NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY Of NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY O NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY Ol SNOiasw jo Aavaan ivnoiivn 3nidiq3w jo Aavaan ivnouvn snidiqjw jo Aavaai NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF 3NOia3w jo Aavaan ivnouvn 3noiq3w jo Aavaan ivnouvn 3nidiq3w jo asvi NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY iNOicnw jo Aavaan ivnouvn snioiosw jo Aavaan ivnouvn snoiqsw jo Aavaai ■o c JATTONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY Of, NI0I03W jo Aavaan ivnouvn 3nidiQ3w jo Aavaan ivnoilvn 3noiq3w jo Aavaai ATIONAI LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF HANDBOOK OF THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE THROAT, NOSE AND NASO-PHARYNX. BY CARL SEILER, M.D., INSTRUCTOR IN LARYNGOLOGY ANDLECTTTRER 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. FOURTH EDITION, THOROUGHLY REVISED AND GREATLY ENLARGED. ILLUSTRATED WITH TWO LITHOGRAPHIC PLATES CONTAINING TEN FIGURES, AND ONE HUNDRED AND SEVEN WOOD ENGRAVINGS. PHILADELPHIA: LEA BROTHERS & CO. 1893. wv I? 9 3 F,Jl.fv> y\o. I© 661 ,3-te^ '£ Entered according to the Act of Congress in the year 1893, by LEA BROTHERS & CO., In the Office of the Librarian of Congress. All rights reserved. D Q R N A N , PRINTER. PREFACE TO FOURTH EDITION. The favorable reception accorded to the first three editions of this work has been exceedingly gratifying to the Author, and has induced him to make a fourth edition, which he hopes may be even more worthy of the commendation of the profession. Numerous additions will be found throughout this edition, among which may be mentioned an entirely new chapter on Influenza and American Grippe, and also a new chapter on Intra-nasal Neoplasms, as well as a description of the effect of uterine disease upon the mucous membranes of the upper air-passages in pro- ducing chronic inflammations, and intra-nasal disease as a cause of acne of the face and neck. The other new chapters and changes which had been made in the third edition were retained, and although very little of the text-matter was expunged, the publisher has en- deavored and partially succeeded in retaining the size and shape of the volume as in its former editions. The number of illustrations has also been increased by the addition of six new and original engravings on wood, which the Author trusts will, together with the vi PREFACE. colored plates and old engravings, prove of assistance to the reader by illustrating the subject-matter. These new drawings were made by the Author himself, but he still takes this opportunity of expressing his gratitude to his friend, Dr. John Madison Taylor, and to his accomplished wife, who have so greatly aided him by making the original drawings for most of the illustra- tions retained from the former editions. CARL SEILER, M.D. Philadelphia, March, 1893. 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 importance have been discussed as concisely as possible, 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 sys- temic diseases, and merely exhibit severe laryngeal 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 viii PREFACE TO FIRST EDITION. Dispensary of the 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 per- mitting 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—Anat- omy of the nasal cavities—The rhinoscopic image- Case record-sheet.......64-99 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........100-133 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 . . . 133-151 CHAPTER VI. CATCHING COLD, PATHOLOGY OF MUCOUS MEMBRANE, THERAPEUTICS. Catching cold—Pathology of the mucous membrane— Therapeutics—Modes of administering remedies . 151-169 CHAPTER VII. ACUTE LARYNGITIS. Varieties, cause, symptoms, duration, and treatment— GCdema of the larynx: treatment—Subacute laryngitis: symptoms, treatment, and diet .... 170-181 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......181-206 CONTENTS. XI CHAPTER IX. FUNCTIONAL DISORDERS OF THE LARYNX. PAGE Aphonia: causes—Aphonia due to cicatricial adhesion: pathology and treatment—Aphonia due to paralysis: pathology and symptoms—Unilateral paralysis: causes and treatment—Aphonia due to the presence of foreign bodies—Laryngeal forceps.....206-223 CHAPTER X. NEOPLASMS OF THE LARYNGEAL CAVITY. Use of instruments—Neoplasms: symptoms and diagnosis —Classification of tumors in the larynx—Treatment— Prognosis........223-232 CHAPTER XI. PHARYNGITIS. Acute pharyngitis : symptoms, duration, and treatment —Traumatic acute pharyngitis—Chronic pharyngitis— Specific chronic pharyngitis: symptoms and treatment —Traumatic chronic pharyngitis .... 232-242 CHAPTER XII. ELONGATED UVULA AND HYPERTROPHY OF TONSILS. Elongated uvula: causes, symptoms, and treatment—Uvu- latomes—Hypertrophy of tonsils: symptoms and treat- ment—Tonsillotomes......242-253 CHAPTER XIII. DISEASES OF THE NASAL CAVITIES AND NASO-PHARYNX. Pathology—Coryza : symptoms, cause, and treatment— Nasal douche—Precautions in the use of the nasal douche ......... 254-275 xii CONTENTS. CHAPTER XIV. INFLUENZA AND AMERICAN GRIPPE, OR EPIDEMIC MYXOID CEDEMA. PAGE Influenza: symptoms, treatment—American grippe or myxoid oedema: history, symptoms, dreams, eye symp- toms, treatment ....... 276-290 CHAPTER XV. CHRONIC NASAL CATARRH. 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 290-343 CHAPTER XVI. HAY FEVER, OR CORYZA VASO-MOTORIUS PERIODICA. History—varieties—symptoms—etiology—treatment 344-353 CHAPTER XVII. ATROPHIC NASAL CATARRH. Atrophic nasal catarrh: cause and treatment—Syphilitic catarrh—Lupus.......354-361 CHAPTER XVIII. NEOPLASMS, RHINOLITHS, AND FOREIGN BODIES IN THE NASAL CAVITIES. General etiology—Polypi — Mucous polypus : etiology— Fibrous polypus, cystic polypus, papillomata, angiomata —Chondromata and osteomata—Malignant neoplasms- Foreign bodies—Rhinoliths—Galvano-puncture . 362-391 CHAPTER XIX. Tables of symptoms of diseases of the larynx and naso-pharynx......392-396 Plate I Fig.! Fig 2. Fig.3. Fig 4 Fig 5 Fig 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 ary-epiglottic folds. Fig. .1 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 ■*s«<^ I 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 laryux. 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 illuminates 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 mention is made of an instrument or apparatus resembling the laryngoscope, but recent excavatious at Pompeii have brought to light small polished metal mirrors attached to slender handles which are supposed to have been used to inspect the cavities of the human body. The 2 14 THE LARYNGOSCOPE. first authenticated attempt at laryngoscopy and rhino- scopy 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 polypoid 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 apparatus 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 apparatus which he had invented for the illumination and examina- tion 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 beud, which served to throw the light downward toward the opening of the larynx when the 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 longitudinal septum, 1 Mercure de France, 1793, p. 2434. 2 "Der Lichtleiter," Philipp Bozzini, Med. und Chir. Dr., Weimar 1807. HISTORY OF THE LARYNGOSCOPE. 15 and two mirrors were inserted at the bend—one for the reflection of the light downward, and the other for re- ceiving the reflected image. This invention of Bozzini was treated, however, with derision by the medical pro- fession, probably on account of the extravagant descrip- tions given of it in the papers, which were not verified by its performances. In 182o, 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 in 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 ('ailed 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 ordi- nary hand-glass, was used to reflect the rays of the sun or ordinary daylight upon the 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 in- stances, and a concave mirror instead of a plane one for reflecting the light. While Babington was still engaged in perfecting his 1 Physiologie de la Voix, par Ed. Tournie, Paris, 1865. 2 Journal de Progres des Sciences, etc., 1829. » Lond. Med. Gazette, 1829, vol. iii. 16 THE LARYNGOSCOPE. 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/ to see the vocal cords. The 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 com- plete 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, BaumSs, of Lyons, described a mirror the size of a two-franc piece (1J- 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 Edinburgh, em- ployed 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 speculum with a mirror in its end for examining the larynx, using as an illumi- nator a concave reflector with a central opening, which was supported by a frame to be worn on the head of the operator.5 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 1 Recherches sur le Mecanisme de la Voix humaine. 2 Compte Rendu des Travaux de la Societe de Medecine de Lvons 1836-38. y ' 3 Practical Surgery, 1840. * Lond. Med. Gazette, vol. xxiv. p. 256. 5 Med. Circ, June, 1862. HISTORY OF THE LARYNGOSCOPE. 17 year 1854, however, Siguor 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 arranging 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 registers of the voice in a paper read before the Royal Society of London in 1855.l Although Garcia was the first who practised laryngo- scopy successfully, his communication to the Royal Society attracted little attention, and would have been forgotten if it had not been that, in 1857, Tiirck, of Vienna, having heard of Garcia's paper, began to 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 different sizes and shapes. While thus engaged Czermak borrowed Tiirck'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, Tiirck continued his experiments, and also succeeded in almost all cases of throat disease which came to his 1 Proc. Royal Society of London, vol. vii. No. 13, 1855. 18 THE LARYNGOSCOPE. department of the hospital in seeing the interior of the larynx and in treating the lesions. Both Tiirck 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 laryngoscope in the form in which it is used at the present day. It is but natural that Tiirck should have claimed priority in the successful use of this instrument, 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 master of the field. In the winter of 1858-59, Mme. E. Seiler, having heard of Czermak's experiments, had a laryngeal mirror constructed from his descriptiou, and practised laryngoscopy successfully on herself and others, among them the writer, with a view to study the physi- ology of the voice. Her efforts being crowned with success, she was able not only to verify Garcia's observa- tions in regard to the registers, but also discovered the so-called head register of the female voice, as well as two small cartilages in the vocal cords. Since that time the instrument has been successfully employed in the diagnosis and treatment of diseases of the upper air- passages, and a number of improvements more or less advantageous have been made. It is owing, however to the labors of the pioneers in this field of medical knowledge, such as Tobold, Storck, Van Bruns, and Voltolini in Germany, Mackenzie and Browne in Eng- land, Elsberg, Cohen, and the author in America, that the laryngoscope is now almost as universally used by the medical practitioner as any of the other instruments of exploration. LARYNGEAL MIRROR. 19 Fig. 1. The Laryngeal Mirror.—The laryngeal mirror (Fig. 1) as it is used now consists of a small rouud 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 increasing its reflecting surface. The stem is made to slide into a hollow handle either of wood, ivory, or of vulcanite rub- ber, and is clamped at any desired length by a set screw. This arrangement is prefer- able to a fixed handle, inas- much as the stem can be pushed entirely into the han- dle, thus economizing space and rendering the 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 different ob- Laryngeal mirror. 20 THE LARYNGOSCOPE. servers, 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 hyper- trophy of the tonsils exists, an oval mirror can be intro- duced between the protruding glands more readily 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 tarnished 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, 1, and so on. The size No 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 advis- able to have at least three different sizes at hand, say Nos. 1, 3, and 4. Yet the greater the reflecting surface of the mirror the brighter will be the laryngeal image, aud therefore the largest sized mirror should always be used whenever practicable. 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 throwing upon the laryngeal mirror when in position a strong light, which must be reflected downward into the laryngeal cavity. For this purpose either direct or reflected arti- ficial light or sunlight may be used. Direct illumina- REFLECTOR 21 tion, by allowing a strong artificial light or sunlight to fall into the patient's mouth, although it is used by several of the eminent laryngologists of Europe, is both inconvenient and unsatisfactory, 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 is the case when sunlight is used, or he must place the lamp, candle, or other source of light between himself 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, caudle, gas-jet, sunlight, or ordinary daylight into the mouth of the patient, by means of a circular, 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, bv means of a ball-and-socket joint, to some contrivance by which it can be supported on the observer's head, or be attached to the source of illumination if artificial light be used. Semeleder recommends for this purpose a spectacle- 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 insecure, 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 reflector is the frontal band introduced by Cramer. This consists of a broad strap of some strong material, 2* 22 THE LARYNGOSCOPE. which passes around the head of the observer, and is fastened at the back by a buckle. 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 Fig. 2. Head-reflector. convenient on account of its portability. It consists of a jointed 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-band, and is therefore not adapted for long-continued use. If a condensing REFLECTOR. 23 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 unsilvered. This opening is intended to be brought before the pupil of one or the other eye of the observer in such manner that the line of vision and that of light have exactly the same direction. Using the reflector in this way, like Fig. 3. Head-reflector in position. the reflector of the ophthalmoscope, it is easier to obtain an image of the larynx well illuminated, but with the great disadvantage of monocular vision, which makes all objects appear on the same plane and prevents a correct interpretation of distances — a very important point in laryngoscopy. It will therefore be found more advan- tageous to place the reflector on the forehead, and from thence to reflect the light into the patient's larynx (Fig. 3). Both eyes may thus be employed in viewing the laryngeal 24 THE LARYNGOSCOPE. image, and a correct idea of the relation of parts in regard to distances may be formed. The line drawn from the pupil of the eye to the laryngeal mirror, and # line from the reflector upon the forehead to the mirror, do not form an angle sufficiently large to make any very great difference in the reflection of the light downward, Fig. 4. Tobold's illuminating apparatus. and very little difficulty will be experienced in obtaining the desired image. The head-reflector should be concave when artificial light or ordinary daylight is used, but should be plaue when direct sunlight is employed, for the concentration of the sun's rays by a concave re- flector produces so much heat as to become painful to the patient. SOURCE OF LIGHT. 25 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 frequently it is desirable to have a much stronger light than can be ob- tained in this manner, and several forms of apparatus for concentrating artificial light have beeu constructed and are in use. The simplest of these is the so-called "Schuster Kugel," first recommended by Tiirck, and used especially 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 powerfully. The concentrated beam of light is then reflected 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 contain- ing 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 eud 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 apparatus by employing gas, and by inserting the rod which carries the concentrator and reflector in a metal stand, so that 26 THE LARYNGOSCOPE. the light can be raised and lowered more easily to suit the different heights of patients. (Fig. 5.) Fig. 5. Cohen's modification of Tobold's lamp. Sir Morell Mackenzie, of London, made use of an adjustable gas fixture, which is secured to the wall like an ordinary bracket-light. For a number of years I SOURCE OF LIGHT. 27 have used in my office a bracket similar to Mackenzie's, made by the Horn, Brannen & Forsyth Manufacturing Company of Philadelphia, upon which the light-concen- trator and reflector are mounted. (Fig. 6.) It has the advantage of being easily moved with one hand into the proper position, and at the same time its joints are stiff enough to support the weight of the light-concen- trator and hold the bracket in any position without the use of a ratchet such as is used in Mackenzie's bracket, Fig. 6. Seiler's gas bracket with Mackenzie's concentrator. and which necessitates the use of both hands in changing its position. Mackenzie's light-concentrator—less com- plicated, more portable, and yet quite as efficient as Tobold's—consists of a cylinder of sheet iron, about 6 inches long by 2J 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 28 THE LARYNGOSCOPE. 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 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 reflected 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 laryn- goscopy, 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, however, when the examinations are conducted in the office of the physician, is the electric incandescent light, which presents nu- merous 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 con- sume the oxygen in the room ; and since the introduction and perfection of dynamo-electric machines and of stor- age 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 laryngoscopy in two ways which are both very satisfactory. The in- candescent lamp is mounted upon the universal o-as- SOURCE OF LIGHT. 29 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 opposite the centre of the lens. Or, the incandescent lamp may be suspended from above Fig. 7. The author's electric illuminator for the laryngoscope. into the light-concentrator by the flexible wire, in which case both the rim of the socket as well as the projecting metallic portion of the lamp should be insulated, to pre- vent possible short-circuiting. In fact, the electric lamp is substituted for the gas-burner, and the whole appar- atus 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 30 THE LARYNGOSCOPE. from the surface and is a little to one side of the centre of the reflector. (Fig. 7.) The light is then thrown for- ward 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 observer can follow the motions of the patient more easily; and if in the first place an easy position of 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 sug- gested 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-aud-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. Still another mode of using the electric light for laryn- goscopy was first suggested by Edison, and later, car- ried out and perfected by the S. S. White Dental Co. (Fig. 8.) It consists in attaching a very small incan- descent lamp close to the laryngeal mirror, 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 ap- paratus 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 com- bines the mirror and illuminator iu one small instru- ment. Unfortunately, however, the light from the SOURCE OF LIGHT. 31 incandescent lamp besides being thrown downward into the laryngeal 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 mirror must necessarily be so thick as to obstruct the view very materially. These defects make the instrument less use- ful in practice than it appears to be in theory. Fig. 8. The S. S. White electric laryngoscope. 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 incandes- cent 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 32 THE LARYNGOSCOPE. mouth of the patient; thus the heat developed by the light does not inconvenience either the examiner or the patient, but there is still some of the light which falls directly into the observer's 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. M '■■' M ' Ml |.,: ':■ W "til. M- Un] i! Jarvis's electric laryngoscope. Sunlight is certainly the best source of light for the illumination of the interior of the larynx and nasal cavi- ties ; but, unfortunately, it is not available at all times and in all localities. When it can be obtained, how- ever, the studeut 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 coming through a southern window. Then turn the mirror until the re- flection falls upon a second plane mirror supported bv 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 SOURCE OF LIGHT. 33 apparatus may be removed and a plane mirror substi- tuted for 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 predominant 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 little 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 transpar- ency.," It consists in concentrating strong sunlight 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 thin and emaciated, only a very dimly lighted image of the larynx can be ob- 34 THE ART OF LARYNGOSCOPY. tained by this means. And even if sufficient light could be passed through the tissues of the neck, the image would still be indistinct, because there would be no shadows. The light being filtered through the tissues emanates from all portions of the larynx, and the out- lines of the different parts of the image would be swal- lowed up in the flood of red light, in the same manner as the outlines of the bones of the fingers are invisible 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 un- derstand the optical principle involved in the process. This principle is the law that the angle of reflection 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 surface 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 to the eye of the observer the better and the more easily will the image be seen. THE LARYNGEAL IMAGE. 35 It should always be borne in mind that the image seen in the mirror is a reflected one, like the image of one's self seen in a looking-glass. On accouut of the Fig 10. Diagram of section of head, showing the position of laryngeal mirror in the pharynx. difference in height of the different parts forming the image, and because the mirror must be placed above and behind the opening of the larynx, it appears reversed in an anteroposterior direction. Parts that are in front appear in the image to be behind, and vice versa. 36 THE ART OF LARYNGOSCOPY, (Fig. 11.) The same holds good when looking at a drawing of a laryngoscopic image. Fig. 11. g tsr h o n qm k I i c d a Laryngeal opening and back of tongue as seen from above in a transverse section of the head. (Turck.) Positions of Patient and Observer.—The relative posi- tions of the observer, the patient, and the source of light are of very great importance, especially for the beginner. The observer and patient should sit opposite each other, POSITIONS OF PATIENT AND OBSERVER. 37 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 prac- titioner can, to a certain extent, control the motions of his struggling patient by holding him with his knees. For office work it is most convenient 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 different patients can be compensated for. The lamp or source of light should be placed to the right of aud a little behind the patient, the centre of the flame being on a level with the patient's eye. (See Fig. 4.) When the laryngoscope is frequently used at the office of the practitioner it is of great advantage to have a head-rest, such as photographers use, attached to the chair occupied by the patient, so as to prevent any change of position of his head (Fig. 12). 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 aud below by the chin. 38 THE ART OF LARYNGOSCOPY. 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, ou the other hand, the head-reflector is employed, it is advisable to obtain an Fig. 12. Chair with head-rest. 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. INTRODUCTION OF LARYNGEAL MIRROR 39 If, on the other hand, the position of his head is a con- strained 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 instauce, 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 over- come the difficulties experienced by all beginners in laryngoscopy. When the reflector has been properly adjusted, the patient is required to open his mouth as widely as possi- ble, 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 displaj'ed, and if the tongue should obstruct the view, by rising at its root, the patient should be required to pronounce the vowel sound " 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 ex- amined, 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 forefinger of the right hand like a penholder, with the reflecting surface of the mirror looking downward. The hand is 40 THE ART OF LARYNGOSCOPY. 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 simultaneous unflexing of both the elbow and hand, and a slight raising of the Position of the hand and arm when introducing the laryngeal mirror, arm, the mirror is quickly carried into the mouth of the patient in a curved line, so that duriug this motion the reflecting surface of the mirror always remains parallel with 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, aud INTRODUCTION OF LARYNGEAL MIRROR. 41 holds it by means of a soft towel or napkin to prevent its slipping through the fingers. This holding of the tongue is necessary in order to increase the space in the pharynx, 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 con- tact with the edge of the lower teeth, aud 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 middle 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 fiuger acts as the fulcrum for the lever which pulls upon the tongue, at the same time it prevents the head of the patient from coming 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 traction upou his tongue himself. 42 THE ART OF LARYNGOSCOPY. In the act of introducing the mirror great care should be taken not to touch the tongue or palate, as this not only injuries the reflecting surface of the mirror for the time, but also produces gagging, especially in persons not accustomed to laryngoscopy examinations. Greater immunity from this inconvenience is obtained by carry- ing 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. Iu this posi- tion 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 immediately results, and prevents any further examination at that time. When in position the mirror is slowly but steadily turned uutil the image of the larynx appears on the sur- face and can be examined (Fig. 14.) The patient is required to say " Eh," in order to cause a rising of the epiglottis and to euable us to see the vocal cords in motion. The position of the mirror in the pharyngeal cavity is of the greatest importance, and unless its re- flecting surface is placed at the proper angle only a por- tion 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 INTRODUCTION OF LARYNGEAL MIRROR. 43 upper surface of the tongue (Fig. 15), only the back of the tongue, the epiglottis, and the arytenoid cartilages Fig. 14. Laryngeal mirror in position, displaying the laryngeal image. (Cohen.) are brought into view. Only when the back of the mirror pushes the velum and uvula as high as possible 44 THE ART OF LARYNGOSCOPY. 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 Faulty positionj)f laryngeal mirror with resultant laryngeal image. withdrawn, for, if this is not done, retching will follow, and not only cause a slight hypersemia 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 INTRODUCTION OF LARYNGEAL MIRROR. 45 position but a short time than to wait until gagging sets in. It 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 Fig. 16. Correct position of laryngeal mirror with resultant laryngeal image. the other, than to attempt to see everything at once. In laryngoscopy, as in many other arts, not only the hand, but also the eye, must be educated to appreciate all the details and the variations from the normal. The throat, however, soon becomes very tolerant to the presence of 3* 46 THE ART OF LARYNGOSCOPY. the mirror when it is held still, aud then the examina- tion of the larynx can be prolonged for a considerable time, and is often terminated only by the mirror be- coming cool and moisture condensing on its surface. In order to obviate this difficulty, Dr. Henry Wright recommended, and actually employed, a very ingenious plan for keeping the mirror at a uniform temperature. 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 estab- lished, the electricity becomes concentrated in the spiral, and elevates its temperature, and also that of the laryn- geal mirror. It has recently been recommended to coat the mirror with glycerin, which would absorb the mois- ture ; 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 amal- gam 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 pre- vent its being placed in position while too hot. Many laryngologists 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 skin of the cheek escapes notice, and may be inocu- lated 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 the danger of inoculation may be avoided. I am in the habit, before examining OBSTACLES TO LARYNGOSCOPY. 47 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 attending 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 him- self, 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 illuminated, 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 occurrence, aud 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 patient drink a glass of ice- water immediately before the mirror is introduced, the cold producing local anaesthesia for a short time ; or by employing some anaesthetic, such as a four per cent. 48 THE ART OF LARYNGOSCOPY. 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 antici- pation of seeing anything on the part of the observer, or by directing the patient to introduce 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 wheu held firmly without trembling. 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 de- pressed 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 repeatedly, until both the patient and the hand of the observer are tired out by futile efforts. The tongue depressor in the simplest form, in which it is daily used by the general practitioner for examining 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 THE TONGUE-DEPRESSOR. 49 mouth, thus obstructing the view and light. An instru- ment has therefore 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 introduced Fig. 17. Fig. 18. Folding tongue-depressor. Cohen's tongue-depressor. 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 con- venience in carryiug the instrument, the blade has been so hinged to the haudle 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 iu 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 50 THE ART OF LARYNGOSCOPY. pocket case (Fig. 17). Soon, however, the metal tongue- depressor becomes tarnished by the secretions of the mouth or by the substances used for application 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 Cohen's tongue-depressor (Fig. 18). It consists of a piece of ebonite bent upon itself, either end being a little over three inches long. The bend being more thau a right angle, the hand holding the instrument 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 instrument 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 introduction 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 pendent 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 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 THE EPIGLOTTIS FORCEPS. 51 Fig. 19. thus prevent slipping (Fig. 19). This is unnecessary, since forceps whose spring is sufficiently strong, and whose ends are well roughened, will hold the epiglottis without slipping. Several German laryn- goscopists, in operations at the anterior angle of the glottis, have drawn a silk thread through the body of the epiglottis, and held it up by pulling upon the ends hang- ing out of the mouth. They assert that no evil consequences have fol- lowed this procedure, and that the amount of pain caused by trans- fixing the epiglottis is scarcely worth mentioning. A better plan, however, is to attach to the epi- glottis a so-called bull-nosed for- ceps, such as is used for the compression of arteries in sur- gical 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 ele- vating the epiglottis. In most cases, at least, the arytenoid car- tilages can be seen without arti- ficially 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. Elsberg's sponge-holder and epiglottis forceps. 52 THE ART OF LARYNGOSCOPY. Auto-laryngoscopy.—-The first successful attempts at laryngoscogy were made by Garcia on himself. He ob- served 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 fortius method of examining the larynx are the same as are used for the examination of the larynx in others, with the addition 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 anyone to practise auto-laryngoscopy. The observer, having seated himself in a chair, with or without a head-rest, places in front of himself 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 in- clined backward. Immediately 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 interfere with dis- tinct 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 INFRA-GLOTTIC LARYNGOSCOPY. 53 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. \Mien 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 nap- kin, 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 mirror before him. The same precautions to prevent gaggiug have to be observed in auto-laryngoscopy as are necessary in ex- amining a patient, and for this reason the beginniuer should commence by examining his own larynx, for then he will learn by his own and often painful expe- rience how to overcome the obstacles to laryngoscopy 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 intro- ducing 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 reddish and not pearl-white as on their upper surface, is noticed. 54 THE ART OF LARYNGOSCOPY. Only in cases where the larynx cannot be seen from above, on account of cicatrization of the epiglottis tying this organ down, or in cases of tumors extending below the glottis, is this method, which was called by Mackenzie "infra-glottic laryngoscopy," of any diagnostic value. Rhinoscopy. Rhinoscopy is the art of inspecting the nasal cavities, and may be divided into anterior rhinoscopy or the ex- amination of the anterior nares through the nostrils, and posterior rhinoscopy or the inspection of the vault of the pharynx and the posterior nares from behind. The anterior nares may in many cases be examined 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 the nose is on a level with the examiner's eye, the latter rests the fingers of one hand upon the forehead of the patient, and elevates the tip of the nose with his thumb. With the probe intro- duced into the nostril he separates the ala from the septum with the other hand, thus opening the nostril sufficiently to illuminate the anterior nasal cavity on that side up to a considerable distance, and to examine the condition of its lining mucous membrane. 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 mar- ket, and among them I have found Bosworth's aud Jarvis's self-retaining dilators (Figs. 20 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 inspection of the anterior nasal cavity, and to make RHINOSCOPY. 55 room for the introduction of instruments far back into the nose. The forcible separation of the soft parts from the septum, thus effected by these instruments, is, however, a great disadvantage for diagnostic purposes, Fig. 20. Fig. 21. Bosworth's nasal dilator. Jarvis's self-retaining nasal dilator. 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, there exists an obstruction caused by hypertrophy or swelling of the tissue at the anterior extremity of the lower turbinated bones, as is so frequently the case in nasal catarrh, this will escape notice, because the obstruction is temporarily removed 56 THE ART OF LARYNGOSCOPY. through the forcible separation of the parts by the blades of the dilators. For this reason, and for others which will be apparent later on, I prefer, for examining the anterior nasal cavi- ties, a rubber nasal speculum, 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 manu- factured and are all that is necessary for most cases. They Nest of rubber nasal specula. should be made of hard rubber aud 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 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 treat- ing nasal diseases, and the internal reflection from the bright inner surface by dazzling the eye materially inter- feres with distinct vision of details in the cavity beyond. In making an examination the speculum is introduced with a slight rotatory motion into the nostril until its end has passed the margin of the vestibule, the ridge or POSTERIOR RHINOSCOPY. 57 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 hemorrhage 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 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 change in the bulk of the different portions should be examined as to their consistency by touching them with a probe bent at an angle to the handle, aud introduced through the speculum. Posterior Rhinoscopy.—Posterior rhinoscopy is much more difficult thau laryngoscopy or anterior rhinoscopy, and requires more patience and dexterity on the part of the examiner than either of the former, because very few persons have control over the movements of the velum palati, and in most of these the upper portion of the pharvngeal wall is so sensitive that the slightest 58 THE ART OF LARYNGOSCOPY. 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 in- spected. 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. In posterior rhinoscopy the head of the patient should not be inclined backward, but the tongue should remain passively on the floor of the mouth, and be held down with the tongue-depressor, so as to increase the space in the fauces as much as possible. With 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 pharyngeal cavity behind the velum palati with its reflecting surface turned up- ward, and by manipulation is caused to reflect the light from the reflector upward and forward so as to illu- minate 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 introduce 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 intro- duction of the mirror, and enables the observer to obtain the proper angle for the mirror more easily. In laryn- goscopy it is necessary that the mirror should be attached to the stem at a fixed angle (120 degrees), but in pos- terior rhinoscopy the angle should be different in differ- POSTERIOR RHINOSCOPY. 59 ent cases, because of the individual differences found in the distance from the vault of the pharynx to the base Fig. 23. Diagram showing rhinoscopic mirror in position. (Bosworth.) 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 1635 60 THE ART OF LARYNGOSCOPY. may be done with Jarvis's rhinoscopic mirror and tongue-depressor (Fig. 24) as modified by myself. The instrument consists of a stout wire which, after having been forked or divided at some distance from its inser- tion 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 Fig. 24. Seiler's modified Jarvis's rhinoscopic mirror and tongue-depressor. by pressing the sides of the larger loop toward each other. The ends of the pincette are perforated by a 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 pharyngeal 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 engag- ing in the teeth of the ratchet holds the mirror at the POSTERIOR RHINOSCOPY. 61 angle given to it before introduction. The large loop acts as a tongue-depressor, so that, with this admirable 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. Having introduced the mirror into the pharynx be- hind the velum, it will be found that in most cases the palate will rise forcibly, thus completely obstructing the view and preventing the introduction of the mirror into the pharyngeal cavity. This difficulty cau be obviated by telling the patient to breathe through his nose, at the same time keeping the mouth open. After a little prac- tice 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 circumstances 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 advan- tageous in my hands, aud I have found that practice on the part of the patient, and a diminution of the irrita- bility of the parts by local applications, will accomplish the purpose much better than any instrument could do. In the case of operations in the post-nasal cavity, however, it is not only desirable but absolutely necessary that the operator should be able to watch his instrument 4 62 THE ART OF LARYNGOSCOPY. in the rhinoscopic mirror; then it becomes necessary to prevent a rising of the soft palate by mechanical means. This may be accomplished by inserting a blunt hook behind the velum and drawing it forward, so as to in- crease 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. Dr. Porcher, of Charleston, has devised an admirable instrument for this purpose, which meets all the require- ments in most cases (Fig. 25). It consists of an ordinary Fig. 25. 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, aud at its rear is an automatic spring-catch, which penetrates the perforations occurring at short intervals in the stem. 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, how- ever, not sufficient to keep the palate out of the way, and then the method devised by Dr. Jarvis must be employed. This is as follows : A eustachian catheter is first introduced along the floor of the nose until its curved end has passed into POSTERIOR RHINOSCOPY. 63 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 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 ends secured by Jarvis's tape-holders. 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 done by slightly compressing 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 64 ANATOMY OF THE LARYNX. 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. CHAPTER III. A N A T OMY AND THE NORMAL LARYNGEAL AND RHINOSCOPIC IMAGES. Although the scope of this manual is not suffi- ciently extended to enter at length into the considera- tion of the anatomy of the larynx and the pharyngeal aud nasal cavities, yet it will be convenient, in a few words, to describe the anatomical relation to each other of those parts which form the laryngeal and the rhinoscopic images, before describing 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 physi- ology, 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 expan- sion presents a triangular appearance. It consists CARTILAGINOUS SKELETON OF LARYNX. 65 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 Fig. 26. Hyoid bone and laryngeal cartilages. (Ellis.) g. Body of the hyoid bone. h. Large cornu. j. Small cornu. a. Epiglottis, b. Thyroid cartilage, c. Arytenoid cartilage, i). Cricoid cartilage, e. Upper cornu, and f. Lower cornu of the thyroid cartilage. mucous membrane, which is thrown into two pairs of folds and is covered with ciliated epithelium, 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 66 ANATOMY OF THE LARYNX. attracts our attention is a large and peculiarly shaped cartilage—the thyroid cartilage. The thyroid cartilage, so called from its resemblance to an old Etruscan shield (dvpedg), is composed of three pieces—two lateral wings or alas, aud 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 great 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 each wing is deeply notched immediately above the greatest anterior projection of the pomum Adami, rising aud falling as we trace it from before backward, so that it presents an S-shaped outline. The lower margin is less complicated, 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 each wing 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 ARYTENOID CARTILAGES. 67 situated at the junction of the wings and forms the key- stone to the arch of the whole cartilage. Its color is slightly different from that of the two wings, being a shade more yellow, aud a microscopic examination 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 (kPckoc), 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 outliue, 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 aryte- noid 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 resem- . blance they bear when approximated to the mouth of a pitcher (apvTcuva), 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 rough- ened, and to it the thyro-arytenoid muscle is attached. 68 ANATOMY OF THE LARYNX. The internal surface is smooth and very narrow, con- cave, and covered with mucous membrane. The base is concave and smooth, articulated with the cricoid carti- lage, and presents two projections or processes in its margin. The anterior process serves for the attachment of the vocal cords, and is called the vocal process, to which in the female larynx is attached a small elongated piece of fibrous cartilage imbedded 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 Santorini. Two small elongated cartilages are also placed in the ary-epiglottic fold. Beside the cartilages 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 hyoid bone, LIGAMENTS. 69 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, in 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 small cartilagi- 4* 70 ANATOMY OF THE LARYNX. nous nodule, which are called the lateral thyro-hyoid ligaments. Connecting the cricoid and thyroid cartilages is a tri- angular 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 articulations of the inferior cornua of the thyroid cartilage with the cricoid are enclosed in two capsular ligaments lined with synovial membrane. This articula- tion is a hinge-like joint which allows of a rocking motion of the thyroid cartilage upon the cricoid. The articulation of the arytenoid cartilages 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 upou 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 exteuds from the anterior surface 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 membrane by which the epiglottis is attached to the sides and base of the tongue, thus forming two large fossae between them. MUSCLES OF THE LARYNX. 71 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. 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. Depressor of the epiglottis. 6. Thyro-hyoideus, cut. 8. Deep or transverse part of thyro-arytenoideus. Muscles.—The muscles of the larynx proper are divided into two classes : those which act in moving the 72 ANATOMY OF THE LARYNX. vocal cords and those which are connected in the move- ments of the epiglottis. The muscles of the first class are again subdivided into muscles which stretch the vocal cords and approximate them, and those which relax aud separate them. The crico-thyroid (Fig. 28) is the first to attract our attention by its size. It is triangular in shape, overlies 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 cartilage upon its base, thus approximating 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 of the thyroid cartilage, and by a few fibres, which become gradually shorter from the inner side of the 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 pos- terior 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 ARYTENOID MUSCLE. 73 parts of the other cartilage. It consists 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. Fig 29. Posterior view of the larynx. (Ellis.) a. Superficial part of the arytenoideus muscle, b. Deep part ot the arytenoideus. c. Crico-arytenoideus posticus. 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 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 acting together will narrow the glottis by approximating the cords. 74 ANATOMY OF THE LARYNX. The crico-arytenoid, a large fan-shaped muscle which occupies the depressions on either side of the median line of the posterior surface of the cricoid cartilage, arises Fig. 30. Mechanical diagram of the action of the intrinsic muscles of the lary from this surface. Its fibres, running 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 CRICO-ARYTENOID MUSCLE. 75 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 follow- ing manner, and fully repays 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, aud at the position indicated by the dotted lines 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 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 a way that when the arch is drawn away from the lower portion of the diagram as much as the pins in the slits will allow, the strips of paper, representing the vocal cords, lay flat. A small square piece of pasteboard should then be passed over the point of each pin project- ing 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 attached to the movable parts at the points indicated, and are passed through holes in the base cardboard at points 76 ANATOMY OF THE LARYNX. 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 aud increases the distance between the vocal pro- cesses of the arytenoid cartilages and the anterior angle of the thyroid, thus stretching the vocal cords. The string 2 represents the posterior crico-arytenoids, string 4 the lateral crico-arytenoids, string 3 the arytenoid muscle, strings 5 and 6 the different fibre layers of the thyroarytenoid, and each one when pulled upon from behind will cause a movement of the vocal cords cor- responding 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 number : 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 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 buudles of muscular fibre, arises from the apex of the arytenoid cartilage, and is lost in the ary-epiglottic fold. 3. Ary-epiglottideus inferioris, arising from the ante- rior surface of the arytenoid cartilage. Its fibres pass upward and are inserted into the margin of the epiglottis. The mucous membraue by which the interior of the larynx is lined is thrown into folds, and, covering the cartilaginous projections and depressions of the skeleton, VOCAL CORDS. 77 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 arytenoid cartilages, and laterally by the ary-epiglottic folds. The cavity proper of the larynx (see Fig. 35) extends from this aperture to the lower edge of the cricoid car- tilage. 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 aud 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 intermingled. These bands present in cross-section the shape of 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 seeu 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 arytenoid cartilage to the angle of the thyroid cartilage, where they are attached to the middle piece of the thyroid car- 1 The designations of the direction are in regard to the larynx, not to tho triangle. 78 ANATOMY OF THE LARYNX. tilage. The lower portion of the vocal bands is lost in the crico-thyroid membrane, with which they are con- tinuous. Iu phonation these bands approach each other with their free edges, aud 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 cartilage, 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 membrane is again supplied with the ciliated variety of epithelium, and runs upward and backward for a considerable dis- tance, 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 runs upward, covering the epi- glottis. This duplicative of mucous membrane thus formed, which lies above the vocal cords and runs par- allel with them, is called the ventricular baud. 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 laryngeal surface of the epi- glottis 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 de- VOCAL CORDS. 79 rived 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, which 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 aud 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. The veins empty into the superior, inferior, and middle thyroid veins. The isthmus is a saddle-like portion of the glandular tissue which connects the two lobes, overlies the trachea, and contains a plexus of veins in childhood, which fact makes the median tracheotomy in children difficult, and frequently necessitates the tying of the isthmus before the trachea can be opened. In later life this portion of the gland, together with the veins, becomes atrophied, and nothing is found in the adult connecting the two lobes but a fibrous band, in place of the isthmus. The nervous force is supplied by the superior laryn- geal and the inferior recurrent laryngeal branch of the pneumogastric, and also by a few fibres of the sympa- thetic and spinal accessory. The superior laryngeal nerve is in the main a sensory nerve and gives sensation to the laryngeal mucous mem- brane, but it also contains a motor branch which supplies the crico-thyroid muscles, while the inferior laryngeal is exclusively a motor nerve and innervates 80 ANATOMY OF THE LARYNX. 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 experiments 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 actiou determine the position of the larynx in the throat. These are the so-called extrinsic muscles of the larynx, and comprise the sterno-thyroid, the thyro-hyoid, the omo-hyoid, and the steruo-cleido-mastoid. Thyroid Gland.—The thyroid gland, a large ductless 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 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 intro- duced, displays a complete image of the laryngeal open- ing, such as is seen in Figs. 31 and 32, we 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 near its insertion into the angle of the thyroid cartilage. In front of this pro- tuberance, extending across the surface of the mirror, THE LARYNGEAL IMAGE. 81 are seen two pairs of bands, the outer reddish, and the inner pearl-white, when normal. These are the ven- tricular bauds and the vocal cords. In quiet breathing a triangular space is noticed between the inner bands, Fig. 31. Fig. 32. Laryngeal image during Laryngeal image during respiration. phonation. with its apex posterior, and usually hidden by the arch of the epiglottis. This space is designated by the name glottis? and in phonation is narrowed down to a slit. In front, at the termination of the vocal cords, we notice two roundish prominences, with a depression- 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 concavity inward, extends back- ward to join the arch of the epiglottis. Along the course of these bauds, which are the ary-epiglottic folds, we see two small nodules, the cartilages of Wrisberg aud those of Santorini. In the female larynx we see, along the inner edges of the vocal cords, two yellowish stripes, very narrow and 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 should be applied to the space between the edges of the cords only. 82 THE LARYNGEAL IMAGE. tapering toward their ends. These are the cartilages of Seiler, which are only rudimentary in the male larynx. Fig. 33. 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 folds, 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. cr. Cricoid cartilage. t. Rings of trachea. Fig. 34. 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. Behind and above the arch of the epiglottis, two dark oval spaces, separated by a light band running backward, THE LARYNGEAL IMAGE. 83 are observed. These are the depressions on either side of the glosso-epiglottic fold, while the light band separ- ating 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 papilla?. 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 infrequently, two dark circles separated by a bright line may be seen in the depths of the trachea, indicating the openings of the bronchi, and the bifurcation of the trachea. In very rare instances a beam of light can be thrown into the right bronchus, but very little can be seen under such circumstances, as everything is very indistinct and differences of color cannot be determined. The normal color of the mucous membrane is a pinkish-red, varying in shade iu different localities. Thus, the epiglottis is usually of a yellowish tint, caused by the shining of the cartilage through the thin layer of mucous membrane. The pearly white of the vocal cords, which has already been mentioned, serves as a landmark to the beginner in laryngoscopy. There may be, however, considerable variation of color in the mucous membrane within the limits of health, in differ- ent individuals, and even in the same individual under different circumstances, 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. 84 ANATOMY OF THE NASAL CAVITIES. The shape of the different parts also may vary con- siderably without being abnormal, and this is especially true 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, partially passed each other, so that the vocal processes seemed to lap without in the least interfering with the function of the vocal cords. Anatomy of the Nasal Cavities. The nasal cavities, which are wedge-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 lachrymal 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 inferior, 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 run- ning parallel with its longitudinal diameter. The ANATOMY OF THE NASAL CAVITIES. 85 Fig. 35. Vertical section ot 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. 17. Tonsil. 18. Epiglottis. 19. Adipose tissue behind tongue. 20. Arytenoid cartilage. 21. Tubercle of epiglottis. 22. Section of arytenoid muscle. 86 ANATOMY OF THE NASAL CAVITIES. spaces or sinuses between these turbinated bones are called meatuses, so that the space between the floor of the nose and the lower turbinated bone is called the inferior meatus, the one between the lower and the middle tur- binated bone is the middle meatus, and the one between the middle and superior turbinated bones is the superior meatus. Fig. 36. Transverse vertical {%. e. coronal) section of the nasal fossae at the plane of the second molar teeth, seen from behind. (Hirschfeld.) The nasal cavities are separated from each other by a septum or division-wall, composed of the perpendicular plate of the ethmoid bone and the vomer posteriorly and the cartilaginous septum anteriorly, thus presenting a smooth surface as the inner wall of each cavity. The floor is formed by the palatine process of the ANATOMY OF THE NASAL CAVITIES. 87 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 by the under surface of the body of the sphenoid bone. Directly communicating with the nasal cavities by nar- row channels are other cavities, situated in the bones of the skull, the lining mucous membrane of which, no doubt, is sometimes affected by the pathological pro- cesses in nasal diseases. These are : The antra of High- more—large triangular cavities situated 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. Mac- kenzie, is partly covered with a fold or projection of the nasal erectile tissue. Then the frontal sinuses—two irregular cavities situated between the two tables of the frontal bone, the communication between them and the nasal cavities being established by the infundibulum—a round opening in the middle meatus. Finally, the sphenoid cells or sinuses found in the body of the sphe- noid bone, communicating with the nasal cavities 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 car- tilages, forming the aire 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 anat- omy of which has lately been described by Kline. This organ in man is, however, only rudimentary. The nasal cavities are lined with mucous membrane, 88 ANATOMY OF THE NASAL CAVITIES. 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 covered by ciliated epithelium in man, with the exception 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 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 iu the accessory cavities in man, but it is very probable that the mucous mem- brane of the frontal sinuses and the antra of Highmore is covered with ciliated epithelium, 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 to about the same level. It is iu this region that the nerve-ends of the olfactory nerve are distributed. Immediately beneath the mucous mem- brane, and between it and the periosteum of the bony walls and the perichondrium of the cartilaginous por- ANATOMY OF THE NASAL CAVITIES. 89 tion of the septum, we find a tissue which bears a striking resemblance to the erectile tissue of the geni- tal organs. (Fig. 37.) It is composed of a network of fibrous tissue, the trabecular of which contain a few organic muscular fibres. Its meshes, of various sizes and Fig. 37. Transverse section of erectile turbinated tissue, X 500.—1,1, epithelial layer ; 2, mucous glands; 3, capillary vessel; 4, 4, venous sinuses. shapes, are occupied by venous siuuses lined with endo- thelium. 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 micro- scope. 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 con- 90 ANATOMY OF THE NASAL CAVITIES. ditions for osmosis, which will cause either a contrac- tion or a distention of the sinuses. In the larger masses of fibrous tissue between the sinuses or caverns we find imbedded the glands, with their ducts opening out between the epithelial cells of the mucous membrane. There are two kinds of glands in this region, which have been described by Kline, viz., serous and mucous glands. Fig. 38. 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. This cavernous erectile tissue is most abundant at the lower portion of the septum and the lower turbinated bone, and although it has been recognized and described as true erectile tissue by Henle, Virchow, 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 " tur- binated corpora cavernosa." THE NASAL NERVES. 91 The naso-pharynx, into which the nasal cavities open by the posterior nares, contains the openings to the Eustachian tubes on either side, and the pharyngeal tonsil, a mass of glands situated below the mucous mem- brane and opening into a number of follicles, some of which are quite large and readily seen in the rhinoscopic mirror. Fig. 39. 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. Nerves.—The nerves of the nose are of two kinds, viz., those of special and those of general sensation. The former consist of filaments from the olfactory bulb, which are distributed upon the superior turbinated bone, the anterior upper third of the middle turbinated bone, 92 THE RHINOSCOPIC IMAGE. and upon the adjacent portion of the septum, and are only concerned with the special sense of smell. The nerves of general sense are : The nasal nerve, a branch of the ophthalmic division of the trifacial, which ramifies upon the upper and anterior portion of the septum and the upper portion of the external nasal walls. The spheno-palatine branch of the second division of the fifth is distributed over the upper posterior portion of the septum and the superior turbinated bones. The Vidian, which has a similar distribution to the spheno-palatine branches. 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. 38 aud 39.) The Rhinoscopic Image. On account of the velum palati and the uvula cover- ing the greater part of the reflecting surface of the mirror in rhinoscopy, a complete image can only be obtained in cases of cleft palate; but, by observing the different parts of the posterior nares in turn, a diagram- matic image can be constructed, which is, perhaps, for study, even better than one drawn from nature. Such a drawing is seen in Fig. 40. 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 sep- tum ; these are the posterior aspects of the turbinated bones. On either side of these and on the margin of THE RHINOSCOPIC IMAGE. 93 the drawing we notice pointed elevations projecting toward the interior of the cavity, with a crater-like depression on their apices ; these are the lateral pharyn- geal walls, with the orifices of the Eustachian tubes. Above we see the vault of the pharynx, and below the posterior surface of the velum palati with the uvula. Fig. 40. Rhinoscopic image. 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 Rosenmiiller's groove. 11. Glandular tissue at the anterior portion of vault of pharynx. 12. Posterior surface of velum. 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. 5* 94 THE RHINOSCOPIC IMAGE. If the uvula is elongated or very large, it is difficult 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 overcoming 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 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 THE RHINOSCOPIC IMAGE. 95 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 per- manent mental impression of the pathological changes which may exist in a given ease. 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 momentary 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 tonsils, and posterior pillars, and the posterior wall of the pharynx, aud note any changes in color of the mucous membrane and condition of its surface, enlargement of the parts, as, for instance, hypertrophy 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 larnygeal mirror may then be introduced and the details of the image examined, always retaining the order in which the physical and functional conditions 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 secre- tion ; and 5. Mobility of parts and functional disturb- 96 THE RHINOSCOPIC IMAGE. ances. Thus it will, be found convenient first to ex- amine the epiglottis and its appendages, the glosso- epiglottic and the ary-epiglottic folds, then the arytenoid cartilages, next the ventricular bands, and finally the vocal cords. If possible, also the trachea as far as it can be seen. In the same manner should the rhino- scopic image be viewed, taking note first of the condition of the pharyngeal tonsil and the roof of the naso-phar- yngeal 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 aud of the vomer. The inspection of the anterior nasal cavities should be conducted in the same systematic manner, using the probe to test the consistency of the parts by the sense of touch. An examination of the upper air-passages made 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 observa- tions 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. THE RHINOSCOPIC IMAGE. 97 A record sheet of this kind on which the headings are printed and the outlines of the parts added, will serve as an illustration (see next page), 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. Name, etc., of patient............ Previous and family history Subjective symptoms < Tongue, Velum, Uvula, Pillars, Tonsils, I Wall of Pharynx, | Epiglottis, I Ary-epiglottic Folds, Arytenoid Cartilages, Ventricular Bands, Vocal Cords, Color ! Position j Foreign and .Secretion. and Mobility.) Bodies ami Surface. , Shape, i \ Neoplasms. y. Vomer, 5 I Turbinated Bones, £ Eustachian Tubes, 7. yS+ i Pharyngeal Tonsils, !/i ! Turbinated I Jones, b I > Septum, 1-1 Floor of Nose, ^q ' Meatuses. 100 PHYSIOLOGY OF THE LARYNX. 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 knowl- edge of the anatomy, and for this reason a chapter on the functions of the larynx, pharnyx, aud 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 frequently 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 functions of the nose. Physiology of the Larynx. The function of the larynx is a threefold 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 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 PHYSIOLOGY OF THE LARYNX. 101 a sentence without interrupting the flow of sound by frequent respiratory movements, as is the ease 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, aud partly by the ventricular bands being tightly pressed together during the passage of food from the pharynx into the oesophagus. The ventricular bands alone are sufficient thus to exclude foreign bodies from the larynx, as is easily seen in cases of partial or complete destruction of the epiglottis by ulceration. Third. Voice-production or vocalization. This im- portant 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 singing without words, and articulation or speech, we must consider a few of the acoustic laws which underlie this function of the larynx. Acoustics.—Sound is a vibratory motion of the air producing waves, or a sequeuce of condensation and rarefaction of the air, which on striking upon the tympanic membrane of the ear gives rise to the sensa- 102 PHYSIOLOGY OF THE LARYNX. tion called sound. This vibration is produced in turn by any body which executes a rapid to-and-fro motion ; iu 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 depends upon the large- ness or amplitude of the vibration 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 siugle sounds are composed 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 possesses 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 vibratiug body. Since strings or string-like bodies and a column of air are the vibrat- ing bodies iu voice-production, we 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 fixed 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 VOICE-PRODUCTION. 103 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 pur- poses, a string of a lighter material, obeys the same 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 ampli- tude 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 rapidity as the string—in other words, when the string and air-column are tuned alike. The effect of resonance upon the character or quality of the sound is very noticeable, and depends upon the fact that through changes iu the form and shape of the air-column some of the overtones can be strengthened or favored, while others are weakened or extinguished altogether, thus changing 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. 104 PHYSIOLOGY OF THE LARYNX. 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 duriug 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 approx- imated 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 pre- sents an 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 elasticity 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 iu vibration; which can readily be seen in the laryngoscopic mirror, by means of which all the changes that take place in the vocal cords during vocalization have been observed. Drs. T. R. French, of Brooklyn, and Lennox 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 laryngoscope, 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 VOICE-PRODUCTION. 105 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 de- tached 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 iu 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 influence 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 constrictor muscle of the pharynx, still par- takes of the vibratory motion, aud 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 dimensions by the action of the tongue, the cheeks, and the lower jaw; and these cavities can thus be attuned to the pitch of 106 PHYSIOLOGY OF THE LARYNX. 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 its root down upon the larynx and encroaching upon the pharyngeal cavity, which would not only materially interfere with the activity of the laryngeal muscles, but would also hinder the free vibration of the column of air. But since a column of air can be tuned lower by reducing the size of the opening by which it communi- cates with the outer air, and vice versa, the cavities can be tuned to even the lowest tone of the voice by slightly closing the lips and making them as voluminous as pos- sible 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 considerable 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 be materially altered for the worse by interfering VOICE-PRODUCTION. 107 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, cer- tain divisions which can be differentiated from each other by the volume and by the quality of the individual tones within the limits of the division, and they have been termed "registers" of the voice. They are variously designated by singers and teachers of vocal music, according to their fancy ; but we will, for the sake of simplicity, accept the terms which are most generally used. Thus, the voice is divided into—(1) the lower, and (2) upper chest registers ; (3) the falsetto ; and, in the female voice, we also find both a second falsetto, and finally a head register. These names are derived from the sensations experienced in the different regions referred to, while singing in the respective registers. The singer feels as though the voice came from the lower part of the chest in the lower division ; from 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 wheu 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. 108 PHYSIOLOGY OF THE LARYNX. 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 au 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 agaiu, but a little closer than before, making the glottis slightly narrower, and the cords are at the same time stretched a little more. This is re- peated 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 participation of the laryngeal walls in the vibratory movement ceases. The vibration of the cords is also less apparent, because quicker and less violent, but they still 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 compara- tively 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 contraction of the muscular fibres forming its body. As in the lower chest register, the VOICE-PRODUCTION. 109 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 iu 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 portions of the cords vibrate, thus making the vibrating cords shorter and increasing the pitch of the tone. 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 investiga- tors, is different from loud vocalization, and by the laryngoscope it is observed that the anterior portion of the vocal cords is approximated until they overlap, while the posterior portion of the glottis, which is bounded bv the vocal processes of the arytenoid cartilages, is open, and allows the air to pass, settiug 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 110 PHYSIOLOGY OF THE LARYNX. cords. Thus the whispering voice, or the noise pro- duced by the rush of air through the triangular opening of the glottis, may be utilized with advantage in study- ing the changes in the resonant cavities, and in deter- mining 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 methods by which the various sounds are produced which, when uttered con- secutively in a certain order, produce what is termed " articulate speech." Since 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 to have a clear understanding, aud par- ticularly regarding a matter which, like articulate speech, is so well known to everyone and at the same time thoroughly understood by so few, it is desirable to give a definition of our subject before we enter upon a detailed description of it; we will therefore endeavor to define Language, Dialect, and Accent. Language, as used by man, is the arbitrary but con- stant 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 ACCENT. HI a similarity both in the words and sentences can be ob- served, but in those not so related a great dissimilarity 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 introduc- tion into the sentences of words foreign to it, or of a change in the sequeuce 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 peculiaritv of speech characterizing foreigners speaking a language different from their mother-tongue, and which is per- ceptible even if the language be spoken correctly in regard to pronunciation, grammar, syntax, and even colloquialisms—consists in the peculiar inflection of the voice in speaking, or, as it may be expressed, 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 speaker is too far removed from the listener for the latter to hear and recognize the individual words and sentences. And, further, we find a great similarity in the melody of the languages which are related to each other, so that it is difficult to distinguish German from Swedish and Italian from Spanish without hearing and understanding the individual words, while there is no 112 PHYSIOLOGY OF THE LARYNX. difficulty in appreciating the difference between English and French, even if the listener should not know any- thing of either language. This melody of the languages becomes so impressed upon the mind when a language is acquired in childhood aud spoken for years, that the impression is never entirely erased, aud is transferred to anv new language which may be acquired 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 iu the same manner, without, however, losing its general character; and thus we find that in English there are differeuts 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 re- tained for the sake of simplicity and convenience in the following description; but be it understood that in reality there is no such class distinction in speech. Startling as this may seem, yet this statement is true, and is borne out by experiments and close observation; for if we listen to a speaker we do not hear him pro- nounce 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 dura- tion by the more or less sudden cessation of the sound. Several years ago the author verified this observation by experiments carried on by one of Edison's loud-speaking telephone-receivers in the following manner: 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 ACCENT. 113 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 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 con- sonants in the pronunciation of a syllable, still retained its characteristics. In those syllables in which the con- sonant 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 experi- ments to determine the action of the soft palate in articulate speech, and has by an ingenious method suc- ceeded iu obtaining tracings of the motion of this organ. The curves which he obtained, and which were produced by the vibrations of the velum transmitted to a long lever, one end of which rested upon the upper surface of the palate, while the other end projected from the nostril and touched the smoked paper, show only 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 characteristics. Finally, Prof. E. W. Blake 114 PHYSIOLOGY OF THE LARYNX. obtained similar curves, showing the composite character of 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 Jour- nal 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 pro- duced by the vibration 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 reso- nant cavities. That this is so, is proved by the investi- gations of Donders, Helmholtz, Wolff, Seiler, and others, who all agree that in the production 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 resonant cavity is the same in all instances, provided, of course, that the vowel sound is the same. The discrepancy in the size of the cavity in the several instances is equalized by the greater or less degree of the opening of the mouth, so that the small oral cavity of the child can be tuned to THE VOWELS. 115 the same pitch as that of the larger one of the man. The reader can verify this by experiment in the follow- ing 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 overtones of the vocal sound, while it makes the sounding of other overtones impossible; and, as it has been shown above that the character of the sound depends 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 char- acter of the vowel sound so as to approach 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 recognized this fact, and de- termined upon the Ah as the elementary vowel, from which all other vowels are derived. He took this vowel sound as the foundation, 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 cveu outflow of the sound. In other words, the parts 116 PHYSIOLOGY OF THE LARYNX. of the resonant cavity remain in a quiescent state, as iu 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. 41. Diagram of vocal apparatus during the pronunciation of the vowel Ah. In referring to Fig. 41, which is a diagrammatic out- line 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 muscles, and thereby closes the opening leading to the nasal cavities, and the larynx is slightly raised in the throat. The pitch of the resonant THE VOWELS. 117 cavity stands at about the middle between the other simple vowel souuds, aud is the cfo2 of the musical scale.* The vowel sound 0 is produced by approximation of the lips, so that the opening between them becomes 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 reso- nant cavity is lower than in Ah, and by experiment is found to be for 0 a I?1. 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 pro- truded, 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 dimi- nution in the opening formed by the lips. The pitch of the resonant 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 somewhat closer together, and the sides of the tongue rise until they come in contact with the roof of the mouth, the * 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, C, Cv C'2. 6* 118 PHYSIOLOGY OF THE LARYNX. vowel sound A, as in " scale," is the result, and that the pitch of the resonant cavity is raised to b'fc2. 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 corre- sponds to the 6'tt3 of the musical scale, and is the highest of all these vowel sounds. The velum palati is in con- tact 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 : 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 THE CONSONANTS. 119 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, how- ever, 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 com- binations may also be formed, in which the characteris- tics 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 gram- marians describe as many as twenty vowel sounds in the English language. They can, however, 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 auatomi- cal parts of the organs of speech by means of which the noise is produced, as, for instance, into labials, dentals, linguals, 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 mak- ing an audible noise. These are the C, K and G, P and B, D and T, F and V, S, J, R, and the Th sounds. 2. Compound self-sounding consonants, as the Sh, and X. 3. The simple tone-borrowing consonants, which bor- 120 PHYSIOLOGY OF THE LARYNX. row their sound from the vowel, and are audible only iu connection with a vowel sound, as H, L, M, N. 4. The compound tone-borrowing consonants, which class contains only two—the Wand the Ng sounds. These noises are produced by a more or less complete obstruction to the outflowing current of air, which obstruction takes place in the oral cavity in three prin- cipal 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 Figs. 42, 43, and 44. 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 obstruc- tion in the oral cavity for a considerable quantity of air, which, by being thrown into vibrations, gives the consonant a pitch which is independent of the pitch of the vowel and the vocal cords, and which never varies in the same consonant. In fact, in the self-soundin^ THE CONSONANTS. 121 consonants, in which the noise is quite loud, this pitch can readily be determined by the unaided ear when the consonant is whispered. Fig. 43. Diagrams of the method of producing obstruction to the air current in the pronunciation of consonants. The mechanism of the production of these consonant sounds is quite complicated, aud it will be necessary to describe it for each sound in detail. 122 PHYSIOLOGY OF THE LARYNX. 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 agaiust 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 be- tween the P aud 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 variation 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 G* sounds the closure of the oral cavity is produced by the back of the tongue, which 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 formation 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 g is the so-called " hard g," as it is pronounced before the dark vowels, a,, o, u. SIMPLE SELF-SOUNDING CONSONANTS. 123 the case of the P and B, produced a slight difference in the pitch of the sounds, which for the G comes close to d2=582 vibrations ; while that of the K lies nearest to etr2=614| 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 sud- denly interrupted, which, as in the case of the foregoing consonant sounds, produces the difference between the two sounds. The pitch of the D sound lies nearest toyjt2=726 vibrations; while the T sound approaches the tone <72=776 vibrations. Here, again, we notice the difference in the pitch of the proper tone of the conso- nants produced by the greater or less air-pressure. In the formation of the F and V sounds the under " lip is gently laid against the edge of the upper 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 portion 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 produced by the under lip and upper incisors. This closure being, however, capable of but little resistance, the air forces its way through, and sets the edges into irregular vibrations, aud thus produces the blowing sound of F. The proper tone or pitch of this sound is very 124 PHYSIOLOGY OF THE LARYNX. close to a2=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 waut of loud- ness of the tone and the 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 8 sound is formed by a con- tinuous flow of breath past an incomplete obstruction, the edges of which are set in vibration. So we find that in the pronunciation of the 8 the teeth are brought almost in contact with each other, leaving 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 between its middle and the palate. The velum closes 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 b&i=3QQQ vibrations per second. The description of the formation of the 8 sound comprises in itself, as a matter of course, the Z and the C when placed before the light vowels E and L, which differ from the 8 only in the greater or less force of the outflowing breath. The / 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 is formed by the anterior portion and the edges of the tougue being laid gently against the palate and the alveolar borders of the upper jaw; SIMPLE SELF-SOUNDING CONSONANTS. 125 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 S sound in mauy 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 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 obstruc- tion causes a slight irregular vibration of the edges of the teeth, which gives rise to the blowing souud 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 c*=2112 vibrations per second. The last of this class of consonants is the R sound, which, however, differs from all other consonants, inas- much as it cau be produced in two different ways. Almost all English-speaking people pronounce this con- sonant with the back of the tongue, but so indistinctly that it is barely audible, while the r in most other lan- guages is made with the tip of the tongue, and is quite audible as a self-sounding consonant. The first is called 126 PHYSIOLOGY OF THE LARYNX. the " guttural r," while the other, the correct sound, is termed the " lingual 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 haug 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, irregular vibrations, which produce the peculiar fluttering sound. The pitch of the proper tone of this sound is near the C3=16| 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 anterior portion of the palate, without, however, quite touching it, while its edges are applied against the alveolar bor- ders 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 consonant is near to (72=33 vibrations; i.e., one octave higher than the "gut- tural 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, aud in the English language but two sounds are comprised in it—viz., the 8h 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 TONE-BORROWING CONSONANTS. 127 the middle of the palate, as iu the / sound, while its edges are firmly pressed against the alveolar 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 sounds are merged into one, modifying each other so as to result in the " rushing" compound sound of the Sh. On account of the combination of these two sounds, there are noticed two proper tones, the one produced by the vibration of the air contained iu 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 appreciable, which is the so-called "resultant" tone, produced by the combiua- tion of the two primary tones.* The pitch of the first of these tones is nearest the #=2328 vibrations ; of the second, nearest the 6^4=3666 ; and of the resultant tone, nearest the/3=1378 vibrations. The AT is a combination of the A" and the 8 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 canuot be heard. Their pitch is that of the K nearest the e^2=CAU, and that of the S, nearest the 6 j4=3666 vibrations. 3. The simple tone-borrowing consonants. The conso- nants belonging to this class can be heard only in con- nection with a vowel, and because in their formation an * 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 phe- nomenon, 128 PHYSIOLOGY OF THE LARYNX. obstruction to the outflowing air-current does not take place, and the breath is emitted noiselessly 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 exhalation of the breath through the perfectly unobstructed oral cavity, which assumes the shape of the vowel in connection with which the H 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 in- ternal 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 lan- gauges as a semi-vowel, and is frequently interchanged with the E sound in the Romanic languages ; as, for in- stance, in the Latin word flos, which is changed into fiore in Italian. In the M the organs of articulation are in a position TONE-BORROWING CONSONANTS. 129 of absolute rest; that is, the tongue, lips, teeth, and velum are in the position which they assume in ordi- nary nasal respiration. In consequence, no sound is heard when it is attempted to whisper the consonant 31, 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 poste- rior nasal orifice opened, letting the sound escape through the nose before Or after the vowel itself is pronounced, according to the position of the M either before or after the vowel. The formation of the N is, 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 Vthe 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 coutains 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 uose, as in the N, the posterior nasal orifice being left open for that purpose. As in the N, no sound, except perhaps the forcible expiration through the nostrils, is heard when the Ng is whispered, and it can only assert itself in connection with a vowel. The same is true of the W, which is a combination of the .ff and the V, aud differs in its formation from the 130 PHYSIOLOGY OF THE NASAL CAVITIES. 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 separ- ated from the rest of the resonant cavity by the velum palati beiug again pressed against the ridge formed by the constrictor of the pharynx. The Physiology of the Nasal Cavities. Like the larynx, so also do we find that the nose performs functions which are of very great impor- tance, and which should be thoroughly understood 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 in the upper air-passages. The first of these functions is to give the most advan- tageous position for the terminal fibres of the olfactory nerves in the upper portion of the anterior nasal cham- bers, where a portion of the inspired air has access to them, and where they can be excited by the minute odoriferous particles floating in the air, if we accept the old theory of the causation of the sense of smell. Within the last few years, however, a new theory, which is more plausible and seems to be better substantiated by facts as well as by analogy, has been advanced and is gaining ground with physicists and physiologists. This theory is : that the olfactory nerve receives and conducts to the brain vibrations of the atmosphere or ether, caused by odoriferous substances, as smell, in the same manner that the auditory nerve receives the sound waves and conducts them to the brain. No matter which theory we may accept, it remains a fact that inas- much as the sense of smell is not so much one of gratifi- PHYSIOLOGY OF THE NASAL CAVITIES. 131 cation, but one of protection, by means of which dele- terious 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 func- tion, aids materially in voice-production aud articulation, which function has, however, already been described in the foregoing 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 allow the air to pass through the nose while speaking. In both cases a so-called nasal voice will be the result, 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 introduction 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 par- ticles of dust floating in the air are arrested, while the finer particles which pass through this sieve are caught by the glutinous mucous 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 respiration, and on account of the erectile tissue overlying the turbinated bones the warm arterial blood is brought very close to 132 PHYSIOLOGY OF THE NASAL CAVITIES. this large surface. Consequently, heat derived from this arterial blood is radiated from the mucous mem- brane and the inspired air is raised in temperature. This temperature difference has been estimated to aver- age 2° F., but much depends upon the temperature of the external 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 inspired air is noticeable. Finally, in consequence of the watery secretion of the serous glands, and also through the outpouring of serous fluid into the nasal cavities by the osmotic action of the lining mucous membrane, the total 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 imper- ceptibly 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 important 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 AUXILIARY INSTRUMENTS. 133 it cannot do so perfectly, aud 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 aud bronchioles. A very few words will suffice for a description of the functions of the pharynx, that inter- mediate 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 DISEASE. Having described the laryngoscope, the different modes of using it, and the appearances of the normal laryngeal and rhinoscopic images, it remains to describe some instruments which, in connection with the laryn- goscope, are used for making further exploration of the parts by the sense of touch and for making applications to the diseased mucous membrane 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 under their respective heads. 7 134 AUXILIARY INSTRUMENTS. The Laryngeal Sound.—The eye is frequently unable 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 pur- pose 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 curve can be given to it, but 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, aud 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 impossible, to determine with the eye or sound alone, whether a Fig. 45. Septometer for measuring thickness of the nasal septum. bulging of the nasal septum to one side 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 sep- tometer, an instrument similar to the one used by mechanics to determine the diameter of a piece of wood SPONGE-HOLDER. 135 or iron being turned in the lathe (Fig. 45). 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 instrument accurately indicates the relative thick- ness 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 localized thickening of the septum, for if it is a deviation the index will move but slightly, while it will travel a con- siderable distance when the points pass over a thickened portion. Sponge-holder.—Most remedies employed as applica- tions 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 solu- tion 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 instrument 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 pur- pose. A piece of wire bent to the proper curve, split at the end, and secured in a wooden handle, is, however, generally used as a sponge-holder. A sliding ring slipped over the split end serves to approximate the two 136 AUXILIARY INSTRUMENTS. halves, thus securely holding a piece of sponge between them (Fig. 46). The sponge should be small, only large enough to cover the ulcer or abrasion, to which alone it is to be applied. The old-fashioned whalebone probang, with a large piece of rough sponge tied to the end, is altogether unfit for any application to the deli- cate mucous membrane of the throat. Fig. 46. Sponge-holder. Cotton Applicator.—When applications of liquid are to be made to lesions in the pharynx or the nasal cavi- ties, it will be found that a tuft of absorbent cotton 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 running 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 allowing 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 toothpicks as THE ATOMIZER. 137 cotton carriers, and throwing them away after having made the application, thus saving time and trouble. The Brush.—In many cases a soft eamel's-hair brush, securely fastened to a stiff curved stem, may be advan- tageously employed for touching ulcers or abrasions in the pharynx and larynx. The brushes should be mounted iu 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, aud 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 unsatisfactory, inas- much as the stem is too thin and elastic, and consequently it is very difficult, or almost impossible, 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, uot only with a view to cleanse the mucous membrane of secretions before making applica- tions 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 dif- ferent degrees of usefulness, may be obtained from the instrument-makers. The best of these are the so-called Sass' atomizing tubes (Fig. 47) made of glass or rubber, 138 AUXILIARY INSTRUMENTS. and throwing an extremely fine spray, either straight forward, upward, or downward. 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 opening 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 Fig. 47. Sass' atomizing tubes. exhausts the air iu 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 iu a finely subdi- vided state. The current of air may be obtained by means of the well-known rubber-ball pump (see Fig. 48), 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 counected with the pump ball, which, acting as a reservoir, stores THE ATOMIZER. 139 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, aud by its pressure on the surface forces the solu- Fig. 48. E. A. YARNALL Co., PhMa. The Burges atomizer. tion 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 an- swers the purpose admirably, but has the disadvantage that the cement with which the cap is fastened to the neck of the bottle very easily becomes loose, and fur- ther that the small inner tube being fastened near the 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 J. Elliot Shaw A Co., 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 140 AUXILIARY INSTRUMENTS. detachable, affording easy access to both tubes, for the purpose of removing obstructions. Three different kinds of atomizers of this pattern are in the market—one straight, one for throwing 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 aud the improved rubber bulb (Fig. 48). 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 any direction, thus avoiding the objections 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 occupyiug 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 under pressure which can be used at any moment. For this purpose the Burges blow- pipe, to which a large reservoir with pressure-gauge is attached, forms a very convenient and cheap apparatus (Fig. 49). It is composed of a small air-pump, worked by the foot, forcing air into the reservoir, which, when the desired pressure (ten to fifteen pounds, as indicated by the gauge) is obtained, should be shut off from the THE ATOMIZER 141 pump by a stop-cock, to prevent leakage through the valve. To another stop-cock at the top of the reservoir is attached a long flexible rubber 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 produces the spray, which can be instantly Fig. 49. Burges air-compressor. stopped by bendiug 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 perfect control over the instrument with one hand, and is free to hold the tongue of the patieut or manipulate the nasal speculum with the other. The air used from the reser- voir must be replenished by pumping as the pressure 7* 142 AUXILIARY INSTRUMENTS. diminishes. By means of a very ingenious air-pump (Fig. 50), worked by a stream of water, this inconveni- ence is obviated, for the apparatus always keeps a cer- tain pressure in the receiver. A regulator which is attached to it enables 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 pump Fig. 50. Water air-pump. automatically stops work, to begin again immediately 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. Various styles of such pumps are in daily use for forcing beer from the barrels in the cellar into the spigots in many of the saloons in the larger cities, and^have given perfect satisfaction in maintaining an THE ATOMIZER. 143 even and definite pressure of air in the reservoir. 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. 51). In the office the physician will find it most convenient to attach the hose conducting the air from the condenser 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, Fig. 51. Double-acting air-pump. 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 or red rubber, the pressure of the thumb against the nipple of the atomizer is sufficient to control and cut-off the air supply, and as a greater pressure than fifteen pounds is iu most cases 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 144 AUXILIARY INSTRUMENTS. 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 Fig. 52. Hand air-compressor. only the natural thumb cut-off is used. They have, however, the very great disadvantage of becoming defec- tive in a very short time by the clogging of the valve through particles of dust contained in the compressed air. Another form which is quite ornamental in the office, and is largely used, is the hand air-compressor (Fig. 52), which consists of an ordinary hand air-pump connected THE ATOMIZER. 145 with a cylinder having a pressure-gauge and stop-cock outlet. When the spray application is to be made frequently at the house of the patient, and especially when it is to be long continued, the steam atomizer (Fig. 53) is the most serviceable instrument for the purpose. It, like the Sass tubes, acts on the exhaust principle, but instead of using a current of air to nebulize the liquid, steam Fig. 53. Steam atomizer. from a small boiler, to which the air-tube is attached, supplies the necessary 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 funnel- shaped tube, 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. 146 AUXILIARY INSTRUMENTS. 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 con- taining 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 con- venient method for hot inhalations, is to place the mix- ture of hot water and resinous liquid iu a small earthen teapot so that the level of the liquid is below the internal 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 inhalations is the so-called inhaling-bottle, a wide-mouth vial holding from four to six fluidounces. Its airtight fitting stopper of cork or rubber is perforated by two holes, each ad- mitting a glass tube, one of which is straight, and long enough to reach from 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 VAPOR INHALATIONS. 147 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 iuhalation 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 chemically 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 iu the state of dense white vapor. In many instances where hot water is not easily procured, it is of advantage to have an apparatus for hot inhalations, in which the water can be heated over a gas flame or spirit lamp. For this purpose the author, several years ago, devised an inhaler com- posed 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 inhalations (Fig. 54). In certain cases of spasmodic affections of the larynx, the inhalation of the vapors of nitrate of potash is used with very good results. Such vapors may be obtained 148 AUXILIARY INSTRUMENTS. by burning in a 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, aud then dried. Fig. 54. The Author's universal inhaler. Insufflator.—Remedies are often applied to the throat in the form of an impalpable powder. For this purpose an instrument called an insufflator is used (Fig. 55). 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 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 INSUFFLATOR. 149 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 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 compressed suddenly, thus causing a puff of air, which carries the powder with it. Fig. 55. For office use I have devised a reservoir insufflator, 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 beut 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 other tube, also bent at right angles just above the stopper, reaches down but a short distauce 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 is straight 150 AUXILIARY INSTRUMENTS. 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 the case may require. The advantages of this form of in- sufflator 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 par- ticles, 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. 56), Fig. 56. OAVIOSON RUBBER CO. Reservoir insufflator. perhaps more elegant than the author's, has lately been put on the market, which, in principle, is, however, the same. Instead of having 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 over a lead pencil, into which the powder is introduced 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 sold form, should be fused on to the roughened end of a silver probe by holding both the end of the stick of CATCHING COLD. 151 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 aud more econom- ical 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 re- melted 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 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 152 catching cold. must be maintained under all circumstances at a tem- perature equal to 98° Fahr., otherwise disease will result, and that the source of this heat is within the organism, the expenditure of which by radiation we endeavor to minimize by living in houses aud by protecting the sur- face 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 oxidation 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, pro- duce more heat when introduced into the system than farinaceous food and fruits do. This we find exempli- fied in contrasting the mode of living of the Esquimaux 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 temperature of which is higher than the normal temperature of his body, eats chiefly fruits and vegetables. 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 mouths. The Catholic Church long ago recognized this fact, and has introduced the Lenten season, a period of abstinence from animal food, CATCHING COLD. 153 at a time of the year when the seasons change from the cold to the warm, for if more heat-produciug 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 eliminated 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 we con- tinue 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 Englishmen 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 intro- duced iuto 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 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 con- tractile 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 exercised, it needs not as much nourishment, and the surplus is deposited as fat within and around the different organs. This is exemplified 154 CATCHING COLD. by the fact that, in order to fatten an animal, it is kept confined within a narrow space aud is overfed. There can be no doubt that sunlight plays an impor- tant 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 tem- perature of the system, and, therefore, this loss must be minimized by interposing between the integuments of the body and the air non-conductors 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 epi- dermis beeomes 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, irre- spective of temperature, has a great deal to do with the temperature of the body, 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 tem- perature, and we can 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 CATCHING COLD. 155 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 exer- cise, 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 capil- laries in the outer integuments, a disturbance of the heart's action, and a congestion of some of the internal organs, and particularly of the mucous membrane of the respiratory tract. Taking it for granted that at a given moment there is a certain quantity of blood in the body which is dis- tributed throughout the vascular system, a greater amount of blood than is normal will accumulate in some portion of the system when a contraction of the capil- laries in an area of the surface takes place. Such an accumulation causes an over-disteution of the capillaries, and consequently a congestion of the part. As exam- ples 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 bowels 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 membrane. 156 CATCHING COLD. In connection with, and perhaps caused by, this con- traction 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 dis- turbances. 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 fact that, among civilized nations, it is hardly ever free from irritation in one or another portion of its extent. We constantly inhale particles of vegetable and 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 respira- tory tract and its capillaries, thus predisposing it to con- gestion. For, as do all fluids, so will the blood in the body when pressed upon at any particular point, seek au 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. CATCHING COLD. 157 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 inclem- ency of the weather ? In order to answer this question I must state that the power of producing heat in the system may be weak- ened by a number of causes, and that when thus weak- ened 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 au atmosphere artificially heated to from 75° to 80° Fahr., accustoms his system habitually to 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 in- voluntarily, of the necessary amount of oxygen, be it by being confined in close rooms or on account of dis- ease of the lungs; or fiually one who does not take ex- ercise, and so does not produce heat by muscular motion, will easily take cold from the slightest exposure. On the other hand, a person who lives an out-of-door life, and thus exercises 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 bedroom, and should not heat the air iu his rooms above 6S° or 70° Fahr. 8 158 pathology of mucous membrane. 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, aud I will therefore confine myself to a few generalities, referring the reader to text-books on pathology, and to the chapters on different diseases of the upper air-pas- sages 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 membraue lining the throat and nasal cavities is exceedingly liable to diseases of an inflamma- tory character, which exhibit the same phenomena that are noticed in other parts of the body. Such inflam- mations, accompanied by pain, redness, and swelling, are sometimes traumatic, as when caused by the intro- duction of foreign bodies, the swallowing of corrosive substances, and the inhalation of irritating vapors; or they are idiopathic inflammations. Diseases of the throat and nose may also be results or symptoms of a systemic affection, such as tuberculosis, syphilis, caucer, 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 THERAPEUTICS. 159 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 iu disease become thick and slimy, running together in semi-transparent drops, to be collected into larger accumulations and ex- pectorated as mucus. This thickening of the secretions is believed to be due to the admixture of new and old epithelial cells which have undergone a retrograde meta- morphosis instead of covering the mucous membrane. Thus the lining of the larynx, pharynx, and nose be- comes 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 cov- ered with pus, and presenting a whitish appearance, depressed in the centre and showing raised edges. From this description it will be seeu that a simple inflammation may develop shallow ulcers which are catarrhal iu 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 protecting the parts from the influence of the air, and, secondly, by stimulating the mucous membraue and its secreting glands to a healthy action. Among these remedies, nitrate of silver stands in the first place as a stimulant 160 THERAPEUTICS. and protecting agent. In the latter capacity it acts first by coagulating the albumin contained in the secretions, and, secondly, by being partly converted into insoluble salts of silver, the chloride, albuminate, and mucinate, by combining with the chloride of sodium, albumin, and muciu 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 of nitrate of silver, which is not immediately converted 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 insufflator. They all act more or less as stimulants to the mucous membrane. As an emollient aud soothing topical application the various coal-oil preparations, such as cosmoline, vaseline, and others of a like nature are used with advantage, and are prefer- able to the animal or vegetable oils or fats. They may be applied in their usual consistence, with a pledget of cotton on the cotton applicator, or mav be sprayed with au atomizer after having been liquefied by heat; if the latter method of application is used the already pre- pared liquid cosmoline, under the various names of that preparation as put upon the market, may with advantage be substituted, and may serve also as a vehicle for various drugs to be applied, such as thymol, eucalyptol, benzoic acid, and other like antiseptics. A very aoreeable and highly fluid preparation of this kind, flavored with ben- zoin, has lately been introduced under the name of THERAPEUTICS. 161 "Benzoinol," as a vehicle for topical applications to the nasal cavities; but the original fluid cosmoline, " No. Zero," seems to be preferable to any of the other like preparations, iu spite of its coal-oil odor. 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 iu absorbing swellings, are given in- ternally to aid the topical applications, and are also locally applied. Modes of Administering Remedies.—Nitrate of silver iu solution is applied to the ulcers, abrasions, or centres of inflammation, by means of a soft camel's-hair brush, mounted ou 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, aud fre- quently the strength can with advantage be increased to sixty, eighty, and even one hundred and twenty grains to the ounce of water, or water and glycerin. (dycerin alone should never be used as a solvent for the silver salt, as its great affinitv for water leaves the mucous membrane unpleasantly dry, and causes a severe burn- ing 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 in- flammation, as, for instance, in tonsillitis, where it allays 162 THERAPEUTICS. the pain by its angesthetic action, contracts the capillaries by its astringent action, and protects the surface of the mucous membrane by the formation of a film of albumin- ate, 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 devitalize the cells composing the tissue with which they come in con- tact, 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 misconcep- tion 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 corrosion of neoplasms too small for operative interference, or for cauterizing the wound after extraction of a neoplasm, with a view to prevent its return. It is 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 re-melted 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 strouger than ten grains to the ounce of equal parts of glycerin and water. Iodine dissolved in glycerin, locally applied, is an THERAPEUTICS. 163 admirable remedy in the hypertrophic conditions of the upper pharynx and nasal cavities, acting as an alterative and promoting absorption of the hypertrophied 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 penetrating and lasting odor, which is very difficult to disguise or pre- vent. I have, however, found that vanillin, 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 dust- ing 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 may be applied in the form of powder, mixed with sugar of milk iu vari- ous 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 in 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-inhalors. The touching of ulcers or abrasions in the cavity of the larynx or posterior nares is rather a difficult opera- tion. 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, 164 THERAPEUTICS. protected by a napkin, and the image of the larynx is in full view, the sponge or brush is iutroduced 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 catrying the brush downward, but always keeping the image of the ulcer and that of the spouge 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 swallowing a draught of cold water. These local remedies, in the form of powder, may often with advantage be combined with each other, or substances may be added to them for the purpose 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 mor- phine aud gum acacia, with a view to lessen pain by the morphia, and to cause the powder to remain longer iu 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, aud the practitioner must use his judgment iu selecting 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. hydrarg. flav., with morphine, largely used by oculists in the treatment of THERAPEUTICS. 165 chronic conjunctival inflammations, and a mixture of oxide of zinc ointment with calomel (gr. x. to 5j). Lately a new preparation, which has for its basis the steariue of zinc in the form of a powder, to which are added the various drugs, such as iodoform, carbolic acid, thymol, etc., has been introduced, and will be found of great advantage in many cases, particularly as it can be introduced into the nose or naso-pharynx by means of the powder-insufflator, and also because it will mix readily with the secretions and form a paste or salve. As caustics for the removal of hypertrophic tissue or small neoplasms, aud 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 pled- gets of cotton and placing them against the spot to be made insensible, or with the atomizer, or, finally, in the shape of lozenges, for the purpose of overcoming the pain during deglutition in some of the laryngeal affections. Local applications should never be made without having first thoroughly cleansed the mucous membrane. This is best done by an alkaline solution, thrown into the cavities by means of the spray. An excellent wash for this purpose is Dobell's solution, composed of— R.—Sod?e bibor. ) .. . > aa ^j Soda' bicarb. > Acid, carbol. gr. xxx. Glycerini, fl 3 j. Aquae font. Oij.—M. 8* 166 THERAPEUTICS. aft gr. xx. aa gr. x. This is not only cleansing, but produces a pleasant sen- sation in the nasal and laryngeal cavities. On account of the fact that so many patients seriously object to the odor of the carbolic acid, I have of late years employed instead a solution composed of the following ingredients : U •—Sodii bicarb. 3 viij. Sodii bibor. 3 viij. Sodii benzoas Sodii salicylas Eucalyptol. \ Thymol. / Menthol. gr. v. 01. gaulther. gtt. vj. Glycerini ^ viijss. Alcoholis §ij. Aquae q. s. Oxvj. 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 is antiseptic and acts as a deodorizer, being in this respect far superior to Dobell's solution, or any other non-irritating de- odorizer and antiseptic. As it is, however, inconven- ient for many patients to have so large a quantity of solution on hand, Mr. Charles G. Dodson, former man- ager for and now successor to 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. Unfortunately for the welfare of patients, a large number of unscrupulous manufacturing chemists all THERAPEUTICS. 167 over the country make and sell this antiseptic pastille without paying attention to the important facts: first, that the solution made from the pastilles should have the proper specific gravity; second, that the ingredients should be mixed in such a manner as to produce a perfect so- lution with warm water; and finally, that only the best and chemically pure ingredients are meant to be used. If the secretions have become inspissated, as is fre- quently 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 interference. Remedies are also frequently used in the form of lozenges—that is, they are combined with a fruit paste, generally currant paste, which is then pressed into 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 con- tact with the posterior wall of the pharynx and also enters the larynx, acting upon the mucous membrane. Among the alternatives which taken internally act more especially upon the mucous membrane of the larynx, pharynx, and upon the nasal mucous mem- brane, are iodide of potassium, bromide of potassium, calomel, cubebs in the form of the resin oil, or the cold fluid extract, crude petroleum, and other substances which might be named. The iodide, bromide, and calomel should be given in small doses; aud I have found that a combination of the former two is prefer- able, and can be borne much longer by the patient than either alone. In syphilitic affections, mercury in the form of the 168 THERAPEUTICS. bichloride, or biniodide alone or iu combination with potass, iodide, should be given, and I have found that in the ordinary run of cases, when such a combination is desirable, the following formula is of great service: K.—Hydrarg. bichlor. gr. j. Potass, iodid. ^ij. Syr. simp, et aquae ^Uj. S.—A teaspoonful three times a day. This mixture, which has received the nickname of " one-two-three," was originally suggested by a French physician, Dr. Gibert, and is known in France, where it is largely used, uuder the name of " sirop Gibert." In cases where a more rapid and decided action of the mercury is necessary the salt may with advantage be introduced into the system by the hypodermatic method, but it should be borne in mind that the dose must be a small one, commencing with gr. -gVj, and should be highly diluted, because even then the bichloride of mercury coagulates the albumin and forms a lump under the skin at the point of injection, which, if very dense, is not readily absorbed, aud gives rise to pain, and even abscess, by pressure. Therefore, to avoid both pain and abscesses, the salt should be highly diluted and the injections made daily into the loose cellular tissue, beneath the skin of the back on either side of the spinal column. Another very satisfactory method of adminis- tering mercury is by inunction, which method is well known to all physicians, and is described in detail in the text-books. 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 THERAPEUTICS. 169 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 y | gether with the arytenoid muscles/in ^W\W^^ moving the cords together,[while]the ^am^^ crico-thyroid on the affected^side fails to stretch the cord; thus a peculiar „ . . :,, ,, . ' < r Paralysis of left vocal hoarseness of the voice is produced, Cord. (Cojusn.) 212 FUNCTIONAL DISORDERS OF LARYNX. and the rima glottidis presents an opening shaped like an Indian bow, the convexity of the curve being toward the affected side. 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 regis- ters, 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 pneumogastric nerve by tumors in the neck, such as goitre, sarcomatous infiltration of the thyroid gland, aneurism of the larger vessels, etc. It may also be due to inflammatory action and infiltration interfering with the exercise of the function of the mus- UNILATERAL PARALYSIS. 213 cles, and, if of long standing, this may cause atrophy of these muscles; or it may be one of the symptoms of hysteria, which is, perhaps, the most frequent cause of aphonia in women ; or, finally may be due to over-exer- tion 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 iu order to determine, if possible, the remote cause of the trouble, as upon the nature of this cause 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 treat- ment should be directed to this systemic affection. If it is found that pressure upon the laryngeal nerve is the cause of the aphonia, this pressure, if posssible, should be removed by operation. If inflammatory action is the cause, the treatment for chronic inflammations should at first be resorted to, aud then the specific for local paralysis of the cords, viz., electricity, should be used, as it should be also in cases depending upon hys- teria 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 stimulating action. Inasmuch as loss of voice and hoarseness are often due to acute inflamma- tory conditions, and, also, inasmuch as paralyses of the other vocal cords are often accompanied by cough, the general practitioner is very apt to prescribe cough mix- tures and gargles to relieve both hoarseness and cough, and thus guesses at the cause of the trouble, when the laryngoscope should be employed to determine the 10* 214 FUNCTIONAL DISORDERS OF LARYNX. cause of the affection, to make a correct diagnosis and come to a definite conclusion as to the best mode of treatment. Fm. 60. Mackenzie's laryngeal electrode. 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 elec- UNILATERAL PARALYSIS. 215 tricity avails nothing, no matter how 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. 60). 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 being intro- duced, the handle is furnished with an interrupter, a lever supported by a spring which is in metallic connec- tion by a hinge with the wire at one end. The other end is furnished with a handle of some non-conducting sub- stance, 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 handle, 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 inter- rupted as soon as the lever is lifted by the supporting spring when the pressure is taken off. The other pole of the battery is attached to an ordinary electrode, and is given to the patient to press against the neck on one side or the other of the larynx. But as this is incon- venient, and the patient in the act of gagging frequently breaks the current by removing the pole from the skin, it has been found more convenient to connect this pole with a metal plate covered with sponge, 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 10* 216 FUNCTIONAL DISORDERS OF LARYNX. affected muscles, the plate is placed over the larynx, 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 platinum 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 the parts to be faradized are reached. In some cases—as, for instance, when paralysis of the arytenoid 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 described. 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. Con- tact is made by the lever when the electrode is in posi- tion. Many patients can endure comparatively strong currents for a considerable length of time, but the instru- ment 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 strychnine, should be given, for the general health is almost always 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 speakers iu 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 prepara- tions of coca erythroxylon, such as wine of coca or the UNILATERAL PARALYSIS. 217 fluid extract, have proved to be valuable voice stimu- lants when taken shortly before vocal exercise, and will, in many cases, prevent " stage fright." It is best not to depend upon the manufactured wines of coca, owing to the fact that not all of them are reliable, but to make the preparation by prescribing a teaspoonful of the fl. ext. coca in a wineglassful of sherry, madeira, or other sweet wine, to be taken about ten minutes before the appearance of the patient in public. When the aphonia or hoarseness is due to general debility and inflammatory deposits in the tissues of the muscles, I have 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 pil. no. xxiv. S.—One, three times a day. Exercise in the fresh air and pleasant mental diversion 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 commenced. There are cases in which the aphonia due to loss of contractility of the muscles comes on suddenly, 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 applica- tions are necessary to restore it. This is especially the case with aphonia due to hysteria, which often requires 218 FUNCTIONAL DISORDERS OF LARYNX. many months of patient treatment before any improve- ment 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 the Presence of Foreign Bodies. If the aphonia is due to the presence of a foreign body accidentally introduced, the cause should be re- moved at once. Usually such foreign bodies are pins or fish-bones, which, with their sharp points penetrate the mucous membrane, and are thus held in position (Plate L, 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 through the larynx. Of foreign bodies causing aphonia, pins are most fre- quently found, especially in women. The almost uni- versal 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 "jood going the wrong way." If a bone thus enters the larynx, it is apt to become imbedded in the soft tissues of this organ, when actual contact with the cords or the irritation and consequent swelling cause aphonia. The same occurs APHONIA DUE TO FOREIGN BODIES. 219 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 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 au irritation which lasts for some time after the removal of the foreign body. It is, there- fore, 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 been removed, unnoticed by the patient, either by coughing or in the act of swallowing. Under such circumstances it is often diffi- cult 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 the nasal cavity, numerous instruments have been invented, some of which I will describe here before entering on the subject of neoplasms and their removal. The great desideratum in such au 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 220 FUNCTIONAL DISORDERS OF LARYNX. grooves, and it is not too tightly imbedded, the already described sponge-holder or epiglottis forceps answers admirably, but when the body is lower down or is tightly embedded, an instrument of different construction must be employed. The most useful kind of forceps is Sir Morell Mackenzie's common laryngeal forceps, which was almost exclusively used by him for the removal of neoplasms and foreign bodies from the larynx (Fig. 61). Fig. 61. Mackenzie's laryngeal forceps. It is made of steel, with stout scissor-like handles, is of considerable length, and bent at right angles, terminat- ing in spoon-shaped extremities, which open either later- ally or antero-posteriorly. In the former case, 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 ouly with one or the other form of forceps. The spoon-shaped blades of the forceps are hollowed 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 designed expressly for LARYNGEAL FORCEPS. 221 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 surface. The introduction of these forceps is somewhat diffi- cult on account of the sharp bend and the length of the extremities, but it has been found that this form is more useful and in a greater number of cases than the curve employed in other instruments designed 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. 62). It consists of a universal handle, into Fig. 62. Stoerk's guillotine and tube-forceps. which a number of different forceps, slings, and cutting instruments can be inserted. The forceps used in this handle is made of a tube of metal, so curved at its ex- tremity 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 within the tube, aud are approximated by retracting them within the tube. This retractiou is effected by means of a slide 222 FUNCTIONAL DISORDERS OF LARYNX. attached to the universal handle; 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 iu 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. 63. J0P *Y Seiler's universal tube-forceps and guillotine. Foreign bodies and neoplasms are frequently situated in such a position that neither au antero-posteriorly nor laterally opening forceps will readily grasp them, and it becomes a very difficult matter to remove them even with the wire loop. In order to obviate this difficulty, and to obtain a forceps which could be adapted to every case, I had one made of the following description (Fig. 63): 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 LARYNGEAL NEOPLASMS. 223 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 projection. 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 con- venient, 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 iu 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. CHAPTER X. neoplasms of the laryngeal cavity. Use of Instruments. Besides the forceps described 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, 224 LARYNGEAL NEOPLASMS. the 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, aud terminating 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 introduction 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 and the knife have to be removed quickly. The laryngeal knives now in use are therefore covered (Fig. 57)—that is, the blade is contained in a curved tube, like the one used for the tnbe-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 iu, 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 in- struments, inasmuch as the blades have cutting edges and act like nippers. Stoerk has attached to his universal handle (see Fig. 62) a very ingenious cutting instrument called a guillo- USE OF INSTRUMENTS. 225 tine, 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 mem- brane 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 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, aud attached to either the Stoerk handle or to the handle of my forceps (see Fig. 63), and as it can be bent in any direction, only one knife is neces- sary, 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 sur- rounded 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 modifications so as to adapt the instrument to the re- quirements 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 226 LARYNGEAL NEOPLASMS. tumors and foreign bodies from the larynx, an exploring instrument should be used in order to ascertain the con- sistency of a tumor, its attachment to the mucous mem- brane, whether by a slender stem or by a broad base, etc., and for various other purposes. 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 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 neoplasms, is of a peculiar character, inasmuch as the voice, which is usually hoarse, or sometimes quite unnatural, is lost sud- denly and completely for a few minutes, and then returns as suddeuly, 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 harassing 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 classification of tumors in larynx. 227 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 ventricle, an exceedingly rare occurrence, in which the mucous mem- brane lining the pouch protrudes like 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 situate on 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, in 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 for- merly were regarded as perfectly harmless have been 228 LARYNGEAL NEOPLASMS. known either to return after operation, or to change their character from a benign to a malignant form. The variety 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, such as cauliflower, raspberry, mulberry, foliated, etc. These growths are usually attached by a broad base, and only occasionally do we find them pedunculated. Their size varies from that of a mustard-seed to that of an Euglish 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 sur- face, 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). TREATMENT. 229 Cystic tumors, on the other hand, are more frequent, aud resemble the fibrous tumors in shape, size, aud color. They differ from them, however, in their mode of attach- ment, which is always broad. Their consistence depends upon the material with which they are filled, whether serous, caseous, purulent, etc. They also have, usually, a zone of irritation around them, and occur most fre- quently on the laryngeal surface of the epiglottis. Fasciculated sarcomata and adenomata, or glandular tumors, show no distinctive features, but may resemble any of the above-described neoplasms. They are very rarely met with in the larynx. Vascular growths, or angiomata, are also very rare, and may be diagnosed by their dark, almost black, color, and granular surface, as well as by their tendency 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, however, is not invariably 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 extirpatiou of the whole organ or part of it. The most frequent form of cancer in the larynx is epithelioma; next in frequency are found, in the following order, round-celled sarcoma, spindle-celled sarcoma, medullary 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 laryngeal cavity. Treatment.—Tumors in the laryngeal cavity produ- cing by their mechanical interference aphonia, dyspnoea, 11 230 LARYNGEAL NEOPLASMS. 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 local return of the growth. In cases of secondary cancerous deposits in the larynx it becomes a difficult 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 pre- cise 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 extirpation of the larynx becomes necessary. In the removal of a tumor from the larynx, its posi- tion, size, mode of attachment, whether pedunculated or sessile, its vascularity, consistence, and other peculiari- ties, 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 introduc- tions either of the instrument to be used in the operation or of the laryngeal sound, and it often requires weeks 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 irrita- ble 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 TREATMENT. 231 was first recommended by Rossbach, aud consists in freezing with the ether spray a portion of the skin 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 4 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 re- sult, 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 considerabble extent, on account of the tumor being so large as to interfere with the free ingress and egress of air, trache- otomy 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 pre- vents respiration, but this closure is usually produced by spasm of the adductor muscles of the larynx approxi- mating the cords, and its immediate cause is some slight irritant, such as dust, carbonic acid gas, ether, etc. If the tumor is attached to the free edge of the vocal cord or ventricular band, either by a broad base or a narrow stem, and if it is not too large, it can frequently be 232 PHARYNGITIS. gotten 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 interference will pro- duce 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 micro- scopical examination. Yet even the benign papilloma has, in some cases, a tendency to return after it has been thoroughly removed, particularly in children, and the process of picking off the neoplasms has to be con- tinued, 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 pro- ducing the inflammation, and according to special feat- ures characteristic of the different forms. Acute Pharyngitis. Acute pharyngitis is found in connection with acute laryngitis and usually precedes it—the velum palati, the acute pharyngitis. 233 pillars, and the 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 aud become swollen and painful to the touch. Ou inspection of the pharynx, which is easily effected by depressing the tongue with a tongue-depressor, we find the anterior pillars red and swollen, and the ton- sils of a purple hue, protruding 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 leaving no ulcerated surface underneath them, are observed on the tonsils, especially on the pos- terior surface. These patches are the hardened secre- tions of the follicles in the glands, pressed out by the swelling of the organs. They differ, however, from pseudo-membranous patches as seen in diphtheria, in- 234 pharyngitis. asmuch as they are usually smaller, of different con- sistence, and leave no ulcerated or raw surface when removed. But they are frequently mistaken for diph- theritic exudations, and the affection is then after a hasty and superficial inspection called diphtheritic sore- throat. It sometimes occurs that these cheesy patches are mistaken for the pus-covered surfaces 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 swollen, 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 in- flamed follicles or glands. The free margin of the epi- glottis is usually swollen from the first. Duration.—The duration of this affection is usually of a few days only, when the swelling and inflammation 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 acute laryngitis after the inflamma- tion 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 respects from the ordinary disease, inasmuch as it is epidemic and infectious, without being contagious. Its most prominent features are a mucoid infiltration of the submucous tissue, the formation of small patches of pseudo-membrane which is white and does not curl up ACUTE pharyngitis. 235 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 ofteu very severe. At the onset very little systemic disturb- ance 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. This form of pharyngitis and laryngitis will be further described in the chapter on Influenza. Treatment.—The treatment should be directed to the removal of the general febrile symptoms, and to hasten- ing the resolution of the local inflammation, as well as to the alleviation of the pain. Saline purgatives, hot foot-baths, and sponging the body with tepid water or whiskey aud 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 tumefaction of the parts is so great as to make the act of deglutition almost impossible; then only iced milk, oyster soup, or cold clam broth, can be swal- lowed in very small quantities, and thirst must be alle- viated by small pieces of ice held in the mouth. All beverages containing 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 pos- terior wall of the pharynx, the tonsils, and pillars. 236 PHARYNGITIS. Strong solutions of alum, tannic acid, benzoic acid, La- barraque's solution in strength of 1 to 5, iron, peroxide of hydrogen, 1 to 5, aud other astringents should be employed in the form of gargles, in combination with some anodyne, or the parts should be irrigated with them by the spray from the hand atomizer, or they may be painted with a brush over the surfaces most inflamed. The tincture of guaiac as a local application, in the form of a gargle with water or spray, and also applied with the brush, has been frequently mentioned as a specific for the rapid resolution of acute tonsillitis. But it has beeu found that it acts well only in those cases in which the tonsillar inflammation is the forerunner of a general outbreak of the rheumatic or gouty diathesis, and it is of no value whatsoever in the ordinary non-rheumatic form of acute tonsillitis. 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 what- ever. An attack of this kind can frequently be cut short or prevented altogether by the early use of this remedy, provided a sufficiently strong solution 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 ansesthetic effect, and reduces the inflammation if applied before any inflammatory infiltration into the submucous tissue has taken place; that is, within a few hours from the start of the disease. Vapor inhalations of carbolic acid, ben- zoin, tar, etc., are also very advantageous. Internally, the mixture of iron, chlorate of potash, and bromide of potash, in liquid form, or in the form of lozenges, re- TRAUMATIC ACUTE PHARYNGITIS. 237 commended in the treatment of acute laryngitis, has been found to give the most satisfactory results in allaying the irritation. Poultices 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 ulceration 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 regularity 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, aud hardening the skin against atmospheric influences by moderate exposure, even in cold weather, will frequently break up the tendency to acute pharyn- gitis and tonsillitis. Traumatic Acute Pharyngitis. As has been said, the common cause of the affection is exposure to cold, but the accidental or intentional swallowing of corrosive or very hot liquids will produce the same results, as well as the imbedding of sharp foreign bodies in the tissues, such as fish-bones, splinters of bone or wood, pins, etc. In the latter case the in- flammation starts from the point of irritation spreading over the whole mucous membrane covering the parts in the neighborhood. If such foreign bodies have pene- trated into the submucous cellular tissue, which in this particular portion of the upper air-passages is very dense, and remain there for any length of time they may give 11* 238 PHARYNGITIS. rise to suppuration and the formation of what is termed post-pharyngeal abscess; but this form of acute pharyn- gitis may also be produced by caries of one or more of the cervical vertebrse, and the two differ from each other according to Cohen, as well as to my own observation, in the situation of the abscess only; being on one side or the other of the median line when produced by an im- bedded foreign body, and in the median line when caused by caries of the vertebrse. On inspection, such an ab- scess appears as a pear-shaped swelling, the greater expansion of which is downward. Its surface is glisten- ing, red, and covered with mucus, more or less thick and tenacious; on pressure with the tip of the probe it im- parts the usual sensation of an abscess beneath the mu- cous membrane, and can thereby readily be distinguished from a neoplasm or gumma, and, as in any other portion of the body, should be opened freely at its most pendent portion, so as to evacuate all the pus it contains at once. The first step in the treatment should, of course, be the removal of the offending body. 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 to- gether, viz., acute pharyngitis and acute tonsillitis, which are differentiated from each other by their names only, but do not differ in reality. The chronic forms of these two affections, on the con- trary, differ widely from each other, both as regards their causes and the symptoms which they present; they will, therefore, be considered separately. SPECIFIC CHRONIC PHARYNGITIS. 239 Chronic Pharyngitis. It has beeu the experience of most laryngologists that the ordinary forms of chronic pharyngitis, such as the so-called granular and follicular pharyngitis, pharyngitis sicca, and so forth, are merely symptomatic 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 (here- tofore called) chronic pharyngites disappear without treatment, after the removal of the cause which pro- duced them. We will, therefore, 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 pharyngitis due to traumatism. Specific Chronic Pharyngitis. Secondary, as well as tertiary, syphilis produces a form of chronic inflammation in the mucous membrane 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, expectoration, of a fulness and dryness of the throat, and of more or less hoarseness of the voice. Often difficulty of deglu- tition is complained of, and frequently articulate speech has a nasal quality. On inspection we find the mucous membrane of the pharynx, soft palate, uvula, and ton- sils of the peculiar 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 240 PHARYNGITIS. outline, with raised edges, and surrounded by a zone of more active inflammation, may be found almost any- where. They are, however, most frequently 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 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 diag- nosis by the history of a primary sore is frequently unnecessary. There are, however, several other affections which give rise to ulceration in the pharynx, and which have already been referred to in the chapter on Specific Laryngitis, viz.: lupus and tuberculosis. Besides these we occasionally meet with phlegmonous ulcers of the pharynx, erythematous patches, and the ulcers seen after the forcible removal of a diphtheritic membrane; these latter forms of ulcers are so well described in detail in the text-books on general medicine and sur- gery that a mere mention of them in this volume will suffice. 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 SPECIFIC CHRONIC PHARYNGITIS. 241 ulcerations if such are present. This is done by cauter- izing 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 when the edges have healed except by a plastic operation or by fitting a plate with an elastic flap over them. The constitutional treatment must, of course, not be omitted, for no amount of local applications will eradi- cate the disease. I have, however, found that iodide of potassium, in small doses, is preferable to mercury in the cases of shallow ulcers, and am iu the habit of always giving the iodide of potassium in combination 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 separately, before pro- ducing disturbance of digestion aud 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 borue for months with- out signs of iodism. The ulcers in the throat heal rapidly, and the mucous membraue assumes its normal condition under such treatment. In the case of deep ulcerations, however, which, as mentioned before, are due to the breaking down of gummata, and where it is important to limit the ulcerative process to the gumma 242 ELONGATED UVULA. itself and prevent it from extending to the neighboring healthy tissue, cicatricial contraction, after their healing, may be avoided by bichloride of mercury hypodermic injections of a very weak solution, into the skin of the back, because it is more prompt in its action, as has already been stated in the chapter on General Thera- peutics. The inunction method may be employed in those cases in which the danger of rapid breaking down of the gumma and invasion of neighboring tissue is not so great. 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 produced by the accidental swal- lowing 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 as those of simple chronic pharyngitis. The treatment does not differ from that required for other forms of the disease. CHAPTER XII. ELONGATED UVULA AND HYPERTROPHY OF THE 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 produce, are ELONGATED UVULA. 243 generally considered as such ; these are elongated uvula aud hypertophy of the tonsils. Elongated Uvula. Elongation of the uvula is due either to genuine hyper- trophy of the tissues of this organ, to dropsical effu- sion, or to simple relaxation of the soft palate and uvula, thus causing the latter to hang down into the pharyngeal cavity during breathing, or to come in contact with the margin of the epiglottis and posterior 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 "eh." If the elongation is due simply to a relaxa- tion 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, and it often happens that one of the branches is relaxed, while the other is not (Plate II, Fig. 3). 244 ELONGATED UVULA. Treatment.—The treatment of the former condition, 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 appli- cations 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 due to dropsical effusion, but to true hypertrophy, refuse to yield to astringent treat- ment, 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 slipping back, and also to prevent its falling into the larynx after it has been cut off by the scissors, as near to the root as possible. The pain and hemor- rhage in this operation are very slight; indeed, not infrequently 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 cases on record, as pointed out by Dr. Carroll Morgan, of Washington, in which the bleeding was profuse, and could not be controlled by ordinary styptic applications. ELONGATED UVULA. 245 In one case Dr. Morgan compressed the stump of the uvula with a clamp from the common shirt-sleeve re- tainer, as the only means of stopping the hemorrhage. In children it often becomes a matter of some diffi- culty 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 combining the forceps with the cutting instrument have been intro- duced, but they all have such disadvantages that most operators prefer the use of the forceps aud scissors sepa- rately, even if they have to struggle with the patient, and can perform the operation with difficulty. Having frequent occasion, in dispensary work, to perform the operation, I endeavored to construct an instrument which would obviate the difficulties attend- ing the use of such uvulatomes. I had, therefore, 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, aud 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 near its root, the hook-like bend of the scissors preventing its slipping backward and out of the grasp of the instrument. Upon the same pivot upon which the blades of the scissors revolve are attached a pair of pronged claws lying on the under surface of the scissor-blades; they serve to catch the amputated piece (Fig. 64). With this instrument no difficulty will be 246 ELONGATED UVULA. experienced in grasping and cutting the uvula even if the patient should struggle, since the handles of the Fig. 64. Seiler's uvula scissors. 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. 247 Hypertrophy of the Tonsils. An acute inflammation of the tonsils, exhibiting the symptoms characteristic of inflammation elsewhere, is of frequent occurrence. It may be either simple or com- plicated with an acute pharyngitis or laryngitis, 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 hypertrophied tonsils, viz. : first, the ordinary soft variety of childhood and early youth, which consists, histologically, 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 enor- mous increase of the intercellular connective tissue, and a canaliculization of the bloodvessels in the gland, 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 inflammation. The third variety is the so-called ragged tonsil, which is the result of frequent tonsillar abscesses, causing the slough- ing away of portions of the tonsillar tissue, leaving a ragged glandular mass, which projects beyond the faucial pillars. Symptoms.—The symptoms of hypertrophy of the tonsils are more passive than active ; that is to say, there is usually no pain or active inflammation. There exists, 9AS hypertrophy of tonsils. 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 experienced. The degree of obstruction to breathing being dependent upon the amount of swelling of the glauds, the latter may lead to alarming symptoms of dyspnoea, especially in children, when 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 secre- tion 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 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 hypertrophied 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 hypoder- mic syringe, however, is often followed by a speedy reduction of the tonsil without causing the unpleasant HYPERTROPHY OF TONSILS. 249 results that are apt to follow the application of the drug to the mucous membrane. The best and most satisfactory way of treating hyper- trophied 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 tonsillo- tome. 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 connectiug the pillar with the tonsil being too strong to be torn, the tonsillotome cannot be used with auy degree of safety, and the galvano-cautery knife should be employed. After the projecting portion of the tonsil has been removed the cut surface should be brushed over with a sixty-grain solution of nitrate of silver to cause contraction of the capillaries 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. I am iu the habit of giving the patient a powder com- posed of acid, gallic. 5j, acid, tanuic. 5ss, with direc- tions to dissolve it in a tumblerful of water, and to gargle with the solution should bleeding occur. The old method of removing the tonsils with the volsellum 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 danger- ous, besides being unnecessary except in the extremely rare cases of cancerous growths in the tonsil. 250 HYPERTROPHY OF TONSILS. There are several kinds of tonsillotome, the older form invented by Fahnestock, and later improved forms. Fahnestock's tonsillotome (Fig. 65) 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, the protruded parts are cut off with the annular knife, by pulling the handle of the tonsillotome. It will be seen that in order to use this instrument both hands are needed, and two motions must be executed, viz., the pushing forward of the needle and the pulling back of the knife. Another instrument requiring but one hand and one motion in its use is shown in Fig. 66. It is very similar in construction to Fahnestock's, 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 the gland through the ring. The annular knife is prevented, by a catch at the stem of the instrument, from moving until the tonsil has been pierced and drawn into the ring. This catch is then lifted and the knife is drawn down, cutting through the protruding tonsil with the same action 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 mouths of children, and even of the average adult. Furthermore, the long diameter of the ring iu this instrument is at right angles to the shaft, which prevents the surrounding of the hypertrophied gland in most patients. By slightly reducing the size HYPERTROPHY OF TONSILS. 251 Fig. 65. Fig. \J Fahnestock's tonsillotome. Seiler's modification of Mathieu' tonsillotome. 252 HYPERTROPHY OF TONSILS. of the ring and having its long diameter in the axis of the shaft, the instrument becomes one of the most ser- viceable kind in the greatest number of cases. Another modification of this instrument consists in having sev- eral 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 copied from au old German instrument, but it is too compli- cated and costly to come into general use. The safest and only applicable one in cases of ragged tonsil is the galvano-caustic method of removing hyper- trophied 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 inter- vals of a week or ten days, and from four to six appli- cations usually suffice to reduce the tonsils to a size compatible with the health and comfort of the patient. Under no circumstances should any operation for the removal 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 its capsule with a sharp curette has been recommended, but this method is not only very bloody, but also painful, and on that account the gal- vano-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 passed arouud the enlarged tonsil, and by HYPERTROPHY OF TONSILS. 253 turning the screw should be gradually decreased in size until the portion encircled by the wire is cut off. If done slowly the operation occasions 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, aud 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 alco- holic stimulants should be avoided, aud 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, aud even that is greatly diminished by taking liquid food through a tube. 12 254 DISEASES OF THE NASAL CAVITIES. 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 distinction is due chiefly to the anatomical arraugement of the parts, as well as to the physiological functions of the organs, which have already been described in detail (see Chapters III. and IV.), and we can, therefore, at once enter upon the consideration of the pathology and the diseases of the nasal and naso-pharyngeal cavities. Pathology.—Most of the diseases of the nasal cavities are due to inflammatory processes, and but very few are due to traumatic injuries inflicted, either from the out- side by blows, falls, etc., or on the inside by foreign bodies and the instrumental interferences 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 simple acute coryza, we shall find that the first symptom is a feeling of fulness, accompanied by sneezing, aud 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 PATHOLOGY. 255 the nasal cavity, and is felt as fulness. The congestion having continued for some time, a watery discharge makes its appearance, which is produced by a hyper- stimulation of the serous glands, and is increased by exudation of serum from the venous sinuses of the tur- binated tissue. According to Cornil and Ranvier, lymph corpuscles are found in this watery discharge of the early stage of acute coryza, while other and later observers have found various bacteria. Later, the dis- charge becomes thicker by the admixture of the secretion of the mucous glands and of epithelial cells which have undergone fatty degeneration, and are thrown off by the rapid formation of new cells under the stimulus of the increased blood-supply. The mucous membraue, as well as the submucous aud cavernous connective tissue, becomes infiltrated with numerous leucocytes, and the venous sinuses become distended. As the acute inflammation subsides these conditions 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 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 linino; the accessory cavities may also participate in the general inflammation, 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, 256 DISEASES OF THE NASAL CAVITIES. the pain is felt on the cheek, while if the frontal sinuses are the seat of inflammation, the pain is mostly felt over Fig. 67. Dilated nostril, showing anterior hypertrophy. the eyebrows. Such involvement of the accessory cavity is, however, very rarely met with. The dull Fig. 68. Rhinoscopic image from a case of posterior hypertrophy on the middle turbinated bone. pain in the head, usually present, is occasioned by pressure of the engorged turbinated tissue, and is reflex in its nature. PATHOLOGY. 257 Frequent repetitions of acute coryza at short intervals must of necessity produce a permanency of the inflam- matory infiltration in the mucous membrane and sub- mucous tissue, which infiltration finally becomes organ- ized so as to form connective tissue; at the same time Fig. 69. Vertical section through nasal cavities. (Diagrammatic] 1. Superior turbinated bone. 2. Middle turbinated bone, with posterior hypertrophy. 3. Section of hypertrophied pharyngeal tonsil. 4. Inferior turbinated bone. 5. Orifice of Eustachian tube. the venous 'siuuses remain more or less distended, and the epithelium of the gland-ducts begins to proliferate. In this way permanent swellings of the mucous mem- brane in the nasal cavities are formed at the most pendent;portions, viz., the lower^edge of the inferior and 258 DISEASES OF THE NASAL CAVITIES. sometimes of the middle turbinated bones ; but they are also found on the septum. These swellings are called hypertrophies, and are divided, according to their loca- tion, into anterior, middle, and posterior. The anterior hypertrophies (Fig. 67)—those which are situated on the anterior extremity of the turbinated bones or on the cartilaginous septum—are usually sessile and of a bright-red color, as are also the middle hypertrophies situated on the anterior portion of the middle turbinated bone, while the posterior ones—occurring on the pos- terior extremity of the turbinated bones (Figs. 68 and 69)—usually have a short pedicle-like attachment and project into the vault of the pharynx. Their color is either a dark brownish-purple or a light yellowish-pink ; and I find that those of a dark color are much softer thau the light ones. Under the microscope a condition of the tissues in these swellings is noticed which has been already outlined. Thus we see in a thin section of one of these hyper- trophies that the epithelium is intact, although many of the cells, especially in the neighborhood of the open- ings of the glandular ducts, have undergone fatty degen- eration. The basement membraue 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 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 iu outline; and here we find the endothelial lining of these caverns proliferating. Scat- PATHOLOGY. 259 tered through the connective tissue are seen numerous lymph-corpuscles. In some sections made from hyper- trophies I have noticed myoxomatous change taking place in the fibrous tissue. There is but a slight differ- ence in structure between the anterior and posterior hypertrophies—viz., the venous sinuses in the anterior hypertrophies are not as numerous or as large as in the posterior variety, and usually the inflammatory infiltra- tion, as well as the new-formed connective tissue, is Fig. 70. Section of posterior hypertrophy. X 250. 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. much more extended; so that we notice the venous sinuses only near the periosteum when situated on the turbinated bones, and close to the perichondrium when the swelling springs from the cartilaginous portion of the septum. Microscopic appearance. Thierfelder describes and figures the microscopic appearance of a nasal hypertrophy found by accident in a subject dead from mitral insuffi- 260 DISEASES OF THE NASAL CAVITIES. ciency, ascribing the origin of the nasal condition to the heart-lesion. There is no doubt, however, that these swellings are of inflammatory origin, and that in Thier- felder's case it coexisted with, but was not directly caused by, the heart trouble, as he supposes. 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 do 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 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 permanently hypertrophied. When thus enlarged, this tissue pre- sents a rugged appearance in the rhinoscopic mirror, with rounded eminences projectiug 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 examined 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 infiltration. This condition, however, but rarely interferes with the func- tions of the nasal cavities, except that it imparts to the PATHOLOGY. 261 voice a nasal sound by decreasing the size of the post- nasal cavity, and thus interferes with the normal nasal resonance. An enlargement of the turbinated bones themselves is sometimes met with, causing obstruction of the nasal chambers, aud simulating ordinary hypertrophy of the erectile tissue when viewed through the nasal specu- lum. Touching them with the probe, however, at once makes their bony nature evident to the observer. 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 sep- tum, giving rise to various reflex symptoms. Woakes states that this cleavage is always accompanied by necro- sis 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 mem- brane, but which, when touched with a probe, have a hard, elastic feel, the same as that conveyed to the hand when touching the cartilaginous septum in other appar- ently normal portions. These are not localized devia- tions of the septum, for we do not find a corresponding depression on the other side, but they are true hyper- trophies of the cartilage, as I had occasion to prove by removing a very large one, and submitting it to micro- scopical examination. The ecchondroses, as they are called, are of various shapes and sizes, sometimes pre- senting a teat-like projection from the smooth surface of the septum ; sometimes they are ridges running horizon- tally, vertically, or obliquely from before backward, or from below upward; and, in not a few cases, we notice 12* 262 DISEASES OF THE NASAL CAVITIES. them as shelf-like projections runuiug 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 ossification in their sub- stance 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 irritation of the mucous membrane of the cartilaginous septum primarily, aud of the perichon- drium secondarily. If we consider that a turgescent or hypertrophied 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 mem- brane, 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 produce local conges- tion of the part pressed upon, be it on the outer integu- ment of the body or the mucous membrane, it seems plausible to assume that this local congestion gives rise to changes of nutrition in the part sustaining the pressure. Taking into consideration the peculiar his- tological structure of cartilage, and particularly of hya- line cartilage, in which the blood is supplied by loops of vessels dipping into the substance of the cartilage from the perichondrium, and the nutrition of the cells is car- ried on by osmosis from one to the other without the intervention 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 m,ore rapid cell-division and proliferation of the intervening carti- lage cells than is demanded to supply the waste by cell- PATHOLOGY. 263 death, and localized increase of cartilage-tissue must result therefrom. In the majority of cases the cartilaginous projections from the surface of the septum correspond in position and size to the line of pressure by the turbinated 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 rise to the ecchon- droses iu the manner described. It is, of course, impos- sible 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 sep- tum becomes apparent. And, further, it is impossible to give any reason why, in some instances, no appar- ent redundancy of tissue results from long-continued pressure by the turgescent turbinated tissue. Individual peculiarities, in this case, as in many other pathological formations in the body, must account for the differences noted in different cases. In some instances an excessive growth of an ecchondrosis from the septum will cause it to press against the opposite turbinated bone, wrhen ero- sion of both surfaces takes place, and a bony union between the septum and the turbinated bone is estab- lished, 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 trau- matic origin. On the floor of the nose we frequently see bony 264 DISEASES OF THE NASAL CAVITIES. 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 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, aud conse- quently 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 deviation 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, aud may there- fore 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 iu the production of deviation of both the bony and cartilaginous septum. CORYZA. 265 Hypertrophy or expansion of one of the turbinated bones also is not infrequently 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. There are, however, a number of other conditions which produce nasal obstruction and deviation of the septum, and even deformity of the external contour of the nose, such as polypi and other intra-nasal neoplasms, foreign bodies, and rhinoliths, all of which will be mentioned in the chapter on Neoplasms and Tumors of the Nasal Cavities. This short description of the pathological conditions 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, pro- ducing there a dull frontal headache. In individuals who have very thick aud 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 266 DISEASES OF THE NASAL CAVITIES. partial or complete stenosis accompanied by a burning sensation in the nose, and finally there is a copious watery discharge, which later on becomes thick by the admixture of mucus. Constitutional disturbances show themselves by gen- eral 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 found to be swollen and intensely red, the swelling frequently obliterating the convolutions of the turbinated bones. Abrasions or ulcerations are entirely absent in simple coryza. Cause.—This affection is caused either by a sudden chilling of the surface of the body or by local irritation 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 introduction of the gonorrhceal virus into the anterior nasal cavities does not seem to be capable of producing acute coryza in the adult, but gonorrhceal rhinitis is occasionally met with in connection with gonorrhceal ophthalmia in children. Coryza may also be produced by the action of drugs introduced into the system, such as iodine and bromine; it is also a prominent symptom of a number of systemic affections. Although it is not ordinarily infectious or contagious, it may appear as an epidemic, being the most prominent symptom of influenza or epizooty. The CORYZA. 267 reason for the immunity and absence of gonorrhceal infection of the nasal mucous membrane in adults must be looked for in the fact that the nasal secretion covers the mucous membrane, and thus acts as an antiseptic. There are, however, a number of other causes which give rise to acute coryza, which depend upon a dis- turbance of the vasomotor system of nerves, inasmuch as idiosyncrasy as well as emotional and mental excite- ment are the most prominent factors in the production of this disorder. These latter causes are, however, con- sidered in detail in the chapter on Hay-Fever, and need not be enlarged upon here. The duration of the affection is, as everyone 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 affec- tion very little is to be said, inasmuch as everyone 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 com- pelled to sneeze incessantly, protection of the irritable mucous membrane from the air is very grateful to him. This may be accomplished by a snuff composed of gum acacia, subnitrate 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 protective to the mucous membrane by the bismuth, when introduced into the nostrils as a snuff. The soda is added to prevent acid fermentation, and the morphine to lessen the sensibility. Bromide of potassium, given in doses of from fifteen 268 DISEASES OF THE NASAL CAVITIES. to twenty grains every three or four hours, hastens reso- lution somewhat in a great number of cases, while in others it seems to have no effect. The fumigation of the mucous membrane by muriate of ammonium vapor from the inhaler described in Chapter V., aud also by vapors of volatile substances, 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 4 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. aconit. rad. in small doses, often repeated, also frequently aborts an attack of acute coryza. If, however, the con- gestion has already set in, alcoholic stimulants will aggravate it. But even then a cold in the head can be CORYZA. 269 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 common table-salt. Nasal Douche.—As the nasal douche is constantly employed in the treatment of acute and chronic inflam- mations of the lining membrane of the nasal cavities, I will here say a few words in regard to the proper use of this instrument. Fig. 71. Thudichum's nasal douche. The nasal douche (Fig. 71) is a vessel either of glass or tin, holding from a half-pint to two pints 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 gravitation runs up one side of the nose until it reaches the posterior surface of the velum palati closing the nasal cavity behind, and runs out by the other nostril, thus bathing the mucous membrane, and cleansing it by removing all hardened mucus, either 270 DISEASES OF THE NASAL CAVITIES. directly or by loosening it so that it can be removed afterward 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 attrib- uted solely to the use of this instrument. Dr. Roosa, of New York, as well as Dr. Lennox Browne, of Lon- don, 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 resulting from the use of this in- strument, where the precautious to be mentioned had been observed by the patient. Dr. Browne does not seem to lay much stress upon the proper density aud temperature of the liquid, and this may be the cause of the unpleasaut 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 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 iu the CORYZA. 271 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 veuous 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 iu the nasal douche be of a greater specific gravity than the serum of the blood, exosmosis of the latter will take place, leaving the corpuscles more densely crowded in the capillaries, thus clogging them, and producing an irritation of the sensory nerve filaments, which we per- ceive 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 dis- tended with the increase of liquid, which again causes pain by excitation of the nerve filaments. It becomes, therefore, 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 obtained by dissolving fifty-six grains of salt in a pint of water. Dr. J. G. Richardson, while engaged in his investigations on blood-stains, found that a 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 wheu suspended either in a heavier or lighter liquid than serum, and he consequently used such a solution 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 272 DISEASES OF THE NASAL CAVITIES. salt to a pint of water at 100° F. To this may be added any astringent, stimulating, or disinfecting drug, 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 precautions is the proper selection of cases. If, as is so frequently the case in nasal catarrh, the nasal chambers are more or less obstructed by deviation of the septum, exostosis or ecchondrosis of the septum, or by anterior or posterior hypertrophies of the erectile tissue covering the turbin- ated bones, and by tumors, the easy outflow of the fluid is prevented, it accumulates in the post-nasal cavity, and is forced into the middle ear, the frontal sinuses, aud even into the antrum and ethmoid cells, giving rise to inflam- mation of the mucous membrane lining these cavities. It frequently 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 pos- terior hypertrophies, which, being attached to the tur- binated bones by a sort of pedicle, are forced by the in-flowing current into the post-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 prevent 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 uuder ordinary conditions, 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 CORYZA. 273 the post-nasal syringe or douche is used, for an obstruc- tion in the nasal chambers in this case also causes an accumulation of liquid in the post-nasal cavity. It will, therefore, be seen that the douche should be used only in those cases of nasal disease in which there is no obstruction; but where there is an accumula- tion of secretion which, becoming inspissated, gives rise to the fetid odor noticed as 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. I am in the habit of adding some soda or borax to the solution 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 alkalies. 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 cleanse the nasal cavities. Dobell's or the author's antiseptic solutions are better adapted to these cases than the plain salt and water. Several forms of the nasal douche are iu the market, some of which have great disadvantages, and are there- fore to be avoided; for instance, the bottle form, which is that generally sold (Fig. 71). The narrow mouth of the bottle makes it inconvenient to introduce the salt, and impossible to use a thermometer to test the temper- ature, while it also prevents a thorough cleansing of the vessel. The glass tube at its bottom, to which the rubber tube is attached, is easily broken off, and then the instru- 274 DISEASES OF THE NASAL CAVITIES. ment is useless. Furthermore, it is too expensive an apparatus for the use of the poorer classes of patients. Another form, called the pocket or siphon nasal douche (Fig. 72), is very convenient, and efficient in the hands of an intelligent patient, but almost useless in the ma- jority of cases, inasmuch as it is nothing but a siphon, which must be started in order to wrork. 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 solution, which is elevated Fig. 72. Siphon nasal douche. 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 necessary 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 inexpensive, consists of a pint tin cup, with a piece of tin tube sol- dered 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 paraffin, or of horn. This form of douche 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. CORYZA. 275 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. 73), was used for the introduction of medicated solutions into the post-nasal cavity, and this instrument is frequently of great advan- tage at the present day in cases where strong astringent and stimulating solutions are to be employed, or in cases where the crusts of hardened mucus fail to become loos- ened and washed away by the geutle stream of the nasal douche. In the latter cases the nozzle of a syringe should have a slit-like opening instead of the usual five or six small holes, because greater force is necessary to dislodge the crusts. Fig. 73. The post-nasal syringe. The introduction of the post-nasal syringe is, however, somewhat difficult, inasmuch as the nozzle has to be carried up behind the soft palate, and it should, there- fore, not be trusted to the patients, although they often do learn to use it on themselves. After the nozzle has been introduced 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 into the mouth. 276 EPIDEMIC MYXOID (EDEMA. CHAPTER XIV. INFLUENZA AND AMERICAN GRIPPE, OR EPIDEMIC MYXOID OEDEMA. A form of acute inflammation of the upper air- passages, which occurs epidemically at varying intervals time in different countries, is the so-called influenza, of which present the same symptoms, only in perhaps a more aggravated form, that are seen in the ordinary non- epidemic acute laryngitis, pharyngitis, and coryza. This disease, which affects also the domestic animals, and particularly horses, has been variously named in the different countries and different languages, but always by a nickname, such as " influenza," " la grippe," "Blitz-catarrh," "epizooty," etc.; but never has the disease received a scientific name, in all proba- bility because it was looked upon as a trifling affair which did not require the attention of physicians, and the latter did not trouble themselves about making careful investigations. Dr. J. C. Wilson, of Philadelphia, in an excellent article on this disease in the System of Medicine, by Pepper, gives a full detailed account of the earlier his- tory of the various epidemics which have been observed. We there find that iu a number of these epidemics in the last century the mortality was very great; but we also find that in those epidemics the symptoms were different in many respects from the simple epidemics without mortality, aud it is therefore probable that this INFLUENZA. 277 great mortality was due to another disease which some- what resembles influenza, and which in this country has been called grippe. In this chapter I will endeavor to draw the distinction between these two diseases in as few words as possible, aud therefore will give simply the outlines of the symptoms of influenza aud of grippe separately. I may be criticised for doing so, as I have beeu before, yet I feel justified in making this distinc- tion, because a large experience has proved the correct- ness of the theory. Influenza. In all the epidemics of iuflueuza which have been carefully observed within the last twenty-five years the patients were usually seized rather suddenly with a burning sensation in the eyes and nose, followed by sneezing, frontal and occipital headache, pain in the pharynx, difficult and often painful deglutition, and hoarseuess. After a few hours the conjunctiva became injected (aud hence the name sometimes given of "pink- eye "), the eyelids are puffed and swollen, and there is profuse lachrymation ; the nasal mucous membrane also becomes swollen so as to occlude the anterior nasal chambers, and pours out a profuse watery discharge. The tonsils and pillars, the velum, and, in aggravated cases, the mucous membrane of the larynx participate in turn in the tumefaction, so that sometimes deglutition and vocalization become not only painful in the extreme, but even impossible, and the swelling in the larynx may produce stenosis, and tracheotomy may be necessary in order to save the life of the patient. On inspection the mucous membraue throughout the affected portions of the upper air-passages is intensely 13 278 EPIDEMIC MYXOID 03DEMA. red, and presents all the features of acute inflammation. But we never see any pseudo-membranes or what appear like mucous patches on the surface of the mucous membraue. In the majority of cases the sub-lingual aud sub- maxillary glands are swollen and painful to the touch ; the constitutional disturbance produced by this extensive inflammation is naturally considerable, and we have a very dry skin, a high pulse-rate and high temperature, together with insatiable thirst, but there is no particular malaise or pronounced weakness or feeling of exhaus- tion. The duration of the disease, which is self-limited, is from ten days to two weeks, from the onset to full recovery. Our treatment, as in the case of acute coryza, does little to shorten this time. Whether there is, or is not, a period of incubation is uncertain, as is also the cause of the widespread epidemics. The recovery is iu all cases complete, and the patient does not experience any inconvenience or impairment of health and vigor from the attack. Treatment.—The treatment should be directed toward the alleviation of the suffering and the general febrile condition. Antiphlogistics, diuretics, and diaphoretics, as well as antipyretics, should be given internally, and I find a modified form of Basham's mixture, made with fresh lemon juice instead of citric acid, excellent as a diuretic. At bedtime a five-grain Dover's powder, re- peated iu an hour if the patient does not sleep, is also of great advantage. And in the latter stages, quinine, in two-grain doses every three hours, acts kindly. The new antipyretics derived from the distillation of coal-tar may be of advantage, but as they have a depressing effect upon the heart it seems to me to be a dangerous experiment to exhibit them. AMERICAN GRIPPE. 279 Sponging the body with lukewarm water or vinegar and water affords great relief from the burning and dryness of the skin, and also lowers the temperature considerably. Stimulants of any kind should not be given, as they invariably increase the tumefaction of the nasal mucous membrane, and thereby increase the head- ache and difficulty of respiration. Locally, the spray of the antiseptic alkaline solution in the nose and throat, every two or three hours, according to the severity of the symptoms, applied with the atomizer, gives relief. Nitrate of silver solution should be painted over the tonsils, as recommended in the chapter on Acute Ton- sillitis. Cold compresses over the swollen eyelids and the instillation of a drop of 4 per cent, solution of cocaine into the eye affords great relief from the pain due to the acute conjunctivitis. Cocaine solution, introduced into the nostrils by means of a pledget of cotton saturated with it, and allowed to remain there a few moments, causes a shrinking of the turbinated tissue, which effect may be prolonged by following the cocaine with a spray of a 4 per cent solution of antipyrine. This gives great relief from the nasal stenosis, but is only temporary in its effect. Poultices to the ueck have a tendency to relieve the pain of the swollen glands. American Grippe : or Epidemic Myxoid (Edema. For a number of years past—as early as the winter of 1885—I observed a peculiar class of cases which did not, according to the symptoms, come under any of the different classes of diseases of the upper air-passages, whether local or systemic, and I was at a loss to classify or name the group of peculiar symptoms as a known disease, and still more at a loss how to treat it, 280 epidemic myxoid cedema. because the ordinary method of treating symptoms where the class is unknown failed utterly. In 1888 I had occasion to compare notes on this subject with my friend Dr. Glasgow, of St. Louis, who had made similar observations, and who, recognizing the malady as an undescribed and heretofore unnamed disease, had, like myself, called it " It," for want of a better name. In April, 1889, I published a very short account of the disease, as it was then prevalent in an epidemic form all over the United States. In the beginning of June of the same year Dr. Glasgow read a paper on the subject at the meeting of the American Laryngological Asso- ciation, at Washington, and I read a more exhaustive paper than my first one on the same subject, before the American Medical Association, at its meeting at New- port, R. I., in June, 1889. In this paper I gave a full description of the symptoms, as well as of the treat- ment, which had proved the only successful one so far. In December, 1889, fully six months later, the news- papers announced the invasion of New York City by an epidemic of influenza or " grippe," with au extremely high death-rate, and this epidemic rapidly spread all over the United States, respecting neither climate nor altitude, and was more fatal than even cholera or yellow fever could have been. This epidemic disease is still in this country, as it had been before, and the alarming epidemic outbreak must be attributed to a mixture of the undescribed " It" and the genuine influenza which was then raging all over Europe and part of Asia. This mixture, as well as the hasty and uncalled-for naming of the epidemic by the newspapers, was extremely un- fortunate, because the two distinct diseases were not differentiated one from the other, and all cases alike SYMPTOMS 281 were treated by physicians, as well as the laity, accord- ing to the well-known efficient treatment for influenza, and many lives were thereby lost, and are to-day lost, for the very same reason. As I am claiming the priority in having described this disease, and because it certainly is necessary, in my estimation, that some distinction should be made between it and the French " la grippe," or influenza, I take the liberty of naming it, and perhaps the best popular name that suggests itself is " The American Grippe." For a similar reason a disease resembling measles in some features, but differing in many other respects from measles, is called " German measles." The scientific name — chosen as expressing the pathological condition which is always present—is " Myxoid oedema Epidc mica," the pathological feature it expresses being a mucoid infiltra- tion into the submucous tissue. Symptoms.—The symptoms in all cases are alike in the beginning; very soon, however, a variation in their char- acter is observed in the different cases, according to the location of the focus of irritation in the alimentary or respiratory mucous tract. Thus, I will describe in detail a typical case of this disease affecting the upper air-passages, because this volume treats properly of such cases only. I will, however, touch upon the other forms incidentally, for the sake of comparison. The first onset is usually very sudden, the patient being stricken in perfect health with a pain, of a rheu- matic or neuralgic character, in the back, neck, or limbs, a feeling of utter prostration and a fear of im- pending evil accompanying the pain. Gradually the temperature rises, aud may reach a very high point, which is maintained with little or no fluctuation. The 282 EPIDEMIC MYXOID CEDEMA pulse, on the other hand, remains normal, but becomes weaker as the heart fails more and more, and may rise after a few days of illness, but never goes above 100 in ordinary uncomplicated cases. The tongue has a moist, grayish- white coating, which does not cover the edges and the tip; the organ is flabby, and shows on its edges the impression of the teeth ; the skin is moist over the whole body, and slight exertion, either mental or physical, in many cases produces profuse perspiration. The patient does not complain of thirst, but the appetite is completely gone, as is the will-power and mental energy, so that the sufferer is in a state of mental lethargy. It will thus be seen that there is no fever present, for the only symptom or indication of fever present is a rise of temperature as indicated by the thermometer ; the other elements—dryness of the skin, increased pulse- rate, and thirst—which must be combined with the elevation of temperature to produce a state of the system termed fever, are absent. (Dunglisou.) Experiments on animals for the purpose of determin- ing the location of the heat-centres in the nervous system have proved that temperature, as indicated by the clinical thermometer, can be raised or lowered by the irritation of one or the other of these centres without either the pulse-rate or the amount of moisture of the skin being affected thereby in the slightest. Unfortu- nately, the fever thermometer alone is relied upon by the physician to determine the presence or absence of fever. He then seeks, as his main object, to lower the temperature, irrespective of the condition of the arterial or venous circulation, and he exhibits at once the powerful heart-depressing patent antipyretics. If it is a case of the respiratory variety the patient complains of sore- SYMPTOMS. 283 throat, painful deglutition, difficulty of breathing, and a slight cough with scant expectoration. There is no run- ning at the nose, no sneezing, no conjunctivitis or swelling of the eyelids, but the eyes have a dull, glassy look. Diffi- culty of breathing is observed occasionally, and in a few cases tracheotomy has to be resorted to, to save life. On inspection, the mucous membrane of the throat appears of a pale bluish-pink color, with here and there spots of a deeper red, and here and there also, in many cases, a pseudo-membrane adheriug tightly to the surface. This membrane differs from the pseudo-membrane of croup and diphtheria, first in color, being of a bluish- white hue, and giving to the eye the impression of opalescence; it never curls up at the edges, nor does it ever become yellow or brownish, and, if pulled off by force, discloses not a true ulceration beneath, but simply a bleeding abrasion of the mucous membrane. As the case progresses toward recovery, or at least beyond the acute stage, the membraue gradually fades, becoming thinner and thinner, until finally it presents the peculiar glistening pinkish surface, so well known in syphilitic affections as a mucous patch, for which, in one or two instances, in the author's experience, it had been mis- taken. This membrane, also, is distinguished from the diph- theritic pseudo-membrane by the absence of any odor. The body of the mucous membrane itself appears puffy and swollen, and feels doughy to the touch of the probe, so that in many cases the anterior or posterior pillars of the fauces, the uvula, the arytenoid cartilages, ventricular bands, and other portions of the mucous membrane appear cedematous—without, however, pre- senting the scarlet color of the ordinary cedematous 284 EPIDEMIC MYXOID (EDEMA. swelling of acute inflammation as described in former chapters. An incision into the swollen portion, with a view of evacuating the contents, fails in its object, and only a drop of straw-colored, viscid, gelatinous material makes its appearance. When grasped with a forceps it can be pulled out to a length of four to six inches without breaking the thread. It may readily be seen that if this mucoid infiltration into the submucous tissue of the respiratory tract, particularly in the anterior nasal cavities and in the larynx, assumes large proportions, it must give rise to the symptoms of dyspnoea, already alluded to, and when it becomes more prominent in the mucous membrane of the bronchi and bronchioles it will produce a condition closely resembling pneumonia as diagnosed by auscultation and percussion. There are, however, a large number of cases in which this mucoid infiltration occurs only in the mucous mem- brane of the stomach, when it gives rise to gastric symptoms only, and is diagnosed as acute gastritis, or in the small intestines, when it is usually diagnosed as typhoid fever, or in the large intestine, when usually typhlitis and enteritis are the diseases diagnosed. And in a few instances the only visible symptom or lesion was a skin eruption, such as urticaria and eczema, covering the whole body, while in other cases au eruption closely resembling measles, scarlet rash, and even varioloid was observed, without, however, presenting the characteristic systemic symptoms of these exanthemata, and they readily yielded in an incredibly short time to the proper treatment of American grippe. Another manifestation of the American grippe is that form of the disease which might be termed nervous, SYMPTOMS. 285 in which the only subjective symptom is a disturbance of the nerve centres, resembling in some cases cerebral meningitis, spinal meningitis, hemiplegia, etc. But in all these obscure and misleading varieties, at least in the early stages, the peculiar clinical features of American grippe, namely, the moist skin, the flabby and white coated tongue, the low pulse-rate, the high temperature, the absence of thirst, and the extreme weakness and apathy, are invariably present; and by these features the true nature of the disease may be at once recognized, and the effect of the treatment proper for the disease will confirm the diagnosis. In those cases iu which the attack is not a very severe one, and in which the heart is not seriously affected, all the above-enumerated symptoms appear in such a light form that they are hardly noticed by the patient, and it is not until weeks afterward that his attention is called to the attack by the appearance of the symptoms of the chronic form. The duration of the disease is unknown, as it is not a self-limited affection, aud is very apt to become chronic, and one attack predisposes to subsequent attacks at fre- quent intervals. There is apparently, also, no period of incubation. The cause or causes of the malady are like- wise unknown, as various and repeated experiments and cultures have failed to show any specific bacteria, and because the disease has made its appearance at all seasons and in a. variety of altitudes, respecting neither the rich nor the poor, and appearing with like force in the squalid alleys and in the fashionable streets of large cities. The chronic form, like the acute, has peculiar clinical features which are present in all cases, no matter what the peculiar specific symptoms may be. These features 13* 286 EPIDEMIC MYXOID (EDEMA. are loss of ambition, weakness, more or less profuse per- spiration on mental or physical exertion, showing itself more particularly in the palms of the hands, insomnia, or fitful sleep, which is not refreshing to the patient, who feels more depressed and out of sorts in the forenoon than in the afternoon and evening. The appetite is fickle, the bowels irregular, and the urine scant and of a high specific gravity, but no albumin nor sugar can be found in it, unless Bright's disease or diabetes had ex- isted prior to the acute attack. The memory, particu- larly for names and numbers is seriously affected, and recent events, owing to the sluggishness of the miud in appreciating them, are more readily forgotten than older remembrances. Concentration of the mind for any leugth of time is impossible, and these mental symptoms in many cases develop into insanity, usually of a mild monomaniacal form. Dreams. The patient almost always complains of ever-conscious, and yet uncontrollable, dreams, which disturb sleep and resemble as closely as can be the visions of delirium tremens. Eye symptoms. In many cases pain in the eyeballs is complained of, and it is described as a pushing from behind, as though a pair of thumbs were pressing upon the eyes within the skull; vision is greatly interfered with, and sometimes totally lost. In still another variety of cases, chronic skin eruptions, due to nerve- irritation, are a prominent symptom—such as lichen, both planus and ruber, eczema, psoriasis, etc. In fact, space does not allow me to enumerate all the various predominant symptoms of chronic American grippe which have come under my notice, and the above must suffice to give an idea of the scope in TREATMENT. 287 which the disease manifests itself. As far as the mucous membrane of the upper air-passages is con- cerned, a little more detailed description of its appear- ance and disturbance of its functions may, however, be admissible in this volume. On inspection of the nasal cavities or throat in a case of this kind we find the mu- cous membrane throughout the upper respiratory tract of a pale bluish pink color ; it feels to the touch of the probe " doughy," and to the eye appears more or less wrinkled and relaxed. The secretions are diminished in quantity, aud collect as white glairy mucus in the laryngeal, naso- pharyngeal, and anterior nasal cavities, thus giving rise to a slight hacking cough, a feeling of fulness in the upper portion of the throat aud obstruction to nasal res- piration. This latter symptom is increased in its severity by the indolent swelling of the turbinated tissue, due to the mucous infiltration into the submucous tissue, thus resembling true hypertrophy of the erectile tissue. The same condition, namely, scant and thickened secretion, together with infiltration into the submucous tissue, is frequently found in the bronchi and bronchioles, thus closely simulating chronic phthisis, both in the general condition of the' patient and in the physical signs. Treatment.—The treatment of the acute form of Ameri- can grippe should be directed not toward the symptom which is most prominent, namely, elevation of tempera- ture, but should aim to eliminate from the system the poison (whether it be a ptomaine or bacteria), which by its powerful effect upon the nerve-centres gives rise to the symptoms. And here, more clearly, perhaps, than in any other disease, Nature asserts herself and shows us the way. The profuse perspiration on exertion, the 288 EPIDEMIC MYXOID (EDEMA. high specific gravity of the urine, without albumin or sugar, and the invariable finding, on post-mortem ex- amination in fatal cases of the disease, of healthy kidney structure, when all other organs were found to be dis- eased, clearly indicate that the skin and the kidneys are the only channels through which the poison can be eliminated from the system. At the same time, through the extreme debility, the weakness and slow- ness of the pulse, Nature indicates that the heart is failing and must be supported, and that the high temperature is only the result of the irritation of the heat-centres, and not due to increased arterial pressure. Thus, acting upon the suggestion thrown outin an article in one of the German medical journals which recom- mended the benzoate of soda in large doses as a specific for diphtheria, Dr. Glasgow aud myself arrived at the con- clusion that this, formerly much-vaunted, but now almost forgotten, drug would be the proper remedy to aid the skin and kidneys, and that the heart was best sustained by alcohol in small but repeated doses, together with absolute rest. This line of treatment has given the greatest satisfac- tion to all who have had the courage to disregard the popular idea extant in the profession, that a high tem- perature, whenever found, must be combated vigorously, and without regard to any other symptoms present, by means of the recent synthetic patent antipyretics. The usual method pursued is, to administer ten grains of benzoate of soda in a half-tumblerful of plain or better carbouated water, a tablespoonful of either whiskey, brandy, or other liquor every three or four hours, and absolute rest and quiet in bed. Simple as this treatment is, it produces the desired result, and the author has seen TREATMENT. 289 most severe cases of the acute form, with the pharynx and nasal cavities filled with pseudo-membrane, and deglutition almost impossible, completely recover iu three times twenty-four hours. And, in one case of eczema, covering the body from head to foot, he has seen the eruption disappear completely in less than a week under this treatment. In the chronic forms of the disease it has been found that the benzoate of soda alone is not well borne by the stomach in such large doses for any length of time, and therefore the author uses the fol- lowing formula : K.—Sodii benzoat. ^ ss. Liq. ammon acet. fi gjss. Inf. buchu (fresh) q s. ad flgviij. Sig.—A tablespoonful in water four times daily. This mixture, which, for the sake of convenience, has been named Mistura Buchu Composita, loses the disa- greeable, acrid, bitter-sweet taste by ageing, and it is well, therefore, to put it up iu large quantities. As a tonic and heart-stimulant, whiskey or brandy, or any other liquor, alone, has its well-known disadvantages when it becomes necessary to admiuister it for any length of time; and the following formula may, with advantage, be substituted for it: K .—Elix. gentianaj fl 3 ss. Tinct. cinch, comp. fl ^jss. Syr. limonis fl gj. Spt. frumenti q. s. fl ^ viij. Sig —A tablespoonful three times a day before meals. At the same time moderate exercise in the fresh air is of great advantage, but the patient should be admon- 290 CHRONIC NASAL CATARRH. ished not to overtax his strength, mental or physical, and rest as soon as the palms of his hands become moist. Change of air and scenery, as well as pleasur- able but moderate excitement, such as theatres, concerts, etc., aid in a great measure in hastening complete re- covery; while on the other hand quinine, antipyrine, phenacetine, and the whole list of antipyretics and analge- sics, invariably retard recovery in the chronic form of the disease, and often produce death in the acute form by their debilitating action on the heart. CHAPTER XV. CHRONIC NASAL CATARRH. A chronic inflammation and consequent derange- ment of the normal conditions of the nasal and naso- pharyngeal 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 universally used, and we will therefore adhere to it. Nasal catarrh is one of the most frequent affections 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 SIMPLE CHRONIC CATARRH. 291 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 rational treatment, and so cure our patients, often in a com- paratively short time. Simple Chronic Catarrh. By this term is meant a chronic catarrhal inflammation of the nasal mucous membrane, not depending 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., hypertrophic and atrophic nasal ca- tarrh, which may arise independently from each other, or the atrophic may be a sequel and consequence of the hypertrophic variety, or, thirdly, they may coexist, one form iu either anterior nasal chamber. As the treat- ment 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 congestion 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 super- abundant 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 nasal 292 CHRONIC NASAL CATARRH. cavities, wrhich is transient in character and appears rather suddenly, when the mucous membrane is irritated by dust or cold air, as well as from any cause which pro- duces an increase of blood pressure in the head, such as alcoholic stimulants, emotional disturbances, etc.; a fre- quent recurrence of an acute coryza from trifling ex- posures, which, however, is not as severe nor as long continued as true acute coryza, in some cases lasting for a few hours only; finally, a slight impairment of nasal resonance. There may or may not be a dis- charge of thick glairy mucus from the glandular tissue of the vault of the pharynx, according to the amount of congestion or inflammation present in that region. Pharyngeal aud laryngeal symptoms are usually not prominent, although a congestion of the mucous mem- brane of the larynx is observed in the laryngeal mirror, and a more or less diffuse inflammation of the pharyn- geal mucous membrane, with enlargement of the follicles, is noticed on examination of these structures (Plate II., Fig. 3). On inspection of the nasal cavities we see that the mucous membrane is red, and swollen and spongy to the touch of the probe ; the cavernous 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 solution (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 cur- rent, five or six niilliamp&res, 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 SIMPLE CHRONIC CATARRH. 293 obstructed, 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 nasal cavities, 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 prominent than normal. On account of the slight inconvenience experienced by the patient, we but seldom have the opportunity to see nasal catarrh iu this stage, unless we examine every case of laryngeal or pharyngeal disease which comes under our notice for this trouble. 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 fol- lowing symptoms : The patient complains that his nose feels stopped up, especially when he assumes the recum- bent position; that during the night his mouth and throat feel dry ; in the morning- and at frequent inter- vals 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 nose feels 294 CHRONIC NASAL CATARRH. 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. Spon- taneous bleeding of the nose is also a frequent occurrence in this condition, and when it occurs the headache is usually diminished, or disappears altogether. 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 ases, 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 pharnyx, with follicular enlargement in the mucous membrane, and a dry, tickling, laryngeal cough are present in cases of long standing. Asthma is also fre- quently found to be dependent upon the nasal obstruction, but it is more particularly noticed when the obstruction is produced by nasal polypi; while many other remote symp- toms, called reflex, such as paresis of the palate, paralytic dysphagia, paralysis of the vocal cords, excessive lachry- mation, paroxysmal sneezing, spasmodic cough, and many other like reflex symptoms are found to be due to intra-nasal disease, and particularly to pressure by ob- structions. 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 preceptible to the patient as well as to others, but this is not usually the case; aud if present, it is different SIMPLE CHRONIC CATARRH. 295 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 tubes by mucus or by hypertrophy of the tissue around their openings. In the same manner do we find, in some cases, a catharrhal conjunctivitis which is dependent upon the nasal trouble, and is probably due to extension of the inflammation into, or to compression of the nasal opening of, the lachrymal duct by the hypertrophies; or it may be due to reflex irritation of the ophthalmic nerve branch causing the 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 aud consequent 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 excessive use of alcoholic stimulants. Acne rosacea, as well as acne punctata are frequently met with in cases of hyper- trophic as well as atrophic nasal catarrh, and this irrita- tion of the skin of the face is due, no doubt, to two causes, viz., first, reflex irritation of the vasomotor nerves of the skin, aud, 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 promiuent as to amount to deformity, and it is highly gratifying to the patient to see them gradually disappear, as the mucous membrane in the nose assumes its normal condition under appropriate treatment. 296 CHRONIC NASAL CATARRH. On inspection of the anterior nasal cavities, which should always be made with the nasal speculum, so as to prevent stretching of the alse, and consequent disturb- ance of the relation of the parts to each other, we find the mucous membrane of a light-red color, darker than normal, but paler than in either acute coryza or in the first stage of the disease. It, as well as the underlying cavernous tissue over the turbinated boues, 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 portion of the turbinated bones (see Fig. 67). These hypertrophies, as they are called, whose anatom- ical nature was described in the preceding chapter, when pressed upon with the probe cannot be reduced but only indented, which depression immediately 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 hypertrophied, or expanded beyond its normal size, which can be readily 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 thence spreading over a larger area. These hypertrophies when situated at the anterior portion of the lower turbinated bone are termed " anterior hypertrophies;" when on the middle turbin- ated bone, as seen from the opening of the nasal cavity, they are known as " middle hypertrophies." In cases of long standing we find thickening of the cartilaginous portion of the septum, and exostoses of the vomer, which not unfrequently are localized, and assume a shelf-like shape (Fig. 74), running the whole HYPERTROPHIC CATARRH. 297 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 cartilaginous 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 maxillary bone Fig. 74. Dilated nostrils, showing ecchondrosis of septum. 1,1. Middle turbinated bone. 2,2. Lower turbinated bone. 3. Edge of vestibule. 4. Shelf-like projection from septum. 5,5. Floor of nose. are also sometimes found to produce obstruction of the anterior nasal chambers ; their pathology and causation have already been mentioned. A posterior rhinoscopic examination, which usually presents 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 near the pos- 298 CHRONIC NASAL CATARRH. terior 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 membrane, and especially so in the depressions around the opening of the Eustachian tubes, as well as in the crypts of the pharyngeal tonsil, which is more or less enlarged. In some cases the enlargement or hypertrophy of this glandular tissue amounts almost Fig. 75. Rhinoscopic image in a case of hypertrophy of pharyngeal tonsil. to a new growth, and may, besides causing au obstruction to the air-current, prevent the posterior nares from being seen in the rhinoscopic mirror (Fig. 75). In other cases the cavernous tissue, 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 cavities, thus producing stenosis (Figs. 68 aud 69). These posterior hypertrophies are of two varieties, viz. : one which appears white in color, with a deeply notched surface and of a tough, fibrous consistence, and another which has a purplish-browu color and a smoother surface and HYPERTROPHIC CATARRH. 299 is 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 obstructiou 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 or both sides of the vomer, usually of a lighter color than the rest of the mucous membrane (Fig. 76), which Fig. 76. Rhinoscopic image in a case of hypertrophic tissue on the vomer. may be the posterior extremities of the shelf-like pro- jections from the septum, or may be exostoses of the vomer, or, finally, are most frequently hypertrophies of the mucous membrane and its underlying tissue. Ulcera- tions 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 par- ticular ; but most of them are intimately connected with the pleasures and vices of civilized life—this disease not being found among the lower animals, and but seldom among the uncivilized races of men. As has been said, a frequent repetition, at short intervals, of an acute coryza, which sequence often happens in our changeable 300 CHRONIC NASAL CATARRH. climate, predisposes the mucous membrane to chronic inflammation, and by weakening the tone of the mus- cular fibres surrounding the sinuses of the cavernous tissue, causes it to become distended and to form the hypertrophies. The breathing of impure air in ill-ventilated rooms, especially at night and during sleep, is a frequent cause; so, also, is the inhalation of air filled with dust, and particularly dust composed of filaments of cotton or wool, such as is to be found iu 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, vene- real excesses, and anything that tends to lower the vitality of the system must be looked upon as a cause of nasal catarrh. Partial or complete stenosis, produced by the intro- duction of foreign bodies into the nostrils, by congenital or acquired malformation of the bony framework of the nose, by neoplasms of any kind, or, finally, by the calcareous deposit around a nucleus of foreign matter, called a rhinolith, which sometimes assumes such propor- tions as to cause complete stenosis of the nasal chamber, will cause chronic nasal catarrh. This is a point of great importance, for, as we have seen, nasal stenosis is produced by the catarrh itself, and is kept up by it. It therefore seems reasonable to suppose that, if the obstruc- tion to nasal respiration be removed, the chronic inflam- mation would either disappear per vis medicatrix naturae, or else would be cured by mild astringent applications in a short time. This is fully verified by clinical TREATMENT. 301 observation, and gives us the keynote to the successful treatment of hypertrophic uasal catarrh. Treatment.—The treatment of hypertrophic nasal catarrh must be directed mainly to the locality in which the disease manifests itself, viz., the mucous membrane of the nasal cavities, and must be calculated to restore that mucous membrane to its normal condition. In both the first and second stages the nasal cavities must be kept free from the accumulations 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 each 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 followiug is the formula : R.—Tinct iodini comp. Tttxx. Ac. carbol. (cryst.) TTLyj- G lycerinse fl 3 vij. Aq. dest. fl 3 v. 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 bene- 14 302 CHRONIC NASAL CATARRH. ficial effect in reducing the turgescence of the venous sinuses in the first stage, but is of no 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 rhinoscopic view can be obtained, which before was impossible. The applica- tions may be made through the mouth by means of a pledget 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 when there are no bony or hard obstructions. The effect of iodine upou the mucous membrane of the anterior nasal chambers is also very beneficial, in reducing the inflammation and sensitive- ness, so that I am in the habit of making an appli- cation both to the naso-pharyngeal cavity through the mouth, and whenever possible also through the nostrils. When the application is made through the mouth, great care must be exercised to prevent the iodine from enter- ing 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 will be found to auswer in most cases : TREATMENT. 303 H. —Iodine grs. xij. Potass, iod. grs. xxxvj Glycerinse fl^vjss. R. —Iodine grs. xv. Potass, iod. grs. xlviij. Glyce rinse fl^vjss. No. 1. R.—Iodine grs. viij. Potass, iod. grs. xxiv. Glycerime fl^vjss. No. 2. No. 3. 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 it is not called for in the majority of cases. The smarting occasioned by the iodine solutions can be miti- gated, to a great extent, by throwiug a spray of fluid cosmoline (No. Zero) into the nostrils, and by blowing some of the morphine aud bismuth powder, recommended in the treatment of acute coryza, into the nostrils. 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 hyper- trophic nasal catarrh, as they invariably give rise to swelling of the mucous membrane, and an increase of the hypertrophies, thereby aggravating the symptoms. Muriate of ammonium in the form of vapor, and the smoke from burning cubebs, are popular remedies 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 lost within a very short time, and it is therefore useless to try them. The only good quality they possess is that they are 304 CHRONIC NASAL CATARRH. 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: iodide of potassium in small doses, combiued with bromide, the oleo-resin and the (cold ex- pressed) 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. A systematic course of one of the natural mineral waters, with the proper regulation of diet, exercise, and rest either at home or, better, at the spring, will greatly aid in restoring the mucous membrane to its normal condition. Among the many springs the waters of Carlsbad, Kissiugen, and Ems in Europe, and Richfield, Saratoga, and Bedford in America, are the most prefer- able. The Bedford water, however, owing to its pecu- liar curative effect upon catarrhal inflammation of the mucous membranes and its diuretic action, is the best of all. But it should be borne in mind that no mineral water can produce the desired effect without regulation of the amount taken, or without restriction in diet, and it is for this reason that patients are sent to European watering-places, where the necessary restrictions are rigidly enforced, while we have in America and close at hand such waters as Bedford, which is far superior to any of the European springs in its curative action. In all cases the treatment must necessarily be a more HYPERTROPHIES. 305 or less protracted one, and it is of importance that the local applications be made at short intervals, in the be- ginning at least. Under no circumstances should any surgical procedure be undertaken until all acute and subacute inflammation has been reduced by these topical applications and by general medical treatment. Thus far we have considered only what might be termed the medicinal treatment of the disease, viz., the in- ternal 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, espe- cally as regards the second stage of hypertrophic catarrh, viz., the removal of the stenosis, which may be termed the surgical treatment; for this can be accomplished only either with caustics or with cutting instruments. Surgical treatment.—As the obstructions to the current of air in the nasal cavities vary in character, different methods must be employed for the removal of the differ- ent 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 par- tial 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 suc- cess ; but it has been my experience that all chemical caustics, if applied to the mucous membrane over the hypertrophies in a sufficiently concentrated form to 306 CHRONIC NASAL CATARRH. destroy the tissue below, give rise to so much pain and subsequent extensive inflammation that I have found it necessary to discard 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 iu the nasal cavity, and then only scorches the mucous membrane without destroying any of the deep-seated tissue. Furthermore, chemical caustics cannot with safety be applied to poste- rior hypertrophies, as their action cannot be readily checked by neutralizing agents. 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 hypertrophied 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 membrane. 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 gal- vano-cautery knife set at an angle to the handle (Fig. 77), 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 HYPERTROPHIES. 307 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 theu bent into a loop and hammered flat, and its ends are inserted Seller's galvano-cautery handle with loop and knives. 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-makers; 308 CHRONIC NASAL CATARRH. while the copper wires can be made of considerable thickness, thus introducing but little resistance to the electric current in its passage through them. The handle is so arranged that the knife can be inserted at different angles, and has a screw attachment for drawing in the wire when the instrument is to be used as a gal- vano-cautery snare for the removal of larger tumors. The current from the battery is then passed through the knife, and when 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 tem- perature when the incision is made, for if it is too hot considerable hemorrhage will follow, and if too cold the application is very painful. Care should also be exer- cised in protecting the skin of the vestibule, for if it is touched with the hot instrument the pain is very con- siderable 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 formation of an eschar, and of a certain amount of inflammation 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 fol- lowed 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 HYPERTROPHIES. 309 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 formation of bands of cicatricial tissue, which by their contraction bind down the swelling, uniting the surface of the mu- cous membrane with the periosteum of the turbinated bone in the line of the incisions, and thus preventing the stenosis. The number of incisions necessary to oblit- erate the hypertrophy will depend upon its size and firm- ness, but from two to four are usually sufficient. Iu some cases where the mucous membrane is pecu- liarly sensitive, the operatiou is followed by an acute coryza within twenty-four hours, which can, however, in a great measure, be prevented by blowing some of the morphine and bismuth powder into the nostril imme- diately 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 aud immediate adjustment 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 satisfac- tion in this and other particulars. This battery (Fig. 78) consists of a series of carbon and ziuc plates con- nected for quantity—i. e., all the zincs as well as the carbon plates are united together, and the circuit is com- pleted through the battery fluid, on the one hand, and 14* 310 CHRONIC NASAL CATARRH. through the platinum loop, which, by means of conduct- ing wires, is connected with the terminal binding-posts, on the other. This system of plates is mounted on a platform which is fastened near the top of the box, so that they hang from it into the interior of the box. Immediately beneath the plates is a hard-rubber cell Fig. 78. Seller's galvano-cautery battery. containing the exciting fluid, mounted upon another platform, which can be raised or lowered by means 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 aud harm's way. When it is depressed the platform with the cell rises, and the system of plates HYPERTROPHIES. 311 is immersed in the exciting fluid, whereby the current is established. The height to which the cell is raised determines the amount of current, and consequently the amount of heat in the platinum loop, for the higher the cell the more surface 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 au assistant, as is necessary in the case of the ordinary galvano cautery batteries, and can regulate the tempera- ture of the knife to a nicety. The rubber cell, being large, contains a large amount of fluid, and as, when the platform is lowered, the plates are entirely out of the liquid, the latter 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 everyone who has ever used a battery with small cups which require refilling after each operation. The battery of one cell is sufficient for the operations in the nose, but when larger operations are to be per- formed in which the heat has to be kept up for a con- siderable time, a two-cell battery should be employed. As both the faradic and the galvanic current of elec- tricity are frequently used in the treatment of diseases of the throat and nose, the advisability of having a battery that should yield the different forms of current presented itself, and at my suggestion Mr. Flemming made the universal battery (Fig. 79), which in principle is the same as the galvano-cautery battery, except that, instead of only one, it contains two systems of plates which, by a commutator, can be combined either for 312 CHRONIC NASAL CATARRH. quantity, when the battery is to be used for galvano- cautery, or for intensity when the galvanic current is desired. In the latter instance, the rubber cells contain- Fig. 79. Seiler's universal battery. ing the liquid must be changed for cells which are subdivided, so as to give a separate compartment for each pair of carbon and zinc plates. This change can be effected with very little trouble, and in a very short HYPERTROPHIES. 313 time, aud 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 the cells and plates is inserted a galvano-faradic apparatus, which is inde- Fig. 80. Gibson's storage battery. pendent, and may be removed for the sake of portability. This battery will be found a most useful piece of appa- ratus in the office. 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 314 CHRONIC NASAL CATARRH. 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 opera- tions (Fig. 80). 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 exhausted. A battery of this kind can be charged with 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 charging varies according to the ampere strength of the primary current, and when fully charged, the battery can be used for a very large number of operations before becoming exhausted. A battery of four cells is sufficient to light up one of the electric laryngoscopes for a considerable length of time. Where the incandescent electric light is used for pur- poses of ordinary illumination, the current as supplied by the central station may be used with advantage for the galvano-cautery in place of the battery, but it must be reduced in strength as otherwise the platinum loop would melt at once. A rheostat has lately been intro- duced by G. C. Stirling, of Hartford, Conn., which gives entire satisfaction. It consists of an oblong box of slate which is divided longitudinally by a partition of slate. This partition, however, does not reach to the bottom of the box, but stops withiu two inches of the floor. In the bottom of the box is a piece of slate which HYPERTROPHIES. 315 is loose, and can be moved up or down by a screw in the bottom of the box. The whole box is filled with small pieces or crumbs of gas-carbon, and the binding- posts are connected through the top of the box to larger pieces of carbou, which being surrounded by the smaller broken pieces conduct the current through this U- shaped conductor of loose carbou. By moving the false bottom upward by meaus of the screw, the pieces of carbon are compressed, and thus a better con- tact being established, the resistance is decreased, and consequently the current strength obtained in the gal- vano-cautery instrument is greater than if the false bottom is moved downward, the particles of carbon separated from each other, and the resistance thereby increased. Thus the operator has perfect control over the amount of current which he deems necessary to employ, and can increase or decrease the heat of his platinum loop by a slight rotation to the right or left of the regulating screw. The whole apparatus is securely fastened to the wall near the operator's chair, and is not unsightly uor is it dangerous, because the slate of which the box is made does not become sufficiently heated to set fire to any woodwork which may be near. 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. 81) consists of a small canula about seven iuches long, made of steel. About four inches from the lower end is a cross-bar, aud the portion between this and the end is threaded aud carries a screw nut, which, by being turned, travels up 316 CHRONIC NASAL CATARRH. Fig. 81. 9 or down. A portion of the circumference of this threaded piece of the canula is filed flat throughout its entire length, and has lines engraved across its face. Over this and behind the nut slips a tube which is fitted to the flattened screw so as to prevent its turning around, aud has a slit cut into that portion over- lying the flat surface of the threaded piece of the instrument, so that the division lines can be seen through it. This tube carries on its end two retention pins and a screw cap, by meaus 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, aud the wire loop pro- jecting from the distal end of the canula is thereby made smaller. The end from which 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 iutroduction of the instrument into the nose. A short curved piece of canula, with a tip of the same shape as the one just described, may be substituted in some instruments for the straight canula, and it can then be used for ablating the hypertrophied pharyngeal tonsil. The wire used for anterior hypertrophies should be a fine annealed steel piano-wire; it is sold by dealers as No. 0, while for posterior hypertrophies, and for the pharyngeal tonsils, it should be several numbers thicker. CI Jarvis' snare. HYPERTROPHIES. 317 Supposing that we have a case of anterior hyper- trophies which are to be ablated with the snare, we proceed as follows: The parts are first anaesthetized with cocaine solution in the manner described above or the operation with the galvano-cautery knife. The base of the hypertrophy is then transfixed with a flat aud slightly curved needle, having a light metal handle (Fig. 82). A piece of the thin steel wire having been cut to the required length, both ends are pushed through the canula, and are fastened securely Fig. 82. Jarvis' transfixing needles. to the sliding tube by winding them around the retain- ing pins, and screwing 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 grad- ually snared off by turning the nut, which, by pushing the sliding tube down, draws the wire loop through the tissue into the tip of the canula. When the wire has passed entirely through the swelling, which it does gen- erally with a jerk, the hypertrophy comes away stick- ing to the transfixing needle. The operation is, how- ever, by no means easy to perform, owing to the fact 318 CHRONIC NASAL CATARRH. that it is often very difficult to get the wire loop over the projecting point of the needle, so that the snare has frequently to be withdrawn and rein- Fig. 83. troduced 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 operation very materially (Fig. 83). This attachment con- sists 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, having a long stem, by which it can be pushed forward, glides over the shanks of the claws, and by this motion presses them against each other, raising them slightly from the canula at the same time. In using this instrument, the canula with the claws open, and the wire loop of the proper size, is introduced into the distended nostril, the claws are pressed through the loop against the hypertrophy and closed by pushing the slide forward, when the piece of tissue grasped betweeu them will be pulled through the wire "loop, which should then be tight- ened around it and the hypertrophy cut off slowly. The piece which has been thus p| ablated is firmly held by the claws. The Seller's claw- operation should occupy fifteen or twenty attachment minutes, because it has been found that if the snare^™' tisSUe is Cllt tnrougn quickly the pain is greater, and the hemorrhage sometimes quite copious. If, on the other hand, it is done slowly, the patient experiences but little pain, and hardly any bleed- HYPERTROPHIES. 319 ing 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 granulation, so that no special treatment is necessary. Middle hypertrophies and hypertrophic tissue on the septum can be removed iu the same manner. If we have to deal with a case of posterior hyper- trophy, however (Fig. 84), the manner of operating is Fig. 84. 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. quite different. In this operation it is of great impor- tance 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 instru- ment, while the wire is drawn tightly over it by pulling 320 CHRONIC NASAL CATARRH. upon the sliding tube. The circumference of the wedge is first measured by making 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 sliding tube. This distance is added to that previously registered by the tube when it clasped the wooden wedge, and the number found will indicate a complete section of the hypertrophied tissue. Fig. 85. Jarvis' snare in position, showing the loop around a posterior hypertrophy. (Jarvis.) The loop might be measured by drawing it into the instrument, only that the wire becomes " kinked" and is very apt to break at that point during the operation, while when measured in the manner described the loop retains its shape. Before introducing the instrument into the anterior nares, when posterior hypertrophies are to be removed, the loop should be made as small as possible without distorting 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 HYPERTROPHIES. 321 are fastened. 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 hypertrophied tissue (Fig. 85). The cross-bar on the instrument in- dicates the position of the tube in relation to the natural bend of the loop. It is of great advantage, especially for the inexperienced operator, to watch the motion of the loop in the naso-pharyngeal cavity by means of the rhinoscopic mirror, and by using the combined tongue depressor aud rhinoscopic 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 which is not pathological and should not be done away with. The removal of posterior hypertrophies is usu- ally undertaken, therefore, by the experienced oper- ator, 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 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 constriction at the base of the hypertrophy, the loop should be care- fully tightened around the tissue by pulling down the sliding tube. When the traction on the wire becomes perceptible the milled nut is run down, further traction being made by rotating it. By giving a turu 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 322 CHRONIC NASAL CATARRH. 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 withdrawn. 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 connec- tion, 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 aggluti- nated venous sinuses by the mechanical vibration, and so starting a hemorrhage. If any bleeding should follow the operation, it can easily be stopped by plugging the anterior nasal cavity with borated cotton or with spunk, such as is used by dentists for drying cavities, in such a a manner that the blood cannot flow out of the nostril. This material has the advantage of readily absorbing any liquid and at the same time becoming swelled, thus stopping the flow of blood more readily ; and it also has the advantage of not sticking to the surface, so that it can be removed easily, and can therefore be used for controlling the hemorrhage after operations in the ante- rior nasal chambers. The blood then backs up, form- ing a clot, which, when it has reached the bleeding spot, will, by its presence and pressure, stop the hemor- rhage. 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 ad- ADENOID GROWTHS. 323 herent to the mucous membrane that it is difficult to remove. In many cases this has given rise to ulcera- tion, which resulted in perforation of the septum. The^low 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 inflamma- tion 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 fouud in old cases of nasal catarrh, and which give rise to partial stenosis, especially if they are situated ou the septum opposite the pen- dent portion of the lower turbinated bones, may also be easily removed with the wire snare iu the same manner as the sessile anterior hypertrophies. The wire used in this operation should, however, be very thin, so that it will cut readily through the cartilage, and the needle, used for transfixing the base of the ecchondrosis, must be strong enough, so that it cannot bend. Adenoid growths in the vault of the pharynx, or hyper- trophied pharyngeal tonsil, are best removed with the wire snare, in the following manner: Having 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 trac- tion is made with the sliding tube it will bend backward ; that is, iu au opposite direction from the curve of the instrument. The loop is then passed behind the velum 324 CHRONIC NASAL CATARRH. 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 en- circle the growth and it may be snared off quite rapidly. As these growths consist of glandular tissue only, the pain is slight, and little, if any, hemorrhage follows the operation. There is usually, however, for a few days, some inflamation of the mucous membrane lining the naso-pharyngeal cavity, and the wound heals by granulation. If, as happens quite frequently, the glandular mass is rather flat, extending over a con- siderable surface of the vault of the pharynx, the snare Fig. 86. Seller's pharyngeal cutting forceps. 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. 86). With children neither the snare nor the cutting forceps can be used with advantage, because the little patients will not hold still long enough for us either to apply the snare or to introduce the forceps more thau once; and I have found that the hypertrophied glandular tissue can be gotten rid of, most easily, by removing it with the finger-nail, which latter should, of course, be long and strong. If the operator does not possess such a natural surgical instru- ment, an artificial claw, attached to a thimble, may be DEVIATION OF THE SEPTUM. 325 used, as suggested by Dr. Farnham, of Milwaukee. In performing the 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 co5peration during the often difficult manipulations. Deviation of the Septum.—Among the hard ob- structions 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 operations have been re- commended for the relief of this condition, and different authors advocate punching 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 portion 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. 87), which has iuserted into one of its blades a number of knife-blades, at right angles to the surface and arranged in the shape of a star, the septum is punched at its greatest curva- ture once, or if the bend extends far back twice, by 15 326 CHRONIC NASAL CATARRH. introducing the blade carrying the knives into the open nostril, and the unarmed blade into the closed one, and Steel's forceps for deviation of septum. then compressing the handles. The punch is then re- moved, and with a pair of forceps having flat blades (Fig. 88) the septum is forcibly straightened, which becomes Fig. 88. Adams' forceps. possible since the triangular pieces produced by the cut made with the punch lap, and thus the distance from the base to the top of the septum becomes diminished. Hav- Fig. 89. Nasal plug. ing accomplished this the forceps is removed, and a wooden or ivory plug shaped to fit the cavity (Fig. 89) is inserted into the formerly obstructed nostril, and is kept DEVIATION OF THE SEPTUM. 327 there for about forty-eight hours, when it is replaced by a plug of cotton or spunk, 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 thickening of the septum, these must be re- moved previously 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 in them we usually find a fracture of the plate 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 Steel 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 membraue in both auterior nasal chambers 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 obstructed side is then slowly introduced into the nos- tril with the palmar surface toward the septum until the edge of the vomer is reached. This procedure, 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 sup- posed. The finger being in situ, the upper end of the 328 CHRONIC NASAL CATARRH. 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 incision, and the septum is cut along the line of the frac- ture 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 the septum. The next step is to secure the septum in its new position, and this is accomplished by inserting 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 Steel 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 tur- binated bone, and can, therefore, 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 DEVIATION OF THE SEPTUM. 329 keep the nasal chambers thoroughly cleansed with the antiseptic solution. There is usually no difficulty in removing the pins with a pair of strong pliers, if they have been allowed to project sufficiently beyond the sur- face 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 been raised by the straightening of the septum. The pin can then be pushed up by grasping its exposed por- tion in the nasal chamber with a pair of small jeweller's pliers, and by making a small incision 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 pieces of spunk 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 deviation of the septum is due to a dislocation of the cartilaginous 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 into the obstructed side, and by manipulation the adhesions can be broken beneath 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 dis- 330 CHRONIC NASAL CATARRH. turbances 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 per- formed solely for the sake of improving the looks of the patient, and in that respect is very satisfactory. Quite frequently we meet with cases of deviation of the cartilaginous plate of the septum, in which the nasal cavity on one side is obstructed or narrowed by Fig. 90. Flaring septum. the bulging of the partition, while that on the other side is obstructed by the projection into it of the free end of the cartilaginous plate, which, having become detached from the columnar cartilage, is pressed into its abnormal position by the deviation of the septum. Still another class of cases is not infrequently met with, iu which the cartilaginous plate has been split through Jacobson's organ by a blow directly upon the nose in the median line. The free ends of the separated plates become detached from the columnar cartilage and flare like the tail-feathers of a swallow, thus obstructing both nostrils. In these classes of cases the simple cutting off of the BONY OBSTRUCTIONS. 331 projecting portion of the cartilaginous plate is sufficient, not only to remove the obstruction, but also greatly to improve the appearance of the patient. Care should, however, be taken to carry the incision through the mucous membrane only, and not to wound the skin lining the vestibule, because, if the skin is cut, the cica- tricial contraction after healing may be so great as to materially diminish the lumen of the nasal cavity; and the healing process is greatly retarded, because the aseptic nasal secretion cannot completely cover the wound. The operation is most easily performed as follows: The mucous membrane is pulled down over the projecting edge of the cartilage, which latter is then grasped with a pair of rat-toothed forceps, held by an assistant. The doubled-edged curved knife (Fig. 95) is then introduced into the dilated nostril, and with a sawing motion the cartilage is cut off from above downward behind the teeth of the forceps. In this way the normal outline of the cavity is preserved, which caunot easily be done with a straight knife. There is usually very little hem- orrhage, which is easily controlled with pieces of spunk introduced into the nostril. If the parts have been thoroughly anaesthetized with cocaine, and the skin of the vestibule is not cut, the operation is absolutely painless. A number of other nasal deformities are sometimes met with, such as too great an upward tilt of the end of the nose, which do not interfere, however, with the func- tion of the organ, and which can be remedied by opera- tion. Space, however, forbids me from entering into a detailed description of such purely cosmetic operatious. Bony Obstructions.—When the localized thicken- ings of the cartilaginous septum have become ossified, as they frequently do, or when the obstruction in the nose is Fig. 91. Dental engine. bony obstructions. 333 due to an exostosis of the bony septum, or to an enlargement of the turbinated bone itself, and not merely 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 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. 91), such as is used by dentists, has to be employed to revolve the drill or burr rapidly enough to cut away the bone; or, better still, a small electric motor to which the tools are attached, either directly to its spindle or by interposing a short flexible shaft between the spindle and the hand-piece 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. 79), 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 manipula- tion of the tool is possible than can be obtained when the dental engine is used, for in the latter instrument the baud has to support the weight of the handpiece and flexible shaft or arm, and besides a good deal of the motion of the foot, working the treadle of the fly-wheel, is communicated to the hand, making it unsteady. 15* 334 CHRONIC nasal catarrh. The tools used in the operation are fluted and twist drills (Fig. 92), and burrs (Fig. 93) of various shapes and sizes. In order to protect the parts on the opposite Fig. 92. Fig. 93. Burrs for dental engine. Fig. 94. Drills for dental engine. Burr with shield. BONY OBSTRUCTIONS. 335 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. 94). In the case of enlargement of the turbinated bone, and bony spur from the palatine process, the operation is performed as follows: The bony obstruction is first riddled with a number of holes made with a cutting drill, and its 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 gen- erally necessary to trim off the surface 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 wTith 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 aud nerves is not injured. 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 inflammation of the mucous membrane of the nose follows these oper- ations, and the wound in the soft tissues heals readily within a few days. As a rule, it is more convenient to place the patient under the influence of an anaesthetic, 336 CHRONIC NASAL CATARRH. so as to have perfect control over his movements; al- though 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 de- scribed, present variously shaped projections from the surface of the septum, the drill and burr are not appli- cable, 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 consideration of the require- ments 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 oper- ators have a particular fondness for this or that instru- ment, and prefer to operate with it rather than use any other, if this is possible; probably because they have acquired especial dexterity in its manipulation. It is, therefore, natural that they should praise their pet tool, and obtain results with it which others, with less dex- terity 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 oper- ation with as little pain and inconvenience to the patient as possible. And this can only be done by adapting the instruments to the requirements of the case. If the ecchondrosis is in the shape of a conical pro- jection 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. 95), with which an incision is made first from below upward to BONY OBSTRUCTIONS. 337 about the middle of the excrescence, and then from above downward until the two cuts meet, and the cartilaginous projection is ablated. If there exists a hard centre which caunot be cut through with the kuife, the two-cuts from Fig. 95. Seiler's cartilage knife, curved on the flat. below and above should be carried to this centre, and then a flat chisel (Fig. 96) used to cut through the bony portion, which is easily effected by tapping the handle slightly with a leaden mallet (Fig. 97). Fig. Seiler's nasal gouges and chisel, with handle. The two cuts are necessary because the knife, after having passed through the cartilaginous tissue, finds not sufficient resistance iu the mucous membrane if the opera- tion is made with one sweep of the knife from above 338 CHRONIC NASAL CATARRH. 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 edge by the mucous membraue. It is then difficult to grasp with the forceps, and much time is lost in finally severing the mucous membrane. Fig. 97. Leaden mallet. If, on the other hand, the shape of the ecchondrosis is shelf-like, with a downward-sloping upper surface, aud a concave under surface separated from the floor of the nose by a narrow space, and running backward for some distance, we may take it for granted that we have to deal with an ossified excrescence, and proceed as fol- lows : After having thoroughly anaesthetized the parts with cocaine solution, a grooved director, slightly bent at an angle, is introduced into the space between the floor of the nose and the under surface of the shelf-like Fig. 98. Seiler's plough-shaped knife. projection, with the groove upward. The nasal cavity is then dilated to its full extent with Bosworth's or Jarvis's self-retaining nasal dilator, and the dull point of a plough-shaped knife (Fig. 98) is inserted into the 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 similar tool. As BONY OBSTRUCTIONS. 339 soon as the bone 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 in- serted 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 patieut, so as to prevent injury to the parts beyond the projection, 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 projection, into the vault of the pharynx. A little prac- tice soon enables the operator to feel when the gouge has cut through the hard tissue. The tool is then re- moved, and, keeping the grooved director in position, a pair of scissors bent at an angle (Fig. 99) 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 caunot be so easily kept in the line in which the cut should be made; aud, 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 turbinated exostosis and the ecchon- drosis of the septum, I have found it best to divide the 340 CHRONIC NASAL CATARRH. exostosis first, with a saw (Fig. 100), close to the turbi- nated bone, and then to ablate the ecchondrosis with the knife and chisel, or gouge. The ablated piece of carti- lage is then grasped with a pair of rat-tooth forceps aud Fig. 99. Seiler's angular scissors. removed from the nostril, while any small projections not removed by the gouge are best cut off with the Farnham alligator forceps (Fig. 101). Fig. 100. Nasal saw. 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 from these cutting operations, BONY OBSTRUCTIONS. 341 as a rule, is comparatively slight, and can always be controlled by placing a pledget of spunk 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; although the danger of the formation of pus and of sepsis is very slight, because the secretion from the uncut mucous Fig. 101. Farnham's alligator forceps. membrane above the wound will completely and effect- ually cover it as soon as the bleeding has stopped, and prove to be the best antiseptic covering and wash that can possibly be desired. The healing process is usually complete iu about ten days, but may, in some cases, be pro- longed for a few days more. Aud this is particularly the case when the patient has had a previous attack of the epidemic American grippe, which leaves the mucous membrane in an unhealthy condition, as described in 342 CHRONIC NASAL CATARRH. Chapter XIV. There is no soreness of the nose, and no great amount of inflammation of the surrounding mucous membrane following the operation, and the patieut is able to attend to his duties at once, provided the oper- ation has been carried to an end at one sitting, that is, all the obstruction has been removed. When, however, ouly a portion of the bone or cartilage is removed, and when this partial operationMs repeated day after day, as some surgeons are in the habit of doing, a great deal of soreness of the nose and head, as well as considerable nervous shock, often confines the patient to bed for a lengthened period. Wheu it is necessary to place the patient under the influence of a general anaesthetic for operations within the nose, and the operator thus loses his cooperation, 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 practi- tioner is frequently called upou to perform, and it will therefore not be out of place to describe it here. In text-books on surgery we find au instrument—Bel- locque'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 nos- trils until its end comes in contact writh 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, aud when its end appears below the margin of PLUGGING THE NOSE. 343 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 cat- gut 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 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, which 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 iu 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 de- tached, and can be drawn out through the mouth. It has been my experience that this disagreeable procedure of plugging is necessary, however, only in cases in which an operation within the nasal cavity under a general anaesthetic is to be performed ; while in those frequently- met-with cases of spontaneous epistaxis in which ordi- nary applications of cold and astringent solutions will not stop the flow of blood, it is unnecessary to plug the nose, because the oozing of blood is due to granula- tion tissue, usually situated half-way up on the septum, the removal of which by scraping with the curette or finger-nail will immediately stop the hemorrhage. 344 HAY-FEVER. CHAPTER XVI. HAY-FEVER, OR CORYZA VASO-MOTORIA PERIODICA. Hay-fever, as well as the numerous forms of neu- rotic coryzas which we so frequently meet with in this country among the more educated class of patients, is a chronic nasal affection which, depending, as it does, upon a greater or less disturbance of the various nerves sup- plying the nasal mucous membrane, 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 only ; nor can he 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 symptoms 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. Mackenzie, of Baltimore, coryza vaso-motoria periodica. The scope of this handbook is, however, too limited to allow of a lengthy dissertation on the HISTORY. 345 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, Bos- worth, Woakes, and others. History.—The first description of the symptoms of hay-fever was given by Rostock, in 1819, and a further paper by the same author, in which he gave the affec- tion 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, Phoebus, of Giessen, pub- lished a collective investigation, and he was followed by Abbott Smith, Pirrie, and Moore, who also expressed the opinion that emanations from flowering plants were the sole cause of the affection. In 1869, Helmholtz published his theory of hay-fever, which was that, as he had by microscopical examination of the nasal discharges discovered certain vibrios, they were the cause of the affection, and that by destroying them with germicides, the disease could be cured. This assertion was, however, not substantiated by extended trials. Morill Wyman, in 1872, described the disease as it is prevalent in the United States, and was the first to make mention of the fact that there were two distinct varieties, viz.: the rose cold in May and June, and the hay-fever in August aud September. Blackley, of Manchester, in 1873, published an excellent treatise on this disease, and was followed by Beard, of New York, in 1876, with a col- lective investigation, and finally, Marsh, in 1877, pub- 346 HAY-FEVER. lished an essay, in which he reiterates the pollen theory of the causation 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, 1881, called attention 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 floating in the atmosphere was but one of the excitants producing an attack of the affection, but by no means the only original cause of the disease. Symptoms.—There is a variety of vaso-motor coryzas, which in their symtomatology 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 regu- larity at the end of August, and lasts, with slight varia- tion in the intensity of the symptoms, until the first frost appears. As its exciting cause, pollen grains, and particularly the pollen of the rag-weed, are named. Then we have the so-called rose cold, which is also re^u- lar and periodic in its appearauce, and comes on at the end of May, lasting as long as the roses are in bloom. SYMPTOMS. 347 Its exciting cause is supposed to be the pollen of the rose. The forms more rarely met with 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 pro- duced 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 fiually a form occasionally met with, the erotic form, which is not due to any external irritant, but is brought on by sexual excitement. In all these latter forms of the disease, the attacks usually last but a short time, from a few minutes, as in the form caused by sexual excitement, to a few days, as in the peach cold. Why so many different exciting causes can produce the same symptoms in different individuals is impossible to say, and we must fall back upon the convenient expla- nation, idiosyncrasy, which in reality is no explana- tion at all. The symptoms of an attack of any of these forms of vaso-motor coryzas are those of au 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 fulness of the nose, followed by a profuse watery discharge. After a short time conjunctivitis, lachrymation, and photophobia are added, together with a dull frontal or occipital headache, frequently neuralgic in its character, make their appear- ance ; and iu the more aggravated forms, a slight hack- ino- coup;h, hoarseness, and asthma, more or less severe, are noticed. At the same time the nasal discharge 348 HAY-FEVER. 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 wip- ing of the nose. General febrile disturbances are more or less pronounced during the first few days of the attack, characterized by increase of pulse and tempera- ture aud a feeliug of malaise. These symptoms in the long-continued attacks of hay-fever and rose cold vary from time to time, being intensified by exposure to dust, 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 mucous membrane is the same as is noticed in an ordinary acute coryza, viz., intense congestion of the mucous membrane, general turgescence of the turbinated erectile tissue, with profuse serous and mucous dis- charge. The congestion extends into the naso-pharyn- geal 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 conjunc- tion to produce the attacks, and if any one of these fac- tors is removed, the disease 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 ETIOLOGY. 349 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 im- munity of others in whom the pathological conditions in the nose exist, and who are also surrounded by the same irritant, but who, nevertheless, do not suffer, owing to the fact that their nerve-ceutres are not altered. The first of these factors, viz., the pathological condition of the nasal chambers, may comprise any of the various changes mentioned in the foregoing chapter, such as anterior, middle, or posterior hypertrophies; exostoses or ecchondroses of the septum ; deviation of the septum, or the pressure 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 sur- face 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 aud 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 irritation will be immediately followed by the appearance of all the early symptoms, and such an artificially produced attack will last from a few min- utes 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 ex- 16 350 HAY-FEVER. ternal irritant, as it is of the least importance, for, as has already been mentioned, a large variety of different sub- stances will cause an attack in as many different indi- viduals, and no particular pollen-grain or emanation 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 the subsequent removal of the intra-nasal pathological con- dition, 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 useless, but ag- gravate 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 iutroduced 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 to the sufferer, if only for a short time. The cocaine solution should not be dropped into the nostrils, nor TREATMENT. 351 injected with a syringe, as iu that case but a small por- tion of the nasal mucous membrane is acted upon by it; nor should the application 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 causing a loss of tonicity, and the swelling of the turbinated 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 intro- duced into the nostrils, so as to filter the inspired 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 washing do not in the least interfere with nasal respiration, aud give great relief. Internally, quinine, in large doses, tonics, and in the first stage atropine act well in reducing the febrile condi- tion ; while in the latter stages, wheu 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 neuralgic headache is very severe, morphine, hypodermatically, is the only drug which will give relief from the 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 illumi- nated, a probe is introduced and its point is run over the 352 HAY-FEVER. 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 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. Cocaine caunot well be used to anaesthetize the mucous mem- brane, because its depleting effect greatly interferes with the distinguishing difference of color between the spot to be burned and the surrounding mucous mem- brane, so that it is difficult, if not impossible, to locate the sensitive area; nor is it necessary to use cocaine, as the operation is not painful, 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 action 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. TREATMENT. 353 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 treatment to cor- rect 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 treatment 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 season after the treatment comes 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 immunity can be expected. The cases of the rarer forms of vasomotor coryzas usually yield much more readily to treatment, probably 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. 354 ATROPHIC NASAL CATARRH. CHAPTER XVII. 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 ozosna, by which this variety of catarrh is designated by many authors, is, however, also present in other affections, and may be noticed in cases of syphi- litic 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 malformation of the walls of the nose, and must, therefore, be looked upon as a symptom, and not as a dis- tinct affection. On inspection of the anterior nares, we find the mucous membrane everywhere dry and shiny, with here and there brownish scabs of dried secretion adhering to CAUSE. 355 it. The calibre of the nasal chambers is very much in- creased, 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. Fre- quently 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 withered condition of the mucous membrane in the naso-pharyn- geal 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 mem- brane of the oral pharynx is also usually involved, pre- senting a dry, shiny appearance and is covered here and there with a grayish, tenacious mucus. This condition 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 exten- sive, and may involve the periosteum of the vomer, thus producing necrosis. Cause.—The causes of this variety of catarrh are essentially the same as those which produce the hyper- trophic form, of which, iu most cases, it is a sequel. Syphilitic, scrofulous, or other specific taint of the system has, in my opinion, no direct influence upon the causa- tion of this form of nasal catarrh. Although we find 356 ATROPHIC NASAL CATARRH. scrofulous patients who are suffering 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 satis- factorily 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 physician, and the nasal douche used by the patient. The solutions should be alkaline, so as to dissolve the mucous more readily. It is best to use Dobell's or the alkaline anti- septic 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 : K.—Sodae bicarb. ^ Sodse bibor. / 3 J Listerinse fl £j. A quae q. s. ad Oij. This and the antiseptic solution are the only means of overcoming the fetid odor and making an examination of the nasal cavities possible without discomfort to the examiner. None of the other disinfectants, in my ex- perience, act as promptly and effectually as these solu- tions. If then any excoriations or ulcerations are seen, they should be touched with a sixty-grain solution of nitrate of silver, and if they are deep and extensive, it TREATMENT. 357 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. Pulv. amyli gr. 1 gr. 154. No. 2. R. —Arg. nit. Pulv. amyli gr- If gr. 154. No. 3. K —Arg. nit. Pulv. amyli gr- H-gr. 154. No. 4. B, —Arg. nit. Pulv. amyli gr- 3f. gr. 154. No. 5. H, —Arg. nit. Pulv. amyli gr. 7.]. gr. 154. No. 6. K.- —Arg. nit. Pulv. amyli gr. 15. gr. 154. These powders are applied iu the following manner: After the nasal mucous membrane has been thoroughly cleansed from all thickened secretion by a spray of anti- septic 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. Com- mencing with No. 1, the application is repeated every two or three days until the slight smarting caused by the particles of solid nitrate of silver is not noticed, when No. 2 should be used, and so on. Gottstein recommends that a plug of cotton be intro- duced 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, 16* 358 ATROPHIC NASAL CATARRH. however, but because the cotton irritates and stimulates the mucous membrane, and by becoming saturated with the watery secretion, imparts to the inspired air sufficient moisture to prevent the drying of the secretions and the formation of scabs, thus materially relieving the dryness of the pharynx. These cotton plugs can be made by twisting a piece of absorbent cotton around a steel knit- ting-needle, then withdrawing the needle and twisting the ends so as to prevent the unwinding of the cotton. These plugs should be worn by the patient continually, and he must, therefore, be taught to make and insert the plugs himself. Whenever they require renewal it is not difficult for patients to learn how to introduce the plugs into the proper place, but I have found great diffi- culty in teaching them to make the plugs always of the size and length required. This difficulty finally was overcome by making the plugs of different sizes, each size being determined by the weight of the cotton used in each plug. The ends are dipped into melted cocoa- butter, which prevents the untwisting, and they can thus be kept for any length of time. In this shape Messrs. John Ogden & Co., a drug firm in Philadelphia, have supplied me aud my patients with plugs which were eminently satisfactory. The cotton, before being twisted into plugs, may be medicated with varions stimu- lant and antiseptic drugs, such as menthol, thymol, boric acid, iodoform, carbolic acid, etc., as the indi- vidual case may require. 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 induced current of electricity, may be applied locally with good results. The general health should be looked after, and any TREATMENT. 359 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, petroleum, grindelia robusta, or any other drug which will stimulate the glands of the nasal mucous membrane, should be given internally. Petroleum seems to have a specific action upon the re- spiratory mucous membrane, and is best given in combi- nation with grindelia robusta. A formula which has given satisfaction is as follows : R.—Petroleum (crude) gr. ij. Ext. grindelia robusta insp. gr. xv. M. et div. in pil. no. i. To be filled in gelatine capsules. With the best and most faithfully carried out treat- ment 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 eveu in a short time as not to annoy the patient. This is especially true of the bad odor, which cau be entirely relieved by thor- oughly washing out the nasal cavities and removing all the collections of mucus. If, however, the odor persists after thorough cleansing, which happens in a few cases, then the disease must be looked for iu the contiguous cavities, the antrum, the frontal sinuses, or sphenoidal cells, and these must be opened and washed out with disinfectant 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 or another of these contiguous cavities. When necrosis of either the vomer or of the turbinated bones is found, the surface must be thoroughly scraped, which is best done with the burr of the dental engine, as 360 ATROPHIC NASAL CATARRH. with the scraper the necessary pressure cannot be brought to bear upon the parts, and, furthermore, there is hardly euough 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 aud the tool comes in contact with the harder sound osseous tissue. Syphilitic Catarrh. Both the secondary and tertiary manifestations of syphilis are found in the nasal cavities as inflammation, 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, dif- ferent 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 ob- struction of the nasal cavities and prevent nasal respira- SYPHILITIC CATARRH. 361 tion, 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 circumstances, 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 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 mani- festations are so much like those of syphilis that it be- comes exceedingly difficult to recognize the disease. We find, however, usually an involvement of the skin, either at the time or soon after the disease shows itself in the nasal cavities, aud 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 satisfaction than any othffer topical application. 362 TUMORS IN THE NASAL CAVITIES. CHAPTER XVIII. NEOPLASMS, RHINOLITHS, AND FOREIGN BODIES IN THE NASAL CAVITIES. The subject of tumors and neoplasms in the nasal cavities is one of great interest, and at the same time a very difficult one to intelligently discuss in a short chapter. The neoplasms which occur within the nasal cavities are divided, for the sake of convenience of description as well as clearness of understanding, into two large classes, considered from the standpoint of the clinician. These classes are, first, the benign tumors, which, clini- cally speaking, do not produce death by metastasis; aud secondly, the cancerous tumors, which latter are again divided histologically into the connective-tissue, or sar- comatous, and the epithelial, or carcinomatous, tumors. General Etiology.—The peculiar anatomical relation- ship of the parts, the still more peculiar histological structure of the soft tissues within the nasal oavities, and also the unusual distribution of glands and blood- vessels, together with the physiological functions of the orgau, must be remembered, in order to appreciate fully the special peculiarities of intra-nasal neoplasms—the reason why some, which are most common in other parts of the respiratory tract, are seldom found in the nose, while on the other hand some of those most commonly met with in the nose are hardly ever seen in other parts of the body. POLYPI. 363 For instance, there are but few cases on record in the literature of intra-nasal papillomata, while warty growths are the most common kind of neoplasms in the larynx. And, on the other hand, where, except occasionally in the vagina, do we meet with a mucoid polypus ? which is the most common form of intra-nasal neoplasm. Polypi. The most common form of intra-nasal neoplasms observed is that form usually termed polypus. Its name, which is derived from the Greek, meaning many- footed, aud which has been applied to certain marine and fresh-water mollusks, indicates that the earliest observers, who gave the name to this neoplasm, were not familiar with either its histology or its etiology, and named it so merely from its resemblance to the trans- lucent mollusk, and from its tendency to recur after apparent total removal. Clinically, as well as from a histological and patho- logical point of view, we must recognize three distinct varieties of this benign neoplasm. Although Zucker- kandl gives five different forms, yet I am in harmony with Bosworth when he says " he [Zuckerkandl] goes beyond the field." The explanation of this apparent discrepancy lies in the fact that Zuckerkandl derived his knowledge from pathological specimens post-mortem, most of which had been for years preserved in alcohol, while Bosworth and others, among them the writer, arrived at their conclusions by clinical observations and microscopical examination of pathological specimens obtained by operations on living subjects. 364 TUMORS IN THE NASAL CAVITIES. Mucous Polypus. The first variety of polypus to be considered is the ordinary mucous polypus so frequently met with, and so easily recognized by its peculiar and characteristic Fig. 102. Vertical section through nasal cavity, showing nasal polypi. resemblance to a small oyster or mollusk. With the ordinary light employed in rhinoscopy, whether artificial or natural, it is seen to present a glistening surface of a pearl-gray or grayish-pink color, and, if not subjected to pressure by the adjacent parts, is of the form of a pear (Fig. 102). In many cases these neoplasms pro- MUCOUS POLYPUS. 365 trude from the nostrils, or hang down into the post- nasal or naso-pharyngeal cavity, and have the peculiar property of absorbing moisture from the atmosphere, so that their bulk is increased, and they protrude more in damp weather than when the atmosphere is dry. In other cases, of not as long standing, they will not be seen at the anterior or posterior orifices of the nasal cavities, but may, like other intra-nasal neoplasms, cause a swelling and lateral enlargement of the external nose. Very frequently they give rise to spontaneous epistaxis, as well as obstruction to nasal respiration, which, owing to the hygroscopic properties above mentioned, increases in damp weather; to loss of the sense of smell to a greater or less degree, and to the accumulation of a viscid, muco-purulent, sometimes sanguineous discharge, which oozes from the nostrils, as it cannot be blown out, and frequently excoriates the skin by its acridity. The usual symptoms due to obstruction of nasal respi- ration—viz., dryness of the pharynx, irritability of the laryngeal mucous membrane, and want of nasal vocal resonance, making the voice sound what is erroneously called nasal—are present to a greater or less extent in all cases. Etiology.—Mackenzie says that the etiology is quite unknown. Sajous attributes mucoid polypi to chronic inflammation of the Schneiderian membrane. Van Meckren quotes a case of polypi as caused by the intro- duction of a splinter of wood into the nasal mucous mem- brane, and Gerdy attributes their origin to fracture of the septum; while Woakes gives us perhaps the most plaus- ible theory of the causation and origin of nasal mucoid polypi, which I can indorse and fully accept, not only as 366 TUMORS IN THE NASAL CAVITIES. a theory, but as a fact demonstrated by clinical as well as pathological observation. In a few words, his theory is that in a long-standing chronic nasal catarrh of the hypertrophic variety it fre- quently happens that the middle turbinated bone returns to its embryonic condition ; that is to say, it becomes cleft into two portions, the two sides being parallel with each other, and the split in the bone running from before back- ward. (Fig. 103.) At first the inner aspects of these two portions of the bone are covered with the normal mucous membrane, which follows the cleaving and becomes thus invaginated in a manner similar to skin found within a dermoid cyst. Gradually, by the pressure cutting off the proper blood-supply, and owiug to the retention and con- sequent putrefaction of the normal secretion, the mucous membrane within the cleft becomes ulcerated and the bone denuded. The necrosis of the bone, however, does not, as is generally the case, cause sequestration, but, owing to the peculiar cancellated structure of the turbinated bones, small spicules of bone are projected, and the natural process of repair by granulation, springing from the still unaffected portions of the mucous membrane, covers these spicules. The blood-supply not being suffi- cient, however, true mucous membrane is not formed, but in its stead a myxomatous structure accumulates around them, which by its gradual enlargement increases the space between the two portions of the middle turbi- nated bone to such au extent that finally these mucoid neoplasms come iu contact with the air-current, whereby their surface becomes hardened, the pressure is somewhat relieved, and the epithelium begins to grow on their sur- face. Of course the lower polypi, having more space to ex- MUCOUS POLYPUS. 367 pand, rapidly enlarge, while those in the upper portion of the cleft grow more slowly, but as they grow they also push (Fig. 102), by their expansion, the lower ones-into the respiratory portion of the nasal chambers, and thus the obstruction of the nose is gradually increased until total occlusion is accomplished. Fig. 103. Cleft middle turbinated bone. (Woakes.) The histological features presented by a section under the microscope are very simple, as we observe nothing but the epithelium on the surface, the large meshes of delicate connective-tissue fibres containing the mucus, and delicate capillaries in this network, without walls or endothelium. Near the base or pedicle of the polypus the bloodvessels are somewhat larger, and the connective- tissue fibres are collected in parallel strands which eman- ate from the periosteum of the spicules of bone. Occa- sionally we meet with open spaces in the centre of a section, which are lined with mucous membrane carrying on its surface (Fig. 104) ciliated epithelium and containing mucous glauds. The cause of the presence of these 368 TUMORS IN THE NASAL CAVITIES. spaces in the centre of the neoplasm is uncertain, but they may be accounted for by a coalescence of two ad- jacent polypi surrounding in their union a portion of still healthy nasal mucous membrane. We also some- times find clots of blood coagulated within the meshes of Fig. 104. 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. the connective-tissue network, due to a rupture of some of the blood-channels, causing an extravasation of blood into the myxomatous tissue. These clots are, as a rule, found near the surface of the neoplasms, and the spon- taneous epistaxis noticed in many cases of nasal polypi is probably due to a rupture of the surrounding membrane FIBROID POLYPUS. 369 of the neoplasm, allowing the extravasated blood to ooze out into the nasal cavities. Mucoid polypi are always multiple, occurring in large numbers in either or both anterior nasal cavities, and varying in size. Cohen says that the masses after removal occupy a larger space than it would seem possible they could have occupied iu the nose, and this may be ac- counted for by the fact that not being subjected to press- ure after removal allows them to swell to a much larger size by absorption of moisture from the atmosphere. Fibroid Polypus. The second variety, which, however, fortunately, is not nearly as common as the mucoid variety, is the Fig. 105. Fibrous polypus of the nose. View of the growth as seen by posterior rhinoscopy. (Mackenzie.) fibroid or fibrous polypus. It presents, on rhinoscopy both anterior and posterior, a mass within the nasal cavities of usually a glistening white or sometimes pinkish color, with bloodvessels of considerable size ramifying over its surface. To the touch, with a probe, or finger if near enough to the orifice to be thus reached, it feels hard and resisting. The mucus which exudes 370 TUMORS IN THE NASAL CAVITIES. from the nostril or nasal pharynx is of a viscid, trans- parent nature, not usually stained, as is the case in the mucoid variety. If the growth has existed for a con- siderable time, it may hang down into the naso-pharynx (Fig. 105), protrude from the nostril, and, as is sometimes the case, invade the adjacent cavities of the nose, such as the antrum, the sphenoidal cells, etc. The subjective symptoms to which this form of polypus gives rise, are somewhat different from those observed in the mucoid variety. For the reason that the mass is hard and unyielding, and not possessed of hygroscopic properties, and furthermore as it occurs usually on one side only and is of slow growth, all the symptoms come on gradually, one after the other. For this reason it is often impossible to determine with any degree of accu- racy the commencement of the trouble from the clinical history. The first symptom, as a rule, is obstruction to breathing in the affected side of the nose, which is fol- lowed by a gradually increasing diminution of nasal resonance. Supra-orbital and dental neuralgia are the next symptoms, which, like the nasal obstruction, are persistent and progressive. When the tumor has reached such a size that it com- pletely fills the anterior nasal cavity, it exerts an amount of pressure which first causes a deviation of the cartila- ginous plate of the septum, and, when that possibility of expansion has become exhausted, atrophy of the mucous membrane and necrosis of the lateral wall of the nasal chamber by pressure ensue, and the neoplasm makes its way into the adjacent cavities. If, on the other hand, the tumor expands backward, it gradually fills up the naso-pharyngeal cavity, depresses the soft palate, aud finally makes its appearance in the fauces. fibroid polypus. 371 Both the mucoid and fibroid variety of polypi, as well as the cystic variety, may be and often are mistaken for other nasal obstructions, such as deviation of the septum, middle hypertrophies, foreign bodies, and so forth, when rhinoscopy alone is used as a means of diagnosis. Therefore in all these cases the probe, as well as the finger, should be employed to test the consistency aud mobility of the tumor or obstruction, thus adding the sense of touch to that of sight, and enabling the observer to arrive at a definite conclusion as to its nature. Histologically, the fibroid variety differs greatly from the mucoid polypi, inasmuch as its structure consists of closely interwoven strands of white fibrous connective tissue, without any meshes, and without mere blood- channels, so that a solid mass of fibrous tissue is formed containing occasional mucous glands, and large ramify- ing bloodvessels, the walls of which are frequently canaliculized, preventing their contraction when cut. The firm attachment to the bed precludes the possibility of a spontaneous expulsion of a fibroid polypus ; yet at the same time we find in many cases the neoplasm to be lobulated, and a localized constriction of the neck of one of these lobules may cause a sloughing off of one of these buds, which then may be blown out, aud such cases have been recorded as spontaneous expulsion of fibroid polypi. The prognosis is, of course, a bad one if the tumor is not removed early, because of its persistent growth and the already mentioned destruction of the parts with which it is in contact, leading to necrosis of the bones and consequent septicaemia, as well as chronic menin- gitis. The external contour of the nose itself is also considerably changed by this pressure, and if the tumor has invaded the antrum the cheek-bone is bulged out- 372 TUMORS IN THE NASAL CAVITIES. ward, and the pressure upon the floor of the orbit causes also a bulging of the eyeball. Cystic Polypus. The third variety of nasal polypi is the so-called cystic variety, which, like the fibroid, is single, usually on one side only, but may occur together with the mucoid variety. The symptoms to which it gives rise are the same as those caused by the mucoid variety, and need not be further detailed. It is comparatively rare, the first case having been recorded by the author1 but a few years ago, and since then some twenty or thirty cases have been recorded in the current medical litera- ture. This neoplasm is nothing more than a delicate membrane covered with the epithelium found in the nasal cavities and filled with a straw-colored, sometimes sanguineous, serous fluid, which escapes, often spon- taneously, or when the membrane is pricked. But the sac rapidly fills again, and the relief from the obstruction to the nasal respiration is of short duration. It is somewhat difficult to understand the etiology of these cysts,- but they are probably merely retention cysts due to the obstruction of one of the serous glands of the nasal mucous membrane. Their usual situation is at the posterior portion of the lower edge of the middle turbinated bones, and their size is generally small, but they may assume such proportions that they make their appearance, like the fibroid variety, at the anterior nasal orifices, or in the naso-pharynx. As they are attached by a narrow pedicle, their removal with the cold snare is a comparatively simple and easy procedure. Archives of Laryngology, 1882. PAPILLOMATA. 373 Papillomata. The next form of benign growths found in the nasal cavities, springing as they do from the mucous mem- brane, are the papillomata, or warty growths. When we consider the histological structure of these growths, as well as that of the mucous membrane of the nose, it seems but natural that this class of benign neoplasms should be quite rare. Mackenzie reports only five cases of undoubted intra- nasal papillomata, and iu four of these polypi were present at the same time. He gives as the site in his five cases the mucous membrane covering the lower and anterior portion of the septum; in Zuckerkandl's case, the tumor was found on the lower turbinated bone, and in Hopmann's cases they were also found springing from the lower border of the lower turbinated bone. The cause of the growth of this variety of neoplasms is, of course, somewhat doubtful, but as papillomata of the mucous membrane in other portions of the body are, as a rule, due to localized irritation or inflammation, by analogy we must assign the same cause to intra-nasal papillomata, from whatever cause such localized inflam- mation may come. And the fact that the most frequent position of these neoplasms was found to be the lower and anterior portion of the septum and of the lower tur- binated bone, scratching with the finger-nail to remove small scabs, or the introduction of the twisted corner of a handkerchief into the nostril for a similar purpose, which is so frequently done by patients, may have been the cause of the localized inflammation of the parts. Erectile tumors, or angiomata, are also extremely rare, and the only cases recorded are by Verneuil, Wagner, 17 374 TUMORS IN THE NASAL CAVITIES. Steinbrugge, Seiler, Richer., Roe, Jarvis, Yanderpoel, and Burckhardt. Roe, in a comprehensive essay on this rare form of intra-nasal neoplasm, also mentions cases reported by N6laton, Huguier, Panas, Guyon, Dumenil, a second case by Richet, and one by Delavan. But a careful examination of the clinical features of all these cases as reported, leaves us but ten in all which Fig. 106. tissue. 3, 3. Caverns filled with blood. were undoubtedly angiomata, and from which number our knowledge of this rare form of intra-nasal neoplasm is derived. They are round, dark, sessile tumors, with regular smooth surface, swelling to the size of a cherry-stone, and are seen to pulsate synchronously with the heart. The only clinical difference between a tumor of this kind and an hypertrophy of the turbinated tissue is this pulsation, and histologically the difference consists in the fact that CHONDROMATA AND OSTEOMATA. 375 the meshes of the erectile tissue are in direct communica- tion with one of the larger arterial branches, and are therefore not venous sinuses, such as we find in the turbinated tissue. (Fig. 106.) This fact is of import- ance in the choice of the method for the removal of such a tumor, as the hemorrhage must necessarily be vastly greater after the removal of an erectile tumor than is the case after removal of an hypertrophy. CHONDROMATA AND OSTEOMATA. Chondromata, as well as osteomata, of the nose are of very rare occurrence, and although they both spring from the same structures, and, pathologically considered, are very closely related to each other, we must clinically consider them under separate heads, because of the difference in consistence and the difference in the rapidity of their growth. Mackenzie states that these cartilaginous tumors occur at an age near puberty, when cell-development is most active, and also makes mention of the fact that in all the cases described the growth sprang from the cartilaginous plate of the septum, and that it is more common in the male than in the female. The clinical features of these neoplasms very closely resemble those noticed in cases of fibroid polypi, and the differential diagnosis between a chondroma and a fibroid is frequently only possible by carefully noticing the difference in the elasticity and mobility of the two tumors. While the fibroid polypus, although hard and resisting to the pressure of the point of the probe, gives slightly, owing to its pedunculated attachment, the chon- droma, being sessile, will not yield, and a peculiar gritty 376 TUMORS IN THE NASAL CAVITIES. feel is imparted to the fingers holding the probe when the point of the latter is gently passed over the surface of the tumor. Another difference in the clinical features of the two is, that, owing to the immobility of the chondroma, the discharge which oozes from the nostrils is generally fetid, which fetor is produced by decomposition of the mucus, due to its retention. The external appearance on inspection with the rhinoscope shows a glistening white or pinkish tumor, with bloodvessels very much like the picture presented by a fibroid polypus. But the surface of the growth is not smooth and rounded, and resembles more the pock-marked cheek of a patient who has recovered from a severe attack of smallpox. The histological features are those common to all chondromata—viz., a solid mass of hyaline cartilage, which sometimes is seen to undergo cystic degeneration in the centre; or calcareous nodules may be found here and there, and finally centres of ossification may have started in various portions of the growth, more or less numerous according to the length of time it has existed. This mass of cartilage is surrounded by a thick sheath of white fibrous tissue, which in turn is covered by a thin mucous membrane devoid of glands. Osteomata, or osseous tumors, like cartilaginous tu- mors, are extremely rare. Cases have been reported by ancient writers, but they are doubtful; Follin1 seems to have been the first to give a good description and make a distinct differential diagnosis between osteomata and exostoses. These tumors do not spring from the osseous tissues of the nose, but are attached by a more or less 1 Traite 61em. de Pathologie externe, Paris, 1877, tome iii. p. 839 et seq. CHONDROMATA AND OSTEOMATA. 377 slender pedicle to the mucous membrane of either the septum or the turbinated bodies. Clinically they present a smooth pinkish surface which may in places be eroded or ulcerated, which ulcers or erosions are then surrounded by areolas of dark and even purplish color, and, if of long standing, exfoliation of sequestra of necrosed bone, together with the presence of the characteristic odor of decaying bone, may be noticed. Like the fibroid polypi and chondromata, the slow but persistent growth of the hard, unyielding bony mass produces deflection of the septum, and erosion of the walls of the nasal cavities, by pressure, and consequent distortion of the nose and disfigurement of the face. The pressure being by an absolutely unyielding sub- stance, the early symptoms, besides occlusion of the affected side, are first itching, and then sharp, lancinating pains of the face and head, and later anaesthesia, and even paralysis, when the tumor has destroyed the nerves as well as the bloodvessels supplying that part of the face. To the touch of the probe it feels hard and unyielding, and the sharpest needle caunot penetrate into its substance, as in the case of exostoses, nor will it break off particles of gritty substance, as is the case with rhinoliths. Histologically two varieties of osteomata are recog- nized, the eburnized or solid form, and the cancellated variety, which latter usually presents a hollow space in the centre. It may happen that a bony tumor of the nasal cavity is covered with calcareous accretion, when the differential diagnosis between it and a rhino- lith becomes almost impossible—except that a rhinolith rarely, if ever, causes neuralgic pain, or erosion of the walls of the nasal cavities. The removal of these 378 TUMORS IN THE NASAL CAVITIES. tumors, which may assume enormous dimensions, from the size of a cherry-stone to that of a hen's egg, can usually be accomplished through the natural openings by first severing the pedicle aud then delivering them with forceps, either through the post-nasal cavity, or, if not too large, through the nostrils. Malignant Neoplasms. Malignant tumors in the nasal cavity have been men- tioned by ancient and mediaeval medical writers, but the differential diagnosis, owing to the absence of patho- logical data, makes many of the cases doubtful. The later records, however, show that malignant tumors of the nose are not of common occurrence; also that, if they do occur, they are usually primary, and that the sarco- mata are much more common than carcinomata and epitheliomata. The malignant tumors usually spring from the septum, although instances have been recorded in which they had their origin from the turbinated bones and the floor of the nasal cavities. Like the fibroid polypi, they are generally on one side, and single. They are attached by a broad base, are soft to the touch, bleed readily, and at an advanced stage of their growth are prone to ulcerate. Their color varies from a light pink, through the dif- ferent shades of red, to purple, and even black, if of the melanotic variety. The first appearance—which is, however, but rarely noticed—is that of a small pimple or flattened elevation of the mucous membrane. They grow more or less rapidly, and may assume enormous proportions. The clinical features to which they give rise are the same MALIGNANT NEOPLASMS. 379 as those referred to in the description of the symptoms produced by the fibroid polypi, with the exception that the discharge is of a greenish color, fetid, but without the characteristic odor of necrosed bone and without the frequent epistaxis. As in other portions of the body, malignant tumors of the nose give rise to the peculiar intermittent lanci- nating pain so pathognomonic of cancer. In the later stages the glands of the neck become enlarged and hard, aud metastasis may take place in other parts of the body. Cachexia soon ensues, and death supervenes usually within eighteen months from the time that the first symptom was noticed. The prognosis, of course, is extremely bad—iu fact, hopeless—and surgical interference, unless early insti- tuted, or when absolutely necessary for the comfort of the patient, is not indicated, as the experience has proved that these neoplasms grow much more rapidly and cachexia sets in much earlier after attempts at removal of the growth. Treatment.—The treatment of nasal tumors consists in their removal, aud it becomes a question, which of the different methods is to be used to accomplish this pur- pose. 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 for- ceps, slightly curved, with elongated fenestrated blades, the inner surfaces of which are ribbed, to afford a better hold upon the tumor. 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 380 TUMORS IN THE NASAL CAVITIES. 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 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 contact with the congested mucous membrane, injuring it and giving rise to hemorrhage; further, the pedicle of the tumor is but rarely removed, so that the polypus speedily grows again, or, if it comes away, a shred of the mucous mem- brane to which it adheres is also torn away, giving rise to a great deal of pain and considerable hemorrhage; and finally the irritation and injury of the mucous mem- brane give rise to considerable and extensive inflamma- tion, which sometimes assumes alarming proportions. A number of surgeons, before the introduction of the modern methods of intra-nasal surgery, were in the habit of removing the whole turbinated bone, together with the polypi, in order to prevent a recurrence, but fortunately such a barbarous mutilation has gone out of fashion. A still more barbarous, unscientific, and unjusti- fiable method of operating has been practised by a noted surgeon of this country, which consists in laying open the nose from without by incision through the skin of the face, and scraping the exposed nasal cavity with a sharp curette, thus removing all vestige of mucoid polypi and mucous membrane. The external operation is only admissible and justifiable in cases of neoplasms of the nasal cavities in which the tumor is too large to be sur- rounded, through the natural openings, by the loop either of the galvano-cautery or the cold snare. Another method for the removal of nasal tumors has MALIGNANT NEOPLASMS. 381 been recommended by some authors, which consists in injecting into their substance, by means of a hypoder- matic syringe, some solution or liquid, such as glacial acetic acid, tincture of iodine, alcohol, etc., with a view to cause mortification of the tissues of which the tumor is composed. 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 solution is made so weak as not to give rise to much pain, the neoplasm is not affected by it. The method which is preferable to any other, consists in removing the polypi or soft neoplasms with a wire snare in the following manner. The nostril being dilated with a dilator, the cavity brightly illuminated, and the mucous membraue anaesthetized with cocaine solution, the Jarvis snare is introduced, and the loop manipulated so that the tumor in view is encircled by it, and slips around it. The wire should be of a 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 tightly grasped the tumor is snared off by turning the milled nut. Iu a few seconds the neoplasm, cut off close to the mucous membrane, and without the latter being in the least torn or injured, will come out held at the end of the canula; consequently very little pain is experienced by the patient, and little, if any, hemor- rhage follows the operation. One after another, in the case of 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. The Jarvis snare in its original form is the best instrument for this purpose, because it can be manipulated with one hand, 17* 382 TUMORS IN THE NASAL CAVITIES. and the polypus can be encircled with the wire loop without changing the direction or position of the instru- ment itself, which is impossible when the milled head has to be turned with the other hand ; this change of position of the instrument almost invariably causes the polypus to slip out of the loop. It is well, therefore, for the operator to make sure that the milled head on the screw turns so easily and accurately that a simple touch with the finger will cause it to run the whole length of the screw. None of the other snares sold by instrument- makers have this advantage, aud, as they are mostly theoretical improvements, they are practically valueless. It is no advantage to have the instrument bent, or the handle at an angle for the purpose of preventing the Fig. 107. Double hook. hand holding it from obstructing the view, as iu the Wilde suare, nor is it necessary or advantageous that the snare should be thick and heavy ; on the contrary, the lighter and thinner the better, provided the tube is made of steel, so that the piano-wire cannot split it when the loop happens to be around a spicule of bone, as is likely to happen when the instrument is made of brass or German-silver. Having accomplished this, every bleed- ing-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. Sometimes the growths are attached high up between MALIGNANT NEOPLASMS. 383 the turbinated bones, so that it becomes impossible 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 eud 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 double hook (Fig. 107), 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. Iu using this instru- ment the canula is pushed down so as to expose the hooks ; these are pressed against the presenting portion 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 poly- pus without support, and the wire loop of the snare can be introduced arouud it and the polypus. If the instru- ment, which has been named a " Devil," is to be re- moved 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 384 TUMORS IN THE NASAL CAVITIES. 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 for- ceps answer the purpose better than the ordinary polypus forceps, because it can be 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, as in the case of fibrous polypi, the neoplasm has pene- trated 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 hypertrophies. 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 removal 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. Foreign Bodies. Foreign bodies are not infrequently met with in the nasal cavities, and according to their situation, and the FOREIGN BODIES. 385 length of time during which they have remained within the nose, give rise to a group of symptoms which often closely resemble those produced by neoplasms. The different foreign bodies are introduced into the nasal cavities either through the nostrils, usually by children and insane persons, or through the naso-pharynx in the act of vomiting or choking ; or thirdly, through the ex- ternal integuments; finally, by growth and development, as in the case of maggots. Of course, the first class is the most common, and the instauces met with by every physician are usually of so little import, that in the general literature and the text-books of medicine the subject is treated very lightly. At the same time the specialist meets with cases which are much more grave, and present features which are not usually seen in those cases iu which the foreign body has remained within the nasal cavity but a short time. The different articles which have been found as foreign bodies are of various kinds, such as shoe-buttons, pieces of wood, small pebbles, beads, beans, peas, paper, allspice, cotton, etc. Usually they are seen to lodge in the lower and anterior portion of the nasal cavity im- mediately beyond the vestibule, but they may also be found further back in the lower meatus, being carried there by the air current in forcible inspiration, or " sniffing;" or they may even lodge in the middle meatus, or be wedged in between the middle turbinated bone aud the septum. The immediate symptoms are nasal obstruction and sneezing, whereby the foreign body in a majority of cases is spontaneously expelled. If this expulsion does not occur, and the foreign body remains, its contact with the mucous membrane gives rise to an acute in- 386 FOREIGN BODIES. flammation, which in no way differs in its symptoms from the ordinary acute coryza, which does not sponta- neously resolve itself within a few days, and persists for weeks aud even months, until finally the mucous membrane becomes tolerant to the presence of the foreign body, and only the ordinary symptoms of chronic hypertrophic rhinitis may supervene. In this way only can we explain the possibility of a foreign body being retained within the nasal cavity for years, as in instauces recorded by Renard,1 Boyer,2 Bosworth,3 Mackenzie,4 and others, and in an interesting paper by Bron.5 Generally, however, a foreign body very speedily gives rise to an ulcerative process of the mucous mem- braue, with pain in the forehead and cheek, paroxysms of sneezing, yellow or sanguineous discharge sometimes mixed with white, cheesy flocculent masses, which Bos- worth6 believes to be cheesy degeneration of inspissated mucus, and that they are characteristic. The breath becomes extremely fetid, the sense of smell is lost, and the voice becomes nasal. As the swelling of the mucous membrane extends to the other side of the nose, and into the naso-pharynx, the hearing becomes affected by obstruction of the orifices of the Eustachian tubes. On inspection by aid of the proper instruments, the foreign body can usually not at first be seen, because it is covered with muco-purulent discharge, and because the 1 Journ. de Medecine, t. xv. p. 525. 2 Traite des Malad. Chirurg. Paris, 1846, t. v. p. 65. 3 Op. cit., p. 321 et seq. 4 Op. cit., p. 432 et seq. 5 Gazette MSdicale de Lyon, 1867, No. 36. 6 Op. cit., p. 323. FOREIGN BODIES. 387 tumefaction of the turbinated tissue in front of the foreign body is so great as to obstruct the view. Only after thorough cleansing with an alkaline wash in the form of a spray, and the introduction of a pledget of cotton saturated with a four per cent, solution of cocaine, for the purpose of temporarily reducing the swelling of the turbinated tissue, can the foreign body be seen, and its nature and location determined. But even then it is not always possible to make a correct diagnosis even with the aid of the probe, because hard substances, such as shoe-buttons, pebbles, etc., are often incrusted with calcareous deposit, and may then be mistaken for a rhinolith, while soft substances, and more particularly seeds of plants, have become swelled and distorted, and may even sprout, so that they can easily be mistaken for polypi or malignant neoplasms. The second class of foreign bodies, which usually lodge in the posterior portion of the nasal cavity, are, as a rule, composed of particles of food, aud are thrown into the naso-pharyngeal cavity in the act of vomiting, or they may also be substances accidentally inhaled into the larynx and propelled into the nose by the spasmodic cough due to the irritation of the laryngeal mucous membrane, and this accident is favored by partial or complete paralysis of the soft palate. The irritation produced by the presence of the foreign body causes sneezing and forcible expiration through the nose, and if the body is small enough, as is the case when cherry- stones, pieces of bone, or similar substances have been vomited into the post-nasal cavity, they are likely to be forced into the anterior nasal chambers from behind, and find lodgment in the same localities in which we gener- ally see the foreign bodies introduced wilfully through 388 FOREIGN BODIES. the nostrils. In these instances the same symptoms and like appearances of the mucous membrane are observed as in the former type. On the other hand, when the foreign body thus intro- duced into the post-nasal cavity is too large to be pro- pelled by the air-current into the anterior nasal chamber, it is not likely to remain very long in its abnormal position. It sometimes, but rarely, happens that a tampon which has been introduced by the physician for the purpose of stopping epistaxis is wedged iu so tight that it is not dis- lodged together with the rest of the tampons, and may remain for a considerable length of time in situ. It there becomes discolored as well as covered by the secre- tions, aud may very easily be mistaken for either a small fibroid polypus or for a posterior hypertrophy. Sometimes it may happen that a foreign body is in- troduced into the nasal cavities, and retained there, through the skin or the bones of the face, or even through the alveolar process of the superior maxillary bone; thus spent musket-balls, shells, lead-pencils, points of knives or daggers, and even toothpicks and needles have been found within the nasal cavity. In all these cases there is naturally an exterior wound or cicatrix which marks the entrance aud method of entering of the foreign body into the nasal cavities, but these instances are extremely rare, and more curious than instructive, particularly as the subjective symptoms do not differ from those produced by foreign bodies intro- duced either through the nostrils or the posterior nares. A still more curious accident is the introduction of the eggs of the ordinary house-fly into the nostrils in south- ern climates. These eggs are deposited by the fly while RHINOLITHS. 389 the victim is asleep, and they develop with remarkable rapidity into maggots, which, crawling upward into the nasal cavities, give rise to the various symptoms already described, with the addition of formication, which is said to be so irritating that convulsions and death have oc- curred in a number of instances within a few hours after the development of the maggots. Rhinoliths. Rhinoliths, which are accumulations of the salts of the nasal secretion, are occasioually met with in the nasal cavities, and they act in a similar manner and give rise to the same symptoms as foreign bodies. They may be situated in any portion of the anterior nasal cavities, and some instances have been recorded in which they have penetrated into the soft tissues and were partly covered with mucous membrane. They are of various shapes and sizes, irregularly elongated, with a rough and spiculated surface, varying in color from a light gray to brown, and even black. The are hard and brittle to the touch, and, when seen in situ, are covered by muco-purulent discharge or scabs of desiccated mucus, which must be removed by washing before a definite diagnosis can be made. It is not known definitely what gives rise to the accretion of the salts forming the rhinolith, and the theory that a foreigu body is invariably the exciting cause around which, as a nucleus, the calcareous material is deposited in layers, is not always borne out by fact. Instances are on record in which rhinoliths were found in both anterior nasal cavities, and iu a number of other cases the calculus, when broken, showed a hollow centre. 390 RHINOLITHS. It is more probable that the nucleus is a dry scab of mucus, and the altered secretion, in a case of atrophic rhinitis, is more likely to undergo calcareous change than is the superabundant secretion from the actively inflamed mucous membrane irritated by a foreign body. The suggestion made that the calcareous deposit in the shape of a rhinolith is due to a gouty diathesis, is not borne out by clinical observation nor by an analysis of the recorded cases. A differential diagnosis, as already suggested, is easily made, because small portions of the surface can be broken off with the point of a needle, and this* fact, together with the peculiar hard and metallic sound which is emitted when the calculus is tapped with the probe, at once distinguishes it from an oste- oma, the only neoplasm for which it could possibly be mistaken. Treatment.—Very little need be said about the treat- ment, because obviously the only course to pursue in cases of foreign bodies or rhinoliths, is to remove the offending substauce and treat the inflammation of the mucous membrane as described in the foregoing chap- ters. The removal of the foreign body should always be undertaken with the aid of the rhinoscope, and under no circumstances is a surgeon justified in groping in the dark with either forceps, probe, hook, or other instru- ment. The method of removal, and the selection of instruments best adapted for the purpose, must be left to the good judgment and mechanical skill of the oper- ator, because no two cases are ever exactly alike; the physician must adapt himself to the circumstances, and make the best use of such instruments as may be at hand. GALVANO-PUNCTURE. 391 Galvano-puncture . There is another method of treatment for the removal of tumors, both in the larynx and in the nasal cavities, which frequently promises success where the other methods already described cannot be employed, 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 absorp- tion. 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 bat- tery, while the other pole is in contact with the skin in the neighborhood 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 electrolytic action. 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. 392 TABLES OF SYMPTOMS. CHAPTER XIX. 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 University Hospital. It will be observed that secondary and tertiary syphi- litic 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 in- cluded, while those which are to be regarded as symp- toms of general systemic disorders have been omitted. Table of Symptoms of Diseases of the Larynx. Acute laryngitis. Hoarse, sometimes aphonic. Not embarrassed except when oedema is pres- ent, then dysp- noea. Dry and hard ; later moist. Usually painful. Feeling of con- striction and acute pain. Chronic laryngitis. Tubercular laryngitis. Syphilitic laryngitis. Benign growths. Hoarse; falter- ing ; easily fatigued. Not embar- rassed. Hacking, with starchy ex- pectoration. Not interfered with. Feeling of ful- ness. Hoarseness of pe- | Hoarse ; seldom culiar character; aphonic. aphonic in later Variable, from slight hoarse- ness to aph- onia. Hurried, embar- Not usually em- Embarrassment rassed in later barrassed. depends upon situation of growth. Painful; amount Slight hacking. Xot severe ; oc- and character i casional ex- depending upon i ' pectoration of the lung impii- j parts of cation. growth. Difficult and pain- ful. Only in degluti- tion and phona- tion. Unimpaired, un- ! Impaired when less epiglottis or growth issitu- arytenoids are ated ou epi- ulcerated. glottis or ary- epiglottic fold. Absent. Absent. Malignant growths. Functional Quickened and paroxysmal. Not severe; oc- casional ex- pectoration of parts of growth. Difficult and painful. Severe. Aphonic in bi- lateral paraly- sis. Hoarse in other forms of paralysis. Embarrassed in paralysis of ab- ductors. Paroxysmal in spasmodic af- fections. Not generally iiffected. Not usually present. „. CO Symptoms. Acute laryngitis. Chronic laryngitis. Tubercular laryngitis. Syphilitic laryngitis. Benign growths. Malignant growths. Functional diseases. CO 4-. Physical : ' Color, Uniformly intense red. Partially in-creased. Grayish-red. Dark-red in sym-metrical patches. Variable with nature of the growth. Bivid. Normal. i-3 Form and texture, Swelling in oede-ma. Abrasions. Swelling of mu-cous membrane, ulcers, and pyri-form swelling of arytenoid carti-lages. Ulcerations and specific neo-plasms. Variable ; no ulcers. Depends upon size and na-ture of the growth; large ulcers. Form of glottis changed. f CO O Position, Unaltered. Unaltered. Usually no dis-placement. Unaltered except when changed by cicatrices of ulcers. Normal parts seldom changed. Displacement by infiltration. No displace-ment. CO External, Pharynx impli-cated. Pharynx impli-cated. Pharynx involv-ed ; physical signs of lung disease. Pharynx, velum, and skin impli-cated. None. Glands impli-cated ; cancer-ous cachexia. Other organs may be af-fected. H O 02 Cause, Exposure to draught. Em-bedded foreign bodies or corro-sive substances. Impure air ; abuse of voice. Same as of lung affection. Primary sore. Uncertain. Primary cancer in other parts. Cerebral dis-ease, hysteria, acute and chronic laryn-gitis. Prognosis. Favorable except iu oedema. Favorable. Unfavorable. Favorable. Depends upon size and posi-tion of growth. Unfavorable. Favorable when cerebral dis-ease is absent. Table of Symptoms of Diseases of the Naso-pharynx, Symptoms. aii.iEcxiVK : Voice, Acute pharyngitis. Usually hoarse, with thick artic- ulations. Respiration, Not interfered with except when tonsils are touching each other. Cough, Hacking moist. Deglutition, Difficult and pain- ful if tonsils and glands are impli- cated. Pain, Severe lancinat- ing. Chronic pharyngitis. Normal, unless larynx is im- plicated, then hoarse and easily fatigued Not interfered with. Dry, but slight, white, stringy expectoration. Sense of dryness and burning. Syphilitic pharyngitis Granular pharyngitis. Normal,orslightly Usually hoarse hoarse. Articu-, from laryngeal latiou nasal if velum or uvula is ulcerated. implication. Articulation normal. Not affected. Often severe and dry, with little expectoration. Difficult according! Not affected, to position of ulcers. Usually absent. Sense of dryr and fulness. Tonsillitis. Nasal polypi. Nasal catarrh. Normal; articu- Normal; articu- Normal; articu- lation thick. | lation nasal. lation more or less nasal. Affected only in Respiration severe cases. through nose more or less obstructed. Slight. Almost impossi- ble, and very painful. Usually absent. Respiration through nose affected, espe- cially in re- cumbent posi- tion. Slight, with ex- pectoration of thick tenacious mucus. Not affected. Fron tal head- ache, sense of dryness in nose and pharynx. 1-3 > a f w CO O *1 CO Kj B ITJ i-3 O « CO CO CO Symptoms. Acute pharyngitis. ■r, Chronic pharyngitis. Syphilitic pharyngitis. Granular pharyngitis. Tonsillitis. Nasal polypi. Nasal catarrh. Physical : Color, General redness of mucous mem-brane. Generally diminished with promi-nent veins. Brick-red. Sym-metrical patches. Usually paler than normal. Tonsils appear livid. General hyper-semia of nasal mucous mem-brane. Redder than normal. Form and texture, Not changed. Mucous mem-brane dry and shining. More or less deep ulcers on phar-ynx, velum, and tonsils. Red nodules and prominent veins on surface of pharynx re-sembling granu-lation. Great tumefac-tion of the glands. Depends upon character of polypus. Tumefaction of mucous mem-brane. Hyper-trophies ; shal-low ulcers. External, Larynx impli-cated. None. Skin implicated. None. Implication of cervical and submaxillary glands. Stoppage of nose; dryness of mouth and pharynx ; bleeding from nose. Stoppage of nose, often wa-tery discharge; slight depres-sion and wide-ning of bridge of nose. Cause, Exposure to cold. Bad air, alco-holism, mas-turbation. Primary sore. Abuse of voice ; gastric derange-ment. Exposure to cold. Uncertain. Vitiated air and changeable climate. Prognosis, Favorable. Favorable. Favorable. Favorable. Favorable in most cases. Favorable. Favorable. CO CO OS INDEX. Ablation of adenoid tissue of pharynx, 260, 323 of anterior and middle hyper- trophies, 306 of ecchondroses of septum, 333 of posterior hypertrophies, 319 Abortive treatment of coryza, 268 Abrasions in chronic laryngitis, 159, 182 method of touching, 163, 164 in pharyngitis, 159 production of, 159 Abscess, 169 postpharyngeal, 238 Acacia, 164, 267 Accent, 111 Acid, acetic, 165, 305, 352 benzoic, 161, 236 boric, 358 carbolic, 161,179, 201, 268,358 carbonic, 179,235 chromic, 165, 201,305 hydrochloric, 201 lactic, 165, 196 nitrate of mercury, 165, 201, 361 nitric, 201, 352 osmic, 266 phosphoric. 353 tannic, 160, 169, 178, 236 Acne as a result of catarrh, 295 causes of, 295 punctata, 295 rosacea, 295 Aconite, 268 Acoustics, 101, 102,103 Acute laryngitis, 170, 179 idiopathic, 172 cedematous, 171, 179 prevention, 204 simple, 170, 176 symptoms, 171 traumatic, 171, 223 Acute laryngitis, treatment, 173, 174 pharyngitis, 231, 232 duration, 234 prevention, 237 symptoms, 237 traumatic, 237 treatment, 235 tonsillitis, 233, 247 Adams's forceps, 326 Adenoid tissue of pharynx, 260 growths, 323 method of removing, 323 ablation of, 260, 323 Adenoma, 229 Administration of remedies, 161 Affections, nervous, of larynx, 169 Air-compressors, 141 Air prepared for respiration by nasal cavities, 131 Alae of nose, 89 Alcohol, 300 Alcoholic stimulants, 185 Alkaline solution as local applica- tion, 165 Allen, Harrison, 113, 167, 264 Alteratives, 161, 167 Alum, 160, 173, 236 American grippe, 276 Ammonium, muriate of, 147, 268 Amputation of tonsils, 249-253 of uvula, 243 Amyl nitrite, 169 Anassthesia of larynx, Eossbach's method, 231 local, by cocaine, 165 Anaesthetics, 165, 327 Anatomy of larynx, 64, 65 of nasal cavities, 84 Aneurism, cause of aphonia, 212 Angioma, 229, 373 Angular scissors, 340 Animal heat, 155 Anodynes, 202 18 398 IND EX. Anterior hypertrophies, 258, 291, 296 pathology, 259 treatment, 306 rhinoscopy, 54 Antiphlogistics, 278 Antipyretics contra-indicated in grippe, 180 Antiseptic pastiles, 166 solution, 267 Antiseptics, 201 Antispasmodics, 148 Antra of Highmore, 87 injured by nasal douche, 270 obstruction of, 370 Aphagia, 192 Aphonia, 172, 206, 207, 226 cause of, 206, 212 due to cicatricial contraction, 208 treatment of, 213 foreign bodies, 218 treatment of, 217-223 hysterical, 193, 210 paralytic, 210, 211 treatment of, 213 prognosis, 217 Applications, topical, method of making, 165-167 Applicator, cotton-, 136,183 Arteries of larynx, 78, 79 Articulate speech, 189 Articulation, 110 of cartilages of larynx, 70 Ary-epiglottic folds, 71, 81 ulceration of, accompanied by peculiar pain, 193 Aryteno-epiglottideus inferioris, 76 superioris, 76 Arytenoid cartilages, 67, 68, 72, 283 detachment of, in syphilis, 202 muscle, 72 muscular process of, 68 pyriform swelling of, in phthi- sis, 194, 195 variations in, 84 vocal process of, 68 Asphyxia from oedema of larynx, 179 from spasm accompanying neo- plasms, 231 Asthma dependent on nasal ob- struction, 294, 347 in chronic laryngitis, 192 hay, 345 Astringents, 160, 173, 178, 183 method of application of, 160, 163 Atomizers, 137, 139, 145 Burges', 140 disadvantages of metal and rubber, HO hard-rubber, 140 magic, 139 perfume, 139 steam, 145 substances not to be used in, 145 Atrophic nasal catarrh, 291 causes, 355 prognosis, 351 symptoms, 354 treatment, 356 Atropine, 351 Auto-laryngoscopy, 17, 52 importance of, to beginner, 53 Autumnal catarrh, 346 Avery, 16 Babbington,15 Bands, ventricular, 81 Barking cough in acute laryngitis, 177 Battery, galvano cautery, 310 storage, 313 universal, 312, 333 Baumes, 16 Beard, 345 Beecher, 203 Bellocque's canula, 342 Benign tumors, 227 Bennati, 16 Benzoate of soda in grippe, 180, 288 Benzoic acid, 161, 236 Benzoin, 236 tincture of, 173, 183, 268 Benzoinol, 161 Benzole, 161 Bicarbonate of sodium, 267 Bichloride of mercury, 168 Bifurcation of trachea, 83 Bigelow, 90 Bilateral paralysis, 210, 211 Biniodide of mercury, 168 Bismuth subnitrate, 267 Blackley,345 Blake, Prof. E. W., 113 Bleeding of nose, 294 Bloodvessels of larynx, 78 Bony obstruction of nose, 331 INDEX. 399 Bony obstruction of nose,treatment of, 333 Borated cotton, 322 Bosworth, 132, 263, 321, 345, 346, 363, 386 nasal dilator, 55, 338 Bougies. 205 Boulton's solution, 301 Boyer, 386 Bozzini, 14 Breathing, laryngeal image in, 82 Bresgen, 357 Bromide of ammonium, 196 of potash, 167, 241, 267 of sodium, 196, 351 Bromine salts, 196 Bron, 386 Browne, L., 270 Brush, laryngeal, 137 Bunsen cell, 391 Burges' air-compressor, 141 atomizer, 140 Burrs, 334 Burr shield, 334 Cachexia, 379 Calipers, nasal, 134 Calomel, 167 Cantharides, 169, 178 Canula, Bellocque's, 342 Carbolic acid, 235 Carbonic acid, 161, 179, 201, 236, 268 inhalation of, 202, 236 Carcinoma, 202 medullary, 229 Carcinomatous tumors, 362 ulcerations, 203 Caries of cervical vertebra as cause of traumatic acute pharyn- gitis, 238 of nasal bones, 354 Cartilages, articulation of, 71 arytenoid, 67, 68 cricoid, 67, 68, 83 necrosis of, 202 of Santorini, 68 of Seiler, 18, 82 of Wrisberg, 71 thyroid, 66 Catarrhal conjunctivitis, 295 ulcers, production of, 159 Catarrh, atrophic, 291, 334 chronic nasal, 291 hypertrophic, 291 Catarrh of middle ear, 295 simple chronic, 291 syphilitic, 360 Catching cold, 151 definition of, 156 preventives for, 157 Catheter, eustachian, 342 female, 342 Cauliflower growths, 228 Cause of atrophic catarrh, 355 of chronic nasal catarrh, 299, 300 laryngitis, 187 middle ear catarrh, 295 pharyngitis, 239 follicular, 196, 239 gastric, 239 granular, 239 of coryza, 266 of elongated uvula, 243 of hay cold, 348 of hypertrophic catarrh, 291 of paralysis, 212 of stenosis of larynx, 205 of tumors of nasal cavities, 362, 365 Caustic-holder, 150 Caustic, lunar, 162 Caustics, 165, 201 Caustique, porte-, 151 Cautery, actual, 305 galvano-, 165, 201, 252, 305, 352 Cavernous tissue of turbinated bones, 90 hypertrophied, 298 Cavity of larynx, 77 Champagne, 186 Chart, case, 98, 99 Chest registers, 188 Chiasm of recurrent laryngeal, 80 Chlorate of potash, 173, 178 Chloroform, 169 Chondromata, 375 clinical features, 375 histology of, 376 Chromic acid, 165, 201, 305 Chronic nasal catarrh, 290 middle ear catarrh, 295 hypertrophic rhinitis, 386 laryngitis, 181, 182, 187, 193 causes, 181 symptoms, 182 treatment, 183 pharyngitis, 239 simple catarrh, 291 400 INDEX. Chronic syphilitic laryngitis, 197 prognosis, 202 symptoms, 197 treatment, 200 pharyngitis, 239 symptoms, 239 treatment, 240, 241 tonsillitis, 169 traumatic laryngitis, 203, 204 expectoration in, 203 pharyngitis, 242 Cicatricial contraction, 205 adhesion, aphonia due to, 208 Cicatrization of vocal cords, 207 treatment, 209 Classification of laryngeal tumors, 227 Cleansing of mucous membrane, 166 importance of, 356 in atrophic catarrh, 356 in hypertrophic ca- tarrh, 301 Cleavage of middle turbinated body,261 Clergyman's sore-throat, 187 Coal oil preparations as emollients, 160 Coca erythroxylon, 216 wine of, 216 Cocaine, 165, 197 as an anaesthetic, 165 hydrochlorate, 165 strength of, 165 Cocoa-butter, 358 Cod-liver oil, 196,200, 242 Cohen, J. Solis, 25, 26, 238, 369 Cohen's tongue-depressor, 49, 50 Condyloma, 199 Conjunctivitis from nasal catarrh, 298 Consonants, 112, 119, 120, 121 self-sounding compound, 126 simple, 123, 125 tone borrowing, compound,129 simple, 127 Constrictor of glottis, 73 Copper, sulphate of, 160, 181, 301 Corditis vocalis, 176 Cornil, 255 Coryza, 265, 344 acute, 254, 257 causes, 266 pathology, 254 symptoms, 265 Coryza, treatment, 267, 268 Cotton-applicator, 136, 183 Cough, 183, 233, 239 barking, in acute laryngitis, 177 laryngeal, 184, 294 peculiar, in neoplasms, 226 in oedema, 177 Counter-irritation, 168, 178 Cramer's reflector, 22 Cricoid cartilage, 67, 83 Crico-arytenoid, 74 Crico-arytenoideus lateralis, 72 posticus, 67 Crico-thyroid membrane, 70 muscle, 72 Croton oil, 178 Crude petroleum, 359 Cubebs, 161, 167, 304, 359 Cultivation of voice, 189 Cupping, 178 mechanical cut-off, 143 Cystic polypi, 372 etiology of, 372 treatment, 372 tumors, 229 Czermak, 17, 18, 33 Daly, 345, 346 Dental engine, 332, 359 neuralgia, 325, 370 Deviation of septum, 264, 265, 272, 325, 329 pathology, 264 treatment, 325 Diagnosis of lupus, 361 of neoplasms, 227 of pharyngitis from diphthe- ria, 233 of syphilis in pharynx, 197 Dialect, 111 Diaphoretics, 278 Diet after amputation of tonsils, 253 in acute and subacute laryn- gitis, 181 pharyngitis, 235 in relation to heat production, 155 Dilators, nasal, 55 Diseases of the nasal cavities, 254 pathology of, 254 signs of specific, 200 Disorders of larynx, functional, 206 Diuretics, 278 Dobell's solution, 165, 356 Donders, 114 INDEX. 401 Double hook, 383 Douche, nasal, 269, 274 Drills, 334 twist, 334 Dry catarrh, 354 inhalations, 147 DuBois-Eaymond, 115 Dumenil, 374 Dunglison, 282 Duration of acute laryngitis, 173 pharyngitis, 234 of hay cold, 346 Dysphagia, 177, 180, 226, 230 paralytic, 294 Dyspnoea, 209, 231 in hypertrophied tonsils, 248 Ear cough,190 Ecchondrosis of septum, 261, 272, 297, 323 ablation of, 336 causes of, 262 method of removing, 323, 336 Eczema, 284 Edison, 30 Electric illuminator, Seiler's, 29 laryngoscope, 30 Jarvis's, 31 S. S. White's, 30 light, 28 motor, 333 Electricity, faradic, 185 galvanic, 311 in aphonia, 214 Electrode, laryngeal, 215 Mackenzie's, 215 Elephantiasis, 202 Elliotson, 345 Elongated uvula, 243 cause and treatment of, 244 Elsberg, 18, 51, 270 Elsberg's epiglottis forceps, 51 nasal dilators, 55 Emollients, coal oil preparations as, 160 Enteritis, 284 Epidemic myxoid oedema, 276 Epiglottidis, 176 Epiglottis, 68 forceps, 51 in acute pharyngitis, 234 ligaments of, 70 management of, 50, 51 muscles, 76, 77 I Epiglottis, oedema of, 172 pendent, 50 turban-like swelling of, in phthisis, 195 variations in shape, 84 Epistaxis, 365, 368 Epithelioma, 229 erosions, 355 Epithelium of nasal cavities, 88 Erectile tissue of nasal cavities, 89, 90 Erythroxylon coca, 216 Eschar, formation of, 308 Ether, 169 Ethereal oils, inhalations of, 161 Eustachian catheter, 342 tubes, 75, 91, 295, 355, 386 Eversion of ventricle, 227 Examination of patient, 95 Exostosis of palatine process, 333 treatment, 335 of septum, 333, 349, 376 treatment, 333 Expectorants, 184 Expectoration, 172, 180, 182, 192, 193, 203, 233, 239 Experiments in American grippe, 282 Fahnestock's tonsillotome, 250, 251 Falsetto voice, 188 Faradic electricity, 185 Farnham, 325 alligator forceps, :!40, 341 Fasciculated sarcoma, 229 Fauces, irritability of, 47 Fauvel, 177 Ferric alum, 301 Fever, definition of, 282 hay, 344 typhoid, 284 Fibro-cellular tumors, 228 Fibroma, 228 Fibrous polypi, 369 rhinoscopic appearance of, 369 Flaring septum, 330 Flemming, 309, 311 Fold, ary-epiglottic, 311 glosso-epiglottic, 83 Foliated growths, 228 Fly-blisters in oedema of larynx, 178 Follicular pharyngitis, 196, 239 Forceps, Adams', 306 402 INDEX. Forceps, Elsberg's epiglottic, 51 introduction of, 227 laryngeal, 220 polypus, 379 Steel's, 326 Foreign bodies, cause of aphonia, 218 in glosso-epiglottic folds, 219 in larynx, 133, 203, 21S as cause of acute trau- matic laryngitis, 171 in nasal cavities, 381 symptoms of, 385, 387 treatment of, 387 in nose, 133, 384 instruments for removal of, 220-223 Formula of Boulton's solution, 301 of antiseptic solution, 166 of compound chlorate of potash lozenges, 173 of cough mixture, 185 of Dobell's solution, 165 of iodine solutions, 303 of iron and potash mixture, 173 of nitrate of silver powders, 357 of tonic pills, 217 Frontal headache, 255, 265, 347 sinuses, 89 disease of, 359 in hay-cold, 347 injured by nasal douche, 270 obstructed in catarrh, 256 Functional disorders of larynx, 206 Gagging, how avoided, 47 Galvanic electricity, 311 Galvano-cautery, 165,201, 252, 305, 352 application of, to anterior and middle hypertrophies, 292 batteries, 306 knife, 205, 209 loop, 384 puncture, 391 Garcia, 17, 52 Gargles, 235 Gas brackets, 25 Mackenzie's, 25 Seiler's, 26 Gaslight, 24, 29 Gastric pharyngitis, 239 Gastric pharyngitis, cause, 239 symptoms, 239 treatment, 240 Gastritis, acute, 284 General therapeutics, 160-169 Gerdy, 365 Gibson's storage battery, 313 Glands, mucous, of nasal cavity, 90,91 serous, 91 thyroid, 80 Glandular tumors, 229 Glasgow, 280, 288, 294 Glosso - epiglottic fossae, foreign bodies in, 219 Glosso-epiglottic ligaments, 70, 83 Glottis, 81 constrictor of, 73 in phonation, 81 oedema of, 169 spasm of, 164 Glycerin as a solvent, 161 Goitre, a cause of aphonia, 212 Goodwillie's shielded burr, 335 Gordon, 345 Gottstein, 363, 257 Granular pharyngitis, 239 cause, 239 symptoms, 239 treatment, 240 Grindelia robusta, 359 Grippe, American, 180, 276-290 history of, 280 Growth, cauliflower, 228 cystic, 229 fibro-cellular, 228 fibroid, 228 foliated, 228 malignant, 227 mulberry, 228 raspberry, 228 vascular, 229 Guaiacum tincture, 169, 236 Guillotine, 222 Gummata, 199, 240, 360 Guyon,374 Haemoptysis, simulated, 299 Hand air compressor, 144 Hard-rubber atomizer, 140 Hay asthma, 345 cold, 344 coryza, 344, 354 fever, 344 etiology, 348 history, 345 INDEX. 403 Hay fever,hypersensitive areas, 349 prognosis, 353 symptoms, 346 treatment, 356 Headache, frontal, 255, 265, 347 Head-mirror, Fox's, 22 Head-reflector, 21, 38 Head-rest, 37 Heat, animal, 155 Helmholtz, 114 Hemorrhage, method of checking, 341 Henle, 88, 90 Highmore, antrum of, 89 History of American grippe, 280 of laryngology, 13 Hoarseness, 182, 192, 207 Hopmann, 373 Horse cold, 347 Huguier, 374 Hungarian wine, 185 Hydrochlorate, cocaine, 165 as an anaesthetic, 165 strength, 165 Hydrochloric acid, 201 Hydrogen peroxide, 236 Hyo-epiglottic ligament, 70 Hyoid bone, 68 Hyperplasia of vocal cords, 207 Hypersensitive areas in hay fever, 349 Hypertrophic nasal catarrh, 291 causes, 291 frequency, 292 stages, 291-293 surgical treatment, 305 symptoms, 291, 294 treatment, 301 rhinitis, chronic, 386 Hypertrophied cavernous tissue, 298 turbinated bone, 261, 272 treatment, 305 Hypertrophies, 258 anterior, 296 description of, 298 method of removing anterior and middle, 306 middle, 296 pathology. 254 posterior, 298 Hypertrophy of tonsils, 242, 243, 247 as an obstacle to laryngos- copy, 50 Hypertrophy of tonsils, oval mirror preferable in, 20 periodic acute inflamma- tion of, 248 pharyngeal, 298 symptoms, 247 treatment, 247-250 anterior nasal, 258, 291, 296 middle nasal, 258, 291, 296 pathology of, 259 posterior nasal, 258, 259 Hysterical aphonia, 193, 210 Ice-bag, 174 Idiopathic acute laryngitis, 172, 176 duration of, 173 symptoms of, 172 inflammation, 158 Idiosyncrasy, 347 Illumination, 20 by artificial light, 24 by direct light, 34 by reflected light, 21 by sunlight, 21, 32 by transparency, 33 management of, 37 Image of larynx, 80 of posterior nares, 93 Influenza, 276, 277 symptoms of, 277, 278 treatment of, 278, 279 Infra-glottic laryngoscopy, 54 Inhalation, 146 dry,147 of benzole, 161 of carbolic acid, 202 of ethereal oils, 161 of muriate of ammonium, 147 of nitrate of potassium, 147 of silver, 162 of powerful sedatives, 170 of vapor, 146 Inhaler, 147 for nascent ammonium chlo- ride, 147 universal, 148 Inhaling bottle, 146, 147 Injection of caustics into nasal polypi, 381 of iodine solution, 169, 302 Inspissated secretion, how to re- move, 167 Instruments accessory to laryngos- copy, 133 Insufflations, 160 404 INDEX. Insufflators, 148-150 Inter-arytenoid ulcerations, 196 Intra-nasal neoplasms, 133,362,374 benign tumors, 362 cancerous tumors, 362, 378 Introduction of laryngeal mirror, 39 of rhinoscopic mirror, 61 Intubation, 175 Inunction, mercury by, 168 Inversion of laryngeal image, 35 Iodide of iron, 359 of potassium, 167, 168 of sodium, 351 Iodine, 169, 302 injection in hypertrophied ton- sils, 169, 248 into nasal polypi, 381 method of applying, to naso- pharynx, 302 solutions, 303, 352 therapeutics of, 169, 302 tincture of, 169 Iodism, 241 Iodoform, how disguised, 163, 196, 358 therapeutics of, 163, 196, 201 Iron styptics, use of, in nose, 322 Irritability of fauces, 47 Irritation, counter-, 168, 178 Jacobson's organ, 89 Jarvis's method in operative rhino- scopy, 63, 374 nasal dilator, 55 self-retaining, 338 rhinoscopic mirror, 60 Seiler's modification, 60 snare, 315, 381 Seiler's attachment, 318 transfixing needles, 300, 317 Judd,346 Keen, W. W., 80 Kelly, Howard A., 191 Kline, 90 Knives, galvano-cautery, 252, 306 composition of, 21 guarded, 224 introduction of, 224 laryngeal, 224 open, 224 Labarraque's solution, 236 Lachrymation, 294 Lactic acid, 165, 196 Lamp-light, 21, 25 Lamp, Tobold's, 25 Cohen's modification, 25 Language, definition of, 110 Laryngeal brush, 137 cough, 184, 294 electrode, Mackenzie's, 215 mode of application, 215, 216 forceps, 220,221 introduction of, 221 guillotine, 221-223 image, 80 in breathing, 82 inversion of, 35 in vocalization, 82 knives, 224 guarded, 224 open, 224 lancet, 175, 209 mirror, 19 devices to prevent chill- ing, 38 glass, 19 introduction, 39 management, 42 reserved for specific cases, 199 steel, 20 testing temperature, 45 total reflecting prisms, 20 warming of, 46 probe, 226 sound, 134, 226 spasm from iodine in larynx, 302 from silver nitrate, 163 stammering, 101 tumors, classification of, 227 ulcers, 194 Laryngitis, acute, 170, 179 chronic, 170, 181, 182, 187 idiopathic, 172, 176 neurotic, 190 cedematous, 171 phthisica, 193, 194 traumatic, 171 tubercular, 193 uterine, reflex, 191 Laryngoscope, 13, 37 description, 13 history, 13 electric, 30 Jarvis's, 31 S. S. White's, 30 IND EX. 405 Laryngoscopy, 34 auto-, 17', 52 infra-glottic, 54 instruments accessory to, 133 obstacles to, 47, 50 optical principles of, 34 Laryngotomy, 209, 210 Larynx, 13, 20 anaesthesia of, 165, 169, 231 anatomy, 64, 65 applications to, 166 ary-epiglottic folds of, 81 bloodvessels, 78 cavity, 77 foreign bodies in, 133, 203, 218 functional disorders, 206 ligaments, 68, 69, 71 mucous membranes, 65, 78 muscles, 71, 80 nerves, 79, 80 oedema of, 174, 176, 177, 179 physiology of, 100 scarification, 178 spasm of, 163, 302 stenosis of, 205,207 superior aperture of, 77 tubercles in, 195 veins, 79 Lateral thyro-hyoid ligaments, 70 Law of reflection, 34 Leaden mallet, 338 Ledge on nasal septum, 262 treatment, 338 Leeches, 169, 178 Leveret, 14 Ligaments of epiglottis, 70 of larynx, 68, 69, 71 Light, artificial, 24 concentrators, 25 Mackenzie's, 26 Seiler's, 27 direct, 34 electric, 28, 33 oxy-hydrogen, 28 position of, 37 reflected, 21 source of, 24, 25 sun,21,32 yellow compared with white, 33 Lime-light, 28 -water, 204 Linear ulcers of cords, 208 Lipoma, 228 Listerine, 356 Liston, 16 Local anaesthesia, 165 Loss of smell, 294 Lozenges, 167, 184 compound chlorate of potash, 175 Lunar caustic, 162 Lupus, 202, 361 diagnosis, 361 treatment, 361 Luschka, 66, 67 Mackenzie, J. N., 344, 345 Sir Morell, 18, 20, 26, 27, 365, 373, 375 Mackenzie's larvngeal electrode, 215 method of applica- tion, 215, 216 forceps, 220 leaden mallet, 338 light-concentrator, 26 Magic atomizer, 139 Malignant neoplasms, 378 cause, 378 treatment, 379-384 tumors, 227 treatment, 227 Management of epiglottis, 50, 51 of illumination, 37 of laryngeal mirror, 42 of reflector, 38 of tongue, 39 Mathieu's tonsillotome, 250 Meatuses of nose, 86 Mechanical cut-off, 143 Mechanism of voice, 189 Medullary carcinoma, 229 Membrane, crico-thyroid, 70 Schneiderian, 365 thyro-hyoid, 68 Menthol, 358 Mercury, acid nitrate of, 165, 201 bichloride, 168 biniodide, 168 inunction in syphilis, 168 Method of making topical applica- tion, 167 of measuring wire loop of snare, 320 of plugging nasal cavity, 342 Microscopical appearance of larynx in phthisis, 195 of nasal hypertrophies, 258 of polypi, 367 Middle ear, 295 406 INDEX. Middle turbinated body, cleavage of, 261 Millers' asthma, or cold, 347 Mineral waters, 304 Mirror, introduction of, 39 Jarvis's electric, 32 laryngeal, 19 Wright's electric, 46 reflecting, 21, 38 rhinoscopic, 61 round glass, 20 Moore, 345 Morphia, 267, 351 Mountain air in chronic laryngitis, 186 Mouth-breathing, cause of chronic laryngitis, 182 Mucoid polypi, 261 Mucous glands, 93 membrane, cleansing of, 166 of larynx, 65, 78 normal color, 85 pathology of, 254 variations in, 88 of nasal cavities, 88 traumati c i n flam - mation of, 203 pathology of, 158 patches, 199, 200 polypi, 364 etiology of, 365 histology of, 367 microscopic appearance of, 364, 371 rhinoscopic appearance of, 364 Mulberry growth, 228 Muriate of ammonium, 147, 268 Muscles of epiglottis, 72, 76 of larynx, 81 of vocalization, paralysis of, 210 Muscular process of arytenoid car- tilage, 68 Mustard, 169, 358 Myrrh, 357 Myxoid (Edema, epidemic, 276 diagnosis, 284 duration, 285 symptoms, 281 Myxoma, 228 Myxomatous tissue, 368 Nasal calipers, 134 catarrh, atrophic, 354 hypertrophic, 291 al catarrh, simple chronic, 291 syphilitic, 360 cavities, anatomy of, 86 diseases of, 254 effects upon, of inspired air, 131 epithelium, 88 erectile tissue of, 89, 90 foreign bodies in, 362, 384 glands, 91 mucous membrane of, 88 color of, 88 nerves of, 91, 92 neoplasms in, 362 olfactory region of, 90 osmosis in, 90, 132 pathology, 254 physiology 130 plugging, method of, 326 respiratory region, 90 rhinoliths in, 362 sinuses connected with, 89 tumors, 363 dilators, 55 douche, 269, 274 forms of, 273, 274 precautions in use of, 270 use of, 273 gouge and chisel, 337 hypertrophies, 258 anterior, 258, 291, 296 microscopical section of, 258 middle, 258, 291, 296 obstruction, 182 pathology of, 254 posterior, 258, 291, 296 obstruction, cause of chronic laryngitis and pharyngitis, 182 plug, 326 saw (Fig. 99), 340 siphon, 274 specula, 56, 296 stenosis, cause of catarrh, 300 voice, 131 Naso-pharynx, 91 diseases of, 254 pathology of, 254 Necrosis of laryngeal cartilages, 202 of turbinated bones, 261 of vomer, 355 Neoplasms, laryngeal, 1S3, 205,363 benign, 199, 363 instruments for removal of, 224, 225 INDEX. 407 Neoplasms, laryngeal, malignant, 199 syphilitic, 199 Nerves of larynx, 79, 80 of nasal cavities, 91 supra-orbital, 161,162 Nervous affections of larynx, 169 Neuralgia, dental, 370 Nitrate of silver, 150,159,161, 169, 196, 198, 200, 201, 230 action of, 160 application of, 161 inhalation of, 162 powdered, 341 solid, 162, 200 solution, 183, 196, 197 strength of, 162 therapeutics, 161, 162 to be avoided in hyper- trophic catarrh, 287 Nitric acid, 201,289,305, 352 Nitrite of amyl, 169 Nose, bleeding, 294 bridge of, broadened in hyper- trophic catarrh, 295 reddened from catarrh, 295 Observer, obstacles to laryngo- scopy presented by, 47 Obstacles to laryngoscopy, 47 on part of observer, 47 on part of patient, 47 to posterior rhinoscopy, 62 (Edema of epiglottis, 172 of larynx,176,177, 179 symptoms, 177 treatment, 178 (Edematous laryngitis, 171 Offensive breath in atrophic ca- tarrh, 354 in disease of sinuses, 359 in hypertrophic catarrh, 294 peculiar, in syphilitic ul- ceration, 360 Ointments, 165 Olfactory region of nasal cavity, 90 Optical principles of laryngoscopy, 35 Osmic acid, cause of coryza, 266 Osmosis in nasal cavity. 90, 132 cause of pain, 89 Oxy-hydrogen light, 28 Ozaena, 273, 354 Painful vocalization, 208 Palate, 62 hook, 62 soft, paralysis of, 294, 387 Papilloma, 228, 373 etiology of. 373 Paralysis caused by aphonia, 210 of muscles of vocalization, 210 bilateral, 210, 211 causes, 212 hysterical, 210 soft palate, 294, 387 prognosis, 213 treatment, 213-218 unilateral, 211 Paste, Vienna, 305 Pathology of coryza, 266 of hypertrophies, 247 of mucous membranes, 158, 159 of nasal cavities, 254-265 of polypi, 363, 364 Peach cold, 347 Pendent epiglottis, 50 Perforation of septum, 335-340 of velum palati, 241 Perichondritis, 202 Periodic inflammation of hyper- trophied tonsils, 247, 248 Petroleum, 167, 359 Pharyngeal cutting forceps, 324 tonsil, 260 ablation of, 323 hypertrophy of, 247 Pharyngitis, 170 acute, 170, 232, 233 mistaken for diphtheria, 234 traumatic, 237 chronic, 239, 242 follicular, 196 treatment of, 196 gastric, 239 granular, 239 sicca, 355 specific, treatment of, 240, 241 syphilitic, 239 traumatic, 242 Pharynx, adenoid tissue of, 323 inspection of, 94, 95 physiology of, 133 vault of, 94, 95 Phoebus, 345 Phosphoric acid, 353 Phthisical laryngitis, 193,194 408 INDEX. Phthisical laryngitis, pyriform swelling of arytenoid cartilages in, 194 symptoms of, 193 Phthisis, 193, 194 Physiology of larynx, 100, 101 of nasal cavities, 130 of pharynx, 133 Pillars, adhesion of posterior, 238 in pharyngitis, 238 inspection of, 39 Pirrie, 345 Plugging nose, method of, 342, 343 Polypi, 363 etiology of, 365 forceps, 379 mucoid, 261, 364, 365 pathology, 362 symptoms, 365 treatment, 379 Pomum Adami, 66 Porte-caustique, 151 Position of light, 37 of patient and observer, 36 Posterior hypertrophy, 298 pathology, 292, 293 treatment, 205 rhinoscopy, 58 obstacles to. 62 Post-nasal syringe, 275 Post-pharyngeal abscess, 238 Potash, bromide of, 167, 241, 267 chlorate of, 178 iodide of, 167, 168, 359 Prevention of acute pharyngitis, 237 of catching cold, 157, 269 of sneezing, 267 Probe, 226 Production of abrasions, 159, 182 of catarrhal ulcers, 159 Prognosis of aphonia, 217 of atrophic catarrh, 359 of hay-cold, 353 of hypertrophic catarrh, 291, 292 of laryngeal tumors, 232 of malignant neoplasms, 379 of mucous polypus, 370 of paralysis of cords, 294 of syphilitic laryngitis, 198, 199 Purgatives, saline, 235 Pyriform swelling of arytenoid cartilages, 194, 195 Eanvier, 255 Easpberry growth, 228 Eecord of cases, 98, 99 Eeflection, law of, 34 Eeflector, 21, 38 attached to jointed arm, 38 concave, 21 Cramer's, 22 Fox's, 22 management of, 23 plane, 24 position of, 23 Semeleder's, 21 supported on head, 23, 28 Eeflex irritation, 184 laryngitis, uterine, 191 Eegisters of voice, 104, 187 Eemedies, administration of, 161- 169 Eemoval of foreign bodies, 219-223 Eenard, 386 Eeservoir insufflator, 149, 150 Eespiration, nasal obstruction of, 365 Respirator, 204 Rheostat, 314 Ehinoliths, 300, 362, 389, 390 caused by chronic nasal ca- tarrh, 300 Rhinoscopic image, 92, 93 in atrophic catarrh, 355 in first stage of hypertro- phic catarrh, 293 in second stage of hyper- trophic catarrh, 297 mirror, 59, 60 Jarvis's, 60 Seiler's modification, 60,61 Rhinoscopy, 54 anterior, 54 posterior, 57-60 examination of upper air- passages, 96 introduction of mirror in, 61, 95 method of examination in, 95 obstacles to, 62 Richardson, J. G., 271 Richet, 373 Rima glottidis, 78 in ordinary breathing, 78 Roberts, John, Dr., 327 Roe, 345, 346, 374 Roosa, 270 INDEX. 409 Rose-cold, 345, 346 Rossbach's method of anaesthetiz- ing the larynx, 231 Rostock, 345 Round-celled sarcoma, 229 Sacculus laryngis, 78 Sajous, 365 Saline purgatives, 235 Salt solution, 197 Santorini, cartilages of, 68 Sarcoma, fasciculated, 229 round-celled, 229 spindle celled, 229 Sarcomatous tumors, 362 Sass's atomizing tube, 137, 140 Scabs, 337 Scarification of larynx, 128 Schneiderian membrane, 365 Schuster kugel, 25 Scirrhous tonsils, 247 Scirrhus, 229 Scissors, 324 Scrofula, 337 Seashore, not suited for chronic laryngitis, 186 Secretions of mucous membrane altered by disease, 158 inspissated, how re- moved, 167 retention in nasal cav- ity, 354 Sedatives in nervous affections of larynx, 169 Seiler, angular scissors, 340 antiseptic solution, 166 pastilles, 166 attachment to Jarvis's snare, 318 cartilage knife, 336 cartilages of, 68 double hook, 38:: electric illuminator, 29 galvano-cautery battery, 310 handles, 307 knives, 307 gas bracket, 27 guillotine and tube-forceps, 222 inhaler, 148 nasal gouges and chisel, 337 pharyngeal cutting forceps, 324 plow-shaped knife, 338 reservoir insufflator, 149 universal battery, 312 uvula scissors, 246 Seiler, Mme. E., 18 Sellique, 16 Semeleder, 21, 264 mirror, 22, 23 Senn,15 Septometer, 134 Septum, deviation of, 265, 272, 325, 329, 370, 372 exostoses of, 272 flaring, 330 method of removing, 325, 339, 340 perforation of, 335-340 thickening, 327 Serous glands, 91 Sexual excitement as a cause of hay-fever, 347 Shallow ulcers, 197 Silver nitrate, 150, 159. 161, 169, 178, 200, 201, 230, 236, 356 action of, 160-162 application of, 161 so'id, 200 strength of solution, 161 Simple chronic catarrh, 291 Simulated haemoptysis, 299 Sinus, frontal, 89 Siphon, nasal douche, 274 Sirop, Gibert, 168 Smell, loss of, 294 Smith, Albert, 345 Snoring in hypertrophied tonsils, 248 Snow-cold, 347 Sodium benzoate in grippe, 180, 288 bicarbonate in grippe, 267 bromide, 196 Solution, alkaline, as local applica- tion, 165 antiseptic, 356 benzoate of soda, 288 Boulton's, 301 cocaine, 279 Dobell's, 165, 356 Labarraque's, 236 of iodine, 303 of nitrate of silver, 161, 279 of salt, 162, 204 Solvent, glycerin as, 161 Sore-throat, 233 clergyman's, 187 Sound, laryngeal, 134, 226 Sounding, 134 Source of light, 24 Spasm of glottis, 164 410 INDEX. Spasm, reflex, of larynx, 302 Speaker's sore-throat, 187 Specific chronic pharyngitis, 239 symptoms, 239 treatment, 241, 246 disease, signs of, 200 Specula, nasal, 56, 296 Sphenoidal cells, disease of, 370 Spindle cell sarcoma, 229 Sponge-holder, 135 Spunk,322 Stage fright, 216, 217 Steam atomizers, 145 Steel laryngeal mirrors, 20 Steel, Dr., 325 Steel's forceps for deviated septum, 326 Steinbriigge, 374 Stenosis of larynx, 205, 207 of nasal cavity, 298, 300 diet in, 181 caused by hypertro- phies, 305 Stirling's rheostat, 314 Stoerk's guillotine and tube-for- ceps, 221 universal handle, 221, 224 Strychnine, 216 Styptics, use of, in nose, 322 Subacute laryngitis, 180 diet in, 181 symptoms of, 180 treatment of, 180 Sub-glottic cavity, 172 Sulphate of copper, 161, 181, 301 of iron, 301, 358 of morphia, 267 of quinine, 358 of zinc, 160, 181, 183, 301 Summer catarrh, 345 Sunlight, 21, 32 Supra-orbital neuralgia, 370 Surgical treatment of hypertrophic catarrh, 305 Swelling, pyriform, of arytenoid cartilage, 194, 195 turban-like, 195 Symmetry in syphilitic inflamma- tions, 199 Symptoms of acute laryngitis, 172 pharyngitis, 233 of American grippe, 281 of atrophic catarrh, 354 of chronic laryngitis, 182 pharyngitis, 239 of coryza, 265, 266 Symptoms of elongated uvula, 243 of hay-fever, 346 of hypertrophic catarrh, 291 of hypertrophied tonsils, 247 of idiopathic acute laryngitis, 172 of influenza, 277, 278 of laryngeal neoplasms, 226 of laryngitis phthisica, 193 of oedema of larynx, 177 of paralysis due to aphonia, 210 of cords, 210, 211 of subacute laryngitis, 180 of syphilitic catarrh, 180 laryngitis, 197 of traumatic acute laryngitis, 171 of tumors of nasal cavities, 370, 385 of uterine reflex laryngitis, 192 specific chronic, 239 Syphilis, signs of, in mouth, 198, 199 use of mercury in, 168 Syphilitic catarrh, 360 treatment, 360 laryngitis, 197, 199,207 prognosis, 202 symptoms, 197 treatment, 200-203 pharyngitis, 239, 240 ulcers, 198-203 Syphiloma, 240 Syringe, post-nasal, 275 Systematic examinations, 92-97 Table of symptoms of disease of the larynx and naso-pharynx, 393- 396 Tannic acid, 160, 169, 178, 236, 244 Tannin, 196 Tar, 161, 236 Taste, loss of the sense of, 294 Therapeutics, general, 160-169 Thickening of vocal cords, 205, 208 Thierfelder, 259 Thudichum's douche, 275 Thymol, 358 Thyro-arytenoid muscle, 72, 74 -epiglottic ligament, 270 -epiglottideus, 77 -hyoid ligaments, lateral, 70 membrane, 70 Thyroid cartilage, 66 gland, 80 Thyrotomy, 205 INDEX. 411 Tincture of benzoin, 173, 183, 268 of guaiacum, 169, 236 of iodine, 169 of iron, 169, 173, 178 Tobold, 18 Tobold's lamp, 25 Cohen's modification, 25 laryngeal lancet, 175 Tolu, 161, 283 Tongue, management of, 48 depressor, 49 Cohen's, 50 Tonsillitis, acute, 233, 247 chronic, 169 Tonsillotomes, 250 Fahnestock, 251 Seiler's modification of Math- ieu's, 251 Tonsils, altered secretion of, mis- taken for diphtheria, 234 amputation of, 249-253 hypertrophied, 247 in pharyngitis, 233 inspection of, 39 pharyngeal, 260 scirrhous, 247 Topical applications, 167 importance of, in syphilis, 200 method of making, 165- 167 Trachea, 65, 83 bifurcation of, 83 Tracheotomy, 175, 179, 209, 231 Transparency, illumination by, 33 Traumatic acute laryngitis, 158, 171,203 duration of, 173 pharyngitis, 237 chronic laryngitis, 158, 181 pharyngitis, 239 inflammation of mucous mem- brane, 291, 292, 324 Treatment of acute laryngitis, 173 pharyngitis, 235 of American grippe, 180, 287- 290 of aphonia due to cicatricial adhesion, 209 of atrophic catarrh, 356 of bony obstruction of nose, 333 of chronic laryngitis, 183, 189 pharyngitis, 239 follicular, 196, 239 gastric, 239 granular, 239 Treatment of chronic pharyngitis, traumatic, 204 of coryza, 267, 268 of elongated uvula, 244 of hay-fever, 350 of hypertrophic catarrh, 301 surgical, 305 of hypertrophied tonsils, 247- 250 of influenza, 278, 279 of laryngeal neoplasms, 229- 232 of laryngitis phthisica, 196 of malignant neoplasms, 379- 384 of nasal catarrh, 302, 303 of oedema, 178 of paralysis, 213 of rhinoliths, 390 of stenosis of larynx from cicatrization, 205 of subacute laryngitis, 181 of syphilitic laryngitis, 200 pharyngitis, 239, 240 specific chronic, 240, 241 of tumors of nasal cavities, 363 of ulcers and abrasions, 163,164 Tube-forceps, 221 Tubercles in larynx, 195 Tubercular deposits, 195 Tumors, benign, 227, 362 cancerous, 362 carcinomatous, 362 classification of, 227 cystic, 229 fibro-cellular, 228 fibrous, 228 laryngeal, 227 malignant, 362 of nasal cavity, 363 cystic, 372 etiology, 365 fibrous, 369 mucous, 364 symptoms, 229, 230 treatment, 379 sarcomatous, 362 Turbinated bones, 86 hypertrophy of, 265 corpora cavernosa, 90 Tiirck, 17, 18, 25 Ulcers, 239 carcinomatous, 203 catarrhal, production of, 159 412 INDEX. Ulcers, deep, 198, 202 method of touching, 163, 16 shallow, 197 syphilitic, 198-203 Unilateral paralysis, 210 causes, 212 complete, 210 partial, 211 treatment, 213 Universal battery, 333 inhaler, 148 tube-forceps, Seiler's, 222 Urticaria, 284 Use of nasal douche, 269 precautions in, 270 Uterine reflex laryngitis, 191 Uvula, amputation of, 244 elongated, 243 treatment of, 244 in pharyngitis, 234 inspection of, 39 scissors, 246 Uvulatomes, 245 Vandf.rpoel, 374 Van Meckren, 365 Vapor inhalations, 146, 268 Variations in color of normal mu- cous membrane, 88 in normal arytenoids, 85 epiglottis, 84 Varieties of hypertrophy of tonsils, 247 Vascular growths, 229 Vaso-motoria periodica, 344-353 etiology, 349 history, 345 prognosis, 336 symptoms, 346 treatment, 350 Vaso-motor nerves, 295 Vault of pharynx, 94, 95 Veins of larynx, 79 Velum palati in pharyngitis, 233, 234 Jarvis's method of control- ling, 63 obstacle to posterior rhin- oscopy, 62 perforation of, 241 Ventilation, defective, cause of nasal catarrh, 300 Ventricle of larynx, 78 Ventricle of larynx, eversion of, 227 Ventricular bands, 81 assuming functions of vocal cords, 202 Verneuil, 373 Vestibule of nose, 90 Vibrissa?, 131 Vienna paste, 305 Virchow, 90 Vocal cords, 78, 187 agglutination, 208 hyperplasia, 207 mucous membrane of, 78 paralysis, 294 ulceration, 207 muscles, 74 process of arytenoid cartilages, 77 Vocalization, laryngeal image in, 82 muscles of, 72 painful, 208 paralysis of muscles. 210 Voice, cultivation of, 189 faulty production of, 187 mechanism, 189 nasal, 131 peculiar in phthisis,.194 production, 104-109 registers of, 107, 187 whispering, 109 Vomer, 92 exostoses of, 281, 296 necrosis of, 355 Von Bruns, 224, 228 Vowels, 112-117 Wagner, 373 Water air-pump, 142 Whispering voice, 109 Wine of cocoa, 216 Hungarian, 185 Wire loop, 222 Witch-hazel, extract of, 301 Woakes, 345, 365 Wolff, 114 Wright, H , 46 Wrisberg, cartilages of, 71 Wyman, 345 Zinc, sulphate of, 160, 181, 301 Zuckerkandl, 363, 373 Catalogue of 1Book$ PUBLISHED BY Lea Brothers & Company, 706, 708 & 710 Sansotn St., Philadelphia. 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