease of the  larynx as well  as of the lungs.
Inasmuch as the laryngeal symptoms are dependent
upon the lung affection, the  prognosis is, of course,
very unfavorable,  but  by  proper treatment  the
patient  can be made  very  comfortable as regards
the laryngeal implication.

             Syphilitic Laryngitis.

   Secondary  and tertiary syphilis  show themselves
very frequently in the mucous membrane of the
larynx,  pharynx, and mouth, and  are one of the
most common causes of chronic laryngitis.
   Symptoms.—The  afflicted patient usually complains
of a slight hacking cough, hoarseness, and  some-
times of difficult and painful deglutition.   On laryn-
goscopic  examination,  the  mucous  membrane  is
found to  be  hyperaemic and swollen, with patches
of a  brick-red  color,  symmetrical in shape and
distribution on both sides of the larynx.   (Plate L,
Fig. 3.)  Two kinds  of ulcerations are  noticed in
syphilitic laryngitis, the shallow and the deep.   The
shallow ulcer, which usually appears very suddenly,
is surrounded  by  an  areola of deep-red  color, has
slightly raised edges, and is colored by a yellowish
creamy pus, which, however, is not very  tenacious,
and is  easily washed away by a  spray, exposing  a 
SYMPTOMS.
195
raw  but seldom  bleeding surface.   It may be of
almost any  shape,  but is  most commonly oval in
outline.  The deep  ulcer, on the other hand, appears
slowly and  gradually, and is  not  surrounded by a
distinct areola.   Its  edges  are raised and often
ragged, and its surface is covered  by a thick, tena-
cious pus, which cannot be easily washed away.  It
is usually of a rounded outline, and contiguous sores
have a tendency to  run together so as to form large
ulcers of an irregular outline.  The deep ulcer has
also  a tendency to  invade the deeper-seated struc-
tures, thereby producing the great  loss  of tissue we
so frequently meet  with in syphilitic disease of the
upper air-passages.   When the epiglottis is the  seat
of the deep ulcer  its  edge usually appears ragged,
with points projecting  from the surt';Ke.   This pecu-
liarity may  be explained by the fact that the glands
which perforate  the cartilage are  destroyed by the
ulcerative process  before the cartilage itself is at-
tacked, thus leaving  the partitions to stand  out
above the surface of the ulcer.  The shallow ulcers
are the result of mucous patches, while  the  deep
ulcers result from the breaking down  of gummata
in the mucous membrane.
  The one great peculiarity of syphilitic ulcerations
in the  upper air-passages,  and  especially  in  the
larynx, is their symmetrical distribution.  Thus we
find ulcerations of similar shape in the same position
on either side of the larynx, occupying,  for instance,
the middle of each  ventricular band, or, if we see an
ulcer on one side only, we notice a focus of inflam-
mation  of similar  shape  in a like position on the
other side,  and what is true  in  regard  to  the  sym- 
196        SYPHILITIC laryngitis.
metry of ulceration is also true of the distribution of
foci of inflammation.  Syphilomata are rarely seen
in the larynx, while  neoplasms of both benign and
malignant nature are  frequently met with in patients
afflicted with syphilitic laryngitis.
  The pharynx and  soft palate  always participate
more or less in  the  general  specific inflammation,
and  form a diagnostic  sign  warning the laryngo-
scopist  not to  use the  instruments  generally  em-
ployed, but to use a mirror marked in some way as
reserved for  specific  cases.  This caution is of the
greatest importance in private practice, as well as in
dispensary or hospital work, for practical experience
has  proved  that  the disease  in  certain stages  is
readily communicated from one  patient to  another
by infectious  material clinging to the instruments,
even after supposed thorough cleansing.
  Signs of  specific disease, which hardly ever fail,
are two brick-red, narrow' bands of inflammation
running  along the  edge of the velum palati and
stopping short equidistant from the root  of  the
uvula, and a symmetrical distribution, in size, shape,
and  position, of brick-red  patches of inflammation
in the oral cavity (Plate II., Fig. 4).
   Treatment.—The treatment of syphilitic laryngitis
must consist in constitutional treatment with iodides
and mercury, tonics, cod-liver oil, fresh air, etc., as is
laid down in the text-books for any case of syphilis,
and of appropriate local treatment.  Some authors
contend that the  constitutional treatment alone is
sufficient to arrest the progress of the  ulceration and
cure the inflammation,  and  that  local  applications
are not only unnecessary but often give rise to great 
TREATMENT.
197
inconvenience to the patient.   My experience has
been,  however, that local applications  not  only
hasten the cure and add to the comfort of the suf-
ferer, but also in a great measure prevent the exten-
sive destruction of  tissue, and  the subsequent,  often
disastrous, cicatricial contraction and  deformity.  I
therefore look upon topical treatment as essential in
these cases.
  The shallow ulcers, the result of mucous patches,
should be touched with solid nitrate of silver melted
on the end of a silver probe, as described in Chap-
ter  IV., and, as a rule, will readily disappear under
this treatment.   Before  touching  them  the pus
should be removed from their  surface with a spray,
and, if necessary, with a sponge or brush moistened
with  an alkaline solution containing carbolic acid
or other antiseptics, so  as  to expose a clean surface
to the action  of the caustic.   It is well, especially
for  the beginner who is not sufficiently dexterous to
prevent the silver from coming in contact with the
non-ulcerated mucous membrane, to follow the appli-
cation with a spray of a strong solution of salt, in
order to convert the surplus of the nitrate into the
inert chloride of silver.
  The  nitrate of  silver is, however, not sufficient
when we have to  deal with deep  ulcerations, and
stronger caustics must be used to check their  prog-
ress.  Among the extended list of caustics, the most
satisfactory in my experience are the galvano-cautery
and a solution of the  acid nitrate  of mercury (one
part to five of water), applied  to the cleansed ulcer-
ated surface.  The galvano-cautery is to  be used as
a first application, making an eschar over the whole
                        17* 
198        syphilitic laryngitis.

surface of the ulcer, and when this has been thrown
off, the acid nitrate of mercury  solution  is to be
applied with a sponge.   After a time, when the pro-
cess of repair is beginning to set in, this application
becomes  painful, and should  then be omitted, and
the ulcerated surface should be dusted over with a
powder composed of iodoform gr. xxx, tannin gr. x,
and pulv. amyli gr. xx.  Under  such treatment I
have seen extensive syphilitic ulcerations heal with
little or no cicatricial contraction resulting.
  Nitric  acid, hydrochloric acid, chromic  acid, and
other  caustics have all been  recommended as appli-
cations to  syphilitic ulcerations in the throat, but
their  action not being  under perfect control, they
cannot with safety be used; besides, they invariably
give a great deal of pain to the patient.
  It sometimes  occurs that the perichondrium be-
coming affected, is detached from the  cartilage, thus
causing necrosis.  If this occurs  in  the  arytenoid
cartilages, they may become detached, and, by fall-
ing into  the trachea, may give rise  to  dangerous
irritation of the trachea.  They should, therefore, be
carefully watched, and  removed with the laryngeal
forceps before there is any  chance of their becom-
ing detached spontaneously.
  Besides the  topical applications  of caustics, the
inhalation of carbolic acid solution from the atomizer,
and the spraying of the larynx with some anodyne
solution,  when the pain is very great,  are to be
recommended.
  The prognosis regarding the affection of the throat
is  rather favorable  if the destruction of tissue has
not gone too far; and patients in whom one  of the
vocal  cords has been destroyed have been known to 
TREATMENT.
199
regain the  voice.  In  such cases the  ventricular
band of the same  side takes upon itself the action
of the lost vocal  cord, and  meets the cord on  the
opposite side to form the rima glottidis and produce
a vocal sound.
  There are also cases on record in which the greater
part of the epiglottis has been eaten away by specific
ulceration, and in which, after the ulcerated edge
had healed,  no difficulty  of any account was  ex-
perienced by the patient in deglutition.
  Deep ulcerations of the larynx are also  seen in
the rarer diseases of lupus, elephantiasis, carcinoma,
and perichondritis, and it  is often very difficult to
make  a differential  diagnosis, especially in lupus,
between  these  affections and syphilis.   Lupus  but
rarely occurs in the larynx primarily, and, if  so, is
soon followed by manifestations of the  disease else-
where.  The ulcerations are not  symmetrical, and
the color  of the  mucous membrane  is not of  the
brick-red hue seen in syphilis.  The treatment is  the
same as  recommended  for  lupoid ulcerations else-
where.  Elephantiasis of the larynx is so extremely
rare in this country at least, that  but very few cases
have been recorded.  The only case I  have seen is a
specimen in the possession of my friend Dr. Beecher,
of Philadelphia, who kindly loaned  it to  me  for
examination.  This disease never shows  itself pri-
marily in the larynx, and is  only seen  as a secondary
manifestation when  other  parts  of the  body have
been affected.
  Carcinomatous  ulceration due  to  the breaking
down of cancerous infiltration  of the tissues of  the
larynx, may readily be diagnosed  by the aid of  the 
200   TRAUMATIC  CHRONIC LARYNGITIS.

microscope.   Perichondritis, as a rule, is secondary
to ulceration  or  inflammation  due to any  of the
above diseases, and  but rarely occurs idiopathically.

         Traumatic Chronic Laryngitis.

  The inhalation of acrid vapors or dust incidental
to many occupations, as well as the  accidental in-
troduction into the larynx of foreign bodies which
remain there for some time, will produce a chronic
laryngitis, which, on account of the causes being
purely external, may be  termed  traumatic chronic
laryngitis.
  Symptoms.—When acrid vapors or dust are the
exciting  cause, the  patient complains of a burning
sensation, together  with  great dryness  and fulness
of the larynx, which' cause him  to  clear his throat
continually.   A  slight  hacking cough  i3  usually
present.  The expectoration, which is very scanty,
and resembles cooked starch in consistence, is either
grayish-white or stained  with dust, and is apt to fly
out of the  mouth  with  considerable  force  in the
shape of small pellicles  when the throat is cleared.
Where foreign bodies embedded in the tissue of the
larynx cause the affection, the sensation is that of a
localized pain increased  in the act of swallowing,
together with a feeling of dryness and fulness of the
throat,
  On laryngoscopic examination we find the appear-
ances noticeable in  simple chronic laryngitis.
   Treatment.—The  treatment must,  of course,  be
directed  toward removing the cause of the trouble
by  extracting the foreign  body if  one be present, 
stenosis  of the  larynx.      201
or by advising the patient to change his occupation,
or, if that be not possible, by telling him to breathe
through a moist sponge or respirator while working
in an atmosphere filled  with dust.   If the vapors of
acids be the cause, the sponge should  be frequently
moistened with  lime-water or a strong solution  of
sodium carbonate.
   As in the other forms of chronic  laryngitis, exer-
cise  in the fresh air,  good nourishing  food, and
topical application of nitrate of silver or astringents
to the abrasions, as well as stimulating inhalations,
should be employed  to counteract the effects of the
irritating causes of the  affection, and  to restore the
mucous membrane to its normal condition.
   As a preventive against acute as well as chronic
laryngitis, the patient should be advised  to bathe
the throat  morning  and evening with cold water or
cold salt  and water, and not to wrap shawls and furs
around the neck when going out into  the open air.
Nothing  more predisposes persons to  throat affec-
tions than this habit  of  keeping the neck warm.  It
interferes with the exhalation of the skin, and  makes
it tender.
            Stenosis of the Larynx.

   Stenosis of the larynx, or obstruction to the free
ingress  and egress  of  air through the larynx, is
either temporary or permanent; that is, it may either
be relieved by the curative power of nature, aided
by internal or topical medication, or requires surgical
interference for its cure.
  Temporary stenosis is caused by swellings  in the
larynx of an inflammatory character, such  as ab- 
. 202  FUNCTIONAL DISORDERS OF LARYNX.

 scesses, or by serous, mucoid, or bloody effusion  in
 the submucous cellular tissue, such as cedema, which
 has already been considered.  Permanent stenosis is
 produced by foreign bodies lodged in the larynx,  by
 neoplasms, and by cicatricial contraction  and  adhe-
 sions following ulceration.
   The treatment must consist in the removal of the
 foreign bodies or neoplasms, as described further
 on, while the cicatricial adhesions must be severed,
 if possible, with the galvano-cautery knife.  It fre-
 quently happens that the vocal cords become agglu-
 tinated by the healing of linear  ulcers, or  after
 thyrotomy, thus producing stenosis of  the glottis.
 They must then be cut apart, and kept so by constant
 motion during the healing process.  If this is not
 possible, or if the  stenosis  exists in the subglottic
 cavity, dilatation with steel bougies must be resorted
 to.  In all cases of stenosis, if the cause cannot  be
 removed at once, tracheotomy should be performed
 as soon as possible to prevent carbonic  acid poison-
 ing of the blood.
               CHAPTER  IX.

  FUNCTIONAL DISORDERS  OF  THE  LARYNX.

  Having described the symptoms and treatment of
inflammation of the mucous membrane lining the
laryngeal  cavity,  we can  now  proceed to  consider
the functional disorders of  the larynx either as the 
APHONIA.
203
result of inflammatory processes or those indepen-
dent of such causes.

                     Aphonia.

  The most common  of these functional  affections
is aphonia or loss  of voice.  It  is due in the first
place to an inability of the vocal  cords  to  vibrate
with sufficient rapidity to produce sonorous vibra-
tions of the air, or  to an inability of the vocal cords
to vibrate in harmony with each  other, thus produc-
ing  an  irregular motion  of the air.   In the first
instance total loss of voice will be the result, in the
latter hoarseness of  the voice to a greater or less
degree will be observed.
  Causes.—This inability of the vocal cords to vibrate*
may be due to several causes:
  1. To thickening or swelling of the  cords in acute
and chronic inflammations, and in cedema  of the
glottis, making them so heavy and inelastic that the
current of air from the lungs cannot move them.
  2. To the destruction of part or the whole of one
or both vocal cords by corrosive  agents accidentally
introduced, or by extensive ulceration, the result  of
syphilis, cancer, or other ulcerative process.
  3. To cicatrization of  the  cords  following the
operation  for the removal  of  neoplasms, or the un-
successful  attempt at cutting the throat, or following
the  healing of linear  ulcers, thus gluing  the cords
together.
  4. To paralysis  of the muscles of vocalization,
either on  one side only or  on both sides, thus pre-
venting the narrowing of the  glottis to a slit,  or
causing  a  relaxation  of  the cords when  approxi- 
 204  FUNCTIONAL  DISORDERS OF LARYNX.

 mated, so that the vibrations are too slow  to be
 appreciated by the ear as a continuous sound.
   5.  To the presence of a neoplasm or foreign body
 which  mechanically interferes with  the sonorous
 vibrations of the cords.
   Hoarseness or partial aphonia, being due to the
 same causes exerting their influence in a less degree,
 may be considered together with total loss of voice.
   The aphonia which is caused by swelling of the
 cords due to inflammatory infiltration, hyperplasia,
 and cedema, the cords becoming so thick and heavy
 that they cannot vibrate with  sufficient rapidity to
 produce an audible sound, together  with its treat-
 ment and duration,  has already been  considered
 under the head of acute and chronic  laryngitis.  In
 the same wray has destruction of one  or both cords
 been  mentioned  under the head of syphilitic laryn-
 gitis.
   The third cause of aphonia,  the cicatrization fol-
 lowing  operations, wounds,  or ulcers, and  gluing
 the edges of the  cords together, has been  hinted at
 under the head of stenosis, but is of sufficient im-
 portance to deserve a more detailed description.

     Aphonia due to Cicatricial Adhesion.

  In case of linear ulcers lying along the free  edge
 of the vocal cords, especially  toward the anterior
 part,  cicatricial  tissue is formed  by  the  healing of
 the sores,  which is very apt to connect the edges of
 the cords  at  their insertion into the thyroid carti-
lage.  This cicatrization, moving from before back-
ward  with the  healing  of the ulcers, produces a 
APHONIA  DUE TO CICATRICIAL ADHESION. 205

gluing together of the cords in the same direction.
By the contraction of the newly  formed tissue the
edges are drawn together until the end of the ulcer
is reached, thus virtually shortening the vocal cords
and glottis until only a small triangular hole is left,
through  which the air rushes inward  and outward
with a whizzing, and often whistling noise,
  Vocalization being painful and the  voice usually
hoarse in cases of long  linear ulcers  of the cords,
the patient desists  from the use of the  voice, and is
advised  to do so  by the medical practitioner who
has not made a laryngoscopic examination.  But this
want of  movement of the vocal cords favors the for-
mation of the cicatricial tissue, and when once a con-
nection between the edges of the cords is established,
it  rapidly travels  backward, making vibration im-
possible, and causing dyspnoea by closing the glottis.
  The same union of the cords takes place after an
unsuccessful  suicidal attempt to cut  the throat, in
which an incision  in a transverse direction is  made
in the  angle of  the  thyroid cartilage  at a point
where the  vocal  cords are  inserted, and cuts them
longitudinally or, more frequently, obliquely.   The
large vessels  of the  neck not having been severed,
the wound heals rapidly, and in  doing so connects
the edges of  the cut cords by cicatricial tissue.
  It is curious to note  what a small opening of the
glottis will admit  sufficient air for the wants of the
system, provided it grows smaller gradually.   The
quantity  of air taken in through such a greatly con-
tracted glottis would be altogether insufficient and
death by asphyxia would result if the glottis were
reduced to such a size suddenly.
                        18 
206  FUNCTIONAL  DISORDERS OF LARYNX.

   Treatment.—The treatment in such cases consists
in cutting  through the cicatricial tissue  connecting
the edges of the cords with the laryngeal lancet, or
the galvano-cautery  knife.  After the division  the
edges should be cauterized with solid nitrate of sil-
ver, and  the patient required to use his voice by
talking or  reading aloud, even  though  the voice
should be hoarse and vocalization painful, in order
to prevent  a  reformation of cicatricial tissue and a
reunion of  the free edges of the cords.
  In making the section of the cicatrix the epiglottis
must be held back by  the forceps described above,
so as to obtain a good view of the anterior angle of
the glottis.
  If the opening of the glottis is so small that the
system suffers from want of oxygen, and the throat
of the  patient is irritable  and must be educated  to
bear the introduction  of  the  instruments, so that
immediate  relief of the dj'spncea cannot be obtained
by  division of the cicatrix, tracheotomy or, better,
laryngotomy  should  be resorted  to  without hesita-
tion or delay.   If the latter operation  is decided
upon, it is  often possible  to separate the cords by
section from below, introducing the knife through
the external wound, and cauterizing the cut edges
in the same  way,  so that the laryngotomy wound
can be closed immediately, when the introduction
of a tube becomes  unnecessary. This, of course, to a
very great  extent increases the chances of a speedy
recovery from the  operation.   If, however, the divi-
sion cannot be made from below, the tracheotomy
tube must be introduced and  the wound  allowed  to
heal around it before any  attempts at laryngoscopic 
         APHONIA DUE  TO PARALYSIS.      207

examination or operative interference from above
should be made.
   After the division has been made and the edges of
the cords have healed, the voice frequently remains
hoarse on account of the increased weight and thick-
ness of the vocal cords by reason of  inflammatory
infiltration  and hyperplasia.  In this case a plan of
treatment must be adopted with a view to remove
this obstacle to clear phonation.

            Aphonia  due  to Paralysis.
   The most common  cause of aphonia  is paralysis
of some  of  the muscles moving  the vocal cords and
employed in vocalization.   Several varieties of paral-
ysis of the  cords are observed, such  as  unilateral
paralysis or bilateral paralysis of the cords, paralysis
of the abductors, or  paralysis  of the tensors and
adductor muscles, or  finally hysterical aphonia, in
which  at one  time  one set of muscles  is affected,
while at another  time another set will  refuse to  act.
All of these are classed under the common head of
aphonia due to paralysis.
   Symptoms.—If both  vocal  cords are affected, no
sound  whatever  will  be   heard  when the  patient
attempts to speak,  except the  accidental  friction
sound produced by the exhaled air striking against
the projections in the  cavities above the larynx.
Laryngoscopic examination informs   us  that   the
vocal cords are relaxed and widely separated from
each other, forming the glottis as we see it in quiet
breathing.   In many  cases the  cords are seen to
make an attempt  to approach each other when  the
patient essays  phonation, but instantly fall back into 
208  FUNCTIONAL  DISORDERS  OF LARYNX.
their original position.  This is caused by the sphinc-
ter  glottidis  refusing to act while the crico-thyroid
muscle momentarily stretches the cords.
  In some cases of  bilateral paralysis of  the cords a
faint fluttering noise is perceptible when  the patient
makes an effort to speak.  The laryngoscopic mirror
shows this to be due  to an attempt at closing the
glottis by the sphincter while the cords remain re-
laxed,  not being  stretched  by  the  crico-thyroid
muscle.  In still other cases we notice a momentary
stretching of the cords and a closing of the glottis,
which, however, cannot be kept up  by the affected
muscles, and consequently no sound is produced.
Fto. 5fi.
             Unilateral Paralysis.

  If the  muscles of one side only  are affected, the
cord on the other side is  seen  to move toward the
                 median  line,  and is made tense,
                 while the cord on  the affected side
                 remains relaxed,  and  applied to
                 the  wall of the  larynx (Fig. 56).
                 Here again, as in bilateral paral-
                 ysis,  we may have an  action  of
                 the thyro-arytenoid, together with
                 the  arytenoid muscles, in  mov-
                 ing  the cords together, while the
                 crico-thyroid  on  the affected side
                 fails to  stretch the cord;  thus a
                 peculiar hoarseness of the voice is.
produced, and the rima glottidis presents an opening
of the shape of an Indian bow, the convexity of the
curve being toward the affected side.
Paralysis of left vocal
   cord (Cohen). 
           UNILATERAL PARALYSIS.        209

  If, on the other hand, the paralysis is only partial
in both the sphincter and tensor muscles, the cord on
the affected side moves toward its fellow sufficiently
to be set in vibration ; being, however, not stretched
to the same extent as  the healthy cord, it vibrates
less  rapidly.   This produces an  irregularity of the
air motion, which we perceive as noise or hoarseness
of the voice.  It frequently happens that the patient
is hoarse in one part of his voice only, generally in
the higher notes and not in the lower registers.  This
is due, if no inflammation or thickening of the cord
exists, to the  fact that the affected muscles may be
strong enough to stretch  the cords and keep them
approximated  as long as this  does  not require
much force, as in the lower registers, but they are
unable to perform their function  when greater force
is required.   Thus it will  be seen that upon the
degree of the affection of the muscles  depends the
degree of aphonia due to paralysis.
   Causes.—The  causes of this affection of the vocal
muscles are very diverse, and the prognosis in every
particular case  should  be very guarded until their
true nature  is  fully  established.  Paralysis  of the
cords may be caused by disease of the nerve centres,
or of the branches supplying the nerve force to the
muscles of the larynx;  or it may be due to pressure
upon the recurrent laryngeal branch of the pneumo-
gastric nerve by tumors in the neck, such as goitre,
sarcomatous  infiltration of the thyroid  gland, aneu-
rism of the  larger vessels, etc.  It may also be due
to inflammatory action and  infiltration interfering
with the exercise of the function of the muscles, and,
if of long standing, this may cause atrophy of these
                       18* 
210  FUNCTIONAL DISORDERS OF  LARYNX.

muscles;  or it  may be  one of the  symptoms  of
hysteria, which is, perhaps, the most frequent cause
of aphonia  in women; or, finally, it may be due  to
over-exertion and sudden  failing or giving out of the
contractile force of the  muscle.
   Treatment.—In all cases of loss of voice  a careful
examination of the larynx and  the  neck should be
made in order to determine, if possible, the remote
cause of the trouble, as upon  the nature of this ca*use
depends the tenor of the prognosis.
  If disease of the nerve centres can be diagnosed by
the presence of symptoms other than mere aphonia,
the prognosis, of course, is very unfavorable, and the
treatment should  be directed to this systemic affec-
tion.  If it is found that pressure upon the laryngeal
nerve is the cause of the aphonia, this pressure, if
possible, should be removed by operation. If inflam-
matory action is the cause, the treatment for chronic
inflammations should  at  first  be resorted to, and
then the specific  for local paralysis of the cords,
viz., electricity, should be used, as it should be also
in cases depending upon hysteria or caused by over-
exertion of the voice.  In  the latter case,  however,
a strong solution of nitrate of silver applied to the
cords often has a very beneficial effect by its stimu-
lating action.
  Electricity applied externally acts as a local tonic,
and frequently is very beneficial in allaying an acute
irritation, such  as  is produced by  the application
to the larynx of astringents  in the form of powder,
without interfering with their intended action.  But
in aphonia  dependent upon  paralysis  this mode  of
applying electricity avails nothing, no matter how 
          .UNILATERAL PARALYSIS.        211

long its use may be continued.   To be of benefit,
the current should in such cases go directly through
the affected muscles.  This may be accomplished by
Mackenzie's laryngeal electrode (Fig. 57).
Fig. 57.
  This instrument is composed of a handle of glass,
wood, or hard rubber, into which is screwed an insu-
lated copper wire curved at the end and terminating
in a small platinum  ball.   In order  to prevent the
current from  passing through the  electrode while 
212   FUNCTIONAL DISORDERS  OF LARYNX.

being introduced, the  handle is furnished with an
interrupter, a  lever supported by  a spring which is
in metallic connection by a hinge with the wire at
one end.  The other end is furnished with a handle
of some non-conducting substance, such  as  glass,
bone, or rubber, for the purpose of affording a hold
for the forefinger to depress the lever and keep it in
contact with a metallic  ring surrounding the handles,
to which one of the connecting wires  from  the
battery  is attached. As long as  the lever is  kept
down upon the ring,  the current  is passing, but is
interrupted  as soon as it is lifted by the  supporting
spring when the pressure  is taken off.   The other
pole of  the battery is attached to  an ordinary elec-
trode, and is given to the patient to press against the
neck on one side or the other of the larynx.  But as
this is inconvenient, and the patient in  the act of
gagging frequently breaks the current  by removing
the pole from  the skin, it has been found  more con-
venient  to connect this pole with  a metal  plate,
which is covered with sponge, and  which rests in
contact with the skin upon the outside of  the larynx,
and is secured in that position by a band attached to
the ends of the plate, and passing around the neck
of the patient.  In applying  the  electricity to the
affected  muscles, the plate is placed over the larnyx,
the sponge having first been moistened with salt and
water.  Next  the laryngeal mirror is  introduced
until a good view of the larynx  is obtained.  Then
the electrode is quickly passed down until the plati-
num ball  lies  in the inter-arytenoid space.  While
introducing the electrode the finger must be  kept
off the  lever,  and contact  must not be  made until 
UNILATERAL  PARALYSIS.        213
the parts  to be  faradized  are reached.   In some
cases, as, for instance, when paralysis of the aryte-
noid muscle alone can  be diagnosed, both  poles are
introduced into the larynx.   The instrument made
for this purpose is very similar to the one just de-
scribed.   It has two covered wires instead of one,
which run parallel with each other to within a short
distance of their bulbed ends, when they separate so
as to take the parts  to be excited  between them.
The wires being  flexible, the distance between the
bulbs or balls can  be increased or diminished as the
case may require.  Contact is made  by  the lever
when  the electrode is in position.  Many patients
can endure a comparatively strong current for a con-
siderable length of time, but the instrument should
invariably be withdrawn as  soon as gagging sets in,
for the bulb of the electrode is easily displaced by
the convulsive movements of the  larynx.
  Internally tonics, and especially strychnia, should
be given, for almost always the general  health is
impaired, partly by the cause of the paralysis itself,
and  partly by the mental anxiety caused by the loss
of voice.  In those cases of  singers or public speak-
ers in which hoarseness sets in after a  short use of
the voice, or in which the hoarseness or failing of the
voice is due to the nervous excitement commonly
called  " stage fright," the preparations  of  coca ery-
throxylon, such as wine of coca or the fluid extract,
have  proved to  be valuable voice stimulants when
taken shortly before vocal exercise, and will, in many
cases, prevent " stage fright."  When the aphonia or
hoarseness is due to general debility and inflamma-
tory deposits in  the tissues  of the  muscles, I  have 
214  FUNCTIONAL DISORDERS  OF LARYNX.

found  the following formula to be of great ad-
vantage :
          R.—Hydr. bichlor. corrosiv. gr. J.
             Acid, arsen.          gr. ^.
             Ferr. pyrophosph.     gr. vj.
             Quin. sulph.          gr. xv.—M.
          Div. in pill, No. xxiv.
     Sig. One 3 times a day.

Exercise in the fresh air and pleasant mental  di-
version should be strongly advised. In hysterical
aphonia the salts of bromine should be administered.
  The duration of the disease is very uncertain.  It
varies  with the cause and the  length  of time the
loss of voice has existed  before  treatment was com-
menced.  There are cases in which the  aphonia, due
to loss of contractility of the muscles, comes on sud-
denly, and  is often removed  by one application of
the poles of the battery.   In  most cases not due to
disease of the nerve centres or to pressure upon the
laryngeal nerve, the voice returns  gradually and
slowly, and many  applications  are  necessary to
restore it.   This is especially  the case with aphonia
due to  hysteria, which often requires many months
of patient  treatment before  any  improvement is
noticed.  But,  on  the other hand, the voice in these
cases  often  suddenly reappears,  sometimes perma-
nently, sometimes for a  short time only.  Females
are more frequently affected in this way, but we find
hysterical aphonia also in males. 
     aphonia  due  to foreign  bodies.  215


   aphonia due to the presence  of  foreign
                    Bodies.

  If the aphonia is due to the presence  of a foreign
body, accidentally introduced, it should be removed
at once.  Usually such foreign bodies are pins and
fish-bones, which, with their sharp points, penetrate
the mucous membrane, and are thus held in position
(Plate I., Fig. 6), while  other  substances, such  as
buttons, seeds of various kinds, and small pebbles, if
inhaled into the larynx, are either expelled by a fit
of violent coughing, or fall down into the trachea or
bronchi, whence they cannot be extracted.  Of for-
eign bodies causing aphonia, pins are most frequently
found, especially in women.   The almost  universal
habit of putting pins in their  mouths frequently
leads to the sudden  inhaling of one of them when
the woman is startled.  Fish-bones, usually of small
size, as well as  small splinters of bone, may enter
the  larynx while  eating.   An inspiration   taken
during the act of swallowing may  cause  a part of
the food to enter the larynx, and a fit of  coughing
follows in order to expel  the foreign body. This is
commonly called "food going the wrong way."  If a
bone thus enters the larynx, it is apt to become em-
bedded in the soft tissues of this organ, when actual
contact with the cords or the irritation and swelling
of them cause  aphonia.  The same occurs when a
pin has been inhaled.   Occasionally we find bristles
from a tooth-brush, pieces of straw,  which some
persons are in the habit of chewing, pieces of tooth-
picks, bristles  from the ears of wheat,  egg- and 
216  FUNCTIONAL  DISORDERS OF LARYNX.

oyster-shell splinters, etc., as foreign bodies.  All
these are, however, more commonly arrested before
entering the larynx proper, and are most frequently
found in the glosso-epiglottic folds or grooves, where
by their piercing the mucous membrane they create
an irritation  which  lasts for some time after the
removal  of the foreign body.  It is, therefore, very
common for  persons to apply to a physician for the
removal  of a fish-bone, oyster-shell splinter,  or piece
of egg-shell, which on examination does  not exist,
but which undoubtedly had been there long enough
to cause  an irritation, and had either been removed,
unnoticed by the patient, by coughing or in the act
of swallowing.  Under such circumstances it is often
difficult to convince the patient that there is  nothing
in his throat but  the  irritation left by the foreign
body,  which will  subside in a few days, and  the
practitioner is  sorely  tempted to  practise a little
fraud in order to obtain  the  patient's good  opinion
of his skill.
  For the removal of foreign bodies from the larynx
or fauces, as well as for the extraction of tumors in
these cavities and  in the nasal cavity, numerous in-
struments have been invented, some of which I will
describe here before entering on the subject of neo-
plasms and  their removal.  The  great desideratum
in such  an  instrument is that it should be  a pair of
forceps curved  at  the end, that it should be strong
enough  to  enable the  operator to make  traction
without  its slipping, and that its body should occupy
as little  room as possible.  When the foreign body
is lodged in the fauces or glosso-epiglottic  grooves,
and is not too tightly embedded,  the already de- 
     APHONIA  DUE TO  FOREIGN BODIES.  217

scribed  sponge-holder  or epiglottis forceps answers
admirably, but when the body is lower down or is
tightly  embedded, an  instrument of different  con-
struction must be employed.   The most useful kind
of forceps is Sir Morell Mackenzie's common laryn-
geal forceps, almost exclusively used by him for the
removal of neoplasms  and foreign bodies from the
larynx  (Fig.  58).  It is made of steel, with  stout

                      Fig. 58.
              Mackenzie's laryngeal forceps.

scissors-like handles, is of considerable length, and
bent at right angles, terminating in spoon-shaped
extremities, which  open either laterally or antero-
posteriorly.  In the former, the  pivot  upon which
the blades  move is  at a point between  the  handles
and the  bent extremities, while in the latter it is at
the bend.  It is necessary to have these two forms
of instruments, since foreign bodies and tumors are
frequently  found  in such positions that they can be
grasped only with one or  the other form of  forceps.
  The spoon-shaped blades of the forceps are hol-
lowed out, so that the opposing edges are sharp, and
can  be used for  cutting  off  pieces  of neoplasms
grasped between them.   In another form, which is
                       19 
218  FUNCTIONAL  DISORDERS OF LARYNX.

designed expressly for the removal of foreign bodies,
the blades are solid,  and  the  opposing  surfaces
ribbed, so as to prevent  slipping.   In still another
form, only one of the blades is hollow, with cutting
edges, while the other presents to it  a  smooth sur-
face.
  The  introduction  of these  forceps is somewhat
difficult on account of the sharp bend, and the length
of the extremities, but it has  been found that this
form is  more useful in a greater number of cases
than the curve employed in other instruments de-
signed for the same purpose.
  The French and German laryngoscopists use what
are called " tube-forceps," and  among them  that
designed by Prof. Stoerk, of Vienna, is perhaps the
most useful of all (Fig. 59).  It consists of a univer-

                      Fig. 59.
Stoerk's guillotine and tube-forceps.
sal  handle, into which  a number of different for-
ceps, slings, and cutting instruments can be inserted.
The forceps used in this handle is made of a tube of
metal,  so curved at its extremity that its end can
reach the vocal  cords  without difficulty.  Within
this tube is a thin flexible  steel wire, to the end  of
which two blades  are attached, projecting  beyond
the end  of the tube, and  having ribbed surfaces.
These  blades  are  separated  by a spring concealed 
APHONIA  DUE TO  FOREIGN BODIES.  219
within the tube, and are approximated by retracting
them within the  tube.   This retraction is  effected
by means of a slide  attached to the universal  han-
dle; to this slide the end of the wire carrying the
forceps blades is fastened, while the tube is inserted
into the handle itself.  Sometimes it happens that a
tumor or foreign body is in such a  position that
neither a  laterally  nor  antero-posteriorly opening
forceps can be employed.  For such cases a wire
loop, extending from the extremity of another tube
secured in  the universal  handle, will  be found very
useful.   The loop can be thrown around the tumor
or foreign body, and then, by making traction upon
the  ends of the  wire secured  to  the slide of the
handle, it can be  grasped and removed.

                      Fig. 60.
         Seder's universal tube-forceps and guillotine.

  Foreign  bodies and  neoplasms  are  frequently
situated  in such a position that neither an antero-
posteriorly nor laterally opening forceps will readily
grasp them, and it becomes a very  difficult  matter
to remove the foreign body or neoplasm.   In order
to obviate  this  difficulty,  and to obtain  a forceps
which could  be adapted to every case, I had a for-
ceps made of the following description (Fig. 60): 
220   FUNCTIONAL DISORDERS  OF LARYNX.

A piece of stiff tube, about three  inches in length,
is attached, by means of a bayonet-joint, to a wooden
handle shaped like the butt of a pistol.   To the end
of the tube is  attached a close spiral of steel wire,
also about three inches  long, terminating in a bell-
like end-piece.   Within this partially flexible tube
slides a stout copper wire, to one  end of which are
attached the blades of  the forceps, while the other
end is securely fastened to a slide within the handle,
which is  moved  by means of  a trigger-like projec-
tion.  Thus, by pulling the trigger  the wire is drawn
backward, and the blades of the forceps are closed.
Both  the  wire and the anterior portion of the tube
being flexible, any desired curve  can be obtained,
and the blades of the forceps may be made to open
in any direction.   This  spiral tube-forceps I had at
first  attached to  the Stoerk universal  handle, but
have found the pistol handle to be not only more
convenient, but also cheaper.
  Several other forms of open or tube-forceps are in
use which are similar in  principle to those described,
and differ from  them only in minor details.   As  a
matter of  course, the same  size of forceps will not
answer for all cases, and different  shapes and sizes
should therefore be kept ready  for  use. 
LARYNGEAL  NEOPLASMS.        221
                CHAPTER  X.

   neoplasms of the laryngeal cavity.

              Use of Instruments.

  Besides  the  forceps describee! in the foregoing
chapter, cutting instruments are frequently used in
operating for  tumors  in  the  laryngeal and nasal
cavities.
  Formerly, when laryngoscopy was in  its infancy,
and  laryngeal  surgery was  only beginning  to  be
made use of, so-called open laryngeal knives were
used, especially by von  Bruns, of Tubingen, who
claims to have been the first to  remove a tumor, or,
at least, perform a surgical operation in the laryngeal
cavity.  Such  an  open  knife consists simply of a
curved steel wire, secured in a handle, and terminat-
ing in a knife blade, either sharp- or blunt-pointed.
This knife blade, which  is very narrow, must have
its cutting edge either laterally or antero-posteriorly,
so that incisions may be made either transversely or
longitudinally to the axis of the glottis.  In order
to be able  to  cut  both forward and backward and
from side to  side, the blade is  made with a cutting
edge on either side, like a dagger.  The introduc-
tion  of such  an open  knife into the larynx is, of
course, rather hazardous, inasmuch as the epiglottis
or the posterior wall of the pharynx or the tongue
would be easily wounded if the patient  should gag
                       19* 
222        LARYNGEAL NEOPLASMS.
and the knife have to be removed quickly.   The
laryngeal  knives now in use are, therefore, covered
(Fig. 55)—that is, the blade is contained in a curved
tube, like the one used  for the tube-forceps, from
which it can be protruded by means of a lever upon
the handle, which either retracts the tube from over
the knife blade, or pushes the latter out of the tube
when the instrument is in position and the incision
is  to  be made.   As  soon as  gagging sets in, the
pressure upon the lever is taken off, and the knife
is  instantly concealed within the tube, so that  no
harm can  be  done to any of the parts  in removing
the instrument.
  Mackenzie's forceps must be regarded as cutting
instruments,  inasmuch as the  blades have cutting
edges and act like nippers.
  Stoerk has attached to his universal handle (see
Fig. 59) a very ingenious cutting instrument  called
a guillotine, which is  the safest and most useful of
all instruments of this  class.    It may be looked
upon  as  a combination of the wire loop and the
covered knife, since it consists of a permanent loop
with an inner cutting edge, or, in  other words, an
annular knife.  This,  like the tube-forceps and the
covered knife, may be retracted into an expanded
and flattened extremity of a curved  tube, and  by
this motion will  cut off as much of a tumor  as can
be pressed through the opening of  the knife  blade.
In order to shave close to the surface of the mucous
membrane or the edge of the vocal cords, the blade
is ground flat on  one  side and hollow on the  other.
This, of course, necessitates the employment of a
right and a left blade, and an anterior and a posterior 
USE OF  INSTRUMENTS.
223
blade.   The former and  the latter pair can each be
inserted into the same tube;  thus it is  necessary to
have four blades and two tubes.  This guillotine may
also be used in connection with the flexible spiral
tube, and attached to either the Stoerk  handle or to
the handle of my forceps (see Fig. 60), and as it can
be bent in any direction, only one knife is necessary,
instead of four, as in the original instrument.
  With this instrument, when once introduced  into
the larynx, a tumor  projecting, for instance,  into
the glottis and attached to the edge of one of the
cords,  can be surrounded  and cut off by the knife
even when the patient gags and struggles, inasmuch
as no part of the larynx can be injured by the knife.
There are,  however, cases in which  none of the
instruments existing is applicable, and the ingenuity
of the operator is called upon  to devise modifica-
tions so as to adapt the  instrument  to  the require-
ments  of the particular case,  or, if this cannot be
done, to invent a new instrument altogether.
  Besides the forceps and  knives for the removal of
tumors and foreign bodies from the larynx, an ex-
ploring instrument should  be used in order to ascer-
tain the consistency of a  tumor, its attachment to
the mucous membrane, whether by a  slender  stem
or by a broad base, etc., and for various other  pur-
poses.   Such an  instrument is called  a laryngeal
sound  or  probe.  It has already been described as
consisting  of a piece of  silver wire, bent to the
proper curve and held in a mirror handle.  In most
cases it serves its purpose of exploring very well, but
in some instances, where it is necessary that a tumor
should be lifted up in order to ascertain its location 
224        LARYNGEAL NEOPLASMS.
and mode of attachment, the end of the probe must
be bent into the shape of a hook.

                   Neoplasms.

  Symptoms.—Besides the aphonia, which, in  neo-
plasms, is of a peculiar character, inasmuch as the
voice, which is  usually hoarse, or  sometimes quite
natural, is lost suddenly  and  completely for a few
minutes,  and then returns as suddenly, often with a
change of position of the head or body of the patient,
we frequently observe dyspnoea.  Dysphagia, on the
other hand, is  rarely met with,  and only occurs
when the tumor is so large as  to interfere with the
movement of the epiglottis, or when it springs from
this  organ.  Pain is  rarely observed, and usually
attends  only malignant   growths  of the  larynx.
Cough, as a rule, is one of the symptoms of laryngeal
tumors.  Slight in most cases, but severe and harass-
ing in a few, it is generally of a peculiar character,
resembling the cough in  croup, and is apt to come
in paroxysms.   The character, location, shape, and
size of neoplasms in the larynx which may produce
the foregoing symptoms are very varied.  According
to Mackenzie's statement, they occur most frequently
upon the vocal  cords, but may be  found in  almost
any part  of the larynx.  (Plate I., Figs. 4 and 5.)
  Diagnosis.—The diagnosis, as regards the presence
of a tumor in the larynx,  is very certain, if a careful
laryngoscopic examination can be made, and the
only sources of error are the  eversion of the ven-
tricle, an exceedingly rare occurrence, in which the
mucous membrane  lining the  pouch protrudes like 
CLASSIFICATION OF TUMORS IN LARYNX.   225

a tumor between the vocal cord and the ventricular
band.  The second source of error is an infiltration
and  consequent  swelling of the ventricular bands,
which in that condition may hide from view a small
tumor  situated in the vocal  cord or on the lower
surface of the ventricular band itself.


    Classification  of Tumors  in  the Larynx.

  Clinically, the tumors met with in  the larynx are
divided into two great classes.   In the one are those
which, after  thorough operative removal, do  not
usually  return; in the other are those  which  will
return,  if not at their former seat,  at some other
part of the body, even after the most careful removal
of all  diseased tissue.   The former  have received
the appellation of benign  tumors, the  latter that
of malignant tumors.  It is, however, exceedingly
difficult at the present time  to draw the line of
distinction between these two classes;  even when
a microscopic examination has determined the nature
of a growth, it is often impossible to say whether a
tumor is benign or malignant,  because  neoplasms,
which formerly were regarded as perfectly harmless,
have been known either to return after operation, or
to change their character from a benign to a malig-
nant form.
  The tumor most frequently met with in the larynx
is the papilloma, or wart-like growth, which springs
from the mucous membrane lining the larynx.  It
assumes various forms, all more or less indented on
their surface.  This indentation has given rise to the
variety of names which this kind of neoplasm bears, 
226        LARYNGEAL NEOPLASMS.
such  as  cauliflower, raspberry,  mulberry, foliated,
etc.   These growths are usually attached by a broad
base,  and only occasionall}7 do we find them pedun-
culated.   Their size varies from that of a mustard-
seed to that  of  an English walnut,  but is usually
that of a good sized pea.  Their color is mostly pink,
but sometimes white or bright red.  A thin section
of such a growth presents under the microscope the
appearance of hypertrophied papillae of the skin or
mucous membrane.
  The next in frequency of occurrence is the fibroma,
a tumor usually pedunculated, pinkish or red in color,
round and sometimes  irregular  or wavy in outline,
with  a smooth surface, hard and unyielding to the
touch of the sound.  Its size varies from  that of a
small seed to that of an acorn, and is most frequently
found to spring from the vocal cords.
  Less frequent  are the fibro-cellular tumors.  They
are usually found on the vocal cords, about the size of
a pea, red or  pinkish in color, sessile, with a smooth
surface, and of a more or less globular shape.
  Still more rarely met  with are  the  myxomata,
which in appearance resemble the fibromata, except
that they are  soft and yielding to the touch.
  Only  one case of lipoma or fatty  tumor in the
larynx has been reported (von Bruns).
  Cystic  tumors,  on the other hand, are more fre-
quent, and  resemble the fibrous tumors in shape,
size, and color.  They differ from them, however,
in their mode of attachment, which is always broad.
Their consistence  depends upon the material with
which they are filled, whether serous, caseous, puru-
lent, etc. They also usually have a zone of irritation 
CLASSIFICATION OF TUMORS IN LARYNX.   227

around  them, and occur  most  frequently on the
laryngeal surface  of the epiglottis.
  Fasciculated sarcomata and adenomata, or glandular
tumors, show no  distinctive features, but may re-
semble any of the above-described neoplasms.  They
are very rarely met with in the larynx.
   Vascular growths, or angiomata, also are very  rare,
and may be  diagnosed  by their dark, almost black,
color, and granular surface, as well as by their ten-
dency to bleed on  being touched.
  The so-called malignant  growths  found in the
larynx are usually  secondary deposits from a primary
cancer elsewhere,  and show the distinctive features
of  the primary  growth.  This is, however, not in-
variably  the rule, as  a considerable number of  cases
of primary cancer  of the larynx have been reported?
some of which have  been  successfully  treated  by
extirpation of the whole organ or part  of it.  The
most frequent form of cancer in the larynx is epithe-
lioma ; next in frequency are found, in the following
order, round-celled  sarcoma,  spindle-celled sarcoma, me-
dullary carcinoma, and scirrhus.
  All of  these are infiltrating and ulcerating, and
give more the appearance of a localized tumefaction
than of a new formation  projecting into the laryn-
geal cavity.

   Treatment.—Tumors in the laryngeal  cavity pro-
ducing by their mechanical  interference aphonia,
dyspnoea, dysphagia, and other  symptoms already
described, should,  if possible, be  removed by means
of  forceps or cutting instruments, and  the seat of
the neoplasm should be cauterized with solid nitrate
of silver, or the galvano-cautery knife, to prevent a 
228        LARYNGEAL  NEOPLASMS.
local return of the growth.  In cases of secondary
cancerous deposits in the larynx it becomes a diffi-
cult  question  as to whether  surgical interference
should be attempted or not.  It is, however, always
advisable in such cases to tear off a small piece for
microscopic examination, so  as  to  determine  the
precise nature of the growth.   If, however, there is
the hope  of  obtaining by operation even a slight
temporary relief from  the harassing symptoms, as
much as possible of the growth and infiltrated tissue
should be removed, even if partial  or total extirpa-
tion of the larynx becomes necessary.
  In the removal  of a tumor  from the larynx, its
position,  size, mode of attachment,  whether pedun-
culated or sessile, its  vascularity, consistence, and
other peculiarities, must be taken  into consideration,
in determining  what  mode  of operation  is to be
adapted to the case.
  Almost all patients suffering from neoplasms in
the larynx require  to be accustomed  to the  presence
of an instrument in the laryngeal  cavity by frequent
introductions either of  the instrument to be used in
the operation or of the  laryngeal sound, and it often
requires wreeks and months of daily  practice  before
the removal of the tumor can  be executed  with
safety.  If, however, the removal of the tumor or
foreign body is very urgent to prevent suffocation,
and the  patient's  throat is too irritable to allow of
instrumental  interference, anaesthesia of the larynx
may be tried before resorting to tracheotomy.   This
method of reducing the  sensibility of  the larynx
was first recommended by Rossbach, and consists in
freezing with  the  ether spray a portion of the skin 
NEOPLASMS.              229
on either side of the neck near the position of the
lesser horns of the hyoid bone, with a view to affect
the superior laryngeal nerve, which at this place
comes near the surface. -In several instances I have
succeeded in rendering the larynx almost completely
insensible to the presence of  an  instrument, but in
other cases have utterly failed to obtain the desired
result.  A fine spray of a four per cent, solution of
cocaine thrown into  the larynx by means of an
atomizer is a more  convenient and reliable method
of producing local anaesthesia of the laryngeal mucous
membrane, and enables the operator to introduce the
forceps without previous training in the majority of
cases.  Yet there are some persons in whom even
the cocaine spray does not produce the desired result,
and who must be educated to allow the introduction
of the instrument into the laryngeal cavity without
contracting the superior laryngeal opening.
  In  cases where dyspnoea exists to a considerable
extent, on account of the tumor being so large as to
interfere with  the  free ingress and  egress of air,
tracheotomy should be  performed at once, as  the
patient  is in imminent  danger of suffocation.  In
most cases of asphyxia caused by  laryngeal growths,
it is not the tumor which suddenly closes the glottis
and thus prevents respiration,  but this closure is
usually produced by spasm of the adductor muscles
of the larynx approximating the cords, and its im-
mediate cause is some slight irritant, such as dust,
carbonic acid gas,  ether, etc.  If the tumor is at-
tached to the free edge of the vocal cord or ventric-
ular band, either by a broad base or a narrow stem,
and if it is not too large, it can frequently  be gotten
                        20 
230
PHARYNGITIS.
through the fenestrated knife of the guillotine, and
extracted in spite of the gagging  and struggles of
the patient.  When the  open or covered knife or
even the forceps is to be used, the patient should be
so trained that no amount of instrumental interfer-
ence will produce gagging.
  Prognosis.—The prognosis, as regards the  local
return of a  tumor,  depends  altogether upon  its
nature, which can only be determined with accuracy
by  careful  microscopical  examination.  Yet  even
the benign  papilloma has, in some cases, a tendency
to return after it has been thoroughly removed, par-
ticularly in children, and the process of picking off
the neoplasms has to be continued often for a long
period before the larynx is entirely and permanently
cleansed of the tumors.
               CHAPTER XI.

                 PHARYNGITIS.

  Pharyngitis is an  inflammation of the mucous
membrane lining the  pharynx, and, like  laryngitis,
is  divided  into  two  large  groups,  the  acute  and
chronic.  These are  again subdivided according to
the causes producing the inflammation, and accord-
ing to special features characteristic of the different
forms.
               Acute Pharyngitis.

  Acute pharyngitis  is  found in connection with
acute laryngitis and usually precedes it, the  velum 
ACUTE  PHARYNGITIS.
231
palati, the pillars, and tonsils participating in the
general inflammation  of the  mucous membrane.
This condition is the so-called sore throat so common
among children as well as adults.
  Symptoms.—This affection is usually caused by wet
feet, an exposure to cold draught, etc.  It is ushered
in  by a more  or less  pronounced chill.  Febrile
symptoms then begin to show themselves, more or
less severe according to  the effect produced by the
exciting cause upon the general system. The throat
feels raw, swollen, and painful, deglutition becomes
painful  and  difficult  on  account of the swelling of
the tonsils, palate, and uvula, and  a thick yellowish
expectoration is  thrown out.   In the first  stage
there is usually  little or no cough; but later, when
the inflammation has extended into the larynx and
perhaps even into the trachea, the cough becomes
very  harassing.   The  lymphatic glands under the
jaw and in the neck usually participate in the gen-
eral inflammation and  become swollen and  painful
to the touch.
  On inspection  of the pharynx,  which  is  easily
effected by  depressing the  tongue by means of  a
tongue-depressor, we find the anterior pillars red
and swollen, and the tonsils of a purple hue, protrud-
ing beyond the anterior pillars  (Plate II, Fig.  2),
thus  hiding  from view  the posterior pillars of the
fauces.  Frequently  small white patches of  cheesy
consistence, easily removed with a probe, but leav-
ing  no ulcerated  surface  underneath  them, are
observed on  the tonsils,  especially  on  the posterior
surface. These patches  are the hardened secretions
of  the  follicles  in the glands, pressed out  by the 
232             PHARYNGITIS.
swelling of the organs.  They differ, however, from
pseudo-membranous  patches as  seen in diphtheria,
inasmuch  as  they are usually  smaller, of different
consistence, and leave no ulcerated or raw surface
when removed.  But they are  frequently mistaken
for diphtheritic exudations, and the affection is then
after a hasty and superficial  inspection called diph-
theritic sore throat.   It sometimes occurs that these
cheesy patches are mistaken for the pus-covered sur-
faces of ulcers, and  the patient is then subjected to
severe treatment in order to heal up the supposed
ulcers.
  The velum palati is uniformly reddened and swol-
len, while the uvula is generally  relaxed and hangs
down into the pharyngeal cavity.   The wall of the
pharynx  is seen to be bright red,  with prominent
veins  fully   injected  ramifying  over its  surface,
which is either glistening and shiny or studded with
enlarged and inflamed follicles or glands.  The free
margin of the epiglottis is usually swollen from the
first.
  Duration.—The duration of this affection is usually
of a few days  only, when the swelling and inflam-
mation subside, and the normal condition of the
parts becomes reestablished; if, however, the larynx
is affected to any extent, the disease is prolonged by
this  complication, and may continue  as  an  acute
laryngitis after the inflammation of the pharynx and
tonsils has subsided.   But this   is  not usual, and
does not occur in vigorous subjects, or when proper
and  active  treatment has been adopted from the
beginning of the affection.  Of late, a form of acute
pharyngitis has been observed, which differs in many 
ACUTE  PHARYNGITIS.
233
respects from  the  ordinary  disease, inasmuch as it
is epidemic and infectious, without being contagious.
Its most prominent features are  a mucoid infiltra-
tion of the submucous tissue, the formation of small
patches of pseudo-membrane  which is white  and
does not curl up at the edges even after a number
of days, and when pulled up does not disclose any
ulceration  of the mucous  membrane  beneath it.
Various forms  of  neuralgic pains, and  particularly
otalgia, are  present and are often very severe.   At
the onset very little systemic disturbance is noticed,
but  later on  the  pulse becomes weak and  more
rapid, and  a slight rise in temperature  becomes
noticeable.  Its duration may be  from a few days to
several weeks, and even months, without apparent
change from treatment.
   Treatment.—The treatment should be directed to
the removal of the  general febrile symptoms, and
to hastening the  resolution of the local inflamma-
tion, as well as to the alleviation  of the pain.
  Saline purgatives, hot foot-baths,  and sponging
the body  with tepid water or whiskey and  water,
should first  be resorted to, and the diet reduced to
milk, mush, gruels, and, if necessary,  beef tea.   All
articles  of food should be soft, and of the  mildest
nature.   Spices,  even  in  very  small  quantities,
aggravate the local symptoms. Frequently the tume-
faction of the parts is so great as  to make the act of
deglutition almost impossible; then only iced milk
or oyster soup can be swallowed in very small quan-
tities, and  the thirst must be alleviated by  small
pieces of ice held in the mouth.  All beverages con-
                       20* 
234
PHARYNGITIS.
taining carbonic acid should be avoided, as the gas
increases the inflammation and pain.
   In this affection only are gargles of any use. They
can be easily brought into  direct contact  with the
parts most affected, namely, the soft palate with the
uvula, the  posterior wall of the pharynx, the ton-
sils, and pillars.   Strong solutions of alum, tannic
acid, benzoic acid, Labarraque's solution in strength
of 1 to 5, iron, and other astringents should  be em-
ployed in the form of gargles in combination  with
some anodyne,  or the parts should be irritated  with
them by the spray from the hand atomizer, or  they
may be painted with a brush over the surfaces  most
inflamed.   Solutions  of nitrate of silver applied to
the apparent centres of inflammation act with great
promptness in  reducing the swelling, except in the
mucoid variety, in which it seems to have  no effect
whatever.  An attack of this kind  can  frequently
be cut short or  prevented altogether by the  early use
of this  remedy, provided  a  sufficiently strong  solu-
tion be  used.  It has been my experience that weak
solutions (fifteen  to thirty grains to the  ounce  of
water) rather increase the inflammation and pain,
while  a sixty,  eighty, or  even  one hundred and
twenty grain solution has an  anaesthetic effect, and
reduces the inflammation if applied before any in-
flammatory infiltration  into  the  submucous tissue
has taken place;  that is, within  a few hours from
the start of the disease.  Vapor inhalations of car-
bolic  acid,  benzoin, tar, etc., are also very  advan-
tageous. Internally, the mixture of iron, chloride of
potash,  and bromide of potash, in liquid formy or in
the form of lozenges, recommended in the treatment 
      TRAUMATIC ACUTE PHARYNGITIS.   235

of acute laryngitis, has been found to give the most
satisfactory results in allaying the irritation.  Poul-
tices of various substances applied externally to the
neck  tend  to  keep the skin soft and  pliable, thus
diminishing the painful pressure upon the enlarged
glands.  If the inflammation  has been very severe,
and the swelling very great, suppuration and ulcera-
tion may occur.
  One attack  of acute pharyngitis predisposes the
patient to other attacks  of the  same kind, and we
frequently have occasion  to observe the great regu-
larity with which the affection returns once or twice
a year in the same person.   It has been found  that
bathing the throat with  cold water every morning
and evening throughout the whole year, and hard-
ening the  skin  against  atmospheric  influences by
moderate exposure, even in cold weather, will fre-
quently break up the tendency to acute pharyngitis
and tonsillitis.

         Traumatic Acute Pharyngitis.

  As  has been said, the common cause of the affec-
tion is exposure to cold, but the  accidental or inten-
tional swallowing of corrosive or  very hot liquids
will produce the same results, as well as the embed-
ding of sharp  foreign bodies in  the tissues, such as
fish-bones, splinters of bone or wood, pins, etc.  In
the latter case the inflammation starts from a point
of irritation spreading over the whole mucous mem-
brane covering the parts in the neighborhood.  The
first step in the treatment  should,  of course, be the
removal of the offending body. 
236
PHARYNGITIS.
  An acute pharyngitis without involvement of the
soft palate and the tonsils is  exceedingly rare, and
is only found when the irritation has started in the
pharynx and has  not had time to  advance to the
parts above.  It was, therefore, necessary to describe
two affections together, viz., acute pharyngitis  and
acute  tonsillitis, which are differentiated from  each
other  by  their names only, while not different in
reality.
  The chronic forms  of these two affections, on the
contrary, differ widely from each  other, both as re-
gards their causes and the symptoms which they pre-
sent ;  they will, therefore, be considered separately.

              Chronic Pharyngitis.

  It has been the experience of most laryngologists
that the ordinary forms of chronic pharyngitis, such
as  the  so-called  granular,  follicular  pharyngitis,
pharyngitis sicca, and so forth, are merely symptom-
atic expressions of chronic diseases of the nose and
naso-pharynx, or of  gastric  irritation, and  are, in
reality,  not  entitled  to be  considered as separate
diseases, inasmuch as these heretofore called chronic
pharyngites disappear without  treatment, with the
removal of the cause which produced them.  I will,
therefore, in  this edition, consider the symptoms to
which they  give rise, together with  those  due to
naso-pharyngeal disease, and describe in this chapter
only the specific pharyngitis and the chronic pharyn-
gitis due to traumatism. 
      specific chronic  pharyngitis.    237


         Specific  Chronic  Pharyngitis.

  Secondary, as well as tertiary, syphilis produces a
form of chronic inflammation  in the mucous mem-
brane of the throat which has sufficient distinctive
features  to entitle it to be  considered  under  a
separate head.
  Symptoms.—The  patient complains usually of  a
slight cough  with  thick  yellowish,  but  scanty, ex-
pectoration, of a fulness  and dryness of the throat,
and of more or less hoarseness of the voice.  Often
difficulty of deglutition is complained  of,  and fre-
quently articulate  speech has  a nasal quality.  On
inspection  we find the  mucous membrane of the
pharynx, soft palate, uvula, and tonsils of the pecu-
liar brick-red hue  already described under the head
of Specific Laryngitis.   The  pharynx  is  dry and
glistening,  and  ulcers  more  or less  deep,  of  a
rounded outline, with raised edges,  and  surrounded
by a zone of more active inflammation, may be found
almost anywhere.    They are, however, most fre-
quently seen on the pharyngeal wall, the soft palate,
the pillars and  tonsils,  and  often  on the tongue.
Symmetrical  patches  of  more active inflammation
are almost  always seen in specific inflammations of
the throat,  and form one of the distinctive  features
of this affection.  (Plate  II., Fig. 4.)
  Gummata or syphilomata are often observed on
the posterior  wall of the  pharynx, and  may be
recognized  by their  peculiar elasticity to the touch
of the sound.   An adhesion  of one or both posterior
pillars to the pharynx is also frequent, and is caused 
238
PHARYNGITIS
by cicatricial tissue  resulting from  the  healing  of
ulcers.  These features are  so peculiar  that when
once seen they  will always  be recognized,  and a
confirmation  of  the diagnosis by the history  of a
primary sore  is frequently unnecessary.
  Treatment.—The treatment of the local affection
must consist  in  stimulating  the mucous  membrane
so as  to  remove the dryness and swelling, and  in
healing up the ulcerations if such are present.   This
is done by cauterizing them thoroughly with nitrate
of silver if  they are of the  shallow kind,  or by
galvano-cautery followed by acid nitrate of mercury,
if they are of the deep and  destructive  variety,  in
the manner  already described  in  the  chapter on
Syphilitic Laryngitis.   It  frequently occurs  that
these ulcers perforate the velum palati or even the
hard palate, and then the peculiar  nasal twang of
the voice is heard.   The progress of these perfora-
tions  may be' stopped  by cauterization, but  they
cannot be closed except by a plastic operation when
the edges have healed, or by fitting a plate with  an
elastic flap over  the perforations.
  The constitutional treatment must, of  course, not
be omitted, for no amount of local applications will
eradicate  the disease.  I have, however, found that
iodide of potassium, in small doses,  is preferable to
mercury  in these cases, and I am in the habit  of
always giving the iodide of potassium in combina-
tion with bromide of potassium, because the one
seems to enhance, and, at the same time, control the
action of the other, so that  they can be  taken  for a
longer time in combination  than when given separ-
ately, before  producing a disturbance of digestion 
ELONGATED UVULA.
239
and eruption on  the skin.   A dose of from three to
five grains of the iodide of potassium and ten grains
of the bromide of potassium, given three times a day,
is often borne for months without signs of iodism.
The ulcers in the throat heal rapidly, and the mucous
membrane assumes its normal condition  under such
treatment.
  The general health of  the patient should  at  the
same  time  be  attended to  by the administration of
tonics, cod-liver oil, and salt baths, and he should be
advised to take exercise in the fresh air.

        Traumatic Chronic Pharyngitis.

  After the ulcers or  the acute inflammation pro-
duced  by the accidental swallowing of hot or  caustic
liquids, causing  acute  traumatic pharyngitis, have
passed away, a chronic inflammation of the mucous
membrane is  frequently left behind, which exhibits
the same symptoms and appearances of the parts as
have been described when treating of simple chronic
pharyngitis.  The treatment required for this form
does not differ  from that  for  other forms  of  the
disease.
              CHAPTER  XII.

  ELONGATED UVULA AND HYPERTROPHY OF TONSILS.

  There are two conditions which, strictly speaking,
do not come under the head of disease of the throat,
but which, on account of the  symptoms they pro- 
240
ELONGATED UVULA.
duce,  are  generally considered as  such;  these are
elongated  uvula and hypertrophy of the tonsils.

               Elongated Uvula.

  Elongation of  the  uvula is due either to genuine
hypertrophy of the tissues  of this organ, to drop-
sical effusion, or to simple relaxation of the soft palate
and uvula, thus causing the latter to hang down into
the laryngeal cavity during breathing, or to come in
contact with the margin  of the epiglottis and pos-
terior wall of the pharynx, as well as the back of the
tongue.
  Symptoms.—The symptoms  produced  by a relaxed
condition  of the uvula are principally a tickling in
the throat,  and consequent   cough and  gagging,
especially  when the patient  assumes the recumbent
position.   Very little or no expectoration is observed
to follow  the cough.   The voice has a very slight
nasal  sound, and sometimes a peculiar jarring noise
accompanies the vowel sounds.  On inspection the
mucous membrane  is usually healthy, or slightly
paler  than normal, and the uvula is seen either to lie
upon  the  back of the tongue, or to hang down so
that its end cannot be seen until the patient draws
up the velum palati  in the effort to pronounce the
vowel ueh."   If  the  elongation is  due  simply to a
relaxation of the loose submucous cellular tissue the
organ is  often seen to adhere to the  wall of the
pharynx or to the pillars; but when it is due to true
hypertrophy  of  the body, the uvula  hangs down
rigidly and feels hard and resisting to  the sense of
touch. Sometimes we meet with cases of bifid uvula, 
ELONGATED  UVULA.
241
and it often happens that one of the branches  is re-
laxed, while the other is not (Plate II., Fig. 3).
   Treatment.—The  treatment  of the former condi-
tion, if of  recent origin, and  especially in children,
consists in  the application twice or even three times
daily of strongly astringent solutions, such as tannic
acid, alum, sulphate of zinc,  and especially of the
tincture of iron, to  the elongated uvula by means of
the brush.   If such applications be continued for  a
considerable length of time, the uvula can gradually
be made to assume its  natural condition.
  If the elongation is  due to serous effusion, as can
be determined by the peculiar club-shape which the
uvula assumes, a few incisions into its integument
often effect immediate  cessation  of all symptoms.
  The  cases, however, in  which  the relaxation  has
lasted  for  some time, and  is not clue to dropsical
effusion,  but to true hypertrophy, refuse to yield to
astringent  treatment, and amputation of  the  uvula
is the only proper mode of treatment.  This may be
done by  means of a pair  of scissors and  forceps in
cases where the patient is willing and determined to
have the operation  performed.   The forceps  should
grasp the end of the uvula so as to  prevent its slip-
ping back, and to  prevent also its falling into the
larynx after it has been cut off by the scissors as near
to the root as possible.  The pain and  hemorrhage
in this operation are very slight; indeed, not infre-
quently altogether absent.  The wound usually heals
by first intention within two or three days, the patient
in  the meanwhile being fed on soft food.  As a rule,
the hemorrhage following  the operation is  very
slight and  hardly noticeable;  but  there  are some
                       21 
242
ELONGATED UVULA.
cases on record, as pointed out by Dr. Caroll Mor-
gan, of Washington, in which the  bleeding  was
profuse, and  could  not  be controlled by ordinary
styptic applications.  In one case Dr.  Morgan com-
pressed the stump of the uvula with a clamp from
the common shirt-sleeve retainer, as the only means
of stopping the hemorrhage.
  In children it  often becomes a  matter of some
difficulty  to  introduce  two  instruments into  the
mouth in order to clip the uvula, and  in  such cases
it is better to use  an instrument called a uvulatome,
which  combines both the forceps and  the scissors in
one instrument.
   Uvulatomes.—Various forms of instruments com-
bining the forceps with the cutting instrument have
been introduced,  but  they  all have such disadvan-
tages that most operators prefer to use the forceps
and scissors separately, even if they have to  struggle
with the patient, and can perform the  operation  but
unsatisfactorily.
  Having frequent  occasion, in dispensary work, to
perform  the  operation, I endeavored to construct
an  instrument which would obviate the  difficulties
attending the use of such uvulatomes.   I  had, there-
fore, an instrument made which consists of a  pair
of strong scissors, the handles of which are bent so
that the hand  holding  them is below the mouth of
the patient when the uvula is grasped.  The right
blade is bent at right angles, forming  a hook at its
end, while the left blade is pointed, and  reaches to
the upper margin of the bend of the right blade. Thus
when the blades are separated, a triangular opening
is formed, into  which the uvula can drop and be cut 
ELONGATED UVULA.           243
near its root, the hook-like bend of the scissors pre-
venting its  slipping backward out of the grasp  of
Fig. 61.
Seiler's uvula scissors.
the instrument,  Upon the same pivot upon which
the blades of the scissors revolve are attached a pair 
244       HYPERTROPHY  OF TONSILS.

of pronged claws lying on the under  surface of the
scissors blades;  they serve to catch the amputated
piece (Fig. 61).  With this  instrument no difficulty
will  be experienced in  grasping and cutting the
uvula even if the patient should struggle, since the
handles of the scissors are held so that  the pressure
of the fingers in closing them keeps the  blades in
close contact with each other.

            Hypertrophy of Tonsils.

  An acute inflammation of the tonsils, exhibiting
the different symptoms of inflammation elsewhere,
is of frequent occurrence.  It may be either simple
or complicated with an acute pharyngitis or laryngi-
tis, under  which head it has already been described;
it remains, therefore, only to describe the symptoms
and  treatment of chronic tonsillitis or hypertrophy
of the tonsils.
  Clinically, we observe three varieties  of  hypertro-
phied tonsils, viz.: first, the  ordinary soft  variety of
childhood and early  youth, which consists  histologi-
cally of a hyperplasia of the cellular elements of
the glands, with a slight increase of the intercellular
connective  tissue.   This  variety usually disappears
spontaneously shortly after puberty, and in strumous
individuals is frequently the seat of acute  periodical
inflammation, which may or may not go  on to  the
development of tonsillar abscess.  The second variety
is the so-called scirrhous  tonsil, first  mentioned by
Jarvis, which  is  characterized by an  enormous in-
crease of  the  intercellular connective  tissue, and  a
canaliculization  of  the bloodvessels of the gland, 
          HYPERTROPHY  OF  TONSILS.      245

giving the tonsil a hard, almost  cartilaginous feel to
the touch.   This form is usually met with in young
adults, and  is rarely, if ever, the  seat  of acute in-
flammation.  And, finally, the third variety, the so- *
called ragged tonsil, which  is the result of frequent
tonsillar abscesses, causing the sloughing  away of
portions of the tonsillar tissue, so as to leave a ragged
glandular mass, which projects beyond the faucial
pillars.
  Symptoms.—The symptoms of hypertrophy of the
tonsil are more passive than active; that is to say,
there is usually  no  pain  or active inflammation.
There exists, however, more or less  obstruction to
the passage  of the air in breathing, which causes the
patient  to snore  when asleep.  The articulation is
what is called " thick," and  more or less difficulty of
deglutition is observed.  The degree of obstruction
to breathing being dependent upon the amount of
swelling of the glands, the latter may lead to alarm-
ing  symptoms of dyspnoea, especially  in  children,
when an acute coryza obstructs  the nasal passages.
Usually these hypertrophied glands are the seat of
periodical acute inflammations, causing a great deal
of suffering to the patient.  In many cases of the first
variety, the  crypts of the glands  are filled with  a
hardened secretion, which is  of a  white color and
of cheesy consistence.   In some cases this retained
secretion undergoes putrefaction, and thus gives rise
to a most disagreeable  odor, which is  imparted to
the breath of the patient.
  Treatment.—In  treating hypertrophied tonsils we
may with propriety look upon  them as  tumors or
neoplasms.   Like  enlarged  glands elsewhere,  they
                       21* 
246       HYPERTROPHY  OF TONSILS.
  may be reduced by the application  of astringents,
  which must be, however, of a very active sort, such
  as strong solutions of nitrate of silver or of the solid
* lunar caustic;  iron and tannic acid  have but little
  effect, even when  the  applications are  frequently
  repeated and continued for a long time. Application
  of  the tincture and solution of iodine to hypertro-
  phied tonsils has been  recommended, but is  apt  to
  cause unpleasant results by producing spasm  of the
  glottis  by reflex  action.  Injection  of solution  of
  iodine into the substance of the gland by means of a
  hypodermic syringe, however, is often followed by a
  speedy reduction of the tonsil without causing the
  unpleasant results that  are apt to follow the applica-
  tion of the drug to the  mucous membrane.
    The best and most  satisfactory way of treating
  hypertrophied tonsils is to cut them off  as close  to
  the pillars of the fauces as possible.  In the ordinary
  soft variety the tonsil  is best removed by ablation
  with the tonsillotome.   *Care should, however,  be
  taken not to wound the edge of the  anterior pillar,
  because a small branch of the tonsillar artery runs
  close  to  this  edge,  and  when cut  gives rise  to
  hemorrhage difficult to control.  If the  anterior
  pillar is adherent to the tonsil, it should be loosened,
  and if this is not possible, owing to  the bands  of
  fibrous tissue connecting the pillar  with the tonsil
  being too strong to be  torn, the tonsillotome cannot
  be used with  any degree of safety, and the galvano-
  cautery knife should be used.  After the projecting
  portion of the tonsil has been ablated, the cut surface
  should be brushed over with a sixty-grain  solution
  of nitrate of silver to cause contraction of the capil- 
HYPERTROPHY  OF TONSILS.      247
laries and  to  cover the wound; and any secondary
hemorrhage, which, however, rarely occurs, should
be controlled with a strong solution of tannic and
gallic acid  used as a gargle.  The old method of re-
moving the tonsils with the volcellum and  bistoury
is unsafe, as the  edge of the anterior  pillar, even
when not  adherent, is too easily wounded by the
heel of  the knife.  Total extirpation or enucleation
is also dangerous, besides being unnecessary except
in the extremely rare cases of cancerous growth in
the tonsil.   There are several kinds of tonsillotomes
in use, the older form invented by Fahnestock, and
later improved forms.
  Fahnestock's tonsillotome (Fig. 62) consists mainly
of an annular knife,  which moves in a split ring,
through which the enlarged tonsil is pushed, and of
a stout needle attached to the instrument in such a
way that it can be pushed forward, thus transfixing
the gland  and preventing  its  slipping out of the
ring. When thus secured, by pulling out the handle
of the tonsillotome the protruded parts are cut off
with the annular knife.  It will be seen that in order
to use this  instrument  both hands are needed, and
two motions must be executed, viz., the pushing back
of the needle and the pulling forward of the knife.
  Another instrument requiring but one hand and
one  motion in its use, is figured in Fig. 63.  It is
very similar in construction to Fahnestock's instru-
ment, and  differs from it only in  the fact  that the
stylus or needle  is replaced  by a fork which, after
having penetrated the tonsil, is  raised, thus drawing
it through the ring. The annular knife is prevented,
by a catch  at the  stem of the instrument, from mov- 
248      HYPERTROPHY OF TONSILS.

ing until the tonsil has been pierced and drawn into
the ring.  This catch is lifted and the knife is drawn
down, cutting  through the protruding  tonsil  with
the same motion of the hand that was employed to
push the fork forward.
  The original instrument was invented by Mathieu,
of Paris, but the author has found the ring too large
to be introduced into the  mouth of children, and
even of the average adult.  Furthermore, the long
diameter of the ring is in this instrument at right
angles to the shaft, which prevents  the surrounding
of the  hypertrophied  gland in most  patients.  By
slightly reducing the size of the  ring and having its
long diameter in the axis of the shaft, the instrument
becomes one of the most serviceable in the greatest
number of cases.  Another modification of this  in-
strument consists  in  having several sizes of rings
with annular knives attachable to the shaft, which
can readily be exchanged for each  other to fit the
different cases.   This modification  was borrowed
from an old German instrument, but it  is  too  com-
plicated and costly to  come into general use.
  The  safest and  only applicable  one  in cases of
ragged tonsil is the galvano-caustic method of remov-
ing hypertrophied tonsils.  In applying  this method
the galvano-cautery knife  should  be heated  to a
bright red heat, and should then be  pressed into the
tissue of the tonsil by  entering  one of the crypts and
cutting  with it from within outward,  so that the
eschar resulting from the  burn can  easily  fall  off
and does not become impacted in the tissue of the
tonsil.   This procedure does not give  rise  to any
pain, and should be repeated at  intervals of a week 
HYPERTROPHY  OF  TONSILS.         249
Fig. 62.
Fig. 63.
W
r
ro
/
Fahnestock's tonsillotome.
Seiler's modification of Matbieu's
          tonsillotome. 
250      HYPERTROPHY OF TONSILS.

or ten days, and from four to six applications usually
sufficed to  reduce the tonsils to a size compatible
with health and the comfort of the patient.  Under
no circumstances should any operation for the re-
moval or reduction of hypertrophied tonsils be under-
taken while the organ is in a state of acute inflamma-
tion.  In the case of the ragged  tonsil, scraping the
tonsillar tissue from the capsule with a sharp curette
has been recommended, but this method is not only
very bloody, but  also painful, and on that  account
the galvano-cautery is to be preferred.
  For the removal of the scirrhous tonsil, the Jarvis
snare is the  best and safest instrument.  The steel
wire loop should  be laid around  the enlarged tonsil,
and  by turning the  screw should  be gradually de-
creased in  size until the portion  encircled by the
wire is cut off.  If done slowly, the operation occa-
sions very little pain, and time is given for the  edges
of the rigid vessels  to become agglutinated, so that
little or no hemorrhage results.  The best way is to
start the snaring process, and then let the patient
turn the screw himself,  trusting to him that it  is not
done too quickly; for  the patient will tighten the
loop until he feels  the  pain, and will then stop, to
begin  again when the pain has  ceased.   The  time
occupied in thus removing a scirrhous tonsil is from
two  to three  hours.   The wound occasioned by the
ablation of the tonsils  by either  of  these methods
usually heals within  a  few days by granulation, so
that, after the  lapse  of a week  from the operation,
the  parts present a  normal  appearance.   During
this  time the diet of the  patient  should be of the
mildest kind; spices and alcoholic stimulants should 
     DISEASES OF  THE  NASAL  CAVITIES.  251

be avoided, and if the patient  complains of great
soreness, flaxseed poultices should  be applied to the
sides of the throat.  Usually, however, no complaint
is  made of  any soreness,  except during the act  of
swallowing,  and even that is greatly diminished by
taking liquid food through a tube.
              CHAPTER XIII.

DISEASES OF THE NASAL CAVITIES AND NASO-PHARYNX.

  The  diseases  of  the  nasal  cavities  and  naso-
pharynx form a class of affections which are distinct
from those of the larynx and pharynx, and this dis-
tinction is due chiefly to  the  anatomical  arrange-
ments  of the  parts,  as well as  to the physiological
function of the  organs,  which have already been
described  in  detail (see Chapters III. and IV.), and
we can, therefore, at once enter upon the considera-
tion of the pathology and the diseases of the nasal
and naso-pharyngeal cavities.
  Pathology.—Most of the diseases of the nasal cavi-
ties are due to inflammatory processes, and but very
few are due  to traumatic  injuries  inflicted, either
from the outside by blows, falls, etc., or  on the in-
side by foreign bodies and the instrumental  inter-
ferences instituted to  remove  them; they  may be
due to  tumors or  neoplasms  growing within the
nasal or pharyngeal  cavities.
  If we closely observe  the  course of a  case  of 
252  DISEASES OF  THE  NASAL  CAVITIES.

simple acute coryza, we will find that the first symp-
tom is  a feeling of fulness, accompanied by sneezing,
and that this usually occurs in one nostril at first,
the other one being  affected later  in the same
manner.  An  inspection of the mucous membrane
shows it to be  in a state of congestion, and so much
swollen in certain portions, especially on the inferior
turbinated bone, as  to  touch that of  the septum.
This produces partial stenosis  of the nasal cavity,
and is felt as fulness.  The congestion having con-
tinued for some time, a watery discharge  makes its
appearance, which is produced by a hyperstimula-
tion of the  serous  glands, and  is  increased by exu-
dation of serum  from  the  venous sinuses  of the
turbinated tissue.  According  to Cornil and Ran-
vier, lymph corpuscles  are  found in  this  watery
discharge of the early stage of acute  coryza, while
other  and later observers have found various bac-
teria.   Later, the discharge becomes thicker by the
admixture of the secretion of the mucous glands and
of epithelial  cells which have undergone fatty degen-
eration, and  are thrown off by the rapid formation
of new cells under  the stimulus of the  increased
blood-supply.   The mucous membrane, as well as
the submucous  and cavernous connective   tissue,
becomes  infiltrated with numerous leucocytes, and
the venous sinuses become distended.
  As  the acute inflammation  subsides, these con-
ditions gradually disappear,  leaving, however, the
stretched  mucous  membrane thrown into folds as
it  contracts, which are  especially noticeable  at the
posterior extremity of  the inferior turbinated bone.
While spreading,  the  inflammation involves the 
PATHOLOGY.
253
glandular tissue situated in the vault of the pharynx,
the so-called adenoid tissue or pharyngeal tonsil, and
excites it to hypersecretion of the thick yellowish
mucus which is expectorated toward the end of the
attack.  The mucous membrane lining the accessory
cavities may also participate in the general inflam-
mation, and the  accumulation of secretion  within
them,  produced by  the obstruction  of  the narrow
outlets by tumefaction of the cavernous tissue, causes
an acute  pain  over  the seat of the accessory cavity
involved in the inflammatory process.   Thus, if the
antrum is involved, the pain is felt on the  cheek,
while  if the frontal sinuses are the  seat of inflam-
mation, the pain  is  mostly felt over the eyebrows.
Such involvement of the accessory  cavity is, how-
ever, very rarely met  with. The dull  pain in the
head, usually present,  is occasioned  by pressure  of
the engorged turbinated tissue, and is  reflex in its
nature.
   Frequent repetitions of acute coryza at  short in-
tervals must of necessity produce a permanency of
the  inflammatory infiltration in  the mucous mem-
brane and  submucous  tissue,  which   infiltration
finally becomes organized so as to form connective
tissue; at the same  time the venous  sinuses  remain
more or less distended, and the epithelium of the
gland-ducts  begins to  proliferate.  In this way per-
manent  swellings of the  mucous membrane in the
nasal cavities are  formed at the  most pendent por-
tions, viz., the lower edge of the  inferior and some-
times of the middle turbinated bones;  but they are
also found on the  septum.  These swellings are
called hypertrophies, and are divided, according  to
                        22 
254   DISEASES  OF  THE  NASAL  CAVITIES.

their location, into anterior, middle, and  posterior.
The anterior hypertrophies (Fig. 64)—those which are
                        Fig  64.
Dilated nostril, showing anterior hypertrophy.
situated on the anterior extremity of the turbinated
bones or on  the cartilaginous septum—are usually
                        Fig. 65.
Rhinsocopic image from a case of posterior hypertrophy on the middle
                    turbinated bone.

sessile and of a bright-red color, as are also the mid-
dle hypertrophies situated on the anterior portion of 
PATHOLOGY.
255
the middle turbinated bone, while the posterior ones
—occurring on the posterior extremity of the turbi-
nated bones (Figs. 65 and 66)—usually have a short
pedicle-like attachment and project into the vault of
the pharynx.  Their color is either a  dark brownish-

                        Fig. 66.
      Vortical section through nasal cavities. (Diagrammatic.)
  1. Superior turbinated bone. 2. Middle turbinated bone, with posterior
hypertrophy.  3. Section of hypertrophied pharyngeal tonsil.  4. In-
ferior turbinated bone. 5. Orifice of Eustachian tube.
purple  or a light yellowish-pink;  and I  find  that
those of a dark color are much softer than the light
ones.  Under the microscope a condition  of the tis-
sues in these  swellings is noticed  which  has been
already outlined. 
256   DISEASES  OF  THE NASAL  CAVITIES.

  Thus we see  in a thin section of one of these
hypertrophies that the epithelium is intact, although
many of the cells, especially in the neighborhood of
the openings of the glandular ducts, have undergone
fatty degeneration.   The basement membrane upon
which the cells are mounted appears thickened,  and
immediately beneath it we find the  mucosa  densely
infiltrated with  a small-celled  infiltration,  so as
almost entirely to obscure the mucous tissue.   The
gland-ducts are  seen to  be  filled with  proliferated
epithelium, as are also the glands themselves.   The

                      Fig. 67.
Section of posterior hypertrophy.  X 2.r>0.
  1. Epithelial layer.  2. Mucous follicle.  3. Submucosa, showing in-
flammatory infiltration.  4. Mucous glands.  5. Venous sinuses filled
with blood.  6.  Small branch of arteriole.  7. Transverse section of
arteriole.

bands of fibrous tissue  forming the caverns in the
erectile tissue are much  thicker than in the normal
structure,  and  the venous sinuses  are large and
irregular  in  outline.  Here and there  we find the
endothelial lining  of  these  caverns proliferating.
Scattered through  the  connective  tissue are  seen 
PATHOLOGY.
257
numerous lymph-corpuscles.  In some sections made
from  hypertrophies  I have  noticed myxomatous
change taking place in the fibrous tissue.  There is
but a slight difference in structure between the an-
terior and posterior hypertrophies—viz., the venous
sinuses  in  the anterior  hypertrophies are  not as
numerous nor as large  as  in the posterior variety,
and usually the inflammatory infiltration, as well as
the new-formed  connective  tissue,  is  much more
extended:  so that we  notice the venous sinuses only
near the periosteum  when situated  on the turbin-
ated bones, and  close to  the perichondrium when
the swelling springs from the cartilaginous  portion
of the septum.
   Thierfelder describes and figures the microscopic
appearance of a nasal hypertrophy found by accident
in a subject dead from  mitral insufficiency, and to
the heart-lesion he ascribes  the  formation of the
swelling in the nose.  There is, however, no doubt
that these swellings are of inflammatory origin, and
that in  Thierfelder's case it coexisted with, but was
not directly caused by, the heart-trouble, as he sup-
poses. The erectile character of the tissue composing
the hypertrophies causes them to increase in bulk
under certain  circumstances.   Thus,  I have noticed
that they are larger in women during the menstrual
periods,  and probably during the first months  of
pregnancy. Alcoholic stimulants cause them to swell
up, as does mental  and sexual excitement; in fact,
anything which tends to increase the blood-pressure
in the head.  In some cases they are  larger in damp
weather, while the moisture in the atmosphere does
not affect them in others.   It is probable that in the
                       22* 
258  DISEASES OF  THE  NASAL  CAVITIES.

first  instance they  have  undergone myxomatous
degeneration, giving  them hygroscopic properties.
  The glandular tissue situated in  the  vault of the
pharynx, and known  as the adenoid tissue or pharyn-
geal  tonsil,  also becomes involved in  the general
chronic inflammation, and is likely to become per-
manently hypertrophied.   When thus enlarged, this
tissue presents a rugged  appearance in the rhino-
scopic mirror, with  rounded eminences projecting
into  the pharyngeal cavity.  The  secretion of this
gland, when  thus  hypertrophied, is a  thick, glairy
mucus,  which  tightly adheres to  the  wall of the
pharynx.  Detached  pieces of the tissue, when exam-
ined under the microscope, show the glandular ele-
ments greatly increased in number, the epithelium
in the glands and ducts proliferating, and  the  scant
connective tissue infiltrated with  small-celled  infil-
tration.  This condition, however, but  rarely inter-
feres with the functions of the nasal  cavities, except
that it imparts to  the  voice a  nasal sound  by
decreasing the size of the post-nasal cavity, and thus
interferes with the normal nasal resonance.  An  en-
largement  of the turbinated bones themselves  is
sometimes met with, causing obstruction of the nasal
chambers, simulating ordinary hypertrophy of the
erectile tissue when viewed  through the nasal spec-
ulum.  Touching  them with the probe, however, at
once  makes their bony nature evident to the ob-
server.   The middle turbinated bone is usually the
one thus affected,  and not infrequently we notice a
splitting or cleavage, causing the  under portion to
be pressed against the septum, giving rise  to various
reflex symptoms.  Woakes  states that  this cleavage 
PATHOLOGY.
259
is always accompanied by necrosis of the interior of
the bone, and by the formation of granulations on its
surface.  He also asserts that this condition gives rise
to the formation of mucoid polypi.
  On the lower portion of the cartilaginous septum
we frequently notice protuberances which to the eye
closely  resemble  the   sessile hypertrophies of the
mucous membrane, but which, when  touched with
a probe, have a hard,  elastic feel, the same as is con-
veyed to the  hand when touching the cartilaginous
septum in other apparently normal portions.   These
are not localized deviations of the septum, for we do
not find a corresponding depression on the other side,
but they are  true hypertrophies of the cartilage, as I
had occasion to prove by removing a very large one,
and  submitting it to  microscopical  examination.
The ecchondroses, as  they are called, are of various
shapes  and sizes, sometimes presenting  a  tit-like
projection from the smooth surface of the septum;
sometimes they  are  ridges  running horizontally,
vertically,  or obliquely from before backward, or
from  below  upward ;  and, in not a few cases, we
notice them as shelf-like projections running along
the lower  portions of  the  septum, leaving  but a
narrow channel between their lower surface and the
floor  of the  nose, and they often extend  along the
whole length of the septum.  In most instances ossi-
fication in their substance has taken  place.   As
regards their origin, I have  come to the conclusion
that these simple cartilaginous excrescences are due,
not to external traumatism, but to internal local irri-
tation of the  mucous membrane of the cartilaginous
septum primarily, and of the perichondrium second- 
260   DISEASES  OF THE  NASAL CAVITIES.

arily.  If we consider that a turgescent or hyper-
trophied portion  of the turbinated tissue, which for
a considerable length of time is in contact with the
mucous membrane of the  septum, must necessarily
exert a certain amount of pressure upon that mucous
membrane, and upon the perichondrium underlying
it, and that even a very slight pressure, when  it is
kept up for a considerable  period of time, will  pro-
duce local congestion of the part  pressed upon, be it
on the outer integument of the body or the mucous
membrane, it  seems plausible to assume that this
local congestion gives rise  to changes of nutrition of
the part  sustaining the pressure.   Taking into  con-
sideration the peculiar histological structure of carti-
lage, and particularly of hyaline  cartilage, in which
the blood is supplied by loops of vessels dipping into
the substance of the cartilage  from the perichon-
drium, and the nutrition of the cells is carried on by
osmosis from  one to the  other  without the inter-
vention of a  capillary network of bloodvessels, we
can readily see  that a localized  increase  of blood-
supply to these loops must necessarily give rise  to a
more rapid cell-division and proliferation of the inter-
vening cartilage-cells than is demanded to supply the
waste by cell-death, and localized increase of carti-
lage-tissue must result therefrom.
  In the majority of cases the cartilaginous projec-
tions from the surface of the septum  correspond  in
position and size to the line of pressure by the tur-
binated tissue, and in  those cases of atrophic rhinitis
in which they  are found, careful examination  of the
patient will elicit the fact that at  some former period
a hypertrophic rhinitis has existed, which has given 
PATHOLOGY.
261
rise to the ecchondroses in the manner described.
It is, of course, impossible to state what length  of
time is required for their formation, and how long
the pressure must exert  its influence  before  any
elevation  on the  surface of the  septum  becomes
apparent.   And, further, it is impossible to give any
reason why, in  some instances, no apparent redun-
dancy of tissue  results from long-continued pressure
by  the turgescent turbinated tissue.   Individual
peculiarities in this case, as in  many other patho-
logical formations in the body, must account for the
differences  noted in  different cases.  In  some in-
stances an excessive growth of an ecchondrosis from
the septum will cause it to press against the opposite
turbinated bone, when erosion of both surfaces takes
place, and a bony union between the septum and the
turbinated bone  is established, forming  a more  or
less extensive bridge across  the nasal  chamber.   In
one case which has come under my observation, the
whole length of the septum was thus united with the
lower turbinated  bone, causing complete stenosis  of
the affected nasal  chamber.  Gottstein holds a similar
view as to the causation of these ecchondroses, while
Bosworth  claims that they are invariably of traumatic
origin.
  On the  floor of the nose we frequently see  bony
excrescences springing from the superior maxillary
bone, which were described by Dr. Harrison Allen.
These  are usually congenital, and, unless they give
rise to pain and inconvenience by pressure through
their size,  are harmless.
  In  many  cases,  deviation of  the cartilaginous
septum is due  to  an  inflammatory process of long 
 262   DISEASES OF THE NASAL CAVITIES.

 duration, and  beginning early in childhood.   The
 thin cartilaginous plate being over-nourished by the
 continually congested perichondrium, has  deposited
 within its substance more new cells than are required
 to substitute the old and defunct ones  which are
 being carried off, and consequently increases in bulk.
 But the bony framework into which it is set prevents
 an extension in height, and consequently a bulge to
 one side or  the  other occurs, just as a card being
 held edgewise  between the thumb  and forefinger
 will bulge when pressed.
   Malformations in  the  bony  walls  of the nasal
 cavities are  by no means rare, and the most common
 one is  deviation of the bony septum.  This is so
 frequent that Semeleder found the septum  straight
 in only ten  out of  forty-nine  skulls examined, and
 Allen found the nasal chambers normal in eighteen
 out of fifty-eight adult skulls  examined.  This devi-
 ation of the septum must in  a great measure be
 attributed to the fact that at birth both the  vertical
 plate of the ethmoid  bone and the cribriform plate
 are not as yet ossified, and do not become rigid until
 a much later period  of life, and  may therefore be
 easily distorted by external violence applied to  the
 nose  by blows  or  falls.   The  act of  blowing and
 wiping the nose with the handkerchief must also be
 considered as a factor in the production of deviation
 of both  the bony and cartilaginous septum.
  Hypertrophy or expansion  of one of the turbi-
nated bones  also is  not unfrequently a cause of
deviation of the septum, which is crowded out of its
normal  position by the protrusion  from the  lateral
wall of the nasal cavity. 
CORYZA.
263
  This short description of the pathological condi-
tions will, I trust, be  sufficient to give an insight
into the nature of the  morbid processes observed in
diseases of the nasal cavities; and we will, therefore,
at once enter upon the consideration of these diseases.

                     Coryza.

  An acute inflammation of the nasal cavities which
is called coryza, or cold in the head, exhibits the well-
known symptoms of, first, a feeling of fulness in the
nose, which gradually ascends into the  forehead,
producing there  a dull frontal headache.  In indi-
viduals who have very thick and long hairs growing
in the vestibule, an intolerable tickling of the skin of
the  vestibule frequently precedes these symptoms,
which is caused by a change in the position of these
hairs, so that the  ends  tickle the opposite wall of the
nostril, this erection  being due to a congestion of the
hair-follicles.
  An irritation of the mucous membrane next shows
itself, by frequent sneezing and tumefaction causing
partial,  or  complete,  stenosis  accompanied  by  a
burning sensation in the nose, and finally a copious
watery discharge, which later on becomes thicker by
the admixture of mucus, makes its appearance.
  Constitutional  disturbances show themselves by
general  languor and slight febrile symptoms, more
or  less  pronounced in  different  individuals, and
varying with the  severity of the local inflammation.
  On inspection of the anterior as well as the posterior
nasal cavities, which, however, is rarely made except
for  the sake of study, the mucous membrane will be 
264  DISEASES OF  THE NASAL CAVITIES.

found to be swollen  and intensely red, the swelling1
frequently obliterating the convolutions of the turbi-
nated bones.   Abrasions or ulcerations are  entirely
absent in a simple coryza.
  Cause.—This affection is caused either by a sudden
chilling of the surface of the body or by local irrita-
tion of the mucous membrane through the inhalation
of acrid vapors, or particles  of dust,  etc.   Among
the former, osmic acid is peculiarly rapid in its action,
producing an active coryza in from one to two hours
after exposure to its acrid fumes.
  The  duration of  the  affection is,  as  every one
knows,  a few  days.   It generally disappears within
nine days from the advent of the first symptoms.
   Treatment.—In  regard to the treatment  of this
affection very  little is to be said, inasmuch as every
one agrees that nothing can be done  to shorten or
stop the symptoms when once fully established, and,
therefore, the disease is usually  left to run its course.
If, however, the irritation becomes so great  that the
patient  is compelled  to sneeze incessantly, protec-
tion  of  the irritable  mucous  membrane from the
air is very grateful  to him.  This   may be accom-
plished  by 'a  snuff composed  of gum acacia,  sub-
nitrate  of  bismuth,  bicarbonate of sodium, and a
little sulphate of morphia.  The gum arabic coming
in. contact with moisture forms a  paste, which  is
made still more protecting to the mucous membrane
by the bismuth, when introduced into the nostrils as
a snuff.   The  soda is added to  prevent acid fermen-
tation, and the morphia to lessen the sensibility.
  Bromide of potassium, given in doses  of  from
fifteen to twenty grains  every  three or four hours, 
CORYZA.
265
hastens resolution somewhat in a great number of
cases, while in  others it seems  to  have no effect.
The fumigation of the mucous membrane by mu-
riate of ammonium vapor from the inhaler described
in Chapter III., and also by vapors of volatile sub-
stances, such as balsam of tolu, tincture of benzoin,
carbolic acid, etc., frequently hastens resolution and
reduces the irritation, thus making the patient more
comfortable.   The instillation  of a four per cent.
solution of cocaine into the  nostrils  also gives great
relief by the contraction of the turgescent turbinated
tissue.  It should, however, not be used more than
two or three times a day, as it loses its effect and
increases  the  tumefaction  of the tissue when  the
reaction sets in.  Washing out the nasal cavities
with  the  author's antiseptic solution (see  Chapter
VI.),  by means of an atomizer,  or even by sniffing it
up  the nose, is very grateful.
  Abortive  treatment is, however, often successful
if commenced in time.   The remedies employed to
cut short a cold in the head are, inhalation  or rather
fumigation with iodine in the  form of the tincture,
which must be used directly after the exposure to
the cause, hot stimulating drinks, such as hot whiskey
punch, a remedy which is used in every household to
avert a cold of any kind. Its action is supposed to
consist in an equalization of the disturbed  capillary
circulation on  the surface of the body.   In doing
this it prevents a local congestion and inflammation.
Tr. of aconite  rad. in small doses,  often  repeated,
also frequently aborts an attack of acute coryza.   If,
however, the congestion has .already  set in, alcoholic
stimulants will aggravate it. But even  then a cold
                        23 
266  DISEAS-ES OF THE NASAL CAVITIES.

in the  head can be aborted in many cases by the
use of the nasal douche, when obstruction of the
anterior nasal  chambers does not as yet exist, using
the water at a  temperature a little above blood-heat,
and adding to it some astringent together with com-
mon table-salt.
  Nasal Douche.—As the nasal douche is constantly
employed in the treatment of acute and  chronic in-
flammations of the lining membrane of the nasal
cavities, I will here say a few words in regard to the
proper use of  this  instrument.
  The  nasal douche (Fig. 68)  is a vessel either of
glass or tin, holding from one-half pint to two pints
Fig. 68.
Thudichum's nasal douche.
of liquid, and having near its bottom an opening.
This opening is in connection with a rubber tube
fitted at the free end with a nozzle of glass, rubber,
or wood, and fashioned  so as to fit the nostril.  The
vessel being filled, and the nozzle introduced into
one of the nostrils  of the patient, the water by gravi-
tation runs up the one side of the nose until it reaches
the posterior surface of the velum palati closing the 
CORYZA.
267
nasal cavity behind, and runs out by the other nostril,
thus bathing the mucous membrane, and cleansing
it by removing  all hardened mucus, either directly
or by loosening  it so that  it can be removed after-
ward by blowing the nose.
   There are, however, certain precautions necessary
in using the nasal douche, which, if disregarded, lead
to very unpleasant results, and there are a few cases
in which a fatal  inflammation of the brain has been
attributed solely to the use  of this  instrument.  Dr.
Roosa, of New York, as well as Dr. Lenox Browne,
of London, record  cases of severe inflammation of
the middle ear, caused by the nasal douche, and they
consequently condemn this instrument as dangerous
and of little use.  On the other hand, Dr. L. Elsberg,
of New York, and many  others,  among them the
author, have never met with  a case of injury  result-
ing from the use of this instrument, where the pre-
cautions to be mentioned had been observed  by the
patient.  Dr. Browne  does not  seem to lay much
stress upon the  proper density and temperature of
the liquid, and  this may be the cause of the un-
pleasant symptoms he observed in many cases fol-
lowing the use of the nasal douche.   If, however, the
precautions are closely observed, not only will there
be no unpleasant  effects following the use  of the
instrument, but, on the contrary, the patient being
pleased with its action is not willing to do without it.
  Precautions in the  Use of the Nasal Douche.—In the
first place, the bottom of the vessel  should, under no
circumstances, be elevated more  than an inch or so
above the eyebrows of the patient, as otherwise the
pressure is so great as to force the water into the 
268   DISEASES OF THE NASAL CAVITIES.

frontal sinuses or into the Eustachian tubes, giving
rise in the first instance to intense frontal headache,
and, in the second, to an inflammation of the mucous
membrane of the middle ear.
  The temperature of the liquid should  be raised in
the vessel to slightly above  blood-heat, so that after
it has run through the tube, and has thereby lost
some of its heat, it will feel  neither  hot nor cold to
the parts.
  Furthermore, the liquid used should be of the same
density or specific gravity as the serum of the blood.
The  congested  capillaries and venous sinuses  being
near the surface of the  mucous membrane,  while
the liquid is on the other side, only a  thin wall of
epithelial cells  separates them, and thus the most
favorable conditions for osmosis  are presented.   If
the liquid used in  the nasal douche be of a  greater
specific gravity than the serum of the  blood, exos-
mosis of the latter will take  place, leaving the cor-
puscles more densely crowded in the capillaries, thus
clogging them, and producing an irritation of  the
sensory nerve  filaments, which  we  perceive as  a
burning pain.  If, on the other hand, the liquid is of
less density than the serum of the blood, endosmosis
will occur, and the capillaries will be distended with
the increase of liquid, which  again  causes pain by
excitation of the nerve filaments.  It becomes, there-
fore, necessary to use in the nasal douche a liquid
which is like the  serum of the blood in  density as
well  as in temperature.   Such a liquid may be  ob-
tained by mixing about fifty-six grains of salt with a
pint  of water.  Dr. J. G. Richardson, while engaged
in his investigations on blood-stains, found that  a 
CORYZA.
269
solution of fifty-six grains of salt in a pint of water
produced a liquid in which blood corpuscles became
neither crenated nor swollen, as they do when sus-
pended either in a heavier  or  lighter liquid than
serum, and he consequently  used such a liquid with
very satisfactory results.  For practical  purposes it
is, however, sufficient to make the  liquid to be used
in the nasal douche, by adding an even  teaspoonful
of salt to a pint of water at 100° F.  To this may be
added any  astringent,  stimulating, or disinfecting
solution, provided the chloride of  sodium does  not
produce a chemical change therein, as would  be  the
case with nitrate of silver,  and  provided also that
the specific gravity of the liquid be not materially
changed by the addition of such other substances.
  More important,  however, than the above precau-
tions  is the proper selection of  cases.   If, as is so
frequently the case  in nasal catarrh, the nostrils  are
more or less obstructed by deviation of the septum,
exostosis  or ecchondrosis of the septum,  or by ante-
rior or posterior hypertrophies of the erectile tissue
covering the  turbinated bones,  and by  polypi, the
easy outflow of the fluid is prevented, it accumulates
in the post-nasa1 cavity, and is forced into the middle
ear, the frontal sinuses, and  even  into the antrum
and ethmoid  cells, giving rise  to  inflammation of
the mucous membrane lining these cavities.   It fre-
quently occurs that the  hypertrophies act as valves,
allowing the  fluid  to pass up, but prevent it from
flowing out again.   This is especially noticeable in
cases   of  posterior  hypertrophies, which, being  at-
tached to the  turbinated bones by a sort of pedicle,
are forced by the inflowing current into the post-
                       20* 
270  DISEASES OF  THE NASAL CAVITIES.

nasal cavity, thus making room for the liquid to pass
in, but are tightly wedged into the posterior opening
of the nasal chamber by the return current, and pre-
vent any outflow.
  In cases where the tissue is not sufficiently hyper-
trophied to  cause  an obstruction  to the current of
liquid  from  the nasal  douche under ordinary  con-
ditions, it will swell up and cause  obstruction when
an acute congestion is present, or if the fluid used is
too cold or  not of the proper density.  The  same
objections hold good when  the post-nasal syringe or
douche is used, for an obstruction in the nostrils also
causes in this  case an accumulation of liquid in the
post-nasal cavity.
  It will, therefore, be seen  that  the nasal douche
should be used  only in those  cases of nasal disease
in which there is no obstruction in the  nasal cham-
ber ; but where there is an accumulation of secretion
which, becoming inspissated, gives rise to the fetid
odor noticed in ozaena, a copious stream, such as can
only be obtained from the anterior or posterior nasal
douche, is needed to remove the dried crusts  and
thoroughly cleanse the nasal  cavities, and I am in
the habit of adding some soda or  borax to the solu-
tion of salt and water,  because I have found that an
alkaline solution dissolves and  dislodges the crusts
more readily  than a neutral one.  The amount of
salt should,  of course, be reduced in proportion to
the addition of the alkali.
  In  cases  of complete or partial stenosis of the
nasal  chambers, it is better to let the patient " sniff"
the salt  or alkaline solution up into the  nose from
the hollow  of the hand, or to use a hand-spray to 
CORYZA.
271
cleanse  the nasal  cavities.   The Dobell's,  or  the
author's  antiseptic solution, is  better adapted to
these cases than the plain salt and water.
  Several forms of the nasal douche are in the mar-
ket, some of which have great disadvantages,  and
are therefore to be avoided : for instance, the bottle
form, which  is most generally sold (Fig. 68).  The
narrow mouth of the bottle  makes  it inconvenient
to introduce the salt, and impossible to use a ther-
mometer to test the  temperature, while it also pre-
vents a thorough cleansing of the vessel.   The glass
tube at its bottom to which the  rubber tube is at-
tached is easily broken off, and then the  instrument
is useless.  Furthermore, it is too expensive an appa-
ratus for the use of the poorer class of patients.
Fig. 69.
Siphon nasal douche.
  Another form, called the pocket or siphon nasal
douche (Fig. 69), is very convenient, and efficient in
the hands of an intelligent patient, but almost useless
in the majority  of cases, inasmuch as it is  nothing
but a siphon, which must be started in order to work.
It consists of a rubber tube with a nozzle at  one end
and a weight attached to the other.   The weighted
end is sunk into the vessel containing  the salt solu- 
272  DISEASES OF  THE NASAL CAVITIES.

tion, which is elevated to the proper height; the air
is then sucked out of the tube and the current thus
started.  In using this siphon-tube it is always neces-
sary to keep the free end a little below the level of
the weighted end.
  The  form of nasal douche which will be found
most satisfactory, durable, and at the  same time in-
expensive, consists of a pint tin cup, with a piece of
tin  tube  soldered  in a hole  cut near the bottom of
the cup, to which the rubber tube is attached.   The
nozzle  at the free end of the tube is made  of hard
wood soaked in paraffine, or of horn.   This form of
douch  cannot be broken, is easily kept clean,  the
temperature can be accurately measured, and it costs
so little that even the poorest patients can  afford to
use it.
  Before the introduction of the nasal  douche by
Prof. Thudichum,  a syringe made of rubber, with a
curved nozzle, called the post-nasal syringe (Fig. 70),

                     Fig. 70.
The post-nasal syringe.
was used for the introduction of medicated solutions
into  the  post-nasal  cavity, and this  instrument is
frequently of great  advantage at the present day in
cases where strong  astringent and stimulating solu-
tions are to be employed, or  in  cases  where  the
crusts of hardened  mucus fail to  become loosened
and washed away by the gentle stream of the nasal 
CHRONIC NASAL CATARRH.       273
douche.  In the latter cases the nozzle of a syringe
should have a slit-like openiug instead of the usual
five or six small holes, because greater force is neces-
sary to dislodge the crusts.
  The introduction of the post-nasal syringe is, how-
ever, somewhat difficult, inasmuch  as  the nozzle
has to be brought up behind the soft palate, and
it should, therefore, not  be  trusted to the patients,
although they often do learn to use it on themselves.
After the nozzle has been  brought up behind  the
soft palate, the patient is directed to keep his mouth
open and bend his head over a basin, so that  the
stream of liquid shall pass out of both nostrils and
not regurgitate back into the mouth.
  We are  now prepared to  return to  the considera-
tion of the diseases  of the  nasal cavities, and will
take up the chronic  forms  of simple rhinitis, com-
monly called chronic  nasal catarrh.
               CHAPTER  XIV.

          CHRONIC NASAL CATARRH.

  A chronic inflammation and consequent derange-
ment of the  normal conditions of the nasal and
naso-phyryngeal cavities, no matter what the cause
may be, is  designated as chronic nasal catarrh, and,
although the term catarrh is not strictly correct  as
applied to  this  group of affections, yet it is uni-
versally used, and we will, therefore, adhere to it. 
274       CHRONIC NASAL CATARRH.

  Nasal catarrh is  one of the  most frequent affec-
tions  in this country, so much so that it has been
estimated that out of one million inhabitants of the
United  States, nine hundred and ninety thousand
suffer therefrom, and this average is even greater in
some localities.  This very frequency of the affection
has probably given  rise to the popular belief, which
is  shared  to a great extent  by the profession, that
nasal  catarrh is incurable.   Yet if we intelligently
examine into the pathological conditions giving rise
to the symptoms we will find that, in the  majority
of cases,  we  can  reasonably hope  to restore  the
healthy condition of the mucous membrane by ra-
tional treatment, and so cure our patients, often in
a comparatively short time.

            Simple Chronic Catarrh.

  By  this term is meant a chronic catarrhal inflam-
mation of the nasal mucous membrane, not depend-
ent upon  any systemic dyscrasia, such as  scrofula,
syphilis, lupus, etc., but  altogether  a local disease,
which, however, as has already been mentioned, may
give rise to systemic disturbances.
  This  affection is conveniently divided into two
large  subdivisions, viz., into  hypertrophic and atro-
phic nasal catarrh, which  may arise  independently
from each other, or  the atrophic may be a sequel and
consequence  of the hypertrophic variety.   As  the
treatment is, however,  very different,  these  two
varieties must be considered under separate heads.
  Hypertrophic Catarrh.—In this variety of the affec-
tion we observe two stages, viz., the stage of conges- 
SIMPLE CHRONIC  CATARRH.      275
tion with turgescence of the  venous sinuses in the
turbinated  cavernous tissue,  producing temporary
obstruction; and the later stage of true hypertrophy
of the cavernous tissue as well as of the mucous
membrane, producing permanent occlusion.
  The symptoms of the first stage are usually  a
superabundant watery discharge from the  nostrils,
which becomes greater when  the patient is exposed
to cold; a partial occlusion  of either one, or the
other, or both nostrils, which is transient in character
and  appears rather suddenly, when  the  mucous
membrane is irritated by dust or by cold air, as well
as from any cause which will produce  an increased
blood pressure in the  head, such as  alcoholic stimu-
lants, emotional disturbances, etc.; a frequent recur-
rence of an  acute coryza from trifling exposures,
which, however, is  not as severe nor  as long con-
tinued as true  acute coryza, in some  cases lasting
for a few hours only; and finally a slight  impair-
ment of nasal  resonance.  There may or may not
be  a discharge of thick glairy  mucus from  the
glandular tissue of the vault of the pharynx, accord-
ing to the amount of congestion or  inflammation
present in  that region.  Pharyngeal and laryngeal
symptoms  are  usually  not prominent, although  a
congestion of the mucous membrane of the larynx  is
observed in the laryngeal mirror, and a more or less
diffuse inflammation of the pharyngeal mucous mem-
brane, with enlargement of the follicles, is  noticed
on examination of these structures (Plate II., Fig. 3.)
  On inspection of the nostrils we see the mucous
membrane to be red,  and  somewhat  swollen  and
spongy to  the  touch of the probe, the cavernous 
276       CHRONIC  NASAL  CATARRH.
tissue covering  the turbinated bones, especially the
lower  ones, is  bulged  out,  thus  diminishing the
calibre of the cavities, but by gentle pressure  upon
it with a flat probe, or by the action of a weak solu-
tion (four per cent.) of cocaine, it can be reduced to
its normal size,  and the same  effect is produced by a
moderately strong, constant galvanic current, five or
six milliamperes, if the positive pole is placed on the
nape of the neck and the negative on the side of the
nose over the affected nostril.  Sometimes the one
and sometimes  the other nostril feels slightly ob-
structed, and when the patient is placed in a recum-
bent position it is the  side on which he  lies which
feels full, to become open, frequently with a sort of
click, when he turns over on  the other side, which,
then,  in turn, becomes  obstructed.  A rhinoscopic
examination, which is usually somewhat difficult to
make on account  of the increased  sensitiveness of
the upper pharynx probably due to the congestion
of the  parts, reveals the  same condition of the
mucous membrane in the vault of the pharynx as
was  noticed in the  nostrils, while the  cavernous
tissue over the posterior portions of the turbinated
bones,  if not  enlarged at  the  time, is usually
" puckered."  The tissue around  the  openings of
the Eustachian  tubes may or may not be swollen,
and the pharyngeal tonsil is somewhat  more promi-
nent than normal.
  On account of the slight  inconvenience experi-
enced by the patient, we but seldom have the oppor-
tunity to see nasal catarrh  in this stage,  unless we
examine every case of laryngeal or pharyngeal dis-
ease which comes under our notice, for this trouble. 
SIMPLE  CHRONIC CATARRH.       277
This condition  may last for years unchanged, or it
may pass into the  second stage within a few weeks
or months.
  The second stage, on the other  hand, is the stage
of catarrh  most frequently met with, and presents
the following symptoms.  The  patient  complains
that his  nose feels stopped up, especially when he
assumes  the recumbent  position ; that during the
night his mouth and throat feel dry ;  in the morning
and at frequent  intervals during the day, he  has  to
" hawk" in  order to  relieve a  feeling of fulness
caused by  the  accumulation of a thick, tenacious,
and more or less discolored mucus in the vault of
the pharynx.  Ordinarily the nostrils feel dry, but a
slimy discharge  appears when the  mucous membrane
is irritated.  In many cases,  a dull frontal, or,  in
some cases, a basilar, headache is present, which at
times, after an exposure to a cold and damp, or dusty
atmosphere,  assumes the character  of  neuralgia.
Spontaneous bleeding of the nose is also a frequent
occurrence in this  condition, and  when it occurs the
headache usually is diminished, or disappears alto-
gether.  Based upon this observation, Dr. Glasgow,
of St. Louis, treats congestive headaches by incisions
into the congested turbinated tissue,  a  procedure
which gives, in many cases,  almost instant relief.
The nasal  resonance  of the  voice  is  materially
impaired, causing what is termed a " nasal twang."
More or less  dryness of the pharynx, with follicular
enlargement  in  the mucous membrane, and  a dry,
tickling, laryngeal  cough  are present in cases of long
standing.   Asthma is also frequently  found to be
dependent upon the nasal obstruction, but it is more
                       24 
278       CHRONIC NASAL CATARRH.
particularly  noticed  when the obstruction  is pro-
duced by nasal polypi; while  many other  remote
symptoms, called reflex, such as paresis of the palate,
paralytic dysphagia,  paralysis  of  the vocal cords,
excessive lachrymation, paroxysmal sneezing, spas-
modic cough, and many other like reflex symptoms
are found to be due to intra-nasal disease, and partic-
ularly to pressure by obstructions.  The sense of
smell, although not lost, is considerably blunted, and
as a consequence the sense of taste also is less acute,
so that patients suffering from this affection  require
more and more seasoning in their food as the disease
progresses.  There may be a bad odor perceptible to
the patient as well as to others, but this is not usually
the case; and if present, it is different in character
and  less pronounced than the odor met  with so
frequently in atrophic nasal catarrh.
   In many  cases a chronic  middle ear catarrh  is
present, accompanied by impaired hearing, and more
or less tinnitus, which is  caused by  closure of the
Eustachian tube by mucus or by hypertrophy of the
tissue around  the opening.  In the same manner do
we find,  in some cases,  a  catarrhal conjunctivitis
which is dependent  upon the  nasal trouble, and is
probably due to  extension  of the inflammation
through, and to compression of the nasal opening of
the lachrymal duct by the hypertrophies, or it may
be due to reflex irritation  of  the ophthalmic branch
causing  this sympathetic  inflammation.  In almost
all cases a broadening of the bridge of the nose, and
a thickening of  the-outer integuments of the organ
are  very noticeable, giving  rise, in some instances,
to compression of the venous trunks and consequent 
SIMPLE  CHRONIC CATARRH.       279
stasis in the capillaries of the skin, which shows
itself as redness of the  skin, almost identical  in
appearance with the red nose of persons addicted to
too  frequent  use  of alcoholic  stimulants.   Acne
rosacea, as well as acne punctata are frequently met
with  in  cases of hypertrophic as well as atrophic
nasal catarrh, and this irritation  of the skin of the
face is due, no doubt, to two causes, viz., first, reflex
irritation of the vaso-motor nerves of  the skin, and,
second, to  the inability of the  erectile tissue of the
nose to act as a safety-valve in relieving the surplus
blood pressure in the capillaries of the skin of the
face and nose.  These conditions often are so promi-
nent  as  to amount to  deformity,  and it is highly
gratifying to the patient to see them  gradually dis-
appear, as the mucous membrane in the nose assumes
its normal condition under appropriate treatment.
  On inspection of the anterior nasal cavities, which
should always be  made with  the nasal speculum, so
as to prevent stretching of the ala, and consequent
disturbance of the relation of the parts to each other,
we find the mucous membrane of a light-red  color,
darker than normal, but lighter than in either acute
coryza or in the first stage of the disease.  It, as well
as the underlying cavernous tissue over  the  turbi-
nated bones, is thickened, so  as  to bulge out into
the nasal chamber,  more or less occluding the  open
space; especially is this noticeable at the  lower por-
tions of the turbinated bones (see  Fig. 64).  These
hypertrophies, as they are  called, whose anatomical
nature  was described  in  the ' preceding chapter,
when pressed upon with the  probe  cannot  be  re-
duced  but only indented, which  depression imme- 
280       CHRONIC  NASAL CATARRH.
diately disappears on the withdrawal  of the probe,
while cocaine solutions reduce their bulk but very
little.   In some cases we find not only the  soft
tissues but also the" turbinated  bone itself  hyper-
trophied, or expanded beyond its normal size, which
can  readily be  demonstrated  by the touch of the
probe.  When the hypertrophies are so large as to
press against  the   septum, we  frequently  notice
shallow ulcers of the  mucous membrane  covering
the septum at the point of contact, and  spreading
from thence  over  a  larger  area.    These  hyper-
trophies when situated  at the anterior portion of the
Fig. 71.
        Dilated nostrils, showing ecchondrosis of septum.
  11. Middle turbinated bone.  2 2. Lower turbinated bone.  3. Edge
of vestibule. 4. Shelf-like projection from septum. 5 5.  Floor of nose.

lower turbinated bone are  termed " anterior hyper-
trophies;" when on the middle turbinated bone, as
seen from the opening of the nostril, they are known
as " middle hypertrophies." 
HYPERTROPHIC CATARRH.       281
  In cases of long standing we find thickening of
the cartilaginous portion of the septum, and  ex-
ostosis of the  vomer, which  not  unfrequently is
localized, and  assumes a shelf-like shape (Fig.  71),
running the whole  length of  the septum, the  flat
surface of the shelf being below and near the floor
of the nose, and leaving  but a small portion of  the
inferior meatus pervious.  In other cases, as already
mentioned, we find ecchondroses from  the  cartilagi-
nous  portion of the septum, which may be in  the
shape of rounded eminences or ridges  running in
various directions.
  Deviation of the septum  and bony excrescences
into the floor of the nose from the superior maxil-
lary bone, are also sometimes  found  to produce
obstruction of the  anterior nasal chambers ; their
pathology and causation  have already  been men-
tioned.
  A  rhinoscopic examination, which usually pre-
sents  no  difficulty in these  cases on  account of a
certain amount of sluggishness of the  velum, shows
the mucous membrane in the vault of the pharynx
and at the posterior nares to be in the same state of
inflammation that was noticed in the anterior nasal
chambers.   If the  nose has not been washed  out
previous  to the examination, flakes of thick white
mucus will be seen adhering  to the mucous mem-
brane, and especially in the depression  around  the
opening of the Eustachian tubes, as well as in  the
crypts of the pharyngeal tonsil, which  latter is more
or less enlarged.  In some cases the enlargement or
hypertrophy of this  glandular tissue amounts almost
to a new growth, and  may, besides causing an  ob-
                       24* 
282       CHRONIC NASAL CATARRH.
struction to the air-current, prevent the  posterior
nares from  being seen in  the  rhinoscopic  mirror
(Fig.  72).   In  other  cases the  cavernous  tissue
  ' Rhinoscopic image in case of hypertrophy of pharyngeal tonsil.

covering the posterior extremities of the lower and
middle turbinated bones is seen to be hypertrophied,
forming  tumor-like  excrescences, which hang by a
short thick pedicle  in  the nasal  cavity, thus pro-
ducing stenosis  (Figs. 65  and 66).  These  posterior
hypertrophies are of  two varieties, viz.:  the kind
which appears  of  a  white color,  with  a  deeply
notched surface  and of a  tough, fibrous consistence,
and the kind which has a  purplish-brown color, with
a smoother surface and much softer than the  other
variety.  This latter kind frequently bleeds, and as
the flow of blood  is prevented  from entering the
anterior nasal chambers by the obstruction  produced
by the hypertrophy itself, it runs down the pharynx,
and on entering the larynx gives rise to cough, thus
simulating haemoptysis.
  In  other cases, still, we notice  protuberances on
one  side, or on both, of the vomer, usually of a 
          HYPERTROPHIC  CATARRH.       283

lighter color than the rest of the mucous membrane
(Fig. 73), which may be the posterior extremities of
the sh elf-like  projections from the septum, or may
be exostoses from the vomer, or, finally, more fre-
Fig. 73.
  Rhinoscopic image in a case of hypertrophic tissue on the vomer.

quently are hypertrophies of the mucous membrane
and its underlying tissue.  Ulcerations are but rarely
seen in the post-nasal cavity in this form of chronic
nasal catarrh.
  Causes.—The causes of chronic nasal catarrh  are
very numerous, and it is difficult to name any one
in particular;  but most of them are intimately con-
nected with the pleasures and  vices of civilized life,
for this disease is not found among the lower animals,
and but seldom among the uncivilized races of man.
As  has been said, a frequent  repetition  at short
intervals of an acute  coryza, which sequence often
happens in our changeable climate, predisposes  the
mucous membrane to chronic inflammation, and thus
weakening the tone of the muscular fibres surround-
ing the sinuses of the cavernous tissue, causes them
to become distended  and form the hypertrophies.
  The  breathing  of  impure   air in  ill-ventilated
rooms, and especially at night and during sleep, is 
284       CHRONIC NASAL CATARRH.
a frequent cause.   So, also, is inhalation of air filled
with dust,  and particularly dust composed of fila-
ments  of cotton or wool, such as is to be found in
cotton  mills, and in  rooms the  floors of which are
covered with carpet.  This is probably the reason why
this disease is so much more  prevalent in America
and England than on the continent of Europe, where
carpets are  only  to be found in the  houses of the
wealthy.   Alcoholism, masturbation, venereal  ex-
cesses,  and anything that tends to lower the vitality
of the system must be looked upon as causes of nasal
catarrh.
  Partial  or complete  stenosis, produced  by  the
introduction of foreign  bodies  into the nostrils, by
congenital  or acquired malformation of the bony
framework  of  the nose,  or  by  neoplasms of  any
kind, or, finally,  by  the  calcareous  deposit around
a nucleus of foreign matter called a rhinolith, which
sometimes  assumes such proportions as to  produce
complete stenosis of the nasal  chamber, will cause
chronic nasal catarrh.  This is  a point of great im-
portance, for, as we have seen, nasal stenosis is pro-
duced by the catarrh itself, and is kept up by it.  It
would, therefore, be  reasonable to suppose that, if
the obstruction to nasal breathing is removed, the
chronic inflammation will either  disappear per vis
medicatrix natural, or else will be cured   by  mild
astringent  applications  in a short  time.   This is
fully verified by  clinical observation, and gives us
the key-note to the  successful  treatment of hyper-
trophic nasal catarrh.
  Treatment.—The treatment of hypertrophic nasal
catarrh must be  directed mainly  to the locality in 
TREATMENT.                285
which the disease manifests itself, viz., the mucous
membrane of the nasal  cavities, and  must be calcu-
lated to restore that mucous membrane to its normal
condition.  Both in the first  and second  stage the
nasal cavities must be kept free from the  accumula-
tions of mucus, by  washing  them  twice daily, or
oftener if necessary, with  the normal salt solution
(an  even teaspoonful of salt to a pint of water), or
with the  author's antiseptic solution, which should
be sniffed up the nose from the hollow of the hand.
Astringent solutions thrown  into the nostrils with
the atomizer should be used by the practitioner only,
two or three times a week, and he should  select the
particular astringent best  suited for the individual
case, such as a  solution of ferric alum (four grains
to the ounce of water)  or weak solutions (five or ten
grains to the ounce) of sulphate of zinc, copper, iron,
etc.; distilled extract of witch-hazel, diluted one-half
with water; or finally, Boulton's solution, of which
the following is  the formula:

           R.—Tinct. iodini comp.  n\xx.
               Ac. carbol. (cryst.)  Ttlvj.
               Glycerinse,        fi^vij.
               Aq. dest.          A 3 v.
  M. et place in water bath of 100°, in tightly corked bottle, until
the solution becomes colorless; then filter and use in atomizer.

   A moderately strong constant current of electricity
(five or  six cells), the positive pole to the neck and
the negative over  the  nose,  applied two  or  three
times a week, for about five minutes at a time, has
a very beneficial effect in  reducing  the  turgescence
of  the venous sinuses in the first stage, but is of no 
286       CHRONIC NASAL  CATARRH.

avail in reducing the permanent hypertrophies of
the second stage.
  In those cases in which there is dryness of the
mucous membrane in the nostrils, and a thick, glairy,
mucous discharge from the vault of the pharynx, the
topical application of iodine to the post-nasal cavity
is of great benefit in stimulating the serous glands
and making the secretions more watery;  besides, it
has the effect of diminishing the hyper-sensitiveness
of the palate, so that after a few applications a rhino-
scopic  view can be  obtained, which before was im-
possible.   The applications may be  made through
the mouth by means of a tuft of cotton  soaked in
the solution and held in the sponge-holder or cotton-
applicator, bent to the right curve to reach the vault
of the  pharynx, or  it  may be made  by passing the
straight cotton-applicator  through the nostril to the
posterior nasal cavity along the lower meatus, which
can always be done  in the first stage, or even in the
second where there are no bony or hard obstructions.
The effect of the iodine upon  the mucous membrane
of the anterior nasal chambers is also very beneficial
in reducing the inflammation and the sensitiveness,
so that I am in the habit of making an application
both to  the naso-pharyngeal  cavity through the
mouth, and whenever possible also through the nos-
trils.   When the application is made through the
mouth, great care must be exercised to prevent the
iodine  from entering  the  larynx, by running down
along the posterior wall of the pharynx, for if it does
so severe laryngeal spasm  almost invariably sets in.
  Three  solutions of the following strength w7ill be
found to  answer in most cases: 
TREATMENT.
287
No. 1.
No. 2.
No. 3.
B.	—Iodine,	grs. viij.
	Potass, iod.	grs. xxxviij.
	Glycerinse,	fl^VjSS.
B.	—Iodine,	grs. xij.
	Potass, iod.	grs. 1 viij.
	Glycerinse,	flgvjss.
B.	—Iodine,	grs. xv.
	Potass, iod.	grs. lxxv.
	Glycerinse,	fl3vj*s.
  Applications should be made with solution No. 1
until the patient ceases to feel any sensation a few
minutes  after.   No. 2  should  then be  used;  and
when it has lost its power to irritate, No. 3 may be
resorted  to, but is not called for in the  majority of
cases.  The smarting occasioned by the iodine solu-
tions can be mitigated to a great extent by throwing
a spray of fluid cosmoiine (No. zero) into the nostrils,
and follow this by blowing some of the morphia and
bismuth  powder recommended in the treatment of
acute coryza.
  Nitrate of silver in any form or strength, as well
as astringents and irritants in the form  of powder,
should under no circumstances be used in the  treatment of
hypertrophic nasal catarrh, as they invariably give rise
to swelling of the  mucous  membrane, and an  in-
crease in the hypertrophies, thereby aggravating the
symptoms.
  Muriate of ammonium in  the form of  vapor, and
the smoke from burning cubebs, are popular reme-
dies in this disease; but after careful trial, extended
over a long period and with a number of patients,
I found that  the effect of these remedies, although
pleasing at first and seemingly beneficial, is entirely 
288       CHRONIC NASAL CATARRH.

lost within a very short time, and it is therefore use-
less to try them The only good quality they possess
is that they are harmless, and may be used as psycho-
therapeutical agents in acting upon the mind of the
patient.
  There are a number of  drugs which, when taken
internally,  act upon the nasal  mucous membrane,
and thus aid the local  applications in their curative
action.  Among them are  the iodide of potassium in
small doses, combined with  bromide, the oleo-resin
and the cold  expressed fluid extract of cubebs, the
fluid  extract of Grindelia robusta, iodoform, crude
petroleum, etc.
  Tonics, fresh air, regulation of diet, and  hygienic
surroundings,  as well as a change of occupation (if
it is found  to be the exciting cause of the  trouble),
should be as a matter of course advised, with a view
to tone up the  system and remove the exciting cause.
In all cases the treatment must necessarily be a more
or less protracted  one, and  it is of importance that
the local applications be made  at short intervals in
the  beginning at  least.   Under no circumstances
should any surgical procedure  be undertaken until
all acute and  subacute inflammation  has  been re-
duced by these topical applications and the general
medical treatment.
  Thus far we have considered only what might be
termed the medicinal treatment of the disease, viz.,
the internal administration and the local application
of remedial agents to the seat  of  the disorder, as
well as attention to the general health of the patient,
and it remains to describe the more important part
of the treatment,  especially as  regards the second 
HYPERTROPHIES.
289
stage of hypertrophic catarrh, viz., the  removal of
the stenosis, which may be termed the surgical treat-
ment; for this can be accomplished only either with
caustics or with  cutting instruments.
  Surgical treatment.—As the obstructions to the cur-
rent of air in the nasal cavities vary in  character,
different methods must be employed for the removal
of the different varieties, and this makes it necessary
that they should be considered under different heads.
  Hypertrophies.—As we have seen, both  anterior,
middle, and posterior hypertrophies of the cavernous
tissue overlying the turbinated bones are of the most
frequent occurrence, and give rise to stenosis, either
partial  or complete.   A number of caustics have
been recommended  by authors on the  subject, for
the removal of these  swellings,  such as  nitric acid,
chromic acid,  acetic  acid (glacial), Vienna paste,
actual and galvano-cautery, and their use is attended
with more or less success;  but it has been my expe-
rience that all chemical caustics, if applied to the
mucous membrane over the hypertrophies in a suffi-
ciently concentrated form to destroy the tissue below,
give rise to so much pain and subsequent extensive
inflammation  that I have found it  necessary to dis-
card  them.  The same is true of the actual cautery
with a glowing wire, for the amount of metal of the
instrument is  so small that it cools before we can
apply it to the desired spot in the  nasal cavity, and
then only scorches the mucous  membrane without
destroying any of the  deep-seated tissue.  Further-
more, chemical  caustics cannot with safety be ap-
plied to posterior  hypertrophies,  as  their  action
cannot be readily checked by  neutralizing agents.
                        25 
290       CHRONIC  NASAL CATARRH.

  I have found that the galvano-cautery is the most
satisfactory agent in removing anterior and middle
hypertrophies, if they are not so large as  to  press
against the septum, thus preventing the introduction
of the platinum loop, and the application should be
made in the following manner : A pledget of cotton
saturated with a four per cent, solution of cocaine,
is introduced into the  nostril and placed over the
hypertrophic portion to be  operated on, and left  in
situ for  about  ten  minutes.  A  stronger  solution
may be used if it is  important to save time, but no
better results are obtained by it, except that it acts
more quickly in anaesthetizing  the  mucous mem-
brane.
  A metal nasal speculum  is then introduced into
the nostril,  until its end has passed the vestibule
and  the  hypertrophy is brought  into view; then a
slender galvano-cautery knife set at an angle to the
handle (Fig. 74), so as  not to  obstruct the view by
the  hand holding  the instrument,  is  introduced.
This galvano-cautery knife is composed of two pieces
of stout  copper wire, having holes drilled in their
ends which are flattened by hammering, and  they
are insulated from each other by suture silk wound
around  them in a figure-of-8 fashion throughout
their whole length.  A  piece of platinum wire  of
the required length and thickness is then bent into
a loop and hammered flat,  and its ends are inserted
into the flattened holes at the  ends of the wires and
pressed down until the loop is firmly fastened.   This
arrangement enables the operator to fashion his own
loops to suit the requirements of the different cases,
and makes  him  independent of the instrument- 
HYPERTROPHIES.
291
makers; while the  copper wires can  be made of
considerable thickness, thus introducing but little re-
sistance to the electric current in its passage through
them.   The handle  is so  arranged that the knife
      Seiler's galvano-cautery handle with loop and knives.

can be inserted at different  angles, and has a screw
attachment for drawing in the wire when the instru-
ment is to be used as a galvano-cautery snare for the
removal  of larger tumors.  The  current from the
battery is then passed through the knife, and when 
292      CHRONIC  NASAL  CATARRH.

the latter is at a cherry-red heat, an incision is made
through the mucous membrane into the cavernous
tissue of the hypertrophy.   It is of great importance
to have the platinum loop at the proper temperature
when the  incision is made, for if it is too hot con-
siderable hemorrhage will follow, and  if too cold
the application is  very painful.  Care should also be
exercised in protecting the  skin of the vestibule, for
if it is touched with the hot instrument the  pain  is
very considerable and lasting.   If the knife is small
enough, it  is not necessary to protect the mucous
membrane of the septum, and even if a  cut is made
into it by accident no harm  is done.  The cut should
be carried down to the surface of the turbinated bone
and the operator  can  readily  feel the grating of the
edge of the platinum loop when the bone is reached.
   The immediate result of the incision is the forma-
tion  of an  eschar, and of  a certain  amount of in-
flammation which stands  in a direct  ratio to the
extent of the burn, and, therefore, not too large  an
incision should be made at any one sitting; extensive
inflammation having followed the operation in some
cases  where too  much  tissue had  been destroyed
with  the galvano-cautery knife.  Care  should also
be taken not to burn the tissue while in a state  of
active inflammation, and the galvano-cautery should
never be applied until the mucous  membrane has
been treated with  the alkaline solution and the iodine
applications, so as to reduce the hyper-sensitiveness
and the consequent risk of excessive inflammation.
   The ultimate result of  the operation is the forma-
tion  of bands of cicatricial tissue, which by their
contraction bind down the  swelling, uniting the sur- 
HYPERTROPHIES.
293
face of the mucous membrane with the periosteum
of the turbinated bone in the line of the incisions,
and thus prevent the stenosis.   The number of inci-
sions  necessary  to  obliterate the hypertrophy  will
depend upon its size and firmness, but from two to
four are usually  sufficient.
  In  some cases where  the mucous  membrane is
peculiarly sensitive, the operation is  followed by an
acute coryza within twenty-four hours, which  can,
however, in a great measure, be prevented by blow-
ing some of the morphia and  bismuth powder  into
the nostril immediately after the  burning has been
accomplished.  As a rule, however, no inflammation,
except in the immediate neighborhood of the burn,
follows, and the operation, if properly performed, is
almost painless.
  To insure this result, however, the temperature
of the loop must be under the perfect control of the
operator, and as the galvano-cautery batteries in the
market  do not  admit of a nice and immediate ad-
justment of the amount of current sent through the
platinum  loop,  I devised a battery  which, having
been perfected in its details by Mr. Otto Flemming,
has given entire satisfaction in this  and other  par-
ticulars.   This  battery (Fig. 75) consists  of a series
of carbon and zinc plates connected for  quantity—
i. e., all  the zincs  as well as the  carbon plates are
united together, and the circuit is completed through
the battery fluid, on the one hand, and through the
platinum loop, which, by means of conducting wires,
is connected with the terminal binding posts, on the
other.  This system of plates is mounted on a plat-
form which is fastened  near the top of the box, so
                        25* 
294       CHRONIC NASAL CATARRH.

that they hang from it into the interior of the box.
Immediately beneath the  plates is a hard-rubbr cell
containing the exciting fluid, mounted upon another
platform, which can be raised or lowered by means
Seiler's galvano-cautery battery.
of a treadle projecting from  the box.  This treadle
is jointed, so that by folding it up it can be placed
inside of the box out of view and harm's way.  When
it is depressed the platform with the cell rises, and
the system of plates is  immersed in the exciting
fluid, whereby the current is established.  The height
to which the  cell is raised determines the amount of 
HYPERTROPHIES.
295
current, and consequently the amount of heat in the
platinum loop, for the higher the cell the more sur-
face of the plates is exposed to the action of the
liquid, and the more  current is developed.  As the
treadle is actuated by the foot of the operator, it will
be  seen that he can  control the amount of current
during the operation without the aid of his hands or
of an assistant, as is necessary in  the case of the
ordinary galvano-cautery batteries,  and can regulate
the temperature of the knife to a nicety.
  The  rubber cell  being large, contains  a large
amount of fluid,  and as the plates are entirely out
of  the  liquid when  the  platform  is lowered, the
liquid is not readily  exhausted, so that the necessity
of refilling the cell with fresh liquid does not occur
very often; a point,  the advantage  of which will be
apparent to every one who  has ever used a  battery
with  small cups which  require refilling after each
operation.
  The battery of one cell is sufficient for the opera-
tions in the nose, but when  larger operations are to
be  performed in which the heat has to be kept up
for a considerable time, a two-cell battery should be
employed.
  As both the faradic and  the galvanic current of
electricity  are frequently used in  the treatment of
diseases of the throat and  nose, the advisability of
having a battery which  would yield the different
forms  of  current presented itself,  and at my sug-
gestion Mr. Flemming made the universal  battery
(Fig. 76),  which  in  principle is the same as the
galvano-cautery battery, except that it contains two
systems of plate instead  of only one, which, by a 
296       CHRONIC  NASAL CATARRH.
commutator, can  be combined  either for quantity,
when the battery is to be used for galvano-cautery,
or for intensity, when the  galvanic current is  de-
Fig. 76.
Seiler's universal batterv.
sired.  In the latter instance, the  rubber cells  con-
taining the liquid  must be changed for cells which
are subdivided, so  as to give for each  pair of plates 
HYPERTROPHIES.
297
of carbon and  zinc a separate compartment.   This
change can be  effected  with very little trouble, and
in a very short time, and then a galvanic battery of
twenty cells is obtained which may be employed to
run the electric motor, or give an  electric light, as
well as for medical use.   In the same box containing

                      Fig. 77.
Gibson's storage battery.
the cells and plates is inserted a galvano-faradic ap-
paratus, which is independent, and may be removed
for the sake of  portability.  This battery thus will
be found  a most useful  piece of apparatus in  the
office. 
298       CHRONIC NASAL CATARRH.

  A more serviceable and less cumbersome battery
has lately been introduced  by the  Gibson Electric
Company, of New York, which consists of a storage
battery of small size, containing one, two, four, or
more cells, according to what  is desired, and giving
a current which is amply sufficient  for all galvano-
cautery  operations  (Fig. 77).   Each cell  has an
electro-motive  force of two  volts  and a current
strength of about six ampere  hours, so that for the
smaller operations in the nose the current must be
reduced.   This can  easily be  done by introducing
a resistance into the  circuit, which need  not be
changed after the proper heat  of the platinum  loop
has been obtained, because the current given off by
a storage  battery is constant until the charge is ex-
hausted.   A battery of  this kind  can be  charged
from a few  cells of the ordinary telegraph battery,
or it can  be placed in the circuit of  an incandescent
light circuit, in place of a lamp.  The  time of charg-
ing varies according to the  ampere strength of the
primary current, while, when fully charged, the bat-
tery can be  used for a  very large number of opera-
tions before becoming  exhausted.  Abattery of four
cells is sufficient  to light up one  of  the  electric
laryngoscopes for a considerable length of time.
  When the anterior  hypertrophies are very large,
or in cases  of posterior hypertrophies, the  galvano-
cautery is not applicable,  and  I  then prefer the
Jarvis' snare for removing  them.
  This admirable little instrument (Fig. 78) consists
of a small canula about seven inches long, made of
steel.  About  four inches from the lower end is  a
cross-bar, and the portion between this and  the end 
HYPERTROPHIES.
299
is threaded and carries a screw nut, which, by being
turned, travels up  or  down.  A portion of  the  cir-
cumference of this threaded piece of the canula is
filed flat throughout its entire length, and
has lines engraved  across its face.   Over  FlCf- 78>
this and behind the nut slips a tube which    \)
is  fitted  to  the  flattened screw so  as to
prevent its turning around, and  has a slit
cut into that portion overlying the flat
surface of the threaded piece of the in-
strument, so that the division lines can be
seen through it.  This tube carries on its
end two retention pins and a screw cap,
by means of which the ends of the wire
are fastened. Thus  it will  be  seen that
by turning the nut  the tube will be pushed
downward, and  the wire loop projecting
from the distal end of the canula is there-
by made  smaller.  The* end from which   C5yP3
the wire loop projects, and which, during
the operation, is pressed against the tissue,
has an olive-shaped tip to prevent injury
to  the tissue.   The  opening in this tip
should be oval to  prevent  the turning of
the  loop  during the introduction  of the
instrument into the nose.  A short curved
piece  of  canula,  with  tip  of  the same    §jjpj
shape as  the one just described, may be   p"^
substituted  in some  instruments for the   /    ]
straight canula, and  it can then be used jarvis'snare.
for ablating the hypertrophied pharyngeal
tonsil.  The wire  used for anterior  hypertrophies
should be a fine  annealed steel piano-wire, and  is 
300       CHRONIC NASAL CATARRH.

sold by dealers as No. 0, while  for posterior  hyper-
trophies, and for the pharyngeal tonsils, it  should be
several numbers thicker.
  Supposing that we have a case of auterior  hyper-
trophies which are to be ablated with the  snare, we
proceed as follows: The parts are first anaesthetized
with cocaine solution in the same manner as was
described  above, for the operation with the galvano-
cautery knife.  The base of the hypertrophy is then
transfixed with a flat  and  slightly  curved needle,
having a light metal handle (Fig.  79).  A piece of
the thin steel wire having been  cut of the required
length, both  ends  are pushed through the canula,
and  are  fastened  securely to the sliding tube by

                     Fig. 79.
Jarvis' transfixing needles.
winding them around the retaining pins, and screw-
ing the cap home.  The  loop, which should project
from the olive-shaped tip for about three-quarters of
an inch, longitudinal diameter, is then passed around
the handle of the transfixing  needle, and over  the
growth and  point of the needle as it emerges from
the tissue, and traction is made on the sliding tube
until the wire encircles the swelling.  The  tissue is
then gradually snared off by turning the nut, which,
pushing the sliding tube down, draws the wire loop
through the tissue into the  tip of the canula.  When 
HYPERTROPHIES.            301
 the wire has passed entirely through the swelling,
 which it does  generally with a jerk, the
 hypertrophy comes away sticking to the   Fl»- 8"
 transfixing needle.  The operation is, how-
 ever, by no means easy to perform,owing
 to the fact that it is often very difficult to
 get  the wire  loop over the  projecting
 point of the needle, so that the snare has
 to be  frequently withdrawn  and reintro-
 duced before the desired end is  accom-
 plished.
   In order to  overcome  this difficulty I
 have lately devised an attachment to the
 Jarvis' snare which facilitates the opera-
 tion very materially (Fig. 80).  This at-
 tachment consists  of  a pair of  curved
 claws, projecting beyond the  end of the
 canula, and  separated  from each other
 about one-half  of an inch.  A slide, hav-
 ing  a long  stem,  by  which it  can be
 pushed forward, slides over the shanks of
 the claws, and by this motion closes them
 against each other, raising them slightly
 at the  same time  from the canula. In
 using this instrument, the canula with the
 claws  open,  and the  wire loop  of the
 proper  size,  is introduced into the  dis-   EI
 tended  nostril, the claws  are  pressed
through the loop against the hypertrophy Seiler's ciaw-
and closed  by pushing the slide forward,  attachment
when the piece  of tissue grasped between  snare
them will be pulled through the wire loop,
which should then be  tightened around  it  and the
                       26 
302       CHRONIC  NASAL CATARRH.

hypertrophy cut  off slowly.  The piece which has
been thus ablated is firmly held by the claws.  The
operation should occupy fifteen or twenty minutes,
because it has been  found that if the  tissue is cut
through quickly the pain is greater, and  the hemor-
rhage  sometimes  quite  copious.   If, on  the  other
hand, it is done slowly, the patient experiences but
little  pain,  and hardly any bleeding  follows the
operation.  The wound  left is very small on account
of the  compression of the mucous membrane during
the process of snaring, and generally heals by  gran-
ulation,  so that no special treatment is necessary.
Middle  hypertrophies  and  hypertrophic  tissue  on
the septum can be removed in  the same manner.

                       Fig. 81.
Rhinoscopic image in a case of cleft palate with posterior hypertrophies.
  1 1. Middle turbinated bone.  2 2. Hypertrophic tissue on vomer.
3 3. Posterior hypertrophies on lower turbinated bone. 4 4. Opening
of Eustachian tube.

  If we have to deal with a case of posterior hyper-
trophy, however (Fig. 81), the manner of operating 
HYPERTROPHIES.            303
is quite  different.  In this  operation it  is of great
importance that the size of the wire loop should  be
measured before introducing it into the nasal cavity,
and this may be  done in the following manner:
  After the ends of the wire have been  made fast a
piece of hard wood, shaped like a wedge, is thrust
into  the loop.  The triangular base of the wedge is
rounded off, and its narrowest part rests on the  tip
of the instrument, while the wire  is drawn tightly
over it by pulling upon the sliding tube.  The cir-
cumference of the wedge is first measured by mak-
ing a wire loop of the same size and drawing it just
within the  orifice of the tip, at the same  time noting
the distance traversed by the slide-tube.  This dis-
tance is added to that previously registered by the
slide-tube when  it  clasped the wooden wedge, and
the  number found will be that indicating complete
section of the hypertrophied tissue.
  The loop might be measured by drawing it into
the instrument, but  then the wire becomes "kinked "
and  is very apt  to  break at  that point during the
operation, while when measured in the  manner  de-
scribed the loop  retains its  shape.  Before introduc-
ing  the  instrument into the  anterior  nares, when
posterior hypertrophies are to be removed, the loop
should be made  as small as possible without distort-
ing  it, by pulling down the sliding-tube.  As soon
as the end of the instrument has entered the  post-
nasal cavity, the loop is again enlarged by pushing
up the tube to which the ends of the wire are fast-
ened.  This has the effect  of throwing the loop out
and  bending it  toward the growth to be removed,
thus  greatly facilitating the catching of the hyper- 
304       CHRONIC NASAL  CATARRH.

trophied tissue (Fig. 82).  The cross-bar on the in-
strument indicates the position of the tube in relation
to the natural bend of  the  loop.  It is of great ad-
vantage, especially for  the inexperienced operator,

                      Fig. 82.
Jarvis' snare in position, showing loop around a posterior hypertrophy.
                      (Jarvis.)
to watch the motion of the loop in the naso-pharyn-
o-eal cavity by means of the rhinoscopic mirror, and
by using the combined tongue depressor and rhino-
scopic mirror (see Fig. 24), together with  the tape
and  holders for retracting the soft palate, this can
be accomplished with comparative ease.  There is,
however, as  Dr. Bosworth  has pointed out, no pro-
jection in the nasal cavity which could engage the
snare that  is not  pathological and should not  be
done away with, and, therefore, the removal of pos-
terior hypertrophies is usually undertaken by the
experienced operator, who  has educated the tactile
surfaces of his fingers to such an extent that he feels
the exact position of the wire  loop in the  posterior
portion of the nasal cavity, and can  dispense with 
HYPERTROPHIES.
305
the preliminary operation of tying back the palate,
which is very disagreeable to both the patient and the
operator.
  As soon as the wire has slipped into the constric-
tion at the base of the hypertrophy, the loop should
be  carefully tightened around the tissue by pulling
down the slide-tube.   When the  traction upon the
wire becomes perceptible the milled  nut is  run
down,  further traction being  made by  rotating it.
By giving a  turn to the milled  head until the patient
winces, every minute at  first,  and later  every three
or four minutes, the growth can be snared off in the
course of an hour or so.  As soon as the point
marked on the scale has  been  passed  by the end of
the sliding tube, a number of  turns should be given
to the  milled nut to insure complete section of that
portion of the mucous membrane  overlying the end
of the  tube,  and  then the  instrument can be with-
drawn.   The growth usually comes out clinging to
the ecraseur by  a shred of tissue which has  been
drawn into it by  the wire, but  sometimes, although
severed from its  connection, it remains in the nasal
cavity, and  should then  be removed  at once  with
a pair of forceps.  After the operation  the  patient
should be cautioned  against blowing his nose, for
fear of opening the agglutinated venous  sinuses by
the mechanical vibration, and   so  starting a hemor-
rhage.  If any bleeding should follow the operation,
it can always be  stopped by plugging the anterior
nasal  cavity with borated cotton  in such a manner
that the blood cannot flow out of the  nostril.  The
blood then backs up forming a clot, which when it
has reached  the  bleeding spot, will by its presence
                       26* 
306       CHRONIC NASAL CATARRH.
and pressure stop the hemorrhage.  While this clot
is forming, which usually takes place within  fifteen
minutes, the patient should hold his head forward
and  spit out any blood which  may  flow  into the
pharyngeal cavity without, however, " hawking" it
out.  Styptics, and especially solutions of iron, should
never be used in the nose as  they act  as irritants,
and the coagulated, sandy blood becomes so tightly
adherent to the mucous membrane  as  to  be very
difficult to  remove,  and in many cases gives  rise to
ulceration.
  The slow and steady constriction of the tissue has
the effect of agglutinating the walls  of the venous
sinuses and bloodvessels, and also  of drawing the
edges of the wound together, so that usually, as in
the case of the  operation for the removal of anterior
hypertrophies, very little, if any hemorrhage results,
and the wound heals by first intention without giving
rise to any inflammation of the  mucous membrane
lining the cavity.
  Localized thickenings of the  cartilaginous portion
of the  septum  or  "ecchondroses," as they  may be
termed, which   are  not infrequently found  in  old
cases of nasal catarrh, and which give rise to partial
stenosis, especially if they are situated on the septum
opposite to the  pendent  portion of the  lower turbi-
nated bones, may also very readily be removed with
the wire snare  in the same  manner as the sessile
anterior hypertrophies.  The wire used in this opera-
tion should,  however,  be  very thin, so as  to  cut
readily through the cartilage, and the  needle used
for transfixing the base  of the ecchondrosis must be
quite strong, so  as not to bend inward. 
ADENOID GROWTHS.
307
  Adenoid growths  in  the  vault of the pharynx, or
hypertrophied pharyngeal tonsil, are best removed
with the wire snare in the following manner:  Hav-
ing removed the tip from the end of the canula, the
curved piece is screwed in its place, and a piece of
wire inserted to form a loop, as in the operation for
posterior hypertrophies.  The loop is then bent in
such a manner that when traction is made with the
sliding tube it will bend backward; that is, in  an
opposite direction from the curve of the instrument.
The loop is then passed behind  the velum into the
naso-pharyngeal cavity, and the  tip of  the canula is
pressed against the wall of the pharynx.  Traction
then being made  by turning the nut,  the wire will
encircle the growth  and it may be snared off quite
rapidly.   As  these  growths  consist  of glandular
tissue only, the pain is but slight, and  little, if any,
hemorrhage follows the operation. There is usually,
however, some inflammation of the mucous mem-
brane lining the naso-pharyngeal cavity of several
days' duration, and the wound heals by granulation.
If, as happens quite frequently, the  glandular mass
is rather flat, extending over a considerable  surface
of the vault of the pharynx, the  snare will not take
hold, and a pair of pharyngeal cutting forceps, of a
peculiar bend, should be used to remove the growth
piece by piece (Fig. 83).  With children neither the
snare nor  the cutting forceps can be used with ad-
vantage, because the little patients will not hold
still long enough either to apply the snare or to in-
troduce  the forceps  more than  once; and I have
found  that the hypertrophied glandular tissue can
be gotten rid of most easily by scratching it off with 
308       CHRONIC NASAL CATARRH.

the finger-nail, which should, of course, be long and
strong.  If  the  operator does not  possess such  a
natural  surgical instrument, an  artificial claw at-
tached to  a  thimble may be used, as suggested by
Dr. Farnham, of  Milwaukee.  In  performing the

                      Fig. 83.
Seiler's pharyngeal cutting forceps.
operation with the  finger, the  operator had  best
take the  child on his lap sideways, letting its head
rest  on his  left arm, and  holding its hands down
with his left hand.  This  position leaves his right
hand and arm free, while the little patient is firmly
held in the best possible position with its legs free to
kick the  air.   As there is very little pain connected
with these  operations,  they can all be  performed
without putting the patient under the influence of
an anaesthetic, and thereby we have the advantage
of the patient's conscious  cooperation during  the
often difficult manipulations.
  Deviation of the Septum.—Among the  hard obstruc-
tions in  the nose  which the  practitioner is called
upon to  remove for the cure of nasal catarrh, the
most common is that produced  by deviation of the
septum, due either to the  inflammatory process, or
to injury to the nose by blows  or falls.  A variety of 
         DEVIATION  OF  THE SEPTUM.      309

operations have been recommended for the relief of
this condition, and different authors advocate punch-
ing a round or oval hole into the septum, or cutting
out a triangular  piece  of the  cartilage, or  shaving
off the projecting portion with a curved knife, etc.,
but the simplest, easiest to perform, and at the same
time very satisfactory operation, in a large  number
of cases,  in which the deviation is  confined to a por-
tion of the cartilaginous plate only, and where there
are no ecchondroses, is the following, recommended
by Dr. Steel, of St. Louis.
  With a pair of strong forceps (Fig. 84), which has
inserted  into one of its blades a number  of knife-
steel's forceps for deviation of septum.
blades, at right angles to the surface and arranged
in the shape of a star, the septum is punched at its
greatest  curvature once, or if the bend extends far
back twice, by introducing the blade carrying the
knives into the open nostril, and the unarmed blade
into the  closed  one,  and then   compressing  the
handles.   The  punch is then removed, and  with  a
pair of  forceps having flat  blades (Fig.  85) the
septum is forcibly straightened, which becomes pos-
sible since the triangular  pieces  produced  by the
cut made with the punch lap, and thus the distance 
310       CHRONIC  NASAL  CATARRH.
from the base to the top of the septum  becomes
diminished.   Having accomplished this the forceps

                      Fig. 85.
Adams' forceps.
is removed, and a wooden or ivory plug shaped to
fit the cavity (Fig. 86) is inserted into the formerly

                      Fig. 86.
obstructed nostril, and is kept there for about forty-
eight hours, when it is replaced by a plug of cotton,
which  must be removed  daily until the cuts in the
septum have firmly  united, and the septum remains
straight without support.  In those  cases in which
ecchondroses are present, causing a localized thick-
ening  of the septum, these must be removed pre-
viously to the operation for straightening the septum,
as they will  not yield to the pressure exerted by the
Adams forceps and the nasal plug;  and, therefore,
the septum will not become straight.  Quite a large
proportion of cases  of deviation of the cartilaginous
plate of the septum are due to external traumatism,
such as falls or blows  on the bridge of the nose, and 
         DEVIATION OF  THE SEPTUM.       311

in them we usually find a fracture of the palate in
a more or less oblique direction.   This fracture is
seen through the nostril as  a ridge on the obstructed
side and a V-shaped depression on the open side of
the nose.  In these cases  the Steele punch is  not
applicable, and the best results are obtained by an
operation  suggested by Dr. John Roberts, slightly
modified by myself.  This  operation is as follows:
The mucous membrane in both anterior nasal cham-
bers is  first  thoroughly anaesthetized with cocaine
solution introduced with cotton pledgets, as already
described, and also with a spray of cocaine after the
pledgets have been removed.  The  well-oiled index
finger of  the operator's hand opposite to the  ob-
structed side, is  then  slowly introduced  into  the
nostril with the palmar surface toward the septum
until the edge of the vomer is reached.  This  pro-
cedure,  although  apparently  impossible,  is readily
executed,  because the cartilaginous plate will  give
to the pressure, and it is not nearly  as painful to the
patient as might be supposed.   The finger being in
situ, the upper end of the fracture can readily be
felt, and a  sharp-pointed  curved bistoury can  be
introduced through the other nostril, and with  its
point a small incision can be made through  the
septum opposite to the tip  of the finger.  A  probe-
pointed bistoury,  also  curved, is  then introduced
through this  cut, and the  septum is cut  along  the
line of the fracture down to the columnar cartilage,
the finger serving as a guide for  the  point of the
knife.  A little manipulation  with  the finger in the
nasal chamber will suffice  to cause the edges of the
cut to lap over each  other, and thus to straighten 
312       CHRONIC  NASAL  CATARRH.

the septum.  The next step is to secure the septum
in its new position, and this is  accomplished by in-
serting a rather large hare-lip pin  through the skin
on the bridge of the  nose at a point near the end of
the nasal  bone, carrying it downward and forward
between the finger and the cartilaginous plate of the
septum, and imbedding its point firmly in the floor
of the nose by a few strokes of a hammer.  In most
cases one pin is sufficient, but if the  cut in  the
septum is rather long and the nose  of the patient
large, another pin had better be introduced in the
same manner a  short distance  from the first one.
The finger is  then withdrawn, the heads of the pins
cut off to within about one-eighth of an inch of the
surface  of the  skin, and  the projecting ends pro-
tected by a pledget of cotton, which is held in place
by a small strip of court plaster.  These  pins serve
the same  purpose as the  nasal  plug in  the  Steele
operation, viz., to keep the straightened  septum in
position, and are preferable, because they do  not
obstruct the nasal chamber, nor do  they exert  any
pressure upon the turbinated bone, and  can, there-
fore, be left in the nose until the cut is healed, which
usually  occurs  in about  two weeks.  All that is
necessary  during that time  is  to  keep the nasal
chambers  thoroughly cleansed  with the antiseptic
solution.  There is usually no difficulty in removing
the pins with a pair of strong plyers, if they have been
allowed to project sufficiently beyond the surface of
the skin.  But if they have been cut off too short, the
cut end will disappear under the  skin, partly because
the pin has a tendency to sink  in the floor  of the
nose, and  partly because the  bridge of the nose has 
         DEVIATION  OF THE  SEPTUM.      313

been  raised by  the  straightening of  the  septum.
The pin can then be pushed up by grasping the ex-
posed portion in the  nasal  chamber with a pair  of
small jeweller's  plyers, and by making a small inci-
sion in  the skin over the end of the pin, it can be
grasped and removed.  There are, however, several
cases  in which  the  pin  has never been removed,
without doing any harm.  The  hemorrhage in this
operation is usually insignificant, and stops of itself
after a few minutes ; or if it should be more copious,
can easily  be  controlled  by introducing pledgets  of
cotton into the nasal chambers, and placing them  in
such a position  that they make pressure upon the
bleeding vessels.
  There is another class of cases in which the devia-
tion of the septum is due to a dislocation of the car-
tilaginous  plate  and a disruption of its  connection
with the vomer  or the superior maxillary bone.  If
such is  the case, and there are no ecchondroses, the
septum  can be placed in  its proper position  by the
introduction of the finger in the obstructed side and
by manipulation the adhesions can be broken under
the mucous membrane without making any cut.  A
large cotton plug in  the obstructed side will keep
the septum in position, and union takes place  in a
very few days.
  As a rule, very little swelling and inflammatory
disturbances follow any of these operations, and it is
but rarely that we experience any trouble from this
source.
  As deviation of the septum  causes  deviation  of
the nose, and disfigures  the face, the operation  is
often  performed solely for  the  sake  of improving 
Fig. 87,
Dental engine. 
BONY  OBSTRUCTIONS.
315
the looks of the patient, and in that respect is very
satisfactory.
  Bony obstructions.—When the localized thickenings
of the cartilaginous septum have become ossified, as
they frequently do,  or when  the obstruction in the
nose is due to an exostosis  of the  bony septum, or
due to an enlargement of the turbinated bone itself,
and not only of the soft tissues  overlying it, or
finally when a bony spur  from the  palatine  process
is so large as to cause  stenosis, neither the wire-
snare nor the  galvano-cautery  is  of any avail, and
the obstructions must be removed by breaking them

                      Fie 88.
Electric motor.
up with a drill and burr, or with a chisel, gouge, and
hammer, or cut off with a saw.  For these operations
a dental engine (Fig. 87), such as is used by dentists,
has to be  employed  to revolve  the drill or  burr 
316       CHRONIC  NASAL CATARRH.
rapidly enough to cut away the bone, or, better still,
a small electric motor (Fig. 88) to which  the  tools
are attached,  either  directly  to its  spindle or by
interposing a short flexible shaft between the spindle
and the handpiece  carrying the  tools.  With this
apparatus the speed of the drill can be regulated to
a nicety, from a  few  hundred to fifteen  thousand
revolutions per minute, by means of the  universal
battery  (Fig. 76), or  any other battery which  will
give a current of about eight volts and one to two
amperes. The storage battery of four cells is perhaps
the best for the purpose.  When used for operations,
the motor whose power is equal if not greater than
that of the dental engine,  is  suspended  from  the
ceiling by cords which run over pulleys and carry
counter-weights, so as to  balance  it in any position
it may be placed in.   This arrangement relieves  the
hand  of all weight, and thus a much more delicate
manipulation  of the  tool is  possible than  can be
obtained when the dental engine is used, for in  the
latter instrument the hand has to support the weight
of the hand-piece and flexible shaft or  arm, and
besides a good deal  of the  motion of  the foot,
working the treadle  of the fly-wheel, is communi-
cated to the hand, making it unsteady.
   The tools  used  in the  operation  are fluted  and
twist drills (Fig. 89), and burrs (Fig. 90) of various
shapes and sizes.   In order to protect the parts on
the opposite  side of the nostril when cutting away
bony projections  from the surface, Dr. Goodwillie,
of New York, has devised a shield within  which the
burr revolves (Fig.  91).  In the case of enlargement
of the turbinated  bone,  and  bony spur  from  the 
BONY OBSTRUCTIONS.           317
palatine process, the operation  is performed as fol-
lows :  The bony obstruction is first riddled with a
number of holes made with a  cutting  drill, and its
Fig. 89.
Fig. 90.
5
Drills for dental engine.
Burrs for"dental engine.
Fig. 91.
Burr with shield.
27* 
318      CHRONIC  NASAL  CATARRH.
substance  is then broken down with a coarse  burr,
the diameter of which is  greater than that of the
drill, and finally any shred of mucous membrane or
spicules of bone which remain  are  cut  off with a
pair of scissors.  After  the lapse  of twenty-four
hours, it is generally necessary to trim off the sur-
face of the wound with scissors, as projections which
have been overlooked in the first instance, then show
themselves,  after which  the wound  is allowed to
heal up.
  In cases where the bony obstruction springs from
the flat surface of the septum, a round or olive-
shaped  burr, encased in a shield, is pressed against
the projection, and the osseous tissue is cut, or rather
ground away, until  the normal surface is obtained.
There  is less pain  or  hemorrhage  connected with
these operations than  might be expected, because
the rapidly revolving drill or burr cuts only into the
hard and  resisting  substance of the bone, while the
soft tissue of the bloodvessels and nerves is not in-
jured.   In cases where it  is desirable, the bone can
be removed without breaking the periosteum, except
to give entrance to  the cutting burr.
   Usually but a very moderate amount of inflamma-
tion of the  mucous membrane  of the nose follows
these operations, and the wTound in  the soft tissues
heals readily within a few  days.   As a  rule, it is
more convenient to place the patient under the in-
fluence of an anaesthetic, so as to have perfect control
over his movements;  although it is  not  absolutely
necessary, as the  pain can very readily be  borne
when cocaine is used.
   In those  cases of ecchondrosis which,  as already 
BONY OBSTRUCTIONS.
319
described, present variously shaped projections from
the surface of the septum, the drill and burr are not
applicable, and various writers have suggested and
used a large variety of different instruments for these
operations, such  as the saw and knife, the  plough,
the gouge, the snare, etc.;  but a careful considera-
tion of the  requirements of individual cases will at
once  show  that  none of  these instruments can  be
successfully used in all cases to the exclusion of the
others,  and the armamentarium  of the  operator
should include them  all.
   But we  must  take into  consideration that most
operators have a particular fondness for this or that
instrument, and prefer to  operate with it rather than
use  any other, if this is possible;  probably because
they have acquired especial dexterity in its manipu-
lation.   It  is, therefore,  natural  that they  should
praise their pet tool, and obtain results with it which
others, with less  dexterity in its use, can never hope
to arrive at.
   The object  is to remove the redundancy of tissue
as thoroughly and  quickly  as practicable, leaving a
plain surface  without ragged edges, and to perform
the operation with as little pain and inconvenience

                       Fig. 92.
          Seiler's cartilage knife, curved on the flat.

to the patient as possible:  And this  can only be
done  by adapting  the  instruments to  the require-
ments of the case.
  If the ecchondrosis  is in  the shape  of a conical 
320       CHRONIC NASAL  CATARRH.

projection or of a ridge running from below upward,
and if no  ossification  has taken place, I  prefer a
small, double-edged knife, slightly curved on the flat
(Fig. 92), with which an incision is made first from

                      Fig. 93.
Seiler's nasal gouges and chisel, with handle.
below upward to about the  middle of the excres-
cence, and then from above downward until the two
cuts meet, and the cartilaginous projection is ablated.
If there  exists  a hard centre which  cannot  be cut
through  with the knife, the two  cuts from  below
and above should be carried to this centre, and then
a flat  chisel (Fig. 93) used to cut through  the bony
portion, which is easily effected by tapping the handle
slightly with a leaden mallet (Fig. 94).
  The two cuts are necessary because the knife, after
having passed through the cartilaginous tissue, finds
not sufficient resistance in the mucous membrane if 
BONY  OBSTRUCTIONS.
321
the operation is made with one sweep of the knife
from  above downward, and the ablated piece falls
over into the mass of coagulated  blood, being still
attached to the surface of the septum at  its lower

                       Fig. 94.
Leaden mallet.
edge by the mucous membrane.  It is then difficult
to grasp with the forceps, and  much time is lost in
finally severing the mucous membrane.
  If, on the other hand, the shape of the ecchondrosis
is shelf-like, with a downward-sloping upper surface,
and a concave under surface separated from the floor
of the nose by a narrow space, and running  back-
ward  for some distance, we may take it for granted
that we have to  deal with an  ossified excrescence,
and proceed as  follows:  After having thoroughly
anaesthetized the  parts  with  cocaine solution,  a
grooved  director, slightly bent at an angle, is intro-
duced into the  space between  the floor of the nose
and the  under surface of  the  shelf-like  projection,

                      Fig. 95.
               Seiler's plough-shaped knife.

with the groove upward.  The nostril is then dilated
to its full  extent  with Bosworth's  or  Jarvis' self-
retaining  nasal dilator, and  the dull point  of a
plough-shaped  knife (Fig. 95) is  inserted into the 
322       CHRONIC  NASAL  CATARRH.
groove of the director, and is pushed backward so
as to  cut through the  base of the projection;  very
much in the same way as a wood-carver uses a simi-
lar tool.  As  soon as  the  bony centre presents an
obstacle  to the  further progress of the knife, the
latter is  removed and a gouge—the cutting edge of
which is slanting—is inserted with its point into the
groove of the director, and with  a few blows from
the mallet upon  the end of the gouge, the ossified
portion  is cut through.  In order that the view of
the nasal cavity be not obstructed by the handle of
the instrument  and the  hand holding it,  I find it
advantageous  to insert the  tool into  the handle at
an  angle of about  sixty degrees, fastening its stem
by a set-screw, and allowing the former to project
slightly so as to receive the blows from the mallet
in a direct line with  the direction of the cut to be
made.   The hand holding  the cutting instrument
should be steadied against the chin of the patient, so
as to  prevent injury to the parts beyond  the  pro-
jection, which might  easily result from the cutting
edge or point of the instrument  getting out of line
and going  beyond the posterior end of the projec-
tion, into the vault of the pharynx.  A little practice
soon enables the operator  to feel when the  gouge
has cut  through the hard  tissue.  The tool is then
removed, and, keeping the  grooved director in posi-
tion, a pair of scissors bent  at an angle (Fig.  96) is
passed along its groove, so as to sever any portion
of the mucous membrane at the upper surface of the
shelf which may not have been cut by the plough or
gouge.   A straight chisel is not as advantageous as
the gouge, because it cannot be so easily kept in the 
BONY  OBSTRUCTIONS.
323
line in which the cut should be made; and, although
the cut surface is slightly concave, I have in no case
observed any retardation in the healing of the wound
from this cause.  In the case of a union between the
                       Fig. 96.
Seiler's angular scissors
turbinated exostosis and the ecchondrosis of the sep-
tum, I have found it best to divide the exostosis first,
with a saw (Fig. 96), close to the turbinated bone,
and then  to ablate the ecchondrosis with the knife
and chisel, or gouge.   The ablated piece of cartilage
is then grasped with a pair of rat-tooth  forceps and
                       Fig. 97.


                     Xusal saw.

removed  from  the nostril, while any small projec-
tions not removed by the gouge are best cut off with
the Farnham alligator forceps (Fig. 98). 
324       CHRONIC NASAL CATARRH.

  These  operations are  absolutely painless  if the
cocaine has fully anaesthetized the parts,  and the
only objection made by the patients is the jarring
produced  by the blows of the mallet upon the end
of the  gouge or chisel.  The hemorrhage resulting

                      Fig. 98.
Farnham's alligator forceps.
from these cutting operations, as a rule, is compara-
tively slight, and can always be controlled b}^ placing
a pledget of borated cotton against the wound for a
few hours.   As soon as all oozing has stopped, this
should be removed and the  nasal cavity should  be
washed out twice daily with the antiseptic solution,
so as to prevent any sepsis.   The healing process is
usually complete in about ten days, but may, in some
cases, be prolonged for a few days more.  There is no
soreness of the nose, and no great amount of inflam-
mation of the surrounding mucous  membrane  fol- 
PLUGGING  THE NOSE.
325
lowing  the  operation, and the patient  is able to
attend to his duties at once.
  When it  is necessary to place the patient under
the influence of a general anaesthetic for operations
within the  nose, and  the  operator  thus loses the
cooperation  of the patient,  the posterior nares must
be plugged  to prevent the  blood from flowing into
the larynx and choking the patient.
  Plugging  the nose is an operation which the  prac-
titioner is frequently called upon to  perform, and it
will therefore not be out of place to describe it here.
In text-books on surgery we find an instrument—
Belloque's  canula—recommended for this purpose,
which, however, if at  hand,  in  many  cases proves
useless on account of its great thickness.   It will be
found that the nose can be  plugged just as well, and
often better, in the following manner: A  large-sized
Eustachian  catheter,  or, if that is  not at hand, a
female  catheter, is introduced  through the  lower
meatus of one of the nostrils until its end comes in
contact with the wall of the pharynx.   A catgut
string or a  piece of twine, well waxed to make  it
stiff, is then pushed through the catheter,  and when
its end appears  below the margin of  the velum, it is
seized with a pair of forceps and drawn out through
the mouth.  A wad  of cotton, tow,  lint, or  any
other substance which will serve the purpose, having
been previously tied to a string  in such  a manner
that two long ends hang from it, is then drawn into
the pharyngeal cavity by tying one  of the ends to
the catgut string as it projects from the mouth, and
pulling  at  the  end projecting from the  nostril, at
the same time removing the catheter.  The plug of
                       28 
326
HAY  FEVER.
cotton will thus be wedged into the post-nasal cavity,
preventing the escape  of blood into  the  pharynx.
The  catgut string is then detached from the string
to which the  cotton is  tied, w7hich hangs out of the
nostril, and may be cut off close if the plug  is to
remain in place for any length of time, while the
other end of the string, which remains in the mouth,
should be secured to the teeth in such a manner
that the velum is not hindered in its motion. When
the plug  is to be removed, all that is necessary is to
pull  at this  end of the string,  when  the  plug  will
become detached, and can be drawn out through the
mouth.
               CHAPTER  XV.

  HAY-FEVER, OR CORYZA  VAS0-M0T0RIA PERIODICA.

  Hay-fever, as well as  the  numerous forms of
neurotic coryzas which we so frequently meet with
in this country among the  more educated class of
patients, is a  chronic nasal affection which, depend-
ing, as it does, upon a greater or less disturbance of
the various nerves supplying the nasal mucous mem-
brane, deserves more  than a passing  notice in this
volume.  For at the present  day the  intelligent
physician  is  not  satisfied with  the explanation of
the causation of this affection given  by the  earlier
writers, and still  accepted by the general public, viz.:
that it is caused  by the introduction into the nasal
chambers  of pollen  grains  or  vibrios; nor can he 
HISTORY.                 327
 accept the dictum of the so-called hay-fever associa-
 tions: that the disease is  incurable, and the only
 relief is obtained  by a sojourn during the season in
 certain localities,  because the various reflex  symp-
 toms due to nasal disease, already mentioned  in the
 foregoing pages, clearly indicate that there must be
 some  pathological condition present in the nasal
 chambers  which,  when irritated more  than  usual,
 by the introduction of dust, pollen grains, or other
 external influences, causes all the symptoms of the
 so-called hay-fever, or  better named by J. N. Mac-
 kenzie, of Baltimore, coryza vaso-motoria periodica.
 The scope of this hand-book is, however, too limited
 to  allow  of a lengthy dissertation  on the various
 theories advanced  from time to time on the minute
 pathology  of  this affection, so that  the  author  can
 only give a mere  outline of them, and  must refer
 the reader for further and a more detailed description
 to the various papers by Daly, Roe, J. N. Mackenzie,
 Bosworth, Woakes, and others.
  History.—The first description of the symptoms of
 hay-fever was  given by Rostock, in 1819, and  a fur-
 ther paper by  the same author, in which he gave the
 affection the name of "summer catarrh," appeared
 in 1828.  These papers were  followed by a  short
 paper  on "Hay Asthma," by  Gordon, in 1820, and
 by a similar one by Ellioston, in 1831, in all of which
 the affection  was  ascribed  to the  introduction  of
 pollen grains  into  the nasal  chambers.  In  1862,
 Phcebus, of Giessen, published a collective investi-
gation, and he  was followed by Abbott Smith, Pirrie,
and  Moore, who also  expressed the opinion that
emanations  from flowering  plants  were the sole 
328               HAY FEVER.
cause of the  affection.  In  1869, Helmholtz pub-
lished his theory of hay-fever, which was, that as he
had  by microscopical examination of the nasal  dis-
charges discovered certain vibrios,  these were  the
cause of  the affection, and by destroying them with
germicides, the disease could  be cured.   This asser-
tion  was, however, not substantiated  by extended
trials.  Morill Wyman, in 1872,  described the  dis-
ease  as it was prevalent in the United States, and
made mention of the fact that there were two  dis-
tinct varieties, viz.: the rose cold in  May and June,
and the hay-fever in August and September.  Black-
ley, of Manchester, in 1873, published an excellent
treatise on this disease, and was followed  by  Beard,
of New York, in 1876, with  a collective  investiga-
tion, and finally, Marsh, in 1877, published an essay,
in which he reiterates the pollen theory of the causa-
tion  of the disease, which  had been  accepted as
proven by all the authors before him.  In 1878,  Dr.
Judd, of Philadelphia, submitted a graduation thesis
to the Faculty of Jefferson  Medical  College, in
which he expressed his opinion that the disease is
not altogether due to  pollen grains,  but is more of
the nature of a nervous affection.
  Not  until Daly, of Pittsburg, in 1881, called atten-
tion  to the  fact that other than  external causes could
produce hay-fever, and that by the removal of such
causes  the  disease could be permanently cured,  was
the faith  in the pollen theory shaken; but it  needed
the corroboration of  Roe, of  Rochester,  Bosworth,
of New York, J. N.  Mackenzie, of Baltimore,  and
many other laryngologists of America and Europe,
to establish the fact firmly that pollen or  other dust 
SYMPTOMS.
329
floating in the atmosphere was but one of the exci-
tants producing  an attack of the affection, but  by
no means the original cause of the disease.
   Symptoms. — There is a  variety of  vaso-motor
coryzas, which in their symptomatology differ from
each other mainly in the variety and duration  of the
symptoms, in the periodicity or non-periodicity, and
in the popularly accepted or actual exciting influence
which produces the attacks.  Thus we have the hay-
fever, hay-asthma, or autumnal catarrh, which recurs
with unvarying regularity at the end of August, and
lasts, with slight  variation in  the intensity of the
symptoms, until the first frost appears.  As its excit-
ing cause, pollen grains, and particularly the pollen
of the rasr-weed,  are named.  Then we have the so-
called rose cold, which is also regular and periodic
in its appearance, and comes on at the end of  May,
lasting as long as the roses are in bloom.  Its ex-
citing cause is supposed to be the pollen  of the rose.
The more rarely met with forms are the horse cold,
which is  developed as soon  as the patient exposes
himself to the emanations from a horse or cow.  The
peach  cold, the exciting cause of which is said to be
the down from the skins of the  fruit.   The snow
cold, which is apparently caused by the sharp, cold
air produced by the evaporation from the surface of
the snow; the  millers'  cold, or asthma, excited by
wheat flour  in some cases and rye flour in others,
and a variety of other forms in which the attacks are
excited by a variety of substances, and, finally, a form
occasionally met with, which is not due to any ex-
ternal  irritant, but is brought on by sexual excite-
ment.  In all these forms of the disease, the attacks
                       28* 
330
HAY  FEVER.
usually last but a short time, from a few minutes, as
in the form caused by sexual excitement, to  a fCw
days, as in the peach cold.   Why so many different
exiting causes can produce the same symptoms in
different individuals is  impossible  to  say, and  we
must fall  back upon the convenient explanation, by
idiosyncrasy, which in  reality is no explanation at
all.  The  symptoms of an attack of any of these
forms of vaso-motor coryzas are those of an ordinary
acute cold in the head of an aggravated form.  First,
a sense of dryness and  itching of the  nose, violent
sneezing, especially in the morning, a sense of ful-
ness of the nose, followed by a profuse watery dis-
charge.  After a short  time  conjunctivitis, lachry-
mation, and photophobia are added, together with a
dull frontal or occipital headache,  frequently neu-
ralgic in its character, make their appearance;  and
in  the more aggravated  forms,  a slight hacking
cough, hoarseness, and asthma, more or less severe,
are noticed.   At  the same time the nasal discharge
becomes thicker and of a yellowish color, difficult to
remove from the nasal cavities by blowing.
  The edges of  the nostrils  as well  as the skin
between the nose and the upper lip become red  and
sore from the action of the nasal discharge and the
frequent  wiping of the  nose.   General febrile dis-
turbances are  more or less pronounced during the
first few days of the attack, characterized by increase
of pulse and temperature and a feeling of malaise.
  These symptoms in the long-continued attacks of
hay-fever  and  rose-cold vary from  time  to time in
intensity,  beings intensified by  exposure to  dust, 
ETIOLOGY.
331
heat, draughts  of cold air, the ingestion of hot or
highly spiced food, and other excitants.
  An inspection of the nasal cavities  reveals  no
specific pathological  change of structure, and the
condition of the raucous membrane is the same as is
noticed in  an  ordinary acute  coryza, viz., intense
congestion of the mucous membrane, general turges-
cence of the turbinated erectile tissue, with profuse
serous and  mucous discharge.  The congestion ex-
tends  into the naso-pharyngeal  cavity, and  later
involves the laryngeal as well as the tracheal mucous
membrane.
  Etiology.—The causes producing  this affection, as
has already been indicated, must be looked for in a
chronic pathological condition of the nasal cavities,
together with a vitiated action of the nerve-centres,
and  an exciting cause producing  the  distal  nerve
irritation.  Thus we  have,  in  reality, three  factors
which must act in conjunction to produce the attacks,
and if any one of these factors is removed, the dis-
ease fails to make its appearance.   In this way only
can we explain the immunity from  an attack of hay-
fever by the removal of the patient to a locality free
from the excitant, and the immediate return of the
symptoms when he is exposed to  the to him dele-
terious influences floating in  the atmosphere, or the
immunity of others in whom the pathological condi-
tions in the nose exist, and  also are surrounded by
the same  irritant,  but who, nevertheless, do  not
suffer,  owing to the fact that their nerve centres are
not altered.  The  first  of  these  factors,  viz., the
pathological  condition of the  nasal chamber, may
comprise any of the various changes mentioned in 
332
HAY  FEVER.
 the  foregoing chapter, such as anterior,  middle, or
 posterior hypertrophies;  exostoses or ecchondroses
 of the septum; deviation of the septum, or the pres-
 sure  of foreign  bodies, rhinoliths, or  polypi  in  the
 nasal chambers;  but above all, hyper-sensitive areas
 on the surface of the nasal mucous membrane, which
 may  readily be distinguished by  their heightened
 color, and by the fact  that a slight elevation  of the
 surface throughout their extent occurs when they
 are touched with the end of a probe.
  The second factor consists in a diseased, or at least
 altered, condition  of the  nerve-centres, the vitiated
 action of which is induced  by the  irritation  of the
 distal nerve fibres in the nose.  This alteration gives
 rise to the train of near  and remote  symptoms by
 reflex action.  This can readily be demonstrated  by
 touching one of the hyper-sensitive areas in the nose
 of a  hay-fever patient at a time  when  he   is not
 suffering from an  attack,  for the mechanical  irrita-
 tion  will be  immediately followed by the appearance
 of all the early symptoms,  and such an  artificially
 produced attack  will  last  from a few minutes to
 several  hours, and,  in  some  cases, even for days,
 though it be the middle of winter.
  Very little need be said about the third factor, the
 external irritant, as it is of the least importance, for,
 as has already been said, a large variety of different
 substances will cause an attack in as many different
individuals,  and no particular pollen-grain or emana-
tion from plants or animals can be singled out as the
one which is the offending substance in all cases.
  Treatment.—The treatment must be directed to the
alleviation of the  symptoms during an attack, and 
TREATMENT.
333
the subsequent removal of the intra-nasal pathological
condition, together with general medical treatment
with a view to  correct the abnormal action of the
nerve-centres.  My experience has  shown that no
other than a palliative  treatment is indicated while
the attack lasts, and  any measure undertaken  for
the radical cure of the  affection during that time
will  not  only  prove  abortive,  but  aggravate the
symptoms and  increase the suffering of the patient.
  The most relief is obtained, and in many cases the
attacks are  cut short,  by frequent spraying of the
nasal cavities with the antiseptic solution already
mentioned,  so  as to remove all offending  particles
which  may have gained access to the sensitive areas.
After the mucous membrane has thus been cleansed
a spray of a four per cent, solution of cocaine should
be blown into  the nostrils, and small pledgets  of
cotton, saturated  with the cocaine solution, should
be introduced  between the septum and the swollen
mucous membrane of the turbinated bones.   The
cocaine acts in contracting the bloodvessels, and  in
thus  shrinking  the  turbinated tissue opens  the
respiratory portion of the nose, at  the same time
diminishing the exudation of serum, and in this way
gives great  relief, if .only  for a short time,  to  the
sufferer.  The cocaine solution should not be dropped
into the nostrils, nor injected with a syringe, as in
that case but a small  portion of the nasal mucous
membrane is acted upon by it; nor should the appli-
cation  be made oftener  than two or three times a
day, because the frequent contraction and expansion
of the vessels, due to the drug, have the effect of caus-
ing a loss of tonicity, and the swelling of the turbin- 
334
HAY  FEVER.
ated tissue is increased instead of  being diminished.
After the removal of the cotton pledgets, small pieces
of fine  surgical sponge, cut to fit  closely, should be
introduced into the nostrils, so as to filter the in-
spired air  and  keep all  irritants out  of the  nasal
cavities.  These  pieces of sponge should be  worn
day and  night, and if kept clean by frequent wash-
ing do not  in the least interfere with nasal respira-
tion, and give great relief.
  Internally, quinine, in  large doses, tonics, and in
the first stage  atropia act  well  in reducing the
febrile condition; while  in  the latter stages, when
the asthma has set in, iodide of sodium, together
with bromide of sodium  in rather large doses (aa
gr.  x three times a day), gives marked relief.  In
some cases, particularly in those in which the neu-
ralgic headache  is very  severe, morphia, hypoder-
mically, is  the only drug which will give relief from
the intense suffering.
  If a foreign body, rhinolith, or polypus is found
in the nasal cavity, it should  be removed at once;
but it is worse than useless to  treat a hypertrophic
condition of the turbinated tissue.   After the attack
has subsided, however, all  pathological  conditions
should be  removed in the manner described in the
foregoing chapters, and  the sensitive areas should
be destroyed with the  galvano-cautery  knife in the
following manner:
  The anterior nasal cavities having been well illum-
inated, a probe  is introduced  and its point is run
over the surface of the mucous membrane.   As soon
as a sensitive spot is touched, it will show itself by
causing an elevation of the surface throughout its 
TREATMENT.
335
extent,  and a  deepening of  the  color  as well as
lachrymation of the eye on the same side.  A flat
galvano-cautery knife, heated to a cherry-red  heat,
is then quickly introduced and  pressed against the
sensitive area with its flat surface, thus destroying
the superficial layer of the mucous membrane.   Co-
caine cannot well be used to anaesthetize the mucous
membrane, because its depleting effect greatly inter-
feres with the distinctness of the difference of  color
between the spot to be burned and the surrounding
mucous membrane, so that it is difficult, if not im-
possible, to locate the sensitive area;  nor is it neces-
sary to use cocaine,  as the operation is  not  pain-
ful, but can easily be borne  by  the patient without
any anaesthesia.  In most cases a large number of
these spots are found on the surface  of the  septum
and the middle turbinated bone, but not more than
one should be operated on at one sitting.   As  soon
as the resultant  inflammation has subsided, which
usually occurs in three or four days, another spot is
to be cauterized, and this  is to be  repeated  until
all  have been  obliterated.  Other caustics, such as
chromic acid, acetic acid, or nitric acid, may be used
for this  purpose, but they are not as satisfactory as
the galvano-cautery, because their effect cannot be
limited  as  accurately.   Under no  circumstances
should the healthy mucous membrane be cauterized ;
and the operator should be absolutely certain  as to
the location of the sensitive spot before applying the
caustic.  After this the case is to be treated, like one
of ordinary hypertrophic catarrh, with the  antiseptic
spray and the  iodine  solution  until all  trace of
chronic inflammation has disappeared. 
336               HAY FEVER.
  Nerve  tonics, and particularly dilute phosphoric
acid, in ten-drop doses three times a day, should be
given from time  to time, as well as general treat-
ment to  correct  any deviations  from the  general
good health of the patient should be instituted, so
as to produce a return to the normal condition of
the vitiated nerve centres.
  The length of time during which the local treat-
ment should  be continued varies in different cases,
from a few weeks to many months, and  in  the  case
of hay-fever the general treatment should be kept up
for at least two years.   For, as a rule, the nerve-
centres will not return to their normal condition in
a few months, so that when the next hay-fever sea-
son  after the  treatment conies around  the patient
will, as a rule, have an attack, although very much
modified in  character as well as in  duration, and it
is only in the second or third season that entire  im-
munity can be expected.
  The cases of the rarer forms of vaso-motor coryzas
usually yield  much more readily to treatment, prob-
ably  because  the nerve-centres  in them  are  not
nearly so deeply impressed by the local irritation,
and return more readily to  their normal condition
after the possibility of the local  irritation has been
done away with. 
ATROPHIC  NASAL  CATARRH.      337
              CHAPTER XVI.

         ATROPHIC  NASAL CATARRH.

  This affection, which  is popularly known as dry
catarrh, may either be a sequence to the hypertrophic
stage (and it is not uncommon to find hypertrophies
in one side of the nose and an atrophic condition of
the  tissues in the other), or it may be of the atrophic
variety from the start.
  The  symptoms complained of by the patient are
chiefly great dryness  of the nose and throat, with
the occasional expulsion of large  scabs  of  dried
secretion, complete or partial loss  of the  sense of
smell, and  an offensive odor, not usually, however,
perceived by the patient himself, but by  his friends
and all with whom he comes in contact.   This odor,
which has given rise  to the term  ozama, by  which
this variety of catarrh is designate 1 by many authors,
is, however, also present in other affections, and may
be noticed in cases of  syphilitic ulceration  of the
nose, of caries, and in  disease  of the antrum, or it
may be caused by the retention and putrefaction of
the  secretions in cases of foreign bodies in  the nasal
cavities, or when complete stenosis exists from  mal-
formation of the walls of  the nose, and must, there-
fore, be looked upon  as a symptom, and  not as a
distinct affection.
  On inspection of the anterior nares, we find the
mucous membrane everywhere dry and shiny, with
                       29 
338      ATROPHIC NASAL CATARRH.
here and  there brownish scabs  of  dried  secretion
adhering to it.   The calibre of the nasal chambers
is  very  much  increased, and the turbinated bones
are barely recognizable or altogether absent, so that
nothing obstructs the view, and  the  wall of the
pharynx can plainly be seen.  Frequently erosions
of the mucous membrane, especially on the septum,
are seen when  the scabs are removed, which lead to
ulceration and perforation.
  With the rhinoscope we observe the same with-
ered  condition of the  mucous  membrane in  the
naso-pharyngeal cavity, and particularly so on the
pharyngeal wall, every trace of the glandular tissue
or pharyngeal  tonsil  having  disappeared.  Large
brownish crusts of dried secretion are here also seen,
especially  in the depressions at the margin of the
mouth of the Eustachian tubes, and on the posterior
aspect of the vomer, places where  they cannot  be
easily dislodged by the ordinary methods of blowing
the nose, or by hawking.   The mucous membrane
of the oral pharynx is also usually involved, present-
ing a dry, shiny appearance and is covered here and
there with a grayish, tenacious  mucus.   This con-
dition is described by many authors as a distinct
disease, under  the name of pharyngitis sicca, but is
in reality merely an extension of the atrophic change
of the nasal mucous membrane downward.  Erosions
and ulcerations are found beneath these scabs, which
are often quite extensive, and may involve the peri-
osteum of the  vomer, thus producing necrosis.
  Cause.—The causes of  this variety of  catarrh are
essentially  the same as  those which produce  the
hypertrophic form, of which, in  most cases, it is a 
TREATMENT.               339
sequel.   Syphilitic, scrofulous, or other specific taint
of the system has, in my opinion, no direct influence
upon the causation of this  form of  nasal catarrh.
Although we find scrofulous patients who are suffer-
ing from atrophic nasal disease, this does not prove
that the taint is the cause.  The reason why certain
individuals  have hypertrophic  and others  atrophic
catarrh, produced, apparently, by the  same exciting
causes,  is a  question not as yet  satisfactorily settled.
   Treatment.—The treatment  must consist chiefly in
keeping the nasal cavities clean,  in preventing  the
formation of crusts, and in stimulating the mucous
membrane,  and those of the  glands which  have  not
been obliterated entirely by the process of atrophy.
The cleansing is best effected by means of  the post-
nasal syringe and the spray in the hands of a physi-
cian, and the  nasal  douche  used  by the patient.
The  solutions  should be alkaline, so as to dissolve
the mucus more readily.  It is best to use DobelPs
or the  alkaline antiseptic solutions  with the post-
nasal syringe, about  three  times a  week, and to
cleanse the nasal cavities thoroughly with it of all
accumulations at each sitting.   If ozaena is present,
Listerine should be added to  an alkaline solution in
the following proportion :
               R —Sodas bicarb.
                   Sodas bibor.  aa 3J.
                   Listerine,   A^j-
                   Aquae,   q. s.  Oij.
This and the antiseptic solution are the only means
of overcoming the fetid odor and making an examina-
tion of the nasal cavities possible without discomfort
to the examiner.   None of the other disinfectants, in 
340      ATROPHIC NASAL  CATARRH.
my experience, act as promptly and  effectually  as
these solutions.   If then any excoriations or ulcera-
tions  are seen, they should be touched with a sixty-
grain solution of nitrate of silver, and  if they are
deep  and extensive, it is best to char  the surface
with  the  galvano-cautery  before using the  silver.
Dr. Bresgen, of  Frankfort-on-Main,  suggests the
following formulae, which are to be used successively
as they lose their power of stimulation; they have
proved very valuable in the treatment of this form
of catarrh :

    No. 1.      R.—Arg.  nit.    gr.    |.
                 Pulv. amyli, gr.  154.
    No. 2.      R.—Arg.  nit.    gr.   1£.
                 Pulv. amyli, gr.  154.
    No. 3.      R -—Arg.  nit.    gr.   2J-.
                 Pulv. amyli, gr.  154.
    No. 4.      R.—Arg.  nit.    gr.   3|.
                 Pulv. amyli, gr. 154.
    No. 5.      R.—Arg.  nit.    gr.   7.}.
                 Pulv. amyli, gr.  154.
    No. 6.      R.—Arg.  nit.    gr.  15.
                 Pulv. amyli, gr.  154.

  These powders are applied in the following man-
ner :  After the nasal mucous membrane  has been
thoroughly cleansed from all thickened secretion by
a spray of  antiseptic  solution or alkaline  Listerine
solution, a little  of the powder is  thrown  into the
anterior nasal cavities through the nostrils  by means
of the insufflator.  Commencing with  No.  1, the
application is repeated every two or three days until
the slight smarting  caused by the particles of solid 
TREATMENT.
341
nitrate of silver is not noticed, when No. 2 should be
used, and so on.
  Gottstein recommends a plug of cotton to  be in-
troduced into the nostril to take  the place  of  the
atrophied  lower turbinated bone, with a view to
diminish the calibre of the canal, and  concentrate
the current of air.  This also acts beneficially, not
for the reason stated, however, but because the cot-
ton irritates and stimulates  the mucous  membrane,
and by becoming saturated with the watery secre-
tion, imparts to the  inspired air sufficient moisture
to prevent  the drying of the secretions and the for-
mation of scabs, thus materially relieving the dryness
of the pharynx.
  Other stimulants, such as myrrh, in powder or in
the form of the tincture,  sulphate of iron, quiniae
sulph., etc., and, above all, a moderately strong in-
duced current of electricity may be  applied locally
with good  results.
  The general health should  be looked after, and
any predisposing causes removed  if possible, while
iodine, in  the form  of  the iodide of potassium in
small doses, and of iodide of iron, or cubebs, petro-
leum, Grindelia robusta,  or any other drug  which
will stimulate the glands of the nasal mucous mem-
brane, should be given internally.  The petroleum
seems to have a specific action  upon the  respiratory
mucous membrane, and is best given in combination
with Grindelia robusta.   A formula wThich has given
satisfaction is as follows :
         R.—Petroleum (crude)        gr. ij.
             Ext. grindelia robusta insp. gr. xv.
          M.— Div. in  pill  No. 1.
  To be filled  in gelatine capsules.
                       29* 
342         SYPHILITIC CATARRH.
  With the  best  and most faithfully  carried out
treatment a cure cannot be effected in less than a
year, and it often requires much more time than that,
but most  of the symptoms  may be  so  ameliorated
even in a short time as not to annoy  the patient.
This is especially true of the bad odor, which can be
entirely relieved by thoroughly washing out the nasal
cavities and removing all  the collections of mucus.
If, however, the odor persists after thorough cleans-
ing, which happens in a few cases, then  the disease
must be looked for  in the contiguous cavities, the
antrum, the frontal sinuses,  or sphenoidal cells, and
these must be  opened  and washed out with disin-
fectant solutions in order to relieve the patient.  As
there is always more or less pain  connected with
disease of these cavities, which is localized, it is not
difficult to locate the trouble in one of  the other of
these contiguous cavities.
  When necrosis of either the vomer or of the turbin-
ated bones is found, the surface must be thoroughly
scraped, which is  best done with the burr of the
dental  engine, as  with the scraper the necessary
pressure cannot be brought to bear upon the parts,
and, furthermore, there is  hardly enough  room to
use this instrument  effectually.  With  the rapidly
revolving  burr, on the other  hand, we both hear and
feel at once when all diseased bone has been removed,
and the tool comes in contact with the harder sound
osseous tissue.      V

               Syphilitic Catarrh.

  Both the secondary and tertiary manifestations of
syphilis are found in the nasal cavities as inflamma- 
SYPHILITIC catarrh.
343
tion, gummata, and shallow or deep ulcerations, and
present the same characteristics as in the pharynx
and larynx.  The destruction of tissue and  loss of
substance occasioned  by the specific ulcerations are,
however, as a rule, much more  extended, owing to
the close contiguity of the parts, and will often cause
irreparable deformity of the nose by destruction of
the septum.  Perforation of the septum, in fact, is
very frequently met with in this disease, but is not
necessarily due to syphilis in  all cases, for it is
occasionally  found in atrophic  catarrh, and  is said
to be  found invariably in workmen  employed  in
bichromate of  potash works.  A bad odor, which
is, however, different in  character from the odor of
atrophic catarrh  and of disease of the  contiguous
cavities, always accompanies syphilitic ulceration of
the nasal cavities.
  The treatment  is the same as that  recommended
in  syphilitic laryngitis  and  pharyngitis,  except
perhaps that we  can  employ  caustic applications
more effectively  in  the nasal  cavities than in the
throat.  In cases where gummata are situated on the
septum so as to cause obstruction of the  nasal cavi-
ties and prevent nasal respiration, as well as intense
headache by pressure upon the nerve-ends, the action
of internal  medication  is  too  slow,  and surgical
measures  must be adopted to  relieve the suffering
of the patient.   These growths, under such circum-
stances, should be scraped from the surface of the
septum with  a curette or sharp spoon, and the raw
surface  should be cauterized with a solution of acid
nitrate  of mercury (one to six).  The operation is
neither painful  nor bloody when cocaine is used, and 
344   TUMORS IN THE NASAL CAVITIES.

no necrosis of the septum need be feared  to follow,
if such has not already taken place.
  Lupus is occasionally found  in  the nose, and its
manifestations are so much like those of syphilis that
it becomes exceedingly difficult to recognize the dis-
ease.   We find, however, usually an involvement of
the skin, either at the time or soon after the disease
shows itself in the nasal cavities, and this helps to
confirm our diagnosis.
  The treatment of this  affection is described in
detail in the text-books on diseases of the skin, and
we need not here enter further into it, except to state
that as a local application iodoform powder dusted
over the ulcerated surfaces has given more satisfac-
tion than any other topical application.

         Tumors  in the Nasal Cavities.

  Tumors are also found in the anterior and posterior
nasal  cavities, and the laryngoscopist is  frequently
called upon to remove them.
  Pathology. — Two varieties of  nasal  polyps are
usually  recognized, the mucous  and  the  fibrous
variety, to which I would add  a third, the cystoid.
  Like the hypertrophies of the mucous  membrane
and of  the cartilaginous septum,  these polyps are
due to inflammation ; and Galen recognized this fact,
for Virchow quotes him as saying  " that  the nasal
polyps are due either to  inflammation or develop
from  a  node  or  from germinal  matter."   And
Virchow  himself says  that  "on  mucous surfaces
tumors for the most part occur in places where there
previously was a simple inflammatory disturbance 
      TUMORS IN THE NASAL CAVITIES.   345

—where the  simple inflammatory hyperplasia  of
chronic catarrh precedes the growth of polyps.
  It is therefore evident that they may occur on any
portion of the nasal mucous membrane, and that
they will be found more usually in those portions of

                      Fig. 99.
Vertical section through nasal cavity, showing nasal polypi.
the nasal  cavities  which are most  exposed to the
irritating  influences of the air and  dust, viz., in the
respiratory portion.  They are, however, also found
in the antra of Highmore.
  Under the microscope the mucous variety is seen
to be composed chiefly of myxomatous tissue, which
is intermingled with fibrous tissue and some organic 
346   TUMORS IN THE  NASAL CAVITIES.

muscular fibres.  Embedded in their  substance we
find some hypertrophied glands as well as venous
sinuses, and sometimes we find in thin sections open-
ings  lined  with  columnar  epithelium, which  are
probably the  cross-sections of invaginated  portions

                      Fig. 100.
Section of mucous polyp,  x 300.
  1. Epithelial layer. 2. Infiltrated submucous layer. 3. Mucous gland.
4. Fibrous band.  5. Venous sinus filled with blood.  6. Myxomatous
tissue.  7. Transverse section of arteriole.  8. Invagination of mucous
membrane.

of mucous membrane.   The polyps are covered with
ciliated columnar epithelium in those portions which
are not exposed to  the direct influences of the air,
while  the convexities  pointing  toward the nostrils
are covered with stratified  epithelium.   Billroth 
      TUMORS IN  THE NASAL CAVITIES.   347

describes them as retaining all the elements of the
mucous membrane, from which they spring.  Occa-
sionally we find that  they have  undergone telan-
giectatic degeneration.
  The more rarely met with fibrous variety, which
is very hard and of a glistening  white  color, stands
in contrast to the soft, gelatinous, pinkish, and highly
hygrometric  mucous variety.   Cornil  and Ranvier
say of the fibrous polyps :  "They usually have their
point of attachment in the posterior portion of the
nasal cavity.  They send  prolongations  in every
direction, into all the cavities, either bending around
obstacles or breaking  through them, enlarging the
nasal fossae, thinning or destroying  the bones, and
penetrating by new ways  or  natural openings into
the sinuses which surround the nasal fossae."
  Under the microscope they appear as true fibro-
mata, containing, however, like the mucoid  variety,
glands, venous  sinuses, and  numerous capillaries.
Both the fibrous and the mucoid  variety  of polyps
are not infrequently combined in  the same growth.
  The  question has  arisen  in  my mind whether
these growths should not be looked upon  as simple
hypertrophies of the mucous membrane which have
undergone mucoid  degeneration or fibrous change,
or  both, as  the  case   may  be,  and  this view  is
strengthened by the observations  of Woakes, who
describes as a primary  stage of polyps, a  granular-
looking mass of hypertropied tissue  covering the
lower portion of the middle turbinated  bone; for in
this way the presence of glands, venous sinuses, and
spaces lined with  epithelium within their  structure,
can readily be explained, while, on the other hand, 
348   TUMORS IN  THE  NASAL  CAVITIES.

the presence of these  foreign elements  cannot so
easily be  accounted for if we consider the polyps
genuine neoplasms.  Having once started in a local-
ized hypertrophy  of the mucous  membrane, the
mucoid or fibrous change rapidly assumes large pro-
portions under the stimulus of continued irritation,
pushing the  mucous membrane  before it; and in
this way the often enormous pear-shaped masses are
produced.  I have  frequently found  a number of
small mucoid polyps on the mucous membrane neai
the site  of larger  ones  which  I  had previously
removed,  and which, if left undisturbed, would soon
have filled the nasal cavity by their increase in size.
This is a question, however, which cannot be deter-
mined by merely  examining extracted polyps, but
may possibly be settled by making sections through
the mucous membrane at the point of origin of the
tumors.
  The third variety of polyps is a large sessile cyst
filled  with thin  watery  mucus  and covered  with
epithelium.  In the few cases which I have seen—too
few to make extended examinations as to the nature
of these growths—they sprang from the lower border
of the inferior turbinated bone.  I have  not met
with any mention of them in the literature to which
I had access.
  Symptoms.—The symptoms  to which  the presence
of polyps  gives rise, when situated in  the  anterior
nasal cavities, are a stoppage of either one or both
nostrils, so that  the patient is obliged to breathe
through his mouth.  This stoppage of the  nose is
usually aggravated  in damp weather on account of
the swelling of the neoplasms due to the hygro- 
TREATMENT.
349
metric condition of the atmosphere.  Articulation is
altered  by the absence of those consonants whose
articulation requires that a  current of air should
pass through the nose,  and the patient speaks  as if
he had a cold in his head.  Bleeding of the nose is
a frequent symptom, and originates either from the
tumor itself or from the congested mucous mem-
brane in its neighborhood.
  Tumors in the nasal  cavities give rise to all the
symptoms of nasal catarrh, and  their  presence is
usually not suspected  until a rhinoscopic examina-
tion is made, or until they appear in the nostrils.
  These neoplasms  are  usually  mucous or fibrous
polypi, but other forms of tumors, such as have been
enumerated as occurring in the larynx, are found.
   Treatment.—The treatment of  nasal polypi con-
sists in their removal, and it becomes a question,
which of the different  methods is to be used to
accomplish  this purpose.
  Before the introduction of the rhinoscope and the
modern methods of inspecting  the anterior nasal
cavities, the surgeon made use of what is termed a
polypus  forceps, slightly  curved,  with elongated
fenestrated  blades, the inner surfaces of which are
ribbed,  to afford a better  hold  upon the polypus.
These were introduced into the nostril, and coming
in contact with anything that felt  like a tumor or
polypus, the blades were forcibly closed, the forceps
twisted in the  hand, and traction  made until the
growth  came away,  either in fragments or, more
rarely, bodily.  This was repeated  until the cavity
seemed clear of polypi, or until  the patient could
no longer endure the pain.  This method even now
                        so 
350   TUMORS  IN THE NASAL CAVITIES.

is practised by many surgeons, but it is, to say the
least, unsatisfactory.   In the first place, the forceps,
not being guided by the eye, comes  roughly  in con-
tact with the congested mucous membrane, injuring
it and giving rise to hemorrhage; further, the pedicle
of the  tumor  is but rarelyr removed,  so that the
polypus speedily grows  again, or, if it comes away,
a shred of the mucous membrane to which it adheres
is also torn away, giving rise to a great deal of pain
and considerable hemorrhage;  and finally the irri-
tation and injury of the mucous membrane give rise
to considerable and extensive inflammation, which
sometimes assumes alarming proportions.
  Another  method for  the removal of nasal polypi
has been recommended by some authors, which con-
sists in injecting into their substance, by means of a
hypodermic syringe, some solution of  liquid, with a
view to cause a mortification of the tissues of which
the tumor is composed, such as glacial  acetic acid,
tincture of iodine, alcohol, etc.   It will be found,
however, that as a rule these injections give rise to
so much pain that  the patient is not willing to have
them repeated on the other polypi;  and if the solu-
tion  is made  so weak as not to give rise to much
pain, the polypus is not affected by it.
  The  method  which  is preferable  to any  other,
consists in removing the polypi with a wire snare in
the following manner.   The nostril  being  dilated
with a dilator, the cavity  brightly illuminated, and
the mucous membrane  anaesthetized  with cocaine
solution, the Jarvis' snare is introduced, and the loop
manipulated so that the polypus in view is encircled
by it, and slips through it.  The wire should be of a 
TREATMENT.
351
medium size, and the loop just large enough to take
in the growth.  The loop is then drawn in with the
sliding tube, thereby causing it to slip around the
pedicle, and  when tight  around  it the tumor is
snared off by  turning  the milled nut.   In  a few
seconds the polypus will come out held at the end
of the canula, and cut off close to the mucous mem-
brane, without the latter being in  the  least torn or
injured, and consequently  very little pain is experi-
enced by  the patient, and little, if  any, hemorrhage
follows  the operation.  One after the other of the
polypi is  removed in the same  manner until the
cavity is clear, which takes some little  time, as they
are generally multiple and quite numerous. Having
accomplished  this, every bleeding point  which was
the seat of a  polypus, should be carefully touched
with  a flat galvano-cautery knife at  a  cherry-red
heat,  in order to prevent a recurrence of the tumors.

                     Fig. 101.
                    Double hook.

  Sometimes the growths are attached high up be-
tween the turbinated bones, so that it becomes im-
possible to throw the wire loop  around the pedicle
and remove them in  this way.   In such  cases it is
often  possible to grasp the  protruding end of the
polyp with a pair of rat-tooth forceps, or, better still,
with the double hook, or devil, and draw it down so
that the wire loop can be thrown around  it, and  by
manipulation caused to slip around the pedicle.  This 
 352   TUMORS IN THE NASAL CAVITIES.

 double hook (Fig. 101), which I devised some years
 ago  for this very purpose, consists of a thin  steel
 shank set in a small wooden handle.  The projecting
 end  terminates in two  small, sharp hooks bent in
 opposite directions, while the  end near the handle
 has a screw  thread cut on it, upon which a milled
 head  runs easily up and down.  The  whole of the
 shank is covered by a  metal canula, the lower end of
 which rests on the milled head, while the upper end
 has a bell-shaped  expansion which, when the canula
 is pushed up, covers the hooks.  In using this instru-
 ment the  canula is pushed down so as  to expose the
 hooks; these are pressed against the presenting por-
 tion of the polypus and the handle is slightly turned
 toward the right.  This causes the hooks to enter the
 tissue and traction upon  the instrument in a straight
 line  will not release  them.   The canula is  then
 pushed up against the polypus and held in position
 by the milled head, which is run up against its lower
 end.  The instrument will then hang securely from
 the lower portion of  the polypus without support,
 and  the wire loop of the snare can be introduced
 around it and the polypus.   If the instrument, which
 has been named a "Devil,'' is to be removed before
 the tumor or polypus is taken away, the milled head
 is run down and the handle is given a slight twist to
 the left, which causes the hooks to leave the tissue
 without tearing it.  If the application of the devil is,
 however, not feasible,  or if the wire loop cannot  be
 laid around the pedicle of the polypus, forceps must
 be used;  and it  will  be found  that my  universal
laryngeal  forceps  answers  the  purpose better than
the ordinary polypus forceps, because it can  be 
GALVANO-PUNCTURE.
353
shaped into the required curve, and its blades can be
opened in a much narrower space, thus grasping the
polypus at or near the pedicle.  When, in the case
of fibrous polypi, the neoplasm has penetrated into
the antrum, by absorbing the bony partition between
the two  cavities by pressure, it can, in most cases,
be removed through the nasal cavity; but if it has
its attachment in  the  antrum, and  has  forced  its
way into the nasal cavity, then the former  must be
opened in order to remove the growth.
  If polypi or other tumors are attached to the walls
of the pharyngeal cavity, or, as is sometimes the case,
to the posterior edge of the  vomer, they should also
be removed with the wire snare in the same manner
as was described for the removal of posterior hyper-
trophies.
  The opening of the sac and emptying  it of its
contents, in  the cystoid variety of polypus, affords
relief from the symptoms of stenosis, but  the cyst
soon fills again, and, therefore, a  more radical  re-
moval is necessary.   To accomplish this, the cyst is
opened  in its  entire length  with a pair of scissors,
and the flaps of tissue removed also with the scissors.
The cut surfaces, as well as the remaining surface of
the cyst, are then scorched with the galvano-cautery
loop to prevent its re-formation.

               Galvano-puncture.

  There is another method of treatment  for the re-
moval of tumors, both in the larynx and in the nasal
cavities,  which frequently promises  success where
                       30* 
354         TABLES  OF SYMPTOMS.
the other methods already described cannot be em-
ployed, viz., galvano-puncture.
   In this mode of operation the powerful chemical
action of electricity is made  use  of in order  to
break up the tissues of the tumor and prepare them
for speedy  absorption.   The  procedure is a very
simple  one, and  consists in the introduction of a
needle into the substance of the neoplasm, to which
is attached one of the  poles of a battery, while the
other pole is in contact with the skin in the neigh-
borhood of the seat of the tumor. The battery need
not be  very strong, and for small tumors a single
pint Bunsen  cell is sufficient.   The needle should
be made of gold or silver, as steel is oxidized more
readily by the electricity.  From two to ten sittings
are necessary  to cause the absorption  of a tumor
the size of a pea  in the larynx, while nasal  polypi,
especially of the  mucous  type,  are often absorbed
very much more quickly.
              CHAPTER XVII.

TABLES OF SYMPTOMS OF THE DISEASES OF THE LARYNX
                AND NASO-PHARYNX.

  The following tables of symptoms of the diseases
of the larynx and naso-pharynx have been compiled
from the carefully kept records of over five thousand
cases, treated both at the German Throat Infirmary
and at the dispensary for throat diseases of the Uni-
versity Hospital. 
TABLES  OF SYMPTOMS.         355
  It will be observed  that secondary and tertiary
syphilitic throat  diseases, which by many authors
are separated, have been classed under one common
head, because the symptoms are very similar in both
forms.
  It will be further noticed that only those diseases
which are strictly affections of the throat have been
included, while those which are to be regarded as
symptoms of general systemic  disorders  have been
omitted. 
Table  of  Symptoms of Diseases of  the  Larynx.
00
en
  Symptoms.


Subjective :

  Voice,
Respiration,
Cough,
Deglutition,
Pain,
Acute laryngitis.
Hoarse, sometimes
 aphonic.
Not  embarrassed
 except when
 oedema  is pres-
 ent, then dysp-
 noea.

Dry  and  hard;
 later moist.
Usually painful.
 Chronic
laryngitis.
Tubercular
laryngitis.
Syphilitic
laryngitis.
Hoarse ; falter- ,  Hoarseness of pe-
 jus ;   easily .   culiarcharacter;
 fatigued.        aphonic in later
                 stages.
Hurried,  embar-
 rassed  in  later
 stages.
Hoarse ;  seldom
 aphonic.
Not  usually em-
 barrassed.
Hacking,  with I  Painful ; amount  Slight hacking.
 starchy   ex- :   and   character
 pectoration.  '   depending upon
                 the lung  impli-
                 cation
Not  interfered  Difficult and pain-
 with.           ful.
Feeling of  con-  Feeling of ful- i Only  in  degluti-
 striction   and I   ness.           tion and phona-
 acutepain.     I                   tion.
Unimpaired,  un-
 less epiglottis or
 arytenoids   are
 ulcerated.
 Benign
growths.
Malignant
 growths.
Variable, from   Variable.
 slight hoarse-
 ness to aph-
 onia.
Embarrassment
 depends upon
 situation   of
 growth.
Not severe; oc-
 casional   ex-
 pectoration of
 parts of
 growth.

Impaired when
 growth is situ-
 ated  on epi-
 glottis or ary-
 epiglottic fold.

Absent.
Functional
 diseases
Aphonic  in bi-
 lateral paraly-
 sii. Hoarse in
 other forms of
 paralysis.
Quickened and , Embarrassed in
 paroxysmal.     paralysis   of
                 abductors.
Not severe; oc- | Paroxysmal  in
 casional   ex-   spasmodic af-
 pectoration of   fections.
 parts of
 growth

Difficult    and  Not  generally
 painful.       ;  affected.
Severe.
Not    usually
 present. 
Symptoms,  i Acute laryngitis.
Physical :
Color,        Uniformly intense
              red.
 Chronic
laryngitis.
Partially    in-
 creased.
Form and  | Swelling in cede- | Abrasions.
  texture,   j  ma.
Position,    ' Unaltered
Unaltered.
External,
Pharynx   impli- I Pharynx impli-
 cated,             cated.
Prognosis,
Exposure  to
 draught.   Em-
 bedded   foreign
 bodies or corro-
 sive substances.
Impure air ;
 abuse of
Favorable except .Favorable.
 in cedema.
Tubercular
laryngitis.
Grayish-red.
Swelling of mu-
 cous membrane,
 ulcers, and pyi i-
 form swelling of
 arytenoid carti-
 lages.

Usually  no  dis-
 placement.
Pharynx involv-
 ed ;    physical
 signs  of  lung
 disease.
Syphilitic
laryngitis.
 Benign
growths.
Dark-red in sym- | Variable  with
 metrical patches.   nature of the
                 |  growth.
Malignant
 growths.
Functional
 diseases.
Ulcerations   and
 specific neo-
 plasms.
Unaltered except
 when  changed
 by  cicatrices of
 ulcers.

Pharynx,  velum,
 and skin impli-
 cated.
Same as of lung | Primary sore.
 affection.
Unfavorable.
Favorable.
Variable ;
 ulcers.
Normal
 seldom
 changed.
parts
		►3
Depends upon size and na-ture of the growth; large ulcers.	Form of glottis changed.	F W O
Displacement by infiltration.	No displace-ment.	
Glands impli-cated ; cancer-ous cachexia.	Other organs may be af fee ted.	O
Depends  upon i Unfavorable.
 Bize  and posi-
 tion of growth
Primary cancer I Cerebral dis-
  iu other parts   ease,  hysteria,
               I  acute  and
                 choruiiic
                 laryngitis.

                Favorable when
                 cerebral  dis-
                 ease is absent.
00
O'
^1 
Table of  Symptoms of  Diseases of  the Naso-pharynx.
  Symptoms.


Subjective :
  Voice,
  Acute
pharyngitis.
  Chronic
pharyngitis.
 Syphilitic
pharyngitis.
 Granular
pharyngitis.
Tonsillitis.     Nasal polypi.
 Nasal
;-atarrh.
Usually  hoarse,   Normal, unless  Normal,orslightly, Usually   hoarse ! Normal; articu-1 Normal; articu-  Normal; articu-
 with thick arti-    larynx is  im-   hoarse.  Articu-   from  laryngeal   lation thick,   i  lation nasal.     lation more or
 culation.          plicated, then '   lation  nasal  if   implication.                                       less nasal
                   hoarse   and   velum or uvula   Articulation
easily fatigued,  is ulcerated.
Not  interfered
 with.
Respiration,  Not   interfered
              with     except
              when tonsils are
              touching  each
              other.
Cough,       Hanking ;  later  Dry, but slight,  Variable.
              moist.             white stringy
                                expectoration.
normal.
Not affected.
Affected only in! Respiration
 severe cases.     through  nose
                 more  or less
                 obstructed.
Deglutition, ; Difhcultand pain-
              ful if tonsils and
              glands are impli-
              cated.
Difficult according
 to  position  of
 ulcers.
Pain,
Severe  lancinat- ! Sense of dryness! Usually absent.
 ing.            ,  and burning.  I
Often severe and
 dry, with little
 expectoration.
Not affected.
Slight.
Absent.
Almost impossi- ! Not affected.
 ble, and very
 painful.
Respiration
 through nose
 affected, espe-
 cially  in  re-
 cumbent posi-
 tion.

Slight, with ex-
 pectoration of
 thick tenacious
 mucus.

Not affected.
Sense of dryness J Severe.
 and fulness.     I
Usually absent.  Frontal  head-
                 ache, sense of
                 dryness in nose
                 and pharynx.
00
Or
00 
Symptoms
  Acute
pharyngitis.
  Chronic
pharyngitis.
 Syphilitic
pbaryngiti
 Granular
pharyngitis.
Tonsillitis.      Nasal polypi,
 Nasal
-atarrh.
Physical
  Color,
Form and
  texture,
External,
Cause,
Prognosis,
General  redness
 of mucous mem-
 brane.
Not changed.
Larynx
 cated.
Exposure to cold.
Generally
 diminished
 with promi-
 nent veins.

Mucous  mem-
 brane dry and
 shining.
Brick-red.  Sym-  Usually paler
 metrical patches.   than normal.
More or less deep
 ulcers on
 pharynx, velum,
 and tonsils.
impli- : None.
Tonsils  appear  General hyper-  Redder  than
 livid.           remia of nasal   normal.
                 mucous mem-
                 brane.
Bad  air, alco-
 holism, mas-
 turbation.
Primary sore.
Red  nodules and
 promiuent veins
 on   surface  of
 pharynx
 resembling
 granulation.
Skin implicated.   ' None.
Great tumefac-
 tion  of  the
 glands.
Depends  upon
 character of
 polypus.
Implication  of  Stoppage of
 cervical  and   nose; dryness
submaxillary
of mouth and
pharynx ;
bleeding
from nose.
Abuse  of voice ;  ] Exposure to
 gastric derange-  ,  cold.
 ment.
Favorable.
Favorable in
 most  cases.
Tumefaction of
 mucous mem-
 brane. Hyper-
 trophies ; shal-
 low ulcers.
Stoppage of
 nose, often wa-
 tery discharge;
 slight  depres-
 sion andwiden-
 ing  of  bridge
 of nose.

Vitiated air and
 changeable
 climate.
00
On
CD 
 
INDEX.
Ablation  of  adenoid  tissue  of
      pharynx, 307
    of ecchondroses of septum, 306
    of anterior  and middle hyper-
      trophies, 300
    of posterior  hypertrophies, 302-
      306
Abortive treatment of coryza, 265
Abrasions in chronic laryngitis, 162,
           182
        pharyngitis, 162, 163
    production of, 162
Abscess, 177, 201
Acacia, 167, 264
Accent, 113
Acid, acetic, 289, 335, 35(1
    benzoic, 163
    carbolic, 163,174, 197, 234
    chromic, 198, 289
    lactic, 193
    muriatic, 149, 198
    nitrate of mercury, 197, 343
    nitric, 198, 289
    osmic, 264
    phosphoric,  336
    tannic, 163, 193, 234, 247
Acne  as result of catarrh, 279
Aconite, 265
Acoustics, 103
Actual cautery, 289
Acute laryngitis, 171-177
        oedematous, 177-180
        prevention, 201
        simple, 171-177
        symptoms, 173
        traumatic, 172
        treatment, 174
    pharyngitis, 230-236
        duration, 232
        prevention, 235
        symptoms, 231
        traumatic, 235
        treatment, 233
    tonsillitis, 236, 244
Adams' forceps, 310
Adenoid tissue of pharynx, 91, 258,
          307
        ablation  of, 307
Adenoma, 227
Adhesion of posterior pillars, 237
Administration of remedies, 163
Air  prepared for respiration  by
  nasal cavities, 134
Air-compressors, 144-145
Alse of nose, 89
Alcohol, 185, 350
Allen, Harrison, 115, 261
Alteratives,  163, 169
Alum, 162,174,180, 234,241
Ammonium, muriate of, 149, 287
Amputation of uvula, 241
    of tonsils, 246
Ainyl, nitrite of, 170
Anaesthesia  of larynx,  Rossbach's
      method, 228
    local, by cocaine, 167
Anaesthetics, 325
Anatomy of larynx, 65-81
    of nasal cavities, 86-98
Aneurism, cause of aphonia, 209
Angioma, 227
Angular scissors, 322
Animal heat, 154
Anodynes, 194, 198
Anterior hypertrophies,  2.34, 280,
          332
        pathology, 256
        treatment, 292-300
    rhinoscopy, 54
Antiseptic solution, 168,169, 265
    pastiles, 169
Antra of Highmore, 89
        injured  by nasal  douche,
          269
        tumors of, 345
            treatment of, 349
        obstruction of, in  catarrh,
          253
31 
362
INDEX.
 Aphonia, 173, 207, 224
     cause of, 203
     due  to  cicatricial contraction,
               204
             treatment of, 206
         foreign bodies, 215
                 treatment of, 216-
                   221
     hysterical, 207
     paralytic, 207, 214
         treatment of, 210
     prognosis, 214
 Applications, topical  method  of
   making, 165
 Applicator, cotton, 139, 184
 Arteries of larynx, 80
 Articulation, 111
     of cartilages of larynx, 75
 Ary-epiglottic folds, 72, 78, 83
         ulceration of, accompanied
           by peculiar pain, 190
 Aryteno-epiglottideus inferioris,
           78
         superioris, 78
 Arytenoid cartilages, 68, 72, 83
     detachment of, in syphilis, 198
     muscle,  73
     muscular process of, 69
     pyriform swelling of, in phthi-
       sis, 191
     variations in, 85
     vocal process of,  69
 Asphyxia  from  cedema of larynx,
       174
     from spasm accompanying neo-
       plasms, 224
 Asthma,  dependent  on nasal ob-
       struction, 135,  277, 331
     hay,327
 Astringents,  163, 165, 174, 180, 193
 Atomizers, 140, 147
     disadvantages  of  metal  and
       rubber, 142
     substances not to be  used in,
       148
 Atrophic nasal catarrh, 337-342
             causes, 338
             prognosis, 342
             symptoms, 337
             treatment, 339-342
 Atropia, 334
 Auto-laryngoscopy, 17, 52
     importance  of,  to beginner,
       53
Autumnal catarrh, 329
Avery, 16
 Babbington, 15
 Battery, galvano-cautery, 293
     storage, 297
     universal, 296
 Beard, 328
 Beecher, 199
 Belloque's canula, 325
 Bennati, 16
 Benzoic acid, 163, 234
 Benzoin, 234
     tincture of, 174, 183, 234
 Benzole, 163
 Bifurcation of trachea, 83
 Bigelow, 91
 Bilateral paralysis, 207, 208
 Billroth, 346
 Blackley, 328
 Bleeding of nose, 277, 282, 324
 Bloodvessels of larynx, 80
 Bony obstruction of nose, 315
             treatment of, 315
 Bosworth, 135, 261, 304, 327, 328
     nasal dilator, 55
 Bougies, 202
 Boulton's solution, 285
 Bozzini, 14
 Breathing, laryngeal image in, 84
 Bresgen, 340
 Bromide of ammonium, 193
     of potash, 170, 238, 288
     of sodium, 193, 334
 Bromine salts, 193
 Browne, L., 267
 Brush, laryngeal, 139
 Bunsen cell, 354
 Burges air-compressor, 144
     atomizer, 142
 Burrs, 317
 Burr shield, 317

 Calipers, nasal, 137
 Calomel, 170
 Cantharides. 170, 179
 Canula, Belloque's, 325
 Carbolic acid, 163,174, 197, 234
     inhalation of, 234
 Carbonic acid, 234
Carcinoma, 199
     medullary, 227
Caries of nasal bones, 337
Cartilages, articulation of, 71
    arytenoid, 68, 83
    cricoid, 68
    of Santorini, 69, 83
    of Seiler, 19, 69-83
    of Wrisberg, 69, 83 
INDEX.
363
Cartilages, thyroid, 66
Catarrhal conjunctivitis, 278
    ulcers, production of, 162,177
Catarrh, atrophic, 337-342
    chronic nasal, 273
    hypertrophic, 274
    syphilitic, 342
Catching cold, 153
         definition of, 159
Catheter, Eustachian, 325
    female, 325
Cauliflower growths, 226
Cause of atrophic catarrh, 338
    chronic laryngitis, 187
         pharyngitis, 236
             follicular, 236
             gastric, 236
             granular, 236
    cicatricial stenosis  of larvnx,
      205
    coryza, 263
    elongated uvula, 240
    hay-cold, 326
    hypertrophic catarrh, 283
    paralysis, 207
    tumors of nasal cavities, 344
Caustic-holder, 153
Caustic, lunar, 1(15
Caustics, 167, 289
Cautei-'v, actual, 289
    ea'lvano-, 197,248, 289, 335
Cavernous  tissue   of  turbinated
   bones. 91
Cavity  of larynx, 78
Chart, case, 98, 99
Chiasm of recurrent laryngeal, 81
Chlorate of potash,  176, 181)
Chloroform, 170
Chromic acid, 289, 334
Chronic nasal catarrh, 273
    simple catarrh, 274
         laryngitis,  181-190
             causes, 181
             symptoms, 182
             treatment, 183
         pharyngitis, 236
    syphilitic laryngitis, 194
             prognosis, 197
             symptoms, 194
             treatment, 196
         pharyngitis, 237
             symptoms, 237
             treatment, 238
    tonsillitis, 237
    traumatic laryngitis, 200
             expectoration in,
 Chronic traumatic  pharyngitis,
   239
 Cicatricial contraction, 205
 Cicatrization of vocal cords, 204
             treatment, 206
 Classification of laryngeal tumors,
   225
 Cleansing of  mucous membrane,
               168
            importance of, 340
            in atrophic catarrh, 340
            in   hypertrophic  ca-
               tarrh, 2S5
 Cleavage of middle turbinated body,
j   258
I Clergyman's sore throat, 186
1 Cocaine, 194, 276, 289, 332
 Cod-liver oil. 183, 193, 196, 239
 Cohen, J. Solis, 26
I Cohen's tongue-depressor, 49
 Conjunctivitis from nasal catarrh,
   278
 Consonants, 121
      compound self-sounding,  129
      simple self-sounding, 124
      simple tone borrowing, 130
 Constrictor of glottis, 74
 Copper sulphate of, 163, 181
 Corditis vocalis, 177
 Coryza, 263
      causes, 264
      pathology, 252
      symptoms, 264
      treatment, 264
 Cotton-applicator, 139.184
 Cough, 237, 240
      laryngeal, 173, 184
      peculiar, in neoplasms, 224
         in cedema, 179
 Counter irritation, 170, 175
 Cramer's reflector, 22
 Cricoid cartilage, 68
 Crico-arytenoid, 75
 Crico-arvtenoideus  lateralis, 72
      posticus, 68
 Crico-thyroid  membrane, 69
      muscle, 72
 Croton oil. 179
 Crude petroleum. 288, 341
 Cubebs, 163, 287, 288, 341
 Cultivation of voice, 189
 Cupping, 179
 Cystic polypi, 348
         treatment, 349
      tumors, 226
 Czermak, 18 
364
INDEX.
Daly, 327, 328
Dental engine, 314
Deviation of septum, 137, 262, 269,
          281, 308, 332
        pathology, 262
        treatment, 353
Diagnosis of lupus,  262, 344
    of neoplasms, 224
    of pharyngitis from diphtheria,
      232
    of syphilis in pharynx, 196
Diet, after amputation of tonsils, 250
    in acute and sub-acute laryn-
      gitis, 181
    in acute pharyngitis, 233
    in relation to heat production,
      154
Dialect, 112
Dilators, nasal, 55
Diseases of the nasal cavities, 251
Disorders of larynx, functional, 202
DobelPs solution, 168
Double hook, 351
Douche, nasal, 266
Duration of acute laryngitis, 174
        pharyngitis, 232
    of hay-cold, 336
Drills, 317
Dry catarrh, 337
Dyspepsia  as a cause  of  chronic
  pharyngitis, 236
Dysphagia, 179, 180, 224, 227
    peculiar character of, in ulcera-
      tion, 190
Dyspnoea, 206, 224, 227
    in hypertrophied tonsils, 245

Ecchondroses of septum, 280, 306,
          310,313, 319,332
        ablation of, 306
Electricity, faradic, 185
    galvanic, 285
    in aphonia, 210
Electric light, 28
    illuminator, Seiler's, 29
    motor, 315
    laryngoscope, 30
        S. S. White's, 30
        Jarvis's,  31
Electrode, laryngeal, 211
Elephantiasis, 199
Ellioston, 327
Elongated uvula, 240
        cause and treatment,
Elsberg, 267
Elsberg's epiglottis forceps, 51
Elsberg's nasal dilators, 55
Epiglottis in acute pharyngitis, 232
    ligaments of, 71
    management of, 46
    muscles, 75
    cedema of, 170
    pendent. 50
    turban-like swelling in phthi-
      sis. 191
    variations in shape, 85
Epiglottidis, 177
    cedema of, 170
Epiglottis-forceps, 51
Epithelioma, 227
Epithelium of nasal cavities, 90
    erosions, 338
Erectile tissue of nasal  cavities, 90,
  91
Ether, 170
Ethereal oils, inhalations of, 163
Eustachian catheter. 325
    tubes, 75, 91, 220, 276
Eversion of ventricle. 224
Examination of patient, 96
Exostoses of palatine process, 315
            treatment, 315
    of septum, 259, 280, 332
        treatment, 321
Expectorants, 185
Expectoration, 173, 180,  182,  190,
  200, 231, 237

Fahnestock's tonsillotome, 247
Falsetto voice, 187
Faradic electricity, 185
Farnham, 308
    alligator forceps, 324
Fasciculated sarcoma, 227
Fauces, irritability of, 47
Faulty production of voice,  186
Fauvel, 178
Ferric alum, 285
Fibro cellular tumors, 226
Fibroma, 226
Fibrous polypi, 347
Flemming, Otto, 293-295
Fold, glosso-epiglottic, 83
Foliated growths, 226
Follicular pharyngitis,  236
Forceps, Adams', 310
    Elsberg's epiglottic, 51
    laryngeal, 217
    polypus, 345
    Steel's 309
Foreign  bodies, cause of aphonia,
  215 
INDEX
365
Foreign bodies in  glosso-epiglottic
           folds, 216
         in larynx, 200, 215
         in nose, 334
         instruments for removal of,
           217-219
Formula of Boulton's solution, 285
    of compound chlorate of potash
      lozenges, 175
    of cough mixture, 185
    of DobelPs solution, 168
    of iodine solutions, 287
    of iron  and  potash  mixture,
      174
    of nitrate of  silver  powders,
      340
    of tonic pills, 214
Frontal headache, 253, 263, 331
    sinuses, 89
         disease of, 342
             treatment of, 342
         in hay-cold, 331
         injured  by nasal douche,
           207
         obstructed in catarrh, 253
Functional disorders  of larynx, 202

Gaocjing, how  avoided, 43
Galen, 344
Galvanic electricity, 276
Galvano-cautery, 167,197, 248, 289,
      335
    application of, to anterior and
      middle hypertrophies, 290
    batteries, 294, 298
    puncture, 353
Garcia, 17
Gargles,  234
Gas brackets, 25
         Mackenzie's, 25
         Seiler's, 26
Gaslight, 24, 29
Gastric pharyngitis, 236
        cause, 237
         symptoms, 237
        treatment, 238
General therapeutics, 162
Gibson's  storage battery, 297
Glands, mucous, of nasal cavity, 90,
      91
    serous, 91
    thyroid, 81
Glandular tumors, 227
Glasgow, 277
Glosso-epiglottic ligaments, 70, 83
    fold, 83
Glosso-epiglottis, foreign  bodies in,
  215
Glottis, 82
    constrictor of, 77
    spasm of, 165
    cedema of, 170
Goitre, a cause of aphonia, 210
Goodwillie's shielded burr, 316
Gordon,327
Gottstein, 261, 341
Granular pharyngitis, 236
        cause, 236
        symptoms, 237
        treatment, 236
Grindelia robusta, 288-341
Growth, cauliflower, 226
    cystic, 226
    nbro-cellular, 226
    fibroid, 226
    foliated,  226
    malignant, 225
    mulberry, 226
    raspberry, 226
    vascular, 227
Guillotine, 222
Gum acacia, 167,  642
Gummata, 237, 343
 Hemoptysis, simulated, 225
 Hay asthma, 327
    cold, 326
    coryza, 326-337
    fever, 326
         etiology, 331
         history, 327
         hypersensitive areas, 332
         prognosis, 336
         symptoms, 329
         treatment, 332
 Headache, frontal, 253, 263, 331
 Head reflector, 21, 38
 Head-rest, 37
 Heat, animal, 154
 Helmholtz, 328
 Henle, 91
 Highmore, antrum of, 89
 History of laryngology, 13
 Hoarseness, 181, 182,  190, 205, 209
 Horse cold, 329
 Hyo-epiglottic  ligament, 71
 Hyoid bone, 69
 Hypersensitive areas  in hay fever,
  332
 Hyperplasia of vocal  cords,  187,
  204
L* 
366
INDEX.
Hypertrophic nasal catarrh, 274
             causes, 283
             frequency, 282
             prognosis, 330
             stages, 339
             surgical    treatment,
              289-326
             symptoms, 275
             treatment, 284, 289
Hypertrophied turbinated bone, 279
             treatment, 289
Hypertrophies, 254
    pathology, 256
Hypertrophy of tonsils, 244
        as obstacle to laryngoscopy,
          51
        oval mirror preferable in,
          20
        periodic  acute inflamma
          tion of, 244
        symptoms, 245
        treatment, 244
    anterior  nasal, 254, 280, 332
    middle nasal, 254, 280, 332
    pathology of, 256
    posterior nasal, 254, 282, 302
      332
Hysterical aphonia, 207, 214

Idiosyncrasy, 215
Illumination, 20
    by artificial light, 24
    by direct light, 34
    by reflected light, 21
    by sunlight, 33
    by transparency, 33
    management of, 37
Image of larynx, 82
    of posterior nares,  93
Infra-glottic laryngoscopy, 53
Inhalation, 148
    of benzole, 163
    of carbolic acid, 197
    of ethereal oils, 163
    of nitrate of  potassium, 150
    of nitrate of silver, 165
    of powerful sedatives, 170
    of vapor, 148
Inhaler, 150
    for  nascent ammonium chlo-
      ride, 149
Injection  of  caustics   into  nasal
      polypi, 350
    of iodine solution, 146,170, 350
Inspissated  secretion,  how  to re-
  move, 168
  Instruments accessory to laryngo-
    scopy, 136
  Insufflations, 165
  Insufflators, 152
  Inter-arytenoid ulcerations, 192
  Introduction of laryngeal mirror,
        39
      of rhinoscopic mirror, 61
  Inversion of laryngeal image, 35
  Iodide of iron, 341
      of potassium, 238, 288, 341
      of sodium, 193, 334
  Iodine, 165
      injection of, into hypertrophied
            tonsils, 170, 246
          into nasal polypi, 350
      method of applying, to naso-
        pharynx, 286
      solutions, 287
      therapeutics  of, 165, 170,  179,
        285
  Iodism, 239
  Iodoform, how disguised, 165, 288
      therapeutics  of, 165, 193,  198,
        344
,  Iron styptics, use of, in nose, 306
  Irritability  of fauces, 47
  Irritation, counter-,  170

  Jacobson's organ, 89
  Jarvis' method in operative rhino-
        scopy, 63
      nasal dilator, 55
      rhinoscopic mirror, 60
               Seiler's  modification,
                 60
      snare, 299
          Seiler's attachment, 301
      transfixing needles,  300

  Judd, 328

  Keen, W. W., 81
  Kline, 91
  Knives, laryngeal, 222
          guarded,176, 222
          open, 221

  Lactic acid, 193
  Lamplight, 21, 24
  Lamp, Tobold's,  25
      Cohen's modification, 25
  Language, definition of,  112
  Laryngeal brush, 140
      'cough,173, 184
      electrode, 211 
INDEX.
367
Laryngeal electrode, mode of appli-
      cation, 212
    forceps, 216, 220
    guillotine, 218, 219
    image, 82
        in breathing, 84
        inversion of, 35
        in vocalization, 84
    knives, 222
        guarded, 176, 222
        open,221
    lancet,  176
    mirror, 19
        devices to  prevent chill-
          ing, 38
        glass, 19
        introduction, 39
        management, 42
        reserved for specific cases,
           196
         steel, 20
        testing temperature of, 45
        total reflecting prisms, 20
         warming of, 46
     sound,  136
     spasm, 221
         from iodine in larynx, 286
         from   silver  nitrate  in
           larynx, 165
         reflex, from applications to
           tonsils, 189
     stammering, 102
     tumors, classification of, 225
     ulcers, 190
 Laryngitis, acute, 171
     chronic, 181
     phthisica, 190
         symptoms, 190
         treatment, 193
     subacute, 180
     syphilitic, 194
     traumatic acute, 172
         chronic, 181
         cedematous, 173
 Laryngoscope, 13
     description, 13
     history, 13
     electric, 30
         S  S.  White's, 30
         Jarvis's, 31
 Laryngoscopy, 24
     auto-, 17, 52
     infraglottic, 54
     instruments accessory to,  136
     obstacles to, 47
     optical principles of, 34
Laryngotomy, 206
Larynx, 13, 20
    anesthesia of, 167, 228
    anatomy, 65
    application to, 166
    bloodvessels, 80
    cavity of, 78
    foreign bodies in, 200, 215
    functional disorders, 202
    ligaments, 69
    mucous membranes, 66, 80
    muscles, 81
    nerves, 81
    cedema of,  177
    physiology of, 101
    scarification, 176
    spasm of, 165
    stenosis of, 205
    superior aperture of,  65
    tubercles in, 192
 Lateral thyrohyoid ligaments, 71
 Law of reflection, 34
 Leaden mallet, 321
 Ledge on nasal septum, 259, 283
             treatment, 321
 Leeches, 170, 179
 Leveret, 14
 Ligaments of epiglottis, 71
    of larynx, 69
 Light, artificial, 24
    concentrators, 25
         Mackenzie's, 25
         Seiler's, 26
    direct, 34
    electric, 28, 33
    oxy-hydrogen, 28
    position of, 37
    reflected 21
     source of, 24
     sun,24
    yellow, compared with white,
       33
 Lime-light, 28
     water, 201
 Linear ulcers of cords, 205
 Lipoma, 226
 Liston, 16
 Local anaesthesia, 167
 Loss of smell, 278
 Lozenges, 169, 184
    compound chlorate of potash,175
 Lunar caustic. 165
 Lupus,  199-344
     diagnosis, 344
     treatment, 344
 Luschka, 67 
368
INDEX.
Mackenzie, 224
    J. N., 327, 328
Mackenzie's light-concentrator, 25
    laryngeal electrode, 211
        forceps, 217
    leaden mallet, 321
Malignant tumors, 227
        treatment, 227
Management of epiglottis, 42
    of illumination, 37
    of laryngeal mirror. 42
    of reflector, 38
    of tongue, 39
Meatuses of nose, 86
Mechanism of voice, 186
Medullary carcinoma, 227
Membrane, crico-thyroid, 69
    Schneiderian, 169
    thyro-hyoid, 67
Mercury, acid nitrate of, 197
Method of making topical applica-
      tion, 166
    of measuring wire loop of snare
      303
    of plugging nasal cavity, 325
Microscopical  appearance of larynx
          in phthisis, 192
        of nasal hypertrophies, 256
        of polypi, 346
Middle ear in nasal catarrh, 278
    hypertrophy, 254, 280, 332
    turbinated body,cleavage of,258
Miller's asthma, 329
    cold, 329
Mirror, laryngeal, 40-45
        Wright's electric, 46
    reflecting, 21-38
    rhinoscopic, 61
Moore, 327
Morphia, therapeutics  of, 167, 264,
  334
Mountain air in chronic laryngitis,
  185
Mouth-breathing, cause of chronic
      laryngitis, 182
    pernicious effects of, 135
Mucous glands, 93
    membrane, cleansing of, 168
        of larynx,  66, 80
            normal color, 85
            pathology of, 160
            variations in, 85
        of nasal cavities, 190
                traumatic inflam-
                  mation of, 288,
                  292, 318, 324
Mucous  membrane, pathology of,
      160
    polypi, 345
         microscopic appearance of,
           346
Mulberry growth, 226
Muriate  of ammonium, 265, 287
Muscles  of epiglottis, 77
    of larynx, 81
    of vocalization, paralysis of, 205
Muscular process of arytenoid  car-
  tilage,  73
Mustard, 170
Myrrh, 341
Myxoma, 226, 345

Nasal calipers, 137
    catarrh, atrophic, 337
         hypertrophic, 339
         simple chronic, 274
         syphilitic, 342
    cavities, anatomy of, 86, 91
         diseases of, 251
         effect upon, of inspired air,
           134
         epithelium of, 90
         erectile tissue of, 90
         glands of, 91
         mucous membrane of, 90
                color of, 90
                nerves of, 92
         olfactory region of, 90
         osmosis and exosmosis in,
          91-134
         pathology, 251
         physiology, 133
         plugging, method of, 325
         respiratory region, 90
         sinuses connected with, 89
         tumors of, 344
    dilators, 55
    douche, 266
         forms of, 266-271
         precautions in use of, 267
         use of, 271
    gouge and chisel, 320
    hypertrophies, 254
         anterior, 254, 280, 332
         microscopical  section  of,
          256
         middle, 254, 280, 332
         myxomatous   degenera-
          tion, 347
        pathology of, 255
        posterior,   254, 282,  302,
          332 
INDEX.
369
Nasal obstruction, cause of chronic
      laryngitis  and  pharyngitis,
      182
    plug, 310
    siphon, 271
    specula, 56,  280
    stenosis, cause of catarrh, 284
    voice, 134
Naso-pharynx, 95
    diseases of, 251
Necrosis of turbinated bones, 258
    of laryngeal cartilages, 198
    of vomer, 342
         treatment, 342
Neoplasms, laryngeal, 221, 224
         diagnosis of, 225
         instruments for removal of,
           217-220
    nasal, 299-301
Nerves of larynx, 81
    of nasal cavities, 92
Nitrate of silver, 162,163, 181, 183,
           193,  197, 287
         inhalation of, 166, 341
         powdered, 341
         solid, 197
         solution, 183, 193, 206, 287
         therapeutics, 163
         to be  avoided  in  hyper-
           trophic catarrh, 287
Nitric acid, 289, 335
Nitrite of amyl, 170
Nose, bleeding,  277, 282, 324
    bridge broadened  in  hyper-
       trophic catarrh, 278
    reddened from catarrh, 279

Observer, 47
    obstacles to laryngoscopy pre-
       sented by, 47
Obstacles to laryngoscopy, 47
    on part of observer. 47
    on part of patient, 47
    to posterior rhinoscopy, 62
Offensive  breath in  atrophic  ca-
           tarrh, 337
         in disease of sinuses, 342
         in hypertrophic  catarrh,
           278
         peculiar  in  syphilitic ul-
           ceration, 343
(Edema of epiglottis, 170
    of glottis, 170
    of larynx,175, 177
         symptoms, 174
         treatment, 176
Ointments, 167
Olfactory region of nasal cavity, 90
Optical principles of laryngoscopy,
    35
Osmic acid, cause of coryza, 264
Osmosis in nasal cavity, 91, 134
    cause of pain, 91
Oxy-hydrogen light, 28
Ozaena, 337, 339

Painful vocalization, 206
Palate hook, 62
        Porcher's, 63
Papilloma, 225
Paralysis of  muscles  of vocaliza-
              tion, 207
            bilateral, 207
            causes, 209
            hysterical, 207
            prognosis, 210
            treatment, 210-215
            unilateral, 208
Pathology of coryza, 263
  '  of hypertrophies, 255
    of mucous membranes, 160
    of nasal cavities, 251
    of polypi, 346
Peach-cold, 329
Pendent epiglottis, 50
Perforation of septum, 343, 338
         traumatic, 309
    of velum palati, 238
Perichondritis, 199, 200
Periodic inflammation of hypertro-
  phied tonsils, 244
Petroleum, 341
Pharyngeal cutting forceps, 308
    tonsil, 91, 25b, 307, 308
         ablation of, 307
         hypertrophy of, 281
Pharyngitis, acute, 171, 230
         mistaken  for diphtheria,
           232
         traumatic, 235
    chronic, 236
         follicular, 236
         gastric, 236
         granular, 236
         syphilitic, 237
         traumatic, 239
Pharynx, adenoid tissue of, 307
    inspection of, 94
    physiology of, 135
    vault of, 94
Phcebus, 327
Phosphoric acid, 336 
370                        in
Phthisical laryngitis, 190
        pyriform swelling of ary-
          tenoid cartilages in, 191
Physiology of larynx, 101
    of nasal cavities, 133
    of pharynx, 135
Pillars, adhesion of posterior, 237
    in pharyngitis, 237
    inspection of, 39
Pirrie, 327
Plugging nose, method of, 325
Polypi, 332, 334, 344
    forceps, 351
    pathology, 345
    symptoms, 348
    treatment, 349
Pomum Adami, 67
Porte-caustique,  153
Position of patient and observer, 36
  of light,  37
Posterior  hypertrophy,  254,  282,
          302, 332
        pathology, 256
        treatment, 302
    rhinoscopy,  58
        obstacles to, 62
Post-nasal syringe, 272
Potash, bromide of, 288
    chlorate of, 180
    iodide of, 288
Prevention  of  acute pharyngitis,
      235
    of catching cold, 231
    of sneezing, 182
Production of abrasions, 162-182
    of catarrhal ulcers, 162
Prognosis of atrophic catarrh, 337
    of aphonia,  215
    of hay-cold, 336
    of hypertrophic  catarrh, 339
    of paralysis of cords, 209
    of syphilitic laryngitis, 194
Purgatives, saline, 233
Pyriform swelling of arytenoid car-
  tilages, 191

Quinia, sulphate of, 334, 341

Raspberry growth, 226
Record of cases, 98, 99
Reflection, law of, 35
Reflector, 21, 38
    attached to jointed arm, 38
    concave,21
    Cramer's, 22
    Fox's, 22
EX.
Reflector, management of, 23
    plane, 24
    position of, 23
    Semeleder's, 22
    supported on head, 23, 38
Reflex irritation, 185
Registers of voice, 108
Remedies, administration of, 163
Removal of foreign bodies, 215
Reservoir insufflator,  152
Respirator, 201
Rhinoliths, 332, 334
Rhinoscopic image, 93
        in atrophic catarrh, 338
        in first stage of hypertro-
          phic catarrh, 274, 339
        in second stage of hyper-
          trophic catarrh, 283
    mirror, 61
        Jarvis', 61
            Seiler's  modification,
               61
Rhinoscopy, 54
    anterior, 54
    posterior, 60
        introduction  of mirror in,
           61
        obstacles to, 62, 95
Richardson, J. G., 268
Rima glottidis, 82
Roe, 327, 328
Roosa, 267
Rose-cold, 329
Rostock, 329
Rossbach's method of anaesthetiz-
  ing the larynx, 228, 229
Round-celled sarcoma, 227
Sacculus laryngis, 80
Saline purgatives, 233
Salt solution, 197
Santorini, cartilages of, 69
Sarcoma, fasciculated,  227
    round celled, 227
    spindle-celled, 227
Sass' atomizing tube, 141
Scabs, 337
Scarification of larynx, 176-179
Schneiderian membrane, 169
Schuster kugel, 25
Scirrhus, 227
Scissors, 323
Scrofula, 337
Seashore, not  suited  for  chronic
  laryngitis, 186 
INDEX.
371
Secretions  of mucous membrane,
               altered by disease,
               161
             inspissated,  how re-
               moved, 169-170
             retention in nasal cav-
               ity,  337
Seiler, angular scissors, 324
    antiseptic solution, 169
        pastiles, 169
    attachment to Jarvis' snare, 301
    cartilage knife, 319
    cartilages of, 19
    double hook, 351
    electric illuminator, 29
    galvano-cautery battery, 293
        handles, 291
        knives, 290
    gas bracket,  26
    guillotine  and tube - forceps,
       219, 352
    nasal gouges and chisel, 320
    pharyngeal cutting forceps, 308
    plow-shaped knife, 321
    universal battery, 296
    uvula scissors,  243
Sellique, 16
Sexual excitement as a cause  of
  hay fever, 329
Semeleder, 262
    mirror, 22, 23
Septometer, 137
Septum, deviation of, 137, 262, 269,
       281, 308, 332
    exostoses of,  259
    ledge on, 259. 283
    perforation of,  338, 343
        traumatic, 309
    thickening, 137
Serous glands, 91
Silver, nitrate of, 162,163,181,183,
  193, 197, 287
Simple chronic catarrh, 274
Simulated haemoptysis, 225
Sinus, frontal, 89
Siphon, nasal, 271
Smell, loss of, 278
Smith, Albert,  327
Snoring in hypertrophied  tonsils,
  244
Snow cold, 329
Solution, Boulton's, 285
    Dobell's, 168
    of iodine, 287
    of nitrate of silver,  163,  181,
       183
Solution of salt, 197
Sore throat, 231
        clergyman's, 186
Sound, laryngeal, 228
Sounding, 228
Source of light, 24
Spasm of glottis,  reflex, 165
    of larynx, 179
Speaker's sore throat, 186
Specific chronic pharyngitis, 237
            symptoms, 237
            treatment, 238
Specula, nasal, 56
Sphenoidal cells,  disease of, 342
Sponge-holder, 138
Steam atomizers,  147
Steel laryngeal mirrors, 20
Steel's forceps for deviated septum,
  309
Stenosis of larynx, 178, 201
    of nasal cavity, 324
Stoerk's  guillotine and  tube-for-
      ceps, 218
    universal handle, 218
Strychnine, 150
Styptics, use of, in nose, 306
Subacute laryngitis, 180
        diet in, 181
Summer catarrh, 327
Sunlight, 21, 33
Sulphate of copper, 163, 181, 285
    of iron, 285,  341
    of quinine, 334, 347
    of zinc, 163,  181,  184, 285
Surgical treatment of  hypertrophic
  catarrh, 284
Symmetry  in syphilitic inflamma-
  tions, 237
Symptoms of acute laryngitis, 172
    of acute pharyngitis, 231
    of atrophic catarrh, 337
    of chronic laryngitis, 182
        pharyngitis, 237
    of coryza, 263
    of elongated  uvula, 240
    of hay-fever, 329
    of hypertrophic catarrh, 275
    of hypertrophied tonsils, 245
    of laryngeal  neoplasms, 224
    of laryngitis  phthisica, 190
    of cedema of larynx, 178
    of paralysis of cords, 207
    of subacute laryngitis, 180
        pharyngitis, 237
    of syphilitic  laryngitis, 194
    of tumors of  nasal cavities, 348 
372
INDEX.
Syphilis, signs of, in mouth, 196
Syphilitic catarrh, 342
        treatment, 343
    laryngitis, 194, 200
        prognosis, 198
        symptoms, 194
        treatment, 196
    pharyngitis, 237
    ulcers, 198,  199
Syphiloma, 195, 237
Syringe, post-nasal, 272
Systematic examinations, 96

Table of symptoms of disease of the
  larynx and naso-pharynx, 354
Tannic acid,  180, 193
Tar, 163, 234
Taste, loss of the sense of, 278
Therapeutics, general, 162,170
Thickening of vocal cords, 203, 209
Thierfelder, 257
Thudichum's douche, 266
Thyro-arytenoid muscle, 72, 74
    -epiglottic ligament, 71
    -epiglottideus, 77
    -hyoid ligaments, lateral,  71
        membrane, 73
Thyroid cartilage,  66
    gland, 81
Thyrotomy, 202
Tincture of benzoin, 174, 183,  234
    of iodine, 170
    of iron, 170, 174, 180
Tobold's lamp, 25
        Cohen's modification, 25
    laryngeal lancet, 176
Tolu, 163, 174, 183
Tongue, management of, 48
    -depressor, 49
        Cohen's, 49
Tonsillitis, acute, 236, 244
Tonsillotomes, 247
Tonsils, altered secretion  of,  mis-
      taken  for diphtheria, 232
    amputation of, 244
    hypertrophied, 245
    in pharyngitis, 232
    inspection of, 39
    pharyngeal, 91, 258, 307, 308
Topical applications, 165
        importance of, in syphilis,
          196
        method of making, 165
Trachea, 65, 83
    bifurcation of, 83
Tracheotomy, 229
Transparency, illumination by, 33
Traumatic acute laryngitis, 172
        pharyngitis, 235
    chronic laryngitis, 181
        pharyngitis, 239
    inflammation of mucous mem-
      brane, 288, 292, 318, 324
    perforation of septum, 309
Treatment of acute laryngitis, 174
        pharyngitis, 232
    of atrophic catarrh, 339, 342
    of bony obstruction  of  nose,
      315, 324
    of chronic laryngitis, 183
        pharyngitis, 236
            follicular, 236
            gastric, 236
            granular, 236
    of coryza, 264
    of elongated uvula, 241
    of hay-fever, 332
    of hypertrophic  catarrh,  284-
      327
    of hypertrophied tonsils,  244
    of laryngeal neoplasms, 227
    of laryngitis phthisica, 174
    of cedema, 176
    of paralysis, 208
    of stenosis of larynx from cica-
      trization, 206
    of subacute laryngitis, 181
    of syphilitic laryngitis, 195
        pharyngitis, 238
    of tumors of nasal cavities, 349
Tube-forceps, 219, 352
Tubercles in larynx, 192
Tumors, laryngeal, 224
    classification of, 225
    cystic, 226
    fibro-cellular, 226
    fibrous, 344
    of nasal cavity, 344-353
            cystic, 344
            fibrous, 348
            mucous,  345
            pathology, 346-348
            symptoms, 348
            treatment, 349
Turbinated  bones, 86
        atrophy of, 338
        hypertrophy of, 315
    corpora, cavernosa,  90
Tiirck, 24

Ulcers, 237, 280, 283, 337
    carcinomatous, 199 
INDEX.
373
Ulcers, catarrhal production of, 162,
       2811
    linear, of vocal cords, 205
    syphilitic, 194, 198, 199
Unilateral paralysis, 268
         causes, 209
         complete, 208
         partial, 209
         treatment, 210
Universal tube-forceps, Seiler's, 219,
       252
    inhaler, 150
Use of nasal douche, 266
           '  precautions in, 267
Uvula, amputation of, 241
    elongated, 240
    in pharyngitis, 231
    inspection of, 39
    scissors, 213
Uvulatomes, 242

Vapor inhalations, 148
Variations in color of normal mu-
      cous membrane, 85
    in normal arytenoids, 85
         epiglottis, 85
Vascular growths, 227
Vaso-motoria periodica, 326-336
             history, 327
             etiology, 331
             prognosis, 336
             symptoms, 329
             treatment, 332
Vault of pharynx, 94
Veins of larynx, 81
Velum palati in pharyngitis, 232
         Jarvis's method of control-
           ling, 63
         obstacle to posterior rhino-
           scopy, 62
         perforation of, 238
Ventilation, defective, cause of nasal
  catarrh, 284
Ventricle, eversion of, 80
Ventricular bands, 80
        assuming functions of vocal
          cords, 199
Vestibule of nose, 90
Vibrissa',  134
Vienna paste. 289
Virchow,  91, 244
Vocal cords, 69, 78, 186
        agglutination, 204
        hyperplasia.  187, 204
        paralysis, 207
        ulceration, 202
    muscle, 74
    process of arytenoid cartilages,
      69
Vocalization, laryngeal image  in,
      85
    painful, 206
    paralysis of muscles of, 207
Voice, cultivation of,  189
    faulty production of, 183
    mechanism, 186
    nasal, 134
    peculiar in phthisis, 190
    production, 105
    registers of, 108
    whispering, 111
Vomer, 91
    exostoses of, 281,  283
    necrosis of, 342
Von Bruns,  221, 226
Vowels, 116,327,346

Water air pump, 145
Whispering  voice, 111
Wire loop, 219
Witch-hazel, extract of, 285
Wright, W. W., 45
Wrisberg,  cartilages of, 83
Wyman, 328

Zinc, sulphate of, 163, 181, 184, 285
32 
 
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